Publications by authors named "Mahmut Nedim Doral"

82 Publications

Anterior cruciate ligament surgery and rehabilitation: does anybody really know what time it is?

Knee Surg Sports Traumatol Arthrosc 2021 Apr 20;29(4):1015-1017. Epub 2020 Nov 20.

Division of Sports Medicine, Department of Orthopaedic Surgery, University of Louisville, Louisville, KY, USA.

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http://dx.doi.org/10.1007/s00167-020-06364-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7678772PMC
April 2021

Mean femoral cartilage thickness is higher in athletes as compared with sedentary individuals.

Knee Surg Sports Traumatol Arthrosc 2021 Apr 15;29(4):1206-1214. Epub 2020 Jul 15.

Department of Orthopaedics and Traumatology, Ufuk University, Ankara, Turkey.

Purpose: It is unclear how high-intensity physical activity (HIPA) affects the knee joint, specifically the femoral cartilage (FC). Therefore, the aims of this study were to evaluate FC thickness via ultrasound among elite athletes involved in different types of HIPA, and to determine whether there is a correlation between serum cartilage oligomeric matrix protein (sCOMP) and rectus femoris (RF) thickness.

Method: A total of 132 male individuals participated in this study and were assigned to two groups, the sedentary (n = 43, 23.9 ± 3.7) and athlete groups (n = 89, 22.7 ± 4.6), which did not significantly differ in age. The athletes were elite and performed HIPA during sports such as volleyball (n = 20), soccer (n = 21), basketball (n = 28), and weightlifting (n = 20). RF thickness and three (mid-point) measurements were obtained for each knee. The mean FC thickness for each knee was defined as the sum of the medial, lateral condyles, and intercondylar areas. Blood samples for sCOMP analyses were also obtained.

Results: All the measurements of the FC of both knees were significantly higher in the athletes than in the sedentary individuals (p < 0.001 and p = 0.001). The mean right and left FC values were also higher in the athletes (p < 0.001). Multiple linear regression analysis showed that participation in sporting activities was a significant predictor associated with the right and left mean FC thickness (p < 0.001 for both). No significant differences in the sCOMP levels were found between the two groups.

Conclusion: It was found that the mean FC was higher among athletes than among sedentary individuals. As a result, it is suggested that sports' participation is an independent factor associated with the right and left mean FC thickness.

Level Of Evidence: III.
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http://dx.doi.org/10.1007/s00167-020-06146-7DOI Listing
April 2021

The challenging battle of mankind against COVID-19 outbreak: Is this global international biological catastrophe the beginning of a new era?

J Orthop Surg (Hong Kong) 2020 Jan-Apr;28(2):2309499020923501

Department of Orthopaedics and Traumatology & Sports Medicine, Meram Medical Faculty Hospital, Necmettin Erbakan University, Selcuklu, Konya, Turkey.

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http://dx.doi.org/10.1177/2309499020923501DOI Listing
May 2020

Effects on Lower Extremity Neuromuscular Control Exercises on Knee Proprioception, Muscle Strength, and Functional Level in Patients with ACL Reconstruction.

Biomed Res Int 2019 15;2019:1694695. Epub 2019 Nov 15.

Department of Orthopaedics & Traumatology, Faculty of Medicine, Ufuk University, Ankara, Turkey.

Objective: The purpose of this study was to determine the effects of lower extremity motor control exercises on knee proprioception, muscle strength, and functional level in patients with anterior cruciate ligament reconstruction (ACL-R).

Materials And Methods: Thirty-two of the 57 patients with ACL-R using tibialis anterior allografts were divided into two groups. Group I: lower extremity motor control exercises were added to the standard rehabilitation program. Group II: standard rehabilitation program was applied. Effects of lower extremity motor control exercises on quadriceps and hamstring muscles strength, knee joint position sense, and hop test were evaluated.

Results: There were no differences in muscle strength and endurance of the quadriceps and hamstring between the operative and nonoperative sides in Group I ( > 0.05) while there were significant differences in strength of the quadriceps and hamstring between the operative and nonoperative sides in Group II ( < 0.05). There were significant differences in the endurance of the quadriceps and hamstring and knee joint position sense at 15°, 45°, and 75° between the operative sides of the patients in both groups ( < 0.05).

Conclusions: The neuromuscular control exercises program was found to be more effective in reducing the difference in strength while the standard program was found to be more effective in reducing the difference in endurance between the operated knee and the other knee. This study revealed that neuromuscular control exercises should also be used to improve knee proprioception sense following ACL-R.
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http://dx.doi.org/10.1155/2019/1694695DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6881759PMC
April 2020

Quadriceps tendon autograft ACL reconstructed subjects overshoot target knee extension angle during active proprioception testing.

Knee Surg Sports Traumatol Arthrosc 2020 Feb 27;28(2):645-652. Epub 2019 Nov 27.

Faculty of Medicine Orthopedics and Traumatology Department, Ufuk University, 06510, Ankara, Turkey.

Purpose: To compare the active joint position sense (JPS), muscle strength, and knee functions in individuals who had anterior cruciate ligament (ACL) reconstruction with quadriceps tendon autograft, hamstring tendon autograft, tibialis anterior allograft and healthy individuals. It was hypothesized that when compared to an age and gender-matched healthy control group, subjects who were post-ACL reconstruction would display impaired active joint position sense, knee extensor and flexor strength symmetry and knee function at 1 year post-surgery. A secondary hypothesis was that differences would exist between the quadriceps tendon autograft, hamstring tendon autograft and tibialis anterior allograft groups.

Methods: Sixty-seven patients with ACL reconstruction and 20 healthy individuals were included. Active JPS reproduction was measured at 15°, 45° and 75° of knee flexion. International Knee Documentation Committee (IKDC) subjective score and one-leg hop test were used to assess the functional status of the patients.

Results: The JPS detection was different at the 15° target angle between groups (F = 24.56, p < 0.001). A significantly higher proportion of quadriceps tendon autograft group patients failed to identify the 15° active JPS assessment position compared to the other groups (p < 0.0001). The quadriceps index was lower in patients compared to healthy individuals (p < 0.001), while the hamstring index was similar (n.s.). The knee functional outcomes were similar between ACL reconstructed groups and healthy controls (n.s.).

