Admission neutrophil-to-lymphocyte ratio and postoperative mortality in elderly patients with hip fracture.

BACKGROUND: Hip fractures in elderly patients are associated with a high mortality rate. Most deaths associated with hip fracture result from complications after surgery. Recent studies suggest that the neutrophil-to-lymphocyte ratio (NLR), which is a laboratory marker used to evaluate systemic inflammation, may be useful to estimate excess mortality. This study aimed to investigate the prognostic value of admission NLR in elderly patients with hip fracture. METHODS: We evaluated patients admitted to the Orthopaedic Surgery Department of Balikesir-Edremit State Hospital. Inclusion criteria were female gender, age between 65 and 80 years, ASA score of 3, unstable intertrochanteric fracture treated with hemiarthroplasty, and time between fracture and surgery less than 72 h. Patients with multiple fracture, previous same side or other side hip surgery, pathological fracture, such as fracture caused by tumor or metabolic bone disease (e.g., Paget's disease), and malignancies were excluded from this study (purposive sampling technique). Finally, "case" (group 1) was defined as patients who died within 1 year after surgery, whereas "control" (group 2) was defined as patients who survived. Patients in group 1 and 2 were statistically compared in terms of NLR value on hospital admission. A total of 22 patients (44%) were included in group 1, and 28 (56%) were included in group 2. RESULTS: We found that the admission NLR values of patients in the mortality group were significantly higher than those of patients in the control group (p<0.001). The cutoff value of NLR was calculated as 4.7 on ROC analysis. CONCLUSION: We believe that the NLR value at admission could be used for risk stratification of mortality in elderly patients with hip fracture.

The biochemical and histological analysis of subcutaneous calcitonin and intramedullary methylprednisolone on bone repair after bone marrow ablation: an experimental comparative study in rats.

BACKGROUND: Although, glucocorticoid (GC) and calcitonin-induced changes in bone repair have been studied previously, the exact effects of these on fracture healing remain controversial. Hence, the purpose of this experimental study is to determine biochemical and histological effects of locally administrated GC and systemically administrated calcitonin on the kinetics of healing response after bone marrow ablation in rats. METHODS: After having undergone marrow ablation, a steroid-treated group of rats (n = 24) received a single dose of intramedullary methylprednisolone (2 mg/kg), a calcitonin-treated group (n = 24) received intermittently administrated subcutaneous salmon calcitonin (16 IU/kg), and a control group (n = 24) received intramedullary saline (25 µl). RESULTS: Blood samples taken on days 1, 3, 7, 9, and 15 after ablation showed an increase in serum calcium, alkaline phosphatase (ALP), and phosphate levels in the Calcitonin and Control groups. Levels of calcium and ALP peaked on day 7 after ablation. However, an increase in phosphate levels indicated a biphasic reaction that peaked on the third and ninth day after ablation. Hypercalcemia was not observed in Steroid group because of the inhibition of osteoclastic bone resorption. In that group, the serum levels of ALP and phosphate were lower than baseline levels. The levels of urinary calcium excretion peaked 3 to 7 days after marrow ablation in the control group and 7 to 9 days after that procedure in the steroid group. Histologic evaluation showed that the rats in the control group demonstrated the expected healing period according to the histological grades and that a delay in healing occurred in the calcitonin group after day 9 because of the inhibition of osteoclastic bone resorption. All rats in the steroid group exhibited a decrease and delayed healing response. CONCLUSION: Total serum calcium, phosphate, and ALP levels increased after bilateral tibial bone marrow ablation and urine calcium and hydroxyproline excretion also increased as a factor of bone resorption. Subcutaneously administrated salmon calcitonin did not affect biochemical changes after marrow ablation. Single-dose intramedullary methylprednisolone inhibited extra-tibial bone resorption induced by cytokines after bone marrow ablation.

[The effects of two different continuous passive motion protocols on knee range of motion after total knee arthroplasty: a prospective analysis]. / Iki farkli sürekli pasif hareket protokolünün total diz protezi sonrasi diz hareket açikligina etkileri: Ileriye dönük bir çalisma.

