The effect of body awareness on trunk control, affected upper extremity function, balance, fear of falling, functional level, and level of independence in patients with stroke.

OBJECTIVES: This study was conducted to examine the effects of body awareness on trunk control, affected upper extremity function, balance, fear of falling, functional level, and level of independence in patients with stroke. METHODS: 35 individuals between the ages of 21 and 78 who were diagnosed with stroke were included in the study. The body awareness of the individuals participating in the study was determined with the Body Awareness Questionnaire (BAQ), trunk control with Trunk Impairment Scale (TIS), the affected upper extremity functions with Motor Activity Log-28 (MAL,-28), and Fugl-Meyer Upper Extremity Assessment (FMUEA), balance with Berg Balance Scale (BBS), fear of falling with Tinetti Falls Efficacy Scale (TFES), functional level with Barthel Activities of Daily Living Index (BI) and level of independence with Functional Independence Measures (FIM). RESULTS: For patients participating in the study, 26% were female, 74% were male and 43% showed left, 57% showed right hemisphere involvement. In simple linear regression analysis, BAQ measurement had a statistically significant effect on TIS (F = 25.439 p = 0.001), MAL-28 (F = 7.852 p = 0.008), FMUEA (F = 12.155 p = 0.001), BBS (F = 13.506 p = 0.001), TFES (F = 13.119 p = 0.001), BI (F = 19.977 p = 0.001) and FIM (F = 22.014 p = 0.001) in patients with stroke. CONCLUSIONS: In conclusion, body awareness was found to be one of the factors affecting trunk control, affected upper extremity function, balance, fear of falling, functional level, and level of independence in patients with stroke. It was thought that there was a need for assessment of body awareness and include bodyawareness in rehabilitation programs in patients with stroke.

Lower extremity alignment due to patellofemoral syndrome and dynamic postural balance.

STUDY DESIGN: This study is a prospective study. AIM: Lower extremity malalignment is an important etiologic factor in patellofemoral pain syndrome (PFPS). We hypothesized that lower limb malalignment may affect dynamic balance and physical function. This prospective study was conducted to investigate the relationship between the lower limb alignment and the dynamic balance and physical function in patients with PFPS. METHODS: The study included 62 individuals with unilateral PFPS. Pain severity was assessed by the numerical pain scale and the pain duration was recorded. Lower extremity bone alignment was evaluated by the lateral distal femoral angle (LDFA) and the medial proximal tibia angle. Dynamic postural balance was assessed by the star excursion balance test. The functional status of the patients was evaluated by the 30-second chair stand test. RESULTS: The mean duration of the pain was 24.2 ± 31.5 months and the mean pain severity was 8.1 ± 1.4. Although there was a significant difference found between the affected and unaffected LDFA values of lower extremities (p < 0.05), there was no difference found with regard to the dynamic balance values of the lower extremities (p > 0.05). However, significant changes of posterolateral balance were identified at a painful side without causing a postural dynamic imbalance (p < 0.05). CONCLUSION: In our study, we found a valgus deformity as a deterioration in the lower limb alignment of patients with PFPS which may cause a deterioration of posterolateral balance only. However, no change in postural dynamic balance was observed in the comparison of affected side and unaffected side. Dynamic postural balance has been influenced by many kinematic changes related to lower extremities including pelvis, hip, and ankle. Thus, reciprocal mechanisms in the anatomical structures may compensate the postural balance dynamically.

The Role of Surgical Closure Position in Total Knee Arthroplasty: Flexion versus Extension-A Randomized Prospective Study.

We aimed to investigate the effect of the knee position during the surgical closure on isokinetic muscle strength, clinical score, and range of motion in total knee arthroplasty. Seventy-five eligible patients were enrolled in the study and randomly divided into two groups; wound closure was performed with the knee flexed at 90° in group 1 and knee extended in group 2. All the surgeries were performed by the same surgeon and by the same prosthesis type. All the patients received the same rehabilitation program postoperatively. The primary outcomes were the knee flexion degrees and the American Knee Society Score values at preoperative and postoperative 6 weeks, 3, and 6 months. The secondary outcome was the isokinetic muscle strength measurements of both knees before the surgery and after 6 months. There were no significant differences in the American Knee Society Scores and knee flexion degrees between the flexion and extension groups. However, a significant decrease was found in the extensor muscle strength in the extension group after 6 months of the surgery. The findings of our study are that the closing of the knee in flexion or extension does not affect the postoperative knee flexion degrees and scores in total knee arthroplasty. However, quadriceps strength recovers early if the knee closure is performed in flexion position.

