Mahmut Nedim Doral

Functional anatomy of the Achilles tendon

The Achilles tendon is the strongest and thickest tendon in the human body. It is also the commonest tendon to rupture. It begins near the middle of the calf and is the conjoint tendon of the gastrocnemius and soleus muscles. The relative contribution of the two muscles to the tendon varies. Spiralisation of the fibres of the tendon produces an area of concentrated stress and confers a mechanical advantage. The calcaneal insertion is specialised and designed to aid the dissipation of stress from the tendon to the calcaneum. The insertion is crescent shaped and has significant medial and lateral projections. The blood supply of the tendon is from the musculotendinous junction, vessels in surrounding connective tissue and the osteotendinous junction. The vascular territories can be classified simply in three, with the midsection supplied by the peroneal artery, and the proximal and distal sections supplied by the posterior tibial artery. This leaves a relatively hypovascular area in the mid-portion of the tendon where most problems occur. The Achilles tendon derives its innervation from the sural nerve with a smaller supply from the tibial nerve. Tenocytes produce type I collagen and form 90% of the cellular component of the normal tendon. Evidence suggests ruptured or pathological tendon produce more type III collagen, which may affect the tensile strength of the tendon. Direct measurements of forces reveal loading in the Achilles tendon as high as 9 KN during running, which is up to 12.5 times body weight.

Variations in anatomy at the suprascapular notch possibly causing suprascapular nerve entrapment: an anatomical study

The purpose of the study was to determine anatomical variations at the suprascapular notch for better understanding of possible predisposing factors for suprascapular nerve entrapment. We dissected 32 shoulders of 16 cadavers between the ages of 39 and 74 years. We observed abnormally oriented superior fibers of the subscapularis muscle in five shoulders of the 16 cadavers, which were covering the entire anterior surface of the suprascapular notch and significantly reducing the available space for the suprascapular nerve. We also detected anterior coracoscapular ligament in six of the 32 shoulders, and calcified superior transverse scapular ligament in four of the shoulders. In this study, we classified the variations for the superior transverse scapular ligament. In conclusion, knowing the anatomical variations in detail along the course of the suprascapular nerve might be important for better understanding of location and source of the entrapment syndrome, especially for individuals who are involved in violent overhead sports activities such as volleyball and baseball. To our knowledge, close relationship of subscapularis muscle with the suprascapular nerve as a possible risk factor for suprascapular nerve entrapment has not been mentioned previously.

Discoid Meniscus An Ultrastructural Study With Transmission Electron Microscopy

Background The ultrastructure of the normal menisci has been thoroughly investigated and found to correlate with meniscal tears. Although discoid menisci are accepted to have the same composition as their normal counterparts, to our knowledge, no study in the literature has investigated this issue. Purpose To investigate the ultrastructure of the discoid menisci and compare it with nondiscoid menisci. Study Design Descriptive laboratory study. Methods Meniscal biopsies were taken from 12 patients who were operated for meniscus tear and diagnosed with discoid meniscus and from 6 patients who were operated for meniscal tear and did not have a diagnosis of discoid meniscus. The samples were examined with transmission electron microscopy. Results The study group demonstrated a decrease in the number of collagen fibers compared with the control group. Also, the homogeneous course of the collagen fibers observed in the control group was replaced by a heterogeneous course in the study group. Conclusion The ultrastructure of the discoid meniscus is different from the normal menisci. Clinical Relevance This difference may contribute to the vulnerability of the discoid meniscus to tears.

Ketamine sedation during spinal anesthesia for arthroscopic knee surgery reduced the ischemia-reperfusion injury markers.

We studied the effect of ketamine sedation on oxidative stress during arthroscopic knee surgery with tourniquet application by determining blood and tissue malonyldialdehyde (MDA) and hypoxanthine (HPX) levels. Thirty ASA I–II patients undergoing arthroscopic knee surgery with tourniquet were randomly divided into two groups. Spinal anesthesia induced with 12.5 mg bupivacaine was administered to all patients. In the ketamine group, after IV administration of 0.01 mg/kg midazolam, a continuous infusion of ketamine (0.5 mg · kg−1 · h−1) was used until the end of surgery whereas the placebo group received a volume-equivalent placebo infusion. Ramsey Sedation Scale (RSS) was used for assessing the sedation level. Venous blood and synovial membrane tissue samples were obtained before ketamine infusion, at 30 min of tourniquet ischemia, and at 5 min after tourniquet deflation for MDA and HPX measurements. Tissue MDA and HPX levels were significantly less in the ketamine group than the control group after reperfusion. RSS scores were higher in the ketamine group without any adverse effect. We conclude that ketamine sedation attenuates lipid peroxidation markers in arthroscopic knee surgery with tourniquet application.

