Importance of shear-wave elastography in prediction of Achilles tendon rupture.

PURPOSE: It was demonstrated that about 6% of patients with a ruptured Achilles tendon experience the rupture of contralateral tendon in the future; the aim of this study was to estimate the risk for rupture of contralateral tendon in patients who underwent surgical reconstruction of ruptured Achilles tendon by using subjective questionnaires and shear-wave elastography. METHODS: Twenty-four patients who underwent surgical repair of the ruptured Achilles tendon and twelve age-matched healthy controls were examined with ultrasound SWE. Functional outcomes were assessed with American Orthopedic Foot and Ankle Society (AOFAS) scoring system and subjective rating system which we introduced and validated. RESULTS: The elasticity of injured tendon was markedly decreased (by 42%) compared to the contralateral tendon of the patient, as expected. Both AOFAS score and our novel subjective assessment scale positively correlate with ultrasound SWE values in ruptured Achilles tendons. The elasticity of contralateral Achilles tendons in patients was 23% lower than among healthy individuals. CONCLUSION: Irrespective of the lack of difference in the subjective feeling assessed by AOFAS, the contralateral tendon in the patients with reconstructed Achilles tendon has significantly lower stiffness than healthy individuals. Therefore, contralateral tendons in patients who suffered from rupture are more prone to future ruptures.

Fluoroscopic iliosacral screw placement made safe.

AIM: Unstable posterior pelvic ring injuries should be stabilised successfully by percutaneous iliosacral screwing. The intervention takes place under intraoperative fluoroscopic guidance. The inlet and outlet views are crucial and are performed by tilting the image intensifier. Safely interpreting fluoroscopic views can be challenging in certain clinical scenarios. We demonstrated on a series of patients howpreoperative CT scans can be used to anticipate the appropriate intraoperative inlet and outlet fluoroscopic views and positioning of the patient on the operating table, thereby avoiding possible operating table obstacles. MATERIALS AND METHODS: We analysed at random 30 pelvic CT scans from patients of different ages and both sexes, utilising the sagittal reconstructions. Inlet and outlet angle measurements were calculated on the scans to determine the appropriate intraoperative inlet and outlet views. RESULTS: The analysed CT scans showed an average inlet view of 22.3° (range 10.4°-39.8°) and an average outlet view of 42.3° (range 31.5°-53.1°). Sex and age had no influence on results. The calculated required free space under the operating table for unobstructed tilting of the C-arm was a minimum of 145cm. CONCLUSION: The significant anatomic variations of the posterior pelvic ring have been well documented in the literature. The angles required to obtain appropriate intraoperative inlet and outlet views are not perpendicular and differ greatly from traditional settings, which directed the beam 45° caudally and 45° cranially. The fluoroscopic beam would need to be angled differently in each patient to obtain ideal cardinal views that ultimately assist in safe iliosacral screw placement. To avoid collision of the C-arm with the operating table, it is essential to provide secure free space under the operating table of at least 145cm.

[Stercoral rectosigmoid colonic perforation with fecal peritonitis]. / Sterkoralna perforacija rektosigmoidnog kolona s fekalnim peritonitisom.

Chronic constipation can lead to fecal impaction and catastrophic complication such as colonic obstruction, perforation and fecal peritonitis. A case is reported of stercoral perforation of the rectosigmoid with pneumoperitoneum and fecal peritonitis. The patient was admitted for the signs of acute abdomen with pneumoperitoneum diagnosed on native radiological imaging.

Mechanical bowel preparation in colorectal surgery.

The aim of this study was to assess the use of mechanical bowel preparation (MBP) and antimicrobial prophylaxis in elective colorectal surgery regarding still existing controversies. A prospective study of 85 patients undergoing elective colon and rectal surgery during 2 years period was performed, divided in two groups. Group A (N = 46) with patients who underwent mechanical bowel preparation, and group B (N = 39) patients without mechanical bowel preparation. We analysed: gender, age, preoperative difficulties, diagnostic colonoscopy, tumor localization, operation performed, pathohystological findings, Dukes classification, number of lymphonodes inspected, liver metastasis, other organ infiltrations, mean time of surgery, length of hospital stay, postoperative complications and mortality. Demographic characteristics, pathohystological findings, the site of malignancy, and type of surgical procedure did not significantly differentiate the two groups. The only significance revealed in mean time of surgery (138/178 minutes) in favor of patients with MBP (p = 0.017). Mechanical bowel preparation (MBP) for elective colorectal surgery is not advantageous. It does not influence radicalism of the procedure, does not decrease neither postoperative complications, nor hospital mortality.

[Laparoscopic diagnosis and desincarceration of inguinal Richter hernia: a case report]. / Laparoskopska dijagnoza i dezinkarceracija ingvinalne Richterove hernije-prikaz bolesnika.

