Immunohistochemical evaluation of tissues following bone implant extraction from upper and lower limb.

Fractured bones can regenerate and restore their biological and mechanical properties to the state prior to the damage. In some cases, however, the treatment of fractures requires the use of supportive implants. For bone healing, three processes are essential: the inflammatory phase, the repair phase and the remodelling phase. A proper course of the first - inflammatory - stage is important to ensure a successful fracture healing process. In our study, we evaluated tissue samples immunohistochemically from the area surrounding the fractures of upper and lower limbs (bone tissue, soft tissue, and the implant-adhering tissue) for markers: CD11b, CD15, CD34, CD44, CD68, Cathepsin K, and TRAcP that are linked to the aforementioned phases. In soft tissue, higher expressions of CD68, CD34, CD15 and CD11b markers were observed than in other locations. TRAcP and Cathepsin K markers were more expressed in the bone tissue, while pigmentation, necrosis and calcification were more observed in the implant-adhering tissue. Since even the implant materials commonly perceived as inert elicit the observed inflammatory responses, new surface treatments and materials need to be developed.

Extremity compartment syndrome: A review with a focus on non-invasive methods of diagnosis.

The article deals with an overview of acute extremity compartment syndrome with a focus on the option of non-invasive detection of the syndrome. Acute extremity compartment syndrome (ECS) is an urgent complication that occurs most often in fractures or high-energy injuries. There is still no reliable method for detecting ECS. The only objective measurement method used in clinical practice is an invasive measurement of intramuscular pressure (IMP). The purpose of this paper is to summarize the current state of research into non-invasive measurement methods that could allow simple and reliable continuous monitoring of patients at risk of developing ECS. Clinical trials are currently underway to verify the suitability of the most studied method, near-infrared spectroscopy (NIRS), which is a method for measuring the local oxygenation of muscle compartments. Less explored methods include the use of ultrasound, ultrasound elastography, bioimpedance measurements, and quantitative tissue hardness measurements. Finding a suitable method for continuous non-invasive monitoring of the syndrome would greatly improve the quality of care for patients at risk. ECS must be diagnosed quickly and accurately to prevent irreversible tissue damage that can occur within hours of syndrome onset and may even warrant amputation if neglected.

Comparison of fluoroscopy and fluoroscopy-based 2D computer navigation for iliosacral screw placement: a retrospective study.

PURPOSE: Treatment of pelvic fractures is often complicated. Here, we intended to evaluate the intraoperative benefits of using 2D computer navigation when compared with traditional fluoroscopy on X-ray burden, surgical time and screw placement accuracy. METHODS: In this study, we retrospectively evaluated the records of 25 patients who underwent osteosynthesis of a posterior pelvic fracture using fluoroscopy at the University Hospital Ostrava, Czech Republic between 2011 and 2019, and 32 patients from the same department and period in whom 2D computer navigation was used. RESULTS: Intraoperative X-ray burden was significantly lower in the group with 2D computer navigation (median 650 vs 1024 cGy/cm2), as was the duration of the surgery (41 vs 45 min). This was most obvious where two screws were inserted (X-ray dose of 994 vs 1847 cGy/cm2 and 48 vs 70 min, respectively). Correction of the path for wire placement after the original drilling was necessary in 2 patients (6%) from the 2D computer navigation group and 15 patients from the fluoroscopy group (60%). Still, no malposition of the screws nor dislocation of the posterior pelvic segment after 12 months was observed in any patient of either group; of complications, only three superficial infections in the 2D navigation group and 2 in the fluoroscopy group were observed. CONCLUSION: 2D computer navigation is a safe and accurate method for placement of screws during posterior pelvic fracture osteosynthesis, associated with lower intraoperative radiation burden and shorter surgical times compared to standard fluoroscopy, especially if two screws are inserted.

Outcomes of Mini-Invasive Arthroscopic Arthrolysis Combined with Locking Screw and/or Intramedullary Nail Extraction after Osteosynthesis of the Proximal Humerus Fracture.

Data on the effectiveness of arthroscopic arthrolysis and extraction of osteosynthetic material after osteosynthesis of the proximal humerus in patients with persisting problems are rare and insufficient. In this study, we performed arthroscopic arthrolysis and extraction of fixation screws, and, where protruding, extraction of the nail in 34 patients with problems persisting 12 months after osteosynthesis of the proximal humerus using an intramedullary nail. The effectiveness of the treatment was assessed using the Constant-Murley shoulder score and forward flexion difference between the treated arm and the contralateral one. A median increase of 16 points in CMS score and 30 degrees reduction in the arm forward flexion difference was recorded 12 months after the arthroscopy. The improvement was significantly higher in the patient group with intramedullary nail extraction (however, this group had worse pre-operative values and the screw was only extracted where likely to cause problems). The median time to heal was 11 weeks; no serious peri- or post-procedural complications occurred. Mini-invasive arthroscopic arthrolysis combined with extraction of osteosynthetic material proved to be a safe and effective method for treatment of patients after osteosynthesis of the proximal humerus using an intramedullary nail with persisting pain and/or mobility limitation.

