Travma 2012-1

Cilt - Volume 18 Say - Number 1

ISSN 1306 - 696x

Ocak - January 2012

TURKISH JOURNAL OF TRAUMA&

EMERGENCY SURGERY

www.tjtes.org

Index Medicus, Medline, EMBASE/Excerpta Medica, Science Citation Index-Expanded (SCI-E), Index Copernicus ve TBTAK-ULAKBM Trk Tp Dizininde yer almaktadr.

Indexed in Index Medicus, Medline, EMBASE/Excerpta Medica and Science Citation Index-Expanded (SCI-E), Index Copernicus and the Turkish Medical Index of TBTAK-ULAKBM.

ULUSAL TRAVMA VE ACL CERRAH DERGSTURKISH JOURNAL OF TRAUMA AND EMERGENCY SURGERY

Editr (Editor)Recep Glolu

Yardmc Editrler (Associate Editors)Kaya Sarbeyolu Hakan Yanar Ahmet Nuray Turhan

Gemi Dnem Editrleri (Former Editors)mer Trel Cemalettin Ertekin Korhan Tavilolu

ULUSAL BLMSEL DANIMA KURULU (NATIONAL EDITORIAL BOARD)Fatih Aalar stanbulYlmaz Akgn anakkaleLevhi Akn stanbulAlper Aknolu AdanaMurat Aksoy stanbuleref Akta stanbulAli Akyz stanbulmer Alabaz AdanaNevzat Alkan stanbulEdit Altnl stanbulAcar Aren stanbulGamze Aren stanbulCumhur Arc AntalyaOktar Asolu stanbulAli Atan AnkaraBlent Atilla AnkaraLevent Avtan stanbulYunus Aydn stanbulnder Aydngz stanbulEran Aygn stanbulMois Bahar stanbulAkn Eraslan Balc ElazEmre Balk stanbulUmut Barbaros stanbulSemih Baskan AnkaraM Murad Baar KrkkaleMehmet Bayramili stanbulAhmet Bekar BursaOrhan Bilge stanbulMustafa Bozbua EdirneMehmet Can stanbulBaar Cander KonyaNuh Zafer Cantrk KocaeliMnacettin Ceviz ErzurumBanu Coar stanbulFigen Cokun Ankararfan Cokun EdirneNahit akar stanbulAdnan alk TrabzonFehmi elebi ErzurumGrhan elik stanbulOuz etinkale stanbulM. Ercan etinus stanbulSebahattin obanolu EdirneAhmet oker zmirCemil Dalay AdanaFatih Dikici stanbulYalm Dikmen stanbulOsman Nuri Dilek SakaryaKemal Dolay AntalyaLevent Demeci AntalyaMurat Servan Dolu DzceKemal Durak BursaEngin Dursun AnkaraAtilla Elhan Ankara

kr zer KonyaHalil zg BursaAhmet zkara stanbulMahir zmen AnkaraVahit zmen stanbulVolkan ztuna MersinNiyazi zelik stanbulSleyman zyaln stanbulEmine zyuvac stanbulSalih Pekmezci stanbulzzet Rozanes stanbulKazm Sar stanbulEsra Can Say stanbulAli Sava Ankaraskender Sayek AnkaraTlay zkan Seyhan stanbulGrsel Remzi Soybir TekirdaYunus Sylet stanbulErdoan Szer KayseriMustafa ahin TokatCneyt ar stanbulMert entrk stanbulFeridun irin stanbulbrahim Tayldz DiyarbakrGl Kknel Talu stanbulErtan Tatlcolu AnkaraGonca Tekant stanbulCihangir Tetik stanbulMustafa Tireli ManisaAlper Toker stanbulRfat Tokyay stanbulSalih Topu KocaeliTurgut Tufan AnkaraFatih Tunca stanbulAkif Turna stanbulZafer Nahit Utkan KocaeliAli Uzunky UrfaErol Erden nler Balkesirzgr Yamur AdanaMslime Yalaz stanbulSerhat Yaln stanbulSmer Yamaner stanbulMustafa Yand TrabzonNihat Yavuz stanbulCumhur Yeen stanbulEbru Yeilda TekirdaHseyin Yetik stanbulCuma Yldrm GaziantepBedrettin Yldzeli stanbulSezai Ylmaz MalatyaKaya Yorganc AnkaraCokun Yorulmaz stanbulTayfun Ycel stanbul

Mehmet Elievik stanbulmdat Elmas stanbulUfuk Emekli stanbulHaluk Emir stanbulYeim Erbil stanbulevval Eren DiyarbakrHayri Erkol BoluMetin Ertem stanbulMehmet Erylmaz AnkaraFigen Esen stanbulTark Esen stanbulrfan Esenkaya MalatyaOzlem Evren Kemer AnkaraNurperi Gaziolu stanbulFatih Ata Gen stanbulAlper Gke TekirdaNiyazi Grm KonyaFeryal Gn stanbulmer Gnal DzceNurullah Gnay KayseriHaldun Gndodu AnkaraMahir Gnen AdanaEmin Grleyik BoluHakan Gven stanbulGkhan z zmirbrahim kizceli stanbulHaluk nce stanbulFuat peki zmirFerda hret Kahveci BursaSelin Kapan stanbulMurat Kara AnkaraHasan Eref Karabulut stanbulEkrem Kaya BursaMehmet Yaar Kaynar stanbulMete Nur Kesim SamsunYusuf Alper Kl AnkaraHaluk Kiper EskiehirHikmet Koak ErzurumM Hakan Korkmaz AnkaraGniz Meyanc Kksal stanbulCneyt Kksoy Ankarasmail Kuran stanbulNecmi Kurt stanbulMehmet Kurtolu stanbulNezihi Kkarslan Ankarasmail Mihmanl stanbulMehmet Mihmanl SakaryaKksal ner stanbulDurkaya ren ErzurumHseyin z stanbulHseyin zbey stanbulFaruk zcan stanbulCemal zelik Diyarbakrlgin zden stanbulMehmet zdoan Ankara

ULUSLARARASI BLMSEL DANIMA KURULUINTERNATIONAL EDITORIAL BOARD

Juan Asensio Miami,USA Zsolt Balogh NewCastle,Australia Ken Boffard Johannesburg,S.Africa Fausto Catena Bologna,Italy Howard Champion WashingtonDC,USA Elias Degiannis Johannesburg,S.Africa Demetrios Demetriades LosAngeles,USA Timothy Fabian Memphis,USA Rafi Grnlolu Denver,USA Clem W. Imrie Glasgow,Scotland Kenji Inaba LosAngeles,USA Rao Ivatury Richmond,USA Yoram Kluger Haifa,Israel Rifat Latifi Tucson,USA Sten Lennquist Malm,Sweden Ari Leppaniemi Helsinki,Finland Valerie Malka Sydney,Australia Ingo Marzi Frankfurt,Germany Kenneth L. Mattox Houston,USA Carlos Mesquita Coimbra,Portugal

Ernest E Moore Denver,USA Pradeep Navsaria CapeTown,S.Africa Andrew Nicol CapeTown,S.Africa Hans J Oestern Celle,Germany Andrew Peitzman Pittsburgh,USA Basil A Pruitt SanAntonio,USA Peter Rhee Tucson,USA Pol Rommens Mainz,Germany William Schwabb Philadelphia,USA Michael Stein Petach-Tikva,Israel Spiros Stergiopoulos Athens,Greece Michael Sugrue Liverpool,Australia Otmar Trentz Zurich,Switzerland Donald Trunkey Oregon,USA Fernando Turegano Madrid,Spain Selman Uranues Graz,Austria Vilmos Vecsei Vienna,Austria George Velmahos Boston,USA Eric J Voiglio Lyon,France Mauro Zago Milan,Italy

ULUSAL TRAVMA VE ACL CERRAH DERNETHE TURKISH ASSOCIATION OF TRAUMA AND EMERGENCY SURGERY

Bakan(President) RecepGlolu BakanYardmcs(Vice President) KayaSarbeyolu GenelSekreter(Secretary General) AhmetNurayTurhan Sayman(Treasurer) HakanYanar YnetimKuruluyeleri(Members) M.Mahirzmen EdizAltnl Grhanelik

LETM (CORRESPONDENCE)

ULUSAL TRAVMA VE ACL CERRAH DERNE YAYIN ORGANIISSUED BY THE TURKISH ASSOCIATION OF TRAUMA AND EMERGENCY SURGERY

UlusalTravmaveAcilCerrahiDernei Tel:+90212-5886246-5311246 stanbulniversitesistanbulTpFakltesi Faks(Fax):+90212-5331882 GenelCerrahiAnabilimDal,Travmave e-posta(e-mail):[email protected] AcilCerrahiServisi,34390apa,stanbul Web:www.travma.org.tr

UlusalTravmaveAcilCerrahiDerneiadna Sahibi(Owner) RecepGlolu YazleriMdr(Editorial Director) RecepGlolu YaynKoordinatr(Managing Editor) M.Mahirzmen Amblem MetinErtem Yazmaadresi(Correspondence address) UlusalTravmaveAcilCerrahiDergisiSekreterlii DenizAbdalMah.,KprlMehmetPaaSok., DadaoluApt.,No:25/1,34104ehremini,stanbul Tel +90212-5311246-5310939 Faks(Fax) +90212-5331882

Abonelik:2011ylabonebedeli(UlusalTravmaveAcilCerrahiDerneinebaolarak)75.-YTLdir.HesapNo:TrkiyeBankas,stanbulTpFakltesiubesi1200-3141069noluhesabnayatrlpmakbuzdernekadresinepostaveyafaksyoluileiletilmelidir. Annual subscription rates: 75.- (USD)

p-ISSN 1306-696x e-ISSN 1307-7945 Index Medicus, Medline; EMBASE, Excerpta Medica; Science Citation Index-Expanded (SCI-E), Index Copernicus ve TBTAK ULAKBM Trk Tp Dizininde yer almaktadr. (Included in Index Medicus, Medline; EMBASE, Excerpta Medica; Science Citation Index-Expanded (SCI-E), Index Copernicus and Turkish Medical Index) Yaync (Publisher): KARE Yaynclk (karepublishing) Tasarm (Design): Ali Cangl ngilizce Editr (Linguistic Editor): Corinne Can statistik (Statistician): Empiar Online Dergi & Web (Online Manuscript & Web Management): LookUs Bask (Press): Yldrm Matbaaclk Basm tarihi (Press date): Ocak (Janu-ary) 2012 Bu dergide kullanlan kat ISO 9706: 1994 standardna uygundur. (This publication is printed on paper that meets the international standard ISO 9706: 1994).

REDAKSYON (REDACTION)ErmanAyta

YAZARLARA BLG

Ulusal Travma ve Acil Cerrahi Dergisi, Ulusal Travma ve Acil Cerrahi Derneinin yayn organdr. Travma ve acil cerrahi hastalklar konularn-da bilimsel birikime katks olan klinik ve deneysel almalar, editryel yazlar, klinik olgu sunumlarn ve bu konulardaki teknik katklar ile son gelimeleri yaynlar. Dergi iki ayda bir yaynlanr.

Ulusal Travma ve Acil Cerrahi Dergisi, 2001 ylndan itibaren Index Me-dicus ve Medlineda, 2005 ylndan itibaren Excerpta Medica / EMBASE indekslerinde, 2007 ylndan itibaren Science Citation Index-Expanded (SCI-E) ile Journal Citation Reports / Science Edition uluslararas in-dekslerinde ve 2008 ylndan itibaren Index Copernicus indeksinde yer almaktadr. 2001-2006 yllar arasndaki 5 yllk dnemde SCI-E kapsa-mndaki dergilerdeki mpakt faktrmz 0,5 olmutur. Dergide aratrma yazlarna ncelik verilmekte, bu nedenle derleme veya olgu sunumu t-rndeki yazlarda seim ltleri daha dar tutulmaktadr. PUBMEDde dergi Ulus Travma Acil Cerrahi Derg ksaltmas ile yer almaktadr.

Dergiye yaz teslimi, almann daha nce yaynlanmad (zet ya da bir sunu, inceleme, ya da tezin bir paras eklinde yaynlanmas dn-da), baka bir yerde yaynlanmasnn dnlmedii ve Ulusal Travma ve Acil Cerrahi Dergisinde yaynlanmasnn tm yazarlar tarafndan uy-gun bulunduu anlamna gelmektedir. Yazar(lar), almann yaynlan-masnn kabulnden balayarak, yazya ait her hakk Ulusal Travma ve Acil Cerrahi Derneine devretmektedir(ler). Yazar(lar), izin almaks-zn almay baka bir dilde ya da yerde yaynlamayacaklarn kabul eder(ler). Gnderilen yaz daha nce herhangi bir toplantda sunulmu ise, toplant ad, tarihi ve dzenlendii ehir belirtilmelidir.

