Analysis of selected pro- and anti-inflammatory cytokines in patients with multiple injuries in the early period after trauma.

INTRODUCTION: Severe trauma causes damage to the protective barriers of the organism, and thus activates immunological reaction. Among substances secreted during this process pro-inflammatory cytokines are of high importance. THE AIM OF THE STUDY: Severe trauma causing multiple injuries is more likely to lead to particularly intensive inflammatory reaction, which can sometimes lead to serious complications, even life-threatening. The aim of the study is to determine those parameters which may serve as predictors of infectious complications and to enable estimation of the patient's immunological status before the decision to introduce elective procedures. MATERIAL AND METHODS: The study population included patients with multiple trauma treated in the Department of Trauma Surgery of the Medical University of Gdansk. The severity of injuries was evaluated with commonly used numerical scales (Revised Trauma Score - RTS, Injury Severity Score - ISS, Glasgow Coma Scale - GCS). Blood samples were collected on the first, second, and fifth day after injury. Evaluated parameters: C-reactive protein (CRP), the level of cytokines: IL-8, IL-1ß, IL-6, TNF, IL-12p70, and IL-10. Control population: individuals without injury. RESULTS: Evaluation of IL-6, IL-8, and CRP levels in patients with multiple trauma in the early period after injury (2-3 days) could be considered as a predictor of delayed infection (5-10 days). CRP level, being cheap and commonly accessible, can be used in clinical practice enabling identification of patients at higher risk of infectious complications and introduction of appropriate treatment and prevention. The analysis of the mentioned parameters may contribute to choosing an appropriate management strategy, including "timing" depending on the patient's biological status.

Shoulder Ultrasound in the Diagnosis of the Suprascapular Neuropathy in Athletes.

PURPOSE: Shoulder pain and weakness are common symptoms in athletes who play sports connected with overhead throwing. Suprascapular neuropathy may be one of the reason of such signs.The aim of the study was to find out if ultrasound examination of the shoulder in athletes reveals signs of suprascapular neuropathy. METHODS: This was a cross-sectional study in which 67 professional volleyball, handball and rugby players of polish teams without shoulder disorders, which have played sport for 10 or more years, were included. An ultrasound examination of both shoulders was performed. Excluding criteria were recent shoulder and/or neck trauma and neurological disorders. RESULTS: No ultrasound signs of suprascapular neuropathy were seen in any player. The only finding was enthesopathy of supraspinatus muscle and this finding was connected with athletes' age, type of sport and with dominant hand. It had statistical significance with p-value respectively 0.01 for athletes' age, 0.0208 for sport type and 0.03 for dominant hand. CONCLUSIONS: Ultrasonography should not be used as the screening examination of shoulders in athletes, but it can sometimes be an additional tool to help to diagnose shoulder disorders.

The influence of a change in the meniscus cross-sectional shape on the medio-lateral translation of the knee joint and meniscal extrusion.

OBJECTIVE: The purpose of this study was to evaluate the influence of a change in the meniscus cross sectional shape on its position and on the biomechanics of a knee joint. METHODS: One main finite element model of a left knee joint was created on the basis of MRI images. The model consisted of bones, articular cartilages, menisci and ligaments. Eight variants of this model with an increased or decreased meniscus height were then prepared. Nonlinear static analyses with a fixed flexion/extension movement for a compressive load of 1000 N were performed. The additional analyses for those models with a constrained medio-lateral relative bone translation allowed for an evaluation of the influence of this translation on a meniscus external shift. RESULTS: It was observed that a decrease in the meniscus height caused a decrease in the contact area, together with a decrease in the contact force between the flattened meniscus and the cartilage. For the models with an increased meniscus height, a maximal value of force acting on the meniscus in a medio-lateral direction was obtained. The results have shown that the meniscus external shift was approximately proportional to the meniscus slope angle, but that relationship was modified by a medio-lateral relative bone translation. It was found that the translation of the femur relative to the tibia may be dependent on the geometry of the menisci. CONCLUSIONS: The results have suggested that a change in the meniscus geometry in the cross sectional plane can considerably affect not only the meniscal external shift, but also the medio-lateral translation of the knee joint as well as the congruency of the knee joint.

The effect of antibiotic therapy on the incidence of Staphylococcus aureus infections in orthopaedic patients.

