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We investigated the frequency of wide-awake local anesthesia no tourniquet (WALANT) use for hand surgery in the a 10- to 18-year-old age group and patients' experiences.Patients aged 10-18 years who had hand surgery in June 2016 to March 2020 were identified. The frequency of patients who agreed to have surgery under WALANT was calculated (%). Patients who received WALANT over the previous year were interviewed for their surgical experiences.A total of 69 patients were identified, and 46 of them received WALANT. The mean age was 14.5 ± 2 years, and 22 of them were boys. Sixteen patients were called for a surgical experience assessment via questionnaire. They reported pain less than 1/10 during anesthesia injection and surgery. Ten patients (62%) found their operation easy, and 14 (87.5%) would prefer WALANT again.This study showed that most patients in the 10-18 years age group accepted WALANT, and their surgical experiences were positive. For its advantages, WALANT should be considered in hand surgery for compliant patients in this age group.Therapeutic III.

In this retrospective study, we evaluated the results of central slip reconstruction with a modified Snow's technique under wide-awake local anesthesia no tourniquet.Between 2016 and 2019, 13 patients with boutonniere deformity were operated. All of the patients had boutonniere deformity with a passively correctable proximal interphalangeal joint. In 7 patients, temporary proximal interphalangeal joint transfixation with a K-wire to secure the repair was preferred. For the rest of the patients, postoperative follow-up was done with an orthosis. All patients were referred to a hand therapist for postoperative rehabilitation.The mean interval between the injury time and the surgery was 55.7 days. After the surgery, the average proximal interphalangeal joint flexion was 104.8° and the loss of proximal interphalangeal joint extension was 6.15°. The average distal interphalangeal flexion was 65.3°. Seven cases had excellent results, 4 patients had good results, and 2 patients had fair results.Our study demonstrated that with a modified Snow technique, encouraging results can be achieved for neglected central slip injuries in which primary repair is impossible. Surgery under wide-awake local anesthesia no tourniquet enables the surgeon to check the stability of the repair, and early active motion with relative motion flexion orthoses can be started with confidence.Therapeutic IV.

Context: Weight-bearing test (WBT) is a noninvasive quantitative test which has been used recently to determine loading capability of the individuals. The aim of this study was to strengthen the evidence for using the WBT test for measuring weight-bearing capacity of the upper-extremity with the specific objective of examining the internal and external responsiveness and concurrent validity of the test in patients with triangular fibrocartilage complex injury. Design: Single-group repeated measures. Methods: Internal responsiveness was assessed using effect size statistics. The correlation coefficient was used to examine external responsiveness by testing 5 hypotheses regarding predefined correlations between the changes in the measurements. Concurrent validity was evaluated by analyzing correlations between the WBT and other measurements. Thirty-one patients with triangular fibrocartilage complex injury were included for the analysis of the concurrent validity. Eighteen patients who completed all measurements at baseline and at 3-month follow-up enrolled for the responsiveness analysis. Measurements included the WBT, pain intensity, grip strength, and upper extremity functional level. Results: The WBT test was able to detect statistically significant changes in weight-bearing capacity between baseline and follow-up (P = .0001). The effect size of the WBT was large. Three out of 5 hypotheses (60%) were confirmed, a good correlation was found between changes scores of the WBT and grip strength (r = .478; P r value range from −.401 to .742; P r = .742; P = .0001). Conclusions: The responsiveness and concurrent validity of the WBT test confirmed that it is able to measure change in weight-bearing capacity in patients with triangular fibrocartilage complex injury.

Recently, the wide-awake local anesthesia no tourniquet (WALANT) technique and relative motion extension (RME) splint changed practice in extensor tendon reconstruction and therapy. We wanted to share our approach for zones 5 to 8 extensor tendon management following the up-to-date developments. The impacts of surgery under WALANT and early active motion therapy with RME splinting were explained frankly and shown in several videos throughout the article.

This study investigated the effectiveness of a relative motion flexion orthosis (RMFO) for increasing the range of motion for boutonniere deformity.We included 28 patients aged 13-62 years with chronic boutonniere deformity who could complete 0° proximal interphalangeal (PIP) joint extension with the pencil test and were stage 1 according to the Burton classification of boutonniere deformity. At the initial hand therapy appointment, the RMFO was made. The duration of the orthosis usage at the initial therapy session, after stopping the use of the orthosis (posttreatment), and at the follow-up period were noted.The mean time for orthosis usage of all patients was 11.7 weeks (6-40 weeks). The mean initial active distal interphalangeal joint flexion was 47° (0° to 90°) and improved to 66.8° (5° to 110°). The mean initial extension lag of the PIP joint was 22.5° (5° to 55°) and improved to 12° (0° to 30°). This did not change between discontinuation of the orthosis and final follow-up.The use of RMFO is effective in increasing active distal interphalangeal joint flexion and improving PIP extension in patients with Burton stage 1 chronic boutonniere deformity. TYPE OF STUDY/LEVEL OF EVıDENCE: Therapeutic IV.

This case series determines the clinical outcomes of relative motion extensor splints (RMES) in extensor mechanism repairs. Nine patients who underwent extensor tendon repair, juncturae tendinum or sagittal band repair were included. A forearm-based volar blocking wrist splint was applied after surgery. The RMES was configured at the initial hand therapy appointment. Total active motion (TAM) at 4 and 8 weeks after surgery and return to work were assessed. There were 7 males and 2 females with a mean age of 28 (16-53 years). The mean TAM of the uninjured digits was 270° (245°-290°). The mean TAM of the injured digits was 209° (125°-275°) at week 4 and 245° (185°-290°) at week 8. The mean return to work time was 25 days. None of the patients had tendon ruptures and required secondary procedures. In our study, active movement with RMES was allowed immediately after surgery. The RMES program supported safer and earlier recovery of motion. All patients were able to perform activities of daily living while wearing the splint.

