Outcomes and special techniques for treatment of penile amputation injury.

INTRODUCTION: Management of severe penile trauma presents great challenges for reconstructive urologists since these injuries vary from abrasions to total emasculation. A review of our case experience with penile amputation is presented, emphasizing techniques used to salvage or reconstruct the most difficult of penile injury cases. MATERIALS AND METHODS: A total of 13 patients with penile amputation injury referred to us between 2007 and 2016 were analyzed. Mean age at surgery was 16 years (ranged from 4 to 29 years). Etiology of penile amputation (partial or total) combined with management and outcomes were evaluated. Management included different surgical procedures with the aim to achieve good functional and esthetical outcomes. Postoperative questionnaire was used for assessment of patient's overall satisfaction. RESULTS: Follow-up ranged from 13 to 182 months (mean 53). Causes of penile injury were iatrogenic trauma (8), self-amputation (2), electrocution (1), intentional sexual assault (1) and mother's hair strangulation (1). Outcome criteria including aesthetic appearance, urinary function and ability to engage in satisfactory coitus, were noted in 11 cases (85%). Two cases with ensuing complications relating to the total phalloplasty required additional treatment due to urethral fistula. CONCLUSIONS: Severe penile injuries should be treated on a case by case basis utilizing the most propitious techniques. We respectfully propose that the needs of such patients are best served by referral centers with extensive experience.

The Outcomes of 150 Consecutive Patients with Digital Nerve Injuries Treated in a Single Center.

AIM: The surgical management of injured digital nerves is a common part of hand trauma surgery. Despite improvements in the surgical techniques and suture material, the final outcomes of peripheral nerve repair can still be disappointing. This study investigates the outcomes following the surgical treatment of traumatic digital nerve lesions of the hand. MATERIAL AND METHODS: 150 consecutive patients with acutely digital nerve injuries were treated through by primary repair in our Unit between January 2005 and December 2009. 126 were male, 24 female (male/female ratio of 5.25:1), with an age range of 16-70 years, and a mean follow-up of 30 months. All 150 patients underwent primary epineural suture within 48 hours of their injury. Sensory recovery was assessed using the Medical Research Council scale (MRC). Sensibility testing was performed after a minimum of 12 months. Disabilities of the Arm, Shoulder and Hand scores (DASH) were used to evaluate the functional outcomes. RESULTS: Eighteen patients (9.33%) had excellent sensibility with two-point discrimination test (S2PD) of ≤ 7 mm (S4). Forty-one patients (21.24%) achieved good sensibility (S2PD ≤ 15 mm, S3+), 76 (39.38%) achieved S3, 55 (28.50%) had poor sensibility (S2 and S1), and two patients had no sensibility (S0). The mean functional DASH score was 9.0 in our group of patients. CONCLUSION: There was a significant correlation between patient age, mechanism of injury and nerve recovery, with younger patients and patients with narrow zone of injury achieving better sensory recoveries.

Open Dislocation of the High Ankle Joint After Fibular Graft Harvesting.

The free microvascular fibula and soft tissue transfer has become a widely used method for reconstruction of different regions. Donor site morbidity for free fibula microvascular flaps has generally been reported to be low, or at least acceptable. We describe the case of a patient who underwent vascularized free fibula graft harvest for mandibular reconstruction. After 21 months, he had sustained an open dislocation of the left high ankle joint during recreational sports activity. We did not found such case in the published data.

Severe penile injuries in children and adolescents: reconstruction modalities and outcomes.

OBJECTIVE: To review our experience with severe penile trauma, mechanism of injury, and their treatment modalities in 16 children younger than 18 years. Management of penile trauma poses diverse challenges to the reconstructive urologist, as injuries vary from abrasions to total emasculation. METHODS: Analysis of 16 patients with severe penile injuries referred to us between 2002 and 2011 was undertaken. The median age at surgery was 13 years (range, 5-17). Etiology of penile trauma and choice of treatment were evaluated. The management included a wide variety of surgical techniques that were tailored to the individual patient. Results were analyzed to define etiology, that is, mechanism of penile injury and to estimate modalities of surgical management and postoperative outcomes. Also, postoperative questionnaire was used, which included questions on functioning and esthetical appearance of participating patients and overall satisfaction. RESULTS: The causes of penile injury in these series were traffic accidents (2), iatrogenic trauma (5), self-amputation (1), electrocution (1), burns (3), dog bite (2), zipper injury (1), and mother's hair strangulation (1). The mean follow-up was 46 months (range, 14-122), and examinations were uneventful, except for 2 fistulae formation after neophallic urethral reconstruction. CONCLUSION: The main goal of reconstructive surgery is to have a penis with normal appearance and functions. Severe penile injuries should be treated on a case-by-case basis using the most propitious techniques.

Fractures of the humerus during arm wrestling.

