A pilot study in Serbia by European Clostridium difficile Infection Surveillance Network.

Clostridium (Clostridioides) difficile infections (CDIs) are among the most frequent healthcare-associated infections in Serbia. In 2013, Serbia participated in the European Clostridium difficile Infection Surveillance Network (ECDIS-Net) who launched a pilot study to enhance laboratory capacity and standardize surveillance for CDI. Two clinics of Clinical Center of Serbia [Clinic for Infectious and Tropical Diseases (CITD) and Clinic of Orthopedic Surgery and Traumatology (COT)] from Belgrade and one general hospital from another metropolitan area of Serbia, Uzice, participated. During a period of 3 months in 2013, all patients with diagnosed CDI were included. The CDI incidence rates in CITD, COT, and General Hospital Uzice were 19.0, 12.2, and 3.9 per 10,000 patient-days, respectively. In total, 49 patients were enrolled in the study with average age of 72 years. A complicated course of CDI was found in 14.3% of all patients. Six (12.2%) of 49 patients died, but not attributable to CDI. Of 39 C. difficile isolates, available for ribotyping, 78.9% belonged to ribotype 027; other PCR ribotypes were 001, 015, 002, 005, 010, 014, and 276. Antimicrobial susceptibility testing revealed low levels of MIC50 and MIC90 for metronidazole (0.5 µg/ml both) and vancomycin (0.25 and 0.5 µg/ml), while 28 strains of ribotype 027 were resistant to moxifloxacin with MIC ≥4 µg/ml. National surveillance is important to obtain more insight in the epidemiology of CDI and to compare the results with other European countries. This study by ECDIS-Net gives bases for a national surveillance of CDI in Serbia.

Ilizarov fixation for the treatment of scaphoid nonunion: a novel approach.

OBJECTIVES: To evaluate the safety and efficacy of the Ilizarov fine-wire compression/distraction technique in the treatment of scaphoid nonunion (SNU), without the use of bone graft. DESIGN: This is a prospective study of 20 consecutive patients in one center. PATIENTS AND METHODS: This study included 20 patients (19 males) with a mean SNU duration of 14.5 months. Four patients had proximal pole, 15 had waist, and 1 had a distal SNU. Patients with carpal instability, humpback deformities, carpal collapse, avascular necrosis, and marked degenerative change were excluded. Following frame application, the treatment comprises three stages: The frame is distracted by 1 mm per day until the radiographs show a 2-3 mm opening at the SNU site (mean 10 days); the SNU site is compressed for 5 days, at a rate of 1 mm per day, with the wrist in 15 degrees of flexion and 15 degrees of radial deviation; the wrist is then immobilized in the Ilizarov fixator for 8 weeks. RESULTS: Radiographic (radiography and CT scan) and clinical bony union was achieved in all 20 patients after a mean of 90.3 days (70-130 days). All patients returned to their pre-injury occupations. Thirteen patients had excellent results, four good, and three fair, according to the Mayo wrist score. CONCLUSIONS: In these selected patients, this technique safely achieved bony union without the need to open the SNU site and without the requirement of bone graft.

Free vascularised fibular grafts in orthopaedics.

Bony defects caused by trauma, tumors, infection or congenital anomalies can present a significant surgical challenge. Free vascularised fibular bone grafts (FVFGs) have proven to be extremely effective in managing larger defects (longer than 6 cm) where other conventional grafts have failed. FVFGs also have a role in the treatment of avascular necrosis (AVN) of the femoral head, failed spinal fusions and complex arthrodeses. Due to the fact that they have their own blood supply, FVFGs are effective even in cases where there is poor vascularity at the recipient site, such as in infection and following radiotherapy. This article discusses the versatility of the FVFG and its successful application to a variety of different pathologies. It also covers the applied anatomy, indications, operative techniques, complications and donor-site morbidity. Though technically challenging and demanding, the FVFG is an extremely useful salvage option and can facilitate limb reconstruction in the most complex of cases.

Current management of the mangled upper extremity.

