Plate Positioning Affects the Pressure on the Axillary Nerve Following a Deltopectoral Approach.

PURPOSE OF THE STUDY To investigate the pressure levels on the axillary nerve at different plate positions after plate fixation of a proximal humerus fracture. MATERIAL AND METHODS Eight fresh-frozen cadaveric specimens were used. The plates were applied on the lateral side of the humerus. A FlexiForce pressure sensor was placed between the nerve and the plate, and the pressure on the nerve was measured (Group 1). The plates were then placed in two different positions such that distal portion of the plates would have 30° anterior and 30° posterior angles to the anatomical axis of the humerus (Group 2 and 3). The anterior of the distal attachment of the deltoid muscle was then elevated and the plates were placed in the middle of the anatomical axis of the humerus (Group 4). The position of the plates were controlled by fluoroscopy and the pressure was measured for each configuration sequentially. RESULTS The mean age of the cadavers was 70.5 ± 6.8 years (range: 61-80 years). Mean pressure values of the groups were 2.65 ± 0.8, 2.52 ± 0.8, 5.65 ± 1.4, and 2.56 ± 0.9 N, respectively. Group 3 had statistically highest-pressure values than the other groups, while no difference was found among groups 1, 2, and 4. DISCUSSION Numbness and weakness of the shoulder muscles are other clinical findings. If numbness on the deltoid muscle is reported, then atrophy is noted in the deltoid muscle in later stages. Persistent pain may be seen even if fracture union occurs after PHF surgery. Axillary nerve entrapment may be considered after the removal of common complications such as avascular necrosis due to fracture, screw migration, infection, and biceps tendon and rotator cuff problems. The sensory branch of the axillary nerve provides the sensation of the anterior joint capsule and lateral part of the deltoid muscle. CONCLUSIONS Proximal humerus plates, which are angled posteriorly along, lead to an increased pressure on the axillary nerve. Anterior orientation of the plate or elevation of deltoid insertion may be used to prevent the possible complications related to axillary nerve. Level of evidence Level II. Key words: proximal humerus fracture, Philos, axillary nerve, nerve injury.

The Role of 3D Modeling in Education of Orthopedic Trainees for the Treatment of Foot Deformities.

PURPOSE OF THE STUDY We hypothesized that preoperative planning with 3D modeling of complex foot deformities would be useful for the education of orthopedics and traumatology residents. MATERIAL AND METHODS This study is prospectively designed study with a control group. Twenty eight residents (study group) who assisted the surgeons during the interventions and ten senior surgeons (control group) were included in the study. All participants assessed virtual 3D-CT images and videos of the cases before the surgery. Ten adult cases of foot bone deformities were evaluated. 3D-CT reconstruction was performed and a 3D model of each deformity was created using the hospital's picture archiving and communication system. The completed 3D models were sterilized in hydrogen peroxide and put on the surgical table in a sterile manner. After surgery, the residents (group I) and surgeons (group II) were questioned regarding their satisfaction with 3D modeling. Responses were structured by a five-point Likert scale (1, strongly disagree; 2, disagree; 3, neither agree nor disagree; 4, agree; and 5, strongly agree). RESULTS The surgeons (group II, n = 10) were satisfied with the sterilized 3D models, which they could touch and re-examine on the operating table. The residents (group I, n = 28) were significantly more satisfied than the senior surgeons (p=0.01). The 3D modeling met both the surgeons' and residents' expectations. DISCUSSION The survey results for the surgeons (group II) were satisfied with the sterilized 3D models, which they could touch and reexamine on the operating table (question 3). They gave the best scores (mean, 4.8/5) for clarity of the 3D model. On the other hand, they gave the lowest scores (mean 3.1/5) to 3D models due to its contribution in understanding deformity over virtual 3D-CT evaluations (question 2 and 5). The residents (group I) differed from those for the senior surgeons. Residents gave the highest scores for understanding of the deformity (question 2 and 5) and clarity (question 1). These outcomes may be interpreted to indicate i) that 3D modeling may be used for education, and ii) that younger surgeons are more interested in novel technological developments. Therefore, the outcomes did differ significantly between the senior surgeons and residents (Table 1). These outcomes may be explicated as; 3D modeling of the foot deformities may not be mandatory for the experienced surgeons for understanding the deformity. On the other hand 3D modeling would be useful tools for younger surgeons and for their education. CONCLUSIONS 3D modeling of foot deformities is more informative than virtual 3D videos. However, with consideration of costs and long processing times, 3D printing may be used optimally for rare deformities. When considering the role of touch sense in surgical learning, 3D modeling gives more detailed and more satisfactory planning than virtual 3D videos. 3D modeling is more useful for young surgeons, and it will be used mainly for education in the future. Key words: 3D printing, deformity, foot and ankle, simulation.