Conclusion: Knee proprioception deficits and impaired muscle strength were evident among patients at a mean 13.5 months post-ACL reconstruction compared with healthy controls. Patients who underwent ACL reconstruction using a quadriceps tendon autograft may be more likely to actively over-estimate knee position near terminal extension. Physiotherapists may need to focus greater attention on terminal knee extension proprioceptive awareness among this patient group.

Level Of Evidence: III.
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http://dx.doi.org/10.1007/s00167-019-05795-7DOI Listing
February 2020

Modern treatment of meniscal tears.

EFORT Open Rev 2018 May 21;3(5):260-268. Epub 2018 May 21.

Ghent University, Faculty of Medicine, Department of Orthopaedics and Traumatology, De Pintelaan, Ghent, Belgium.

The complex ultrastructure of the meniscus determines its vital functions for the knee, the lower extremity, and the body.The most recent concise, reliable, and valid classification system for meniscal tears is the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS) Classification, which takes into account the subsequent parameters: tear depth, tear pattern, tear length, tear location/rim width, radial location, location according to the popliteal hiatus, and quality of the meniscal tissue.It is the orthopaedic surgeon's responsibility to combine clinical information, radiological images, and clinical experience in an effort to individualize management of meniscal tears, taking into account factors related to the patient and lesion.Surgeons should strive not to operate in most cases, but to protect, repair or reconstruct, in order to prevent early development of osteoarthritis by restoring the native structure, function, and biomechanics of the meniscus.Currently, there are three main methods of modern surgical management of meniscus tears: arthroscopic partial meniscectomy; meniscal repair with or without augmentation techniques; and meniscal reconstruction. Meniscus surgery has come a long way from the old slogan, "If it is torn, take it out!" to the currently accepted slogan, "Save the meniscus!" which has guided evolving modern treatment methods for meniscal tears. This last slogan will probably constitute the basis for newer alternative biological treatment methods in the future. Cite this article: 2018;3 DOI: 10.1302/2058-5241.3.170067.
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http://dx.doi.org/10.1302/2058-5241.3.170067DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5994634PMC
May 2018

Thirty Minutes of Running Exercise Decreases T2 Signal Intensity but Not Thickness of the Knee Joint Cartilage: A 3.0-T Magnetic Resonance Imaging Study.

Cartilage 2019 10 20;10(4):444-450. Epub 2018 Apr 20.

Department of Sports Medicine, Hacettepe University, Ankara, Turkey.

Objective: Recent studies showed a potential of magnetic resonance imaging (MRI), which can be used as an additional tool for diagnosing cartilage degeneration in the early stage. We designed a cross-sectional study in order to evaluate knee joint cartilage adaptation to running, using 3.0-T MRI equipped with the 3-dimensional turbo spin echo (VISTA = Volume ISotropic Turbo spin echo Acquisition) software. By this thickness (mm) and signal intensity (mean pixel value) can be quantified, which could be closely related to the fluid content of the knee joint cartilage, before and after running.

Methods: A total of 22 males, aged 18 to 35 years, dominant (right) and nondominant (left) knees were assessed before and after 30 minutes of running. Cartilage thickness and signal intensity of surfaces of the patella, medial and lateral femoral and tibial condyles were measured.

Results: Cartilage thickness of the lateral condyle decreased at the dominant knee, while it increased at the medial tibial plateau. Signal intensity decreased at all locations, except the lateral patella in both knees. The most obvious decrease in signal intensity (10.6%) was at the medial tibial plateau from 949.8 to 849.0 of the dominant knee.

Conclusion: There was an increase in thickness measurements and decrease in signal intensity in medial tibial plateau of the dominant knee after 30 minutes of running. This outcome could be related to fluid outflow from the tissue. Greater reductions in the medial tibial plateau cartilage indicate greater load sharing by these areas of the joint during a 30-minute running.
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http://dx.doi.org/10.1177/1947603518770246DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6755866PMC
October 2019

Reverse total shoulder arthroplasty.

EFORT Open Rev 2018 Feb 28;3(2):58-69. Epub 2018 Feb 28.

Division of Shoulder Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, USA.

Since the introduction of reverse total shoulder arthroplasty (RTSA) in 1987 (in Europe) and 2004 (in the United States), the number of RTSAs performed annually has increased.Although the main indication for RTSA has been rotator cuff tears, indications have expanded to include several shoulder conditions, many of which involve dysfunction of the rotator cuff.RTSA complications have been reported to affect 19% to 68% of patients and include acromial fracture, haematoma, infection, instability, mechanical baseplate failure, neurological injury, periprosthetic fracture and scapular notching.Current controversies in RTSA include optimal baseplate positioning, humeral neck-shaft angle (135° 155°), glenosphere placement (medial, lateral or bony increased offset RTSA) and subscapularis repair.Improvements in prosthesis design, surgeon experience and clinical results will need to occur to optimize this treatment for many shoulder conditions. Cite this article: 2018;3:58-69 DOI: 10.1302/2058-5241.3.170044.
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http://dx.doi.org/10.1302/2058-5241.3.170044DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5890133PMC
February 2018

Infrapatellar Fat Pad-Derived Stem Cell-Based Regenerative Strategies in Orthopedic Surgery.

Knee Surg Relat Res 2018 Sep;30(3):179-186

Department of Orthopedics and Traumatology, Hacettepe University Faculty of Medicine, Ankara, Turkey.

Infrapatellar fat pad is a densely vascularized and innervated extrasynovial tissue that fills the anterior knee compartment. It plays a role in knee biomechanics as well as constitutes a source of stem cells for regeneration after knee injury. Infrapatellar fat pad-derived stem cells (IPFP-ASCs) possess enhanced and age-independent differentiation capacity as compared to other stem cells, which makes them a very promising candidate in stem cell-based regenerative therapy. The aims of this review are to outline the latest advances and potential trends in using IPFP-ASCs and to emphasize the advantages over other sources of stem cells for applications in orthopedic surgery.
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http://dx.doi.org/10.5792/ksrr.17.061DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6122943PMC
September 2018

Injuries Among Recreational Football Players: Results of a Prospective Cohort Study.

