Effects of anesthesia and perioperative management on mortality in geriatric orthopedic surgery: a retrospective study of 451 patients.

OBJECTIVE: We aimed to investigate the effects of anesthesia methods and perioperative procedures on mortality in geriatric patients operated for hip fracture. PATIENTS AND METHODS: This retrospective study included patients over 65 years of age who underwent hip fracture surgery. Demographic data, risk scores, perioperative and anesthesia management were analyzed in terms of mortality. RESULTS: Data from 451 patients who were eligible for the study were analyzed. It was determined that there was no difference in mortality between the anesthesia methods administered to the patients in hip fracture surgery (p>0.05).  Being male increased the mortality risk by 4.568 times (95% CI: 1.215-17.168), and a one-unit increase in the number of erythrocyte suspensions given perioperatively increased the mortality risk by 2.801 times (95% CI: 1.509-5.197). Additionally, an American Society of Anesthesiologists (ASA) II score increased the mortality risk by 0.120 times (95% CI: 0.021-0.690), and a higher modified Charlson comorbidity index (mCCI) of 5-7 increased the mortality risk by 0.052 times (95% CI: 0.009-0.289). CONCLUSIONS: Although high ASA and mCCI scores, male sex, and blood transfusion were associated with mortality in geriatric hip fracture surgery, we found that the method of anesthesia did not affect mortality.

Adaptation process of the skin graft to vaginal mucosa after McIndoe vaginoplasty.

OBJECTIVE: There are many methods of treatment of vaginal agenesis. METHODS: In this study, patients who underwent McIndoe vaginoplasty were evaluated for development of vaginal mucosa. Vaginal pH measurements, smears, and punch biopsies were obtained from seven patients postoperatively at 3, 6, and 12 months after having McIndoe vaginoplasty. RESULTS: Neovaginal smears indicated no specific data for mucosal development at the 3rd and 6th month after the operation. However, Doderlein bacilli were determined at the 12th month. Histopathological examination of punch biopsies revealed dermal and subdermal thickening at the 3rd month, partial adaptation to mucosa at 6th month, and full adaptation to mucosa at 12th month. Also normal vaginal pH levels were recorded at the 12th month. CONCLUSION: As a result of the adaptation process, the split thickness skin graft acquired both histological and physiological characteristics of normal vaginal mucosa. Also, neovaginal epithelium was evaluated to be macroscopically similar to normal vaginal mucosa, 12 months after the operation.

Variations of hepatic veins: helical computerized tomography experience in 100 consecutive living liver donors with emphasis on right lobe.

Anatomical variations in the venous system of liver are not a rarity. A prospective helical computerized tomography (CT) study was undertaken to determine the prevalence of surgically significant hepatic venous anatomic variations among 100 consecutive living liver donors. The studies evaluated the ramification pattern of hepatic veins, the presence of accessory hepatic veins, and of segment 5 or 8 veins (or both) draining into middle hepatic vein. These data obtained by CT influenced surgical planning. Sixty-four donors donated their right lobes and 24 donors, left lateral segments. Only one donor candidate was refused due to combined hepatic and portal venous variations accompanied by multiple bile ducts. Eleven donors were also refused due to reasons other than anatomical variations. Seventeen segment 5 and 17 segment 8 veins draining into middle hepatic vein were anastomosed to inferior vena cava in 23 (36%) of the right lobe liver transplantations. The middle hepatic vein was harvested in only one of the donors. Among the 100 cases, 47 had accessory right inferior hepatic veins, 13 of which were multiple. Twenty-two of the right lobe grafts required surgical anastomoses of these accessory hepatic veins (34%). An isolated hepatic vein anomaly or the presence of accessory hepatic veins are not contraindications to be a living liver donor candidate. However, preoperative knowledge of vascular variations alters surgical management. Helical CT is a valuable tool to delineate the hepatic venous anatomy for surgical planning in living liver donors.

Interpupillary index: a new parameter for hypo-hypertelorism.

