Yakup Yildirim

The effect of proteolytic enzyme serratiopeptidase in the treatment of experimental implant-related infection

BACKGROUND Infection around an implanted orthopaedic device is a devastating complication, and the treatment of infections involving slime-forming bacteria is especially difficult. The purpose of the present study was to evaluate the effectiveness of a proteolytic enzyme, serratiopeptidase, in the eradication of a periprosthetic infection in an in vivo animal model. METHODS In sixty Sprague-Dawley rats, the medullary canal of the right femur was drilled through the intercondylar notch and was inoculated with a Staphylococcus epidermidis strain (ATCC 35984) with a high slime-producing capacity. The cavity was filled with polymethylmethacrylate cement, and a Kirschner wire that had contact with the knee joint was inserted. None of the animals received any treatment for two weeks. Twenty rats were killed at two weeks after the inoculation in order to determine if the infection had become established. The remaining forty rats were randomized into two groups. One group received serratiopeptidase enzyme injections into the knee joint in addition to antibiotic therapy for four weeks, and the other group received intra-articular saline solution injections together with the same antibiotic therapy. The animals from both groups were killed two weeks after the end of therapy (on Day 56). The knee specimens were evaluated bacteriologically and histologically to determine the prevalence of persistent infection and the effects of the enzyme on local tissue. RESULTS At two weeks, inoculated bacteria grew on culture of specimens from twelve (63.2%) of nineteen animals in the no-treatment group. Microbiological testing suggested that infection persisted in only one (5.6%) of eighteen animals in the serratiopeptidase-and-antibiotic group, whereas it was present in six (37.5%) of sixteen animals in the antibiotic-only group (p = 0.001). Histological evaluation showed similar results (kappa = 0.92). CONCLUSIONS Serratiopeptidase was effective for eradicating infection caused by biofilm-forming bacteria in this experimental animal model. The antibiofilm property of the enzyme may enhance antibiotic efficacy in the treatment of staphylococcal infections.

Chondrolysis, Osteonecrosis, and Slip Severity in Patients with Subsequent Contralateral Slipped Capital Femoral Epiphysis

BACKGROUND Prophylactic pinning of the radiographically and clinically normal contralateral hip in a patient with a unilateral slipped capital femoral epiphysis remains controversial. The purpose of this study was to identify the prevalence of chondrolysis and osteonecrosis and the degree of slip severity in contralateral hips with a subsequent slipped capital femoral epiphysis to determine whether the outcome or complications on the contralateral side were greater than the risks of prophylactic pinning. METHODS The medical records of the patients operated on between 1993 and 2003 at a single hospital for treatment of a slipped capital femoral epiphysis were retrospectively evaluated. The severity and the chronicity of the slips were graded. Only children who initially had had a unilateral slip and had been followed for a minimum of twenty-four months or until skeletal maturity were included in the analysis for detection of a subsequent contralateral slip. Patients with more than twelve months of follow-up were included in the analysis for detection of osteonecrosis and chondrolysis. RESULTS Two hundred and twenty-seven patients had a unilateral slipped capital femoral epiphysis at the time of the primary admission. A subsequent slip developed in the contralateral hip of eighty-two children (36%) within a mean of 6.5 months. Eighteen of the contralateral slips were of moderate or severe severity, with a potential for a poor outcome due to a risk of osteoarthritis in the future. Osteonecrosis or chondrolysis, each an established complication with a poor long-term prognosis, developed in five of the patients with a subsequent contralateral slip. CONCLUSIONS The high prevalence of a subsequent contralateral slip (36%) and the potential complication (high slip severity) and established complications (osteonecrosis and chondrolysis) related to the contralateral slip indicate that prophylactic pinning of the contralateral hip in a patient with a unilateral slipped capital femoral epiphysis is safer than and preferable to observation and symptomatic treatment.

