THE BEGINNINGS OF KIDNEY TRANSPLANTATION IN SOUTH-EAST EUROPE

Organ transplantation is one of the most important medical achievements of the 20th century. Kidney transplantation is the most efficient method of renal replacement therapy. The first successful kidney transplantation in human was performed in 1954 in Boston, USA. In former Yugoslavia, the first kidney transplantation was performed on April 16, 1970 in Ljubljana, Slovenia, and second one on January 30, 1971 in Rijeka, Croatia. In both cases, the mother donated kidney to the son. In the article, we describe the prerequisite conditions for this operation, the characteristics of first patients, and the impact of transplantation program on the development of the hospitals and medical schools.

[APPLICATION OF NEGATIVE PRESSURE THERAPY]

Negative pressure therapy is gradually taking an increasingly important role in the treatment of chronic wound healing because of its simple application in hospital or outpatient setting and good comfort with no pain for the patient. Chronic wound healing is accelerated in comparison with other conservative treatments. The level of negative pressure is between 40 and 125 mm Hg below ambient. Direct and indirect effect of the negative pressure therapy helps in wound healing and provides good preparation for definitive surgical management of wounds.

[BASIC PRINCIPLES OF SURGICAL TREATMENT OF CHRONIC WOUNDS – SHARP DEBRIDEMENT]

The ever improving health standards in terms of quality and more efficient health care result in an increase in life expectancy, thus increasing the number of elderly people in the population. A higher level of activity in elderly population leads to greater incidence of injuries, and on the other hand, there is an increasing number of comorbidities. Circulatory disorders, diabetes mellitus, metabolic imbalances, etc. and a reduced biological potential of tissue regeneration result in an increased number of chronic wounds that pose a significant health, social and economic burden on the society. These conditions require significant involvement of medical and non-medical staff in pre-hospital institutions. Significant material and other health care resources are allocated for the treatment of chronic wounds. These conditions result in a lower quality of life of patients and their families and caregivers. Debridement is a crucial medical procedure for the treatment of acute and chronic wounds. The result of debridement is removal of all barriers within and around the wound that obstruct physiological processes of wound healing. Debridement is a repeating process when indicated. There are several types of debridement, each with its advantages and disadvantages. The method of debridement should be determined by the physician or other professional trained person on the basis of wound characteristics and in accordance with their expertise and capabilities. In the same wound, we can combine different types of debridement, all with the goal of faster and better wound healing.

Chronic unreduced shoulder dislocations: Experience in a developing country trauma centre

Chronic shoulder dislocations are extremely rare. The goal of this retrospective study was to describe the epidemiology of chronic shoulder dislocation in our environment and to evaluate the outcome of treatment. Bio-demographic data and injury details were retrieved from case files. Definitive method of reduction and stabilisation and duration of follow-up care were also noted. Nine cases of subcoracoid anterior chronic shoulder dislocation were seen during the 6-year period of the study. Seven (78%) of these patients were male and two (22%) were female. The mean age was 42 (±17.5) years. The common mechanisms of injury were road traffic crash in four patients (44%), domestic falls in four patients (44%) and dislocation while getting out of bed in one patient (12%). None of the patients had neurovascular deficit at presentation. Five patients were managed operatively and four were managed non-operatively. Mean follow-up was 8 months (range 6-12 months). Clinical evaluation by Rowe shoulder score revealed that operated cases had significantly higher mean rank scores than non-operated cases using the Mann-Whitney U test. Two operated cases were graded fair and three poor. All cases managed non-operatively had poor outcome grades. Meticulous attempt at soft tissue repair and early supervised physiotherapy can contribute to a favourable outcome.

Complications of ESIN osteosynthesis--Experience in 270 patients

BACKGROUND

Elastic stable intramedullary nailing (ESIN) osteosynthesis has been used in our department for the treatment of long-bone fractures in children and adolescents for more than 17 years. During this period we have shown that ESIN has several advantages compared with other methods of treatment. However, as with every other method, ESIN has its drawbacks and complications. These occur primarily if indication criteria are not respected or ESIN technique is inadequate. This paper presents the rate of complications that occurred with this method in our patients, and the means of prevention and treatment of these complications.

PATIENTS AND METHODS

A total of 270 patients treated with ESIN osteosynthesis for fractures of long bones of the extremities completed treatment. The study was conducted at the Department of Child Surgery and Orthopaedics of the Clinical Hospital Centre in Rijeka. All the Nancy Nails used in the study were of the same quality, from one manufacturer and were applied using the standard ESIN technique. In 228 patients (84%), ESIN was the primary treatment, whereas in the remaining 42 patients (16%), ESIN was applied after an attempt at manual reposition and immobilisation of bone fragments. All patients had control radiography at least three times and postoperative monitoring was conducted for at least two years.

RESULTS

A total of 35 of the 270 observed patients developed complications; some patients had several complications. There were 53 early intraoperational complications and 29 late postoperative complications. All complications resolved with appropriate therapy. The treatment was satisfactory in all patients except those with an elongation of the extremity (leg) of more than 1cm.

CONCLUSION

Postoperative complications related to the ESIN method of osteosynthesis in the patients in this study were detected by radiological control examinations and long-term clinical monitoring. All the complications of ESIN were relatively easy to treat with current medical methods. The frequency of particular complications is significantly reduced if indication criteria for ESIN are respected and correct ESIN technique is used.

