travma 2012-5

Cilt - Volume 18 Sayı - Number 5

ISSN 1306 - 696x

Eylül - September 2012

TURKISH JOURNAL OF TRAUMA&

EMERGENCY SURGERY

www.tjtes.org

Index Medicus, Medline, EMBASE/Excerpta Medica, Science Citation Index-Expanded (SCI-E), Index Copernicus ve TÜB‹TAK-ULAKB‹M Türk Tıp Dizini’nde yer almaktadır.

Indexed in Index Medicus, Medline, EMBASE/Excerpta Medica and Science Citation Index-Expanded (SCI-E), Index Copernicus and the Turkish Medical Index of TÜB‹TAK-ULAKB‹M.

ULUSAL TRAVMA VE ACİL CERRAHİ DERGİSİTURKISH JOURNAL OF TRAUMA AND EMERGENCY SURGERY

Editör (Editor)Recep Güloğlu

Yardımcı Editörler (Associate Editors)Kaya Sarıbeyoğlu Hakan Yanar Ahmet Nuray Turhan

Geçmiş Dönem Editörleri (Former Editors)Ömer Türel Cemalettin Ertekin Korhan Taviloğlu

ULUSAL BİLİMSEL DANIŞMA KURULU (NATIONAL EDITORIAL BOARD)

Fatih Ağalar İstanbulYılmaz Akgün ÇanakkaleLevhi Akın İstanbulAlper Akınoğlu AdanaMurat Aksoy İstanbulŞeref Aktaş İstanbulAli Akyüz İstanbulÖmer Alabaz AdanaNevzat Alkan İstanbulEdit Altınlı İstanbulAcar Aren İstanbulGamze Aren İstanbulCumhur Arıcı AntalyaOktar Asoğlu İstanbulAli Atan AnkaraBülent Atilla AnkaraLevent Avtan İstanbulYunus Aydın İstanbulÖnder Aydıngöz İstanbulErşan Aygün İstanbulMois Bahar İstanbulAkın Eraslan Balcı ElazığEmre Balık İstanbulUmut Barbaros İstanbulSemih Baskan AnkaraM Murad Başar KırıkkaleMehmet Bayramiçli İstanbulAhmet Bekar BursaOrhan Bilge İstanbulMustafa Bozbuğa EdirneMehmet Can İstanbulBaşar Cander KonyaNuh Zafer Cantürk KocaeliMünacettin Ceviz ErzurumBanu Coşar İstanbulFigen Coşkun Ankaraİrfan Coşkun EdirneNahit Çakar İstanbulAdnan Çalık TrabzonFehmi Çelebi ErzurumGürhan Çelik İstanbulOğuz Çetinkale İstanbulM. Ercan Çetinus İstanbulSebahattin Çobanoğlu EdirneAhmet Çoker İzmirCemil Dalay AdanaFatih Dikici İstanbulYalım Dikmen İstanbulOsman Nuri Dilek SakaryaKemal Dolay AntalyaLevent Döşemeci AntalyaMurat Servan Döşoğlu DüzceKemal Durak BursaEngin Dursun AnkaraAtilla Elhan Ankara

Halil Özgüç BursaAhmet Özkara İstanbulMahir Özmen AnkaraVahit Özmen İstanbulVolkan Öztuna MersinNiyazi Özüçelik İstanbulSüleyman Özyalçın İstanbulEmine Özyuvacı İstanbulSalih Pekmezci İstanbulİzzet Rozanes İstanbulKazım Sarı İstanbulEsra Can Say İstanbulAli Savaş Ankaraİskender Sayek AnkaraTülay Özkan Seyhan İstanbulGürsel Remzi Soybir TekirdağYunus Söylet İstanbulErdoğan Sözüer KayseriMustafa Şahin TokatCüneyt Şar İstanbulMert Şentürk İstanbulFeridun Şirin İstanbulİbrahim Taçyıldız DiyarbakırGül Köknel Talu İstanbulErtan Tatlıcıoğlu AnkaraGonca Tekant İstanbulCihangir Tetik İstanbulMustafa Tireli ManisaAlper Toker İstanbulRıfat Tokyay İstanbulSalih Topçu KocaeliTurgut Tufan AnkaraFatih Tunca İstanbulAkif Turna İstanbulZafer Nahit Utkan KocaeliAli Uzunköy UrfaErol Erden Ünlüer İzmirÖzgür Yağmur AdanaMüslime Yalaz İstanbulSerhat Yalçın İstanbulSümer Yamaner İstanbulMustafa Yandı TrabzonNihat Yavuz İstanbulCumhur Yeğen İstanbulEbru Yeşildağ TekirdağHüseyin Yetik İstanbulCuma Yıldırım GaziantepBedrettin Yıldızeli İstanbulSezai Yılmaz MalatyaKaya Yorgancı AnkaraCoşkun Yorulmaz İstanbulTayfun Yücel İstanbul

Mehmet Eliçevik İstanbulİmdat Elmas İstanbulUfuk Emekli İstanbulHaluk Emir İstanbulYeşim Erbil İstanbulŞevval Eren DiyarbakırHayri Erkol BoluMetin Ertem İstanbulMehmet Eryılmaz AnkaraFigen Esen İstanbulTarık Esen İstanbulİrfan Esenkaya MalatyaOzlem Evren Kemer AnkaraNurperi Gazioğlu İstanbulFatih Ata Genç İstanbulAlper Gökçe TekirdağNiyazi Görmüş KonyaFeryal Gün İstanbulÖmer Günal DüzceNurullah Günay KayseriHaldun Gündoğdu AnkaraMahir Günşen AdanaEmin Gürleyik BoluHakan Güven İstanbulİbrahim İkizceli İstanbulHaluk İnce İstanbulFuat İpekçi İzmirFerda Şöhret Kahveci BursaSelin Kapan İstanbulMurat Kara AnkaraHasan Eşref Karabulut İstanbulEkrem Kaya BursaMehmet Yaşar Kaynar İstanbulMete Nur Kesim SamsunYusuf Alper Kılıç AnkaraHaluk Kiper EskişehirHikmet Koçak ErzurumM Hakan Korkmaz AnkaraGüniz Meyancı Köksal İstanbulCüneyt Köksoy Ankaraİsmail Kuran İstanbulNecmi Kurt İstanbulMehmet Kurtoğlu İstanbulNezihi Küçükarslan Ankaraİsmail Mihmanlı İstanbulMehmet Mihmanlı İstanbulKöksal Öner İstanbulDurkaya Ören ErzurumHüseyin Öz İstanbulHüseyin Özbey İstanbulFaruk Özcan İstanbulCemal Özçelik Diyarbakırİlgin Özden İstanbulMehmet Özdoğan AnkaraŞükrü Özer Konya

ULUSLARARASI BİLİMSEL DANIŞMA KURULUINTERNATIONAL EDITORIAL BOARD

Juan Asensio Miami,USA Zsolt Balogh NewCastle,Australia Ken Boffard Johannesburg,S.Africa Fausto Catena Bologna,Italy Howard Champion WashingtonDC,USA Elias Degiannis Johannesburg,S.Africa Demetrios Demetriades LosAngeles,USA Timothy Fabian Memphis,USA Rafi Gürünlüoğlu Denver,USA Clem W. Imrie Glasgow,Scotland Kenji Inaba LosAngeles,USA Rao Ivatury Richmond,USA Yoram Kluger Haifa,Israel Rifat Latifi Tucson,USA Sten Lennquist Malmö,Sweden Ari Leppaniemi Helsinki,Finland Valerie Malka Sydney,Australia Ingo Marzi Frankfurt,Germany Kenneth L. Mattox Houston,USA Carlos Mesquita Coimbra,Portugal

Ernest E Moore Denver,USA Pradeep Navsaria CapeTown,S.Africa Andrew Nicol CapeTown,S.Africa Hans J Oestern Celle,Germany Andrew Peitzman Pittsburgh,USA Basil A Pruitt SanAntonio,USA Peter Rhee Tucson,USA Pol Rommens Mainz,Germany William Schwabb Philadelphia,USA Michael Stein Petach-Tikva,Israel Spiros Stergiopoulos Athens,Greece Michael Sugrue Liverpool,Australia Otmar Trentz Zurich,Switzerland Donald Trunkey Oregon,USA Fernando Turegano Madrid,Spain Selman Uranues Graz,Austria Vilmos Vecsei Vienna,Austria George Velmahos Boston,USA Eric J Voiglio Lyon,France Mauro Zago Milan,Italy

ULUSAL TRAVMA VE ACİL CERRAHİ DERNEĞİTHE TURKISH ASSOCIATION OF TRAUMA AND EMERGENCY SURGERY

Başkan(President) RecepGüloğlu BaşkanYardımcısı(Vice President) KayaSarıbeyoğlu GenelSekreter(Secretary General) AhmetNurayTurhan Sayman(Treasurer) HakanYanar YönetimKuruluÜyeleri(Members) M.MahirÖzmen EdizAltınlı GürhanÇelik

İLETİŞİM (CORRESPONDENCE)

ULUSAL TRAVMA VE ACİL CERRAHİ DERNEĞİ YAYIN ORGANIISSUED BY THE TURKISH ASSOCIATION OF TRAUMA AND EMERGENCY SURGERY

UlusalTravmaveAcilCerrahiDerneği Tel:+90212-5886246-5886246 ŞehreminiMah.,KöprülüMehmetPaşaSok. Faks(Fax):+90212-5861804 DadaşoğluApt.,No:25/1, e-posta(e-mail):[email protected] 34104Şehremini,İstanbul Web:www.travma.org.tr

UlusalTravmaveAcilCerrahiDerneğiadına Sahibi(Owner) RecepGüloğlu YazıİşleriMüdürü(Editorial Director) RecepGüloğlu YayınKoordinatörü(Managing Editor) M.MahirÖzmen Amblem MetinErtem Yazışmaadresi(Correspondence address) UlusalTravmaveAcilCerrahiDergisiSekreterliği ŞehreminiMah.,KöprülüMehmetPaşaSok., DadaşoğluApt.,No:25/1,34104Şehremini,İstanbul Tel +90212-5311246-5886246 Faks(Fax) +90212-5861804

Abonelik:2011yılıabonebedeli(UlusalTravmaveAcilCerrahiDerneği’nebağışolarak)75.-YTL’dir.HesapNo:TürkiyeİşBankası,İstanbulTıpFakültesiŞubesi1200-3141069no’luhesabınayatırılıpmakbuzdernekadresinepostaveyafaksyoluileiletilmelidir. Annual subscription rates: 75.- (USD)

p-ISSN 1306-696x • e-ISSN 1307-7945 • Index Medicus, Medline; EMBASE, Excerpta Medica; Science Citation Index-Expanded (SCI-E), Index Copernicus ve TÜBİTAK ULAKBİM Türk Tıp Dizini’nde yer almaktadır. (Included in Index Medicus, Medline; EMBASE, Excerpta Medica; Science Citation Index-Expanded (SCI-E), Index Copernicus and Turkish Medical Index) • Yayıncı (Publisher): KARE Yayıncılık (karepublishing) • Tasarım (Design): Ali Cangül • İngilizce Editörü (Linguistic Editor): Corinne Can • İstatistik (Stat-istician): Empiar • Online Dergi & Web (Online Manuscript & Web Management): LookUs • Baskı (Press): Yıldırım Matbaacılık • Basım tarihi (Press date): Eylül (September) 2012 • Bu dergide kullanılan kağıt ISO 9706: 1994 standardına uygundur. (This publication is printed on paper that meets the international standard ISO 9706: 1994).

REDAKSİYON (REDACTION)ErmanAytaç

YAZARLARA BİLGİ

Ulusal Travma ve Acil Cerrahi Dergisi, Ulusal Travma ve Acil Cerrahi Derneği’nin yayın organıdır. Travma ve acil cerrahi hastalıklar konuların-da bilimsel birikime katkısı olan klinik ve deneysel çalışmaları, editöryel yazıları, klinik olgu sunumlarını ve bu konulardaki teknik katkılar ile son gelişmeleri yayınlar. Dergi iki ayda bir yayınlanır.Ulusal Travma ve Acil Cerrahi Dergisi, 2001 yılından itibaren Index Me-dicus ve Medline’da, 2005 yılından itibaren Excerpta Medica / EMBASE indekslerinde, 2007 yılından itibaren Science Citation Index-Expanded (SCI-E) ile Journal Citation Reports / Science Edition uluslararası in-dekslerinde ve 2008 yılından itibaren Index Copernicus indeksinde yer almaktadır. 2001-2006 yılları arasındaki 5 yıllık dönemde SCI-E kapsa-mındaki dergilerdeki İmpakt faktörümüz 0,5 olmuştur. Dergide araştırma yazılarına öncelik verilmekte, bu nedenle derleme veya olgu sunumu tü-ründeki yazılarda seçim ölçütleri daha dar tutulmaktadır. PUBMED’de dergi “Ulus Travma Acil Cerrahi Derg” kısaltması ile yer almaktadır. Dergiye yazı teslimi, çalışmanın daha önce yayınlanmadığı (özet ya da bir sunu, inceleme, ya da tezin bir parçası şeklinde yayınlanması dışın-da), başka bir yerde yayınlanmasının düşünülmediği ve Ulusal Travma ve Acil Cerrahi Dergisi’nde yayınlanmasının tüm yazarlar tarafından uy-gun bulunduğu anlamına gelmektedir. Yazar(lar), çalışmanın yayınlan-masının kabulünden başlayarak, yazıya ait her hakkı Ulusal Travma ve Acil Cerrahi Derneği’ne devretmektedir(ler). Yazar(lar), izin almaksı-zın çalışmayı başka bir dilde ya da yerde yayınlamayacaklarını kabul eder(ler). Gönderilen yazı daha önce herhangi bir toplantıda sunulmuş ise, toplantı adı, tarihi ve düzenlendiği şehir belirtilmelidir.Dergide Türkçe ve İngilizce yazılmış makaleler yayınlanabilir. Tüm yazı-lar önce editör tarafından ön değerlendirmeye alınır; daha sonra incelen-mesi için danışma kurulu üyelerine gönderilir.Tüm yazılarda editöryel değerlendirme ve düzeltmeye başvurulur; ge-rektiğinde, yazarlardan bazı soruları yanıtlanması ve eksikleri tamam-lanması istenebilir. Dergide yayınlanmasına karar verilen yazılar “ma-nuscript editing” sürecine alınır; bu aşamada tüm bilgilerin doğruluğu için ayrıntılı kontrol ve denetimden geçirilir; yayın öncesi şekline getiri-lerek yazarların kontrolüne ve onayına sunulur. Editörün, kabul edilme-yen yazıların bütününü ya da bir bölümünü (tablo, resim, vs.) iade etme zorunluluğu yoktur.Yazıların hazırlanması: Tüm yazılı metinler 12 punto büyüklükte “Times New Roman” yazı karakterinde iki satır aralıklı olarak yazılmalıdır. Sayfa-da her iki tarafta uygun miktarda boşluk bırakılmalı ve ana metindeki say-falar numaralandırılmalıdır. Journal Agent sisteminde, başvuru mektubu, başlık, yazarlar ve kurumları, iletişim adresi, Türkçe özet ve yazının İngi-lizce başlığı ve özeti ilgili aşamalarda yüklenecektir. İngilizce yazılan ça-lışmalara da Türkçe özet eklenmesi gerekmektedir. Yazının ana metnin-deyse şu sıra kullanılacaktır: Giriş, Gereç ve Yöntem, Bulgular, Tartışma, Teşekkür, Kaynaklar, Tablolar ve Şekiller.Başvuru mektubu: Bu mektupta yazının tüm yazarlar tarafından okun-duğu, onaylandığı ve orijinal bir çalışma ürünü olduğu ifade edilmeli ve yazar isimlerinin yanında imzaları bulunmalıdır. Başvuru mektubu ayrı bir dosya olarak, Journal Agent sisteminin “Yeni Makale Gönder” bölü-münde, 10. aşamada yer alan dosya yükleme aşamasında yollanmalı-dır.Başlık sayfası: Yazının başlığı, yazarların adı, soyadı ve ünvanları, ça-lışmanın yapıldığı kurumun adı ve şehri, eğer varsa çalışmayı destekle-yen fon ve kuruluşların açık adları bu sayfada yer almalıdır. Bu sayfaya ayrıca “yazışmadan sorumlu” yazarın isim, açık adres, telefon, faks, mo-bil telefon ve e-posta bilgileri eklenmelidir. Özet: Çalışmanın gereç ve yöntemini ve bulgularını tanıtıcı olmalıdır. Türkçe özet, Amaç, Gereç ve Yöntem, Bulgular, Sonuç ve Anahtar Söz-cükler başlıklarını; İngilizce özet Background, Methods, Results, Conclu-sion ve Key words başlıklarını içermelidir. İngilizce olarak hazırlanan ça-lışmalarda da Türkçe özet yer almalıdır. Özetler başlıklar hariç 190-210 sözcük olmalıdır. Tablo, şekil, grafik ve resimler: Şekillere ait numara ve açıklayıcı bil-giler ana metinde ilgili bölüme yazılmalıdır. Mikroskobik şekillerde resmi açıklayıcı bilgilere ek olarak, büyütme oranı ve kullanılan boyama tekni-ği de belirtilmelidir. Yazarlara ait olmayan, başka kaynaklarca daha önce yayınlanmış tüm resim, şekil ve tablolar için yayın hakkına sahip kişiler-

den izin alınmalı ve izin belgesi dergi editörlüğüne ayrıca açıklamasıy-la birlikte gönderilmelidir. Hastaların görüntülendiği fotoğraflara, hasta-nın ve/veya velisinin imzaladığı bir izin belgesi eşlik etmeli veya fotoğ-rafta hastanın yüzü tanınmayacak şekilde kapatılmış olmalıdır. Renkli resim ve şekillerin basımı için karar hakemler ve editöre aittir. Yazarlar renkli baskının hazırlık aşamasındaki tutarını ödemeyi kabul etmelidirler. Kaynaklar: Metin içindeki kullanım sırasına göre düzenlenmelidir. Ma-kale içinde geçen kaynak numaraları köşeli parantezle ve küçültülme-den belirtilmelidir. Kaynak listesinde yalnızca yayınlanmış ya da yayın-lanması kabul edilmiş çalışmalar yer almalıdır. Kaynak bildirme “Uniform Requirements for Manuscripts Submitted to Biomedical Journals” (http://www.icmje.org) adlı kılavuzun en son güncellenmiş şekline (Şubat 2006) uymalıdır. Dergi adları Index Medicus’a uygun şekilde kısaltılmalıdır. Altı ya da daha az sayıda olduğunda tüm yazar adları verilmeli, daha çok ya-zar durumunda altıncı yazarın arkasından “et al.” ya da “ve ark.” eklen-melidir. Kaynakların dizilme şekli ve noktalamalar aşağıdaki örneklere uygun olmalıdır:Dergi metni için örnek: Velmahos GC, Kamel E, Chan LS, Hanpeter D, Asensio JA, Murray JA, et al. Complex repair for the management of du-odenal injuries. Am Surg 1999;65:972-5.Kitaptan bölüm için örnek: Jurkovich GJ. Duodenum and pancreas. In: Mattox KL, Feliciano DV, Moore EE, editors. Trauma. 4th ed. New York: McGraw-Hill; 2000. p. 735-62.Sizlerin çalışmalarınızda kaynak olarak yararlanabilmeniz için www.trav-ma.org.tr adresli web sayfamızda eski yayınlara tam metin olarak ulaşa-bileceğiniz bir arama motoru vardır.Derleme yazıları: Bu tür makaleler editörler kurulu tarafından gerek ol-duğunda, konu hakkında birikimi olan ve bu birikimi literatüre de yansı-mış kişilerden talep edilecek ve dergi yazım kurallarına uygunluğu sap-tandıktan sonra değerlendirmeye alınacaktır. Derleme makaleleri; başlık, Türkçe özet, İngilizce başlık ve özet, alt başlıklarla bölümlendirilmiş me-tin ile kaynakları içermelidir. Tablo, şekil, grafik veya resim varsa yukarı-da belirtildiği şekilde gönderilmelidir.Olgu sunumları: Derginin her sayısında sınırlı sayıda olgu sunumu-na yer verilmektedir. Olgu bildirilerinin kabulünde, az görülürlük, eğiti-ci olma, ilginç olma önemli ölçüt değerlerdir. Ayrıca bu tür yazıların ola-bildiğince kısa hazırlanması gerekir. Olgu sunumları başlık, Türkçe özet, İngilizce başlık ve özet, olgu sunumu, tartışma ve kaynaklar bölümlerin-den oluşmalıdır. Bu tür çalışmalarda en fazla 5 yazara yer verilmesine özen gösterilmelidir.Editöre mektuplar: Editöre mektuplar basılı dergide ve PUBMED’de yer almamakta, ancak derginin web sitesinde yayınlanmaktadır. Bu mektup-lar için dergi yönetimi tarafından yayın belgesi verilmemektedir.Daha önce basılmış yazılarla ilgili görüş, katkı, eleştiriler ya da farklı bir konu üzerindeki deneyim ve düşünceler için editöre mektup yazılabilir. Bu tür yazılar 500 sözcüğü geçmemeli ve tıbbi etik kurallara uygun ola-rak kaleme alınmış olmalıdır. Mektup basılmış bir yazı hakkında ise, söz konusu yayına ait yıl, sayı, sayfa numaraları, yazı başlığı ve yazarların adları belirtilmelidir. Mektup bir konuda deneyim, düşünce hakkında ise verilen bilgiler doğrultusunda dergi kurallarına uyumlu olarak kaynaklar da belirtilmelidir. Bilgilendirerek onay alma - Etik: Deneysel çalışmaların sonuçlarını bil-diren yazılarda, çalışmanın yapıldığı gönüllü ya da hastalara uygulana-cak prosedür(lerin) özelliği tümüyle anlatıldıktan sonra, onaylarının alındı-ğını gösterir bir cümle bulunmalıdır. Yazarlar, bu tür bir çalışma söz konu-su olduğunda, uluslararası alanda kabul edilen kılavuzlara ve T.C. Sağlık Bakanlığı tarafından getirilen yönetmelik ve yazılarda belirtilen hükümle-re uyulduğunu belirtmeli ve kurumdan aldıkları Etik Komitesi onayını gön-dermelidir. Hayvanlar üzerinde yapılan çalışmalarda ağrı, acı ve rahatsız-lık verilmemesi için neler yapıldığı açık bir şekilde belirtilmelidir.Yazı gönderme - Yazıların gönderilmesi: Ulusal Travma ve Acil Cer-rahi Dergisi yalnızca www.travma.org.tr adresindeki internet sitesinden on-line olarak gönderilen yazıları kabul etmekte, posta yoluyla yollanan yazıları değerlendirmeye almamaktadır. Tüm yazılar ilgili adresteki “Onli-ne Makale Gönderme” ikonuna tıklandığında ulaşılan Journal Agent sis-teminden yollanmaktadır. Sistem her aşamada kullanıcıyı bilgilendiren özelliktedir.

INFORMATION FOR THE AUTHORS

The Turkish Journal of Trauma and Emergency Surgery (TJTES) is an official publication of the Turkish Association of Trauma and Emer-gency Surgery. It is a peer-reviewed periodical that considers for pub-lication clinical and experimental studies, case reports, technical con-tributions, and letters to the editor. Six issues are published annually.As from 2001, the journal is indexed in Index Medicus and Medline, as from 2005 in Excerpta Medica and EMBASE, as from 2007 in Science Citation Index Expanded (SCI-E) and Journal Citation Reports / Sci-ence Edition, and as from 2008 in Index Copernicus. For the five-year term of 2001-2006, our impact factor in SCI-E indexed journals is 0.5. It is cited as ‘Ulus Travma Acil Cerrahi Derg’ in PUBMED. Submission of a manuscript by electronic means implies: that the work has not been published before (except in the form of an abstract or as part of a published lecture, review, or thesis); that it is not under consideration for publication elsewhere; and that its publication in the Turkish Journal of Trauma and Emergency Surgery is approved by all co-authors. The author(s) transfer(s) the copyright to the Turkish Asso-ciation of Trauma and Emergency Surgery to be effective if and when the manuscript is accepted for publication. The author(s) guarantee(s) that the manuscript will not be published elsewhere in any other lan-guage without the consent of the Association. If the manuscript has been presented at a meeting, this should be stated together with the name of the meeting, date, and the place.Manuscripts may be submitted in Turkish or in English. All submissions are initially reviewed by the editor, and then are sent to reviewers. All manuscripts are subject to editing and, if necessary, will be returned to the authors for answered responses to outstanding questions or for ad-dition of any missing information to be added. For accuracy and clarity, a detailed manuscript editing is undertaken for all manuscripts accepted for publication. Final galley proofs are sent to the authors for approval.Unless specifically indicated otherwise at the time of submission, re-jected manuscripts will not be returned to the authors, including ac-companying materials.TJTES is indexed in Science Citation Index-Expanded (SCI-E), Index Medicus, Medline, EMBASE, Excerpta Medica, and the Turkish Medi-cal Index of TUBITAK-ULAKBIM. Priority of publications is given to original studies; therefore, selection criteria are more refined for re-views and case reports.Manuscript submission: TJTES accepts only on-line submission via the official web site (please click, www.travma.org.tr/en) and refuses printed manuscript submissions by mail. All submissions are made by the on-line submission system called Journal Agent, by clicking the icon “Online manuscript submission” at the above mentioned web site homepage. The system includes directions at each step but for fur-ther information you may visit the web site (http://www.travma.org/en/journal/).Manuscript preparation: Manuscripts should have double-line spac-ing, leaving sufficient margin on both sides. The font size (12 points) and style (Times New Roman) of the main text should be uniformly taken into account. All pages of the main text should be numbered consecutively. Cover letter, manuscript title, author names and institu-tions and correspondence address, abstract in Turkish (for Turkish au-thors only), and title and abstract in English are uploaded to the Journal Agent system in the relevant steps. The main text includes Introduc-tion, Materials and Methods, Results, Discussion, Acknowledgments, References, Tables and Figure Legends.The cover letter must contain a brief statement that the manuscript has been read and approved by all authors, that it has not been submit-ted to, or is not under consideration for publication in, another journal. It should contain the names and signatures of all authors. The cover letter is uploaded at the 10th step of the “Submit New Manuscript” sec-tion, called “Upload Your Files”.

Abstract: The abstract should be structured and serve as an informa-tive guide for the methods and results sections of the study. It must be prepared with the following subtitles: Background, Methods, Results and Conclusions. Abstracts should not exceed 200 words.Figures, illustrations and tables: All figures and tables should be numbered in the order of appearance in the text. The desired position of figures and tables should be indicated in the text. Legends should be included in the relevant part of the main text and those for photo-micrographs and slide preparations should indicate the magnification and the stain used. Color pictures and figures will be published if they are definitely required and with the understanding that the authors are prepared to bear the costs. Line drawings should be professionally pre-pared. For recognizable photographs, signed releases of the patient or of his/her legal representatives should be enclosed; otherwise, patient names or eyes must be blocked out to prevent identification.References: All references should be numbered in the order of men-tion in the text. All reference figures in the text should be given in brack-ets without changing the font size. References should only include articles that have been published or accepted for publication. Refer-ence format should conform to the “Uniform requirements for manu-scripts submitted to biomedical journals” (http://www.icmje.org) and its updated versions (February 2006). Journal titles should be abbrevi-ated according to Index Medicus. Journal references should provide inclusive page numbers. All authors, if six or fewer, should be listed; otherwise the first six should be listed, followed by “et al.” should be written. The style and punctuation of the references should follow the formats below:Journal article: Velmahos GC, Kamel E, Chan LS, Hanpeter D, Asensio JA, Murray JA, et al. Complex repair for the management of duodenal injuries. Am Surg 1999;65:972-5.Chapter in book: Jurkovich GJ. Duodenum and pancreas. In: Mattox KL, Feliciano DV, Moore EE, editors. Trauma. 4th ed. New York: Mc-Graw-Hill; 2000. p. 735-62.Our journal has succeeded in being included in several indexes, in this context, we have included a search engine in our web site (www.travma.org.tr) so that you can access full-text articles of the previous issues and cite the published articles in your studies.Review articles: Only reviews written by distinguished authors based on the editor’s invitation will be considered and evaluated. Review ar-ticles must include the title, summary, text, and references sections. Any accompanying tables, graphics, and figures should be prepared as mentioned above.Case reports: A limited number of case reports are published in each is-sue of the journal. The presented case(s) should be educative and of in-terest to the readers, and should reflect an exclusive rarity. Case reports should contain the title, summary, and the case, discussion, and refer-ences sections. These reports may consist of maximum five authors.Letters to the Editor: “Letters to the Editor” are only published elec-tronically and they do not appear in the printed version of TJTES and PUBMED. The editors do not issue an acceptance document as an original article for the ‘’letters to the editor. The letters should not ex-ceed 500 words. The letter must clearly list the title, authors, publica-tion date, issue number, and inclusive page numbers of the publication for which opinions are released.Informed consent - Ethics: Manuscripts reporting the results of ex-perimental studies on human subjects must include a statement that informed consent was obtained after the nature of the procedure(s) had been fully explained. Manuscripts describing investigations in animals must clearly indicate the steps taken to eliminate pain and suffering. Authors are advised to comply with internationally accepted guidelines, stating such compliance in their manuscripts and to include the approval by the local institutional human research committee.

ULUSAL TRAVMA VE AC‹L CERRAH‹ DERG‹S‹TURKISH JOURNAL OF TRAUMA & EMERGENCY SURGERY

C‹LT - VOL. 18 SAYI - NUMBER 5 EYLÜL - SEPTEMBER 2012

İçindekiler - Contents

Deneysel Çalışma - Experimental Study

367-375 The effect of catheter use on vein grafting of a peripheral nerve defect: an experimental study Ven grefti ile periferik sinir defektlerinin onarımında kateter kullanımının sinir rejenerasyonuna etkisi: Deneysel çalışma BayraktarAM,ÖzbekS,ÖzcanM,NoyanB,Çavuşoğluİ

376-383 Comparison of topical zinc oxide and silver sulfadiazine in burn wounds: an experimental study Yanık yarası tedavisinde topikal çinko oksit ile gümüş sülfadiazinin karşılaştırılması: Deneysel çalışma ArslanK,KarahanÖ,OkuşA,ÜnlüY,EryılmazMA,AyS,Sevinç

Klinik Çalışma - Original Articles

384-388 The value of serum fibrinogen level in the diagnosis of acute appendicitis Akut apandisit tanısında serum fibrinojen düzeyinin değeri MenteşÖ,EryılmazM,HarlakA,ÖztürkE,TufanT

389-396 Incarcerated abdominal wall hernia surgery: relationship between risk factors and morbidity and mortality rates (a single center emergency surgery experience) Boğulmuş abdominal duvar herni cerrahisi: Morbidite ve mortalite insidansının risk faktörleriyle ilişkisinin analizi (Tek merkezli acil cerrahi deneyimi) ÖzkanE,YıldızMK,ÇakırT,DulunduE,ErişC,FersahoğluMM,TopaloğluÜ

397-404 Randomized controlled trial of morphine in elderly patients with acute abdominal pain Akut karın ağrısı olan yaşlı hastalarda morfinin randomize kontrollü bir çalışması GüngörF,KartalM,BektaşF,SöyüncüS,YiğitÖ,MesciA

405-410 Treatment of acute and closed Achilles tendon ruptures by minimally invasive tenocutaneous suturing Minimal invaziv tenokutanöz dikişle akut ve kapalı Aşil tendonu yırtığının tedavisi DingW,YanW,ZhuY,LiuZ

411-416 Çocuk ve erişkin minör kafa travmalarında kan S100B ile laktatın rolü ve bilgisayarlı beyin tomografisi ile korelasyonu The role of blood S100B and lactate levels in minor head traumas in children and adults and correlation with brain computerized tomography SezerAA,AkıncıE,ÖztürkM,CoşkunF,YılmazG,KarakaşA,ToksözT

417-423 Erken fasyotominin yılan ısırıkları tedavisindeki etkinliği Effectiveness of early fasciotomy in the management of snakebites FıratC,ErbaturS,AytekinAH,KılınçH

424-428 Temporal bone fractures: evaluation of 77 patients and a management algorithm Temporal kemik kırıkları: 77 hastanın değerlendirilmesi ve bir yaklaşım algoritması YalçınerG,KutluhanA,BozdemirK,ÇetinH,TarlakB,BilgenAS

Cilt - Vol. 18 Sayı - No. 5 vii

ULUSAL TRAVMA VE AC‹L CERRAH‹ DERG‹S‹TURKISH JOURNAL OF TRAUMA & EMERGENCY SURGERY

C‹LT - VOL. 18 SAYI - NUMBER 5 EYLÜL - SEPTEMBER 2012

İçindekiler - Contents

429-435 The mid-term results of treatment for tibial pilon fractures Tibia pilon kırıklarında orta dönem cerrahi sonuçlarımız GülabiD,ToprakÖ,ŞenC,AvcıCC,BilenE,SağlamF

436-440 Early period psychiatric disorders following burn trauma and the importance of surgical factors in the etiology Yanık travması sonrası erken dönemde görülen psikolojik bozukluklar ve etyolojide cerrahi faktörlerin yeri YabanoğluH,YağmurdurMC,TaşkıntunaN,KarakayalıH

441-445 Penetran kardiyak yaralanmalar: 21 olgunun değerlendirilmesi Penetrating cardiac injuries: assessment of 21 patients DereliY,ÖzdemirR,AğruşM,ÖncelM,HoşgörK,ÖzdişAS

Olgu Sunumu - Case Reports

446-448 A rare cause of small bowel obstruction in adults: persistent omphalomesenteric duct Erişkinlerde ince bağırsak tıkanıklığının nadir bir nedeni: Persistan omfalomezenterik kanal GünerA,KeçeC,BozA,Kahramanİ,ReisE

449-452 Spontaneous migration of a retained bullet within the brain: a case report Beyin içinde kalan kurşunun kendiliğinden yer değiştirmesi: Olgu sunumu ArslanM,EseoğluM,GüdüBO,Demirİ,KozanAB

453-454 The hidden devil: unexpected retained knife in the chest wall Gizli şeytan: göğüs duvarı içinde beklenmedik biçimde kalmış bıçak ChangCC,LinHJ,FooNP,ChenKT

455-457 Bilateral simultaneous anterior obturator dislocation of the hip by an unusual mechanism - a case report Olağandışı bir mekanizmayla çift taraflı, eşzamanlı anterior obturator kalça çıkığı: Olgu sunumu SultanA,DarTA,WaniMI,WaniMM,ShafiS

458-460 Emergency surgery due to go-kart injuries: report of two consecutive cases Go-kart yaralanmalarına bağlı acil cerrahi: Ardışık iki olgunun sunumu YılmazKB,AkıncıM,KayaO,KulaçoğluH

461-462 Isolated basal ganglia hemorrhage due to blast injury Blastik yaralanmaya bağlı izole bilateral bazal ganglion kanaması AygünFM,AygünMS,ÖnalMB,DemirciOL

viii Eylül - September 2012

367

Turkish Journal of Trauma & Emergency Surgery

Experimental Study Deneysel Çalışma

Ulus Travma Acil Cerrahi Derg 2012;18 (5):367-375

The effect of catheter use on vein grafting of a peripheral nerve defect: an experimental study

Vengreftiileperiferiksinirdefektlerininonarımındakateterkullanımınınsinirrejenerasyonunaetkisi:Deneyselçalışma

Alper Mehmet BAYRAKTAR,1 Serhat ÖZBEK,2 Mesut ÖZCAN,2 Behzat NOYAN,3 İlkin ÇAVUŞOĞLU4

1Department of Plastic and Reconstructive Surgery, Çekirge State Hospital, Bursa; Departments of 2Plastic and Reconstructive Surgery, 3Physiology,

4Histology, Uludağ University Faculty of Medicine, Bursa, Turkey.

1Çekirge Devlet Hastanesi, Plastik ve Rekonstrüktif Cerrahi Kliniği, Bursa; Uludağ Üniversitesi Tıp Fakültesi, 2Plastik ve Rekonstrüktif Cerrahi

Anabilim Dalı, 3Fizyoloji Anabilim Dalı, 4Histoloji Anabilim Dalı, Bursa.

Correspondence (İletişim): Alper Mehmet Bayraktar, M.D. Çekirge Devlet Hastanesi, Osmangazi, Bursa, Turkey.Tel: +90 - 224 - 239 36 36 e-mail (e-posta): [email protected]

AMAÇSinir defektlerinin rekonstrüksiyonunda ven greftlerininkullanılması ile ilgiliçalışmalarınartmasıvebuuygula-manınkliniktekullanımagirmesiylebirlikte,vengreftininkollabeolmasorunununortayaçıktığıgörülmüştür.GEREÇ VE YÖNTEMÇalışmada40adetSpraque-Dawleysıçankullanıldı.Beşgruptan,1.grubaherhangibircerrahigirişimyapılmadı;2.grubunsiyatiksinirindeoluşturulandefektonarılmadanbırakıldı,3.gruptadefektsinirgreftiileonarıldı,4.grup-tadefektvengreftiile5.gruptaisevengreftivekataterbirliktekullanılarakonarımyapıldı.Birinciveikincigrupkontrol grubu olarak kullanıldı. Fonksiyonel iyileşmeyi,sinirrejenerasyonunudeğerlendirmekamacıyla,12.haf-tanınsonunda,yürümeanalizi,elektrofizyolojikvehisto-morfometrikanalizleryapıldı.BULGULARDefektinvengreftivekataterileonarıldığıgrup(grup5)ilegrup3ve4arasındafonksiyonelaçıdanfarkbulunmaz-ken, sinir iletim hızı açısından bakıldığında, 5. gruptakisonuçlar, ven grefti ile onarım yapılan gruptan (grup 4)daha iyibulundu.Onarımdistalindenveonarımalanınınortasındanalınansiyatiksinirkesitlerindekiaksonsayısı-nabakıldığında3.ve5.gruparasındafarkbulunamazken;4.ve5.gruparasındakifarkanlamlıydı.SONUÇBu çalışma sonucunda, ven grefti ile onarılan periferiksiniryaralanmalarındagörülebilenvengreftikollapsınınvengreftiiçinekateteryerleştirilmesiileaşılabileceğivebusayedeonarımdasinirgreftikullanmaihtiyacınınorta-dankalkabileceğideneyselolarakgösterilmiştir.Anahtar Sözcükler: Periferiksiniryaralanması;sinirhasarı;vengrefti.

BACKGROUNDSinceveingraftshavebeenusedintherepairofnervede-fects, studies regarding thisprocedurehaveaccumulated,andaftercomingintoclinicaluse,itwasnoticedthatthereisaproblemofcollapseintheveingraft.METHODSForty Sprague-Dawley rats were used, divided into fivegroups.Nosurgicalinterventionwasperformedinthefirstgroup.ThedefectwascreatedinthesciaticnerveinGroup2andleftunrepaired.InGroup3,thedefectwasrepairedwithanervegraft.InGroup4,thedefectwasrepairedwithaveingraft,whileinGroup5,therepairwasperformedus-ingaveingraftwithaninsertedcatheter.Inordertoevalu-ate functional recovery and nerve regeneration, walkingtrack analysis, electrophysiologic and histomorphometricanalysesweredoneattheendofthe12thweek.RESULTSAlthough there were no functional differences betweenGroups5and4,comparisonsregardingnerveconductionvelocitydemonstratedthattheresultsobtainedinGroup5werebetterthanthoseinGroup4.Whenthenumberofax-onsonthedistalpartofthesciaticnerveandmid-segmentoftherepairedareawastakenintoaccount,nosignificantdifference was found between Groups 3 and 5, whereastherewasasignificantdifferencebetweenGroups4and5.CONCLUSIONInourstudy,itwasexperimentallyshownthattheproblemofcollapseofaveingraftoccurringafteritsuseinthere-constructionofanervedefectcanbeovercomebyplacinga catheter into the vein graft. Consequently, thismethodmayeliminatetheneedfortheuseofanervegraftinse-lectedcases.Key Words: Peripheralnerveinjury;nervedefect;veingraft.

doi: 10.5505/tjtes.2012.59932

Ulus Travma Acil Cerrahi Derg

368 Eylül - September 2012

The repair of a peripheral nerve injury is a chal-lengingprobleminreconstructivesurgery.End-to-endrepairisthefirstalternative,ifthenerveendscanbeapproximatedwithoutunduetension.Ifthereisanervedefect,manytechnicalprocedureshavebeenreportedfor the repair. Repair with autogenous nerve grafts,vascularizednervegrafts,autogenousveingrafts,useofsynthetic tubes,andend-to-sidenervecoaptationsaretheoptions.[1-3]

If end-to-end repair isnot available, theuseof anervegraftisthegoldstandardintherepairofnervedefects.[4]Althoughnervegraftinghassuperiorresults,italsohassomedonor-sitemorbiditiesandusuallyne-cessitates preparation of a distant operation site andfurtherdissection.[5-7]

Ifveingraftisnotthechoice,orincasesofabsentproximal nerve stump, end-to-side nerve coaptationhasbeenacceptedasareliablealternativemethodinnerve repair.[8,9]Themainadvantagesof thismethodaretoeliminatetheneedforanervegraftanddonorsitemorbidityandtolocatethecoaptationsiteandthetargetorgan incloseproximity.However, functionalloss in the intactneighboringnerve that isusedasadonornerveremainscontroversial.[8,9]

Intherepairofnervedefects,theuseofaveingraftis another alternative procedure.[10-12] In contrast tomanyresorbablenervetubemodels,veingraftshavebiologicpermeabilityandareusedasanalternativetonervegrafts in longsegmentalnervedefects.[13]Bio-logic permeability permits diffusion of the releasedneurotrophicfactorsandpreventsfibroustissueinfil-tration.[14]Sinceveingraftshavebeenusedinthere-pairofnervedefects,studiesregardingthisprocedurehavebeenaccumulated,andaftercomingintoclinicaluse,itwasfoundthatthereisaproblemofcollapseintheveingraft.[15-17]

Thebestresultsareachievedaftertherepairof3cm or smaller defects due to the collapse of longerveingrafts.[17]Someresearchersplacedpiecesofnerve[18-20]andmuscletissue[21,22]insidetheveingrafttopre-ventthecollapseofthegraft,andtheyobtainedgoodresultsindefectsshorterthan3cmwiththiscombinedtechnique.[18-20]

Theaimofthisstudywastoplaceacatheterinsidetheveingrafttopreventthecollapseofthegraftoc-curring after its use in the reconstructionof a nervedefect.Byusingthistechnique,transitionofproximalregenerationtothedistalpartispresumedtobecom-pleteandeffective.

MATERIALS AND METHODSAnimal PreparationThis study was approved by the Animal Ethi-

cal Committee of Uludağ University. Forty femaleSprague-Dawleyratsweighing225-300gwereusedandmaintainedunderstandardlaboratoryconditions.The ratswere randomlydivided intofivegroups fordifferentsurgicaltreatments,exceptforthegroupcon-sisting of animals with non-operated sciatic nerves.Therewereeightratsineachgroup.Theanimalswereallowedfreeaccesstoratchowandwater.

Surgical ProceduresSurgerywasperformedusingabinocularoperative

microscope (MTX-1H1SVI; Olympus Optical Co.,Ltd., Tokyo, Japan) and microsurgical techniques.After induction of sodium pentobarbital anesthesia(Nembutal, 30-50 mg/kg intraperitoneally; AbbottLaboratories,Quebec,Canada),temporaryinhalation-aletherwasprovidedduringtheelectrophysiologicalstudies.Aftertheanesthesia,thelefthindlimbsoftheratsweretreatedinasterilemanner.

Skin and gluteal muscle were incised, and thesciaticnervesegmentbetweenthesciaticforamenandthebifurcationoftibial-peronealbrancheswasisolat-ed from theneighboring tissuesby separatingmem-branousstructures.Thesciaticnervewaspreservedatalevel7mmdistaltothesciaticforamenandatalevel7mmproximaltoitsbifurcation(thecommonperone-alandtibialnerves).A1.5cmsegmentofsciaticnervelocated in themiddlewas excised to create a nervedefect.Thisprocedurewasappliedtoallexperimen-talgroupsexceptGroup1.Additionally,inGroups4and5,afterreachingtheexternaljugularveinbya3cmverticalskinincision,asegmentofvein20mminlengthwasobtained.

InGroup1,thesciaticnervesoftheanimalswerenotoperatedandwereusedtoobtainnormativedata(Fig.1).

In Group 2, the sciatic nerve defect was not re-paired and both ends of the defectwere buried intonearbymusclesusingnylonstitches(Fig.1).

InGroup3,theexcisednervesegmentwasrotated180°andsuturedtoitsownplaceasanervegraft(Fig.1).

InGroup4,thenervedefectwasrepairedusingaveingraft(Fig.1).

InGroup5,therepairwasperformedbyplacingacatheterinsidetheveingraft(Fig.1).

AfterthecatheterwasplacedintotheveingraftinGroup5,thedistalpartofthecatheterwastakenoutdistaltothegraft-nerveanastomosisline.Inordertobeabletoremovethecatheterinthepostoperativepe-riod,asecondcatheterwasplacedintoapointclosetothem.gluteussuperficialisinsertion.Theproximalpartofeachcatheterwasremovedoutoftheneckbypassingitthroughsubcutaneoustissue(Fig.2).

The effect of catheter use on vein grafting of a peripheral nerve defect

After the first postoperativeweek, catheter no. 1waspulledoutthroughcatheterno.2stepwiseeveryseconddayaccording to themean rateofneural re-generationinrats,whichwasconsideredtobe2.5-3mm/day.[23]Etheranesthesiawasusedduringthisma-nipulation.Totalremovalofthecathetersnecessitatedthreestepsbypulling5mmateachstep,and in thethirdstep,bothcatheterswereremoved.

Allcoaptationswereperformedusing10-0nylonsutures.Muscle incisionswere suturedwith 4-0 ab-sorbablematerials,andtheskinwasclosedwith4-0nylonsutures.

Gait Analysis

Twelveweeksafterthesurgicalprocedures,agaitanalysiswas performed for all of the rats.The hindpawsofeachratweresoakedinmethylenebluesolu-tion,andtheratwasallowedtowalkonapaperthathadbeenplacedonthebottomofawalkingtracktoprovideapawprintrecord.Theprocedurewasrepeat-edwhentheresultswereunsatisfactory.Asciaticfunc-tionalindex(SFI)wascalculatedforeachratusingthefollowingformula(reportedbyBrownetal.):[24,25]

Sciatic Functional Index = -38.3 ([EPL-NPL]/

Cilt - Vol. 18 Sayı - No. 5 369

Fig. 1. ExperimentalGroups:(a)Group1,non-operatedsciaticnervegroup,normativedatawasobtained,(b)Group2,defectgroupthatwasnotrepaired,(c)Group3,theexcisednervesegmentwasrotated180°andsuturedtoitsownplacetobeusedasanervegraft,(d)Group4,nervedefectwasrepairedbyusingaveingraft,and(e)Group5,therepairwasper-formedplacingacatheterinsidetheveingraft.D:Distal;P:Proximal.

(a)

(c)

(b)

(d)

(e)

D

DD

D

D

P

PP

P

P

(c) (d)

Sciaticnerve

Viengraft

Catheter1

Catheter2

Fig. 2. ThecatheterusedinGroup5wasplacedintotheveingraft,andthedistalpartofthecatheterwastakenoutdistaltothegraft-nerveanastomosisline(a).Inordertobeabletoremovethecatheterinthepostoperativeperiod,asecondcathe-terwasplacedintoapointclosetothem.gluteussuperficialisinsertion(b).Thefirstcatheterwasplacedintothesecondcatheterinordertoobtaincontrolledremoval.Theproximalportionofeachcatheterwasremovedfromtheneckbyin-sertingitthroughthesubcutaneousdissectionplaneofrats(c).(d)Aschematicdrawingofthismethod.

(a) (b)


NPL)+109.5([ETS-NTS]/NTS)+13.3([EIT-NIT]/NIT)-8.8,

Where EPL=Experimental print length,NPL=Normal print length, ETS=Experimental toespread(first–fifth toe),NTS=Normal toespread,andEIT=theindices.SFIswerecalculatedbyaninvestiga-torblindedtotheexperimentalconditions.

Anindexof0reflectsnormalfunctionandanindexof-100representscompletelossoffunction.[24-26]

Electrophysiological TestsAfter the walking track procedure, the rats were

anesthetizedwithtemporaryinhalationofether,rein-cisionwasmadeonthelefthindlimb,andthenerveswereexposedanddissectedcarefully.Followingex-posureofthenerves,nerveconductionvelocity(NCV)forthesciaticnerveineachanimalwasmeasuredinallgroupsusingMP100dataacquisitionandanalysissystem(BiopacSystemsInc.,CA,USA).

Duringthesemeasurements,stimulatingelectrodeswere placed under the sciatic nerve proximal to thesutureline(7mmaway),andrecorderelectrodeswereplacedunderthedistalpartofthesciaticnerve,atthedivisionoftibialandperonealnervebranches(7mmaway).

Supramaximal stimulus (7V, 0.5-msec duration)generatedbyanMP100stimulatorwasusedtostimu-latethenerve,andthedistancebetweentheelectrodeswasmeasured.NCVwascalculatedbyquotientofdis-tancewithtimerecordedasm/sec.

Histomorphometric AssessmentFollowingtheelectrophysiologicalmeasurements,

the animalswere sacrificedbyhighdosageof anes-theticagentandsciaticnerveswere removed,5mmproximaltotheproximalanastomosislineand5mmdistal to the distal anastomosis line.A single nervetissue samplewas taken fromGroup1; nerve tissuesamplesfromthemedialpartofgraftedsitesaswellasfromproximalanddistalpartsweretakenfromallgroupsexceptforthoseinGroup2(Fig.3).

Harvestedtissuesampleswerefixedin4%glutar-aldehyde in0.1MphosphatebufferatpH7.4.Eachsamplewas then postfixedwith 1%OsO4 in 0.1Mphosphate buffer for 2 hours, dehydrated through agradedseriesofethanol,andembeddedinSpurrresin(Agar Scientific, Stansted,UK). Semi-thin (0.5 µm)sectionsoftheentirenerveperpendiculartothelongaxisofthenervefiberswerethenobtainedandstainedwithamixtureof1%toluidineblueand1%boraxindistilledwater.

A digital camera (Cybershot DSC-F717; Sony,Tokyo, Japan) attached to a light microscope (4S-2Alphaphot; Nikon, Tokyo, Japan) and Scion Image

software(ScionCorp.,Frederick,MD)wereused tocapture images, and the image analysis systemwascalibrated using a hemocytometer before measure-mentswereobtained.Tenmicroscopicfields,selectedrandomly,were thencapturedforeachnervesamplethroughanobjective(magnificationX40;Nikon,To-kyo,Japan)foraccuraterecognitionandcountingofthemyelinatednervefibers.AccountingframeoftheknownareawascreatedusingScion-Imagesoftwareandsuperimposedonthedigitalimagetobecounted.Myelinated axonswere then quantified according totheunbiasedcountingrule[27]andresultsexpressedasareadensitiesofmyelinatedaxons(axonspersquaremillimeter).

Statistical AnalysisConcurrencyofthevariablevaluestonormaldistri-

butionwasinitiallytestedbyaone-sampleKolmogo-rov-Smirnovtesttodecidewhethertouseparametricor nonparametric tests. Functional and electrophysi-ologicevaluationresultsandaxonnumberswereeval-uated byMann-WhitneyU andKruskal-Wallis testsusing theStatisticalPackage for theSocialSciences(SPSS) 13.0 program. Pearson correlation test wasusedforcorrelationof intergroupvariableswithoneanother.

Allofthequantitativeresultswereexpressedas±standarderrorandtheresultofp<0.05wasconsideredsignificantinthestatisticalanalysis.


Group1

Group2

Group3

Group4

Group5

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P

P

Showsthelevelofhistologicsectiontakenfromeachgroup

Fig. 3. Schematicdrawingofexperimentalgroupsandhisto-logicalsections.D:Distal;P:Proximal.

RESULTSTwelveweeks after the surgery, all of the rats in

GroupsA,B,C,D,andEweresubjectedtowalkingtrackanalysis. -100showedwholefunction lossand0showednormalfunction.TheSFIwasfoundas0inthecontrolgroup(Group1),-83.038±6.93inGroup2,-52.8±14.10inGroup3,-63.33±13.26inGroup4,and-53.78±20.70inGroup5,respectively(Fig.4).

WhengroupswerecomparedwithKruskal-Wallistest,itwasfoundasp<0.01,thatis,atleastonegroupwasdifferentfromtheothers.

