Spontaneous tendon or ligament ruptures in patients undergoing dialysis: First pediatric case report and literature review.

Spontaneous tendon or ligament ruptures are quite rare and mostly associated with chronic systemic diseases such as diabetes mellitus, systemic lupus erythematosus, rheumatoid arthritis, and chronic kidney disease (CKD). In this study, we present the first documented case of a spontaneous rupture of the medial patellofemoral ligament (MPFL) in a pediatric patient. The patient was undergoing long-term peritoneal dialysis (PD) and had a history of severe secondary hyperparathyroidism. Additionally, we discussed spontaneous tendon and ligament ruptures associated with CKD or dialysis through a comprehensive literature review. This case report highlights the importance of recognizing that spontaneous tendon or ligament injuries are not exclusive to adults; children with CKD can also be affected. Several factors including poor parathyroid hormone (PTH) and metabolic acidosis control, prolonged CKD duration and presence of malnutrition play role in the pathogenesis. Early diagnosis is crucial as it allows for timely surgical intervention and leads to a favorable functional recovery.

Perioperative alendronate, risedronate, calcitonin and indomethacin treatment alters femoral stem fixation and periprosthetic bone mineral density in ovariectomized rats.

BACKGROUND: Many factors affect implant stability and periprosthetic bone mineral density (BMD) following total joint arthroplasty. We asked whether perioperative alendronate, risedronate, calcitonin and indomethacine administration altered (1) femoral stem shear strength and periprosthetic bone mineral density BMD in ovariectomized rats and (2) whether there were differences in the effect of these drugs. METHODS: Thirty overiectomized rats were divided into five groups and implanted with intramedullary mini-cortical screws in the femur. Four groups were treated with alendronate, risedronate, salmon calcitonin and indomethacin for 4 weeks preoperatively and 8 weeks postoperatively. RESULTS: Although alendronate and risedronate increased the periprosthetic BMD more than calcitonin, they did not alter implant fixation compared to calcitonin. Indomethacin significantly decreased the BMD around the stem and implant stability compared to all other groups. CONCLUSIONS: This study showed that perioperative treatment with bisphosphonates and calcitonin improved the BMD around the stems and implant stability. Although bisphosphonates increased the BMD more than calcitonin, there was no difference in implant stability. Indomethacin markedly decreased the periprosthetic BMD and implant stability. The main clinical significance of our study was the finding about the need to strictly avoid long-term use of high-dose nonsteroidal antiinflammatory drugs for patients who have major joint arthritis and a previous history of arthroplasty.

Bupivacaine and levobupivacaine induce apoptosis in rat chondrocyte cell cultures at ultra-low doses.

PURPOSE: Osteoarthritis (OA) is characterized by chondrocyte apoptosis and necrosis which play a key role during the progression of OA. Intra-articular administration of bupivacaine is a practical and effective way of postoperative pain control following various joint surgeries. 0.25 % bupivacaine showed to be safe in terms of chondrocyte toxicity. Around 200 nM of bupivacaine was shown to be effective for peripheral nerve block. This study aims to observe the possible cytotoxic effects of bupivacaine and its enantiomer levobupivacaine on chondrocyte cell culture at 7.69, 76.9, and 384.5 µM or at 0.0125, 0.0025, and 0.00025 % concentrations, respectively. METHODS: Chondrocytes were isolated from rat articular cartilage after incubating with collagenase in RPMI-1640 medium. Cells were treated with bupivacaine and levobupivacaine at 7.69, 76.9, and 384.5 µM concentrations for 6, 24, and 48 h. Treated chondrocytes were stained with acridine orange and ethidium bromide and examined under a fluorescence microscope at a 490 nm excitation wavelength for apoptotic changes. RESULTS: Study results suggest that both bupivacaine and levobupivacaine have dose-dependent chondrocyte toxicity, and this is significantly lesser at 7.69 µM dose. There was no significant difference in terms of chondrocyte apoptosis, (p > 0.05). CONCLUSIONS: Clinicians should be skeptic for the serious long-term side effects of bupivacaine and its analogs, even at ultra-low doses.

