Orthopedics and Traumatology Residency - Working Conditions, Training, and Psychological Stress.

PURPOSE OF THE STUDY The specialty of orthopedics and traumatology that is completed in the 5 years period in our country is a challenging educational process and our purpose in this study is to demonstrate through a survey training conditions of the orthopedic assistants in our country and the effects of this process on assistants. MATERIAL AND METHODS 524 (70.05%) of 748 assistants who receive specialization training in Turkey were reached. There were 20 multiple choice questions ( 1 mark each) and 3 questions (more than 1 mark each) in the survey consisting of twenty-three questions. Our study group was formed by doctors who have still worked as assistant in our country and have accepted to participate in the study. The doctors who finished assistantship with any reason and did assistantship for time less than 6 months and did not exactly fill the questionnaire form were excluded from the study. RESULTS 524 (71.97%) of 728 assistant who are in 40 (100%) of 40 provinces where assistant training given in Turkey were reached. 474 (90.45%) participants were satisfied to do orthopedic specialization. When considering working hours, it was observed that 337 (64.31%) participants had over 90 hours weekly including night shift and 521 (99.42%) participants had to work after night shift. The majority of participants (361 persons 68.89%) were receiving salaries between TL 4000-6000. When looking at the entire working group, the rate of participants who said that scientific training is weak or there is no scientific training was 427 (81.48%). CONCLUSIONS Our survey study is one of the first statistical study which investigating professional and social problems of orthopedic assistants. Some of important problems as training satisfaction, abuse by patients and/or manager, the average monthly income and psychological status assessment is emphasized. Orthopedics and Traumatology assistantship is a challenging process to cause physical and psychological problems with the hard working conditions in our Turkey. Key words:residency training, orthopedic surgery, life quality, salary.

The Effect of Incorrect Foot Placement on the Accuracy of Radiographic Measurements of the Hallux Valgus and Inter-Metatarsal Angles for Treating Hallux Valgus.

PURPOSE OF THE STUDY Accurate radiographic measurements are crucial in treating hallux valgus (HV). This three-dimensional deformity should not be evaluated from one joint on one plane. However, in practice, surgeons measure the deformity only on transverse dorsoplantar radiographs. We determined the amount of error associated with positioning the foot incorrectly on radiographs. MATERIAL AND METHODS To simulate incorrect positions of the foot in radiographic evaluation, we designed an angled device that can move in transverse and frontal plane. In four patients with symptomatic HV, we took weight-bearing radiographs of the involved foot in seven different positions. These 28 radiographs were given identifying but meaningless labels. On each radiograph, six surgeons blinded to the position of the radiograph measured the HV angle (HVA) and the inter-metatarsal angle (IMA) and state the treatment plan according to five treatment options were given to participants. RESULTS Inter-observer agreement was high for measurements of HVA and IMA in all positions (interclass correlation coefficients, 0.96 and 0.88, respectively). However, intra-observer agreement was poor for HVA (intra-observer agreement, 0.17) but good for IMA (intra-observer agreement, 0.64). According to the measurements in different positions, intra-observer treatment choices revealed moderate results (ICC: 0.524). Clinical Relevance Radiographic measurements are very important on the treatment decisions of hallux valgus. The foot position can influence the measurement accuracy and can cause incorrect decisions. In this study, we evaluated the impact of foot positions on measurements of hallux valgus angle and inter-metatarsal angle. Additionally, we evaluated the incorrect foot positioning on treatment decisions. Moreover, we analyzed intra-observer and inter-observer agreements of these angles in various positions. CONCLUSIONS We recommend that measurements of IMA are more reliable than those of HVA for managing hallux valgus in terms of false weight bearing radiographs taken in different positions. Positional changes during foot radiographs could lead clinicians to perform incorrect HVA and IMA measurements. This could change the treatment option. HVA measurements were more affected with foot positioning. It is important to take full weight bearing foot radiographs in correct technique. Key words: hallux valgus, radiology, data accuracy.

The effectiveness of erector spinae plane block in patients with chronic low back pain.

