Ulus Travma Acil Cerrahi Derg: 10 (2)
Volume: 10  Issue: 2 - April 2004
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1.Three-dimensional orthotopic tissue reconstruction with a free, prefabricated high-density porous polyethylene implant flap
Orhan Murat Özdemir, Savaş Serel, Serdar Gökrem, Arda Katırcıoğlu, Zeki Can, Sibel Serin
PMID: 15103564  Pages 75 - 82
BACKGROUND: We investigated the appropriateness of the implant to be used in free-tissue transfers in a rabbit model in which a full-thickness skin graft was wrapped around a prefabricated high-density porous polyethylene implant.
METHODS: In ten New Zealand white rabbits, high-density porous polyethylene implants (Medpor), 10x15x3 mm in size, were bilaterally placed and anchored underneath the superficial inferior epigastric artery and vein pedicle under anesthesia. The flaps were prefabricated through vascular induction. Eight weeks later, the flaps were wrapped by a full-thickness postauricular skin graft, following orthotopic transplantation. Two weeks after grafting, full-thickness biopsy samples were obtained from the distal
one-third of the implants and stained with hematoxylin-eosin and Masson trichrome for histologic examination.
RESULTS: Graft compliance was observed in all the implants. Histologic sections showed rich fibro-neovascular tissue, neovascularization, and development of connective tissue cells. There were very few polymorphonuclear cells. No signs of inflammation were observed.
CONCLUSION: Prefabrication of the high-density porous polyethylene implant under the superficial inferior epigastric artery and vein results in sufficient conditions for its use in free transfers.

2.The value of Ranson and APACHE II scoring systems, and serum levels of interleukin-6 and C-reactive protein in the early diagnosis of the severity of acute pancreatitis
Günay Gürleyik, Oya Zahidullahoğlu Çırpıcı, Ali Aktekin, Abdullah Sağlam
PMID: 15103565  Pages 83 - 88
BACKGROUND: We investigated the effectiveness of scoring systems, acute inflammation and acute phase responses in the early diagnosis of the severity of acute pancreatitis. METHODS: In a prospective design, we determined Ranson and APACHE II scores, and serum interleukin-6 (IL-6) and C-reactive protein (CRP) levels in 30 patients (21 females, 9 males; mean age 56 years; range 28 to 82 years) with acute pancreatitis. The patients were divided into two groups as mild and severe pancreatitis according to the clinical, biochemical, and computed tomography findings. Ranson and APACHE II scores were determined after 48 hours, IL-6 levels within 24 hours, and CRP levels after 24, 48, and 72 hours of admission. Ranson scores of 4 or above, APACHE II scores of 8 or above, baseline serum IL-6 and CRP levels of 50 pg/ml and 150 mg/L, respectively, were regarded as strong predictors of acute pancreatitis. RESULTS: Severe pancreatitis was diagnosed in six patients (20%), one of whom died due to multiple organ failure. Biliary symptoms were the most common presenting signs in both groups. The mean Ranson (p=0.004) and APACHE II (p=0.001) scores, serum IL-6 (p=0.001) and CRP levels at 24, 48, and 72 hours (p=0.02) were significantly high in patients with severe pancreatitis. The sensitivity was found as 66.6%, 83.3%, 100%, and 83.3%; the specificity as 87.5%, 91.7%, 87.5% and 71%; and the accuracy as 83.3%, 90%, 90%, and 73.3% for Ranson and APACHE II scores, IL-6 and CRP levels, respectively. CONCLUSION: Ranson and APACHE II scores, CRP and, in particular, serum IL-6 levels are strong predictors of severe ancreatitis.

3.The effects of immunonutrition on the development of nosocomial infections and on clinical outcome in critically ill patients
Simru Tuğrul, Perihan E. Özcan, İ. Özkan Akıncı, Murat İsmailov, Atahan Çağatay, Nahit Çakar, Figen Esen
PMID: 15103566  Pages 89 - 96
BACKGROUND: We investigated the effects of early immunonutrition on the development of nosocomial infections and clinical outcome in intensive care patients. METHODS: Thirty mechanically ventilated patients were randomly assigned to two enteral nutrition regimens in the intensive care unit. Fifteen patients (8 males, 7 females; mean age 54 years; range 21 to 72 years) received immunonutrition solution containing arginine, nucleotides, and polyunsaturated fatty acids, while controls (10 males, 5 females; mean age 55 years; range 24 to 78 years) received isocaloric solution. The patients were evaluated daily using the
APACHE II and SOFA (Simplified Organ Failure Assessment) scoring systems. Infections were sought in tracheal, blood, urine,
and catheter cultures. Changes in nitrogen balance, leukocyte count, and APACHE II and SOFA scores were compared. RESULTS: Significant changes in nitrogen balance, APACHE II and SOFA scores, and leukocyte count were found in the study group (p<0.001, p<0.0001, p<0.0001, p<0.05, respectively), whereas no significant differences were detected in the control group. Cultures were positive in nine patients in the immunonutrition group, and in 12 patients in the control group. Septic shock and mortality rates were 26% and 20% in the study patients, and 40% and 33% in the controls, respectively (p>0.05). CONCLUSION: Patients receiving immunonutrition exhibit better nutritional status and improved scores showing clinical severity and organ failure.