The fluoroquinolones may positively affect tendon healing after surgical repair.

OBJECTIVES: This study aimed to evaluate the biomechanical and histological effects of fluoroquinolones on surgically repaired tendon healing. MATERIALS AND METHODS: The Achilles tendons of 40 Wistar rats (mean weight: 213.5 g; range 201 to 242 g) were bilaterally surgically cut and repaired. The rats were randomly divided into four groups: the first and third groups were designated as control groups and did not receive drug therapy, whereas the second and fourth groups received 300 mg/kg ciprofloxacin for a week after the surgical procedure. The first and second groups had both tendons dissected at the end of the first week, while the third and fourth groups were dissected at the end of the third week. The left tendons were examined biomechanically, while the right tendons were examined histologically. RESULTS: Statistical analysis revealed that the mean maximum tensile forces of tendons in the first and second groups were 5.2±1.84 N (range, 2.9 to 8.5 N) and 11.1±2.65 N (range, 7.3 to 13.9 N), respectively, which was found to be statistically significant (p< 0.05). At the end of the third week, mean maximum tensile forces of the third and fourth groups were determined to be 20.7±5.0 N (range, 22.1 to 29.8 N) and 28.7±4.6 N (range, 22.1 to 36.8 N), respectively, which was also statistically significant (p< 0.05). Histologically, our results were compatible. CONCLUSION: This study demonstrated that ciprofloxacin did not exhibit the expected adverse effects on surgically repaired tendon healing in the early stages but likely contributed to healing in the short term by affecting the inflammatory phase.

The treatment of segmental bone defects in rabbit tibiae with vascular endothelial growth factor (VEGF)-loaded gelatin/hydroxyapatite "cryogel" scaffold.

The aim of this study was to investigate the effectiveness of a novel hydroxyapatite containing gelatin scaffold--with and without local vascular endothelial growth factor (VEGF) administration--as the synthetic graft material in treatment of critical-sized bone defects. An experimental nonunion model was established by creating critical-sized (10 mm. in length) bone defects in the proximal tibiae of 30 skeletally mature New Zealand white rabbits. Following tibial intramedullary fixation, the rabbits were grouped into three: The defects were left empty in the first (control) group, the defects were grafted with synthetic scaffolds in the second group, and synthetic scaffolds loaded with VEGF were administered at bone defects in the third group. Five rabbits in each group were killed on 6th and 12th weeks, and new bone growth was assessed radiologically, histologically and with dual-energy X-ray absorptiometry (DEXA). At 6 weeks, VEGF-administered group had significantly better scores than the other two groups. The second group also had significantly better scores than the control group. At 12 weeks, while no significant difference was noted between the second and third groups, these two groups both had significantly better scores in all criteria compared with the control group. There were no signs of complete fracture healing in the control group. The administration of hydroxyapatite containing gelatin scaffold yielded favorable results in grafting the critical-sized bone defects in this experimental model. The local administration of VEGF on the graft had a positive effect in the early phase of fracture healing.

What is the clinical and functional effect of performing suspension arthroplasty with abductor pollicis longus tendon slip to carpometacarpal joint osteoarthritis of the thumb?

