Analyzing the wastewater treatment facility location/network design problem via system dynamics: Antalya, Turkey case.

Wastewater treatment facility location selection and network design issues have become attractive topics in the field of wastewater management due to increasing human population, resource scarcity, environmental concerns, and rise of necessity for sustainable solutions for future policy designs. Especially in areas where the demand for wastewater treatment increases dramatically over the years because of reasons such as high migration levels, rapid industrialization, and tourism activities, the problem turns out to be more critical and dynamic. The existing studies try to deal with the issue through mathematical modeling approaches based on optimization perspectives, which require significant computational effort. In this study, an alternative approach based on system dynamics (SD) method is proposed to examine the complex dynamic and nonlinear structure of wastewater treatment facility location selection and network design problems. The proposed SD simulation model is designed for a densely populated industrial and tourism spot, the city of Antalya, located on the Mediterranean coast of Turkey. The model is capable of determining where and when to build a new wastewater treatment facility as well as generating the generic wastewater network structure to be built for the five districts situated in the city center based on cost issues for 2015-2040 period. In addition, the impacts of demand level changes for wastewater treatment due to population variations are analyzed via several scenarios to help decision makers to develop sustainable and cost-efficient management policies. Although SD is a frequently utilized approach in the water/wastewater management arena, to the best of our knowledge, this study is the first attempt to examine the complex and dynamic nature of wastewater treatment facility location selection and network design problems through SD approach.

Outcome of Locked Compressive Nailing in Aseptic Tibial Diaphyseal Nonunions without Bone Defect.

BACKGROUND: Treatment of tibial diaphyseal nonunions are rather difficult. Plate-screw, intramedullary nailing and external fixation are the methods used for treatment. The aim of this study is to evaluate the treatment results of aseptic diaphyseal nonunions following tibia fractures by intramedullary compressive tibia nailing (IMCN) with or without bone graft. MATERIALS AND METHODS: Twenty eight patients who had aseptic tibial nonunion without bone defects operated between 2005 and 2015 were included in the study. The mean age of our patients was 36.4 years (range 20-56 years). There were 22 males and 6 females. Fifteen of the patients exhibited hypertrophic nonunion and thirteen exhibited atrophic nonunion. The average time between fracture occurrence and presentation to our department was 1.6 years (range 1-20 years). All patients underwent fibular osteotomy by removal of a 2 cm bone block from the middle one-third of the fibulas. In all cases, IMCN was applied following the reaming procedure, then maximum bone contacts were achieved manually between proximal and distal bone fragments afterward, and dynamic compressive fixation with 1 mm of compression was performed by a single rotation of the compression screw at the top of the nail. Direct X-ray images were assessed according to the Rust criteria, and functional outcomes were assessed according to the Johner-Wrush criteria. Finite-element analysis was performed for 1 mm of compression. For statistical analysis, Fisher's exact test, Pearson's Chi-square test, and Mann-Whitney U-test were used. RESULTS: Union was achieved in all patients. Radiological union was obtained at an average of 15.5 ± 1.86 weeks. Functional results were found to be good or excellent in 25 (89.2%) patients and average or poor in 3 (10.8%) patients. One patient developed skin necrosis at the wound site, which was treated with rotational flap and skin graft. None of the patients developed implant failure, thromboembolism, deep-vein thrombosis, or infection. CONCLUSIONS: The use of compressive intramedullary nailing with or without bone graft is an effective method for the treatment of tibial nonunion.

Alteration of Thiol-Disulfide Homeostasis in Fibromyalgia Syndrome.

