Locking retrograde nail, non-locking retrograde nail and plate fixation in the treatment of distal third femoral shaft fractures: radiographic, bone densitometry and clinical outcomes.

BACKGROUND: Distal third femoral shaft fractures are characterized by increasing incidence and complexity and are still considered a challenging problem (high morbidity and mortality). No consensus on best surgical option has been achieved. This study aims to investigate radiographic, mineral bone densitometry and clinical outcomes of locking retrograde intramedullary (LRN) nailing, non-locking retrograde intramedullary nailing and anatomical locking plate to surgically treat distal third femoral shaft fractures in young adults. Our hypothesis was that there is no significant statistical difference among the surgical options in terms of results (radiographic, bone densitometry and outcomes assessment). METHODS: Retrospective study: 90 patients divided into three groups (group 1 LRN, group 2 NLRN, group 3 plating). Average age was respectively 42.67 (± 18.32), 44.27 (± 15.11) and 42.84 (± 18.32) years. Sex ratio F:M was respectively 2.75, 2.33 and 2.00. AO Classification, KOOS, NUSS and RUSH score, VAS, DEXA scans and plain radiographs were used. Evaluation endpoint: 12 months after surgery. RESULTS: There were no statistical differences in terms of surgery time, transfusions, and wound healing. Results were similar with regard to average time of bone healing, RUSH scores, VAS, KOOS, regression between RUSH and VAS, average correlation clinical-radiographic results and patients outcomes. CONCLUSIONS: Our results showed no statistical difference in the use of LNR, NLNR and plating for treatment of distal third femur shaft fractures in terms of radiographic, bone densitometry and clinical outcomes. Good subjective and objective results are provided by all three techniques. The choice among the studied techniques must be based on surgeons' experience, indications and subjective patients' aspects. The absence of relevant similar data in the published literature does not allow definitive validation (or rejection) of our hypothesis. A more powered study with a bigger cohort is needed for definitive validation.

Effectiveness of teriparatide combined with the Ilizarov technique in septic tibial non-union.

Aim The septic non-union is a common compliance in bone healing due to bone infection. Bone resection, associated with Ilizarov osteo-distraction technique, is commonly used in these cases. The aim of this study was to analyse clinical and radiological results of teriparatide in combination with the Ilizarov technique and to compare this treatment with the standard treatment. Methods Forty adult patients underwent surgery because of type C of the Association for the Study and Application of Methods of Ilizarov (ASAMI) classification non-union were enrolled. The patients were divided in two groups: those treated with Ilizarov technique (Norm group) and those treated with Ilizarov technique combined with teriparatide injection (Teri group). Surgical duration, complication rate, bone healing status, clinical and functional outcomes were assessed according to the A.S.A.M.I. classification in the mean follow-up of 12 months. The subjective quality of life was assessed by the Short Form Survey (SF)-12. Results Teri group showed less time wearing Ilizarov's frame (p <0.05) than the Norm group and a statistical significance in the inter-rater reliability Cohen's k (p>0.05) respect to Norm according the score between the bone healing and clinical outcome results. There was no statistically significant difference between the two groups in other parameters that were assessed. Conclusion A benefit of teriparatide was found as adjuvant in the treatment of septic non-union.

Platet Rich Plasma or Hyperbaric Oxygen Therapy as callus accellerator in aseptic tibial non union. Evaluate of outcomes.

