First experiences with the Fitmore® hip stem: Early results of the 16-month monitoring.

Background/Aim: Fitmore® hip stem belongs to the group of short stem prostheses with the metaphysar stabilization, with its shape and form that protects the bone mass in the greater trochanter region and the distal part of the femur. The aim of this paper was to present the early postoperative results in patients with implanted Fitmore® hip stem and point out some of the advantages. Methods: A series of 10 patients with implanted Fitmore® hip stem, was included in this study. The average age of the patients was 54.5 (48­65) years. There were 5 women and 5 men. The total monitoring time was 16 months. To rate the condition of the hip joint we used The Western Ontario and Mc Master Universities Arthritis Index (WOMAC) score. We also monitored the degree of hip pain, hip flexion, heterotopic ossification and indentation in the stem of the prosthesis. Results: After 12 months of monitoring 9 (90%) of the patients had no pain in the thigh region, and only 1 (10%) experienced mild pain. The hip flexion rose from the average 89° to postoperative 114°. WOMAC score rose as well, from 49 to 94 average points. Indentation in the stem was registered 3 months after the operation in 2 (20%) of the patients ­ in one of the patients the indentation was 3 mm and in the other patient 5 mm. After the 16-month monitoring, the results were excellent. The monitoring period was short though it should be continued and the results should be presented after 5 and then after 10 years. Conclusion: Early results of the implantation Fitmore stem showed good bone ingrowth with excellent functional result.

Surgical treatment of dislocated fracture of the scapula column and glenoid: a 22-year follow-up.

INTRODUCTION: Most scapular fractures are caused by high-impact blunt injuries, often as the result of motor vehicle accidents, fall from height, etc. In 80% to 90% of cases, scapula fractures are associated with multiple injuries (clavicle fracture, rib fractures, humeral fracture, pulmonary injury, brachial plexus injury). CASE REPORT: We presented scapular fracture in a 27-years-old male who had sustained a work-related injury when a ground soil brick machine pressed him. Fracture line was identified on radiotherapy and computed tomography scan from the distal scapular angle enclosing scapular neck. The whole lateral part of the scapula was dislocated laterally from the scapular body. Scapular fracture was treated operatively. The posterior approach was used for reposition, while for fixation after reposition we used two Blunt clamps. We presented functional outcome 22 years after the injury and the surgical treatment. The patient can perform all physical activities, still works, and there is no need to remove the ostheosynthetic material as it causes no discomfort nor problems. The strength of the shoulder muscles is estimated as physician as the grade 5. CONCLUSION: Displaced intra- articular fractures of the scapula should be treated operatively, with open reduction and internal fixation.

Unusual case of mixed form of femoroacetabular impingement combined with nonspecific synovitis of the hip joint in a young adult-- A case report.

INTRODUCTION: Minimal bone changes in the acetabulum and/or proximal femur, through mechanism known as femoroacetabular impingement, during flexion, adduction and internal rotation lead to early contact between femoral head-neck junction and acetabular brim, in anterosuperior region. Each additional pathological substrate which further decreases specified clearance provokes earlier onset of femoroacetabular impingement symptoms. CASE REPORT: We presented a 20-year-old male patient with groin pain, limping, positive impingement test, radiological signs of mixed form of femoroacetabular impingement and unrecognized chronic hypertrophic synovitis with earlier development of clinical hip symptoms than it has been expected. Open surgery of the left hip was done. Two years after the surgery, patient was asymptomatic, painless, and free of motion, with stable x-rays. CONCLUSION: Hypertrophic synovial tissue further reduces the distance between the femoral head-neck junction and the acetabulum, leading to the earlier onset of femoroacetabular impingement symptoms. Surgical treatment is the method of choice.

Surgical dislocation of the hip in patients with femoroacetabular impingement: Surgical techniques and our experience.

