Selim Turkkan

Evaluation and comparison of the effect of hypothermia and ozone on ischemia–reperfusion injury of skeletal muscle in rats

BACKGROUND Tourniquet-induced ischemia-reperfusion, which affects local and distant organs, is very common in orthopedic surgery. Hypothermia is used in traumatic tissue during ischemic period commonly. Ozone (O3) has been recommended as a novel therapeutic agent in various medical conditions. The objective of the study was to evaluate and compare the effect of hypothermia (H) and O3 on ischemia-reperfusion injury of skeletal muscle in rats by measuring oxidative parameters and inducible nitric oxide synthase (iNOS) levels. MATERIALS AND METHODS Eighteen rats (Wistar albino) were separated into five groups randomly (sham, IR, IR + H, IR + O3, IR + H + O3; n = 6). The lower right extremity of all rats was subjected to 2 h of ischemia and 22 h of reperfusion clamping the common iliac artery and using the rubber-band technique at the level of the lesser trochanter under general anesthesia. Two hours of hypothermia were applied during the first 2 h of reperfusion in two groups. O3 was applied in two groups. All rats were sacrificed after the IR period with high dose of anesthesia. The tibialis anterior muscle and blood were saved. Levels of superoxide dismutase, glutathione peroxidase, MDA, NOx, and interleukin-1β were measured in the muscle. Creatinine kinase, lactate dehydrogenase, aspartate aminotransferase, urea, creatinine, and electrolytes were measured in serum. Immunohistochemical iNOS staining was performed on muscle samples. RESULTS The levels of MDA, NOx, and interleukin-1β in muscle were raised in the IR group compared with those in the sham group. The same parameters were lower in the groups of IR + H, IR + O3, and IR + H + O3 compared with those in the IR group. Superoxide dismutase and glutathione peroxidase activities in muscle were lower in the IR group compared with those in the sham group; however, same parameters were higher in the groups of IR + H, IR + O3, and IR + H + O3 compared with those in the IR group. Score and intensity of iNOS staining in skeletal muscle in the IR group was increased compared with that in the sham group and decreased in the groups of IR + H, IR + O3, and IR + H + O3 compared with that in the IR group. Levels of creatinine kinase, aspartate aminotransferase, and K in the three treatment groups decreased compared with those in the IR group. CONCLUSIONS These findings showed that hypothermia, which has more affect, and O3 decreased the tourniquet-induced IR injury in the rats muscle-skeletal system by reducing the levels of oxidative and nitrosative stress parameters and enhancing antioxidant enzymes. Hypothermia and O3 had no synergistic effect. Hypothermic reperfusion and O3 preconditioning might be beneficial in skeletal muscle IR injury-associated tourniquet.

Comment on: “Bicolumnar 90-90 plating of AO 13C Type fractures”

Dear colleagues, Thank you for your interest in our manuscript entitled “Bicolumnar 90e90 plating of AO 13C Type Fractures”. We also thank you for your warning to prevent the misunderstanding. The correct form of this sentence should be “All patients were previously active, and only 2 had to change their occupation after the operation due to lasting impairment” In our hospital, most of our patients belong to the low socioecenomic status and have severe osteoporosis. AO type 13C fractures are more likely to develop nonunion and failure especially in osteoporotic patients. For these reasons we prefer to start the gentle physiotheraphy after 2-3 weeks and our functional results are comparable to the literature. In our opinion, close follow-up are very important in these group of patients and succesfull functional results can be provided by multidisciplinary team approach. Every physiotheraphy protocol should be organised according to the each patient’s own status not to the generalised opinions. We should keep our mind that “every problem has its own solution”. To the Editor

Case Report: Late Reconstruction of the Land Mine–Injured Heel With an Osteomyocutaneous Composite Fibular Flap

The heel comprises the epidermis, minimal subcutaneous tissue, a dense septum, and the calcaneus. Injury to any of these structures can impair the ability to walk. The soft tissue or calcaneal bone can be injured by trauma. Injuries incurred in war are usually high-energy traumas caused by weapons such as rifles, rockets, and land mines. Such injuries can be life threatening and involve the loss of tissue, including skin, soft tissue, bone, and neurovascular tissue. Two main treatment protocols are used for such injuries with large tissue defects: amputation and reconstruction. We describe a reconstruction with an osteomyocutaneous fibular flap for a heel injury. At the 2-year follow-up point, the patient had 30% loss of ankle range of motion. The visual analog scale score had dramatically decreased from 8 to 1, and the patient was satisfied with the result. In conclusion, patients with significant problems such as infection, pain, and anatomic deterioration of the calcaneus can be successfully treated using an osteomyocutaneous fibular flap in a single surgery.