Mangled describes an injury caused by cutting, tearing, or crushing, which leads to the limb becoming unrecognizable; in essence, there are two treatment options for mangled upper extremities, amputation and salvage reconstruction. With advances in our understanding of human physiology and basic science, and with the development of new fixation devices, modern microsurgical techniques and the possibility of different types of bony and soft tissue reconstruction, the clinical and functional outcomes are often good, and certainly preferable to those of contemporary prosthetics. Early or even immediate (emergency) complete upper extremity reconstruction appears to give better results than delayed or late reconstruction and should be the treatment of choice where possible. Before any reconstruction is attempted, injuries to other organs must be excluded. Each step in the assessment and treatment of a mangled extremity is of utmost importance. These include radical tissue debridement, prophylactic antibiotics, copious irrigation with a lavage system, stable bone fixation, revascularization, nerve repair, and soft tissue coverage. Well-planned and early rehabilitation leads to a better functional outcome. Despite the use of scoring systems to help guide decisions and predict outcomes, the decision to reconstruct or to amputate still ultimately lies with the surgical judgment and experience of the treating surgeon.

Risk factors and distribution of symptomatic venous thromboembolism in total hip and knee replacements: prospective study.

PURPOSE: Venous thromboembolism (VTE) is a common complication of orthopaedic surgery in the industrialised world; though there may be variability between population groups. This study aims to define the incidence and risk factors for symptomatic VTE following primary elective total hip and knee arthoplasty surgery in a single centre in Eastern Europe. METHODS: This prospective study included 499 adult patients undergoing total hip and knee arthroplasty for symptomatic osteoarthritis over a two-year period at the Clinic of Orthopaedic Surgery and Traumatology, Belgrade. RESULTS: The overall rate of confirmed symptomatic VTE during hospitalisation was 2.6%. According to the univariate logistic regression, an age greater than 75 years (OR = 3.08; 95%CI = 1.01-9.65), a family history of VTE (OR = 6.61; 95% CI = 1.33-32.90), varicose veins (OR = 3.13; 95% CI = 1.03-9.48), and ischemic heart disease (OR = 4.93; 95% CI = 1.61-15.09) were significant risk factors for in-hospital VTE. A family history of VTE and ischemic heart disease were independent risk factors according to multivariate regression analysis. Preoperative initiation of pharmacological thromboprophylaxis (p = 0.03) and a longer duration of thromboprophylaxis (p = 0.001) were protective for postoperative DVT. Though thromboprophylaxis was safe, with very few patients suffering major haemorrhage or heparin-induced thrombocytopenia, there was a general reluctance by our local surgeons to use prolonged thromboprophylaxis. CONCLUSION: VTE is common following hip and knee arthroplasty surgery. Orthopaedic patients with a family history of VTE, heart failure and coronary heart disease are at a considerable risk of thromboembolic complications in the postoperative period. There may be a role for preoperative thromboprophylaxis in addition to prolonged postoperative treatment.

The effects of potassium channel opener P1075 on the human saphenous vein and human internal mammary artery.

Because adrenergic contractions can contribute to the development of life-threatening spasm of coronary artery bypass graft, this study was performed to investigate the effect of adenosine 3-phosphate (ATP)-sensitive K channel (KATP) opener P1075 on contractions of isolated human saphenous vein (HSV) and human internal mammary artery (HIMA). Phasic contractions were evoked by electric field stimulation (20 Hz) and noradrenaline. The sustained contractions were evoked by phenylephrine. The presence of pore-forming Kir6.1 and Kir6.2 subunits of the KATP channels in the HIMA and only Kir6.2 in the HSV was confirmed immunomorphologically. P1075 inhibited in the HSV only, the electrical field stimulation contractions more strongly than noradrenaline contractions. In addition, the phenylephrine contractions of HSV were more sensitive to P1075 in comparison to those of HIMA. Glibenclamide, a KATP channel blocker antagonized the vasodilatation produced by P1075 in both grafts differently, because its effect was more prominent on the P1075-induced inhibition of contractions of HSV than of HIMA. We conclude that P1075 has a vasorelaxant effect and inhibited adrenergic contractions of the tested grafts. This effect is graft and vasoconstrictor selective and seems to be mediated by Kir6.1- and/or Kir6.2-containing KATP channels. Thus, P1075 can be considered as a potential drug in the prevention of graft spasm.

