Murat Uludag

Total oxidative stress and antioxidant status in patients with carpal tunnel syndrome

Abstract Objectives Studies in the carpal tunnel syndrome (CTS) are supported ischemia-induced changes rather than inflammation of the flexor tenosynovium. In this study, total antioxidant status (TAS), total oxidative stress (TOS) and oxidative stress index (OSI) in patients with CTS has been investigated. Methods Forty-three patients (38 female and 5 male, 81 hands in total) diagnosed as CTS after the physical examination and electrophysiological findings included in study. The mean age of patients was 43.30 ± 10.49 years. Results Bilateral CTS in 38 (88%) patients and unilateral CTS in five patients were detected. Dominant hand was involved in all patients. The mean symptoms duration was 30.9 months (range, 5–67 months). TAS in patients with CTS was significantly lower compared with control (1.01 ± 0.14 versus 1.11 ± 0.20 mmol Trolox equiv./l), (P = 0.008). TOS and OSI in patients with CTS were significant higher compared with control (15.60 ± 7.03 versus 11.86 ± 2.18 µmol H2O2 equiv./l and 1.57 ± 0.72 versus 1.09 ± 0.28), (respectively P = 0.002 and <0.001). Conclusion This study shows that there is a change in the oxidative stress and antioxidant defences in patients with CTS. Increased TOS and OSI and decreased TAS might be stimulate fibrosis through disturbed signaling pattern in the tenosynovium and median nerve. These processes might play a role in occurrence and progression of CTS.

De Quervain’s syndrome associated with osteopoikilosis: a case report and review of the literature

Osteopoikilosis is a rare, usually asymptomatic, autosomal-dominant bone disorder, which is generally diagnosed incidentally on X-ray. De Quervain’s syndrome is a disorder characterized by pain on the radial (thumb) side of the wrist, impairment of thumb function and thickening of the ligamentous structure covering the tendons in the first dorsal compartment of the wrist. In this case report, we present a young woman with De Quervain’s syndrome associated with osteopoikilosis.

A Randomized Trial on the Effect of Bone Tissue on Vibration-induced Muscle Strength Gain and Vibration-induced Reflex Muscle Activity.

BACKGROUND Whole-body vibration (WBV) induces reflex muscle activity and leads to increased muscle strength. However, little is known about the physiological mechanisms underlying the effects of whole-body vibration on muscular performance. Tonic vibration reflex is the most commonly cited mechanism to explain the effects of whole-body vibration on muscular performance, although there is no conclusive evidence that tonic vibration reflex occurs. The bone myoregulation reflex is another neurological mechanism used to explain the effects of vibration on muscular performance. Bone myoregulation reflex is defined as a reflex mechanism in which osteocytes exposed to cyclic mechanical loading induce muscle activity. AIMS The aim of this study was to assess whether bone tissue affected vibration-induced reflex muscle activity and vibration-induced muscle strength gain. STUDY DESIGN A prospective, randomised, controlled, double-blind, parallel-group clinical trial. METHODS Thirty-four participants were randomised into two groups. High-magnitude whole-body vibration was applied in the exercise group, whereas low-magnitude whole-body vibration exercises were applied in the control group throughout 20 sessions. Hip bone mineral density, isokinetic muscle strength, and plasma sclerostin levels were measured. The surface electromyography data were processed to obtain the Root Mean Squares, which were normalised by maximal voluntarily contraction. RESULTS In the exercise group, muscle strength increased in the right and left knee flexors (23.9%, p=0.004 and 27.5%, p<0.0001, respectively). However, no significant change was observed in the knee extensor muscle strength. There was no significant change in the knee muscle strength in the control group. The vibration-induced corrected Root Mean Squares of the semitendinosus muscle was decreased by 2.8 times (p=0.005) in the exercise group, whereas there was no change in the control group. Sclerostin index was decreased by 15.2% (p=0.031) in the exercise group and increased by 20.8% (p=0.028) in the control group. A change in the sclerostin index was an important predictor of a change in the vibration-induced normalised Root Mean Square of the semitendinosus muscle (R2=0.7, p=0.0001). Femoral neck bone mineral density was an important predictor of muscle strength gain (R2=0.26, p=0.035). CONCLUSION This study indicates that bone tissue may have an effect on vibration-induced muscle strength gain and vibration-induced reflex muscle activity. TRIAL REGISTRATION ClinicalTrials.gov: NCT01310348.

Effects of sex steroids on serum sclerostin levels during the menstrual cycle.