Clin J Sport Med 2018 05;28(3):249-254

Departments of Orthopaedics and Traumatology, Hacettepe University School of Medicine, Ankara, Turkey.

Objectives: To establish the incidence and patterns of football injuries and associated consequences in daily life and labor loss, among public employees.

Design: Prospective cohort study.

Setting: Football tournament between public employees in Turkey.

Participants: A total of 1821 recreational players from 78 teams.

Main Outcome Measures: Injury rates (injuries per 1000 hours of football exposure) during tournament by age group, as well as prevalence, severity, and injury types were recorded. The data regarding the occurrence (eg, location, type, circumstances) and consequences (eg, absenteeism, medical treatment, labor loss) of injuries were collected.

Results: Of the 1821 football players registered for participation, 57% (n = 1038) were included in the study with the returned questionnaire forms. In total, 257 matches were played with a total exposure time of 5654 hours. A total of 218 injuries were recorded in 192 players (10.5%), resulting in a mean of 0.85 time-loss injuries per match (38.6 per 1000 hours). Severe injuries constituted 42.6% of all injuries, and 28.9% of all injuries caused the participants to be absent at least 1 day for the next working day. The total labor loss was 1196 days for all injuries. The rate of missing subsequent working day was significantly less for muscle injuries (P < 0.05).

Conclusions: The risk of injury in recreational football players is relatively high causing significant labor loss. The results suggest that prevention programs should consider specific injury characteristics, as there is a greater incidence of muscle and anterior cruciate ligament injuries in this population.
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http://dx.doi.org/10.1097/JSM.0000000000000425DOI Listing
May 2018

Tri-layered composite plug for the repair of osteochondral defects: in vivo study in sheep.

J Tissue Eng 2017 Jan-Dec;8:2041731417697500. Epub 2017 Apr 13.

Department of Orthopedics and Traumatology, Faculty of Medicine, Hacettepe University, Ankara, Turkey.

Cartilage defects are a source of pain, immobility, and reduced quality of life for patients who have acquired these defects through injury, wear, or disease. The avascular nature of cartilage tissue adds to the complexity of cartilage tissue repair or regeneration efforts. The known limitations of using autografts, allografts, or xenografts further add to this complexity. Autologous chondrocyte implantation or matrix-assisted chondrocyte implantation techniques attempt to introduce cultured cartilage cells to defect areas in the patient, but clinical success with these are impeded by the avascularity of cartilage tissue. Biodegradable, synthetic scaffolds capable of supporting local cells and overcoming the issue of poor vascularization would bypass the issues of current cartilage treatment options. In this study, we propose a biodegradable, tri-layered (poly(glycolic acid) mesh/poly(l-lactic acid)-colorant tidemark layer/collagen Type I and ceramic microparticle-coated poly(l-lactic acid)-poly(ϵ-caprolactone) monolith) osteochondral plug indicated for the repair of cartilage defects. The porous plug allows the continual transport of bone marrow constituents from the subchondral layer to the cartilage defect site for a more effective repair of the area. Assessment of the in vivo performance of the implant was conducted in an ovine model (n = 13). In addition to a control group (no implant), one group received the implant alone (Group A), while another group was supplemented with hyaluronic acid (0.8 mL at 10 mg/mL solution; Group B). Analyses performed on specimens from the in vivo study revealed that the implant achieves cartilage formation within 6 months. No adverse tissue reactions or other complications were reported. Our findings indicate that the porous biocompatible implant seems to be a promising treatment option for the cartilage repair.
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http://dx.doi.org/10.1177/2041731417697500DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5496685PMC
April 2017

A comparison of the effects of platelet-rich plasma and demineralized bone matrix on critical bone defects: An experimental study on rats.

Ulus Travma Acil Cerrahi Derg 2017 Mar;23(2):91-99

Department of Orthopedics and Traumatology, Hacettepe University Faculty of Medicine, Ankara-Turkey.

Background: Delayed union of fractured bone is one of the main problems of orthopedics and traumatology practice. It was hypothesized that the beneficial effects of allogeneic platelet-rich plasma (PRP) would be valuable in the treatment of segmental bone defects. This study is a comparison of the effects of demineralized bone matrix (DBM) and PRP in a segmental bone defect model.

Methods: Total of 48 Wistar albino rats were separated into 4 groups. Segmental bone defect was created at right radius diaphysis in all specimens using dorsal approach. Four additional rats were used as PRP source. Intracardiac blood was withdrawn before the operation for preparation of allogeneic PRP. Group 1 (n=12) served as control group and defects were left untreated. Group 2 (n=12), was PRP group, and received grafting with PRP. Group 3 (n=12) was PRP+DBM combination group, and was treated with grafting and mixture of DBM and PRP. In Group 4 (n=12), defect area was grafted with DBM only. At the end of 10th week, rats were sacrificed, forearms were dissected, and defect areas were examined with radiological and histopathological parameters.

Results: Radiological evaluation revealed that ossification was best in PRP group, followed by DBM group. According to results of histopathological studies, union quality was better than control group in all treatment groups (Groups 2, 3, and 4), and was best in PRP group (p<0.05). Results were also better in PRP group when examined in terms of cortex development and remodeling (p<0.05). When examined in terms of new osteogenesis, results were comparable in Groups 2, 3, and 4, but all were better than control group.

Conclusion: It was concluded that PRP and DBM have comparable effect on recovery of defective bones, but there is no synergistic effect when used together. We believe that PRP can be a cost-effective, readily available alternative to DBM with minimal morbidity.
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http://dx.doi.org/10.5505/tjtes.2016.68249DOI Listing
March 2017

Meloxicam and diclofenac do not change VEGF and PDGF-ABserum levels of platelet-rich plasma.

Turk J Med Sci 2017 Apr 18;47(2):570-576. Epub 2017 Apr 18.

Department of Orthopedics and Traumatology, Faculty of Medicine, Hacettepe University, Ankara, Turkey.

Background/aim: Platelet-rich plasma (PRP) application has gained widespread interest for musculoskeletal injuries. Nonsteroidal antiinflammatory drugs are frequently used in sports medicine before and/or after PRP application. Our study seeks to determine whether serum levels of platelet-derived growth factor-AB (PDGF-AB) and vascular endothelial growth factor (VEGF) levels of PRP would be affected by nonsteroidal antiinflammatory drugs.