Tibiotalocalcaneal Arthrodesis in Osteoarthritis Deformation of Ankle and Subtalar Joint: Evaluation of Treatment Results.

Tibiotalocalcaneal arthrodesis (TTCA) is an increasingly used method of stiffening the ankle and subtalar joints in advanced degenerative deformities. The study group consisted of 19 men who were subjected to intramedullary and intraosseous arthrodesis using an intramedullary nail. The average age of patients was 46 (range 19-68) years. The main indication for surgical treatment was post-traumatic arthrosis 11 (58%). In the studied group, clinical condition was assessed using the American Orthopedic Foot and Ankle Score (AOFAS) classification, quality of life using the SF-12 scale, and assessment of pain intensity using the visual-analog scale (VAS) scale. The above parameters were evaluated before surgery (under 2 years), intermediate (from 2 to 5 years), and late (over 5 years) postoperative period. The clinical condition on the AOFAS scale improved from an average of 20.6 points before tibiotalocalcaneal arthrodesis to 63.5 after the procedure. The result was statistically significant (p < .0001). Analyzing the results using the SF-12 scale, a statistically significant increase was found. In the physical sphere of Physical Health Component Score-12 (p = .0004) and in the mental sphere of Mental Health Component Score-12 (p = .030). The intensity of pain assessed in the VAS scale, decreased in all three periods-p < .05. The strongest analgesic effect was observed in the early postoperative follow-up period. Tibiotalocalcaneal arthrodesis using an intramedullary nail causes a significant improvement in the clinical condition according to the AOFAS classification, enabling most patients to move independently, a significant improvement quality of life assessed in the SF-12 scale and a significant reduction of pain ailments assessed in the VAS scale, especially in the early postoperative period.

Endovascular Repair of Thoracic Aorta Injury: 17 Years of Single-Center Experience.

BACKGROUND Traumatic thoracic aortic transection is one of the most severe complications of high-energy injuries, but patients rarely receive treatment, and it is fatal in the vast majority of cases. Due to the complexity of surgical revision for transection, endovascular repair with stent graft implantation is the preferred approach. MATERIAL AND METHODS We retrospectively analyzed the short-term and long-term treatment results for 31 patients (29 men, 2 women) treated at the Interventional Radiology Department, University Hospital Ostrava, for the isthmus part of a descending thoracic aorta injury between 2004 and 2020. RESULTS The median patient age was 48 years (interquartile range [IQR]: 28-63 years). The most common causes of injury were traffic accidents and falls or jumps, with the trauma location at the Ishimaru zones 2 to 4 of the aortic isthmus. Aortic stent grafts were successfully implanted in all patients; 13% of patients had complications and 10% died due to the trauma severity. The median procedure duration was 30 min (IQR: 25-43 min) and the median hospital stay was 29 days (IQR: 28-63 days). CONCLUSIONS Aortic stent graft implantation appears to be a safe and effective method for dealing with thoracic aorta injury, with a low complication rate and high patient survival. The endovascular approach is the method of choice for treating this severe disease, and a multidisciplinary approach for emergency medical treatment with a comprehensive trauma protocol is essential.

Tension Hemothorax in Aortic Rupture: A Case Report.

Background: The standard ATLS protocol calls for chest drain insertion in patients with hemothorax before performing further diagnostic steps. However, if trauma-induced thoracic aortic rupture is the underlying cause, such drainage can lead to massive bleeding and death of the patient. Case report: This report describes a case of a polytrauma patient (car accident), aged 21, with symmetrical chest and decreased breath sounds dorsally on the left. An urgent CT scan revealed subadventitial Grade III thoracic aortic transection with mediastinal hematoma, a massive left-sided hemothorax with mediastinal shift to the right, and other injuries. Stent-graft implantation with subsequent left hemithorax drainage was urgently performed, during which the patient became increasingly unstable from the circulatory point of view. This traumatic hemorrhagic shock was successfully managed at the ICU. Conclusion: Although hemothorax is a serious condition requiring rapid treatment, the knowledge of its origin is of utmost importance; performing chest drainage without bleeding control can lead to circulatory instability and death of the patient. Hence, where aortic injury can be suspected based on the mechanism of the injury, it is beneficial to perform spiral CT angiography for accurate diagnosis first and, in cases of aortic injury, to control the bleeding prior to drainage.

