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BACKGROUND: Many formulations and dosing regimens are available for hyaluronic acid (HA). OBJECTIVE: To compare different doses of linear, high-molecular weight (HMW) HA injections among patients with knee osteoarthritis (OA). METHODS: Hundred patients were included in this randomized, single-blinded trial and randomly divided into three HA injection groups. The first group received five weekly 20 mg HA injections, the second group received three weekly 32 mg HA injections, and the third group received a single 48 mg HA injection. Patients were evaluated at baseline, 1, 3, and 6 months after the last injection for pain, stiffness, and function using the visual analog scale (VAS) and the Western Ontario and McMaster Universities Arthritis Index (WOMAC) questionnaire. Quality of life, patient's global assessment, and Timed Up and Go (TUG) test scores were also evaluated. RESULTS: There was significant improvement in the WOMAC, VAS-pain, quality of life, patient's global assessment, and TUG test mean scores at all follow-up time points (p< 0.001). However, the groups showed no significant differences in WOMAC, VAS-activity pain, and patient global scores at any follow-up point. CONCLUSION: Intra-articular injections of different doses of linear HMW HA can improve pain, stiffness, function, and quality of life in patients suffering from knee OA over a six-month period.

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BACKGROUND: The relationship between vitamin D and cognitive status remains controversial. We aimed to evaluate the effect of vitamin D replacement on cognitive functions in healthy and cognitively intact vitamin D deficient older females. METHODS: This study was designed as a prospective interventional study. A total of 30 female adults aged ≥60 with a serum 25 (OH) vitamin D level of <10 ng/ml were included. Participants were administered 50 000 IU vitamin D3 weekly for 8 weeks followed by a maintenance therapy of 1000 U/day. Detailed neuropsychological assessment was performed prior to vitamin D replacement and repeated at 6 months by the same psychologist. RESULTS: Mean age was 63 ± 6.7 years and baseline vitamin D level was 7.8 ± 2.0 (range: 3.5-10.3) ng/ml. At 6 months, vitamin D level was 32.5 ± 3.4 (32.2-55) ng/ml. The Judgement of Line Orientation Test (P = 0.04), inaccurate word memorizing of the Verbal Memory Processes Test (P = 0.02), perseveration scores of the Verbal Memory Processes Test (P = 0.005), topographical accuracy of the Warrington Recognition Memory Test (P = 0.002), and the spontaneous self-correction of an error in the Boston Naming Test (P = 0.003) scores increased significantly, while the delayed recall score in the Verbal Memory Processes Test (P = 0.03), incorrect naming of words in the Boston Naming Test (P = 0.04), interference time of the Stroop Test (P = 0.05), and spontaneous corrections of the Stroop Test (P = 0.02) scores decreased significantly from baseline. CONCLUSION: Vitamin D replacement has a positive effect on cognitive domains related to visuospatial, executive, and memory processing functions.

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BACKGROUND: Cervical radiculopathy is characterized by pain, numbness, tingling, and weakness, mostly in an affected extremity, reflecting compression of a nerve in the neck is compressed or irritated where it emerges from the spinal cord. Diagnosis requires a detailed anamnesis, physical examination, and imaging. Physical therapy, exercise, medical therapy, and injections are the preferred treatments, but injections into the cervical region are only indicated if conservative treatment is ineffective. OBJECTIVE: This study explored the utility of selective cervical nerve root blocks (SNRBs) performed at various levels under ultrasound guidance (USG). METHODS: We evaluated patients diagnosed with cervical radiculopathy via physical examination and magnetic resonance imaging from November 2019 to March 2020. We included those who did not respond to conservative treatment and therefore received SNRBs at various levels. Sixty-three patients were evaluated over 6 months in terms of pain, functional status, and complications. RESULTS: We retrospectively evaluated patients with cervical herniated discs who received SNRBs at various levels between C4-7 under USG. Pain and functional status improved in month 1 and was maintained until at least month 6. CONCLUSION: SNRB injections performed under USG effectively treated pain and poor functional status in selected patients. The procedure is safe (especially) for patients who do not respond to conservative treatment.