Materials And Methods: Two different final concentrations of diclofenac (0.5 μg mL and 2.5 μg mL), meloxicam (0.8 μg mL and 2.0 μg mL), and acetylsalicylic acid (final concentration 450 μm) were obtained in separate tubes with PRPs prepared from 20 healthy male volunteers. Medicine-free PRP was the control group. Growth factors were measured using ELISA.

Results: PDGF-AB and VEGF serum levels did not change with diclofenac, meloxicam, or acetylsalicylic acid addition. PDGF-AB and VEGF serum levels correlated with each other.

Conclusion: Diclofenac, meloxicam, and acetylsalicylic acid did not affect PDGF-AB and VEGF serum levels.
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http://dx.doi.org/10.3906/sag-1602-60DOI Listing
April 2017

Translation, cross-cultural adaptation, reliability and validity of the Turkish version of the Olerud-Molander Ankle Score (OMAS).

Acta Orthop Traumatol Turc 2017 Jan 10;51(1):60-64. Epub 2016 Dec 10.

Istanbul University Faculty of Health Sciences, Division of Physiotherapy and Rehabilitation, Istanbul, Turkey.

Objective: The aim of this study was to translate and culturally adapt the Olerud-Molander Ankle Score (OMAS) into Turkish and to assess its reliability and validity.

Methods: The Turkish version of the OMAS (OMAS-Tr) was developed after the translation and back-translation, which included the stages recommended by Beaton. The OMAS-Tr was administered to one hundred patients (49 females, 51 males; average age: 42.3 ± 17.7; range 16-81 years) with malleolar fractures. The OMAS-Tr was completed twice by each participant at 7- to 10-days intervals to assess test-retest reliability based on the interrater correlation coefficient, whereas Cronbach's alpha evaluated internal consistency. The external validity was evaluated with correlations between the Turkish version of the Foot and Ankle Ability Measure (FAAM) and the Turkish version of the SF-12 questionnaire. The distribution of floor and ceiling effects was also analyzed.

Results: The internal consistency (Cronbach's α = 0.84) and the test-retest reliability (ICC = 0.98) were excellent. The mean interval between the two tests was 8.6 ± 1.4 days. The mean and standard deviation of the first and second assessments of the OMAS-Tr were 74.1 ± 23.7 and 75.7 ± 23.9, respectively. There was a strong correlation between the OMAS-Tr and the FAAM subscales on activities of daily living and sports (r = 0.86, r = 0.83; p < 0.001, respectively). The OMAS-Tr displayed very good to good correlation with the SF-12 physical component score and the SF-12 mental component score (r = 0.72, r = 0.60, p < 0.001, respectively).

Conclusion: OMAS-Tr was a valid and reliable tool to assess ankle fracture-related problems. Nonetheless, further studies are needed to assess its responsiveness.

Level Of Evidence: Level III, diagnostic study.
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http://dx.doi.org/10.1016/j.aott.2016.06.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6197354PMC
January 2017

Prosthetic design of reverse shoulder arthroplasty contributes to scapular notching and instability.

World J Orthop 2016 Nov 18;7(11):738-745. Epub 2016 Nov 18.

Gazi Huri, Mahmut Nedim Doral, Department of Orthopaedic and Traumatology Surgery, Hacettepe University Medical School, Ankara 06100, Turkey.

Aim: To evaluate whether implant design, glenoid positioning, and other factors influenced instability and scapular notching in reverse total shoulder arthroplasty.

Methods: We retrospectively reviewed records of patients who had undergone reverse total shoulder arthroplasty by the senior author from July 2004 through October 2011 and who had at least 24 mo of follow-up. The 58 patients who met the criteria had 65 arthroplasties: 18 with a Grammont-type prosthesis (Grammont group) and 47 with a lateral-based prosthesis (lateral-design group). We compared the groups by rates of scapular notching and instability and by radiographic markers of glenoid position and tilt. We also compared glenoid sphere sizes and the number of subscapularis tendon repairs between the groups. Rates were compared using the Fisher exact test. Notching severity distribution was compared using the test of association. Significance was set at < 0.05.

Results: The Grammont group had a higher incidence of scapular notching (13 of 18; 72%) than the lateral-design group (11 of 47; 23%) ( < 0.001) and a higher incidence of instability (3 of 18; 17%) than the lateral-design group (0 of 47; 0%) ( = 0.019). Glenoid position, glenoid sphere size, and subscapularis tendon repair were not predictive of scapular notching or instability, independent of implant design. With the lateral-based prosthesis, each degree of inferior tilt of the baseplate was associated with a 7.3% reduction in the odds of developing notching (odds ratio 0.937, 95%CI: 0.894-0.983).

Conclusion: The lateral-based prosthesis was associated with less instability and notching compared with the Grammont-type prosthesis. Prosthesis design appears to be more important than glenoid positioning.
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http://dx.doi.org/10.5312/wjo.v7.i11.738DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5112343PMC
November 2016

Peritoneum and omentum are natural reservoirs for chondrocytes of osteochondral autografts: A comparative animal study.

Acta Orthop Traumatol Turc 2016 Oct 5;50(5):539-543. Epub 2016 Oct 5.

Hacettepe University, Faculty of Medicine, Department of Anatomy, Ankara, Turkey.

Objective: The purpose of this study was to investigate the effects of the omentum, peritoneum, paratenon and skeletal muscle on the proliferation of the cartilage tissue using rabbit model as an in vivo culture medium.

Methods: 6 months old forty-five New Zealand rabbits were randomized into omentum, peritoneum, muscle, and Achilles paratenon groups. Standard sized osteochondral grafts were harvested from right knees and immediately placed into the specified tissues. Control group was fresh cartilage at the end of follow-up. After five months, samples were collected and evaluated macroscopically by measuring their dimensions (vertical = D1, horizontal = D2, and depth = D3) and volumes, and histologically by counting the chondrocyte number using camera lucida method.