Strength Analyses of Screws for Femoral Neck Fractures.

This article represents a multidisciplinary approach to biomechanics (engineering + medicine) in the field of "collum femoris" fractures. One possible treatment method for femoral neck fractures, especially for young people, is the application of cancellous (i.e. lag or femoral) screws (with full or cannulated cross-section) made of Ti6Al4V or stainless steel. This paper therefore aims to offer our own numerical model of cancellous screws together with an assessment of them. The new, simple numerical model presented here is derived together with inputs and boundary conditions and is characterized by rapid solution. The model is based on the theory of beams on an elastic foundation and on 2nd order theory (set of three differential 4th order equations, combination of pressure and bending stress-deformation states). It presents the process for calculating displacements, slopes, bending moments, stresses etc. Two examples (i.e. combinations of cancellous screws with full or cannulated cross-section made of stainless steel or Ti6Al4V material) are presented and evaluated (i.e. their displacement, slopes, bending moments, normal forces, shearing forces and stresses). Future developments and other applications are also proposed and mentioned.

Analysis of Locking Self-Taping Bone Screws for Angularly Stable Plates.

Paper focuses on biomechanics, specifically on locking cortical bone screws in angularly stable plates used for the treatment of bone fractures in the medical fields of traumatology and orthopaedics. During extraction of titanium-alloy implants, problems are encountered in an effort to loosen some locking bone screws from the locking holes of an angularly stable plate and the subsequent stripping of the internal hexagon of the screw head. The self-locking of the screw-plate threaded joint was verified by calculation and the effect of the angle of the thread on the head of the locking cortical bone screw on self-locking was evaluated. The magnitude of the torque, causing the stripping of the internal hexagon (the Inbus type head) of a locking cortical bone screw with a shank diameter of 3.5 mm from Ti6Al4 V titanium alloy to ISO 5832-3, was determined experimentally. Also, it was experimentally found that the rotation of the screwdriver end with a hexagonal tip inside the locking cortical bone screw head during stripping of the internal hexagon causes strain of the screw head perimeter and thereby an increase of thread friction. The effect of tightening torque on the possibility of loosening of the locking cortical bone screw from the locking hole of an angularly stable plate was assessed experimentally. From the evaluation of five alternative shapes of locking cortical bone screw heads in terms of the acting stress and generated strains, it follows that the best screw is the screw with the Torx type head, which demonstrates the lowest values of reduced stress and equivalent plastic strain. Based on experiments and simulations the authors recommend that all global producers of locking cortical bone screws for locking holes of angularly stable plates use the Torx type heads, and not heads of the Inbus type or the Square, PH, PZ types.

Anaerobic metabolism associated with traumatic hemorrhagic shock monitored by microdialysis of muscle tissue is dependent on the levels of hemoglobin and central venous oxygen saturation: a prospective, observational study.

BACKGROUND: Traumatic hemorrhagic shock resulting in tissue hypoxia is a significant cause of morbidity and mortality in polytraumatized patients. Early identification of tissue hypoxia is possible with microdialysis. The aim of this study was to determine the correlation between a marker of tissue hypoxia (L/P; lactate to pyruvate ratio) and selected parameters of systemic oxygen delivery (Hb; hemoglobin) and oxygen extraction (ScvO2; central venous oxygen saturation). We also investigated the severity of tissue hypoxia over the course of care. METHODS: Adult patients with traumatic hemorrhagic shock were enrolled in this prospective, observational study. Microdialysis of the peripheral muscle tissue was performed. Demographic data and timeline of care were collected. Tissue lactate, pyruvate, glycerol, glucose levels, hemoglobin, serum lactate and oxygen saturation of the central venous blood (ScvO2) levels were also measured. RESULTS: The L/P ratio trend may react to changes in systemic hemoglobin levels with a delay of 7 to 10 hours, particularly when systemic hemoglobin levels are increased by transfusion. Decrease in tissue L/P ratio may react to increase in ScvO2 with a delay of up to 10 hours, and such a decrease may signify elimination of tissue hypoxia after transfusion. We also observed changes in the L/P trend in the 13 hours preceding a change in the hemoglobin level. Fluid administration, which is routinely used as a first-line treatment of hypovolemic shock, can cause hemodilution and decreased hemoglobin. When ScvO2 decreases, increase in L/P ratio may precede the ScvO2 trend by 10 or 11 hours. An increase in the L/P ratio is an early warning sign of insufficient tissue oxygenation and should lead to intensive observation of hemoglobin levels, ScvO2 and other hemodynamic parameters. Patients who were treated more rapidly had lower maximal L/P values and a lower degree of tissue ischemia. CONCLUSION: The L/P ratio is useful to identify tissue ischemia and can estimate the effectiveness of fluid resuscitation. An increase in the L/P ratio is an early warning sign of inadequate tissue oxygenation and should lead to more detailed hemodynamic and laboratory monitoring. This information cannot usually be obtained from global markers.

