The positive impact of platelet-derived growth factor on the repair of full-thickness defects of articular cartilage.

OBJECTIVES: This study aims to investigate the potential use and histological effects of the local administration of platelet-derived growth factor (PDGF) in the repair of full-thickness osteochondral defects in articular cartilage in an animal model. MATERIALS AND METHODS: Twenty-four adolescent 18-week-old New Zealand White rabbits with an average weight of 2500 g (range, 1600 g to 3200 g) were used in the study. The rabbits were randomly divided into three groups (n=8) as the control group (group A) and two experimental groups (groups B and C). Defects of cylindrical full-thickness (3.5 mm wide, 4 mm deep) were created in the weight-bearing area of the right knee medial femoral condyles. In group A, the defect was left empty. In group B, the defect was filled with a collagen sponge. In group C, the defect was filled with a collagen sponge impregnated with PDGF. All rabbits were followed-up for 12 weeks. Right knee medial femoral condyles were used for macroscopic and histological analyses. RESULTS: At macroscopic level, the repair tissue was similar to normal adjacent cartilage at 12 weeks in group C. The surface of the repair tissue in group C was smoother and more regular compared to groups A and B. The total histological score of defects in group C was statistically significantly superior compared to groups A and B (p<0.05). Matrix staining and immunostaining of collagen type 2 were stronger in group C compared to the other groups, indicating the presence of a tissue similar to a normal cartilage. CONCLUSION: Platelet-derived growth factor can induce repair in full-thickness defects of articular cartilage in an animal model. Thus, this study demonstrates the potential use of PDGF for full-thickness osteochondral defects.

Minimal invasive fixation of distal tibial fractures does not result in rotational malalignment: A report of 24 cases with CT imaging.

BACKGROUND: Tibial torsion is rotation of the proximal versus the distal articular axis in the transverse plane. This study used computed tomography (CT) to examine rotational malalignment in the crus following use of minimally invasive plate osteosynthesis (MIPO) technique in distal tibial fractures and evaluated effect of rotational difference on clinical outcomes and VAS scores. METHODS: Analysis of 24 patients who were operated on for closed distal tibial fracture with MIPO technique between 2010 and 2012 was conducted. Malrotation was defined as rotational difference >10°. Operated knees were evaluated with 0.5-mm, fine-cut, 3-dimensional CT scan performed in cooperation with radiology department. Side-to-side difference in tibial torsion angle >10° was considered significant degree of malrotation. All patients were assessed clinically (visual analogue scale [VAS] and American Orthopaedic Foot and Ankle Society [AOFAS] scores) and radiologically at final visit. RESULTS: Mean follow-up period was 20.00±9.46 months (range: 18-51 months). Mean VAS score was 2.58±0.83 (range: 1-4) and mean AOFAS score was 87.50±4.05 (range: 78-93). Mean tibial rotation angle was 31.54±6.00° (range: 18-45°) on healthy side and 32.00±6.24° (range: 10-43°) on the operated side. No statistically significant difference was determined (p>0.05). CONCLUSION: Use of intraoperative fluoroscopy, cable technique, and uninjured extremity as reference, can reduce incidence of rotational malalignment of distal tibial fractures treated with MIPO.

Can rhBMP-2 containing collagen sponges enhance bone repair in ovariectomized rats?: a preliminary study.

With an aging population the frequency of postmenopausal fractures is increasing. Methods to enhance the repair of osteoporotic bone repair therefore become more important to reduce the society burden of care. We asked if absorbable collagen sponges containing recombinant human bone morphogenetic protein-2 (rhBMP-2) have the potential to enhance bone repair. We randomly assigned 40 rats into the ovariectomy and sham operation groups. A segmental defect was created in the right tibia 12 weeks after ovariectomy. rhBMP-2-containing absorbable collagen sponges were implanted into the defect in half of the animals in each group. We analyzed radiographs and histological sections and performed three-point bending tests to assess repair. Radiological scores in the rhBMP-2 applied rats were higher than those in controls at the end of 8 weeks after tibial osteotomy. The specimens failed under higher loads in the rhBMP-2-applied groups and histology revealed a higher fracture healing score, including callus formation, bone union, marrow changes, and cortex remodeling. We observed no adverse tissue responses such as fibrous connective tissue formation and inflammatory cellular infiltration. rhBMP-2 in absorbable collagen sponges enhanced bone repair in segmental tibial defects of ovariectomized rats. The sponges with rhBMP-2 appeared to enhance bone repair.