4.The prognostic value of the Hand Injury Severity Score in industrial hand injuries
Lale Altan, Selçuk Akın, Ümit Bingöl, Serhat Özbek, Merih Yurtkuran
PMID: 15103567  Pages 97 - 101
BACKGROUND: We evaluated the value of the “Hand Injury Severity Score” (HISS) in determining the prognosis of industrial hand
injuries. METHODS: Hand injury severity scores of 112 patients (17 females, 95 males; mean age 31 years; range 15 to 54 years) were calculated following surgery for industrial hand injuries. During the course of rehabilitation program, the patients were followed-up regularly. Pearson correlation coefficients were used to determine the relationship between the HISS scores and the time intervals from injury to healing and return to work. RESULTS: The mean HISS score was 37.1±27 (range 6 to 116). The time
to healing ranged from 12 to 210 days (mean 73.7±40.7 days). All the patients returned to work after a mean of 80.4±52.9 days (range 7 to 300 days), mainly to previous working places with (12%) or without (79%) changing job activities. Nine per cent of the workers had to change their jobs. The HISS scores were found to be correlated with the healing period and the time to work (p<0.05 and p<0.000, respectively). CONCLUSION: The results of this study indicated that HISS was a useful system in predicting the prognosis in the early stages of industrial hand injuries.

5.Flail chest due to blunt trauma: clinical features and factors affecting prognosis
Akın Eraslan Balcı, Koray Özalp, Mehmet Duran, Erhan Ayan, Sadık Vuraloğlu
PMID: 15103568  Pages 102 - 109
BACKGROUND: We evaluated the clinical features of patients with flail chest, together with treatment results, and the factors affecting prognosis. METHODS: The study included 34 patients (27 males, 7 females; mean age 41 years; range 15-61 years) who underwent treatment for flail chest. A retrospective analysis was made regarding the etiology, injury to the chest wall, pulmonary contusion, hemothorax and pneumothorax requiring chest tube, associated injuries, injury severity score (ISS), the presence of shock on admission, the amount of blood transfusions within the first 24 hours, treatment, and the results. RESULTS: The most common cause of flail chest was traffic accidents (79.4%). Shock was detected in 41.2% and pulmonary contusions in 55.9%. Ventilatory support was required in 70.6%. The mean ISS was 36; mortality occurred in 32.4%. In seven patients without associated injuries and who did not receive ventilatory support, the mean ISS was 22.8 and all survived. However, in 18 patients with associated organ injuries, the mean ISS was 43.6, with mortality being 50% (p<0.05). Factors responsible for prolonged ventilatory support, pneumonia, and septic deaths included ISS above 31, associated fractures and injuries, blood transfusions, the need for chest tube, age equal to or above 50 years, and the presence of bilateral flail chest. The incidences of pneumonia and mortality were significantly less in patients treated with internal fixation (p<0.05). CONCLUSION: Our data show that careful fluid management and effective pain control, stabilization of the chest wall, immediate ventilatory support and early weaning from ventilation are the mainstays of treatment.

6.Clinical evaluation and treatment results of 30 patients with necrotizing fasciitis
Güzin Yeşim Özgenel, Selçuk Akın, Ramazan Kahveci, Serhat Özbek, Mesut Özcan
PMID: 15103569  Pages 110 - 114
BACKGROUND: We retrospectively evaluated patients who underwent treatment for necrotizing fasciitis within a five-year period. METHODS: Thirty patients (4 females, 26 males; mean age 55 years; range 19 to 78 years) with necrotizing fasciitis were evaluated with respect to age, sex, etiology, predisposing factors, localization of infections, culture results, and treatment methods and results. RESULTS: The most common etiologic and predisposing factors were anorectal lesions (36.7%) and diabetes (53.3%), respectively. Wound cultures yielded Pseudomonas aeruginosa in 50% of the patients. Two strains of aerobic bacteria were isolated in three patients. All patients underwent extensive surgical debridement and received antibiotic therapy. Twenty-nine patients (96.6%) required more than one debridement, with a mean of 4.5 debridements. The ensuing skin defects following debridement were reconstructed with grafts or local flaps. No complications were encountered in the postoperative period. CONCLUSION: Early diagnosis and treatment result in decreased morbidity and prevent mortality in necrotizing fasciitis.

