Analysis of Patients with Major Fractures with and without COVID-19 Infection.

PURPOSE OF THE STUDY As in orthopedic trauma patients, a hyperinflammatory response due to cytokine release occurs in patients with moderate and severe COVID-19 infection. In these patients, untimely surgical intervention can create more destructive situations in the postoperative period. Our aim in this study was to investigate the effect of COVID-19, trauma and surgical intervention on acute phase reactants' levels in patients with and without COVID-19 infection. MATERIAL AND METHODS Twenty-four patients diagnosed with COVID-19 infection and major fractures requiring surgical treatment were evaluated retrospectively (Group 1). Twenty-four COVID-19 negative patients with similar trauma were included in the study as a control group (Group 2). These two groups were compared in terms of demographic data, time to surgery, total hospitalization time, and preoperative and postoperative acute phase reactants' [C-reactive protein (CRP), D-dimer, ferritin, fibrinogen and white blood cell (WBC)] values. RESULTS Time to surgery was 8.3 ± 0.7 days and the total hospital stay was 15.2 ± 0.8 days, in Group 1. These values were determined as 3.3 ± 0.4 and 6.5 ± 0.6 days, respectively for the patients in Group 2 (p < 0.001 and p < 0.001, respectively). When the acute phase reactant values studied during admission were examined, a significant difference was found between the two groups in terms of CRP, D-dimer, ferritin and WBC (p = 0009, p = 0.002, p < 0.001 and p < 0.001, respectively). In the preoperative period, a significant difference was observed between the groups in terms of CRP and ferritin (p = 0.011, p < 0.001, respectively). A significant difference was found only in terms of ferritin from the laboratory values studied in the postoperative period (p < 0.001). DISCUSSION To our knowledge, the present study is the first study which compares and investigates the effects of COVID-19 infection, major fracture and surgical intervention on acute phase reactants' values. Surgical treatment is generally recommended as soon as possible in daily orthopedic practice. However, in patients with asymptomatic or mildly symptomatic COVID-19 infection, it remains unclear how long surgical intervention will be delayed after admission and clinical stabilization of patients with a fracture that requires surgical fixation. In a meta-analysis, patients with COVID-19 infection accompanying hip fracture had a mortality rate of 32.6% in the early postoperative period, and the mortality risk of these patients was found to be 5.66 times higher compared to patients without COVID-19 infection. In our study, one patient (4.2%) with COVID-19 infection who underwent partial hip arthroplasty due to femoral neck fracture. CONCLUSIONS The follow-up and treatment of patients with COVID-19 infection with accompanying a major fracture requiring orthopedic surgery is a complex situation. We recommend that acute phase reactants such as CRP, D-dimer, erythrocyte sedimentation rate (ESR), and ferritin should be closely monitored in these patients during the period from admission to surgery, and surgical intervention should be performed while these values are in remission or decline. Key words: COVID-19, fracture, trauma, acute phase reactants, surgical timing.

The use of molded tympanic heterograft (lamb peritoneum).

The molded heterograft tympanic membrane was applied to twenty-five ears during tympanoplasty. The advantages and disadvantages of the graft material are discussed. Although autograft use is the principal choice, we strongly believe that this heterograft technique may be an alternative for tympanic membrane grafting; especially in revision cases in which temporalis fascia has already been used.

Modification of Bankart reconstruction with lateral capsulotomy and selective anatomic repair using suture anchors.

Twenty consecutive patients (17 male, 3 female) with a diagnosis of traumatic recurrent anterior instability of the shoulder were treated by a modified Bankart procedure using suture anchors. The technique consists of vertical incision of the capsule, just medial to the lateral insertion on the humerus and anatomic repair of the Bankart lesion. Humeral-based capsular shifting was performed in patients with anterior-inferior instability. The average age was 24 years (range: 14 to 39 years), and average follow-up period 68 months (range: 2 to 8 years). The average Bankart rating score was 92.5 (range: 70 to 100); with 16 (80%) excellent (score 90 to 100), 2 (10%) good (score 75 to 89), and 2 (10%) fair results. Failure in terms of recurrent dislocation was not reported. Eleven patients (55%) had a loss of 5 degrees to 10 degrees of external rotation either with the extremity at the side or at 90 degrees of abduction. Nine (45%) patients had external rotation equal to the contralateral side. We believe selective anatomic Bankart reconstruction by lateral capsulotomy and humeral-based capsular shifting in cases with marked inferior laxity is a more anatomic and physiologic technique.

Correction of saddle nose deformities by coral implantation.

The coral or Madrepororia is a sea invertebrate with a skeleton morphologically and chemically very similar to mineral bone. In 1990 we implanted coral blocks, sterilized by gamma irradiation, into the nasal dorsa of ten dogs. Resorption and substitution with bone or fibrous tissue were observed within 6 months. Between 1991 and 1994 biocoral was used in 20 patients with saddle nose deformities in order to augment the nasal pyramid and dome. Two extrusions were observed in the early postoperative period during follow-up. One of these extrusions was related to trauma and necessitated removal of the implant. Our findings show that coral is a suitable alloplastic material that can be used in the correction of saddle nose deformities.

Primary replacement of the humeral head in iatrogenically displaced fracture-dislocations of the shoulder: a report about six cases.

Dislocation of the shoulder is a common injury and may be associated with a variety of complications. We report six cases of primary replacement of the humeral head where closed reduction of a shoulder dislocation associated with an undisplaced fracture of the humeral neck led to displacement of the neck fracture. All dislocations examined were anterior with a displaced greater tubercle fracture. The patients had undergone closed reduction at other medical centres and were referred to us because of iatrogenically displaced fracture-dislocations of the shoulder. Three were women and three were men with a mean age of 52.8 years (range 38-72). Primary replacement of the humeral head was done in an average of 9.3 days (range 2-30 days) following the injury. The average follow-up period was 30.2 months (range 12-55 months). Postoperative pain, active range of motion and function were evaluated with the American Shoulder and Elbow Surgeons Criteria. The forward flexion averaged 124 degrees, active external rotation averaged 29 degrees and internal rotation (achieved movement) to the second lumbar vertebra. Because of the high risk of avascular necrosis and severe collapse of the humeral head, we conclude that the primary replacement of the humeral head is the superior treatment option in iatrogenically displaced fracture dislocations of the shoulder.