Background: Stack splint is commonly used for mallet finger treatment but patients had a tendency to frequently remove it because of skin complications. We hypothesized that a comprehensively instructed splinting regime would increase patients’ compliance and lead to favorable outcomes with fewer skin complications. The aims of this study were to assess the patients’ compliance and to evaluate outcomes with that particular splinting regime. Methods: Forty-six consecutive patients were enrolled in this prospective study. They were instructed to wear the Stack splint for 24 hours a day every day in the first six weeks and remove it once a day for 10 minutes to vent. They were told to support distal interphalangeal joint volarly both while wearing the splint and when it was removed. Free movement of proximal interphalangeal joint within the splint was checked after each application. Following whole-day regime for 6 weeks, night splinting continued for 2 more weeks. Range of motion, skin complications, patients’ compliance and satisfaction were assessed at last follow-up. Results: There were 26 patients with a mean age of 39.8 and mean follow-up period of 6.7 months. No skin complications or proximal interphalangeal joint stiffness were reported. However, nine patients declared that they wore the splint ≤ 4 weeks, the compliance rate to our regime was 65.4% (17/26). In the 17 fully compliant patients, mean distal interphalangeal joint extension lag was 12.4 and nine of them (52.9%) were satisfied with the outcome. Conclusions: Our both hypotheses failed; comprehensive instructions for the splinting regime did not improve patients’ compliance satisfactorily, nor did it lead to favorable outcomes. Although Stack splint has practical points, we no longer use it.

Although rare, the thumb can trigger because of de Quervain disease. An 18-year-old woman presented with painful triggering during thumb movements. Physical examination revealed locking upon thumb extension and painful snapping upon thumb flexion, with tenderness over the first extensor compartment. During the ultrasonography examination, the extensor pollicis brevis tendon snapped with a jerky movement. According to intraoperative active movement under wide-awake local anesthesia no tourniquet, only the extensor pollicis brevis tendon subcompartment was released, and the snapping was resolved. The patient was symptom-free at the second postoperative week control. Triggering because of de Quervain tenosynovitis is a rare condition, and surgical release is required in most cases. Dynamic ultrasonography is an effective tool for precise preoperative assessment of pathology and assists surgical planning. Surgery under wide-awake local anesthesia no tourniquet is advised, which helps intraoperative assessment of pathology and ensures accurate treatment.

There is limited literature evidence on the use of relative motion flexion splint after flexor tendon repairs.We aimed to report the clinical use of early active movement with a relative motion flexion splint and to determine the outcomes of a consecutive series in patients with zone 1-2 flexor tendon repair.We included 14 patients with one-stage flexor tendon repair. An active rehabilitation program was initiated in the first week with a static dorsal block splint, which was removed in the third week, and patients started to use the relative motion flexion splint. Total active motion (TAM) of the injured finger at 8, 12, and 16 weeks after surgery was assessed as described by Strickland and Glogovac.The mean TAM of the injured fingers was as follows: 102.5 ± 41.49° (25°-180°) at week 8; 123.42 ± 40.94° (45°-190°) at week 12; and 148 ± 38.18° (90°- 200°) at week 16. Final TAM grades of the patients at week 16 were as follows: excellent (six patients); good (five patients); and fair (three patients). There were no tendon ruptures and secondary surgeries.Early active movement and the use of relative motion flexion splint seem to be promising strategies for flexor tendon zone 1-2 repair management.

The authors conducted a prospective study to compare patients' intraoperative experience of open carpal tunnel release under "wide awake, local anesthesia, no tourniquet" (WALANT) on the one hand and intravenous regional anesthesia on the other. The authors hypothesized that WALANT would offer a better intraoperative experience than intravenous regional anesthesia.Twenty-four patients with bilateral carpal tunnel syndrome had one hand operated on using WALANT and the contralateral hand with the intravenous regional anesthesia method. At the postoperative second hour, patients completed a questionnaire to quantify their pain levels on a numerical rating scale and compare the operation with dental procedures. They were also asked about their expectations and feelings about reoperation with the anesthesia methods. The results were compared for the two anesthesia methods.There were no significant differences between numerical rating scale pain values during anesthetic administration or for surgical site pain on the WALANT and intravenous regional anesthesia sides. Patients reported moderate tourniquet pain for intravenous regional anesthesia sides. For WALANT sides, a significantly higher number of patients reported carpal tunnel release to be an easier procedure than dental procedures (91.6 percent WALANT and 37.5 percent intravenous regional anesthesia). For WALANT sides, a significantly higher number of patients reported carpal tunnel release to be an easier procedure than they expected (91.6 percent WALANT and 50 percent intravenous regional anesthesia). For the reoperation, 83.3 percent of patients preferred WALANT, 8.3 percent preferred intravenous regional anesthesia, and 8.3 percent reported no preference.WALANT offered a better intraoperative experience. Tourniquet pain, preoperative preparation basics, and the extended anesthesia duration are likely the major drawbacks of the intravenous regional anesthesia method.

Hand surgery is rapidly changing. The wide-awake approach, minimum dissection surgery and early protected movement have changed many things. This is an update of some of the important changes regarding early protected movement with K-wired finger fracture management, simplification of nerve decompression surgery, such as elbow median and ulnar nerve releases, and some new areas in performing surgery with wide-awake local anaesthesia without tourniquet.

