Kamil Cagri Kose

The prevalence of low back pain and risk factors among adult population in Afyon region, Turkey

OBJECTIVES This study was designed to determine the prevalence of and risk factors for low back pain (LBP) in a sample of Turkish population among adults living in the Afyon region, Turkey. METHODS A field screening investigation was performed in a total of 75 areas including the city center, 18 districts, and 57 associated small municipalities. Adequate sample size was determined as 1,990 and a total of 2,035 individuals (1,194 females, 841 males) were enrolled. Participants were inquired about age, occupation, sex, height, weight, history of LBP, hypertension, diabetes, and smoking. Depression symptoms were evaluated using the Symptom Checklist-90-Revised. RESULTS The prevalence of lifetime LBP was 51%, and the prevalence of chronic LBP was 13.1%. Overall, 63.2% of women and 33.8% of men had LBP at least once in their lives (p=0.001). With regard to occupation, the highest incidence of LBP was seen in housewives (64.2%; p=0.0001), whose age and body mass index (BMI) were also higher compared to employed women. Depression (p=0.016) and increased BMI (p=0.000) were found to increase the risk for LBP, whereas smoking, hypertension, or diabetes were not correlated with the prevalence of LBP. Poverty was found to be the leading cause (39.7%) for not presenting to a physician. CONCLUSION Among risk factors reported for LBP, many are also effective in Turkish population. Special attention should be given to the education of housewives in terms of low back protection, healthy nutrition, and family planning. Poverty seems to be a significant barrier to patient presentation to physicians, requiring extended social security coverage.

Percutaneous release of the trigger thumb: is it safe, cheap and effective?

Percutaneous release of the trigger finger and trigger thumb has recently gained popularity. The aim of this study was to determine the clinical results and safety of percutaneous release in trigger thumbs. Twenty-five thumbs of 21 patients were relased percutaneously in the polyclinic under local anaesthesia. Steroid injection was performed following the release procedure using the same needle. The thumb function was evaluated by a patient questionnaire, and functional thumb scores (VAS) were calculated in the preoperative and postoperative periods. At the 1 week follow-up, four patients had signs of discomfort and triggering because of incomplete release. These patients underwent open A1 pulley release. Three superficial tendon lacerations were seen during these open procedures. There were no wound complications or signs of digital nerve or artery injury in any of the patients. The preoperative mean VAS was 26.62 (18–36). This decreased to 2.57 (0–5) at the first postoperative month (P<0.001) and to 2.19 (0–3; P<0.001) at the sixth month. When the VAS scores at the first and sixth months were compared, the difference was statistically significant. We concluded that percutaneous release of trigger thumbs is a cheap, safe and effective procedure with a low rate of complications.

Use of a splint following open carpal tunnel release: A comparative study

This study was undertaken to compare the clinical effectiveness and costs of postoperative splintage and late rehabilitation with a bulky bandage dressing versus early rehabilitation after carpal tunnel release. In this comparative study, 46 patients were randomly divided into 2 groups. In each group, 3 patients were excluded because of improper follow-up, leaving a total of 40 patients. Group 1 used a splint (exercises given 3 wk postoperatively) and group 2 was given a bulky bandage (exercises provided immediately) after open release. Patients were assessed preoperatively and at the first and third postoperative months with the Questionnaire of Levine for Clinical Assessment of Carpal Tunnel Syndrome. The 2 groups were similar in terms of preoperative functional status scores and in controls at the first and third months (P=.549,P=.326,P=.190). When both groups were compared, no statistical significance was found regarding symptom severity scale scores preoperatively and at the first postoperative month (P=.632 vsP=.353). At the third month, scores were lower in favor of group 2 (P=.023). Additionally, 16 of 20 patients (80%) in group 1 reported a heavy feeling and discomfort caused by the splint. This problem was not reported by the patients in group 2. The cheapest splint on the market was 9 times more expensive than a bulky dressing. The investigators concluded that postoperative immobilization with a splint has no detectable benefits. Use of bulky dressings and abandonment of the use of postoperative splints may prevent unnecessary expenditures without sacrificing patient comfort or compromising the course of healing in carpal tunnel surgery.

