Evaluation of the orthopaedics and traumatology resident education in Turkey: A descriptive study.

OBJECTIVE: The objective of this study is to describe the current situation regarding the training, working conditions, future plans, fields of interest and satisfaction of orthopaedics and traumatology residents in Turkey. METHODS: A descriptive survey questionnaire consisting of 24 questions was designed to identify the problems and solution suggestions concerning training of orthopaedic residents. All orthopaedics and traumatology residents who took the 2013 Progress Testing for Speciality in Medicine (UEGS) held by Turkish Orthopaedics and Traumatology Education Council (TOTEK) were surveyed in the class at the end thereof as well as the young orthopaedic surgeons who were reached through the email groups of Turkish Society of Orthopaedics and Traumatology - Residents and Young Attendings Council (TOTBID-AGUH). RESULTS: A total of 725 residents and 132 young attendings were surveyed. The most outstanding answers are as follows: 62,7% of the respondents replied to the question "Is there a training program/Is it being applied" as "yes/yes". It was found out that 94,3% of the respondents wanted to be involved in a rotation abroad. The "patient care" was the most common answer, with a ratio of 36,9%, to the question "What's the priority of the department you are studying in?". Regarding work conditions, "many emergency on-calls" was found to be the most important parameter affecting life conditions (p < 0.05). CONCLUSION: Aiming to identify the challenges that orthopaedics and traumatology residents in Turkey face as regards their training, this survey stands as a pioneering study with a high participation rate. Analysis of survey data highlights the importance of several key factors such as the development of training programs and increasing the time spent with academicians as well as spreading and promotion of log book application.

An alternative patellar resurfacing technique in knee replacement: patellofemoral fascial interposition arthroplasty.

The present study reports the early clinical results of 38 osteoarthritic patients (38 knees) who were treated by total knee replacement in conjunction with patellofemoral fascial interposition arthroplasty (PFIA). After the femoral and tibial components were inserted, a fasciotendinous graft was harvested from the anterior surface of the quadriceps tendon and sutured around the articular surface of the patella. The patients were followed-up for a minimum of 24 months. The durability of the fascial graft was assessed radiographically by addition of a wire suture marker placed into the fascia in the first five patients. Patients were evaluated using the Hospital for Special Surgery (HSS) knee-rating system, and anterior knee pain was assessed using specific patellofemoral-related questions. The average HSS knee score improved from 61 points preoperatively to 92 points at 24 months' follow-up (P<0.001). Twenty-five patients (65.7%) had anterior knee pain preoperatively, and seven patients (18.4%) revealed anterior knee pain at their last visits (P<0.001). The position of the markers in the fascial grafts did not show any change during radiological follow-ups. Our data suggest that, PFIA provides good pain relief and it may be an alternative resurfacing technique avoiding the complications of patellar components.

Intra-articular injection of tenoxicam in osteoarthritic knee joints with effusion.

Thirty patients who had grade II to III osteoarthritis according to Kellgren-Lawrence system and presenting with acute effusion of the knee joint were randomly assigned to 2 groups. All patients were treated with aspiration of the synovial fluid, cold application, and rest. Fifteen patients received an intra-articular injection of tenoxicam 20 mg following aspiration. The other group was administered oral tenoxicam 20 mg a day for 10 days. Patients were examined at 2, 4, and 8 weeks and then in 3-month intervals. At followup visits, pain was assessed using visual analog scale: range of motion, and effusion of the knee joint were recorded. A repeated measure test was used to determine the significance of changes in pain and mobility between the groups. Student's Neyman Keuls test was used to determine the significance of differences within the groups. Chi-square test was used for the number of episodes. The intra-articular injection group had more rapid pain relief than the oral treatment group (P < .01). At the end of 1 year, the number of effusions was significantly lower in the intra-articular treatment group (P < .01). These results indicate that intra-articular injection of tenoxicam provides rapid pain relief in the patients with acute flare-up of knee osteoarthritis and helps to prevent effusion.

Histoacryl glue in meniscal repairs (a biomechanical study).

The purpose of this study was to investigate the biomechanical efficacy of Histoacryl (cyanoacrylate, N-asetil 2 butyl sistein) in meniscal tear repair. In our study, the primary stability of three different repair techniques in delaying the formation of a gap of 2 mm was investigated. A meniscal tear was repaired with two vertical sutures and Histoacryl in the first group; it was repaired only with Histoacryl in the second group, and with only two vertical sutures in the third group. Menisci were then placed in a tensile loading machine, and the primary stability of the repair zones was measured until a displacement of 2 mm occurred. Biomechanical force was significantly (P<0.05) high (112.0+/-17.20 N) in all groups when vertical suture and Histoacryl glue were used together during displacements of 0.5, 1.0, 1.5 and 2.0 mm. We believe that Histoacryl is superior to vertical sutures regarding gap delaying. It potentiates the effect of vertical suture strength, permits early motion and thus merits an in vivo study.

