One-stage reconstruction of war wounds with free osteocutaneous flaps.

Thirty-one patients with traumatic osteocutaneous defects of the extremities sustained during the war in Croatia and Bosnia and Herzegovina were treated at the Institute of Plastic-Reconstructive and Breast Surgery in Zagreb. Injuries were categorised using the Mangled Extremity Syndrome Index (MESI). The average length of bone defect was 5.9 cm (range 4-12 cm). Patients were divided in two groups according to the time they had reconstruction with a free osteocutaneous flap: group 1, within 6 days after injury, and group 2, after more than 6 days. The mean time to reconstruction in group 2 was 5.2 weeks. Average time to solid bone union was 13.3 weeks in group 1 and 16.6 weeks in group 2. Functional outcome was better in group 1 with fewer complications, smaller number of operations and shorter hospital stay. One-stage reconstruction of osteocutaneous defects with free composite flaps provides reliable treatment solution with good functional outcome.

Wound infection after median sternotomy during the war in Croatia.

From 1990 to 1994 at Clinical Hospital Center, Zagreb, 1904 median sternotomies were performed for cardiac operations. Patients shared the same intensive care unit (ICU) with the wounded persons, admitted to the hospital from battlefield. Infection developed in 124 patients, an incidence of 6.51%. Methicillin resistant Staphylococcus aureus (MRSA) was isolated from 90, methicillin resistant Staphylococcus epidermidis (MRSE) from 19, and gram negative bacilli (GNB) from 56 patients, Pseudomonas aeruginosa in 2, and Clostridium pneumoniae in 1 case. Ninety-six patients (5.04%) developed superficial localized infection of subcutaneous tissues and they were treated with frequent dressing changes with antibiotic-soaked gauze in combination with systemic antibiotics. Twenty-eight patients (1.47%) developed mediastinitis and sternal dehiscence. They were treated by operative debridement followed by reclosure of the sternum with continuous antibiotic irrigation. We obtained satisfactory results with our method of closure of sternum which is a modification of Robicsek's technique. Nine of them required further operation. In seven cases we performed muscle flaps and in two omentoplasty. One hundred and twenty patients were discharged in satisfactory condition. The uncontrolled mediastinal sepsis caused death in 4 patients. Higher infection rate after median sternotomy during 1991 and 1992 could be possibly explained with the war circumstances in Croatia, and especially with MRSA strain becoming endemic in surgical ICU.

[Reconstruction of the cervical esophagus with free autotransplantation of the jejunum--direct monitoring of viability]. / Rekonstrukcija vratnog jednjaka slobodnim autotransplantatom jejunuma--izravno pracenje vitalnosti.

Although free jejunum transfer has become an accepted form of hypopharyngeal reconstruction, an ideal method of monitoring the viability of the graft has not been devised yet. The method of direct visualisation through the incision in the skin above the transferred jejunum has proven very reliable and easy to perform, especially for the nursing staff. This reliable method of monitoring free vascularised jejunum to the neck region has been used in two patients. After two days of direct monitoring, the incision in the skin healed without additional sutures. No failures of the graft occurred, and 12 days later the patients were able to swallow fluids without difficulty. The effectiveness of this technique has surpassed that of all previously published methods.

The management of war wounds to the extremities.

We present our experience in the treatment of war wounds in 174 patients treated in the Institute of Plastic and Reconstructive Surgery, Department of Surgery, Clinical Hospital Center in Zagreb. The wounds were divided into four categories depending on the type of injury and the extension of the soft tissue defect which showed the differences in primary excision and reconstruction of wounds. Patients were placed in one of two groups depending on their primary treatment and time of definitive reconstruction. Group A comprised 79 patients who were initially treated by plastic surgeons and whose reconstructive procedure was done within five days. Group B comprised 95 patients who were initially treated in a field hospital and referred later to the plastic surgery unit for definitive reconstruction more than five days after the injury. Sixty-nine (87%) of the patients in group A had only one or two debridements before definitive closure and stayed in hospital 20 days or less. In group B, 59 (62%) of the patients required three or more debridements before definitive closure and remained in hospital more than 21 days (p < 0.001). Proper primary treatment and early reconstruction result in significantly shorter duration of hospital stay and lead to more effective rehabilitation and recovery of the patients. A knowledge in terminal ballistics is important in the understanding of the pathophysiology of war wounds.

War wounds management--early reconstruction of soft tissue defects.

The authors emphasize that the knowledge of terminal ballistics is important for understanding the pathophysiology of war wounds. They present their own experiences in the treatment of war wounds in 504 casualties treated at the Institute of Plastic and Reconstructive Surgery, Department of Surgery, Clinical Hospital Center in Zagreb. The locations of soft-tissue defects were: head and neck, 103; trunk, 90; and extremities, 903. War wounds were divided into four main categories with regard to the type of the injury and the extension of soft-tissue defect, thus showing the differences in primary excision and reconstruction of the wounds. About 30% of head and neck injuries were treated by primary or delayed primary reconstruction. All thoraco-abdominal wounds were type I or II, and most of them (53.3%) were reconstructed with split-thickness skin grafts. The greatest number of sophisticated reconstructions were performed on extremity injuries (63 wounds were reconstructed by local flaps, while free flaps were used in 40 cases). The authors emphasize the importance of proper primary treatment, which is the condition for early reconstruction. This results in significantly shorter hospitalization, so that 62% of the patients were cured in 20 days and then discharged to early rehabilitation.

[Surgical management of war injuries involving soft tissue defects]. / Kirurski postupak kod ratne rane s manjkom mekog tkiva.