The Evaluation of Exogenous Melatonin Administration in Supraspinatus Overuse Tendinopathy in an Experimental Rat Model.

BACKGROUND: Increased oxidative stress and inflammation play a critical role in the etiopathogenesis of chronic tendinopathy. Melatonin is an endogenous molecule that exhibits antioxidant and anti-inflammatory activity. The aim of this study was to evaluate the biochemical and histopathological effects of exogenous melatonin administrations in supraspinatus overuse tendinopathy. METHODS: Fifty rats were divided into the following four groups: cage activity, melatonin treatment, corticosteriod therapy, and control. Melatonin (10 mg/kg, intraperitoneal; twice a day) and triamcinolone (0.3 mg/kg, subacromial; weekly) were administered to the treatment groups after the overuse period. Biochemical and histopathological evaluations were performed on serum samples and biopsies obtained from rats. Plasma inducible nitric oxide synthase (iNOS), vascular endothelial growth factor (VEGF), total antioxidant status (TAS), total oxidant status (TOS), and oxidative stress index (OSI) levels were evaluated biochemically. RESULTS: The TAS, TOS, OSI, iNOS, and VEGF values were significantly lower than the pre-treatment levels in rats receiving exogenous melatonin treatment (3 or 6 weeks) (p<0.05). TOS, iNOS, VEGF, and OSI values after 3 weeks of triamcinolone administration, and TOS, VEGF, and OSI levels after 6 weeks of triamcinolone application, were significantly lower than the pre-treatment levels (p<0.05). CONCLUSIONS: Exogenous melatonin application in overuse tendinopathy reduces oxidative stress and inflammation. Melatonin might be an alternative potential molecule to corticosteroids in the treatment of chronic tendinopathy.

Subacromial space volume in patients with rotator cuff tear: The effect of surgical repair.

OBJECTIVE: The aim of this study was to evaluate the effect of the rotator cuff tear repair on subacromial space volume. METHODS: We retrospectively identified 21 eligible patients (5 males and 16 females; mean age: 56.4 (range; 46-71) years) who had shoulder arthroscopy for unilateral full-thickness small to medium rotator cuff tear and normal controlateral shoulder joint. The mean follow-up time was 16.1 (range; 12-25) months. Preoperative and postoperative 1 year bilateral shoulder MRIs and Constant scores were reviewed. Subacromial volume was calculated by using Osirix software. Pre-, postoperative and healthy side (contralateral control group) subacromial volumes were recorded. Paired sample and t-tests were used to compare the pre- and postoperative groups. Independent sample t-tests were used to compare the healthy and pre- and postoperative groups. The correlation between the changes in the subacromial volume and the shoulder Constant score were analyzed using Pearson correlation analyses. RESULTS: The mean subacromial volume of the preoperative group was 2.95 cm3 (range; 1.53-4.23) and the postoperative group was 3.59 cm3 (range; 2.12-4.84). The volume increase was statistically significant (p < 0.05). The mean subacromial volume of the control group was 3.93 cm3 (range; 2.77-5.03), and the difference between the preoperative group and the control group was statistically significant. There was no significant difference found between the postoperative group and the control group (p = 0.156). There was no significant correlation found between the volume and the constant score changes (r = 0.170, p = 0.515). CONCLUSION: The subacromial space volume significantly decreases in full-thickness rotator cuff tears smaller than 3 cm and the surgical repair increases the subacromial volume significantly. LEVEL OF EVIDENCE: Level IV; Diagnostic Study.

Acetabular components with or without screws in total hip arthroplasty.

