Travma 2018 / 3

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

ISSN 1306 - 696X

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

Özbal Güneş S, et al. p. 239

Volume 24 | Number 3 | May 2018

Volume 24 | Number 3 | May 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): May (Mayıs) 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 3 May - Mayıs 2018

Contents - İçindekiler Deneysel Çalışma - Experimental Experimental Studies - DeneyselStudy Çalışma 185-190 The protective effect of Montelukast against skeletal muscle ischemia reperfusion injury: an experimental rat model

İskelet kasında iskemi-reperfüzyon yaralanmasına karşı Montelukastın koruyucu etkisi: Sıçanlarda deneysel çalışma Bilgiç Mİ, Altun G, Çakıcı H, Gideroğlu K, Saka G 191-198 The microRNA expression profile in rat lung tissue early after burn injury

Sıçan akciğer dokusunda yanık yaralanmasından sonra erken dönemde mikro RNA ekspresyon profili Zhang D, Chang Y, Han S, Yang L, Hu Q, Yu Y, Liu L, Chai

Original Articles - Orijinal Çalışma 199-206 Prediction of mortality in pediatric traumatic brain injury: Implementations from a tertiary pediatric intensive care facility

Çocukluk çağı kafa travması olgularında mortaliteye etki eden faktörler: Üçüncü basamak çocuk yoğun bakım ünitesi uygulamaları Ongun EA, Dursun O 207-210 Predictive value of preoperative neutrophil-to-lymphocyte ratio while detecting bowel resection in hernia with intestinal incarceration

Nötrofil-lenfosit oranı inkarsere hernisi olan hastalarda ameliyat öncesi dönemde bağırsak nekrozunu öngörmede bir belirteç olabilir mi?

Köksal H, Ateş D, Nazik EE, Küçükosmanoğlu İ, Doğan SM, Doğru O 211-215 Role of circulating microRNAs in acute appendicitis

Akut apandisitte dolaşımdaki mikroRNA’lar Seyhan AU, Şener EF, Bol O, Taheri S, Topaloglu T, Tufan E, Tahtasakal R, Ekici Günay N, Karabulut H, Günay N 216-223 Examination of morbidity and mortality of cases according to intra-vehicle position and accident mechanism

Araç içi pozisyon ve kaza mekanizmasına göre olguların morbidite ve mortalitesinin incelenmesi Meral O, Aktaş EÖ, Ersel M 224-233 Targeted cardiopulmonary resuscitation training focused on the family members of high-risk patients at a regional medical center: A comparison between family members of high-risk and no-risk patients

Yerel bir tıp merkezinde risk düzeyi yüksek olan hastaların aile üyelerine yönelik kardiyopulmoner resüsitasyon (kalp masajı) eğitimi: Risk düzeyi yüksek hastalar ile risk taşımayan hastalarda aile üyelerinin karşılaştırılması Han KS, Lee JS, Kim SJ, Lee SW 234-238 Management of traumatic arteriovenous fistulas: A tertiary academic center experience

Travma sonrası gelişen arteriyovenöz fistüllerin tedavisi: Üçüncü basamak akademik merkez deneyimi Şahin M, Yücel C, Kanber EM, İlal Mert FT, Bıçakhan B

Ulus Travma Acil Cerrahi Derg, May 2018, Vol. 24, No. 3

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

Number - Sayı 3 May - Mayıs 2018

Contents - İçindekiler

239-243 Evaluation of pterygoid plate fractures unrelated to Le Fort fractures using maxillofacial CT

Bilgisayarlı tomografide Le Fort dışı pterygoid plate kırıkları Özbal Güneş S, Aktürk Y, Güldoğan ES 244-248 Determination of trace element levels in patients with burst fractures

Burst kırığı olan hastalarda bazı eser element seviyelerinin incelenmesi Gezh SAS, Aycan A, Demir H, Bozlına C 249-254 Cardiac findings of sternal fractures due to thoracic trauma: A five-year retrospective study

Toraks travmasına bağlı sternal kırıkların kardiyak bulguları: Beş yıllık geriye dönük bir çalışma Uluşan A, Karakurt Ö 255-262 Volar locking plate versus K-wire-supported external fixation in the treatment of AO/ASIF type C distal radius fractures: a comparison of functional and radiological outcomes

AO/ASIF tip C distal radius kırıklarının tedavisinde volar kilitli plak mı? K-teli destekli eksternal fiksatör mü?

Fonksiyonel ve radyolojik sonuçların karşılaştırılması Duramaz A, Bilgili MG, Karaali E, Bayram B, Ziroğlu N, Kural C 263-267 Application of hybrid external fixation by the “joystick method” in bicondylar tibial plateau fractures: Technical note

Tibia plato kırıklarında “joystik yöntemi” ile hibrid eksternal fiksatör uygulaması: Teknik not Kuyucu E, Kara A, Say F, Erdil M, Bülbül M, Gülenç B 268-273 Intramedullary nail with integrated cephalocervical screws in the intertrochanteric fractures treatment: Position of screws in fracture stability

İntertrokanterik femur kırıklarının tedavisinde entegre sefaloservikal vidalı intramedüller çivi: Kırık stabilitesine vida pozisyonunun etkisi Kaynak G, Ünlü MC, Güven MF, Erdal OA, Tok O, Botanlıoğlu H, Aydıngöz Ö 274-277 The comparison of arthroscopic acromioplasty with and without acromioclavicular coplaning

Akromioklaviküler eşplanlama yapılan ve yapılmayan artroskopik akromioplastilerin karşılaştırılması Aydın N, Kocaoğlu B, Sarıoğlu E, Tok O, Güven O

Case Report - Olgu Sunumu 278-280 Rare case of bilateral incarcerated obturator hernia: A case report

Nadir görülen inkarsere iki taraflı obturator herni: Olgu sunumu Hatipoğlu E, Dal F, Umman V, Demiryas S, Demirkıran O, Ertem M, Ergüney S, Pekmezci S

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EXPERIMENTAL STUDY

The protective effect of Montelukast against skeletal muscle ischemia reperfusion injury: An experimental rat model Mehmet İlker Bilgiç, M.D.,1 Güray Altun, M.D.,2 Hüsamettin Çakıcı, M.D.,3 Kaan Gideroğlu, M.D.,4 Gürsel Saka, M.D.2 1

Department of Plastic, Reconstructive and Aesthetic Surgery, Çağıner Hospital, İstanbul-Turkey

2

Department of Orthopedics and Traumatology, Ümraniye Training and Research Hospital, İstanbul-Turkey

3

Department of Orthopedics and Traumatology, Abant Bolu İzzet Baysal University Faculty of Medicine, Bolu-Turkey

Department of Plastic, Reconstructive and Aesthetic Surgery, İstanbul Kartal Dr. Lütfi Kırdar Training and Research Hospital, İstanbul-Turkey

4

ABSTRACT BACKGROUND: Montelukast is a selective leukotriene D-4 receptor antagonist, which specifically and reversibly inhibits cysteinyl leukotriene-1 receptor. The aim of this study was to investigate the protective effect of Montelukast on skeletal muscle reperfusion injury created as acute ischemia-reperfusion (IR) injury in Wistar-albino rats.

METHODS: The study comprised 16 male Wistar-albino rats. The rats were randomly separated into two groups as control (IR) and treatment (IR+Montelukast). Ischemia was obtained using a femoral artery clamp. After reperfusion following a 2-hour ischemia, muscle samples were taken for biochemical and histopathological analyses.

RESULTS: Malondialdehyde levels were determined to be at statistically higher levels in the control compared with that in the Montelukast group (p=0.002, p<0.01). The superoxide dismutase levels were determined to be at statistically higher level in the Montelukast group compared with that in the control group (p=0.001, p<0.01). In the histopathological examination of the ischemic muscles, edema, polymorinfiltration and erythrocyte extravasation levels were found to be statistically significant higher in the control group than in the Montelukast group. Edema, polymorphonuclear infiltration, and erythrocyte extravasation levels were observed to be significantly reduced in the treatment group compared with that in the control.

CONCLUSION: In this model of skeletal muscle acute IR injury, the protective effect of Montelukast against skeletal muscle reperfusion injury was emphasized. We concluded that Montelukast could accelerate functional recovery in the extremity by limiting the local and systemic complications caused by reperfusion in cases such as extremity trauma with vascular injuries and extremity surgery with prolonged tourniquet application. However, further experimental and clinical studies are required to confirm this effect.

Keywords: Ischemia; Montelukast; reperfusion; skeletal muscle.

INTRODUCTION Ischemia-reperfusion (IR) is a iatrogenically created process by the use of a tourniquet, and is often used in extremity surgery. When tissue is exposed to ischemia, a series of chemical events occur in the basal metabolism, progressing as far as functional impairment and necrosis. To be able to provide the appropriate intracellular energy and for the removal of toxic metabolites, the blood circulation of ischemic tissues is crucial.

However, this phenomenon of reperfusion results in a series of metabolic effects paradoxically leading to further damage in the tissue.[1–4] With the expression of several vasoactive mediators, cytokines, endothelin and free toxic oxygen radicals in the reperfused tissue, leukocyte activation, endothelial dysfunction and tissue edema occur. Although several mediators associated with IR have been determined to play a role in local tissue and distant organ dysfunction, leukotrienes (LT) and free toxic oxygen radicals are known to play a crucial role in this process.[5]

Cite this article as: Bilgiç Mİ, Altun G, Çakıcı H, Gideroğlu K, Saka G. The protective effect of Montelukast against skeletal muscle ischemia reperfusion injury: an experimental rat model. Ulus Travma Acil Cerrahi Derg 2018;24:185–190.

Address for correspondence: Mehmet İlker Bilgiç, M.D. Özel Çağıner Hastanesi, Plastik ve Rekonstrüktif Cerrahi, Yıldız Mh., Mirim Çelebi Sk., No: 1, Kadıköy, İstanbul, Turkey Tel: +90 216 - 428 48 00 E-mail: ilkerbilg@yahoo.com Ulus Travma Acil Cerrahi Derg 2018;24(3):185-190 DOI: 10.5505/tjtes.2017.22208 Submitted: 22.10.2016 Accepted: 10.11.2017 Online: 08.05.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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Montelukast has been shown to be a strong, selective antagonist of cysteinyl leukotriene receptor 1 (CystLT1) and an antioxidant that is used as an anti-asthmatic drug in a clinical setting. Montelukast prevents leukocyte adhesion and degranulation by inhibiting LTD4 on cysteinyl leukotriene receptors.

It has been reported that it protects the kidney and bladder from ischemia/reperfusion damage, and that this molecule is beneficial in ethanol-induced mucosa injury, multi-organ failure due to sepsis, colitis, and testis torsion.[5–9] In addition, the use of various pharmacological and immunological agents has been suggested to decrease or avoid reperfusion injury.

However, there has been no appropriately designed study regarding the effect of Montelukast on tourniquet use models.

The aim of this experimental study was to investigate the protective effect of Montelukast on skeletal muscle reperfusion injury in a model of lower extremity skeletal muscle acute IR injury. Therefore, the muscle tissue of rats which were administered Montelukast following IR was compared with that of a control group by measurements taken of malondialdehyde (MDA), which is an indicator of oxidative stress, superoxide dismutase (SOD) levels in the tissue, and histopathological examination.

MATERIALS AND METHODS Approval for this experimental study was granted by the Local Ethics Committee. A total of 16 male Wistar-albino rats were used, each weighing 200–250 g. Before the experiment, the rats were kept in wire cages in a 12-hour light–dark cycle at a temperature of 24°C–26°C and humidity of 50%–60%.

At 12 hours before the experiment, nutrition, but not water, was stopped. The care of the rats was applied in accordance with the Laboratory Animals Care and Use guidelines pub-

(a)

(b)

lished by the National Health Institute and prepared by the Laboratory Animal Resource Institute, and the Experimental Animal Care Principles defined by the Medical Research National Association. The muscle tissue samples taken were stored in 10% formaldehyde for histopathological examination and at –80°C for biochemical examination.

Study Protocol All the rats used in the study were acclimatized to the same laboratory environment for one week before the study. They were given standard laboratory food and water, and food but not water was terminated at 12 hours before the operations.

Anesthesia was administered to all the rats as an intraperitoneal mixture of 30 mg/kg ketamine HCL (Ketalar flacon, Pfizer, Istanbul, Turkey) and 25 mg/kg Chlorpromazine (Largactil ampoule, Eczacıbaşı, Istanbul, Turkey) and was maintained as required without changing the dosage table. Oxygen support was provided to all the rats with a mask at 3 L/min and heart rate was monitored and recorded at 30-min intervals.

Under a heating lamp, the rats were placed in a supine position and both lower extremities were shaved from below the abdomen. The rats were randomly separated into two groups of eight animals, defined as the control (C) and the treatment (T) groups. The animals in the control group were intraperitoneally injected with 1 mL saline 30 mins before the intervention. At the same time, the subjects in the treatment group were intraperitoneally injected 10 mg/kg Montelukast and the all doses were completed to 1 mL with saline solution. At 30 mins after the injection, the skin of the left lower extremity of each rat was cleaned with Betadine (10% povidone iodine solution). The inguinal canal was opened with a 2-cm incision exactly over the inguinal ligament (Fig. 1a).

(c)

Figure 1. (a) Inguinal canal exploration and exposing of femoral artery and vein. (b) Clamping of femoral vessels (Vascu–Statt® mini clamp Scanlan Surgical Equipments, Minnesota, USA). (c) Skin completely stripped off from the extremity.

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Bilgiç et al. The protective effect of Montelukast against skeletal muscle ischemia reperfusion injury

Table 1. Light microscope results Group

Edema

PMNL infiltration

Erythrocyte extravasation

Necrosis

Ischemia-reperfusion (control) (n=8)

2,2,3,2,2,3,2,2

3,2,1,2,2,2,2,2

2,2,3,3,3,2,2,3

0,0,0,0,0,0,0,0

Treatment (n=8)

1,1,2,1,1,2,1,2

1,2,1,1,2,1,1,1

2,2,1,1,1,2,1,2

0,0,0,0,0,0,0,0

PMNL: Polymorphonuclear leukocytes.

The femoral artery and vein were explored. The extremity was emptied by wrapping an Esmarch bandage around the extremity from distal to proximal. By placing a clamp on the femoral artery and vein, circulation was stopped and ischemia was achieved (Fig. 1b). After perfusion following a 2-hour period of ischemia, the left lower extremity was disarticulated from the acetabulum in all rats. The skin was completely stripped off (Fig. 1c). The muscle tissues of the lower extremities were separated into a total of eight groups for biochemical and histopathological examination, as paired samples from the control and treatment groups and the samples were sent under appropriate conditions for evaluation. At the end of the experiment, all the animals were sacrificed by high-dose anesthesia.

Histopathological Analyses The muscle samples of the groups were fixed in 10% formaldehyde then passed through a series of graded alcohol and then paraffin blocks were prepared. Slices 5 µm in thickness were cut and examined by staining with hematoxylin eosin.

For each subject, a series of five tissue slices were taken and these were evaluated and scored for edema, PMNL cell infiltration and erythrocyte extravasation. Evaluation was made at ×40 microscope magnification and scoring was accepted as 0 = normal, 1 = mild effect, 2 = moderate effect, and 3 = severe effect (Table 1).[10]

Biochemical Analyses Malondialdehyde Level Measurement MDA measurement is the most frequently used test for determining the level of lipid peroxidation and oxidant damage. Each tissue sample was prepared for homogenization by adding a 1/10 1.15 M KCL buffer. The tissue protein content was determined using the Biuret method; 0.2 mL of 8.1% sodium dodecyl sulfate, 1.5 mL of 3.5 pH 20% acetic acid, and 1.5 mL 0.8% thiobarbituric acid (TBA) solution were added to 0.4 mL homogenate, mixed and heated to 95°C for 60 mins.

After cooling, 5 mL n-Butanol/pyridine (15 l; v/v) was added.

The absorbency of the top layer at 532 nm was measured by centrifugation at 4000 rpm for 10 mins. Using standard 1,1,3,3-tetraethoxypropane, the calculated MDA levels were stated as nmol/g protein (Table 2).

Determining Tissue SOD Activity SOD activity was measured with the technique on the basis of the inhibition by SOD of the reduction of nitroblue tetraUlus Travma Acil Cerrahi Derg, May 2018, Vol. 24, No. 3

Table 2. Tissue malondialdehyde levels Malondialdehyde level (nmol/g protein) Ischaemia-reperfusion (Control Group)

Ischaemia-reperfusion+Montelukast (Treatment Group)

37.96

26.10

46.58

28.97

44.04

37.96

47.02

26.99

48.48

30.25

46.95

32.24

48.02

44.40

48.54

31.02

zolium of superoxide formed in the reaction of photoreduced riboflavin and oxygen.

The tissue samples were homogenized with a 7.8pH buffer of 1/10 0.05 M KPO4. The tissue protein content was measured with the Biuret method. 0.2 mL of 0.1 M EDTA containing 1.5 mg NaCN of 100 mL, and 0.1 mL of 1.5 mM NBT were added to 0.05 mL homogenate. The total volume of the tube was completed to 3 mL with phosphate buffer and the tubes were heated to 20°C–22°C. To all the tubes, 0.5 mL 0.12 mM riboflavin was added and they were then placed in an illumination box, 60×15×20 cm in size, with 15 W uniform fluorescent lighting. After waiting for 15 mins, using the tube where no homogenate was placed as a blind, the absorbency at 532 nm was measured. By tracing the given SOD standard inhibition on the graph, the SOD activity of the samples was determined. By defining one SOD unit as the amount of enzyme providing half the maximum inhibition of NBT reduction, the enzyme activity in tissues was stated as U/mg protein (Table 3).

Statistical Analyses In the evaluation of the findings obtained in the study, all statistical analyses were made using IBM SPSS Statistics 22 software (IBM, SPSS, TR). The conformity of the data of the parameters to normal distribution was evaluated using the Shapiro-Wilks test. In the comparison between two groups of parameters not showing normal distribution, the Mann– Whitney U test was used. Values were stated as mean ± 187

Bilgiç et al. The protective effect of Montelukast against skeletal muscle ischemia reperfusion injury

Table 3. Tissue superoxide dismutase activity Superoxide dismutase activity (U/mg protein) Ischaemia-reperfusion (Control Group)

10.80

Ischaemia-reperfusion+Montelukast (Treatment Group)

29.20

17.70

19.50

15.60

17.50

11.70

26.70

11.00

20.10

12.20

18.10

14.70

14.20

11.00

20.10

ident edema and erythrocyte extravasation were observed across the width of the muscle section in this group. No necrosis or nuclear centralization was determined in the muscle cells. In the treatment group, edema, PMNL infiltration and erythrocyte extravasation levels were observed to be reduced to a statistically significant level compared with that of the control group.

DISCUSSION When blood circulation to the tissues is interrupted as a result of tourniquet application in extremity surgery, a series of biochemical changes occur starting with impaired cell function of that tissue and progressing as far as cell death and finally damage occurs.

standard deviation (SD). A value of p<0.05 was accepted as statistically significant.

RESULTS The MDA levels were determined to be at a statistically higher level in the control group compared with the Montelukast group (p=0.002, p<0.01). The SOD levels were determined to be at a statistically higher level in the Montelukast group compared with the control group (p=0.001, p<0.01) (Table 4). Edema, PMNL infiltration and erythrocyte extravasation levels were found to be statistically significant higher in the control group than in the treatment group (Table 5).

In the control group, increased connective tissue cells and neutrophils were determined between the muscle fibers. Ev-

Blood circulation insufficiency may occur effect of tourniquet application during prolonged extremity surgery and this causes a series of biochemical reactions in the extremity tissue which may cause cell damage and more.

Neuromuscular damage associated wih tourniquet application, as much as it is related to pressure and tissue deformation, is also closely related to reperfusion damage following ischemia. Skeletal muscle is more resistant to ischemia than other tissues. In orthopedic surgery, prolonged duration of tourniquet application, extremity trauma with artery injuries, reconstructive microsurgery, and acute compartment syndrome are frequently encountered ischemic events.[11,12] The basic aim in ischemic events is to prevent muscle necrosis by providing early reperfusion. In addition, reperfusion itself, known as “reperfusion injury,” leads to a pathophysiological condition.[11] Tissue damage following ischemia mostly occurs

Table 4. Evaluation of the malondialdehyde and superoxide dismutase levels of the groups

Control

Montelukast p

Mean±SD (median)

Mean±SD (median)

Malondialdehyde (nmol/g protein)

45.95±3.53 (46.99)

32.24±6.12 (30.64)

0.002**

Superoxide dismutase (nmol/mg protein)

13.09±2.59 (11.95)

20.68±4.92 (19.8)

0.001**

Mann-Whitney U Test. **p<0.01. SD: Standard deviation.

Table 5. Evaluation of edema and superoxide dismutase levels of the groups

Ischemia-reperfusion (control) Min–Max Mean±SD Median

Treatment

p

Min–Max Mean±SD Median

Edema

2–3 2.25±0.46 2

1–2 1.38±0.52 1 0.007**

PMNL infiltration

1–3

1–2

2±0.53

2

Erythrocyte extravasation 2–3 2.5±0.53 2.5

1.25±0.46

1

0.013*

1–2 1.5±0.53 1.5 0.006**

Mann-Whitney U Test. *p<0.05; **p<0.01. PMNL: Polymorphonuclear leukocytes; SD: Standard deviation.

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during reperfusion.[13] Reperfusion damage occurs through a complex mechanism of free oxygen radicals, endothelial factors, and neutrophils together. It is believed that the primary trigger of the damage is damage to the endothelial cells.[14–16] Numerous substances and biochemical reactions have been determined to directly or indirectly contribute to reperfusion damage. As a result of the interaction between these substances, free oxygen radicals emerge, which are partial mediators of reperfusion in IR damage.

Although the results obtained in this study have shown a protective effect of Montelukast on skeletal muscle, there were some limitations. These include the relatively small number of subjects, different biochemical parameters that have not been measured, such as lactate dehydrogenase, creatine kinase, and the apoptosis of the post-reperfusion tissues, no assessment being made of the effects of the application of Montelukast at different doses and periods of ischemia.

There have been studies in literature on the use of several agent substances to prevent the formation of tissue damage following reperfusion.[6,15,17,18] One of these substances is Montelukast, a strong and specific LTD4 receptor antagonist, which was used in this study. Montelukast was used in this experimental study as it was appropriate to the aims of the study, successful results have been obtained in the experiments of IR in different tissues and it is currently safely used in asthma treatment. A specific aspect of this study was that to the best of our knowledge there has not been any study published in literature associated with the effect of Montelukast on IR in a skeletal muscle model. Thus, as one of the indicators of free radical damage formed in the IR process, the levels were measured of SOD as an enzymatic antioxidant, and malondialdehyde (MDA ). The levels of SOD and MDA are the biochemical indicators of free radical damage formed in the IR process.MDA is a product of cell membrane lipid peroxidation and the measurement of this indicates the amount of free radical formation.[19] SOD is an enzymatic antioxidant which catalyses the reaction changing superoxide to hydrogen peroxide and molecular oxygen and is an endogenous metalloenzyme protecting tissues against free radicals, especially O2. This reaction is known as “the first defense against oxidative stress,” because superoxide is a strong initiator of the radical chain reactions. The O2 levels in the cellular compartment are kept under control through this system.[20] In the present experimental study, when the MDA levels were examined as an indicator of skeletal muscle reperfusion damage, the MDA levels of the control group were found to be statistically significantly higher than those of the Montelukast group (p=0.002, p<0.01) (Table 1). This shows that Montelukast has an effect of reducing free radicals (Table 3).

In the control group of this study, edema, PMNL infiltration, and erythrocyte extravasation levels were determined to be statistically significantly higher than those of the treatment Ulus Travma Acil Cerrahi Derg, May 2018, Vol. 24, No. 3

group (Table 2). This supports the protective effect of Montelukast against reperfusion damage formed in the muscle tissue after IR. In studies of IR, antioxidant enzyme activity has been seen to fall following reperfusion, which has been associated with the increased use of these enzymes because of increasing oxidative stress.[21,22] In the present study, a reduction was determined in the activity of SOD antioxidant enzymes in the control group and an increase was determined in SOD enzyme activities in the treatment group. This finding supports IR studies in literature in general. However, in contrast, in a skeletal muscle IR study by Ozyurt et al.,[18] the SOD and Catalase (CAT) antioxidant enzyme activity levels were found to be high in muscle tissue after reperfusion. This increase has been associated with the over-production of free oxygen radicals in IR events which then stimulates the antioxidant defense system and causes the increase in antioxidant enzyme expressions.

In conclusion, in this experimental study, the expected oxidative damage was determined which was believed to be caused

by IR in the lower extremity where a tourniquet was applied.

Regarding the treatment efficacy, as the Montelukast administered against skeletal muscle reperfusion injury was found to have prevented cell damage at a significant level in the histological and biochemical examinations, suppressed the formation of MDA, and increased the antioxidant capacity, these findings were seen to be consistent with those of previous studies. It was concluded that with these effects, Montelukast could accelerate functional recovery of the extremity tissue by limiting the local and systemic complications caused by reperfusion. We did not study the effect of Montelukast on I-R injury at different doses or different administration times.

Additional studies are required for examining these factors on the effect of Montelukast. However, there still remains a requirement for further extensive experimental and clinical studies to be able to use Montelukast in clinical applications against IR damage. Montelukast has a protective effect against I/R injury in skeletal muscle and may reduce the incidence of compartment syndrome, especially after acute or chronic peripheral arterial occlusion.

Conclusions In this experimental study, the protective effect of Montelukast on skeletal muscle reperfusion injury was investigated. It was concluded that Montelukast could accelerate recovery by limiting the complications caused by reperfusion in cases where tissue ischemia has formed, such as extremity traumas with acute vascular injuries, prolonged tourniquet application in extremity surgery. However, there is a need for further experimental and clinical studies to support and confirm these findings.

Conflict of interest: None declared.

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DENEYSEL ÇALIŞMA - ÖZET OLGU SUNUMU

İskelet kasında iskemi-reperfüzyon yaralanmasına karşı Montelukastın koruyucu etkisi: Sıçanlarda deneysel çalışma Dr. Mehmet İlker Bilgiç,1 Dr. Güray Altun,2 Dr. Hüsamettin Çakıcı,3 Dr. Kaan Gideroğlu,4 Dr. Gürsel Saka2 Özel Çağıner Hastanesi, Plastik ve Rekonstrüktif Cerrahi Kliniği, İstanbul Ümraniye Eğitim ve Araştırma Hastanesi, Ortopedi ve Travmatoloji Kliniği, İstanbul Abant Bolu İzzet Baysal Üniversitesi Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, Bolu 4 Kartal Dr. Lütfi Kırdar Eğitim ve Araştırma Hastanesi, Plastik ve Rekonstrütif Cerrahi Kliniği, İstanbul 1 2 3

AMAÇ: Montelukast, sisteinil lökotrien-1 reseptörünü spesifik ve geri dönüşümlü olarak inhibe eden, selektif bir lökotrien D-4 reseptör antagonistidir. Bu deneysel çalışmada, akut iskemi/reperfüzyon (İ/R) yaralanması oluşturulan Wistar albino türü sıçanlarda montelukastın iskelet kası reperfüzyon yaralanmasına karşı olası koruyucu etkisi araştırıldı.

GEREÇ VE YÖNTEM: Bu çalışmaya 16 erkek Wistar albino türü sıçan alındı. Sıçanlar, rastgele sırasıyla kontrol (İ/R) ve çalışma (İ/R + Montelukast) olmak üzere iki gruba ayrıldı. Ekstremite iskemisi, femoral artere klemp konarak sağlandı. İki saatlik iskemi süresini takiben iki saat süren reperfüzyon sonrasında, biyokimyasal analiz ve histopatolojik inceleme için kas örnekleri alındı.

BULGULAR: Kontrol grubunun melondialdehit düzeyleri, montelukast grubundan istatistiksel olarak anlamlı düzeyde yüksekti (p=0.002; p<0.01).

Montelukast grubunun süperoksit dismutaz düzeyleri ise kontrol grubundan istatistiksel olarak anlamlı düzeyde yüksek bulundu (p=0.001; p<0.01). İskemik kasların histopatolojik incelemesinde iskemi reperfüzyon grubunun ödem, polimorfonükleer lökosit (PMNL) infiltrasyonu ve eritrosit ekstravazasyonu düzeyleri, tedavi grubundan istatistiksel olarak anlamlı düzeyde yüksekti. Tedavi edilen grupta ödem, PMNL infiltrasyonu ve eritrosit ekstravazyonu ise iskemi grubuna göre oldukça azalmış olarak izlendi.

TARTIŞMA: Bu iskelet kası akut İ/R yaralanması modelinde; montelukastın iskelet kası reperfüzyon yaralanmasına karşı koruyucu etkisi vurgulandı.

Montelukast, akut vasküler yaralanmalı ekstremite travmaları olgularda ve turnike süresi uzamış ekstremite cerrahisinde, reperfüzyonun neden olduğu lokal ve sistemik komplikasyonları sınırlandırarak ekstremitede fonksiyonel iyileşmeyi hızlandırabileceği sonucuna varılmıştır. Ancak yine de bu etkinin yapılacak deneysel ve klinik çalışmalar ile de desteklenmesinin gerekli olduğu kanaatindeyiz.

Anahtar sözcükler: İskelet kası; iskemi; montelukast; reperfüzyon.

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EXPERIMENTAL STUDY

The microRNA expression profile in rat lung tissue early after burn injury Donghai Zhang, M.D.,1 Yang Chang, M.D.,2 Shaofang Han, M.D.,2 Longlong Yang, M.D.,2 Quan Hu, M.D.,2 Yonghui Yu, M.D.,2 Lingying Liu, M.D.,2 Jiake Chai, M.D.2 1

Department of Postgraduates, Chinese PLA Medical School, the Chinese PLA General Hospital, Beijing-People’s Republic China

2

Department of Burn and Plastic Surgery, the First Affiliated Hospital of the PLA General Hospital, Beijing-People’s Republic China

ABSTRACT BACKGROUND: Severe burn causes acute lung injury in many victims, but the related mechanisms have been barely investigated. microRNAs (miRNAs) important regulators in numerous physiological and pathophysiological process. However, the roles of miRNAs in burn lung injury are untested.

METHODS: Six healthy male Sprague–Dawley rats were randomly assigned into burn and sham groups. Lung injury was evaluated by hematoxylin and eosin (HE) staining at 24 h after injury. Differentially expressed miRNAs were determined by array hybridization and verified by real-time quantitative polymerase chain reaction (RT-qPCR). Bioinformatics analysis was undertaken to predict the target genes. Gene Ontology and Kyoto Encyclopedia of Genes and Genomes databases were employed to identify potentially related biological processes and pathways, respectively. Neutrophil infiltration and apoptosis of the lung were confirmed by immunohistochemical staining of myeloperoxidase (MPO) and terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling (TUNEL).

RESULTS: HE sections showed obvious lung injury, and 21 upregulated and three downregulated miRNAs were detected. Target genes of these miRNAs were most highly enriched in inflammation and apoptosis related GO biological processes and pathways. Inflammation and apoptosis were confirmed by MPO and TUNEL staining.

CONCLUSION: The differentially expressed miRNAs most likely participate in burn-induced lung injury by being involved in inflammation and apoptosis.

Keywords: Apoptosis; burn; inflammation; lung injury/ARDS; microRNA.

INTRODUCTION Patients with extensive burns are at high risk of developing acute respiratory distress syndrome (ARDS)[1] Approximately one-third of patients with burns who require mechanical ventilation on admission develop ARDS with severity correlating with mortality.[2,3] Despite ongoing research, ARDS diagnosis remains largely based on clinical manifestations, whereas treatment focuses primarily on mechanical ventilation.[4,5] Biomarkers for application in clinical laboratory testing and pharmacological management are lacking.[5,6] MicroRNAs (miRNAs) are small (approximately 22 nucleo-

tides) noncoding RNAs that regulate gene expression. They do this by binding to mRNA 3’-untranslated regions, causing translational repression or degradation of target mRNAs. [5,7,8] The miRBase database[9] includes 2588 entries of mature human miRNAs that participate in various physiological and pathophysiological processes.[7,10] Studies have elucidated the changes in miRNA expression that occur during ARDS, along with the pathogenic roles of certain miRNAs under various conditions.[11–22] However, little is known about the relationship between these changes and lung injury in patients with burns.

We hypothesized that specific miRNAs are involved in the initiation of lung injury in patients with extensive burns. Thus,

Cite this article as: Zhang D, Chang Y, Han S, Yang L, Hu Q, Yu Y, et al. The microRNA expression profile in rat lung tissue early after burn injury.

Ulus Travma Acil Cerrahi Derg 2018;24:191-198.

Address for correspondence: Jiake Chai, M.D. 51 Fucheng Road, Haidian District, Beijing 100048, China Beijing, People’s Republic China Tel: +86 10 66867972 E-mail: cjk304@126.com Ulus Travma Acil Cerrahi Derg 2018;24(3):191-198 DOI: 10.5505/tjtes.2018.98123 Submitted: 20.11.2017 Accepted: 07.03.2018 Online: 09.05.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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the aim of this study was to determine the expression profile of miRNAs in rat lung early after burn lesion.

MATERIALS AND METHODS Animal Care Six healthy male Sprague–Dawley rats (180–220 g) were purchased from Peking University Laboratory Animal Center.

They were then acclimatized for 1 week each in single cage at 22–24°C with 12 h day/night cycles, and food and water ad libitum. The experimental protocol adhered to the Guide for Care and Use of Laboratory Animals by the Chinese Academy of Science. Approval was granted by the Institutional Animal Care & Use Committee of the First Affiliated Hospital of the People’s Liberation Army General Hospital [SYXK(JUN)2012-0014] (Beijing, China).

Animal Model Three rats each were randomly assigned into sham and burn groups and anesthetized before being injured and sacrificed.

The 30% total body surface area full-thickness burn rat model was built as previously described.[23] Briefly, the rats in burn group had their backs shaven and then immersed in 94°C water for 12 s. Anti-shock therapy was administrated as sodium chloride 0.9% (normal saline) 40 mL/kg by intraperitoneal injection. Wounds were treated with 1% tincture iodine and left open. For the sham group, the only difference in process was that the immersion temperature of the water was 37°C instead of 94°C.

RNA isolation, labeling, array hybridization, and data analysis These procedures were conducted by Kangchen Biotech Inc. (Shanghai, China) in accordance with the relevant manufacturer’s instructions. Briefly, total RNA was isolated using TRIzol (Invitrogen, Grand Island, NY) and purified with RNeasy mini kit (QIAGEN, Valencia, CA). RNA quality and quantity was measured using nanodrop spectrophotometer ND-1000 (Nanodrop Technologies, Madison, WI) and integrity determined by gel electrophoresis. RNA labeling and array hybridization was undertaken following Exiqon’s instructions (Exiqon, Vedbaek, Denmark). After quality control, the miRCURY™ Hy3™/Hy5™ Power labeling kit (Exiqon) was used for miRNA labeling. Hy3™-labeled samples were hybridized on the miRCURYTM LNA Array (v.19.0) (Exiqon). The slides were scanned using the Axon GenePix 4000B microarray scanner (Axon Instruments, Foster City, CA), and images then imported into GenePix Pro 6.0 software (Axon) for grid alignment and data extraction. Replicated miRNAs were averaged and miRNAs with intensities ≥30 in all samples were chosen for calculating the normalization factor. Expressed data were normalized using the median normalization. After normalization, significant differentially expressed miRNAs between two groups were identified through fold change (>2 or <0.5) and p-value (<0.05).

Real-Time Quantitative Polymerase Chain Reaction (RT-qPCR)

After fixing for at least 24 h, left lung tissue was embedded with paraffin and cut into 5-μm-thick sections. The sections were then deparaffinized in dimethylbenzene, rehydrated, and stained with HE before observation under a light microscope (Leica, Germany).

To validate the array result, both the upregulated and downregulated miRNAs with the highest fold change were selected for RT-qPCR. Prepared RNAs were reverse transcribed into cDNA with Gene Amp PCR System 9700 (Applied Biosystems, Forster City, CA). RT-qPCR was performed with SYBR® Green qPCR master mix (Arraystar, Rockville, MD) by using ViiA 7 Real-time PCR System (Applied Biosystems). The primers used for amplification were rnomiR-664-1-5p (forward: 5’-GGCTGGCTGGGGAAAA-3’; reverse: 5’-GTGCGTGTCGTGGAGTCG-3’); rno-miR-2223p (forward: 5’-GGGAGCTACATCTGGCTA-3’; reverse: 5’-TGCGTGTCGTGGAGTC-3’) and U6 (forward: 5’-GCT TCGGCAGCACATATACTAAAAT-3’; reverse: 5’-CGCTTC ACGAATTTGCGTGTCAT-3’). The thermal conditions for RT-qPCR were 95°C for 10 min, followed by 40 cycles of 95°C for 10 s and 60°C for 60 s. RNA expression levels were evaluated by the comparative threshold cycle (ΔCt) method.

U6 RNA was used as the endogenous reference.

Immunochemistry Staining

Bioinformatics Analysis

Myeloperoxidase (MPO) immunochemistry staining was performed with MPO-specific antibody (Abcam, Cambridge, MA) to detect neutrophil sequestration as per the manufacture’s instruction. Apoptosis was determined with terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling (TUNEL). The positivity rates for MPO and TUNEL staining were determined.

Bioinformatics analysis was conducted by GMINIX Informatics Co., Ltd. (Shanghai, China). Targetscan (www.targetscan.org) and miRanda (www.microrna.org) databases were used for target prediction. Significantly enriched biological processes and pathways were analyzed with Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) Pathway Databases.

Sample Collection The rats were sacrificed under anesthesia with tribromoethanol (Avertin®, 300 mg/kg, Sigma, USA) by drawing blood from the abdominal aorta with 10-mL syringes at 24 h after injury. Their tracheas were exposed and clamped immediately after blood was drawn. Whole lungs were harvested via midline sternotomy, and the lobes separated one by one.

The left lung was fixed in formalin and the right lung accessory lobe of was placed in liquid nitrogen immediately.

Hematoxylin and Eosin (HE) Staining

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(a)

(b)

Figure 1. HE staining of lung tissue. (a) Is the sham group. (b) Is the burn group. The original magnification was 10×10. The scale bar was 100 μm.

Statistical Analysis Array data were analyzed with random variance model t-test.

Fisher’s exact test was applied to identify significantly enriched biological processes and pathways, and false discovery rate was used to correct the p values. ΔΔCt of each miRNA validated by RT-qPCR between two groups was compared using t-test. Differences were considered significant at a p-value of <0.05.

RESULTS Lung Injury Was Obvious in this Rat Model In the sham group, the general structure of the lung tissue was normal i.e., the alveolar space was clear, the alveolar septum was of regular thickness, and there was no significant leukocyte infiltration. In contrast, the burn group had significant histological changes featuring hyaline membrane formation, hemorrhage, alveolar septal thickening, and slight edema (Fig. 1).

miRNAs Expressed Differentially in Burn-Induced Lung Injury According to the predefined criteria involving fold change (>2 or <0.5) and p-value (<0.05), 24 differentially expressed miRNAs were filtrated (Table 1). Of these, 21 were upregulated and three were downregulated in the lung tissues of rats with burns. The expressions of rno-miR-222-3p and rno-miR664-1-5p determined with RT-qPCR were in accordance with the microarray data (Fig. 2).

Bioinformatics Analysis Highlighted Inflammation and Apoptosis Related GO Biological Processes and Pathways There were 1846 genes predicted as targets for the 24 differentially expressed miRNAs, including eukaryotic translation initiation factor 2 subunit gamma (Eif2s3x), Rac/Cdc42 Ulus Travma Acil Cerrahi Derg, May 2018, Vol. 24, No. 3

guanine nucleotide exchange factor 6 (Arhgef6), G proteincoupled receptor 143 (Gpr143), and membrane magnesium Table 1. Differentially expressed miRNAs in rat lung tissue post-burns miRNA

Fold change* p

rno-miR-222-3p 4.88 0.020 rno-miR-429

4.16 0.025

rno-miR-503-3p 4.04 0.016 rno-miR-221-3p 3.59 0.043 rno-miR-106b-5p 3.51 0.024 rno-miR-34c-5p 3.51 0.046 rno-miR-24-2-5p 3.48 0.031 rno-miR-331-3p 3.48 0.044 rno-miR-1-3p

3.47 0.002

rno-miR-339-5p 3.47 0.048 rno-miR-96-5p 3.38 0.042 rno-miR-674-5p 3.18 0.021 rno-miR-379-5p 3.13 0.013 rno-miR-99b-5p 3.08 0.028 rno-miR-672-5p 3.05 0.028 rno-miR-423-3p 2.94 0.037 rno-miR-135a-5p 2.93 0.011 rno-miR-376a-3p 2.6 0.049 rno-miR-488-5p 2.41 0.034 rno-miR-190a-3p 2.07 0.036 rno-miR-411-5p 2.05 0.039 rno-let-7d-5p

0.37 0.046

rno-miR-19b-1-5p 0.36 0.035 rno-miR-664-1-5p 0.3 0.049 *Fold change >1, upregulated; fold change <1, down-regulated. The p-value was calculated with random variance model t-test. miRNAs: MicroRNAs.

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(a)

*

8

related items such as mechanosensory behavior, satellite cell maintenance involved in skeletal muscle regeneration, and cerebral cortex tangential migration in GO biological processes as well as olfactory transduction, dilated cardiomyopathy, and malaria in pathways were ruled out. The remaining items were characterized by inflammation-related and apoptosis-related GO biological processes and pathways. Some of the most related GO biological processes items are listed in Figure 3 and ordered by the enrichment score. The most related pathways are listed in Figure 4 and ordered byâ&#x20AC;&#x201C;LgP.

Array

Fold Change

RT-qPCR 6

4

*

2

Apoptosis and Inflammation Condition in the Lung 0

(b)

Sham

Burn

Sham

*

5

Array RT-qPCR

4 Fold Change

Inflammation represented by neutrophil infiltration and apoptosis in the lung tissue were verified by immunochemistry.

The positive rates of TUNEL and MPO in the burn group were significantly higher than in the control group. This indicated that the burn had caused conspicuous neutrophil infiltration and apoptosis in the lung (Fig. 5).

Burn

DISCUSSION

3

2

*

1 0

Sham

Burn

Sham

Burn

Figure 2. The fold change of the two miRNAs selected for validation. (a) Is the rno-miR-222-3p. (b) Is the rno-miR-664-1-5p. *Comparison between the two groups using t-test, p<0.05.

transporter 1 (Mmgt1), etc. These genes were significantly enriched in 548 GO biological processes and in 89 pathways.

GO biological processes with an enrichment score >5 and pathways with a p-value of < 0.01 were filtered. Then, the less

Several studies[11â&#x20AC;&#x201C;22] have revealed the miRNA expression profile of ARDS lung tissue from different conditions including radiation-induced injury in rat lung, oleic acid-induced acute lung injury and cardiopulmonary bypass-induced acute lung injury. However, to the best of our knowledge, no one has investigated the miRNA expression profile in lung tissue after extensive burns. The present study demonstrated that burn-induced lung injury in rats was associated with aberrant miRNA expression.

After a severe skin scald, histological changes characterized by hyaline membrane formation, hemorrhage, alveolar septal thickening, and edema were observed in HE-stained specimens. Array hybridization of lung tissue samples detected 21 upregulated and three downregulated miRNAs. The most

Enrichment score 0 5

10

15

20

25

30

Nitric oxide production involved in inflammatory response Regulation of nitric-oxide synthase activity Positive regulation of respiratory burst Leukotriene production involved in inflammatory response Negative regulation of toll-like receptor 4 signaling pathway Negative chemotaxis Endothelin receptor signaling pathway Negative regulation of mitochondrial outer membrane permeabilization Macrophage activation Regulation of cell adhesion mediated by integrin Leukocyte tethering or rolling Mitochondrial fusion Intrinsic apoptotic signaling pathway in response to DNA damage by p53 class mediator Positive regulation of release of cytochrome c from mitochondria Responce to interleukin-1

Figure 3. Some of the most related GO biological processes with enrichment score of >5.

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Zhang et al. The microRNA expression profile in rat lung tissue early after burn injury

-Log P 0

1

2

2

4

5

6

7

8

Wnt signaling pathway MAPK signaling pathway PI3K-Akt signaling pathway Insulin signaling pathway Calcium signaling pathway Leukocyte transendothelial migration mTOR signaling pathway NF-kappa B signaling pathway Hippo signaling pathway Cytokine-cytokine receptor interaction T cell receptor signaling pathway HIF-1 signaling pathway Chemokine signaling pathway Cell adhesion molecules (CAMs) TGF-beta signaling pathway

Figure 4. Highly related pathways with p<0.01. The p-value was calculated with Fisher’s exact test and false discovery rate was used to correct the p values.

upregulated and downregulated of these were rno-miR-2223p and rno-miR-664-1-5p, respectively. The reliability of the array result was confirmed by RT-qPCR. Bioinformatics analysis elucidated that predicted target genes of the differentially expressed miRNAs were mainly enriched in GO biological processes and pathways associated with inflammation and apoptosis. The inflammatory state represented by neutrophil infiltration and the apoptotic condition were confirmed by immunochemical staining of MPO and TUNEL, respectively.

Accordingly, miRNAs most likely participate in burn-induced lung injury via regulation of inflammation and apoptosis.

Inflammation and apoptosis have been previously highlighted in ARDS pathophysiology.[24–26] Extensive burns can trigger an excessive inflammatory response resulting in intrinsic alveolar macrophages activation and recruitment of circulating neutrophils.[27] Neutrophils roll around and tether to the endothelium, migrate into the interstitial and alveolar spaces, and produce plenty of cytotoxic substances, including reactive oxygen species and proinflammatory cytokines and enzymes.[28] These substances lead to apoptosis of various functional cells, including capillary endothelial cells and alveolar epithelial cells, resulting in respiratory dysfunction. Our bioinformatics analysis suggests that miRNAs are involved in many of these inflammatory and apoptotic cellular processes. miR-96-5p expression was upregulated in mouse macrophage line RAW264.7 cells after Candida albicans infection.[29] miR96-5p was also upregulated in burn lung tissue and was predicted to play a role in GO_macrophage activation by targeting arginine demethylase and lysine hydroxylase 6 (Jmjd6).

The upregulated miR-24-2-5p was predicted to participate in Ulus Travma Acil Cerrahi Derg, May 2018, Vol. 24, No. 3

GO_leukocyte tethering or rolling via targeting vascular cell adhesion molecule-1 (Vcam-1). miR-24-2-5p also takes part in the leukocyte transendothelial migration pathway and the cell adhesion molecules (CAMs) pathway by targeting Vcam1. CAMs are essential for leukocyte tethering to and rolling around the vascular endothelium, while leukocyte tethering and rolling in turn is the beginning of leukocyte transendothelial migration. Thus, it is possible that miR-24-2-5p contributes to burn-induced lung injury by mediating leukocyte infiltration.

A group of GO biological processes focused on mitochondrial damages and intrinsic apoptosis. miR-221-3p and miR222-3p were upregulated in the lung tissue in burn cases. {1.1.

[TK] Anlam belirsiz. Yapılan düzenlemeyi kontrol edin} Xue[30] reported that miR-221-3p and miR-222-3p overexpression in human aortic endothelial cell leads to mitochondrial dysfunction, resulting in cellular apoptosis. Moreover, some of the differentially expressed miRNAs induce apoptosis in lung epithelial cell lines, although it is not clear whether the mechanisms are mitochondrial dependent.[31,32] More information about listed GO biological processes and pathways including the related miRNAs and their target genes is available in the supplementary material.

Our study has some limitations that should be taken into consideration when interpreting the results. The miRNA expression profile was determined at a single time point (24 h after injury) rather than observed continuously. While 24 h after injury was quite an early stage of lung damage, miRNA expression had already changed consistent with their rapid 195

Zhang et al. The microRNA expression profile in rat lung tissue early after burn injury

(a)

(b)

(c)

(d)

(f)

*

*

25

25

20

20

TUNEL Positive Rate (%)

MPO Positive Rate (%)

(e)

10 10 5

10 10 5 0

0 Control

Burn

Control

Burn

Figure 5. Immunohistochemical staining of MPO and TUNEL. (a) (Sham group) and (c) (burn group) are MPO staining. (b) (Sham group) and (d) (burn group) are TUNEL staining. The original magnification was 20Ă&#x2014;10. The scale bar was 100 Îźm. (e, f) Are the column charts of quantified positive rate of MPO and TUNEL, respectively. *Comparison between the two groups using t-test, p<0.05.

reaction to stimuli. It remains unclear how miRNA expression changes beyond 24 h. The small animal size might also decrease the sensitivity of array hybridization to unknown miRNAs that might be involved in burn-induced lung injury.

