Lower limb replantation: 27 years follow up.

Replantation of lower extremity is a very complex and difficult procedure. There are still a lot of controversies about indications, even numerous scoring systems are now available that can facilitate the surgeon's decision. We present the functional results of a replanted below-knee amputation in an elderly patient, 27 years after the injury and discuss the indication for replantation.

"Close-open-close free-flap technique" for the cover of severely injured limbs.

The treatment of severely injured extremities still presents a very difficult task for trauma orthopaedic surgeons. Despite improvements in technology and surgical/microsurgical techniques, sometimes a limb must be amputated, otherwise severe and potentially fatal complications may develop. There is a well-established belief that severe open fractures should be left open. However, Godina proved wound coverage in the first 72 h (after an injury) to be safe and to bring good final results. So early wound cover (no later than one week after an injury) with well vascularized free flaps became the gold standard. Yet for many patients (some of whom have serious health problems), operative treatment needs to be postponed when they arrive to specialized microsurgical departments for microsurgical reconstruction much later than one week after incurring an injury.  As the definite wound cover period from one week to 3 months seems to be hazardous, especially due to the potential of infection, we developed a safe, original flap technique that prevents infection and covers important structures such as exposed bones, tendons, nerves and vessels. We named this technique the "close-open-close free flap technique". It enables difficult wound cover in any biological phase of the wound, by combining complete flap cover first, with the removal of stitches from one side of the flap after 6-12 h. This technique works very well for borderline cases as well; where even after a complete debridement, dead tissue still remains in the wound - making wound cover very dangerous. Closing completely severe open fractures with free (or pedicled) flaps and removing the stitches on one side after 6-12 h, enables orthopaedic surgeons to safely cover any kind of wound in any biological phase of the wound. Additional debridements, lavages and reconstructions can easily be performed under the flap and after the danger of a serious infection has disappeared, definitive wound closure can be carried out.

Prolonged pre-operative hospital stay as a predictive factor for early outcomes and mortality after geriatric hip fracture surgery: a single institution open prospective cohort study.

INTRODUCTION: The aim of this open prospective cohort study was to determine if a prolonged pre-operative hospital stay is a true predictor of higher morbidity or mortality in geriatric patients with hip fractures. MATERIALS AND METHODS: We analysed early outcome parameters, such as functional independence measure (FIM), at discharge and four months post-operatively, peri-operative nonsurgical complications, intra-hospital and one year mortality compared with prolonged pre-operative hospital stay in 308 patients from a continuous cohort of 344. RESULTS: Average pre-operative stay was 8.39 ± 5.80 days. Delaying surgery for > 72 hours was independently predictive for general complications and lower motor FIM gain at four months. All findings worsen progressively after the fifth day of delay. Pre-operative period was not found to be an independent predictor of mortality. CONCLUSION: In all observed outcome parameters except mortality, pre-operative delay > 72 hours was shown to be a true predictive factor.

Microsurgical anatomy of the extra-articular segment of middle genicular artery.

PURPOSE: Knowledge of the incompletely studied microsurgical anatomy of the extracapsular part of the middle genicular artery (MGA) could imply an educational value and clinical significance because of the possible risk of injury during knee surgery. METHODS: Thirty formol-fixed cadaveric lower limbs in full extension were dissected and used for the measurements of MGA parameters. A second group of measurements was performed on distal ends of 30 adult femurs. Two fresh injected cadaveric lower limbs were explored by means of multidetector computed tomographic angiography (MDCTA). RESULTS: The MGA originated from the popliteal artery (PA), facing the lateral half of the intercondylar fossa in 16 (53.4 %) specimens, together with the superior lateral genicular artery (SLGA) in ten (33.3 %) cases, or from the same point of origin with SLGA and superior medial genicular artery (SMGA) in 4 (13.3 %) cases. The MGA averaged 15.6 mm in length and 1.8 mm in the outer diameter. After its curved direction the MGA entered the posterior capsule. The average distances of the point of MGA entrance into the joint capsule were as follows: to the lateral femoral epicondyle it was 34.88 mm, to the medial femoral epicondyle 46.38 mm, 5.74 mm lateral to the posterior midline, with an average vertical distance to the femoral subcondylar plane of 28.73 mm. CONCLUSION: This detailed anatomical examination with measurements of the extracapsular part of a MGA could be of clinical importance and useful in knee surgery for the prevention of vascular injury of MGA and PA, as well as in radiological examination of the knee region.

