Femoral bowing plane adaptation to femoral anteversion.

BACKGROUND: Femoral bowing plane (FBP) is the unattended subject in the literature. More over the femoral shaft with its bowing is neglected in established anteversion determination methods. There is limited information about the relationship between FBP and anteversion. Thus we focused on this subject and hypothesized that there could be an adaptation of FBP to anteversion. MATERIALS AND METHODS: FBP is determined on three-dimensional solid models derived from the left femoral computerized tomography data of 47 patients which were taken before for another reason and comparatively evaluated with anteversion. There were 20 women and 27 men. The mean age of patients was 56 years (range 21-84 years). RESULTS: The anteversion values were found as the angle between a distal condylar axis (DCA) and femoral neck anteversion axis (FNAA) along an imaginary longitudinal femoral axis (LFA) in the true cranio-caudal view. The FBP was determined as a plane that passes through the centre-points of three pre-determinated sections on the femoral shaft. The angles between DCA, FNAA and FBP were comparatively evaluated. The independent samples t-test was used for statistical analysis. At the end, it was found that FBP lies nearly perpendicular to the anteversion axis for the mean of our sample which is around 89° in females and 93° in males (range 78-102°). On the other hand, FBP does not lie close to the sagittal femoral plane (SFP); instead, there is an average 12.5° external rotation relative to the SFP. FBP is correlated well with anteversion in terms of FBP inclination from SFP and femoral torsion (i.e., angle between FBP and femoral neck anteversion axis (P < 0.001; r = 0.680 and r = -0.682, respectively). Combined correlation is perfect (R2 = 1) as the FBP, SFP, and posterior femoral plane forms a triangle in the cranio-caudal view. CONCLUSIONS: We found that FBP adapts to anteversion. As FBP lies close to perpendicularity for the mean, femoral component positioning perpendicular to the FBP can be an alternate way in the replacement surgeries. In addition, it has been found that FBP lies externally rotated relative to the SFP.

Osteochondral mosaicplasty along with osteochondroplasty of the femoral head in femoroacetabular impingement: a case report.

Although femoroacetabular impingement (FAI) syndrome is included in the etiology of lesions involving the acetabular labrum and acetabular cartilage, it is one of many possible reasons behind osteochondral lesions in the femoral head. Herein, we present clinical findings and outcomes of two cases with osteochondral defects and cam type impingement of femoral head. Both cases underwent autologous osteochondral mosaicplasty along with femoral osteochondroplasty following controlled hip dislocation. Harris hip scores improved significantly postoperatively and magnetic resonance imaging showed an adequate graft union and formation of a healthy chondral surface at the final assessment. Autologous osteochondral mosaicplasty of parafoveal region defects and femoral neck osteochondroplasty combination may be an effective treatment method for young patients with FAI syndrome. In addition, we believe that cam type impingement may also have a role in the etiology of parafoveal osteochondral lesions.

Chronic Exposure to Static Magnetic Fields from Magnetic Resonance Imaging Devices Deserves Screening for Osteoporosis and Vitamin D Levels: A Rat Model.

Technicians often receive chronic magnetic exposures from magnetic resonance imaging (MRI) devices, mainly due to static magnetic fields (SMFs). Here, we ascertain the biological effects of chronic exposure to SMFs from MRI devices on the bone quality using rats exposed to SMFs in MRI examining rooms. Eighteen Wistar albino male rats were randomly assigned to SMF exposure (A), sham (B), and control (C) groups. Group A rats were positioned within 50 centimeters of the bore of the magnet of 1.5 T MRI machine during the nighttime for 8 weeks. We collected blood samples for biochemical analysis, and bone tissue samples for electron microscopic and histological analysis. The mean vitamin D level in Group A was lower than in the other groups (p = 0.002). The mean cortical thickness, the mean trabecular wall thickness, and number of trabeculae per 1 mm2 were significantly lower in Group A (p = 0.003). TUNEL assay revealed that apoptosis of osteocytes were significantly greater in Group A than the other groups (p = 0.005). The effect of SMFs in chronic exposure is related to movement within the magnetic field that induces low-frequency fields within the tissues. These fields can exceed the exposure limits necessary to deteriorate bone microstructure and vitamin D metabolism.