BACKGROUND/AIM: Arthrosis of the hip is the most common cause of a hip joint disorders. The aim of this study was to present our experience in the application of a safe surgical dislocation of the hip in patients with minor morphological changes in the hip joint, which, through the mechanism of femoroacetabular impingement, cause damage to the acetabular labrum and adjacent cartilage as an early sign of the hip arthrosis. METHODS: We have operated 51 patients with different morphological bone changes in the hip area and resultant soft tissue damage of the acetabular labrum and its adjacent cartilage. Surgical technique that we applied in this group of patients, was. adapted to our needs and capabilities and it was minimaly modified compared to the original procedure. RESULTS: The surgical technique presented in this paper, proved to be a good method of treatment of bone and soft tissue pathomorphological changes of the hip in patients with femoroacetabular impingement. We had no cases with avascular necrosis of the femoral head, and two patients had nonunion of the greater trochanter, 9 patients developed paraarticular ossification, without subjective symptoms, while 3 patients suffered from postoperative pain in the groin during more energetic physical activities. CONCLUSION: Utilization of our partly modified surgical technique of controlled and safe dislocation of the hip can solve all the bone and soft tissue problems in patients with femoroacetibular impingement to stop already developed osteoarthritis of the hip or to prevent mild form of it.

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.

Distal tibial pilon fractures (AO/OTA type B, and C) treated with the external skeletal and minimal internal fixation method.

BACKGROUND/AIM: Distal tibial pilon fractures include extra-articular fractures of the tibial metaphysis and the more severe intra-articular tibial pilon fractures. There is no universal method for treating distal tibial pilon fractures. These fractures are treated by means of open reduction, internal fixation (ORIF) and external skeletal fixation. The high rate of soft-tissue complications associated with primary ORIF of pilon fractures led to the use of external skeletal fixation, with limited internal fixation as an alternative technique for definitive management. The aim of this study was to estimate efficacy of distal tibial pilon fratures treatment using the external skeletal and minimal internal fixation method. METHODS: We presented a series of 31 operated patients with tibial pilon fractures. The patients were operated on using the method of external skeletal fixation with a minimal internal fixation. According to the AO/OTA classification, 17 patients had type B fracture and 14 patients type C fractures. The rigid external skeletal fixation was transformed into a dynamic external skeletal fixation 6 weeks post-surgery. RESULTS: This retrospective study involved 31 patients with tibial pilon fractures, average age 41.81 (from 21 to 60) years. The average follow-up was 21.86 (from 12 to 48) months. The percentage of union was 90.32%, nonunion 3.22% and malunion 6.45%. The mean to fracture union was 14 (range 12-20) weeks. There were 4 (12.19%) infections around the pins of the external skeletal fixator and one (3.22%) deep infections. The ankle joint arthrosis as a late complication appeared in 4 (12.90%) patients. All arthroses appeared in patients who had type C fractures. The final functional results based on the AOFAS score were excellent in 51.61%, good in 32.25%, average in 12.90% and bad in 3.22% of the patients. CONCLUSION: External skeletal fixation and minimal internal fixation of distal tibial pilon fractures is a good method for treating all types of inta-articular pilon fractures. In fractures types B and C dynamic external skeletal fixation allows early mobility in the ankle joint.

Measuring the osteochondral connection of the femoral head and neck in patients with impingement femoroacetabular by determining the angle of 2alpha in lateral and anteroposterior hip radiographic images.

BACKGROUND/AIM: Femoroacetabular impingement, a pathophysiological mechanism of small morphological changes of the hip leads to early arthritic changes. The aim of this study was to present a simple method for the quantification of femoral head and neck junction in patients with cam form of femoroacetabular impingement, in standardized anteroposterior and profile DUNN 90 radiograms of the hips. METHODS: In standardized anteroposterior and profile DUNN 90 images of the hips we determined the angle of 2 alpha, defined by our own original method. We tested 141 hips in 81 patients without clinical signs of femoroacetabular impingement, and 153 hips in 76 patients with clinically clear signs of femoroacetabular impingement. RESULTS: The value of the angle 2 alpha in anteroposterior hip radiograms was on average 113.7 degrees for the patients with clinical symptoms of impingement, and 84.2 degrees for the control group of patients (p < or = 0.0001), and in DUNN 90 profile radiography of the hip, the value of 2 alpha angle in the patients group was 97.2 degrees, and 74.6 degrees in the control group (p < or = 0.0001). The proposed method of determining the angle 2 alpha showed a high level sensitivity (97.8%) and specificity (98.7) and positive predictive value (98.6%). It was false positive in only 1.3%, and false negative in 2.12% of patients. CONCLUSION: Using standardized anteroposterior and profile radiographs of the hips, and without determination of femoral neck axis in patients with femoroacetabular impingement with the cam effect at the junction of the femoral head and neck, we proposed the method of measuring joint abnormalities of femoral head and neck junction, very capable to predict the disease development in an asymptomatic risk group of patients and high sensitive in the diagnosis of the disease in the group of patients.