Free nerve endings and morphological features of the ligamentum capitis femoris in developmental dysplasia of the hip.

A conflict exists on whether the ligamentum capitis femoris has the neuro-morphological structures required for nociception or proprioception of the hip joint. Therefore, we investigated the morphological features and the presence of mechanoreceptors in 24 ligamentum capitis femoris biopsies obtained at open reduction in patients with developmental dysplasia of the hip. Of these 24 hips, 16 were completely dislocated and eight were subluxated. The mean age was 33.8 months (range 13-52 months) at the time of surgery. En bloc ligamentum capitis femoris and pulvinar were taken for biopsy specimen. Ligamentum capitis femoris was dissected and the weight of each ligament was determined using a highly sensitive balance. Specimens were stained with hematoxylin and eosin and Masson trichrome for routine histolopathological evaluation and examined immunohistochemically using monoclonal antibody against S-100 protein. All specimens were graded on a four-grade system according to the amount of coarse-thick collagen bundles and hyalinization. The mean number and type of mechanoreceptors of each specimen were recorded. When the mean age, the patient's weight and the ligamentum capitis femoris weight of each group (completely dislocated vs. subluxated) were compared, there were no significant differences. In the ligamentum capitis femoris of the dislocated hips, the cells were irregularly distributed, had different shapes, and appeared to be in different stages of functional activity. The collagen fiber bundles were thicker than in the subluxated hips, distributed and of varied thickness. The elastic fibers of the dislocated hips were thicker and more numerous than those in the subluxated hips. We found a significant difference between the two groups with regard to the grade of collagen and hyalinization of ligamentum capitis femoris (P<0.004). We found type IVa, free nerve endings in 16 of 24 samples of ligamentum capitis femoris. The 66.6% presence of free nerve endings in the ligamentum capitis femoris suggests a role in nociception/proprioception of the hip in developmental dysplasia of the hip. Interestingly, the percentage and the mean numbers of free nerve endings containing ligamentum capitis femoris were similar in completely dislocated hip group and the subluxated group (62.5 vs. 75%, 12.13+/-9.07 vs. 9.37+/-9.24, respectively). We conclude that the morphological features of ligamentum capitis femoris are influenced by the severity of developmental dysplasia of the hip, whereas the distribution of free nerve endings are not influenced.

Relationship between synovial fluid and plasma manganese, arginase, and nitric oxide in patients with rheumatoid arthritis.

Nitric oxide (NO) participates in the pathogenesis of inflammatory reactions in many autoimmune diseases such as rheumatoid arthritis (RA). There is a reciprocal pathway between arginase and nitric oxide synthase (NOS) for NO production, and Mn is required for arginase activity and stability. To investigate whether NO production related with the arginine-nitric oxide pathway in patients with RA, we measured synovial fluid and plasma nitrite (NOx) levels, arginase activities, and its cofactor manganese (Mn) concentrations in 21 RA patients and 13 healthy control subjects. Plasma albumin levels were measured as an index of nutritional status. NOx levels were determined after the reduction of nitrates to nitrites using the Griess reaction. Whereas, synovial fluid arginase activities and Mn levels were found to be significantly lower (p<0.001, p<0.001, respectively), plasma arginase activities and Mn levels were similar in patients with RA when compared to the control subjects. Plasma and synovial fluid NO levels were similar in patients with RA and in healthy subjects (p>0.05, p>0.05, respectively). There were significantly positive correlations between synovial fluid and plasma arginase activities vs Mn content (r=0.543, p=0.011; r=0.516, p=0.017, respectively) and significantly negative correlations between synovial fluid and plasma NO levels vs arginase activities (r=-0.497, p=0.022; r=-0.508, p=0.019 respectively) in the patients group. Our results indicate that the lower concentration of synovial fluid Mn could cause lower arginase activity and this could also upregulate NO production by increasing L-arginine content in patients with RA.

