Mangled extremity- Modern concepts in treatment.

A mangled extremity is the most devastating limb injury and presents a challenge for the orthopedic surgeon. There are two main treatment options, reconstruction or amputation, but sometimes indications for either are not clear. There are many pro and contra arguments for both options. To make the decision easier numerous score systems have been introduced, but the final decision is based on the judgment and experience of the treating surgeon. Early extremity reconstruction appears to give better results than delayed or late reconstruction and should be the treatment of choice where possible. The goal in reconstruction of a lower extremity is to restore and maintain balance and ambulation, while restoration of an upper extremity's numerous functions is more demanding. In this paper the authors describe and suggest treatment approaches in patients with a severely mangled extremity, including assessment and treatment of all injured tissues, using defined protocols, with special attention to bone stabilization, revascularization, soft-tissue coverage and nerve reconstruction. These have a great impact on the outcome and function of the injured extremity. Rehabilitation and return to the preinjury level is slow and sometimes uncertain.

Pedicled vascularized bone grafts compared with xenografts in the treatment of scaphoid nonunion.

INTRODUCTION: Fractures of the scaphoid account for 60-70% of all wrist bone fractures. The results of treatment in terms of bone healing vary depending on the type and location of the fracture, the time elapsed since the injury, the type of surgical treatment. Nonunion occurs in 5-15% of the cases on average. The purpose of this paper is to compare the surgical techniques and results of treating scaphoid nonunion (SNU) with osteoplastic xenografts of bovine origin or a vascularized autograft of the distal part of the dorsal radius. METHODS: We compare two groups of patients with symptomatic SNU, treated surgically with either a vascularized graft (n = 15) or a xenograft of bovine origin (n = 15). In the presurgical stage, the demographic characteristics of the patients, the time elapsed between injury and surgery, and classification of the injury (Schonberg, Herbert-Fisher, and Geissler-Slade) were recorded. One year following surgery, bone healing, total duration of the treatment, complications, the Mayo wrist score, and answers to the DASH questionnaire were analyzed. RESULTS: No statistically significant differences between the two groups of patients were observed for bone healing (86.7% vs 80%) or functional results. A highly significant difference was observed with respect to duration of the surgical intervention in favor of xenografts. CONCLUSION: The xenograft method is simple and relatively acceptable, providing good results in terms of healing and functionality.

Trends in the incidence of hip fractures.

UNLABELLED: Hip fracture incidence in the capital city of Serbia was assessed over a period of 10 years (2000-2009). Crude annual incidence rates increased significantly for all ages and both sexes (p = 0.002). Age-adjusted rates also showed a steady increase. The mean rate of annual change for age-adjusted rates was 8.6 % (95 %CI 7.5-9.7) in males, 8.0 % (95 %CI 7.4-8.6) in females, and 8.2 % (95 %CI 7.7-8.7) in the total population. INTRODUCTION: The aim of this study was to estimate the incidence rate and trend of hip fractures in the population of Belgrade, the capital of Serbia. METHODS: Data sources were the official statistics of the Public Health Institute in Belgrade. The patient's age, gender, residence, hospital admission, and diagnosis were registered for each hospital admission. Population estimates were based on census data from 2002 and on published estimates for the intercensus years. The annual incidence (crude) rates and age- and sex-specific incidence rates were calculated with 95 % confidence intervals (CI) and age-adjusted incidence rates for persons over the age of 50 years were computed. RESULTS: A significantly increasing trend of crude incidence rates for all ages was observed in males (p = 0.002), females (p = 0.001), and overall (p = 0.002). The proportion of trochanteric fractures rose significantly with age in women (p < 0.0001), whereas it decreased nonsignificantly in men ≥70 years (p = 0.44). The age-adjusted incidence rates (per 100,000 in subjects ≥50 years old) showed a steady increase. The mean rate of annual change for age-adjusted rates was 8.6 % (95 %CI 7.5-9.7) in males, 8.0 % (95 %CI 7.4-8.6) in females, and 8.2 % (95 %CI 7.7-8.7) in the total population. CONCLUSION: Hip fracture incidence continues to increase. In view of the rapid aging of the population, it is necessary to implement a comprehensive preventive policy in our community.

Thalassemia major. A report of two cases with severe skeletal involvement.

