Will a single periarticular lidocaine-corticosteroid injection improve the clinical efficacy of intraarticular hyaluronic acid treatment of symptomatic knee osteoarthritis?

PURPOSE: A local injection of corticosteroid-lidocaine into the periarticular soft tissue structures is used commonly for rapid pain relief. It is hypothesized that knee pain associated with knee osteoarthritis would be relieved quickly and effectively in patients receiving intraarticular hyaluronic acid combined with a periarticular lidocaine-corticosteroid injection. To test this hypothesis, the clinical effect of the combined treatment with hyaluronic acid injection alone in patients with symptomatic knee osteoarthritis as compared in this prospective single-blinded randomized trial. METHODS: This study included 70 patients. Group 1 (n = 35) received intraarticular hyaluronic acid injections only, whereas group 2 (n = 35) received intraarticular hyaluronic acid injections combined with a single local injection of corticosteroid-lidocaine. Injections were administered to the most painful areas of the anterior or posterior medial condyle of the femur or tibia. The outcome was measured by independent assessors (blinded to treatment) using a linear VAS pain scale and WOMAC and HSS knee scores. Assessments were performed at baseline and at 1, 3, 6, 12, 26, and 52 weeks. RESULTS: During the first 3 weeks, group 2 patients showed significantly better all scores than did group 1 patients (p < 0.01). However, no significant differences were detected at 6, 12, 26 or 52 weeks (n.s.). CONCLUSION: The combined treatment may lead to earlier pain relief compared with intraarticular hyaluronic acid alone in patients with knee osteoarthritis and can be considered a useful adjunctive treatment modality. This combined method may provide early return to patient's daily activity. LEVEL OF EVIDENCE: Therapeutic study, Level I.

Clinical and radiographic outcomes of medial open-wedge high tibial osteotomy with Anthony-K plate: prospective minimum five year follow-up data.

PURPOSE: The purpose of this study was to prospectively evaluate the clinical and radiographic outcomes, and complication rates, after a minimum of five years of follow-up after medial open wedge high tibial osteotomy (MOWHTO) using an Anthony-K plate. METHODS: MOWHTO was performed on 35 knees of 34 consecutive patients. A visual analogue scale (VAS), and Western Ontario and McMaster University Osteoarthritis (WOMAC) and Lysholm scores, were used in clinical evaluation. Upon radiographic assessment, alignment was expressed as the femorotibial angle (FTA). The posterior tibial slope (PTS) and the Insall-Salvati Index (ISI) were also measured. RESULTS: VAS, WOMAC, and Lysholm scores improved significantly upon follow-up (p < 0.001 for all). The overall mean FTA was 4.68 ± 4.39° varus pre-operatively; at the last post-operative follow-up, the value was 8.43 ± 2.02° valgus. The mean correction angle was 13.1 ± 2.7°. A significant increase in PTS was evident (p < 0.01), as was a significant decrease in the ISI (p < 0.01). The overall complication rate was 8.6 %. CONCLUSIONS: The Anthony-K plate affords accurate correction, initially stabilises the osteotomy after surgery, and maintains such stability until the osteotomy gap is completely healed, without correction loss. The plate survival rate was 97.2 % after a minimum of five years of follow-up. The plate increased the PTS, as do other medial osteotomy fixation plates.

Mitchell's osteotomy with mini-plate and screw fixation for hallux valgus.

BACKGROUND: The aim of this study was to evaluate the use of mini-plate and screw fixation to stabilize the first metatarsal osteotomy in patients undergoing Mitchell bunionectomy, with the outcomes of interest being radiological alignment and the time to bony union. METHODS: We used mini-plates and screws in 43 feet of 25 patients to avoid cast immobilization and prevent osteotomy displacement. The mean age at operation was 45.4 ± 13.4 years (range, 17.0-65.0 years). The mean follow-up was 16.9 ± 3.6 months (range, 12.0-30.0 months). The hallux valgus angles, intermetatarsal angles, and American Orthopaedic Foot and Ankle Society (AOFAS) forefoot scores were evaluated preoperatively and at postoperative month 12. RESULTS: The mean preoperative value for the hallux valgus angle was 35.9 ± 4.4 degrees (range, 26.0-45.0 degrees) and for the intermetatarsal angle was 12.1 ± 1.4 degrees (range, 10.0-15.0 degrees). The mean postoperative value for the hallux valgus angle was 16.0 ± 2.12 degrees (range, 12.0-20.0 degrees) and for the intermetatarsal angle was 7.7 ± 1.2 degrees (range, 5.0-10.0 degrees). The mean AOFAS score was 50.5 ± 12.8 points (range, 30.1-76.0 points) preoperatively and 75.9 ± 11.3 points (range, 43.3-92.3 points) at postoperative month 12. Improvement of range of motion of the metatarsophalangeal joint, pain relief, and satisfactory alignment of the first ray were achieved in 41 feet (95.3%). CONCLUSIONS: We recommend this fixation for Mitchell's bunionectomy because it provided stable fixation without the need for casting. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Review of Van earthquakes form an orthopaedic perspective: a multicentre retrospective study.