Pullout strength of meniscal repair after cyclic loading: comparison of vertical, horizontal, and oblique suture techniques.

This in vitro biomechanical study with cyclic loading compared the pullout strength of vertical, horizontal, and oblique sutures used for meniscal lesion repair. Following repair of vertical longitudinal lesions created in bovine medial menisci, three groups of seven specimens (vertical, horizontal, and oblique sutures) underwent cyclic loading in a randomized test order (5 mm/min, cycling between 5 and 50 N at 1 Hz for 100 cycles) prior to load to failure testing (5 mm/min). Displacement did not differ between groups during cyclic or load to failure testing. Construct stiffness during cyclic testing was superior for the oblique suture (6.9 +/- 1.5 N/mm, P = 0.007) and the vertical suture (6.4 +/- 7 N/mm, P = 0.03) groups compared to the horizontal suture group (4.4 +/- 0.52 N/mm). The oblique suture (171.9 +/- 25.9 N, P < 0.0001) and the vertical suture (145.9 +/- 32.3 N, P = 0.001) groups displayed superior load at failure compared to the horizontal suture group (88.8 +/- 8.2 N). Construct stiffness during load to failure testing did not differ between groups. Suture rupture was the failure mode for all specimens of the oblique suture group. Suture rupture was the failure mode for 57% (4/7) of the vertical suture group with the remaining specimens (3/7, 43%) failing from intact suture pullout through meniscal tissue. All horizontal suture group specimens failed by intact suture pulling through meniscal tissue. With comparable stiffness during cyclic testing, comparable load at failure as vertical sutures, and less evidence of intact suture pullout through the meniscus, an oblique suture technique may combine the beneficial characteristics of vertical (superior biomechanical strength) and horizontal (ease of application, longer sutures with a tendency to cover a larger meniscal tissue area) suture-repair techniques.

[The effect of the tibial tunnel fixation level on the results of cyclic loading in anterior cruciate ligament reconstruction]. / On çapraz bag rekonstrüksiyonunda tibial tünel tespit seviyesinin tekrarlayici yüklenme testi sonuçlarina etkisi.

OBJECTIVES: This study was designed to compare the biomechanical characteristics of non-anatomic (far from joint) and anatomic (close to joint) levels of tibial tunnel fixation with soft tissue graft using a soft tissue interference screw in anterior cruciate ligament (ACL) reconstruction. METHODS: Twelve bovine tibiae and digital extensor tendons were divided into two homogeneously equal groups after removing soft tissues. Tibial tunnels were prepared with a 7-mm drill with the use of an ACL guide adjusted to 45 degrees . Each tunnel was then dilated to 9 mm in 0.5 mm increments. Digital extensor tendons were fixed at non-anatomic (group I) or anatomic (group II) tibial tunnel levels with a soft tissue metal interference screw, 9 x 30 mm in size. All the specimens were cycled 500 times from 50 to 250 N with 1 Hz frequency in a servo-hydraulic testing machine followed by ultimate load at-failure testing at a rate of 20 mm/min. Statistical analyses were made using the Mann-Whitney U-test. RESULTS: The mean screw insertion torque values were 8.2+/-2.4 Nm and 7.8+/-2.3 Nm in groups I and II, respectively (p=0.88). The mean values of graft displacement (1.9+/-0.75 mm versus 2.2+/-1.2 mm, p=0.63) and stiffness (132.72+/-10.93 N/mm versus 125.14+/-15.93 N/mm, p=0.63) did not differ significantly. CONCLUSION: The biomechanical properties of ACL reconstruction with soft tissue graft fixation using a soft tissue interference screw are not influenced by the level of tibial tunnel fixation.

Anteversion of the acetabulum and femoral neck in early walking age patients with developmental dysplasia of the hip.

