Mehmet Eroglu

Evaluation of open and closed kinetic chain exercises in rehabilitation following anterior cruciate ligament reconstruction.

[Purpose] To compare outcomes of anterior cruciate ligament (ACL) reconstruction after open kinetic chain (OKC) exercises and closed kinetic chain (CKC) exercises. [Subjects and Methods] The subjects comprised 11 female and 47 male patients who are randomly divided into two groups: which performed a CKC exercise program Group I and Group II which performed an OKC exercise program. Pain intensity was evaluated using visual analogue scale (VAS). Knee flexion was evaluated using a universal goniometer, and thigh circumference measurements were taken with a tape measure at baseline and at 3 months and 6 months after the treatment. Lysholm scores were used to assess knee function. [Results] There were no significant differences between the two groups at baseline. Within each group, VAS values and knee flexion were improved after the surgery. These improvements were significantly higher in the CKC group than in the OKC group. There were increases in thigh circumference difference at the 3 and 6 month assessments post-surgery. A greater improvement in the Lysholm score was observed in the CKC group at 6 months. [Conclusion] The CKC exercise program was more effective than OKC in improving the knee functions of patients with ACL reconstruction.

Femoral neck stress fracture in children: a case report, up-to-date review, and diagnostic algorithm.

Stress fracture of the femoral neck in skeletally immature individuals is a rare condition and generally seen as compressive type. Because the condition may lead to disastrous complications, femoral neck stress fracture must also be kept in mind in the differential diagnosis of pediatric hip pain. We present a case of compressive-type stress fracture of the femoral neck in a 10-year-old girl with left hip pain that was sustained for 4 weeks and emphasize the difficulty of early diagnosis with only a radiographic evaluation and put forward an algorithm for diagnosis and treatment.

Biomechanical Evaluation of Syndesmotic Screw Design via Finite Element Analysis and Taguchi's Method

BACKGROUND Screw fixation of syndesmotic injuries facilitates ligament healing and restoration of ankle stability, but failure of the screw might threaten the success of the treatment. Screw design parameters, such as outer diameter, inner diameter, thread pitch, leading edge radius, trailing edge radius, leading edge angle, and trailing edge angle, might have effects on the stresses that occur in the screws. This is the first study, to our knowledge, to investigate which geometric screw parameters play key roles in stresses that occur in screws used for syndesmotic fixation. METHODS A three-dimensional finite element model of an ankle was reconstructed. Four different types of titanium screws—4.5-mm malleolar, 4-mm cancellous, 4-mm machine, and 3.5-mm cortical—were placed on this model. Physiologic load was applied to evaluate the stress in the screw. Then the contribution of each design factor to stress in the screws was analyzed systematically by Taguchis robust design method. RESULTS The maximum equivalent ductile failure (von Mises equivalent stress) value was found in the 4-mm cancellous screw (402 MPa). Taguchis analysis showed that the descending order of contribution of the design factors to stress emerging on the screw is inner diameter, leading edge angle, thread pitch, outer diameter, and trailing edge angle. CONCLUSIONS Stress that occurs in syndesmotic screws is closely related to their geometry and dimensions. According to the results, a 3.5-mm cortical screw with the ideal screw design regarding optimal parameters to resist against stresses in the syndesmosis seems more reasonable to choose in syndesmotic fixation.

An assessment of sleep quality in patients undergoing total knee arthroplasty before and after surgery.

OBJECTIVE The aim of this study was to compare the sleep quality of patients who underwent total knee arthroplasty before and after the surgery and analyze the effect of total knee arthroplasty on sleep quality. METHODS The study included 42 patients (32 females, 10 males) who underwent total knee arthroplasty for primary knee osteoarthritis. For each patient the preoperative 1 day and postoperative 3 months results of Pittsburgh Sleep Quality Index (PSQI) and 100-mm visual analogue scale (VAS) were compared. RESULTS The preoperative mean PSQI was 9. VAS score decreased in 97.6% of the patients, while sleep quality increased in 78.6%. 85.7% of the patients reported to have less episodes of pain related sleep disturbances. While both the PSQI and VAS improved after the surgery, there was no correlation between the parameters (p>0.05). CONCLUSION Our results suggested that total knee arthroplasty surgery relieves pain and improves sleep quality. The improvement in sleep quality does not appear to be related to pain relief.

Consultation of traditional bone setters instead of doctors: is it a sociocultural and educational or social insurance problem?

