Impact of surgery simulation using a 3-dimensional printed model on outcomes of hallux valgus surgery with distal chevron osteotomy: A randomized controlled trial.

OBJECTIVE:  This study aimed to compare the outcomes of traditional surgery (TS) with those of a 3-dimensional model-assisted surgery (3DS) in hallux valgus (HV) surgery with distal chevron osteotomy. METHODS: This randomized controlled trial study included 30 patients randomly grouped as TS and 3DS. In the 3DS group, the surgery was simulated on the 3D model before surgery, and that simulation was used as a guide during surgery. Various parameters, such as angles of the HV, intermetatarsal (IM), and distal metatarsal articular, were measured pre-surgery and during the final follow-up. The extent of lateralization of the first metatarsal (FM) head and plantar displacement of the FM head were assessed. Metrics like the duration of the osteotomy+lateralization+K wire fixation, tourniquet time, and fluoroscopy usage were recorded. All assessments were conducted independently and blindly. Patients remained unaware of their group allocation and the randomization procedure. RESULTS: Both groups showed no statistical differences in gender, operated side, age, or follow-up duration. For instance, in the 3DS group (n=15, age: 44.6 ± 9.6 years, male/female: 14/1, side right/left: 11/4, follow-up duration: 29.4 ± 8.7 months) and TS group (n=15, age: 44.8 ± 9.6 years, male/female: 13/2, side right/left: 10/5, follow-up duration: 28.8 ± 8.4 months). The 3DS group, however, showed better metrics with osteotomy+lateralization+K wire fixation, tourniquet duration, and number of fluoroscopies at 12.4 ± 1.2 minutes, 41.5 ± 3.8 minutes, 2.5 ± 0.6 times. In contrast, the TS group recorded 17.1 ± 1.5 minutes, 50.8 ± 3.4 minutes, and 3.3 ± 0.8 times, respectively (P <.001 for all). The 3DS group also achieved a more significant restoration of the IM angle (P < .001). Postsurgery, the 3DS group demonstrated superior outcomes in FM head lateralization, FM shortening, and plantar displacement (P <.001, P <.001 and P = .006, respectively, for all metrics). Only 1 patient in the 3DS group experienced a pin-tract infection, which was treated with wound care and oral antibiotics. CONCLUSION: Simulating surgery on a 3D model and using it as a guide significantly enhances surgical outcomes. Benefits include reduced operation time, tourniquet duration, decreased fluoroscopy usage, and improved first-ray alignment. The 3DS method also ensures better lateralization of the first metatarsal head and correction of the IM. Although 3D model-assisted HV chevron osteotomy surgery provides ideal deformity correction, it does not significantly affect postoperative functional outcomes. LEVEL OF EVIDENCE: Level I, Therapeutic Study. Cite this article as:Süer O, Özer MA, Govsa F, Öztürk AM, Aktuglu SK. Impact of surgery simulation using a 3-dimensional printed model on outcomes of hallux valgus surgery with distal chevron osteotomy: A randomized controlled trial. Acta Orthop Traumatol Turc., 2024;58(2):95-101.

Should the level of the posterior instrumentation combined with the intermediate screw be a short segment or a long segment in thoracolumbar fractures with fusion to the fractured segment?

PURPOSE: It was aimed to compare the results of long segment posterior instrumentation with intermediate pedicular screw + fusion at the level of the fractured segment including one vertebra above and one below the fractured vertebra (LSPI) and short segment posterior instrumentation with intermediate pedicular screw + fusion at the level of the fractured segment including one vertebra above and one below the fractured vertebra (SSPI) in the surgical treatment of thoracolumbar vertebral fractures. METHODS: Ninety patients with thoracolumbar vertebral (T11-L2) fractures operated between March 2015 and February 2022 were included in this retrospective study. The patients were divided into two groups as those who underwent LSPI (n, 54; age, 40.3) and those who underwent SSPI (n, 36; age, 39.7). Radiological evaluations like vertebral compression angle (VCA), vertebral corpus heights (VCH), intraoperative parameters, and complications were compared between the groups. RESULTS: Correction in early postoperative VCA was statistically significantly better in LSPI (p = 0.003). At 1-year follow-up, postoperative VCA correction was significantly more successful in LSPI (p = 0.001). There was no difference between the two groups in terms of correction loss in VCA measured at 1-year follow-up. There was no statistically significant difference between the two groups in terms of postoperative VCH, VCH at 1-year follow-up, and correction loss in VCH. CONCLUSION: LSPI provides better postoperative kyphosis correction of the fractured vertebra than SSPI. Regarding the segment level of posterior instrumentation, there was no difference between the two groups in terms of the loss of achieved correction of VCA, ABH, and PBH at 1-year follow-up. Operating a thoracolumbar fracture with LSPI will lengthen the operation and increase the number of intraoperative fluoroscopies compared to SSPI.