The effect of pentoxifylline in treatment of skin degloving injuries: an experimental study.

BACKGROUND: Management of skin degloving injuries is still a problematic issue and the avulsed part of the skin may become necrotic. In this pilot study, we attempted to develop an experimental model for degloving injuries and investigated the efficacy of pentoxifylline, a well-known potent agent in enhancement of erythrocyte flexibility and tissue vascularization, in treatment of this injury model. METHODS: Degloving injuries were created in 15 rats' tails by circular puncturing of the skin at the middle of the tail and then applying moderate force to avulse the skin from the underlying tissue. Then, the skin was repaired back to its original position. No treatment was given in the first group (n=6). In the second group (n=3), 0.4cm(3) physiological serum was administered intraperitoneally for 10 days. In the third group (n=6), intraperitoneal 25mg/kg pentoxifylline was administered for 10 days. Tails were observed daily for 21 days and then examined histopathologically. RESULTS: At the end of the study, the avulsed segment of the skin became cyanotic and ulcerated in the first and the second group, and in the third group, the skin was intact. In histopathological examination, loss of superficial ephitelium and dense infiltration of inflammatory cells were seen in groups 1 and 2, and the skin layers were normal in the group 3. CONCLUSION: Pentoxifylline improved tissue preservation and was proved to be highly beneficial in treatment of skin degloving injuries.

Early internal fracture fixation prevents bacterial translocation.

The aim of our study was to determine whether early internal fixation of major bone fractures helps prevent bacterial translocation in patients with multitrauma. Thirty-seven Sprague-Dawley rats were divided into three groups: (1) anesthesia only (n = 12); (2) the trauma group: tibia and femur fractures and moderate head trauma under anesthesia (n = 14); and (3) the fixation group: fixation of tibia and femur fractures and moderate head trauma under anesthesia (n = 11). After 24 hours, mesenteric lymph nodes, liver, spleen, and systemic blood samples were quantitatively cultured. The terminal ileum was assessed histopathologically. The incidence of bacterial translocation was less in the anesthesia group (two of 12 rats) and the fixation group (two of 11 rats) than in the trauma group (10 of 14 rats). The number of organs containing viable bacteria was significantly lower in the fixation group than in the trauma group. Histopathologically, villous architecture was preserved mostly in the fixation group; however, marked mucosal damage was detected in the trauma group. Our data suggest early internal fixation of long bone fractures in polytraumatized experimental animals with head injury results in preservation of the intestinal mucosal barrier and decreased bacterial translocation from the gut.

Effect of patient age and symptom duration on subjective and objective outcomes of carpal tunnel surgery.

This study prospectively examined the relationship between patient age and symptom duration on surgical outcome of carpal tunnel syndrome. Surgical outcomes were evaluated using both subjective and objective measures and statistical analysis was performed using canonical analysis. The result revealed patient age and symptom duration have significant effects on bot subjective and objective outcomes of carpal tunnel surgery.

[The use of N-butyl-2-cyanoacrylate (Histoacryl) in primary tendon repair: a biomechanical study with sheep flexor tendons]. / Tendon onariminda N-butil-2-siyanoakrilat (Histoakril) kullanimi: Koyun fleksör tendonuyla biyomekanik çalisma.

OBJECTIVES: In this study, the biomechanical properties of peripheral tendon repair with the use of epitendinous suture technique and N-butyl-2-cyanoacrylate (Histoacryl) (NBSA), a biodegradable glue, were compared. METHODS: Twenty-four flexor tendons were harvested from sheep hind limbs. Following transection of the tendons, 12 tendons (group 1) were repaired with modified Kessler core sutures using no 2 prolene and epitendinous running sutures with 3/0 prolene. In the other 12 tendons (group 2), NBSA was applied between the cut surfaces before placing modified Kessler core sutures. Placed on an hydrolic test machine, half of the tendons from each group were subjected to load to failure with a tensile force of 20 mm/min and the other half to cyclic loading with a tensile loading between 1-15 N at a rate of 20 cycles/min. Observation of a gap of 1 mm between the tendon ends in each test was regarded as repair failure. RESULTS: The mean load to failure was 27.3 N (range 25 to 32 N) for group 1 and 50.4 N (range 32 to 63 N) for group 2 (p=0.022). The mean number of cycles at failure was 140 (range 45 to 250) in group 1 and 350 (range 150 to 600) in group 2 (p=0.032). CONCLUSION: Our results showed that peripheral tendon repair with the use of NBSA has biomechanical advantages over repair with the epitendinous running suture technique.

Topographic localization of the motor branch of the median nerve.