Thegroupswerethenevaluatedamongthemselvesusing Mann-Whitney U test. There were statisti-callysignificantdifferencesbetweenGroups2and3(p<0.01),Groups2and4(p<0.05)andGroups2and5(p<0.01).Conversely,nostatisticallysignificantdif-ferenceswerefoundbetweenGroups3and4,Groups3and5andGroups4and5.AlthoughthedifferencebetweenGroups 4 and 5was not found statisticallyimportant (p>0.05), therewas a considerable differ-enceinparameters(p=0.08)(Fig.4).

AverageNCVwasfoundas51.08±1.85inGroup1,43.2±1.87inGroup3,42.54±2.22inGroup4and50.7±3.24 in Group 5, respectively. NoNCV couldbemeasured inGroup2 (Fig.5).While therewasastatistically significant difference betweenGroups 1and3andGroups1and4(p<0.01),nosignificantdif-ferencewasfoundbetweenGroups1and5(p>0.05).Similarly,thedifferencebetweenGroups3and4andbetweenGroups3and5wasnotsignificant.However,thedifferencebetweenGroups4and5(p<0.01)wasofvalue(Fig.5).

During histomorphometric evaluation, as shownin Fig. 3, different nerve tissue sampleswere takenfromdifferentlevelsindifferentgroups.Whenexam-inedintermsofproximalsections,nostatisticallysig-nificantdifferencewasdeterminedbetweenGroups1and2withregardtomeanvaluesofmyelinatedaxonnumber.Atthesametime,nostatisticallysignificantdifferencewas determined betweenGroups 3-4 and

5 (p>0.05).On the contrary, the difference betweenGroups1-2and3-4-5was significant (p<0.05) (Fig.6).



Group10

-20

-40

-60

-80

-100

Group2 Group3 Group4 Group5

Fig. 4. ComparisonwithrespecttoSciaticFunctionalIndex. Fig. 5. Comparisonwithrespecttonerveconductionveloci-tiesinallgroups.

Group1

60

45

30

15

0Group2 Group3 Group4 Group5

Fig. 6. Comparison of histomorphometry of sciatic nerveproximalsections.

Group1 Group2

Axon/mm2 Axon/nerve

Group3 Group4 Group50

3000

6000

9000

12000

15000

Fig. 7. Comparisonwithrespecttohistomorphometricanaly-sis.Bargraphshowingthenumberofmyelinatedaxo-nspersquaremillimeterandnerveunitareaobservedinmedialanddistalsectionsfromratsinGroups1,3,4,and512weeksaftersurgicalprocedures. (Histo-morphometricanalysiswasnotperformedinGroup2duetothelackofmyelinatedfibersintissuesamplesfromthisgroup.)

0

3000

6000

9000

12000

15000

Axon’mm2 (Midsection)Axon/Nerve(Midsection)

Axon/mm2 (Distalsection)Axon/Nerve (Distalsection)

Group1 Group2 Group3 Group4 Group5

For the histomorphometry of medial and distalnervesections,thenumberofmyelinatedaxonsinthesciatic nerve in Groups 3 and 5 was comparativelyhighercomparedtothepositivecontrolgroup(Group1) (p<0.001), but there was no significant differencebetweenGroups3 and5. InGroup5, thenumberofmyelinatedaxonsinthedistalsciaticnervesectionwascomparativelyhighercomparedtoGroup4,andthedif-ferencewasstatisticallysignificant(p<0.05)(Fig.7,8).Similarly,thedifferencebetweenGroups3and4wassignificant(p<0.05)(Fig.7,8).ForGroup2,myelinatedaxonswerenot found indistal sciaticnerve sections,andhistomorphometricanalysiswasnotperformedinthisgroup.InGroups3and5,inspiteofthehighnum-berofmyelinatedaxonsindistalnervesections,axondiameterswere smaller than normal. Similarly,whenthenumberofaxonswasexaminedinmedialanddistalsectionsforeachmm2,Groups3and5hadhigheraxonnumberscomparedtoGroup4,whichwasstatisticallysignificant(p<0.05)(Fig.7,8).

DISCUSSIONTherepairofanervedefectisoneoftheimportant

problemsofreconstructivesurgery.Althoughtheuseofanervegraft intherepairofanervedefectis themain choice,[1-4] some problems faced during acqui-sitionofanavailablenerve,and resultingdonorsitemorbidity,limititsuse.[5-7]Theuseofaveingraftin

suchdefects is anotherpreferred surgicalmethod.[10] Astheuseofveingraftsinreconstructionofanervedefectbecamepopularandgainedaplaceinclinicalpractice,[10-12]itwasobservedthatveingraftsusedinthisprocedurehaveaproblemofcollapse.[17]

Autogenic vein grafts are supportive tunnels forregeneration andmaturation of nerve fibers that areexperimentally and clinically proven.[10] Developingthe skeleton structure of nerve buds emerging fromregenerated nerve ends, providing axonalmigration,possessingextracellularmatrixcontents,andutilizingthemwiththehelpofgrowthfactors,veingraftsareshowntohaveallconditionsfornerveconduitmodels.[2]Chiu[10]andWalton[11] reportedsuccessfulresultsonthissubject.

Contrarytomanyresorbablenerveconduitmodelsthatareusedfornervedefectrepairs,veingraftsarealternativesfornervegraftsinlongdefectsbecauseoftheir biological permeability.This current biologicalpermeabilityhasanadvantageofallowingthediffu-sionofneurotrophicfactorsandpreventingfibroustis-sue infiltration.Nowadays, themost importantprob-lemofsyntheticandresorbablenerveconduitmodelsand tissueengineers isprovidingbiologicalpermea-bility.[14]Theelasticstructureoftheveinpreventsfor-mationofadhesionandscartissueandalsoformationofcompression.



Fig. 8. Photographsof(a)medial,and(b)distalsectionsofGroups3-4and5.

(a)

(b)

Because vein grafts are non-immunogenic, theyform less inflammatory reaction. Obtaining veingrafts is easier, they last longer than bioabsorbablenerve conduits, and they havemany alternatives fordiameter tunes.[15]After nerve regeneration, becausetheveinisanautogenoustissue,thereisnoneedfortaking theveinoutof the surgicalarea.[10]The threelayers of veins are rich in laminin, and this showssimilaritywithbasallaminathatsurroundsnormalortraumatizednervefibers.Laminintakesapartinadhe-sion,multiplicationanddifferentiationofnervecells.[16]Despitealltheadvantagesofveingrafts,theseri-ousproblemrepairingnervedefectswithveingraftsiscollapse,especiallyinlongdefects.[17]Someresearch-ers used vein grafts filledwithmuscle tissue[21,22] or dividednervetissue[18-20]topreventcollapse,butbestresultswiththiscombinedtechniquewereobtainedindefectsthatwereshorterthan3cm.

In this experimental study, a catheterwas placedinto a vein graft in order to overcome the collapseproblem.The rate of drawback of the catheter fromthedistal coaptationpointwas arrangeddue to “de-layingtimeinscar”[23,28,29]andnerveregenerationrate[23,28,29]inratsandveingraftlength.Therefore,wenotonlypreventedcollapsebut alsoobtainednecessary,adequatenervetubelengthfortheregeneration.Fur-thermore,bydrawingthecatheterback,therateoftheregenerationwasnotdelayedandtheforeignbodyre-actionwasprobablyreduced.

In experimental nerve repair models, histology,morphometry, electron microscopy, NCV measure-ment, muscle mass index, and electromyelographyhave been used to determine the quantity and qual-ityofnerveregeneration.[24,30,31]Inordertodeterminethe regeneration functionally,SFIobtainedbywalk-inganalysisandperonealfunctionalindexhavebeenused.[24,30,31]

When our study is evaluated in terms of nervefunctional index,especially the relationshipbetweenGroups3,4and5wasinvestigated,andgroupswerecompared both among themselves and to controlgroups.Eventhoughtherewasastatisticallysignifi-cant difference betweenGroup 2 andGroups 3-4-5,respectively, it was accepted as an estimated result.Despitethefactthatnostatisticallysignificantdiffer-encewasdeterminedamonggroupswhencomparingGroups 3-4-5, the considerable difference in param-etersbetweenGroup4andGroups3-5suggeststhatifthestudyisconductedinlargerseries,itmaychangeinfavorofGroup3andGroup5.Comparedwithotherevaluationtests,SFIisthebestmethodintheevalua-tionoffunctionandclinicalperiodsinceitdependsonsensoryandmusclefunction.[24,32]

Nerveconductionvelocity(NCV)andmorphomet-

ricanalysiscannotreflectfunctionalhealing,whichisthemainaimofperipheralnervesurgery.Whenepi-neuralsuturetechniqueisperformedduringtherepair,axonsintheproximalstumpsproutthroughthedistalendoneural tube, and therefore, NCV measurementdonewithelectricalstimulationgivesapositiveresult.However,iftheregeneratedaxonsreachingthedistalstumpcannotreachthetargetorgan,asuitablefunc-tionalresultwillnotappear,althoughthereisanelec-tricalflowthroughoutthenerve.[33,34]Whenthiscondi-tionistakenintoaccount,thefactthattheparametersinGroup3andGroup5demonstratednoticeabledif-ferencescomparedwithGroup4showsgoodpromiseforourstudy.

WhentheresultsofNCVwereexamined,astatisti-callysignificantdifferencewasfoundbetweenGroup1andGroups3and4.Thefactthatthenervegraftofthecontrolgroupwassignificantlygoodcomparedtothatoftheveingraftwasnotsurprising.WhereasthesuperiorityofGroup5tothenervegraftgroup(Group3) could not be shown, the statistically significantdifference that could be obtained between Group 5(catheterizedveingraftgroup)andGroup4(veingraftgroup)wasof importance.Thereasonfor this resultwasthatthenumberofaxonsreachingtherepairsiteanddistalregionintheveingraftgroupwithcatheterwasmorethanintheveingraftgroup.

In histomorphometric measurements, proximalsectionswereexaminedfirst.NosignificantdifferencewaspresentbetweenGroups1and2,whereasastatis-ticallysignificantdifferencewaspresentcomparedtoGroups3,4and5.Nostatisticallysignificantdiffer-encecouldbedeterminedbetweenGroups3,4and5.Thesefindingswerenormalastheyshouldregenerateafternervedamage.ThenumberofaxonsinthenerveinGroups3,4and5wasconsistentwithregenerationfindings,whichtakesplaceinadamagednerve.Therewereanumberofmyelinatedaxonsandnerveclumpsthatwere in smallerdimensions; axonswithoutmy-elinwerealsopresentandnumberedmorethaninthecontrolgroup.

Thedistalandmedialsections,whichareofimpor-tanceintermsoftheresultofourstudy,wereexaminedwithregardtothenumberoftheaxonsinthenerve.Whereasnosignificantdifferencecouldbefoundbe-tweenthenervegraftgroup(Group3)andGroup5inwhichacatheterwasplacedintotheveingraft,itwasobservedthatthedifferencesbetweenGroups3and4(veingraftgroup)andbetweenGroups5and4werestatisticallysignificant.Thefactthatthedifferenceoc-curring in favorofGroup3between thenervegraftgroup(Group3)andveingraftgroup(Group4)wasnotpresentbetweenGroup3andGroup5(veingraftgroupwithcatheters)isduetothepositiveeffectsofthecatheterplacement.





Theresultsinalltests,exceptinSFI,wereinfavorofnervegraftandcatheterizedveingraft.Inthisex-perimentalstudy,weaimedtoovercomethecollapseproblemoftheveingraftbyusinganenclosedcathe-ter.Whenitisconsideredthattheproblemofveincol-lapseusuallyoccurswhenthegapislongerthan3cm(asmostly seen in clinical procedures),[17] this studycannotcontribute to the literaturebecause themaxi-mumlengthofasciaticnervedefectcannotexceed3cm ina ratmodel.Unfortunately, standard scientificteststhatcanbeusedtoevaluatenerveregenerationinbiggeranimalmodels,suchasindogsormonkeys,arenotavailable.Themodelusedinthisstudy,inwhichnervedefectswererepairedbyplacingacatheterintoaveingraft,hasthefollowingadvantages:

1) Incaseswhereobtaininganidealandextremelyacceptable nerve graft is difficult, vein graft-ingisaprocedureinwhichaveingraftcanbeobtainedeasily,andthetechnicalapplicationiseasy.Diameteradaptationisnotnecessary,andthegraftisnon–immunogenic.Astheveinisanautogenic tissue, it isnotnecessary toremovetheveinfromthesurgicalsiteafterthecomple-tionofnerveregeneration.

2) Donor sitemorbidity isminimal compared tonervegrafting.

3) Thecollapseproblemof theveingraftcanbeovercomebycatheterplacement into thevein,anditseemspossibletousethistechniquein3cmandlongernervedefects.

4) Micro biological media occurring in the veingraftandaxoplasmicfluidaccumulationatthegraftsiteareusefulandvaluablefornervere-generation.

5) Comparedtosyntheticnervetubemodels,bio-logicpermeabilityoftheveingraftisoneofitsadvantages.

With thisexperimentalstudy,sciaticnervedefectrepairdonebyaveingraftwithanenclosedcatheterdemonstrated better results compared to single veingraft application. This procedure may eliminate theneedforanervegrafttorepairaperipheralnervede-fectandtheriskofafunctionallossinthedonornerve.Incaseswherenervedefectrepairisplannedtobeper-formedusingaveingraft,thecollapseproblemoftheveingraft,whichconstitutesaseriousproblem,maybeovercomewiththismethod.However,todate,noadequatedataarepresentforitsclinicaluse.

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13.Mackinnon SE, Dellon AL. Clinical nerve reconstructionwithabioabsorbablepolyglycolicacidtube.PlastReconstrSurg1990;85:419-24.

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376


Experimental Study Deneysel Çalışma


Comparison of topical zinc oxide and silver sulfadiazine in burn wounds: an experimental study

Yanıkyarasıtedavisindetopikalçinkooksitilegümüşsülfadiazininkarşılaştırılması:Deneyselçalışma

Kemal ARSLAN,1 Ömer KARAHAN,1 Ahmet OKUŞ,1 Yaşar ÜNLÜ,2 Mehmet Ali ERYILMAZ,1 Serden AY,1 Barış SEVİNÇ1

Presented at the 8th Turkish Congress of Trauma and Emergency Surgery (September 14-18, 2011, Antalya, Turkey).

Departments of 1General Surgery, 2Pathology, Konya Training and Research Hospital, Konya, Turkey.

8. Ulusal Travma ve Acil Cerrahi Kongresi’nde sunulmuştur (14-18 Eylül 2011, Antalya).

Konya Eğitim ve Araştırma Hastanesi, 1Genel Cerrahi Kliniği, 2Patoloji Bölümü, Konya.

Correspondence (İletişim): Kemal Arslan, M.D. Necip Fazıl Mah., Ateşbazı Sok., Meram Yeniyol, 42040 Meram, Konya, Turkey.Tel: +90 - 332 - 323 67 09 e-mail (e-posta): [email protected]

AMAÇBuçalışmada,yanıkyaralarındayaygınolarakkullanılançinkooksit vegümüş sülfadiazinin tedavi etkileri karşı-laştırıldı.GEREÇ VE YÖNTEMYeniZelandacinsi20tavşandapirinçproplayanıkyarasıoluşturuldu.Tavşanlarrastgeleikigrubaayrıldı.Yanıklargünlükuygulamaylabirincigruptaçinkooksitle(GrupO),ikincigrupta(GrupS)gümüşsülfadiazinletedaviedildi.Yaraiyileşmesiklinikvehistopatolojikolaraktakipedil-di.Yaraölçümleriyapıldıve%50ve%80reepitelizasyo-naulaştığıgünlerbelirlendi.BULGULAROrtalama %50 ve %80 reepitelizasyona ulaşma süreleriGrupO’dasırasıyla21,4ve25,4gün,GrupS’de25,8ve30,2gündü(p<0,001).Yarakolonizasyonuise1,2,3,4,5ve6.haftalardaortalamaolarakGrupO’dadahadüşüktü.Fark2,3,4ve6.haftalardaanlamlıidi(p<0,001).Histo-patolojikdeğerlendirmesonucundaGrupO’daepidermis,dermisveskardokusununkalınlıklarısırasıyla0,12,3,80ve2,44mmidi.GrupS’deise0,16,4,76ve3,16mmola-rakbulundu(p<0,001).SONUÇBudeneyselçalışmada,çinkooksityanıktedavisindeepi-telizasyon,epidermismaturasyonuveskaroluşumundagü-müşsülfadiazindendahaetkilibulunmuştur.Anahtar Sözcükler: Çinkooksit;gümüşsülfadiazin;parsiyelka-lınlıktakiyanık.

BACKGROUNDWeaimedtocomparetheeffectsoftopicalzincoxideandtopicalsilversulfadiazineinthetreatmentofpartial-thick-nessburnwounds.METHODSThestudywasconductedwith20NewZealandrabbits,andburnwoundswerecreatedbyabrassprobe.Theanimalswere randomlydivided into twogroups.Theburnsweretreated with zinc oxide (Group O) or silver sulfadiazine(GroupS)withdailyapplication.Thewoundhealingpro-cesswasfollowedbothclinicallyandhistopathologically.Wedeterminedthedaysatwhich50%and80%re-epithe-lizationwasobserved.RESULTSThemeantimefor50%and80%re-epithelizationwas21.4and25.4daysinGroupOand25.8and30.2daysinGroupS,respectively(p<0.001).Themeanscoreforwoundcolo-nizationwaslowerinGroupO.Thedifferencewasstatisti-callysignificantatweeks2,3,4,and6(p<0.001).Inthehistopathologicalexamination, the thicknessesof theepi-dermis,dermisandscartissuewere0.12mm,3.80mmand244mminGroupO,and0.16mm,4.76mmand3.16mminGroupS,respectively(p<0.001).CONCLUSIONIn thisexperimentalburnstudy,zincoxidewasmoreef-fective thansilver sulfadiazine in termsofepithelization,dermismaturationandscarformation.Key Words: Zincoxide;silversulfadiazine;partial-thicknessburn.

doi: 10.5505/tjtes.2012.45381

Inthetreatmentofburns,theaimistotreatburns,preventinfectionsandachievethebestfunctionalandaesthetic results in a shorter time with lower costs.While healing burn wounds, a topical agent shoulddecreasetheratesofmortalityandmorbiditybypre-ventingbacterialcontaminationandsepsis.Theagentshouldalsobeeasilyaccessible.Anidealagentwiththosepropertieshasyet tobemarketed. In the topi-caltreatmentofburnwounds,1%silversulfadiazine(SSD) pomade is the most commonly used agentworldwide.[1]SSDhasbeenshowntodecreasebacteri-alcontamination,tohastenepithelizationandtodelaywoundcontraction.[2-8]However,SSDisalsoknowntodelaywoundhealingandseparationofscartissue,tocauseatrophicandhypertrophicscars,especiallymorethanthreeweeksaftertheapplications,tohaverenaltoxicity, to cause leukopenia, and to carry a risk forresistance.[9-19]

Zinc is anessential element for thehumanbody,andatthemeetingoftheWorldUnionofWoundHeal-ingSocietiesinParisin2004,itwasacceptedashav-ingpotentialbenefits inwoundhealing.[20]Therearestudies showing thebenefitsof systemic and topicaluseofzincinwoundhealing.It isalsoreportedthatzincacceleratesthewoundhealingprocesswhenap-pliedonopenwounds.[21]

Toourknowledge,nostudyexistsintheliteraturecomparingtheeffectsoflocalapplicationofSSDandoxide zinc ointment (OZO) in burnwounds.There-fore, thepresent studywasdesigned tocompare theeffectsoftopicalSSDandOZOinexperimentalpar-tial-thicknessburnsinrabbits.

MATERIALS AND METHODSStudy designPermission was obtained from the ethical board

ofMeramMedicalSchoolofSelçukUniversity.Thestudywas designed under the criteria of theHealthGuide for the Care andUse of LaboratoryAnimalsbytheNationalInstitutesofHealth(NIHPublicationNo:86-23,Revised1985Bethesda).Theresearchwasconducted at the Experimental Research Center ofSelçukUniversity.Theweightofrabbitsrangedfrom3200-3600 g. The rabbits were accommodated in a12/12 hour light and dark cycle at 22-26°C and fedwithastandardrabbitdiet.Asananalgesic,100mg/5mlofibuprofenwasadministeredviadrinkingwateraftertheformationofburns.Therabbitswereaccom-modated individuallyandapproachedwithappropri-ateequipmenttopreventcontamination.

Beforethestudy,punchbiopsiesassampleswereobtained from eight rabbits to determine the thick-nessesofnormalepidermisanddermis.Meanvaluesobtainedfromthesesampleswereacceptedasnormal

values.Partial-thickness burns were formed in 20 adult

NewZealand rabbits.The rabbitswere divided intotwogroups.OZO20%wasusedinGroup1(GroupOZO), and SSD 1% was used in Group 2 (GroupSSD).Thehealingperiodwasfollowedupclinicallyandhistopathologically.

Fiveparameterswereusedinthedeterminationofwoundhealing:

1. Dayswhen 50% and 80% of re-epithelizationwasobserved.

2.Thescoreforwoundcolonization.3.Thehistopathologicthicknessoftheepidermis.4.Thehistopathologicthicknessofthedermis.5.Thehistopathologicthicknessofthescarissue.Burn formationAnesthesiawas achieved by a single dose of in-

tramuscular6mg/kgofxylazinehydrochloride(Rom-pun,Bayer,23.32mg/ml)and50mg/kgofketaminehydrochloride(Ketalar,Parke-Davis,50mg/ml).Theback region of the rabbits was shaved and cleanedwith 10%of povidone-iodine solution (Kim-Pa, Po-viiodeks,10%povidone-iodine).Aspeciallydesignedbrassprobewith10cm²ofsurfacearea(2.5x4cmdi-ameter)wasusedfortheformationofburns(Fig.1a).Havingbeensterilizedinboilingwaterfor5minutes,theprobewasappliedtotheskinofanesthetizedrab-bitsfor15secondswithnopressure.Usingthispro-cedure, second-degree partial-thickness burns wereformed(Figs.1b,c).Aftertheformationofburns,alltherabbitswereplacedandkeptinindividualcages.

Local treatmentGroupOwastreatedwithOZOandGroupSwith

SSD.OZOwasformedwith20%zincoxideand80%Vaseline.OZOcanbefoundcommerciallyas20%ofOxidedeZinc(OROzinccream,OROdrugs).SSDwasformedfrom1%SSDand99%paraben,andcancommerciallybefoundas1%Silvadiazincream(To-prakDrugCo.).Accordingtoourtreatmentprotocol,the drugs were administered as a thin layer on thewoundsonceperday.Then,allwoundswereprotectedwithnon-stickcottonandsterilegauzewithadhesiveelastic bandage (Setanet® No: 3) and changed on adailybasis(Fig.1d).

Assessment of wound healingThis studywas continued for sixweeks after the

formation of burns. Each wound was clinically ob-served meticulously, and digital photos were takenwithacamera(Sony®CyberShotDSC-W120)everythree days during the following sixweeks.Atweek6,skinsampleswerecollected,andwoundswereas-

Comparison of topical zinc oxide and silver sulfadiazine in burn wounds




sessedhistologically.Alltheclinicalandhistologicalassessmentsofwoundswereperformed inablindedfashion.Ateverychangeofdressings,woundhealingwasexaminedbyanexperiencedclinician(asurgeonintheburnunit),andgeneralcommentswererecorded(Fig.2).

1. Assessment of re-epithelizationDuringthestudy,thephotosofwoundsweretak-

en once every three days after cleaningwith serumphysiologic.The photoswere taken from a distanceof20cm, in thesameroomunder thesamelightingconditions by the same researcher.The photoswere

Fig. 1. Theapplicationofbrassandburnformation.

(a)

(b)

(c)

(d)

Fig. 2. Burnwoundsondays3,14,28,and42.



evaluatedunderthecriteriaofNIHImageJprogram(ImageJver:1.44p,WayneRasband,NIH,USA).Themargins of burn areas were marked and measured,andthemeasurementswererecorded.Therateofre-epithelizationareaswascalculatedwiththefollowingformula:

Percentageofre-epithelization=firstburnarea–currentburnarea∕firstburnarea.

Thedaysonwhich50%and80%ofre-epitheliza-tionwasobservedweredetectedforeachrabbit.

2. Assessment of wound colonizationWound colonization was assessed according to

exudation,purulentefflux,effluxodor,erythema,andedema.Ascorebetween0and3wasgiventoeachas-sessmentasfollows:0:Nofindingofcolonization,1:Mildexudationandodor,2:Erythema,moderatepuru-lentefflux,exudation,andodor,and3:Severeexuda-tion,purulentefflux,odor,edema,anderythema.

Eachassessmentwasperformedbythesameblind-edresearcher,whowasunawareofthescoresofrab-bitsdeterminedbeforeandduringthetreatment.

3. Histopathological assessmentThestudywascontinuedforsixweeksanddiscon-

tinuedattheendofweek6.Attheendofthestudy,alltherabbitsweresacrificedaftertheirphotosweretak-en.Full-thicknessskinsamplesatburnareaswerere-sected.Skinsampleswerepreservedinformaldehydesolutionandstainedwithhematoxylin-eosin(HE)andMassontrichromedyes.Thethicknessesoftheepider-mis, dermis and scar tissueswere blindly evaluatedthroughtheNIHImageJprogram.Intheassessment,thebiopsyresultsofhealthyrabbitspriortothestudywereacceptedasnormalvalues.

Statistical analysisCollected data were analyzed using the Statisti-

calPackage for theSocialSciences (SPSS)13.0 forWindows program. The values were evaluated as

mean±SD.Student’sttestwasusedforcomparisonofthegroups.Apvaluelowerthan0.05wasacceptedtobesignificant.

RESULTSAtthebeginningofthestudy,alltheburnwounds

were similar.At the end of six weeks, no unhealedwoundswerepresent.

Result of re-epithelizationThemean time for 50% of re-epithelizationwas

21.4daysintheOZOgroupand25.8daysintheSSDgroup(p<0.001).Themeantimeto80%ofre-epithe-lizationwas25.4daysintheOZOgroupand30.2daysintheSSDgroup(p<0.001).Re-epithelizationofburnwoundswasfasterinGroupOZOcomparedtoGroupSSD(Fig.3).

Wound colonizationThe scores ofwound colonizationwere lower in

GroupOthaninGroupSwithinallweeks.However,thesedifferencesweresignificantonlyatweeks2,3,4,and6(p<0.05)(Fig.4).

Thickness of epidermisThemeanthicknessoftheepidermiswas0.12mm

inGroupOZOand0.16mminGroupSSD(p<0.001).

Daysp

ostburninjury

0

5

10

15

20

25

30Reepithelization50%

Daysp

ostburninjury

0

5

10

15

20

25

30

Reepithelization80%

30

40

Fig. 3.Timesto50%and80%re-epithelization. Fig. 4.WoundcolonizationintheOZOandSSDgroups.

ZincoxideSilversulfadiazine

0

0.5

1

1.5

2

2.5

1.week 2.week 3.week 4.week 5.week 6.week

(mm)

00.020.04

0.060.08

1

0.16

Epidermis

0.12

0.14

0.18

Fig. 5. Mean epidermisthicknessinbothgroups(mm).

(mm)

Zincoxide

Silversulfadiazine

Zincoxide

Silversulfadiazine

Zincoxide

Silversulfadiazine



These values were higher than normal values, indi-catingthatepidermalmaturationwasbetterinGroupOZO thanGroupSSD (Fig. 5).The histopathologicappearancesofnormalepidermis,ofepidermisfromarabbittreatedwithOZOandofepidermisfromarab-bit treatedwithSSDarepresented inFigures6a,6band6c,respectively.

Thickness of dermisIn both groups, the histologically detected thick-

nesses of the dermis were higher than normal val-ues (3.8mm in Group OZO and 4.7mm in GroupSSD), and thedifferencewas statistically significant(p<0.001) (Fig. 7). The histopathologic appearancesofnormaldermis,ofdermisfromarabbittreatedwith

OZO,andofdermisfromarabbittreatedwithSSDarepresentedinFigures8a,bandc,respectively.

Thickness of scar tissueThemeanthicknessesofscartissuewere2.4mm

inGroupOZOand3.2mminGroupSSD(p<0.001).The scar tissue was significantly thinner in GroupOZOcomparedtoGroupSSD(Fig.9).Thehistopath-ological appearancesof scar tissue in rabbits treatedwithOZOandSSDareshowninFigures10aandb,respectively.

DISCUSSIONBurnsareoneofthemostimportanthealthissues.

Topical treatment is very important in the treatmentofburns,andmultipleagentshavebeenusedforthispurpose.Somehavebeenusedforalongtime;how-ever,othershaveonlyrecentlyappeared in the liter-ature.An ideal topical agent should heal thewoundinashorterperiodwiththebestresults,decreasetheratesofmortalityandmorbiditybypreventingbacte-rialcontaminationandsepsis,andbeeasilyaccessibleandcheaper.Asagentswithsuchpropertieshaveyettobe identifiedormanufactured, studies todiscoverthe idealagentareongoing.As themainpartof thestudy, the effects ofOZOon burnwoundswere in-vestigated,andtheresultswerecomparedwiththoseobtainedwithSSD.Recently,SSDhasemergedasthemost commonly used topical agent in burn wounds

Fig. 6. (a)Histopathologicappearanceofnormalepidermis;(b)histopathologicappearanceofepidermisofarabbittreatedbyOZO;c:histopathologicappearanceofepidermisofarabbittreatedbySSD.(OZO:Zincoxide,SSD:Silversulfadiazine)

(a) (b) (c)

00.51

1.52

2.5

4

Dermis

3

3.5

4.5

Fig. 7. Mean dermisthicknessinbothgroups(mm).

(mm)

Zincoxide

Silversulfadiazine

5

Fig. 8. (a)Histopathologicappearanceofnormaldermis;(b)histopathologicappearanceofdermisofarabbittreatedbyOZO;(c)histopathologicappearanceofdermisofarabbittreatedbySSD.(OZO:zincoxide,SSD:silversulfadiazine).

(a) (b) (c)



duetoitsantimicrobialeffects.[1] SilvercontainedresolvedbySSDhasapreventive

effectbyterminatingmostofthemicroorganisms,evenfungi.[2]Italsoacceleratesthewoundhealingprocessthrough the inhibition of matrix metalloproteinasesandincreasestheepithelization.[3-8]StudiesopposedtoSSDcanalsobefoundintheliterature.InastudybyMaghsoudietal.,[9]wetgauzedressingswerereport-edtogivebetterresultsthanSSDinthetreatmentofburnwounds.ThesamestudyshowedthatSSDdelayswoundhealing.Likewise,inarandomizedcontrolledstudybyKhorasanietal.[10]comparingaloeverawithSSD, itwas concluded thatwoundhealingwasbet-terinthealoeveragroupandthatSSDdelaysre-epi-thelizationinburnwounds.SSDwasalsodeterminedtodelaytheseparationofscartissueindeepwounds.[10-14]HypertrophicandatrophicscarformationcanbeseeninthetreatmentofSSD,especiallyinprocesseslongerthanthreeweeks.[15,16]ItwasalsoreportedthatrenaltoxicityresolvesafterthetreatmentwithSSDisdiscontinued.[17]SSDmaycausetransientleukopenia,probablyduetobonemarrowtoxicity.[18]Inthelightofsuchdata,itmaybesuggestedthatSSDisnotanidealtopicalagentinthetreatmentofburnwounds.

Thesignificanceofzinchasbeenknowninmedicalsciencesinceancienttimes.[19-21]Recentdatashowthatzincisfoundinmorethan300enzymesinthehumanbodyandalsohaspreventiveeffectsagainstinfections.

[22-24]At the meeting of theWorld Union ofWoundHealingSocietiesinParisin2004,zincwasacceptedtohavepotentialbenefitsinwoundhealing.[20]Thede-fectofzinc-fingertranscriptionfactorsinmRNAcod-ing growth factors causes impaired wound healing.[25,26]Inaratburnmodel,itwasreportedthatthezinclevelincreasesto15-20%atthemarginofthewoundinthefirst24hours,andthelevelreaches30%whentheepidermalproliferationandgranulationtissueareatmaximumlevel.Themorethezincleveldecreases,themoremitoticactivitydecreases,andthenscarmatura-tionoccurs.[27-29]Topicalapplicationofzincdecreasestherateofdebrisandnecroticmaterialandincreasestheepithelization.[30-33]AccordingtoKietzmann,[35]lo-callyappliedzincacceleratesthehealingofulceratedskin.Accordingtovariousrandomizedcontrolledstud-ies, topical application of zinc has beneficial effectsonlegulcers,pressureulcersanddiabeticfootulcers.[25,33,36-38]Inlightofthesedata,zincmaybesuggestedtobeclosely related towoundhealing.However,nostudyhasbeenreportedorencounteredintheliteratureabouttheeffectsofOZOonburnwounds.Inseveralpreviousstudies,zincwasusedtopicallyforbothnor-malskinandopenwounds;asaresultof thesestud-ies,nosystemictoxiceffectswerementionedaftertheabsorption.[27-30]Therefore, inourstudy, investigationofthesystemiceffectsofzincwasconsideredtobeun-necessary,consistentwithpreviousstudies.

Inorder to determine the effects of zinconburnwounds,OZOwasused ina rabbitburnmodel,andthe effects of zincwere compared to thoseobtainedfromtheuseofSSD.InGroupOZO,thetimeswhen50% and 80% of re-epithelization were observedwere found to be 4 and 5 days shorter, respectively(p<0.001).Theperiodrangingfromonetofourdaysisveryimportantinthetreatmentofburnwoundswithzincinhumanandanimalwounds.[39-41]Asaresult,afour- or five-day healing period gained through thetreatmentofOZOmakesitmoreadvantageouscom-paredtoSSD.

0

0.5

1

1.5

2

3.5

2.5

3

Fig. 9. Meanscartissuethicknessinbothgroups(mm).

(mm)

Zincoxide

Silversulfadiazine

Fig. 10. (a) Histopathological appearance of scar tissue of a rabbit treated by OZO, (b) histopathologicalappearanceofscartissueofarabbittreatedbySSD.(OZO:zincoxide,SSD:silversulfadiazine)

(a) (b)



The score of wound colonization was lower inGroupOZO than inGroupSSDat allweeks.How-ever,thisdifferencewasonlysignificantatweeks2,3,4,and6(p<0.005).Thisparametermaybesuggestedto show the superiority ofOZO in the treatment ofburnwounds.Anothercriterionofburnwoundheal-ingdeterminedinthepresentstudywasthethicknessof theepidermis,dermisandscar tissues.The thick-nesses of epidermis anddermismeasuredhistopath-ologically were higher in both groups compared tonormalvalues.Themean thicknessof theepidermiswas0.12mminGroupOZOand0.16mminGroupSSD(p<0.001).ThemeanthicknessofthedermiswasalsolowerinGroupOZOthanGroupSSD(p<0.001).Likewise,themeanthicknessofscartissuewaslowerinGroupOZOcomparedtoGroupSSD(p<0.001).

Inthisstudy,thedurationtore-epithelization,scaleofwoundcolonization,andthicknessesoftheepider-mis,dermisandscar tissueswereused toassess theprocessofburnwoundhealing.Givenalltheseparam-eters,OZOwasdeterminedtobesuperiortoSSDinthetreatmentofpartial-thicknessburnwounds.Con-sidering the adverse effects of SSD, the superiorityofOZO becamemore prominent.As no burn studyrelatedtotheuseoftopicalzincisavailableatpres-ent,ourresultscouldnotbecomparedtotheliterature.Therefore, further experimental and clinical studiesregardingtheeffectsofzincoxideonburnwoundsareneeded toprovidebetter results formedical science.Ourstudyconcludedthatpartial-thicknessburnsmaybe treatedwithOZO, and newer studies should ad-dresstheseissuesforapplicationinhumans.

Inconclusion,inanexperimentalburnmodel,zincoxidewasindicatedtobesuperiortoSSDwhenusedtopically.Cliniciansshouldbeawareofthebeneficialeffectsofzincoxideinthetreatmentofburnwounds.

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Original Article Klinik Çalışma


Depertments of 1General Surgery, 2Emergency Medicine,Gulhane Military Medical Faculty, Ankara, Turkey.

Gülhane Askeri Tıp Akademisi, 1Genel Cerrahi Anabilim Dalı,2Acil Cerrahi Anabilim Dalı, Ankara.

Correspondence (İletişim): Öner Menteş, M.D. Gülhane Askeri Tıp Akademisi, Genel Cerrahi Anabilim Dalı, Etlik 06018 Ankara, Turkey.

Tel: +90 - 312 - 304 50 15 e-mail (e-posta): [email protected]

AMAÇBuçalışmadaakutapandisittanısındaserumfibrinojendü-zeyininönemiaraştırıldı.

GEREÇ VE YÖNTEMKliniğimizebaşvuran201hastaçalışmayaalındı.Hastala-rınsemptomları,semptomsüreleri,muayenebulguları,la-boratuvarbulgularıveakutapandisitiçinAlvaradoskorlarıkaydedildi.Kesintanıhistopatolojikincelemeilekonuldu.Ameliyatöncesikanfibrinojendeğerinebakıldı.Tekbirtes-tinvetestkombinasyonlarınınduyarlılık,özgüllükveöngö-rüdeğerifarklıseviyelerindehesaplandı.

BULGULARÇalışma süresinde 201 hasta akut apandisit ön tanısı ileameliyatedildi.Histopatolojikincelemesonrası179(%89)hasta akut apandisit tanısı aldı.Hastalarınyaşortalaması24,8±7,7 (dağılım20-57)yıldı, 154 (%76.6)hasta erkek,47(23.4%)hastakadındı.Akutapandisittanısıiçinkesimdeğerifibrinojeniçin245,5mg/dl,beyazküresayımıiçin11.900x109/LveAlvaradoskoruiçin7olarakbulundu.

SONUÇAkutapandisittanısındafibrinojeninserumdeğeriyenibirakutfazreaktamıolarakkullanılabilir.Üçlütestformülü-nünkullanılmasıgözlemveyaacilcerrahikararınıvermedeyardımcıolabileceğidüşünülmektedir.

Anahtar Sözcükler: Akutapandisit;fibrinojen;tanı.

BACKGROUNDTheaimofthisstudywastoinvestigatetheimportanceofserumfibrinogenlevelinthediagnosisofacuteappendicitis.

METHODSThisstudywasperformedon201patientswhoadmittedtoourclinic.Symptoms,signs,durationofsymptoms,andlab-oratoryindicatorsofappendicitiswererecorded,inkeepingwiththeAlvaradoscoreforacuteappendicitis.Theultimatediagnosiswasbasedonhistopathologicalresults.Serumfi-brinogenlevelsweredetectedbeforesurgery.Thesensitiv-ity,specificity,andpredictivevaluesofsingletestandtestcombinationswerecalculatedatdifferentcut-offlevels.

RESULTSDuring the study period, 201 patients underwent surgeryfor suspected acute appendicitis. Appendicitis was con-firmedin179(89%)patients.Themeanagewas24.8±7.7(range,20-57)years,and154(76.6%)patientsweremaleand47 (23.4%) female.Thebestdiagnosticcut-offpointforfibrinogenwasfoundat245.5mg/dl, forwhitebloodcells(WBC)at11,900x109/LandforAlvaradoscoreat7.

CONCLUSIONTheuseoffibrinogenbloodlevelmaybeanewdiagnosticacute-phasereactantinthediagnosisofacuteappendicitis.Theformulationofatripletestisrecommendedascriteriaindecidingemergencysurgeryorobservation.Key Words: Acuteappendicitis;fibrinogen;diagnosis.

doi: 10.5505/tjtes.2012.58855

The value of serum fibrinogen level in the diagnosis of acute appendicitis

Akutapandisittanısındaserumfibrinojendüzeyinindeğeri

Öner MENTEŞ,1 Mehmet ERYILMAZ,2 Ali HARLAK,1 Erkan ÖZTÜRK,1 Turgut TUFAN1

Acuteappendicitis(AA)isthemostcommonindi-cationforemergentsurgeryandaffectsawiderangeofpatientsatanyage.Approximately7%ofthepopu-

lationwilldevelopappendicitisat some timeduringtheir lives.[1,2] The aim of the clinical evaluation ofpatientswithsuspectedAAisprimarilyperformedin

ordertoavoidappendicealperforationandsubsequentcomplications, whileminimizing the number of un-necessarylaparotomies.[3]Thegoalofmodernsurgicalmanagementisessentiallythesameandfocusesonabalancebetweentherateoffalse-negativelaparotomyandtherateofperforationatthetimeofsurgicalex-ploration.[4,5]

Various imaging modalities, biochemical mark-ers,andscoringsystemshavebeenintroduced,withaviewtolowerthenegativeappendectomyrate.How-ever,thereiscontinuingcontroversyabouttheirrou-tineuse,whilestudiesareongoingtoinvestigatehowtoimprovethediagnosticaccuracyinAA.[6]

In the past, studies have discussed the high in-cidence of negative appendectomy as away of pre-ventingperforationof theappendix. Itwasassumedthat themorbidityassociatedwithanegativeappen-dectomywasnot severeenough toallow the riskofappendiceal perforation.This aspectwas challengedbyFlumet al.,[7]who showed that patientswhoun-derwent negative appendectomywere also observedtohavemorecomorbidities,longerlengthofhospitalstay,andhigherinfectionandcasefatalityrates.ThisandotherstudieshavedescribedthesignificantburdenofnegativeappendectomyandhaveaimedtoidentifybetterdiagnostictestsinthemanagementofAA.

Theaimofthisstudywastodeterminethepredic-tivevalueofserumfibrinogenlevelinindicatingap-pendectomyimmediately.

MATERIALS AND METHODSThis study was performed on 201 patients who

admittedtoourclinicbetweenMarch2005andMay2007with suspectedAA. Patient demographics andpresenting signs and symptoms were documented.Thepatients’symptoms,signs,durationofsymptoms,and laboratory indicators were recorded, in keepingwith theAlvaradoscoreforappendicitis.[8]Basedonthesefindings,Alvaradoscorewascalculatedforeachpatient. Patient symptoms included nausea, vomit-ing, migratory pain, anorexia, right lower quadrantpain, body temperature >37.3°C, and white bloodcell(WBC)count,leftshiftondifferential.TheWBCcount was determined by a technical hematologi-calcellcounter(Beckman-Coulter,Krefeld),andtheupper limitwas defined as 10.0x109/L.All removedappendixes were examined by a routine protocol inwhichtheultimatediagnosiswasbasedonhistopatho-logicalresults.

Blood samples for determining fibrinogen serumlevels were collected before the surgical procedureandmeasuredbytheclottingassayofClaussmethod.Theuppernormallimitwasdefinedas400mg/dl.Thesensitivity,specificity,andpredictivevaluesofsingle

testandtestcombinationswerecalculatedatdifferentcut-offlevels.

Thedecisiontooperatewastheprerogativeofthesurgeonbasedonoverallclinicaljudgment.

Statistical AnalysisThenon-parametricKruskal-Wallis testwasused

for multiple group comparisons. In case of signifi-cance,individualdifferenceswereidentifiedwiththeMann-Whitney U test. All p values of <0.05 wereconsideredas statistically significant.Receiveroper-atingcharacteristic (ROC)curvesand therelatedar-easunderthecurve(AUC)werecalculated.Testsforsignificance ofAUC to be>0.5, calculation of 95%confidencelimitsoftheAUCandcomparisonofROCcurvesweredone.

RESULTSDuring the study period, 201 patients underwent

surgeryforsuspectedAA.Appendicitiswasconfirmedin 179 (89%) patients. Themean agewas 24.8±7.7(range,20-57)years,and154 (76.6%)patientsweremaleand47(23.4%)female.Toinvestigatethediag-nosticvalueoffibrinogen,WBC,andAlvaradoscore,ROCcurveswerecalculated.Forthediagnosisofap-pendicitis, the best cut-off point for fibrinogen wasfoundat245.5mg/dl,forWBCat11,900,andforAl-varadoscoreat7(Fig.1).Predictivevalue,sensitivity, specificity,andaccuracyofcombinedtestsinthedi-agnosisofAAareshown inTable1.Distributionoffibrinogenbloodlevel,WBCandAlvaradoscoreac-cordingtothefinalpathologyareshowninTable2.

According to the cut-off levels, risk factorswerederived from an unconditional logistic regression

Fibrinogen

WBC

AlvaradoReferenceline

0.0

0.4

0.2

0.6

0.8

1.0

0.0 0.2 0.4 0.6 0.8 1.0

1-Specificity

Sensitivity

Fig. 1. ROCcurveforfibrinogenbloodlevel,WBC,andAl-varadoscore.

Serum fibrinogen levels in acute appendicitis




analysis.According to themodel, the probability ofAAforanindividualpatientcanbecalculatedas:

1/1+2.66-y

y= -2.8066 + (0.0076 x fibrinogen blood level)+ (0.5094 xAlvarado score) + (0.000035 xWBC)–(0.7082xdurationofsymptoms[<24h(1);≥24h(0)]).

Thescorehadaminimumofzeroandmaximumofonepoint.Thecut-offlevelforAAis≥0.75.Overthis level,we can estimate the realAAcase inover92.18%.Ifthescorewas<0.75,thepossibilityofap-pendicitiswaslessandthepatientshouldbekeptun-der observation.When the score reaches ≥0.75, thepatientshouldbetakenforsurgery.

DISCUSSIONTheaimofthisstudywastoevaluatethevalueof

theserumfibrinogenlevelinthediagnosisofsuspect-edAAandtodeterminetherelationshipbetweentheAlvaradoscoreandWBC.

Many attempts have been made to determineways of decreasing the negative laparotomy rate inclinically suspectedAA. Itwouldbevery importantto differentiate early appendicitis from non-specificabdominalpain.However,acarefullydetailedhistory,physicalexamination,andstandardlaboratorystudiesdonotalwaysclearlydetect earlyAA.Furthermore,delaysindiagnosiscanbeharmfulandmayconvertarelativelyuncomplicatedcasetosubstantialmorbidityorevenmortalityinpatientswithcomorbidillnesses.

Table 1.Predictivevalue,sensitivity,specificity,andaccuracyofcombinedtestsinthediagnosisofacuteappendicitis

95%CIforOR

Tests PPV NPV Sensitivity Specificity Accuracy OR Lower Upper (%) (%) (%)

Fibrinogen>245.5mg/dl 91.97 17.18 70.39 50.0 68.16 2.38 0.97 5.82WBC>11.900/L 96.24 25.0 71.51 77.27 72.14 8.53 2.99 24.35Alvaradoscore>7 96.43 20.22 60.34 81.82 62.69 6.85 2.22 21.06Fibrinogen>245.5mg/dlWBC>11.900/L 96.81 36.0 85.05 75.0 84.03 17.06 4.16 69.92Fibrinogen>245.5mg/dlAlvaradoscore>7 94.77 29.03 77.78 81.81 78.18 15.75 3.17 78.30Alvarado>7WBC>11.900/L 96.94 29.63 71.42 84.21 73.02 13.33 3.67 48.4Fibrinogen>245.5mg/dlAlvaradoscore>7WBC>11.900/L 98.55 42.86 85.0 90.0 86.0 51.0 5.91 440.11

Diagnosis Fibrinogenbloodlevel*(mg/dl) Whitebloodcell* Alvaradoscore*(accordingtofinalpathology) Mean±SDΔ(range,-) Mean±SDΔ(range,-) Mean±SDΔ(range,-)

≤245.5 >245.5 ≤11.900/L >11.900/L <7 ≥7Normalappendix 9 13 18 4 15 7 200.3±37.22 327±56.63 9030±1682.07 16.100±1186.03 4.8±1.08 7.75±0.88 (range,122-245) (range,246-449) (range,9100-11,800) (range,15,200-17,700) (range,3-6) (range,7-9)Simpleacuteappendicitis 24 60 25 59 22 62 206.82±32.06 339±71.64 9487.5±2172.22 15.160±2350.23 5.04±084 8.16±1.05 (range,111-245) (range,246-505) (range,3900-11.800) (range,12.000-21.300) (range,3-6) (range,7-10)Gangrenousappendix 19 43 14 48 9 53 219.15±20.35 362.95±79.75 9542.85±2145.01 16.229.16±3118.8 4.8±1.16 8.3±0.76 (range,160-245) (range,251-596) (range,4600-11,600) (range,12,000-24,400) (range,3-6) (range,7-10)Perforatedappendix 8 25 3 30 2 31 215.25±25.7 37.4±83.84 10.600±608.27 14.900±2208.65 5.5±0.5 8.29±0.9 (range,170-245) (range,250-605) (range,9900-10,900) (range,12,000-21,300) (range,5-6) (range,7-10)

*Cut-offlevelsofparameters,ΔStandarddeviation.

Table 2.Distributionoffibrinogenbloodlevel,WBC,andAlvaradoscoreaccordingtothefinalpathology

Serum fibrinogen levels in acute appendicitis


Theoptimal test shouldcombineahigh sensitiv-itywithahighpredictivevalueofanegative result.When using the test’s standard reference interval,themanualdeterminationofbandsshowedasignifi-cantlylowersensitivitycomparedwiththeothertests.Further,thediagnosticaccuracyofatestmaybeim-provedbychangingthecut-offlevelifthetestresultisconsideredpositive.Ifthecut-offleveliselevated,thesensitivityornumberoftrue-positivepatientsdetectedbythetestwilldecrease,whilethespecificityornum-beroftrue-negativepatientswill increase.TheexactvalueofthetestisdeterminedbyROCcalculation.WedeterminedtheexactvalueforWBC,AlvaradoscoreandfibrinogenbloodlevelbyROCcalculation.

TheWBCcountisthetestprobablyusedmostof-ten to support thediagnosis ofAA.However,WBCis anon-specific reaction inducedbymanydifferentcauseslikephysicalstress,acuteorchronicinflamma-tionandseveralotherconditions.InpatientswithAA,WBC show an average elevation to approximately15.0x109/L.[9]Pieperandcolleagues[10]reportedexpe-riencewith493patientsofwhomonly67%hadWBCgreater than 11.0x109/L. Cardall and colleagues[11] found the sensitivityofWBCas76%, specificity as52%, positive predictive value (PPV) as 42%, andnegativepredictivevalue(NPV)as82%.

Inourstudy,thebestcut-offpointofWBCforear-lydiagnosisofAAwasfoundas11,900x109/L,andatthispoint, thesensitivity, specificity,PPV,NPV,andaccuracywerecalculatedas72%,77%,96%,25%,and72%,respectively.Inthisrespect,itcanbesaidthatiftheWBClevel isacceptedasover11,900x109/L, itsdiagnosticvaluewillbemorereliableinthediagno-sis ofAA. In addition,we determined the probabil-ityofAAtobe8.53 timesmorewhenWBCisover11,900x109/L.

Diagnostic scores for AA have been claimed tolowerthenon-therapeuticoperationrate.TheAlvara-do scoring system is a point scoring system for thediagnosisofappendicitisbasedonclinicalscienceandsymptoms and a differentialWBC.The accuracy oftheAlvaradoscoreinaclinicalpreoperativediagno-sisofAAhasbeenreportedasrangingfrom50%to95%.[9,10]Inhisoriginalpaper,Alvaradorecommendssurgeryforallpatientswithascoreof7ormoreandobservationforpatientswithscoresof5or6.[8]

Inourstudy,thebestcut-offpointoftheAlvaradoscoreforearlydiagnosisofAAwasfoundas7,andat this point, sensitivity, specificity, PPV, NPV, andaccuracy were calculated at 60%, 82%, 96%, 20%,and63%,respectively.Accordingtoourstudyresults,probability ofAAwas found to be 6.85 timesmorewhentheAlvaradoscorewasover7.Plasmafibrino-genisanacutephaseproteinandthereforeprobably

increaseswithinflammationortissuenecrosis.Inter-pretationofraisedfibrinogenmaybecomplicatedbyitsbehaviorasanacute-phasereactant.Forexample,plasmafibrinogenconcentrationsareraisedafteracutestrokeandacutemyocardial infarction.[12]Amongallknown thrombin substrates, fibrinogen stands out asacentralfactorinhemostasisandacontributortotheinflammatoryresponse.[13]

Fibrinogendepositionisauniversalfeatureinin-jured tissues and inflammatory foci. In vitro studieshaveshownthatfibrinogencanprofoundlyalterWBCfunction,leadingtochangesincellmigration,phago-cytosis,productionofchemokinesandcytokines,de-granulation,andotherprocesses.Manyoftheeffectsoffibrinogenonleukocyteactivityappeartobemedi-atedbyaspecificreceptoronleukocytes,theintegrinreceptorαMβ2.[14,15]

Leukocyte interactionwith fibrinogen or its deg-radation products has special importance at sites ofinflammationsincefibrinogenmaygainaccesstotheextravascularcompartmentbyexudation,whereiten-countersmigratingleukocytes.[16]Itiswellknownthatboththeextentofleukocyterecruitmentandthepro-inflammatory actionof themigrating leukocytes de-terminetheintensityofaninflammatoryreaction,andperipheralhumanneutrophilsarecapableofphagocy-tosis,spreading,andchemotaxis.[17-19]

WeaimedtoinvestigateserumfibrinogenlevelasanewmarkerinthediagnosisofAA.Ourstudyisprob-ablythefirstreporttousefibrinogenbloodlevelinthediagnosisofAA.Inourcurrentstudy,thebestcut-offforserumfibrinogenlevelwasfoundas245.5mg/dl,andatthispoint,thesensitivity,specificity,PPV,NPV,and accuracy were calculated as 70%, 50%, 92%,17%, and 68%, respectively. Probability ofAAwasfound to be2.38 timesmorewhenfibrinogenbloodlevelwasover245.5mg/dl.Fibrinogen resultswerefoundtohavesimilarefficacytoWBCandAlvaradoscoresinthediagnosisofAA.

