Distraction osteogenesis by Ilizarov and unilateral external fixators in a canine model.

We studied distraction osteogenesis in canine experimental model using two types of external fixators, Ilizarov (n=6) or AO unilateral (n=9) external fixator. Distraction started 1 week after surgery (2 x 0.5 mm/day) and lasted for 3 weeks. Specimens were harvested from weeks 7 through 12. The outcome was assessed by X-ray, histology, histomorphometry and microradiography. Bone regeneration as observed by X-rays was satisfactory and similar in both groups. Both endochondral ossification and intramembranous ossification were found simultaneously in both groups. In both groups, bone formation parameters were significantly higher in the area of consolidating bone. No differences in histomorphometric parameters existed between the groups. In the study period, the bone formation was enhanced and prevailed in the distraction area. This study demonstrated the utility of the canine experimental model for the study of distraction osteogenesis.

CMC external fixator.

PURPOSE OF THE STUDY: Imobilisation of wounded extremity decreases pain and shock, diminishes the possibilities of soft tissue, vessels and nerves injury with bone fragments, that influences the volume and success of surgical debridement of the wound. Optimal external fixator for war purposes must be rigid in construction, have to be simple to master, allow simple approach to wound during the whole period of fixation, have to be in sterile package with all its necessary part and should not be too expensive. DESIGN OF THE STUDY: Prof. Korzinek in correspondence with "Instrumentarija" from Zagreb developed a new type of external fixateur applicable in war situation and natural disasters. It was named CMC (Croatian Medical Corps) external fixateur, and it ensures imobilisation of extremity during transport to area of final treatment and it could also ensure conditions for definitive fixation. CMC is compound of bar, clamps and Schanz screws. Standard packing are CMC-30 and CMC-40. CONCLUSION: CMC external fixator is the applicable device in war and natural disaster situations. It is simple to master even for less experienced surgeons, it's low volume allows appropriate wound treatment, it could be resterilised and reused and it has acceptable price.

Treatment of defect pseudoarthroses with bone segment transport.

PURPOSE OF THE STUDY: The most severe injuries during defense war in Croatia were caused by projectiles of high kinetic energy. Shell fragments bone they break the bone, transferring bone segments into additional individual projectiles. During this process periostal and endomedullary circulation is cut off reducing to a minimum the possibility of healing, leading to defects in long bone diaphyses. These are referred to as defect pseudoarthroses and are among the most difficult problems in reconstructive surgery of the musculo-articular system. This article presents bone segment transport as a method of choice for treating defect pseudoarthrosis. MATERIAL: During the defense Croatian war, in six-years period, 62 wounded persons were treated with Ilizarov method of bone segment transport. Among them, only one was female. Average age was 33 years. METHODS: The authors performed modified Ilizarov's method as standard procedure for bone segment transport in treatment of defect pseudoarthroses. After all soft tissues are held, corticotomy in metaphysis is performed and free bone segment transport started with Ilizarov method. Physical therapy provided adequate mechanical load, essential for bone healing and restoring the functionality of injured extremity. RESULTS: In the group of treated patients, the largest bridged defect was 20 cm, and the smallest one was only 1 cm. Infection arises in 20 of 60 patients. Contracture complications were ankle contractures, knee contractures and one elbow contracture. We also found one n. peroneus palsy and one limb amputation should be performed. DISCUSSION: Ilizarov method of bone segment transport presents the only procedure that could successfully and completely treat pseudarthroses, thus avoiding necessaries for limb amputations. Requirements in this procedure are experienced and highly qualified surgical team and high motivation and compliance of the patient.

A secure locking knot for microsuturing.

Perfect balance between maximal suture strength and minimal foreign-body reactivity guarantees success, using microsurgical techniques. The proposed initial locking knot allows optimal edge approximation. It has strength, it is simple to master, and is not too bulky. The knot is kept in its first position, without danger of slipping, before securing it with an additional knot of two loops. No additional knots are necessary, because the completed knot may fail by breaking, but never by slippage.

Leukocytoclastic vasculitis as a complication of infected total hip prosthesis.

We present a case of leukocytoclastic vasculitis, associated with an exacerbation of chronic osteomyelitis in a pseudoarthrosis of the hip. Skin lesions of the lower limb were the most prominent features.

Arthroscopic Bankart repair with extracapsular and extra-articular knot using the Mitek suture anchor.

The recurrence of instability after arthroscopic stabilization has been significantly higher than after open repair. One of the reasons for the high failure rate is the inability of arthroscopic repairs to address the plastic deformity of the capsule that occurs in the glenohumeral ligament-labrum complex. The arthroscopic technique is used to repair the torn labrum to the glenoid, but without adequate tightening of the anterior capsule, which is successfully accomplished with an open technique. This report describes the new technique of arthroscopic Bankart repair with extracapsular and extra-articular knot using suture anchors that allows tightening of the anterior capsule sufficiently as with an open Bankart procedure.

External fixator for war purposes: the CMC fixator.

