Yuksel Yurttas

Immobilization of the shoulder in external rotation for prevention of recurrence in acute anterior dislocation

OBJECTIVES We aimed to compare the functional and stability outcomes of the patients with acute anterior shoulder dislocation, who were stabilized at external versus internal rotation. METHODS A total of 33 patients (31 males and 2 females) with the diagnosis of acute primary traumatic anterior shoulder dislocation were immobilized at internal (n=17) or external rotation (n=16). The mean follow-up period was 20.85 months (range 6-41 months). Patients received rehabilitation program immediately after splinting. We assessed functionality by Constant-Murlay score and stability by Rowe scoring system in 6th month. Control examinations were performed in 12th and 24th months. RESULTS There were no statistically significant differences between internal rotation and external rotation groups in terms of Constant-Murlay and Rowe scores. Recurrent dislocation rate was 6.3% (1/16) in external rotation group and 29.4% (5/17) in internal rotation group (p>0.05). In the subgroup of patients aged between 21-30 years, while no recurrent dislocation was seen in external rotation group, 5 patients developed recurrent dislocation in internal rotation group(p=0.035). CONCLUSION Immobilization of the shoulder in external rotation is an effective technique for prevention of recurrent dislocations in acute anterior shoulder dislocation and should be preferred to traditional splinting in internal rotation in clinical practice.

The role of preconditioning and N-acetylcysteine on oxidative stress resulting from tourniquet-induced ischemia-reperfusion in arthroscopic knee surgery.

BACKGROUND The aim of this study was to investigate the effects of ischemic preconditioning (IPC) and N-acetylcysteine (NAC) on oxidative stress resulting from tourniquet-induced ischemia-reperfusion (IR) period in arthroscopic knee surgery. METHODS Forty-five patients who had arthroscopic knee surgery for meniscal and chondral lesions and for pathologic medial plica were included in this study. They were assigned to the following treatment groups: control (group C; n=15), IPC (group P; n=15), and NAC (group N; n=15). Subjects in the control group underwent routine surgical procedures. Subjects in the preconditioning group were subjected to temporary ischemia, with tourniquet performed by three compression cycles of 5 minutes followed by 5 minutes of reperfusion just before the application of tourniquet inflation. Subjects in the NAC group received 10 mg/kg NAC dissolved in 100 mL 0.9% normal saline intravenously 30 minutes before tourniquet inflation. An hour before the tourniquet was applied (preischemia) and 2 hours after tourniquet was removed (reperfusion), blood samples (to test for metabolites) were obtained. Levels of malondialdehyde (MDA), superoxide dismutase (SOD), glutathione peroxidase (GSH-Px), total antioxidant capacity (TAC), and total oxidant status (TOS) were measured in all serum samples. Results were compared between preischemia and reperfusion in three groups. RESULTS MDA in the control group was found to be increased significantly compared with preischemia, whereas MDA in IPC and NAC groups did not change insignificantly. SOD and GSH activities in the control group were found to be increased significantly, whereas SOD and GSH activities in IPC and NAC groups did not change significantly after reperfusion. TAC in the control group was found to be decreased and TOS was found to be increased significantly, but TAC and TOS in IPC and NAC groups were not significantly different after reperfusion. Mean serum MDA, TOS, SOD, and GSH-Px levels were lower in group P than group C at reperfusion period (p<0.05). Mean serum SOD levels were lower in group P than group N at reperfusion period (p<0.05). CONCLUSIONS Tourniquet-induced IR period in routine arthroscopic knee surgery resulted in oxidative stress by increasing MDA, SOD, GSH-Px, TOS and decreasing TAC. NAC and IPC had protective effect on occurrence of oxidative stress resulting from IR period by preventing MDA, SOD, GSH-Px, TAC, and TOS changes in routine arthroscopic knee surgery.

Effect of hyperbaric oxygen and ozone preconditioning on oxidative/nitrosative stress induced by tourniquet ischemia/reperfusion in rat skeletal muscle

OBJECTIVES The aim of the study was to investigate the effect of hyperbaric oxygen-preconditioning (HBO-PC) and ozone-preconditioning (O3-PC) on oxidative/nitrosative stress induced by tourniquet ischemia/reperfusion (I/R) in rat skeletal muscle. METHODS Thirty-two Wistar-Albino-type male rats included in the study were divided into four groups of equal number: 1) sham operation, 2) I/R, 3) I/R+HBO-PC, or 4) I/R+O3-PC. One session of 3-4 L/min 100% oxygenation for 60 min at 3 absolute atmosphere (ATA) was defined as one dose of HBO; in total, 7 doses of HBO-PC were administered before ischemia. One dose of O3 comprised 0.7 mg/kg ozone/oxygen mixture, administered intraperitoneally; a total of 4 doses of O3-PC were administered before ischemia. The I/R model was performed in anesthetized rats by clipping right femoral artery to induce 2 h ischemia followed by 22 h of reperfusion. The right gastrocnemius muscle and venous blood samples were harvested. Tissue was assayed for levels of malondialdehyde (MDA), inducible nitric oxide synthase (iNOS), superoxide dismutase (SOD), and glutathione peroxidase (GSH-Px). Serum was assayed to measure the level of nitrite-nitrate (NOx). RESULTS Tissue MDA level, SOD activity, and serum NOx level were increased, whereas GSHPx was decreased in the I/R group. MDA and NOx levels were decreased, whereas GSH-Px activity was increased in both the I/R+HBO-PC and I/R+O3-PC groups. SOD activity was increased in the I/R+O3-PC group, but did not change significantly in the I/R+HBO-PC group. iNOS staining score and intensity were lower in the I/R+HBO-PC and I/R+O3-PC groups than I/R group. CONCLUSION Both O3-PC and HBO-PC reduced tissue lipid peroxidation, NOx levels, and iNOS staining scores in the experimental I/R model. Our data suggest that HBO-PC and O3-PC protect against oxidative/nitrosative stress induced by I/R in rat skeletal muscle.

