Murat Tonbul

Synergistic Effect of TGF-β1 And BMP–7 on Chondrogenesis and Extracellular Matrix Synthesis: An In Vitro Study

Introduction: The purpose of the present study seeks to determine the signal timing of BMP–7 and TGF-β1 from a novel chitosan based hydrogel system that may affect chondrocyte proliferation resulting in the presence of a synergism seen conspicuously in consecutive controlled delivery. Methods: Four groups of cultured chondrocytes were seeded on a novel designed chitosan based hydrogel. The hydrogel was left empty (control) in one group and loaded with BMP–7, TGF-β1 and their combination in the other groups, respectively. Hydrogel structure was analyzed with scanning electron microscope. The release kinetics of Growth Factors (GFs) was determined with ELISA. Chondrocyte viability and toxicity after being tested with MTS and collagen type II synthesis, were quantified with western blotting. Canonical regression analysis was used for measuring statistical evaluation. Results: Chitosan based hydrogel allowed controlled release of GFs in different time intervals for BMP–7 and TGF-β1. Double peak concentration gradient was found to be present in the group loaded with both GFs. In this group, substantially higher chondrocyte growth and collagen synthesis were also detected. Conclusions: We concluded that, chitosan based hydrogel systems may be adjusted to release GFs consecutively during biodegradation at the layers of surface, which may increase the cell number and enhance collagen type II synthesis.

Long-term results of conservative treatment for thoracolumbar compression fractures

OBJECTIVES We evaluated the radiologic and clinical outcomes of conservative treatment for thoracolumbar compression fractures. METHODS Forty-three patients (28 males, 15 females; mean age 39 years; range 24 to 54 years) were treated conservatively for 47 thoracolumbar compression fractures. All the patients were assessed by plain radiograms and computed tomography. According to the Denis classification, there were eight type A, 20 type B, 12 type C, and seven type D fractures. Involvement was at L1 in 30, L2 in five, and T12 in 12 fractures. There were no neurological deficits. Treatment involved use of a body cast for two months, followed by a thoracolumbosacral orthosis for four months. Radiographically, local kyphosis angle and sagittal index were measured before treatment, after casting, and at the final follow-ups. Pain and functional scales proposed by Denis et al. were also utilized. The mean follow-up was 7.5 years (range 6 to 11 years). RESULTS The mean local kyphosis angle and sagittal index were measured as 12.6 and 13.7 degrees before treatment, and 5.9 and 7.0 degrees after casting, respectively (p<0.05). However, both did not differ significantly from the baseline at the final measurements (12.7 and 13.9, respectively; p>0.05). The mean pain and functional scores were 1.4 and 1.6, respectively. Four patients had moderate to severe back pain despite mean kyphosis angles of 12 (baseline), 13.5 (after casting), and 14.8 (final). Two patients required substitution of the body cast for orthosis due to excessive sweating, and three patients received local treatment for skin problems secondary to the use of orthosis. CONCLUSION If the kyphosis angle is less than 30 degrees, compression fractures are supposed to be stable to be treated conservatively with satisfactory clinical results. Functional results seem to be unaffected from the fact that casting does not improve radiographic parameters in the long-term.

The Efficacy of Magnetic Resonance Imaging and X-Ray in the Evaluation of Response to Radiosynovectomy in Patients with Hemophilic Arthropathy

Objective: We aimed to assess the role of Magnetic Resonance Imaging (MRI) and X-Ray in the evaluation of response to radiosynovectomy (RS) in patients with hemophilic arthropathy. Material and Methods: Eleven patients who suffered from hemophilic arthropathy with a mean age of 11.7 (range between 7-15) were included in this study. 148-185 MBq Yttrium 90 silicate (Y-90) was administered intraarticularly to ten knee joints and one patient was treated with intraarticular 74 MBq Rhenium 186 (Re-186) injection into his ankle. Before radiosynovectomy, plain anteroposterior and lateral X-rays of the target joints were obtained by standard technique. The follow-up MRI and X-ray studies of the patients were done 6 months after RS. Pettersson hemophilic arthropathy scales were utilized to stage the condition of the joints on plain X-ray and classification of the investigated joints on MRI were done according to Denver score. The clinical assessment of the efficacy of the RS was made with the comparison of the average bleedings before and after the intervention. Results: During the 6-month follow-up period after RS, an improvement in number of hemarthrosis 75% or greater compared with the prior six months occurred in six joints (54.5%). The Pettersson scores worsened in 1/11 (9%), remained unchanged in 9/11 (81.8%), and improved in 1/11 (9%) joints. At the 6-month follow-up, the MRI score worsened in one (9%) and was unchanged in 10/11 joints (90.9%). Conclusion: MRI is a more sensitive tool than plain radiography for evaluating and follow-up of joint disease in persons with hemophilia, but both methods don’t show correlation with the therapeutic response Conflict of interest:None declared.

