Segmental Humeral Head Reconstruction in Patients with Chronic Locked Posterior Shoulder Dislocation.

Background and Objectives: The goal of this study was to evaluate the functional outcomes of patient treatment using an allograft after chronic locked posterior shoulder dislocation associated with a bony defect of the upper edge of the humerus that involves 25-50% of the articular surfaces. Materials and Methods: A total of 20 patients were included in this study. Electrocution was the cause of injury in eight patients; in ten patients, the cause was direct trauma; and in two patients, the cause of injury was a fall due to hypoglycemic coma. A standard deltoid pectoral approach was used and a fresh-frozen osteochondral allograft of the femoral condyle was applied. In evaluating the results, Constant's scoring scale was used. Results: The average value of Constant's point scale for the operated shoulder is 84.14 points. This result is good according to the average value of Constant's point scale. Conclusions: Patients with locked chronic posterior dislocation in combination with a bony defect of the humeral head that covers 25-50% of the articular surface, in our opinion, should be treated using bone allografts rather than non-anatomical reconstruction methods.

Tubularization of Bone-Tendon-Bone Grafts: Effects on Mechanical Strength and Postoperative Knee Stability in Anterior Cruciate Ligament Reconstruction.

Background and Objectives: The study addresses a significant limitation in applying bone-patellar tendon-bone (BTB) grafts in anterior cruciate ligament (ACL) surgery. By exploring the tubularization of grafts, the study extends the understanding of this surgical technique. The dual approach of the study-focusing on biomechanical properties using an animal model and postoperative outcomes in humans-offers a comprehensive perspective. Materials and Methods: The experimental cohort encompassed ten pairs of fresh porcine bone-tendon-bone grafts. One graft in each pair underwent modification through sutures that transformed the flat graft into a cylindrical structure. Testing determined the force required for the modified graft to rupture mechanically, expressed as N/mm2, compared to conventionally prepared bone-tendon-bone grafts. The second phase of the research involved a prospective randomized clinical trial comprising 120 patients undergoing operative ACL reconstruction. For half the cases, grafts were tubularized using a random selection process. Clinical evaluations preoperatively and 12 months postoperatively employed the Tegner, Lysholm, and IKDC scoring scales for knee assessment. Results: Experiments showed that ligaments made using the tubularized surgical technique have statistically significantly higher values of measured force and higher maximum elongation values than ligaments made using the classical method. The clinical study concluded that there was no significant difference between the two groups of patients in the average score on the Tegner, Lysholm, and IKDC scales before and after surgery. Conclusions: The study results showed that suturing the graft does not negatively affect its biomechanical properties, and tubularization significantly increases the values of force required to cause rupture and the values of maximum elongation during rupture. Given the possibility of the one-year follow-up period being insufficient, future investigations should extend this period to acquire objective functional insights post-surgery.

[Morphology of ulnar trochlear notch and defining ideal position for olecranon osteotomy]. / Morfología de la ulna muesca troclear y definiendo de la posición ideal para la osteotomía del olecranon.

Aim: The aim of the study was to calculate the most important parameters of ulna and to determine its gender. Classifying trochlear notch joint surface types and to establish their representation in Serbian population. To determine the ideal position for olecranon osteotomy. Material and methods: The study included 69 bones. Gender determination was performed using digital scale and photographs of the ulna. The bones weight, maximum and physiological length were measured. The place for the ideal position of olecranon osteotomy (projection of the bare area on its posterior wall) was determined on profile images. Results: Gender related, 45 (65.21%) bones belonged to males, 24 (34.79%) ulnas belonged to females. Type I of the bare area was present in 38 (55%) ulnas, type II in 20 (29%), whereas type III was present in 11 (16%) bones. The average value for the ideal position of olecranon osteotomy was 23.02 mm. In males' ulnas, it was 23.22 mm, in females, it was 22.59 mm. Conclusion: Type I of the bare area is the most common type of trochlear notch joint surface in Serbian population. The average value for the ideal position of olecranon osteotomy was 23.02 mm. We believe that a uniform name for the bare area should be established.

