Neutrophil to lymphocyte ratio may be a predictive marker of poor prognosis in Legg-Calvé-Perthes disease.

BACKGROUND: Legg-Calvé-Perthes disease (LCPD) is the idiopathic avascular necrosis of the femoral head in childhood. The pathologic changes seen in the femoral head are likely a result of vascular factors. Blood neutrophil to lymphocyte (N/L) ratio is a simple marker of subclinical inflammation. This study aims to to analyse the predictive ability of N/L ratio for the prognosis in LCPD patients. METHODS: Patients who had been diagnosed as LCPD from 2008 to 2014 were investigated retrospectively and 40 LCPD patients (33 male and 7 female) and 25 healthy age and sex-matched children (controls) were included in the study. LCPD patients were divided into 2 groups according to expected prognosis (good prognosis expected Herring A and B patients as Group I and poor prognosis expected Herring B-C and C patients as Group II) and healthy children (control) were included in Group III. All the patients' hematological markers were analysed. RESULTS: Mean age was 7.1 ± 2.0 years in group I (4.9-12 years), 8.3 ± 2.2 years (4-12.5 years) in group II and 7.8 ± 1.3 years (6-12 years) in group III. Mean values for Groups I, II and III for neutrophil to lymphocyte (N/L) ratio were 1.13 ± 0.65, 1.75 ± 0.95, 1.08 ± 0.37, respectively. The mean neutrophil to lymphocyte (N/L) ratio of Group II was higher than the other 2 groups (p = 0.003). CONCLUSIONS: N/L ratio may give us information about the natural course of LCPD and may be used as independent predictor of prognosis in patients with LCPD.

Effects of boric acid on the healing of Achilles tendons of rats.

PURPOSE: Tendinous lesions are among the most frequent pathologies encountered in sportsmen. The objectives of new treatments are to improve the healing process and reduce the recovery time. Boron plays an important role in the wound repair process by increasing components of extracellular matrix and angiogenesis. This animal study aimed to investigate the effect of boric acid on healing of the Achilles tendon. METHODS: The right Achilles tendons of 40 rats were completely sectioned, and the rats were randomly divided into five groups. Each group consisted of eight rats. Groups 1 and 2 were oral boric acid groups with the doses of 4 and 8 mg/kg/day boric acid, respectively. Group 3 was the local boric acid group (8 mg/kg boric acid intratendinous injection). Group 4 was administered both oral and local boric acid (8 mg/kg/day orally and 8 mg/kg boric acid intratendinous injection), and group 5 was the control group with no boric acid application. At the end of the fourth week, all the rats were killed and histopathological examination of the Achilles tendon repair site was made. RESULTS: Histopathological examination of the tissue sections revealed more properly oriented collagen fibres, more normal cellular distribution of tenocytes and more properly organized vascular bundles in group 1 and group 2, which were the groups administered oral boric acid. Pathological sum scores of groups 1 and 2 were less than those of the other groups, and the differences between the oral boric acid groups (group 1 and group 2) and the other three groups (groups 3, 4 and 5) were statistically significant (p = 0.001). CONCLUSION: As boric acid is safe and toxicity even after very high doses is unusual, oral boric acid may be used as an agent to improve the healing process of tendon injuries. However, biomechanical tests should also be performed to show the effect of boric acid on strength and endurance of the tendon before it can be used in clinical practice.

Safety and feasibility of lumbar spine for intralaminar screw fixation: a computed tomography-based morphometric study.

OBJECTIVE: The use of intralaminar screws (ILS) in spinal surgery has experienced a recent increase in popularity. The aim of this study is to define the morphological parameters of the lumbar laminas so that guidance may be defined for ILS placement. METHODS: The study involved the evaluation of lumbar computed tomography (CT) images of patients. Two hundred thirty-five patients (127 male, 108 female) were included in the study. The mean patient age was 44.2 years (19-78 years). The measured parameters of the lamina were the transverse inner diameter, transverse outer diameter (lamina width), lamina length, subdural space (safe zone), and spinolaminar angle for each lumbar level (L1-L5). RESULTS: The mean transverse outer diameter (L1-L5) ranged from 7.2-7.8 mm, and mean transverse inner diameter ranged from 2.5-3.0 mm. The lamina of L3 had the largest width and the lamina of L1 and L5 the smallest. The mean lamina length was 26.6 mm, ranging from 21.0-34.0 mm, and the mean spinolaminar angle was 124.7°, ranging from 111-135°. The L1 level had the shortest mean lamina length and L4 the lowest spinolaminar angle. Mean subdural space (safe zone), which was narrowest at the L5 level, was 2.4 mm, ranging from 1.3-3.6 mm. CONCLUSION: ILS of the appropriate size (3.5-4.5 mm) and length (20 and 25 mm) can be used safely in the lumbar spine. However, further biomechanical studies should be performed to measure strength of the fixation.