BACKGROUND: This paper reports on aetiological factors, including mostly S. aureus infections, and antibiotic use in the pretreatment and treatment of complicating infections in patients hospitalised at the Department of Orthopaedics and Musculoskeletal Traumatology, Gdansk Medical University, between 1995 and 2004. The analysis sought to establish a correlation, via statistical analysis, between the usage of specific antibiotic classes, with special regard to lincosamides, and S. aureus infection rates. MATERIALS AND METHODS: The study population included 22,686 patients admitted for elective surgery (accounting for 86.9% to 75.1% of the sample in different years) or with acute injuries. RESULTS: The rate of infections ranged from 2.79% to 1%, decreasing in a statistically significant manner over time. S. aureus was the dominant pathogen, accounting for 67.3% to 27.6% of the total number of bacterial strains. During the time frame of the study, the incidence of osteitis fell considerably, from 0.8% to 0.05% of the total number of patients. This was paralleled by a major increase in the use of lincosamides, mostly clindamycin. The increase in lincosamide use correlated with the decreasing incidence of S. aureus infections. CONCLUSIONS: The statistical outcome of this 10-year study has been used to develop schemes of antibiotic therapy in the Department, a necessary component of the Hospital's economic policy at the moment.A major fall in the incidence of nosocomial infections can be achieved by focussing on adequate antibiotic prophylaxis, pretreatment and appropriate treatment of acute infections.

Limited arthrodesis for wrist instability.

The knowledge on limited (intercarpal, partial) wrist arthrodeses was summarized on the basis of the contemporary literature review. They are used to treat various conditions of painful wrist pathology such as limited intercarpal arthrosis, instability, scaphoid nonunion, Kienböck's disease and rheumatoid arthritis. The goal of the procedure was pain relieve and maintainance a functional range of motion. The indications, contraindications, limitations of range of motion, nonunion rates of the most frequently performed intercarpal arthrodeses: STT (scaphotrapeziotrapezoid), SC (scaphocapitate), SCL (scaphocapitatolunate), SL (scapholunate), LT (lunotriquetral), CLTH (capitolunotriquetrohamate or four-corner arthrodesis), RL (radiolunate), RSL (radioscapholunate) and RS (radioscaphoid) were presented.

Surgical treatment of late carpal dislocations.

Background. Perilunate carpal subluxation is quite rare. The aim of our study was to assess outcome in the delayed treatment of these injuries. Material and methods. We studied treatment outcome in 25 perilunate carpal dislocations. The follow-up averaged 11 years and 4 months. The age of the patients ranged from 18 to 52 (average 32). The period from injury to surgery ranged from 1 day to 360 days (average 60 days). The range of motion and grip strength of the wrist were evaluated. In radiological assessment the ulnar dislocation index, carpal height index, and capitolunate, radiolunate, and scapholunate angles were examined. Subjective evaluation was based on the DASH questionnaire. Results. Only slight changes were observed during the observation period in the radiological parameters. There was no significant correlation between the use of traction in preparation for open reduction and the radiological, functional or subjective outcome. Contrary to expectations none of the outcome measures correlated with the type of dislocation or patient age, or with the delay from injury to surgery. In DASH evaluations, the strongest correlation was found between the subjective outcome and the radiological parameters, global grip strength, the sum of all four measures of range of movement, and wrist flexion. In three cases there were late complications: one case of aseptic necrosis of the lunate bone, and two cases of scaphoid pseudarthrosis. Conclusions. The best method of late treatment for perilunate carpal dislocation proved to be open reduction using the dorsal approach with Kirschner wire fixation.

Scapholunate ligament repair using suture anchors.

Background. This article describes the surgical repair of scapholunate ligament injury using Mitek suture anchors. Material and methods. 3 patients with neglected injuries of the scapholunate ligament were operated from 8 weeks to 5 months after trauma. The authors found that using the Mitek anchor suture simplifies the operative technique, obviates the technical difficulties involved in guiding the tendon through the bone tunnel, and reduces the possibility of the complications seen in the standard ligament repair techniques. Results and Conclusions. The operative technique used in the Clinic of Hand Surgery at the Medical University of Gdansk combines reduction of the displaced scaphoid bone from the dorsal approach and temporary scaphocapitate fixation with K wires, bringing the ruptured ligament closer with capsulodesis using Mitek suture anchors.

Use of pedicled bone grafts in the treatment of nonunion of the scaphoid.