Distal First Metatarsal Dome (Crescentic) Osteotomy for Repair of Mild to Moderate Hallux Valgus Deformity

Hallux valgus is one of the most common foot deformities. Despite the large number of techniques described for hallux valgus correction, there has been much controversy regarding the best procedure to use. Distal osteotomies have long been done for mild to moderate deformities. Although presented previously, based on a review of the literature, this technique does not appear to be regularly used by many surgeons. This article presents a distal metatarsal osteotomy as easy to perform and useful for the repair of mild to moderate hallux valgus deformity, wherein the first metatarsal angle measures less than 14 degrees.

Crescentic distal metatarsal osteotomy for the treatment of hallux valgus: a prospective, randomized, controlled study of two different fixation methods

OBJECTIVES This study was designed to draw attention to a distal metatarsal osteotomy technique, which has been somewhat overlooked for the treatment of hallux valgus, and to compare the clinical and radiographic results of two different fixation methods. METHODS The study included 16 feet of 13 patients (11 women, 2 men) who were treated with crescentic distal metatarsal osteotomy for mild-to-moderate hallux valgus (<35 degrees ). The patients were randomized to two fixation methods with two cross K-wires (group 1; 7 patients, 8 feet) and a compressive screw (group 2; 6 patients, 8 feet). The results were evaluated using the AOFAS (American Orthopaedic Foot and Ankle Society) clinical rating scale for hallux, and a visual analog scale for pain. Radiographic measurements included the hallux valgus angle (HVA), first/second intermetatarsal angle (IMA), and distal metatarsal articular angle (DMAA), before and 12 months after surgery. RESULTS There were no significant differences between the two groups with regard to pre- and postoperative AOFAS scores and pain scores, which showed significant improvements in both groups at the end of one-year follow-up (p<0.001). The HVA and IMA significantly decreased from 32 degrees to 19 degrees and from 12 degrees to 6 degrees in group 1, and from 30 degrees to 17 degrees and from 12 degrees to 8 degrees in group 2, respectively (p<0.001). A similar improvement was also seen in the DMAA (p<0.001). Postoperative radiographic improvements were similar in both groups. One patient in group 1 underwent revision surgery with the same technique due to recurrence, and one patient in group 2 had delayed union. CONCLUSION Crescentic distal metatarsal osteotomy may be an appropriate technique in the treatment of mild-to-moderate hallux valgus.

Is there any correlation between the preoperative parameters and correction loss in patients operated for hyperkyphosis

OBJECTIVES Preoperative, postoperative, and latest follow-up data of sagittal balance and spinopelvic parameters of our patients treated surgically for hyperkyphosis were evaluated retrospectively, to determine whether there is any correlation between the preoperative pelvic incidence and postoperative correction loss. METHODS Totally 33 patients (18 females) who were operated for hyperkyphosis and, were reached at the latest follow-up were included in the study. Age at operation, gender, date of operation, etiology and level of the deformities, instrumentation, and graft types were noted in detail. The kyphosis angles were measured by the Cobb method. The preoperative and postoperative spinopelvic parameters (pelvic incidence, sacral slope, and pelvic tilt) were recorded. RESULTS The average follow-up was 4 years (range 3-8 years). The mean age at operation was 21 years (range 14-40 years). Scheuermann kyphosis was diagnosed as the etiological factor in 18 patients (53%). The mean preoperative kyphosis angle was 76° (range 55-98°), which decreased postoperatively to 38° (range 20-55°) (p<0.05). The mean kyphosis angle two years postoperatively was 41° (p>0.05). Preoperative and latest follow-up spinopelvic parameters were also not significantly different. Furthermore, no correlation could be found between the age at operation, instrumentation level, spinopelvic parameters, and correction loss. CONCLUSION There is no correlation between the preoperative pelvic incidence and postoperative correction loss in patients treated surgically for hyperkyphosis. Further studies with larger sample size and longer follow-up should be conducted.