Coccygectomy with or without periosteal resection

The purpose of this study was to compare the clinical outcomes and wound complications in coccygectomy with or without subperiosteal resection. This retrospective study included 25 patients who underwent coccygectomy. Resection of all mobile coccygeal segments including the periosteum was performed in 11 patients (group 1) and resection was performed subperiostally sparing the periosteum in the remaining 14 patients (group 2). A visual analogue scale was used for pain assessment before and after the surgery both in sitting and standing positions. A questionnaire to evaluate subjective patient satisfaction was also used. The two groups were statistically similar in terms of age, sex, aetiology, duration of symptoms before surgery and follow-up time. Both surgical techniques resulted in a statistically similar clinical outcome. Overall, 84% of patients who underwent coccygectomy benefited from surgery. We observed four wound infections (two superficial and two deep) that caused delayed wound healing in group 1. The rate of infection in group 1 was statistically higher than in group 2. The results of this study suggest that periosteal preservation and closure are related to low risk of infection.

Effect of Preconditioned Hyperbaric Oxygen and Ozone on Ischemia-Reperfusion Induced Tourniquet in Skeletal Bone of Rats

BACKGROUND The aim of the study was to investigate effect of I/R injury on bone tissue and protective role of hyperbaric oxygen precondition (HBO-PC) and ozone precondition (O(3)-PC) on I/R injury by using biochemical analysis. MATERIALS AND METHODS Thirty-two rats were included in study. The animals were divided into four equal groups: sham operation, I/R, I/R+HBO and I/R+O(3). One session of 60 min, 3 ATA, 3-4 L/min, 100% oxygenation was defined as one dose of HBO. First dose of HBO was administrated 72 h before ischemia. Subsequent, one-dose of HBO administrated per 12 hours until ischemia time (total seven doses); 0.7 mg/kg ozone/oxygen mixture intraperitoneally was defined as one dose of ozone. First dose of O(3) was administered 72 h before ischemia (total four doses). I/R model was induced in anesthetized rats by unilateral (right) femoral artery clipping for 2 h followed by 22 h of reperfusion. The right tibia and were harvested. Tissue was assayed for levels of malondialdehyde (MDA) and protein carbonyl (PCO), activities of superoxide dismutase (SOD), and glutathione peroxidase (GSH-Px). RESULTS MDA and PCO levels were increased in I/R group. SOD activity was increased; GSH-Px activity was decreased in I/R group. MDA and PCO levels were decreased, SOD and GSH-Px activities were increased in both HBO+I/R and O(3)+I/R groups. CONCLUSION It has been shown that levels of MDA and PCO in bone were increased followed by 2 h of ischemia and 22 h of reperfusion period. Ozone-PC and HBO-PC has protective effect against skeletal bone I/R injury by decreasing levels of MDA and PCO, increasing activities of SOD and GSH-Px in rats.

Evaluation and Comparison of the Effects of Hyperbaric Oxygen and Ozonized Oxygen as Adjuvant Treatments in an Experimental Osteomyelitis Model

BACKGROUND We evaluated and compared the efficacy of ozone (O(3)) and hyperbaric oxygen (HBO) therapies in an experimental rat model of osteomyelitis. MATERIALS AND METHODS Forty-eight male Sprague-Dawley rats were divided into sham, osteomyelitis (control), vancomycin (V), vancomycin + HBO (VHB), vancomycin + O(3) (VO), and vancomycin + HBO + O(3) (VOHB) groups. Osteomyelitis was induced by a bone injection of 10(8) CFU/mL methicillin-resistant Staphylococcus aureus. HBO was administered daily at 2.8-atm pressure for 90 min; O(3) therapy was provided as intraperitoneal injections of 0.7 mg/kg O(3)/O(2) gas mixture once daily. Treatments were continued from d 7 to 21 after induction of osteomyelitis. Bone tissues and blood samples were harvested for biochemical, histopathologic, and microbiologic analyses. RESULTS Rats in the sham, VO, and VOHB groups gained weight but those in the control, V, and VHB groups did not. Levels of malondialdehyde, superoxide dismutase, and glutathione peroxidase were lower in the VHB, VO, and VOHB groups than in V and control groups. Levels of interleukin-10 and -1β and tumor necrosis factor-α were decreased in the VHB, VO, and VOHB groups; transforming growth factor-β was increased in these groups compared with V and control groups (P ≤ 0.001). Bacteria counts in VOHB were significantly lower than those in group of V (P = 0.012). Histopathologic scores in group VO were significantly lower than those in group V (P = 0.046). CONCLUSIONS O(3) was as effective as HBO in decreasing oxidative parameters and inflammatory cytokines. Rats in the VO and VOHB groups gained more weight than did the other groups. Bacteria counts were significantly decreased in group VOHB compared with the other groups. Histopathologic scores in group VO were significantly decreased compared with the other groups.