BACKGROUND AND AIM OF THE WORK: The incidence of long bone non-unions has been estimated to range between 5-10%. Nonunion of fracture is a delayed complication of fracture. A large bone resection, associated with Ilizarov's osteo-distraction technique, is commonly used in these cases. The war experience was very important for dealing with these injuries. The purpose of this study is to report whether the use of Platelet Rich of Plasma(PRP) or Hyperbric Oxygen Therapy(HOT) as an adjuvant to the osteogenic distraction of Ilizarov with respect to the classical method has advantages. METHODS: From 183 tibial non union, we enrolled 50 patients suffering by Type B according ASAMI non union classification.  We divided the patients into two groups. The first group was a retrospective group of patient treated by Ilizarov Tecnique plus PRP. Instead the second group, patients were treated by Ilizarov Tecnique associated with  HOT. The chosen criteria to evaluate the two groups during the clinical and radiological follow-up were: the complication after the surgery in the two groups; the duration of surgery; the objective quality Bone results and functional results were evaluated according to ASAMI classification while the subjective quality of  life correlated with Ilizarov frame function by the Short Form 12 Health Survey (SF-12); The correlation between bone regenerate/bone healing and X-rays. The evaluation endpoint was set at 12 months from the remotion of Ilizarov's frame for both groups. RESULTS: In comparing the complications  of the two populations, there were a significant statistically difference(p<0.05) in the local skin inflammation and Dockin Point Skin retraction  for HOT group while  in refracture  p<0.05 was for group PRP. From the SF-12 we discovered not statistically differences p<0.05. The average correlation between Bone Regenerate-Bone Healing/ X-rays is absolutely in the PRP as in the HOT, p>0.05. The average Time for remove Ilizarov's Frame in months was 15.37(±7.34; range 9-32) in PRP while in HOT was15.22(± 7.83; range 9-31), p>0.05. CONCLUSIONS: From our study we can conclude that the association of HOT and PRP with the Ilizarov technique does not improve the functional outcomes but allows a more rapid healing of the regenerated bone and therefore an early removal of the device and a corresponding improvement in the quality of life.

Transient osteomyelitis of the distal radius in a three-year-old patient.

Aim Reporting on an atypical case of a three-year-old patient affected by osteomyelitis of the distal radius, completely healed without antibiotic therapy. Methods The clinical case is related to a three-year-old patient, whose clinical picture began with fever, pain and swelling of the right wrist. After three days, fever and swelling disappeared, but pain persisted. Plain x-rays of the right wrist, hematologic analyses, magnetic resonance imaging (MRI) with contrast medium and biopsy were performed in order to make a differential diagnosis between acute osteomyelitis and a malignant neoplasm, i.e. Ewing's sarcoma. Results The plain x-rays of the right wrist showed an osteolytic area of the distal radio, with blurred rim. Haematology showed high erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP); MRI confirmed the presence of a lesion, of no certain origin, therefore a biopsy was done. The histology was that of an inflammatory tissue. The patient, after the biopsy, was completely asymptomatic, ESR and CRP were back to normal. Before starting antibiotic therapy, it was preferred repeating x-rays. From the latter, the osteolysis completely disappeared. On the basis of the x-rays, blood exam and symptomatology, it was decided not to submit the patient to any treatment. After two years, the patient never had similar episodes. Conclusion Patient presented with all characteristics of an osteomyelitis of distal radius, was unexpectedly spontaneously healed, without antibiotic therapy. Two years after the onset of the disease the patient recovered without clinical and radiographic sequelae. No similar cases are found in the literature .

A new plate design to treat displaced 3-4 parts proximal humeral fractures in comparison to the most tested and used plate: clinical and radiographic study.

Aim Proximal humeral fractures are common and most complex patterns currently represent a challenge for surgeons. Difficulties in obtaining good anatomical reduction (particularly of great tuberosity) often lead to unsatisfactory results; choices often fall onto prosthesis implantation against fixation options. The aim of this study was to compare a new design of proximal humeral plate with the most used plates in the treatment of these injures by analysing outcomes and complications. Methods Two hundred patients with proximal 3 or 4 parts humeral fracture were enrolled (Neer 3-4). First group treated with PGR Plate composed of 98 patients. Second group treated with Philos Plate composed of 102 patients. Evaluation criteria were Non-Union Scoring System, duration of surgery, complications, objective quality of life and elbow function (Constant Shoulder Score), subjective quality of life and elbow function (Oxford Shoulder Score), post-op radiographs, centrum collum diaphyseal angle. Evaluation endpoint was 12 months. Results There was no statistically significant difference between the groups with regard to the selected evaluation parameters. Achievement of good shoulder range of motion and ability to perform normal daily living activities was obtained in both groups. The PGR had a positive impact on treatment results of varuspattern of proximal humeral fractures. Conclusions The PGR allowed good clinical and radiographic results in the treatment of proximal humeral fractures, comparable to those obtained with Philos. Also, PGR had the advantage to aid and keep the anatomical reduction of patterns of fracture involving the greater tuberosity.

The challenge of nonunion and malunion in distal femur surgical revision.

