Ellipsoidal patellar bone tunnel fixation with Toggleloc suspension system for medial patellofemoral ligament reconstruction: A 5 years follow-up.

BACKGROUND: This study aimed to evaluate the clinical and radiological features of the patella fixation technique using Toggleloc suspension system in a single ellipsoidal blind patellar tunnel during medial patellofemoral ligament (MPFL) reconstruction. METHODS: This study included 52 patients (25 men, 27 women) who underwent MPFL reconstruction using a semitendinosus tendon graft. The graft was fixed to the ellipsoidal single blind tunnel opened on the medial side of the patella with an endobutton and was fixed to the femoral tunnel by using bioabsorbable screw. Clinical scores (Kujala score, Lysholm score, Tegner activity score and the visual analog scale [VAS] score) were evaluated preoperatively and at the end-follow up. Preoperative and postoperative radiological measurements (trochlea depth, sulcus angle, patellar height, patellar congruence angle, patellar tilt angle and lateral patellofemoral angle) were evaluated with X-ray (Merchant X-ray, anteroposterior and lateral radiography) and computed tomography (CT) of the knee. RESULTS: Postoperative patellar redislocation or subluxation was not observed in any patient. Patellar congruence angle, patellar tilt angle and lateral patellofemoral angle mean values were found to return to normal values in the postoperative period and the results were statistically significant. Also statistically significant improvement in all clinical scores postoperatively. According to the Insall-Salvati index (ISI) and Caton-Deschamps index (CDI) on lateral radiography of the knee at 30° flexion, patellar height decreased in the postoperative period statistically significant. The CDI was above 1.3 in 17 (%32) of our patients. Thirteen of these values decreased to normal values. No radiological progression of patellofemoral osteoarthritis was observed in all patients at the final follow-up evaluation. CONCLUSION: In cases of patellofemoral instability, fixation of the tendon graft in blind ellipsoid tunnel using the Toggleloc suspension system provides satisfactory patellar graft fixation strength, significant functional improvement and a low failure rate.

The effect of pharmacological treatment in combination with vitamin K on healing in an experimental rat model of osteoporosis.

OBJECTIVES: This study aims to compare the effects of teriparatide, zoledronic acid, and their combination therapy with vitamin K on osteoporotic rats. MATERIALS AND METHODS: We divided a total of 50 female Sprague-Dawley rats into five groups: A (the control group), B and D (the teriparatide group), and C and E (the zoledronic acid group). Following ovariectomy and subcutaneous heparin administration at a dose of 2 IU/kg for four weeks, osteoporosis was created. Groups A, B, and C were fed with standard feed, while Groups D and E were fed with vitamin K-rich feed. After four weeks of treatment, sacrification was performed. The right and left femurs were separated for histopathological and biomechanical evaluation, respectively. For histopathological evaluation, the femurs were decalcified, and the sections were stained with hematoxylin-eosin and evaluated under a light microscope. Fracture healing was evaluated using the classification system as described previously. For biomechanical evaluation, the 3-point stress test and torsion stress test were applied to 10 femurs from each group. RESULTS: Groups B-E were histopathologically and biomechanically superior to Group A in fracture healing of osteoporotic rats; however, it was not statistically significant (p>0.05). The group that received additional vitamin K was histopathologically and biomechanically superior to the group which was fed with standard feed, although it was not statistically significant (p>0.05). CONCLUSION: Our study results indicated that both teriparatide and zoledronic acid had beneficial effects on osteoporotic fractures with comparable histological and biochemical results. Vitamin K promoted teriparatide and zoledronic acid treatment on osteoporotic fracture healing. Based on these findings, combination therapies may yield the most optimal results in biomechanical and histological examinations.

Comparison of efficacy of Oral versus Intra-articular Corticosteroid Application in the treatment of Frozen Shoulder: An experimental study in rats.

