Ali Engin Ulusal

Negative pressure wound therapy in patients with diabetic foot

OBJECTIVE In this study our aim was to compare the results of standard dressing treatment to negative pressure wound therapy (NPWT) performed with a vacuum-assisted closure (VAC) device in patients with diabetic foot ulcers. METHODS We assessed the results of 35 patients treated for diabetic foot ulcer between 2006 and 2008. Of these cases, 20 (4 women and 16 men; mean age: 66 years; range: 52-90 years) were treated with standard wet dressings and 16 feet in 15 patients (10 men, 5 women; mean age: 58.9 years; range: 42-83 years) with VAC therapy. The success of treatment was evaluated in terms of hospitalization length and rate of limb salvation. RESULTS The average hospitalization period with VAC treatment was 32 days compared to 59 days with standard dressing treatment. All patients treated with standard dressings eventually had to undergo amputation. However, the amputation rate was 37% in the VAC treated group and 88% of patients had a functional extremity at the end of treatment. CONCLUSION VAC therapy, together with debridement and appropriate antibiotic therapy, enables a higher rate of limb salvage, especially in Wagner Grade 3 and Grade 4 ulcers.

The BstUI and DpnII Variants of the COL5A1 Gene Are Associated With Tennis Elbow

Background: Tennis elbow entails pain and tenderness over the lateral epicondyle. The exact cause of the condition is not fully understood. Type V collagen is a minor fibrillar collagen that intercalates with type I collagen and forms collagen fibrils. It is encoded by the COL5A1 gene. Sequence variants within COL5A1 3′-UTR have been implicated in musculoskeletal diseases. Purpose: To determine whether rs12722 (BstUI C414T polymorphism) and rs13946 (DpnII C230T polymorphism) of the COL5A1 gene are associated with an increased risk of tennis elbow. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 152 patients with tennis elbow and 195 healthy participants were enrolled in this study. The rs12722 (BstUI C414T) and rs13946 (DpnII C230T) polymorphisms were investigated with the polymerase chain reaction–restriction fragment length polymorphism (PCR-RFLP) method. Results: There was a significant difference in both BstUI and DpnII genotype frequencies between patients with tennis elbow and healthy participants. The A2 allele of BstUI and the B1 allele of DpnII were significantly underrepresented in the patient group. Conclusion: Individuals with the BstUI A1 allele and DpnII B2 allele of the COL5A1 gene have a high likelihood of developing symptoms of the tennis elbow. This is the first study reporting that rs12722 and rs13946 SNPs (single nucleotide polymorphisms) are genetic risk factors for tennis elbow.

Short-Term Clinical Outcomes After First Metatarsal Head Resurfacing Hemiarthroplasty for Late Stage Hallux Rigidus

The purpose of the present study was to evaluate the short-term results of metatarsal head resurfacing hemiarthroplasty in the treatment of advanced hallux rigidus. We reviewed 14 consecutive patients (5 males [35.71%], 9 females [64.29%]; mean age, 58.7 ± 7.4 years). These patients underwent first metatarsal head resurfacing hemiarthroplasty (HemiCAP(®)) for hallux rigidus from March 2010 to September 2012 at our institution. According to the Coughlin and Shurnas clinical and radiographic classification, 10 feet (71.43%) were classified as grade III and 4 (28.57%) as grade IV. We clinically rated all patients before surgery and at the final follow-up visit using the American Orthopaedic Foot and Ankle Society hallux metatarsophalangeal-interphalangeal scale, the visual analog scale for pain, and first metatarsophalangeal joint (MTPJ) range of motion. The mean follow-up duration was 24.2 ± 7.2 (range 12 to 36) months. The mean preoperative hallux metatarsophalangeal-interphalangeal scale score was 33.9 ± 9.8 (range 22 to 59), and it increased to 81.6 ± 10.1 (range 54 to 96; p < .05) postoperatively. The mean preoperative 10-cm visual analog scale for pain score was 8.4 ± 0.9 (range 7 to 10), which decreased to 1.21 ± 1.2 (range 0 to 5; p < .05) postoperatively. The mean preoperative MTPJ range of motion was 22.8° ± 7.7° (range 15° to 45°), which increased to 69.6° ± 11.8° (range 50° to 90°; p < .05) postoperatively. None of the 14 patients experienced component malalignment or loosening, infection, or neurovascular compromise during the follow-up period. One patient (7.14%) experienced postoperative pain and subsequently underwent first MTPJ arthrodesis. From the results of our investigation, first MTPJ arthroplasty is an effective treatment modality that can reduce pain and increase motion in the case of advanced hallux rigidus.