OBJECTIVES: This study aimed to determine the radial styloid osseous changes observed on posteroanterior wrist radiographs of patients with de Quervain’s tenosynovitis who required surgery or conservative treatment. MATERIALS AND METHODS: The surgically treated group included 24 patients with de Quervain’s tenosynovitis. The conservative treatment group and the healthy control group each comprised 24 age- and sex-matched subjects. We evaluated the presence of bone apposition, periosteal reaction, sclerosis, osteopenia, erosion, and contour bulge in the epiphyseal remnant at the radial styloid. The incidences of abnormal radiographic findings were compared between these three groups. The correlation of radial styloid bony changes with the duration of symptoms was also analyzed. RESULTS: No significant differences were found between the three groups in terms of periosteal reaction, erosion, and contour bulge at the epiphysial remnant. Significant differences were found between the three groups in the incidence of bone apposition, sclerosis, and osteopenia (p 0.05). CONCLUSION: We found a variable incidence of abnormal radiographic findings on the radial styloid in patients with de Quervain’s tenosynovitis and asymptomatic individuals. The presence of sclerosis and osteopenia may be potential risk factors for patients who do not respond to conservative treatment and need surgical intervention.

INTRODUCTION Posttraumatic brachial plexus (BP) palsy was used to be treated by reconstruction with nerve grafts. For the last two decades, nerve transfers have gained popularity and believed to be more effective than nerve grafting. The aim of this systematic review was to compare elbow flexion restoration with nerve transfers or nerve grafting after traumatic BP injury. METHODS PRISMA-IPD structure was used for 52 studies included. Patients were allocated as C5-C6 (n = 285), C5-C6-C7 (n = 150), and total BP injury (n = 245) groups. In each group, two treatment modalities were compared, and effects of age and preoperative interval were analyzed. RESULTS In C5-C6 injuries, 93.1% of nerve transfer patients achieved elbow flexion force ≥M3, which was significantly better when compared to 69.2% of nerve graft patients (p

This article reviews the impact of wide-awake hand surgery without tourniquet on departmental settings and savings on patients' medical cost, and efficiency of fellowship training and practice of junior hand surgeons in 3 units in 3 countries. The medical cost of the commonly performed procedures is decreased remarkably with this approach in the 3 units. Hand surgery fellowship training and practice of junior surgeons are benefited from this approach in 2 units in Turkey and Switzerland. Overall, this approach improves the surgeons' and patients' quality of life and its application is expanding to almost all procedures of hand surgery.

Summary. Recently, better outcomes have been reported when up-to-date developments in flexor tendon surgery and therapy were followed. Slightly tensioned multistrand repairs, judicious venting of pulleys, and early active motion are widely accepted principles. In addition to these principles, tailoring of the repair according to intraoperative active movement with wide awake local anesthesia no tourniquet (WALANT) surgical setting is recommended for better results. We aimed to describe our up-to-date approach to flexor tendon surgery and therapy with the help of visual communication tools of this age. The ideal primary repair of flexor tendons, the management of delayed presentation flexor tendon injuries, the key steps to achieve better results with flexor tendon therapy, and the tele-rehabilitation experience during COVID-19 pandemic will be highlighted. Zone 2 flexor tendon injuries are the most demanding part and will be focused on.

Objective The aim of this study was to evaluate the results of the innervated digital artery perforator (IDAP) flap and to analyze the relationship between patient satisfaction and outcome measures. Methods A total of 17 fingertips of 15 patients (14 men and one woman; mean age: 47.2 (26-62) years) were included in this retrospective study. Patients' injured finger and defect type were recorded. At the last follow-up, the static two-point discrimination (s2PD) test, Semmes Weinstein monofilament (SWM) test, and range of motion of the affected finger were analyzed. We interviewed patients to determine hand dominance, cold intolerance, and their satisfaction with the result. We performed correlation and logistic regression analyses between patient satisfaction and outcome measures. Results The mean follow-up period was 13.8 (7-18) months. The mean range of motion was 77.3±3.5 (70-80) degrees for the distal interphalangeal joints of affected fingers. The mean s2PD was 6.4 (3-10) mm, and the SWM records ranged from 2.83 to 4.93 monofilament markings. Cold intolerance was noted in seven fingers (41%). Patient satisfaction was negatively correlated with cold intolerance, and cold intolerance decreased as the follow-up period extended. Conclusion IDAP flap satisfies both patient and surgeon, with the only significant problem being cold intolerance, regarding which patients must be informed. Although cold intolerance is hard to treat, fortunately, it generally improves with time. Level of evidence Level IV, Therapeutic study.

This chapter introduces the kinesiology of the elbow joint both in normal and pathologic conditions. It starts by presenting a detailed anatomy and biomechanics of elbow joint. The forearm complex is also included in the chapter with its important pronation-supination movement and load transmission activity of interosseous membrane. The stability philosophy of elbow joint is explained, and the instability patterns are presented. The kinesiology of common disorders of elbow joint is comprehended as acute elbow trauma, sequela of elbow trauma, and elbow injuries in the athletes. To simplify understanding, the other disorders are classified as medial, lateral, posterior, and anterior elbow injuries. The pathomechanics of injuries and kinesiology during injured conditions are discussed in a clinical view.

This chapter introduces the kinesiology of the wrist joint and the hand both in normal and pathologic conditions. It starts by presenting detailed anatomy and biomechanics of the wrist in the first part of the chapter. The stability philosophy of wrist joint is explained, and the instability patterns are presented. The pathomechanics of wrist injuries are also discussed. In the second part, anatomy and biomechanics of hand are presented in detail, including its flexor and extensor system and the intrinsic mechanism. The pathomechanics of hand injuries are also discussed in a clinical view.