OBJECTIVE: The aim of this study was to compare clinical and histopathological effects of oral versus intraarticular corticosteroid application in a rat model of frozen shoulder. METHODS: In this study, eighty adult Sprague-Dawley rats were used. The animals were divided into 5 equal groups. The frozen shoulder model was created by immobilizing animals' shoulders with internal fixation with sutures for 8 weeks. At the 8th week, sham (n: 16) and control (n: 16) groups were sacrificed to collect data for healthy and affected shoulders. Also, at the 8th week, 50 mg/ kg methylprednisolone was started for the oral treatment group, and a single dose of 0.5 mg/kg triamcinolone acetonide was injected for the intraarticular treatment group. The effect of additional steroid treatment was expected for 2 weeks, then all remaining treatment and natural course groups were sacrificed on the 10th week. RESULTS: After sacrification, specimens taken as "en bloc" scapulothoracic disarticulation were randomly divided into two groups for a range of motion measurement and histopathological examination. The control (frozen shoulder model) group's shoulder range of motion in all directions was lower than the sham (healthy) group (P < 0.01). Natural course and intraarticular steroid groups, compared to the frozen shoulder model showed a significant increase in the direction of abduction (P < 0.05). Also, it was found for treatment groups that in all directions the range of motion was not as good as the healthy values (P < 0.01). The intraarticular treatment group showed higher degrees of abduction compared to the natural course and oral steroid treatment groups (P < 0.01). Oral steroid treatment group's range of motion was not significantly better than the disease model and had no superiority to the natural course group (P > 0.05). Histopathologically, no statistically significant difference was observed between the groups for signs of frozen shoulder which was found in the immobilized group (P > 0.05). Histopathologically, immobilization was found to cause thickening of the capsule that cannot be resolved by treatment. (P < 0.05). CONCLUSION: In frozen shoulder disease, intraarticular steroid injection seems to be superior in increasing the range of motion than oral steroid treatment.

A comparative study on use of two versus three double-loaded suture anchors in arthroscopic Bankart repair.

OBJECTIVES: This study aims to compare clinical results of repair using two versus three double-loaded suture anchors in arthroscopic Bankart repair. PATIENTS AND METHODS: Between July 2012 and December 2017, a total of 40 patients (38 males, 2 females; mean age: 31.6±8.1; range: 17 to 47 years) who underwent Bankart arthroscopic surgery and were followed for minimum two years were retrospectively analyzed. Group 1 (n=17) underwent arthroscopic Bankart repair with two double-loaded suture anchors, while Group 2 (n=23) underwent repair with three double-loaded suture anchors. Clinical outcomes of the patients and recurrences were compared. RESULTS: At the final postoperative follow-up, a significant improvement was observed in the functional outcomes in all patients. No statistically significant difference was found (p>0.05) in the mean clinical scores of the Constant Shoulder Score between Group 1 (94.2±7.8) and Group 2 (95.4±4.1). There was no significant difference in the mean Rowe scores (Group 1: 95.6±4.6 vs. Group 2: 96.3±3.8, respectively) and external rotation loss (at neutral Group 1: 1.9° vs. Group 2: 2.2°, respectively). Three of our patients had recurrent dislocation during a major traumatic event (n=2 in Group 1 and n=1 in Group 2). CONCLUSION: Our study results suggest that stability is not correlated with the use of either two versus three double-loaded suture anchors in arthroscopic Bankart repairs.

Supramalleolar osteotomy with a hexapod type external fixator for the treatment of ankle joint three planar deformity: Case report.

The varus ankle deformity can lead to osteoarthritis; therefore, numerous supramalleolar tibia osteotomy techniques are described to correct this deformity. Many of these techniques are more suitable for uniplanar ankle deformity. Particularly, if there are multiplane ankle deformities, the use of the six-axis deformity correction system may be successful in solving the problems which may occur during the correction. In this article, we report two cases of three plane deformities of ankle joint due to trauma sequelae, which were treated with supramalleolar osteotomy using a hexapod fixator which is called the Smart Correction Frame®.

Restoration of pull-out strength of the failed pedicle screw: biomechanical comparison of calcium sulfate vs polymethylmethacrylate augmentation.

OBJECTIVE: The aim of the present study was to compare calcium sulfate (CAS) and polymethylmethacrylate (PMMA) bone cements used for the augmentation of a failed pedicle screw with biomechanical pull-out strength (POS) testing. METHODS: Thirty lumbar vertebrae were harvested from 6 calves and bone mineral densities (BMD) were measured. Primary polyaxial pedicle screws were randomly inserted and pulled out and the POSs of the specimen were recorded. For revision, specimens were randomly assigned to the CAS-augmented pedicle screws group (Group 1) or PMMA-augmented pedicle screw group (Group 2). Pull-out tests were repeated to compare both groups. RESULTS: Mean BMD of the specimens was 1.006 ± 0.116 g/cm(2). There were no statistically significant differences between BMD results of the two groups (p=0.116). For Group 1, mean POS of primary screws was 2,441.3 ± 936.4 N and was 2,499.5 ± 1,425.1 N after CAS augmentation, demonstrating no statistically significant difference (p=0.865). In Group 2, mean POS of the primary screws was 2,876.6 ± 926.6 N and significantly increased to 3,745.5 ± 1,299.2 N after PMMA augmentation (p=0.047). There was also a significant difference in mean POS between the CAS and PMMA groups (p=0.026). CONCLUSION: Although CAS augmentation facilitates a revision screw POS as strong as that of primary screws, it is not as strong as PMMA augmentation.

