Gurkan Ozkoc

Necrotizing Soft-Tissue Infection of a Limb: Clinical Presentation and Factors Related to Mortality

Background: Necrotizing fasciitis is a rare and often fatal soft-tissue infection. Prompt diagnosis and immediate aggressive surgical debridement of all compromised tissues are critical to reducing morbidity and mortality in these rapidly progressive infections. The purpose of this study was to analyze the clinical presentation and evaluate factors that determine mortality associated with this uncommon surgical emergency. Methods: The study retrospectively investigated the medical records of 22 patients who were diagnosed and treated for necrotizing fasciitis of the lower extremity, 14 of whom had involvement of the foot (nine patients) or foot and ankle (five patients) at our hospital. The data collected for each of the 22 patients were age, sex, underlying systemic factors, location of infection, duration of symptoms, portal of entry of infection, initial diagnosis on admission, physical, radiographic and laboratory findings, microbiological cultures, the type of therapy used (debridement or amputation), treatment outcome, and number of days in the hospital. Results: A total of 23 extremities of 22 consecutive patients with necrotizing fasciitis who underwent surgical debridement or amputation were retrospectively reviewed. Radical surgical debridement was done in 16 extremities initially, and this treatment was repeated a mean of two times (range one to four debridements) to completely remove all the necrotic tissue. Nine patients (41%) required below-knee or above-knee amputation. There were three deaths, one related directly to sepsis and organ failure, one due to gastrointestinal hemorrhage, and one caused by pulmonary embolism. There were no significant differences between patients who had the amputations and those who did not with respect to mortality rate or age (p = 0.538 and p = 0.493, respectively). Those who died were significantly older than the survivors (p = 0.038). Conclusions: The diagnosis of necrotizing fasciitis should be considered for any individual who has unexplained limb pain, especially if that person has diabetes mellitus or chronic liver disease. There was no difference in mortality rates between patients with or without amputation. The primary treatment is early and aggressive debridement of involved skin, subcutaneous fat, and fascia.

Tunnel enlargement after arthroscopic anterior cruciate ligament reconstruction: Comparison of bone-patellar tendon-bone and hamstring autografts

Bone tunnel enlargement associated with anterior cruciate ligament (ACL) reconstruction has recently become a topic of interest in the literature. This association was examined, along with the effect of femoral and tibial tunnel enlargement on the clinical results of ACL reconstruction performed with either bone-patellar tendon-bone (BPTB) or hamstring (HST) autografts. Forty-six patients underwent arthroscopic ACL reconstruction (23 receiving BPTB autograft and 23 HST) between March 1999 and July 2001. Thirty patients (13 receiving BPTB autograft and 17 HST) completed the last clinical and radiologic evaluations and were included in the study. The mean age of patients in the HST group was 29.8 years (range 18–39) and that in the BPTB group was 27.6 years (range 20–37). The mean follow-up period was 24.6 months (range 12–36) in HST group and 18.5 months (range 12–40) in BPTB group. The effect of tunnel enlargement on the clinical results was evaluated by comparing preoperative and postoperative Lysholm, Tegner, and International Knee Documentation Committee scores and ligament laxity measurements between and within the groups. Postoperative femoral and tibial tunnel diameters in both groups were significantly larger than their corresponding preoperative tunnel diameters. In an intergroup evaluation, the enlargement of the tibial tunnel was similar in both groups (P=.556), but the femoral tunnel diameter was significantly larger in the HST group than in the BPTB group (P>.001). Preoperative laxity of the knees significantly improved after the operations in both groups, but no difference between the groups was evident at the final follow-up visit. No correlation between tunnel widening and the clinical results of the BPTB and HST procedures was observed.

Synovial cysts of proximal tibiofibular joint causing peroneal nerve palsy: report of three cases and review of the literature

IntroductionSynovial cyst of the proximal tibiofibular joint is a very rare condition, for which there is no consensus regarding treatment. Case presentationWe present three patients who had synovial cysts of proximal tibiofibular joint that caused peroneal nerve palsy. We discuss the special features of synovial cysts and review the literature. ConclusionWe consider the best treatment of synovial cysts originating from proximal tibiofibular joint and causing peroneal nerve palsy to be total surgical removal as soon as possible after the diagnosis is made. It should be kept in mind that despite surgical treatment the neurological symptoms may not recover.