Dergide Trke ve ngilizce yazlm makaleler yaynlanabilir. Tm yaz-lar nce editr tarafndan n deerlendirmeye alnr; daha sonra incelen-mesi iin danma kurulu yelerine gnderilir.

Tm yazlarda editryel deerlendirme ve dzeltmeye bavurulur; ge-rektiinde, yazarlardan baz sorular yantlanmas ve eksikleri tamam-lanmas istenebilir. Dergide yaynlanmasna karar verilen yazlar ma-nuscript editing srecine alnr; bu aamada tm bilgilerin doruluu iin ayrntl kontrol ve denetimden geirilir; yayn ncesi ekline getiri-lerek yazarlarn kontrolne ve onayna sunulur. Editrn, kabul edilme-yen yazlarn btnn ya da bir blmn (tablo, resim, vs.) iade etme zorunluluu yoktur.

Yazlarn hazrlanmas: Tm yazl metinler 12 punto byklkte Times New Roman yaz karakterinde iki satr aralkl olarak yazlmaldr. Sayfa-da her iki tarafta uygun miktarda boluk braklmal ve ana metindeki say-falar numaralandrlmaldr. Journal Agent sisteminde, bavuru mektubu, balk, yazarlar ve kurumlar, iletiim adresi, Trke zet ve yaznn ngi-lizce bal ve zeti ilgili aamalarda yklenecektir. ngilizce yazlan a-lmalara da Trke zet eklenmesi gerekmektedir. Yaznn ana metnin-deyse u sra kullanlacaktr: Giri, Gere ve Yntem, Bulgular, Tartma, Teekkr, Kaynaklar, Tablolar ve ekiller.

Bavuru mektubu: Bu mektupta yaznn tm yazarlar tarafndan okun-duu, onayland ve orijinal bir alma rn olduu ifade edilmeli ve yazar isimlerinin yannda imzalar bulunmaldr. Bavuru mektubu ayr bir dosya olarak, Journal Agent sisteminin Yeni Makale Gnder bl-mnde, 10. aamada yer alan dosya ykleme aamasnda yollanmal-dr.

Balk sayfas: Yaznn bal, yazarlarn ad, soyad ve nvanlar, a-lmann yapld kurumun ad ve ehri, eer varsa almay destekle-yen fon ve kurulularn ak adlar bu sayfada yer almaldr. Bu sayfaya ayrca yazmadan sorumlu yazarn isim, ak adres, telefon, faks, mo-bil telefon ve e-posta bilgileri eklenmelidir.

zet: almann gere ve yntemini ve bulgularn tantc olmaldr. Trke zet, Ama, Gere ve Yntem, Bulgular, Sonu ve Anahtar Sz-ckler balklarn; ngilizce zet Background, Methods, Results, Conclu-sion ve Key words balklarn iermelidir. ngilizce olarak hazrlanan a-lmalarda da Trke zet yer almaldr. zetler balklar hari 190-210 szck olmaldr.

Tablo, ekil, grafik ve resimler: ekillere ait numara ve aklayc bil-giler ana metinde ilgili blme yazlmaldr. Mikroskobik ekillerde resmi aklayc bilgilere ek olarak, bytme oran ve kullanlan boyama tekni-i de belirtilmelidir. Yazarlara ait olmayan, baka kaynaklarca daha nce yaynlanm tm resim, ekil ve tablolar iin yayn hakkna sahip kiiler-

den izin alnmal ve izin belgesi dergi editrlne ayrca aklamasy-la birlikte gnderilmelidir. Hastalarn grntlendii fotoraflara, hasta-nn ve/veya velisinin imzalad bir izin belgesi elik etmeli veya foto-rafta hastann yz tannmayacak ekilde kapatlm olmaldr. Renkli resim ve ekillerin basm iin karar hakemler ve editre aittir. Yazarlar renkli basknn hazrlk aamasndaki tutarn demeyi kabul etmelidirler.

Kaynaklar: Metin iindeki kullanm srasna gre dzenlenmelidir. Ma-kale iinde geen kaynak numaralar keli parantezle ve kltlme-den belirtilmelidir. Kaynak listesinde yalnzca yaynlanm ya da yayn-lanmas kabul edilmi almalar yer almaldr. Kaynak bildirme Uniform Requirements for Manuscripts Submitted to Biomedical Journals (http://www.icmje.org) adl klavuzun en son gncellenmi ekline (ubat 2006) uymaldr. Dergi adlar Index Medicusa uygun ekilde ksaltlmaldr. Alt ya da daha az sayda olduunda tm yazar adlar verilmeli, daha ok ya-zar durumunda altnc yazarn arkasndan et al. ya da ve ark. eklen-melidir. Kaynaklarn dizilme ekli ve noktalamalar aadaki rneklere uygun olmaldr:

Dergi metni iin rnek: Velmahos GC, Kamel E, Chan LS, Hanpeter D, Asensio JA, Murray JA, et al. Complex repair for the management of du-odenal injuries. Am Surg 1999;65:972-5.

Kitaptan blm iin rnek: Jurkovich GJ. Duodenum and pancreas. In: Mattox KL, Feliciano DV, Moore EE, editors. Trauma. 4th ed. New York: McGraw-Hill; 2000. p. 735-62.

Sizlerin almalarnzda kaynak olarak yararlanabilmeniz iin www.trav-ma.org.tr adresli web sayfamzda eski yaynlara tam metin olarak ulaa-bileceiniz bir arama motoru vardr.

Derleme yazlar: Bu tr makaleler editrler kurulu tarafndan gerek ol-duunda, konu hakknda birikimi olan ve bu birikimi literatre de yans-m kiilerden talep edilecek ve dergi yazm kurallarna uygunluu sap-tandktan sonra deerlendirmeye alnacaktr. Derleme makaleleri; balk, Trke zet, ngilizce balk ve zet, alt balklarla blmlendirilmi me-tin ile kaynaklar iermelidir. Tablo, ekil, grafik veya resim varsa yukar-da belirtildii ekilde gnderilmelidir.

Olgu sunumlar: Derginin her saysnda snrl sayda olgu sunumu-na yer verilmektedir. Olgu bildirilerinin kabulnde, az grlrlk, eiti-ci olma, ilgin olma nemli lt deerlerdir. Ayrca bu tr yazlarn ola-bildiince ksa hazrlanmas gerekir. Olgu sunumlar balk, Trke zet, ngilizce balk ve zet, olgu sunumu, tartma ve kaynaklar blmlerin-den olumaldr. Bu tr almalarda en fazla 5 yazara yer verilmesine zen gsterilmelidir.

Editre mektuplar: Editre mektuplar basl dergide ve PUBMEDde yer almamakta, ancak derginin web sitesinde yaynlanmaktadr. Bu mektup-lar iin dergi ynetimi tarafndan yayn belgesi verilmemektedir.

Daha nce baslm yazlarla ilgili gr, katk, eletiriler ya da farkl bir konu zerindeki deneyim ve dnceler iin editre mektup yazlabilir. Bu tr yazlar 500 szc gememeli ve tbbi etik kurallara uygun ola-rak kaleme alnm olmaldr. Mektup baslm bir yaz hakknda ise, sz konusu yayna ait yl, say, sayfa numaralar, yaz bal ve yazarlarn adlar belirtilmelidir. Mektup bir konuda deneyim, dnce hakknda ise verilen bilgiler dorultusunda dergi kurallarna uyumlu olarak kaynaklar da belirtilmelidir.

Bilgilendirerek onay alma - Etik: Deneysel almalarn sonularn bil-diren yazlarda, almann yapld gnll ya da hastalara uygulana-cak prosedr(lerin) zellii tmyle anlatldktan sonra, onaylarnn alnd-n gsterir bir cmle bulunmaldr. Yazarlar, bu tr bir alma sz konu-su olduunda, uluslararas alanda kabul edilen klavuzlara ve T.C. Salk Bakanl tarafndan getirilen ynetmelik ve yazlarda belirtilen hkmle-re uyulduunu belirtmeli ve kurumdan aldklar Etik Komitesi onayn gn-dermelidir. Hayvanlar zerinde yaplan almalarda ar, ac ve rahatsz-lk verilmemesi iin neler yapld ak bir ekilde belirtilmelidir.

Yaz gnderme - Yazlarn gnderilmesi: Ulusal Travma ve Acil Cer-rahi Dergisi yalnzca www.travma.org.tr adresindeki internet sitesinden on-line olarak gnderilen yazlar kabul etmekte, posta yoluyla yollanan yazlar deerlendirmeye almamaktadr. Tm yazlar ilgili adresteki Onli-ne Makale Gnderme ikonuna tklandnda ulalan Journal Agent sis-teminden yollanmaktadr. Sistem her aamada kullancy bilgilendiren zelliktedir.

INFORMATION FOR THE AUTHORS

The Turkish Journal of Trauma and Emergency Surgery (TJTES) is an official publication of the Turkish Association of Trauma and Emer-gency Surgery. It is a peer-reviewed periodical that considers for pub-lication clinical and experimental studies, case reports, technical con-tributions, and letters to the editor. Six issues are published annually.

As from 2001, the journal is indexed in Index Medicus and Medline, as from 2005 in Excerpta Medica and EMBASE, as from 2007 in Science Citation Index Expanded (SCI-E) and Journal Citation Reports / Sci-ence Edition, and as from 2008 in Index Copernicus. For the five-year term of 2001-2006, our impact factor in SCI-E indexed journals is 0.5. It is cited as Ulus Travma Acil Cerrahi Derg in PUBMED.

Submission of a manuscript by electronic means implies: that the work has not been published before (except in the form of an abstract or as part of a published lecture, review, or thesis); that it is not under consideration for publication elsewhere; and that its publication in the Turkish Journal of Trauma and Emergency Surgery is approved by all co-authors. The author(s) transfer(s) the copyright to the Turkish Asso-ciation of Trauma and Emergency Surgery to be effective if and when the manuscript is accepted for publication. The author(s) guarantee(s) that the manuscript will not be published elsewhere in any other lan-guage without the consent of the Association. If the manuscript has been presented at a meeting, this should be stated together with the name of the meeting, date, and the place.

Manuscripts may be submitted in Turkish or in English. All submissions are initially reviewed by the editor, and then are sent to reviewers. All manuscripts are subject to editing and, if necessary, will be returned to the authors for answered responses to outstanding questions or for ad-dition of any missing information to be added. For accuracy and clarity, a detailed manuscript editing is undertaken for all manuscripts accepted for publication. Final galley proofs are sent to the authors for approval.

Unless specifically indicated otherwise at the time of submission, re-jected manuscripts will not be returned to the authors, including ac-companying materials.

TJTES is indexed in Science Citation Index-Expanded (SCI-E), Index Medicus, Medline, EMBASE, Excerpta Medica, and the Turkish Medi-cal Index of TUBITAK-ULAKBIM. Priority of publications is given to original studies; therefore, selection criteria are more refined for re-views and case reports.

Manuscript submission: TJTES accepts only on-line submission via the official web site (please click, www.travma.org.tr/en) and refuses printed manuscript submissions by mail. All submissions are made by the on-line submission system called Journal Agent, by clicking the icon Online manuscript submission at the above mentioned web site homepage. The system includes directions at each step but for fur-ther information you may visit the web site (http://www.travma.org/en/journal/).

Manuscript preparation: Manuscripts should have double-line spac-ing, leaving sufficient margin on both sides. The font size (12 points) and style (Times New Roman) of the main text should be uniformly taken into account. All pages of the main text should be numbered consecutively. Cover letter, manuscript title, author names and institu-tions and correspondence address, abstract in Turkish (for Turkish au-thors only), and title and abstract in English are uploaded to the Journal Agent system in the relevant steps. The main text includes Introduc-tion, Materials and Methods, Results, Discussion, Acknowledgments, References, Tables and Figure Legends.

The cover letter must contain a brief statement that the manuscript has been read and approved by all authors, that it has not been submit-ted to, or is not under consideration for publication in, another journal. It should contain the names and signatures of all authors. The cover letter is uploaded at the 10th step of the Submit New Manuscript sec-tion, called Upload Your Files.

Abstract: The abstract should be structured and serve as an informa-tive guide for the methods and results sections of the study. It must be prepared with the following subtitles: Background, Methods, Results and Conclusions. Abstracts should not exceed 200 words.