Results: Macroscopically, increase in mean values for D1 and D2 dimensions of specimens from paratenon and omentum compared to pretransplant dimensions was statistically significant (p < 0.05). Although, volume measurements were higher in omentum and peritoneum group compared to pretransplant dimensions, increase was not significant (p > 0.05). Histologically, mean chondrocyte count was 14.0 ± 0.6 in fresh articular cartilage. Mean chondrocyte counts were 14.4 ± 0.9 in omentum group, 15.4 ± 1.0 in peritoneum group, 9.7 ± 1.3 in muscle group and 9.2 ± 0.4 in Achilles paratenon group respectively. However, mean chondrocyte counts were higher in samples of omentum and peritoneum group compared to fresh articular cartilage, increase was not statistically significant (p > 0.05).

Discussion: Transplantation of the cartilage grafts into mesothelium enhanced the chondrocyte counts and volumes compared with the pretransplant measurements. Mesothelium may have the potential to be used as an in vivo culture medium for osteochondral tissue growth.
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http://dx.doi.org/10.1016/j.aott.2016.08.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6197382PMC
October 2016

Effects of immobilization and whole-body vibration on rat serum Type I collagen turnover.

Acta Orthop Traumatol Turc 2016 Aug 29;50(4):452-7. Epub 2016 Jul 29.

Hacettepe University, Dept. of Sports Medicine, Ankara, Turkey; Hacettepe University, Faculty of Sport Sciences, Ankara, Turkey.

Objective: The aim of this study was to investigate the effects of short-term, high-magnitude whole-body vibration (WBV) on serum type I collagen turnover in immobilized rats.

Materials And Methods: Thirty Wistar albino rats were randomly divided into the following 5 groups: immobilization (IS), immobilization + remobilization (IR), immobilization + WBV (IV), control (C), and WBV control (CV). Immobilization was achieved by casting from the crista iliaca anterior superior to the lower part of the foot for 2 weeks. The applied WBV protocol involved a frequency of 45 Hz and amplitude of 3 mm for 7 days starting a day after the end of the immobilization period. Serum type I collagen turnover markers were measured by using ELISA kits.

Results: Serum NH2-terminal propeptide of type I collagen (PINP) levels were significantly lower in the immobilization groups (p < 0.02) compared with the control groups. Although WBV improved PINP levels in the control groups, there were no differences in PINP levels among the immobilization groups. Similarly, serum COOH-terminal telopeptide of type I collagen (CTX) levels were higher in the WBV controls than their own controls (p < 0,05). Immobilization led to deterioration of tendon tissue, as observed by histopathological analysis with a transmission electron microscope.

Conclusion: Although 1 week of WBV had a positive effect on type I collagen turnover in controls, it is not an efficient method for repairing tissue damage in the early stage following immobilization.
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http://dx.doi.org/10.1016/j.aott.2016.07.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6197172PMC
August 2016

Correlation between quadriceps to hamstring ratio and functional outcomes in patellofemoral pain.

Knee 2016 Aug 13;23(4):610-5. Epub 2016 May 13.

Department of Orhopaedics and Traumatology, Faculty of Medicine, Hacettepe University, 06100 Ankara, Turkey.

Background: The aim of this study was to investigate the correlation between quadriceps to hamstring (Q:H) ratio and the functional outcomes in Patellofemoral Pain (PFP) patients.

Methods: The study included forty-four women diagnosed with unilateral PFP. Eccentric and concentric quadriceps and hamstring strength were recorded. Conventional Q:H ratio was calculated as the concentric quadriceps to concentric hamstring peak torque (Ratio 1). Functional ratios were calculated as the eccentric quadriceps to concentric hamstring peak torque (Ratio 2) and as the concentric quadriceps to eccentric hamstring torque (Ratio 3). Functional levels of the patients were determined by using Kujala scores, hop test and step test. Pain levels during activities were recorded. The relationship among Ratio 1, Ratio 2 and Ratio 3 with functional outcomes and pain levels were evaluated using Spearman's correlation coefficient test.

Results: Eccentric and concentric quadriceps and hamstring strength were lower on involved side than uninvolved side. Ratio 2 correlated stronger with Kujala score (r=0.69) than Ratio 1 (r=0.49) and Ratio 3 (r=0.30). Step test (r=0.35) and hop test (r=0.38) only correlated with Ratio 2. Pain levels correlated more with Ratio 2 (r values ranged between 0.38 and 0.48).

Conclusion: Eccentric quadriceps to concentric hamstring ratio was observed more related to the functional outcomes and painful activities in patients with PFP.

Level Of Evidence Iii: Cross-sectional study.
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http://dx.doi.org/10.1016/j.knee.2016.04.004DOI Listing
August 2016

Scintigraphic evaluation of the osteoblastic activity of rabbit tibial defects after HYAFF11 membrane application.

J Orthop Surg Res 2016 May 3;11(1):57. Epub 2016 May 3.

Department of Orthopaedics and Traumatology, Yalvaç State Hospital, Isparta, Turkey.

Background: An unfavorable condition for bone healing is the presence of bone defects. Under such conditions, a material can play a role to cover fractured or defective bone. Technological advances now allow for the use of such material. Hyalonect(®) (Fidia Advanced Biopolymers SLR, Italy), a novel membrane comprising knitted fibers of esterified hyaluronan (HYAFF11) can be used to cover fractured or grafted bone and can also serve as a scaffold to keep osteoprogenitor cells in place. The aim of this study was to compare osteoblastic activity by the use of scintigraphic methods in defective rabbit tibias during early-phase bone healing with or without a hyaluronan-based mesh.

Methods: Two groups (A and B) of New Zealand albino rabbits were used; each group included 10 animals. Operations on all rabbits were performed under general anesthesia. We also resected 10-mm bone segments from each animal's tibial diaphysis. After resection, tibias with defects were fixed using Kirschner wires. In group A, no hyaluronan-based mesh was used. In group B, tibial segmental defects were enclosed with a hyaluronan-based mesh. The rabbits were followed up for 4 weeks postoperatively, after which bone scintigraphic studies were performed on each animal to detect and compare osteoblastic activity.

Results: The mean count in the fracture side of the hyaluronan-based mesh group was significantly higher compared to that of the group A (p = 0.019). However, there was no significant difference between group B and control rabbits with respect to the mean count on the intact bone side (p = 0.437). The bone defect (fracture)/intact bone mean count ratio was significantly higher in group B compared to group A (p = 0.008).