PURPOSE: To redefine the localization of the thenar branch (TB) of the median nerve in relation to the surface landmarks that are in routine use. METHODS: The study was performed in 37 hands of 34 patients who had carpal tunnel release. All of the patients were women and the mean age was 50 years (range, 35-67 y). A radiologic marking technique was used to determine the localization of the TB, the middle finger radial side line, and Kaplan's cardinal line. The TB was marked by circumscribing with a soft radiopaque yarn and the surface landmark lines were shown by taping a K-wire to the hand for each line. An image-intensifier-printed image was obtained for each case and the distances between the markers of the TB and the wires were measured. RESULTS: The TB had a mean ulnar offset of 12.6 mm (range, 4.0-19.7 mm) from the middle finger radial side line and was located 4.4 mm (range, 0-9.5 mm) proximal to the cardinal line. CONCLUSIONS: During carpal tunnel release surgery the surgeon must pay more attention to the localization of the TB of the median nerve because it was found to be 12.6 mm more ulnar than the location described in the literature.

Clarithromycin destroys biofilms and enhances bactericidal agents in the treatment of Pseudomonas aeruginosa osteomyelitis.

In this study, the effect of clarithromycin on the destruction of bacterial biofilm in Pseudomonas aeruginosa osteomyelitis was investigated. Foreign body-related osteomyelitis caused by ceftazidime-sensitive Pseudomonas aeruginosa was produced in the tibias of 26 rats. After osteomyelitis was verified on Day 14, 10 rats had ceftazidime (1500 mg/kg/day) given subcutaneously, and 10 rats had ceftazidime given subcutaneously and clarithromycin (100 mg/kg/day, two 50-mg/kg doses every 12 hours) given orally; three rats formed the control group. After a treatment period of 20 days, the tibias and the foreign bodies were removed, cultured, and examined by electron microscopy. The number of microorganisms growing on the bone tissue in the group receiving combined treatment was significantly lower than in the other groups. The number of microorganisms growing on the foreign body in the group receiving only ceftazidime was significantly higher than that of the group receiving combined treatment. Electron microscope examination revealed that the biofilm layer was eradicated in the group that had combined therapy; however, biofilm formation was evident on the foreign body in the group receiving only ceftazidime. Clarithromycin enhanced the activity of concomitantly used bactericidal agents by destroying biofilm on the surface of the materials.

The anterior center edge angle: a study of 102 volunteers.

OBJECTIVES: To measure the anterior center edge (VCE) angle that reflects anterior coverage of the femoral head. PATIENTS AND METHODS: False profile views of both hips of 102 volunteers, 23 male and 79 female, were taken between October 2000 and October 2001. Radiographs with evidence of degenerative hip disease and those with poor image quality were excluded from the study. This left 181 radiographs. RESULTS: An orthopedic surgeon and a radiologist used a standard protractor to examine each of the 181 radiographs twice, at an interval of 24 h. The mean VCE angle was 49.27 +/- 7.77 degrees (range, 24.75-68.75), a value different from those found in previous studies. No significant intraobserver or interobserver differences were found. CONCLUSIONS: Our findings may contribute to the determination of a new parameter for evaluating anterior femoral head covering. In patients with acetabular dysplasia and deficient anterior coverage, this parameter may prove useful for selecting patients for surgery, planning the procedure, and evaluating postoperative results.

Head injury-associated bone fractures induce bacterial translocation: an experimental study.

OBJECTIVES: To determine whether long bone fractures cause bacterial translocation and to investigate the effect of concomitant head trauma on this process. DESIGN: An in vivo animal model. SETTING: Animal Laboratory, University of Mersin School of Medicine, Mersin, Turkey. SUBJECTS: Male Sprague-Dawley rats (n = 60). INTERVENTION: Sixty male Sprague-Dawley rats were divided into five groups: (1). anesthesia only (control group, n = 12); (2). anesthesia and tibia fracture (n = 12); (3). anesthesia, tibia fracture, and femur fracture (n = 12); (4). anesthesia, tibia fracture, femur fracture, and moderate head trauma (n = 12); and (5). moderate head trauma only (n = 12). After 24 hours, mesenteric lymph nodes, liver, spleen, ileum, and systemic blood samples were quantitatively cultured for aerobic organisms. MAIN OUTCOME MEASUREMENTS: Colony-forming unit per gram for bacteria count. RESULTS: The incidence of bacterial translocation was higher in groups that had fractures (4/12 in group 2; 5/12 in group 3) than in the control group (2/12); however, this did not reach statistical significance. There was a significant increase in the number of subjects with bacterial translocation in group 4 (9/12) compared with the control group and group 5 (3/12) (P = 0.0123, P = 0.0391). CONCLUSIONS: Multiple fractures of long bones associated with head injury promote bacterial translocation.

Late psychosocial effects of congenital hand anomaly.

