Nurzat Elmalı

Clinical Effects of Platelet-Rich Plasma and Hyaluronic Acid as an Additional Therapy for Talar Osteochondral Lesions Treated with Microfracture Surgery A Prospective Randomized Clinical Trial

Background: Osteochondral ankle injuries commonly affect the dome of the talus, and these injuries are a common cause of athletic disability. Various treatment options are available for these injuries including intra-articular hyaluronic acid (HA) and platelet-rich plasma (PRP) injections. The purpose of this study was to compare the effects of HA and PRP as adjunct therapies after arthroscopic microfracture in osteochondral lesions (OCLs) of the talus. Methods: In this prospective, randomized blinded study, 40 patients with talar OCLs in their ankle joints were treated with arthroscopic debridement and a microfracture technique. Thirteen randomly selected patients received PRP, 14 patients received HA, and the remaining 13 patients received saline as a control group. The participants were assessed using the American Orthopaedic Foot & Ankle Society (AOFAS) and visual analog pain scale (VAS) scores after a 15.3-month (range, 11-25 months) follow-up. Results: Postoperatively, all the groups exhibited significantly increased AOFAS scores and decreased VAS scores compared with their preoperative results (P < .005). The AOFAS scores were significantly increased in the PRP group versus the HA and control groups (P < .005), although the increased AOFAS scores in the HA group versus the control group were also significant (P < .005). Similar to the AOFAS scores, the decrease in the VAS scores was significantly lower in the PRP group versus the HA and control groups (P < .005). In addition, the HA group had significantly lower VAS scores than the control group (P < .005). Conclusion: Both PRP and HA injections improved the clinical outcomes of patients who underwent operation for talar OCLs in the midterm period and can be used as adjunct therapies for these patients. Because a single dose of PRP provided better results, we recommend PRP as the primary adjunct treatment option in the talar OCL postoperative period. Level of Evidence: Level I, prospective randomized study.

Cervical myositis ossificans traumatica: a rare location

Abstract. An unusual case of myositis ossificans traumatica lesion located in the paraspinal region is reported. Despite the contiguity of the lesion with the cervical vertebrae and ominous appearance of the biopsy material, the history of antecedent trauma and computed tomography findings allowed preoperative accurate diagnosis. To our knowledge, myositis ossificans traumatica located in the cervical paraspinal region is very rare.

The Influence of Atorvastatin on Tendon Healing: An Experimental Study on Rabbits

Hyperlipidemia is a major risk factor for coronary heart disease. The most commonly used antihyperlipidemic drugs are 3-hydroxy-3-methylglutaryl coenzyme A (HMG CoA) reductase inhibitors (statins), of which atorvastatin is one of the most widely used. Little is known about the relationship between tendinopathy and HMG CoA reductase inhibitors (statins) or the effects of atorvastatin use on tendon healing following surgical repair of tendon rupture. We hypothesized that atorvastatin negatively affects this healing process. The Achilles tendons of 16 New Zealand rabbits were ruptured surgically and repaired with sutures. Eight of the rabbits were given oral atorvastatin. The other 8 served as a surgical control group. Six weeks postoperatively, all the rabbits were sacrificed, and the repaired tendons were removed. After standard histological preparation, fibroblastic activity, re-vascularization, collagenization, collagen construction, and inflammatory-cell infiltration were evaluated. On comparing the atorvastatin and surgical control groups, we observed no difference in fibroblastic activity. Although it did not reach statistical significance in our study, a difference was noted in revascularization, collagenization, and inflammatory cell infiltration; and a statistical difference was observed in collagen construction. Doubt remains about the adverse effect of atorvastatin use during tendon healing. Further investigations in animal and human models are needed on the effects of tendon healing when atorvastatin is administered for a longer time frame prior to the injury.

The stone man: myositis (fibrodysplasia) ossificans progressiva

Abstract. Myositis ossificans progressiva (MOP) is a rare hereditary connective tissue disorder characterized by progressive ossification of striated muscle and connective tissue associated with pain and disability. It is presumably transmitted as an autosomal dominant defect. Congenital anomalies of the hands and feet are early signs of this disease. Involvement of the spine, hips and extremities lead to the development of the “stone man” with only less than 600 cases reported in the literature. We present a case of MOP with typical muscle ossifications and skeletal malformations.