In this article, the authors emphasize that the knowledge of terminal ballistics is important for understanding of the pathophysiology of war wounds. They present their own experiences in the treatment of war wounds in 126 casualties, treated in the Institute of Plastic and Reconstructive Surgery, Department of Surgery, Clinical Hospital Center, Zagreb. About 96% of the wounded sustained extremity injuries, while head, neck and thoracoabdominal injuries appeared in a significantly smaller number of cases. War wound were divided into four main categories with regard to type of injury and extension of soft-tissue defect, thus showing the differences in primary excision and in reconstruction of the wounds; 78.6% of head and neck injuries were treated by primary or early primary reconstruction (within three to five days after the injuries have been sustained), while 45.4% of thoracoabdominal injuries were treated by a secondary closure. The greatest number of sophisticated reconstructions were used in extremity injuries (15 wound were reconstructed by local flaps, while free flaps were used in 8 cases). The authors emphasize the importance of proper primary treatment which enables an early reconstruction. This results in significantly shorter hospitalization, so that 87.5% of patients were treated within 20 days and then transferred to early rehabilitation.

High-energy war wounds: flap reconstruction.

In this article, we emphasize that knowledge of terminal ballistics is essential for understanding the pathophysiology of war wounds. We present our own experiences in treatment of high-energy war wounds in 75 patients treated in the Institute of Plastic and Reconstructive Surgery, Department of Surgery, Clinical Hospital Center in Zagreb. Patients were divided into three groups with regard to the time of definite reconstruction, using local or free microvascular flaps. About 12% of patients underwent flap reconstruction in the acute phase, associated with low complication rate and the shortest hospital stay. Group II was comprised by 18% of the patients and, considering the number of complications, presented the most unfavorable time for reconstruction. Flap reconstruction in the chronic phase resulted in a substantial prolongation of the hospital stay in 82% of patients. Therefore, we advocate proper primary treatment of wounds aimed at early flap closure. This type of management results in a significantly shorter hospitalization and leads to more effective rehabilitation and recovery of patients.

[Microdochectomy with perioperative dye localization of ducts in patients with nipple secretion]. / Mikrodohektomija s perioperativnim bojenjem izvodnih kanala kod sekrecije iz dojke.

A series of 1321 women having a discharge from the nipple were examined at the outpatient clinic. Of seven basic types of discharge: milky, multicolored, purulent, watery, yellow (serous), serosanguineous and bloody, only the last four represent and indication for surgery. Galactography was performed in 55 patients as a necessary element in the surgical plan of management. In 36 women, the operation of microdochectomy was indicated, but only 24 accepted to be subjected to that procedure. The authors describe a new technique of colour mammary ductal localization which identifies the duct from which the discharge is emerging and assures its complete excision. The procedure combines preoperative methylen blue dye injection followed by periareolar incision of the involved duct using a pair of binocular loops for magnification of the nipple. In all tissue specimens, the cause of a pathological discharge was found: 15 (62.5%) cases presented with fibrocystic disease, and in 6 carcinoma was present. This technique provides a safe and effective method of complete excision of the pathologically involved mammary duct with good cosmetic results.

[Developmental and involutional breast disorders]. / Razvojna i involucijska poremecenja dojke.

The majority of benign breast disorders may be classified as developmental and involutive. Mastalgia and breast nodularity represent the greatest groups of these disorders, while epithelial hyperplasia is a complex benign disorder which is most difficult to be evaluated. Sixty women with diagnosis of cyclic mastalgia and 30 with noncyclic breast pain were followed-up. Patients were administered bromocryptine, danazol or a local progestogel. Better treatment results were achieved in cyclic mastalgia than in women with noncyclic mastalgia. One hundred and forty-five biopsies of the benign breast tissue were examined histologically. Nonproliferative forms were found in 66.9% of the women, proliferative without atypia in 29.65%, and proliferative with atypia in 3.45% of the patients. Atypical ductal hyperplasia and atypical lobular hyperplasia increase four-to fivefold the risk for breast cancer. Prophylactic subcutaneous or total mastectomy is not as a rule indicated in atypical epithelial hyperplasia, only regular follow-up is required.

[Transplantation of the peripheral nerves]. / Transplantacija perifernih zivaca.

The development of microsurgery made possible neurorrhapy of even very tiny peripheral nerves. In case of a transsection of a nerve without a defect or with a minor one up to 15 mm, approximation of stumps can be done directly. Larger defects are bridged with autogenous nerve grafts. In order to avoid this, novel technics like cadaveric allogenous grafts or using veins and small tubes of absorbable materials as a guiding rail have been introduced. For purpose of this degenerated muscle grafts are being also applied.

[An anatomic study of the septofascial layer in the forearm]. / Anatomsko istrazivanje septofascijalnog sloja podlaktice.

In the anatomical investigation the authors dissected 20 fresh cadaveric forearms to study septofascial layers. It's vascularization was based on radial artery and concomitant veins. We perfused those flaps with methylene blue in the proximal part of radial artery. In 10 cases we found fine vascular network colored in blue. In the second group we isolated free septofascial tissue which was perfused with radiopaque contrast Hexabrix. Five flaps were perfused in the proximal part of vascular pedicle and five in the distal part. Afterwards the radiographs confirmed good vascular network, independent of flow direction. Fascia dimension in the proximal part of the forearm varied from 7-15 cm and in the distal part from 6-10 cm, depending on the forearm size. Fascia length varied from 21-27 cm. The authors found thicker and stronger fascia in the ulnar part of the forearm. The length of vascular pedicle was reversely proportional with the flap dimension. This anatomical investigation may find it's greatest application in plastic and reconstructive surgery.