Aim To demonstrate validity of a bio-metallic solution in bone healing combined with the quadriceps safe approach in the treatment of nonunions of distal femur while malunions were treated by metallic solution. Methods We treated 57 patients with nonunion or malunion of distal femur at the Orthopaedics and Traumatology Department of a single orthopaedic trauma centre (Italy). A total of 57 patients were divided in two groups: the first (NU) group was composed of 35 patients affected; the second group (MU) was composed of 22 patients affected by malunion of distal femur. Criteria chosen to evaluate the two groups during a clinical and radiological followup were: the quality of life measured by the Short Form (12) Health Survey, the knee function and quality of life related to it measured by the Knee Injury and Osteoarthritis Outcome Score KOOS and the Knee Society Score, bone healing measured by modified Radiographic Union Score by X-rays during the follow-up and CT at one year after the surgery, the difference of the limbs length before and after the revision surgery, and postoperative complications. The evaluation endpoint was set at 12 months. Results There were no statistical differences between the two groups. Conclusion The role of bio-metallic solution in the treatment of nonunions and malunions is to recreate the knee anatomy and functionality compatible with a satisfactory quality of life.

Challenges in the management of floating knee injuries: Results of treatment and outcomes of 224 consecutive cases in 10 years.

INTRODUCTION: Floating knee is a flail knee joint resulting from fractures of the shafts or adjacent metaphyses of the femur and the ipsilateral tibia. It is usually associated with several complications and mortality. This study was designed to present our experience with the treatment of this injury. MATERIAL AND METHOD: This study was performed between January 2004 and December 2014. 224 cases of floating knee injuries gathered from the 34,480 lower extremities trauma files were studied, and the target information recorded. The injuries most frequently occurred in subjects between 16 and 35 years of age (60.71%), and in male subjects (85.71%). The most frequent mechanism of injury was traffic accident (92.85%). External fixation was the common type of treatment (82.14%) in emergency or as a definitive treatment. The treatment was performed within 24 h of the trauma. We performed a 36-month follow up with clinical examination, radiographs, assessing the complications, and using the Modified Cincinnati Rating System Questionnaire (MCRSQ) and the Karlström/Olerud Score (KOS) to evaluate the progression of the outcomes. RESULTS: Early complications included 8 cases of compartment syndrome, 60 open fractures and 24 partially amputated limbs. A total amputation was performed in 3 patients. The most common late complication was heterotopic calcifications of the knee (n = 68, 30.6%). Good scores for MCRSQ and KOS were obtained only after patients were sent to a reference center for knee surgery. CONCLUSIONS: Our experience revealed that the complication rate associated with floatingknee injuries remains high, regardless of the performed treatment. Surgeons should focus on reducing complications while treating these severe injuries.

Comparison of biomechanical stability of osteosynthesis materials in long bone fractures.

Aim To calculate stress and deformation under the force of pressure and bending in the dynamic compression plate (DCP), locking compression plate (LCP), selfdynamisable internal fixator (SIF) and locked intramedullary nail (LIN) in the models of juvidur, beef tibia bone (cadaver) and software of bone model simulator. Methods Juvidur and bone models were used for the experimental study, static tests were performed with SHIMADZU AGS-X tester. CATIA software was used to create a 3D model for the SCA simulator, while software ANSYS to calculate the tension and deformation for compressive and bending forces. Stress and deformation analysis was performed with the use of Finite Element Analysis (FEA). Results Weight coefficients of research methods were different (juvidur=0.3; cadaver=0.5; SCA Simuator=0.2), and weight coefficients of the force of pressure Kp =0.5 and bending forces in one plane K1 =0.25 and K2 =0.25 in another plane, the overall result on the dilatation of DCP, LCP, LIN and SIF on juvidur and veal cadaver models showed that the first ranking was the LIN with a rank coefficient KU-LIN = 0.0603, followed by the IFM with KU-IFM = 0.0621, DCP with KU-DCP = 0.0826 and LCP with KU-LCP = 0.2264. Conclusion Dilatation size did not exceed 0.2264 mm, hence the implants fulfilled biomechanical conditions for the internal stabilization of bone fractures. Prevalence goes to the locked intramedullar nailing and Mitkovic internal fixator in the treatment of diaphyseal, transversal, comminuted fractures in relation to DCP and LCP.

WITHDRAWN: Challenges in the management of floating knee injuries: Results of treatment and outcomes of 224 consecutive cases in 10 years.

The Publisher regrets that this article is an accidental duplication of an article that has already been published in Injury, 50(2) (2019) 453­461, https://doi.org/https://doi.org/10.1016/j.injury.2018.12.009. The duplicate article has therefore been withdrawn. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.

