The antinociceptive efficacy of morphine-ketamine-magnesium combination is influenced by the order of medication administration.

OBJECTIVE: Ketamine and magnesium, both N-methyl-D-aspartate (NMDA) receptor antagonists, enhance the antinociceptive effects of opioid analgesics in different animal models of pain, as well as in humans. This study aimed at evaluating whether magnesium sulphate added to morphine-ketamine combination produces a higher level of analgesia. MATERIALS AND METHODS: Analgesic activity was assessed by tail-immersion test in male Wistar rats (200-250 g). RESULTS: Magnesium sulphate (0.5-60 mg/kg, s.c.) and ketamine (5-30 mg/kg, i.p.) administered alone did not produce any effect. Magnesium sulphate (5 and 60 mg/kg) and ketamine (5 and 30 mg/kg) increased the antinociceptive effect of morphine (2.6 mg/kg, i.p.). Magnesium sulphate (5 mg/kg) increased the antinociceptive effect of the morphine (2.6 mg/kg)-ketamine (2.5 or 5 mg/kg) combination when magnesium sulphate was added to morphine after, and not before ketamine. It is also demonstrated that magnesium sulphate prolonged the duration of the antinociceptive effect of the morphine-ketamine combination. Low dose of morphine (2.6 mg/kg), ketamine (5 mg/kg) and magnesium sulfate (5 mg/kg) given together did not cause motor impairment that could be verified on a rotarod test. The antinociceptive effect of the triple combination was readily antagonized with naloxone (3 mg/kg, s.c.), a nonselective antagonist of opioid receptors, indicating that the effect is mediated via opioid receptors. CONCLUSIONS: This study revealed that the efficacy of the morphine-ketamine-magnesium sulphate combination in tail-immersion test in rats is influenced by the order of medication administration; a higher level of activity is demonstrated only when ketamine is added to morphine before magnesium sulphate.

A synergistic interaction between magnesium sulphate and ketamine on the inhibition of acute nociception in rats.

OBJECTIVE: Magnesium is an endogenous voltage-dependent NMDA receptor-channel blocker and ketamine is a non-competitive NMDA receptor antagonist. Magnesium may potentiate the effect of ketamine in analgesia and anaesthesia, but may also interact in an opposing manner. This study aimed at evaluating type of the interaction between magnesium sulphate and ketamine administered systemically in rats with an acute nociceptive pain (tail-immersion test). MATERIALS AND METHODS: Analgesic activity was assessed by tail-immersion test in male Wistar rats (200-250 g). The distal 5 cm of the tail was immersed in a warm water bath (55 ± 0.5°C) and the time for tail-withdrawal was measured as response latency. RESULTS: Magnesium sulphate (2.5-30 mg/kg, s.c.) and ketamine (2.5-30 mg/kg, i.p.) administered alone did not produce any effect. However, significant antinociception (synergistic interaction) was revealed at the following doses of ketamine: magnesium sulphate of 5:5 mg/kg, 2.5:5 mg/kg and 10:5 mg/kg. The effect was not dose-dependent, and a greater response was obtained when ketamine was administered before magnesium sulphate. CONCLUSIONS: This study revealed that (1) magnesium sulphate and ketamine given alone were not effective against acute nociceptive pain in rats, but (2) a combination of both drugs resulted in synergistically inhibited nociception, (3) which occurred only at selected low doses and proportions of the medications in a combination and (4) suggested the importance of the order of drug administration.

[Complications on skin and subcutaneous tissue among drug addicts caused by non sterile intra venous injections and burns].

The use of psychoactive substances causes various consequences and is harmful for all organs. Some of the health consequences among intravenous drug users are HIV infections, hepatitis C, local tissue infections after drug injection, family, professional and social consequences. Throught the world various harm reduction programs are established in order to educate drug users about safer drug injecting techniques, with the use of sterile needles and materials for disinfection of the drug injecting area. Authors presented epidemiological data, consequences on extremities after non sterile drug injecting and accidental burns, harm reduction programs as well as other guidelines in this field. In three case reports of intravenous drug addicts with surgical complications on the extremities and burns, surgical and anaesthesiological approaches were described. Special emphasis was given to preoperative preparations and the postoperative treatment as well as social-psychiatric aspect.

