Travma 2018 / 2 by KAREPUBLISHING

ISSN 1306 - 696X

TURKISH JOURNAL of TRAUMA & EMERGENCY SURGERY Ulusal Travma ve Acil Cerrahi Dergisi

Volume 24 | Number 2 | March 2018

www.tjtes.org

TURKISH JOURNAL of TRAUMA & EMERGENCY SURGERY Ulusal Travma ve Acil Cerrahi Dergisi Editor-in-Chief Recep Güloğlu Editors Kaya Sarıbeyoğlu (Managing Editor) M. Mahir Özmen Hakan Yanar Former Editors Ömer Türel, Cemalettin Ertekin, Korhan Taviloğlu Section Editors Anaesthesiology & ICU Güniz Meyancı Köksal, Mert Şentürk Cardiac Surgery Münacettin Ceviz, Murat Güvener Neurosurgery Ahmet Deniz Belen, Mehmet Yaşar Kaynar Ophtalmology Cem Mocan, Halil Ateş Ortopedics and Traumatology Mahmut Nedim Doral, Mehmet Can Ünlü Plastic and Reconstructive Surgery Ufuk Emekli, Figen Özgür Pediatric Surgery Aydın Yagmurlu, Ebru Yeşildağ Thoracic Surgery Alper Toker, Akif Turna Urology Ali Atan, Öner Şanlı Vascular Surgery Cüneyt Köksoy, Mehmet Kurtoğlu

www.tjtes.org

THE TURKISH ASSOCIATION OF TRAUMA AND EMERGENCY SURGERY ULUSAL TRAVMA VE ACİL CERRAHİ DERNEĞİ President (Başkan) Vice President (2. Başkan) Secretary General (Genel Sekreter) Treasurer (Sayman) Members (Yönetim Kurulu Üyeleri)

Kaya Sarıbeyoğlu M. Mahir Özmen Hakan Yanar Ali Fuat Kaan Gök Osman Şimşek Orhan Alimoğlu Mehmet Eryılmaz

CORRESPONDENCE İLETİŞİM Ulusal Travma ve Acil Cerrahi Derneği Şehremini Mah., Köprülü Mehmet Paşa Sok. Dadaşoğlu Apt., No: 25/1, 34104 Şehremini, İstanbul, Turkey

Tel: +90 212 - 588 62 46 Fax (Faks): +90 212 - 586 18 04 e-mail (e-posta): travma@travma.org.tr Web: www.travma.org.tr

ISSUED BY THE TURKISH ASSOCIATION OF TRAUMA AND EMERGENCY SURGERY ULUSAL TRAVMA VE ACİL CERRAHİ DERNEĞİ YAYIN ORGANI Owner (Ulusal Travma ve Acil Cerrahi Derneği adına Sahibi) Editorial Director (Yazı İşleri Müdürü) Managing Editor (Yayın Koordinatörü) Publication Secretary (Yayın Sekreteri) Emblem (Amblem) Correspondence address (Yazışma adresi) Tel Fax (Faks)

Kaya Sarıbeyoğlu Kaya Sarıbeyoğlu M. Mahir Özmen Kerem Ayar Metin Ertem Ulusal Travma ve Acil Cerrahi Dergisi Sekreterliği Şehremini Mah., Köprülü Mehmet Paşa Sok., Dadaşoğlu Apt., No: 25/1, 34104 Şehremini, İstanbul +90 212 - 531 12 46 - 588 62 46 +90 212 - 586 18 04

p-ISSN 1306-696x • e-ISSN 1307-7945 • Included in Index Medicus, Medline; EMBASE, Excerpta Medica; Science Citation Index-Expanded (SCI-E), Index Copernicus, DOAJ, EBSCO, and Turkish Medical Index (Index Medicus, Medline; EMBASE, Excerpta Medica; Science Citation Index-Expanded (SCI-E), Index Copernicus, DOAJ, EBSCO ve TÜBİTAK ULAKBİM Türk Tıp Dizini’nde yer almaktadır.) Publisher (Yayımcı): KARE Yayıncılık (KARE Publishing) • www.kareyayincilik.com • Design (Tasarım): Ali Cangül • Graphics (Grafikler): Edibe Çomaktekin • Linguistic Editor (İngilizce Editörü): Suzan Atwood • Redaction (Redaksiyon): Erman Aytaç • Online Manuscript & Web Management (Online Dergi & Web): LookUs • Press (Baskı): Yıldırım Matbaacılık • Press date (Basım tarihi): March (Mart) 2018 • This publication is printed on paper that meets the international standard ISO 9706: 1994 (Bu dergide kullanılan kağıt ISO 9706: 1994 standardına uygundur.)

KARE P U B L I S H I N G

www.tjtes.org

INFORMATION FOR THE AUTHORS The Turkish Journal of Trauma and Emergency Surgery (TJTES) is an official publication of the Turkish Association of Trauma and Emergency Surgery. It is a peer-reviewed periodical that considers for publication clinical and experimental studies, case reports, technical contributions, and letters to the editor. Six issues are published annually.

tion, called “Upload Your Files”.

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 / Science Edition, and as from 2014 in EBSCOhost. Our impact factor in SCI-E indexed journals is 0.473 (JCR 2016). It is cited as ‘Ulus Travma Acil Cerrahi Derg’ in PubMed.

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 photomicrographs 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 prepared. 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.

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 Association 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 language 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 must be submitted 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 addition 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, rejected manuscripts will not be returned to the authors, including accompanying materials. TJTES is indexed in Science Citation Index-Expanded (SCI-E), Index Medicus, Medline, EMBASE, Excerpta Medica, and the Turkish Medical Index of TUBITAK-ULAKBIM. Priority of publications is given to original studies; therefore, selection criteria are more refined for reviews and case reports. Open Access Policy: Full text access is free. There is no charge for publication or downloading the full text of printed material. 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 further information you may visit the web site (http://www.travma.org/en/ journal/). Manuscript preparation: Manuscripts should have double-line spacing, 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 institutions and correspondence address, abstract in Turkish (for Turkish authors only), and title and abstract in English are uploaded to the Journal Agent system in the relevant steps. The main text includes Introduction, 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 submitted 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-

Abstract: The abstract should be structured and serve as an informative 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.

References: All references should be numbered in the order of mention in the text. All reference figures in the text should be given in brackets without changing the font size. References should only include articles that have been published or accepted for publication. Reference format should conform to the “Uniform requirements for manuscripts submitted to biomedical journals” (http://www.icmje.org) and its updated versions (February 2006). Journal titles should be abbreviated 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: McGraw-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 articles 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 issue of the journal. The presented case(s) should be educative and of interest to the readers, and should reflect an exclusive rarity. Case reports should contain the title, summary, and the case, discussion, and references sections. These reports may consist of maximum five authors. Letters to the Editor: “Letters to the Editor” are only published electronically 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 exceed 500 words. The letter must clearly list the title, authors, publication date, issue number, and inclusive page numbers of the publication for which opinions are released. Informed consent - Ethics: Manuscripts reporting the results of experimental 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.

YAZARLARA BİLGİ Ulusal Travma ve Acil Cerrahi Dergisi, Ulusal Travma ve Acil Cerrahi Derneği’nin yayın organıdır. Travma ve acil cerrahi hastalıklar konularında 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 TÜBİTAK TR Dizinde taranmaktadır, ayrıca uluslararası indekslerde, 2001 yılından itibaren Index Medicus, PubMed’de, 2005 yılından itibaren EMBASE’de, 2007 yılından itibaren Web of Science, Science Citation Index-Expanded’de (SCI-E), 2014 yılından itibaren de EBSCOhost indeksinde dizinlenmektedir. 2016 Journal Citation Report IF puanımız 0.473 olmuştur. Dergide araştırma yazılarına öncelik verilmekte, bu nedenle derleme veya olgu sunumu türündeki 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 dışında), başka bir yerde yayınlanmasının düşünülmediği ve Ulusal Travma ve Acil Cerrahi Dergisi’nde yayınlanmasının tüm yazarlar tarafından uygun bulunduğu anlamına gelmektedir. Yazar(lar), çalışmanın yayınlanmasının kabulünden başlayarak, yazıya ait her hakkı Ulusal Travma ve Acil Cerrahi Derneği’ne devretmektedir(ler). Yazar(lar), izin almaksızın 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 İngilizce yazılmış makaleler yayınlanır. Tüm yazılar önce editör tarafından ön değerlendirmeye alınır; daha sonra incelenmesi için danışma kurulu üyelerine gönderilir. Tüm yazılarda editöryel değerlendirme ve düzeltmeye başvurulur; gerektiğinde, yazarlardan bazı soruları yanıtlanması ve eksikleri tamamlanması istenebilir. Dergide yayınlanmasına karar verilen yazılar “manuscript editing” sürecine alınır; bu aşamada tüm bilgilerin doğruluğu için ayrıntılı kontrol ve denetimden geçirilir; yayın öncesi şekline getirilerek yazarların kontrolüne ve onayına sunulur. Editörün, kabul edilmeyen yazıların bütününü ya da bir bölümünü (tablo, resim, vs.) iade etme zorunluluğu yoktur. Açık Erişim İlkesi: Tam metinlere erişim ücretsizdir. Yayınlanan basılı materyali tam metni indirmek için herhangi bir ücret alınmaz. Yazıların hazırlanması: Tüm yazılı metinler 12 punto büyüklükte “Times New Roman” yazı karakterinde iki satır aralıklı olarak yazılmalıdır. Sayfada her iki tarafta uygun miktarda boşluk bırakılmalı ve ana metindeki sayfalar numaralandırılmalıdır. Journal Agent sisteminde, başvuru mektubu, başlık, yazarlar ve kurumları, iletişim adresi, Türkçe özet ve yazının İngilizce başlığı ve özeti ilgili aşamalarda yüklenecektir. İngilizce yazılan çalışmalara da Türkçe özet eklenmesi gerekmektedir. Yazının ana metnindeyse şu sıra kullanılacaktır: Giriş, Gereç ve Yöntem, Bulgular, Tartışma, Teşekkür, Kaynaklar, Tablolar ve Şekiller. Başvuru mektubu: Bu mektupta yazının tüm yazarlar tarafından okunduğu, 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” bölümünde, 10. aşamada yer alan dosya yükleme aşamasında yollanmalıdır. Başlık sayfası: Yazının başlığı, yazarların adı, soyadı ve ünvanları, çalışmanın yapıldığı kurumun adı ve şehri, eğer varsa çalışmayı destekleyen fon ve kuruluşların açık adları bu sayfada yer almalıdır. Bu sayfaya ayrıca “yazışmadan sorumlu” yazarın isim, açık adres, telefon, faks, mobil 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 Sözcükler başlıklarını; İngilizce özet Background, Methods, Results, Conclusion ve Key words başlıklarını içermelidir. İngilizce olarak hazırlanan çalışmalarda da Türkçe özet yer almalıdır. Özetler başlıklar hariç 190210 sözcük olmalıdır. Tablo, şekil, grafik ve resimler: Şekillere ait numara ve açıklayıcı bilgiler ana metinde ilgili bölüme yazılmalıdır. Mikroskobik şekillerde resmi açıklayıcı bilgilere ek olarak, büyütme oranı ve kullanılan boyama tekniği de belirtilmelidir. Yazarlara ait olmayan, başka kaynaklarca daha önce yayınlanmış tüm resim, şekil ve tablolar için yayın hakkına sahip kişilerden izin alınmalı ve izin belgesi dergi editörlüğüne ayrıca açıklamasıyla

birlikte gönderilmelidir. Hastaların görüntülendiği fotoğraflara, hastanın ve/veya velisinin imzaladığı bir izin belgesi eşlik etmeli veya fotoğrafta 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. Makale içinde geçen kaynak numaraları köşeli parantezle ve küçültülmeden belirtilmelidir. Kaynak listesinde yalnızca yayınlanmış ya da yayınlanması 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 yazar durumunda altıncı yazarın arkasından “et al.” ya da “ve ark.” eklenmelidir. 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 duodenal 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.travma.org.tr adresli web sayfamızda eski yayınlara tam metin olarak ulaşabileceğiniz bir arama motoru vardır. Derleme yazıları: Bu tür makaleler editörler kurulu tarafından gerek olduğunda, konu hakkında birikimi olan ve bu birikimi literatüre de yansımış kişilerden talep edilecek ve dergi yazım kurallarına uygunluğu saptandıktan sonra değerlendirmeye alınacaktır. Derleme makaleleri; başlık, Türkçe özet, İngilizce başlık ve özet, alt başlıklarla bölümlendirilmiş metin ile kaynakları içermelidir. Tablo, şekil, grafik veya resim varsa yukarıda belirtildiği şekilde gönderilmelidir. Olgu sunumları: Derginin her sayısında sınırlı sayıda olgu sunumuna yer verilmektedir. Olgu bildirilerinin kabulünde, az görülürlük, eğitici olma, ilginç olma önemli ölçüt değerlerdir. Ayrıca bu tür yazıların olabildiğince kısa hazırlanması gerekir. Olgu sunumları başlık, Türkçe özet, İngilizce başlık ve özet, olgu sunumu, tartışma ve kaynaklar bölümlerinden 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 mektuplar 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 olarak 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 bildiren yazılarda, çalışmanın yapıldığı gönüllü ya da hastalara uygulanacak prosedür(lerin) özelliği tümüyle anlatıldıktan sonra, onaylarının alındığını gösterir bir cümle bulunmalıdır. Yazarlar, bu tür bir çalışma söz konusu olduğunda, uluslararası alanda kabul edilen kılavuzlara ve T.C. Sağlık Bakanlığı tarafından getirilen yönetmelik ve yazılarda belirtilen hükümlere uyulduğunu belirtmeli ve kurumdan aldıkları Etik Komitesi onayını göndermelidir. Hayvanlar üzerinde yapılan çalışmalarda ağrı, acı ve rahatsızlık verilmemesi için neler yapıldığı açık bir şekilde belirtilmelidir. Yazı gönderme - Yazıların gönderilmesi: Ulusal Travma ve Acil Cerrahi 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 “Online Makale Gönderme” ikonuna tıklandığında ulaşılan Journal Agent sisteminden yollanmaktadır. Sistem her aşamada kullanıcıyı bilgilendiren özelliktedir.

TURKISH JOURNAL OF TRAUMA & EMERGENCY SURGERY ULUSAL TRAVMA VE ACİL CERRAHİ DERGİSİ Vol. - Cilt 24

Number - Sayı 2 March - Mart 2018

Contents - İçindekiler Deneysel Çalışma - Experimental Experimental Studies - DeneyselStudy Çalışma 89-96 Oxytocin for preventing injury due to testicular torsion/detorsion in rats Sıçanlarda testiküler torsiyon/detorsiyon nedeniyle oluşan hasarın önlenmesinde oksitosin Fırat F, Erdemir F, Kölükçü E, Gevrek F, Benli İ, Ünsal V 97-103 The success of endotracheal intubation with a modified laryngoscope using night vision goggles Gece görüş gözlükleri kullanarak modifiye laringoskopla endotrakeal entübasyon başarısı Aydın A, Bilge S, Aydın C, Bilge M, Çevik E, Eryılmaz M

Original Articles - Orijinal Çalışma 104-109 Successful non-operative management of blunt abdominal trauma in highly selective cases: A safe and effective choice Yüksek derecede selektif olgularda künt abdominal travmanın başarılı cerrahidışı tedavisi: Güvenli ve etkili bir seçim Liagkos GT, Spyropoulos C, Tsourouflis G, Papadopoulos A, Ioannides P, Vagianos C 110-115 Can serum soluble urokinase plasminogen activator receptor be an effective marker in the diagnosis of appendicitis and differentiation of complicated cases? Çocuk hastalarda suPAR’ın (Serum soluble urokinase plasminogen activator receptor) akut panadisit tanısında yararı var mıdır? Akın M, Erginel B, Sever N, Özel K, Bayraktar B, Yıldız A, Karadağ ÇA, Tokel M, Dokucu Aİ 116-120 Features and treatment of gas-forming synergistic necrotizing cellulitis: a nine-year retrospective study Gaz oluşumuyla karakterize sinerjistik nekrotizan selülit özellikleri ve tedavisi: Dokuz yılı kapsayan geriye dönük çalışma Ling X, Ye Y, Guo H, Liu Z, Xia W, Lin C 121-128 Computed tomography use in minor head injury: attitudes and practices of emergency physicians, neurosurgeons, and radiologists in Turkey Minör kafa travmasında bilgisayarlı tomografi kullanımı: Türkiye’deki acil tıp hekimleri, beyin cerrahları ve radyologların tutum ve uygulamaları Özan E, Ataç GK 129-135 Media-based clinical research on selfie-related injuries and deaths Özçekim ilişkili yaralanma ve ölümlerin analizi Dokur M, Petekkaya E, Karadağ M 136-144 Acil servislerde travmatik dental yaralanmaların tedavisi konusunda bilginin önemi Importance of knowledge of the management of traumatic dental injuries in emergency departments Aren A, Erdem AP, Aren G, Şahin ZD, Güney Tolgay C, Çayırcı M, Sepet E, Güloğlu R, Yanar H, Sarıbeyoğlu K 145-148 Spiked railing penetration that causes injuries in the upper extremities of children Çocuklarda korkuluk demiri ile üst ekstremite penetran yaralanmaları Ayhan E, Çevik K, Bağır M, Çolak M, Eskandari MM

Ulus Travma Acil Cerrahi Derg, March 2018, Vol. 24, No. 2

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TURKISH JOURNAL OF TRAUMA & EMERGENCY SURGERY ULUSAL TRAVMA VE ACİL CERRAHİ DERGİSİ Vol. - Cilt 24

Number - Sayı 2 March - Mart 2018

Contents - İçindekiler

149-155 Mortality in Code Blue; can APACHE II and PRISM scores be used as markers for prognostication? Mavi Kod’da Mortalite; Apache II ve PRISM skorları, prognoz için belirteç olabilir mi? Bakan N, Karaören G, M.D., Tomruk ŞG, Keskin Kayalar S 156-161 Surgical treatment of displaced intraarticular calcaneus fractures using anatomical lateral frame plate Deplase eklem içi kalkaneus kırıklarının anatomik lateral çerçeve plak kullanılarak cerrahi tedavisi Esenkaya İ, Türkmensoy F, Kemah B, Poyanlı OŞ 162-167 Open reduction and internal fixation in AO type C distal humeral fractures using olecranon osteotomy: Functional and clinical results AO Tip C humerus distal kırıklarında olekranon osteotomisi ile açık redüksiyon ve internal tespit: Fonksiyonel ve klinik sonuçlar Asfuroğlu ZM, İnan U, Ömeroğlu H

Case Series - Olgu Serisi 168-174 Fixation of rotationally unstable extracapsular proximal femoral fractures Rotasyonel instabil ekstrakapsüler proksimal femur kırıkları Massoud EIE

Case Report - Olgu Sunumu 175-177 Traumatic evisceration after blunt trauma in a 20-month-old boy Yirmi aylık erkek çocukta künt travmadan sonra travmatik eviserasyon Komarowska MD, Matuszczak E, Debek W, Hermanowicz A 178-180 Intestinal nonrotation and left-sided perforated appendicitis İntestinal nonrotasyon ve sol alt kadranda perfore apandisit Zengin E, Turan A, Calapoğlu AS, Nalbant E, Altuntaş G 181-183 Acute arterial occlusion due to vascular closure device: A report of two cases Vasküler kapatma cihazına bağlı gelişen akut arter tıkanıklığı: İki olgu sunumu Çelik SU, Çetinkaya ÖA, Konca C, Koç MA, Kırımker EO, Kocaay AF, Alaçayır İ

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EXPERIMENTAL STUDY

Oxytocin for preventing injury due to testicular torsion/detorsion in rats Fatih Fırat, M.D.,1 Fikret Erdemir, M.D.,2 Engin Kölükçü, M.D.,1 Fikret Gevrek, M.D.,4 İsmail Benli, M.D.,3 Velid Ünsal, M.D.3 1

Department of Urology, Tokat State Hospital, Tokat-Turkey

Department of Urology, Gaziosmanpaşa University Faculty of Medicine, Tokat-Turkey

Department of Biochemistry, Gaziosmanpaşa University Faculty of Medicine, Tokat-Turkey

Department of Histology, Gaziosmanpaşa University Faculty of Medicine, Tokat-Turkey

ABSTRACT BACKGROUND: We aimed to demonstrate the effectiveness of oxytocin on the testes for treating ischemia-reperfusion injury. METHODS: A total of 24 male Wistar albino rats weighing 250–320 g were used. The rats were randomized into three groups of eight rats. Group 1 was assessed as the control group. In Group 2 rats, testicular torsion was first performed, followed by testicular detorsion to induce reperfusion injury. In Group 3, following testicular torsion and detorsion, oxytocin was administered before inducing reperfusion. Testicular tissues were histologically evaluated, spermatogenic parameters were assessed using the Johnsen scoring system, and the mean Johnsen score was calculated. RESULTS: Histological tests revealed significantly different results between the testicular torsion group and the oxytocin-treated torsion and control groups as well as between the oxytocin-treated torsion group and the control and testicular torsion groups (p=0.010 and 0.012, respectively). Biochemical test results revealed that superoxide dismutase and glutathione peroxidase levels were significantly lower in Group 2 than in Group 1 (p=0.007 and 0.007, respectively). Malondialdehyde and nitric oxide levels were significantly lower in Group 3 than in Group 2 (p=0.017 and 0.014, respectively). CONCLUSION: These results indicate that oxytocin can be considered as an alternative agent for treating testicular torsion in clinical practice to minimize tissue damage. Keywords: I/R injury; oxytocin; torsion.

INTRODUCTION Testicular torsion is known as the rotation of the spermatic cord around its axis; its incidence is especially high during childhood and adolescence, with approximately 1 in 4000 males affected by 25 years of age.[1,2] In testicular torsion, spermatogenesis is affected secondary to the impairment of testicular blood flow, which may subsequently cause infertility. The fundamental approach for treating testicular torsion, which is accepted as an emergency pathology, is manual or surgical detorsion of the testes.[3] However, depending on the duration of the torsion, permanent testicular damage can oc-

cur. Reactive oxygen species (ROS) can be released depending on this pathology, which comprises processes of ischemia caused by torsion and further reperfusion due to detorsion.[4] Under normal conditions, ROS, which assume certain physiological tasks, are generated in tissues and are eliminated by antioxidants. However, in cases of smoking, diabetes, cancer, trauma, intracranial pathologies, varicocele, infection, and testicular torsion, they can be produced in excessive amounts. [4–6] Accordingly, the high amounts of ROS released in stress-

Cite this article as: Fırat F, Erdemir F, Kölükçü E, Gevrek F, Benli İ, Ünsal V. Oxytocin for preventing injury due to testicular torsion/detorsion in rats. Ulus Travma Acil Cerrahi Derg 2018;24:89–96 Address for correspondence: Fatih Fırat, M.D. Tokat Devlet Hastanesi, Üroloji Kliniği, 60100 Tokat, Turkey Tel: +90 356 - 212 95 00 / 1039 E-mail: ffrat60@yahoo.com Ulus Travma Acil Cerrahi Derg 2018;24(2):89–96 DOI: 10.5505/tjtes.2017.25730 Submitted: 24.07.2017 Accepted: 26.09.2017 Online: 26.12.2017 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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Fırat et al. Oxytocin for preventing injury due to testicular torsion/detorsion in rats

ful conditions cannot be eliminated by antioxidants in the human body. Excessive amounts of ROS and those formed in cases wherein antioxidants remain incapable adversely affect many anatomical entities, including lipid membranes and protein-containing structures, consequently leading to potential disruption of cellular integrity and functional impairments. Sperms contain polyunsaturated fat and are therefore very much vulnerable to oxidative injury.[7] Antioxidants are used as a classical approach for eliminating oxidative damage. Although surgical management is the fundamental treatment approach in testicular torsion, many treatment modalities have been attempted to minimize destructive changes, which may occur secondary to oxidative injury, following the surgical management of testicular torsion. To date, many pharmaceutical agents have been used in cases of testicular torsion or oxidative injury; however, limited number of studies have been conducted on the testicular effects of oxytocin, the receptors of which have been identified in the urinary system.[8,9] Oxytocin is generally known as a female hormone involved in lactation and childbirth. However, in recent years, its presence in the male reproductive system has been revealed, and in various studies, its antioxidative, anti-inflammatory, and anti-apoptotic effects have been demonstrated.[10] This study aimed to evaluate the effects of oxytocin on testicular tissue and spermatogenesis in rats with induced testicular torsion.

MATERIALS AND METHODS A total of 24 male Wistar albino rats weighing 250–320 g were used. All procedures were performed in compliance with the provisions of 1986 Strasbourg Universal Declaration on Animal Welfare and were approved by the Ethics Committee (2015 HADYEK 25). Rats were housed in standard rat cages, with maximum three rats in each cage. Rats were provided with standard pellets prepared for rodents and tap water ad libitum.

were drawn for biochemical analysis. Group 3 rats underwent torsion and detorsion as described for Group 2 rats but were intraperitoneally injected with oxytocin (80 IU/kg) injected 30 min before detorsion. After the procedure, the rats were sacrificed with cervical dislocation under ketamine and xylazine anesthesia. Testicular tissue samples were obtained and placed in 4% buffered neutral formaldehyde solution for histopathological analysis. Serum levels of superoxide dismutase (SOD), glutathione peroxidase (GSH-Px), malondialdehyde (MDA), and nitric oxide (NO) were measured.

Biochemical Analysis Measurement of Plasma Thiobarbiturate Reactive Substances (TBARS) Levels Plasma TBARS levels were determined by a method[11] based on the reaction with thiobarbituric acid (TBA) at 90–100°C. In the TBA test reaction, MDA or MDA-like substances and TBA react with each other and produce a pink pigment with maximum absorbance at 532 nm. This reaction was performed at pH 2-3 and 90°C for 15 min. The sample was mixed with two volumes of cold 10% (w/v) trichloroacetic acid to precipitate protein. The precipitate was pelleted by centrifugation, and an aliquot of the supernatant was reacted with an equal volume of 0.67% (w/v) TBA in a boiling water bath for 10 min. After cooling, the absorbance was read at 532 nm. The results were expressed as micromole per liter plasma (mmol/l) according to a standard graph, which was prepared based on serial dilutions of standard 1,1,3,3-tetramethoxypropane.

The rats were randomized into three groups, each containing eight rats. Group 1 was assessed as the control group. In Group 2 rats, testicular torsion was first performed, followed by testicular detorsion to induce reperfusion injury. In Group 3, following testicular torsion and detorsion, oxytocin was administered before inducing reperfusion.

Measurement of Plasma NO Levels NO has a half-life of only a few seconds because it is readily oxidized to nitrite (NO2) and subsequently to nitrate (NO3), which serve as index parameters of NO production. The method used for measuring plasma nitrite and nitrate levels was based on the Griess reaction.[12] Samples were initially deproteinized with Somogyi reagent. Total nitrite (nitrite + nitrate) was measured by spectrophotometry at 545 nm after converting nitrate to nitrite using copperized cadmium granules. A standard curve was obtained using a set of serial dilutions (108–103 mol/l) of sodium nitrite. Linear regression analysis was performed using the peak area obtained using nitrite standards. The resulting equation was used to calculate the unknown sample concentrations. Results were expressed as micromole per liter plasma (mmol/l).

The rats were anesthetized using intraperitoneal injections of ketamine hydrochloride (50 mg/kg) and xylazine (0 mg/ kg). Subsequently, in Group 1, orchiectomy was performed; in Group 2, testes were removed under sterile conditions through the left inguinoscrotal incision, rotated 720° counterclockwise, and left testicle fixated to the scrotum using 5.0 prolene sutures for 3 h. At the end of 3 h, the testes were detorsioned, and after 3 h of reperfusion, left testes were extracted for histopathological analysis and blood samples

Determination of Plasma SOD Activity Total (Cu–Zn + Mn) SOD (EC 1.15.1.1) activity was determined according to the method of Sun et al.[13] The principle of the method is based on the inhibition of NBT reduction by the xanthine–xanthine oxidase system as a superoxide generator. The activity was assessed in the ethanol phase of the plasma sample after 1.0-ml ethanol/chloroform mixture (5/3, v/v) was added to the same volume of plasma and centrifuged. One unit of SOD was defined as the amount of enzyme caus-

Experimental Method

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Fırat et al. Oxytocin for preventing injury due to testicular torsion/detorsion in rats

ing 50% inhibition in the NBT reduction rate. SOD activity was also expressed as units per liter plasma (U/l). Determination of Plasma GSH-Px Activity Plasma GSH-Px (EC 1.6.4.2) activity was measured using the method of Paglia et al.[14] The enzymatic reaction in the tube, which contained NADPH, reduced glutathione, sodium azide, and glutathione reductase, was initiated by the addition of H2O2, and the change in absorbance at 340 nm was monitored using a spectrophotometer. The activity was expressed in units per milliliter plasma (U/ml).

Histopathological Analysis Following the experiment, the testes were removed from the deeply anesthetized rats and were kept in suitable amounts of buffered 4% neutral formaldehyde solution for 36 h for fixation. Subsequently, following successive steps of routine tissue processing and follow-up protocol, which comprised rinsing, dehydration, permeabilization, and impregnation, the samples were embedded in paraffin blocks. Tissue samples embedded in paraffin blocks were cut into 4–5-µm-thick sections using a rotary microtome (LEICA RM2125RT, China), which were then placed on glass slides. The cut sections were kept overnight in an incubator at 58°C–60°C for deparaffinization. Subsequently, the sections were stained with hematoxylin– eosin and covered with a coverslip. These testicular preparations were histopathologically analyzed under a light microscope (Nikon Eclipse, Japan). Histopathological analyses were realized as a double-blind study, and the slides were randomly numbered. From each group containing eight rats, eight sections from each rat and an average of 25 seminiferous tubuli from each section were evaluated. Testicular tissues were evaluated with respect to histological and spermatogenic parameters using the Johnsen scoring system, and the mean Johnsen score was calculated. The Johnsen scoring system evaluates a total of 10 histological criteria as follows:[15] Johnsen scoring criteria: Score 10: Multilayered germinal epithelium, multiple spermatozoa

Score 09: Disorganized germinal epithelium piling up toward the lumen, spermatozoa are present Score 08: Multilayered germinal epithelium, less than 10 spermatozoa in the lumen Score 07: Spermatozoa are absent, multiple spermatids Score 06: Spermatozoa are absent, less than 10 spermatids Score 05: Spermatozoa and spermatids are absent, spermatocytes are seen Score 04: Spermatozoa and spermatids are absent, less than five spermatocytes Score 03: Only spermatogonia are present as germ cells Score 02: Germ cells are absent, only Sertoli cells are seen Score 01: Seminiferous tubuli do not contain any cell

Statistical Analyses The statistical comparison of the mean Johnsen scores of the groups was performed using IBM SPSS 20 Windows Statistical Package for Social Sciences. The intergroup comparisons of mean Johnsen scores were performed using oneway ANOVA, followed by Tukey’s HSD multiple comparison test.

RESULTS Biochemical Test Results SOD and GSH-Px levels were significantly lower in the testicular torsion group than in the control group (p=0.007 and 0.007, respectively). MDA and NO levels were increased in testicular torsion group compared to control group, but this increases were not statistically significant (p>0.05). In the testicular torsion group treated with oxytocin, MDA and NO levels decreased statistically significantly compared with those in the testicular torsion group (p=0.017 and 0.014, respectively), whereas increases in SOD and GSH-Px levels were not significantly different between these groups (p>0.05) (Table 1).

Histological Findings Light microscopy analyses revealed that the histological

Table 1. Biocehemical results of the groups

Control

Groups p Testicular torsion

Oxytocin-treated torsion

Mean±SD Mean±SD

Superoxide dismutase (U/mL)

5.82±0.73

4.07±0.94a

4.71±1.5 0.009

Malondialdehyde (µmol/L)

0.58±0.19

0.72±0.13

0.5±0.14b 0.021

Nitric oxide (mmol/L)

66.09±8.86

72±3.56

63.58±3.26c 0.016

Glutathione peroxidase (U/L)

460.58±89.73

Mean±SD

310.39±100.42d 372.21±93.43 0.009

a A significant difference was found when compared with the control group (p=0.007). bA significant difference was found when compared with the testicular torsion group (p=0.017). cA significant difference was found when compared with the testicular torsion group (p=0.014). dA significant difference was found when compared with the control group (p=0.007). SD: Standard deviation.

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Oxytocin for preventing injury due to testicular torsion/detorsion in rats

appearance of the testicular tissues of control group rats generally resembled that of the testicular tissues of normal rats. Testicular microscopy of the control group rats completely demonstrated normal seminiferous tubuli (Fig. 1), germ cells, Sertoli cells, and Leydig cells without any signs of infiltration or bleeding. In the testicular torsion group, disorganization of the germinal epithelial cells of seminiferous tubuli, empty tubuli, dilatations in the interstitial tissue, patchy areas of severe edema, diffuse blood cells at the basement membrane, vascular dilatations, and vascular con-

Figure 1. In the control group, seminiferous tubuli and intertubular connective tissue preserved their normal integrity. Sertoli cells and cells of all spermatogenic stages are present in a specific array in the seminiferous epithelium. Numerous spermatozoa are observed in the tubular lumen, and the testicular tissue retained its normal histological structure (H&E staining, Bar: 50 Âľm).

Figure 2. Integrity of seminiferous tubuli and intertubular connective tissue was disrupted. Vascular dilatation in the interstitial connective tissue and severe tissue loss; deformities and detachment of seminiferous tubuli; and disorganization and desquamations in the seminiferous tubuli epithelium are observed in Group 2. In general, very small amount (even absence) of spermatozoa, consistent with impaired spermatogenic cells, in the tubular lumens, which somewhat preserved their integrity, is observed. Overall, severe tissue damage is present in testicular tissues (H&E staining, Bar: 50 Âľm).

gestion were found. Coagulation necrosis in spermatogenic cells lining the tubular lumen and empty tubuli or tubuli containing very scarce number of germinal cells were observed (Fig. 2). Patchy areas of dehiscence were observed between germinal epithelial cells of seminiferous tubuli and basal lamina surrounding the tubuli. Histopathological findings observed in the oxytocin-treated torsion group were found in a mild form in certain areas of the testicular tissue in the testicular torsion group. In addition, slightly deformed seminiferous tubules containing all stages of the spermatogenic series were remarkable. However, patchy areas of detachment were observed between the basal lamina surrounding tubuli and the germinal epithelium of some seminiferous tubuli. Slightly edematous areas of intertubular interstitial tissue and some mildly congested vessels were observed. In general, intertubular loose connective tissues had preserved their histological architecture, and Leydig cells had retained their normal appearance (Fig. 3). Consistent with these histopathological findings, Johnsen scores, which indicate epithelial deformity of seminiferous tubuli, and spermatogenesis were found to be significantly lower in the testicular torsion group than in the other groups (p<0.05) (Table 2). Johnsen scores in the oxytocin-treated torsion group were in between those of the control and testicular torsion groups and significantly different from both (p<0.05). In other words, the three groups were significantly different from each other, and milder destructive changes were detected in the oxytocin-treated torsion group than in the testicular torsion group.

Figure 3. Histologically, Oxytocin-treated torsion group resembles the testicular structure in the control group rather than in the testicular torsion group wherein a slight but incomplete improvement is observed. The integrity of seminiferous tubuli and interstitial tissue is generally preserved. However, vascular dilatation, moderately severe congestion, and bleeding foci are observed in the interstitial tissue. Although epithelial deformities of some seminiferous tubuli are observed, spermatogenic cells and Sertoli cells demonstrate a tendency to preserve their unique epithelioid sequence. Less number of spermatozoa are observed in the tubular lumen (H&E staining, Bar: 50 Âľm).

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Fırat et al. Oxytocin for preventing injury due to testicular torsion/detorsion in rats

male urinary system, i.e., in the testis and epididymis, has been reported. In addition to ejaculation and penile erection, two Control Testicular Oxytocin-treated primary functions have been ascribed to testicular oxytocin, torsion torsion namely the regulation of seminiferous tubule contractility and the modulation of steroidogenesis. In the testis, seminiferous Mean±SD Mean±SD Mean±SD tubules are surrounded by smooth muscle-like myoid cells. Their function is necessary for sperm transport and maturaJohnsen Scores 9.39±0.13 8.55±0.28 8.96±0.44 tion.[29] Overall, the regulation by gonadal and adrenal steroids SD: Standard deviation. is one of the most remarkable features of the oxytocinergic system.[30] In this context, the effects of oxytocin on the penis, 10.00 testes, and kidney have been evaluated in several studies. a Table 2. Mean Johnsen scores of the groups

9.00

Mean JOHNSEN

8.00 7.00 6.00 5.00

9.39

4.00

8.97

8.55

3.00 2.00 1.00 0.00

Control

Oxytocin Error Bars: ±2. SE

Torsion

Graphic: Comparison of mean Johnsen scores of the groups. (Each letter on the bar signifies statistically significant difference; when compared with c b:p=0.012, a:p=0.000)

DISCUSSION Oxytocin was first introduced as a peptide hormone in 1953. [16] It is produced in magnocellular neurons and is stored in posterior hypophysis.[17] The expression of oxytocin receptors has been shown not only in the uterine myometrium and mammary glands but also in the endometrium, decidua, ovary, thymus, pancreas, adipocytes, heart kidney, and brain. [18,19] Oxytocin plays a role in successful milk ejection, cardiovascular regulation, analgesic effects,[20] motor activity,[21] thermoregulation,[22] gastric motility,[23] natriuresis, osmoregulation,[24] and sexual behavior. It is well documented that levels of circulating oxytocin increase during sexual stimulation and arousal and peak during orgasm in both men and women.[25] In rats, oxytocin exerts potent anti-stress effects, such as decrease in blood pressure and corticosterone/cortisone levels and increase in insulin and colecystokinin levels. In addition, stress-induced central release of oxytocin can ameliorate stress-associated symptoms, such as anxiety.[26] Synthesis of oxytocin in the male reproductive system was first revealed by Nicholson et al in 1984.[27] Oxytocin is present at higher concentrations in the prostate than in the plasma and can increase the resting tone of prostatic tissue. Oxytocin is involved in prostate contraction and in the resulting expulsion of prostatic secretions at ejaculation.[28] Oxytocin is a potent stimulator of spontaneous erections in rats.[19] Recently, its presence as an endocrine and a paracrine hormone in the Ulus Travma Acil Cerrahi Derg, March 2018, Vol. 24, No. 2

Testicular torsion, which is a typical ischemia-reperfusion (I/R) injury, may cause male infertility. Therefore, early diagnosis and treatment of testicular torsion are quite important for preserving testes and fertility capacity. Surgical detorsion is the gold standard treatment approach for testicular torsion and provides reperfusion of testicular tissues. As reported above, the main pathophysiology of testicular torsion–detorsion is I/R injury of the testes, which causes overproduction of ROS.[31] It has been clearly revealed that reperfusion of the ischemic tissue is associated with oxidative stress.[32] Therefore, treatment by detorsion may further damage the testes. ROS are short-lived reactive molecules having one or more unpaired electrons, rendering them highly unstable and highly reactive.[33] In normal conditions, ROS expression plays physiological roles in cellular differentiation, sperm capacitation, acrosome reaction, and maintenance of fertilizing ability, whereas oxygen free radicals at concentrations beyond physiological limits result in oxidative stress.[34,35] ROS overexpression secondary to oxidative stress can negatively affect proteins, lipids, nucleic acids, carbohydrates, and other molecules and leads to cell membrane lipid peroxidation, protein denaturation, DNA damage, inflammation, cell proliferation, cell dysfunction, and apoptosis.[36] Thus, ROS may play a role in the pathogenesis of several diseases, such as atherosclerosis,[37] cancer,[38] diabetes mellitus,[39] infection,[40] central nervous system disorders,[41] and testicular torsion due to its involvement in lipid peroxidation.[38] In addition, negative effects of oxidative stress on the testes after the initiation of reperfusion have been reported in the testicular torsion induced rat model.[39] Indeed, it has been reported that activities of antioxidant enzymes are diminished and ROS production is increased in the testicular torsion induced rat model. The present study also showed that testicular I/R caused testicular damage, as evidenced by biochemical and histological changes. The levels (expression) of MDA as a marker of lipid peroxidation and NO were found to be high in Group 2. Levels of antioxidant enzymes, such as SOD and GSH-Px, decreased, whereas those of MDA and NO, which are indicators of oxidative stress, increased in the testicular torsion group (Group 2) compared with those in the control group. This indicated complete realization of the I/R injury. Antioxidants break the oxidative chain reaction, thereby reducing the effects of oxidative stress.[42] Positive effects of 93

Fırat et al. Oxytocin for preventing injury due to testicular torsion/detorsion in rats

antioxidants on oxidative stress parameters and different tissues in oxidative stress conditions, such as atherosclerosis, hypertension,[43] type 2 diabetes mellitus,[44] ulcerative colitis,[45] and testicular torsion, have been shown. In this context, for preventing harmful effects of oxidative stress, many antioxidant agents, such as vitamin E, melatonin, retinol, β-carotene, omega-3, resveratrol, allopurinol, melatonin, Nacetylcysteine, zinc aspartate, and caffeic acid phenethyl ester, vitamin C, coenzyme Q10, and acetylcysteine have been used with different success rates.[46–50] Although numerous experimental animal studies have confirmed the efficacy of antioxidants in reducing short-term damaging effects of testicular torsion, different antioxidant agents have been investigated to reduce the short- and long-term reperfusion damage on the testes. Anti-apoptotic, anti-inflammatory, and antioxidant properties of oxytocin have been reported. The effects of oxytocin on I/R have been reported in limited number of studies.[51,52] Oxytocin reduces I/R injury in rat kidney, with improved renal function, as indicated by decreased serum creatinine and BUN levels in addition to improved antioxidant status and reduced ROS.[53] Moreover, the protective effect of oxytocin on I/R injury in the liver, kidney, stomach, and urinary bladder have been reported. [54–58] In addition, the anti-apoptotic effect of oxytocin in the heart and ovaries has been revealed.[51,59] However, to our knowledge, the effect of oxytocin on testicular tissues in I/R injured rat model has been reported in only one study. In an experimental study, Ghasemnezhad et al. demonstrated that Johnsen scores were higher in the oxytocin-treated torsion group than in the testicular torsion group.[10] Similarly, in our study, Johnsen scores were significantly different between the oxytocin-treated torsion group and the testicular torsion group. In the oxytocin-treated torsion group (Group 3), levels of antioxidant enzymes, such as SOD and GSH-Px, increased and approached the levels in the control group. Similarly, levels of MDA and NO in this group decreased below those in the control group. These outcomes revealed that oxytocin increases antioxidant capacity and relieves the effects of oxidative stress. In conclusion, although this is an experimental study, the results indicate that oxytocin can be considered as an alternative agent for treating testicular torsion in clinical practice to minimize tissue damage. However, additional experimental and clinical studies are necessary to confirm our findings.

Ethics Committee Approval Ethics committee approval was received for this study from the ethics committee of Gaziosmanpaşa University School of Medicine.

Peer-review Externally peer-reviewed. 94

Financial Disclosure The authors declare that this study has received no financial support. Conflict of interest: None declared.

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Pereira-Sampaio MA. Effect of antioxidants on outcome of testicular torsion in rats of different ages. J Urol 2014;191:1578–84. 43. Siti HN, Kamisah Y, Kamsiah J. The role of oxidative stress, antioxidants and vascular inflammation in cardiovascular disease (a review). Vascul Pharmacol 2015;71:40–56. 44. Jamalan M, Rezazadeh M, Zeinali M, Ghaffari MA. Effect of ascorbic acid and alpha-tocopherol supplementations on serum leptin, tumor necrosis factor alpha, and serum amyloid A levels in individuals with type 2 diabetes mellitus. Avicenna J Phytomed 2015;5:531–9. 45. Jena G, Trivedi PP. A review of the use of melatonin in ulcerative colitis: experimental evidence and new approaches. Inflamm Bowel Dis 2014;20:553–63. 46. Payabvash S, Salmasi AH, Kiumehr S, Tavangar SM, Nourbakhsh B, Faghihi SH, et al. Salutary effects of N-acetylcysteine on apoptotic damage in a rat model of testicular torsion. Urol Int 2007;79:248–54. 47. Suwalsky M, F Villena, Gallardo MJ. In vitro protective effects of resveratrol against oxidative damage in human erythrocytes. Biochim Biophys Acta 2015;1848:76–82. 48. Espino J, Bejarano I, Ortiz A, Lozano GM, García JF, Pariente JA, et al. Melatonin as a potential tool against oxidative damage and apoptosis in ejaculated human spermatozoa. Fertil Steril 2010;94:1915–7. 49. Judge AR, Selsby JT, Dodd SL. Antioxidants attenuate oxidative damage in rat skeletal muscle during mild ischaemia. Exp Physiol 2008;93:479– 85. 50. Williams AL, Chen L, Scharf SM. Effects of allopurinol on cardiac function and oxidant stress in chronic intermittent hypoxia. Sleep Breath 2010;14:51–7. 51. Alizadeh AM, Faghihi M, Sadeghipour HR, Mohammadghasemi F, Imani A, Houshmand F, et al. Oxytocin protects rat heart against ischemia-reperfusion injury via pathway involving mitochondrial ATP-dependent potassium channel. Peptides 2010;31:1341–5. 52. Alizadeh AM, Faghihi M, Khori V, Sohanaki H, Pourkhalili K, Mohammadghasemi F, et al. Oxytocin protects cardiomyocytes from apoptosis induced by ischemia-reperfusion in rat heart: role of mitochondrial ATPdependent potassium channel and permeability transition pore. Peptides 2012;36:71–7. 53. Tuğtepe H, Sener G, Biyikli NK, Yüksel M, Cetinel S, Gedik N, et al. The protective effect of oxytocin on renal ischemia/reperfusion injury in rats. Regul Pept 2007;140:101–8. 54. Houshmand F, Faghihi M, Zahediasl S. Biphasic protective effect of oxytocin on cardiac ischemia/reperfusion injury in anaesthetized rats. Peptides 2009;30:2301–8. 55. Işeri SO, Gedik IE, Erzik C, Uslu B, Arbak S, Gedik N, et al. Oxytocin ameliorates skin damage and oxidant gastric injury in rats with thermal trauma. Burns 2008;34:361–9. 56. Erkanli Senturk G, Erkanli K, Aydin U, Yucel D, Isiksacan N, Ercan F, et al. The protective effect of oxytocin on ischemia/reperfusion injury in rat urinary bladder. Peptides 2013;40:82–8. 57. Zhang W, Zhang J, Xu M, Zhang Y. Effect of oxytocin on gastric ischemia-reperfusion injury in rats. Front Med China 2007;1:433–7. 58. Düşünceli F, Işeri SO, Ercan F, Gedik N, Yeğen C, Yeğen BC. Oxytocin alleviates hepatic ischemia-reperfusion injury in rats. Peptides 2008;29:1216–22. 59. Akdemir A, Erbas O, Gode F, Ergenoglu M, Yeniel O, Oltulu F, et al. Protective effect of oxytocin on ovarian ischemia-reperfusion injury in rats. Peptides 2014;55:126–30.