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BACKGROUND: Low back pain affects 80% of people worldwide at least once in a lifetime and reduces the quality of life and causes absence from work. OBJECTIVE: To evaluate the pain and functional status of patients with lumbar disc disease who received blind caudal epidural injections (CEI) for pain relief. METHODS: The records of 107 patients who had been given CEI between September 2017 and January 2018 were retrospectively analyzed. The inclusion criteria were age > 18 years, > 3-month history of low back pain, and diagnosis of lumbar disc disease by magnetic resonance imaging. The epidural injection solution consisted of 2 mL of betamethasone sodium and 8 mL saline. Follow-up examinations were conducted 3 and 6 months post-injection and the patients were evaluated using a visual analog scale (VAS) and the Oswestry Disability Index (ODI). RESULTS: The most common disc pathology was at the L4-L5 level. The VAS and ODI scores indicated significantly reduced pain at 3 and 6 months compared with the pre-injection baseline. Two patients experienced total anesthesia and paresis of the lower limbs, but recovered fully after 2 weeks. Blood was aspirated during the injection in two patients, but second-attempt injections were successful in both cases. No other complications were observed. CONCLUSION: Our results suggest that the blind method is safe for administering CEI to patients with chronic low back pain in the absence of radiological screening and results in significant pain relief with improved functional capacity.

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INTRODUCTION/OBJECTIVES: Intra-articular injections may be useful in terms of pain and functional status, in knee osteoarthritis (OA). Besides hyaluronic acid (HA) and platelet-rich plasma (PRP), peptide molecules recently begin to be used. The aim of this study was to compare the efficacy of intra-articular peptide Prostrolane® (CAREGEN Co. Ltd.) injection with that of the HA and PRP in the persons with OA. METHOD: Fifty-four patients with OA were included in this prospective, randomized study. Patients were randomized into three groups as intra-articular HA, peptide, and PRP groups. Paracetamol was permitted three times a day to all groups. All the patients were evaluated by the Western Ontario and McMaster Universities Arthritis Index (WOMAC), Health Assessment Questionnaire (HAQ), and visual analogue scale (VAS) at rest and during movements. Measurements performed at the baseline, after the first week of injection, and at the first and third months of follow-up. RESULTS: Mean age was 55.8 ± 8.9 years. Forty-four (81.6%) were women. A week after the injections, rest and movement pain severity was measured by VAS decreased significantly in all the study groups (p < 0.05). There were no statistically significant differences between the groups in terms of first week pain relief (p > 0.05). WOMAC pain, stiffness, function, and total scores were improved significantly in all the groups a week after the injections (p < 0.05). Improvement continued at the third month control; however, the improvement in the WOMAC pain score was significantly better in the peptide group at the third month control (p < 0.05). The decrease in the rest and movement pain was continued for 3 months except the HA group's rest pain. There were no differences among the groups for all measurements, except for the WOMAC pain score at 3 months after treatment, which was significantly lower in the peptide group. CONCLUSION: As a result, pain relief and functional improvement were obtained after the intra-articular HA, peptide, and PRP injections in OA, and decrease in pain was better in the peptide group. Key Points • The short-term effects of intra-articular HA, peptide, and PRP injections were compared in knee osteoarthritis. • HA, peptide, and PRP injections may be useful in pain relief and functional improvement in knee osteoarthritis.

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BACKGROUND: We hypothesized that cervical radiculopathy (CR) has a role in subacromial impingement syndrome (SAIS) etiology, which cannot be directly connected to anatomical causes. OBJECTIVE: We aimed to investigate the presence of cervical radiculopathy in patients with SAIS diagnosed clinically and radiologically. METHODS: Patients who had a clinical and radiological SAIS diagnosis between 2014 and 2016 were included in the study. Patients with secondary causes that led to SAIS were excluded. Cervical MRI of all patients with SAIS was examined for cervical radiculopathy. RESULTS: A significant (p< 0.05) relationship was found between SIAS and the presence of root compression on the same side. 35% of the patients with SIAS had root compression on the same side. CONCLUSIONS: Cervical radiculopathy and shoulder impingement syndrome can be easily confused due to the similarity of the symptoms and the anatomical proximity of the lesions. Although both diseases can occur with different mechanisms, we believe that there is a cause and effect relationship between them.