Use of Common Inflammatory Markers in the Long-Term Screening of Total Hip Arthroprosthesis Infections: Our Experience.

Orthopedic implants have become essential components of modern medicine. The risk of infection of total hip arthroplasty (THA) is 1.5%-2%. Are the C-reactive protein (CRP), the erythrocyte sedimentation rate (ESR), and procalcitonin (PCT) good markers for THA infection screenings? From February 2009 to December 2012 at our Department of Orthopedics and Traumatology, 1248 patients were treated with THA. No prosthesis was cemented. All patients received antibiotic prophylaxis. All patients were discharged approximately 7.4 days after surgery with this clinical and radiographic follow-up program at 15 days and 1, 3, 6, 12, 24, and 36 months after surgery. Blood samples to determine ESR, CRP, and PCT values were taken at 1 hour before surgery and 15 days and 1, 3, 6, 12, 24, and 36 months after surgery. During follow-ups there were 22 cases of THA infections; according the Widmer classification, infections are hematogenous ones in 16 cases, late chronic ones in 5 cases, and early postoperative ones in 1 case. In all cases the three markers were considered positive; in 6 cases there were no radiological signs of septic loosening. ESR, CRP, and PCT proved to have a greater diagnostic accuracy than X-rays in predicting late chronic and early postoperative infections. These markers are valuable support for the surgeon in monitoring the prosthetic implant lifespan.

Examination of Risk Factors for the Development of Surgical Site Infections.

INTRODUCTION: Hospital-acquired infections (HAI) and surgical site infections (SSI) are a global public health problem. The aim of the study was to determine the incidence of SSIs at the Surgical Clinics of the University Clinical Centre Banja Luka and to identify risk factors for the development of SSIs. METHODS: In order to determine the frequency of SSIs through the incidence compared to the patients operated at the Surgical Clinics of the University Clinical Centre Banja Luka, we conducted a prospective cohort study which encompassed 11.216 operated patients, in the period from November 11th, 2014 to September 30th, 2015. In order to identify risk factors for the development of SSIs, a nested case-control study of risk factors for SSIs was conducted. The study group consisted of patients who were diagnosed with SSIs in the period of monitoring, while the control group was consisted of patients without SSIs who corresponded with the study group in age and sex. RESULTS: The highest values of incidence of SSIs were observed at the Department of Anesthesia and Intensive Care (2.65%), Department of Orthopaedic Surgery (2.48%) and the Department of Vascular Surgery (2.15%), and the lowest ones at the Department of Urology (0.59%). Among the cases of SSIs, deep infections of the surgical site were the most represented (82.7%). Multivariate logistic regression was used to identify the following independent risk factors: length of pore-operative stay in hospital (p=0.000; OR=1.062; 95% CI=1.037-1.087), reintervention (p=0.000; OR=22.409; 95% CI=6.361-79.071) and cotrticosteroids (p=0.023; OR=4.141; 95%CI=1.221-14.047). CONCLUSION: The incidence of SSIs at the Surgical Clinics of the University Clinical Centre Banja Luka is at the level of hospitals in developed countries. There are a number of risk factors for SSIs, which may be prevented.

Biomechanical Stability of Juvidur and Bone Models on Osteosyntesic Materials.

INTRODUCTION: Artificial models can be useful at approximate and qualitative research, which should give the preliminary results. Artificial models are usually made of photo-elastic plastic e.g.. juvidur, araldite in the three-dimensional contour shape of the bone. Anatomical preparations consist of the same heterogeneous, structural materials with extremely anisotropic and unequal highly elastic characteristics, which are embedded in a complex organic structure. THE AIM OF THE STUDY: Examine the budget voltage and deformation of: dynamic compression plate (DCP), locking compression plate (LCP), Mitkovic internal fixator (MIF), Locked intramedullary nailing (LIN) on the compressive and bending forces on juvidur and veal bone models and compared the results of these two methods (juvidur, veal bone). MATERIAL AND METHODS: For the experimental study were used geometrically identical, anatomically shaped models of Juvidur and veal bones diameter of 30 mm and a length of 100 mm. Static tests were performed with SHIMADZU AGS-X testing machine, where the force of pressure (compression) increased from 0 N to 500 N, and then conducted relief. Bending forces grew from 0 N to 250 N, after which came into sharp relief. RESULTS: On models of juvidur and veal bones studies have confirmed that uniform stability at the site of the fracture MIF with a coefficient ranking KMIF=0,1971, KLIN=0,2704, KDCP=0,2727 i KLCP=0,5821. CONCLUSION: On models of juvidur and veal bones working with Shimadzu AGS-X testing machine is best demonstrated MIF with a coefficient of 0.1971.

