Reamed interlocking intramedullary nailing for the treatment of tibial diaphyseal fractures and aseptic nonunions. Can we expect an optimum result?

The need for reaming and the number of locking screws to be used in intramedullary (IM) tibial nailing of acute fractures as well as routine bone grafting of tibial aseptic nonunions have not been clearly defined. We describe the results of reamed interlocked IM nails in 233 patients with 247 tibial fractures (190 closed, 27 open and 30 nonunions). Ninety-six percent of the fractures were united at review after an average of 4.9 years. No correlation was found between union and nail diameter (P = 0.501) or the number of locking screws used (P = 0.287). Nail dynamization was effective in 82% of fractures. Locking screw(s) breakage was associated with nonunion in 25% of cases. Bone grafting during IM nailing was found not to increase the healing rate in tibial nonunions (P = 0.623). None of the IM nails were removed or revised due to infection. A dropped hallux and postoperative compartment syndrome were found in 0.8 and 1.6% of cases, respectively. Anterior knee pain was reported in 42% of patients but nail removal did not alleviate the symptoms in almost half. This series confirms the place of reamed intramedullary nailing for the vast majority of tibial diaphyseal fractures. It provides an optimum outcome and minimizes the need for supplementary bone grafting in aseptic nonunions

Ceramic on ceramic bearing fractures in total hip arthroplasty : an analysis of data from the national joint registry

Aims: Ceramic-on-ceramic (CoC) bearings in total hip arthroplasty (THA) are commonly used but concerns exist regarding ceramic fracture. This study aims to report the risk of revision for fracture of modern CoC bearings and identify factors that might influence this risk, using data from the National Joint Registry (NJR). Patients and Methods: We analysed data on 111,681 primary CoC THA’s and 182 linked revisions for bearing fracture recorded in NJR. We used implant codes to identify ceramic bearing composition and generated Kaplan-Meier estimates for implant survivorship. Logistic regression analyses were performed for implant size and patient specific variables to determine any associated risks for revision. Results: 99.8% of bearings were CeramTec Biolox® products. Revisions for fracture were linked to 7 of 79,442 (0.009%) Biolox® Delta heads, 38 of 31,982 (0.119%) Biolox® Forte heads, 101 of 80,170 (0.126%) Biolox® Delta liners and 35 of 31,258 (0.112%) Biolox® Forte liners. Regression analysis of implant size revealed smaller heads had significantly higher odds of fracture (χ2=68.0, p<0.0001). The highest fracture risk were observed in the 28mm Biolox® Forte subgroup (0.382%). There were no fractures in the 40mm head group for either ceramic type. Liner thickness was not predictive of fracture (p=0.67). BMI was independently associated with revision for both head fractures (OR 1.09 per unit increase, p=0.031) and liner fractures (OR 1.06 per unit increase, p=0.006). Conclusions: We report the largest study of CoC bearing fractures to date. The risk of revision for CoC bearing fracture is very low, however previous studies have underestimated this risk. There is good evidence that the latest generation of ceramic has greatly reduced the odds of head fracture but not of liner fracture. Small head size and high patient BMI are associated with an increased risk of ceramic bearing fracture

Yatırım ve politika: Türk-Yunan davası

105 pagesKüreselleşen ekonomi çerçevesinde, ekonomik işbirliği, ülkeler arası ikili ilişlikerin düzeltilmesi için alternatif olarak sunulmuştur. Bu tez, bu görüşün Türk-Yunan ilişkileri üzerindeki uygulamasını, yabancı doğrudan yatırımlar konusunda yoğunlaşarak inceler. İki ülke arasındaki ilişkilerin politik ve finansal bağlamda gelişmesi, 'her alanda rekabet' modelinin işbirliği ve finans sektöründeki dayanışmaya doğru kaymasını sağlamıştır. Bu değişim, tezin ikinci kısmında incelenen, ikili yatırımları düzenleyen yasal çerçeve açısından çok açıktır. Her ne kadar mevcut yasal çerçeve daha yakın mali ilişkilerin kurulması için yeterli olsa da, bu tez, sağlam bir ilerlemenin, ekonomik işbirliğinin iki ülkede de dış politika karar mekanizmasında gerçek bir etki bırakmadan önce yapılması gerektiğini tartışır.Economic cooperation in the context of a globalized economy has been proposed as an alternative means for the amelioration of bilateral relations between states. The present paper examines the application of this statement on Turkish-Greek relations, concentrating on the issue of foreign direct investments. An account of the evolution of political and financial ties between the two states shows the shift of paradigm from one of competition in every field to that of cooperation and interdependency in the financial sector. This shift is evident in the legal framework regulating bilateral investments, which is analyzed in the second part of the paper. Even though the existent legal framework is considered adequate for the establishment of closer financial ties, the paper argues that substantial progress needs to be made before economic cooperation can have any real effect on the decision making of foreign policy in both countries

Comparison between MR arthrography and conventional MRI in the diagnosis of triangular fibrocartilage complex (TFCC) tears and correlation with the arthroscopic findings