War-related infected tibial nonunion with bone and soft-tissue loss treated with bone transport using the Ilizarov method.

PATIENTS AND METHODS: This single centre retrospective study reviews the outcomes of 30 war-injured patients with established infected tibial nonunion after sustaining grade IIIB open fractures. Patients were treated by radical bony and soft-tissue resection and bone transport using the Ilizarov bifocal technique, without the use of systemic antibiotics or bone grafting. RESULTS: The series comprised 29 males and 1 female with a mean age of 30.4 years and a mean nonunion of 8.6 months at index operation. Patients had previously undergone a mean of 1.3 operations (range 1-3), and the mean size of tibial defect was 6.9 cm (range 4-11 cm) post radical debridement. Bony union was achieved at the tibial docking sites after a mean of 4.5 months in 29 patients (97%) and frames were worn for a mean of 9.7 months (range 7.2-15 months), giving a mean fixation index of 1.48 months/cm. One patient failed to unite at their tibial docking site. Soft-tissue transport successfully closed the soft-tissue defects in all but four patients, who required split-skin grafting. According to the Paley scoring system 19 patients had excellent bony results, 10 good and 1 poor; the functional results were excellent in 13 patients, good in 14, fair in 2 and poor in 1; and there were 1.4 complications per patient. Over a mean follow-up of 99 months no patient refractured their reconstruction, developed any symptoms or signs of recurrent infection, or required amputation. CONCLUSION: The Ilizarov technique with bone transport continues to be the most versatile, adaptive and effective method of treatment in these complex cases, and can very successfully deal with the associated large soft-tissue and bony defects without the use of routine bone-grafting, systemic antibiotics or soft-tissue flaps.

The management of humeral shaft fractures with associated radial nerve palsy: a review of 117 cases.

PATIENTS AND METHODS: This single center retrospective study reviews the management and outcomes of 117 consecutive patients with humeral shaft fractures and associated radial nerve palsy (RNP) treated over a 20-year period (1986-2006). A total of 101 fractures were managed conservatively and 16 fractures underwent external fixation for poor bony alignment. Sixteen grade 1 and 2 open fractures underwent wound toileting alone. No patients underwent initial radial nerve exploration or opening of the fracture sites. RESULTS: All patients achieved clinical and radiological bony union at a mean of 8 weeks (range 7-12 weeks). There were no complications or pin tract infections in the operated patients. A total of 111 cases had initial spontaneous RNP recovery at a mean of 6 weeks (range 3-24 weeks) with full RNP recovery at a mean of 17 weeks (range 3-70 weeks) post-injury. Fourteen patients had no clinical/EMG signs of nerve activity at 12 weeks and 6 subsequently failed to regain any radial nerve recovery; 2 had late explorations and the lacerated nerves underwent sural nerve cable neurorraphy; and 4 patients underwent delayed tendon transposition 2-3 years after initial injury, with good/excellent functional outcomes. CONCLUSIONS: Humeral fractures with associated RNP may be treated expectantly. With low rates of humeral nonunion, 95% spontaneous nerve recovery in closed fractures and 94% in grade 1 and 2 open fractures, one has the opportunity of waiting. If at 10-12 weeks there are no clinical/EMG signs of recovery, then nerve exploration/secondary reconstruction is indicated. Late tendon transfers may also give good/excellent functional results.

The current state of bionic limbs from the surgeon's viewpoint.