AIM: To establish a new clinical index to evaluate the presence of hypo-hypertelorism with greater accuracy. MATERIAL AND METHODS: After screening a wide range of population, 310 elementary school children (185 boys, 125 girls) aged 7-15 years were included in this study. For this cross-sectional study, a millimetre ruler was used. The anatomical interpupillary distance was measured by a modified Viktorin's method. In addition, inner and outer intercanthal distances were obtained. The data were analyzed by Student's t-test for two independent samples using SPSS for Windows. There were children with clinical hypertelorism (n = 92, group 1), children with large fronto-occipital circumference (FOC) (n = 101, group 2), and age- and sex-matched normal controls (n = 117, group 3). Due to variations in FOC among healthy subjects, we introduced a new practical concept for evaluation of interpupillary distance, namely the interpupillary index, the simple product obtained by dividing the interpupillary distance by the FOC, multiplied by 100. RESULTS: The overall idiopathic benign macrocephalic children (group 2) had significantly (p < 0.001) larger interpupillary distances (6.13 +/- 0.36 cm) and FOCs (56.99 +/- 1.46 cm) than those of normal controls (5.70 +/- 0.26cm and 52.82 +/- 1.22 cm, respectively). But, the difference between the combined product of interpupillary distance and FOC, the interpupillary index, was not significant (10.76 +/- 0.50 and 10.79 +/- 0.35, respectively) (p > 0.05). On the other hand, the children with hypertelorism had significantly (p < 0.001) larger interpupillary distances (6.47 +/- 0.29cm) and FOCs (54.90 +/- 2.18cm) when compared with the controls. In addition, the interpupillary index was significantly (p < 0.001) higher (11.80 +/- 0.45) than both macrocephalic children (10.76 +/- 0.50) and controls (10.79 +/- 0.35). Intercanthal distances and intercanthal index of hyperteloric children were also significantly (p<0.001) larger than both macrocephalic children and controls. CONCLUSION: This new index offers a new concept for more accurate evaluation of the presence of ocular hypo-hypertelorism.

Facilitated tissue expansion with topical estriol.

Tissue expansion is a helpful technique in reconstructive plastic surgery. Unfortunately, tissue expansion still needs to be improved. Twenty-four male Wistar rats were used to evaluate the effect of estriol on tissue expansion. The agents hyaluronidase, estriol, and base cream (as a control) were applied topically to separate animal groups for 5 weeks, and their effects were studied on tissue expansion. Both hyaluronidase (p < 0.05) and estriol (p < 0.001) enhanced the rate of expansion when compared with control animals. Estriol was more effective than hyaluronidase (p < 0.05). Breaking strengths were measured in the estriol and the control groups. Breaking strength was not evaluated in the hyaluronidase group because of the necrotic changes seen at the end of the fifth week. The breaking strength was higher in the control group than in the estriol group (p < 0.05). The authors suggest that topical estriol be used as an adjunctive agent to facilitate tissue expansion.

Adenoid cystic carcinoma of the vulva: conservative surgery using a de-epithelized rhomboid flap.

Adenoid cystic carcinoma of the vulva is a very rare entity manifested by an indolent clinical course, late recurrence and a propensity for perineural and local invasion. A 41-year-old women underwent radical local excision and ipsilateral superficial lymph-node dissection using a de-epithelized rhomboid flap for adenoid cystic carcinoma of the left vulva. On follow-up after two years the patient is alive and well with no evidence of disease. In this report we present the first case of adenoid cystic carcinoma of the vulva using a de-epithelized rhomboid flap.

Severe constricting ring syndrome: case report.

This report presents a case of a male newborn with a severe circumferential amniotic band, treated by single-stage excision of the ring, and microvascular venous anastomosis between the proximal and distal parts of the affected site. No complications were encountered. A microsurgical approach to improve the circulation may be useful in some cases.

Defibrotide activity in experimental frostbite injury.

The pathogenesis of frostbite injury has not been completely elucidated although the available evidence suggests it is an inflammatory reaction following reperfusion injury. Defibrotide given i.p. at 40 mg/kg/ day for three days to rabbits, the ears of which were subjected to frostbite, decreased the presence of inflammatory cells (mast cells -76%; neutrophils -40.4%) and increased prostaglandin I2 (PGI2) (as 6-Keto-PGF1 alpha) in the involved skin. Thromboxane A2 (TxA2) (as TxB2) was unaffected. These data strengthen the view that an inflammatory process is the underlying cause of frostbite injury and that Defibrotide is active in pathological situations involving an inflammatory process like in frostbite.

Comparative study of the effect of ultrasound and electrostimulation on bone healing in rats.

This study was performed to compare the effects of direct current with ultrasound on fracture healing. Thirty-two rats were subjected to the experiment. Each rat's right legs were used as the experimental sample, and their left legs were used as the control. Four groups were formed, each consisting of 16 ultrasound, 16 electrostimulation, 16 ultrasound control, and 16 electrostimulation control animals. Fibular osteotome was applied to the rats under anesthesia. In the electrostimulation and electrostimulation control groups, a stainless steel cathode electrode was installed in the fractured side. In the electrostimulation group, 10 microA of direct current for 30 min, using a semi-invasive method, was given one day after fracture, for 15 days. On the control side, the aforementioned protocol was followed but sham treated. The ultrasound group was treated with 0.1 W/cm2 ultrasound for 2 min every second day for 6 days after fracture (4 times). Rats were killed on the 7th and 14th days to investigate the macroscopic, radiologic, and histopathologic parameters of fracture healing. There was a difference (P < 0.05) between the electrostimulation and the electrostimulation control groups on the 7th day. There was a difference (P < 0.05) between the ultrasound and ultrasound control groups on the 14th day. After statistical evaluation of the experimental results, it was found that in both the ultrasound and the electrostimulation groups, the fracture healing had been accelerated more so than in the control groups. There was no observed statistical difference between ultrasound and electrostimulation effects.