OBJECTIVES: We prospectively evaluated the effects of continuous passive motion (CPM) started after two different time intervals following total knee arthroplasty (TKA) on short- and long-term results, in comparison with standard physical therapy. METHODS: Eighty-six patients were randomized to three groups following TKA for primary osteoarthritis. The control group (n=28) received only conventional physical therapy. Group I and II, each consisting of 29 patients, were treated with conventional physical therapy combined with CPM that was started on the first and third postoperative days, respectively, and continued until discharge with three one-hour sessions daily. Preoperative and postoperative measurements of the knee range of motion were recorded. Clinical and functional results were assessed using the Knee Society rating system. The patients were followed-up for at least two years (range 26 to 52 months). RESULTS: The duration of CPM was 22 hours in group I, and 19 hours in group II (p>0.05). Knee flexion values measured in the CPM groups on day 3 and at discharge showed significant differences with those of the control group, but no significant differences were found between the groups after the first postoperative month in this respect (p>0.05). The mean duration to reach 100 degrees of passive knee flexion (p=0.03) and the mean length of hospital stay (p=0.04) in the CPM groups were shorter by three and two days compared to the control group, respectively. Clinical and functional knee scores showed significant improvements in all the groups postoperatively (p<0.001), but there were no significant differences between the groups with respect to pre-and postoperative knee scores (p>0.05). CONCLUSION: Even though CPM protocols applied following TKA may shorten the length of hospital stay, CPM applications do not offer additional short- and long-term benefits over standard physical therapy with respect to knee flexion and clinical and functional results.

Bilateral staged total knee arthroplasty in obese patients.

INTRODUCTION: The purpose of this study was to compare the clinical and functional results and complications associated with staged bilateral total knee arthroplasty (TKA) performed 4-11 days apart during a single hospitalization in patients who were obese and patients who were not obese. METHODS: We retrospectively evaluated 48 (96 knees) patients who were obese and divided into two groups based on their body mass indices (BMI). Morbidly obese patients (group A1, BMI > or = 40 kg/m2) consisted of 21 patients (42 knees), and obese patients (group A2, BMI > or = 30 kg/m2) consisted of 27 patients (54 knees). The control group (group B, BMI < 30 kg/m2) consisted of 20 non-obese patients (40 knees), who were undergoing staged bilateral procedure within the same time frame. All patients had cemented TKAs with use of posterior cruciate sparing prosthesis without patellar resurfacing. If medically stable after the first arthroplasty the patients then underwent the second arthroplasty 4-11 days later. The data on major complications and minor complications were evaluated. RESULTS: Although, there was no statistically significant difference in overall complication rates in any of the groups, the non-obese group had fewer wound complications than the other groups (P > 0.05). No significant differences in preoperative or postoperative Knee Society score, and functional score could be demonstrated between the three groups (P > 0.05). Both obese and nonobese patients showed improvements in pain and function from pre-surgery to a minimum 2 years follow-up. CONCLUSION: Results of bilateral staged TKAs in obese patients have low complication and high success rates and increased BMI has no negative effect on the early outcome. Bilateral staged TKA might be a good treatment alternative for the improvement of the patient's quality of life and functional and clinical outcomes.

[Early results of kyphoplasty in osteoporotic vertebral compression fractures]. / Osteoporotik vertebra kompresyon kiriklarinda kifoplasti sonrasi erken dönem sonuçlar.

OBJECTIVES: We evaluated early results of kyphoplasty for osteoporotic vertebral compression fractures with regard to the level of pain, activity levels of patients, and radiographic restoration of the vertebra bodies. METHODS: Sixteen patients (4 males, 12 females; mean age 63 years; range 55 to 72 years) with osteoporotic vertebral compression fractures in the lumbar spine were treated with kyphoplasty. The procedure was performed at 21 levels, with a minimum of 3 ml (range 3 to 6 ml) of cement per level. The mean time from the onset of symptoms to the application was six days (range 2 to 16 days). The effectiveness of the procedure was evaluated by a visual analog scale (VAS: 0 no pain; 10 very severe pain) before kyphoplasty, and after the first day and one month of the procedure. In addition, restoration of the vertebra bodies was assessed on pre- and postoperative radiographs by measuring the anterior, middle, and posterior heights. The mean follow-up was 11 months (range 4 to 30 months). RESULTS: The mean VAS scores were 8.8 (range 7 to 10), 2.4 (range 1 to 5), and 1.6 (range 0 to 3) before kyphoplasty, and after the first day and one month of the procedure, respectively (p<0.0001). All the patients returned to preinjury levels of activity within the first month. No collapse or refracture occurred in the treated vertebrae. Changes in the anterior, middle, and posterior heights of the vertebra bodies after the procedure were not significant. The only complication was the development of an additional fracture in the nearby segment in two patients, for which kyphoplasty was performed. CONCLUSION: With proper patient selection, kyphoplasty is an effective and reliable option for osteoporotic vertebral compression fractures, yielding 80% to 95% success rates.