Figures, illustrations and tables: All figures and tables should be numbered in the order of appearance in the text. The desired position of figures and tables should be indicated in the text. Legends should be included in the relevant part of the main text and those for photo-micrographs and slide preparations should indicate the magnification and the stain used. Color pictures and figures will be published if they are definitely required and with the understanding that the authors are prepared to bear the costs. Line drawings should be professionally pre-pared. For recognizable photographs, signed releases of the patient or of his/her legal representatives should be enclosed; otherwise, patient names or eyes must be blocked out to prevent identification.

References: All references should be numbered in the order of men-tion in the text. All reference figures in the text should be given in brack-ets without changing the font size. References should only include articles that have been published or accepted for publication. Refer-ence format should conform to the Uniform requirements for manu-scripts submitted to biomedical journals (http://www.icmje.org) and its updated versions (February 2006). Journal titles should be abbrevi-ated according to Index Medicus. Journal references should provide inclusive page numbers. All authors, if six or fewer, should be listed; otherwise the first six should be listed, followed by et al. should be written. The style and punctuation of the references should follow the formats below:

Journal article: Velmahos GC, Kamel E, Chan LS, Hanpeter D, Asensio JA, Murray JA, et al. Complex repair for the management of duodenal injuries. Am Surg 1999;65:972-5.

Chapter in book: Jurkovich GJ. Duodenum and pancreas. In: Mattox KL, Feliciano DV, Moore EE, editors. Trauma. 4th ed. New York: Mc-Graw-Hill; 2000. p. 735-62.

Our journal has succeeded in being included in several indexes, in this context, we have included a search engine in our web site (www.travma.org.tr) so that you can access full-text articles of the previous issues and cite the published articles in your studies.

Review articles: Only reviews written by distinguished authors based on the editors invitation will be considered and evaluated. Review ar-ticles must include the title, summary, text, and references sections. Any accompanying tables, graphics, and figures should be prepared as mentioned above.

Case reports: A limited number of case reports are published in each is-sue of the journal. The presented case(s) should be educative and of in-terest to the readers, and should reflect an exclusive rarity. Case reports should contain the title, summary, and the case, discussion, and refer-ences sections. These reports may consist of maximum five authors.

Letters to the Editor: Letters to the Editor are only published elec-tronically and they do not appear in the printed version of TJTES and PUBMED. The editors do not issue an acceptance document as an original article for the letters to the editor. The letters should not ex-ceed 500 words. The letter must clearly list the title, authors, publica-tion date, issue number, and inclusive page numbers of the publication for which opinions are released.

Informed consent - Ethics: Manuscripts reporting the results of ex-perimental studies on human subjects must include a statement that informed consent was obtained after the nature of the procedure(s) had been fully explained. Manuscripts describing investigations in animals must clearly indicate the steps taken to eliminate pain and suffering. Authors are advised to comply with internationally accepted guidelines, stating such compliance in their manuscripts and to include the approval by the local institutional human research committee.

ULUSAL TRAVMA VE ACL CERRAH DERGSTURKISH JOURNAL OF TRAUMA & EMERGENCY SURGERY

CLT - VOL. 18 SAYI - NUMBER 1 OCAK - JANUARY 2012

indekiler - Contents

ix Editrden - Editorial

Deneysel alma - Experimental Studies

1-4 Is neopterin a diagnostic marker of acute appendicitis? Neopterin akut apandisit tansnda kullanlabilecek bir belirte midir? CokunK,Mente,AtakA,AralA,ErylmazM,Onguru,BalkanM,KozakO,etinerS

5-10 Effect of epidural anesthesia on anastomotic leakage in colonic surgery: experimental study Epidural anestezinin kolon cerrahisinde anastomoz kaa zerine etkisi: Deneysel aratrma AdanrT,AksunM,YlmazKararenG,KarabuaT,NazlO,encanA,KseoluM

Klinik alma - Original Articles

11-17 Effects of repetitive injections of hyaluronic acid on peritendinous adhesions after flexor tendon repair: a preliminary randomized, placebo-controlled clinical trial Fleksr tendon onarm sonras, tekrarlayan hyaluronik asit enjeksiyonlarnn, peritendinz adezyon zerine etkisi: Randomize plasebo kontroll klinik n alma

zgenelGY,EtzA

18-22 Cerrahi youn bakm hastalarnda ziyaretin yaam bulgular zerine etkisi: Pilot alma The impact of visits on vital signs of the patients in surgical intensive care unit: a pilot study Karabacak,enturanL,zdilekS,imekA,KaratekeY,EtiAslanF,YldzN,KayaB,ErtekinC

23-30 Analysis of the necessity of routine tests in trauma patients in the emergency department Acil servise bavuran travma hastalarnda rutin testlerin gerekliliinin analizi Kksal,Erenevik,AkkseAydn,zdemirF

31-36 Work-related injuries in textile industry workers in Turkey Trkiyede tekstil sektr alanlarnda i kazalarna bal yaralanmalar SerinkenM,Trker,DalB,Karcolu,ZencirM,UyankE

37-42 Diagnostic peritoneal lavage in hemodynamically stable patients with lower chest or anterior abdominal stab wounds Hemodinamik adan stabil, gs alt veya n karn blgesinde bak yaralanmas olan hastalarda tansal peritoneal lavaj

HashemzadehS,MameghaniK,FouladiRF,AnsariE

43-48 Factors affecting the number of debridements in Fourniers gangrene: our results in 36 cases Fournier gangreninde debridman saysn etkileyen faktrler: 36 olguda sonularmz GktaC,YldrmM,HoruzR,FaydacG,AkaO,etinelCA

49-54 An alternative classification of occupational hand injuries based on etiologic mechanisms: the ECOHI classification Etyolojik mekanizmalarnn temelinde i kazasna bal el yaralanmalarnda alternatif bir snflama: KEYES snflamas

zelikB,ErtrerE,MersaB,PurisaH,Sezer,TunerS,KabakaF,KuvatSV

Cilt - Vol. 18 Say - No. 1 vii

ULUSAL TRAVMA VE ACL CERRAH DERGSTURKISH JOURNAL OF TRAUMA & EMERGENCY SURGERY

CLT - VOL. 18 SAYI - NUMBER 1 OCAK - JANUARY 2012

indekiler - Contents

55-60 Upper extremity injuries due to threshing machine Harman dvme makinesine bal st ekstremite yaralanmalar IkD,CeylanMF,TekinH,KaradaS,GnerS,CanbazY

61-64 Falling television related child injuries in Turkey: 10-year experience Trkiyede televizyon dmesi nedeni ile gelien ocuk yaralanmalar: 10 yllk deneyim GloluR,Sarc,BademlerS,EmirikiS,severH,YanarH,ErtekinC

65-70 Comparative results of percutaneous cannulated screws, dynamic compression type plate and screw for the treatment of femoral neck fractures Femur boyun krklarnn tedavisinde perktan kanle vida, dinamik kompresyon plak ve vidann karlatrmal sonular

KaplanT,AkesenB,DemiraB,BilgenS,DurakK

71-74 Immediate appendectomy for appendiceal mass Apendikler kitlelerde erken apendektomi KayaB,SanaB,EriC,KutaniR

75-79 Foreign body traumas of the eye managed in an emergency department of a single-institution Bir merkezin acil servisinde tedavi edilen gzn yabanc cisim travmalar Yiit,YrktmenA,ArslanS

Olgu Sunumu - Case Reports

80-82 Vertebra kr veya k olmakszn gelien ift seviyeli omurilik yaralanmas: Olgu sunumu Double-level spinal cord injury without vertebral fracture or dislocation: A case report AtlganM

83-86 Repair of an extensive iatrogenic tracheal rupture with a pleural patch and a vascular graft Geni iyatrojenik trakea rptrnn vaskler ve plevral yama ile onarm BostancEB,zer,EkizF,AtcAE,ReyhanE,AkoluM,ErklnA,YakutC

87-88 Traditional Kehrs sign: Left shoulder pain related to splenic abscess Geleneksel Kehr bulgusu: Splenik apseye bal sol omuz ars SyncS,BektaF,eteY

89-91 A fish bone causing ileal perforation in the terminal ileum Balk klnn neden olduu terminal ileum perforasyonu MutluA,UysalE,UlusoyL,DuranC,SelamoluD

92-94 Late-diagnosed bilateral intertrochanteric femur fracture during an epileptic seizure Epilepsi nbeti srasnda gelimi ge tan konmu, iki tarafl intertrokanterik femur kr opuroluC,zcanM,DlgerH,YalnzE

95-98 Knt travmaya bal diyafram yrtna sekonder akut mekanik intestinal obstrksiyon olgusu Evaluation of an acute mechanic intestinal obstruction case secondary to diaphragma rupture due to a blunt trauma

SzenS,AysuF,ElkanH,akmakA,YldzF

viii Ocak - January 2012

Turkish Journal of Trauma & Emergency Surgery Ulus Travma Acil Cerrahi Derg 2012;18 (1)

EDTRDEN

Cilt - Vol. 18 Say - No. 1 ix

Deerlimeslektalarm,

OnbeyldanfazlayaynhayatndaolanUlusalTravmaveAcilCerrahiDergisiileyenibirylabalamaktanduyduumuzsevincisizlerlepaylamaktaneditryelekipolarakmutlulukduymak-tayz.Getiimizylyldaaltsayolarakkandergimizbuylyineaynformattadevamedecek.Geenylyaymlananyazsaystoplam120dir.Yaynlananmakaleleringeneldalm;17 De-neysel,61Klinik,38OlguSunumu,3EditreMektup,1Derlemedir.

UlusalTravmaveAcilCerrahiDergisindengilizceolarakyaynlanantoplammakalesays93olmutur.Ayrcayurtdkaynaklyaymlananmakaleler18dir.Yzgldrcolarak,dergi-mizegnderilenmakalesayshergeengnartmaktadr.

UlusalTravmaveAcilCerrahiDerneinindzenlemiolduu8.UlusalTravmaveAcilCer-rahiKongresi(UluslararasKatlml)meslektalarmzarasndayaptmzanketlerdorultusun-da14-18Eyll2011tarihleriarasndaMardanPalaceKongreMerkezi,Antalyadadzenlenmi-tir.ncekikongrelerimizdeolduugibiyounkatlmloturumlardabilimselveteknolojikdei-ikliklerinbadndrchzlayaandTravmaveAcilCerrahialanndakiyeniliklerivedeiik-liklerisizlerlepaylamak,meslektalarmznkarlatklarsorunlarnvezmnerilerinisizler-letartmaimkanbulduk.Sunulanbildirilerinizetravmawebsitemizdenhttp://www.travma.org.tr (PDFformatnda)ulaabilirsiniz.DergimizinTravmaveAcilCerrahisahasndakigncelliterat-rekatksalamayadevamedeceinebelirtmekistiyoruz.Buamalabilimselierikve etkinlika-sndanenstdzeydeolmasiinsizlerinbilimselalmalarilekatlmnzyanndailgivedeste-inizeihtiyacmzvardr.Hertrlnerivegrlerinizimemnuniyetlebekliyoruz.

Buylsizlerememnunkalacanzumduumuzbiryeniliklekarnzakyoruz.Dergikindleile(iPad,iPhone,Android)uyumluhalegetirilmitir.angerektirdiielektronikyaynclkileilgilialmalarmzhzkazanmtr.Budorultudadergimakalelerinehertrlelektronikortam-daneriilebilmesiiinbalatlanalmalartamamlanmakzeredir.

GnmzdeTravmaveAcilCerrahiileuraanGenelCerrah,Ortopedist,KalpDamarCerra-h,ocukCerrah,Radyoloji,AcilTp,BeyinCerrahisi.vebirokalandakimeslektalarmznalmalarn,nazikkatkveyoundesteinibekliyor,yeniylda dahagzelalmalardabulu-makmidiileesenliklerdiliyorum.

Dr.RecepGLOLU

Editr

xUlus Travma Acil Cerrahi Derg

Ocak - January 2012

www.tjtes.org

www.travma.org.tr

1Turkish Journal of Trauma & Emergency Surgery

Experimental Study Deneysel alma

Ulus Travma Acil Cerrahi Derg 2012;18 (1):1-4

Is neopterin a diagnostic marker of acute appendicitis?

Neopterinakutapandisittansndakullanlabilecekbirbelirtemidir?

Kaan COKUN,1 ner MENTE,1 Ayegl ATAK,2 Arzu ARAL,2 Mehmet ERYILMAZ,3

nder ONGURU,4 Mjdat BALKAN,1 Orhan KOZAK,1 Sadettin ETNER1

Departments of 1General Surgery, 3Emergency Medicine, 4Pathology, Gulhane Military Medical Faculty, Ankara;

Department of Immunology, Gazi University Faculty of Medicine, Ankara, Turkey.