Complications in leg lengthening using an Ilizarov external fixator and intramedullary alignment in children: comparative study during a fourteen-year period

BACKGROUND

The purpose of this retrospective study was to evaluate the complications associated with leg lengthening in children treated with the Ilizarov external fixator (IEF) and compare them between two groups of patients: one group was treated using an IEF alone and the other group was treated using an IEF in association with intramedullary alignment (IA).

PATIENTS AND METHODS

The study was performed at the University Children's Hospital in Belgrade, Serbia during a fourteen-year period (from 2000 to 2014). Complications occurred in 73 paediatric patients who underwent the leg lengthening procedure. Complications were classified according to the Caton classification and compared between two groups. Group I comprised 39 patients who underwent the limb lengthening procedure using IEF alone. Group II consisted of 34 patients who were treated with the combination of IEF and IA using two Kirschner wires (K-wires) or Titanium Elastic Nails (TEN). The duration of hospital treatment was also compared between the two groups and the impact of the type of IA on the occurrence of complications was assessed.

RESULTS

There was a high rate of complications in patients treated using an IEF compared with those treated using the combination of IEF and IA, but there was no statistically significant difference between the two groups. There was a statistically significant difference in the duration of initial hospitalisation between the two groups, particularly when comparing TEN usage in IA. A comparison of the group of patients treated using an IEF in association with K-wires and patients treated using IEF and TEN showed there was no statistically significant difference in complication rate and duration of initial hospitalisation.

CONCLUSION

IA has multiple advantages as a method of treatment of leg length inequality. The major effect of applying IA in association with a circular IEF is significantly reduced complication rate and duration of initial hospitalisation, particularly when using TEN as a method of IA. This method of treatment also decreases hospital costs.

Femoral neck fractures in children and the role of early hip decompression in final outcome

BACKGROUND

Femoral neck fractures in children are very rare and account for about 1% of all paediatric fractures. The aim of this retrospective study was to analyse the clinical and radiographic outcome in paediatric femoral neck fracture and to review the role of early decompression of the hip in the final outcome.

PATIENTS AND METHODS

The study was performed at the Department of Paediatric Orthopaedics and Traumatology, University Children's Hospital in Belgrade, Serbia from January 1996 to January 2010. The study included 28 patients, 12 female and 16 male, aged 4-14 years. Patients who were aged over 14 years or who had pathological femoral neck fractures or metabolic disturbances were excluded from the study. The type of neck fracture was determined according to the Delbet and Colonna classification. The patients were treated using different surgical procedures: closed reduction and cast immobilisation, closed reduction and percutaneous fixation with Kirschner wires (K-wires), closed reduction and fixation with cannulated screws and open reduction with Wagner plate stabilisation. The final outcome was evaluated using the clinical outcome (based on the Howorth-Ferguson scale), radiographic outcome and occurrence of complications.

RESULTS

The median age of patients included in the study was 10.75 years and the average follow up was 9 years. According to the Delbet classification, there was one patient with type I, eight patients with type II, 16 patients with type III and three patients with type IV femoral neck fracture. Based on the Colonna classification, there were 23 displaced and five non-displaced femoral neck fractures. Decompression of the hip was performed in 21 patients. Avascular necrosis (AVN) developed as the main complication in 11 patients. The final outcome was excellent in 14 patients, good in four patients and poor in 14 patients.

CONCLUSION

Our study unequivocally confirms the positive effect of urgent treatment on the incidence of AVN as well as on the outcome. We have established a 12-hour interval after injury as an optimal time limit for commencing treatment. Unambiguously positive effects of hip decompression on the incidence of AVN were also noted. We found similar efficiency for open and needle hip decompression.

Pattern of emergency room mortality among road traffic crash victims

Road traffic injuries are a major cause of death in the emergency room. The goal of this study was to highlight the demographic pattern of road traffic-related deaths in the accident and emergency room of a regional trauma centre. This was a 5-year retrospective study in which road traffic-related cases of emergency room mortality between June 2009 and June 2014 were reviewed. A total of 33 road traffic crash-related deaths occurred during this period with a male-to-female ratio of 2.3:1. Most of these patients were pedestrians with severe injuries involving two or more Abbreviated Injury Scale (AIS) coded regions. The mean time between injury and presentation in the first trauma facility was 112.1 (±55.4)min, and between presentation in the emergency room and death was 410 (±645)min. Mangled lower extremity, bilateral long bone lower limb fractures, pelvic injuries, blunt injuries to the chest and abdomen, and cranial fossae fractures were the common injury pattern. Median ISS and NISS in these patients were 22 (interquartile range [IQR]=11) and 25 (IQR=17), respectively. Severe injuries, delayed presentation, multiple referrals and delayed resuscitative measures contribute to road traffic crash-related mortality.

A retrospective study of antibiotic prophylaxis value in surgical treatment of lower limb fracture

BACKGROUND

Surgical site infections (SSI) are nosocomial infections that cause considerable problems in orthopaedic surgery. Antibiotic prophylaxis can be used to reduce the risk for SSI. There is no universal antibiotic that can be recommended for prophylaxis in terms of coverage of all possible pathogens because of antibiotic resistance, and there are no universal recommendations for different types of patients in terms of injury type, selected operation and risk factors for development of SSI. The aim of this study was to analyse the effectiveness of antibiotic prophylaxis in surgical treatment (ORIF) of closed lower limb fractures in young, healthy patients.

PATIENTS AND METHODS

Patient details were collected from the patient histories. Inclusion criteria for participants were age 20-30 years, not suffering from any type of chronic disease or state that may affect postoperative infection and ISS≤9. Antibiotic prophylaxis use and outcome (SSI) were compared between two groups of patients. Data were analysed using descriptive statistics, Fisher's exact test and t-test for proportions.