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INTRODUCTION: Comparison was made of the clinical and radiological results of the surgical treatments of proximal femoral nail (PFN), dynamic hip screw (DHS) or proximal femoral locking compression plate (PF-LCP) in patients with AO 31A2.2/2.3 unstable intertrochanteric femoral fracture(ITF). METHODS: Evaluation was made of a total of 91 patients in respect of age, gender, time from fracture to surgery, operating time, amount of blood replacement, total hospitalisation, follow-up period, time to full weight-bearing, time to union, complications and Harris hip scores(HHS). RESULTS: A statistically significant difference was determined between the groups in respect of perioperative operating time, blood replacement and hospitalisation period with the values of the PFN group seen to be superior to those of the other two groups (p < 0.001). No significant difference was determined beween the DHS and PFN groups in respect of time to union and in the long-term HHS, both groups were seen to be superior to the PF-LCP group (p < 0.001). Full weight-bearing was statistically significantly earlier in the PFN group (p < 0.001). The numbers of implant failures was statistically significantly higher in the PF-LCP group (p < 0.001). CONCLUSION: The new generation intra-medullar nails are easy to apply and have more successful clinical results compared to extra-medullar implants in the treatment of A2 unstable ITF. Due to the high rates of implant failure, PF-LCP should not be preferred in these fractures.

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BACKGROUND: Osteoarthritis (OA) is a chronic disease most often occurring in knee joints, leading to pain of varying severity and deterioration in daily living activities. OBJECTIVE: To compare efficacy of platelet-rich-plasma (PRP) versus PRP in combination with ozone gas injection in patients with early stage knee OA. METHODS: Retrospective data of patients who received PRP alone (n= 45) or combined treatment (PRP + ozone, n= 35) injection was analyzed. Patients were evaluated using the visual analogue scale (VAS) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores. RESULTS: In both PRP alone and combined treatment groups, post-treatment VAS and WOMAC scores at month 1, month 3, and month 6 showed a significant reduction compared to pre-treatment scores (p< 0.001). Physical function and total WOMAC scores as well as VAS scores at post-treatment month 3 were significantly lower in the combined treatment group compared to the PRP alone group. Moreover, in the combined treatment group, VAS scores on Day 10 and hyper-inflammation at the injection site was significantly lower than the PRP alone group. CONCLUSION: In general, similar efficacy was observed between treatment with PRP alone and treatment with PRP in combination with ozone. However, patients receiving ozone treatment are less likely to experience post-injection pain and are more likely to recover faster when compared to patients receiving PRP treatment alone.

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Objective: The aim of this study is to compare the effectiveness of dry needling therapy combined with exercise and exercise treatment alone for alleviating the dizziness caused by cervical myofascial pain syndrome. Design: This was a prospective randomized clinical study that included 61 women who had dizziness and myofascial trigger points on the neck muscles. The patients were randomized into a dry needling + exercise group (N = 31) and an exercise only group (N = 30). Results: The mean age of the patients (±SD) was 38.4 ± 8.3 years. The intragroup comparisons of the severity of neck pain, algometric measurement, number of dizziness attacks per week, severity of the dizziness, fall index, and the Dizziness Handicap Inventory were improved in both groups at the first and fourth months (P < 0.05). The intergroup comparisons of the severity of neck pain, algometric measurement, number of dizziness attacks per week, the severity of the dizziness, and the Dizziness Handicap Inventory were more improved in the dry needling + exercise group at the first or fourth month compared with their inital assessments (P < 0.05). There was no diffence in fall index scores between the groups (P > 0.05). Conclusions: Both dry needling + exercise therapy and exercise therapy alone were effective in treating dizziness caused by cervical myofascial pain syndrome. However, dry needling + exercise treatment was superior to exercise treatment alone.

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[Purpose] The purpose of this study was to evaluate the efficacy of subcutaneous injection with lidocaine in patients with chronic venous insufficiency in the early stage. [Subjects and Methods] Patients (n=50) randomized to the treatment group received subcutaneous injections from a mixture of physiological saline sterile solution and lidocaine once a week to both legs below the knee for 5 sessions. Patients in the treatment group were also given ankle pumping exercises and compression stockings throughout the treatment. Patients randomized to the control group (n=50) received only ankle pumping exercises and compression stockings. Patients were evaluated using the visual analog scale (VAS) for pain and Chronic Venous Disease Quality of life Questionnaire (CIVIQ-20) for quality-of-life at months 1, 3, 6, at the end of month 12, and at the end of the injection treatment for 5 sessions. [Results] CIVIQ-20 and VAS results were significantly lower in the treatment group, than in the control group at months 1, 3 and 6. However, CIVIQ-20 and VAS results were not significantly different, compared with the pre-operative period at month 12. [Conclusion] We observed that 5-week subcutaneous lidocaine injection treatment was effective in patients who do not respond to oral medical treatment or in whom surgery is not considered.