Effect of Metatarsophalangeal Joint Position on the Reliability of the Tangential Sesamoid View in Determining Sesamoid Position

Background: Lateral displacement of the sesamoids of the first toe relative to the metatarsal head is a common finding in hallux valgus deformity. Several methods have been described for quantifying the amount of subluxation from anteroposterior radiographs but a tangential sesamoid radiograph has been determined to be the best view to evaluate sesamoid displacement. Method: We evaluated the sesamoid position at different angles of the first metatarsophalangeal (MTP) joint to determine the effect of first MTP joint dorsiflexion on sesamoid position when tangential sesamoid view radiographs are made. Sesamoid positions of 22 feet with hallux valgus were graded from the short axis computed tomography (CT) images obtained with the MTP joint in 0, 35, and 70 degrees of dorsiflexion. Results: Approximation of the sesamoids to reduction was apparent as dorsiflexion of the first MTP joint increased. Conclusion: Different dorsiflexion degrees of the first MTP joint when tangential sesamoid radiographs are made modulate the position of the sesamoids and may lead to misclassification on grading.

Lateral shifting of the first metatarsal head in hallux valgus surgery: effect on sesamoid reduction.

Thirty feet with hallux valgus (HV) having grade 2 and 3 sesamoid stations on AP radiographs were examined after Lindgren-Turan oblique distal metatarsal osteotomy with a minimum follow-up of 12 months. Adductor tendon release from the lateral sesamoid was not performed to determine the isolated effect of distal metatarsal osteotomy on metatarsosesamoidal reduction. Of the 30 feet, 20 (67%) had reduced and 10 (33%) unreduced sesamoids at the follow-up. Ultimately, distal metatarsal osteotomy (DMO) with lateral shifting of the first metatarsal head more than 7.2 mm was found to reduce the sesamoids in the great majority of the cases (95% CI 7.243–9.757). Sesamoid release is redundant for metatarsosesamoidal reduction if sufficient lateral shift of the first metatarsal head over the sesamoids is accomplished.

Suture holding capacity of the Achilles tendon during the healing period: an in vivo experimental study in rabbits.

Background: Early motion and weightbearing is known to promote the healing of Achilles tendon repair. It is important to be informed about the repair strength for a secure rehabilitation. There are reports about the initial repair strength of Achilles tendons; however, they are mainly in vitro studies that represent the time zero strength of the repair. Softening of the tendon observed during the biological process of the tendon healing, which may effect the suture holding capacity and in turn the repair strength of the tendon has not been evaluated before. Methods: In the current study, the suture holding capacity of rabbit Achilles tendon was observed at various times during the healing period. Results: The suture holding capacity of the tendon at the end of the first and third weeks after surgery was found to be similar within 30% of the control tendon. However, at the end of the fourth week it was doubled reaching 65% of the control tendon. Conclusions: Intrinsic tendon insufficiency which causes a decrease in the suture holding capacity of the tendon may lead to pull-out of the suture material during the postoperative third week. This period is precarious for early motion and weightbearing since the suture holding capacity of the tendon doubled relative to the previous three weeks.

Effect of Sagittal Plane Deformity of the Lumbar Spine on Epidural Fibrosis Formation After Laminectomy : An Experimental Study in the Rat

Study Design. An animal model of postlaminectomy lumbar column sagittal plane deformity was designed in rats. Objectives. To analyze the effect of lumbar column deformity (lordosis and kyphosis) on postlaminectomy epidural fibrosis formation. Summary of Background Data. Incidence of peridural fibrosis formation after lumbar spinal surgery is considerably high. Instability and sagittal plane deformity of the lumbar spine has been implicated (not proven) as the factors for the development of epidural fibrosis. The effect of traction (kyphosis) or relaxation (lordosis) of the lumbar spine on epidural fibrosis formation is not known. Methods. L4 laminectomies were performed in 30 rats. Three equal groups were formed. In the control group (group I), only laminectomy was performed. In other groups after laminectomy, lumbar lordosis (group II) and kyphosis (group III) was maintained with steel implants. The scar formation was evaluated both histologically and histomorphometrically on the 12th postoperative week. Results Kyphosis developed in group I. The mean amount of peridural scar tissue was significantly more evident in groups I and III than the lordosis group. The extent of adherence to the dura mater and the nerve roots was most apparent in group III. Conclusions. Kyphosis and consequent traction of the lumbar spine is one of the causes for increased epidural fibrosis formation after laminectomy. On the contrary, establishment of lordosis and relaxation of the lumbar spine decreased the scar tissue formation in rats.