Treatment of pelvic aneurysmal bone cysts in two children: selective arterial embolization as an adjunct to curettage and bone grafting.

Treatment options of aneurysmal bone cysts include complete resection, curettage, curettage with bone grafting, selective arterial embolization (as a primary treatment or preoperative adjuvant therapy), and percutaneous injection of fibrosing agent. Treatment in pelvic locations is difficult because of the relative inaccessibility of the lesions, the proximity of the lesions to neurovascular structures, and the vulnerability of the acetabulum. Herein, we present 2 pediatric cases of pelvic aneurysmal bone cysts successfully treated with curettage with bone grafting following preoperative selective arterial embolization.

Common peroneal nerve palsy from an untreated popliteal pseudoaneurysm after penetrating injury.

A 17-year-old boy presented with drop foot and loss of extension in his left knee after penetrating injury to the popliteal region. Color duplex ultrasonography and angiography revealed a popliteal artery pseudoaneurysm in the popliteal fossa. Electrodiagnostic tests demonstrated nearly total common peroneal nerve injury. The delay in diagnosis from the time of injury was 1 month. The pseudoaneurysm was repaired with primary suture through a medial incision. Epineurolysis of the common peroneal nerve was performed a week later through a posterolateral incision. Pain and knee contracture resolved after surgery. Drop foot recovered completely after 1 year.

Glove punctures in major and minor orthopaedic surgery with double gloving.

We assessed the frequency of glove perforation during major and minor orthopaedic surgeries, in order to determine the efficacy of double gloving. A total number of 1528 gloves (622 inner and 906 outer) used in 200 procedures (100 major-100 minor), and 100 pairs of unused gloves were examined. Glove perforation rate, incidence among surgical team, location of perforation and duration of surgery were compared. The overall perforation rate was 15.8% (242/1528). Perforation rates for major versus minor surgical procedures were 21.6% and 3.6%, respectively. The perforation rate for the unused control group was 1% (2/200). Inner-outer gloves perforation rates were 3.7% (23/622) and 22.7% (206/906), respectively. Surgeons had a higher perforation rate compared with the other staff. The right thumb and left index finger had more punctures than other fingers. Routine use of double gloving during orthopaedic procedures is recommended, because this significantly reduces the perforation of inner gloves.

[The effect of bone marrow ablation on regional biomechanical properties of rat tibia]. / Kemik iligi ablasyonunun siçan tibiasinin bölgesel biyomekanik özellikleri üzerine etkileri.

OBJECTIVES: Regional (metaphyseal-diaphyseal) biomechanical properties of normal rat tibia, and changes on these biomechanical properties after bone marrow ablation, a model of fracture healing, were examined. METHODS: The study included 24 Sprague-Dawley rats that underwent tibial marrow ablation, and eight control rats with no surgical procedure. Proximal metaphyseal, proximal diaphyseal, distal diaphyseal, and distal metaphyseal samples were prepared from the tibias of all rats. In the control group, stiffness (elastic modulus, E), strength (maximum strength, Smax), and toughness (total energy absorption, U) parameters of the regional tibial segments were evaluated under compression loads. In the experimental group, compression was applied following bone marrow ablation on days 1, 3, 7, 9, and 15, and ablation-induced changes in the regional biomechanical properties were studied. RESULTS: The lowest E, Smax, and U values were obtained from the proximal metaphysis. The highest E and Smax values were from the distal diaphyseal, and the highest U values were from the proximal diaphyseal regions. In ablation-induced rats, decreases were observed in all the mechanical test values during days 1 to 7, followed by slight increases on days 7 to 9, and eventual decreases on days 9 to 15. There were significant differences between the two groups with respect to biomechanical parameters (p<0.05), but no significant differences were found between the tibial regions (p>0.05). CONCLUSION: Biomechanically, the most resistant and the weakest anatomic regions of normal rat tibia are the diaphyseal region and proximal metaphysis, respectively. The metabolic changes occurring after bone marrow ablation lead to changes in the mechanical properties of the tibia. The most affected tibial segments from ablation-induced intramedullary injury are the metaphyseal segments.