Conclusions: A hyaluronan-based mesh plays a role in promoting osteoblastic activity. Hyalonect(®) is suitable for restoring tissue continuity whenever the periosteal membrane is structurally impaired or inadequate. Our results demonstrated that, during early-phase bone healing, osteoblastic activity was increased in bone defect sites when a hyaluronan-based mesh was also used. The most important aspect of this study concerns its scintigraphy-based design. This study is the first to use a scintigraphic method to demonstrate the effectiveness of hyaluronic acid-based material for bone healing.
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http://dx.doi.org/10.1186/s13018-016-0393-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4855359PMC
May 2016

Double layer repair of tibialis anterior muscle hernia in a soccer player: a case report and review of the literature.

Muscles Ligaments Tendons J 2015 Oct-Dec;5(4):331-4. Epub 2016 Feb 13.

Department of Sports Medicine, Hacettepe University, Ankara, Turkey.

Background: muscle herniations usually present in athletes especially in the lower legs; occurring through defects in the deep fascial layer of the muscles and typically seen following local blunt trauma or muscle hypertrophy after strenuous exercise. Management of muscle hernias varies from conservative therapy to surgical repair and usually needs multidisciplinary collaboration for differential diagnosis.

Methods: herein tibialis anterior muscle hernia in 17-year-old male soccer player was presented. The diagnosis was confirmed with dynamic ultrasonographic views changing with the different movements of the ankle. Since the symptoms were not relieved with conservative methods, surgical repair of the defect was offered.

Results: we preferred to repair fascial defect with double layer and Mesh graft that were placed over primary suture repair. No complications were reported such as wound or mesh infection postoperatively. The patient was clinically satisfied and returned his previous activity level after 3 months of surgery. After 2 years of follow-up the feature of the bulge was dissolved and player was satisfied with the operation.

Conclusion: knowledge of the lower extremity muscle herniation is essential for both proper management and/or surgical referral. The importance of protective devices in prevention, dynamic ultrasonography in diagnosis and double layer repair of the fascial defect with Mesh graft in treatment of muscle herniations were highlighted.
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http://dx.doi.org/10.11138/mltj/2015.5.4.331DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4762648PMC
March 2016

Focal anatomic resurfacing implantation for bilateral humeral and femoral heads' avascular necrosis in a patient with Hodgkin's lymphoma and literature review.

Int J Surg Case Rep 2015 25;17:128-32. Epub 2015 Nov 25.

Cleveland Clinic Sports Health Center, 5555 Transportation Blvd, Garfield Heights, OH 44125, USA. Electronic address:

Introduction: The femoral and humeral heads are among the most common sites of osteonecrosis. The aims of this case report was to report three years' results for sequential treatment of bilateral, concomitant involvement of humeral and femoral heads with focal anatomic resurfacing implantation in a single patient with Hodgkin's lymphoma and to review the relevant literature, which is relatively scarce.

Presentation Of Case: We present a 48-year-old male patient with concomitant, bilateral femoral and humeral head avascular necrosis. He was diagnosed as Hodgkin's lymphoma in 1984. He had bilateral groin and shoulder pain, lasting for three years and aggravated by joint motions. Radiological evaluations demonstrated bilateral focal osteonecrosis of femoral heads and humeral heads, respectively. Despite conservative treatment, he did not obtain any symptomatic relief. Following the common decision, he was treated with sequential implantations with the HemiCAP(®) device for both bilateral pathologies, by a single surgeon and standard surgical approaches. Neither intraoperative nor postoperative complication was encountered. After the follow-up period of 36 months after the last surgery, he was symptomless and with normal range of motion for all four joints.

Discussion: The bilateral, concomitant involvement of humeral and femoral head in the setting of avascular necrosis is relatively rare. Moreover, the optimal treatment method at earlier stages, in young patients has not been established yet.

Conclusion: This study is the first report to present the three-years' clinical result of a single, relevant case, who was treated with sequential focal anatomic resurfacing implantations (HemiCAP(®)) in four aforementioned joints.
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http://dx.doi.org/10.1016/j.ijscr.2015.10.034DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4701814PMC
January 2016

Effects of boric acid on the healing of Achilles tendons of rats.

Knee Surg Sports Traumatol Arthrosc 2016 Dec 1;24(12):3738-3744. Epub 2015 May 1.

Department of Orthopaedics and Traumatology, Medical School, Hacettepe University, Ankara, Turkey.

Purpose: Tendinous lesions are among the most frequent pathologies encountered in sportsmen. The objectives of new treatments are to improve the healing process and reduce the recovery time. Boron plays an important role in the wound repair process by increasing components of extracellular matrix and angiogenesis. This animal study aimed to investigate the effect of boric acid on healing of the Achilles tendon.

Methods: The right Achilles tendons of 40 rats were completely sectioned, and the rats were randomly divided into five groups. Each group consisted of eight rats. Groups 1 and 2 were oral boric acid groups with the doses of 4 and 8 mg/kg/day boric acid, respectively. Group 3 was the local boric acid group (8 mg/kg boric acid intratendinous injection). Group 4 was administered both oral and local boric acid (8 mg/kg/day orally and 8 mg/kg boric acid intratendinous injection), and group 5 was the control group with no boric acid application. At the end of the fourth week, all the rats were killed and histopathological examination of the Achilles tendon repair site was made.

Results: Histopathological examination of the tissue sections revealed more properly oriented collagen fibres, more normal cellular distribution of tenocytes and more properly organized vascular bundles in group 1 and group 2, which were the groups administered oral boric acid. Pathological sum scores of groups 1 and 2 were less than those of the other groups, and the differences between the oral boric acid groups (group 1 and group 2) and the other three groups (groups 3, 4 and 5) were statistically significant (p = 0.001).

Conclusion: As boric acid is safe and toxicity even after very high doses is unusual, oral boric acid may be used as an agent to improve the healing process of tendon injuries. However, biomechanical tests should also be performed to show the effect of boric acid on strength and endurance of the tendon before it can be used in clinical practice.
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http://dx.doi.org/10.1007/s00167-015-3617-5DOI Listing
December 2016

Treatment of osteonecrosis of the femoral head with focal anatomic-resurfacing implantation (HemiCAP): preliminary results of an alternative option.