Amputations have a devastating impact on patients' health with consequent psychological distress, economic loss, difficult reintegration into society, and often low embodiment of standard prosthetic replacement.The main characteristic of bionic limbs is that they establish an interface between the biological residuum and an electronic device, providing not only motor control of prosthesis but also sensitive feedback.Bionic limbs can be classified into three main groups, according to the type of the tissue interfaced: nerve-transferred muscle interfacing (targeted muscular reinnervation), direct muscle interfacing and direct nerve interfacing.Targeted muscular reinnervation (TMR) involves the transfer of the remaining nerves of the amputated stump to the available muscles.With direct muscle interfacing, direct intramuscular implants record muscular contractions which are then wirelessly captured through a coil integrated in the socket to actuate prosthesis movement.The third group is the direct interfacing of the residual nerves using implantable electrodes that enable reception of electric signals from the prosthetic sensors. This can improve sensation in the phantom limb.The surgical procedure for electrode implantation consists of targeting the proximal nerve area, competently introducing, placing, and fixing the electrodes and cables, while retaining movement of the arm/leg and nerve, and avoiding excessive neural damage.Advantages of bionic limbs are: the improvement of sensation, improved reintegration/embodiment of the artificial limb, and better controllability. Cite this article: EFORT Open Rev 2020;5:65-72. DOI: 10.1302/2058-5241.5.180038.

Lower limb replantation: 27 years follow up.

Replantation of lower extremity is a very complex and difficult procedure. There are still a lot of controversies about indications, even numerous scoring systems are now available that can facilitate the surgeon's decision. We present the functional results of a replanted below-knee amputation in an elderly patient, 27 years after the injury and discuss the indication for replantation.

A radiographic and clinical comparison of two soft-tissue procedures for paralytic subluxation of the hip in cerebral palsy.

This article summarises a comparative retrospective study (1983-2001) of 42 consecutive spastic-diplegic ambulatory patients (aged 2-10 years) by examining the radiographic and clinical results of two soft-tissue procedures for paralytic hip subluxation (PSH). Group A comprised 20 patients (26 PSHs) who were treated by iliopsoas tenotomy, and group B comprised 22 patients (31 PSHs) who were treated by rectus femoris and iliopsoas tenotomy with iliac crest resection (sartorius release). All patients had bilateral adductor tenotomies. At 8.8 years mean follow-up, group A migration percentages (MP) improved from 39.8% to 24.7% with 92.3% good/average results. At a mean follow-up period of 8.3 years, group B improved from 58.0% to 25.9% with 96.8% good/average results. Long-term hip reduction was achieved in 84.6% of group A and 80.6% of group B hips. Relative MP correction was superior in group B. No patient had MP progression in either the PSH or non-PSH hip. Walking ability improved in 55% of group A and 86% of group B patients (Functional Mobility Scale). In conclusion, we recommend release of all the principle hip flexors: rectus femoris, sartorius, and iliopsoas, coupled with adductor tenotomies, in this patient group.

What microsurgeon, orthopaedic and plastic surgeon should know about bionic hand.

Hand loss is a catastrophic event that generates significant demands for orthopedics and prosthetics. In the course of history, prostheses evolved from passive esthetic replacements to sophisticated robotic hands. Yet, their actuation and particularly, their capacity to provide patients with sensations, remain an unsolved problem. Sensations associated with the hand, such as touch, pain, pressure and temperature detection are very important, since they enable humans to gather information from the environment. Recently, through a synergistic multidisciplinary effort, medical doctors and engineers have attempted to address these issues by developing bionic limbs. The aim of the bionic hands is to replace the amputated hands while restoring sensation and reintroducing hand-motor control. Recently, several different approaches have been made to interface this sophisticated prosthesis with residual neuro-muscular structures. Different types of implants, such as intramuscular, epineural and intraneural, each have their own complementary advantages and disadvantages, which are discussed in this paper. After initial trials with percutaneous leads, present research is aimed at making long-term implantable electrodes that give rich, natural feedback and allow for effortless control. Finally, a pivotal part in the development of this technology is the surgical technique which will be described in this paper. The surgeons' insights into this procedure are given. These kinds of prostheses compared with the classic one, hold a promise of dramatic health and quality of life increase, together with the decrease the rejection rate.