Anterosuperior calcaneal process fracture or OS calcaneus secundarius

A 36-yr-old woman was admitted to our emergency department after having sustained an inversion injury of her right ankle. On physical examination, there was diffuse swelling and ecchymosis on the dorsolateral aspect of her foot. The ankle joint movements were in normal range without laxity. The anteroposterior and lateral x-rays of the right foot were considered to be normal by the emergency physician. The patient was diagnosed with simple ankle sprain and was treated accordingly with classical RICE protocol and a nonsteroidal antiinflammatory drug. Four weeks after the initial trauma, the patient presented to our orthopedic outpatient clinic with persistent complaint of right foot pain on weight bearing. On physical examination, severe pain on the dorsal part of the calcaneocuboid joint was present. The initial anteroposterior and lateral x-rays were reevaluated, and a fracture was suspected at the anterior calcaneal process (Fig. 1A). Medial oblique foot x-ray revealed a bony fragment located between the anterosuperior calcaneal process and the cuboid (Fig. 1B). In the differential diagnosis, anterosuperior calcaneal process fracture and OS calcaneus secundarius were considered. Further computed tomography imaging delineated the anatomy of the fragment better, while the ovoid shape, well corticated margins, regular interface, and blunt edges of the fragment supported the diagnosis of OS calcaneus secundarius, wide proximal base and considerably large size favored the anterosuperior calcaneal process fracture. Magnetic resonance imaging was eventually performed and, with the presence of bone marrow edema adjacent to the fracture line, an anterosuperior calcaneal process fracture rather than an OS calcaneus secundarius was confirmed at diagnosis (Fig. 2). She was treated with a medial longitudinal arc support, and after 1 mo, she was free of pain during mobilization. OS calcaneus secundarius and anterosuperior calcaneal process fractures are two similar clinical syndromes, both of which present with anterior ankle pain. The differentiation of these two entities may be quite challenging only with physical examination or classical x-rays. Herewith, we imply that the distinction may be possible when oblique x-rays or, even better, magnetic resonance imaging is performed. This is important because the treatment of each syndrome is different.

Adjunctive hyperbaric oxygen therapy in the treatment of atrophic tibial nonunion with Ilizarov external fixator: a radiographic and scintigraphic study in rabbits*

OBJECTIVE The aim of this experimental study was to determine the effects of adjunctive hyperbaric oxygen therapy (HBO) on atrophic tibial nonunion treatment using Ilizarov external fixator. METHODS Twenty New Zealand white rabbits were randomly divided into two equal groups. A circular external fixator was applied to the right tibia of all the rabbits. A 5-mm bone block was resected and a tibial pseudarthrosis was obtained after a 6-month waiting period. The experimental group rabbits (n=10) underwent daily 2.5 ATA HBO therapy for 2 hours for 20 days and the control group rabbits (n=10) did not receive any corresponding treatment. Osteoblastic activity was evaluated with bone scintigraphy on days 30 and 90. Fracture healing was evaluated by plain radiographs on days 30 and 90. RESULTS On Day 30, radiological scores were statistically similar in both groups (p=0.167). However, on Day 90, the experimental group displayed significantly higher radiological scores (p<0.001). Osteoblastic activity was also higher in the experimental group on both scintigraphic assessments (p=0.005 and p=0.001). CONCLUSION The results of this study suggest that HBO can be used as a supplementary therapy in the management of atrophic tibial nonunion.

A case of Nicolau syndrome treated with hyperbaric oxygen

A 3-year-old boy with a Nicolau Syndrome (NS) on the left side of the body and the limbs after benzathine penicilline injection is reported. To the authors’ best knowledge, this is the first report of hyperbaric oxygen used in the late treatment of NS preventing the progress of the necrosis and therefore limiting the amputation level.

Congenital agenesis of pubic bones: a case report

Congenital absence of bilateral pubic bones is extremely uncommon. A 2-year-old boy presented with a history of intoeing at our outpatient clinic. The testes were found located at the inguinal canal on ultrasonography. A pelvic radiograph and a spiral computed tomography scan of the pelvis with three-dimensional reconstruction revealed the absence of both pubic bones. In conclusion, we report that the absence of the pubic bones, either as an isolated finding or associated with undescended testes, is peculiar.