Lifetime-standing psychosocial effects of congenital hand anomalies are inevitable in patients who have not received a comprehensive treatment with appropriate timing and approach. Herein, two adult cases of untreated thumb polydactyly are presented. Both of them had hands with striking appearance and late consequent psychosocial problems.

Involvement of the proximal tibiofibular joint in osteoarthritis of the knee.

This study was performed to evaluate the possible involvement of the proximal tibiofibular joint in primary osteoarthritis of the knee. A total of 40 patients with primary osteoarthritis of the knee who had magnetic resonance imaging scans were reexamined for proximal tibiofibular joint involvement. The patient was questioned if pain was present in the proximal tibiofibular joint while at rest, when walking and climbing stairs. Symptoms were evaluated by applying moderate compression over the proximal tibiofibular joint during active ankle and knee motions. Magnetic resonance imaging scans were reexamined by two radiologists. Three of the 40 patients had minimal or moderate pain in the proximal tibiofibular joint during stair-climbing and on clinical examination. Magnetic resonance imaging scans of these three patients revealed osteophyte or subchondral cyst formation, or both. Degenerative changes in the proximal tibiofibular joint may be evident in association with osteoarthritis of the knee and may result in lateral-sided pain at the knee.

[The development of the wrist joint in the fetal period]. / El bilegi ekleminin fetal dönemdeki gelisimi.

OBJECTIVES: This study was designed to investigate the development and anatomical features of the wrist joint, particularly the scapholunate ligament and triangular disc in the fetal period and to identify possible congenital variations. METHODS: The study included 16 wrist joints of eight fetuses aborted at ages 8 to 14 weeks. The samples had no macroscopically discernible anomalies. Tissue specimens were fixed in 10% formalin solution, embedded in paraffin, and mounted on a microtome to obtain 5-micron sections in the coronal plane. Following staining with hematoxylin and eosin, conventional light microscopic examinations were performed. RESULTS: Organization of the carpal ligaments in the wrist joint began on the radial side in the 9th week. In the 10th week, the scapholunate ligament was formed; a membranous structure was observed, which lied from the interfacet prominence of the radius to the scapholunate ligament and divided the wrist joint into two cavities. The triangular disc formation began to appear at this stage. During the 11th and 12th weeks, the membranous structure underwent regression from the dorsal to the volar aspects, and at the end of the 14th week, the wrist joint became a single cavity. Also noted was the development of fibrous appearance of the scapholunate ligament and the triangular disc into fibrocartilage. Vascular areas were identified on the radial rather than the ulnar side of the scapholunate ligament, but vice versa for the triangular disc. Bicompartmental structure seemed to persist in the wrist joint of a 14-week-old fetus. CONCLUSION: In this study, we demonstrated that the scapholunate ligament and the triangular disc were not homogeneous in the fetal period in terms of vascularity and cellularity. We speculate that a plica-like membranous structure may persist in the wrist joint as a remnant of the fetal life. An accurate knowledge of the anatomy is necessary for the treatment planning and arthroscopic interpretation of the wrist joint.

Measurement of the humeral head retroversion angle. A new radiographic method.

BACKGROUND: In this study, a simple and reliable radiographic method is described to determine the torsional profile of the humeral head. METHODS: First, by using a specially developed frame, the humeral head retroversion angles (HRAs) of 20 dry humeri were measured by an anatomist and an orthopedist. Then the HRA of these humeri were measured by two orthopedists on radiographs taken in semi-axial view when the humeri were in 20 degrees abduction. RESULTS: The results were assessed with the SPSS 9.05 program, and the repeatability coefficient of both methods was 98%. The average difference in angle determination between the two methods was 0.9 degrees; the maximum difference was 3 degrees. After that, posteroanterior semi-axial radiographs of both humerus bones of 40 healthy volunteers were taken by positioning their arms in 20 degrees abduction to the X-ray axis. The mean HRA difference between the right and left sides was 0.4 degrees (maximum difference 3 degrees ) and is of no clinical significance. It was determined that left and right HRAs can be taken as a reference to each other. For measurement of the HRA in the planning of proximal humeral rotation osteotomy and prosthesis replacement arthroplasty, the presented radiographic method can be used with a high rate of accuracy.

Nerve entrapment in painful heel syndrome.

Subcalcaneal heel pain is one of the most common foot ailments, yet the exact etiology is still controversial. Nerve entrapment has been suggested as one of the possible causes of this painful condition in recalcitrant cases. The purpose of this study is to determine the role of nerve entrapment in painful heels. Twenty patients with heel pain (25 heels) were compared with an age and body mass index-matched control population using electrodiagnostic methods. The results of the study revealed 22 heels (88%) with heel pain had lateral plantar nerve entrapment signs with or without medial plantar nerve findings on EMG. There were no abnormal values in the control group. Nerve entrapment syndrome has previously been considered only in cases with intractable heel pain, but this study suggests that it may play a role the early phases of painful heel syndrome.