The current study revealed differentially expressed miRNAs in rat lung in the early post-burns stage. This variable miRNA expression probably participates in the pathophysiology of the lung injury via regulation of inflammation and apopto196

sis. The miRNAs may provide targets for further research on the mechanisms and therapies of burn-induced lung injury.

Acknowledgments This study was financially supported by the National Natural Science Foundation of China (81571894, 81772067). The authors appreciate Kangchen Biotech Inc. (Shanghai, China) Ulus Travma Acil Cerrahi Derg, May 2018, Vol. 24, No. 3

Zhang et al. The microRNA expression profile in rat lung tissue early after burn injury

and GMINIX Informatics Co., Ltd. (Shanghai, China) for the technological supports.

Conflict of interest: None declared.

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Zhang et al. The microRNA expression profile in rat lung tissue early after burn injury

DENEYSEL ÇALIŞMA - ÖZET OLGU SUNUMU

Sıçan akciğer dokusunda yanık yaralanmasından sonra erken dönemde mikro RNA ekspresyon profili Dr. Donghai Zhang,1 Dr. Yang Chang,2 Dr. Shaofang Han,2 Dr. Longlong Yang,2 Dr. Quan Hu,2 Dr. Yonghui Yu,2 Dr. Lingying Liu,2 Dr. Jiake Chai2 1 2

Çin PLA Tıp Okulu, Çin PLA Genel Hizmet Hastanesi, Mezunlar Bölümü, Pekin-Çin Halk Cumhuriyeti PLA Genel Hizmet Hastanesi, Yanık ve Plastik Cerrahi Bölümü, Pekin-Çin Halk Cumhuriyeti

AMAÇ: Ağır yanık birçok yaralıda akut akciğer hasarına neden olmakla birlikte ilişkin mekanizmalar pek araştırılmamıştır. Mikro RNA’lar (miRNA’lar) sayısız fizyolojik ve fizyopatolojik sürecin önemli düzenleyicidirler. Ancak yanığa bağlı akciğer hasarında miRNA’ların rolü test edilmemiştir.

GEREÇ VE YÖNTEM: Altı sağlıklı erkek Sprague–Dawley sıçanı yanık ve plasebo gruplarına rastgele dağıtıldı. Yanık olayından 24 saat sonra hematoksilen-eozin (HE) boyasıyla akciğer hasarı değerlendirildi. Farklı oranlarda eksprese edilen miRA’lar dizilim hibridizasyonu ile belirlenmiş, gerçek zamanlı nicel polimeraz zincir reaksiyonuyla (RT-qPCR) doğrulanmıştır. Biyoinformatik analizi ile hedef genler öngörüldü. Potansiyel olarak ilişkili biyolojik süreçler ve yolakları tanımlamak için sırasıyla Gen Ontolojisi (Gene Ontology) ve Kyoto Gen ve Geom Ansiklopedisi (Kyoto Encyclopedia of Genes and Genomes) veri tabanları kullanıldı. Akciğeri nötrofil infiltrasyou ve akciğer apoptozu miyeloperoksidaz immünohistokimyasal boyaması (MPO) ve TUNEL (terminal dezoksinükleotidil transferaz-aracılı dUTP nick- end labeling) yöntemiyle doğrulandı.

BULGULAR: HE boyalı kesitler açıkça akciğer hasarını gösterdi. Toplam 21 ‘up’regüle ve 3 ‘down’regüle miRNA saptandı. Bu miRNA’ların hedef genleri en yüksek oranda enflamasyon ve apoptozla ilişkili GO biyolojik süreç ve yolakları içerdi. MPO ve TUNEL boyamasıyla enflamasyon ve apoptoz doğrulandı.

TARTIŞMA: Farklı oranlarda eksprese edilen miRNA’lar enflamasyon ve apoptoza katılarak yanığa bağlı akciğer hasarında en büyük olasılıkla rol oynarlar.

Anahtar sözcükler: Akciğer hasarı/ARDS; apoptoz; enflamasyon; mikroRNA; yanık.

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doi: 10.5505/tjtes.2018.98123

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ORIG I N A L A R T IC L E

Prediction of mortality in pediatric traumatic brain injury: Implementations from a tertiary pediatric intensive care facility Ebru Atike Ongun, M.D., Oğuz Dursun, M.D. Department of Pediatric Critical Care, Akdeniz University Faculty of Medicine, Antalya-Turkey

ABSTRACT BACKGROUND: To explore the mortality risk factors of traumatic brain injury in pediatric intensive care unit admissions.

METHODS: Eighty-eight children (categorized using the Glasgow Coma Scale) between September 2014 and December 2016 were analyzed. Emergency department and intensive care course, treatment strategies, axonal injury, intubation and tracheostomy rates, length of intensive care and hospitalization, Rotterdam-CT scores, injury severity scores, and PRISM-III scores were recorded.

RESULTS: Older age was associated with trauma severity (p=0.010). Target serum osmolality was reached at 8.5 (3.5–40) hours in patients undergoing anti-edema therapy. ICP-monitoring rates was 8%; in absence of ICP-monitorization clinical follow-up was performed through repeated brain tomographies. Axonal injury was associated with prolonged intubation, intensive care and hospital stay (p<0.001, p<0.001, p=0.030). Six children required tracheostomy at 14.33±1.03 days; decannulations were performed within 6 months in five children.

CONCLUSION: Mortality rate was 12.5%; six patients progressed to brain death with organ donor approvals in five. Initial hypotension, lung contusion, injury severity scores and Rotterdam-CT scores were related with mortality. Rotterdam-CT score was determined as the independent risk factor for mortality; one increment in the score increased the odd of recovery by 20.334 times (%95 CI 1.999–206.879). ISS score was also borderline significant (p=0.052; OR:1.195 %95 CI 0.999–1.430).

Keywords: Brain edema therapy; children; mortality; pediatric critical care; Rotterdam-CT score; traumatic brain injury.

INTRODUCTION Traumatic brain injury (TBI) is one of the major causes of mortality and morbidity in children aged 1–19 years.[1,2] The Centers for Disease Prevention and Control, USA 2015 data estimates 475000 children <14 years of age sustain TBI annually with 37,000 hospitalizations and a mortality rate of 2,685 between 1999 and 2013.[3] There is limited data regarding TBI incidence in Turkey. Given the fact that traffic accidents constitute only a fraction of all trauma etiologies, latest Turkish Statistical Institute’s 2016 data verifies 864 deaths and 55198 injuries related to traffic accidents in children.[4] Prognosis depends on the severity of the primary injury and prevention of secondary insults, including hypoxemia, hyper-

carbia, hypotension, hyperthermia, seizure, and elevated intracranial pressure (ICP).[1] After initial management in the field and emergency department (ER), the primary goal of treatment in pediatric intensive care units (PICU) is to maintain age-appropriate cerebral perfusion pressure (CPP) and to minimize secondary injuries.[5,6] As being one of the most referred pediatric trauma centers in the Mediterranean region, we conducted a retrospective study on PICU admissions between September 2014 and December 2016 to determine the characteristics of admissions and therapy strategies, and we evaluated the risk factors affecting the mortality and short term morbidity of TBI.

Cite this article as: Ongun EA, Dursun O. Prediction of mortality in pediatric traumatic brain injury: Implementations from a tertiary pediatric intensive care facility. Ulus Travma Acil Cerrahi Derg 2018;24:199-206.

Address for correspondence: Ebru Atike Ongun, M.D. Dumlupınar Bulvarı, Üniversite Hastanesi, A2 Blok, 1. Kat, Konyaaltı, 07070 Antalya, Turkey Tel: +90 242 - 249 60 00 E-mail: ebruongun@akdeniz.edu.tr Ulus Travma Acil Cerrahi Derg 2018;24(3):199-206 DOI: 10.5505/tjtes.2017.37906 Submitted: 14.07.2017 Accepted: 17.10.2017 Online: 08.05.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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MATERIALS AND METHODS Following IRB approval with waiver of consent, the electronic database of 88 children (age: 1 month–18 years) admitted to PICU between September 2014 and December 2016 was explored. Patients were categorized into three groups to define the severity of TBI based on initial Glasgow Coma Scale (GCS) at ER admission:[1] severe head trauma (GCS ≤8), moderate TBI (GCS: 9–12), mild TBI (GCS: 13–15). After initial categorization, patients with neurological deterioration were also noted. Data were analyzed for demographics and injury characteristics. Patients’ vital signs, laboratory data, computed tomography (CT), intracranial and co-existing pathologies of other systems, treatment strategies, transfused blood products, and urgent surgical operations before PICU admission were recorded.

Intensive care course of the study included patients’ vital signs and laboratory data, ICP-monitoring rates and if received, the anti-edema medications and duration that were required to attain the initial target serum osmolality (measured serum osmolality: 300–320 mosmol/L),[7,8] and the adverse effects related to hyperosmolar therapy (central pontine myelinolysis because of rapid increase in serum sodium, acute tubular necrosis, and hyperchloremic metabolic acidosis). To avoid medication-related side effects, intensive care protocol for patients who were administered mannitol and/ or 3% NaCl included the following: if serum osmolality was >320 mosm/L, discontinue mannitol; if serum osmolality was 320–350 mosml/L, decrease the infusion rate of 3% NaCl; or if serum osmolality was >350 mosm/L, discontinue NaCl infusion. We also examined patient records for diabetes insipidus, anti-convulsive therapy (decision of initiating antiseizure drug regimen was made by the pediatric neurologists based on the severity of parenchymal damage and neurological status of the patient without routine EEG monitoring) and if present, hemodynamic instability as well as transfused blood products and massive transfusion rates (administered upon the advice of Neff et al.;[9] 40 ml/kg of all blood products transfused per 24 h). Rate of neurosurgical operations during PICU admission, axonal injury observed in cranial magnetic resonance (MR) imaging, assessment of GCS of the patients based on the records at the time of admission to emergency care, injury severity score (ISS), Rotterdam computerized tomography scores (Ro-CT),[10] and PRISMIII scores after admission to PICU were performed. Finally, the total number of cranial CT scans (from the moment of ER admission to the hospital discharge), intubation and tracheostomy rates, length of PICU, and length of hospital stay were noted.

Statistics were analyzed using SPSS version 23. Descriptive analyses were presented as frequency (n), percentage (%), mean, standard deviation, and median, with minimum and maximum values. Categorical data was assessed using the chisquare test and Fisher’s exact test. Shapiro–Wilks test was 200

used to assess normality distribution. Continuous variables were analyzed using the Mann–Whitney U-test or Independent Samples t-test. One way ANOVA and/or Kruskal–Wallis tests were applied to compare the mean values or center of location parameters in three groups. Wilcoxon rank-sum test or paired samples t-test was used for statistical comparison.

All the statistical tests were two-tailed, and P-values <0.05 were considered to be significant. Multivariate logistic regression was used to determine independent predictors of the studied outcomes.

RESULTS In total, 88 patients were enrolled in the study. The study population was categorized according to GCS on ER admission as severe TBI (42/88, 47.7%), moderate TBI (15/88, 17%), and mild TBI (31/88, 35.2%). Female/male ratio was 1:1.3 with a median age of 6 years (1–17 years) (Table 1).

TBI severity and accompanying injuries of other organs were noted to increase by older age (p=0.010; p=0.007). Children with initial GCS <9 and neurological deterioration at followup required intubation at a rate of 69.3% to establish a secure airway. Length of MV stay was median 3 days (1–21 days).

GCS was reciprocally associated with the length of MV and PICU stay (p=0.001; p=0.002), though it had no effect on the duration of hospitalization (p=0.155).

Accompanying pathologies of other organ systems and thoracic region injuries were observed more frequently in the severe TBI group (p=0.019; p=0.001). Table 2 shows intracranial pathologies and treatment-oriented data. Of the 20 children (22.7%) who required urgent neurosurgical interventions at ER (decompressive craniectomy/hematoma drainage/extraventricular drainage-EVD), only seven had been followed by ICP monitoring at PICU. In the absence of ICP monitoring, repeated brain CT scans were applied to children at a rate of median 2.5 (1–9) scans/per patient from ER admission to hospital discharge; however, only one patient underwent urgent surgical hematoma drainage because of the clinical signs of elevated ICP due to an enlarged epidural hematoma. The number of CT scans were inversely proportional to GCS (p=0.018, r=−0.304).

In case of brain edema or neurological deterioration, antiedema therapy in the form of 20% Mannitol and/ or hypertonic saline (3% NaCl) were applied (Table 2). Note that only 11.3% of the study population received the first dose of anti-edema therapy at ER. After PICU admission, the median duration to achieve initial target serum osmolality was 8.5 h (3.5–40 h), and we did not observe any side effect related to hyperosmolar therapy (hypercloremic metabolic acidosis, acute tubular necrosis, or central pontine myelinolysis). Despite treatment, 21.6% of the patients presented clinical signs of elevated intracranial pressure. Anti-epileptic medication was initiated at the rate of 44.3%; however, seizures appeared in 15.9% of the study population (Table 2).

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Table 2. Intracranial pathologies and therapy strategies

Table 1. Demographics of the study population Variables

n (%)

Age (median)

6 years (1–17 years)

Age groups

Variables Intracranial pathology

Isolated subarachnoid hemorrhage

25 (28.4) 11 (12.6)

<5 years

36 (40.9)

Isolated epidural hematoma

6–10 years

25 (28.4 )

Isolated subdural hematoma/

11–18 years

27 (30.7)

Sex

n (%)

Fluid accumulation

Intraparenchymal hemorrhage

13 (14.8) 7 (8)

Females

38 (43.2)

Intraventricular hemorrhage

2 (2.3)

Males

50 (56.8)

Multi-localized hemorrhage

30 (34.1)

TBI Severity

Brain edema

43 (48.9)

Mild (GCS: 13–15)

31 (35.2)

Midline shift

19 (21.6)

Moderate (GCS: 9–12)

15 (17.7)

Elevated intracranial pressure

19 (21.6)

Severe (GCS: ≤8)

42 (47.7)

ICP monitoring

Mechanism of injury

Vehicle

Pedestrian

Motorcycle accident

Fall (higher than 1.5 m)

16 (18.2) 27(30.7) 6 (6.8) 35 (39.7)

Other Fall (less than 1.5 m)

3 (3.4)

Crush (television)

1 (1.1)

Accompanying other organ systems injury

63/88 children (71.6)

Thoracic region

47/88 (53.4)

Pneumothorax/hemothorax

12/47 (25.5)

Lung contusion

38/47 (80.9)

Abdominal region

25/88 (28.4)

Multiorgan injury

9/25 (36)

Isolated hepatic injury

9/25 (36)

Isolated splenic injury

3/25 (12)

Isolated kidney injury

3/25 (12)

Retroperitoneal bleeding

1/25 (4)

7 (8)

Anti-edema therapy

59 (67)

Mannitol alone

9 (10.2)

Hypertonic saline alone

13 (14.8)

Mannitol+Hypertonic saline

Serum sodium at PICU arrival

37 (33) 140.88±4.74 meq/L

Length of hypertonic saline therapy (median)

4 (1–10) days

Length of mannitol therapy (median)

3 (1–6) days

Reason of discontinuation for mannitol

Neurological recovery

25/46 (54.3)

Elevated serum osmolality

15/46 (32.6)

Diabetes insipidus

Target (measured) serum osmolality

Mannitol alone

6/ 46 (13) 315±16.39 310.43±25.22

Hypertonic saline alone

310.22±9.12

Mannitol+Hypertonic saline

319.00±15.28

Duration to reach target serum osmolality

8.5 (3.5–40) hours

Extremity injury

49/88 (55.7)

Diffuse axonal injury

20/49 (40.8)

Diabetes insipidus

9 (10.2)

29/49 (59.2)

Anti-seizure therapy

40 (45.5)

23/88 (26.1)

Levetiracetam

3 (38.6)

Phenytoin

6 (6.8)

Upper extremity fractures Lower extremity fractures

Spinal cord injury

Cervical spine fractures

12/23 (52.2)

Thoracic spine fractures

6/23 (26.1)

Clinical seizure

5/23 (21.7)

Rate of brain computed tomography

Lumbar/sacral spine fractures

GCS: Glascow Coma Scale; TBI: Traumatic brain injury.

Diffuse axonal injury (diagnosed at cranial MR imaging) occurred at a rate of 17% among those who did not present the anticipated neurological recovery. It seemed to increase with the severity of brain injury (p=0.038), but the neurological deterioration at follow-up did not affect the frequency of diffuse axonal injury (p=0.325). However, it extended the length of MV stay, PICU stay, and the hospitalization (p<0.001, Ulus Travma Acil Cerrahi Derg, May 2018, Vol. 24, No. 3

(median)

15 (17)

14 (15.9) 2.5 (1–9)/person

p<0.001, and p<0.001, respectively). In six of the axonal injurydiagnosed patients, tracheostomy cannulation was performed at an average of 14.33±1.03 days because of prolonged endotracheal intubation (Table 3). Tracheostomies’ decannulation were performed within 6 months following hospital discharge in five children; only one child remained in the vegetative state and continued to receive home ventilation for >1 year.

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Co-injuries to other organ systems were noted in 71.6% of the study group (Table 1). They were also related to prolonged MV, PICU, and hospital stays (p<0.001, p<0.001, p=0.030 respectively). Presence of lung contusion extended the length of stay in MV and PICU (p=0.002, p=0.002); however, it had no impact on hospital stay (p=0.104).

Observations on hemodynamics revealed that 31.8% of the children had presented age-specific hypotension at initial ER admission and received blood transfusions (Table 3).

Hypotension was observed more frequently in severe TBIs and co-existing injuries of other organ systems (p=0.009, p=0.012). After the initial stabilization, 27.3% required urgent surgical intervention before PICU admission (Table 3).

To maintain a hemoglobin level that was >8 g/dl, 37.5% of the children received blood transfusions during the first 48 h of PICU admission, while the massive transfusion rate against hemorrhagic shock was 8%. The ones with co-existing injuries of other organ systems and lower GCS seemed to require more frequent transfusions (p<0.001, p=0.001 respectively). Table 4 represents a comparison of variables within the GCS groups.

Table 3. Follow-up at emergency department and pediatric critical care unit

n (%)

Emergency department

Initial hypotension at arrival

28 (31.8)

Blood transfusion

28 (31.8)

Neurological deterioration at follow-up

21 (23.9)

Urgent surgery

24 (27.3)

Neurosurgical procedures

2 (2.3)

Pediatric surgery procedures

2 (2.3)

Pediatric critical care unit

Blood transfusion within 48 h Massive blood transfusion

Surgery Interventions (neurosurgery/

orthopedics/pediatric surgery)

33 (37.5) 7 (8) 6 (6.8)

Intubation rates

61 (69.3)

Length of mechanical ventilation (days)

3 (1–21)

Tracheostomy cannulation

Average tracheostomy cannulation

timing (days)

Length of PICU stay (median) (days)

Length of hospital stay (median) (days)

Mortality

6 (6.8) 14.33±1.03 4 (1–22) 10.5 (1–96) 11 (12.5)

Brain death

6 (6.8)

Organ donor

5 (5.7)

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Brain death [diagnosis based on clinical findings indicating permanent loss of brain stem functions with apnea test and Single Photon Emission Tomography (SPECT)] occurred in six patients, five of whom became organ donors.

DISCUSSION Increased intracranial pressure as a leading cause of secondary brain damage on TBI prognosis is well established in literature.[6,11,12] The goal in pediatric critical care in TBI management is to maintain age-appropriate CPP by maintaining ICP <20 mmHg.[6,11,13] Despite the recommendations of the American Neurosurgery Association and Brain Trauma Association guidelines for ICP monitoring, the rates vary between 9.6% and 75%, and compliance to guidelines remains low because of either underestimation of the clinical importance of ICP monitoring or ignorance of the potential risks of invasive monitoring.[14,15] Our observations were concordant with previous reports, verifying low compliance; despite a relatively higher percentage of neurosurgical procedures (22.7%), ICP rates were merely 8%.

20 (22.7)

Orthopedic procedures

Overall, 11 children (12.5%) died of TBI. To determine the independent risk factors for mortality, the variables that did not create multicollinearity with p<0.2 were included in multivariable logistic regression model at a ratio of 1/20 sampling cases. According to the model in which initial hypotension observed at ER, the presence of lung contusion, ISS score, and Ro-CT score were included as the variables, and only RoCT score was determined to be an independent risk factor for mortality. One increment in the score increased the odds of recovery by 20.334 times (95% CI: 1.999–206.879). ISS score was also found to be borderline significant (p=0.052; OR: 1.195; 95% CI: 0.999–1.430).

Note that, in the absence of ICP monitoring, patient followup was achieved through repetitive CTs under the influence of neurological examinations; however, only one patient who presented neurological deterioration underwent neurosurgery (epidural hematoma drainage) following CT evaluation at PICU. Despite the routine radiological evaluation in adults, it rarely intervenes the course of therapy in neurologically stable pediatric patient causing unnecessary ionized radiation exposure.[16–18] Hill et al.[16] reported surgical intervention because of an enlarged intracranial hemorrhage in only one out of 95 patients (32.3%), who underwent repeated CTs in their study population. They concluded that repeated cranial imaging did not alter therapy, and standardized guidelines for repeated scanning at any age groups, including adults and children, were necessitated to be developed. Repeating neurological examination is a cheaper and safer method; the choice of radiological evaluation should be considered only if neurological deterioration occurs in those with mild/moderate TBI (GCS >8).[15,19] Long-term effects of ionized radiation in adolescent children are well established in previous reports; exposure to radiation because of a single dose brain Ulus Travma Acil Cerrahi Derg, May 2018, Vol. 24, No. 3

Ongun et al. Prediction of mortality in pediatric traumatic brain injury

Table 4. Group comparisons according to TBI severity Variables

Age (median) Age groups, n (%) <5 years 6–10 years 11–18 years Male sex, n (%) Mechanism of injury, n (%) Vehicle Pedestrian Motorcycle Fall Other Accompanying other organ system injury, n (%) Thoracic injury, n (%) Lung contusion, n (%) Abdominal injury Extremity injury Spinal cord injury Brain edema, n (%) Midline shift, n (%) ICP monitoring, n (%) Increased intracranial pressure, n (%) Serum sodium at PICU arrival, Mean±SD Duration to reach target serum osmolality, Mean±SD Diffuse axonal injury, n (%) Anti-seizure therapy, n (%) Clinical seizure, n (%) Diabetes insipidus, n (%) Emergency department, n (%) Initial hypotension (at arrival) Blood transfusions Neurological deterioration Urgent surgical interventions Pediatric critical care unit, n (%) Intubation rates Length of mechanical ventilation (days) (median) Tracheostomy cannulation, Blood transfusions Massive blood transfusions Brain CT scans, Mean±SD Surgical intervention Length of PICU stay (days), Mean±SD Length of hospitalization (days) (median) Injury Severity Score (ISS) (median) Rotterdam-CT score, Mean±SD PRISM-III score, Mean±SD Mortality Brain death

Severe (GCS ≤8) (n=42)

Moderate (GCS 9–11) (n=15)

Mild (GCS 12–15) (n=31)

p

8.5 (1–17)

3 (1.5–17)

5 (1.5–17)

=0.010

10 (23.8) 16 (38.1) 16 (38.1) 29 (69.05)

10 (66.7) 3 (20) 2 (13.3) 6 (40)

16 (51.6) 6 (19.4) 9 (29.03) 15 (48.4)

NA

9 (21.4) 15 (35.7) 5 (11.9) 11 (26.2) 2 (4.8) 36 (85.7) 30 (71.4) 24 (57.1) 16 (38.1) 23 (54.8) 15 (35.7) 32 (76.2) 15 (35.7) 6 (14.3) 17 (40.5) 142.52±5.19 12.93±5.55 10 (23.8) 29 (69.05) 9 (21.4) 9 (21.4)

2 (13.3) 4 (26.7) 0 9 (60) 0 9 (60) 3 (20) 2 (13.3) 1(6.7) 5 (33.3) 1 (6.7) 6 (40) 1 (6.7) 1 (6.7) 0 140.93±2.87 20.75±12.96 4 (26.7) 4 (26.7) 3 (20) 0

5 (16.1) 8 (25.8) 1 (3.2) 15 (48.4) 2 (6.5) 18 (58.1) 14 (45.2) 12 (38.7) 8 (25.8) 12 (38.7) 7 (22.6) 5 (16.1) 3 (9.7) 0 2 (6.5) 138.93±4.27 16±5.80 1 (3.2) 6 (19.4) 2 (6.5) 0

=0.019 =0.001 =0.012 =0.063 =0.121 =0.076 <0.001 =0.007 NA <0.001 =0.005 =0.216 =0.038 <0.001 NA NA

20 (47.6) 20 (47.6) 5 (11.9) 16 (38.1)

2 (13.3) 2 (13.3) 6 (40) 5 (33.3)

6 (19.4) 6 (19.4) 10 (32.3) 3 (9.7)

=0.009 =0.009 =0.036 =0.022

42 (100) 4 (1–21) 6 (14.3) 24 (57.1) 7 (16.6) 3.4±1.97 3 (7.1) 7.33±5.78 16.5 (1–96) 15.5 (9–50) 3.83±1.48 12.93±10.34 11 (26.2) 6 (14.3)

8 (53.3) 1 (0–11) 0 3 (20) 0 2.73±1.16 1 (6.7) 4.53±3.04 12 (5–35) 9 (9–34) 2.0±0.53 2.33±1.98 0 0

11 (35.5) 1 (0-7) 0 6 (19.4) 0 2.32±1.51 2 (6.5) 3.51±2.07 8 (3–38) 9 (3–41) 1.74±0.77 1.74±2.19 0 0

<0.001 =0.001 NA =0.001 NA =0.018 NA =0.002 =0.155 =0.003 <0.001 <0.001 NA NA

=0.075

NA

TBI: Traumatic brain injury; ICP: Intracranial pressure; PICU: Pediatric intensive care units; CT: Computed tomography; SD: Standard deviation; NA: Not available.

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tomography in a 1-year-old pediatric patient increases the mortality risk by 10-fold compared to that in an adult patient, and it adversely affects cognitive function and cataract upon reaching adulthood.[16,20] Our results indicate the necessity of further studies to compose standardized guidelines on decision of radiological evaluation.

20% Mannitol and 3% NaCl are hyperosmolar agents, proven to be effective in lowering intracranial pressure.[21] The goal of osmotherapy is to attain the target measured serum osmolality to lower intracranial pressure and maintain the achieved osmolality.[21] We confirmed that the medication were initiated with the admission to PICU in a majority of the children, and the duration to reach the target serum osmolality extended to 8.5 h (3.5–40 h). In the prospective randomized double blind study, Li et al.[22] demonstrated the serum osmolality for mannitol and 3% NaCl infusion was as 292.4±9.1 mosm/L and 294.1±6.6 mosm/L, respectively, and both these values were below the threshold levels at 6 h. As shown by Francony et al.,[23] 20% Mannitol and 7.4% NaCl infusions elevated serum osmolality only by 2%. Delays in achieving the target osmolality result in prolonged exposure to elevated ICP which are directly related to negative prognosis, and a multidisciplinary approach towards TBI management (medical staff responding in the field, ER physicians, and neurosurgeons) contributes to positive prognosis.[1,5] Therefore, we believe that osmotherapy, one of the main determinants in preventing secondary injuries, should be initiated at an earlier stage with an aggressive approach upon admission to the ER. In studies comparing hyperosmolar therapies 3% NaCl infusions have been shown to decrease ICP better than mannitol infusions, and 3% NaCl is suggested as the first choice of drug in therapy at a dosage of 0.1–1 ml/kg/h infusion.[11,21,24] We found that the time required to reach the target serum osmolality in combination therapy (Mannitol + 3% NaCl) was shorter than that required by monotherapy (mannitol or 3% NaCl); however, our intention in this retrospective study was not to compare the efficiency of each hyperosmolar agent as the majority of the study population received combination therapy (62.7%).

Instead, we identified drug-related potential side effects using clinical/laboratory and radiological data. Our results showed no side effects related to hyperosmolar drugs used for central pontine myelinolysis (due to rapid increase in serum sodium in hyponatremic patient) and hyperchloremic metabolic acidosis or acute kidney failure;[20] possibly because the administration of isonatremic 5% Dextrose and 0.09% NaCl solutions to protect children against hyponatremia or the dynamic therapy interaction (discontinue or decrease the infusion rate of drugs) to keep the serum osmolality below threshold levels (discontinue mannitol if serum osmolality <320 mosm/L; decrease 3% NaCl infusion rate if serum osmolality is 320–350 mosm/L, or discontinue NaCl if osmolality exceeds 350 mosm/L).

Mortality rates in children r is 9%–16% in multicentered cohort studies.[25,26] Low GCS (RR 3.06, 95% CI: 2.74–3.43), 204

male gender (RR 1.17, 95% CI: 1.09–1.25), initial hypotension at admission (RR 1.83, 95% CI: 1.61–2.09), and ISS scores (RR 1.86, 95% CI: 1.41–2.45) have been identified as risk factors for mortality in adult studies.[27] Pupillary response at admission, hypothermia, mechanism of injury, hypotension, and hypoxia are directly related to survival.[28,29] In a pediatric series of 451 children obtained from the National Pediatric Trauma Registry database, mortality rate was reported as 61% in hypotensive alone and 85% in hypoxic and hypotensive children.

[29] However, because of sedation and neuromuscular blocking agent treatment at arrival, limitations in the clinical predictors of outcome (more specifically GCS) in severe TBI have been described in previous studies.[13,30] Therefore, radiographic imaging (CT) and CT-derived scoring systems are also used as objective data to determine prognosis. Ro-CT is one of the radiographic scoring systems to predict hospital mortality and is also validated in children with moderate and severe TBI.[31,32] Liesemer et al.[32] reported that Ro-CT score may be used for risk stratification with incorporating variables as GCS, ISS, and mechanism of injury (p<0.001; OR: 0.91; 95% CI: 0.84–0.98). Our results also demonstrated Ro-CT score to be an independent risk factor predicting mortality in a model of initial hypotension at ER, lung contusion, higher ISS scores, and Ro-CT scores. One unit increment in Ro-CT score increased the odds of recovery by 20.334 times (95% CI: 1.999–206.879), and ISS score was found to be borderline significant (p=0.052; OR: 1.195; 95% CI: 0.999–1.430).

Axonal injury accompanies 50% of brain damage in hospitalized TBI population.[33] As a result of damage to brain parenchyma, cognitive, autonomic, motor, or sensory deficiencies develop upon injury and may result in inability to protect a secure airway and cause prolonged intubation which constitutes greater risks for long-term morbidity and mortality.[33] We also found an association between axonal injury and prolonged mechanical ventilation as well as PICU and hospitalization period. Six children required tracheostomy cannulation at 14.33±1.03 days because of inability to maintain a secure airway or ventilator dependency. The optimal timing of tracheostomy is controversial and varies from 7 to 10 days or even less in adults (3 days).[34,35] In pediatric series the cannulation timing is reported to be 10±8 days (0–38 days) for post-injury events; the decision of cannulation may be shortened to four days and early timing is associated with shorter intubation period, PICU admission and hospitalization.[35] Relatively extended duration in our study may be due to reluctance of families towards the procedure. When we investigated the long-term prognosis, decannulation was performed within 6 months in all the patients except for one who was still in a vegetative state. This favorable outcome possibly resulted from the nature of the underlying condition: prognosis in acute conditions is better than chronic events.[36] International Registry in Organ Donation and Transplantation 2013 data reported Turkey’ organ transplantation rates from donors and cadavers to be 46,64 and 5,05 per million and Ulus Travma Acil Cerrahi Derg, May 2018, Vol. 24, No. 3

Ongun et al. Prediction of mortality in pediatric traumatic brain injury

Turkish Transplant Foundation data announced organ donor rates as 23%.[37,38] However,pediatric data on brain death and organ donors is very limited in Turkey. One study conducted

by Gencpınar and her colleagues confirmed the pediatric organ donor rate in 2015 as 46%, while Yalındağ Öztürk et al.[40] reported the rate of brain death as 1.1% and organ donor rate as 20%.[39] In this study, we diagnosed TBI-related brain death in six children (6.8%), of whom five became organ donors following family declarations. Although TBI-related brain death is only a small fraction of brain death etiology, recognizing the increase in donor trend at our center compared to previous years is inevitable.[39] Positive physician-family communication and raising public awareness towards organ donation undeniably play an important role in the escalating trend.[41] Our study has some limitations: (i) retrospective nature of this study because of risks of potential bias, not allowing definite interpretations; (ii) a limited number of patients included owing to inclusion criteria for those admitted to PICU in 2-year period; (iii) evaluation of long-term cognitive functions on the study population was not possible; (iv) uncertainty about the time elapsed from the moment of trauma incident to PICU admission, which was quoted to be the most critical hours. However, recording all available data obtained through the length of stay (from the moment of ER arrival till the hospital discharge), duration and cessation of anti-edema therapy, and evaluation of potential side effects were stronger points of the study. Being one of the most referred centers in terms of trauma and neurocritical care in the Mediterranean region, the outcomes of our study will guide the clinical approach towards TBI on a nationwide scale.

Acknowledgment Authors thank Busra Gundogan Uzunay MD (Akdeniz University Faculty of Medicine, Department of Pediatrics, Antalya) for assistance in obtaining data.

Source of support: None Conflict of interest: None declared.

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gramme on outcomes after severe traumatic brain injury: a retrospective cohort study. Lancet Neurol 2013;12:45–52.

6. Picetti E, Caspani ML, Iaccarino C, Pastorello G, Salsi P, Viaroli E, et al. Intracranial pressure monitoring after primary decompressive craniectomy in traumatic brain injury: a clinical study. Acta Neurochir (Wien) 2017;159:615–22.

7. Hardcastle N, Benzon HA, Vavilala MS. Update on the 2012 guidelines for the management of pediatric traumatic brain injury - information for the anesthesiologist. Paediatr Anaesth 2014;24:703–10.

8. Ropper AH. Hyperosmolar therapy for raised intracranial pressure. N Engl J Med 2012;367:746–52.

9. Neff LP, Cannon JW, Morrison JJ, Edwards MJ, Spinella PC, Borgman MA. Clearly defining pediatric massive transfusion: cutting through the fog and friction with combat data. J Trauma Acute Care Surg 2015;78:22–8.

10. Maas AI, Hukkelhoven CW, Marshall LF, Steyerberg EW. Prediction of outcome in traumatic brain injury with computed tomographic characteristics: a comparison between the computed tomographic classification and combinations of computed tomographic predictors. Neurosurgery 2005;57:1173–82.

11. Shein SL, Ferguson NM, Kochanek PM, Bayir H, Clark RS, Fink EL, et al. Effectiveness of Pharmacological Therapies for Intracranial Hypertension in Children With Severe Traumatic Brain Injury--Results From an Automated Data Collection System Time-Synched to Drug Administration. Pediatr Crit Care Med 2016;17:236–45.

12. Güiza F, Depreitere B, Piper I, Citerio G, Chambers I, Jones PA, et al.

Visualizing the pressure and time burden of intracranial hypertension in adult and paediatric traumatic brain injury. Intensive Care Med 2015;41:1067–76.

13. Kochanek PM, Carney N, Adelson PD, Ashwal S, Bell MJ, Bratton S, et al; American Academy of Pediatrics-Section on Neurological Surgery; American Association of Neurological Surgeons/Congress of Neurological Surgeons; Child Neurology Society; European Society of Pediatric and Neonatal Intensive Care; Neurocritical Care Society; Pediatric Neurocritical Care Research Group; et al. Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescentssecond edition. Pediatr Crit Care Med 2012;13 Suppl 1:S1–82.

14. Aiolfi A, Benjamin E, Khor D, Inaba K, Lam L, Demetriades D. Brain Trauma Foundation Guidelines for Intracranial Pressure Monitoring: Compliance and Effect on Outcome. World J Surg 2017;41:1543–9.

15. Dawes AJ, Sacks GD, Cryer HG, Gruen JP, Preston C, Gorospe D, et al; Los Angeles County Trauma Consortium. Compliance With EvidenceBased Guidelines and Interhospital Variation in Mortality for Patients With Severe Traumatic Brain Injury. JAMA Surg 2015;150:965–72.

16. Hill EP, Stiles PJ, Reyes J, Nold RJ, Helmer SD, Haan JM. Repeat head imaging in blunt pediatric trauma patients: Is it necessary? J Trauma Acute Care Surg 2017;82:896–900.

17. Aziz H, Rhee P, Pandit V, Ibrahim-Zada I, Kulvatunyou N, Wynne J, et al. Mild and moderate pediatric traumatic brain injury: replace routine repeat head computed tomography with neurologic examination. J Trauma Acute Care Surg 2013;75:550–4.

18. Joseph B, Aziz H, Pandit V, Kulvatunyou N, Hashmi A, Tang A, et al.

A three-year prospective study of repeat head computed tomography in patients with traumatic brain injury. J Am Coll Surg 2014;219:45–51.

19. Schonfeld D, Bressan S, Da Dalt L, Henien MN, Winnett JA, Nigrovic LE. Pediatric Emergency Care Applied Research Network head injury clinical prediction rules are reliable in practice. Postgrad Med J 2015;91:634–8.

20. Brenner D, Elliston C, Hall E, Berdon W. Estimated risks of radiation-induced fatal cancer from pediatric CT. AJR Am J Roentgenol 2001;176:289–96.

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22. Li Q, Chen H, Hao JJ, Yin NN, Xu M, Zhou JX. Agreement of measured and calculated serum osmolality during the infusion of mannitol or hypertonic saline in patients after craniotomy: a prospective, doubleblinded, randomised controlled trial. BMC Anesthesiol 2015;15:138.

23. Francony G, Fauvage B, Falcon D, Canet C, Dilou H, Lavagne P, et al.

Equimolar doses of mannitol and hypertonic saline in the treatment of increased intracranial pressure. Crit Care Med 2008;36:795–800.

24. Bell MJ, Adelson PD, Hutchison JS, Kochanek PM, Tasker RC, Vavilala MS, et al; Multiple Medical Therapies for Pediatric Traumatic Brain Injury Workgroup. Differences in medical therapy goals for children with severe traumatic brain injury-an international study. Pediatr Crit Care Med 2013;14:811–8.

25. Tasker RC, Fleming TJ, Young AE, Morris KP, Parslow RC. Severe head injury in children: intensive care unit activity and mortality in England and Wales. Br J Neurosurg 2011;25:68–77.

26. Hutchison JS, Ward RE, Lacroix J, Hébert PC, Barnes MA, Bohn DJ, et al; Hypothermia Pediatric Head Injury Trial Investigators and the Canadian Critical Care Trials Group. Hypothermia therapy after traumatic brain injury in children. N Engl J Med 2008;358:2447–56.

27. Spaite DW, Hu C, Bobrow BJ, Chikani V, Barnhart B, Gaither JB, et al. The Effect of Combined Out-of-Hospital Hypotension and Hypoxia on Mortality in Major Traumatic Brain Injury. Ann Emerg Med 2017;69:62–72.

28. Araki T, Yokota H, Morita A. Pediatric Traumatic Brain Injury: Characteristic Features, Diagnosis, and Management. Neurol Med Chir (Tokyo) 2017;57:82–93.

29. Pigula FA, Wald SL, Shackford SR, Vane DW. The effect of hypotension and hypoxia on children with severe head injuries. J Pediatr Surg 1993;28:310–4.

30. Saatman KE, Duhaime AC, Bullock R, Maas AI, Valadka A, Manley GT; Workshop Scientific Team and Advisory Panel Members. Classification of traumatic brain injury for targeted therapies. J Neurotrauma 2008;25:719–38.

31. Deepika A, Prabhuraj AR, Saikia A, Shukla D. Comparison of predictability of Marshall and Rotterdam CT scan scoring system in determining early mortality after traumatic brain injury. Acta Neurochir (Wien) 2015;157:2033–8.

32. Liesemer K, Riva-Cambrin J, Bennett KS, Bratton SL, Tran H, Metzger RR, et al. Use of Rotterdam CT scores for mortality risk stratification in children with traumatic brain injury. Pediatr Crit Care Med 2014;15:554–62.

33. Su E, Bell M. Diffuse Axonal Injury. In: Laskowitz D, Grant G, editors.

Translational Research in Traumatic Brain Injury. Boca Raton (FL): CRC Press/Taylor and Francis Group; 2016.

34. Khalili H, Paydar S, Safari R, Arasteh P, Niakan A, Abolhasani Foroughi A. Experience with Traumatic Brain Injury: Is Early Tracheostomy Associated with Better Prognosis? World Neurosurg 2017;103:88–93.

35. Holscher CM, Stewart CL, Peltz ED, Burlew CC, Moulton SL, Haenel JB, et al. Early tracheostomy improves outcomes in severely injured children and adolescents. J Pediatr Surg 2014;49:590–2.

36. Dursun O, Ozel D. Early and long-term outcome after tracheostomy in children. Pediatr Int 2011;53:202–6.

37. Gómez MP, Arredondo E, Páez G, Manyalich M. International Registry in Organ Donation and Transplantation 2010. Transplant Proc 2012;44:1592–7.

38. Turkish Transplant Foundation. Donor activity in Turkey, 2013.

Available at: http://www.tonv.org.tr/wp-content/uploads/2016/11/ TURKEY-ORGAN-DONATION-AND-TRANSPLANTATIONSTATISTICS-IN-2013.pdf. Accessed Mar 28, 2018.

39. Gençpınar P, Dursun O, Tekgüç H, Ünal A, Haspolat Ş, Duman Ö. Pediatric Brain Death: Experience of a Single Center. Turkiye Klinikleri J Med Sci 2015;35:60–6.

40. Yalındağ Öztürk N, İnceköy Girgin F, Birtan D, Cinel I. Exploring Brain Death at a Tertiary Pediatric Intensive Care Unit in Turkey; Incidence, Etiology and Organ Donation. J Pediatr Emerg Intensive Care Med 2016;3:11–4.

41. Gündüz RC, Şahin Ş, Uysal-Yazıcı M, Ayar G, Yakut Hİ, Akman AÖ, et al. Brain death and organ donation of children. Turk J Pediatr 2014;56:597–603.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Çocukluk çağı kafa travması olgularında mortaliteye etki eden faktörler: Üçüncü basamak çocuk yoğun bakım ünitesi uygulamaları Dr. Ebru Atike Ongun, Dr. Oğuz Dursun Akdeniz Üniversitesi Tıp Fakültesi, Çocuk Yoğun Bakım Ünitesi, Antalya

AMAÇ: Çalışmanın amacı, travmatik beyin hasarı nedeniyle yoğun bakım yatışı yapılan çocuklarda morbidite ve mortaliteye etki eden faktörleri belirlemektir.

GEREÇ VE YÖNTEM: Eylül 2014–Aralık 2016 arasında 88 hasta değerlendirildi. Glaskow koma skoruna göre üç grupta incelenen hastaların acil servis ve yoğun bakım süreçleri, verilen anti-ödem tedavileri, hedef serum ozmolariteye ulaşma süreleri, aksonal hasar varlığı, entübasyon, trakeostomi oranları, yoğun bakım ve hastane yatış süreleri, Rotterdam-CT skorlaması, travma şiddet ve PRISM–III skorları kayıt edildi.

BULGULAR: Yaş arttıkça kafa travması şiddetinin arttığı görüldü (p=0.010). Beyin ödemi tedavisi alan hastalarda, hedef serum ozmolariteye (ölçülen) ulaşma zamanı 8.5 (3.5–40) saat idi. ICP monitorizasyon oranı %8 olup, monitorizasyon yapılamadığı durumda takiplerin tekrarlayan tomografiler ile yapıldığı ancak tedavi sürecini değiştirmediği saptandı. Aksonal hasarın entübasyon, yoğun bakım ve hastane yatış sürelerini uzattığı saptandı (p<0.001, p<0.001, p=0.030). Altı hastaya 14.33±1.03 günde trakeostomi açıldı; beşinin trakeostomileri ilk altı ay içinde kapatıldı.

TARTIŞMA: Mortalitenin %12.5 olduğu görüldü; hipotansiyon, akciğer kontüzyonu, travma şiddet ve Rotterdam-CT skorlarının mortalite ile ilişkili idi. Rotterdam-CT skorunun sağ kalımda etkili bağımsız risk faktörü olduğu (p=0.001), skordaki bir birimlik artışın sağ kalım oranını 13.235 kat artırdığı (%95 GA 2.792–62.735); travma şiddet skorunun ise sınırda anlamlı olduğu saptandı (p=0.052; OO: 1.195 %95 GA 0.999–1.430). Beyin ölümü tanısı alan altı hastanın beşi hasta organ donorü oldu.

Anahtar sözcükler: Beyin ödemi tedavisi; çocuk; mortalite; Rotterdam CT skoru; travmatik beyin hasarı; yoğun bakım.

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ORIG I N A L A R T IC L E

Predictive value of preoperative neutrophil-to-lymphocyte ratio while detecting bowel resection in hernia with intestinal incarceration Hande Köksal, M.D.,1 Derviş Ateş, M.D.,1 Emet Ebru Nazik, M.D.,1 İlknur Küçükosmanoğlu, M.D.,2 Serap Melek Doğan, M.D.,1 Osman Doğru, M.D.1 1

Department of General Surgery, Health Sciences University, Konya Training and Research Hospital, Konya-Turkey

2

Department of Pathology, Health Sciences University, Konya Training and Research Hospital, Konya-Turkey

ABSTRACT BACKGROUND: The aim of this study was to evaluate the relationship between preoperative hematological inflammatory markers of the patients who underwent a surgery for incarcerated hernia and intestinal resection requirement.

METHODS: The data of 102 patients who underwent a surgery for incarcerated hernia were retrospectively evaluated. Whole blood cell counts were preoperatively measured, and operation types and pathology results were recorded. The patients with intestinal resections were compared with those without any resection in terms of leukocyte number, neutrophil rate, red cell distribution width (RDW), platelet distribution width, neutrophil-to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), and mean platelet volume (MPV).

RESULTS: Eighty-one patients were operated for incarcerated groin hernia, 17 for incarcerated umbilical hernia, and 4 for incarcerated incisional hernia. Twenty-six patients (25%) had intestinal resections; in 4 of them, intestinal perforation was detected. In patients with intestinal resections,the neutrophil rate, PDW, NLR, and PLR values were significantly higher than those in the patients without any resections.

CONCLUSION: High NLR rates, certainly with clinical correlation, can be used as a biomarker to predict intestinal necrosis and the need for intestinal resection in patients who will undergo surgery for incarcerated hernia, particularlyin situations with lacking radiological imaging methods.

Keywords: Incarcerated hernia; neutrophil to lymphocyte ratio; resection.

INTRODUCTION Abdominal wall hernias such as groin, femoral, or incisional are one of the common problems during surgeries, and the incarceration of the hernias is one of the emergent situations, which are generally urgently operated. When the bowel is strangulated, it can lead to life-threatening complications, including bowel necrosis, perforation, or peritonitis. An early prediction of these complications and surgery planning are crucial for surgeons. It is essential to develop new diagnostic methods or markers for the early detection of these compli-

cations. The studies on similar complications in acute mesenteric ischemia have been reported so far.[1–4] Leukocyte and platelet counts and neutrophil ratio are known and often used as hematological inflammatory markers. In particular, neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) have been recently used as hematological inflammatory markers. The increase in neutrophil count during inflammation is recognized, which leads to relative lymphopenia in these cases. Hence, NLR reflects the underlying inflammation. It has been used for the early

Cite this article as: Köksal H, Ateş D, Nazik EE, Küçükosmanoğlu İ, Doğan SM, Doğru O. Predictive value of preoperative neutrophil-to-lymphocyte ratio while detecting bowel resection in hernia with intestinal incarceration. Ulus Travma Acil Cerrahi Derg 2018;24:207-210.