"Close-open-close free-flap technique" for the cover of severely injured limbs.

The treatment of severely injured extremities still presents a very difficult task for trauma orthopaedic surgeons. Despite improvements in technology and surgical/microsurgical techniques, sometimes a limb must be amputated, otherwise severe and potentially fatal complications may develop. There is a well-established belief that severe open fractures should be left open. However, Godina proved wound coverage in the first 72 h (after an injury) to be safe and to bring good final results. So early wound cover (no later than one week after an injury) with well vascularized free flaps became the gold standard. Yet for many patients (some of whom have serious health problems), operative treatment needs to be postponed when they arrive to specialized microsurgical departments for microsurgical reconstruction much later than one week after incurring an injury.  As the definite wound cover period from one week to 3 months seems to be hazardous, especially due to the potential of infection, we developed a safe, original flap technique that prevents infection and covers important structures such as exposed bones, tendons, nerves and vessels. We named this technique the "close-open-close free flap technique". It enables difficult wound cover in any biological phase of the wound, by combining complete flap cover first, with the removal of stitches from one side of the flap after 6-12 h. This technique works very well for borderline cases as well; where even after a complete debridement, dead tissue still remains in the wound - making wound cover very dangerous. Closing completely severe open fractures with free (or pedicled) flaps and removing the stitches on one side after 6-12 h, enables orthopaedic surgeons to safely cover any kind of wound in any biological phase of the wound. Additional debridements, lavages and reconstructions can easily be performed under the flap and after the danger of a serious infection has disappeared, definitive wound closure can be carried out.

Sensory feedback restoration in leg amputees improves walking speed, metabolic cost and phantom pain.

Conventional leg prostheses do not convey sensory information about motion or interaction with the ground to above-knee amputees, thereby reducing confidence and walking speed in the users that is associated with high mental and physical fatigue1-4. The lack of physiological feedback from the remaining extremity to the brain also contributes to the generation of phantom limb pain from the missing leg5,6. To determine whether neural sensory feedback restoration addresses these issues, we conducted a study with two transfemoral amputees, implanted with four intraneural stimulation electrodes7 in the remaining tibial nerve (ClinicalTrials.gov identifier NCT03350061). Participants were evaluated while using a neuroprosthetic device consisting of a prosthetic leg equipped with foot and knee sensors. These sensors drive neural stimulation, which elicits sensations of knee motion and the sole of the foot touching the ground. We found that walking speed and self-reported confidence increased while mental and physical fatigue decreased for both participants during neural sensory feedback compared to the no stimulation trials. Furthermore, participants exhibited reduced phantom limb pain with neural sensory feedback. The results from these proof-of-concept cases provide the rationale for larger population studies investigating the clinical utility of neuroprostheses that restore sensory feedback.

Enhancing functional abilities and cognitive integration of the lower limb prosthesis.

Lower limb amputation (LLA) destroys the sensory communication between the brain and the external world during standing and walking. Current prostheses do not restore sensory feedback to amputees, who, relying on very limited haptic information from the stump-socket interaction, are forced to deal with serious issues: the risk of falls, decreased mobility, prosthesis being perceived as an external object (low embodiment), and increased cognitive burden. Poor mobility is one of the causes of eventual device abandonment. Restoring sensory feedback from the missing leg of above-knee (transfemoral) amputees and integrating the sensory feedback into the sensorimotor loop would markedly improve the life of patients. In this study, we developed a leg neuroprosthesis, which provided real-time tactile and emulated proprioceptive feedback to three transfemoral amputees through nerve stimulation. The feedback was exploited in active tasks, which proved that our approach promoted improved mobility, fall prevention, and agility. We also showed increased embodiment of the lower limb prosthesis (LLP), through phantom leg displacement perception and questionnaires, and ease of the cognitive effort during a dual-task paradigm, through electroencephalographic recordings. Our results demonstrate that induced sensory feedback can be integrated at supraspinal levels to restore functional abilities of the missing leg. This work paves the way for further investigations about how the brain interprets different artificial feedback strategies and for the development of fully implantable sensory-enhanced leg neuroprostheses, which could drastically ameliorate life quality in people with disability.

