A Comparison of the Effects of Neuronal Nitric Oxide Synthase and Inducible Nitric Oxide Synthase Inhibition on Cartilage Damage.

The objective of this study was to investigate the effects of selective inducible nitric oxide synthase and neuronal nitric oxide synthase inhibitors on cartilage regeneration. The study involved 27 Wistar rats that were divided into five groups. On Day 1, both knees of 3 rats were resected and placed in a formalin solution as a control group. The remaining 24 rats were separated into 4 groups, and their right knees were surgically damaged. Depending on the groups, the rats were injected with intra-articular normal saline solution, neuronal nitric oxide synthase inhibitor 7-nitroindazole (50 mg/kg), inducible nitric oxide synthase inhibitor amino-guanidine (30 mg/kg), or nitric oxide precursor L-arginine (200 mg/kg). After 21 days, the right and left knees of the rats were resected and placed in formalin solution. The samples were histopathologically examined by a blinded evaluator and scored on 8 parameters. Although selective neuronal nitric oxide synthase inhibition exhibited significant (P = 0.044) positive effects on cartilage regeneration following cartilage damage, it was determined that inducible nitric oxide synthase inhibition had no statistically significant effect on cartilage regeneration. It was observed that the nitric oxide synthase activation triggered advanced arthrosis symptoms, such as osteophyte formation. The fact that selective neuronal nitric oxide synthase inhibitors were observed to have mitigating effects on the severity of the damage may, in the future, influence the development of new agents to be used in the treatment of cartilage disorders.

In vitro release and In vivo biocompatibility studies of biomimetic multilayered alginate-chitosan/ß-TCP scaffold for osteochondral tissue.

Biomimetic three-layered monolithic scaffold (TLS) intended for the treatment of osteocondral defects was prepared by using alginate, chitosan and ß-tricalcium phosphate (ß-TCP) to study drug release behavior of the alternative drug delivery system and to investigate the therapeutic efficacy of the scaffold. Dexamethasone sodium phosphate (Dex) as a model drug was incorporated into the scaffold by solvent sorption method and in vitro release studies were conducted. In addition, the scaffold was implanted into the defects formed in the trochlea of Sprague-Dawley rats to assess the healing potential of the TLS on the osteochondral defect against reference Maioregen® comparatively. The release studies showed that after an initial burst at 3rd h, dexamethasone is released slowly during a 72-h period. In vivo studies indicated that the TLS has good tissue biocompatibility and biodegradation rate and showed better results during osteochondral healing process compared to the reference. All results demonstrated that the alginate-chitosan/ß-TCP scaffold could be evaluated as a good candidate for osteochondral tissue applications.

Does insulin, transferrin and selenous acid preparation effect chondrocyte proliferation?

OBJECTIVE: The aim of this study was to test the hypothesis that insulin, human transferrin, and selenous acid (ITS) preparation have positive effects on chondrocyte proliferation and morphology and investigate the biochemical and histological effects of these additive substances in different cell culture media. METHODS: Human cartilage-derived cells (hCDCs) were isolated from the cartilage tissue of a 57-year-old woman diagnosed with gonarthrosis. Tissue samples were cultured in Dulbecco's modified Eagle's medium (DMEM) and RPMI-1640. The cells' chondrogenic activities were observed. After serial passagings, cells were divided into 4 groups at the end of the 6th week. On the 14th day, proliferated cells were examined using an inverted microscope with x4, x10, x20 and x40 magnification and microphotographs were taken. Living cell quantity was determined on the first and 14th days using MTS-ELISA cell proliferation assay. RESULTS: DMEM (without adding ITS premix solution) and RPMI-1640 containing ITS premix solution provide proliferation of the chondrogenic cells. The proliferation and viability of chondrocytes were revealed in this study in the 3rd group (DMEM solution without additives). CONCLUSION: It is suggested that the culture medium ingredients play crucial roles on chondrogenic proliferation in osteochondral tissue cultures.

Patella infera or patellar tendon adherence after high tibial osteotomy.