Address for correspondence: Hande Köksal, M.D. Sağlık Bilimleri Üniversitesi, Konya Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, Konya, Turkey Tel: +90 332 - 221 00 00 E-mail: drhandeniz@yahoo.com Ulus Travma Acil Cerrahi Derg 2018;24(3):207-210 DOI: 10.5505/tjtes.2017.93937 Submitted: 26.12.2016 Accepted: 26.09.2017 Online: 09.05.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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208

a: No resection & bowel necrosis; p=0.026; b: No resection & bowel necrosis; p=0.002; c: No resection & bowel necrosis; p=0.019; d: No resection & bowel necrosis; p=0.032. WBC: White blood cells; RDW: Red cell distribution with; PDW: Platelet distribution with; NLR: Neutrophil/lymphocyte ration; PLR: Platelet/lymphocyte ratio; MPV: Mean platelet volume.

NS d c b NS a

9.93±1.35 9.68±1.68 9.9±1.7 172.14±88.39 127.12±27.67 244.42±159.11 5.15±4.01 4.21±2.69 7.72±5.69 12.69±2.25 13.01±1.47 15.02±3.36 70.46±12.54 70.12±8.99 76.23±12.16 10126.85±3273.08 10503.75±2743.52 11258.07±5523.56

14.36±1.75 14.51±1.57 15.06±1.91

10.62±2.83 9.87±1.4 NS 212.77±91.12 189.42±115.16 NS 6.73±3.74 5.76±4.59 NS 16.65±4.44 13.18±2.52 0.05 75.75±5.79 71.81±12.42 NS

14.82±2.18 14.57±1.83 NS

220.98±143.73 172.14±88.39 NS 6.89±5.22 5.15±4.01 NS 14.38±3.01 12.69±2.25 0.002

11742.5±4254.24 10406.31±4124.47 NS

NS p

The PDW values of the patients with and without bowel resection were 14.38±3.01 and 12.69±2.25, respectively, and the difference was significant statistically (p=0.002). According to the pathologic examination, the neutrophil rate, PDW, NLR and PLR values of the patients with bowel necrosis were higher than those of the patients without bowel necrosis (p=0.026, p=0.002, p=0.019, and p=0.032, respectively).

We enrolled 102 patients who underwent surgery for incarcerated hernia in this study. The age of the patients ranged from 21 to 89 years with a median age 68 years; 60 of the patients were males (59%) and 42 patients were females (41%). Eighty-one patients were operated for incarcerated groin hernia, 17 for incarcerated umbilical hernia, and 4 patients for incarcerated incisional hernia. Twenty-six patients (25%) had intestinal resections; in 4 of them, intestinal perforation was detected. In the patients with intestinal resections, the neutrophil rate, PDW, NLR, and PLR values were significantly higher than in those without any resections (Table 1).

Table 1. Patients’ hematological inflammatory markers

RESULTS

WBC (/mm3)

Neutrophil rate (%)

RDW (%)

For statistical assessment, the Statistical Package for Social Sciences (version 16.0; Chicago, IL, USA) program was used.

Median values were used to analyze demographic characteristics. Parametric data is provided as arithmetic mean±standard deviation. For comparing categorical variables, Pearson chi-square test was used, and the comparison between the groups was assessed by Student’s t-test or Mann–Whitney U-test (parametric and non-parametric data, respectively). In the statistical evaluations, a p-value <0.05 was regarded as statistically significant.

14.96±1.93 14.36±1.75 NS

PDW (%)

The patients who underwent surgery for incarcerated hernias in our clinic from January 2014 to December 2015 were retrospectively evaluated. Preoperatively obtained complete blood counts, operation types, and pathology results were recorded from their files. Leukocyte count, neutrophil rate, RDW, PDW, and MPV were obtained from the patients’ complete blood counts. NLR and PLR were also calculated.

74.5±11.41 70.46±12.54 NS

NLR

MATERIALS AND METHODS

11017.63±5243.81 10126.85±3273.08 NS

PLR

The aim of this study was to evaluate the predictive value of the preoperative hematological inflammatory markers, including NLR, PLR, red cell distribution width (RDW), platelet distribution width (PDW), and mean platelet volume (MPV), while detecting the need for bowel resection in hernia with intestinal incarceration.

Resection Performed (n=38, 37%) No performed (n=64, 63%) p Perforation Positive (n=4, 4%) Negative (n=98, 96%) p Pathology No resection (n=64, 63%) Omental inflammation (n=8, 7%) Bowel necrosis (n=26, 25%)

MPV (fL)

detection of different inflammatory processes such as acute appendicitis, pancreatitis, and mesenteric ischemia.[1,4–8] The number of similar studies on complicated hernias, including strangulation and incarceration, is limited.[9,10]

9.84±1.66 9.93±1.35 NS

Köksal et al. NLR in incarcerated hernia

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Köksal et al. NLR in incarcerated hernia

DISCUSSION Abdominal wall hernias are one of the common problems during surgeries. Surgical approach is only a treatment choice.

Sometimes, the contents of the hernia sac can be incarcerated in the abdominal wall. Incarcerated hernia can become strangulated, particularly when the bowel blood flow impairs, and it can cause bowel ischemia and necrosis. Incarceration, bowel ischemia, and necrosis can be life-threatening. In particular, the early detection of bowel ischemia and necrosis are crucial for planning the surgery. The studies on the early detection of ischemia and necrosis are mostly about acute mesenteric ischemia.[1–4] In a study by Karabulut et al.,[3] the role of procalcitonin and phosphorus in the early diagnosis of acute mesenteric ischemia were evaluated. They found that the maximum elevation in the procalcitonin and phosphorus levels was detected at the third hour of ischemia. They concluded that procalcitonin and phosphorus can be used in the early diagnosis of acute mesenteric ischemia. In another study, a different biomarker such as C-reactive protein, leukocyte count, MPV, RDW, and NLR were used in the early detection of acute mesenteric ischemia. The NLR levels were high in patients with acute mesenteric ischemia. Optimal sensitivity (50%) and specificity (66.1%) for NLR was 7.85% in the ROC analysis.[1] The roles of NLR, leukocyte count, RDW, and MPV in the patients with acute mesenteric ischemia, acute appendicitis, and normal appendix were investigated. The RDW and NLR values were higher in the patients with acute mesenteric ischemia than those in patients with acute appendicitis. Moreover, leukocyte count, MPV, RDW, and NLR were higher in the patients with acute mesenteric ischemia than those in patients with normal appendix. They concluded that high NLR can be valuable for the early detection of acute mesenteric ischemia.[4] Recently, NLR calculated from complete blood count has been used in different inflammatory conditions.[1,4–10] Different studies reported about patients diagnosed with acute appendicitis.[5–7] Preoperative NLR seems to be a valuable predictor of gangrenous appendicitis. In this study, they concluded that high NLR (>8) levels can predict severe acute appendicitis.[5] In another study by Cigsar et al.,[6] it was found that NLR could predict positive appendectomy in non-geriatric patients; however, it could not be valid in geriatric patients. In a detailed report by Sevinç,[7] if a patient with a suspected diagnosis of acute appendicitis has high NLR (>3), it was correlated with a definitive diagnosis. If a patient with acute appendicitis has NLR >4.8, the probability of perforation is high.

In incarcerated hernias, the role of the ischemia-modified albumin in the early detection of ischemia was investigated in Ulus Travma Acil Cerrahi Derg, May 2018, Vol. 24, No. 3

an animal study by Kadioğlu et al.[10] In this study, the ischemia-modified albumin levels in incarceration and strangulation groups were higher than those in sham group. Furthermore, the ischemia-modified albumin level of the strangulation group was higher than that of the incarceration group. They concluded that ischemia-modified albumin seems to be an effective predictive marker of early detection of necrosis in patients with incarcerated hernias. In the study about the patients with strangulated inguinal hernia by Zhou et al.,[11] they studied the clinical value of NLR. NLR of the patients with obvious bowel ischemia was higher than that of the patients without bowel ischemia. Another finding from the study was that NLR, hernia type, and the organ in the hernia sac were significantly related to strangulation according to the multivariate analysis.

In our study, the patients with intestinal resections were compared with those without any resection in terms of the leukocyte number, neutrophil rate, RDW, PDW, NLR, PLR, and MPV. In the patients with bowel resections, the neutrophil rate PDW, NLR, and PLR were significantly higher.

In conclusion, routinely used preoperative hematologic parameters can aid in the preoperative decision of bowel resection in patients with incarcerated hernia, particularlyin situations with lacking radiological imaging methods. However, prospective studies with large number of patients are needed in the further determination of the cut-off values of these parameters.

Conflict of interest: None declared.

REFERENCES 1. Tanrıkulu Y, Şen Tanrıkulu C, Sabuncuoğlu MZ, Temiz A, Köktürk F, Yalçın B. Diagnostic utility of the neutrophil-lymphocyte ratio in patients with acute mesenteric ischemia: A retrospective cohort study. Ulus Travma Acil Cerrahi Derg 2016;22:344–9.

2. Chau GY, Lui WY, King KL, Wu CW. Evaluation of effect of hemihepatic vascular occlusion and the Pringle maneuver during hepatic resection for patients with hepatocellular carcinoma and impaired liver function.

World J Surg 2005;29:1374–83.

3. Karabulut K, Gül M, Dündar ZD, Cander B, Kurban S, Toy H. Diagnostic and prognostic value of procalcitonin and phosphorus in acute mesenteric ischemia. Ulus Travma Acil Cerrahi Derg 2011;17:193–8.

4. Aktimur R, Cetinkunar S, Yildirim K, Aktimur SH, Ugurlucan M, Ozlem N. Neutrophil-to-lymphocyte ratio as a diagnostic biomarker for the diagnosis of acute mesenteric ischemia. Eur J Trauma Emerg Surg 2016;42:363–8.

5. Ishizuka M, Shimizu T, Kubota K. Neutrophil-to-lymphocyte ratio has a close association with gangrenous appendicitis in patients undergoing appendectomy. Int Surg 2012;97:299–304.

6. Cigsar G, Yildirim AC, Anuk T, Guzel H, Gunal E, Gulkan S, et al. Neutrophil to lymphocyte ratio on appendectomy of geriatric and nongeriatric patients. J Invest Surg 2017;30:285–90.

7. Sevinç MM, Kınacı E, Çakar E, Bayrak S, Özakay A, Aren A, et al. Diagnostic value of basic laboratory parameters for simple and perforated

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Köksal et al. NLR in incarcerated hernia acute appendicitis: an analysis of 3392 cases. Ulus Travma Acil Cerrahi Derg 2016;22:155–62.

8. Azab B, Jaglall N, Atallah JP, Lamet A, Raja-Surya V, Farah B, et al. Neutrophil-lymphocyte ratio as a predictor of adverse outcomes of acute pancreatitis. Pancreatology 2011;11:445–52.

9. Hwang SY, Shin TG, Jo IJ, Jeon K, Suh GY, Lee TR, et al. Neutrophilto-lymphocyte ratio as a prognostic marker in critically-illseptic patients.

Am J Emerg Med 2017;35:234–9.

10. Kadioğlu H, Ömür D, Bozkurt S, Ferlengez E, Memmı N, Ersoy YE, et al. Ischemia modified albumin can predict necrosis at incarcerated hernias. Dis Markers 2013;35:807–10.

11. Zhou H, Ruan X, Shao X, Huang X, Fang G, Zheng X. Clinical value of the neutrophil/lymphocyte ratio in diagnosing adult strangulated inguinal hernia. Int J Surg 2016;36:76–80.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Nötrofil-lenfosit oranı inkarsere hernisi olan hastalarda ameliyat öncesi dönemde bağırsak nekrozunu öngörmede bir belirteç olabilir mi?

Dr. Hande Köksal,1 Dr. Derviş Ateş,1 Dr. Emet Ebru Nazik,1 Dr. İlknur Küçükosmanoğlu,2 Dr. Serap Melek Doğan,1 Dr. Osman Doğru1 1 2

Sağlık Bilimleri Üniversitesi, Konya Eğitim ve Araştırma Hastanesi, Genel Cerrahi Bölümü, Konya Sağlık Bilimleri Üniversitesi, Konya Eğitim ve Araştırma Hastanesi, Patoloji Bölümü, Konya

AMAÇ: Çalışmanın amacı inkarsere herni nedeniyle acil ameliyat planlanan hastalarda ameliyat öncesi dönemdeki nötrofil/lenfosit oranı (NLR) ile olası bağırsak rezeksiyonu gerekliliği arasında ilişki olup olmadığının araştırılmasıdır.

GEREÇ VE YÖNTEM: İnkarsere herni nedeniyle ameliyat edilen 102 hastanın verileri geriye dönük olarak incelendi. Ameliyat öncesi tam kan sayımları ile yapılan ameliyat ve varsa patoloji sonuçları kaydedildi. Bağırsak rezeksiyonu yapılan hastalarla yapılmayan hastalar lökosit sayısı, nötrofil oranı, eritrosit dağılım genişliği (RDW), trombosit dağılım genişliği (PDW), NLR, trombosit/lenfosit oranı (PLR) ve ortalama trombosit hacmi (MPV) açısından karşılaştırıldı.

BULGULAR: Hastaların 81’i inkarsere inguinal herni, 17’si inkarsere umblikal herni ve dördü de inkarsere insizyonel herni nedeniyle ameliyat edilmişti. Hastalardan 26’sına (%25) ameliyat sırasında bağırsak rezeksiyonu yapılmış ve dördünde bağırsak perforasyonu saptanmıştı. Bağırsak rezeksiyonu yapılan grupta nötrofil oranı, PDW, NLR ve PLR değerleri bağırsak rezeksiyonu yapılmayan gruba göre anlamlı oranda yüksekti.

TARTIŞMA: Yüksek NLR değerleri klinikle birlikte değerlendirildiğinde; özellikle görüntüleme yöntemlerinin kullanılamadığı durumlarda inkarsere herni nedeniyle ameliyat edilecek hastalarda bağırsak nekrozu ve rezeksiyon gerekliliğini ameliyat öncesi dönemde öngörmede yardımcı bir belirteç olarak kullanılabilir.

Anahtar sözcükler: İnkarsere herni; nötrofil-lenfosit oranı; rezeksiyon.

Ulus Travma Acil Cerrahi Derg 2018;24(3):207-210

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doi: 10.5505/tjtes.2017.93937

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ORIG I N A L A R T IC L E

Role of circulating microRNAs in acute appendicitis Avni Uygar Seyhan, M.D.,1 Elif Funda Şener, M.D.,2 Oğuzhan Bol, M.D.,3 Serpil Taheri, M.D.,2 Tugba Topaloglu, M.D.,4 Esra Tufan, M.D.,4 Reyhan Tahtasakal, M.D.,4 Nahide Ekici Günay, M.D.,5 Hatice Karabulut, M.D.,6 Nurullah Günay, M.D.6 1

Department of Emergency Medicine, Health Sciences University, Kartal Dr. Lütfi Kirdar Training and Research Hospital, İstanbul-Turkey

2

Department of Medical Biology, Erciyes University Faculty of Medicine, Kayseri-Turkey

3

Department of Emergency Medicine, Namık Kemal University Faculty of Medicine, Tekirdağ-Turkey

4

Genome and Stem Cell Center (GENKOK), Erciyes University, Kayseri-Turkey

5

Department of Clinical Biochemistry, Health Sciences University, Kayseri Training and Research Hospital, Kayseri-Turkey

6

Department of Emergency Medicine, Erciyes University Faculty of Medicine, Kayseri-Turkey

ABSTRACT BACKGROUND: Acute appendicitis (AA) is a momentous, emergency, surgical pathology that has still been investigated for both etiopathogenetic unknowns and challenges in diagnosis. Presently, there is little information about the role of microRNAs (miRNAs), which have basic biological functions in the cell, can be a marker, and are associated with various pathologies, in patients with AA. The aim of this study was to investigate the expressions of some miRNAs in AA. METHODS: Overall, 41 miRNAs were screened in 48 individuals comprising 24 patients with AA and 24 healthy controls at Erciyes University Genome and Stem Cell Center (GENKOK). The obtained data were analyzed using appropriate statistical methods.

RESULTS: miR-29c-3p was found to be increased 2-fold during the first 4–6 h in AA, and this increase was revealed to be statistically significant compared with healthy individuals. Similarly, expressions of let-7b-5p, let-7i-5p, miR-30a-5p, miR-29b-3p, and miR-23a-3p also increased approximately 2-fold in AA, although not statistically significant. No significant differences were found in the screening of the remaining 35 miRNAs in patients with AA. CONCLUSION: Although there is little information about the relationship between AA and miRNAs currently, miR-29c-3p was reported to increase in the acute period of AA in this study. With the current results, it can be argued that miR-29c-3p bears the potential to be a marker in patients with AA. The present study may also be a basic research for more extensive and necessary miRNAs screening in this field.

Keywords: Acute appendicitis; inflammation; microRNAs.

INTRODUCTION New horizons can be established to directed to its diagnosis and treatment via a new and different researches related to AA that is still an unknown of its definitive etiopathogenesis; AA carries a 6%–7% risk of development in human beings during their lifetime.[1] As a new and different point of view, the present study aimed to challenge the possible relationship be-

tween microRNAs (miRNA) and AA that is yet still unknown.

The number of miRNAs, which were detected in the 1990s and new ones have been discovered so far, in humans is about 1880.[2] Currently, there are little data to conclude whether these groups of molecular biologic entities that are known to take part in the regulation of many cellular functions and for example as oncogene or tumor suppressors or not have a role in the etiopathogenesis of AA. There is only one report show-

Cite this article as: Seyhan AU, Şener EF, Bol O, Taheri S, Topaloglu T, Tufan E, et al. Role of circulating microRNAs in acute appendicitis.

Ulus Travma Acil Cerrahi Derg 2018;24:211-215.

Address for correspondence: Nurullah Günay, M.D. Erciyes Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, Kayseri, Turkey Tel: +90 352 - 207 66 66 E-mail: ngacil@hotmail.com Ulus Travma Acil Cerrahi Derg 2018;24(3):211-215 DOI: 10.5505/tjtes.2017.22379 Submitted: 13.07.2017 Accepted: 13.09.2017 Online: 10.05.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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Seyhan et al. Role of circulating microRNAs in acute appendicitis

ing no relation between AA and miR-21.[3–6] It is suggested that miRNAs that do not encode proteins in terms of genetics but take part in cellular metabolism by regulating protein expression play a role in various pathologies; for example, miR-146a and miR-223 levels have been reported to be low in sepsis.[7] In addition to their role in elementary biological functions and as a biological marker, they are considered to create a therapeutic pathway by affecting a specific gene target by changing the expression of miRNAs.[4,5] It is still early to generate a miRNAmediated therapeutic hypothesis in patients with AA, but it is possible to screen some miRNAs in AA. This probability is the aim of this present study.

MATERIALS AND METHODS This study was conducted in cooperation with Kayseri Training and Research Hospital Emergency Department, Erciyes University Medical Faculty Emergency Medicine Department and Medical Biology Departments. The present study was approved by the local ethics committee (10.02.2015/441), and the support by the Scientific Research Project numbered TTU-2016-6072 was terminated on 01.30.2017. MiRNA analyses were performed at the GENKOK of the same university. The project budget was the main determinant in the detection of 41 miRNAs scanned in a total of 48 individuals, including the study and control groups.

Patient Selection Patients with AA are carefully selected among cases presenting to the emergency service of a hospital where around 8–10 emergency appendectomies are performed daily. A total of 24 patients with AA could have been included in the study as per the project budget; hence, cases that were almost certainly clinically diagnosed as AA and have a positive finding by computed tomography were included in the study. In addition, patients complaining of AA symptoms since 4–6 h were selected as the target study group. No pediatric cases were included in the study because the pediatric emergency service functions as a separate unit. Subsequently, pathologic diagnosis confirmed the diagnosis of AA in all cases. During the establishing of the study group, cases with any systemic disease, chronic drug use, and even presence of any suspicion for an additional pathology were excluded from the study. In summary, although the patients with AA have been defined by the method used in a previous study, a more sensitive approach has been exhibited and patients in the 4–6-h period after the start of AA symptomatology have been selected.[8] Control group samples were obtained at blood center from healthy subjects whose age and gender concordant with the study group.

Serum Samples Collection and Preparation From each patient and control subject, 5 ml of venous blood samples was obtained, centrifuged at 3000×g, 4°C, and for 20 min and then serum was separated. All serum samples were stored at −80°C for later analysis.

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RNA Extraction and qRT-PCR for miRNA Expressions Total RNA, including miRNAs, was extracted from sera samples of patients and controls using the miRNeasy Mini Kit (Qiagen, Germany, Cat. No.217004). RNA (50 ng) was reverse transcribed using a miScript II RT Kit (Qiagen, Cat. No.218161) in a Qiagen SensQuest Lab cycler (Qiagen, Germany), according to the manufacturer’s protocol. Complementary DNA (cDNA) was then diluted in RNase-free water.

Quantitative real-time PCR (qRT-PCR) was performed using miScript Syber Green PCR kit (Qiagen, Cat. No.218075).

Gene expression profiles were generated in 96-well arrays using the custom miScript miRNA PCR array, according to manufacturer’s instructions, for the following 41 microRNAs: Hs_let-7b-5p, Hs_let-7c, Hs_let-7d-5p, Hs_let-7i-5p, Hs_miR29a-3p, Hs_miR-29c-3p, Hs_miR-30b-5p, Hs_miR-34a-5p, Hs_miR-98, Hs_miR-381, Hs_miR-449a, Hs_miR-449b-5p, Hs_miR-590-5p, Hs_miR-656, Hs_let-7f-5p, Hs_miR-29b-3p, Hs_miR-181b-5p, Hs_miR-30a-5p_1, Hs_let-7g-5p, Hs_miR101-3p, Hs_miR-128, Hs_miR-181a-5p, Hs_miR-181c-5p, Hs_miR-202-3p, Hs_miR-21-5p, Hs_miR-30c-5p, Hs_miR30d-5p, Hs_miR-30e-5p, Hs_miR-374a-5p, Hs_miR-543, Hs_ miR-875-3p_1, Hs_miR-548e, Hs_miR-144-3p, Hs_let-7a-5p, Hs_let-7e-5p, Hs_miR-181d, Hs_miR-23a-3p, Hs_miR-23b3p, Hs_miR-300, Hs_miR-340-5p, and Hs_miR-524-5p. Qiagen Rotor-Gene Q system were used as follows: 15 min at 95°C for 1 cycle and 15s at 94°C, 30s at 55°C, and 30s at 70°C for 40 cycles. The controls were used when the differential expression of miRNAs was investigated using commercially available single primer assays (Qiagen, USA) samples with (i) No RNA, (ii) No reverse transcriptase and (iii) C. elegans spike-controls in cDNA synthesis and (iv) No cDNA control in the reaction. Threshold cycle data were analyzed using the RT2 Profiler software (version 3.4; SABiosciences).

Relative gene expression levels were normalized to housekeeping genes (SNORD61, Hs_RNU6-2_11). The 2ΔΔCT method of relative quantification was used to calculate the relative abundance of miRNAs in serum.

Statistical Analysis The relative expression of miRNAs was analyzed using SABiosciences software, and the p-value was calculated based on Student’s t-test of the replicate 2ΔΔCT (-Delta Ct) values for each gene in the control and patient groups. P-values <0.05 were considered statistically significant. The relevant clinicopathological features were determined by one way ANOVA for quantitative data and X2 test for qualitative data. All tests were two-sided, and p-value <0.05 was considered statistically significant.

RESULTS The study and control groups consisted of 48 individuals from the same number and gender. The mean ages of subjects in the study and control groups were 33.00±13.82 and 33.50±13.71 Ulus Travma Acil Cerrahi Derg, May 2018, Vol. 24, No. 3

Seyhan et al. Role of circulating microRNAs in acute appendicitis

years, respectively. All patients in the study group were found to have AA favorable CT imaging in the emergency department, and no other pathology was found; the pathologic results after appendectomy were consistent with AA. Based on the miRNA analyses that constituted the main part of the study, it was determined that six of the 41 miRNAs demonstrated about two-fold increase in expression, whereas the remaining 35 miRNAs did not vary in patients with AA. Patient and Control Group

4 Log10 Normalized Expression Group 1

3.5

Gene symbol

Fold change

p

95% CI

let-7b-5p

2.015

0.085941

0.85, 3.18

let-7i-5p

2.0006

0.236203

0.54, 3.47

miR-29c-3p

2.3778

0.034991

0.39, 4.36

miR-29b-3p

2.3089

0.110923

0.28, 4.33

miR-30a-5p

2.1094

0.070602

0.61, 3.61

miR-23a-3p

2.0006

0.099282

0.64, 3.36

let-7b-5p miR-23a-2

3 miR-30a-5pâ&#x20AC;&#x201C;1

2.5

*

2

let-7i-5p

miR-29c-3p miR-29b-3p

1.5 1 0.5 0 -0.5

Upregulated Unchanged Downregulated

-1 -1.5

Table 1. Differential expression of the studied miRNAs in AA group compared with the control group

-1

-0.5 0 0.5 1 1.1 2 2.5 Log10 (Normalized Expression Control Group)

Figure 1. miRNAs scatter plot graph for groups.

3

The increased expression of miR-29c-3p, which was approximately doubled in patients with AA compared with healthy individuals, was found to be statistically significant (p=0.034).

There was no statistically significant increase in miRNAs encoded with let-7b-5p, let-7i-5p, miR-30a-5p, miR-29b-3p, and miR-23a-3p among the groups (Table 1). When comparing AA patients with healthy individuals, it was found that other scanned miRNAs did not demonstrate any difference in expression levels among the groups. Scatterplot and heatmap graphics of all miRNAs are presented in Figures 1 and 2.

Additionally, it was set that there is no statistically significant variation in terms of gender of miR-29c-3p, which is detected elevated in patients with AA compared to healthy

Figure 2. Heatmap graphic.

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Seyhan et al. Role of circulating microRNAs in acute appendicitis

Table 2. Potential inflammatory gene targets of identified miRNAs in patients with AA Potential marker of elevated miRNAs in AA

Potential inflammatory gene targets of identified miRNAs

let-7b-5p

ACVR2A, CCL7, CCR7, FASLG, GDF6, IL10, IL13, LY75, OSMR, POU2F2, TGFBR1

let-7i-5p miR-23a-3p

ATRN, CCL7, CXCL12, IL12B, IL6R, KITLG, M6PR, PROK2, TGFBR2, TPST1

miR-29c-3p*

CD276, HDAC4, IL1RAP, LIF, PTX3, TNFRSF1A, VEGFA

miR-29b-3p miR-30a-5p

ACVR1, ATRN, IL1A, LEPR, LIFR, NR4A2

*Statistically significant.

individual. Furthermore, no correlation was detected between miR-29c-3p and abdominal pain, nausea, vomiting, loss of appetite, complete blood count, and some serum parameters.

DISCUSSION It is stated that AA has still been primarily in the differential diagnosis of all age and gender patients presenting to the emergency departments with complaints of inflammatory abdominal pain, which is the leading cause of emergency surgery.

AA is still under investigation because its early diagnosis and treatment is challenging. Currently, it is known that early and accurate diagnosis of AA is indispensable in terms of not to be delaying of its treatment. Besides, it is extremely important to be able to prevent the undesirable morbimortality that negative laparotomy can cause.[9] The present study, performed with the consideration that miRNAs in AA might have a positive contribution to both concerns, yielded some positive results despite its limited budget.

This is the first study to characterize changes in AA with profiling of the selected miRNAs associated with inflammation.

Our results revealed upregulation of miR-29c-3p, miR-23a3p, miR-29b-3p, miR-30a-5p, let-7i-5p, and let-7b-5p in the AA group compared with the control group.

We found that miR-29c-3p could be used as a potential molecular marker to identify AA diagnosis with significant p-values (p=0.035). We identified the possible miR-29c-3p molecular targets, which include CD276, HDAC4, IL1RAP, LIF, PTX3, TNFRSF1A, and VEGFA (Table 2).

In literature, miR-29c-3p is defined as a tumor suppressor gene. MiR-29c-3p is reported to regulate the P53 expression in particular. In the study by Galani et al.,[10] miRNA profiles have been investigated in benign, atypical, and malignant meningioma groups. Therefore, in meningiomas, miR-29c3p, miR-200a, miR-145, miR-219-5p have been reported to be downregulated, whereas miR-21, miR-335, and miR-190a have been reported to be upregulated. Another study reported that the recurrence rates are lower in meningioma patients with low mir-29c-3p expression.

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Geng Chen et al.[12] reported that miR-29c-3p is expressed in almost any type of cancer. Pleckstrin homology-like domain family B member 2 (PHLDB2) gene is a valid target gene for mir-29c-3p as well. It was demonstrated that the inhibition of PHLDB2 gene by miR-29c-3p gene suppresses cell growth significantly in colon cancer in the presence of ectopic PHLDB2 expression. Therefore, mir-29c-3p is directly associated with p53 gene in colon cancer metastasis, and PHLDB2 is an important target gene for mir-29c-3p expression. Cells with an inactive p53 gene have low mir-29c3p expression.[11] In the study by Liu et al., miR-29c-3p is reported to be associated with vascular endothelial growth in cancer patients.

In another study, RNA from tissues of 87 individual lung cancer patients was isolated, and 1105 miRNA expression profiles known for humans have been demonstrated. Eventually, it was determined that mir-29c-3p gene downregulation is negatively related to the sustainability of the disease in cancer patients.[13] AA is an inflammatory emergency situation, which manifests by acute abdominal pain. As a result of the study we conducted, when the data from patients with AA were compared with those from healthy controls, miR-29c-3p expression was found out to be significantly higher. When the studies conducted till date were investigated, miR-29c-3p was reported to be associated with cancer. However, miRNA expression profiles in AA have not been investigated yet. As it has already been established, a specific miRNA can control more than 100 genes at once. Till date, the association between miR-29c-3p and AA has not been demonstrated in literature. AA is an inflammatory and painful condition, in which patients usually present to the emergency services. Patients can present to emergency services with symptoms or with serious complications varying from simple pain to symptoms of perforation such as fever, vomiting, and abdominal rigidity. Because the diseaseâ&#x20AC;&#x2122;s clinical window is broad, the rates of negative appendectomy have been reported to be high.

Therefore, early and precise diagnosis of AA is important. mir-29c-3p can be a marker for the necessity of early diagnosis and treatment of AA. Ulus Travma Acil Cerrahi Derg, May 2018, Vol. 24, No. 3

Seyhan et al. Role of circulating microRNAs in acute appendicitis

Conclusion In conclusion, this is the first study to report the expression profiles of selected miRNAs in AA. It is suggested that miRNA-29c-3p levels are elevated in the first 4–6 h after the beginning of symptoms in patients with AA.

Acknowledgment This study was supported by a project (TTU-2016-6072) from the Scientific Research Projects Department of Erciyes University, Kayseri.

Conflict of interest: None declared.

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2. Homo sapiens miRNAs (1917 sequences) [GRCh38]. Available at: http://www.mirbase.org/cgi-bin/mirna_summary.pl?org=hsa. Accessed Mar 26, 2018.

3. Menéndez P, Villarejo P, Padilla D, Palomino T, Nieto P, Menéndez JM, et al. Serum microRNA-21 usefulness in inflammatory pathology of the colon. Rev Gastroenterol Mex 2013;78:70–4.

4. Zhang L, Huang J, Yang N, Greshock J, Megraw MS, Giannakakis A, et al. microRNAs exhibit high frequency genomic alterations in human

cancer. Proc Natl Acad Sci U S A 2006;103:9136–41.

5. Zekri ARN, Youssef ASED, Lotfy MM, Gabr R, Ahmed OS, Nassar A, et al. Circulating Serum miRNAs as Diagnostic Markers for Colorectal Cancer. PloS One 2016;11:e0154130.

6. Le Quesne J, Caldas C. Micro-RNAs and breast cancer. Mol Oncol 2010;4:230–41.

7. Wang JF, Yu ML, Yu G, Bian JJ, Deng XM, Wan XJ, et al. Serum miR146a and miR-223 as potential new biomarkers for sepsis. Biochem Biophys Res Commun 2010;394:184–8.

8. Taşlıdere B, Şener EF, Taşlıdere E, Ekici Günay N, Bol O, Bülbül E, et al. Role of endothelial nitric oxide synthases system on acuteappendicitis.

Ulus Travma Acil Cerrahi Derg 2016;22:338–43.

9. Ceresoli M, Zucchi A, Allievi N, Harbi A, Pisano M, Montori G, et al.

Acute appendicitis: Epidemiology, treatment and outcomes- analysis of 16544 consecutive cases. World J Gastrointest Surg 2016;8:693–9.

10. Galani V, Lampri E, Varouktsi A, Alexiou G, Mitselou A, Kyritsis AP. Genetic and epigenetic alterations in meningiomas. Clin Neurol Neurosurg 2017;158:119–25.

11. Liu L, Bi N, Wu L, Ding X, Men Y, Zhou W, et al. MicroRNA-29c functions as a tumor suppressor by targeting VEGFA in lung adenocarcinoma. Mol Cancer 2017;16:50.

12. Chen G, Zhou T, Li Y, Yu Z, Sun L. p53 target miR-29c-3p suppresses colon cancer cell invasion and migration through inhibition of PHLDB2.

Biochem Biophys Res Commun 2017;487:90–5.

13. Li X, Zhuang X, Xu T, Mao M, Wang C, Chen Y, et al. Expression analysis of microRNAs and mRNAs in ovarian granulosacells after microcystin-LR exposure. Toxicon 2017;129:11–9.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Akut apandisitte dolaşımdaki mikroRNA’lar Dr. Avni Uygar Seyhan,1 Dr. Elif Funda Şener,2 Dr. Oğuzhan Bol,3 Dr. Serpil Taheri,2 Dr. Tugba Topaloglu,4 Dr. Esra Tufan,4 Dr. Reyhan Tahtasakal,4 Dr. Nahide Ekici Günay,5 Dr. Hatice Karabulut,6 Dr. Nurullah Günay6 Sağlık Bilimleri Üniversitesi, Kartal Dr. Lütfi Kırdar Eğitim ve Araştırma Hastanesi, Acil Tıp Kliniği, İstanbul Erciyes Üniversitesi Tıp Fakültesi, Tıbbi Biyoloji Anabilim Dalı, Kayseri 3 Namık Kemal Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, Tekirdağ 4 Erciyes Üniversitesi, Genom ve Kök Hücre Merkezi (GENKÖK), Kayseri 5 Sağlık Bilimleri Üniversitesi, Kayseri Eğitim ve Araştırma Hastanesi, Tıbbi Biyokimya Kliniği, Kayseri 6 Erciyes Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, Kayseri 1 2

AMAÇ: Akut apandisit (AA) gerek tanı anında yaşanan güçlükler nedeniyle gerekse de etiyopatogenetik bilinmeyenler açısından halen araştırılmaya devam eden önemli bir acil cerrahi patolojidir. Hücrede temel biyolojik işlevleri olan, biyolojik bir belirteç olabilen ve çeşitli patolojiler ile ilişkilendirilmiş mikroRNA’ların (miRNA) AA’lı hastalardaki rolü hakkında bugün için yeterli bir veri bulunmamaktadır. Bu çalışma ile bazı miRNA’ların AA’daki ekspresyonlarını araştırmak amaçlanmıştır.

GEREÇ VE YÖNTEM: Erciyes Üniversitesi Genome and Stem Cell Center (GENKOK) Merkezi’nde 24 AA’lı ve 24 sağlıklı toplam 48 bireye ait numunelerde 41 miRNA’nın real time PCR ile taraması yapıldı. Elde edilen veriler uygun istatistiksel testlerle değerlendirildi.

BULGULAR: Akut apandisitli hastaların ilk dört–altı saatlik döneminde miR-29c-3p iki kat arttı, bu yükselme sağlıklı bireylere göre istatistiksel açıdan anlamlı bulundu. Benzer şekilde let-7b-5p, let-7i-5p, miR-30a-5p, miR-29b-3p ve miR-23a-3p ekspresyonları da AA’da yaklaşık iki kat artış gösterdi, ancak istatistiksel açıdan anlamlılık saptanmadı. Geri kalan 35 miRNA taramasında, AA’lı hastalar için özellik tespit edilmedi.

TARTIŞMA: Akut apandisit ve miRNA arasındaki ilişki hakkında şimdiye kadar elde edilmiş yeterli veri olmamasına rağmen, mevcut araştırmaya göre AA’lı hastalarda akut dönemde miR-29c-3p’nin yükseldiği tespit edilmiştir. Elde edilen bu veri ile miR-29c-3p’nin AA’lı hastalarda bir belirteç olabilme potansiyeli taşıdığı ileri sürülebilecektir. Bu çalışmanın, alanında ihtiyaç duyulan daha geniş miRNA taramalarına temel bir araştırma olabileceği de düşünülmüştür.

Anahtar sözcükler: Akut apandisit; enflamasyon; mikroRNA. Ulus Travma Acil Cerrahi Derg 2018;24(3):211-215

doi: 10.5505/tjtes.2017.22379

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ORIG I N A L A R T IC L E

Examination of morbidity and mortality of cases according to intra-vehicle position and accident mechanism Orhan Meral, M.D.,1 Ekin Özgür Aktaş, M.D.,2 Murat Ersel, M.D.3 1

Department of Forensic Medicine, Health Sciences University Bozyaka Training and Research Hospital, İzmir-Turkey

2

Department of Forensic Medicine, Ege University Faculty of Medicine, İzmir-Turkey

3

Department of Emergency Medicine, Ege University Faculty of Medicine, İzmir-Turkey

ABSTRACT BACKGROUND: Traffic accidents are still an important public health issue in our country and intra-vehicle accidents cause substantial morbidity and mortality. In this study, we aimed to investigate the effect of seating position on morbidity and mortality in traffic accidents.

METHODS: Patients who were admitted to the Emergency Department, Faculty of Medicine, Ege University between May 1, 2014 and November 30, 2014 due to injuries in motor vehicles and who signed informed consent were included.

RESULTS: In total, 519 cases were included, and 329 (63.4%) were male and 190 (36.6%) were female. The average age was 33.11±16.86 (range, 0–85) years. It was noted that the accidents most frequently occurred between 18.00 and 23.59 (36.3%) hours, in the car (79%), and due to collision with another car (61.7%). Although 39.5% of the injured individuals were drivers, 26.4% were front seat passengers. From a forensic medicine perspective, life-threatening injuries were approximately twice more common (37.5%– 13.6%) in accidents with >110 km/h speed compared with accidents with <110 km/h speed. Accidents with >110 km/h speed caused approximately twice the amount (56.3%–26.3%) of injuries that cannot be resolved with simple medical intervention compared with accidents with <110 km/h speed.

CONCLUSION: Since most people who are injured or die in traffic accidents have an active professional life, significant rehabilitation expenditure and labor loss occur along with diagnosis and treatment costs. Our study and similar studies not only show the effectiveness of the measures taken but also provide an insight into changing injury profiles and precautions to prevent them.

Keywords: Intra-vehicle position; morbidity; mortality; traffic accidents.

INTRODUCTION Traffic accidents are among the first in the world among all accidents;[1] deaths due to traffic accidents are 11th among all deaths and constitute 2.1% of all deaths.[2] According to the World Health Organization, about 1.24 million people lose their lives in traffic accidents every year and between 20 and 50 million people are injured.[3] In this study, we aimed to investigate the association of mortality and morbidity with the intra-vehicle position of patients

who suffered from intra-vehicle accident and were admitted to the emergency department.

MATERIALS AND METHODS This was a prospective study. Among the 764 patients who suffered from intra-vehicle accident and were admitted to the Emergency Department, Faculty of Medicine, Ege University between May 1, 2014 and November 30, 2014, 519 patients participated in the study either voluntarily or by the consent of their relatives because they were children or unconscious.

Cite this article as: Meral O, Aktaş EÖ, Ersel M. Examination of morbidity and mortality of cases according to intra-vehicle position and accident mechanism. Ulus Travma Acil Cerrahi Derg 2018;24:216-223.

Address for correspondence: Orhan Meral, M.D. İzmir Bozyaka Eğitim ve Araştırma Hastanesi, Saim Çıkrıkçı Cad., No: 59, Karabağlar, İzmir, Turkey.

Tel: +90 232 - 250 50 50 / 5832 E-mail: orhanmeral@ymail.com Ulus Travma Acil Cerrahi Derg 2018;24(3):216-223 DOI: 10.5505/tjtes.2017.34662 Submitted: 19.09.2017 Accepted: 17.10.2017 Online: 08.05.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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Personal characteristics, such as age and sex; the type of vehicle they were in; the intra-vehicle position of the patients; the mechanism, date, and collision speed of accident; and the type of injury were determined. Vehicle and accident data were obtained from information given by the subjects. In addition, forensic medical evaluation of the identified injuries of cases was performed.

Statistical Analysis

Table 1. Demographic data

n (%)

Distribution of child subjects Woman

35 (48.6)

Man

37 (51.4)

Age range of subjects

0–85

Mean age of subjects (year)

33.11±16.86

The data were analyzed with the SPSS program (version 18.0). Demographic data were expressed as mean ± standard deviation and/or percentage.

Adult

36.83±14.87

Child

9.62±6.57

The comparison values were calculated at 95% confidence interval. A p-value of <0.05 was considered statistically significant.

0–10

78 (7.3)

11–20

74 (14.3)

21–30

147 (28.3)

31–40

106 (20.4)

41–50

73 (14.1)

Of the 519 cases included in the study, 329 (63.4%) were male and 190 (36.6%) were female, and 72 (13.9%) were children and 447 (86.1%) were adults. The highest proportion of the accidents occurred in October (n=67, 17.0%) and June (n=65, 16.5%) and most frequently in the evening (between 18.00 and 23.59 hours, n=143, 36.3%). The demographic data of subjects and accidents are given in Table 1.

51–60

44 (8.5)

61–70

20 (3.8)

71 and over

17 (3.3)

In this study, it was found that the majority of the cases were drivers (n=205, 39.5%) followed by the driver-side passengers (n=137, 26.4%). The intra-vehicle positions of the cases are shown in Table 2.

RESULTS

The total number of accidents was 394, and it was found that the accidents were mostly in the form of car collision (n=169, 42.9%) (Table 3), and 136 of the collisions (40.1%) were from the front of the car (Fig. 1).

At the time of accident, abrasions due to the safety belt were detected in 40 (17.9%) of the 224 cases who were found to have a safety belt attached to their neck and/or torso and/or the front of the abdomen. Of these cases, 26 (65%) were drivers, 11 (27.5%) were driver-side passengers and three (7.5%) were right rear seat passengers. Table 4 shows the sitting positions of the cases, the number of safety belts in the vehicle, the usage of the safety belt, and the abrasions due to safety belts.

There were air cushions in 224 vehicles (56.9%), no air cushions in 164 vehicles (41.6%), and the presence of air cushions was unknown in 6 (1.5%) vehicles. At the time of the accident, air pillows of 105 subjects were opened, 33 of them (31.4%) were injured for this reason, and all of these cases were adult (p<0.01).

When we look at the distribution of the injuries from the traffic accidents according to the body regions, it is seen that Ulus Travma Acil Cerrahi Derg, May 2018, Vol. 24, No. 3

Age groups (year)

Distribution of accidents by month May

62 (15.7)

June

65 (16.5)

July

61 (15.5)

August

46 (11.7)

September

57 (14.5)

October

67 (17.0)

November

36 (9.1)

Distribution of accidents by hours 00.00–05.59

67 (17.0)

06.00–11.59

76 (19.3)

12.00–17.59

108 (27.4)

18.00–23.59

143 (36.3)

Table 2. Subjects’ position in the vehicle Position

Number Percent

In the driver’s seat

205

39.5

Next to the driver

137

26.4

Rear seat on the right

55

10.6

Rear seat on the left

48

9.2

Other positions

74

14.3

Total

519 100.0

the head is the most frequently injured body part (n=225, 43.4%) and the second and third frequent parts were thorax (n=114, 22%) and upper extremity (n=111, 21.4%), respectively. The injury areas of the cases are shown in Figure 2. In 217

Soyisim et al. Examination of morbidity and mortality of cases according to intra-vehicle position and accident mechanism

Table 3. Mechanism of accident occurrence Position

Number Percent

Collision with a car

169

42.9

Collision with pole/tree/refuge

96

24.3

Rolling over

22

5.6

Sudden brake/acceleration

20

5.1

Collision with a minibus

19

4.8

Collision with a camion

17

4.3

Collision with a van

16

4.1

Collision with a truck

14

3.6

Collision with a bus

8

2.0

Skidding

8 2.0

Flying

5 1.3

Total

394 100.0

addition, the analysis of the concomitant injuries is detailed in Table 5.

In our study, the frequency of injuries according to body regions was examined in children and adults. The head injury rate was 56.9% in the pediatric age group and 41.2% in the adult group (p<0.01). The incidence of neck injury was 2.8% in the pediatric age group and 10.3% in the adult (p<0.05). The incidence of thoracic injuries was 9.7% in the pediatric age group and 23.9% in the adult group (p<0.01). Finally, the incidence of upper extremity injuries was 12.5% in the pediatric age group and 22.8% (p<0.05) in the adult group. There was no significant difference between the pediatric and adult age groups in the wrist, pelvis, and lower extremity injuries. In addition, it was found that single region injuries were more frequent in children and multiple region injuries in adults (p<0.01).

n=7 (2.1%)

When the injury regions and the in-car position of the patients were compared, nine of 12 (75%) children aged between 0 and 5 years who were sitting on the lap were injured in the head region; none of these 12 children and none of the 21 passengers sitting in the middle of the rear seat were injured in the neck region (p<0.05). None of the three children aged between 1 and 5 years who were sitting in child safety seat were injured, and 91.7% of the passengers who were sitting on the rear left were not injured in the thorax region. No significant difference was found in other comparisons.

When the region of injury and vehicle collision zones were compared, the rate of thoracic injuries occurring in the front (21.9%) and side (28.8%) collisions was higher than that of the collisions in the back (7.4%) (p<0.05). The distribution of injured body parts according to the collision areas of vehicles is shown in Figure 3.

It was determined that 22 cases applied to the emergency department for the purpose of control, 151 cases (30.4%) of the 497 cases were injured in one region, and 346 cases (69.6%) were injured in more than one region. When the number of injured body regions and in-car position were compared, most of the cases that had single-site injuries were drivers (n=41, 27.2%) or driver-side passengers (n=39, 25.8%); and most of the patients who had more than one injured region were drivers (n=160, 46.3%) or driver-side passenger (n=95, 27.5%).

In this study, the injury of 15% (n=78) of the patients led to vital danger when evaluated from the point of forensic medicine. When the accident speed of the vehicles were classified as below and above 110 km/h and the injuries as being treated by simple medical intervention or not and when the injuries were evaluated according to the presence or absence

n=23 (6.8%)

n=41 (12.1%)

n=136 (40.1%)

n=42 (12.4%)

n=27 (7.9%)

n=8 (2.4%)

n=55 (16.2%)

No collision zone was observed in 55 vehicles due to sudden brake/acceleration, skidding, rolling over, or flying.

Figure 1. Collision zones.

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Meral et al. Examination of morbidity and mortality of cases according to intra-vehicle position and accident mechanism

Table 4. Safety belt use and lesion incidence

Driver

Next to the driver

Rear seat on the right

Rear seat on the left

Rear seat in the middle

Others

Total

Seatbelt attached

No abrasion

96 (46.8%)

60 (43.8%)

7 (12.7%)

14 (29.2%)

3 (14.3%)

4 (7.5%)

184 (35.5%)

There is abrasion

26 (12.7%)

11 (8%)

3 (5.5%)

0 (0%)

0 (0%)

0 (%0)

40 (7.7%)

83 (40.5%)

66 (48.2%)

45 (81.8%)

34 (70.8%)

18 (85.7%)

49 (92.5%)

295 (56.8%)

Seatbelt not attached

No abrasion

Total

205 137 55 48 21 53 519

*The percentages are calculated according to the columns.