Glhane Askeri Tp Akademisi, 1Genel Cerrahi Anabilim Dal, 3Acil Tp Anabilim Dal, 4Patoloji Anabilim Dal, Ankara; 2Gazi niversitesi Tp Fakltesi, mmnoloji Bilim Dal,

Ankara.

Correspondence (letiim): Kaan Cokun, M.D. GATA, Gen. Tevfik Salam Cad., Etlik 06018 Ankara, Turkey.Tel: +90 - 312 - 304 50 16 e-mail (e-posta): [email protected]

AMADeneyimlibircerrahiinbileakutapandisittanskimiza-man zor olabilir. Tandaki gecikme komplikasyon oran-narttrmaktadr.Budeneyselalmadakiamacmz,akutapandisittansndabelirteolarakneopterininuygunluu-nunvenemininaratrlmasdr.

GERE VE YNTEMOtuzbeadetYeniZellandatipierkektavandaoluturul-muakutapandisitmodelindeneopterindzeylerilld.Hayvanlar apendektomi uygulanana kadar geen zamanagre5grubaayrld.(Grup1:Kontrol,Grup2:Sham,Grup3:12.saat,Grup4:24.saat,Grup5:48.saat).Herbirgrup-tanalnankanrneklerinde(Grup3,Grup4veGrup5teapendektomincesinde)neopterindzeylerienzimimmu-noasseykitindelld.

BULGULARAkut apandisit tans iin optimal eik deeri noktas34,475 nmol/lt olarak saptand.Neopterin dzeyi 34,475nmol/ltzerindeolduuzamanakutapandisitolmaolasl-4,667katfazlaolarakbulundu.

SONUBualmadeneyselbirhayvanalmasolsadaklinikuy-gulamalarasndandeerliipularvermektedir.Neopteri-ninakutapandisittansndakullanlabilecekpotansiyelesa-hipbirbelirteolduunudnyoruz.

Anahtar Szckler: Akutapandisit;belirte;neopterin.

BACKGROUNDThediagnosisofacuteappendicitis,evenforexperiencedsurgeons,cansometimesbecomplex.Adelayindiagnosisincreases the complication rate. This experimental studyaimedtoinvestigatethesuitabilityandsignificanceofne-opterinasamarkerforacuteappendicitis.

METHODSThe levels of neopterin were measured using an acuteappendicitisanimalmodelin35NewZealandmalerabbits.Theyweredividedinto5groupsasGroup1=control;Group2=sham;andGroups3(12-hour);4(24-hour);and5(48-hour)(basedontheelapsedtimeperiodbeforetheirappendectomies).Theneopterinlevelsofeachgroupweremeasuredbyneopterinenzyme immunoassaykit inbloodsamples (takenbeforetheappendectomiesinGroups3,4and5).

RESULTSForthediagnosisofacuteappendicitis,theoptimalcut-offpointwas34.475nmol/L.Theprobabilityofacuteappendi-citiswasfoundtobe4.667timeshigherwhentheneopterinlevelwasgreaterthan34.475nmol/L.

CONCLUSIONThisstudywasanexperimentalanimalstudy;however,itprovidesvaluablecluesusefulinclinicalassessment.Ne-opterinseemstohavegreatpotentialasanewdiagnosticmarkerforthediagnosisofacuteappendicitis.

Key Words: Acuteappendicitis;marker;neopterin.

doi: 10.5505/tjtes.2012.00087

Acute appendicitis was first defined by Fitz in1886. Several years later, McBurney performed thefirstoperationforacuteappendicitis.[1]Thediagnosisofacuteappendicitis is routinelymadeusingpatient

history and physical examination, usuallywith highprecision.However,anidealdiagnostictesthasyettobedeveloped.Althoughthegoldstandardtreatment-appendectomy-wasdefinedmorethan100yearsago,

Ulus Travma Acil Cerrahi Derg

2 Ocak - January 2012

Table 1. Theserumneopterinlevelsofthecontrolandthestudygroups(p=.0001)

Group Neopterin(nmol/L)

1 28.181.74 2 33.560.75 3 38.160.81 4 49.102.63 5 85.872.48

surgeonsarestill facedwitheithercomplicationsre-lated to a latediagnosisorunnecessary appendecto-mies,therateofwhichisbetween4and27%indiffer-entseries.[2]Inbothcases,themorbidityandmortality,aswellasthefinancialcost,areincreased.

Neopterin [D-erythro-neopterin] is a low-molec-ular-weight (253.2 kDa) aromatic pteridinemoleculeproducedmainlybyactivatedmonocytesandmacro-phages,anditservesasamarkerforcellularimmunesystemactivation.[3,4]Itisshownthatthereisanincreaseinthelevelsofneopterinwithsepsis,malignancy,acuteviralinfections,andrheumatologicaldiseases.[5]

Inthisexperimentalstudy,weaimedtoinvestigatethesuitabilityandimportanceofneopterinasamarkerforacuteappendicitis.

MATERIALS AND METHODSThe study was supported by the Gulhane Mili-

taryMedicalAcademy Research Fund and was ap-provedby theResearchandAnimalEthicsCommit-tees.Thirty-fiveNewZealandmalerabbits(weighing28503200g)wereincludedinthestudy.EachanimalwashousedindividuallyaccordingtotherulesoftheAnimalEthicsCommittee.

For the study, 5 groupswere constituted, with 7rabbitsineachgroup.Group1wasthecontrolgroup;Group2animals receivedashamoperation;Groups3,4,and5underwentappendectomiesat12hours(h),24h, and48h, respectively.The inductionof anes-thesiaineachgroupwasthroughinjectionsof50mg/kgintramuscular(i.m.)ketamine(Ketalar,Eczacba,stanbul,Turkey)and4mg/kgi.m.xylazine(Rampun,Bayer,stanbul,Turkey).InGroups2,3,4,and5,af-tertheanimalswereanesthetized,theabdominalskinwasopenedwitha3-cmmidlineincision.InGroup1,bloodsampleswereobtainedafterinitiatinganesthe-sia.InGroup2,bloodsampleswereobtainedaftertheshamoperations.

InGroups3,4,and5,theappendixwasexterior-ized and ligated from its base, preserving the mes-entery and blood supply.Appendectomieswere per-formedat12h,24h,and48hforGroups3,4,and5, respectively.Blood sampleswereobtainedbeforeappendectomy inGroups3,4 and5.Theappendec-tomyspecimensfromallgroupswereexaminedhisto-pathologically.Thebloodsampleswerecentrifugedat3000xgfor15minutes(min),andtheseraseparated.Serumsampleswere storedat -80Cuntil theneop-terinELISAstudy.

We used a commercially available neopterin en-zymeimmunoassaykit(NeopterinELISA,TanMed-ical Laboratories, Ankara, Turkey) for quantitativeanalysisoftheneopterinlevelsintheserumsamples.Thisneopterinassayisacompetitiveenzymeimmu-

noassayforthequantitativedeterminationofneopterin(nmol/L)inserum,plasmaandurineusingahighaf-finitymonoclonalantibodyspecificforneopterin.Theassaywasperformedaccordingtothemanufacturersinstructions.

Statistical AnalysisTheKruskal-Wallis testwasused tocompare the

differencesbetweenallgroups.TheMann-WhitneyUtestwasused forevaluating thedifferencesbetweenthe non-appendicitis and appendicitis groups.A re-ceiveroperatingcharacteristiccurve(ROCcurve)wasderivedbyplottingsensitivityagainst1-specificityfordifferent possibledecision levels to compare the as-setsofthetestperformances.Theareaunderthecurve(AUC)wascalculatedusingtheStatisticalPackagefortheSocialSciences(SPSS)program.Thebestcutoffpoints were selected by comparing specificities andsensitivitiesatvariouslevels.Theresultswereevalu-ated inmeanSDvalues.All p values

Is neopterin a diagnostic marker of acute appendicitis?

indiagnosis increases thecomplicationrate,causinganincreaseinmortalityandmorbidity.[6]Ontheotherhand, negative appendectomies are performed (withnoappendicitis)atratesbetween4and27%indiffer-entseries.[2]Bothcasesresult in increasedmorbidityandmortality, aswell as increasedfinancial cost. Inthefirstcase,asecondarylaparotomymaybeneeded.Every procedure that is performed during an opera-

tionincreasestheriskofnewmorbidities.Inthesec-ondcase,unnecessaryappendectomiesareperformed.AccordingtoFlumetal.,[7] inanationwideanalysis,261,134 patients had appendectomies in the UnitedStatesin1997.Ofthese,15.3%wereunnecessaryap-pendectomies,resultinginatotalhospitalexpenseofapproximatelyUS$741.5million.

There are laboratory and radiological methodsusedtoassistinthediagnosisofacuteappendicitis.[8,9] However, todate,neitheran ideal laboratorymarkernoragold-standardradiologicaltechniquewith100%sensitivityorspecificityhasbeenfound.Afterclinicalpresentationandacarefulanddetailedphysicalexam-ination,ifthesurgeonstillhasdifficultywiththediag-nosisorifthecaseisparadoxic,adiagnosticmarkerwithhighsensitivityandspecificityisrequired.There-fore,weaimedtoinvestigatethepotentialofneopterinmoleculesasmarkers thatcanbeusedasadetermi-nantforthediagnosisofacuteappendicitis.

Neopterin isa low-molecular-weight(253.2kDa)aromatic molecule belonging to the group of pteri-dines.Neopterin,aswellasotherpteridines,arede-rivedin vivofromguanosinetriphosphate(GTP).TheenzymeGTP-cyclohydrolase-Icatalyzesthisreactioninmonocytesandmacrophages.Neopterinisexcretedbyactivatedmonocytes/macrophages,andservesasamarker forcellular immunesystemactivation.[3]Theincrease of neopterin levels in sepsis,malignancies,acute viral infections, rheumatological diseases, andin the follow-up of graft rejection has been demon-stratedpreviously.[5]Besidesbeinganimportantmark-erforfollow-upofgraftrejectionaftertransplantation,

Cilt - Vol. 18 Say - No. 1 3

Fig. 1. Anappendix,(a)12h(b)24h(c)48hafterligationfrom its base, preserving the mesentery and bloodsupply.

(Color figure can be viewed in the online issue, which is available at www.tjtes.org)

(a)

(b)

(c)

0,0

0,0

0,2

0,4

0,6

0,8

1,0

0,2 0,4

1-Specificity

Sensitivity

0,6 0,8 1,0

Fig. 2. TheROCplot shows the power of neopterin in thediagnosisofacuteappendicitis.

(Color figure can be viewed in the online issue, which is available at www.tjtes.org)


it isalsoan importantmarkerused inprotecting therecipientfrominfections.Sincedonorbloodsamplesare not usually tested for all possible infections, themeasurement of neopterin in blood donor samplesisauseful tool inreducing theriskof infectionsviablood transfusion or transplantation. Neopterin lev-els may be significantly increased in some diseasestatescompared tocontrolsandserialmeasurementsof neopterin levels in the same patientmay be use-levels in the same patientmay be use- in the same patientmay be use-fulinordertomonitorthecourse.Neopterinmaybepotentially useful for diagnostic/prognostic purposesinfollowinguptraumaandhumanimmunodeficiencyvirus (HIV) patients, in early detection of graft-vs-hostdiseaseinbonemarrowtransplantation,inearlydetectionofgraftrejection,inmonitoringdiseaseac-tivity in autoimmune diseases, in diagnosis of viralinfections,indifferentialdiagnosisofacuteviralandbacterialinfections,asaprognosticindicatorofmalig-nancy,inmonitoringimmunostimulatorytherapy,andinthefollow-upofchronicinfections.[10,11]Fromthisperspective,westudiedneopterininthediagnosisofacuteappendicitis.

Severalmarkers,suchasserotonin,bilirubinemia,serum D-lactate, D-dimer, and C-reactive protein,have been studied for the diagnosis of acute appen-dicitis.Singhetal.[12]andKalraetal.[13]measuredtheserotonin levelofplasma inearlyacuteappendicitisand found that serotonin could be used as amarkerat this stage.Sandet al.[14] found thathigh levelsofbilirubinemiaandclinicalsymptomsrelatedwithap-pendicitisindicatedtheprobabilityofappendicealper-foration.Duzgunetal.[15]statedthattherewasacorre-lationbetweenacuteappendicitisandserumD-lactatelevelsandthattheselevelscouldbeusedasadiagnos-andthattheselevelscouldbeusedasadiagnos-ticmarker.Mentesetal.[16]studiedD-dimerforacuteappendicitis,andfoundnorelationshipbetweenthem.However,Wu et al.[17] found that C-reactive proteinwasaprognosticmarkerforearlyacuteappendicitis.Our study also showed that neopterin is a valuablemarkerat48hoursforacuteappendicitis.Between24and48hours,thelevelofneopterinwasfoundtobeparticularlysignificant.

