Avascular necrosis of the femoral head after traumatic posterior hip dislocation with and without acetabular fracture.

PURPOSE: Traumatic hip dislocation can be isolated or associated with acetabular fracture. Both injuries require emergency reduction of the dislocated hip. Avascular necrosis of the femoral head (AVN) is a potential complication that accompanies these severe injuries. Our objective is to identify the risk factors that cause AVN. METHODS: We retrospectively analyzed 44 patients with traumatic hip dislocations (Group A) and patients with posterior fracture-dislocation of the acetabulum (Group B). The average follow-up was 5.38 years in Group A, 5.59 years in Group B. We used the Thompson-Epstein classification for hip dislocation and the Harris Hip Score (HHS) for evaluating final outcomes. RESULTS: In Group A, we analyzed 21 patients with isolated posterior hip dislocation. We had one (4.76%) case of AVN. In Group B, we analyzed 23 patients with posterior acetabular fracture-dislocation. We had eight (34.78%) patients with AVN (p = 0.016, p < 0.05). With hip reduced 6-12 h after injury, we had AVN in one (4.34%) patient, with reduction 12-24 h, AVN was present in two (8.69%), while in hip reduction done after 24 h of injury, AVN was present in five (21.73%) patients (p = 0.030, p < 0.05). CONCLUSION: An essential prerequisite for the prevention of AVN of the femoral head after hip dislocation is emergency hip reduction. In acetabular fracture-dislocation, emergency hip reduction, anatomical reduction of the acetabular fracture and early stable osteosynthesis are also important. Main factor affecting the development of AVN is late reduction of the hip.

The Selection of Main Surgical Work Factors in Operating Rooms.

The main component of error minimization in operating rooms (ORs) is to maintain high reliability of surgical teams. The analysis of adverse events in the OR reveals deficiencies in cognitive and interpersonal skills as the main factors influencing surgeons' errors. Therefore, research of these additional factors is necessary, besides factors related to surgeons' clinical knowledge and technical skills. In this paper, the key factors for evaluating activities in surgical operating rooms are identified. Fuzzy analytic hierarchy process is used for identification of key factors. Fifteen key factors are identified for evaluating activities in surgical operating rooms to improve the efficiency of surgical operations. For each group of activities (surgical "capabilities," operating room characteristics, and non-technical skills), five factors are identified. As the most important, the following factors are obtained: communication, indoor environment standardization, and tool handle design. The aim of the analysis of these key factors is surgeons' work capability enhancement, rational design of operating rooms, and advancement of operators' cognitive and interpersonal skills.

Influence of coronavirus disease 2019 pandemic state of emergency in orthopaedic fracture surgical treatment.

PURPOSE: After the appearance of first COVID-19 cases in Serbia, state of emergency was declared on 15 March 2020 and lasted for 54 days. The aim of this report is to compare orthopaedic fracture frequencies in this period, when the walk was limited at the home mostly, with those during the same part in the previous year with regular state, thus to examine staying at home as a factor influencing the frequency of different fracture types. METHODS: There were 86 patients during the state of emergency in year 2020 and 106 patients during the same part of year 2019 with a regular state, having orthopaedic trauma surgery. Number of fractures, gender distribution, and age of patients have been compared between these periods. RESULTS: Total number of fractures decreased for about 19% during the state of emergency. There was nonsignificant difference in fracture frequency for all skeletal areas (p > 0.05), except for distal femoral fractures which occurred more often during the state of emergency (p < 0.05). Female ratio was higher during state of emergency than in regular state for femoral neck fractures. CONCLUSION: Restricted going outside the home for 54 days has the influence in total number of fractures and gender distribution in femoral neck fractures. The method of external fixation used could be assumed as a reducing factor of intraoperative virus pandemic propagation among medical staff.

Lateral tibial plateau fractures-functional outcomes and complications after open reduction and internal fixation.

