Hakan Aycan

Demographic, clinical, and laboratory features of Turkish patients with late onset ankylosing spondylitis

Ankylosing spondylitis (AS) is a chronic inflammatory disease, which typically begins in early decades of life with primarily axial joints involvement. This disease rarely affects patients older than 50 years of age. The aim of this study was to compare and evaluate the demographic, clinical, and laboratory features of late onset and early onset AS patients who were followed up in a single rheumatology center. A total of 339 patients who have been diagnosed with AS according to modified New York criteria were included in the study. The patients whose initial symptoms were observed after 50 years of age were accepted as late onset AS. Out of 339 patients, 27 (7.9%) were diagnosed as late onset AS and 312 (92.3%) patients were evaluated as early onset AS. Of 27 late onset patients, 10 were male and 17 were female. Delay in the diagnosis was 5.8 years for early onset AS, while it was 3.8 years for late onset AS (p = 0.001). Higher levels of acute phase reactants and more methotrexate (MTX) use were detected in early onset AS patients compared to late onset AS (p = 0.001, p = 0.007, respectively). Statistically, there was no difference between these two groups, with regard to disease clinical activity indexes, anthropometric measurement parameters, uveitis and peripheral joint involvement. In this study, we showed that early and late onset AS patients may present with different clinical, genetic, and laboratory features. Late onset AS patients are characterized with lower human leukocyte antigen-B27 sequence, less inflammatory sign, delayed diagnosis, and less MTX and anti-tumor necrosis factor alpha drug usage.

Traumatic Distal Ulnar Artery Thrombosis

This paper is about a posttraumatic distal ulnar artery thrombosis case that has occurred after a single blunt trauma. The ulnar artery thrombosis because of chronic trauma is a frequent condition (hypothenar hammer syndrome) but an ulnar artery thrombosis because of a single direct blunt trauma is rare. Our patient who has been affected by a single blunt trauma to his hand and developed ulnar artery thrombosis has been treated by resection of the thrombosed ulnar artery segment. This report shows that a single blunt trauma can cause distal ulnar artery thrombosis in the hand and it can be treated merely by thrombosed segment resection in suitable cases.

Femur nail-cortex contact length and aging

Aims: For prevention of interfragmentary shear motion in intramedullary nailing, the nail-cortex contact (N-CC) length should be long enough. This study was designed to assess the N-CC length changes related to the aging process. Materials and Methods: Femur anteroposterior (AP) radiograms of 204 patients older than 20 years were reamed virtually to be 13-mm, 14-mm, and 15-mm diameter artificial medullary cavities. Patients were divided into two major groups (males and females). Each group was subdivided into four subgroups - 20-39 years, 40-59 years, above 60 years, and above 70 years. The N-CC lengths of the femur diaphysis were measured in all groups and changes were compared between the groups. Results: For the 13-mm diameter artificial medullar cavity in female groups, the mean N-CC length value in the 20-39 years age group was 13.8 ± 4 cm, mean N-CC length value in the 40-59 years group was 11.6 ± 4.3 cm, mean N-CC length value in the above 60 years group was 9.4 ± 5.3 cm, and mean N-CC length value in the above 70 years age group were 8.8 ± 3 cm. A significant 48.6% decrease of N-CC length between 20-39-year and 40-59-year aged female groups was noticed (Z = −2.423; P = 0.015), whereas in the male groups, the significant N-CC length decrease (86%) was between the 40-59 years age group and above 70 years age group (Z = −4.279; P = 0.001). Conclusion: As N-CC length decreases after the age of 40 years in women and after the age of 70 years in men, thicker intramedullary nails should be used in these age groups for long N-CC area.

