Alper Gokce

Synergistic Effect of TGF-β1 And BMP–7 on Chondrogenesis and Extracellular Matrix Synthesis: An In Vitro Study

Introduction: The purpose of the present study seeks to determine the signal timing of BMP–7 and TGF-β1 from a novel chitosan based hydrogel system that may affect chondrocyte proliferation resulting in the presence of a synergism seen conspicuously in consecutive controlled delivery. Methods: Four groups of cultured chondrocytes were seeded on a novel designed chitosan based hydrogel. The hydrogel was left empty (control) in one group and loaded with BMP–7, TGF-β1 and their combination in the other groups, respectively. Hydrogel structure was analyzed with scanning electron microscope. The release kinetics of Growth Factors (GFs) was determined with ELISA. Chondrocyte viability and toxicity after being tested with MTS and collagen type II synthesis, were quantified with western blotting. Canonical regression analysis was used for measuring statistical evaluation. Results: Chitosan based hydrogel allowed controlled release of GFs in different time intervals for BMP–7 and TGF-β1. Double peak concentration gradient was found to be present in the group loaded with both GFs. In this group, substantially higher chondrocyte growth and collagen synthesis were also detected. Conclusions: We concluded that, chitosan based hydrogel systems may be adjusted to release GFs consecutively during biodegradation at the layers of surface, which may increase the cell number and enhance collagen type II synthesis.

Spinal osteotomy: correcting sagittal balance in tuberculous spondylitis.

Study Design Retrospective case analysis. Objective Tuberculosis spondylitis is a cause of sagittal imbalance and neurologic impairment. In this study, the result of decompression and closing wedge osteotomy with instrumented fusion performed in patients with tuberculous spondylitis were analyzed retrospectively. Summary of Background Data Twelve patients with angular kyphotic deformity underwent decompression and closing wedge osteotomy with instrumented fusion between 2000 and 2004. Clinical and radiologic assessment was based on pain, functional and neurologic status, and radiologic measurements. Methods There were 7 men and 5 women with median age of 52 years (range, 24 to 76 y). The average follow-up period was 62 months (range, 48 to 70 mo). The radiologic involvement included the angle of kyphosis on the anteroposterior and lateral radiographs. The preoperative and postoperative clinical assessments were performed by the using Oswestry Disability Index. All patients were asked to rate their preoperative and postoperative pain measurement using a pain visual analog scale. Results Visual analog scale scores improved from 5.8 in average (range, 4 to 8) to 2.2 in average (range, 1 to 4) and in the mean and Oswestry Disability Index from 54.2 (46 to 60) preoperatively to 15.2 (8 to 22) at the latest follow-up. Four patients presented neurologic findings. Three patients had improvement in their neurologic status, 1 patient did not improve and remained as American Spinal Injury Association (ASIA) grade C. Kyphotic deformity of the patients has improved from 51.1 to 23.2 degrees postoperatively. One of them has to be revised and instrumentation was extended to upper levels. Fusion was achieved at the last follow-up. Conclusions Despite developing pseudarthrosis secondary to implant failure in 1 case, we recommend debridement, closing wedge osteotomy, and posterior instrumented fusion to correct sagittal balance in tuberculous spondylitis.

Sonographically Guided Corticosteroid Injection for Treatment of Plantar Fasciosis

The purpose of this study was to prospectively investigate the effect of sonographically guided corticosteroid injection on the clinical and radiologic responses in patients with proximal plantar fasciosis.

[Long-term results of total hip arthroplasty in patients with juvenile rheumatoid arthritis].

OBJECTIVES We evaluated the long-term results of total hip arthroplasty (THA) in patients with juvenile rheumatoid arthritis (JRA). METHODS The study included 37 hips of 23 patients (22 females, 1 male; mean age 22 years; range 17 to 30 years) who underwent THA for hip degeneration secondary to JRA. All arthroplasties were performed through an anterolateral approach by the same senior surgeon. The mean body surface of the patients was 1.5 m2 (range 1.1 to 1.7 m2) and the mean symptom duration to surgery was 12 years (range 7 to 16 years). Twenty-three hips received cemented, 14 hips received hybrid prostheses. In seven hips with an extremely narrow femoral medulla and shallow acetabulum, a CDH prosthesis was used. The hips were evaluated using the Harris hip score. Prosthetic loosening and displacement and heterotopic bone formation were assessed on follow-up radiographs. The mean follow-up period was 135 months (range 58 to 212 months). RESULTS The mean Harris hip score increased from 27.2 (range 11 to 69) to 79.5 (range 37 to 87) postoperatively. At final follow-ups, all the patients were satisfied with the outcome and were able to walk without support. Three hips (8.1%; 3 patients) required revision. The overall Kaplan-Meier implant survival rate was 86.5%. There were no significant correlations between the Harris hip score and radiographic loosening and the presence of calcification around the prosthesis. Heterotopic bone formation of grade I was observed in 17 hips (46%). CONCLUSION Even though it is performed at young ages, THA considerably improves quality of life of patients with JRA having hip joint involvement and has a comparable implant survival.