[A case of pigmented villonodular synovitis of the elbow joint with bone invasion]. / Dirsek ekleminde kemik invazyonlu pigmente villonodüler sinovit.

Pigmented villonodular synovitis is a benign proliferative disorder of the joint and of the tendon sheath synovium. It has a predilection for the lower extremities, particularly the knee and the hip. The elbow joint is rarely affected. A 56-year-old woman had complaints of pain and swelling in the left elbow for three years. She had no history of trauma. On physical examination, she had swelling of the left elbow, varus deformity, and flexion contracture of 20 degrees. Active and passive joint movements were painful. Magnetic resonance imaging showed synovial thickening and signal changes. An incisional biopsy yielded a diagnosis of pigmented villonodular synovitis. She underwent subtotal synovectomy and excision of the radius head. No evidence of clinical or radiologic recurrence was detected within a follow-up of 16 months.

A new material for prevention of epidural fibrosis after laminectomy: oxidized regenerated cellulose (interceed), an absorbable barrier.

Epidural fibrosis, which may cause persistent back and leg pain, may develop after laminectomy. Several materials have been used in attempts to minimize epidural fibrosis, with varying results. We evaluated the efficacy of an absorbable cellulose adhesion barrier in preventing epidural fibrosis. In 25 New Zealand white rabbits, laminectomies were performed at L3 and L5 vertebrae. The dura mater was covered by the adhesion barrier (Interceed, TC7, Johnson & Johnson, USA) at L3 laminectomy site (group 1), with L5 laminectomy site serving as an internal control (group 2) in each animal. There was no neurological deficit in any of the animals during the postoperative period. Animals were sacrificed at postoperative day 28. The lumbar spine was removed en bloc and placed in neutral, buffered formalin for 72 h. The specimens were then decalcified and embedded in paraffin. Permanent sections of 5 to 7 microm were stained with hematoxylin and eosin and Masson trichrome dye. Epidural fibrosis was evaluated in a double-blinded manner. The extent of epidural fibrosis was graded as 0, no reaction seen; 1, mild reaction; 2, moderate reaction; 3, extensive reaction, and 4, severe reaction. The histological findings of each group were compared. For the statistical analysis, Wilcoxon signed rank test was used. In group 1, the fibrotic tissue formation was minimal in 19 and moderate in 6 laminectomy sites. In group 2, the fibrotic tissue formation was determined as being extensive in 17 and moderate in 8 laminectomy sites. Statistical analysis showed significant decrease in epidural fibrosis in group 1 (P<0.05). This study showed that Interceed, which is commercially available in the market, especially for abdominal and gynecological surgeries, could be used to prevent epidural fibrosis.

Limb-sparing surgery for primary malignant tumours of the pelvis.

Treatment of malignant tumours of the pelvis represents one of the most difficult problems in musculoskeletal oncology. The aim of this paper is to present our results in 16 cases of primary malignant pelvic tumours following resection only or following reconstruction with autogenous or allogenous bone grafts without using megaprostheses, and to assess the possibility to restore acceptable function with autogenous or allogenous bone grafts while avoiding the high risks of massive endoprostheses. Wound complication was the most common complication in our series, with 10 patients requiring additional treatment in the form of local surgical debridement, appropriate multi-drug antimicrobial therapy and wound care. Secondary pelvic reconstruction was performed in two patients with chondrosarcoma, due to local recurrence. External hemipelvectomy was not required in any patient. Morbidity also included the sacrifice of nerve roots in 4 patients. The mean follow-up was 42.4 months (range, 24 to 60). One patient is alive with disease, five patients have died of metastatic disease (2 of them had evidence of local recurrence), and the remaining ten patients are alive with no evidence of disease. Major blood loss and long operation time, aggressive radical surgery due to the frequent delay in diagnosis, and wound complications after surgery are important points that should be considered in the treatment of primary malignant pelvic tumours. Therefore, the management requires meticulous preoperative investigation, a multidisciplinary approach and experienced surgeons.

Neglected major vessel injury after anterior spinal surgery: a case report.

