Effects of intraperitoneally administered folic acid on the healing of repaired tibial nerves in rats.

BACKGROUND: Complete nerve regeneration and clinical healing remain a challenge despite considerable advances in the treatment of peripheral nerve injuries. To improve nerve regeneration, several experimental molecular procedures have been attempted. This study aimed to investigate the effects of folic acid on peripheral nerve healing after transection and end-to-end suture repair of the tibial nerve in rats. METHODS: In this study, 20 adult male Wistar Albino rats weighing 225 to 250 g were used. The right tibial nerves of 20 rats were explored, transected, and sutured using the end-to-end technique. The rats were randomly allocated to either the intraperitoneally administered folic acid group (test group) or the control group. Preoperative and 6-week postoperative neurophysiological studies were performed by the same researcher. Myelin-sheathed axons were counted. RESULTS: The results demonstrated that the folic acid-treated group exhibited improved electromyographic results compared with the control group. Histological evaluation revealed that the axons were well preserved and that the axon quantity and density were increased in the test group compared with the control group. Quantitative results also increased in the test group compared with the control group (p = 0.001). CONCLUSION: In this study, 6-week intraperitoneal administration of 80 µg/kg of folic acid significantly improved peripheral nerve healing. Histological analysis of the group that received folic acid revealed increased axon myelination with little granular tissue or fibrosis. We propose that folic acid supplementation may be an effective component of peripheral nerve injury treatment.

Total body height estimation using sacrum height in Anatolian Caucasians: multidetector computed tomography-based virtual anthropometry.

OBJECTIVE: Estimation of total body height is a major step when a subject has to be identified from his/her skeletal structures. In the presence of decomposed skeletons and missing bones, estimation is usually based on regression equation for intact long bones. If these bones are fragmented or missing, alternative structures must be used. In this study, the value of sacrum height (SH) in total body height (TBH) estimation was investigated in a contemporary population of adult Anatolian Caucasians. MATERIALS AND METHODS: Sixty-six men (41.6 ± 14.9 years) and 43 women (41.1 ± 14.2 years) were scanned with 64-row multidetector computed tomography (MDCT) to obtain high-resolution anthropometric data. SH of midsagittal sections was electronically measured. The technique and methodology were validated on a standard skeletal model. RESULTS: Sacrum height was 111.2 ± 12.6 mm (77-138 mm) in men and 104.7 ± 8.2 (89-125 mm) in women. The difference between the two sexes regarding SH was significant (p < 0.0001). SH did not significantly correlate with age in men, whereas the correlation was significant in women (p < 0.03). The correlation between SH and the stature was significant in men (r = 0.427, p < 0.0001) and was insignificant in women. For men the regression equation was [Formula: see text] (r = 0.54, SEE = 56.9, p < 0.0001). CONCLUSION: Sacrum height is not susceptible to sex, or to age in men. In the presence of incomplete male skeletons, SH helps to determine the stature. This study is also one of the initial applications of MDCT in virtual anthropometric research.

Grisel syndrome: nontraumatic atlantoaxial rotatory subluxation.

Grisel syndrome is the subluxation of atlantoaxial joint as a result of infectious or inflammatory processes of the head and neck region. The etiopathogenesis of this clinical entity is not clear yet. Early interventions (antibiotherapy, cervical traction, and immobilization) are critical to avoid catastrophic outcome. Early detection of pediatric atlantoaxial subluxation is essential. It requires a combination of clinical assessment and appropriate radiographic imaging. In this report, we present a clinical and radiologic follow-up of a Grisel syndrome; by this way, we discuss the role of radiology on the diagnosis of this rare entity and preview the relevant literature.

Femoral shaft bowing with age: a digital radiological study of Anatolian Caucasian adults.