PURPOSE: Alterations in patellar height after high tibial osteotomy are found in many instances. Fibrosis of the tendon is implicated as the cause of the mechanism of patella lowering. This study aimed to determine the relationship between the position of the patella and the histopathological findings at the patellar tendon after high tibial osteotomy. METHODS: Nineteen knees in seventeen patients who were consecutively hospitalised for implant extraction are studied. All of the patients had previously undergone closing wedge osteotomy by the same surgeon at the same department. The median follow-up time is 15 months (range: 11-35). Five patients who all underwent high tibial osteotomy at the same time are also included in the study as a control group for histopathological evaluation. All of the patients are evaluated radiologically, patellar tendon biopsies are taken during the operation, and histopathological analyses are performed. RESULTS: The shortening of the patellar tendon is statistically significant (P < 0.05). The severity of the vascularisation, inflammation, and fibrotic change observed at the distal part of the tendon is evident. However, there is no statistically significant correlation between these findings and the degree of shortening. CONCLUSIONS: The shortening of the tendon occurs as a result of adherence in the distal part of the tendon. It would appear that it is this shortening that causes the difficulties encountered during arthroplasty surgery of osteotomy patients, and not patella infera.

How different methodologies of harvesting and analysing the samples affect the test results in determining joint mediators.

Purpose. This study has researched the affect of different methodologies of harvesting and analysing the samples in determining the mediators emerging after the rat articular cartilage injury. Materials and Methods. One hundred and forty-four male wistar rats were divided into 2 groups. Synovial fluid samples were taken from all of the rats. We entered into the right knees of the rats in group I (n = 36) under anaesthesia and took cartilage tissue samples from their distal femur. Samples were taken as reference values for enzyme linked immunosorbent assay (ELISA) and histopathological evaluations. We entered into the right knees of the rats in group II (n = 108) and formed complete layer of cartilage injury in their medial femoral condyles. At the end of the 15th day, the rats were sacrificed after taking synovial fluid samples from their right knees creating defect in the rats in group II. The molecular markers in the synovial fluid and cartilage tissue samples which were taken from the experimental and control groups (MMP-9, MMP-13, TIMP-1, TNF- α , and NO) were analysed by direct or indirect methodologies. SPSS 18.0 Package program was used in the statistical evaluation. Students t-test where the measurement variables between the experimental and control groups were compared was applied. Receiver Operating Characteristics (ROC) curves were used in the determination of the diagnostic sufficiency from the tissue. Results. No difference was found between TIMP-1 (P = 0.67) and MMP-9 (P = 0.28) levels in synovial fluid and cartilage tissue. From the molecular markers, when MMP-9, MMP-13, NO, TIMP-1, TNF- α ', the area under ROC curve, and P values were examined, MMP-13 (P < 0.0001, 95% CI: 0.70-0.85), NO (P < 0.0001, 95% CI: 0.72-0.86), and TNF- α (P < 0.0001, 95% CI: 0.91-0.98) results were found to be statistically significant. Inferences. The indirect ELISA protocol which we apply for the cartilage tissue as an alternative to synovial lavage fluid is a reliable method which can be used in the determination of articular cartilage injury markers.

Clinical and radiological outcome of the growing rod technique in the management of scoliosis in young children.

OBJECTIVE: The aim of this study was to investigate the effects of growing rod treatment on the clinical and radiographic outcome and respiratory function of young children with scoliosis. METHODS: Data from 25 patients (24 females, 1 male) who underwent surgical treatment with growing rods for scoliosis between 1997 and 2007 were evaluated retrospectively. Dual growing rods were used in 16 patients and single growing rods in 9. Patients' average age was 7.38 ± 3.8 years at the initial surgery. Cobb angle, T1-S1 length, and instrumentation length were measured radiographically. Respiratory functions were evaluated at the final follow-up. RESULTS: Patients received an average of 4.2 lengthening treatments over an average period of 44.9 months. Cobb angles improved from 56.7° to 25.1° after final fusion. T1-S1 length increased from 27.2 ± 3.4 to 34.9 ± 3.6 cm after the initial surgery and 38.6 ± 3.7 cm post final fusion. Average growth was 1 ± 0.4 cm per year. Mean values of respiratory parameters at the last follow-up were FVC: 83.5 ± 3.5, FEV: 84.8 ± 5.3, and FVC/FEV1: 1 ± 0.046. Twelve patients experienced complications, of which eight were instrument-related and four medical. CONCLUSION: The growing rod technique is effective in the treatment of spinal deformity in young scoliosis patients and appropriate for improving both spinal column height and pulmonary function.

Synergistic Effect of TGF-ß1 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-ß1 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-ß1 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-ß1. 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.

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.