BACKGROUND The authors conducted a prospective study to compare patients' intraoperative experience of open carpal tunnel release under "wide awake, local anesthesia, no tourniquet" (WALANT) on the one hand and intravenous regional anesthesia on the other. The authors hypothesized that WALANT would offer a better intraoperative experience than intravenous regional anesthesia. METHODS Twenty-four patients with bilateral carpal tunnel syndrome had one hand operated on using WALANT and the contralateral hand with the intravenous regional anesthesia method. At the postoperative second hour, patients completed a questionnaire to quantify their pain levels on a numerical rating scale and compare the operation with dental procedures. They were also asked about their expectations and feelings about reoperation with the anesthesia methods. The results were compared for the two anesthesia methods. RESULTS There were no significant differences between numerical rating scale pain values during anesthetic administration or for surgical site pain on the WALANT and intravenous regional anesthesia sides. Patients reported moderate tourniquet pain for intravenous regional anesthesia sides. For WALANT sides, a significantly higher number of patients reported carpal tunnel release to be an easier procedure than dental procedures (91.6 percent WALANT and 37.5 percent intravenous regional anesthesia). For WALANT sides, a significantly higher number of patients reported carpal tunnel release to be an easier procedure than they expected (91.6 percent WALANT and 50 percent intravenous regional anesthesia). For the reoperation, 83.3 percent of patients preferred WALANT, 8.3 percent preferred intravenous regional anesthesia, and 8.3 percent reported no preference. CONCLUSIONS WALANT offered a better intraoperative experience. Tourniquet pain, preoperative preparation basics, and the extended anesthesia duration are likely the major drawbacks of the intravenous regional anesthesia method.

WOS: 000462822700006 Background: We aimed to evaluate the correlation of patients' satisfaction with sensorial evaluation results after primary repair of digital nerves and flexor tendons. Materials and Methods: In total, 31 fingers of 25 patients that underwent primary repair for clear-cut digital nerve and flexor tendon injuries were included in this retrospective study. The mean age of the patients was 34.8 +/- 9.4 years. Patients' gender, age at admission, trauma date, and injured finger were obtained from patients' folders. We called the patients for the last follow-up and used two-point discrimination (2PD) and Semmes-Weinstein monofilament (SWM) tests to evaluate sensorial recovery. Patients were interviewed for hand dominance, cold intolerance, and if they were satisfied. Visual analog scale (VAS) was used to evaluate the satisfaction of patients related to the injured finger. We analyzed correlations between VAS score and age, follow-up period, 2PD score, SWM score, cold intolerance score, gender, hand dominance, and the injured finger. Results: Patients' satisfaction was significantly correlated only with cold intolerance score. There was no significant correlation between patients' satisfaction and age, follow-up period, gender, hand dominance, injured finger, 2PD score, and SWM score. Conclusion: Our study revealed that patients' satisfaction was not only correlated with sensorial recovery scores but also significantly negatively correlated only with cold intolerance, and novel modalities to treat this phenomenon are required. Moreover, patients' satisfaction was not related to age, gender, hand dominance, and the injured finger; hence, surgeons should focus on meticulous repair of digital nerves in any age, for any gender, and any finger of patients.

Objective: The aim of this study was to report the outcomes of patients applied with zone 1 and 2 flexor tendon repairs using the with strong core sutures, venting of critical pulleys, intraoperative active movement testing with a wide-awake surgical setting, and early active mobilization approaches. Patients and Methods: Twenty pulleys impairing excursions during intraoperative active movement were totally vented and up to half of two A2 pulleys were judiciously vented. Therapy started on the third postoperative day. Assessments were performed at the end of the sixth, eighth, and 12th weeks. The Strickland score was calculated for each injured finger and the Disabilities of Arm, Shoulder and Hand (DASH) scale was completed. The Strickland and DASH scores in the consecutive assessments were compared. Results: Evaluations of 21 fingers of 17 (11 males, six females) patients with a mean age of 30.0±7.9 years were made. There were 17 zone 2 and four zone 1 repairs. One finger (1/21, 4.7%) was operated on again for stiffness (tenolysis) and there was no rupture. The Strickland and DASH scores improved with a statistically significantly at each assessment. Conclusion: The low tenolysis rates, the absence of ruptures, and improved outcome scores signaled encouragement to follow current flexor tendon repairs. Keywords: early active mobilization; flexor tendon; venting of annular pulleys; walant [Hand Microsurg 2021; 10(3.000): 219-226]

Objectives Recently, wide awake local anesthesia no tourniquet (WALANT) technique has been rapidly increasing in popularity because of its benefits for surgeons, patients, and institutions. In this study, we wanted to evaluate Turkish patients’ operative experiences with different hand surgery procedures under WALANT. Methods There were 138 patients included in this study who were operated under WALANT and accepted to fill a questionnaire during telephone interview. Patients were asked to quantify their pain levels on a numerical rating scale (NRS) and compare the operation to a dental procedure. They were also asked about their expectations and their feelings about re-operation with the same anesthesia method. Results The mean age was 43.5 years, and the mean follow-up was 11.2 months. The mean NRS pain score was 2.3 during local anesthetic administration, and it was 1.2 during surgery. Seventy-six percent of responders reported a better operative experience when compared with dental procedures, and 77.5% of them reported a better operative experience than they had expected. Eighty-eight percent of the patients wished to be operated on with the same anesthesia method for any possible operations in the future. Conclusions We observed that Turkish patients readily adopted the WALANT technique and were satisfied with their operative experience. We advise WALANT technique for a variety of hand surgery procedures.