OBJECTIVES: This study aims to investigate the clinical, radiological, and functional results of trapeziectomy, ligament reconstruction and suspensionplasty surgery with abductor pollicis longus (APL) tendon slip autograft to thumb carpometacarpal (CMC) osteoarthritis. PATIENTS AND METHODS: Between January 2011 and June 2017, a total of 25 hands of 25 patients (4 males, 21 females; mean age: 63.6±5.8 years; range, 54 to 76 years) were included. All patients underwent trapeziectomy and ligament reconstruction and suspensionplasty procedure due to the diagnosis of thumb CMC joint osteoarthritis. The patients were administered the Patient-Rated Wrist Evaluation Questionnaire (PRWE), Quick Disabilities of the Arm, Shoulder, and Hand (Q-DASH), and Visual Analog Scale (VAS). Scaphometacarpal distance (SMD), Kapandji opposition score, thumb range of motion (ROM), grip strength, tip pinch, lateral pinch, and palmer pinch values were measured for both hands. The values calculated for the operated and contralateral hands of the patients were compared. RESULTS: The ROM measurements, Kapandji opposition scores, and pinch values of the operated hands of the patients were found to be statistically significant lower compared to the contralateral hands (p<0.001, p<0.001, p=0.002; respectively). The grip strength values were similar for both hands (p=0.147). The median SMD in the operated hand was found to be 7.5 mm and 12.1 mm in the contralateral hand (p<0.001). CONCLUSION: The ROM, strength and functional results were reached a satisfactory level, particularly in the patients with a follow-up period of ≥36 months. In patients with thumb CMC joint osteoarthritis, ligament reconstruction and suspensionplasty using APL tendon slip are considered to be a useful and preferable surgical technique modification.

Comparison between external fixation and cast treatment in the management of distal radius fractures in patients aged 65 years and older.

PURPOSE: The aim of this study was to compare the functional and radiographic outcomes of dorsally displaced distal radius fractures treated by closed reduction plaster cast fixation (CRPCF) and external fixation (EF) in patients 65 years and older. METHODS: This retrospective and nonrandomized study comprised 46 consecutive patients older than 65 years who had distal radial fractures. Patients were divided into 2 groups according to treatment: a CRPCF group and an EF group. All the fractures were dorsally displaced and AO/ASIF type A or C, without articular stepoff or gap. Cases were evaluated based on the criteria of Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire score, wrist range of motion, and radiologic results. RESULTS: The mean follow-up period was 25.1 months. Union was achieved in all cases. Although it was not a statistically significant difference, posttreatment complications were more common in the CRPCF group (10 patients) than in the EF group (7 patients). In the CRPCF group, most complications were discomfort from the cast, whereas in the EF group, most were pin site infections. The average wrist extension and ulnar deviation (clinically) and palmar tilt and radial height (radiologically) were statistically better in the EF group at the final follow-up. The mean DASH scores were 20.3 in the CRPCF group and 21.9 in the EF group. There was no statistically significant difference in the DASH scores; in wrist flexion, radial deviation, pronation, supination, grip strength, or pinch strength (clinically); or in ulnar variance or radial inclination (radiologically). There was no correlation between the DASH scores and palmar tilt and ulnar variance. CONCLUSIONS: We concluded that both CRPCF and EF are useful methods for distal radius fractures in elderly patients. The results showed significant differences in wrist extension and ulnar deviation.

[The effect of low-molecular-weight heparin on rat tendon healing]. / Düsük molekül agirlikli heparinin siçan tendon iyilesmesi üzerine etkisi.

OBJECTIVES: We investigated the effect of low-molecular-weight heparin (LMWH) on the healing of tendons. METHODS: Forty-five adult Wistar rats weighing 300 g were randomized into three groups equal in number. All the rats underwent full-thickness surgical incision of the Achilles tendon followed by primary repair. After the operation, two groups received daily subcutaneous LMWH injections (nadroparin calcium) for four weeks at high or low doses (group I, 6 mg/kg, 170 IU AXa; group II, 3 mg/kg, 85 IU AXa). Group III remained untreated as the control group. Histologically, the specimens were examined under light and electron microscopy with regard to the amount of fibrillar collagen synthesis, mitochondrial degeneration, and the composition of the extracellular matrix collagen. Biomechanically, maximum load to failure and correspondent elongation of the tendons were measured. RESULTS: Compared to the control group, histologically, both LMWH-treated groups exhibited increased number of fibroblasts, increased fibrillar collagen formation in the extracellular matrix, and higher counts of granular endoplasmic reticula in cytoplasmic contents of fibroblasts as well as decreased mitochondrial vacuolization and degeneration. Biomechanical assessments showed that tendons in group I had significantly higher maximum load to failure and elongation values than group II and III (31 N vs. 24.6 N and 23.1 N; 25 mm vs. 19.6 mm and 17.3 mm, respectively; p<0.05). Groups II and III did not differ significantly in this respect (p>0.05). CONCLUSION: Daily administration of single dose LMWH improves tendon healing through increasing the number of fibroblasts and fibrillar collagen synthesis and decreasing mitochondrial degeneration.