OBJECTIVE: The erector spinae plane block (ESPB) has been widely used as a treatment strategy for a variety of acute and chronic painful conditions. The purpose of this study was to determine the analgesic efficacy of ESPB in patients with chronic low back pain and radicular symptoms who had lumbar disc herniation. PATIENTS AND METHODS: Patients aged 18 to 80 years who had chronic low back pain with radicular symptoms associated with pain from lumbar disc herniation and had undergone ESPB were included in the study retrospectively. As part of a routine clinical procedure, the patient's age, gender, weight, height, body mass index, injection site, level of the injection, disc herniation level and visual analog scale score, Oswestry Disability Index, and five-point patient satisfaction questionnaire were recorded before and following the procedure. RESULTS: A total of 96 patients were included in this study. The mean age was 52.28±14.12 and 55 (57.3%) of the patients were female. The mean visual analog scale value and Oswestry Disability Index score were significantly decreased consecutively after the procedure (p<0.05). The mean patient satisfaction questionnaire score increased gradually compared to the baseline scores (p<0.05). CONCLUSIONS: Our results suggest that ESPB is an effective strategy to reduce the intensity of chronic low back pain with radicular symptoms in patients with lumbar disc herniation.

Are differences in shoulder morphology and hand dominance risk factors for rotator cuff tears?

OBJECTIVE: The purpose of this study was to evaluate whether there was a difference in shoulder morphology and hand dominance between a healthy shoulder and a shoulder with rotator cuff tear (RCT) in the same patient. PATIENTS AND METHODS: Between 2015 and 2020, 120 shoulders from 60 patients with complete RCT and contralateral intact rotator cuffs were enrolled in this retrospective analysis. Physical examinations, shoulder radiographs, and magnetic resonance imaging (MRI) pictures of the patients were reviewed. On radiographs, the AT, CSA, LAA, and AI values were compared between shoulders with complete RCT and contralateral healthy shoulders from the same individuals. Additionally, the association between hand dominance and RCT was evaluated. RESULTS: This study enrolled 60 patients. 59.17% of the participants are female, and 40.83% are male. The mean age of the patients was 54.5±7.1 years. There were statistically significant differences in AI, CSA, and LAA measurements between the study group (RCT group) and the control group. There was no significant difference in AT between the two groups. CONCLUSIONS: There are morphological differences between a healthy shoulder and a shoulder with an RCT in the same patient, and these differences (LAA/CSA/AI/AT) may have an effect on the prevalence of RCT.

A comparison of isokinetic muscle strength in patients with chondromalacia patella: a cross-sectional study.

OBJECTIVE: Chondromalacia patella (CMP), which is one of the most common causes of anterior knee pain in young adults, is often accompanied by reflex inhibition of the quadriceps muscle. In this respect, a significant correlation between isokinetic parameters and knee muscle strengths would be expected. We hypothesized that an isokinetic dynamometer, which objectively evaluates muscle strength, may be an important guide in detecting muscle weakness in new-onset CMP and determining early treatment strategies. PATIENTS AND METHODS: A total of 113 participants (mean age 30.33 ± 6.96 years, min: 18, max: 44) were recruited and divided into two groups, thus a CMP group (n=48) and a control group (n=65). The symptom duration of the CMP group and the demographic characteristics of all participants were recorded. Knee flexion and extension muscle strengths were measured at angular velocities of 60°/s and 180°/s [Knee extension Peak Torque at 60°/s (PTE60), Knee flexion Peak Torque at 60°/s (PTF60), Knee extension Peak Torque at 180°/s (PTE180), Knee flexion Peak at 180°/s (PTF180) respectively] (five sets) using an isokinetic dynamometer. We also recorded the total work done in flexion and extension (TWDF and TWDE). A modified MRI staging system based on the Outerbridge arthroscopy system was used to stage CMP. Isokinetic dynamometric parameters were compared between CMP patients and healthy volunteers. RESULTS: 59 healthy volunteers (90.8%) were right-side dominant and 6 (9.2%) left-side dominant. 33 CMP patients (68.8%) were right-side dominant, and 15 (31.3%) left-side dominant. 20 (41.7%) CMP patients were classified as Stage 1, 20 (41.7%) as Stage 2, and 8 (16.7%) as Stage 3. All the PTF60, PTE60, PTF180, and PTE180 values were significantly lower in the CMP group than in healthy controls (all p < 0.05). CMP symptom duration ≥ 6 months was associated with significantly lower knee muscle strength than with symptom duration < 6 months (p < 0.05). Also, a statistically negative correlation was found between MRI stages and PTE60 values (p < 0.05). CONCLUSIONS: In conclusion, our findings show that the isokinetic dynamometer reveals muscle weakness in CMP patients, and weakness in isokinetic parameters was negatively correlated with symptom duration and MRI stages. Isokinetic knee muscle strength testing, together with other functional tools, enables the assessment of muscle weakness and early rehabilitation planning for patients with CMP.

