Milan Grubor

Controversies in treatment of acetabular fracture.

Introduction: Acetabular fractures treatment represents a great controversy, challenge and dilemma for an orthopedic surgeon. Aim: The aim of the paper was to present the results of treatment of 96 acetabular fractures in the Clinic of Traumatology Banja Luka, in the period from 2003 to 2013, as well as to raise awareness regarding the controversy in the methods of choice in treating acetabulum fractures. Material and methods: The series consists of 96 patients, 82 males and 14 females, average age 40.5 years. Traffic trauma was the cause of fractures in 79 patients (85%), and in 17 patients (15%) fractures occurred due to falls from height. Polytrauma was present in 31 patients (32%). According to the classification of Judet and Letournel, representation of acetabular fractures was as follows: posterior wall in 32 patients, posterior column in 28, anterior wall in 4, anterior column in 2, transverse fractures in 8, posterior wall and posterior column in 10, anterior and posterior wall in 6, both- column in 4 and transversal fracture and posterior wall in 2 patients. 14 patients were treated with traction, that is, 6 patients with femoral traction and 8 patients with both lateral and femoral traction. 82 patients (86.4%) were surgically treated. Kocher-Langenbeck approach was applied in the treatment of 78 patients. In two patients from the Kocher-Langenbeck’s approach, the Ollier’s approach had to be applied as well. Two acetabular were primarily treated with Ollier’s approach. Extended Smith- Peterson’s approach was applied 4 times, and Emile Letournel’s (ilioinguinal) approach 14 times. Results: Functional outcome (after follow-up of 18 months), according to the Harris hip score of surgical treatment in 82 patients, was as follows: good 46 (56%), satisfactory 32 (39%) and poor 4 (5%). Results of acetabulum fractures treated with traction were: good 8 (57%), satisfactory 4 (28%) and poor 2 (15%). According to the Brook’s classification of heterotopic ossification, periarticular hetero-tropic calcifications after surgical treatment were: 0° in 65 patients (79%), I-II° in 9 patients (11%) and III-IV ° in 8 patients (10%). Calcifications in 14 patients treated with traction of heterotopic ossification by Brook-s classification were as follows: 0° in 10 patients (72%), I-II ° in 3 patients (22%) and III-IV° in 1 patient (6%). Conclusion: At the occurrence of acetabular fracture, it is necessary to start the treatment immediately, with an obligatory application of thromboembolic and antibiotic prophylaxis. Conservative treatment is acceptable if the dislocation of fracture is less than 5 mm. Indications for surgical treatment are incongruent or unstable fractures with verified dislocation greater than 5 mm, as well as when the radiography measured by JM Matta shows incongruence of acetabular roof less than 40° in all planes. Kocher-Langenbeck approach is the choice of surgical approach for the management of posterior column / wall, and Letournel’s (ilioinguinal) approach is the choice for the management of anterior wall/column.

Treatment of Bone Defects in War Wounds: Retrospective Study.

Introduction: Results of the treatment of open fractures primarily depend on the treatment of connected soft tissue injuries. Objective: The aim was to present the experience and methods gained during the treatment of diaphyseal bone defects as a consequence of gunshot fracture soft war trauma. Patients and Methods: The study consisted of 116 patients with the diaphyseal bone defect who were treated with the usage of primary and delayed autotransplantation of bones, transplants of the fibula and Ilizarov distraction osteogenesis. Results: The results of compensation of bone defect less than 4 cm and conducted by an early cortico-spongioplastics were as follows: good in 8 respondents (45%), satisfactory in 6 (34%) and poor in 4 respondents (21%). In cases of delayed cortico-spongioplastics, the above mentioned results were: good in 36 (41%) respondents, satisfactory in 24 (34%) and poor in 16 (25%) respondents. The results of compensation of bone defect greater than 4 cm with the usage of fibular transplant were as follows: good in 3 (38%) respondents, satisfactory in 3 (38%) and poor in 2 (24%), and with the usage of using the Ilizarov method, the results were as follows: good in 8 (57%) respondents, satisfactory in 3 (21.5%) and poor in 3(21.5%) respondents. Conclusion: The results showed that, in cases of compensation of bone defects less than 4 cm, the advantage is given to the primary spongioplastics over the delayed one. In cases of compensation of bone defects greater than 4 cm, the advantage is given to the Ilizarov distraction osteogenesis when compared to the fibular transplant.