BACKGROUND: Fibromyalgia syndrome (FMS) is an extra-articular rheumatological disease, characterized by widespread pain and somatic symptoms. The etiology has not yet been clarified. Oxidative stress may play an important role in FMS etiology. Thiol group is a very strong antioxidant. We aimed to investigate whether thiol/disulfide homeostasis in FMS is altered or not. MATERIAL AND METHODS: A total of 80 female FMS patients and 64 healthy female control individuals were included in this study. Thiol and disulfide values were measured by Erel's novel methods. RESULTS: Native thiol (330.6 ± 46.1 vs. 356.8 ± 55.5 µmol/L, p = 0.005) and native thiol/total thiol (89.4 ± 3.2 vs. 93.3 ± 4.0, p < 0.001) levels of FMS patients were significantly lower when compared to the values of control group. However, disulfide (19.4 ± 6.3 vs. 12.2 ± 6.3 µmol/L, p < 0.001) levels of FMS patients were significantly higher than healthy individuals. A negative correlation was found between the native thiol/total thiol and fibromyalgia impact questionnaire (FIQ) score among the FMS patients. A positive correlation was found between disulfide values and FIQ score among the patients. CONCLUSIONS: In FMS patients, there was a significant correlation between the decrease in the thiol levels and an increase in the disulfide levels with the FIQ scores. We determined that thiol-disulfide rate was deteriorated in FMS patients and it increases in favor of disulfide amounts.

Effect of intramedullary nail compression amount on the union process of tibial shaft fracture and the evaluation of this effect with a different parameter.

OBJECTIVES: This study aims to investigate the effects of different amounts of compression used in intramedullary nailing on the stress values of the fracture surface and time of the union process in tibia diaphysis fractures treated with intramedullary nails. PATIENTS AND METHODS: Seventy patients (50 males, 20 females; mean age 34.0±10.7 years; range, 20 to 56 years) who had suffered from tibial shaft fractures between January 2007 and December 2015 were included in the study. Patients who had A2, A3, and B2 type fractures according to AO (Arbeitsgemeinschaft für Osteosynthesefragen) classification and those with closed fractures were included. The patients were divided into three groups. No compression was applied to Group A, dynamic compressive fixation intramedullary nailing was applied to Groups B and C. Amount of applied compression was 1 mm for Group B and 1.5 mm for Group C. Postoperative and follow-up radiographs of patients were evaluated according to Rust criteria, and functional results were evaluated according to Johner-Wrush criteria. Additionally, finite element analyses were performed separately for 1 mm and 1.5 mm compressions that were applied in Group B and C, respectively. The data were analyzed using a statistical software package. RESULTS: Clinical and radiological union was achieved in all patients. The average time of radiological union was 15.05±2.06 weeks in Group A, 12.48±1.42 weeks in Group B, and 11.64±1.63 weeks in Group C. The time of union for the group in which no compression was applied (Group A) was significantly longer than the other groups in which compression was applied (Group B and C) (p<0.001). Functional outcomes were 17 patients (85%) with excellent and three patients (15%) with good-moderate results in Group A, 23 (92%) excellent and two (8%) good-moderate in Group B, and 23 (92%) excellent and two patients (8%) with good-moderate results in Group C. In total, seven patients had knee pain. No infection was seen in any patient. CONCLUSION: Interlocking compression intramedullary nailing is a very effective treatment method for tibial shaft fractures. As the compression applied by the nail increases, the time of union shortens significantly.

Is locked compressive intramedullary nailing for adult humerus shaft fractures advantageous?

OBJECTIVES: This study aims to evaluate the radiological and functional outcomes of locked compressive intramedullary nailing (IMN) cases in adult humerus shaft fractures. PATIENTS AND METHODS: A total of 24 patients (12 males, 12 females; mean age 42 years; range 23 to 55 years) with humerus fractures were treated with locked compressive IMN at the Orthopedics and Traumatology Clinic, Antalya Training and Research Hospital between December 2009 and March 2015. Fluoroscopy was used only to check fracture reduction before the reaming procedure. Of the patients, closed IMN was performed in 21, while open reduction was performed in three. Lock screws were locked without fluoroscopy in all patients. Of the patients in whom open reduction was performed, radial nerve lesion developed in one. Anteroposterior and lateral graphs of all patients were taken postoperatively. Fracture union was assessed according to existence of the fracture line and the callus tissue in the anteroposterior and lateral graphs. The Constant-Murley scoring system was used for functional evaluation. The mean follow-up period was 24 months (range 12 to 72 months). Finite element analysis was performed for the stress distribution on fracture site. RESULTS: Radiological fracture union was achieved in all patients at mean 14.8 weeks (range 12 to 17 weeks). The Constant-Murley score was mean 90 (range 72 to 100). There was a statistically significant, negative and strong correlation between union period and the Constant-Murley score (r=-0.78, p<0.001). In one patient who developed postoperative radial nerve symptoms, all functions were regained in fourth month. No infection occurred in any patient. In two patients, tip of the nail remained high. Of these patients, one developed impingement findings, and the other patient had no problems. CONCLUSION: Treatment of humerus shaft fractures with locked compressive IMN provides sufficient fixation and early movement opportunity in the shoulder and elbow joints, and gives satisfactory radiological and functional results.