An investigation into the frequency and risk factors of low back pain following surgical treatment of isolated calcaneal fractures.

OBJECTIVE: This study aimed to determine the frequency of low back pain after calcaneal fractures treated with open reduction internal fixation (ORIF) and the risk factors that cause this condition. METHODS: Thirty-one patients (27 males and 4 females) who underwent surgery for a unilateral calcaneal fracture between 2016 and 2020 and had no complaints of low back pain before fracture surgery were included in the study. The patients were divided into 2 groups: those who developed low back pain after the operation and those who did not. Patients were evaluated with the Life Quality Short Form SF-36, the Oswestry Disability Index (ODI), and American Orthopedic Foot-Ankle Association Score (AOFAS). Sanders' fracture type, joint range of motion (ROM) measurements of injured and uninjured limbs, maximal isometric muscle strength measurements, balance on 1 leg with pedobarographic measurements, and walking time were evaluated. The obtained data were compared among the 2 groups. RESULTS: Low back pain was observed in 71% of the patients and was detected after an average of 6 months from the operation. In ODI, 59.1% of the patients reported that low back pain limited their lives slightly. Patients with low back pain have lower AOFAS scores and worse SF-36 physical functionality than those without low back pain (P < .001, P=.016). Balance time on 1 foot in pedobarographic measurements, foot in ROM, ankle in ankle active, passive plantar flexion, inversion, active hip, passive internal, external rotation, muscle is the foot eversion force. In these measurements, the values of the injured side are intact. It was statistically significantly lower than the other side (interaction P < .1). CONCLUSION: Low back pain may occur after unilateral calcaneal fractures treated by ORIF. This may be caused by decreased angles of ankle dorsi and plantar flexion, foot inversion, hip abduction, and internal and external rotation. In the rehabilitation program, not only the ankle region but also the hip joint of the affected side should be included, and the kinetic chain that describes the interaction mechanism of the human body should not be forgotten. LEVEL OF EVIDENCE: Level IV, Prognostic Study.

The effect of the size of pedicle screw on the long-term radiological and clinical results of short-segment posterior instrumentation in the management of thoracolumbar vertebral fractures.

OBJECTIVE: It was aimed at evaluating the effect of the size of the pedicle screw placed on the fractured vertebra on the long-term radiological and clinical results of short-segment posterior instrumentation applied in the surgical treatment of thoracolumbar vertebral fractures. METHODS: This retrospective study included 36 patients who underwent short-segment posterior instrumentation surgery for a single-level thoracolumbar (T11-L2) fracture between January 2015 and March 2021. The patients included in the study were divided into 2 groups according to the size of the pedicle screw placed in the fractured vertebra (group A: intermediate screw 4.5 mm, ≤35 mm+less than 50% of the vertebral corpus length, m/f: 13/4, n: 17, age: 36.5; group B: intermediate screw 5.5 mm, ≥40 mm+more than 70% of the vertebral corpus length, m/f: 11/8, n: 19, age: 42.6). All patients were periodically evaluated clinically and radiologically. Vertebral compression angle (VCA), anterior and posterior vertebral body height (ABH-PBH), intraoperative parameters (instrumentation time and intraoperative fluoroscopy number), and complications were compared between the 2 groups. RESULTS: Both groups were comparable with respect to age, sex, level of injury, AO classification, mechanism of injury, and American Spinal Cord Injury Association impairment scale. Restoration of VCA and vertebral corpus heights was achieved sufficiently in both groups after operation (P < .0001). There was no significant difference between the 2 groups in terms of early postoperative VCA, VCA measured at final follow-up, or loss of correction in VCA. At the last follow-up, PBH was statistically significantly better preserved in group B (P=.0424). There was no difference between the 2 groups in terms of operation time and the number of intraoperative fluoroscopies. Implant failure was observed in 1 patient in group A. CONCLUSION: This study has revealed that using a long, thick pedicle screw placed in the fractured vertebra can better preserve the PBH at the final follow-up. No correlation was found between the size of the intermediate screw and the preservation of the correction in the postoperative vertebral heights and VCA during the follow-up. LEVEL OF EVIDENCE: Level III, Therapeutic Study.

Factors affecting return to work time and functional outcome after low-velocity gunshot injuries related to foot in civilian population.