Does the anteromedial portal provide clinical superiority compared to the transtibial portal in anterior cruciate ligament reconstruction in nonprofessional athletes in short-term follow-up?

OBJECTIVE Two drilling techniques of the femoral tunnel are commonly used in anterior cruciate ligament (ACL) reconstruction: through the transtibial (TT) portal or through the anteromedial (AM) portal. The aim of the present study is to investigate the radiological and clinical outcomes of arthroscopic single-bundle ACL reconstruction using AM and TT portal techniques for drilling the femoral tunnel in nonprofessional athletes. METHODS A retrospective review was made of 44 nonprofessional athletes undergoing ACL reconstruction using AM and TT techniques between 2011-2013. The femoral tunnel clock position on axial magnetic resonance imaging (MRI) and the anterior-posterior position of the tibial tunnel on sagittal-cut MRI scan were measured. Radiological femoral tunnel and tibial tunnel anterior-posterior inclination angles were assessed. At final follow-up, the Lachman test and pivot-shift test were used in the evaluation of the anterior-posterior stability of the knee and the rotational stability of the knee. For clinical and functional evaluation, the modified Cincinnati knee grading system, Lysholm knee scoring scale, and International Knee Documentation Committee (IKDC) form were used. RESULTS No statistically significant difference was determined between the groups in terms of patient age, follow-up period, gender, and affected side distribution. There were 6 outliers in the TT group due to the clock face position. The mean femoral tunnel inclination angle was 31.07°±8.44° in the AM group and 19.02°±8.93° in the TT group. The tibial tunnel inclination angle was 21.08°±5.42° in the TT group and 16.58°±7.02° in the AM group. A statistically significant difference was determined between the 2 groups. No statistically significant difference was observed between the 2 groups in terms of Lachman test, pivot-shift test, Lysholm score, IKDC score, and modified Cincinnati score results. CONCLUSION The AM technique has no clinical superiority compared to the TT technique in ACL reconstruction in nonprofessional athletes.

Effect of BMI on the clinical and radiological outcomes of pilon fractures

OBJECTIVE The aim of this study was to evaluate the effect of BMI on clinical and radiological outcomes of pilon fractures. We hypothesized that obese patients, defined as having a BMI of 30 or higher, would not have worse functional and radiological outcome compared to non-obese patients. METHODS This study retrospectively reviewed 42 patients (33 males and 9 females; mean age: 42.67±12.29 years, range: 18 to 67 years) who sustained tibial pilon fractures between January 2008 and May 2011. Each patients postoperative course, including the incidence of postoperative complications, and the length of hospital stay was determined from medical charts. At the final follow-up, clinical assessment was made according to the AOFAS score and radiological evaluation was made according to the Kellgren-Lawrence classification. RESULTS Twenty-nine patients had low-energy trauma, while 13 had high-energy trauma. Mean BMI was 28.96±4.86 kg/m2. There were 18 obese patients and 24 non-obese patients. Mean AOFAS score at the final follow-up was 68.36±20.71. The average follow-up time was 30.0±11.48 months. Superficial infection in the obese group occurred at a statistically significantly higher rate (p<0.05). Operation and hospitalization times occurred at a significantly higher rate in the obese group (p=0.001 and p= 0.041, respectively). CONCLUSION Body mass index does not affect the clinical and radiological outcomes of tibial pilon fractures, with the exception of superficial infection. Obese patients could be treated as non-obese patients with close monitoring of the wound.

Bilateral clavicle osteomyelitis: A case report.

INTRODUCTION Osteomyelitis of the clavicle is rare. Infection occurs from hematogenous spread or trauma. In adults infection is usually secondary due to an exogenous cause such as open fractures, surgery (iatrogenic) or spread from local tissue with infection. PRESENTATION OF CASE The case is presented here of a 50-year old female with bilateral clavicular fractures, who was operated on with open reduction and internal fixation. At the 6-month follow-up, she had complaints of bilateral osteomyelitis which was successfully treated with resection of the infected segment of the bone, and antibiotic impregnated collagen. DISCUSSION Predisposing factors include diabetes, intravenous drug abuse, tuberculosis or immune suppression. Management involves the removal of bone fixation, debridement of the bone and if there is a defect, coverage with a muscle flap is applied. CONCLUSION In cases of clavicular osteomyelitis where infection continues despite debridement and antibiotic therapy, excision of the sequestered clavicular section is a successful treatment approach and has been seen to improve quality of life without any functional loss.