Evaluation of reversal osteofixation using K-wires in digital replantation.

INTRODUCTION: Modified, reversal technique of fixation in digital replantation using K-wires was analyzed. The results obtained from the standard technique and reversal technique of fixation using K-wires were compared. OBJECTIVE: The aim was to compare the results of osteofixation using K-wires in digital replantation when either standard or reversal, modified technique was used. METHODS: A retrospective study included 103 replanted fingers in 72 patients. The first group included standard fixation using K-wires and the second group included fixation using K-wires, but with a modified technique. Modification consisted of the opposite order of moves during the phalanges fixation compared to the standard technique: first, K-wire was introduced intramedullary in the proximal phalanx and the top of the wire was drawn out through the skin in proximal part of the finger or hand. Second, distal part of the wire was introduced in the phalanx of the amputated part of the finger intramedullary until the wire entered the cortex. RESULTS: Duration of bone healing after digital replantation was shorter in cases where reversal technique was used in comparison with standard technique (7.2 weeks compared to 7.5 weeks). CONCLUSION: The comparison of standard and reversal technique of phalangeal fixation with K-wires in digital replantation shows that both techniques are useful. Reversal technique expands the choice of operative techniques for bone fixation during the replantation. It shows some advantages and enables avoidance of vein injuries.

Replantation of upper extremity, hand and digits.

Replantation is defined as reattachment of the part that has been completely amputated and there is no connection between the severed part and the patient. In Boston in 1962 Malt successfully replanted a completely amputated arm of a 12-year-old boy. Komatsu and Tamai reported the first successful replantation of an amputated digit by microvascular technique. There are no strict indications and contraindications for replantation. It's on surgeon to explain to the patient the chances of success of viability, expected function, length of operation, hospitalization and long rehabilitation protocol. Survival and useful function in replantation of upper extremity amputations is questionable. Success depends on microvascular anastomoses, but the final function is related with tendon, nerve, bone and joint repair.

Forearm reconstruction after loss of radius: case report.

INTRODUCTION: Osteomyelitis of the radius resulting in the radial clubhand is a very rare condition and few studies have been published about its prognosis and treatment. CASE OUTLINE: This is a case report of hematogenous osteomyelitis of the radius with a complete loss of the radius leaving only the distal radial metaphysis to carry the carpus. In order to achieve best functional results, four-step operative protocol was performed for reconstruction; lengthening of the forearm by external fixator, radioulnar transposition to create a one-bone forearm, plate removal and transposition of brachioradialis to the extensor pollicis longus as well as proximal row carpectomy. After nine years of the last operation, the function of the elbow and hands is good with acceptable cosmetic result. The forearm is 5 cm shorter and there has been a persistent mild limitation of palmar flexion. CONCLUSION: Creation of the one-bone forearm normalizes the elbow and wrist function, corrects forearm malalignment, and improves forearm growth potential.

[Friedrich von Esmarch--surgeon, one career].

Friedrich von Esmarch was born in 1823 in Germany and he is one of the greatest surgeons of the Germany of that time. Fridrich von Esmarch introduced the Esmarch tourniquet, which enables operative field bloodless. This revolutionary innovation is still present in the orthopaedic surgery all around world, as well as for the first line hemostasis. Beside this, Esmarch also improves others fields of surgery: immobilizations, methods of antiseptic surgery, modified Esmarch mask for anesthesia. He joined few wars and had a rang surgeon-general. Although his experience was primary from the trauma, he also introduced the training courses of the First aid for the ordinary people, making medicine of that time more modern and efficient

[Medial subtalar dislocation--case report].