Anxiety and trauma perception and quality of life in patients who have undergone replantation.

The difficulty in keeping an amputated limb biologically alive is overcome day by day thanks to the successful replantation procedures applied in the early period. However, the reflections of this biological success on patients in functional and psychological terms may not be pleasing all the time. In our study, we aimed to evaluate the perceptual responses of patients to trauma after replantation and their possible effects on clinical results. We conducted a retrospective study of 43 patients who underwent replantation. The average age was 32.4 years and the average follow-up period was 38.6 months. When the results of the Short Form-36 (SF-36), Beck's Depression Inventory, and the assessment scores of the disabilities of the arm, shoulder, and hand survey were evaluated, there was a negative correlation between the patients diagnosed with depression and all SF-36 subunits. A negative correlation between the severity of trauma and the average physical and mental values included in the SF-36 evaluations was observed (R = 0.48, R = 0.51, respectively),. These results revealed that the psychology of the patient was one of the important factors that could not be ignored in the success of replantation.

Sonographically guided corticosteroid injection for treatment of plantar fasciosis.

OBJECTIVES: The purpose of this study was to prospectively investigate the effect of sonographically guided corticosteroid injection on the clinical and radiologic responses in patients with proximal plantar fasciosis. METHODS: Thirty-one consecutive patients with unilateral plantar fasciosis were enrolled. A 4-cm 21-gauge needle was positioned in a caudocranial oblique manner, and the needle was withdrawn to the near edge of the fascia so that the solution dispersed around the edge. Two milliliters (20 mg/mL) of lignocaine/prilocaine, 1%, and 0.5 mL (20 mg) of methylprednisolone acetate solutions were injected separately. The plantar fascia and fat pad thickness, fascial echogenicity, and perifascial edema were assessed with a 10-5 MHz linear array transducer. The American Orthopedic Foot and Ankle Society midfoot scale was used to assess function, alignment, and pain. The initial radiologic and clinical measurements were compared with data obtained not less than 6 weeks after the injections. RESULTS: A statistically significant decrease in the mean plantar fascia thickness was detected after treatment (P < .0001). There was no statistically significant difference in the plantar fascia echogenicity before and after treatment (P = .11). A statistically significant decrease was found for perifascial edema (P < .0001), and a statistically significant increase in American Orthopedic Foot and Ankle Society scores was detected (P = .0007). There was no decrease in fat pad thickness (P > .1). Plantar fascia rupture was detected in 1 patient. CONCLUSIONS: Sonographically guided corticosteroid injection enables real-time imaging of the plantar fascia during needle insertion. A caudocranial oblique injection beneath the fascia may have an incremental value in the treatment response in patients with plantar fasciosis.

Cementless total hip arthroplasty for the management of tuberculosis coxitis.

INTRODUCTION: Tuberculosis arthritis of the hip is a crippling disease and there is need for an effective and acceptable treatment for the hips with bone destruction. The aim of this report was to evaluate the efficacy of the diagnostic method for hip tuberculosis and clinical results of the patients to clarify the question of whether a total hip arthroplasty (THA) should be attempted on a patient with a current or previous infection. MATERIALS AND METHODS: Nine patients with active tuberculosis of the hip, treated by cementless THA, were analyzed retrospectively. The mean age of the patients at diagnosis was 43.4 years (range 22-72 years). Laboratory tests of all the patients revealed high erthrocyte sedimentation rates (ESR) and C-reactive proteins. Plain radiographs showed bone destruction with joint space narrowing in all patients. Magnetic resonance imaging (MRI) scans showed fluid within the joint in five patients. Two patients had associated pulmonary tuberculosis. To confirm the clinico-radiological diagnosis, an open biopsy was performed for histopathological examinations of all the hips. Tuberculosis of the hips was treated with primary cementless THA, followed by postoperative antituberculous medication for 1 year. The inflamed soft tissues and the destroyed bones were completely resected and curetted out at the time of operation. RESULTS: At the final evaluation, the mean Harris Hip Score improved to 94.8 (range 90-98; P = 0.003). ESR became normal, less than 15 mm/h, with a mean time of 4 months (range 2-9 months). The C-reactive protein was normal, less than 0.8 mg/dl, after a mean time of 3 months (range 1-7 months). With an average follow-up of 5.6 years (range 2-8 years), no reactivation of tuberculosis infection was found in each patient. All of the femoral stems and acetabular cups were radiologically stable and demonstrated signs of bone ingrowth at the final follow-up. All histopathologic examinations showed granulomatous lesions including epitheloid histiocytes surrounded by lymphocytes. CONCLUSIONS: Cementless THA can be safely performed in advanced tuberculosis of the hip for providing symptomatic relief and functional improvement of the hips. Complete curettage and resection of the infected tissue and postoperative antituberculous chemotherapy with a minimum of 1-year duration are very important in preventing reactivations.