Is Sp1 binding site polymorphism within COL1A1 gene associated with tennis elbow

Tennis elbow defines a condition of pain and tenderness over the lateral epicondyle of the humerus. The exact aetiology of the injury is not yet fully understood. The major constituent of tendons is type 1 collagen which is encoded by COL1A1 gene. The aim of the study was to determine whether Sp1 binding site polymorphism (SNP rs1800012; 1546G/T) within the intronic region of COL1A1 gene is associated with tennis elbow. One hundred and three tennis elbow patients and one hundred and three healthy subjects without any history of previous ligament or tendon injuries were recruited for this genetic association study. All participants were genotyped for the COL1A1 Sp1 binding site polymorphism by using PCR-RFLP method. There were no observed statistical differences in the genotype (p=0.17) or allele (p=0.11) distributions between the groups. G allele frequency in patients and controls was 82.5% and 76.21%, and T allele frequency was 17.5% and 23.79% respectively. This study has shown that there is no association between this polymorphism and tennis elbow within the population studied.

The complete type of suprapatellar plica and lipoma arborescens: a case report

Lipoma arborescens is a rare intra-articular benign lesion. It is characterized by villous lipomatous proliferation of the synovial tissue and its etiology is not certain. Clinical presentation is usually long-standing, painless and slowly progressive swelling of the related joint. Magnetic resonance imaging plays an important role in diagnosis. Diagnosis can be determined by hypertrophied synovial tissue with synovial lining cells containing adipose tissue on examination using a light microscope. The synovial plica of the knee is formed during the embryogenic phase of development. This development is incomplete in many individuals. When the synovial plica of the knee persists, it is transformed into an embryonic relic that is located in either the suprapatellar or midpatellar region of the knee. We present a rare case with both a complete type of suprapatellar plica and a symptomatic lipoma arborescens in the suprapatellar recess.

A complication due to shock wave therapy resembling calcaneal stress fracture.

Shock wave therapy was first used for kidney stones. Later, it was used for some orthopaedic disorders such as pseudoarthrosis, lateral epicondylitis, tendonitis, Achilles tendinitis, plantar fasciitis, and shoulder calcific tendinitis. Local tissue effects of extracorporeal shock wave therapy (ESWT) on bone, soft tissues, and some calcified tissues led to sucessful results in the treatment of the orthopaedic problems mentioned previously. Furthermore, the method is noninvasive, easily applicable, does not require hospitalization, and the complication rate is low. Knowledge about shock wave therapy continues to advance. Shock waves are sound waves that have high amplitudes and certain physical characteristics. They produce both direct and indirect mechanical forces at the focused tissue. It differs from diagnostic ultrasound in character and peak pressure. Basically, the peak pressure of a shock wave is approximately 1000 times greater than the peak pressure of diagnostic ultrasound. The effect of this high pressure sound wave in biological tissues is not completely understood but is believed to cause direct destructive effects and cavitation occuring due to the indirect effect causing trabecular microfractures, hematoma formation, and cell death. These effects are believed to cause the physiological processes resulting with new bone formation, and thus fracture healing. But the effects of high doses of shock waves on normal bone have not been studied extensively. Some animal studies showed a destructive effect of ESWT when applied to a normal bone. There are no standardized safe doses and treatment protocols for ESWT in orthopaedic disorders. Thus, it is difficult to compare the results of different studies and to explore the efficiency and safety of ESWT in orthopaedic problems. Despite the aforementioned uncertainties, no significant complications have been described related to ESWT. In general, skin rash, petechiae, superficial limited hematoma, swelling, and local pain have been reported as minor local complications. Only Durst et al encountered a relatively serious problem in 1 case, osteonecrosis of the humeral head during treatment of calcific tendinitis of the shoulder. They theorized that ESWT caused vascular damage to the vascular supply of the humeral head. In this report we present a case of bone damage that resembled a stress fracture of the calcaneus following ESWT due to the plantar fasciitis.