Comparison of conservative and surgical treatment in Gartland Type IIB fractures in pediatric patients.

OBJECTIVE: In this study, our aim was to compare conservative treatment and surgical treatment radiologically and clinically in the treatment of pediatric Gartland type IIB SCHF, which is a controversial issue in the literature. PATIENTS AND METHODS: This retrospective study included 86 patients with a Gartland type IIB humerus fracture. Forty-three patients were treated conservatively, and 43 patients were surgically treated. Radiological results were evaluated according to the Baumann angle and anterior humerus line. The Mayo Elbow Performance Score (MEPS) and Flynn's criteria were used to assess the functional evolution. RESULTS: The mean MEPS was 94 for the conservative treatment group and 93 for the surgical treatment group. According to Flynn's criteria, 31 (72.09%) excellent results were obtained in patients who were treated conservatively, and 26 (60.46%) excellent results were obtained in the surgical treatment group. CONCLUSIONS: The conservative and surgical treatment of Gartland type IIB SCHF is not superior to each other if anatomic reduction is achieved. Complications of each treatment can be prevented by following strict treatment principles.

Preserving effects of melatonin on the levels of glutathione and malondialdehyde in rats exposed to irradiation.

In this study we investigated whether pretreatment with melatonin was protective against the injury of the central nervous system (CNS) in rats receiving LD(50) whole body irradiation. The wistar rats were randomized into four groups: i) the control group (CG), ii) melatonin-administered group (MG; 1 mg/kg body weight), iii) irradiated group (RG; 6.75 Gy, one dose), and iv) melatonin-administered and irradiated group (MRG). Blood samples were drawn from the rats 24 h after the treatment and plasma glutathione levels were assayed. Plasma glutathione level was significantly higher in RG than CG. The melatonin pretreatment prevented GSH increase induced by irradiation. Lipid peroxidation and glutathione levels of rat cerebral cortex were determined in all groups after 24 h. Cortical malondialdehyde (MDA) was significantly higher in the RG. The melatonin pretreatment prevented cortical MDA increase induced by irradiation. Cortical GSH was significantly lower in RG than the CG. The melatonin pretreatment prevented cortical GSH decrease induced by irradiation. Tissue samples were obtained from cerebral cortex and hypothalamus which also were affected by ionizing irradiation in the CNS and were evaluated with electron microscopy. Histopathological findings showed that LD(50) whole body irradiation resulted in damage of the neuronal cells of CNS. The results obtained from this study demonstrated that pretreatment with melatonin prevented the damage that develops in CNS following irradiation. The beneficial effect of melatonin can be related to protection of the CNS from oxidative injury and preventing the decrease in the level of cortical glutathione.

Prevention of doxorubicin induced cardiotoxicity by catechin.

Doxorubicin (dox) is an anthracycline antibiotic which is broadly used in solid tumors. Long-term therapy with this drug is accompanied by potentially lethal, dose-dependent side effects. Several reports suggest that oxygen free radicals produced during the metabolic activation of dox may have toxic effects on heart muscle. We tried to protect dox cardiotoxicity in rats using catechin which is a known antioxidant and iron chelating agent. Different dose levels and combinations of catechin and doxorubicin have been studied in different experimental groups. Electrocardiograms, myocardial contractility, body weight and the electron microscope were used to assess the cardioprotective effect of catechin in dox-treated animals. We found significant prevention of dox-induced cardiotoxicity by catechin in rats.

Conjunctival impression cytology in patients wearing contact lenses.