RESULTS

A total of 347 patients with closed lower limb fractures treated with ORIF met the inclusion criteria. There were 290 male and 57 female patients, with an average age of 24.47 years. Prophylactic antibiotics were given to 242 patients (69.74%); 2g ceftriaxone was administered to 88.02% of the patients who received antibiotic prophylaxis. Ten patients developed postoperative infection (eight out of 242 with antibiotic prophylaxis and two out of 105 without antibiotic prophylaxis). The difference between the two groups was not statistically significant (Fisher's exact test, P=0.749).

CONCLUSION

Antibiotic prophylaxis was ineffective in preventing SSI in patients with no risk factors for SSI who were undergoing ORIF for closed lower limb fractures.

The role of negative pressure wound therapy in patients with kidney transplantation

Kidney transplantation is the best treatment modality for patients with end-stage renal disease. Wound healing is impaired in these patients, and factors such as immunosuppression, older age and comorbidities have a negative impact on wound healing. Recently, negative pressure wound therapy has become an important wound management technique. We present two patients with wound healing issues in the early posttransplant period. In both patients, an imrnunosup- pressive treatment was administered, which included tacrolimus, mycophenolate mophetil and high-dose corticosteroids with anti-IL-2 induction therapy. Postoperatively, the wounds became inflamed with dehiscence. Negative pressure wound therapy was successfully applied to aid the wound healing. The treatment duration period was two weeks for one patient and three weeks for the other. After the treatment period, the wounds were significantly improved and were closed. After the secondary wound closures, the posttransplant course was uneventful in both patients. Presently, one and three years after the transplantations, both patients have well functioning kidneys. According to our limited experience, negative pressure wound therapy is a feasible and effective dehiscence wound treatment following kidney transplantation.

Treatment of hardware infection after osteosynthesis of lower leg using negative pressure wound therapy and transforming powder dressing

Fractures of the distal part of the lower leg are more common in everyday practice and traumatology. In young and active patients these injuries are mainly caused by high energy trauma. They are treated with external fixator in first step, and in second step, after sanation of the soft tissue, with open reduction and internal fixation (ORIF). It is very safe and effective method of treatment. Treatment of the infections that occur in the early postoperative period after open reduction and internal fixation represents a great problem and challenge for surgeons. It is widely accepted that the presence of deep infection can't be cured in the presence of hardware. However, removal of hardware in the presence of unhealed fractures significantly complicates sanation of infection and fracture itself We have decided to present a 35-years-old patient with a hardware infection with present chronic wound with hardware exposed eight months after the first operation and six months after second operation. The wound measured one centimeter in diameter with cell detritus and bad granulations tissue inside the wound. Hardwre was exposed in the depth of the wound.The secretion was minimal. Negative Pressure Wound Therapy (NPWT) was applicated after debridemet and lavage performed in ambulatory conditions. The starting therapy was continuously -125 mm Hg of vacuum. After five days of NPWT the defect was partially filled with granula- tion tissue. For another five days we continue with NPWT with the same values of-125 mm Hg pressure but in the inter- mitent mode. After that period we used transforming powder dressing for covering and protection of the wound with was filled with granulation tissue. Five days later, wound was completely healed with epithelisation. After four months of patient follow-up, we found the wound is completely repaired. The patient denies pain and has continued orderly flow of fracture healing, with no signs of infection.

Periprosthetic infections after total hip and knee arthroplasty--a review

Periprosthetic joint infections (PJI) in orthopedic surgery are considered to be very serious and dangerous complications of total joint arthroplasty. PJI becomes a long-lasting medical problem and a heavy burden on patient and his family. Patients with such a complication are a significant financial burden for the health care system. Recognizing this issue, investing in scientific research and simultaneously developing technologies in medicine are efforts taken to increase successfulness in preventing and treating PJI. Each year the number of total joint arthroplasties increases which entails a rise in the number of complications among which infections are the leading ones. Sometimes, in the worst case scenarios, infections can endanger patients' lives. New procedural algorithms and new diagnostic possibilities help us make accurate and early diagnoses of postoperative PJI with a great degree of certainty. These diagnostic methods include laboratory tests, imaging, histopathology and microbiological analyses. Treatment options depend on many factors which include the onset of symptoms, patients'general physical condition and type of pathogen. The approach to treating PJI is complex and it requires a multidisciplinary approach in order to ensure the most successful treatment possible. For adequate and successful treatment we need to take into account antibiotic therapy, one-stage or two-stage revision, Girdlestone operation, athrodesis and amputation. In this review we will try to sum up all relevant findings and suggest further steps in management of PJI.

[Plausible solution to prevent major amputation in diabetic foot patients]

Diabetes mellitus is one of the leading public health problems in the world. Complications of diabetes mellitus include cardiovascular diseases, retinopathy, neuropathy and diabetic foot, which can in turn lead to lower extremity amputations. This is the main cause of mortality and the biggest expenditure for health system. Treatment is long and frustrating for the patient and also for medical staff. Amputations are becoming more frequent, while the quality of life after amputation is greatly reduced. Healing of postoperative infection is long lasting and demands a lot of hard work from the surgeon and the rest of medical staff, while causing severe suffering for the patient. Progression of infection increases mortality. Negative pressure therapy after minor foot amputations greatly reduces healing time. Negative Pressure Wound Therapy (NPWT) was applied after surgical treatment. All necrotic tissue and fibrin deposits were removed. Initial therapy was administered continuously with 125 mm Hg of vacuum. The NPWT was continued intermittently. Additionally, all patients underwent additional hyperbaric treatment and local hemoglobin administration. In conclusion, in all cases presented, combined NPWT, hyperbaric and topical hemoglobin therapy proved to be a highly effective therapeutic option in preventing pending major amputation following minor diabetic foot amputation.