AMAÇ: Çocuklar duvarlara, merdivenlere ve korkuluklara tırmanmaya meraklıdır. Bu durum düşme sonucu travmaları da artırmaktadır. Çalış- mamızda korkuluk demiri ile üst ekstremite penetran yaralanması olan çocuk hastalarımızdaki tecrübelerimizi paylaşmayı ve çocuklardaki bu tip yaralanma riskine dikkat çekmeyi amaçladık. GEREÇ VE YÖNTEM: Çalışmamızda ortalama yaşı 8.8 olan beş erkek çocuk dâhil edildi. Saplanmış olan korkuluk demirleri ameliyathanede çıkartıldı. BULGULAR: Eksplorasyon sonucu yaralandığı tespit edilen yapılar (fleksör digitorum profundus tendonu, A4 pulleyi, distal interfalangeal eklem volar plak, radial dijital sinir, ulnar dijital sinir ve radial dijital arter) hemen onarıldı. TARTIŞMA: Korkuluk demiri yaralanmaları, ameliyathanede eksplorasyon gerektirmekte ve önemli yapıların yaralanmasına neden olabilmektedir. Özellikle erkek çocukları risk altındadır ve ebeveynler bu açıdan dikkatli olmalıdır. Korkuluk demirlerinin kullanımında standart bir hukuki düzenleme olması gerektiğini düşünmekteyiz. Bu çalışmayı, olası yaralanmalar açısından toplumun, olası hukuki sonuçları açısından da kullanan kurumların ve kişilerin dikkatine sunuyoruz. AMAÇ: Çocuklar duvarlara, merdivenlere ve korkuluklara tırmanmaya meraklıdır. Bu durum düşme sonucu travmaları da artırmaktadır. Çalış- mamızda korkuluk demiri ile üst ekstremite penetran yaralanması olan çocuk hastalarımızdaki tecrübelerimizi paylaşmayı ve çocuklardaki bu tip yaralanma riskine dikkat çekmeyi amaçladık. GEREÇ VE YÖNTEM: Çalışmamızda ortalama yaşı 8.8 olan beş erkek çocuk dâhil edildi. Saplanmış olan korkuluk demirleri ameliyathanede çıkartıldı. BULGULAR: Eksplorasyon sonucu yaralandığı tespit edilen yapılar (fleksör digitorum profundus tendonu, A4 pulleyi, distal interfalangeal eklem volar plak, radial dijital sinir, ulnar dijital sinir ve radial dijital arter) hemen onarıldı. TARTIŞMA: Korkuluk demiri yaralanmaları, ameliyathanede eksplorasyon gerektirmekte ve önemli yapıların yaralanmasına neden olabilmektedir. Özellikle erkek çocukları risk altındadır ve ebeveynler bu açıdan dikkatli olmalıdır. Korkuluk demirlerinin kullanımında standart bir hukuki düzenleme olması gerektiğini düşünmekteyiz. Bu çalışmayı, olası yaralanmalar açısından toplumun, olası hukuki sonuçları açısından da kullanan kurumların ve kişilerin dikkatine sunuyoruz.

BACKGROUND Children have a curiosity for climbing walls, stairs, and railings and have an increased risk of falling. Here, we report our experience with railings causing injuries by penetrating the upper extremities, and aim to call attention to spiked railing injuries in children. METHODS We report on five children with a mean age of 8.8. All of the children were male. The penetrating railing parts were removed in a surgical room. RESULTS The injured structures repaired immediately were as follows: flexor digitorum profundus tendon, A4 pulley, volar plate of the distal interphalangeal joint, radial digital nerve, ulnar digital artery, and radial digital artery. CONCLUSION Spiked railings can lead to significant injury that requires further exploration. Boys particularly are at risk, and parents should be alert regarding these type of injuries. We recommend a standard regulation for fence erection, and we wish to warn owners of this type of fence regarding probable legal sanctions.

Background We evaluated the factors that affect the natural course of subacromial impingement syndrome in patients without rotator cuff tears. Methods In total, 63 patients were included. During the first evaluation, we recorded each patient’s age, gender, profession, body mass index (BMI), hand dominance, alcohol and tobacco consumption, comorbidities, causative event of pain, presence of a functional limitation, duration of symptoms, shoulder scores (American Shoulder and Elbow Surgeons [ASES], Constant-Murley, and visual analog scale), history of subacromial steroid injections, and magnetic resonance imaging (MRI) classification. A subacromial lidocaine injection test was performed to confirm the diagnosis, and patients were initially treated conservatively. Of the 63 patients, 7 underwent a subsequent surgical procedure. We recalled the patients and questioned them about recurrences. According to their answers, the patients were grouped as follows: group 1, no recurrence; group 2, relapsing course; and group 3, chronic course. We compared the groups regarding the factors proposed to affect the course of the disease. Results The mean follow-up time was 8.45 ± 0.9 years. There were no significant differences regarding gender, profession, hand dominance, alcohol consumption, smoking, comorbidities, causative event of pain, visual analog scale score, or history of subacromial steroid injections between groups. The patients in group 1 were significantly younger than those in group 2 ( P = .038). The mean BMI value of the group 1 patients was significantly lower than that of the group 3 patients ( P = .034). Patients with a functional limitation besides pain tended to have a relapsing course. The Constant-Murley and ASES scores were significantly higher for patients in group 1 than for patients in group 2 ( P = .024 and P = .041, respectively). The duration of symptoms was significantly shorter ( P = .001). Most of the patients in group 1 had reversible changes on MRI ( P = .038). Conclusion In our study, younger age, lower BMI, more functional capacity, a shorter symptomatic period, reversible changes on MRI, and higher Constant and ASES scores at the first evaluation were good prognostic factors.

