A new algorithm for the management of diabetic foot ulcer: recommendations from Central and Eastern Europe.

There is wide regional variation in clinical practice and access to treatment for patients with diabetic foot ulcer (DFU) from countries in Central and Eastern Europe (CEE). A treatment algorithm that reflects current treatment practices while providing a common framework may facilitate best practice in DFU management and improve outcomes across the CEE region. Following a series of regional advisory board meetings with experts from Poland, the Czech Republic, Hungary and Croatia, we present consensus recommendations for the management of DFU and outline the key features of a unified algorithm for dissemination and use as a quick tool in clinical practice in CEE. The algorithm should be accessible to specialists as well as non-specialist clinicians and should incorporate: patient screening; checkpoints for assessment and referral; triggers of treatment change; and strategies for infection control, wound bed preparation and offloading. Among adjunctive treatments in DFU, there is a clear role for topical oxygen therapy, which can be used concomitantly with most existing treatment regimens in hard-to-heal wounds following standard of care. Countries from CEE face a number of challenges in the management of DFU. It is hoped that such an algorithm will help standardise the approach to DFU management and overcome some of these challenges. Ultimately, a regionwide treatment algorithm in CEE has the potential to improve clinical outcomes and save limbs.

An International Delphi Consensus on Diagnostic Criteria for Buerger's Disease.

BACKGROUND: Buerger's disease (BD) remains a debilitating condition. Despite multiple published diagnostic criteria for BD, none is universally accepted as a gold standard. METHODS: We conducted a 2-round modified Delphi consensus study to establish a consensus on the diagnostic. The questionnaire included statements from several commonly used diagnostic criteria for BD. Qualitative and quantitative analysis methods were performed. An agreement level of 70% was applied. RESULTS: Twenty nine experts from 18 countries participated in this study. Overall, 75 statements were circulated in Round 1. Of these, 28% of statements were accepted. Following comments, 21 statements were recirculated in Round 2 and 90% were accepted. Although more than 90% of the experts did not agree that the diagnosis of BD can be based only on clinical manifestation, none of the nonclinical manifestations of BD were agreed as a part of the diagnostic criteria. There was an agreement that a history of tobacco consumption in any form, not necessarily confined to the current use, should be a part of the diagnostic criteria of BD. The history of thrombophlebitis migrans, even if not present at presentation, was accepted as a clue for BD diagnosis. It was also agreed that discoloration of the toes or fingers could be included in the diagnostic criteria of BD. Experts agreed that histology results could differentiate BD from atherosclerosis obliterans and other types of vasculitis. The presence of corkscrew collaterals on imaging and burning pain reached the agreement at the first round but not at the second. There was no consensus regarding age cut-off, the requirement of normal lipid profile, and normal blood glucose for BD diagnosis. CONCLUSIONS: The present study demonstrated discrepancies in the various published diagnostic criteria for BD and their selective utilization in routine clinical practice worldwide. We propose that all published diagnostic criteria for BD be re-evaluated for harmonization and universal use.

Position Paper on Young Vascular Surgeons Training of the Mediterranean Federation for the Advancing of Vascular Surgery (MeFAVS): State of the Art and Perspectives.

The Mediterranean Federation for the Advancing of Vascular Surgery (MeFAVS) was founded in 2018, with the aim to promote cooperation among vascular professionals within Mediterranean countries. Due to its prominent social and economic impact on national health systems, diabetic peripheral artery was selected as the very first topic to be investigated by the federation. In this second paper, different experiences from delegates of participating countries were shared to define common strategies to harmonize, standardize, and optimize education and training in the Vascular Surgery specialty.

Vascular e-Learning During the COVID-19 Pandemic: The EL-COVID Survey.