Computed tomography measurements were made to quantify the relationship between the anteversion of the acetabulum and femoral neck in 27 early walking age patients (age range; 18-48 months) with developmental dysplasia of the hip. The centre-edge angle and acetabular index were measured in standard pelvis radiographs, and anteversion of acetabulum and femoral neck were measured by use of two-dimensional computed tomography in 25 complete dislocated, 19 subluxated and 10 unaffected hips (a total of 54 hips). The diagnosis of dysplasia, subluxation and complete dislocation of developmental hip dysplasia were determined radiographically using Ishida's criteria. There were statistically significant differences between the three groups for the centre-edge angle, the acetabular index, and acetabulum anteversion. There was no statistically significant difference between the three groups for femoral neck anteversion. The acetabular anteversion was found to be 13.4+/-2.8 degrees (mean+/-SD) in unaffected hips, 16.7+/-1.9 degrees in subluxated hips and 19.8+/-2.5 degrees in complete dislocated hips. There was statistically significant difference between the three groups, with a wide range of acetabular anteversion values noted in all groups (9-26 degrees ). The acetabular anteversion was increased on the dislocated side in each patient and we found no retroverted acetabulum. On the other hand there was no significant difference between the groups with regards to femoral neck anteversion. We conclude that confirming anteversion of the acetabulum and the femoral neck by two-dimensional computed tomography is needed in treatment planning of early walking age patients with developmental hip dysplasia.

Orthopaedic techniques of Sabuncuoglu in the 15th century Ottoman period.

Serefeddin Sabuncuoglu (1385-1468) was the author of the surgical textbook Cerrahiyyetü'l-Haniyye (Imperial Surgery). It was the first illustrated surgical textbook in the Turkish-Islamic medical literature. Cerrahiyyetü'l-Haniyye is significant because it includes Sabuncuoglu's color illustrations of surgical procedures, incisions, fracture dislocation reduction techniques, and instruments. There are only three handwritten copies. Two originally were written by Sabuncuoglu and are exhibited in Paris and Istanbul. The book was rediscovered in 1936, but some parts are suspected to be missing. The book currently consists of three chapters divided into 193 sections. The third chapter includes orthopaedics and traumatology, reduction techniques of lower and upper extremities, fractures and dislocations, and relevant Greek, Arabic, and Persian textbooks are cited. Sabuncuoglu also wrote about surgical treatment of congenital hand anomalies. He was the first to advise placing a wooden splint under the palmar side after hand surgery. We reviewed the sections of Cerrahiyyetü'l-Haniyye related to orthopaedics and traumatology. Compared with previous writings by Hippocrates, Ibn-i Sina, and Al-Zahrawi, there are no major differences in the treatment of fracture dislocations.

Plasma total antioxidant capacity, lipid peroxidation, and erythrocyte antioxidant enzyme activities in patients with rheumatoid arthritis and osteoarthritis.

OBJECTIVES: The metabolism of cells in inflammatory and noninflammatory arthritic joint diseases is subject to complex environmental controls. The aim of the present study was to investigate the total antioxidant capacity (TAC), levels of lipid peroxidation (LPO), and antioxidant enzyme activities in patients with rheumatoid arthritis (RA) and osteoarthritis (OA). DESIGN AND METHODS: Plasma levels of TAC, malondialdehyde (MDA), the activities of some erythrocyte antioxidant enzymes, as well as erythrocyte sedimentation rates (ESR) were estimated in patients with RA and OA and compared with controls. RESULTS: The plasma TAC levels were significantly lower in the RA group than the OA and control group (P < 0.05). Plasma MDA concentrations were significantly higher in patients with RA than those with OA and healthy subjects (P < 0.05). Erythrocyte GSH-Px and CAT activities were found to be significantly lower in patients with RA than those with OA and healthy subjects (P < 0.05, P < 0.05, respectively). However, there were no significant differences in erythrocyte SOD activities between the groups (P > 0.05). ESR were significantly higher in RA patients than in healthy subjects and patients with OA (P < 0.01). Moreover, there were significant negative correlations between TAC vs. MDA, ESR vs. TAC, and a positive correlation between ESR vs. MDA in the RA group (r = -0.398, P < 0.05; r = -0.422, P < 0.05; r = 0.530, P < 0.05, respectively). CONCLUSIONS: Our results demonstrated that levels of LPO are increased in patients with RA compared to patients with OA. In addition, plasma TAC levels are decreased in RA due to its inflammatory character. We conclude that detecting plasma TAC levels with this novel method may be used as a routine and rapid test to verify the levels of oxidative stress in RA. Furthermore, correlating TAC and LPO levels with acute phase reactants such as ESR may give some clues about disease activity in RA.