INTRODUCTION: Subtalar dislocation (SI) is a term that refers to an injury in which there is dislocation of the talonavicular and talocalcanear joint, although the tibiotalar joint is intact. CASE OUTLINE: A case of medial subtalar dislocation as a result of basketball injury, so-called "basketball foot", is presented. Closed reposition in i.v. anaesthesia was performed with the patient in supine position and a knee flexed at 90 degrees. Longitudinal manual traction in line of deformity was carried out in plantar flexion. The reposition continued with abduction and eversion simultaneously increasing dorsiflexion. It was made in the first attempt and completed instantly. Rehabilitation was initiated after 5 weeks of immobilization. One year after the injury, the functional outcome was excellent with full range of motion and the patient was symptom-free. For better interpretation of roentgenogram, bone model of subtalar dislocation was made using the cadaver bone. CONCLUSION: Although the treatment of such injury is usually successful, diagnosis can be difficult because it is a rare injury, and moreover, X-ray of the injury can be confusing due to superposition of bones. Radiograms revealed superposition of the calcaneus, tarsal and metatarsal bones which was radiographically visualized in the anterior-posterior projection as one osseous block inward from the talus, and on the lateral view as in an osteal block below the tibial bone. Prompt recognition of these injuries followed by proper, delicately closed reduction under anaesthesia is crucial for achieving a good functional result in case of medial subtalar dislocation.

[Vasculature of the distal part of optic nerve].

BACKGROUND/AIM: Vascularisation of the distal, namely intracranial and intracanalicular parts of the optic nerve have not been explained in conventional textbooks of anatomy, while there have been explanations of proximal, that is intraorbital segment. The aim of this research was to study the pattern of arterial supply of the intracranial and intracanalicular part (the distal part) of human optic nerve. METHODS: The optic nerve and the ophthalmic artery (OA), predominately in their intracranial and intracanalicular parts, were investigated in 25 human specimens by three different methods: macroscopic, stereomicroscopic, and histological observations. Mixture with 10% of India ink and gelatin was injected through the intracranial part of the internal carotid artery, and the most proximal part of the OA. Each optic canal specimen was fixed in formaldehyde and finally paraffin embedded, sectioned, and stained with Masson trichrome, Azan, Toluidin blue, and Van Gieson methods. RESULTS: OA passed through the optic canal within the dural sheath of the optic nerve. In 44% of our specimens the OA was on the inferomedial side of the optic nerve at the entrance point to the optic canal. OA left the optic canal at its lateral border in the apex of the orbit in 72% of our specimens. The intracanalicular portion of the optic nerve receives arterial blood principally from the intracanalicular part of OA. OA gives one (72% of the specimens) to two branches that supply the intracanalicular part of the optic nerve. Each branch pierces the dura mater from below and then supplies the nerve through the pia mater. These arteries then terminate in a pial vascular network of continuous transverse centripetal arterioles and capillaries that surround each optic nerve. The rich anastomoses with branches of superior hypophyseal artery, from the cranial cavity, which take part in the optic nerve vascularization in its hole length, was observed. There were no intraaxial vessels in the intracranial and intracanalicular parts of the nerve in our specimens. CONCLUSION: These anatomical data offer important informations for understanding the variety of the pathology in the region of optic canal and orbito-cranial junction, and is also useful for designing operative strategies. This report indicates the delicacy and vulnerability of the intracranial and intracanalicular capillary network to traumatic disruption.

[Possible factors for ankle fractures].