Table 5. Co-occurrence of injured areas

n=225 (43.4%)

Areas Number* n=48 (9.2%)

Head–Thorax 41 Head–Lower extremity

32

Head–Upper extremity

30

Head–Abdomen 25

n=114 (22%) n=71 (13.7%)

n=111 (21.4%)

Head–Neck 16 Head–Pelvis

n=22 (4.2%)

5

Neck–Thorax 16 Neck–Abdomen

7

Neck–Lower extremity

6

Neck–Upper extremity

6

Neck–Pelvis

2

n=79 (15.2%)

Thorax–Abdomen 32 Thorax–Upper extremity

29

Thorax–Lower extremity

14

Because >1 area of injury were seen in 346 cases, the total

7

number of injury sites (n=670) was greater than the number

Thorax–Pelvis Abdomen–Upper extremity

11

Abdomen–Lower extremity

9

Abdomen–Pelvis

7

Pelvis–Upper extremity

5

Pelvis–Lower extremity

5

Upper extremity–Lower extremity

16

*In 346 cases, multiple site injuries were seen, no total number of injuries.

of cases (n=519); rate calculation was done according to the number of cases.

Figure 2. Distribution of injury areas.

and treatment and left the emergency department. Of the patients admitted to the emergency department, four (0.8%) died and 64 (12.3%) were admitted to the related clinics. Of the patients admitted to clinics, 61 (95.3%) were discharged and three (4.7%) died. Among the victims, three were drivers, two were driver-side passengers, and the other two were children who sat in the lap. It was noted that none of the victims were wearing their safety belts during the accident, and only one of them had an air pillow.

of life-threatening hazard, it was observed that the increase in speed resulted in tripling of the number of life-threatening injuries (13.6%–37.5%) and doubling of the number of injuries that could not be treated by simple medical intervention (26.3%–56.3%). These findings were found to be statistically significant (p<0.01).

DISCUSSION

It was observed that 444 patients (85.5%) were discharged after interventions in the emergency department, and seven patients (1.4%) did not admit the recommended follow-up

Traffic accidents constitute a significant part of the admissions made to emergency departments.[4] Similar to what we found in our study (male = 63.4%), it is reported that most of the victims of deaths in traffic accidents around the world

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Soyisim et al. Examination of morbidity and mortality of cases according to intra-vehicle position and accident mechanism

Head: 14 Neck: 2 Thorax: 8

Head: 23

Abdomen: 6 Head: 8 Lower extremity: 2

Neck: 6

Pelvis: 1

Thorax: 16

Upper extremity: 8

Abdomen: 9

Lower extremity: 2

Upper extremity: 11 Lower extremity: 12

Head: 15

Head: 86

Neck: 6

Neck: 15

Thorax: 5

Thorax: 40

Abdomen: 6

Abdomen: 22

Pelvis: 3

Pelvis: 5

Upper extremity: 11

Upper extremity: 35

Lower extremity: 5

Lower extremity: 32

Head: 5

Head: 14

Head: 28

Neck: 1

Neck: 4

Neck: 3

Thorax: 1

Thorax: 9

Thorax: 11

Abdomen: 1

Abdomen: 7

Abdomen: 7

Upper extremity: 3

Pelvis: 4

Pelvis: 4

Lower extremity: 1

Upper extremity: 6

Upper extremity: 18

Lower extremity: 3

Lower extremity: 9

Figure 3. Distribution of injured body parts according to vehicle collision areas.

are male.[5–7] The mean age of the cases was found to be 33.11±16.86 and injuries due to traffic accidents were found to be the most frequent in the 21–30-year age group (n=147, 28.3%), and this finding is coherent with many studies.[1,5,7–10] When the studies performed in our country were reviewed, the 30–49-, 30–49-, and 0–14-year age groups were the leading age groups in the study performed by Mandıracıoğlu,[11] Gören,[12] and Varol,[13] respectively.

In our study, it was observed that accidents occurred at a higher rate in October (n=67, 17%) and June (n=65, 16.5%).

In many studies conducted in our country, accidents have been reported to occur more frequently in summer.[1,4,7,12,14] It is thought that this is due to the excessive number of travelers due to summer holidays and because people drive more carefully by considering the weather condition and traffic intensity during the winter months.

In this study, it was seen that accidents occur frequently between 18.00 and 23.59 hours (n=143, 36.3%). This ratio was found to be consistent with the large number of studies conducted in our country.[4,7–9,14,15] The frequency of accidents in this time period was considered to be associated with fatigue and inattentiveness of the drivers during work, inadequacy of sunset lighting, and limitation of sight distance.

220

It was determined that most of the cases detected in the study were drivers (n=205, 39.5%) and a significant number of cases (n=137, 26.4%) were sitting next to the driver. In Bilgin’s study, which was conducted in İzmir, it was reported that drivers and passengers sitting next to the driver are the most frequently injured people in accidents.[5] In this study, there was a collision with another vehicle or barrier in 339 (86%) of the 394 accidents. In all accidents, car crash (n=169, 42.9%) was the leading cause, and 136 (40.1%) of the 339 crashes occurred in front of the vehicle they were in. A four-year retrospective study conducted in İzmir[15] and another study that analyzed all of the accidents in Düzce[16] reported that the most common type of accident mechanism was collision.

One of the passive safety measures in the vehicle, the safety belt prevents a passenger from being thrown out of the car due to the impact of the collision, allowing the gradual reduction of the collision in the body and allowing the collision effect to spread rather than accumulate in one spot on the body.[17–19] It was noted that 295 of the cases (56.8%) were not wearing a seat belt during the accident; 59.2% of the cases in the study of Bilgin,[5] 85% in the study of Karbeyaz[7] and 32.7% in a foreign study[20] were not wearing safety belts at the time of the accident.

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Meral et al. Examination of morbidity and mortality of cases according to intra-vehicle position and accident mechanism

It is thought that the difference between this study and the other studies is due to the fact that other studies are retrospective and that sufficient information about the cases could not be reached in other studies. According to TURKSTAT’s 2013 data,[21] 85.9% of the patients involved in accidents in 2013 had worn safety belts. Any sufficient information about the safety belt usage of 95% of the drivers in these cars could not be reached. The only information that could be obtained was that 2.6% of the drivers were wearing safety belts during the accident. All of these findings support our thinking. It can be said that the use of the safety belt is not sufficient at present with having limited data. There has also been a lack of access to the availability of safety belts throughout the country and it is considered necessary to increase efforts to disseminate the use of safety belts.

Thus, one of every three passengers with air cushions was injured. All of the injured patients were adults (p<0.01) and most injuries (n=14, 42.4%) occurred in the face region. This ratio was found to be quite high, and it is considered that new generation airbags should be produced to reduce the injuries due to airbags and new measures should be taken.

Regarding the distribution of injuries detected in our cases according to body regions, the head (n=225, 33.6%) was the most common region among single-site injuries, followed by the thorax (n=114, 17%) and upper extremity (n=111, 16.5%).

It is notable that head injuries are more frequent in children and that neck, thorax, and upper extremity injuries are more frequent in adults. There are several reasons for head injury in children. First, children are more likely to be seated on the back seat and are not ready for an accident. Second, passive safety measures such as air cushions and seat belts are relatively uncommon in the backseat. Additionally, they would be thrown during the accident in the vehicle because they have shorter body length and greater head/torso ratio compared with adults and due to scattering they may have head trauma as a result of collision with seat, door, and passenger and so on. As adults prefer the front seat, scattering results in injuries to the neck, thorax, and upper extremities, which are more likely to occur primarily due to collision with the steering wheel, front panel, door, and so on in relation to the seating height.

While examining 346 cases in which more than one region injury occurred, it was observed that although the head–thorax association was seen most frequently, the thorax–abdomen, head–lower extremity, and thorax–upper limb associations were also common.

When compared with other studies related to traffic accidents in our country, in studies conducted by Karbeyaz,[7] Serinken,[14] Varol,[13] Bilgin,[5] and Aydeniz,[8] it was observed that head and neck injuries were the second most common injuries following lower extremity injuries. Although our study includes intra-vehicle traffic accidents, in outer vehicle Ulus Travma Acil Cerrahi Derg, May 2018, Vol. 24, No. 3

traffic accidents, injured zone changes according to the type of accident are normal when the following facts are considered: first, the number and severity of injuries increases due to the absence of effective safety measures such as safety belts and air cushions in non-vehicular traffic accidents; second, extremity injuries are more frequent in pedestrians; and additionally, the type of associated injury regions differ related to the injury site.

It is stated that the severity of the injury profile and damage differs due to several factors such as the speed and physical characteristics of the vehicle, application of brake during the accident, in-vehicle position of the passengers during the accident, being a child or adult, and whether the accident happened in or out of the car.[22–24] In our study, it was seen that single-site injuries were observed in children and more than one region injuries were seen in adult cases (p<0.01). When the number of injured zones was compared with the in-car position of the cases, drivers and driver-side front passenger injuries from more than one body region were seen more frequently than other passengers and those traveling on public transport and child passengers sitting on the lap had single-site injuries more often compared with other passengers. When these two conditions are evaluated together, it is thought that adults have multiple-site injuries, while children have single-site injuries more commonly because children often travel in the back seat and adults often travel in the front seat.

In our study, no statistically significant difference was found between the severities of injuries due to the position of the injuries in the vehicle (p>0.05). In the international studies, it was stated that the back seat passengers without safety belts were more at risk and injured than the front seat passengers[20,25] and that traveling without a seat belt on the rear seat increases the mortality of the passenger sitting on the front seat by 2.5 times.[26] In this study, it has been determined that 15% of the injuries have put the life of the victim in jeopardy in terms of forensic medicine. Another study[5] in İzmir showed that 15.3% of the cases had a life-threatening injury and it was found to be compatible with our findings.

When the cases presented in this study were examined in terms of accident speeds below or above 110 km/h, whether the injuries could be resolved by simple medical intervention from a forensic medical point of view, and whether there was a life-threatening hazard, it was seen that the life-threatening potential of injury tripled and the likelihood of the injury to resolve with simple medical intervention decreased double times as the speed increased (p<0.01); in this case, it is clear that journeys at high speeds are not safe and related to high mortality and morbidity.

Despite medical interventions, four cases died in the emergency department and three in the department where they 221

Soyisim et al. Examination of morbidity and mortality of cases according to intra-vehicle position and accident mechanism

were admitted. Our data are consistent with the study of Aktaş[9] and Bilgin,[5] both of which were conducted in Izmir, and with the study of Emet[27] in Erzurum.

4. Göksu E, Çete Y, Kanalıcı H, Kılıçaslan İ. Demographic and clinical properties of patients presenting with traffic accidents and its association with blood alcohol concentration. Turk J Emerg Med 2008;8:26–31.

Conclusion and Recommendations

5. Bilgin UE, Meral O, Koçak A, Aktaş EÖ, Kıyan S, Altuncı YA. Legal examination of the patients admitted to the Emergency Service of Ege University Hospital due to traffic accidents in 2011 [Article in Turkish].

Ege Journal of Medicine 2013;52:93–9.

Our study presents an important cross-section of mechanisms and injury patterns of in-vehicle traffic accidents in Turkey. According to the results obtained, airbags are not found in four out of every 10 cars involved in traffic accident with injury. While 40% of drivers involved in these accidents did not wear seat belts, the use of seat belts is even lower in the rear seat.

Most of the accidents occurred in the form of frontal collision, and it is determined that head injury is the most common type of injury in all ages, followed by thorax and upper limb injuries. In addition, head injuries were significantly higher in the pediatric age group than in adults.

Traffic accidents in our country are still an important cause of morbidity and mortality. Although the use of safety belts was imperative for drivers and passengers in all vehicle seats on the date of this study, the use of protective equipment appears to be limited. However, we believe that it is wise to focus on the technological precautions that protect the head and chest area to reduce the severity of injuries, since it has been seen that accidents are often the result of collisions with the front and side regions of the vehicle and that drivers and passengers are injured more frequently in the head and thorax region.

In this study, it was clearly revealed that the accidents that occurred at a speed of 110 km/h caused more serious injuries.

We would like to emphasize that the use of electronic equipment in vehicles that can reduce vehicle speed independently from the driver in the event of a collision may be a matter of reducing morbidity and mortality. We believe that our study, which examines accident mechanism and injury patterns, will possibly help to better analyze accident injury mechanisms and will help take measures in this respect by helping those performing similar studies in larger national databases.

Conflict of interest: None declared.

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8. Aydeniz E, Ünaldı M, Güneysel Ö, Eryiğit H. The Retrospective Evaluation of Injuries Owing to Traffic Collisions in Emergency Department. J Kartal TR 2014;25:5–12.

9. Aktaş EÖ, Koçak A, Zeyfeoğlu Y, Solak İ, Aksu H. Ege Üniversitesi Tıp Fakültesi Adli Tıp Anabilim. Dalı’na trafik kazası nedeniyle başvuran adli olguların değerlendirilmesi. Uluslararası Trafik ve. Yol Güvenliği Kongresi. Ankara: 2002.

10. Töro K, Hubay E, Sotonyi P, Keller E. Fatal traffic injuries among pedestrians, bicyclists and motor vehicle occupants. Forensic Sci Int 2005;151:151–6.

11. Mandıracıoğlu A, Hancı İH, Yavuz C, Aktaş EÖ. İzmir ilinde trafik kazalarında insan faktörü. IV. Ulusal Halk Sağlığı Kongresi Sept 12-16, 1994 Didim. Didim: Bildiriler Kitapçığı; 1994. p. 131–5.

12. Gören S, Subaşı M, Tıraşçı Y, Kaya Z. Deaths related to traffic accidents [Article in Turkish]. J Foren Med 2005;2:9–13.

13. Varol O, Eren ŞH, Oğuztürk H, Korkmaz İ, Beydilli İ. Investigation of the Patients Who Admitted After Traffic Accident to the Emergency Department [Article in Turkish]. C. Ü. Tıp Fakültesi Dergisi 2006;28:55–60.

14. Serinken M, Özen M. Characteristics of injuries due to traffic accidents in the pediatric age group [Article in Turkish]. Ulus Travma Acil Cerrahi Derg 2011;17:243–7.

15. Yavuz C, Mandıracıoğlu A, Hancı İH, Aktaş EÖ. İzmir İli’nde Trafik Kazalarında Teknik Boyutu. IV. Ulusal Halk Sağlığı Kongresi Sept 1216 1994, Didim. Didim: Bildiriler Kitabı; 1994. p. 136–9.

16. Ozgan E. Analysis of the relationship between results of accidents with highways’ vehicle type and kinds of the accidents. J Fac Eng Arch Gazi Univ 2008;23:97–104.

17. Elvik R, Vaa T, Hoye A, editors. The Handbook of Road Safety Measures. 2nd ed. Emerald Group Bingley: Publishing Limited; 2009.

18. Shkrum MJ, Ramsay DA. Forensic Pathology of Trauma. Totowa: Humana Press Inc.; 2007.

19. Soysal Z, Eke SM, Çağdır S. Adli Otopsi. Volume I. İstanbul Üniversitesi: Cerrahpaşa Tıp Fakültesi Yayınları; 1999.

20. Brown CK, Cline DM. Factors affecting injury severity to rear-seated occupants in rural motor vehicle crashes. Am J Emerg Med 2001;19:93–8.

21. http://www.tuik .gov.tr/Kitap.do?metod=KitapDetay&KT_ ID=15&KITAP_ID=70. Erişim Tarihi: 03.05.2018.

2. Joshi AK, Joshi C, Singh M, Singh V. Road traffic accidents in hilly regions of northern India: What has to be done? World J Emerg Med 2014;5:112–5.

22. Çetin G, Yorulmaz C. Trafik Kazasına Bağlı Yaralar. Soysal Z, Çakalır C, editors. Adli Tıp. 1st ed. Istanbul: Istanbul Üniversitesi Basımevi ve Film Merkezi; 1999.

3. World Health Organization. Global status report on road safety 2013: supporting a decade of action. Available at: apps.who.int/iris/bitstre am/10665/78256/1/9789241564564_eng.pdf. Accessed 3rd May, 2018.

23. Saukko PJ, Knight B. Knight’s forensic pathology. 3rd ed. London: Arnold; 2004.

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Meral et al. Examination of morbidity and mortality of cases according to intra-vehicle position and accident mechanism 25. Broughton J. The actual threat posed by unrestrained rear seat car passengers. Accid Anal Prev 2004;36:627–9.

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ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Araç içi pozisyon ve kaza mekanizmasına göre olguların morbidite ve mortalitesinin incelenmesi Dr. Orhan Meral,1 Dr. Ekin Özgür Aktaş,2 Dr. Murat Ersel3 Sağlık Bilimleri Üniversitesi İzmir Bozyaka Eğitim ve Araştırma Hastanesi, Adli Tıp Bölümü, İzmir Ege Üniversitesi Tıp Fakültesi, Adli Tıp Anabilim Dalı, İzmir 3 Ege Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, İzmir 1 2

AMAÇ: Trafik kazaları halen ülkemizde önemli bir halk sağlığı sorunu olup, araç içi trafik kazaları da önemli bir morbidite ve mortalite nedenidir. Bu çalışmada, trafik kazalarında kazazedenin araç içi pozisyonunun morbidite ve mortalite üzerine olan etkisinin araştırılması amaçlandı.

GEREÇ VE YÖNTEM: Ege Üniversitesi Tıp Fakültesi Hastanesi Acil Servisi’ne 01.05.2014–30.11.2014 tarihleri arasında araç içi trafik kazası sonucu yaralanma nedeniyle başvuran olgulardan onam verenler çalışmaya dâhil edildi.

BULGULAR: Çalışmaya dâhil edilen 519 olgunun 329’u (%63.4) erkek, 190’ı (%36.6) kadındı. Yaşları 0–85 arasında değişmekte olup ortalaması 33.11±16.86 olarak bulundu. Kazaların en sık 18.00–23.59 saat aralığında (%36.3), otomobil içinde (%79) ve bir başka araçla çarpışma (%61.7) sonucu gerçekleştiği tespit edildi. Kazazedelerin %39.5’inin sürücü, %26.4’ünün sürücü yanı yolcu olduğu saptanmış olup, 110 km/sa hızın üzerinde oluşan kazalarda, 110 km/sa hızın altında olan kazalara göre, adli tıbbi açıdan, yaralanmanın yaşamsal tehlike oluşturmasının yaklaşık üç katına (%37.5–%13.6), basit bir tıbbi müdahale ile giderilemeyecek olmasının ise yaklaşık iki katına (%56.3–%26.3) çıktığı belirlendi.

TARTIŞMA: Trafik kazalarında yaralanan veya ölen kişilerin çoğunun aktif iş yaşamında olması, tanı ve tedavi giderlerinin yanında ciddi bir rehabilitasyon ve iş gücü kaybı oluşturmaktadır. Bu çalışma ve benzer çalışmalar, alınan önlemlerin etkinliklerini gösterdiği gibi değişen yaralanma profillerinin de anlaşılması ve bunları önlemek için alınacak önlemlere ışık tutması açısından önemlidir.

Anahtar sözcükler: Araç içi pozisyon; morbidite; mortalite; trafik kazası.

Ulus Travma Acil Cerrahi Derg 2018;24(3):216-223

doi: 10.5505/tjtes.2017.34662

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ORIG I N A L A R T IC L E

Targeted cardiopulmonary resuscitation training focused on the family members of high-risk patients at a regional medical center: A comparison between family members of high-risk and no-risk patients Kap Su Han, M.D., Ph.D.,1 Ji Sung Lee, Ph.D.,2 Su Jin Kim, M.D., Ph.D,1 Sung Woo Lee, M.D., Ph.D1 1

Department of Emergency Medicine, Korea University Anam Hospital, Seoul-Republic of Korea

2

Clinical Research Center, Asan Medical Center, Seoul-Republic of Korea

ABSTRACT BACKGROUND: We developed a hospital-based cardiopulmonary resuscitation (CPR) training model focused on the target population (family members of patients with potential risks for cardiac arrest) and compared the outcome of CPR training between target and non-target populations for validity.

METHODS: Family members of patients in training were divided into three groups on the basis of patientsâ&#x20AC;&#x2122; diseases, as follows: 1) the cardio-specific (CS) risk group, including family members of patients with cardiac disease at risk of cardiac arrest; 2) the cardiovascular (CV) risk group, including family members of patients with risk factors for cardiovascular disease; and 3) the no-risk group. Pre- and posttraining surveys and skill tests as well as a post-training 3-month telephone survey were conducted. Educational outcomes were analyzed.

RESULTS: A total of 203 family members were enrolled into 21 CPR training classes. The CS group (n=88) included elderly persons and housewives with a lower level of education compared with the CV (n=79) and no-risk groups (n=36). The CS group was motivated by healthcare professionals and participated in the training course. The CS, CV, and no-risk groups showed improvements in knowledge, willingness to perform CPR, and skills. Despite the older age and lower level of education in the CS group, the effects of education were similar to those in the other groups. A high rate of response and secondary propagation of CPR training were observed in the CS group.

CONCLUSION: Family members of patients with heart disease could be an appropriate target population for CPR training, particularly in terms of recruitment and secondary propagation. Targeted intervention may be an effective training strategy to improve bystander CPR rates.

Keywords: Bystander; cardiopulmonary resuscitation; family; high risk; training.

INTRODUCTION Bystander cardiopulmonary resuscitation (CPR) is a crucial factor contributing to the improvement of survival in individuals undergoing cardiac arrest.[1] Bystander CPR rates between 10% and 65% have been reported, with particularly low rates among rural, minority, and low-income communi-

ties. The percentage of ventricular fibrillation and survival to discharge rates in Asia were found to be lower than those in other countries.[2,3] Public policies and resources have focused on increasing bystander CPR rates by implementing dispatcher-assisted CPR, publicizing compression-only CPR by layrescuers from 2011,

Cite this article as: Han KS, Lee JS, Kim SJ, Lee SW. Targeted cardiopulmonary resuscitation training focused on the family members of high-risk patients at a regional medical center: A comparison between family members of high-risk and no-risk patients. Ulus Travma Acil Cerrahi Derg 2018;24:224-233.

Address for correspondence: Su Jin Kim, M.D. Inchon-ro 73, Seongbuk-gu Seoul, South Korea Tel: 821046528192 E-mail: icarusksj@gmail.com Ulus Travma Acil Cerrahi Derg 2018;24(3):224-233 DOI: 10.5505/tjtes.2017.01493 Submitted: 31.05.2017 Accepted: 25.08.2017 Online: 09.05.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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Han et al. Hospital-based targeted CPR training intervention for target population

and conducting mandatory CPR training in schools from 2013; however, the bystander CPR rate still remains low in Korea (Fig. 1).[4] The expansion of CPR training is a form of community intervention to raise bystander CPR rates, and it requires enormous expenses. However, there is no clear correlation between bystander CPR rates and efforts to implement CPR training. Community investment in providing bystander CPR training needs to be cost effective.[5] A system-wide CPR program was established in our region, Seongbuk, with a population of approximately 500,000 in Seoul, Korea. We have aimed at enhancing five major CPR deliveries including early emergency medical system (EMS) activation, bystander CPR provision, appropriate usage of automated external defibrillators (AEDs), high-quality advanced cardiac life support (ACLS) and standard post-cardiac arrest care for improving good outcomes in patients with out-of-hospital cardiac arrest (OHCA) in our region from 2011.[6] The bystander CPR and dispatcher-assisted CPR rates increased to approximately 50% in the patients with OHCA at Korea university medical center.

However, only the bystander CPR rate was approximately 30% from 2011 to 2013, despite continuous community intervention, such as bystander CPR training and public AEDs provided by public healthcare centers and emergency medical services.[6] Because most cardiac arrests occur in private residences, it is likely that family members will witness an arrest. However, most of the people undergoing CPR training are young and not family members, and in most cases, CPR training serves to fulfill a job requirement.[7]

Because 70%â&#x20AC;&#x201C;80% of cardiac arrests occur at home and not in a public place,[8] the provision of CPR training courses to a target population of families of patients with heart disease or those with risk factors for cardiovascular disease may be an effective strategy.

The integral factors for a community-based CPR program are population, location, and barriers to participation in training, such as accessibility, cost, distance, and motivation.[9] Regional medical centers play a central role in caring for patients with heart disease and those with risk factors for cardiovascular disease. Family members of high-risk patients can be exposed to a Basic Life Support (BLS) training program, provided by regional medical centers during patient admission or outpatient clinic reviews. Family members may have a high motivation for CPR training and can be easily selected for hospitalbased CPR training modules.

We hypothesized that improvements in CPR performance would be better among family members of high-risk patients and would include changes in attitude toward resuscitation.

Family members were identified as the target population. We conducted CPR training for family members of high-risk patients after developing a hospital-based CPR training model at a regional medical center. We assessed educational outcomes, including skill, knowledge, and attitude, and compared the improvement in CPR performance between family members of high-risk and no-risk patients.

MATERIALS AND METHODS Korean association of cardiopulmonary resuscitation -Propagation of CPR trainingStandard Bystander CPR training program Good Samaritan Legislation

2008

2010

Compression only CPR

(Promoted by Korea CDC)

Dispatcher-assisted CPR

Mandatory CPR training in elementary school

2011

2013

2015

A system-wide approach from the community in region

(b) 80

Study Setting and Design This was a prospective study conducted at a single tertiary medical center. The Institutional Review Board approved (IRB No.ED14301) the data collection and informed consent process for managing data on training outcomes, based on a survey and assessment.

The hospital-based CPR training model was structured as a regular open class for family members. No fees were charged.

We developed a 1-h training program with assessment and evaluation tools, comprising a brief lecture about the importance of CPR, video-instructed compression practice with instructor support, and practice using an AED. The Resusci Anne manikin (Laerdal Medical, Stavanger, Norway) was used.

70 60 50 40 30 20 10 0 (%)

2009

2010

2011

2012

Training (yes)

Training (no)

2013

2014

2015 (year)

Unknown

Figure 1. (a) Major changes of policy and protocol for increasing the bystander cardiopulmonary resuscitation rate. (b) Annual trends of the rate of previous training experience and the rate of no training experience among bystanders, who provided CPR in out-of-hospital cardiac arrests at a regional medical center. CPR: Cardiopulmonary resuscitation; CDC: Center for disease control and prevention.

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Content was based on a standardized program operating guidelines of BLS for lay rescuers from the Korea Centers for Disease Control and Prevention and focused on risk factors.

Instructor qualifications were restricted to healthcare workers with an instructor certificate from the American Heart Association BLS. An instructor-training program for this session was developed, including a pre-class preparation checklist and a self-checklist of the program content. Instructors were taught for three sessions about delivering teaching and 225

Han et al. Hospital-based targeted CPR training intervention for target population

assessments according to the instructor’s manual. Instructors used instruction checklists for every class. Instructors participated in the CPR education program after successfully completing training.

The heart disease (coronary artery or valvular heart disease, arrhythmia, cardiomyopathy, heart failure, and a history of cardiac arrest), risk factors for cardiovascular disease (hypertension, diabetes, smoking, hyperlipidemia, and a family history of arrest), and chronic kidney disease by experts’ opinions and literature review, are defined as the high risk disease of cardiac arrest.[10,11]

Participant Recruitment We developed a data processing program to select patients with potential risk factors from the international classification of disease-10, on the basis of the computerized medical record. We disseminated information on the training program to the family members of at-risk patients through posters and pamphlets, direct recommendation from healthcare workers, and in-hospital and website-based announcements. Family members voluntarily applied for the program by contacting the training coordinator by telephone and e-mail. The coordinator reminded the course participants by text message and e-mail on three occasions before the class commenced.

The training class was conducted on a regular weekly basis at the same time and on the same weekday between November 2014 and July 2015. Volunteer participants completed a 1-h training session led by BLS instructors. A certificate of course completion was awarded to participants. Participants underwent surveys and assessment by BLS instructors before the hospital-based CPR training session. A telephone survey was conducted 3 months after the class, and no response was defined as a lack of response after the participant was called on three occasions at different times.

Participants were eligible for enrollment based on the following criteria: (1) age ≥18 years and (2) the family member felt fit and able to perform moderate physical activity.

Family members were divided into three groups for analysis, according to patient risk factors, as follows: 1) the cardiospecific (CS) risk group, including family members of patients with a diagnosis potentially related to underlying cardiac disease; 2) the cardiovascular (CV) risk group, including family members of patients with risk factors for cardiovascular disease; and 3) the no-risk group. Characteristics, basic knowledge, skill, and attitude for CPR were analyzed (Fig. 2).

Design & Develop the Hospital-based CPR training model – Defining potential risk diseases for cardiac arrest – – Development of 1-hour training program, survey & skill checklist – – Instructor Training: preparation, assessment, teaching methods –

Targeted Recruitment Identifying the patients with potential risk factor for cardiac arrest Developing computerized program using ICD -10 code based on the hospital order communication system Inform the family members of patients with potential risk factors about CPR training program (Phamlet, poster, Announcement, recommendation by healthcare providers) Easy accessible registration & reassurance – Regular open class at same time & place – – Registration by call or e-mail or voluntarily visits by announcement – – Inform the family members for 3 times by text message and e-mail – – No participation fees, give certificates after completing training –

Training, Assessment & Evaluation Pre-survey and skill test Training Post-survey and skill test Telephone survey at 3 months later

Figure 2. Flow chart of the regional medical center-based CPR training model focused on a target population, targeted location, targeted approach, and targeted time. CPR: Cardiopulmonary resuscitation; ICD: International classification of disease.

used. SAS version 9.4 (SAS Institute, Cary, NC, USA) was used for statistical analysis. A p-value <0.05 was considered statistically significant.

Ethics Statement The study protocol was approved by the Institutional Review Board of Korea University Anam Hospital (IRB No.ED14301).

Informed consent was confirmed by IRB.

RESULTS

Statistical Analysis

A total of 203 family members were enrolled into 21 CPR training classes, and 14 instructors [median age = 42 (28–53) years] were recruited to conduct the classes. The instructor:trainee ratio was 1:3-4. One class had a ratio of approximately 2.12 instructors to 8.28 trainees. Total numbers of participants in the CS, CV, and no-risk groups were 88, 79, and 36, respectively.

Participant demographics, characteristics, and outcomes were compared using Pearson’s Chi-square test, Fisher’s exact test, and ANOVA, where appropriate. The Generalized Estimating Equation method for repeat measure analysis was

Compared with the CV and no-risk groups, the CS group had higher rates of elderly and female participants and participants with a low level of education (< high school),

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Han et al. Hospital-based targeted CPR training intervention for target population

not knowing how to perform CPR. However, when cardiac arrest occurred in an unknown person, 31.8% of participants in the CS group, 34.2% in the CV group, and 25.0% in the no-risk group stated that they would commence chest compressions. After training, most family members (95.5% in the CS group, 94.9% in the CV group, and 94.4% in the no-risk group) reported high willingness to start chest compressions with improved knowledge, regardless of whether the person with the cardiac arrest was a family member or an unknown person. There was no difference among the groups before and after training in willingness/unwillingness to perform cardiac compression or in the reason for willingness/unwillingness to perform cardiac compression (Table 2).

housewife occupation, or no occupation. Motivation for training in the CS group was more frequently triggered by a healthcare professional’s recommendation than by other causes. Participants in the CS group perceived that their relative had a higher risk of cardiac arrest than that in the general population. Most participants did not have any exposure to CPR training over the preceding 2 years, and there were no differences in CPR training exposure between the three groups (Table 1).

Participants (40.9%, CS group; 41.8%, CV group; and 44.4%, no-risk group) stated that facing a cardiac arrest involving a family member, they would start chest compressions, despite

Table 1. Demographics and characteristics of family members according to group

Age (years), Mean±SD

Cardio-specific group (n=88)

Cardio-vascular group (n=79)

No-risk group (n=36)

p

49.5±15.6

46.3±11.72

43.4±15.3

0.048

Sex, n (%)

Male

Female

29 (33.0)

37 (46.8)

20 (55.6)

59 (67)

42 (53.2)

16 (44.4)

Education level, n (%)

Middle school

11 (12.5)

5 (6.3)

High school

37 (42.0)

24 (30.4)

12 (33.3)

College

34 (38.6)

30 (38.0)

16 (44.4)

6 (6.8)

18 (22.8)

6 (16.7)

0

2 (2.5)

1 (2.8)

Graduate school Other

Occupation, n (%)

Housewife

37 (42.0)

Professional

White collar

21 (26.6)

6 (16.7)

12 (13.6)

20 (25.3)

12 (33.3)

9 (10.2)

13 (16.5)

5 (13.9)

Blue collar

1 (1.1)

2 (2.5)

2 (5.6)

Student

6 (6.8)

2 (2.5)

7 (19.4)

Other

9 (10.2)

18 (22.8)

3 (8.3)

None

14 (15.9)

2 (2.5)

2 (5.6)

Exposure to CPR training over the past 2 years, n (%)

0

79 (89.9)

64 (81.0)

0.000

0.348

30 (83.3)

1

4 (4.5)

12 (15.2)

3 (8.3)

2

4 (4.5)

2 (2.5)

2 (5.6)

3

Concern about patient’s risk of cardiac arrest, n (%)

0.031

1 (2.8)

0.041

1 (1.1)

1 (1.3)

1 (2.8)

69 (78.4)

36 (45.6)

9 (25.0)

0.000

28 (31.8)

10 (12.7)

4 (11.1)

0.003

Motivation for training, n (%)

Recommendation by healthcare professional

Help a family member

44 (50.0)

32 (40.5)

11 (30.6)

0.120

Help a stranger

30 (34.1)

29 (36.7)

15 (41.7)

0.727

For my job/career

1 (1.1)

2 (2.5)

3 (8.3)

0.096

Other

2 (2.3)

13 (16.5)

5 (13.9)

0.006

SD: Standard deviation; CPR: Cardiopulmonary resuscitation.

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Han et al. Hospital-based targeted CPR training intervention for target population

Table 2. Attitude about cardiopulmonary resuscitation before and after training

CS group (n=88)

CV group (n=79)

No-risk group (n=36)

p

Willing to perform CPR on family member

Pre

10 (11.4)

5 (6.3)

4 (11.8)

Pre 0.791

No CPR, due to uncertainty of arrest

Post

(–)

2 (2.5)

1 (2.8)

Post 0.471

Pre

5 (5.7)

4 (5.1)

3 (8.3)

No CPR, due to fear of doing harm

Post

Pre

No CPR, due to fear of infection

Post

Pre

No CPR, due to lack of knowledge

(–) 2 (2.3)

(–) (–)

(–) 11 (5.4)

10 (12.7)

4 (11.1)

Post

Start CPR, despite lack of knowledge on how to

Pre

36 (40.9)

33 (41.8)

16 (44.4)

perform CPR

Post

3 (3.4)

2 (2.5)

1 (2.8)

Start CPR, with knowledge on how to perform CPR

Pre

24 (27.3)

27 (34.2)

8 (22.2)

Post

85 (96.6)

75 (94.9)

34 (94.4)

Pre

9 (10.2)

5 (6.3)

7 (19.4)

(–)

1 (2.8)

(–) (–)

Willing to perform CPR on unknown person

No CPR, due to uncertainty of arrest

Post

(–)

1 (1.3)

(–)

Pre

6 (6.8)

6 (7.6)

6 (16.7)

No CPR, due to fear of doing harm

Post

(–)

1 (1.3)

(–)

Pre

1 (1.1)

(–)

(–)

No CPR, due to fear of infection

Post

1 (1.1)

(–)

(–)

Pre

16 (18.2)

17 (21.5)

5 (13.9)

No CPR, due to lack of knowledge

Post

(–)

1 (1.3)

1 (2.8)

Start CPR, despite lack of knowledge how to

Pre

28 (31.8)

27 (34.2)

9 (25.0)

perform CPR

Post

3 (3.4)

1 (1.3)

1 (2.8)

Start CPR, with knowledge on how to perform CPR

Pre

28 (31.8)

24 (30.4)

9 (25.0)

Pre 0.451

Post 0.543

Post

84 (95.5)

75 (94.9)

34 (94.4)

Confidence level for performing CPR

Pre

3.61±1.20

3.39±1.30

3.58±1.10

0.477

Post

4.34±0.93

4.28±0.89

4.53±0.79

0.378

Willing to use AED after training

Post

85 (96.6)

78 (100)

36 (100)

0.344

Willing to disseminate information on CPR training

Post

4.62±0.91

4.52±0.90

4.67±0.63

0.300

CS: Cardio-specific; CV: Cardio-vascular; CPR: Cardiopulmonary resuscitation; AED: Automatic external defibrillator.

No differences in the rate of correct response for each step were observed among the groups. Following training, all groups achieved remarkable improvement in their knowledge of the BLS sequence and of each step of CPR skills as well as in the confidence level for performing CPR compared with pre-training levels (Appendix 1).

The knowledge level of the BLS sequence, confidence levels for performing CPR, and CPR skill performance in all groups increased after training (Appendix 2). There were no differences among the groups in differential improvement in knowledge, skills, and confidence after training, regardless of adjustments for age (Table 3).

228

Participant evaluation of the training class indicated that the class provided an easy learning opportunity, was helpful, and conveyed a clear message. Participants stated that they would highly recommend the course and reported that they were keen to participate in further training and were highly satisfied that the time allocated was adequate. There were no differences among the groups in the evaluation of the class.

Response rates to the telephone survey at 3 months were 53.4%, 55.1%, and 43.2% for the CS, CV, and no-risk groups, respectively. Participant knowledge level of the BLS sequence declined at 3 months across all groups (67.4%, CS group; 70.5%, CV group; and 78.6%, no-risk group). The proporUlus Travma Acil Cerrahi Derg, May 2018, Vol. 24, No. 3

Han et al. Hospital-based targeted CPR training intervention for target population

Table 3. Comparison of the improvement differential between pre- and post-training levels of knowledge about CPR and CPR skills among participants by group

CS group

CV group

No-risk group

a

p

b

p

c

p

Knowledge

Basic Life Support sequence

Importance of CPR in survival

Pre

26 (29.5)

30 (38.0)

12 (33.3)

Post

81 (92.0)

73 (92.4)

32 (88.9)

0.346

<0.0001

Pre

74 (84.1)

62 (78.5)

32 (88.9)

Post

82 (93.2)

71 (89.9)

34 /94.4)

0.465

0.061

0.643 0.963

Skill performance

Check response and breathing

Pre

21 (24.4)

26 (41.9)

10 (38.5)

(–)

(–)

Post

84 (97.7)

62 (100)

26 (100)

Pre

13 (15.1)

19 (30.6)

6 (23.10)

Post

85 (98.8)

60 (96.8)

26 (100)

Pre

2 (2.5)

3 (5.4)

Call 119 Ask for AED

(–)

0 (0)

(–)

(–)

(–)

Post

73 (92.4)

52 (92.9)

23 (100)

Pre

78 (90.7)

53 (85.5)

22 (84.6)

Start chest compressions

(–)

(–)

Post

86 (100)

62 (100)

26 (100)

Pre

28 (32.6)

28 (45.2)

8 (30.8)

Correct hand position

0.442

<0.0001

Post

84 (97.7)

60 (96.8)

24 (92.3)

Pre

17 (19.8)

18 (29.0)

5 (19.2)

Compression rate (100–120/min)

0.684

<0.0001

Post

83 (96.5)

59 (95.2)

24 (92.3)

Pre

14 (16.3)

17 (27.4)

4 (15.4)

25 (96.2)

Compression depth (5–6 cm)

Post

76 (88.4)

56 (90.3)

Pre

11 (12.8)

6 (9.7)

Post

83 (96.5)

60 (96.8)

Minimize handoff time

0.542

2 (7.7)

<0.0001

(–)

(–)

(–) (–) (–) (–) 0.568 0.580 0.309 (–)

26 (100)

CS: Cardio-specific; CV: Cardio-vascular; BLS: Basic Life Support; CPR: Cardiopulmonary resuscitation; AED: Automatic external defibrillator. a p-value by generalized estimating equation (GEE) for group effect. bp-value by GEE for time effect. cp-value by GEE for group × time effect.

Table 4. Telephone survey results at 3 months after training

Response rate, n (%)

Cardio-specific group

Cardio-vascular group

No-risk group

p

47 (53.4)

44 (55.1)

15(43.2)

0.441

1

(-)

(-)

31 (67.4)

39 (70.5)

11 (78.6)

Did you witness any arrest patient after training?

Knowledge, n (%)

Basic Life Support sequence

0.725

Step, n (%)

Check response and breaths

39 (83.0)

35 (79.5)

12 (80.0)

0.909

Call 119 and AED

41 (87.2)

42 (95.5)

13 (86.7)

0.318

Starting chest compressions

46 (97.9)

42 (95.5)

14 (93.3)

0.682

Defibrillation

32 (68.1)

28 (63.6)

8 (53.3)

0.587

Identify the AED location closest to the house

31 (66.0)

28 (63.6)

10 (66.7)

0.964

Secondary propagation

31 (72.3)

22 (50.0)

7 (46.7)

0.050

AED: Automatic external defibrillator.

tion of participants who remembered the step of checking for patient response and spontaneous breathing was as follows: 83%, CS group; 79.5%, CV group; 80%, no-risk group.

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The proportion of participants who remembered to call 119 and to request for an AED was as follows: 89.3%, CS group; 95.5%, CV group; 86.7%, no-risk group. Only 68.1% of the 229

Han et al. Hospital-based targeted CPR training intervention for target population

participants in the CS group, 63.6% of the participants in the CV group, and 53.3% of the participants in the no-risk group replied correctly to the step on defibrillation. Approximately 63.6%â&#x20AC;&#x201C;66.7% of responders could identify the location of an AED near their house after training. The rate of conducting secondary propagation after 3 months was superior in the CS group (72.3%) (Table 4).

DISCUSSION Bystander CPR may help to preserve heart and brain function and improve survival from OHCA.[1,12] While the rate of bystander CPR recently increased to 36.3% in the United States[13,14] and was reported as 44% in Denmark,[15] bystander CPR rates remain low, particularly in Asian countries.

[3] Good Samaritan legislation, CPR training as a prerequisite of elementary school education, and dispatcher-assisted CPR programs are forms of community-based interventions.[5] The rate of survival to discharge and good neurologic outcome increased from 2011 by our system-wide approach from community to hospital for five delivery enhancements (early EMS activation, bystander CPR, usage of AED, high-quality ACLS and standard post-cardiac arrest care).[6] The bystander CPR rate and the rate of previous CPR training experience in bystanders at the scene also increased from 2011 (Fig. 1).[6] However, the bystander CPR rate and the rate of previous CPR training experience in bystanders shows no change, despite continuous community intervention, support by the state, and change in policy over several years.

Common barriers to performing CPR include emotional stress, lack of knowledge, low self-confidence in performing CPR correctly, fear of harming the patient, concerns about legal repercussions, infection transmission, and individual differences.[5,12,16] CPR training can increase layperson confidence and willingness to perform CPR, and training within 5 years may contribute to CPR performance in real situations.[16,17] Sasson et al.[14] considered disparities in the provision of bystander CPR and survival, suggesting a paradigm to identify high-risk patients and barriers to learning, performing CPR, and implementing training programs focused on persons with high needs.

Reports indicate that 70%â&#x20AC;&#x201C;84% of cardiac arrests occur in private residences, patients tend to be elderly, and bystander family members also tend to be elderly.[13,15,18] Potential trainees, such as family members, may not have convenient training opportunities. Most participants enrolling in CPR training are young with the purpose of fulfilling job requirements.[7] The discrepancy between low bystander CPR training and the high incidence of cardiac arrests highlights the importance of targeted education as a community-based intervention.[19] The present study focused on the discrepancy between the limited opportunities for CPR training and the high likelihood 230

of witnessing a cardiac arrest in a family comprising patients with heart disease or those with risk factors for cardiovascular disease. We divided recruited participants into CS, CV, and no-risk groups according to potential risk factors for cardiac arrest. The following are considered risk factors for sudden cardiac death: poor left ventricular function, malignant arrhythmia, electrolyte derangements, chronic renal disease, and diabetes.[10,11] Considering the degree of risk and the influencing impact of risk factors, family members in the present study were allocated to the CS group when the patient had known heart disease or the CV group when the patient had risk factors for cardiovascular disease.

Compared with the CV and no-risk groups, the CS group comprised older women and a greater proportion of housewives with a lower level of education. Compared with the no-risk group, the CV group comprised older women and a greater proportion of housewives. Papalexopoulou et al.[20] reported that old age and a low level of education are associated with low scores in practical and written tests. Low rates of CPR training in the United States were observed in black or Hispanic residents with a lower median household income and a higher median age, living in rural areas.[2] However, in the present study, the CS group, which included older participants, with a low level of education, revealed comparable results with other groups for willingness and confidence in performing CPR and in the assessment of the knowledge level and BLS skills. Several studies support our results and have demonstrated a high CPR training success among elderly subjects, despite relatively low interest in training.[21,22] There was no difference among the three groups in the results of the assessments of attitude, knowledge, and skill performance. There was considerable improvement across all groups in the knowledge level and skill after training. There were no differences among the three groups in improvement differentials, defined as the increasing degree of knowledge and skills.

Regardless of adjustments for age, the group with at-risk patients, particularly the CS group, reported an increased perception of the risk of cardiac arrest. We hypothesized that the CS group would be associated either with poor outcomes because of the high proportion of elderly persons with a low level of education or with a strong performance because of the prevalence of family members with increased perception of risk of arrest. However, old age and the level of education did not affect the outcome after this 1-h training class.

Although the CS group was concerned about the high risk of cardiac arrest in patients, recommendation by a healthcare professional to attend CPR training was an important contributing factor in prompting persons to participate in the program. These results support the reports that the interest in CPR of family members of patients with known heart disease is more likely to be influenced by physician recommendation.[23] Potential barriers to learning CPR include the lack of information on CPR classes, lack of intellectual and/or Ulus Travma Acil Cerrahi Derg, May 2018, Vol. 24, No. 3

Han et al. Hospital-based targeted CPR training intervention for target population

physical capability to learn CPR, and concern about causing anxiety in the patient.[24] The reasons for the lack of targeted training for family members were the limitation of resources for CPR training, difficulty in identifying the target population with high-risk patients, failure to access family members of high-risk patients, and lack of attention to the target population by healthcare professionals.[8,23,24] The attention of healthcare professionals can be important for recruiting the target population that lacks opportunities and interest for CPR training.

focused, cost-effective training strategy. The training focused on a target population (family members of high-risk patients for cardiac arrest), targeted location (regional medical centers have a significant number of high-risk patients), targeted approach (patients were identified on admission to a ward or in the outpatient department upon recommendation by a healthcare professional), and targeted time (available waiting time for the test). The training can be offered as a part of cardiac rehabilitation programs for family members and highrisk patients.[26]

The provision of CPR training for laypersons, as a communitybased intervention for improving survival in OHCA, requires significant public resources. Targeted program interventions recruiting participants who are most likely to witness a cardiac arrest may be a cost-effective strategy to increase bystander CPR rates.[8] Moreover, CPR training alone may not be sufficient to increase bystander CPR rates, and intentionfocused strategies may provide specific targets to strengthen the intention to perform CPR. To increase bystander CPR rates, specific interventions taking into consideration bystander characteristics are required, including the provision of different instruction material and the implementation of modules for specific target learners.[25] CPR training programs need to recognize individual differences and enhance motivational readiness and confidence.[23]

Conclusions

The present study found that although participants did not know how to perform CPR, there was a greater willingness across all groups to perform CPR on a family member than on an unknown person. Bystander CPR training focusing on performing CPR on a family member could increase the rate of performing CPR in private locations, where the incidence rate of cardiac arrests is high. It is also necessary to understand different bystander characteristics that affect belief and underlying reasons for learning CPR because ultimately these have a positive effect on performing CPR, particularly in the CS group. Identification of family members of high-risk patients; easy access to training; and participant characteristics, such as perception of the risk of cardiac arrest and a high willingness to perform CPR, can be positive influencing factors for successful learning and strengthening of the intention to perform CPR. Old age, low levels of education, limited interest in CPR training, and CPR training on the recommendation of healthcare professionals can be negative influencing factors. However, the potential bystander group achieved a similar successful learning outcome compared with the norisk group.

The present study is a small-sized, single center study. The number of participants was not enough to generalize our results. Moreover, we should consider the cultural and regional differences while analyzing results. The risk factors for cardiac arrest were not clearly known. However, regional medical center-based bystander CPR training may be a model of targeted intervention, characterized by an adequate intentionUlus Travma Acil Cerrahi Derg, May 2018, Vol. 24, No. 3

Family members of patients with risk factors for sudden cardiac arrest, particularly heart disease, tend to be elderly women with a low level of education. Nevertheless, improvement in the educational outcome in this category of respondents was comparable to that of other respondents.