Beta thalassemia major is rare in Serbia. Previously incurable, affected patients now live to adulthood with regular blood transfusions. The improvement in supportive treatment over recent decades has given rise to many more patients suffering from the associated metabolic complications of anaemia and iron overload, such as osteopenia and other skeletal changes. We present two patients with severe beta thalassemia major from early childhood, who encountered pathological long-bone fractures during the clinical course of their disease. One suffered a distal femoral diaphyseal fracture, and the second a distal tibia fracture. Both fractures occurred in osteopenic bone and were managed non-operatively due to the patients' general medical condition. Despite intense medical intervention, both patients died from disease progression within one year of their fractures, aged 23 and 24 years. As life expectancy rises it is anticipated that an increased number of beta thalassemia major patients will suffer pathological long-bone and other osteoporotic fractures. These fractures appear to both herald and contribute to a general clinical deterioration of this disease. Advances in stem-cell technology may hold the key for a definitive cure.

[Richard von Volkmann, one career of orthopaedic surgeon and poet].

Richard von Volkman was one of the most famous and important surgeons in the 19th century. He pioneered antiseptic procedures and was especially known for his achivements in orthopedic surgery. Von Volkmann was born in Leipzig, Germany and attended medical schools in Giessen, Halle, and Berlin. Starting in 1867, he worked as a professor of surgery at the University of Halle, also leading its surgical clinic. He was active as a surgeon during Seven Weeks' War with Austria in 1866 and the Franco-Prussian war 1870/1871, in the latter as consulting Generalarzt. He was important in the introduction of antiseptic wound treatment in Germany, and through it to the United States of America. Two observations in orthopaedic surgery bear his name to these days: Volkmans contracture and Heuter-Volkmans low. Volkmann also wrote poetry under the name Richard Leander and his book entitled "Dreams by French Firesides" which still has a place in literature. He died of paralysis due to a chronic spinal disease, following a prolonged illness, in the Binswanger institution in Jena in 1889, at the top of his careere.

The challenge of osteo-articular tuberculosis in the twenty-first century: a 15-year population-based study.

SETTING: Serbia, an intermediate tuberculosis (TB) incidence country in socio-economic transition. OBJECTIVE: To examine the epidemiological and clinical pattern of osteo-articular TB (OATB) in Serbia over 15 years. DESIGN: This retrospective observational study included OATB cases diagnosed between 1 January 1993 and 31 December 2007, according to the National Referral Institute of Lung Diseases and TB in Belgrade and the Central TB Register. Population estimates with extrapolations were based on 1991 and 2002 census data. RESULTS: The 295 OATB cases represented 10.9% (range 5.3-20.2) of all extra-pulmonary TB cases notified in Serbia over the period. One tenth of these were relapses. The incidence rate showed a significant increasing trend (y = 0.1167 + 0.0175x, R(2) = 0.3196), with an average age-specific incidence rate of 0.26 per 100 000 population. The peak number of cases was in the 45-64 year age group for both men and women. The average male:female ratio was 0.85. The outcome was favourable for 279 of the 295 patients (94.6%). In addition to a standardised chemotherapy regimen, 25.4% patients underwent surgery. CONCLUSION: The increasing time trend of OATB is caused by increased morbidity, a higher TB detection rate and better notification. Although rare in children, OATB remains a challenge in clinical practice.

Burnout in Belgrade orthopaedic surgeons and general practitioners, a preliminary report.

BACKGROUND: Burnout syndrome (BOS) is caused both by psychological-emotional and physical stress. It is associated with decreased job performance and low career satisfaction. BOS has a significance influence both to physicians' performance in health care system, and in their private life. Until now, there was no data about this aspect of orthopaedic surgeon condition and health in our community. AIM: To assess the level of the burnout syndrome in orthopaedic surgeons and general practitioners (GPs), and the relations of their demographic features, job characteristics to the burnout syndrome DESIGN: Questionnaire-based survey METHODS: The sample consisted of 30 orthopaedic surgeons from the University Clinical Centre, and 40 GPs from the primary health care centres. The Burnout syndrome was measured by the Maslach Burnout Inventory (MBI). In addition to the MBI, the demographic data were collected and analyzed (age, age of practicing, gender, marital status) in relation to BOS. RESULTS: Both groups expressed moderate to high rate of emotional exhaustion, depersonalization and low personal accomplishment. However, statistical significance between the groups had not been demonstrated. Neither gender nor years of practice or marital status did express statistically significant impact on the BOS items, i.e. they were not predictors of the BOS. Our results showed that about 70% of the physicians were emotionally exhausted considering both groups. On the other hand, orthopaedics demonstrated slightly higher depersonalisation level (55%) than GPs (38%). While GPs expressed lower personal accomplishment (48%) comparing to orthopaedics (29%). DISCUSSION: The obtained MBI scores in this study were similar to those registered in US among residents, but when comparing to physicians in West Europe, which have similar health care system, our results demonstrated higher rates of BOS items. CONCLUSION: The Burnout syndrome represents an important problem for actively practicing physicians. The results of this and other similar studies should be used to evaluate medical training, practice, professional relations and introduce necessary changes.