PURPOSE: Tibial plateau fractures are severe intra-articular injuries; their treatment is accompanied by numerous complications and requires extensive surgical experience. In this manuscript, we compared our experiences with data from the literature. METHODS: Retrospectively, we analyzed 41 patients with closed lateral tibial plateau fracture (Schatzker's I-III). All fractures were treated surgically with open reduction and internal plate fixation. Post-operative complications and final outcomes were monitored according to the Tegner Lysholm Knee Scoring System. The average follow-up was 5.7 years (2-10). RESULTS: We analyzed 41 patients (Schatzker I-III), average age 46.7 ± 13.0 years. Traumatic lesion of the lateral meniscus was present in 15 (36.58%) patients. Post-traumatic knee osteoarthritis was present in all (100%) patients after lateral meniscectomy and in 20% of patients it occurred after meniscus repair (p = 0.007). Post-traumatic knee osteoarthritis was present in 12 (29.68%) patients. Infection occurred in five (12.19%) patients, DVT in three (7.3%) patients, and we had one (2.43%) case of non-lethal PE. Final functional outcomes were excellent in 13 (31.7%), good in 21 (51.21%), moderate in five (12.19%), and poor in two (4.87%) patients. CONCLUSION: Lateral tibial plateau fractures are severe intra-articular injuries which can leave lasting consequences, regardless of the restoring of the articular surface and stable internal fixation. Local skin condition and associated soft tissue injuries, comminution, degree of dislocation, and depression can significantly affect the development of post-traumatic osteoarthritis and poor outcomes.

Total hip arthroplasty after acetabular fracture surgery.

PURPOSE: Acetabular fractures are accompanied by complications such as post-traumatic osteoarthritis (OA) of the hip and avascular necrosis (AVN) of the femoral head. The aim of the study was to evaluate improvement of life quality and functional recovery after total hip arthroplasty (THA) in patients with post-traumatic OA and AVN. METHODS: We retrospectively reviewed 23 patients with post-traumatic OA of the hip and AVN of the femoral head who undergone THA, out of 63 patients who were previously surgically treated for acetabular fractures. Final functional outcomes are defined according to the Merle d'Aubigné score, and the pain intensity according to VAS from 0 to 10. RESULTS: Out of 63 patients with acetabular fractures from 2008 to 2018, we analyzed 23 (36.5%) patients, with an average age of 51.5 ± 13.8 years, who required THA due to post-traumatic OA and AVN of the femoral head. THA was done after the average of 4.28 years (range 1 to 8) from previous acetabular osteosynthesis. According to Merle d'Aubigné score, final functional outcomes before THA were moderate with average points of 4.86 (4-6). Post-THA final functional outcomes were excellent with an average point of 10.04 (10-12) (p < 0.001). The ratio of VAS before and after THA was 9.04:1.95(p < 0.001). CONCLUSION: THA is a method which gives the best results in the treatment of post-traumatic OA of the hip and AVN of the femoral head after previous osteosynthesis of the acetabular fracture. After THA, life quality and functional status of a patient are significantly improved.

External fixation of segmental tibial shaft fractures.

PURPOSE: Tibial shaft fractures are the most common type of large long-bone fractures. Segmental tibial shaft fractures are severe injuries and its treatment can be followed by a high incidence of complications, nonunion, delayed union, malunion, infection or compartment syndrome. The most common treatment strategy is intramedullary fixation. Results of the unilateral external fixation treatment for segmental tibial shaft injuries are presented in this paper. METHODS: Patients with segmental tibial shaft fractures, AO/OTA 42-C2 were treated as urgent cases by unilateral external fixation. Mitkovic-type external fixator was used in all of these fractures. RESULTS: There were 32 patients with segmental tibial shaft fractures (AO/OTA 42-C2), 20 males and 12 females, average age of 43.5 years. Average time of union was 5.9 (4.1-7.4) months for closed and 6.2 (5.1-7.9) months for open fractures. Average follow-up was 18 (26-60) months. Nine patients (28.12%) had open segmental tibial shaft fracture (2 Grade I, 2 Grade II, 1 Grade IIIA, 4 Grade IIIB). Union rate was 81.25% (26 cases). Nonunion rate was 18.75% (6 cases) and malunion 3.12% (1 case). Nonunion was higher in patients with open fractures (4). Compartment syndrome had been diagnosed in 6 cases (18.75%) with closed fracture and fasciotomy was performed when external fixator was applied. There were no deep infections. Pin tract infection was present in 7 cases (21.85%). CONCLUSION: Treatment of segmented tibial shaft fractures can be followed by a number of complications. Unilateral external fixation with convergent orientation of pins provides three-dimensional stability of the fracture and good biomechanical conditions for fracture healing, with lower complications rate.