Objetivos: Calcular los parámetros más importantes del cúbito y determinar su género. Clasificar los tipos de superficie de la articulación de la escotadura troclear y establecer su representación en la población serbia. Determinación de la posición ideal para la osteotomía del olécranon. Material y métodos: El estudio incluyó 69 huesos. La determinación del sexo se realizó mediante escala digital y fotografías del cúbito. Se midió el peso de los huesos, la longitud máxima y fisiológica. El lugar para la posición ideal de la osteotomía del olécranon se determinó en imágenes de perfil. Resultados: Relacionado con el género, 45 (65.21%) huesos pertenecían a hombres, 24 (34.79%) cúbitos pertenecían a mujeres. El tipo I del área descubierta estuvo presente en 38 (55%) ulna, el tipo II en 20 (29%), mientras que el tipo III estuvo presente en 11 (16%) huesos. El valor medio para la posición ideal de la osteotomía del olécranon fue de 23,02 mm. Conclusión: El área desnuda tipo I es el tipo más frecuente de superficie articular de muesca troclear en la población serbia. El valor promedio para la posición ideal de la osteotomía del olécranon fue de 23,02 mm. Creemos que se debe establecer un nombre uniforme para el área descubierta.

THE TIBIAL APERTURE SURFACE ANALYSIS IN ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION PROCESS.

INTRODUCTION: The tibial tunnel aperture in the anterior cruciate ligament reconstruction is usually analyzed as an ellipse, generated as an intersection between a tibial plateau and a tibial bone tunnel. The aim of this study is to show that the tibial tunnel aperture, which utilizes 3D tibial surface bone model, differs significantly from common computations which present the tibial tunnel anterior cruciate ligament aperture surface as an ellipse. MATERIAL AND METHODS: An interactive program system was developed for the tibial tunnel aperture analysis which included the real tibia 3D surface bone model generated from a series of computed tomography images of ten male patients, their mean age being 25 years. In aperture calculation, the transverse drill angle of 10 degrees was used, whereas sagittal drill angles of 40 degrees, 50 degrees and 60 degrees were used with the drill-bit diameter set to 10 mm. The real 3D and 2D tibial tunnel aperture surface projection was calculated and compared with an ellipse. RESULTS: According to the calculations, generated 3D aperture surfaces were different for every patient even though the same drill parameters were used. For the sagittal drill angles of 40 degrees, 50 degrees and 60 degrees, the mean difference between the projected 3D and 2D area on the tibial plateau was 19.6 +/- 5.4%, 21.1 +/- 8.0% and 21.3 +/- 9.6%, respectively. The difference between the projected 3D area on the tibial plateau and ellipse surface was 54.8 +/- 16.3%, 39.6 +/- 10.4% and 25.0 +/- 8.0% for sagittal drill angles of 40 degrees, 50 degrees and 60 degrees, respectively. CONCLUSION: The tibial tunnel aperture surface area differs significantly from the ellipse surface area, which is commonly used in the anterior cruciate ligament reconstruction analysis. Inclusion of the 3D shape of the tibial attachment site in the preoperative anterior cruciate ligament reconstruction planning process can lead to a more precise individual anatomic anterior cruciate ligament reconstruction on the tibial bone. Both tibial aperture area generated in 3D and its projection on a tibial plateau are larger than the ellipse surface; therefore, individual characteristics of each patient have to be taken into consideration.

THE RELATIONSHIP BETWEEN THE RANGE OF MOTON OF THE HIP JOINT WITH RUPTURED ANTERIOR CRUCIATE LIGAMENT.

INTRODUCTION: A knee injury, especially anterior cruciate ligament. has recently become more common significantly affecting the life standard. There are many factors that cause an injury of the anterior eruciate ligament, ~nd one of them is limited range of motion in the hip joint. This studyhas been aimed at finding a relationship between the range of motion in the hip joint and the anterior eriiciate ligament injury. Matcrial and Methods. Of88 male athletes included in the study sample in 2014, 60 (68%) had ruptured knee anterior cruciate ligament and 28 (32%) were without an injury. There was no sianificant difference in sex, height, weight, age and time of injury between the two groups. RESULTS: Significant differences were found in the range ofmotion between the lefi and right leg in both groups. The athletes with a ruptured anterior cruciate ligament had an abduction limit of the hip joint (p0.007) and a wider rang of motion of the knee joint (p0.O02) than thc athletes without the inj Liry. CONCLUSION: Data obtained in this study suggest a possible relationship between a limited hip abduction of range of motion in athletes and an increased risk of anterior cruciate ligament injury.