Validity of Magnetic Resonance Imaging in Knee Injuries

Introduction: Knee injuries are common in athletes, recreationists, and other people in their everyday activities. Objective: The study is aimed at establishing the validity of clinical findings, MRI and diagnostic arthroscopy of the knee in ACL, PCL, medial or lateral ligament lesions. Methods: The prospective research involved 63 inpatients at the Traumatology Clinic in Banja Luka- Niš between 1 January 2011 and 1 June 2012. Results: When clinically examining the ACL and based on the calculated post-test probability amounting to (LR+) = 0.8017, we conclude that there is a considerable probability (80.17%) that a patient with an arthroscopically diagnosed ACL lesion will have the same lesion diagnosed by MRI. The post-test probability following the clinical examination of the medial meniscus and amounting to (LR+) = 0.6943 suggests that there is a considerable probability (69.43%) that an arthroscopically diagnosed lesion of the medial meniscus will also be diagnosed by MRI. On the basis of the clinical examination of the lateral meniscus in the examined sample and calculated post-test probability amounting to (LR+) = 0.6346, we conclude that there is a considerable difference (63.46%) between the diagnostic arthroscopy and MRI of lateral meniscus lesions. Conclusion: Arthroscopic examination of the knee is a more valuable method than diagnosis by MRI and clinical examination for detecting lesions of the ACL, PCL, medial and lateral meniscus.

Treatment of Achilles tendon rupture using different methods.

BACKGROUND/AIM Today there are controversies about searching for the ideal surgical method (conservatively with plaster cast, with open and percutaneous tenorrhaphy) for repairing a ruptured Achilles tendon. The aim of this study study was to examine the results of treating Achilles tendon ruptures in patients by using the following methods: percutaneous suturing, open surgery technique and non-surgical treatment by plaster cast immobilisation. METHODS Forty two patients treated at our facility in the period August 2003 - September 2010 for Achilles tendon ruptures were included in the study. They were operated on by using different orthopedic procedures (percutaneous reconstruction of the Achilles tendon, open surgery, plaster cast only) and two anaesthesia technique (spinal aneasthesia and local infiltrational anaesthesia). The following parameters were monitored after interventions performed and compared: duration of hospital stay, postsurgical complications, incidence of the reruptures of the Achilles tendon and time for full leg functionality. RESULTS The patients sustained their respective injuries in the following manner: 8 of them while pursuing sports activities, 24 while pursuing recreational activities, 4 at workplace, 4 while performing everyday activities, and 2 of the patients did not know how they had sustained their injuries. The average age of the patients was 40.5, with 37 (88%) men and 5 (12%) women. Surgeries were performed under spinal anaesthesia in 29 (69%) patients, and in 5 (12%) patients tenorrhaphy was performed under local anaesthesia. Anaesthesia was not used in 8 (19%) patients treated with plaster cast. We performed percutaneous reconstruction of the Achilles tendon in 19 (45%) patients. A total of 14 (33%) patients were treated under spinal anaesthesia, and 5 (11.90%) under local infiltrational anaesthesia with 2% xylocain. We treated 15 (36%) patients with open surgery. The patients treated conservatively stayed in hospital on average for up to 5 hours. Those who underwent an percutaneous surgery stayed 2 days and those who underwent an open surgery stayed 9 days. A total of 28 (66%) patients from the given series experienced no complications. The patients treated with open surgical reconstruction experienced skin complications ranging from inflammatory changes on the skin in 6 (14%) patients to dehiscence and skin necrosis in 3 (7%). The 5 (11.9%) patients whose ruptured Achilles tendon was treated percutaneously experienced temporary redness and delayed healing of the incision(s) longer than 5 mm. A total of 3 (7%) patients treated with open surgery and 1 (2%) patient treated with percutaneous tenorrhaphy had temporary peroneal nerve prolapses. A total of 7 (16.6%) patients had reruptures: 4 were treated with plaster cast, 2 underwent open surgery, and 1 was treated percutaneously. Out of the 8 patients who were treated with plaster cast, 4 sustained reruptures and 3 of the 4 had diabetes. CONCLUSION Surgical treatment, percutaneous tenorrhaphy, performed in a small operating theatre under local anaesthesia, should be preferred in cases of fresh ruptures of the Achilles tendon.