Background/Aims: Previous studies on the effects of estrogen on sclerostin regulation were conducted in postmenopausal women in humans or animals following estrogen treatment or induced estrogen deficiency. The aim of this study was to evaluate the effects of sex hormones on serum sclerostin levels in premenopausal women with normal menstrual cycles. Methods: A prospective observational clinical study. 80 voluntary premenopausal women were recruited for the study. Data from 31 patients were available for the statistical analysis. Serum sclerostin, free estradiol, free testosterone, and progesterone levels were measured during the menstruation, late follicular and mid-luteal phases. The unique protocol IDs were BEAH FTR-4 and NCT01418924 at ClinicalTrials.gov ID. Results: Serum sclerostin values were 1.03 ± 0.58 ng/ml during the menstruation phase, 1.0 ± 0.36 ng/ml during the late follicular phase, and 1.18 ± 0.67 ng/ml during the mid-luteal phase (p = 0.543). There was no significant relationship between serum levels of sex steroids and sclerostin. Conclusions: Previous studies have not investigated the impact of sex hormone fluctuations on serum sclerostin levels during the menstrual cycle. The present study shows that serum sclerostin levels were not affected by sex steroids in premenopausal women with normal menstrual cycles.

Effect of Whole-Body Vibration on Balance Using Posturography and Balance Tests in Postmenopausal Women.

ObjectiveThe authors examined the impacts of whole-body vibration (WBV) applications on balance control in postmenopausal women using clinical balance tests and computerized static posturography. DesignPatients were randomly divided into two groups and treated with WBV and/or home-based balance coordination exercises (BCEs). Patients in the WBV-BCE group were asked to stand on the platform in standing, squat, and deep squat positions. During each position, 30-sec vibration (30–35 Hz) and 60-sec rest periods were applied twice (20 sessions in total). The BCE program was performed by subjects twice per day. All subjects were evaluated before and after treatment using the Timed Up and Go test and the Berg Balance Scale (BBS). The fall index and the Fourier index were assessed via computerized static posturography. ResultsSixty patients were recruited for the study, but only 42 patients (21 in each group) completed it. Fall index and the total values of the Fourier index 2–4 and Fourier index 5–6 frequencies indicated a significant improvement in the WBV-BCE group (P < 0.05). Both groups showed significant improvements in the Berg Balance Scale and Timed Up and Go test (P < 0.05). ConclusionsThe ease of applying WBV furthermore supports its inclusion in daily treatment protocols for age-related decline in balance performance in women and improved balance and mobility measures associated with increased fall risk.

A 14-year-old girl with Smith-McCort dysplasia misdiagnosed as seronegative juvenile idiopathic arthritis

Dear Editor, Spondylo-epi-metaphyseal dysplasias (SEMDs) are a heterogeneous group of disorders with differing modes of inheritance, all of which are defined by the combination of vertebral, epiphyseal and metaphyseal abnormalities. The specific diagnosis is based on the specificity of the skeletal manifestations or the presence of characteristic extraskeletal features. Dyggve-Melchior-Clausen syndrome (DMC) and Smith-McCort dysplasia (SMC) are rare autosomal recessive SEMDs. SMC (OMIM: 607326), which is a rare variant of DMC syndrome without evidence of mental retardation, has been shown to be allelic to DMC syndrome. Smith-McCort dysplasia is a progressive, autosomalrecessive SEMD that may be misdiagnosed in clinical practice as juvenile idiopathic arthritis (JIA). The clinical importance of this rare disorder may be attributed to its clinical similarity to JIA, which has a very different prognosis and treatment regimen. Typical dysplastic skeletal abnormalities, which occur mainly in the spine and iliac bones, and the absence of synovial inflammation enable the differential diagnosis of SMC from JIA. We present the case of a 14-year-old girl with SMC who was misdiagnosed as having JIA. A 14-year-old girl was admitted to our hospital with pain in the bilateral hip and leg that had hindered her normal walking for 3 months. Evaluation of the clinical history revealed that the pain had started from both hips and spread to the legs, and had gradually reduced her ability to walk. She reported that she could not stand or walk without support for the previous 2.5 months. The history of the patient revealed no evidence of swelling, redness or warmth of the joints during this time period. Approximately 3.5 months prior to presentation at our hospital with these complaints, she had consulted an orthopedic surgeon, who had recommended bilateral total hip arthroplasty. In the meantime, she was admitted to our hospital and was evaluated at the Departments of Pediatrics and Rheumatology, _Istanbul University Cerrahpasa Medical Faculty, Turkey. After a diagnosis of a seronegative rheumatoid arthritis, treatment was initiated with a regimen of prednisolone 5 mg once daily, methotrexate 15 mg/ week, calcium–vitamin D once daily, and folic acid once daily, twice a week in the Department of Rheumatology. These treatments did not produce any change in her pain or walking ability. The patient is the fifth child in a family in which the parents are non-consanguineous. She had no history of severe disease or disability, apart from slow growth and developmental delay. Neurological examination was normal, and the patient was still receiving primary education. She had short and fusiform hand fingers. Increased anteroposterior chest diameter and kyphoscoliosis were present, and the proximal portions of the upper and lower limbs were short. She had pain and limitation regarding range of motion in the knee and hip joints bilaterally. She also had bilateral valgus deformity of the knee and ankle joint. The right and left leg lengths were 63 and 67 cm, respectively. The patient’s serum 25-hydroxyvitamin D, parathyroid hormone, thyroxine, thyroid stimulating hormone, acute phase response proteins, serum protein electrophoresis, and bone, liver, and kidney profiles were all normal. Urine amino acids were normal and there was no excretion of mucopolysaccharides. Spinal radiography revealed platyspondyly in almost all the vertebral bodies (Fig. 1), and pelvis radiography revealed lacy iliac bones and dysplasia of the acetabulum and femoral heads bilaterally (Fig. 2). In a cervical magnetic resonance imaging, there was odontoid hypoplasia, platyspondyly at multiple levels, irregularities of the end-plates, and characteristic double-humped appearance due to a wedge-shaped ossification defect. The bone mineral density (BMD) of the patient was measured using dual-energy X-ray absorptiometry (DEXA; Hologic QDR-4500, Bedford, International Journal of Rheumatic Diseases 2012; 15: e55–e57