[The results of open surgical treatment in patients with chronic refractory lateral epicondylitis]. / Kronik, konservatif tedaviye dirençli lateral epikondilitte açik cerrahi tedavi sonuçlari.

OBJECTIVES: We evaluated the clinical and subjective functional results of open surgical treatment in patients with chronic refractory lateral epicondylitis. METHODS: Eleven patients (7 females, 4 males; mean age 42 years, range 29 to 56 years) underwent open surgical treatment for chronic refractory lateral epicondylitis. All the patients had received conservative treatment for at least a year without favorable response. Surgical procedure included release of the lateral extensor origin, excision of the degenerative tissue, decortication or drilling of the anterior lateral condyle, and repair of the extensor tendons. The results were evaluated according to the criteria proposed by Verhaar et al. The mean follow-up was 29 months (range 18 to 45 months). RESULTS: The results were excellent or good in 10 patients (90.9%) and acceptable in one patient (9.1%). The mean time to return to work was two months. Nine patients were free of pain in the forearm in the postoperative third month. No wound-related complications were encountered. On subjective evaluations, 10 patients reported full satisfaction, and one patient reported partial satisfaction with the result of the treatment. CONCLUSION: Open surgical procedure including release of the origins of the common extensor tendons and excision of the degenerative tissue yields favorable results in the treatment of patients with chronic refractory lateral epicondylitis.

Aplasia of the pubic bone in conjunction with hip dislocation.

We describe here unilateral left hip dislocation in a 2-year-old child in conjunction with ipsilateral absence of the pubic bone. He was admitted to our hospital at 1 year of age and diagnosed with teratogenic dislocation of the left hip, aplasia of the left pubic bone, an undescended palpable left testicle and hypospadias. We performed open reduction through an anterior approach with preliminary skin traction for 1 week and spica cast for 3 months. The acetabular index was high both on admission and in the last radiographic control. Computerized tomography demonstrated dysplasia of the acetabulum and absence of the pubic bone. We concluded that the congenital absence of the left pubis was the major cause of the residual acetabular dysplasia. To our knowledge the conjunction of hip dislocation, aplasia of pubic bone and genitourinary anomalies has not been reported in the orthopaedic literature previously.

[The effect of anterior or posterior tibial tunnel placement of a soft tissue graft with a soft tissue interference screw on fixation biomechanics]. / On çapraz bag rekonstrüksiyonunda tendon greftinin yumusak doku interferans vidasi ile tibial tünelde öne veya arkaya tespitinin biyomekanik etkisi.

OBJECTIVES: We investigated the biomechanical characteristics of anterior or posterior tibial tunnel placement of the soft tissue graft with a soft tissue interference screw in anterior cruciate ligament (ACL) reconstruction. METHODS: Twelve bovine tibiae and digital extensor tendons were divided into two homogeneously equal groups after they were stripped of all soft tissues. Tibial tunnels were prepared and digital extensor tendons were fixed at nonanatomic (apart from the joint) anterior (n=6, group I) or posterior (n=6, group II) tibial tunnel positions with a soft tissue metal interference screw, 9x30 mm in size. All the specimens were cycled 500 times from 50 to 250 N at 1 Hz frequency in a servo hydraulic test device, after which ultimate load-at-failure testing was performed at a rate of 20 mm/min. RESULTS: The mean screw insertion torque values were 8.2+/-2.4 Nm and 8.4+/-2.8 Nm in groups I and II, respectively (p=0.88). No significant differences were found between the two groups with respect to graft displacement (1.9+/-0.8 mm vs 2.3+/-0.4 mm; p=0.38) and stiffness (132.7+/-10.9 N/mm vs 126.4+/-8.5 N/mm, p=0.98) at the end of cyclic loading. CONCLUSION: Our results show that the site of nonanatomic soft tissue graft fixation in the tibial tunnel (anterior or posterior) with a soft tissue interference screw do not affect the biomechanical parameters in ACL reconstruction.