AIM: To compare the operation time, blood loss, and early outcomes of acetabular components with and without the screw. METHODS: Thirty patients who underwent cementless acetabular component with or without screw and whose follow-up exceeded one year period in total hip arthroplasty were evaluated. A posterior approach was used in all surgical procedures by one experienced surgeon. Demographic data, operation time, intra- and postoperative blood loss volume, follow-up clinical score, cup migration, and osteolysis were recorded. The Kolmogorov-Smirnov test was performed for testing the normality of study data. Mann-Whitney U test was used to analyze the inter-group differences. A P-value of ≤ 0.05 was considered statistically significant. RESULTS: Acetabular components were used in 16 (53.3%) patients with screw and 14 (46.7%) without screw. After one year of follow-up, an osteolytic lesion of 3 mm was found in only one patient in the screw group. No cup migration was encountered. Intra-group mean Harris hip score significantly increased, but there was no significant inter-group difference. While the mean operation time of the screw group was 121.8 min (range; 95-140), it was 102.7 min (range; 80-120) in the no-screw group, and this difference was statistically significant (P = 0.002). The mean intraoperative/postoperative, and total blood loss were 556.6 mL (range: 350-800)/423.3 mL (range: 250-600), and 983.3 mL (range: 600-1350), respectively in the screw group; and 527 mL (range: 400-700)/456 mL (range: 230-600), and 983 mL (range: 630-1250), respectively in the no-screw group. The blood loss difference between the two groups was not significant. In the screw group, the operation time was 19.1 min longer than the no-screw group, and this difference was statistically significant. CONCLUSION: Acetabular components with or without screw have similar results, but the use of screw increases the operation time significantly, while not changing the blood loss volume.

A Radiographic Dye Method for Intraoperative Evaluation of Syndesmotic Injuries.

BACKGROUND: The Chertsey test has been recently defined as an intraoperative test for the detection of the syndesmotic injuries by the application of intra-articular contrast. However, no study has investigated the reliability and comparative analysis of the Chertsey test. The purpose of this study was to explore the diagnostic accuracy of the Chertsey test in predicting syndesmosis instability of the injured ankle, with correlation to preoperative computed tomography (CT) findings. METHODS: A total of 39 patients who were operated on due to the unilateral ankle fracture and had no complaint on the contralateral ankle joint were included in the study. An intraoperative Chertsey test was performed on all ankle fractures and bilateral ankle CT was obtained preoperatively. Ankles were classified as Chertsey +, Chertsey -, and contralateral control group. The morphology categorization, width, and volume of the syndesmotic region were measured on axial images of the CT. Mann-Whitney U test was used to compare the data. Intraobserver and interobserver agreements were accessed by calculating the intraclass correlation coefficient (ICC) for radiologic parameters and the Chertsey test. RESULTS: The Chertsey test was positive in 13 (33.3%) of 39 ankle fractures. Patients with a positive Chertsey test showed a significant increase in syndesmotic width and volume compared with Chertsey - and control group. However, there was no significant difference between Chertsey - and the control group. All the ICC values were excellent for both radiologic measurements and test. CONCLUSION: The Chertsey test is a reliable and useful test that can be used intraoperatively in the diagnosis of syndesmotic injuries. LEVEL OF EVIDENCE: III, comparative series.

Use of the smartphone for end vertebra selection in scoliosis.

OBJECTIVES: The aim of our study was to develop a smartphone-aided end vertebra selection method and to investigate its effectiveness in Cobb angle measurement. METHODS: Twenty-nine adolescent idiopathic scoliosis patients' pre-operative posteroanterior scoliosis radiographs were used for end vertebra selection and Cobb angle measurement by standard method and smartphone-aided method. Measurements were performed by 7 examiners. The intraclass correlation coefficient was used to analyze selection and measurement reliability. Summary statistics of variance calculations were used to provide 95% prediction limits for the error in Cobb angle measurements. A paired 2-tailed t test was used to analyze end vertebra selection differences. RESULTS: Mean absolute Cobb angle difference was 3.6° for the manual method and 1.9° for the smartphone-aided method. Both intraobserver and interobserver reliability were found excellent in manual and smartphone set for Cobb angle measurement. Both intraobserver and interobserver reliability were found excellent in manual and smartphone set for end vertebra selection. But reliability values of manual set were lower than smartphone. Two observers selected significantly different end vertebra in their repeated selections for manual method. CONCLUSION: Smartphone-aided method for end vertebra selection and Cobb angle measurement showed excellent reliability. We can expect a reduction in measurement error rates with the widespread use of this method in clinical practice. LEVEL OF EVIDENCE: Level III, Diagnostic study.

