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.

Pulmonary and Vertebral Mycobacterium avium Disease in a HIV-negative 71-year-old Man - A Case Report.

Nontuberculous mycobacteria (NTM) caused pulmonary disease is on increase worldwide, especially in countries with decreasing time trend of tuberculosis incidence. NTM skeletal affection is rare. Mycobacterium avium related disease, with still unclear clinical and radiologic features, is in current focus of both clinicians and researchers. An exhausted severely ill 71-year-old man was admitted on emergency due to cough, dyspnea and lumbar back pain to be diagnosed with terminal phase M. avium disease. Three sputum smears were positive for acid fast bacilli and M. avium was identified with hybridization reaction by means of GenoType ® MTBC (Hain). Apart from pulmonary disease, compressive fractures of the 12th thoracic and 1-4th lumbar vertebrae were detected. We found age, chronic alcoholism, previous professional exposure, tobacco smoking, chronic obstructive pulmonary disease and previous tuberculosis as risk factors for NTM disease in the HIV-negative patient. Despite combined antibiotic treatment, disease had lethal outcome. This case report might contribute to clinicians' awareness and improved knowledge on this sort of pathology, and lead to earlier diagnosis with possibly better disease outcome.

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.

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.

[50 years of total hip prosthesis--a tribute to Prof. Sir John Charnley].

November 2012 marked the 50th anniversary of the first implantation of a successful and long-lived hip endoprosthesis, which was performed by Prof Sir John Charnley in the "Centre for Hip Surgery" at a small country place in the north-west England. John Charnley (1911-1982) finished medical school at the Victoria University of Manchester in 1935, and than started training in orthopaedics at the Manchester Royal Infirmary, and completed it after the Second World War, in which he served as a volunteer. After that he continued working in the same hospital, and, apart from that he worked as a lecturer at the University of Manchester, and from 1949 as a visiting surgeon in the Wrightington Hospital. In 1958 Charnley decided to put his efforts into the development of hip replacement research and surgery, and initiated the foundation of the "Centre for Hip Surgery" with Biomechanical laboratory in the Wrightington Hospital in 1960, where the intesive basic and clinical research started, and becuase of that Charnley in 1962 left Manchester and moved with a full time practice at the Wrightington Hospital. That period of research time was not easy, there were many "trial and tribulations", but, owing to the tenacity and inventive mind of Charnley, in 1962 a new prosthesis consisting of a cemented metal stem with a 22 mm head articulating with a cemented polyethilene acetabular component, and with a low frictional torque was designed. The first such prosthesis, which later produced excellent long-term results, was implanted on November 22nd, 1962, and today, when we look back over a distance of fifty years, we can conclude that that day could be considered as a beginning of a modem aloarthroplastic surgery, and certainly as one of the greatest orthopaedic advance in the whole of the 20th century; and all that was initiated and promoted by Prof. Sir John Charnley.

Current treatment options of acquired flatfoot.

Symptomatic acquired flatfoot is an important orthopaedic problem, due to progressive loss of whole foot function and the increasing problem of patient disability. It is a complex entity, involving the tibialis posterior tendon, ankle joint, hindfoot and midfoot. In most cases the posterior tibial tendon (PTT) is the root cause of acquired flat foot, but there are other contributors and many different factors have an influence. The clinical picture varies depending on the stage of the deformity, as well as the treatment approach. Initially soft tissue procedures, synoviectomy and augmentation of the PTT are advised. In stage 2, lateral column lengthening and calcaneal osteotomy, with soft tissue - tendon transfers (TA, FHL, FDL) are recommended. In stage 3 subtalar, double or triplearthodesis is preferable, while in stage 4 pantalar fusion is indicated. This article elaborates on the etiology, the clinical picture, diagnosis and treatment modalities.

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.

Time trend and clinical pattern of extrapulmonary tuberculosis in Serbia, 1993-2007.

