COMPARATIVE RADIOLOGICAL DIAGNOSTICS OF ACUTE TRIANGULAR FIBROCARTILAGE COMPLEX INJURIES.

The aim was to analyze patients with clinical diagnosis of triangular fibrocartilage complex (TFCC) lesion using standard x-ray, ultrasound, conventional magnetic resonance imaging (MRI) and MR arthrography (MRA); to evaluate the accuracy of MRA compared with MRI in the diagnosis of this lesion; and to evaluate ultrasound as a method of diagnosing TFCC lesion. We analyzed 72 patients (46 female and 26 male; age range, 22-61 years; mean age 37 years; 50 right and 22 left wrists) with suspected TFCC lesion with clinical examination, standard x-rays, and ultrasound. We confirmed patients with traumatic TFCC injury on MRI and MRA. Ultrasound found 13 lesions in 72 patients with suspected TFCC lesions. Conventional MRI found 66 and MRA 68 TFCC lesions. Ultrasound is useful for visualizing intra-articular effusion, soft tissue, bone surface, and for early detection of occult fractures. MRI is a better diagnostic modality, fully able to visualize the TFCC cartilage and ligaments. MRA is consistently and accurately able to visualize structural abnormalities of TFCC.

Validation of a clinical score in predicting pancreatic fistula after pancreaticoduodenectomy.

BACKGROUND: Postoperative pancreatic fistula (POPF) is one of the most severe complications after cephalic pancreaticoduodenectomy, with mortality as high as 30%. Risk scores may help predict the risk of POPF. Multiple external validations substantially improve generalized clinical acceptability of a scoring system. AIM: The aim of this study was to externally validate previously described fistula risk score in the prediction of clinically relevant POPF. METHODS: All patients who underwent pancreaticoduodenectomy for any indication during a 5-year period were prospectively analyzed. A total of 132 patients were analyzed. RESULTS: Of the 132 patients, 44 (33.3%) developed pancreatic fistula, including 12.9% biochemical leaks, 7.6% grade B fistula, and 12.9% grade C fistula. Cut-off point of 4.5 was determined to best separate patients who developed clinically relevant POPF with area under curve of 78% (p = .00003). Sensitivity and specificity for the prediction of clinically relevant POPF with the cut-off value of 4.5 was 70.4 and 74.3%, respectively. Positive predictive value with cut-off value 4.5 was 57.8%, and negative predictive value was 83.4%. CONCLUSION: Fistula risk score identified low risk patients with false negative rate of 16.6%. Further external validation studies on large cohorts of patients and with wide case-mix may enable additional refinements of the score model.

FROM ERECTILE DYSFUNCTION TO BRAIN SUBEPENDYMOMA: A CASE REPORT.

Endocrinopathies are relatively rare causes of erectile dysfunction. Cases of hyperprolactinemia and pituitary adenomas have been previously reported. We present a clinical case of a 27-year-old male with suspected infertility and recent symptoms of erectile dysfunction. Additional radiological and endocrinologic workup revealed underlying subependymoma, which was expanding in the sellar and suprasellar regions, causing pressure against the pituitary gland. The resulting endocrine disorder caused problems that were subjectively at first manifested mainly as erectile dysfunction. The case is an educative example pointing to the need of taking possible intracranial lesions in consideration when starting workup in a patient presenting with erectile dysfunction. It may be of broad clinical interest not only for endocrinologists but also for practitioners in various fields.

Aggressive progression of Takayasu's arteritis in infancy: a case report.

Takayasu's arteritis (TA) affects the aorta and its branches. Immunosuppressants are the usual course of therapy, while surgery has been used in acute cases. There is only scant information on TA in infancy, and the nonspecific symptoms in the initial stage of the disease make the diagnosis difficult and delayed, thus increasing the mortality rate. We describe a case of aggressive progression of TA in an infant. This child was the youngest to be affected with the disease as reported in the literature. A 3.5-month-old boy presented with cyanosis of both legs, tachycardia and antithrombin III deficiency. Computed tomography angiography (CTA) revealed thrombosis of distal aorta and both iliac arteries. Thrombectomy was performed at the level of both common femoral arteries. In addition, thigh amputation of the left leg had to be performed. TA was diagnosed postmortem with thrombosis of the distal aorta, its branches and upper mesenteric artery which was not occluded on previous CTA, glomerulonephritis and pulmonary parenchymal granulomatous infiltrations.

From Postpartum Metastatic Cancer to Parathyroid Adenoma: A Case Report.