BACKGROUND: Purpose of this study was to identify factors affecting return to work time and functional outcomes after low-velocity gunshot injuries related to foot. Related complications are also analyzed. METHOD: This study conducted as retrospective cohort study in tertiary care university hospital. Data on 26 patients obtained through retrospective database search. Type of causing weapon, anatomic location of wound, wound type according to Gustilo Anderson classification, extend of damage regarding injured structures, extend of soft tissue damage, duration of hospital stay, need of reconstructive surgery, return-to-work time, follow-up period and functional scores at final follow-up were recorded. Factors affecting functional outcome and return-to-work time were analyzed. RESULTS: Total of 12 patients (46.2 %) experienced complications, with eight being deep soft tissue infections. The mean MFS score for the study group was 77.27 (±11.82). The mean MFS for the pistol group was 83.46 (±6.90), extent of soft tissue damage was an independent risk factor (OR 10.67, 95 % CI 1.70-66.72, p = 0.011) for poor outcomes. On average, patients took 10.12 months (±7.59) to return to work, the type of gun used was an independent variable associated with delayed return to work (OR 144, 95 % CI 8.04-2578.09, p = 0.011). CONCLUSION: Gunshot injuries related to foot can lead to a high rate of complications, loss of workdays, and permanent functional losses. Therefore, it is crucial to develop appropriate treatment plans and manage inevitable complications in these injuries. LEVEL OF EVIDENCE: Level IV, Case series.

Efficacy of telemedicine applications in patients with diabetic foot ulcers: A focus on mortality and major amputation rates.

Amputations related to diabetic foot ulcers (DFU) are associated with high morbidity and mortality rates. Glycaemic control and close follow-up protocols are essential to prevent such ulcers. Coronavirus disease (COVID) related restrictions and regulations might have a negative impact on patients who are with DFU or candidates for DFU. We retrospectively analysed 126 cases that had DFU underwent amputation surgery. Comparative analyses were done between cases that were admitted before COVID restrictions (Group A) and cases admitted after COVID restrictions (Group B). Two groups were homogenic demographically. There was no significant difference between groups in terms of mortality (p = 0.239) and amputation rates (p = 0.461). The number of emergent cases in the pandemic period doubled the number in pre-pandemic period even though this finding was not statistically significant (p = 0.112). Fastly adapted consulting practice and follow-up protocols to compensate for the problems created by COVID-related regulations seem to be effective in terms of mortality and amputation rates.

Predictive Value of Complete Blood Count, Venous Blood Gas Measurements, and Glucose/Potassium Ratio for Delayed Neuropsychiatric Syndrome in Children with Acute Carbon Monoxide Poisoning Due to Coal-Burning Stove.

OBJECTIVE: Delayed neuropsychiatric syndrome may occur after carbon monoxide poisoning has completely healed. The literature on indicators to predict delayed neuropsychiatric syndrome in pediatric patients is limited. The aim of the study is to investigate the effectiveness of complete blood count parameters, neutrophil/lymphocyte ratio, platelet/lymphocyte ratio, systemic immune inflammation index, glucose/potassium ratio, venous blood gas parameters, and carboxyhemoglobin in predicting delayed neuropsychiatric syndrome in children with carbon monoxide poisoning due to coal-burning stove. MATERIALS AND METHODS: The patients admitted to the pediatric emergency department with acute carbon monoxide poisoning between 2014 and 2019 were analyzed. The patients were divided into 2 groups as delayed neuropsychiatric syndrome (+) and delayed neuropsychiatric syndrome (-). Neutrophil/lymphocyte ratio, platelet/lymphocyte ratio, systemic immune inflammation index (platelet count×neutrophil count/lymphocyte count), and glucose/ potassium ratio were calculated. RESULTS: Of the 137 patients, 46 were diagnosed with delayed neuropsychiatric syndrome within 1 year of carbon monoxide poisoning. A control group was formed from 137 age- and sexmatched children. Glasgow Coma Scale < 15 was found in 11% of patients with delayed neuropsychiatric syndrome (-) and 8.7% of patients with delayed neuropsychiatric syndrome (+) (P = .773). Blood glucose, potassium, glucose/potassium ratio, platelet/lymphocyte ratio, white blood cell, neutrophil count, lymphocyte count, neutrophil/lymphocyte ratio, systemic immune inflammation index, venous partial pressure of carbon dioxide, carboxyhemoglobin, and methemoglobinemia levels were significantly different between control, delayed neuropsychiatric syndrome (+), and delayed neuropsychiatric syndrome (-) groups (P < .05). The most effective predictors for delayed neuropsychiatric syndrome were systemic immune inflammation index (area under the curve = 0.852; cut-off value > 1120; sensitivity = 89.1%; specificity = 75.8%), neutrophil (area under the curve = 0.841; cut-off value > 8000/mm3; sensitivity = 78.2%; specificity = 79.1%), and neutrophil/lymphocyte ratio (area under the curve = 0.828; cut-off value > 4; sensitivity = 78.2%; specificity = 75.5%). CONCLUSION: About one-third of children with carbon monoxide poisoning due to coal-burning stove develop delayed neuropsychiatric syndrome. Systemic immune inflammation index, neutrophil count, and neutrophil/lymphocyte ratio obtained immediately after the poisoning in the pediatric emergency department may be effective predictors for delayed neuropsychiatric syndrome.