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STUDY DESIGN: Prospective comparative study. PURPOSE: To investigate the efficacy of gluteal trigger point (TP) injections with prilocaine in patients with lumbosacral radiculopathy complaining of gluteal pain. OVERVIEW OF LITERATURE: TP injections can be performed using several anesthetic agents, primarily lidocaine and prilocaine. While several studies have used lidocaine, few have used prilocaine. METHODS: A total of 65 patients who presented at the polyclinic with complaints of lower back pain with lumbar disc herniation (based on physical examination and magnetic resonance imaging) and TPs in the gluteal region were included in this prospective comparative study. Group 1 comprised 30 patients who were given TP injections, a home exercise program, and oral medications, and group 2 comprised 35 patients who were only treated with a home exercise program and oral medications. The patients' demographic data, Oswestry Disability Index (ODI) scores, and Visual Analog Scale (VAS) scores were recorded, and these data were evaluated at 1- and 3-month follow-ups. RESULTS: The ODI and VAS scores of both groups significantly decreased initially and at the follow-up examinations, but the decreases were more marked in group 1. CONCLUSIONS: We obtained better results with TP injections than only a home exercise program and oral medications in patients with radiculopathy and TPs in the gluteal region.

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[Purpose] To investigate and compare the efficacy of three hyaluronic acid formulations in patients with early-stage meniscal injuries. [Subjects and Methods] Male and female patients who were admitted to our clinic between January 2013 and December 2013, diagnosed with early-stage meniscus lesions of the knee, and given a hyaluronic acid treatment were included in this retrospective study. Patients were categorized into 3 groups according to their treatments: MONOVISC, OSTENIL PLUS, or ORTHOVISC. Scores from a Visual Analog Scale and the Western Ontario and McMaster Universities Arthritis Index were evaluated at baseline and one, three, and six months after baseline. [Results] A total of 55 patients were included in this study. Most of the patients were female (55%), and the mean age of the patients was 42.4 (± 8.1) years. Based on the pre- and post-injection data, there was significant reductions both in the Visual Analog Scale score and the Western Ontario and McMaster Universities Arthritis Index score after the injections for all groups. According to intergroup comparisons, no significant difference was observed in terms of efficacy. [Conclusion] Three hyaluronic acid formulations produced a similar efficacy in patients with meniscal injuries, and further studies are needed to evaluate long-term results.

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[Purpose] To compare two platelet-rich plasma kits with different platelet concentrations for treatment of knee osteoarthritis. [Subjects and Methods] Male and female patients with knee osteoarthritis who had confirmed diagnosis with X-ray and magnetic resonance imaging were included in this retrospective study. Eligible patients were divided into two groups: Group I, which received platelet-rich plasma kit I, and Group II, which received platelet-rich plasma kit II. Platelet concentrations of both kits were measured by manual counting. For each group, platelet-rich plasma kit was injected twice with a one-month interval between injections. The Western Ontario and McMaster Universities Osteoarthritis Index and the Visual Analog Scale were applied for clinical evaluation before the first injection and one, three and six months after the second injection. [Results] Kits I and II contained 1,000,000 and 3,000,000 platelets/µl respectively. In both groups, initial Western Ontario and McMaster Universities Osteoarthritis Index and Visual Analog Scale scores were significantly higher compared to the latter evaluations. However, no significant difference was observed between groups in terms of clinical evaluations. [Conclusion] Similar clinical results were found in groups receiving different platelet concentrations, therefore, a concentration of 1,000,000 platelet/µl is considered sufficient for pain relief and functional recovery.

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PURPOSE: This study was performed to compare the efficacy of treatment in three groups of patients with knee osteoarthritis (OA) given an intra-articular injection of platelet-rich plasma (PRP), hyaluronic acid (HA) or ozone gas. METHODS: A total of 102 patients with mild-moderate and moderate knee OA who presented at the polyclinic with at least a 1-year history of knee pain and VAS score ≥4 were randomly separated into three groups. Group 1 (PRP group) received intra-articular injection of PRP × 2 doses, Group 2 (HA group) received a single dose of HA, and Group 3 (Ozone group) received ozone × four doses. Weight-bearing anteroposterior-lateral and Merchant's radiographs of both knees were evaluated. WOMAC and VAS scores were applied to all patients on first presentation and at 1, 3, 6 and 12 months. RESULTS: At the end of the 1st month after injection, significant improvements were seen in all groups. In the 3rd month, the improvements in WOMAC and VAS scores were similar in Groups 1 and 2, while those in Group 3 were lower (p < 0.001). At the 6th month, while the clinical efficacies of PRP and HA were similar and continued, the clinical effect of ozone had disappeared (p < 0.001). At the end of the 12th month, PRP was determined to be both statistically and clinically superior to HA (p < 0.001). CONCLUSION: In the treatment of mild-moderate knee OA, PRP was more successful than HA and ozone injections, as the application alone was sufficient to provide at least 12 months of pain-free daily living activities. LEVEL OF EVIDENCE: Therapeutic study, Level I.