Fırat et al. Oxytocin for preventing injury due to testicular torsion/detorsion in rats

DENEYSEL ÇALIŞMA - ÖZET OLGU SUNUMU

Sıçanlarda testiküler torsiyon/detorsiyon nedeniyle oluşan hasarın önlenmesinde oksitosin Dr. Fatih Fırat,1 Dr. Fikret Erdemir,2 Dr. Engin Kölükçü,1 Dr. Fikret Gevrek,4 Dr. İsmail Benli,3 Dr. Velid Ünsal3 Tokat Devlet Hastanesi, Üroloji Kliniği, Tokat Gaziosmanpaşa Üniversitesi Tıp Fakültesi, Üroloji Anabilim Dalı, Tokat Gaziosmanpaşa Üniversitesi Tıp Fakültesi, Biyokimya Anabilim Dalı, Tokat 4 Gaziosmanpaşa Üniversitesi Tıp Fakültesi, Histoloji Anabilim Dalı, Tokat 1 2 3

AMAÇ: Testislerdeki iskemi reperfüzyon hasarı üzerine oksitosinin etkilerini göstermeyi amaçladık. GEREÇ VE YÖNTEM: Çalışmamızda ağırlıkları 250–320 gr arasında değişen toplam 24 adet Wistar-Albino cinsi sıçan kullanıldı. Sıçanlar, sekiz sıçandan oluşan randomize üç gruba ayrıldı. Grup 1 kontrol grubu olarak değerlendirildi. Grup 2’de önce testis torsiyonu gerçekleştirildi. Sonrasında detorsiyone edilerek reperfüzyon hasarı oluşturuldu. Grup 3’de ise torsiyon ve detorsiyon işlemlerini takiben reperfüzyondan önce oksitosin uygulandı. Testiküler dokular, Johnsen skorlama sistemi kullanılarak histolojik ve spermatogenik parametrelere göre değerlendirildi ve ortalama Johnsen skoru hesaplandı. BULGULAR: Histolojik test sonuçları torsiyon grubu tedavi ve kontrol gruplarından istatistiksel olarak anlamlı derecede farklıydı. Oksitosin ile tedavi edilen grup hem kontrol hem de torsiyon gruplarından farklıydı (p=0.010 ve p=0.012). Biyokimyasal test sonuçları testis torsiyonu oluşturulan grupta süperoksit dismutaz ve glutatyon peroksidaz düzeyleri kontrol grubuna göre istatistiksel olarak anlamlı derecede düşük bulundu (p=0.007 ve p=0.007). Daha sonra oksitosin ile tedavi edilen testiküler torsiyon grubunda malondialdehit ve nitrik oksit düzeyleri yalnızca testis torsiyonu yapılan grupla karşılaştırıldığında istatistiksel olarak anlamlı şekilde azaldı (p=0.017 ve p=0.014). TARTIŞMA: Bu sonuçlara göre, oksitosin klinik uygulamada testiküler torsiyon tedavisinde doku hasarını en aza indirgemek için alternatif bir ajan olarak düşünülebilir. Anahtar sözcükler: İskemi reperfüzyon hasarı; oksitosin; torsiyon. Ulus Travma Acil Cerrahi Derg 2018;24(2):89–96

doi: 10.5505/tjtes.2017.25730

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EXPERIMENTAL STUDY

The success of endotracheal intubation with a modified laryngoscope using night vision goggles Attila Aydın, M.D.,1 Sedat Bilge, M.D.,1 Cemile Aydın, M.D.,2 Meltem Bilge, M.D.,3 Erdem Çevik, M.D.,4 Mehmet Eryılmaz, M.D.1 1

Department of Emergency Medicine, Gülhane Training and Research Hospital, Ankara-Turkey

Department of Internal Medicine, Ankara Etimesgut State Hospital, Ankara-Turkey

Department of Anesthesiology and Reanimation, Dışkapı Training and Research Hospital, Ankara-Turkey

Department of Emergency Medicine, Sultan Abdülhamit Training and Research Hospital, İstanbul-Turkey

ABSTRACT BACKGROUND: Endotracheal intubation (ETI) procedure in the combat area differs from prehospital trauma life support procedures because of the danger of gunfire and the dark environment. We aimed to determine the success, difficulty degree, and duration of ETI procedures with a classical laryngoscope (CL) in a bright room and with a modified laryngoscope (ML) model in a dark room. METHODS: All interventions were performed by a combatant medical staff of 10 members. We developed an ML model to obtain a tool that can be used in combination with night vision goggles (NVGs) to perform ETI at night. The procedures were performed using a CL with the naked eye in a bright room and using a ML with NVGs in a dark room. The ETI procedure that used the ML was performed by engaging and locking the blade on the handle either in the mouth (ML-IM) or outside of the mouth (ML-OM). RESULTS: The mean completion times for the ETI procedures, namely Day-CL, ML-OM+NVG, and ML-IM+NVG, performed by the operators were 14.46, 26.9, and 32.38 s, respectively. The ML-OM+NVG and ML-IM+NVG procedures were significantly longer than the Day-CL procedure (p<0.05). The ML-IM+NVG procedure was significantly longer than the ML-OM+NVG procedure (p<0.05). All ETI procedures were found to be 100% successful. The Day-CL procedure was easier than the ML-OM+NVG and ML-IM+NVG procedures (p>0.05). CONCLUSION: The ETI procedure is applicable using NVGs in dark conditions on the battlefield. Medical interventions performed using NVGs in the dark should be a part of the basic training provided in tactical emergency medicine. Keywords: Battlefield; darkness; endotracheal intubation; night vision goggles.

INTRODUCTION Airway obstruction, life-threatening hemorrhages, and tension pneumothorax are preventable causes of death in the combat area.[1] Endotracheal intubation (ETI) is a definitive and life-saving procedure, which maintains the patency of the airway.[1–3] In addition, prehospital ETI is the gold standard and potentially life-saving maneuver if the patient’s Glasgow Coma Scale score is <8.[4] All medical interventions in the combat area differ from prehospital trauma life support pro-

cedures due to the risk of gunfire by enemy forces and the dark environment. In the emergency medical services system, prehospital ETI is used with varying success rates, and it is well-known that the type of trauma (i.e., facial trauma, hemorrhage, etc.), personnel, environmental factors, and equipment further complicate ETI in the combat area.[5] Butler et al.[6] reported an Israeli combat medic who was shot by a sniper while performing ETI at night. This previously reported study is a tragic illustration of the harm and damage

Cite this article as: Aydın A, Bilge S, Aydın C, Bilge M, Çevik E, Eryılmaz M. The success of endotracheal intubation with a modified laryngoscope using night vision goggles. Ulus Travma Acil Cerrahi Derg 2018;24:97–103 Address for correspondence: Attila Aydin, M.D. Gülhane Eğitim ve Araştırma Hastanesi, Acil Tıp Kliniği, Ankara, Turkey Tel: +90 312 - 304 20 00 E-mail: drattilaaydin@gmail.com Ulus Travma Acil Cerrahi Derg 2018;24(2):97–103 DOI: 10.5505/tjtes.2017.27546 Submitted: 03.02.2017 Accepted: 29.06.2017 Online: 03.07.2017 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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Aydın et al. The success of endotracheal intubation with a modified laryngoscope using night vision goggles

that can be caused when an extra light source other than night vision goggles (NVGs) is used by paramedics/medics on the combat field. With the naked eye, the light of the classical laryngoscope (CL) can be viewed; however, infrared (IR) light cannot be visualized unless observed with NVGs. There is still ongoing debate regarding the technical equipment that should be used while performing ETI in the dark environment of a combat area to avoid the limited visibility of the CL and ensure safety. In the present study, by replacing the CL bulb with an IR lightemitting diode (IR-LED) bulb, we created a modified laryngoscope (ML) model to be used with NVGs while performing ETI in a dark environment. Thus, here we aimed to determine the success, difficulty degree, and duration of ETI procedures with a CL in a bright room and with an ML in a dark room.

MATERIALS AND METHODS Materials An endotracheal tube (Kendall, Cuffed tracheal tube, Switzerland, 2009), a 10-cc injector, Airway Management Manikin (Laerdal, Airway Management Trainer, Norway, 2013), lubricant gel, intubation stylet, silicone resuscitator with mouthpieces (Laerdal, Adult Standart, Norway, 2013), and monocular NVGs (Aselsan, 983A, Turkey, 1995) were provided for the ETI procedure. All devices were used according to the manufacturer’s instructions. CL A laryngoscope (Truphatek Macintosh, no. 3 Blade, Israel) and a blade bulb (5-mm external diameter, 2.5 V, 28 mA, vacuumed nickel coating) were used. Formation of a New Laryngoscope Model Nickel coating of the CL bulb was transversely cut off while preserving the internal structures. The white light source was removed and replaced with an IR-LED light bulb (5-mm distal external diameter, 1.6 V, 20 mA, 940 nm peak wavelength,

(a)

30° view angle, convex lens), and the bulb was soldered to the previously cut bulb area and coated with silicon (Fig. 1a).

Methods Aim of The Method The study protocol with resuscitation manikins was approved by the Gülhane Military Medical Academy Ethics Committee. Our experimental study was performed on a resuscitation model in a simulated dark environment. In conflict environment with dark conditions, practitioners still use classical laryngoscopes for ETI procedures. Although NVGs are used in combat fields for tactical purposes (map reading, determination of enemy targets, etc.), it is routinely not used during ETI and other medical interventions. Military paramedics/ medics have to not only perform medical interventions on the combat field but also observe their environment while taking their NVGs off during battle. Therefore, it is essential for the practitioner to perform medical interventions, such as ETI, without removing NVGs in dark conditions. Because the light of CL can inevitably be seen with the naked eye of the enemy in dark conditions, we developed an ML model. Participants and Assessment Tool in Bright and Dark Rooms All interventions were administered by an experienced combatant medical staff (CMS) of 10 members who were trained in the Battlefield Advanced Trauma Life Support, which is a part of the military tactical training. All members had more than 5 years of experience in tactical emergency medicine and tactical night operations with NVGs. The operators used classical ETI and had not used ETI with NVGs before. This was a new technique. The operators were trained for the ETI procedure by military emergency medicine specialists (MEMS); these refreshment training programs (theoretical and practical), including anatomical landmarks and procedural tools, lasted for 60 min for each intervention. The methods were performed using CL with the naked eye in an illuminated area and using ML with NVGs in a dark

(b)

Figure 1. (a) View of the modified laryngoscope with infrared light-emitting diode lamp using night vision goggles. (b) Endotracheal intubation with the modified laryngoscope using night vision goggles and the view of vocal cords.

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Aydın et al. The success of endotracheal intubation with a modified laryngoscope using night vision goggles

room (Fig. 1b). The ETI procedure employing ML was performed by engaging and locking the blade on the handle either in the mouth (ML-IM) or outside of the mouth (MLOM). To minimize the light filtering from the laryngoscope, the operators were instructed to loosely insert laryngoscope blades into the mouth (ML-IM) and then pull up the handle to visualize vocal cords. Using this approach, the anatomical structure of the oropharynx was used as a natural barrier to avoid light scattering. The following abbreviations were used in the corresponding circumstances: Day-CL, ETI using CL in the daylight; ML-OM, locking the blade of ML on the handle out of the mouth in a dark room; and ML-IM, locking the blade of ML on the handle in the mouth in a dark room. The procedures performed with NVGs in a dark environment were indicated with “+NVG.” The procedures performed in daylight (Day-CL) and in the dark room (ML-OM+NVG, ML-IM+NVG) were randomized using research randomizer (www.randomizer.org). All methods were evaluated for their success and compared with each other. All operators repeated each intervention twice. The success, difficulty degree, and duration of ETI were explored in the study. No more than a single attempt was permitted for each insertion of the endotracheal tube (ETT), after which the procedure was considered as failed. Necessary steps for the success of the ETI procedure are shown in Table 1. An unsuccessful procedure was defined as (a) taking more than 60 s to secure the airway, (b) no ventilation, (c) esophageal intubation, and (d) no lung inflation. The duration of ETI was defined as the time from the preparation of the laryngoscope to the ventilation of the lungs, depending on the method selected by the participant. These parameters were observed by MEMS, and the results were recorded.

In addition, MEMS observed the success of the ETI procedure with the naked eye in daylight and using NVG in the dark room. Operators graded the ease of ETI (in bright and dark rooms) using a numerical rating scale with scores varying from 1 to 10, 10 for the most difficult interventions and 1 for very easy interventions.

Statistical Analysis Statistical analysis was performed using SPSS for Windows version 22.0 (SPSS Inc., Chicago, IL, USA). Descriptive data were expressed in median values, standard deviation (minimum– maximum). The Wilcoxon test was used to compare two groups, whereas the Friedman test was performed to compare more than two groups. Dual analyses were performed using the Bonferroni-corrected Wilcoxon test if the Friedman test revealed statistically significant differences. A p value of <0.05 was considered statistically significant. We calculated that a minimum of eight patients in each group would be required to detect a 20-s difference between groups, assuming a standard deviation of 20 s with 80% power at an α level of 0.05.

RESULTS Difficulty Degree of Procedures Operators (n=10) rated the Day-CL procedure as easier than the ML-OM+NVG and ML-IM+NVG procedures (p<0.05), and no significant difference was observed in difficulty between the ML-OM+NVG and ML-IM+NVG procedures (p=1) (Tables 2 and 3).

Success Rate All ETI procedures, namely Day-CL, ML-OM+NVG, and MLIM+NVG, performed by the operators were found to be 100% successful.

Table 1. Mandatory steps for the success of the selected endotracheal intubation procedure Endotracheal intubation procedure Day-CL

ML-OM + NVG

ML-IM + NVG

(a) Engagement of blade on the handle

(a) Engagement of blade on the handle of ML

(a) Engagement of blade on the

of CL

(b) Handle pull blade up

(b) Handle pull blade up out of the mouth

handle of ML

(b) After loose insertion in the mouth

pull blade up

(d) Inflation of cuff

(e) Observation of the expansion of the

(e) Observation of the expansion of

lungs in the mannequin with silicone

the lungs in the mannequin with

resuscitator by MEMS

silicone resuscitator by MEMS

Day-CL: Endotracheal intubation performed with a classical laryngoscope and naked eye in daylight in a bright room; ML-OM + NVG: Endotracheal intubation performed with a modified laryngoscope with the blades locked on the handle out of the mouth in a dark room using night vision goggles; ML- IM + NVG: endotracheal intubation performed with a modified laryngoscope with the blades locked on the handle in the mouth in a dark room using NVG; NVG: Night vision goggles; CL: Classical laryngoscope; ML: Modified laryngoscope; ETT: Endotracheal tube; MEMS: Military Emergency Medicine Specialist.

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Table 2. Intubation results Scenario Intubation success

Intubation time (sec) Mean±SD, min-max

No of attempts (Mean)

Numerical rating scale (Mean)

Day-CL

100%

14.46±2.31 (11.7–17.9)

1.0 (0)

1.5±0.5 (1–2)

ML-OM + NVG ML- IM + NVG

100%

26.90±2.77 (23.3–32.7)

1.0 (0)

5.9±0.7 (5–7)

100%

32.38±2.10 (28.8–35.1)

1.0 (0)

5.9±0.7 (5–7)

NRS: Numeric rating scale; Day-CL: Endotracheal intubation performed with a classical laryngoscope and naked eye in daylight in a bright room; ML-OM + NVG: Endotracheal intubation performed with a modified laryngoscope with the blades locked on the handle out of the mouth in a dark room using night vision goggles; ML- IM + NVG: Endotracheal intubation performed with a modified laryngoscope with the blades locked on the handle in the mouth in a dark room using night vision goggles; NVG: Night vision goggles; SD: Standard deviation.

Table 3. Comparison of intubation techniques

p value

Intubation NRS Comparison Time Day-CL vs ML-OM + NVG

=0.005

=0.004

Day-CL vs ML-IM + NVG

=0.005

ML- OM + NVG vs ML-IM + NVG

=0.005

NRS: numeric rating scale; Day-CL: Endotracheal intubation performed with a classical laryngoscope and naked eye in daylight in a bright room; ML-OM + NVG: Endotracheal intubation performed with a modified laryngoscope with the blades locked on the handle out of the mouth in a dark room using night vision goggles; ML- IM + NVG: Endotracheal intubation performed with a modified laryngoscope with the blades locked on the handle in the mouth in a dark room using night vision goggles; NVG: Night vision goggles.

Completion Time for the Interventions The mean completion times for the ETI procedures, namely Day-CL, ML-OM+NVG, and ML-IM+NVG, performed by the operators in the bright and dark rooms were 14.46, 26.9, and 32.38 s, respectively. On comparing, the completion times of the ML-OM+NVG and ML-IM+NVG procedures were found to be significantly longer than Day-CL procedure (p<0.05). The ML-IM+NVG procedure was significantly longer than the ML-OM+NVG procedure (p<0.05) (Tables 2 and 3).

DISCUSSION Rapid airway management by tactical medical providers is a key skill, which may affect the survival of injured soldiers and civilians. Advanced airway management is feasible in the modern combat setting.[7] In civilian settings, the indications for airway management include traumas, such as traffic collision-induced blunt injuries, whereas in the military setting, they include penetrating facial, neck, and maxillofacial injuries; significant airway hemorrhage secondary to vascular injury; and airway obstruction.[3,8,9] It is, therefore, one of the most important steps in the combat setting to maintain a patent airway. Considering the nature of the combat area, the ETI procedure is affected by the previous experiences and skills of 100

the CMS; the difficulty of the procedure completion on the field; and factors such as darkness, excessive noise, access to the patient, transportation of the patient to a safe location, insufficient equipment, clinical condition of the patient (for instance, maxillofacial injuries, cervical trauma, etc.), and difficult airway.[10,11] All these factors are independent of each other and need to be addressed to improve the success of ETI and to ensure tactical safety. Among these independent factors affecting the success of ETI and tactical safety, the present study focused on problems that were likely to interfere with light discipline while performing ETI in darkness. Military paramedics/medics also have to observe their environment without removing their NVGs during battle. When white/yellow light is used for ETI, there is a risk of the personnel performing the ETI procedure to be spotted by the enemy forces.[6] Butler et al. reported an Israeli military health care personnel who was killed by a sniper fire while manipulating the laryngoscope to perform ETI at night. In addition, a possible disadvantage of using video laryngoscopes in a tactical environment may be the backlit video screens, which may increase intubation exposure in a low-light environment.[12] The evaluation and management of the patient are highly dependent on good lighting conditions. Strict blackout discipline is extremely important for the military and allied units. However, practicing ETI in a tactical light-restricted environment is still a matter of debate. Tactical NVGs can be utilized for determining wound characteristics and for performing relevant interventions at night. The study by Butler et al. is a tragic illustration of the harm and damage that can be caused when an extra light source other than NVGs is used by paramedics/medics on the combat field. Furthermore, there have been a few studies on the use of NVGs in airway interventions, including one on ETI with NVGs;[13] one on emergency cricothyroidotomy with NVGs;[14] and one on ETI with NVGs.[15] These studies reported that NVGs might be used while performing these procedures in darkness. However, there are few studies that guide operators on the principles of performing ETI in the dark and on the success of this procedure. Ulus Travma Acil Cerrahi Derg, March 2018, Vol. 24, No. 2

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The light of a CL can be seen with the naked eye, whereas IR light is not visible to the naked eye. In the present study, the bulb of the CL blade was replaced with an IR-LED bulb for the operator to perform ETI with NVGs. Thus, we could test the success and completion time of ETI performed by CMS in darkness without removing NVGs. ETI procedures performed with ML were as successful as those performed with CL in daylight, but there was a statistically significant difference in completion times between the two (p<0.05). The operators in the present study were also experienced in performing ETI with CL and in the tactical use of NVGs. However, this was their first time for performing ETI using ML and NVGs in darkness (ML-OM+NVG and ML-IM+NVG). We believe that this may have contributed to the differences in the completion times and success of ETI. Prehospital ETI performed by the operators with limited experience increased mortality, whereas those performed by more experienced operators were associated with lower mortality rates.[16,17] The success of prehospital ETI in the combat area also decreased the rate of preventable deaths. In another study on ETI in humans, Wang et al.[18] reported prehospital first-pass intubation success rates to be approximately 70%, whereas Deakin et al.[7] reported 30% failure rate for ETI performed by non-physician personnel in the prehospital setting. In studies wherein ETI was performed on mannequins, Bahathiq et al.[16] reported a first-pass intubation success rate of 68%, Yun et al.[12] reported that the success rate of ETI ranged from 96% to 100%, and Gellerfors et al.[13] reported a success rate of 100%. The present study reports a success rate of 100%. In this respect, the present study yielded consistent findings with the studies by Yun et al. and Gellefors et al., which can be attributed to the extensive clinical experience of the CMS personnel and to the fact that they practiced with ETI procedures on the same airway management manikins during daytime. On the other hand, the studies by Wang et al. and Deakin et al. were conducted on real patients and their ETI success rates were lower than those in our study. Bahathiq et al. used paramedics without previous experience on ETI and therefore obtained a low success rate. In addition, success rates of the ETI procedures performed in the dark room were as high as those of the ETI procedures performed in daylight, suggesting the importance of advanced skills of the CMS personnel in the tactical use of NVGs. The mean time to ventilation in the ETI procedures performed on mannequins was reported as 31.5 s by Bahathiq et al.,[16] 63.3 s by Prekker et al.,[8] 26.1 s by Yun et al.,[12] 16.5 s by Gellerfors et al.,[13] and 14.46 s in the present study. The findings of the present study are also consistent with those reported by Gellerfors et al. and Yun et al. Among studies that evaluated the ETI procedures performed in darkness using NVGs, Schwartz et al.[19] reported a success rate of 91.7% in humans using an IR filter and monocular NVGs, whereas the rate of first-pass intubation was 46.1% and the Ulus Travma Acil Cerrahi Derg, March 2018, Vol. 24, No. 2

procedure time was 188.2 s in the study by Brummer et al.[15] using an additional light source (IR light) and monocular NVGs during ETI on mannequins. Furthermore, Gellefors et al. reported a success rate of 100% and a completion time of 26.9 s in ETI on mannequins using binocular NVGs. Similarly, the present study reports a success rate of 100% and time to ventilation of 26.9 s using monocular NVGs. The study by Schwartz et al. differs from the present study as they worked on human subjects and used different success criteria. They evaluated ETI as successful until five attempts. Therefore, our study is consistent with the study of Gellefors et al. in terms of the success rate and completion time. In contrast to our study, however, in the study of Gellefors et al., ETI was performed by anesthesiologists using binocular NVGs. In addition, capnography verification was also performed between the ETI steps. We suggest that CMS personnel should practice in dark environment and ML-OM+NVG/ML-IM+NVG trainings should be repeated frequently to reduce the time to ventilation in the ETI procedures. This would enable precise and rapid decisions by the personnel performing ETI in a combat setting and under dark conditions. The feedback received from the operators suggested that the Day-CL procedure was easier than the ML-OM+NVG and ML-IM+NVG procedures (p<0.05). This finding was attributed to the fact that operators were not trained to perform ETI using NVGs and that they only had experience of performing ETI in daytime. In routine practice, operators engage and lock the blade onto the handle to prepare the CL for operation and to test if the lamp illuminates. During this preparation, illumination provided by the lamp inevitably reveals the operator’s location to the enemy forces. To reduce illumination by the lamp, we demonstrated CMS personnel to deploy the blade into its locked position after inserting the blade loosely into the mouth and pulling up the blade to expose vocal cords. Via this maneuver, the anatomical structure of the oropharynx was used as a natural barrier to avoid light scattering. Schwartz et al.[19] demonstrated the difficulty of performing intubation with monocular NVGs due to reduced depth perception. Despite that, in the present study, CMS personnel successfully (100%) performed ETI using monocular NVGs in the dark environment; however, the feedback we received from the operators indicates that the ETI procedure performed with ML is more difficult than the Day-CL procedure. Based on the evidences from several healthcare disciplines, simulation can improve the knowledge (clinical decision making, patient assessment etc. and skill performance. We still require gaining excellence in using NVGs for medical interventions. Simulation training is an essential training strategy in healthcare systems to improve the patient’s safety, and there are some evidences supporting that procedural simulation improves the actual operational performance in the clinical setting. The increasing trend of the use of simulation in 101

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healthcare training can be attributed to its many benefits. The ETI procedures and scenarios performed with ML-IM+NVG and ML-OM+NVG in a room simulating dark conditions must be integrated into such simulation systems. In a chaotic environment, we suggest that civilian healthcare workers involved in humanitarian relief services (Red Crescent, Red Cross, etc.) should deploy the CL blade in the mouth during intubation and perform the procedures under a lightproof cover if they lack facilities, such as NVGs. In night operations, we consider that advanced life support can be provided in the helicopter’s cabin using night vision systems and laryngoscopes with IR-LED lamps, thereby eliminating the need for turning on lights. Laryngoscope bulb manufacturers develop a product that diminishes the power of the IR light and focuses the light exclusively on the epiglottis and vocal cords. Instead of carrying a separate device that would add an additional weight into the medical packs, combat medics should have at their disposal IR-LED laryngoscope bulbs, such as the ML, designed in the present study, which should be kept at a location that is readily accessible to all personnel when required. Nonetheless, there are some limitations to this study. First, the extent of the light reflected from the oropharynx of the human that becomes visible by the enemy forces remains unknown. Different challenges may occur in real-life practice as all ETI procedures in this study were performed on mannequins. In the real-life setting, the intubation may be complicated by blood and vomit in the airway and trismus. Second, auscultation with a stethoscope to confirm tracheal intubation may not be feasible due to excessive noise. Such challenges may affect the success and duration of the interventions. Therefore, further animal and human studies with challenging intubation mannequins are required to establish a conclusion.

Conclusion In conclusion, ETI conducted in darkness using NVGs is a reliable method. Military paramedics/medics have to not only perform medical intervention on the combat field but also observe their environment without removing their NVGs during battle. Considering this finding, we believe that it would be relatively safer to open the CL blade inside the mouth and perform the procedure using NVGs. Medical interventions performed using NVGs in the dark should be a part of the basic training provided in tactical emergency medicine. Further studies conducted in battlefield area are needed to evaluate the safety and success of this procedure.

Acknowledgement Dedicated in the memory of Lt. Col. İhsan EJDAR. Conflict of interest: None declared. 102

REFERENCES 1. Mabry R, Frankfurt A, Kharod C, Butler F. Emergency Cricothyroidotomy in Tactical Combat Casualty Care. J Spec Oper Med 2015;15:11–9. 2. Bogdański Ł, Truszewski Z, Kurowski A, Czyżewski Ł, Zaśko P, Adamczyk P, et al. Simulated endotracheal intubation of a patient with cervical spine immobilization during resuscitation: a randomized comparison of the Pentax AWS, the Airtraq, and the McCoy Laryngoscopes. Am J Emerg Med 2015;33:1814–7. 3. Bilge S, Aydin A, Eryilmaz M. Endotracheal intubation with tactical fiberoptic imaging systems. Am J Emerg Med 2016;34:664–5. 4. Kulla M, Helm M, Lefering R, Walcher F. Prehospital endotracheal intubation and chest tubing does not prolong the overall resuscitation time of severely injured patients: a retrospective, multicentre study of the Trauma Registry of the German Society of Trauma Surgery. Emerg Med J 2012;29:497–501. 5. Schalk R, Byhahn C, Fausel F, Egner A, Oberndörfer D, Walcher F, et al. Out-of-hospital airway management by paramedics and emergency physicians using laryngeal tubes. Resuscitation 2010;81:323–6. 6. Butler FK Jr, Holcomb JB, Giebner SD, McSwain NE, Bagian J. Tactical combat casualty care 2007: evolving concepts and battlefield experience. Mil Med 2007;172:1–19. 7. Deakin CD, Peters R, Tomlinson P, Cassidy M. Securing the prehospital airway: a comparison of laryngeal mask insertion and endotracheal intubation by UK paramedics. Emerg Med J 2005;22:64–7. 8. Prekker ME, Kwok H, Shin J, Carlbom D, Grabinsky A, Rea TD. The process of prehospital airway management: challenges and solutions during paramedic endotracheal intubation. Crit Care Med 2014;42:1372–8. 9. Kempema J, Trust MD, Ali S, Cabanas JG, Hinchey PR, Brown LH, et al. Prehospital endotracheal intubation vs extraglottic airway device in blunt trauma. Am J Emerg Med 2015;33:1080–3. 10. Eastridge BJ, Mabry RL, Seguin P, Cantrell J, Tops T, Uribe P, et al. Death on the battlefield (2001-2011): implications for the future of combat casualty care. J Trauma Acute Care Surg 2012;73:S431–7. 11. Mabry RL, Edens JW, Pearse L, Kelly JF, Harke H. Fatal airway injuries during Operation Enduring Freedom and Operation Iraqi Freedom. Prehosp Emerg Care 2010;14:272–7. 12. Yun BJ, Brown CA 3rd, Grazioso CJ, Pozner CN, Raja AS. Comparison of video, optical, and direct laryngoscopy by experienced tactical paramedics. Prehosp Emerg Care 2014;18:442–5. 13. Gellerfors M, Svensén C, Linde J, Lossius HM, Gryth D. Endotracheal Intubation With and Without Night Vision Goggles in a Helicopter and Emergency Room Setting: A Manikin Study. Mil Med 2015;180:1006– 10. 14. MacIntyre A, Markarian MK, Carrison D, Coates J, Kuhls D, Fildes JJ. Three-step emergency cricothyroidotomy. Mil Med 2007;172:1228–30. 15. Brummer S, Dickinson ET, Shofer FS, McCans JP, Mechem CC. Effect of night vision goggles on performance of advanced life support skills by emergency personnel. Mil Med 2006;171:280–2. 16. Bahathiq AO, Abdelmontaleb TH, Newigy MK. Learning and performance of endotracheal intubation by paramedical students: Comparison of GlideScope(®) and intubating laryngeal mask airway with direct laryngoscopy in manikins. Indian J Anaesth 2016;60:337–42. 17. Diggs LA, Viswakula SD, Sheth-Chandra M, De Leo G. A pilot model for predicting the success of prehospital endotracheal intubation. Am J Emerg Med 2015;33:202–8. 18. Wang HE, Yealy DM. Out-of-hospital endotracheal intubation: where are we? Ann Emerg Med 2006;47:532–41. 19. Schwartz RB, Gillis WL, Miles RJ. Orotrachial intubation in darkness using night vision goggles. Mil Med 2001;166:984–6.

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DENEYSEL ÇALIŞMA - ÖZET OLGU SUNUMU

Gece görüş gözlükleri kullanarak modifiye laringoskopla endotrakeal entübasyon başarısı Dr. Attila Aydın,1 Dr. Sedat Bilge,1 Dr. Cemile Aydın,2 Dr. Meltem Bilge,3 Dr. Erdem Çevik,4 Dr. Mehmet Eryılmaz1 Gülhane Eğitim ve Araştırma Hastanesi, Acil Tıp Kliniği, Ankara Ankara Etimesgut Devlet Hastanesi, İç Hastalıkları Kliniği, Ankara Dışkapı Eğitim ve Araştırma Hastanesi, Anesteziyoloji ve Reanimasyon Kliniği, Ankara 4 Sultan Abdülhamit Eğitim ve Araştırma Hastanesi, Acil Tıp Kliniği, Istanbul 1 2 3

AMAÇ: Karanlık ortamda düşman ateşi altında endotrakeal entübasyon (ETE) prosedürü hastane öncesi travma yaşam desteği prosedürlerinden farklıdır. Amacımız; aydınlık odada klasik laringoskop (KL), karanlık odada modifiye laringoskop (ML) modeli ile ETE prosedürlerinin başarı, zorluk derecesi ve ETE prosedür süresini ortaya çıkartmaktır. GEREÇ VE YÖNTEM: Tüm girişimler 10 kişiden oluşan muharip sağlık personeli tarafından yapıldı. Gece koşullarında, gece görüş gözlükleri (GGG) ile ETE prosedürünün gerçekleştirmek için ML modeli geliştirdik. Girişimler; KL kullanılarak aydınlatılmış bir alanda ve ML ile GGG kullanılarak karanlıkta gerçekleştirildi. Modifiye laringoskop bıçağı ağız içinde (ML-Aİ+GGG) veya ağız dışında (ML-AD+GGG) açılacak şekilde iki ayrı metod şeklinde kullanıldı. BULGULAR: Uygulayıcılar tarafından aydınlık ve karanlık odada yapılan ETE girişimlerinin (Gündüz-KL, ML-AD+GGG, ML-Aİ+GGG) ortalama tamamlanma süreleri sırasıyla 14.46 sn., 26.9 sn., ve 32.38 sn. olarak saptandı. ML-AD+GGG ve ML-Aİ+GGG, Gündüz-KL’ye göre istatistiksel olarak anlamlı derecede daha uzundu (p<0.05). Modifiye laringoskop-Aİ+GGG, ML-AD+GGG’ye göre göre istatistiksel olarak anlamlı derecede daha uzun bulundu (p<0.05). Bütün ETE girişimleri %100 başarılıydı. Gündüz-KL, ML-AD+GGG ve ML-Aİ+GGG ile karşılaştırıldığında daha kolaydı (p<0.05). TARTIŞMA: Endotrakeal entübasyon savaş alanında GGG kullanarak karanlıkta uygulanabilir bir prosedürdür. Gece görüş gözlükleri ile karanlıkta yapılan tıbbi müdahaleler, taktik acil tıbbında verilen temel eğitimlerin bir parçası olmalıdır. Anahtar sözcükler: Endotrakeal entübasyon; gece görüş gözlükleri; karanlık; savaş alanı. Ulus Travma Acil Cerrahi Derg 2018;24(2):97–103

doi: 10.5505/tjtes.2017.27546

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ORIG I N A L A RTIC L E

Successful non-operative management of blunt abdominal trauma in highly selective cases: A safe and effective choice Georgios Theodoros Liagkos, M.D.,1 Charalampos Spyropoulos, M.D.,2 Gerasimos Tsourouflis, M.D.,3 Aris Papadopoulos, M.D.,1 Paulos Ioannides, M.D.,1 Constantine Vagianos, M.D.3 1 Department of Surgery, Nikaia General Hospital, Nikaia, Piraeus-Greece

1 st

3 Department of Surgery, Iaso General Hospital, Holargos, Athens-Greece

2 rd

2 Propedeutic Department of Surgery, Laikon Hospital, National & Kapodestrian University of Athens, Athens-Greece

3 nd

ABSTRACT BACKGROUND: The non-operative management (NOM) of abdominal injuries has gained wide acceptance over the last few decades. The present study evaluated the efficacy of NOM in blunt abdominal trauma (BAT) at a regional Hellenic hospital. METHODS: We analyzed the results of a pre-decided treatment protocol, which was applied to all patients hospitalized for BAT, from 2008 to 2015. The protocol proposed NOM in hemodynamically stable patients with no signs of peritonitis. The demographic characteristics, type of injury, injured organ(s), type of management (operative vs. non-operative), Injury Severity Score (ISS), morbidity, mortality rates, and health costs were evaluated. RESULTS: One hundred and forty-six patients hospitalized for BAT at our department were included. Among them, 49 were operated and 97 were subjected to NOM. Although ISS was significantly higher in the surgical group, the severity of injuries in liver, spleen, and kidneys was not different between the two groups. Surprisingly, no case subjected to NOM required a conversion to operative management, which may probably be because of the strict inclusion criteria for NOM. CONCLUSION: Patients with hemodynamic stability and normal physical examination may be non-operatively treated, independent of the grade of injury, in highly selective cases. ISS score is an independent risk factor for surgical treatment. Keywords: Blunt abdominal trauma; hemodynamic stability; non-operative management.

INTRODUCTION Most fatalities in individuals aged ≤35 years are due to trauma.[1] Blunt mechanisms account for 78.9%–95.6% of all injuries,[2] with the abdomen being affected in 6.0%–14.9% of all traumatic injuries.[2,3] In any case, patients with signs of peritonitis and/or hemodynamic instability and those with ultrasound findings of intra-abdominal fluid should undergo laparotomy.[4] However, the selection of these patients, particularly in the poly-trauma setting, is always a challenge. The definition of hemodynamic stability remains a significant problem, which often ignores that >30%–35% of circulating blood volume may be lost before the onset of hypotension.

[5] The classification of patients, as proposed by the Advanced Trauma Life Support Committee on Trauma (ATLS), into hemodynamic categories, namely responders, transient responders, and non- responders, may help in avoiding the underestimation of bleeding.[6] However, in general, patients with minimum systolic arterial blood pressure of >90 mmHg without vasopressors and maximum heart rate (HR) of <110 beats/min may be considered hemodynamically stable.[7]

Over the last few decades, a shift has been noted from operative management (OM) to non-operative management (NOM) in hemodynamically stable blunt abdominal trauma (BAT) patients.[8,9] This approach may be safely applied in

Cite this article as: Liagkos GT, Spyropoulos C, Tsourouflis G, Papadopoulos A, Ioannides P, Vagianos C. Successful non-operative management of blunt abdominal trauma in highly selective cases: A safe and effective choice. Ulus Travma Acil Cerrahi Derg 2018;24:104–109 Address for correspondence: Georgios Theodoros Liagkos, M.D. Kountourgiotou 43 12351 Athens-Greece Tel: +30 693 6994 993 E-mail: gliagkos.surg@gmail.com Ulus Travma Acil Cerrahi Derg 2018;24(2):104–109 DOI: 10.5505/tjtes.2017.83404 Submitted: 20.07.2017 Accepted: 13.09.2017 Online: 12.02.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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trauma centers that are sufficiently equipped with recent imaging modalities, intensive care capabilities, blood bank, and 24-h operative services.[10] The close monitoring of patients along with modern imaging and laboratory examinations play a key role in attaining therapeutic decisions, thereby preventing unnecessary laparotomies. In general, liver injuries present a higher successful rate of NOM, which exceeds 90%. [11] Hemodynamically stable patients with liver and spleen injuries may be non-operatively managed, independent of the grade of the injury; NOM is also highly successful in patients with renal trauma.[12,13] The revision organ injury scale by the American Association for the Surgery of Trauma, which was established in 1994, is the most widely used grading system for abdominal trauma.[14] In the present study, we used OM and NOM for abdominal injuries in a regional hospital. The aim of the study was to outline the major indications for NOM, feasibility of this approach in this setting, morbidity and mortality rates, and outcomes compared with cases of surgical approach and to exhibit the success of NOM in selective trauma cases.

MATERIALS AND METHODS A prospective study, based on a pre-decided treatment protocol, was conducted between 2008 and 2015 at a regional hospital, which included all patients hospitalized for BAT. The type of injury, injured organ(s), and method of treatment (OM vs. NOM) were recorded. The failure of NOM as well as morbidity and mortality rates were also documented. On admission, all patients were assessed and resuscitated, if necessary, in accordance to the ATLS protocol. Focused assessment with sonography for trauma (FAST) was conducted in most cases, depending on its availability. Hemodynamically unstable patients with positive FAST as well as those with signs of peritonitis were surgically explored. Unstable patients included non-responders and transient responders. Stable patients with positive FAST were selected for NOM and further evaluated by performing CT scan with IV contrast. CT scan was also performed in stable patients when FAST ultrasound was unavailable. Diagnostic peritoneal lavage (DPL) was performed only in poly-trauma patients with hemodynamic instability and when FAST was unavailable. Patients with an HR of <110/min and systolic BP of >90 mm Hg on admission or following initial resuscitation were considered stable. Based on the hemodynamic status, clinical findings, and investigations, 97 (66.4%) patients were selected for NOM. According to the study protocol, the exclusion criteria for NOM included persistent hemodynamic instability with no response to initial resuscitation and positive FAST or signs of peritonitis. Because of the application of the rather strict criteria, “gray-zone” patients were surgically managed. Thus, all patients with splenic injury and active arterial extravasation and most poly-trauma patients with multiple injuries Ulus Travma Acil Cerrahi Derg, March 2018, Vol. 24, No. 2

and borderline hemodynamic status underwent emergency explorative laparotomy. Indications for revision were the deterioration of hemodynamic stability, ongoing drop of hematocrit, and suspicion of missed hollow organ injuries. Angioembolization was performed in hemodynamically stable patients with expanding pelvic hematoma or active arterial extravasation due to pelvic and liver injuries. Statistical Package for the Social Sciences (SPSS) 19.0 for Windows was used for data analysis. Descriptive statistics were presented as mean and standard deviation. Categorical data were analyzed using the chi-square test. Significance level was set at p<0.05.

RESULTS One hundred and forty-six patients (102 males, 44 females) with various types of BAT were included in the study and statistically analyzed. The mean age of NOM and OM groups was 42.7±20.3 and 46.4±18.8 years, respectively. After the initial evaluation, 97 (66.4%) patients were selected for NOM and 49 (33.6%) were operated. The decision for surgical exploration in the OM group was made on the basis of the presence of hemodynamic instability and/or peritonitis (28 patients), intraperitoneal rupture of the bladder (two patients), hemi-diaphragmatic injury (two patients), multiple injuries, and borderline hemodynamic status with mean Injury Severity Score (ISS) of 27.2 (nine patients) and splenic injuries with active arterial extravasation (eight patients). The patients of both groups had similar age, comorbidities, and mechanisms of injury. ISS was significantly higher in the group of patients who required surgical exploration (p=0.001). The mean ISS in this group was 22.1 vs. 10.6 in the NOM group. It is noteworthy that the grade of injury in the most commonly affected solid abdominal organs (liver, spleen, and kidney) was similar between the two groups. The characteristics of patients in both groups are presented in Table 1. The grade of injury in patients subjected to surgery was established by both radiological modalities and operative findings. The grade of spleen injury was slightly higher in the OM group, but the difference was not statistically significant (Figs. 1–3). FAST was unavailable in two patients with hemodynamic instability and severe co-existent head trauma, and DPL was performed to establish the indication for exploratory laparotomy. In both cases, intraperitoneal bleeding was revealed. Eight trauma patients with splenic injury and blushing in the arterial phase of CT scan were surgically explored. Splenectomy was performed in all patients. In four patients with signs of peritoneal irritation, surgical exploration demonstrated hollow organ injury, and primary repair was performed. Two patients with the intraperitoneal rupture of the bladder were treated by primary suturing and long-term urinary catheterization, whereas in two patients with left expandable 105

Liagkos et al. Successful non-operative management of blunt abdominal trauma in highly selective cases

Table 1. Characteristics of patients in both studied groups

Non-operative management group (97 pts.)

Operative group (49 pts.)

Age (Mean±SD)

42.7±20.3

46.4±18.8

0.728

Injury Severity Score (Mean±SD)

10.6±8.4

22.1±12.1

0.001

Diagnostic modality on admission

Focused assessment with sonography for trauma

Computed tomography

Focused assessment with sonography for trauma +

Computed tomography

Diagnostic peritoneal lavage

SD: Standard deviation.

retroperitoneal hematoma and splenic injury, splenectomy and nephrectomy were performed in one and splenectomy and renal suturing were performed in the other. Hepatic hemLiver injury grade Grade I Grade II Grade III

Patients

0 Operative group

Non-operative group

Figure 1. Grade of liver injury in patients treated surgically and non-operatively (p=0.531).

All patients subjected to surgery because of splenic injuries underwent splenectomy. No splenic preservation was attempted because of hemodynamic instability. A massive pancreatic injury with concomitant splenic trauma was treated by splenectomy and distal pancreatectomy (resection of the tail of the pancreas). Surgical re-exploration was necessary in five (10.2%) patients, including four patients for the scheduled liver unpacking after DCS and one for intra-abdominal bleeding (epiploic vessels). There were eight deaths recorded in the OM group (16.3%). Six of these patients had sustained severe head injury and two developed severe and irreversible respiratory complications. CT scan was the diagnostic modality of choice in the NOM group, which was always performed after the initial evalua-

Spleen injury grade Grade I Grade II Grade III Grade IV Grade V

0 Operative group

Non-operative group

Figure 2. Grade of spleen injury in patients treated surgically and non-operatively (p=0.06).

106

Kidney injury grade Grade I Grade II Grade III

Patients

orrhage was controlled by applying local hemostatic agents. Hepatic packing was utilized in four patients “in extremis,” as part of the damage control surgery (DCS) protocol. These patients were reoperated within 48 h, and the packing was successfully removed without any sign of residual bleeding.

Operative group

Non-operative group

Figure 3. Grade of kidney injury in patients treated surgically and non-operatively (p=0.777).

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Table 2. In-hospital parameters of patients depending on the strategy of treatment

Non-operative management group (97 pts.)

Operative group (49 pts.)

0.38±1.1

3.4±2.2

Intensive care unit/high dependency unit admission (%)

9.3

46.3

Morbidity (%)

12.4

55.3

Blood transfusion (units, mean±SD)

Mortality (%) Hospital stay (days, mean±SD) Cost in € (median, range)

2.1

16.3

6.7±4.5

13.9±10.4

560 (100–18102)

3499 (10.4–75896)

SD: Standard deviation.

tion and resuscitation. FAST was the only diagnostic modality applied in eight patients because of the unavailability of CT scan. Eighty-seven patients with positive FAST were further evaluated by CT scan. In three patients, CT scan demonstrated pelvic arterial blushing, and successful embolization was performed in both internal iliac arteries using microcoils. Two other successful embolizations were performed for liver injury with active arterial contrast extravasation. NOM was successful in all patients. Two deaths were documented in this group due to severe head trauma on the 17th and 20th day of hospitalization, respectively. Autopsy revealed no abdominal causes related to the fatal outcome. Only minor complications were seen in this group of patients, which were mostly related to the respiratory system. As expected, the necessity for blood transfusion was higher in patients treated surgically. Overall, the OM group had an ICU/HDU admission rate of 46.3%, mean hospital stay of 13.9±10.4 d, morbidity rate of 55.3%, and mortality rate of 16.3%. The NOM group had an ICU/HDU admission rate of 9.3%, mean hospital stay of 6.7±4.5 d, morbidity rate of 12.4%, and mortality rate of 2.1%. The total cost for the patients’ healthcare was also higher in the OM group. The results are summarized in Table 2.

DISCUSSION Although Sir McCormack has advocated since 1900 that “A man wounded in war in the abdomen dies if he is operated upon and remains alive if he is left in peace,”[15] this aphorism faded and was gradually replaced by the dogma of mandatory laparotomy in all cases of hemoperitoneum after the Second World War. The operative approach was once again questioned and significantly modified after 1990 when the NOM of BAT in selected cases was introduced, leading to a significant reduction in the number of unnecessary laparotomies.[16] Several reports in the literature have validated NOM as an established and accepted management protocol for solid organ injuries in hemodynamically stable patients.[17,18] However, NOM may be challenging in cases of severe associated Ulus Travma Acil Cerrahi Derg, March 2018, Vol. 24, No. 2

injuries, particularly head injury and alcohol/drug abuse, which may fade or hide abdominal signs and symptoms. All hemodynamically stable patients with no signs of peritoneal irritation and solid organ injury should be considered for NOM. CT scan represents the gold standard in the evaluation of these patients; however, its usefulness in the diagnosis of bowel injuries remains controversial.[19] It has been proposed that the presence of free fluid without any evidence of solid organ injury is a significant marker of possible mesenteric or bowel injury.[20] However, in patients with BAT, even in these cases, the initial application of NOM is appropriate in most patients.[21] Although the radiological grade of severity of injury is not a contraindication for NOM, the higher grade of injury is often accompanied by a higher rate of failure. IV contrast blushing by minor vessels in solid organs should be interpreted with extreme caution during NOM. If an ongoing hemorrhage is evident, then NOM should probably be abandoned, although arterial embolization could be helpful in selected cases.[22] Recent studies have suggested that the injured organ is important and sometimes even critical in the success of NOM. Non-splenic blunt injury has been identified as an independent prognostic factor. Furthermore, splenic trauma is reported to be associated with the highest failure rates of up to 30%.[23,24] Moreover, splenic embolization has limited benefits and is associated with higher rates of re-embolization.[25] Based on these data, no splenic embolization was performed in our study. In the present study, the success rate of NOM was 100%, which is higher than the mean reported rate of 80%.[26] This fact was obviously attributed to the “over-strict” management of trauma patients, which resulted in the exclusion of the so-called “gray-zone” patients who could be initially treated non-operatively, but with a higher possibility of failure and surgical conversion.[27] Personal judgment and experience of the trauma surgeon, hospital’s infrastructure, and the homogeneity of the team are important factors. In our study, ISS was higher in the group of patients treated surgically. ISS >15 is indicative of poly-trauma patients, and 107

Liagkos et al. Successful non-operative management of blunt abdominal trauma in highly selective cases

ISS >25 is related to higher failure rates for NOM.[28] Interestingly, the grade of injury of the most usually injured organs (liver, spleen, and kidney) was similar in both groups and did not affect the outcomes of NOM. NOM for BAT is highly successful and safe when applied in hemodynamically stable patients without any sign of peritonitis. NOM reduces blood transfusion requirement, morbidity, mortality, and the incidence of unnecessary laparotomies. Even cases with multiple abdominal injuries can be successfully managed by NOM, independent of the grade of injury, if they are closely monitored, preferably by the same clinical team. ISS is an independent risk factor for surgical treatment. NOM is associated with a low overall morbidity and mortality and does not increase the length of hospital stay and cost. Conflict of interest: None declared.