[Algorithm of nursing procedure in debridement protocol]

Debridement is an essential act in the treatment of various wounds, which removes devitalized and colonized necrotic tissue, also poorly healing tissue and all foreign bodies from the wound, in order to enhance the formation of healthy granulation tissue and accelerate the process of wound healing. Nowadays, debridement is the basic procedure in the management of acute and chronic wounds, where the question remains which way to do it, how extensively, how often and who should perform it. Many parameters affect the decision on what method to use on debridement. It is important to consider the patient's age, environment, choice, presence of pain, quality of life, skills and resources for wound and patient care providers, and also a variety of regulations and guidelines. Irrespective of the level and setting where the care is provided (hospital patients, ambulatory or stationary, home care), care for patients suffering from some form of acute or chronic wound and requiring different interventions and a large number of frequent bandaging and wound care is most frequently provided by nurses/technicians. With timely and systematic interventions in these patients, the current and potential problems in health functioning could be minimized or eliminated in accordance with the resources. Along with daily wound toilette and bandaging, it is important to timely recognize changes in the wound status and the need of tissue debridement. Nurse/technician interventions are focused on preparation of the patient (physical, psychological, education), preparation of materials, personnel and space, assisting or performing procedures of wound care, and documenting the procedures performed. The assumption that having an experienced and competent person for wound care and a variety of methods and approaches in wound treatment is in the patient's best interest poses the need of defining common terms and developing comprehensive guidelines that will lead to universal algorithms in the field.

[Continuous nursing education to improve the quality of health care]

Health care and today's medical and technical achievements and approved standards of treatment provide comprehensive quality, safety and traceability of medical procedures respecting the principles of health protection. Continuous education improves the quality of nursing health care and increases the effectiveness of patient care, consequently maintaining and enhancing patient safety. Patient health problems impose the need of appropriate, planned and timely nursing care and treatment. In providing quality nursing care, attention is focused on the patient and his/her needs in order to maintain and increase their safety, satisfaction, independence and recovery or peaceful death, so the health and nursing practices must be systematized, planned and based on knowledge and experience. Health and nursing care of patients at risk of developing acute and chronic wounds or already suffering from some form of this imply preventive measures that are provided through patient education, motivation, monitoring, early recognition of risk factors and causes, and reducing or removing them through the prescribed necessary medical treatment which is safe depending on the patient health status. Except for preventive measures, nursing care of patients who already suffer from some form of acute or chronic wounds is focused on the care and treatment of damaged tissue by providing appropriate and timely diagnosis, timely and proper evaluation of the wound and patient general status, knowledge and understanding of the wide range of local, oral and parenteral therapy and treatment, aiming to increase patient safety by preventing progression of the patient general condition and local wound status and reducing the possibility of developing infection or other complications of the underlying disease. In the overall patient management, through nursing process, medical interventions are implemented and aimed to maintain and optimize health status, prevent complications of existing diseases and conditions, provide appropriate wound treatment, increase satisfaction, reduce pain, increase mobility, reduce and eliminate aggravating factors, and achieve a satisfactory functional and aesthetic outcome. Many scientific researches and knowledge about the pathophysiological processes of wound formation and healing are currently available. Modern achievements can accelerate independence, reduce pain and encourage faster wound healing, thus it is important to continuously develop awareness, knowledge and experience, along with the treatment to achieve, maintain and enhance the quality of health care and patient safety.

[Use of new materials in the treatment of chronic post-traumatic wounds]

Postoperative infection and the presence of osteosynthetic material in human body pose a major problem for patients and operators. Previously, it was considered that osteosynthetic material must be removed, and only then the expected full infection recovery could occur. However, removal of osteosynthetic material in unhealed fractures complicates bone fracture healing, as well as infection recovery. Nowadays, it is indicated to place an external bone fixator and in case of soft tissue recovery access to reosteosynthesis. The negative pressure wound therapy has brought new opportunities for treatment of this type of infections without the need of osteosynthetic material removal. Direct and indirect effects of negative pressure wound therapy create optimal healing conditions. Local use of new materials, transforming powder (Altrazeal) and topical hemoglobin spray (Granulox), provide and improve physiological conditions for appropriate and safe healing.

[Chronic wound in waiting-room]

Chronic wounds are wounds that in addition to standard methods of treatment do not heal within 6-8 weeks, depending on their localization and etiology. Wound healing is affected by a number of factors: physical, psychosocial, relationship to the patient's disease, the condition of the wound itself, as well as the experience and knowledge of medical personnel and financial resources of the institution. Treating chronic wounds begins taking adequate history. Holistic approach is very important in each patient. It should take into account all the situations that can lead to the prolonged healing of wounds. The psychosocial status of the patient plays an important role in the treatment of chronic wounds.

[debridement algorithm]

Prolonged life expectancy increases the proportion of elderly population. The incidence of injury increases with older age. A variety of comorbidities (circulation disorders, diabetes mellitus, metabolic imbalances, etc.) and reduced biological tissue regeneration potential that accompanies older age, lead to a higher prevalence of chronic wounds. This poses a significant health, social and economic burden upon the society. Injuries in the elderly demand significant involvement of medical and non-medical staff in the prehospital and hospital treatment of the injured, with high material consumption and reduced quality of life in these patients, their families and caregivers. Debridement is a crucial medical procedure in the treatment of acute and chronic wounds. The aim of debridement is removal of all residues in wound bed and environment. Debridement can be conducted several times when there is proper indication. There are several ways of debridement procedure, each having advantages and disadvantages. The method of debridement is chosen by the physician or other medical professional. It is based on wound characteristics and the physician's expertise and capabilities. In the same type of wound, various types of debridement can be combined, all with the aim of faster and better wound healing.