Letter to Editor: the effectiveness of bedside point-of-care ultrasonography in the diagnosis and management of metacarpal fractures

We read the published article by Kozacı et al [1]titled “The effectiveness of bedside point-of-care ultrasonography in the diagnosis and management of metacarpal fractures”with great interest. The objective of the study is noteworthy, and we would like to add several points about metacarpal fracture management in orthopedic practice. Metacarpal fractures, which require surgery, must be diagnosed with radiography, and follow-up imaging of these fractures must be done with radiography. In our practice, whenwe performmetacarpal fracture surgery, we use either fluoroscopy or radiography to determine the plate, K-wire, or screw placement and fracture reduction. Moreover, if the conservative management is chosen, then follow-up radiography is also important to determine the displacement degree, because if the reduction is lost, then surgerymay be necessary. Furthermore, the authors did not point out how they examined the metacarpal fractures with ultrasound, as the fractures were within a splint. To conclude, ultrasound may be effective for diagnosing metacarpal fractures, but it is not completely proper for the management of metacarpal fractures [2,3]. We think that this article should state these situations. Finally, this article did not mention the main disadvantages of ultrasound, namely, that it is a subjective diagnostic tool and whole results depend on the examiners abilities [4,5].

Accuracy of bedside ultrasonography for the diagnosis of phalanx fractures

We read the published article by Aksay et al “Accuracy of bedside ultrasonography for the diagnosis of phalanx fractures” with great interest [1]. The aim of the study is noteworthy, and we would like to add several points about phalanx fracture diagnosis and management in orthopedic practice. In this article, the authors stated that phalanx fractures often missed with the use of conventional radiography. However, as long as true anteroposterior, lateral and oblique radiographs are taken for phalanx fractures, the diagnosis can be made easily. Therefore, there is no need to examine other diagnostic tools such as magnetic resonance imaging or computed tomography. If we have doubt about ligament injury, we may use magnetic resonance imaging to confirm our diagnosis. Furthermore, the authors stated that if volar avulsion fractures of the middle phalanx were less than 50%, these fractures can be treated with conservatively. However, volar avulsion fractures of the middle phalanx more than 40% collateral ligaments are attached only to the fragment and not to the middle phalanx, which would be unstable without surgery [2,3]. Finally, ultrasound may be effective for diagnosing phalanx fractures, but it is not completely proper for the management and follow-up of phalanx fractures.

Anatomical challenges in ultrasound-guided ulnar nerve block for boxer fractures

We read the article published by Ünlüer et al, “Ultrasound-Guided Ulnar Nerve Block for Boxer Fractures,” with great interest [1]. The aim of the study is noteworthy, andwewould like to add several points about ulnar nerve block in hand surgery practice. In this article, the authors stated that boxer fractures can be painlessly reduced with ulnar nerve block. However, there are several anastomoses between the median and ulnar nerves in the upper limb, such as Martin-Gruber anastomosis, Marinacci anastomosis, Riche-Cannieu anastomosis, and Berrettini anastomosis [2]. Therefore, some cases of boxer fractures cannot be reduced painlessly as a result of these anastomoses. In these cases, painless reduction of boxer fractures would block the median nerve as well. Furthermore, the authors stated that they had performed ulnar nerve block approximately 10 cm above the wrist and saw no motor function in the fifth metacarpal. However, the flexor digitorum profundus (FDP) receives 1 or 2 ulnar nerve branches, and the average distance from these branches to the medial epicondyle is 5.0 cm. Therefore, the fifth metacarpophalangeal joint can be flexed with the FDP tendon [3]. Finally, use of convenience nerve blocks for fracture reduction is very important for patients as long as we pay attention to nerve anatomy.