Atypical Localization of Enchondroma in the Calcaneus.

A 53-year-old man presented to the orthopedic outpatient clinic with pain and swelling in the right heel without any trauma. On physical examination and radiologic assessment, a lesion with calcification and peripheral sclerosis was detected in the medullary cavity of the calcaneus, and computed tomographic images revealed cortical thinning adjacent to the lesion. Magnetic resonance images showed a 23 × 19-mm lesion. Tru-Cut biopsy, performed to clarify the diagnosis, revealed an enchondroma. As a definitive treatment, curettage of the lesion and grafting of the cavity was performed. Although enchondromas are common pathologic abnormalities of the skeleton and are usually asymptomatic, atypical localization, such as the calcaneus, and atypical clinical manifestations, such as heel pain, should also be kept in mind.

Association between mean platelet volume and bone mineral density in patients with ankylosing spondylitis and diagnostic value of diffusion-weighted magnetic resonance imaging.

[Purpose] The aim this study was to assess the relation between bone mineral density (BMD) and mean platelet volume (MPV) in ankylosing spondylitis (AS) patients, and evaluate the diagnostic role of the diffusion-weighted magnetic resonance imaging (MRI). [Subjects and Methods] Fifty patients diagnosed with AS were divided into two groups on the basis of BMD, a normal group (n=30) and an osteopenic (n=20) group. [Results] Duration of disease in the group with a normal BMD was 10.3±7.0 years, while it was 16.7±12.2 years in the osteopenia group. MPV was high in the osteopenia group, while no significant differences were observed between the groups in terms of apparent diffusion coefficient (ADC) and platelet distribution width (PDW). There was a positive correlation between MPV and duration of disease. Correlations between ADC value and the lumbar T score, femoral neck T score, and duration of disease were insignificant. A negative correlation was observed between BMD and disease duration. [Conclusion] Diffusion-weighted imaging provides valuable results in osteoporosis but is not a suitable technique for evaluating BMD in patients with AS because of the local and systemic inflammatory effects in the musculoskeletal system. The common pathophysiology of atherosclerosis and osteoporosis plays an important role in the negative correlation observed between MPV and BMD in patients with AS.

Effects of Boric Acid on Fracture Healing: An Experimental Study.

Boric acid (BA) has positive effects on bone tissue. In this study, the effects of BA on fracture healing were evaluated in an animal model. Standard closed femoral shaft fractures were created in 40 male Sprague-Dawley rats under general anesthesia. The rats were allocated into five groups (n = 8 each): group 1, control with no BA; groups 2 and 3, oral BA at doses of 4 and 8 mg/kg/day, respectively; group 4, local BA (8 mg/kg); and group 5, both oral and local BA (8 mg/kg/day orally and 8 mg/kg locally). After closed fracture creation, the fracture line was opened with a mini-incision, and BA was locally administered to the fracture area in groups 4 and 5. In groups 2, 3, and 5, BA was administered by gastric gavage daily until sacrifice. The rats were evaluated by clinical, radiological, and histological examinations. The control group (group 1) significantly differed from the local BA-exposed groups (groups 4 and 5) in the clinical evaluation. Front-rear and lateral radiographs revealed significant differences between the local BA-exposed groups and the control and other groups (p < 0.05). Clinical and radiological evaluations demonstrated adequate agreement between observers. The average histological scores significantly differed across groups (p = 0.007) and were significantly higher in groups 4 and 5 which were the local BA (8 mg/kg) and both oral and local BA (8 mg/kg/day orally and 8 mg/kg locally), respectively, compared to the controls. This study suggests that BA may be useful in fracture healing. Further research is required to demonstrate the most effective local dosage and possible use of BA-coated implants.

Atypical Localization of Enchondroma in the Calcaneus.