Obliteration of Intercondylar Notch Mimicking Flexion-Extension Gap Imbalance in a Cruciate Retaining Total Knee Arthroplasty.

Following total knee arthroplasty (TKA), the most frequent cause of extension deficit and limitation of range of motion in early postoperative period is related to improper tensioning of soft tissues and failure to balance extension and flexion gaps. If a cruciate retaining (CR) prosthesis is the planned implant, then attention should be given to balancing the posterior cruciate ligament (PCL), and any factor that alters this balance may also cause deterioration of knee balance in postoperative period. Here, we report on an unusual case referred from another hospital because of continuous pain and restriction of knee motion in early postoperative period following CR-designed TKA that was initially thought to be due to flexion-extension imbalance. However, during the revision procedure, extruded cement to the intercondylar notch was found to be both mechanically blocking terminal extension and limiting flexion by possible mechanism of irritation of the synovial nerve endings around the stretched anterior fibers of PCL during flexion. This case was successfully treated by removal of extruded cement from intercondylar notch to decompress PCL, polyethylene exchange, and secondary patellar resurfacing.

[Orthopedic surgeons' view for the prevention of osteoporotic secondary fractures: a survey]. / Osteoporotik ikincil kiriklarin önlenmesine ortopedik cerrahlarin bakis açisi: Bir anket.

OBJECTIVES: This study aims to investigate the tendencies related to assessment and treatment modalities administered to patients with osteoporotic fractures by orthopedics and traumatology specialists for the prevention of secondary fractures in our country. MATERIALS AND METHODS: A survey composed of 10 questions was applied in electronic environment to actively practicing 144 orthopedics and traumatology specialists to detect their demographics, protocol they administer for the diagnosis and follow-up of primary osteoporosis, and assessment and treatment modalities they administer for the prevention of secondary fractures. Categorical variables were compared statistically based on duration of specialization, affiliated institution, and academic career along with the descriptive results. RESULTS: Use of the Fracture Risk Assessment Tool (FRAXTM) developed by World Health Organization is limited among orthopedics and traumatology specialists in our country (11%). There was no statistical difference between the groups (p>0.05). The rate of starting the appropriate treatment after hip and vertebral fractures due to osteoporosis was 21%. In addition, 46% of the physicians preferred to wait for the dual-energy X-ray absorptiometry results. Only academic career was statistically significantly different between the groups (p=0.043). CONCLUSION: In our country, majority of patients who present with osteoporotic hip and vertebra fractures are assessed and treated insufficiently for the prevention of secondary fractures. Supporting our results with clinical studies can accelerate the development of sufficient research and treatment programs for patients with osteoporotic fractures.

Significance of asymmetrical posteromedial and posterolateral femoral condylar chamfer cuts in total knee arthroplasty.

PURPOSE: Orthopedic surgeons remove more bone from the posteromedial femoral condyle than the posterolateral condyle to achieve the desired femoral component rotation. Here, the correlation between the asymmetry of chamfer cuts and femoral component rotation in total knee arthroplasty was determined. METHODS: A model was built to simulate anterior chamfer cuts performed during total knee arthroplasty to measure posterior condylar offset. Right knee axial magnetic resonance imaging slices were examined from 280 consecutive patients (142 men, 138 women; mean age 31.4 ± 6.6 years). The anatomic and surgical transepicondylar axes, as well as the posterior condylar joint line, were drawn. Differences in the posteromedial and posterolateral offsets and the femoral rotation angles relative to the posterior joint line were measured. RESULTS: The mean surgical femoral rotation angle was 4.8° ± 1.2°, and the mean posterior condylar offset difference was 4.4 ± 1 mm, with a strong correlation (p < 0.0001; r = 0.803). There was no statistically significant difference between genders. Linear regression analyses revealed that a 0.8-mm difference between the anteroposterior dimensions of the medial and lateral posterior condylar offsets corresponded to 1° of femoral external rotation (p < 0.0001, R (2) = 0.645). CONCLUSION: The accuracy of the applied technique intra-operatively can be verified by correlating the asymmetry of posterior chamfer cuts with the achieved femoral component rotation, as determined by measuring the thicknesses of posterior chamfer cuts with a caliper. Technical errors can also be minimized by confirming the association between the femoral component rotation-as predicted by the posterior condylar offset difference-and the preoperatively measured femoral rotation angle. LEVEL OF EVIDENCE: II.