BACKGROUND/AIM: Humeral shaft fractures may occur as a result of arm wrestling. The aim of this study was to present our treatment of humerus fracture sustained during arm wrestling. METHODS: A total of six patients, aged 22 to 48, were treated at our department form January 2008 to January 2010 with open reduction and internal fixation and with hanging arm casts. A review of all the relevant literature on the subject was also presented. RESULTS: In all the cases, the fractures healed and function returned to normal. No patient had any neural or vascular compromise. CONCLUSION: Closed and operative treatments were equally successful in all reported cases.

[Use of free vascularized fibular graft flap in the treatment of large bone defects after limb injury].

Free vascularized fibular graft is of the greatest importance in the orthopaedics and trauma. Bone, skeletal defects due to the trauma, infections and congenital anomalies could be successfully solved by the free vascularized fibular grafts. In this article the main anatomical data of fibular graft, surgical techniques, indications for the FVFG in the treatment of trauma caused bone defects or its complications -sequels are described.

Replantation of upper extremity, hand and digits.

Replantation is defined as reattachment of the part that has been completely amputated and there is no connection between the severed part and the patient. In Boston in 1962 Malt successfully replanted a completely amputated arm of a 12-year-old boy. Komatsu and Tamai reported the first successful replantation of an amputated digit by microvascular technique. There are no strict indications and contraindications for replantation. It's on surgeon to explain to the patient the chances of success of viability, expected function, length of operation, hospitalization and long rehabilitation protocol. Survival and useful function in replantation of upper extremity amputations is questionable. Success depends on microvascular anastomoses, but the final function is related with tendon, nerve, bone and joint repair.

Distal radius fractures--systematic review.

Distal radius fractures are an increasingly prevalent upper extremity injury, especially among elderly patients. They represent approximately 3% of all upper extremity injures. Severity of these fractures is directly related to bone mineral density of the patient, and clinical results are dependent on this parameter as well. There is a bimodal distribution of these injuries, with a peak between 18 to 25 years of age, predominantly male population and a second peak in the elderly, older than 65 years, predominantly female population. Early reports of fractures of the distal radius considered these fractures to be group of injuries with a relatively good prognosis irrespective of the treatment given. When it comes to complex fractures, regardless of the method applied, major or minor functional invalidity persists. With that in mind fractures of the distal radius are medical, social and economic problems of modern society.

Operative treatment of metacarpal and phalangeal fractures with Kirschner wire fixation--a review.

Although hand fractures are most common fractures treated in orthopedic practice, many practicians treat them as trivial injuries. Improperly managed they can cause consequences and impair hand function. Metacarpal and phalangeal fractures are classified based on geometry, anatomic localization and wound presence and treatment depend on mechanism of injury. Many of them can be treated nonoperatively with reposition and immobilization, but in some cases osteosynthesis is a method of choice. Surgeon can choose various range of fixation material, and choice depends on fracture type and surgeons affinity. Kirschner wire fixation is one of the most frequently used operative procedure for hand fracture treatment. It provides good stability, early mobilization and excellent functional result.

Fractures of the scaphoid, diagnosis and management--a review.

The scaphoid is vitally important for the proper mechanics of wrist function. Fracture of the scaphoid bone is the most common carpal fracture. Among all wrist injuries the incidence of scaphoid fracture is second only to fractures of the distal radius. Scaphoid fractures are significant because a delay in diagnosis can lead to a variety of adverse outcomes that include nonunion, delayed union, decreased grips strength, range of motion and osteoarthritis of the radiocarpal joint. To avoid missing this diagnosis, a high index of suspicion and a through history and physical examination are necessary, because initial radiographs are often negative. Regardless of the technique of bone grafting, there will almost always be some loss of motion even if the fracture unites.

Emil Theodor Kocher (1841-1917)--orthopaedic surgeon and the first surgeon Nobel Prize winner.

Theodor Emil Kocher (1841-1917), born in Bern, educated in many universities in Europe. Kocher as many surgeons of that time performed orthopedic surgery, general surgery, neurosurgery and endocrine surgery, but he become famous in orthopaedic surgery and endocrine surgery. He is remember as a surgeon who described the approach to the hip joint, elbow joint, maneuver for the reduction of dislocated shoulder joint. He introduced many instruments and many of them, such as Kocher clamp is still in use. Most important Kocher work was the thyroid gland surgery, and he received the Nobel Prize for Medicine in 1909, for-in this matter. His nature of meticulous surgeon, scientific and hard working person, dedicated to his patients and students made- found him the place in a history of medicine.

[Friedrich von Esmarch--surgeon, one career].

Friedrich von Esmarch was born in 1823 in Germany and he is one of the greatest surgeons of the Germany of that time. Fridrich von Esmarch introduced the Esmarch tourniquet, which enables operative field bloodless. This revolutionary innovation is still present in the orthopaedic surgery all around world, as well as for the first line hemostasis. Beside this, Esmarch also improves others fields of surgery: immobilizations, methods of antiseptic surgery, modified Esmarch mask for anesthesia. He joined few wars and had a rang surgeon-general. Although his experience was primary from the trauma, he also introduced the training courses of the First aid for the ordinary people, making medicine of that time more modern and efficient

Talar injuries--the orthopaedic challenge.