Anterior inferior iliac spine avulsion fracture.

A 13-yr-old boy was admitted with right groin pain that began after kicking a ball in a soccer game 1 wk before. He reported persistent pain in his groin, which was aggravated by movement of the hip; he also demonstrated tenderness upon palpation in the right inguinal area. Active flexion and passive hyperextension of the right hip were painful. An anterior-posterior radiograph of his pelvis demonstrated a minimally displaced ipsilateral avulsion fracture of the right anterior inferior iliac spine (AIIS) (Fig. 1). He was treated with bed rest for 3 days and simple analgesia for a week. Passive-assisted range-of-motion exercises were initiated as soon as pain allowed. He had limited active hip motion for 4 wks and then was permitted only light activity for another 4 wks. He returned to full activity at 12 wks after his injury. Children and adolescents account for almost half of sports-related injuries for all age groups, and 3%Y5% of all sports injuries occur in the groin area. The diagnosis of groin pain in athletes is difficult because the anatomy of the region is complex and two or more injuries often coexist. The most common avulsion fracture sites in the pelvis are the rectus femoris attachment on the AIIS, the sartorius attachment on the anterior superior iliac spine, and the hamstring attachment on the ischial tuberosity. Avulsion fractures of the AIIS are most commonly associated with sprinting activity or kicking sports, which entail a sudden pull of the rectus femoris muscle during forceful extension of the hip. These usually occur in adolescents when the ratio of muscular strength to physeal strength is greatest. Nonoperative treatment is usually recommended for avulsions from the AIIS. Avulsion fractures of the AIIS are often mistaken for muscle or tendon injuries. These must also be differentiated from os acetabuli (an accessory ossicle at the superior rim of the acetabulum), traumatic myositis ossificans of the rectus femoris, and bone tumors. Early diagnosis and proper management of AIIS fractures are imperative to prevent them from becoming chronic and potentially career limiting. Physicians must cautiously perform detailed physical examinations and correlate the clinical condition and radiologic findings to avoid misdiagnosis. AIIS avulsion injuries should be considered in the differential diagnosis of groin pain occurring while taking part in vigorous sports.

Multilevel thoracic disk herniations in a young woman.

A 34-yr-old woman with back pain, right chest pain, and difficulty walking that started 15 days earlier while doing housework was evaluated. She reported that her household duties frequently including pushing and lifting heavy objects. Her physical examination revealed spasm of the thoracic and lumbar paravertebral muscles, hypalgesia below the T8 dermatome and decreased lower-limb muscle strength (Medical Research Council Grade 4/5). She had hyperactive reflexes at the knees and ankles, a positive Babinski sign, ankle clonus, and grade 2 spasticity (modified Ashworth scale), with no pathological findings in the upper limbs. She also reported urge incontinence. Magnetic resonance imaging showed an extruded disk at T2Y3, protruded disks at T3Y4, T4Y5, and T5Y6 with mild spinal cord compression, and extruded disks at T7Y8, T8Y9, T9Y10, and T10Y11 with severe spinal cord compression (Fig. 1). Symptomatic multilevel thoracic disk herniations with myelopathy was diagnosed. Disk herniations were seen at eight of the 12 thoracic levels, and the extruded disks at T7Y8 and T8Y9 were thought to be symptomatic. The patient was referred for surgical intervention but preferred conservative management. She was subsequently lost to follow-up. Thoracic disk herniation (TDH) occurs much less frequently than cervical or lumbar disk herniation, and multiple TDHs are rare. The symptoms and signs are usually slowly progressive and are not strongly associated with the herniated disk position, level, composition, or size. TDH accounts for only about 0.25%Y0.75% of all symptomatic herniated disks and about 0.15%Y1.8% of surgically treated disk herniations. Most TDHs are found in the lower thoracic spine, with more than 75% occurring below T8, mainly at T11Y12, probably related to weakness of the posterior longitudinal ligament and the hypermobility of the lower thoracic segment. In a study of 78 cases of TDH, 26% of the patients had herniations at multiple levels, and 12% had disk protrusions at noncontiguous levels. A history of trauma is present in almost half of the patients, although the role of trauma in the pathogenesis of herniation is still not clear. The clinical presentation can be extremely varied, from no symptoms to symptoms mimicking those of other conditions such as lumbar disk herniation and cardiac, abdominal, gastrointestinal, neoplastic, and demyelinating diseases. Band-like dermatomal sensory disturbance, girdle pain, low back pain, motor weakness, or even symptoms of myelopathy can occur. Although uncommon and often asymptomatic, multiple TDHs can easily be misdiagnosed and should not be overlooked.