A total of 70% of respondents disseminated the contents of the course among their friends 3 months after training. The regional medical center-based CPR training model can be one of the targeted interventions as intention-focused, cost-effective training. By expanding this hospital-based CPR training program, community and medical facilities could contribute to the prevention and increased survival of patients with outof-hospital cardiac arrests.

Acknowledgement We are grateful to BLS instructors at the Korea University Anam Hospital BLS training site for their assistance and participation in training.

Disclosure This work was supported by a grant funded by the Korea Centers for Disease Control & Prevention, Health and Welfare Ministry in Korea (grant number Q143131). Sung Woo Lee received funding. These funding sources had no role in the study design, data collection, data analysis, data interpretation, or writing of the report. The authors declare that they have no competing interests.

Author Contribution SJK and SWL conceived the study design and wrote the manuscript. KSH was responsible for target population training and helped conduct the trial and data collection. SJK, JSL, and SWL managed and analyzed the data, including quality control. All authors contributed substantially to the revision of the manuscript. KSH and SWL are co-first authors.

Conflict of interest: None declared.

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6. Hwang WS, Park JS, Kim SJ, Hong YS, Moon SW, Lee SW. A systemwide approach from the community to the hospital for improving neurologic outcomes in out-of-hospital cardiac arrest patients. Eur J Emerg Med 2017;24:87–95.

7. Brennan RT, Braslow A. Are we training the right people yet? A survey of participants in public cardiopulmonary resuscitation classes. Resuscitation 1998;37:21–5.

8. Swor R, Fahoome G, Compton S. Potential impact of a targeted cardiopulmonary resuscitation program for older adults on survival from private-residence cardiac arrest. Acad Emerg Med 2005;12:7–12.

9. King R, Heisler M, Sayre MR, Colbert SH, Bond-Zielinski C, Rabe M, et al. Identification of factors integral to designing community-based CPR interventions for high-risk neighborhood residents. Prehosp Emerg Care 2015;19:308–12.

10. Sotoodehnia N, Zivin A, Bardy GH, Siscovick DS. Reducing mortality from sudden cardiac death in the community: lessons from epidemiology and clinical applications research. Cardiovasc Res 2001;50:197–209.

11. Pun PH. The interplay between CKD, sudden cardiac death, and ventricular arrhythmias. Adv Chronic Kidney Dis 2014;21:480–8.

12. Nolan JP. High-quality cardiopulmonary resuscitation. Curr Opin Crit Care 2014;20:227–33.

13. Chan PS, McNally B, Tang F, Kellermann A; CARES Surveillance Group. Recent trends in survival from out-of-hospital cardiac arrest in the United States. Circulation 2014;130:1876–82.

14. Sasson C, Meischke H, Abella BS, Berg RA, Bobrow BJ, Chan PS, et al; American Heart Association Council on Quality of Care and Outcomes Research, Emergency Cardiovascular Care Committee, Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation, Council on Clinical Cardiology, and Council on Cardiovascular Surgery and Anesthesia. Increasing cardiopulmonary resuscitation provision in commu-

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nities with low bystander cardiopulmonary resuscitation rates: a science advisory from the American Heart Association for healthcare providers, policymakers, public health departments, and community leaders. Circulation 2013;127:1342–50.

15. Wissenberg M, Lippert FK, Folke F, Weeke P, Hansen CM, Christensen EF, et al. Association of national initiatives to improve cardiac arrest management with rates of bystander intervention and patient survival after out-of-hospital cardiac arrest. JAMA 2013;310:1377–84.

16. Swor R, Khan I, Domeier R, Honeycutt L, Chu K, Compton S. CPR training and CPR performance: do CPR-trained bystanders perform CPR? Acad Emerg Med 2006;13:596–601.

17. Cho GC, Sohn YD, Kang KH, Lee WW, Lim KS, Kim W, et al. The effect of basic life support education on laypersons’ willingness in performing bystander hands only cardiopulmonary resuscitation. Resuscitation 2010;81:691–4.

18. Swor RA, Jackson RE, Compton S, Domeier R, Zalenski R, Honeycutt L, et al. Cardiac arrest in private locations: different strategies are needed to improve outcome. Resuscitation 2003;58:171–6.

19. Fosbøl EL, Dupre ME, Strauss B, Swanson DR, Myers B, McNally BF, et al. Association of neighborhood characteristics with incidence of out-of-hospital cardiac arrest and rates of bystander-initiated CPR: implications for community-based education intervention. Resuscitation 2014;85:1512–7.

20. Papalexopoulou K, Chalkias A, Dontas I, Pliatsika P, Giannakakos C, Papapanagiotou P, et al. Education and age affect skill acquisition and retention in lay rescuers after a European Resuscitation Council CPR/ AED course. Heart Lung 2014;43:66–71.

21. Neset A, Birkenes TS, Furunes T, Myklebust H, Mykletun RJ, Odegaard S, et al. A randomized trial on elderly laypersons’ CPR performance in a realistic cardiac arrest simulation. Acta Anaesthesiol Scand 2012;56:124–31.

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24. Chu KH, May CR, Clark MJ, Breeze KM. CPR training in households of patients with chest pain. Resuscitation 2003;57:257–68.

25. Panchal AR, Fishman J, Camp-Rogers T, Starodub R, Merchant RM. An “Intention-Focused” paradigm for improving bystander CPRperformance. Resuscitation 2015;88:48–51.

26. Richardson ME, Lie KG. Cardiopulmonary resuscitation training for family members of patientson cardiac rehabilitation programmes in Scotland. Resuscitation 1999;40:11–9.

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ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Yerel bir tıp merkezinde risk düzeyi yüksek olan hastaların aile üyelerine yönelik kardiyopulmoner resüsitasyon (kalp masajı) eğitimi: Risk düzeyi yüksek hastalar ile risk taşımayan hastalarda aile üyelerinin karşılaştırılması Dr. Kap Su Han,1 Dr. Ji Sung Lee,2 Dr. Su Jin Kim,1 Dr. Sung Woo Lee1 1 2

Kore Üniversitesi Anam Hastanesi, Acil Tıp Bölümü, Seul-Kore Cumhuriyeti Klinik Araştırma Merkezi, Asan Tıp Merkezi, Seul-Kore Cumhuriyeti

AMAÇ: Hedef popülasyona (ani kalp durması yönünden potansiyel riskleri taşıyan hastaların aile üyeleri) yönelik hastane merkezli bir kardiyopulmoner resüsitasyon eğitim modeli geliştirilmiş olup, geçerli kılmak amacıyla hedef popülasyon ile hedef dışında kalan popülasyon arasında CPR eğitim sonuçlarını karşılaştırdık.

GEREÇ VE YÖNTEM: Hastaların eğitim sürecindeki aile üyeleri hastanın rahatsızlığına bağlı olarak üç gruba ayrılmıştır: 1) ani kalp durması riski taşıyan kalp hastalarının aile üyelerinin dahil edildiği kardiyak (CS) risk grubu; 2) kardiyovasküler hastalık yönünden risk faktörlerini taşıyan hastaların aile üyelerinin dahil edildiği kardiyovasküler (CV) risk grubu; ve 3) risk taşımayan grup. Eğitim öncesi ve eğitim sonrası anketler ve beceri testleri ile eğitim sonrasında 3 ay süreyle telefon üzerinden gerçekleştirilen bir anket uygulanmıştır. Eğitime ilişkin sonuçlar değerlendirilmiştir.

BULGULAR: Toplam 203 aile üyesinin, 21 ayrı CPR eğitim sınıfına kaydı gerçekleştirilmiştir. CV grubuyla (n=79) ve risk taşımayan grupla (n=36) kıyaslandığında CS grubunda (n=88) eğitim düzeyi daha düşük olan ev hanımları ve yaşlı bireyler yer almıştır. CS grubu, sağlık uzmanları tarafından motive edilerek eğitime katılmıştır. CS, CV ve risk taşımayan gruplarda bilgi, CPR gerçekleştirme konusundaki isteklilik ve beceriler yönünden ilerleme olduğu kaydedilmiştir. CS grubunda yaşlı bireylere ve eğitim düzeyinin düşük olmasına rağmen, eğitimin katkısı diğer gruplardaki kişilerle benzerlik göstermiştir. CS grubunda, CPR eğitiminin getirdiği ilave yararlar ve yüksek yanıt oranı gözlenmiştir.

TARTIŞMA: Kalp rahatsızlığı olan hastaların aile üyeleri, özellikle iyileşme ve ilave yararlar açısından CPR eğitimi için uygun bir hedef popülasyon teşkil edebilmektedir. Hedefe yönelik uygulamalar, CPR işlemini gerçekleştirecek olan üçüncü kişilerin sayısını artırmak amacıyla etkili bir eğitim stratejisi olabilmektedir.

Anahtar sözcükler: Aile; eğitim; kardiyopulmoner resüsitasyon; seyirci; yüksek risk.

Ulus Travma Acil Cerrahi Derg 2018;24(3):224-233

doi: 10.5505/tjtes.2017.01493

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ORIG I N A L A R T IC L E

Management of traumatic arteriovenous fistulas: A tertiary academic center experience Mazlum Şahin, M.D.,1 Cihan Yücel, M.D.,1 Eyüp Murat Kanber, M.D.,2 Fatma Tuba İlal Mert, M.D.,1 Burcu Bıçakhan, M.D.1 1

Department of Cardiovascular Surgery, Haseki Training and Research Hospital, İstanbul-Turkey

2

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

ABSTRACT BACKGROUND: To present the surgical experience at a tertiary academic center of treating patients with traumatic arteriovenous fistulas (AVFs) who in whom endovascular treatment was contraindicated or in whom unsuccessful endovascular treatment had been performed.

METHODS: A total of 27 patients with traumatic AVFs who underwent surgery between September 2014 and May 2016 were included. The site of injury, timing of surgery, and the surgical methods utilized were analyzed retrospectively.

RESULTS: Arteriovenous fistulas were located in the lower extremity in 26 patients (96.29%) and in the upper extremity in one patient (3.7%). Etiological factors included gunshot injuries in 23 patients (85.18%) and penetrating injury in four patients (14.81%).

AVFs in the lower extremity were between the popliteal artery and vein in 21 patients and between the femoral artery and vein in five patients. The one patient with upper-extremity AVF had a communication between the brachial artery and cephalic vein. Primary repair of the artery and vein after ligation, arterial graft interposition plus primary vein repair, and arterial and venous graft interposition were performed for surgical repair in two, five, and 20 patients, respectively. The saphenous vein was used for grafting in all cases needing grafts.

CONCLUSION: In patients enduring penetrating trauma in the close vicinity of major vascular structures, a detailed history-taking and physical examination should be performed along with auscultation. The endovascular approach may represent the initial choice of management because of its lower rate of complications, noninvasive nature, decreased in-hospital costs, and decreased loss of work productivity. However, surgery is still unavoidable option in a significant proportion of patients who are either hemodynamically unstable, contraindicated for endovascular treatment, or in whom endovascular treatment was unsuccessful.

Keywords: Arteriovenous fistulas (AVFs); endovascular treatment; surgical treatment; traumatic.

INTRODUCTION Arteriovenous fistula (AVF) was first described as a medical entity by William Hunter in 1757, followed by the first surgical attempt at its correction in 1837 by Breschet, who tried to eliminate the fistula via ligation of the proximal artery.[1] Various factors play role in the etiology of traumatic AVF, the incidence of which is difficult to determine because of the possibility of delay in diagnosis up to years.[2,3] Absence of spontaneous regression within a 2-week period is an in-

dication for endovascular or surgical management of AVFs. [4] Surgery may involve direct primary repair or anatomical reconstruction (repair with autogenous venous graft, autogenous or synthetic graft interposition, or bypass).

MATERIALS AND METHODS A total of 27 male patients (mean age 37.58 years, range: 18–52 years) treated surgically in our cardiovascular unit for traumatic AVF between September 2014 and May 2016 were

Cite this article as: Şahin M, Yücel C, Kanber EM, İlal Mert FT, Bıçakhan B. Management of traumatic arteriovenous fistulas: A tertiary academic center experience. Ulus Travma Acil Cerrahi Derg 2018;24:234-238.

Address for correspondence: Mazlum Şahin, M.D. Haseki Eğitim ve Araştırma Hastanesi, Kalp ve Damar Cerrahisi Kliniği, İstanbul, Turkey Tel: +90 212 - 529 44 00 E-mail: mzlmshn@gmail.com Ulus Travma Acil Cerrahi Derg 2018;24(3):234-238 DOI: 10.5505/tjtes.2017.49060 Submitted: 19.06.2017 Accepted: 07.09.2017 Online: 05.04.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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Ĺ&#x17E;ahin et al. Management of traumatic arteriovenous fistulas

included in this study. Patient data were retrieved through a retrospective case record search. The etiology involved a gunshot fire in 23 patients (85.18%) and penetrating injury in four (14.81%).

The diagnosis was established following hemodynamic instability after trauma in seven patients. The remaining patients had been initially treated in other health facilities without presenting with hematoma formation or absence of pulses, and had been discharged after hemodynamic stability was attained.

AVF diagnosis was primarily on the basis of physical examination and the results of color Doppler ultrasound. In all seven patients undergoing emergency surgery for treating hemodynamic instability, an anatomical assessment was performed using computed tomography (CT) angiography. In other subjects, angiography was performed for anatomical assessment as well as for endovascular treatment.

RESULTS In all patients, a murmur could be heard on auscultation and a thrill could be palpated over the fistula. Twenty patients had edema and venous dilation in the involved lower extremity, whereas AVF was accompanied by a pseudoaneurysm in four.

Three patients had signs of cardiac failure. Femur fracture was present in three patients; all these patients were treated with external fixator and skeletal traction after orthopedic consultation.

Figure 1. Angiographic image showing the stent migration during endovascular procedure.

In the lower extremity, AVF was located between the popliteal artery and vein in 21 cases, and between the femoral artery and vein in five. The only patient with upper-extremity AVF had a communication between the brachial artery and cephalic vein (Table 1). Except for the seven cases requiring emergency surgery for treating hemodynamic instability, the most frequent cause of unsuccessful endovascular treatment was the inability to advance the guidewire in 14 patients (51.85%). In one patient, emergency surgery was required for treating stent migration (Figs. 1, 2). Elective operations were performed between 1 and 26 months after the initial trauma and the mean operation time after trauma was 16Âą8 months.

Patients were prepared for surgery after anesthesia appropriate for the site of injury was provided. While approaching the site of AVFs, the artery was accessed both proximally and distally. Following systemic heparinization (100 IU/kg), arterial and venous clamps were placed both proximally and distally. In two cases, ligation and primary arterial and venous repair was possible. Other subjects were contraindicated for primary repair because of large defects underwent graft interposition of the artery and primary repair of the vein (n=5) or arterial and venous graft interposition (n=20). In cases with pseudoaneurysms, the sac was exposed after proximal and distal inspection, and the AVF was accessed. The saphenous vein Ulus Travma Acil Cerrahi Derg, May 2018, Vol. 24, No. 3

Figure 2. The image of the stent slipping during the procedure.

was used in all patients requiring grafting. In patients in whom emergency surgery was performed we evaluated the quality of saphenous vein with surgeon experience considering tortious 235

Şahin et al. Management of traumatic arteriovenous fistulas

Table 1. Clinical properties of the patients Injury etiology

Patient no

Age

Sex

Location

Symptom

Gunshot

1

45

Male

Popliteal artery-Popliteal vein

Leg edema

Gunshot

2

58

Male

Popliteal artery-Popliteal vein

Leg edema

Gunshot

3

37

Male

Femoral artery-Femoral vein

Hemodynamic instability

Gunshot

5

43

Male

Femoral artery-Femoral vein

Leg edema + heart failure

Gunshot

6

28

Male

Popliteal artery-Popliteal vein

Leg edema

Gunshot

7

37

Male

Femoral artery-Femoral vein

Leg edema

Gunshot

10

18

Male

Popliteal artery-Popliteal vein

Hemodynamic instability

Gunshot

11

27

Male

Popliteal artery-Popliteal vein

Hemodynamic instability

Gunshot

12

35

Male

Popliteal artery-Popliteal vein

Leg edema

Gunshot

13

44

Male

Popliteal artery-Popliteal vein

Leg edema

Gunshot

15

26

Male

Popliteal artery-Popliteal vein

Leg edema

Gunshot

16

44

Male

Femoral artery-Femoral vein

Leg edema

Gunshot

17

50

Male

Popliteal artery-Popliteal vein

Leg edema + heart failure

Gunshot

18

35

Male

Popliteal artery-Popliteal vein

Hemodynamic instability

Gunshot

19

38

Male

Popliteal artery-Popliteal vein

Leg edema

Gunshot

20

41

Male

Popliteal artery-Popliteal vein

Leg edema

Gunshot

21

39

Male

Popliteal artery-Popliteal vein

Hemodynamic instability

Gunshot

22

37

Male

Popliteal artery-Popliteal vein

Leg edema

Gunshot

23

30

Male

Popliteal artery-Popliteal vein

Hemodynamic instability

Gunshot

24

43

Male

Popliteal artery-Popliteal vein

Leg edema

Gunshot

25

38

Male

Popliteal artery-Popliteal vein

Leg edema

Gunshot

26

37

Male

Popliteal artery-Popliteal vein

Hemodynamic instability

Gunshot

27

39

Male

Popliteal artery-Popliteal vein

Leg edema

Penetrating

4

25

Male

Brachial artery-Cephalic vein

Leg edema

Penetrating

8

49

Male

Popliteal artery-Popliteal vein

Leg edema

Penetrating

9

52

Male

Popliteal artery-Popliteal vein

Leg edema+ heart failure

Penetrating

14

21

Male

Femoral artery-Femoral vein

Leg edema

structure of saphenous vein, hyperthermıa and presence of skin disorder (ulcer or dermatitis) around saphenous vein. In elective cases, we routinely used Doppler ultrasound to assess saphenous ven wall thickness, saphenous vein insufficiency, and presence of thrombophlebitis. We used saphenous vein of 3–8-mm diameter, without insufficiency and thrombophlebitis.

In postoperative period, all patients received 100 mg of acetyl salicylic acid. No patient had postoperative venous thrombosis. All patients were discharged within a mean duration of 3 days (2.23±1.52) without complications. In follow-ups, success of surgery and healing of AVF was checked with Doppler ultrasound at 1, 6, and 12 months after surgery. No morbidity or mortality was recorded (Table 2).

DISCUSSION Traumatic AVFs generally occur at anatomical sites where an artery is paired by or is in close vicinity of a vein. The most common etiological factors include gunshot injuries, pene236

trating injuries, or fractures. More than half of all traumatic AVFs occur in the lower extremity. Of these, 29% and 16% have been reported to involve the femoral artery and the popliteal artery, respectively.[5] Among our 27 participants, 26 had a lower-extremity AVF. History and physical examination suffice for a diagnosis of traumatic AVF in almost all cases. Physical examination findings are generally typical, and involve a palpable thrill and continous murmur on auscultation. Additional physical examination findings may include the signs of chronic venous stasis such as ulceration, pigmentation, edema, and varicose veins.

In addition, increase in skin temperature may be detected proximal and distal to the fistula. Signs of cardiac failure may also guide the physician in establishing the diagnosis. Depending on the size and localization of the fistula, congestive cardiac failure may also develop. Major systemic effects include increases in cardiac output, total blood volume, venous pressure, and heart rate along with cardiomegaly.[6] Ulus Travma Acil Cerrahi Derg, May 2018, Vol. 24, No. 3

Ĺ&#x17E;ahin et al. Management of traumatic arteriovenous fistulas

Table 2. Surgical indications and procedures Patient no

Surgical indication

Procedure

1

Failure to advance guidewire

Saphenous vein interposition to artery and vein

2

Failure to advance guidewire

Saphenous vein interposition to artery and vein

3

Hemodynamic instability

Saphenous vein interposition to artery + primary venous repair

4

Failure to advance guidewire

Primary repair

5

Failure to advance guidewire

Saphenous vein interposition to artery + primary venous repair

6

Highly mobile lesion site

Saphenous vein interposition to artery and vein + pseudoaneurysm repair

7

Highly mobile lesion site

Saphenous vein interposition to artery + primary venous repair + pseudoaneurysm repair

8

Failure to advance guidewire

Saphenous vein interposition to artery and vein

9

Highly mobile lesion site

Saphenous vein interposition to artery and vein

10

Hemodynamic instability

Saphenous vein interposition to artery and vein

11

Hemodynamic instability

Saphenous vein interposition to artery and vein

12

Highly mobile lesion site

Saphenous vein interposition to artery and vein + pseudoaneurysm repair

13

Failure to advance guidewire

Primary repair

14

Failure to advance guidewire

Saphenous vein interposition to artery + primary venous repair + pseudoaneurysm repair

15

Stent migration

Saphenous vein interposition to artery and vein

16

Failure to advance guidewire

Saphenous vein interposition to artery + primary venous repair

17

Failure to advance guidewire

Saphenous vein interposition to artery and vein

18

Hemodynamic instability

Saphenous vein interposition to artery and vein

19

Highly mobile lesion site

Saphenous vein interposition to artery and vein

20

Failure to advance guidewire

Saphenous vein interposition to artery and vein

21

Hemodynamic instability

Saphenous vein interposition to artery and vein

22

Failure to advance guidewire

Saphenous vein interposition to artery and vein

23

Hemodynamic instability

Saphenous vein interposition to artery and vein

24

Hemodynamic instability

Saphenous vein interposition to artery and vein

25

Failure to advance guidewire

Saphenous vein interposition to artery and vein

26

Failure to advance guidewire

Saphenous vein interposition to artery and vein

27

Failure to advance guidewire

Saphenous vein interposition to artery and vein

Angiography is the most accurate diagnostic modality for localizing the fistula, identifying its communications, and obtaining data on fistula hemodynamics. Noninvasive diagnostic techniques may be utilized for assessing smaller AVFs, measuring shunt volume, and identifying the degree of peripheral ischemia owing to distal steal effect.[7] In our patients, fistulas were diagnosed on the basis of the findings of physical examination and subsequent Doppler ultrasound assessment. In seven patients with hemodynamic instability, CT angiography was performed for anatomical assessment. In the remaining patients, angiography was used for anatomical assessment and therapeutic intervention.

Therapeutic options include surgery and endovascular intervention (coated stent graft or coil embolization).[7] Although, endovascular interventions were preferred, less-invasive procedures offer shorter hospitalization period, lower treatment cost, and lower complication rates.[8,9] Open surgery is still unavoidable option in a significant proportion of patients Ulus Travma Acil Cerrahi Derg, May 2018, Vol. 24, No. 3

who are either hemodynamically unstable or contraindicated for endovascular treatment, or in those where endovascular treatment was unsuccessful.[10,11] In addition, in some cases, open surgery is unavoidable in highly mobile anatomical sites or when the procedure is unsuccessful occurs because of the inability to further advance the guidewire. Patency rates reported for AVF stent graft repairs at 1 year vary between 88 and 100%.[12,13] In present study, we achieved 100% patency rate at the sixth month after operation and we concluded that open surgical repair is still a valuable option for the management of AVF. Indications for surgery generally include hemodynamically unstable or life-threatening lesions, availability of an experienced surgical team, injury in adjacent tissues (e.g., muscles, nerves), lesions contraindicated for endovascular treatment, and prior unsuccessful endovascular treatment.[8â&#x20AC;&#x201C;11] The most frequent type of indication for surgery in our group was unsuccessful endovascular intervention, resulting from to inability to fur237

Şahin et al. Management of traumatic arteriovenous fistulas

ther advance the guidewire in 14 patients, whereas surgery was performed for slipping in one, hemodynamic instability in seven, and fistula localization at a highly mobile anatomical region in five other patients.

Graft interposition should be surgically undertaken in patients who are contraindicated for surgical primary repair.

The saphenous vein should be used for grafting whenever possible. Accordingly, the saphenous vein was used for the continuity of both the vein and artery in all of our patients requiring grafting. The average time to discharge was 3 days, with no morbidity or mortality. Moreover, at 1-year follow-up assessments, both veins and arteries were found to be patent.

In conclusion, endovascular treatment may be considered to represent as preferred treatment option in AVFs owing to a number of advantages. However, hemodynamically unstable patients, absence of a skilled surgical team or appropriate equipment, lesions contraindicated for endovascular interventions, or unsuccessful endovascular treatment remain common indications for surgery, which may be accomplished with high success rates.

Conflict of interest: None declared.

fistula: a rare complication of arterial puncture for cardiac catheterization.

Am J Cardiol 1985;55:1445–6.

3. Kaptanoğlu M, Önen A, Manduz Ş, Doğan K. Peripheral vascular injuries. Ulus Travma Acil Cerrahi Derg 1997;3:16–22.

4. McArthur CS, Marin ML. Endovascular therapy for the treatment of arterial trauma. Mt Sinai J Med 2004;71:4–11.

5. Rich NM, Hobson RW 2nd, Collins GJ Jr. Traumatic arteriovenous fistulas and false aneurysms: a review of 558 lesions. Surgery 1975;78:817–28.

6. Erkut B, Karapolat S, Kaygin MA, Unlü Y. Surgical treatment of posttraumatic pseudoaneurysm and arteriovenous fistula due to gunshot injury. Ulus Travma Acil Cerrahi Derg 2007;13:248–50.

7. Sumner DS. Diagnostic evaluation of arteriovenous fistula. In: Rutherford RB, editor. Vascular Surgery. 2nd ed. Philadelphia: W.B. Saunders; 1984.

8. Mylankal KJ, Johnson B, Ettles DF. Iatrogenic arteriovenous fistula as a cause for leg ulcers: a case report. Ann Vasc Dis 2011;4:139–42.

9. O’Brien J, Buckley O, Torreggiani W. Hemolytic anemia caused by iatrogenic arteriovenous iliac fistula and successfully treated by endovascular stent-graft placement. AJR Am J Roentgenol 2007;188:W306.

10. Zhou T, Liu ZJ, Zhou SH, Shen XQ, Liu QM, Fang ZF, et al. Treatment of postcatheterization femoral arteriovenous fistulas with simple prolonged bandaging. Chin Med J (Engl) 2007;120:952–5.

11. Mellière D, Barres G, Saada F, Becquemin JP. Late arterial aneurysm proximal to corrected post-traumatic arteriovenous fistula. J Cardiovasc Surg (Torino) 1987;28:510–5.

REFERENCES

12. Waigand J, Uhlich F, Gross CM, Thalhammer C, Dietz R. Percutaneous treatment of pseudoaneurysms and arteriovenous fistulas after invasive vascular procedures. Catheter Cardiovasc Interv 1999;47:157–64.

1. Dry LR, Conn JH, Chavez CM, Hardy JD. Arteriovenous fistula: an analysis of fifty-eight cases. Am Surg 1972;38:154–60.

2. Kron J, Sutherland D, Rosch J, Morton MJ, McAnulty JH. Arteriovenous

13. Ruebben A, Tettoni S, Muratore P, Rossato D, Savio D, Rabbia C. Arteriovenous fistulas induced by femoral arterial catheterization: percutaneous treatment. Radiology 1998;209:729–34.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Travma sonrası gelişen arteriyovenöz fistüllerin tedavisi: Üçüncü basamak akademik merkez deneyimi Dr. Mazlum Şahin,1 Dr. Cihan Yücel,1 Dr. Eyüp Murat Kanber,2 Dr. Fatma Tuba İlal Mert,1 Dr. Burcu Bıçakhan1 1 2

Haseki Eğitim ve Araştırma Hastanesi, Kalp ve Damar Cerrahisi Kliniği, İstanbul İstanbul Eğitim ve Araştırma Hastanesi, Kalp ve Damar Cerrahisi Kliniği, İstanbul

AMAÇ: Bu çalışmada, kardiyoloji ünitemizde gerçekleştirilen endovasküler tedavide başarısız olan, travmatik arteriovenöz fistüllü (AVF) hastalarda cerrahi deneyimimizi sunmayı amaçladık.

GEREÇ VE YÖNTEM: Eylül 2014–Mayıs 2016 tarihleri arasında travmatik AVF’si olan toplam 27 hasta ameliyat edildi. Yaralanma yeri, cerrahi zamanlaması ve kullanılan cerrahi yöntemler geriye dönük olarak incelendi.

BULGULAR: Arteriyovenöz fistüller alt ekstremitede 26 hastada (%96.29), üst ekstremitede tek bir olguda (%3.7) bulundu. Etiyolojik faktörler 23 hastada (%85.18) ateşli silah yaralanması ve dört hastada (%14.81) penetran yaralanma idi. Alt ekstremitedeki AVF’ler, 21 hastada popliteal arter ve ven arasında, beş hastada femoral arter ile ven arasında idi. Üst ekstremite AVF’li tek olguda brakiyal arter ve sefalik ven arasında iletişim vardı.

Cerrahi onarım için ligasyondan sonra arter ve venin primer onarımı, arteriyel greft interpozisyon artı primer ven tamiri ve arteryal ve venöz greft interpozisyonu iki, beş ve 20 hastada gerçekleştirildi. Tüm olgularda safen ven greft olarak kullanıldı.

TARTIŞMA: Majör vasküler yapıların yakınında penetran travmalara maruz kalan hastalarda oskültasyon ile birlikte ayrıntılı öykü alma ve fizik muayene yapılmalıdır. Arteriyovenöz fistüller cerrahi olarak veya endovasküler girişimle (kaplı stent greft veya embolizasyon) tedavi edilebilir. Son yaklaşım, daha düşük komplikasyon oranları, prosedürün invaziv olmayan doğası ve hastane içi maliyetlerin azalması ve iş verimliliğinde azalma temel alınarak ilk tercih yönetimini temsil edebilir. Bununla birlikte hemodinamik olarak kararsız, endovasküler tedavi için uygulanabilir olmayan veya endovasküler tedavinin başarısız olduğu hastaların önemli bir bölümünde ameliyat kaçınılmazdır.

Anahtar sözcükler: Arteryovenöz fistüller; cerrahi tedavi; endovasküler tedavi; travmatik.

Ulus Travma Acil Cerrahi Derg 2018;24(3):234-238

238

doi: 10.5505/tjtes.2017.49060

Ulus Travma Acil Cerrahi Derg, May 2018, Vol. 24, No. 3

ORIG I N A L A R T IC L E

Evaluation of pterygoid plate fractures unrelated to Le Fort fractures using maxillofacial computed tomography Serra Özbal Güneş, Yeliz Aktürk, Esra Soyer Güldoğan, M.D., Department of Radiology, University of Health Sciences, Dışkapı Yıldırım Beyazıt Training and Research Hospital, İstanbul-Turkey

ABSTRACT BACKGROUND: This study aims to describe the major pterygoid plate fractures (PPFs) patterns unrelated to Le Fort fractures (LFFs) using maxillofacial computed tomography (CT).

METHODS: After obtaining our hospital ethics committee approval (37-05), data for PPF were acquired from the medical records of all the trauma patients who were diagnosed using CT at our hospital from April 2014 to April 2017.

RESULTS: Of the 178 patients, 135 (male/female = 86/49; mean age = 37.2 years) had LFF and 43 (male/female = 35/8; mean age = 38.6 years) had PPF without associated LFF. PPF patterns unrelated to LFF included temporal bone (11.6%), sphenotemporal buttress (25.5%), zygomaticomaxillary complex (30.2%), displaced mandible (23.3%), nasal (4.7%), and isolated fractures (4.7%). The etiologies of facial fractures were not significantly different between both sexes (p=0.576). No significant difference between Le Fort and non-Le Fort groups was found for age (p=0.603) and the causes of trauma (p=0.183).

CONCLUSION: PPF is most commonly seen with LFF, but it may also be seen alone or with other non-LFF indicating that all PPF are not related to LFF. Axial reformatted CT images can easily display PPF and the degree of displacement of the fragments, and they can be used to guide surgical reduction of the fractures.

Keywords: Computed tomography; Le Fort fractures; pterygoid plate.

INTRODUCTION

MATERIALS AND METHODS

Facial injuries are common presentations to the emergency department, and various fractures concerning the calvarial, skull base, and facial structures after the craniofacial trauma can be observed. The clinical and radiological evaluation of facial fractures is important for the accurate diagnosis and treatment of patients. Therefore, the most commonly used imaging method in the detection of facial fractures is computed tomography (CT). The pterygoid plate fracture (PPF) was originally described and classified by Rene Le Fort[1] and the findings of PPF don’t refer to only the Le Fort fractures (LFF). This study aimed to focus on the PPF patterns using maxillofacial CT scans and to describe the major PPF patterns unrelated to LFF.

Study Population Data for PPF were retrospectively collected from the medical records of all the trauma patients who were diagnosed using maxillofacial CT scan at our hospital from 1 April 2014 to 1 April 2017. After obtaining our hospital ethics committee approval (37-05), clinical information including the patient’s age, sex, and etiology of injury were extracted from the medical records. Patients with inadequate medical records or inadequate CT scan due to motion or breathing artifacts were excluded.

CT Technique and Image Analysis Imaging was performed using a 128-slice CT scanner (Op-

Cite this article as: Özbal Güneş S, Aktürk Y, Güldoğan ES. Evaluation of pterygoid plate fractures unrelated to Le Fort fractures using maxillofacial CT. Ulus Travma Acil Cerrahi Derg 2018;24:239-243.

Address for correspondence: Serra Özbal Güneş, M.D. SBÜ Dışkapı Yıldırım Beyazıt Eğitim ve Araştırma Hastanesi, Radyoloji Kliniği, Ankara, Turkey Tel: +90 312 - 596 20 00 E-mail: sozbal@gmail.com Ulus Travma Acil Cerrahi Derg 2018;24(3):239-243 DOI: 10.5505/tjtes.2017.27927 Submitted: 12.07.2017 Accepted: 04.12.2017 Online: 08.05.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

Ulus Travma Acil Cerrahi Derg, May 2018, Vol. 24, No. 3

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Özbal Güneş et al. Evaluation of pterygoid plate fractures unrelated to Le Fort fractures using maxillofacial CT

tima CT 660, GE Healthcare System, Milwaukee, USA), (120 kV; 150 mAs; collimation = 64 × 0.5; slice thickness = ≤2 mm; matrix = 512 × 512 pixels; gantry tilt = 0°). We used the medical image processing software (AW Volume Share 5) to show the 2-dimensional (2D) and 3-dimensional (3D) CT images that were acquired in the axial plane. The reformatted coronal and sagittal images were obtained from the axial images on a workstation. All images of the patients were reviewed for PPF and other accompanying facial fractures, and then they were separated into two groups (Le Fort and nonLe Fort [LF]) by one author who had 10 years of experience in neuroimaging.

Statistical Analysis The descriptive statistics used for statistical analyses included mean and standard deviation for the numerical variables. The frequency and percentages were used for the categorical variables. The numerical variables were compared using independent-samples t-test for LF and non-LF groups. The qualitative data of the both groups were compared using chi-square test.

The statistical analysis was conducted using statistical software (SPSS, version 21.0; SPSS Inc, Chicago, IL, USA). A pvalue of <0.05 was considered statistically significant.

RESULTS According to the medical records, 196 patients were diagnosed with PPF between April 2014 and April 2017. Eighteen patients were excluded because of inadequate CT scans. Finally, CT images of 178 patients [male (M)/female (F) = 121/57; mean age (MA) ± standard deviation (SD) = 37.3±18.9 years; range = 4–82 years] who had PPF were included.

Of these patients, 135 had LFF (M/F=86/49; M/F ratio=1.7/1; MA±SD=36.9±18.7 years, range 8–82 years), and the distribution of their fractures were as follows: type I (38/135; 28.1%), type II (72/135; 53.3%), and type III (25/135; 18.6%).

Furthermore, 14 patients had more than one LFF type, and 43 patients (M/F=35/8; M/F ratio = 4.3/1; MA±SD=38.6±19.7 years, range = 4–80 years) had non-LFF (unilateral, n=37; bilateral, n=6). PPF patterns in these patients were as follows: temporal bone fracture (5/43; 11.6%) (Fig. 1), sphenotemporal buttress fracture (11/43; 25.5%) (Fig. 2), zygomaticomaxillary complex fracture (13/43; 30.2%) (Fig. 3), displaced mandible fracture (10/43; 23.3%) (Fig. 4), nasal bone fracture (2/43; 4.7%) (Fig. 5), and isolated fracture (2/43; 4.7%).

The causes of the trauma in the LF group were motor vehicle accidents (MVAs) (78/135; 57.8%), work-related injuries (12/135; 8.9%), assaults (35/135; 25.9%), and falls (10/135; 7.4%). In non-LFF group, the causes of the trauma were MVAs (23/43; 53.5%), work-related injuries (9/43; 20.9%), assaults (8/43; 18.6%), and falls (3/43; 7%). Fractures were more in males than in females in the LF (63.7%) and non-LF groups (81.3%). The most common cause of facial fractures 240

(a)

(b)

Figure 1. A 26-year-old man with temporal fracture. Axial computed tomography (CT) image (a) reveals an oblique fracture of the left temporal bone (arrow). The fracture extends through the left pterygoid plates (b, arrow).

(a)

(b)

Figure 2. A 36-year-old man with sphenotemporal buttress fracture. Axial CT image (a) reveals a fracture of the right sphenotemporal buttress (arrows). The left zygoma is also fractured (asterisk).

The fracture extends through the central skull base (a, arrowhead) and into the right pterygoid plates (b, arrow).

was MVAs in the LF (57.8%) and non-LF groups (53.5%). The etiologies of facial fractures were not significantly different between the sexes (p=0.576). No significant difference between the LF and non-LF groups was found for age (p=0.603) and the causes of trauma (p=0.183).

DISCUSSION Facial fractures occur in many severely injured patients with facial trauma. The causes of fractures vary for different countries because of various contributing factors such as environmental, cultural, and socioeconomic factors. Collecting regional data on trauma patients is important as it allows for better management and prevention in that region. In Europe, assault and fall are the main causes of facial fractures, whereas in our country, MVAs and assaults are the main causes.[2,3] According to our study, the most common causes of facial fractures were MVAs and assaults, as previously demonstrated by other studies.[3–8] Violation of speed limits, failure to wear seat belts, use of intoxicating agents, behavioral disorders, and inadequate road safety awareness are the major reasons for the large numbers of MVAs in our country. Our patients were predominantly male, as in the previous studies.[3–8] The male predominance in a country depends on the culture and socioeconomic status of that country. In Turkey, there is male dominance. In our study, the mean age of patients with nonUlus Travma Acil Cerrahi Derg, May 2018, Vol. 24, No. 3

Özbal Güneş et al. Evaluation of pterygoid plate fractures unrelated to Le Fort fractures using maxillofacial CT

Figure 3. A 28-year-old man with zygomaticomaxillary complex fracture. Axial (a) CT image shows the left zygomaticomaxillary complex fracture (white arrows). The fracture extends into the ipsilateral pterygoid plates (b, black arrow). Coronal reformatted CT image (c) reveals the maxillary components of this complex fracture (white arrow).

LFF was 38.6 years. Previous studies have shown that facial fractures are more common between the second and fourth decades of life and can affect both sexes, and our results correspond with these studies.[4,9]

Figure 4. A 44-year-old man with displaced mandible fracture.

Reformatted axial oblique CT image reveals fractures of the right basis and the left angle region of the mandible (white arrows). The left pterygoid plates are also fractured (black arrow).

(a)

(b)

Figure 5. A 17-year-old man with nasal fracture. Axial CT image (a) reveals fracture of the left nasal process of the maxilla (arrow). The left pterygoid plate is also fractured (arrow) on coronal CT image (b).

Ulus Travma Acil Cerrahi Derg, May 2018, Vol. 24, No. 3

For the diagnosis of facial fractures, knowledge of the regional anatomy is important. In practice, the buttresses that represent areas of the relative increased bone thickness supporting the functional units of the face are used to systematically evaluate the facial anatomical structure.[10] One such buttress is the posterior maxillary buttress, which is a column of bone at the pterygomaxillary junction. PPs, which are posteroinferior projections of the sphenoid bone, connect to the base of the middle cranial fossa and the posterior of the maxilla at this junction. Different types of fractures may affect this region, and LFF is mostly observed in these fractures.[11] LFF can be unilateral or bilateral, symmetrical or asymmetrical, and are often concomitant with other facial fractures such as frontal sinus and naso-orbital-ethmoid fractures. The findings of PPF don’t refer to only LFF, but other fracture types may cause PPF unrelated to LFF. Jingang et al. reported that if CT images reveal PPF in patients with maxillofacial injury, LFF is likely to have occurred.[12] In our study, about one-fourth of the patients with PPF did not have LFF. Garg et al. reported that 37.3% of the cases with PPF did not have LFF.[13] Similar findings were reported by different studies.[14,15] Our results show that PPF can be used as an indirect diagnostic evidence of LFF, but not in all patients, since other types of fractures can involve PP such as temporal and sphenotemporal buttress.

These fractures result from a direct or indirect traumatic force exerted on the calvarial, skull base, and facial structures.

There are several mechanisms of injury that propagate along the zones of weakness within the facial structures. In the skull base fractures, the temporal bone is usually involved, and the temporal fracture extends toward PP. This finding is in line with the work of Lanigan et al.[16] The status of the external canal and facial nerve can be the most important aspect of temporal fractures. Ecchymosis of the postauricular skin and 241

Özbal Güneş et al. Evaluation of pterygoid plate fractures unrelated to Le Fort fractures using maxillofacial CT

periorbital area may be noted in the skull base/temporal fractures. In sphenotemporal buttress fractures, the connections with the temporal, zygomatic, and sphenoid bones are lost, and the fracture line extends to PP. Also, the fracture line may radiate into the weak structures around the superior orbital fissure or the optic canal, and the visual acuity and ocular motility may be affected in patients with sphenotemporal buttress fracture. The zygomatic arch fracture can be a component of the zygomaticomaxillary complex fracture, LFF, or may be isolated. The zygomaticomaxillary complex fracture is the result of an oblique injury to the face, and the depressed zygoma fractures are frequently accompanied by this injury.

PPF can be seen in this complex fracture due to displaced bone fragments. There may be entrapment, dystopia, enophthalmos, and numbness in the infraorbital nerve distribution because of orbital floor and/or lateral orbital wall fractures.

When the mandible is fractured by a lateral force, it may be displaced medially toward the posterior maxillary sinus or PP.[17,18] Contusions over the jaw or preauricular area, malocclusion, and neurapraxia of the facial nerve can be observed.

We also identified a small number of patients who had nasal fractures accompanied by PPF or isolated PPF that was only seen one side. The possible causes of these unilateral fractures may be penetrating trauma or traction of the pterygoid muscle.[13,19] It is worth noting that Garg et al.[13] reported PPF patterns similar to the ones we observed in our study.

The cause of trauma may be important in predicting the fracture pattern and clinical findings (e.g., assaults most often cause mandibular fractures).[9] For the accurate diagnosis and treatment of patients, the clinical and radiological evaluation should proceed systematically. On physical examination, some findings may suggest underlying abnormality such as bony step-offs, maxillary mobility, malocclusion, and enophthalmos. Airway compromise is not uncommon in patients with facial fractures, and the airway should be secured. Indications and methods of surgical treatment of facial fractures are quite diverse. It is important for clinicians/surgeons to know the location of the fracture and affected bones. If any abnormalities are encountered on physical examination that may suggest an underlying fracture, maxillofacial CT scans should be ordered. A thin-slice high-resolution CT scan has become the standard imaging method for evaluating the facial fractures and decisions for treatment.[20,21] As the facial films frequently lack the details of facial involvement seen on CT, both nondisplaced and minimally displaced fractures can be overlooked.[22] Axial and reformatted CT images can easily show the fractured bones, degree of displacement of the fragments, and soft tissue changes.[23] In our study, axial reformatted and 3D-CT images helped to show and characterize the fracture patterns.

Our study has some limitations. First, not all patients with facial trauma underwent CT scans in clinical settings. Second, in the facial trauma cases examined using CT; it is possible to miss PPF due to the different levels of experience of clinicians 242

and radiologists. Third, we did not do the clinical follow-up of the majority of the patients.

In conclusion, PPF is most commonly seen with LFF, but may be seen alone or with other non-LFF, indicating that all PPF are not related to LFF. Axial and reformatted CT images can easily show PPF and the degree of displacement of the fragments, and they can be used to guide surgical reduction of the fractures.

Conflict of interest: None declared.

REFERENCES 1. Le Fort R. Etude experimentale sur les fractures de la machoire superieure. Rev Chir 1901;23:208–27,360–79,479–507.

2. Boffano P, Roccia F, Zavattero E, Dediol E, Uglešic V, Kovacic Ž, et al.

European Maxillofacial Trauma (EURMAT) project: A multicentre and prospective study. J Craniomaxillofac Surg 2015;43:62–70.

3. Aksoy E, Unlü E, Sensöz O. A retrospective study on epidemiology and treatment of maxillofacial fractures. J Craniofac Surg 2002;13:772–5.

4. Motamedi MH. An assessment of maxillofacial fractures: a 5-year study of 237 patients. J Oral Maxillofac Surg 2003;61:61–4.

5. Salentijn EG, van den Bergh B, Forouzanfar T.A ten-year analysis of midfacial fractures. J Craniomaxillofac Surg 2013;41:630–6.

6. Erdmann D, Follmar KE, Debruijn M, Bruno AD, Jung SH, Edelman D, et al. A retrospective analysis of facial fracture etiologies. Ann Plast Surg 2008;60:398–403.

7. Septa D, Newaskar VP, Agrawal D, Tibra S. Etiology, incidence and patterns of mid-face fractures and associated ocular injuries. J Maxillofac Oral Surg 2014;13:115–9.

8. Kaul RP, Sagar S, Singhal M, Kumar A, Jaipuria J, Misra M. Burden of maxillofacial trauma at level 1 trauma center. Craniomaxillofac Trauma Reconstr 2014;7:126–30.

9. Iida S, Kogo M, Sugiura T, Mima T, Matsuya T. Retrospective analysis of 1502 patients with facial fractures. Int J Oral Maxillofac Surg 2001;30:286–90.

10. Winegar BA, Murillo H, Tantiwongkosi B.. Spectrum of Critical Imaging Findings in Complex Facial Skeletal Trauma. Radiographics 2013;33:3– 19.

11. Tessier P. The classic reprint: experimental study of fractures of the upper jaw. 3. René Le Fort, M.D., Lille, France. Plast Reconstr Surg 1972;50:600–7.

12. Rhea JT, Novelline RA. How to simplify the CT diagnosis of Le Fort fractures. AJR Am J Roentgenol 2005;184:1700–05.

13. Garg RK, Alsheik NH, Afifi AM, Gentry LR. Pterygoid Plate Fractures: Not Limited to Le Fort Fractures. J Craniofac Surg 2015;26:1823–5.

14. Unger JM, Gentry LR, Grossman JE. Sphenoid fractures: prevalence, sites, and significance. Radiology 1990;175:175–80.

15. Unger JD, Unger GF. Fractures of the pterygoid processes accompanying severe facial bone injury. Radiology 1971;98:311–6.

16. Lanigan DT, Loewy J. Postoperative computed tomography scan study of the pterygomaxillary separation during the Le Fort I osteotomy using a micro-oscillating saw. J Oral Maxillofac Surg 1995;53:1161–6.

17. Simonds JS, Whitlow CT, Chen MY, Williams DW 3rd. Isolated fractures of the posterior maxillary sinus: CT appearance and proposed mechanism. AJNR Am J Neuroradiol 2011;32:468–70.

18. Nahum AM. The biomechanics of maxillofacial trauma. Clin Plast Surg

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Özbal Güneş et al. Evaluation of pterygoid plate fractures unrelated to Le Fort fractures using maxillofacial CT 1975;2:59–64.

Curr Probl Diagn Radiol 1993;22:145–88.

19. Truong AQ, O’Brien DC, Strong EB, Dublin A. Lateral pterygoid plate fractures associated with mandible fractures. JAMA Facial Plast Surg 2014;16:437–9.

22. Tanrikulu R, Erol B. Comparison of computed tomography with conventional radiography for midfacial fractures. Dentomaxillofac Radiol 2001;30:141–6.

20. Cooper PW, Kassel EE, Gruss JS. High-resolution CT scanning of facial trauma. AJNR Am J Neuroradiol 1983;4:495–8.

23. Kaeppler G, Cornelius CP, Ehrenfeld M, Mast G. Diagnostic efficacy of cone-beam computed tomography for mandibular fractures. Oral Surg Oral Med Oral Pathol Oral Radiol 2013l;116:98–104.