Reliability of isokinetic ankle inversion- and eversion-strength measurement in neutral foot position, using the Biodex dynamometer

This study was designed to investigate the intratester and intertester reliability of isokinetic ankle inversion and eversion-strength measurement in neutral foot position in healthy adults using the Biodex dynamometer. Twenty-five men and women performed five maximal concentric contractions at 60 and 180°/s angular velocities. Two physicians tested each subject. The first physician applied the test four times, and the second physician three times. Reliability of peak torque was assessed by calculating the intraclass correlation coefficient (ICC). At both angular velocities, inversion strength was greater than eversion, and when the angular velocity was increased, inversion and eversion strength were decreased, as tested by both physicians. The first measurements of inversion and eversion strength of the first physician were significantly lower than the other measurements (p<0.01). The intratester ICCs for ankle inversion in healthy young adults were highly reliable (ICC 0.92–0.96), and for the eversion values ranged from 0.87 to 0.94. Intertester ICCs for ankle inversion and eversion peak torque values demonstrated a value of 0.95. Isokinetic tests of ankle inversion and eversion strength at 60 and 180°/s angular velocities in neutral foot position for healthy adults are highly reliable with the Biodex dynamometer.

A giant extrasynovial osteochondroma in the infrapatellar fat pad: end stage Hoffa’s disease

The infrapatellar fat pad of Hoffa is commonly injured but rarely discussed in the orthopaedic literature. Hoffa’s disease is the extension of various traumatic events due to impingement and inflammation of the infrapatellar fat pad and known as a vague reason for anterior knee pain. Inflammation is foreground during acute phase of the disease while impingement due to fibrosis and scar tissue of infrapatellar fat pad plays a major role in the chronic phase. The osteochondroma of the infrapatellar fat pad secondary to the Hoffa’s disease can be more problematic. Although, the fibrocartilaginous transformation and osteochondral metaplasia of infrapatellar fat pad was pointed out frequently in the literature, the published papers seem far from clarifying the relation between chronic impingement and formation of osteochondroma. We present a case of a giant ossifying chondroma in the infrapatellar fat pad that resulted from chronic Hoffa’s disease. Complete open resection was performed successfully after arthroscopic examination. The infrapatellar fat pad contains the entire progenitor cells for the development of an osteochondroma and chronic impingement may have promoter affect on this issue, thus, an osteochondroma may occur at the end-stage Hoffa’s disease.

Differences in sole arch indices in various sports

Background: There are controversial data about the relation between foot morphology and athletic injuries of the lower extremity. Studies in soldiers have shown some relationship, whereas those involving athletes have not shown any significant relationship. The reason for these differences is not clear. Objective: To determine the effect of various sports on sole arch indices (AIs). Method: A total of 116 elite male athletes (24 soccer players, 23 wrestlers, 19 weightlifters, 30 handball players, and 20 gymnasts) and 30 non-athletic men were included in this cross sectional study. Images of both soles were taken in a podoscope and transferred to a computer using a digital still camera. AIs were calculated from the stored images. Results: The AI of the right sole of the gymnasts was significantly lower than that of the soccer players, wrestlers, and non-athletic controls (p<0.01). The AI of the right sole of the wrestlers was significantly higher than that of the soccer players, handball players, weightlifters, gymnasts, and non-athletic controls (p<0.03). The AI of the left sole of the gymnasts was significantly lower than that of the wrestlers and non-athletic controls (p<0.001). The AI of the left sole of the wrestlers was significantly higher than that of the soccer players, handball players, and gymnasts (p<0.007). The AI of both soles in handball players was significantly lower than those of the non-athletic subjects (p  =  0.049). The correlation between the AI of the left and right foot was poor in the soccer players, handball players, and wrestlers (r  =  0.31, 0.69, and 0.56 respectively), but was high in the gymnasts, weightlifters, and non-athletic controls (r  =  0.96, 0.88, and 0.80 respectively). Conclusion: The AIs of the gymnasts and wrestlers were significantly different from those of other sportsmen studied, and those of the gymnasts and handball players were significantly different from those of non-athletic controls.