BACKGROUND/AIM: Classification of ankle fractures is commonly used for selecting an appropriate treatment and prognosing an outcome of definite management. One of the most used classifications is the Danis-Weber classification. To the best of our knowledge, in the available literature, there are no parameters affecting specific types of ankle fractures according to the Danis-Weber classification. The aim of this study was to analyze the correlation of the following parameters: age, body weight, body mass index (BMI), height, osteoporosis, osteopenia and physical exercises with specific types of ankle fractures using the Danis-Weber classification. METHODS: A total of 85 patients grouped by the Danis-Weber classification fracture types were analyzed and the significance of certain parameters for specific types of ankle fractures was established. RESULTS: The proportion of females was significantly higher (p < 0.001) with a significantly higher age (59.9 years, SD +/- 14.2) in relation to males (45.1 years, SD +/- 12.8) (p < 0.0001). Type A fracture was most frequent in the younger patients (34.2 years, SD +/- 8.6), and those with increased physical exercises (p = 0.020). In type B fracture, the risk factor was osteoporosis (p = 0.0180), while in type C fracture, body weight (p = 0.017) and osteoporosis (p = 0.004) were significant parameters. CONCLUSION: Statistical analysis using the Danis-Weber classification reveals that there are certain parameters suggesting significant risk factors for specific types of ankle fractures.

[Angiosome of the fibular artery as anatomic basis for free composite fibular flap].

INTRODUCTION: The free osteoseptocutaneus fibular flap is, anatomically, an angiosome of the fibular artery. Knowledge of detailed topography anatomy of the fibular artery and its branches is necessary for successful creation and elevation of the flap. OBJECTIVE: The aim of the study was to determine topography of the tissue of the leg supplied only by the fibular artery, to describe topography relations of the branches of the fibular artery, their number, anastomoses, vascular plexus and the way of vascularization of the skin, muscle and bone tissue. METHOD: The popliteal artery was cannulated in 15 cadaveric legs, flushed with ink and then with 10% ink-gelatin. Fixation of tissue was performed with formalin and then micropreparation of the side branches of the fibular artery was performed. Also, two corrosive models were made. Localization of foramen nutrition was determined by measuring 50 fibulas. RESULTS: The skin supplied by the fibular artery forms distal two thirds of the lateral-posterior aspect of the leg. Vascularization of the skin arises from the side branches of the fibular artery forming a rich fascia plexus at the deep fascia level. From 3 up to 7 side branches of the fibular artery are incorporated in the fascia arterial plexus and can be separated as septocutaneus and myocutaneus, according to topography relations. The nutritive artery enters the fibula cortex at a spot that, measured from the top of the fibula, lies in the area between 32% and 65% of the whole length of the fibula. Periosteal circulation of the fibula originates from the short side branches of the fibular artery that anastomoses at the periosteum level. CONCLUSION: The axial line of flap has to be marked 2 cm posterior to the line from caput fibulae to malleolus lateralis. Numerous anastomoses between the side branches of the fibular artery in the fascia plexus enable good circulation of the skin even when some of the branches are not included in the flap. The middle third of fibula has to be used as bone graft because of localization of the foramen nutrition.

Free fibula and corticocancellous bone grafting for salvage of a war-injured forearm.

The treatment of a complex forearm injury inflicted by a wartime mine explosion is presented in this study. Apart from the soft tissue damage, a 4-part fracture of the radius and loss of 19 cm of the ulnar diaphysis were present along with lesions of the median and ulnar nerves. The radial pulse was intact. The first formal treatment of the wounding consisted of extensive soft tissue and bone debridement and external fixation of radius with an additional intramedullary K-wire. After wound closure was obtained, a free vascular fibula grafting of the ulna and corticocancellous bone grafting of the radius were performed. Bone union of both the radius and ulna was subsequently achieved and 9 years after the injury, the patient has full flexion and extension of the elbow, full pronation and 70% of supination. Motion of the wrist is limited because of an ulnar plus variant of the distal radioulnar joint. Hand function is still limited by chronic low-moderate median nerve palsy, but the ulnar nerve has recovered completely. The patient is able to pinch, has full finger extension and can make a fist. He is satisfied that he made the correct decision in not having an initial amputation for his injury.