In Silico Optimization of Femoral Fixator Position and Configuration by Parametric CAD Model.

Structural analysis, based on the finite element method, and structural optimization, can help surgery planning or decrease the probability of fixator failure during bone healing. Structural optimization implies the creation of many finite element model instances, usually built using a computer-aided design (CAD) model of the bone-fixator assembly. The three most important features of such CAD models are: parameterization, robustness and bidirectional associativity with finite elements (FE) models. Their significance increases with the increase in the complexity of the modeled fixator. The aim of this study was to define an automated procedure for the configuration and placement of fixators used in the treatment of long bone fractures. Automated and robust positioning of the selfdynamisable internal fixator on the femur was achieved and sensitivity analysis of fixator stress on the change of major design parameters was performed. The application of the proposed methodology is considered to be beneficial in the preparation of CAD models for automated structural optimization procedures used in long bone fixation.

The diaphyseal aseptic tibial nonunions after failed previous treatment options managed with the reamed intramedullary locking nail.

BACKGROUND: The nonunion of open and closed tibial shaft fractures continues to be a common complication of fractures. Tibial nonunions constitute the majority of long bone nonunions seen by orthopaedic surgeons. In this article, we present our approach to the surgical treatment of noninfected tibial shaft nonunions. METHODS: Between 2008 and 2014, 33 patients with aseptic diaphyseal tibial nonunion was treated by reamed intramedullary nailing and were retrospectively reviewed. The initial fracture management consisted of external fixation (27 patients), plate fixation (2 patients) and cast treatment (4 patients). All patients, preoperatively, were evaluated for the signs of the infection, by the same protocol. There were 13 hypertrophic, 16 oligotrophic (atrophic) and 4 defect nonunions registered in our material. The primary goal was to perform a closed intramedullary nailing on antegrade manner. An open procedure was only unavoidable when implants had to be removed or an osteotomy had to be performed to improve the alignment. Functional rehabilitation was encouraged with the assistance of a physiotherapist early postoperative. Patients were examined regularly during followed-up for a minimum of 12 months period for clinical and radiological signs of union, infection, malunion, malalignment, limb shortening, and implant failure. RESULTS: The time that elapsed from injury to intramedullary nailing ranged from 9 months to 48 months (mean 17 months).Open intramedullary nailing was unavoidable in 25 cases (75,75%), while closed nailing was performed in 8 patients (24,25%). Osteotomy or resection of the fibula was performed in 78,8% of the cases. All patients were followed up in average period of 2 years postoperative (range 1-4 years), and 31(93,9%) patients achieved a solid union within the first 8 months. Mean union time was 5±0.8 months. Complications included 2 (6,06%) patients, one with deep infection and another case with absence of bone healing. Anatomical alignment has been achieved in the majority of patients, 28 patients (84,8%). The additionally autogenous bone chips were added in 4 patients (12,1%) where cortical defect was greater than 50% of the bone circumference. CONCLUSION: In conclusion, a reamed intramedullary nail provides optimal conditions for stable fixation, good rotational control, adequate alignment, early weight-bearing and a high union rate of tibial non-unions. Reaming of the medullary canal with preservation of periosteal sleeve create the "breeding ground" for sound healing of tibial shaft nonunions. Additionally cancellous bone grafting is recommended only in the case of defect nonunion.

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.

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 stable and unstable intertrochanteric fractures with selfdynamisable internal fixator (concept of double dynamisation).