Efficacy of 5-fluorouracil in inhibition of unintended bone formation in spinal surgery: a histological evaluation on a rat model of spontaneous spinal fusion.

OBJECTIVE: The aim of this study was to investigate the influence of the antiproliferative agent 5-Fluorouracil (5FU) over inhibition of spinal bone formation in an experimental rat model. METHODS: The study included 30 6-month-old Sprague-Dawley rats divided into 3 groups. Aggressive periosteal denuding was performed by scalpel to induce punctuate bleeding in the posterior elements of the L4-L5 vertebrae in the spontaneous fusion model. Spinous processes were fixated by wires and no graft substitute was applied. Adcon-L was applied in Group 1, single-touch technique 5FU in Group 2. Group 3 was the control group. Rats were sacrificed at 4 weeks and specimens acquired for histological examination. RESULTS: 5FU substantially inhibited fibroblast and inflammatory cell densities as well as bone formation compared to the control group. 5FU was considerably superior to Adcon-L with regard to inhibition of bone formation and inflammatory cells (p=0.0001). CONCLUSION: 5FU can inhibit fusion, fibrosis and unwanted scar tissue in spinal surgery. We believe that after further studies on its local delivery dose, it can be used in humans for inhibition of unintended fusion.

Ultrasonographic measurement of the distal femoral cartilage thickness in patients with unilateral transtibial amputation.

BACKGROUND: Lower limb amputation sometimes predisposes to degenerative secondary disorders. OBJECTIVES: To evaluate the distal femoral cartilage thicknesses of patients with unilateral transtibial amputations using ultrasound and to investigate the relationship between cartilage thickness and disease-related parameters. STUDY DESIGN: Cross-sectional study. METHODS: Twenty-four unilateral transtibial amputees (mean age: 46.4 ± 8.5 years, range: 28-60 years) were evaluated. Duration of prosthesis use (years) and daily walking time with prosthesis (hours) were recorded. Functional status was assessed by gate velocity (m/s), and 6-min walking distance (m) with prosthesis. Ultrasound was used to measure distal femoral cartilage thicknesses bilaterally at medial/lateral condyles and the intercondylar areas. The percentages of cartilage loss (of the amputee-side in comparison with the nonamputee-side) were calculated. RESULTS: Compared to the nonamputee-sides, distal femoral cartilage was significantly thinner at lateral condyles and the intercondylar areas on the amputee-sides (p < 0.05). Significant positive correlations were detected between the percentage of cartilage loss (at all three sites of measurement) and gate velocity, 6-min walking distance, and daily walking time with prosthesis (all p < 0.05). CONCLUSIONS: Future prospective controlled studies are warranted to determine the principles of optimum prosthetic use regarding its possible effects on the femoral cartilage of amputee patients. CLINICAL RELEVANCE: The correlations between the cartilage loss in the amputee extremity with faster gait and longer daily prosthetic use suggest that abnormal gait patterns might increase the loading on the amputated extremity.

[Functional status, patient satisfaction and quality of life in patients with arthroscopic partial meniscectomy]. / Artroskopik parsiyel menisektomili hastalarda fonksiyonel durum, hasta memnuniyeti ve yasam kalitesi.