Open reduction via posterior triceps sparing approach in comparison with closed treatment of posteromedial displaced Gartland type III supracondylar humerus fractures.

The results of closed and open reduction via posterior approach with percutaneous pinning of posteromedial displaced supracondylar humerus fractures in children were evaluated. Fifty-five consecutive patients with Gartland type III fractures were reviewed. The mean follow-up period was 22 months (12-48 months). The closed reduction group consisted of 32 patients and the open reduction group with the posterior approach using the triceps-sparing method consisted of 23 patients. Both groups were stabilized with cross Kirschner wire fixation and followed the same protocol. In comparison with closed reduction, despite the fact that better bone alignment was obtained with open reduction, longer union time (7 vs. 5.8 weeks), significantly reduced range of motion of the elbow (12.3 degrees vs. 3.8 degrees), poorer functional outcomes and bad cosmetics because of hypertrophic scar tissue of the skin were found. The patients were analyzed according to their Bauman angle and Flynn criteria: good or excellent functional and cosmetic results were 91% in the closed reduction group but 52% in the open reduction group. On the basis of results of this study, closed reduction and percutaneous fixation of the posteromedial totally displaced fractures are preferable to open reduction with posterior approach.

[Pressure distribution patterns under the metatarsal heads in healthy individuals]. / Saglikli kisilerde metatars baslarinda dinamik basnç dagilim sekilleri.

OBJECTIVES: Recognition of plantar pressure distribution patterns of healthy individuals would be helpful in the management of metatarsalgia. We investigated plantar pressure distribution patterns under metatarsal heads in healthy individuals using the EMED-SF plantar pressure analysis system. METHODS: Plantar pressure measurements were performed in 106 healthy volunteers (45 females, 61 males; mean age 24 years; range 20 to 35 years) during walking on the EMED-SF platform. Footprints were divided into three areas based on the three functional columns of the tarsometatarsal joint, that is, the first metatarsal head, the second and third metatarsal heads, and the fourth and fifth metatarsal heads. The mean and peak pressures obtained in these areas were recorded. RESULTS: Pressure distribution patterns did not differ significantly between the two sexes and the right and left soles (p>0.05). The mean and peak pressures of the middle column during the mid-stance phase of the gait cycle were significantly higher than those recorded for the medial and lateral columns (p=0.000). There were no significant differences between the medial and lateral columns in this respect. At the pre-swing phase, pressures were significantly greater in the medial column compared to the lateral column. Four different patterns were noted with respect to the distribution of pressures among the three columns. Body mass index (BMI) was below the limit for obesity (<30 kg/m(2)) in all the participants. Peak pressure values obtained from each column at the pre-swing phase were significantly correlated with BMI (p<0.05); however, no correlation existed between the plantar pressures and BMI at the mid-stance phase (p>0.05). CONCLUSION: Our data show that there are four distinct pressure distribution patterns, but the greatest plantar pressure occurs in the middle column of the foot in the majority of healthy individuals.

[Flexible intramedullary nailing of children]. / Cocuk femur cisim kiriklarinda esneyebilen intramedüller çivi uygulamasi.