INFLUENCE OF DIFFERENT LEVELS OF SPORTS ACTIVITIES ON THE QUALITY OF LIFE AFTER THE RECONSTRUCTION OF ANTERIOR CRUCIATE LIGAMENT.

INTRODUCTION: The goal of this study was to examine the nature and presence of influence of different levels of sports activity on the life quality of the patients a year after the reconstruction of anterior cruciate ligament. MATERIAL AND METHODS: The study included 185 patients operated at the Department of Orthopedic Surgery and Traumatology of the Clinical Centre of Vojvodina, who were followed for twelve months. Data were collected using the modified Knee Injury and Osteoarthritis Outcome Score questionnaire which included the Lysholm scale. RESULTS: This study included 146 male and 39 female subjects. The reconstruction of anterior cruciate ligament was equally successful in both gender groups. In relation to different types of sports activity, there were no differences in the overall life quality measured by the questionnaire and its subscales, regardless of the level (professional or recreational). However, regarding the level of sports activities, there were differences among the subjects engaged in sports activities at the national level as compared with those going in for sports activities at the recreational level, and particularly in comparison with physically inactive population. A significant correlation was not found by examining the aforementioned relationship between sports activities. CONCLUSIONS: This study has shown that the overall life quality a year after the reconstruction of the anterior cruciate ligament does not differ in relation to either the gender of the subjects or the type of sports activity, while the level of sports activity does have some influence on the quality of life. Professional athletes have proved to train significantly more intensively after this reconstruction than those going in for sports recreationally.

DEFINITE MANAGEMENT OF BILATERAL LOWER LEG NONUNION FRACTURES BY ILIZAROV APPARATUS IN POLYTRAUMATIZED PATIENT - CASE REPORT.

INTRODUCTION: Nonunion of long bones may often be associated with significant function loss of affected extremity, joint stiffness, and even extremity amputation or systemic manifestations in the case of infection. The aim of this case report is to highlight the possibilities of Ilizarov apparatus in the treatment of fracture nonunions of both lower legs treated by different operative methods and to show that it is not necessary to remove osteosynthetic material (intramedullary nail) in every case when nonunion occurs to achieve its recovery. CASE REPORT: A 62 year-old man was injured in a traffic accident as a pedestrian in April2012, when he experienced polytrauma, including shaft fracture of the right femur, and segmental open fractures of the right (Gustillo-Anderson grade I) and left (Gustillo-Anderson grade II) lower leg. The fractures of right femur and right tibia were stabilized initially with intramedullary nails, while the left lower leg fracture was treated by unilateral external fixator. After 5 months, there were no clinical and radiographic signs of union on lower legs, therefore the patient underwent re-surgery. Ilizarov apparatus was applied on both lower legs. The patient was early verticalized and both apparatus were removed after 4 months. According to the modified protocol of the Association for the Study and Application of Methods of Ilizarov, the lower leg bony results were good and excellent, and the functional results were excellent on both sides. CONCLUSION: Nonunion fracture of the right lower leg initially treated by the method of intramedullary osteosynthesis and afterwards by placing Ilizarov apparatus shows that in some cases it is not indicated to remove fixative material in order to achieve full recovery of fracture, thus eliminating the danger of all negative effects resulting from the classical extensive surgical treatment.

Patellar tendon rupture--treatment results.