Is it possible to avoid intra-articular screw penetration with minimal use of fluoroscopy in the application of distal radius volar plate?

OBJECTIVES: This study aims to investigate whether or not it is possible to avoid intra-articular screw penetration in the application of distal radius volar plate with minimal use of fluoroscopy and thereby reduce to a minimum the risk of exposure of the surgical team to radiation. PATIENTS AND METHODS: Volar plate with distal screw application with minimal use of fluoroscopy was performed in a total of 50 patients (22 males, 28 females; mean age 43.52 years; range 18 to 76 years) with unstable distal radius fracture following reduction of fracture between June 2014 and May 2016. A specially designed volar anatomic plate was applied by creating a 3 mm gap proximal from the tip of the facet of the lunate fossa. RESULTS: No intra-articular screw complication was observed during plate-screw applications that we performed by using fluoroscopy at a minimum level and paying attention to the surgical technique described with the plate designed by giving a specific angle to screw beds. During the operation, fluoroscopy was performed at a minimum level and no finding was observed which could suggest use of intra-articular screw. No findings of restriction in wrist movements, locking or friction were observed intra- or postoperatively. CONCLUSION: With improvements in the design of the volar plate and the distal locking screw bed, it is possible to rule out the possibility of intra-articular screw complications and the need for surgical re-correction in the early-term, and to reduce to a minimum the risk of exposure of the surgical team to radiation.

Comparison of non-compression and compression interlocking intramedullary nailing in rabbit femoral shaft osteotomy model.

OBJECTIVES: This study aims to compare non-compression and compression intramedullary nailing in an experimental femoral shaft osteotomy model in terms of radiological, histological, and biomechanical aspects. MATERIALS AND METHODS: Twenty-four white New Zealand rabbits (average weight 4.3 kg; range 4 to 4.8 kg) were divided into three groups. A right femoral osteotomy was performed in all rabbits and all femurs were fixed with titanium compression interlocking intramedullary nail. After locking of nails, no compression was performed in group 1 while 0.5 mm and 1 mm compressions were performed in group 2 and 3, respectively. All rabbits were sacrificed four weeks after operation. Fracture sites were examined histologically and radiologically. Finite element analyses were performed. RESULTS: Radiological scores of groups 2 and 3 were significantly higher than group 1. There was no significant difference between groups 2 and 3 radiologically. Best histological scores were achieved in group 2. According to finite element analyses, osteotomy site in group 2 was exposed to 1240 N of load and 34.5 MPa of mean stress. CONCLUSION: Compression interlocking intramedullary nailing provides faster fracture healing than non-compression interlocking intramedullary nailing. Best histological fracture healing scores were obtained with 0.5 mm compression performed at the fracture site.

Efficiency of Balloon Kyphoplasty in the Treatment of Osteoporotic Vertebral Compression Fractures.