BACKGROUND: Various methods are being used in the treatment of femur diaphysial fractures in children aged between 6 to 12 years. Titanium elastic nailing is one of the alternatives. We evaluated our experience in flexible intramedullary nailing. METHODS: We investigated 21 patients with femur diaphysial fractures who were with titanium elastic nailing. RESULTS: The mean age of the patients was 9.6+/-2.4 (range between 5.1-14.7 years) and all the fractures were at the diaphysis. The fracture pattern was as following: 9 (42.9%) transverse, 7 (33.3%) oblique, 5 (23.8%) spiral. Fixations were performed with two nails which were implanted in retrograde manner. The average time of follow-up was 29+/-11.6 months (range; 9-48 month). The mean time to fracture union was 13+/-11.9 weeks (4-52). Implant removal was performed after a mean time of 7+/-2.2 months (range; 6-16 month). Patients's hip and knee range of motions were complete and clinically there were no angular or rotational deformity at postoperative one year. There were radiologically 11+/-1.7 (range; 10-15) degrees of varus valgus malalignment in 8 patients; these angles were reduced to 5+/-1.9 (range; 3-9) degrees at the follow of two years. CONCLUSION: The results of the flexible titanium nailing in femur diaphysial fractures of the children, aged between 6 to 12 years, suggest that this method may be a first choice therapy in this particular group of patients.

Bio-engineered synovial membrane to prevent tendon adhesions in rabbit flexor tendon model.

During tendon injuries, the tendon sheath is also damaged. This study aims to test effectiveness of engineered tendon synovial cell biomembrane on prevention of adhesions. Forty New Zealand Rabbits enrolled into four study groups. Engineered synovial sheath was produced by culturing cell suspension on fabricated collagen matrix membrane. Study groups were: tendon repair (group A), tendon repair zone covered with plane matrix (Group B), synovial suspension injection into the zone of repair over matrix (Group C), and biomembrane application (Group D). Biomechanical evaluations of tendon excursion, metacarpophalangeal and proximal interphalangeal joints range of motion, H&E and Alcian Blue with neutral red staining, and adhesion formation graded for histological assessments were studied. Ten non-operated extremities used as control. Tendon excursions and range of motions were significantly higher and close to control group for Group D, p < 0.05. Adhesion formation was not different among Groups C, D, and Control, p > 0.005. Hyaluronic acid synthesis was demonstrated at groups C and D at the zone of injury. Application of synovial cells into the tendon repair zone either by cell suspension or within a biomembrane significantly decreases the adhesion formation. Barrier effect of collagen matrix and restoration of hyaluronic acid synthesis can explain the possible mechanism of action.

Bilobed flaps for nonhealing ulcer treatment.

Healing of round ulcers may be difficult particularly in the plantar area. Rigidity and thickness of the plantar skin do not allow fusiform excision and primary suturing. The bilobed flap is a simple reconstructive technique principally used to repair substantial defects in the facial region. The authors' experience with this local flap in the foot is presented with good short-term results. Between 1995 and 1998, five female and seven male neuropathic foot patients with round plantar ulcers were treated with bilobed flaps. The average age of the patients was 50 (range, 15-76). The average size of the ulcers was 1.6 cm (1-3.2 cm). Debridement and orthotic insoles were used at least for 3 months before considering bilobed flaps. Seven patients were diagnosed as type II diabetes mellitus, four patients had cerebral palsy, and another patient had meningomyelocele. The minimal follow-up period was 1 year (average, 19.5 months). The only complication was wound dehiscence at the lateral side of the heel in a type II diabetic. Subsequently, this complicated ulcer was managed with a sliding flap and skin graft without further problem. The study concluded that nonhealing foot ulcers can be effectively treated with a bilobed skin flap of healthy tissues rotated from nonweightbearing parts of the sole.

[Evaluation of functional results following surgical treatment of supracondylar femoral fractures]. / Cerrahi olarak tedavi edilen suprakondiler femur kirikli hastalarda fonksiyonel sonuçlarin degerlendirilmesi.