PURPOSE: This is a descriptive analysis, of victims of Turkey's October 23, 2011 and November 21, 2011 Van earthquakes. The goal of this study is investigated the injury profile of the both earthquakes in relation to musculoskeletal trauma. METHODS: We retrospectively reviewed medical records of 3,965 patients admitted to in seven hospitals. A large share of these injuries were soft tissue injuries, followed by fractures, crush injuries, crush syndromes, nerve injuries, vascular injuries, compartment syndrome and joint dislocations. A total of 73 crush injuries were diagnosed and 31 of them were developed compartment syndrome. RESULTS: The patients with closed undisplaced fractures were treated with casting braces. For closed unstable fractures with good skin and soft-tissue conditions, open reduction and internal fixation was performed. All patients with open fracture had an external fixator applied after adequate debridement. Thirty one of 40 patients with compartment syndrome were treated by fasciotomy. For twelve of them, amputation was necessary. The most common procedure performed was debridement, followed by open reduction and internal fixation and closed reduction-casting, respectively. CONCLUSIONS: The results of this study may provide the basis for future development of strategy to optimise attempts at rescue and plan treatment of survivors with musculoskeletal injuries after earthquakes.

Sonographic evaluation of subclinical entheseal involvement in patients with Behçet disease.

OBJECTIVE: The aim of the current study was to determine the prevalence of subclinical entheseal involvement in patients with Behçet disease via ultrasound using a newly developed method, the Madrid sonography enthesitis index. SUBJECTS AND METHODS: The study was conducted with 36 patients with Behçet disease and 46 healthy sex- and age-matched control subjects. All patients with Behçet disease who had no clinical evidence of arthritis or enthesitis underwent an ultrasound examination. All sonographic findings were identified according to the Madrid sonography enthesitis index. Madrid sonography enthesitis index values of patients and control subjects were compared by Student t test and Mann-Whitney U test. Validity was analyzed by receiver operating characteristic curve. RESULTS: Total enthesitis score was 12.16 ± 6.16 among patients with Behçet disease and 2.06 ± 2.18 among healthy control subjects (p < 0.001). The receiver operating characteristic curve established an ultrasound score greater than 4.5 in the Behçet disease group as the best cut-off point differentiating case subjects from control subjects. This cutoff was exceeded by 88.8% of the patients with Behçet disease. When the Madrid sonography enthesitis index score in each affected enthesis was evaluated, patients with Behçet disease had significantly higher scores than did control subjects when all entheseal sites were compared (all p values < 0.05). CONCLUSION: This is the first study to our knowledge to show significant subclinical enthesopathy of the triceps tendon enthesis in patients with Behçet disease who had no arthritic involvement. These data suggest that the Madrid sonography enthesitis index scoring system for sonographic detection of enthesopathy should be incorporated into the clinical protocol for evaluating patients with Behçet disease in routine clinical practice.

Hunter's technique without Hunter's rod.

Silicon rods initially advocated by Hunter have been widely used in two-stage flexor tendon reconstruction. Two-stage tendoplasty is an expensive procedure; with the addition of the high cost of rods, it is still more expensive. An experimental study investigated cheaper alternatives to silicon rods, but no clinical studies seem to have been reported so far. This study involved 17 patients undergoing two stage flexor tendon grafting. In all fingers, silicon urinary catheters were used as tendon prosthesis. The Wehbe et al modification of the Boyes and Stark classification was used for preoperative classification and Strickland formulation and Buck-Gramcko criteria for postoperative analysis. This clinical study showed that comparable clinical results and proper pseudosheaths for tendon grafting with similar histological and physical features can be obtained using a silicon urinary catheter which is fifty times less costly than Hunter's rod.