Treatment of Bone Defects in War Wounds: Retrospective Study.

INTRODUCTION: Results of the treatment of open fractures primarily depend on the treatment of connected soft tissue injuries. OBJECTIVE: The aim was to present the experience and methods gained during the treatment of diaphyseal bone defects as a consequence of gunshot fracture soft war trauma. PATIENTS AND METHODS: The study consisted of 116 patients with the diaphyseal bone defect who were treated with the usage of primary and delayed autotransplantation of bones, transplants of the fibula and Ilizarov distraction osteogenesis. RESULTS: The results of compensation of bone defect less than 4 cm and conducted by an early cortico-spongioplastics were as follows: good in 8 respondents (45%), satisfactory in 6 (34%) and poor in 4 respondents (21%). In cases of delayed cortico-spongioplastics, the above mentioned results were: good in 36 (41%) respondents, satisfactory in 24 (34%) and poor in 16 (25%) respondents. The results of compensation of bone defect greater than 4 cm with the usage of fibular transplant were as follows: good in 3 (38%) respondents, satisfactory in 3 (38%) and poor in 2 (24%), and with the usage of using the Ilizarov method, the results were as follows: good in 8 (57%) respondents, satisfactory in 3 (21.5%) and poor in 3(21.5%) respondents. CONCLUSION: The results showed that, in cases of compensation of bone defects less than 4 cm, the advantage is given to the primary spongioplastics over the delayed one. In cases of compensation of bone defects greater than 4 cm, the advantage is given to the Ilizarov distraction osteogenesis when compared to the fibular transplant.

Controversies in treatment of acetabular fracture.

INTRODUCTION: Acetabular fractures treatment represents a great controversy, challenge and dilemma for an orthopedic surgeon. AIM: The aim of the paper was to present the results of treatment of 96 acetabular fractures in the Clinic of Traumatology Banja Luka, in the period from 2003 to 2013, as well as to raise awareness regarding the controversy in the methods of choice in treating acetabulum fractures. MATERIAL AND METHODS: The series consists of 96 patients, 82 males and 14 females, average age 40.5 years. Traffic trauma was the cause of fractures in 79 patients (85%), and in 17 patients (15%) fractures occurred due to falls from height. Polytrauma was present in 31 patients (32%). According to the classification of Judet and Letournel, representation of acetabular fractures was as follows: posterior wall in 32 patients, posterior column in 28, anterior wall in 4, anterior column in 2, transverse fractures in 8, posterior wall and posterior column in 10, anterior and posterior wall in 6, both- column in 4 and transversal fracture and posterior wall in 2 patients. 14 patients were treated with traction, that is, 6 patients with femoral traction and 8 patients with both lateral and femoral traction. 82 patients (86.4%) were surgically treated. Kocher-Langenbeck approach was applied in the treatment of 78 patients. In two patients from the Kocher-Langenbeck's approach, the Ollier's approach had to be applied as well. Two acetabular were primarily treated with Ollier's approach. Extended Smith- Peterson's approach was applied 4 times, and Emile Letournel's (ilioinguinal) approach 14 times. RESULTS: Functional outcome (after follow-up of 18 months), according to the Harris hip score of surgical treatment in 82 patients, was as follows: good 46 (56%), satisfactory 32 (39%) and poor 4 (5%). Results of acetabulum fractures treated with traction were: good 8 (57%), satisfactory 4 (28%) and poor 2 (15%). According to the Brook's classification of heterotopic ossification, periarticular hetero-tropic calcifications after surgical treatment were: 0° in 65 patients (79%), I-II° in 9 patients (11%) and III-IV ° in 8 patients (10%). Calcifications in 14 patients treated with traction of heterotopic ossification by Brook-s classification were as follows: 0° in 10 patients (72%), I-II ° in 3 patients (22%) and III-IV° in 1 patient (6%). CONCLUSION: At the occurrence of acetabular fracture, it is necessary to start the treatment immediately, with an obligatory application of thromboembolic and antibiotic prophylaxis. Conservative treatment is acceptable if the dislocation of fracture is less than 5 mm. Indications for surgical treatment are incongruent or unstable fractures with verified dislocation greater than 5 mm, as well as when the radiography measured by JM Matta shows incongruence of acetabular roof less than 40° in all planes. Kocher-Langenbeck approach is the choice of surgical approach for the management of posterior column / wall, and Letournel's (ilioinguinal) approach is the choice for the management of anterior wall/column.