[A role of negative pressure therapy in the treatment of surgical wound infection after intramedullary osteosynthesis in pertrochanteric femoral fracture]

Fractures of the proximal femur are specific to older adults. Today, life expectancy for men and women is increasing, so one can expect an increased number of hip fractures. Elderly people suffer from associated diseases that may compromise the biological potential in healing of surgical wounds. On the other hand, there is an increased number of microorganisms resistant to antimicrobial drugs, so an increased number of postoperative infections can be expected. With conventional treatment methods of postoperative infections where the osteo-synthetic material is present in tissue, negative pressure therapy is gradually taking an increasingly important role in the treatment of these conditions. Because of its simple application in hospital or outpatient setting and good comfort with no pain for the patient, negative pressure therapy contributes significantly to healing of the wounds without removing osteosynthetic material from the wound.

[Use of negative pressure therapy in the treatment of primary infected traumatic wounds of the foot caused by high energy impact]

Foot injuries caused by firearms and high pressure washing machines are not common, but due to high energy can be very destructive and contaminated with microorganisms. Due to the anatomical specificity of the foot, injures of the specific structure such as blood vessels, nerves and tendon-ligament apparatus are frequent. Soft tissue defect is often present. Functional and aesthetic recovery of the foot is a challenge for the surgeon. Direct and indirect effect of the negative pressure therapy helps in wound healing and provides good preparation for definitive surgical management of wounds.

[Weight loss and healing of ulcers - case report]

Diabetes mellitus type 2 is one of the most common diseases with a prevalence increasing with age. If blood sugar is not controlled, complications arise and diabetic foot ulcer occurs. Depending on the blood vessels involved, we distinguish venous and arterial ulcers. Venous ulcers respond very well to modern methods of treatment such as compression therapy and hydrocolloid dressings, but for arterial ulcer prevention is most significant, e.g. weight loss, dietary modification, etc. The aim of this study was to show that despite all the available therapeutic options, we cannot cure ulcers completely because the patient's readiness to change his lifestyle plays a decisive role. Therefore, we present a patient having suffered from venous ulcers for several years and arterial ulcer that healed only after the patient had lost about 20 pounds.

[What is behind a wound?- case report]

Chronic wound is a wound that does not heal in four to eight weeks. The most important predisposing factors are tissue ischemia and infection. In approximately 80% of cases, chronic wounds of lower limbs are the final form of chronic venous insufficiency. We report a case of chronic wound of lower limb that was treated as a posttraumatic war wound. After proper treatment of chronic venous wound of lower limb, it healed after almost 20 years. When chronic wound of lower limb is present, all diagnostic criteria should first exclude chronic venous insufficiency, and then proper treatment should be introduced.

[Nursing process for patients treated with negative pressure therapy afther severe foottrauma]

Foot injuries inflicted by firearms and high pressure washing machines cause distortion of psychophysical and biomechanical characteristics with decrease of ability to satisfy the basic human needs and existing mode of living. Treatment with negative pressure accelerates wound healing process and recovery. Nursing role is significant in all these problems, which arise as patient reaction to the severe trauma. With the extensive surgical procedures required and nursing intervention, the actual and potential patient problems are minimized or eliminated, as evidenced from the good functional and esthetic results, and resuming independence and usual daily activities.

Gunshot injury of the foot: treatment and procedures--a role of negative pressure wound therapy

Civilian gunshot injuries of the foot are not so common in Croatia. They are related with accidents in hunting or weapon cleaning. Gunshot injuries represent a special challenge for surgeon because of specific anatomical relations and biomechanical function of the foot. We have decided to present a patient with a complex foot injury caused by hunting firearm in self-inflicted accident. A 45-year-old male presented with 12-gauge shotgun wound to his left foot. We found a complicated fracture with bone defect of 3rd, 4th and 5th metatarsals and wide soft tissue injury with skin and subcutaneous defect of the dorsal and lateral side of the foot. The wound was contaminated with numerous metal fragments, particles of rocks and ground. Surgical treatment was performed three hours after trauma and included extensive debridement of damaged soft tissue, removing of the non-viable bone and metal fragments, rocks and other foreign bodies. Negative Pressure Wound Therapy (NPWT) was applicated in the operating table. The starting therapy was continuously -125 mm Hg of vacuum. We continued with intermittent therapy of -100 mm Hg and change NPWT dressing every fourth day. After four weeks of NPWT the defect was filled with granulation tissue and split thickness skin graft was applied. Skin graft was additionally fixed with NPWT using continuous therapy at -100 mm Hg for a period of four days. Forthy days after injury there was a complete healing of all soft tissue. Control X-ray showed good bone healing process.