Safety and Efficacy of Intra-Articular 20 mg/2 ml Hyaluronic Acid Injection for the Non-Operative Palliation Treatment of Osteoarthritis of the Knee Joint.

PURPOSE OF THE STUDY In this study it is aimed to prospectively evaluate the safety and efficacy of 20 mg/2 ml Hyaluronic Acid (HA) injections for non-operative palliation treatment of osteoarthritis (OA) of the knee joint. MATERIAL AND METHODS After institutional review board approval was obtained for the study, 63 patients were enrolled and followed prospectively. All the patients have signed informed consent form. Patients who had diagnosis of gonarthrosis according to clinical and radiological evaluation, were given nonsteroid antiinflammatory drug (NSAID) treatment for four weeks. Patients between 55-80 years old in both sexes, whose pain did not relieve were included to the study and were followed up for 6 months. They were applied HA injections in total; three times with one week of interval. Patients were evaluated three times during the study. First one at third week (at the control visit of third injection), secondly at third month and lastly at sixth month. Western Ontario and McMaster Universities Osteoarthritis (WOMAC) and Short Form Health Survey (SF-36) scores were used to clinically evaluate the patients at follow ups. RESULTS 56 (88.9%) patients completed the study and 7 (11.1%) patients did not show up for follow-up examinations and they were excluded. The mean age of the patients was 63.6 ± 6.90 (range 47 and 76) years old. 22 (39.2%) of the patients were male and 34 (60.7%) were female. Any adverse events and adverse effects were not seen in the enrolled patients group. CONCLUSIONS Results of this study revealed that the use of 20 mg/2 ml HA injection was effective in improving the WOMAC index score in patients of knee OA. Additionally, patients' quality of life as measured by SF-36 questionnaire was also significantly improved at the end of the study. None of the patient reported any of the adverse events during the study. Overall, the 20 mg/2 ml HA injection can be considered as a good treatment option for the knee OA in patients who do not respond to non-pharmacological therapy, NSAIDs or analgesics. Key words: osteoarthritis, hyaluronic acid, injection, non-operative.

Improved Functional Outcomes with Reverse Shoulder Arthroplasty Compared to Hemiarthroplasty after Proximal Humeral Fractures in the Elderly.

PURPOSE OF THE STUDY Unsatisfactory functional results following hemiarthroplasty (HA) are seen in the treatment of 3- and 4-part proximal humeral fractures due to tuberosity healing problems and rotator cuff tears. Reverse shoulder arthroplasty (RSA) has been popular for improving functional outcomes. This study compares the results of HA and RSA in the treatment of comminuted proximal humeral fractures in the elderly. MATERIAL AND METHODS Patients over 60 years of age with three- or four-part proximal humeral fractures were included in the study. Twenty-five patients were treated with HA and 33 patients with RSA. The patients were evaluated with/using the American Shoulder and Elbow Surgeons (ASES) and Constant scores, active and passive ranges of motions of the shoulders and muscle strength measurements of HA and RSA patients were compared. RESULTS The mean age of the patients was 66 (60-85) years in the HA group and 73 (60-83) years in the RSA group. The mean ASES and Constant scores were 44.6 and 70 (p=0.06), 24 and 49 (p=0.022), respectively. The mean active abduction was measured as 50° and 90° (p=0.001), flexions as 70° and 120° (p=0.02), and external rotation as 30° and 50° (p=0.210), respectively. CONCLUSIONS In the treatment of three- or four-part proximal humeral fractures of the elderly, RSA gives significantly better functional results compared to HA. Key words: proximal humeral fractures, hemiarthroplasty, reverse shoulder arthroplasty.

