Surgical treatment of patients with penetrating chest injuries sustained in war.

AIM: To show our experience in treatment of patients with penetrating chest injuries sustained during the Homeland War in Croatia METHODS: It was a retrospective study based on the records of the Department of Surgery of the University Hospital of Osijek (Croatia). All patients surgically treated during the wartime period (1991.-1995.) were analysed with respect to death rate, causes of injuries, frequency of injuries of thoracic organs and frequency of combined injuries of thorax and abdomen. Most of our patients were treated with thoracotomy as opposed to the common protocol (thoracostomy) applied in usual treatments. RESULTS: The study includes 157 patients with penetrating chest wounds, 111 (70.7%) of which were from metal fragments of bursting artillery, 37 (23.6%) of the wounded were exposed to gunshot bullets, and 9 (5.7%) had stab injuries. Lung injuries had 134 (85.4%) patients, and 15 (9.6%) had injuries of the heart. Chest injuries combined with injuries of abdominal organs happened in 30 (19%) cases. The abdominal organs in question were the liver, spleen, stomach, and colon, in eight (26.6%), seven (23.3%), four (13.3%), and three (10.0%) cases, respectively. Thoracotomy was performed in 144 (91.7%) cases, 13 (8.3%) of the patients underwent thoracostomy, and 134 (85.3%) patients stayed alive. CONCLUSIONS: It points out that, in our case due to organizational problems, aggressive surgical procedure of patients with penetrating chest and multiple injuries sustained in war was the good choice.

The main biomechanical risk factors for the prevalence of the left hip joint traumatic and degenerative changes.

The aim of this paper is to examine characteristic biomechanical features leading to the acetabular fracture and hip joint arthrosis, and to explain the prevalence of the left side traumatic and degenerative pelvic pathology that is usually seen in diverse groups of patients. A total of 253 patients were analyzed in a retrospective case-control study during a six-year period. The patients were divided into the case group of 103 patients suffering traumatic acetabular fractures and into the control group of 150 patients with hip joint arthrosis, where operative aloarthroplasty was not yet performed. The data of the affected hip joint range of motions in the case and control group of patients were statistically analyzed correlating the difference in frequency of the left and right hip joint pathology. The left acetabulum was affected more commonly in both groups of patients, while arthrosis of the left hip joint was more commonly recorded in the control group. More frequent pathology of the left hip joint, found in both groups of patients, was probably due to weaker neuromuscular function of the left pelvic side, which was also more exposed to injury due to the greater input of forces to the left hip joint during a traffic accident.

Intercostal catheter analgesia is more efficient vs. intercostal nerve blockade for post-thoracotomy pain relief.

A pain after thoracotomy may result in a postoperative hypoventilation and lead to atelectases and pneumonia. This study was aimed to compare two analgesic regimens after posterolateral thoracotomy. 80 patients (40-70 years) undergoing thoracotomy were randomized to intercostal catheter analgesia (group A, n = 40) and intercostal nerve block (group B, n = 40). Patients in group A were given 20 mL of 0.5% bupivacaine injections twice a day by intercostal catheter. Intercostal nerve blockade was performed using 5 mL of 0.5% bupivacaine. Intercostal nerve in thoracotomy wound, nerves below and above thoracotomy wound was also injected. PaO2, PaCO2, FVC, FEV1 and visual analog pain scale (VAS) were obtained preoperatively, 24, 48 and 72 hours after operation. Postoperative complications were recorded at the patient discharge. Differences between groups were calculated using Mann-Whitney, KW test and chi square test. The arterial blood gas analyses did not show statistically significant change in any group and time according to the baseline values. FVC and FEV1 decreased significantly in both groups at first postoperative day according to baseline measurements. Patients in B group had significantly higher FEV1 values in the third postoperative day (73.05 +/- 11.25 in A vs. 83.50 +/- 9.17 in B group, p < 0.05). Intercostal catheter analgesia resulted in significantly lower postoperative VAS scores and reduced opioid requirement as compared to intercostal nerve blockade. No differences in the postoperative complications were observed between groups.

The analysis of the unstable tibia fracture treatment applying internal stabilization method.

The study included 51 patients with tibia fractures, who underwent percutaneous bone reposition and stabilization with unrimed tibial locking nail. The results obtained using this method were compared with those obtained by standard fracture treatment where flat and anatomic plates were applied (n = 64). In patients who had osteosynthetic material implanted percutaneously (using unrimed tibial locking nail) there was no incidence of post surgical osteitis or any pseudarthrosis. The healing callus of the fracture was of lesser quality and spindle shaped, suggesting that fracture stabilization using this method was less efficient. In patients with fractures stabilized by the open method using flat and anatomic plates (n = 64), we noticed 3.1% (n = 2) cases of osteitis and 4.7% (n = 3) cases of pseudarthrosis. Due to lesser incidence of postoperative osteitis, our method of choice in tibia fractures would be percutaneous stabilization with unrimed tibial locking nail. However, this treatment method has its disadvantages, too. Fracture callus is of lesser quality and it is spindle shaped. Furthermore, there are problems with adequate percutaneous reposition in some cases, as well as necessity for radiological checking.

Tumor growth fraction, expression of estrogen and progesterone receptors, p53, bcl-2 and cathepsin D activity in primary ductal invasive breast carcinoma and their axillary lymph node metastases.