Sagittal plane tilting deformity of the patellofemoral joint: a new concept in patients with chondromalacia patella.

PURPOSE: The aims of this study were to evaluate sagittal plane alignment in patients with chondromalacia patella via magnetic resonance imaging (MRI), analyse the relationships between the location of the patellar cartilaginous lesions and sagittal alignment and finally investigate the relationships between the sagittal plane malalignment and patellofemoral loadings using by finite element analysis. METHODS: Fifty-one patients who were diagnosed with isolated modified Outerbridge grade 3-4 patellar chondromalacia based on MRI evaluation and 51 control subjects were evaluated. Chondromalacia patella patients were divided into three subgroups according to the chondral lesion location as superior, middle and inferior. The patella-patellar tendon angle (P-PT) was used for evaluation of sagittal alignment of patellofemoral joint. Each subgroup was compared with control group by using P-PT angle. To investigate the biomechanical effects of sagittal plane malpositioning on patellofemoral joint, bone models were created at 30°, 60° and 90° knee flexion by using mean P-PT angles, which obtained from patients with chondromalacia patellae and control subjects. The total loading and contact area values of the patellofemoral joints were investigated by finite element analysis. RESULTS: The mean age of all participants was 52.9 ± 8.2 years. The mean P-PT angle was significantly lower in chondromalacia group (142.1° ± 3.6°) compared to control group (144.5° ± 5.3°) (p = 0.008). Chondral lesions were located in superior, middle and inferior zones in 16, 20 and 15 patients, respectively. The mean P-PT angles in patients with superior (141.8 ± 2.7) and inferior subgroups (139.2 ± 2.3) were significantly lower than the values in the control group (p < 0.05). The contact area values were detected higher in models with chondromalacia than in the control models at the same flexion degrees. There were increased loadings at 30° and 90° flexions in the sagittal patellar tilt models. CONCLUSION: This study revealed that sagittal plain malpositioning of the patellofemoral joint might be related to chondromalacia, especially in the presence of lesions in the upper and lower part of the patella. This condition leads to supraphysiological loadings on the patellofemoral joint. Sagittal patellar tilt should be considered in the evaluation and management of patellar cartilage defects. Taking sagittal plane malalignment into consideration in patellofemoral joint evaluation will enable us to design new physical and surgical modalities. LEVEL OF EVIDENCE: IV.

Is There Any Difference Between The Biomechanical Strengths Of The Current Fixation Techniques For Comminuted Distal Patellar Fractures? (Comparison Of Distal Patella Fracture Fixation Techniques).

In this biomechanical study, the strength of five different fixation techniques -anterior tension band wiring with K-wires, separate vertical wiring, headless compression screws with anterior tension band wiring, cannulated screws with tension band wiring and memory shape patellar fixator- for distal patellar fractures were compared. Forty calf knees were used for the biomechanical testing. Each specimen was pre-loaded with 10 N at 1 N/s. The distraction forces were applied consistently with the velocity of 5 mm/s. The ultimate load (N) and displacement (mm) values were recorded. The headless compression screw with anterior tension band wiring (656.9±167.9 N) and the cannulated screws with anterior tension band wiring (642.6±166.0 N) obtained significantly higher ultimate loading values compared to the other fixation methods (p<0.05). Fixation via cannulated screws with anterior tension band wiring techniques are more stabile than the patellar shape memory fixator and anterior K wire fixation.

Gartland Type 3 Supracondylar Humeral Fractures in Children: Which Open Reduction Approach Should Be Used After Failed Closed Reduction?