We present a 36 year old female patient with suspected postpartum advanced metastatic cancer and multiple osteolytic lesions due to which she was referred to the Internal medicine clinic for further diagnostic evaluation. After extensive investigation, it was discovered that the underlying condition was a parathyroid gland adenoma and the patient was treated surgically. Clinicians should note that parathyroid adenoma can mimic metastatic malignant disease, and should make appropriate diagnostic tests that will lead to the correct diagnosis.

Operative treatment of Bennett's fracture.

We present 89 patients (average age 33 years) with Bennett's fracture (two part fracture to the first metacarpal base). All patients were treated surgically with open reduction internal fixation: 26 patients with K-wires, 19 with titanium mini T-plate, and 44 with titanium osteosynthetic screws (Herbert, AO, TwinFix). The surgical approach we used is a minimal incision of 2-3 cm modification of the radiopalmar curving incision. The Bennett fracture healed and full recovery of function was found between 4-8 weeks. There was no evidence of operative complications, instability of the trapeziometacarpal joint or degenerative changes postoperatively. K-wires were removed in 26 patients after 5-7 weeks, while all other osteosynthetic materials were not removed. We believe that it is important to choose osteosynthetic material according to the type of Bennett fracture to be treated, surgical treatment at the earliest possible time, even if the fracture dislocation is 1 mm. Physical rehabilitation is also important to start as soon as possible.

Effects of Electromyographic Biofeedback-Assisted Exercise on Functional Recovery and Quality of Life in Patients after Total Hip Arthroplasty: A Randomized Controlled Trial.

The goal of the trial was to examine the effects of adding electromyographic biofeedback (EMG-BF) to the conventional program of physiotherapy after total hip arthroplasty (THA) on functional recovery and quality of life. The trial was designed as a prospective, interventional, single-blinded randomized controlled study. Ninety patients were randomized into an experimental group (EG) (n = 45; mean age 63.9 ± 8.8) and control group (CG) (n = 45; mean age 63.9 ± 9). All patients received 21 days of physiotherapy which consisted of therapeutic exercise (land-based and aquatic), electrotherapy, and education. Electromyographic biofeedback was added to a portion of the land-based exercise in EG. The Hip Disability and Osteoarthritis Outcome Score (HOOS), Numeric Rating Scale (NRS), Short Form Health Survey-36 (SF-36), use of a walking aid, 30 s chair stand test (CST) as well as the Timed Up and Go (TUG) test were used for outcome measurement. A higher proportion of the participants in both groups did not need a walking aid after the intervention (p < 0.05). All participants improved their 30 s CST and TUG results (p < 0.001), as well as their NRS and HOOS scores (p < 0.05). No significant differences between the groups were found. There were no additional benefits from adding EMG-BF to the conventional physiotherapy protocol.

Multifragmentary distal crural fracture ski injury in an athlete: a case report.

While alpine skiing, a professional skater fell. He was examined at the nearest hospital and diagnosis was distal crural fracture with multifragmentary tibial metaphysis. The patient left the hospital with only temporary immobilization after the suggested treatment for his injury was crural amputation. Thirteen hours after injury he arrived at his home hospital. He was immediately operated on to perform osteosynthesis on his left lower leg. The healing of the damaged soft tissue as well as the bones was excellent even though Sudeck's syndrome appeared. Six month after injury he returned to skating and 1 year after injury he had completely returned to his everyday athletic routine without any complications.

Emergency treatment for clinically unstable patients with pelvic fracture and haemorrhage.

Unstable pelvic fractures very frequently occur with haemorrhage, not only from the broken pelvis but from the presacral venous plexus and/or iliac arterial or venous branches which may cause hypotension and increases the mortality rate. Very often this type of injury is concurrent with injuries in other organ systems. The compounded nature of these injuries makes it necessary for doctors who may encounter this type of patient to be educated in the techniques to effectively stabilise and treat the patient's complex injuries. After completing the international standard ATLS (Advanced Trauma Life Support) primary survey to identify a haemodinamically unstable patient with pelvic fracture, we discuss adequate replenishment of lost blood volume and standards of care for such a patient. The best diagnostics are described from transport immobilisation to the placement of external fixators or C-clamps. Likewise indication for intervention of pelvic angiography and therapeutic embolisation are also discussed. The direct surgical hemostasis method of pelvic packing is described in detail. All presented methods are mutually complementary in today's treatment of these patients.