Relation between foot arch index and ankle strength in elite gymnasts: a preliminary study.

Background: Gymnasts usually start intensive training from early childhood. The impact of such strenuous training on the musculoskeletal system is not clear. Objectives: To evaluate the relation between muscle strength of the ankle joint and foot structure in gymnasts. Methods: The study population comprised 20 high level male gymnasts and 17 non-athletic healthy male controls. Arch indices were measured using a podoscope. Ankle plantar/dorsiflexion and eversion/inversion strengths were measured using a Biodex 3 dynamometer within the protocol of concentric/concentric five repetitions at 30°/s velocity. Results: The mean arch index of the right and left foot of the gymnasts and the controls were respectively: 31.4 (29.1), 34.01 (34.65); 60.01 (30.3), 63.75 (32.27). Both the arch indices and the ankle dorsiflexion strengths were lower in the gymnasts. Although no correlation was found between strength and arch index in the control group, a significant correlation was observed between eversion strengths and arch indices of the gymnasts (r  =  0.41, p  =  0.02). Conclusions: Whether or not the findings indicate sport specific adaptation or less training of the ankle dorsiflexors, prospective data are required to elucidate the tendency for pes cavus in gymnasts, for whom stabilisation of the foot is a priority.

Static Balance in Patients With Patellofemoral Pain Syndrome

Background: The relationship between one-leg static standing balance (OLSSB) and patellofemoral pain syndrome (PFPS) is unknown. Hypothesis: OLSSB decreases in patients with PFPS. Design: Prospective case series. Methods: Fifty-two women with unilateral PFPS were enrolled in this study. OLSSB was evaluated with a stabilometer. Q angle was measured with a lengthened-arm universal goniometer. Lower extremity alignment was analyzed with full-length standing anteroposterior teleroentgenograms. Quadriceps and hamstring strength was measured on an isokinetic dynamometer. Results: There were significant differences in OLSSB, Q angle, and strength of quadriceps and hamstring between the symptomatic and asymptomatic sides. There was a correlation between the strength of the quadriceps and hamstring and OLSSB, while there was no correlation between OLSSB and the severity of pain, lower extremity alignment, and Q angle on the symptomatic side. Conclusions: OLSSB and quadriceps and hamstring strength decreased and Q angle increased on the symptomatic side in PFPS patients. A relationship between OLSSB and pain, Q angle, and lower extremity alignment was not detected, while there was a correlation between the strength of the quadriceps and hamstring and OLSSB. Clinical Relevance: A quadriceps and hamstring strengthening may be beneficial to improve OLSSB in patients with PFPS.

The Effect of an Exercise Program in Conjunction With Short-Period Patellar Taping on Pain, Electromyogram Activity, and Muscle Strength in Patellofemoral Pain Syndrome

Background: McConnell recommended that patellar tape be kept on all day, until patients learn how to activate their vastus medialis obliquus (VMO) during an exercise program. This application may pose problems because prolonged taping may be inadvisable for some patients or even contraindicated owing to skin discomfort, irritation, or allergic reaction. Hypothesis: Wearing patellofemoral tape for a shorter duration during an exercise program would be just as beneficial as a prolonged taping application. Study Design: Prospective cohort. Methods: Twelve patients and 16 healthy people participated. Patients underwent short-period patellar taping plus an exercise program for 3 months. Numeric pain rating, muscle strength of the knee extensors, and electromyogram activity of the vastus lateralis and VMO were evaluated. Results: There were significant differences in electromyogram activity (P = .04) and knee extensor muscle strength (P = .03) between involved and uninvolved sides before treatment. After treatment, pain scores decreased, and there were no significant differences between involved and uninvolved sides in electromyogram activity (P = .68) and knee extensor strength (P = .62). Before treatment, mean VMO activation started significantly later than that of vastus lateralis, as compared with the matched healthy control group (P = .01). After treatment, these differences were nonsignificant (P = .08). Conclusion: Short-period patellar taping plus an exercise program improves VMO and vastus lateralis activation. Clinical Relevance: A shorter period of taping for the exercise program may be as beneficial as a prolonged taping application.