Bülent Erdemli

Anterior Instrumentation for the Treatment of Spinal Tuberculosis

BACKGROUND Kyphosis and neurological impairment are the major residual problems of spinal tuberculosis after the microorganism has been eradicated with use of appropriate medications. Spinal instrumentation is needed to support anterior strut grafts in patients who have kyphosis that affects more than two levels. Most surgeons use posterior instrumentation. Anterior instrumentation, despite its advantages, has not been widely accepted, partly because of concerns about introducing foreign material into infected tissue. The purpose of the current study was to address those concerns. METHODS Twenty-two patients who had tuberculosis of the spine with moderate-to-severe localized kyphosis and sixteen patients who had more than two involved levels had stabilization with anterior instrumentation. Antituberculous medication was used postoperatively according to a standardized regimen. The patients were followed to determine if there was any recurrence of the disease and if the correction had been maintained. RESULTS The twenty-two patients who had involvement of one or two levels had an average correction of the deformity of 64 percent (range, 58 to 90 percent), and the sixteen patients who had more than two levels of involvement had an average correction of 81 percent (range, 75 to 97 percent). The correction was maintained in twenty-one patients, the maximum loss was 3 degrees in sixteen, and one patient died on the second postoperative day. There was no recurrence of the disease. CONCLUSIONS We believe that anterior instrumentation is more effective than posterior instrumentation for reducing the deformity and stabilizing the vertebral column in patients who have kyphosis related to tuberculosis of the spine.

The contribution of vitamin C to healing of experimental fractures.

Abstract The benefits of various minerals and vitamins on fracture healing have been demonstrated in animal models. Vitamin C is an essential substance in fracture healing but has not been studied previously on an experimental basis. Sixteen rats were grouped randomly into control and vitamin C-supplemented groups. The right tibias of all rats were fractured by digital manipulation. One group received single high dose of vitamin C intramuscularly. On the 5th, 10th, 15th, and 20th days, two rats from each group were killed and the tibias examined under light microscopy. It was seen that the vitamin C-supplemented group went through the stages of fracture healing faster compared with the control group.

Risk of Superior Gluteal Nerve and Gluteus Medius Muscle Injury During Femoral Nail Insertion

BACKGROUND Abduction weakness and limping is a well-recognized complication of closed antegrade insertion of femoral nails. Iatrogenic injuries to the superior gluteal nerve and the gluteus medius muscle are the most likely contributing factors. The purpose of this study of cadavers was to assess the risk of nerve and muscle injury with various lower-limb positions used during nail insertion. METHODS We studied thirteen hips of ten formalin-fixed adult cadavers. With the cadaver in the full lateral position, a 9-mm reamer was introduced in a retrograde fashion from the intercondylar notch and passed through the gluteus medius muscle. The distance between the point of entry of the reamer into the undersurface of this muscle and the inferior main branch of the superior gluteal nerve (the nerve-reamer distance) and the distance between the entry and exit points of the reamer in the gluteus medius muscle (the intramuscle distance) were measured in three different hip positions: 15 degrees of flexion and 15 degrees of adduction (Position 1), 30 degrees of flexion and 30 degrees of adduction (Position 2), and 60 degrees of flexion and 30 degrees of adduction (Position 3). RESULTS In Position 1, the average nerve-reamer distance was 7 mm and the average intramuscle distance was 24 mm. In three hips the reamer injured the nerve directly, and in two other hips the distance was <or=5 mm. In Position 2, the average nerve-reamer distance was 21 mm and the average intramuscle distance was 18 mm. In Position 3, the average nerve-reamer distance was 33 mm and the average intramuscle distance was 11 mm. None of the reamers in this position came closer than 20 mm to the nerve. CONCLUSIONS The risk of injury to the superior gluteal nerve and the gluteus medius muscle during closed antegrade insertion of a femoral nail is lessened by increasing the amount of hip flexion and adduction. CLINICAL RELEVANCE The risk of injury to both the superior gluteal nerve and the gluteus medius muscle is higher with limited degrees of hip flexion and adduction, such as are possible in the supine position on a fracture table, than it is with greater degrees of hip flexion and adduction, which are possible in the lateral position on a fracture table or in the so-called sloppy lateral position on an ordinary table. Therefore, insertion of a femoral nail with the hip in increased flexion and adduction might help to lower the risk of injuries to the superior gluteal nerve and the gluteus medius muscle.