Endoprosthesis and Obesity

ABSTRACT Introduction: Obesity represents a significant risk factor in the pathophysiology of degenerative changes in coxarthrosis. Objective: The study aims to investigate obesity as a risk factor in the examined sample comprising 136 patients who underwent hip endoprothesis implantation. Material and methods: The series comprised 136 patients with a hip endoprosthesis implanted, where the patients’ BMI, amount of blood used, duration of surgery, number of assistants, and type of anaesthesia were observed. Wounds and late post-operative complications, infections, haemorrhage, vein thrombosis, endoprosthesis dislocations, length of inpatient stay, start of physical therapy and full weight-bearing were also observed. The observation period lasted six months on average. Discussion: In simple terms, the three greatest factors when implanting a hip endoprosthesis are as follows: properties of the endoprosthesis, the orthopaedic surgeon’s skill and experience, and individual characteristics of the patient, i.e. age, sex, health condition, body weight, BMI, adequate physical therapy. Conclusion: We believe that the implantation of a hip endoprosthesis should be postponed for patients with a BMI exceeding 29.99. Such patients should receive endocrine treatment, they should undergo a weight loss programme in order to reduce their body weight and in order to reduce their BMI to under 29.99.

Treatment of Bone Defects in War Wounds Retrospective Study

Introduction: Results of the treatment of open fractures primarily depend on the treatment of connected soft tissue injuries. Objective: The aim was to present the experience and methods gained during the treatment of diaphyseal bone defects as a consequence of gunshot fractures of war trauma. Patients and Methods: The study consisted of 116 patients with the diaphyseal bone defect who were treated with the usage of primary and delayed autotransplatation of bones, transplants of the fibula and Ilizarov distraction osteogenesis. The results of compensation of bone defect less than 4 cm and conducted by an early corticospongioplastics were as follows: good in 8 respondents (45%), satisfactory in 6 (34%) and poor in 4 respondents (21%). In cases of delayed cortico-spongioplastics, the abovementioned results were: good in 36 (41%) respondents, satisfactory in 24 (34%) and poor in 16 (25%) respondents. The results of compensation of bone defect greater than 4 cm with the usage of fibular transplant were as follows: good in 3 (38%) respondents, satisfactory in 3 (38%) and poor in 2 (24%), and with the usage of using the Ilizarov method, the results were as follows: good in 8 (57%) respondents, satisfactory in 3 (21.5%) and poor in 3 (21.5%) respondents. Conclusion: The results showed that, in cases of compensation of bone defects less than 4 cm, the advantage is given to the primary spongioplastics over the delayed one. In cases of compensation of bone defects greater than 4 cm, the advantage is given to the Ilizarov distraction osteogenesis when compared to the fibular transplant. War wounds caused by firearms; characterize the extensive destruction of tissues, organs and the primary contamination polymorphic bacterial flora. Upon receipt of the injured we have not been in position to take from contributory a swab from the wounds of war, to identify the primary causes of infection and prescribe targeted, obtained by the antibiotic, antibiotic therapy. This is due to the material and technical conditions. We are a small country, where there is no industry for the production of medical equipment, disposable medical supplies, antibiotics. We were dependent on the humanitarian organizations and the not specially organized industry, we organized the production of external fixator because it was easiest.