Injuries of the talus represents an important part of the foot and ankle trauma. Since talar bone connect the lower limb and foot, the sequelas of its trauma could have significant influence on the function of the whole lower limb and gait. The specific vascularization of the talus results in delayed union and even in the avascular necrosis. The diagnosis of the fractures of the talus can be made on the x-rays, but sometimes real picture of the fracture pattern can be seen only in the CT scans. Ocult fractures such as osteochondral fractures and avascular necrosis can be exactly detected on MRI in aim not to be overlookded as the ankle sprain diagnosis. The precise reduction and stable internal fixation is mandatory in the treatment to enable the anatomical position of the talonavicular, talocrural and subtalar joint and to make possible early motion and rehabilitation, without weight bearing. On the other hand, crushed fractures, open fractures and the Hawkins III-IV fractures with the dislocations of the talar body sometimes needs salvage procedures like Blair or tibio-talar or tibio-calcaneal fusion.

The development of internal fixation - historical overview.

Since the ancient times, man was faced with the problem of fracture treatment, which is first described in the records from ancient Egypt. Ever since, many treatment methods have been developed, but the real revolution in the fracture treatment was achieved by internal fixation. Since it was described for the first time, at the end of the 18th century, this method has continuously developed, but sterilization, radiographies, anaesthesiology, antibiotics made this surgery modern and safe. The great ideas and practical solutions of the new methods were done by Albin Lambotte, William Arbuthnot Lane, Robert Danis, William Hey Groves. They lead to the expansion of this method and truly made the principles for the future AO school. New methods, biological internal fixation, minimally invasive procedures, new technologies and devices for internal fixation are introduced in the surgical practice daily.

Calcaneal fractures - the orthopaedic challenge.

Calcaneal fractures, since their description in 1843 by Malgaigne, still remain a challenge in orthopaedic surgery. They are significant from an epidemiological point of view - they represent 60% of all tarsal fractures, and of an increasing number of fractures due to traffic accidents and their outcome is unpredictable. In contrast to the disappointing results after nonoperative treatment and at the beginnings of calcaneal surgery, the outcome is promising nowadays. New imaging and fixation devices, with proper classification and indication for certain surgical procedures have led to the improved outcome. But, there are still controversies, and we emphasize the most rationale treatment for the calcaneal fractures, as well as best surgical options.

Impact of the injury pattern on the pedestrian fatalities in the city of Belgrade.

INTRODUCTION: In the city of Belgrade pedestrians are under the high risk to sustain injuries in the road traffic accidents, they are often with multiple injuries, with long-term treatment and significant consequences. Most of them are in the )senior or in the school age group. METHODS: We present the results of the epidemiological analysis of the mechanism of injury and treatment outcome of the pedestrians who sustained the lower limb injuries and additional, the injuries of the other organic systems. We also analysed the relevant data about the moment of the collision. RESULTS: Regarding the gender, male were significant more injured., in the senior age of life. Patients with multiple injuries, especially with the pelvic injuries or injuries of more than two systems were significant more likely to have a fatal outcome. CONCLUSION: The pedestrians are the most vulnerable group in road traffic accidents. Thus, we need to make actions on two levels: appropriate environment conditions and effective prehospital and hospital treatment.

[Professor Dr Borivoje Gradojevic--the first university professor of orthopaedic surgery].

Prof. dr Borivoje Gradojevic was one of the greatest figures of our medicine, and one of the pioneers and founders of orthopedic surgery in our country. He was the first professor of orthopedic surgery in Serbia ie. the professor of Belgrade Faculty of Medicine. Beside well education and professional skills dr Gradojevic published the numerous scientific papers and he published the first textbook of orthopedics in this country. Unfortunately, his professional career was brutally interrupted in 1945, when he was forced to retire and moved from Medical faculty, together with other professors in these times. This resulted in enormous regression--fall in academic community, and our health care system and country also.

[Baron Gijom Dipitren, Guillaume Dupuytren (1777-1835)].

Baron Dupuytren, Guillaume (1777-1835), French anatomist, pathologyst and surgeon, although was a personal doctor of Napoleon, Lui XVI and Sharles X, remain known for Dupuytrene contracture, due to his name, after he described this disease of palmar fascia in 1833. He started his education at Paris at age of 12, at 18 he was chief demostrator of anatomist prosectors. In 1802. he become surgeon assistant and in 1812 professor of surgery. At age of 38 he become surgeon-in-chief in Hôtel-Dieu the most famous hospital in Europe of that time. Dipitren was a dostor of Lui VIII, who gave him the title of baron in 1823. Also, he was the doctor of Sharles X, and from Napoleon he was decorated by Legue of the Honour. He was the richest doctor of the France, and that time was named Dupuytrens time. He was working the whole day, and was dealing with all parts of surgery, but he become most prominent in orthopaedics, making connections between anatomy, pathology and surgery, what make him popular and famous. Dupuytren dies in age of 58 due to the pleural empyema, but he refused surgery. Before that he had brain stroke, from which he never recover, although he continue with lectures.