Patient-specific three-dimensional printing spine model for surgical planning in AO spine type-C fracture posterior long-segment fixation.

OBJECTIVE: The aim of this study was to compare duration of surgery, intraoperative fluoroscopy exposure, blood loss and the accuracy of pedicular screw placement between 3D model-assisted surgery and conventional surgery for AO spinal C-type injuries. METHODS: In this study 32 patients who were admitted with thoracolumbar AO spinal C-type injuries were included. These patients were divided randomly into two groups of 16 where one group was operated on using conventional surgery and the other group was operated on using 3D model-assisted surgery. During surgery, instrumentation time, amount of blood loss and intraoperative fluoroscopy exposure were recorded. Moreover, the status of the screws in the pedicles was assessed as described by Learch and Wiesner's and regional sagittal angles (RSA) were measured preop and postoperatively. RESULTS: It was found that there was a statistically significant difference in instrumentation time, blood loss and intraoperative fluoroscopy exposure in the 3D model-assisted surgery group (61.9 ± 4.7 min, 268.4 ± 42.7 ml, 16.3 ± 1.9 times) compared to the conventional surgery group (75.5 ± 11.0 min, 347.8 ± 52.2 mL, 19.7 ± 2.4 times) (t=4.5325, P < 0.0001 and t=4.7109, P < 0.0001 and t=4.4937, P < 0.0001, respectively) Although the screw misplacement rate of the conventional surgery group was higher than that of the 3D model-assisted surgery group, the only statistically significant difference was in the medial axial encroachment (t=5.101 P=0.02) . There was no severe misplacement of pedicle screws in either group. There were no statistically significant differences between postoperative RSA angles and were in both groups restored significantly. CONCLUSION: The results of this study have shown us that the 3D model helps surgeons see patients' pathoanatomy and determine rod lengths, pedicle screw angles and lengths preoperatively and peroparatively, which in turn shortens operative time, reduces blood loss and fluoroscopy exposure. LEVEL OF EVIDENCE: Level I, Therapeutic Study.

Evaluation of the effects of using 3D - patient specific models of displaced intra - articular calcaneal fractures in surgery.

BACKGROUND: It was aimed to compare conventional surgery and three-dimensional (3D) model-assisted surgery used in the treatment of calcaneal fractures. MATERIALS & METHODS: A total of 37 patients with unilateral calcaneal fractures were randomly divided into two groups as a conventional surgery group (n: 19) and a 3D model-assisted surgery group (n: 18). The preoperative, postoperative and last follow up angles of the Bohler and Gissane, calcaneal width and facet height were measured. The duration of the operation, blood loss volume, fluoroscopy usage, instrumentation time for both groups were recorded. Finally, the follow-up AOFAS scores were evaluated. A questionnaire was used to determine the perceptions of the resident doctors about the 3D model. RESULTS: The duration of the operation, blood loss volume, fluoroscopy usage, instrumentation time for 3D model-assisted surgery group were 83.3 ± 4.6 minutes, 83.6 ± 4.6 ml, 6.8 ± 1.4 times and 13.0 ± 0.8 weeks, and as for conventional group they were 130.0 ± 5.8 minutes, 105.1 ± 5.6 minutes, 11.7 ± 1.5 ml, 22.2 ± 2.4 times and 13.3 ± 0.8 weeks, respectively (p < 0.0001). The both groups significantly restored Bohler angle, Gissane angle, calcaneal width and calcaneal facet height after operation (p < 0.0001). The 3D model-assisted group was significantly more succesful in restoration and protection of achieved correction of calcanel facet height (p < 0.0001). The difference was determined among the groups at the final follow-up examination with respect to the amount of change according the values achieved post-op. were significant in Bohler angle (p < 0.001), calcaneal facet height (p < 0.0001) and calcaneal widht (p = 0.017). There was no significant difference between AOFAS scores of the two groups at last follow-up. Resident doctors exhibited high scores of overall satisfaction with the use of a 3D printing model. CONCLUSIONS: Compared to the conventional group, the 3D model-assisted group provide successful intervention and reduce operation, instrumentation time and the fluoroscopy usage with less blood loss. Performing 3D-assisted surgery helps the quality of reduction during the surgery and stability of internal fixation to protect achieved reduction at follow-up more succesfully.

Is there a relationship between thyroid hormone levels and suicide attempt in adolescents?