PURPOSE: Evaluation of contact lens-induced cytologic changes on the conjunctival surface. METHODS: Fifty eyes of 25 patients wearing soft or rigid gas-permeable contact lenses, and 50 healthy eyes of 25 control subjects were examined with conjunctival impression cytology. Of the patients wearing contact lenses, 40% did not have any contact lens-related complaints, whereas 60% had some minor complaints related to contact lens intolerance. The material obtained by impression cytology was examined with regard to epithelial cell morphology, goblet cell density, and snake-like nuclear chromatin changes. RESULTS: When epithelial cell morphology was graded according to the system described by Nelson, specimens from the control group revealed 90% of the eyes to be grade 0 and 10% to be grade 1, whereas of the eyes wearing contact lenses, 8% were grade 0, 36% grade 1, 32% grade 2, and 24% grade 3. Thus statistically significant differences were observed between the control group and the contact lens group with regard to each grade (p < 0.05) as well as to the goblet cell densities (p < 0.05). Snake-like chromatin changes, on the other hand, were observed in 30 and 27% of the eyes wearing soft and rigid gas-permeable contact lenses, respectively, whereas these were not encountered in any eye in the control group. CONCLUSION: Epithelial changes were noted to be more frequent and more severe in symptomatic patients than in those without any complaints. No correlation was found between average duration of contact lens wear and the risk of contact lens intolerance or development of squamous metaplasia.

A calcifying fibroma of the meninges report of a case and review of the literature.

We report an unusual tumor related to the meninges designated as a calcifying fibroma of the meninges. Our patient was a 44-year-old man.The tumor was located in the right frontotemporoparietal region and was excised totally via a right frontotemporoparietal craniotomy. The patient had recovered completely, and no recurrence was observed in a follow-up period of three years. Histopathologically, we noted scattered spindle cells among the hyalinized collagenous stroma, dystrophicpsammomatous calcifications, abundant perivascular hyalinization and cartilagenous metaplasia. Immunohistochemically, the tumor cells showed actin, smooth muscle and vimentin immunreactivities. Ultrastructurally, spindle cells showed fibroblastic features. The lesion is a true tumor and it should be kept in mind in the differential diagnoss of meningeal calcifying lesions.

A new technique for microvascular anastomosis: external metallic circle.

Vessel anastomosis is the most critical step in free tissue transfers and replantation surgery. We report on a new microvascular anastomosis technique that uses a metallic circle around the anastomotic circumference. Sutures are first passed inside the circle and tied outside and over the circle so as to stretch open the anastomotic site. By retraction of vessel ends, the circle is totally exteriorized and thus there is no contact with blood. In 48 rats, the external circle method was compared with the conventional technique for constructing end-to-end anastomosis between carotid arteries (1 to 1.2 mm) and femoral veins (1 to 1.5 mm). The external circle method proved to be superior to the conventional end-to-end technique in speed of execution for both arterial and venous anastomoses. Patency rates at the third week were significantly higher in the venous group using the metallic circle (100 percent versus 70.8 percent, p < 0.05). This new method may be applicable in clinical microvascular surgery.

Iloprost protects the spinal cord during aortic cross-clamping in a canine model.

BACKGROUND: Surgical procedures on the thoracoabdominal part of the aorta make the spinal cord vulnerable to ischemia. Paraplegia is the most severe complication following thoracoabdominal operations. In this study, iloprost was used as an agent to decrease the severity of ischemia and reperfusion injury to the spinal cord during aortic occlusion and declamping. METHODS: Twelve adult mongrel dogs weighing 17+/-2 kg were used in this study. The animals were randomly assigned to either group I, which received saline solution (6 dogs), or group II, which received prostacyclin. Group I was referred to as the control group and group II as the iloprost group. After baseline measurements were completed, the aorta was cross-clamped for sixty minutes distal to the left subclavian artery. No pharmacologic agents were used to control blood pressure in group I. Proximal and distal mean arterial pressures (DMAP) were monitored continuously. DMAP were considered as diastolic pressure in preocclusion and reperfusion periods. Iloprost administration was started at a rate of 5 ng/kg/minute five minutes before the aortic occlusion. This dosage was increased to 25 ng/kg/minute during aortic occlusion. RESULTS: Mean proximal arterial pressure was 147+/-12 mmHg in the control group and 116+/-13 mmHg in the iloprost group at occlusion (p<0.01). Mean distal arterial pressure was 19+/-7 in the control group and 37+/-5 in the iloprost group during clamping (p<0.05). Functional outcome was evaluated according to Tarlov scores 24 hours after the study. Although none of the animals recovered completely from the control group, 4 animals from the iloprost group recovered (p<0.05). Following the neurologic assessment, animals were sacrificed and specimens were taken for the electron microscopic study. Electron microscopic changes documented that severe mitochondrial damage and vacuolisation occurred in the control group. However these changes were more subtle in the iloprost group. CONCLUSIONS: As a result of this study we concluded that iloprost infused before and during clamping of the thoracic aorta mitigates the spinal cord injury due to ischemia and reperfusion following unclamping.