21. Laine FJ, Conway WF, Laskin DM. Radiology of maxillofacial trauma.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Bilgisayarlı tomografide Le Fort dışı pterygoid plate kırıkları Dr. Serra Özbal Güneş, Dr. Yeliz Aktürk, Dr. Esra Soyer Güldoğan Sağlık Bilimleri Üniversitesi Dışkapı Yıldırım Beyazıt Eğitim ve Araştırma Hastanesi, Radyoloji Kliniği, Ankara

AMAÇ: Bu çalışmada geriye dönük olarak bilgisayarlı tomografide (BT) saptanan pterygoid plate (PP) kırıkları incelenerek, Le Fort kırıkları ile ilişkisiz olan PP kırık paternlerinin tanımlanması ve sınıflandırılması amaçlandı.

GEREÇ VE YÖNTEM: Hastanemizde Nisan 2014 ile Nisan 2017 tarihleri arasında BT’de PP kırığı saptanmış hastaların tıbbi bilgileri etik kurul onayı (37–05) alındıktan sonra incelendi. Klinik bilgilerine ulaşılamayan, BT görüntüleri tanısal kalitede olmayan hastalar çalışma dışında bırakıldı.

BULGULAR: Çalışmaya 178 hasta dahil edildi. Hastaların 135’inde Le Fort tipi kırıklar (Erkek/Kadın = 86/49; ortalama yaş 37.2), 43’ünde (Erkek/ Kadın = 35/8; ortalama yaş 38.6) Le Fort kırıkları ile ilişkisiz PP kırıkları saptandı. Le Fort dışı PP kırıkları; zigomatikomaksiller kompleks (%30.2), temporal (%11.6), sphenotemporal buttress (%25.5), deplase mandibula (%23.3) ve nazal (%4.7) kırıklara eşlik ediyordu. Ayrıca PP kırıkları, hastaların %4.7’sinde izoleydi. PP kırıkları, Le Fort ile birlikte olan ve olmayan hasta grupları arasında cinsiyet, yaş, travmanın tipi bakımından istatistiksel olarak anlamlı ilişki bulunmadı (p>0.05).

TARTIŞMA: Klinik ve radyolojik olarak PP kırıkları sıklıkla Le Fort tipi kırıkları işaret etse de izole veya Le Fort dışı diğer kraniofasial kırıklarla da az olmayan oranda birlikte görülebilir. Bilgisayarlı tomografi, farklı PP kırık paternlerinin tanısında, tedavi şekillerinin belirlenmesinde ve takiplerinde değerlidir.

Anahtar sözcükler: Bilgisayarlı tomografi; Le Fort kırıkları; pterygoid plate.

Ulus Travma Acil Cerrahi Derg 2018;24(3):239-243

doi: 10.5505/tjtes.2017.27927

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ORIG I N A L A R T IC L E

Determination of trace element levels in patients with burst fractures Shahab Ahmed Salih Gezh, M.D.,1 Abdurrahman Aycan, M.D.,2 Halit Demir, M.D.,1 Cemal Bozlına, M.D.3 1

Department of Chemistry, Yüzüncü Yıl University Faculty of Science and Literature, Van-Turkey

2

Department of Neurosurgery, Yüzüncü Yıl University Faculty of Medicine, Van-Turkey

3

Department of Neurosurgery, Van Training and Research Hospital, Van-Turkey

ABSTRACT BACKGROUND: This study aimed to determine trace element levels (Zn, Fe, Mn, Mg, Cu, Cd, Co, and Pb) in patients with burst fractures in Van Province, Turkey.

METHODS: The study included a total of 44 participants with no additional pathologies, including 22 patients with burst fractures aged over 18 years who were admitted to the neurosurgery departments at two hospitals between June 15, 2015 and January 20, 2016 and 22 healthy volunteers. Serum samples were obtained from all participants to measure the serum levels of trace and heavy elements, including Mn, Cd, Cu, Pb, Fe, Co and Zn, using atomic absorbance spectrophotometry.

RESULTS: The trace element levels of Zn, Mn, Cu, Co, and Mg were significantly lower (p<0.001), whereas those of Fe, Cd, and Pb were significantly higher in the patient group than in the control group. In addition, the levels of Zn, Mn, Cu, Co, and Mg were lower and the levels of Fe, Cd, and Pb were higher in the patient group than in the control group.

CONCLUSION: The probability of burst fracture and its causes leading to any injury may be considered as an indicator balance for the concentration of trace elements between the patient group and control group and may also be a risk factor associated with the bone exposed to burst fracture Significant changes in serum levels of Zn, Cd, Mn, Mg, Pb, Fe, Cu and Zn elements can be observed in patients with burst fractures.

Keywords: Burst fracture; Cd; Co; Cu; Fe; Mg; Mn; Pb; Zn.

INTRODUCTION Vertebral fractures predominantly occur in young people as a result of traumatic injuries and in elderly people as a result of osteoporosis.[1] Burst fractures account for 17% of all major vertebral fractures.[2,3] Of all spinal regions, burst fractures commonly occur in the thoracolumbar region due to its biomechanical properties and anatomical structure.[4,5] The term “burst fracture” was first defined by Holdsworth.

[6] The most frequent causes of burst fractures are motor vehicle accidents and falls from a height. The clinical criteria for spinal instability were first defined by Denise.[2] The an-

terior and middle vertebral columns are often damaged due to high-energy axial loading, leading to repositioning of the nucleus pulposus of the vertebral disc toward the corpus.[5] In some cases, bone fracture fragments can enter the spinal canal, causing neurological deficits as well as instability.[7–9] Neurological injury has been shown to occur in 30%–90% of patients with burst fracture due to damage in the proximal portion of the spinal cord, conus medullaris, or the filaments of the cauda equina.[10,11] The treatment of burst fractures remains controversial. Some authors propose non-surgical methods, such as resting for a while, stability, or medical treatments, unless neurological

Cite this article as: Gezh SAS, Aycan A, Demir H, Bozlına C. Determination of trace element levels in patients with burst fractures. Ulus Travma Acil Cerrahi Derg 2018;24:244-248.

Address for correspondence: Abdurrahman Aycan, M.D. Yüzüncü Yıl Üniversitesi Tıp Fakültesi, Nöroşirürji Anabilim Dalı, Van, Turkey Tel: +90 432 - 444 50 65 E-mail: abdurrahmanaycan07@gmail.com Ulus Travma Acil Cerrahi Derg 2018;24(3):244-248 DOI: 10.5505/tjtes.2017.08839 Submitted: 28.12.2016 Accepted: 07.09.2017 Online: 05.10.2017 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

244

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Gezh et al. Determination of trace element levels in patients with burst fractures

deficits are presented.[12] On the other hand, the common view is that the stabilization of burst fractures should be achieved by emergency surgery, and compression on the neural tissue should be eliminated by enlarging the spinal canal if there are fractures inside the canal.[13,14] Moreover, surgery becomes unavoidable in the presence of neurological deficits.

Table 1. Demographic data, etiology and level of vertebral fracture No

Age

Gender

Level

Etiology

1 36 Male L1

γ

2 41 Male T12

γ

3 39 Female L3

∞

4 42 Female L4

α

5 44 Female L4

∞

6 40 Male T7

α

7 38 Female T9

∞

8 41 Male L5

γ

9 41 Female L1

∞

10 35 Female L1

α

11 44 Female T12

∞

MATERIALS AND METHODS This study included a total of 44 participants with no additional pathologies, including 22 patients with burst fractures aged over 18 years who were admitted to the neurosurgery departments at Yuzuncu Yil University School of Medicine and Van Regional Training and Research Hospital between June 15, 2015 and January 20, 2016; 22 healthy volunteers were included as a control group (Table 1). The patient group included 8 (36.4%) women and 14 (63.6%) men with a mean age of 39.77±3.81 years, and the control group included 8 (36.4%) women and 14 (63.6%) men with a mean age of 40.5±0.473 years.

Biochemical Analysis Blood samples (3 cm3) were drawn from each participant in the morning after a 12-h fasting. Venous blood samples were placed in NF 800 tubes (Nüve-Bench Top Centrifuge, NF 800R, Ankara-Turkey ) and were immediately stored in a freezer at 4°C. Blood samples were centrifuged at 5,000 rpm for 10 min to obtain serum. The serum samples to be used for the measurement of trace element levels were stored at −80°C until analysis. Serum samples were processed using atomic absorbance spectrophotometry at Central Research Laboratory of Yuzuncu Yil University.

12 38 Female T12

γ

13 44 Male T12

γ

14 37 Male T11

α

15 40 Female L3

Statistical Analysis

α

16 40 Female T5

γ

17 38 Female L4

¥

Table 2 presents the statistical evaluation of the concentrations of Zn, Fe, Mn, Mg, Cu, Cd, Co, and Pb using Error (Mean ± Standard Deviation) or (± SH) parameters. The serum levels of trace were compared in both groups.

18 43 Male L1

γ

19 43 Female L4

∞

20 40 Female T12

γ

21 33 Female T11

¥

22 41 Male L1

γ

RESULTS The trace element levels of Zn, Mn, Cu, Co, and Mg were significantly lower (p<0.001), whereas those of Fe, Cd, and Pb were significantly higher in the patient group than in the control group. In addition, the levels of Zn, Mn, Cu, Co, and

γ: Trauma; ∞: Falling from high; ¥: Spontaneous; α: Traffic accident.

Table 2. Trace element levels in the patient and control groups

Control group (n=22)

Burst fracture patient group (n=22)

Mean SD

Min. Max. Mean SD Min. Max.

Zn (mg/L)

3.1849

2.235

0.1599

4.551

0.5699

0.0859

0.17

1.497

p <0.0001

Fe (mg/L)

0.3026

0.0317

0.043

0.603

2.8893

0.3319

1.36

5.799

<0.0001

Mn (mg/L)

0.2932

0.0132

0.222

0.414

0.136

0.0124

0.04

0.2585

<0.0001

Mg (mg/L)

25.033

0.4345

22.162

30.435

7.6365

0.7432

3.24

14.2625

<0.0001

Cu (mg/L)

5.1564

0.2904

3.55

8.663

0.5552

0.0553

0.11

1.26

<0.0001

Cd (mg/L)

0.0067

0.0002

0.004

0.009

0.1408

0.0111

0.03

0.236

<0.0001

Co (mg/L)

0.4609

0.0338

0.28

0.93

0.1713

0.0274

0.03

0.4545

<0.0001

Pb (mg/L)

0.4048

0.0259

0.2123

0.6519

1.9719

0.0981

1.39

2.911

<0.0001

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

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Gezh et al. Determination of trace element levels in patients with burst fractures

Mg were lower and the levels of Fe, Cd, and Pb were higher in the patient group than in the control group.

DISCUSSION Burst fractures constitute a type of traumatic spinal injury caused by severe compression of the vertebrae. These fractures typically result from severe traumas such as motor vehicle accidents, falls from a height, or assaults. Burst fractures can occur in any part of the vertebra. A vertically directed force on the spine may lead to vertebral fractures. Trace elements, in addition to being primary constituents of biological structures, have significant roles in various diseases. They also have a crucial role in the structure of bones. Numerous studies have investigated the concentrations of trace elements.

[15,16] In the present study, the levels of certain trace elements (Zn, Fe, Mn, Mg, Cu, Cd, Co, and Pb) were measured in patients with burst fractures. The results revealed marked differences between the concentrations of these elements in patients with burst fractures and healthy volunteers.

The serum levels of all trace elements in patients with burst fractures are shown in Table 2. Zinc (Zn) is an essential nutritional microelement and plays a significant role in the growth of humans and animals.[17] As shown in Table 2, serum levels of Zn were lower in the patient group than in the healthy group.

Although these findings were consistent with those reported

by Cobanoglu et al. (2010),[11] Mazdak et al. (2010),[18] and Cebi et al. (2010),[10] they contradicted the findings reported for patients with malignant glioma by Arslan et al.[19] Although Zn has the ability to stimulate collagen synthesis in osteoblasts and activate alkaline phosphatase, these processes have a crucial role in the mineralization and calcification of bones.[20] Zn deficiency is commonly associated with numerous disorders such as retarded bone growth.[21] Intervertebral discs have the lowest Zn concentration because the peak concentrations start from the cartilage, bone, and posterior longitudinal ligaments.[22] Zn has also been shown to be effective in fracture healing. The primary role of Zn in fracture healing has been shown in diaphyseal tissues of rats that were removed 7 or 14 days after femoral diaphyseal fractures.[23] The serum levels of Fe were higher in the patient group than in the control group. This finding was consistent with that reported by Cobanoglu et al. (2010)[11] and Arslan et al.

(2011)[19] but contradicted the findings reported by Arslan et al. (2011).[24] Oxidative stress affects the mitochondrial DNA by impairing the balance.[25] Free Fe ions, which lead to the formation of reactive oxygen species (ROS), including superoxide and hydrogen peroxide, in mammalian cells, are released via the Fenton and Haberâ&#x20AC;&#x201C;Weiss reactions. Fe is a physiologically important trace element; however, it is biochemically hazardous. Fe is an important nutritional element for all living organisms, and low levels of Fe may have a role in the prevention of numerous diseases such as infection and cancer. Fe deficiency may also lead to various bone abnor246

malities in patients with thalassemia major.[26] The deposition of Fe in the bone marrow has been shown to cause delayed bone maturation and focal osteomalacia and to prevent local mineralization.[21] In our study, the serum levels of Mn were lower in the patient group than in the healthy group. This finding was consistent with that reported by Onyeaghala et al.[16] and Asker et al.[24] but contradicted the findings reported by Cobanoglu et al.[11] and Arslan et al.[19] Mn is a trace mineral required for bone development, and it affects the activation of superoxide dismutase (SOD) and certain other enzymes that play a key role in antioxidant defense mechanisms.[27] Therefore, in patients with low serum levels of Mn, the antioxidant activity in the organs may be reduced and thus, these patients may become susceptible to various diseases. These findings were consistent with those reported by Mazdak et al.[18] Mn deficiency leads to numerous disorders in humans such as bone deficiency, joint pain, diabetes, and dysmnesia.

The serum levels of Mg were lower in the patient group than in the healthy group. This finding was consistent with that reported by Cobanoglu et al.[11] and Asker et al.[24] but contradicted the findings reported by Arslan et al.[19] More than 60% of Mg ions may accumulate in the bones and muscles and may also be present in hydroxyapatite surfaces. Because Mg is diffused into the components of the body, the concentration of Mg in the bones is twice higher than that in the intervertebral disc (IVD).[28] Mg deficiency may result from reduced intestinal absorption and excessive urine retention, and it is also associated with osteoporosis, diabetes, hypertension, metabolic syndrome, nephropathies, and age-related diseases.[29] Moreover, Mg deficiency may also have a role in the progression of oxidative damage.

The serum levels of Cu were lower in the patient group than in the control group. This finding was consistent with that reported by Cobanoglu et al.,[11] Asker et al., and Onyeaghala et al. but contradicted the findings reported by Arslan et al.[5,17,19] Although free Cu+ is a potent oxidant, it may lead to certain diseases due to the production of ROS in the cells. Cu deficiency may result in osteoporosis and joint problems.[30] Although Cu deficiency may not affect the collagen content, it may lead to fragile bones in animals.[31] The serum levels of Cd were lower in the patient group than in the control group. This finding was consistent with that reported by Kellen et al.[32] and Arslan et al.[19] The amount of toxic Cd in the bones and cartilage is three times higher than that in the IVD because the end-plate forms a barrier for the removal of Cd.[28] Cd has been shown to generate free radicals via the Fenton reaction. However, in other reaction models, Cd can activate oxidative stress and produce superoxide and hydrogen peroxide radicals.[33] Cd is a mutagen in mammals.[34] Ulus Travma Acil Cerrahi Derg, May 2018, Vol. 24, No. 3

Gezh et al. Determination of trace element levels in patients with burst fractures

The serum levels of Co were lower in the patient group than in the control group. This finding was consistent with that reported by Angelova et al. but contradicted the findings reported by Cobanoglu et al.[11] and Arslan et al.[19,35] The serum levels of Co have been assessed in the cell culture of experimental animal and human models.[36] Furthermore, the serum levels of Co have been investigated in various organs of experimental rat models, such as testicular edema and mitochondrial cardiac muscle, and significant findings have been reported.[37] The serum levels of Pb were higher in the patient group than in the control group. This result was consistent with the reference values reported in the literature.[16,11,19,24] Excessive exposure to Pb leads to accumulation in bone tissues, thereby leading to toxic levels. Moreover, increasing concentration of Pb may pose a serious risk. Although it is a severe toxic element, Pb has been shown to yield an age-related positive correlation.[28]

Conclusion This study determined the levels of trace elements in patients diagnosed with burst fractures. There was a relationship between the levels of trace elements and burst fractures. Therefore, we considered that the levels of Zn, Fe, Mn, Mg, Cu, Cd, Co, and Pb may be beneficial parameters for the clinical evaluation and diagnosis of burst fractures. Nevertheless, further prospective studies are needed to investigate the relationship between the changes in Mn and Zn levels and burst fractures.

Conflict of interest: None declared.

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37. Anderson MB, Pedigo NG, Katz RP, George WJ. Histopathology of testes from mice chronically treated with cobalt. Reprod Toxicol 1992;6:41–50.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Burst kırığı olan hastalarda bazı eser element seviyelerinin incelenmesi Dr. Shahab Ahmed Salih Gezh,1 Dr. Abdurrahman Aycan,2 Dr. Halit Demir,1 Dr. Cemal Bozlına3 1 2 3

Yüzüncü Yıl Üniversitesi Fen Fakültesi, Kimya Anabilim Dalı, Van Yüzüncü Yıl Üniversitesi Tıp Fakültesi, Nöroşirürji Anabilim Dalı, Van Van Eğitim ve Araştırma Hastanesi, Nöroşirürji Kliniği, Van

AMAÇ: Bu çalışmada Van ilinde burst kırığı olan hastalarda, bazı eser element seviyelerini (Zn, Fe, Mn, Mg, Cu, Cd, Co ve Pb) araştırmayı amaçladık.

GEREÇ VE YÖNTEM: Bu çalışma, 15 Haziran 2015 ile 20 Ocak 2016 tarihleri arasındaki dönemde iki hastaneye başvuran burst kırığı olan hastalardan alınan serum örnekleri üzerinde yürütüldü. Çalışma, ek patolojileri olmayan toplam 44 katılımcıyı kapsadı. Bunlara, 18 yaş üzeri patlama kırıkları olan ve nöroşirürji bölümüne kabul edilen 22 hasta ve 22 sağlıklı gönüllü dahildi. Mn, Cd, Cu, Pb, Fe, Co ve Zn dahil olmak üzere eser element ve ağır metallerin serum seviyeleri Atomik Emilim Spektrofotometrisi (AAS) ile analiz edildi.

BULGULAR: Sonuçlar, Zn, Mn, Cu, Co ve Mg iz düzeylerinin anlamlı olarak düşük (p<0.001) olduğunu ve Fe, Cd ve Pb düzeylerinin hasta grubunda kontrol grubuna göre anlamlı olarak daha yüksek olduğunu ortaya koymuştur. Zn, Mn, Cu, Co ve Mg seviyelerinin daha düşük olduğu ve Fe, Cd ve Pb düzeylerinin kontrol grubuna göre hasta grubunda daha yüksek olduğu bulundu.

TARTIŞMA: Patlamanın olasılığı ve herhangi bir yaralanmaya neden olan sebepleri, hasta grubu ile sağlıklı grup arasındaki eser element konsantrasyonu için bir gösterge dengesi olarak düşünülebilir ve patlama kırığına maruz kalan kemik ile ilişkili bir risk faktörü olabilir. Burst kırığı etiyolojisinde Zn, Cd, Mn, Mg, Pb, Fe, Cu ve Zn düzeyleri önemli rol oynayabilir.

Anahtar sözcükler: Burst kırığı; CD; Co; Cu; Fe; Mg; Mn; Pb; Zn. Ulus Travma Acil Cerrahi Derg 2018;24(3):244-248

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ORIG I N A L A R T IC L E

Cardiac findings of sternal fractures due to thoracic trauma: A five-year retrospective study Ahmet Uluşan, M.D., Özgür Karakurt, M.D. Department of Chest Surgery, Hitit University Çorum Training and Research Hospital, Çorum-Turkey

ABSTRACT BACKGROUND: This study mainly aimed to determine the frequency of sternal fractures in thoracic trauma patients and to assess the differences in surgical need, cardiac findings, and treatment processes between patients with fracture on different sternal zones and displaced and non-displaced sternal fractures.

METHODS: We analyzed the data of patients with sternal fracture due to thoracic trauma admitted to a state hospital between January 2011 and December 2015. Patient data comprised demographics, trauma characteristics, clinical findings, and treatment process.

RESULTS: Of the 2764 thoracic trauma patients admitted during the study period, 72 (2.6%) had sternal fracture. The median age was 52 (inter quartile range: 61–38) years; the patients were predominantly male (F/M: 18/54). The most common causes of sternal fractures were motor vehicle accident, fall, and work accident. Of all the patients, 15 had displaced fracture. Abnormal echocardiogram findings were significantly more frequent in patients having fractures on the manubrium than in those having fractures on the corpus of the sternum. Patients who had fracture on the corpus had significantly lesser surgery need than those who had fracture on the manubrium of the sternum. Also, there was statistically significant difference between displaced and non-displaced sternal fracture cases in terms of surgery need (p<0.005).

CONCLUSION: Abnormal echocardiography findings were more frequent in patients with sternal fracture on the manubrium and displaced fracture.

Keywords: Cardiac findings; sternal fracture; thoracic trauma.

The number of emergency department visits for unintentional injuries is 31.0 million, and also trauma accounts for >100,000 deaths annually in the United States.[1] Blunt thoracic trauma accounts for nearly 10% of all trauma cases admitted to emergency departments.[2,3]

hospital in Turkey.[5] In this study, authors found that rib fractures were diagnosed in 1424 cases, of which 1008 (23.9%) had one or two rib fractures and 344 (8.1%) had >2 rib fractures; however, clavicle (n=65, 1.5%) and sternum (n=33, 0.7%) fractures were detected less commonly.[5] In another study, 48 of 448 (10.7%) blunt chest trauma patients had sternum fracture.[6]

Trauma-related thoracic injuries are considerable causes of morbidity and mortality in trauma cases. These injuries attribute to roughly 25% of trauma-related deaths in the United States.[4] In a ten-year retrospective study on 4205 patients with chest trauma, the morbidity rate was 25.2% and the fatality rate was 9.3% for all cases in a level I trauma

A wide range of outcomes such as pleural effusion, hemothorax, pneumothorax, pericardial effusion, pneumomediastinum, and retrosternal hematoma can occur after sternum fracture (SF).[7,8] Studies have shown that the incidence of cardiac injury related with sternal fracture ranges from 18.0% to 62.0%.[9,10] Rarely, cardiac tamponade can occur due

INTRODUCTION

Cite this article as: Uluşan A, Karakurt Ö. Cardiac findings of sternal fractures due to thoracic trauma: A five-year retrospective study. Ulus Travma Acil Cerrahi Derg 2018;24:249-254.

Address for correspondence: Ahmet Uluşan, M.D. Adres bilgisi: Bahçelievler Mahallesi, Çamlık Caddesi, No: 2, 19200 Çorum, Turkey Tel: +90 364 - 219 30 00 E-mail: draulusan@gmail.com Ulus Travma Acil Cerrahi Derg 2018;24(3):249-254 DOI: 10.5505/tjtes.2017.01336 Submitted: 13.04.2017 Accepted: 21.09.2017 Online: 05.10.2017 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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to extrapericardial blood collection without intrapericardial hematoma or injury, requiring surgical procedures.[11] This study mainly aimed to determine the frequency of sternal fractures in thoracic trauma patients and to assess the differences in cardiac findings, surgical needs, and treatment processes between patients with fractures on different sternal zones and displaced and non-displaced fractures.

MATERIALS AND METHODS This study was performed at a tertiary hospital, which is a single-state hospital in a medium sized city in the Central Anatolian region of Turkey. Only this hospital has a thoracic surgeon across the city. Trauma patients from the neighboring cities are transferred to this hospital because of the lack of a thoracic surgeon during the summer (June to August) months.

The study was approved by the Hittite University Institutional Review Board with the approval number 2016-53, and the tenets of the Declaration of Helsinki were followed.

After the approval, we retrospectively reviewed the hospital records of thoracic trauma patients between January 2011

and December 2015 (60 months). The inclusion criteria were as follows: (1) admission with thoracic trauma, (2) presence of sternal fracture on computed tomography (CT), (3) age over 18 years. Patients with missing clinical and laboratory data or radiographic findings were excluded from the study.

Totally, 2764 thoracic trauma patients were admitted during the study period. Of these patients, 1135 (41.1%) had multiple rib fractures, 972 (35.2%) had one rib fracture, 218 (7.9%) had hemopneumothorax, 172 (6.2%) had hemothorax, 157 (5.7%) had pneumothorax, 72 (2.6%) had sternal fracture, 25 (0.9%) had flail chest, and 10 (0.4%) had diaphragm rupture.

Initially, all patients were evaluated, and then, all stable patients were scanned with CT. Sternal fractures were diagnosed and fracture zones were detected using CT scanning (Fig. 1). If needed, immediate surgical operations were performed. The indications for surgery were as follows: (a) the presence of displaced fracture, (b) paradoxical chest movement (c) severe pain, and/or (d) cases not reduced with simple maneuvers.

During surgery, the sternum was approached via vertical midline incision, and the ends of the fracture were fixed with titanium reconstruction plates (Litos, Hamburg, Germany).

(a)

(b)

(c)

(d)

Figure 1. Axial and sagittal planes of CT scan of the patients were constructed. Figures show displaced fracture (a) and non-displaced fracture on the corpus (b); displaced fracture (c) and non-displaced fracture on the manubrium (d).

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Table 1. Baseline characteristics of the study population Characteristics Median age (IQR)

52 (61–38)

Sex (Female/Male)

18/54

Cause of trauma (n/N)

Motor vehicle accident

41/72

Fall

18/72

Work accident

8/72

Violence

3/72

Animal-related injury

2/72

Sternal fracture zone (n/N)

Corpus

50/72

Manubrium

19/72

Corpus and manubrium

3/72

Type of fracture (n/N)

Displaced

12/72

Non-displaced

60/72

Type of care (n/N) Inpatient

57/72

Outpatient

15/72

Patient Data Patient demographics (age and sex), cause of trauma, zone of sternal fracture (manubrium and corpus), type of fracture (displaced, non-displaced), findings of electrocardiography (ECG) and echocardiography, elevation of cardiac enzyme, type of treatment (clinical follow-up, operation), presence of complication, type of care (inpatient, outpatient), and length of stay were analyzed.

Pericardial effusion, myocardial contusion, and vascular pathologies were considered as abnormal echocardiography findings. ST segment changes were accepted as abnormal ECG findings. Troponin I (Tn-I) and creatine kinase-MB (CK-

MB) isoenzyme tests were evaluated; Tn-I levels >0.06 ng/mL and CK-MB (percentage of total CK) ≥5% were considered as cardiac enzyme elevation.

Statistical Analysis Statistical analysis was performed using IBM SPSS Statistics version 23.0 software (SPSS Inc., Chicago, IL). Median and inter quartile range (IQR) were used as descriptive statistics for continuous variables. To compare qualitative variables, Fisher’s Exact Test was used. Mann–Whitney U test was used for the analysis of non-parametric continuous data. P<0.05 was considered statistically significant.

RESULTS During the study period, 72 patients with sternal fracture (2.6%) were admitted to the hospital. The median age of patients with sternal fracture was 52 (IQR: 61–38) years, and they were predominantly male (F/M: 18/54). Of the 72 sternal fracture cases, 41 were caused by motor vehicle accident, 18 by fall, eight by work accident, three by violence, and two by animal-related injury. Most of the fractures were observed on the corpus of the sternum (n=50); fractures on the manubrium of the sternum were observed in 19 cases.

Conversely, there were fractures on both the manubrium and corpus in three cases. Of all cases, 15 had displaced sternal fracture. Although the majority of the patients (57/72) were inpatient, 15 of them were outpatient (Table 1).

No statistically significant difference was seen regarding the presence of abnormal ECG findings in patients with fracture on the manubrium and corpus of the sternum. Also, no significant difference was seen in the presence of abnormal ECG findings among patients with displaced and non-displaced fracture. Abnormal echocardiographyfindings were detected in four of the 15 patients with the manubrium fracture; none of the patients with corpus fracture had abnormal echocardiographyfindings. This difference was statistically significant (p=0.004). Cases with displaced sternal fracture had significantly more frequent abnormal echocardiography findings

Table 2. Clinical findings according to the sternal fracture zone and type of fracture

Clinical findings Abnormal ECG p* Abnormal Echo p* Cardiac enzyme elevation (n/N) (n/N) (n/N)

p*

Sternal fracture zone

Manubrium

4/19 0.062 4/15 0.004

3/15

Corpus

2/44 0/40

2/40

0.119

Type of fracture

Displaced

3/12 0.107 3/12 0.023

Non-displaced 4/54 2/46 *

3/12

0.096

3/46

Fisher’s Exact Test was used. ECG: Electrocardiography.

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Table 3. Treatment process according to the sternal fracture zone and type of fracture

Treatment process Surgery need (n/N)

p

Length of stay (median day/IQR)

p

Sternal fracture zone Manubrium

5/20

0.109* 4.0/6.0–3.0 0.288**

Corpus

4/49

6.0/8.0–3.0

Type of fracture Displaced

11/12

<0.005* 6.0/7.0–5.0 0.153**

Non-displaced

0/60

5.0/7.0–3.0

Fisher’s Exact Test was used. **Mann-Whitney U test was used. IQR: Inter quartile range.

*

than non-displaced sternal fracture cases (4/15 and 2/46 respectively, p=0.023). No statistically significant difference was seen regarding the presence of cardiac enzyme elevation between subjects with fracture on the manubrium and corpus.

Also, similar results were seen in patients with displaced and non-displaced fracture (Table 2).

Five of 20 patients with fracture on the manubrium had surgery need; patients with corpus fracture had less surgery need (4/49). This difference was not statistically significant (p=0.109). Two patients underwent surgery due to paradoxical chest movement. One of these patients had manubrium fracture and the other had corpus fracture. There was statistically significant difference between displaced and nondisplaced sternal fracture cases in term of surgery need (p<0.005). Of 12 patients with displaced fracture, 11 had surgery need; none of the patients who had non-displaced fracture had surgery need. Conversely, the length of stay of the patients was similar between the patients with different fracture zone and fracture type (p=0.288 and p=0.153, respectively) (Table 3).

DISCUSSION We found that the median age of the patients was 52 years, and they were predominantly male. The three most common causes of the fracture were motor vehicle accident, fall, and work accident. Rashid et al.[8] found that the main causes of injury in patients with sternal fracture were motor vehicle accident (19/29, 66%), fall (9/29, 31%), and assault (1/29, 3%) in their study of 418 patients with blunt chest trauma of whom 29 had a fractured sternum. These results were similar to ours.

They also reported that patient age ranged 30–92 years and the mean age was 64 years; 17 patients were women and 12 were men.[8] Velissaris et al.[12] reviewed 73 patients with sternal fracture over a 7-year period; 51 of the cases were male with a median age of 51 years. In another study with 14,553 patients in two multicentre trauma cohorts, 292 (2.0%) subjects were diagnosed with SF (2.0%) and 94% of them were visible on chest CT scan. The authors also reported that the median age of patients was 54 years, 65.3% of them were 252

male, and most frequent cause of trauma was motor vehicle accident (71.9%).[13] In their five-year retrospective study, Wojcik and Morgan[10] also found that the most common cause of sternal fracture was motor vehicle accident (59%).

Monaco et al.[7] reported that 16 of the 50 patients (32%) with sternal fracture had displaced fracture. In our study, we found that the frequency of displaced sternum fracture was 15/75 (20%).

Skinner et al.[14] found that the incidence of blunt cardiac injury was 50% in their retrospective observational study of 169 patients with blunt thoracic trauma. Wojcik and Morgan[10] reported that the frequency of myocardial contusion was 18% in patients with trauma-related sternal fracture.

Athanassiadi et al.[15] found that four of the 100 patients with trauma-related sternal fracture had cardiac injury. Knobloch et. al.[16] analyzed 42.055 motor vehicle accidents and reported that there were 12 cardiac contusions among 267 patients with sternal fracture. In patients with sternal fractures, cardiac injury should be excluded. ECG changes and elevated troponin levels should indicate cardiac injury. If there is continued crushing-type chest pain, cardiac murmur, ECG changes or cardiovascular instability, the patient should be monitored with telemetry for 48 h and an echocardiogram should be performed.[17] Johnson and Branfoot[18] reported that only five cases had abnormal ECG findings and none had cardiac enzyme elevation in their seven-year retrospective study with 103 patients. Perez et al.[13] found that of the 184 patients who underwent a cardiac contusion testing, 24.4% had abnormal ECG, 15.9% had abnormal troponin levels, and 8.8% had abnormal echocardiography findings. Wiener et al.[19] reviewed 50 cases with sternal fracture after blunt chest trauma. They found that 11 patients had one or more abnormal cardiac test (eight abnormal Echo, four abnormal ECG, and three elevated cardiac enzyme), but only three of them had clinically symptomatic myocardial contusion. They suggested that echocardiography should be used as a diagnostic tool in every patient with sternal fracture.

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Sadaba et al.[20] reported nine patients (25%) with acute changes in ECG of the 37 patients with sternal fracture over a 2-year study period. Of these nine patients, two had pericardial effusions in echocardiography. Authors also reported that five patients (14%) had cardiac enzyme elevation, and one of these patients had small pericardial effusion. In another study with 72 patients admitted to a hospital during five years, authors reported that 66 of them had cardiac enzyme measurements, and 47 of these cases (56%) had elevations in one or more of the cardiac enzymes. Only one of 72 patients had acute changes in ECG examination.[21] Von Garrel et al.[22] analyzed 200 patients with sternal fractures and found that 89.2% of them had motor vehicle crashes, 76.5% had fracture on the corpus sterni, 24.5% had displaced fracture, 11.5% (23) had abnormal ECG or cardiac enzyme elevation, and 10% (20) had pericardial effusion in echocardiography. Authors also found a significant positive correlation between the degree of displacement and the appearance of pericardial effusion. We found that abnormal echocardiography findings were significantly more frequent in cases with manubrium fracture than in those with corpus fracture and displaced fracture. There was no statistically significant difference in ECG findings and presence of cardiac enzyme elevation between sternal fracture zone and fracture type groups.

We found that subjects with corpus fracture had statistically significantly lesser surgery need than those with manubrium fracture; also, the median length of stay of the patients with manubrium fracture was 4 days and of those with corpus fracture was 6 days. Perez et al. reported that median hospital length of the stay was 5 days in patients with trauma-related sternal fracture.[13]

Limitations and Strengths of the Study One of the limitations of the study is the external validity of the results. This study was conducted at a tertiary hospital with patient record data; therefore, the results may not be generalizable for the whole population. The other limitation of the study is the quality and missing data of the patients’ records. However, some transferred patients from the other centers had printed reports of the laboratory or radiological test from referrer center. These patients’ laboratory or radiological data were not available in the hospital records.

The main strengths of the study are the data from the fiveyear period and the analysis according to the different sternal fracture zone and types of fracture.

Conclusions There are many studies about clinical cardiac findings in patients with sternal fractures; however, these findings were not evaluated according to the zone of fracture or type of fracture (displaced/non-displaced). In our study, we aimed Ulus Travma Acil Cerrahi Derg, May 2018, Vol. 24, No. 3

to determine the cardiac findings between patients with fracture on different sternal zones and fracture types. We found that abnormal echocardiography findings were more frequent in patients with sternal fracture on the manubrium and those with displaced fracture. Further prospective studies with larger cohorts are needed to evaluate the long-term outcomes of the patients with sternal fracture according to different fracture zones and fracture types.

Funding The authors received no financial support for the research and/or authorship of this article.

Acknowledgment We are cordially grateful to Dr. Veli Özbek from Erol Olçok Training and Research Hospital, Hitit University, Department of Thoracic Surgery, for helping us.

Conflict of interest: None declared.

REFERENCES 1. Canevelli M, Lucchini F, Quarata F, Bruno G, Cesari M. Nutrition and Dementia: Evidence for Preventive Approaches? Nutrients 2016;8:144.

2. Ziegler DW, Agarwal NN. The morbidity and mortality of rib fractures.

J Trauma 1994;37:975–9.

3. Besson A, Saegesser F. Color Atlas of Chest Trauma and Associated Injuries. Vol 1. NJ:Medical Economics; 1983. p. 9.

4. Kaewlai R, Avery LL, Asrani AV, Novelline RA. Multidetector CT of blunt thoracic trauma. Radiographics 2008;28:1555–70.

5. Demirhan R, Onan B, Oz K, Halezeroglu S. Comprehensive analysis of 4205 patients with chest trauma: a 10-year experience. Interact Cardiovasc Thorac Surg 2009;9:450–3.

6. Cangır A, Nadir A, Akal M, Kutlay H, Özdemir N, Güngör A, et al.Thoracic trauma: Analysis of 532 patients. Turk J Trau 2000;6:100–5.

7. Monaco M, Mondello B, Monaco F, Vasta I, Perrone O, Micali V, et al.

Misunderstood cardiac involvement with heart impairment in traumatic sternal fracture: an enzyme-guided evaluation. G Chir 2009;30:117–20.

8. Rashid MA, Ortenwall P, Wikström T. Cardiovascular injuries associated with sternal fractures. Eur J Surg 2001;167:243–8.

9. Buckman R, Trooskin SZ, Flancbaum L, Chandler J. The significance of stable patients with sternal fractures. Surg Gynecol Obstet 1987;164:261–5.

10. Wojcik JB, Morgan AS. Sternal fractures-the natural history. Ann Emerg Med 1988;17:912–4.

11. Rambaud G, Desachy A, François B, Allot V, Cornu E, Vignon P. Extrapericardial cardiac tamponade caused by traumatic retrosternalhematoma. J Cardiovasc Surg 2001;42:621–4.

12. Velissaris T, Tang AT, Patel A, Khallifa K, Weeden DF. Traumatic sternal fracture: outcome following admission to a Thoracic Surgical Unit. Injury 2003;34:924–7.

13. Perez MR, Rodriguez RM, Baumann BM, Langdorf MI, Anglin D, Bradley RN, et al. Sternal fracture in the age of pan-scan. Injury 2015;46:1324–7.

14. Skinner DL, Laing GL, Rodseth RN, Ryan L, Hardcastle TC, Muckart DJ. Blunt cardiac injury in critically ill trauma patients: a single centre experience. Injury 2015;46:66–70.

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19. Wiener Y, Achildiev B, Karni T, Halevi A. Echocardiogram in sternal fracture. Am J Emerg Med 2001;19:403–5.

16. Knobloch K, Wagner S, Haasper C, Probst C, Krettek C, Otte D, et al.

Sternal fractures occur most often in old cars to seat-belted driverswithout any airbag often with concomitant spinal injuries: clinicalfindings and technical collision variables among 42,055 crash victims. Ann Thorac Surg 2006;82:444–50.

20. Sadaba JR, Oswal D, Munsch CM. Management of isolated sternal fractures: determining the risk of blunt cardiac injury. Ann R Coll Surg Engl 2000;82:162–6.

17. Burnside N, McManus K. Blunt thoracic trauma. Surgery (Oxford) 2014;32:254–60.

18. Johnson I, Branfoot T. Sternal fracture-a modern review. Arch Emerg Med 1993;10:24–8.

21. Wedde TB, Quinlan JF, Khan A, Khan HJ, Cunningham FO, McGrath JP. Fractures of the sternum: the influence of non-invasive cardiac monitoring on management. Arch Orthop Trauma Surg 2007;127:121–3.

22. von Garrel T, Ince A, Junge A, Schnabel M, Bahrs C. The sternal fracture: radiographic analysis of 200 fractures with special reference to concomitant injuries. J Trauma 2004;57:837–44.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Toraks travmasına bağlı sternal kırıkların kardiyak bulguları: Beş yıllık geriye dönük bir çalışma Dr. Ahmet Uluşan, Dr. Özgür Karakurt Hitit Üniversitesi Çorum Eğitim ve Araştırma Hastanesi, Göğüs Cerrahisi Kliniği, Çorum

AMAÇ: Bu çalışmanın temel amacı; torasik travmalı hastalarda sternal kırık sıklığını, farklı sternal zonlarda kırığı olan ve deplase ve non-deplase sternal kırıklı hastalardaki, cerrahi gereksinim, kardiyak bulgular ve tedavi sürecindeki farklılıkları belirlemektir.

GEREÇ VE YÖNTEM: Ocak 2011–Aralık 2015 tarihleri arasında bir devlet hastanesine başvuran torasik travmaya bağlı sternal kırıklı olguların verileri analiz edildi. Hastaların verileri, demografik özellikler, travma özellikleri, klinik bulguları ve tedavi yöntemlerini içermektedir.

BULGULAR: Çalışma süresince başvuran 2764 torasik travmalı hastanın 72’sinde (%2.6) sternal kırık saptandı. Hastaların medyan yaşları 52 (ÇAA: 61–38) iken, ağırlığı erkekler oluşturdu (kadın/erkek: 18/54). Sternal kırık olgularının en sık üç nedeni motorlu taşıt kazası, düşme ve iş kazasıydı.

Olguların 15’inde deplase kırık olduğu bulundu. Anormal ekokardiyografi bulguları, manubrium kırıklı olgularda, korpus kırıklı olgulara göre istatistiksel olarak anlamlı şekilde daha fazla idi. Korpus kırıklı hastalarda, manubrium kırıklılara oranla istatistiksel olarak daha az sıklıkta cerrahi ihtiyacı gelişti.

Ayrıca, deplase kırığı olan ve olmayan hastalar arasında cerrahi girişim gereksinimlerine göre istatistiksel olarak anlamlı farklılık vardı (p<0.005).

TARTIŞMA: Manubriumda görülen ve deplase sternal kırıklarda anormal ekokardiyografi bulguları daha fazla sıklıkta görülmektedir.

Anahtar sözcükler: Kardiyak bulgular; sternal kırık; torasik travma.

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Volar locking plate versus K-wire-supported external fixation in the treatment of AO/ASIF type C distal radius fractures: A comparison of functional and radiological outcomes Altuğ Duramaz, M.D., Mustafa Gökhan Bilgili, M.D., Evren Karaali, M.D., Berhan Bayram, M.D., Nezih Ziroğlu, Cemal Kural, M.D. Department of Orthopedics and Traumatology, Bakırköy Dr. Sadi Konuk Training and Research Hospital, İstanbul-Turkey

ABSTRACT BACKGROUND: The aim of this study was to compare the functional and radiological outcomes of K-wire-supported bridging external fixation (KW-EF) and volar locking plate (VLP) in the treatment of comminuted intra-articular distal radius fractures.

METHODS: Patients treated for complex intra-articular distal radius fractures between February 2010 and April 2013 were retrospectively investigated. A total of 114 patients (42 females and 72 males) with a mean age of 44.9±15.4 (range: 18–86) years were evaluated. Wrist ranges of motion were measured using a universal goniometer, and hand grip strength was determined using hand dynamometers. The results were evaluated with Gartland–Werley score. QuickDASH questionnaire was administered in subjective functional assessment. Radiological evaluations were performed, with wrist radiographs obtained on the 3rd month and 2nd year.

RESULTS: Wrist flexion, extension, pronation, and supination were all significantly better in the VLP group than in the KW-EF group at last control (p=0.001). Gartland–Werley, QuickDASH, and Visual Analog Scale were significantly better in the VLP than group than in the KW-EF group (p=0.003, p=0.003, and p=0.001, respectively). At the last follow-up, loss of grip strength compared with that on the uninjured side was 4% in the VLP group and 7% in the KW-EF group.

CONCLUSION: VLP is a safe method with low complication rates. It is superior to KW-EF as it facilitates early return to daily activities and shows better functional and radiological outcomes in the 2nd year of treatment.

Keywords: Bridging external fixation; functional outcomes; intra-articular distal radius fracture; volar locking plate,

INTRODUCTION Distal radius fractures are the most common upper extremity injuries treated by trauma surgeons and constitute 17% of all fractures.[1] Intra-articular distal radius fractures represent one-sixth of all fractures treated in emergency departments.

[2] In these types of fractures, the main aims of treatment are to provide and resume the anatomical restoration of joint surfaces, early mobilization, and better functional results; to avoid degenerative changes in future; and to provide stability

allowing professional and other activities in all age groups.[3] However, the best treatment modality is still controversial.[4,5] Displaced intra-articular fractures are unstable, and in general, they are treated with some different methods such as external fixation (EF) and volar locking plate (VLP). Although EF may not always provide anatomical reduction and may cause residual instability and subsequent displacement, it is still in use in the traditional treatment of unstable intra-articular fractures.[6] Although this technique seems successful, some complications have been reported including stiffness in

Cite this article as: Duramaz A, Bilgili MG, Karaali E, Bayram B, Ziroğlu N, Kural C. Volar locking plate versus K-wire-supported external fixation in the treatment of AO/ASIF type C distal radius fractures: a comparison of functional and radiological outcomes. Ulus Travma Acil Cerrahi Derg 2018;24:255-262.

Address for correspondence: Altuğ Duramaz, M.D. Bakırköy Dr. Sadi Konuk Eğitim ve Araştırma Hastanesi, Ortopedi ve Travmatoloji Kliniği, İstanbul, Turkey Tel: +90 212 - 414 71 71 E-mail: altug.duramaz@yahoo.com Ulus Travma Acil Cerrahi Derg 2018;24(3):255-262 DOI: 10.5505/tjtes.2017.35837 Submitted: 25.03.2017 Accepted: 21.09.2017 Online: 08.05.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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fingers, pin tract infections, loss of reduction, and radial sensory neuropathy.[7] In the last two decades, VLP has gained popularity in the anatomical restoration of the wrist joint as it results in high stability, early motion, and low complication rates in osteoporotic bones.[8] However, very small or comminuted distal articular parts may not allow open reduction internal fixation (ORIF). Moreover, this technique may also have some complications such as tendon irritation and rupture, superficial and deep infections, delays in wound healing, and loss of fixation in complex fractures.[9] In this retrospective study, we aimed to compare the functional and radiological outcomes of K-wire-supported bridging EF (KW-EF) and VLP in the treatment of unstable intraarticular distal radius fractures. Our hypothesis is that VLP will have better functional and radiological outcomes than bridging EF in the treatment of unstable intra-articular distal radius fractures.

MATERIALS AND METHODS After approval was obtained from the local ethics committee, patients treated for complex intra-articular distal radius fractures between February 2010 and April 2013 were retrospectively investigated. Patients aged >18 years, with unilateral complete displaced intra-articular distal radius fractures, with closed fractures, treated in the first 2 weeks after injury, and followed up for at least 2 years, and who had no dysfunction before the injury were included in the study. Patients with bilateral fractures or accompanying other fractures on the injured extremity (except ulnar styloid process) or open fractures, treated with methods other than VLP or KW-EF, with a previous history of injury in fractured wrist, with fracture history more than 2 weeks ago, with medical contraindications, and with accompanying extremity fractures or head injuries were excluded. Only C1, C2, and C3 fractures according to the AO/ASIF classification system were included in the study. (a)

Among 136 patients who met the inclusion criteria, 22 were excluded due to loss to follow-up, inaccessibility owing to address change, or non-attendance to the control. A total of 114 patients were evaluated in the study. Fifty-six patients treated with VLP and 58 patients treated with KWEF were functionally and radiologically evaluated. All surgical procedures were performed by the same surgeon with the standard protocol under general or regional anesthesia. In the VLP group, the standard volar approach was performed with the longitudinal incision. Two different plates were preferred for fixation: 2.5-mm distal radius plates (TST, Istanbul, Turkey) and 2.4 LCP distal radius systems (Synthes, Oberdorf, Switzerland) (Figs. 1 and 2). All patients were splinted below the elbow for 2 weeks. Active finger exercises were started on postoperative day 1. Dressings and sutures were removed on postoperative day 15. The plaster splint was also removed, and another removable splint that allows active rehabilitation was inserted for 15 days. In the KW-EF group, alignment was achieved with manual traction in all patients, and the closed reduction was performed. Uni-planar bridging EF system (Tasarım-Med, Istanbul, Turkey) was used for the fixation. Pins and the connection rod were joined to each other and tightened while the wrist was ulnar deviated at 15° (Figs. 3 and 4). Additionally, one 1.5-mm subchondral Kwire was used for the fixation of the articular parts. Arthrotomy was not performed. All patients were splinted below the elbow for 1 week. Finger movements were allowed on postoperative day 1. In all patients, KW-EF was removed after 6–8 weeks (mean: 7.6 weeks) in the outpatient clinic. Wrist joint movements were started after the removal of the splint in the VLP group and after the removal of the fixator in the KW-EF group.