Abstract Background: Thoughts about suicide are quite common in adolescent. While such thoughts can be caused by many reasons, the most well-known of these are mood disorders. There are studies related to coexistence of thyroid pathologies and mood disorders in adult. Objectives: In this study, we aimed to investigate the difference of thyroid hormone levels in between adolescents with suicide attempt history and normal population. Methods: The study was prospective and was designed as a case-control study. Demographic characteristics of the patients were obtained and Serum fT3, fT4 and TSH levels were examined. Results: 222 cases were included in the study, including 101 cases and 121 controls. As for TSH levels, the mean serum levels of the whole group was 1.96 ± 1.08 mU/L, while the mean serum levels of the control group was 2.33 ± 1.5 mU/L and the mean serum levels of the case group was 0.50 ± 0.3 mU/L which revealed that the mean serum levels of the case group was significantly lower (p<0.01). Conclusion: It was found that serum TSH levels were significantly lower in case group than control group and the individuals with subclinical hyperthyroidism had more suicide attempts than the ones in control group.

Three-Dimensional Printed Anatomical Models Help in Correcting Foot Alignment in Hallux Valgus Deformities.

BACKGROUND: Hallux valgus (HV) is the most common pathologic entity affecting the great toe. The goal of corrective surgery is to restore foot mechanics and provide pain relief. The purpose of the study was to create individual angle using life-size foot models with three-dimensional (3D) printing technology to design a section on HV osteotomy. MATERIALS AND METHODS: Ten female patients with a diagnosis of HV were included. Radiologic [HV angle and intermetatarsal (IM) angle] and clinical [American Orthopaedic Foot and Ankle Score (AOFAS)] assessment was done pre- and postoperatively. All the operations were planned together with 3D life-size models generated from computed tomography (CT) scans. Benefits of using the 3D life-size models were noted. The 3D model's perception was evaluated. RESULTS: The mean AOFAS score, mean HV, and IM angles had improved significantly (P < 0.05). The visual and tactile inspection of 3D models allowed the best anatomical understanding, with faster and clearer comprehension of the surgical planning. At the first tarsometatarsal joint, the HV models showed significantly greater dorsiflexion, inversion, and adduction of the first metatarsal relative to the medial cuneiform. At the first metatarsophalangeal joint, the HV models showed significantly greater eversion and abduction of the first proximal phalanx relative to the first metatarsal. It provided satisfactory results about operation time and blood loss. 3D model's perception was statistically significant (P < 0.05). CONCLUSION: 3D models help to transfer complex anatomical information to clinicians, which provide guidance in the preoperative planning stage, for intraoperative navigation. It helps to create a patient-specific angle section on osteotomy to correct IM angle better and improve postoperative foot function. The 3D personalized model allowed for a better perception of information when compared to the corresponding 3D reconstructed image provided.

A retrospective comparison of the conventional versus three-dimensional printed model-assisted surgery in the treatment of acetabular fractures.

OBJECTIVE: The aim of this study was to compare the clinical and radiological outcomes of the conventional versus individualized three-dimensional (3D) printing model-assisted pre-contoured plate fixation in the treatment of patients with acetabular fractures. METHODS: The data from 18 consecutive patients who underwent surgery for the acetabular fractures were retrospectively analyzed. The patients were divided into two groups (9 in each): conventional and 3D printed model-assisted. The groups were then compared in terms of the duration of surgery, time of instrumentation, time of intraoperative fluoroscopy, and volume of blood loss. The quality of the fracture reduction was also evaluated postoperatively by radiography and computed tomography in both the groups. The quality of the fracture reduction was defined as good (<2 mm) or fair (>2 mm) based on the amount of displacement in the acetabulum. RESULTS: The conventional group included 9 patients (9 males; mean age=41.7 years; age range=16-70) with a mean follow-up of 11.9 months (range=8-15); the 3D printed model-assisted group consisted of 9 patients (9 males; mean age=46.2 years; age range=30-66) with a mean follow-up of 10.33 months (range=7-17). The average duration of surgery, mean time of instrumentation, time of intraoperative fluoroscopy, and mean volume of blood loss were 180.5±9 minutes, 36.2±3.6 minutes, 6±1 times, and 403.3±52.7 mL in the 3D printed model-assisted group, and 220±15.6 minutes, 57.4±10.65 minutes, 10.4±2.2 times, and 606.6±52.7 mL in the conventional group, respectively. Procedurally, the average duration of surgery, mean time of instrumentation, and mean time of fluoroscopy were significantly shorter, and the mean volume of blood loss was significantly lower in the 3D printed model-assisted group (p<0.05). The quality of the fracture reduction was good in 7 patients (78%) in the conventional group and 8 patients (89%) in the 3D printed model-assisted group. CONCLUSION: As compared with the conventional surgery, the 3D printing model-assisted pre-contoured plate fixation technique can improve the clinical and radiological outcomes of the acetabular fractures, with shorter surgery, instrumentation, intraoperative fluoroscopy times, and blood loss. LEVEL OF EVIDENCE: Level III, Therapeutic study.