A 53-year-old man presented to the orthopedic outpatient clinic with pain and swelling in the right heel without any trauma. On physical examination and radiologic assessment, a lesion with calcification and peripheral sclerosis was detected in the medullary cavity of the calcaneus, and computed tomographic images revealed cortical thinning adjacent to the lesion. Magnetic resonance images showed a 23 × 19-mm lesion. Tru-Cut biopsy, performed to clarify the diagnosis, revealed an enchondroma. As a definitive treatment, curettage of the lesion and grafting of the cavity was performed. Although enchondromas are common pathologic abnormalities of the skeleton and are usually asymptomatic, atypical localization, such as the calcaneus, and atypical clinical manifestations, such as heel pain, should also be kept in mind.

Effects of Local Administration of Boric Acid on Posterolateral Spinal Fusion with Autogenous Bone Grafting in a Rodent Model.

Spinal fusion is among the most frequently applied spinal surgical procedures. The goal of the present study was to evaluate whether the local administration of boric acid (BA) improves spinal fusion in an experimental spinal fusion model in rats. Currently, there is no published data that evaluates the possible positive effects if the local administration of BA on posterolateral spinal fusion. Thirty-two rats were randomly divided into four independent groups: no material was added at the fusion area for group 1; an autogenous morselized corticocancellous bone graft was used for group 2; an autogenous morselized corticocancellous bone graft with boric acid (8.7 mg/kg) for group 3; and only boric acid was placed into the fusion area for group 4. The L4-L6 spinal segments were collected at week 6, and the assessments included radiography, manual palpation, and histomorphometry. A statistically significant difference was determined between the groups with regard to the mean histopathological scores (p = 0.002), and a paired comparison was made with the Mann-Whitney U test to detect the group/groups from which the difference originated. It was determined that only the graft + BA practice increased the histopathological score significantly with regard to the control group (p = 0.002). Whereas, there was no statistically significant difference between the groups in terms of the manual assessment of fusion and radiographic analysis (respectively p = 0.328 and p = 0.196). This preliminary study suggests that BA may clearly be useful as a therapeutic agent in spinal fusion. However, further research is required to show the most effective dosage of BA on spinal fusion, and should indicate whether BA effects spinal fusion in the human body.

The effect of intraoperative sounds of saw and hammer on psychological condition in patients with total knee arthroplasty: prospective randomized study.

PURPOSE: Surgical procedures are likely to be stressful for patients and their families. Total knee arthroplasty (TKA) is a major surgical procedure used in the treatment of osteoarthritis. During this procedure the sounds of the saw and hammer may irritate the patient and adversely affect mood. The present study examines the effect of these intraoperative sounds during TKA on postoperative mood and anxiety, by comparing two different anesthetic procedures. METHODS: A total of 40 patients who underwent TKA for grade IV gonarthrosis participated in the study. Patients were randomly divided into two groups: 20 patients in the general anesthesia group and 20 patients in the spinal anesthesia group. Mood and anxiety changes were evaluated using the Profile of Mood States (POMS) and State-Trait Anxiety Inventory (STAI) instruments, respectively. RESULTS: The postoperative POMS value in the spinal anesthesia group was definitively higher than the general anesthesia group, though the difference in preoperative and postoperative POMS and STAI scores between the two groups was not significant. CONCLUSION: It would seem that sounds of hammer and saw have no evident negative effect on patient's mood. Regional anesthesia is advisable for TKA patients and appropriate sedation can be administered during the operation if needed.

Consultation of traditional bone setters instead of doctors: is it a sociocultural and educational or social insurance problem?

BACKGROUND: Patients consulting bone setters is common in the eastern and south-eastern regions of Turkey. The reasons for consulting bone setters instead of qualified doctors remains unclear. We investigated the characteristics of such patients who consult traditional bone setters after trauma prior to admission to hospital. METHODS: In the study, 3,422 of 14,080 patients were investigated admitted to hospital between January 2012 and February 2013 with trauma or sequelae of such who were previously treated by bone setters. The characteristics of these patients and the main reasons for consultation of bone setters instead of doctors were recorded. RESULTS: Most of the patients consulting bone setters were found to be young adults or children. Generally speaking, the poorly educated prefer bone setters despite having social insurance. The most common reason (29.3%) was a general preference and secondarily (27.1%) the fear of being disabled after medical treatment. However, the most common cause of patients' consultation at hospital subsequently was due to complications of treatment (46.8%); indeed the complication rate after bone setters' intervention was found to be 54.8%. CONCLUSION: Although improvements have occurred in the access to and utilisation of healthcare services, consultation by patients of bone setters seems to be a sociocultural and educational issue rather than a problem of lack of medical insurance.

Investigation of knee pain in osteoarthritic and neuropathic pain awareness.