Medial approach open reduction for congenital dislocation of the hip using the Ferguson procedure

SummaryBetween January 1979 and October 1984, 31 congenitally dislocated hips in 19 patients were treated using open reduction via the medial approach, as described by Ferguson, at the Ankara University Faculty of Medicine. Patient age at operation ranged from 3 to 33 months (mean 12.1 months). The average follow-up was 94.7 months. All hips were evaluated both radiographically and clinically. Avascular necrosis of the femoral head was observed in 9.7% and slight, transient ischaemic radiographic changes of the femoral head in 22.6% of the hips; 25.8% of the hips have already undergone or are due to undergo subsequent surgery due to an insufficient radiographic result. The medial approach was found to be a reliable procedure for infants who have not had extensive previous conservative treatment and who are between 7 and 18 months of age.

Osseointegration in arthroplasty: can simvastatin promote bone response to implants?

Cementless fixation depends on bone ingrowth for long-term success. Simvastatin as a lipid lowering agent has been demonstrated to have osteoanabolic effects. This study was designed to measure the possible effect of simvastatin on implant osseointegration. Bilateral femoral implantation of titanium cylinders was performed in 20 rabbits. Blood lipid levels were measured pre- and postoperatively. Scanning electron microscopy (SEM) was used to measure the percentage of the surface of each implant in contact with bone and mechanical pull-out testing was performed. The blood lipid levels were significantly reduced in the simvastatin group. Histomorphometric examination revealed increased bone ingrowth and mechanical examination showed increased interface strength in the simvastatin group. Mechanical and histological data showed superior stability and osseous adaptation at the bone/implant interface for the simvastatin group. We conclude that simvastatin has potential as a means of enhancing bone ingrowth, which is a key factor in the longevity of cementless implants.RésuméLa fixation d’une prothèse sans ciment dépend de la réhabitation osseuse. La Simvastatine est un agent lipidique qui a un effet ostéo anabolique. Cette étude a pour but de montrer les effets de la Simvastatine sur l’ostéo intégration osseuse. Matériel et méthode : une implantation de cylindres de titane a été réalisée sur les deux fémurs de vingt lapins. Le taux de lipide a été mesuré en pré et post opératoire. L’examen en microscopique électronique a mesuré le pourcentage de la surface de réhabitation et des essais d’arrachage ont également été réalisés. Résultats : le niveau des lipides sanguins est réduit de façon significative dans le groupe de Simvastatine. L’histomorphométrie osseuse montre la croissance, l’orientation de la réhabitation et les tests mécaniques, l’augmentation de l’interface avec augmentation des forces nécessaires pour l’arrachage. En conclusion, les données mécaniques et histologiques montrent une stabilité supérieure dans le groupe Simvastatine. Nous pouvons conclure que la Simvastatine a un potentiel d’augmentation de la réhabitation osseuse facteur clé du succès à long terme des implants sans ciment.

Venous thromboembolism prophylaxis in major orthopaedic surgery: A multicenter, prospective, observational study

OBJECTIVES We investigated risk factors for venous thromboembolism (VTE), prophylaxis measures employed, and incidence of symptomatic deep venous thrombosis (DVT) and pulmonary embolism (PE) in patients undergoing major orthopaedic surgery (MOS). METHODS An open, multicenter, prospective, observational study was conducted in 21 medical centers, comprising 899 patients. Of these, 316 patients (35.2%) underwent total hip arthroplasty (THA), 328 patients (36.5%) underwent total knee arthroplasty (TKA), and 255 patients (28.4%) underwent surgery for hip fractures (HF). Pharmacologic prophylaxis was employed in all the patients. RESULTS Risk factors for VTE were seen in 73.2% of the patients, the most common being obesity (72%) and prolonged immobilization (36.3%). Low-molecular-weight heparin (91.1%) and fondaparinux (8.9%) were used for prophylaxis, which was short-term in 273 patients (30.4%) and long-term in 626 patients (69.6%). Mechanical prophylaxis was performed with compression stockings in 610 patients (67.9%) and by intermittent pneumatic compression in 67 patients (7.5%). During three-months of follow-up, symptomatic DVT and PE were seen in eight (0.9%) and four patients (0.4%), respectively. Mortality occurred in 10 patients (1.1%). Complications of major and minor bleeding were seen in eight (0.9%) and 40 (4.5%) patients, respectively. CONCLUSION Effective VTE prophylaxis is associated with low risk of clinically apparent DVT and PE in MOS.