Vascular pedicled iliac bone grafting is effective in patients with an early stage of femoral head avascular necrosis.

OBJECTIVES This study aims to evaluate clinical and radiological findings of a series of patients with avascular necrosis of the femur head (ANFH) treated by core decompression and vascular pedicled iliac crest grafting. PATIENTS AND METHODS This retrospective study included 26 hips of 22 patients (14 males, 8 females; mean age 36 years; range 16 to 48 years) with ANFH using the vascularized iliac bone grafting between March 2003 and July 2010 in our clinic. The main predisposing factor was steroid use in 13 patients. All patients were assessed clinically according to the Harris hip score and by radiographs by the Association Internationale de Recherche sur la Circulation Osseuse (ARCO) staging system. RESULTS The mean follow-up was 36 (range 14 to 62) months. Eleven hips (42%) had stage II and 15 hips (58%) had stage III ANFH. The mean Harris scores increased from 52 (range 31 to 63) to 82.8 (range 62 to 90) after surgery. Based on clinical outcomes, 18 hips (69%) were presented as excellent and good, while eight hips presented fair and poor. According to the ARCO staging system, satisfactory results were provided in 17 (65%) of the 26 hips. Two of four hips at preoperatively stage II progressed to stage III, two other hips to stage IV. Five hips at stage III preoperatively progressed to stage IV and these hips had to undergo hip replacement. CONCLUSION Our results suggest that core decompression and the vascular pedicled iliac bone grafting are effective in early stages of ANFH.

Chronic wrist pain in a goalkeeper; bilateral scaphoid stress fracture: A case report

Highlights • We examine changes in the treatment of scaphoid fractures.• In this case, the patient presented with what was considered to be a rare case of a stress fracture of both scaphoid bones secondary to repetitive dorsiflexed movements.• It was aimed to present an unusual cause of chronic wrist pain due to the bilateral stress fractures of the scaphoid bone.

Posterior cruciate ligament reconstruction via tibial inlay technique in multiligament knee injuries

OBJECTIVE The aim of this study is to report our institutions experience regarding the use of open tibial inlay technique in patients undergoing single-stage combined posterior cruciate ligament (PCL) reconstruction. METHODS Records of 17 patients who underwent PCL reconstruction with tibial inlay technique were retrospectively reviewed. Patients with ipsilateral femoral or tibial osteochondral avulsion fractures or ipsilateral concomitant tibia and femur shaft fractures were excluded. Out of these 17 patients, six cases underwent anterior cruciate ligament (ACL) + PCL reconstruction, nine cases underwent ACL+ PCL + posterolateral corner reconstruction, one case underwent ACL + PCL + MCL reconstruction and one case underwent ACL+ PCL + posterolateral corner + MCL reconstruction. Mean follow-up was 14.27±6.77 (range: 6-30) months. RESULTS In preoperative assessments, all patients had 3+ posterior laxity in posterior drawer test; at final follow-up, 6 patients had 0 laxity, 7 patients had 1+ laxity, and 4 patients had 2+ laxity (p<0.001). International Knee Documentation Committee (IKDC) objective evaluation showed severe disability in all patients preoperatively, whereas 5 knees were grade A, 8 knees were grade B, 3 knees were grade C, and 1 knee was grade D at final follow-up. Mean IKDC subjective score was 75.22±7.53 at final follow-up. Postoperatively, mean side-to-side difference in KT-1000 arthrometer measurement was 2.45±1.80 mm. At final follow-up, mean range of motion (ROM) was 0º on extension and 123.56±6.31º on flexion. CONCLUSION Open tibial inlay approach is beneficial during PCL reconstruction. Further study is warranted to establish its effectiveness on functional outcomes and prevention of complications.