PURPOSE: To determine the dimensions of the femoral shaft and their relationship to age in Anatolian Caucasian men and women. MATERIALS AND METHODS: Maximum femoral length (MFL), mid-shaft transverse diameter (MTD), and anterior bowing (AB) were studied in a sample of 104 adults. The linear dimensions and AB of the femoral shafts were measured on digital images. RESULTS: In males, mean MFL, MTD, and AB were 448.2 mm, 26.5 mm, and 759.3 mm, respectively. In females these measurements were 419.0 mm, 25.6 mm, and 779.5 mm. Males had longer MFL (P < 0.0001) and there was no difference between males and females regarding the other parameters. MFL and age were correlated in females (r = -0.374, P < 0.005), whereas they were not correlated in males. In females, MFL decreased until about 45 years of age and stabilized thereafter. MTD was correlated with age in males (r = 0.428, P < 0.002), increasing from adolescence to maturity. This correlation was insignificant in females and there was only a slight increase in diameter after about 30 years of age. AB and age were significantly correlated in females (r = -0.401, P < 0.003), with AB continuously increasing with age. The correlation between AB and age was insignificant in males. CONCLUSION: The increase in bone cross-sectional area in aging males may contribute to the maintenance of adequate mechanical competence throughout adulthood. In females this compensatory mechanism appears to be much less efficient and, accordingly, the end result of this process is AB of the femur and inevitable shortening of the bone.

Evaluation of the gluteus medius muscle after a pelvic support osteotomy to treat congenital dislocation of the hip.

BACKGROUND: Many authors have reported that the pelvic support osteotomy prevents a Trendelenburg gait by restoring the biomechanics of the abductor muscle in patients with congenital dislocation of the hip. However, we are not aware of any studies in which the hip abductor muscles were examined following pelvic support osteotomy. The purpose of this study was, first, to use magnetic resonance imaging to measure alterations in the length and volume of the gluteus medius muscle after pelvic support osteotomy and, second, to determine which factors influence the results of the Trendelenburg test. METHODS: Eleven patients with a history of congenital hip dislocation who had been treated with a pelvic support osteotomy were examined clinically with the Harris hip score and the Trendelenburg test, radiographically to measure limb-length discrepancy and valgus angulation of the proximal part of the femur, and with magnetic resonance imaging to measure changes in the gluteus medius length and volume. RESULTS: The pelvic support osteotomy achieved a functional and painless hip in all eleven patients. Five of the eleven patients had a persistently positive Trendelenburg gait at the time of the last follow-up visit, at an average of three years after the osteotomy. The muscle volumes were restored to 43% to 89% of the muscle volumes on the normal contralateral side, and the postoperative muscle volume correlated significantly with the result of the Trendelenburg test (r = -0.63; p = 0.03). There was a positive association between age and the result of the Trendelenburg test (p = 0.01): four of the five patients who had a positive test were at least thirty-one years of age at the time of the operation. There was no correlation between the Trendelenburg test and the change in the length of the gluteus medius muscle, which averaged 19.2 mm in the patients with a positive test and 19.3 mm in those with a negative test. CONCLUSIONS: Patient age at the time of the operation and the postoperative change in the volume of the gluteus medius muscle have a significant influence on the result of the Trendelenburg test after a pelvic support osteotomy. Moreover, our study demonstrated that restoration of the muscle volume after a pelvic support osteotomy is not sufficient to prevent a Trendelenburg gait in older patients with congenital dislocation of the hip. LEVEL OF EVIDENCE: Therapeutic Level IV.

Successful treatment of high congenital dislocated hips in older children by open reduction, pelvic and femoral osteotomy with external fixator stabilization (average 8.2 years of age).

A new technique using a hinged external fixator to stabilize an open reduction with pelvic and femoral osteotomies has been developed for treating high-dislocated hips in older children with developmental dislocated hip (DDH). This technique was performed in 11 patients (12 hips) at a mean age of 8.2 years. At follow up, radiographic results showed no redislocation/subluxation and clinical results demonstrated 11 hips as excellent/good and only one hip as poor from persistent stiffness. In conclusion, this new technique produces acceptable results in the treatment of older children with high dislocation of the hip from DDH.

[The factors affecting thermal necrosis secondary to the application of the Ilizarov transosseous wire]. / Ilizarov transosseöz telin kemikten geçirilmesine bagli olusan termal nekrozu etkileyen faktörler.