BACKGROUND: The corona virus disease (COVID-19) pandemic has radically changed the possibilities for vascular surgeons and trainees to exchange knowledge and experience. The aim of the present survey is to inventorize the e-learning needs of vascular surgeons and trainees as well as the strengths and weaknesses of vascular e-Learning. METHODS: An online survey consisting of 18 questions was created in English, with a separate bilingual English-Mandarin version. The survey was dispersed to vascular surgeons and trainees worldwide through social media and via direct messaging from June 15, 2020 to October 15, 2020. RESULTS: Eight hundred and fifty-six records from 84 different countries could be included. Most participants attended several online activities (>4: n = 461, 54%; 2-4: n = 300, 35%; 1: n = 95, 11%) and evaluated online activities as positive or very positive (84.7%). In deciding upon participation, the topic of the activity was most important (n = 440, 51.4%), followed by the reputation of the presenter or the panel (n = 178, 20.8%), but not necessarily receiving accreditation or certification (n = 52, 6.1%). The survey identified several shortcomings in vascular e-Learning during the pandemic: limited possibility to attend due to lack of time and increased workload (n = 432, 50.5%), no protected/allocated time (n = 488, 57%) and no accreditation or certification, while technical shortcomings were only a minor problem (n = 25, 2.9%). CONCLUSIONS: During the COVID-19 pandemic vascular e-Learning has been used frequently and was appreciated by vascular professionals from around the globe. The survey identified strengths and weaknesses in current e-Learning that can be used to further improve online learning in vascular surgery.

Abdominal aortic and iliac aneurysm presented as lower limb deep vein thrombosis: case report.

Introduction: We report a rare case of a symptomatic abdominal aneurysm presented as a lower limb deep vein thrombosis (DVT).Case presentation: A 63-year old male presented to our hospital with a recent progressive onset of the right lower limb swelling and pain. The patient had a history of a previous cardiovascular disease. A Duplex ultrasound was performed, which confirmed a right lower limb DVT extending to the right iliac vein. The patient had a pulsatile abdominal mass. Computed tomography scan of the abdomen showed an abdominal aortic and a right iliac artery aneurysm compressing the thrombosed inferior caval and the right iliac vein. The patient was treated with low molecular weight heparin. After resolution of the DVT on day 3 of hospitalization, a surgery on the abdominal and iliac artery aneurysm was performed. The aneurysm was resected and an aortobifemoral bypass was placed using a Dacron prosthesis. The patient remained to be asymptomatic for 6 months after the surgery. Follow up computed tomography demonstrated a fully patent inferior caval and iliac vein and the absence of the aneurysmal disease.Conclusion: Although rare, our case confirms that the DVT should be considered as a possible symptom of an abdominal aneurysm in selected patients.

Coil embolization and surgical removal of carotid body paraganglioma.

Carotid body paraganglioma has considerable malignant potential and locally aggressive behavior, so it should be treated as soon as it is discovered.We report the case of 60-year-old male patient with a carotid body paraganglioma (Shamblin group II) that was causing the carotid arteries to spread. Angiography showed 1 dominant feeding artery arising from the right external carotid artery. Selective angiography was performed 2 days before surgical removal of the tumor, and the feeding artery was successfully embolized with coils.Literature review reveals previous reports where preoperative embolization of the feeding arteries was done using ethanol, polymers, or other liquid agents. In our case, angiography (via femoral artery) was performed 2 days before surgical removal of the tumor, and the main feeding artery (a single branch arising from external carotid artery) was successfully embolized with coils rather than liquids.Performing coil embolization before operating reduced subsequent blood loss and made it easier to identify the feeding artery during surgery. Supraselective coiling, although as difficult as embolization with liquids, may reduce the incidence of postoperative stroke. At 1 year after surgery, the patient had no signs of tumor recurrence.

Awareness, attitudes, and perceptions of Croatian-based orthopedic and trauma surgeons toward scientific manuscripts, publishing internationally and medical writing. Results of an online questionnaire.