Endoscopic versus Open Bursectomy for Prepatellar and Olecranon Bursitis

Objectives Bursitis of the olecranon and the patella are not rare disorders, and conservative management is successful in most cases. However, when patients do not respond to conservative treatment, open excisional surgery or, recently, endoscopic bursectomy, can be used. The aim of this study was to evaluate the results of open and endoscopic treatments of olecranon and prepatellar bursitis. Patients and methods Forty-nine patients (37 male and 12 female), who were treated with endoscopic bursectomy (25 patients) or open bursectomy (24 patients) were included in this study. Thirty patients had olecranon bursitis, while 19 patients had prepatellar bursitis. The patients’ average age was 61.1 ± 12.3 (range 33-81) years. All of the patients’ hospitalization and surgery times were recorded. The satisfaction of the patients was evaluated with a satisfaction scoring system, as well as by evaluating residual pain, the range of joint movement, and the cosmetic results of the procedure. Results The average follow-up time was 16 ± 9 months (range 12–27). The median operation time was 23.2 ± 3.5 minutes for the endoscopic bursectomy group and 26.4 ± 6.8 minutes for the open bursectomy group. The median hospitalization time was 0.56 ± 0.5 days (range 0-1 day) for the endoscopic group and 1 ± 0 days for the open bursectomy group (P<0.01). According to the patient satisfaction questionnaire, the endoscopic bursectomy group’s score was 8.5 ± 1.3 (range 5-10), and the open bursectomy group’s score was 5.29 ± 1.8 (range 1-9) (P<0.01). Conclusion Endoscopic bursectomy is a time-saving and efficient surgical treatment option for patients with prepatellar and olecranon bursitis.

Congenital Pseudarthrosis of Index Metacarpal Bone Treated with Distraction Osteogenesis Followed by Autologous Grafting.

The term “congenital pseudoarthrosis” refers to the semblance of a false joint formation which is present from birth. The soft tissue at the pseudoarthrotic site is composed of a variable admixture of fibrous tissue, fibrocartilage, and hyaline cartilage with evidence of enchondral ossification. Spaces and clefts are lined by a synovial-like tissue [1]. Congenital pseudoarthrosis is mostly seen in the lower extremity, particularly involving the tibia, fibula and femur [2]. In upper extremities, it may also involve clavicle and one or both bones of the forearm [3, 4]. However, metacarpal bone involvement is exceedingly rare with only three previous case reports in current literature [5–7]. But, to the best of our knowledge, there have been two cases of bilateral congenital pseudarthrosis of index metacarpals reported in literature up to date [5, 6]. Congenital pseudoarthrosis is usually associated with genetic syndromes and presented as a component of several other abnormalities [2]. In 1950, Aegerter suggested a possible relationship between neurofibromatosis, congenital pseudarthrosis, and fibrous dysplasia [8]. In 1949, Moore stated that “the treatment of congenital pseudarthrosis will probably never be entirely effective until the etiology has been determined. Osteosynthesis by bone-grafting still offers the principal means of attacking the problem” [9]. The treatment of congenital pseudoarthrosis is challanging because achieving complete union of pseudoarthrosis site, providing an acceptable alignment and functional extremity is difficult and refracture rate is high. This is probably due to low osteogenic capacity of the affected whole segment. The principle of the treatment is complete resection of the pseudoarthrosis, grafting the bone defect and ensure bony union either with internal or external fixation. Currently Ilizarov external fixation has gained wide acceptance as a gold standard treatment for the management of congenital tibial pseudoarthrosis [2]. Herein, we intend to present a rare case of bilateral congenital pseudoarthrosis involving bilateral index metacarpal bones. This is not a unique case and previously two other cases has been published. But what makes our case different than previous cases is the treatment of choice. We have treated this patient with excision of the pseudoarthrosis, gradual distraction to overcome the short metacarpal length without neurovascular compromise, followed by tricortical grafting and internal fixation.

Leech treatment for prolonged digital ischemia

A n ingrown toenail is a common problem that can be treated conservatively or surgically. Surgery is mostly performed under digital block anesthesia with the use of a digital tourniquet. Herein, we present an emergent case of a forgotten digital tourniquet that was used during the surgical treatment of an ingrown toenail and the subsequent treatment with hirudotherapy. Informed consent was obtained from the patient.