ATP-MgCl2 utilization for spinal cord protection during experimental thoracic aortic occlusion.

BACKGROUND: In this experimental study we investigate the effect of intravenous ATP-MgCl**2 administration for prevention of spinal cord injury occurring due to ischemia induced by aortic cross clamping. METHODS: Ten rabbits were studied. The abdominal aorta is ligated below the left renal artery. Five rabbits served as a control group and received no medication during 30 minutes of ischemic period. The other 5 rabbits received during 30 minutes of aortic occlusion ATP-MgCl2 solution (100 micromol/ml for each). Distal and proximal aortic pressures are measured during the procedure and incisions are closed. Rabbits are observed for 24 hours for their neurological status and scored accordingly. Specimens from the spinal cord are taken for electron microscopic investigations. RESULTS: All of the control group rabbits were paraplegic. One of the ATP-MgCl2 group rabbits was paraparesic and the others were normal Distal aortic pressure was 9+/-3 mmHg for the control group and was 17+/-4 mmHg for the ATP-MgCl2 group (p<0.05). Electron microscopic studies showed the preserved ultrastructure for ATP-MgCl2 group. CONCLUSIONS: ATP-MgCl2 administration during spinal cord ischemia reduces spinal cord injury. This may be an alternative modality for the protection of the spinal cord during aortic surgery.

Functional and morphological effects of fotemustine on the auditory system of the rat.

OBJECTIVE: This study aimed to elucidate the potential inner-ear effects of fotemustine, a chemotherapeutic agent which crosses the blood-brain barrier and is used in the treatment of primary and metastatic brain tumours and metastatic melanoma. METHODS: This study utilised distortion product otoacoustic emissions and transmission electron microscopy in order to conduct electrophysiological and morphological assessments, using a rat experimental model. Twelve ears of six male rats were examined two months following intraperitoneal slow infusion of fotemustine (100 mg/m2 or 7.4 mg/kg). Pre- and post-treatment measurements were compared. Finally, electron microscopy was performed on three rat temporal bones. RESULTS: After infusion of fotemustine, distortion product otoacoustic emissions revealed a significant reduction in signal-to-noise ratios only at 3600 Hz (from 11.95 +/- 7.52 to -0.26 +/- 9.45 dB) and at 3961 Hz (from 18.09 +/- 7.49 to 6.74 +/- 12.11 dB) (referenced to 2f1 - f2). Transmission electron microscopy of the temporal bone revealed ultrastructural changes in the outer hair cells, stria vascularis and cochlear ganglion at the cochlear basal turn. The ganglion cell perikarya were unaffected. CONCLUSIONS: Fotemustine was administered via intraperitoneal slow infusion in a rat experimental model. Twelve ears of six survivors, from 10 rats, were evaluated at the second month. Fotemustine was determined to have a potential for ototoxicity at 3600 and 3961 Hz. Three randomly chosen rats underwent electron microscopy for morphological analysis. Morphological effects in the cochlear basal turn were observed. Oedematous intracytoplasmic spaces and perivascular areas of the stria vascularis, as well as distorted chromatin content, were detected, thereby suggesting potential ototoxic effects for this agent. Further experimental and clinical studies are required in order to determine whether the effect seen in this pilot study is reversible, and to analyse effects in humans.

An axillary arch.

An axillary (axillopectoral) muscle (arch) was observed extending between the upper border of the latissimus dorsi and the lower border of the pectoralis major muscles in a 48-year-old male cadaver during our dissections. In the same cadaver, the pectoralis major muscle has entirely inserted into the most distal part of the tendon of deltoideus.