[Surgical treatment of the aseptic femoral shaft nonunion].

Femoral shaft nonunions is difficult complication and a big challenge for the orthopaedic surgeons. These complications occur after open femoral fractures, comminuted fractures, segmental fractures, the infection, after the inadequate fixed osteosynthesis, the systemic disease, and smokers. The paper presents the results of treatment aseptic femoral shaft nonunion in 18 patients. They were primarily operated by the method of internal compresive plate fixation and external fixation (open fractures). For fixation we used dinamic internal fixator by Mitkovic. All nonunions treated by this method are healed. In patients with atrophic femoral shaft nonunions in addition to fixation was performed and bone grafting. This implant has proved successful in the treatment of femoral shaft nonunion. During the fixation no periostal and intramedullary vascularization damage, which is an important prerequisite for bone healing. Implant enables biological and mechanical conditions for nonunion healing.

Treatment of subtrochanteric femoral fractures using Selfdynamisable internal fixator.

BACKGROUND: Surgical treatment is the preferred method for treating subtrochanteric femoral fractures and the variety of extramedullary and intramedullary implants continues to evolve. The purpose of our study was to retrospectively evaluate the clinical and radiological results of subtrochanteric fractures that are treated with the Selfdynamisable internal fixator. METHODS: From January 2000 to January 2004, we treated 49 consecutive patients who had subtrochanteric fractures. According to the AO classification, 8 (16.3%) fractures were type 32-A, 16 (32.7%) were type 32-B and 25 (51%) fractures were type 32-C. The mean follow-up time was 22.3 months. RESULTS: The average operating time was 45 minutes (range, 32 to 90 minutes). The average blood loss was 250 mL (range, 125 to 350 mL). The average hospital stay was 10 days (range, 7 to 59 days). Implant failure was not observed and union was achieved in all the patients. Deep infection occurred in one (2%) patient in the early postoperative period. Fracture union was achieved at a mean of 14 weeks. Varus malalignment less then 10 degree was noted in three (6.1%) patients at the end of follow-up. Thirty-five patients were pain-free and 14 had mild pain. CONCLUSIONS: The selfdynamisable internal fixator was successfully used for subtrochanteric fracture. It provides a short operative time, low blood loss, spontaneous biaxial dynamisation and healing in an optimal period of time without the need for secondary intervention.

[Fractures of the upper part of the femur treated with Mitkovic selfdynamisable internal fixator (SIF)].

UNLABELLED: Complex transtrochanteric and subtrochanteric fractures need dynamisation in two axis: in neck axis and in the long axis of the femur. In this study is present one new concept of the surgical treatment of the fractures of proximal femur using new double dynamic selfdynamisable internal fixator (SIF). Dynamisation along the femoral neck axis is available immediately after the fixation, while dynamisation in the long axis of the femur is activated spontaneously 4-6 weeks after the fixation. It is shown seris of 30 consecutive fractures of the upper femur. The average operative time was 42 minutes and average blood loss was 70 (seventy) milliliters. All fractures healed within an average period of sixteen weeks (ranging from 12 to 24 weeks). There were no serious complications. CONCLUSION: SIF is one effective minimally invasive method for the treatment of complex trochanteric and subtrochanteric femoral fractures.

Treatment of the humeral shaft aseptic nonunion using plate or unilateral external fixator.