More than 75% of all injuries in modern wars are localized on the extremities, and more than one-third of these injuries are accompanied by bone fracture. Application of an external fixator is one of the basic procedures in the treatment of war fractures. In this article, we present an external fixator for war purposes of our own construction called the CMC (Croatian Medical Corps) fixator. Although designed as a transport fixator, because of good biomechanical properties it has been widely used for definitive osteosynthesis of war injuries. The CMC fixator is manufactured as a sterile set, ready to use, with all necessary parts for application. On the battlefields of Croatia and Bosnia and Herzegovina during the war from 1991 to 1995, more than 2,500 CMC fixators were applied. The fixator has satisfied all required conditions and considerably contributed to diminishing the consequences of war fractures.

Initial throw locking internal knotting technique.

Internal knotting is a highly versatile technique that closely resembles classic suturing. However, most intracorporeal knots are cumbersome and require a long time to master. We describe a simple, easy, and safe method for internal knotting that can also be used in open procedures and practiced until mastery is achieved. With this technique, the initial throw will never fail to hold tissues in apposition until the whole knot is constructed. The completed knot combines the maximum in suture support with a minimum of foreign body reactivity.

[The Klippel-Trenaunay syndrome]. / Klippel-Trenaunayev sindrom.

The article presents the Klippel-Trenaunay syndrome. The diagnosis was set upon birth based on typical skin angiomatous nevi and hypertrophy of soft tissue and bones. Later on, the patient also developed the third element of the syndrome, i.e. varicose veins. The patient has a rare form of the disease, with hypertrophy of soft tissue in the left forearm and soft tissue and bones of his right leg. The static type macrodactylia is present on both hands and feet. The paper gives clinical description of this rare, nonhereditary disease. The need of continuous multidisciplinary monitoring of such patients is emphasized, since this syndrome should be distinguished from Parkes Weber syndrome which has essentially different prognosis.

War injuries to the bone and joint system: reconstructive surgery.

Reconstructive bone and joint surgery in war is discussed. Bone and joint injuries account for over 70% of all injuries, 30% including a fracture. They pose a serious medical, surgical, and public health problem. The methods described aim to restore full function to the injured extremity. War injuries incorporate severe circulatory disorders and severe soft tissue and bacterial contamination. The war surgeon is faced with defectively healed or unhealed fractures, bone and tissue defects, joint injuries, traumatic amputations, large joint contractures, and infections. Clinically, external fixators, the Ilizarov method, antibiotic prophylaxis, and a new antiseptic agent have proved highly beneficial.

War injuries of the extremities.

This paper describes experience acquired during the war against Croatia under improvised conditions at the Kutina War Hospital in the immediate vicinity of the first front lines. Over a period of almost 6 months a total of 701 soldiers and civilians, 546 of whom had been wounded by firearm missiles, were treated at the Kutina War Hospital, which has a capacity of 30-40 beds. As many as 87% of the injuries were due to mine, bomb or artillery shell shrapnel. The percentage of gunshot wounds was very low, mainly caused by sniper shots. Most patients (419, or 76.7%) were admitted with injuries to the extremities, including 893 severe soft tissue injuries and 182 fractures (32.3%). Soft tissue injuries were treated by routine procedures of war surgery, associated with ample use of Lavasept, an antiseptic solution (Fresenius, Stans, Switzerland), which has proved to be highly efficacious in preventing and decontaminating infection without disturbance of the wound healing process. Long bone fractures were fixed with the aid of external fixators of various designs, including the CMC external fixator of our own construction. External fixators have once again proved indispensable in the treatment of open fractures sustained in war settings. Amputations were performed in 10.4% of cases, including fingers and toes. Only 8 patients died during or immediately after surgery, corresponding to a very low mortality rate of 1.46%. The main prerequisites for successful treatment are a professional relationship to war surgery and its specific requirements, satisfactory technical equipment, and excellent organization of medical and non-medical services.

Lengthening and spatial correction of limbs.

Limb inequality, axial deformity and other problems of reconstructive bone and joint surgery are discussed. Limb length equalisation and correction of axial deformities are complex surgical and rehabilitation procedures associated with a high incidence (0-50%) of complications and side effects requiring prompt remedial measures. The basic principles of limb lengthening by the Wagner method and the essential features of the Ilizarov method for elongation and spatial correction of congenital and acquired limb deformities are described. Further indications for the use of the Ilizarov method in the management of posttraumatic and congenital anomalies of the bone and joint system are presented. The results of operative treatment of these anomalies obtained by the Wagner and Ilizarov techniques over the period from 1979 to 1992 in a total of 274 patients are presented. Attention was focused on the problem of complications or rather side effects arising during such treatment procedures, their prevention and management.

[Reconstructive surgery in war injuries of the bones and joints]. / Rekonstruktivna kirurgija ratnih ozljeda kostano-zglobnog sustava.

