Murat Ali Hersekli

Effects of methylprednisolone and betamethasone injections on the rotator cuff: An experimental study in rats

Thirty-one female Sprague-Dawley rats were used to determine the effects of subacromial corticosteroid injections on the rotator cuff. The injection technique was tested in 6 animals, which were excluded from the study. The remaining 25 rats were randomly divided into three groups of 8 animals each; a single rat received no injections. Every other week for 8 weeks, one shoulder in each rat was injected with methylprednisolone, betamethasone, or saline in a dosage equivalent to that used in humans. The supraspinatus and infraspinatus tendons were removed 10 days after the last injection and evaluated. There were no pathologic changes in the tendons injected with saline. In 43% of the methylprednisolone-treated rats and 29% of the betamethasone-treated rats, the tendons were abnormally soft and light-colored. In 43% of the methylprednisolone group and 71% of the betamethasone group, fragmentation of collagen bundles and inflammatory cell infiltration were evident. Subacromial injections of methylprednisolone or betamethasone repeated frequently can cause deleterious changes in the normal structure of the rat rotator cuff. In light of these findings, therapy for subacromial impingement syndrome of the shoulder with frequent, repeated steroid injections is potentially harmful.

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.

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.

Prospective evaluation of the functional and anatomical results of arthroscopic repair in small and medium-sized full-thickness tears of the supraspinatus tendon.

OBJECTIVE The purpose of this study was to analyze the relation between tendon integrity and functional results following the arthroscopic treatment of small- and medium-sized rotator cuff tears. METHODS Arthroscopic repair was performed on 26 consecutive patients (21 women, 5 men;mean age: 55.9 years; range: 33-72 years) with small- and medium-sized tears of the supraspinatus tendon. Patients were postoperatively evaluated at 12 and 24 months using the Constant and UCLA functional outcome scores and ultrasound examinations. RESULTS The supraspinatus tendon did not heal in nine patients (34.6%) and was partially healed in three (11%), 12 months after surgery. Mean postoperative Constant and UCLA scores of these patients were 73.1 and 27.8, respectively, which were not significantly different from those with an intact tendon on the final follow-up (Constant: 78 and UCLA: 30; p=0.107 and p=0.164). Both rating systems reflected significant improvement with treatment (p<0.01). The mean age of patients with a re-tear was 66.8 years, which was significantly higher than those with an intact repair (54 years; p<0.01). CONCLUSION The arthroscopic repair of small and medium-sized supraspinatus tendon tears yields good long-term results independent of tendon integrity. Healing potential may be decreased with increased age.

The effects of two different fixation methods on femoral bone tunnel enlargement and clinical results in anterior cruciate ligament reconstruction with hamstring tendon graft

OBJECTIVES We investigated the effects of anatomic and non-anatomic tunnel fixations on femoral tunnel widening and clinical results in anterior cruciate ligament (ACL) reconstructions. METHODS We retrospectively evaluated 35 patients who underwent arthroscopic ACL reconstruction with quadrupled hamstring tendon graft. Fixation was performed in the tunnel using the transcondylar RigidFix pin (group 1) in 18 patients (mean age 32 years), and from outside the tunnel using the EndoButton-CL device (group 2) in 17 patients (mean age 30 years). The patients were assessed using the IKDC (International Knee Documentation Committee) and Lysholm knee scores and tunnel widening was assessed by computed tomography. Ligament laxity was measured bilaterally using the Rolimeter knee tester. The mean follow-up was 24 months (range 21 to 38 months) in group 1, and 24.6 months (range 12 to 36 months) in group 2. RESULTS The two groups were similar with respect to age and sex distribution, operated side, the size of the tunnel created, and follow-up period (p>0.05). Postoperative knee scores did not show a significant difference (p>0.05). There was marked and excessive tunnel enlargement in 14 patients (77.8%) in group 1, and in 15 patients (88.2%) in group 2, with no significant difference between the two groups (p>0.05). Ligament laxity exceeded 3 mm in eight patients (44.4%) in group 1, and in three patients (17.7%) in group 2 (p<0.001). There was no relationship between tunnel widening and ligament laxity (p>0.05; r=0.175 and r=-0.01 for group 1 and group 2, respectively). CONCLUSION Our results suggest that differences in the localization of the tunnel fixation have no effect on tunnel enlargement and that joint laxity may be affected by biomechanical properties of fixation materials.

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.

Restoration of pull-out strength of the failed pedicle screw: biomechanical comparison of calcium sulfate vs polymethylmethacrylate augmentation

OBJECTIVE The aim of the present study was to compare calcium sulfate (CAS) and polymethylmethacrylate (PMMA) bone cements used for the augmentation of a failed pedicle screw with biomechanical pull-out strength (POS) testing. METHODS Thirty lumbar vertebrae were harvested from 6 calves and bone mineral densities (BMD) were measured. Primary polyaxial pedicle screws were randomly inserted and pulled out and the POSs of the specimen were recorded. For revision, specimens were randomly assigned to the CAS-augmented pedicle screws group (Group 1) or PMMA-augmented pedicle screw group (Group 2). Pull-out tests were repeated to compare both groups. RESULTS Mean BMD of the specimens was 1.006 ± 0.116 g/cm(2). There were no statistically significant differences between BMD results of the two groups (p=0.116). For Group 1, mean POS of primary screws was 2,441.3 ± 936.4 N and was 2,499.5 ± 1,425.1 N after CAS augmentation, demonstrating no statistically significant difference (p=0.865). In Group 2, mean POS of the primary screws was 2,876.6 ± 926.6 N and significantly increased to 3,745.5 ± 1,299.2 N after PMMA augmentation (p=0.047). There was also a significant difference in mean POS between the CAS and PMMA groups (p=0.026). CONCLUSION Although CAS augmentation facilitates a revision screw POS as strong as that of primary screws, it is not as strong as PMMA augmentation.