Bloodtestshavebeenshowntohavelowsensitivity and specificity in differentiating simple AA froma perforated appendix in a majority of the studies.[20,21]However, ina fewstudies, theWBCwasmoresensitive thanC-reactive protein (CRP) in the diag-nosisofsimpleAA,[22]andCRPwasreportedasmoresensitivethanWBCincasesofaperforatedappendix.[23]

NumerousstudieshaveshownthatincreasedCRPlevelsinthebloodaidintheaccuratediagnosisofAA.Han-pingWuandcolleagues[24]noticedthatthemeanCRPlevelinpatientswithperforatedappendicitiswasmuchgreaterthaninpatientswithsimpleappendicitis,andtheyfoundtheroleofCRPdidserveinthediffer-entialdiagnosisofperforatedappendicitis.Thatstudy



mentionedCRP levels using different cut-off valuesbasedonhowlongthepatient’ssymptomswerepres-enttoimprovethediagnosticaccuracyofsimpleandperforatedappendicitis,andthatCRPwouldbehelp-fulinpredictingappendicitisearlierandreducingtherate of complications caused by delay in diagnosis.Inourstudy,wefoundthesameresultsaccordingtofibrinogenbloodlevelandthedurationofsymptoms(<24hor>24h).FibrinogenbloodlevelanddurationofsymptomshaveshowntocontributegreatlytothediagnosisofAA.

The diagnostic value of a single test in AA islimitedbecause thisprocesscannotbedifferentiatedfromotheracuteinflammatoryconditions.Thetripletest combination’s sensitivity, specificity,PPV,NPV,and accuracy were calculated as 85%, 90%, 99%,43%, and 86%, respectively. Probability ofAAwasfoundtobe51timesmorewhenthetripletestlevelswereovercut-offlevels.

Inconclusion,AAremainsthemostcommoncon-dition requiring emergent surgery. Early diagnosisplaysakeyroleinpreventingcomplicationsoriginat-ingfromperforation.However,surgeonsmustachievea balance between premature operation with a highnegativeappendectomyrateandadelayeddiagnosis(andsurgery)withahigherperforationrate.Thereisnosign,symptom,orlaboratorytestthatis100%reli-ableinthediagnosisofAA.

Ourresultssuggestthattheuseoffibrinogenbloodlevelmay be a new diagnostic acute-phase reactantinthediagnosisofAA.Theformulationofthetripletest’s result is recommended as a guide in decidingwhichpatientundergoesemergencysurgeryorobser-vation.

AcknowledgementsMr.AhmetGulmade significant contributions to

thestudythoughhisstatisticalanalysis.

REFERENCES1. FeldmanM.Thesmallintestine.In:SleisengerM,Fordtran

J,editors.Gastrointestinalandliverdiseases.6thed.Phila-delphia,PA:W.B.Saunders;1998.p.1778-87.

2. AddissDG,ShafferN,FowlerBS,TauxeRV.Theepidemiol-ogyofappendicitisandappendectomyintheUnitedStates.AmJEpidemiol1990;132:910-25.

3. DueholmS,BagiP,BudM.Laboratoryaidinthediagnosisof acute appendicitis.Ablinded, prospective trial concern-ing diagnostic value of leukocyte count, neutrophil dif-ferential count, andC-reactive protein.DisColonRectum1989;32:855-9.

4. VelanovichV,SatavaR.Balancingthenormalappendecto-myratewiththeperforatedappendicitisrate:implicationsforqualityassurance.AmSurg1992;58:264-9.

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7. FlumDR,KoepsellT.Theclinicalandeconomiccorrelatesof misdiagnosed appendicitis: nationwide analysis. ArchSurg2002;137:799-804.

8. AlvaradoA.Apracticalscorefortheearlydiagnosisofacuteappendicitis.AnnEmergMed1986;15:557-64.

9. RicciMA,TrevisaniMF,BeckWC.Acute appendicitis.A5-yearreview.AmSurg1991;57:301-5.

10.PieperR,KagerL,NäsmanP.Acuteappendicitis:aclinicalstudyof1018casesofemergencyappendectomy.ActaChirScand1982;148:51-62.

11.CardallT,Glasser J, GussDA.Clinical value of the totalwhite blood cell count and temperature in the evaluationof patients with suspected appendicitis.Acad EmergMed2004;11:1021-7.

12.DormandyJ,ErnstE,MatraiA,FlutePT.Hemorrheologicchangesfollowingacutemyocardialinfarction.AmHeartJ1982;104:1364-7.

13.MolmentiEP,ZiambarasT,PerlmutterDH.Evidenceforanacutephase response inhuman intestinal epithelial cells. JBiolChem1993;268:14116-24.

14.FlickMJ,DuX,WitteDP,JirouskováM,SolovievDA,Bu-suttilSJ,etal.Leukocyteengagementoffibrin(ogen)viatheintegrinreceptoralphaMbeta2/Mac-1iscriticalforhostin-flammatoryresponseinvivo.JClinInvest2004;113:1596-606.

15.TangL,EatonJW.Fibrin(ogen)mediatesacuteinflammatoryresponsestobiomaterials.JExpMed1993;178:2147-56.

16.Sitrin RG, Pan PM, Srikanth S, Todd RF 3rd. FibrinogenactivatesNF-kappaB transcription factors inmononuclearphagocytes.JImmunol1998;161:1462-70.

17.WatsonRW,RotsteinOD,NathensAB,ParodoJ,MarshallJC.Neutrophilapoptosisismodulatedbyendothelialtrans-migration and adhesion molecule engagement. J Immunol1997;158:945-53.

18.NathanC,SrimalS,FarberC,SanchezE,KabbashL,AschA,etal.Cytokine-inducedrespiratoryburstofhumanneu-trophils: dependence on extracellular matrix proteins andCD11/CD18integrins.JCellBiol1989;109:1341-9.

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389




5th Department of General Surgery, Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey.

Haydarpaşa Numune Eğitim ve Araştırma Hastanesi, 5. Genel Cerrahi Kliniği, İstanbul.

Correspondence (İletişim): Erkan Özkan, M.D. Bosna Bulvarı, Taşlıbayır Sok. No: 28 B Blok Kat: 3 Da: 7, Üsküdar, İstanbul, Turkey.


AMAÇBu çalışmada, acil cerrahi kliniğimizde boğulmuş abdo-minal duvar hernisi nedeniyle ameliyat edilen hastalardamorbiditevemortaliteyleilişkiliriskfaktörlerinininsidansıaraştırıldı.

GEREÇ VE YÖNTEMHastalarhemfıtıktürünegöre(inguinal,umblikal,insizyo-nel,femoral)kendiaralarındahemdemorbiditevemorta-liteüzerineetkilifaktörlerbakımından;yaş,cinsiyet,Ame-rikanAnesteziyoloji Derneği (AAD) skoru, anestezi tipi,eşlikedenhastalıklar,intestinalboğulmavenekrozvarlığıgibiverilerledeğerlendirildi.

BULGULARİnguinal herni erkeklerde, umblikal ve femoral herni ka-dınlarda sıktı (p<0,001). Femoral hernide boğulma venekrozdan dolayı intestinal rezeksiyon diğer fıtık türleri-negöreanlamlıolarakyükseksaptandı(sırasıyla,p<0,005ve p<0,001).Morbiditevemortaliteüzerine;ileriyaş(≥65yaş),ekhastalık,strangülasyon,nekroz,yüksekAADsko-ru (III, IV), semptomların başlamave hastaneyebaşvurusüresininanlamlıetkisibulundu.Genelanestezinindemor-biditeiçinriskoluşturduğugörüldü(p<0,05).

SONUÇBoğulmuşabdominalduvarhernileriyüksekmorbiditevemortaliteoranınasahipbircerrahiproblemdir.Buyüzdenhernisaptandığındaelektifkoşullardaameliyatplanlanma-lıdır.

Anahtar Sözcükler: Abdominalduvarhernisi;inkarserasyon;nek-roz;strangülasyon.

BACKGROUNDTheaimofthepresentstudywastoinvestigatemorbidity-and mortality-related risk factors in patients undergoingsurgeryduetoincarceratedabdominalwallhernia.

METHODSThepatientsweregroupedaccordingtothetypeofhernia(inguinal,umbilical,incisional,femoral),andthesegroupswereevaluatedintermsofriskfactorsaffectingmorbidityandmortalitysuchasage,gender,AmericanSocietyofAn-esthesiologists(ASA)score,typeofanesthesia,concomi-tantdiseases,andthepresencesofintestinalstrangulationandnecrosis.

RESULTSInguinalherniawasfrequentinmales,whereasfemoralherniawasfrequentinfemales(p<0.001).Therateofintestinalresec-tionduetostrangulationandnecrosiswasfoundsignificantlyhigheramongfemoralherniasascomparedtotheothertypesofhernia(p<0.005andp<0.001,respectively).Advancedage(≥65 years), concomitant disease, strangulation, necrosis,highASAscore(III-IV), timefromtheonsetofsymptoms,andtimetohospitaladmissionwerefoundtohavesignificantinfluencesonmorbidityandmortality.Generalanesthesiawasfoundtobeariskfactorformorbidityaswell(p<0.05).

CONCLUSIONIncarceratedabdominalwallherniasaresurgicalproblemswithhighmorbidityandmortalityrates.Therefore,surgeryshouldbeplannedunderelectiveconditionswhenherniaisdetected.Key Words: Abdominal wall hernia; incarceration; necrosis;strangulation.

doi: 10.5505/tjtes.2012.48827

Incarcerated abdominal wall hernia surgery: relationship between risk factors and morbidity and mortality

rates (a single center emergency surgery experience)

Boğulmuşabdominalduvarhernicerrahisi:Morbiditevemortaliteinsidansınınriskfaktörleriyleilişkisininanalizi(Tekmerkezliacilcerrahideneyimi)

Erkan ÖZKAN, Mehmet Kamil YILDIZ, Tuğrul ÇAKIR, Ender DULUNDU, Cengiz ERİŞ, Mehmet Mahir FERSAHOĞLU, Ümit TOPALOĞLU


Abdominalwall hernia (AWH) surgery is amongthemostfrequentlyperformedgeneralsurgicalopera-tionsthroughouttheworld.[1]Incarcerationandstran-gulationarethemostseverecomplicationsandaccountforasubstantialportionofthepatientspresentingtoemergencysurgeryclinicswithacuteabdominalcom-plaints. Of theAWH cases, approximately 5%-13%may require emergency surgerydue to incarcerationandobstruction,andofthecasesundergoingemergen-cysurgery,10%-15%mayrequireintestinalresectiondue tonecrosis.[2,3] Insuchsurgicaloperations, inad-equatepreoperativepreparationandtheadvancedageof themajority of the patients lead to a remarkableincreaseinmorbidityandmortality.[4]

Theaimof thepresent studywas toevaluate therateofmorbidity-andmortality-relatedriskfactorsinpatients undergoing surgical operation in our emer-gencysurgeryclinicduetoincarceratedAWH.

MATERIALS AND METHODSOnehundredandninetypatientsunderwentemer-

gency surgery due to incarceratedAWH in the 5thGeneral Surgery Clinic of HaydarpasaTraining andResearchHospitalbetweenDecember2003andJanu-ary2011.Indicationsforemergencysurgeryincludedirreduciblemass,painlocalizedtotheabdominalwall,andthesignsandsymptomsofmechanicalintestinalobstruction. All patients were systematically evalu-ated prior to the operation. Complete blood count,biochemicalanalysis,andelectrocardiography(ECG)were performed. Chest and direct abdominal radio-graphswereobtainedwhilethepatientwasinastand-ingposition.Thosewithaconcomitantdiseasewerepreoperativelyreferredtotherelatedclinicsforcon-sultationaccording topathologicaldata andmedicalhistories.A single dose of second-generation cepha-losporinwasadministeredasprophylaxis.Caseswithintestinalnecrosis,whichfailedtonormalizedespitehot saline application and waiting after the releaseof theneckof theherniasac, required resectionandanastomosis.Inpatientswithintestinalnecrosis,anti-biotherapywascontinuedinthepostoperativeperiodforanadditionalfivedaysonaverage.Allthepatientsunderwentsurgicaloperationwithinthefirst24hoursof their hospital admission. General anesthesia waspreferred for incarcerated umbilical hernia and inci-sional hernia of the upper abdomen,whereas spinalorgeneralanesthesiawasperformedforincarceratedinguinalandfemoralherniasandincisionalherniaofthelowerabdomen.Theanesthesiologistdecidedthetypeofanesthesiatobeperformed.Inguinalincisionswereusedforinguinalandfemoralhernias.However,theoperationwascompletedbyconverting the inci-sion into superior and inferior umbilical incision ininguinal and femoral hernia cases undergoing intes-tinal resection and anastomosis. Cooper’s ligament

hernioplasty (McWay) and anterior prostheticmesh-plughernioplastymethodswereusedinfemoralher-niacases,whereastension-freeherniarepairwasper-formedwithmonofilamentpolypropylenemeshintheothertypesofhernia.Thetermmorbiditywasusedforpostoperativemajorandminorcomplications(woundsite,pulmonaryandcardiaccomplications).Thetermmortalitywasused for deathswithin30daysof theoperationorbeforedischarge from thehospital.Thepatientswere grouped according to the hernia type,andthegroupswerethenevaluatedwithrespecttothefactorsaffectingmorbidityandmortality,suchasage,gender,AmericanSocietyofAnesthesiologists(ASA)score,typeofanesthesia,intestinalstrangulationandnecrosis, and thepresenceofaconcomitantdisease.StatisticalanalysesofthedatawereperformedusingNumberCruncherStatisticalSystem(NCSS)2007andPowerAnalysisandSampleSize(PASS)2008Statis-ticalSoftware(Utah,USA)program.Inadditiontothedescriptivestatisticalmethods(mean,standarddevia-tion, ratio),Kruskal-Wallis testwas used for the in-tergroupcomparisonofthequantitativedata,whereasMann-WhitneyU-testwasusedtoidentifythegroupthatcaused thedifferenceandfor thecomparisonoftwo groups. Qualitative data were compared usingchi-squaretestandFisher’sexacttest.Apvalue<0.05wasconsideredstatisticallysignificant.

RESULTSOfthe2,380AWHcases(inguinal,umbilical, in-

cisional,femoral)operatedinthe5thGeneralSurgeryClinicofIstanbulHaydarpasaTrainingandResearchHospitalbetweenDecember2003andJanuary2011,190(7.98%)underwentemergencysurgeryduetoin-carceration.Considering the hernia type, the rate ofemergency surgery was the highest among femoralhernias (47.1%),but the lowestamong inguinalher-nias(6.1%)(Table1).Oftheemergencycaseswithin-carceration,55.8%hadinguinal,21.1%hadumbilical,14.7%hadincisional,and8.4%hadfemoralhernias.Themeanageof thecaseswas60.81±15.51 (range,27-92years).Ofthecases,64.7%(n=123)weremalesand35.3%(n=67)werefemales.


Table 1. Theprevalenceofemergencysurgicalproceduresaccordingtotheherniatype

Typeof Emergencysurgical Totalsurgicalhernia procedure procedures n(%) n

Inguinal 106(6.12%) 1732Umbilical 40(9.95%) 402Incisional 28(13.2%) 212Femoral 16(47.05%) 34

Incarcerated abdominal wall hernia surgery

General anesthesiawas preferred in 135 (71.0%)andspinalanesthesiain55(29.0%)cases.Therateofusing general anesthesia was significantly higher inumbilicalandincisionalherniasurgeries(p<0.001).

Hernias were simply reduced in 98 (51.5%) pa-tients; however, strangulation was detected in 92(48.5%)patientsduringthesurgery.Whereasintesti-nalbloodcirculationrecoveredin55(29%)patients,37 (19.5%) patients underwent intestinal resection(33[17.3%]small intestineand4[2.2%]colon)andanastomosis due to necrosis.Omental resectionwasrequiredin6(3.1%)patients.

Therewasasignificantdifferencebetweengendersin terms of hernia types. Inguinal hernia was morecommoninmales,whereasumbilicalandfemoralher-niasweremorecommoninfemales(p<0.001)(Fig.1,Table2).Therateofintestinalresectionduetostran-gulationandnecrosiswas found significantlyhigher

infemoralherniasascomparedtotheothertypesofhernia(p<0.005andp<0.001,respectively)(Table2).Therewasnosignificantdifferencebetweenthetypesofherniaintermsofage,morbidity,mortality,orre-currencerates(p>0.05)(Table2).


Table 2. Evaluationsaccordingtotheherniatypes

Typeofhernia

Inguinal Incisional Umbilical Femoral p (n=106) (n=28) (n=40) (n=16)

Age <65 64(60.4%) 12(42.9%) 25(62.5%) 8(50%) 0.309 ≥65 42(39.6%) 16(57.1%) 15(37.5%) 8(50%)Gender Male 90(84.9%) 16(57.1%) 12(30%) 5(31.3%) 0.001** Female 16(15.1%) 12(42.9%) 28(70%) 11(68.8%)AmericanSocietyofAnesthesiologists I 6(5.7%) 2(7.1%) 6(15%) 0(0%) 0.026* II 42(39.6%) 15(53.6%) 16(40%) 8(50%) III 46(43.4%) 3(10.7%) 12(30%) 4(25%) IV 12(11.3%) 8(28.6%) 6(15%) 4(25%)Anesthesia General 58(54.7%) 24(85.7%) 40(100%) 13(81.3%) 0.001** Spinal 48(45.3%) 4(14.3%) 0(0%) 3(18.7%)Intestinalstrangulation Positive 44(41.5%) 16(57.1%) 18(45%) 14(87.5%) 0.005** Negative 62(58.5%) 12(42.9%) 22(55%) 2(12.5%)Concomitantdisease Positive 51(49.2%) 12(42.8%) 17(42.5%) 7(43.7%) 0.913 Negative 55(51.8%) 16(57.2%) 23(57.5%) 9(56.3%)Intestinalnecrosis Positive 14(13.2%) 7(25%) 6(15%) 10(62.5%) 0.001** Negative 92(86.8%) 21(75%) 34(85%) 6(37.5%)Morbidity Positive 14(13.2%) 7(25%) 4(10%) 2(12.5%) 0.336 Negative 92(86.8%) 21(75%) 36(90%) 14(87.5%)Mortality Positive 5(4.7%) 1(3.6%) 0(0%) 0(0%) 0.443 Negative 101(95.3%) 27(96.4%) 40(100%) 16(100%)Recurrence Yes 6(5.9%) 1(3.8%) 1(2.5%) 0(0%) 0.642 No 95(94.1%) 25(96.2%) 39(97.5%) 16(100%)

Chi-squaretestwasused*p<0.05;**p<0.01.

Inguinal Femoral Incisional Umblical

Percent(%)

%85

%31

%57

%30

%15

%69

%43

%70

0

10

20

30

40

50

60

70

80

90Male Female

Fig. 1. Distributionoftypesofherniaaccordingtogenders.


Mortalitywas detected in 6 (3.1%) patients, andthereasonsformortalitywerecongestivecardiacin-sufficiencyin4,pulmonaryembolismin1,andadultrespiratorydistresssyndrome(respiratoryinsufficien-cy)in1patient.

Morbiditywasdetectedin27(14.2%)patients,andthereasonsformorbiditywerelocalwoundsitecom-plications in14 (10woundsite infection,4 seroma),postoperativeileusin4,testicularedemain3,atelecta-sisin2,pneumoniain2,andcongestivecardiacinsuffi-


Table 3. Evaluationsaccordingtomorbidity

Morbidity p

Positive Negative n(%) n(%)

Age <65 4(14.8%) 105(64.4%) 0.001**≥65 23(85.2%) 58(35.6%)Gender Male 17(63%) 106(65%) 0.835 Female 10(37%) 57(35%)Typeofhernia Inguinal 14(51.9%) 92(56.4%) 0.336 Femoral 2(7.4%) 14(8.6%) Incisional 7(25.9%) 21(12.9%) Umbilical 4(14.8%) 36(22.1%)Concomitantdisease Positive 21(77.7%) 66(40.4%) 0.001** Negative 6(22.3%) 97(59.6%)Intestinalstrangulation Positive 22(81.5%) 70(42.9%) 0.001** Negative 5(18.5%) 93(57.1%)Symptomduration ≤24hours 6(22.2%) 114(69.9%) 0.001** >24hours 21(77.8%) 49(30.1%)ASA I-II 2(7.4%) 93(57.1%) 0.001** III-IV 25(92.6%) 70(42.9%)Intestinalnecrosis Positive 14(51.9%) 23(14.1%) 0.001** Negative 13(48.1%) 140(85.9%)Anesthesia General 25(92.6%) 114(69.9%) 0.017* Spinal 2(7.4%) 49(30.1%)

ASA:AmericanSocietyofAnesthesiologists.Chi-squaretestwasused.*p<0.05;**p<0.01.

Table 4. Evaluationsaccordingtomortality

Mortality p

Positive Negative n(%) n(%)

Age <65 0(0%) 109(59.2%) 0.005** ≥65 6(100%) 75(40.8%)Gender Male 5(83.3%) 118(64.1%) 0.427 Female 1(16.7%) 66(35.9%)Typeofhernia Inguinal 5(83.3%) 101(54.9%) 0.443 Femoral 0(0%) 16(8.7%) Incisional 1(16.7%) 27(14.7%) Umbilical 0(0%) 40(21.7%)Intestinalstrangulation Positive 4(66.7%) 88(47.8%) 0.433 Negative 2(33.3%) 96(52.2%)Symptomduration ≤24hours 1(16.7%) 119(64.7%) 0.026* >24hours 5(83.3%) 65(35.3%)Concomitantdisease Positive 6(100%) 81(44.0%) 0.008** Negative 0(0%) 103(56%)ASA score I-II 0(0%) 95(51.6%) 0.029* III-IV 6(100%) 89(48.4%)Intestinalnecrosis Positive 4(66.7%) 33(17.9%) 0.014* Negative 2(33.3%) 151(82.1%)Anesthesia General 5(83.3%) 134(72.8%) 1.000 Spinal 1(16.7%) 50(27.2%)ASA:AmericanSocietyofAnesthesiologists.Chi-squaretest,Fisher’sexacttestwereused.*p<0.05;**p<0.01.

Percent(%)

0

10

20

30

40

50

60

70

80

90

100Morbidity(+)

Morbidity(–)

≤24time I-II Positive General Positive>24time III-IV Negative Spinal NegativeSymptomduration ASA Intestinalnecrosis Anesthesia Concomitantdisease

Fig. 2. Factorsaffectingmorbidity.

ciencyin2patients.Concomitantdiseasewasdetectedin87(45.7%)patients.Concomitantdiseasesincludedchronicobstructivepulmonarydisease(COPD),coro-nary artery disease, congestive cardiac insufficiency,hypertension,andtype2diabetesmellitus.

The rates of advanced age (≥65 years), strangu-lation, necrosis, highASA score (III-IV), symptomduration,andpresenceofconcomitantdiseaseswerefoundsignificantlyhigh in thegroupwithmorbidityandmortalityascomparedtothegroupwithoutmor-bidityandmortality(Tables3,4,Figs.2,3).Thepres-entstudydemonstratedthatgeneralanesthesiawasariskformorbidityaswell(p<0.05).

Therewasasignificantdifferencebetweenherniatypes in termsofdurationofhospital stay (p<0.01).Duration of hospital stay was found significantlyshorter in the inguinal hernia group as compared tothe femoral, incisional and umbilical hernia groups(p<0.003, p<0.001 and p<0.004, respectively). Nosignificantdifferencewasfoundbetweenthefemoral,incisionalandumbilicalherniagroupsintermsofdu-rationofhospitalstay(Table5)(p>0.05).Durationofhospitalstaywassignificantlyhigherinthecaseswithnecrosisascomparedtothosewithoutnecrosis(Table6)(p<0.001).

DISCUSSIONDespite the advances in anesthesia, antisepsis,

antibiotics,andfluid replacement, themorbidityand

mortalityfollowingincarceratedAWHsurgeryremainhigh.Theratesofmortalityandmorbidityhavebeenreported tobe approximately5%and20%-30%, re-spectively.[2,4-6] The results obtained in the presentstudy were consistent with the literature showing amortalityrateof3.1%andamorbidityrateof14.2%.Manyfactorsaffectingmortalityandmorbidityhavebeenreported.Inthepresentstudy,themorbidityratewasthehighestinincisionalhernia,whereasthemor-talityratewas thehighest in inguinalhernia,andnosignificant effect of the hernia typewas determined(p>0.05).

While incarcerated inguinal hernias have beenmorecommonlyreportedinmales,femoralandum-bilicalherniasaremorecommon in females,andnosignificanteffectofgenderonmortalityandmorbidityhasbeenshown.[2,7]Similarly,inthepresentstudy,in-guinalherniawasmorecommoninmalesandfemoralandumbilicalherniasweremorecommoninfemales



Table 5. Evaluationoftimeofdischargeaccordingtotheherniatypes

Typeofhernia

Inguinal Femoral Incisional Umbilical p Mean±SD(median) Mean±SD(median) Mean±SD(median) Mean±SD(median)

Timeofdischarge(days) 4.20±2.23(4) 7.75±6.84(5) 6.22±2.61(6) 6.30±4.51(5.5) 0.001**

Chisquaretest;**p<0.01.

Table 6. Durationofhospitalstayaccordingtointestinalnecrosis

Durationofhospitalstay p

Intestinalnecrosis Mean±SD Median

Positive 8.78±6.42 4.0 0.001**Negative 4.63±2.49 7.0

Mann-WhitneyUtest**p<0.01.

Percent(%)

0

10

20

30

40

50

60

70

80

90

100

Mortality(+)

Mortality(–)

≤24time I-II Positive General Positive>24time III-IV Negative Spinal NegativeSymptomduration ASA Intestinalnecrosis Anesthesia Concomitantdisease

Fig. 3. Factorsaffectingmortality.

(p<0.001);nosignificanteffectofgenderonmorbidity(p=0.835)ormortality(p=0.427)wasobserved.

Advancedage(≥65years)isaneffectivefactoronmorbidityandmortalityinincarceratedAWHsurgeries.[8,9]Alverezetal.[7]reportedthatpostoperativepulmo-naryandcardiovascularcomplicationswerefrequentlyencounteredintheelderly,andconsequently,thedura-tion of hospital staywas prolonged in such patients.Martínez-Serranoetal.[6]statedthatadvancedagewasaneffectivefactoronmorbidityandmortalityinincar-ceratedAWHcases.Likewise,inthepresentstudy,itwasdemonstratedthatadvancedagehadasignificanteffectonmorbidity(p<0.001)andmortality(p<0.005).Ofthepatientswithmorbidity,85.2%were≥65years,whereasallpatientswithmortalitywere≥65years.

HighASAscore(III-IV)andconcomitantdiseasesare the other factors that affect mortality and mor-bidity.[7]Gloubetal.[10]reportedthathighASAscorewasoneof themost important independentriskfac-torsaffectingmortality.Asignificantly longerhospi-talstayandasignificantlyhighermorbidityratehavealsobeenreportedinelderlypatientswithASAclassIII or IVwho underwent emergency hernia repair.[4] ThestudyconductedbyAlvarezetal.[7]reportedthathighASAscorewasafactoraffectingmorbidityandmortality. The present study demonstrated that pa-tientswithhighASAscorehadsignificantmorbidity(p<0.001)andmortality(p=0.029).

Latepresentationtothehospitalisalsoanimpor-tantfactorformorbidityandmortalitysinceitislikelyto forma basis for intestinal necrosis and resection.Ashirov et al.[11] stated that the mortality was highamongthefemoralherniacasespresentingtothehos-pitallaterthan48hours.Kulahetal.[4]demonstratedthatmorbidityandmortalityrateswereincreaseddueto strangulation and necrosis in incarcerated herniacasespresenting to thehospital laterascompared tothose presenting earlier. Patients presenting to thehospital24hoursafterthedevelopmentofincarcera-tionaccountedfor81.8%ofthecaseswhodied.Inthepresentstudy,83.3%ofthecaseswhodiedand77.8%ofthecaseswithmorbiditywerethepatientswhopre-sentedtothehospital24hoursafterthedevelopmentofincarceration.Latepresentationtothehospitalwasattributed to thesocioeconomicstatusof thepatient,topresentationtosmallhospitalsthatlackarelevantspecialist,andtomisdiagnosisbythephysicians.Thepresentstudyalsodemonstratedthatlatepresentationto the hospital had a significant effect onmorbidityandmortality(p<0.001andp=0.026,respectively).

Generalanesthesiahasbeenreportedtobeoneofthefactorsaffectingmortalityduetothepresenceofconcomitant disease.[4,7] Derici et al.[5] reported thatthetypeofanesthesiahadnoeffectonmortality,but

generalanesthesiasignificantlyincreasedthemorbid-ityascomparedtospinalanesthesia.Thepresentstudydemonstrated that general anesthesia increased themorbidityascomparedtospinalanesthesia(p=0.017),buthadnosignificanteffectonmortality(p=1.00).

Strangulationofahernia isa surgicalemergencyand has high mortality. Mortality increases in casethereisaneedforintestinalresection.[12]Femoraltypehernia substantially leads to incarceration and stran-gulation, and thus requires intestinal resection.[13,14]Among the hernia types, intestinal necrosis is mostcommonlyencounteredinfemoralhernias.However,nosignificanteffectoftheherniatypeonmortalityandmorbidityhasbeendemonstrated.[4,15]Femoralherniamaybemisdiagnosed as inguinal hernia, lymphade-nopathy, lipoma,orpsoasabscess.[16]The rateof in-carcerationandstrangulationhasbeenreportedtobe44%-86%infemoralhernias.[8,17]Inthepresentstudy,theratesofstrangulationandnecrosisinfemoralher-niaswerefoundas87.5%and62.5%,respectively.

In thestudyconductedbyKurtetal.,[3] intestinalnecrosiswasmostcommoninfemoralherniacases.Inthepresentstudy,therateofnecrosiswasfoundsig-nificantlyhigherinfemoralherniacasesascomparedtotheothertypesofhernia.

Inthepresentstudy,whilestrangulationwasfoundto have a significant effect onmorbidity (p=0.001),it had no significant effect on mortality (p=0.433).However,itwasobservedthatnecrosishadasignifi-canteffectonbothmorbidity(p=0.001)andmortality(p=0.014).

Thedurationofhospitalstayincreasesduetone-crosisandresection.Kurtetal.[3]reportedthatthepe-riodafter theresectiondue tonecrosiswaseffectiveonmorbidity andprolonged thedurationofhospitalstay.Inthepresentstudy,thedurationofhospitalstaywas found to be prolonged in the patients undergo-ingresectionduetonecrosis(p=0.001).Necrosiswaslowest in inguinalhernia cases, and the time todis-chargewas shorter as compared to the other herniatypes(p<0.001).

Thegoldstandardinthesurgical treatmentofin-carcerated AWHs is repair of the hernia with lowmorbidity and mortality and low recurrence rate inthelong-termfollow-up.Factorsthatinfluencerecur-rences in hernia surgery include inadequate surgicaltechnique,sizeof thehernia,obesity,woundsite in-fection,cigarettesmoking,diabetes,COPD,advancedage, and the use of steroid.[18-22]Recurrence rate hasbeenreportedintheliteratureas1-22%forincarcer-atedinguinalhernias[23,24]andas1-10%forincarcerat-edfemoralhernias.[25]Inthepresentstudy,recurrencewasdetermined in totally8 (4.2%) cases; the recur-renceratewashighestininguinalhernia(n=6,5.9%)



ascomparedtoallherniatypes.Syntheticgraftshavebeenused inherniasurgery

for30years.Thepolypropylenegraft isdurableandstimulates fibroplasia due to itsmonofilament struc-ture.Itneithertriggersinfectionnorisrejectedbythetissues.[26,27]Meshusehasnocontraindicationinmanypatientsthatrequireintestinalresection.Ithasbeenre-portedthatpolypropylenemeshescanbeusedsafelyininguinalherniacasesthatundergointestinalresection.[28] Polypropylenemeshes are resistant against infec-tionsduetotheirmacroporousstructureandcanbeusedsafely inAWHdefects.Repair techniquesperformedusingProlenemeshinanteriorAWHsinthehandsofexperiencedsurgeonsandinaccordancewiththetech-niquewouldprovidelowermorbidityandrecurrencerates.Intheirstudy,Beltranetal.[29]usedmeshinbothelectiveandstrangulatedherniarepairsandcouldnotfindanysignificantdifference in termsofpostopera-tivecomplications.Bessaetal.[30]statedthattherewasno difference between elective or emergency meshuse in termsof postoperative complications and thatmeshcouldbeusedsafely.Papaziogasetal.[31]foundnodifferencebetweeninguinalherniarepairwithandwithoutmeshintermsofpostoperativecomplicationsandwoundinfection.Surgicalrepairusingmeshisthecurrenttrendinthetreatmentofprimaryorrecurrentumbilicalherniasinbothobeseandnon-obeseadultsduetoitslowerrecurrencerateascomparedtosurgicalrepairbysuturing(1%vs.11%).[32,33]

Inconclusion,thepresentstudydemonstratedthatadvanced age (≥65 years), presence of concomitantdisease, intestinal strangulation,necrosisand intesti-nalresection,highASAscore(III-IV),andtimefromonset of the symptoms were effective on morbidityandmortality.Generalanesthesiaposesariskformor-bidityaswell.AsAWHisidentified,surgeryshouldbeperformedunderelectiveconditionsinordertoavoidtherisksofemergencysurgery.

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nias.In:MulhollandMW,DohertyGM,LillemoeKD,MaierRV,SimeoneD,UpchurchGR,editors.Greenfieldssurgery.Scientific principles & practice. 5th ed. Philadelphia, PA:LippincottWilliamsandWilkins;2011.p.1159-98.

2. KulahB,Kulacoglu IH,OrucMT,DuzgunAP,MoranM,OzmenMM,etal.Presentationandoutcomeofincarceratedexternalherniasinadults.AmJSurg2001;181:101-4.

3. KurtN,OncelM,OzkanZ,BingulS.Riskandoutcomeofbowelresectioninpatientswithincarceratedgroinhernias:retrospectivestudy.WorldJSurg2003;27:741-3.

4. KulahB,DuzgunAP,MoranM,KulacogluIH,OzmenMM,CoskunF.Emergencyherniarepairsinelderlypatients.AmJSurg2001;182:455-9.

5. DericiH,UnalpHR,BozdagAD,NazliO,TansugT,KamerE.Factorsaffectingmorbidityandmortalityinincarceratedabdominalwallhernias.Hernia2007;11:341-6.

6. Martínez-SerranoMA,Pereira JA,Sancho JJ,López-CanoM,BombuyE,HidalgoJ;StudyGroupofAbdominalHerniaSurgeryoftheCatalanSocietyofSurgery.Riskofdeathafteremergencyrepairofabdominalwallhernias.Stillwaitingforimprovement.LangenbecksArchSurg2010;395:551-6.

7. Alvarez JA, BaldonedoRF, Bear IG, Solís JA,Alvarez P,Jorge JI. Incarcerated groin hernias in adults: presentationandoutcome.Hernia2004;8:121-6.

8. OishiSN,PageCP,SchwesingerWH.Complicatedpresenta-tionsofgroinhernias.AmJSurg1991;162:568-71.

9. Heydorn WH, Velanovich V. A five-year U.S. Army ex-perience with 36,250 abdominal hernia repairs. Am Surg1990;56:596-600.

10.GolubR,CantuR.Incarceratedanteriorabdominalwallher-niasinacommunityhospital.Hernia1998;2:157-61.

11.AshirovAA,MalevannyĭAV.Immediateresultsof treatingstrangulatedhernias.[ArticleinRussian]VestnKhirImIIGrek1986;136:37-41.[Abstract]

12.Tiernan JP, Katsarelis H, Garner JP, Skinner PP. Excel-lent outcomes after emergency groin hernia repair. Hernia2010;14:485-8.

13.GallegosNC,DawsonJ,JarvisM,HobsleyM.Riskofstran-gulationingroinhernias.BrJSurg1991;78:1171-3.

14.Ihedioha U, Alani A, Modak P, Chong P, O’Dwyer PJ.Hernias are the most common cause of strangulation inpatients presenting with small bowel obstruction. Hernia2006;10:338-40.

15.NesterenkoIuA,ShovskiĭOL.Outcomeoftreatmentofin-carcerated hernia. [Article in Russian] Khirurgiia (Mosk)1993:26-30.[Abstract]

16.AlimogluO,KayaB,OkanI,DasiranF,GuzeyD,BasG,etal.Femoralhernia:areviewof83cases.Hernia2006;10:70-3.

17.Hachisuka T. Femoral hernia repair. Surg Clin NorthAm2003;83:1189-205.

18.VenclauskasL,MaleckasA,KiudelisM.One-year follow-upafterincisionalherniatreatment:resultsofaprospectiverandomizedstudy.Hernia2010;14:575-82.

19.BurgerJW,LuijendijkRW,HopWC,HalmJA,VerdaasdonkEG, Jeekel J. Long-term follow-up of a randomized con-trolledtrialofsutureversusmeshrepairofincisionalhernia.AnnSurg2004;240:578-85.

20.LuijendijkRW,HopWC, van denTolMP, deLangeDC,BraaksmaMM,IJzermansJN,etal.Acomparisonofsuturerepairwithmeshrepairforincisionalhernia.NEnglJMed2000;343:392-8.

21.LeH,Bender JS.Retrofascialmesh repair of ventral inci-sionalhernias.AmJSurg2005;189:373-5.

22.IqbalCW,PhamTH,JosephA,MaiJ,ThompsonGB,SarrMG.Long-termoutcomeof254complex incisionalherniarepairsusingthemodifiedRives-Stoppatechnique.WorldJSurg2007;31:2398-404.

23.DericiH,UnalpHR,NazliO,KamerE,CoskunM,TansugT,etal.Prostheticrepairofincarceratedinguinalhernias:isitareliablemethod?LangenbecksArchSurg2010;395:575-9.

24.HaapaniemiS,NilssonE.Recurrenceandpain threeyearsaftergroinhernia repair.Validationofpostalquestionnaireandselectivephysicalexaminationasamethodoffollow-up.EurJSurg2002;168:22-8.

25.Naude GP, Ocon S, Bongard F. Femoral hernia: the direconsequences of a missed diagnosis. Am J Emerg Med1997;15:680-2.

26.HetzerFH,HotzT,SteinkeW,SchlumpfR,DecurtinsM,



LargiaderF.Goldstandardforinguinalherniarepair:Shoul-diceorLichtenstein?Hernia1999;3:117-20.

27.LichtensteinIL,ShulmanAG,AmidPK,MontllorMM.Thetension-freehernioplasty.AmJSurg1989;157:188-93.

28.WysockiA,KulawikJ,PoźniczekM,StrzałkaM.IstheLi-chtensteinoperationofstrangulatedgroinherniaasafepro-cedure?WorldJSurg2006;30:2065-70.

29.BeltránMA,CrucesKS.AretheoutcomesofemergencyLi-chtenstein hernioplasty similar to the outcomes of electiveLichtensteinhernioplasty?IntJSurg2007;5:198-204.

30.BessaSS,KatriKM,Abdel-SalamWN,Abdel-BakiNA.Ear-lyresultsfromtheuseoftheLichtensteinrepairintheman-

agementof strangulatedgroinhernia.Hernia2007;11:239-42.

31.PapaziogasB,LazaridisCh,MakrisJ,KoutelidakisJ,PatsasA,GrigoriouM, et al.Tension-free repair versusmodifiedBassini technique(Andrewstechnique)forstrangulatedin-guinalhernia:acomparativestudy.Hernia2005;9:156-9.

32.ArroyoA,GarcíaP,PérezF,AndreuJ,CandelaF,CalpenaR.Randomizedclinicaltrialcomparingsutureandmeshrepairofumbilicalherniainadults.BrJSurg2001;88:1321-3.

33.SanjayP,ReidTD,DaviesEL,ArumugamPJ,WoodwardA.Retrospectivecomparisonofmeshandsuturedrepairforadultumbilicalhernias.Hernia2005;9:248-51.



397




1Department of Emergency Medicine, Antalya Training and Research Hospital, Antalya; Departments of 2General Surgery, 3Emergency Medicine,

Akdeniz University Faculty of Medicine, Antalya, Turkey.

1Antalya Eğitim Araştırma Hastanesi Acil Tıp Kliniği, Antalya; Akdeniz Üniversitesi Tıp Fakültesi, 2Acil Tıp Anabilim Dalı, 3Genel Cerrahi

Anabilim Dalı, Antalya.

Correspondence (İletişim): Fırat Bektaş, M.D. Akdeniz Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, Kampüs 07059 Antalya, Turkey.


AMAÇBuçalışmanınamacı,morfinveplasebogruplarındakikli-nik olarak önemli tanısal doğruluk ve fizikmuayenedekideğişiklikleribelirlemektir.

GEREÇ VE YÖNTEMHastalar 1:1 oranında kör olarakmorfin veya plasebo al-makiçinrandomizeedildi.Çalışmanınbirinciltakipverisi,morfinveplasebogruplarındakitanısaldoğrulukvefizikselincelemedeklinikolarakönemlideğişikliklerolupolmadı-ğınıbelirlemektir.

BULGULARSeksen hasta (39morfin ve 41 plasebo) çalışmaya dahiledildi.Klinikolarakönemlitanısaldoğrulukoranımorfingrubunda%80(31/39),plasebogrubunda%78(32/41)ve%2’lik bir fark oranı saptandı (güven aralığı [GA]%95,-7%ile13%,p=0,9802).Morfingrubundakihastalarıntümfizikselincelemebulgularıiçindesadeceabdominalrijidi-tebulgusunda(%15)istatistikselolarakanlamlıdeğişikliksaptandı, ancakplasebogrubundaherhangibir değişiklik(%0)yoktu.İkigruparasındakifarkanlamlıidi(GA%95,%2.3ile%30.5,p=0.031).

SONUÇBuçalışmaileacilservisteopioidanaljeziuygulanmasınıngüvenliolduğuveakutnonspesifikkarınağrısıolanyaşlıhastalarda klinik olarak önemli tanısal değişikliğe nedenolmadığı, fakat hastalarda abdominal rijidite gibi önemlifiziksel inceleme bulgularını değiştirebileceği sonucunavarılmıştır.Anahtar Sözcükler: Analjezi/ağrıkontrolü;klinikdeğerlendirme;acilservis.

BACKGROUNDTheobjectiveofthisstudywastodeterminetheclinicallyimportantchangeindiagnosticaccuracyandphysicalex-aminationinthemorphinevs.placebogroup.

METHODSSubjectswererandomizedina1:1ratiotoreceiveasingledoseintravenousmorphineorplaceboinablindedfashion.Primary outcomemeasure was to determine if there wasa clinically important change in diagnostic accuracy andphysicalexaminationinthemorphinevs.placebogroup.

RESULTS80subjects(39wereassignedtomorphineand41toplace-bo)wereincludedinthefinalanalysis.Clinicallyimportantdiagnosticaccuracyratewasfoundtobe80%inthemor-phinegroup(31/39)and78%intheplacebogroup(32/41),withadifferencerateof2%(95%CI-7%to13%,p=0.9802.There was a statistically significant change in abdominalrigidityfinding (15%) inmorphinegroup inallof theab-dominalphysicalexaminationsfindings;howevertherewasnochangeinplacebogroup(0%).Thedifferencebetweentwogroupswasalsostatisticallysignificant(95%CI2.3%to30.5%,p=0.031).

CONCLUSIONAdministration of opioid analgesia is safe and does notseemto impairclinicaldiagnosticaccuracy inelderlypa-tientswith acute undifferentiated abdominal pain.Never-more,opioidsmaychange thephysicalexaminationfind-ingssuchasabdominalrigidity.Key Words: Analgesia/pain control; clinical assessment;emergencydepartments.

doi: 10.5505/tjtes.2012.62534

Randomized controlled trial of morphine in elderly patients with acute abdominal pain

Akutkarınağrısıolanyaşlıhastalardamorfininrandomizekontrollübirçalışması

Faruk GÜNGÖR,1 Mutlu KARTAL,2 Fırat BEKTAŞ,2 Secgin SÖYÜNCÜ,2 Özlem YİĞİT,2 Ayhan MESCİ3


Analgesia before surgical consultation has tradi-tionallybeenanareaofcontroversyandwaswithhelduntiladefinitivediagnosiswasestablishedforfearofmaskingthesymptoms,changingphysicalfindingsorultimatelydelayingdiagnosisandtreatmentofasurgi-calcondition.[1]

Recentstudiesandsystematicreviewshaveshownthat administration of opioid analgesics in adult pa-tients with undifferentiated acute abdominal pain,prior tomaking a decision andwhile the diagnosticprocess was underway, did not increase the risk ofinadequatetreatmentdecisionsandmayhavesignifi-cantlyimprovedpatientcomfortwhencomparedwithaplacebo.[2,3]

Elderly patients who have undifferentiated acuteabdominalpainrequirecareful,timelyevaluationsandaggressivemanagementbecauseofthehighriskandsubtlepresentationsofseriouspathologicconditions.[4,5]Theevidencesupportingtheuseofanalgesiaintheelderlywithundifferentiatedacuteabdominalpainislimitedandbasedonclinicalexperience.

The objective of this study was to determine ifthereisaclinicallyimportantchangeinthediagnosticaccuracy and physical examination in themorphinevs.placebogroup.

MATERIALS AND METHODSStudy DesignIn this single-center, prospective, randomized,

double-blind,placebo-controlledclinicaltrial,elderlypatients with undifferentiated acute abdominal painweredividedintotwogroups,receivingeitherintrave-nousmorphineorplacebo.

Study SettingStudy participantswere recruited from the emer-

gency department (ED) of a tertiary-care univer-sityhospitalwithanannualcensusofapproximately80,000adultvisits.Bothlocalandcentralgovernmentethics committees approved the study protocol andall subjectsprovidedwritten informedconsent.Sub-jectspresentingtotheEDbetweenApril1,2009andDecember31,2009onweekdaysbetween08:00a.m.and24:00p.m.,theintervalcoveringtheshiftsoftwoattendingemergencyphysicians in theED,wereen-rolledintothestudy.

Selection of ParticipantsElderly(65yearsorolder)patientswithnon-trau-

matic undifferentiated acute abdominal pain of lessthan 48 hours’ duration were included in the study.Participants were required to have an undifferenti-ated acute abdominal pain and report either “mild”or greater pain intensity on a four-point verbal rat-ingscale(VRS)orat least20mmona100mmvi-

sualanaloguescale(VAS).Exclusioncriteriaincludedknownallergyorcontraindicationtomorphineoranyopioid analgesic, hemodynamic instability (systolicbloodpressure<100mmHg),anduseofanyanalge-sicwithinsixhoursbeforeEDpresentation;patientswhorefusedtoparticipateinthestudy,whowereun-cooperativewithrespecttotheVAS,whohadisolatedflank pain or previous study enrollment, and thosewithknownrenal,pulmonary,cardiacorhepaticfail-urewerealsoexcluded.

InterventionsSubjectswererandomizedina1:1ratiotoreceive

asingledoseintravenousmorphine(0.1mg/kgin100mlnormalsaline)orplacebo(100mlnormalsaline)in a blinded fashion. The randomization schedule,constructed with a random numbers table, was pre-paredbeforethebeginningofthestudybyanassistantblindedtothestudy.Treatmentallocationassignmentswere contained in sealed and labeled envelopes andplacedintoabox.Whenthetreatingphysiciandecidedtoincludeapatientintothestudy,thestudynursedrewanenvelopefromtheboxrandomlyandpremixedthestudydrug.Asecondnurseblindedtothestudyadmin-isteredtheprepareddrugtothepatientandrecordedthepreviouslylabeleddrugnumberonthestudyform.

Methods of Measurements After enrollment, emergency residents gathered

basic demographic information of participants usingastandardizeddatacollectionform.Subjectsreportedpain intensity on both a 100mmVAS (bounded by“nopain”and“worstpain”)andafour-pointVRS(no,mild,moderate,orseverepain)immediatelypriortoreceivingthestudydrug,andat30minutesafterdrugadministration.Subjectswereblindedtotheirpriorre-ports.Beforereceivingthestudydrug,thefirstattend-ingEDphysicianevaluatedthepatient’shistory,signsofacuteabdomen(abdominal tenderness,abdominalrigidity and rebound tenderness) anddetermined thethreemost likely diagnoses for that patient.At thattime,studydrugsweregivenasbolusinfusioninfiveminutes.Thirtyminutes after drug administration, asecondattendingEDphysicianonthesameworkshiftwhowasblindedtothepatientandtothefirstattend-ingphysician’spossiblediagnosis, evaluated thepa-tient’shistory,signsofacuteabdomen(abdominalten-derness, abdominal rigidity and rebound tenderness)and determined the three most likely diagnoses forthatpatient.Thequantificationofabdominalsignswasstatedaspresent,absentordebatable.Thepreliminarydiagnosisprovidedbythesecondphysicianwasmadewithoutaccesstoanylaboratoryorradiographicinfor-mationinordertominimizediagnosticsuspicionbias.After receiving the preliminary diagnosis, if the pa-tientswerejudgedtohaveinadequatepainreliefat30



minutes,theyreceivedrescuedrugssuchasadditionalanalgesia,protonpumpinhibitors,oranyotheragentsdeemedappropriatebythefirstphysiciantreatingthepatient.ThefirstattendingEDphysicianhadnoroleindeterminingthediagnosticaccuracy.Reportsofad-verseeventswerecollectedspontaneouslyandcatego-rizedasnausea/vomiting,alteredmentalstatus,dizzi-ness,hypotension,headache,allergy/pruritus,urinaryretention,ventilationfailure,anddrymouth.Anyad-ditionaladverseeventswerenotedas“other”andde-scribedonthecasereportform.

A research assistant performed a retrospectivemedical chart review, recording results of all diag-nostic tests, and contacted all subjects by telephonetodetermineifanyonehadasurgicalinterventionorhospital readmission, had undergone a diagnostic ortherapeuticmedicalprocedure,orwasconsultedtoan-otherphysician.Finaldiagnosiswasobtainedthroughfollow-up at least four weeks after their index EDvisitanddeterminedbyaconvincingradiologicalorpathologicaldiagnosis,responsetomedicalorsurgi-calintervention,orspontaneousresolutionaccordingtothepatient’sphysician,medicalrecords,orpatientself-report.

Outcome MeasuresOur primary outcomemeasure was to determine

iftherewasaclinicallyimportantchangeindiagnos-ticaccuracyorphysicalexaminationinthemorphinevs.placebogroup.Oursecondaryoutcomemeasuresweretoevaluatetheanalgesiceffectivenessandsafetyofintravenousmorphinevs.placebo,theneedforres-

cuedrugsat30minutes,thepresenceofatleastoneadverseevent,demographicfeatures,andfinaldiagno-sisofthepatients.

Afterfollow-upinformationwasobtainedandpa-tient data were recorded on the Statistical PackagefortheSocialSciences(SPSS)datachart, twocoau-thors(ageneralsurgeonandanemergencyphysician)blinded to the study collaboratively determined theclinicallyimportantdiagnosticaccuracyandchangeinphysicalexamination.Anydisagreementbetweenthepreliminaryandfinaldiagnosisthatmightbeexpectedtohaveanadverseeffectonthepatient’sgeneralsta-tus was defined as a clinically important diagnosticerror. If coauthors decided an instanceof diagnosticerror as clinically important, this was coded “diag-nosticdiscordance”forstatisticalanalysis.Whenthepreliminarydiagnosiswasdeterminedasaccurateornotdifferentfromthefinaldiagnosis,thiswascodedas“diagnosticaccuracy”forstatisticalanalysis.Diag-nostic accuracywas determinedbetween the secondattendingphysician’spreliminarydiagnosisandfinaldiagnosisofthepatients.