Biomechanical Stability of Juvidur and Bone Models on Osteosyntesic Materials.

Introduction: Artificial models can be useful at approximate and qualitative research, which should give the preliminary results. Artificial models are usually made of photo-elastic plastic e.g.. juvidur, araldite in the three-dimensional contour shape of the bone. Anatomical preparations consist of the same heterogeneous, structural materials with extremely anisotropic and unequal highly elastic characteristics, which are embedded in a complex organic structure. The aim of the study: Examine the budget voltage and deformation of: dynamic compression plate (DCP), locking compression plate (LCP), Mitkovic internal fixator (MIF), Locked intramedullary nailing (LIN) on the compressive and bending forces on juvidur and veal bone models and compared the results of these two methods (juvidur, veal bone). Material and Methods: For the experimental study were used geometrically identical, anatomically shaped models of Juvidur and veal bones diameter of 30 mm and a length of 100 mm. Static tests were performed with SHIMADZU AGS-X testing machine, where the force of pressure (compression) increased from 0 N to 500 N, and then conducted relief. Bending forces grew from 0 N to 250 N, after which came into sharp relief. Results: On models of juvidur and veal bones studies have confirmed that uniform stability at the site of the fracture MIF with a coefficient ranking KMIF=0,1971, KLIN=0,2704, KDCP=0,2727 i KLCP=0,5821. Conclusion: On models of juvidur and veal bones working with Shimadzu AGS-X testing machine is best demonstrated MIF with a coefficient of 0.1971.

Značaj ultrazvučnog skrininga za dijagnostiku i liječenje razvojnog poremećaja kuka

Uvod. Uvođenje ultrazvuka u dijagnostiku razvojnog poremecaja kuka (RPK) osamdesetih godina proslog vijeka doprinijelo je njegovom ranom otkrivanju, a time i lijecenju ovog poremecaja. Klinicki pregled se pokazao nedovoljnim za uspjesno lijecenje. RPK je cesci kod djevojcica, a razlicito je zastupljen i regionalno. Na nastanak RPK uticu egzogeni i endogeni faktori. Cilj rada je bio da se utvrdi ucestalost RPK dijagnostikovanih u Klinici za ortopediju i traumatologiju KC Banja Luka kod djece do navrsene jedne godine i uspjesnost lijecenja neoperativnim putem. Metode. U kabinetu za ultrazvuk (UZV) Klinike za traumatologiju aparatom „LOGIQ 5“ od januara do juna 2008.godine pregledano je 506 beba standardnom metodom po Grafu. Kod djece sa nestabilnim kukovima koristen je cetverofazni sonoscrining (Harcke-Graf-Clarke). U postupku kontrole djece nakon aplikacije Pavlikovih remencica primjenjivan je i prednji pristup po Suzukiju. Pored UZV dijagnostike koristena je i radiografija. Za statisticku obradu podataka koristen je analiticko-statisticki sistem SPSS verzija 18. Rezultati. U prvih sest mjeseci pregledano je 506 djece među kojima je uzrasta od jednog mjeseca bilo 350 (69%), dva mjeseca 9 (17,9%), između drugog i cetvrtog 48 (9,4%), preko cetvrtog 17 (3,3%). Od ukupnog broja pregledanih vise je bilo ženske djece, 293 (58%). Dominantan tip kuka je bio Ib po Grafu, 342 (67,2%), a tip IIIb i IV nisu nađeni u ispitivanoj grupi. Dodatna dijagnostika je bila potrebna kod 68 (13,4%) djece. Praceno je 56 (11,06%) odojcadi, od toga 53 (10,47%) djevojcice. Lijecenje Pavlikovim remencicima provedeno je kod 9 (17,78%) odojcadi, gips u humanom položaju kod 2 (3,57%) odojceta, a u jednom slucaju (1,78%) je primjenjivana trakcija, a potom gips u humanom položaju. Srednja vrijednost ugla alfa na kraju lijecenja desno 62°, lijevo 60°, a beta 53° desno i 58° lijevo. Zakljucak. Klinicka incidenca RPK u ispitivanoj grupi bila je 11,06%, a ultrazvucna 1,77%. Dodatna dijagnostika je rađena kod 68 (13,4%) djece, a lijecenje RPK je bilo iskljucivo neoperativno.