[10]

In last controls, all patients were clinical and functionally and radiologically evaluated. The objective functional evaluation was performed with the range of motion (ROM) and grip strength. Wrist ROMs of all patients were performed using

(b)

Figure 1. A 59-year-old female was admitted for falling while standing. (a) Displaced distal radius fracture seen in standard wrist radiographs. (b) Communited, intra-articular displaced distal radius fracture seen in axial, coronal, and sagittal CT scans.

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Duramaz et al. Treatment of AO type C distal radius fractures (a)

(b)

(c)

Figure 2. Radiological evaluation of the patient after the operation. (a) Two-planned radiographs obtained on the first day after closed reduction and external fixation supported with a K-wire. (b) Fracture healing on standard wrist radiographs obtained 3 months after operation. (c) Standard two-sided wrist radiographs obtained 2 years after treatment. (a)

(b)

Figure 3. A 56-year-old male patient was admitted for falling from the stairs. (a) Distal radius displaced fracture extending toward distal radioulnar joint seen on standard wrist radiographs. (b) Metaphyseal impaction and comminuted, intra-articular displaced distal radius fracture seen in axial, coronal, and sagittal computed tomographic scans. (a)

(b)

(c)

Figure 4. Radiological evaluation of the patient after the operation. (a) Two-planned radiographs obtained on the first day after open reduction and internal fixation with volar locking plate. (b) Fracture healing on standard wrist radiographs obtained 3 months after the operation. (c) Two-planned radiographs obtained 2 years after treatment.

a universal goniometer. Hand grip strength was measured using Jamar dynamometers (Jamar, Preston, USA) while the elbow was at 90° flexion and forearm was on neutral rotation. Grip strength was compared between the injured and Ulus Travma Acil Cerrahi Derg, May 2018, Vol. 24, No. 3

uninjured side, and the difference was defined as a percentage. The subjective functional evaluation was performed with Gartland–Werley score of 20 points (excellent: 0–2, good: 3–8, fair: 9–20, and poor: >20), Visual Analog Scale (VAS) 257

Duramaz et al. Treatment of AO type C distal radius fractures

of 10 points for pain (0: no pain, 10: widespread pain), and summarized disabilities of the arm, shoulder, and hand questionnaire (QuickDASH) Turkish version.[11] For radiological evaluations, radial height, palmar tilt, radial inclination, ulnar variance, and articular step-off were measured with the standard anteroposterior and lateral radiographs. The presence of arthritic changes was evaluated with Jupiter criteria on last radiographs.[12] Patients were evaluated for postoperative complications such as infection, loss of reduction, tendon injuries, neuropathy, implant failure, and complex regional pain syndrome (CRPS) in all controls. The follow-up period was at least 2 years with a mean of 34.3±9.6 months (range: 24–58 months).

Statistical Analysis Statistical analyses were performed with Number Cruncher Statistical System (NCSS) 2007 (Kaysville, Utah, USA) program. In the evaluation of data, together with the descriptive statistical methods (mean, standard deviation, median, frequency, ratio, and minimum, maximum); in comparison of quantitative data between two groups with normal distribution Student’s t-test and in comparison of parameters between two groups with abnormal distribution Mann–Whitney U test were performed. In a comparison of qualitative data, Pearson’s chi-squared test, Fisher–Freeman–Halton test and Yates’ Continuity Correction test (Yates corrected chisquare) were performed. A p-value of <0.05 was considered significant. Some parameters were statistically significant at an advanced level. A p-value of <0.001 was used to demonstrate advanced statistical significance.

RESULTS Forty-two patients (36.8%) were female, and 72 (63.2%) were male with a mean age of 44.9±15.4 (range: 18–86) years.

There was no statistically significant difference between the VLP and KW-EF groups regarding age, sex, preoperative period, and follow-up periods (p>0.05). There was no statistically significant difference between groups regarding fracture side, dominant side fracture ratio, trauma mechanism, and fracture type (p>0.05) (Table 1). In functional evaluation at last control, flexion, extension, pronation, and supination were all significantly better in the VLP group than in the KWEF group (p=0.001, p=0.001, p=0.001, and p=0.001, respectively) while ulnar deviation was significantly lower and radial deviation was significantly higher (p=0.001 and p=0.001, respectively). Palmar tilt, radial height, and radial inclination were determined as significantly lower in the VLP group than in the KW-EF group in radiological evaluation at postoperative month 3 (p=0.001, p=0.001, and p=0.001, respectively).

However, there was not any significant difference between groups regarding ulnar variance (p=0.798; p>0.05). On the last follow-up, radial height and radial inclination were significantly lower in the VLP group than in the KW-EF group (p=0.001 and p=0.001, respectively). However, there was no 258

significant difference between the two groups regarding palmar tilt and ulnar variance (p=0.294 and p=0.075; p>0.05, respectively). It was taking attention that ulnar variance measurements were higher in the VLP group than in the KW-EF group. Ulnar variance alterations were significantly lower in the VLP group than in the KW-EF group (p=0.001; p<0.01) (Table 2).

There was a statistically significant difference between the groups regarding Gartland–Werley scores (p=0.037; p<0.05).

Good score in the KW-EF group and excellent score in the VLP group were statistically significant. Gartland–Werley, QuickDASH, and VAS scores were all significantly better in the VLP group than in the KW-EF group (p=0.003, p=0.003, and p=0.001, respectively; p<0.01). At the last follow-up, loss of grip strength compared with the uninjured side was 4% in the VLP group and 7% in the KW-EF group. All patients underwent preoperative computed tomographic scan and intraoperative stress radiography under fluoroscopy for wrist instability after the fixation of the fracture. Two patients in the VLP group and three patients in the KW-EF group had midcarpal instability. Furthermore, one patient in the VLP group and one in the KW-EF group had distal radioulnar instability. All patients with wrist instability were treated with two or three KW as an early treatment. KWs were removed after 6–8 weeks (mean: 7.6 weeks) in the outpatient clinic for all patients. However, as a result of wrist instability, three patients in the VLP group and four patients in the KW-EF group had stage 1 osteoarthritis according to the Jupiter Osteoarthritis Criteria, at the last follow-up. Although there was not any significant difference regarding joint mismatch (>1 mm) between the groups, the complication rate was significantly higher in the KW-EF group than in the VLP group (p=0.149 and p=0.005, respectively; p>0.05). In this study, there were two patients with median nerve neuropathy, three with stage-1 CRPS, and two with tendon irritations in the VLP group, while there was one patient with median nerve neuropathy, six with pin tract infections, two with superficial radial nerve neuropathy, and 12 with stage-1 CRPS in the KW-EF group. Median nerve compression was required in none of our patients. Patients with pin tract infection were treated with antibiotics. All patients with CRPS recovered with hand rehabilitation.

DISCUSSION Regarding the anatomy of the distal radius and effects of the forces in various directions, different types of fractures may be observed. It is mostly not possible to achieve success with the same approaches and materials in various fracture types. Mechanical features are important in the selection of surgical technique, while strategic insertion of the selected material may be more important than the features of material in especially intra-articular fractures.[13] In the treatment of unstable intra-articular distal radius fractures, many different surgical techniques may be performed includUlus Travma Acil Cerrahi Derg, May 2018, Vol. 24, No. 3

Duramaz et al. Treatment of AO type C distal radius fractures

Table 1. Descriptive features of patients

External fixation (n=58)

n %

Volar locking plate (n=56)

Mean±SD n %

p

Mean±SD

Age (years) 42.90±15.99 47.02±14.64 a0.154 Time to surgery (days); (median)

7.97±4.04 (6)

8.18±4.11 (7)

b

0.842

Duration of follow-up (months); (median)

34.97±8.78 (32)

33.73±10.53 (29)

b

0.122

Sex

Male

38 65.5

34 60.7

Female

20 34.5

22 39.3

Right

30 51.7

25 44.6

Left

28 48.3

31 55.4

Dominant

34 58.6

34 60.7

Nondominant

24 41.4

22 39.3

c

0.595

c

0.449

c

0.820

Handedness

Wrist fractured

Mechanism of trauma

Bike accident

4

6.9

6

10.7

Motor vehicle accident

6

10.3

1

1.8

Fall from standing

30

51.7

37

66.1

Fall from height

16

27.6

10

17.9

Fall stairs

2 3.4

2 3.6

C1

20 34.5

16 28.6

C2

16 27.6

18 32.1

C3

22 37.9

22 39.3

0.189

d

Fracture Classification (AO-ASIF) 0.750

d

Complications

Median nerve neuropathy

1

3.4

2

1.8

Pin tract infection

6

10.3

0

0

Complex regional pain syndrome

12

20.7

3

5.4

Tendon irritation

0

0

2

3.6

Superficial radial neuropathy

2

3.4

0

0

0.005**

e

Gartland-Werley Score Fair

14 24.1

5

8.9

Good

26 44.8

23 41.1

Excellent

18 31

28 50

No

34 58.6

41 73.2

Yes

24 41.4

15 26.8

0.037*

a

Articular Step-off (≥1 mm) 0.149

e

Student’s t-test; bMann-Whitney U Test; cPearson’s chi-square test; dFisher-Freeman-Halton Test; eYates’ Continuity Correction Test; **p<0.01; *p<0.05.

a

ing arthroscopy-assisted surgery, fragment-specific fixation methods, EF, and locked or unlocked palmar plates. Direct view of the joint and reduction, diagnosis and treatment of related ligament injuries, removal of intra-articular cartilage debris are advantages of arthroscopy-assisted surgery. However, the necessity of imaging with fluoroscopy, because of the long and difficult procedure, cost increase, and excessive Ulus Travma Acil Cerrahi Derg, May 2018, Vol. 24, No. 3

resource utilization are the disadvantages of arthroscopy.

Fragment-specific fixation has some advantages such as secure fixation of comminuted fracture, complete anatomical correction, and prevention of tendon problems due to lowprofile plates. EF and VLP have been compared in many previous studies in the treatment of intra-articular distal radius fractures.[6,7,11] The main advantages of EF are relatively easy 259

Duramaz et al. Treatment of AO type C distal radius fractures

Table 2. Comparison of radiological outcomes and functional scores between volar locking plate and external fixation at the end of 2 years of follow-up

External fixation (n=58)

Volar locking plate (n=56)

Mean±SD (median)

Mean±SD (median)

p

Range of motion (°)

Flexion

56.17±7.24

68.71±3.42

a

Extension

56.48±3.87

64.39±3.45

a

Pronation

67.48±4.95

72.59±2.96

a

Supination

61.21±6.55

71.89±3.81

a

Ulnar deviation

30.55±2.52

26.77±2.18

a

Radial deviation

12.14±2.08

16.54±2.20

a

b

0.001*

0.001* 0.001* 0.001* 0.001* 0.001*

Radiographic data

Palmar tilt (°)

3rd month

7.94±4.83 (9.8)

6.67±3.13 (7)

2nd year

4.15±5.14 (5.4)

5.60±3.32 (5.9)

b

Alteration

3.79±1.83 (4)

1.58±1.28 (1.1)

b

3rd month

11.76±1.24

10.82±1.03

a

2 year

10.73±1.01

10.13±0.59

a

Alteration

1.03±0.57 (1)

0.72±0.74 (0.3)

b

3 month

20.09±1.03

19.08±1.13

a

2nd year

18.85±1.14

17.95±1.16

a

Alteration

1.24±0.71 (1.4)

1.11±0.79 (0.9)

b

0.268

Ulnar variance (mm)

0.798 0.075

Radial length (mm)

nd

Radial inclination (°)

rd

0.001*

0.001* 0.001* 0.001*

0.001* 0.001*

3 month

0.75±1.17 (1.2)

0.78±0.88 (0.9)

b

2nd year

0.29±1.20 (0.6)

0.75±0.67 (0.9)

b

Alteration

0.52±0.41 (0.5)

0.38±0.22 (0.3)

b

rd

0.294

0.001*

0.001*

Functional scores

Gartland-Werley Score

4.86±3.40 (4)

3.02±2.79 (2.5)

b

QuickDASH Score

5.96±5.23 (4.5)

3.33±3.58 (2.3)

b

Visual Analog Score

2.35±2.09 (2)

1.02±1.15 (1)

b

0.003* 0.003* 0.001*

Student’s t-test; bMann-Whitney U Test. *p<0.01.

a

application, less surgical trauma, preservation of height and alignment, minimal surgical exposure, and achievement and maintenance of reduction under fluoroscopy with ligamentotaxis.[14] However, ligamentotaxis in EF is not successful enough to accomplish the anatomical restoration of the joint surface. Percutaneous pins support EF stability. However, EF has some potential complications in the treatment of distal radius fractures such as pin tract infections, over-distraction, joint stiffness, restriction in finger movements, loss of grip strength, superficial radial nerve injury, and CRPS. Management of these complications reported between 6% and 60% is difficult, and they negatively affect the functional results.[15] On the other hand, VLP has some advantages including direct view and intervention of fracture parts with ORIF, maintenance of stable and rigid fixation, subchondral support, anatomical restoration of joint surface, and early mobilization and preservation of upper extremity functions in the postoperative period. However, FPL tendon ruptures were reported to be as high as 12% in recent studies. The 260

possible causes of tendon ruptures were thought to be distal localization of VLP and sharp corners of the screws.[16] Moreover, carpal tunnel syndrome (CTS) may develop following VLP. In some studies, CTS ratios were determined to decrease with the release of transverse carpal ligament.[17] Egol et al.[18] reported that wrist ROM results were initially better in patients in the VLP group, but only pronation could be maintained better during the follow-ups. In our study, when wrist ROM results of the VLP and KW-EF groups were compared for all parameters, there were significant differences in favor of VLP at the end of the follow-up. Richard et al.[19] determined that VLP was superior to EF in early return to daily activities and functional results and on the 12th month of treatment in EF, and wrist ROM decreased while QuickDASH and VAS scores were higher. However, Williksen et al.[20] did not determine any significant difference between VLP and EF regarding QuickDASH scores at the end of 12 months of follow-up. In our study, in functional evaluations, wrist ROM, Gartland–Werley, VAS, and QuickDASH Ulus Travma Acil Cerrahi Derg, May 2018, Vol. 24, No. 3

Duramaz et al. Treatment of AO type C distal radius fractures

scores were significantly better in the 24th month in the VLP treatment. Motion superiority determined in the VLP group was associated with the patients’ being able to start wrist movements earlier due to the rigid fixation. Kumbaracı et al. reported that despite the early start of wrist ROM in the VLP group, there was no significant difference between the two groups regarding grip strength at the end of at least 12 months of evaluation.[9] In our study, loss of grip strength was determined to be lesser in the VLP group. All KW-EFs were passing through the joint and were dynamized. For that reason, until the removal of the fixator, the wrist was immobilized. This condition may explain the greater movement loss and diminished grip strength in EF. Roh et al.[6] reported that VLP had better radiological outcomes regarding ulnar variance but these radiological results did not affect the functional outcomes on the 12th month. In this study, when radiological results were compared, radial length and radial inclination were better corrected with EF. However, these results were observed not to have any effect on functional outcomes during the 2 years of follow-up.

Especially in very distally located comminuted fractures that do not allow the placement of screws, K-wire supported EF may have successful outcomes. On the other hand, EF may not resist the collapse of the fracture since it could not stabilize the fracture as rigid as VLP and since it should be removed after a period. Moreover, loss of palmar angulation may continue in the EF group in the long term, even after the removal of the fixator. Since ORIF may be directly and visually performed, the palmar tilt may be corrected better with VLP. Subchondral inserted distal screws of VLP maintain support against palmar angulation loss and also prevent the collapse of fracture in the long term.[21] In this study, there were no significant differences observed between groups regarding palmar tilt at the end of follow-ups. However, in both groups, but especially in EF, loss of wrist flexion and supination was determined in patients who were restored with shortness and palmar angulation loss. A study by Juedy et al. evaluating articular step-off radiologically, there were no significant differences between the groups.[22] In the present study, there were no significant differences between the groups regarding articular step-off at the last follow-up.

Shukla et al. reported that EF was superior to VLP at the end of the 1st year, and also the results were better in patients aged <50 years if treated with EF.[21] In our study, patient satisfaction was determined to be significantly higher in the VLP group regarding objective and subjective functional evaluations. Moreover, all parameters except ulnar variance and palmar tilt were radiologically better in the VLP group.

Additionally, the complication rate in the KW-EF group was significantly higher than that in the VLP group, consistent with previous studies.[6,11] The present study is taking attention with its follow-up period of at least 2 years. On the other hand, its retrospective design, lack of randomization, and absence of functional monitoring data between the 3rd month and 2nd year are the main limitations of this study.

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Conclusions This study results indicate that VLP is a safe method with low complication rates. Patients’ preference is an increasingly prominent factor in the choice of treatment method.

However, VLP is a better option in young and active patients with the expectation of high functional achievements. On the other hand, KW-EF may be successful in older patients with low activity levels and in very distal and comminuted fractures that contraindicate the use of VLP, but the complications should be kept in mind. We believe that VLP is superior to KW-EF for early return to normal daily activities as well as functional and radiological outcomes in the 2nd year of treatment.

Conflict of interest: None declared.

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ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

AO/ASIF tip C distal radius kırıklarının tedavisinde volar kilitli plak mı? K-teli destekli eksternal fiksatör mü? Fonksiyonel ve radyolojik sonuçların karşılaştırılması Dr. Altuğ Duramaz, Dr. Mustafa Gökhan Bilgili, Dr. Evren Karaali, Dr. Berhan Bayram, Dr. Nezih Ziroğlu, Dr. Cemal Kural Bakırköy Dr. Sadi Konuk Eğitim ve Araştırma Hastanesi, Ortopedi ve Travmatoloji Kliniği, İstanbul

AMAÇ: Eklem içi ve parçalı distal radius kırıklarının tedavisinde volar kilitli plak uygulaması ile K teli destekli eksternal fiksatör uygulamasının fonksiyonel ve radyolojik sonuçlarının karşılaştırılması amaçlandı.

GEREÇ VE YÖNTEM: Şubat 2010–Nisan 2013 tarihleri arasında kompleks intraartiküler distal radius kırığı için tedavi edilmiş hastalar geriye dönük olarak tarandı. Dâhil edilme kriterlerini karşılayan 18 ile 86 yaş arasında (ortalama yaş, 44.9±15.4) 114 hasta değerlendirildi. Hastaların fonksiyonel değerlendirmelerinde gonyometre ile eklem hareket açıklıkları ve el dinamometresi ile kavrama güçleri ölçüldü. Sonuçlar Gartland–Werley ölçeği ile değerlendirildi. Subjektif fonksiyonel değerlendirmede Quick DASH ölçeği kullanıldı. Radyolojik değerlendirme hastaların ameliyat sonrası üçüncü ay ve ikinci yılda el bileği grafileri ile yapıldı.

BULGULAR: Son kontroldeki fonksiyonel değerlendirmede volar kilitli plakta (VLP) fleksiyon, ekstansiyon, pronasyon ve supinasyon eksternal fiksatörden (EF) anlamlı düzeyde yüksekti (p=0.001). Volar kilitli plağın Gartland-Werley skoru, QuickDASH skoru ve vizüel analog skoru (VAS), EF’den iyiydi (p=0.003, p=0.003 ve p=0.001, sırasıyla). VLP’de ameliyat sonrası son kontrolde sağlam tarafa göre kavrama gücü kaybı ortalama %4, EF’de ise %7 oranındaydı.

TARTIŞMA: Volar kilitli plağın güvenli ve komplikasyondan uzak bir yöntem olduğu görülmüştür. Volar kilitli plak günlük yaşam aktivitelerine erken dönüş, fonksiyonel ve radyolojik sonuçlar açısından tedavinin ikinci yılında eksternal fiksatörden daha üstün bir yöntemdir.

Anahtar sözcükler: Fonksiyonel sonuçlar; intraartiküler distal radius kırığı; köprü eksternal fiksatör; volar kilitli plak.

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Application of hybrid external fixation by the “joystick method” in bicondylar tibial plateau fractures: Technical note Ersin Kuyucu, M.D.,1 Adnan Kara, M.D.,1 Ferhat Say, M.D.,2 Mehmet Erdil, M.D.,1 Murat Bülbül, M.D.,1 Barış Gülenç, M.D.1 1

Department of Orthopedics and Traumatology, İstanbul Medipol University Faculty of Medicine, İstanbul-Turkey

2

Department of Orthopedics and Traumatology, Ondokuz Mayıs University Faculty of Medicine, Samsun-Turkey

ABSTRACT BACKGROUND: This study aimed to present clinical outcomes in patients with tibial plateau fractures who were treated with hybrid external fixators and describe the details of our technique. Schanz screws were synchronously applied and used as a joystick for fracture reduction.

METHODS: The study population included 72 patients with bicondylar tibial plateau fractures classified as type 41-C2 according to the AO classification. Joint reduction was maintained using Schanz screws transmitted through tibial condyles as a joystick under fluoroscopy. The patients then underwent surgery with these Schanz screws and a hybrid external fixation system.

RESULTS: The median age of the patients was 39 (21–67) years, and the median follow-up time was 21 (12–35) months. The mean knee flexion and extension were 105° (80°–125°) and 0° (−5°–7°), respectively. The mean varus laxity and valgus laxity were 4.30° (2°–7°) and 3.10° (2°–5°), respectively. Four patients had leg shortness of 0.4–1.1 cm. The external fixators were removed between 8 and 16 weeks (mean = 11 weeks) postoperatively. The KSS scores at the end of 1 year were “excellent” for 48 patients, “good” for 19 patients, and “inadequate” for 5 patients.

CONCLUSION: With the synchronous application of the two Schanz screws of 6.5-mm thickness and the two-drill technique under fluoroscopic guidance, we obtained stable reductions over a short period. No patient experienced major complications, and this enabled early weight bearing and a return to daily living activities.

Keywords: Fracture complication; hybrid external fixation; tibial plateau fracture.

INTRODUCTION The treatment of bicondylar tibial plateau fractures remains a complex and challenging issue for orthopedic surgeons despite numerous treatment alternatives.[1] Bicondylar tibial plateau fractures constitute 2.9% of all tibial fractures.[2] The goal of treatment is to provide joint-surface regularity, restore normal alignment, and achieve early joint movement.[3,4] Anatomical restoration of the joint surface is recommended, except for cases of tibial plateau fracture displaced less than

2 mm.[5,6] Previous studies have reported excellent treatment outcomes following conservative treatment.[7,8] External fixation, internal plate fixation, and arthroscopy-assisted techniques are surgical treatment alternatives. Despite the development of minimally invasive techniques and plate technology, open reduction and internal fixation represent the gold standard for treatment.[9–12] However, owing to soft tissue compromise and its attendant complications, studies have reported superior or equivalent results using a hybrid external fixator.[11] Herein, we aimed to present clinical outcomes in patients with tibial plateau fractures who were treated with

Cite this article as: Kuyucu E, Kara A, Say F, Erdil M, Bülbül M, Gülenç B. Application of hybrid external fixation by the “joystick method” in bicondylar tibial plateau fractures: Technical note. Ulus Travma Acil Cerrahi Derg 2018;24:263-267.

Address for correspondence: Ersin Kuyucu, M.D. İstanbul Medipol Üniversitesi, TEM Avrupa Otoyolu Göztepe Çıkısı, Bağcılar, 34214 İstanbul, Turkey Tel: +90 212 - 460 77 77 E-mail: ersinkuyucu@yahoo.com.tr Ulus Travma Acil Cerrahi Derg 2018;24(3):263-267 DOI: 10.5505/tjtes.2017.27848 Submitted: 04.04.2016 Accepted: 13.09.2017 Online: 10.05.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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hybrid external fixators and describe the details of our technique. Schanz screws were synchronously applied and used as a joystick for fracture reduction.

MATERIALS AND METHODS Patients with bicondylar tibial plateau fractures who were treated with surgery between 2007 and 2013 at two hospitals were retrospectively evaluated using their electronic charts, which included patient backgrounds and radiological findings.

Patients with pediatric fractures without growth plate closure, fractures with vessel and nerve injuries, open fractures, and instability requiring additional repair and reconstruction and patients who had posterior fragments with serious posterior slope changes were excluded; those who needed postoperative internal care unit follow-up visits, those who did not attend follow-up visits, and those with follow-up periods less than 12 months were also excluded. Patients with closed tibial plateau fractures were included in this study. Ultimately, the study included 72 patients (49 males and 23 females) with complete and simple articular bicondylar and metaphysical multifragmentary tibial plateau fractures classified as type 41-C2 according to the AO classification. Two consultant orthopedic surgeons performed the operations at different hospitals. All patients provided written informed consent for the operations, and they were informed of the length of the rehabilitation period.

Joint reduction was maintained using Schanz screws transmitted through tibial condyles as a joystick under fluoroscopy.

The patients then underwent surgery with these Schanz screws and a hybrid external fixation system. Full knee flexion, extension, and ambulation with partial weight bearing were allowed on the first postoperative day. All patients were discharged from the hospital on the second postoperative day. Two patients had additional extremity fractures (a contralateral distal diaphysis femur fracture and an ipsilateral distal diaphysis tibial fracture). One patient had post-polio sequelae on the operated side; however, these sequelae were not associated with our operation. The AO/OTA classification was used for fracture type classification.[13] Fracture healing was evaluated using roentgenograms at the follow-up visits. The Knee Society Clinical Rating System (KSS) was used for clinical evaluation.[14]

Surgical Technique For fluoroscopy, the patients were placed in a supine position with slight elevators under their hips. For antibiotic prophylaxis, 1000 mg intravenous cefazolin was administered to patients preoperatively. Sedation and spinal anesthesia were administered to the patients preoperatively. A tourniquet was not used. Fluoroscopy was performed at opposite the surgical site. Flexion and 5/8” circular frame rings were selected for the proximal tibia. Distal monolateral external fixators were selected based on tibial lengths. These two modular apparatuses were combined.

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Reduction was applied after the preparation procedure as follows: Schanz screws of 6.5-mm thickness and 50-mm groove lengths coated with 2-hydroxyapatite were fixed to two separate drills. Localization of the major fracture fragments was determined using fluoroscopy. After 1-cm skin incision and soft tissue dissection, two Schanz screws were placed 1 cm distally to the knee joint and vertical to the medial and lateral fracture fragments synchronously with two separate drills under fluoroscopic guidance by the same surgeon. After passing through the single cortex with the two Schanz screws medially and laterally, the Schanz screws were drilled forward to the end of the fracture fragments. After checking the movement of the fracture fragments for articular reduction using the same Schanz screws under fluoroscopy, the screws were used as joysticks, and reduction was performed. When the best anatomical reduction was obtained with fluoroscopy, the Schanz screws were passed through the far cortex synchronously. The aim of this technique is to allow sufficient reduction with minimal soft tissue dissection and prevent opening of the joint and fracture zones.

Block movement of the tibia in the antero-posterior and lateral directions was observed under fluoroscopy; after determining the appropriate joint regularity, the screws were fixed to the 5/8” rings. Previously selected monolateral external fixators were applied with three Schanz screws. A size 4 lengthening cube was applied to a suitable hole on the medial side of the proximal ring. The Schanz screws of 6.5-mm thickness and 50-mm groove lengths coated with 2-hydroxyapatite were fixed to the lower holes of the lengthening cube (Figs.

1a-c–2a-c). In this study, for each fragment, only one Schanz screw was inserted, and in order to prevent pulling out or loosening, hydroxyapatite screws were used.

After providing a final reduction of the system through distraction and compression, the system was completely stabilized. The screw and skin contact points were cleansed with hydrogen peroxide, and a sterile medical dressing was applied. Radiological evaluations were conducted using roentgenograms on the third week, sixth week, third month, sixth month, and first year postoperatively (Fig. 1c).

RESULTS The median age of the 72 patients was 39 (21–67) years; this is the standard treatment of AO 41-C2 plateau fractures with our exclusion criteria. The median follow-up time was 21 (12–35) months. The etiologies of the fractures were traffic accidents for 45 patients (62.5%), falls from heights for 17 patients (23.6%), and falls for 10 patients (13.8%). The median operation duration was 47 (25–68) minutes. Blood transfusions were not required for any of the patients during the postoperative period. The mean knee flexion and extension were 105° (80°–125°) and 0° (−5°–7°), respectively. The mean varus laxity and valgus laxity were 4.30° (2°–7°) and 3.10° (2°–5°), respectively. Four patients had leg shortness of 0.4–1.1 cm (mean = 0.72 cm). After confirming full radiUlus Travma Acil Cerrahi Derg, May 2018, Vol. 24, No. 3

Kuyucu et al. Application of hybrid external fixation by the “joystick method” in bicondylar tibial plateau fractures (a)

(b)

(c)

Figure 1. (a) Preoperative antero-posterior and lateral tibial roentgenogram of a 49-year-old male patient. The etiology of this bicondylar tibial plateau fracture was a traffic accident. (b) Postoperative roentgenograms of the patient. (c) Knee range of motion 6 months after treatment.

ological fracture healing, the external fixators were removed between 8 and 16 weeks (mean = 11 weeks) postoperatively.

The KSS scores at the end of 1 year were “excellent” for 48 patients, “good” for 19 patients, and “inadequate” for 5 patients. Four patients with poor results underwent another operation, three underwent total knee arthroplasty, and one was treated with arthroscopic debridement and micro fracture. One of the patients with poor results was not accepted for the second operation, underwent physical examination, and was treated with platelet-rich plasma.

Full fracture healing was observed for all members of the study group. No patient experienced delayed union, malunion, or nonunion. Reflex sympathetic dystrophy was observed as (a)

a complication in two patients who reported inadequate results (2.7%), and pin tract infection was observed as another complication in five patients; this complication was treated with local wound care and antibiotic therapy. Pin loosening was not observed in any patient. All patients showed good satisfaction, were mobilized at the first postoperative day, and were discharged from the hospital on the second postoperative day (Fig. 2a, b).

During the rehabilitation period, early active and passive range-of-motion exercises were recommended. All patients were allowed ambulation with partial weight bearing as tolerated with crutches for the first 6 weeks. Full weight bearing without crutches was recommended after the sixth week. (b)

(c)

Figure 2. (a) Preoperative coronal view computed tomography of a 63-year-old female patient and postoperative antero-posterior and lateral images of the tibia. (b) The antero-posterior and lateral images of the patient’s knee joint taken at 14 months postoperatively. (c) Illustrations of the surgical technique.

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DISCUSSION Most bicondylar tibial plateau fractures result from high-energy traumas.[15,16] The goal of treatment is to achieve a painfree and stable knee joint with a functional range of motion.

[4,12,17] Despite excellent results reported using conservative treatment, prominent displacement and ligament injuries causing instability are the major indications for surgery[4,14,17] Circular external fixators such as the Ilizarov apparatus and computer-assisted frames have been used for more than 30 years as a treatment for tibial plateau fractures; the problems with the Ilizarov apparatus are prolonged hospital stay and long surgery duration.[18] Computer-assisted frames have a higher equipment cost difference compared with that of other external fixation systems.[19] Previous studies have documented skin necrosis as a result of soft-tissue trauma and open reduction with internal fixation as a risk factor for an increased infection rate.[12,16–18] Mallik et al. reported similar results but showed a decreased complication rate using a hybrid external fixator compared with that for open reduction and plate osteosynthesis.[10] In our study, five patients experienced pin tract infection, and two patients experienced reflex sympathetic dystrophy; the bearing was not correctly applied by these two patients.

In another study, the use of a hybrid external fixator was compared with closed reduction and conservative treatment methods. The authors of that study warned against the risk of joint-surface derangement because of early movement among patients in which a hybrid external fixator was applied with K-wires.[19] This disadvantage was not observed when the external fixator with Schanz screws was applied and a stable fixation was maintained. In the current study, jointsurface derangement was not observed in any of the patients, as confirmed by fluoroscopy, despite the recommendation of early active and passive range-of-motion exercises as well as partial weight bearing.

Krupp et al. compared the hybrid external fixators with plate screw fixation for Schatzker type V/VI plateau fractures. He reported that the union time, stiffness, and overall complications decreased with the plate screw technique. They depicted that hybrid fixation may be reserved for spanning the joint before definitive open surgery.[20] In our study, we used hybrid external fixators or open reduction and plate screw fixators only when posterior fragments existed. Reduction of posterior fragments with close manner can increase the risk of vessel or nerve injury; thus, our patients were treated with open reduction and internal plate screw fixation.

Stable fixation and early motion are indispensable in this type of intra-articular fracture.[13] Fixation systems enabling early motion provide better cartilage nutrition, which might pre266

vent osteoarthritis development. In our study, we allowed a safe range of motion and partial weight bearing without yielding joint-surface derangement.

Tourniquet use during open reduction and internal fixation of lower extremity fractures might lead to complications such as deep vein thrombosis, muscle necrosis, or nerve injury.

[21,22] Tourniquet-related complications, such as ischemia and deep vein thrombosis, were not observed in our study, owing to the absence of a tourniquet requirement. No patient required blood transfusion due to the minimally invasive nature of the operation. The mean operation duration was 47 (25–86) minutes.

One of the limitations of this study was its retrospective design. The limited number of patients and the relatively brief duration of the follow-up period are additional limitations.

The lack of an objective evaluation of joint step formation using magnetic resonance imaging or computed tomography was a disadvantage of this study.

Conclusions With the synchronous application of the two Schanz screws of 6.5-mm thickness and the two-drill technique under fluoroscopic guidance, we obtained stable reductions over a short period. No patient experienced major complications, which enabled early weight bearing and a return to daily living activities.

Hybrid external fixation using Schanz screws via the “joystick method” should be considered as a rapid, easy-to-apply method with low morbidity and successful results for treating bicondylar tibial plateau fractures. However, long-term randomized prospective studies are required in the future.

Conflict of interest: None declared.

REFERENCES 1. Yao Y, Lv H, Zan J, Li J, Zhu N, Jing J. Functional outcomes of bicondylar tibial plateau fractures treated with dual buttress plates and risk factors: a case series. Injury 2014;45:1980–4.

2. Apley AG. Fractures of the tibial plateau. Orthop Clin North Am 1979;10:61–74.

3. Watson JT. High-energy fractures of the tibial plateau. Orthop Clin North Am 1994;25:723–52.

4. Moore TM, Patzakis MJ, Harvey JP. Tibial plateau fractures: definition, demographics, treatment rationale, and long-term results of closed traction management or operative reduction. J Orthop Trauma 1987;1:97– 119.

5. Schatzker J. Fractures of the Tibial Plateau. In: Schatzker J, Tile M, editors. The Rationale of Operative Fracture Care. Berlin: Springer –Verlag; 1987. p. 279–95.

6. Szyszkowitz R. Patella and Tibia. In: Allgöwer M, editor. Manual of Internal Fixation. 3rd ed. Berlin: Springer-Verlag; 1991. p. 554–6.

7. DeCoster TA, Nepola JV, el-Khoury GY. Cast brace treatment of prox-

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8. Ballard BL, Antonacci JM, Temple-Wong MM, Hui AY, Schumacher BL, Bugbee WD, et al. Effect of tibial plateau fracture on lubrication function and composition of synovial fluid. J Bone Joint Surg Am 2012;94:e64.

9. Yu L, Fenglin Z. High-energy tibial plateau fractures: external fixation versus platefixation. Eur J Orthop Surg Traumatol 2015;25:411–23.

10. Neogi DS, Trikha V, Mishra KK, Bandekar SM, Yadav CS. Comparative study of single lateral locked plating versus doubleplating in type C bicondylar tibial plateau fractures. Indian J Orthop 2015;49:193–8.

11. Ahearn N, Oppy A, Halliday R, Rowett-Harris J, Morris SA, Chesser TJ, et al. The outcome following fixation of bicondylar tibial plateau fractures. Bone Joint J 2014;96-B:956–62.

12. Küçükkaya M. Tibia Plato Kırıkları. TOTBİD (Türk Ortopedi ve Travmatoloji Birliği Derneği) Dergisi 2008;7:67–71.

13. Schatzker J, McBroom R, Bruce D. The tibial plateau fracture. The Toronto experience 1968-1975. Clin Orthop Relat Res 1979:94–104.

14. Insall JN, Dorr LD, Scott RD, Scott WN. Rationale of the Knee Society clinical rating system. Clin Orthop Relat Res 1989:13–4.

15. Işıklar ZU. Diz Çevresi Kırıklar. In: Tandoğan R, Alparslan M, editors.

Diz Cerrahisi. Ankara: Haberal Eğitim Vakfı; 1999. p. 399–419.

16. Honkonen SE, Järvinen MJ. Classification of fractures of the tibial condyles. J Bone Joint Surg Br 1992;74:840–7.

17. Rasmussen PS. Tibial condylar fractures. Impairment of knee joint stability as an indication for surgical treatment. J Bone Joint Surg Am 1973;55:1331–50.

18. Conserva V, Vicenti G, Allegretti G, Filipponi M, Monno A, Picca G, et al. Retrospective review of tibial plateau fractures treated by twomethods without staging. Injury 2015;46:1951–6.

19. Shore BJ, DiMauro JP, Spence DD, Miller PE, Glotzbecker MP, Spencer S, et al. Uniplanar Versus Taylor Spatial Frame External Fixation For PediatricDiaphyseal Tibia Fractures: A Comparison of Cost and Complications. J Pediatr Orthop 2016;36:821–8.

20. Krupp RJ, Malkani AL, Roberts CS, Seligson D, Crawford CH 3rd, Smith L. Orthopedics 2009 Aug;32(8).

21. Faldini C, Manca M, Pagkati S, Leonetti D, Nanni M, Grandi G, et al.

Surgical treatment of complex tibial plateau fractures by closed reduction and external fixation. A review of 32 consecutive cases operated. J Orthop Trauma 2005;6:188–93.

22. Boogaerts JG. Lower limb exsanguination and embolism. Acta Anaesthesiol Belg 1999;50:95–8.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Tibia plato kırıklarında “joystik yöntemi” ile hibrid eksternal fiksatör uygulaması: Teknik not Dr. Ersin Kuyucu,1 Dr. Adnan Kara,1 Dr. Ferhat Say,2 Dr. Mehmet Erdil,1 Dr. Murat Bülbül,1 Dr. Barış Gülenç1 1 2

İstanbul Medipol Üniversitesi Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, İstanbul Ondokuz Mayıs Üniversitesi Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, Samsun

AMAÇ: Tibia plato kırıklarında, hibrid eksternal fiksatör uyguladığımız hastalarımızın klinik sonuçlarını sunmayı ve uyguladığımız joystik tekniğinin detaylarını sunmayı amaçladık. Tekniğimizde Shanz çivileri eşzamanlı joystik olarak kullanılmakta ve redüksiyon sağlanmaktadır.

GEREÇ VE YÖNTEM: Çalışmamız AO sınıflama sistemine göre tip 41-C2 olan 72 bikondiler tibia plato kırıklı hastayı içermektedir. Eklem redüksiyonu, kondillerden geçen shanz çivilerinin floroskopi eşliğinde eş zamanlı yapılması ilksine dayanmaktadır. Daha sonra hybrid eksternal fiksatör sistemine adapte edilmektedir.

BULGULAR: Ortalama hasta yaşı 39 (21–67) ve ortalama takip süresi 21 (12–35) ay idi. ortalama diz fleksiyon ve ekstansiyon değerleri sırası ile 105 (80–125) ve 0 (-5–7) dereceydi, ortalama varus ve valgus laksitesi 4.3 (2–7) ve 3.1 (2–5) dereceydi. Dört hastada 0.4–11 cm arasında değişen ekstremite kısalığı mevcuttu. Knee Society Clinical Rating System (KSS) skoru birinci yıl sonunda 48 hasta için mükemmel ve 19 hasta için iyiydi. Beş hasta için yetersizdi.

TARTIŞMA: 6.5 mm kalınlığında Shanz çivileri ile eş zamanlı yapılan tekniğimizle kısa cerrahi sürede hastanın kırığı floroskopi eşliğinde redükte edilmekte ve fiksasyonu sağlanmaktadır. Hiçbir hastada majör komplikasyon gelişmedi, erken yük verme ve hareket ile günlük yaşama çabuk döndüler.

Anahtar sözcükler: Hybrid eksternal fiksasyon; kırık komplikasyonu; tibia plato kırığı.

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Intramedullary nail with integrated cephalocervical screws in the intertrochanteric fractures treatment: Position of screws in fracture stability Gökhan Kaynak, M.D., Mehmet Can Ünlü, M.D., Mehmet Fatih Güven, M.D., Ozan Ali Erdal, M.D., Okan Tok, M.D., Hüseyin Botanlıoğlu, M.D., Önder Aydıngöz, M.D. Department of Orthopedics and Traumatology, İstanbul University Cerrahpasa Faculty of Medicine, İstanbul-Turkey

ABSTRACT BACKGROUND: Stable fracture fixation is important in the treatment of intertrochanteric femur (ITF) fractures in the elderly population to prevent the loss of reduction, achieve early mobility, and restore independence. The aim of this study was to present the results of surgical treatment of stable and unstable ITF fractures using a trochanteric antegrade intramedullary nail with two cephalocervical screws in an integrated mechanism (Intertan®; Smith & Nephew, Memphis, TN) and evaluate the relationship between the loss of reduction and screw position in the femoral neck in two planes.

METHODS: The authors investigated all varus misalignments and losses of reduction in 57 patients (22 males, 35 females) treated for ITF fractures with the Intertan® between 2010 and 2011. Two indices (screw alignment index in the frontal projection [SAIcoronal] and screw alignment index in the lateral projection [SAIsagittal]) were defined to evaluate the loss of reduction. Patients were also evaluated according to the Harris hip score and Barthel independence index.

RESULTS: The mean patient age was 77.1 years. The mean follow-up period was 21.7 months. All patients achieved complete union.

We did not detect any varus collapse or loss of reduction. At the end of the follow-up period, the mean Barthel independence index was 90.7, and the mean Harris hip score was 83.7.

CONCLUSION: The use of a trochanteric antegrade intramedullary nail with two cephalocervical screws allows for linear intraoperative compression and rotational stability of the head/neck fragment, prevents reduction loss, and has a wide application area in the femoral head. Its inherent continuous stability permits early weight-bearing and mobilization. It is a safe and an efficient option for the treatment of ITF fractures.

Keywords: Hip fractures; integrated cephalocervical screws; intertrochanteric fractures; outcome; screw position.

INTRODUCTION Intertrochanteric femur (ITF) fractures are among the most common orthopedic injuries in the elderly population and are mainly treated surgically.[1,2] The surgical treatment of ITF fractures aims to achieve early ambulation and to restore the patient’s walking capacity to the pre-injury level. Intramedullary (IM) nail-screw devices offer distinct biomechanical advantages over other types of fixation devices. IM nails are load-sharing devices, offer three-point fixation, and are located more

closely to the axis of weight-bearing.[3] The main problem with these devices is varus collapse due to loss of reduction.

There are a few studies on the trochanteric antegrade IM nails that use two cephalocervical screws in an integrated mechanism, allowing for linear intraoperative compression and rotational stability of the head/neck fragment.[4,5] The aim of this study was to present the results of the treatment of stable and unstable ITF fractures using a trochanteric

Cite this article as: Kaynak G, Ünlü MC, Güven MF, Erdal OA, Tok O, Botanlıoğlu H, et al. Intramedullary nail with integrated cephalocervical screws in the intertrochanteric fractures treatment: Position of screws in fracture stability. Ulus Travma Acil Cerrahi Derg 2018;24:268-273.

Address for correspondence: Mehmet Can Ünlü, M.D. İstanbul Üniversitesi Cerrahpaşa Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, İstanbul, Turkey Tel: +90 212 - 414 30 00 E-mail: unludilek@hotmail.com Ulus Travma Acil Cerrahi Derg 2018;24(3):268-273 DOI: 10.5505/tjtes.2017.96933 Submitted: 08.08.2017 Accepted: 22.09.2017 Online: 09.11.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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antegrade IM nail with two cephalocervical screws in an integrated mechanism (Intertan®; Smith & Nephew, Memphis, TN) and evaluate the relationship between the loss of reduction and placement of the screws in the femoral neck in both the coronal and sagittal planes.

MATERIALS AND METHODS Our Institutional Review Board approved the chart review for this study, and informed consent was obtained from all patients. From February 2010 to June 2011, a total of 71 patients with ITF fractures underwent operations at our institution. We retrospectively reviewed the medical records of all patients. Patients with ITF fractures who underwent closed reduction and internal fixation with IM nails and integrated cephalocervical screws (Intertan® nail; Smith & Nephew, Memphis, TN) were included in the study. Exclusion criteria were the pathological fractures, inadequate radiographs, incomplete data, and loss to follow-up.

In total, 57 patients (22 males and 35 females) matched these criteria. The mean age of the patients at the time of surgery was 77.1 years (range, 58–98 years,) and the mean follow-up time was 21.7 months (range, 13–30 months). All fractures were classified according to the AO/OTA classification system[6] using preoperative radiographs; 18 of the patients were had stable fractures, whereas the remaining 39 had unstable fractures.

Surgical procedures were performed by an orthopedic surgeon of either registrar grade (unsupervised) or consultant grade (all are authors of this manuscript).

All patients gave written informed consent before any studyrelated procedure was conducted. The study was carried out in accordance with the latest version of the Declaration of Helsinki, and the study protocol was approved by the local ethics committee.

Surgical Technique General or regional anesthesia was used for all patients. All patients were placed on a radiolucent fracture table in the supine position and 1 g of cefazolin sodium was administered for surgical prophylaxis. After the satisfactory completion of closed reduction was verified by fluoroscopy (Fig. 1), standard skin preparation and sterilization was performed. A 5to 7-cm longitudinal incision was used proximal to the tip of the greater trochanter. A threaded-tip guide wire was placed on the tip of the trochanter under fluoroscopic control and driven into the bone for up to 5 cm. The entry point was then drilled with a cannulated 16-mm double drill. Once the appropriate size and neck angle of the implant was determined, the nail was inserted into the shaft so that the entry point of the lag screw would be placed into the head/neck of the femur in the fluoroscopic anteroposterior view. The insertional sleeves were placed into the screw guide, and a guide wire was drilled Ulus Travma Acil Cerrahi Derg, May 2018, Vol. 24, No. 3

into the proximal fragment for the proximal lag screw. The guide wire was advanced to the subchondral portion of the femoral head. The lag screw guide wire was measured, and a one-size-shorter screw was selected. The lag screw was then advanced, bringing its tip as close to the subchondral bone as possible. During the insertion of the lag screw, an antirotation blade was used to prevent the rotation of the proximal fragment. After the insertion of the lag screw, a compression screw was applied to achieve compression at the fracture site.

When the interlocking screws were in appropriate places, the preassembled set screw was firmly tightened to prevent pullout. A distal locking screw was then statically inserted into the nail through the screw guide via a stab wound incision of 1–2 cm in length, and the wounds were then closed.

Postoperative Rehabilitation Full weight-bearing was allowed on the first postoperative day as tolerated by the patient. Vigorous mobilization, rangeof-motion exercises, and respiratory physiotherapy were initiated immediately.

Postoperative Follow-up Full weight-bearing without pain and callus formation on both anteroposterior and lateral radiographs of the affected hip were the criteria for fracture union.

Patients were evaluated clinically using the Harris hip score[7] and Barthel independence index[8] at the final follow-up.

The Harris hip score rates the patient’s complaints and functional status based on a severity-symptom scale and functional status. This scale contains four question categories (pain, function, functional activities, and physical exam results). The total score ranges from 0 to 100 points; a score of 100 is considered the best. A score of 90–100 is considered excellent, 80–89 is considered good, 70–79 is considered fair, and <70 is considered poor.

The Barthel independence index comprises 10 items that measure a person’s daily functioning, specifically the activities of daily living and mobility. The total score ranges from 0 to

(a)

(b)

Figure 1. Anteroposterior (a) and lateral (b) fluoroscopic views showing closed reduction of the right hip of a 77-year-old female.