[Quality of life in patients with surgical treatment of hip fractures, preliminary study].

INTRODUCTION: Fractures of the proximal segment of the femur occurring most commonly in elderly patients are a serious, both medical (orthopaedic) and socioeconomic, problem. MATERIAL AND METHODS: 46 patients (14 male and 32 female) operated for hip fracture in the January-June 2008 period, who were available for analysis (as 24 patients were not) were investigated. In addition to descriptive analysis, general health status-quality of life was assessed by means of SF-36 questionnaire comprising eight groups of questions determining the physical, psychological and social status of the patients within the 0 to 100 (problem) points range. RESULTS: The findings were that the average patient age was 74 years (76.9 for male patients and 74.06 fro female ones). The values of all eight parameters were lower by up to 89% in comparison to the pre-injury values, but improved by as much as 50% after six months (for physical functioning and the role of physical functioning) or by 30% for the role of emotions. The values never return to their pre-injury levels. In foreign studies, the parameters are higher, especially post-treatment values for vitality and role of emotions. CONCLUSION: In patients treated for hip fractures, it is necessary to carry out an assessment of general, physical, mental and social functioning of the patient in addition to the assessment of their clinical and radiological findings, so as to get a more realistic insight in the status of the treated and operated patients. The SF-36 questionnaire is widely used in such investigations along with other questionnaires. It is also necessary to investigate the general health status-quality of life of the entire healthy population in our country.

[Etiology of surgical site infections at the orthopaedic trauma units].

OBJECTIVES: The aim of the study was to analyze the epidemiological and microbiological analysis of surgical site infections in the orthopedic wards. MATERIALS AND METHODS: A 6-month prospective cohort study was conducted at the major teaching hospital in Belgrade. Patient's basic demographic data and data about surgical site infections were collected. Bacteria cultured from the surgical site were also analyzed. RESULTS: A total of 277 patients operated in the Institute of Orthopedics and trauma surgery, Clinical Center of Serbia. Sixty-three cases of SSI were detected, and the overall incidence rate was 22.7% (95% IP = 17.8-27.6). Fifty-three (84.1%) SSIs had microbiological confirmation and overall 82 bacterial strains were isolated. The most frequent isolated bacteria were Staphylococcus aureus, Acinetobacter sp, Klebsiella pp, Pseudomonas sp and Enterococcus sp. Nineteen (79.2%) strains of Staphylococcus aureus isolated from infected surgical sites were meticillin- resistant. CONCLUSION: This study suggests that it is necessary to maintain continuous surveillance of surgical site infections. It is important to emphasize the need for implementation the measures of contact isolation in order to prevent the nosocomial transmission of resistant bacteria.

Verrucous carcinoma of the foot: a case report.

We present a case of verrucous carcinoma of the foot in a 34-year-old man. This is a rare, locally invasive, well-differentiated, low-grade squamous cell carcinoma, with human papilloma virus as a possible causative agent. It follows a chronic course and mimics a variety of skin lesions, delaying diagnosis by up to 15 years. The definitive diagnosis is made histologically, and treatment by wide local excision is recommended. Our patient underwent wide local excision and partial 5th metatarsal amputation because of invasive disease, local infection, and peripheral vascular disease. There were no postoperative complications. At the 10-year follow-up, there were no signs of tumour recurrence.

[Anatomical and functional outcome in nonoperative management of patients with fractures of the distal radial bone].

Tracking of anatomical and functional results obtained after non-surgical treatment of the distal radius included 115 patients in total, of whom 51 cases were available to be analysed and processed within this work. Tracking of the results was based upon Anatomical Score System and Gartland-Werley Score System. The final numerical results obtained through Anatomical Score were the following:excellent in 12 cases (23.52%), good in 30 cases (58.82%), satisfactory in 8 cases (15.68%), dissatisfactory in 1 case (1.96%). According to the Gartland-Werley Score System, the final results included: excellent in 19 cases (37.25%), good in 24 cases (47.00%), satisfactory in 7 cases (13.72%), dissatisfactory in 1 case (1.96%). This work also presents correlation between Residual Deformity score, Subjective Hardship score and Objective dysfunction, with the results obtained by Anatomical score and Gartland-Werley total score. The possibility of dissatisfactory results obtained by radiological screening followed by dissatisfactory outcome is described in literature; however, dissatisfactory screening results could be found in up to 31.7% of cases with satisfactory clinical findings. Our work records 15.7% of the latter cases. We might say that non-surgical treatment is not to be accepted as the only and exclusive approach to distal radius fracture. Thus, proper evaluation is mandatory.