Eighty-seven osteoporotic vertebral fractures of 82 patients were treated with balloon kyphoplasty. Preoperative, postoperative and follow-up outcomes of functional impairment, pain scores and vertebral height restorations of the patients were recorded and evaluated statistically. Seventy-two of the patients were female (87.8%) and 10 (12.2%) were male. Mean age of all patients were 66.4 years. Preoperative mean Anterior Vertebral Body Height of 48.20±13.94 % and Middle Vertebral Body Height of 59.40±14.26 % were recorded as 79.91±9.50 % and 86.90±8.38 % respectively postoperatively and noted to be 73.26±8.59 % and 84.65±8.19 % at last controls respectively. The mean Oswestry Disability Index and Visual Analog Pain Scale also improved significantly. Local Kyphosis of all the patients were also evaluated and a significant improvement was noted postoperatively. The long term results of this study suggest that balloon kyphoplasty is an effective and safe treatment option in osteoporotic vertebral fractures and should be considered for functional improvement, pain relief and height restoration.

A detailed analysis of messages posted on the 'Turk-Orthopod' mailing list over a 13-year period.

OBJECTIVE: The objective of this study was to analyze the content of the 'Turk-Orthopod' mailing list between 2000 and 2013. METHODS: All messages posted to the 'Turk-Orthopod' mailing list were documented and categorized by 4 orthopedic surgeons who were active members of the mailing list into 11 categories based on the content of the messages. RESULTS: A total of 15,699 messages were evaluated and included in the analysis. The mean number of daily messages in 2000 was 0.98 messages/day and increased to 7.23 messages/day in 2013. The most common type of message was announcements (37.5%) about national or international congresses, conferences, symposia, meetings, and panels. The second most common type of message was condolence messages (11.7%). Case discussions and academic discussions comprised 6.3% and 4.5% of the messages, respectively. CONCLUSION: The 'Turk-Orthopod' mailing list serves primarily as an information board and a powerful social media platform for communication among Turkish orthopedic surgeons. However, scientific case discussions and other professional issues comprise a minority of the messages.

Ipsilateral supracondylar humerus fracture and Monteggia lesion with a 5-year follow-up: a rare injury in a young girl.

Although elbow injuries and fractures of the forearm are common in children, the combination of these injuries is rare. We present a case of a 5-year-old patient with a concomitant ipsilateral supracondylar humerus fracture and Monteggia lesion. After physical and radiographic examination of the injured extremity in the emergency department, closed reduction and percutaneous pinning were performed under image intensifier under general anaesthesia. A long-arm cast was applied for postoperative immobilisation. Excellent radiological and functional outcomes were obtained at the end of 1-year follow-up and no deformity was observed at 5-year follow-up.

The effects of laparoscopic sleeve gastrectomy on head, neck, shoulder, low back and knee pain of female patients.

As the rise on the prevalence of obesity, it is related with physical impairment of joints, especially in the lumbar spine and knee joints. Losing body weight can reduce or eliminate pain of head, neck, shoulder, lumbar spine and knees. By performing a laparoscopic bariatric surgery we demonstrated a significant improvement on the pain by body weight reduction. In this study we aimed to explore the efficacy and safety of Laparoscopic Sleeve Gastrectomy (LSG) on the relief of pain on head and neck, shoulder, low back and knee among the severely morbid obese female patients. A total of 39 morbidly obese female patients who underwent LSG for morbid obesity were included in this study. Body weight, height, body mass index (BMI), head and neck, shoulder, low back and knee pain intensity were measured with Visual Analog Scale (VAS) before and after LSG at the 6(th) month. 39 morbidly obese female patients were enrolled to this study. The mean age of the patients was 37.69 ± 11.33 years. Preoperative and postoperative body weights were 127.3 kg and 91.21 kg, respectively. Mean height was 165.23 ± 5.78 cm. Preoperative and postoperative BMIs were 46.49 kg/m(2) and 32.33 kg/m(2), respectively. A significant correlation between preoperative and postoperative parameters was found according to BMI. Our data showed that LSG is an efficient and safe procedure on severely obese patients and showed a predictive remission of head and neck, shoulder, low back and knee pain intensity of female patients by analyzing with VAS during the first 6 months.

[Morphometric anatomic study and clinical significance of lunate fossa]. / Lunat fossanin morfometrik anatomik çalismasi ve klinik önemi.