OBJECTIVES: This study aims to investigate the effects of clinical and demographic variables on functional status, patient satisfaction and quality of life following arthroscopic partial meniscectomy. PATIENTS AND METHODS: Between January 2001 and December 2010, 98 patients (44 males, 54 females; mean age 52.1±12.5 years; range 18 to 88 years) who underwent arthroscopic partial meniscectomy in our clinic and were eligible for the study. Demographic and clinical data of patients and surgical characteristics were recorded. Preoperative activity levels of patients were measured. Severity of activity pain and patient satisfaction following surgery were evaluated using Visual Analog Scale (VAS). Functional status was evaluated by Lysholm knee score and WOMAC (Osteoarthritis Index Western Ontario and McMaster Universities), while quality of life was evaluated by Short Form-36 (SF-36). RESULTS: Postoperative mean time from surgery was 62.5±26.1 (8-120) months, GAS score at rest was 1.7±2.6 (0-10), GAS activity score was 3.4±3.3 (0-10) and GAS patient satisfaction score was 7.0±3.0 (0-10). It was found that 68 of the patients (69.4%) were evaluated themselves as excellent or better than preoperative period with a mean Lysholm knee score of 73.8±17.4 (24-95). Significant influences of body mass index and preoperative symptom duration on evaluation parameters were not detected. Male gender, less than five years after surgery, less intraoperative joint degeneration and moderate to severe activity level before the onset of symptoms had a positive influence on the severity of pain, patient satisfaction and functional status. CONCLUSION: Our study provided critical data for optimal patient selection during the preoperative period to predict which patients may have better results in the mid-term follow-up after arthroscopic partial meniscectomy.

Ultrasonographic evaluation of the Risser sign. Is it a reliable and reproducible method?

STUDY DESIGN: A prospective study of ultrasonographic evaluation (UE) results of the Risser sign (RS) in adolescents. OBJECTIVE: This study aims to assess the efficiency of UE of RS, compare it with radiographic evaluation, and investigate the intraexaminer and interexaminer reliability of UE. SUMMARY OF BACKGROUND DATA: The use of ultrasound in orthopedic practice has a growing popularity. As a noninvasive radiological method, the evaluation of RS seems to be a promising alternative in patients suffering from scoliosis who require a long-term follow-up. METHODS: This study consists of 142 patients (70 female and 72 male cases) aged between 10 and 17 years, with a mean age of 13.8 ± 1.7 years. Menarche experience, body mass index, and skinfold thickness of the patients were recorded. Forty-five patients were found to have scoliosis. All ultrasonographic and radiographic evaluations were made by 2 blinded orthopedists. X-ray was considered as the gold standard. RESULTS: Percentage accuracy of UE was found to be 77.7% (κ = 0.698) for the first examiner and 64.30% (κ = 0.542) for the second examiner. Intraexaminer and interexaminer agreement were 0.971 and 0.924 for the UE, respectively. Moreover, interexaminer agreement for radiographic evaluation was 0.689. No significant difference was observed between the values of scoliosis and nonscoliosis patients. When the patients with a skinfold thickness of 16 mm or less and more than 16 mm were examined, the percentage accuracy of the UE was 80.43% (κ = 0.727) for the first group, whereas it was 72.91% (κ = 0.637) in the other group. CONCLUSION: We found the intraexaminer and interexaminer agreement for the UE of RS to be reliable. In radiographic evaluation of RS, the intraexaminer and interexaminer agreement were lower. These findings were also consistent with data from the literature. In conclusion, UE of RS is a reliable method; however, the results may vary when x-ray is considered as the gold standard.

Comparison of the calcaneal pitch angle and modified projection area per length squared method for medial longitudinal arch evaluation of the foot.