The wrist is a complex joint with multiple anatomical structures involved in order to achieve its functional role. The ligaments of the wrist are divided into extrinsic and intrinsic and their role is to hold together the carpal bones and stabilize the joints. The Triangular Fibrocartilage Complex (TFCC) is a very important and complex anatomical structure of the wrist joint which plays a vital role in its stability and mobility. The role of the TFCC is to distribute stresses from the carpus to forearm and provides stability to the distal radioulnar joint especially during pronation and supination. Tears of the TFCC are categorized by Palmer as either traumatic injuriew (Palmer type 1) or degenerative injuries (Palmer type 2) and are proven to be a major factor of ulnar sided wrist pain and carpal instability. Because of the complexity of the anatomical structures involved lesions of the TFCC are difficult to address and their diagnosis is based on clinical examination and imaging. TFCC lesions were originally diagnosed by radiographic Arthrography which was replaced by magnetic resonance imaging (MRI) as being non invasive and providing excellent soft tissue contrast and resolution. Despite its advantages has certain limitations with low sensitivity and accuracy especially regarding peripheral TFCC tears which have the most clinical significance. MR athrography (MRA) combines the advantages of both methods and seems to overcome their limitations with higher diagnostic performance. In our study a total of 60 patients with clinical findings suggestive of TFCC tear participated in our study protocol. All patients underwent initially a conventional MRI exam followed by a wrist MR arthrogram and then referred for arthroscopy which correlated the two methods. We proved the superiority of MRA especially in peripheral tears with specificity 100%, accuracy 94,9% and sensitivity 89,5% over MRI with 63,1%, 50% και 31,6% respectively, in the diagnosis of the TFCC tears either these tears are central or peripheral. The most important result of our study is that MRA is useful in detecting not only central full thickness tears but also peripheral partial tears, which have the most clinical significance. As a conclusion we can state that MRA should be used as a the method of choice in the diagnosis of the TFCC tears, which will lead to a reduction in misdiagnosis that is usually followed by unnecessary surgery.O καρπός είναι μία σύνθετη άρθρωση με πολλαπλές ανατομικές δομές να συμμετέχουν στη διαμόρφωσή της έτσι ώστε να επιτευχθεί ο λειτουργικός της ρόλος. Oι σύνδεσμοι του καρπού χωρίζονται σε εσωτερικούς και εξωτερικούς και ο ρόλος τους είναι να σταθεροποιούν τα οστά και τις αρθρώσεις. Το τρίγωνο ινοχόνδρινο σύμπλεγμα του καρπού (TFCC) αποτελεί μία σύνθετη ανατομική δομή που παίζει βασικό ρόλο στη σταθερότητα και κινητικότητα της κερκιδοκαρπικής άρθρωσης. O ρόλος του TFCC είναι η ομαλή κατανομή των φορτίων από τον καρπό στο αντιβράχιο και η σταθεροποίηση της άπω κερκιδωλενικής άρθρωσης κυρίως κατά τον πρηνισμό και υπτιασμό.Αλλοιώσεις και ρήξεις του τρίγωνου ινοχόνδρινου συμπλέγματος κατηγοριοποιούνται με την κατάταξη κατά Palmer ως τραυματικές (Palmer 1) ή εκφυλιστικές (Palmer 2) και αποτελούν συχνό αίτιο πόνου στην ωλένια επιφάνεια του καρπού και αστάθειας της κερκιδοκαρπικής άρθρωσης. Λόγω ακριβώς της πολυπλοκότητας των ανατομικών δομών του καρπού η προσέγγιση των προβλημάτων της περιοχής εμφανίζει αρκετές δυσκολίες και στηρίζεται στην κλινική εξέταση και την απεικόνιση. Oι βλάβες του TFCC αρχικά προσεγγίστηκαν διαγνωστικά με την κλασσική αρθρογραφία η οποία στη συνέχεια αντικαταστάθηκε από τη μαγνητική τομογραφία (MRI) καθώς ήταν μη παρεμβατική και απεικόνιζε εξαιρετικά τις ανατομικές δομές του καρπού. Παρόλα αυτά και αυτή ως μέθοδος δείχνει να εμφανίζει χαμηλή ευαισθησία και ακρίβεια ειδικότερα ως αναφορά τις περιφερικές ρήξεις του TFCC που εμφανίζουν και τη μεγαλύτερη κλινική σημασία. Η μαγνητική αρθρογραφία συνδυάζει τα πλεονεκτήματα των δύο μεθόδων ξεπερνώντας τα επιμέρους μειονεκτήματα. Στη μελέτη μας εξετάστηκαν συνολικά 60 ασθενείς με κλινικά ευρήματα συμβατά με ρήξη του TFCC, οι οποίοι υποβλήθηκαν σε MRI και σε MRA και στη συνέχεια υποβλήθηκαν σε διαγνωστική αρθροσκόπηση με στόχο να συγκριθούν οι δύο μέθοδοι. Αποδείχθηκε από τη μελέτη μας η σημαντική υπεροχή της MRA και ιδιαίτερα στις περιφερικές ρήξεις με ειδικότητα 100%, ακρίβεια 94,9% και ευαισθησία 89,5% έναντι της MRI με ποσοστά 63,1%, 50% και 31,6% αντίστοιχα, στην ανάδειξη των ρήξεων του τρίγωνου ινοχόνδρινου συμπλέγματος τόσο των κεντρικών όσο και των περιφερικών. Όλες οι ρήξεις κατηγοριοποιήθηκαν με βάση την ταξινόμηση Palmer. Η σημαντικότερη παρατήρηση ήταν η πολύ μεγαλύτερη ακρίβεια της MRA στη διάγνωση των περιφερικών ρήξεων που έχουν τη μεγαλύτερη κλινική σημασία. Συμπερασματικά θα πρέπει να τονίσουμε ότι η μαγνητική αρθρογραφία θα πρέπει να χρησιμοποιείται ως μέθοδος εκλογής στην διάγνωση των ρήξεων του τρίγωνου ινοχόνδρινου συμπλέγματος, γεγονός που θα οδηγήσει στη μείωση λανθασμένων διαγνώσεων που συνήθως οδηγούν σε άσκοπες χειρουργικές επεμβάσεις