OBJECTIVES: For displaced supracondylar humeral fractures in children, in the event of closed reduction failure, anatomic reduction is achieved via open reduction techniques; however, there are no confirmative reports among the published open reduction approaches that deliver the best functional and cosmetic results. Here, we compared long-term functional and cosmetic results of different surgical approaches. DESIGN: Retrospective cohort study. SETTING: Ankara Education and Research Hospital/Turkey. Secondary care hospital and trauma center. PATIENTS/PARTICIPANTS: We evaluated 70 surgically treated Gartland type 3 supracondylar humeral fractures. Patients, with detailed history record, were divided into 5 groups with respect to surgery methods. INTERVENTION: All patients were treated surgically using closed reduction and percutaneous pinning or 4 different open reduction approaches and percutaneous pinning. MAIN OUTCOME MEASURES: Flynn cosmetic and functional score results were compared between surgical groups. RESULTS: Posterior open reduction and triceps transection groups showed worst results, whereas medial and lateral open reduction groups showed good to excellent results similar to closed reduction group. CONCLUSION: Medial and lateral approaches demonstrated better functional results than posterior and triceps transection approaches. Posterior approaches lead to restrictions in extension and poor functional results. In the posterior approach, transecting triceps from olecranon does not benefit from fracture reduction but results in loss of triceps strength and should be avoided. In failed closed reduction, medial and lateral open reduction approaches lead to similar cosmetic outcomes and functional results that are only slightly worse compared with those in closed reduction. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Evaluation of Reduction Accuracy of Suture-Button and Screw Fixation Techniques for Syndesmotic Injuries.

BACKGROUND: Among the most important predictors of functional results of treatment of syndesmotic injuries is the accurate restoration of the syndesmotic space. The purpose of this study was to investigate the reduction performance of screw fixation and suture-button techniques using images obtained from computed tomography (CT) scans. METHODS: Patients at or below 65 years who were treated with screw or suture-button fixation for syndesmotic injuries accompanying ankle fractures between January 2012 and March 2015 were retrospectively reviewed in our regional trauma unit. A total of 52 patients were included in the present study. Fixation was performed with syndesmotic screws in 26 patients and suture-button fixation in 26 patients. The patients were divided into 2 groups according to the fixation methods. Postoperative CT scans were used for radiologic evaluation. Four parameters (anteroposterior reduction, rotational reduction, the cross-sectional syndesmotic area, and the distal tibiofibular volumes) were taken into consideration for the radiologic assessment. Functional evaluation of patients was done using the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scale at the final follow-up. The mean follow-up period was 16.7 ± 11.0 months, and the mean age was 44.1 ± 13.2. RESULTS: There was a statistically significant decrease in the degree of fibular rotation (P = .03) and an increase in the upper syndesmotic area (P = .006) compared with the contralateral limb in the screw fixation group. In the suture-button fixation group, there was a statistically significant increase in the lower syndesmotic area (P = .02) and distal tibiofibular volumes (P = .04) compared with the contralateral limbs. The mean AOFAS scores were 88.4 ± 9.2 and 86.1 ± 14.0 in the suture-button fixation and screw fixation group, respectively. There was no statistically significant difference in the functional ankle joint scores between the groups. CONCLUSION: Although the functional outcomes were similar, the restoration of the fibular rotation in the treatment of syndesmotic injuries by screw fixation was troublesome and the volume of the distal tibiofibular space increased with the suture-button fixation technique. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

The effects of the sagittal plane malpositioning of the patella and concomitant quadriceps hypotrophy on the patellofemoral joint: a finite element analysis.