Southwick osteotomy stabilised with external fixator.

INTRODUCTION: Epiphysiolysis of the femoral head is the most common accident occurring towards the end of pre-puberty and puberty growth. CASE REPORT: The author describes the experience in the treatment of chronic epiphysiolysis in two patients treated by Southwick osteotomy. The site is accessed by way of a 15-cm long lateral skin incision and the trochanteric region is reached through the layers. The osteotomy angles prepared beforehand on a thin aluminium model are used to mark the Southwick osteotomy site on the anterior and lateral sides at the level of the lesser trochanter. Before performing the trochanteric osteotomy, two Mitkovic convergent pins type M20 are applied distally and proximally, above the planned osteotomy site. A tenotomy of the iliopsas muscle is performed, and then the previously marked bone triangle is redissected up to three quarters of the width of the femur. The distal part of the femur is rotated inwards, so that the patella is turned towards the ceiling. The osteotomised fragments of the femur are adapted, repositioned and fixated by installing an external fixator on the previously placed pins. Two more pins are placed, one proximally and one distally, with a view to adequately stabilising the femur. The patient was mobile from day two after the surgery. If, after the surgery, the lead surgeon realises that there is a requirement to make a correction of 5, 10 and 15 degrees of the valgus, varus, anteversion or retroversion deformity, the correction shall be performed without surgically opening the patient, using the fixator pins. CONCLUSION: After performing a Southwick osteotomy it is easier to adapt, reposition and fixate the osteotomised fragments of the femur using a fixator type M20. Adequate stability allows regaining mobility quickly, which in turn is the best prevention of chondrolysis of the hip. It is possible to make post-operative valgus, varus, anteversion and retroversion corrections of 5, 10 and 15 degrees without performing a surgery. Once the osteotomy is healed, the fixator type M20 is removed without any additional surgery.

Dilemmas in the treatment of tibial diaphyseal fractures.

INTRODUCTION: Tibial fractures accompanied by radius fractures at typical sites are the most common type of fractures. OBJECTIVE: The study is aimed at using the examined sample to make an efficient and economically acceptable choice in the treatment of tibial diaphyseal fractures. MATERIAL AND METHODS: The series comprises a retrospective and prospective study of the treatment of 131 fresh tibial fractures: 31 in women (23.66%) and 100 in men (76.34%) of the average age of 37.89. Nineteen patients (14.50%) were treated conservatively and 112 (85.50%) surgically: 22 (16.79%) with anti-rotation intramedullary nails, 74 (56.49%) with Mitkovic external fixator type M20, and 16 (12.21%) with locking compression plate. General anaesthesia was used in 46 patients (35.11%), while spinal anaesthesia was used in 85 of them (64.89%). RESULTS: According to the Karlstrom-Olerud scoring system, the treatment results were as follows: for the 22 tibiae treated with anti-rotation intramedullary nails: in 15 (68.18%) the results were excellent, in 3 (13.64%) they were good and in 4 (18.18%) they were poor. As for the results for the 74 tibiae treated with Mitkovic external fixator type M20, they were as follows: in 62 (83.78%) excellent, in 9 (12.16%) good, and in 3 (4.05%) they were poor. The results for the 16 patients treated with locking compression plate were excellent in 10 (62.50%), good in 2 (12.50%) and poor in 4 patients (25.00%). The treatment results for the 19 tibiae treated with plaster cast were excellent in 12 patients (63.16%), good in 2 (10.53%) and poor in 5 (26.32%). The definite results for the 131 fractured tibiae treated with the aforementioned techniques were as follows: excellent in 99 (75.57%), good in 17 (12.98%) and poor in 15 patients (11.45%). DISCUSSION: There is a variety of controversial positions concerning the treatment of the tibial diaphysis. CONCLUSION: On the basis of the results of surgical treatment for the given series, the number of surgical interventions, the price of osteosynthetic material, my preferences in treating tibial diaphyseal fractures would be as follows: Mitkovic external fixator type M20, anti-rotation intramedullary nails and locking compression plate. Conservative treatment is indicated when the X-ray examination confirms that the fragments have a position acceptable for conservative treatment with plaster cast.