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BACKGROUND: Carpal tunnel syndrome (CTS) is a commonly seen peripheral nerve mononeuropathy. Corticosteroid injection within the carpal tunnel is among the conservative treatment options. The exact mechanism of action of steroids is not fully clear; decreased inflammation surrounding nerves or tendons is thought to be the main effect. Lidocaine has been shown to have anti-inflammatory effects on certain cells (monocytes, macrophages, neutrophils etc.). The aim of this study is to evaulate the efficacy of lidocaine treatment as a alternative to corticosteroid treatment in carpal tunnel syndrome. METHODS: A total of 67 carpal tunnel syndrome patients who were diagnosed with physical examination and EMG were evaluated. Twenty-nine patients received a mixture of normal saline solution and lidocaine (0.5 cc of normal saline solution and 0.5 cc of lidocaine) while 38 patients were administered betamethasone dipropionate (1 cc). Quick DASH (Disabilities of the Arm, Shoulder and Hand) and Visual Analog Scale (VAS) scores were noted in 1st, 3rd and 6th month follow-ups. RESULTS: There were no significant difference between saline solution + Lidocaine group and betamethasone dipropionate groups; initial, 1st, 3rd and 6th month VAS scores and QDASH scores (p > 0.05). CONCLUSION: Considering the potential side effects of corticosteroid, lidocaine injection is a good alternative treatment of carpal tunnel syndrome instead of corticosteroids.

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[Purpose] There are many types of hyaluronic acid preparations, but no clear data are available about which preparations is more effective. The aim of this trial was to investigate the effectiveness of different types of hyaluronic acid preparations on pain and function of inpatients with knee osteoarthritis. [Subjects and Methods] All patients were diagnosed by clinical examination and x-ray. Ostenil PLUS® was injected into 28 patients (group 1, 1.6 million daltons), and MONOVISC® (group 2, 2.5 million daltons) was injected into 46 patients. Demographic data and Western Ontario and McMaster Universities Osteoarthritis Index and Visual Analog Scale scores were used for clinical evaluation at 1, 3, and 6 months post injection. [Results] In both groups, baseline Ontario and McMaster Universities Osteoarthritis Index and Visual Analog Scale scores were higher compared with those in subsequent evaluations. Based on the pre- and post-injection data, a significant reduction in all scores was observed after the injections for in both groups. According to intergroup comparisons, there was no significant difference in any of the scores between the two groups. [Conclusion] There were no difference in Ontario and McMaster Universities Osteoarthritis Index and Visual Analog Scale scores in patients with knee osteoarthritis injected with two different hyaluronic acid structures in short-term preparations.

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The aim of this study was to investigate disability in community-dwelling individuals aged 65 years and over using the International Classification of Functioning, Disability and Health (ICF) checklist and the World Health Organization Disability Assessment Schedule II (WHODAS-II) and to compare how these two ICF-based instruments measured disability in an attempt to show the utility of the ICF checklist in a field setting to describe disability. In this population-based, cross-sectional and descriptive study, data on the ICF checklist and the WHODAS-II were collected from 200 selected participants who lived in a small town. Both the ICF checklist and the WHODAS-II identified a considerable proportion of the elderly with a disability in life areas relevant to cognition and domestic life in a similar manner, the proportions ranging from 52.5 to 68.5%. However, the proportions of those with a disability showed a statistically significant difference in the domains of the two instruments relevant to mobility, self-care, and participation in society. Although the absolute intrarater agreement for matching items of the instruments ranged from 40.5 to 87.5%, kappa statistics showed slight to moderate agreement for the original ICF qualifier and mostly moderate agreement with reduced response options. ICF qualifiers were found to discriminate between the WHODAS-II domain scores in those with no, mild-moderate and severe-complete difficulty. The disparity between the data obtained from the ICF checklist and the WHODAS-II in some domains may have resulted from differing interpretations of the items of the ICF checklist, lower reliability of some of the items, and the current feature of the qualifiers used without any adaptations. The ICF checklist has the potential to be used in a field setting, provided that some modifications are made.

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