PURPOSE: Anterior knee pain is a common symptom after intramedullary nailing in tibia shaft fracture. Moreover, patellofemoral malalignment is also known to be a major reason for anterior knee pain. Patellofemoral malalignment predisposes to increased loading in patellar cartilage. In the previous study, we have demonstrated the quadriceps atrophy and patellofemoral malalignment after intramedullary nailing due to tibia shaft fracture. In this study, our aim was to clarify the effects of quadriceps atrophy and patellofemoral malalignment with the pathologic loading on the joint cartilage. METHODS: Mesh models of patellofemoral joint were constructed with CT images and integrated with soft tissue components such as menisci and ligaments. Physiological and sagittal tilt models during extension and flexion at 15°, 30° and 60° were created generating eight models. All the models were applied with 137 N force to present the effects of normal loading and 115.7 N force for the simulation of quadriceps atrophy. Different degrees of loading were applied to evaluate the joint contact area and pressure value with the finite element analysis. RESULTS: There was increased patellofemoral contact area in patellar tilt models with respect to normal models. The similar loading patterns were diagnosed in all models at 0° and 15° knee flexion when 137 N force was applied. Higher loading values were obtained at 30° and 60° knee flexions in sagittal tilt models. Furthermore, in the sagittal tilt models, in which the quadriceps atrophy was simulated, the loadings at 30° and 60° knee flexion were higher than in the physiological ones. CONCLUSIONS: Sagittal malalignment of the patellofemoral joint is a new concept that results in different loading patterns in the patellofemoral joint biomechanics. This malalignment in sagittal plane leads to increased loading values on the patellofemoral joint at 30° and 60° of the knee flexions. This new concept should be kept in mind during the course of diagnosis and treatment in patients with anterior knee pain. Definition of the exact biomechanical effects of the sagittal tilting will lead to the development of new treatment modalities.

Arthroscopic treatment of synovial chondromatosis in the ankle joint.

INTRODUCTION: Synovial chondromatosis is characterized by the presence of metaplastic cartilage nodules originating from the synovia, bursa and tendon sheaths. Although it is extremely rare in the ankle joint, malignant transformation is possible. The choice of treatment is usually open surgery for excision of loose bodies and synovectomy. Limited data is available concerning arthroscopic approaches. PRESENTATION OF CASE: A 28-year-old male patient was evaluated for pain and swelling of the right ankle joint. Based on the findings of physical examination and radiographic investigations, arthroscopic surgery was performed due to ankle impingement syndrome. A diagnosis of synovial osteochondromatosis was made following the pathological survey. DISCUSSION: Synovial chondromatosis is slowly progressive and is considered to be a self-limiting situation. Treatment strategies are decided on according to the patient's complaints, age and disease stage. Open or arthroscopic surgery. can be performed. Some advantages of arthroscopic surgery are wide visualization areas, easy access to areas difficult to reach, lower morbidity, no necessity for casting and immobilization, early rehabilitation and quick recovery period. CONCLUSION: In conclusion, arthroscopic management can be successful in selected patients with synovial osteochondromatosis localized to the ankle joint.

Aperture fixation instead of transverse tunnels at the patella for medial patellofemoral ligament reconstruction.

PURPOSE: Medial patellofemoral ligament (MPFL) reconstruction is an effective option for the treatment of recurrent patellar instability. Most techniques utilize the passage of a tendon graft through tunnels at the patella with the risk of patellar fracture. The purpose of this study was to investigate the strength of the recent MPFL reconstruction techniques (transverse tunnel, interference screw, anchor, and docking technique). METHODS: Thirty-six saw bones were divided into four groups (transverse tunnel, interference screw, anchor fixation, and docking technique) with nine patellae in each. Patella-tendon constructs were pre-loaded to 10 N and cyclically loaded for 20 cycles from 2 to 30 N under load control at a rate of 5 N/sec. The construct was then tested to failure at a constant displacement rate of 6 mm/sec. Ultimate load (N), stiffness (N/mm), and failure mode were recorded for each specimen. RESULTS: The docking group had lower ultimate load [106 (SD 41) N] and stiffness [14 (SD 2) N/mm] values than the other groups tested (P = 0.007). The anchor group had lower stiffness [21 (SD 6) N/mm] values than the tunnel group [28 (SD 3) N/mm (P = 0.01)] and the interference screw group [31 (SD 6) N/mm, (P = 0.004)]. There was no significant difference in the ultimate load between anchor [299 (SD 116) N], tunnel [304 (SD 140) N], and interference screw groups [241 (SD 103) N] (n.s.). CONCLUSION: Aperture fixation techniques, especially interference screw fixation, were as strong as the technique utilizing tunnels in the patella for MPFL reconstruction.