Ilizarov frame fixation without bone graft for atrophic humeral shaft nonunion: 28 patients with a minimum 2-year follow-up.

OBJECTIVES: To evaluate the outcomes of patients with atrophic humeral shaft nonunion (HSNU) treated by Ilizarov frame fixation without the use of bone graft. DESIGN: A retrospective review of 28 consecutive patients treated in 1 center between 1996 and 2002. SETTING: Tertiary referral center. PATIENTS AND METHODS: We studied 28 consecutive patients: 12 male and 16 female. Of the patients, 21 had been previously operated (15 by internal fixation using compression plates, 3 by intramedullary nailing, and 3 by external fixation), and 9 of those 21 patients also had failed revision procedures; 7 patients had been treated nonoperatively from the time of injury to the time of the index procedure for HSNU. Mean age at the time of the index operation was 44 years (16-73 years). INTERVENTION: Removal of the previous fixation device, excision of fibrous tissue at the HSNU site, opening of the intramedullary canal, excision of avascular bony ends, and stabilization fixation and compression of the humerus with an Ilizarov circular frame (proximal semicircular ring) using smooth 1.8-mm K-wires. No bone graft was used. The mean postoperative follow-up was 76 months (24-174 months). MAIN OUTCOME MEASUREMENTS: Radiologic union using plain radiographs. Clinical and functional outcome using the Lammens system, which evaluates pain, range of shoulder and elbow movements (and their limitations), and humeral alignment and union. Patient subjective outcomes were assessed using a 4-point patient satisfaction questionnaire. RESULTS: Bony union was achieved in all 28 cases after a mean of 4.1 months (3.4-5.7 months). There were 6 superficial pin tract infections (which resolved with antibiotics) and 1 transient radial nerve palsy (which resolved at 2.5 months). One patient refractured his humeral shaft following a fall, but the fracture successfully united 5.7 months later after a further Ilizarov frame application. All patients had good or excellent functional outcomes and range of shoulder and elbow movements as rated by the Lammens scoring system. CONCLUSIONS: Ilizarov circular frame fixation without bone graft is a reliable method for the treatment of atrophic nonunion of the humerus, even after failed previous surgery.

The Outcomes of 150 Consecutive Patients with Digital Nerve Injuries Treated in a Single Center.

AIM: The surgical management of injured digital nerves is a common part of hand trauma surgery. Despite improvements in the surgical techniques and suture material, the final outcomes of peripheral nerve repair can still be disappointing. This study investigates the outcomes following the surgical treatment of traumatic digital nerve lesions of the hand. MATERIAL AND METHODS: 150 consecutive patients with acutely digital nerve injuries were treated through by primary repair in our Unit between January 2005 and December 2009. 126 were male, 24 female (male/female ratio of 5.25:1), with an age range of 16-70 years, and a mean follow-up of 30 months. All 150 patients underwent primary epineural suture within 48 hours of their injury. Sensory recovery was assessed using the Medical Research Council scale (MRC). Sensibility testing was performed after a minimum of 12 months. Disabilities of the Arm, Shoulder and Hand scores (DASH) were used to evaluate the functional outcomes. RESULTS: Eighteen patients (9.33%) had excellent sensibility with two-point discrimination test (S2PD) of ≤ 7 mm (S4). Forty-one patients (21.24%) achieved good sensibility (S2PD ≤ 15 mm, S3+), 76 (39.38%) achieved S3, 55 (28.50%) had poor sensibility (S2 and S1), and two patients had no sensibility (S0). The mean functional DASH score was 9.0 in our group of patients. CONCLUSION: There was a significant correlation between patient age, mechanism of injury and nerve recovery, with younger patients and patients with narrow zone of injury achieving better sensory recoveries.

Iliopsoas haematoma in Gaucher disease.