Unilateral lymphedema as first presentation of sarcoidosis

Sarcoidosis is a systemic disease characterized by the involvement of multiple tissues and organs with a non-calcified granuloma reaction, which is not yet well understood.1 Although the exact pathogenesis of sarcoidosis is not known, it is currently accepted that, in genetically susceptible individuals, it is caused through alteration of the cellular immune response after exposure to an environmental, occupational or infectious agent.2 It is presented with bilateral hilar lymphadenopathies, infiltrations in the lung, skin and eye lesions. The pathognomonic histological finding is the presence of non-calcified granulomas.3 These granulomas may form in almost any organ in the body. Sarcoidosis is one of the most important causes of granulomatous lymphadenitis.4 Development of lymphedema is the result of the involvement of lymph nodes and obstruction of lymphatic drainage. In this report we present a female case of sarcoidosis and ankylosing spondylitis co-occurrence that applied to our clinic with widespread lymphedema on her left leg. The patient is 50-year-old female who presented to our clinic with lymphedema and swelling started from the left inguinal region and spread to the whole left lower extremity. She had also complaints of inflammatory low back pain going on for the last 15 years. In her physical examination there was widespread lymphedema on her left foot, lymphadenopathies on her left inguinal region, restriction on her neck and hip range of motion and bilateral Fabere/Fadir test positivity. Laboratory studies showed erythrocyte sedimentation rate and C-reactive protein elevation, serum calcium and angiotensin converting enzyme (ACE) elevation and chronic disease anemia. There were widespread conglomerate lymphadenopathies in the left inguinal region according to the soft tissue ultrasonography examination. Thorax CT showed paratracheal, mediastinal and bilateral hilar lymphadenopathies (Fig. 1). Sacroiliac joint radiography showed bilateral joint space narrowing and sclerosis. Sacroiliac MRI scan was reported as chronic sacroiliitis with the presence of active lesions (Fig. 2). Genetic analysis showed that HLA-B27 was positive. Biopsy of the inguinal lymphadenopathies revealed granulomatous

The best location for proximal locking screw for femur interlocking nailing: A biomechanical study

Background: Proximal locking screw deformation and screw fracture is a frequently seen problem for femur interlocking nailing that affects fracture healing. We realized that there is lack of literature for the right level for the proximal locking screw. We investigated the difference of locking screw bending resistance between the application of screws on different proximal femoral levels. Materials and Methods: We used a total of 80 proximal locking screws for eight groups, 10 screws for each group. Three-point bending tests were performed on four types of screws in two different trochanteric levels (the lesser trochanter and 20 mm proximal). We determined the yield points at three-point bending tests that a permanent deformation started in the locking screws using an axial compression testing machine. Results: The mean yield point value of 5 mm threaded locking screws applied 20 mm proximal of lesser trochanter was 1022 ± 49 (range 986–1057) (mean ± standard deviation, 95% confidence interval). On the other hand, the mean yield point value of the same type of locking screws applied on the lesser trochanteric level was 2089 ± 249 (range 1911–2268). Which means 103% increase of screw resistance between two levels (P = 0.000). In all screw groups, on the lesser trochanter line we determined 98–174% higher than the yield point values of the same type of locking screws in comparison with 20 mm proximal to the lesser trochanter (P = 0.000). Conclusion: According to our findings, there is twice as much difference in locking screw bending resistance between these two application levels. To avoid proximal locking screw deformation, locking screws should be placed in the level of the lesser trochanter in nailing of 1/3 middle and distal femur fractures.

The treatment of focal dystonia of index finger of the hand with tendon transfer

Dystonia is a disorder of motion; accompanied by unintentional muscle spasms leading to repetitive movements and/or aberrant posture that appears during a specific activity. Examples of focal task-specific dystonia (TSD) are “writer’s cramp” and “musician’s dystonia”, and it specifically involves the hand. A 54-year-old male presented with a complaint that the index finger of his right hand moved repetitively that scratched the wrist and palm when he shook hands. He could not find a solution to his problem through non-surgical treatment options. Based on the fact that the problem was limited to the index finger, non-progressive (stable) and refractory to non-surgical treatment, it was attempted to treat the patient with a tendon transfer as a last option. A case of focal TSD of the right index finger treated with tenotomy and tendon transfer is presented here.