OBJECTIVES: We investigated thermal changes associated with the application of the Ilizarov transosseous wires, the extent of necrosis, and the factors affecting necrosis. METHODS: We used a pair of tibiae from a 1-year-old cow. After removal of metaphyseal areas, each of four equal diaphyseal zones marked on both tibiae was drilled at 600, 900, 1,200 and 1,800 rpm, each time with a new wire. Heat changes were recorded with heat electrodes during the application and the speed of the wire was calculated. For histopathological examination, specimens were obtained at the access and exit sites to assess the extent of necrosis. Thermal changes between the zones and immediate and remote cortices were compared. The most significant factor affecting the heat changes was analyzed by linear regression. RESULTS: Heat changes varied between 48.4 degrees C (at 1,200 rpm) and 151.9 degrees C (at 600 rpm). The thickness of the immediate cortex, the time and speed for the wire to pass the cortex were found as significant parameters in heat changes (p=0.003, p=0.01, and p=0.01, respectively). A negative correlation was found between the speed of the wire and the thickness of the necrotic area (r=-0.901, p=0.001). Regression analysis showed that the time for the wire to pass through the cortex was the most significant factor in inducing heat changes in both cortices (p=0.001, p=0.003, respectively). Histopathologically, the extent of necrosis and bone erosion was associated with lower drill speeds. Necrosis was significantly notable in the immediate cortex than that of the remote one (p=0.006). CONCLUSION: Transosseous wires should be passed at high drill speeds and with earliest time elapses to reduce thermal necrosis.

The mechanical or electrical induction of medullary angiogenesis: will it improve sternal wound healing?

We induced angiogenesis in the tibial medulla and cortex of rabbits by electrical and mechanical stimulation, with the aim of future application to ischemic disease. Sixteen New Zealand rabbits were divided into 4 groups: in Group 1, a K wire was inserted into the medullary channel; in Group 2 a hole was drilled into the tibia; in Group 3, electrical stimulation was applied to the medullary channel; and in Group 4 (the control group), nothing was done. The interventions were applied during a 21-day period, after which all animals were evaluated scintigraphically and histopathologically. All 3 interventional groups were significantly superior to the control group in regard to medullary and cortical vascularity: the P values were 0.021 in all comparisons to control. However, the most fibrotic changes in the medulla occurred in the group that had been treated with electricity (P = 0.008). Slight fibrotic changes occurred in the hole group (P = 0.040), and none occurred in the K-wire group. In sum, all 3 interventions are capable of inducing medullary angiogenesis, but electricity is inferior in regard to fibrotic change. We believe that this present study can establish a baseline for further work that explores clinical applications to problematic ischemic conditions, including delayed sternal wound healing after cardiac surgery.

[The Morel-Lavallée lesion: a conservative approach to closed degloving injuries]. / Morel-Lavallée lezyonu: Kapali soyulma yaralanmalarinda konservatif yaklasim.

OBJECTIVES: We evaluated the results of conservative treatment for closed degloving injuries (Morel-Lavallée lesion) of the pelvic girdle and lower extremities. METHODS: The Morel-Lavallée lesion developed in five male patients (mean age 25.6 years; range 6 to 40 years) due to crush under a vehicle (n=3) and traffic accidents (n=2). The lesions were localized in the pelvic girdle in three cases (2 lumbosacral, 1 lateral lumbar) and gluteal and trochanteric regions in two cases. Treatment was performed with compressive elastic bandages or corsets in all the patients, three of whom also underwent surgery due to accompanying pelvic fractures. Healing was defined as the loss of fluctuation and elicitation of the normal mobility of the injured skin on manual examination. The mean follow-up period was 23.6 months (range 10 to 41 months). RESULTS: Sacral decubitus ulcer developed in a patient in whom the detection of the lesion was obscured because of an associated femoral fracture and a perianal deep soft tissue lesion. Another patient with a wide fluctuating lesion in the gluteal-trochanteric region required aspiration, which yielded a negative culture. However, the lesion recurred early. Except for the patient with a sacral decubitus ulcer, all the lesions healed within a mean of six weeks (range 4 to 12 weeks) without any infections or necrosis. No recurrences were detected during the follow-up period. CONCLUSION: Closed degloving lesions in the pelvic and gluteal regions can be managed conservatively when the overlying skin is intact and the fluid accumulation is not excessive.