Tissue ischemia microdialysis assessments following severe traumatic haemorrhagic shock: lactate/pyruvate ratio as a new resuscitation end point?

BACKGROUND: Intensive care of severe trauma patients focuses on the treatment of haemorrhagic shock. Tissues should be perfused sufficiently with blood and with sufficient oxygen content to ensure adequate tissue oxygen delivery. Tissue metabolism can be monitored by microdialysis, and the lactate/pyruvate ratio (LPR) may be used as a tissue ischemia marker. The aim of this study was to determine the adequate cardiac output and haemoglobin levels that avoid tissue ischemia. METHODS: Adult patients with serious traumatic haemorrhagic shock were enrolled in this prospective observational study. The primary observed parameters included haemoglobin, cardiac output, central venous saturation, arterial lactate and the tissue lactate/pyruvate ratio. RESULTS: Forty-eight patients were analysed. The average age of the patients was 39.8 ± 16.7, and the average ISS was 43.4 ± 12.2. Hb < 70 g/l was associated with pathologic arterial lactate, ScvO2 and LPR. Tissue ischemia (i.e., LPR over 25) developed when CI ≤ 3.2 l/min/m(2) and Hb between 70 and 90 g/l were observed. Severe tissue ischemia events were recorded when the Hb dropped below 70 g/l and CI was 3.2-4.8 l/min/m(2). CI ≥ 4.8 l/min/m(2) was not found to be connected with tissue ischemia, even when Hb ≤ 70 g/l. CONCLUSION: LPR could be a useful marker to manage traumatic haemorrhagic shock therapies. In initial traumatic haemorrhagic shock treatments, it may be better to maintain CI ≥ 3.2 l/min/m(2) and Hb ≥ 70 g/l to avoid tissue ischemia. LPR could also be a useful transfusion trigger when it may demonstrate ischemia onset due to low local DO2 and early reveal low/no tissue perfusion.

[Metabolism monitoring with microdialysis in the intensive care]. / Sledování metabolismu v intenzivní péci pomocí mikrodialýzy.

Therapy of haemorrhagic shock presents a huge challenge nowadays. Changes in circulation and metabolism are preceded with changes in cells, vessels and extracellular fluid. The main disorder takes place in microcirculation. Monitoring of extracellular fluid is possible with microdialysis. This method was verified on animal models and a became base of many clinical examinations in the world. First of all it is monitoring of lactate, pyruvate, glucose and glycerole as main markers of cell metabolism. Tissue condition can be described not only with absolute values but also as relations between individual parameters e.g. lactate/pyruvate and lactate/glucose. These values do not only inform us about forthcoming change from aerobic to anaerobic metabolism but also about the degree of reperfusion. Precious information about mitochondrial dysfunction which is the essence of multiorgan dysfunction in intensive care is collected as well. Based on changes we can asses the quality of resuscitation care together with speed of shock elimination, increasing oxygen delivery and mitochondrial dysfunction treatment.

Our experiences with the treatment of periprosthetic fractures of femur.

In the statement authors want to draw attention to the possibilities of treatment of periprosthetic fractures of femur. They present their own experiences with the treatment of these fractures by using various types of internal and external fixation evaluated from 1996 to 2003. They present some less common types of internal fixation as e.g. fixation by clamp plates.

Abdominal compartment syndrome in polytrauma.

Authors inform about the group of 8 patients with abdominal compartment syndrome (ACS) occurred as a complication in large blunt injury of abdominal cavity. To the ACS diagnose, the measurement of intracystic pressure is used routinely, whose values correlate fully with values of intraabdominal pressure (IAP). In case of increasing values of IAP over 25 mm Hg with positive clinical signs of ACS, authors indicate decompression laparotomy with temporary closing of abdominal cavity by sterile plastic foil or Ethizip. This preventive temporary laparostomy is recommended also in serious injuries of abdominal cavity in patients with fatal haemorrhage, treated by the method of staged laparotomy with tamponade of abdominal cavity and with massive blood and volume resuscitation.