Ahmet Ozgur Atay

Tunnel Enlargement After Anterior Cruciate Ligament Surgery

Bone tunnel enlargement has been reported after anterior cruciate ligament (ACL) reconstruction surgery. Although the long-term outcome of this phenomenon is not yet known, tunnel lysis or expansion may be clinically significant in revision surgery because the enlarged tunnels may complicate graft placement and fixation. There any many proposed theories for tunnel lysis. The most accurate statement is that this condition has a multifactorial etiology. Mechanical and biological causes have been reported, and both contribute to enlarged graft tunnels. This article describes the multiple causes of bone tunnel enlargement after ACL surgery. Future techniques and advances in primary ACL surgery must seek to eliminate this phenomenon.

MR imaging of meniscal bucket-handle tears: a review of signs and their relation to arthroscopic classification

Abstract. Our objective was to review the MR imaging signs of meniscal bucket-handle tears and assess the relevance of these signs to the arthroscopic classification of displaced meniscal tears. Forty-five menisci in 42 patients who had a diagnosis of bucket-handle tear either on MR imaging or on subsequent arthroscopy (in which Dandys classification of meniscal tears was used) were retrospectively analyzed for MR imaging findings of double posterior cruciate ligament (PCL), fragment within the intercondylar notch, absent bow tie, flipped meniscus, double-anterior horn, and disproportional posterior horn signs. Arthroscopy, which was considered as the gold standard, revealed 41 bucket-handle tears (either diagnosed or not diagnosed by MR imaging) in 38 patients (33 males, 5 females). There was a stastistically significant male preponderance for the occurrence of meniscal bucket-handle tears. Overall, sensitivity and positive predictive value of MR imaging for the detection of meniscal bucket-handle tears were calculated as 90%. Common MR imaging signs of meniscal bucket-handle tears in arthroscopically proven cases of such tears were the fragment in the notch and absent bow tie signs (98% frequency for each). Double-PCL, flipped meniscus, double-anterior horn, and disproportional posterior horn signs, however, were less common (32, 29, 29, and 27%, respectively). An arthroscopically proven bucket-handle tear was found in all patients who displayed at least three of the six MR imaging signs of meniscal bucket-handle tears. The presence of three or more MR imaging signs of meniscal bucket-handle tears is highly suggestive of this condition.

MR imaging of the anterior intermeniscal ligament: classification according to insertion sites

Abstract. Our objective was to study the frequency of anterior intermeniscal ligament on MR imaging and to make a classification according to its insertion sites on MR images. Sagittal T1-weighted and thin-section transverse T2*-weighted MR images of the knee were prospectively evaluated in 229 subjects without significant synovial effusion or total rupture of the anterior cruciate ligament. By using thin-section transverse images, the ligament was classified into three types according to its insertion sites (type A: between anterior horns of medial and lateral menisci; type B: between anterior horn of medial meniscus and anterior margin of lateral meniscus; type C: between anterior margins of medial and lateral menisci). On sagittal images location of the ligament was determined with respect to a line drawn between anterior of the tibial epiphysis and posterior of the intercondylar notch to look for a relation between its type on transverse images and location on sagittal images. Separately, arthroscopy was made in 36 patients to verify the MR assessment of the presence of the ligament. Anterior intermeniscal ligament was found in 53% of the subjects. Type B was the most common group (58%). Magnetic resonance imaging has a sensitivity and a specificity of 67 and 100%, respectively, in the detection of the ligament. Types A and C had a statistically significant location posterior and anterior, respectively, to the master line on sagittal images. In arthroscopy, the ligament was either cord-like (67%) or flat (33%) in appearance. Routine sagittal MR images can help identify anterior intermeniscal ligament.

A giant extrasynovial osteochondroma in the infrapatellar fat pad: end stage Hoffa’s disease

The infrapatellar fat pad of Hoffa is commonly injured but rarely discussed in the orthopaedic literature. Hoffa’s disease is the extension of various traumatic events due to impingement and inflammation of the infrapatellar fat pad and known as a vague reason for anterior knee pain. Inflammation is foreground during acute phase of the disease while impingement due to fibrosis and scar tissue of infrapatellar fat pad plays a major role in the chronic phase. The osteochondroma of the infrapatellar fat pad secondary to the Hoffa’s disease can be more problematic. Although, the fibrocartilaginous transformation and osteochondral metaplasia of infrapatellar fat pad was pointed out frequently in the literature, the published papers seem far from clarifying the relation between chronic impingement and formation of osteochondroma. We present a case of a giant ossifying chondroma in the infrapatellar fat pad that resulted from chronic Hoffa’s disease. Complete open resection was performed successfully after arthroscopic examination. The infrapatellar fat pad contains the entire progenitor cells for the development of an osteochondroma and chronic impingement may have promoter affect on this issue, thus, an osteochondroma may occur at the end-stage Hoffa’s disease.