Measuring improvement following total hip and knee arthroplasty using the SF-36 Health Survey

The aim of this study was to evaluate the impact of total hip or knee arthroplasty upon quality of life in elderly patients. The study was carried out at the Clinic for Orthopaedic Surgery Lovran on 74 total hip arthroplasty and 70 total knee arthroplasty patients. All patients had completed the Medical Outcomes Study 36-Item Short Form in the week having preceded their surgery and then again postoperatively, 2 years after. The data obtained were statistically processed at the level of physical function, role limitations due to physical problems, role limitations due to emotional problems, social function, mental health, energy or vitality, pain and general health perception, and change in health. The primary total hip arthroplasty patients showed significant improvement at all levels measured. Similarly, the primary total knee arthroplasty patients expressed significant improvement according to all the parameters but the mental health assessment. Comparison of outcomes between the two assessment groups of patients resulted in slightly superior quality of life outcomes in total hip arthroplasty patients. It can be concluded that total hip or knee arthroplasty significantly enhances the health related quality of life in elderly patients.

Analysis of senior population visits to physical medicine in Croatia

The aim of the study was to analyze the senior population when deciding to choose either going to the private or public physical medicine practice in Croatia. 240 patients (public and private group, 120 participants each) from the Croatian medium large county Primorje-Gorski kotar, were enrolled from 6 physical medicine practices (3 public and 3 private). Between December 1st 2009 and January 31st 2010, in the public and private practices seniors aged 65 to 85 years were 64.17%, 52.40% respectively, of all interviewed participants in single group. The results showed that in Croatia majority of seniors visiting the physical medicine were females in revisit and dependents of government health insurance. Study suggested the great influence of general practitioner, closeness to home and time of the appointment for patients going to public physical medicine, while in private peers and sooner appointment outweigh. In either practice seniors were satisfied with the overall quality of health services and graded the best average-higher in favor for the private. Elderly Croatian residents showed to be the important feature in physical medicine and rehabilitation and to participate actively in their health issues. Following those results, we will perform the study in the rest of the country and compare it to this data. That could enable the specific improvement for the health care of seniors in Croatia.

Histomorphometric analysis of subchondral bone of the femoral head in osteoarthritis and osteoporosis

There have been reports both supporting and refuting an inverse relationship between hip fracture and hip osteoarthritis (OA). We have investigated this relationship using histomorphometric study of femoral head subchondral bone. We studied 74 subjects with hip fracture (74% females) and 24 subjects with osteoarthritis (45% females). By histomorphometric analysis of parafined sections, we analysed followed subhondral trabecular bone parameters bone volume (BV), bone volume/tissue volume (BV/TV), trabecular thickness (Tb.Th.), trabecular number (Tb.N.) and trabecular separation (Tb.S.). The subjects with osteoarthritis and subjects with hip fracture had BV/TV 31.3% and 19.6% respectively. BV/TV of osteoarthritis group was rather uniform whereas BV/TV of hip fracture group was greatly ranged and we divided it into three subgroups, 13.2%, 19.8% and 25.9% respectively. The OA group and hip fracture groups had Tb.Th. as followed 0.205 mm, 0.148 mm, 0.170 mm and 0.183 mm respectively. The OA group and hip fracture three subgroups had Tb.N. as followed 1.454/mm, 0.897/mm, 1.170/mm and 1.425/mm respectively. The OA group and hip fracture three subgroups had Tb.S. as followed 0.518 mm, 0.681 mm, 0.620 mm and 0.550 mm respectively. The results of our study support an inverse relationship between hip fracture and hip osteoarthritis.

Polytrauma in elderly

The aim of this study is to present certain particularities in treating polytraumatized patients age of 65 and above. All of the patients were treated in our hospital. 413 patients were included in this 4 year study (2006-2010). Injury severity score was 17 and above (ISS > 17). Patients aged above 65 were sub grouped. In this 4-year period, we treated 52 or 13% elderly patients. In this subgroup there were 30 (58%) males and 22 (42%) females, with mean age of 74 (max age 95 years old). Demographic factors, injury mechanisms, patients resuscitation protocols, imaging used, etc. were also included as variables. Mortality rate in elderly patients was 31%, while in patients below 65 years of age as 12%. Taking relevant data into consideration, a special emphasis was given to certain circumstances of intensive and surgical treatment of elderly patients. A large portion of polytraumatized patients are consisted of elderly. Patients aged 65 and above have higher mortality rate with lower ISS in the mortal group and falls are the most frequent mechanism of trauma. In this study, we tried to emphasize some clinical implications when treating those patients, as well as importance in continuous medical staff education in trauma principles to minimize mortality rates.

Cross-talk between NKT and regulatory T cells (Tregs) in modulation of immune response in patients with colorectal cancer following different pain management techniques

Natural killer T (NKT) and regulatory T cells (Tregs) play an important role in innate immune response. Natural killer (NK) and NKT cells are indispensable factors in the body's ongoing defense against tumor development, as well as viral infection. NKT cells are a subset of T cells that shares properties of natural killer cells and conventional T cells. They are involved in innate immune responses, tumor rejection, post transplantation immunotherapy, immune surveillance and control of autoimmune diseases. They may also play both protective and harmful roles in the progression of certain autoimmune diseases, such as diabetes, lupus, atherosclerosis, and allergen-induced asthma. Immune surveillance involves the process whereby precancerous and malignant cells are recognized by the host immune system as damaged and are consequently targeted for elimination. The pharmacological management of postoperative pain in patients with malignancies uses very different techniques whose possible cytotoxic functions we still known very poor. The present study compared effects of two different postoperative pain management techniques in patients undergoing colorectal cancer surgery on the innate immunity. Our data indicate that the patients with colorectal cancer have significantly increased the percentage of Tregs and NKT cells. The values were statistically higher during epidural analgesia in comparison with intravenous analgesia, indicating that epidural pain management technique ameliorate the immune suppression after surgery.