REFERENCES 1. Søreide K. Epidemiology of major trauma. Br J Surg 2009;96:697–8. 2. Smith J, Caldwell E, D’Amours S, Jalaludin B, Sugrue M. Abdominal trauma: a disease in evolution. ANZ J Surg 2005;75:790–4. 3. Ogura T, Lefor AT, Nakano M, Izawa Y, Morita H. Nonoperative management of hemodynamically unstable abdominal trauma patients with angioembolization and resuscitative endovascular balloon occlusion of the aorta. J Trauma Acute Care Surg 2015;78:132–5. 4. Franklin GA, Casós SR. Current advances in the surgical approach to abdominal trauma. Injury 2006;37:1143–56. 5. Mackersie RC, Dicker RA. Pitfalls in the evaluation and management of the trauma patient. Curr Probl Surg 2007;44:778–833. 6. The American College of Surgeons. Advanced Trauma Life Support. 7th ed. Chicago; 2004. 7. Hamada SR, Delhaye N, Kerever S, Harrois A, Duranteau J. Integrating eFAST in the initial management of stable trauma patients: the end of plain film radiography. Ann Intensive Care 2016;6:62. 8. Velmahos GC, Toutouzas KG, Radin R, Chan L, Demetriades D. Nonoperative treatment of blunt injury to solid abdominal organs: a prospective study. Arch Surg 2003;138:844–51. 9. Giannopoulos GA, Katsoulis IE, Tzanakis NE, Patsaouras PA, Digalakis MK. Non-operative management of blunt abdominal trauma. Is it safe and feasible in a district general hospital? Scand J Trauma Resusc Emerg Med 2009;17:22. 10. van der Vlies CH, Olthof DC, Gaakeer M, Ponsen KJ, van Delden OM, Goslings JC. Changing patterns in diagnostic strategies and the treatment of blunt injury to solid abdominal organs. Int J Emerg Med 2011;4:47. 11. van der Wilden GM, Velmahos GC, Emhoff T, Brancato S, Adams C, Georgakis G, et al. Successful nonoperative management of the most severe blunt liver injuries: a multicenter study of the research consortium of

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new England centers for trauma. Arch Surg 2012;147:423–8. 12. Swift C, Garner JP. Non-operative management of liver trauma. J R Army Med Corps 2012;158:85–95. 13. Santucci RA, Wessells H, Bartsch G, Descotes J, Heyns CF, McAninch JW, et al. Evaluation and management of renal injuries: consensus statement of the renal trauma subcommittee. BJU Int 2004;93:937–54. 14. Injury Scoring Scale: A Resource for Trauma Care Professionals. Available at: http://www.aast.org/library/traumatools/injuryscoringscales. aspx. Accessed Dec 27, 2017. 15. McCormack: J. Royal Soc. Medicine. 84th edition. Derbyshire Royal Infirmary Derby DEI 2 QY; 1991. 16. Stassen NA, Bhullar I, Cheng JD, Crandall M, Friese R, Guillamondegui O, et al. Nonoperative management of blunt hepatic injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg 2012;73:S288–93. 17. Peitzman AB, Ferrada P, Puyana JC. Nonoperative management of blunt abdominal trauma: have we gone too far? Surg Infect (Larchmt) 2009;10:427–33. 18. Magu S, Agarwal S, Gill RS. Multi detector computed tomography in the diagnosis of bowel injury. Indian J Surg 2012;74:445–50. 19. Chen ZB, Zhang Y, Liang ZY, Zhang SY, Yu WQ, Gao Y, et al. Incidence of unexplained intra-abdominal free fluid in patients with blunt abdominal trauma. Hepatobiliary Pancreat Dis Int 2009;8:597–601. 20. Kong VY, Jeetoo D, Naidoo LC, Oosthuizen GV, Clarke DL. Isolated free intra-abdominal fluid on CT in blunt trauma: The continued diagnostic dilemma. Chin J Traumatol 2015;18:357–9. 21. Cohn SM, Arango JI, Myers JG, Lopez PP, Jonas RB, Waite LL, et al. Computed tomography grading systems poorly predict the need for intervention after spleen and liver injuries. Am Surg 2009;75:133–9. 22. Cadeddu M, Garnett A, Al-Anezi K, Farrokhyar F. Management of spleen injuries in the adult trauma population: a ten-year experience. Can J Surg 2006;49:386–90. 23. Okuş A, Sevinç B, Ay S, Arslan K, Karahan Ö, Eryılmaz MA. Conservative management of abdominal injuries. Ulus Cerrahi Derg 2013;29:153–7. 24. Harbrecht BG, Ko SH, Watson GA, Forsythe RM, Rosengart MR, Peitzman AB. Angiography for blunt splenic trauma does not improve the success rate of nonoperative management. J Trauma 2007;63:44–9. 25. Raza M, Abbas Y, Devi V, Prasad KV, Rizk KN, Nair PP. Non operative management of abdominal trauma - a 10 years review. World J Emerg Surg 2013;8:14. 26. Bala M, Edden Y, Mintz Y, Kisselgoff D, Gercenstein I, Rivkind AI, et al. Blunt splenic trauma: predictors for successful non-operative management. Isr Med Assoc J 2007;9:857–61. 27. Butcher N, Balogh ZJ. The definition of polytrauma: the need for international consensus. Injury 2009;40 Suppl 4:S12–22. 28. Olthof DC, Joosse P, van der Vlies CH, de Haan RJ, Goslings JC. Prognostic factors for failure of nonoperative management in adults with blunt splenic injury: a systematic review. J Trauma Acute Care Surg 2013;74:546–57.

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ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Yüksek derecede selektif olgularda künt abdominal travmanın başarılı cerrahidışı tedavisi: Güvenli ve etkili bir seçim Dr. Georgios Theodoros Liagkos,1 Dr. Charalampos Spyropoulos,2 Dr. Gerasimos Tsourouflis,3 Dr. Aris Papadopoulos,1 Dr. Paulos Ioannides,1 Dr. Constantine Vagianos3 1 2 3

Nikaia Genel Hastanesi I. Cerrahi Bölümü, Nikaia, Pire-Yunanistan Iaso Genel Hastanesi 3. Cerrahi Bölümü, Holargos, Atina-Yunanistan Atina Ulusal ve Kapodestrian Laikon Üniversite Hastanesi, Propedik Cerrahi Bölümü, Atina-Yunanistan

AMAÇ: Abdominal yaralanmaların cerrahi dışı tedavisi (CDT) son 10 yıllarda geniş kabul görmüştür. Bu çalışmada, bölgesel Yunanistan hastanesinde künt abdominal travmada (KAT) CDT etkinliği değerlendirildi. GEREÇ VE YÖNTEM: Künt abdominal travma için 2008–2015 arası hastaneye yatırılmış hastaların tümüne önceden kararlaştırılarak uygulanmış tedavi protokollerinin sonuçları incelendi. Protokol peritonit belirtileri olmayan hemodinamik açıdan stabil hastalarda CDT’yi önerdi. Demografik özellikler, yaralanmanın tipi, yaralanmış organ(lar), tedavi tipi (cerrahi’ye karşın cerrahi dışı) Yaralanma Şiddeti Skoru (YŞS), morbidite, mortalite oranları ve sağlık bakım maliyetleri değerlendirildi. BULGULAR: Künt abdominal travma nedeniyle bölümümüze yatırılmış146 hasta çalışmaya alındı. Bunlar arasında 49’u ameliyat edilmiş, 97’sine CDT uygulanmıştı. Yaralanma Şiddeti Skoru cerrahi grubunda istatistiksel açıdan daha yüksek olmasına rağmen iki grup arasında karaciğer, dalak ve böbreklerdeki yaralanmanın şiddet derecesi açısından farklılık yoktu. Cerrahi dışı tedavi uygulanan hiçbir olgu için muhtemelen CDT’nin katı dahil edilme kriterleri nedeniyle cerrahi tedaviye geçiş gerekmemişti. TARTIŞMA: Hemodinamik açıdan stabil, fizik muayenesi normal yüksek derecede selektif olgular yaralanmanın derecesine bakılmaksızın cerrahi dışı yöntemlerle tedavi edilebilir. Yaralanma Şiddeti Skoru cerrahi tedavi riskine ilişkin bağımsız bir risk faktörüdür. Anahtar sözcükler: Cerrahi dışı tedavi; hemodinamik stabilite; künt karın travması. Ulus Travma Acil Cerrahi Derg 2018;24(2):104–109

doi: 10.5505/tjtes.2017.83404

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ORIG I N A L A R T IC L E

Can serum soluble urokinase plasminogen activator receptor be an effective marker in the diagnosis of appendicitis and differentiation of complicated cases? Melih Akın, M.D.,1 Başak Erginel, M.D.,1 Nihat Sever, M.D.,1 Kerem Özel, M.D.,2 Banu Bayraktar, M.D.,3 Abdullah Yıldız, M.D.,1 Çetin Ali Karadağ, M.D.,1 Meltem Tokel, M.D.,1 Ali İhsan Dokucu, M.D.1 1

Department of Pediatric Surgery, Şişli Hamidiye Etfal Training and Research Hospital, İstanbul-Turkey

Department of Pediatric Surgery, İstanbul Bilim University Faculty of Medicine, İstanbul-Turkey

Department of Microbiology, Şişli Hamidiye Etfal Training and Research Hospital, İstanbul-Turkey

ABSTRACT BACKGROUND: Soluble urokinase plasminogen activator receptor (suPAR) is a new biomarker of inflammation level. The aim of the study was to evaluate whether suPAR levels could be useful to detect acute appendicitis and to differentiate uncomplicated appendicitis (UA) from complicated appendicitis (CA). METHODS: We prospectively studied 105 patients consisting of 40 UA cases, 40 CA cases, and 25 control patients. Blood samples were collected to measure suPAR level, C-reactive protein level, leukocyte counts, neutrophil counts, and neutrophil percentages preoperatively. RESULTS: Median values of suPAR level, C-reactive protein level, leukocyte counts, neutrophil counts, and neutrophil percentages in UA and CA were significantly higher than control patients. suPAR levels of the UA and CA groups showed a statistically significant difference (p=0.016). CONCLUSION: The current study demonstrated that serum suPAR concentrations can be helpful in differentiating CA from UA and in diagnosing acute appendicitis. Keywords: Complicated appendicitis; soluble urokinase plasminogen activator receptor; uncomplicated appendicitis.

INTRODUCTION Traditionally, the standard diagnostic method for acute appendicitis is physical examination, and the most common treatment is appendectomy. Additionally, there are randomized controlled studies on medical treatment for appendicitis. The treatment of patients with complicated appendicitis is controversial, and there is no clear consensus on the optimal treatment. Acute appendicitis is the most common surgical emergency in children and adolescents.[1] Many inflammatory markers such as white blood cell count (WBC), C-reactive protein (CRP),

procalcitonin, and D-dimer were used for the diagnosis of appendicitis.[2,3] These biomarkers have been shown to be useful in diagnosing appendicitis. In literature, no biomarkers have been identified for the preoperative differentiation of uncomplicated appendicitis (UA) from complicated appendicitis (CA). The soluble urokinase plasminogen activator receptor (suPAR), a soluble form of the urokinase-type plasminogen activator receptor, is a biomarker that is produced by monocytes, macrophages, neutrophils, endothelial cells, active T cells, and tumor cells in serum, plasma, and cerebrospinal fluid. Urokinase bound to the cytoplasm and membrane of the proteolytic

Cite this article as: Akın M, Erginel B, Sever N, Özel K, Bayraktar B, Yıldız A, et al. Can serum soluble urokinase plasminogen activator receptor be an effective marker in the diagnosis of appendicitis and differentiation of complicated cases? Ulus Travma Acil Cerrahi Derg 2018;24:110–115 Address for correspondence: Başak Erginel, M.D. Şişli Hamidiye Etfal Eğitim ve Araştırma Hastanesi, Çocuk Cerrahisi Kliniği, İstanbul, Turkey Tel: +90 212 - 373 50 00 E-mail: basakerginel@hotmail.com Ulus Travma Acil Cerrahi Derg 2018;24(2):110–115 DOI: 10.5505/tjtes.2017.05752 Submitted: 24.01.2016 Accepted: 29.06.2017 Online: 12.02.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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pathway is secreted by the plasminogen activator receptor.[4,5] suPAR levels increase in inflammation levels in cases such as pneumonia, urinary tract infections, Human Immunodeficiency virus (HIV) infection, urosepsis, sepsis, and malignancy.[6–8] The aim of this study was to investigate the efficiency of serum suPAR levels in the diagnosis of appendicitis and differentiation of the complicated cases.

MATERIALS AND METHODS Patient Selection and Study Design This was a single-center, prospective study conducted between March 2012 and February 2015. Written informed consent was obtained from each patient’s family, and the study was approved by the University of Health Sciences, Şişli Hamidiye Etfal Training and Research Hospital’s Ethics Committee (04.12.2012-129). This study was supported by Istanbul Bilim University’s Scientific Research Project Coordination Unit, which is under the category of Research Projects pursuant to sub-clause a of article 5 in the Directive of the Board of Evaluation for Scientific Projects (Project No: 201201-01). The study groups consisted of 40 patients with UA (acute, suppurative) and 40 patients with CA (gangrenous, perforated). The control group consisted of 25 patients who had undergone surgery for inguinal hernia, lipoma, pilonoidal sinus without infections, circumcision, or hypospadias. UA was defined as inflamed or suppurative appendicitis, and CA was defined as gangrenous or ruptured appendicitis.[9] Demographic variables and clinical findings were recorded and statistically compared. Blood samples were collected to measure suPAR level, CRP level, and WBC preoperatively.

Serum suPAR Analysis Blood (2 mL) from the patients was centrifuged for 10 min at 1000 g (=3000 rpm), and the serum samples were stored at −80°C; these samples were collectively evaluated. The serum suPAR values were quantified using the suPARnostic assay (ViroGates, Copenhagen, Denmark), a suPARnostic TM ELISA kit, according to the manufacturer’s instructions. Briefly, serum specimens (25 µL) were added to the wells of the ELISA plate, followed by addition of a peroxidase conjugate solution (225 µL). A second test was carried out using 100 µL of serum and the conjugate in duplicate wells. The re-

action mixtures were incubated for 1 h at room temperature (18°C–26°C) in the dark. After washing, TMB substrate (100 µL) was added to each well and incubated for another 20 min at room temperature. The reaction was stopped by adding a stopping solution (100 µL) to each well. The absorbance was read at 450 nm within 30 min of stopping the reaction.[5]

Statistical Analysis Statistical calculations were performed with the NCSS 2007 program for Windows. Besides standard descriptive statistical calculations [mean, standard deviation, median, interquartile range (IQR)], Kruskal–Wallis test was used in the comparison of the groups. Post-hoc Dunn’s multiple comparison test was used in the comparison of the subgroups, and a Chi square test was used to evaluate the qualitative data. The results were evaluated within a 95% confidence interval (CI). The statistical significance level was p<0.05. To calculate the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and likelihood ratio (LR) for the suPAR level, CRP level, WBC count, neutrophil count (NC), and neutrophil percentage (NP) at varying cutoff values, a conventional receiver operating characteristic (ROC) curve was generated. The area under the curve (AUC) was calculated for suPAR, CRP, WBC, NC, and NP as a biomarker. ROC analysis was used to calculate AUC for the suPAR, CRP, WBC, NC, and NP cutoff values and to identify the progression to appendicitis.

RESULTS The study group comprised 34 females and 71 males. The median ages were 10 (IQR, 4.5–12) years in the control group, 10 (IQR, 8.25–14) years in the UA group, and 10.5 (IQR, 7.25–13) years in the CA group (p=0.226). There were no significant differences between the demographic properties of the groups. The median length of hospital stay was 2 (IQR, 1–2) in the UA group and 6 (IQR, 5–8) in the CA group (p=0.0001). There was a significant difference between the duration of hospitalization in the two groups (Table 1). As the three groups marker were compared, suPAR level, CRP level, WBC count, NC, and NP were found to be significantly increased in the UA and CA groups than in the control

Table 1. Median and IQR values of age (years) and gender Age Median (IQR)

Control group

Uncomplicated appendicitis group

Complicated appendicitis group

10 (4.5–12)

10 (8.25–14)

10.5 (7.25–13)

0.226 0.345

Gender

Female

9 (36.0%)

10 (25.0%)

15 (37.5%)

Male

16 (64.0%)

30 (75.0%)

25 (62.5%)

IQR: Interquartile range.

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Table 2. Median and IQR values of the serum suPAR (ng/mL) and CRP (mg/dL) levels, WBC (mm3) and NC (mm3), and NP (%) in the three groups of patients

Control group

Uncomplicated appendicitis group

Complicated appendicitis group

suPAR

2.84 (2.63–3.41)

3.76 (2.97–4.37)

4.17 (3.55–5.5)

0.0001

CRP

3.19 (1.14–3.19)

16.5 (2.6–87.43)

21.75 (11.35–67.35)

0.0001

WBC

7.8 (7.3–9.7)

16.05 (11.08–19.3)

16.85 (14.2–19.6)

0.0001

3.2 (2.2–3.5)

13.55 (8.29–16.93)

14.23 (11.69–16.65)

0.0001

35.5 (28.45–44.3)

84.25 (73.23–88.65)

86.86 (79.28–89.83)

0.0001

suPAR: Soluble urokinase plasminogen activator receptor; CRP: C-reactive protein; WBC: White blood cell count; NC: Neutrophil count; NP: Neutrophil percentage.

Table 3. Dunn’s multiple comparison test for serum suPAR and CRP levels, NC, and NP in the three groups Groups

100

suPAR CRP WBC NC NP

UA/CA

0.016 0.279 0.199 0.240 0.153

suPAR: Soluble urokinase plasminogen activator receptor; CRP: C-reactive protein; WBC: White blood cell count; NC: Neutrophil count; NP: Neutrophil percentage; UA: uncomplicated appendicitis; CA: Complicated appendicitis.

group (p=0.0001). The suPAR levels in the CA group were significantly higher than those in the UA group (p=0.016). This parameter was the only statistically significant difference between these two groups (Tables 2, 3). The ROC curves of sensitivity (true positive rate) versus specificity (false positive rate) for the different cutoff values of the suPAR, CRP, NC, NP, and WBC in relation to different outcomes in the control and appendicitis groups are illustrated in Figure 1. The AUC was 0.811 (95% CI 0.723–0.881) for suPAR, 0.864 (95% CI 0.784–0.923) for CRP, 0.912 (95% CI 0.841–0.958) for WBC, 0.975 (95% CI. 0.925–0.995) for NC, and 0.980 (95% CI 0.931–0.997) for NP. There was a correlation between suPAR and WBC, suPAR and NC, and suPAR and NC between the appendicitis and control groups. To investigate the value of suPAR as a diagnostic marker for appendicitis, a cutoff value of 3.5 ng/mL and an LR equal to 4.37 were used (LR >2: statistically significant value). The results of other markers value are showed in Table 4. The ROC curves of sensitivity (true positive rate) versus specificity (false positive rate) for the different cutoff values of suPAR, CRP, NC, NP, and WBC in relation to outcomes in the UA and CA groups is illustrated in Figure 2. The AUC was 0.656 (95% CI 0.542–0.759) for suPAR, 0.570 (95% CI 0.455–0.681) for CRP, 0.583 (95% CI0.468–0.693) for WBC, 0.576 (95% CI 0.461–0.686) for NC, and 0.593 (95% CI 0.477–0.701) for NP. There was no significant correlation between the ability of the markers to differentiate UA from CA. 112

suPAR CRP WBC NC NP

40 60 100-Specificity

100

Figure 1. ROC curves of the discrimination ability of serum suPAR, CRP, WBC, NC, and NP to differentiate the control and the appendicitis cases.

100

Sensitivity

Control/CA 0.0001 0.0001 0.0001 0.0001 0.0001

Sensitivity

Control/UA 0.001 0.0001 0.0001 0.0001 0.0001

suPAR CRP WBC NC NP

40 60 100-Specificity

100

Figure 2. ROC curves of the discrimination ability of serum suPAR, CRP, WBC, NC, and NP to differentiate UA and CA.

To investigate the value of suPAR as a differential marker of UA and CA, a cutoff value of 4.1 ng/mL was founded. LR was equal to 2 with statistically significant. The cutoff values of sensitivity and specificity of suPAR, CRP, WBC, NC, and Ulus Travma Acil Cerrahi Derg, March 2018, Vol. 24, No. 2

AkÄąn et al. Serum soluble urokinase plasminogen activator receptor in diagnosis of appendicitis in children

Table 4. Cutoff values, sensitivity, and specificity of the suPAR, CRP, NC, and NP for the prediction of outcomes in the control and appendicitis groups Control/appendicitis

Cutoff values

Sensitivity

Specificity

PPV

NPV

Likelihood ratio

suPAR

3.5

70.00

84.00

93.3

46.7

4.37

CRP

3.19

82.50

36.00

80.5

39.1

1.29

5.29

93.75

96.00

98.7

82.8

23.44

55.8

95.00

96.00

98.7

85.7

23.75

suPAR: Soluble urokinase plasminogen activator receptor; CRP: C-reactive protein; NC: Neutrophil count; NP: Neutrophil percentage; PPV: positive predictive value; NPV: Negative predictive value.

Table 5. Cutoff values, sensitivity, and specificity of suPAR, CRP, NC, and NP for the prediction of outcomes in uncomplicated and complicated appendicitis groups UA/CA groups

Cutoff values

Sensitivity

Specificity

PPV

NPV

Likelihood ratio

suPAR

4.1

55.00

72.50

66.7

61.7

2.00

CRP

7.6

82.50

40.00

57.9

69.6

1.37

WBC

15.4

70.00

47.50

57.1

61.3

1.33

8.16

92.50

25.00

55.9

83.3

1.23

71.9

95.00

25.00

55.9

83.3

1.27

suPAR: Soluble urokinase plasminogen activator receptor; CRP: C-reactive protein; NC: Neutrophil count; NP: Neutrophil percentage; PPV: positive predictive value; NPV: Negative predictive value; UA: uncomplicated appendicitis; CA: Complicated appendicitis.

NP for the prediction of outcomes in UA and CA groups are shown in Table 5.

DISCUSSION Acute appendicitis is generally diagnosed by physical examination and clinical evaluation. Biochemical markers and radiologic evaluations are helpful for clinicians to diagnose this disease. Progression from UA to CA is fast in children. It can be difficult to differentiate preoperative CA from UA. Many markers for inflammation were evaluated during CA and UA periods. It has been reported that during the progression of appendicitis, WBC counts and CRP levels rise due to inflammation, yet these parameters have not proved adequate in determining the degree of inflammation for CA evaluation.[10] BeltrĂĄn et al.[11] have stated that BKS and CRP can be beneficial in the diagnosis of appendicitis and in distinguishing UA from CA. According to the findings of our study, differently from other parameters, serum suPAR level is an effective marker in both diagnosing appendicitis and distinguishing CA from UA. The results are statistically significant (Table 3). It has been found that increases in serum CRP level, WBC count, NC, and NP are also statistically significant in diagnosing acute appendicitis; yet none of these markers have proven to be adequate parameters for statistically distinguishing CA from UA (Table 3). In our study, the cutoff value for a UA diagnosis has been measured to be 3.5 ng/mL, with 84% specificity and 93% PPV. Ulus Travma Acil Cerrahi Derg, March 2018, Vol. 24, No. 2

In patients with acute abdominal findings, suPAR levels seem to be an effective parameter in establishing a diagnosis. The cutoff value for suPAR in distinguishing CA from UA has been measured to be 4.1 ng/mL, with 72.5% specificity, 66.7% PPV, and 55% sensitivity. Although sensitivity levels have not been found to be high, the serum suPAR level is an effective indicator in distinguishing CA from UA. As seen in Table 2, the IQR values of suPAR do not show wide fluctuations. These results demonstrated that serum suPAR levels are more effective in terms of their impact on diagnosis and differential diagnosis. Through a comparison with existing literature, it may be said that the results of our study have revealed less of an increase in suPAR levels in the case of appendicitis than in cases of sepsis, pneumonia, or pyelonephritis. In various studies, suPAR levels for community-acquired pneumonia and pyelonephritis have been measured as >8 ng/dL.[7,12] In another study, the median suPAR level in pneumonia patients has been found to be 10.5 ng/mL, and it has been reported that suPAR levels >12.9 ng/mL predict undesirable outcomes such as death, with 80% specificity and 76.1% PPV.[13] Different cutoff values in different illnesses may assist clinicians in establishing a differential diagnosis. Similar results have been found in patients infected with HIV. While suPAR levels <3.28 ng/mL may indicate patients infected with HIV, suPAR levels >4.19 ng/mL are associated with mortality risk due to AIDS.[14] It appears that cutoff val113

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ues for patients infected with HIV are close to the values of those infected with acute appendicitis. There are studies demonstrating that suPAR levels are also important markers in terms of mortality and morbidity. suPAR levels in patients with sepsis have also been evaluated, and the cutoff value has been measured as 5.5 ng/dL, with 75% sensitivity and 72% specificity. In another study, the cutoff value has been found to be >6.61 mcg/L in the case of sepsis.[15,16] In yet another study, suPAR levels >10–12 ng/dL have been demonstrated as a prognostic marker for estimated mortality rates in pneumonia-related sepsis.[13] In a study by Okulu et al.,[17] suPAR level has been found to be an effective marker in infants with sepsis, and the cutoff value has been measured to be 11.3 ng/dL. In our study, the median suPAR level in the CA group amounted to 4.17 (IQR, 3.55–5.5) ng/ mL. There were no patients in life-threatening or critical condition due to appendicitis in any group. No high suPAR levels were found. Among other markers, a wide range of results were observed, particularly in terms of CRP levels. Consequently, it is important that an appendicitis diagnosis could be established clinically, especially with physical examination. None of the currently existing markers have yet proven to be definitively sensitive or selective. Biomarkers are helpful for formulating the diagnosis. High suPAR levels have been observed to be beneficial in diagnosing appendicitis, differentiating cases of CA, and demonstrating the seriousness of the illness. It is also beneficial in establishing a differential diagnosis for illnesses such as pneumonia, which give rise to symptoms such as stomach pain. For serum suPAR levels to attain clinical use, there is need for large-scale and well-attended studies evaluating patients with complaints of acute abdominal pain. Conflict of interest: None declared.

REFERENCES 1. Addiss DG, Shaffer N, Fowler BS, Tauxe RV. The epidemiology of appendicitis and appendectomy in the United States. Am J Epidemiol 1990;132:910–25.

Surg 2013;100:322–9. 4. Madsen CD, Sidenius N. The interaction between urokinase receptor and vitronectin in cell adhesion and signalling. Eur J Cell Biol 2008;87:617– 29. 5. Tzanakaki G, Paparoupa M, Kyprianou M, Barbouni A, Eugen-Olsen J, Kourea-Kremastinou J. Elevated soluble urokinase receptor values in CSF, age and bacterial meningitis infection are independent and additive risk factors of fatal outcome. Eur J Clin Microbiol Infect Dis 2012;31:1157–62. 6. Andersen O, Eugen-Olsen J, Kofoed K, Iversen J, Haugaard SB. Soluble urokinase plasminogen activator receptor is a marker of dysmetabolism in HIV-infected patients receiving highly active antiretroviral therapy. J Med Virol 2008;80:209–16. 7. Wittenhagen P, Andersen JB, Hansen A, Lindholm L, Rønne F, Theil J, et al. Plasma soluble urokinase plasminogen activator receptor in children with urinary tract infection. Biomark Insights 2011;6:79–82. 8. Mölkänen T, Ruotsalainen E, Thorball CW, Järvinen A. Elevated soluble urokinase plasminogen activator receptor (suPAR) predicts mortality in Staphylococcus aureus bacteremia. Eur J Clin Microbiol Infect Dis 2011;30:1417–24. 9. Chan KW, Lee KH, Mou JW, Cheung ST, Sihoe JD, Tam YH. Evidencebased adjustment of antibiotic in pediatric complicated appendicitis in the era of antibiotic resistance. Pediatr Surg Int 2010;26:157–60. 10. Stefanutti G, Ghirardo V, Gamba P. Inflammatory markers for acute appendicitis in children: are they helpful? J Pediatr Surg 2007;42:773–6. 11. Beltrán MA, Almonacid J, Vicencio A, Gutiérrez J, Cruces KS, Cumsille MA. Predictive value of white blood cell count and C-reactive protein in children with appendicitis. J Pediatr Surg 2007;42:1208–14. 12. Wrotek A, Pawlik K, Jackowska T. Soluble receptor for urokinase plasminogen activator in community-acquired pneumonia in children. Adv Exp Med Biol 2013;788:329–34. 13. Savva A, Raftogiannis M, Baziaka F, Routsi C, Antonopoulou A, Koutoukas P, et al. Soluble urokinase plasminogen activator receptor (suPAR) for assessment of disease severity in ventilator-associated pneumonia and sepsis. J Infect 2011;63:344–50. 14. Sidenius N, Sier CF, Ullum H, Pedersen BK, Lepri AC, Blasi F, et al. Serum level of soluble urokinase-type plasminogen activator receptor is a strong and independent predictor of survival in human immunodeficiency virus infection. Blood 2000;96:4091–5. 15. Gustafsson A, Ljunggren L, Bodelsson M, Berkestedt I. The Prognostic Value of suPAR Compared to Other Inflammatory Markers in Patients with Severe Sepsis. Biomark Insights 2012;7:39–44.

2. Kaya B, Sana B, Eris C, Karabulut K, Bat O, Kutanis R. The diagnostic value of D-dimer, procalcitonin and CRP in acute appendicitis. Int J Med Sci 2012;9:909–15.

16. Kofoed K, Eugen-Olsen J, Petersen J, Larsen K, Andersen O. Predicting mortality in patients with systemic inflammatory response syndrome: an evaluation of two prognostic models, two soluble receptors, and a macrophage migration inhibitory factor. Eur J Clin Microbiol Infect Dis 2008;27:375–83.

3. Yu CW, Juan LI, Wu MH, Shen CJ, Wu JY, Lee CC. Systematic review and meta-analysis of the diagnostic accuracy of procalcitonin, C-reactive protein and white blood cell count for suspected acute appendicitis. Br J

17. Okulu E, Arsan S, Akin IM, Ates C, Alan S, Kilic A, et al. Serum Levels of Soluble Urokinase Plasminogen Activator Receptor in Infants with Late-onset Sepsis. J Clin Lab Anal 2015;29:347–52.

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ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Çocuk hastalarda suPAR’ın (Serum soluble urokinase plasminogen activator receptor) akut panadisit tanısında yararı var mıdır? Dr. Melih Akın,1 Dr. Başak Erginel,1 Dr. Nihat Sever,1 Dr. Kerem Özel,2 Dr. Banu Bayraktar,3 Dr. Abdullah Yıldız,1 Dr. Çetin Ali Karadağ,1 Dr. Meltem Tokel,1 Dr. Ali İhsan Dokucu1 1 2 3

Şişli Hamidiye Etfal Eğitim ve Araştırma Hastanesi, Çocuk Cerrahisi Kliniği, İstanbul Bilim Üniversitesi Tıp Fakültesi, Çocuk Cerrahisi Anabilim Dalı, İstanbul Şişli Hamidiye Etfal Eğitim ve Araştırma Hastanesi, Mikrobiyoloji Kliniği, İstanbul

AMAÇ: suPAR (Soluble urokinase plasminogen activator receptor) enflamasyon düzeyinin tesbitinde kullanılan yeni bir biyobelirteçtir. Çalışmamızın amacı suPAR düzeylerinin çocuklarda akut apandidsit tanısındaki ve akut ve kronik apandisit ayırımındaki yerini tartışmaktır. GEREÇ VE YÖNTEM: Çalışmamıza 40 komplike apandisit, 40 komplike olmaya apandisit ve 25 kontrol grubu oluştumak üzere 105 çocuk alındı. Tüm hastalardan ameliyat öncesinde suPAR, C-reaktif protein, lökosit, nötrofil ve nötrofil yüzdesi bakılmak üzere kan örnekleri alındı. BULGULAR: Apandisitli gruplarda kontrol grubuna göre suPAR, C-reaktif protein, lökosit, nötrofil ve nötrofil yüzdesi anlamlı olarak yüksek bulundu. Komplike apandisitlerde suPAR değeri anlamlı olarak daha yüksek bulundu (p=0.016). TARTIŞMA: Çalışmamız kan suPAR seviyelerinin akut ve komplike apandisit ayırımında faydalı olduğunu göstermiştir. Anahtar sözcükler: komplike apandisit; komplike olmayan apandisit; soluble urokinase plasminogen activator receptor (suPAR). Ulus Travma Acil Cerrahi Derg 2018;24(2):110–115

doi: 10.5505/tjtes.2017.05752

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Features and treatment of gas-forming synergistic necrotizing cellulitis: a nine-year retrospective study Xiangwei Ling, M.M.,1* Yuanyuan Ye, M.M.,2* Hailei Guo, M.M.,1 Zhengjun Liu, M.M.,1 Weidong Xia, M.M.,1 Cai Lin, M.D.1 1

Department of Burn, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, People’s Republic of China

Operating Rooms, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, People’s Republic of China

*Xiangwei Ling and Yuanyuan Ye contributed equally and share the first authorship.

ABSTRACT BACKGROUND: As many doctors know little about gas-forming synergistic necrotizing cellulitis, we retrospectively explored it in our study. METHODS: Totally, 30 patients diagnosed with gas-forming synergistic necrotizing cellulitis between November 2006 and September 2015 were included. They were divided into two groups: open drainage group (19 patients) and aggressive debridement group (11 patients). Retrospectively analyzed data comprised demographic characteristics, APACHE II scores, pathogen culture results, bleeding amount during the operation, white blood cell count, length of hospital stay and recovery. RESULTS: The mortality rate was 26% in the open drainage group and 73% in the aggressive debridement group (p=0.023). There was no statistical difference in the APACHE II score before treatment between the open drainageand aggressive debridement groups (16.6±4.5 vs 18.1±7.5, p=0.511). The APACHE II score was significantly higher after treatment in the aggressive debridement group (14.2±5.8 score vs 20.1±9.1, p=0.038). There were no statistical differences in the white blood count cell before and after treatment (13.49 × 109±5.05×109 cells/L vs 17.46×109±6.94×109 cells/L, p=0.082; 10.37×109±3.54×109 cells/L vs 15.47×109±7.51×109 cells/L, p=0.055; respectively). The bleeding amount during the operation was significantly more in the aggressive debridement group (315±112 ml vs 105±45 ml, p<0.001. CONCLUSION: For treating gas-forming synergistic necrotizing cellulitis, performing open drainage as early as possible isthe most important procedure after admission. Keywords: Gas-forming infections; gas gangrene; synergistic necrotizing cellulitis.

INTRODUCTION Necrotizing fasciitis is a serious soft tissue infectious disease and is characterized by fascial necrosis and sepsis.[1] Based on the causativebacteria, it canbe divided into two types: type I necrotizing fasciitis is causedby various bacteria, including gram-positive Streptococcus hemolyticus and Staphylococcus aureus and type II necrotizing fasciitis is generally monomicrobial and is typically caused by beta hemolytic Streptococcus. [2] Type I necrotizing fasciitis often occurs in the lower limbs; patients with diabetes and peripheral vascular disease are at

a high risk of developing this disease. Sometimes, the neck region or the perineum isalso involved. Necrotizing fasciitis involving the perineum can rapidly spread to the abdominal wall, gluteal muscles, scrotum, and penis. Gas-forming synergistic necrotizing cellulitis is a special category of type I necrotizing fasciitis and is characterized by muscle involvement. Bacillus cereushas beendemonstrated to cause this disease.[3] In clinical settings, gas-forming synergistic necrotizing cellulitis is always considered as gas gangrene. Many doctors believe that no advantage results from the distinction in regard to patient care. [4] In our opinion, gas-forming synergistic necrotizing cellulitis

Cite this article as: Ling X, Ye Y, Guo H, Liu Z, Xia W, Lin C. Features and treatment of gas-forming synergistic necrotizing cellulitis: a nine-year retrospective study. Ulus Travma Acil Cerrahi Derg 2018;24:116–120 Address for correspondence: Cai Lin, M.D. The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, People’s Republic of China Wenzhou, China Tel: +86-15868096213 E-mail: 177981554@qq.com Ulus Travma Acil Cerrahi Derg 2018;24(2):116–120 DOI: 10.5505/tjtes.2017.93453 Submitted: 25.12.2016 Accepted: 04.12.2017 Online: 14.02.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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and gas gangrene are two different diseases. Gas gangrene has a unique treatment: (1) Extended resection is necessary, such as amputation. The real range of Clostridium infection is wider than it could be observed, extended resection must be done to control infection.[5] (2) Regarding anti-infective therapeutics, penicillin combined with clindamycin is effective against Clostridium.[6] Clindamycin treatment is highly effective in gas gangrene because gas gangrene is caused by an exotoxin whose synthesis is inhibited by clindamycin.[7] While treating gas-forming synergistic necrotizing cellulitis, many doctors tend to perform aggressive debridement in the early period. In their opinion, aggressive debridement needs to be started as early as possible forgettingrid of the necrotic tissue and toxins to improve the chance of patient survival. However, after doing this, many patients die because of massive hemorrhaging. Therefore, we conducted this retrospective study to find a better treatment and explored the features of this disease.

MATERIALS AND METHODS

Data Collection A retrospective review was performed onthe medical records of all patients who were admitted to our hospital between November 2006 and September 2015 and who metthe study criteria. Inclusion criteria were (1) serious infection of the lower limbs or perineum (Fig. 1a, b), (2) infection involving muscle layers, and (3) subcutaneous emphysema (Fig. 1c, d). Exclusion criteria were (1) incomplete clinical information (2) patients givingup treatment and (3) gas gangrene. Clinical data included age, gender, location of infection, underlying disease, APACHE II score, pathogen culture results, bleeding amount during the operation,white blood cell count,length of hospital stay, and recovery.

Microbiological Methods For pathogen cultures, blood agar and Sabouraud dextrose agar were utilized for all specimens. Physicians then selected the pathogens thought to be suitable. VITEK 2 Compact was used for identification. Minimum inhibitory concentrations were assessed during drug sensitivity tests.

Ethics

Treatment

This study was approved by our local medicotechnical committee (Wenzhou Medical Association, Wenzhou, China).

Early Stage Intervention According to the medical records, 19 patients underwent

(a)

(b)

(c)

(d)

Figure 1. (a) The left foot was seriously infected,and the tissues were severelydamaged. (b) The perineum was ruptured and exuded. (c) The left foot was overly swollen; radiography demonstrated soft tissue emphysema medially (arrow). (d) The scrotum had large amounts of gas inthe radiograph (arrow).

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Table 1. Patient characteristics and mortality rates in open drainage (n=19) and aggressive debridement (n=11) groups Variable

Open drainage group

Aggressive debridement group

n % Mean±SD n % Mean±SD

Sex, male

13 68 8 73 1.000

Age (years) 57.8±8.5 56.4±20.6 0.824 Liver disease

7 37

Diabetes mellitus

12 63 6 55 0.712

Location of infection, lower limbs

5 45 10

Mortality rate 26 73

0.712 1.000 0.023

SD: Standard deviation.

open drainage (open drainage group) and 11 underwent aggressive debridement (aggressive debridement group) as early as possible after admission. In the open drainage group, two ways were recommended for drainage: (1) incisions at the apparent position of crepitus. (2) removal part of necrotic tissues created open drainage. In the aggressive debridement group, all necrotic tissues were removed. Then, broad-spectrum antibiotics and support treatment were provided. Negative pressure wound therapy was not used for these wounds in the early duration. Later Stage Intervention In the following days, dressings were changed and wounds were observed. A rapidly spreading infection was indicative of gas gangrene. Empiric treatment for gas gangrene was implemented, such as extended resection, anti-infective therapeutics (penicillin combined with clindamycin), and amputation. In case of gradual infection, patients were diagnosed with gas-forming synergistic necrotizing cellulitis. In the open drainage group, aggressive debridement was not performed until the vital signs became stable. The dressings were changed, necrotic tissueswere removed, and bleeding amount was reduced by as much as possible. In the aggressive debridement group, the dressings were changedto promote granulation. Antibiotics were changed depending on culture results. Cultures from the 30 patients yielded 42 different species. The most prevalent organisms were Staphylococcus (n=6, 14.3%) (Staphylococcus aureus, S. haemolyticus, S. epidermidis, S. hominis), Proteus (n=6, 14.3%) (Proteus vulgaris, P. mirabilis), Klebsiella pneumonia (n=5, 11.9%), Enterococcus (n=5, 11.9%), Stenotrophomonas maltophilia (n=2,4.8%), Escherichia coli (n=2, 4.8%), Streptococcus (n=2, 4.8%), Citrobacter (n=2, 4.8%), and Corynebacterium (n=2, 4.8%). Acinetobacterbaumannii, Raoultellaplanticola, Rhodococcus equi, Serratia marcescens, Pseudomonas mendocina, Morganella morganii, Enterobacter cloacae, Pseudomonas aeruginosa, Myroides, and Aeromonas caviae. The wounds were finally repaired using skin grafting. 118

RESULTS Patient Characteristics and Mortality Rates Thirty patients (21 males and 9 females) with a mean age of 57.3 years [standard deviation (SD), 13.8] were reviewed. Twenty-sevenpatients had infection that involved the lower limbs and threehad infection that involved the perineum. Eighteenpatientshad diabetes mellitus and 12 had liver disease. The median APACHE II score after hospitalization was 17.2 (SD, 5.7). The median length of hospital stay was 29.2 days (SD, 23.7). A total of 13 patients died (mortality rate of 43%). Among the 14 patients who were successfully treatedfor infection involving the lower limbs, one underwentamputation. There was no statistical difference in terms of age, gender, underlying diseases(diabetes mellitus or liver disease), and position between the open drainage and aggressive debridement groups.The mortality rate was 26% in the open drainage group and 73% in the aggressive debridement group (Table 1).

Changes in the APACHE II Score and White Blood Cell Count After Treatment and Bleeding Amount During the Operation The APACHE II score was significantly higherafter treatment 35

APACHE II score

30 Open drainage group Aggressive debridement group

25 20 15 10 5 0

Before treatment

After treatment

Figure 2. There was no statistical difference in the APACHE II score before treatment between the open drainage and aggressive debridement groups (16.6±4.5 vs 18.1±7.5, p=0.511). The APACHE II score was significantly higher after treatment in the aggressive debridement group (14.2±5.8 vs 20.1±9.1, p=0.038).

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White blood cell (x109 cells/L)

25 Open drainage group Aggressive debridement group

20 15 10 5 0

Before treatment

After treatment

Figure 3. There was no statistical difference in the white blood cell count before and after treatment between the open drainage and aggressive debridement groups (13.49×109 cells/L ±5.05×109 cells/L vs 17.46×109 cells/L ±6.94×109 cells/L, p=0.082; 10.37×109 cells/L ±3.54×109 cells/L vs 15.47×109 cells/L ±7.51×109 cells/L, p=0.055). 450

Bleeding amount during the operation (ml)

400 350 300 250 200 150 100 50 0

Open drainage group

Aggressive debridement group

Figure 4. The bleeding amount during the operation was significantly less in the open drainage group (105±45ml vs 315±112 ml, p<0.001).

in the aggressive debridement group (Fig. 2). There was no statistical difference in the white blood cell count before and after treatment between the open drainage and aggressive debridement groups (Fig. 3). The bleeding amount during the operation was 315±112 ml inthe aggressive debridementgroup, which was significantly higherthan that in the open drainagegroup (105±45 ml; p<0.001) (Fig. 4).

DISCUSSION Gas-forming synergistic necrotizing cellulitis is a very serious and rare disease. Surgery, antimicrobial therapy, and support treatment areessential early interventions. Surgery is thought to be the most important to improve the survival rate and should be conductedas early as possible.[8] Unfortunately, doctors do not know how to conductthe surgery. They think that aggressive debridement is the best way. After many years of treatingpatients with gas-forming synergistic necrotizing cellulitis, we have gained some experience. Gasforming synergistic necrotizing cellulitis requires immediate surgery thatneeds to be started as early as possible to improve the chances of patient survival. Waiting for bacterial Ulus Travma Acil Cerrahi Derg, March 2018, Vol. 24, No. 2

culture growth, which takes several days, is not an option. During the operation, open drainage is the most important procedure; reducing the bleeding amount should also be considered. These patients always show unstable vital signs and poor coagulation function and cannot tolerate aggressive debridement. In our study, we found that the APACHE II score was significantly higher after treatment in the aggressive debridement group. The bleeding amount during the operation was significantly more in the aggressive debridement group. Based on the white blood cell count, we inferredthat open drainage can also control inflammation and infection. After the surgery, doctors must observe the wound and carry out the differential diagnosis of gas gangrene in the following days. Gas gangrene, as a gas-forming infection, is caused by Clostridium, which is a large gram-positive rod. Predisposing conditions for gas gangrene include local trauma or surgery; synergistic necrotizing cellulitis is often found in patients with diabetes mellitus and perirectal infection. The incubation period of gas gangrene is much shorter than that of synergistic necrotizing cellulitis, and the range of muscle infectionis much larger in gas gangrene. In China, some doctors do not pay much attention to wounds in the early period; this results indeath. For example, Wen treated five patients with gas-forming infections; one died because more attention was paid to the vital signs, ignoring the wounds. The others survived because the authorsobserved the rapidly spreading wounds and treated them as gas gangrene.[9] Fu-Qiang treated seven patients; they all died because the authorsignored the wounds and it was too late when they identify Clostridium. [10] After many years of treatment, we hadaccumulated experiences. On the first day, immediate open drainage and broad-spectrum antibiotics were administered. Subsequently, the wounds did not deteriorate, patients were diagnosed with gas-forming synergistic necrotizing cellulitis. We partly removed necrotic tissues when we changed the dressings. Until the vital signs stabilized, aggressive debridement wasperformed. Finally, the patients were cured. Negative pressure wound therapy is useful for treating wounds, such as diabetic foot.[11] However, there is little evidence that it can be used for gas-forming infections in the early period. In our opinion, it is inappropriate to control infection and inhibit aerogenic bacteria. If debridement is aggressively done in the later period, negative pressure wound therapy is a good option.[12] Regarding the underlying diseases, the most frequent is diabetes mellitus. It was found in 60% of the patients in our study. Infectious wounds in diabetes are thought to be associated with neuropathy and angiopathy, and advanced glycation end products are initiating agents.[13,14] The reason why diabetes mellitus is a co-morbidity in patients with synergistic necrotizing cellulitis isunknown. In our opinion, advanced glycation end products may offer a good environment for the bacteria of synergistic necrotizing cellulitis, and diabetes patients have no resistance to the bacteria. Gender was proposed as another risk factor, with men having a higher chance 119

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of being infected. This percentage was 70% in our study; however, some researchersshowed there was no correlation.[15,16] The major limitation of our study is that it was retrospective; aprospective study needs to be conducted. Another limitation is that thestudy did not assess many patientsand that the patients were from one medical center; anotherfurther multi-institutional study to strengthen our findings is required. Despite these limitations, we founda new surgical procedure thatis of great significance for treating gas-forming synergistic necrotizing cellulitis.

Acknowledgments This study was supported by the Zhejiang Provincial Natural Science Foundation of China (Grant No. Z2080985) and the Science and Technology Program of Wenzhou (Grant No. Y20150273,Y20160328, and Y20140187). Conflict of interest: None declared.