INTRODUCTION: Patellar tendon rupture is a rare injury which, if missed, leads to delayed surgical treatment and may result in the loss of the knee joint function. The aim of this study was to report our results of operative treatment of the patellar tendon rupture and point out the significance of timely diagnosis and surgical procedure. MATERIAL AND METHODS: This retrospective ten-year study included 20 patients, 15 males and 5 females, their mean age being 42 (20-84) years. Seven participants had an injury on the right side and 13 had an injury on the left side. Thirteen participants had the diagnosis set in the first seven days after the injury. The applied techniques were surgical suture of the tendon, bone-tendon-bone ligamentoplasty using allograft from a bone bank and bone-tendon-bone ligamentoplasty using contralateral autograft, and they were performed in 12, 5 and 3 patients, respectively. The treatment results were assessed by using the Lysholm score, measuring the range of movement in the knee joint and measuring the girth of the thigh 10 cm above the patella. RESULTS: The follow-up period after the surgery was 4 years on average (1-10 years) and the average value of the Lysholm score was 83 (27-100). The result was found to be excellent in 11 cases, satisfactory in 5 cases and unsatisfactory in 4. A statistically significant difference (p=0.0197 p<0.05) was found in the average values of the Lysholm score between the group of patients with risk factors (71.78) and the subjects without risk factors (92.18). A statistically significant difference (p=0.008 p<0.01) was found in the Lysholm score between the patients with timely diagnosis (91.62) and cases of chronic tendon tear (67). CONCLUSION: Timely diagnosis and early surgical reparation are the basic imperatives in the treatment of this injury. Comorbidity and risk factors are related to a poorer postoperative Lysholm score. The method of choice is early surgical treatment.

BONE-PATELLAR TENDON-BONE GRAFT PREPARATION TECHNIQUE TO INCREASE CROSS-SECTIONAL AREA OF THE GRAFT IN ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION.

INTRODUCTION: Not much has changed in the way the bone-patellar tendon-bone graft is prepared before implantation. We present a modified bone-patellar tendon-bone graft preparation technique by implying the increased cross-sectional area. MATERIAL AND METHODS: Measurements of bone-patellar tendon-bone graft were made during the reconstruction of the anterior cruciate ligament in 93 male patients. The bone part of bone-patellar tendon-bone graft 10 mm wide and the tendon part 12-14 mm wide was placed on the holder with a handle in a way which allowed sewing the edges of the patellar tendon in a shape of a tube. The circumference of the central part of the graft was measured using a suture tightened around the graft. The diameters of the circle and cross-sectional areas were then calculated using geometrical calculation. RESULTS: After preparation of the bone-patellar tendon-bone graft, the fol- lowing measures were recorded: the circumference of 30 mm, the diameter of 9.55 mm, and the cross-sectional area of 72 mm2 in 9 patients; the circumference of 31mm, the diameter of 9.87 mm, and the cross-sectional area of 76 mm2 in 15 patients, and the circumference of 32 mm, the diameter of 10.19 mm, and the cross-sectional area of 82 mm2 in 69 patients. CONCLUSION: For the average thickness (3-5 mm) and width (10 mm) of the patellar tendon graft, the cross-sectional area will be 30-50 mm2. The modified bone-patellar tendon-bone graft preparation technique made it possible to increase its cross-sectional area to 71-81 mm2.

Surgical treatment of shoulder rotator cuff injuries.

INTRODUCTION: The rotator cuff is the most important functional structure of the shoulder. The aim of this study was to determine which factors contribute to a rotator cuff injury and to evaluate the results of the surgical treatment at the Department of Orthopedic Surgery and Traumatology in Novi Sad since December 2009 until May 2012. MATERIAL AND METHODS: The study sample consisted of 20 patients who had been operated for a shoulder rotator cuff injury. Their mean age was 56.8 +/- 9.1. RESULTS: According to the Constant Shoulder Score, 75% of the patients had excellent and good results. A statistically significant difference (p < 0.05) was found between Constant Shoulder Score of the operated should and the opposite shoulder as well as between the range of external and internal rotation and abduction. After the surgical treatment, 95% of the patients have no limitations in the activities of daily living and they are satisfied with the results of treatment. CONCLUSION: Surgical treatment of a shoulder rotator cuff injury is reliable, time-tested and provides good clinical results especially in patients who were operated within the first three weeks after the injury.

Treatment of complex tibial plateau fractures using Ilizarov technique.