OBJECTIVE: To compare the calcaneal pitch angle (CPA) values measured on direct lateral radiographs of feet, and the modified projection area per length squared (PAL), which was calculated as a new method for the evaluation of the medial longitudinal arch (MLA) of the foot. MATERIAL AND METHODS: Direct lateral radiographs of patients who had weightbearing feet radiographies for any reason except trauma were retrospectively obtained from the archives. Direct lateral radiographs of the feet were printed and a transparent sheet was placed on it. A straight line was drawn between the most plantar process of the calcaneus and the head of the first metatarsal bone for the calculation of the PAL of the MLA. Two semilunar arcs were drawn upon this straight line. PAL1 and PAL2 were estimated using a point-counting technique. The CPA, lateral talo-calcaneal angles (LTCA), and talo-first metatarsal angles (TFMA) were measured. The correlations between PAL1, PAL2 of right and left feet and CPA, LTCA, and TFMA were explored. RESULTS: Fifty patients (27 females, 23 males) with a mean age of 40.12 (4-78) years were evaluated. Significant correlations were detected between PAL1, PAL2 and CPA, and TFMA for both right and left feet (p<0.05). CONCLUSION: A significant correlation was detected between the modified PAL method as a new technique and the standard CPA method for MLA evaluation. The PAL method is suggested as a simple and practical method for MLA evaluation.

Spontaneous regeneration of the large femoral defect in patient with diffuse osteomyelitis after intramedullary nailing.

Infection of the long bones after intramedullary nailing is a troublesome condition and management of the infection remains challenging to orthopedic surgeons. Associated infection can be more problematic and more diffuse in intramedullary bone fixation, since it may spread along the nail. Surgical treatment choices are also difficult especially in cases with large bone defects after debridement. In this article, we present a 75-year-old woman that had been treated only with in-situ external fixation, antibiotic therapy and observation. Despite diffuse femoral osteomyelitis, a 10 cm femoral defect healed with unexpected bone regeneration which couldn't be explained reasonably.

Dose dependent effect of C-type natriuretic peptide signaling in glycosaminoglycan synthesis during TGF-ß1 induced chondrogenic differentiation of mesenchymal stem cells.

Recent investigations credited important roles to C-type natriuretic peptide (CNP) signaling during chondrogenesis. This study investigated the putative role of CNP in transforming growth factor (TGF)-ß1 induced in vitro chondrogenic differentiation of mesenchymal stem cells (MSCs) in pellet culture. MSCs were derived from human trabecular bone and were characterized on the basis of their cell surface antigens and adipogenic, osteogenic, and chondrogenic differentiation potential. TGF-ß1 induced chondrogenic differentiation and glycosaminoglycan (GAG) synthesis was analyzed on the basis of basic histology, collagen type II, Sox 9 and aggrecan expressions, and Alcian blue staining. Results revealed that human trabecular bone-derived MSCs express CNP and NPR-B analyzed on the basis of RT-PCR and immunohistochemistry. In pellet cultures of MSCs TGF-ß1 successfully induced chondrogenic differentiation and GAG synthesis. RT-PCR analyses of both CNP and NPR-B during this process revealed an activation of this signaling pathway in response to TGF-ß1. Similar cultures induced with TGF-ß1 and treated with different doses of CNP showed that CNP supplementation at 10(-8) and 10(-7) M concentrations significantly increased GAG synthesis in a dose dependent manner, whereas at 10(-6) M concentration this stimulatory effect was diminished. In conclusion, CNP/NPR-B signaling pathway is activated during TGF-ß1 induced chondrogenic differentiation of human trabecular bone-derived MSCs and may strongly be involved in GAG synthesis during this process. This effect is likely to be a dose-dependent effect.

Immunohistochemical demonstration of nerve endings in iliolumbar ligament.