REFERENCES 1. Sturgeon JP, Segal L, Verma A. Going Out on a Limb: Do Not Delay Diagnosis of Necrotizing Fasciitis in Varicella Infection. Pediatr Emerg Care 2015;31:503–7. 2. Davoudian P, Flint NJ. Necrotizing fasciitis. Continuing Education in Anaesthesia Critical Care & Pain 2012:245–50. 3. Sada A, Misago N, Okawa T, Narisawa Y, Ide S, Nagata M, et al. Necrotizing fasciitis and myonecrosis “synergistic necrotizing cellulitis” caused by Bacillus cereus. J Dermatol 2009;36:423–6. 4. Brucato MP, Patel K, Mgbako O. Diagnosis of gas gangrene: does a discrepancy exist between the published data and practice. J Foot Ankle Surg 2014;53:137–40. 5. Pragatheeswarane M, Balaji NN, Duvuru S, Gubbi Shamanna S. Gas

gangrene: need for aggressive management in delayed presentation. Surg Infect (Larchmt) 2014;15:361–2. 6. Gilbert D, Moellering R, Eliopoulos G. The Sanford Guide to Antimicrobial Therapy. 40th ed. Sperryville, VA: Antimicrobial Therapy; 2010. 7. Stevens DL, Aldape MJ, Bryant AE. Life-threatening clostridial infections. Anaerobe 2012;18:254–9. 8. Chao WN, Tsai CF, Chang HR, Chan KS, Su CH, Lee YT, et al. Impact of timing of surgery on outcome of Vibrio vulnificus-related necrotizing fasciitis. Am J Surg 2013;206:32–9. 9. Qin W, Li GY, Zeng YD. Early treatment experience of gas gangrene. Chinese Journal of Traditional Medical Traumatology & Orthopedics 2007;15:27–8. 10. He FQ, Li QY. Death causes of gas gangrene. People’s Military Surgeon 2002;45:437–8. 11. Isaac AL, Armstrong DG. Negative pressure wound therapy and other new therapies for diabetic foot ulceration: the current state of play. Med Clin North Am 2013;97:899–909. 12. Hu N, Wu XH, Liu R, Yang SH, Huang W, Jiang DM, et al. Novel application of vacuum sealing drainage with continuous irrigation of potassium permanganate for managing infective wounds of gas gangrene. J Huazhong Univ Sci Technolog Med Sci 2015;35:563–8. 13. Liu C, Xu L, Gao H, Ye J, Huang Y, Wu M, et al. The association between skin autofluorescence and vascular complications in Chinese patients with diabetic foot ulcer: an observational study done in Shanghai. Int J Low Extrem Wounds 2015;14:28–36. 14. Lu W, Li J, Ren M, Zeng Y, Zhu P, Lin L, et al. Role of the mevalonate pathway in specific CpG site demethylation on AGEs-induced MMP9 expression and activation in keratinocytes. Mol Cell Endocrinol 2015;411:121–9. 15. Benjelloun el B, Souiki T, Yakla N, Ousadden A, Mazaz K, Louchi A, et al. Fournier’s gangrene: our experience with 50 patients and analysis of factors affecting mortality. World J Emerg Surg 2013;8:13. 16. Morua AG, Lopez JA, Garcia JD, Montelongo RM, Guerra LS. Fournier’s gangrene: our experience in 5 years, bibliographic review and assessment of the Fournier’s gangrene severity index. Arch Esp Urol 2009;62:532–40.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Gaz oluşumuyla karakterize sinerjistik nekrotizan selülit özellikleri ve tedavisi: Dokuz yılı kapsayan geriye dönük çalışma Dr. Xiangwei Ling,1 Dr. Yuanyuan Ye,2 Dr. Hailei Guo,1 Dr. Zhengjun Liu,1 Dr. Weidong Xia,1 Dr. Cai Lin1 1 2

Wenzhou Tıp Üniversitesi Hastanesi, Yanık Bölümü, Wenzhou-Çin Halk Cumhuriyeti Wenzhou Tıp Üniversitesi Hastanesi, Ameliyathaneler, Wenzhou-Çin Halk Cumhuriyeti

AMAÇ: Birçok doktor gaz oluşumuyla karakterize sinerjistik nekrotizan selülit hakkında az bilgi sahiptir, çalışmamızda bu durumu geriye dönük araştırdık. GEREÇ VE YÖNTEM: Kasım 2006 ile Eylül 2015 arasında gaz oluşumuyla karakterize sinerjistik nekrotizan selülit tanısı konmuş toplam 30 hasta çalışmaya alındı. On dokuz hastaya açık drenaj uygulandı, 11 hastaya agresif debridman yapıldı. Geriye dönük olarak demografiler, APACHE II skorları, patojenlerin kültür sonuçları, ameliyat sırasında kanama miktarı, beyaz küreler ve derlenme geriye dönük olarak incelendi. BULGULAR: Ölüm oranları açık drenaj ve agresif debridman gruplarında sırasıyla %26 ve %73 idi (p=0.023). Tedavi öncesinde iki grup arasında APACHE II skorları açısından herhangi bir istatistiksel farklılık yoktu (16.6±4.5’e karşın 18.1±7.5, p=0.511). Tedavi sonrasında agresif tedavi grubunda APACHE II skoru anlamlı derecede daha yüksek idi (14.2±5.8’e karşın 20.1±9.1, p=0.038). Tedavi öncesi ve sonrası arasında beyaz küre sayısında istatistiksel farklılık yoktu (13.49±5.05×109 hücre/L’e karşın 17.46±6.94×109 hücre/L, p=0.082; 10.37±3.54×109 hücre /L ve 15.47±7.51×109 hücre /L, p=0.055). Ameliyat sırasında kanama agresif debridman grubunda anlamlı derecede daha fazla idi (315±112 ml’ye karşın 105±45 ml, p=0.000). TARTIŞMA: Sinerjistik nekrotizan selülit tedavisi için hasta kabulden sonra olabildiğince en kısa sürede açık drenaj yapılacak en önemli girişimdir. Anahtar sözcükler: Gaz oluşturan enfeksiyonlar; gazlı kangren; sinerjistik nekrotizan selülit. Ulus Travma Acil Cerrahi Derg 2018;24(2):116–120

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doi: 10.5505/tjtes.2017.93453

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Computed tomography use in minor head injury: attitudes and practices of emergency physicians, neurosurgeons, and radiologists in Turkey Ebru Özan, M.D., Gökçe Kaan Ataç, M.D. Department of Radiology, Ufuk University Faculty of Medicine, Ankara-Turkey

ABSTRACT BACKGROUND: We aimed to determine the attitudes and practices of emergency physicians (EPs), neurosurgeons, and radiologists in Turkey regarding computed tomography (CT) use for adults with minor head injury (MHI). METHODS: This cross-sectional study was conducted between August 2015 and October 2016 after obtaining the approval of the institutional ethical committee. The purpose of this study was disclosed to the participants prior to beginning the survey. The study was performed conducting a questionnaire via e-mail on three groups of participants including EPs, neurosurgeons, and radiologists. Participants comprised academic staff at university hospitals as well as department chiefs, specialists, and residents working at university, government, and private hospitals, all of whom are in charge of evaluating MHI patients. RESULTS: A total of 607 participants including 201 (33.1%) EPs, 179 (29.5%) neurosurgeons, and 227 (37.4%) radiologists responded to the survey; 31% of the participants reported awareness and 27.3% reported use of head CT rules in MHI. Awareness and use of the rules were most prominent in EPs group, while the lowest rates were observed in radiologists group (p<0.01). The leading factors inhibiting the use of head CT rules in MHI stated by EPs were medicolegal anxiety (73.6%), expectations of patients and/or patient relatives (72.6%), and time constraints (44.3%). The leading factors stated by neurosurgeons were medicolegal anxiety (60.9%) and expectations of patient and/or patient relatives (46.4%); “not being consulted in the decision-making process to obtain CT in MHI” (65.6%) and medicolegal anxiety (49.8%) were the leading factors stated by radiologists. CONCLUSION: The results of our study show that many physicians in Turkey do not have favorable attitudes regarding head CT rules in MHI. Medicolegal anxiety, expectations of patient and/or patient relatives, time constraints, wide availability of CT, and lack of adequate education on radiation protection or on patient dose from imaging are the common reasons for this practice pattern. Keywords: Adult; appropriate use of computed tomography; head computed tomography rules; minor head injury.

INTRODUCTION Imaging guidelines may help clinicians decide the most appropriate imaging modality and provide standardization of the imaging strategies. Increasing use of computed tomography (CT) in various countries worldwide, particularly at a higher rate in the emergency department (ED) than in other settings, has been well established.[1–3] To minimize CT radiation risk and to provide more economically effective utilization of CT, clinical decision rules have been developed. The Canadian CT

Head Rule (CCHR) and New Orleans Criteria (NOC) represent the most notable examples that were developed to correctly identify the adult patients with minor head injury (MHI) who are at elevated risk of intracranial injury or injury requiring neurosurgical interventions.[4,5] The use of clinical decision rules could safely reduce CT imaging in MHI and, thus, provide adherence to the justification principle of radiation protection. Despite the availability of validated clinical decision rules in MHI, variabilities in the awareness and use of these rules were

Cite this article as: Özan E, M.D., Ataç GK. Computed tomography use in minor head injury: attitudes and practices of emergency physicians, neurosurgeons, and radiologists in Turkey. Ulus Travma Acil Cerrahi Derg 2018;24:121–128 Address for correspondence: Ebru Özan, M.D. Mevlana Bulvarı (Konya Yolu), No: 86–88, Balgat, 06520 Ankara, Turkey Tel: +90 312 - 204 40 00 E-mail: ebrusanhal@yahoo.com Ulus Travma Acil Cerrahi Derg 2018;24(2):121–128 DOI: 10.5505/tjtes.2017.56884 Submitted: 20.12.2016 Accepted: 21.08.2017 Online: 22.08.2017 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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found among different countries.[6–8] Therefore, the purpose of this study was to determine the attitudes and practices of emergency physicians (EPs), neurosurgeons, and radiologists in Turkey regarding CT use for MHI in adults with a special emphasis on head CT rules. To the best of our knowledge, this is the first national survey to investigate the attitudes regarding CT use for MHI, as well as the awareness of head CT rules for MHI in our country. Furthermore, our approach of including different groups of physicians, all of whom are in charge of evaluating MHI cases, was novel and allowed us to obtain considerable results.

MATERIALS AND METHODS This cross-sectional study was conducted between August 2015 and October 2016 after obtaining the approval of the institutional ethical committee. The purpose of this study was disclosed to the participants prior to beginning the survey. The study was performed conducting a questionnaire via email on three groups of participants including EPs, neurosurgeons, and radiologists. Participants comprised academic staff at university hospitals as well as department chiefs, specialists, and residents working at university, government, and private hospitals, all of whom are in charge of evaluating MHI patients. We refer to all as “EPs,” “neurosurgeons,” and “radiologists.”

Data Collection The questionnaires were conducted using links to an online survey system (http://www.surveey.com/) that were presented via e-mails. Neurosurgeons and radiologists were e-mailed through their national societies, while EPs were emailed through personel contacts. After providing consent, participants completed the survey online. Those who did not respond were e-mailed two more times. The questionnaire was multiple-choice; besides, some questions that the participants could answer by choosing more than one answer were also included. The survey was designed so that the participants could not proceed to the next question without answering the previous one. Exceptionally, the last question allowed the participants to optionally mention their comments and suggestions. The questionnaire was divided into four main sections. In the first section, participants were asked about their demographic information, employment organizations, and positions. The second section assessed the frequency of head injury (HI) cases, the physician who decides whether or not to obtain CT in MHI cases, and the availability of CT at participants’ institutions. In the third section, the participants were asked about their educational status on radiation protection. In addition, their knowledge about the radiation dose administered during a head CT was assessed by asking them simply to compare the effective dose of a head CT to anteroposterior (AP) and lateral skull radiographs. Choices for this question were as follows: a) Roughly the same, b) 10–50 fold, c) 50–100 fold, d) 100–500 fold, e) 122

Survey of CT use in minor head injury, sample survey form I. Demographics 1. Current hospital you are working at: a. University hospital b. Education and research hospital c. State hospital d. Private practice 2. Your position: a. Head/chief of department b. Teaching staff c. Specialist d. Resident II. Approximate number of head injury cases, physician to decide whether or not to obtain CT in MHI cases, availability of CT 1. App. number of HI cases in your institution: a. <100 b. 100–500 c. 500–100 d. >1000 2. Physician to decide whether or not to obtain CT in HI cases in your institution: a. EPs b. Neurosurgeons c. Radiologist d. Agreed decision 3. Availability of CT in your institution: a. No b. Yes, during working hours c. Yes, 24 hours a day III. Edicational status on radiation protection, knowledge about the radiation dose 1. Have you ever received any formal education on radiation protection? a. Yes b. No 2. Radiation dose (effective dose, milisievert) administered during a head CT in comparison to anteroposterior (AP) and lateral skull radiographs is: a. Roughly the same b. 10–50 fold c. 50–100 fold d. 100–500 fold e. I do not know IV. Awareness and use of head CT rules in MHI, main factors to inhibit the use of these rules 1. Your knowledge level on head CT rules in MHI: a. Absent b. Insufficient c. Sufficient 2. How often do you use head CT rules in MHI? a. Never b. Sometimes c. Mostly d. Always 3. The main factors for you to inhibit the use of head CT rules in (you may choose one to five statements): a. I adhere to a head CT rule effectively b. I don’t know tne radiation dose administered during a head CT c. Medico legal anxiety d. Administrational ond/or institutional pressure to order imaging examinations e. Expectations of patient and/or patient relatives about the obtainment of a head CT f. Lack of other imaging modality in my institution g. Time constraints due to work overload h. Nobody ask and/or cares about my opinion on obtaining head CT in MHI cases i. Diagnostic information provided by head CT in MHI cases is more important than the radiation exposure, unnecessary costs or work overload V. Please mention any of your comments and suggestions regarding CT use in MHI and/or radiation protection...

Figure 1. Survey of CT use in minor head injury, sample survey form. EPs, emergency physicians; App.: Approximate; HI: Head injury; CT: Computed tomography; MHI: Minor head injury.

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Do not know. Typical effective doses per procedure for a head CT, an AP skull radiography, and a lateral skull radiography are 2, 0.03, and 0.01 mSv, respectively (https://hps.org/physicians/ documents/Doses_from_Medical_X-Ray_Procedures.pdf ). Thus, the correct answer for this question was 10–50 fold (choice b). Choice a was accepted as “underestimation” and choices c and d were accepted as “overestimation” regarding this question. In the fourth section, participants were asked three questions to assess their practices on ordering CT in MHI, awarenesses and attitudes regarding head CT rules in MHI, and the main factors that inhibit the use of these rules. The last section of the survey asked participants about their comments and suggestions on CT use in MHI and/or radiation protection, if any. A sample survey form that contains the questions and choices is shown in Fig. 1.

55.5% of the participants. Employment organizations and positions of the participants are presented in Table 1.

Second Section: Approximate Number of HI Cases, Physician who Decides Whether or Not to Obtain CT in MHI Cases, and Availability of CT The most reported (37.2%) approximate number of head trauma cases per month at participants’ institutions was 100–500. When the participants were asked which physician at their institution decides whether or not to obtain CT in MHI cases; the majority (79.9%) responded “EPs”; 93.4% of the participants stated that CT is available 24 h a day at their institutions. Table 2 presents the responses given by each participant group regarding the questions included in the second section of the survey.

Statistical Analysis

Third Section: Educational Status on Radiation Protection and Knowledge About the Radiation Dose

Analysis of the results was performed using the IBM SPSS Statistics Version 21.0 software for Windows (Armonk, NY). For descriptive analysis, means, standard deviations, and frequency tables were used. To investigate differences between the groups, Mann–Whitney U-test was used for two groups and Kruskal–Wallis H test for more than two groups. Χ2 test was performed for categorical variables. Significance was defined as p<0.05.

Of all the particpants, 42.3% stated that they have received formal education (course, congress, symposium, lecture, etc.) on radiation dose from medical imaging or on radiation protection, while 57.7% stated that they have not. Regarding a question on the radiation dose administered during a head CT, 25.4% of the participants gave the correct answer, 58.3% of underestimated the radiation dose, 3.8% overestimated the radiation dose, and 12.5% responded “do not know.” The distribution of the answers in each participant group regarding these two questions is presented in Table 3.

RESULTS A total of 607 participants including 201 (33.1%) EPs, 179 (29.5%) neurosurgeons, and 227 (37.4%) radiologists responded to the survey.

Fourth Section: Awareness and Use of Head CT Rules in MHI and Main Factors Inhibiting the Use of These Rules

First Section: Demographics Of the 607 participants, 32.9% worked in university hospitals, 26.2% in education and research hospitals, 23.1% in state hospitals, and 17.8% in private practice. Specialists comprised

When the participants were asked about their knowledge level on head CT rules in MHI, 35.7% of the participants re-

Table 1. Employment organizations and positions of each participant groups

EPs

Neurosurgeons Radiologists

Total

n % n % n % n %

Employment organizations University hospitals

Education and research hospitals

77 38.3 44 24.6 79 34.8 200 32.9 69

34.3

20.1

23.8

159

26.2

State hospitals

38 18.9 45 25.1 57 25.1 140 23.1

Private practice

17 8.5 54 30.2 37 16.3 108 17.8

Positions

Head / chief of department

8.4

2.2

4.9

Teaching staff

34 16.9 48 26.8 38 16.7 120 19.8

Specialist

90 44.8 110 61.5 137 60.4 337 55.5

Resident

67 33.3 6 3.4 47 20.7 120 19.8

EPs: Emergency physicians.

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Table 2. Distribution of the responses given by each participant group regarding the questions included in the second section of the survey

EPs

Neurosurgeons Radiologists

Total

n % n % n % n %

App. No. of HI cases <100

44 21.9 89 49.7 63 27.8 196 32.3

100–500

89 44.3 62 34.6 75 33 226 37.2

500–1000

41 20.4 19 10.6 54 23.8 114 18.8

>1000

27 13.4 9 5.0 35 15.4 71 11.7

Physician who decides whether or not to obtain CT in MHI cases EPs Neurosurgeons

184 91.5 105 58.7 196 86.3 485 79.9 6 3 53 29.6 15 6.6 74 12.2

Radiologists

0 0 1 0.6 2 0.9 3 0.5

Agreed decision

11 5.5 20 11.2 14 6.2 45 7.4

Availability of CT No

Yes. during working hours

Yes. 24 h a day

3 1.5 2 1.1 14 6.2 19 3.1 4

1.1

6.6

3.5

194

96.5

175

97.8

198

87.2

567

93.4

App.: Approximate; HI: Head injury; CT: Computed tomography; EPs: Emergency physicians.

Table 3. Distribution of the answers in each participant group regarding the questions included in the third section of the survey

EPs

Neurosurgeons Radiologists

Total

n % n % n % n %

Formal education on radiation protection Yes

45 22.4 44 24.6 168 74 257 42.3

156 77.6 135 75.4 59 26 350 57.7

Radiation dose administered during a head CT Responded correctly

47 23.4 30 16.8 77 33.9 154 25.4

Underestimated

128 63.7 97 54.2 129 56.8 354 58.3

Overestimated

5 2.5 12 6.7 6 2.6 23 3.8

Responded “Do not know”

10.4

22.3

6.6

12.5

CT: Computed tomography; EPs: Emergency physicians.

sponded “absent,” 33.2% responded “insufficient,” and 31.1% responded “sufficient.” Majority (59%) of the radiologists and (36.9%) neurosurgeons responded “absent,” while majority (60.8%) of EPs responded “sufficient” regarding this question. Percantage distribution of the responses regarding this question in each participant group is presented in Figure 2.

“mostly,” 22.4% responded “sometimes,” and 50.2% responded “never.” Majority (43.3%) of EPs responded “mostly,” while majority (51.4%) of the neurosurgeons and (79.7%) radiologists responded “never.” Percantage distribution of the responses regarding this question in each participant group is presented in Figure 3.

When the participants were asked how often they use head CT rules in MHI, 6.9% responded “always,” 20.4% responded

The third question in the fourth section asked about the main factors inhibiting the use of head CT rules in MHI. The first

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70 60

70 60.2

50 31.3

27.9

8.50

7.5 Sufficient

Insufficient

EPs

Neurosurgeons

Absent

70 60

51.4 43.3

31.3

20.7

16.8

9.5 11.2

Always

15.9

3.1

1.3

Mostly

EPs

Sometimes

Neurosurgeons

EPs

Neurosurgeons Awareness

79.9

7.5

Radiologists

27.9

Figure 2. Percantage distribution of the responses in each participant group regarding their knowledge level on head CT rules in minor head injury.

27.9

30 20

52.7

36.9

35.2 33.5

60.2

40 30

Never

Radiologists

Figure 3. Percantage distribution of the responses in each participant group regarding the frequency of usage of head CT rules in minor head injury.

choice was “I adhere to a head CT rule efficiently,” while the remaining eight choices mentioned possible factors inhibiting the use of rules. The respondents could choose more than

4.4

Radiologist Use

Figure 4. Percantage of the respondents in each group who reported awareness and use of head CT rules in minor head injury.

one statement without exceeding five. Responses regarding each of the possible factors were separately evaluated; 16.9% of EPs, 16.2% of the neurosurgeons, and 2.6% of the radiologists stated that they adhere to a head CT rule efficiently. The leading factors inhibiting the use of head CT rules in MHI stated by EPs were medicolegal anxiety (73.6%), expectations of patients and/or patient relatives (72.6%), and time constraints (44.3%). The leading factors stated by neurosurgeons were medicolegal anxiety (60.9%) and expectations of patient and/or patient relatives (46.4%); “not being consulted in the decision-making process to obtain CT in MHI” (65.6%) and medicolegal anxiety (49.8%) were the most rated factors by radiologists. The distribution of the responses regarding the factors inhibiting the use of head CT rules in MHI in each participant group is presented in Table 4.

Fifth Section: Comments and Suggestions on CT Use in MHI and/or Radiation Protection A total of 183 responses (30.1%) were obtained in this section.

Table 4. Distribution of the responses regarding the factors to inhibit the use of head CT rules in MHI in each participant group

EPs

Neurosurgeons Radiologists Total

n (%)

I don’t know the radiation dose administered during a head CT

5 (2.5)

3 (1.7)

1 (0.4)

9 (1.5)

148 (73.6)

109 (60.9)

113 (49.8)

370 (61)

8 (4)

6 (3.4)

29 (12.8)

43 (7.1)

146 (72.6)

83 (46.4)

102 (44.9)

331 (54.5)

9 (4.5)

5 (2.8)

16 (7)

30 (4.9)

Time constraints due to work overload

89 (44.3)

31 (17.3)

61 (26.9)

181(29.8)

Nobody asks and/or cares about my opinion on obtaining

16 (8.0)

41(22.9)

149 (65.6)

206 (33.9)

74 (36.8)

46 (25.7)

48 (21.1)

168 (27.7)

Medicolegal anxiety Administrational and/or institutional pressure to order imaging examinations Expectations of patients and /or patient relatives about the obtainment of a head CT Lack of other imaging modality in my institution

head CT in MHI cases Diagnostic information provided by head CT in MHI cases is more important than the radiation exposure, unnecessary costs, or work overload CT: Computed tomography; EPs: Emergency physicians; MHI: Minor head injury.

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Participants most commonly pointed out medicolegal anxiety, expectations of patient and/or patient relatives, and time constraints as the factors restricting the use of the head CT rules in MHI in this section of the survey. The requirement for an improved medicolegal climate was commonly adressed by participants in all three groups. Radiologists and some of the neurosurgeons commonly stated that they are not involved in the decision-making process because EPs decide whether or not to obtain CT in MHI cases. Education on radiation dose from medical imaging of both the referring physicians and patients was stated as a significant factor to reduce CT overutilization in MHI. The importance of a compatible national guideline for management of MHI to be designated by the consensus of Ministry of Health and national medical societies of related physicians was also emphasized. Many physicians stated that they would welcome any kind of head CT rule or national imaging guideline in improved medicolegal settings.

Comparison of Groups a) Educational status on radiation protection and knowledge about the radiation dose When participant groups were compared in terms of their educational status on radiation protection, a significant difference was found between radiologists and the other two groups (p<0.01), while no significant difference was found between EPs and neurosurgeons (p=0.614). Accordingly, the number of radiologists who had received formal education on radiation dose from medical imaging or on radiation protection was more prominent than EPs and neurosurgeons. When three groups were compared regarding their knowledge about the radiation dose administered during a head CT, no significant difference was found between EPs and radiologists (p=0.079), while the differences between EPs and neurosurgeons as well as neurosurgeons and radiologists were found to be significant (p<0.01 and p<0.01, respectively). Accordingly, the number of neurosurgeons who stated that they do not know the radiation dose administered during a head CT was more prominent than EPs and radiologists, while the correct answer rate of radiologists was higher than the neurosurgeons. b) Awareness and use of head CT rules in MHI To compare the groups, we considered “sufficient” knowledge level on head CT rules in MHI as “awareness”; furthermore, we considered respondents who reported that they use the rules “always” or “mostly” as users and those who reported that they use the rules “sometimes” or “never” as nonusers. Accordingly, 31% of the participants reported awareness and 27.3% reported use of head CT rules in MHI. A significant difference was found between the groups regarding the awareness and use of the rules (p<0.01 and p<0.01, respectively). Awareness and use of the rules were most prominent in EPs group, while the lowest rates were observed in radiologists group. Percantage of the respondents in each group who reported awareness and use of head CT rules in MHI is presented in Figure 4. 126

DISCUSSION HI accounts for a significant part of ED attendances; most of these are MHIs (Glasgow Coma Scale score, 13–15), with an annual incidence estimated to be 100–600 per 100,000 in the general population.[9,10] Head CT is the standard imaging modality in acute HI; it is increasingly being performed routinely in patients with MHI, although the incidence of clinically significant findings on head CT is reported to be 5%–9% with less than 1% of these requiring neurosurgical interventions.[11–14] CT overutilization, particularly at a higher rate in EDs, has been well established.[15–17] This overutilization consequently led to concerns about CT radiation risk and increasing health care costs. Thus, appropriate use of CT has become an issue, and efforts to decrease overutilization put clinical decision rules forward. CCHR and NOC represent the most sensitive and specific head CT rules at identifying clinically important intracranial lesions in adult patients with MHI.[18,19] Although the implementation of head CT rules, CCHR specifically, has the potential to increase CT use in MHI by 35%, substantial variations among countries regarding CT use in MHI, as well as awareness and the use of head CT rules have been established.[7,20–22] High frequency of noncompliance with guidelines even after intensive implementation efforts has also been reported.[8] This is the first national survey specifically aimed at identifying the attitudes and practices regarding CT use in adult patients with MHI. Three groups of participants including EPs, neurosurgeons, and radiologists, all of whom are in charge of evaluating MHI cases in our country were included. We found that overall awareness and use of head CT rules in our country were relatively low compared with other countries, as reported by some studies. An international survey of EPs showed that awareness and use of CCHR were highest (86% and 57%, respectively) in Canada and lowest (31% and 12%, respectively) in the United States.[7] Heskestad et al.[8] reported a 51% overall physicians compliance after the national implementation process of the Scandinavian Guidelines for initial management of minimal, mild, and moderate HIs. Our study revealed that EPs are the physicians who mainly decide whether to obtain CT or not in MHI in our country. Therefore, we must point out that while overall awareness and use of head CT rules were found to be low in our study, the highest rates were reported by EPs, 60.2% and 52.7% respectively. Awareness and use of the rules were found to be lower in neurosurgeons. Management of MHI cases, especially those where no neurosurgical interventions are required, seems to be handled mainly by EPs, and head CTs are mainly being ordered depending on EPs’ decisions. Notably, lower rates reported by neurosurgeons may somewhat be reasonable. However, lowest rates of awareness and use of head CT rules reported by radiologists can not be explained solely on the basis of the abovementioned management and CT ordering practice in MHI in our country. Moreover, the most rated Ulus Travma Acil Cerrahi Derg, March 2018, Vol. 24, No. 2

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factor restricting the use of head CT rules in MHI stated by radiologists was “not being consulted in the decision-making process to obtain CT in MHI.” While justification is one of the three fundamental principles of radiation protection, radiologists, as masters of the radiation enviroment, have the responsibility of being proactive in this area instead of remaining in the background.[23,24] Although there is no reliable data regarding the rate of CT use in MHI cases in our country, the reported awareness and use rates of the rules as well as the statements in the comments and suggestions section of this survey led us to conclude that most referring physicians do not have favorable attitudes regarding head CT rules in MHI. Given the wide availability of CT (93.4% of the participants stated that CT is available 24 h a day at their institutions), increasing physician pressure related to both medicolegal issues and expectations of patients and/or patient relatives, and time constraints due to work overload, some of the physicians in our country seem to welcome the nonselective CT use in MHI cases. As medicolegal anxiety, expectations of patients and/or patient relatives, and time constraints were the most rated factors, particularly by EPs, our results draw particular attention to the role of nonclinical factors in restricting the use of head CT rules, as already reported in some studies.[25–27] Furthermore, this data may provide more insight into the defensive medicine practices of physicians in our country. Physicians’ concerns about medicolegal issues and perceptions on medicolegal risk play a significant role in their patient management, and this may lead to additional imaging, particularly increased CT use.[28,29] Most EPs and neurosurgeons stated that they had not received any kind of formal education on radiation protection. While the majority of the participants underestimated the radiation dose administered during a head CT, a greater percentage of radiologists provided a correct estimation than EPs and neurosurgeons. The tendency to underestimate the radiation dose administered during a head CT may partially be explained based on the lack of sufficient education and may lead to unnecessary CT utilization in MHI cases. Therefore, we believe that requirement of referring physician education on radiation protection is a remarkable implication of our study. There are several limitations to our study. First, a survey of physicians may not necessarily reflect the actual practice patterns. It has been shown that self-reported guideline adherence rates exceed objective rates, and self-reported measures are subject to response bias.[30] However, the primary goal of our study was to get information on physicians attitudes regarding CT use in MHI, not to measure adherence to guidelines, as currently, neither a national guideline nor an implementation process exist in our country. Additionally, advocating the use of any head CT rules was also not intended in this study. Second, this survey provides information on atUlus Travma Acil Cerrahi Derg, March 2018, Vol. 24, No. 2

titudes and practices at a single point in time; longitudinal surveys would be useful to determine the alterations. In conclusion, we believe this study provides valuable information on CT use in MHI and physicians’ attitudes regarding head CT rules in our country. It seems many physicians do not have favorable attitudes on CT head rules in MHI. Medicolegal anxiety, expectations of patient and/or patient relatives, time constraints, wide availability of CT, and the lack of adequate education on radiation protection or patient dose from imaging are defined as common reasons for this practice pattern. Thus, referring physician education on radiation protection as well as improvement of the current medicolegal climate and the physicians’ working conditions (i.e., workload) are the potential solutions. As some of the participants indicated, implementation of either developed or adopted national guidelines showing the appropriate imaging algorithm that includes possible radiation doses for common clinical scenarios may help all stakeholders to share similar strategies for patients. Beyond these, we believe that radiologists should be encouraged to involve themselves rather than being disregarded in the decision-making process to obtain CT, particularly in MHI cases.

Acknowledgements The authors thank the following for their much appreciated assistance: Turkish Society of Radiology, Turkish Neurosurgical Society for supporting this endeavor; Drs. Drs. Togay Evrin, Basak Yilmaz and Ismail Atik for facilitating e-mail distribution among emergency physicians. Conflict of interest: None declared.

REFERENCES 1. Mettler FA Jr, Bhargavan M, Faulkner K, Gilley DB, Gray JE, Ibbott GS, et al. Radiologic and nuclear medicine studies in the United States and worldwide: frequency, radiation dose, and comparison with other radiation sources-1950-2007. Radiology 2009;253:520–31. 2. Larson DB, Johnson LW, Schnell BM, Salisbury SR, Forman HP. National trends in CT use in the emergency department: 1995-2007. Radiology 2011;258:164–73. 3. Chang JC, Lin YY, Hsu TF, Chen YC, How CK, Huang MS. Trends in computed tomography utilisation in the emergency department: A 5 year experience in an urban medical centre in northern Taiwan. Emerg Med Australas 2016;28:153–8. 4. Haydel MJ, Preston CA, Mills TJ, Luber S, Blaudeau E, DeBlieux PM. Indications for computed tomography in patients with minor head injury. N Engl J Med 2000;343:100–5. 5. Stiell IG, Wells GA, Vandemheen K, Clement C, Lesiuk H, Laupacis A, et al. The Canadian CT Head Rule for patients with minor head injury. Lancet 2001;357:1391–6. 6. Stiell IG, Wells GA, Vandemheen K, Laupacis A, Brison R, Eisenhauer MA, et al. Variation in ED use of computed tomography for patients with minor head injury. Ann Emerg Med 1997;30:14–22. 7. Eagles D, Stiell IG, Clement CM, Brehaut J, Taljaard M, Kelly AM, et al. International survey of emergency physicians’ awareness and use of the

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Özan et al. Computed tomography use in minor head injury Canadian Cervical-Spine Rule and the Canadian Computed Tomography Head Rule. Acad Emerg Med 2008;15:1256–61. 8. Heskestad B, Baardsen R, Helseth E, Ingebrigtsen T. Guideline compliance in management of minimal, mild, and moderate head injury: high frequency of noncompliance among individual physicians despite strong guideline support from clinical leaders. J Trauma 2008;65:1309–13. 9. Cassidy JD, Carroll LJ, Peloso PM, Borg J, von Holst H, Holm L, et al. Incidence, risk factors and prevention of mild traumatic brain injury: results of the WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury. J Rehabil Med 2004:28–60. 10. Pandor A, Goodacre S, Harnan S, Holmes M, Pickering A, Fitzgerald P, et al. Diagnostic management strategies for adults and children with minor head injury: a systematic review and an economic evaluation. Health Technol Assess 2011;15:1–202. 11. Miller EC, Derlet RW, Kinser D. Minor head trauma: Is computed tomography always necessary? Ann Emerg Med 1996;27:290–4. 12. Haydel MJ, Preston CA, Mills TJ, Luber S, Blaudeau E, DeBlieux PM. Indications for computed tomography in patients with minor head injury. N Engl J Med 2000;343:100–5. 13. Stiell IG, Clement CM, Rowe BH, Schull MJ, Brison R, Cass D, et al. Comparison of the Canadian CT Head Rule and the New Orleans Criteria in patients with minor head injury. JAMA 2005;294:1511–8. 14. Morton MJ, Korley FK. Head computed tomography use in the emergency department for mild traumatic brain injury: integrating evidence into practice for the resident physician. Ann Emerg Med 2012;60:361–7. 15. Boone JM, Brunberg JA. Computed tomography use in a tertiary care university hospital. J Am Coll Radiol 2008;5:132–8. 16. Larson DB, Johnson LW, Schnell BM, Salisbury SR, Forman HP. National trends in CT use in the emergency department: 1995-2007. Radiology 2011;258:164–73. 17. Broder J, Warshauer DM. Increasing utilization of computed tomography in the adult emergency department, 2000-2005. Emerg Radiol 2006;13:25–30. 18. Harnan SE, Pickering A, Pandor A, Goodacre SW. Clinical decision rules for adults with minor head injury: a systematic review. J Trauma 2011;71:245–51.

19. Papa L, Stiell IG, Clement CM, Pawlowicz A, Wolfram A, Braga C, et al. Performance of the Canadian CT Head Rule and the New Orleans Criteria for predicting any traumatic intracranial injury on computed tomography in a United States Level I trauma center. Acad Emerg Med 2012;19:2–10. 20. Melnick ER, Szlezak CM, Bentley SK, Dziura JD, Kotlyar S, Post LA. CT overuse for mild traumatic brain injury. Jt Comm J Qual Patient Saf 2012;38:483–9. 21. Andruchow JE, Raja AS, Prevedello LM, Zane RD, Khorasani R. Variation in head computed tomography use for emergency department trauma patients and physician risk tolerance. Arch Intern Med 2012;172:660–1. 22. Marin JR, Shofer FS, Chang I, Mills AM. Adherence to a clinical decision policy for head computed tomography in adult mild traumatic brain injury. Am J Emerg Med 2015;33:299–300. 23. ICRP Publication 105. Radiation protection in medicine. Ann ICRP 2007;37:1–63. 24. Frey GD. Control and management of the radiation environment. AJR Am J Roentgenol 2010;194:867. 25. Wong AC, Kowalenko T, Roahen-Harrison S, Smith B, Maio RF, Stanley RM. A survey of emergency physicians’ fear of malpractice and its association with the decision to order computed tomography scans for children with minor head trauma. Pediatr Emerg Care 2011;27:182–5. 26. Melnick ER, Shafer K, Rodulfo N, Shi J, Hess EP, Wears RL, et al. Understanding Overuse of Computed Tomography for Minor Head Injury in the Emergency Department: A Triangulated Qualitative Study. Acad Emerg Med 2015;22:1474–83. 27. Rohacek M, Albrecht M, Kleim B, Zimmermann H, Exadaktylos A. Reasons for ordering computed tomography scans of the head in patients with minor brain injury. Injury 2012;43:1415–8. 28. Katz DA, Williams GC, Brown RL, Aufderheide TP, Bogner M, Rahko PS, et al. Emergency physicians’ fear of malpractice in evaluating patients with possible acute cardiac ischemia. Ann Emerg Med 2005;46:525–33. 29. Solaroglu I, Izci Y, Yeter HG, Metin MM, Keles GE. Health transformation project and defensive medicine practice among neurosurgeons in Turkey. PLoS One 2014;9:e111446. 30. Adams AS, Soumerai SB, Lomas J, Ross-Degnan D. Evidence of selfreport bias in assessing adherence to guidelines. Int J Qual Health Care 1999;11:187–92.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Minör kafa travmasında bilgisayarlı tomografi kullanımı: Türkiye’deki acil tıp hekimleri, beyin cerrahları ve radyologların tutum ve uygulamaları Dr. Ebru Özan, Dr. Gökçe Kaan Ataç Ufuk Üniversitesi Tıp Fakültesi, Radyoloji Anabilim Dalı, Ankara

AMAÇ: Türkiye’deki acil tıp hekimleri, beyin cerrahları ve radyologların, minör kafa travmasında (MKT) bilgisayarlı tomografi (BT) kullanımı ile ilgili tutum ve davranışlarını belirlemektir. GEREÇ VE YÖNTEM: Çalışma acil tıp hekimleri, beyin cerrahları ve radyologlara anket formu uygulanarak gerçekleştirildi. BULGULAR: Ankete 201 acil tıp hekimi, 179 beyin cerrahı ve 227 radyolog dahil olmak üzere toplam 607 katılımcı yanıt verdi. Minör kafa travmasında beyin BT kuralları ile ilgili genel farkındalık oranı %31 olarak bulundu. Katılımcıların %27.3’ü kuralları uyguladığını bildirdi. Kuralların farkındalığı ve kullanımı acil tıp hekimi grubunda en belirgin iken en düşük oranlar radyologlar grubunda gözlendi (p<0.01). Acil tıp hekimlerinin MKT’de beyin BT kurallarını kullanmalarını engelleyen başlıca etkenler; mediko legal kaygı (%73.6), hastaların ve/veya hasta yakınlarının beklentileri (%72.6) ve zaman kısıtlamaları (%44.3) idi. Beyin cerrahlarının belirttikleri başta gelen faktörler; mediko legal kaygı (%60.9) ve hasta ve/veya hasta yakınlarının beklentileri (%46.4) idi. Radyologlar tarafından belirtilen başlıca etken “karar verme sürecinde danışılmamaktadır” (%65.6) idi. TARTIŞMA: Çalışmamızın sonuçları, Türkiye’de birçok hekimin MKT’de beyin BT kuralları ile ilgili olumlu tutumları olmadığını göstermektedir. Mediko legal kaygı, hastanın ve/veya hasta yakınlarının beklentileri, zaman kısıtlamaları, BT’nin yaygınlığı ve tıbbi görüntülemede radyasyondan korunma veya hasta radyasyon dozu konularında eğitim yetersizliği bu uygulama şekli için ortak nedenler olarak tanımlanmaktadır. Anahtar sözcükler: BT uygunluğu; beyin BT kuralları; erişkin; minör kafa travması. Ulus Travma Acil Cerrahi Derg 2018;24(2):121–128

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doi: 10.5505/tjtes.2017.56884

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ORIG I N A L A R T IC L E

Media-based clinical research on selfie-related injuries and deaths Mehmet Dokur, M.D.,1 Emine Petekkaya, Ph.D.,2 Mehmet Karadağ, Ph.D.3 1

Department of Intensive Care Unit, Başkent University Hospital, Ankara-Turkey

Department of Anatomy, Beykent University Faculty of Medicine, İstanbul-Turkey

Department of Biostatistic and Medical Informatics, İnönü University Health Sciences Institue, Malatya-Turkey

ABSTRACT BACKGROUND: The incidence of taking selfies and sharing them on social media as well as selfie-related behaviors is increasing, particularly among young people, possible leading to selfie-related trauma. Therefore, we performed this clinical study to draw attention to selfie-related injuries and deaths. METHODS: We analyzed 159 selfie victims from 111 events or accidents, which were reported in the media sources. We evaluated vital results, demography, rhythmicity, preferences, event or accident types, selfie-related risk factors, affected body regions of victims with causes of injury, and death. RESULTS: We found that the majority of selfie victims were students. Selfie-related injuries and deaths were reported most frequently in India, the US, and Russia. The most preferred site of taking selfies was the edge of the cliff. The most frequently reported event or accident type was falling from a height. Mostly multiple body parts were affected in selfie-related injuries and deaths. The most frequent causes of selfie-related deaths were multitrauma and drowning. CONCLUSION: Selfie-related injuries and deaths have increased in the past years. Particularly, teenagers and young adults are at high risk for selfie-related traumas and deaths; therefore, drastic measures should be taken to reduce their incidence. Keywords: Death; injury; selfie.

INTRODUCTION With the increase in the smart phone production and innovative social media applications in the last decade, selfies have become an essential part of our daily lives, with multiple influences as a social media phenomena or a syndrome of crazy behaviors, particularly among young people. A study has shown that 98% of the youth owns a mobile phone and they are heavy users (>4 h day−1).[1] In 2014, a social survey conducted by the TIME Magazine listed 459 cities as “The Selfiest Cities in the World.” Among 459 cities, Makati City, Pasig, and Philippines were ranked as number 1 (258 selfietakers per 100,000 people); Manhattan and New York as number 2 (202 selfie-takers per 100,000 people); and Miami

and Florida as number 3 (155 selfie-takers per 100,000 people).[2] Clinical researches in the realm of psychiatry suggest that heavy selfie-taking and sharing selfies on social media sites (selfie-related behaviors) and/or smartphone addiction are closely associated with narcissism and psychopathology.[3] Furthermore, some clinical trials on selfie-posting suggest that self-objectification and self-presentation behaviors on social websites, particularly for males, are also components of the dark triad of personality (Machiavellianism, narcissism, and psychopathy). [4,5] The neurocognitive reflections of intensive smartphone usage and selfie-related behaviors have been reported as temporary distractions and momentary lack of self-awareness in the

Cite this article as: Dokur M, Petekkaya E, Karadağ M. Media-based clinical research on selfie-related injuries and deaths. Ulus Travma Acil Cerrahi Derg 2018;24:129–135 Address for correspondence: Mehmet Dokur, M.D. Başkent Üniversitesi Hastanesi, Yoğun Bakım Ünitesi, Çankaya, 06490 Ankara, Turkey Tel: +90 312 - 203 68 68 E-mail: drdokur@gmail.com Ulus Travma Acil Cerrahi Derg 2018;24(2):129–135 DOI: 10.5505/tjtes.2017.83103 Submitted: 04.03.2017 Accepted: 21.08.2017 Online: 12.02.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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current literature.[6,7] Selfie-related behaviors and smartphone addiction also result in selfie-related traumatic risks and may cause injuries and deaths, generally in teenagers and young adults who take selfies in every moment of their daily lives.[8,9] Smartphone addiction and selfie-related behavioral phenomena may also have negative effects on preteenagers as well as other living things in the nature.[10,11] The number of selfie-related events and accidents is still on the rise. Recently, certain countries have introduced protective projects and a number of restrictive regulations to encourage safe use of smartphones and reduce selfie-related hazards or risks.[12,13] In this study, we prepared a media-based clinical research with a multifaceted perspective that was targeted to emphasize the importance of selfie-related injuries and deaths

MATERIALS AND METHODS Study Design Study type: Clinical observational study (Original Research); cross-sectional design without controls. Level of evidence: 4.[14]

Cases and Data Collection In this media-based clinical study, we included 159 victims (humans only) involved in 111 different events or accidents related to selfies that were reported in media resources between December 2013 and January 2017 (a 38-months period). Following media resources were cited for selfie-related cases: 108 cases from Wikipedia’s official website,[15] two from Turkish national media resources,[16,17] and one from a Pakistani media resource.[18] We performed a careful and detailed examination of all media resources to evaluate selfie-related injuries and deaths, (131 media resources from Wikipedia Pages and three from others). Among these media resources, we picked the ones that fit the criteria previously determined by us for our study and transferred the resources to an excel file as scientific data. We coded the data we could not find on media resources as “unknown or not reported.” We determined that a group selfie consisted of >2 people in a particular pose and heavy selfie-taking as >4 h day−1. Those aged 18–64 years were considered as the active age group taking selfies and using social media. We also regarded the injuries and deaths that occurred outside of the selfie-taking, but happened coincidentally during or after as “extra injuries” and “extra deaths.”

Statistical Analysis Our study comprises data measured on categorical levels. Thus, descriptive statistics are given in tables showing frequency and percentage values along with pie-charts and bar graphs. In the inferential statistics section, Chi-square statistics method was used for comparing two categorical variables, and Cramer’s V coefficient was used for the correlation relation between two categorical variables. 130

Ethical Statement Ethics Committee Approval: Authors declared that the research was conducted according to the principles of the World Medical Association Declaration of Helsinki, “Ethical Principles for Medical Research Involving Human Subjects.” The protocol was approved by Zirve University Ethics Committee (Permit number: 2014/19).

RESULTS Demography Among the 111 events or accidents examined, we determined that the total case (dead and injured) number was 159, the average age was 23.36±10.1 years, the number of dead people was 137, and the number of injured people was 22. We determined that the male to female ratio in these cases was higher. The average ages in selfie-related deaths and injuries were 23.48±10.1 (9–68) years and 22.63±10.1 (6–50) years (Table 1), respectively. We determined that the injury and death rates per event or accident were 0.19 (0–5) and 1.23 (0–7), respectively. When the social statuses of selfie victims were examined through our study, it was determined that students (particularly high school and university students) were predominant (84, 52.8%); the numbers of domestic and foreign (international) tourists were 78 (49%) and 15 (9.4%), respectively. The number of local resident was 66 (41.6%). We found that the country distribution and nationality distribution of selfie-related injury and death cases were highly compatible. The first three countries in terms of frequency of such events and victims were India (45 events or accidents, 40.5%; 75 victims, 47.2%), the US (10 events or accidents, 9%; 11 victims, 6.9%), and Russia (8 events or accidents, 7.2%; 10 victims, 6.2%), respectively (Fig. 1). The total number of extra injured people and extra dead was reported as 19 and 6, respectively by media sources.

Rhythmicity We determined that the number of selfie-related injuries and deaths significantly increased per year (2014–2015 and 2016) (Fig. 2). When selfie-related injuries and deaths were examined according to months, we determined that the most Table 1. Demographic data of selfie victims Variable

Age (Mean±SD)

(Min–Max)

Dead

137 23.48±10.1 (9–68)

Male

104

23.12±9.7

(13–66)

Female

24.60±11.6

(9–68)

Injured 22 22.63±10.1 (6–50) Male

21.5±10.6

(14–50)

Female

24.0±9.8

(6–43)

Total

159 23.36±10.1 (6–68)

SD: Standard deviation; Min: Minimum; Max: Maximum.

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50 45

40 35 30 25 20

Lebanon

Mexico

Norway

Oman

Portugal

Romania

1 Vietnam

Sri Lanka

Serbia

South Africa

Kenya

Englanr

Hong Kong

Chile

Turkey

Bangladesh

Nepal

Australia

Peru

Italy

China

Indonesia

(n=111)

Croatia

Russia

India

Philippiness

Pakistan

Spain

Figure 1. The distribution of selfie-related injuries and deaths according to countries.

(Table 2). In this study, we determined that selfie victims mostly preferred to take selfies on the edge of a cliff (17 events or accidents, 15.3%). Selfie stick usage among selfie victims was remarkably low (2 events or accidents, 1.8%) We determined that total number of people in a selfie pose was 206, and 75.7% of these people were affected from selfie-related injuries and deaths.

Injuries & Deaths

50 40 30

Table 2. Some preferences of selfie victims 20

Preferences

57.7

42.3

Place 2014

(n=151)

2015 Years

2016

Figure 2. Increase in selfie-related injuries and deaths by years.

events or accidents occurred in August (18 events or accidents, 16.2%), July (16 events or accidents, 14.4%), and June (13 events or accidents, 11.7%). Conversely, the number of events or accidents reported in March, November, and December was the lowest and the same (5 events or accidents, 4.5%). When selfie-related injuries and deaths were examined in weekdays, most cases occurred on Saturdays (24 events or accidents, 21.6%) and Fridays (23 events or accidents, 20.7%); the lowest number of events or accidents was reported on Thursdays (15 events or accidents, 13.5%). Additionally, higher number of events or accidents occurred in the postmeridiem (p.m.) time interval (74 events or accidents, 66.7%).

Preferences We found that selfie-related injuries and deaths mostly occurred in city suburbs (64 events or accidents, 57.7%). We also determined that selfie victims preferred natural scenes for a selfie (48 events or accidents, 43.2%); we also found out that the number of mono or alone selfies is higher than that of group selfies (>2 people) (60 events or accidents, 54%) Ulus Travma Acil Cerrahi Derg, March 2018, Vol. 24, No. 2

Outside the city

In the city

Total

111 100

Scene

Nature and associated environments

43.2

Train, railway, and associated structures

19.9

Buildings and associated structures

15.3

Road, bridge, and associated structures

10.8

Dam and associated structures

6.3

Fields, farms, and associated structures

3.6

0.9

Others Total

111 100

Selfie stick use

Unknown or not reported

Yes Total

109 2

98.2 1.8

111 100

Selfie type

Mono Selfie

Group Selfie (>2 people)

Total

111 100

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No deaths during transportation from the scene of accident to a hospital were reported. The most common body parts to be affected in selfie-related injuries and deaths were multiple body parts (>3) (76 victims, 47.8%) (Table 3).