Inourstudy, theprobabilityofacuteappendicitiswas found tobe4.667 timeshigherwhen theserumneopterinlevelwasgreaterthan34.475nmol/L.ThemeanserumneopterinleveloftheanimalsinGroups3,4and5(acuteappendicitisgroups)washigherthanin thenon-appendicitisgroups, indicating thatneop-terincouldbeusedasaserummarkerforthediagnosisofacuteappendicitis.

Inconclusion,thisstudyisanexperimentalanimalstudy;however,itprovidesseveralvaluablecluesuse-ful in clinical assessment.Togetherwith a carefullyextracted medical history, an accurate interpretationof theclinicalpresentation, anda completephysical

examination,neopterinseemstohavegreatpotentialasanewdiagnosticmarkerforthediagnosisofacuteappendicitis.

AcknowledgementsTheauthorsgreatlyappreciatethecontributionof

thestatistician,Mr.AhmetGl.

REFERENCES1. SaidiHS,ChavdaSK.UseofamodifiedAlvoradoscorein

thediagnosisofacuteappendicitis.EAfrMedJ2003;80:411-5.

2. Jones PF. Suspected acute appendicitis: trends inmanage-mentover30years.BrJSurg2001;88:1570-7.

3. OettlK,ReibneggerG.Pteridinesas inhibitorsofxanthineoxidase: structural requirements. Biochim Biophys Acta1999;1430:387-95.

4. KatohS,SueokaT,MatsuuraS,SugimotoT.Biopterinandneopterininhumansaliva.LifeSci1989;45:2561-8.

5. Hamerlinck FFV. Neopterin: a review. Exp Dermatol1999:8:167-76.

6. PegoliW.Acuteappendicitis.In:CameronJL,editor.Currentsurgicaltherapy.6thed.St.Louis:Mosby;1998.p.263-6.

7. FlumDR,KoepsellT.Theclinicalandeconomiccorrelatesof misdiagnosed appendicitis: nationwide analysis. ArchSurg2002;137:799-804.

8. RolandEA,HuganderA,RavnH,OffenbartlK,GhaziSH,NystromPO,etal.Repeatedclinicalandlaboratoryexami-nationsinpatientswithanequivocaldiagnosisofappendici-tis.WorldJSurg2000;24:479-85.

9. MichaelAZ,SelzmanCH,CothrenC, SorensenAC,Rae-burnCD,HarkenAH.DiagnosticimplicationsofC-reactiveprotein.ArchSurg2003;138:220-4.

10.MurrC,WidnerB,WirleitnerB,FuchsD.Neopterin as amarker for immune system activation. Curr Drug Metab2002;3:175-87.

11.FuchsD,WeissG,ReibneggerG,WachterH.The role ofneopterinasamonitorofcellularimmuneactivationintrans-plantation,inflammatory,infectiousandmalignantdiseases.CritRevClinLabSci1992;29:307-41.

12.SinghMS,DeanHG,DombelFT,WilsonDH,FlowersMW.Concentrationsofserotonin inplasma-a test forappendici-tis?ClinChem1988;34:2572-4.

13.KalraU,ChitkaraN,DadooRC,SinghGP,GulatiP,NarulaS.Evaluationofplasmaserotoninconcentrationinacuteap-pendicitis.IndianJGastroenterol1997;16:18-9.

14.SandM,BecharaFG,Holland-LetzT,SandD,MehnertG,MannB.Diagnosticvalueofhyperbilirubinemiaasapredic-tivefactorforappendicealperforationinacuteappendicitis.AmJSurg2009;198:193-8.

15.DuzgunAP,BugdayciG,SayinB,OzmenMM,OzerMV,CoskunF.SerumD-lactate:ausefuldiagnosticmarker foracuteappendicitis.Hepatogastroenterology2007;54:1483-6.

16.MentesO,EryilmazM,HarlakA,OzerT,BalkanM,KozakO,etal.CanD-dimerbecomeanewdiagnosticparameterforacuteappendicitis?AmJEmergMed2009;27:765-9.

17.WuHP,LinCY,ChangCF,ChangYJ,HuangCY.PredictivevalueofC-reactiveproteinatdifferentcutofflevelsinacuteappendicitis.AmJEmergMed2005;23:449-53.


5Turkish Journal of Trauma & Emergency Surgery

Experimental Study Deneysel alma


Effect of epidural anesthesia on anastomotic leakage in colonic surgery: experimental study

Epiduralanestezininkoloncerrahisindeanastomozkaazerineetkisi:Deneyselaratrma

Tayfun ADANIR,1 Murat AKSUN,1 Glah YILMAZ KARAREN,1 Trker KARABUA,2

Okay NAZLI,3 Atilla ENCAN,1 Mehmet KSEOLU4

Presented at the Congress of Euroanaesthesia 2009 (June 6-9, 2009, Milan, Italy).

Departments of 1Anesthesiology and Reanimation, 2Surgery, 4Biochemistry, Ataturk Training and Research Hospital, Izmir; 3Department of Surgery,

Mugla University Faculty of Medicine, Mugla, Turkey.

Euroanaesthesia 2009 Kongresinde sunulmutur(6-9 Haziran 2009, Milan, talya).

Atatrk Eitim ve Aratrma Hastanesi, 1Anesteziyoloji ve Reanimasyon Klinii, 2Genel Cerrahi Klinii, 4Biyokimya Blm, zmir;

3Mula niversitesi Tp Fakltesi, Genel Cerrahi Anabilim Dal, Mula.

Correspondence (letiim): Tayfun Adanr, M.D. Atatrk Eitim ve Aratrma Hastanesi, Anesteziyoloji ve Reanimasyon Klinii, zmir, Turkey.Tel: +90 - 232 - 250 50 50 e-mail (e-posta): [email protected]

AMABirhayvanmodelinde,srekliepiduralanestezi ilekolonanastomozunungcarasndakiilikiaratrld.

GERE VE YNTEMBeyazerkek14adetYeniZelandatavanalmayaalndverandomizeikigrupoluturuldu.Grup1de(n=7)epidu-raldensrekliolarak%0,9lukNaClinfzyonu(0,4mlkg-1 bolusve0,2mlkg-1sa-1infzyon)veGrup2de(n=7)epi-duralden srekli olarak %1lik lidokain infzyonu (0,4mlkg-1bolusve0.2mlkg-1sa-1infuzyon)uyguland.nfz-yonlara,operasyonlarnbandabalandvecerrahisonra-s6.saatekadarsrdrld.Btndeneyhayvanlarnage-nelanestezialtndasakolonrezeksiyonuvekolo-kolonikanastomozuyguland.Cerrahisonras4.gn,re-laparotomiyaplpin situolarakanastomozpatlamabasnlarlld.Dikihattniinealan1cmliksegmentkartlp,hidrok-siprolinvekollajendzeylerilld.

BULGULARAnastomozpatlamabasnlar,epidurallidokaingrubunda(medyan248mmHg-[117-300])serumfizyolojikgrubu-na(medyan109mmHg-[47-176])greanlamlderecedeyksek bulundu (p=0,006). Doku rneindeki hidroksip-rolinvekollajendzeyleriasndangruplararasndafarkyoktu(p>0,05).

SONUKolon anastomozunun dayankllnn epidural lidokaininfzyonuileartabileceinidnyoruz.

Anahtar Szckler: Anastomoz dayankll; kolon cerrahisi;epiduralanestezi;lidokain.

BACKGROUNDTheassociationbetweentheinfusionofcontinuousepidu-ralanesthesiaandtheanastomoticstrengthofcolonicanas-tomosiswasexaminedinananimalmodel.

METHODSFourteenwhitemaleNewZealand rabbitswere includedinthestudyandrandomlyassignedtotwogroups.Group1(n=7)hadcontinuousepidural0.9%NaClinfusion(0.4mlkg-1bolusand0.2mlkg-1h-1infusion)andGroup2(n=7)hadcontinuousepidural1%lidocaineinfusion(0.4mlkg-1 bolusand0.2mlkg-1h-1infusion).Infusionsstartedatthebeginningoftheoperationandwerecontinuedforsixhourspostoperatively.Allexperimentalanimalsunderwentrightcolonresectionandcolo-colonicanastomosisundergeneralanesthesia.Onthefourthpostoperativeday,relaparotomywasappliedandtheburstingpressuresoftheanastomosis(BPA) were measured in situ. Segments 1-cm longconsistingof thecompletesuture lineswereexcised,andthelevelsofhydroxyprolineandcollagenweremeasured.

RESULTSBPAs were statistically higher in the epidural lidocainegroup (median:248mmHg;min117 -max300) than inthesalinegroup(median:109mmHg;min47-max176)(p=0.006).Therewasnodifferencebetweenthegroupsintermsofhydroxyprolineandcollagenlevelsinthesampletissues(p>0.05).

CONCLUSIONWeconcludedthatthestrengthofcolonicanastomosismaybeincreasedbyepidurallidocaineinfusion.

Key Words: Anastomoticstrength;colonicanastomosis;epiduralanesthesia;lidocaine.

doi: 10.5505/tjtes.2012.67044



Several studies comparing epidural anesthesiaversusbalancedgeneralanesthesiaandsystemicopi-oid analgesia have reported a more rapid recoveryof bowel function in epidural anesthesia patients.[1-7] However,someauthorshavequestionedwhetherepi-duralanalgesiacouldbedetrimentaltothehealingofgastrointestinalanastomosesbecauseoftheincreasedbowelmotility.[8]

There is, however, substantial experimental andclinical evidence that epidural anesthesia/analgesiaissafeforpatientsundergoingbowelresectionswithanastomoses.[9,10] In addition, studies carried out onanimals and humans have demonstrated that epidu-ral anesthesia with local anesthetics during surgicalstimulation maintains intestinal mucosal blood flowandgastricmucosalpHatphysiological levelscom-parable with controls treated with general anesthet-ics.[11-13] It has been hypothesized that the increasedmucosalflowcanpromoteanastomotichealing.[14]Infact, retrospective cohort controlled studies suggestthatregionalanesthetictechniquesareassociatedwitha beneficial effect on anastomotic healing rates.[10-15] Thestimulatoryeffectofepiduralanesthesiaongas-trointestinalmobility can lead to theoretical concernabout increasinganastomotic leakage,but segmentalautonomic blockade may increase the blood supplytotheanastomosisandimprovehealing.Inarecentlypublishedmeta-analysis,therateofanastomoticleak-age remained the same, regardless of the analgesictechniqueused.[16]

Epiduralanesthesiaisbelievedtobenefitcolorec-talanastomoticbloodflowbecauseitproducessym-patheticblockade.[17,18]However,continuousinfusionof epidural local anesthetic can lead to an increasedincidenceofanastomoticleakageowingtothestimu-latoryeffectonbowelmotility.[19,20]

Inthisstudyinarabbitmodel,continuousepiduralanesthesiawithlidocainewasinvestigatedintermsoftheburstingpressureofcolonicanastomoses (BPA).Hydroxyprolineandcollagenareconsideredas indi-cators of anastomotic strength, and thus their levelsasmeasuredinanastomosissampletissueswerealsoexamined.

MATERIALS AND METHODSAnimal PreparationThestudydesignwasapprovedbytheAnimalIn-

vestigationsEthicsCommitteeofAtaturkTrainingandResearchHospital,which conforms to standard ani-mal treatment guidelines (Homeoffice licensenum-ber:489,Date:11.27.2008).FourteenwhitemaleNewZealand rabbitsweighing2150-2850gwereused inthisstudy.Beforetheexperiment,therabbitswereac-climatedforaminimumof72hours(h),andcarefullycheckedforpre-existingdisease.Thedailyfoodration

was not withdrawn until the procedure was carriedout.Alltheprocedureswereperformedbetween12:00and24:00h.Onthedayoftheexperiment,anesthesiawasinducedwith20mgkg-1intramuscularketamine (Ketasol 10%, Richter Pharma AG, Wels, Austria)and8mgkg-1 intramuscularxylazine(Alfazyne2%,Alfasan International BV, Woerden, Netherlands).Aftercannulationintotheright-earmarginalveinsoftheanimals,anesthesiawasmaintainedintravenouslywith10mgkg-1h-1ketamineand0.9%NaCl (5mgkg-1).The left-earmarginal arterywascannulated tomeasuremeanarterialpressureandheart rate (PetasKMA800,ProfessionalElectronic IndustryandTic.AS,Turkey).Therabbitswerewarmedtomaintainaconstantbodytemperature.Theirtracheaswerenotin-tubated,andtheanimalsbreathedspontaneously.Allanimalsreceivedantibioticcoverage(cephamezine20mgkg-1,i.v.).