The basic problems of bone-and-joint surgery with special emphasis on war injuries and the role of reconstructive surgery in relieving the gravest consequences of war injuries are discussed. Since bone and joint injuries rank high among the war injuries with a share of over 70% including more than 30% of fractures, they pose not only a serious medical and surgical but also a major public health problem. The economic and social consequences of these injuries are further aggravated by the necessity for prolonged treatment and multiple surgical interventions. The basic preconditions which must be fulfilled for bone healing to take place are discussed in the light of the ultimate goal of all therapeutic efforts. i.e. restoration of full functional ability of the injured extremity. The importance of bone fragment immobilization for the process of bone healing is emphasized. Impaired bone healing, resulting from insufficient immobilization or inadequate reposition of bone fragments, is a common problem with war fractures, mainly because of the great forces involved and extensive destruction of bone and all other surrounding tissues. One of the main features of war fractures is delayed bone healing caused by massive circulatory defects in the injured bone. Some special problems attending war injuries, such as pseudarthroses and associated defects, soft tissue infections and defects, may only be effectively solved by cooperation with a plastic-vascular- or neurosurgeon. In one and joint surgery profound understanding of the physiology, pathophysiology and biomechanics of bone healing, knowledge of modern methods of osteosynthesis, skill in the management of bone and other infections as well as knowledge of the latest developments in postoperative care are essential for achieving satisfactory therapeutic results. Availability of various implants and a wide range of surgical instruments is a precondition which needs no further discussion. It is only in this way that the most promising course of action can be selected for each wounded person individually, a course of action which will, in the shortest possible time and the most convenient manner, lead to the desired therapeutic goal, i.e. restoration of satisfactory bone and joint function.

[War injuries of the extremities. Use of the CMC fixator]. / Ratne ozljede ekstremiteta. Primjena CMC fiksatora.

The injuries of the extremities in the military setting, during hostilities, are classified to be the most frequent in general. Among them there are those caused by the missiles from rifles and automatic and semiautomatic weapons and those due to mine and shell fragments. The characteristics of modern array of weapons are missiles of high kinetic energy provoking extensive tissue injuries, often together with fractures of the long bones. When taking care of such fractures, in addition to surgical treatment of the wounds, the administration of medicine and prevention, the immobilization of the fragments is of fundamental significance. All modern armies in the world use external fixators for the immobilization of the fragments, those fixators being the most reliable and the most uncomplicated means of immobilization. The paper presents a new type of the external fixator to be used in war surgery. It is called the CMC fixator (Croatian Medical Corps). The fixator is made according to the original designs in the factory (Instrumentarija) at Zagreb. Following its biomechanic characteristics the fixator is classified into the group of unilateral or joining external fixators. It is designed for fixation of the long bone fractures in the war setting and disaster conditions. It may be used for two purposes: 1. for the transport immobilization to a medical facility where the problem is to be finally solved, 2. as the means of an external immobilization until the final secondary bone-healing. The fixator has only three elements and the universal kee. It is easily applied. The way how to apply this fixator is described in details. The first experiences in the field have given satisfactory results.

Limb lengthening and three-dimensional deformity corrections. A retrospective clinical study.

Different methods of limb lengthening as used at the Orthopedic Surgery Clinic of the Medical School, University of Zagreb, are compared. The results of operations performed between 1979 and 1989 on 111 patients are presented. These patients were subjected to surgery aimed at length equalization of limbs and/or correction of three-dimensional deformities. Lengthening was performed in 104 patients at one level, and in 7 patients at two levels of the same limb for a total of 118 procedures. In order to compare limb lengthening techniques the patients were divided into four groups: group I, original Wagner technique (45 patients); group II, Wagner technique using corticotomy (33 patients); group III, original Ilizarov technique (35 patients); group IV, continuous lengthening (2 patients). The evaluation covered radiological aspects of regenerated bone, complications and basic lengthening parameters. The results indicate that corticotomy has considerable advantages over osteotomy, provided bone circulation is maintained. These advantages manifest themselves in a reduced number of operations, lower incidence of infection and improved bone regeneration. It is preferable to perform corticotomy at the metaphysis site because of its optimum blood supply and its higher potential for osteogenesis. With corticotomy performed at the diaphysis site, satisfactory results were observed in only one-third of the cases.

Biomechanical analysis of hip function after Chiari pelvic osteotomy.

The reasons are discussed for differences in functional results of the pelvic osteotomy after Chiari, regardless of the fact that the CE and AC angles were equal in all patients. When lateralization and distal displacement of the greater trochanter were performed in addition to the pelvic osteotomy, the functional results proved to be better. Biomechanical analysis of the relationship between gluteal force and body weight revealed that these relations change; in all examined cases where lateralization and distal displacement of the greater trochanter were performed, the relationship proved postoperatively to be considerably more favorable. In the same group of patients, the relationship between the force of reaction and body weight was also changed after surgery. Therefore, lateralization and distal displacement of the greater trochanter are important factors for the undisturbed functioning of a hip; in all examined patients the functional results were better when lateralization and distal displacement of the greater trochanter were performed.