Mini-open versus all-arthroscopic rotator cuff repair: Comparison of the operative costs and the clinical outcomes

IntroductionRotator cuff injury is one of the most frequently encountered problems of the shoulder in the daily practice of orthopaedic surgeons. This study compared all-arthroscopic cuff repair (ARCR) and mini-open rotator cuff repair (MORCR) methods in regard to clinical outcomes and costs.MethodsFifty patient charts and operative repairs were analysed (25 ARCR and 25 MORCR). Pre-and postoperative Constant-Murley and UCLA scores along with factors such as tear size, tear type, pre-operative physical therapy, motion and satisfaction levels were compared for the two procedures. Cost-benefit analysis was also performed for comparison between procedures. The duration of follow-up was 31.20 and 21.56 months for MORCR and ARCR groups, respectively.ResultsTear sizes (P=0.68), pre-and postoperative Constant-Murley and UCLA scores (P=0.254) and satisfaction levels were not significantly different between groups. However, the differences between pre-and postoperative Constant-Murley and UCLA scores were statistically significant within both groups (P<0.01). The MORCR group stayed 1 day longer in hospital than the ARCR group, which was statistically significant (P=0.036). The differences regarding mean pain scores, abductions, internal and external rotations in Constant-Murley scores and forward flexion scores in UCLA scores were not significant. The ARCR group cost more, leaving less profit.ConclusionResults suggest that ARCR yields similar clinical results but at a higher cost compared with MORCR.

The comparison of the effects of intraoperative bleeding control and postoperative drain clamping methods on the postoperative blood loss and the need for transfusion following total knee arthroplasty

OBJECTIVE The aim of this retrospective study was to evaluate the relation between a new index we created for the assessment of distal radius fractures involving the ulnar styloid, and the clinical outcome. METHODS We devised a radiographic separation index (RSI), to evaluate the displacement of the ulnar styloid. We used this index in 44 patients (28 men and 16 women; mean age: 43.2 years; range: 24-64 years) with distal radius fractures involving the the ulnar styloid. In all cases, the distal radius fracture was fixed using a volar locking plate. The styloid fracture was treated conservatively. The relation between the RSI value and clinical results was then investigated. RESULTS In the 44 patients there were clinically 38 excellent, 4 good, and 2 moderate results. RSI ratios ranged from 2% to 11%. The patients with an excellent result had an RSI ratio of less than 5%. We found a significant correlation between the RSI ratio values and the clinical outcomes. CONCLUSION Our results suggested that the RSI can be used as a predictor of the clinical outcome in patients with distal radius fractures involving the ulnar styloid.OBJECTIVE We aimed to determine and compare the effects of intraoperative bleeding control and two hours postoperative drain clamping method on postoperative wound drainage and the need for donor blood transfusion following total knee arthroplasty (TKA). METHODS Seventy-one patients who underwent TKA were randomly assigned into two groups. Fourty-four knees of 32 patients comprised Group A and 51 knees of 39 patients comprised Group B. In Group A, no bleeding control was done and postoperatively, the drain was clamped for 2 hours. Then it was unclamped to begin aspiration after the 2nd hour. In Group B, the bleeding was controlled intraoperatively, and the drain was not clamped after the surgery. Drains were removed 48 hours after the surgery in both groups. Bilateral and unilateral arthroplasty patients were evaluated separately. The groups were compared for their preoperative and postoperative 3-day haemoglobin (Hb) levels, total drainage amount and total number of blood transfusions. RESULTS The haemoglobin levels were similar in both groups preoperatively and at the 1st, 2nd and 3rd postoperative days. In Group A, the wound drainage was 696.1±235.4 ml in unilateral TKA patients and was 1010.8±535.5 ml in bilateral arthroplasty patients. In Group B, the wound drainage was 710.1±380.1 ml in unilateral TKA patients and was 878.3±489.6 ml in bilateral arthroplasty patients. The mean number of transfusions was 1.41 units with no significant differences between the groups. CONCLUSION The two hour drain clamping method without intraoperative bleeding control does not seem to affect the amount of blood loss and the need for transfusion when compared to intraoperative bleeding control in total knee arthroplasty patients. Hovewer, it is a simple and feasible method and can be used to decrease the operation time.OBJECTIVE Unreconstructed anterior cruciate ligament (ACL) tears cause repeated incidences of giving-way and rotational-translational instability. The aim of this study was to test our hypothesis that delayed surgical treatment of patients with ACL tears, especially those with high Tegner activity levels, results in more severe and complicated meniscal and osteochondral lesions with potential affect on the outcome. METHODS This study included 385 patients who underwent arthroscopic ACL reconstruction between 2001 and 2009. Patients arthroscopic video records or MRI scans and patient files at the time of surgery were analyzed. We defined severe meniscal and osteochondral lesions which could negatively affect the outcome and labeled them meniscal lesions affecting outcome (MLAO) and osteochondral lesions affecting outcome (OLAO). The relation between MLAO, OLAO, time since injury and Tegner activity levels were statistically analyzed. RESULTS The incidences of MLAO and OLAO grew statistically higher as time elapsed between the injury and surgery increased (p=0.001, p<0.05; p=0.001, p<0.05). The relation between the Tegner activity score, MLAO and OLAO risk were found to be statistically insignificant (p=0.317, p=0.184, p>0.05). CONCLUSION Delays in ACL reconstruction surgery result in an increase in the incidence of meniscal and osteochondral lesions which have the potential to negatively affect the surgical outcome.