Factors Influencing Complication Rates in the Orthopaedic Theatre.

PURPOSE OF THE STUDY The prevalence of complications in surgical units is available in the literature. The aim of this study was to compare the "rotational" (more than one surgeon) and "full-time single surgeon" use of the orthopedic theater. MATERIAL AND METHODS We retrospectively evaluated patients who underwent orthopedic surgery in 2016 in different theaters. A total of 604 of 1973 patients were excluded from the study, and 1369 patients were analyzed. The follow-up period was 1 year. While evaluating the cases, the duration and order of each case, the total operation time on the table, the number of surgeons, the total number of cases, the number of residents, and the experiences of the surgeons were investigated, and the effects of these parameters on the complication rates were analyzed. The Dindo-Clavien system was used to classify the complications. RESULTS When comparing the methods, the complication rate of the full-time single-surgeon method (12.9%) was less than that of the rotational method (21.7%) (p: 0.022). A higher rate of complications (8.5%) was observed in operations with a duration of 115 minutes or more compared to other operations (p <0.001). A higher complication rate (23.7%) was observed in cases lasting more than 345 minutes (p = 0.002). CONCLUSIONS According to our study, full-time use of the orthopedic theater by a single surgeon was found to be safer than rotational use. In addition, the duration of surgeries lasting longer than 115 minutes or longer than 345 minutes during the day increased the rate of surgical complications. Key words: patient safety, surgical planning, operation time, operation order, orthopedic complication.

An unusual case of mammary gland-like carcinoma of vulva: case report and review of literature.

INTRODUCTION: Accessory breast tissue is a very rare finding in the general population with an incidence of one to two percent. An even rarer occurrence is accessory mammary-like tissue which developed breast carcinoma. The authors present a case of aggressive and metastatic carcinoma of vulvar originating from mammary-like tissue. CASE: A 73-year-old Caucasian female presented with a lesion in her left vulva. The lesion was ulcerated and fragile. A dermatologist had evaluated the lesion and took a punch biopsy. Result was vulvar carcinoma. She was admitted to the gynecologic oncology clinic then after and was operated. After a radical vulvectomy and bilateral inguinal lymphadenectomy she received adjuvant radiotherapy because of lymph node metastasis. One year after the finish of radiotherapy patient was found to have lung and femur metastasis. She began to receive systemic chemotherapy for metastasis. CONCLUSION: Primary mammary-like adenocarcinoma of the vulva is exceedingly rare. There is no consensus about the diagnosis, treatment, and follow up of these patients in literature. However, given that histological data confirms these cancers are behaving like breast cancers instead of known patterns of vulva cancer, the best treatment practices for breast cancer may be applied to treat these vulvar carcinoma patients.

C-Met expression pattern in uterine leiomyoma.

AIM: Growth factors take place in the formation and growth of uterine leiomyomas (LMs). Transforming growth factor beta (TGF-beta), epidermal growth factor (EGF), platelet-derived growth factor (PDGF), vascular endothelial growth factor (VEGF), fibroblast growth factor-2 (FGF-2), and insulin-like growth factor (IGF) contribute to the pathophysiology of LMs when they bind with a specific membrane receptor and transmit a signal into the cell. Little is known about hepatocyte growth factor (HGF) and its receptor system c-Met in formation and growth of uterine LMs. The aim of this study was to evaluate the c-Met receptor expression on human myometrium and uterine LMs. MATERIALS AND METHODS: The study was performed on human myometrium and uterine LMs. Expression of c-Met receptor was evaluated by immunohistochemical analysis. RESULTS: Overexpression of c-Met was found in all LM cases and in none of normal myometrium samples c-Met overexpression was seen. CONCLUSION: HGF and c-Met receptor complex seem to have role in development of uterine LMs.