Data Analysis AllstatisticalanalyseswereperformedusingSPSS

version15.0forWindowsandMedCalcforWindows,version 9.3.0.0 (MedCalc Software, Mariakerke,Belgium). Continuous variables were expressed asmean±standard deviation and categorical variablesas percentage. Frequent variableswere expressed asrates. Comparison of two independent groups wasperformed by Student t-test while the related com-


Assessedforeligibility(n=385) Excluded(n=304)• Painof>48hours’duration(n=152)• Patientswithoutworkingtimeintervaloftwoattendingemergencyphysicians(n=65)• Useofanalgesicwithin6hours(n=35)• Patientsrefusedanalgesictreatment(n=28)• UncooperativewiththeVAS(n=16)• Refusedtoparticipate(n=6)• Hemodynamicinstability(n=1)• Knownallergyorcontraindicationtomorphineoranyopioidanalgesic(n=1)

Randomized(n=81)

AllocatedtoMorphine(n=40)Receivedallocatedintervention(n=39)Didnotreceiveallocatedintervention(n=1)(Persistentvomitingrequiringmetoclopramide)

Losttofollow-up(n=0)

Analyzed(n=39)Excludedfromanalysis(n=0)

Allocatedtoplacebo(n=41)Receivedallocatedintervention(n=41)Didnotreceiveallocatedintervention(n=0)

Losttofollow-up(n=0)

Analyzed(n=41)Excludedfromanalysis(n=0)

Allocation

Enrollm

ent

Followup

Analysis

Fig. 1.CONSORTdiagram,patientflowchart.


parisonoftwogroupswasperformedbypairedt-testforcontinuousvariables.RelatedcomparisonoftwogroupswasperformedbyMcNemartestforcategori-calvariables.KolmogorovSmirnov testwasused inordertoanalyzethedistributionofthedataasnormalorabnormal.Todetectadifferenceof20mmwithan80%powerandatwo-sidedlevelofsignificance,37patientswereneededforeachgroup.Allthehypoth-eseswereconstructedastwo-tailedandthecriticalal-phavaluewasacceptedas0.05.

RESULTSThree hundred and eighty-eight consecutive pa-

tientswere assessed for eligibility, and 304 patientsmetoneoftheexclusioncriteriaandonepatientwasnotincludedintotheanalysisbecauseofprotocolvio-lation(Fig.1).Ultimately,80subjectswereincludedintothefinalanalysis:39assignedtomorphineand41toplacebo.

Characteristics of Study SubjectsThemeanageofthestudysubjectswas73±7and

46% (n=37)of themweremale.The subjectgroupsappeared to bewell-matched for baseline character-isticsanddiagnosticstudyresults.Demographicfea-turesofthestudygroupsareshowninTable1.

Main ResultsThebaselinepainintensitywassimilarinthemor-

phine (75.3±22 mm) and placebo (68.6±28.5 mm)groups. The mean reduction in pain intensity at 30minutes was statistically significant in both groups:

31.6±29.7 mm in morphine group (p<0.0001; 95%confidenceinterval[CI]41.2to22.0),and18.8±28.6mm in placebo group (p=0.0001; 95%CI -27.8 to-9.7),butthedifferencebetweenthetwogroupshadaborderlinestatisticalsignificance(12.8mm,95%CI-25.8to0.1;p:0.0529)(Table2,Fig.2a,b).

Theaccuracyofthefinaldiagnosisbythesecondphysicianswassimilarinbothgroups(80%vs.78%;2%,95%CI:-7%to13%;p=0.9802,respectively).

Theabdominal tenderness in thephysical exami-nation did not decrease significantly in either group(8%,95%CI: -3.2%to7.7%vs.8%,95%CI: -5.3 to12,respectively).

Althoughthereductioninabdominalrigiditywas15% (95%CI: -5.8 to29.9;p=0.17) in themorphinegroup,abdominalrigidityincreased5%(95%CI:-13to20.4;p=0.77) after theplacebo infusion.Thedif-ference in reduction rates between the two groupswasstatisticallysignificant(d:15%,95%CI:2.3%to30.5%;p=0.031).

Reboundtendernessalsodecreasedinthemorphinegroup(13%,95%CI-7.62to27.3,p=0.266);however,as inabdominalrigidity, thereboundtendernessratewashigherafterplaceboinfusion(10%,95%CI:-7.5to 21; p=0.34), and the difference between the twogroups was 13% (95%CI: 0.7% to 27.4%; p=0.05)withaborderlinestatisticalsignificance(Table3).

Forty-threepatients(53.7%)weredischargedfromtheED,and37patients(46.3%)werehospitalized.Of


Table 1. Demographicfeaturesofthestudygroups

Age(mean±SD)Gender Female MaleHypertensionDiabetesmellitusHistoryofanoperationHistoryofCADVitalSigns Systolicbloodpressure Diastolicbloodpressure Pulse/min Fever◦C Respiratoryrate/min PulseoximetryDiagnosis AbdominalUS AbdominalCT Surgicalintervention Plainradiography Follow-up Endoscopy

Morphine(n=39)

73.3±7.2

21(53.8%)18(46.2%)21(53%)10(25.6%)11(28.2%)8(20.5%)

144±2479±1383±1336.6±0.618±298±2

19(48%)12(31%)2(5%)3(8%)

10(26%)0

Placebo(n=41)

73.1±7.9

22(53.6%)19(46.4%)21(51.2%)11(26.8%)18(43.9%)2(4.9%)

135±2574±1284±1636.3±0.417±298±2

17(41%)8(20%)

01(2%)7(17%)1(2%)

p

0.90

0.99

0.870.950.640.048

0.070.070.830.0010.520.47

the37patients,15 (20%)wereoperatedand3died.Themostcommondiagnosiswasbiliarytractdiseasefollowed by dyspepsia and small bowel obstruction(Table4).Five(12.8%)patientsinthemorphinegroupand4(9.7%)intheplacebogroupwerehospitalizedwithin the 15-day follow-up after ED discharge (d:3%,95%CI:-12to18;p:0.68).

Althoughnoneofthestudypatientscomplainedof

serioussideeffects,theincidenceofsideeffectswashigherinthemorphinegroup,withlackofstatisticalsignificance(28%vs.12%,d:16%,95%CI:-4to36,respectively;p=0.10)(Table5).

The need for rescue drug did not differ signifi-cantlybetweengroups(46%vs.54%;d:8%,95%CI:-15to30;p=0.62).Thesatisfactionwasbetterinthemorphinegroup(70.3±28mmvs.44.7±31.3;d:25.5,



Fig. 2. (a, b)Boxandwhiskerplotofthemeanreductionsinpainscoresatthe30thminuteafterthetreatment.Themidlinesoftheboxesrepresentthemediansandtheoutlineoftheboxesrepresentsinterquartilerati-os.Thethinlinesinsidetheboxesareforthe95%CIofthemeans.Thelinesaboveandbelowtheboxesshowtheminimumandmaximumvaluesofeachgroup.

0

2

4

6

8

10

0

2

4

6

8

10

VASBaseline VAS30thminute VASBaseline VAS30thminute

Placebogroup Morphinegroup(a) (b)

Table 2. Themeanreductionsinpainintensityinthetwogroups

VASScores Morphine Placebo

InitialVASScore±SD 75.3±22.1 68.6±28.530thminuteVASScore±SD 43.6±31.4 49.8±28.6MeanReductioninVASScore±SD -31.6±29.7 -18.8±28.695%CI -41.2to-22.0 -27.8to-9.7pvalue <0.0001 <0.0001SD:Standarddeviation;VAS:Visualanaloguescale;CI:Confidenceinterval.

Table 3. Changesinphysicalexaminationanddiagnosticaccuracyafterthestudydrugadministration

Physicalexaminationfindings Morphinegroup Placebogroup Differencebetweenbeforeandafterstudy differencewithingroup difference twogroupsdrugadministration (95%CI) (95%CI) (95%CI) Abdominaltenderness 100%vs.92% 98%vs.90% 0%(-15to14) d:8%(-3.2to7.7) d:8%(-5.3to12) p=0.25 p=0.375 p=0.68Abdominalrigidity 51%vs.36% 34%vs.39% 15%(2.3to30) d:15%(-6to30) d:5%(-13to20.4) p=0.17 p=0.77 p=0.03Reboundtenderness 38%vs.25% 19%vs.29% 13%(0.8to28) d:13%(-7.6to27.3) d:10%(-7.5to21) p=0.26 p=0.34 p=0.05Diagnosticaccuracy 80% 78% 2%(7%to13%) p=0.9802

95CI%:12.3to38.8;p=0.0003).LimitationsThis study had several limitations that should be

mentioned.Wechosetoremovepatientsfromanaly-sis if they required rescueanalgesicswithin thefirst30minutes of the study and if their final diagnosiswasunclear.Inretrospect,weshouldhaveplannedanintent-to-treatanalysis;however,onepatientwasex-cludedfromtheanalysisbecauseofprotocolviolation.

Someadverseeffectssuchasnauseaandvomitingmayberelatedtotheabdominalpathologyratherthanthestudydrug.Althoughwecollectedadverseeffectdata,wedidnotassessthelikelihoodthattheadverseeffectcouldbeattributedtothestudydrugatthetimeofdatacollection.Inaddition,wedidnotweighoursubjectsandreliedonself-reportofweighttocalcu-latemorphinedoses.Itispossiblethatthedosesusedwere based on poor weight estimates; however, we

suspect such errors were small and randomizationshouldminimizeanyimpactonstudyoutcomes.

Another limitation was the lack of interobserverconsistency at the beginning of the study.Althoughthiscanbe thought tocausedifferencesbetween thephysiciansevaluatingthestudypatients,theparame-tersofthephysicalexaminationsdetectedinthestudywereroutineandclassicalfindingsthatallphysicianslearnsimilarlyintheirclinicalpractice;thus,wedidnotfeelthatinterobserverconsistencywasnecessaryfor this study. Nevertheless, future researchers canconsiderthisfactbeforebeginningtheirstudies.

The time interval between the first and secondexaminations was also a limitation.We determinedan intervalof30minutes,whichmaynothavebeenadequatetodemonstratephysicalexaminationdiffer-ences for some patients. New studies with differenttimeintervalsorwithmultipleexaminationrepeatsindifferent time frames can givemore information onthispoint.

Thefinallimitationwasthelackofastandardizedalgorithmforevaluating thepatients in thestudy. Infact,thereisnouniversalalgorithmforacuteabdomi-nalpainasfoundforacutecoronarysyndromes.

All of the attempts applied to the patients wereconvenient,scientificandacademicinterventionsnec-essaryfortheirfinaldiagnosis.

We designed a placebo-controlled trial to assesstheclinicallyimportantchangeindiagnosticaccuracyandphysicalexaminationinthemorphinevs.placebogroup.Wepreferredtousenormalsalinesolutionasplacebo,asitwascolorlessandeasytofindandpre-pare.Furthermore,itisessentialtouseaplacebofordesigningthiskindofstudy.Theuseofplacebowasnotanunethicalmethodbecauseadministeringplace-bocouldimprovesubjectiveandobjectiveoutcomesinupto30-40%ofpatientswithawiderangeofclinicalconditionsbeyondthepain.[6]Thus,itisthepatient’sperceptionsofeffectivetreatmentthatreducepainorpainbehavior.Asa result,painscoresmaydecreaseintheplacebogroupaswellastheinterventiongroup.Inourstudydesign,studymedicationorplacebowasadministeredandthenpatientsweregiven30minutestoachievepainrelief.Thismethodologywassimilar



Table 4. Finaldiagnosis,surgicalinterventionsandrehospitalizationofthestudypatients

Finaldiagnosis Morphine Placebo

Biliarytractdisease 9 7Smallbowelobstruction 3 9Acid-pepticdisease 5 7Nonspecificabdominalpain 4 6Renalcolic 2 4Diverticulitis 2 1Gastroenteritis 3 2Acutecoronarysyndrome 3 0Appendicitis 1 1Incarceratedinguinalhernia 2 0Splenicinfarction 1 0Ovariandisease 1 0Psoashematoma 0 1Hepaticcysthydatid 0 1Malignancies 0 1Pancreatitis 0 1Rightheartfailure(hepaticcongestion) 1 0Urinarytractinfection 2 0Surgicalintervention 8(20.5%) 7(17%)Rehospitalization 5(12.8%) 4(9.7%) d:3%,95%CI:-12to18 p=0.68

Table 5. Comparisonofsideeffectsbetweenthetwogroups

Sideeffects Morphine Placebo Difference% p (n,%) (n,%) (95%CI)

Nauseaandvomiting 5(12.8%) 2(4.9%) 8(-5to21) 0.23Hypotension 1(2.6%) 0(0%) 2.6(-2to7) 0.30Headache 1(2.6%) 1(2.4%) 0.1(-7to7) 0.97Fatigue 4(10%) 2(5%) 5(-6to17) 0.40Total 11(28) 5(12) 16(-4to36) 0.10

tothatofmostpreviousstudies,whichhaveallowedforreassessmentofparametersinasearlyas15to30minutes. If the patients were judged to have inade-quatepainreliefat30minutes,theythenreceivedres-cuedrugssuchasadditionalanalgesia,protonpumpinhibitors,oranyotheragentsdeemedappropriatebythe first physician treating the patient. Interventiontimewasfinishedat30minutesafter thestudydrugadministration.TheInstitutionalHumanStudiesCom-mitteebelievedstronglythatastudyperiodshouldnotexceedonehourbecauseof thepotentialdangersofopioidadministrationandalsotheneedforpatientstobeabletobe“offprotocol”relativelyquicklysotheycouldreceiveanalgesiaasclinicallyindicated.

DISCUSSIONTheuseofanalgesia foracuteabdominalpain in

emergency departments has been debated for manyyears. Because of the concerns about masking im-portant physical examination findings or ultimatelydelayingdiagnosisandtreatmentofasurgicalcondi-tion,analgesicswerewithheldinundifferentiatedab-dominalpainpatients.Thisconceptusedtobeusefuland valid in the pastwhen themedical science anddiagnosticmodalitieswere limited andmostly inva-sive.However,intoday’sadvancedera,withdifferentandnoninvasivediagnosticmodalities,alleviatingthepainwithopioidanalgesicsinsteadofleavingpatientsindistressforlongperiodsismorehumanitarianandrational.

According to our study results,morphine admin-istration to relieve acute abdominal pain in patientsover65yearsofagemaychangephysicalexamina-tionfindingssuchasabdominalrigidityandreboundtenderness, but only the change in abdominal rigid-itywasstatisticallysignificant.Despitethechangeinthephysicalexaminationfindings,thefinaldiagnosisofthepatientswasnotchangedsignificantly.Inlightoftheabove,morphineadministrationforpainrelieftopatientsover65yearsofagewithacuteabdominalpaincanbeapplicable.However,thefactthatphysi-cal examination findings can change with analgesiashould not be forgotten, and further diagnostic testswithhighsensitivityandspecificityshouldbeorderedfor precluding diagnostic errors in patient manage-ment.

Therehavebeenvariouspreviousreportsinthelit-eratureaboutadministratingopioidanalgesiaforab-dominalpain.Theoutcomemeasuresfor thesestud-iesvary;however,manyofthemanalyzeddiagnosticaccuracy,managementdecisions,painmeasurements,adverseevents,andchangesinphysicalexaminationfindings. In 1992,Attard et al.[7] conducted a studywithpapaveretumandmeasuredpain scores,patientcomfortanddiagnosticaccuracy.Sincethestudysub-

jects were patients with significant abdominal painwhowereadmittedtothehospital,theresultscannotbe adapted to ED patients entirely. Nevertheless, astheactionofpapaveretumissimilarwithopioids,thestudyisworthyforshowingnosignificantnegativeef-fectsofopioidsondiagnosticaccuracy.In1999,Ver-meulenetal.[8]consideredmorphineversusplacebointheEDpatientswhoweresuspectedofacuteappendi-citis,andthediagnosticaccuracywasfoundtobe89%inthemorphinegroupand91%intheplacebogroup.Althoughtheselectedpatientpopulationofthestudyimpeded the generalization of the results,which theauthorsofthestudydeterminedwasalimitation,thestrongpain reliefandboth thepatientandphysiciancomfort and satisfaction with morphine streamlinedthe study results. Similar to these results,Gallagheretal.[3]foundhighpatientcomfortintheirstudy,andconcludedthatmorphineadministrationrelievedpainand raisedpatient comfortwithout clinically signifi-cantdiagnosticchanges.Incorrelationwiththeresultsstated above,we foundhighpatient satisfaction andpain relief without diagnostic errors in the presentstudy.

Despitethebeliefregardingchangesinthephysicalexamination, this variablewas reported inonly fourstudies.[9-12]PaceandBurke[9]conductedthefirstran-domized double-blind controlled trial with adequateallocationconcealmentinEDpatientswithacuteab-dominalpainin1996andconcludedthatmorphinedidnotleadtoanydiagnosticerrororphysicalexamina-tionalteration.Contrarytotheseresults,physicalex-aminationfindingschanged in thepresent study,butdidnotleadtoanydiagnosticerror.In1997,LoVec-chioetal.[10] randomized48patientsadmitted to theEDwithacuteabdominalpainandmeasuredchangesinthephysicalexaminationandadverseevents.Asta-tisticallysignificantchange in thephysicalexamina-tionwas noted in both groups receiving analgesics;however, the diagnostic accuracy between the pre-liminaryandfinaldiagnosiswasnotdifferent,andtheauthorsconcludedthatnoadverseeventsordelaysindiagnosiscouldbeattributedtotheadministrationofanalgesics.Although the heterogeneity of the studypopulationand thedisparity ingroupsdecreased thepower of the statistical analysis, as the authors con-cludedwasalimitation,theconcordanceindiagnosticaccuracyratesbetweenthegroupswasexpressiveandsimilartothoseofthepresentstudy.Furthermore,thechangesinphysicalexaminationfindingsweresimilarto those determined in the present study. In anotherstudy,thechangesinphysicalexaminationsignswerenot statistically significant and diagnostic accuracywas unchanged.[11] These results were similar withthepresentstudy.Mahadevanetal.[12]randomized66EDpatientssuspectedofacuteappendicitiswithrightlower quadrant (RLQ) pain equally to tramadol or



placebointheirdouble-blindcontrolledtrialin2000andmeasuredthepresenceandabsenceofsevenab-dominalsigns(tendernessonlightanddeeppalpation,tenderness in RLQ and elsewhere, rebound, cough,and percussion tenderness) before analgesic and 30minutes after analgesic. The difference between thegroups was not statistically significant (RR: 1.27(95%CI:0.68to2.38).

As was to be expected and compatible with theliteraturementionedabove,abdominalrigidityandre-boundtendernessfindingsdifferedanddecreasedinthemorphinegroupinthepresentstudy.Furthermore,bothabdominalrigidityandreboundtendernessfindingsin-creasedintheplacebogroup.Rationalexplanationsforthe increasewould be the progression of the clinicalsignsbythetimeofthesecondexaminationorfailuretomeetthepatient’sexpectationsregardingtheallevia-tionofpaininthewaitingperiod.Thestatisticallysig-nificantdecreaseinabdominalrigidityfindingshouldwithhold administering morphine analgesics. On theotherhand,thedeclineinabdominalrigidityinthemor-phinegroupcouldminimizethevoluntaryrigidity,thusimproving the diagnostic process and facilitating thephysician’sdecisions.Theunchangeddiagnosticaccu-racybetweenthemorphineandplacebogroupscanbeconsideredsupportingevidenceforthelatteropinion.Nevertheless, it is clearlyknown thatwhetheropioidanalgesicsareusedornot,thediagnosticprocessinel-derlypatientswithabdominalpainisproblematicandcomplicatedandneedsthegreatestattention.

In conclusion, the findings of the present studyaboutdiagnosticaccuracyareparallelwiththelitera-tureinadultandpediatricpatients.Nonetheless,opi-oidadministrationtotheelderlywithacuteabdominalpainhasnotbeenstudiedbefore.Earlyadministrationofopioidanalgesiaissafeanddoesnotseemtoimpairclinical diagnostic accuracy in elderly patients withacuteundifferentiated abdominal pain.Nevertheless,opioids can change physical examination findingssuchasabdominalrigidity.

AcknowledgedThis studywas supported byAkdenizUniversity

ResearchandProjectUnit.

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RM,MutterRL.Emergencydepartmentcare in theUnitedStates: a profile of national data sources.AnnEmergMed2010;56:150-65.

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3. GallagherEJ,EssesD,LeeC,LahnM,BijurPE.Random-izedclinicaltrialofmorphineinacuteabdominalpain.AnnEmergMed2006;48:150-60.

4. ManterolaC,AstudilloP,LosadaH,PinedaV,SanhuezaA,VialM.Analgesiainpatientswithacuteabdominalpain.Co-chraneDatabaseSystRev2007;3:CD005660.

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8. VermeulenB,MorabiaA,UngerPF,GoehringC,GrangierC, Skljarov I, et al.Acute appendicitis: influence of earlypain relief on the accuracy of clinical andUS findings inthe decision to operate--a randomized trial. Radiology1999;210:639-43.

9. PaceS,BurkeTF. Intravenousmorphine forearlypain re-liefinpatientswithacuteabdominalpain.AcadEmergMed1996;3:1086-92.

10.LoVecchioF,OsterN,SturmannK,NelsonLS,FlashnerS,FingerR.The use of analgesics in patientswith acute ab-dominalpain.JEmergMed1997;15:775-9.

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405




Department of Orthopaedic Surgery, 3rd Affiliated Hospital of Suzhou University, PRC.

Suzhou Üniversitesi 3. Hastanesi, Ortopedi ve Travmatoloji Kliniği,Çin Hak Cumhuriyeti.

Correspondence (İletişim): Weihong Yan, M.D. Ju Qian Street, 185 Changzhou, China.

Tel: +0519 - 68871316 e-mail (e-posta): [email protected]

AMAÇAşiltendonuyırtığısıkrastlananbiryaralanmadır,komp-likasyonlarıişlevinibozabilir.Yırtılmıştendonunrekons-trüksiyonu için sayısız operasyon tanımlanmış olmasınarağmen bu yöntemler tendonda mikrosirkülasyonu riskeatabildiği gibi tendonun iyileşmesini ciddi derecede bo-zabilir.Yırtıktan hemen sonraminimal invaziv tenokuta-nöz teknikledikişatmavesistemikfonksiyonelegzersiz,komplikasyonriskinibüyükölçüdeazaltabilir.

GEREÇ VE YÖNTEMHaziran1996ileŞubat2009arasındabuyöntemle21-66yaşarası88(54erkek)hastatedaviedildi.

BULGULARBir ile 7 yıl arası izlemden sonra ortalama (AmerikanOrtopedikAyakveAyakBileğiDerneği (AmericanOrt-hopedicFootandAnkleSociety)ayakbileğiayakarkasıskoru95(90-98arası)veameliyatsonrasıskarınmaksi-maluzunluğu3cmidi.Birhasta,cerrahiden1yılsonrabirkazadaAşiltendonunuyenidenyırtmıştı.Ancak10aysonraonarılmıştendonhâlâsağlamdı.Başkabirhastadauca doğru atılan gerim dikişinin delip geçmesine bağlıolaraknervussuraliszedelendi,ameliyatsonrasıhiskaybıveödemenedenoldu.Budikişhemençıkartıldıvehastakonservatiftedaviyleiyileşti. Aşiltendonuüzerindeuzunsüre hareketsiz kalanlarda olduğu gibi düzensiz büyükskarlaryoktu.

SONUÇMinimalinvazivperkütanözdikişAşiltendonununorijinaluzunlukvebütünlüğünüsağlayabildiğigibidiğeryöntem-leregöreameliyatsonrasıkomplikasyonlarıdahaazolanminimalinvazivbiryöntemdir.Anahtar Sözcükler: Ayakbileği;yaralanma;cerrahi;travma.

BACKGROUNDAchillestendonruptureisacommoninjury,anditscom-plicationscanimpairfunction.Numerousoperationshavebeendescribedforreconstructingtherupturedtendon,butthesemethodscancompromisemicrocirculationintheten-donandcanseriously impair itshealing.Suturingwithaminimallyinvasivetenocutaneoustechniquesoonaftertheruptureandsystematicfunctionalexercisecangreatlyre-ducethepossibilityofcomplications.

METHODSBetweenJune1996andFebruary2009,wetreated88pa-tients(54males;agerange,21-66years)withthismethod.

RESULTSAfterfollow-uprangingfrom1-7years,themeanAmeri-can Orthopedic Foot andAnkle Society ankle-hind footscorewas95(range,90-98),andthemaximumlengthofpostoperativescarringwas3cm.Onepatient re-rupturedhisAchilles tendononeyearaftersurgeryinanaccident,butafter10months,therepairedtendonwasstillintact.Inanotherpatient,thenervussuraliswasdamagedduringsur-gerybypiercingthetensionsutureatthenearend,causingpostoperativenumbnessand swelling.The tension suturewasquicklyremoved,andthepatientrecoveredwellwithconservative treatment. No large irregular scars, such asthosesustainedduring immobilization,werepresentovertheAchillestendon.

CONCLUSIONMinimally invasive percutaneous suturing can restore theoriginal length and continuity of theAchilles tendon, isminimallyinvasive,andhasfewerpostoperativecomplica-tionsthanothermethods.Key Words: Ankle;injury;surgery;trauma.

doi: 10.5505/tjtes.2012.59376

Treatment of acute and closed Achilles tendon ruptures by minimally invasive tenocutaneous suturing

MinimalinvazivtenokutanözdikişleakutvekapalıAşiltendonuyırtığınıntedavisi

Wenge DING, Weihong YAN, Yaping ZHU, Zhiwei LIU


DespitethefactthatacuterupturesoftheAchillestendonaccountforabout35%ofalltendontears,[1]theoptimal treatment is still controversial.[2-5] Proposedtechniquescanbeclassifiedasconservativemanage-ment,openrepair,andpercutaneousrepair.[6]

Some authors strongly recommend conservativemanagement,[5,7]butcastimmobilizationmayleadtoelongationofthetendonwithreducedstrengthofthecalfmuscles,anditcarriesahighrateofre-ruptures.[8]

Open repair of acute and closed ruptures of theAchillestendoniswidelyaccepted.[9,10]However,sur-gicalcomplicationscaninfluencepatients’functionalrestoration and quality of life.[11,12] These complica-tions are of particular importance to athletes, whohavehighrequirementsforfunctionalrestoration.[13]

PercutaneoussutureofanAchillestendonruptureisasimpleandsafemethodthathasfunctionalresultssimilar to those of open repair and a substantiallylower complication rate.[14,15] However, our surgicalstrategy in treatingacuteandclosedAchilles tendonrupturediffersfromstandardpercutaneousapproachesinthatweuseminimallyinvasivetenocutaneoussutur-ing,“comb”therupturedAchillestendontopromotehealing,andsuturethetendinoussheathcompletelytopreservethebloodsupply.

We report hereour results in treating88patientswith acute and closedAchilles tendon ruptureswiththisminimally invasive tenocutaneous suturing.Thesurgery was followed by regular visits over severalyearstoobservetheclinicaleffectsandpossiblecom-plicationsofthistechnique.

MATERIALS AND METHODSWestudiedallpatientswithacuteandclosedAchil-

les tendon ruptureswho underwentminimally inva-sivetenocutaneoussuturingatourinstitutionbetweenJune 1996 and February 2009.None of the patientsunderwent bilateralAchilles tendon repair. Achillestendon ruptureswerediagnosedwithmagnetic reso-nanceimagingscans(MRI)scansandphysicalexami-

nation (Fig.1b,c)by the surgeon.Allpatientswerealsofollowedthroughclinicvisitsandtelephonecallsbyoursurgeon.

Surgical Procedure Surgerywasperformedwithin threedaysofpre-

sentation. All patients received continuous epiduralanesthesiawhile in a ventricumbent positionwith atourniquet applied above the knee in the exsangui-natedfoot.Insurgery,thesurgeonlocatedtherupturegap,placeda3-cmtransverseincisionalongtherup-turesite(Fig.2a),andthencutopentheaponeurosislengthwise. The tendinous sheath was usually com-plete,andtherupturedendoftheAchillestendonwasshapedlikeahorsetail(Fig.2b).Thehematomaattherupturedendwasremoved,andthe“horsetails”atthetwo ruptured endswere combed (Fig. 2c).The skinwaspiercedwithacuttingneedlefrominsidetoout-sideatabout4-5cmonthesideneartherupturedsec-tion,andabout2-3cmatthefarsideoftherupturedsection toavoid thesurfaceprojectionof thenervussuralisandpreventitsdamage.

Double-stranded #10 thread was passed throughthe skinand theAchilles tendon.Theanklewasputinplantarflexionsothattheendsofthetendonover-lappedby2 cm, and the tension suturewas knottedoutsidetheskin(Fig.2c).Beforeknotting,ankleflex-ionwasconfirmedtobethesameasthatofthecontra-lateralanklejointsothatthetendoncouldberestoredtoitsoriginallength.Theincisionwasthenclosedandcoveredwitharubberurethralcathetertoreducecom-pressionontheskin(Fig.2c).Incaseofexstrophyofthehorsetailthread-likefiberanddistention,theinci-sioncouldbelooselyclosedwithabsorbablesuturestobringendsof the tendon into an introversionandto ensureproper continuity in the appearanceof thetendon,aswellastoreducescarring.Meanwhile,theaponeurosisandtissuessurroundingthetendonwererepairedwitha4-0absorbablesuturetomaintaincir-culation(Fig.2d).AstepbystepschematicdiagramofthesurgicaltechniqueisshowninFig.3.


Fig. 1. TherupturedAchillestendonofa19-year-oldman.(a)Preoperativescan;(b)PreoperativeT1MRIscan;(c)Preopera-tiveT2MRIscan.

(a) (b) (c)


Postoperative Care

Aftersurgery,thekneeandanklewereeachflexed30°andimmobilizedinaplastercast.AwindowwasleftattheAchillestendontoallowthedressingtobechanged.Thedayaftersurgery,patientsbeganplan-tar flexion and dorsal angulation exercises for themetatarsophalangeal and interphalangeal joints andcontractingandrelaxingexercisesforthequadricepsfemoristoreduceswellingandpreventtheformationofvenousemboli.

Patientswere encouraged tomove other parts oftheirbodytopreventatrophyofthequadricepsfem-oris, strengthen the body’s immunity, and enhancebloodcirculationatthewound,whichhelpedreducedinflammationandswellingatthesurgicalsite.Patientswerealsoaskedtodoisometricexercisesofthegas-trocnemiusandmusculussoleus.

After surgery, patientswere allowed to rise fromtheirbedsoncrutches,butwerecautionednottoplaceweightontheinjuredlegandtokeepthefootinplan-tarflexion.Thecastwaschangedafter2weeks,andthedegreeofplantarflexionwasreducedto15°.Af-terthecastwasremovedat4weeks,patientswerein-

structedtoflextheanklewhileinbed.After8weeks,patientswereallowedtostandwithcrutchesandwereencouragedtoplacesomeweightontheleg,gradually


Fig. 2. OperativerepairofarupturedAchillestendonofa19-year-oldman.(a)A3cmincisionismadeovertherupturesite;(b)TherupturedendoftheAchillestendonisidentifiedbyitshorsetailshape;(c)Thesuturedtendoniscoveredwitharubberurethralcathetertoreducecompressionontheskin;(d)Theaponeurosisandtissuessurroundingthetendonwererepairedwitha4-0absorbablesuture.

(a) (b)

(c) (d)

Fig. 3. Stepbystepschematicdiagramofthesurgicaltech-nique.(a)3-cmtransverseincisionalongtherupturesite; (b) Incision of the aponeurosis lengthwise; (c) Thesuturedtendoniscoveredwitharubberurethralcatheter.(d)Knotofthetensionsuture;(e)Theapo-neurosisandtissuessurroundingthetendonwerere-pairedwithabsorbablesuture;(f)Sutureinskin;(g) Tensionsuturewasknottedoutsidetheskin.

a

bd e

cg

f


increasethedegreeofflexionandextension,andwalkwitha thickgauzecushion in theshoe.Fullweight-bearingwasallowed8to10weeksaftersurgery.

The athletes and opera actors were encouragedto conduct adaptive rehabilitationexercises after theplasterwasremoved,suchasswimmingandcycling,and could gradually resume their training after 3-4months.Steroidandaldosteronedrugswerenotusedduringthetreatment.

Follow-Up Examinations and EndpointsPatientswere followeduntil 2009.Threemonths

after surgery,MRI scansof theanklewereobtainedand the healing of theAchilles tendonwas visuallyevaluated by three of the present authors, and theAmericanOrthopedicFootandAnkleSociety’s(AO-FAS)ankle-hindfootscorewasdeterminedforall.[16] Inaddition,theradiologicalandvisualappearancesoftherepairedtendonwerecomparedwithnormalradio-logicalandvisualappearance.

RESULTSWeidentified88patients(54males)ranginginage

from21-66years(mean,39.5years)whowereeligi-bleforthestudy.Byprofession,8(9%)weremartialartsactorsfromtheBeijingOpera,5(5.68%)wereop-erateachers,25(28.41%)wereathletes,45(51.14%)weresportsfans,and5(5.68%)wereelderlypatientswithaslightinjuryexperiencedwhilewalking.Mostinjurieswerework-related,butin2(2.27%)patients,a direct strike fromaheavyobject had ruptured thetendon.

All patients had recent closed injuries withoutsymptomsofautoimmunization,geneticcollagendis-order,contagiousdiseases,orincompleteneuralfunc-tions.Onepatientdiedandonewaslosttofollow-up

aftertwomonths.Thispatientlosttofollow-upwasnot known.Follow-up for the remaining86patientsrangedfrom1-7years(mean,2years).

Postoperative Functional Assessment Ofthe88patients,78(88.6%)hadanMRIcheckup

threemonthsafterthesurgery.Ingeneral,check-upsrevealedcontinuityoftheAchillestendon,whichwasproperlyrepairedandshapedandwascloseto,orhadapproached, the imaging result of a normalAchillestendon(Fig.4a,b).Theraisingheeltestshowedthat83(94.3%)patientscouldraisetheirheelsforcefullyand that the shape of theAchilles tendonwas good(Fig.4c).MeanAOFASankle-hindfootscorewas95(range,90-98),andthemaximumlengthofpostopera-tivescarringwas3cm.Nolargeirregularscars,suchasthosesustainedduringimmobilization,werepres-entovertheAchillestendon.

Postoperative Complications Onepatient re-ruptured thesameAchilles tendon

oneyearaftersurgeryinasportsaccident.ThetendonwasrepairedwithKesslersuturingandpurelyreversereinforcedsuturingofthegastrocnemius.Tenmonthsafterrepair,therepairedtendonwasstillintact.

Inanotherpatient,thenervussuraliswasdamagedduringsurgery(possiblybyinadvertentlypiercingthetensionsutureatthenearend),causingpostoperativenumbnessandswelling.Thetensionsuturewasquick-lyremovedatthepatient’sbedside,externalimmobi-lizationwiththecastwasprolongedbytwomonths,and exercise intensitywas increasedmoregraduallythaninotherpatients.Thesymptomsdisappearedafterfourmonths, and thepatient recoveredwell andhasexperiencednomoreruptures.

No other complications, such as infection, skin


Fig. 4. TherepairedrupturedAchillestendonofa19-year-oldman.(a)PostoperativeMRIscan.(b)MRIscanofthecontralateral,uninjuredAchillestendon.(c)Appearanceofthetendonwiththeheelraised.

(a) (b) (c)

necrosis,adhesionbetweenthetendonandskin,for-mationofacystic lesionat the tendon,or stiffeningof the ankle joint,were found in any patient duringsurgeryorthefollow-upvisits.

DISCUSSIONWetreatedtherupturedAchillestendonsof88pa-

tientswith ourminimally invasive percutaneous su-turing.Thisprocedurepreserved theoriginal length,continuity, and appearance of the tendon with fewpostoperativecomplications.

TheAchillestendonisthestrongestandlargestten-doninthehumanbody.About15cmlong,itoriginatesfromthelowerthirdofthecalfandinsertsatthemid-pointofthetuberosityofthecalcaneus.Ithasapadofbursasynovialisatthefrontandback.Thetendonhasnosheath,onlyloosereticulartissuethatlinkstheten-donwiththesurroundingaponeurosis.Itisvascular-ized.[17]Duringsurgery,werepairedtheaponeurosis to ensureagoodbloodsupplytothetendon.Webelievewecanachievebetterhealingby“combing”thehorse-tail-likeendsofthetendonandoverlappingthemby2cmwhenmakingtherepair.Otherpercutaneoussutur-ingmethodsdonotstraightenthetendonfiber,sowebelievethesemethodsarenotasstrong.

TraditionalAchillessuturingmethods include thesteelwireBunnellmethodand themattress suturingmethod, amongmanyothers.These“directopen re-pairs”of the ruptured tendoncan requirea large in-cision, seriously damage tissues around the tendon,impair circulation to the tendon, and predispose therepair topostoperative infectionandadhesion.Stud-iesofthebloodsupplytotheAchillestendon[18,19] re-vealedthatthesemethodscanimpairmicrocirculationinsidethetendonandseriouslyimpairhealing.

Incontrast,manysurgeonsfindthemodifiedKes-sler suturing and fine-thread intermittent suturing oftendonbundlestobesimpler,moreefficient,andmorepractical, and therefore, thepreferredmethod for re-storing theAchilles tendon.[20]Furthermore,somere-searchhasfoundthatsuturingwithaminimalpercu-taneousincisionsoonaftertheruptureandsystematicfunctional exercise cangreatly reduce thepossibilityofcomplications.[21-23]Lansdaaletal.foundthatmini-mally invasive Achilles tendon repair in Bunnell’ssutureincombinationwithafunctionalrehabilitationprogramisasafeandquickprocedurewithalowrateof re-rupture and ahigh level ofpatient satisfaction.[24,25]Recentstudieshavefoundthatlong-termoutcomeafterminimallyinvasiveAchillestendonrupturerepairisexcellent,withalowrateofcomplications.[26,27]

We believe ourminimally invasive percutaneoussuturing conforms to the anatomical physiologicalfeatureof theAchilles tendonandmeets thehealing

requirementsinsidethetendon.Inparticular,thetech-niquehasthefollowingadvantages:

1)The small incision reduces damage to the tis-suessurroundingthetendon.Weonlymakeasimplerepairontherupturedendtomakeitneat.Thismethoddoesnotrequirearegulardirectincisionthatrequiresstrong suturingof the rupturedends toprovidecon-tinuousandsteadytension.Themethodprovidesgoodbloodcirculationattherupturedends,reducesthepos-sibilityofpostoperativeadhesions,andprovidesgoodconditionsfortendonrepair.

2)Weplacedtenocutaneoussuturesinthehealthypart of the tendon, far away from the ruptured end.Thismethodprovidessteadyandcontinuous tensionfortherepairofthetendon.This“distant”tensional-lowsthematchingofrupturedends,sharesmostofthetensionattherupturedend,andavoidstheinfluenceoftensiononthebloodsupplytotherupturedends.

3)Themethodretainsthehorsetailshapeatthere-sidualendoftherupturedtendon.Overlappingtissuesareproperlyarrangedandnotdirectlysutured,whichmaintainstheappearanceofthetendon.Theoverlap-pinglengthprovidesarepairthatwillnotdiffergreat-ly from the desired length of the tendon.Moreover,itwillnotleadtopossibleshorteningoftheAchillestendoncausedby“directopen”surgery,andtheanklejointhasabetterdegreeofmobilityafterthesurgery.

4)TherupturedendsoftheAchillestendonwererepairedusingabsorbablefinesuturetomaintainneatmatchingbetweentherupturedends.Hence,knotsofregularsuturingarenotseenatthetworupturedendsof the tendon, and the possibility of infections andpostoperativecomplicationsisreduced.

5)Agradualfunctionalrestorationplanisfollowedafterthesurgery.Patientsareencouragedtostartfunc-tionalexerciseasearlyaspossibletoreducepostoper-ativeadhesionaswellastorestorefunction.Thegoalisrestoretheleveloffunctionthatexistedbeforetherupture.

In conclusion, minimally invasive tenocutaneoussuturing for repair of rupturedAchilles tendons canprovide good results with few complications. Themethod combines features of tension suturing andpercutaneous suturing, and it preserves blood circu-lation to theAchilles tendon through “distant” ten-sion.Throughasingleneatandaccurateincision,themethod can restore the original length, continuity,appearance,andfunctionofthetendon.

Thelimitationsofourresearcharethatthesamplesizeissmall,theoutcomeassessorsarealsopartofthesurgicalteam,andtherewerenomeansofcomparingtheinterventiontoothertherapiesortheoutcomesta-tustothepreoperativestatus.However,ourresearch



ishypothesis-generating, and thedescriptive statisti-calfindingscanbeusedinthedevelopmentoffutureprospectivecohortstudiesandrandomizedcontrolledtrials.

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Çocuk ve erişkin minör kafa travmalarında kan S100B ile laktatın rolü ve

bilgisayarlı beyin tomografisi ile korelasyonu

TheroleofbloodS100Bandlactatelevelsinminorheadtraumasinchildrenandadultsandcorrelationwithbraincomputerizedtomography

Ahmet Ali SEZER,1 Emine AKINCI,1 Miraç ÖZTÜRK,1 Figen COŞKUN,1 Gülsen YILMAZ,2 Alpaslan KARAKAŞ,2 Talip TOKSÖZ2

Ankara Eğitim ve Araştırma Hastanesi, 1Acil Tıp Kliniği, 2Biyokimya Bölümü, Ankara.

Departments of 1Emergency Medicine, 2Biochemistry, Ankara Training and Research Hospital, Ankara, Turkey.

İletişim (Correspondence): Dr. Emine Akıncı. Şenlik Mah., Baldıran Sok., No: 40/18, 06310, Keçiören, Ankara, Turkey.

Tel: +90 - 312 - 355 22 19 e-posta (e-mail): [email protected]

AMAÇBuçalışmada,kanS100Bvelaktatdeğerlerininçocukveerişkinminörkafatravmasısonrasındadüzeylerininbelir-lenmesivebilgisayarlıbeyintomografi(BBT)ilekarşılaş-tırılmasıamaçlandı.GEREÇ VE YÖNTEMBuçalışmada,AnkaraEğitimveAraştırmaHastanesiAcilServisi’nebaşvuran,100kafa travmasıhastasıgeriyedö-nükolarakincelendi.BULGULARS100B için kesim noktası 0-0,15 ve laktat için 0,9-1,5alındığında; bireylerin %42’sinde S100B’nin yüksekve%56’sında laktat’ın yüksek olduğu saptandı.Hasta-ların %12’si 18 yaş ve altı, %88’i 18 yaş üstündeydi.YaşgruplarıarasındaS100Bvelaktataçısındananlamlıfarklılıkbulunamadı.BBTileS100Bvelaktatdüzeyle-ri ilişkilendirildiğinde istatistiksel olarak anlamlı ilişkisaptanmadı.SONUÇBunagöreminörkafatravmalarındaserumS100BvelaktatyüksekliğibelirlenmesiklinikmuayeneveyaBBTkullanı-mının yerini alamaz veminör kafa travmalarındaS100Bvelaktatınprognoztahminlerindegüvenilir işaretleyicilerolmadığıkanaatindeyiz.

Anahtar Sözcükler: Laktat;minörkafatravması;s100B.

BACKGROUNDIn this study,weaimed to set levelsofbloodS100Bandlactateandtodetermineanycorrelationwithbraincomput-erized tomography inminorhead traumas inchildrenandadults.METHODSThisclinicaltrialisaprospectivestudyincluding100headtraumapatientswho applied toAnkaraTraining andRe-searchHospitalemergencyservice.RESULTSInthisstudy,cut-offrangesof0.0-0.15ug/mland0.9-1.7mmol/LforbloodS100Bandlactatelevels,respectively,wereused.S100Blevelwashigherthanthecut-offrangein42%ofpatientsandlactatelevelwashigherin56%ofpatients.No significant differenceswere determined be-tweenagegroups.WhentherelationbetweenS100BandlactatelevelswithbrainCTwasevaluated,nostatisticallysignificantrelationwasdetermined.CONCLUSIONAccordingtoourresults,inminorheadtraumas,thedeter-minationofelevatedserumS100Bandlactatelevelscan-not take theplaceof clinical examinationand theuseofcranialCT.Although thepatients inour studygrouphadminorheadtrauma,wedonotconsiderS100Bandlactatetobereliablemarkersforestimatingprogression.Key Words: Lactate;minorheadtrauma;S100B.

doi: 10.5505/tjtes.2012.76736


Kafa travmalı olgularda travma sonrası meyda-nagelen intrakraniyal hasarın tespitinde, bazı serumbelirteçlerinin etkinliği araştırılmaktadır. S100B, nö-ronspesifikenolaz(NSE),glialfibrilerasidikprotein(GFAP), interlökinler gibi bazı işaretleyicilerin öneçıktığı görülmektedir.[1] Bizim acil servisimizde ol-duğugibiyoğunhastabaşvurusuolanacilservislerdekafa travmalı hasta takipleri, yer, zaman vemaliyetaçısındansıkıntıoluşturmaktayenierkentanıvetakipyöntemlerineihtiyaçduyulmaktadır.

Bu çalışmada, kan S100B ve laktat değerlerininçocukveerişkinminörkafatravmasısonrasındadü-zeylerini ve beyinbilgisayarlı tomografisi (BBT) ilekarşılaştırılmasınıamaçladık.

GEREÇ VE YÖNTEMBuçalışma1Aralık2010ile30Nisan2011tarihle-

riarasındaAnkaraEğitimveAraştırmaHastanesiAcilServis’inebaşvuran,çocukveyetişkinyaşgrupların-dakihastalarınalındığıprospektifbirçalışmadır.

Çalışmadandışlanmaölçütleri:Kafatravmasıhikâyesinin24saattenuzunolması,Serebrovaskülerhastalıklaberaberkafatravması,Nöbethikâyesininolması,Penetrankafatravmaları.Kan analiziHastanınacil servise alınmasından ilk1 saat içe-

risinde2,5 cc kan150 IU lityumheparin içeren en-jektöre, 7,5 cckannormal biyokimya tüpüne alındı.KangazıRocheCobas221cihazıileS100BdüzeylerikemilüminasyonyöntemileSangtecS100Bkitikulla-nılarakLIAISONcihazındaçalışıldı.

S100B’ninreferansaralığı0-0,15ug/ml,laktat’tınreferansaralığıise0,9-1,7mmol/Lolarakkabuledildi.

İstatistiksel verilerElde edilen verilerin istatistiksel değerlendirmesi

“SPSSforWindows15.0”paketprogramındayapıl-dı.Değerlendirmelerdekategorikveriler içinki-kareveFisher-Exacttesti,S100B,laktatdüzeylerininyaşgruplarınagörekarşılaştırmasındaStudent’st-testiveMann-Whitney U-testi, S100B, laktat düzeylerinindiğer kategorik değişkenlerle ilişkilerinde Student’st-testi,Mann-WhitneyU-testi,tekyönlüvaryansana-liziveKruskall-Wallisvaryansanalizikullanıldı.Ay-

rıcaölçümlebelirtilendeğişkenlerarasındakiilişkilerSpearman-Rankkorelâsyonanaliziiledeğerlendirildi.Tanımlayıcı değerler olarak kategorik verilerde fre-kansveyüzdedeğerleri,ölçümlebelirtilendeğişken-ler için aritmetik ortalama±standart sapma değerlerikullanıldı. İstatistiksel anlamlılık sınırı 0.05 olarakalındı.

BULGULARAraştırmaya alınan bireylerin hepsinde Glasgow

komaskalası (GKS)15olup,olguların%61’ierkek,%39’ukadındı.Hastaların%12’si≤18yaş,%88’i>18yaşidi.Travmamekanizmasıaçısındanbakıldığında,basit düşme ilk sırayı almakta idi (%28), hastaların%77’siningelişsüresiiseilkbirsaatteolduğugörül-dü.Hastaların%96’sınınBBT’lerinormalsınırlariçe-risindeydi,sadecebirhastayakafatravmasınedeniyleyatışyapıldı(Tablo1).


Tablo 1. Hastalarailişkintanımlayıcıdeğerler(n=100)

Ort.±SS Sayı

Yaş(min-maks) 43,37±20,57 3-87Yaşgrubu ≤18yaş 12 >18yaş 88Cinsiyet Kadın 39 Erkek 61GKS(min-maks) 15±0,0 3-15Travmatipi Basitdüşme 28 Yüksektendüşme 23 Araçiçitrafikkazası 19 Araçdışıtrafikkazası 10 Darp 20Gelişsüresi(saat) 0-1 77 1-3 19 >3 4Beyinbilgisayarlıtomografisi Normal 96 Kontuzyon 1 Kırık 3Sonuç Taburcu 99 Yatış 1

Tablo 2. S100Bvelaktatdüzeylerineilişkintanımlayıcıdeğerler

Normal Yüksek Ort.±SS Medyan Min.-Maks.

S100B 58 42 0,41±1,12 0,13 0,003-6,50Laktat 44 56 2,12±0,99 1,80 0,90-8,40

Çocuk ve erişkin minör kafa travmalarında kan S100B ile laktatın rolü ve BBT ile korelasyonu

BireylerinS100Bve laktat değerlerine ilişkin ta-nımlayıcıdeğerlerTablo2’deverilmiştir.S100Biçinkesimnoktası0-0,15velaktatiçin0,9-1,5alındığında;bireylerin%42’sindeS100B’ninyüksekve%56’sındalaktat’ınyüksekolduğusaptandı(Tablo2).

On sekiz yaş ve altı hasta grubunda S100B’nin%33,3’üve laktat’ın%41,7’sindeyüksek tespitedil-mesinekarşın18yaşüstühastagrubundaS100B’nin

%43,2’sinde,laktat’ın%58,0’indeyüksekolduğusap-tandı.YaşgruplarıarasındaS100Bvelaktataçısındananlamlıfarklılıkbulunmadı(Tablo3).

HastalarıngelişsüreleriileS100Bvelaktatdeğer-lerine bakıldığında ise geliş süresi>3 saat olanlardaS100Bdüzeyi<3saatolanlaragöreanlamlıderecededüşükçıktı(p<0,05)(Tablo4).

Eşlikedenyaralanmalarailişkindağılımlarabakıl-dığında%41’indeizolekafatravması,%28’indever-tebrayaralaması,%13’ütoraksyaralanması,%8’indekarın travması, %24’ünde ekstremite yaralanması%37’sindeskalpyaralanmasıolduğusaptandı.

İzolekafatravmasıolanlardaS100B,olmayanlaragöreanlamlıderecededüşükbulundu(p<0.05).Kafatravmasıilebirliktebaşkabirsistemyaralanmasıolanhastalardeğerlendirildiğinde,vertebratravmasıolan-larda,olmayanlaragöreS100Banlamlıderecedeyük-sekken(p<0.05),göğüstravmasıveskalpyaralanmasıolan hasta grubunda laktat düzeyi anlamlı derecedeyüksekti(p<0,01,p<0.05)(Tablo5).

Çoklutravmaveizolekafa travmasıdurumuiçinBBTileS100BveLaktatdüzeyleriilişkilendirildiğin-de; istatistikselolarakanlamlı ilişkilersaptanmamış-tır. S100B için izole kafa travması olanlarda özgül-lük%74,4,duyarlılık%50bulunurken,çoklutravmaolanlardaisebudeğerlersırasıyla%49,1ve%100ola-rakbulundu.