[A comparison between the use of a monolateral external fixator and the Ilizarov technique for pelvic support osteotomies]. / Pelvis destek osteotomilerinde tek tarafli eksternal fiksatör ile klasik Ilizarov tekniginin karsilastirilmasi.

OBJECTIVES: We compared the results of monolateral external fixator and the Ilizarov technique for pelvic support osteotomies in the treatment of neglected congenital hip dislocation. METHODS: Seventeen female patients with congenital dislocation of the hip underwent pelvic support osteotomy using a monolateral external fixator (MEF) (n=7; mean age 23.2 years; range 17 to 39 years) or the hybrid advanced Ilizarov method (HAIM) (n=10; mean age 25.9 years; range 17 to 36 years). The mean leg discrepancies, durations of the external fixator, and follow up-periods in the MEF and HAIM groups were as follows, respectively: 5.5 cm and 5.2 cm; 201.5 days (range 185 to 241 days) and 197 days (164 to 248 days); 30.4 months (23 to 39 months) and 40.5 months (21 to 65 months). The two groups were compared with respect to patients' discomfort related to the use of external fixators and pin tract infections classified according to the Paley criteria. RESULTS: Overall, six pins required removal because of grade 3 pin track infections (5 in the HAIM group, 1 in the MEF group). The number of patients who reported extreme discomfort for the use of external fixator was three in the HAIM group and one in the MEF group. Although the range of motion of the knee was similar in both groups (p>0.05), clinically, patients treated with MEF exhibited a more comfortable range of motion of the knee with external fixation and, after removal of the fixator, reached a knee flexion of 90 degrees in a shorter time (36 days versus 47 days). CONCLUSION: The use of MEF for pelvic support osteotomies seems to be preferable because it is associated with a lower rate of pin tract infections and a higher degree of patient comfort.

The subpubic angle in sex determination: anthropometric measurements and analyses on Anatolian Caucasians using multidetector computed tomography datasets.

INTRODUCTION AND AIM: The investigation of new anatomical criteria and revalidation of existing ones in sex determination for different populations are among main research foci of forensic anthropometry. In that context, the pelvis is the most extensively studied bone. A number of qualitative classifications, dimensional measurements and indices have been proposed for investigative anthropometry and forensic studies. Independent use of these parameters generally provided an accuracy rate of 70-75%. In this study, the accuracy rate of the subpubic angle in sex determination was investigated in living Anatolian Caucasians. MATERIAL AND METHOD: The subpubic angle was identified and measured on three-dimensional computed tomographic images of pelves. Data were obtained using 64-detector computed tomography (MDCT) with an isotrophic resolution of 500 µm. The sample included 66 males (41.6 ± 14.9 years of age) and 43 females (41.1 ± 14.2 years of age). Measurements were taken on a dedicated three-dimensional image analysis workstation. The subpubic angle was electronically measured. The technique and methodology was validated on a standard skeletal model. Intraobserver agreement was analyzed with intraclass correlation coefficient, and intraobserver variability was evaluated with technical error of measurement (inter- and intra-observer TEM), relative technical error of measurement (rTEM) and coefficient of reliability (R) measures. The subpubic angle for the study group and for both sexes was reported as minimum-maximum (mean ± SD). Independent-Samples T Test for equality of means was used to determine the difference between the two sexes regarding the subpubic angle. The correlation between the subpubic angle and the age of subjects were using Pearson Correlation Coefficients in males and in females. Logistic regression model was used to classify subjects according to their sex. Receiver operating characteristic curve analysis was performed to determine a cut-off value for further studies and to test the performance of the binary classification test. RESULTS: Intraclass correlation for the subpubic angle (0.990), TEM (1082), rTEM (1.492), and R (0.990) represented almost complete reliability and accuracy of the measurement method. The subpubic angle was between 48° and 81° (65.9° ± 7.2°) in males and was between 64° and 100° (82.6° ± 7.7°) in females. Statistically significant difference was found between males and females regarding the subpubic angle (p < 0.0001). The subpubic angle was not significantly correlated with age in males (p = 0.953), or in females (r = 0.975). The accuracy of the subpubic angle in sex determination was 90.8%. With a cut-off value of 74°, sensitivity of subpubic angle to detect female phenotype was 88% and its specificity was 95%. CONCLUSION: The subpubic angle is an accurate parameter in sex determination with high sensitivity and specificity.