7.Emergency pelvic external stabilization as the first step treatment in high risk pelvic fractures
Ahmet Harma, Muharrem İnan
PMID: 15103570  Pages 115 - 122
BACKGROUND: We evaluated the clinical effectiveness of emergency pelvic external stabilization (EPES) as a first step of resuscitation and pelvic stabilization in trauma patients with hemodynamic and/or fracture instabilities. METHODS: Twenty-three patients (12 males, 11 females; mean age 32 years; range 9 to 67 years) with high risk pelvic fractures underwent EPES. The presence of a systolic blood pressure equal to or below 90 mmHg, vertical and/or rotational instabilities, or fractures at risk were defined as high risk fractures. Pelvic fractures were assessed according to the Tile’s classification. RESULTS: Hemodynamic instability was detected in 10 patients. The mean durations to the elective pelvic stabilization were three days (range 2 to 8 days) and 17.7 days (range 7 to 28 days) in patients with or without hemodynamic instability, respectively. The mean duration for EPES application was below 30 minutes (range 20 to 40 minutes). No deaths occurred due to blood loss caused by pelvic fractures. One
patient died due to sepsis 14 days after hemodynamic stabilization. Superficial pin-track infections of grade 1 were detected in five patients, four of whom were treated with local dressings. In one patient, two pins had to be replaced because of loosening. CONCLUSION: Emergency pelvic external stabilization for resuscitation and high risk fractures is an effective intervention in the acute phase of polytraumatized patients presenting with high risk pelvic fractures.

8.A comparison of different fixation combinations for the treatment of ipsilateral hip and femoral diaphyseal fractures
Bülent Dağlar, Kenan Bayrakçı, Bülent Adil Taşbaş, Alper Deveci, Uğur Günel
PMID: 15103571  Pages 123 - 127
BACKGROUND: The effects of four different fixation combinations were retrospectively evaluated on the treatment results of ipsilateral hip and femur fractures. METHODS: Ipsilateral hip and femur fractures of 19 patients (4 females, 15 males; mean age 26 years; range 18 to 41 years) were treated by four fixation combinations. In two groups, diaphysis fractures were treated by plate and screw fixation, and hip fractures by three cannulated screws (n=5) or dynamic hip screws (n=4). In another group, femur fractures were fixed with a retrograde intramedullary locking nail, and hip fractures by three cannulated screws (n=7). Finally, hip and diaphysis fractures in three patients were treated by an antegrade intramedullary locking nail through which a screw was sent to the collum. The mean time to surgery was four days (range 1 to 9 days) and the mean follow-up period was 22.5 months (range 12 to 33 months). RESULTS: All femoral diaphyseal fractures healed in a mean of 3.5 months (range 2.5 to 8 months). No significant differences were found with respect to localization of fractures and amount of displacement, time to healing for hip fractures, the length of hospital stay, and complications. Compared to the other groups, fixation with a retrograde intramedullary locking nail resulted in significantly less healing period (p=0.034), operation time (p<0.001), and blood transfusion during surgery (p=0.025). No patients exhibited decreased range of motion of the hip or implant failure. CONCLUSION: The use of a retrograde intramedullary locking nail with percutaneous screw fixation seems to be more advantageous in the treatment of ipsilateral hip and diaphyseal femoral fractures.