STUDY DESIGN: Immunohistochemical study on fresh cadaver specimens. OBJECTIVE: Assessment of mechanoreceptor and nociceptor levels and distribution in iliolumbar ligament. SUMMARY AND BACKGROUND DATA: The function of iliolumbar ligament and its role in low back pain has not been yet fully clarified. Understanding the innervation of this ligament should provide a ground which enables formation of stronger hypotheses. METHODS: Bilateral 30 iliolumbar ligaments of 15 fresh cadavers were included in the study. Morphologic properties were recorded and the ligaments were examined by focusing on 3 main parts: ligament, bone insertions, and tendon body. Assessment of mechanoreceptor and nociceptor levels and their distribution in iliolumbar ligament were performed on the basis of immunohistochemistry using the S-100 antibody specific for nerve tissue. RESULTS: Iliac wing insertion was found to be the richest region of the ligament in terms of mechanoreceptors and nociceptors. Pacinian (type II) mechanoreceptor was determined to be the most common (66.67%) receptor followed by Ruffini (type I) (19.67%) mechanoreceptor, whereas free nerve endings (type IV) and Golgi tendon organs (type III) were found to be less common, 10.83% and 2.83%, respectively. CONCLUSION: Immunohistochemical staining has shown that iliolumbar ligament had a rich nerve tissue. Those results indicate that ILL plays an important role in proprioceptive coordination of lumbosacral region alongside its known biomechanic support function. Moreover, the presence of type IV nerve endings suggest that the injury of this ligament might contribute to the low back pain.

Distribution of the metatarsophalangeal sesamoids in Turkish subjects.

No statistically significant pattern of metatarsophalangeal sesamoid distribution has been reported in the literature in relation to genetic pool or group, unilaterality or bilaterality, or sesamoid division. A study was undertaken to evaluate the presence and distribution of the metatarsophalangeal sesamoid bones of the foot in Turkish subjects. A total of 602 foot radiographs from 371 patients without forefoot complaints other than those of the hallux were included in the study. Absence or hypoplasia of the first-ray sesamoids was seen on 0.7% of the radiographs, and second-, third-, fourth-, and fifth-ray sesamoids were present on 2.8%, 0.5%, 1.0%, and 15.1% of the radiographs, respectively. Fifth-ray sesamoids were more prevalent in men (odds ratio, 2.71; 95% confidence interval, 1.52-4.84). The frequency of a normal foot profile (two sesamoids in the first ray) was 83.2%. Divisions of the sesamoids were seen on 4.0% of the radiographs at the first ray and on 20.9% at the fifth ray. Distribution and division of sesamoids were predominantly bilateral (kappa = 0.91, 0.91, and 0.95 for the first, second, and fifth digits, respectively; P < .001).

Comparison of injection modalities in the treatment of plantar heel pain: a randomized controlled trial.

In a prospective randomized study of plantar heel pain, 44 patients were treated with injection of 1 mL of 2% prilocaine using the peppering technique, 1 mL of 2% prilocaine combined with 2 mL of autologous blood, or 1 mL of 2% prilocaine mixed with 40 mg of methylprednisolone acetate. At 6-month follow-up, clinical improvement was evaluated by using a 10-cm visual analog scale and the rearfoot score of the American Orthopaedic Foot and Ankle Society. Results were analyzed using sample t-tests within groups and repeated-measures analyses of variance between groups. Mean +/- SD visual analog scale scores in the peppering technique, autologous blood injection, and corticosteroid injection groups improved from 6.4 +/- 1.1, 7.6 +/- 1.3, and 7.28 +/- 1.2 to 2.0 +/- 2.2 (P < .001), 2.4 +/- 1.8 (P < .001), and 2.57 +/- 2.9 (P < .001), respectively. Mean +/- SD rearfoot scores in the same groups improved from 64.1 +/- 15.1, 71.6 +/- 1, and 65.7 +/- 12.7 to 78.2 +/- 12.4 (P = .018), 80.9 +/- 13.9 (P = .025), and 80.07 +/- 17.5 (P = .030), respectively. There were no statistically significant differences among the groups. Good outcomes have been documented using the peppering technique and autologous blood injection for the treatment of lateral epicondylitis. Although the curative mechanisms of both injection modalities are based on a hypothesis, they seem to be good alternatives to corticosteroid injection for the treatment of plantar heel pain.

Callus formation of the tibial hallux sesamoid mimicking a bone tumor.

Sesamoid tumors of the hallux are rare, and their incidence and differential diagnosis have not been well described. We present a case with a bizarre callus formation of the medial sesamoid of the hallux that mimicked a bone tumor. After excision of the mass and related sesamoid, the patient remained asymptomatic during 3 years of follow-up.