Effect of epidermal growth factor receptor status on the outcomes of patients with metastatic gastric cancer: A pilot study.

The expression of epidermal growth factor receptor (EGFR) has been linked to clinical outcome in several solid tumors. However, the clinical significance of EGFR (c-erbB1) in gastric cancer remains unclear. The present study was designed to detect the clinical implications of EGFR in the Turkish population. Paraffin-embedded tissue microarrays containing gastric cancer tissue were obtained from 30 patients. EGFR expression was detected using immunohistochemistry. The correlation of this biomarker to the clinicopathological features and survival of patients with gastric cancer was studied. The overall positivity rate of EGFR was 63.3%. EGFR expression was significantly correlated with an improved progression-free survival (PFS) and overall survival (OS) rate (P=0.039 and 0.01, respectively). EGFR expression is a good prognostic marker for patients with gastric cancer.

Structural motifs of pre-nucleation clusters.

Structural motifs of pre-nucleation clusters prepared in single, optically levitated supersaturated aqueous aerosol microparticles containing CaBr2 as a model system are reported. Cluster formation is identified by means of X-ray absorption in the Br K-edge regime. The salt concentration beyond the saturation point is varied by controlling the humidity in the ambient atmosphere surrounding the 15-30 µm microdroplets. This leads to the formation of metastable supersaturated liquid particles. Distinct spectral shifts in near-edge spectra as a function of salt concentration are observed, in which the energy position of the Br K-edge is red-shifted by up to 7.1 ± 0.4 eV if the dilute solution is compared to the solid. The K-edge positions of supersaturated solutions are found between these limits. The changes in electronic structure are rationalized in terms of the formation of pre-nucleation clusters. This assumption is verified by spectral simulations using first-principle density functional theory and molecular dynamics calculations, in which structural motifs are considered, explaining the experimental results. These consist of solvated CaBr2 moieties, rather than building blocks forming calcium bromide hexahydrates, the crystal system that is formed by drying aqueous CaBr2 solutions.

Primary mucinous borderline tumor of the vermiform appendix mimicking ovarian carcinoma; case report.

INTRODUCTION: Primary adenocarcinoma of the vermiform appendix is a very rare entity. Borderline mucinous tumor of the appendix is a much more rare disease. CASE: We present a 71-year-old woman with primary mucinous borderline tumor of the vermiform appendix. She was misdiagnosed as an ovarian carcinoma patient and operated on by a gynecologic oncology team. Her frozen section analysis of an appendicial mass resulted as borderline tumor of appendix vermiformis, and right hemicolectomy, as is advised in invasive colon tumors, was not carried out. CONCLUSION: Borderline mucinous tumor of the appendix vermiformis should be kept in mind in patients who have pseudomyxoma peritonei during surgery. Tumoral resection may be the definitive therapy in these patients.

Malignant primary peritoneal mesothelioma: report of two cases and review of literature.

INTRODUCTION: Malignant primary peritoneal mesothelioma is a rare and highly aggressive tumor. This tumor can be misdiagnosed as ovarian carcinoma. CASE: Two cases of malignant primary peritoneal mesothelioma that were misdiagnosed as ovarian carcinoma were operated in our instutition. Patients were 74 and 45 years-old at admittance. CONCLUSION: Malignant primary peritoneal mesothelioma is being a problem for gynecologic oncologists because of the close similarity with epithelial ovarian cancer. Diagnosis and treatment of these patients are still under debate.

Effects of inulin supplementation on selected faecal characteristics and health of neonatal Saanen kids sucking milk from their dams.