Background Patients consulting bone setters is common in the eastern and south-eastern regions of Turkey. The reasons for consulting bone setters instead of qualified doctors remains unclear. We investigated the characteristics of such patients who consult traditional bone setters after trauma prior to admission to hospital. Methods In the study, 3,422 of 14,080 patients were investigated admitted to hospital between January 2012 and February 2013 with trauma or sequelae of such who were previously treated by bone setters. The characteristics of these patients and the main reasons for consultation of bone setters instead of doctors were recorded. Results Most of the patients consulting bone setters were found to be young adults or children. Generally speaking, the poorly educated prefer bone setters despite having social insurance. The most common reason (29.3%) was a general preference and secondarily (27.1%) the fear of being disabled after medical treatment. However, the most common cause of patients’ consultation at hospital subsequently was due to complications of treatment (46.8%); indeed the complication rate after bone setters’ intervention was found to be 54.8%. Conclusion Although improvements have occurred in the access to and utilisation of healthcare services, consultation by patients of bone setters seems to be a sociocultural and educational issue rather than a problem of lack of medical insurance.

An uncommon cause of anterior knee pain: patellar chondroma.

A 16-year-old boy presented with a patellar mass and anterior knee pain without any trauma. On physical and radiologic assessment, a mass at the superolateral edge of the patella and a hyperintense lesion on T2 sequences of magnetic resonance imaging was detected. Excisional biopsy revealed a chondroma of patella. Primary bone tumors of the patella are extremely rare and occurence of chondroma in this localization is very uncommon. Although anterior knee pain is a very frequent and usually harmless, it is essential to consider the more severe disorders such as bone tumors.

A rare cause of ulnar-side wrist pain: Ganglion cyst of the triquetrum

Diagnosing chronic wrist pain may sometimes be challenging and the differential diagnoses include many conditions (traumatic, rheumatoid, neoplasms, etc.). This report describes a case of chronic wrist pain due to intraosseous ganglion cyst of triquetrum. The wrist pain had lasted for 6 months and was not relieved by conservative treatment. Magnetic resonance imaging revealed an intraosseous ganglion cyst. The triquetrum was tender on palpation. After curettage and grafting of the cyst, and 6 months of follow-up, the patient was free of complaints with full range of motion of the wrist. Although mostly asymptomatic, intraosseous ganglion cysts should be kept in mind when assessing wrist pain.

Ligamentum flavum thickening at lumbar spine is associated with facet joint degeneration: An MRI study

OBJECTIVE Degenerative changes in posterior elements of the spine such as thickening or hypertrophy of the ligamentum flavum (LF) may result in spinal stenosis. In the present study, we aimed to investigate the potential factors including age, intervertebral disc degeneration (IDD), facet joint degeneration (FJD), end plate degeneration (EPD), which may affect LF thickening and to reveal the relationship among those factors at each level of lumbar spine by evaluating the magnetic resonance images (MRI). METHODS A total of 200 individuals with low back and/or leg pain complaints who had undergone lumbar MRI were included in this study. The thickness of LF, FJD, IDD and EPD were assessed at all lumbar levels. RESULTS Totally 1000 end plates, 1000 intervertebral discs and 2000 facet joints were evaluated and the thicknesses of 2000 LFs were measured from MRI images of 200 patients (100 males and 100 females). The mean age was 46.87 ± 12.47 years. LF thickness was strongly associated with FJD especially on the ipsilateral side. Age and IDD were correlated at whole vertebral levels. The age related changes (LF thickness, FJD, IDD and EPD) were more prominent at L4-L5 vertebral level. However, gender had no effect on LF thickness. CONCLUSION The results of this study suggest that LF thickening may occur independently or could be associated with FJD especially on the ipsilateral side and this relationship is due to the vertebral level. The degree of disc degeneration increases with age and age related changes may be predominantly observed at L4-L5 vertebral level.