Analyzing acetabular deficiency by computed tomography in osteoarthritis after Crowe type 2 developmental dysplasia of the hip.

OBJECTIVES: Images of acetabular deficiency in Crowe type 2 developmental dislocated hips were evaluated by computed tomography (CT) and acetabular component was placed surgically. PATIENTS AND METHODS: Twenty-nine hips of 18 patients (2 males, 16 females; mean age 46 years; range 37 to 56 years) have been reviewed through CT imaging. The roof edge angle, the acetabular index of depth to width and bone mass of the anterior and posterior acetabular rim have been measured over the cross sections obtained from the CT. RESULTS: Acetabular structure was normal in four hips, and there was no posterior rim deficiency in any hips. However, there was anterior rim deficiency in 21 hips, and there was both posterior and anterior deficiency in four hips. The acetabular anteversion was the most common finding. CONCLUSION: In this study, increased acetabular anteversion and anterior rim deficiency were frequently observed in patients with Crowe type 2 hip dislocation. An orthopaedist should consider anteversion and this deficiency when fitting acetabular component.

Does bone impaction technique reduce tunnel enlargement in ACL reconstruction?

The aim of this study was to investigate effects of bone impaction technique on tunnel enlargement after ACL reconstruction at a minimum 2 years follow-up. Two groups of patients who had been operated upon with the same arthroscopic technique with the exception of tibial tunnel constitution were compared. Twenty-one patients of group A (drilling to 6 mm followed enlargement to 8-9 mm by using dilators) and 23 patients of group B (directly drilling to the size of the graft) were evaluated clinically and radiographically based on multislice computerised tomography (MSCT) retrospectively. At follow-up, there was no statistical difference between tunnel diameters between two groups at the femoral site, but significant difference at the tibial site (p = 0.00192 for coronal; p = 0.0171 for sagittal diameter). Both groups were comparable according pre- and postoperative Lysholm and IKDC scores (p < 0.5 Mann-Whitney U test). Compacted tunnel walls may resist enlargement, suggesting this technique resulted in better tunnel diameter values especially with intratunnel fixation.

Spinal osteotomy: correcting sagittal balance in tuberculous spondylitis.

STUDY DESIGN: Retrospective case analysis. OBJECTIVE: Tuberculosis spondylitis is a cause of sagittal imbalance and neurologic impairment. In this study, the result of decompression and closing wedge osteotomy with instrumented fusion performed in patients with tuberculous spondylitis were analyzed retrospectively. SUMMARY OF BACKGROUND DATA: Twelve patients with angular kyphotic deformity underwent decompression and closing wedge osteotomy with instrumented fusion between 2000 and 2004. Clinical and radiologic assessment was based on pain, functional and neurologic status, and radiologic measurements. METHODS: There were 7 men and 5 women with median age of 52 years (range, 24 to 76 y). The average follow-up period was 62 months (range, 48 to 70 mo). The radiologic involvement included the angle of kyphosis on the anteroposterior and lateral radiographs. The preoperative and postoperative clinical assessments were performed by the using Oswestry Disability Index. All patients were asked to rate their preoperative and postoperative pain measurement using a pain visual analog scale. RESULTS: Visual analog scale scores improved from 5.8 in average (range, 4 to 8) to 2.2 in average (range, 1 to 4) and in the mean and Oswestry Disability Index from 54.2 (46 to 60) preoperatively to 15.2 (8 to 22) at the latest follow-up. Four patients presented neurologic findings. Three patients had improvement in their neurologic status, 1 patient did not improve and remained as American Spinal Injury Association (ASIA) grade C. Kyphotic deformity of the patients has improved from 51.1 to 23.2 degrees postoperatively. One of them has to be revised and instrumentation was extended to upper levels. Fusion was achieved at the last follow-up. CONCLUSIONS: Despite developing pseudarthrosis secondary to implant failure in 1 case, we recommend debridement, closing wedge osteotomy, and posterior instrumented fusion to correct sagittal balance in tuberculous spondylitis.