J Orthop Surg Res 2015 Apr 28;10:56. Epub 2015 Apr 28.

Cleveland Clinic Sports Health Center, 5555 Transportation Blvd, Garfield Heights, Ohio, 44125, USA.

Background: The optimal treatment of osteonecrosis of the femoral head has not been established yet. The aim of this study was to report preliminary clinical results of focal anatomic-resurfacing implantation for the treatment of osteonecrosis of the femoral head.

Methods: Five patients (four male, one female) with seven surgical procedures, ages between 37 and 52 with an average age of 45.2 (+/- 7.2), diagnosed as femoral head avascular necrosis and who were unresponsive to conservative management or had failed previous surgical treatments were treated with a focal anatomic femoral head resurfacing between the years 2011-2012 and were retrospectively reviewed. Five patients with at least two years of follow-up, one left hip, two right hips, and two patients with bilateral hip surgery were included in this review. After safe surgical dislocation of the hip, full exposure of the femoral head was established. A focal-resurfacing implant matching patient anatomy and femoral head curvature was performed accordingly. Neither intraoperative or postoperative complications nor revision ensued. Visual analogue scores and Harris Hip Scores were recorded both preoperatively and at postoperative 2 years for all seven surgeries.

Results: The mean follow-up period was 26.6 +/- 3.8 months, with a range between 24-33 months. The mean visual analogue scores were 8.9 +/- 0.9 preoperatively and 2.3 +/- 1.0 postoperatively at year two (p = 0.017). Harris Hip Scores at postoperative follow-up were found to improve significantly from good to excellent scores (86.0 +/- 7.9), compared with preoperative poor scores (26.7 +/- 11.8) (p = 0.018). The clinical improvements in visual analogue scores (VAS) and Harris Hip Scores were also found to correlate with each other (p < 0.05).

Conclusions: In the present study, the alternative technique of focal anatomic hip resurfacing with HemiCAP® yielded preliminary successful results for the treatment of osteonecrosis of the femoral head. To the best of our knowledge, this is the first case series in the literature, reporting functional clinical results with the use of a focal anatomic-resurfacing implant for the treatment of focal femoral head osteonecrosis.
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http://dx.doi.org/10.1186/s13018-015-0199-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4423414PMC
April 2015

The relationship between quadriceps strength and joint position sense, functional outcome and painful activities in patellofemoral pain syndrome.

Knee Surg Sports Traumatol Arthrosc 2016 Sep 14;24(9):2966-2972. Epub 2015 Apr 14.

Department of Orthopaedics and Traumatology, Faculty of Medicine, Hacettepe University, 06100, Ankara, Turkey.

Purpose: The aim of this study was to investigate how strongly the concentric and eccentric quadriceps strengths were correlated with the joint position sense, functional outcomes and painful activities in patients with patellofemoral pain syndrome (PFPS).

Methods: The study included forty-six women diagnosed with unilateral PFPS. Eccentric and concentric quadriceps strengths were recorded at 60 and 180°/s. Active knee joint position sense (JPS) was measured at 20° and 60° of flexion. Functional levels were determined by using Kujala patellofemoral scores. Pain levels during stair descending and ascending, squatting and prolonged sitting were measured using 0-10 cm visual analogue scale. The relationship of isokinetic quadriceps strength with JPS results, Kujala score and pain levels were evaluated using Spearman's correlation coefficient test.

Results: Eccentric and concentric quadriceps strengths were significantly lower on involved side than uninvolved side. JPS results were poorer on the painful knee when compared to uninvolved side. While eccentric strength correlated with both JPS target angles, concentric strength was correlated only with 20°. Both eccentric and concentric strengths were significantly correlated with Kujala scores and pain levels.

Conclusion: Quadriceps eccentric strength was correlated more to joint position sense than concentric strength. Both eccentric and concentric quadriceps strength related to pain and functional level in PFPS patients.
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http://dx.doi.org/10.1007/s00167-015-3599-3DOI Listing
September 2016

Surgical treatment of Achilles tendon ruptures: the comparison of open and percutaneous methods in a rabbit model.

Ulus Travma Acil Cerrahi Derg 2014 Sep;20(5):311-8

Department of Sports Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey.

Background: This study was intended to investigate the healing properties of open and percutaneous techniques in a rabbit model and compare histological, electron microscopical, and biomechanical findings of the healed tendon between the groups.

Methods: Twenty-six rabbits were randomly assigned to two groups of thirteen rabbits each. Percutaneous tenotomy of the Achilles tendon (AT) was applied through a stab incision on the right side 1.5 cm above the calcaneal insertion in all animals. Using the same Bunnell suture, the first group was repaired with the open and the second group was repaired with the percutaneous method. ATs were harvested at the end of eight weeks for biomechanical and histological evaluation.

Results: When the sections were evaluated for fibrillar density under electron microscopy, it was noted that fibrils were more abundant in the percutaneous repair group. The tendon scores in the percutaneous group were less than the open group indicating closer histological morphology to normal. The difference was not significant (p=0.065). The mean force to rupture the tendon was 143.7± 9.5 N in percutaneous group and 139.2±8.2 N in the open group. The difference was not significant (p=0.33).

Conclusion: Percutaneous techniques provide as good clinical results as the open techniques do. The healing tendon shows better findings in histological and electron microscopical level with percutaneous technique.
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http://dx.doi.org/10.5505/tjtes.2014.42716DOI Listing
September 2014

A Unique Rectus Femoris Injury in an Adolescent Professional Soccer Player: A Case Report.

JBJS Case Connect 2014 Oct/Dec/Nov;4(4):e115

Department of Sport Medicine (D.K.) and Department of Orthopaedics and Traumatology (M.N.D.), Hacettepe University, Hacettepe Street, 06230 Ankara. Turkey.

Case: A sixteen-year-old professional soccer player presented with persistent pain in the right thigh of two years' duration and the inability to return to play. Evaluation revealed a chronic rupture of the rectus femoris muscle. Because physiotherapy and rehabilitation failed to help, a surgical repair was performed. He returned to his previous activity level within nine months after surgery.