Laktatdüzeyiizolekafatravmasıolanlardaözgül-lük%46,2,duyarlılık%50bulunurken,çoklutravma


Tablo 3. YaşgruplarınagöreS100Bvelaktatdüzeylerineilişkintanımlayıcıdeğerlervekarşılaştırmasonuçları

Yaşgrubu ≤18yaş >18yaş p Ort.±SS Ort.±SS

S100B 0,63±1,66 0,38±1,04 (medyan=0,37) (medyan=0,13) >0,05Laktat 1,79±0,77 2,16±1,01 >0,05

Tablo 4. HastalarıngelişsüreleriileS100Bvelaktatdeğerleriarasındakiilişki

S100B Laktat

Gelişsüresi Ort.±SS p Ort.±SS p0-1 0,43±1,13 2,13±0,791-3 0,39±1,23 <0,05 2,09±1,61 >0,05>3 0,13±0,11 1,88±0,75

Tablo 5. EşlikedenyaralanmalarveS100Bvelaktatdüzeyleri

S100B Laktat n Ort.±SS p Ort.±SS p

İzolekafatravması Evet 41 0,13±0,10 <0,05 1,99±0,73 >0,05 Hayır 59 0,61±1,43 2,20±1,13Vertebratravması Yok 72 0,25±0,65 <0,05 2,11±1,07 >0,05 Var 28 0,83±1,80 2,13±0,75Gögüstravması Yok 76 0,37±1,07 >0,05 2,02±0,70 <0,01 Var 24 0,70±1,46 2,79±2,00Karıntravması Yok 92 0,43±1,17 >0,05 2,12±0,98 >0,05 Var 8 0,17±0,20 2,03±1,08Ekstremitetravması Yok 76 0,34±0,99 >0,05 2,05±0,78 >0,05 Var 24 0,64±1,47 2,33±1,46Skalpyaralanması Yok 63 0,46±1,24 >0,05 1,93±0,65 <0,05 Var 37 0,34±0,89 2,43±1,33


olanlardaisebudeğerlersırasıyla%43,9ve%100ola-rakbulundu,budeğerleranlamlıdeğildi(Tablo6).

TARTIŞMAS100B insan vücudunda metabolize edilmeden

böbrektenatılır.S100B’ninyarıömrü120dakikadır.Yaralanmazamanıilekanörneğininalınmasıarasın-daki geçen zaman sonuçları etkileyebilmektedir. Li-teratürde genellikle S100B’nin yarı ömrü 30 dakikaolduğu,bazıçalışmalarda180dakikayakadaruzaya-bileceğinisavunulmaktadır.[2]Ancak,çalışmalarınço-ğunda ilk3 saatten sonraalınanS100Bsonuçlarınıngüvenilmez olduğu ve çalışma sonuçlarını etkilediğigösterilmiştir.[3]Çalışmamızaalınanhastaların%77’sitravmaolduktansonrailk1saatteacilservisebaşvur-muşlardır.Gelişzamanı ileS100Bilişkisinebakıldı-ğındagelişsüresi>3saatolanlardaS100Bdüzeyi<3saat olanlara göre anlamlı derecede düşük çıkmıştır.Busonuçliteratürileuyumludur.Hastalarınçoğundanilksaatekanalındığıiçineldeettiğimizsonuçlarıngü-venilirolduğunudüşünmekteyiz.

Çalışmamızda yaş grupları arasında S100B açı-sından anlamlı farklılık yoktu.Özellikle çocukhas-talardabazalserumS100Bseviyesininbelirlenmesiniençoketkileyenparametrehastanınyaşıdır.Geyervearkadaşları[4]1004çocuktanormalserumS100Bsevi-yeleriniincelemişvereferanseğrisiniçizmiştir. Gaz-zolo,[5]biryaşınınaltındadiğeriergendönemdeolanikipikbulmuştur.TümbuçalışmalarS100B’ninyaşabağlı olduğunu kesin olarak göstermiştir ve minörtravmatik beyin yaralanmalarında (TBY) S100B ileilgiliçalışmalardayaşaspesifikreferanskullanılmasıkonusundanbahsedilmektedir, ancakbizimçalışma-mızdaçocuksayısıazolduğu içinyetişkinhastalar-dan daha farklı referans değerleri almadık.[6] Çocuk TBY’lerinde S100B rolü henüz açıklığa kavuşma-mıştır. Yapılan birkaç çalışmada pediatrik TBY’siolanhastalardabuproteininerkenartışıgüvenilirbirnörolojikprognostikveriolarakdeğerlendirilmemek-tedir.ÇünküçoğuolguserilerindeS100Beldeedilenenyüksekdeğerdeolsabilehastalarınçoğunda tambir nörolojik iyileşme görülmüştür.[7] Çalışmamızdaçocukhastasayımızınazolmasınarağmensadece4çocukta S100B yüksekliği saptadık.Aksini kanıtla-

yan çalışmalar olsa da çocuk hastalarda S100B’ningüvenilir bir prognostik endeks olmadığını düşün-mekteyiz.

TravmalardaS100Bseviyesinindeğişkenolması-nınbirdiğernedenidebaşkavücuthasarınınolması-dır.S100Bsadecebeyindeğilbeyindışıdokulardandasalınır.S100Bastrogliavenöronlardayüksekse-viyedeolsada,çoklutravmailebirliktebeyinhasarıolanlarda bu biyoişaretleyicinin santral sinir sistemespesifikliğiazdır.Çalışmamızdahastaların%41’iizolekafatravması,%59’uiseçoklutravmalıidi.Hastaları-mızda,kafatravmasındansonraensıketkilenenikincibölge%28oranındavertebralar,üçüncüsıklıklaeks-tremitelerdi.EtkilenyaralanmabölgesiileS100Biliş-kisine baktığımızda özellikle vertebra travması olanhastalarda diğer bölge yaralanmalarına göre anlamlıoranda yüksekti. Litertatürde S100B’nin sadece be-yinhasarlarındadeğil,uzunkemikkırığı,yaygınderihasarı,yağdokusuhasarı,kasveyaeklemhasarıgibieksistemikhasarlarındadayükseldiğigösterilmiştir.[6]BirçalışmadatravmahastalarıarasındaS100B’nintorasikkontüzyonvekemikkırığındansonrayüksekolduğugösterilmiştir.Aynızamandayanıkveyumu-şakdokuyaralanmasıS100Bartışınanedenolmuştur.BubulgularS100B’ninTBY’daki tanısal kesinliğiniazaltmaktadır.[8]

LiteratürdekiS100BileilgilibirkısımçalışmalarS100B’ninprognostikindeksolarakkullanılabilirliğiileilgilidir.[9]Bukonudaulaşılansonuçlarçelişkilidir.Piazza ve arkadaşlarının[7] yaptığı çalışmada trav-ma sonrası S100B’nin erken yükselmesini nörolojiksurveyi tahminetmedegüvenilirbirmarkerolmadı-ğı sonucuna varmışlardır. Bunun tersine Wiesmannve arkadaşlarının[8] çalışmasında ise özellikle ciddikafa travmalarında serum S100B ve GFAP’ın trav-masonrasınörolojikprognozilekoreleolduğunuönesürmüşlerdir. Klinik bulgular ve BBT ile kombineedildiğinde prognoz üzerine bilgiyi artıracağını sa-vunmaktadırlar.

Doku laktatının progresif kötüleşen hücre etkile-rine eşlik eden önemli bir özellik olduğunu bulun-muştur.Kafatravmalarındabeyindokusuveyabeyinomurliksıvısındakilaktatmiktarınınartmasıhasarın


Tablo 6. Genel,izoleveçokluolanlardaS100BvelaktatileBBTsonuçlarıarasındakiilişkiler

İzolekafatravması Çoklutravma

BBT Normal Anormal p Normal Anormal

S100B Normal 29(74,4) 1(50,0) >0,05 28(49,1) 0(0) Yüksek 10(25,6) 1(50,0) 29(50,9) 2(100)Laktat Normal 18(46,2) 1(50,0) >0,05 25(43,9) 0(0) Yüksek 21(53,8) 1(50,0) 32(56,1) 2(100)

şiddetiileilişkilidir.[10]Beyinkanakımındaerkendö-nemdekiazalmavebeyiniskemisibeyindokusundakilaktatseviyesininartmasınayolaçar.Beyindokusun-da ve serebrospinal sıvıdaki kalıcı laktat yüksekliğikötüprognozbelirtisiolabilir.[11]Çoklutravmalıhas-talardaarterlaktatdüzeyihasarınşiddeti,resüsitasyo-nunyeterliliğiveprognozileilgiliönemlibirparamet-reolarakyaygınkabulgörmektedir.[12]Majörtravmageçirenhastalarınçoğundalaboratuvarveradyolojikdeğerlendirmeler yapılmakla birlikte baz defisiti velaktat düzeyi beraber kullanılarak ölümcül olabile-cekhastalarıntriyajıyapılabilmektedir.Yoğuntravmamerkezlerinde baz defisiti ve laktat düzeyi travmalıhastalarınyönetimindesıkçakullanılmaktadır.[13]

Lannoo ve arkadaşları[14] l5 şiddetliTBY’si olanhastalardaki artmış serebral laktat düzeyininmorta-liteyi belirlemede önemli olduğunu saptamışlardır. Goodman ve arkadaşları[15] mikro diyalizle belirle-nen serebrospinal laktat düzeyi ile serebral hipoksiveiskemiarasındailişkiolduğunugöstermişlerdir. Bu bulgulararağmenizolekafatravmalıhastalardaarter-yel laktatdüzeyinin serebrospinal/santral sinir siste-mindeki laktat düzeyini ne kadar yansıttığını araştı-rançalışmalarınsayısıazdır.Siegelvearkadaşları25kafatravmalıhastadabazdefisitininoksijenihtiyacınıgöstermede değişken önemi olan bir işaretleyici ol-duğunu ve arteriyel baz defisitinin kafa dışı hasarlabirlikteolankafatravmalarındakötüprognozlailişki-liolduğunugöstermişlerdir.[16]Bizimsonuçlarımızdahastaların %55’inde laktat yüksek çıkmış olmasınarağmen, BBT bulguları, klinikle karşılaştırıldığındaistatistikselolarakanlamlısonuçeldeedemedik.Budurumunhastalarımızınminörkafatravmasıolmasın-dan kaynaklandığını düşünmekteyiz. Çalışmamızınsonuçları laktat düzeyininminör kafa travmalarındatravmatikbeyinhasarınıöngörmedeyararlıolmadığı-nıgöstermiştir.

BizimçalışmamızdaBBTileS100Bve laktat ileilişkilendirildiğinde istatistiksel olarak anlamlı ilişkisaptamadık. S100B için tüm bireyler için özgüllük%59,4,duyarlılık%75,0bulunurken, laktat için tümbireyler için özgüllük %44,8, duyarlılık %75,0 bu-lundu.Budeğerleristatistikselolarakanlamlıdeğildi.Bu sonuçMüller ve arkadaşlarının[3]yaptığı çalışmaile benzerdir. Çalışmalarında minör kafa travmalarıyönetiminde,GKS14-15olanhastalardaüçhastadanbiriiçinBBTkullanımınıönlemekiçinkullanılabilirolduğunuvesonuçtaS100B’ninBBT’ninyeriniala-mayacağıancak,BBTiçinhastaseçimindeBBT’ningerekli olup olmadığı konusunda destekleyici bilgisunabileceğini öne sürmüşlerdir. Filippidis’in çocukhastalarüzerindeyaptığı,ortaciddikafatravmalıhas-talardaS100B’ninkullanımının sınırlı olduğuancakgereksizBBTçekimini azaltabileceği sonucunavar-mışlardır.[6]

Bizim sonuçlarımıza göre minör kafa travmala-rındaserumS100Bve laktatyüksekliğibelirlenmesiklinikincelemeveyaBBTkullanımınınyerinialamaz.Ayrıca minör kafa travmalarında S100B ve laktatınprognoztahminlerindegüvenilir işaretleyicilerolma-dığıkanaatindeyiz

Yazarların çıkar çatışması yoktur.

KAYNAKLAR

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3. Müller K, Townend W, Biasca N, Undén J, Waterloo K,Romner B, et al. S100B serum level predicts computedtomography findings after minor head injury. J Trauma2007;62:1452-6.

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Erken fasyotominin yılan ısırıkları tedavisindeki etkinliği

Effectivenessofearlyfasciotomyinthemanagementofsnakebites

Cemal FIRAT, Serkan ERBATUR, Ahmet Hamdi AYTEKİN, Hıdır KILINÇ

İnönü Üniversitesi Tıp Fakültesi, Plastik Rekonstrüktif ve Estetik Cerrahi Anabilim Dalı, Malatya.

Department of Plastic Reconstructive and Aesthetic Surgery, İnönü University School of Medicine, Malatya, Turkey.

İletişim (Correspondence): Dr. Cemal Fırat. İnönü Üniversitesi Tıp Fakültesi Plastik Rekonstrüktif ve Estetik Cerrahi Anabilim Dalı, Malatya, Turkey.

Tel: +90 - 422 - 341 06 60 / 5505 e-posta (e-mail): [email protected]

AMAÇBuçalışmamızdaamacımız,yılansokmalarınabağlıgeli-şenkompartmansendromlarının tedavisinde,klasikkom-partman sendromu kriterlerinden uzaklaşarak yapılan er-kenfasyotomininhemklinikiyileşmeyihızlandırdığıhemdeilerleyicidokuhasarınıazalttığınıvurgulamaktır.GEREÇ VE YÖNTEMYılan ısırmasınedeniylebaşvuran14hastageriyedönükolarakincelendi.Hastaların5’irutintedaviiletakipedile-rekiyileştirildi.Tedaviyeyanıtvermeyen6hastayaekstre-mitede artan ödem, ağrı, peteşi-ekimoz, bül formasyonu,ilerleyiciderinekrozuvegerilemeyenklinikvelaboratuvarbozukluklar nedeniyle ilk 48 saat içerisinde erken fasyo-tomiyapıldı.Geçdönemdekompartmantanısıilekliniği-mizesevkedilen3hastayaisebaşvurduklarındafasyotomiyapıldı.Fasyotomiinsizyonları4ila6günsonrakapatıldı.BULGULARErken fasyotomiuygulanan6hastadaödeminhızla azal-dığı,ekstremitederisindeki lokalnekrozların ilerlemediğigözlendi.Ayrıcabuhastalardalokalısıartışıveyaateşgibitoksikbelirtilerhızlageriledi.Geçfasyotomiyapılan3has-tadaiseiyileşmehızıerkencerrahiyapılanlarlakıyaslandı-ğındaoldukçayavaştıvekasvederidekinekrotikilerlemekısmengeriledi.SONUÇFasyotomiyılanısırıklarındaözelbiryeresahipolupkom-partmansendromuolgularındagereklitümtedavileruygu-lanmalıkliniğin tamolarakoturmasınıveyakompartmanbasıncınıneşikdeğereulaşmasınıbeklemedenerkenfasyo-tomiyapılmalıdır.Anahtar Sözcükler: Fasyotomi; kompartman sendromu; yılanısırıkları.

BACKGROUNDThepurposeofthisstudywastoemphasizethatearlyfas-ciotomy performed in the treatment of snakebites in theabsenceof theclassiccompartmentsyndromecriteriaac-celeratestheclinicalrecoveryandreducestheprogressivetissuedamage.METHODSFourteenpatientswithsnakebitewereexaminedretrospec-tively. Five of them healed with routine treatments. Sixpatientswhodidnot respond to the treatmentunderwentearlyfasciotomyprocedurein48hours.Allofthepatientshad edema, pain, ecchymosis, bulla formation, and pro-gressiveskinnecrosisovertheextremity.Fasciotomywasperformed in threepatientswhowere referred in the lateperiodwithcompartmentsyndrome.Fasciotomyincisionswereclosedafter4-6days.RESULTSAftertheearlyfasciotomy,edemadiminishedrapidly,theskinbecamemoreviableandlocalnecrosisdidnotprog-ress. Further, the toxic symptoms like local temperatureincreaseandfeveralsodiminished.Thehealingprocessinthethreepatientswhounderwentlatefasciotomywasmuchslowercomparedwiththeearlyfasciotomygroup.Inpar-ticular,necrosisonthemuscleandskinhaddeteriorated.CONCLUSIONFasciotomyhasa specialplace in snakebites. Incasesofcompartmentsyndrome,allnecessarytreatmentsincludingearlyfasciotomyshouldbeperformedbeforethefullclini-calsymptomsdeveloporthecompartmentpressurereachesthethresholdvalue.Key Words: Fasciotomy;compartmentsyndrome;snakebites.

doi: 10.5505/tjtes.2012.28158


Zehirli hayvan sokmaları dünya genelinde ciddimorbidite vemortalite nedenlerinden biri olup yılda4.000.000 insanınyılan sokmasınamaruzkaldığı vebunların40.000’ininbunedenleöldüğü tahminedil-mektedir.[1,2] Dünyada mevcut 3000 yılan türünün%10’u zehirlidir.[3] Ülkemizde 40 yılan türü vardır,bunların10’uzehirli,2’siyarızehirli,28’izehirsizdir.[1,4]Zehirli10yılantürünün9’uViperideaailesindençıngıraklı engerek yılanı (Vipera ammodytes), diğeriiseElepidaeailesindendir.[1-5]Viperidaeailesindekiyı-lantürleriekstremiteödemivekompartmansendromugibilokaldokuhasarıvejeneralizeödem,hipotansi-yon,gastrointestinalsemptomlar,hematolojik,nörolo-jikvekardiyakbozukluklarilerenaldisfonksiyongibisistemiksemptomlaranedenolabilmektedir.[5]Yılanınzehirsizolduğuveyayılanınzehriniboşaltamadığıısı-rıklarakuruısırıkadıverilmektedir.Yılanzehirlenme-lerinde toksisite, yılanın türü, büyüklüğü, zerk ettiğizehirmiktarı,ısırıksayısı,ısırılankişininyaşı,ısırılanyervezehirekarşıduyarlılıkgibibirçokparametreyebağlıdır.[5,6]Isırılankişidekisistemikhastalıkların(di-abetesmellitus,hipertansiyon,koagülasyonbozukluk-larıvs.gibikronikhastalıklar)varlığıveyaşfaktörüne(çocukyadayaşlı)bağlıolarakkliniktablodeğişken-likgösterebilir.[3-5]

Ülkemizdeensıkgörülenengerekyılanzehirlen-melerindeisedahaçoklokalvehematolojikbulgulararastlanmaktadır.[7]Isırıkbölgesindebaşlayanvegide-rek artan ağrı, ödem, ısı artışı veya ateş, yayılmayameyilli peteşi ve ekimozlar genel klinik bulgulardır.Yılan ısırıklarında oluşan zehirlenmelerinin tedavi-sindeacildurumlardışındagenelyaklaşımantiserumtedavisi, tetanozprofilaksisive lokalyarabakımıdır.[7,8]Yılanısırıklarınınbüyükbirçoğunluğuekstremi-telerdeolmaktavebunlarınbirkısmındakompartmansendromu gelişmektedir. Literatürde yılan ve böcek

sokmalarınaveyatravmayabağlıgelişenkompartmansendromutedavisikonusundafikirbirliğisağlanama-mıştır.[9-16] Cerrahi tedavi için kompartman basıncı-nıneşikdeğerikonusundafarklıgörüşlervardır.[13-16] Bazı çalışmalarda fasyotominin son aşamaya kadarbeklenilmesigerektiğivefasyotomininoldukçafazlakomplikasyonlara yol açabileceği vurgulanmıştır.[9-11] Bunedenlekompartmansendromundaklinikbulgulartamolarakoturanakadarelevasyon,mannitoltedavisigibi tıbbi tedavileruygulanarakbeklenebileceğiöne-rilmiştir.[17] Buna karşın diğer bazı çalışmalarda iseekstremitelerdeki ısırıkların,olasıkompartmansend-romuaçısındansıkıtakipedilmesigerektiğiveklinikolarakşüphelenildiğindefasyotomiaçılmasıgerektiğigörüşü savunulmuştur.[13,18] Kompartman sendromutanısınıngecikmesi iskemikkontraktürlereveyaekt-remitedeçeşitliseviyelerdeamputasyonlaranedenol-maktadır(Şekil1).[19]


Şekil 1.Isırıktan 72 saat sonra kliniğimize sevk edilmiş birhastadagörünüm.

Şekil 2. (a) Isırıktan12saat sonrakigörünüm, (b) elbileğidorsomedialindedişizleri,(c)36saatsonraönkolungörünümü,(d, e)fasyotomiden12saatsonrakigörünüm.(f) Isırıldıktan15günsonrakigörüntü.

(a)

(d)

(b)

(e)

(c)

(f)

Renkli şekiller derginin online sayısında görülebilir. (www.tjtes.org)

Renkli şekiller derginin online sayısında görülebilir. (www.tjtes.org)


Bu çalışmada, yılan sokmalarına bağlı gelişenkompartmansendromlarınıntedavisinde,klasikkom-partman sendromu kriterlerinden uzaklaşarak dahaçok proflaktik amaçlı planlanan fasyotominin hemklinikiyileşmeyihızlandırdığıhemdeilerleyicidokuhasarını azalttığı yönündeki klinik tecrübelerimizisunmayıamaçladık.

GEREÇ VE YÖNTEMBuçalışmadaAğustos2009ileEkim2011tarihleri

arasında kliniğimize yılan ısırması nedeniyle başvu-ran14hastageriyedönükolarakincelendi.Hastalar-dan5’i rutin tedavi ile izlendi,9’unacerrahigirişimyapıldı. İki çocuk hasta öldü.Hastaların demografiközellikleri,ısırığınyeri,ısırıldıktansonrageçensüre,kliniğimizdekiizlemsüresi,Tablo1’deözetlenmiştir.Hastalarınçoğuna ilkbaşvurduklarımerkezlerinacilservislerindeilkmüdahaleleriyapılmış,tetanozprof-laksisi,antiserumtedavisiuygulanmıştı.Yılanısırma-sı sonrasında hastalar kliniğimize yatırılarak tedavialtına alındılar. Hastaların kliniğine göre antiserumtedavisine devam edildi. Hastaların kan sayımları,kanama ve pıhtılaşma zamanları, biyokimya değer-leri, idrar analizlerivekardiyakparametreleri8 saataralıklarlamonitörizeedildi.Kompartmansendromu

proflaksisiamacıylamannitoltedavisiuygulandı.Eks-tremitedeartanödem,ağrı,peteşi-ekimoz,bülformas-yonu,ilerleyiciderinekrozuvegerilemeyenklinikvelaboratuvarbozukluklarnedeniylefasyotomiyapıldı.Buhastalardakompartmansendromuiçingereklibul-guların tamolarakgelişmesibeklenilmeden6hasta-ya ilk 48 saat içerisinde erken fasyotomi açıldı. Üçhasta ise başvurduğunda kompartman sendromununtümkriterlerinitaşıyordu.Hiçbirhastayakompartmanbasınçölçümütestiyapılmadı.Fasyotomiaçılanhas-talar4ila6günbekletilerekpansumanlatakipedildivesonrasındafasyotomikesisikapatıldı.Dörthastadagreftleonarımgerekirkenerkencerrahiyapılan5has-tadaprimeronarımyapıldı.

BULGULARKliniğimizebaşvuran14hastanın5’inesadecetıb-

bitedaviuygulandıveherhangibircerrahiişlemege-rekduyulmadı.Buhastalarınbirkısmındakuruısırıkolabileceğiveyatedavininetkinsonuçvermişolabile-ceğidüşünüldü.Erkenfasyotomiuygulanan6hasta-daödeminhızlaazaldığı,kasdokusundaki siyanotikkanamaodaklarınınveyaiskemiksahalarıngerilediği,ekstremitederisinindahacanlıhalegeldiğivederide-ki lokalnekrozların ilerlemediğigözlendi.Ayrıcabu


Tablo 1.Hastalarındemografikvekliniközellikleri

No Yaş/ Isırığın Isırıktansonra Tedaviyöntemi İzlemsüresi Komplikasyon Cinsiyet yeri geçensüre

1 3/E Solbacaklaterali 5gün Rutintedavi 5.günölüm2 73/K Sağelbileğidorsali 12saat 36.sattefasyotomi+ 3ay Fasyotomi rutintedavi hattındaskar3 48/E Sağel2.parmak 30saat 36.sattefasyotomi+ 1ay Fasyotomihattında rutintedavi skar2.parmakpıp eklemdenamputasyon4 24/E Sağbacaklaterali 24saat 48.sattefasyotomi+ 3ay Fasyotomi rutintedavi hattındaskar5 8/K Sağkolmediali 4gün Fasyotomi+rutin 2ay Greftlenenalanlarda tedavi skarpigmentasyon değişiklikleri6 14/K Solbacakpostero 6gün 6.günfasyotomi+ 1.5ay Fasyotomi lateraltibialbölge rutintedavi hattındaskar7 55/E Sağelbileğiradialtaraf 6saat Rutintedavi 1ay8 12/K Sağayakbileği 36saat 3.günfasyotomi+ 2 Fasyotomi rutintedavi hattındaskar9 60/E Sağel1. 6saat 24.sattefasyotomi+ Fasyotomi parmakpulpası rutintedavi hattındaskar10 26/K Sağel2.parmak 4saat Rutintedavi 2ay Pulpadefekti11 1/E Sağeldorsumu 24saat 48.sattefasyotomi+ 4.günölüm rutintedavi12 35/E Sağayakbileği 2saat Rutintedavi 1ay13 23/E Solel1.parmak 6saat Rutintedavi 3hafta14 48/K Sağönkol 6gün 6.günfasyotomi+ 3ay Fasyotomi volaryüz rutintedavi hattındaskar


hastalardalokalısıartışıveyaateşgibitoksikbelirti-lerhızlageriledi.Lökositoz, trombositopenigibipa-rametreleri bozulmuş olgularda bu değerlerin birkaçgüniçerisindenormalleştiğigözlemlendi.

Sağelbileğidorsalindenısırılanhastada,ısırıktan36saatsonratümüstekstremitedeaşırıödem,ağrı,ısıartışıvekoyurenkdeğişikliğigelişti.Elveönkolaya-pılanfasyotomisonrasındahastanınomuzdanitibarentümekstremitedekişişlikveısıartışıgeriledivelabo-ratuvardeğerleriameliyatsonrası2.günnormalleşti.Altıgünsonrafasyotomisikapatıldı(Şekil2).

Sağkolmedialindenısırılan8yaşındakızçocuğuna

4.güntümüstekstremite,göğüsduvarıveboyunaya-yılanaşırıödem,ağrıveekimoznedeniyleönkol,kolvesternumafasyotomiaçıldı.Fasyotomisonrası5güniçerisindehastanınödemigeriledi,renkveısıdeğişik-liğigidereksoldu(Şekil3).Hastanıncerrahiöncesi/sonrası 5. gün laboratuvar değerleri: WBC: 19,1/7,Hb:5,1/11,4(transfüzyon),PLT:114000/438000,CK:1605/16,LDH:5062/811,TİT:koyukırmızı/açıksarı,D-Dimer:36,8/1,4idi.Kolmedialindekalannekrotiksahavekesihattı14günsonragreftlenerekonarıldı.

Sağel1.parmağıısırılan60yaşındaerkekhasta-yaparmaktatotalsiyanoz,antekubitalbölgeyekadar


Şekil 3. (a) Isırıktan sonra 4. gün görünüm.(b) Dördüncü gün miyonekroz, (c) fasyotomiden24saatsonrakigörün-tü,(d) defektin15.güngörüntüsü.

(b)

(d)

(a)

(c) Renkli şekiller derginin online sayısında görülebilir. (www.tjtes.org)

Şekil 4. (a, b)Isırıktan6saatsonraparmağınvenözkanayan,siyanotikgörünümü,(c)24saatsonrahızlıgelişenödemindiğer ekstremiteyle karşılaştırmalıgörüntüsü.(d, e)Yirmibirgünsonrafasyotomihattıveparmağıngörünü-mü.

(a) (b) (c)

(e)(d)Renkli şekiller derginin online sayısında görülebilir. (www.tjtes.org)

masif ödem, ağrı, ısı artışı ve eritamatöz renk deği-şikliğinedeniyle24saat sonraparmak,elveönkolafasyotomi yapıldı. Fasyotomi sonrası ödem, renk veısı değişikliği dirsekten itibaren2 gün içindegerile-di. Parmaktaki nekroz sadece pulpaya lokalize kaldı(Şekil 4). Bu örnek olgular dışında diğer fasyotomiaçılandiğer3olgudadaklinikvelaboratuvarverile-rindeaynısonuçlargözlemlendi.Kliniğimizebaşvur-duğundakompartmansendromutanısıkonulupfasyo-tomiyapılan3hastadaiseiyileşmehızıerkencerrahiyapılanlarla kıyaslandığında oldukça yavaştı ve kasvederidekinekrotikilerlemekısmengeriledi.Ayrıcabuhastalardaaralıklıdebridmanlaryapıldıvetamamıkısmikalınlıktaderigreftiileonarıldı.

Erken cerrahi uygulanan hastaların 5’inde ödemgeçtiktensonraprimeronarımilekesiyerikapatıldı.Hastaların hiçbirinde uzuv amputasyonu yapılmadı.Bu hastaların hiçbirinde ortalama 3 aylık takiplerin-deskardokusundankaynaklananekstansiyondahafifçekmedışındakontraktür,kasgüçsüzlüğügörülmedi.Greftle onarım yapılan 4 hastada hipertrofik skarlargözlendi.

TARTIŞMAYılan ısırmalarında yılanın türünü saptamak her

zaman olası değildir. Ölüme kadar varabilen komp-likasyonlaranedenolabileceğinden, tümyılan ısırık-larızehirlikabuledilerekizlenmelidir.[20]Kanbasıncıkontrolaltınaalınmalı,kansayımı,kandakifibrinojendüzeyi,trombositsayısı,serumelektrolitleri,kanglu-kozu,BUN,kreatinin,KCFT,amilaz,CPK,PT,PTT,TİTvearteriyelkangazları incelenmelidir.EKGçe-kilmelive incelemeler8-12 saat arayla tekrarlanma-lıdır.[5,7] Zehirli yılan ısırmalarının%30’u tedavi ge-rektirmez,ısırığın5-10cmyukarısındasadecelenfatikakımıengelleyecekkadarbirbasınçtailk30dkiçeri-sindeuygulanacakbirturnikezehrinsistemikdolaşı-mageçmesinibüyükölçüdeazaltır.[21]

Yılanzehiri%70su,%30proteinli[enzimkompo-nentivetoksinkomponenti]maddedenoluşur.[22]En-zimkomponentihiyaluronidazve fosfolipazAbaştaolmaküzereoksidaz,esteraz,peptidazveproteazdanzenginpıhtılaşmayıbozanbiryapıdadır.Toksinkom-ponenti isenörotoksinlervehemotoksinle içerir.[22,23] Nörotoksinlerpostsinaptikmembrandakürarbenzerietkiilediyaframkaslarınıetkileyerekanisolunumsı-kıntısınayolaçabilirken,hematoksinler iseekstrava-zasyon,hemoliz,fibrinolizyadaintravaskülerkoagü-lasyonayolaçabilir.[22,23]

Ülkemizde var olan zehirli yılanların toksini isedahaçokhemolitiközelliktedir.[22]Göğsünüstkısmıvebaşboyunbölgesineyaklaşıldıkçaısırığıntehlikesiartmaktadır.Isırığındamariçinedenkgelmesidezehi-rintoksisitesinivemorbiditeyioldukçaartırmaktadır.[22]Yılanısırmalarısonucugörülenlokalbulgular30

ila60dakikaiçerisindeortayaçıkmasınakarşınilkbirhaftaiçindekompartmansendromugelişebilmektedir.[24]Buyüzdenekstremitelerdeolanyılanısırmaların-daoluşabilecekkompartmansendromuaçısındansıkıtakip gerekmekte ve klinik olarak şüphelenildiğindefonksiyoneltamiyileşmesağlanabilmesiiçinfasyoto-miyapılmalıdır.[25,26]

Zehir,hasarladığıdokudansalınanhistamin,bradi-kinin,serotoningibimediyatörlerinartmasınayolaça-raketkinliğiniartırır.[1,23]Isırıktansonrabaşlayansüreçaslındabirkısırdöngüdür.Zehiretkinliğiniartırdıkçavazodilatasyon amacıylamediatörler artmakta vazo-dilatasyonvevaskülerpermeabilitearttıkçakompart-man içindevedışındakibasınç artmaktadır.Sonuçtatek başına dolaşımın yetersizliği nedeniyle nekrotikperiyot tetiklenmesebilezehrinlizisvedegredasyonetkisiartmaktadır.Bunedenleyılanısırıklarındakom-partmanbasıncı fasyotomi için temelendikasyonol-mamalıdır.Diğer travmatiknedenlerle(yanık,kemikfraktürleri vs.) oluşan kompartman sendromlarındabasınçölçümüveyaklinikölçütlerönplanda tutula-bilirancakyılanısırıklarınabağlıkompartmansend-romlarındabuölçütlerin, tümmedikal veprofilaktiktedaviler yapılması şartı ile ikinci planda kalmasıgerektiğini düşünüyoruz. Fasyotominin kompartmandolaşımını rahatlatma etkisi dışında toksinlerin buyöntemleaktivasyonlarınınazaldığıveyakaybolduğukanaatindeyiz.

Williams ve arkadaşları[13] da ekstremite travma-larınınnedenolduğukompartmansendromlarındadaerkenfasyotomininoldukçaetkiliveküratifolduğunubelirtmişlerdir. McQueen ve Court-Brown[27] fasyo-tomi için eşik basınç değerini 30mmHg olarak bil-dirmiştir. Parestezi, solukluk, nabızsızlık, ağrı, pasifhareketle ağrı gibi klinik semptomların oluşmasınınbeklenilmesiçoğuzamanyagecikmeyeyadatanıdakarışıklığayolaçmaktadır.Anılvearkadaşları[17] an-ti-serumtedavisininzehrinyıkıcıekişiniortadankal-dırarak kompartman sendromonu önleyeceğini raporetmişlerdir.Ayrıcaaynıçalışmadamannitol tedavisi-nin antioksidan etkisi, antiödem etkisi ile nekroz veapopitozu önlediğini savunmuşlardır. Söz konusu butedaviler zaten rutin uygulamalar olup tek başlarınaveyakombineolaraketkinlikleriyadsınamaz.Ancakkompartman sendromunu önleme konusunda tama-menküratifolması,kendiolgularımızdave literatür-deyeralanfasyotomigerekliliğivesıklığıgözönünealınacak olursa mümkün gözükmemektedir. Ayrıcaantiserum tedavisinin etkinliğinde en önemli belir-leyicilerden birinin hastanın zehire olan duyarlılığıolduğu unutulmamalıdır.Yılan ısırmalarının bir kıs-mındadamiyonekrozabağlıbazenlokalizeödemveekimozgelişmektebazendenekrotizanfasiitbenzeriilerleyicidokuyıkımıgözlenebilmektedir.Budurum-larda da fasyotomi oldukça küratif olmaktadır.Gold




vearkadaşları[11]kompartmanbasıncı55mmHgolanbirolgudamannitol,hiperbarikoksijenveantiserumkombinetedavisiiletedaviettikleriniraporetmişler-dir. 55mmHgbasıncakadarbeklenildiğindekasdo-kusu büyük oranda canlılığını kaybedebileceği gözardıedilmemelidir.Tanenvearkadaşları[10]yaptıklarıdomuzçalışmasında tibialisanteriorkasları içinedi-rektyılan zehiri enjekte etmişlervedeneklerinyarı-sınaantiserumdiğeryarısınasalinvererekfasyotomiyapmışlardır.Fasyotomiyapılanlardakasnekrozunundahayüksekolduğunubulduklarınıraporetmişlerdir.Bu çalışmanın oldukça subjektif oluğu ve direk kasiçi enjeksiyon yapılması ve kompartman sendromukliniğini direkt sağlayamadığı Fulton veHoffman[12] tarafındanbelirtilmiştir. Ayrıcayılanısırmalarındaze-hirçoğunluklakasiçineulaşmazgenelliklesubkutandokudakalmaktadır.Subkutandokudabaşlayanenfla-masyoniletetiklenenvekısırdöngüylegiderekartanödemöncelikleekstrakompartmansahayıetkilemek-tedir.Lokaldokuhasarızehrinmiyotoksikvesitolitiketkileriyleoluşmaktadır.[23]Ayrıcazehirebağlıoluşandoku nekrozu çinko bağımlı metalloproteinazlar vemiyotoksikfosfolipazA2etkisiyleoluşmaktadır.[28]

Yılanzehrininçeşitlinörolojikdefisitlereyolaça-bileceği ya da kompartman sendromu bulgularınıtaklitedebileceğivekullanılançeşitliağrıkesicilerinkliniğimaskeleyeceğidegözardıedilmemelidir.Yı-lan sokmalarında sessizkompartmansendromugeli-şebilmektedir.Özellikleçocuklardaklinikbulgularınsübjektif olması, çocukların koopere olmamaları vekompartman basınç ölçümünün kolay yapılamamasıgibi nedenlerle tanı gecikmesi olabilir.Bu nedenler-le fasyotomiyılan ısırıklarında farklı endikasyonlarasahiptir.

Sonuç olarak, yılan sokmalarından sonra gelişenkompartmansendromuolgularındakliniğintamolarakoturmasını veya kompartman basıncının eşik değereulaşmasını beklemeden yapılan erken fasyotomi uy-gulamalarıoldukçaetkilidir.Buolgularda fasyotomiöncesinde gerekli tüm tedaviler uygulanmalı sadececerrahidahaerkenyapılmalıdır.Ayrıca2.olgudaol-duğugibiyılansokmalarındakompartmansendromuolmadan geç dönemde yapılan fasyotomi nekrotizanfasiit benzeri ilerleyenklinik tabloyubelirginolarakazaltmaktavedokuyıkımınıdurdurmaktadır.Yukarı-dadahaöncebelirttiğimizgibizehiretkisinienflama-tuvarmediatörlerüzerindenartırdığıiçinantihistami-nikler,aprotinin(bradikininsalınımınıazaltmakiçin),metiserjid veyaketanserin (serotonin antagonistleri),antioksidanlar (allopurinol, deferoksamin, viaminC-E…),montelukast gibi ajanlarla yapılan kombinetedavilerdeetkiliolabilir.

Ayrıcayılansokmasıtedavisindezehrininaktivas-yonu gelişebilecek komplikasyonların önlenmesi vefasyotomigerekliliğiniazaltmakiçindahagenişkap-

samlıdeneyselveklinikçalışmalaraihtiyaçvardır.

KAYNAKLAR 1. GündüzA,HasanbaşoğluA,TopbaşM.Yılansokması.Aka-

demikAcilTıpDergisi2003;2:43-7.2. Çetin O. Türkiye sürüngenleri. Available at: http://reptile.

fisek.com.tr.3. RusselF.Whenasnakestrikes.EmergMed1990;22:33-43.4. BüyükY,KoçakU,YazıcıYA,GürpınarSS,KırZ.Yılan

ısırığına bağlı ölüm. Türkiye Klinikleri J Foren Med2007;4:127-30.

5. AlB,OrakM,AldemirM,GüloğluC.SnakebitesinadultsfromtheDiyarbakirregioninsoutheastTurkey.UlusTravmaAcilCerrahiDerg2010;16:210-4.

6. Russell EF. Snake venom poisoning in the United States.AnnRevMedb1980;31:247-56.

7. KöseR.Themanagementof snake envenomation: evalua-tionoftwenty-onesnakebitecases.UlusTravmaAcilCer-rahiDerg2007;13:307-12.

8. DavidsonTM,SchaferSF.Rattlesnakebites.Guidelinesforaggressivetreatment.PostgradMed1994;96:107-14.

9. ErtemK.Venomous snakebite inTurkey.Eur JGenMed2004;1:1-6.

10.TanenDA,DanishDC,GriceGA,RiffenburghRH,ClarkRF. Fasciotomy worsens the amount of myonecrosis in aporcinemodelofcrotalineenvenomation.AnnEmergMed2004;44:99-104.

11.GoldBS,BarishRA,DartRC, SilvermanRP,BochicchioGV.Resolutionofcompartmentsyndromeafter rattlesnakeenvenomationutilizingnon-invasivemeasures.JEmergMed2003;24:285-8.

12.KernsW2nd,BeuhlerM,TomaszewskiC.Hydroxocobala-min versus thiosulfate for cyanide poisoning.Ann EmergMed2008;51:338-9.

13.WilliamsAB, Luchette FA, Papaconstantinou HT, Lim E,HurstJM,JohannigmanJA,etal.Theeffectofearlyversuslatefasciotomyinthemanagementofextremitytrauma.Sur-gery1997;122:861-6.

14.CawrseNH,InglefieldCJ,HayesC,PalmerJH.Asnakeintheclinicalgrass:latecompartmentsyndromeinachildbit-tenbyanadder.BrJPlastSurg2002;55:434-5.

15.Matsen FA 3rd,Winquist RA,KrugmireRB Jr.Diagnosisandmanagementofcompartmentalsyndromes.JBoneJointSurgAm1980;62:286-91.

16.MarsM,HadleyGP.Raisedcompartmentalpressureinchil-dren:abasisformanagement.Injury1998;29:183-5.

17.AnılBA,AnılM,KaraOD,BalA,OzhanB,AksuN.Yılanısırığınabağlıağırödemsaptananüçolgudamannitolteda-visi.TürkiyeKlinikleriJMedSci2011;31:720-3.

18.Grace TG. Closed compartment ischemia and snakebite.WestJMed1988;148:707.

19.McQueen MM, Gaston P, Court-Brown CM.Acute com-partment syndrome.Who is at risk? JBone Joint SurgBr2000;82:200-3.

20.ChewKS,KhorHW,AhmadR,RahmanNH.Afive-yearret-rospectivereviewofsnakebitepatientsadmittedtoatertiaryuniversityhospitalinMalaysia.IntJEmergMed2011;4:41.

21.TanenD,RuhaA,GraemeK,CurryS.Epidemiology andhospitalcourseofrattlesnakeenvenomationscaredforatatertiaryreferralcenterinCentralArizona.AcadEmergMed2001;8:177-82.

22.Dökmeciİ.Hayvansalkaynaklızehirler.In:Dökmeciİ,Dök-meciAH,editör.Toksikolojizehirlenmelerdetanıvetedavi.


4.baskı.İstanbul:NobelTıpKitabevleri;2005.s.500-5.23.WarrellDA.Snakebite.Lancet2010;375:77-88.24.BulutM,ErenS,OzdemirF,KoksalO,DurmusO,EsenM,

etal.SnakebitescasesadmittedtoUludağuniversityfacultyofmedicineemergencydepartmentandcurrentmanagementofsnakebite.AkademikAcilTıpDergisi2009;8:31-4.

25.HsuKY,ShihHN,ChenLM,ShihCH.Lowerextremitycom-partmental syndrome following snake-bite envenomation--onecasereport.ChanggengYiXueZaZhi1990;13:54-8.

26.WagnerHE,BarbierP,FreyHP,JanggenFM,RothenHU.Acutecompartmentsyndromefollowingsnakebite.[ArticleinGerman]Chirurg1986;57:248-52.[Abstract]

27.McQueenMM,Court-BrownCM.Compartmentmonitoringintibialfractures.Thepressurethresholdfordecompression.JBoneJointSurgBr1996;78:99-104.

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424




Departments of 1Otolaryngology, 2Radiology, Ankara Atatürk Training and Research Hospital, Ankara, Turkey.

Ankara Atatürk Eğitim ve Araştırma Hastanesi 11. KBB Kliniği,Radyoloji Kliniği, Ankara.

Correspondence (İletişim): Gökhan Yalçıner, M.D. Ankara Atatürk Eğitim ve Araştırma Hastanesi,

1. KBB Kliniği, Bilkent Yolu Lodumlu Mevkii No: 2, 06800 Ankara, Turkey.

Tel: +090 - 312 - 291 25 25 / 4338 e-mail (e-posta): [email protected]

AMAÇTemporalkemikkırığıolanhastalardaetyoloji,otolaringo-lojiksemptomvebulgularınradyolojikdeğerlendirmeleri,tedaviyaklaşımlarıvesonuçlardeğerlendirildi.

GEREÇ VE YÖNTEMYetmişyeditemporalkemikkırığıolgusu,yaş,cinsiyet,kı-rığınyeri,kırığınetyolojisivekanlıotore,timpanikmemb-ranperforasyonu,serebrospinalotore,işitmekaybı,hemo-timpanum, fasiyal ve diğer kraniyal sinir paralizilerininvarlığıvebilgisayarlıtomografisonuçlarıyönündengeriyedönükolarakdeğerlendirildi.

BULGULAROlgularda kırıkların%55’i trafik kazası sonucumeydanagelmişti ve çoğunluğu erkekti (%76,6). Otolaringolojikbulgularsıklıksırasıileerkendönemiletimtipiişitmekay-bı(%65,8),kanlıotore(%61,2),hemotimpanum(%58,5),timpanikmembranperforasyonu(%25,6),fasiyalsinirpa-ralizisi(%12,3),serebrospinalotore(%8,5)vesensörinöralişitmekaybı(%5,4)idi.Kırıklarınçoğupetroz(%65,8)veuzunlamasınatip(%51,2)idi.

SONUÇBuaraştırmada77temporalkemikkırığıhastasındasıklıksırasıileotolaringolojikbulgularıvetedaviyaklaşımımızıliteratürbulgularıilekarşılaştırıptartıştık.Temporalkırık-lardasistematikbirdeğerlendirmevetedaviiçinbiralgo-ritmaoluşturduk.Anahtar Sözcükler: Kafa travması; maksillofasiyal yaralanma;temporalkemik.

BACKGROUNDWeaimedtoevaluatetheetiologies,otolaryngologicalfea-tures, radiological findings, management strategies, andoutcomesoftemporalbonefractures.

METHODSSeventy-seventemporalbonefracturecaseswereretrospec-tivelyevaluatedforageandgenderdistribution,sideofthefracture, etiology of injuries, the presence of blood otor-rhea, tympanicmembrane perforation, cerebrospinal fluidotorrhea,hearingloss,hemotympanum,andfacialorothercranialnervepalsies,andcomputerizedtomographyreports.

RESULTSNearly55%ofthecaseswerecausedbytrafficaccidentsandwerepredominantlymale (76.6%).Otolaryngologicalpre-sentationsinordertofrequencywereearlyconductivehear-ingloss(65.8%),bloodotorrhea(61.2%),hemotympanum(58.5%), tympanic membrane perforation (25.6%), facialnerveparalysis(12.3%),cerebrospinalfluidotorrhea(8.5%),andsensorineuralhearingloss(5.4%).Mostofthefractureswerepetrous(65.8%)andlongitudinaltype(51.2%).

CONCLUSIONInthisresearch,otolaryngologicalfindingsinorderoffre-quencyandtreatmentapproacheswerecomparedwithlit-eraturefindingsanddiscussedin77temporalbonefracturecases.Weformedamanagementalgorithmforthesystem-aticevaluationandtreatmentoftemporalfractures.Key Words: Headtrauma;maxillofacialinjuries;temporalbone.

doi: 10.5505/tjtes.2012.98957

Temporal bone fractures: evaluation of 77 patients and a management algorithm

Temporalkemikkırıkları:77hastanındeğerlendirilmesivebiryaklaşımalgoritması

Gökhan YALÇINER,1 Ahmet KUTLUHAN,1 Kazım BOZDEMİR,1 Hüseyin ÇETİN,2 Behçet TARLAK,1 Akif Sinan BİLGEN1

Nowadays, head trauma is a common injury towhichallofusaresusceptiblebecauseofhighspeedtravel.[1] Skull fractures affect 23%-66% of patientswithheadtraumaandapproximately4%-30%ofheadinjuriesinvolveafractureofthecranialbase,includ-ing18%-75%oftemporalboneinvolvement.[2,3]

Afterasevereheadinjury,themaintenanceoflifeisthemostimportantconcern.Afterprovidingstablevital functions likebreathing, circulation andneuro-surgical evaluation and evaluation of the chest andabdomen, it isappropriate foranotolaryngologist toevaluatethepatient.Theimportanceoftemporalbonefracturesaccordingtotheotolaryngologististhefacialnerveandthestructuresrelatedtohearingandbalancelocated therein and prevention of functional losses.Themost commonphysical examinationfindings oftemporalbonefracturesarebloodotorrhea,tympanicmembraneperforation,hearingloss,hemotympanum,cerebrospinalfluid(CSF)otorrhea,andfacialandoth-ercranialnervepalsies.

In this research, we retrospectively reviewed thecauses, gender distribution, otolaryngological fea-tures,radiologicalfindings,andoutcomesof77tem-poral bone fracture cases betweenMarch 2007 andApril2011.

MATERIALS AND METHODSSeventy-seven patients who were evaluated and

treated for temporal bone fracture by our clinic be-tweenMarch2007andApril2011andwhoserequireddatawereobtained from theirfileswere included inthis retrospective research.Age, gender distribution,sideoffracture(right,left,bilateral),etiologyofinju-ries,presenceofbloodotorrhea,CSFotorrhea, tym-panic membrane perforation, hearing loss (conduc-tive, sensorineural or mixed), hemotympanum, andfacial and other cranial nerve palsies, computerizedtomography(CT)reports,andfollow-upresultswereevaluated.Thecollecteddatawerethenanalyzedandcomparedwiththeliteratureseries.

RESULTSAgesofthepatientsrangedfrom8-76years.Age,

genderdistribution,sideofthefracture,andetiologyoftheinjuriesareseeninTable1.Inadditiontotheotolaryngologicexamination,allpatientswereevalu-atedwithaxial andcoronalCT. InCT, the fractureswereevaluatedaccording to twodifferentclassifica-tion systems as petrous-non-petrous and transverse-longitudinal-oblique-mixed. The presence of bloodotorrhea, tympanic membrane perforation, hearingloss (conductive-sensorineural-mixed), hemotympa-num,CSFotorrhea,andfacialandothercranialnervepalsieswasnotedaccordingtotheaboveclassificationsystems.

Thefacialandothercranialnervepalsiesthatwerefoundinthefirstexaminationwerecountedasimme-diateandthosefoundlater(afterthefirstfewhours)wereevaluatedaslate.Thepatientswhowereuncon-sciousandwerenotappropriateforevaluationofhear-ing loss and facial functionwere ignoredduring thecalculation of the percentages.Therefore,when cal-culatinghearinglossandfacialandothernervefunc-tions,thetotalnumberoffractureswasacceptedas73,andtheotherratioswerecalculatedonthebasisof77patientswith82temporalfractures(5patientshadbi-lateralfractures).ResultsareseeninTable2.Fourteenpatientsdiedofsevereintracranialandotherinjuries.

DISCUSSIONTemporal bone fractures occur from high energy

mechanisms,particularlyasa resultofside impacts,typicallybutnotlimitedtomotorvehicleaccidents.[4] Intheliterature,riskfactorsforandcausesoftemporalbonefracturesare:youngerage,malegenderandmo-torvehicleaccidents.[5-8]Similarly,inourseries,trafficaccidentsweretheprimarymechanismoftheinjury,witha54.5%ratio;76.6%ofthecasesweremaleandthemeanagewas34.1years.Thisresultmayberelat-edtothefactthatyoungmalesaregreaterparticipantsintrafficandindustrialbusiness.

When otolaryngologists were consulted for thetreatment of these patients, their primary concernwas the evaluationof the external ear and tympanicmembrane, the presence of blood otorrhea andCSFotorrhea, hearing status, facial nerve function, andthepresenceofhemotympanum.However,notinfre-quently,theseverityoftheinjury,thepatient’suncon-

Table 1. Distributionofcasesaccordingtoage,gen-der,fracturesideandmechanismofinjury

Age

Gender

Side

Mechanismofinjury

8-1011-2021-3031-4041-5051-6061-7071+MaleFemaleRightLeftBilateralTrafficaccidentsFallsIndustrialaccidentsAssaultGunshotwound

31028121085159183834542191231

3.8912.9836.3615.5812.9810.386.491.2976.6223.3749.3544.156.4954.5424.6715.583.891.29

Total n %

Temporal bone fractures




scious status, and other severe injuries requiring ur-gentinterventionleadtoadelayintheotolaryngologicevaluationandmanagement.Afteraphysicalexami-nationfortheestablishmentofanaccuratefracturedi-agnosis,axialandcoronaltemporalCTshaveacriticalimportance.[9,10]We formedamanagementalgorithmfortheevaluationoftemporalbonefractures.Thisal-gorithmformatoftemporalfracturemanagementmayofferarapidexperienceopportunityforinexperiencedpractitioners(Fig.1).Toourbestknowledge,nosuchalgorithmhasbeenreportedtodate.

There are several classification systems for theevaluation of temporal fractures with CT. Some ofthem are longitudinal-transverse-oblique or mixed,petrous–non-petrous, and otic capsule sparing–oticcapsule violating.[2,3,6,7] In the different series, statis-tical correlation between clinical findings and theseclassificationshasbeenreported.[3,6]Inourseries,wealsoevaluatedthedistributionofclinicalfindingsac-cording topetrous-non-petrous and transverse-longi-tudinal-oblique-mixed classifications. The distribu-tionoffracturetypesandclinicalfindingsduetotheseclassifications are seen in Table 2. In our opinion,theseclassificationsystemsmaybeimportantforsta-tisticalresults,butarenotclinicallyimportant,asweevaluatethepatientsaccordingtotheexistenceoftheabove-mentionedsymptomsandfindingsandnottheclassificationsystems.