The mechanism of neuropathic pain (NP) and osteoarthritic (OA) pain, although different, are both defined as chronic pain, and combinations are possible. In this study, the awareness of both types of chronic pain was investigated among patients and doctors. This prospective study was planned and coordinated by the orthopedic and internal medicine clinics and included 100 patients with a diagnosis of knee OA evaluated with the DN4 questionnaire. Patients with an OA diagnosis included those with NP linked to diabetes and those without NP, and these groups were compared using a visual analogue scale (VAS) and the Western Ontario and McMaster Universities Osteoarthritic Index (WOMAC). Data analysis of both groups focused on descriptive statistics of demographic and clinical characteristics. Twenty-four of the patients with type 2 diabetes mellitus (DM) were diagnosed with NP according to DN4 criteria, and began treatment. Of these patients, 21 (84%) had DM for 10 years or more, while 19 (86.4%) had HbA1c of 7 and above. The average WOMAC pain score for patients with NP was 4.33 ±â€ˆ1.2 while the score for VAS was 8.25 ±â€ˆ0.8. Patients without NP had a WOMAC pain score of 2.49 ±â€ˆ0.6 and a VAS of 6.28 ±â€ˆ1.8. It was observed that in these two knee OA patient groups, NP had a statistically significant enhancing effect on the WOMAC pain score and the VAS (p < 0.001). As underlying pathophysiological mechanism of pain caused by OA is complex, and OA is considered to have a component of NP, it has been proven to be useful to use drugs apart from conventional treatments for NP. We believe that, as a source of pain that is not relieved after arthroplasty, awareness level of NP among orthopedists should be increased and multidisciplinary studies are required on this topic.

Neutrophil-Lymphocyte Ratio Connected to Treatment Options and Inflammation Markers of Ankylosing Spondylitis.

BACKGROUND: In recent years, white blood cells (WBCs) and their subtypes have been studied in relation to inflammation. The aim of our study was to assess the relationship between neutrophil-lymphocyte ratio (NLR) and ankylosing spondylitis (AS). MATERIALS AND METHODS: We enrolled a total of 177 patients, 96 AS and 81 healthy controls. Complete blood count, WBC, neutrophil and lymphocyte levels were measured, and the NLR was calculated. In the assessment of AS, we used the erythrocyte sedimentation rate, C-reactive protein (CRP), the Bath Ankylosing Spondylitis Disease Activity Index, and the Bath Ankylosing Spondylitis Functional Index. RESULTS: In the present study, 96 AS and 81 healthy individuals were enrolled. The mean age was 43.8 ± 12.9 and 46.5 ± 11.2 years, respectively. Mean disease duration of AS patients was 6.9 ± 5.6 years (median = 5, min-max = 1-25). The patients with AS had a higher NLR than the control individuals (mean NLR, 2.24 ± 1.23 and 1.73 ± 0.70, respectively, P < 0.001). A statistically significant positive correlation was observed between NLR and CRP (r = 0.322, P = 0.01). The patients receiving antitumor necrosis factor α therapy had a lower NLR than the patients receiving nonsteroidal anti-inflammatory drug therapy (mean NLR, 1.71 ± 0.62 and 2.41 ± 1.33, respectively, P = 0.02). CONCLUSION: NLR may be seen as a useful marker for demonstrating inflammation together with acute phase reactants such as CRP and in evaluating the effectiveness of anti-TNF-α therapy.

Relationship between extremity fractures and attention-deficit/hyperactivity disorder symptomatology in adults.

OBJECTIVE: Recent studies showed that attention deficit hyperactivity disorder (ADHD) is a lifelong disorder which may be seen in adults as well as children. However, information about the relationship between ADHD and general medical conditions in adulthood is limited. This case-control study aims to determine whether ADHD symptoms are associated with extremity fractures and their clinical characteristics. METHODS: Forty patients (25 male and 15 female; aged 18-50 years) who were seen due to extremity fractures and 40 control subjects were enrolled. Childhood and present ADHD symptoms of the participants were assessed using Wender Utah Rating Scale (WURS) and Adult ADHD Self-Report Scale (ASRS), respectively. Trauma type, reason of the trauma, fracture localization, hospitalization requirement, treatment type, and history of previous fracture(s) of the patients were recorded. RESULTS: Total score and all subscale scores of WURS were higher in the fracture groups compared with controls. Patients also had higher ASRS total score and ASRS hyperactivity-impulsivity subscore than the controls did. WURS irritability, inattentiveness, and behavioral problems/impulsiveness subscore and total score were positively correlated with the history of previous fracture. The patients in whom the reason for the fracture was fighting were also showed higher WURS irritability subscore. CONCLUSIONS: Our results suggest that extremity fractures are associated with ADHD symptoms in adults. These findings may provide an insight into better understanding the lifelong negative impact of ADHD on the physical health of its sufferer.