Event or Accident Categories We determined that the most common event or accident type causing selfie-related injuries and deaths was falling from height (28 events or accidents, 25.2%) (Fig. 3). The most frequent causes of selfie-related deaths were multitrauma due to various causes (58 victims, 42.3%) and drowning (57 victims, 41.6%) (Fig. 4). The most frequent cause of selfie-related injuries was multitrauma due to falling from height (6 victims, 27.3%). The most common place of death in selfierelated deaths was the scene of accident (99 victims, 72.3%). Fall from height to the ground

Risk Factors The most common behavioral risk factor in selfie-related injuries and deaths was people exhibiting dangerous behaviors for themselves and others around them (61 events or accidents, 55%). Neurocognitive risk factor causing negative effects (losing balance, temporary distraction, and/or lack of self-awareness) during selfie-taking was determined in 99 events or accidents (89.2%).

28 19

Fall into the water Crush under the train

Gunshot wounds Capturing by strong waves

Comparisons

Chi-square test was conducted to determine the relation be-

Contact with high-voltage electric wires Exposure to the attack of wild/dangereous animals

Fall from height to the sea/the river

Table 3. Body regions and/or systems affected by selfie-related injuries and deaths

Fall down the stairscase

2 2

Crushing under the truck Bomb-loaded car explosion

Hand-bomb explosion

Snake bite

Fall into the crater

Body regions and/or systems

Head-Neck

8.8

Chest-Abdomen-Back

3.7

Fall intoa gayser

Extremity

1.9

Collision of the motorcycle with the pedestrian

Multiple body parts (>3)

47.8

Collision of the bicycle with the vehicle

Non-traumatic or systemic effects

35.2

Collision of the car with the vehicle

High-voltage electric wires and fall from high

Multiple body parts (>3) and systemic effects

1.3

(n=111)

Extremity and systemic effects

Total

Figure 3. Event or accident types in selfie-related injuries and deaths. 60

1.3

159

100

50 40 30

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(g un

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Figure 4. Causes of death of selfie victims.

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tween the affected body parts and/or systems and event or accident types and causes of death. The results were significant in both relations (p=0.001). Additionally, mildly positive relationships between the affected body parts and/or systems and event or accident types and causes of death of (r=0.67) and (r=0.83), respectively, were determined according to the Cramer’s V coefficient. Similarly, the results of chi-square test were significant in terms of relation; a mildly positive relationship between event or accident types and causes of death was determined according to the Cramer’s V coefficient (p=0.001 and r=0.85).

DISCUSSION In 2013, more than 23 million selfies were shared on Instagram, and by the end of that year, the Oxford Dictionary declared “selfie” as “the word of the year” because its number reached 57 million.[19] Selfie phenomenon particularly in young adult males[20] has been a focus for neuropsychiatry for the last couple of years to point out narcissistic, psychopathologic,[3] and prejudice-based asymmetrical behavioral tendencies,[21,22] along with its negative effects (loss of balance, temporary distraction, and momentary loss of selfawareness)[6,7] and positive effects (promoting positive affect through smartphone photography)[23] with reference to reflecting the complexity of human behavior.[4] People with high narcissism demonstrate intense self-focus, activity changes particularly in the anterior insula, and neuronal differences mainly in the right anterior insula.[24] Selfie syndrome mainly concerns active, traveling age group; the various preventable traumatic risks of this syndrome[8] concern travel medicine, emergency medicine, and preventive medicine. Heavy selfietaking or smartphone, selfie, and social media[25,26] addiction introduced a new generation to social area researchers, the “Screenagers,” who learn everything from the digital screen. Screenagers are thought to be in the teenager age group (13– 19 years).[27,28] Due to their high intellectual abilities and dynamism, screenagers tend to create a whole new special risk group in selfie-related injuries and deaths. Another important risk group is young adults (15–29 years). The studies of Dutta et al.[20] and Saroshe at al.[29] conducted on school-age adolescents and professional students showed that these age groups are heavy selfie-takers. No significant difference was determined in their gender-wise statistics. A research conducted in 2014 showed that social media was most frequently used by individuals aged between 18 and 29 years.[26] Although the cases used in our study were in accordance with current researches in terms of social status and age groups, our study showed that males had a significantly higher risk for selfierelated injuries and deaths. Wikipedia, a free online encyclopedia launched in 2001, is one of the most visited websites worldwide and is often consulted for health-related information;[30] it was the major source of cases in this study. It is a common belief that the media sources in many cases are unreliable or false;[31] therefore, all Ulus Travma Acil Cerrahi Derg, March 2018, Vol. 24, No. 2

media resources (134 in total) in our study were meticulously and exactly evaluated by all researchers to increase the reliability of this media-based clinical research. A research conducted by the TIME Magazine in 2014 listed “The Selfiest Cities in the World”.[2] Even though none of the Indian cities were listed in the top 100 selfiest cities, we determined that India had the highest number in selfie-related injuries and deaths, suggesting that there is no strong correlation between the selfiest cities list and the cities where most selfie-related injuries and deaths actually occur. The security of the environment while taking a selfie might be a more important factor. However, India’s high teenager and adolescent population and the easy access of these groups to smartphone technology along with the fast increase of smartphone addiction[25,29] might be regarded as potential factors for selfie-related injuries and deaths. The significant increase in the number of selfie-related injuries and deaths per year (2014–2015 and 2016) may be associated with the increase in the number of heavy selfie-takers[1] and dangerous selfie-taking, with smartphone addiction and selfie-related behaviors, particularly among young people in recent years.[3–5,32] In addition, the fact that the smartphone technology has developed a lot in such a short time and become accessible to everyone, along with the Selfie Phenomenon[8] becoming popular, may also be important factors for the increase in selfie-related injuries and deaths. The sudden increase in selfie-related injuries and deaths especially in summer months and on weekends might be explained by people preferring these times for social activities and traveling. Selfie-related injuries and deaths are mostly seen in post-meridiem (p.m.) time interval, and this can be explained by people’s preference in daily communication and activity in social media sites timelines. We determined that certain behavioral (exhibiting dangerous behaviors as the most frequently reported one) and cognitive (losing balance, temporary distraction, and/or the lack of self-awareness) risk factors had significantly high ratios in our study. Some neuroscience researches suggested that selfie victims often use emotionally controlled mental reflection by emphasizing extroversion of the crazy personality by choosing natural environments and dangerous areas such as the edge of a cliff and railways for posing. So, the Amygdale’s representation of the motivational activity of happy and angry facial expressions has been a neurocognitive explication of adventure and fearful poses.[33] Therefore, dangerous places and poses exhibiting dangerous behaviors of selfie victims in our study are consistent with the current literature. In terms of functional anatomy, the left-sided face poses are predominantly controlled by the right hemisphere during selfie, and the right amygdala is active in fear expression. Moreover, in narcissism, the suppression of the left hemisphere that controls cognitive functions with right insular activity results in loss of environmental control in the victims.[34,35] In such a case, it is difficult to prevent possible accidents including self133

Dokur et al. Media-based clinical research on selfie-related injuries and deaths

ie-related ones. This may explain the importance of cognitive risk factors in our study. The fact that affected multiple body parts (>3) and multiple traumas from various reasons (falling from height, being hit/ crushed by trains, truck collision, and many more) being the most frequent consequences can be explained by event or accident types and severity. In addition, the events that trigger each other can be explained as the domino effect.[36] A typical example of this might be a victim being run over while taking a selfie in front of a moving train, experiencing multiple body parts and serious injuries or death caused by multiple traumas. The low selfie stick usage rate we determined in our study may be explained by alone or mono selfies being more common. Injury type or severity, physical conditions of the scene, and helping hands in the selfie pose and around the scene may be effective in selfie-related deaths mostly occurring on the accident scene. In this study, we also determined that the majority of our selfie victims were tourists (domestic or international), and this can be explained by the fact that people take more selfies during traveling. Our findings are also supported by the current literature.[8,37]

Conclusion Selfie-related injuries and deaths have increased in recent years. All countries, particularly India, US, and Russia are at a high risk. Teenagers and young adult males are in the highrisk group for selfie-related injuries and deaths. Dangerous pose preferences, exhibiting dangerous behaviors, deaths and injuries wherein many body parts are affected caused by multiple traumas, and cognitive and behavioral risk factors are important for selfie-related injuries and deaths. Dangerous consequences of selfie-related behaviors should be assessed from a multidisciplinary point of view. Drastic measures should be taken to reduce selfie-related risks, and social projects to protect young people from selfie-related hazards should be encouraged.

Acknowledgment

sites. Personality and Individual Differences 2015;76:161–5. 6. American College of Emergency Physicians (ACEP). Participation in activities while distracted by mobile device use. Policy statement. Ann Emerg Med 2014;64:563. 7. Bhogesha S, John JR, Tripathy S. Death in a flash: selfie and the lack of self-awareness. J Travel Med 2016;23. pii: taw033. 8. Flaherty GT, Choi J. The ‘selfie’ phenomenon: reducing the risk of harm while using smartphones during international travel. J Travel Med 2016;23:tav026. 9. Nasar J, Hecht P, Wener R. Mobile telephones, distracted attention, and pedestrian safety. Accid Anal Prev 2008;40:69–75. 10. Stavrinos D, Byington KW, Schwebel DC. Effect of cell phone distraction on pediatric pedestrian injury risk. Pediatrics 2009;123:e179–85. 11. Dolphin was ‘already dead’ when crowd in Argentina handled it – tourist Environment. The Guardian. Available at: http://www.theguardian.com. Accessed Jan 3, 2017. 12. https://au.finance.yahoo.com/news/first-japan-project-aims-prevent-050100272.html. Accessed Jan 3, 2017. 13. http://mashable.com/2015/07/07/russia-safe-selfies/#cNo3Sfj15EqT. Accessed Jan 3, 2017. 14. The United Stated Department of Health and Human services. Avaible at: http://www.ahrq.gov/. Accessed Jul 31, 2017. 15. List of selfie-related injuries and deaths. Available at: https:// en.wikipedia.org/w/index.php?title=List_of_selfie- related_injuries_ and_deaths&oldid=757719342. Accessed Jan 10, 2017. 16. http://www.birgun.net/haber-detay/3-kopru-de-ilk-kaza-selfie-yuzunden-126267.html123. Accessed Jan 2, 2017. 17. http://www.timeturk.com/mersin-de-sel-felaketi-2-olu-1-kayip/ haber-430346. Accessed Jan 1, 2017. 19. Storella AC. It’s Selfie-Evident: Spectrum of Allienability and Copyrighted Content on Social Media. Boston University Law Review 2014;94:2045–9. 18. http://tribune.com.pk/story/1285573/fatal-mistake-deadly-selfietakes-man-off-sukkurs-lansdowne-bridge/. Accessed Jan 9, 2017. 20. Dutta E, Sharma P, Dikshit R, Shah N, Sonavane S, Bharati A, et al. Attitudes Toward Selfie Taking in School-going Adolescents: An Exploratory Study. Indian J Psychol Med 2016;38:242–5. 21. Bruno N, Bode C, Bertamini M. Composition in portraits: Selfies and wefies reveal similar biases in untrained modern youths and ancient masters. Laterality 2017;22:279–93.

The authors did not declare any financial support.

22. Lindell AK. The silent social/emotional signals in left and right cheek poses: a literature review. Laterality 2013;18:612–24.

Conflict of interest: None declared.

23. Chen Y, Mark G, Ali S. Promoting Positive Affect through Smartphone Photography. Psychol Well Being 2016;6:8.

REFERENCES 1. Barkley JE, Lepp A. Cellular telephone use during free-living walking significantly reduces average walking speed. BMC Res Notes 2016;9:195. 2. The Definitive Ranking of The Selfiest Cities in the World. Available at: www.time.com. Accessed Jan 3, 2017. 3. Lee JA, Sung Y. Hide-and-Seek: Narcissism and “Selfie”-Related Behavior. Cyberpsychol Behav Soc Netw 2016;19:347–51. 4. Sorokowski P, Sorokowska A, Oleszkiewicz A, Frackowiak T, Huk A, Pisanski K. Selfie posting behaviors are associated with narcissism among men. Personality and Individual Differences 2015;85:123–7. 5. Fox J, Rooney MC. The dark triad and trait self-objectification as predictors of men’s use and self-presentation behaviors on social networking

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24. Fan Y, Wonneberger C, Enzi B, de Greck M, Ulrich C, Tempelmann C, et al. The narcissistic self and its psychological and neural correlates: an exploratory fMRI study. Psychol Med 2011;41:1641–50. 25. Davey S, Davey A. Assessment of Smartphone Addiction in Indian Adolescents: A Mixed Method Study by Systematic-review and Meta-analysis Approach. Int J Prev Med 2014;5:1500–11. 26. http:/www.pewinternet.org/files/2015/01/PI_SocialMediaUpdate20144.pdf. Accessed Jan 12, 2017. 27. https://mindmake2.blogspot.com.tr/2016/07/are-your-kids-addictedto-their-phones.html. Accessed Jan 3, 2017. 28. https://mediatechparenting.net/2016/03/17/screenagers-an-excellentnew-documentary-digital-parenting-resource/. Accessed Jan 3, 2017. 29. Saroshe S, Banseria R, Dixit S, Patidar A. Assessment of Selfie Syndrome among the Professional Students of a Cosmopolitan City of Central In-

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Dokur et al. Media-based clinical research on selfie-related injuries and deaths dia: A Cross-sectional Study. Int J Prevent Public Health Sci 2016;2:1–4. 30. Watad A, Bragazzi NL, Brigo F, Sharif K, Amital H, McGonagle D, et al. Readability of Wikipedia Pages on Autoimmune Disorders: Systematic Quantitative Assessment. J Med Internet Res 2017;19:e260. 31. Pribble JM, Goldstein KM, Fowler EF, Greenberg MJ, Noel SK, Howell JD. Medical news for the public to use? What’s on local TV news. Am J Manag Care 2006;12:170–6. 32. The Huffington Post. Too many smartphone users taking dumb, dangerous selfies with bears, Tahoe officials say. Available at: http://www.thehuffingtonpost.com. Accessed Jan 24, 2017. 33. Critchley H, Daly E, Phillips M, Brammer M, Bullmore E, Williams S, et al. Explicit and implicit neural mechanisms for processing of social infor-

mation from facial expressions: a functional magnetic resonance imaging study. Hum Brain Mapp 2000;9:93–105. 34. Wager TD, Phan KL, Liberzon I, Taylor SF. Valence, gender, and lateralization of functional brain anatomy in emotion: a meta-analysis of findings from neuroimaging. Neuroimage 2003;19:513–31. 35. Fusar-Poli P, Placentino A, Carletti F, Allen P, Landi P, Abbamonte M, et al. Laterality effect on emotional faces processing: ALE meta-analysis of evidence. Neurosci Lett 2009;452:262–7. 36. Darbra RM, Palacios A, Casal J. Domino effect in chemical accidents: main features and accident sequences. J Hazard Mater 2010;183:565–73. 37. Patel D, Jermacane D. Social media in travel medicine: a review. Travel Med Infect Dis 2015;13:135–42.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Özçekim ilişkili yaralanma ve ölümlerin analizi Dr. Mehmet Dokur,1 Dr. Emine Petekkaya,2 Dr. Mehmet Karadağ3 1 2 3

Başkent Üniversitesi Hastanesi, Yoğun Bakım Ünitesi, Ankara Beykent Üniversitesi Tıp Fakültesi, Anatomi Anabilim Dalı, İstanbul İnönü Üniversitesi Sağlık Bilimleri Enstitüsü, Biyoistatistik ve Tıp Bilişimi Anabilim Dalı, Malatya

AMAÇ: Yoğun olarak özçekim ve bunları sosyal medyada paylaşmak ya da bununla ilişkili davranışlar, özellikle gençler arasında giderek artmaktadır. Bu durum özçekim nedenli travmalara yol açabilir. Bu klinik çalışmayı, özçekim ilişkili yaralanma ve ölümlere dikkat çekmek için gerçekleştirdik. GEREÇ VE YÖNTEM: Çalışmamızda medya kaynaklarında rapor edilen 111 özçekim olayı veya kazası ile ilişkili 159 olgu değerlendirildi. Özçekimle ilişkili yaralanma ve ölümlerin nedenleri ile birlikte kurbanların vital bulguları, demografileri, ritmisiteleri, tercihler, olay veya kaza tipleri, risk faktörleri ve etkilenen vücut bölgeleri değerlendirildi. BULGULAR: Özçekim kurbanlarının birçoğunun öğrenci olduğu belirlendi. Özçekim ilişkili yaralanma ve ölümler en sık Hindistan, ABD ve Rusya’dan bildirilmişti. Kurbanların en sık poz tercihi uçurum kenarı idi. En sık rapor edilen kaza tipi yüksekten zemine düşme idi. Özçekim ilişkili yaralanma ve ölümlerde en sık etkilenen çoklu vücut bölgesi idi. En sık saptanan ölüm nedeni multitravma ve suda boğulma idi. TARTIŞMA: Özçekim ilişkili yaralanma ve ölümler son yıllarda giderek artmaktadır. Özellikle ergenler ve genç yetişkinler tehlikeli özçekim açısından yüksek risk taşırlar. Bu nedenle özçekim ilişkili yaralanma ve ölümleri azaltmak için bilinçlendirme yapılmalıdır. Anahtar sözcükler: Ölüm; yaralanma; özçekim. Ulus Travma Acil Cerrahi Derg 2018;24(2):129–135

doi: 10.5505/tjtes.2017.83103

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ORIG I N A L A R T IC L E

Importance of knowledge of the management of traumatic dental injuries in emergency departments Acar Aren, M.D.,1 Arzu Pınar Erdem, M.D.,2 Gamze Aren, M.D.,2 Zeynep Deniz Şahin, M.D.,1 Ceren Güney Tolgay, M.D.,2 Merve Çayırcı, M.D.,2 Elif Sepet, M.D.,2 Recep Güloğlu, M.D.,3 Hakan Yanar, M.D.,3 Kaya Sarıbeyoğlu, M.D.4 1

Department of General Surgery, İstanbul Training and Research Hospital, İstanbul-Turkey

Deparment of Pediatric Dentistry, İstanbul University Faculty of Dentistry, İstanbul-Turkey

Deparment of General Surgery, İstanbul University İstanbul Faculty of Medicine, İstanbul-Turkey

Deparment of of General Surgery, İstanbul University Cerrahpaşa Faculty of Medicine, İstanbul-Turkey

ABSTRACT BACKGROUND: Hospital emergency departments (EDs) are confronted with managing dental emergencies of both traumatic and non-traumatic origin. However, the literature suggests inadequate knowledge of the management of traumatic dental injuries (TDIs) among medical professionals. The aim of this study was to investigate the knowledge and attitudes regarding management of TDIs among Istanbul ED physicians. METHODS: Surveys were distributed to emergency departments (ED) directors and their physicians. The survey contained questions about their characteristics and tested their knowledge of managing dental trauma. RESULTS: A total of 126 surveys (13 ED directors and 113 physicians) were returned and included in the analysis. ED physician’s knowledge of the appropriate management of crown fractures and avulsion was generally good (p=0.221), but poor for luxation injuries (p=0.0001). Physicians were more likely to have a better knowledge about permanent teeth than about primary teeth (p=0.027). CONCLUSION: Education, monitoring, improved availability of resources, and disciplinary measures in cases of poor compliance are necessary to improve TDI management in hospitals, especially among physicians. Keywords: Dental trauma; orofacial injury; traumatic dental injuries.

INTRODUCTION Several epidemiological studies continue to show significant levels of dental trauma in many countries.[1–3] In industrialized countries, about one in five children experience a traumatic dental injury (TDI) to permanent teeth before leaving school. Prevalence of injured teeth reported in the literature varies from 10% to 51%.[4,5] The nature and complexity of dental trauma in children vary widely.[6] Prompt and appropriate management is necessary to significantly improve prognosis of many dentoalveolar injuries, especially in a young patient.[7–9]

The emergency medical service doctors are frequently the first to provide the primary treatment.[10] It has been well documented that the prognosis of traumatized teeth depends largely on both timely and appropriate emergency management.[6] Tooth fracture affecting the pulp, luxation injuries, and, especially, avulsions require prompt evaluation and treatment to obtain the best possible outcomes. Delays in treatment may result in poor prognoses of a child’s tooth/teeth that have sustained these time-sensitive dental injuries.[11] To ensure appropriate treatment of children with dental trauma, it is essential that emergency medical professionals are adequately trained in the basic principles of dental trauma management.[10]

Cite this article as: Aren A, Erdem AP, Aren G, Şahin ZD, Güney Tolgay C, Çayırcı M, et al. Importance of knowledge of the management of traumatic dental injuries in emergency departments. Ulus Travma Acil Cerrahi Derg 2018;24:136–144 Address for correspondence: Acar Aren, M.D. İstanbul Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, İstanbul, Turkey Tel: +90 212 - 588 44 00 / 1576 E-mail: acararen@gmail.com Ulus Travma Acil Cerrahi Derg 2018;24(2):136–144 DOI: 10.5505/tjtes.2017.57384 Submitted: 04.12.2016 Accepted: 24.05.2017 Online: 14.02.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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Aren et al. Importance of knowledge of the management of traumatic dental injuries in emergency departments

In our previous article about predominant causes and types of orofacial injury in children seen in the emergency department (ED),[12] a total of 1296 children among 12055 patients with orofacial trauma were evaluated. Although there is a high probability of encountering orofacial trauma, our search of the literature revealed only one study from Turkey that evaluated the knowledge of medical professionals in the management of tooth avulsion injuries. Therefore, this study aimed to evaluate the first-aid knowledge of the emergency physicians on the management of common pediatric dental traumas such complicated/uncomplicated crown fractures, luxation, and avulsion.

the long-term success, importance of not replanting primary teeth, optimal storage media, critical extra-alveolar time of an avulsed tooth, proper handling of an avulsed tooth, proper cleaning technique for an avulsed tooth before replantation, first place to contact in seeking professional help, and dental trauma experience.

MATERIALS AND METHODS

Statistical Analyses

The present study was a cross-sectional observational study. The project was approved by the Ethics Committee of Istanbul University, Faculty of Dentistry (2015/24). The nature and purpose of the study was explained to all participants, its voluntary nature emphasized. Informed consent to participate was subsequently obtained from each study participant. Strict confidentiality was assured as no names or phone numbers were required.

Data were analyzed using NCSS (Number Cruncher Statistical System) 2007 Statistical Software (Utah, USA). A descriptive analysis including average, standard deviations, medians, minimum, and maximum was performed. We performed oneway analysis of variance for different groups and Tukey’s multiple comparison test for subgroups; Independent t-test was also performed. The results were considered to be significant for p<0.05.

The survey was developed by gathering the questions used in the articles of Needleman, Subhashraj, and Addo.[11,13,14] In addition, physicians’ experience in first-aid management of dental trauma was examined with new questions framed by the authors. The original questionnaire was developed and piloted to 10 volunteers and revised before being completed by the first group of participants. The survey was distributed to the emergency rooms departments of Istanbul University Faculty of Istanbul Medicine and Faculty of Cerrahpaşa Medicine and Health Science University Istanbul Training and Research Hospital.

RESULTS

The questionnaire was divided into three parts. The first part comprised questions on personal information. It included information about (age, gender, year of medical graduation, profession, academic title, level of experience in emergency medicine, if first-aid training included training on dental trauma and if the medical training involved any dental educational programs, whether the participants find their knowledge of dental trauma management sufficient or not, previous experience, and interest in learning dental trauma management). Parts II and III comprised questions regarding uncomplicated crown fracture, complicated crown fracture, luxation, and avulsion of both primary and permanent teeth as well as the emergent nature of each of these injuries. The multiple-choice or yes/no questions were used. The survey was given to the participants under the supervision of the authors. The following fields of knowledge were assessed: importance of the emergent treatment of complicated crown fractures for pulpal healing, management of luxation, importance of immediate management of an avulsed permanent tooth for Ulus Travma Acil Cerrahi Derg, March 2018, Vol. 24, No. 2

The guidelines for managing TDI as published at that time by the International Association of Dental Traumatology were used to determine the correct choice for each trauma question in the survey as defined by Needleman, Diaz, and coworkers.[11,15]

In total, 126 physicians participated in the study; 72.22% of the participants were male and 27.78% were female. The mean age of the participants was 36.67±8.87 years. The first part of the questionnaire included the personal data of the physicians. Personal data has been summarized in Table 1; 73.81% of the respondents were general surgeons and 89.68% were medical specialists. In this study, the mean of professional experience duration was 10.73±8.82. The professional experience duration was calculated taking into account the time spent in this area after receiving the title of medical specialist. Experience level in emergency medicine was calculated as taking in consideration of the emergency service working time and it was 9.10±7.98 years. 72.22% of the participants did not receive any training on oral and dental health and 97.62% did not attend any dental trauma management training. Three participants reported that they received education on dental trauma at a medical faculty. Of all the physicians, 84.92% stated that their knowledge of dental trauma management was insufficient and 80.80% were willing to attend training on this subject. Knowledge of the appropriate emergent treatment for dental fractures, both uncomplicated and complicated, was satisfactory as indicated by physicians’ correct response rates between 65.08%–92.86%. The questions regarding emergent treatment need of lateral luxation cases, where primary or 137

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Table 1. (a) Personal data of the physicians (b) Knowledge of TDI management (c) Interest in TDI management (d) Experience in emergency medicine (a) Personal data of the physicians

Profession

General Surgery

76.2

Internal Medicine

8.7

Pediatrics

7.1

113

89.68

Emergency Medicine

Academic Title

Medical specialist

Assistant professor

1.59

Associate professor

6.35

2.38

72.22

Yes

27.78

123

97.62

Yes

2.38

Professor Did you attend any oral health training during your educational/professional career?

Did you attend any dental trauma management training during your educational/professional career?

If the answer is yes, when did you attend?

123

97.62

5th grade of medical faculty

No answer given

2.38

(b) Knowledge of traumatic dental injuries management

0.79

Do you think you have sufficient knowledge of dental trauma?

Yes, my knowledge is sufficient

My knowledge is almost sufficient

7.94

No, not sufficient

107

84.92

I have no idea

6.35

Yes, I am interested

101

80.80

No, I am not interested

16.00

I have no idea

3.20

(d) Experience in emergency medicine

Mean

Standar deviation

Minimum

Maximum

Years of experience

126

10.73

8.82

Years of experience in emergency medicine

124

9.10

7.98

permanent teeth are displaced by 1–2 mm without traumatic occlusion, were correctly responded to in the range of 65.08%–76.19%. However, the correct response ratio for questions regarding the emergent nature of avulsion injuries was low (26.19%–53.97%). Table 2 presents the percentage of physicians’ correct responses to each of the questions regarding emergent nature of treatment of dental fractures and luxation of primary/permanent teeth. 138

Correct response ratios between crown fracture, luxation, and avulsion question groups were significantly different (p=0.0001) (Table 3). Luxation question group had less correct responses than crown fracture and avulsion groups (p=0.0001). No significant differences were observed between crown fracture and avulsion question groups (p=0.221). Correct responses to permanent teeth questions were higher than those to primary teeth questions (p=0.027). Ulus Travma Acil Cerrahi Derg, March 2018, Vol. 24, No. 2

Aren et al. Importance of knowledge of the management of traumatic dental injuries in emergency departments

Table 2. Correct responses regarding the emergent management of TDI as a function of the type of injury (crown fracture, luxation, and avulsion) (a) and tooth type (primary vs permanent) (b) (a)

Mean±SD correct response to survey questions

Median

Minimum

Maximum

Crown fracture

1.04±0.76

0.0001

Luxation

0.59±0.75

0 0 2

Avulsion

1.2±0.77

1 0 2

(b)

Mean±SD correct of survey questions

Median

Minimum

Maximum

p 0.027

Primary teeth

1.31±0.70

Permanent teeth

1.52±0.78

Table 3. Comparison of correct responses among different question groups p Crown fracture / Luxation

0.0001

Crown fracture / Avulsion

0.221

Luxation / Avulsion

0.0001

Last part of the questionnaire included detailed questions regarding the management of avulsion (if treatment is needed in cases of permanent tooth avulsion, proper management of the avulsed tooth, proper cleaning technique of an avulsed tooth before replantation, proper handling of an avulsed tooth, optimal storage media, and prescription of antibiotics). Responses were grouped as “correct,” “incorrect,” and “no comment”; Table 4 presents the percentages of the responses. While the incorrect response ratio for the question “Should avulsed permanent tooth be replaced?” was 30.95%, 56.35% of the participants declared that they have no idea; 10.32% of the physicians were aware of the appropriate treatment of an avulsed tooth. The correct response ratio for questions “If the tooth looks dirty, what would you do?” and “From which part would you hold the tooth?” was 50.79% and 48.41%, respectively. The correct response ratio for the question re-

garding appropriate storage media was very high (94.54%). Table 5 presents the distribution of responses to questions regarding appropriate storage media. The majority of respondents (80.96%) stated they would prescribe antibiotic and anti-inflammatory medicaments following avulsion, which was considered the correct response regarding treatment. Critical extra-alveolar time of the avulsed tooth and first place to contact in seeking professional help were also questioned. Responses to these questions were distributed as the best response getting the highest score and the worse getting the lowest score [Table 6 (a, b)]. When we evaluated the duration between avulsion and seeking professional help, the response of 26.19% of the participants was immediately, that of 5.87% was in a couple of hours, and that of 19.05% was within 24 h; 7.14% participants responded that there was no need for urgent professional help and 19.05% had no idea about situation. For professional help, only 7.94% participants preferred a dentist and 1.59% preferred a pediatric dentist, which is very low. Physicians’ dental trauma experiences were also examined in the last part of the questionnaire. Participants’ previous experiences of dental trauma, with type and reason, were evaluated. Their knowledge about clinics in Istanbul that can manage emergency dental trauma cases and working hours of such clinics was also asked.

Table 4. Distribution of the responses to questions regarding avulsion injury

Correct responses

Incorrect responses

No comment

n % n % n %

Should avulsed permanent tooth be replaced?

12.7

30.95

56.35

What is the appropriate treatment of avulsed tooth?

10.32

70.63

19.05

If the tooth looks dirty, what would you do?

50.79

20.64

28.57

From which part would you hold the tooth?

48.41

2.38

49.21

Which storage media are appropriate for the avulsed tooth?

119

94.54

63.48

15.87

Would you prescribe antibiotics after avulsion?

102

80.96

19.05

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Table 5. Distribution of responses to questions regarding appropriate storage media

Table 6. Extra-alveolar time of the avulsed tooth (a) the preference of professional help (b)

(a) Extra-alveolar time of the avulsed tooth

Correct responses

Saline solution

62.70

Salt water

15.08

Patient’s mouth

8.73

Contact lens solution

3.97

Milk Incorrect responses

Cold water

23.81

Paper towel/gauze

8.73

Disinfectant solution

7.94

Plastic bag

7.14

There’s no need to keep the tooth

4.76

Ice

3.94

3.17

Coke

Tap water

3.17

0.79

15.87

Hot water

No idea

Their opinions on interfering with dental trauma cases were estimated [Table 7 (a, b)]; 55.56% of the physicians had experienced a dental trauma and 50.79% had witnessed tooth fracture. Reasons for the trauma were traffic accident (32.54%), fall (35.71%), sports accident (10.32%), and stroke (28.57%). Of all, 88.89% of the physicians were not aware of the emergency clinics managing dental trauma in Istanbul and their working hours. While witnessing a dental trauma, 44.44% and 27.78% of the physicians do not interfere with the patient because of lack of knowledge and because of legal obligations, respectively. No significant differences were found between the demographic features of physicians and correct response ratios (Table 8).

DISCUSSION This study aimed to evaluate the first-aid knowledge of the medical hospital ED physicians about the management of the common pediatric dental traumas. In our previous article, we reported that a high number of children visited EDs with orofacial injury complaints.[12] Although high probability of orofacial trauma exists, our search of the literature revealed only one study from Turkey that evaluated the knowledge of medical professionals in the management of tooth avulsion injuries. [16] Because an emergency dental practitioner is rarely present in public or university hospitals in Turkey, it is inevitable that physicians will sometimes be required to provide emergency dental treatment before professional dental contact. 140

All groups n

In case of avulsion, when should the patient seek professional help?

Immediately (score: 5)

26.19

Within first 24 h (score: 2)

19.05

I have no idea

19.05

Within 30-60 minutes (score: 4)

15.87

Within a few hours (score: 3)

12.70

There is no need for professional

help (score: 1)

7.14

(b) Preference for professional help

All groups n

Which one would you communicate with for the treatment?

Medical doctor (score: 3)

103

81.75

Dentist (score: 4)

7.94

There is no need for treatment (score: 1)

3.97

I would treat by myself (score: 6)

3.17

Pediatric dentist (score: 5)

1.59

Plastic surgeon (score: 2)

0.79

I have no idea

0.79

Unlike most of the previously cited studies,[10,14–20] which primarily queried physicians about avulsions, our study examines the management of the common pediatric dental traumas such as complicated/uncomplicated crown fractures, luxation, and avulsion. Díaz et al.[15] interviewed 82 medical staff in hospital emergency rooms in Chile; 90% of them had not received formal training, and it was concluded that the overall TDI knowledge was relatively poor. In 2011, Trivedy et al.[20] found that the majority (88%) of the physicians in the United Kingdom did not receive any formal training in TDI, and they were not confident in managing dentofacial emergencies. Ulusoy et al.[16] reported that 41% of the respondents assessed their knowledge as insufficient, and the majority (78%) stated that they would like further education. All of these studies reveal that physicians have an inadequate understanding of providing appropriate first-aid when confronted with TDI. In this study, the professional experience duration and experience level of the study group in emergency medicine were approximately 10 years. During this period, the majority of the physicians did not get any education about oral health or dental trauma management. Ulus Travma Acil Cerrahi Derg, March 2018, Vol. 24, No. 2

Aren et al. Importance of knowledge of the management of traumatic dental injuries in emergency departments

Table 7. (a) Previous experience of dental trauma, (b) behavior of the physician facing dental trauma (a) Previous experience of dental trauma

Have you ever witnessed a dental trauma incident?

44.44

Yes

55.56

Type of trauma

103

81.75

Avulsion

Yes

18.25

49.21

Tooth fracture

Yes

50.79

112

88.89

Yes

11.11

67.46

Yes

32.54

64.29

Luxation

Reason of trauma

Traffic accident Fall

Yes

35.71

113

89.68

Yes

10.32

71.43

Sports accident Stroke

Yes

28.57

124

98.41

Yes

1.59

Others

(b) Behavior of the physician witnessing dental trauma

If you are present at the scene of dental trauma accident, and the tooth is avulsed

I would not do anything because I do not know what to do

44.44

I would not do anything because of legal issues

27.78

I would confidently replant the tooth

1.59

I would try to replant the tooth, without surety

0.79

I have no idea

25.40

Are you familiar with dental clinics and their workings hours in Istanbul

112

88.89

that can manage emergency dental trauma cases?

Yes

11.11

Only three participants had attended a lecture on TDI in medical faculty. Furthermore, 84.92% of the physicians found their knowledge of TDI to be insufficient and were willing to get educated on this subject. The results of this study are similar to those of other studies, revealing the inefficient knowledge of dental trauma management among ED physicians. The physicians’ knowledge of the appropriate emergency treatment for dental fractures, both uncomplicated and complicated, was satisfactory as indicated by their correct response rates between 65.08% and 92.86%. The questions regarding lateral luxation injuries, which cause 1–2 mm displacement of the permanent/primary teeth without traumatic occlusion, were mostly correctly responded to (between 65.08% and 76.19%). However, questions regarding avulsion Ulus Travma Acil Cerrahi Derg, March 2018, Vol. 24, No. 2

injuries had a low correct response ratio (26.19%–53.97%). Questions regarding luxation had a lower correct response ratio than those regarding crown fractures and avulsion (p=0.0001); no significant difference was found between correct responses to questions regarding crown fractures and avulsion (p=0.221). Questions regarding permanent teeth had a significantly higher correct response ratio than those regarding primary teeth (p=0.027). Needleman[11] and coworkers stated contrary results when comparing emergency physicians in Turkey. They reported poor knowledge about dental fractures, both uncomplicated and complicated, and good responses to luxation and avulsions, especially avulsions. Similar to Needleman et al., physicians’ knowledge of TDI to permanent teeth was found to be better than that to primary teeth. 141

Aren et al. Importance of knowledge of the management of traumatic dental injuries in emergency departments

Table 8. Analyses of association between the characteristics of various emergency department physicians and their knowledge of emergency management of dental trauma as determined by the mean number of correct responses to eight survey questions regarding complicated/uncomplicated crown fractures, luxation, and avulsion Physician/Institution characteristics

No. of physicians

% of Mean±SD correct responses Median physicians to eight survey questions

Min.

Max.

0.272

Age

20–39 years of age

72.80

9.84±2.41

40–49 years of age

16.00

8.95±1.79

50–69 years of age

11.20

9.36±2.34

9.8

Men

72.80

9.55±2.39

18 0.478

Women

27.20

9.88±2.17

Sex

Specialty

76.2

9.58±2.41

Pediatrics

General surgery

8.00

10.5±1.58

Internal medicine

8.7

9.67±1.94

Emergency Medicine

7.1

9,33±2.45

10.5

0.664

Professional experience

0–5 years

36.80

9.8±2.17

6–10 years

24.80

9.87±2.43

11–15 years

14.40

9.61±2.87

16–20 years

5.60

9.57±2.76

>20 years

18.40

9.04±1.94

112

89.60

9.71±2.31

0.731

Academic position

Medical specialist

Assistant professor

1.60

7±2.83

Associate professor

6.40

10±2.51

9.5

2.40

Professor

In the present study, it was found that the age, gender, medical specialization, academic title, and experience level in emergency medicine of the respondents had no significant effect on emergency physicians’ correct responses regarding emergency treatment for complicated/uncomplicated crown fractures, luxation, and avulsion (p>0.05). Needleman[11] and coworkers also reported the same results about the effect of ED physicians’ characteristics on the knowledge of TDI. In previously cited studies, the correct answers about appropriate knowledge of avulsion management stated in a very wide range 3% to 50%.[10,18] A favorable prognosis for avulsed and replanted teeth significantly depends upon the combination of minimal time spent outside the socket, appropriate storage and transportation media, and minimal aggression to the root surface and periodontal ligament.[21] In this study, regarding the question if an avulsed permanent tooth should be replanted when the patient doesn’t have any systemic disorder, only 12.70% of the participants agreed to put the tooth back in its socket; 3.92% of the physicians stated that an avulsed permanent incisor 142

8±1

0.226

should be replanted in any event, while 24.6% of them would not replant an avulsed tooth under any circumstances, and 56.35% of respondents did not have any idea. In a study by Holan and Shmueli[10] at Israel, 4% of the physicians stated that an avulsed permanent incisor should be replanted in any event, while McIntyre et al.[22] reported that approximately 72% of the respondents would not immediately replant an avulsed tooth. The data of Hamilton et al.[2] showed that 36.4% of respondents did not know a tooth could be replanted. In the study of Abu-Dawoud et al.,[17] the majority of physicians surveyed (83.3%) reported that they did not receive any information concerning when tooth avulsion occurred. Appropriate replantation of an avulsed permanent tooth within 30 min has a 90% chance of success. After 2 h, there is negligible (5%) chance of long-term retention of the tooth. [23] An attempt should, thus, be made to immediately replant the avulsed tooth. Last part of the questionnaire in this survey includes questions related to the topics considered very important for the prognosis of avulsed permanent teeth. We evaluated the duration between trauma occurrences and reUlus Travma Acil Cerrahi Derg, March 2018, Vol. 24, No. 2

Aren et al. Importance of knowledge of the management of traumatic dental injuries in emergency departments

ferring the patient for professional help after avulsion; 26.19% physicians replied immediately, 15.87% replied within 30–60 min, 12.70% replied within a few hours, and 19.05% replied within 24 h. Furthermore, 7.14% physicians stated that there is no need for professional help and 19.05% did not have any idea. In this study, only 10.32% physicians chose the appropriate management technique for an avulsed tooth. Ulusoy et al.[16] stated that approximately half of the respondents were not aware of the appropriate procedures regarding replantation of avulsed permanent (42.0%) or primary (47.8%) teeth. Furthermore, approximately half of the respondents identified appropriate clinical procedures prior to replantation, such as proper cleaning (wash briefly under cold running water for a few seconds without touching the tooth) and handling techniques (from crown area) of an avulsed tooth before replantation. Hamilton et al.[24] obtained worse results in a study on root surface preparation when compared with this study. They stated that 28.5% respondents would scrub the tooth prior to replantation, 8.5% would wash and scrub the tooth with cotton, and 43.9% would wash the tooth with an antiseptic solution. The significance of the media is to preserve the vitality of the periodontal ligament. The type of storage media required for avulsed permanent teeth were mainly responded to correctly. In this study, 62.7% physicians chose saline solution; 35% of the participants considered sterile saline as the best medium for storage and transportation in the study of Subhashraj et al.[14] In our study, 8.73% participants recognized that an avulsed tooth should be intraorally transported, while in the studies by Lin et al.[18] and Díaz et al.,[15] 13.2% and 9.8% of the participants, respectively, responded that the best transport medium for an avulsed tooth is saliva. In the study of Subhashraj et al.,[14] none of the participants was aware that patient’s mouth (saliva) may also function well as a storage medium. In this study, 3.97% (a low percentage) of the physicians described “milk” as an alternative storage medium. In the study of Díaz et al.,[15] 40% of the respondents stated milk as a storage medium. A majority (80.96%) of respondents in this study, while 72.4% Turkish ED physicians in another study,[16] stated that they would prescribe antibiotics and anti-inflammatory medicaments following avulsion, which was considered the correct response regarding treatment. Most (81.75%) of the emergency physicians would refer the patient to a medical doctor after avulsion; 7.94% would choose a medical doctor. Only 1.59% (n=2) would refer the patient to a pediatric dentist, which was very low. In the study of Ulusoy et al.,[16] it is stated that only 13 (18.8%) participants would refer the patient to a pediatric dentist. Hamilton et al.[2] and Addo et al.[13] highlighted that the physicians Ulus Travma Acil Cerrahi Derg, March 2018, Vol. 24, No. 2

are frightened of hurting the child and of the possible legal implications of incorrectly replanting the tooth. In our study, 27.78% of the participants refused to treat the child because of legal issues and 44.44% found their knowledge about dental trauma to be inefficient. Physicians’ previous experience of dental trauma ratio was found to be 55.56% in this study; 88.89% of the participants were unaware of the dental emergency clinics and their working hours in Istanbul. Published studies have revealed that physicians have an inadequate understanding of how to provide appropriate first-aid when confronted with TDI.[10,14– 20] One study from Turkey[16] stated that most (66.7%) participants were unaware of the urgency of seeking professional care following TTAI. In this study, 84.92% of the physicians found their knowledge about dental trauma to be insufficient and 80.80% volunteered to get educated.

Conclusion Dental trauma may occur as an isolated injury or as a component of a severe maxillofacial injury. Physicians sometimes perform emergency dental treatment because emergency dental practitioners are rarely present in either public or university hospitals in Turkey. This study indicates a lack of adequate knowledge about TDI among physicians, similar to reports published over the last decade. Most of the physicians did not attend any training on dental trauma management or oral health during their educational or professional career. Regarding their unsatisfactory knowledge about dental trauma and enthusiasm for education, a dental trauma management training should be organized with the guidance of dental faculties. Continuing education, postgraduate programs, interdisciplinary seminars, case discussions, clinical posters, and flow charts with clinical guidelines for TDI management in emergency rooms should be provided to emergency physicians to help improve their level of knowledge on the emergency management of dentoalveolar tooth injuries. In addition, efforts by local dental organizations should provide emergency doctors with lists of dentists who are knowledgeable and willing to be available 24 h a day for consultation and, if necessary, provide timely management to the individuals sustaining TDI. These efforts would enhance the longterm outcomes for patients experiencing dental trauma who require emergency management. Conflict of interest: None declared.

REFERENCES 1. Hamdan MA, Rajab LD. Traumatic injuries to permanent anterior teeth among 12-year-old schoolchildren in Jordan. Community Dent Health 2003;20:89–93. 2. Hamilton FA, Hill FJ, Mackie IC. Investigation of lay knowledge of the management of avulsed permanent incisors. Endod Dent Traumatol 1997;13:19–23. 3. Kramer PF, Zembruski C, Ferreira SH, Feldens CA. Traumatic dental

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Aren et al. Importance of knowledge of the management of traumatic dental injuries in emergency departments injuries in Brazilian preschool children. Dent Traumatol 2003;19:299– 303. 4. Gassner R, Bösch R, Tuli T, Emshoff R. Prevalence of dental trauma in 6000 patients with facial injuries: implications for prevention. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;87:27–33. 5. Soriano EP, Caldas Ade F Jr, De Carvalho MV, Caldas KU. Relationship between traumatic dental injuries and obesity in Brazilian schoolchildren. Dent Traumatol 2009;25:506–9. 6. Andreasen JO, Andreasen FM, Skeie A, Hjørting-Hansen E, Schwartz O. Effect of treatment delay upon pulp and periodontal healing of traumatic dental injuries-a review article. Dent Traumatol 2002;18:116–28. 7. Levin L, Ashkenazi M, Schwartz-Arad D. Preservation of alveolar bone of un-restorable traumatized maxillary incisors for future implantation. J Israel Dent Assoc 2004;21:54–9. 8. Schwartz-Arad D, Levin L, Ashkenazi M. Treatment options of untreatable traumatized anterior maxillary teeth for future use of dental implantation. Implant Dent 2004;13:120–8. 9. Schwartz-Arad D, Levin L. Post-traumatic use of dental implants to rehabilitate anterior maxillary teeth. Dent Traumatol 2004;20:344–7. 10. Holan G, Shmueli Y. Knowledge of physicians in hospital emergency rooms in Israel on their role in cases of avulsion of permanent incisors. Int J Paediatr Dent 2003;13:13–9. 11. Needleman HL, Stucenski K, Forbes PW, Chen Q, Stack AM. Massachusetts emergency departments’ resources and physicians’ knowledge of management of traumatic dental injuries. Dent Traumatol 2013;29:272– 9. 12. Aren G, Sepet E, Pınar Erdem A, Tolgay CG, Kuru S, Ertekin C, et al. Predominant causes and types of orofacial injury in children seen in the emergency department. Ulus Travma Acil Cerrahi Derg 2013;19:246– 50. 13. Addo ME, Parekh S, Moles DR, Roberts GJ. Knowledge of dental trauma first aid (DTFA): the example of avulsed incisors in casualty departments and schools in London. Br Dent J 2007;202:E27.