Osteopoikilosis associated with fibromyalgia and active myofascial trigger point in upper trapezius muscles

Osteopoikilosis is a sclerosing bone dysplasia, characterized by multiple oval spots of radiodensities within the trabecular bone. It occurs equally common among men and women. Prevalence is estimated to be as high as 1:50,000. Most reported cases have been found incidentally on roentgenograms taken for other purposes. We present a 58-year-old woman with OPK associated with fibromyalgia and active myofascial trigger point in upper trapezius muscles.

Hip Pain and Gait Disturbance Associated with Idiopathic Hypoparathyroidism.

Idiopathic Hypoparathyroidism (IHP) is a disease characterized by diminishes in production of parathyroid hormone due to dysfunction of the parathyroid glands [1]. IHP is characterized by soft-tissue ectopic calcifications and skeletal abnormalities. Subcutaneous calcifications around the hips and shoulders may be seen in the course of this disease [2]. Muscle cramps involving the back and legs, paresthesias, and convulsions are common complaints. The clinical manifestations of this condition are varied and nonspecific. Consequently, IHP is usually diagnosed many years after its onset [3]. Back and hip pain and stiffness are is commonly overlooked in these patients [1]. We hereby report a case of a 40-year-old man who presented with bilateral hip pain that had hindered his normal walking for 6 months. He also had a 30-year history of epilepsy and cataract surgery 10 years earlier. His family history was non-contributory. He had no history of surgical excision or damage to the parathyroid glands, radiation, or neoplastic/granulomatosis infiltration. He had no muscle weakness or cranial nerve involvement and no difficulty with speech, apathy, or mental slowness. The FADIR (flexion, abduction, and internal rotation) and FABERE (flexion, abduction, external rotation, and extension) tests were positive and painful at 15° of flexion due to hip contractures. Laboratory results demonstrated the typical findings of hypoparathyroidism: parathormone value 2 (normal level = 15–65) pg/mL, serum calcium 4.6 (normal level= 8.4–10.6) mg/dL, and phosphate 7.2 (normal level = 2.3–4.7) mg/dL. Pelvis radiography revealed bilateral ossification extending along the acetabulum [Table/Fig-1]. Computed tomography of the brain showed calcifications in the pallidum and caudate nuclei bilaterally [Table/Fig-2]. The electroencephalogram was normal. [Table/Fig-1]: Pelvis radiography shows bilateral ossification around the acetabulum. Note the preservation of the joint space. [Table/Fig-2]: Head computed tomography shows bilateral symmetrical calcifications in the pallidum and caudate nuclei. No other cause of hypoparathyroidism was found. Tests for polyendocrinopathy were normal. A diagnosis of idiopathic primary hypoparathyroidism was made. Calcium, vitamin D supplementation, paracetamol 500 mg tid, diclofenac sodium 50 mg bid, and physical therapy with range of motion and strengthening exercises were started and continued until the pain limit was reached. These therapies reduced the severity of his complaints within 1 week. IHP causes hypocalcaemia by hindering calcium reabsorption in the renal tubules and bone, and to a insufficiency in the production of 1,25-dihydroxyvitamin D. The most frequent osseous findings of IHP are localized or generalized sclerosis. Extraosseous calcification is typically seen in the basal ganglia, periarticular tissue, blood vessels, and ocular lens. The development of calcification may be associated not only parathyroid hormone deficiency but also to the duration of hypocalcaemia and hyperphosphataemia [3]. The imaging findings of IHP closely resemble those of diseases such as diffuse idiopathic skeletal hyperostosis and ankylosing spondylitis [1–5]. Our patient’s main complaint was pain and gait difficulty and the diagnosis of IHP was delayed until the age of 40 years. Delaying diagnosis and treatment resulted in cataracts, speech difficulty, pain, limited range of motion of the hip and gait disturbance. Disclosures: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article.