UNLABELLED: BACGROUND/AIM. Intertrochanteric fractures of the femur are the third most common fractures among all bone fractures. Today in everyday orthopedic practice a number of different methods of treatment of trochanteric fractures of the femur are applied. Despite the improvement in the development of new implants, the percentage of serious complications of the treatment of these fractures remains very high, varying from 10% to 20%. One of the most serious complications of internal fixation of intertrochanteric fractures is nonunion of fractures due to the lack of additional axial dynamisation of implants. The aim of this study was to determine the efficacy of double dynamisation in stable and unstable intertrochanteric fractures treatment using the self dynamisable internal fixator. METHODS: During the period from 2000 to 2009 we analyzed the use of selfdynamisable internal fixator (SIF implant) in the treatment of 247 patients with stable and unstable intertrochanteric fractures. Fracture types were classified according to the AO Fracture Classification/Orthopaedic Trauma Association Scheme. Salvati and Wilson scoring systems were used for functional assessment considering pain, walking ability and hip movements of operated patients. RESULTS: Of the total number of treated patients, 134 were males and 113 females, aged 19 to 90 (average 49.6) years. More than a half of the patients were older than 50 years. Monitoring of the patients after the operation was carried out clinically and radiographically for a period of three to six months in all the patients, whereas a 2-year follow-up was conducted in 176 (71.2%) patients. The average duration of surgery was 47 min, the average blood loss 145 mL, and the average fluoroscopy time was 16 sec (8-97 sec). The average time for union was 3.7 months (3-6.6 months). Double dynamisation (dynamisation along the neck and shaft of the femur) was observed in 85 (34.4%) patients, and was on average 4.3 mm (1.5-8 mm). All fractures managed with dynamisation implants healed completely within no later than six months after the surgery. In 17 cases there was a cut-out phenomenon of implant, while in seven cases there was mechanical implant failure. Complications were detected within 3 to 6 weeks after surgery, and treated by the method of intramedullary fixation. During the study, there were no cases of infection and thromboembolic complications detected. CONCLUSION: The concept of double dynamisation improves the fracture healing in the stable and unstable intertrochangeric fractures using the selfdynamisable internal fixator. This biological method of fixation provides healing of intertrochanteric fracture in the optimum period of time, significantly reducing the risk for mechanical failure.

Antibiotic-loaded cement spacer for treatment of Klebsiella infected total hip and knee arthroplasty.

BACKGROUND/AIM: Infection following total hip arthroplasty (THA) or total knee arthoplasty (TKA) may have devastating consequences. Some bacterial strains are often encountered as agents of these infections, others occur less frequently but are sometimes burdened with more severe complications. Kebsiella spp. are uncommon causes of THA or TKA infection. The aim of this study was to identify an effective treatment algorithm for multidrug resistant Kebsiella spp. caused THA or TKA infections. METHODS: During the 3-year period, from January 1 2009 to December 31 2011, we registered and treated 5 patients with THA or TKA multidrug resistant Klebsiella spp. caused infection. All the patients were primarily operated in other institutions, and were admitted in our clinic after the onset of infection symptoms. In three of the cases Klebsiella infection was complicated by additional infection (Staphyloccocus aureus, Pseudomonas aeruginosa and Serratia marscescens). In 3 of the cases we performed revision arthroplasty after double exchange of antibiotic-loaded articulating cement spacer, and in 2 of the cases the standard two-stage revision approach with one antibiotic cement spacer exchange was applied. RESULTS: The mean length of follow-up after reimplantation surgery was 17.1 months (range 2-31 months). One patient died 2 months after the final reimplantation procedure. The initial Klebsiella infection was eradicated in all the patients. At the end follow-up after definitive reimplantation, the patients had no clinical, laboratory or microbiological parameters positive for active infection. CONCLUSION: According to our experience with multidrug-resistant Klebsiella TKA/THA infections, two-stage approach, in some cases with double articulating cement spacer exchange prior to definitive reimplantation, is the most effective treatment option.

Early clinical results of surgical treatment of patients with femoroacetabular impingement.

INTRODUCTION: Surgical treatment is the treatment of choice in patients with symptoms and radiological signs of femoroacetabular impingement. OBJECTIVE: Our experience and early results of surgical treatment of patients with signs of femoroacetabular impingement and early hip osteoarthritis are reported. METHODS: The results of treatment of 21 patients aged 23-54 years with different types of femoroacetabular impingement are presented. Safe open surgical dislocation of the hip was performed in all patients. Before and after surgery, the WOMAC score was performed, clinical and radiographic data of the operated hips were evaluated and t-tests were used for statistical analyzes of data. RESULTS: The WOMAC score improved from 70.5 points (range 56.3 to 89.8 points) to 90.3 points (range 70.3 to 100 points) at one year of follow-up (p < 0.0001), anterior impingement test was negative in all operated cases, average hip internal rotation improved significantly, no complications were found, except trochanteric nonunion at the site of osteotomy, which was reaffixed. CONCLUSION: Postoperative results have shown that the surgical approach to treating patients with femoroacetabular impingement is the method of choice. Three operated patients, with advanced osteoarthritis of the hip, had to be converted to total hip replacement.

Contribution to the method for determining femoral neck axis.