[Comminuted intra-articular fractures of distal humerus treated with minimal fixation, one of treatment options].

Fractures of distal humerus on human skeleton are rare and intraarticular fractions of distal part of humerus occur even less freqvently, they comprise abouth 3% of fractures of humerus. However,these fractures can result in a functional deficiency of elbow joint and permanent disability. The main goal if our work was to present one of the surgical treatment options of this kind of fracture with minimal amount of fixation material. Treatment result were evaluated by Broberg-Morrey score system. Pilot study consisted of eight patient with comminuted type IV fracture of distal humerus during 2004-2005 time period. Comminuted fracture was fixed with minimal amount of material: a Kirchner needle and a screw. Patient treatment progress was evaluated initially and followed up after four, nine and twenty four months by B-M score after removal of cast and bone fixing material. The results of the B-M score after four months were: excellent in 0 patient, good in 2 patients, fair in 4 patients and poor in 2 patients. After physical therapy and follow up check- up at the end of nine months the result were: excellent in 3 patients, good in 3 patients, fair in 2 patients and no patients had shown poor result. This B-M score result was identical after 24 months follow up with minor deviations in range of motions of elbow, which did not influence the final result of B-M score.

[Nonunion--pseudoarthrosis of the scaphoid bone treated with percutaneous fixation, with compression and distraction].

Fractures, and especially pseudoarthroses of the scaphoid bone, are a great problem in orthopedic surgery, because the failure percentage is remarkably high (20-30%) even with the top modem treatment methods. Use of grafts, especially well-vascularized ones, along with good fixation, has improved treatment outcomes, but the failure and complication percentages remain high. In the pilot study, we present the first five patients with the pseudoarthrosis of the scaphoid bone, male, of 26.8 years of average age (from 22 to 34-years-old), in whom the method of extrafocal fixation, with distraction and compression, was applied. The fracture healing was achieved in all patients after an average period of 87 days (from 60 to 100 days), with the healing time also including a minimum of a month of physical therapy, after the fixator was removed. The result was evaluated using the Mayo wrist score, and from the preoperative 26 points, 82 points were achieved.

[Historical aspects of external fixation and possibilities for the future developement].

External fixation is not such a novel method, but it is interesting to learn its history, countries in which it has developed and the time when it gained full expert acceptance in treating not only fractures but orthopedic disorders, inequalities, and articular arthrodeses. The beginnings of external fixation are associated to the name of Malgaigne, followed by the authors of Western European, German and American school of external fixation. In the U.S.A., this method was accepted as late as in 1950s; being accepted in Russia through Ilizarov. In our country, the method was accepted in 1950s, through the work of Prof. Bumbaireviae and Prof. Raduloviae, who are the founders of modem external fixation in our country.

[Treatment of unstable closed tibial shaft fractures by external fixation].

The fracture of tibia shaft is one of the most common fracture of long bones. The authors bring out the results of the treatment of 90 patients with unstable closed tibial shaft fractures treated by the use of Mitkovic external fixation systems. Within the analayzed group there were 66 (73%) male and 24 (27%) female. The average patients age was 43.9 years (range 15 to 82). Excellent result in treatment of unstable closed tibial shaft fractures with external fixation were achieved in 15 (16,7%) patients, very good in 38 (42,2%) patients, good in 24 (26,7%), poor in 9 (10%) and bad in 4 (4,4%) patients. With 4 (4,4%) patients pseudoarthrosis was formed. Additional treatment of patients with pseudoarthrosis (spongioplastic and placing of CD device) led to pseudoarthrosis healing. Within the analyzed group in all patients treated with extenal fixation there were no registered cases of postoperative osteitis. External fixation by the use of Mitkovic external fixation is one of the method of choose in the treatment of unstable closed tibial fractures, providing dynamic and balanced biomehanical conditions for fracture healing.

Epidemiology of hip fractures in Belgrade, Serbia Montenegro, 1990-2000.