The purpose of this article is to present some contemporary views regarding the treatment of scaphoid nonunion using pedicled bone grafts. Based on a review of the literature, the authors discuss surgical technique, including the advantages and disadvantages of various methods and their modifications, as well as outcomes. Among the methods discussed are pronator quadratus pedicled bone grafts, grafts pedicled on arteries (radial artery branches), and free vascularized bone grafts. Experimental studies of the use of free vascularised bone-ligament-bone autografts for the reconstruction of the scapholunate ligament are described. The clinical application of scaphoid allograft is also discussed.

Posterior interosseous nerve neuropathy in distal radius fracture.

Background. The anatomy of the posterior interosseous nerve, which lies directly on the periostium of the distal epiphysis of the radius, may predispose to nerve migration between fragments after a fracture. This is especially like to be the case in a comminuted fracture of the distal radius, when the runs in the sagittal plane. Case histories. Based on 2 cases of patients treated for distal radius fracture immediately after trauma and 1 case of correction osteotomy, we describe entrapment of the articular branch of the posterior interosseous nerve was observed (DPIN). All these patients had pain syndrome in the narrow fourth compartment of the extensor, which included EIP and EDC. Our clinical observations are supported by cadaver studies and radiological imaging. Results. Good results were obtained after DPIN neurectomy or neurolysis.

Evaluating degenerative changes in the wrist after surgical treatment for scaphoid pseudarthrosis using a corticocancellous graft for anatomical reconstruction.

Background. Pseudoarthrosis of the scaphoid results in the development of carpal instability and severe posttraumatic osteoarthritis. Modern methods of treatment focus on reconstruction of the anatomical shape and length of the scaphoid. The purpose of our study was to determine the occurrence of carpal osteoarthritis after surgical treatment of scaphoid pseudoarthrosis using a cortico-cancellous bone grafting technique. Material and methods. 48 patients who had undergone surgical treatment for scaphoid union failure were examined. The surgical method included the anatomical reconstruction of the scaphoid bone, which resulted in normal ligament tension and carpal stability. The clinical examination included pain evaluation, return to work, range of wrist motion, and grip strength. On comparative x-rays of both wrists we evaluated union, the length and shape of the scaphoid bone, the scapho-lunate angle, the carpal height ratio, and the carpal ulnar shift. Results. Union was obtained in 42 cases. In 26 patients there were no signs of osteoarthritis, while 11 patients had slight degenerative changes in the radio-scaphoid joint. Conclusions. According to our analysis, cortico-cancellous bone grafting is an effective surgical procedure, useful not only in obtaining union, but also in reconstructing the shape and length of the scaphoid and preventing posttraumatic carpal asteoarthritis.

Assessment of the Relationship between the Shape of the Lateral Meniscus and the Risk of Extrusion Based on MRI Examination of the Knee Joint.

BACKGROUND: Meniscus extrusion is a serious and relatively frequent clinical problem. For this reason the role of different risk factors for this pathology is still the subject of debate. The goal of this study was to verify the results of previous theoretical work, based on the mathematical models, regarding a relationship between the cross-section shape of the meniscus and the risk of its extrusion. MATERIALS AND METHODS: Knee MRI examination was performed in 77 subjects (43 men and 34 women), mean age 34.99 years (range: 18-49 years), complaining of knee pain. Patients with osteoarthritic changes (grade 3 and 4 to Kellgren classification), varus or valgus deformity and past injuries of the knee were excluded from the study. A 3-Tesla MR device was used to study the relationship between the shape of the lateral meniscus (using slope angle, meniscus-cartilage height and meniscus-bone angle) and the risk of extrusion. RESULTS: Analysis revealed that with values of slope angle and meniscus-bone angle increasing by one degree, the risk of meniscus extrusion raises by 1.157 and 1.078 respectively. Also, an increase in meniscus-cartilage height by 1 mm significantly elevates the risk of extrusion. At the same time it was demonstrated that for meniscus-bone angle values over 42 degrees and slope angle over 37 degrees the risk of extrusion increases significantly. CONCLUSIONS: This was the first study to demonstrate a tight correlation between slope angle, meniscus-bone angle and meniscus-cartilage height values in the assessment of the risk of lateral meniscus extrusion. Insertion of the above parameters to the radiological assessment of the knee joint allows identification of patients characterized by an elevated risk of development of this pathology.

Dependency between treatment outcome in pseudarthrosis of the humeral shaft and the surgical technique applied.