OBJECTIVES: This study aims to investigate the depth, transverse and sagittal diameters of lunate fossa which is a significant structure of the wrist in terms of reducing the risk for volar plate screws, which are administered in distal radius fractures, from penetrating into the joint. MATERIALS AND METHODS: Depth, transverse and sagittal diameters of lunate fossa in 50 right and 50 left adult dried radius bones without distal tip damage were measured by using MicroscribeG2X from the MicroScribe G series. RESULTS: Mean lunate fossa depth: left 2.419886±0.51 mm/right 2.543052±0.78 mm, mean lunate fossa sagittal diameter: left 19.656±1.57 mm/right 18.796±1.53 mm, mean lunate fossa transverse diameter: left 11.382±0.65 mm/right 11.106±0.91 mm. There was no statistically significant difference between right and left depth values of lunate fossa (p=0.320), whereas there was statistically significant difference between right and left transverse and sagittal diameters (p=0.006, p=0.048). CONCLUSION: Measurements involving depth of lunate fossa may guide the development of new anatomic plates and decrease complications like the penetration of screw into joint whilst volar plate administrations.

Iloprost inhibits fracture repair in rats.

BACKGROUND: Previous studies have shown that prostaglandins (PGs) dramatically stimulate healing processes in bone. However, the effect of prostaglandin I2 (PGI2) on fracture healing remains unclear. To investigate the effect of PGI2, a study on fracture healing process in closed tibia fractures was designed. METHODS: Thirty-six Sprague-Dawley male rats were randomized into two groups. On the first day, their right tibias were fractured by three-point bending technique. The study group (n = 18) received a single injection of 10 µg/kg iloprost for 5 days, while the control group (n = 18) received saline solution in the same way. On the 7th, 14th and 28th days following the fracture, six rats were sacrificed and their right legs were harvested in each group. The progression of fracture healing was assessed for each specimen by the scores of radiography (by Lane-Sandhu) and histology (by Huo et al). RESULTS: On the 7th day, the radiographic and histologic scores were equal. On the 14th day radiographic total score was 6 and histologic total score was 23 in the iloprost group, whereas radiographic total score was 11 and histologic total score was 33 in the control group. On the 14th day radiographic and histologic scores were significantly decreased in the iloprost group compared to the control group (P < 0.05). On the 28th day radiographic total score was 12 and histologic total score was 37 in the iloprost group, whereas radiographic total score was 15 and histologic total score was 40 in the control group. On the 28th day although there was a decrease in radiographic and histologic scores of the iloprost group acording to control group, it was not statistically significant (P > 0.05). CONCLUSION: Iloprost delays fracture healing in early stage in rats.

[Distal locking techniques without fluoroscopy in intramedullar nailing]. / Intramedüller çivilemede floroskopi olmadan distal kilitleme teknikleri.

OBJECTIVES: In this study, we present three distal locking techniques and two checking methods in intramedullar nailing. PATIENTS AND METHODS: Between January 1999 and December 2011, we performed distal locking with locked intramedullary nails on 501 femoral bone fractures using bone alignment and aspiration technique without fluoroscopy and 578 tibial bone fractures using medial malleolus alignment, bone alignment and aspiration technique without fluoroscopy at Antalya Training and Research Hospital. RESULTS: With the combination of these three locking techniques and two checking methods, locking was successful in all cases except one. In the latter case, the nail remained anteriorly, as the distal screws were not fully compliant with the surgical technique. CONCLUSION: Distal locking can be achieved in a short time using one or combining two or more techniques and methods without fluoroscopy.

Simultaneous shoulder and elbow dislocation.

Ipsilateral shoulder and elbow dislocation is very rare and only six articles are present in the literature mentioning this kind of a complex injury. With this presentation we aim to emphasise the importance of assessing the adjacent joints in patients with trauma in order not to miss any accompanying pathologies. We report a case of a 43-year-old female patient with ipsilateral right shoulder and elbow dislocation treated conservatively. The patient reported elbow pain when first admitted to emergency service but she was diagnosed with simultaneous ipsilateral shoulder and elbow injury and treated conservatively. As a more painful pathology may mask the additional ones, one should hasten to help before performing a complete evaluation. Any harm caused to the patient due to this reason would not be a complication but a malpractice.