[Long-term results of total hip arthroplasty in patients with juvenile rheumatoid arthritis]. / Juvenil romatoid artrit hastaliginda total kalça artroplastisinin uzun dönem sonuçlari.

OBJECTIVES: We evaluated the long-term results of total hip arthroplasty (THA) in patients with juvenile rheumatoid arthritis (JRA). METHODS: The study included 37 hips of 23 patients (22 females, 1 male; mean age 22 years; range 17 to 30 years) who underwent THA for hip degeneration secondary to JRA. All arthroplasties were performed through an anterolateral approach by the same senior surgeon. The mean body surface of the patients was 1.5 m2 (range 1.1 to 1.7 m2) and the mean symptom duration to surgery was 12 years (range 7 to 16 years). Twenty-three hips received cemented, 14 hips received hybrid prostheses. In seven hips with an extremely narrow femoral medulla and shallow acetabulum, a CDH prosthesis was used. The hips were evaluated using the Harris hip score. Prosthetic loosening and displacement and heterotopic bone formation were assessed on follow-up radiographs. The mean follow-up period was 135 months (range 58 to 212 months). RESULTS: The mean Harris hip score increased from 27.2 (range 11 to 69) to 79.5 (range 37 to 87) postoperatively. At final follow-ups, all the patients were satisfied with the outcome and were able to walk without support. Three hips (8.1%; 3 patients) required revision. The overall Kaplan-Meier implant survival rate was 86.5%. There were no significant correlations between the Harris hip score and radiographic loosening and the presence of calcification around the prosthesis. Heterotopic bone formation of grade I was observed in 17 hips (46%). CONCLUSION: Even though it is performed at young ages, THA considerably improves quality of life of patients with JRA having hip joint involvement and has a comparable implant survival.

[Aseptic drainage associated with polyglactine sutures used for repair of Achilles tendon ruptures]. / Asil tendonu tamirlerinde poliglaktinin yol açtigi aseptik akintilar.

The aim of surgical treatment of Achilles tendon ruptures is to restore stability of the tendon. Various suture techniques and materials can be used for this purpose. Suture materials may be polyfilament or monofilament, absorbable or nonabsorbable. We presented four patients who developed severe chronic discharges associated with thick polyglactine (Vicryl) used during open repair of acute Achilles tendon ruptures. Surgical removal of suture materials and debridement resulted in complete improvement without any complications. The use of thick suture materials and large knots should be avoided in the repair of Achilles tendon ruptures. Polyfilament and absorbable sutures may pose problems due to their tendency to cause bacterial colonization and tissue rejection.

[The contribution of locked screw-plate fixation with varying angle configurations to stability of osteoporotic fractures: an experimental study]. / Osteoporotik kemikte kilitli plak ve açili vida kullaniminin stabilizasyonun dayanikliligina katkisi: Deneysel çalisma.

OBJECTIVES: This experimental study was designed to find new ways of improving stabilization of fractures in osteoporotic elderly patients through alterations made in the configuration and geometry of locked screw-plate fixation used in the conventional plate technique. METHODS: Four screw configurations with varying angulations were used for plate-bone construction. Forty iron plates of high quality (100x35x3 mm) were divided into four groups and two screw holes, 3 mm in diameter, were drilled on each plate at a distance of 15 mm. In group A, the holes were drilled so that the screws would be vertically sent to the bone interface. In the remaining groups, the holes were drilled for convergent (group B, 15 degrees ) and divergent (group C, 15 degrees ; group D, 30 degrees ) screw orientation. Screw-plate fixation was tested in a modified osteoporotic bone (Osteoporotic Generic Bone, Synbone) on an Instron materials testing system with an axial pullout force of 0.1 mm/sec. Failure loads were read from load-displacement curves and the type of failure was noted. RESULTS: Screws placed in divergent orientations showed the highest axial pull-out strength (group C, 83.3 N/mm; group D, 80.8 N/mm), followed by convergent placement (72 N/mm) and vertical placement (66.7 N/mm). The type of failure was breakage of the bone sample in divergent configurations, and screw pull-out in convergent and vertical configurations. CONCLUSION: Divergent constructs may be a promising alternative to conventional screw placement in treating osteoporotic fractures.