["I am sorry, I have bad news... "- principles in informing patients on the gravity of a disease and the treatment].

The discovery of the appearance of a serious disease, and the necessity for diagnostics, treatment and rehabilitation, particularly when malignity is involved, represents exceptionally stressful news for the patient and his family. Most often this is a task for the physician. In this paper the authors consider the meaning of bad news in unexpected life events which significantly disturb the individual psycho-social ballance of the patient, as well as the familly dynamics and structure. It presents a review of available literature on the subject of the definition of so-called "bad news", the development of approaches in announcement, and current practical approaches and models which assist physicians in helping suffering patients in professional and humane ways. It points out inadequacies in the education of phisicians for this kind of task, and the variety of approaches. With the aim of improving the education of phisicians, and especially clinicians in surgical fields, the authors recommend a number of educational programs: education in the area od psychological and psychiatric aspects of learning of a serious disease, including acute reactions such as depressive states, reactive psychotic states, consumption of alcohol, etc.; education in the area of the family life cycle, and the effect of the disease as an unexpected life crisis on the family dinamic; education in the area of fundamental principles of psycho-and pharmaco-therapy, as well as the provision of support to the patient and his familly; training in the skills of announcing bad news to the patient and his familly through the explanatory presentation of the case and supervised simulation of sessions.

Our first experience with extended proximal femoral osteotomy for revision hip surgery.

INTRODUCTION: The extended proximal femoral osteotomy (EPFO) is a demanding but useful technique for revision of both cemented or noncemented femoral components. MATERIALS AND METHODS: Between 2000 and 2004 we performed extended proximal femoral osteotomy (EPFO) in 25 cases during revision hip surgery. The main indication for doing revision surgery was aseptic loosening of both total hip arthroplasty (THA) components (18 patients), whilst in the remaining 7 patients the indications were: aseptic loosening of acetabular component in three patients, septic loosening of THA in two patients, recurrent dislocation of the THA because of incorrectly positioned femoral component in one patient and aseptic loosening of cemented hip hemiarthroplasty in one patient. RESULTS: There were 14 women and 11 men. The mean follow-up was 22 months. The average time to revision was 8.3 years. The mean age at the time of revision was 70.3 years (range 55 to 81). At the time of the last control examination all osteotomy sites had healed with signs of remodelling. The mean time to union ranged from 11 weeks to 6 months, shown by the bridging callous formation in both radiographic projections. Bone remodelling occurred in all patients by 12 months and no complications such as nonunion, excessive fragment migration or wire breakage were found. CONCLUSION: In our experience, the extended proximal femoral osteotomy when properly indicated represents an efficient and reliable technique in revision hip surgery.

[Developmental dislocation of the hip is still important problem--therapeutic guidelines].

The authors are describing currently important problem--developmental dislocation of the hip. Guidelines for the treatment have been given according to literature date and upon their own experience. Therapeutic suggestions for the first twelve months of life are based on the ultrasound typing--it is advised to perform nonoperative treatment (abduction devices, "over head" traction, Pavlik harnesses). During the second year of life a pause in the treatment should be adviced in order to avoid postreduction avascular hip necrosis as a very important complication. After that period surgical treatment has to be done (open reduction, pelvic and femoral osteotomies). Special suggestions have been given for the treatment of consecutive leg length inequality and the deformities caused by postreduction avascular hip necrosis.

[Digital video technology in orthopedics].

Digital video technologies are new and powerful tools with wide applications in orthopaedics. Already integral to several common medical devices, digital images can be used for case documentation and presentation as well for diagnostic and surgical patient care information. Digital technologies allow easy manipulation of photographic, video and graphic materials in ways that were impossible with conventional techniques. Educational presentation has been transformed by use of computers and digital projectors. Understanding the basic foundations of digital imaging technology is important for effectively creating digital images, videos and presentations. In this review, we are going to discuss some of the issues that are raised by digital imaging in orthopaedics, digital image processing, as well as, we are giving some recommendations for good quality of pre-, post- and intra-operative photographs in clinical use.