Letter to the Editor: Symptomatic Pulmonary Embolus After Joint Arthroplasty: Stratification of Risk Factors

To the editor, We read the article by Parvizi et al. with great interest [8]. Parvizi and colleagues identified the preoperative comorbidities associated with an increased risk of symptomatic pulmonary embolism (PE) after total joint arthroplasty (TJA) in a large group of patients. The authors concluded that patients with obesity, chronic obstructive pulmonary disease, atrial fibrillation, anemia, depression, or postoperative deep vein thrombosis, as well as those patients who undergo knee procedures, or have a high Charlson Comorbidity Index, are at an increased risk of having a postoperative PE development. Those risk factors should be considered when deciding on postoperative anticoagulation prophylaxis. According to Parvizi and colleagues, the reasons why preoperative anemia is a risk factor for PE development remains unclear. Several studies from internal medicine [2–4, 6, 7] suggest some possible mechanisms for PE development in iron deficiency anemia (IDA). We reviewed and summarized the mechanisms to explain the association between IDA and thrombosis. First, iron is a crucial regulator of thrombopoiesis due to its negative feedback effect on platelet production and lower levels of iron disinhibit megakaryocyte activity [2]. These characteristics promote secondary thrombocytosis, which lead to a hypercoagulable state [4]. Additionally, when erythropoietin increases to stimulate the red cell production, it also stimulates the megakaryocyte production [3]. Second, in IDA, microcytosis causes lower red cell deformability, which increases the blood viscosity [7]. Third, when the oxygen-carrying capacity of erythrocytes decreases, anemic hypoxia may occur, especially in situations where the metabolic demands are increased. The vessels undergo autoregulatory dilatation, which can lead to a turbulent blood flow, causing more frequent contact of the platelets with the endothelial lining of the vessels [3, 6]. Fourth, platelets may become hyperresponsive in anemic states due to the increased levels of erythropoietin. The abnormal platelet count and function observed in IDA can promote thrombus formation, especially in the setting of an underlying atherosclerotic disease [2, 3]. Fifth, the decrease in antioxidant defense may cause increased oxidant stress, which could result in platelet aggregation [2]. And finally, acute bleeding raises platelet adhesiveness and lowers fibrinolytic activity, which leads to intravascular thrombogenesis [7]. As would be expected, other forms of anemia such as sickle cell disease, thalassemia or autoimmune hemolytic anemia may also cause both arterial and venous thrombosis [1, 5, 9]. After considering the possible mechanisms, the question, “Should we better detect the cause of anemia and treat it firstly prior to TJA?” emerges and needs further investigation.

Comment on "compression screw fixation of the syndesmosis".

Dear Editor, We read with interest the article titled “Compression Screw Fixation of the Syndesmosis” by Darwish et al. The authors conducted a study to determine whether lag screws would generate greater syndesmosis compression and maintain a smaller medial clear space than tricortical screws during the course of cyclically applied mechanical challenges to the fixation. They also investigated if 4.5-mm or 3.5-mm lag screws would show better performance for measures of reduction. We believe that this is an important topic for study, but question some of the basic study design methodology. They stated that because in clinical practice the limb is largely protected from weight-bearing postoperatively, they chose a more direct method of medial and lateral cyclic loading for provoking diastasis to focus on the resistance of the screws to pulling out. First of all, we believe that this point of view is not exactly true. Many studies suggest that screws should be removed 6 to 8 weeks after a 4-cortical fixation, and even routine removal is probably not necessary after a 3-cortical fixation. If a stable osteosynthesis is achieved with placement of a syndesmotic screw, weight-bearing in plaster cast could be allowed. Moreover the authors stated that they did not use a model of axial compression, because the syndesmosis does not undergo any loading during the period of immobilization in cast. Suggesting that the point of view is true, the syndesmosis does not undergo any kind of stresses as described in the text, either. Even with ankle dorsiflexion, the distal fibula moves proximally and posteriorly and rotates externally. Physiological loads occur under anatomical circumstances, thus simulations for those should also contain the appropriate model of physiological loading. In addition, in our opinion authors applied maximum torque as much as possible to tighten the lag screws, but in clinical practice it is inappropriate because overtightening the syndesmosis may cause complications such as restricted range of motion (ROM) of ankle, fibular fracture, and so on. Besides, because the anterior aspect of the talus is wider than the posterior aspect, many textbooks describe fixation of the syndesmosis with the foot in dorsiflexion to prevent overcompression. Aim of syndesmosis fixation is not compression of syndesmosis, but holding the distal tibiofibular joint in reduced position during the healing of disrupted ligaments. This can be achieved by the screw that can optimally resist both deformation and pull-out forces generated during passive ROM and partial weight-bearing as well. It is a well-known fact that the pull-out strength of a screw is directly proportional to the thread diameter of it. Moreover, there is not any evidence-based data that more compression leads to better clinical results. Thus, we believe that the results found by the authors are not feasible in clinical practice.