Epidural ProcedureThehaironthetailsandwaistregionsoftheani-

malswereshavedaftertheywereplacedintheproneposition. The tail regions were scrubbed with 10%povidoneiodine.Askinincisionwasperformed1cmfromtheanus,followingsterilecoverage,andthesub-cutaneous injectionof1%lidocaine.Theconnectivetissueandparaspinalmusclesweredissectedandthesacralhiatusopened.An18-Gepiduralcatheter(Mini-packSIMSPortexLtd,Hyde,Kent,UK)wasinsertedintotheepiduralspacethroughthesacralcanalupto4-5cmcranially.Aspirationwasusedtocheckwheth-ertheduramaterwaspunctured.Thefreeedgeofthecatheter was placed in a subcutaneous tunnel usingaTuohyneedle;itwasshortenedandconnectedtoascrewconnectorforsubsequentuse.Thecatheterwasfixedtotheskinandtheincisionsutured.Neurologicalinjuryassociatedwiththeuseoftheepiduralcatheterwasevaluatedafterrecoveryfromtheketamine.Para-plegiaandabsentflexionreflexofbothlowerextremi-ties followingpainful stimulion the toesof theani-malswereconsideredaspositivesignsofneurologicalinjury.Anyanimalsexhibitingsignsofaneurologicalormotordeficitwereeliminatedfromthestudy.Inor-dertoverifythatthecatheterwaswithintheepiduralspace,1%lidocaine(0.4mlkg-1)wasadministered5hlaterviatheepiduralcatheterandflushedwith0.2mlof0.9%NaCl.Ifanymotororsensoryblockadewasobservedwithin5minutes(min),itwasconcludedthatthecatheterwasinthesubduralandnotepiduralspace.Itwasverifiedthatmotorblockadewasobservedaf-ter20minofdrugadministration.Motorfunctionwasassessedaccording to thecriteriaofDrummondandMoore[21] (0: freemotionwithout limitation in lowerextremities;1:asymmetryandlimitationinprovidingbodysupportandwalkinginlowerextremities;2:in-abilitytoprovidebodysupportbylowerextremities;and3:paralysisofbothlowerextremities).

Effect of epidural anesthesia on anastomotic leakage in colonic surgery

Animalswererandomlyassignedtotwogroupsofsevenanimalschosenbycomputer-generatedrandomnumbers.Aftertheevaluationofsensoryblockade,an-imalsinGroup1weresubjectedtocontinuousepiduralsalineinfusion(0.9%NaClbolusand0.2mlkg-1h-1in-fusions)andthoseinGroup2to1%lidocaine(AritmalBiosel amp, Beykoz, Turkey). The epidural catheterwasused to administer0.4mlkg-1 bolus and0.2mlkg-1h-1infusiontotheanimalsinGroup2.Allepiduralinfusions(salineorlidocaine)werecontinuedfor6hduringthepostoperativeperiod,andthedegreeofmo-torblockadeofanimalsinGroup2wasmaintainedat1or2(byadministeringadditionalepidural1%lido-caine, 0.2mlkg-1, asneeded). InGroup1, ketaminewasinfused(2-5mgkg-1h-1)throughoutthepostopera-tive6-hperiodtoprovideadequateanalgesia.

SurgeryAllanimalswereplacedinasupineposition.Af-

tertheevaluationofsensoryblockade,anesthesiawasmaintainedintravenouslywith10mgkg-1h-1ketamine.Theanimalswerepreparedanddraped,andperitonealaccesswasgainedusingmidlinelaparotomy.Anequallengthof incisionwasused inallanimals.Therightcolonwasidentified,incisedanddivided5cmdistaltotheileocecalvalve.Colonicintegritywasestablishedwithend-to-endanastomosesinallanimals.Atraumat-ic5/0VicrylRapidestitchwasusedforcolonanas-tomoses.Theprocedureswereperformedbysurgeonsblindedtothestudygroupsusingastandardizedtech-nique.Therightcolonwasselectedforthestrengthoftheanastomosismodel toensure that thedistanceoftheanastomoseswasstandardforallanimals.

Onthefourthpostoperativeday,relaparotomywasperformed under general anesthesia by another sur-geon,alsoblindedtogroupassignments.Grossobser-vationofcircumferentialhealingofanastomoticlineswasdocumented.TheBPAweremeasuredin situbyanother anesthetist blinded to the study groups.Theanastomotic segment was dissected from the adher-ingtissue,openedatthemesentericside,anda1-cmlongsegmentcontainingthecompletesuturelinewasexcisedandwashedgentlywith saline solution.Thelevelsofhydroxyprolineandcollagenweremeasuredinthissampletissue.

Bursting Pressure MeasurementsMeasurementswerecarriedoutin vivo,whilethe

intestinalflowwasintact.Thecolonwasligated3cmdistaltotheanastomoticline.A14Gsilicondouble-lumencatheterwasinsertedfromtheproximalendofthe colon, and this endwas ligated 3 cm above theanastomosesoverthecatheterwithsilkstitch.Salinesolutionwasinfusedviaonelumenofthecatheterata rateof 10mlmin-1.Thehubof the second lumenofthecatheterwasattachedtothetransducer(Sasanpressure set, Sasan,Ankara, Turkey) for BPA mea-

surement.When normal saline solutionwas infusedviatheonelumenofthecatheter,themaximumpres-surerecordedonthemonitorjustbeforesuddenlossofpressurewasrecordedastheBPA.

Aftertheprocedures,theanimalswereeuthanizedusingthiopental(120mgkg-1,i.v.).

Biochemistry AnalysesTissue samples were homogenized and stored at

-40C.Anautoclavewasusedtohydrolyzethespeci-mens.Chloramine-Twasaddedtoprovideoxidationat room temperature. Finally, Ehrlich reactive wasalsousedtostainsamplesmeasuredat550nmusinga spectrophotometer.[22] Hydroxyproline levels weremeasured using standard graphics (0.05-1.5 mmolL-1) and collagen concentrations were measured(micgmg-1).These assessmentswere provided by abiochemistblindedtothestudy.

Statistical AnalysisStatistical analyses were carried out using SPSS

forWindows version 15.0 (SPSS Inc., Chicago, IL,USA).Becausethiswasapilotstudy,weconsideredthat seven animals constituted an adequate samplesize for each condition investigated. Seven animalswere adequate for the non-parametricANOVA tests(Mann-WhitneyU tests). In addition, the previouslypublisheddata[10]revealedthatsevenanimalswerere-quiredineachgroup.Resultswereexpressedasme-dianvalue(minandmaxvalue)with95%confidenceinterval.Thegroupsweresubsequentlycomparedus-ing theMann-WhitneyU test, andvaluesofp0.05).

Burstingpressuresoftheanastomoses(BPAs)werestatisticallyhigherintheepidurallidocainegroupthanthecontrolgroup(median:248mmHg[min117,max300]inGroup2vs.median:109mmHg[min47,max176]inGroup1;p=0.006)(Fig.3).



DISCUSSIONIn thepresent study, the tissue levelsof collagen

andhydroxyprolinewerecomparablebetweenthetwogroups.However,theelongationofepiduralanesthe-siawithlidocaineforsixhoursintothepostoperativeperiodincreasedtheanastomoticburstingpressure.

Anastomotic disruption is a serious complicationofcolorectalsurgery.Adequatebloodflowandoxygenperfusionarekeyelementsinthesuccessfulhealingofananastomosis.[23]Sympatheticblockadebyepiduralanalgesia can increase colonicbloodflowandmini-mizedistensionofthecolonbystimulatingpropulsiveforces.[17,18]Throughthesemechanisms,epiduralanal-gesia could facilitate anastomotic healing.However,case reports have suggested that early recovery ofcolonicmotility inducedbyepiduralanalgesiacouldincrease the anastomotic disruption rate.[19,20] Onestudyhasfurthersuggestedthatexposuretoepiduralbupivacainedecreasesoxygenperfusionincolorectalanastomosis.[14]

Animal, retrospective and randomized clinicalstudieshaveaddedtothedebateregardingtheeffectof epidural analgesiaonanastomotic integrity.Blassetal.[24]demonstratedmoreadvancedcolonicanasto-motichealingatpostoperativeday7inacanineexper-imentalmodel that receivedepidural comparedwithanimals receiving no epidural.However, this differ-encedidnot persist 14dayspostoperatively.Anoth-er studydemonstrated that rats treatedwithepiduralropivacaineaftercolonresectionhadbetterpropulsivebowelfunction,morecollagenintheanastomosis,andsimilar bursting pressure to controls.[17] In a porcinemodel,Schnitzleretal.[10]reportednodifferencesbe-tweenepiduralbupivacaine,morphineorsalinewithrespecttoburstingpressureorhydroxyprolinecontentoftheanastomosis.Noanastomoticcomplicationsoc-curredintheseanimals.Furthermore,Jansenetal.[25] reported that theburstingpressuresof intactcolonicanastomoses indogsweresimilar incontrolanimalsandthosereceivingepiduralbupivacaine.However,ofthefouranimalsintheepiduralgroup,onehadabowelintussusceptionandanotherhadananastomoticleak.Theauthorsproposedthatthefasterreturnofcolonicmotilitywasnotfunctionallypropulsiveandcouldberesponsible for these complications. In another ani-malstudy,epiduralanesthesiaincreasedgutmucosalbloodflowbutreducedintermittentflowinthevillusmicrocirculationinthepresenceofadecreasedperfu-sionpressure.[18]Inarecentlypublishedmeta-analysis,theanastomoticleakrateremainedconstantirrespec-tiveoftheanalgesictechniqueused.[16]Althoughtotalsplanchnicflowcanbeincreasedwithepiduralanalge-sia,tonometricbowelpHmeasurementsdemonstratethat this isaccompaniedbyaredistributionofbloodflowawayfromanastomoses.Theinabilityof juxta-anastomoticvesselstodilateasmuchasnormalbowelvesselsmayresultinastealofbloodflowfromtheanastomoses tonormalbowel.[14] Inananimalstudy,nosignificantdifferenceinanastomoticburstingpres-suresevendaysafteranastomoseswithepiduralanal-gesiawasevidentwhencomparedwithconventionalgeneral anesthetic.[10] In a recently published review


Group10

0.5

1

1.5

2

2.5

mm

ol/L

Group2

Fig. 1. Measured anastomotic tissue hydroxyproline levelswerecomparablebetweenthegroups(mmolL-1).

Group10

50

100

150

200

250

mcg

m/L

Group2

Fig. 2. Measured anastomotic tissue collagen levels werecomparablebetweenthegroups(gL-1).

Fig. 3. Burstingpressuresof the anastomoses in the epidu-ral group were statistically higher than in controls(mmHg).*p

article,nodatademonstratedaharmfulorbeneficialeffectofepiduralanalgesiaontheratesofanastomoticleakage.[26]

Thinner nerve fibers are affected by lower localanestheticconcentrationsthanthickerfibers,suggest-ingthatneuronalblockisafunctionofdiameter.Withincreasinglocalanestheticconcentration,theBfibers(preganglionic sympathetic fibers) are blocked first,followedbyCfibers(painandautonomicfibers)andthenthelargestAfibers(touch,pressuresensationandmotorfibers).Theaimofepiduralanalgesiaistopro-duceadifferentialnerveblock,predominantlyaffect-ingnociceptiveandsympatheticfiberswithnomotoreffects. However, critical concentrations required toblock sympathetic fibers can vary considerably be-tweenpatients.Therefore,applyingepiduralanalgesiaalonemaynotincreasebloodflowintheanastomoticlineasitdoesnotconsistentlyproducesufficientsym-patheticblockade.

In all previous studies concerning this issue, ei-therintra-operativeepiduralanesthesia(whichcausessympathetic blockade) or postoperative analgesiawas applied generally. In the case of postoperativeepidural analgesia, theremay be no direct effect onanastomotichealingassympatheticblockademaynotoccur.Inthecaseofepiduralanesthesia,sympatheticblockadeoccursbecauseofthegreaterconcentrationoflocalanestheticsused.Forthisreason,wecontin-ued epidural anesthesia (i.e., sympathetic blockade)forsixhourspostoperatively.Epiduralanesthesiawasapplied toavoid theexactevaluationofsympatheticblockade in the experimental animals (by formingmoderatemotorblockade).Theresultsdemonstratedhigheranastomoticburstingpressuresintheepiduralanesthesiagroup,anindicatorofanastomoticstrengthandanastomoticleakage.