Osteochondritis dissecans of the medial femoral condyle associated with malformation of the menisci.

Osteochondritis dissecans is a form of osteochondrosis limited to the articular epiphysis and the relationship of osteochondritis dissecans and discoid lateral meniscus has been clearly identified. This article presents a 10-year-old boy with osteochondritis dissecans of the medial femoral condyle associated with hypoplastic medial and partial deficient lateral menisci. The patient presented with activity-related pain and intermittent swellings of his left knee for 2 months without any evidence of significant knee trauma. Magnetic resonance imaging revealed anomalous medial meniscus mimicking displaced bucket-handle tear and partially deficient lateral meniscus with osteochondritis dissecans at the lateral aspect of medial femoral condyle without any significant bone loss with a non-dislocated fragment. Arthroscopy of the knee revealed an incomplete separated osteochondral flap with partial discontinuity that was unstable on probing on the lateral aspect of the medial femoral condyle. The medial meniscus was hypoplastic without a body and only the meniscal rim could be seen. The lateral meniscus had an anomalous vertical insertion of the posterior horn, normal body, but an absent anterior horn. The anterior cruciate ligament was intact, but looked like a peacocks tail. Arthroscopic fixation of the chondral lesion was performed. At 30-months follow-up, the boy had no limitation in his daily and sports activity. The present case is the first description of congenital anomaly of the both menisci and osteochondritis dissecans together. Meniscal or ligamentous anomalies of the knee may be associated with osteochondritis dissecans.

How Different Methodologies of Harvesting and Analysing the Samples Affect the Test Results in Determining Joint Mediators

Purpose. This study has researched the affect of different methodologies of harvesting and analysing the samples in determining the mediators emerging after the rat articular cartilage injury. Materials and Methods. One hundred and forty-four male wistar rats were divided into 2 groups. Synovial fluid samples were taken from all of the rats. We entered into the right knees of the rats in group I (n = 36) under anaesthesia and took cartilage tissue samples from their distal femur. Samples were taken as reference values for enzyme linked immunosorbent assay (ELISA) and histopathological evaluations. We entered into the right knees of the rats in group II (n = 108) and formed complete layer of cartilage injury in their medial femoral condyles. At the end of the 15th day, the rats were sacrificed after taking synovial fluid samples from their right knees creating defect in the rats in group II. The molecular markers in the synovial fluid and cartilage tissue samples which were taken from the experimental and control groups (MMP-9, MMP-13, TIMP-1, TNF-α, and NO) were analysed by direct or indirect methodologies. SPSS 18.0 Package program was used in the statistical evaluation. Students t-test where the measurement variables between the experimental and control groups were compared was applied. Receiver Operating Characteristics (ROC) curves were used in the determination of the diagnostic sufficiency from the tissue. Results. No difference was found between TIMP-1 (P = 0.67) and MMP-9 (P = 0.28) levels in synovial fluid and cartilage tissue. From the molecular markers, when MMP-9, MMP-13, NO, TIMP-1, TNF-α′, the area under ROC curve, and P values were examined, MMP-13 (P < 0.0001, 95% CI: 0.70–0.85), NO (P < 0.0001, 95% CI: 0.72–0.86), and TNF-α (P < 0.0001, 95% CI: 0.91–0.98) results were found to be statistically significant. Inferences. The indirect ELISA protocol which we apply for the cartilage tissue as an alternative to synovial lavage fluid is a reliable method which can be used in the determination of articular cartilage injury markers.

Skin and subcutanous fat atrophy after corticosteroid injection for medial epicondylitis.