Nature and results of treatment of war wounds caused by cluster bombs.

The aim of this study is to describe the nature of war wounds with fracture caused by cluster bombs and to suggest treatment options for such injuries. The nature of wounds caused by cluster bombs differs from those caused by conventional arms (they are more severe). The sides of the wounds are represented by conquasated soft tissues (such as fat and muscle) with thick dead tissues, ordinarily with a thickness of 0.5-4.5 cm. Another main characteristic of such injuries is the high percentage of amputations needed due to the high rate of neurovascular damage. This paper investigates the cases of 81 patients who sustained a total of 99 war wounds with fractures. The average age of the patients was 32.7 years while the youngest was 20 and the oldest, 77. According to The International Committee of the Red Cross (ICRC) classification of war wounds, 14 patients had grade I injuries, 48 patients grade II, and 29 patients, grade III. Mitkovic external fixation system, known also as the "War Fixator" was used for all fractures fixation. One protocol, which was a modification of the ICRC's protocol adapted to our specific conditions, was used throughout the study. For solving soft tissue defects, a rotator fasciocutan flap was the most frequently used. For solving of bones defect Mitkovic reconstructive external fixation device was used. All fractures we treated healed. We concluded that shortening the procedural time and being a very simple, immediate using of Mitkovic versatile external fixator ("War Fixator") is, leads to desirable results.

Validity of magnetic resonance imaging in knee injuries.

INTRODUCTION: Knee injuries are common in athletes, recreationists, and other people in their everyday activities. OBJECTIVE: The study is aimed at establishing the validity of clinical findings, MRI and diagnostic arthroscopy of the knee in ACL, PCL, medial or lateral ligament lesions. METHODS: The prospective research involved 63 inpatients at the Traumatology Clinic in Banja Luka- Nis between 1 January 2011 and 1 June 2012. RESULTS: When clinically examining the ACL and based on the calculated post-test probability amounting to (LR+) = 0.8017, we conclude that there is a considerable probability (80.17%) that a patient with an arthroscopically diagnosed ACL lesion will have the same lesion diagnosed by MRI. The post-test probability following the clinical examination of the medial meniscus and amounting to (LR+) = 0.6943 suggests that there is a considerable probability (69.43%) that an arthroscopically diagnosed lesion of the medial meniscus will also be diagnosed by MRI. On the basis of the clinical examination of the lateral meniscus in the examined sample and calculated post-test probability amounting to (LR+) = 0.6346, we conclude that there is a considerable difference (63.46%) between the diagnostic arthroscopy and MRI of lateral meniscus lesions. CONCLUSION: Arthroscopic examination of the knee is a more valuable method than diagnosis by MRI and clinical examination for detecting lesions of the ACL, PCL, medial and lateral meniscus.

Endoprosthesis and obesity.

INTRODUCTION: Obesity represents a significant risk factor in the pathophysiology of degenerative changes in coxarthrosis. OBJECTIVE: The study aims to investigate obesity as a risk factor in the examined sample comprising 136 patients who underwent hip endoprothesis implantation. MATERIAL AND METHODS: The series comprised 136 patients with a hip endoprosthesis implanted, where the patients' BMI, amount of blood used, duration of surgery, number of assistants, and type of anaesthesia were observed. Wounds and late post-operative complications, infections, haemorrhage, vein thrombosis, endoprosthesis dislocations, length of inpatient stay, start of physical therapy and full weight-bearing were also observed. The observation period lasted six months on average. DISCUSSION: In simple terms, the three greatest factors when implanting a hip endoprosthesis are as follows: properties of the endoprosthesis, the orthopaedic surgeon's skill and experience, and individual characteristics of the patient, i.e. age, sex, health condition, body weight, BMI, adequate physical therapy. CONCLUSION: We believe that the implantation of a hip endoprosthesis should be postponed for patients with a BMI exceeding 29.99. Such patients should receive endocrine treatment, they should undergo a weight loss programme in order to reduce their body weight and in order to reduce their BMI to under 29.99.