Elcil Kaya Bicer

Current knowledge in the anatomy of the human anterior cruciate ligament.

The anterior cruciate ligament (ACL) is one of the most frequently studied structures of the musculoskeletal system and continues to stimulate debate and challenges among researchers and surgeons. The ultimate goal of anatomic reconstruction surgery is to restore the native anatomy as much as possible. However, this requires thorough knowledge of its anatomy. The aim of this article is to review the current knowledge of the anatomy of ACL along with its macrostructural and ultrastructural properties.

The effect of 2 adhesive products on skin integrity used for fixation of hip and knee surgical dressings: a randomized controlled trial.

PURPOSE: The aim of this study was to compare effects of 2 adhesive products, a nonwoven porous adhesive bandage (NPAB) and transparent film adhesive bandage (TFAB), on skin integrity for fixation of hip and knee surgical dressings. MATERIALS AND METHODS: A prospective, randomized study was conducted on 300 patients who underwent hip and knee surgery (arthroplasty, fixation of fractures, tumor operations, etc). Participants were randomized into 2 equal groups according to the applied surgical dressing fixation product (NPAB or TFAB). Skin changes (edema, erythema, blister, peeling of blister, mechanical peeling, and maceration), drying of incision, serous discharge, and early infection symptoms were evaluated. RESULTS: The skin integrity was found to be impaired in 4.0% (n = 6) of the 150 NPAB patients and in 10.7% (n = 16) of the 150 TFAB patients (P = .02). Logistic regression analysis showed that the risk of impaired skin integrity increased 2.5-fold when TFAB was applied (P = .03). CONCLUSION: The NPAB was associated with a reduced likelihood of impaired skin integrity following hip and knee surgery.

The Structure, Function, and Healing of the Meniscus

The menisci have indispensable functions in the knee joint such as load bearing, shock absorption, articular nutrition, and joint lubrication, along with roles in maintaining joint stability and proprioception. Meniscal tissue loss results in early degenerative changes in the knee joint because of alterations in the loading pattern of articular cartilages. With the improved understanding of the fundamental roles of the menisci and the detrimental effects of their absence, repair of torn menisci, instead of amputation, is supported today. Its healing potential is directly related to its vascularization. The tears of the less-vascularized zone are suggested to be not only repaired but also augmented with various techniques. If it is indicated to perform a segmental meniscectomy in a knee without arthritic changes, it is possible to replace the removed part with a synthetic matrix graft. In patients who had a total meniscectomy, meniscal allograft transplantation can be regarded as a treatment option.

Changes of ankle inclinations after total knee arthroplasty

Aim: To evaluate the changes in ankle joint line inclination in patients who had total knee arthroplasty due to degenerative osteoarthritis. Material/Method: Sixty-two knees (with a mean age of 71,66±6,78 years, follow-up 52,34±27,42 months) which had undergone total knee arthroplasty between November 1996 and May 2014 were included in this retrospective study. The knee joint line orientations (KJLO) of the prosthesis and ankle joint line inclination (AJLI) relative to the floor were evaluated on postoperative standard standing long-leg X-rays. The AJLI relative to the floor was defined as the angle between the tangent to the subchondral plate of the talus and the horizontal grid line on radiographs. In order to determine the effects of KJLO and high varus on AJLI, patients were divided into two each groups that were pre-operative mechanical axes (MA) as <20° (n=35, group1) and >=20° (n=27, group2) and post-operative MA <3° (n=32, group a) and >=3° (n=30, group b). In addition, the changes in AJLI were compared between each group. The patients were regrouped as either <=3° (n=28, group i) or >3° (n=34, group ii), in terms of the postoperative KJLO. Inclination angles of the prosthesis were compared between each groups. Statistical analysis was performed with SPSS v18. Results: Mean MA of pre-operative and post-operative were 16,35±6,56° and 3,92±3,35°, respectively. All ankle inclinations were lateralized. AJLI, were significantly decreased from pre-operative mean 7,37°±3,19° to post-operative mean 3,71°±2,22° (p<0,0001). The mean of change was 3,65°±3,03°. However, pre-operative AJLIs were significantly increased in high varus group (group1: 6,34°±2,54°, group2: 8,70°±3,48°, p=0,003); post-operative AJLIs did not differ significantly (group1: 3,55°±2,36°, group2: 3,92°±2,05°, p=0,516) with respect to the MA. The changes in preop-postop AJLI’s were significantly higher in high varus group again (p=0,009). When the KJLO groups were compared, pre-operative AJLIs were significantly different (group i: 6,25°±2,33°, group ii: 8,29°±3,53°, p=0,004) while post-operative AJLIs did not differ significantly (group i: 3,46°±2,38°, group ii: 3,92°±2,08°, p=0,489). Conclusion: Pre-operatively high varus knees also had high ankle varus, hence ankle deformity was corrected by the restoration of the optimal lower limb aligment. Obtaining parallel orientation of the components relative to the ground, restored the AJLI. Pre-operative planning and convenient implantation of the components lead to achieve optimum knee orientation which restored the ankle joint line orientation independent from mechanical axes. Not only the goal of optimum mechanical axes but also optimum knee joint line orientation’s importance was demonsrated.

