Aleksandar Lesic

Treatment of blast injuries of the extremity.

&NA; 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 embolisminduced injury, compartment syndrome, and others. Secondary injuries are the most common extremity blast injuries. Like primary injuries, they may necessitate limb amputation, be lifethreatening, 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 softtissue reconstruction.

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.

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.

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.

The treatment of scaphoid nonunion using the Ilizarov fixator without bone graft, a study of 18 cases

ObjectivesEvaluating 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.DesignA retrospective review of 18 consecutive patients in one centre.Patients and Methods18 patients; 17 males; 1 female, with a mean SNU duration of 13.9 months. Patients with carpal instability, humpback deformity, carpal collapse, avascular necrosis or marked degenerative change, were excluded. Following frame application the treatment consisted of three stages: the frame was distracted 1 mm per day until radiographs showed a 2-3 mm opening at the SNU site (mean 10 days); the SNU site was then 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 third stage involved immobilization with the Ilizarov fixator for 6 weeks. The technique is detailed herein.ResultsRadiographic (CT) and clinical bony union was achieved in all 18 patients after a mean of 89 days (70-130 days). Mean modified Mayo wrist scores improved from 21 to 86 at a mean follow-up of 37 months (24-72 months), with good/excellent results in 14 patients. All patients returned to their pre-injury occupations and levels of activity at a mean of 117 days. Three patients suffered superficial K-wire infections, which resolved with oral antibiotics.ConclusionsIn these selected patients this technique safely achieved bony union without the need to open the SNU site and without the use of bone graft.

Effect of potassium channel opener pinacidil on the contractions elicited electrically or by noradrenaline in the human radial artery.

In order to discover an agent that can prevent spasm of the human radial artery, the aim of our study was to evaluate the effect of the K(+) channel opener, pinacidil, on contractions in the radial artery. Contractions of the radial artery were evoked by exogenously applied noradrenaline or by electrical field stimulation (EFS, 20Hz, neurogenic). Pinacidil induced concentration-dependent inhibition of both EFS- and noradrenaline-evoked contractions of the radial artery. Glibenclamide, a selective blocker of ATP-sensitive K(+) channels (Kir6.x containing subunit) antagonized in the same manner the pinacidil-induced inhibition of neurogenic contractions and contractions evoked by exogenous noradrenaline. The inhibition of pinacidil relaxation by tetraethylammonium (TEA), a blocker of Ca-sensitive K(+) (K(Ca)) channels, was more pronounced in EFS-contracted preparations. A blocker of voltage-sensitive K(+) (K(V)) channels, 4-aminopyridine (4-AP), inhibited pinacidil relaxation only in EFS-contracted preparations. In order to test the presence of different K(+) channels, immunohistochemistry of K(+) channels expression in the radial artery was performed. The vascular wall of the human radial artery showed variable positivity with the following applied antibodies: Kv1.2, Kv1.3, Kir6.1, and K(Ca)1.1. The antibodies against Kv1.6, Kv2.1, and Kir6.2 channel subunits were completely negative. These results suggest that the inhibitory effect of pinacidil on contractions of the human radial artery might be postsynaptic and associated with opening of smooth muscle Kir6.1-containing K(ATP) channels. TEA- and 4-AP-sensitive K(+) channels may also contribute to pinacidil effect in the human radial artery.

Malignant Intraosseous Peripheral Nerve Sheath Tumour of the Proximal Femur: A Case Report

We report a rare case of an intraosseous malignant peripheral nerve sheath tumour of the femoral head and neck. The tumour presented as a well-defined radiolucent lesion on plain radiography. Computed tomography showed aggressive destruction of the bone with no involvement of the adjacent soft tissues. Magnetic resonance imaging revealed an isointense signal intensity on T1-weighted images, hyperintensity on T2-weighted images, and non-homogeneously increased signal intensity after administration of contrast media. The final diagnosis was based on pathohistologic analyses due to the non-specific nature of the lesion.

Ilizarov treatment of scaphoid nonunion

INTRODUCTION This is single centre retrospective review of a consecutive series of patients with scaphoid nonunion (SNU) treated using the Ilizarov technique without bone graft. Fifteen of the original 18 patients were available for clinical and radiological examination at a minimum follow-up of 5 years (range 5-10 years). An evaluation was made of the late functional results, satisfaction scores, residual symptoms, grip strength and the presence of radiocarpal and scaphoid degenerative changes. METHODS The series consisted of 15 patients; 14 males; 1 female, with a mean SNU duration of 15.7 months, and a mean age of 23.6 years. Patients with carpal instability, humpback deformity, carpal collapse, avascular necrosis or marked degenerative change, were excluded from this treatment method. Following frame application the treatment consisted of three stages: distraction, compression and immobilisation. The technique is detailed herein. RESULTS Radiographic (CT) and clinical bony union was achieved in all 15 patients after a mean of 88 days (70-130 days). Mean modified Mayo wrist scores initially improved from 21 preoperatively to 86 at previous review, and were 96 at a mean follow-up of 81 months (62-120 months), with excellent results in 10, and good results seen in 5 patients. At latest review the mean grip strengths had returned to 96% of the uninjured hand, and 7 patients had regained full strength; mean wrist flexion/extension arc of motion had also continued to improve to 136° from 131°. All patients returned to their pre-injury occupations and levels of activity at a mean of 117 days. Three patients suffered superficial K-wire infections, which resolved with oral antibiotics. One patient continues to suffer intermittent mild aching in the wrist. No patient suffered loss of scaphoid height, humpback deformity, DISI instability or collapse of the regenerate bone. CONCLUSION In these selected patients this technique safely achieved bony union without the need to open the SNU site and without the need for bone graft. These patients also had the capacity to continually improve their wrist function beyond 3 years following their treatment.

Iliopsoas haematoma in Gaucher disease

SummaryExtrapelvis 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.

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.