Selection Methods in the Treatment of Diaphyseal Tibial

Introduction: Tibial fractures accompanied by radius fractures at typical sites are the most common type of fractures. Objective: The study is aimed at using the examined sample to make an efficient and economically acceptable choice in the treatment of tibial fractures. Material and methods: The series comprises a retrospective and prospective study of the treatment of 131 fresh tibial fractures: 31 in women (23.66%) and 100 in men (76.34%) of the average age of 37.89. Nineteen patients (14.50%) were treated conservatively and 112 (85.50%) surgically: 22 (16.79%) with anti-rotation intramedullary nails, 74 (56.49%) with Mitkovic external fixator type M20, and 16 (12.21%) with LCP. General anaesthesia was used in 46 patients (35.11%), while spinal anaesthesia was used in 85 of them (64.89%). Results: According to the Karlstrom-Olerud scoring system, the treatment results were as follows: for the 22 tibiae treated with anti-rotation intramedullary nails: in 15 (68.18%) the results were excellent, in 3 (13.64%) they were good and in 4 (18.18%) they were poor. As for the results for the 74 tibiae treated with Mitkovic external fixator type M20, they were as follows: in 62 (83.78%) excellent, in 9 (12.16%) good, and in 3 (4.05%) they were poor. The results for the 16 patients treated with LCP were excellent in 10 (62.50%), good in 2 (12.50%) and poor in 4 patients (25.00%). The treatment results for the 19 tibiae treated with plaster cast were excellent in 12 patients (63.16%), good in 2 (10.53%) and poor in 5 (26.32%). The definite results for the 131 fractured tibiae treated with the aforementioned techniques were as follows: excellent in 99 (75.57%), good in 17 (12.98%) and poor in 15 patients (11.45%).

Southwick Osteotomy Stabilised with External Fixator

ABSTRACT Introduction: Epiphysiolysis of the femoral head is the most common accident occurring towards the end of pre-puberty and puberty growth. Case report: The author describes the experience in the treatment of chronic epiphysiolysis in two patients treated by Southwick osteotomy. The site is accessed by way of a 15-cm long lateral skin incision and the trochanteric region is reached through the layers. The osteotomy angles prepared beforehand on a thin aluminium model are used to mark the Southwick osteotomy site on the anterior and lateral sides at the level of the lesser trochanter. Before performing the trochanteric osteotomy, two Mitković convergent pins type M20 are applied distally and proximally, above the planned osteotomy site. A tenotomy of the iliopsas muscle is performed, and then the previously marked bone triangle is redissected up to three quarters of the width of the femur. The distal part of the femur is rotated inwards, so that the patella is turned towards the ceiling. The osteotomised fragments of the femur are adapted, repositioned and fixated by installing an external fixator on the previously placed pins. Two more pins are placed, one proximally and one distally, with a view to adequately stabilising the femur. The patient was mobile from day two after the surgery. If, after the surgery, the lead surgeon realises that there is a requirement to make a correction of 5, 10 and 15 degrees of the valgus, varus, anteversion or retroversion deformity, the correction shall be performed without surgically opening the patient, using the fixator pins. Conclusion: After performing a Southwick osteotomy it is easier to adapt, reposition and fixate the osteotomised fragments of the femur using a fixator type M20. Adequate stability allows regaining mobility quickly, which in turn is the best prevention of chondrolysis of the hip. It is possible to make post-operative valgus, varus, anteversion and retroversion corrections of 5, 10 and 15 degrees without performing a surgery. Once the osteotomy is healed, the fixator type M20 is removed without any additional surgery.