Application of wound dressing Molndal technique in clean and potentially contamined postoperative wounds--initial comparative study

Because of a possible delayed wound healing, critical colonization and infection of wounds present a problem for surgeons, particularly in patients with compromised immune system or in case where the wound is heavy contaminated or poorly perfused. Molndal technique of wound dressing has proven to be effective in prevention of infection. In our study we wanted to describe the benefits of the application of Molndal technique wound dressing compared to traditional wound dressing technique at potentially contaminated and clean postoperative wounds. We examined postoperative wound after radical excision of pilonidal sinus and after implantation of partial endoprosthesis in hip fracture. Molndal technique consisted of wound dressing with Aquacel Ag - Hydrofiber. Traditional technique was performed using gauze compresses and hypoallergic adhesives. We analyzed the results of 50 patients after radical excision of pilonidal sinus. 25 patients were treated by Molndal technique and 25 patients by the traditional technique of wound dressing. In the group treated by Molndal technique only 1 (4%) patient has revealed a wound infection, proven by positive microbiological examination and suppuration. In the traditional technique group 4 (16%) patients developed wound infection as inflammation and secretion as a sign of superficial infection. In the other group we analyzed the results of 50 patients after implantation of partial endoprosthesis after hip fracture. 20 patients were treated by Molndal technique and 30 patients by the traditional technique of wound dressing. In the group treated by Molndal technique no patient has revealed a wound infection (0%). In the traditional technique group 4 (13%) patients developed wound infection. All complication in both group were superficial incisional surgical infection (according to HPSC). There was no deep incisional surgical site infection or organ/space surgical site infection. Our results are clearly showing that Molndal technique is effective in preventing the postoperative wound infection.

Giant pseudocyst of the rectus femoris muscle--repetitive strain injury in recreational soccer player

We report a case of a traumatic pseudocyst, in a recreational soccer player, after rupture of rectus femoris muscle. 37-year-old male, with history of repetitive painful accidents, was examined because of a double fist-sized mass in the anterior thigh. Ultrasound examination revealed a cystic mass in the rectus femoris muscle. Surgical removal of the mass and proximal remnant of muscle was done. Primary healing and functional recovery was achieved. Histological analysis revealed pseudocyst filled with degenerating clot and surrounded with thick fibrous capsule. The repetitive strain muscle injury, with prolonged period of healing, can occur like pseudocyst.

Obtaining the child testimony in the criminal proceedings

Children fall under the special category of vulnerable witnesses. Children's vulnerability is the reason that we must approach obtaining the child's testimony in the criminal proceedings with special attention. It is important to take the child's testimony as soon as possible and to avoid the repetition of interrogation. The criminal proceedings law and the juvenile court law enable children interrogation through the professional person without the presence of other parties in the procedure and enable the recording of such interrogation by audio-video link which considerably diminish the secondary victimization. The professionals who obtain the testimony must be well acquainted with children's psychological development. Knowledge of psychological development is of major importance in order to make the quality arrangements for interrogation and to interrogate the child and to achieve positive social contact between the examiner and the examinee and it is also of great importance for the credibility evaluation of the child's testimony. The adequate way of children interrogation will enable the child to say the correct information and to recognize the perpetrator. The forensic interview is well elaborated and child adapted technique of interrogation. Respecting the rules of forensic interview will enable the child's testimony on court to be relevant evidence.

Application of wound closure Molndal technique after laparoscopic cholecystectomy--initial comparative study

Because of a possible delayed wound healing, critical colonization and infection of wounds present a problem for surgeons. Colonized and infected wounds are a potential source for cross-infection. Molndal technique of wound dressing has proven to be effective in prevention of infection. Also the wound heal better and faster. In our study we wanted to describe the benefits of the Molndal technique wound dressing after laparoscopic cholecistectomy compared to traditional wound dressing technique. Molndal technique consisted of wound dressing with Aquacel Ag--Hydrofiber (ConvaTec, Dublin, Ireland). Traditional technique was performed using gauze compresses and hypoallergic adhesives. We analyzed the results of 100 patients after laparoscopic cholecystectomy. 50 patients were treated by Molndal technique and 50 patients by the traditional technique of wound dressing. In the group treated by Molndal technique only 1 (2%) patient has revealed a wound infection, proven by positive microbiological examination and suppuration, mostly in the subumbilical incision. In the traditional technique group 7 (14%) patients developed wound infection also predominantly in the subumbilical incision. The difference was statistically significant (p < 0.01). Our results are clearly showing that Molndal technique is effective in preventing the infection of subumbilical incision wound and is to by recommend for regular use at designated site after laparoscopic cholecistectomy.

Perioperative and early postoperative neurological deficit in older patients during carotid artery thrombendarterectomy

Cerebrovascular accidents, strokes in particular, are among the most frequent causes of death today in developed countries. In the last two decades, stroke was the second most frequent cause of death in Primorsko-Goranska Region in Croatia. In older patients, individuals older than 65 years of age have an increased risk of stroke, mainly because the degree of carotid artery stenosis increases with age. The most frequent complication of the high percent stenosis of the carotid arteries is thrombosis in the area of atherosclerotic changes of blood vessels. With the increase in the age of the population, there is also an increase in the number of risk factors of cerebrovascular accident. Doppler ultrasound sonography and Multi Slice CT scans have the most prominent role in the early detection of atherosclerotic changes and in the assessment of the degree of carotid artery narrowing. Today, in Croatia as well as worldwide, thrombendarterectomy holds the most important place in stroke prevention. Between 2006 and 2009, 209 patients underwent surgical intervention at the Clinical Hospital Center in Rijeka for high degree of carotid artery narrowing. In the group younger than 65 years of age, which consisted of 53 patients, a neurological deficit was noted in 4 patients (7.54%) in the perioperative and early postoperative course. In the group of individuals older than 65 years of age, which consisted of 156 patients, a neurological deficit was noted in 9 patients (5.76%). There was no significant statistical difference in the incidence of neurological deficit, nor in the mortality in individuals older than 65 years of age during carotid arteries thrombendarterectomy.