Comparative assessment of the acute ankle injury by ultrasound and magnetic resonance.

We compared ultrasound (US) with magnetic resonance (MR) findings of muscle tendon and ligaments (mt&l) of 17 men and 13 women, 16-66 years old, who suffered from acute ankle injury without bone fracture visible on conventional radiographs. Joint effusion (JE), and injury of the Tibials anterior muscle tendon (TAmt), Calcaneofibular ligament (CFl), Long flexor of the great toe muscle tendon (LFGTmt), Short peroneus muscle tendon (SPmt), Long peroneus muscle tendon (LPmt), and Anterior talofibular ligament (ATFl) were assessed by the US, at seven days, and MR, at seventeenth day. Grading of ligament and muscle tendon injury as stretching (Grade 1), partially ruptured (Grade 2), and complete rupture (Grade 3); no lesion was considered to be Grade 0. Joint effusion and ATFl were the most common lesions whereas the TAmt lesion was the least frequent: JE approximately ATFl > SPmt approximately LPmt > LFGTmt approximately CFl approximately TAmt. Both US and MR were equally sensitive in detecting the presence (or absence) of the mt&l ankle injury, whereas US was less specific than MR in detecting G3 injury.

Isolated capitellum humeri fractures in adults.

From 2003 through 2009 we treated 35 patients who suffered from an isolated capitellum humerus fracture whom we treated with osteosynthesis. Patients who presented with concomitant fractures were not included. Thirty-four patients were categorized as Type I (Hahn-Steinthal) while one patient was Type IV (McKee). We describe the mechanism of injury and compared our results with works available in the literature. The average age of our patients was 38.6 years which was much younger than many articles about this type of injury found in the literature. The ratio of women to men in our study was 20:15. The surgical treatment was performed with various methods including: Kirschner wires, AO screws, Herbert screws and TwinFix screws. We discuss type of injury, days after injury operative treatment is performed, type of osteosynthesis used, the surgical approaches used for our treatment of capitellum humeri fractures, possible complications and our postoperative treatment. Results at the conclusion of treatment were excellent. Range of motion, shown in detail for each patient, was measured preoperatively, 1 month and 3 months postoperatively. We concluded that the major factors in successful treatment are how quickly the surgical treatment is performed after injury and early postoperative rehabilitation.

Quality of Life and Mental Distress in Patients with Chronic Low Back Pain: A Cross-Sectional Study.

The aim of this study was to examine the levels of health-related quality of life (HRQoL), pain intensity, and mental distress in participants with chronic low back pain (CLBP), and to examine the differences in the HRQoL of participants with respect to mental distress and the correlations of the examined variables. Data were collected from 148 patients using the SF-36 Health Status Questionnaire (SF-36), the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) questionnaire, and the visual-analog pain scale (VAS). The results indicate poorer self-assessment of physical health (Me = 28.1) compared to mental health (Me = 39.4). Participants with higher levels of mental distress reported significant emotional limitations (p = 0.003), lower energy (p < 0.001), poorer psychological health (p < 0.001) and social functioning (p < 0.001), more pain (p = 0.007), and, ultimately, poorer general health (p < 0.001). The level of mental distress was related to the level of HRQoL, while a correlation with the level of pain of the participants was not found. The study results indicate a connection between the presence of mental distress and almost all aspects of HRQoL in participants with CLBP.

Influence of the Cognitive and Emotional Status of Patients with Chronic Pain on Treatment Success (Reduction in Pain Intensity and Adherence to Pharmacotherapy): A Prospective Study.

This prospective study aimed to determine the cognitive and emotional status among patients with chronic pain and to examine the potential influence on the treatment success, measured by the reduction in pain intensity and adherence to pharmacotherapy. A total of seventy patients were followed for two months. The results of the comparison between patients who did and did not follow the physician's instructions regarding adherence to pharmacotherapy showed a significant difference in cognitive status and a reduction in pain intensity. Patients who followed the physician's instructions on taking analgesics had significantly higher scores on the Montreal Cognitive Assessment (MoCA) of cognitive status and a substantially higher reduction in pain intensity. Scores on the MoCA test provide statistically significant indications regarding patients' decision to follow instructions regarding adherence to pharmacotherapy. Scores on the MoCA test, anxiety, age, and pain intensity (measured with a numeric rating scale­NRS) on admission were identified as potential predictors for the reduction in pain intensity. The linear regression model was statistically significant (χ2 = 40.0, p < 0.001), explained between 43.5% and 61.1% of variance regarding the reduction in pain intensity. The findings of this study show that cognitive status, measured with MoCA, and emotional status, measured with the Depression, Anxiety, and Stress Scale (DASS-21), significantly influence the reduction in pain intensity and adherence to pharmacotherapy. The results suggest that cognitive and emotional status may be potential predictors of treatment success. This finding points to the importance of a biopsychosocial approach in the treatment of chronic pain, where an important emphasis can be placed on the psychosocial determinants of pain.