Fifty newborn Saanen kids were used to study the effects of inulin supplementation on faecal score, faecal pH, selected faecal bacterial population, BW, body temperature, haematological traits, selected health parameters and the incidence of diarrhoea. Kids were sorted by parity of their dams and multiple birth (twin or triplet) and assigned to one of the two groups (control: CG, and experimental: EG) at birth. Each group consisted of 25 kids. The groups were similar with regard to sex and birth weight. All kids were fed colostrum for the first 3 days after birth, and then the kids in EG were adapted to inulin supplementation by an increased dosage from day 4 to 7. Each kid in EG was supplemented with 0.2 g, 0.3 g, 0.4 g, 0.5 g and 0.6 g inulin on day 4, 5, 6, 7 and from day 8 to 28, respectively, whereas the kids in CG did not receive inulin. Faecal score and faecal bacterial population were not affected by inulin supplementation (P > 0.05). There were differences in faecal pH on day 14 (P = 0.01) and 28 (P<0.05), whereas no difference in faecal pH on day 21 (P > 0.05) was detected between groups. No differences (P > 0.05) in BW and haematological traits were found between groups. Body temperature did not differ on day 14 and 21 (P > 0.05), whereas there was a difference in body temperature on day 28 (P = 0.01) between groups. The numbers of kids with pneumonia and kids treated for pneumonia and diarrhoea were similar for CG and EG. Kid losses during the study were the same for CG and EG. The incidence of diarrhoea was not affected by inulin supplementation (P > 0.05). Inulin supplemented to kids did not adversely affect faecal score. The effect of inulin on faecal pH was not consistent. The results of our study suggested that daily dose (0.6 g) of inulin might not be enough to observe effects of it. Our data will be useful to determine the dose and timing of inulin supplementation in future studies investigating the effects of inulin on the parameters associated with performance and health status in kids and other young ruminants.

Fattening performance and feed source preference of native Awassi lambs fed individually in a cafeteria feeding system.

This experiment was conducted to investigate the effect of cafeteria (CF) and conventional (CN) feeding systems on feed intake, feed preferences with respect to voluntary feed source intake, feed conversion rate (FCR) and fattening performance of native Awassi lambs. Sixteen, 3 month old male lambs were used and kept individually for 70 days. Lambs in CF (n = 8) were offered to consume the main ingredients of barley, soybean meal (SBM), sunflower seed meal (SFM) and alfalfa straw, separately, while lambs in CN (n = 8) were fed with a concentrate feed containing 11.34 MJ/kg ME, 17.53% crude protein with the mixture of the same feed sources and alfalfa straw. The initial and final live weights of lambs were similar among groups (P > 0.05). Daily voluntary intake of ash, fat and neutral detergent fiber (NDF) consumptions among groups were quite different during the experiment (P < 0.001). Neither biweekly nor total results of voluntary protein intake between groups were not found statistically significant (P > 0.05). From beginning to the end of the study, the proportional barley intake increased 34 to 43% but reduced for SBM intake from 37 to 23% for the lambs in CF. On the other hand, the SFM intake of lambs did not changed significantly during the experiment and ranged between 2-5%. Lambs in CF did not consume SFM to meet their protein requirement and had 12.5% better total FCR result than the lambs in CN (6.86 and 7.84, respectively) (P > 0.05). The difference of average DWG, total live weight gain, final live weight of lambs in groups were similar (P > 0.05). In conclusion, Awassi lambs in CF can select a diet matching their nutritional requirements from a group of feed sources in response to their growth period when compared to CN system and better FCR result might help to decrease the feed expenses for fattening of native Awassi lambs.

[The results of tendon transfer in irreparable radial nerve palsy]. / Onarilmasi mümkün olmayan radial sinir felcinde tendon transferi sonuçlari.