Conclusion: Rupture of the proximal part of the rectus femoris should be acknowledged in the differential diagnosis, especially when presenting with persistent pain in the anterior aspect of the thigh lasting more than one year. Delayed repair might be recognized as a reasonable option for chronic rupture of the proximal part of the rectus femoris.
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http://dx.doi.org/10.2106/JBJS.CC.M.00290DOI Listing
December 2017

Anterior cruciate ligament reconstruction using a hamstring graft: a retrospective comparison of tunnel widening upon use of two different femoral fixation methods.

Knee Surg Sports Traumatol Arthrosc 2015 Aug 13;23(8):2283-2291. Epub 2014 May 13.

Department of Orthopaedics and Traumatology, Hacettepe University, Ankara, Turkey.

Purpose: To compare femoral and tibial tunnel widening (TW) in patients undergoing anterior cruciate ligament (ACL) reconstruction using an interference screw (IS), or an EndoButton-Continuous Loop(®) on the femoral side, and an IS/staple on the tibial side.

Methods: Between 2006 and 2009, at a single institution, 72 patients who underwent arthroscopic ACL reconstruction with quadrupled hamstring tendon grafting were retrospectively reviewed. Fixation was performed, and with the EndoButton-Continuous Loop(®) device (Group Ι) in 48 patients (mean age 29.1 ± 7.3 years) with a bioabsorbable IS (Group ΙΙ) in 24 patients (mean age 28.5 ± 8.4 years) on the femoral side. Evaluation included standardized anteroposterior (AP) and lateral radiography. The diameters of tunnels at the last follow-up visit (at a median time of 17 months postoperatively) were compared to those noted on radiographs taken 1 day postoperatively.

Results: The two groups were similar in terms of age and gender distribution, the operated side, the size of the tunnel created, and the follow-up period (n.s.). Femoral TW at the proximal and middle levels (on both AP and lateral views) in Group ΙΙ was significantly greater than in Group Ι (p < 0.050 for all comparisons). No significant difference in femoral TW at the distal level was evident between the groups, and tibial TW at all levels was similar in both groups (n.s.).

Conclusion: Femoral TW is less after EndoButton-Continuous Loop(®) fixation and not reduced after IS fixation. Surgeons should be aware of TW when selecting a fixation device for hamstring graft.

Level Of Evidence: Therapeutic, retrospective comparative study, Level III.
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http://dx.doi.org/10.1007/s00167-014-3034-1DOI Listing
August 2015

Semitendinosus snapping: analysis of movement, electromyographic activities, muscle strength and endurance, motor control and joint position sense.

Muscles Ligaments Tendons J 2013 Jul 11;3(3):166-72. Epub 2013 Aug 11.

Orthopaedics and Traumatology Department, Faculty of Medicine, Hacettepe University, Ankara, Turkey.

A female ballet with a history of two-years of semi-tendinosus (ST) snapping was assessed. On physical examination snapping was observed during hyperextension of the knee. Neither any history of trauma nor treatment was recalled. Magnetic resonance imaging (MRI), movement analysis, onset timing of ST and Bisceps Femoris (BF), motor control, isokinetic muscle strength and endurance, joint position sense (JPS) were assessed. The MRI findings were normal. There were abnormal oscillations observed during hyperextension of the snapping knee compared to healthy side. There were no isokinetic muscle strength nor do muscle endurance differences. The motor control and JPS deficits were greater on the snapping knee than the healthy side. ST onset timing was earlier than BF on the snapping side. Snapping of the semitendinosus tendon has an adverse affect on JPS, motor control and onset timing of the knee muscles.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3838325PMC
July 2013

The biomechanical and histological effects of platelet-rich plasma on fracture healing.

Knee Surg Sports Traumatol Arthrosc 2015 May 30;23(5):1378-83. Epub 2013 Oct 30.

Department of Orthopaedics and Traumatology, Faculty of Medicine, Ordu University, Ordu, Turkey,

Purpose: Platelet-rich plasma (PRP) includes growth factors and proteins that accelerate and stimulate bone regeneration and tissue recovery. The aim of this study was to evaluate the effects of PRP on fracture healing in terms of biomechanics and histology.

Methods: Seventy female rats were included in this experimental study. They were divided into three groups: Group I (no PRP, n = 30), Group II (PRP added, n = 30) and Group III (control, n = 10). The left femurs of the rats in Groups I and II were osteotomized and fixed by K-wires. Although no additional intervention was performed on Group I rats, PRP was applied to the fracture sites of Group II rats. The remaining ten rats were used as the control group of the biomechanical test (Group III). In the fourth week, nine femurs from Group I and ten femurs from Group II, and in the ninth week, nine femurs from each group were removed, and bone recovery was assessed histologically according to Modified Lane-Sandhu histological scoring criteria. Three-point bending test was applied to femurs for biomechanical evaluation in the ninth week.

Results: Histological healing was found to be significantly higher in Group II than in Group I (p < 0.05). Furthermore, biomechanical test results showed that healing quantity and bone strength were significantly better in Group II than in Group I (p < 0.05).

Conclusion: PRP is a widely studied material in the physiology of fracture healing. The results of this study demonstrated the ameliorative biomechanical effects of PRP on fracture healing, in addition to accelerating the histological union of fractures. In the light of these results, PRP could be a viable alternative to accelerate the healing of fractures, late unions or non-unions.

Level Of Evidence: Prospective comparative study, Level II.
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http://dx.doi.org/10.1007/s00167-013-2734-2DOI Listing
May 2015

Rehabilitation after endoscopically percutaneous intramuscular splintage for vastus medialis partial rupture - A case report and review of the literature.

Muscles Ligaments Tendons J 2012 Oct 21;2(4):302-4. Epub 2013 Jan 21.

Hacettepe University, Faculty of Medicine, Department of Sports Medicine, Sihhiye Ankara, Turkey.

Isolated rupture of the vastus medialis muscle is rare, and surgical repair is recommended. The results of rehabilitation programme after the percutaneous intramuscular splintage of a nearly total vastus medialis muscle tear in a 52-year professional-master degree weight-lifter is presented in this report.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3666532PMC
October 2012