The objective of this survey was to identify the importance placed by Croatian-based surgeons on writing scientific manuscripts and publishing them internationally, as well as their awareness of and attitudes toward medical writing. A link to an online survey was sent to 327 Croatian-based orthopedic and trauma surgeons. The electronic questionnaire consisted of rating scales, multiple choice questions and free text reply boxes. A total of 61 surgeons based in Croatia replied to the survey, yielding a response rate of 19% (61/327). The survey results indicate that surgeons in Croatia are active in both research and the writing of manuscripts. There is also a high level of interest among them to publish internationally in English to further their careers. While 68% (38/56) of respondents initially claimed to know about medical writing, further questioning on the subject revealed a reduced level of familiarity with the concept. Only 19% (11/58) of respondents had ever engaged the services of a medical writer and they were generally satisfied with the work done across the three areas of language, editing and scientific knowledge. Medical writers are advised to increase awareness of their services among Croatian-based orthopedic and trauma surgeons who may well have a need for their expertise.

Diagnostic criteria for Buerger's disease: International Consensus of VAS - European Independent Foundation in Angiology/Vascular Medicine.

Buerger's disease (BD) remains a debilitating condition and early diagnosis is paramount for its effective management. Despite many published diagnostic criteria for BD, selective criteria have been utilized in different vascular centers to manage patients with BD worldwide. A recent international Delphi Consensus Study on the diagnostic criteria of BD showed that none of these published diagnostic criteria have been universally accepted as a gold standard. Apart from the presence of smoking, these published diagnostic criteria have distinct differences between them, rendering the direct comparison of patient outcomes difficult. Hence, the expert committees from the Working Group of the VAS-European Independent Foundation in Angiology/Vascular Medicine critically reviewed the findings from the Delphi study and provided practical recommendations on the diagnostic criteria for BD, facilitating its universal use. We recommend that the 'definitive' diagnosis of BD must require the presence of three features (history of smoking, typical angiographic features and typical histopathological features) and the use of a combination of major and minor criteria for the 'suspected' diagnosis of BD. The major criterion is the history of active tobacco smoking. The five minor criteria are disease onset at age less than 45 years, ischemic involvement of the lower limbs, ischemic involvement of one or both of the upper limbs, thrombophlebitis migrans and red-blue shade of purple discoloration on edematous toes or fingers. We recommend that a 'suspected' diagnosis of BD is confirmed in the presence of a major criterion plus four or more minor criteria. In the absence of the major criterion or in cases of fewer than four minor criteria, imaging and laboratory data could facilitate the diagnosis. Validation studies on the use of these major and minor criteria are underway.

Mangled extremity--case report, literature review and borderline cases guidelines proposal.

Treatment of a mangled lower extremity represents a major challenge. The decision whether to amputate or attempt reconstruction is currently based upon surgical evaluation. The aim of this paper is to propose a new approach to surgical evaluation based on scoring systems, local clinical status of the patient as well as comorbidities, mechanism of trauma and hospital resources. Available literature regarding this topic was evaluated and a case of patient with mangled extremity is presented. Based on current literature guidelines and evidence-based medicine, management for borderline cases is proposed to aid clinical decision making in these situations. We describe a 44-year old male patient who presented with mangled lower left leg. Despite a borderline Mangled Extremity Severity Score (MESS), due to the overall health status of the patient and local clinical status with preserved plantar sensitivity and satisfactory capillary perfusion, reconstruction was attempted. After 6 months of treatment, all wounds healed completely with no pain, and satisfactory motor and sensory function was achieved. In conclusion, the treatment of mangled extremity treatment should be based on evidence based literature along with a clinical evaluation of every individual patient. Scores are helpful, but should not be taken as the sole indication for amputation.

Axillary artery dissection after scapular fracture.

Blunt shoulder trauma rarely causes damage to either arteries or nerves. Neurovascular structures are covered by muscles and protected by the surrounding bones deep in the axilla. We report a case of a 34-year-old male motorbike driver referred to us 5 hours after injury. Standard X-ray of the left shoulder revealed multipart fracture of the left scapula, and angiography showed that the first segment of the left axillary artery was dissected proximal to the minor pectoral muscle. Urgent diagnosis using imaging techniques and restoration of blood flow using open or endovascular repair are crucial for optimal outcome. Damage to the nerves predicts the final functional outcome regardless of prompt revascularization.