Inourresearch,themostcommonotolaryngologi-calfindingswereconductivehearingloss(CHL)intheearlyperiod(64.9%),bloodotorrhea(62.1%),hemo-tympanum(58.5%),andtympanicmembraneperfora-

tion(25.6%).Thehearinglossratiointheearlyperiodisdeterminedbythediapasontestresultsofthefirstex-amination.Thishighratiomaybeduetothehighrateofhemotympanumandtympanicmembraneperfora-tions.Aftertheaverage4-6weekfollow-upperiod,inpatientswithhearingloss,theCHLratiowas12.3%,whichwasdeterminedbytheaudiologicexamination.Intheliterature,thereportedincidenceratesforCHLwere10%-57%.[3,7]CHLgenerallyresolvesovertime(usually within 3-4 weeks).[2] Pure hemotympanumgenerally resolveswithout sequelaewithin this timeperiodaswell.[2]Small tympanicmembraneperfora-tion also heals within 4-6 weeks. If CHL and tym-panicmembraneperforationspersist after 3months,thentympanoplastyand,ifnecessary,ossicularchainreconstructionshouldbeperformed.[2]Themostcom-monossicularchaindisruptionisincudostapedialdis-location (11%-14%), followed by dislocation of theincudomallearjoint.[3]Inourseries,5patientsunder-wenttympanoplasty,and2ofthemunderwentincudo-stapedialjointrepairwithbonecement.

Accordingtoourresearch,themostcommonthreesymptoms (apart from early CHL), blood otorrhea,hemotympanumandtympanicmembraneperforation,were seen above the rate of 90%with petrous frac-tures.Therefore, if a classification system has to beused, petrous-non-petrous classification seems moreappropriateforotolaryngologicalpurposes.

The sensorineural hearing loss (SNHL) rate wasfoundas5.4%,andallofthesecaseswerecausedbypetrousfracture.Intheliterature,SNHLrateswerere-portedas0%-14%.[2,7]As iswellknown, there isno

Table 2. Distributionoffindingsduetotwodifferentclassificationsystems

Total A B C D E F (n,%) (n,%) (n,%) (n,%) (n,%) (n,%)

Totalfracture 82 54,65.8 28,34.2 42,51.2 21,25.6 5,6.1 14,17.1Bloodotorrhea 51,62.1 43,52.4 8,9.7 33,40.2 11,13.4 3,3.6 4,4.8Tympanicmembraneperforation 21,25.6 20,24.3 1,1.2 12,14.6 6,7.3 2,2.4 1,1.2Hemotympanum 48,58.5 41,50 7,8.5 29,35.3 12,14.6 3,3.6 4,4.8Cerebrospinalfluidotorrhea 7,8.5 6,7.3 1,1.2 4,4.8 1,1.2 – 2,2.4Conductivehearingloss 50,64.9 Immediate 44,57.1 6,7.8 35,45.4 9,11.6 1,1.3 5,6.5 9,12.3 Late 7,9.5 2,2.7 4,5.4 3,4.1 – 2,2.7Sensorineuralhearingloss 4,5.4 4,5.4 – 3,4.1 1,1.3 – –Facialnervepalsy 3,4.1 Immediate 2,2.7 1,1.3 – 2,2.7 – 1,1.3 6,8.2 Late 6,8.2 – 4,5.4 1,1.3 1,1.3 –Othercranialnerve(CNIII,IV,VI)palsies 2,2.7 2,2.7 – 2,2.7 – – –Meningitis 1,1.3 1,1.3 – 1,1.3 – – –

A:Petrous;B:Non-Petrous;C:Longitudinal;D:Transverse;E:Oblique;F:Mixedorcomminuted.

Temporal bone fractures


effectivetreatmentforSNHL,andrehabilitationwithhearingaids,andifnecessarycochlearimplant,isrec-ommended.AlthoughthereisnotenoughdataintheliteratureabouttheusageofsteroidsforthetreatmentofSNHLduetotemporalfracture,thereisapossibil-itythattheycanbeapplied.Wealsodonothaveanyexperienceaboutsuchtreatment,butweintendtoap-plyitinthefuture.

Inour research, therewere9 facialnerveparaly-sis cases,with3of themhavingearlyor immediateand6havinglateonset(Fig.2).Allofthe6paralysiscaseswithlateonsetwereseenwithpetrousfracturesand2ofthe3caseswithearlyorimmediateonsetpa-ralysiswereseenwithpetrousfractures,while1hadnon-petrous,mixedtypefracture.Intheliterature,fa-cialnerveparalysisrateswerereportedas10%-25%forlongitudinalfracturesand38%-50%fortransversefractures.[3]Fortransientandpersistentfacialparaly-sis,ratesupto65.5%werealsoreported.[11]Inourse-ries,allofthelateonsetcasesweregivencorticoste-roidtherapyandthenfollowedup.Allofthemalmostcompletely recovered. One of the early onset caseswhoalsohad3rd,4thand6thcranialnerveparalysisdied.Oneofthemremainedunconsciousintheneuro-surgicalintensivecareunitfor6weeksandhadsepti-

cemia.Whenhisgeneralconditionimproved,hehadblindnessduetoopticatrophyand3rdand6thnerveparalysison the facialparalysis side.His familydidnotacceptsurgeryforfacialnerveexploration.

Medical history and physical examination-Cause of injury-Consciousness-Other injuries

TEMPORALTRAUMA

Laboratory-CBC-Coagulation tests-Radiological evaluation of other injuries-Screening of alcohol and other toxic substances

Evaluate/Stabilize-Airway-Circulation-Cervical vertebrae-Major system or life-threatinhg injuries

-Otolaryngological Examination

-Temporal bone CT axial-coronal

Blood otorrheaInsignificant

Massive

Follow-up (3 months)

-B2 transferrin-Follow-up(2 weeks)-Antibiotics?

Aspiration

Temporary Packing

Tympanic Membran Perforation

Haematympanum

CSF otorrhea

Follow-up (3-4 weeks)

Tympanoplasty

Healed

Non-healed Surgical repair

Conductive heraing loss

Follow-up(3 months)

Exploration and ossiculer chain reconstruction

Healed

Persistant

Healed

Non-healed

Sensorineural hearing loss

Other cranial nerve paralysis

Steroid therapy (?) Hearing aid

or cochlear implant

Meningitis Antibiotics therapy

Neurosurgical consultation

Immediate

Late

Surgical exploration

Corticoste-roids

Healed

Non-healed

Electrodiagnostic testing

Non-regeneration signs

ExplorationFollow-up

Regeneration signs

Facial nerve palsy

Healed

Non-healed

Fig. 1. Thealgorithmformatoftemporalbonefracturemanagement.

Fig. 2. CT of a patientwith early facial paralysis showingtransversefracture.



Duringthefollow-upofthethirdpatientinthein-tensivecareunitforimprovementingeneralstatusforthefacialexplorationoperation,onthe20thday,signsofregenerationweredetectedintheelectromyographyandtheoperationdecisionwasabandoned.

Agenerallyacceptedprincipleofthetreatmentoffacialparalysisisthatthemanagementdependsonthetimingofparalysisrelatedtotheinjury.[3]Rapidlossoffacialnervefunction(immediateorwithinthefirstfewhours)islikelyduetotransactionandistradition-allymanagedwithsurgicalexplorationafterimagingandelectricalstudiesindicateaneedfornervedecom-pressionorrepair.Ontheotherhand,adelayedlossismorelikelyduetoedemaandistypicallytreatedwithhigh-dose corticosteroids with further interventionbasedonresultsoftheelectrodiagnostictesting.[2,3]

Kim et al.[12] reported that the patient with trau-matic facial nerve paralysiswho had nerve conduc-tionstudiesconsistentwithapoorprognosisregainedconsiderablefacialfunctionafterearlysurgicalinter-vention;however,lateexplorationdidnotresultinapositiveoutcome.

Eventhoughpositiveresultshavebeenreportedinthe literaturewith early surgery in selected cases, arecentsystematicanalysisrevealedthattheroleofsur-geryversusnonsurgicalinterventionsforthisclinicalentityremainsinconclusive.[13]

Therewere7(8.5%)CSFotorrheacasesinourre-search,1ofwhichwasseenwithnon-petrousfracture,and6ofwhichwereseenwithpetrousfractures.Allofthemwerehealedwithconservativetreatment(bedrest,headelevation,stoolsofteners,andprophylacticantibiotics). The reported incidence of CSF leak intemporalfracturesrangesfrom11%-45%.[3,7]Inthedi-agnosisofCSF,thepresenceofahaloaroundthebloodonthespongeisoftensuggestive.Insuspectedcases,theβ2-transferrintestofthefluidishighlysensitiveinidentifyingCSFleakage.[2]Withtheabove-mentionedconservativemeasures,CSFleakswillgenerallyhealintwoweeks.CSFleaksthatpersistlongerthan10-14daysmostlikelyrequiresurgicalrepair.[2,3]Theuseofprophylactic antibiotics remains controversial.How-ever,inameta-analysis,asignificantincreaseinmen-ingitisinpatientswhodidnotreceiveantibioticswasreported.Meningitis occurred in one of our patientswho remained in the intensive care unit for a longtime, but this patient did not haveCSF leakage andhealedwithantibiotictreatmentwithinthreeweeks.

One of the most common findings of temporalbonefracturesisbloodotorrhea.Thesebleedingsusu-allystopspontaneously.Incasesofmassivebleeding,atemporarypackisplacedintotheexternalauditorycanal.Thispackshouldberemovedin24hoursandaprophylacticantibioticshouldbegiven.Incasesin

whichthereisevidenceofneurocranialinjuryonCT,angiographyshouldbeobtainedinordertodetectvas-cularinjuries.[13]

In conclusion, temporal bone fractures generallyoccur as a component of a severe head trauma, andtrafficaccidentsarethemostcommonetiologicfactor.Anotolaryngologist isan importantpartof the teamtogetherwiththeneurosurgeonwhocaresforpatientswithtemporalbonefracture.Theeventstartswiththefirstevaluationofthepatientintheemergencydepart-mentandmaycontinuewithfollow-upandtreatmentofotolaryngologicallyimportantfeatures,suchasCSFfistula or facial nerve paralysis, repair of tympanicmembrane,andmanagementofhearingloss.Insomecases,aprolongedfollow-up,uptoayear,maybere-quiredforthetreatmentandrehabilitationofpatients.

REFERENCES1. IşıkHS,BostancıU,YıldızO,OzdemirC,GökyarA.Ret-

rospective analysis of 954 adult patientswith head injury:an epidemiological study. Ulus TravmaAcil Cerrahi Derg2011;17:46-50.

2. GladwellM,ViozziC.Temporalbonefractures:areviewfortheoral andmaxillofacial surgeon. JOralMaxillofacSurg2008;66:513-22.

3. JohnsonF,SemaanMT,MegerianCA.Temporalbonefrac-ture:evaluationandmanagementinthemodernera.Otolar-yngolClinNorthAm2008;41:597-618.

4. Yoganandan N, Baisden JL, Maiman DJ, Gennarelli TA,GuanY,PintarFA,etal.Severe-to-fatalheadinjuriesinmo-torvehicleimpacts.AccidAnalPrev2010;42:1370-8.

5. AhmedKA,AlisonD,WhatleyWS,ChandraRK.Theroleof angiography in managing patients with temporal bonefractures:aretrospectivestudyof64cases.EarNoseThroatJ2009;88:922-5.

6. IshmanSL, FriedlandDR.Temporal bone fractures: tradi-tional classification and clinical relevance. Laryngoscope2004;114:1734-41.

7. AminZ,SayutiR,KahairiA,IslahW,AhmadR.Headinjurywith temporalbone fracture:oneyear reviewof case inci-dence,causes,clinicalfeaturesandoutcome.MedJMalaysia2008;63:373-6.

8. BurgutHR,BenerA,SidahmedH,AlbuzR,SanyaR,KhanWA. Risk factors contributing to road traffic crashes in afast-developingcountry:theneglectedhealthproblem.UlusTravmaAcilCerrahiDerg2010;16(6):497-502.

9. HiroualM,ZougarhiA,ElGanouniNC,EssadkiO,OusehalA,TijaniAdilO,etal.High-resolutionCToftemporalbonetrauma:reviewof38cases.JRadiol2010;91:53-8.

10.SaraiyaPV,AygunN.Temporalbonefractures.EmergRa-diol2009;16:255-65.

11.YetiserS,HidirY,GonulE.Facialnerveproblemsandhear-inglossinpatientswithtemporalbonefractures:demograph-icdata.JTrauma2008;65:1314-20.

12.KimJ,MoonIS,ShimDB,LeeWS.Theeffectofsurgicaltimingonfunctionaloutcomesoftraumaticfacialnervepa-ralysis.JTrauma2010;68:924-9.

13.NashJJ,FriedlandDR,BoorsmaKJ,RheeJS.Managementand outcomes of facial paralysis from intratemporal blunttrauma:asystematicreview.Laryngoscope2010;120:1397-404.

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11st Department of Orthopedics and Traumatology, Dr. Lütfi Kırdar Kartal Education and Research Hospital, Istanbul; 2Department of Orthopaedics

and Traumatology, Bezmi Alem University, Istanbul; 3Department of Orthopaedics and Traumatology, Memorial Hospital, Istanbul, Turkey.

1Dr. Lütfi Kırdar Kartal Eğitim ve Araştırma Hastanesi, 1. Ortopedi ve Travmatoloji Kliniği, İstanbul; 2Bezmi Alem Üniversitesi,

Ortopedi ve Travmatoloji Kliniği, İstanbul; 3Memorial Hastanesi, Ortopedi ve Travmatoloji Kliniği, İstanbul.

Correspondence (İletişim): Deniz Gulabi, M.D. Caferağa Mah., Hacı Şükrü Sok., Sülün Apt. No: 11/9, Kadıköy, 34710 İstanbul, Turkey.

Tel: +90 - 216 - 441 39 00 / 1351 e-mail (e-posta): [email protected]

AMAÇBuyazıda,distaltibia(pilon)kırıklarınıncerrahitedaviso-nuçları,radyolojikveklinikolarakaraştırıldı.

GEREÇ VE YÖNTEM2002-2009 tarihleri arasında cerrahi olarak tedavi edilen31 hastanın (25 erkek, 6 kadın; ortalama yaş 46; dağılım17-72 yaş) 32 ayağı değerlendirildi. Bu kırıkların 24’üneaçık redüksiyonve internalfiksasyon,8’ineeksternalfik-sasyonyapıldı.Hastalarortalama46ay takipedildi.Has-talarTeeny-Wissfonksiyonelayakbileğiskorlamasınagöredeğerlendirildi.Radyolojikolarakkırıkredüksiyonskorla-masıOvadiaveBealskriterlerinegöreyapıldı.

BULGULARTip 2 kırıkların 9’unda (%47,4), tip 1 kırıkların 5’inde(%26,3)vetip3kırıkların5’inde(%26,3)mükemmelso-nuçeldeedildi.Tip3kırıkların9’unda(%69,2)kötüsonuçeldeedilmişken, tip1ve tip2kırıkların2’sinde (%15,4)kötü sonuç elde edildi. Eksternal fiksatör uygulaması ilekarşılaştırıldığında, çok iyi ve iyi sonuçlar anlamlı dere-cede yüksek sayıda açık redüksiyon internal fiksasyonuygulamasıileeldeedildi(sırasıyla,n=3,%15,8ven=16,%84,2;p<0.05).

SONUÇPilonkırıklarınıncerrahitedavisinde,atravmatikyumuşakdokudiseksiyonu,eklemyüzününanatomikredüksiyonu,stabilbir tespit, erkenhareketvehastanınmobilizasyonuilkelerineuyulduğundabaşarılı sonuçlaralınabilmektedir,ancak bu prensiplere uyulmasına rağmen tip 3 kırıklardatravmasonrasıartritkaçınılmazdır.Anahtar Sözcükler: Rüedi-Allgower sınıflaması; cerrahi tedavi;pilontibiakırıkları.

BACKGROUNDIn thisreport, thesurgical treatmentresultsofdistal tibia(pilon)fracturesareanalyzedradiologicallyandclinically.

METHODSBetween2002and2009,32feetof31patients(25males,6females;meanage46years;range17to72years)whoweretreatedsurgicallyfortibialpilonfractureswereevalu-ated.Openreductionandinternalfixationwereappliedto24andexternalfixation to8 fractures.Thepatientswereevaluated according to the Teeny-Wiss functional anklescore,andoverallassessmentofreductionwascalculatedradiographically according to the criteria of Ovadia andBeals.

RESULTSWhile excellent resultswere achieved in 9 (47.4%) type2,5type1(26.3%),and5(26.3%)type3fractures,fair/pooroutcomeswereobtainedin9(69.2%)type3andin2(15.4%)types1and2fractureseach(p<0.015).Comparedto the external fixation application, a statistically signifi-cantlyhighernumberofexcellentandgoodoutcomeswereobtainedwithopenreductioninternalfixationapplication(n=3,15.8%vsn=16,84.2%,respectively;p<0.05).

CONCLUSIONIf the principles of atraumatic soft tissue dissection, ana-tomicreductionofthejointface,stablefixation,andearlymobilizationofthepatientarecompliedwithinthesurgi-cal treatment of pilon fractures, successful results can beachieved.However,intype3fractures,eveniftheseprinci-plesarecompliedwith,post-traumaticarthritisisinevitable.Key Words: Rüedi-Allgöwer classification; surgical treatment;tibialpilonfractures.

doi: 10.5505/tjtes.2012.86094

The mid-term results of treatment for tibial pilon fractures

Tibiapilonkırıklarındaortadönemcerrahisonuçlarımız

Deniz GÜLABİ,1 Özgür TOPRAK,1 Cengiz ŞEN,2 Cem Coşkun AVCI,1 Erkal BİLEN,3 Fevzi SAĞLAM1


Recently, the frequencyofdistal tibia intraarticu-lar fractures has increased rapidly.A pilon fractureof the tibia involves the horizontal articular surfaceofthedistaltibiawithproximalextension.Themainreasonsareindustrialization,prevalenceofsportsac-tivities,andincreaseindomesticandtrafficaccidents.Thepilon fracture is an intraarticular fractureof thelowerendofthetibiaandcanbeassociatedwithvari-ousdegreesofcollapseanddisintegrationonthejointsurface.Onepercentoflowerextremityfracturesand7-10%ofalltibiafracturesarepilonfractures.[1-3]

Theusualmechanismofinjuryisaxialloadingofthelimbthroughtheankle,withorwithouttorsionalload.[1,3,4]Forthemanagementofpilonfractures,vari-ousmethodsarerecommended,suchasmanipulationandplasterapplication,externalfixation,verticaltran-sarticularandpercutaneouspinfixationoflargefrag-mentsandplasterapplication,stabilizationofthefibu-la,openreductionandinternalfixation(ORIF)tobothtibiaandfibula,primaryarthrodesis,andevenamputa-tion.However,themostcommonlyusedmethodistheORIFapproach.[2,4-6]Externalfixationofintraarticularfracturesreliesondistraction.[2]

In the literature up to 1969, good results for pi-lon fractureswere achieved in fewer than 50%.Af-terRüediandAllgöwerintroducedtheiropenreduc-tiontechniquesin1969,theyreported71%goodandexcellent results for their four-year study.HeimandNaser[7] reported 90% good and excellent results inanotherstudy.

Thereasonfortheincreaseingoodandexcellentresults is compliance to the ORIF principles intro-ducedbyRüediandAllgöwer.Theoperationconsistsoffoursurgicalsteps.1-Reductionandfixationofthefibula,2-Reconstructionandfixationofthetibiajoint,3-Filling of themetaphysical defect, which remainsafterthereconstructionofthejoint,withautogenousspongiousbonegraft,and4-Applicationofasupportplateinordertopreventvarusdeformity,whichmightoccuratalaterstage.[2,8-14]

In this study, the mid-term results of the ORIFmethod,whichwe applied to 31 patientswith pilontibiafractures,wereevaluatedinlightoftheliterature.

MATERIALS AND METHODSBetween2002and2009,westudied32anklesof

31patients(25[81.25%]males,6[18.75%]females)in our clinic. Two senior attending surgeons treatedall cases. Medical records, operative notes, and ra-diographswere reviewedby a surgeon not involvedin the care of the patients. They had been operatedwith the establisheddiagnosisofpilon tibia fractureand presented regularly for follow-ups.The extrem-itydistributionof thecaseswasas follows:19 right

(61.3%),11 left (35.4%)and1bilateral (3.3%).Theyoungestpatientinourstudypopulationwas17yearsold,andtheoldestwas72yearsold,withameanageof 46 years.When the etiology of the traumas wasconsidered,therewere18(58%)fallsfromaheight,9(29%)simplefallsand4trafficaccidents(13%).Thir-teenof32patientswithpilonfractureshadopenfrac-tures.According to Gustilo-Anderson classification,our open fractureswere of type 1 (n=3; 23%), type2(n=7;53.9%),andtype3(n=3;23%),respectively.Twenty of our patients had 21 (65.6%)fibula lowerendfractures.In9ofourpatients, therewere11ad-ditionalorthopedicpathologies(Table1).

Forfiveoftheseaccompanyingadditionalpatholo-gies(45%),asurgicaloperationwasapplied,andtherest (55%) received conservative treatment. Meanhospitalizationperiodofourpatientswas15.8(5-44)days.Inthepreoperativeevaluation,standardantero-posterior(AP)andlateralankleradiographsandcom-puterized tomographic (CT) images of the affectedanklewereobtained.The fractureswerecategorizedaccording to Rüedi-Allgöwer fracture classification.Accordingtothisclassification,7type1(21.8%),11type2 (34.2%) and14 type3 (44%)pilon fracturesweretreated.

First,theskinconditionofthepatientshospitalized with a tibia pilon fracture was evaluated and theirneurovascularexaminationsweremade.Then,radio-logical examinationswereperformed.Skeleton trac-tion from the calcaneus was applied to all patientswith type 3 fractures, to 5 caseswith type 2 and to4caseswithtype1fractures,andtheaffectedankleswere supported with a Braun’s brace. Traction wasnot applied to the patients with minimal soft tissuedamage; theywere instead placed into a bracewithample cotton pad support, their affected kneeswereelevated,andicecompressionwasapplied.Inpatientswithopenfractures,weapplieddebridementandse-rumisotonicirrigationintheoperatingroomassoonaspossible.Weappliedprophylaxistopreventthede-velopmentoftetanusandgaseousgangrene.Fortype1openfractures,weinitiatedtreatmentwitha1stgen-


Table 1. Distributionofaccompanyinginjuriestopilonfractures

Accompanyinginjuries Casenumber

Vertebrafracture 4Calcaneusfracture 1Scaphoidfracture 1Radiusfracture 1Proximaltibiafracture 1Patellafracture 1Cuneiformfracture 1Fibulafracture 1


erationcephalosporin(cephazolinsodium;1gintrave-nous[iv]),whilefortype3openfractures,westartedgentamicin(160mgintramuscular[im]x5days)andmetronidazole(500mgivx3days)therapyaddition-ally.Afterregressionofthefootandankleedemaandpreoperative anesthesia examinations, the patientsweretakentosurgery.Meantimefromthehospitaliza-tiontotheoperationwas10.7days(1-28days).For32pilonfractures,ORIF(n=24;75%)andexternalfixa-tion(n=8;25%)wereperformed.

Surgical TechniqueDuring the surgical procedures performed on 21

patients with a fibula fracture, firstly fibula fixationwas applied to gain length according to the surgicaltechnique suggested by Rüedi-Allgöwer. To fix thefibula, 1/3 tubular plate (n=9; 42.8%), intramedul-larywire (n=8; 38.3%), dynamic compression (n=3;14.2%),andsemitubularplate(n=1;4.7%)wereused.

ORIF was performed for tibias using an antero-lateral (n=2), anteromedial (n=19), or short anterior(n=3)approach.Thesurgeonstriedtoleaveatleast7cmofhealthyskintissuebetweentwoincisions.Afterreconstructionofthetibiajointsurface,osteosynthe-siswas appliedusingK-wires, cancellous screwsorcannulatedscrews.Stabilizationof3pilonfracturesof2patientswasachievedwiththesemethodsofosteo-synthesis.In21fracturesextendingtothemetaphysis,plateswereappliedbecauseofinadequatefixation.Fortibialfixations,acloverleafplate(n=2;9.5%),ordistaltibialateral(n=2;9.5%)ormedial(n=17;81%)com-patibleanatomicplateswereused.Duetoametaphy-sealdefect,graftswereappliedto12patients.Afterthescopeexaminationofthefracturesite,thepreviouslyapplied tourniquet was opened, hemostatic controls

weremade, and aHemovac drainwas applied.Thedrainwasremovedonthe2ndpostoperativeday.Theshort legbracewasleft inplace.Afterpostoperativeregressionoffootandankleedema,activelegrangeofmotion (ROM) exerciseswere started. In the 6thweek,thepatientwasallowedtoperformpartialandattheendofthe3rdmonthfullload-bearingexercises.

External fixation was applied to 4 patients withsecond-andthird-degreeopenfracturesandto4pa-tientswhosecomminutedfracturescouldnotbefixedusinginternalfixationmaterials.Theanklejointsof6ofthesepatientswereexploredanteriorlywitha3cmincision.For4patients,largefragmentswerereduced,fixed by means of K-wire, cannulated screws andspongiousscrews,andminimalosteosynthesiswasap-plied.Afterwards,threepiecesof5mmcorticalnailswereplacedinthetibiaandthreepiecesof4mmspon-giousnailsinthecalcaneus,andthenanOrthofixtypemonolateralexternalfixatorwasapplied.Theother2patientsweretreatedwiththeIlizarovjointdistractionmethodafterfixationofthefibulawithoutapplyingos-teosynthesistoachievethecorrectalignment.Beforethesurgery,allpatientsweregiven1gcephazolinivinjection.Thesamepostoperativeantibiotherapywascontinuedfor3daysasdailyinjectionsx3.Afterthefirstdayoftheirhospitalizations,thepatientsreceivedlowmolecularweightheparin (LMWH)prophylaxisuntilthe5thpostoperativeday.Thepatientsmanagedwithexternalfixationweremobilizedwiththeaidoftwocrutchesonthe1stdaypostoperatively.Afterdoc-umentationofradiologicalsynostosis(approximately16weeks postoperatively), the fixator was removedandfullload-bearingwasallowed.Thepatientswithacirculartypefixatorweremobilizedonthe1stdaypostoperativelywithfullload-bearingstatus.


Fig. 1. (a)X-raysshowingacomminutedtibialpilonfractureextendingtothediaphysisina49-year-oldmanwithtype3fracture,whowasoperatedonthe11thdaypostinjury.(b)X-raysofthesamepatientafterinternalfixationwiththeuseofplateandscrews.

(a) (b)


Thefootringsofthepatientswereremovedinap-proximatelythe10thweekpostoperatively.Theoper-atedanklewasmobilized.Atapproximatelythe16thweek,aftertheobservationofcallusformationradio-logically,thefixatorwasremoved(Figs.1a,band2a,b).

RESULTSThepatientswereevaluatedaccordingtotheTee-

ny-Wissanklesymptomandfunctionalanklescores.Inthisprotocol,theevaluationwasmadebycompar-ingthehealthyanklewithadamagedankle.Accordingtothesecriteria,32pilontibiafracturesof31patients,whoweremonitoredregularly,wereevaluated.Thesepatientswerefollowed-upforanaverageof46months(8-97months).Inallofourpatients,weachievedos-seousunionwithoutasecondintervention.Themeantimetounionwas16weeks(10-25weeks).Accord-ingtotheevaluationcriteria,excellent(n=4;12.5%),good(n=15;46.8%),fair(n=6;18.9%),andpoor(n=7;21.8%)outcomeswereobtained.Theradiographsob-tainedatthelastfollow-upwerereviewedforunion,lossoffixation,malunion,nonunion,andalsoforthequality of reduction according to Ovadia and Bealscriteria.TheresultsarelistedinTable2.

Wedidnotdetectanyinadequacyoffixingmate-rialasacomplicationinourpatients.Nocaseofpseu-doarthrosisorvaruscollapsewasseen inanyofourpatients.Skinnecrosisdevelopedonthepostoperativewoundsof1casewithaclosedRüedi-Allgöwertype1fractureand1casewithRüedi-Allgöwertype3andGustilo-Anderson type 2 open fractures. These skinwoundswere treated and healedwith local dressingwithoutthenecessityofsurgicalintervention.In4ofourpatients,aninfectiondevelopedonthepostopera-tivewound.Threeofthese4patientswithsuperficialinfectionshadtype2and1ofthemhadtype3openfractures.Thesepatientsweretreatedandhealedwithsurfacewound treatment and antibiotherapywithoutthe necessity of a revision operation. In 1 patient, adeepinfectiondevelopedatalaterstage.Thispatienthad Rüedi-Allgöwer type 3 and Gustilo-Andersontype1openfracture.Thefixingmaterialwasextractedfromthepatient.Debridementandantibiotherapywereapplied. The patient recoveredwithout any sequela.Sudeck’satrophyin6(18.75%),late-termsynostosisin3(9%),andpost-traumaticarthrosisin7(21.8%)ofour patients developed postoperatively.Our patientswith Sudeck’s atrophy healed using physiotherapy.Those with post-traumatic arthritis were monitoredandinformedaboutarthrodesislater.However,noad-ditionalsurgerywasperformedinanyofourpatients.

DISCUSSIONPilon fractures generally occur after high energy

traumas,andsignificantsofttissueinjuryisfrequentlypresent.[1-3]Forthesefractures,theseverityofthetrau-ma,inadequacyoflocalbloodcirculation,frequencyofcomplications,andthehighriskofbecomingdis-abledhavetobeconsidered.[1,2,6]

Etter and Ganz[15] studied 41 patients with pilonfractures, and stated that sport traumas are themostcommon etiologic factor. In his series with 42 pa-tients,Bourne[16]foundthatthemainetiologicfactorsarefallingfromaheight, followedbymotorvehicle


(a) (b)

Fig. 2. Clinicalpicturesofthesamepatientshowinggoodanklejointrangeofmotion:dorsiflexion(a)andplantarflexion(b).

Table 2. Themid-termresultsofthetreatmentfortibialpilonfractures

Qualityofreductionbyfracturetype

Fracture Patient Anatomic Good Fair Poortype no

1EF 1 0 1 0 01ORIF 6 4 2 0 02EF 2 0 2 0 02ORIF 9 5 4 0 03EF 5 0 2 2 13ORIF 9 0 7 2 0EF:Externalfixation;ORIF:Openreductionandinternalfixation.

accidents.Ayeni[17]reportedfallingfromheights,thensimplefalling,andthirdlytrafficaccidentsasthemaincausesofpilonfractures.

Heim andNasser obtained 90% good results forpatientswithlowenergytraumascausedmostlybyskiinjuries.ThesetypesoftraumasrequiredORIF.Theyhadreported that theseverityof the initial traumaticepisodehasa significant influenceon theprognosis.[2,18]Intheetiologicanalysisofthe32pilonfractureswe treated,we saw a parallelwith theAyeni series.We obtained poor treatment outcomes in caseswithhighenergytraumas,whichwereproportionaltotheseverityofthetrauma,softtissuedamageandpatientdemographics.Inourseries,therewerenocasesofpi-lonfracturessecondarytoskiinjuriesaswasthecaseintheRüediseries.

The typeof thefracture(openorclosed)alsoaf-fected the outcomes. In open fractures, the generalapproachtothemanagementconsistsofdebridement,irrigationandexternalfixatorapplication.[19-22]Forourpatientswithtype3(n=2)and2(n=2)openfractures,we applied debridement, irrigation and an externalfixator.Wetreatedtheremaining9patientswithopenfracturesusingsecondaryirrigation,debridementandthenORIF,asthesofttissuewassuitableforthisap-proach.Thesepatientshadtype3(n=1),1(n=3),and2(n=5)openfractures.TheTeeny-Wissanklesymptomandfunctionalscoresofpatientswithtype1openfrac-turesweregoodwhilethoseofthepatientswhowereoperatedduetotypes2and3openfracturesindicatedfair outcomes.TheTeeny-Wiss ankle scores in 2 ofourpatients,whoweretreatedwithanexternalfixatorduetotype3openfractures,wereindicativeofpooroutcomes.Inoneofthosepatients,superficialwoundinfectionanddegenerativearthritisdevelopedduringthepostoperativeperiod.Thesuperficialwoundinfec-tionwashealedwithantibiotherapyanddressing.Forthe treatment of degenerative arthritis, glucosaminewasgivenandthepatientwasmonitored.Thepatientwas informedabout the fact thatarthrodesismaybenecessary in the future.TheTeeny-Wiss scoresof 2ofourpatients,whoweretreatedwithanexternalfix-ator because of type 2 open fractures,were sugges-tive of fair outcomes. Surfacewound infection alsodevelopedinthesepatients,andhealedwithdressingandantibiotherapy.

Theaiminpilonfracturesistoensureastablefixa-tion after anatomical restoration of the injured jointandtoinitiateactivemovementoftheankleassoonaspossible,whileloadisappliedatalatertime;however,this isnotalwayspossible.Primarilydue to thesofttissuedamagethatalsooccursbecauseoftheextremetraumaanddefectinthejointandmetaphysis,astableosteosynthesiscannotbeperformed.

Thetimingofthesurgeryinpilonfractureshasal-waysbeenamatterofdebate.Earlysurgeryshouldbeappliedwithinthefirst8to12hours.Rüedi-Allgöwerapplied early surgery for the injuries in their series,whichweremostlyski injuries.Burnandcolleaguesappliedlate-termsurgery(7-10daysaftertheincident)totheirpatientswhohadmostlyhighenergytraumas.Nosignificantdifferencebetweenearlyandlatesur-gical outcomes was found.[23-26] The most importantfactorthatdeterminesthetimingofthesurgeryistheurgent operability of the fractures. For instance, insomecases,inordertopreventskinandwoundprob-lems,thepatientsarenotoperatedwithinthefirst8-12hours,andthesurgeryshouldbepostponedfor7-10days.Wedidnotapplyearlysurgerytoanyofourpa-tients.In4ofourpatients,superficialwoundinfectiondeveloped,andwashealedwithdressingandantibio-therapy.Forapatientwithtype3fracture,alate-termdeepinfectiondeveloped.Afterfusionofthefracture,the platewas removed and the fracture healed afterdebridementandirrigation.

Infracturesofthedistaltibiaextendingtothejoint,where functional good results can only be achievedin50-60%ofthecases,themaintreatmentprinciplesremain:anatomicalopenreductionandrigidinternalfixationandearlymobilizationandprinciplesoflate-termload-bearingoftheAO/ASIFgroup.[5,28,29]Whendifferentseriesareexamined,thesuccessrateintype1andtype2fracturesisabout80%,whileit isonly40-50%intype3fractures.Accordingtotheliterature,thefunctionalresultsdependonthetypeofthefrac-ture,andasthefracturebecomesmorecomplex,theresultswillalsoworsen.InBourne’sserieswith50pa-tients,theresultsofthetreatmentsbasedonprinciplesofAO (Arbeitsgemeinschaft für Osteosythesefragen[AssociationforInternalFixationResearches],whichisaninternationalorganizationthatoriginatedinSwit-zerland)weresignificantlygood.[4,30]TheTeeny-Wissankle symptom and functional score average of ourtype1patientswas87(76-94),oftype2patientswas85(64-94)andoftype3patientswas77.14(64-96),respectively.

The external fixation of pilon fractures was firstcombinedwithopenreductionbyScheckin1965,andhereportedsuccessfulresults.Withexternalfixation,thegoalistoobtainreductionbyusingtheligamen-totaxis property.However, in type 3 fractures, openreduction and minimal internal fixation of the jointmightbenecessary.

While in type1and type2 fractures it isenoughtoincludethetibia inthefixationprocedure, in type3fractures,thejointhastobeincludedaswell.[22,31,32] Otherwise, prevention of early joint movement andunfavorablehealingofthecartilagemightbeencoun-tered.



We evaluated 32 pilon fractures of 31 patientstreated in our clinic. Twenty-three of the fractures(72%)werecausedbyhighenergytrauma.Thirty-twopilonfractureswereevaluatedastype1(n=7;21.8%),2(n=11;34.2%),and3(n=14;44%),while13ofthem(40.3%)wereopenfractures.ORIFwasappliedto24fracturesandexternalfixationto8fractures.Indepen-dentofthetreatmenttype,thefunctionaloutcomesof18patientswithtype1and2fractureswereratedasexcellent andgood (78%)and fair (22%). In14pa-tientswithtype3fractures,excellentandgood(36%)andfairandpoor(64%)resultswereobtained.Inourseries,whichisinlinewiththeliterature,wealsode-terminedthatthesuccessratechangeswiththetypeofthefracture.

We believe thatwe obtained relatively better re-sults(66%)withtheORIFmethodinthemanagementofpilonfractures.

Pilonfracturesareproblematicfractureswithhighcomplicationrates.Themainfactorsthatincreasethecomplication rate and decrease the functional out-comes are the type of the fracture (open or closed),severity of soft tissue injury, location of the openand joint fractures, and severity of the trauma.[1,6,33] Thecomplicationsweencounteredinourserieswerepost-traumatic degenerative arthritis (22%), reflexsympathicdystrophy(21%),surfacewoundinfection(12.5%),latesymphysis(9%),skinnecrosis(6.25%),angulation(3%),andlateinfection(3%).Ourresultsareinparallelwiththeliteraturefindings.

Late arthritic changes are among the most im-portantcomplicationsseenafter thesurgeryofpilonfractures.Theydependon the typeof fracture, jointcartilagedamage,andthetypeofthetrauma.Ourpa-tientswithpost-traumaticarthritishadtypes1(n=1),2 (n=1), and 3 (n=5) fractures, respectively. In 5 ofthe 14 patientswith type 3 fractures, post-traumaticarthritisdeveloped.Theseresultsagreewellwiththeliteraturefindings.

It is known that degenerative changes occur de-pendingonthesuccessofthereduction.However,thedamage in the joint cartilage during the trauma cancausedegenerativearthritisinthelateperiodevenifasuccessfulanatomicalreductionwasachieved.

Toachievesuccessfulresultsinthetreatmentofpi-lon fractures,averygoodpreoperativeplanninghastobemade.Successful results canbeachievedwithatraumaticsofttissuedissectionaccordingtobiologi-cal principles, anatomic restoration of the joint sur-face, if necessary, rigid fixation using a bone graft,movement of the ankle in the early postoperativeperiod, and late-term load application. Especially inadvancedtype3fractures,whereananatomicaljointreconstructionisimpossible,andalsoinpolytrauma-

tizedpatients,acceptableresultscanbeachievedwithanexternalfixator application.However, there isnosinglesuccessfultreatmentmethodthatcanbeappliedtoallpilonfractures.Eachfracturehas tobe treatedindividuallyandatreatmentincompliancewithsurgi-calprincipleshastobewell-planned.

REFERENCES1. ReidJS.Pilon fracturesupdate.CurrentOrthopaedicPrac-

tice.2009;20:527-33.2. ScottAT,OwenJR,KhiataniV,AdelaarRS,WayneJS.Exter-

nalfixationinthetreatmentoftibialpilonfractures:compari-sonoftwoframesintorsion.FootAnkleInt2007;28:823-30.

3. SandsA,GrujicL,ByckDC,AgelJ,BenirschkeS,Swiont-kowski MF. Clinical and functional outcomes of internalfixationofdisplacedpilonfractures.ClinOrthopRelatRes1998:131-7.

4. BourneRB,RorabeckCH,MacnabJ.Intra-articularfracturesofthedistaltibia:thepilonfracture.JTrauma1983;23:591-6.

5. MastJW,SpiegelPG,PappasJN.Fracturesofthetibialpi-lon.ClinOrthopRelatRes1988:68-82.

6. BoraiahS,KempTJ,ErwtemanA,LucasPA,AsprinioDE.Outcome followingopen reductionand internalfixationofopenpilonfractures.JBoneJointSurg[Am]2010;92:346-52.

7. FinsenV,SaetermoR,KibsgaardL,FarranK,EngebretsenL,BolzKD, et al.Early postoperativeweight-bearing andmuscleactivityinpatientswhohaveafractureoftheankle.JBoneJointSurgAm1989;71:23-7.

8. ToplissCJ,JacksonM,AtkinsRM.Anatomyofpilonfrac-turesofthedistaltibia.JBoneJointSurg[Br]2005;87:692-7.

9. Giachino AA, Hammond DI. The relationship betweenoblique fractures of themedialmalleolus and concomitantfractures of the anterolateral aspect of the tibial plafond. JBoneJointSurgAm1987;69:381-4.

10.LeonardM,MagillP,KhayyatG.Minimally-invasivetreat-ment of high velocity intra-articular fractures of the distaltibia.IntOrthop2009;33:1149-53.

11.Møller BN, Krebs B. Intra-articular fractures of the distaltibia.ActaOrthopScand1982;53:991-6.

12.RhinelanderFW.Tibialbloodsupplyinrelationtofracturehealing.ClinOrthopRelatRes1974:34-81.

13.YorgancıgilME,BaranA,YıdızM,AksuS,GürbüzA.PilonkırıklarınıntedavisindeARİF’ninyeri.ActaOrthopTrauma-tolTurc1994;28:87-9.

14.SirkinM,SandersR,DiPasqualeT,HerscoviciDJr.Astagedprotocolforsofttissuemanagementinthetreatmentofcom-plexpilonfractures.JOrthopTrauma2004;18:32-8.

15.EtterC,GanzR.Long-termresultsoftibialplafondfracturestreatedwithopen reductionand internalfixation.ArchOr-thopTraumaSurg1991;110:277-83.

16.BourneRB.Pylonfracturesof thedistal tibia.ClinOrthopRelatRes1989:42-6.

17.Ayeni JP. Pilon fractures of the tibia: a studybased on 19cases.Injury1988;19:109-14.

18.Bhattacharyya T, Crichlow R, Gobezie R, Kim E, VrahasMS. Complications associated with the posterolateral ap-proachforpilonfractures.JOrthopTrauma2006;20:104-7.

19.BoneL,StegemannP,McNamaraK,SeibelR.Externalfixa-tionofseverelycomminutedandopentibialpilonfractures.



ClinOrthopRelatRes1993:101-7.20.LaughlinRT,CalhounJH.Ringfixatorsforreconstructionof

traumaticdisordersofthefootandankle.OrthopClinNorthAm1995;26:287-94.

21.LeoneVJ, Ruland RT,Meinhard BP. Themanagement ofthe soft tissues in pilon fractures. Clin Orthop Relat Res1993;:315-20.

22.MurphyCP,D’AmbrosiaR,DabeziesEJ.Thesmallpincir-cularfixatorfordistal tibialpilonfractureswithsoft tissuecompromise.Orthopedics1991;14:283-90.

23.BoneLB.Fracturesofthetibialplafond.Thepilonfracture.OrthopClinNorthAm1987;18:95-104.

24.HelfetDL,KovalK,PappasJ,SandersRW,DiPasqualeT.Intraarticular“pilon”fractureofthetibia.ClinOrthopRelatRes1994:221-8.

25.OvadiaDN,BealsRK.Fracturesofthetibialplafond.JBoneJointSurgAm1986;68:543-51.

26.ThordarsonDB.Complicationsaftertreatmentoftibialpilonfractures:preventionandmanagementstrategies.JAmAcadOrthopSurg2000;8:253-65.

27.TeenySM,WissDA.Openreductionandinternalfixationoftibialplafondfractures.Variablescontributingtopoorresultsandcomplications.ClinOrthopRelatRes1993:108-17.

28.RüediT.Fracturesofthelowerendofthetibiaintotheanklejoint:results9yearsafteropenreductionandinternalfixa-tion.Injury1973;5:130-4.

29.Rüedi TP,Allgöwer M. The operative treatment of intra-articularfracturesofthelowerendofthetibia.ClinOrthopRelatRes1979:105-10.

30.BourneRB.Pylonfracturesof thedistal tibia.ClinOrthopRelatRes1989;240:42-6.

31.KimHS,JahngJS,KimSS,ChunCH,HanHJ.Treatmentoftibialpilonfracturesusingringfixatorsandarthroscopy.ClinOrthopRelatRes1997;334:244-50.

32.McDonaldMG, Burgess RC, Bolano LE, Nicholls PJ. Il-izarov treatment of pilon fractures.ClinOrthopRelatRes1996;325:232-8.

33.WatsonJT,MoedBR,KargesDE,CramerKE.Pilonfrac-tures.Treatmentprotocolbasedonseverityofsofttissuein-jury.ClinOrthopRelatRes2000;(375):78-90.



436




Departments of 1General Surgery, 2Psychiatry, Baskent University Faculty of Medicine, Ankara, Turkey.

Başkent Üniversitesi Tıp Fakültesi, 1Genel Cerrahi Anabilim Dalı, 2Psikiyatri Anabilim Dalı, Ankara.

Correspondence (İletişim): Hakan Yabanoğlu, M.D. General Tevfik Sağlam Cad., Esertepe Mah., Bağevi Sok., Emlakbank Konutları. A2 Blok,

No: 21, Kat: 5. Etlik 06100 Ankara, Turkey.


AMAÇYanıktravmasısonrasındaerkendönemdeortayaçıkanpsi-kiyatrikbozukluklardeğerlendirildi.

GEREÇ VE YÖNTEMYanıktravmasınamaruzkalan1369hastanındosyasıgeri-ye dönük olarak incelendi. Psikiyatrik bozukluk saptanan45 hasta yaş, cinsiyet, kronik hastalık, yanık öncesindekipsikiyatrik bozukluk, yanık nedeni, yanık yüzdesi, yanıkderecesi,ektravma,ameliyatsayısı,hastanedekalışsüresi,ekstremite amputasyonu, entübasyon durumu, psikiyatriksemptomlar,travmasonrasıpsikiyatrikbozuklukvemorta-liteaçısındandeğerlendirildi.

BULGULARYanık travmasısonrasıerkendönemde45hastadapsiki-yatrik bozukluk saptandı.Hastaların 7’si (%15,5) kadın,38’i(%84,5)erkekti.Ortalamayaş32±14,3yıl,yanıkyüz-desi%40,09±20,69,geçirilmişameliyatsayısı2,95±1,75,hastanede kalış süresi 51.57±38.62 gün idi. Hastaların12’sinde(%26,6)posttravmatikstresbozukluğu(PTSD),11’inde (%24,4)deliryum,8’inde (%17,7) anksiyetebo-zukluğu,7’sinde (%15,5)depresyon,1’inde (%2,2)yok-sunluk sendromu, 1’inde (%2.2) şizoaffektif bozukluk,2’sinde(%4,4)PTSDvedepresyon,2’sinde(%4,4)PTSDvedeliryumve1’inde(%2.2)PTSDveanksiyetebozuk-luğugörüldü.

SONUÇYanıkmultisipliner yaklaşımla tedavi edilebilen bir trav-madır.

Anahtar Sözcükler: Yanık;erkentanı;psikiyatrikbozukluk.

BACKGROUNDWeaimedtoassessearlyperiodpsychiatricdisordersfol-lowingburntrauma.

METHODSThefilesof1369patientswhohadburntraumawereana-lyzedretrospectively.Forty-fivepatientswiththediagnosisofpsychiatricdisorderwereassessedbasedonthevariablesofage,gender,presenceofchronicdiseases,psychiatricdis-orderspriortoburntrauma,causeoftheburn,burnpercent-age,degreeofburn,additionaltrauma,numberofsurgeries,duration of hospitalization, extremity amputation, intuba-tionstatus,psychiatric symptoms,post-traumapsychiatricdisorders,andmortality.

RESULTSForty-five patients developed psychiatric disorder inthe early period following burn trauma. Of the 45 pa-tients,7(15.5%)werefemaleand38(84.5%)weremale.The mean age was 32±14.3 years, burn percentage was40.09±20.69%,numberofoperationswas2.95±1.75,andthetotaldurationofhospitalizationwas51.57±38.62days.Twelve(26.6%)patientshadpost-traumaticstressdisorder(PTSD),11(24.4%)haddelirium,8(17.7%)hadanxietydisorder, 7 (15.5%) had depression, 1 (2.2%) had absti-nencesyndrome,1(2.2%)hadschizoaffectivedisorder,2(4.4%)hadPTSDanddepression,2(4.4%)hadPTSDanddelirium,and1(2.2%)hadPTSDandanxietydisorder.

CONCLUSIONBurnisatraumathatcanbetreatedwithamultidisciplinaryapproach.Key Words: Burns;earlydiagnosis;psychiatricdisorder.

doi: 10.5505/tjtes.2012.98511

Early period psychiatric disorders following burn trauma and the importance of surgical factors in the etiology

Yanıktravmasısonrasıerkendönemdegörülenpsikolojikbozukluklarveetyolojidecerrahifaktörlerinyeri

Hakan YABANOĞLU,1 Mahmut Can YAĞMURDUR,1 Nilgün TAŞKINTUNA,2 Hamdi KARAKAYALI1

Burn is one of the most important physical andpsychological traumas thatan individualcanexperi-ence in his life.Burn trauma carries highmorbidityandmortalityratesduetonumerouscausessuchashy-povolemicshock,infectionandconcurrentadditionaltraumas.Duetothesocialandpsychologicalproblemsassociatedwithburn trauma, ithasgonebeyondbe-ing solely a physical trauma and has evolved into aseriousproblemthathasasignificantinfluenceontheindividual’slife.Especiallyinrecentyears,therehavebeen serious advancements inburn treatmentdue totheincreasedqualityofmedicalcare,developmentofbroad-spectrum antibiotics that are also effective onburninfections,improvedintensivecareconditionsforburnpatients,increasedexperienceamongphysiciansand supportive health personnel in burn trauma, pa-tient referrals,nutritional support, earlydebridementandgrafting,tissueproduction,andmultidisciplinaryapproaches.Mortalityandmorbidityratesduetoburncomplicationshavediminishedwiththeadvancementsinburntreatment.Becauseofhighmortalityratesandhigh costs, thebest treatment option in burn traumaisprevention.Theincreasedlifespanofpatientswithburntraumashasincreasedtheneedforrehabilitationandpsychosocialtreatmentoptionsforburn.[1]

Inpatientswithburntrauma,theinitialchoiceoftreatmentislocalandsystemictreatmentoftheburnedtissue.However, during theprolonged treatment pe-riod,psychologicalfactorswillalsoappeartobeinflu-entialontreatment.Especiallyinpatientswhoarehos-pitalized for extended periods,who have undergonenumerousoperations,haveseverepainduringmedi-caldressing,havepermanentphysicalandfunctionaltissueloss,andhavepermanentlaborloss,treatmentcompliancewoulddecreaseovertime.Thisunderlinestheimportanceofprovidingpsychologicalsupportinadditiontophysicalsupporttothepatient.Prevalenceof psychiatric disorders in burn patients is between28-75%.[2,3] Psychological disorders observed mostfrequentlyduringtheearlyperiodfollowingtheburntraumaincludeacutestressreactions,anxietydisorder,depression,behavioraldisorders,anddelirium.[4]

Psychological disorders observed in hospitalizedpatientsdependon the eventsoccurringbothduringthe trauma itself and during treatment approaches.Physical and psychological trauma in these patientsshouldbetreatedmedicallyandsurgicallyforalongperiodoftime.Ifpatientsareonlytreatedphysically,physiological disorders can emerge during the lateperiodoftreatmentandthismaydisturbthepatient’sattendanceandcooperationwith therapy, causinganincrementinthepatient’shospitalstay,morbidityandmortalityrates,andcosts.Theaimofthisstudywastodiagnoseandtreat thepsychologicaldisordersintheearlyperiodofburn traumainorder toprevent later

medicalandsociologicalcomplicationsandtoidentifythesurgicalfactorscausingpsychologicaldisorderstoemerge.

MATERIALS AND METHODSIn thisstudy, thefilesof1369patientswhowere

hospitalized at the Burn Intensive Care Unit (ICU)of the Burn and Fire Incidents Institute of AnkaraBaşkent University betweenOctober 1997 and July2011 were analyzed retrospectively for psychiatricdisordersemerginginthefirst15daysofhospitaliza-tion.Forty-fivepatientswhowerefoundtohavepsy-chiatricdisorderswereassessedbasedonthevariablesofpsychiatricdisorderspriortoburntrauma,causeoftheburn,burnpercentage,degreeofburn,additionaltrauma,numberofsurgeries,durationofhospitaliza-tion,extremityamputation,intubationstatus,psychi-atric symptoms, post-trauma psychiatric disorders,andmortality.Surgical factors thatmightcausepsy-chiatricdisorderswerestudied.TheStatisticalPack-agefortheSocialSciences(SPSS,version11.5)soft-wareprogramwasusedfordataanalysisinacomputerenvironment.