Traction apophysitis of the fifth metatarsal base in a child: Iselin's disease.

Although Iselin's disease, apophysitis of the fifth metatarsal base, is not infrequent in clinical practice, it is accepted as a rare cause of lateral foot pain in young adolescents. Usually a simple clinical examination and radiographs are sufficient for diagnosis. We present a patient with Iselin's disease and discuss its clinical and radiographic characteristics, differential diagnosis, aetiopathogenesis and treatment.

Dislocated ankle fracture complicated by near total distal ischaemia.

Total arterial ischaemia is rarely seen following a dislocated ankle fracture but if it does and intervention is not made, it can lead to serious morbidity. We present a 39-year-old woman with almost total occlusion in the arteria tibialis and arteria dorsalis pedis following a dislocated ankle fracture as a result of a bicycle fall.

Isolated unilateral absent patella and contralateral small patella.

Isolated bilateral absent patella is seen very rarely. It is generally encountered as a part of nail-patella syndrome. An 18-year-old male patient presented with left absent patella and right small patella.

Fixation of femoral neck fractures with three screws: results and complications.

OBJECTIVES: To evaluate the results and complications of femoral neck fractures treated with internal fixation with three screws with an average follow-up of three years. METHODS: Thirty seven patients operated upon between June 2000 and May 2005 for fractures of the femoral neck with three screws were identified as the study population. The final results of 26 patients (11 male, 15 female, with an average age of 39.8, range 16-69) that had a minimum of two year follow-up (average 37 months, range 24-64 months) were evaluated. Those patients that had additional fractures were not included in the evaluation. Preoperatively based on Garden classification four patients (15%) were Type I, eight patients (31%) were type 2, six patients (23%) were type three and eight patients (31%) were type 4. Functional results were evaluated according to the UCLA hip score. RESULTS: The average time to union was 5.5 months (range 3-12 months). One patient did not achieve union and a total hip replacement was done in the 15th postoperative month. Four patients had avascular necrosis (AVN) of the femoral head. The incidence of AVN in patients who had an operation within 24 hours of fracture was 9.5% while 40% in patients operated later than that. In patients with AVN one required a total hip replacement, another required treatment with bipolar hemiarthroplasty, the other two patients did not require further operations. One patient underwent bipolar hemiarthroplasty after screw pullout occurred on the 35th postoperative day. Fifteen patients (58%) had excellent results, five (19%) had good, 5 (19%) had moderate results and one (4%) had a poor result. CONCLUSION: Operative treatment with internal fixation using three screws in femoral neck fractures in the first 24 hours after a fracture gives favourable results in young patients that are too young to be considered for arthroplasty.

[Assessment of surgical and conservative treatment of forearm fractures: results in juveniles]. / Büyük çocuklarda önkol çift kiriklarinin konservatif ve cerrahi tedavi sonuçlarinin degerlendirilmesi.

BACKGROUND: We aimed to assess treatment outcomes of forearm fractures in patients aged between 10-18 years, for whom strict guidelines for surgical and conservative treatment are not yet clear. METHODS: From a total of 41 patients between the ages of 10-18 years, 34 patients with a minimum of one-year follow-up in our clinic with the diagnosis of forearm fracture were evaluated retrospectively. All the patients had open epiphyses. Twenty-three of these patients were treated conservatively and 11 surgically. Patients were evaluated according to time of union, function and cosmesis. Average follow-up was two years (12-36 months). RESULTS: Conservative treatment gave excellent and good results in 21 (91%), while surgical treatment gave excellent and good results in 9 (82%) of the patients when evaluated according to Anderson's criteria. A bad result was seen in one patient who did not accept an operation, and had an angulation of over 15 degrees. We also had one bad result in the operatively treated group because of implant failure and a need for a second operation. CONCLUSION: According to our results, conservative treatment should be the mainstay in the treatment of childhood fractures of the forearm. However, we should not hesitate in considering surgical treatment when the patients have a malalignment of more than 15 degrees.