Surgical advantages of using 3D patient-specific models in high-energy tibial plateau fractures.

PURPOSE: Treatment of tibial plateau fractures are difficult due to the intra-articular nature of the proximal tibia and extensive involvement of the soft tissue envelope. In this study, we investigated the surgical experience acquired using digitally designed life-size fracture models to guide as a template to place plates and screws in the treatment of tibial plateau fractures and anatomic reduction of joint. METHODS: 20 tibial plateau frature patients were divided into two equal surgery groups as conventional versus 3D model assisted. The fracture line angles, depression depth, and preoperative/postoperative Rasmussen knee score were measured for each patient. RESULTS: The duration of the operation, blood loss volume, turniquet time and number of intraoperative fluoroscopy was 89.5 ± 5.9 min, 160.5 ± 15.3 ml, 74.5 ± 6 min and 10.7 ± 1.76 times, for 3D printing group and 127 ± 14.5 min, 276 ± 44.8 ml, 104.5 ± 5.5 min and 18.5 ± 2.17 times for the conventional group, respectively. 3D model-assisted group indicated significantly shorter operation time, less blood loss volume, shorter turniquet and fluoroscopy times, and better outcome than the conventional one. CONCLUSIONS: The customized 3D model was user friendly, and it provided a radiation-free tibial screw insertion. The use of these models assisted surgical planning, maximized the possibility of ideal anatomical reduction and provided individualized information concerning tibial plateau fractures.

Patient-Specific Three-Dimensional Model for a Safe Surgical Pathway in Sacral Chondrosarcoma.

Sacral tumors are amongst the most challenging procedures to treat because of the complex anatomy. This study determined whether patient-specific models change preoperative planning decisions made in preparation for en bloc resection of complex sacral mass surgical procedures. Imaging showed a big encapsulated mass at the S2-3 level involving the neural foramina and obscuring the nerve roots. High-resolution images were acquired and utilized to generate a patient-specific 3D tumor model. The visual and tactile inspection of 3D models allowed the best anatomical understanding, with faster and clearer comprehension of the surgical anatomy. The 3D sacral model was for observation of previously unapparent anatomical details; with this new technology, surgeon can observe their planned surgical intervention, explore the patient-specific anatomy and extension of the tumor, and sharpen their procedure choices. Moreover, multiple planes showed how far the angles on the plane would extend for osteotomy of the sacrum. Another result was identifying correct guides and safe venture landmarks. The study helped to establish safe osteotomy line wherever the nerve roots were retained and enabled osteotomy by preserving bilaterally the S1 and S2 nerve roots for wide excision of wide excision of primary sacral tumor to get adequate bowel and bladder functions. Finally, it helped to determine whether or not the remaining bone in the sacrum is sufficient for spinopelvic stability and needed fixation. It was decided spinopelvic fixation was not necessary for this case. Surgical intervention of sacral tumors varies depending on the tumor, its size, extension, and location. Surgery can have profound risks including unnecessary nerve root resection spinopelvic instability and suboptimal oncological resection. 3D models help to transfer complex anatomical information to clinicians and provide guidance in the preoperative planning stage, for intraoperative navigation and for surgical training purposes.

Multidisciplinary Assessment of Planning and Resection of Complex Bone Tumor Using Patient-Specific 3D Model.

Oncological interventions in thoracic cavity have some important problems such as choice of correct operative approaches depending on the tumor, size, extension, and location. In sarcoma surgery, wide resection should be aimed for the curative surgery. Purpose of this study was to evaluate pre-operative planning of patient-specific thoracic cavity model made by multidisciplinary surgeon team for complex tumor mass for oncological procedures. Patient's scans showed a large mass encroaching on the mediastinum and heart, with erosion of the adjacent ribs and vertebral column. Individual model of this case with thoracic tumor was reconstructed from the DICOM file of the CT data. Surgical team including six interdisciplinary surgeons explained their surgical experience of the use of 3D life-size individual model for guiding surgical treatment. Before patients consented to surgery, each surgeon explained the surgical procedure and perioperative risks to her. A questionnaire was applied to 10 surgical residents to evaluate the 3D model's perception. 3D model scans were useful in determining the site of the lesion, the exact size, extension, attachment to the surrounding structures such as lung, aorta, vertebral column, or vascular involvement, the number of involved ribs, whether the diaphragm was involved also in which order surgeons in the team enter the surgery. 3D model's perception was detected statistical significance as < 0.05. Viewing thoracic cavity with tumor model was more efficient than CT imaging. This case was surgically difficult as it included vital structures such as the mediastinal vessels, aorta, ribs, sternum, and vertebral bodies. A difficult pathology for which 3D model has already been explored to assist anatomic visualization was mediastinal osteosarcoma of the chest wall, diaphragm, and the vertebral column. The study helped to establish safe surgical line wherever the healthy tissue was retained and enabled osteotomy of the affected spinal corpus vertically with posterior-anterior direction by preserving the spinal cord and the spinal nerves above and distal the tumor. 3D tumor model helps to transfer complex anatomical information to surgeons, provide guidance in the pre-operative planning stage, for intra-operative navigation and for surgical collaboration purposes. Total radical excision of the bone tumor and reconstructions of remaining structures using life-size model was the key for successful treatment and better outcomes. The recent explosion in popularity of 3D printing is a testament to the promise of this technology and its profound utility in orthopedic oncological surgery.