The aim of this paper is to determine similarities and differences between tumor cell subclones in cases of ductal invasive breast carcinoma, and which occupy primary tumor and local axillary lymph metastases. The tumor growth fraction evaluated by Ki-67 was analyzed along with the expression level of estrogen and progesterone receptors, protein p53, proto-oncogene protein bcl-2 and cathepsin D in 60 patients. Metastatic lymph node in axilla has a higher growth fraction of the tumor cells than the primary tumor (p = 0.045), as well as the higher level of bcl-2 overexpression (p = 0.014). No statistically significant difference was found in the presence of immunohistochemically identified estrogen receptors (p = 0.161) and progesterone receptors (p = 0.081) between the primary tumor and the metastatic lymph node in axilla. Likewise, no difference was found between the immunohistochemical evaluation of p53 (p = 0.356) and cathepsin D activity (p = 0.928). A higher growth fraction of the tumor cells and the higher level of bcl-2 overexpression in metastatic tumor cells indicate the more aggressive cell subclones. This study does not support the routine testing of both primary tumor and locoregional metastasis to evaluate the breast cancer hormone receptor status.

Assessment of intra-cranial pressure after severe traumatic brain injury by transcranial Doppler ultrasonography.

PRIMARY OBJECTIVE: To investigate the potential of transcranial Doppler ultrasonography in estimating post-traumatic intra-cranial pressure early after severe traumatic brain injury. RESEARCH DESIGN: The group of 24 patients was analysed for the observation of an early post-traumatic cerebral haemodynamic by middle cerebral artery blood velocity measuring. METHODS AND PROCEDURES: The standard method of measuring the mean blood middle cerebral artery velocity by transcranial Doppler ultrasonic device was performed. MAIN OUTCOMES AND RESULTS: The increased duration of intra-cranial hypertension correlated to the middle cerebral artery low blood velocity (p = 0.042; r = -0.498) (n = 17) and to elevated pulsatility indices (p = 0.007; r = 0.753) (n = 11) significantly. The increased duration of lowered cerebral perfusion pressure correlated to the middle cerebral artery low blood velocity significantly (p = 0.001; r = -0.619) (n = 24). CONCLUSIONS: The significance of transcranial Doppler ultrasonography as a method to estimate an early post-traumatic intra-cranial pressure after severe brain injury was confirmed. This simple and non-invasive technique could be easily used in daily clinical practice and precede intra-cranial pressure monitoring in selected patients.

Intact radial and median nerve after open third degree distal fracture of the humerus.

A 54 year old man sustained a third degree open fracture at the distal part of the right humerus with massive soft tissue defect involving most of the upper arm. The radial and median nerves were completely bared and exposed by 6 cm for radial and 3 cm for median nerve. The nerves were in continuity, but there was complete rupture of surrounding muscles: biceps, triceps and brachialis. The fracture was stabilized by external fixation method--reinforced by wires. Preoperative and postoperative sensorimotor status of the right hand was good. One year later sensory and motoric status of right hand showed no deficiencies, but flexion and extension in elbow were limited to 100 and 180 degrees respectively. Pronosupination was restricted. This case report is consistent with results of biomechanical studies in vitro confirming high tolerance of radial and median nerve to stretching injury.

External fixation and infection of soft tissues close to fracture localization.

We evaluated the method of external fixation for stabilization of unstable closed and open first-degree diaphyseal fractures of long bones of lower extremities in 19 patients with infections of soft tissues close to the fracture location. The results are compared with those of another group (n = 392) of patients, with similar fractures without infections close to the fracture site, treated with inner stabilization methods. In the first group of patients, we noticed postoperative osteitis of the tibia in two cases (10%), but no pseudarthrosis or lesions of important blood vessels. In the second group of patients, the incidence of postoperative osteitis was 8.6% (n = 34) and the incidence of pseudarthrosis was 2% (n = 8). Among these patients, three lesions of important blood vessels were diagnosed. Our conclusion is that when the method of external fixation is used in combination with skillful operative techniques, the infection of soft tissues near the fracture location has no principal influence on the frequency of osteitis.

Influence of instability and muscular weakness in ethiopathogenesis of hip fractures.

The aim of our study was to, in accordance with the presented theoretical presumptions, analyze the possible reasons for hip fractures of the older population in the north-eastern part of Croatia. A group of 2,696 persons (1,936 women and 760 men) with hip fractures has been analyzed during a 12 year period (from 1993. until 2005. year) in the Clinical Hospital Osijek. The date of admittance, age, gender and fracture location were recorded. In men, the incidence of total hip fracture number on the left side was greater 23.5% (p<0.01) compared to the right side, while in women this difference does not exist. Men have a greater incidence of trochanteric fractures than fractures of femoral neck on both sides, while in women this difference could be shown on the right side only. In women, a 30.5% (p<0.001) higher fracture incidence occurred in the winter compared to the summer. It has been concluded that in men the impaired neuromuscular function on the left body side caused the greater incidence of falls on this side. The more frequent multifragmental fractures of the trochanteric massive in men indicate the possible role of preserved pelvitrochanteric muscle tension in fracture characterization. Increased incidence of falls and fractures in the older female population can be interpreted with a more pronounced weakness of pelvitrochanteric muscles and consequent walking instability. Furthermore, a smaller incidence of hip fractures was noticed in the summer compared with winter. This is explained by a reduced exhaustion of pelvic muscles in summer (primarily pelvitrochanteric) and decrease in fall frequency.