Extrapelvis or retroperitoneal haemorrhage has long been appreciated as having many causes and considerable variability in subsequent morbidity; however, to date only two cases have been reported in patients with Gaucher disease, the most common lysosomal storage disorder. It had been our assumption that these cases were unique and a consequence of severe disease in patients who had not been treated with enzyme (or other disease-specific) therapy. Herein we present three more cases (as well as our first patient), which allow one to make some generalizations. Ultrasound was used in one centre and computed tomography in the second centre to make the definitive diagnosis. The trigger for the bleeding in all cases was muscle strain after activity. All patients were young with massive hepatosplenomegaly, anaemia, thrombocytopenia, and bone pain with skeletal involvement; the last was the most obvious commonality among these patients. Differential diagnosis is complicated by exquisite groin pain that is common to both Gaucher disease and extrapelvis haemorrhage, but not necessarily.

Treatment of blast injuries of the extremity.

Blast trauma is a complex event. Pathophysiologically, blast injuries are identified as primary (caused solely by the direct effect of blast overpressure on the tissue), secondary (caused by flying objects or fragments), tertiary (caused by bodily displacement), or quaternary (indirectly caused by the explosion). The range of primary blast injuries includes fractures, amputations, crush injury, burns, cuts, lacerations, acute occlusion of an artery, air embolism-induced injury, compartment syndrome, and others. Secondary injuries are the most common extremity blast injuries. Like primary injuries, they may necessitate limb amputation, be life-threatening, and produce severe contamination. Tertiary blast injuries of the extremity may result in traumatic amputations, fractures, and severe soft-tissue injuries. Quaternary injuries most often are burns. Following treatment and stabilization of immediate life-threatening conditions, all patients are given antibiotic and tetanus prophylaxis. Débridement and wound excision are started as early as possible, with repeat débridement performed as necessary; fasciotomies also are performed to prevent compartment syndrome. Well-vascularized muscular free flaps provide soft-tissue coverage for blast-injured extremities. The closed-open technique of flap closure allows reexamination of the wound, further irrigation, débridement, and later bone and soft-tissue reconstruction.

Modification of the Ilizarov external fixator for aseptic hypertrophic nonunion of the clavicle: an option for treatment.

OBJECTIVE: To assess the results of treatment of aseptic hypertrophic nonunion of the clavicle by external fixation using a modified Ilizarov apparatus. DESIGN: Prospective study. SETTING: A consecutive series of 12 patients from 2 specialized orthopaedic institutions, treated by the 3 senior authors. PATIENTS: Twelve patients (5 females) with a mean age of 38.7 +/- 12.4 (range, 18-50) years with an aseptic hypertrophic nonunion of the clavicle were treated operatively during the period 1994 to 1998. Ten patients had previously been treated nonoperatively, whereas 2 had been treated surgically; the treatment in all had failed. All patients had pain with shoulder stiffness. INTERVENTION: Patients were treated using the Ilizarov external fixation technique. The operation was performed under general anesthesia and an Ilizarov external fixator was applied percutaneously under fluoroscopic control, without a skin incision or bone grafting. The patients were then monitored clinically and radiologically for 24 to 96 (mean, 45.4) months. MAIN OUTCOME MEASUREMENTS: Radiologic evaluation and clinical assessment by the Constant numerical score. RESULTS: The mean Constant preoperative score was 30.4 +/- 9 (range, 18-44). Healing of the nonunion occurred in all patients treated by the Ilizarov technique. Nine patients had pain relief and gained unlimited range of motion, whereas 3 patients had mild pain during elevation of the arm. A mean period of 75.4 (range, 50-95) days was needed for gradual bone reduction and union. The mean Constant outcome score was 68.8 +/- 14.7 (range, 46-85). COMPLICATIONS: 2 patients had superficial pin infections that cleared with local therapy and antibiotics, and 1 patient had a reoperation for a nonunion after a fall onto the floor. CONCLUSIONS: Ilizarov fixation seems to be an effective method in the treatment of aseptic hypertrophic clavicle nonunions, even in patients where previous surgery has failed.