Neglected bilateral femoral neck fracture associated with pregnancy and primary hyperparathyroidism.

We report a case of neglected bilateral femoral neck fracture related with transient osteoporosis in pregnancy (TOP) and primary hyperparathyroidism, in a 33-year-old female who presented with a fracture of both femoral necks without any history of trauma 20 days after delivery. Her pain was at first accepted as common musculoskeletal discomfort following labour, and the final diagnosis was made only 25 days after fracture. She was treated with primary internal fixation with cannulated lag screws and received medical treatment for hyperparathyroidism and TOP. She was followed up for 29 months following the operation. No complications, and more specifically no avascular necrosis (AVN) were noted during this time interval. The patient made a complete functional recovery. We would like to emphasize that major medical problems may be underdiagnosed during the last pregnancy trimester and postpartum period. Delay in the diagnosis and treatment of a femoral neck fracture is an important but not a decisive factor for the development of AVN.

Retendo (mucopolygen complex) effects on achille tendon healing.

INTRODUCTION: The injuries of achilles tendon which is among the most important tendons in the body include many problems. Limited tendon recovery is provided through the surgical procedures available. Re-rupture occurs during and after recovery and the long time it takes to return to work, impossibility of early movement of the affected ankle and not being able to provide a physiological recovery in tendon constitute a problem. Thus, our objective in this study was to demonstrate the recovery effects of Retendon (mucopolygen complex) on achilles tendon. MATERIAL-METHOD: After taking the consent of the ethics board we applied for animal experiments, the experiment animals in our study were separated into two groups as those which were given Retendo® (Mucopolygen Complex - Mucopolysaccharides, Hydrolyzed Collagen Type I, Vitamin C) and the control group. These two groups were separated into four groups. In a total of eight groups, 40 female Wistar-Albino rats with an average weight of 200-350 gr. were included in the study. RESULTS: The study had biomechanical and histological results. While there was no significant difference in vascularization, inflamation and fibroblastic level among the groups in histological terms, collagen formation was detected to be more regular in the experiment group than the control group. A significant efficiency couldn't be acquired in biomechanical terms. DISCUSSION: Although Retendo® (mucopolygen complex) is commonly used in muscle and tendon diseases, its effect mechanism is not definitely known. But in the light of the findings we acquired in our study, we detected that Retendo® (mucopolygen complex) applied after achilles tendon ruptures positively effected collagen sequencing during recovery in histological terms but didn't have a significant effect on the mean load achilles tendon can tolerate before rupturing.

Mini-open technique for the achilles tenotomy in correction of idiopathic clubfoot: a report of 25 cases.

Achilles tenotomy is performed for the residual equinus deformity in the Ponseti method of clubfoot treatment. In the present article, we describe a mini-open Achilles tenotomy technique to prevent complications that could occur during tenotomy. This technique was performed on 15 patients (25 feet) during a 3-year period in our clinic on patients whose equinus deformities could not have been corrected by manipulations. Clear improvement (mean angle, 30 degrees ) was observed in equinus in our patients, and we have not seen any complication in this method. We conclude that direct visualizing of the tendon with mini-open incision may reduce the risk of neurovascular injury, especially for surgeons who are not experienced.

The effect of erythropoietin on biomechanical properties of the Achilles tendon during the healing process: an experimental study.

BACKGROUND: The aim of this study was to examine the potential biomechanical and histological benefits of systemic erythropoietin administration during the healing of Achilles tendon injury in a rat experimental model. METHODS: Eighty Sprague-Dawley female rats were included in this study. Animals were randomly assigned into two groups with 40 animals in each: erythropoietin group and control group. Then each group was further divided into four subgroups corresponding to four time points with 10 animals in each. A full-thickness cut was made on the Achilles tendon of each animal and then the tendon was sutured with modified Kessler method. Erythropoietin groups received intraperitoneal erythropoietin (500 IU/kg/day) every day at same time throughout the study period, and the control groups received saline in a similar manner. Animals were sacrificed at four time points, and tensile test was performed on each tendon sample to assess maximum load for each sample. In addition, histopathological examination and scoring was done. RESULTS: Both groups had improvement on tensile test (maximum load) over time. However, groups did not differ with regard to maximum load in any of the time points. Similarly, groups did not differ with regard to any of the histopathological scores over time. CONCLUSIONS: The findings of this study do not support the benefit of systemic erythropoietin administration in Achilles tendon healing process. Further evidence from larger experimental studies is required to justify any such potential benefit.