OBJECTIVES: The purpose of this study was to evaluate the results of tendon transfers in patients with irreparable radial nerve palsy. METHODS: The study included 29 patients (5 females, 24 males; mean age 29 years; range 9 to 51 years) who underwent tendon transfers for radial nerve palsy. Four patients had low- and 25 patients had high-level radial nerve palsy. The mean duration of tendon transfer after injury (paralysis time) was 19.7 months (range 1 day to 180 months). Clinical evaluations included joint range of motion and muscle strengths. Functional evaluation was made using the Tajima criteria. The mean follow-up was 56.9 months (range 5 to 90 months). RESULTS: Muscle strengths were measured as follows: 3 (n=3), 4 (n=10), and 5 (n=12) for the wrist extensor muscle; 3 (n=7), 4 (n=10), and 5 (n=12) for the finger extensor muscle; and 3 (n=6), 4 (n=13), and 5 (n=10) for the thumb extensor muscle. The mean wrist range of motion was 67.4 degrees , extension was 48.3 degrees (10 degrees to 70 degrees ), and flexion was 21.5 degrees (10 degrees to 55 degrees ). The mean metacarpophalangeal joint extension was 1.7 degrees (0 degrees to 12 degrees ), thumb abduction was 45.6 degrees (34 degrees to 56 degrees ), and thumb interphalangeal joint extension was 18 degrees (0 degrees to 30 degrees ). According to the Tajima criteria, the results were excellent in 15 patients (51.7%), good in nine patients (31%), and moderate in five patients (17.2%). Eight patients (27.6%) had radial deviation deformity and four patients (13.8%) had 1-level weaker finger extensor muscle strength compared to the other fingers. The flexor carpi ulnaris (FCU) was used in the transfer of patients who developed radial deviation deformity. CONCLUSION: Treatment of irreparable radial nerve palsy with tendon transfers yields successful results. Radial deviation deformity mostly occurs in patients receiving FCU transfer for finger extension.

[Evaluation of complications of femoral neck fractures in children operated on at least 24 hours after initial trauma]. / Femur boynu kirigi nedeniyle ilk 24 saatten sonra ameliyat edilen çocuklarda gelisen komplikasyonlarin degerlendirilmesi.

OBJECTIVES: We evaluated complications and the factors affecting the development of avascular necrosis of the femoral head in children who underwent surgery for femoral neck fractures after at least a 24-hour delay. METHODS: We reviewed the results of 22 children (11 boys, 11 girls; mean age 10 years; range 4 to 14 years) who were operated on after the first 24 hours for femoral neck fractures. According to the Delbet classification, two patients had type I, eleven patients had type II, and nine patients had type III fractures. Associated injuries were detected in seven patients. The mean duration from trauma to surgery was seven days (range 1 to 15 days). Internal fixation was performed following closed (n=20) or open (n=2) reduction. The results were assessed using the Ratliff criteria at the end of a mean follow-up of 73 months (range 18 to 184 months). The patients were evaluated with respect to age, type of fracture, displacement, complications, and avascular necrosis. RESULTS: The results were good in 12 (54.6%), fair in eight (36.4%), and poor in two patients (9.1%). Complications developed in 17 patients (77.3%), 12 of whom had more than one. The most frequent complication was premature physeal closure (n=14; 63.6%) followed by avascular necrosis (n=12; 54.6%). No significant differences were found (i) with regard to age and the type of fracture between patients with and without avascular necrosis, and (ii) with regard to avascular necrosis between patients who were treated within the first and second week of trauma (p>0.05). CONCLUSION: The results of surgery performed after the first 24 hours are mainly influenced by the occurrence of avascular necrosis and, secondarily, by the type of fracture.

Bilateral anterior shoulder dislocation in a weight lifter.

A young man experienced bilateral anterior dislocation of the shoulders while doing seated behind-the-neck military presses. When improperly performed, military presses can cause injury because the shoulder muscles may be unable to support the weight being lifted. To improve form, avoid injury, and maximize gain from workouts, beginning weight lifters and those with shoulder instability should be counseled to use safer alternative techniques such as frontal military presses that do not allow movement posterior to the plane of the body.