Treatment of trans-scaphoid perilunate dislocations using a volar approach with scaphoid osteosynthesis and temporary Kirschner wire fixation.

Trans-scaphoid perilunate fracture dislocations (TSPLD) are uncommon injuries and constitute about 3% of all carpal injuries. Up to 25% of these high energy trauma cases go undiagnosed. Presented are 43 (3 female, 40 male) consecutive patients treated for dorsal TSPLD, all were closed fractures. Patients were between 17 and 66 years old. Twenty male patients were injured in active duty military service. Surgical treatment was made with a volar approach using titanium cannulated headless compression screws (3.2 mm) placed via a guide wire. Repositioning the dislocated carpus is then conducted using 3 temporary fixation Kirschner wires (1.6 mm). The patient had a volar short arm splint for 4 weeks, then given an orthosis. Triple fixation Kirschner wires were removed 6-8 weeks postoperatively. Mean followup period was 29 months (range 20-38). The average Mayo wrist score for all 43 patients is 87 (good) (range 65-99). All patients returned to their previous employment.

Major defect to the brachial artery following blunt trauma--a five year follow-up.

A 29-year-old soldier was injured when a collapsible side of an army truck fell on his left upper arm creating lesion to the brachial artery with a defect in the artery of about 10 cm in length. Injury to one brachial vein, of the same length, was also sustained without bone or neural injury. Intraoperative Doppler ultrasonography was performed. A reverse autologous saphenous vein interposition graft with a circumference similar to that of the injured brachial artery was used to perform end-to-end anastomosis between artery and reversed vein graft. The patient returned to his military formation 16 days post operatively, with a return to full military calisthenics routine 2 months after injury. Surgical and Doppler ultrasonography control was kept regularly. Excellent late result revascularization of the injured brachial artery with reversed interposition vein graft can be seen in CT angiography five years after injury.

Rat sciatic nerve crush injury and recovery tracked by plantar test and immunohistochemistry analysis.

An experimental crush injury to the sciatic nerve, with a crush force of 49.2 N (pressure p=1.98x10(8) Pa), was inflicted in 30 male rats (Wistar). A control group (sham), with the same number of rats, was also operated upon exactly as the experimental group but without the crush injury. We tested the sensory and motor recovery of the sciatic nerve with Hargreaves method, using an apparatus from Ugo Basile, Italy. Testing was continued for both legs of each rat, injured and uninjured, starting preoperatively (0 day), and then 1, 7, 14, 21, and 28 days postoperatively. The same experiment was run simultaneously with the sham group. The Plantar test showed recovery of the sensory and motor function of the sciatic nerve, though not complete recovery, by 28 days. An immunohistochemical experiment was run in parallel with the plantar test on L3-L6 segments of the spinal cord from where the sciatic nerve extends. We used antibodies for Myelin-associated glycoprotein (MAG), and gangliosides GD1a and GT1b on the aforesaid part of the spinal cord. The immunohistochemical methods showed changes in sensory and motor axons in the spinal cord segment L3-L6 which suggest correspondence with the results of the Plantar test, in terms of recovery of the sensory and motor function after injury of the sciatic nerve. The immunohistochemical results also show ipsilateral and contralateral changes following injury. Results of the plantar test are suggestive that the rat shows compensation for an injury in its contralateral leg.

[Literature review of whiplash injuries of the cervical spine]. / Trzajna ozljeda vratne kraljeznice.

The paper presents the latest information in world literature on whiplash injury of the cervical spine. This injury has been noted through history, mentioned as early as Ancient Egypt, and prevalent in the 19 century, the time before using the car, until today. The mechanism of injury is described, as well as treatment, and news in view of the frequency of injuries in different parts of the world and the impact of socio-cultural, economic, ethnic and geographic factors. Impacts of traffic laws, automobile production and automobile seats that would indicate the possibility of prevention as a result of a whiplash injury of the cervical spine are also presented.

Experimental shortening of the radius in the treatment of Kienböck's disease.