The effect of dexketoprofen trometamol on the healing of diaphysis fractures of rat tibia.

OBJECTIVE: The aim of this study was to analyze the effect of dexketoprofen trometamol, a non-steroidal anti-inflammatory drug, on fracture healing. METHODS: Closed tibia fracture was created in the right tibia of 60 male Wistar albino rats. Fixation was achieved by closed reduction and 0.5 mm intramedullary nails. Intramuscular dexketoprofen trometamol was administered at a dose of 5 mg/kg daily to the 30 rats in the study group. Rats were sacrificed in groups of 10 at the 2nd, 4th, and 6th weeks following the fracture. Fracture healing was compared mechanically, radiologically, and histopathologically between the groups. RESULTS: There was no statistically significant difference between the study and control groups in terms of mean values of radiological or histopathological scores at the 2nd, 4th and 6th weeks (p>0.05). Biomechanical evaluation could not be conducted in all rats in the study and control groups at the 2nd week due to early stage fracture healing. Mean biomechanical examination values were not statistically significant at the 4th and 6th weeks between the study and control groups (p>0.05). CONCLUSION: No radiological, biomechanical, and histological effects were detected in the healing of closed fractures of the tibia fixed with intramedullary nail with the long-term use of dexketoprofen trometamol. Dexketoprofen trometamol may be used in patients undergoing surgical fixation for traumatic fractures, taking into account other drugs administered together.

Medicinal plant extract (Ankaferd Blood Stopper) application in deep tissue injuries in rats: histopathological investigation of the effect on regional and systemic tissues.

BACKGROUND: This study was planned to evaluate both the histopathological changes under light microscope as well as the systemic organ effects following application of Ankaferd Blood Stopper® (ABS) (a mixture of five plant extracts) in an animal model of deep tissue hemorrhage. METHODS: A total of 50 Wistar Albino rats were divided into five groups of 10 rats each. The rats underwent femoral vein puncture and were treated with ABS tampon, ABS spray, or Surgicel, and one group was left untreated. After two weeks, each group underwent partial tissue excision from the same femoral region as well as from the brain, heart, kidney, and liver. RESULTS: The specimens from all groups were obtained from the femoral region after two weeks and evaluated under light microscope. The light microscope revealed no histopathological changes in neurovascular structures or in deep connective tissues in any of the groups. CONCLUSION: ABS provided hemostasis and was observed to stop bleeding. There were no histopathological changes at the tissue level and no pathological effects in other organs tissues under light microscope, and the remote organ tissue remained clear.

Negative pressure wound therapy and skin graft in madura foot treatment.

Madura foot is a rare, loca, chronic granulomatous skin infection which commonly affects the adult male foot. Medical treatment reduces the size of the lesion but surgical excision is necessary for radical treatment. We present a case of a 59 year old male farmer diagnosed as actinomadura of the right foot treated with medical treatment, total excision, negative pressure wound therapy and split thickness skin graft.

The diagnostic value of diffusion-weighted magnetic resonance imaging in soft tissue abscesses.

PURPOSE: To study the diagnostic value of diffusion-weighted imaging (DWI) in soft tissue abscesses. MATERIALS AND METHODS: Fifty patients were included in this study who were thought to have soft tissue abscess or cystic lesion as a result of clinical and radiological examinations. Localisations of the lesions were: 1 periorbital, 3 breast, 14 intraabdominal, and 32 intramuscular lesions. After other radiological examinations, DWI was performed. The signal intensity values of the lesions were evaluated qualitatively according to the hyperintensity on b-1000 DWI, using 1.5 T MR system. All of the lesions were aspirated after DWI, and detection of pus in the aspiration material was accepted as gold standard for the diagnosis of abscess. RESULTS: In 38 of the 50 patients, hyperintensity was obtained on diffusion-weighted images. False-positive results were maintained in 2 of these patients, and true-positive results were maintained in 36 of them. In 11 of the 50 patients, hypointensity was visualised on diffusion-weighted images. False-negative results were maintained in 3 of these patients, and true-negative results were maintained in 8 of them. An abscess which was seen on post-contrast conventional MRI could not be seen on DWI, and this was regarded as false-negative. CONCLUSION: The sensitivity and specificity of diffusion-weighted images for detecting soft tissue abscesses were found to be 92% and 80%, respectively. DWI has a high diagnostic value in soft tissue abscesses, and is an important imaging modality that may be used for the differentiation of cysts and abscesses.