BACKGROUND: Although the use of a plate and bone graft is described as a well-known treatment for aseptic humeral shaft nonunion, unilateral external fixator can be alternative as a minimally invasive method. There has been no report comparing two methods of plate and external fixator for humeral shaft nonunion. Also, a few studies described humeral shaft aseptic nonunion treatment using unilateral external fixator. METHODS: We retrospectively reviewed 31 patients (15 men and 16 women) with aseptic humeral shaft nonunion treated by plate (n = 20) and unilateral external fixator (n = 11). Patients were followed for a mean of 31.8 months. The right upper arm was involved in 19 patients (17 dominant) and left in 12 patients (2 dominant). The inclusion criteria were aseptic, middle shaft nonunion, without bone defects more than 2 cm. Four patients had hypertrophic, and 27 patients had atrophic nonunion. RESULTS: Solid union, as documented on plain radiographic views, was obtained in 28 (90.3%) patients without additional operation. The average operative time was 92.8 minutes in plate group and 47.8 minutes in external fixator group (p < 0.05). The average blood loss was 142.5 mL in plate group and it was 45.5 mL in external fixator group (p < 0.05). Average hospital stay was 10.9 days in plate group and 3.9 days for external fixator group (p < 0.05). Overall, healing time in the plate group was 4.4 months, compared with 3.6 months in the external fixation group (p < 0.05). The mean Constant and Murley score for plate group was 85.6 points and it was 74.3 points for the external fixator group. According to Stewart and Hundley criteria, 16 (80%) patients in the plate group and 6 (54.5%) patients in the external fixator group had good outcome. Two-pin track infection of the external fixator (18.2%) and two transient radial nerve palsy (10%) were recorded. CONCLUSIONS: In this retrospective study of the humeral shaft nonunion, unilateral external fixator tended to yield equally favorable treatment results as did plate fixation. Advantages of the plate are good stability on the nonunion site and comfortability for patient. On the contrary, the advantages of the unilateral external fixator are minimal exposure to the nonunion site with minimal surgical trauma to the soft tissue, easy application of the fixator and consecutively minimal blood loss and short operative time. Unilateral external fixator could be a valuable alternative to plate fixation in aseptic humeral shaft nonunions.

[External skeletal fixation of femoral shaft fractures in polytrauma patients].

INTRODUCTION: Polytrauma remains a major social, economic and medicine affliction. A successful surgical treatment of polytrauma patients requires an approach predicated on prioritizing injuries. An isolated femur fractures rarely poses any threat but in association with multiple injuries, this fracture assumes greater significance. The proper management of femur fractures in polytrauma can greatly reduce the mortality and morbidity. MATERIAL AND METHODS: We present our results in the treatment of 24 femur shaft fracture in 22 polytrauma patients treated by Mitkovic external fixator in 5 year period (2000-2004) on Orthopeadic and Traumatology Clinic--Clinical Center Nis. The average of patients age was 32.8 years (ranging from 17 to 62). There were 11 (46%) closed and 13 (54%) open fractures. RESULTS: Eighteen fractures were treated by external fixation until union. The remaining six fractures were treated by conversion of the external fixation to internal fixation. Sixteen fractures (88.88%), in which the external fixation was the definitive method of treatment, healed completely. The average healing time was 6.29 (4-9) months. There were three pin-track infections (16.66%), one nonunion (5.55%) and only one deep infection (5.55%). CONCLUSION: The external fixation by the use of Mitkovic external fixator in the treatment of femur fractures is a safe procedure to achieve temporary rigid stabilisation in polytrauma patients before the subsequent internal fixation (damage control orthopaedics). The external fixation using Mitkovic external fixator can be definitive method of choice in treatment of open and comminutive femur fractures in polytrauma patients until union.

Treatment of the humeral shaft nonunion after surgical failure using the Selfdynamisable internal fixator.

INTRODUCTION: A nonunion of the humeral shaft is not a rare condition and is a complication of both nonoperative and operative treatment of the fracture. Several fixation options were used in the nonunion treatment, including various plate techniques, intramedullary nails and external fixator. We applied our Selfdynamisable internal fixator for the treatment of humeral shaft nonunion after surgical failure and evaluated its clinical outcome. MATERIALS AND METHODS: Six patients with persistent atrophic nonunion of the humeral shaft were treated with Selfdynamisable internal fixator. The inclusion criteria were mobile, unstable resistant nonunion of the humeral diaphysis which persisted after surgical treatment for nonunion. All patients were men with a mean age of 32 (27-39) years. The initial fracture treatment was external fixator in two patients and plaster cast for four patients. All cases failed to unite after primary treatment. Plate fixation was resorted for fracture union but failed. The revision surgery consisted of removal of hardware, freshening of bone ends and bone grafting, and internal fixation with a Selfdynamisable internal fixator. RESULTS: The average follow-up was 33 months. All the nonunions healed after indexed operation. The average time for union was 5.5 months (range 4-9 months). There was no loosening or breakage of the fixation device. The functional results, according to the scale of Constant and Murlay modified by Ring, were excellent in five and good in one patient. There were no complications of nerve injuries or infections related to the operation. CONCLUSION: Selfdynamisable internal fixator with bone graft for the treatment of recalcitrant humeral shaft nonunion provided successful clinical outcome with minimal complications.