However, therewasnodifferenceintermsoftis-suecollagenandhydroxyprolinelevels,whicharein-dicatorsofanastomotichealing.Anastomoticleakageisgenerallydetermined5to7dayspostoperatively.[27] The strengthof the anastomosis decreasesmarkedlyduringthefirst3-4daysowingtochangesintheen-zymaticstructureofcollagenbundles,butitincreasesafterthefourthday,withprominentcollagenproduc-tionandaccumulation.[28,29]Asanastomoticleakageisclinicallydeterminedduringthe5thto7thpostopera-tivedays,re-laparotomiesoftheexperimentalanimalswereperformedonthe4thpostoperativeday,duringwhichcollagenproductionbeginstoincreasebutthestrengthofanastomosis isstillpoor.For thisreason,enough timemay not have elapsed for collagen de-velopmenttoensue.Inpreviousexperimentalstudies,anastomotic bursting pressures and tissue collagenlevelsweregenerallyevaluatedbetweenthe7thtothe14th postoperative days.However, during this time,

anastomotic leakage could have formed or healingcould be complete. For this reason, re-laparotomieswere performed during the 4th postoperative day,andanastomoticburstingpressuresweremeasuredasanastomoticleakagehadnotyetdeveloped.

Shortfallsinthepresentstudyincludetheabsenceofmeasurementsofsplanchnicbloodfloworoxygen-ation at the anastomotic line and failure to keep thesympatheticblockadeformorethansixhours.How-ever,thesympatheticblockadewasnotmaintainedformore than six hours because the toxic dose level oflidocaine could have been reached. In the lidocainegroup, all animals were administered over 20 mgkg-1 lidocaine.However, further studies are requiredtoclarifytheassociationbetweenlongersympatheticblockadebyepiduralinfusionoflocalanestheticandstrengthofcolonicanastomoses.

Inthisexperimentalrabbitmodel,epidural1%li-docaine,whichwasappliedintra-operativelyandcon-tinued for six hours, increased anastomotic burstingpressure(consideredasanindicatorofpotentialanas-tomotic strength).This could be due to the epidurallidocaine causing sympathetic blockade, resulting inincreasedsplanchnicbloodflow.

Declaration of interestTheauthorshavenodeclarationofinterest.

AcknowledgementsTheauthorsthankDr.OzlemGunduzforperform-

ingthestatisticalanalysisandthestaffoftheanimalresearch laboratory for skilled technical assistance.WealsothanktheFoundationofIzmirHospitalsfortheirsupportofthestudyandBioMedsfortheEnglishediting.

REFERENCES1. LiuS,CarpenterRL,NealJM.Epiduralanesthesiaandan-

algesia.Theirroleinpostoperativeoutcome.Anesthesiology1995;82:1474-506.

2. Grass JA.The roleof epidural anesthesia andanalgesia inpostoperative outcome. Anesthesiol Clin North America2000;18:407-28.

3. CarpenterRL.Gastrointestinalbenefitsofregionalanesthe-sia/analgesia.RegAnesth1996;21:13-7.

4. RyanP, Schweitzer SA,WoodsRJ.Effect of epidural andgeneralanaesthesiacomparedwithgeneralanaesthesiaaloneinlargebowelanastomoses.Aprospectivestudy.EurJSurg1992;158:45-9.

5. StevensRA,Mikat-StevensM,FlaniganR,WatersWB,Fur-ryP,SheikhT,etal.Doesthechoiceofanesthetictechniqueaffecttherecoveryofbowelfunctionafterradicalprostatec-tomy?Urology1998;52:213-8.

6. CarliF,MayoN,KlubienK,SchrickerT,TrudelJ,BelliveauP.Epiduralanalgesiaenhancesfunctionalexercisecapacityandhealth-relatedqualityoflifeaftercolonicsurgery:resultsofarandomizedtrial.Anesthesiology2002;97:540-9.

7. LiuSS,CarpenterRL,MackeyDC,ThirlbyRC,RuppSM,ShineTS,etal.Effectsofperioperativeanalgesictechnique

Effect of epidural anesthesia on anastomotic leakage in colonic surgery


on rate of recovery after colon surgery. Anesthesiology1995;83:757-65.

8. CarlstedtA,NordgrenS, Fasth S,AppelgrenL,HultnL.Epiduralanaesthesiaandpostoperativecolorectalmotility--apossiblehazardtoacolorectalanastomosis.IntJColorectalDis1989;4:144-9.

9. CarliF,TrudelJL,BelliveauP.Theeffectofintraoperativethoracicepiduralanesthesiaandpostoperativeanalgesiaonbowel functionaftercolorectal surgery:aprospective, ran-domizedtrial.DisColonRectum2001;44:1083-9.

10.SchnitzlerM,KilbrideMJ,SenagoreA.Effect of epiduralanalgesiaoncolorectalanastomotichealingandcolonicmo-tility.RegAnesth1992;17:143-7.

11.KapralS,GollmannG,BachmannD,ProhaskaB,LikarR,JandrasitsO,etal.Theeffectsofthoracicepiduralanesthesiaonintraoperativevisceralperfusionandmetabolism.AnesthAnalg1999;88:402-6.

12.SutcliffeNP,MostafaSM,GannonJ,HarperSJ.TheeffectofepiduralblockadeongastricintramucosalpHintheperi-operativeperiod.Anaesthesia1996;51:37-40.

13.Johansson K, Ahn H, Lindhagen J, Tryselius U. Effectof epidural anaesthesia on intestinal bloodflow.Br JSurg1988;75:73-6.

14.SalaC,Garca-GraneroE,MolinaMJ,GarcaJV,LledoS.Effectofepiduralanesthesiaoncolorectalanastomosis:ato-nometricassessment.DisColonRectum1997;40:958-61.

15.AitkenheadAR,WishartHY,BrownDA.Highspinalnerveblockforlargebowelanastomosis.Aretrospectivestudy.BrJAnaesth1978;50:177-83.

16.Marret E, Remy C, Bonnet F; Postoperative Pain ForumGroup. Meta-analysis of epidural analgesia versus paren-teral opioid analgesia after colorectal surgery. Br J Surg2007;94:665-73.

17.JansenM,LynenJansenP,JungeK,AnurovM,TitkovaS,OttingerA,etal.Postoperativeperiduralanalgesiaincreasesthestrengthofcoloniccontractionswithoutimpairinganas-tomotichealinginrats.IntJColorectalDis2003;18:50-4.

18.SielenkmperAW,EickerK,VanAkenH.Thoracicepidural

anesthesiaincreasesmucosalperfusioninileumofrats.An-esthesiology2000;93:844-51.

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11

Turkish Journal of Trauma & Emergency Surgery

Original Article Klinik alma


Effects of repetitive injections of hyaluronic acid on peritendinous adhesions after flexor tendon repair:

a preliminary randomized, placebo-controlled clinical trial

Fleksrtendononarmsonras,tekrarlayanhyaluronikasitenjeksiyonlarnn,peritendinzadezyonzerineetkisi:Randomizeplasebokontrollkliniknalma

Gzin Yeim ZGENEL,1 Abdullah ETZ2

1Department of Plastic, Reconstructive and Aesthetic Surgery, Division of Hand Surgery, Uludag University Faculty of Medicine, Bursa;

2Department of Plastic Surgery, Inegl State Hospital, Bursa, Turkey.

1Uluda niversitesi Tp Fakltesi, Plastik, Rekonstrktif ve Estetik Cerrahi Anabilim Dal, El Cerrahisi Bilim Dal, Bursa;

2negl Devlet Hastanesi, Plastik Cerrahi Blm, Bursa.

Correspondence (letiim): Gzin Yeim zgenel, M.D. Uluda niversitesi Plastik Cerrahi Anabilim Dal, Grkle 16059 Bursa, Turkey.Tel: +090 - 224 - 442 81 93 e-mail (e-posta): [email protected]

AMABu almada, zon-II fleksr tendon onarmlarndan son-ra,ikihaftalksreierisindeenjekteedilen3dozhyalu-ronikasit(HA)enjeksiyonununplaseboya(salin)karet-kinliiaratrld.

GERE VE YNTEMalmayakinciparmakizolezon-IIfleksrtendonhasar-lanmasolan22hastadahiledildi.Tenorafincesi,parmak-larrandomizeolarakikigrubaayrld;11parmaktatenora-fievresine3dozHAenjekteedilirken,aynekildesalinenjekteedilen11parmakdaplasebogrubunuoluturdu.Bi-rincidoztenorafisrasndaverildiveilave2doz1haftaaraileenjekteedildi.OperasyonsonrasKleinertrehabilitasyonprotokoluyguland.Eklemhareketakl,3.hafta,3.ayveuzundnemdetotalaktifvepasifeklemakllle-rekdeerlendirildi.Fonksiyonelsonu,Stricklandsnflan-drmasnagrebelirlendi.

BULGULARnchaftadaeklemhareketaklasndanikigruparasndabirfarktespitedilmedi.Ancak,3.ayveuzund-nemde,eklemhareketaklnda,HAenjekteedilenpar-maklardaplasebogrubunagreanlamlderecedeiyilemeolduugzlendi.

SONUBuplasebokontrollnalmada,mkerrerHAenjeksi-yonlarnn, primer tendononarmnda,muhtemelen adez-yonazaltcetkisinebalolarak,kliniksonulariyileti-rebildiiilerisrlmektedir.

Anahtar Szckler: Adezyon nleme; hyaluronik asit; tendonadezyonlar;tendononarm.

BACKGROUNDTheaimofthisstudywastoinvestigatetheefficacyofthreeinjectionsofhyaluronicacid(HA)versusplacebo(saline)overatwo-weekperiodonfunctionaloutcomesafterzone-IIflexortendonrepairs.

METHODSTwenty-twopatientswithisolatedzone-IIflexortendonin-juryoftheindexfingerswereincludedinthisstudy.Beforetenorrhaphy,fingerswererandomlydividedintotwogroups;11weretreatedwiththreeinjectionsofHAaroundthetenor-rhaphysiteand11servedasaplacebogroupandweretreat-edwithsalineinthesameway.Thefirstdosewasgivenatthetimeoftenorrhaphyandtwoadditionaldosesweregivenatone-weekintervals.AKleinertrehabilitationprotocolwasemployed postoperatively. Range of motion was assessedwithtotalactiveandpassivemovementevaluationsystemsat 3weeks, 3months and long-term. Functional outcomewasevaluatedusingtheStricklandclassification.

RESULTSTherewerenodifferencesbetweenthetwogroupsintermsofrangeofmotionat3weeks.However,at3monthsandlong-term,asignificantimprovementwasobservedinfin-gerstreatedwithHAcomparedtoplacebo.

CONCLUSIONThis preliminary placebo-controlled study suggests thatrepetitiveinjectionsofHAcanimproveclinicaloutcomespresumably due to the effect on decreasing adhesions inprimarytendonrepairs.

Key Words: Adhesion prevention; hyaluronic acid; tendonadhesions;tendonrepair.

doi: 10.5505/tjtes.2012.95530


Despite advances in surgical techniques and im-proved postoperative rehabilitation programs, adhe-sionsbetweenthetendonandthesurroundingtissuescontinue to be an important problem after primaryflexortendonrepair,especiallyinzoneII.[1-5]Variouspharmacologic agents have been used in an attempttoreduceperitendinousadhesionsafterflexortendonsurgery.[6-14] One of these agents is hyaluronic acid(HA),afibroblast-derivedglycosaminoglycan.Previ-ousexperimentalstudiesshowthattopicalapplicationofhighmolecularweightHAinhighconcentrationsbetween an injured tendon and its sheath promotestendonhealinganddecreasesadhesionformation.[15-20] Intheseexperimentalstudies,thepreventionofperi-tendinousadhesionswasexplainedbythefactthatHAcreatedascaffoldaroundthetenorrhaphysitebecauseof its highviscoelastic property.Thismacromolecu-larnetworkwouldpreventfibrousingrowthfromthesurrounding tissues.[21-23] The other explanation wasthatHA,beinganeffectivesofttissuelubricant,mightdecrease the newextracellularmatrix formationduetotheinhibitionofmononuclearphagocytesandlym-phocytes.[24]

ThegoalofthisclinicalstudywastocomparetheeffectsofrepetitiveinjectionsofHAwithplaceboonthefunctionaloutcomeafterprimarydigitalzone-IIflexortendonrepair.

MATERIALS AND METHODSStudy DesignA randomized, double-blind, placebo-controlled

trialwas performed to determinewhether peritendi-nousadhesionsdecreaseasaresultoftreatmentwithHA(Orthovisc;AnikaTherapeutics,USA)asopposedtoaphysiologicsalinesolution(placebo).Thestudywas approved by our institutional review board andall patients signed an informed-consent form beforesurgery.