Kyphectomy for congenital kyphosis due to meningomyelocele: a case treated with a modified approach to skin healing

This study is a case report of a meningomyelocele patient with congenital kyphosis who was treated with kyphectomy and a special approach to soft tissue healing. The objective of this study is to show a step by step approach to surgical treatment and postoperative care of a meningomyelocele patient with congenital kyphosis. In meningomyelocele the incidence of kyphosis is around 12–20%. It may cause recurrent skin ulcerations, impaired sitting balance and respiratory compromise. Kyphectomy has first been described by Sharrard. This surgery is prone to complications including pseudoarthrosis, skin healing problems, recurrence of deformity and deep infections. A 15‐year‐old male presented with congenital kyphosis due to meningomyelocele. He had back pain, deformity and bedsores at the apex of the deformity. The wound cultures showed Staphylococcus epidermidis colonisation at the apex. He was given appropriate antibiotic prophylaxis. During surgery, the apex of the deformity was exposed through a spindle‐shaped incision. After instrumentation and excision of the apex, correction was carried out by cantilever technique. Two screws were inserted to the bodies of L3 and T11. After the operation, the skin was closed in a reverse cross fashion. He was sent to hyperbaric oxygen treatment for prevention of a subsequent skin infection and for rapid healing of skin flaps post operation. The patients deformity was corrected from a preoperative Cobb angle of 135°–15° postoperative. The skin healed without any problems. Preoperative culture and appropriate antibiotic prophylaxis, spindle‐shaped incision, reverse cross‐skin closure and postoperative hyperbaric oxygen treatment can be useful adjuncts to treatment in congenital kyphosis patients with myelomeningocele to prevent postoperative wound healing and infection problems. Reduction screws and intracorporeal compression screws help to reduce the amount of screws and aid in corection of the deformity.

Short segment pedicle screw instrumentation with an index level screw and cantilevered hyperlordotic reduction in the treatment of type-A fractures of the thoracolumbar spine

The purpose of this study was to evaluate and compare the effect of short segment pedicle screw instrumentation and an intermediate screw (SSPI+IS) on the radiological outcome of type A thoracolumbar fractures, as judged by the load-sharing classification, percentage canal area reduction and remodelling. We retrospectively evaluated 39 patients who had undergone hyperlordotic SSPI+IS for an AO-Magerl Type-A thoracolumbar fracture. Their mean age was 35.1 (16 to 60) and the mean follow-up was 22.9 months (12 to 36). There were 26 men and 13 women in the study group. In total, 18 patients had a load-sharing classification score of seven and 21 a score of six. All radiographs and CT scans were evaluated for sagittal index, anterior body height compression (%ABC), spinal canal area and encroachment. There were no significant differences between the low and high score groups with respect to age, duration of follow-up, pre-operative sagittal index or pre-operative anterior body height compression (p = 0.217, 0.104, 0.104, and 0.109 respectively). The mean pre-operative sagittal index was 19.6° (12° to 28°) which was corrected to -1.8° (-5° to 3°) post-operatively and 2.4° (0° to 8°) at final follow-up (p = 0.835 for sagittal deformity). No patient needed revision for loss of correction or failure of instrumentation. Hyperlordotic reduction and short segment pedicle screw instrumentation and an intermediate screw is a safe and effective method of treating burst fractures of the thoracolumbar spine. It gives excellent radiological results with a very low rate of failure regardless of whether the fractures have a high or low load-sharing classification score.