Background: The choice of prosthesis in hemiarthroplasty is controversial for geriatric patients after femoral neck fracture. We hypothesised that selection criteria for unipolar or bipolar prostheses could be constructed based on factors affecting mortality. Aims: The aims of this retrospective study were: (1) to determine the factors affecting mortality of femoral neck fracture patients ≥65 years of age; (2) to compare patient mortality rates, radiological findings, and functional outcomes according to prosthesis type (unipolar or bipolar); and (3) to evaluate the persistence of inner bearing mobility of bipolar prostheses. Study Design: Retrospective comparative study. Methods: In total, 144 patients operated for hemiarthroplasty and aged ≥65 were included. We classified the patients into either unipolar or bipolar prosthesis groups. To reveal factors that affected mortality, age, sex, delay in surgery, and American Society of Anesthesiologists score were obtained from folders. Barthel Daily Living, Harris hip, and acetabular erosion scores were calculated and bipolar head movement was analysed for live patients. Results: One-year mortality was 31.94%. Age ≥75 (p=0.029), male sex (p=0.048), and delay in surgery ≥6 (p=0.004) were the patient characteristics that were related to increased mortality. There were no significant differences in sex, age, American Society of Anesthesiologists score, delay in surgery, mortality, or Barthel, Harris, acetabulum scores between the two groups. Twenty patients from each group were admitted for last follow-up. Bipolar head movement was preserved for 33.3% of patients. They were inactive patients with low Barthel and Harris scores. Conclusion: Although bipolar head movement was preserved in inactive patients, we suppose that this conferred no advantage to these patients, who could hardly walk. In this study, male patients, those aged ≥75 years, and those operated at ≥6 days had an increased risk of mortality. Also, although not significant in multivariate analysis, high American Society of Anesthesiologists score (≥3) was related to increased mortality. Considering that one of three patients died during the first postoperative year, we think that these patients should be operated as soon as possible, and expensive bipolar prostheses must be used selectively in regard to patient characteristics. Turkish Başlık:Geriatrik Nüfusta Femur Boyun Kırıkları Sonrası Bipolar veya Unipolar Hemiartroplasti Anahtar Kelimeler:Femur boyun kırığı, mortalite, hemiartroplasti Arkaplan: Yaşlı hastalarda hemiartroplasti ile femur boyun kırığı tedavisinde protez tipi tercihi tartışmalıdır. Biz çalışmamızda mortaliteyi etkileyen faktörleri baz alarak unipolar veya bipolar protez için tercih ölçütleri oluşturabileceğimizi düşündük. Amaç: Bu retrospektif çalışmanın amaçları; (1) 65 yaş ve üstü hastalarda femur boyun kırığı sonrası mortaliteyi etkileyen faktörleri belirlemek, (2) protez tipine (unipolar veya bipolar) göre hastaların mortalite oranlarını, radyolojik bulgularını ve fonksiyonel sonuçlarını karşılaştırmak, (3) bipolar protezlerde iç taşıyıcı yüzey hareketinin sebatını değerlendirmektir. Çalışma Tasarımı: Retrospektif karşılaştırmalı çalışma Yöntemler: Çalışmamıza hemiartroplasti ameliyatı yapılan 65 yaş ve üstü toplam 144 hasta dâhil edildi. Hastaları unipolar ve bipolar protez grupları olarak sınıflandırdık. Mortaliteyi etkileyen faktörleri ortaya koymak için hasta dosyalarından yaş, cinsiyet, cerrahi bekleme süresi ve American Society of Anesthesiologists (ASA) skorları belirlendi. Sağ olan hastaların Barthel günlük yaşam aktivite, Harris kalça ve asetabuler erozyon skorları hesaplandı ve radyografilerle bipolar baş hareketi incelendi. Bulgular: Bir yıllık mortalite oranı % 31.94 hesaplandı. Yaşın ≥75 olması (p=0.029), erkek cinsiyet (p=0.048) ve cerrahi bekleme süresinin ≥6 gün olması (p=0.004) artmış mortalite ile ilişkili hasta karakterleriydi. İki grup arasında cinsiyet, yaş, ASA skoru, cerrahi bekleme süresi, mortalite, Barthel, Harris ve asetabulum skorları arasında anlamlı fark yoktu. Her iki gruptan yirmişer hasta son kontrol için başvurdu. Bipolar baş hareketi bu hastaların % 33.3'ünde mevcuttu. Onlar düşük Barthel ve Harris skorları olan inaktif hastalardı. Sonuç: Bipolar baş hareketi inaktif hastalarda korunmuş olsa da, bunun zorlukla yürüyebilen hastalar için bir avantaj sağlamadığını düşünmekteyiz. Bu çalışmada erkek hastalar, 75 yaş ve üstü olanlar, cerrahi bekleme süresi ≥6 gün olanlar yüksek mortalite riskine sahipti. Çok değişkenli analizlerde anlamlı bulunmamasına rağmen yüksek ASA skoru (≥3) da artmış mortalite riski ile ilişkiliydi. Her üç hastadan birinin ameliyat sonrası ilk yılda öldüğü düşünüldüğünde, bu hastaların olabildiğince erken zamanda ameliyat edilmesi gerektiğini ve pahalı bipolar protezin hasta karakterleri dikkate alınarak seçilmiş hastalarda kullanılması gerektiğini düşünmekteyiz.

We hypothesized that regional migratory osteoporosis (RMO) and transient osteoporosis of the hip (TOH) terms describe a common disease process. Therefore, based on our patient, we aimed to review the pathogenesis, diagnosis, and treatment of both diseases. The patient was a pregnant woman in her third trimester with sacral insufficiency fracture, which was shortly followed by migratory arthralgia of both hips and ankles in a proximal to distal direction. She was operated (core decompression) for both hips and ankles, and she was symptom free at 17th month. RMO and TOH have an unclear etiology, share the similar course, and bear a self-limiting nature. Both disorders may be the same clinical entity with a common pathogenesis. Probably, many of RMO patients were labeled as TOH, and therefore, RMO has been underrepresented. In conclusion, we think that both RMO and TOH describe a common disease process. Either the diagnosis is RMO or TOH, the management will be the same. Finally, the conservative treatment protocol is a better treatment modality and must be obeyed even in resistant cases.