Is it possible to use stress radiographs as a tool to diagnose medial meniscus posterior root tears

Aim: Medial meniscus posterior root tear (MMPRT) causes meniscal extrusion, loss of meniscus function, arthritic changes. Clinical history, physical examination and magnetic resonance imaging (MRI) findings are useful for the diagnosis of MMPRT. The aim of this study is to evaluate the utility of stress X-rays in the diagnosis of MMPRT. Methods: Twenty patients who had undergone high tibial osteotomy between March 2015 and May 2016 and whose preoperative bilateral varus and valgus stress x-rays (Telos device) along with weight bearing x-rays were available were included. These patients were grouped into two according to integrity of posterior roots of their medial menisci; there were ten patients both in the study and control groups. Lateral joint space width (LJW) on varus stress x-rays, medial joint space width (MJW) on valgus stress x-rays as well as LJW and MJW on weight bearing x-rays were measured bilaterally. Intragroup comparisons of joint space widths between index and opposite knees were performed. Differences of MJW and LJW between index and opposite knees were calculated. Differences of joint space widths between stress x-rays and weight bearing x-rays were also calculated. The changes in joint space widths between the two groups were compared. Statistical analyses were performed utilizing SPSS 18.0. Significance level was set at 0.05. Results: In MMPRT group, opening of LJ space of index knees under varus stress was greater than that of opposite knees (Index: (mean±SD) 10,27±1,17 mm, opposite: 8,61±1,37 mm; p<0,0001). In the control group the difference was not significant (Index: 9,29±2,55 mm, opposite: 9,68±1,44 mm; p=0,566). The difference in the opening of LJW (under varus stress) between index and opposite knees was significantly greater in the study group (p=0,013). The difference between LJW under weight-bearing and varus stress conditions was significantly greater in the study group. (Study: 3,64±0.217 mm, control:2,28±0,182 mm, p=0.018). Conclusions: The findings of this study showed that in patients who had MMPRTs, an increased opening in the LJW was observed under varus stress conditions. This may be relevant with the fact that when varus stress is applied, meniscal extrusion is increased in case of a MMPRT. Stress x-rays could be a useful tool in the diagnosis of MMPRTs. Further studies are needed to determine the sensitivity and specificity of this diagnostic tool.

Central defect type partial ACL injury model on goat knees: the effect of infrapatellar fat pad excision

BackgroundThe mid-substance central defect injury has been used to investigate the primary healing capacity of the anterior cruciate ligament (ACL) in a goat model. The sagittal plane stability on this model has not been confirmed, and possible effects of fat pad excision on healing have not been evaluated. We hypothesize that excising the fat pad tissue results in poorer ligament healing as assessed histologically and decreased tensile strength of the healing ligament. We further hypothesize that the creation of a central defect does not affect sagittal plane knee stability.MethodsA mid-substance central defect was created with a 4-mm arthroscopic punch in the ACLs of right knees of all the subjects through a medial mini-arthrotomy. Goats were assigned to groups based on whether the fat pad was preserved (group 1, n = 5) or excised completely (group 2, n = 5). The left knees served as controls in each goat. Histopathology of the defect area along with measurement of type I collagen in one goat from each group were performed at 10th week postoperatively. The remaining knees were evaluated biomechanically at the 12th week, by measuring anterior tibial translation (ATT) of the knee joints at 90° of flexion and testing tensile properties (ultimate tensile load (UTL), ultimate elongation (UE), stiffness (S), failure mode (FM)) of the femur-ACL-tibia complex.Results and discussionHistopathology analysis revealed that the central defect area was fully filled macroscopically and microscopically. However, myxoid degeneration and fibrosis were observed in group 2 and increased collagen type I content was noted in group 2. There were no significant differences within and between groups in terms of ATT values (p = 0.715 and p = 0.149, respectively). There were no significance between or within groups in terms of ultimate tensile load and ultimate elongation; however, group 2 demonstrated greater stiffness than group 1 that was correlated with the fibrotic changes detected microscopically (p = 0.043).ConclusionsThe central defect type injury model was confirmed to be biomechanically stable in a goat model. Resection of the fat pad was noted to negatively affect defect healing and increase ligament stiffness in the central defect injury model.