AIM: The aim of the research was to determine the smallest amount of loading on the lunate bone obtained by gradually shortening the radius in different ulnar variants as the potential treatment of Kienböck's disease. METHODS: The research was conducted on anatomic preparations of 20 upper extremities using only the distal part of the forearm and hand, placing them in exactly defined positions. A Fuji Prescale film was inserted in the open radiocarpal joint to measure pressure after compressing axially by changing the length of forearm in four stages by the gradual shortening of the radius. RESULTS: The greatest reduction of average pressure on the lunatum achieved by shortening the radius depended on ulnar variant. In ulnar variant 0, the greatest reduction of average pressure on lunatum was achieved by shortening the radius for 3 mm (24% reduction). For ulnar variant -1, the greatest reduction of average pressure on lunatum was achieved by shortening the radius for 2 mm (37% reduction). For ulnar variants -2, -3 and +1, the greatest reduction of average pressure on lunatum was achieved by shortening the radius for 3 mm (5%, 75% and 9% respectively). CONCLUSIONS: The pressure distribution in the distal radiocarpal joint is vital for healing, and shortening of the radius relieves the pressure on the lunate bone. The exact type of surgery and the amount of radial osteotomy depends on preoperative ulnar variant.

Operative versus non-operative management of blunt pancreatic trauma in children: Systematic review and meta-analysis.

AIM: Blunt abdominal trauma is the major cause of abdominal injury in children. No clear guidelines exist for the initial management of blunt pancreatic trauma in children. The aim of this study was to perform a systematic review and meta-analysis of initially non-operative versus initially operative treatment in children with blunt pancreatic injury. METHODS: Studies including children (<18 years) with blunt pancreatic injuries published in any language after year 1990 were included. Total of 849 studies were identified by searching PubMed, Scopus, CINAHL and Cochrane Database. After review, 42 studies met inclusion criteria and were included in this systematic review. There were 1754 patients, of whom 1095 were initially managed non-operatively (NOM), and 659 operatively (OM). Primary outcome was non-operative management success rate, and secondary outcomes were mortality, complications (including specifically pseudocysts and pancreatic fistulas), percent of patients and days on total parenteral nutrition (TPN), length of hospital stay and readmissions. RESULTS: There was no difference in mortality between NOM and OM groups. The incidence of pseudocysts was significantly higher in NOM group compared to OM (P<0.001), especially for AAST grade III or higher (P<0.00001). Overall incidence of pancreatic fistulas was significantly lower for NOM group (p = 0.02) but no difference was observed for AAST grades III or higher (p = 0.49). There was no difference in the length of hospital stay (P = 0.31). Duration of total parenteral nutrition was not different for all AAST grades (P = 0.35), but was significantly shorter for OM group for AAST grades III and higher (p = 0.0001). There was no overall difference in readmissions (P = 0.94). Overall success rate of initial non-operative treatment was 87%. CONCLUSIONS: Most patients with pancreatic trauma can initially be treated non-operatively, while early surgical treatment may benefit patients with lesions of the main pancreatic duct. ERCP offers both highly accurate diagnosis and potential treatment of ductal injuries.

Retrorenal fat predicts grade C pancreatic fistula after pancreaticoduodenectomy.

BACKGROUND: Pancreatic fistula after pancreaticoduodenectomy is one of the most severe complications with mortality rates as high as 45%, and the prediction of most severe form of fistula (grade C) is crucial for successful management of patients who are to undergo cephalic pancreatoduodenectomy. It has been found that the amount of abdominal fat may predict grade C postoperative pancreatic fistula. In this study, we analysed the value of retrorenal fat thickness in the prediction of grade C pancreatic fistula. METHODS: A total of 140 patients who underwent pancreaticoduodenectomy were retrospectively analysed. Retrorenal fat thickness and intra-abdominal fat, expressed as total fat area, visceral fat area and subcutaneous fat area, were determined from computed tomography slices using the known range of attenuation values (-190 to -30). Blood loss, operating time, pancreatic texture and main pancreatic duct diameter as well as body mass index were also analysed. RESULTS: Retrorenal fat thickness (P = 0.0004), duct diameter (P = 0.0008), subcutaneous fat area (P = 0.023) and total fat area (P = 0.014) were found to be significant predictors of grade C pancreatic fistula. CONCLUSION: Although retrorenal fat tissue thickness may seem robust, it is a simple measure that can be used to predict the most severe grade of pancreatic fistula after pancreaticoduodenectomy.