Background The purpose of this study was to describe an arthroscopic technique for lateral parameniscal cyst (LPC) decompression with preservation of meniscal substance and to report the short- to mid-term outcome of 20 patients. Methods All patients underwent a complete physical examination and magnetic resonance imaging (MRI) of the knee prior to surgery. After arthroscopic diagnosis of a LPC, partial lateral meniscectomy was performed via anterolateral (AL) and anteromedial (AM) portals. For LPC treatment, we used AL and superomedial (SM) portals. We describe a SM portal at the most proximal part of suprapatellar pouch, just medial to quadriceps tendon for the arthroscope. To decompress the cyst, an intra-articular (IA) portal was created with a shaver on the anterior synovial wall of the cyst from the AL portal. Decompression was performed via the AL portal and through the IA portal under the view of the arthroscope in the SM portal in SM portal. At the last follow-up, Lysholm score was used, and patients' clinical outcomes were classified into four categories: excellent, good, acceptable, and poor. Additionally, during the last control, patients underwent an MRI which was assessed for recurrence. Results Mean follow-up period was 37.5±18.8months. Clinical outcomes were excellent in 15 patients, good in four, and fair in one. The mean Lysholm score was 96.2±7.59. No recurrence of the cyst was seen on control MRIs. Conclusions Arthroscopic LPC decompression with superior and anterior portals is a novel, safe, and effective technique for experienced surgeons. It allows conservation of meniscal tissue, easier handling of instruments, and provides an excellent view of the cyst.

Objectives: Recently, many surgeons started to prefer wide awake local anesthesia no tourniquet (WALANT) approach to provide an almost bloodless field for the vast majority of hand surgery procedures. We aimed to present our two-year experience with WALANT technique. Methods: A wide variety of 682 hand surgery operations in 626 patients were performed with WALANT technique. For infiltrative local anesthesia, the mixture of 1% lidocaine, 1:100.000 epinephrine and 8.4% bicarbonate was prepared. The need for intraoperative sedation and intraoperative patient cooperation were evaluated. Patients' fingers were observed in case of postoperative circulatory compromise. A simple cost-effectivity analysis for the anesthesia types was performed. Results: Mean age of the patients was 43.7. None of the patients needed intraoperative sedation, and patients obeyed to orders of surgeon throughout the procedure. The postoperative circulatory compromise was observed in two fingers; one finger resolved spontaneously and the other rescued with phentolamine. WALANT technique was more cost-effective than Bier block or general anesthesia. Conclusion: The WALANT technique seems like a great innovation to perform a wide variety of hand surgery cases. Increased patient comfort without a tourniquet, cost-effectivity, no preoperative tests, no risks of general anesthesia, no need to stay in the hospital overnight, and intraoperative active motion assessment facility are important advantages. [Hand Microsurg 2018; 7(3.000): 125-134]

Objectives: Hand surgery has been a major theme throughout the education of orthopedics and traumatology (OT) along with plastic, reconstructive, and aesthetic (PRA) surgery residents. However, to work as a hand surgeon during compulsory health service (CHS) is a new topic for Turkey. We aimed to share the elective surgical experience of six hand surgeons during CHS in different centers of Turkey. Methods: The hand surgeons who have already finished their CHS or were up to finish their CHS was requested to fill operation records (OR) form for elective procedures performed in the surgeon's usual daily practice. The records from all six surgeons were integrated. Results: Five OT and one PRA originated hand surgeons were available for this study. Tendon procedures were the most commonly performed procedure (14.3%), followed by phalanx (10.6%), and then by nerve (10.4%) procedures. A small percentage (2.7%) of operations performed were beyond the scope of hand surgery. Simple procedures (trigger finger release, carpal tunnel release, foreign material extraction, ganglion cysts excision, de Quervain's tenosynovitis release) were comprising 20.9% of all the operations performed. Conclusion: Hand surgery comprises a broad spectrum of disorders and requires a distinct fellowship period. Hand surgeons bear an important mission about basic hand surgery education of OT and PRA residents and encourage them to perform simple procedures. The possibility of team-work will definitely increase the interest for hand surgery and result in better outcomes for patients. Finally, we honestly declare that we feel satisfied with our special work and invite residents to walk together in this endless hand surgery road. [Hand Microsurg 2018; 7(2.000): 83-87]

We present a case report involving the flexor digitorum accessorius longus (FDAL) tendon which travels through a fibro-osseous tunnel together with the flexor hallucis longus (FHL) tendon, causing a stenosing tenosynovitis. The patient was admitted with posteromedial ankle pain and diagnosed clinically as FHL tenosynovitis. We found two tendons in the tunnel during hindfoot endoscopy. The stenosis was relieved by endoscopic debridement. After the operation, we checked the MRI images and observed two tendons. We concluded that the accessory tendon was the FDAL. Two years later the patient was admitted with the same symptoms. We excised the FDAL muscle and the patient's symptoms resolved. The FDAL muscle is a cause of FHL tenosynovitis. Because of its variability and mostly asymptomatic nature, it may not be noticed it on an MRI scan. Hindfoot endoscopy is a safe tool for the diagnosis of this condition and curative treatment is afforded by excision of the FDAL muscle.

Background: Any intraoperative rotational malalignment during intramedullary nailing (IMN) of femoral shaft fractures will become permanent. We hypothesized that rotational malalignment of the femur and its compensatory biomechanics may induce problems in the hip, knee, patellofemoral and ankle joints. We purposed to clarify the influence of a femoral rotational malalignment of ?10° on daily activities. Methods: Twenty-four femoral shaft fracture patients treated with closed antegrade IMN were included. At last follow-up, to reveal any rotational malalignment, computerized tomography (CT) scans of both femurs (injured and uninjured sides) were examined. The patient groups with or without CT-detected true rotational malalignment ?10° were compared with respect to the activity scores. Results: Ten of the 24 patients (41.7 %) had a CT-detected true rotational malalignment of ?10° compared with the unaffected side. The AOFAS scores were 100.00 for all of the patients. LKS, WOMAC knee, and WOMAC hip scores were significantly decreased in the patients with rotational malalignment compared to those without. Patients without rotational malalignment tolerated climbing stairs significantly better than those with rotational malalignment. Patients who could not tolerate climbing stairs were consistently complaining of anterior knee pain. Conclusions: A femoral rotational malalignment of ?10° is symptomatic for the patients, and the hip, knee, and patellofemoral joints were affected. Because of the possibly altered joint loadings and biomechanics, these could render patients prone to degenerative joint disease. In addition, due to the high rates of rotational malalignment after femoral shaft fracture and consequent malpractice claims, it is important for surgeons to be more aware of rotational alignment during surgery.