Interpedicular approach in percutaneous sacroplasty for treatment of sacral vertebral body pathologic fractures.

For this technique, bone needle is introduced into the S1 vertebral body through the interpedicular route by penetrating the central spinal canal at the level of S3-4 and passing through the vertebral body of S2-3 parallel to the anterior border of sacrum. With the interpedicular approach, two sacral vertebral bodies can be injected in one session and lower sacral body injection also is available. interpedicular technique is a safe, practical, and effective technique for the treatment of sacral vertebral body pathologic fractures.

Determination of sex from the femur in Anatolian Caucasians: a digital radiological study.

Determination of the sex is one of the most important steps when evaluating decomposed bodies or skeletal remnants. However, relevant data exhibit significant ethnic and temporal variation. This study provides information on in vivo femoral dimensions of Anatolian Caucasians. 50 males and 54 females with ages between 18 and 68 years were investigated with computed tomography. For males, mean maximum length (ML) was 448.2mm, mean vertical head diameter (VHD) was 48.8mm, mean midshaft transverse diameter (MTD) was 26.5mm, and mean anterior bowing (AB) was 759.3mm. For females, these were 419.0mm, 43.4mm, 25.6mm, and 779.5mm, respectively. Femoral dimensions of Anatolian Caucasians were not entirely similar to a single racial group that was already reported. There was a significant difference between males and females regarding ML and VHD (p<0.0001 for both). MTD and AB did not exhibit sexual dysmorphism. Discriminant analysis for sex type produced 83.3% accuracy when ML was used, and 76.9% accuracy when VHD was used (p<0.0001). Combined use of both parameters increased overall accuracy to 84.6% (p<0.0001). For VHD, cut-off value of 44.9mm produced 94% sensitivity and 83% specificity. For ML, cut-off value of 428.6 produced 80% sensitivity and 67% specificity.

Surgical management of transforaminal sacral fractures.

Fourteen patients with transforaminal sacral fractures were treated with posterior iliosacral instrumentation. Patients were assessed in terms of surgical technique and functional results. A subjective functional scoring with a five-point scale was performed at the last follow-up. Activity pain, pain at rest, limping and patient satisfaction were evaluated. By considering symptom and satisfaction scores, subjective functional assessment revealed that ten patients had excellent results, two good and two moderate. There were no patients with poor functional outcome. The surgical technique is not a new concept. Combining sacral bar and pediculo-iliac fixation methods, provides vertical as well as horizontal stability and allows early weight bearing, the methods has many advantages. However, vertical and horizontal stabilities achieved by this technique may require further assessment with comparative biomechanical studies.

The comparison of femoral curves and curves of contemporary intramedullary nails.

UNLABELLED: The aim of this study was to evaluate both the cortical and the medullary anterior bowing of the femur, and to compare these measurements with current intramedullary nails to assess the adequacy of their design. METHODS: Lateral digital radiographic views of left femurs of 104 normal subjects (18-68 years old) were obtained. Radii of cortical and medullary curvatures of femurs were calculated using these images. The values obtained were compared to the radius of curvatures of ten different intramedullary nails. RESULTS: Medullary bowing was between 114 and 1,389 mm (mean: 722 mm, SD: 230 mm) and the cortical bowing was between 109 and 1,666 mm (mean: 770 mm, SD: 267 mm). For males, these values were 114-1,389 mm (mean: 722 mm, SD: 230 mm) and 109-1,666 mm (mean: 770 mm, SD: 267 mm), respectively. For females, they were 114-1,389 mm (mean: 722 mm, SD: 230 mm) and 109-1,666 mm (mean: 770 mm, SD: 267 mm), respectively. The differences between genders were not significant. Cortical and medullar bowing was strongly correlated with age (r=-0.269, p<0.006 and r=-0.234, p<0.017, respectively). These significances were produced by females only. Radii of curvatures of intramedullary nails ranged between 150 and 300 cm and were higher than the mean cortical (77 cm) and medullary (72.2 cm) bowings. CONCLUSION: The difference between the curves of femur and the contemporary femoral nails implicates the inadequacy of the design of such nails for the Caucasian race living in Anatolia. Therefore, such nails should be revised accordingly to prevent the above-mentioned complications.