STUDY DESIGN: This is a case report. OBJECTIVES: To present a case of neglected major vessel injury after anterior spinal surgery. SUMMARY OF BACKGROUND DATA: Vascular complications during spinal surgery are fortunately few in number. The incidence and management of vascular complications during anterior approaches to the thoracolumbar spine are not well known, and it is likely that most acute or delayed vascular injuries and complications are not reported. METHODS: A case that underwent anterior spinal surgery for T12 burst fracture with an iatrogenic injury to the aorta was presented. RESULTS: Paraparesis (Frankel B) was present before last operation and disappeared completely at 30 months of follow-up. CONCLUSIONS: As with any complication, the best treatment is prevention. Careful and meticulous exposure of the involved anatomic area is very important for prevention. Early recognition with rapid treatment of vascular complications can reduce potential morbidity and mortality.

[Periarticular fractures of the knee in child and adolescent athletes]. / Cocukluk ve ergenlik dönemindeki sporcularda diz çevresi kiriklari.

Most of the sports-related lower limb injuries in children and adolescents involve the knee. Due to the physiological characteristics of the growing skeleton, fractures are more common than ligamentous injuries in this age group. The most frequent type of injury is distal femoral physeal fractures followed by proximal tibial physeal injuries. Tibial tubercle avulsions are rare. Reduction should be gently performed and fixation methods should ensure that no further damage to the physeal plate occurs. Even after proper treatment, there is a significant risk for subsequent leg length discrepancies and/or angular deformities, requiring that children be followed closely for at least two years. Arthroscopic techniques have become popular in recent years in the treatment of displaced tibial eminence fractures. Residual anterior laxity remains an important problem after the healing of these fractures.

Double reverse-flow island flaps for two adjacent finger tissue defect.

INTRODUCTION: Soft-tissue reconstruction of fingertip injuries remains a challenge for hand surgery. Tissue loss of multiple digits is a serious problem for hand surgeons. Surgical possibilities include regional, distant and local flaps. In this study, five patients presented with tissue loss of two adjacent fingers and were treated by double reverse-flow island flaps. MATERIALS AND METHODS: The surgical technique is an application of the reverse-flow homodigital island flap for two adjacent finger tissue defects. Instead of one flap, double island flaps are applied to two adjacent finger tissue defects. The flaps are raised from the lateral or medial palmar surface of the proximal phalanx level. Anastomoses between the radial and ulnar digital arteries at the distal interphalangeal joint level are preserved. RESULTS: Three of the patients had tissue defects at the fingertip. In these cases, digital nerve anastomosis with the counter lateral digital nerve made the flaps sensitive. In two patients, the tissue defect was on the dorsum of the middle phalanx level. In these cases, the flaps were non-sensitive. Neither infection nor flap failure was seen in the patients. Sensitive function was satisfactory in fingertip applications. CONCLUSION: The reverse-flow homodigital island flap is a commonly used surgical technique for tissue defects in the fingers. The double reverse-flow island flaps involve the application of this technique for two adjacent fingers. The important point in the surgical technique is that the vascular supply of the two flaps should originate from the same common palmar digital artery. This technique offers a possibility to repair the defects of two adjacent fingers.

Surgical approach in T4N0M0 (vertebral involvement) lung cancer.

Approximately 5% of the cancers involve the chest wall and spine by direct extension and remain localized at the time of diagnosis. T4 lesions invading the vertebra are considered inoperable. We reviewed a new evolution in the surgical treatment of lung cancer involving the vertebra (T4N0M0) and report preliminary results of our approach. Four patients with T4N0M0 (vertebral involvement) lung cancer underwent en bloc surgical resection of tumor between 1998 and 2002. Posterior stabilization, hemilaminectomy, and osteotomy of the involved vertebral bodies below the corresponding pedicle were performed in the prone position and then, in the lateral position, en bloc resection was completed along with the lung resection (large wedge resection or lobectomy) and involved vertebral bodies. There was no immediate postoperative mortality. Three patients died during the follow-up period at the 6th, 8th, and 14th postoperative months with a postoperative recognized metastasis. The fourth patient was in follow-up at 20 months. Although T4N0M0 (vertebral involvement) lung cancers are considered inoperable, lung resection with hemivertebrectomy of the involved vertebra after neoadjuvant chemotherapy and radiotherapy is an alternative treatment in this type of lung cancer. Staging should be made meticulously for the expected surveillance.