The aim of this study is to describe the indications for two-portal hindfoot endoscopy in the treatment of posterior ankle compartment pathologies and to express the effectiveness of this technique by short- to mid-term outcomes on 59 consecutive patients. In our institute, between 2003 and 2009, patients operated by single surgeon with hindfoot endoscopy were enrolled. The American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot and Maryland foot scores (MFS) were obtained preoperatively and postoperatively. In the final follow-up, besides the scores, patients were asked whether they were satisfied and whether they would elect this treatment again. The indications for 59 patients were posterior ankle impingement syndrome (14), osteochondral lesion of talus (13), isolated flexor hallucis longus (FHL) tenosynovitis (11), synovial osteochondromatosis (2), pigmented villonodular synovitis (2), peroneal tenosynovitis (4), subtalar joint arthrosis (4), tibiotalar arthrosis (4), intraosseous talus cyst (4; 1 bilateral), and talus fracture (1). FHL tendon was affected in all cases, and tenolysis was performed for each patient. The mean preoperative AOFAS-hindfoot scores increased from 56.7 ± 14.5 to 85.9 ± 12.5 (P

In Sanders’ classification of calcaneus fractures, the medial fracture line (subtype C) is close to the tarsal canal, which contains an artery for the talus and calcaneus. We hypothesized that because of this brittle vascular localization, patients with C line fracture patterns might describe radiologic subtalar arthritis more often and have more complaints. The purpose of the present study was to compare the results of C line fracture patterns with other types of calcaneus fractures. A total of 25 surgically treated feet were involved. Regarding Sanders’ classification, group 1 included fractures involving the C line (11 feet), and group 2 included fractures not involving the C line (14 feet). Patient age at admission, trauma date, and interval until surgery were obtained from the patients’ medical records. The Bohler angles were determined from the radiographs. At the last follow-up visit, the radiologist graded subtalar arthritis using computed tomography. For clinical follow-up, the American Orthopaedic Foot and Ankle Society and Maryland scores were assessed. No significant differences were found in mean age, follow-up period, delay to surgery, or postoperative Bohler angle between the 2 groups. The mean preoperative Bohler angle was significantly low for group 1. Although not significantly different, the mean American Orthopaedic Foot and Ankle Society and Maryland scores were lower for group 1 (81.9 and 84.3) than group 2 (87.8 and 92.0), and the median subtalar arthritis grade was greater for group 1 (score 2) than for group 2 (score 1.5). The worse results with C line fracture patterns despite satisfactory reduction might result from sinus tarsi artery damage. Angiographic investigations could clarify this theory in the future. Consequently, surgeons must inform and should hesitate to operate on patients with these highly comminuted C line calcaneus fractures.

We retrospectively analyzed 112 intertrochanteric femur fracture patients and 136 femoral neck fracture patients to determine mortality rates and factors affecting mortality. Internal fixation is the standard treatment method for intertrochanteric femur fracture patients in our institute, and arthroplasty, as a treatment choice, shows an increase in mortality rates. We wanted to convey if there was any decrease in mortality rate of intertrochanteric femur fracture patients when compared with femoral neck fracture patients who were almost always treated with arthroplasty.Patients' age at admission, trauma date, delay until surgery, comorbidities, operation durations, anesthesia, and treatment types were evaluated by patients' folders. All preoperative and postoperative radiographs checked over for treatment type. Patients' recent health and activity status were determined by telephone interview.There were no significant differences in mortality rates between patients of two fracture types. Treatment type, anesthesia type, and sex were significant predictors in univariate analyses. In multivariate analyses, only age and delay in surgery identified as predictors of mortality, age was the most significant. Although intertrochanteric femur fracture patients were significantly older than femoral neck fracture patients, the estimated mean survival time was higher for intertrochanteric femur fracture patients (57.9 months) than for femoral neck fracture patients (48.8 months).We think that, in addition to the shorter delay in surgery, internal fixation choice led to decrease the mortality rate of intertrochanteric femur fracture patients. In conclusion, to decrease the mortality rate after hip fracture, since age and sex cannot be changed, needless delays in surgery should be avoided. Also, we recommend internal fixation and regional anesthesia to decrease the mortality rate.

Osteoarthritis (OA) is a complex "whole joint" disease pursued by inflammatory mediators, rather than purely a process of "wear and tear". Besides cartilage degradation, synovitis, subchondral bone remodeling, degeneration of ligaments and menisci, and hypertrophy of the joint capsule take parts in the pathogenesis. Pain is the hallmark symptom of OA, but the extent to which structural pathology in OA contributes to the pain experience is still not well known. For the knee OA, intraarticular (IA) injection (corticosteroids, viscosupplements, blood-derived products) is preferred as the last nonoperative modality, if the other conservative treatment modalities are ineffective. IA corticosteroid injections provide short term reduction in OA pain and can be considered as an adjunct to core treatment for the relief of moderate to severe pain in people with OA. IA hyaluronic acid (HA) injections might have efficacy and might provide pain reduction in mild OA of knee up to 24 wk. But for HA injections, the cost-effectiveness is an important concern that patients must be informed about the efficacy of these preparations. Although more high-quality evidence is needed, recent studies indicate that IA platelet rich plasma injections are promising for relieving pain, improving knee function and quality of life, especially in younger patients, and in mild OA cases. The current literature and our experience indicate that IA injections are safe and have positive effects for patient satisfaction. But, there is no data that any of the IA injections will cause osteophytes to regress or cartilage and meniscus to regenerate in patients with substantial and irreversible bone and cartilage damage.