The effects of extracorporeal shock waves on carrageenan-induced Achilles tendinitis in rats: a biomechanical and histological analysis.

OBJECTIVE: The aim of this study was to investigate the influence of low-dose extracorporeal shock waves (ESW) on the healing potential of Achilles tendinitis in the rat. METHODS: The 36 adult Sprague-Dawley rats used in this study were randomly divided into four groups. Group A (n=10) were injected with carrageenan, Group B (n=10) were injected with carrageenan and received ESW, Group C (n=10) received ESW only, and Group D (n=6) was a sham group. Rats were injected with 10 microliters of 3% carrageenan or a saline solution eight times during a one-week period with a subcutaneous needle. One week following the final injection, ESW was applied at a rate of 500 impulses in 5 minutes at 2 bars (comparative to 0.09 mJ/mm²) to rats in Groups B and C. Rats were sacrificed three weeks later. Tensile strength, inflammation, and vascularity and collagen density were measured. RESULTS: Failure of the tendon ultimate loads was significantly lower in the study groups than in the control group (p<0.05). Collagen fiber density was higher in the control group than in the other groups (p=0.59). No other histological differences were found. CONCLUSION: Low-dose ESW has a negative effect on tendon tensile strength in this animal model.

Extracorporeal shock waves in articular cartilage defects in the rats.

Thirty adult Sprague-Dawley rats were used to assess the nature of healing tissues in hyaline cartilage defects and to compare the healing in defects treated with shock waves, with those in defects without treatment. A 2 × 2 mm cartilage defect with exposed cancellous bone was created in a nonweight-bearing area of each medial femoral condyle. Each right knee defect was received extracorporeal shock waves (Swiss Dolorclast) of 500 impulses in 5 min at 2 bar (comparative to 0.09 mJ/mm(2)), and the left knee defects were assigned as controls. The rat groups were sacrificed at 6 and 12 weeks postsurgery. Sections from each knee were stained with hematoxylin-eosin to analyze synovial adhesion, synovial thickness, bone maturation, and chondroid metaplasia and with masson trichrome to analyze collagen fiber intensity. There was not a significant difference found between the study and control groups (P > 0.05). Extracorporeal shock waves did not effect healing of the chondral defects.

[Elastofibroma dorsi: an unusual cause of shoulder pain]. / Elastofibroma dorsi: Nadir görülen bir omuz agrisi nedeni.

OBJECTIVES: We evaluated patients who underwent surgical treatment for elastofibroma dorsi (ED). METHODS: The study included 13 patients (11 women, 2 men; mean age 54 years; range 43 to 74 years) who were treated surgically for ED that caused persistent symptoms. Involvement was on the right in six patients, on the left in five patients, and bilateral in two patients. All the patients presented with a mass lesion that became apparent at the lower corner of the scapula on shoulder flexion and adduction. The complaints were swelling and pain on the back in nine patients, and a snapping sound on shoulder movements together with pain in four patients. Diagnosis of ED was made by magnetic resonance imaging (n=10) and computed tomography (n=3), with no utilization of preoperative biopsy. Marginal tumor excision was performed in all cases. Evaluation for recurrence was made by ultrasonography. The mean follow-up period was 32 months (range 8 to 90 months). RESULTS: All the masses were located at the inferior corner of the scapula, with adherence to the thorax between the serratus anterior, rhomboid, and latissimus dorsi muscles. The mean size of the surgical specimens was 9 x 6 x 3 cm (range 5 x 3 x 1 to 14 x 8 x 3 cm). Clinical diagnosis was confirmed by histopathologic examination in all cases. All major complaints resolved after surgery. Hematoma occurred in four cases postoperatively, but resolved without the need for surgical intervention. No recurrence was observed. CONCLUSION: Even though ED is a rare clinic entity, it should be recalled while evaluating shoulder pathologies. Marginal excision is adequate for the treatment of patients with sustaining complaints.

[The effects of two different fixation methods on femoral bone tunnel enlargement and clinical results in anterior cruciate ligament reconstruction with hamstring tendon graft]. / Hamstring tendon otogrefti ile yapilan ön çapraz bag rekonstrüksiyonunda iki farkli tespit yönteminin femoral kemik tünel genislemesi ve klinik sonuçlar üzerine etkisi.