Intra-Articular Polyacrylamide Hydrogel Injections Are Not Innocent

Osteoarthritis is a chronic disorder characterized by joint cartilage degeneration with concomitant changes in the synovium and subchondral bone metabolism. Many conservative treatment modalities, one of which is intra-articular injections, have been described for the treatment of this disorder. Traditionally, hyaluranic acid and corticosteroids are the agents that have been used for this purpose. Recently, polyacrylamide hydrogels are being used widely. Biocompatibility, nonbioabsorbability, and anti-infectious effect obtained by silver addition made polyacrylamide hydrogels more popular. In this paper, we present a case and the method of our management, in whom host tissue reaction (foreign body granuloma, edema, inflammation, and redness induration) has been observed, as the first and unique adverse effect reported in the literature.

The results of bone deformity correction using a spider frame with web-based software for lower extremity long bone deformities

Aim: To present the functional and radiological results and evaluate the effectiveness of a computer-assisted external fixator (spider frame) in patients with lower extremity shortness and deformity. Materials and methods: The study comprised 17 patients (14 male, 3 female) who were treated for lower extremity long bone deformity and shortness between 2012 and 2015 using a spider frame. The procedure’s level of difficulty was determined preoperatively using the Paley Scale. Postoperatively, the results for the patients who underwent tibial operations were evaluated using the Paley criteria modified by ASAMI, and the results for the patients who underwent femoral operations were evaluated according to the Paley scoring system. The evaluations were made by calculating the External Fixator and Distraction indexes. Results: The mean age of the patients was 24.58 years (range, 5–51 years). The spider frame was applied to the femur in 10 patients and to the tibia in seven. The mean follow-up period was 15 months (range, 6–31 months) from the operation day, and the mean amount of lengthening was 3.0 cm (range, 1–6 cm). The mean duration of fixator application was 202.7 days (range, 104–300 days). The mean External Fixator Index was 98 days/cm (range, 42–265 days/cm). The mean Distraction Index was 10.49 days/cm (range, 10–14 days/cm). Conclusion: The computer-assisted external fixator system (spider frame) achieves single-stage correction in cases of both deformity and shortness. The system can be applied easily, and because of its high-tech software, it offers the possibility of postoperative treatment of the deformity.

Bilateral Simultaneous Heterotopic Ossification of the Reflected Head of Rectus Femoris Muscle: A Case Report and Review of the Literature

Lamellar bone formation in an abnormal location is defined as heterotopic ossification. It commonly occurs around the hip joint and most often involves the abductor muscles. It is a benign condition; however, its etiology remains largely unknown. Most previously reported cases have been due to trauma or intramuscular hemorrhage. In this paper, we present a case of bilateral heterotopic ossification of the reflected head of rectus femoris muscle without antecedent trauma or any other known cause, as the first and unique case in the literature. She was treated by excision of the right symptomatic bony mass via a modified Smith-Petersen approach. Postoperatively, she received 75 mg indomethacin daily for six weeks. She was pain-free and obtained full range of motion 3 weeks after the first intervention.

The role of debridement and reconstruction of sagittal balance in tuberculous spondylitis

Background: An accepted comprehensive clinical approach to the deformed spine with tuberculous infection is still lacking. We aimed to determine the usage of a staged algorithm in the treatment of kyphotic spine with tuberculous infection and to present the clinical results of the patients treated with the help of this protocol. Materials and Methods: 54 patients (28 females, 26 males) with a mean age of 39.2 (22-76) years. Preoperative, early postoperative, and followup clinical and radiologic results were evaluated retrospectively. The patients were classified into Kaplan A (kyphotic deformity <30°), Kaplan B (kyphotic deformity 30°-60°) and Kaplan C (kyphotic deformity >60°). They were operated by posterior instrument with anterior debridment (Kaplan A), debridment with anterior bone grafting (Kaplan B) and anterior column resection and bone grafting in Kaplan C. Results: Tuberculous involvement were seen at more than one level in 40 patients and paraspinal abscess were detected in 31. Preoperative focal kyphotic deformity was reconstructed with an average of 19 (9-38) degrees. Twenty-six patients had neurologic compromise with different severities and 12 of them improved after the surgical intervention. Improvement in work ability and pain status was detected in 52% and 61% of the patients, respectively. Wound complications responding to medical care were detected in nine patients. Initial kyphotic deformity was found as an important parameter in selecting the surgical procedure. Conclusion: Regarding resected amount of infected osseous material, as planned preoperatively, have resulted with better concordance between anterior and posterior column heights and better sagittal alignment. We could correct kyphosis and improve sagittal balance with staged algorithm as used by us.