To the Editor: Medial and lateral epicondylitis are the most common elbow problems in adults. Corticosteroid injection for the treatment of medial epicondylitis is a frequently used method of conservative management. A 34-year-old right-handed woman was referred to our clinic with a 4-month history of pain along the medial side of her right elbow. She had been treated for medial epicondylitis with oral nonsteroidal anti-infl ammatory drugs, activity modifi cation, and local cold application for 1 month, and then had a 40 mg injection of methylprednisolone acetate to the right elbow for medial epicondylitis due to the resistance of pain. In 3 months’ time, her pain worsened. She could not wear short sleeves due to severe tenderness at the medial elbow, occurring even after contact with the torso. Examination revealed atrophy of the skin and subcutaneous fat over the medial epicondyle causing the epicondyle to become prominent like an osseous mass (Figure). Marked tenderness was observed over the prominent medial epicondyle by palpation. Intraoperatively, the atrophied skin and subcutaneous fat tissue were excised from an ellipsoid incision. Two chalky, whitish deposits of corticosteroid were observed over the fl exor aponeurosis. The deposits were excised. The common fl exor-pronator origin was partially detached by sharp dissection and refl ected without disturbing the medial collateral ligament. The underlying fi brous tissue was debrided. The medial epicondyle was drilled, creating multiple bleeding small holes, and then the fl exorpronator origin was reattached. The adjacent subcutaneous tissue and skin were released and brought over the epicondyle, forming good soft tissue coverage. Three years postoperatively, the patient had unlimited range of elbow motion with no epicondylar pain, and no pathologic bony prominence of the epicondyle was observed. Although steroid injection for the conservative treatment of medial epicondylitis is an alternative method, previously reported complications of periarticular injections and the case presented here demonstrate related adverse effects or complications. Injection into the medial site of the elbow may not be as innocent as expected if appropriate injection technique is disregarded. Tahsin Beyzadeoglu, MD Halil Bekler, MD Alper Gokce, MD Istanbul, Turkey doi: 10.3928/01477447-20110627-01

Aseptic drainage associated with polyglactine sutures used for repair of Achilles tendon ruptures

The aim of surgical treatment of Achilles tendon ruptures is to restore stability of the tendon. Various suture techniques and materials can be used for this purpose. Suture materials may be polyfilament or monofilament, absorbable or nonabsorbable. We presented four patients who developed severe chronic discharges associated with thick polyglactine (Vicryl) used during open repair of acute Achilles tendon ruptures. Surgical removal of suture materials and debridement resulted in complete improvement without any complications. The use of thick suture materials and large knots should be avoided in the repair of Achilles tendon ruptures. Polyfilament and absorbable sutures may pose problems due to their tendency to cause bacterial colonization and tissue rejection.

The contribution of locked screw-plate fixation with varying angle configurations to stability of osteoporotic fractures: an experimental study

OBJECTIVES This experimental study was designed to find new ways of improving stabilization of fractures in osteoporotic elderly patients through alterations made in the configuration and geometry of locked screw-plate fixation used in the conventional plate technique. METHODS Four screw configurations with varying angulations were used for plate-bone construction. Forty iron plates of high quality (100x35x3 mm) were divided into four groups and two screw holes, 3 mm in diameter, were drilled on each plate at a distance of 15 mm. In group A, the holes were drilled so that the screws would be vertically sent to the bone interface. In the remaining groups, the holes were drilled for convergent (group B, 15 degrees ) and divergent (group C, 15 degrees ; group D, 30 degrees ) screw orientation. Screw-plate fixation was tested in a modified osteoporotic bone (Osteoporotic Generic Bone, Synbone) on an Instron materials testing system with an axial pullout force of 0.1 mm/sec. Failure loads were read from load-displacement curves and the type of failure was noted. RESULTS Screws placed in divergent orientations showed the highest axial pull-out strength (group C, 83.3 N/mm; group D, 80.8 N/mm), followed by convergent placement (72 N/mm) and vertical placement (66.7 N/mm). The type of failure was breakage of the bone sample in divergent configurations, and screw pull-out in convergent and vertical configurations. CONCLUSION Divergent constructs may be a promising alternative to conventional screw placement in treating osteoporotic fractures.

Anxiety and trauma perception and quality of life in patients who have undergone replantation.

The difficulty in keeping an amputated limb biologically alive is overcome day by day thanks to the successful replantation procedures applied in the early period. However, the reflections of this biological success on patients in functional and psychological terms may not be pleasing all the time. In our study, we aimed to evaluate the perceptual responses of patients to trauma after replantation and their possible effects on clinical results. We conducted a retrospective study of 43 patients who underwent replantation. The average age was 32.4 years and the average follow-up period was 38.6 months. When the results of the Short Form-36 (SF-36), Becks Depression Inventory, and the assessment scores of the disabilities of the arm, shoulder, and hand survey were evaluated, there was a negative correlation between the patients diagnosed with depression and all SF-36 subunits. A negative correlation between the severity of trauma and the average physical and mental values included in the SF-36 evaluations was observed (R = 0.48, R = 0.51, respectively),. These results revealed that the psychology of the patient was one of the important factors that could not be ignored in the success of replantation.