Accessory lateral discoid meniscus

The lateral meniscus tends to have more developmental variation than the medial counterpart. This is a report of an accessory discoid layer of lateral meniscus. All arthroscopic, magnetic resonance imaging and histopathological views are presented.

The effect of dehydration and irrigation on tendon adhesion formation after tendon exposure

OBJECTIVE The aim of this study was to evaluate the effects of dehydration due to tendon exposure on adhesion formation on the tendon surface. METHODS Achilles tendons of 60 New Zealand white rabbits were surgically exposed and evaluated. In the control group (Group 1), the wound was closed immediately; and in the remaining two groups, Achilles tendons were exposed to air for 60 minutes without (Group 2) or with (Group 3) regular saline irrigation. After undergoing clinical examination, 50% of rabbits in each group were sacrificed 3 weeks postoperatively and 50% at the 6th postoperative week. RESULTS All tendons exposed to air exhibited mild or moderate degrees of adhesion. Compared to the control group, the incidence of adhesion formation was significantly higher in the groups where tendons had been exposed to air for 60 minutes, whereas no significant difference was found between the irrigated and non-irrigated groups. No limitations or contractures were detected in the hind limbs of the animals at the clinical examination. CONCLUSION Regardless of irrigation, tendons are not prone to form clinically apparent adhesions during operations under 60 minutes of duration.

Do timing of injection and status of the suction drain effect postoperative pain scores after intra-articular bupivacaine injection in arthroscopic ACL reconstruction?

OBJECTIVE The aim of this study was to determine if the timing of intra-articular local anesthetic injection and the status of the suction drain affect variable pain scores after ACL reconstruction. METHODS The study included 40 patients undergoing arthroscopic ACL reconstruction randomized into 4 groups. Patients in Group 1 received intra-articular 20 ml of 0.25% bupivacaine 20 minutes before the start of the operation (preemptive: PE), Group 2 at the end of the operation with the suction drain opened (DO). Group 3 also received intra-articular bupivacaine at the end of the operation and the drain was kept closed for one hour postoperatively (DC). Group 4 did not receive any intra-articular injection (control group: CG) and served as the control group. Visual analog scale (VAS) scores and additional analgesic requirements were recorded. RESULTS The PE group had the lowest and the control group the highest VAS scores at the second postoperative hour. At the fourth postoperative hour, VAS scores were significantly higher in the DC group than the DO group (p<0.05). At the sixth postoperative hour, the PE and DC groups had significantly lower VAS scores than the other groups (p<0.05). At Hour 12, the PE and control groups had higher VAS scores than the DO and DC groups. VAS scores were not different among groups at Hour 24. The interval to first analgesic requirement was significantly shorter in the control group and longer in the PE group in comparison to the other two groups (p<0.001). CONCLUSION Intra-articular bupivacaine injection at different stages of the operation yielded variable VAS scores in the postoperative period. Closing the drain after intra-articular injection resulted in an early onset analgesic effect without shortening the duration.

Calcaneocuboid joint dislocation: a case report.

Tarsal bone dislocation is a rare entity. It is usually undiagnosed in the emergency department. We present the case of a 44-year-old man who was diagnosed as having calcaneocuboid joint dislocation in the emergency department. The dislocation was reduced in the emergency department, and a below-the-knee cast was applied. Successful clinical and radiologic results were obtained during follow-up. In this case, unlike the previous reports in the literature, conservative management succeeded in the treatment of calcaneocuboid joint dislocation.