Inflammatory malignant fibrous histiocytoma of the retroperitoneum.

The authors present a case of inflammatory malignant fibrous histiocytoma located in the left retroperitoneum. The tumor was resected enblock with kidney and suprarenal gland. During the resection the system of retractors called the pillars of Kocman was used which allowed wide exposure of the abdominal cavity. The tumor measured 23 x 17 x 10 cm with the left kidney and suprarenal incorporated. The tumor was centrally pseudocystic made of xanthomatous cells, foamy cells and rare giant cells with storiform formations and infiltrated with neutrophils. Imunohistochemically, the tumor cells were vimentin and CD 68 positive and CD 20, CD3, EMA, S-100, HMB 45, CD 34 and CD 1a negative. Neutrophils were CD 15 positive.

MRI study of the ACL in children and adolescents.

UNLABELLED: Reconstruction of the ACL (anterior cruciate ligament) requires precise anatomical placement of the tendon graft. Anatomic variations may increase/decrease risk of the ACL rupture. Twenty-eight children with clinical, MRI and arthroscopic verified ACL ruptures were compared with match case control group. MRI was done one to 12 months after trauma. The thresholds values for identifying the ACL rupture were set; ACL angle < 45 degrees, Blumensat angle > 0 degrees, and the PCL angle < 115 degrees. RESULTS: There was no significant difference of tibial attachment for the ACL and measured parameters of the femur. The ACL angle (p < 0.001), the Blumensat angle (p = 0.001), and the PCL angle (p < 0.001) were significantly different. Each of the patients in group with a torn ACL had at least one parameter positive. DISCUSSION: ACL angle, Blumensat angle and PCL angle might help to diagnose ruptured ACL. Pediatric patients with the ruptured ACL show no difference in notch width or the tibial roof inclination angle as compared with pediatric patients without ACL rupture.

Milestones in thromboangiitis obliterans: a position paper of the VAS-European independent foundation in angiology/vascular medicine.

Even today thromboangiitis obliterans has disease features that remain misunderstood or underappreciated. The epidemiology, etiology and pathophysiology of the disease are still unclear. Biomarkers and disease activity markers are lacking, thus clinical assessment is difficult. We are still struggling to establish unique diagnostic, staging and treatment criteria. This is an academic-collaborative effort to describe the pathophysiology, the clinical manifestations, the diagnostic approach, and the challenges of management of patients with TAO. A systematic search for relevant studies dating from 1900 to the end of 2020 was performed on the PubMed, SCOPUS, and Science Direct databases. Given the intriguing nature of presentation of TAO, its management, to some extent is not only different in different regions of the world but also varies within the same region. Following this project, we discovered ambiguity, overlap and lack of clear-cut criteria for management of TAO. An international group of experts however came to one conclusion. They all agree that management of TAO needs a call for action for a renewed global look with multi-center studies, to update the geographical distribution of the disease and to establish a unique set of diagnostic criteria and a consensus-based guideline for best treatment based on current evidence.

Dataset of the vascular e-Learning during the COVID-19 pandemic (EL-COVID) survey.

This dataset supports the findings of the vascular e-Learning during the COVID-19 pandemic survey (the EL-COVID survey). The General Data Protection Regulation (GDPR) of the European Union was taken into consideration in all steps of data handling. The survey was approved by the institutional ethics committee of the Primary Investigator and an online English survey consisting of 18 questions was developed ad-hoc. A bilingual English-Mandarin version of the questionnaire was developed according to the instructions of the Chinese Medical Association in order to be used in mainland People's Republic of China. Differences between the two questionnaires were minor and did affect the process of data collection. Both questionnaires were hosted online. The EL-COVID survey was advertised through major social media. All national and regional contributors contacted their respective colleagues through direct messaging on social media or by email. Eight national societies or groups supported the dissemination of the EL-COVID survey. The data provided demographics information of the EL-COVID participants and an insight on the level of difficulty in accessing or citing previously attended online activities and whether participants were keen on citing these activities in their Curricula Vitae. A categorization of additional comments made by the participants are also based on the data. The survey responses were filtered, anonymized and submitted to descriptive analysis of percentage.