OBJECTIVES: We investigated the effects of anatomic and non-anatomic tunnel fixations on femoral tunnel widening and clinical results in anterior cruciate ligament (ACL) reconstructions. METHODS: We retrospectively evaluated 35 patients who underwent arthroscopic ACL reconstruction with quadrupled hamstring tendon graft. Fixation was performed in the tunnel using the transcondylar RigidFix pin (group 1) in 18 patients (mean age 32 years), and from outside the tunnel using the EndoButton-CL device (group 2) in 17 patients (mean age 30 years). The patients were assessed using the IKDC (International Knee Documentation Committee) and Lysholm knee scores and tunnel widening was assessed by computed tomography. Ligament laxity was measured bilaterally using the Rolimeter knee tester. The mean follow-up was 24 months (range 21 to 38 months) in group 1, and 24.6 months (range 12 to 36 months) in group 2. RESULTS: The two groups were similar with respect to age and sex distribution, operated side, the size of the tunnel created, and follow-up period (p>0.05). Postoperative knee scores did not show a significant difference (p>0.05). There was marked and excessive tunnel enlargement in 14 patients (77.8%) in group 1, and in 15 patients (88.2%) in group 2, with no significant difference between the two groups (p>0.05). Ligament laxity exceeded 3 mm in eight patients (44.4%) in group 1, and in three patients (17.7%) in group 2 (p<0.001). There was no relationship between tunnel widening and ligament laxity (p>0.05; r=0.175 and r=-0.01 for group 1 and group 2, respectively). CONCLUSION: Our results suggest that differences in the localization of the tunnel fixation have no effect on tunnel enlargement and that joint laxity may be affected by biomechanical properties of fixation materials.

[Early results of treatment of proximal humerus fractures with the PHILOS locking plate]. / Proksimal humerus kiriklarin PHILOS plagi ile tedavisinde erken dönem sonuçlarimiz.

OBJECTIVES: The aim of this study was to evaluate early results of proximal humerus fractures treated with the PHILOS locking plate. METHODS: Proximal humerus fractures of 22 patients (13 males, 9 females; mean age 57 years; range 35 to 83 years) were treated with the PHILOS locking plate. According to the Neer classification, 13 patients had comminuted fractures, four patients had valgus impact injuries, two patients had fracture-dislocations, and three patients had fractures involving the proximal 1/3 of the humerus. The fractures were reduced by the transdeltoid lateral approach (n=8) using minimally invasive surgery, and by the anterior deltopectoral approach (n=14) using open surgery. Passive and active exercises were initiated on the second postoperative day and after 4 to 6 weeks, respectively. The results were assessed using the Constant-Murley shoulder scoring system. The mean follow up was 14 months (range 12 to 19 months). RESULTS: Radiographically, union was observed in 20 patients at the end of 10 weeks. In one patient, time to union was 16 weeks. One patient underwent autogenous bone grafting because of nonunion after 16 weeks. The mean Constant-Murley score was 75.5 (range 51 to 93). There was no significant difference between Constant-Murley scores of patients undergoing the transdeltoid lateral and anterior deltopectoral approaches (p>0.05). Plate fixation was associated with minimal varus deformity in two patients, and subacromial impingement in one patient. Implant failure did not occur. Reflex sympathetic dystrophy and avascular necrosis were observed in two patients, respectively. CONCLUSION: Fixation with the PHILOS plate is a near-ideal technique with a high union rate in the treatment of proximal humeral fractures.

[Blumensaat line and patellar height]. / Blumensaat çizgisi ve patella yüksekligi.

OBJECTIVES: We investigated the agreement between the Blumensaat method and patellar height ratios and evaluated the reliability of the method in patellar height measurements. METHODS: We retrospectively evaluated 105 digital knee x-rays of 77 patients (23 males, 54 females; mean age 32 years; range 21 to 62 years), whose radiographs were obtained at 30 degrees of knee flexion. Patellar heights were measured with the use of the Blumensaat, Insall-Salvati, modified Insall-Salvati, and Blackburne-Peel methods. Patellar height was also evaluated after standardization of the angle between the femoral shaft and the Blumensaat's line (corrected Blumensaat method). Agreement and correlations were sought between the qualitative and quantitative results of the methods, respectively. RESULTS: When the qualitative results were considered, agreement of the Blumensaat method was very weak with the Insall-Salvati, modified Insall-Salvati, and Blackburne-Peel methods (kappa coefficients: 0.21, -0.14, and 0.12, respectively). The corrected Blumensaat method also had a very weak agreement with the other indices (kappa coefficients: 0.27, -0.11, and 0.13, respectively). Correlation analyses of the quantitative results showed very weak to moderate correlations between the methods used. The Blumensaat method was relatively well correlated with the modified Insall-Salvati method (r=0.514, p<0.05). Correlations were weak to moderate between the patellar height indices, the highest correlation being between the modified Insall-Salvati and Blackburne-Peel methods (r=0.557, p<0.05). CONCLUSION: The results of the patellar height measurements obtained by the Blumensaat method do not agree with widely used patellar height indices.