Preventive effects of coenzyme Q10 (CoQ10) on steroid-induced osteonecrosis in rats.

OBJECTIVE: The aim of this study was to examine the role of coenzyme Q10 (CoQ10) in the prevention of steroid-induced osteonecrosis of the femoral head (ONFH) in rats. METHODS: The study included 20 Sprague-Dawley rats injected once with 20 mg/kg of methylprednisolone acetate into the right gluteus medius muscle to induce osteonecrosis. Animals were divided into two equal groups; Group 1 received no prophylaxis (control group) and the Group 2 received CoQ10. Hematological examinations were performed before steroid injection (0 weeks) and at 4 weeks after steroid injection. Femoral heads were examined histologically to evaluate osteonecrosis. RESULTS: Changes in blood glutathione (GSH) and malondialdehyde (MDA) concentrations were less significant in the CoQ10 group. The incidence of histologic changes consistent with early osteonecrosis was lower in the CoQ10 group (2 of 10; 20%) than the control group (7 of 10; 70%). CONCLUSION: Coenzyme Q10 may be useful as a preventing agent in steroid-induced ONFH. Inhibited oxidative stress is a possible mechanism for this effect.

A hybrid schwannoma of median nerve.

Schwannomas are the most common benign neoplasms of the peripheral nerves in the upper extremity originating from the schwann cells of nerve sheath. They account for 5% of all tumours in upper extremity. Schwannomas are usually solitary, encapsulated and homogeneous masses and present with slowly growing masses, sometimes associated with pain and paresthesia. Pre-operative evaluation is based on ultrasonography and magnetic resonance imaging, but final diagnosis requires histopathology. It is important to distinguish plexiform schwannoma from plexiform neurofibroma because of the possibility of malignant transformation in plexiform neurofibroma. Plexiform schwannoma may be confused with neurofibromatosis and this can lead to overtreatment. We present a very rare case of solitary mass which had a plexiform type multicentric extension: hybrid schwannoma of the median nerve of a 20-year-old young girl.

An unusual location for cellular schwannoma.

Schwannomas are solitary benign tumours derived from peripheral nerve sheath that are difficult to diagnose using imaging only. Diagnoses are commonly confirmed with conventional surgical resection. Small proportion of cases are formed by cellular schwannoma usually seen at paravertebral, pelvic, retroperitoneal, or mediastinal location. This patient had a 3 x 2 cm hard mass at the dorsal side of proximal phalanx of the right third toe. Bone destruction was seen on radiography and MR imaging. Curettage after excision and grafting were performed. No complication was seen after surgery. The histopathology result was reported as cellular schwannoma. It was an atypical location for cellular schwannoma not previously described in literature.

Effect of surgical closing in total knee arthroplasty at flexion or extension: a prospective, randomized study.

PURPOSE: The aim of this study was to evaluate the effect of knee position during wound closure (flexed vs. extended) in total knee arthroplasty on knee strength and function, as determined by knee society scores and isokinetic testing of extensor and flexor muscle groups. METHODS: In a prospective, randomized, double-blind trial, 29 patients were divided in two groups: for Group 1 patients, surgical closing was performed with the knee extended, and for Group 2 patients, the knee flexed at 90°. All the patients were treated with the same anaesthesia method, surgical team, surgical technique, prosthesis type, and rehabilitation process. American Knee Society Score values and knee flexion degrees were recorded. Isokinetic muscle strength measurements of both knees in flexion and extension were taken using 60° and 180°/s angular velocity. The peak torque and total work values, isokinetic muscle strength differences, and total work difference values were calculated for surgically repaired and healthy knees. RESULTS: No significant difference in the mean American Knee Society Score values and knee flexion degrees was observed between the two groups. However, using isokinetic evaluation, a significant difference was found in the isokinetic muscle strength differences and total work difference of the flexor muscle between the two groups when patients were tested at 180°/s. Less loss of strength was detected in the isokinetic muscle strength differences of the flexor muscle in Group 2 (-4.2%) than in Group 1 (-23.1%). CONCLUSION: For patients undergoing total knee arthroplasty, post-operative flexor muscle strength is improved if the knee is flexed during wound closure. LEVEL OF EVIDENCE: II.