PatientsFrom March 2002 to January 2005, 22 patients

witha totalof22flexordigitorumprofundus (FDP)and 22 flexor digitorum superficialis (FDS) tendontransectionsof the indexfingerscausedbysharp in-struments were operated. Specific characteristics ofthe patients, including gender, mean age, smoking,handdominance,etiology,siteofinjury,andpresenceofdigitalnerveinjury,aresummarizedinTable1.Thetwogroupsweresimilar in termsofage, sex,domi-nanceoftheinjuredhand,injuryzone,andthenumberofthedigitswithnerveinjury.

Fingers that were included in this clinical studywere those that had a lacerationof theFDP tendon,withaconcomitantinjuryoftheFDStendon,inzoneIIoftheindexfingers,whichhadoccurredwithin24hours prior to the surgery. Correspondingly, fingers

that were excluded from this study were those thathadacutaneousdefectattherepairsite,aconcomitantfracture,priorhandtrauma,orcongenitalhanddefectinordertoavoidcomplicationsrelatedtothewoundsite.

RandomizationRandomization was performed after it had been

determined that the inclusion criteria had beenmet,butbeforethepatientwastakentotheoperatingroom.Theresultof therandomizationwasnotavailable toanyoftheinvolvedcliniciansorpatientsotherthantothesurgeonwhoperformedthetendonrepairandsub-sequentlyinjectedHAorsalinesolution.Inallcases,theclinicianinjectingthetestsubstanceandtheexam-inerperformingtheclinicalevaluationwereseparateindividuals.

Surgical ProcedureAll operationswere performed by one of the in-

vestigatorsinastandardizedwayunderaxillaryblockanesthesia and tourniquet controlwithin the first 24hoursofinjury.BothFDPandFDStendonswereap-proached through palmar zigzag incisions describedbyBrunner,andeachFDPtendonwasrepairedwithpolypropylenesuture(4-0Prolene,Johnson&John-


TotalnumberofpatientsGenderMaleFemaleMeanage(range)(yr)SmokerYesNoDominanthandRightLeftInjuredhandRightLeftCauseofinjuryKnifeGlassSawSiteofinjuryProximaltoA2pulleyUnderA2pulleyDistaltoA2pulleyNumberofdigitswithnerveinjuryInjuredRepaired

*Demographicdatafor22patients

Treatmentgroup

11

11

28(21-35)

92

101

101

362

38

99

Placebogroup

11

101

31(26-36)

11

92

92

443

38

88

Table 1. Patientdetails*

Effects of repetitive injections of hyaluronic acid on peritendinous adhesions after flexor tendon repair

son, Switzerland) using the modified Kessler tech-nique, followed by an epi-tendinous running suture(6-0Prolene,Johnson&Johnson,Switzerland).TheinjuredFDS tendonwas treated in the sameway astheFDPtendon.Inallcases,themembranousportionoftheflexortendonsheathwassutured.Themanage-mentofthepulleysystemofflexortendonsheathwasperformedaccordingto thesiteof the tendoninjury.WhenthecutwasalittledistaltotheA2pulley,thedistalone-thirdoftheA2pulleywasreleased.Whenthetendonwasrepairedunderthemiddleandproxi-malpartoftheA2pulley,halfoftheA2pulleywasdi-vided.WhenthetendoncutwasattheleveloftheA3pulley,allannularpulleyswerepreserved.Whenthecutwas between the proximal interphalangeal (PIP)jointandA4pulley,onlytheA3pulleywasdivided.Inaddition,allassociateddigitalnervedivisionswererepaired with polypropylene suture (10-0 Prolene,Johnson&Johnson,Switzerland).

Beforeclosingthewound,thecatheter(23Gx3/4inch, Vacuette) tip was placed closest to the FDPtenorrhaphysiteadjacent to theclosedflexor tendonsheathand threadedsubcutaneously,exiting theskinattheleveloftheA1pulleyjustlikeasuctiondrain,anditwasfixedtotheskinattheexitpointbyasu-ture inorder tomaintain the catheter tip adjacent tothe tenorrhaphysite.Afterclosingthewound, in thetreatmentgroup,0.4mlofhighmolecularweightHA(1.0-2.9millionDaltons) in high concentrations (15mg/ml)wasinjectedthroughthecatheter,andthentheendofthecatheterwascoveredwithatap.Inthepla-cebogroup,anequivalentvolumeofphysiologicsa-linesolutionwasadministeredinthesameway.Next,a sterile dressingwas applied, followed by a dorsalplastersplint,extendingfrombeyondthefingertiptotheproximalforearm.Thewristwasheldinapproxi-mately 30 palmar flexion, themetacarpophalangeal(MCP)jointswereflexedapproximately60andthePIPanddistalinterphalangeal(DIP)jointswereflexed0.The splint allowed full extensionof thePIP andDIPjoints.

After surgery, two injectionswere given throughtheinsertedcatheteratone-weekintervalsandatthecompletion of the injections, the catheter waswith-drawn.Theskinsutureswereremovedonthe10thday.

Post-Operative Follow-UpAlloperatedfingershadsimilarpostoperativecare.

Rehabilitation was started on the 3rd postoperativedaywithapassiveflexionandactiveextensionproto-colaccordingtothemethodofKleinertandcontinuedforthefirst4weeks.[25,26]Atthe5thweek,theplastersplintwasremovedandactiveflexionwasstarted.

All patients were followed by the same blindedclinician(twiceaweekforthefirst12weeksandthen

onceat6months).Eachvisitincludedvisualinspec-tionandphysicalexaminationof theoperatedfingerandassessmentforsignsofwounddehiscenceorin-fection.RangeofmotionofMCP,PIPandDIPjointsofeachfingerwasmeasuredusingagoniometerat3weeks,3monthsandlong-term(range:58-91months)afterthesurgery.Rangeofmotionvaluesforpassiveand activemovements of three joints in each fingerwere summedup and recorded as the total range ofpassivemotion (TPM) and the total range of activemotion(TAM).TherevisedStricklandgradingsystem(Strickland,1985)wasusedtoassessthefinalactivemotionofeachoperatedfingeratthelong-termfollow-up.Theactivemotionvaluewasfoundbysubtractingthe extension deficit of the involved joints from themaximal possible flexion.Resultswere classified asexcellent (>131), good (88-131), fair (44-87) andpoor(


andwasfoundtoincreaseto166.4(14.8)(135-185)at theendof the3rdmonthand176.4 (12.7) (150-190)atlong-term.In11fingers,3wereratedasex-cellentand8asgoodaccordingtotherevisedStrick-landclassificationsystem(Table2).[27]

ComparisonTherewasnostatisticallysignificantdifferencein

TPMandTAMvalues between the twogroups at 3weeksafter surgery (p>0.05).However,at3monthsandlong-term,asignificantincreasewasobservedinthetotalvaluesofthepassiveandactiverangeofmo-tionsofthefingerstreatedwithHAcomparedwiththefingerstreatedwithsaline(p

experimental promise, but cannot be used clinicallybecauseoftoxicityorimpairmentofwoundhealing.[7,8,13]Additionally, aprotinin and 5-fluorouracil havebeenusedwithvariable results.[9,11]Humanamnioticfluidhassometypeof inhibitoryeffectonfibroblastproliferation.Itwasshownthattheleastadhesionandthebesthealingwereobservedintendonstreatedwithhumanamnioticfluidapplication.[30]However,nohu-mantrialhasbeenreported.

Recently, there has been a great interest in HA,whichisrichlyfoundintheextracellularmatrixofsoftconnective tissues and synovial fluids in the humanbody.[31]HAprovidesahealingprocessthroughregen-eration andgrowth rather than scarring andfibrosis.[21,22] However, this effect has been variable.[32] Themolecularweightandtheconcentrationoftheprepa-ration are critical to its potential beneficial effects.Low concentration and low molecular weight seemtohaveastimulatingeffectongranulocytefunction.[33]Incontrast,highconcentrationandhighmolecularweightHAinhibitsthemovementsandphagocytosisofgranulocytes.[34,35]Itwasfoundthatthecriticalmo-lecularweightseemstobearound105to106Daltonsforinhibitionofgranulocytefunction.[15]Inthispres-entstudy,Orthovisc(AnikaTherapeutics,USA)wasused.Themolecularweightandtheconcentrationofhyaluronan inOrthoviscwasabout106Daltonsand15mg/ml.

Severalexperimentalstudieshaveclaimedthatex-ogenouslyadministeredsodiumhyaluronatehelps topreventtheformationofpostoperativeadhesionsafterflexortendonrepairinzoneIIwithoutinterferingwithhealing.[15,17-20,36] The first prospective, double-blind,randomizedclinicalstudyabouttheHAeffectonpre-ventionofadhesionsinhandsurgerywasperformedbyHagberg.[36]Inthatstudy,Hagbergdidnotdemon-strate any significantbenefitof single-dose injectionofHAintothetendonsheathafterflexortendonrepairinlimitingadhesions.Webelievethistobeduetotherapideliminationofsingle-doseapplicationoftheHApreparationaroundthesitesoftendonrepair.Addition-ally, thewoundwoulddilutetheeffectivenessoftheHAsolution. Inorder toovercome these limitations,inthisclinicalstudy,wepreferredthreeinjectionsofHA.Thefirstinjectionwasgivenatthetimeofthere-pairandtwoadditionaldosesweregivenatone-weekintervals.Therefore,weprovidedthemaintenanceofsufficientamountsofHAaroundthetenorrhaphysiteduringthefirsttwoweeks,whichisdefinedasacriti-calperiodforperitendinousadhesions.Aone-weekin-tervalwaschosenbecauseitwasshownthatHAwaseliminatedwithin7days.[15,30,31]

This clinical study compared HA to saline. Theconcentrationofelectrolytesinnormalsalinesolution(0.9%NaCl)issimilartothatofbloodanditismeta-

bolicallyinert(Hoppeetal.,2010).Therefore,salinedoes not create an inferior environment for the ten-donsandinthemajorityoftheexperimentalandclini-cal studies, saline is used as placebo.[36-38]However,a study that had both placebo and untreated groups(simplyleavingthecatheterin)canbeplannedinor-dertodistinguishtheplaceboeffect.

Postoperative rehabilitationmethods improve theclinicaloutcomesinflexortendonsurgerybyreducingtheperitendinousadhesionsandprovidingmoreten-silestrengthbyfavoringtendonnutritionandintrinsictendonhealing.[4]However,earlyactivemobilizationprotocolsmayincreasetherepairsiteelongationandrupture rates.[39,40] In order to solve these problems,manymulti-strandtendonsuturetechniqueshavebeendescribed.[41,42]Experimentalstudieshaveshownthatsuturestrengthandresistancetorepairsitegapforma-tionincreasewiththenumberofsuturestrandscross-ing the tendon repair site.[43-45] However, thismakesthe suture techniques more complex and increasesthe difficulty of using these configurations in clini-calcases.Ontheotherhand,multi-strandrepairsmayincreasetheperitendinousadhesionsanddamagethenutritioninthetendonends.Inaddition,ifappropri-atepulleysarenot releasedduring theflexor tendonsurgery, multi-strand repairs alone cannot eliminatethedangeroftendonrupture.[46]Forthesereasons,wepreferredtousethemodifiedKesslersuturetechnique.This conventional two-strand repair augmentedwithaperipheralsutureprovidessufficientgapresistanceandtensilestrengththatmaybeabletowithstandearlyactivemobilizationafterflexortendonrepair.Inaddi-tion,thematerialusedforcoreandperipheralsuture,lengthofthecoresuturepurchaseanddepthandlengthoftheperipheralsuturepurchasearetheotherfactorsthataffecttheresultsofthetendonsurgery.[42]Inthisclinicalstudy,aperipheralsuturewasplaceddeepintothe tendon instead of superficially only through theepitenonand2mmfromthecuttendonendsinordertoincreasetherepairsitestrength.

Stricklandclassification[27]ismostcommonlyusedevaluationsystemespeciallyforzone-IIflexortendonrepairs.[27,44,46-49] In this article, functional status wasevaluated using the revised Strickland classificationsystem.ThefingerstreatedwithHAshowed27%ex-cellentand73%goodresults,whereasfingerstreatedwithsalineshowed64%goodand36%fairresults.Asa result, HA-treated fingers showed superior resultscomparedwiththesaline-treatedfingers.

Inconclusion,thispreliminaryclinicalstudyshowsthat repetitive injectionsofHAaround the tenorrha-physiteafterflexortendonsurgeryreducestheforma-tionofrestrictiveadhesions.However,largeseriesareneededinordertosupport theresultsofthisclinicalstudy.

Effects of repetitive injections of hyaluronic acid on peritendinous adhesions after flexor tendon repair


AcknowledgementsWethank lkerERCANfor supportwith thesta-

tistical analysis.No benefits in any form have beenreceivedrelatedtothesubjectofthisarticle.

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