A new femoral nail with single distal locking screw for maximum interfragment rotational stability

OBJECTIVE One of the problems for interlocking nailing of the femur is interfragment rotation motion, affecting fracture healing. The nails with single distal locking screw are advantageous for decreasing operation time and radiation exposure. We investigated which single distal screw nail is the best for interfragment rotational stability. METHODS We used a total of 30 composite femurs, ten for each group. We determined interfragment rotational displacement of composite femurs with three types of single distal screw nails (10 interlocking nails, 10 compression nails and 10 Mehmet anti-rotation nails compressed by tube) at 6-Nm external- 6 Nm internal and 10 Nm extern- 6 Nm internal torques, which imitating respectively the level walking and descending stairs, using an axial distraction testing machine and a custom designed rotation apparatus. RESULTS Between 10 Nm external and 6 Nm internal torques with single distal locking screw, the interfragment rotational displacement in the Mehmet nail compressed by the 8 Nm torque wrench was mean 1.14 mm and 540% less than mean 7.31 mm in interlocking nails and 400% less than 5.72 mm in compression nails compressed by the 2.5 Nm torque wrench. CONCLUSION The single distal screw Mehmet nail is superior than other single (or even some double) distal screw nails for maximum rotational stability, with no interfragment distraction gap, no superior nail migration, decreased operation time, and less radiation exposure in axially stable transverse and short oblique femur fractures in daily activities like stair descending or level walking.

Reliability of threaded locking screws

OBJECTIVE A frequent problem for interlocking nailing that affects the treatment of the fracture is locking screw deformation. The aim of this study is to determine whether bending resistance is different between high, low, and unthreaded locking screws of interlocking femoral nails. METHODS Ninety screws were used in this experimental study, with 10 screws used in each of 9 groups. Three-point bending tests were performed on 6 groups of 5 mm screws (titanium, stainless steel, crossed with unthreaded, low threaded, and high threaded) and the same 3 thread types of 5.5 mm stainless steel screws in a 30-mm inner diameter steel tube, imitating the level of the lesser trochanter. An axial compressor was used to determine the yield points for permanent deformation in the locking screws by way of 3-point bending tests. RESULTS The mean yield point value of the 3-point bending tests of 5-mm low threaded stainless steel locking screws was 2071 N, 53% less than that of unthreaded screws (3169 N). The mean yield point value of 5-mm high threaded stainless steel locking screws was 556 N, 272% less than that of low threaded screws (2071 N). CONCLUSION To avoid locking screw deformation, high threaded screws must not be used as locking screws. In cases of unreliable patients, 5-mm low threaded screws should not be used in the nailing of comminuted or oblique femur shaft fractures. All 5-mm unthreaded screws and 5.5-mm low threaded stainless steel screws can be used safely in full weight-bearing conditions of unreliable patients.

Pulmonary Embolism after Knee Arthroscopy in 57-Year-Old Woman

Objectives: Pulmonary embolism (PE) after knee arthroscopy is even a rare occurrence in older patients. In this report, we present an unusual case of PE following knee arthroscopy. Methods: A 57-year-old woman normally active patient presented to the orthopaedic clinic has been suffering a right knee pain responseless to the medical treatment for a year. Hystory was unremarkable with the exception of hypertension and cervical biopsy. Results: An arthroscopic meniscectomy was received under spinal anesthesia after the application of an Esmarch and pneumatic tourniquet. Post-operatively first day, she was discharged. While transporting, she developed dyspnea, weakness and low-right breast pain. An immediate pulmonary angiography and cardiac echograpy demonsrated the obstruction in the right common pulmonary artery and subsegmentary occlutions in the left side. Conclusion: After a 24-hour streptokinase therapy(ST), coumadine was started. Near the end of ST, she complained a severe knee pain healed by the punctures. Because of a severe epigastric pain unable to control by gastric prophilaxy and therapy.The patient was consulted by a gastroenterology specialist and gastric endoscopy showed an acute gastritis. A control pulmonary angiography on eighth day demonstrated no thrombus including right common pulmonary artery. The patient was successfully discharged on the 11th day.