The effects of two different closed kinetic chain exercises on muscle strength and proprioception in patients with patellofemoral pain syndrome

OBJECTIVES The effects of two different closed kinetic chain exercises were compared in patients with patellofemoral pain syndrome (PFPS). METHODS Forty female patients with unilateral PFPS were randomly divided into two groups to receive exercises with the hip internally rotated (n=20, mean age 39.1 + or - 8.0 years) or externally rotated (n=20, mean age 36.1 + or - 8.7 years) with the use of the Monitored Rehab Functional Squat (MRFS) System. The duration of exercises was four weeks with a total of 20 sessions. Both groups were evaluated before therapy, after four weeks of exercises, and after six weeks of home exercise program with the MRFS System for muscle strength and proprioception, with a visual analog scale for pain, and with the Kujala questionnaire for functional assessment. RESULTS Among baseline features, the only significant difference between the two groups was in the mean height (p<0.05). Pain severity decreased significantly in both groups after treatment and home exercises (p<0.05). Concentric and eccentric peak forces, concentric proprioceptive deficit, and Kujala scores improved significantly in both groups after treatment (p<0.05), whereas improvements after home exercises were not significant in this respect (p>0.05). Eccentric proprioceptive deficit, however, did not change significantly both after treatment and home exercises (p>0.05). No significant differences were observed between the two groups during the study period with respect to the parameters assessed (p>0.05). CONCLUSION Our results show that functional knee squat exercises with internally and externally rotated hip positions provide similar improvements in muscle strength and proprioception in patients with PFPS.

The Clinical and Sonographic Effects of Kinesiotaping and Exercise in Comparison With Manual Therapy and Exercise for Patients With Subacromial Impingement Syndrome: A Preliminary Trial

OBJECTIVE The purpose of this study was to compare the effects of manual therapy with exercise to kinesiotaping with exercise for patients with subacromial impingement syndrome. METHODS Randomized clinical before and after trial was used. Fifty-four patients diagnosed as having subacromial impingement syndrome who were referred for outpatient treatment were included. Eligible patients (between 30 and 60 years old, with unilateral shoulder pain) were randomly allocated to 2 study groups: kinesiotaping with exercise (n = 28) or manual therapy with exercise (n = 26). In addition, patients were advised to use cold packs 5 times per day to control for pain. Visual analog scale for pain, Disability of Arm and Shoulder Questionnaire for function, and diagnostic ultrasound assessment for supraspinatus tendon thickness were used as main outcome measures. Assessments were applied at the baseline and after completing 6 weeks of related interventions. RESULTS At the baseline, there was no difference between the 2 group characteristics (P > .05). There were significant differences in both groups before and after treatment in terms of pain decrease and improvement of Disability of Arm and Shoulder Questionnaire scores (P < .05). No difference was observed on ultrasound for tendon thickness after treatment in both groups (P > .05). The only difference between the groups was at night pain, resulting in favor of the kinesiotaping with exercise group (P < .05). CONCLUSION For the group of subjects studied, no differences were found between kinesiotaping with exercise and manual therapy with exercise. Both treatments may have similar results in reducing pain and disability in subacromial impingement in 6 weeks.

Hospital-based versus home-based proprioceptive and strengthening exercise programs in knee osteoarthritis

OBJECTIVES This study aimed to establish the effects of hospital- and home-based proprioceptive and strengthening exercise programs on proprioception, pain, and functional status in patients with knee osteoarthritis (OA). METHODS Sixty patients with bilateral knee OA were randomly allocated into either a home-based or hospital-based exercise program. Hospital-based exercise group (n=30, mean age 50.23±9.07 years) received functional training program with proprioceptive ability, ice, and home exercises. Home-based exercise group (n=30, mean age 54.4±7.9 years) had a program of ice and home exercises. Treatment programs was conducted 5 days per week for 6 weeks (30 sessions). Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Monitorized Functional Squat System-Proprioceptive Test (MFSS), timed performance test (TUG), and visual analogue scale (VAS) for the intensity of pain were used to quantify the variables. RESULTS Both groups demonstrated significant improvement when pre- and post-treatment results were compared for pain intensity, WOMAC, and TUG test scores (p<0.05). No statistically significant improvement was found in proprioception of the home-based group (p>0.05). Hospital-based group demonstrated significantly greater improvement in MFSS, TUG test, and VAS in activity when compared with the home-based group (p<0.05). CONCLUSION Both hospital- and home-based exercise programs decreased joint symptoms and improved function in patients with knee OA.