14. Subhashraj K. Awareness of management of dental trauma among medical professionals in Pondicherry, India. Dent Traumatol 2009;25:92–4. 15. Díaz J, Bustos L, Herrera S, Sepulveda J. Knowledge of the management of paediatric dental traumas by non-dental professionals in emergency rooms in South Araucanía, Temuco, Chile. Dent Traumatol 2009;25:611–9. 16. Ulusoy AT, Onder H, Cetin B, Kaya S. Knowledge of medical hospital emergency physicians about the first-aid management of traumatic tooth avulsion. Int J Paediatr Dent 2012;22:211–6. 17. Abu-Dawoud M, Al-Enezi B, Andersson L. Knowledge of emergency management of avulsed teeth among young physicians and dentists. Dent Traumatol 2007;23:348–55. 18. Lin S, Levin L, Emodi O, Fuss Z, Peled M. Physician and emergency medical technicians’ knowledge and experience regarding dental trauma. Dent Traumatol 2006;22:124–6. 19. Qazi SR, Nasir KS. First-aid knowledge about tooth avulsion among dentists, doctors and lay people. Dent Traumatol 2009;25:295–9. 20. Trivedy C, Kodate N, Ross A, Al-Rawi H, Jaiganesh T, Harris T, et al. The attitudes and awareness of emergency department (ED) physicians towards the management of common dentofacial emergencies. Dent Traumatol 2012;28:121–6. 21. Boyd DH, Kinirons MJ, Gregg TA. A prospective study of factors affecting survival of replanted permanent incisors in children. Int J Paediatr Dent 2000;10:200–5. 22. McIntyre JD, Lee JY, Trope M, Vann WF Jr. Elementary school staff knowledge about dental injuries. Dent Traumatol 2008;24:289–98. 23. Andreasen JO, Hjorting-Hansen E. Replantation of teeth. I. Radiographic and clinical study of 110 human teeth replanted after accidental loss. Acta Odontol Scand 1966;24:263–86. 24. Hamilton FA, Hill FJ, Holloway PJ. An investigation of dento-alveolar trauma and its treatment in an adolescent population. Part 1: The prevalence and incidence of injuries and the extent and adequacy of treatment received. Br Dent J 1997;182:91–5.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Acil servislerde travmatik dental yaralanmaların tedavisi konusunda bilginin önemi Dr. Acar Aren,1 Dr. Arzu Pınar Erdem,2 Dr. Gamze Aren,2 Dr. Zeynep Deniz Şahin,1 Dr. Ceren Güney Tolgay,2 Dr. Merve Çayırcı,2 Dr. Elif Sepet,2 Dr. Recep Güloğlu,3 Dr. Hakan Yanar,3 Dr. Kaya Sarıbeyoğlu4 İstanbul Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, İstanbul İstanbul Üniversitesi Dişhekimliği Fakültesi, Pedodonti Anabilim Dalı, İstanbul 3 İstanbul Üniversitesi İstanbul Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, İstanbul 4 İstanbul Üniversitesi Cerrahpaşa Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, İstanbul 1 2

AMAÇ: Hastane acil servisleri hem travmatik hem de travmatik kökenli olmayan acil dental durumlarla karşı karşıya gelirler. Öte yandan literatür, tıp uzmanları arasında travmatik dental yaralanmalarının (TDY) yönetimi konusunda bilgi eksiklikleri bulunduğunu ileri sürmektedir. Bu çalışmanın amacı, İstanbul acil cerrahi doktorlarının TDY’nin tedavisine yönelik bilgi ve tutumlarını araştırmaktır. GEREÇ VE YÖNTEM: Anketler acil servis yöneticilerine ve doktorlara dağıtıldı. Anket, özellikleri ve dental travma yönetimi konusundaki bilgilerini değerlendiren soruları içermekteydi. BULGULAR: Toplamda 126 anketin (13’ü acil sevis yöneticisi, 113 doktor) geri dönüşü olmuş ve değerlendirme kapsamına alınmıştır. Acil çalışanlarının kron kırıkları ve avülsiyon konusundaki uygun tedavi bilgi düzeyleri genelde iyi düzeyde olmasına karşın (p=0.221), lüksasyon yaralanmalarda konusundaki bilgileri yetersizdi (p=0.0001). Doktorlar kalıcı dişler konusunda süt dişlerine oranla daha iyi bir bilgi düzeyine sahiplerdi (p=0.027). TARTIŞMA: Bu çalışmadan elde edilen bulgulara dayanarak, hastanelerde özellikle doktorlar arasında TDY yönetimini iyileştirmek için eğitim, izleme, kaynakların daha iyi kullanılabilirliği ve disiplinler arası uyum eksikliğinin değerlendirilmesi gereklidir. Anahtar sözcükler: Acil girişim; dental avülsiyon; travmatik diş yaralanmaları. Ulus Travma Acil Cerrahi Derg 2018;24(2):136–144

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doi: 10.5505/tjtes.2017.57384

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ORIG I N A L A R T IC L E

Spiked railing penetration that causes injuries in the upper extremities of children Egemen Ayhan, M.D.,1 Kadir Çevik, M.D.,2 Melih Bağır, M.D.,3 Mehmet Çolak, M.D.,4 Metin Manouchehr Eskandari, M.D.4 1

Department of Orthopaedics and Traumatology & Hand Surgery, Dışkapı Yıldırım Beyazıt Training and Research Hospital, Ankara-Turkey

Department of Orthopaedics and Traumatology, Mersin University Faculty of Medicine, Mersin-Turkey

Department of Orthopedics and Traumatology & Division of Hand Surgery, Çukurova University Faculty of Medicine, Adana-Turkey

Department of Orthopaedics and Traumatology & Hand Surgery, Mersin University Faculty of Medicine, Mersin-Turkey

ABSTRACT BACKGROUND: Children have a curiosity for climbing walls, stairs, and railings and have an increased risk of falling. Here, we report our experience with railings causing injuries by penetrating the upper extremities, and aim to call attention to spiked railing injuries in children. METHODS: We report on five children with a mean age of 8.8. All of the children were male. The penetrating railing parts were removed in a surgical room. RESULTS: The injured structures repaired immediately were as follows: flexor digitorum profundus tendon, A4 pulley, volar plate of the distal interphalangeal joint, radial digital nerve, ulnar digital artery, and radial digital artery. CONCLUSION: Spiked railings can lead to significant injury that requires further exploration. Boys particularly are at risk, and parents should be alert regarding these type of injuries. We recommend a standard regulation for fence erection, and we wish to warn owners of this type of fence regarding probable legal sanctions. Keywords: children; penetrating injury; spiked railings; upper extremity.

INTRODUCTION

MATERIALS AND METHODS

Preschoolers and school-going children have a curiosity for climbing walls, stairs, and railings. This may seem advantageous for the physical and emotional growth of a child; however, it may bring about a risk for penetrating injuries caused by the sharp ends of railings. Because this type of upper extremity injury is rare, it can be a thrilling challenge for surgeons. In the present study, our objectives are to report our experience with railings causing injuries by penetrating the upper extremities, and to call attention to the risk of spiked railing injuries in children. To the best of our knowledge, this case series is the first in the Turkish literature.

Six injured children admitted to our institute between the 1st July of 2010 and 1st July of 2015 were included in the present study. We excluded one patient because we were unable to contact him; therefore, we present five patients here. Written informed consent from the patient’s legal representatives was obtained, and the study was approved by Mersin University Clinical Researches Ethical board. In all the cases, the railing parts were cut on the spot to free and transport the patients. The patients were admitted to the emergency department with parts of the railings penetrating their upper extremities. The penetrating railing parts were removed un-

Cite this article as: Ayhan E, Çevik K, Bağır M, Çolak M, Eskandari MM. Spiked railing penetration that causes injuries in the upper extremities of children. Ulus Travma Acil Cerrahi Derg 2018;24:145–148 Address for correspondence: Egemen Ayhan, M.D. Dışkapı Yıldırım Beyazıt Eğitim ve Araştırma Hastanesi, Ortopedi ve Travmatoloji & El Cerrahisi Kliniği, Ankara, Turkey Tel: +90 312 - 596 20 00 E-mail: egemenay@yahoo.com Ulus Travma Acil Cerrahi Derg 2018;24(2):145–148 DOI: 10.5505/tjtes.2017.85349 Submitted: 10.04.2017 Accepted: 21.08.2017 Online: 12.02.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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der general anesthesia in the surgical room. All the patients were called for follow-up.

Case 1 A 13-year-old boy was admitted with a spiked railing that pierced his left index finger. He was injured after falling down from a horizontal bar. The spiked railing penetrated the second web space, passed through the volar side of the index finger, and finally emerged from the radial side of the distal interphalangeal joint. The finger was ischemic at presentation (Fig. 1). Following the removal of the railing, circulation in the finger was immediately restored. We repaired the flexor digitorum profundus tendon, A4 pulley, and volar plate of the distal interphalangeal joint.

Case 2 A 9-year-old boy was admitted with a spiked railing that penetrated the ulnar side of the left wrist flexor crease, passed through the Guyon canal and palm, and finally emerged from the fourth web space (Fig. 2). During the exploration, the neurovascular structures were found to be intact.

Case 3 A 5-year-old boy was admitted with a spiked railing that penetrated the right wrist flexor crease, passed through the carpal tunnel, and finally emerged from the third web space (Fig. 3). He was injured while climbing over a garden wall in pursuit of another child. During the exploration, we found that the radial digital nerve of the fourth finger and the ulnar digital artery of the third finger were transected. Circulation was normal, and only the digital nerve was repaired. (a)

Case 4 An 8-year-old boy was injured after falling down from a plum tree. He was admitted with a spiked railing that penetrated the distal palmar crease of the right hand and emerged from the third web space (Fig. 4). During the exploration, injury to the radial digital artery of the fourth finger was observed. Circulation was normal, and the digital artery was not treated.

Case 5 A 9-year-old boy was admitted with a spiked railing that penetrated the right arm from the medial side, passed through the posterior proximal humerus, and finally emerged from the lateral side (Fig. 5). He was injured after falling from a wall whilst being chased by his friend. The preoperative neurovascular examination was normal. During the surgery, we extended the entry and exit points and then carefully extracted the object. We performed a limited exploration of neurovascular structures and found no active bleeding with palpable pulses.

RESULTS All the patients were male with a mean age of 8.8 (5â&#x20AC;&#x201C;13). All the patients had only soft tissue injuries without any fracture. There were no early preoperative complications, and all the patients were discharged a day after the surgery. The mean follow-up was 32.4 (12â&#x20AC;&#x201C;70) months. All the patients were symptom-free at the last follow-up. The patient in Case 1 was symptom-free with full restoration of the range of motion. In Case 3, the two-point discrimination value in the injured finger was the same as that in the contralateral normal finger (4 mm). (b)

Figure 1. (a, b) Ischemia of the index finger after a spiked railing penetration through the second web space. (a)

(b)

(c)

Figure 2. Spiked railing penetration through the Guyon canal and palm (a, b); intact small finger ulnar digital nerve after careful extraction of the object (c).

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Ayhan et al. Spiked railing penetration that causes injuries in the upper extremities of children (a)

(b)

(c)

Figure 3. Spiked railing penetration through the carpal tunnel (a); intact median nerve but transected radial digital nerve of the fourth finger (b); and repaired radial digital nerve of the fourth finger (c). (a)

(b)

(c)

Figure 4. Spiked railing penetration from the distal palmar crease to the dorsal third web space (a); exit site of the railing after safe extraction (b); and intact third common digital nerve (c). (a)

(b)

Figure 5. (a, b) Spiked railing penetration of the right arm.

DISCUSSION Unintentional injury is the most common cause of mortality and morbidity in preschoolers and school-going children.[1] The patients in the present study had striking presentations and clearly indicate the possibility of serious damage after falling over the sharp ends of railings. In most spiked railing penetrations, the upper extremity, particularly the hand, is injured. This is due to the body-shielding function of the hand and upper extremity. These sharp, pointed objects cause significant injury independent of the wound size Ulus Travma Acil Cerrahi Derg, March 2018, Vol. 24, No. 2

because of the delicate anatomy of the hand.[2–5] Supporting this, in our four patients with hand injuries, we explored deep structure lacerations in three. We recommend a thorough exploration of the entire track of the hand injury in the surgical room. However, as in Case 5, if the preoperative neurovascular examination is normal with obvious patient cooperation, we think that there may be no need to comprehensively expose the entire track in upper limb penetrating injuries that do not involve the hand. Anyway, the approach is based on the surgeons’ preference, and some surgeons support the exploration of the entire tract to clear all doubts. Finally, although we did not encounter any fracture, a roentgenographic examination is mandatory for such serious injuries. The tips of the railings presented in the present study were arrow-type. The wide base of these tips creates a buttonhole effect; thus, safe extraction of the object is impossible without extending the wound size at the entry and exit points. Therefore, we recommend extraction of any penetrating material in the surgical room, even if the penetrated object tip is suitable for simple withdrawal. Similar to the study conducted by Rasheed et al.,[5] all the patients in our study were male. The explanation for this has been reported in several studies; boys tend to take more risks than girls, exhibit more risky attitudes, and be more confident in dealing with danger.[6–8] So, parents should be more alert concerning male children. Spiked railings are a significant danger to preschoolers and school-going children who bear the spirit of adventure. Some children run after a ball, or climb a tree to pick fruits, or have curiosity for empty houses. Likewise, our patients share similar characteristics. In fact, even warning signs do not show promise as a deterrent for this fearless population. [4] Therefore, other precautions must be considered. To prevent these injuries, the reasons and sequences of the accidents must be analyzed.[5,9] Is it possible to change the nature of children? Is it possible to forbid children from climbing? These precautions do not make sense and are not beneficial for their growth and development.[4] Some precautions may include the prohibition of spiked railings in places where children play. Such railings are extensively used in Turkey, both in public places and private residences. Lawyers have pointed out that there is no standard regulation for fence erection in Turkey.[10] They insisted that excessive prevention of private property which causes someone’s injury is punished according to the Turkish Criminal Law. It appears that the owners are prone to legal sanctions. We believe that in countries with no standard regulations for fence erection (as in Turkey), institutions regarding public health (e,g., Turkish Public Health Association) may play an important role in alerting the society and legal system. Legislations against the manufacture of this type of railing need to be considered. 147

Ayhan et al. Spiked railing penetration that causes injuries in the upper extremities of children

Although we tried to restrict the penetrating injuries to the upper extremities in the patients, the injuries were not homogenous; this was a major limitation of this study. However, it is hard to establish a more homogenous group with documentation in this rare type of injury. Moreover, we did not try to emphasize the treatment or outcome but tried to highlight the significance of the injuries and possible legal actions. In conclusion, spiked railings can lead to significant injury that must be explored in the surgical room only. Boys are particularly at risk due to gender characteristics. We recommend the removal of these types of railings around play areas of children and the preparation of standard regulations for fence erection. Also, we wish to warn owners of this type of fence regarding probable legal sanctions. Conflict of interest: None declared.

REFERENCES 1. Committee on Child Abuse and Neglect; Committee on Injury, Violence,

and Poison Prevention; Council on Community Pediatrics. American Academy of Pediatrics. Policy statement-child fatality review. Pediatrics 2010;126:592–6. 2. Amjadi M, Harries R. Corrugated-iron fence injury to the hand. J Hand Surg Eur Vol 2009;34:809–10. 3. Griffin PA, Robinson DN. Paediatric hand injuries and the galvanizediron fence. Med J Aust 1989;150:644–5. 4. Murphy SM, Cronin KJ. Paediatric hand injuries caused by palisade railings. J Hand Surg Eur Vol 2010;35:70–1. 5. Rasheed T, Hill C, Khan K, Brennen M. Paediatric hand injuries caused by spiked railings. J Hand Surg Br 1999;24:615–6. 6. Byrnes JP, Miller DC, Schafer WD. Gender differences in risk taking: a meta-analysis. Psychol Bull 1999;125:367–83. 7. Morrongiello BA, Dawber T. Parental influences on toddlers’ injury-risk behaviors: are sons and daughters socialized differently? J Appl Dev Psychol 1999;20:227-51. 8. Peterson L, Brazeal T, Oliver K, Bull C. Gender and developmental patterns of affect, belief, and behavior in simulated injury events. J Appl Dev Psychol 1997;18:531–46. 9. Evans DM. The prevention of hand injuries. J Hand Surg Br 1991;16:239. 10. http://www.hurriyet.com.tr/dut-faciasina-hukukcu-tepkisi-26385299. Accessed Mar 11, 2017.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Çocuklarda korkuluk demiri ile üst ekstremite penetran yaralanmaları Dr. Egemen Ayhan,1 Dr. Kadir Çevik,2 Dr. Melih Bağır,3 Dr. Mehmet Çolak,4 Dr. Metin Manouchehr Eskandari4 Dışkapı Yıldırım Beyazıt Eğitim ve Araştırma Hastanesi, Ortopedi ve Travmatoloji ve El Cerrahisi Kliniği, Ankara Mersin Üniversitesi Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, Mersin Çukurova Üniversitesi Tıp Fakültesi, Ortopedi ve Travmatoloji ve El Cerrahisi Kliniği, Adana 4 Mersin Üniversitesi Tıp Fakültesi, Ortopedi ve Travmatoloji ve El Cerrahisi Anabilim Dalı, Mersin 1 2 3

AMAÇ: Çocuklar duvarlara, merdivenlere ve korkuluklara tırmanmaya meraklıdır. Bu durum düşme sonucu travmaları da artırmaktadır. Çalışmamızda korkuluk demiri ile üst ekstremite penetran yaralanması olan çocuk hastalarımızdaki tecrübelerimizi paylaşmayı ve çocuklardaki bu tip yaralanma riskine dikkat çekmeyi amaçladık. GEREÇ VE YÖNTEM: Çalışmamızda ortalama yaşı 8.8 olan beş erkek çocuk dâhil edildi. Saplanmış olan korkuluk demirleri ameliyathanede çıkartıldı. BULGULAR: Eksplorasyon sonucu yaralandığı tespit edilen yapılar (fleksör digitorum profundus tendonu, A4 pulleyi, distal interfalangeal eklem volar plak, radial dijital sinir, ulnar dijital sinir ve radial dijital arter) hemen onarıldı. TARTIŞMA: Korkuluk demiri yaralanmaları, ameliyathanede eksplorasyon gerektirmekte ve önemli yapıların yaralanmasına neden olabilmektedir. Özellikle erkek çocukları risk altındadır ve ebeveynler bu açıdan dikkatli olmalıdır. Korkuluk demirlerinin kullanımında standart bir hukuki düzenleme olması gerektiğini düşünmekteyiz. Bu çalışmayı, olası yaralanmalar açısından toplumun, olası hukuki sonuçları açısından da kullanan kurumların ve kişilerin dikkatine sunuyoruz. Anahtar sözcükler: Çocuklar; korkuluk demiri; penetran yaralanmalar; üst ekstremite. Ulus Travma Acil Cerrahi Derg 2018;24(2):145–148

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doi: 10.5505/tjtes.2017.85349

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ORIG I N A L A R T IC L E

Mortality in Code Blue; can APACHE II and PRISM scores be used as markers for prognostication? Nurten Bakan, M.D., Gülşah Karaören, M.D., Şenay Göksu Tomruk, M.D., Sinem Keskin Kayalar, M.D. Department of Anaesthesiology and Reanimation, Health Sciences University, İstanbul Ümraniye Training and Research Hospital, İstanbul-Turkey

ABSTRACT BACKGROUND: Code blue (CB) is an emergency call system developed to respond to cardiac and respiratory arrest in hospitals. However, in literature, no scoring system has been reported that can predict mortality in CB procedures. In this study, we aimed to investigate the effectiveness of estimated APACHE II and PRISM scores in the prediction of mortality in patients assessed using CB to retrospectively analyze CB calls. METHODS: We retrospectively examined 1195 patients who were evaluated by the CB team at our hospital between 2009 and 2013. The demographic data of the patients, diagnosis and relevant de-partments, reasons for CB, cardiopulmonary resuscitation duration, mortality calculated from the APACHE II and PRISM scores, and the actual mortality rates were retrospectively record-ed from CB notification forms and the hospital database. RESULTS: In all age groups, there was a significant difference between actual mortality rate and the expected mortality rate as estimated using APACHE II and PRISM scores in CB calls (p<0.05). The actual mortality rate was significantly lower than the expected mortality. CONCLUSION: APACHE and PRISM scores with the available parameters will not help predict mortality in CB procedures. Therefore, novels scoring systems using different parameters are needed. Keywords: APACHE II; code blue; mortality; PRISM.

INTRODUCTION Code systems are emergency call and management systems for rapid response in healthcare institutions. The primary aim of these systems is to provide common institutional understanding about what is necessary to be done immediately at the time of the event. Code blue (CB) is used worldwide to define the necessary emergency interventions in cases of respiratory or cardiac arrest,[1] and this was defined in the healthcare quality standards of Turkey in 2008. It is the only color code in which the same color is used for the same emergency worldwide. The CB process includes the establishment of a professional team, maintaining the alertness of the team, technological call systems, preparation until the team arrives, the time to ar-

rival of the CB team, availability of equipment, and effective intervention and post-intervention management and records. In the last decade, several scoring systems have been used to assess the severity of disease in the emergency department (ED), including Rapid Acute Physiology Score (RAPS), Rapid Emergency Medicine Score (REMS), Glasgow Coma Scale (GCS), Charlson co-morbidity index (CCI), modified Early Warning Score (MEWS), and Worthing physiological scoring system (WPS). However, the majority of these scoring systems are not appropriate for use in ED because most are disease specific, and it is difficult to use the systems in a technical manner or they do not correspond to the ED patient profile. APACHE II and PRISM scores (adult and pediatric, respectively) are accepted for both surgical and medical patients and have been widely used in intensive care units (ICUs) for the last three decades.[2]

Cite this article as: Bakan N, Karaören G, Tomruk ŞG, Keskin Kayalar S. Mortality in Code Blue; can APACHE II and PRISM scores be used as markers for prognostication? Ulus Travma Acil Cerrahi Derg 2018;24:149–155 Address for correspondence: Gülşah Karaören, M.D. İstanbul Ümraniye Eğitim ve Araştırma Hastanesi, Anesteziyoloji ve Reanimasyon Kliniği, İstanbul, Turkey Tel: +90 216 - 632 18 18 E-mail: drgyilmaz@yahoo.com Ulus Travma Acil Cerrahi Derg 2018;24(2):149–155 DOI: 10.5505/tjtes.2017.59940 Submitted: 19.12.2016 Accepted: 21.08.2017 Online: 19.09.2017 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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Bakan et al. Mortality prediction for Code Blue procedures

All patients (n=1198)

Excluded (n=160) • Not meeting inclusion criteria

Study group (n=1035)

True CB calls (n=654; 63.1%)

Improper CB calls (n=381; 36.9%)

Survivor

Non-survivor

Already dead

Improper

(n=248; 37.92%)

(n=406, 62.07%)

(n=12; 3.14%)

(n=369; 96.85%)

Figure 1. Consort diagram.

The APACHE II and PRISM scores describe the severity of disease by using changes in physiological parameters and can be used to define prognosis of the disease in ICU.[3] The APACHE II score consists of 12 distinct physiological parameters, age, and previous health status. In this system, the parameters including heart rate, systolic blood pressure, body temperature, Fraction of inspired oxygen (FiO2) electrolytes (sodium, potassium, and bicarbonate), and white blood cell count are rated from 0 to 4 (higher scores indicating extreme measurements). The lowest GCS score is 11 points, while the highest is 71 points; 6 points are assigned to the patients aged >75 years. Chronic diseases are also included in the evaluation. However, to the best of our knowledge, in literature, there are no scoring systems that have been developed to predict mortality in CB procedures. The aim of this study was to investigate the effectiveness of the estimated APACHE II and PRISM scores in the prediction of mortality in patients assessed using CB in a 500-bed regional reference hospital between 2009 and 2013 and to retrospectively analyze the CB calls.

CB was true or improper, application of cardiopulmonary resuscitation (CPR), and CPR duration, if applied, were extracted from the CB notification forms. The APACHE II and PRISM scores and the expected mortality rate were calculated from the data on the CB notification forms and hospital database. The APACHE II scoring was used for patients aged >18 years, whereas PRISM scoring was used for those aged <18 years. Patients aged 1–12 months were considered under the age group of 1 year. A CB call was defined as improper if no CPR was applied to the patient, only medical treatment was provided to the patient, or the CB call involved a patient who was already dead. Patient records were excluded from the study if treatment was refused or data were incomplete for the parameters needed to calculate the APACHE II and PRISM scores.

Statistical Analysis All statistical analyses were performed using IBM SPSS version 22.0. Kruskal–Wallis test was used to compare descriptive data (means, standard deviation), quantitative data, and n

MATERIALS AND METHODS Approval for the study was granted by the Clinical Research Ethics Committee of Health Sciences University, Istanbul Umraniye Research Hospital (Chairman: Sait Naderi, Professor, MD.; Approval#5089/2015). A retrospective review was made of the CB notification forms completed by an anesthesiologist as a CB team leader between 2009 and 2013. Demographic data, diagnosis at admission, department admitted to, time of CB activation, time to arrival of CB team, reason for CB, data regarding whether 150

Number of Code Blue announcements

300

261

274

250 200

197 160

143

150 100 50 0

2009

2010

2011 Years

2012

2013

Figure 2. Number of Code Blue announcements according to years.

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Table 1. Number of cases, gender, and survival and mortality data according to age groups in true CB calls

<18 years

18–65 years

>65 years

Total

Number of cases, n (%)

30 (4.6)

238 (36.4)

386 (59)

654

Male, n (%)

18 (4.4)

167 (43.5)

211 (52.1)

405 (61.9)

Female, n (%)

12 (4.8)

62 (25.9)

175 (70.3)

249 (38.07)

Survivor, n

141

248

Non-survivor, n

143

245

406

Survival, %

40.0

39.9

36.50

37.92

Mortality, %

60.0

60.8

63.47

62.08*

isher’s Exact test; *p≥0.05; when three groups were compared. CB: Code Blue.

Table 2. Expected and actual mortality rates according to PRISM and APACHE II scores

Mean±SD

Expected mortality

Actual mortality

36.7±5.2

87.8%

60%

=0.03*

PRISM

<18 year

APACHE II

18-65 years

37.2±5.6

84.7%

60.10%

<0.05*

>65 years

41.3±5.3

90.6%

63.47%

<0.05*

Chi Square test; *p≤0.05; when three groups were compared.

parameters with skewed distribution between the groups. Mann–Whitney U-test was used to identify the origin of differences and to compare skewed parameters between the groups. For comparing the qualitative data, Χ2, Fisher’s exact, and Continuity Correction (Yates) tests were applied. Spearman’s rho correlation analysis was used to assess the relationship between parameters. P<0.05 was considered significant.

RESULTS Overall, 1195 CB calls were evaluated during the 5-year period. Of these, 160 patients were excluded from the final analysis as the data needed for prognostic scoring were missing. Of the remaining 1035 patients, CB was evaluated as true in 654 and improper in 381 patients; among the latter, 12 CB activations were for patients who were already dead (Graphic 1). When the distribution of CB calls was assessed according to year, CB activations were found to be most frequent in 2010 and 2011 (Graphic 2). Of 248 patients with return of spontaneous circulation (ROSC) after CPR, 73 (29.44%) were admitted to our ICU and 175 (70.56%) were admitted to other ICUs after stabilization. The mean age of 654 patients evaluated as true CB was 64.25±20.6 years, with 59% of these patients aged ≥65 years. No significant difference was detected in mortality between the age groups of <18 years, 18–65 years, and ≥65 years (p>0.05; Table 1). Ulus Travma Acil Cerrahi Derg, March 2018, Vol. 24, No. 2

In true CB calls, a significant difference was detected between the actual and expected mortalities in all age groups (p<0.05), with actual mortality rate being significantly lower (Table 2). A weak, positive correlation was detected between the expected mortality and age, while there was a strong, posiTable 3. Correlation analyses among age, PRISM and APACHE II scores, CPR duration, and expected mortality and actual mortality

CPR duration

Expected mortality

Age r

-0.75

0.255

0.056

<0.05

654

PRISM score r

0.464

0.930

0.010

<0.05

APACHE II score r

0.177

0.910

<0.05

624

Spearman’s rho test; *p<0.05. CPR: Cardiopulmonary resuscitation.

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Table 4. Distribution of true and improper Code Blue calls according to departments Department True Code Blue Improper Code Blue Total

Improper/True Code Blue

n % n % n %

Emergent Internal Medicine

284

Internal Medicine

144 82.3 31 17.7 175 100

77.0

369

0.29 0.21

Emergent Surgery

44 41.1 63 58.9 107 100

1.43

Surgery

39 60.0 26 40 65 100

0.66

Orthopedics

29 74.4 10 25.6 39 100

0.34

Emergency Department 27 65.9 14 34.1 41 100

0.51

Gastroenterology

22 81.5 5 18.5 27 100

0.22

Neurology

19 57.6 14 42.4 33 100

0.73

Pediatric Emergency

18 40 27 60 45 100

1.5

Neurosurgery

6 25 18 75 24 100

Radiology

5 18.5 22 81.5 27 100

4.4

Chest

4 23.5 13 76.5 17 100

3.25

ETN

4 50 4 50 8 100

Urology 42.9 4 57.1 7 100 22.2

Obstetrics & Gynecology

Pediatrics

2 50 2 50 4 100

Infection Diseases

2 28.6 5 71.4 7 100

2.5

Other

100

0 31 100 31 100

tive correlation between expected mortality and PRISM or APACHE II scores (p<0.05; Table 3). True CB was most frequently announced from the Emergency-internal medicine and Internal Medicine departments, whereas improper CB was most frequently announced from the Emergency-internal medicine and Emergency-surgery departments. The rate of improper CB was found to be highest in the Radiology Department. In the departments classified as miscellaneous, all CB calls were improper (n=1 in pathology department, n=9 in blood sampling unit, n=3 in ophthalmology department, n=16 in outpatient clinics, and n=2 in waiting rooms) (Table 4). True CB calls involved 250 patients with cardiac disease (38.22%), 105 patients with terminal cancer (16.5%), 77 patients with neurological disease (11.77%), 62 patients with trauma (9.4%), and 54 patients with acute respiratory failure (8.25%). On assessment of true CB calls, 33.18% (n=217) of true CB calls were found to have been announced during working hours (08:00–16:00) and 66.82% (n=437) were announced out of working hours (16:00–08:00). The distribution of true CB calls was as follows: 5.7% during the period 21:00–22:00; 5.7%, 23:00–24:00; 5.4%, 01:00–02:00; and 5.4%, 16:00–17:00. 152

77.8

1 1.75 3.5

–

Of the improper CB calls, 39.37% (n=217) were found to have been announced during working hours (08:00–16:00) and 60.63% (n=437) were announced out of working hours (16:00–08:00). The distribution of improper CB calls was as Table 5. Time to arrival of the CB team and CPR duration in true CB calls Time to arrival of CB team (s) (Mean±SD) 2009

112.25±22.87 <0.001*

2010 102.90±22.99 2011 104.98±20.53 2012 98.12±22.40 2013 93.64±19.91 Duration of CPR (min) p (Mean±SD) <18 years

36.8±21.6

18–65 years

27.5±16.2

>65 years

26.2±12.9

<0.05**

Kruskal–Wallis test; *p<0.01 **p<0.05; when three groups were compared. CB: Code Blue; CPR: Cardiopulmonary resuscitation; SD: Standard deviation.

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follows: 6.3% during the period 13:00–14:00; 5.3%, 21:00– 22:00; and 5.8%, 11:00–12:00. On assessment of the time to arrival of the CB team, it was found that the time was significantly shortened over the years (p<0.001). Regarding CPR duration, no significant difference was found between the groups aged 18–65 years and >65 years but the duration was significantly longer in the age group <18 years (p<0.05) (Table 5). No correlation was detected between CPR duration and age in true CB calls, while there was a significant, moderate positive correlation between CPR duration and PRISM or APACHE II scores (p<0.05; Table 3).

DISCUSSION This study was conducted in a tertiary, training hospital with 25 ICU beds, where the mean number of ED visits is 1200 per year. A comparison was made between the CB call data at our hospital and the information in literature. The primary outcome measure of the expected mortality as estimated using PRISM and APACHE scores was found to be significantly higher than the actual mortality. Therefore, it was concluded that the APACHE II and PRISM scores are not useful in the prediction of mortality in CB calls and that CB call applications were successful in accordance with literature. Different scoring systems have been developed for the assessment of disease severity in EDs. These scoring systems are the mainstay of the management for critical illnesses, and the common goal of determining disease severity requires the objective measurement of changes in different physiological parameters, which must be recognizable by all clinicians. In ED, an ideal scoring system should include a limited number of physiological variables, which can be obtained on presentation to ED, and it should also accurately predict clinically important outcomes. RAPS, REMS, GCS, CCI, MEWS, and WPS are the most intensively studied scoring systems. However, according to the literature, none of these scoring systems has reached the highest level of evidence.[2] In many studies, it has been reported that the disorder present before arrest has an effect on survival.[4,5] However, there is no scoring system used in the prediction of mortality in CB patients. In this study, a comparison was made between the expected and actual mortality rates and an assessment was made of the PRISM and APACHE II scores in all true CB calls to evaluate the effectiveness of CB procedures and treatments as well as the usefulness of the PRISM and APACHE scores in CB procedures. The results of this study showed that the expected mortality rates as estimated using prognostic scoring systems were significantly higher than the actual mortality rates. However, a significant, moderate positive correlation was detected the CPR duration and APACHE II and PRISM scores. This was attributed to a shorter response time to CPR in patients with Ulus Travma Acil Cerrahi Derg, March 2018, Vol. 24, No. 2

lower APACHE II and PRISM scores. In conclusion, it was found that expected mortality was increased by an increasing number of comorbidities and CPR duration was increased due to lack of rapid response to CPR. The most important issue is the time to arrival of the CB team. Previous studies have confirmed that the likelihood of survival is increased by a shorter arrival time of the CB team and early defibrillation.[3,6] In the American Heart Association guidelines, it is aimed to initiate interventions and to provide the first electric shock within 2 min.[7–9] Thus, CPR should be started within 3 min.[10] This is also defined as a parameter in the Quality Standard of the Turkish Ministry of Health. In the present study, the time to arrival of the CB team ranged from 60 to 170 s (mean: 93.64 s), which is in accordance with the target time. The team organization, physical conditions of our hospital (40.000 m2 on three floors, with the Anesthesiology Department on the first floor), and regular training can be considered to have been effective in this result. In addition, field exercises performed by the quality department are also effective in maintaining a dynamic process. Reports in literature have stated that cardiac arrest is more commonly seen among males (56%–69.9%) and cardiac problems are the leading cause of cardiac arrest.[6,7,10] The lower incidence of arrest among females could be due to the lower prevalence of coronary syndromes among females.[7] In the present study, CB calls more commonly involved male patients and cardiac problems were the most common reason for CB calls, which was consistent with literature. CPR duration is known to be another important factor affecting prognosis in CPR.[3,11] It has been reported that the mortality rate is higher in cases with CPR duration >10 min, while the survival rate is increased in cases with successful CPR with a duration <10 min.[3,10–14] Several studies have examined the optimal CPR duration, with reported CPR durations ranging from 12 to 30.5 min,[11–13] and this may be longer in pediatric patients.[14] In the present study, CPR duration was longer in the age group of <18 years (36.8±21.6 min) than in other age groups, in agreement with literature (p<0.05). In CB procedures, mortality is still high reaching up to 85% despite medical advances and the evolution of CB teams[13] and survival rates range from 13% to 40%.[3,15–17] In this study, the mortality rate in the CB procedures was found to be 62.61% and the survival rate was 38.07%. True CB calls were often announced out of working hours (66.82%), including immediately after working hours and before midnight. Both periods represent the beginning of out of work (after 16:00) and before sleeping (21:00–02:00) hours. Improper CB calls were often announced at the times of lunch and dinner and before midnight (19:00–20:00, 11:00– 153

Bakan et al. Mortality prediction for Code Blue procedures

14:00, and 16:00–17:00). These findings suggest that CB procedures do not involve the same conditions over 24 hours. Although the effects of CB activation time on mortality were not investigated in the current study, in a previous study by Pembeci et al., it was reported that mortality is lower in CB calls activated during working hours.[18] Initial rhythm is also an important indicator for prognostication. It has been reported that the likelihood of survival and disposition is higher in patients with VT/VNT than in those with asystole.[6,7] In a study on CPR and early defibrillation in an adult in-patient setting, Spearpoint et al. reported that the primary cause of the cardiac arrests was VT/VF in 25% of cases, defibrillation was performed within the first 2 min, and 90% of cases responded to CPR.[19] Delayed defibrillation has been associated with a decreased survival rate, with a 10% decrease in survival for each minute.[20] One of the limitations of this study was the inability to use initial rhythm in prognostication due to insufficient data. However, there are defibrillators in all the wards and in ED in our hospital, and portable emergency kits are available at certain points. Given the short time to arrival of the CB team observed in this study, it can be suggested that this did not lead to any disadvantage. In a study of 134 patients assessed due to CB activation, Pembeci et al. found the immediate survival rate to be 49%.[18] In the current study, the immediate survival rate was determined to be 37.92% for 654 CB calls. This difference could be attributed to many factors, including the time of CPR, the number of anesthesiologists in the CPR team, the experience of the anesthesiologist, and monitorization conditions etc. Of 248 patients with ROSC after CPR, 73 (29.44%) were admitted to the anesthesia ICU and 175 were admitted to other ICUs. Of the 73 patients admitted to the anesthesia ICU, 15 (20.54%) were discharged, but survival data was not collected for the patients admitted to other ICUs after stabilization. Thus, the mortality data of all patients could not be calculated, which could be considered another limitation of this study.

Conclusion The results of this study demonstrated that the CB process in our hospital was being successfully implemented in accordance with literature. It was also determined that expected mortality should be known to be able to establish standardization when assessing CB procedures; furthermore, APACHE II and PRISM scores with the parameters available are not helpful in the prediction of mortality in CB procedures. It was therefore concluded that there is a need for novel scoring systems using different parameters in CB procedures.

Acknowledgements The authors thank Arzu Baygul for statistical analysis of the 154

data and Gokmen Sakar for English editing. This study was presented as a poster presentation in part at the “ISICEM, 35th International Symposium on Intensive Care and Emergency Medicine, March 17–20, 2015, in Brussels, Belgium. Conflict of interest: None declared.

REFERENCES 1. Sahin KE, Ozdinc OZ, Yoldas S, Goktay A, Dorak S. Code Blue evaluation in children’s hospital. World J Emerg Med 2016;7:208–12. 2. Brabrand M, Folkestad L, Clausen NG, Knudsen T, Hallas J. Risk scoring systems for adults admitted to the emergency department: a systematic review. Scand J Trauma Resusc Emerg Med 2010;18:8. 3. Mendes A, Carvalho F, Dias C, Granja C. In-hospital cardiac arrest: factors in the decision not to resuscitate. The impact of an organized in-hospital emergency system. Rev Port Cardiol 2009;28:131–41. 4. Sandroni C, Barelli A, Piazza O, Proietti R, Mastria D, Boninsegna R. What is the best test to predict outcome after prolonged cardiac arrest? Eur J Emerg Med 1995;2:33–7. 5. Herlitz J, Rundqvist S, Bång A, Aune S, Lundström G, Ekström L, et al. Is there a difference between women and men in characteristics and outcome after in hospital cardiac arrest? Resuscitation 2001;49:15–23. 6. Saghafinia M, Motamedi MH, Piryaie M, Rafati H, Saghafi A, Jalali A, et al. Survival after in-hospital cardiopulmonary resuscitation in a major referral center. Saudi J Anaesth 2010;4:68–71. 7. Villamaria FJ, Pliego JF, Wehbe-Janek H, Coker N, Rajab MH, Sibbitt S, et al. Using simulation to orient code blue teams to a new hospital facility. Simul Healthc 2008;3:209–16. 8. Brindley PG, Markland DM, Mayers I, Kutsogiannis DJ. Predictors of survival following in-hospital adult cardiopulmonary resuscitation. CMAJ 2002;167:343–8. 9. Abella BS, Alvarado JP, Myklebust H, Edelson DP, Barry A, O’Hearn N, et al. Quality of cardiopulmonary resuscitation during in-hospital cardiac arrest. JAMA 2005;293:305–10. 10. Field JM, Hazinski MF, Sayre MR, Chameides L, Schexnayder SM, Hemphill R, et al. Part 1: executive summary: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010;122:S640–56. 11. Goldberger ZD, Chan PS, Berg RA, Kronick SL, Cooke CR, Lu M, et al; American Heart Association Get With The Guidelines—Resuscitation (formerly National Registry of Cardiopulmonary Resuscitation) Investigators. Duration of resuscitation efforts and survival after in-hospital cardiac arrest: an observational study. Lancet 2012;380:1473-81. 12. Nadkarni VM, Larkin GL, Peberdy MA, Carey SM, Kaye W, Mancini ME, et al. First documented rhythm and clinical outcome from in-hospital cardiac arrest among children and adults. JAMA 2006;295:50–7. 13. Möhnle P, Huge V, Polasek J, Weig I, Atzinger R, Kreimeier U, et al. Survival after cardiac arrest and changing task profile of the cardiac arrest team in a tertiary care center. ScientificWorldJournal 2012;2012:294512. 14. Kleinman ME, Chameides L, Schexnayder SM, Samson RA, Hazinski MF, Atkins DL, et al; American Heart Association. Pediatric advanced life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Pediatrics 2010;126:e1361–99. 15. Peters R, Boyde M. Improving survival after in-hospital cardiac arrest: the Australian experience. Am J Crit Care 2007;16:240–6.

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Bakan et al. Mortality prediction for Code Blue procedures 16. Peberdy MA, Ornato JP, Larkin GL, Braithwaite RS, Kashner TM, Carey SM, et al; National Registry of Cardiopulmonary Resuscitation Investigators. Survival from in-hospital cardiac arrest during nights and weekends. JAMA 2008;299:785–92. 17. Mondrup F, Brabrand M, Folkestad L, Oxlund J, Wiborg KR, Sand NP, et al. In-hospital resuscitation evaluated by in situ simulation: a prospective simulation study. Scand J Trauma Resusc Emerg Med 2011;19:55. 18. Pembeci K, Yildirim A, Turan E, Buget M, Camci E, Senturk M, et al. Assessment of the success of cardiopulmonary resuscitation attempts per-

formed in a Turkish university hospital. Resuscitation 2006;68:221–9. 19. Spearpoint KG, McLean CP, Zideman DA. Early defibrillation and the chain of survival in ‘in-hospital’ adult cardiac arrest; minutes count. Resuscitation 2000;44:165–9. 20. Nolan JP, Soar J, Cariou A, Cronberg T, Moulaert VR, Deakin CD, et al. European Resuscitation Council and European Society of Intensive Care Medicine Guidelines for Post-resuscitation Care 2015: Section 5 of the European Resuscitation Council Guidelines for Resuscitation 2015. Resuscitation 2015;95:202–22.

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Mavi Kod’da Mortalite; Apache II ve PRISM skorları, prognoz için belirteç olabilir mi? Dr. Nurten Bakan, Dr. Gülşah Karaören, Dr. Şenay Göksu Tomruk, Dr. Sinem Keskin Kayalar Sağlık Bilimleri Üniversitesi, İstanbul Ümraniye Eğitim ve Araştırma Hastanesi, Anesteziyoloji ve Reanimasyon Kliniği, İstanbul

AMAÇ: Mavi Kod, hastanelerde kalp ve solunum arrestine yanıt vermek üzere geliştirilmiş acil çağrı sistemidir. Ancak, literatürde Mavi Kod işlemlerinde mortaliteyi öngörmek için bir skor sistemi geliştirilmemiştir. Bu çalışmada Mavi Kod ile değerlendirilen hastalarda mortalite tahmininde hesaplanan APACHE II ve PRISM skorlarının etkinliğinin araştırılması ve Mavi Kod çağrılarının geriye dönük analizi amaçlandı. GEREÇ VE YÖNTEM: Hastanemizde 2009 ile 2013 yılları arasında Mavi Kod ekibi tarafından değerlendirilen 1195 hasta geriye dönük olarak incelendi. Hastalara ait demografik veriler, tanı ve ilişkili bölümler, Mavi Kod nedenleri, kardiyopulmoner resüsitasyon süresi, APACHE II ve PRISM skorları ile hesaplanan mortalite ve gerçekleşen mortalite değerleri hastane veritabanı ile Mavi Kod Bildirim Formlarından geriye dönük olarak kayıt edildi. BULGULAR: Mavi Kod çağrılarında gerçek mortalite ile APACHE II ve PRISM skorları tarafından hesaplanan beklenen mortalite arasında tüm yaş gruplarında anlamlı fark vardı (p<0.05). Gerçek mortalite oranı beklenen mortaliteden anlamlı derecede daha düşüktü. TARTIŞMA: Mevcut parametrelerle APACHE ve PRISM skorları, Mavi Kod işlemlerinde mortalitenin öngörülmesine yardımcı olmayacaktır. Bu yüzden, farklı parametrelerin kullanıldığı yeni skor sistemlerine gereksinim vardır. Anahtar sözcükler: APACHE II; Mavi Kod; mortalite; PRISM. Ulus Travma Acil Cerrahi Derg 2018;24(2):149–155

doi: 10.5505/tjtes.2017.59940

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Surgical treatment of displaced intraarticular calcaneus fractures using anatomical lateral frame plate İrfan Esenkaya, M.D.,1 Fatih Türkmensoy, M.D.,2 Bahattin Kemah, M.D.,3 Oğuz Şükrü Poyanlı, M.D.1 1

Department of Orthopaedics and Traumatology, İstanbul Medeniyet University, Göztepe Training and Research Hospital, İstanbul-Turkey

Department of Orthopaedics and Traumatology, Afyon Dinar State Hospital, Afyon-Turkey

Department of Orthopaedics and Traumatology, Ağrı State Hospital, Ağrı-Turkey

ABSTRACT BACKGROUND: The present study evaluated the results obtained from the anatomical lateral frame plate treatment of displaced intraarticular calcaneus fractures. METHODS: Overall, 14 displaced intraarticular fractures of 13 patients (3 females, 10 males; Mean age, 37.5 years) were included in the present study. Surgery was performed using widened lateral approach and supported by auto grafts following joint line reduction in all patients. They were then fixated by anatomical lateral frame plate. All the joints were stabilized by casting after the operation. All patients were prescribed controlled and full weight bearing at 6–8th and 12th weeks, respectively. RESULTS: Mean follow-up of patients was 28 months. The fractures were classified according to Sanders system. Clinical scoring of the patients was performed according to American Orthopaedic Foot and Ankle Society, Creighton-Nebraska, and Maryland systems. According to these systems, the mean scores of the patients were 83.7, 75.7, and 88.5 respectively. CONCLUSION: In the present study, we have defined the results of anatomical lateral frame plate treatment in patients with displaced intraarticular calcaneus fractures. We have obtained clinically and radiologically satisfactory results with the anatomical compatibility of plate to the lateral surface of the calcaneus. Keywords: Calcaneus fracture; intraarticular calcaneus fracture; lateral frame plate.

INTRODUCTION Calcaneus, the largest of the seven tarsal bones, acts like a strong lever to direct the body weight to the ground. Many approaches have been tried in the treatment of these historically important fractures and they have been changed over time. Although conservative treatment modalities were preferred previously, they have been replaced by surgical treatment options with the development in techniques.[1,2] Surgical treatment of calcaneus fractures with lateral approach according to medial approach is frequently preferred because it is relatively easy to perform and less tissue damage. On the contrary, this approach has some limitations, such as

inefficiency in reaching the pieces in medial aspect, calcaneus having a thin epidermal and dermal surface lining on the lateral side, and postoperatively observable corner necrosis.[3] The aim of this study is to show that our anatomical lateral frame plate design, which we use to treat the displaced intraarticular calcaneus fractures, improve the three dimensional anatomy of calcaneus and have satisfactory clinical results.

MATERIALS AND METHODS Overall, 14 fractures of 13 patients who were hospitalized and underwent open reduction and internal fixation in Is-

Cite this article as: Esenkaya İ, Türkmensoy F, Kemah B, Poyanlı OŞ. Surgical treatment of displaced intraarticular calcaneus fractures using anatomical lateral frame plate. Ulus Travma Acil Cerrahi Derg 2018;24:156–161 Address for correspondence: Bahattin Kemah, M.D. Ağrı Devlet Hastanesi, Ortopedi ve Travmatoloji Polikliniği, 04200 Ağrı, Turkey Tel: +90 472 - 215 10 56 E-mail: bahattinkemah.md@gmail.com Ulus Travma Acil Cerrahi Derg 2018;24(2):156–161 DOI: 10.5505/tjtes.2017.62355 Submitted: 07.01.2017 Accepted: 29.06.2017 Online: 12.02.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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tanbul Medeniyet University Goztepe Training and Research Hospital Orthopedics and Traumatology Clinic, between January 2009 and March 2013 were included in the study. The surgeries were performed by first author or under the supervision of first author. One patient had bilateral fractures. Following the first aid in emergency department, anteroposterior and lateral X-ray images of the feet and ankles were obtained from each patient (Fig. 1). Subsequently, computed tomography (CT) scans were obtained from each patient to understand the exact mechanism of fractures and to be able to perform classification (Fig. 2). Sanders system was used for calcaneus fracture classifications. The patients who had depression in posterior aspect of subtalar joint and had abnormal Bohler and Gissane angles were given appointments for surgery. The bullae that were seen during the time period spent to expect normal skin circulation were drained, and the patients who had affirmative wrinkle test underwent surgery.

is an important complication after such operations. When the lateral wall of the calcaneus was reached, most of the times it was observed that a calcaneal window was formed and that its borders were well defined (Fig. 4). The depressed posterior facet joint was elevated through this window (Fig. 5). Subsequently, the joint line was visualized and reduction was performed and controlled using fluoroscopy. Iliac wedge auto grafts were used to fill the gap formed because of the suppressed spongious bone beneath the posterior facet joint after elevation. Elevated posterior facet joint was supported by auto grafts from beneath and then the cortical bone window was closed.

The operations started by preparing the fractured calcaneus bones and ipsilateral iliac wings. Widened lateral approach was preferred (Fig. 3). Over retraction of dermal and epidermal structures was avoided, and K-wires were used additionally for retraction to reduce the risk of corner necrosis, which

Figure 3. Widened lateral approach in the same patient.

Figure 1. 42 year-old, male patient who fell down from height. Sanders Type 3AB displaced calcaneus fracture. Preoperative X-ray images of left calcaneus.

Figure 4. Deep incision and the lateral wall window. Skin necrosis is not present when retraction is performed gently, as seen in the case.

Figure 2. Preoperative CT scans and 3D images of the same patient.

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Figure 5. Depressed posterior facet joint and fixation with anatomical lateral frame plate in the same patient.