In the cases of incarcerated Richter hernia the diagnosis is difficult especially for obese patients. Laparoscopic diagnostics and desincarceration, can be combined with mini laparotomy in lieu of bowel resection and open hernioplasty, or conversion to classic laparotomy and open hernioplasty. Here is presented a case of incarcerated Richter inguinal hernia managed through the combination of laparoscopy, mini laparotomy for segmental bowel resection and open hernioplasty.

Protective intramedullary fixation after harvest of an osteocutaneous radial free flap.

The osteocutaneous radial free flap, even after 30 years, is still considered to be the "workhorse" for head and neck reconstruction. A high incidence of donor site fractures has remained a major problem, however. The technique described here is a method developed for the prophylaxis of fractures of the donor site of the harvested radial bone and is based on a modification of the intramedullary Rush nail fixation. The data were collected from 18 patients in whom the radial forearm free flap had been used during reconstruction. None of the prophylactically-nailed radii fractured. The complications experienced with this technique are general complications, such as scarring of the forearm and dehiscence of the wound. This technique is simple, and has given excellent results. Aesthetic and functional results were comparable to those of other flaps used for reconstruction. We recommend this technique because of its simplicity, vascular safety, and cost effectiveness.

Laparoscopic treatment of iatrogenic endoscopic sigmoid colon perforation: a case report and literature review.

Iatrogenic colon injury during a colonoscopy procedure is rare. The controversy exists when the surgical treatment of such lesions is concerned: operative or conservative. This case report is in favor of the operative endoscopic approach, with a literature review. An 80-year-old male sustained an iatrogenic endoscopic sigmoid colon perforation. Laparoscopic suturing was done within 5 hours after the perforation, with no complications after 4 months of follow-up.

[Laparoscopic surgery in acute abdominal trauma]. / Laparoskopska kirurgija kod akutne ozljede trbuha.

In the past few years, laparoscopy has been increasingly used in patients with acute abdominal trauma. This metod in experienced hands enables direct eye visualisation of abdominal cavity, ensures accurate and early diagnosis and leads to prompt decision on the therapy. Reviewing the literature, laparoscopy in acute abdominal trauma is a safe and accurate procedure to yield diagnosis, enable laparoscopic interventions and help avoid unnecessary laparotomy. In acute abdominal trauma, laparoscopy is mostly used as a diagnostic method, not so often as a therapeutic method, but an expanding range of therapeutic interventions is available. We show our early results with diagnostic and therapeutic laparoscopy from January 1st 2003 to March 31st 2004, stressing therapeutic laparoscopy. We performed 79 laparoscopic explorations in patients with diagnosis of acute abdomen. 7 of them were explored because of acute abdominal trauma. In 3 patients there was no need for intervention after laparoscopic exploration, in 1 patient we electrocoagulates smaller bleeding from the spleen and in other 3 patients we made conversion to open surgery procedure, because of III-IV grade liver or spleen injury. In our group we didn't have injuries of any other internal abdominal organs. Laparoscopic treatment of acute abdominal trauma with spleen or liver injury is applicable in I-III grade liver injury and I-II grade spleen injury, while in greater injuries it is necessary to make conversion to laparotomy.

[Blast injury to the spleen and pancreas after a non-penetrating gunshot wound--result after 12 years]. / Ratna ozljeda slezene i gusterace nastala bocnim udarnim valom metka--rezultat nakon 12 godina.

The spleen is the most frequently injured organ in adults who sustain blunt abdominal trauma. The aim is to report on a patient with non-penetrating gunshot traumatic injury to the spleen and pancreas, and to evaluate the result after 12 years A soldier with gunshot wound of the left lateral abdominal wall was admitted to the Military Hospital in Mostar in the year 1993. The patient was hemodynamically unstable and underwent emergency surgery. On wound exploration, there was no abdominal penetration. Because of hemodynamic instability, we decided to perform emergency laparotomy and abdominal exploration. The spleen and distal pancreas were shattered. Splenectomy and hemostasis were performed. The peritoneum was closed and the abdominal wall wound healed secondarily. The patient was in good condition postoperatively. Now, after 12 years, the patient is free from any sequel of the war injury. Blast injury to the spleen can result from non-penetrating abdominal gunshot wounds despite the absence of injury to the peritoneum. In war conditions, the diagnosis and indications are usually based on clinical findings only because special investigations, including ultrasound and CT are not readily available. The management of splenic injury has been rapidly modified over the last decade, with ever more emphasis on splenic salvage and nonoperative management, however, these procedures cannot be performed in war conditions. War injuries to the spleen are life threatening and emergency open splenectomy is the only solution.