Treatment of femoral nonunions by using cyclic compression and distraction.

UNLABELLED: Eleven patients with femoral diaphyseal nonunions after intramedullary nailing were treated with cyclic compression and distraction with an external fixator over the nail. We evaluated the limitations of this technique and whether patients having this closed procedure could achieve union without additional operative procedures. Patients with hypertrophic nonunions (n = 4) were treated with gradual compression of the nonunion site. Cyclic compression and distraction was done in patients with oligotrophic (n = 2) or atrophic nonunions (n = 5) to stimulate consolidation. The average age of the patients was 32.9 years (range, 21-48 years), and the average followup was 40.5 months (range, 24-64 months). Union was achieved in an average of 5.8 months in all patients after one operation and without additional surgical intervention. However, pain necessitating strong analgesic agents and pin-related complications consisting of osteomyelitis, septic arthritis, and pin breakage in the atrophic nonunion group were a major limitation of this technique. Based on our study, the cyclic compression and distraction technique can be used in hypertrophic and oligotrophic nonunions that have failed one or more prior exchange nailings. However, it might not be an option for treatment of patients with atrophic nonunions unless pin-site problems are resolved. LEVEL OF EVIDENCE: Therapeutic study, Level IV (case series--no, or historical control group). See the Guidelines for Authors for a complete description of levels of evidence.

[Emergency pelvic external stabilization as the first step treatment in high risk pelvic fractures]. / Acil pelvik eksternal stabilizasyon: Yüksek riskli pelvis kiriklarinda ilk adim.

BACKGROUND: We evaluated the clinical effectiveness of emergency pelvic external stabilization (EPES) as a first step of resuscitation and pelvic stabilization in trauma patients with hemodynamic and/or fracture instabilities. METHODS: Twenty-three patients (12 males, 11 females; mean age 32 years; range 9 to 67 years) with high risk pelvic fractures underwent EPES. The presence of a systolic blood pressure equal to or below 90 mmHg, vertical and/or rotational instabilities, or fractures at risk were defined as high risk fractures. Pelvic fractures were assessed according to the Tile's classification. RESULTS: Hemodynamic instability was detected in 10 patients. The mean durations to the elective pelvic stabilization were three days (range 2 to 8 days) and 17.7 days (range 7 to 28 days) in patients with or without hemodynamic instability, respectively. The mean duration for EPES application was below 30 minutes (range 20 to 40 minutes). No deaths occurred due to blood loss caused by pelvic fractures. One patient died due to sepsis 14 days after hemodynamic stabilization. Superficial pin-track infections of grade 1 were detected in five patients, four of whom were treated with local dressings. In one patient, two pins had to be replaced because of loosening. CONCLUSION: Emergency pelvic external stabilization for resuscitation and high risk fractures is an effective intervention in the acute phase of polytraumatized patients presenting with high risk pelvic fractures.

[Radial artery pellet embolism: a case report]. / Radial arterde saçma tanelerinin yol açtigi emboli: Olgu sunumu.

A fifty-four-year-old male patient presented to our emergency department with a gunshot injury in his arm, caused by pellets. Surgical exploration showed injury to the brachial artery, which was then repaired with a saphenous vein graft. Conservative treatment was planned for associated nerve injuries. After arterial flow began, two pellet-like solid bodies were palpated in the radial artery trace at the wrist level and the pellets were removed from the lumen of the artery. Ten days after surgery, the patient had profuse bleeding in the arm. On exploration, partial necrosis was detected in the saphenous vein graft and primary repair was performed. However, on the 19th day, the bleeding recurred and increased necrosis and rupture of the artery, 2-3 cm in size, were detected. Arterial repair was repeated with another saphenous vein graft from the other limb. The patient returned to normal daily activities nine months after the injury, with slight cold intolerance. Clinical examination and Doppler studies did not show any signs of vascular deficiency. Arterial or venous pellet embolism should be included in the evaluation of patients with gunshot injuries.