9.Monitoring of uncooperative, polytraumatized patients with tibial shaft fractures for acute compartment syndrome
Nadir Özkayın, Kemal Aktuğlu
PMID: 15103572  Pages 128 - 132
BACKGROUND: The results of intracompartmental pressure monitoring were assessed in uncooperative, polytraumatized patients with tibial shaft fractures. METHODS: The study included 29 tibial fractures of 26 polytraumatized patients (9 females, 17 males; mean age 36 years; range 15 to 75 years) admitted to the intensive care unit. The fractures were on the right side in eight patients, on the left in 15 patients. Three patients had bilateral involvement. All the patients were unconscious. Following trauma, absolute compartment pressures and ?P (diastolic blood pressure – absolute compartment pressure) were monitored at 12-hour intervals for 72 hours via the intracompartmental pressure monitoring system. Patients whose ?P values were 30 mmHg or below underwent fasciotomy. The mean follow-up period was 21.2 months (range 18 to 25 months). RESULTS: The overall mean absolute compartment pressure was 30.25 mmHg, and the mean ?P was 48.47 mmHg at the end of 72 hours. Fasciotomy was performed in two patients (7%) in whom a diagnosis of acute compartment syndrome was made depending on ?P values less than 30 mmHg. None of the patients had complications associated with acute compartment syndrome. Union was achieved in all the patients without an additional intervention. The mean time to union was 5.21 months (range 3 to 9 months). CONCLUSION: Intracompartmental pressure monitoring should be considered for an early diagnosis of acute compartment syndrome in uncooperative, polytraumatized patients with tibial shaft fractures.

10.Early treatment results with expandable intramedullary nails in lower extremity shaft fractures
Taner Bekmezci, Murat Tonbul, Rıfat Kocabaş, Okan Yalaman
PMID: 15103573  Pages 133 - 137
BACKGROUND: We investigated the use of expandable intramedullary nails, their efficacy, and short term results in the treatment of lower extremity shaft fractures. METHODS: The study included 23 patients (10 females, 13 males; mean age 33 years; range 17 to 60 years) who were treated with expandable intramedullary nails (the Fixion nail) for the lower extremity shaft fractures. Fourteen patients had femoral, nine patients had tibial fractures, all of which were closed. Eight patients had associated injuries. The mean duration from injury to surgery was 3.2 days (range 24 hours to 14 days). The results were evaluated using the Kalström-Olerud criteria. The mean follow-up was 15.3 months (range 10 to 20 months) for tibial fractures, and 13.1 months (range 10 to 19 months) for femoral fractures. RESULTS: Union was achieved in all the patients. In tibial fractures, the mean operation time was 50 minutes (range 25 to 90 min) and the mean time to union was 12 weeks (range 8 to 24 weeks). The results were excellent in six patients, and good in three patients. In femoral fractures, the mean operation time was 83.5 minutes (range 55 to 120 min) and the mean time to union was 13.2 weeks (range 10 to 20 weeks). The results were excellent in eight patients, good in three patients, fair in two patients, and poor in one patient. No complications were seen such as delayed union, early or late infections, compartment syndrome, or bone necrosis. CONCLUSION: Expandable intramedullary nails offer advantages in terms of ease of application and are less invasive than static nails and reamed applications. However, they may not provide adequate stability in metadiaphyseal regions and in fractures with fragments larger than 50 percent.

11.An isolated complete pancreatic fracture primarily diagnosed by ultrasound
Fatih Kantarcı, Bengi Gürses, Ramazan Albayrak, Süleyman Hilmi Aksoy, Sebuh Kuruoğlu, İsmail Mihmanlı
PMID: 15103574  Pages 138 - 140
Pancreatic fractures due to blunt abdominal trauma are rare and are usually symptom-free and silent in many cases. Therefore, a high degree of suspicion is required either early in the course of trauma or later during follow-up. Computed tomography (CT) is the primary imaging modality for the diagnosis of traumatic pancreatic injuries. In this report, we present a 10-yearold child in whom ultrasound enabled the detection of a complete fracture between the body and tail of the pancreas, while initial CT findings were not suggestive of a lesion. The need for ultrasonography is emphasized especially in the presence of a history of trauma even if CT scans appear normal.

12.Conservative treatment of giant abdominal wall hematoma
Nurdan Ergün, Arif Alper Çevik, C. James Holliman, Metin Manisalı, Feyzullah İnan, Tahsin Sarısoy
PMID: 15103575  Pages 141 - 144
A fifty-seven-year-old male patient on warfarin therapy presented to the emergency department with severe abdominal pain that
had started after a cough episode and persisted for four days. Ultrasonography showed an extensive hematoma, 17x14x7 cm
in size, but failed to determine whether it was located intraabdominally or in the abdominal wall. Computed tomography confirmed the diagnosis of abdominal wall hematoma (25x21x10 cm). The patient was treated conservatively, and abdominal findings esolved progressively in three days. This case report illustrates that ultrasonography findings may sometimes be inconclusive and, in the early period, computed tomography may be required to confirm the diagnosis of abdominal wall hematomas. Giant abdominal wall hematomas can be successfully treated with conservative methods even physical findings of acute abdomen accompany the clinical picture. To our knowledge, this is the largest abdominal wall hematoma hitherto reported in the literature.

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