First step toward a better trauma management: Initial results of the Northern Izmir Trauma Registry System for children.

BACKGROUND: Trauma is an important health problem in children, and improvement in national trauma care is only possible through the knowledge gathered from trauma registry systems. This information is not available in our country, because there is no current trauma registry system at the hospitals. Our aim is to explain the trauma registry system we have developed and present the first year's data. METHODS: The planned trauma registry system was integrated into the emergency department registry system of 14 hospitals in Izmir province. The data of pediatric multiple trauma patients have been recorded automatically through the registry system. Demographics, vital signs, mechanism, type of trauma, anatomical region, ISS, PTS, GCS, length of hospital stay and need for blood transfusion/endotracheal intubation/surgery/hospitalization were evaluated by patient transfer status and outcome. RESULTS: At the end of one year, a total of 356 pediatric major trauma patients were included in the study. The most common type of trauma was blunt trauma (91.9%) and the mechanism was vehicle-related traffic accidents (28.1%). In the group with the worse outcome than the Glasgow outcome score, age was greater, ISS was higher and PTS was lower. Motorcycle accidents, sports injuries, and penetrating injuries were more frequent in this group. All the scales were significantly different between direct and transferred patients. The referral time to the hospital of the transferred patients were longer than directly admitted patients, but the results were not different. CONCLUSION: Pediatric major trauma is an important cause of mortality and morbidity, and our trauma registry system, which is a successful example abroad, is not enough in the country. We hope that the trauma registry system we planned and started the pilot application will be expanded to include other hospitals throughout the country with the aim of developing a national registry system.

A neglected causative agent in diabetic foot infection: a retrospective evaluation of 13 patients with fungal etiology

Background/aim: Clinicians often neglect fungal infections and do not routinely investigate deep tissue from the wound for fungal culture and sensitivity due to insufficient information in the literature. In this study, we aimed to evaluate fungal etiology of invasive fungal diabetic foot which is rarely reported in the literature. Materials and methods: The patients who were unresponsive to antibiotic therapy and those with positive fungal in bone or deep tissue culture were enrolled in the study. Detailed hospital records were retrieved for demographics and clinical features. Results: A total of 13 patients who were diagnosed with invasive fungal diabetic foot (ten females, three males, mean age 59.8 ± 9 years) were included. All of the patients had type-2 diabetes mellitus. Eleven (84.6%) patients had mixed infection. The most common cause of fungal infections of diabetic foot ulcers was the Candida species. Ten (76.9%) patients underwent amputation, two (15.4%) patients refused amputation, and one patient died before surgery. Conclusion: Invasive fungal infections may also be a causative pathogen in deep tissue infections. Therefore, fungal pathogens should be considered in patients unresponsive to long-term antibiotic therapy. Early detection of fungal infections in high-risk individuals is critical for the prevention of severe consequences such as foot amputation.

Human myiasis in patients with diabetic foot: 18 cases.