[Functional and radiographic results in partial unipolar hip joint arthroplasty after 6-15 years].

Due to extreme conditions during civil war in early 1990's we were forced to deviate from accepted guidelines in treatment of intracapsular fractures of the femoral neck. Therefore, majority of patients were treated non-operatively. In those that were subjected to surgery, unipolar hemiarthroplasty was treatment of choice, since conditions permitted us to attempt osteofixation in very few, youngest of our patients. As a result of this practice born of necessity, we can now look back and learn from this unique experience.

[The influence of duration of Kleinert immobilization on the functional recovery of primarly reconstructed flexor tendons in children and adult patients].

Flexor tendon repair in the hand is very often complicated by the formation of peritendinous adhesions that result in loss of normal tendon gliding, digital stiffnes and functional disability. While stability is critical for a successful tendon repair, mobility is also important, as motion of the repaired tendon decreases the formation of postoperative adhesions and increases the strength of the repair. Immobilization and its duration, can ensure the integrity of the repair but can also lead to scaring, stiffness, and joint contractures. This study included 20 children and 39 adult patients, in the period from January 2000 to April 2003., with flexor tendon ruptures of the hand. Tendons were primary repaired using direct tennoraphy, and postoperately patients were treated with Kleinert dynamic imobilization. The aim of this study was to investigate the influence of the duration of the dynamic immobilization on successful postoperative functional recovery, separately in children and adult patients. Research in this area has been directed at achieving the optimal balance between stability and mobility, without compromising one for the other.

[Implementation of the radiolabelled antibiotic in the detection of orthopedic infections].

The aim of the study is detection and evaluation of the orthopedic infections using 99mTc-ciprofloxacin, radiopharmaceutical supposed to distinguish inflammation from infection. There were 15 true positive findings, 9 true negative, and two were false positive, while 1 was false negative. Sensitivity was 94%, specificity 82%, positive predictive value 88%, negative predictive value 90% and accuracy 89%. According to our results, scintigraphy with 99mTc-ciprofloxacin is a useful method for detection and assessment of exact localization of orthopedic infections, which might be useful for (differential) diagnosis, surgical treatment in due time as well as monitoring of the treatment of conservative therapy.

[Principles and new methods of flexible fixation of fractures of long bones]. / Aktuelni principi i neke od novih metoda fleksibilne fiksacije preloma dugih kostiju.

The modern developments in orthopedic traumatology brought various modifications of modes and principles in operative fixation of fractures. Contrastingly to previous concept of rigid fixation as a priori necessary element for complete fracture union, a principle of flexible or elastic fixation took an equal place in contemporary professional doctrine. The results of these changes were technological innovations of fixation implants, with their mechanical characteristics as a base for their biological application that promoted essential advancements in fracture treatment and full functional recovery of injured patients. We review in this paper the modern principles and some new implant generations in flexible fracture fixation.

[Incidence and severity of degenerative changes in the wrist in pseudoarthrosis of the scaphoid bone]]. / Ucestalost i intezitet degeneracionih promena zgloba rucja u pseudoartrozi skafoidne kosti.