Complex tibial plateau fractures are most commonly caused by high-energy trauma and they are often associated with severe soft tissue injuries that can frequently result in severe complications. Ilizarov external circular fixation is an ideal method of treatment for high- energy fractures of the tibial plateau when extensive soft tissue dissection and internal fixation are contraindicated. Our research included 50 consecutive patients and clinical features of the patients were evaluated during the follow up period using the following instruments: Gustillo-Anderson, Sc- hatzker and Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/ OTA) classification methods. Bony results were evaluated using the Association of the Study and Application of the Method ofIlizarov (ASAMI) protocol. The mean functional recovery scores were obtained by the modified functional evaluation system of Karlstrom-Olerud. All fractures healed successfully. Circular fixators could be removed without anesthesia for type IV fractures at 16 weeks (range 12-21) and for type V-VI at 18 weeks (range 15-26) after the operation. According to ASA- MI bone results, there were 39 (78%) excellent, 7 (14%) good, 3 (6%) fair results and 1 (2%) poor result. Analysis of data obtained by the Karlstrom-Olerud functional evaluation system in this study yielded a mean value of 24.7 after six months, which implies recovery. Functional recovery at 12 months after surgery revealed satisfactory recovery with a mean value of 27.7, whereas the mean sco- re of 29.8 recorded at the last evaluation suggested good functional status. The treatment of patients with open and closed multiple intra-articular fractures of proximal tibia applying Ilizarov apparatus showed good functional outcome, which had positive impact on our patients' quality of life.

Disruption of the knee extensor apparatus complicating anterior cruciate ligament reconstruction.

Disruption of the knee extensor apparatus, after harvesting the central third of the patellar tendon for a bone-tendon-bone autograft, is a rare complication. We made 2215 reconstructions of the anterior cruciate ligament of the knee using bone-patellar tendon-bone technique, and 10 patients had fracture of the patella (0.45%), and fore patients had rupture of the patellar tendon (0.18%). The fracture of the patella in two patients was treated nonoperatively and 8 patients was treated with operative reduction and osteosynthesis. Reconstruction of the patellar ligament in four patients with a rupture of patellar tendon (0.18%) was performed by a technique previously published with BTB allograft taken from the local bone bank. The mean Lysholm score was 90 (85-100), and all of them have continued to engage in sporting activities. In all patients the Lachman test was with the firm stop compared to the other leg. X-ray changes in the patella were found in 2 patients, who had multifragmentary fractures of the patella. Disruption of the knee extensor apparatus, after harvesting the central third of the patellar tendon for a bone-tendon-bone autograft, can be prevented by avoiding to take too much bone graft, by using the most precise tools for cutting, while rehabilitation must be carefully planned. The optimal treatment disruption of the knee extensor apparatus after the reconstruction of the anterior cruciate ligament is a operative reconstruction, which allows continuation of the rehabilitation program.

Dislocation of the proximal tibiofibular joint.

INTRODUCTION: Dislocation of the proximal tibiofibular joint is a rare injury. It occurs during a sports activity that includes rough twisting movements of the bent knee. The role of the proximal tibiofibular joint is to reduce torsional loads to the ankle, to distribute the bending moment of the outer side of tibia, and transfer the vertical load while standing. In the literature there is no larger series; only several cases of the proximal tibiofibular joint dislocation treated by different methods have been published so far. CASE REPORT: A 23-year-old male soccer player sustained an injury after he had joined the game without previous warming-up. He fell on his right side because of a sudden change of direction while his foot was fixed to the base. He felt a severe pain and had a sensation as if something had snapped in his right knee. Pain and swelling at the head of fibula were found by physical examination, which, however, did not reveal any pain, swelling and instability of the ankle or peroneal nerve palsy. The x-ray showed anterolateral dislocation of the proximal tibiofibular joint, Ogden type II. Since manual reposition in general anesthesia failed, open reduction internal fixation was performed and proximal tibiofibular joint was transfixed with a screw After the wound closure, the above-the-knee plaster cast was applied. The screw was extracted six weeks later, full weight bearing was allowed and he started with physical therapy. Four months after the injury he returned to sports activities. On the follow-up one year after the injury he had the full range of motion of the knee, no complains, and continued with active soccer playing. X-ray showed no signs of arthrosis of the proximal tibiofibular joint. CONCLUSION: The proximal tibiofibular joint dislocation may be the cause of the chronic pain of the knee so it has to be taken into account when making differential diagnosis in case of the pain at the lateral side of the knee. The key for making the accurate diagnosis is the technically correct X-ray of the injured knee compared with the opposite one, showing the displacement of fibular head. If manual reposition fails, open reduction internal fixation and screw transfixation of the proximal tibiofibular joint allow good results and fast return to sport activities.