BACKGROUND/AIM: Increased incidence of extrapulmonary tuberculosis (XPTB) is reported worldwide. Serbia is a country in socio-economic transition period with low-middle HIV prevalence and intermediate-to-low tuberculosis (TB) incidence rate, 100% directly observed treatment (DOT) coverage, and mandatory BCGC vaccination at birth. The aim of the study was to examine the incidence trend and clinical features of XPTB in Serbia during a 15-year period. METHODS: This retrospective observational study included XPTB cases diagnosed in the period between 1st January 1993 and 31st Decembre 2007, according to the reports of the National Referral Institute of Lung Diseases and Tuberculosis in Belgrade and Central Tuberculosis Register. Population estimates with extrapolations were based on 1991 and 2002 census data. RESULTS: While the overall TB incidence rate showed a slight, not significant decreasing trend (p = 0.535), a significant increase was found for XPTB (y = 1.7996 + 0.089x; R2 = 0.4141; p = 0.01). A total of 2,858 XPTB cases (newly diagnosed and 10% relapses) gave an average age specific incidence rate of 2.51/100,000 population (95% confidence interval, SD = 0.6182) with 8.9% annual increase. The male-to-female ratio was 0.54. Lymph nodes were most frequently affected site (48.5%) followed by genitourinary (20.5%), pleural (12%), and osseo-arthicular (10.3%) TB. Treatment outcome was successful in 88.29% of patients (cured and completed), 3.64% died, 5.18% interrupted, 0.57% displaced, and 2.3% unknown. CONCLUSION: Increasing trend of XPTB incidence rate may be a result of increased morbidity due to still present risk factors, possible higher detection rate in Serbia and better notification. A high coverage of newborns with BCG vaccination at birth might contribute to a decreased number and rare XPTB cases in children.

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.

The effects of potassium channel opener P1075 on the human saphenous vein and human internal mammary artery.

Because adrenergic contractions can contribute to the development of life-threatening spasm of coronary artery bypass graft, this study was performed to investigate the effect of adenosine 3-phosphate (ATP)-sensitive K channel (KATP) opener P1075 on contractions of isolated human saphenous vein (HSV) and human internal mammary artery (HIMA). Phasic contractions were evoked by electric field stimulation (20 Hz) and noradrenaline. The sustained contractions were evoked by phenylephrine. The presence of pore-forming Kir6.1 and Kir6.2 subunits of the KATP channels in the HIMA and only Kir6.2 in the HSV was confirmed immunomorphologically. P1075 inhibited in the HSV only, the electrical field stimulation contractions more strongly than noradrenaline contractions. In addition, the phenylephrine contractions of HSV were more sensitive to P1075 in comparison to those of HIMA. Glibenclamide, a KATP channel blocker antagonized the vasodilatation produced by P1075 in both grafts differently, because its effect was more prominent on the P1075-induced inhibition of contractions of HSV than of HIMA. We conclude that P1075 has a vasorelaxant effect and inhibited adrenergic contractions of the tested grafts. This effect is graft and vasoconstrictor selective and seems to be mediated by Kir6.1- and/or Kir6.2-containing KATP channels. Thus, P1075 can be considered as a potential drug in the prevention of graft spasm.

[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.

[Psoas major abscess by heroin addictive patients--a case report].

Drug abuse is related to many medical complications, which depend on the drug type, dose injected, the method of delivery and site of injection. We report a case of psoas abscess in young heroin addict, HIV negative, who was admitted in Emergency Center of Clinical Center in Belgrade because of fever, anaemia, prostration and right groin pain. Clinical and radiological examination were performed. CT showed large abscess of the right psoas muscle, 12 x 4 cm large. Treatment included percutaneous drainage and administration of iv antibiotics. There is regression of inflamation. At discharge patient was in good condition without signs of infection.

[Karakteristike pacijenata sa implantiranom totalnom protezom zgloba kuka i kolena].

UNLABELLED: Osteoarthrosis is the most frequent joint disorder in the world. An increased incidence of total hip replacement (THR) and total knee replacement (TKR) has been noticed recently. AIM: To investigate demographic characteristics, comorbidities, surgical factors and postoperative complications of patients who received THR or TKR. MATERIAL AND METHOD: Patients aged at least 30 years hospitalized at the Clinics for Orthopaedic Surgery and Traumatology, Clinical Centre of Serbia, for THR or TKR between January 1, 2008 and January 1, 2010. were included in a retrospective cohort study. RESULTS: Out of 529 investigated patients, 421 (79.6%) were in the THR group, and 108 were in the TKR group. Patients in the TKR group were 68.7+7.8 year old in average and were significantly older than patients in the THR group (p<0.01). There were more women than men in both gro-ups, but no statistical significance was observed. Hyperte-nsion, which was the most frequent comorbidity, was noticed in 96 (18.1%) patients. 40% of patients were of poor physical condition (ASA 3 and more) approximately. Re-gional anaesthesia was performed more frequently in the TKR group than in the THR group (p < 0.01). The operations of knee replacement surgery lasted longer than hip replacement surgery (139.9 +/- 30.1 min; p < 0.01O). All patients received thromboprophylactic drugs. Five patients (0.9%) who were in the THR group had prosthesis dislocation as one of the observed postoperative complication. The mean duration of hospitalization of patients in the TKR group was 29.7+24.7 days which was longer than in the THR group (p < 0.01). CONCLUSION: Older population, especially women were operated on more frequently in the both groups. Regional anaesthesia was performed more frequently in the TKR group. Although a large percentage of patients had cardiovascular disorders and were of poor physical condition, postoperative complications were rare.