INTRODUCTION: Femoral neck axis plotting is of great significance in measuring parameters that define femoral head-neck junction sphericity in the group of patients with the femoroacetabular impingement. Literature methods of femoral neck axis determination have weaknesses associated with the risk of obtaining inaccurate values of certain parameters. OBJECTIVE: Method of plotting of the femoral neck axis by two parallel lines that belong to the medial quarter of the femoral neck is proposed. Method was tested on the anatomic specimens and the respec tive radiograms. METHODS: A total of 31 anatomic specimens of the proximal femur and respective radiographs were used, on which three axes of the femoral neck were plotted; accordingly, alpha angle value was determined and tested with corresponding parametric tests, with the measurement error of less than 5% and the strength of the applied tests of 80%. RESULTS: Alpha angle values obtained by plotting femoral neck axis using the literature and methods we have proposed were not significantly different in our series, and, in more than a half of the specimens, the two axes overlapped each other. CONCLUSION: The advantage of the proposed method does not depend on the position of the femoral head rotation center in relation to the femoral neck, which favors proposed method for measuring the angles of femoral head sphericity in patients with the femoral head translation. Disadvantage of the study is a small sample size for valid conclusions about the applicability of this method in clinical practice.

Influence of different methods of internal bone fixation on characteristics of bone callus in experimental animals.

INTRODUCTION: Correct choice of osteosynthesis method is a very important factor in providing the optimal conditions for appropriate healing of the fracture. There are still disagreements about the method of stabilization of some long bone fractures. Critically observed, no method of fracture fixation is ideal. Each osteosynthesis method has both advantages and weaknesses. OBJECTIVE: The objective of this study was to compare the results of the experimental application of three different internal fixation methods: plate fixation, intramedullary nail fixation and self-dynamisable internal fixator (SIF). METHODS: A series of 30 animals were used (Lepus cuniculus) as experimental animals, divided into three groups of ten animals each. Femoral diaphysis of each animal was osteotomized and fixed with one of three implants. Ten weeks later all animals were sacrificed and each specimen underwent histological and biomechanical testing. RESULTS: Histology showed that the healing process with SIF was more complete and bone callus was more mature in comparison to other two methods. During biomechanical investigation (computerized bending stress test), it was documented with high statistical significance that using SIF led to stronger healing ten weeks after the operation. CONCLUSION: According to the results obtained in this study, it can be concluded that SIF is a suitable method for fracture treatment.

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.

Urinary tract injury associated with pelvic fractures.

INTRODUCTION: Pelvic trauma associated with urinary tract injury is a severe trauma, mostly caused by traffic accidents and falls from heights. These injuries require urgent treatment and close teamwork between urologic and orthopaedic surgeons. MATERIAL AND METHODS: In this retrospective study there were analyzed patients with pelvic trauma and extraperitoneal injury of urinary tract, treated surgically at Clinic for Ortopaedic Surgery and Traumatology and Urology Clinic in Clinical Center Nis. Surgical intervention in these patients had been realized as the synchronized work of both orthopaedic and urologic surgeons. The pelvis was treated by external and internal fixation. Mitkovic type external fixator was used for pelvic external fixation. Plating was used for pelvic internal fixation. Pelvic fractures were classified using Tile's classification system. The final functional results had been scored using Majeed score system. RESULTS: There were 42 patients with the injury of pelvic ring, treated at Clinic for Ortopaedic Surgery and Traumatology and at Urology Clinic, Clinical Center Nis, in the period of 01.01.2011. to 31.12.2013, 30 males and 12 females, with average age of 53.69 (19-84) years old. In 80% of cases pelvic fractures were caused by high energy trauma in traffic accidents. According to Tile's classification, 9 patients (21,42%) had pelvic fracture type A, 23 patients (54,46%) had pelvic fracture type B and 10 patients (23,80%) had pelvic fracture type C. Urinary tract injury was diagnosed in 9 patients (21,42%): 5 patients (11,9%) with bladder injury, 3 patients (7,14%) with posterior urethra injury and 1 patient (2,38%) with both bladder and posterior urethra injury. CONCLUSION: Urgent repair of extraperitoneal urinary tract injury by urologic surgeons and synchronized pelvic reduction and fixation using external or internal fixation by ortopaedic surgeon, in the same surgical procedure, is the standard method for treatment of this severe injury.

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.