[Blood transfusion in patients with pertrochanteric femoral fracture]. / Transfuzijsko lijecenje bolesnika s pertrohanternim prijelomom femura.

AIM: The aim of the study was to investigate the pattern of transfusion in patients with pertrochanteric femoral fracture, and to compare the results obtained with literature data. METHODS: It was a retrospective study including 246 consecutive patients operated on for pertrochanteric femoral fracture at University Hospital for Traumatology in Zagreb from January 1, 2001 to December 31, 2003. The analysis included the method of operative treatment, type of anesthesia, physical status according to the American Society of Anesthesiology (ASA), preoperative hemoglobin levels, use of thromboprophylaxis, transfusion, and mortality. RESULTS: There were 246 patients with pertrochanteric femoral fracture; 244 (99.2%) underwent surgery and only 2 (0.8%) were treated conservatively. The method of treatment was DHS in 90.2%, and gamma nail in 8.9% of patients. Most patients were classified as ASA II, III and ASA IV (26.4%, 54.9% and 18.7%, respectively), and most were operated on in spinal anesthesia. Thromboprophylaxis with low molecular weight heparins was administered to 98.4% of patients. The mean preoperative hemoglobin was 120 (88-152) g/L, and estimated blood loss during surgery was 300 (100-500) mL. Transfusion of packed erythrocytes was administered 135 (54.9%) patients, 62 (25.2%) during surgery. Fifteen (6.1%) patients received transfusion of blood plasma. DISCUSSION: Fractures in trochanteric region usually occur at age over 60 (80% of patients). Due to the patients' cardiovascular status the "transfusion trigger" remains undefined. Even relatively small alterations of the circulating volume make intraoperative blood pressure control rather challenging. CONCLUSION: The preoperative level of hemoglobin, clinical status of the patient, type of surgery, and anesthesia are useful predictors of transfusion therapy in patients with pertrochanteric hip fracture.

[Prevention of thromboembolism and survival after trauma]. / Tromboembolijska profilasksa i prezivljenje nakon ozljede.

AIM: Thromboembolism (TE) is a well-known and potentially fatal complication after injury and orthopedic surgery. Thromboembolic prophylaxis is generally recognized as a factor of significant interest concerning posttraumatic comorbidity and mortality. In this context, the aim of the study was to analyze hospital mortality 24 hours after injury, and to assess the proportion of fatal pulmonary embolism in overall hospital mortality. Finally, the purpose of the study was to explore the possible correlation between different prophylactic approaches and hospital mortality. METHODS: A retrospective-prospective study was conducted at the University Hospital of Traumatology, Zagreb, over a 14-year period (1988-2001). The study was based on documented clinical and autopsy findings and comprised all trauma patients admitted for hospital treatment. The overall and thromboembolic mortality were analyzed for each individual year during the study period. These two variables were compared and expressed as a proportion for each year. Further analysis included comparison of the data obtained between years and sequences of years. The modes of TE prophylaxis in various periods were analyzed as well. Differences in the mortality rates were tested for statistical significance. Results obtained for each period of time were compared and expressed as a function of different approaches to thromboembolic prevention. RESULTS: Results obtained in the study demonstrated a clear tendency towards the decrease in the overall mortality as well as in the mortality due to fatal pulmonary embolism. Mortality rates showed significant differences during the study period. The most prominent difference was found between the first and final year of investigation. In 1988, the overall mortality was 3.78% and TE mortality 2.05%, whereas in 2001 the respective rates were 1.17% and 0.3% (p < 0.001). A continuous significant mortality decrease in trauma patients was recorded for some years and sequences of years (p < 0.05). The proportion of TE fatality in the overall mortality was > 50% in 1988 and about 25% in 2001. Our results demonstrated a 70% reduction in the overall mortality and even 85% reduction in the fatal TE rate. Finally, a significant reduction of TE fatality by 55% independently of overall mortality reduction was observed. The decreasing mortality rate correlated with different approaches to TE prophylaxis during the 14-year-period. DISCUSSION: Thromboembolism accounted for a considerable proportion of the mortality rate in trauma patients during the study period. The observed dynamics, expressed as a 70% reduction in the overall hospital mortality and an 85% decrease in the fatal PE rate reflected significant improvement in trauma treatment. Further, independently of the overall mortality, TE mortality was reduced by more than 55%, which was obviously related to the changing approaches to TE prevention. At the beginning, physical methods of prophylaxis prevailed. Prophylactic anticoagulation with heparin was started sporadically around 1991 and have been enhanced over time. In 1995, it was included in the routine treatment of specific patient categories. Since 1998, low molecular weight heparin has become the gold standard in TE prophylaxis, with more prominent application in severe multiple injuries. With the recent approach, we have managed to overcome the controversies in the treatment of severe injuries, primarily concerning bleeding and TE, and achieved considerable improvement. CONCLUSION: A significant reduction in the mortality, especially due to fatal pulmonary embolism after injury, was clearly demonstrated. This could be explained by improvements in the management of trauma and organized TE prevention.