Early results of treatment of proximal humerus fractures with the PHILOS locking plate

OBJECTIVES The aim of this study was to evaluate early results of proximal humerus fractures treated with the PHILOS locking plate. METHODS Proximal humerus fractures of 22 patients (13 males, 9 females; mean age 57 years; range 35 to 83 years) were treated with the PHILOS locking plate. According to the Neer classification, 13 patients had comminuted fractures, four patients had valgus impact injuries, two patients had fracture-dislocations, and three patients had fractures involving the proximal 1/3 of the humerus. The fractures were reduced by the transdeltoid lateral approach (n=8) using minimally invasive surgery, and by the anterior deltopectoral approach (n=14) using open surgery. Passive and active exercises were initiated on the second postoperative day and after 4 to 6 weeks, respectively. The results were assessed using the Constant-Murley shoulder scoring system. The mean follow up was 14 months (range 12 to 19 months). RESULTS Radiographically, union was observed in 20 patients at the end of 10 weeks. In one patient, time to union was 16 weeks. One patient underwent autogenous bone grafting because of nonunion after 16 weeks. The mean Constant-Murley score was 75.5 (range 51 to 93). There was no significant difference between Constant-Murley scores of patients undergoing the transdeltoid lateral and anterior deltopectoral approaches (p>0.05). Plate fixation was associated with minimal varus deformity in two patients, and subacromial impingement in one patient. Implant failure did not occur. Reflex sympathetic dystrophy and avascular necrosis were observed in two patients, respectively. CONCLUSION Fixation with the PHILOS plate is a near-ideal technique with a high union rate in the treatment of proximal humeral fractures.

Hallucal sesamoid osteonecrosis: an overlooked cause of forefoot pain.

Four cases of osteonecrosis of hallucal sesamoids are reported here. Surgical excision of necrotic sesamoid tissue yielded satisfactory results, with the patients reporting no residual pain. Although it has not been frequently addressed in the literature, avascular necrosis of the sesamoid bones should be considered in the differential diagnosis of persistent forefoot pain.

Hydatid disease with atypical localization: 4 cases report.

Hydatid disease caused by Echinococcus often manifests as slowly growing cystic mass and mainly affects the liver or lung and rarely other parts of the body such as brain, heart, bone and muscle. Cyst may be single or multiple, uni-or multiloculated. In this paper 4 hydatic cases, multiple and atypically localized are presented. Of the 4 cases, 2 were known to suffer from hydatid disease, having had a hepatic cyst removal previously. Thus, when faced with a hydatid cyst in any part of the body, it is preferable to examine other parts of the body by radiological imaging methods.

Combined ulnar and carpal tunnel syndrome caused by pigmented villo-nodular tenosynovitis: a rare case

Pigmented villo-nodular synovitis/tenosynovitis (PVNS) is a rare cause of combined ulnar and median nerve compression neuropathy at the wrist. In our case, a 53-year-old house-wife had sensorial and motor complaints at her left hand. In clinical examination, painless soft tissue mass was palpated at her wrist and both the tenar and hypotenar muscles were atrophic. Electromyography showed prolonged distal latencies for median and ulnar nerve. A space-occupying soft tissue lesion was revealed in magnetic resonance imaging. Carpal tunnel and Guyon canal were released and lesion was excised. PVNS was confirmed by histopathological examination. If compression neuropathy of medial and ulnar nerves together is caused by a space-occupying lesion, PVNS should be considered in etiology.

Comparison of tunnel expansion and isometric muscle strength after ACL reconstruction with single- or dual-bundle hamstring allograft: a prospective, randomized study