Effects of hypothermia on skeletal ischemia reperfusion injury in rats

Abstract Objective: The aim of this study was to investigate the effect of hypothermia (H) on skeletal ischemia-reperfusion (IR) injury in rats by measuring malondialdehyde (MDA), superoxide dismutase (SOD), glutathione peroxidase (GSH-Px), nitric oxide (NO), and interleukin-1 beta (IL-1β) in muscle, and measureing immunohistochemical- inducible nitric oxide synthase (iNOS) staining of skeletal muscle. Materials and Methods: Eighteen Wistar Albino rats were divided randomly into three groups (sham, IR, hypothermia) (n=6). The sham group had all procedures without the IR period. The lower right extremity of rats in the IR and hypothermia groups was subjected to 2 hours of ischemia and 22 hours of reperfusion by applying a clamp on the common iliac artery and a rubber-band at the level of the lesser trochanter under general anesthesia. Rats in the hypothermia group underwent 4 hours of hypothermia during the first four hours of reperfusion in addition to a 2-hour ischemia and 22-hour reperfusion period. All rats were sacrificed at end of the IR period using a high dose of anesthesia. The tibialis anterior muscles were preserved. Immunohistochemical iNOS staining was performed, and MDA, SOD, GSH-Px, NO, and IL-1β were measured in the muscle. Results: The level of MDA, NO, and IL-1β in muscle was increased in the IR group compared with that in the sham group, but these parameters were decreased in the hypothermia group compared with the IR group. The activities of SOD and GSH-Px in muscle were decreased in the IR group; however, these parameters were increased in the hypothermia group. The score and intensity of iNOS staining of skeletal muscle was dens in IR group, mild in hypothermia group, and weak in sham group. Conclusion: The present study has shown that hypothermia reduced IR injury in the skeletal muscle by decreasing the levels of MDA, NO, and IL-1β, and increasing the activities of SOD and GSH-Px. In addition, hypothermia attenuated the score and intensity of iNOS staining.

Schwannoma on palmar surface of the hand: A rare case report -

Schwannomas, also known as neurilemmomas, are benign, intracapsular peripheral nerve sheath tumors. They are the most common type of peripheral nerve sheath tumors and can be seen between the third and sixth decades of life, but are nevertheless rare. The goal of this report is to raise awareness in the medical community for this type of tumor. A 21-year-old male patient presented with a mass in the right palm. He reported that he had noticed the mass two years before and that the numbness started three months before. We detected a mobile, soft, palpable mass, 3X1 cm in size, in zone three of the palm. Tinel’s test was positive. There was no history of neither neurofibromatosis nor any other hereditary diseases. USG showed a lobulated, encapsulated, highly vascularized and high resistant arterial flow solid mass with 11.5X28mm in size. Total excision was planned. Under general anesthesia the patient was placed in supine position. A 3 cm mid-palmar incision was made on the volar side of the right hand. Digital nerves and arteries were explored. The mass, which was found to be 30X15X10mm in size, emerged from the common digital nerve in zone three and was excised with microsurgical instruments via blunt dissection. The patient healed uneventfully. Histopathological examination of the mass revealed Vimentin S-100 positive schwannoma. Schwannomas are rare, benign tumors. To the best of our knowledge, a similar large mass was reported in an infant and no case has been reported in adults. Hand surgeons should keep the schwannomas’ diagnosis in mind if upper extremity masses are isolated that are palpable and slow growing with positive Tinel’s sign. The presented study showed how big schwannomas can be in size and that the cure is achieved by total excision.

Management of cold and pulseless hand after closed reduction and percutaneous pinning of pediatric humerus supracondylar fracture: Is it really necessary to explore brachial artery?

Introduction: Vascular and neurologic complications are common following pediatric humerus supracondylar fractures. Vascular injuries always require urgent surgical intervention and are responsible for major complications, such as Volkmann’s ischemic contracture and amputation. When a patient suffers from a cold and pulseless extremity following a fracture, brachial arterial exploration is generally needed. The aim of the current study is to report our experience in six patients having cold and pulseless hands after closed reduction who were managed by conservative methods. Patients and Methods: Six patients were included in the study. The mean patient age was 3.2 years (range of 1-6 years). Before the operation, all patients underwent a doppler examination, as all of them had non-palpable radial arteries. Doppler examinations revealed monophasic flow in the brachial and radial arteries. Therefore, patients were immediately operated upon and closed reductions with percutaneous pinning were performed. Results: We verified anatomical reduction using plain radiographs. However, all patients had cold and pulseless hands. Therefore, papaverine was injected subcutaneously and the operated extremities were warmed and elevated for at least 1 hour. During this period, serial doppler examinations were performed. After a mean period of 30 minutes (range of 15 to 90 minutes), we detected brachial and radial arterial flow upon doppler examination, along with warm hands. Patients were followed for at least two days in the clinic and all of the patients healed without any complications. Conclusions: We advise initial conservative management of cold and pale hands after reduction of a supracondylar fracture, including warming, elevation and papaverine-HCL injection within at least 30 minutes following surgery. If this treatment fails, emergency arterial exploration is needed. Additionally, if the patient has a cold and pale hand before the operation, arterial exploration is needed along with reduction.

A Rare Case: Radial Shaft Fracture Seen at Torg-Winchester Syndrome -

Torg-Winchester syndrome is an autosomal recessive inherited disease characterized by diffuse osteoporosis and osteolysis due to matrix metalloproteinase-2 (MMP2) enzyme deficiency. Flexion contractures at hand, wrist, feet, hip and knee joints occasionally accompany. In this paper, we aimed to present the conservative treatment of radial shaft fracture at a patient with Torg-Winchester Syndrome.