Background. Treatment of non-union has always been one of the most difficult problems in bone pathology. In the present study we compare outcomes using 9 different methods of non-union treatment. Material and methods. From 1976 to 2003, 70 patients with 85 cases of pseudoarthrosis in the humeral shaft were operated. During that period, 103 operations using 9 different methods were performed. The study group consisted of 17 females, 36 males and 17 children, ranging in age from 3 to 85 years. The operation techniques were compared based on the achievement of bone union and recovery of limb functional efficiency. Nonunion type was also taken into account. Results. A high percentage of bone union was obtained by using a perforated block of corticocancellous graft taken from the iliac crest. The most complete limb function recovery was achieved using this method, as well as Judet's decortication with cancellous grafting and firm osteosynthesis. Conclusions. In oligotrophic and non-viable humeral shaft non-union, the most effective method is pseudarthrosis excision, using a perforated block of corticocancellous graft from the iliac crest to fill the gap, and firm osteosynthesis. Judet's decortication with cancellous grafting and firm osteosynthesis secured good outcome in hypertrophic pseudarthrosis.

High Pressure Injection Injury of the Thumb. Case Study.

High-pressure injection injury (HPII) is a rare severe hand trauma associated with high rates of complications and amputations of the peripheral parts of the fingers and permanent hand dysfunction. Early detection and treatment are crucial as any delay may result in a considerable functional deficit of the affected limb or amputation. The rate of amputation following HPII is 48%. This case report aims mainly to present the problem of HPII and general standards of management of such injuries. The routine use of supportive treatment in hyperbaric chambers, in the absence of contraindications, is also encouraged.

[Radiometric assessment of wrist angle values, linear parameters of the forearm and wrist ratios]. / Normy wybranych katów nadgarstka, dlugosci przedramienia i wspólczynników nadgarstka.

With the device of our own invention suitable for static X-ray examination of the wrist 12 radiographic parameters were evaluated. 100 radiograms regarded normal were analyzed, obtained as a comparative in unilateral wrist trauma patients group. Age of the patients ranged from 18 to 60 years. No comparative studies in regard to sex were performed. Obtained data were statistically analyzed. Subsequent values of the radiometric parameters were obtained: scaphoid-lunate angle (SL) 48.61 degrees, radio-lunate angle (RL): -0.83 degrees, palmar inclination of the distal radius metaphysis (RI): 25.96. The most significant linear parameters measured: ulnar length 0.18 mm, ulnar transposition (UT): 0.339 mm.

[Application of block of corticocancellous graft in the treatment of forearm shaft nonunions]. / Zastosowanie litego przeszczepu korowo-gabczastego w leczeniu stawów rzekomych trzonu kosci przedramienia.

The paper presents a method for tratment of nonunions of the forearm, using a perforated corticocancellous graft from the iliac crest. After excising the sclerotic ands of the pseudoarthrosis, the bone graft from the iliac crest is inserted into the obtained free space and then fixed to the forearm bone by means of a plate. Satisfactory results using this method were achieved in 18 patients (age ranging from 3 to 61 years; 6 female and 12 male).

[Operative treatment of scaphoid nonunions]. / Leczenie operacyjne stawów rzekomych kosci lódeczkowatej.

43 reconstructive procedures were performed in nonunions and malunions of the scaphoid waist. In 8 cases of proximal pole nonunions the Chacha operation was carried out. Before surgical treatment SL angles and scaphoid length were measure on radiograms, taken with both hands in neutral position. Reconstruction procedures of the scaphoid waist were implemented basing on the carpal stretch test. Five different types of scaphoid nonunions were noted, basing on the localisation of the pathology. Operative procedures were selected in close correlation to nonunion localisation: simple reconstruction, reconstruction and revascularisation on the proximal part of the waist and rerevascularisation of the proximal pole. Additionally 3 revision procedures were performed in cases of nonunion after scaphoid reconstruction. Bone healing was observed in 49 cases, including the revision procedures.

[Osteotomy of the navicular bone in scaphoid malunion]. / Osteotomia kosci lódeczkowatej w zroscie wadliwym.

In scaphoid malunions corrective osteotomy and filling the gap of scaphoid waist with bone graft was carried out. Corrective osteotomy of malunion was needed in 2 cases among 43 waist reconstructions. The size of the gap was assessed intraoperatively by carpal stretch test. In both 2 cases bone healing, correction of scaphoid angle and pain relief was achieved.