Safe zone for the descending genicular artery in the midvastus approach to the knee

Minimally invasive total knee arthroplasty is performed using a modified version of the standard total knee arthroplasty without complete knee exposure. Traditional medial parapatellar arthrotomy has been criticized because it may disturb patellar blood flow and the extensor mechanism. Devascularization of the patella leading to osteonecrosis places the patella at risk for fracture. Alternative vastus-orientated approaches have the potential to preserve the descending genicular artery. Although this arterial supply to the patella potentially can be compromised throughout surgery, it is particularly vulnerable during deep dissection and arthrotomy. Knowledge of the anatomic course of the descending genicular artery would likely be helpful in its preservation. We investigated the course of the descending genicular artery and its entry angle to peripatellar network to determine the distance between the artery and superomedial patella during medial parapatellar arthrotomy and proximal capsular release. We dissected the descending genicular artery in 15 cadaveric knees. The average entry angle was 32.6°, and the average distance between the descending genicular artery and superomedial pole of the patella during parapatellar arthrotomy was 13.5 mm. The safest distance for splitting the vastus medialis during median parapatellar arthrotomy was 15 mm from the superior pole of the patella because of the course of the descending genicular artery.

A new approach to the treatment of osteoporosis.

Osteoporosis remains a significant clinical problem despite the availability of effective therapies. The main therapy still needed is an anabolic agent for the treatment of osteoporosis. This study examined the in vivo effect of the enzyme 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitor simvastatin, which controls the first step in the biosynthesis of cholesterol, on bone formation in rats. Histologic specimens were collected 7, 14, and 21 days after administration of 1 mg of simvastatin for 5 days and compared with control specimens for changes in bone tissue. The observed effects on the bone in a healthy animal model included advancement of the blood supply, acceleration of the proliferation and differentiation of osteoprogenitor cells, and formation of osteoid tissue.

Effect of Tourniquet Inflated for All the Surgery Versus Tourniquet Inflated Only at the Time of Cementation on Early Blood Loss at Total Knee Arthroplasty

Hakan Kocaoğlu1, Mahmut Kalem1, Anıl Özbek2, Kerem Başarır1, Bülent Erdemli1 1Ankara Üniversitesi Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, Ankara, Türkiye 2Yozgat Şehir Hastanesi, Ortopedi ve Travmatoloji Kliniği, Yozgat, Türkiye Total Diz Artroplastisinde Cerrahi Süresince Pnömatik Turnike Kullanımı ile Çimentolama Sırasında Pnömatik Turnike Kullanılmasının Erken Dönem Kan Kaybı Üzerinde Etkisi DOI: 10.4274/atfm.22931 CERRAHİ TIP BİLİMLERİ / SURGICAL SCIENCES

Proinflammatory biomarkers' level and functional genetic polymorphisms in periprosthetic joint infection

Objective The aims of this study were 1) to identify the level of inflammatory biomarkers interleukin (IL)-1α, IL-1β, IL-6, IL-8, IL-17, C-reactive protein (CRP), granulocyte colony-stimulating factor (GCSF), ferritin, and tumor necrosis factor (TNF)-α in serum and synovial fluid samples of patients who underwent revision arthroplasty surgery; 2) to establish the relationship between serum and synovial fluid levels; 3) to determine if any of the 11 genetic polymorphisms of TNFα, IL-1, IL-6, IL-8, IL-17, and GCSF on the encoding genes was associated with periprosthetic joint infection (PJI). Methods Synovial fluid and serum was collected from 88 patients who underwent revision arthroplasty surgery. The Musculoskeletal Infection Society definition was used to classify these patients into 2 groups: 36 PJIs and 52 aseptic failures. Synovial fluid and serum samples were tested for 9 biomarkers using a micro enzyme-linked immunosorbent assay. Genetic polymorphisms were evaluated with polymerase chain reaction and restriction endonuclease analysis. Results Synovial fluid-derived IL-1α, IL-1β, IL-8, IL-17, CRP, GCSF, TNFα, and serum-derived IL-6, IL-17, ferritin, CRP were found suitable to classify PJI and aseptic failure. In addition, IL-17 and CRP levels demonstrated a positive correlation between synovial fluid and serum. TNFα-238, IL6-174, GCSF3R, and IL1 RN-VNTR genetic polymorphisms occurred more frequently in individuals with septic failure. Conclusion Significant differences between the two groups were observed in the functional polymorphisms of the genes encoding the cytokines investigated. These differences could be interpreted as indicating that there is an association between PJI and genetic polymorphisms. Level of evidence Level III, diagnostic study.