The effect of Gingko biloba extract (Egb 761) as a free radical scavenger on the survival of skin flaps in rats. A comparative study.

Free radicals may have a role in pedicle flap necrosis. We undertook this study to compare the effect of various antioxidants and scavengers of free radicals such as vitamin E, vitamin C, deferoxamine, and Gingko biloba extract (Egb 761) on McFarlane caudal-based dorsal rat flaps. Fifty rats were divided into five groups of 10 animals each. One group served as a control (saline) group. The remaining four groups were given vitamin C 340 mg/kg, deferoxamine 150 mg/kg, Egb 761 100 mg/kg, and vitamin E 20 mg/kg. The necrosed area of flap was significantly reduced in the deferoxamine (p < 0.001), Egb 761 (p < 0.001), and vitamin C (p < 0.05) groups compared with the control group. Vitamin E had no effect on distal flap necrosis (p = 0.20).

Eicosanoids and inflammatory cells in frostbitten tissue: prostacyclin, thromboxane, polymorphonuclear leukocytes, and mast cells.

The pathophysiology of cold injury is still controversial. An inflammatory process has been implicated as the underlying mechanism and certain anti-inflammatory substances such as ibuprofen and acetylsalicylic acid have been used in the clinical treatment of frostbite injury. It has been postulated that the progressive ischemic necrosis is secondary to excessive thromboxane A2 production, which upsets the normal balance between prostacyclin (prostaglandin I2) and thromboxane A2. It was aimed to clarify the pathophysiology of cold injury in this study. Twenty-one New Zealand White rabbits, each weighing 1.2 to 2.9 kg, were divided into control (n = 10) and frostbitten (n = 11) groups the randomly. The rabbit ears in the frostbitten group were subjected to cold injury, and the levels of thromboxane A2 (as thromboxane B2) and of prostaglandin I2 (as 6-keto-prostaglandin F1alpha) and the number of inflammatory cells (polymorphonuclear leukocytes and mast cells) were measured in normal and frostbitten skin of rabbit ears. The levels of 6-keto prostaglandin F1alpha and thromboxane B2, the stable metabolites of prostaglandin I2 and thromboxane A2, respectively, were increased in a statistically significant way (p < 0.002) by frostbite injury; however, thromboxane B2 increased more than 6-keto prostaglandin F1alpha. Polymorphonuclear leukocytes and mast cells, absent in normal skin, were present in the frostbitten skin. There was a statistically significant (p < 0.01) correlation between the time a rabbit ear was maintained at below -10 degrees C and skin survival and between the weights of rabbits and skin survival (p < 0.024). All these findings suggest that inflammation is involved in frostbite injury; a decrease in prostaglandin I2/thromboxane A2 ratio could be one of the factors leading to necrosis; the bigger the animal, the better its ability to counter frostbite.

A comparative study of the effect of ultrasound and electrostimulation on wound healing in rats.

A comparative study has been carried out to investigate the effects of electrical stimulation and ultrasound on wound healing. Eighty-four female rats were divided into four groups depending on the treatment received. The first group was given electrical stimulation of 300 microA direct current, 30 minutes daily, starting with negative polarity and then changed after 3 days of treatment. Group 2 received sham electrostimulation treatment. The third group received 0.1 W/cm2 pulsed ultrasound using the moving applicator technique for 5 minutes a day. Group 4 received sham ultrasound treatment. A total of 7 days of treatment was given to all groups. Histopathologic and biochemical analyses on the fourth and seventh days and wound breaking strength on the twenty-fifth day were performed for all groups. By accelerating the inflammatory phase, electrical stimulation had progressed the proliferative phase of wound healing earlier than ultrasound had done. Both electrical stimulation and ultrasound have positive effects on proliferative phases, but electrical stimulation was superior to ultrasound at the maturation phase. There was no difference between the two experimental groups on the mast cell reduction effect. Although ultrasound treatment may seem to be efficient in terms of time, when the effects of electrical stimulation and ultrasound on wound healing with the methods employed in our study are considered, it is concluded that electrical stimulation is a means of treatment superior to ultrasound in wound healing.

Neuroblastoma and Poland syndrome in a 15-year-old boy.

A 15-year-old boy with neuroblastoma associated with Poland syndrome is presented. He was admitted with a 2-month history of progressive back pain and a 3-day history of weakness of the lower extremities, encopresis and enuresis. On physical examination, in addition to paraplegia, absence of the pectoralis major muscle was diagnosed on the right side of his chest. A large heterogeneous mass in the right side of the thorax was revealed on computerized tomography. Neuroblastoma was diagnosed on histopathological analysis of the mass. To the authors' knowledge this is the first case of neuroblastoma associated with Poland syndrome in the literature.