RESULTSInthisstudy,weanalyzedretrospectivelythecase

filesof1369patients.Asaresultof theanalysis,45(3.2%)patientshadpsychiatricdisorderaccompany-ingtheburntrauma.Ofthe45patients,7(15.5%)werefemaleand38(84.5%)weremale.Theaverageageofthepatientswas32±14.3(8-80)years,burnpercentagewas40.09±20.69%(5-85),numberofoperationswas2.95±1.75(0-9),andthetotaldurationofhospitaliza-tionwas51.57±38.62(2-180)days.Seventeen(37%)patientshadonly2nddegreedeepburn,2(4.4%)hadonly3rddegree,and26(58%)had2nddegreedeepand 3rd degree burn.When themechanism of burnwasconsidered,32(71%)wereflameburn,11(24%)were electricity burn and 2 (4.4%) were hot waterscaldburn(4.4%).Withregardtochronicdiseases,1patient haddiabetesmellitus (DM), 1hadhyperten-sion(HT),1hadDM,HTandchronicobstructivelungdisease,and1hadepilepsy.Six(13.3%)patientsun-derwentextremityamputationinadditiontodebride-mentandgrafting.Noneofthepatientshadahistoryofadditional traumas.Twelve (26.6%)patientswereadministeredtrachealintubationatdifferenttimesdur-ingtheirhospitalization.Ananalysisofthepsychiatricdiagnosis prior to the trauma revealed that 1patienthadalcoholaddiction,2haddepression,1hadanxi-etydisorder,1hadschizoaffectivedisorder,and1hadhyperactivitydisorder.Distributionofthepatients’de-mographiccharacteristicsandthedataobtainedbasedontheprocessofburnformationaregiveninTable1.An analysis of the psychiatric disorders in the earlyperiodaftertheburntraumashowedthat12(26.6%)





patientshadpost-traumaticstressdisorder(PTSD),11(24.4%)haddelirium,8had(17.7%)anxietydisorder,7 (15.5%) had depression, 1 (2.2%) had abstinencesyndrome, 1 (2.2%) had schizoaffective disorder, 2(4.4%)hadPTSDanddepression,2(4.4%)hadPTSDanddelirium,and1(2.2%)hadPTSDandanxietydis-order(Table2).Themostfrequentpsychiatricsymp-toms observed in patients included sleep disorder,agitation,andvisualandauditoryhallucinations.Two(4.4%)patientsdiedduetosepsisand1patient(2.2%)duetopneumonia.

DISCUSSIONBurn trauma, affecting the entire organism and

causing pathophysiological and psychologicaldisorders,mustbeevaluatedcomprehensively.Burns,causingmortalityandmorbidity,areseriousproblemsforpeopleandsociety.Inadvancedburnunits,mortal-ityinmajorburnsis5.6%,andinTurkeyitisreportedas7.5%.[5-8] In theUnitedStates, treatmentcostofa

patientwithmajor burnswas reported as $200,000.Thecostofthetreatmentofentireburncasesis18bil-liondollarsperyear.[6]

Having both serious physical and psychologi-cal implications, burn trauma brings about not onlyserious medical problems but serious psychologicalproblems aswell.With the advancement ofmedicalservices and rehabilitation services geared towardsburnpatients,survivalrateshaveincreased.Allthesedevelopmentshavecarriedpsychiatrytoanewlevelwith regard to a multidisciplinary approach to burntrauma.Themedicalandsurgicaltreatmentofthepa-tientisnolongertheultimategoalandprovidingpsy-chiatricsupporttothepatienthasbecomeanindispen-siblepartoftreatmentduringboththehospitalizationperiodandthepatient’ssociallifeafterdischargefromthe hospital. Especially complaints of severe pain,repeatedmedicaldressingproceduresandoperationsduringthehospitalizationperiod,cosmeticanxieties,permanent loss of labor skills, permanent limitationorlossofmobility,communicationdisorder,andex-tendedperiodsofhospitalizationoftenmanifestthem-selvesaspsychiatricdisorders.Failure todetect andtreat these psychiatric disorders in a timelymannerwoulddecreasethepatient’scompliancewithmedicalandsurgical treatment.A reviewof the literature re-vealsthatthestudiesconductedhavefocusedingen-eralonparameterssuchasthetypesandprevalenceofpsychiatric disorders, their short-term and long-termfollow-up,pre-existingpsychiatricdisorders,andgen-der.[9-13]Inthisstudy,inadditiontothesevariables,theauthors have also focused on other factors that theybelieved might be influential in causing these dis-orders, suchasburnpercentage,degreeofburn, theprocessofburnformation,intubationstatus,amputa-tion,totalnumberofoperations,anddurationofhos-pitalization.Ananalysisoftheresultsrevealsthatthepatients face avery serious trauma.A reviewof thefilesofallpatientsshowsthatburnpercentageinthepatient group for which consultation was requested(3.2%)was40%,burndegreewasatleast2nddegreedeepburn, theaveragenumberofoperationswas3,andtheaveragehospitalizationdurationwas51days.Intubation(26.6%)andamputation(13.3%)rateswerefoundtobehigher thanthosefor thegeneralpatientpopulation.Allparametersanalyzedindicatedamoreseveretraumathanthatobservedinthegeneralpatientpopulation.Itisinevitableforsuchanintensephysicaltraumatohavepsychiatricoutcomesinboththeshort-andlongterm.Duringthisperiodoftime,theimpor-tantpointistoutilizethattimetoensuretheleastdam-agewiththehelpofappropriatepsychologicalsupportfromthebeginningoftraumaandatallstages.

Recently, there has been a rise in the number ofstudiesassessingthepsychologicalandmentalstatus

Table 1. Distributionofpatientsaccordingtodemographiccharacteristicsandmechanismofburn

Mechanismofburn Electrical Flame Scald burns burns burns

Numberofpatients 11 32 2Sex 11M 25M/7F 2MNumberofamputatedpatients 3 3 0Numberofintubatedpatients 3 8 1Numberofpatientswithpsychiatric 1 3 2disorderspre-traumaMostcommon Delirium PTSD SD,WSpsychiatricdiagnosisPTSD:Post-traumaticstressdisorder;SD,WS:Schizoaffectivedisorderandwithdrawalsyndrome;M:Male;F:Female.

Table 2. Generaldistributionofpsychiatricdisordersintheearlyperiodafterburn

Psychiatricdiagnosis Numberofpatients

PTSD 12(26.6%)Delirium 11(24.4%)Anxietydisorder 8(17.7%)Depression 7(15.5%)PTSD+Depression 2(4.4%)PTSD+Delirium 2(4.4%)PTSD+Anxietydisorder 1(2.2%)Withdrawalsyndrome 1(2.2%)Schizoaffectivedisorder 1(2.2%)PTSD:Post-traumaticstressdisorder.



of burn patients. Prevalence of psychiatric disordersinburnpatients isbetween28-75%.[2,3] Inourstudy,this ratewas found to be 3.2%. In fact, the numberofpatientstreatedatourburnICUbetween1997and2007was1167,andapsychiatricconsultationwasre-questedforonly24ofthem(2.1%).Psychiatriccon-sultationwasrequestedforonly21(10.3%)ofthe202patients treated between 2007 and 2011.And over-all, consultationwas requested for 45 (3.2%) of the1396patients.Itisnoteworthythatburntreatmenthasreachedanadvancedlevelowingtothedevelopmentsin the medical and surgical fields and that survivalrates have increased.Thesefindings havemotivatedpractitionerstoevaluatethepsychologicalaspectsofthetraumaandadoptamultidisciplinaryapproachtoburntrauma.Inourclinic,thenumberofburntraumapatientswhogo throughpsychiatric assessment alsoincreasesinparalleltoourincreasedexperienceinthisfield.Nevertheless,thisrateisfarbelowthatinthelit-erature.Oneofthereasonsforthisisthataround30%ofthepatientsinourburnICUarepediatricpatients.AmongtheotherreasonsarethefactsthatthenumberofburnICUsinourcountryislimited,thenumberofpatients referred toour center ishigh, andaportionof these patients had intubation, a high burn rate ormortalityintheearlyperiod;thus,itwasnotpossibletoprovidetherequiredpsychiatricsupporttothesepa-tients.

Inburn trauma,handledand treatedbymostsur-geonsasonlyphysicaltrauma,itmustbekeptinmindthatburntraumaalsohassocialandpsychologicalele-ments.Thetreatmentprocessmaybeacceleratedforbothpatientandphysicianwithpsychologicalsupportintheearlyperiod.Bythisprocess,mortalityandmor-bidityofburn,aserioussocialtrauma,willdecrease.Especially for patients with major burns, psycho-logicalsupportmustbeappliedroutinelyasapartofmedicalandsurgicalapproaches.

Themost frequentpsychiatricdisordersobservedin burn patients are PTSD (5-45%) and depression(13-23%).[4,10,14,15]While the rate of depression aftertheburnincidentwas2.2-53%duringthefirstmonth,thisratiowas13-34%duringthe12thmonth.Ontheotherhand,whilethefrequencyofPTSDintheearlyperiodwas2.2-26%,thisratiowas13-45%duringthe12thmonth.[16-21]Risk factors for depression includepresenceofdepressionpriortotheburnincident,fe-male gender and scars causing deformations in theface.Risk factors forPTSD includepresenceofde-pressionpriortotheburnincident,typeandseverityofthesymptomsattheonset,presenceofpain-relatedanxiety,andvisibilityoftheburnscar.[22]Inourstudy,12 (26.6%) patients were found to have PTSD, 11(24.4%) delirium and 7 (15.5%) depression. Thesefindingswere consistentwith those in the literature.

Threeofourpatientsdiagnosedwithdepressionwerefemale,andonly1patientwasdiagnosedwithdepres-sion prior to the trauma. Of those patients with thediagnosisofPTSD,only1ofthemhadanxietydisor-derpriortothetrauma.Burnratesof12patientswhowere diagnosed with PTSDwere 20-85%. Of thesepatients,4had2nddegreedeepburn,1had3rdde-greeburnand9had2ndand3rddegreeburn.Over-all,itwasobservedthattheburnratesofpatientsarehighandthattherelatedpainsymptomsareexcessive.Themostcommonpsychiatricsymptomobserved inPTSDpatientswassleepdisorder.Thestudiesrevealthat people with personality disorders, depressionandalcohol and substanceaddictionbecomesubjectto burn traumas more often than individuals in thegeneral population. Probability of observing a psy-chiatricdisorder inpatientsprior to theburn traumais28-78%.[2,3]Six(13.3%)ofourpatientswereprevi-ouslydiagnosedwithapsychiatricdisorder.Inanotherstudy,apsychiatricdisorderwasdiagnosedin38.9%ofthepatientsfollowingtheburntrauma;however,itwasalsofoundthatapsychiatricdisordercausedbytraumawasobservedinonly27.8%ofthesepatientsandthatotherpatientshadpsychiatricdisorderspriortothetraumaaswell.[13]Problemsrelatedtopatiencecomplianceandcooperationarecommonlyobservedduring the hospitalization process of these patients.Theseproblemsdelayphysicalrecoveryandprolongthe hospitalization period.[4] Psychological problemsexperienced in the early period following the burntraumaincludeoverstimulationorsub-thresholdstim-ulation,delirium,confusion,communicationdisorder,andsleepdisorder. Inourstudy, themost frequentlyobservedsymptomsincludedsleepdisorder,agitation,andvisualandauditoryhallucinations.

The treatment process that is started following aburn trauma isoneof themostpainfulandstressfulexperiences that a patient may experience. Medicalinterventionsmadeduringthetreatmentandaimedathelping the patient survivemost often disregard thepsychologicalsupportthatshouldbegiventothepa-tient.Psychologicaldisordersobservedinpatientsareusually not limited to the hospitalization period andcontinue to be observed even many years after thetreatment.[9,13]Regardlessofhowwellthepatientsmaybefunctionallyandcosmetically,theyshouldbepro-videdpsychiatricsupportinordertobeabletoadaptthemselvestosociallife,regaintheirself-esteemandovercomethepsychologicaleffectsofthetrauma.

The results and sequelae of burn trauma have agreatimportancebothfortheindividualsociety.Burncauses functional losses and social and psychologi-calproblemsintheearlyandlatehealingperiod.Thebest treatmentofburnisprevention.Individualsandinstitutions must take good care of themselves and



other individuals with respect to the prevention ofburn.Itmustbekeptinmindthatburnisaprevent-abletrauma;thus,effectiveburnpreventioneducationprogramsmustbedevelopedorimproved.

Inconclusion,burnisatraumathatcanbetreatedwith a multidisciplinary approach. Psychiatric con-sultationshouldberequestedassoonaspossibleforpatients who refer to the burn ICU and who havehigh burn percentages and degrees, are candidatesfor multiple surgery, have a history of psychiatricdiseases, and have extended periods of hospitaliza-tion. Surgical andmedical treatment by itself is notsufficientforthetreatmentofburnpatients.Psychiat-ricproblemsexperiencedbypatientsbothduringandafterthetraumashouldalwaysbeconsidered.Patientsand their families should seek professional supportfrompsychiatrists.Thiswould both improve patientcomplianceandexpeditetheprocessforthepatienttoresumehis/hersociallife.Surgeonswhoplayanim-portant role in thesurgicalandmedical treatmentofburnpatientsshouldkeepinmindthatthesepatientswillrequirepsychologicalsupportaswell.

REFERENCES1. MunsterAM.Measurementsofqualityoflife:thenandnow.

Burns1999;25:25-8.2. BrezelBS,KassenbrockJM,SteinJM.Burns insubstance

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Penetran kardiyak yaralanmalar: 21 olgunun değerlendirilmesi

Penetratingcardiacinjuries:assessmentof21patients

Yüksel DERELİ,1 Ramis ÖZDEMİR,1 Musa AĞRIŞ,1 Murat ÖNCEL,2 Kemalettin HOŞGÖR,1 Ali Suat ÖZDİŞ1

1Numune Hastanesi, Kalp ve Damar Cerrahisi Kliniği, Konya; 2Selçuk Üniversitesi, Göğüs Cerrahisi Kliniği, Konya.

1Department of Cardiovasculer Surgery, Numune State Hospital, Konya; 2Department of Thoracic Surgery, Selçuk University, Konya, Turkey.

İletişim (Correspondence): Dr. Yüksel Dereli. Numune Hastanesi Kalp Damar Cerrahisi Kliniği, Konya, Turkey.

Tel: +90 - 332 - 235 45 00 e-posta (e-mail): [email protected]

AMAÇPenetrankardiyakyaralanmalar,ciddikliniksonuçlarıse-bebiyle yüksekmortalite oranına sahiptir. Bu çalışmanınamacı, hastanemizde penetran kardiyak yaralanma nede-niylecerrahitedaviuygulananhastalarınaraştırılmasıdır.GEREÇ VE YÖNTEMBuyazıda,Şubat2006veOcak2011tarihleriarasındahas-tanemizepenetrankalpyaralanması şikayeti ilebaşvuran21hasta(18erkek,3kadın)geriyedönükolarakincelendi.Hastalarklinikbulgular,tedaviyöntemlerivesonuçlarıaçı-sındandeğerlendirildi.BULGULAROlguların19’udelicikesicialet,2’siateşlisilahyaralanma-sışeklindeydi.Tümolgularaacilcerrahigirişimuygulandı.Kardiyakyaralanma13olgudasağventrikül,5olgudasolventrikülve3olgudasağatriyumyaralanmasınıiçeriyor-du. Sol atriyumyaralanması gözlenmedi.Kardiyak yara-lanmalarprimerdikişyöntemiileonarıldı.Mortalite6olguile%28,6olaraksaptandı.SONUÇPenetran kardiyak yaralanmalar genellikle genç yaş gru-bundagörülmektedir.Erkentransport,uygunresüsitasyonveacilcerrahitedavipenetrankalpyaralanmasıolanhasta-larınhayattakalmaoranınıartıracaktır.Anahtar Sözcükler: Acil cerrahi; kardiyak yaralanma; penetrantravma.

BACKGROUNDPenetratingcardiacinjuriescarryhighmortalityratesduetoseriousclinicaloutcomes.Thisstudywasplannedtoin-vestigatepatientstreatedsurgicallyinourhospitalforpen-etratingcardiacinjury.METHODSInthisarticle,wereviewedretrospectively21patients(18male, 3 female) suffering from penetrating heart injurieswhoadmittedtoourhospitalbetweenFebruary2006andJanuary2011.Patientswereevaluatedwithrespecttoclini-calfindings,treatmentmethodsandclinicaloutcomes.RESULTSAmongthepatients,19caseswereduetostabinjuryand2casestogunshotinjury.Emergentsurgicalinterventionswere performed in all patients.Cardiac injuries involvedtherightventriclein13patients,leftventriclein5patientsandrightatriumin3patients.Therewasnoleftatrialin-jury. Cardiac injuries were repaired by primary suturingmethod.Mortalitywasdeterminedin6patients(28.6%).CONCLUSIONPenetrating cardiac injuries are seen generally in youngpeople.Earlytransport,properresuscitationandemergentsurgery treatment improvedsurvival inpatientswhosus-tainedpenetratingcardiacinjuries.Key Words: Urgentsurgery;cardiacinjury;penetratingtrauma.

doi: 10.5505/tjtes.2012.93467

Penetran kardiyak yaralanmalar, genellikle kesi-ci delici aletler veya ateşli silahlarlameydana gelenyaralanmalardır.Acil cerrahigirişimgerektiren trav-maolgularının%10,4’ünü toraks travmasıoluşturur-ken,bunların%1’ikardiyakyaralanmalardır.[1]Diğertravmalaragöredahaazgörülmesinerağmen,yüksek

mortalitesi nedeniyle önemli yaralanmalardır. Penet-rankalpyaralanmasındayaşamıtehditedenunsurlarkoronerarteryaralanması,kapakyaralanmasıvekalp-tekiyaranınyerivebüyüklüğünebağlıolarakgelişebi-lecekhipovolemiveyakalptamponadıdır.[2]Kardiyakyaralanmalardahastalarınkısasuredehastaneyenakli,


erken tanıve resüsitasyonu takibencerrahigirişiminenkısasüredeyapılmasıhayatkurtarıcıdır.Buçalış-mada,hastanemizeson5yıliçindepenetrankardiyakyaralanmailebaşvuran21hastaetyoloji,kliniközel-likler,cerrahitedavivesonuçlarıaçısındangeriyedö-nükolarakdeğerlendirildi.

GEREÇ VE YÖNTEMŞubat2006ileOcak2011tarihleriarasındapenet-

ran kalp yaralanması sebebiyle Numune HastanesiKalp veDamar Cerrahisi Kliniğinde cerrahi girişimuygulanan 21 olgu geriye dönük olarak incelendi.Hastalar etyoloji, fizik muayene bulguları, kardiyaktutulum, tedavi yöntemleri ve sonuçları açısındandeğerlendirildi (Tablo1).Akciğerdışındaeşlikedenorgan yaralanması olan, başvuru anında uygulananresüsitasyona cevap vermeyip kaybedilen ve cerrahigirişim uygulanmayan hastalar çalışma dışı bırakıl-mıştır.Hastalaranamnezvefizikselincelemesonrasıvakitkaybedilmedenameliyataalındı.Hemodinamikolarakstabilolan3hastadailavevalvülerveyaseptalpatolojivarlığınıaraştırmakiçin transtorasikekokar-diyografiyapıldı.

Tümolgularasolanterolateral torakotomiilecer-rahi girişim uygulandı. Perikart açılarak tamponadboşaltıldı. Kanama kontrol altına alındıktan sonrakardiyak yaralanmalar prolen dikişlerle primer ola-rakonarıldı.Tümolgulardaperikartdistalucundabirmiktar açıklık bırakılarak kapatıldı.Olguların tümü-negöğüscerrahisiuzmanlarıdaeşlikettivekardiyakonarım sonrası, akciğer hasarı olan7olgudagereklitedaviprosedürleriuygulandı.Toraksadrenkonularakameliyat tamamlandıvehastalaryoğunbakımünite-sinealındı.

BULGULARHastaların ortalama yaşı 32,2 (dağılım, 18-62)

olup,18’ierkek,3’ü isekadın idi.Yaralanma19ol-gudadelicikesicialet,2olgudaiseateşlisilahyara-lanmasınabağlı idi.Anamnezbilgilerinegörehasta-ların hastaneye ulaşma süresi ortalama 25 (dağılım,10-120)dakikaidi.Beşhastakendiözelaraçlarıveyaticari araçlarla, diğer 16 hasta ise ambulans ile has-taneyegetirilmişti.Üçhastadabaşvuruanındayaşambelirtisiyoktuveresüsitasyonileameliyataalındı.Onbeşolguhipovolemikşokvetamponadtablosundaidi,10olgununşuurukonfü,solunumuyüzeyel,hipotansifvenabzıçokzayıfidi.Beşolgununbilinciaçık,hipo-tansifvetaşikardikidi.Diğer3olguisehemodinamikolarakdahastabilolup,sistolikarteriyelbasınçları80mmHg’nınüzerindevenabızlarıdakikada100’ünal-tında idi.Ameliyat sırasında kardiyak yaralanmanın13olgudasağventrikül,5olgudasolventrikülve3olguda sağ atriyumdaolduğugözlendi.Sol atriyum-dayaralanmagözlenmedi.Sağventrikülyaralanmasıolan2olgudaönduvardakikesinin tamiredilmesin-densonrakanamanındevamettiğigörüldü.Kontroldebuolgulardaventrikülünarkaduvarındadakesitespitedildiveprimerdikişlerleposteriorduvardaonarıldı.Sağventrikülyaralanmasıolanbirolguda,sağkoro-ner arter yaralanması da vardı. Bu olguda ventrikülyaralanmasınıntamirindensonraçalışankalpte,safen-vengreftiilebaypasuygulandı.Ateşlisilahyaralanma-sı ilebaşvuran2olgudaameliyat sırasındakardiyakarrestgelişti.Buhastalardasolventriküldegenişgirişveçıkışyeri lezyonlarıgözlendi.Uygulananinternalkardiyakmasajveilaçtedavisinecevapalınamadıvebuhastalarkaybedildi.

Ateşli silahyaralanmasıetyolojisiolanve resüsi-tasyon ile ameliyataalınan2hastada,masifkanamanedeniyleintraoperatifdönemdetekrarkardiyakarrestgelişti.Uygulananinternalkardiyakmasajavemedi-kalresüsitasyonacevapalınamadıvebuhastalarkay-bedildi.Ameliyattansonra1hastamultiplkantrans-füzyonuna bağlı yaygın damar içi pıhtılaşma (DIC),2hastaçokluorganyetmezliği(MOF)veciddiakci-ğeryaralanmasıolan1hastaiseenfeksiyonnedeniylekaybedildi.Toplamda6hastakaybedildivemortalite%28,6olaraktespitedildi.Diğerhastalarortalama2,5(1-7)günyoğunbakımünitesindetakipedildi,drenle-rialındıktanvehemodinamiktablolarıstabilhalegel-diktensonraservisealındı.Buhastalarınpostoperatifyoğunbakımvekliniktakibindeilavekomplikasyongözlenmedi ve genellikle ameliyat sonrası 7’inci (5-13)gündeşifailetaburcuedildi.Hastalarataburculuköncesindeveameliyatsonrası1’inciaydakikontrolle-rindeekokardiyografiyapıldıvepatolojikbulgusap-tanmadı.

TARTIŞMAPenetran kardiyak yaralanmalar sık görülmeyen,


Tablo 1.Hastalarınözellikleri

Sayı(Oran)

Ortalamayaş(yıl) 32,19(18-62)Cinsiyet Kadın 3(%14,3) Erkek 18(%85,7)Etyoloji Ateşlisilah 2(%9,5) Kesicidelicialet 19(%90,5)Kliniktablo İnstabil 18(%85,7) Stabil 3(%14,3)Etkilenenkardiyakbölge Sağventrikül 13(%61,9) Solventrikül 5(%23,8) Sağatriyum 3(%14,3)Koronerarteryaralanması 1(%4,8)Mortaliteoranı 6(%28,6)


bunakarşınmortalitesioldukçayüksekolantravma-lardır. Penetran toraks travmalarında kardiyak yara-lanmaoranı%10civarındaolmasınarağmen,torakstravması nedeniyle oluşan ölümlerin%40’ını kardi-yakyaralanmalaroluşturmaktadır.[3]Çoksayıdaolguhastaneye ulaşmadan, olay yerinde hayatını kaybet-mektedir. İlkyardım, iletişimve transportalanındakiilerlemelere paralel olarak hastaneye ulaştırılan vetedaviedilenolgusayısındaartışgözlenmektedir.Pe-netrankardiyakyaralanmalargençyaşgrubundaveerkeklerdedahasıkgörülmektedir.[1]Bizimçalışma-mızdadaortalamayaş32,19(18-62)ve21olgunun18’i (%85,7) erkek olup literatür verileri ile benzeridi.

Penetrankardiyakyaralanmalardamortaliteileil-giliolarakbirçokçalışmadafarklıoranlarverilmekte-dir.Mortalite,hastaneyeulaşanakadargeçensüre,et-yoloji,etkilenenkardiyakbölge,lezyonunbüyüklüğü,hastanın başvuru anındaki klinik tablosu, eşlik edenorganyaralanması,hastaneninimkanlarıveekibinde-neyiminebağlıolarakdeğişmektedir.[4]Ateşlisilahya-ralanmalarındamortalitekesicidelicialetyaralanma-larınagöredahayüksektir.Çünkükardiyakdokulardadahagenişhasarmeydanagelir,eşlikedenorganyara-lanmasıdahasıkgörülürvesonuçtabuhastalarhasta-neyedahakötükliniktabloilebaşvurur.[5]Ateşlisilahyaralanmasına bağlı kardiyak yaralanmalarda ortala-masağkalım%40 iken,kesicidelicialetyaralanma-larında%80olarakbildirilmektedir.[6]Çalışmamızda,ateşlisilahyaralanmasınabağlı2olgudakaybedilir-ken, kesici delici alet yaralanmasına bağlı olguların4’ükaybedildivetoplamda6olguilemortalite%28,6olaraksaptandı.

Penetran kardiyak yaralanmalarda hızlı transporthayat kurtarıcıdır. Hastaya ilk girişimi yapan ekibintecrübe ve donanımı ile hastanın getirildiği acil ser-visin olanakları da mortalite üzerine etkili önemlifaktörlerdir.Hastaneöncesiönlemlerindealındığıbirçalışmadamortaliteoranınınhelikopterambulansıilehastaneyegetirilenhastalarda%33,ambulanslagetiri-lenhastalarda%76,niteliksizaraçlarlagetirilenhasta-larda%100bulunduğubelirtilmektedir.[7]Buckmanvearkadaşları[5] tümölümlerin%78’ininkardiyakyara-lanmadansonrakiilksaatteoluştuğunubildirmektedir.Bizimçalışmamızda,anamnezbilgilerinegörehasta-larınhastaneyeulaşımsüresi10ile120dakikaarasın-dadeğişiyordu.Olgularınçoğunluğuambulansla,bazıolgularisekendiolanaklarıilegetirilmişti.

Acilservistehastayıgörenhekiminkardiyakyara-lanmadanşüphelenmesierkentanıvetedaviaçısındanönemlidir.Anatomikolarakprekordiyalbölgede;herikimemebaşındangeçendikeyçizgiler,sternaljugu-lumve arkus kostarumdan geçen yatay çizgiler ara-sındagörülenyaralanmalaraksiispatlanıncayakadarkardiyakyaralanmaolarakdeğerlendirilmelidir.[8]Tanı

içinöyküvefizikselincelemeyeterlidir.Buhastalardaileri tanısal testler içingenellikle zamanbulunamaz.Hemodinamikolarak stabil olan az sayıdaki hastadaekokardiyografi, bilgisayarlı tomografi gibi ileri tet-kikler yapılabilir.Ekokardiyografi ile kardiyak yara-lanma, tamponad, kapak ve septum hasarı hakkındabilgi edinilebilir.[9] Ancak stabil olmayan olgulardaresüsitatif işlemlerin ardından acil operasyon uygu-lanmalıdır.[10]Özellikleagonivederinşoktakihasta-larda torakotominin geciktirilmesi mortalite oranınıartırmaktadır.[8]Çalışmamızdahastalarınbüyükkısmıhemodinamikolarak instabilolup,fiziksel inceleme-ninardındanacilolarakameliyataalındı.Klinikduru-mustabilolan3hastadaameliyatöncesitranstorasikekokardiyografikdeğerlendirmeyapıldı.

Kardiyakyaralanmalardatamponadınınmortalite-yeetkisiiçinfarklıgörüşlermevcuttur.Genelolarak,tek bir kalp boşluğunu içeren ve özellikle sağ vent-rikülyaralanmalarında tamponadın sağkalımüzerineolumlu etkisi olduğu kabul edilmekte, ancak bununhangimekanizmaileolduğutamolarakbilinmemek-tedir.[11] Kesici delici alet yaralanmalarında %80-90oranındaperikardiyaltamponadoluşurkenateşlisilahyaralanmalarındabuoran%20kadardır.[6]Kesicide-licialetlerlemeydanagelenkardiyakyaralanmalardamortaliteninateşlisilahyaralanmalarınagöredahadü-şükolması,dahayüksekorandagörülentamponadınmortaliteye olumlu etkisi olduğu şeklinde yorumla-nabilir.Bizim çalışmamızdahastaların 3’ü haricindetamponadbulgularıvardı,düşükmortalitedebunundapayıolabilir.

Penetrankardiyakyaralanmada,anatomik lokali-zasyonuitibarıileenfazlasağventrikülyaralanmasıgörülmektevebunusırasıylasolventrikül,sağatriyumvesolatriyumizlemektedir.[10]Karrelvearkadaşlarıpenetran kardiyak yaralanmalarda kardiyak odacık-ların tutulum oranlarını araştırdıkları çalışmalarında%42,5 sağ ventrikül,%33 sol ventrikül,%15,4 sağatriyumve%5,8solatriyumtutulumutespitetmişler-dir.[12]Diğeryandan, sağventrikülyaralanmalarındamortalitenin daha düşük olduğu belirtilmektedir.[13] Çalışmamızda13olgudasağventrikül,5olgudasolventrikülve3olguda sağatriyumyaralanmasıgöz-lendi,solatriyumyaralanmasıgözlenmedi.Sağkalımoranımızınyüksekolması,kısmensağventrikültutu-lumununfazlaolmasıileilgiliolabilir.Penetrankar-diyakyaralanmalardakoronerarter,kapak,septumvediğerkardiyakyapılardahasargelişebilmektevebudurummortaliteyi olumsuz etkilemektedir.[14] Bizimçalışmamızda1olgudasağventrikülyaralanmasıilebirlikte sağ koroner arter yaralanması gözlendi. Buhastadakardiyakyaralanmanıntamirindensonraçalı-şankalpte,safenvengreftiilesağkoronerarterebay-pasuygulandıvehastaşifailetaburcuedildi.

Operasyon için seçilecek insizyon konusunda da



farklıgörüşlervardır.Hemodinamisistabilolanolgu-lardamediansternotomitercihedilebilir.Çünkümedi-ansternotomikalp,büyükdamarlarvehilerbölgenindeğerlendirilmesi için çok iyi birgörüş alanı sağlar.[15]Ayrıca torakotomiilekarşılaştırıldığındasolunumfonksiyonlarınıdahaazetkilemekteveağrıiçindahaazmedikasyona ihtiyaçduyulmaktadır.Median ster-notominindezavantajıise,kalbinposteriorunavepos-teriormediasten yaralanmalarında aort ve özefagusaulaşabilmek içinuygunolmamasıdır.[15]Klinikduru-mukritikolanhastalardatercihedilecekyöntemacildepartmanda uygulanacak anterolateral torakotomiolmalıdırvesağkalımoranlarındaanlamlıartışlabir-likteolduğugösterilmiştir.[16]Sternotomiyegöredahahızlı uygulanabilir, gerektiğinde sternum kesilerekkarşıhemitoraksauzatılabilir.[8]Bizdeçalışmamızdatümhastalardaacilameliyathanemizdesolanterolate-raltorakotomiuyguladık.

Kardiyak yaralanmada onarım için primer dikiş-lerle,teflonveyaperikartdesteklidikişlerlevegerek-tiğinde yama kullanılarak onarım önerilmektedir.[17] Kardiyakstabilitesağlandıktansonrailaveyaralanmaaçısından tüm yapılar kontrol edilmelidir. Kardiyakyaralanmanın tamirinden sonra, oluşabilecek sızıntı-nıntoraksasızmasıvetekrartamponadayolaçmamasıiçinperikardındistalucundaküçükbiraçıklıkkalacakşekilde kapatılması uygun yaklaşım şeklidir. Kalbinonarımısırasındaanikardiyakarrestgelişerekhastalarkaybedilebilir.Anikardiyakarrestnedenleriarasındakoronerarteryaralanması,aritmilervehavaembolisisayılabilir.[18]Çalışmamızdakardiyakyaralanma tümolgulardaprimerdikiş tekniği ileonarıldı.Sağvent-rikülyaralanmasıolan2olgudaönduvardakikesinintamiredilmesindensonrakanamanındevamettiğigö-rüldü.Kontrolde ventrikülün arka duvarında da kesitespit edildi ve primer dikişlerle posterior duvar daonarıldı. Sağ ventrikül yaralanması olan bir olgudailaveten sağ koroner arter yaralanması gözlendi vekardiyakyaralanmanıntamirindensonraçalışankalp-te,safenvengreftiilebaypasuygulandı.Ateşlisilahyaralanmasıilebaşvuran2olgudaameliyatsırasındakardiyak arrest gelişti.Buhastalarda sol ventriküldegenişgirişveçıkışyerilezyonlarıgözlendi.Uygula-nan internalkardiyakmasajvemedikal tedaviyece-vapalınamadıvebuhastalarkaybedildi.

Kardiyak yaralanmanın onarımını takiben koa-gulopati, sepsis, ensefalopati, mediastenit, yara yerienfeksiyonu,pnömoni, rezidüelhematomvepostpe-rikardiyotomi sendromu gibi ciddi ameliyat sonrasıkomplikasyonlar gelişebilir.[19] Koagülopati genellik-le çok sayıdaki kan transfüzyonuna bağlıdır. Penet-rankalpyaralanmasındansonrageçdönemdeatriyalseptal defekt, ventrikül septal defekti, valvüler yet-mezlik, anevrizma formasyonu, iletim bozuklukları,ventriküler disfonksiyon, endokardit, perikardit ve

arteriovenöz fistül gibi komplikasyonlar görülebilir.[16]Çalışmamızdahastalareksterneedilmedenönceveameliyatsonrası1’inciaydaekokardiyografikontrolüyapıldıvepatolojikbulgusaptanmadı.

Sonuçolarak,kardiyakyaralanmalargençyaşgru-bunda daha sık görülen, ancak zamanında ve uyguntıbbi girişimlemortalitenin düşürülebileceği travma-lardır.Sağkalımınartırılmasıiçin,acilservisteoluş-turulacakgirişimodalarınıntamdonanımlıolmasıveyardımcı sağlık personeline hizmet içi eğitim prog-ramlarıuygulanmasınınönemlifaktörlerolduğukanı-sındayız.

KAYNAKLAR

1. ArikanS,YücelAF,KocakuşakA,DadükY,AdaşG,OnalMA.Retrospectiveanalysisofthepatientswithpenetratingcardiactrauma.UlusTravmaAcilCerrahiDerg2003;9:124-8.

2. MihmanlıM,ErzurumluK,TürkayB,KalyoncuA,GuneyM.PenetranKalpYaralanmaları.TurkishJThoracCardio-vascSurg1994;2:270-3.

3. MandalAK, Oparah SS. Unusually lowmortality of pen-etrating wounds of the chest. Twelve years’ experience. JThoracCardiovascSurg1989;97:119-25.

4. KulshresthaP,DasB, IyerKS,SampathKA,SharmaML,RaoIM,etal.Cardiacinjuries-aclinicalandautopsyprofile.JTrauma1990;30:203-7.

5. BuckmanRFJr,BadellinoMM,MauroLH,AsensioJA,Ca-putoC,GassJ,etal.Penetratingcardiacwounds:prospectivestudy of factors influencing initial resuscitation. J Trauma1993;34:717-27.

6. AttarS,SuterCM,HankinsJR,SequeiraA,McLaughlinJS.Penetratingcardiacinjuries.AnnThoracSurg1991;51:711-6.

7. Naughton MJ, Brissie RM, Bessey PQ, McEachern MM,DonaldJMJr,LawsHL.Demographyofpenetratingcardiactrauma.AnnSurg1989;209:676-83.

8. GaoJM,GaoYH,WeiGB,LiuGL,TianXY,HuP,LiCH.Penetratingcardiacwounds:principlesforsurgicalmanage-ment.WorldJSurg2004;28:1025-9.

9. MeyerDM,JessenME,GrayburnPA.Useofechocardiogra-phytodetectoccultcardiacinjuryafterpenetratingthoracictrauma:aprospectivestudy.JTrauma1995;39:902-9.

10.IvaturyRR,NallathambiMN,RohmanM,StahlWM.Pen-etratingcardiactrauma.Quantifyingtheseverityofanatomicandphysiologicinjury.AnnSurg1987;205:61-6.

11.AsensioJA,BerneJD,DemetriadesD,ChanL,MurrayJ,Fa-labellaA,etal.Onehundredfivepenetratingcardiacinjuries:a2-yearprospectiveevaluation.JTrauma1998;44:1073-82.

12.KarrelR,ShafferMA,FranaszekJB.Emergencydiagnosis,resuscitation,andtreatmentofacutepenetratingcardiactrau-ma.AnnEmergMed1982;11:504-17.

13.ÇıkrıkçıoğluM,YağdıT,PosacıoğluH,ÖzkısacıkE,Çal-kavurT,AtayYveark.Penetrankalpyaralanmaları.UlusTravmaDerg2000;6:189-92.

14.Campbell NC,Thomson SR,Muckart DJ,MeumannCM,VanMiddelkoopI,BothaJB.Reviewof1198casesofpen-etratingcardiactrauma.BrJSurg1997;84:1737-40.

15.MitchellME,MuakkassaFF,PooleGV,RhodesRS,Gris-


woldJA.Surgicalapproachofchoiceforpenetratingcardiacwounds.JTrauma1993;34:17-20.

16.HardikarAA,ThakurSS,KarmarkarPS,AmbikeVS,Ka-netkarAV,GolharKB.Penetratingcardiacinjuryduetoballpointpen.AsianCardiovascThoracAnn1999;7:158-60.

17.HoodRM,BoydAD,CullifordAT.Toracictrauma.Philadel-

phia:WBSaundersCompany;1989.p.178.18.DemetriadesD.Cardiacpenetratinginjuries:personalexpe-

rienceof45cases.BrJSurg1984;71:95-7.19.Velmahos GC, Degiannis E, Souter I, Saadia R. Penetrat-

ingtraumatotheheart:arelativelyinnocentinjury.Surgery1994;115:694-7.



446


Case Report Olgu Sunumu


A rare cause of small bowel obstruction in adults: persistent omphalomesenteric duct

Erişkinlerdeincebağırsaktıkanıklığınınnadirbirnedeni:Persistanomfalomezenterikkanal

Ali GÜNER, Can KEÇE, Aydın BOZ, İzzettin KAHRAMAN, Erhan REİS

Mekanikincebağırsaktıkanıklığınınensıknedeniöncedenyapılmışkarın ameliyatlarıdır.Bunakarşın, karın ameliyatıhikayesi olmayan hastalarda tanı koyulması ve tedavi zor-dur.Omfalomezenterikkanalfetalgelişimsırasındamidgutileyolkkesesiarasındayeralanembriyonikbiryapıdır.Bazıkişilerde,varlığısebatederveözellikleçocuklukyaşlarındabazıkomplikasyonlaranedenolur.Erişkinlerde iseomfalo-mesenterikkanalınsebatetmesinebağlıgelişenbağırsaktı-kanıklığıoldukçanadirrastlanılanbirdurumdur.Buyazıda,omfalomezenterikkanalaçıklığınındevametmesinebağlıba-ğırsaktıkanıklığıgelişmiş42yaşındakierkekhastasunuldu.Anahtar Sözcükler: Bağırsak tıkanıklığı; persistan omfalome-zenterikkanal;incebağırsak.

Previousabdominalsurgeryisthemostcommoncauseofmechanicalsmallbowelobstruction.However,inpatientswithnoabdominalsurgeryhistory,itisdifficulttodiagnoseand treat.Omphalomesenteric duct is a primitive embry-onicstructureoffetaldevelopmentbetweenthemidgutandyolksac.Insomecases,itmaypersistandresultinseveralcomplications,particularlyinchildhood.Inadults,intesti-nalobstructiondue topersistentomphalomesentericductisanextremelyrarecircumstance.Wereporta42-year-oldmalepatientpresentingwithomphalomesentericductrem-nantcausingsmallbowelobstruction.Key Words: Intestinalobstruction;persistentomphalomesentericduct;smallbowel.

Omphalomesentericduct(OMD)isanembryonicstructureprovidingcommunicationfromtheyolksactothemidgutduringfetaldevelopment.[1]Normally,itobliterates spontaneously and separates from the in-testinebetweenapproximatelythe5thand9thweeksofgestation.Completeorpartial failureofsuchclo-sure may result in various lesions.While Meckel’sdiverticulum is the most common of these residualstructures(2%ofthepopulation),presenceofonlyafibrouscordbetweenthesmall intestineandthesur-faceoftheumbilicusistherareentity.Whiletheymaybeasymptomatic,somesymptomscanoccurbecauseofOMD,andmostofthesesymptomsusuallyappearbeforetheageoffouryears.[2]Intestinalobstructioninadultsisanextremelyrareclinicalpresentation.

Inthisreport,wepresentacaseofpersistentOMDcausingintestinalobstructioninanadultpatient.

CASE REPORTA 42-year-old man presented to our department

with intermittent abdominal pain, nausea, vomiting,andabdominaldistensionfor24hours.Hedefinedtheabsenceofgasandfecesfor48hours.Physicalexami-nation demonstrated a distended abdomen andmildtenderness.Hyperactivebowelsoundswereheardonauscultation.Theblood test revealed leukocyte levelof 12000/mm3 and no other laboratory abnormal-ity.Plainabdominalfilmshoweddilatedsmallbowelloopsandair-fluidlevels(Fig.1).Ultrasoundreporteddilatedsmallbowelloopsfilledwithfluid.Hehadnomedicalhistory,noherniaandnohistoryofpreviousabdominal operations. After conservative follow-upwithrestrictionoforalintake,nasogastricsuctionandfluidresuscitation,therewasnoresolutionoftheob-struction. Therefore, the operative intervention was

Presented at the 17th Turkish National Surgical Congress (May 26-29, 2010, Antalya, Turkey).

Department of General Surgery, Trabzon Numune Training and Research Hospital, Trabzon.

17. Ulusal Türk Cerrahi Kongresi’nde sunulmuştur (26-29 Mayıs 2010, Antalya).

Trabzon Numune Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, Trabzon.

Correspondence (İletişim): Ali Güner, M.D. Trabzon Numune Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, 61010 Trabzon, Turkey.Tel: +90 - 462 - 230 61 09 / 1822 e-mail (e-posta): [email protected]

doi: 10.5505/tjtes.2012.77609

decidedandmidlinelaparotomywasperformed.Dur-ingtheexploration,afibroticbandwasidentifiedbe-tweentheantimesentericborderoftheterminalileumandtheposteriorwalloftheumbilicus,causingsmallbowelvolvulus(Fig.2a).Thebandwasresectedwith-outanybowelresection(Fig.2b).Thepostoperativeperiodwasuneventfulandthepatientwasdischargedonthe6thdaywithfullrecovery.Thepathologiceval-uationwasreportedasfibroustissue.

DISCUSSIONMechanical small bowel obstruction is the most

frequentlyencounteredsurgicalproblemofthesmallintestine. Intraabdominal adhesions related to pre-vious abdominal surgery account for up to 75% ofthecasesof smallbowelobstruction.Lessprevalentetiologiesincludehernias,neoplasms,andinflamma-toryprocessessuchasCrohn’sdiseaseortuberculosis.[3,4] Intestinalobstructiondue topersistentOMD,es-

peciallyinadultpatients,isextremelyrare,withveryfewcasesreportedintheliterature.[5-8]

Immediatediagnosisanddifferentialdiagnosisoftheconditionareimportantfordecidingthetreatmentto be applied.The appropriate treatment and timingof the surgery remain controversial. However, theinitialtherapyofthebowelobstructionisstandardandindependentoftheetiology.Fluidandelectrolytere-placement, restrictionoforal intake,andnasogastricsuctionaretheimportantaspectsofsupportivecareofpatientswithintestinalobstruction.[4]Broad-spectrumantibioticsmay be administered in some because ofconcernsthatbacterialtranslocationmayoccurorasaprophylaxisforpossibleresection.However,therearenocontrolleddata tosupport thisantibiotherapy.Weperformedtheinitialtherapyforsmallbowelobstruc-tionandantibioticwasadministeredonlyasprophy-lacticbeforethesurgery.

Non-operative treatments are effective and safemethods, particularly for adhesive small bowel ob-structions.[4,6]However,ifthereisnohistoryofanab-dominaloperationandnoresolutionoftheobstructionfindings,greatercautionisrequired.Immediatediag-nosis is especially important for thedangerous formof the obstruction, closed loop type obstruction, inwhichasegmentofintestineobstructedbothdistallyandproximallyleadstorapidriseintheluminalpres-sure,andprogressestostrangulation.[9,10]Smallbowelvolvulus,suchasinthepresentedcase,isoneofthecausesofclosedloopobstruction;therefore,earlysur-gerypreventedthestrangulationoftheintestinalloops.

Omphalomesenteric duct or vitelline duct is theconnection between the yolk sac and the primitivemidgut.Undernormalcircumstances,theductobliter-atestoathinfibrousbandandisabsorbedspontane-ously during the 5th to 9thweeks of gestation.Theintestineresidesfreewithintheperitonealcavity.Per-sistence of the ductmay result in several anomaliesoftheOMDincludingablindOMD(Meckel’sdiver-

Fig. 1. Plainfilmshowsmultipleloopsofdilatedsmallbowel andair-fluidlevels.

Fig. 2. (a)IntraoperativeviewoftheOMDbetweentheintestinalloopsandtheabdomen.(b) TheviewoftheOMDafterresection.

(a) (b)


A rare cause of small bowel obstruction in adults



ticulum), omphalomesenteric cyst (a central cysticdilatationinwhichtheductisclosedatbothendsbutpatentinitscenter),anumbilical-intestinalfistulare-sultingfromtheductremainingpatentthroughoutitslength,umbilicalpolypresultingfromthepersistenceofthedistalendoftheOMD,andcompleteoblitera-tionoftheduct,resultinginafibrouscordextendingfromtheileumtotheumbilicus.[11]Themostcommonpresentationofapersistentduct(67%)istheMeckel’sdiverticulum,foundinapproximately2%ofthepopu-lation.[12] Other OMD remnants occur infrequently.Althoughtheymaybeasymptomatic,commonsymp-tomsofOMDmalformationsincludeabdominalpain,intestinalbleeding,intestinalobstruction,infectionofthecyst,umbilicaldrainage,andumbilicalhernia,andall of these symptoms appear to be age-dependent,usually before the age of four years.Adult cases ofOMDremnantother thanMeckel’sdiverticulumareextremelyrare.Thoughsurgicalinterventionisneces-saryforasymptom-producingOMDremnant,itisnotrequiredforasymptomaticsubjects.Intestinalobstruc-tion,oneofthecomplicationsofOMD,occursowingtomanymechanismsincludingintussusceptionofthediverticulumandvolvulusorinternalherniationfromafibrousconnection,asinourpatient.

Itisdifficulttounderstandtheetiologyoftheob-structionwithoutdiagnosticlaparotomyorlaparosco-py.Abdominalplainradiographsandultrasonographyarenon-specificforsmallbowelobstruction.Abdomi-nalcomputerizedtomographymaybeusefultoshowthebandoriginatingfromtheumbilicusandcontinu-ingbetweenthesmallbowelloops,asreportedbefore.[6]Inourcase,wedidnotusecomputerizedtomogra-phy,andboththeplainradiographsandtheabdomi-nal ultrasonography were non-diagnostic. However,diagnosiswaspossibleduringlaparotomy.Thesurgi-calexcisionofthefibroticbandissufficienttherapy.If intestinal strangulation ispresent, intestinal resec-tionshouldbeconsidered.OthertypesofsymptomaticpersistentOMDrequiredifferentapproaches,suchasopensurgicalexcisionorlaparoscopicexcision.[8,11,12]

Inconclusion,smallbowelvolvulusduetopersis-

tentOMDisaveryrarecauseofintestinalobstructioninadults.However, inpatientswithoutanypreviousabdominalsurgery,acorrectdiagnosisbecomesmoreimportant. The excision of the OMD remnant is aneasy,safeanddefinitivetherapy.

REFERENCES1. MooreTC.Omphalomesentericductmalformations.Semin

PediatrSurg1996;5:116-23.2. Vane DW, West KW, Grosfeld JL. Vitelline duct anoma-

lies. Experience with 217 childhood cases. Arch Surg1987;122:542-7.

3. MillerG,BomanJ,ShrierI,GordonPH.Etiologyofsmallbowelobstruction.AmJSurg2000;180:33-6.

4. Sarraf-Yazdi S, Shapiro ML. Small bowel obstruction:the eternal dilemma of when to intervene. Scand J Surg2010;99:78-80.

5. AmendolaraM,PasqualeS,PerriS,CarpentieriL,ErranteD,BiasiatoR.etal.IntestinalocclusioncausedbypersistentomphalomesentericductandMeckel’sdiverticulum: reportof2cases.ChirItal2003;55:591-5.[Abstract]

6. MarkogiannakisH,TheodorouD,ToutouzasKG,DrimousisP,PanoussopoulosSG,KatsaragakisS.Persistentomphalo-mesentericductcausingsmallbowelobstructioninanadult.WorldJGastroenterol2007;13:2258-60.

7. HermanM,GryspeerdtS,KerckhoveD,MatthijsI,LefereP.Smallbowelobstructionduetoapersistentomphalomesen-tericduct.JBR-BTR2005;88:175-7.

8. BuenoLledó J,SerraltaSerraA,PlaneéisRoigM,DobónGiménezF, IbáñezPalacínF,RoderoRoderoR. Intestinalobstructioncausedbyomphalomesentericductremnant:use-fulnessoflaparoscopy.RevEspEnfermDig2003;95:736-8,733-5.

9. MakitaO,IkushimaI,MatsumotoN,ArikawaK,YamashitaY, Takahashi M. CT differentiation between necrotic andnonnecroticsmallbowelinclosedloopandstrangulatingob-struction.AbdomImaging1999;24:120-4.

10.FanHP,YangAD, ChangYJ, Juan CW,WuHP. Clinicalspectrumofinternalhernia:asurgicalemergency.SurgTo-day2008;38:899-904.

11.NursalTZ,YildirimS,TarimA,NoyanT.Laparoscopicre-sectionofpatentomphalomesentericduct inanadult.SurgEndosc2002;16:1638.

12.Sawada F,Yoshimura R, Ito K, Nakamura K, Nawata H,MizumotoK,etal.Adultcaseofanomphalomesentericcystresectedbylaparoscopic-assistedsurgery.WorldJGastroen-terol2006;12:825-7.

449




Spontaneous migration of a retained bullet within the brain: a case report

Beyiniçindekalankurşununkendiliğindenyerdeğiştirmesi:Olgusunumu

Mehmet ARSLAN, Metehan ESEOĞLU, Burhan Oral GÜDÜ, İsmail DEMİR, Abdul Baki KOZAN

Başınkurşunyaralanmalarıgenellikleölümcüldürvebe-yiniçindekalankurşununkendiliğindenhareketinadirbirdurumdur.Buolgusunumunda,23yaşındakierkekhasta-nınbeynindekendiliğindenhareketedenkurşunsunuldu.Beyinbilgisayarlı tomogafisi (BT)kurşunun sol parietalbölgedederinyerleşimliolduğunugösterdi.Hastanınbi-linciaçıktıvesağhomoniumhemianopsivardı.Kurşun,hayatiyapılarayakınvederinyerleşimliydi.Buyüzden,cerrahigirişimdüşünülmedi.İkiaysonraçekilenkontrolBT’sindekurşununyerçekimietkisiilekaudaleveposte-riyoradoğruyerdeğiştirdiğigörüldü.Beyiniçindekalankurşununtedavisitartışmalıdır.Derindeyerleşenkurşunuçıkarmak ek nörolojik hasara neden olabileceği gibi ka-lankurşununhareketidehayatiyapılarınzarargörmesineneden olabilir.Sonuç olarak, ek nörolojik defisite nedenolmayacak kolay ulaşılabilir kurşunların çıkarılmasınıöneriyoruz.Anahtar Sözcükler:Beyinyaralanması;kurşun;spontanhareket.