Comparison of functional outcomes of two anterior cruciate ligament reconstruction methods with hamstring tendon graft

OBJECTIVE The aim of this study was to compare the effects of Endobutton post-fixation and femoral (TransFix) transfixation in ACL reconstruction on lower extremity muscle strength, joint position sense, and knee stability. METHODS Subjects who had undergone ACL reconstruction with hamstring tendon using Endobutton post-fixation (n=20, mean age: 26.5 years) or femoral transfixation (n=20, mean age: 29.9 years) were recruited to an ACL rehabilitation program. Twelve months after surgery, quadriceps and hamstring torque values were recorded using an isokinetic dynamometer. Computerized coordination and proprioception tests (Functional Squat System; Monitored Rehab System) were performed to determine the deficits in joint position sense. The anterior translation test was performed using a Kneelax 3 arthrometer to determine knee laxity. RESULTS Side-to-side differences between groups for hamstring and quadriceps muscle strength, concentric and eccentric motor coordination and anterior tibial laxity were not significantly different (p>0.05). CONCLUSION No statistically significant differences in functional outcome were found 1 year after the ACL reconstruction using Endobutton post-fixation and femoral transfixation with hamstring tendon graft. Deficits in hamstring-quadriceps muscle strength, motor coordination and proprioception were still found in both groups. We therefore recommend that long-term follow-up and rehabilitation including neuromuscular exercises should be continued for longer than one year after ACL reconstruction.

The outcomes of anterior cruciate ligament reconstructed and rehabilitated knees versus healthy knees: a functional comparison

OBJECTIVE In this study, we aimed to evaluate and compare the functional performance and muscle strength of cases of ACL reconstruction using bone-patellar tendon-bone graft followed by rehabilitation with those of healthy subjects. METHODS This study included fifteen patients (range: 20 to 35 years) who underwent ACL reconstruction 18 to 24 months previously and a control group of 15 healthy volunteers with similar characteristics. Cases were evaluated with physical examinations, functional tests, subjective scales (Lysholm, Hospital for Special Surgery Knee Score (HSSS), and Tegner activity scale) and isokinetic test. Differences between the reconstruction group and control group were analyzed. RESULTS Significant differences were found in the activity level of the reconstruction group (p<0.05) and in the clinical findings of the subjects with involved and uninvolved legs (p<0.05). When the reconstructed and control groups were compared according to the limb symmetry index, there were significant differences in single-leg hop test, timed hop test, shuttle run and stair hop test (p<0.05). The study also revealed a significant correlation between the vertical hop and quadriceps strength in the isokinetic test (r=0.56). When the operated knees were compared to the healthy side, mean limb symmetry index was over 92% (with two cases at 88%). When the dominant leg was compared to the non-dominant leg in the control group, the mean limb symmetry index was over 95%. CONCLUSION Functional outcomes similar to those of healthy legs can be achieved following ACL reconstruction with bone-patellar tendon-bone grafting and rehabilitation. The similar functional test results of the operated and healthy subjects prove the effectiveness of the rehabilitation program.

The effect of electrical stimulation in combination with Bobath techniques in the prevention of shoulder subluxation in acute stroke patients

Objective: To examine the efficiency of electrical stimulation in combination with Bobath techniques in the prevention of inferior and anterior shoulder subluxation in acute stroke patients. Design: A prospective randomized controlled trial. Setting: Intensive care unit and inpatient clinics of neurology in a university hospital. Subjects: Forty-eight patients with acute stroke, divided equally into control and study groups. Intervention: Subjects in both groups were treated in accordance with the Bobath concept during the early hospitalization period. In addition to Bobath techniques, electrical stimulation was also applied to the supraspinatus muscle, mid and posterior portions of the deltoid muscle of patients in the study group. Main measures: Two radiological methods were used to measure the horizontal, vertical and total asymmetry and vertical distance values of the shoulder joint. Motor functions of the arm were evaluated with the Motor Assessment Scale. Results: The hospitalization period was 12.62 ± 2.24 days for the control group and 11.66 ± 1.88 days for the study group. Shoulder subluxation occurred in 9 (37.5%) subjects in the control group, whereas it was not observed in the study group. All shoulder joint displacement values were higher in the control group than in the study group (horizontal asymmetry P = 0.0001, vertical asymmetry P = 0.0001, total asymmetry P = 0.0001, vertical range P = 0.002). Conclusion: Application of electrical stimulation combined with the Bobath approach proved to be efficient in preventing inferior and anterior shoulder subluxation in the acute stages of stroke.