INTRODUCTION: In patients with symptomatic scaphoid nonunion there was an increased evidence of progressive osteoarthrosis expressed as instability of the wrist [1, 2]; it is defined as a scapholunate angle of more than 70 degrees or a radiolunate angle of more than 10 degrees. Intercarpal instability causes unnatural joint movement of the wrist. This disorganization of the wrist mechanism associated with hypermobility of the schapoid bone induces degenerative changes [3]. Arthritic changes begin at the distal scaphoid-radial styloid joint and later progress to the capitolunate joint. A similarity was noted with rotatory instability of the scaphoid bone associated without fracture [2]. If mid-carpal joint exists the joint becomes unstable, the lunate rotates backwards and carpal bones show the so-called concertina deformity [4] or dorsal intercalated segment instability pattern [5]. AIM: We tried to determine the factors of risk and prognostic indicators of degenerative arthritis. METHOD: In this study 40 patients with painful nonunion of the scaphoid bone were analysed. Duration of nonunion was 1.43 year (range from 8 months to 15 years). Roentgenograms of the hand were done in anteroposterior, lateral and oblique projections. Fracture location and configuration were determined as described by Russe. Instability was determined by measuring the scapholunate and radiolunate angle in the lateral roentgenogram. Scapholunate angle more than 70 degrees and radiolunate angle more than 10 degrees were considered abnormal. To asses the amount of carpal collapse the carpal index was determined as described by Youm [6]. Abnormal value was 0.50 or less (normal value: 0.54 +/- 0.03). Four roentgenographic groups were established based on the extent of degenerative changes [7]. Group I showed no sign of degenerative changes. Group II had sclerotic lesions in fracture margins with or without a cystic formation. Group III showed lesions of radioscaphoid arthritis, including joint-space narrowing and pointing the radial styloid. Group IV had lesions of generalized arthritis of the wrist. RESULTS: Duration of nonunion was not in correlation with development of osteoarthritic changes (p = 0.644, p > 0.05) (Table 1). Progressive degenerative changes correlated well with radiolunate angle (p = 0.398, p < 0.05), capitolunate angle (p = 0.381, p < 0.05) and carpal index (p = 0.392, p < 0.05) (Table 2). The average values of intercarpal angles increased with progression of osteoarthritic changes (Table 3). There were 14 (35%) proximal third located fractures and 26 (65%) in the middle third or waist. There was a statistically strong correlation between location of the fracture in proximal third and presence of degenerative changes (p = 0.341, p < 0.01) (Table 4). Intensity of arthritic changes showed no statistically significant correlation regarding untreated fractures (p = 0.665, p > 0.05). DISCUSSION: In our study the most significant factors associated with arthritis were instability of the wrist and fracture location at the proximal third of the scaphoid bone. Mack [7] reviewed forty-seven symptomatic nonunions of the scaphoid and found a correlation between the presence of arthritis and the duration of nonunion. Also, he concluded that instability of the wrist can occur as late phenomenon in previously stable nonunion. Similar results were noted by Ruby [8] in his series. Conclusion of these authors was that the incidence of degenerative changes increased with the time after fracture of the scaphoid bone occurred [8-12]. We demonstrated that in untreated fractures associated with carpal instability, arthritis developed much earlier. Fourteen (35%) patients in our study were not treated and 92.8% belonged to Group II and Group III, with average time of nonunion duration of 27.2 months. Lunate dorsiflexion is a useful guide to carpal instability. In our experience the lunate silhouette is easily visualized on a lateral roentgenogram even in the presence of degenerative arthritis. There is a high probability that degenerative changes will occur. We recommend that a scaphoid nonunion associated with carpal instability should be operated before degenerative changes develop.

[Pseudoarthrosis of the scaphoid bone associated with carpal collapse: factors in choice of surgical approach]. / Pseudoartroze skafoidne kosti udruzene s kolapsom rucja: faktori od znacaja za izbor operacionog postupka.