The criteria for satisfactory closed reduction were continuity of tensile and compressive force lines, continuity of the cortex in the coronal and sagittal planes, and adequate anteversion in the sagittal plane.

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100 points; a score of 100 is considered best. The higher the score, the more “independent” the person. Independence means that the person needs no assistance with any part of the task. If a person performs approximately 50% of the task independently, then the middle score would apply.

Plain anteroposterior and lateral radiographs of the affected hip taken on the day of surgery and at the last follow-up were used for radiographic measurements. All radiographic measurements were performed uniformly by the same orthopedic surgeon (author of this manuscript).

Measuring the Screw Alignment in the Coronal Plane The outer sides of the superior and inferior cortices of the femoral neck at its narrowest points were marked on the anteroposterior view. The distances from each point perpendicular to the midline of the compression and lag screw combination were measured. The lateral measurement was the “x” value, medial measurement was the “y” value, and the “x + y” value was calculated. We reproduced the screw alignment index in the coronal plane (SAIcoronal) by calculating y / (x + y) × 100 (Fig. 2a). In this way, we could determine the location of the screw placement in the coronal plane. A ratio of 0 to 33 was accepted as inferior placement, 34 to 66 as central placement, and 67 to 100 as superior placement of the screws.

Measuring the Screw Alignment in the Sagittal Plane We drew a line tangential to the proximal tip of the nail and

(a)

Measuring the Varus Angle The varus angle (VA) was measured on anteroposterior radiographs. A transverse line was drawn across the proximal femoral shaft, passing through the most distal part of the lesser trochanter and lateral projection of the tip of the cephalocervical screws. A line connecting the center of the femoral head and lateral projection of the tip of the cephalocervical screws was drawn. The angle between these two lines was defined as VA (Fig. 3).

Measuring the Tip Apex Distance (TAD) Tip apex distance (TAD)11 is the combined distance, measured in millimeters, from the tip of the cannulated screw to the apex of the femoral head on both anteroposterior and lateral radiographs. The magnification is standardized by measuring the diameter of the cannulated screw.

SAIcoronal and SAIsagittal measurements at the last followup were compared with those on the day of surgery to assess

(b)

Figure 2. Screw alignment index (a) (measurement of screw location) was defined as the absolute distance of the screws from the medial cortex (y) or posterior cortex (b) at the narrowest point of the femoral neck as measured on an anteroposterior or lateral radiograph, respectively, divided by the width of the femoral neck [(x + y) or (a + b)] at the narrowest point of the femoral neck as measured on an anteroposterior or lateral radiograph, respectively.

This number was then multiplied by 100 to yield a percentage. This percentage allowed for a magnification correction on radiographs taken at different times and with different magnifications.

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perpendicular to the line drawn in the middle of the axis of the lag screw. We then measured the distances from the intersection point to each cortex. The anterior measurement was “a,” the posterior measurement was “b,” and the “a + b” value was calculated. We reproduced the screw alignment index in the sagittal plane (SAIsagittal) by calculating b / (a + b) × 100 (Fig. 2b). In this way, we could determine the position of the screws in the sagittal plane. A ratio of 0 to 33 was accepted as posterior placement, 34 to 66 as central placement, and 67 to 100 as anterior placement of the screws.

Figure 3. The varus angle was measured on anteroposterior radiographs. A transverse line was drawn across the proximal femoral shaft, passing through the most distal part of the lesser trochanter and the lateral projection of the tip of the cephalocervical screws (a). A line connecting the center of the femoral head and lateral projection of the tip of the cephalocervical screws was drawn (b).

These lines were extended until they intersected, and the angle of intersection was measured. VA: Varus angle.

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any loss in reduction. VA at the last follow-up was compared with that on the day of surgery to assess any varus collapse.

The TAD measurement on the day of surgery was used to assess the adequacy of implant position; a TAD of >25 mm was used as a predictor of cut-out 11.

Revision surgeries, additional procedures, and complications (including wound infection, deep infection, hematoma, and fractures around the implant) were documented.

Statistical Analyses

Table 1. Positions of the screws in the coronal and sagittal planes

Day of surgery

Last follow-up

SAIcoronal

Inferior

5 (9%)

6 (10%)

Central

52 (91%)

49 (86%)

Superior

None

2 (4%)

SAIsagittal

Posterior

4 (7%)

6 (10%)

Central

48 (84%)

47 (83%)

Anterior

5 (9%)

4 (7%)

Statistical methods designed for independent observations were used. The mean value and standard deviation were calculated. Continuous variables were compared using the Student’s t-test, and categorical variables were compared using the chi-square test. The level of significance was defined as p < 0.05. Pearson’s correlation analyses were applied for the relationships. All analyses were performed using the SPSS statistical software package (ver. 17.0 for Windows; SPSS, Chicago, IL, USA).

nificant finding was a negative correlation between age and the Harris hip score (p=0.044) or Barthel index (p=0.002) at the final follow-up.

RESULTS

DISCUSSION

Closed reduction was achieved in all patients. All patients achieved union with no complications. The mean union time was 12.2 weeks (range, 10.0–16.0 weeks). The mean time interval between trauma and surgery was 8.7 days (range, 0–32 days). The mean surgery time was 25 min (range, 14–40 min). The average hospital stay was 17.9 days (range, 7–63 days), depending on the length of the postoperative physiotherapy period, social circumstances, and length of intensive care unit stay.

In this retrospective study, we analyzed the clinical and radiological outcomes of ITF fractures treated with trochanteric antegrade nails with two cephalocervical screws in an integrated mechanism in 57 patients. ITF fractures in the elderly population are associated with considerable morbidity and mortality because of accompanying comorbidities.[9,10]

There were three superficial wound infections, all of which resolved with oral antibiotics by the time the sutures were removed. No patient required revision surgery or other procedures at the final follow-up.

In the majority of the patients, the screws were located in the central position in both the coronal and sagittal planes (Table 1). The differences in SAIcoronal, SAIsagittal, and VCI on the day of surgery and at the final follow-up were not significant. There was no varus collapse in any patient. The mean TAD was 22.3 mm (range, 8.0–39.2 mm).

The mean Barthel index was 90.7 (range, 20–100), and in 43 patients (75%), the indices were >90 at the last follow-up.

The mean Harris hip score was 83.7 (range, 44–98). The results of 16 patients (28%) were poor or fair, whereas 41 patients (72%) were defined as either good or excellent according to the Harris hip score. The Barthel index and Harris hip scores were evaluated in terms of the presence of any statistically significant correlation between these scores and age, gender, fracture type, preoperative hospital stay, and total length of hospitalization. The only statistically sigUlus Travma Acil Cerrahi Derg, May 2018, Vol. 24, No. 3

Values are numbers of patients with percentages in parentheses. SAI: Screw alignment index.

Since the first report on the use of a sliding hip screw (SHS), this device has become a standard treatment modality for ITF fractures.[6,11] However, comminuted and unstable ITF fractures treated with SHS may result in significant malunion and femoral neck shortening.[3] Although free of complications, early weight-bearing is unlikely with SHS.[3] IM nail-screw devices offer distinct biomechanical advantages over other types of fixation devices. IM nails are load-sharing devices, offer three-point fixation, and are located closer to the weightbearing axis.[3] This is especially important in unstable fractures that present with medial column compromise.[12] The most serious and often devastating complication of the first-generation IM fixation devices that have a single centrally placed lag screw to secure the femoral head and neck[13] is the varus collapse of the femoral neck; this is also called “cut-out” and is caused by the perforation of a lag screw through the cortex.[14] This is thought to be caused either by improper lag screw placement in the anterior–superior quadrant of the head or by not placing the screw close enough to the subchondral region of the head. However, in reality, when the patient starts walking, the lag screw becomes a pivot point and the femoral head starts rotating at this point, which results in loosening of the bone–screw interface.[4,14] To avoid this complication, second-generation systems using 271

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two separate screws were developed. Unfortunately, these devices are associated with the complications such as the migration of screws in opposite directions (Z-effect and reverse Z-effect), which is caused by the disproportionate load during weight-bearing.[15] Many previous studies advocated the central placement of the screws to prevent cut-out and promote more stable fracture fixation,[16,17] although Kaufer[18] advised the placement of the screws in the posteroinferior quadrant of the femoral head.

However, the application of the lag screw into a specific quadrant of the femoral head can sometimes be difficult and result in prolonged operation duration, especially in overweight patients or when the intraoperative fluoroscopic views are not clear enough.

The limitations and complications of both first- and secondgeneration systems have led to the development of a thirdgeneration system consisting of an IM nail with integrated cephalocervical screws.

The Intertan® device (Smith & Nephew, Memphis, TN) with integrated cephalocervical screws is a reliable device that permits compression at the fracture site.

The compression screw prevents rotation by interlocking into the lag screw. The Z-effect can be prevented by the proximal preassembled set screw that locks the interlocking screws. Ruecker et al.[4] and Qin also reported that the Intertan® device appears to be a reliable implant for the treatment of ITF femoral fractures and to have low complication rates with a shorter recovery period from the pre-injury level.[5] Femoral neck shortening because of uncontrolled ITF fracture collapse is another complication of both IM nails and SHS constructs, causing limb length discrepancy and maladaptation of the abductor lever arm.[19] Although some compression is needed for fracture healing, uncontrolled fracture collapse can cause migration of the screw, which results in pain and shortening. Satisfactory functional outcomes with near-normal gait restoration can be achieved in cases of ITF hip fractures with an emphasis on calcar reduction and compression.[20] We believe that devices allowing controlled compression at the fracture site help surgeons to reconstruct the medial column and prevent further collapse. Our findings indicate that the central or inferior placement of the lag screws in the coronal plane and in any of the three quadrants in the sagittal plane is sufficient for stable fracture fixation as long as good reduction and compression of the fracture site is achieved with a secure implant.

Although Norris reported that proximal femoral IM nails have been associated with a risk of late fracture around the implant,[21] we experienced no implant-related femoral fractures in our series. Matre 22 reported five postoperative 272

peri-implant femoral fractures in patients treated with the Intertan® device for ITF fractures within the first 3 months.

Such complications may occur with increased follow-up durations.

There were a few limitations to this study. First, our findings were limited to the specific implant used in this study.

Although its design is not dissimilar to many other currently available anatomic implants, our findings may not be generalizable to all other IM nails with integrated cephalocervical screws. Second, this study was performed without randomization. Third, we did not obtain repeatability or intraobserver variability data for the radiological measurements.

In the surgical treatment of ITF fractures, the application of the lag screw into a specific quadrant of the femoral head can sometimes be difficult and result in prolonged operation durations and additional intraoperative fluoroscopic imaging, causing more radiation exposure. Multiple drillings of the osteoporotic bone to locate the lag screw placement site may lower the quality of the bone stock for adequate fixation stability.

Conclusion Trochanteric antegrade nails that involve the use of two cephalocervical screws in an integrated mechanism allow for linear intraoperative compression and rotational stability of the head/neck fragment, prevent reduction loss, have a wide range of application areas in the femoral head, and are a good option for the treatment of ITF fractures in the elderly population.

Conflict of interest: None declared.

REFERENCES 1. Chan KC, Gill GS. Cemented hemiarthroplasties for elderly patients with intertrochanteric fractures. Clin Orthop Relat Res 2000;(371):206–15.

2. Zhou F, Zhang ZS, Yang H, Tian Y, Ji HQ, Guo Y, et al. Less invasive stabilization system (LISS) versus proximal femoral nail anti-rotation (PFNA) in treating proximal femoral fractures: a prospective randomized study. J Orthop Trauma 2012;26:155–62.

3. Bienkowski P, Reindl R, Berry GK, Iakoub E, Harvey EJ. A new intramedullary nail device for the treatment of intertrochanteric hip fractures: Perioperative experience. J Trauma 2006;61:1458–62.

4. Ruecker AH, Rupprecht M, Gruber M, Gebauer M, Barvencik F, Briem D, et al. The treatment of intertrochanteric fractures: results using an intramedullary nail with integrated cephalocervical screws and linear compression. J Orthop Trauma 2009;23:22–30.

5. Qin H, An Z. Therapeutic evaluation of femoral intertrochanteric fractures by InterTan. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2010;24:1424–7.

6. Müller ME, Nazarian S. Classification of fractures of the femur and its use in the A.O. index. Rev Chir Orthop Reparatrice Appar Mot 1981;67:297–309.

7. Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a

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Kaynak et al. Treatment of intertrochanteric fractures with Intertan new method of result evaluation. J Bone Joint Surg Am 1969;51:737–55.

8. Wade DT, Collin C. The Barthel ADL Index: a standard measure of physical disability? Int Disabil Stud 1988;10:64–7.

9. Kesmezacar H, Ayhan E, Unlu MC, Seker A, Karaca S. Predictors of mortality in elderly patients with an intertrochanteric or a femoral neck fracture. J Trauma 2010;68:153–8.

10. Richmond J, Aharonoff GB, Zuckerman JD, Koval KJ. Mortality risk after hip fracture. J Orthop Trauma 2003;17:53–6.

11. Rupprecht M, Grossterlinden L, Ruecker AH, de Oliveira AN, Sellenschloh K, Nüchtern J, et al. A comparative biomechanical analysis of fixation devices for unstable femoral neck fractures: the Intertan versus cannulated screws or a dynamic hip screw. J Trauma 2011;71:625–34.

12. Mahomed N, Harrington I, Kellam J, Maistrelli G, Hearn T, Vroemen J. Biomechanical analysis of the Gamma nail and sliding hip screw. Clin Orthop Relat Res 1994:280–8.

13. Williams WW, Parker BC. Complications associated with the use of the gamma nail. Injury 1992;23:291–2.

14. Kawatani Y, Nishida K, Anraku Y, Kunitake K, Tsutsumi Y. Clinical results of trochanteric fractures treated with the TARGON® proximal femur intramedullary nailing fixation system. Injury 2011;42 Suppl 4:S22–7.

15. Pervez H, Parker MJ, Vowler S. Prediction of fixation failure after sliding hip screw fixation. Injury 2004;35:994–8.

16. Baumgaertner MR, Curtin SL, Lindskog DM, Keggi JM. The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fractures of the hip. J Bone Joint Surg Am 1995;77:1058–64.

17. Pires RE, Santana EO Jr, Santos LE, Giordano V, Balbachevsky D, Dos Reis FB. Failure of fixation of trochanteric femur fractures: Clinical recommendations for avoiding Z-effect and reverse Z-effect type complications. Patient Saf Surg 2011;5:17.

18. Kaufer H. Mechanics of the treatment of hip injuries. Clin Orthop Relat Res 1980:53–61.

19. Paul O, Barker JU, Lane JM, Helfet DL, Lorich DG. Functional and radiographic outcomes of intertrochanteric hip fractures treated with calcar reduction, compression, and trochanteric entry nailing. J Orthop Trauma 2012;26:148–54.

20. Han N, Sun GX, Li ZC, Li GF, Lu QY, Han QH, et al. Comparison of proximal femoral nail antirotation blade and reverse less invasive stabilization system-distal femur systems in the treatment of proximal femoral fractures. Orthop Surg 2011;3:7–13.

21. Norris R, Bhattacharjee D, Parker MJ. Occurrence of secondary fracture around intramedullary nails used for trochanteric hip fractures: a systematic review of 13,568 patients. Injury 2012;43:706–11.

22. Balm R, Hoornweg LL. Traumatic aortic ruptures. J Cardiovasc Surg (Torino) 2005;46:101–5.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

İntertrokanterik femur kırıklarının tedavisinde entegre sefaloservikal vidalı intramedüller çivi: Kırık stabilitesine vida pozisyonunun etkisi Dr. Gökhan Kaynak, Dr. Mehmet Can Ünlü, Dr. Mehmet Fatih Güven, Dr. Ozan Ali Erdal, Dr. Okan Tok, Dr. Hüseyin Botanlıoğlu, Dr. Önder Aydıngöz İstanbul Üniversitesi Cerrahpaşa Tıp Fakültesi, Ortopedi ve Tavmatoloji Anabilim Dalı, İstanbul

AMAÇ: Yaşlı popülasyondaki intertrokanterik femur (İTF) kırıklarının tedavisinde, redüksiyon kaybını önlemek, erken mobilite sağlamak ve bağımsız yaşamın restorasyonu için stabil kırık fiksasyonu çok önemlidir. Bu çalışmanın amacı, entegre iki sefaloservikal vida mekanizması içeren trokanterik antegrad intramedüller çivi (Intertan®; Smith & Nephew, Memphis, TN) kullanılarak cerrahi tedavi edilen stabil ve instabil İTF kırıklarının sonuçlarını ortaya koymak ve redüksiyon kaybı ile femur boynuna giden iki vidanın pozisyonu arasındaki ilişkiyi değerlendirmektir.

GEREÇ VE YÖNTEM: Çalışmada 2010 ve 2011 yılları arasında İTF kırığı olan ve Intertan® ile cerrahi tedavi edilen 57 hasta (22 erkek, 35 kadın) tüm plan deformiteleri ve redüksiyon kaybı açısından incelendi. Redüksiyon kaybını tarif etmek amacıyla iki indeks (frontal planda vida hiza indeksi [VHİkoronal] ve lateral planda vida hiza indeksi [VHİlateral]) belirlendi. Hastalar ayrıca Harris kalça skoru ve Barthel indeksine göre de değerlendirildi.

BULGULAR: Ortalama hasta yaşı 77.1, ortalama takip süresi 21.7 aydı. Tüm hastalarda tam kaynama elde edildi. Hiçbir hastada varus kollapsı ya da redüksiyon kaybı gözlenmedi. Takip süresi sonunda, ortalama Barthel indeksi 90.7 olarak bulunurken, ortalama Harris kalça skoru 83.7 olarak belirlendi.

TARTIŞMA: Femur baş/boyun fragmanının rotasyonel stabilitesini sağlamaya ve lineer intraoperatif kompresyona olanak tanıyan, entegre iki sefaloservikal vida mekanizması içeren trokanterik antegrad intramedüller çivi, redüksiyon kaybını önler ve femur başında geniş uygulama sahası mevcuttur. Mekanizmanın doğası, stabilitenin devamlılığını sağlayarak erken yük verdirilmesine ve erken mobilizasyona olanak tanır. İntertrokanterik femur kırıklarının tedavisinde güvenli ve etkili bir tedavi seçeneğidir.

Anahtar sözcükler: Entegre sefaloservikal vida; intertrokanterik kırık; kalça kırığı; sonuç; vida pozisyonu.

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doi: 10.5505/tjtes.2017.96933

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ORIG I N A L A R T IC L E

The comparison of arthroscopic acromioplasty with and without acromioclavicular coplaning Nuri Aydın, M.D.,1 Barış Kocaoğlu, M.D.,2 Ender Sarıoğlu, M.D.,2 Okan Tok, M.D.,3 Osman Güven, M.D.2 1

Department of Orthopaedic and Traumatology, İstanbul University Cerrahpaşa Faculty of Medicine, İstanbul-Turkey

2

Department of Orthopaedic and Traumatology, Acıbadem Kadiköy Hospital, İstanbul-Turkey

3

Department of Orthopaedic and Traumatology, Lütfiye Nuri Burat State Hospital, İstanbul-Turkey

ABSTRACT BACKGROUND: Coplaning means the removal of medial acromial spurs and inferior aspect of the distal clavicle. The aim of the study was to evaluate the outcomes of arthroscopic acromioplasty with and without coplaning in patients without acromioclavicular (AC) joint arthritis.

METHODS: Because of impingement syndrome, arthroscopic subacromial decompression and acromioplasty was performed in Group 1 (9 males/31 female). In addition, coplaning was performed in Group 2 (8 males/21 females) by two different surgeons. The mean age was 48 in Group 1, 46 in Group 2. The mean follow-up was 50 months and 44 months, respectively.

RESULTS: Constant score, cross-body adduction test and AC joint tenderness was used for follow-up. The mean preoperative Constant scores were 45 points (range: 34–76 points) in Group 1, 39 points (range: 32–69 points) in Group 2. The mean Constant scores at the latest follow-up was 78 points (range: 68–100 points) for Group 1, 84 points (range: 72–100 points) for Group 2. There was no statistically difference between two groups at the latest follow-up (p<0.05). In two patients in Group 2, cross-body adduction test was positive but asymptomatic.

CONCLUSION: Excision of the inferior side of the lateral clavicle to the level of the acromion with minimal disruption of the joint capsule does not develop AC joint symptoms in long-term follow-up.

Keywords: Acromioclavicular joint; acromioplasty; arthroscopy; coplaning; impingement; shoulder.

INTRODUCTION The subacromial impingement syndrome of the shoulder is treated with acromioplasty and subacromial decompression.

[1] The frequency of this procedure has increased dramatically in the last decade.[2,3] Subacromial decompression, described

by Neer, includes acromioplasty, division of the coracoacromial ligament, and excision of the inferior spurs of the distal clavicle. Outlet impingement typically begins at the anteroinferior aspect of the acromion and progress medially to involve the acromioclavicular (AC) joint.[4,5] After acromioplasty, an abrupt step-off may be formed between acromion and distal end of the clavicle, which may behave like a spur. Distal clavicle coplaning was advocated in the original descriptions of arthro-

scopic subacromial decompression.[6–9] Coplaning means the removal of the inferior side of the distal clavicle. Previous studies have reported that the disruption of the AC joint increased joint mobility, suggesting that this would lead to AC joint pain.[10,11] Spurs located at the inferior aspect of the joint were shown to be associated with rotator cuff pathologies.[12] This asymptomatic, coincidental situation is treated by most shoulder surgeons by coplaning at the end of the arthroscopic acromioplasty procedure. There is no enough data in the published literature regarding the results of coplaning procedure with minimal disruption of the joint capsule.

The aim of this study was to compare two groups of patients who were operated with an arthroscopic acromio-

Cite this article as: Aydın N, Kocaoğlu B, Sarıoğlu E, Tok O, Güven O. The comparison of arthroscopic acromioplasty with and without acromioclavicular coplaning. Ulus Travma Acil Cerrahi Derg 2018;24:274-277.

Address for correspondence: Nuri Aydın, M.D. İstanbul Üniversitesi Cerrahpaşa Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, Fatih, İstanbul, Turkey Tel: +90 212 - 414 30 00 E-mail: nuri.aydin@istanbul.edu.tr Ulus Travma Acil Cerrahi Derg 2018;24(3):274-277 DOI: 10.5505/tjtes.2017.61178 Submitted: 24.07.2017 Accepted: 19.09.2017 Online: 08.05.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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plasty with and without coplaning in patients without AC arthritis.

(a)

(b)

MATERIALS AND METHODS A retrospective review of the surgical database was performed to detect all patients operated with impingement syndrome.

The surgical data was collected from the patient files. The patients who had shoulder impingement with chronic symptoms were included in the study. There were 69 patients, including 17 men and 52 women with a mean age of 48 years (range: 29–66 years). All patients underwent plain radiography and MR imaging of the shoulder. The inclusion criteria were a positive Neer’s test, type-II or type-III acromion shape; pain in the shoulder which was non-responsive to immobilization, anti-inflammatory drugs, subacromial steroid injections, and physiotherapy; and symptoms persisting for >3 months. All patients had thus been treated with physical therapy at their primary hospital or at our institution. This included exercise programs, massage, heat, and transcutaneous nervous stimulation. The patients with history of glenohumeral surgery, acromioplasty with rotator cuff repairs, AC joint arthritis, labral tears, rotator cuff with fatty infiltration, intraarticular biceps tendon pathologies, and arthritis were excluded. The surgeries were performed by two surgeons. Patient groups were assigned by the surgeon. Surgeon A was routinely not performing coplaning in acromioplasty cases (Group 1). Surgeon B was performing coplaning in acromioplasty cases. The review of the surgical data resulted with the classification of the patients into two groups. Group 1 included the patients with acromioplasty alone and Group 2 included the patients with acromioplasty and coplaning.

During the surgery, surgical field was palpated and the bony structures were marked with a sterile pen. Surgery was performed under general anesthesia. All operations were performed with the patient in the beach chair position. The scope was placed through the posterior portal and a systematic evaluation of intraarticular structures was performed. The same standard portal was used to access the subacromial space.

Debridement and decompression were performed through an anterolateral portal by radiofrequency probe (Starvac 90, ArhroWand, Arthrocare, Texas, USA). Acromioplasty was performed using an oval burr; the resection of the lateral acromion starting anteriorly was performed first, followed by the resection of the medial acromion extending up to the AC joint. Range of motion of the shoulder was evaluated under arthroscopic visualization to check for any local impingement.

Bone resection was performed to remodel type-II or type-III acromion to a type-I acromion. In the Group 1, no coplaning was performed (Fig. 1). In the Group 2, the inferior side of the lateral clavicle was excised to the same level of the acromion with minimal disruption of the joint capsule (Fig. 2).

A sling was used for a week, and mobilization was permitted with free active movements, starting with gravity-assisted rotation movements as pendulum exercises. Following this, paUlus Travma Acil Cerrahi Derg, May 2018, Vol. 24, No. 3

Figure 1. (a) The scope is at the posterior portal: Before the acromioplasty of type-III acromion. (A) Acromion. (b) After performing acromioplasty. (A) Acromion after resection, (B) Distal end of the clavicle without coplaning, (C) Acromioclavicular joint. (a)

(b)

Figure 2. (a) After performing acromioplasty. (A) Acromion after resection, (B) Distal end of the clavicle before coplaning, (C) Acromioclavicular joint. (b) After the acromioplasty and coplaning.

(A) Acromion after resection, (B) Distal end of the clavicle after coplaning, (C) Acromioclavicular joint.

tients received personalized, progressive exercise programs.

The patients were followed-up with Constant scores. At the final examination, AC joint tenderness and cross-body adduction test was performed to test for any AC joint issues.

The t-test was used to compare the differences between preoperative and postoperative Constant scores in both groups.

All statistical analyses were performed by an independent statistician using SPSS 11.0 software (SPSS Inc.). The significance level was set at p=0.05.

Ethical clearance for this study was provided by Acıbadem University Medical Research and Evaluation Board.

RESULTS Group 1 included of 40 patients (9 men and 31 women).

The mean age was 48 years (range: 28–60 years). The mean follow-up duration was 50 months (range: 26–70 months).

Group 2 had 29 patients (8 men and 21 women). The mean age was 46 years (range: 29–63 years). The mean follow-up was 44 months (range: 24–66 months).

The mean preoperative Constant scores were 45 points (range: 34–76 points) in Group 1 and 39 points (range: 32–69 points) in Group 2. The mean Constant scores at the latest follow-up was 78 points (range: 68–100 points) for Group 1 and 84 points (range: 72–100 points) for Group 2. There was no statistically significant difference in mean Constant scores between two groups at the latest follow-up (p>0.05).

No patients had AC joint symptoms in Group 1. Mild pain 275

Aydın et al. The comparison of arthroscopic acromioplasty with and without acromioclavicular coplaning

was detected in cross-body adduction test in two patients in Group 2. In these two patients, there was no joint pain or tenderness around. One patient in Group 2 had fracture of the distal end of the clavicle with intra-articular extension after a fall at home. Complete removal of the AC joint was performed arthroscopically in a second operation.

DISCUSSION Excision of the inferior side of the distal end of the lateral clavicle to the level of the acromion with minimal disruption of the joint capsule does not result in AC joint symptoms in long-term follow-up. After the removal of the anterior acromion, a visible step between the resected area and the lateral clavicle may occur. This step may behave like a spur.

Petersson et al.[12] showed that coplaning would decrease the pressure on supraspinatus tendon and muscle by this step created by the acromioplasty.

Klintberg et al.[13] have reported satisfactory results in patients treated with arthroscopic subacromial decompression in long-term follow-up. When the arthroscopic acromioplasty is performed, the AC joint could be disrupted to some extent unless the resection of the acromion stops short of the medial end of the acromion.[14] The common finding is that the coplaning may disrupt the AC joint capsule and the joint may become unstable.[6,8,15–18] Resection of a big portion of the joint capsule may likely result in increase of the movement.

Destabilization of the AC joint would make it possible for future arthritis of the joint with symptoms.[5,19] Human cadavers which various arthroscopic procedures performed were evaluated.[20] It was shown that the resection of 25% of the AC joint increased joint range of motion. Elevation and rotation of the lateral clavicle were the significant movements.

It is also well known that a total resection of the lateral clavicle may result in the destabilization of the whole clavicle.[19] Another study by Kim[4] showed that excision of the distal clavicle combined with rotator cuff repair for asymptomatic AC joint arthritis has lower functional scores because of temporary pain in the early postoperative period, but better functional outcomes with satisfactory pain relief and no reoperation rate were observed after 2 years.

A retrospective study on coplaning in connection with subacromial decompression did not report these issues.[21] In Weber’s study, the lateral joint capsule was observed to include 25% of the medial acromial side, with some osteophytes located on the medial acromion. This means that it is not possible to perform acromioplasty, as it is commonly thought, without joint capsule damage. The review of 1259 arthroscopic acromioplasties with a follow-up was 7 years, three patients were undergone total removal of the lateral clavicle. In this study, the medial aspect of the acromion was resected. In addition, the joint capsule was damaged. Any visibly prominent inferior portion of the lateral clavicle beyond the level of the medial acromion was removed. The impor276

tant surgical point is that the articular cartilage of the AC joint was not damaged. However, in the recent study, the cartilage was disrupted. But this was not shown with an increase in AC joint pain. Weber stated that if a significant portion of the joint is not damaged, it will not result in AC joint pain.

[14,19,21] The clinical evaluation of AC joint motion is a simple and trustworthy method to assess the clinical results.[22] Our findings are similar to Weber’s findings. In two patients, pain was seen in cross-body adduction test at long-term follow-up without any joint symptoms. A patient in the coplaning group had a distal clavicle fracture after a fall at home.

Coplaning might have led to weakening and mechanical failure of the bone. The most common two causes for persistent pain after acromioplasty are the failure of diagnosis and surgical technique. The common surgical issue associated with arthroscopic acromioplasty is inadequate bone excision.[14,23– 25] It is shown that 23% patients still have a hooked acromion after acromioplasty.[25] The study has some limitations. The first, only Constant score, which is not specific for AC joint, was evaluated during follow-up evaluations. The second is the varying preoperative management in the patients. All patients in the study received preoperative physiotherapy in their primary hospital or in our institution. Hence, the patient group was not standardized for preoperative physical therapy. Some patients were referred to clinics to other institutions. That is why we could not manage to have them in our physical rehabilitation department to have the same postoperative rehabilitation protocol.

Overall, without enough coplaning of the distal inferior portion of the lateral clavicle and spur of the acromion, the supraspinatus tendon becomes tight; the long-term consequences of this on rotator cuff anomalies might not manifest for years.[14]

Conclusion Although the coplaning of AC joint might influence AC joint motion, it is unclear if these effects are clinically relevant.

Excision of the inferior side of the distal end of the lateral clavicle to the level of the acromion with minimal disruption of the joint capsule does not lead to AC joint symptoms in long-term follow-up.

Conflict of interest: None declared.

REFERENCES 1. Neer CS 2nd. Anterior acromioplasty for the chronic impingement syndrome in the shoulder: a preliminary report. J Bone Joint Surg Am 1972;54:41–50.

2. Papadonikolakis A, McKenna M, Warme W, Martin BI, Matsen FA 3rd.

Published evidence relevant to the diagnosis of impingement syndrome of the shoulder. J Bone Joint Surg Am 2011;93:1827–32.

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Aydın et al. The comparison of arthroscopic acromioplasty with and without acromioclavicular coplaning 3. Mauro CS, Jordan SS, Irrgang JJ, Harner CD. Practice patterns for subacromial decompression and rotator cuff repair: an analysis of the American Board of Orthopaedic Surgery database. J Bone Joint Surg Am 2012;94:1492–9.

4. Kim J, Chung J, Ok H. Asymptomatic acromioclavicular joint arthritis in arthroscopic rotator cuff tendon repair: a prospective randomized comparison study. Arch Orthop Trauma Surg 2011;131:363–9.

5. Chen AL, Rokito AS, Zuckerman JD. The role of the acromioclavicular joint in impingement syndrome. Clin Sports Med 2003;22:343–57.

6. Altchek DW, Carson EW. Arthroscopic acromioplasty: indications and technique. Instr Course Lect 1998;47:21–8.

7. Caspari RB, Thal R. A technique for arthroscopic subacromial decompression. Arthroscopy 1992;8:23–30.

8. Ellman H. Arthroscopic subacromial decompression: analysis of one- to three-year results. Arthroscopy 1987;3:173–81.

9. Ellman H, Kay SP. Arthroscopic subacromial decompression for chronic impingement. Two- to five-year results. J Bone Joint Surg Br 1991;73:395–8.

10. Blazar PE, Iannotti JP, Williams GR. Anteroposterior instability of the distal clavicle after distal clavicle resection. Clin Orthop Relat Res 1998:114–20.

11. Edwards SG. Acromioclavicular stability: a biomechanical comparison of acromioplasty to acromioplasty with coplaning of the distal clavicle.

Arthroscopy 2003;19:1079–84.

12. Petersson CJ, Gentz CF. Ruptures of the supraspinatus tendon. The significance of distally pointing acromioclavicular osteophytes. Clin Orthop Relat Res 1983:143–8.

13. Klintberg IH, Svantesson U, Karlsson J. Long-term patient satisfaction and functional outcome 8-11 years after subacromial decompression.

Knee Surg Sports Traumatol Arthrosc 2010;18:394–403.

14. Barber FA. Long-term results of acromioclavicular joint coplaning.

Arthroscopy 2006;22:125–9.

15. Fischer BW, Gross RM, McCarthy JA, Arroyo JS. Incidence of acromioclavicular joint complications after arthroscopic subacromial decompression. Arthroscopy 1999;15:241–8.

16. Hazel RM, Tasto JP, Klassen J. Arthroscopic subacromial decompression (A 9-year follow-up). Arthroscopy 1998;14:419.

17. Kuster MS, Hales PF, Davis SJ. The effects of arthroscopic acromioplasty on the acromioclavicular joint. J Shoulder Elbow Surg 1998;7:140–3.

18. Esenyel CZ, Oztürk K, Bülbül M, Ayanoğlu S, Ceylan HH. Coracoclavicular ligament repair and screw fixation in acromioclavicular dislocations. Acta Orthop Traumatol Turc 2010;44:194–8.

19. Barber FA. Coplaning of the acromioclavicular joint. Arthroscopy 2001;17:913–7.

20. Roberts RM, Tasto JP, Hazel MH. Acromioclavicular joint stability after arthroscopic coplaning. In: 17th Annual Meeting of the Arthroscopy Association of North America: 1998 Apr 30–May 3; Orlando, Florida.

[Abstracts] 21. Weber SC:Coplaning the acromioclavicular joint at the time of acromioplasty (A long-term study). Arthroscopy 15:555, 1999.

22. Motta P, Bruno L, Maderni A, Tosco P, Mariotti U. Acromioclavicular motion after surgical reconstruction. Knee Surg Sports Traumatol Arthrosc 2012;20:1012–8.

23. Connor PM, Yamaguchi K, Pollock RG, Flatow EL, Bigliani LU. Comparison of arthroscopic and open revision decompression for failed anterior acromioplasty. Orthopedics 2000;23:549–54.

24. Hawkins RJ, Chris T, Bokor D, Kiefer G. Failed anterior acromioplasty.

A review of 51 cases. Clin Orthop Relat Res 1989:106–11.

25. Ogilvie-Harris DJ, Wiley AM, Sattarian J. Failed acromioplasty for. impingement syndrome. J Bone Joint Surg Br 1990;72:1070–2.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Akromiyoklaviküler eşplanlama yapılan ve yapılmayan artroskopik akromiyoplastilerin karşılaştırılması Dr. Nuri Aydın,1 Dr. Barış Kocaoğlu,2 Dr. Ender Sarıoğlu,2 Dr. Okan Tok,3 Dr. Osman Güven2 1 2 3

İstanbul Üniversitesi Cerrahpaşa Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, İstanbul Acıbadem Kadıköy Hastanesi, Ortopedi ve Travmatoloji Kliniği, İstanbul Lütfiye Nuri Burat Devlet Hastanesi, Ortopedi ve Travmatoloji Kliniği, İstanbul

AMAÇ: Eşplanlama medial akromiyal spurların ve distal klavikulanın alt kısmının çıkarılması demektir. Bu çalışmanın amacı, akromiyoklaviküler artrit olmayan hastalarda, eşplanlama uygulanan ve uygulanmayan artroskopik akromiyoplasti tedavisi yapılan hastaların değerlendirilmesidir.

GEREÇ VE YÖNTEM: Sıkışma sendromu nedeniyle, Grup 1’deki hastalara (9 erkek/31 kadın) artroskopik subakromiyal dekompresyon ve akromiyoplasti uygulandı. Aynı endikasyon ile Grup 2’deki hastalara (8 erkek/21 kadın) Grup 1’deki tedaviye ilave olarak eşplanlama uygulandı. Ortalama yaş, Grup 1’de 48, Grup 2’de 46 idi. Ortalama takip süresi sırasıyla 50 ay ve 44 ay idi.

BULGULAR: Takipte Constant skoru, çapraz addüksiyon testi ve akromiyoklaviküler hassasiyet kullanıldı. Ortalama ameliyat öncesi Constant skoru Grup 1’de 45 (aralık: 34–76), Grup 2’de 39 (aralık: 32–69) olarak bulundu. En son takipte ortalama Constant skorları Grup 1 için 78 (aralık: 68–100 puan), Grup 2 için 84 (aralık: 72–100 puan) olarak bulundu. En son takipte iki grup arasında istatistiksel olarak anlamlı fark yoktu (p<0.05). Grup 2’deki iki hastada, çapraz addüksiyon testi pozitif fakat semptomsuzdu.

TARTIŞMA: Klavikula lateralinin alt tarafının eklem kapsül bütünlüğünde minimal bozulma oluşturarak akromiyon ile aynı seviyeye gelecek şekilde eksizyonu uzun dönemde akromiyoklaviküler eklem semptomları oluşturmamaktadır.

Anahtar sözcükler: Akromiyoklaviküler eklem; akromioplasti; artroskopi; eşplanlama; omuz; sıkışma.

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CA S E REP OR T

Rare case of bilateral incarcerated obturator hernia: a case report Engin Hatipoğlu, M.D.,1 Fatih Dal, M.D.,1 Veysel Umman, M.D.,1 Süleyman Demiryas, M.D.,1 Oktay Demirkıran, M.D.,2 Metin Ertem, M.D.,1 Sabri Ergüney, M.D.,1 Salih Pekmezci, M.D.1 1

Department of General Surgery Istanbul University Cerrahpaşa Faculty of Medicine, İstanbul-Turkey

2

Department of Anesthesiology and Reanimation, İstanbul University Cerrahpaşa Faculty of Medicine, İstanbul-Turkey

ABSTRACT Here, we report the case of an 84-year-old woman with acute mechanical intestinal obstruction (AMIO) who was admitted to our Emergency Department. Computed tomography (CT) scan revealed an incarcerated bilateral obturator hernia, and the defect was resolved using transabdominal preperitoneal (TAPP) technique with polypropylene mesh. The patient was administered an oral regimen two days after the operation. The patient stayed in the intensive care unit for 4 days and was uneventfully discharged on the 9th postoperative day. Follow-up was scheduled at the 6th month, during which no adverse events were detected and the patient did not report any complaints. Obturator hernia is among the differential diagnoses of intestinal obstruction requiring early diagnosis and prompt surgical intervention. Laparoscopic approach is less invasive compared with open surgery, and it can be attempted in cases presenting with no sign of ischemia or peritonitis. TAPP technique should be preferred since it allows the control of all intraabdominal pathologies and the viability of the intestines.

Keywords: Hernia; laparoscopy; obsutruction; obturator.

INTRODUCTION

CASE REPORT

Obturator hernia is rare among abdominal wall hernias, with an incidence of 0.05% to 1.4%.[1] Old age, high intraabdominal pressure, pelvic floor dysfunction, and multiparity have been found to be predisposing factors.[2] Because this is a rare but serious condition with a high mortality rate, understanding its characteristics is important to suspect and easily diagnose OH.

An 84-year-old female patient presented to our Emergency Department with nausea, vomiting, and pain in the abdomen and right hip. She presented with a history of chronic renal failure and arterial hypertension. Physical examination revealed abdominal distension and diffuse abdominal tenderness.

Here, we report the case of an 84-year-old woman with acute mechanical intestinal obstruction (AMIO) who was admitted to our Emergency Department. CT scan revealed an incarcerated bilateral obturator hernia, and she underwent laparoscopic repair via transabdominal preperitoneal (TAPP) approach.

Blood tests revealed leukocytosis (23.000/mm3) and high CRP (42.6 mg/dl), BUN (198 mg/dl), and creatinine (8.92 mg/dl) levels. Other values were normal.

Abdominal X-ray revealed dilated small bowel loops with gasfluid levels. Oral and rectal contrast-enhanced abdominal CT revealed a distal ileal loop herniated bilaterally to the obtu-

Cite this article as: Hatipoğlu E, Dal F, Umman V, Demiryas S, Demirkıran O, Ertem M, et al. Rare case of bilateral incarcerated obturator hernia: a case report. Ulus Travma Acil Cerrahi Derg 2018;24:278-280.

Address for correspondence: Engin Hatipoğlu, M.D. İstanbul Üniversitesi Cerrahpaşa Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, İstanbul, Turkey Tel: +90 212 - 414 24 24 E-mail: enginhatipoglu@yahoo.com Ulus Travma Acil Cerrahi Derg 2018;24(3):278-280 DOI: 10.5505/tjtes.2018.36559 Submitted: 02.12.2017 Accepted: 07.03.2018 Online: 08.05.2018 Copyright 2018 Turkish Association of Trauma and Emergency Surgery

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rator canal and proximal bowel loops dilated up to 3.5 cm in diameter (Fig. 1). After a brief preparation, the patient underwent an emergency surgical operation with a diagnosis of bilateral incarcerated obturator hernia. Diagnostic laparoscopy revealed distal ileal loops bilaterally entrapped into the obturator canal (Fig. 1). No sign of bowel ischemia or perforation was observed. The defect was repaired using TAPP technique with polypropylene mesh (Fig. 1). The patient was administered an oral regimen two days post-operation.

The patient stayed in the intensive care unit for 4 days and was uneventfully discharged on the 9th postoperative day.

Follow-up was scheduled at the 6th month, in which no adverse events were noted and the patient did not report any complaints.

DISCUSSION Obturator hernia is a rare but serious condition, and its diagnosis considered in cases with an intestinal obstruction.

The most common presenting sign is intestinal obstruction, followed by abdominal pain.[3] Delay in diagnosis can result in morbidity and mortality.[1] Abdominal X-ray and ultrasound can provide useful information, but early CT scan is crucial and has been shown to decrease morbidity and mortality. CT is an indispensable modality in preoperatively determining any signs of ischemia or infarct, and thus, has a major effect when selecting the appropriate operative approach.

Although most of the obturator hernia cases in the literature are unilateral, reported cases of bilateral hernia are available as well. Tee et al.[4] have reported a case that presented with intestinal obstruction and was discharged with no complaints after conservative treatment. The patient was readmitted 1 month later with the same complaints and was operated with a diagnosis of bilateral obturator hernia. In cases of obturator hernia, a conservative approach is not recommended.

When patients present with obstruction and signs of ischemia, obturator hernia is generally repaired with open sur-

(a)

gical technique. Although abdominal, inguinal, preperitoneal, and laparoscopic approaches have been defined, minimally invasive laparoscopic approach is preferred today.

In a review of 28 cases that were laparoscopically operated, 8 were treated TAPP mesh repair, 15 with totally extraperitoneal (TEP) mesh repair, 4 with direct repairs by stapling or suturing, and 1 with intraperitoneal plug repair. While 6 patients of the 8 in the TAPP group were operated for emergency presentations, all TEP repairs were electively performed.[5] In a recent study by Karashima et al.,[6] of the 22 patients examined, 10 underwent laparotomy and 12 underwent laparoscopic operation with TEP technique. In 3 patients, the operation was converted to open surgery. The duration of operation and blood loss were comparable in both techniques, and the length of hospital stay was shorter in the laparoscopic group.

Hayama et al.[7] have recently reported six cases of obturator hernia treated with TAPP approach. In two of these patients, bowel resection was performed. Synthetic mesh was used in five patients, and one case was repaired with simple peritoneal closure. In cases with ischemia/necrosis, open surgery can be preferred for the resection and anastomosis of the necrotic segments. Thus, except for cases with bowel necrosis and peritonitis, laparoscopy is a suitable technique because it is minimally invasive and enables both the diagnosis and treatment of obturator hernia.

Conclusions Obturator hernia is among the differential diagnoses of intestinal obstruction requiring early diagnosis and prompt surgical intervention. Laparoscopic approach is less invasive compared with open surgery, and it can be attempted in cases presenting with no sign of ischemia or peritonitis.

TAPP technique should be preferred since it allows the control of all intraabdominal pathologies and the viability of the intestines.

Conflict of interest: None declared.

(b)

Figure 1. (a, b) A Afferent loop, B incarcerated segment, and C efferent loop.

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secondary to bilateral obturator hernia: a rare occurrence. J Surg Case Rep. 2014;2014. pii: rju009.

1. Mandarry MT, Zeng SB, Wei ZQ, Zhang C, Wang ZW. Obturator hernia-a condition seldom thought of and hence seldom sought. Int J Colorectal Dis 2012;27:133–41.

2. Ng DC, Tung KL, Tang CN, Li MK. Fifteen-year experience in managing obturator hernia: from open to laparoscopicapproach. Hernia 2014;18:381–6.

3. Shukla S, Garge S. Obturator hernia of the Richter type: A case report.

Indian J Surg 2010;72:299–301.

4. Tee CL, Evans T, Ratnayake S, Strekozov B. Small bowel obstruction

5. Deeba S, Purkayastha S, Darzi A, Zacharakis E. Obturator hernias: A review of the laparoscopic approach. J Minim Access Surg 2011;7:201–4.

6. Karashima R, Kimura M, Taura N, Shimokawa Y, Nishimura T, Baba H. Total extraperitoneal approach for incarcerated obturator hernia repair.

Hernia 2016;20:479–82.

7. Hayama S, Ohtaka K, Takahashi Y, Ichimura T, Senmaru N, Hirano S. Laparoscopic reduction and repair for incarcerated obturator hernia: comparison with open surgery. Hernia 2015;19:809–14.

OLGU SUNUMU - ÖZET

Nadir görülen inkarsere iki taraflı obturator herni: Olgu sunumu Dr. Engin Hatipoğlu,1 Dr. Fatih Dal,1 Dr. Veysel Umman,1 Dr. Süleyman Demiryas,1 Dr. Oktay Demirkıran,2 Dr. Metin Ertem,1 Dr. Sabri Ergüney,1 Dr. Salih Pekmezci1 1 2

İstanbul Üniversitesi Cerrahpaşa Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, İstanbul İstanbul Üniversitesi Cerrahpaşa Tıp Fakültesi, Anesteziyoloji ve Reanimasyon Anabilim Dalı, İstanbul

Acil cerrahi kliniğimize akut mekanik intestinal obstrüksiyon semptomları ile başvuran 84 yaşında kadın hasta sunuldu. Bilgisayarlı tomografi görüntülemesinde iki taraflı inkarsere obturator herni saptandı. Defektler poliprolen yama kullanılarak Trans Abdominal Pre Peritoneal (TAPP) tekniği uygulanarak tamir edildi. Hasta ameliyat sonrası dört gün boyunca yoğun bakım ünitesinde takip edildi, dokuzuncu gün sorunsuz taburcu edildi.

Altıncı ay kontrollerinde herhangi bir sorunla karşılaşılmadı. Obturator herni, intestinal obstrüksiyonun ayırıcı tanısında düşünülmesi gereken, erken tanı ve uygun cerrahi tedavi gerektiren bir kliniktir. Laparoskopik yaklaşım, açık yaklaşıma göre daha az invaziv olup, iskemi ve peritonit bulgusu olmayan olgularda denenebilir. Bu hastalarda TAPP tekniği, tüm intraabdominal patololerin değerlendirilmesi ve bağırsakların görüntülenebilmesi nedeniyle tercih edilmelidir.

Anahtar sözcükler: Herni; laparoskopi; obstrüksiyon; obturator.

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