Gunshotinjurytotheheadisusuallymortal,andspontane-ousmigrationofaretainedbulletisrare.Wereportthecaseofa23-year-oldmanwithaspontaneouslymigratedbulletwithinthebrain.Cranialcomputerizedtomography(CT)in-dicatedthatthebulletwaslodgeddeeplyintheleftparietalregion.Thepatientwas conscious andhad right homony-moushemianopsia.Thebulletwasclosetothevitalstruc-tures anddeep-seated; therefore, surgical interventionwasnotconsidered.Twomonthsaftertheinjury,repeatCTre-vealedthatthebullethadmigratedposteriorlyandcaudallyduetogravitationalfactors.Managementoftheretainedbul-letwascontroversial.Removalofadeep-seatedbulletmaycauseadditionalneurologicaldeficit,butmigrationofare-tainedbulletmaycausedamagetovitalstructures,producingsignificantneurologicaldamage.Weproposedthatthebulletinthebrainshouldberemovedifitcouldbereasonablyac-cessedwithoutcausingadditionalneurologicaldamage.Key Words:Braininjury;bullet;spontaneousmigration.

Gunshotheadinjuriesarethemostlethaltypesofthecranial traumasand theyareusuallymortal.Themortalityratehasbeenreportedasrangingfrom51-84%.[1]Thevelocity,distanceofflight,refraction,cali-ber,trajectory,bulletmigration,braindamagedegree,andvascularinjuryarethefactorsthataffectmortality.[2]OneofthemostimportantfactorsintheprognosisistheGlasgowComaScale(GCS)scoreofthepatientatthetimeoftheinitialevaluation.[1]Thefrequencyofgunshotinjuriestotheheadisontheincreaseanditbecomesanimportantpublichealthproblem.Migra-tionoftheretainedbulletisrare,andhasbeenreportedtooccurin0.06-4.2%ofcases.[3,4]Manycasesofspon-taneousmigrationhavebeenreportedinthebrainand

spinalcanal.[2,3,5-9]Treatmentofgunshotinjuriesisstilldebatable.Theneurologicalstatusatthetimeofentryandlocationofthebulletoftendictatethedecisionre-gardingsurgicalremoval.

Wereportacaseofspontaneousmigrationofare-tainedbulletbyreviewingtherelevantliterature.

CASE REPORTA 23-year-oldmale admitted with firearm injury

tohishead.Inhisphysicalexamination,therewasasingleentrywoundsituatedontheleftsideoftheoc-cipital bone, about 2 cm left of themidline and ap-proximately 2.5 cm above the superior nuchal line;theexitwoundcouldnotbefound.Braintissuewas

Department of Neurosurgery, Yüzüncü Yıl University, Faculty of Medicine, Van, Turkey.

Yüzüncü Yıl Üniversitesi, Tıp Fakültesi, Nöroşirürji Anabilim Dalı, Van.

Correspondence (İletişim): Mehmet Arslan, M.D. Yüzüncü Yıl Üniversitesi, Tıp Fakültesi, Nöroşirürji Anabilim Dalı, Van, Turkey.Tel: +90 - 432 - 215 04 70 / 6315 e-mail (e-posta): [email protected]

doi: 10.5505/tjtes.2012.88965

seen through theopenwound. In thefirstneurologi-calexamination,thepatientwasconfusedandGCSatthetimeofadmissionwas10(E3V2M5).Pupilswereequally reactive, and his vitals were stable. Cranialcomputerized tomography (CT) revealed a bone de-fectof0.5cmintheleftoccipitalregionandametallicobject located in the posterosuperior side of the leftlateralventricle’soccipitalhorn.Thebullethadpassedthroughtheleftoccipitallobe.Therewashemorrhagealongitstrajectory,butthemetalartifactsobscuredthe

damage(Figs.1a,b).Theentrywoundwasdebridedand sutured. The patient was treated conservativelywithantibiotics,antiepileptics,andanti-edemadrugs.Havingrecovered,repeatedneurologicalexaminationrevealeddefectof the rightvisualfieldsofeacheye(righthomonymoushemianopsia).Hewasdischargedfromthehospitalaftersevendaysofobservation.Twomonthslater,repeatcranialCTdemonstratedthatthebulletwas lying on the tentorium cerebelli near themidlineintheposterioroccipitalregion(Figs.2a,b);



Fig. 1. (a)InitialCTshowingdeep-seatedbulletintheleftparietalregion.(b)InitialCTscansusingabonealgorithm.Thebulletislocatedintheleftparietallobe.

(a) (b)

(a) (b)

Fig. 2. (a)AxialCTscanaftertwomonthsusingabonealgorithm,demonstratingthenewpositionofthebulletintheoccipi-talregiononthetentoriumcerebelli.(b)SagittalCTusingabonealgorithmshowingbulletmigrationtotheoccipitallobeonthetentoriumcerebelli.


whencomparedtotheinitialCT,itwasobservedthatthebullethadmigrated.Surgicalinterventionwasnotconsidered,asthepatientdisplayednonewneurologi-caldeficitduringthefollow-up.

DISCUSSIONMigrationofanintracranialbulletisararecompli-

cationofgunshotinjuriestothehead.Thetimecourseformigrationrangesfrom2daysto3months.[2,7,10]Thecourseofaricochetbulletisdifferentfrommigrationmovementofaretainedbullet.Aricochetbulletchang-esitsdirectionafterhittingthewallofthecraniumorspinalcanal,whereasretainedbulletmigrationmaybeaffectedbyseveralfactors,suchasgravitationalfac-tors.Abulletalwaystendstomigrate.[9,11]

Various theories have been put forward regard-ingmigrationofthebullet.Themovementofabulletin thenervous systemoccursmainlydue togravita-tionalforces.[3]Gravitationalforceactingonthebul-let,whichisdenserthanthesurroundingmedium,hasbeensuggestedasacause formigrationcaudallybytheeffectofgravityrelatedtothepositionofthebody,especiallyintheabsenceofsignificantcranialswell-ing.[7,10]Castillo-RangelandSalvati[2,12]suggestedthattheventricularsystemprovidestransportofthebulletfromoneareaof thebrain toanother.Cerebrospinalfluid(CSF)flowandpulsationwillfacilitatethebul-let’smovementwithintheventricle.However,itisdif-ficulttosaywhetherornotthemovementofthebulletin thebrainparenchymadependsonbrainpulsation.BulletsreachingtheCSFmaymigratetoadistantpartofthebrainorthespinalcanalthroughtheCSF.Lang[2] notedanintraventricularbullethadmigratedtotheaq-ueductofSylvius,producingacutehydrocephalus.In-creasedintracranialpressureduetocerebralswellinghasbeenreportedasacause thatpreventsmigrationbycompressingthepathwayinthebrainparenchyma.Intheearlystageafterinjury,brainedemamaynotal-lowmigrationofthebullet.However,migrationalongtheCSFcanstilloccureveninincreasedintracranialpressure.Penetrationofthebulletleadstodestructioninthewhitematterpartoftheparenchyma.Thistypeofmigrationhasbeenattributedtocerebralsofteningsecondarytoedemaandlocaltissuedamage,specificgravityof thebulletandgravitational factors.[2]Bul-letsthatcannotmovewithinthebrainafteraninitialmovement arepresumablywalledoff bygliosis andfibrotic scarring. These processes usually take fromweekstoyears.[2]Thedeformedornon-deformedstateof the bullet is significant;migration of a deformedbulletmaybedifficultduetoincreasedresistanceofthebrainparenchyma.[6]Inourcase,cranialCTtakentwomonthsaftertheinjuryrevealedthatthebullethadmigrated towards the left posterioroccipital lobeonthetentoriumcerebelliwhencomparedtothepreviouslocation,withcaudalandposteriormigration.Inthis

case,movementoftheintracranialbulletwasascribedto the specific gravity of the bullet, brain softeningwithlossoftissueresistance,whitematterdevitaliza-tion, and gravitational factors; however, gravity ap-pearstobethemostimportantfactorresponsibleforthemigrationof thebullet.Thepetrousridge, tento-riumcerebelliandfalxarenaturalbarrierspreventingmigrationofthebullet;[9]therefore,weconsideredthatthebullet couldnotmigrate from the tentoriumcer-ebellitoanotherpartofthebrain.

The indications for removalofan intracranial re-tainedbulletarecontroversialandpresentadilemmatotheneurosurgeon.Themanagementoftheseinjuriesneedstobestudiedindetailduringthetreatmentpro-cedure.Özkanandcolleagues[9]advised thatabulletinthebrainshouldberemovedifitcanbereasonablyaccessedandifitcanberemovedwithoutcausingad-ditionalneurologicaldamage.Kumaretal.[5]reportedthatremovalofthebulletshouldbedoneinpatientsundergoingsurgeryforevacuationofahematomaifitiseasilyaccessibleandremovaldoesnotleadtofur-therdeteriorationoftheneurologicalstatusduetoitsproximity tovital structures.Fujimotoet al.[6] statedthatpresenceofaretainedbulletandbonefragmentsdonotincreasetherateofintracranialinfection;there-fore,inanefforttopreventinfection,removalofthebulletisnotnecessary.Zafonteetal.[13]reportedtwocases with neurological deterioration from sponta-neousmigration of a bullet; postoperatively, the pa-tients demonstrated significant functional recovery.ThestudyofFujimoto[6]notedthatabulletwithintheventricularsystemshouldberemovedbecausehydro-cephaluscanbecausedbyobstructionoftheforamenofMonro or aqueduct of Sylvius; however, a bulletwithinthebrainparenchymashouldberemovedonlywhen it canbe easily accessed. Intracranial retainedbulletsrequireneurologicalobservationandserialCTbecausemigrationmayresultinadditionalneurologi-caldeficits,andremovalofthemigratedbulletisthusadvisable.

Surgery tends to achieve debridement of devital-ized tissue, removal of bone fragments, hemosta-sis,duralclosure,andsuturationof theentranceandexit wounds. In addition, antiepileptic and anti-ede-ma agents and antibiotics should be administered.It shouldbekept inmind that a retainedbulletmaycause potential complications, such as migration,abscess, ventriculitis, toxicity, epilepsy, and hydro-cephalus,whichwarrant surgical intervention.How-ever, removalofthebulletmaycauseiatrogenicdam-agetothebrainparenchyma;therefore,ifthereisnoevidenceofinfectionorbrainabscessformationorofadditionalneurologicaldeficitduringhospitalization,conservativemanagementcanbepreferred.Thedeci-sionofsurgicaltreatmentofabulletinjuryisdifficultifitisincloseproximitytovitalstructures,sincere-

Spontaneous migration of a retained bullet within the brain

movalofthebulletmaycausesignificantneurologicaldamage;however,migrationcanleadtoaworseningof the neurological status of the patient. Therefore,itwasdecided to treat the case conservatively sincethebulletwasclosetoopticradiationcarryingvisualinformation to the visual cortex andwas also deep-seated(initsfirstlocation).Weassumedthatthebulletonthetentoriumcerebelli(secondlocation)wasfixed,andtherewasnonewneurologicaldeficitasaresultofthebullet’smigration.Preoperativelocalizationofthebulletisimportantforitssaferemoval.CTtakenshortlybeforesurgerywillbehelpfulforsurgicallyac-cessing the bullet. Intraoperativefluoroscopy shouldalsobeperformed to localize thebulletaccurately.[6]WhileplainX-raysareusefulindemonstratingchangeinposition,theyarenotsufficientforanaccurateana-tomicallocalizationfortheimportantoperation.

Inconclusion, if thebullet isclose tovital struc-tures,surgicalinterventionmaynotbeconsidered.Itisalsorecommendedthatdeep-seatedbulletsbeleft,as any attempt at removal may increase the risk ofmorbidityandmortality;however,itshouldbekeptinmindthatthemigratedbulletmayalsocausedamagetoavitalstructure,leadingtosignificantneurologicaldamage.

REFERENCES1. OzdemirM,UnlüA.Gunshotinjuriesduetocelebratorygun

shootings.TurkNeurosurg2009;19:73-6.2. Castillo-Rangel C, Reyes-Soto G, Mendizábal-Guerra R.

Cranio-thoracicbulletmigrationoveraperiodof27years:

casereport.Neurocirugia(Astur)2010;21:326-9.3. FarrugiaA,RaulJS,GérautA,LudesB.Ricochetofabullet

inthespinalcanal:acasereportandreviewoftheliteratureonbulletmigration.JForensicSci2010;55:1371-4.

4. RappLG,ArceCA,McKenzieR,DarmodyWR,GuyotDR,MichaelDB.Incidenceofintracranialbulletfragmentmigra-tion.NeurolRes1999;21:475-80.

5. Kumar R, Garg P, Maurya V, Sahu RN, Mahapatra AK.Spontaneous bullet migration-uncommon sequelae of fire-arminjurytothebrain.IndJNeurotrauma2008;5:119-21.

6. FujimotoY,CabreraHT,PahlFH,deAndradeAF,MarinoJR. Spontaneous migration of a bullet in the cerebellum--casereport.NeurolMedChir(Tokyo)2001;41:499-501.

7. AgrawalA,PratapA,RauniarRK,KumarA,NepalU.In-tracranialricochetingofbulletfromanteriorclinoidprocess.JNMAJNepalMedAssoc2008;47:145-6.

8. YoungWFJr,KatzMR,RosenwasserRH.Spontaneousmi-grationofanintracranialbulletintothecervicalcanal.SouthMedJ1993;86:557-9.

9. OzkanU,OzateşM,Kemaloğlu S,GüzelA. Spontaneousmigrationofabulletintothebrain.ClinNeurolNeurosurg2006;108:573-5.

10.ArasilE,TaşçioğluAO.Spontaneousmigrationofanintra-cranialbullettothecervicalspinalcanalcausingLhermitte’ssign.Casereport.JNeurosurg1982;56:158-9.

11.Duman H, Ziyal IM, CanpolatA. Spontaneous subfalcialtranscallosalmigrationofamissiletothecontralateralhemi-sphere causingdeterioration inneurological status-case re-port.NeurolMedChir(Tokyo)2002;42:332-3.

12.SalvatiM,CervoniL,RocchiG,RastelliE,DelfiniR.Spon-taneousmovementofmetallicforeignbodies.Casereport.JNeurosurgSci1997;41:423-5.

13.Zafonte RD,Watanabe T, Mann NR. Moving bullet syn-drome:acomplicationofpenetratingheadinjury.ArchPhysMedRehabil1998;79:1469-72.



453




The hidden devil: unexpected retained knife in the chest wall

Gizlişeytan:göğüsduvarıiçindebeklenmedikbiçimdekalmışbıçak

Chi-chen CHANG,1 Hung-jung LIN,1 Ning-ping FOO,2 Kuo-tai CHEN1

Bu yazıda, sırtında ve üst ekstremitelerinde bıçak yara-larıyla gelen 52 yaşında bir kadın olgu sunuldu. Göğüsduvarında kalmış bıçak acil servis bölümünde fark edil-memişti.Olgubize,ayrıntılıhastaöyküsü, tambirfizik-selincelemevedüzfilmçekilmesinerağmenbelirginbiryabancıcismingözdenkaçabildiğinihatırlatmaktadır.Çı-kartılmamışbiryabancıcisimenfeksiyonriskiniarttırabi-leceğigibi ilerdeiçorganhasarınanedenolabilir.Penet-ranyarayeterinceincelenemediğindeveyatravmacerrahıyaralıhastalardaayrıntılıincelemeyapamıyorsahastalarınbilgisayarlı tomografi taramasından geçmesini öneririz.Bilgisayarlı tomografi görüntüleri penetran yaralanmayı,şiddetiniveyabancıbircisimriskiniaydınlatabilir.

Anahtar Sözcükler:Yabancıcisim;görüntüleme;penetrangöğüstravması;bıçakyarası.

We report a 52-year-old woman presenting with stabwoundsonherbackandupperextremities.Akniferetainedinherchestwallwasnotdiscoveredintheemergencyde-partment. This case reminds us that an obvious foreignbodycanbemissedevenafterobtainingadetailedhistory,completephysicalexaminationandplainfilm.Particularly,aretainedforeignbodyincreasestheriskofinfectionandmaycausefurtherinternalorganinjury.Wesuggestthatpa-tientsundergocomputedtomography(CT)scanningwhen-ever a penetratingwound cannot be explored adequatelyorthetraumasurgeonsareunabletoperformdetailedex-aminationson the injuredpatients.TheCT imagescoulddelineatethecourseandseverityofthepenetratinginjury,anddecreasetheriskofaretainedforeignbody.Key Words:Foreignbody;imaging;penetratingchesttrauma;stabwound.

Wereportacaseofawomanpresentingwithstabwounds on her back and upper extremities. Neitherthepatientherselfnorthetraumasurgeonsdiscoveredtheretainedknifeinherwounduntilsurgery.Thisre-porthighlightstheunpredictabilityofretainedforeignbodyinpatientswithpenetratinginjury.

CASE REPORTAn obese 52-year-old woman was taken to the

emergency department by ambulance. She had suf-feredanassaultwithaknife toherback,elbowandhands. On admission, the patient was coherent butinhypovolemicstatewithabloodpressureof61/50mmHg, heart rate of 83 per minute and respiratoryrateof24perminute.Wecoveredthewoundsandthebleedingwasstoppedshortlythereafter.Afterinfusionof isotonicsalineandblood,herbloodpressurenor-malized.Chestroentgenogramrevealedneitherhemo-

pneumothorax nor signs of pulmonary parenchymalinjury(Fig.1).Eighthourslater,thepatientwastrans-ferred to theoperatingroomforwounddebridementandsuture.An18-cmknifethathadenteredfromthebackwasfoundretainedinthechestwall(Fig.2).Theblade had penetrated the right diaphragm and lung.Theknifewas surgicallywithdrawnand thepostop-erativerecoverywasuneventful.

DISCUSSIONAforeignbodymaybeobservedanywhereinthe

chestasaresultofatraumaticevent.Althoughthereisusuallyevidenceofpenetratingthoracicwound,are-tainedforeignbodymayoccurunexpectedly.Previousstudiessuggestthatthetraumasurgeonsshouldpayat-tentiontotheclinicalhistoryandtraumamechanisms,aswellastotheradiologicfindings.[1,2]However,theretained foreign bodiesmay be small or radiolucent

Departments of 1Emergency, 2Emergency Medicine, Chi-mei Medical Center, Liouying, Taiwan.

Chi-mei Tıp Merkezi, 1Acil Servis, 2Acil Tıp Kliniği, Liouying, Tayvan.

Correspondence (İletişim): Kuo-tai Chen, M.D. 901 Chung-Hwa Road, Yung Kang, Tainan 710, Taiwan.Tel: +0886-6-2812811 (ext. 57196) e-mail (e-posta): [email protected]

doi: 10.5505/tjtes.2012.08931

incharacterandthusdifficulttodiscoverontheplainfilm.Inaddition,theforeignbodiesmaymigrateawayfrom the wounds due to the exerted force from thetrauma ormay be pushed by the contracture of themuscles surrounding the object; further, the foreignbodiesmaybeoverlookedormisinterpretedasobjectsoutsidethepatient’sbody.[2,3]

Inourcase, thewoundon thepatient’sbackwassmallandtheknifehadpenetrateddeepalongthechestwall,whichcausedittobemisseduponexplorationofthewound. Inaddition, thepatientarrived inastateof shock; therefore, thewoundwas covered to stopthebleeding as soon aspossible insteadof ensuringthat a cautious examinationwasperformed.Further,the patient had thick subcutaneous soft tissue (bodymass index:30.4)andneither thepatientherselfnorthe trauma surgeons discovered the retained foreignbodyduringthephysicalexamination.Thepositionoftheknifemadeitappearasametallineontheplainfilm.All these factors contributed tomissing the re-tainedforeignbodyinthispatient.

Aretainedforeignbodycarriesseveralriskstothepatient.Theimplantedforeignbodiesarehighlysus-ceptibletopyogenicinfections,andtheinfectionsareresistanttoantibiotictherapybeforetheforeignbod-iesareremoved.[3]Asidefrompossibleinfections,the

foreignbodiesmaymigrateandcausefurtherdamagetointernalorgans.[4]Thus,itiscrucialtodiscoveranyretained foreignbodies inpenetratingchestwounds.Inadditiontoadetailedhistoryofthetraumamech-anisms and careful physical examination, imagingstudiesareuseful tools to identifyaretainedforeignbody. Therefore, we suggest that patients undergocomputed tomography (CT) scanning whenever apenetratingwoundcannotbeexploredadequatelyorthetraumasurgeonsareunabletoperformadetailedexaminationofaninjuredpatient.TheCTimagespro-vide informationabout thecourseof thepenetratingobject,theinvolvedorgansandtheseverityoforganinjuries.[1,2]Mostimportantly,theCTimagehelpsthetraumasurgeonsdiscovertheretainedforeignbodiesandarrangefortheirproperremoval.[2,3,5]

REFERENCES1. Demetriades D, Velmahos GC. Penetrating injuries of the

chest:indicationsforoperation.ScandJSurg2002;91:41-5.2. deVriesCS,AfricaM,GebremariamFA,vanRensburgJJ,

OttoSF,PotgieterHF.Et al.The imagingof stab injuries.ActaRadiol2010;51:92-106.

3. KimTJ,GooJM,MoonMH,ImJG,KimMY.Foreignbod-iesinthechest:howcometheyareseeninadults?KoreanJRadiol2001;2:87-96.

4. SokoutiM,MontazeriV. Delayedmassive hemoptysis 20yearsafterlungstabbing:anunusualpresentation.EurJCar-diothoracSurg2007;32:679-81.

5. KavanaghPV,MasonAC,MüllerNL.Thoracicforeignbod-iesinadults.ClinRadiol1999;54:353-60.



Fig. 1. Chestroentgenogramof thepatient.Thestraightra-diopaquelineinherrightlowerchestwallwasinter-pretedasawireofvariousmonitorsusedintheemer-gencydepartment.

Fig. 2. Theretainedforeignbody:an18-cmknife.

455




Bilateral simultaneous anterior obturator dislocation of the hip by an unusual mechanism - a case report

Olağandışıbirmekanizmaylaçifttaraflı,eşzamanlıanteriorobturatorkalçaçıkığı:Olgusunumu

Asif SULTAN,1 Tahir Ahmad DAR,1 Mohd Iqbal WANI,1 Mubashir Maqbool WANI,1 Samina SHAFI2

Otuzyaşındabirkadınhastaçifttaraflıveeşzamanlıolarakher iki kalça ekleminde anterior dislokasyonla başvurdu.Hastakonservatifyollatedaviedildi.İkiyıllıktakipavas-küler nekroz belirtileri olmaksızın mükemmel sonuçlaralındığınıgösterdi.Yaralanmanınöncedenbildirilenolgu-lardanfarklıolannedenivemekanizmasıtartışıldı.Anahtar Sözcükler:Avaskülernekroz;bilateralanteriorkalçaçı-kığı;travmatik;yaralanmamekanizması.

Acaseofbilateralsimultaneousanteriordislocationofthehip in a 30-year-old female is presented herein.The pa-tientwasmanagedconservatively.Follow-upattwoyearsshowed excellent results with no signs of avascular ne-crosis.Thecauseandmechanismofinjuryarediscussed,whicharedifferentfromthoseofpreviouslyreportedcases.Key Words:Avascularnecrosis;bilateralanteriordislocationofthehip;traumatic;mechanismofinjury.

Bilateralanteriordislocationofthehipisveryrare.Onlya fewcaseshavebeen reportedpreviously.[1-12] Themajority of these caseswere either due to roadtrafficaccidents[2-4,7-9]orhigh-impacttrauma.[1,5,11,12]

Wedescribe a case involving simultaneousbilat-eral traumaticanteriorobturator typehipdislocationwithadistinctlydifferentcauseandmechanismofin-jury.

CASE REPORTA30-year-oldfemalepresentedtoouremergency

departmentwithahistoryofslippinginthebathroom.Bothherlegshadextendedoutwards,andherbuttockshadhit thebathroomfloor.She immediately experi-encedseverepaininbothhips,whichshewasunableto move. She arrived in the emergency departmentwithintwohoursoftheinjury.Onphysicalexamina-tion,bothhipswereinflexion,abductionandexternalrotation.Passiveandactivemovementswerenotpos-sibleineitherhip.Therewerenoneurovasculardefi-citsineitherofherlowerlimbs.Therewerenoasso-ciatedinjuries,andshewashemodynamicallystable.

Radiographs of the pelvis were taken, whichshowedbilateralanteriordislocationofthehipjointsintotheobturatorforamen.Noassociatedfracturewasseen(Fig.1).Thedislocationswere immediatelyre-ducedundergeneralanesthesiawithoutanydifficultyby traction in the line of the deformity followed bygentleadductionandinternalrotation,withthepelvisstabilized by an assistant. Both hips were clinicallystableaftertheclosedreduction,withnorestrictionofrangeofmotion.Post-reduction radiographs showedconcentricandcongruentreductionofbothhips.

Skin traction (below knee) was applied on bothsides and the patientwas kept on bed rest for threeweekswithcontinuoustraction,followedbyafurtherthree weeks on non-weight-bearing.Weight-bearingwasstartedsixweeksaftertheinjury,withthepatientreturningtofullactivitiesatthreemonths.

At the two-year follow-up, the patientwas pain-freewithfullrangeofmotionofbothhipsandhadnoradiographicsignsofavascularnecrosisofthefemoralhead(Fig.2).

1Department of Orthopaedics, Bone and Joint Hospital, Barzulla Srinagar; 2Government Medical College, Srinagar, India.

1Barzulla Kemik ve Eklem Hastanesi, Ortopedi Kliniği, Srinagar;2Devlet Tıp Koleji, Srinagar, Hindistan.

Correspondence (İletişim): Asif Sultan, M.D. Government Hospital for Bone and Joint Surgery, Barzulla 190005 Srinagar, India.Tel: +919 858814700 e-mail (e-posta): [email protected]

doi: 10.5505/tjtes.2012.77012

DISCUSSIONDislocationsofthehipareclassifiedasanterioror

posterioraccordingtothepositionofthefemoralhead.Anteriordislocationshavebeen further subclassifiedas superior, inferior, and luxatio erectaof hip, obtu-ratorandpubictype.[13,14]Anteriordislocationsofthehiparelesscommonthanposteriortype,comprising10-15%ofallhipdislocations,[15]andinferiordisloca-tionisthemostcommontypeofanteriordislocation,comprisingmore than 70% of anterior dislocations.[13]ThelowerincidenceofanteriordislocationmaybedueinparttothestronganteriorcapsuleandY-shapedligamentofBigelow,whichisastrongdisincentivetoanteriordislocation.[13]

Superiordislocationoccurswhenthehipisforcedinto abduction and external rotation with extensionofthehip.Inferiordislocationoccurswhenthehipisforcedintoabductionandexternalrotationwithflex-ion of the hip. Obturator-type dislocation occurs inforcedabduction,externalrotationandflexionofthehip,andtheforceappliedinthispositionseemstobethemostlikelymechanism.[7,13]Roadtrafficaccidentswerethecauseofbilateralanteriordislocationsofthehipinthemajorityofcases[2-4,7-9]withdashboardim-pact,wheresuddendecelerationcreatedthedislocat-ingforce.Othercasesreportedalsohadhigh-energytraumaintheformsofacollapsedrooffallingontothelowerback,[1]duringelectroconvulsivetherapy,[5] by a collapsed floor on to a lower flat,[11] and by astrikingblowfromaheavyobject(weighing600lbs)overthebuttocksarea,[12]withbothlowerextremitiesfixed and both hips flexed, abducted and externallyrotated.

Ourpatienthadslippedinthebathroomwithbothherlowerlimbsgoingintowideabduction,withexter-nalrotationandflexionatthehipsandwithherbut-

tockshittingthefloorandactingasaforceinthishipposition,causingbothhipstobedislocatedanteriorlyandinferiorlyintotheobturatorforamen.Tothebestofourknowledge,thiscause/mechanismofinjuryhasnotbeenreportedpreviously.

Allthecasesofbilateralanteriordislocationofthehipsreportedpreviouslywerereducedbyclosedmeth-ods,includingourcase,exceptforoneneglectedcase.[1]Dislocationofthehipisanorthopedicemergency.Earlyreductionofthedislocatedjointisnecessarytoreducetheriskofavascularnecrosis,whichisseenin0-5%ifthehipisreducedinlessthansixhoursafterthe injury versus in 50% if the hip is reducedmorethan six hours after the injury.[13,14] In our case, thereductionwasdonewithin threehoursof the injury.Promptandgentlereductionundersuitableanesthesiaisvery important toavoidcomplications,andforallhipdislocations,thegoalistoobtainacongruentandstablehip.

Consent: Thereporthasbeenpublishedafterob-tainingthedueconsentofthepatient.

REFERENCES1. Aggarwal ND, Singh H. Unreduced anterior dislocation

of the hip. Report of seven cases. J Bone Joint Surg Br1967;49:288-92.

2. M’BamaliEI.Unusualtraumaticanteriordislocationofthehip.Injury1975;6:220-4.

3. GibbsA.Bilateralobturatordislocationofthehipjoint.In-jury1980;12:250-1.

4. Zamani MH, Saltzman DI. Bilateral traumatic anteriordislocation of the hip: case report. Clin Orthop Relat Res1981:203-6.

5. SethiTS,MamMK,KakrooRK.Bilateraltraumaticanteriordislocationofthehip.JTrauma1987;27:573-4.

6. TezcanR,ErginerR,BabacanM.Bilateral traumaticante-riordislocationofthehip:briefreport.JBoneJointSurgBr1988;70:148-9.



Fig. 1. Anteroposteriorradiographofthepelvisshowingbi-lateralanteriordislocationofthehipintotheobturatorforamen.

Fig. 2. Atthetwo-yearfollow-up,anteroposteriorradiographofthepelvisshowingbothhipjointswithnoavascu-larchanges.


7. EndoS,HoshiS,TakayamaH,KanE.Traumaticbilateralobturatordislocationofthehipjoint.Injury1991;22:232-3.

8. TerahataN,MatsuiH,MakiyamaN.Bilateralanteriordislo-cationofthehips.Acasereport.IntOrthop1996;20:125-6.

9. SneathRJ,MorganNP.Bilateraltraumaticanteriordisloca-tionofthehipjoint.JAccidEmergMed1997;14:391.

10.Duygulu F, Karaoglu S, Kabak S, Karahan OI. Bilateralobturatordislocationof thehip.ArchOrthopTraumaSurg2003;123:36-8.

11.DomingoA,SegurJM,SazL,RamiroSG.Unusualtraumaticanterior bilateral hip dislocation. JOrthopSurgTraumatol2008;18:475-8.

12.ChungKJ,EomSW,NohKC,KimHK,HwangJH,YoonHS,etal.Bilateraltraumaticanteriordislocationofthehipwith an unstable lumbar burst fracture. Clin Orthop Surg2009;1:114-7.

13.Phillips AM, Konchwalla A. The pathologic features andmechanismoftraumaticdislocationofthehip.ClinOrthopRelatRes2000;377:7-10.

14.EpsteinHC.Traumaticdislocationsofthehip.ClinOrthopRelatRes1973;92:116-42.

15.DeLeeJC,EvansJA,ThomasJ.Anteriordislocationofthehipandassociatedfemoral-headfractures.JBoneJointSurgAm1980;62:960-4.

Bilateral simultaneous anterior obturator dislocation of the hip by an unusual mechanism

458




Emergency surgery due to go-kart injuries: report of two consecutive cases

Go-kartyaralanmalarınabağlıacilcerrahi:Ardışıkikiolgununsunumu

Kerim Bora YILMAZ, Melih AKINCI, Oskay KAYA, Hakan KULAÇOĞLU

Go-kart kazasına bağlı yaralanma Türkiye’de yeni biracilcerrahitürüdür.Hastalaragöreçokdeğişikşekillerdeizlenebilirler.Araçların tasarımıvehastakarakteristikle-ri arasında ince ayrıntılarlarvardır.Buyazıda, iki farklıgo-kartkazasındaikiciddiyaralanmaolgususunuldu.Buhastalardakaraciğerlaserasyonuvemezenterikintestinalavulsiyona bağlı şiddetli karın içi kanama izlendi. Has-talarcerrahiyöntemlerletedaviedildi,problemsizolaraktaburcuedildiler.Anahtar Sözcükler:Acilcerrahi;go-kart;travma.

Injuryduetogo-kartingaccidentsisanewkindofsurgi-calemergencyinTurkeyandmayshowvariationsbetweenpatients.Therearespecialdetailsasrelatetothedesignofthevehiclesandpatientcharacteristics.Wereporttwoseri-ously injuredpatientsasa resultof twodifferentgo-kartaccidents.Severeintraabdominalhemorrhageduetoliverlacerationwasseeninonepatientandmesentericintestinalavulsionintheother.Bothpatientsweretreatedsurgicallyanddischargeduneventfully.Key Words:Emergentsurgery;go-kart;trauma.

ThefirstkartwasbuiltbyKurtisKraft inSouth-ernCalifornia in1956.The sporthas rapidly spreadto otherWestern countries. Recently, go-karting hasbecomeanattractivepartofamusementparksinde-velopingcountriesaswell.ItisgaininginpopularityinTurkey,especiallyamongtheyoungpopulationin-cludingteenagers.

ProctorandMiller[1]firstreportedgo-kartinjuriesfromtheUnitedKingdomin1973.Todate,therehavebeenalimitednumberofreportsaboutgo-kartcasual-tiesintheliterature.[1-8]

Wepresenthereintwodifferentcasesadmittedtothesamehospital(aregisteredtraumacenter)withintwodaysduringalocalholiday.

CASE REPORTSCase 1-Overalongvacation,a16-year-oldmale

was admitted to the emergencydepartmentwith ab-dominalpainduetoahigh-speedfrontalcollisiontothe tiresnear a racecoursewhilego-karting.He re-ported thathewasdrivinga9hpgo-kartataspeed

of60km/handwaswearingahelmet.Hehadgen-eralized abdominal pain and tenderness and left an-klepain,withmovingrestriction.Hewasconscious,orientedandcooperative.Arterialbloodpressurewas100/60mmHgandpulseratewas74perminute.Whitebloodcountwas13,960/mm3,hematocrit42.5%andhemoglobin14.5g/dl.Alaninetransaminasewas193U/Landaspartate transaminasewas242U/L.Otherhematologic and biochemical parameters were nor-mal, but microscopic hematuria was determined onurineanalysis.TheplainX-rayfilmsofcranium-neck,chest,abdomen,andextremitieswerenormal.Ultra-soundrevealedminimalfreeliquidinthehepatorenalfossaandalso in thepelvic region,with thedeepestverticalheightdeterminedas5cm.Nodisintegrationof parenchymatous organswas observed.Computedtomographycouldnotbedonebecauseofthepatient’sallergyhistory.Thelesionontheanklewasevaluatedasasofttissueinjuryandconservativetreatmentwasoffered by an orthopedist. The urologist, neurosur-geonandthoracicsurgeonreportednormalexamina-tionfindings.Exploratorylaparotomywasdecidedto

4th Department of General Surgery, Diskapi Training and Research Hospital, Ankara, Turkey.

Dışkapı Yıldırım Beyazıt Eğitim ve Araştırma Hastanesi, 4. Genel Cerrahi Kliniği, Ankara.

Correspondence (İletişim): Kerim Bora Yılmaz, M.D. Dışkapı Yıldırım Beyazıt Eğitim ve Araştırma Hastanesi, İrfan Baştuğ Cad., Ankara, Turkey.Tel: +90 - 312 - 596 20 00 e-mail (e-posta): [email protected]

doi: 10.5505/tjtes.2012.80000

determinethesourceofapossiblehemorrhage.Dur-ingtheexplorationundergeneralanesthesia,approxi-mately 300 ml of blood was aspirated and grade-1liverlacerationinsegment7-8wasobserved.Hemo-stasiswas obtained by surface suturing of the liver.Hebeganoralfeedingonthepostoperativeseconddayandabdominaldrainswereremovedonthethirdday.Postoperative abdominal ultrasound revealed diffuseurinarybladdermucosalwallthickness.Theurologistrecommendedconservativetreatmentandprophylaxisfor theurinaryinfection.Thepatientwasdischargedonthepostoperativeeighthday.

Case 2-Thedayafterthefirstpatientpresented,a32-year-oldmalewasbroughturgentlytoouremergen-cyserviceaftercollidingwiththeguardrailandwallathighspeedwhilego-karting.Hishistoryrevealedthathewasdrivingago-kartat40km/handwearingahel-metasasafetyprecaution.Hewasconscious,orientedandcooperative.Hehadgeneralizedabdominalpainand tenderness in all quadrants.Other systemswerenormal. Arterial blood pressure was 90/50 mmHgandpulserate110perminute.Whitebloodcountwas10,000/mm3,hematocrit44.3%andhemoglobin15g/dl.Otherhematologicandbiochemicalparametersandurineanalysiswerenormal.Theplainradiographsofcranium-neck,chest,abdomen,andextremitieswerenormal.Abdominal ultrasound revealed diffuse freeliquidbetweentheintestinalloops,buttheintegrityofparenchymatousorganswasnormal.Freshbloodwasfoundonparacentesis.Computedtomographywasnotdonebecauseoftheclearfindingsonultrasound.Dur-ingthesurgicalexploration,approximately2000mlofbloodwasseenandaspirated.Therewasalsoa70cmmesenteric intestinal avulsion 70 cm proximal fromtheileocecalvalve.Thissegmentwasresectedandanend-to-end anastomosiswas donewith double layersutures.Otherpartsofintra-andretroperitonealspac-eswerenormal.ThreeunitsoferythrocytesuspensionandoneunitoffreshfrozenplasmaweregivenintheIntensiveCareUnit(ICU).Thepatientwasconsultedbyaurologist,neurosurgeon,orthopedist,andthoracicsurgeon.Noadditionaladvicewasgiven.Onthepost-operative secondday, thepatientbeganoral feedingandwastransportedtoaclinic.Onthepostoperativeseventhday,hisdrainswereremoved,andhewasdis-chargedwithoutcomplication.

DISCUSSIONGo-karting is a variant of an open-wheel motor

sportwith small, open, four-wheeledvehicles calledkarts (or go-karts, gearbox/shifter karts) dependingonthedesign.Theyareusuallyracedonscaled-downcircuits.Indoorandoutdoorgo-kartingtracksaccom-modatethousandsofpeople.Newsregardinggo-kartaccidents can be seen frequently in newspapers, au-diovisualmediaandtheInternet;however,accidents

havebeenreportedinbiomedicaljournalsrarely.In-terestingly, the first scientific paper on this subjectused a newspaper report fromTheTimes, dated 14September1972.[1]

ItwasreportedfromtheNetherlandsthatapproxi-mately600patientswereadmittedtoemergencyde-partmentsannuallyaftergo-kartaccidents,and12se-verely injured patientswere treated at ErasmusMCover a six-year period.[2] The abdominal injury canbeas severeaspancreatic fracture requiringpancre-aticojejunostomy.[3] In fact, go-kart emergencies arenotlimitedtotraumaticinjuries;acutecardiovasculareventscanbeseenduetohazardousairpollutantlev-elswithinthefacilitiesforindoorgo-karting.[9]

Go-kartaccidentscauseinjuriesofvariableextentandoutcome.Ekerandcolleagues[2]dividedthetraumamechanismandrelatedinjuriesintothreemaingroupsas direct trauma, high energetic deceleration traumaandacceleration/decelerationtrauma.Theydescribeddifferentkindsoffracture,contusion,abrasion,lacera-tion,andburnwoundingroup1,bluntabdominalorthoracictraumaandcompressioninjurytolowerex-tremities in group 2, and flexion/extension injury ingroup3.Bothofourpatientscanbeincludedingroup2accordingtothisclassification.

Karts vary widely in speed and some can reachspeeds exceeding 160miles (260 km) per hour, buttheygenerallymaybe limited to speedsofnomorethan15miles(24km)perhour.[10]Thechassisismadeofaflexiblesteeltubebecausethereisnosuspension.Thus,itisstrongenoughnottobreakorgivewayonturn.Amusement park go-karts can be powered by4-strokeenginesorelectricmotors,whileracingkartsuse small 2-stroke or 4-stroke engines.As opposedto other sports that involvemotorized vehicles suchasmotocrossorFormula1,implementationofsafetymeasuresbymanufacturersandmanagersofgo-kart-ingtractsisnotmandatoryinmostcases.[2]However,driverequipment,suchasseatbelt, full-facehelmet,drivingsuit,gloves,drivingboots, ribprotector,andneck collar, has been determined.[10] In Germany,guidelinesforthesecurityofindoorkartcenterswereworkedoutbuttheydonothaveanylegalliabilityinthecaseofinjury.[3]Thelackofsafetydevicesandthesubjective inexperiencemake this sport a dangeroustype of entertainment. The importance of seat beltswashighlightedinanexperimentalteststudyinclud-inggo-karts.[11] InTurkey,weobservegenerally thatthedriversuseonlyahelmetinamusementparks.Itwasmentionedthatthesafetyhelmetisawidelyuti-lizedsafetymeasure,resultinginarelativelylowin-cidenceofheadandneck injuries as comparedwithtrafficaccidents.[2]

Themechanismofinjurydiffersamongcases;how-


Emergency surgery due to go-kart injuries



ever,themostprevalentmechanismissteeringwheeltrauma.Thiskindof traumausuallycauseschest in-juriesincaraccidents.[12]However,itwasshownthatsteeringwheeltraumacanalsocauseabdominaldam-age.[13]Thetwocasesinthepresentreporthadabdom-inalinjuriesduetosteeringwheelcontact.

Althoughgo-kartaccidentshavebeenarecognizedtypeoftraumainWesterncountriesforyears,thissur-gicalemergencyhasbecomeaproblemindevelopingcountriesonlyrecently.Itisasomewhatlow-velocity vehicular accident, but can cause serious trauma inplaceswheretheformalprotectivemeasuresarestilllacking. Both the customers and the personnel inchargeofthefacilityshouldbeawareofthepotentialhazardsandcomplywithsafetyrulesandequipmentrequirements.

REFERENCES1. Miller SS, Proctor D. Go-kart injuries at a fairground. Br

MedJ1973;3:685-6.2. EkerHH,Van Lieshout EM,DenHartogD, Schipper IB.

Traumamechanismsandinjuriesassociatedwithgo-karting.OpenOrthopJ2010;4:107-10.

3. GovaertMJ,PonsenKJ,deJongeL,deWitLT,ObertopH.Fractureof thepancreas in twopatientsafterago-kartac-cident.HPB(Oxford)2001;3:3-6.

4. Suddaby B, Sourbeer M. Go-kart trauma-the heart of thematter.PediatrNurs2004;30:336-7.

5.BleyT,GahrRH.Risksandinjuriesofgo-karting.[ArticleinGerman]ZentralblChir2002;127:523-6.[Abstract]

6. FreemanBJ,FeldmanA,MackinnonJ.Go-kart injuriesoftheshoulderregion.Injury1994;25:555-7.

7. YoungsonGG,BakerR.Go-kartinjuries.Injury1978;9:212-5.

8. HeddleRM,RobbWA.Go-kartinjuriesoftheurethra.JRCollSurgEdinb1974;19:310-2.

9. KimT,WagnerJ.PM2.5andCOconcentrationsinsideanindoorgo-kart facility. JOccupEnvironHyg2010;7:397-406.

10.http://en.wikipedia.org/wiki/Kart_racing.11.StreffFM,GellerES.Anexperimentaltestofriskcompensa-

tion:between-subjectversuswithin-subjectanalyses.AccidAnalPrev1988;20:277-87.

12.Santavirta S,Arajärvi E. Ruptures of the heart in seatbeltwearers.JTrauma1992;32:275-9.

13.LauIV,HorschJD,VianoDC,AndrzejakDV.Biomechan-ics of liver injury by steering wheel loading. J Trauma1987;27:225-35.

461




Isolated basal ganglia hemorrhage due to blast injury

Blastikyaralanmayabağlıizolebilateralbazalganglionkanaması

Fuldem Mutlu AYGÜN,1 Murat Serhat AYGÜN,2 Mehmet Bülent ÖNAL,3 Osman Lütfi DEMİRCİ4

Bilateral travmatik bazal ganglion kanaması son derecenadirbirnöropatolojikantitedir.Blastikyaralanmayabağ-lı bilateral bazal ganglion kanaması daha öncesinde hiçtanımlanmamıştı.Patlamayabağlıgelişmişbilateralbazalganglionkanamasıolanbirolgusunuldu.Anahtar Sözcükler:Basalganglion;kanama;travma.

Bilateral traumatichemorrhageof thebasalganglia isanextremelyrareneuropathologicentity.Bilateralbasalgan-gliahemorrhagesecondarytoblastinjuryhasnotdescribedbefore.Wereportacasewithbilateralbasalgangliahemor-rhagesecondarytoexplotion.Key Words:Basalganglia;hemorrhage;trauma.

Bilateralbasalgangliahemorrhagesareextremelyrareandgenerallyoccurduetohypertension.[1]Therearesomereportsaboutbilateralbasalgangliahemor-rhageetiologieslikelightening,[2]diabeticketoacido-sis,[3]andalcoholandcocaineintoxication,[4]butonlyafewarticlesabouttrauma.[5,6]

Wereporthereinacaseofbilateralbasalgangliahemorrhageduetoblastinjury.

CASE REPORTA35-year-oldmanwasadmittedtoourclinicaf-

terinjuryduetoarocketexplosion.Neurologicalex-aminationrevealedthatthepatientwascomatose,andthephysical examination revealedonly amild scalplaceration.Chestradiography,electrocardiogram,andbloodpressurewereallnormal.

Non-contrast computed tomography (CT) wasperformed,andrevealedbilateralbasalgangliahem-orrhagewithperipheral edema (Fig. 1),without anysignsofsubduralorsubarachnoidbleeding.

Conservative treatment was carried out, and thepatientwasdischargedaboutsevendayslaterwithoutanydeficit.

DISCUSSIONBlastinjuriesaredividedintofourclasses:prima-

ry, secondary, tertiary, andquaternary.Primary inju-riesarecausedbyblastoverpressurewavesorshockwaves.These are especially likelywhen a person isclosetoanexplosion.Theextentandtypesofprimaryblast-inducedinjuriesdependonthepeakoftheover-pressure,numberofoverpressurepeaks,timelagbe-tweenoverpressurepeaks,characteristicsoftheshearfronts between overpressure peaks, frequency reso-nance,andelectromagneticpulse.Researcheshavefo-cusedonthemechanismsofblastinjurieswithingas-containing organs/organ systems such as the lungs,whileprimaryblast-inducedtraumaticbraininjuryhasremainedunderestimated.Secondaryinjuriesaredueto bomb fragments, tertiary injuries are due to blastwind,andquaternaryinjuriesincludeallotherinjuries

1Department of Radiology, Siirt Obstetrics and Gynecology and Children Health Hospital, Siirt; Departments of 2Radiology, 3Neurosurgery, 4Emer-

gency Medicine, Siirt State Hospital, Siirt, Turkey.

1Siirt Kadın Doğum ve Çocuk Hastalıkları Hastanesi Radyoloji Bölümü, Siirt; Siirt Devlet Hastanesi, 2Radyoloji Bölümü, 3Beyin Cerrahisi Kliniği,

4Acil Servis, Siirt.

Correspondence (İletişim): Murat Serhat Aygün, M.D. Siirt Devlet Hastanesi, 56100 Siirt, Turkey.Tel: +90 - 484 - 223 10 21 e-mail (e-posta): [email protected]

doi: 10.5505/tjtes.2012.35033

notcoveredinthefirstthreeclasses.[7] To our best knowledge, there are a few articles

about traumatic bilateral basal ganglia hemorrhage,butnoneaboutblastinjury.[5,6]Themechanismoftrau-matic basal ganglia hemorrhage has not been clear,butisbelievedtoarisefromashearstraininthegan-glionicregion.Likewise,wecouldnotdeterminethefactors that led to thebilateral basal ganglia hemor-rhageinourcase.Thehighpressureoftheblastinjury(primaryinjury)orheadtraumabyblastwind(tertiary

injury)canexplaintheetiology,butitispossiblethatthe sudden-onset hypertension due to the adrenalinedischarge caused the bilateral basal ganglia hemor-rhage.Thistopicrequiresfurtherinvestigationsaboutblast injury to understand the actual mechanism ofblastbilateralbasalgangliahemorrhage.

Computed tomography (CT) remains essential inblasttrauma,asitshowsinjuriestothelungorotherparenchymalorgans.Likewise, cranial injurycanberevealedwithnon-contrastcranialCT,andcranialex-aminationshouldbeperformedinpatientswithblastinjury. Bilateral basal ganglia hemorrhage must bedocumentedasacomplicationofblastinjury.

Inconclusion,researchesaboutbilateralbasalgan-gliahemorrhageareneededinordertounderstandthemechanismofhemorrhagesecondarytoblastinjury.

REFERENCES1. WeisbergLA,StazioA,ElliottD,ShamsniaM.Putaminal

hemorrhage: clinical-computed tomographic correlations.Neuroradiology1990;32:200-6.

2. OzgunB,CastilloM.Basalgangliahemorrhage related tolightningstrike.AJNRAmJNeuroradiol1995;16:1370-1.

3. ChoSJ,WonTK,HwangSJ,KwonJH.Bilateralputaminalhemorrhagewithcerebraledemainhyperglycemichyperos-molarsyndrome.YonseiMedJ2002;43:533-5.

5. RenardD,BrunelH,GaillardN.Bilateralhaemorrhagicin-farctionoftheglobuspallidusaftercocaineandalcoholin-toxication.ActaNeurolBelg2009;109:159-61.

6. YanakaK,EgashiraT,MakiY,TakanoS,OkazakiM,Mat-sumaruY,etal.Bilateraltraumatichemorrhageinthebasalganglia:reportoftwocases.[ArticleinJapanese]NoShinkeiGeka1991;19:369-73.[Abstract]

7. Jang KJ, Jwa SC, KimKH, Kang JK. Bilateral traumatichemorrhage of the basal ganglia. JKoreanNeurosurg Soc2007;41:272-4.



Fig. 1. Axial plane computed tomography shows bilateralbasalgangliahemorrhage(arrows)withmildedema.

Değerli Meslektaşlarım,

Sizleri 19-23 Nisan 2013 tarihleri arasında Antalya’da gerçekleşecek olan 9. Ulusal Travma ve Acil Cerrahi Kongresi’ne davet etmekten mutluluk duyuyoruz. Bu kongrede, Travma ve Acil Cerrahi konusunda en üst düzeyde bilgi birikimi ve yoğun deneyimle elde edilebilecek, tanı, tedavi, organizasyon ve hasta bakımı alanındaki tüm gelişmeler bilgilerinize sunulacaktır. Kongre programı kongre öncesi kursları, uzman oturumları, video sunumları, interaktif paneller, tartışma oturumları, uzlaşma toplantıları, konferanslar ve uzmanlık alanındaki yenilikleri içermektedir. Hedefimiz değerli görüşlerinizle bilimsel programımızı zenginleştirip, herkesin birbirinden bir şeyler öğrenebileceği bilimsel bir platform gerçekleştirmektir. Antalya tarih boyunca kültürün, sanatın, mimarinin ve mitolojinin merkezi olmuştur. Muhteşem doğası, açık maviden laciverte uzanan denizi, şelaleleri, Toros dağları ve palmiye ağaçları ile bu gölgenin büyüsüne kapılacaksınız. Bu özellikleri ile de Antalya, Travma ve Acil Cerrahideki son gelişmeleri tartışabileceğimiz en uygun yer. Sizi Antalya’da ağırlamaktan büyük memnuniyet duyacağız.

Saygılarımızla,

Recep Güloğlu Salih PekmezciUlusal Travma ve Acil Cerrahi Derneği Başkanı Kongre Başkanı

DÜZENLEME KURULU

Kongre BaşkanıSalih PEKMEZCİ

Kongre Eş BaşkanıTayfun YÜCEL

Genel SekreterM. Mahir ÖZMEN

Bilimsel SekreteryaKaya SARIBEYOĞLU

Hakan YANAR

ÜyelerEdiz ALTINLIAcar AREN

Gürhan ÇELİKCemalettin ERTEKIN

Recep GÜLOĞLUAhmet Nuray TURHAN

travma 2012-5

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