Comparison of anti-edema effects of iloprost and diclofenac sodium on traumatic rat paw edema.

OBJECTIVES: The aim of this study was to compare the anti-edema effects of a stable prostacyclin analogue, iloprost, with parenteral and local forms of a non-steroidal anti-inflammatory drug, diclofenac sodium, on traumatic soft tissue edema. METHODS: Thirty-two adult male rats were randomly divided into 4 equal groups. Traumatic edema in one paw of each rat was produced by established protocol. Different drugs were then administered to each group: intraperitoneal (i.p.) saline (group 1, control group), topical diclofenac gel (group 2), i.p. diclofenac sodium (group 3), and i.p. iloprost (group 4). The volume of the paws was measured at baseline (before trauma) and at 1 hour, 2 hours, 4 hours, 8 hours, 24 hours, 48 hours, and 72 hours after trauma. The anti-edema effects of these 3 drugs (diclofenac gel, diclofenac sodium i.p., iloprost i.p.) were compared to each other and to the control group. RESULTS: The greatest increase in paw edema in the first, second and fourth hours was seen in the control and iloprost groups. At the 4-hour measurement, edema levels were all equal except control group. Following 4- and 8-hour measurements, edema began to decrease in all groups. After 8 and 24 hours, the fastest decrease in edema was in iloprost group, with complete resolution of edema by 72 hours. The next fastest decrease in paw volume was seen with i.p. diclofenac sodium, followed by diclofenac gel. CONCLUSION: Iloprost has experimentally higher anti-edema effect than diclofenac sodium for the conservative treatment of the traumatic soft tissue edema.

Treatment of gun-shot defect of the foot with bovine collagen matrix application.

Nonoperative therapy might be chosen for patients with small wounds or defects around the foot and ankle region. Lyophilized bovine collagen matrix is one of ideal biological dressings used in wound treatment. We present an example of type 1 bovine collagen (Gelfix, Euroresearch, Inc., Milano, Italy) usage in a complex gun-shot wound of the foot and relevant literature is discussed.

"Ring leg deformity" in Bartsocas-Pappas syndrome.

INTRODUCTION: We reported an extremely rare foot deformity in Bartsocas-Pappas syndrome. This patient family is from Van that is a city in the east part of Turkey and the family is Turkish origin. In literature review we find only two cases resembling to this deformity. CASE PRESENTATION: A 20-day-old infant with an extremely rare type lower extremity anomaly. There was a skin band between the syndactylia 2nd and 3rd toes of the right and left feet. CONCLUSION: This deformity resembles to a ring. We could not find a specific name for this anomaly. Therefore we want to advise a name "ring leg" deformity to describe this deformity.

Effect of Zofenopril on regeneration of sciatic nerve crush injury in a rat model.

BACKGROUND: Zofenopril is an antioxidant agent which has been shown to have beneficial effects in hypertension and heart failure. The aim of this study was to test the effects of Zofenopril on nerve regeneration and scarring in a rat model of peripheral nerve crush injury. METHODS: Twenty-one adult Sprague-Dawley rats underwent a surgical procedure involving right sciatic nerve crush injury. 15 mg/kg Zofenopril was administered orally to seven rats in group Z for seven days. Seven rats in group S received saline orally for seven days. Seven rats in the control group C received no drug after crush injury. Fourteenth and 42nd days after injury, functional and electromyography assessments of nerves were performed. Functional recovery was analyzed using a walking track assessment, and quantified using the sciatic functional index (SFI). After these evaluations, all rats were sacrificed and microscopic evaluations were performed. RESULTS: The Sciatic functional Index (SFI) in group Z on 14th day is different significantly from group S and group C (p = 0.037). But on 42nd day there was no difference between groups (p = 0.278). The statistical analyses of electromyelographic (EMG) studies showed that the latency in group Z is significantly different from group S (p = 0.006) and group C (p = 0.045). But on 42nd day there was no difference between groups like SFI (p = 0.147). The amplitude was evaluated better in group Z than others (p < 0.05). In microscopic evaluation, we observed the highest number of nerve regeneration in the group Z and the lowest in the group C. But it was not significant statistically. CONCLUSION: Our results demonstrate that Zofenopril promotes the regeneration of peripheral nerve injuries in rat models.