Unreduced chronic dislocation of the humeral head with ipsilateral humeral shaft fracture: a case report.

The purpose of reporting this case is to illustrate a treatment plan for a chronically anteriorly dislocated shoulder associated with an ipsilateral humerus fracture, a condition heretofore not addressed in the literature to our knowledge. An 18-year-old female, left hand dominant, injured her left upper extremity and liver in a motor vehicle accident. X-rays at time of injury revealed a diaphyseal facture of her left humerus. No x-rays of the shoulder were taken at time of injury. Treatment consisted of a plaster cast application and discharge at 1 week. The patient was seen again 4 weeks postinjury, at which time only humerus films were taken and the immobilization was continued. At 45 days postinjury, the patient complained of left shoulder pain, and shoulder x-rays at that time revealed an anterior subcoracoid dislocation of the left humeral head. At surgery 52 days postinjury, the humeral shaft fracture was found to be unstable and external fixation of both the fracture (2 pins above and below the fracture) and the reduced but still unstable humeral head was performed (a pin through the humeral head into the glenoid). The external fixator was removed at 3 weeks, and at a 3-year follow-up, the patient had acquired nearly full range of motion of her shoulder without pain and no significant limitations of her arm movements or activities. In conclusion, given a patient with a chronic anteriorly dislocated shoulder and a healing ipsilateral shaft fracture, an external fixation stabilization of both the fracture and the relocated repaired dislocation is a viable treatment option.

[External fixator by Mitkovic in the treatment of comminuted intraarticular fractures of the distal radius]. / Spoljasnji fiksator po mitkovicu u lecenju kominutivnih intraartikularnih preloma distalnog okrajka radijusa.

INTRODUCTION: Comminuted intraarticular fractures of the distal radius metaphysis are a major challenge for orthopedic surgeons. The aim of this study was to present results of the survey on treatment of these fractures using an external fixator. MATERIAL AND METHODS: 73 patients (30 females and 43 males) with closed comminuted intraarticular fractures of the distal radius, type C AO/ASIF (based on radiography at the moment of injury) were treated by a Mitkovic external fixator and followed-up for at least 2 years. An external fixator and Kirschner wires were used in 43 patients. An external fixator without Kirschner wires was used in 30 patients. RESULTS: At the end of treatment, functional results and outcomes were excellent in 39 (53.4%), good in 19 (26%), fair in 10 (13.7%), and poor in 5 (6.8%) patients according to Jakim score. Lesser degree of limitation of the movement of the wrist joint was established in 19 patients (26%). Joint incongruity of the distal radius, 0-2 mm, was observed in 22 patients (30%) and over 2 mm in 3 patients. A minimal degree of posttraumatic osteoarthrosis was recorded in 21 patients (28.7%) and moderate ostheoarthrosis in 5 patients (6.8%). CONCLUSION: The anatomic reduction of the articular surfaces and healing of the fracture in a proper functional position are prerequisites for adequate function of the wrist and hand. It appears that an external fixator, with or without Kirschner wires, can be a method of choice in treatment of these complex articular fractures.

[Surgical treatment of pertrochanteric fractures using dynamic methods of internal and external fixation]. / Hirursko lecenje pertrohanternih preloma dinamickim metodama spoljasnje i unutrasnje fiksacije.

Pertrochanteric fractures usually occur in patients over 65 years of age, with greater loss of skeletal mass (osteoporosis). Nonsurgical methods of treatment are accompanied by relatively high lethality rate. Moreover, they do not produce satisfactory anatomical and functional results. Surgical treatment by using dynamic implants represents a method of choice in the fixation of pertrochanteric fractures. This paper presents the treatment results of 110 patients, 61 with pertrochanteric fractures, who were surgically treated by the dynamic method of internal fixation, and 49 patients who were treated by the method of external fixation. Dynamical implants enabled both dynamization and compression of the fracture in the axis of the neck, as well as the diaphysis of the femur, which lowered the risk of mechanical complications, and, at the same time, provided effective healing of the fracture, early activation, and mobilization of the patients on whom the surgery was performed. In patients infected by various diseases, for whom surgical trauma represents a life threat, the external fixation is recommended as a method of choice.