INTRODUCTION: This study retrospectively determined the incidence rates of hip fractures in Belgrade, Serbia and Montenegro, during the period 1990-2000. MATERIALS AND METHODS: All patients with hip fractures treated at all Belgrade hospitals were identified from the Republic of Serbia's Ministry of Health National Health Care database. Patient demographics, type of hip fracture, and details of the mechanism of injury were collected. The annual incidence rates were calculated with interpolation according to the Belgrade population census of 1991 and 2002. RESULTS: There were a total of 8,904 hip fractures with a mean annual incidence of 51.7 per 100,000 adults (62.2 females and 35.5 males). Mean age at the time of fracture was 67 years (72.6 for females and 59.3 for males), with 64.7% of all fractures occurring in women. There was a significant increase in hip fracture incidence rates over the observed period in females (P = 0.006), but not in males (P = 0.962). Trochanteric fractures predominated, accounting for 53% compared with cervical fractures. In patients over 50 years of age there was an exponential increase in the incidence of hip fractures in both sexes; though more so in females. 91% of hip fractures occurred in these older patients with incidence rates of 143.6 per 100,000 (185.9 for female and 92.2 for male patients). The most common mechanism of injury in the older group was low-energy trauma (70.3%) resulting from a fall from standing height onto a flat surface (same level). Standardizing incidence rates in the older age group to the US 1985 white population gave values of 228 per 100,000 females and 96 per 100,000 males. These incidence rates are similar to those reported in Italy, France and Great Britain, but lower than those in Scandinavian countries. CONCLUSION: In view of growing population numbers and an increase in the proportion of patients aged over 60 years, we can expect an increase in the prevalence of osteoporosis and an increase in the incidence of fragility hip fractures in the future, with resource implications.

Malignant intraosseous peripheral nerve sheath tumour of the proximal femur: a case report.

We report a rare case of an intraosseous malignant peripheral nerve sheath tumour of the femoral head and neck. The tumour presented as a well-defined radiolucent lesion on plain radiography. Computed tomography showed aggressive destruction of the bone with no involvement of the adjacent soft tissues. Magnetic resonance imaging revealed an isointense signal intensity on T1-weighted images, hyperintensity on T2-weighted images, and non-homogeneously increased signal intensity after administration of contrast media. The final diagnosis was based on pathohistologic analyses due to the non-specific nature of the lesion.

Gunshot injury to the face with a missile lodged in the upper cervical spine without neurological deficit.

An unusual case of facial gunshot injury with the missile lodged in the cervical spinal canal, but without any neurological impairment is reported. The extent of tissue damage and missile track termination in a male patient who sustained gunshot trauma to the face was assessed by plain radiography and by CT scans. The patient was treated conservatively and observed for clinical manifestations of neurological deficit for 3 weeks. CT of the head and neck performed 13 years after injury with the three-dimensional (3D) reconstruction of skeletal elements revealed healed fractures of the right nasal bone, the labyrinth of the right ethmoid bone, and position of the missile on the medial aspect of the right lateral mass of the atlas. There was no migration of the missile during this period. This case report of gunshot wound to the face associated with injury of the cervical spine indicated possibility of survival and atypical absence of clinical manifestation that may occur even when a bullet remains in the spinal canal.

[History of orthopedic surgery in Belgrade--100 years of orthopedics in Serbia (1905-2005)].

The history of orthopedics in Serbia is related to a hand x-ray made in 1905 by dr. Nikola Krstic. The first orthopedic word was founded in 1919, to be enlarged into a full-fledged orthopedic surgical ward of the General State Hospital in 1932. Until 1941, the ward headed by Dr. Nikola Krstic. The Orthopedics course was headed by Dr. Borivoje Gradojevic, who also wrote the first textbook in our country in 1934. In 1947, the ward became the Clinic for Orthopedic Surgery and Traumatology in Belgrade which is the orthopedic basis of Serbia, together with the Special Orthopedic Surgery Hospital Banjica, even today.

[Modern aspects of shoulder injury treatment].

The article describes injuries of soft and bone structures of the shoulder region, with special emphasis on the following clinical forms: instabilities and luxations of the glenohumeral joint, fractures of the proximal humerus, clavicle and the states of painful shoulder. Fractures and dislocations, but also significant entities - painful states caused not only by fractures but also by minor trauma such as tendinitises and m.supraspinatus tendon and bicipital tendon ruptures are discussed in more detail. Moreover, their consequences - painful and stiff shoulder - as well as modern diagnostic and therapeutic procedures applied in the painful shoulder treatment are also discussed.