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(a)

(b)

(c)

(d)

Figure 6. Anatomical plates used in our study (c and d) and conventional plates (a and b) on real calcaneus bone.

Unlatched and low-profile anatomical frame plate, which was uniquely designed according to the anatomical structure of the lateral surface of the calcaneus by the author in first reference [TÄąpsan, Izmir; Patent Nr. 2010 01325], was used for reduction and fixation (Fig. 6). Subcutaneous fat tissue and skin were closed together following the plate fixation. A drainage tube was placed to avoid hematoma formation. Casting of lower extremity of the same side was performed. X-ray and CT were performed for all patients after surgery (Fig. 7 and 8). The sutures were removed approximately in the following second week after examining the wound.

Clinical evaluation of the patients was done using American Orthopaedic Foot and Ankle Society (AOFAS), CreightonNebraska (C-N) score, and Maryland foot score systems. Data pertaining to Bohler and Gissane angles, presence of thigh and calf atrophy, any limitations to walking, limping, and period of time until working were collected for all patients before and after the operation and on their last follow-up visit. The statistical analyses were performed using Number Cruncher Statistical System 2007 Statistical Software (Utah,

Following the removal of sutures, patients were prescribed active and passive ankle and subtalar joint movement exercises. Patients were allowed to supported weight bearing in 6thâ&#x20AC;&#x201C;8th weeks following the operation. The amount of weight was increased gradually until the 3rd month, when the patients were allowed to bear full weight.

Figure 7. Postoperative X-Rays images of the same patient.

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Figure 8. Postoperative CT scans and 3D images of the same patient.

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Table 1. Clinical improvement and scores of the patients Patient Age Sex Side Type Waiting time Stepping Weight bearing AOFAS MARY. C-NEB. (days) (weeks) (weeks) A.G. 33 Male Left

3AB

79 90 88

A.Ç. 42 Male Left

3AB

85 97 80

B.Ö.

38 Male Right 3AB

88 89 78

B.D.

48 Male Right 3AB

87 94 85

C.Ç. 46 Male Right 3AB

50 69 32

E.G.

26 Male Right

81 80 58

H.Ç.

41 Female Right

3AC

H.B.

39 Male Right 3AB

95 90 85

90 97 80

M.B.T. 32 Female Right

M.A. 36 Male Right 3AC

94 78

88 63

M.C.D. 52 Male Right 2B 12 12 16 90 93 95 N.G.

27 Female Left/Right 3AC/2B

Ş.K.

39 Male Left

86 89 73

3AB

USA) software. The data were compared using Friedman test, Dunn’s multiple comparison analysis, Mann–Whitney U test, chi-square, and Fisher’s test. P values lower than 0.05 were accepted as statistically significant.

last follow-up calculations (p=0.002, p=0.001, respectively); however, Bohler angles that were calculated right after the surgery and on the last follow-up did not show any statistically significant changes.

RESULTS

A statistically significant improvement was observed in patients’ Gissane angles when preoperative and last follow-up values were compared (p=0.002). Preoperative Gissane angle means were significantly narrower than those of postoperative and on last follow-up calculations (p=0.019, p=0.013, respectively); however, Gissane angles that were calculated right after the surgery and on the last follow-up did not show any statistically significant changes.

Of the 13 patients (14 calcaneus fractures), 3 (23.07%) were females and 10 (76.93%) were males. All of them had closed fractures. One female patient had bilateral fractures. In all the patients, the mechanism of injury was fall from the height. The mean age of all patients was 37.5 years (26–52 years). Four of the fractures (28.52%) were on the left, while ten of them (71.48%) were on the right side. One patient had tibia pylon fracture on the contralateral ankle. This patient underwent open reduction and plate fixation during the same session. The mean follow-up period was 28 months (12–56 months). According to Sanders system, seven fractures (50%) were Type 3AB, three (21.4%) were Type 3AC, two (14.3%) were Type 2B, and two (14.3%) were Type 2A. Mean period of time between trauma and operation was 4.7 days (2–12 days); between operation and postoperative partial weight bearing (stepping) with the help of crutches was 11.5 weeks (6–20 weeks), and full weight bearing was 18.6 weeks (9–32 weeks). In clinical evaluation of the patients, mean AOFAS, Maryland, and C-N scores were 83.7 (50–95), 88.57 (69–97), and 75.79 (32–95), respectively (Table 1). Bohler angle means calculated before and after operation and on the last follow-up showed statistically significant improvement (p=0.0001). Preoperative Bohler angle means were significantly narrower than those of postoperative and on Ulus Travma Acil Cerrahi Derg, March 2018, Vol. 24, No. 2

There was no statistically significant difference between thigh diameters of healthy and traumatic legs (p=0.141). There was no statistically significant difference between calf diameters of healthy and traumatic legs (p=0.098). There was no significant difference between the mean ages of Sanders Type 2 and Sanders Type 3 groups (p=0.228). There were no significant differences in periods of resting (days), limited weight bearing (weeks), full weight bearing and starting to work (weeks) times between Type 2 and 3 fracture types of patients (p>0.05) (Table 1). AOFAS, Maryland, and C-N improvement percentages did not give any statistically significant results between Type 2 and 3 patients (p>0.05). In addition, there were no statistically significant differences between these two groups in following aspects: means of Bohler and Gissane angles (p>0.05) and thigh and calf diameters compared to those of the healthy legs. All patients returned to their previous jobs, except for one 159

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patient who needed some improvement in working conditions because of pain. All patients are able to walk without any limitation arising from calcaneal fractures. Because the plate is produced in the production phase in such a way that it can be anatomically compatible with the bone surface, its application and fracture reduction are easy to fix.

DISCUSSION For the treatment of calcaneal fractures, there have been many options from conservative to open surgical techniques. In literature, the first conservative treatment choice technique of these fractures, suggested by Herman, was the disimpaction, in which the deformity was corrected under general anesthesia by hitting the lateral surface of calcaneus with a wooden hammer after placing a towel on the skin.[4] Hermanâ&#x20AC;&#x2122;s aim was to achieve the original height of the calcaneal bone. He believed that this technique would restore the functions of the heel and back of the foot. The studies that assess the use of conservative treatment showed that these patients may have had pain after prolonged physical activity even if they can go back to work after treatment. Walking analyses performed on these patients also support this result.[5,6] However, when the conservative treatment is compared to surgical options, there was no statistically significant difference between them.[7] In another study that gave priority to conservative treatment, in patients who had segmental fractures that cannot be treated conservatively, they tried conservative treatment first. Subsequently, corrective osteotomy and arthrodesis were performed to treat the remaining complaints. When the results were evaluated, it was well understood that earlier surgery, which was performed before the malunion developed, had given better results.[8] The use of grafts is another contradictive topic on the treatment of these fractures. Studies show that patients in whom grafts were involved gave better and more satisfactory results with earlier full weight bearing than without using greft.[2,9â&#x20AC;&#x201C;11] Minimally invasive and fixation by screw onto the percutaneous canulla techniques were tried to avoid complications such as corner necrosis, infections, and osteomyelitis arising from surgical treatment of calcaneus fractures, and they gave satisfactory results. However, it was stated that these treatment modalities could only be used in moderate fractures in which the conservative treatment would not be insufficient and the open surgery would be too invasive because displaced fractures with many segments cannot be reduced externally.[12â&#x20AC;&#x201C;14] Sanders classification is a system that is frequently used in calcaneal fractures and it also predicts the prognosis. Type 1 160

fractures often give more satisfactory results, the other high grade types of fracture result have more unfavorable outcomes. Therefore, some authors defend the idea that surgical techniques should only be used in moderate-class fractures (i.e., excluding types 1 and 4).[15] When kinematic data of the feet and ankles were assessed after conservative and surgical treatment of calcaneal fractures, there was no statistically significant difference between healthy and fractured extremities in both groups.[16,17] In another study evaluating cost effectiveness of these two options, it was observed that surgical treatment of these fractures is both more effective and cheaper than conservative treatment methods.[18] In accordance with the developments in surgical techniques and biomechanics, nowadays, surgical treatment is usually the first choice in calcaneus fractures. In literature, the aims of the surgical treatment are defined as follows: 1) Reducing the posterior facet joint, 2) Providing original height and width of calcaneus, 3) Achieving fibular tendon mobility, 4) Regaining the valgus position of tuber calcanei, and 5) Reducing the calcaneo-cuboidal joint.[14,15] The authors who support the open reduction and internal fixation in recent studies emphasize that cases that are treated surgically have more positive feedbacks, that the patients in which the surgery is chosen as the first treatment option have better outcomes, and that these patients have higher long term quality of life.[14,17,19,20]

Conclusion The results of our study are similar to those in the literature in that patients with displaced intraarticular calcaneal fractures benefit from open reduction and internal fixation. When all patients are evaluated, the statistically significant difference of Bohler and Gissane angles before and after the operation indicates that the technique is satisfactory in correction; patients having no difference in Bohler and Gissane angles measured after the operation and on the last follow-up (mean, 28 months) shows that the anatomical lateral frame plate has sufficient fixation feature. This statistically significant improvement in all the patients is also observed in Sanders Type 2 and Type 3 fractures, and this shows the success of open reduction and fixation with an anatomical plate. There is still no common treatment modality for calcaneal fractures in literatures; however, the current approaches favor conservative management in fractures that lack displacements and deterioration in the dimensional configuration of the calcaneal bone, while surgery is preferred in cases with depression on joint surfaces, particularly on posterior facet joint, or with changes in height, width, or lining of calcaneus. The most common surgical approach is widened lateral approach. There are many materials developed for fixation after the reduction Ulus Travma Acil Cerrahi Derg, March 2018, Vol. 24, No. 2

Esenkaya et al. Surgical treatment of displaced intraarticular calcaneus fractures using anatomical lateral frame plate

of joint and fracture line. The anatomical lateral calcaneus plate, which is shaped in accordance with the anatomical structure of the lateral surface of the calcaneus, fits to the lateral aspect of the bone very well. It also reduces the risk of necrosis and it does not disturb the patients with its well-fitting screws to the holes; therefore, it does not form any bulges in this area, which has a very thin skin and delicate circulation. This and other aforementioned features make the anatomical lateral calcaneus plate advantageous compared to other fixation materials. Conflict of interest: None declared.

REFERENCES 1. Sanders R. Displaced intra-articular fractures of the calcaneus. J Bone Joint Surg Am 2000;82:225–50. 2. Gülabi D, Sarı F, Sen C, Avcı CC, Sağlam F, Erdem M, et al. Mid-term results of calcaneal plating for displaced intraarticular calcaneus fractures. Ulus Travma Acil Cerrahi Derg 2013;19:145–51. 3. Muñoz F, Forriol F. Current management of intra-articular calcaneal fractures. Rev Esp Cir Ortop Traumatol 2011;55:476–84. 4. Herman OJ. Conservative therapy for fracture of the os calcis. J Bone Joint Surg 1937;19:709–18. 5. Barnard L, Odegard JK. Conservative approach in the treatment of fractures of the calcaneus. J Bone Joint Surg Am 1970;52:1689. 6. Kitaoka HB, Schaap EJ, Chao EY, An KN. Displaced intra-articular fractures of the calcaneus treated non-operatively. Clinical results and analysis of motion and ground-reaction and temporal forces. J Bone Joint Surg Am 1994;76:1531–40. 7. Buckley R, Tough S, McCormack R, Pate G, Leighton R, Petrie D, et al. Operative compared with nonoperative treatment of displaced intraarticular calcaneal fractures: a prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am 2002;84-A:1733–44. 8. Clare MP, Lee WE 3rd, Sanders RW. Intermediate to long-term results of a treatment protocol for calcaneal fracture malunions. J Bone Joint

Surg Am 2005;87:963–73. 9. Palmer I. The mechanism and treatment of fractures of the calcaneus; open reduction with the use of cancellous grafts. J Bone Joint Surg Am 1948;30A:2–8. 10. Horn CE. Fractures of the calcaneus. Diagnosis and treatment. Calif Med 1968;108:209–15. 11. Yang Y, Zhao H, Zhou J, Yu G. Treatment of displaced intraarticular calcaneal fractures with or without bone grafts: A systematic review of the literature. Indian J Orthop 2012;46:130–7. 12. Levine DS, Helfet DL. An introduction to the minimally invasive osteosynthesis of intra-articular calcaneal fractures. Injury 2001;32 Suppl 1:SA51–4. 13. Tomesen T, Biert J, Frölke JP. Treatment of displaced intra-articular calcaneal fractures with closed reduction and percutaneous screw fixation. J Bone Joint Surg Am 2011;93:920–8. 14. Kayalı C, Altay T, Kement Z, Çıtak C, Yağdı S. The effect of early weightbearing on comminuted calcaneal fractures treated with locking plates. Eklem Hastalik Cerrahisi 2014;25:85–90. 15. Jain V, Kumar R, Mandal DK. Osteosynthesis for intra-articular calcaneal fractures. J Orthop Surg (Hong Kong) 2007;15:144–8. 16. Hetsroni I, Nyska M, Ben-Sira D, Arnson Y, Buksbaum C, Aliev E, et al. Analysis of foot and ankle kinematics after operative reduction of highgrade intra-articular fractures of the calcaneus. J Trauma 2011;70:1234–40. 17. Potter MQ, Nunley JA. Long-term functional outcomes after operative treatment for intra-articular fractures of the calcaneus. J Bone Joint Surg Am 2009;91:1854–60. 18. Brauer CA, Manns BJ, Ko M, Donaldson C, Buckley R. An economic evaluation of operative compared with nonoperative management of displaced intra-articular calcaneal fractures. J Bone Joint Surg Am 2005;87:2741–9. 19. Radnay CS, Clare MP, Sanders RW. Subtalar fusion after displaced intra-articular calcaneal fractures: does initial operative treatment matter? J Bone Joint Surg Am 2009;91:541–6. 20. Agren PH, Wretenberg P, Sayed-Noor AS. Operative versus nonoperative treatment of displaced intra-articular calcaneal fractures: a prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am 2013;95:1351–7.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Deplase eklem içi kalkaneus kırıklarının anatomik lateral çerçeve plak kullanılarak cerrahi tedavisi Dr. İrfan Esenkaya,1 Dr. Fatih Türkmensoy,2 Dr. Bahattin Kemah,3 Dr. Oğuz Şükrü Poyanlı1 1 2 3

İstanbul Medeniyet Üniversitesi Tıp Fakültesi, Göztepe Eğitim ve Araştırma Hastanesi, Ortopedi ve Travmatoloji Anabilim Dalı, İstanbul Afyon Dinar Devlet Hastanesi, Ortopedi ve Travmatoloji Kliniği, Afyon Ağrı Devlet Hastanesi, Ortopedi ve Travmatoloji Kliniği, Ağrı

AMAÇ: Bu çalışmanın amacı deplase eklem içi kalkaneus kırıklarının tedavisinde uyguladığımız anatomik lateral çerçeve plak sonuçlarını değerlendirmektir. GEREÇ VE YÖNTEM: Çalışmaya 13 hastanın (3 kadın, 10 erkek, ortalama yaş: 37.5) 14 deplase eklem içi kırığı olan hasta alındı. Tüm hastalara genişletilmiş lateral yaklaşım uygulandı ve eklem hattı redükte edildikten sonra otogreft kullanılarak desteklendi. Daha sonra da anatomik lateral çerçeve plak ile tespit edildi. Ameliyattan sonra tüm hastalara atel uygulandı. Ameliyattan sonra hastalara 6–8. haftalarda kontrollü, 12. haftadan sonra ise tam yük verdirildi. BULGULAR: Hastaların ortalama takip süresi 28 aydı. Kırıkların sınıflaması Sanders sistemine göre yapıldı. Hastaların klinik skorlamaları AOFAS, Creighton-Nebreska ve Maryland skorlama sistemleri kullanılarak yapıldı. Hastaların bu skor sistemlerine göre ortalaması sırası ile 83.7, 75.7, 88.5 olarak bulundu. TARTIŞMA: Çalışmamızda deplase eklem içi kalkaneus kırığı olan hastalarda kullandığımız anatomik lateral çerçeve plak tasarımımızın sonuçlarını tanımladık. Kullandığımız plağın kalkaneusun lateral yüzüne anatomik olarak oturmasıyla hem klinik hem de radyolojik olarak yeterli ve tatmin edici sonuçlar elde ettik. Anahtar sözcükler: Eklem içi kalkaneus kırığı; kalkaneus kırığı; lateral plaklama. Ulus Travma Acil Cerrahi Derg 2018;24(2):156–161

doi: 10.5505/tjtes.2017.62355

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Open reduction and internal fixation in AO type C distal humeral fractures using olecranon osteotomy: Functional and clinical results Zeynel Mert Asfuroğlu, M.D.,1 Ulukan İnan, M.D.,2 Hakan Ömeroğlu, M.D.3 1

Department Orthopedics and Traumatology, Eskişehir State Hospital, Eskişehir-Turkey

Department Orthopedics and Traumatology, Eskişehir Osmangazi University Faculty of Medicine, Eskişehir-Turkey

Department Orthopedics and Traumatology, TOBB ETÜ Hospital, Ankara-Turkey

ABSTRACT BACKGROUND: To investigate the outcomes of patients undergoing open reduction and internal fixation with olecranon osteotomy due to AO type13C fractures of the distal humerus. METHODS: Data of 39 patients (mean age, 44.7 years; males, 56.4%) undergoing surgery with the diagnosis of AO type 13C distal humeral fractures were retrospectively evaluated. Patients’ demographic characteristics, medical history, and radiological and functional outcomes were recorded. The patients were evaluated at the final follow-up according to the Mayo Elbow Performance Index (MEPI). RESULTS: The mean degrees of flexion and extension loss were 102.2 degrees (range, 60–120 degrees) and 11.4 degrees (range, 0–25 degrees), respectively, at the final follow-up. According to the MEPI score, outcomes were excellent in seven, good in 12, fair in 13, and poor in seven patients. All patients achieved a radiological union of the fracture site within the first postoperative six months. It was found that the loss of extension was more severe, the range of flexion was decreased, and the mean MEPI score was lower in the patients with type C3 fractures than in those with type C1 and type C2 fractures. No significant difference was determined between fixation techniques (tension band vs. cannulated screw) regarding the functional outcomes. CONCLUSION: Our results revealed better prognosis in AO type C1 and type C2 fractures than in AO type C3 fractures and no different effects of two fixation techniques in olecranon osteotomy on the outcomes. Keywords: Comminuted fractures; elbow joint; osteotomy.

INTRODUCTION Fractures of the elbow, 30% of which include fractures of the humerus, account for 7% of all fractures in adults.[1] The elbow joint has the highest contribution to the functional movement of the upper extremity. Treatment of elbow fractures is challenging due to the complex anatomic structure of the elbow joint.[2] Correction of an insufficient or unstable surgical fixation is always more difficult than the initial operation. It is important to provide an appropriate means of therapy to restore upper extremity functions.[3]

Management of the distal humerus fractures has long been a problem for orthopedic surgeons. Restricted movement and pain occurring after treatment negatively affect the treatment outcomes. Currently, the utility of conservative methods is limited due to the advancements in implant technology and developments of new techniques. Therefore, surgery is the mostly preferred treatment for the management of the distal humerus fractures.[4] The present study aimed to investigate the outcomes of patients who underwent open reduction and internal

Cite this article as: Asfuroğlu ZM, İnan U, Ömeroğlu H. Open reduction and internal fixation in AO type C distal humeral fractures using olecranon osteotomy: Functional and clinical results. Ulus Travma Acil Cerrahi Derg 2018;24:162–167 Address for correspondence: Zeynel Mert Asfuroğlu, M.D. Yenidoğan Mahallesi, Eskişehir Devlet Hastanesi, Odunpazarı, 26040 Eskişehir, Turkey Tel: +90 222 - 237 48 00 E-mail: z.mert.asfuroglu@gmail.com Ulus Travma Acil Cerrahi Derg 2018;24(2):162–167 DOI: 10.5505/tjtes.2017.32916 Submitted: 16.05.2017 Accepted: 02.07.2017 Online: 12.02.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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fixation with olecranon osteotomy due to AO type 13C fractures.

MATERIALS AND METHODS The present study was designed as a retrospective comparative study. Data of 39 adult patients who underwent surgical treatment with the diagnosis of AO type 13C fractures of the distal humerus (Fig. 1), according to the AO principles,[5] were retrospectively evaluated. In addition to the demographic characteristics of the patients, data regarding cause of injury, type of fracture according to the Gustilo–Anderson classification,[6] the surgical approach and the technique used, fixation technique, duration of follow-up, and radiological and functional outcomes were recorded. The patients were operated on for a mean duration of 3.8 days (range, 1–16 days) after sustaining trauma. All patients underwent open reduction and internal fixation with olecranon osteotomy. Fixation of the osteotomy site was per-

formed using cannulated screws in 21 patients and using tension bands in 18 patients. The fixation technique was chosen depending on the preference of the responsible surgeon. The medial and lateral columns were fixed using plates in 19 patients, and transcondylar screws were used to strengthen the fixation in eight of these 19 patients. The fixation was performed using medial and posterolateral plates in 20 patients, and transcondylar screws were used to strengthen the fixation in 12 of these 20 patients (Fig. 2). After the operation, the operated extremities of all patients were immobilized in a long arm splint, with the elbow flexed at 90 degrees and with the forearm held in the neutral position; the cast was removed after resolution of edema at 15day checkup. Prophylaxis with intravenous cefazolin (3 g/day) was administered for the first 48 h until removal of the drain. After removal of the splint, all patients participated in an exercise program supervised by a physiotherapist. The mean length of hospital stay was 5 days (range, 3–15 days). The patients were evaluated at the final follow-up visit according to the Mayo Elbow Performance Index (MEPI).[7] A MEPI score of <60 was evaluated as poor, a MEPI score of 60–74 was evaluated as fair, a MEPI score of 75–89 was evaluated as good, and a MEPI score of ≥90 was evaluated as excellent.

Statistical Analysis Data analysis was performed using the IBM SPSS Statistics for Table 1. General characteristics of the study patients Characteristics Patients (n=39)

Figure 1. Anteroposterior and lateral X-rays of a type C3 distal intra-articular humeral fracture.

Age (year), Mean±SD,

44.7±12.3

Median (minimum-maximum)

44 (20–69)

Gender, n (%)

Males

22 (56.4)

Females

17 (43.6)

Cause of injury, n (%)

Traffic accidents

26 (66.7)

Fall

13 (33.3)

Type of fracture according to the AO principles, n (%)

10 (25.6)

14 (35.9)

15 (38.5)

Presence of multiple fractures, n (%) Presence of open fracture , n (%) *

Figure 2. Anteroposterior and lateral views at the postoperative 5th month of a 27-year-old female patient in whom fixation was performed using medial and posterolateral plates and transcondylar screw was used.

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24 (61.5) 7 (17.9)

Duration of follow-up, months

36.7±19.4

Mean±SD, median (minimum-maximum)

30 (10–83)

*All open fractures were type 1 open fractures according to the Gustilo-Anderson classification. SD: Standard deviation.

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post-hoc analysis of normally distributed variables, whereas for non-normally distributed variables, Kruskal–Wallis H tests were tested using the Monte Carlo simulation technique, and non-parametric post-hoc test was performed for post-hoc analysis. Comparison of categorical variables was performed using Pearson’s chi square test with the Monte Carlo simulation technique A p-value of <0.05 was considered statistically significant.

Table 2. Findings of the patients at the postoperative and follow-up periods Characteristics Patients (n=39) Postoperative complications, n (%)

Superficial wound site infection

3 (7.7)

Ulnar nerve problem

3 (7.7)

Heterotrophic ossification

2 (5.1)

RESULTS

According to the MEPI score, n (%)

Excellent

The mean age of the patients (n=39) at the time of admission was 44.7±12.3 years, and 56.4% of them were males. The general characteristics of the patients are summarized in Table 1.

7 (17.9)

Good

12 (30.8)

Fair

13 (33.3)

Poor

7 (17.9)

Functionality at the last follow-up Mean±SD, Median (Minimum-Maximum)

Elbow joint flexion, degree

Loss of extension, degree

102.2±12.3 105 (60–120) 11.4±6.97 10 (0–25)

MEPI: Mayo Elbow Performance Index; SD: Standard deviation.

Windows, version 22.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics were expressed as number and percentage for categorical variables and as mean, median, standard deviation, and minimum and maximum for numerical variables. Comparison of two independent groups was performed using independent t-test for normally distributed variables and using Mann–Whitney U-test with the Monte Carlo simulation technique for non-normally distributed variables. For multiple group comparisons, one-way analysis of variance was performed, and the least significant difference was used for

Superficial wound-site infections were observed in the early postoperative period in three patients. These patients were treated with appropriate intravenous antibiotics and healed without any sequelae. Three patients developed ulnar nerve palsy in the postoperative period. Implant removal was planned in the early period after observing the evidence of union, and ulnar nerve transposition was performed in all patients. Recovery of the ulnar nerve palsy was not achieved in one patient. Heterotrophic ossification was observed in two patients at 12 months during the follow-up period. A radiological union of the fracture site was achieved within the first postoperative six months in all patients. None of the patients experienced nonunion of the olecranon osteotomy site. The findings of the patients at the postoperative and follow-up periods are presented in Table 2. Evaluation of the patients according to the type of fractures determined based on AO principles revealed that the loss of extension was more severe, the range of flexion was decreased, and the MEPI score was lower in the patients with

Table 3. Characteristics of the patients according to the type of fractures based on the AO principles

Fracture type

Type C1 (n=10)

Type C2 (n=14)

p Type C3 (n=15)

Mayo Elbow Performance Index score, Mean±SD

81.0±12.2a 77.1±10.7a 62.0±13.2 0.001

Flexion, degree, Mean±SD

111.5±6.7a 106.4±6.6a 92.0±12.2 <0.001

Presence of loss of extension, n (%)

5 (50.0)

13 (92.9)

15 (100.0)

0.001

2.5 (0–20)a

10 (0–20)a

20 (10–25)

<0.001

1 (10.0)

3 (21.4)

1 (6.7)

0.508

Loss of extension, degree Median (Minimum-Maximum) Presence of complication, n (%)

Osteotomy fixation type, n (%)

Cannulated screw

3 (30.0)

9 (64.3)

9 (60.0)

Tension band

7 (70.0)

5 (35.7)

6 (40.0)

0.243

Significantly different from the patients with type C3 fracture at p<0.001. SD: Standard deviation.

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Table 4. Characteristics of the patients according to the osteotomy fixation type

Osteotomy fixation with

Cannulated screw Tension band n=21 n=18

Mayo Elbow Performance Index score, Median (Minimum-Maximum)

80 (35–90)

72.5 (45–90)

0.995

Flexion, degree, Mean±SD

101.0±14.5

103.6±9.4

0.508

Presence of loss of extension, n (%)

18 (85.7)

15 (83.3)

1.000

Loss of extension, degree, Median (Minimum-Maximum)

10 (0–25)

10 (0–20)

0.854

3 (14.3)

2 (11.1)

1.000

Presence of complication, n (%) SD: Standard deviation.

type 13C3 fractures compared with the patients with type 13C1 and type 13C2 fractures (Table 3).

difference was determined between the two fixation techniques in terms of functional outcomes and complications.

In the present study, no significant difference was determined between the two fixation techniques (tension band vs. cannulated screw) with respect to the functional outcomes and complications (Table 4).

Complications may occur in distal humeral fractures either due to the injury itself or due to treatment. It has been reported that complications are more frequently observed in open fractures than in closed fractures.[14] Majority of the patients (82.1%) in the present study had closed fractures. Evaluation of the patients according to the fracture types determined based on AO principles revealed a more severe loss of extension, a decreased range of flexion, a lower MEPI score in the patients with type 13C3 fractures than in those with type 13C1 and type 13C2 fractures.

DISCUSSION Management of the distal humerus fractures is challenging due to its complex anatomic structure and poor bone reserve. The main goal of treatment is to provide a complete range of joint motion and a painless and stable joint.[8] The optimal treatment for the distal humerus fractures is surgery, and the surgical technique to be selected in these fractures is related to the fracture type.[9,10] A medial or lateral incision can be preferred in single-column fractures involving the joint. A posterior incision can provide better visibility of the surgical site in bicolumnar fractures affecting both columns and involving the joint. An olecranon osteotomy is a technique used in posterior incisions. This technique provides better surgical visibility than other techniques such as triceps incision and separation.[9] In the present study, all patients underwent olecranon osteotomy. Different fixation techniques have been used in previous studies. Flinkkilä et al.[11] reported parallel plate fixation as an effective method for the treatment of comminuted fractures of the distal humerus. Sanchez-Sotelo et al.[12] suggested that using 2.7-mm locking screws in addition to medial and lateral plates would increase the stability in comminuted fractures. Babhulkar and Babhulkar[13] reported successful outcomes using posterior transolecranon approach, dual fixation of both columns, and restoration of the continuity of articular surface. In the present study, double plates were used in all patients; we believe this is important in the treatment of such complex fractures. Moreover, in the present study, fixation of the osteotomy site was performed using cannulated screws in 21 patients and tension bands in 18 patients; no significant Ulus Travma Acil Cerrahi Derg, March 2018, Vol. 24, No. 2

One of the complications encountered in distal humeral fractures is infection. The rate of surgical site infections has been reported to range between 3% and 12% in the distal humerus fractures.[15,16] In the present study, a superficial infection was observed in three patients. The patients did not require debridement, and all recovered with the administration of an appropriate anti-biotherapy recommended by infectious disease specialists and with the use of wound dressing. The rate of ulnar nerve injury has been reported to be 0%– 12% in fractures of the elbow joint.[11,15,17] Protection of the ulnar nerve is recommended in posterior approaches. However, there is a debate over the necessity of anterior transposition of the ulnar nerve. Wang et al.[18] recommended that anterior transposition of the ulnar nerve should be routinely performed. In the present study, the ulnar nerve was identified in all patients; however, transposition was not performed. Ulnar nerve palsy was observed in three patients, and ulnar nerve transposition was performed in the postoperative 6th month. However, we do not perform a routine ulnar nerve transposition during our surgical treatments in such cases. Another important complication following the treatment of elbow fractures is the presence of heterotrophic ossification that results in a limited range of motion.[19] Anti-inflammatory drugs (such as indomethacin) and radiation therapy have been suggested as a part of the surgical treatment of heterotrophic 165

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ossification.[19] In distal humerus fractures, the rate of heterotrophic ossification as a complication has been reported to be 0%–15%.[15,17,20] In the present study, none of the patients were administered prophylactic indomethacin; two patients, who had a type 13C3 fracture at the initial presentation, developed heterotrophic ossification and were monitored. Nonunions are encountered as unwanted complications for orthopedists after surgical treatment of the elbow joint.[21] The complication of nonunion of the olecranon has been reported at a rate of 3%–7% after the treatment of type 13C fractures of the distal humerus.[15,20] In the present study, none of the patients experienced a complication related to the union of the olecranon. Rehabilitation after surgery is of major importance in distal humerus fractures. Appropriate rehabilitation techniques improve patient outcomes.[22] In the present study, the mean duration of follow-up was 36.7 months. After the treatment, the mean degrees of flexion and loss of extension were found to be 102.2 and 11.4 degrees, respectively. In their study, Ozdemir et al.[15] reported the mean degree of flexion in the elbow joint as 115.1 degrees and the mean degree of loss of extension as 26.3 degrees. In studies evaluating functional outcomes of surgical treatment of elbow fractures, the rate of patients with excellent and good outcomes after the treatment were reported as 62% by Ozdemir et al.,[15] as 81% by Flinkkilä et al.,[11] as 72% and 86% in their two different groups by Babhulkar and Babhulkar,[13] and 92% by Schmidt-Horlohé et al.[20] In the present study, excellent and good outcomes were obtained in 48.7% (n=19) of the patients. The main limitation of the present study was the absence of a control group including patients treated using a different surgical procedure. Another limitation was the absence of a patient group including patients treated with plate-screw fixation technique for olecranon fixation. In conclusion, complex fractures of the distal humerus are difficult to treat. Functional outcomes worsen when the fracture type becomes more complex. The results of the present study revealed that the prognosis in type C1 and type C2 fractures was better than in type C3 fractures and that the type of fixation (tension band or cannulated screw) in olecranon osteotomy did not influence the outcome.

Funding The authors received no financial support for the research and/or authorship of the article. Conflict of interest: None declared.

REFERENCES 1. Pollock JW, Faber KJ, Athwal GS. Distal humerus fractures. Orthop Clin North Am 2008;39:187–200.

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2. Kocaoglu M, Şener N, Şar C, Hamzaoglu A, Tuncay İ. Intraarticular fractures of the distal humerus in the adult: Surgical treatment and results. Joint Dis Rel Surg 1999;10:149–54. 3. Chan K, King GJ, Faber KJ. Treatment of complex elbow fracture-dislocations. Curr Rev Musculoskelet Med 2016;9:185–9. 4. Nauth A, McKee MD, Ristevski B, Hall J, Schemitsch EH. Distal humeral fractures in adults. J Bone Joint Surg Am 2011;93:686–700. 5. Holdsworth BJ. Humerus: distal. In: Ruedi TP, Murphy WM, editors. AO Principles of Fracture Management. Stuttgart New York: Thieme; 2000. p. 307–21. 6. Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am 1976;58:453–8. 7. Morrey BF, An KN. Functional evaluation of the elbow. In: Morrey BF, editor. The Elbow and Its Disorders. 3rd ed. Philadelphia: WB Saunders; 2000. p. 82. 8. O’Driscoll SW. Optimizing stability in distal humeral fracture fixation. J Shoulder Elbow Surg 2005;14:186S–94S. 9. Bégué T. Articular fractures of the distal humerus. Orthop Traumatol Surg Res 2014;100:S55–63. 10. Lee DH. Treatment options for complex elbow fracture dislocations. Injury 2001;32 Suppl 4:SD41–69. 11. Flinkkilä T, Toimela J, Sirniö K, Leppilahti J. Results of parallel plate fixation of comminuted intra-articular distal humeral fractures. J Shoulder Elbow Surg 2014;23:701–7. 12. Sanchez-Sotelo J, Torchia ME, O’driscoll SW. Principle-based internal fixation of distal humerus fractures. Tech Hand Up Extrem Surg 2001;5:179–87. 13. Babhulkar S, Babhulkar S. Controversies in the management of intra-articular fractures of distal humerus in adults. Indian J Orthop 2011;45:216–25. 14. Min W, Ding BC, Tejwani NC. Comparative functional outcome of AO/ OTA type C distal humerus fractures: open injuries do worse than closed fractures. J Trauma Acute Care Surg 2012;72:E27–32. 15. Ozdemir H, Urgüden M, Söyüncü Y, Aslan T. Long-term functional results of adult intra-articular distal humeral fractures treated by open reduction and plate osteosynthesis. Acta Orthop Traumatol Turc 2002;36:328–35. 16. Claessen FM, Braun Y, van Leeuwen WF, Dyer GS, van den Bekerom MP, Ring D. What Factors are Associated With a Surgical Site Infection After Operative Treatment of an Elbow Fracture? Clin Orthop Relat Res 2016;474:562–70. 17. Mardanpour K, Rahbar M. Open reduction and internal fixation of intraarticular fractures of the humerus: evaluation of 33 cases. Trauma Mon 2013;17:396–400. 18. Wang KC, Shih HN, Hsu KY, Shih CH. Intercondylar fractures of the distal humerus: routine anterior subcutaneous transposition of the ulnar nerve in a posterior operative approach. J Trauma 1994;36:770–3. 19. Englert C, Zellner J, Koller M, Nerlich M, Lenich A. Elbow dislocations: a review ranging from soft tissue injuries to complex elbow fracture dislocations. Adv Orthop 2013;2013:951397. 20. Schmidt-Horlohé KH, Bonk A, Wilde P, Becker L, Hoffmann R. Promising results after the treatment of simple and complex distal humerus type C fractures by angular-stable double-plate osteosynthesis. Orthop Traumatol Surg Res 2013;99:531–41. 21. Gallay SH, McKee MD. Operative treatment of nonunions about the elbow. Clin Orthop Relat Res 2000:87–101. 22. Wong AS, Baratz ME. Elbow fractures: distal humerus. J Hand Surg Am 2009;34:176–90.

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ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

AO Tip C humerus distal kırıklarında olekranon osteotomisi ile açık redüksiyon ve internal tespit: Fonksiyonel ve klinik sonuçlar Dr. Zeynel Mert Asfuroğlu,1 Dr. Ulukan İnan,2 Dr. Hakan Ömeroğlu3 Eskişehir Devlet Hastanesi, Ortopedi ve Travmatoloji Kliniği, Eskişehir Osmangazi Üniversitesi Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, Eskişehir 3 TOBB ETÜ Hastanesi, Ortopedi ve Travmatoloji Kliniği, Ankara 1 2

AMAÇ: Çalışmada AO tip 13C humerus distal kırıklarında olekranon osteotomisi ile birlikte açık redüksiyon ve internal tespit yapılan hastaların fonksiyonel ve klinik sonuçlarını ortaya koymaktır. GEREÇ VE YÖNTEM: AO Tip 13C distal humerus kırığı tanısı mevcut olan ve cerrahisi yapılan 39 hasta (ortalama yaş, 44.7; Erkek, %56.4) geriye dönük olarak değerlendirildi. Hastaların demografik verileri, tıbbi öyküleri, radyolojik ve fonksiyonel sonuçları kayıt altına alındı. Hastaların fonksiyonel sonuçları Mayo Dirsek Performans Puanlama Sistemi’ne (MEPI) göre değerlendirildi. BULGULAR: Ortalama dirsek fleksiyon derecesi 102.2 (60–120 derece) ve ortalama ekstansiyon kaybı derecesi 11.4 (0–25 derece) olarak hesaplandı. Mayo Dirsek Performans Puanlama skorlama sistemine göre yedi hastada mükemmel, 12 hastada iyi, 13 hastada orta ve 7 hastada kötü sonuç elde edildi. Tüm hastalarda ameliyat sonrası altıncı ayda radyolojik olarak kaynama görüldü. Tip 13C3 kırıklarda tip 13C1 ve 13C2’ye göre daha fazla ekstansiyon kaybı, daha düşük fleksiyon derecesi ve daha düşük ortalama MEPI skoru tespit edildi. Fonksiyonel sonuçlara bakıldığında olekranon fiksasyon yönteminin (tansiyon bant ve kanüle vida) anlamlı farklılık yaratmadığı tespit edildi. TARTIŞMA: AO tip 13C1 ve tip 13C2 kırıkların klinik ve fonksiyonel sonuçlarının AO tip 13C3 kırıklara göre daha iyi olduğu ve iki farklı olekranon fiksasyon yönteminde fonksiyonel sonuçların değişmediği görüldü. Anahtar sözcükler: Dirsek eklemi; osteotomi; parçalı kırıklar. Ulus Travma Acil Cerrahi Derg 2018;24(2):162–167

doi: 10.5505/tjtes.2017.32916

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CA S E SER I ES

Fixation of rotationally unstable extracapsular proximal femoral fractures Elsayed Ibraheem Elsayed Massoud, M.D. Department of Orthopaedic, Sohag Teaching Hospital, General Organization for Teaching Hospitals and Institutes, Sohag - Egypt

ABSTRACT BACKGROUND: It was thought that the AO types A1.2 and A1.3 fractures are rotationally stable; however, it revealed instability when fixed using the dynamic hip screw. Therefore, we hypothesized that these fractures should be treated as rotationally unstable. METHODS: A series of 83 fractures of the AO types A1, A2, and B2.1 were treated using dynamic hip screw with derotation screw (DHS/DRS) composite and then prospectively followed for 24 months. Adequacy of reduction and fixation were immediately assessed after surgery, and fracture collapse was assessed at six months or when fractures healed.To investigate the feasibility of our hypothesis, fractures were classified into two groups: 1) the inevitably unstable group (IUG) included the AO types A1.1, A2.1, A2.2, A2.3, and B2.1 fractures and 2) the potentially unstable group (PUG) included the AO types A1.2 and A1.3 fractures. The results were statistically analyzed. RESULTS: Adequate reduction was achieved in 77 and adequate fixation in 71 fractures. All fractures healed in a mean time of 13.5 weeks, and the amount of the fracture collapse averaged 5.8 mm. Equalization of the lower limbs was achieved in 66 patients, and hip motion range equalized the healthy contralateral in 80 patients. Re-operation was performed in one case with AO type A1.2. Comparison of IUG and PUG using the outcomes revealed insignificant differences. CONCLUSION: Using the DHS/DRS composite, anatomical features of the proximal femoral end were restored and maintained during the follow-up period. Insignificant differences between outcomes of IGU and PGU render the addition of the AO types A1.2 and A1.3 to the rotationally unstable fractures reasonable. Keywords: Basicervical fracture; derotation screw; DHS/DRS composite; dynamic hip screw; proximal femoral fractures; rotational instability; trochanteric fractures.

INTRODUCTION Extracapsular proximal femoral fractures occur distal to the hip joint capsule.[1] These fractures are subdivided into subtrochanteric, intertrochanteric, and basicervical fractures, with each type having different management options and prognostic implications.[2,3] Generally, successful management necessitates differentiation between stable and unstable fractures. However, the current classification systems have restricted the instability only at the vertical plane.[2,4] Recently,

rotational instability has resurfaced as a potential hazard and this could threaten even a stable fracture. This has been predicted increasingly when a single cephalic screw was used for fixation, of a fracture in which the proximal fragment was separated from the trochanters through a high-angle fracture line.[3,5–7] For achieving a stable fixation, many modifications have been introduced on the already existing implants. Although the dynamic hip screw (DHS) has been considered as the standard

Cite this article as: Massoud EIE. Fixation of rotationally unstable extracapsular proximal femoral fractures. Ulus Travma Acil Cerrahi Derg 2018;24:168–174 Address for correspondence: Elsayed Ibraheem Elsayed Massoud, M.D. Nile St Sohag 00 Sohag, Egypt Tel: +2 0934790632 E-mail: elsayedmassoud@hotmail.com Ulus Travma Acil Cerrahi Derg 2018;24(2):168–174 DOI: 10.5505/tjtes.2017.47041 Submitted: 23.09.2017 Accepted: 10.11.2017 Online: 15.02.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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implant for the fixation of intertrochanteric fractures,[1,2] it failed in the fixation of unstable fractures. Therefore, some authors have augmented DHS with resorbable cement, and others preferred the peripheral femoral nails (PFN).[2,8] However, for the reported complications with PFN,[9,10] the proximal femoral nail antirotation was designed.[11] However, the anti-rotational device was related to early complications arising from its position, and later, like as a “Z effect.”[5,12] Z-effect, defined as a complication results from the collapse of the proximal fracture fragment that lead to a medial migration of the superior lag screw and lateral migration of the inferior lag screw.[5] In a previous study,[3] we have achieved successful results using a composite of DHS with derotation screw (DHS/DRS composite) for the fixation of a group of fractures, which were assigned as rotationally unstable. The AO types A1.2 and A1.3 fractures were not included in the previous study because they were thought to be rotationally stable.[4] However, when these fractures types were fixed with the DHS alone, have reported complications likely related to the rotational instability. Therefore, we hypothesized that these fractures do not differ from the rotationally unstable fractures because it carries multiple criteria of the rotational instability. The aims of this study were two-fold: firstly, to present the results of using the DHS/DRS composite in the fixation of a prospective series of 83 rotationally unstable fractures; secondly, to investigate the feasibility of our null hypothesis using the outcomes.

METHODS Between August 2009 and August 2013, we conducted a prospective study that included 83 patients who agreed to participate. The Local Ethics Committee approved the study. The primary assessment included interviews with the patients regarding their walking ability that was classified into two categories: 1) ability to walk independently without any aid and 2) ability to walk independently with one cane. A radiologist and a senior orthopedic surgeon identified the fractures pattern using X-ray, and the fractures were then classified according to the AO classification system.[13] We included who were walks and who were using one walking stick, present with extracapsular proximal femoral fractures that have met the criteria of the rotational instability. The included fractures were the AO types A1.1, 2, 3, A2.1, 2, 3, and B2.1 fractures. The criteria of rotational instability are as follows: the head–neck fragment does not remain connected to the trochanters, is separated by a high-angle fracture line, and its inferior cortical extension is not long enough to hinder its rotation.[3,5] For this study, the AO types A1.2 and A1.3 fractures were exceptionally included because they lacked one criterion of the rotational instability. The head– neck fragment has a fraction of the greater trochanter in the Ulus Travma Acil Cerrahi Derg, March 2018, Vol. 24, No. 2

type A1.2, whereas it has a long inferior cortical extension in the type A1.3. Consequently, fractures were classified into two groups: 1) the inevitably unstable group (IUG) included 60 fractures of the AO types A1.1, A2.1, 2, 3, and B2.1 fractures and 2) the potentially unstable group (PUG) included 23 fractures of the AO types A1.2 and A1.3 fractures. To explore the feasibility of gathering both groups within a group for the rotationally unstable fractures, results were statistically analyzed. We excluded patients with intracapsular fractures, the AO type A3, pathological fractures, and hips with advanced arthritis.

Operative Technique The fracture was exposed by a straight lateral incision. Using the angle guide, a pin was inserted into the subchondral level of the femoral head. A K-wire was placed parallel and proximal to the guide pin at a distance of approximately 13 mm, so that spinning of the head–neck fragment during the reaming or screw insertion can be controlled. After insertion of the DHS components, a partially threaded cannulated cancellous screw of suitable length, with a washer, was inserted onto the K-wire to act as a DRS. A suction drainage system was inserted submuscular, and the wound was closed.

Follow-Up Postoperative management was determined based on the quality of reduction obtained. Patients with good reduction were allowed to walk using crutches until a good callus was observed, and then progressive weight bearing was started. However, if the reduction was considered as not good, partial weight bearing was allowed only when the callus bridged the fracture line. Patients received antithrombotics (low molecular weight heparins) and prophylactic doses of antibiotics (third generation cephalosporin). Follow-up examinations were carried out every other week for 16 weeks and then every other month. After the first year, patients were evaluated twice per year, and outcomes were assessed at 24 months postoperatively.

Radiological Assessment Adequacy of reduction was immediately assessed after surgery and classified as adequate when the neck–shaft angle <10° varus or <15° valgus compared with the contralateral hip and displacement between the fragments was <3 mm in any of the AP and lateral radiographs.[3] Adequacy of fixation was rated by assessing the placement of the lag screw within the femoral head using two independent classifications. First, according to the nine zones classification of the femoral head,[14] adequate grade was given when the screw was placed inferior/central, central/central, or inferior/ posterior in AP/ lateral views. However, superior and/or anterior placement was considered inadequate. Second, the tip apex distance (TAD) of <20 mm in both AP and lateral views was considered adequate.[3] The parallelism between the lag screw and DRS was deemed adequate and was used as an indicator 169

Massoud. Fixation of rotationally unstable extracapsular proximal femoral fractures

of the preservation of reduction in subsequent radiographs. Convergence of the DHS/DRS composite is deemed inadequate.[3] Time to union was calculated from the surgery date to the healing date, which was indicated when the trabeculae extended across the fracture line. Non-union was defined as absence of the bridging bone at the fracture line by follow-up at six months, including progressive displacements.[3] Fracture collapse was equivalent to the sliding distance, which was defined as the length of protrusion of the lag screw from the lateral edge of the barrel when measured at the 6th month postoperatively or when the fracture healed. According to Mattsson et al.,[15] the sliding distance was classified into excellent (<6 mm), good (<15 mm), and poor (at 16 mm or more).

equacy of reduction, adequacy of fixation, and legs’ lengths. Chi-square Calculator for 2×2 Contingency Table test was used for the analysis of the legs’ lengths variable. Fisher Exact Test Calculator for 2×2 Contingency Table test was used for the analysis of the adequacy of reduction and adequacy of fixation (this test was employed instead of Pearson’s chi-square test when sample sizes are <5). Second, Chi-square Calculator for 5×5 (or less) Contingency Table test was used for the analysis of the variables with three-category data, which were sliding distance and functional outcomes. Significant difference was set at p<0.05. Statistical analysis was performed using the online calculator at the website http://www.socscistatistics.com/tests/Default.aspx.

RESULTS

Clinical Assessment Motion of the hip joint was measured using a goniometer and compared with the healthy contralateral. The lengths of both the lower extremities were measured and compared. Functional outcomes were evaluated according to the modified criteria of Kyle et al.[14] The excellent result was given for patients who had a normal range of motion, who had minimum limp without pain, and who rarely used a cane (provided that they did not use a cane in the pre-fracture period). The good result was given for patients who had a normal range of motion, but had a noticeable limp with occasional mild pain, and who used a cane (provided that they did not use a cane in the pre-fracture period). The fair result was given for patients who had a limited range of motion, a noticeable limp, moderate pain and who used two canes or a walker. The poor result was given for patients who had pain on any motion and who were in a wheelchair or who were non-ambulatory.