INTRODUCTION: The most common fracture involving the wrist is a fracture of the scaphoid bone [1], and only 5% to 10% of these fractures proceed to nonunion. Although not symptomatic initially, most (if not all) nonunions later produce a painful wrist with impaired function, clinically significant loss of motion, increased weakness and degenerative arthritis. Nonunion of the scaphoid bone should be treated by open reduction and internal fixation. Many surgical procedures have been advocated to achieve union. Most widely used technique for the treatment of scaphoid nonunion was described by Russe [2], but this method may overcome the flexion deformity of the scaphoid and carpal deformities. The ununited scaphoid usually undergoes resorption of the fractures surfaces, principally over the anterolateral aspect of the fracture, so that the scaphoid becomes misshapen. The restoration of the exact length and form is enabled by insertion of a tight-fitting trapezoidal corticocancellous graft, a technique described by Fernandez [11]. AIM: We analysed the results of treatment of scaphoid nonunion utilized by two bone-grafting techniques and pointed out the need of choice of the best operative method. METHODS: From 1977 to 1993, at the Institute of Orthopaedic Surgery and Traumatology in Belgrade, 40 patients were surgically treated for symptomatic nonunion of the scaphoid bone. The mean duration of follow-up was 10.2 years (range, from 6 to 22 years). Eighteen (45%) patients were operated by Fernandez technique and 22 (55%) patients were operated using Russe's technique. Volar approach and Kirschner's wire fixation were performed in both operative methods. We used two rating scales proposed by Cooney [13] to evaluate the results. Objective scale (Table 1a) included the radiographic appearance of the wrist, the range of motion and grip strength. Subjective scale (Table 1b) comprised function, pain perception of a decrease in performance because of limited motion or strength, and satisfaction. These scales were used to compare the objective and subjective results in patients who had postoperatively carpal collapse with the results in patients who had not such deformity. RESULTS: The union rate was 92.5% in both methods. Russe's technique resulted in union in 20 (91%) of 22 cases with two ununited. Fernandez technique achieved union in 17 (94%) of 18 cases. Fracture union was determined by both clinical and roentgenographic examinations. Correction of the lateral interscaphoid angle was obtained in 14 (82%) patients operated by Fernandez technique and 9 (45%) patients operated by Russe's technique. Correction of dorsal tilt of the lunate were achieved in 6 (30%) patients operated by Russe's technique, and 13 (76.6%) patients operated by Fernandez technique. There was a highly significant correlation (p < 0.01) between increased deformity of the scaphoid and extent of carpal collapse (Graph 1). Also, there was significant difference between two operative techniques regarding correction of lateral interscaphoid angle (p < 0.05). Arthrosis of the wrist was present in all patients. We could not demonstrate a significant difference (p > 0.05) between intensity of degenerative changes and increase of lateral interscaphoid angle, but obviously, the large flexion deformity of the scaphoid the worse intensity of degenerative changes (Graph 2). The grip strength significantly increased after Fernandez technique (p > 0.05) (Graph 3), but wrist motion changed a little. The average objective score was 71 points for the patients in whom the lateral interscaphoid angle was 45 degrees or less, and 63 points for those in whom the angle was more than 45 degrees. This difference was significant (p < 0.05), but we could not demonstrate a significant difference between the two groups in terms of the average subjective score. DISCUSSION: In our series, both procedures provided a high union rate [2]. In cases with severe scaphoid shortening and flexion deformity, Russe's procedure has proved to be insufficient to restore anatomic length and correction of carpal alignment [6, 11, 17]. Previous authors have reported that the progression in degenerative changes was slower in patients who had a lateral interscaphoid angle less than 45 degrees [13]. Also, grip strength and range of motion increased in patients in whom flexion deformity of the scaphoid had been corrected [2, 4, 6, 16, 17]. Our study supports these findings, except results regarding the movement. We believe that this was due to postoperative scarring. Discrepancy between the subjective and objective results may have been due to postoperative relief of pain obtained by increased carpal stability or decreased range of motion of the carpal joints due to postoperative scarring. If pain is relieved, patients readily adapt to the functional deficit of decreased range of motion. We concluded that angulatory collapse of the scaphoid resulted in nonunion as well as malunion with secondary functional loss. Recognition and avoidance in acute fractures were important. When recognised late, volar wedge grafting appeared to be a satisfactory method of treatment.

Avulsion injuries of the thumb.

Avulsion amputations of the thumb are generally thought to have a worse prognosis after replantation than other amputations. We report the results of 17 thumbs that had an avulsion amputation and were replanted. Fourteen of the 17 survived (82 percent). Our experience indicated that the survival rate was improved by restoring continuity of at least two veins and two arteries, using a Y-shaped vein graft and the princeps pollicis artery for the source of arterial circulation. Nerve grafts were used to bridge defects in avulsed digital nerves. When possible, avulsed tendons were reattached to their muscle. Key pinch strength was 60 percent of normal, and grip strength was always less than that of the normal hand. The age of the patients and the cold ischemia time had no significant effect on either survival or function of the replanted thumb. When excellent venous backflow occurred immediately after the vessel repair and continued for at least 20 minutes, the thumb always survived without complications.