[Study of friction and loosening in hip endoprostheses]. / Ispitivanje trenja i rasklimavanja endoproteze kuka.

AIM: Like any other operative procedure, the implantation of hip prosthesis is associated with certain complications, which diminishes the value and purpose of such a procedure. One of the complications in artificial hip implantation is loosening of the alloplastic material. Therefore, the aim of this study was to examine the effect of lubrication on the torsional moment and its role in the loosening of the femoral component, using an experimental mechanical model. The following hypothesis was tested: the magnitude of torsional loading in the "bone-endoprosthesis-bone cement system" is similar to any other known loading. METHODS: The testing device was constructed with the possibility of simulation of positions similar to original performances in the implanted hip prosthesis. It refers primarily to the possibilities of achieving definite forces and velocities. The intention was to point quantitatively to the role of friction moment between the acetabular and femoral endoprosthesis part. Trials were conducted by combining 7 types of loading and 4 kinds of lubrication: dry, water, plasma, and light oil. The testing joint (Ring's prosthesis) was connected through tensometric measuring shaft upon the working forepart oscillating mechanism. Graded by the changeable static loading by means of the pendulum and via lever mechanism the testing joint was loaded by force from 610 to 7137 N. As the cause of friction resistance in the moving joint, torque deformaties of the measuring shaft occurred. The testing joint enabled oscillating movement using a four-part mechanism. In this way, it was possible to define not only the maximum values of the frictional moment (or the coefficient of friction) during one movement cycle but also to examine its relation to the kind of lubrication. Change in the measuring torsional moment were computer recorded. Before each trial, the gauging of the complete outfit was performed. Thereafter, cleaning of the frictional surfaces of the whole outfit was done. RESULTS: The results obtained in combination with lubrication showed a slight increase in the values of the frictional moment. With dry lubrication and greater loading, an extremely progressive gradient of change was recorded. The course of change in the coefficient of friction was essentially different from the course of change in the frictional moment. It was noted particularly during trials with lubrication. In trials without lubrication, a constant increase of loading (force) resulted in a progressive increase in the coefficient of friction, similar to the friction moment. Such a character of the friction moment increase in the observed loading field was explained by the presence of boundary friction in cases with lubrication and by dry friction in cases without lubrication. In dry friction, scratching occurs relatively early, at a loading of F = 1854 N. It occurs with substances of approximately the same hardness like Ring's prosthesis, where the acetabular and femoral prosthesis parts are of metal characteristics. CONCLUSION: The increase in the frictional moment within the observed loading range can be explained by the presence of bordering friction in cases with lubrication, and of dry friction in cases without lubrication. Contrary to this, dry friction relatively early leads to "scratching", especially when sparing materials of similar hardness are combined.