Clinical results versus subjective improvement with anterior transposition in cubital tunnel syndrome

This study was conducted to compare the results of anterior transposition methods and to determine the time needed to attain subjective well-being in patients with cubital tunnel syndrome. A total of 49 cases were retrospectively evaluated. Patients were called for follow-up, completed a questionnaire, and were reexamined. They were assigned to one of 3 groups: subcutaneous transposition (SCT), submuscular transposition (SMT), or intramuscular transposition (IMT). The McCowan classification and Wilson-Krout criteria were used for classification and outcomes assessments. Categorical variables were analyzed with the χ2 test, and metric variables by analysis of variance or through Kruskal-Wallis variance analysis. Improvement of at least 1 McCowan grade was observed in 87.63% of patients. The least responsive group was assigned a McCowan grade of III. The most effective procedure for resolving clawing was SMT. Clinical results were excellent in 26 patients (53.06%), good in 12 (24.48%), fair in 4 (8.16%), and poor in 7 (14.28%). At the latest follow-up, overall grip and pinch strength had improved by 23% and 34%, respectively, compared with the contralateral side. Thirty-six patients exhibited an improvement in grip power and 38 in fine dexterity. Complete resolution of numbness was observed in 32 patients, and complete resolution of pain was noted in 30 patients. The preoperative mean visual analog scale score of 6.82 improved to 3.36 postoperatively. Clawing improved in 4 patients and atrophy in 7. The mean time to subjective improvement was shortest in the SMT group and longest in the IMT group. The greatest pain relief was reported in the IMT group and the least in the SMT group. One case with IMT required reoperation because of recompression of the nerve. The most frequent complication in the SMT and IMT groups was muscular tenderness. In conclusion, SCT offers an alternative to other anterior transposition methods because of its simplicity and quicker recovery time, especially in mild to moderate cases.

The use of intralaminar screws in patients with spinal deformity.

Study Design: Retrospective study. Objective: To demonstrate that intralaminar screws (ILS) can be used as supplements in spinal deformity surgery in the thoracic and lumbar levels in pediatric and adult patients. Summary of Background Data: Rigid posterior fixation of the spine is generally accomplished using pedicle screws, hooks, or wires. ILSs are useful tools when other spinal fixation techniques have failed or the bony anatomy precludes hook or screw placement. Materials and Methods: All spinal deformity patients (primary/revision) operated between 2007 and 2011 were retrospectively reviewed. The patients with ILS were included in the study. The anteroposterior and lateral standing x-rays were evaluated in terms of preoperative and postoperative coronal and sagittal deformities. The number and level of ILS, intraoperative complications, and postoperative complications were noted. Results: There were 20 patients (12 male and 8 female). The mean age was 21.75 years. The mean follow-up period was 17.4 months. Fifty-seven ILS were inserted. Seventeen screws were used in the uppermost to lowermost levels. Forty screws were used in the middle. There was 1 lamina fracture and screw pull out (1.75%). There were 3 canal violations (corrected intraoperative) and 2 instrument prominences which required implant removal. The mean preoperative/postoperative cobb angles were 78.5 degrees/27.8 degrees and the mean preoperative/postoperative kyphosis angles were 57.2 degrees/32.5 degrees, respectively. The loss of correction was 1.2 degrees. There were no neurological deficits and no instrument failures. Conclusions: ILS are safe and effective when used in deformity correction. However, biomechanical studies and randomized controlled trials are needed to conclude whether ILS will be considered a first-line technique, or will remain a technique for salvage situations.

Isolated intrauterine femoral fracture in an otherwise normal fetus.

Multiple fractures of the long bones can be seen in the intrauterine period as a result of disorders such as skeletal dysplasias or maternal trauma, but isolated intrauterine femoral fracture is an extremely rare condition. Congenital short femur should be kept in mind, especially during the intrauterine period in the differential diagnosis. We report a case diagnosed as isolated femoral fracture in the 34th gestational week with post‐partum confirmation of the diagnosis by X‐rays and physical examination.