Statistical Analysis The data are categorical and included two and three categories. First, the variables with two-category data were ad-

The study included 83 patients with 83 fractures; their mean age at surgery was 61.3 (range: 38–85 years). The preoperative details are listed in Table 1.

Radiographic Results The reduction was rated as adequate in 77 and inadequate in six fractures. The inadequacy of reduction was related to that the neck–shaft angle exceeded the contralateral by <15° in four fractures and lowered by >10° in one fracture, and the displacement between the fragments was >3 mm in six fractures. Criteria for the inadequacy of reduction were noticed together in five fractures (Table 2). Measurements of the neck–shaft angles remained preserved to the final assessment, except in one case that was re-operated upon (Fig. 1). Fixation was considered adequate in 71 fractures and inadequate in 12 fractures, because TAD exceeded 20 mm in 12 fractures and the lag screw was placed superior in 11 femoral heads. Criteria of the inadequacy of fixation were noticed together in 11 fractures (Table 2). All fractures healed within a mean period of 13.5 weeks (range: 10–30 weeks). Fracture

Table 1. Preoperative details for patients with rotationally unstable proximal femoral fractures Types of fractures Fractures numbers

Age (years)

Gender

Side

Walking aid

Average Range Male Female Right Left No Yeas Inevitably unstable

60.5

38–85

66.3

50–85

AO type A1.1

AO type A2.1

56.6

38–70

AO type A2.2

59.4

44–78

AO type A2.3

60.8

46–79

AO type B2.1

61.8

42–80

Potentially unstable

63.5

43–80

AO type A1.2

55–80

AO type A1.3

43–66

50 33 70 13

Total

170

83 61.3 38–85 37

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Table 2. Adequacy of the reduction and fixation in immediate postoperative radiographs Types of fractures Inevitably unstable

Adequacy of reduction

Adequacy of fixation

FNS angle Fragmentary Tip apex Lag screw (compared to displacement distance placement other side) Equal

Unequal <3 mm >3 mm <20 mm

AO type A1.1

AO type A2.1

AO type A2.2 AO type A2.3

1 valgus

2 valgus

AO type B2.1

Potentially unstable

AO type A1.2 AO type A1.3

>20 mm

C/C I/C I/P

Derotation screw parallelism S/C

Parallel

Converge

1 varus

1 valgus

FNS angle: Femoral neck–shaft angle; C/C: Central/central; I/C= Inferior/central; I/P = Inferior/posterior; S/C: Superior/central.

collapse was estimated according to the sliding distance that averaged 5.8 mm (range: 2–20 mm). The rating was excellent in 59, good in 22, and poor in two fractures (Table 3).

According to the modified criteria of Kyle et al.,[14] 69 patients obtained excellent, 11 achieved good, and three achieved fair results (Table 3).

Clinical Results

Comparison of IUG and PUG using outcomes: In IUG, the reduction was rated as adequate in 56/60 and inadequate in 4/60 fractures, whereas in PUG, it was adequate in 21/23 and inadequate in 2/23 fractures. The difference between both groups was statistically insignificant (p=0.67). The fixation in IUG was rated as adequate in 52/60 and inadequate in 8/60 fractures, whereas in PUG, it was adequate in 19/23 and inadequate in 4/23 fractures. The difference was statistically insignificant

At the final visit, the numbers of patients who used one cane increased from 13 to 18, and three of them use two walking aids instead of one. Equalization of both lower limbs was achieved in 66 patients; however, leg shortening that averaged 4.6 mm (range: 0–30 mm)] was reported in 17 patients (Table 3). Hip motion range equalized the healthy contralateral in 80 patients, but three patients exhibited a limitation of motion.

(a)

(b)

(c)

Figure 1. (a) Preoperative anteroposterior radiograph for the right hip joint of a 69-year-old female shows the AO type A1.2 trochanteric fracture. (b) AP radiograph at two weeks after surgery shows varus drift and excessive displacement of the head–neck fragment due to inadequate reduction and fixation. Note the placement of the DHS/DRS composite superior in the femoral head and convergence of DRS. (c) AP radiograph at six months after re-operation shows fracture healing, preserved neck–shaft angle, maintained parallelism between the cephalic screws of the DHS/DRS composite, and excellent sliding of the lag screw.

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Table 3. Outcomes of limb functions for patients treated for rotationally unstable fractures Types of fractures

Sliding distance

Legs length

Functional outcomes

Excellent Good Poor Equal Unequal Excellent Good Fair Poor

Inevitably unstable 43 16 1 48 12 51 7 2 0 AO type A1.1 6 2 0 6 2 6 2 0 0 AO type A2.1 10 2 0 10 2 12 0 0 0 AO type A2.2 12 5 0 15 2 15 1 1 0

AO type A2.3

AO type B2.1 6 3 0 6 3 7 2 0 0 Potentially unstable 16 6 1 18 5 18 4 1 0

AO type A1.2

AO type A1.3 2 3 0 4 1 4 1 0 0

(p=0.73). In IUG, the sliding distance was rated as excellent in 43/60, good in 16/60, and poor in 1/60 fractures. In PUG, the sliding distance was rated as excellent in 16/23, good in 6/23, and poor in 1/23 fractures. The difference was statistically insignificant (p=0.77). Equalization of legs’ lengths in IUG was achieved in 48/60 patients; however, 12/60 patients reported discrepancy, whereas in PUG, the equalization was achieved in 18/23 and discrepancy was reported in 5/23 patients. The difference was statistically insignificant (p=0.86). The functional outcome in IUG was rated as excellent in 51/60, good in 7/60, and fair in 2/60 patients. In PUG, it was rated as excellent in 18/23, good in 4/23, and fair in 1/23 patients. The difference was statistically insignificant (p=0.76).

Complications There were no general complications or deaths during the follow-up period. However, a re-operation was performed in one case with AO type A1.2 that showed excessive displacement of the proximal fragment in the postoperative radiograph due to inadequate reduction and fixation (Fig. 1). Superficial infection was noticed in four patients at the postoperative 3rd week. Infection was controlled with parenteral antibiotic and daily wound dressing. According to Brooker et al.[16] classification, heterotopic ossification classes II and III was observed in eight patients, 3 of whom reported limitation of hip motion at the final visit.

DISCUSSION In terms of rotational instability, extracapsular proximal femoral fractures are not alike. When constructed using solitary cephalic screw implant, most of them demonstrated instability. Identification of the rotationally unstable fractures offers insight for selecting the suitable fixation device. A simple modification of DHS through an addition of DRS will offer a compatible solution. In a previous study, we identified a group of rotationally un172

stable fractures, which reported satisfactory results when fixed using the DHS/DRS composite.[3] These fractures are the AO types A1.1, A2.1, 2, 3, and B2.1. In these fractures, the commonalities are that the head–neck fragment does not remain connected to the trochanters, is separated by a highangle fracture line, and has no distal extension that can hinder the rotation.[3,5] The AO types A1.2 and A1.3 fractures that were not included in the previous study when were fixed using DHS alone exhibited rotation of the proximal fragment around the lag screw during its insertion as well as loss of reduction postoperatively. It is worth noting that the head– neck fragment in the AO types A1.2 and A1.3 fractures is separated by a high-angle fracture line, which can generate a shear force as well as rotational instability.[6,7] Although the AO types A1.1, 2, and 3 fractures are equivalent to the stable fractures in Jensen classification,[4] Jensen et al.,[17] in another study, when used an implant with a single cephalic screw, reported varus displacement in 11 of the stable fractures group.[17] Jensen has related the instability to the separation of the head–neck fragment from the trochanters; however, he did not explain how it occurred.[4] The hip joint is a ball-and-socket joint; therefore, its motions are completely rotational.[18] Lenich et al.,[19] described that the rotation will not occur when the single cephalic implant is placed in the theoretical center of the femoral head, which its anatomy renders this is impossible. The authors, therefore, believed that implantation of a single cephalic screw leads to cutout.[19] Immediate postoperative radiography measures adequacy of reduction and fixation (Table 2). This suggested that the differences in outcomes were because of the inefficiency of the DHS/DRS composite to control rotation. In this study, changes in the neck–shaft angle, re-displacement, excessive sliding, and limb shortening are primarily correlated to the inadequacy of reduction and/or fixation, rather than the implanted composite, so why the adequately reduced and fixed fractures achieved satisfactory outcomes (Tables 2, 3). Ulus Travma Acil Cerrahi Derg, March 2018, Vol. 24, No. 2

Massoud. Fixation of rotationally unstable extracapsular proximal femoral fractures

Shortening of the femoral neck and/or limb can be a result of the bone collapse, varus drift, or distal migration of the proximal fragment.[8,15,19] Pajarinen et al.[8] have reported fracture collapse of 6.1 mm (range 0–30 mm) and a mean shortening of the limb of 4.7 mm (range 0–25 mm) in a group of patients (n=41) treated with DHS. Mattsson et al.[15] have compared the outcomes of using DHS without and with resorbable cement augmentation in the fixation of trochanteric fractures. They reported mean sliding distances of 15.9 mm with DHS alone and 13.5 mm when augmented. Moreover, they pointed out that a sliding distance of <6.7 mm did not affect limb mobility; therefore, they have correlated reduction of limb mobility with the sliding distance.[15] In the present study, a mean fracture collapse of 5.8 mm (range: 2–20 mm) and a mean limb shortening of 4.6 mm (range: 0–30 mm) were observed. Noteworthy, fracture collapse and limb shortening were consistently noticed together (Table 2). It has been reported that the high-angle fracture line contributes to limb shortening because it can displace the head–neck fragment distally.[3,7] Accordingly, we appreciate the role of DRS, which is fastened as a rafter between the lateral femoral cortex and subchondral bone of the femoral head, in control of the shear force. The present study has resurfaced the phenomenon of a rotational instability to the light and presents it as a potential hazard could be avoided as well identified a group of fractures has a susceptibility for rotation, albeit clinically. The hypothesis and outcomes have support from published biomechanical and clinical studies. However, the limitations of this study lie in being a case series study including a small number of patients and lacking biomechanical evaluation of its hypothesis. Therefore, a power, multicenter, and randomized control study is required to demonstrate the merits of the present technique compared with other techniques, coinciding with the biomechanical studies to provide more evidence for the assumptions.

Conclusion The DHS/DRS composite has restored and maintained the anatomical features of the proximal femoral end for the treated fractures as well as restored the limbs’ functions during the follow-up period. The similarity in the anatomical features of the head–neck fragment and the insignificant differences between the outcomes of the inevitable and potential rotationally unstable groups renders addition of the AO types A1.2 and A1.3 fractures to the rotationally unstable fractures reasonable.

Acknowledgement I’m really grateful to pharmacist Abdulsamad Mahran (Sohag Teaching Hospital) he exerted an effort and spent a time in making the statistical analysis of the present study. Conflict of interest: None declared.

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REFERENCES 1. Oliver D, Griffiths R, Roche J, Sahota O. Hip fracture. BMJ Clin Evid 2007. pii: 1110. 2. Mittal R, Banerjee S. Proximal femoral fractures: Principles of management and review of literature. J Clin Orthop Trauma 2012;3:15–23. 3. Massoud EI. Fixation of basicervical and related fractures. Int Orthop 2010;34:577–82. 4. Jensen JS. Classification of trochanteric fractures. Acta Orthop Scand 1980;51:803–10. 5. Aguado-Maestro I, Escudero-Marcos R, García-García JM, Alonso-García N, Pérez-Bermejo D D, Aguado-Hernández HJ, et al. Results and complications of pertrochanteric hip fractures using an intramedullary nail with a helical blade (proximal femoral nail antirotation) in 200 patients. Rev Esp Cir Ortop Traumatol 2013;57:201–7. 6. Deneka DA, Simonian PT, Stankewich CJ, Eckert D, Chapman JR, Tencer AF. Biomechanical comparison of internal fixation techniques for the treatment of unstable basicervical femoral neck fractures. J Orthop Trauma 1997;11:337–43. 7. Baitner AC, Maurer SG, Hickey DG, Jazrawi LM, Kummer FJ, Jamal J, et al. Vertical shear fractures of the femoral neck. A biomechanical study. Clin Orthop Relat Res 1999:300–5. 8. Pajarinen J, Lindahl J, Michelsson O, Savolainen V, Hirvensalo E. Pertrochanteric femoral fractures treated with a dynamic hip screw or a proximal femoral nail. A randomised study comparing post-operative rehabilitation. J Bone Joint Surg Br 2005;87:76–81. 9. Foulongne E, Gilleron M, Roussignol X, Lenoble E, Dujardin F. Miniinvasive nail versus DHS to fix pertrochanteric fractures: a case-control study. Orthop Traumatol Surg Res 2009;95:592–8. 10. Watson ST, Schaller TM, Tanner SL, Adams JD, Jeray KJ. Outcomes of Low-Energy Basicervical Proximal Femoral Fractures Treated with Cephalomedullary Fixation. J Bone Joint Surg Am 2016;98:1097–102. 11. Xu YZ, Geng DC, Mao HQ, Zhu XS, Yang HL. A comparison of the proximal femoral nail antirotation device and dynamic hip screw in the treatment of unstable pertrochanteric fracture. J Int Med Res 2010;38:1266–75. 12. Takano MI, de Moraes RC, de Almeida LG, Queiroz RD. Analysis of using antirotational device on cephalomedullary nail for proximal femoral fractures. Rev Bras Ortop 2014;49:17–24. 13. Müller ME, Allgöwer M, Schneider R, Willenegger H, editors. Proximal femur. In: Manual of internal fixation: techniques recommended by the AO-ASIF Group. 3rd ed. Berlin: Springer; 1992. p. 522–30. 14. Kyle RF, Gustilo RB, Premer RF. Analysis of six hundred and twenty-two intertrochanteric hip fractures. J Bone Joint Surg Am 1979;61:216–21. 15. Mattsson P, Alberts A, Dahlberg G, Sohlman M, Hyldahl HC, Larsson S. Resorbable cement for the augmentation of internally-fixed unstable trochanteric fractures. A prospective, randomised multicentre study. J Bone Joint Surg Br 2005;87:1203–9. 16. Brooker AF, Bowerman JW, Robinson RA, Riley LH Jr. Ectopic ossification following total hip replacement. Incidence and a method of classification. J Bone Joint Surg Am 1973;55:1629–32. 17. Jensen JS, Michaelsen M. Trochanteric femoral fractures treated with McLaughlin osteosynthesis. Acta Orthop Scand 1975;46:795–803. 18. Baerlocher P, Boulic R. Parametrization and range of motion of the balland socket joint. Proceedings of AVATARS’2000 Conference. Lausanne: 2000; p. 180–90. 19. Lenich A, Bachmeier S, Prantl L, Nerlich M, Hammer J, Mayr E, et al. Is the rotation of the femoral head a potential initiation for cutting out? A theoretical and experimental approach. BMC Musculoskelet Disord 2011;12:79.

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OLGU SERİSİ - ÖZET

Rotasyonel instabil ekstrakapsüler proksimal femur kırıkları Dr. Elsayed Ibraheem Elsayed Massoud Sohag Eğitim Hastanesi, Ortopedi Bölümü, Eğitim Hastaneleri ve Kurumları Organizasyonu, Sohag-Mısır

AMAÇ: AO tipleri A1.2 ve A1.3 kırıklarının rotasyonel instabil olduğu düşünülmesine rağmen, dinamik kalça vidası ile tespitten sonra stabil olmadıkları ortaya çıkmıştır. Bu nedenle bu kırıkların rotasyonel instabil kırıklar gibi tedavi edilmesi gerektiğini varsaymaktayız. GEREÇ VE YÖNTEM: AO tip A1, A2 and B2.1 kırıkları olan 83 kırıklık bir seri DKV/DRV ile tedavi edildikten sonra 24 ay izlendi. Ameliyattan hemen sonra, redüksiyonun ve fiksasyonun yeterliliği, altıncı aylarda veya kırıklar iyileştiğinde ise kırık bölgesindeki çökme değerlendirildi. Varsayımımızın uygulanabilirliğini araştırmak için kırıklar iki gruba ayrıldı: Kaçınılmaz olarak instabil kırık grubu (KİKG) AO tip A1.1, A2.1,2,3 ve B2.1 kırıkları, potansiyel olarak instabil kırık grubu (PİKG) AO tip A1.2 ve A1.3 kırıkları içermekteydi. Sonuçlar istatistiksel açıdan analiz edildi. BULGULAR: Yetmiş yedi kırıkta yeterli redüksiyon ve 71’inde yeterli fiksasyon sağlandı. Kırıkların tümü ortalama 13.5 haftada iyileşti ve kırık bölgesinde ortalama 5.8 mm’lik çökme (kolaps) oluştu. Altmış altı hastada her iki alt ekstremite eşitlendi, 80 hastada kalça hareket erimi diğer sağlam kalçanın hareket erimine kavuştu. Bir AO tip A1.2’li hasta yeniden ameliyata alındı. Sonuçların karşılaştırılmasına göre KİKG ile PİKG arasında önemsiz farklılıklar vardı. TARTIŞMA: DKV/DRS ile femurun proksimal ucunun anatomik özellikleri orijinal haline getirilmiş ve takip dönemi sırasında bu durum korunmuştur. KİKG ile PİKG sonuçları arasında önemsiz farklılıklar, rotasyonel instabil kırıklara AO tip A1.2 ve A1.3 kırıkların da ilavesi akla yakındır. Anahtar sözcükler: Bazoservikal kırık; derotasyon vidası; DHS/DRS kompozit; dinamik kalça vidası; proksimal femor kırıkları; rotasyonel instabilite; trokanterik kırıklar. Ulus Travma Acil Cerrahi Derg 2018;24(2):168–174

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doi: 10.5505/tjtes.2017.47041

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CAS E R EP O RT

Traumatic evisceration after blunt trauma in a 20-month-old boy Marta Diana Komarowska, M.D., Ewa Matuszczak, M.D., Wojciech Debek, M.D., Adam Hermanowicz, M.D. Department of Pediatric Surgery and Urology, Medical University of Bialystok, Children’s Clinical Hospital, Bialystok-Poland

ABSTRACT Blunt traumatic evisceration is extremely rare.We describe the case of a 20-month-old boy with stomach and small and large intestine evisceration after blunt trauma. Immediate laparotomy and surgical repair were performed.There was no injury, other than a small hole in the mesentery. The bowels were drained into the abdominal cavity, and the skin was closed. The patient recovered well. Keywords: Blunt trauma; emergent surgery; evisceration.

INTRODUCTION There are only a few cases of traumatic abdominal evisceration in literature. A more common injury is traumatic abdominal wall hernia. This rare condition could be caused by penetration or blunt trauma. Most of the presented cases concern adult patients. In our report, we describe a case of traumatic abdominal wall disruption with stomach and bowel evisceration in a 20-month-old boy.

CASE REPORT A 20-month-old boy was admitted to our Pediatric Emergency Department after he suffered a blunt abdominal wall injury. He was playing near the house when suddenly his older sister accidentally drove a car into him and pressed him into the concrete house wall. His parents immediately took him to their car and drove the child to the oncoming ambulance team. On examination at admission, he had signs of traumatic shock, but was conscious and scored 13 points on the Pediatric Glasgow Coma Scale. The vital signs were as follows: heart rate, 145 beats/min; blood pressure, 70/50 mmHg; respiratory rate, 30 breaths/min; and temperature, 36.0°C. The obvious injury was a protrusion of the greater part of the

stomach and small and large bowels, with the omentum outside the abdominal wall, and some skin abrasions and bilateral contusions on the parietal region of the head and on both arms (Fig. 1a). Abnormalities in laboratory tests included elevated aminotransferases (ALT 205 U/l and AST 351 U/l) and D-dimer (7877 ng/ml). Due to the mechanism of the trauma, after preliminary fluid resuscitation, computer tomography (CT) was performed (Fig. 1b). Besides evisceration, the CT scan demonstrated a first-grade left pulmonary contusion and small pneumothorax on the right side. The child was immediately taken to the operating theatre. We administered broad spectrum antibiotics (cefuroxime, metronidazole, and amikacin). Intraoperatively, we found an 8-cm transverse wound in the umbilical region and some skin abrasion in the right lumbar and iliac regions. Exploration of the abdominal cavity and retroperitoneum was done through the full-thickness anterior abdominal wall rupture. To the right of the umbilicus, the anterior rectus fascia, rectus abdominal muscle, and peritoneum were damaged. We investigated and closed a 5-cm defect in the mesentery. The stomach and the small and large intestines were not injured. We excluded other abdom-

Cite this article as: Komarowska MD, Matuszczak E, Debek W, Hermanowicz A. Traumatic evisceration after blunt trauma in a 20-month-old boy. Ulus Travma Acil Cerrahi Derg 2018;24:175–177 Address for correspondence: Adam Hermanowicz, M.D. Waszyngtona 17 15-27 Bialystok, Poland Tel: 608612288 E-mail: ahermanowicz@wp.pl Ulus Travma Acil Cerrahi Derg 2018;24(2):175–177 DOI: 10.5505/tjtes.2017.37807 Submitted: 10.11.2017 Accepted: 01.12.2017 Online: 12.02.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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(a)

(b)

(c)

Figure 1. (a) Preoperative image showing small and large bowel evisceration. (b) Trauma scan shows evisceration of the stomach (with nasogastric tube inside) and small and large intestines. (c) Postoperative results. Two weeks after surgery.

inal damages. The eviscerated organs were cleaned with a warm saline solution and returned into the abdomen. The abdominal cavity was drained, and then the abdominal wall was reconstructed in whole layers. The postoperative period was complicated with diarrhea caused by Morganella morganii and was successfully treated using cefotaxime, a third-generation cephalosporin. The patient recovered well; he was discharged from the hospital 16 days after the accident and remains stable under ambulatory control (Fig. 1c).

DISCUSSION The incidence of all abdominal wall injuries after blunt trauma is only 9%.[1] Traumatic evisceration after blunt trauma is extremely rare. In most cases, it is associated with a penetrating injury. There are only a few reports in literature with this type of injury. To our knowledge, only two pediatric cases have been reported in literature. One case was of a 6-yearold boy with small bowel evisceration who felt onto bicycle handlebars.[2] The other was a 7-year-old girl after a motor vehicle accident and with small and large intestine evisceration.[3] In both cases, a laparotomy and primary closing were performed. The postoperative period was uneventful. Table 1. Abdominal wall injury grading scale[1] Grade Description I

Subcutaneous tissue contusion

Abdominal wall muscle hematoma

III

Singular abdominal wall muscle disruption

Complete abdominal wall muscle disruption

Complete abdominal wall muscle disruption with

herniation of the abdominal contents

Complete abdominal wall disruption with evisceration

Based on the CT scan findings, complete abdominal wall disruption with evisceration was extreme (grade VI on the abdominal wall injury grading scale) (Table 1).[4] The causes of injury differ and could be due to high or low energy mechanisms (accidents, falls, handlebar injury). Evisceration is obvious and can occur in natural orifices (anus,[5] vagina, diaphragm) or in anatomically weak places (lateral rectus, lower abdomen, because of the absence of a posterior rectus sheath in this area, and inguinal canal).[6] Every time a patient is hemodynamically stable, other injuries must be excluded, and a trauma CT should be performed,[6] because the frequency of the associated intra-abdominal damage could be 30%.[7] Obviously, the procedure of choice is prompt laparotomy and surgical repair.[4] The best option is primary wall closure, but when there is a giant abdominal wall defect, we can temporarily cover the defect with absorbable or non-absorbable mesh, any other surgical material (even urine bags and intravenous fluid bags were described), or a vacuum pack dressing.[8] We should remember that a fascia closure with tension could lead to necrosis of the fascia or life-threatening abdominal compartment syndrome. Other early complications include wound infection and enteric fistula formation.[9] All patients should stay under long-term follow-up care to observe the functional and cosmetic outcomes.

Conclusion Traumatic abdominal evisceration after blunt injury is extremely rare. If the patient is clinically stable, associated injuries should be excluded before an operation using CT. Exploratory laparotomy is mandatory, and if possible, primary abdominal wall closure should be performed. Isolated evisceration is potentially life-threating, but has a very good prognosis, if adequate treatment is immediately provided. Conflict of interest: None declared.

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REFERENCES 1. Dennis RW, Marshall A, Deshmukh H, Bender JS, Kulvatunyou N, Lees JS, et al. Abdominal wall injuries occurring after blunt trauma: incidence and grading system. Am J Surg 2009;197:413–7. 2. Nguyen MH, Watson A, Wong E. A 6-year-old boy presenting with traumatic evisceration following a bicycle handle bar injury: a case report. Cases J 2009;2:6315. 3. van As AB, Rode H. Evisceration through multiple abdominal wall defects following blunt abdominal injury. Pediatr Emerg Care 2003;19:353–4. 4. McDaniel E, Stawicki SP, Bahner DP. Blunt traumatic abdominal wall disruption with evisceration. Int J Crit Illn Inj Sci 2011;1:164–6. 5. Gelas T, Combet S, Perinel J, Javouhey E, Mure PY. Transrectal

small bowel evisceration after abdominal crush injury. J Pediatr Surg 2012;47:e53–6. Choi HJ, Park KJ, Lee HY, Kim KH, Kim SH, Kim MC, et al. Traumatic abdominal wall hernia (TAWH): a case study highlighting surgical management. Yonsei Med J 2007;48:549–53. Ganchi PA, Orgill DP. Autopenetrating hernia: a novel form of traumatic abdominal wall hernia-case report and review of the literature. J Trauma 1996;41:1064–6. Jernigan TW, Fabian TC, Croce MA, Moore N, Pritchard FE, Minard G, et al. Staged management of giant abdominal wall defects: acute and long-term results. Ann Surg 2003;238:349–55. Bansal S, Jain S, Meena LN. Staged management of giant traumatic abdominal wall defect: A rare case report. Burns Trauma 2013;1:144–7.

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Yirmi aylık erkek çocukta künt travmadan sonra travmatik eviserasyon Dr. Marta Diana Komarowska, Dr. Ewa Matuszczak, Dr. Wojciech Debek, Dr. Adam Hermanowicz Bialystok Tıp Fakültesi, Çocuk Klinikleri Hastanesi, Çocuk Cerrahisi ve Üroloji Bölümü, Bialystok, Polonya

Künt travmaya bağlı eviserasyon son derece nadirdir. Yirmi aylık erkek çocukta künt travma sonrası mide, ince ve kalın bağırsakta eviserasyonu tanımladık. Acil laparotomi ve cerrahi onarım yapılmıştı. Mezenterde küçük bir delikten başka bir yaralanma yoktu. Bağırsaklar karın boşluğuna drene edildi ve cilt kapatıldı. Hasta iyileşti. Anahtar sözcükler: Acil cerrahi; eviserasyon; künt travma. Ulus Travma Acil Cerrahi Derg 2018;24(2):175–177

doi: 10.5505/tjtes.2017.37807

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CA S E REP OR T

Intestinal nonrotation and left-sided perforated appendicitis Ertan Zengin, M.D.,1 Arzu Turan, M.D.,1 Ahmet Salih Calapoğlu, M.D.,3 Ercan Nalbant, M.D.,2 Gürkan Altuntaş, M.D.2 1

Department of Radiology, Recep Tayyip Erdoğan University Faculty of Medicine, Rize-Turkey

Department of Emergency Medicine, Recep Tayyip Erdoğan University Faculty of Medicine, Rize-Turkey

³Department of Pediatric Surgery, Recep Tayyip Erdoğan University Faculty of Medicine, Rize-Turkey

ABSTRACT Acute appendicitis is the most common cause of acute abdominal pain, requiring emergency surgery. Approximately one third of cases have pain unexcepted location due to its various anatomical location. Acute appendicitis is a very rare cause of left lower quadrant pain; if it occurs, a few congenital anomalies should be considered such as Situs Inversus totalis and Midgut Malrotation (MM). MM is a rare congenital anomaly; it occurs due to error in process of rotation or fixation of intestines around the superior mesenteric vessels and it refers to nonrotation or incomplete rotation of intestines. Here we report a case who presented with left lower abdominal pain and was diagnosed with acute perforated appendicitis with intestinal nonrotation. Clinicians should be aware that intestinal nonrotation may be presented with left lower quadrant pain and complicated by acute appendicitis. Keywords: Acute appendicitis; intestinal nonrotation; left lower abdominal pain; midgut malrotation.

INTRODUCTION When the intestines move outside the abdominal cavity during the development of a fetus, it is called a physiological umbilical hernia. In about the 10th week of the prenatal period, once the abdomen enlarges, the small intestines can reenter the abdominal cavity after completing a complex developmental process outside the abdomen. Due to the complexity of this process, a number of digestive tract abnormalities can occur, such as midgut malrotation (MM), as a result of the rotation of the midgut loop. It is very important for radiologists and surgeons to be aware of the anatomical location of the intestines.

CASE REPORT A 13-year-old male patient was admitted to the emergency department of our hospital with acute abdominal pain and vomiting. He had no significant medical history, except for

abdominal pain that started 3 days previously. Patient explained that initially the pain began in the paraumblical area and later expanded through the left lower quadrant. Physical examination revealed left lower quadrant rebound tenderness with guarding. Routine vital signs of the patient (blood pressure, body temperature, and the pulse rate) were normal. Laboratory tests revealed leukocytosis (12.31 X 103/ UL), with 88% neutrophils, and C-reactive Protein was elevated (6.31 mg/dl). Other laboratory tests including blood sugar, electrolyte, and liver and kidney functions were normal. Because of the persistence of pain and rebound tenderness, abdominal ultrasonography (USG) examination was performed first. Abdominal USG showed dilated blind non-peristaltic intestinal loop, with fecalith on left lower quadrant, and minimal free fluid in the abdominal cavity. The liver and spleen were in their normal anatomical locations. These findings were consistent with acute appendicitis in left lower quadrant. Contrast-Enhanced Computed Tomogra-

Cite this article as: Zengin E, Turan A, Çapaloglu AS, Nalbant E, Altuntaş G. Intestinal nonrotation and left-sided perforated appendicitis. Ulus Travma Acil Cerrahi Derg 2018;24:178–180 Address for correspondence: Arzu Turan, M.D. Recep Tayyip Erdoğan Üniversitesi Tıp Fakültesi, Radyoloji Anabilim Dalı, Rize, Turkey Tel: +90 464 - 212 30 09 E-mail: rztrn72@gmail.com Ulus Travma Acil Cerrahi Derg 2018;24(2):178–180 DOI: 10.5505/tjtes.2017.58726 Submitted: 09.10.2017 Accepted: 10.11.2017 Online: 12.02.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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phy (CECT) was performed for preoperative management and to confirm the diagnosis. CT revealed that small bowel was on the right half of the abdomen and large bowel was on the left half of the abdomen. Considering these findings, secondary left-sided acute appendicitis (LSAA) is contemplated in MM (Fig. 1). In addition, left kidney was malrotated. Superior mesenteric vein (SMV) was on the left side of the superior mesenteric artery (SMA) (Fig. 2a). Moreover, type 1a hepatic vein and right portal vein variation as well as polysplenia were observed (Fig. 2b). Coronal reformatted CT images showed markedly dilated appendix (2 cm) and fecalith (2 cm). There were a few enlarged lymph nodes in the mesentery (Fig. 2c), and free air and focal mesenteric stranding were around the proximal part of appendix on axial CT images (Fig. 2d). Based on these findings, left sided acute perforated appendicitis was diagnosed and emergent

Figure 1. Axial contrast enhanced computed tomography, small bowel was on the right half of the abdomen and large bowel was on the left half of the abdomen.

(a)

(c)

surgery was performed. Surgical findings and pathology revealed perforated appendicitis. The patient had uneventful recovery and was discharged on the sixth postoperative day.

DISCUSSION The incidence of MM is 1:200â&#x20AC;&#x201C;500.[1] These numbers may not reflect the truth of undetected asymptomatic cases. The nonrotation rate is relatively higher. In the intrauterine period, defects in the 2nd and 3rd stages of midgut rotation were caused by abnormalities such as malrotation and reverse rotation. When the intestinal loop does not enter the abdominal cavity again, because of exomphalos, nonrotation occurs. In the case of nonrotation, while the small intestines are observed on the right side and the large intestines are observed on the left side of the midline.[2] Symptoms of MM are not well understood and it may remain asymptomatic.[3] If malrotation is symptomatic, it usually occurs during the first months of life and is diagnosed within 1 year in 75%â&#x20AC;&#x201C;85% of cases.[1] MM should be considered important by surgeons, because the location of the appendix can be different. Another condition is the presence of volvulus and intestinal obstruction. Therefore, the surgeon should be informed about the embryology, malrotation, and anatomy of the intestinal rotation.[4] Recently, the diagnosis of malrotation is increasing in asymptomatic patients. An urgent operation is necessary for patients with symptomatic MM, and treatment of asymptomatic incidental cases is still controversial. There is a lack of quality data to guide the management of these patients.

(b)

Midgut nonrotation is defined in the related extraintestinal anomalies. The related extraintestinal anomalies are leftsided SMV, polysplenia, short pancreas, absence of pancreatic uncinate process, SMA axis variation, prepancreatic portal vein and situs inversus are known to be associated with the extraintestinal anomalies.[5] Polysplenia, left-sided SMV, and type 1a hepatic vein right portal vein variation were observed in our case. Renal malrotation was also observed, which was not before previously decsribed in literature.

(d)

In conclusion, because of the majority of cases with MM/ Nonrotation are asymptomatic, studies involving multicentre data are needed to better evaluate the profile of this patient group.[6] In the differential diagnosis of left lower quadrant pain, there may be abnormal localized appendix problems; LSAA and nonrotation/MM anomalies related to LSAA should be considered. As a result, it is very important to be aware of the anatomical location of the intestines, due to errors the rotation of the midgut loop for surgeons and radiologists,

Figure 2. Contrast enhanced computed tomography. Superior mesenteric vein (white arrow) was on the left side of the superior mesenteric artery on axial CT image (a). Axial CT images showing polysplenia (white arrow) (b). Coronal reformatted CT images showing dilated appendix (2 cm) and 2 cm fecalith (white arrow) and a few enlarged lymph node in mesentery (black arrows) (c), Free air and focal mesenteric stranding were around the proximal part of appendix on axial CT image (white arrow) (d).

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Conflict of interest: None declared.

REFERENCES 1. Soffers JH, Hikspoors JP, Mekonen HK, Koehler SE, Lamers WH. The growth pattern of the human intestine and its mesentery. BMC Dev Biol 2015;15:31.

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Zengin et al. Intestinal nonrotation and left-sided perforated appendicitis 2. Mohan P, Ramamoorthy M, Venkataraman J. Clinical vistas: nonrotation of the intestine. CMAJ 2008;179:49–50. 3. Nehra D, Goldstein AM. Intestinal malrotation: varied clinical presentation from infancy through adulthood. Surgery 2011;149:386–93. 4. Appaji AC, Kulkarni R, Kadaba JS. Nonrotation of intestine: a case report. J Clin Diagn Res 2013;7:2575–6. 5. Yang B, Chen WH, Zhang XF, Luo ZR. Adult midgut malrotation: mul-

ti-detector computed tomography (MDCT) findings of 14 cases. Jpn J Radiol 2013;31:328–35. 6. Graziano K, Islam S, Dasgupta R, Lopez ME, Austin M, Chen LE, et al. Asymptomatic malrotation: Diagnosis and surgical management: An American Pediatric Surgical Association outcomes and evidence based practice committee systematic review. J Pediatr Surg 2015;50:1783– 90.

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İntestinal nonrotasyon ve sol alt kadranda perfore apandisit Dr. Ertan Zengin,1 Dr. Arzu Turan,1 Dr. Ahmet Salih Calapoğlu,3 Dr. Ercan Nalbant,2 Dr. Gürkan Altuntaş2 1 2 3

Recep Tayyip Erdoğan Üniversitesi Tıp Fakültesi, Radyoloji Anabilim Dalı, Rize Recep Tayyip Erdoğan Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, Rize Recep Tayyip Erdoğan Üniversitesi Tıp Fakültesi, Çocuk Cerrahisi Anabilim Dalı, Rize

Akut apandisit, acil cerrahi gerektiren en yaygın akut karın ağrısı nedenlerinden biridir. Apendiksin varyasyonel anatomik lokalizasyonlarından dolayı olguların yaklaşık üçte birinde farklı bir kadranda ağrı olabilir. Akut apandisit, sitüs inversus totalis (SIT), Midgut malrotasyon (MM) gibi birkaç doğuştan anomali dışında sol alt kadran ağrısında nadiren akla gelir. Midgut malrotasyon nadir bir doğuştan anomali olup superior mezenterik damarların etrafında rotasyon veya bağırsakların fiksasyonu hatasından kaynaklanır ve bağırsağın inkomplet rotasyonu veya nonrotasyonu anlamına gelir. Burada sol alt kadran ağrısı ile başvuran ve akut perfore apandisit tanısı alan intestinal nonrotasyonlu bir olgu sunuldu. Klinisyenler intestinal nonrotasyonun sol alt kadran ağrısı ile prezente olan akut apandisit ile komplike olabileceğini bilmeli, sol alt kadran lokalizasyonlu apandisitlerde intestinal nonrotasyon akla gelmelidir. Anahtar sözcükler: Akut apandisit; intestinal nonrotasyon; Midgut malotasyon; sol alt karın ağrısı. Ulus Travma Acil Cerrahi Derg 2018;24(2):178–180

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CAS E R EP O RT

Acute arterial occlusion due to vascular closure device: A report of two cases Süleyman Utku Çelik, M.D., Ömer Arda Çetinkaya, M.D., Can Konca, M.D., Mehmet Ali Koç, M.D., Elvan Onur Kırımker, M.D., Akın Fırat Kocaay, M.D., İskender Alaçayır, M.D. Department of General Surgery, Ankara University Faculty of Medicine, Ankara-Turkey

ABSTRACT Vascular closure devices are frequently used after percutaneous arterial interventions to achieve hemostasis at the puncture site and facilitate early ambulation. Occasionally, complications have been reported with closure devices, such as hematoma, infection, arteriovenous fistula, pseudoaneurysm, and ischemia. This is a report of 2 cases of severe, acute-onset arterial occlusion and critical limb ischemia, one of which occurred in the upper limb following the use of a vascular closure device, and the required surgical treatment. Keywords: Arterial catheterization; arterial occlusive disease; complication; vascular closure devices.

INTRODUCTION

CASE REPORT

Vascular closure devices (VCDs) were specifically designed to provide faster hemostasis following arteriotomy. One of these devices, the Angio-Seal vascular closure device (St. Jude Medical, Inc., St. Paul, MN, USA), consists of a polymer anchor, a small bovine collagen sponge, and a traction suture; all components of the device are absorbed within 60 to 90 days. [1,2] The device seals and compresses the arterial wall between the anchor and the collagen sponge.[3]

Case 1 – A 55-year-old woman experienced severe pain, pulselessness, and pallor in the right leg immediately after digital subtraction angiography to assess a coiled middle cerebral artery bifurcation aneurysm via femoral access that was closed with an Angio-Seal vascular closure device (St. Jude Medical, Inc., St. Paul, MN, USA). An hour after the procedure, there were no audible Doppler signals at the right ankle and aorto-ilio-femoral angiography demonstrated a thrombus in the distal right popliteal artery (Fig. 1a,b). After informed consent was obtained, the entire closure device, collagen sponge, and suture tail were located at the puncture site anterior to the common femoral artery and extracted from the lumen. A thrombectomy was performed (Fig. 1c), the patient was monitored in the intensive care unit, and later discharged from the hospital without any complication. At 1-month follow-up, the patient had no claudication or complaints.

VCDs have many advantages, such as immediate hemostasis, and early ambulation and hospital discharge.[1,4] However, in terms of minor or major vascular complications, it is still controversial as to whether VCDs are more efficient than manual compression (MC).[4,5] VCD-related complications have been reported, including access site infection and acute arterial occlusion that may require extra-surgical intervention.[2,3] Herein, 2 cases of limb-threatening ischemic complications following the use of Angio-Seal vascular closure device are reported.

Case 2 – A 60-year-old man with a history of aorto-bifemoral bypass graft and endovascular stenting for superior mesenteric

Cite this article as: Çelik SU, Çetinkaya ÖA, Konca C, Koç MA, Kırımker EO, Kocaay AF, et al. Acute arterial occlusion due to vascular closure device: A report of two cases. Ulus Travma Acil Cerrahi Derg 2018;24:181–183 Address for correspondence: Süleyman Utku Çelik, M.D. Ankara Üniversitesi Tıp Fakültesi, İbn-i Sina Hastanesi, Sıhhiye, 06100 Ankara, Turkey Tel: +90 312 - 508 33 33 E-mail: s.utkucelik@hotmail.com Ulus Travma Acil Cerrahi Derg 2018;24(2):181–183 DOI: 10.5505/tjtes.2017.10705 Submitted: 18.11.2017 Accepted: 21.12.2017 Online: 23.02.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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(a)

(b)

(c)

Figure 1. (a) Femoral angiography revealing stenosis in the right common femoral artery caused by the vascular closure device (arrow). (b) Angiogram illustrating an occluded right popliteal artery (arrow). (c) Final angiography demonstrating patency of the popliteal artery after balloon embolectomy.

artery (SMA) occlusion was admitted with severe abdominal pain after eating. The patient underwent digital subtraction angiography to assess the SMA via a left axillary artery approach. An Angio-Seal vascular closure device was used for arterial closure. After the procedure, the patient developed sudden severe pain, pulselessness, pallor, and coolness in the left arm. Immediate arterial duplex scanning revealed an occlusion of the left axillary artery. After obtaining informed consent, an embolectomy was performed and the closure device was removed from the distal brachial artery with the collagen sponge and suture tail (Fig. 2). The patient was discharged on postoperative day 2 without symptoms of claudication.

DISCUSSION VCDs were developed in the early 1990s as a faster means to close arterial puncture areas than MC.[1,2,5,6] Though recent meta-analyses have failed to demonstrate the clear superiority of VCDs to MC, their use in clinical practice is widely accepted, despite an increase in device-related complications.[4,5,7]

Figure 2. The successfully removed Angio-Seal vascular closure device, which consists of a polymer anchor (thick arrow), a traction suture (thin arrow), and a small collagen sponge (star), and the thrombus material (arrowhead).

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MC requires an educated medical staff, manpower, prolonged bed rest, and long-time pressure on the puncture area.[1â&#x20AC;&#x201C;3,7] To overcome these disadvantages of compression, an alternative was found: closure devices. VCDs offer many advantages, such as immediate hemostasis, successful use in patients who are highly anticoagulated, and early ambulation and hospital discharge.[1,4] On the other hand, these devices may lead to some complications, including hematoma, acute limb ischemia, and infection, which occur in up to 2.5% of patients. [5,8] Nikolsky et al.[5] described in a meta-analysis that the risk of major or minor vascular complications was similar to that of MC. In another study of 7376 patients in whom the Angio-Seal VCD was applied, device-related symptomatic lower limb ischemia was found in 14 cases (0.2%).[9] The cause of these iatrogenic complications was not clear, but they may have been related to malpositioning of the device, intimal dissection, or significant atherosclerosis at the puncture site.[2,3] The risk factors for limb-threatening ischemic complications following the use of a vascular closure device are diabetes, obesity, peripheral vascular disease with arterial wall calcification, and severe ischemic heart disease.[8,11] Complication rates can be higher in women than in men due to the smaller arteries found in women.[11] There is no consensus on the treatment strategy for patients with ischemic complications. Device-related complications can be treated with interventional therapy, including balloon angioplasty, stent grafting, extraction with a snare catheter, and arterectomy. Repetitive surgical approaches may be unavoidable if an acute ischemic complication is present.[10] In Case 1, the device-related complication seems to have been related to distal embolization originating around the polymer anchor in a stenotic length of artery with or without an arterial wall lesion (Fig. 1a). In Case 2, which occurred in the upper limb, intra-arterial deployment of the anchor led Ulus Travma Acil Cerrahi Derg, March 2018, Vol. 24, No. 2

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to displacement of the collagen plug in the small arterial lumen. When treating device-related complications, the special structure of the VCD should be kept in mind and therapeutic options must be reviewed.

Conclusion The use of closure devices to provide immediate hemostasis in patients undergoing interventional procedures may enhance patient comfort and facilitate early ambulation; nevertheless, they can also result in significant life and limb-threatening ischemic complications. Thus, cardiologists, interventional radiologists, and vascular surgeons should be aware of rare, but serious, complications. The use of routine duplex scanning after the interventional procedure may be beneficial, especially in patients with comorbidities, such as diabetes, obesity, peripheral vascular disease, and severe ischemic heart disease. Moreover, careful assessment of the arterial wall structure before the use of VCDs may also play a pivotal role in avoiding complications. Finally, and most importantly, close observation of patients following the use of a VCD is important and highly recommended in order not to overlook any acute complications, especially limb ischemia. Conflict of interest: None declared.

REFERENCES 1. Modi S, Gadvi R, Babu S. Initial experience with Angioseal™: Safety and efficacy of the endovascular closure device. Indian J Radiol Imaging

2013;23:134–8. 2. Mattens E. Acute claudication caused by Angio-Seal closure devices: a report of four cases. Acta Chir Belg 2008;108:247–50. 3. van der Steeg HJ, Berger P, Krasznai AG, Pietura R, Schultze Kool LJ, van der Vliet JA. Acute arterial occlusion after deployment of the AngioSeal closure device: is it as uncommon as we think? Eur J Vasc Endovasc Surg 2009;38:715–7. 4. Robertson L, Andras A, Colgan F, Jackson R. Vascular closure devices for femoral arterial puncture site haemostasis. Cochrane Database Syst Rev 2016;3:CD009541. 5. Nikolsky E, Mehran R, Halkin A, Aymong ED, Mintz GS, Lasic Z, et al. Vascular complications associated with arteriotomy closure devices in patients undergoing percutaneous coronary procedures: a meta-analysis. J Am Coll Cardiol 2004;44:1200–9. 6. Cianci C, Kowal RC, Feghali G, Hohmann S, Stoler RC, Choi JW. Critical lower limb ischemia from an embolized Angio-Seal closure device. Proc (Bayl Univ Med Cent) 2013;26:398–400. 7. Koreny M, Riedmüller E, Nikfardjam M, Siostrzonek P, Müllner M. Arterial puncture closing devices compared with standard manual compression after cardiac catheterization: systematic review and meta-analysis. JAMA 2004;291:350–7. 8. Siani A, Accrocca F, Gabrielli R, Antonelli R, Giordano AG, Ambrogi C, et al. Management of acute lower limb ischemia associated with the Angio-Seal arterial puncture closing device. Interact Cardiovasc Thorac Surg 2011;12:400–3. 9. Thalhammer C, Aschwanden M, Jeanneret C, Labs KH, Jäger KA. Symptomatic vascular complications after vascular closure device use following diagnostic and interventional catheterisation. Vasa 2004;33:78–81. 10. Bito Y, Sakaki M, Inoue K, Yoshioka Y, Mizoguchi H. Surgical treatment of complications associated with the angio-seal vascular closure device: report of three cases. Ann Vasc Dis 2010;3:144–7. 11. Dregelid E, Jensen G, Daryapeyma A. Complications associated with the Angio-Seal arterial puncture closing device: intra-arterial deployment and occlusion by dissected plaque. J Vasc Surg 2006;44:1357–9.

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Vasküler kapatma cihazına bağlı gelişen akut arter tıkanıklığı: İki olgu sunumu Dr. Süleyman Utku Çelik, Dr. Ömer Arda Çetinkaya, Dr. Can Konca, Dr. Mehmet Ali Koç, Dr. Elvan Onur Kırımker, Dr. Akın Fırat Kocaay, Dr. İskender Alaçayır Ankara Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Ankara

Vasküler kapatma cihazı, endovasküler girişimsel işlemler sonrasında hemostazı sağlamak amacıyla sıklıkla kullanılmaktadır. Bu cihazlar, ponksiyon yerinde hızlı bir hemostaz sağlamasının yanı sıra, hastanın erken mobilizasyonuna ve kliniğin iş yükünün azalmasına da olanak sağlamaktadır. Ancak nadir de olsa işleme bağlı komplikasyonlar bildirilmiştir. Bu yazıda, vasküler kapatma cihazı kullanımı sonrasında ani başlayan ve cerrahi girişim gerektiren iki akut arter tıkanıklığı olgusu paylaşıldı. Anahtar sözcükler: Arteryel kateterizasyon; arteriyel oklüzif hastalıklar; komplikasyon; vasküler kapatma cihazları. Ulus Travma Acil Cerrahi Derg 2018;24(2):181-183

doi: 10.5505/tjtes.2017.10705

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