OBJECTIVES: We evaluated functional results of patients who underwent surgical treatment for supracondylar femoral fractures. METHODS: Functional results of surgical treatment for supracondylar femoral fractures were evaluated in 23 patients (14 males, 9 females; mean age 34 years; range 14 to 64 years) with the use of the Neer and HSS (The Hospital for Special Surgery) scoring systems. The strength of the quadriceps muscle was measured using Cybex isokinetic testing. The mean follow-up was 52 months (range 13 to 160 months). RESULTS: The average HSS score was 93.8 (range 68 to 100) and the average Neer score was 90.1 (range 55 to 100). The average losses of extension strength at 60 degrees /s and 180 degrees /s were 27.30% and 22.13%, respectively. Statistically significant correlations were found between the losses of extension strength and the Neer and HSS scores (p<0.01). The results showed that the patient's age and sex, the length of time between trauma occurrence and surgery, immobilization period, and the presence of subjective pain complaints had no significant influence on the HSS and Neer scores and on Cybex isokinetic test results (p>0.05). CONCLUSION: Evaluation of the quadriceps muscle strength with the use of objective tests proved helpful in the determination of functional results of surgery following supracondylar femoral fractures.

Acute Phase Reaction after Femur Fracture in a Child with Griscelli Syndrome.

Griscelli syndrome (GS) is an autosomal recessive disorder that is characterized by partial albinism of the skin and hair shaft. Prompt and early diagnosis is a crucial step for the follow up and management of GS, which would otherwise dramatically decrease the life expectancy of the patients. This case report presents the clinical course of a femoral fracture treated with closed reduction and pelvic-pedal cast, and progression of acute phase reaction during the follow up period.

Does hyaluronic acid decrease the apoptotic effect of bupivacaine?

OBJECTIVES: In this study, we aimed to study the anti-apoptotic effects of hyaluronic acid on the apoptotic effects of bupivacaine in cultured rat chondrocytes in a time and dose-dependent manner. MATERIAL AND METHODS: The rat chondrocytes were treated with 7.69 µM, 76.9 µM, and 384.5 µM bupivacaine and 50 µg/ml hyaluronic acid concentrations for six, 24, and 48 hours. At the end of the treatment period, cells were stained with mixture of acridine orange and ethidium bromide. Apoptosis was evaluated using a fluorescence microscope. RESULTS: A significant protective effect of hyaluronic acid on chondrocytes against bupivacaine exposure at 7.69 µM and 76.9 µM concentrations, particularly was observed. There was also a significant protective effect in the exposure time at six and 24 hours for 7.69 µM and 76.9 µM bupivacaine doses. CONCLUSION: Our study results show that hyaluronic acid against chondrotoxicity of bupivacaine may have a protective effect in a time and dose-dependent manner.

Alendronate enhances antibiotic-impregnated bone grafts in the treatment of osteomyelitis.

Bisphosphonates are systemic drugs. There is limited knowledge about their effects when applied locally and in osteomyelitis treatment. A prospective longitudinal randomised controlled study was designed in rat tibia to test the efficacy of local or systemically administered bisphosphonates for controlling the osteolytic reactions and possible effects on local infection control. Tibial osteomyelitis was induced in 72 Wistar albino rats with Staphylococcus aureus ATCC 25923 strain. Débridement was performed on all rats in all groups. No other treatment was given to the control group. Treatment groups received "plain bone grafts", "vancomycin-loaded bone grafts", "vancomycin-loaded bone grafts+systemic alendronate", "alendronate-impregnated bone grafts" and "vancomycin+alendronate-impregnated grafts". Study results were evaluated by swab cultures, radiology, quantitative computed tomography, dual-energy X-ray absorptiometry (DEXA) and histopathology. S. aureus was eradicated in groups II and IV by the sixth week. Diaphyseal widening, bone deformation, diaphyseal widening and osteolysis scores were significantly lower (p < 0.05), and bone mineral content, density measurements and DEXA scores were significantly higher (p = 0.001) with alendronate administration. Histology revealed marked osteoblastic activity. Local alendronate interfered with local infection control. Even though local alendronate at the given dose has stronger effects, the possible effects on the local inflammatory process needs to be clarified.