OBJECTIVE The aim of this study was to compare tunnel expansion and isokinetic muscle strength after single- and dual-bundle reconstruction of the anterior cruciate ligament (ACL). METHODS This study included 34 patients who underwent ACL reconstruction in our clinic between November 2007 and March 2008. Eighteen patients (average age: 27.3 years; range: 19 to 35 years) underwent single-bundle ACL reconstruction and sixteen patients (average age: 30.1 years; range: 20 to 40 years) underwent dual-bundle ACL reconstruction. Method selection was determined by draw. Isokinetic hamstring and quadriceps muscle strength was tested preoperatively using Biodex 3. Three-dimensional computed tomography of the knee joint was taken in the 2nd and 3rd postoperative month. The three-dimensional computed tomography and isokinetic muscle strength tests were repeated at the 6th month follow-up. Each tunnel was divided into six equal parts, and the tunnel width in the sagittal and coronal planes was measured and the same points in the axial plane were measured in the tunnel area. RESULTS No significant difference was found between the single- and dual-bundle reconstructions in isokinetic muscle strength values. No statistically significant difference was detected between the tunnel expansions in 2nd, 3rd and 6th month tomographies following single- and dual-bundle ACL reconstruction. CONCLUSION Single- and dual-bundle ACL reconstructions seem to provide similar results in terms of early tunnel enlargement and isokinetic muscle strength.

Comparison of tunnel expansion, isometric muscle strength and clinical condition after anterior cruciate ligament reconstruction with single- or dual-bundle: Randomized, prospective 8 years follow up study

Thirty-one patients who suffered anterior cruciate ligament (ACL) injury and underwent ACL reconstruction (16 single-bundle, 15 double-bundle) with ENDOBUTTON between November 2007 and March 2008 were included in the study. Isokinetic and concentric strength measurements of the quadriceps and hamstring muscles at the 6th month and 8th year were made using a Biodex 3 device at angular velocities of 60°/sec, 120°/sec and 180°/sec. The peak torque and peak torque to body weight ratios were recorded. 3D-CT scans of the joints were performed on the 2nd, 3 rd and 6th month and 8th year. CT slices were divided into six equal parts marking the distance between the femoral and tibial tunnels with the most distant part of the knee joint as L1, and with the entry point on the knee joint as L6. The tunnel length was measured in millimeters and perpendicularly to the tibial axis in the sagittal and coronal planes. Tunnel cross-sectional areas were also measured in mm2 using the same device on axial reconstructions. Clinical evaluations on the 8th year were performed with the IKDC, Tegner and Lysholm knee scoring systems and laxity in the patients was evaluated with the anterior drawer test. Posterolateral tunnel widening was analyzed with the repeated measures ANOVA technique whereas two-way mixed ANOVA was employed in evaluating the anteromedial tunnel widening. Three-way ANOVA was used in assessing the Biodex results and comparison of the scoring systems results were done with the t-test. Results: No difference was found between the groups in terms of IKDC, Lysholm and Tegner scores and anterior drawer test results at the 8th year follow-up (p>0.05). Points where significant amounts of tunnel widening were observed are shown in Table 1. On evaluation of the anteromedial bundles alone, it was observed that double-tunnel reconstruction led to greater widening. No significant difference was found between the groups in terms of muscle strength in the 8th year assessments, however, there was a statistically significant difference between the preoperative and 6th month results (p<0.05). Patients in both groups had better results at the 8th year follow-up when compared to their preoperative and 6th month results. The results of our study confirmed significant amounts of widening at parts of the femoral tunnel close to the knee joint in patients treated with single-bundle or double-bundle ACL reconstruction. However, there is no difference between the groups in terms of clinical results and isometric muscle strengths in the long term. CT sections which are statistically significant widening detected (p<0,05) Side Section Single Bundle Anteromedial Bundle Posterolateral Bundle Sagittal 1,2,6 1,2 3 Femoral Coronal 1,5,6 1,2,6 1 Axial 6 1,2,5,6 1,4 Sagittal 1 1,5,6 3 Tibial Coronal 1,5 4,5,6 Axial 1,2,5,6 2,3,4,5,6 Discussion: It has been suggested that the tunnel widening will lead to failure of the reconstruction. It is hypothesized that, in double-bundle reconstruction, the tunnels will widen more and finally coalesce, which in turn, will result in failure of the reconstruction. In our study, we found no evidence pointing out to a coalescence of the tunnels in the long term. We believe the greater widening in the anteromedial bundle in the double-tunnel surgery vs. the single-tunnel method is due to the smaller diameter of the graft and its greater mobility

Zoledronic Acid Effect on Chondrocyte Apoptosis in Degenerative Osteoarthritis Model

Apoptosis refers to cell death without inflammatory process, and is related to degenerative changes in joints. We hypothesized that zoledronic acid (ZA) would have a positive effect on chondrocyte ...