BACKGROUND: Myiasis complication of diabetic foot ulcer has only been presented in a few case reports. Therefore, there is a need for additional data on this infestation. OBJECTIVE: Evaluate clinical characteristics of human myiasis in patients with diabetic foot. DESIGN: Case series. SETTINGS: A tertiary referral healthcare institution and a diabetic foot center. PATIENTS AND METHODS: Patients with diabetic foot infection com.plicated by myiasis who were admitted between June 2012 and July 2017. MAIN OUTCOME MEASURES: Bacterial infection rate, accompanying bacterial agents, amputation (morbidity) and mortality rate. SAMPLE SIZE: 18. RESULTS: Eight (44.4%) of the patients were female. Sixteen (88.9%) had moderate-to-severe infections; 15 (83.3%) had necrotic tissue. Larval debridement therapy was performed on all patients at the bed.side in consecutive sessions. A third-stage larva of Calliphora was detected in one case (5.6%). Second- and third-stage larvae of Lucilia sericata were detected in 5 (27.8%) and 7 (38.9%) patients, respectively. All the patients had a bacterial infection with myiasis. Twelve (66.7%) patients underwent amputation. Three (16.7%) patients died. Myiasis was more frequent in the months of May, June and July. CONCLUSION: To our knowledge, this is the largest reported series of cases of diabetic foot with myiasis. The most common parasitic agent was Lucilia sericata. Bacterial soft tissue infections were observed in all cases. Poor hygienic conditions were noteworthy and all patients were in need of radical surgery. Myiasis complication of diabetic foot is more frequently seen in the spring and summer. LIMITATIONS: Insufficient follow-up time for analysis of possible confounding factors. CONFLICT OF INTEREST: None.

[Simultaneous detection of respiratory viruses and influenza A virus subtypes using multiplex PCR]. / Solunum viruslari ve influenza A virus alt tiplerinin multipleks PCR yöntemi ile ayni anda saptanmasi

This study was conducted to investigate the respiratory viruses and subtyping of influenza A virus when positive by multiplex PCR in patients with flu-like symptoms, after the pandemic caused by influenza A (H1N1)pdm09. Nasopharyngeal swab samples collected from 700 patients (313 female, 387 male; age range: 24 days-94 yrs, median age: 1 yr) between December 2010 - January 2013 with flu-like symptoms including fever, headache, sore throat, rhinitis, cough, myalgia as defined by the World Health Organization were included in the study. Nucleic acid extractions (Viral DNA/RNA Extraction Kit, iNtRON, South Korea) and cDNA synthesis (RevertAid First Strand cDNA Synthesis Kits, Fermentas, USA) were performed according to the manufacturer's protocol. Multiplex amplification of nucleic acids was performed using DPO (dual priming oligonucleotide) primers and RV5 ACE Screening Kit (Seegene, South Korea) in terms of the presence of influenza A (INF-A) virus, influenza B (INF-B) virus, respiratory syncytial virus (RSV), and the other respiratory viruses. PCR products were detected by automated polyacrylamide gel electrophoresis using Screen Tape multiple detection system. Specimens which were positive for viral nucleic acids have been further studied by using specific DPO primers, FluA ACE Subtyping and RV15 Screening (Seegene, South Korea) kits. Four INF-A virus subtypes [human H1 (hH1), human H3 (hH3), swine H1 (sH1), avian H5 (aH5)] and 11 other respiratory viruses [Adenovirus, parainfluenza virus (PIV) types 1-4, human bocavirus (HBoV), human metapneumovirus (HMPV), rhinovirus types A and B, human coronaviruses (HCoV) OC43, 229E/NL63] were investigated with those tests. In the study, 53.6% (375/700) of the patients were found to be infected with at least one virus and multiple respiratory virus infections were detected in 15.7% (59/375) of the positive cases, which were mostly (49/59, 83%) in pediatric patients. RSV and rhinovirus coinfections were the most prevalent (18/29, 62.7%) dual infections. The distribution of 436 respiratory viruses identified from 375 patients were as follows; 189 (43.3%) RSV, 93 (21.4%) rhinovirus, 86 (19.8%) INF-A, seven (1.6%) INF-B, 22 (5%) PIV types 1-3, 14 (3.2%) HMPV, 11 (2.5%) HCoV, nine (2%) HBoV, and five (1.2%) adenovirus. Fifty-five (64%) out of 86 INF-A viruses were subtyped as hH3, 24 (27.9%) were sH1 and seven (8.1%) were hH1. Avian H5 was not detected in any samples. The overall prevalence rates of INF-A, INF-B, RSV and other respiratory viruses were 12%, 1%, 27%, and 14.6%, respectively. RSV was the most prevalent respiratory agent in pediatric (161/313, 51%) cases, while INF-A virus in adult (24/62, 38.7%) patients. Influenza viruses were detected as responsible pathogens in 13.3% (93/700) of the patients with flu-like symptoms. Among the cases, a 1-month-old baby was infected with three virus strains (INF-A hH1+INF-A sH1+HCoV OC43) and a 82-year-old patient was infected with two INF-A virus subtypes (hH3 + sH1). INF-A viruses were mostly detected (79/86) in winter period, from December to March. INF-A virus sH1, was the most prevalent subtype in flu cases till February 2011 (22/86), after replaced by INF-A virus hH3. Beginning from February 2012, a significant increase observed in the cases infected with INF-A virus subtype hH3 (39/86). In conclusion, the identification and surveillance of influenza virus types and subtypes circulating in populations have importance both for epidemiological data and selection of vaccine strains.