Hip fractures in elderly--ten years analysis

Geriatric hip fractures (GHP) are the major problem in the geriatric traumatology and it is estimated that treatment of GHF will spend a large amount of health care resources. The aim of this retrospective study was to compare differences in incidence of operatively treated patients with GHF, type of treatment depending of the type of fracture, early postoperative mortality, length of stay and costs of used implants within a 10 years period. Surgically treated 2478 patients, older than 65 years with hip fractures were included in the study. Patients were grouped according to the type of fracture (femoral neck fracture or intertrochanteric femoral fracture) and used implant. Results showed increasing trend in GHF in our County in the last 10 years. There was a shifting trend in used implants, and new surgical techniques were used more commonly in the last few years. In observed period there were no significant changes in revision surgery and length of hospital stay. The mortality decreased, especially in males, but generally it was not in correlation with used implant. At the 10-years period increase in patients with GHF of 179% was followed with 4 time higher increase in implant prices. Present reimbursement in health care system does not calculate the difference of implant costs in hospital expenses, therefore proper usage of modern implants and careful planning in the treatment of GHF is necessary.

The relationships between self-esteem, emotional reactions and quality of life in pediatric locomotory trauma patients

The main aim of this study was to establish the relationships between several psychosocial characteristics in children and adolescents differently treated for isolated long tubular bones' fractures. Examined variables were: self-esteem, basic emotional reactions toward illness or injury including depression and anxiety, as well as perception of quality of life and social support during the treatment. Whole sample comprehends 135 patients, both gender, 10-18 years of age, treated for mentioned fractures in period 2003-2005 at the Departments of Pediatric Surgery of 3 hospitals: University Hospital Centre in Rijeka and Clinical Children's Hospital in Zagreb, both in Croatia and University Hospital in Mostar, BiH. 73 patients were treated conservatively (CT), 40 of them underwent Elastic Stable Intramedullary Nailing (ESIN) and 22 of them underwent other surgical techniques (OST). Basic methods of work were: interview to collect data for half-structured socio-demographical questionnaire, evaluation of medical records and self-reported questionnaires including: Rosenberg Self-esteem Scale (RSS), Children Depression Inventory (CDI), Spielberg State Trait Anxiety Inventory (STAI), Short Form 36 Health Survey (SF-36) and Test of Perception of Social Support (TPSS). RSS, CDI and STAI were administered to the patients at baseline and after 6 months of the trauma, while SF-36 and TPSS after 1 month of the trauma. Results of this study point to close and strong relationships between examined variables, mostly statistically significant at level p < 0.01 in all patients with fractures, regardless of the type of the treatment. There were also statistically significant differences in all variables between first and second measure; self-esteem increased and depression and anxiety decreased during the time in all patients (with different dynamics regarding the type of treatment); higher perception of social support enhanced that effect. Perception of quality of life in whole sample in summary measures was statistically significant at level p < 0.01 correlated positively with self-esteem and negatively with depression and anxiety, thus connection with perception of social support was statistically significant only in sibdomain of physical pain. There was also statistically significant difference in self-perception of quality of life related to psychosocial variables according to the type of treatment (F = 3.27; p = 0.01). Results of this study suggest that there are strong connections between physical trauma and different psychosocial variables in patients which point at need of understanding locomotory trauma in children in wider context including physical state and social functioning of the patient as well as the choice of type of treatment of fractures which influences complete process of healing.

Initial experience with external thoracic stabilization by the "figure of eight" osteosynthesis in polytraumatized patients with flail chest injury

The aim of this study was to describe initial experience with external thoracic stabilization by the "figure of eight" osteosynthesis in polytraumatized patients with flail chest injury. From January 2002, fifteen patients underwent this surgical procedure at the University Hospital of Rijeka. Their mean age was 52 +/- 13.69 (range 18-65) and mean ISS was 29.8 (range: 20-41). Twelve patients were weaned from artificial respiration on same day when operated, two on the post-operative day 1, and one on the post-operative day 2. Their stay within the intensive care unit following extubation was within the range of 1-12 days (mean 3.93 +/- 2.99). The early external thoracic stabilization by the "figure of eight" osteosynthesis was followed by swift extubation of patient and direct normalization of respiratory parameters. This method contributed significantly to patient's shorter stay within the intensive care unit.

Expression of bone morphogenetic proteins, cartilage-derived morphogenetic proteins and related receptors in normal and osteoarthritic human articular cartilage

Newborn and adult articular cartilage expresses bone (BMPs) and cartilage derived morphogenetic proteins (CDMPs). These morphogenetic proteins act over membrane receptors (BMPRs). We examined the expression pattern of BMP-7, BMP-3, CDMP-1, CDMP-2 and their receptors in adult normal and osteoarthritic, articular, knee cartilage. Immunostaining was carried out using polyclonal antibodies. The expression of BMP-7,-3, CDMP-1,-2 was detected in all layers of normal articular cartilage with the strongest expression in chondrocytes of the transitional layer. BMP-7 and CDMPs expression decreased in osteoarthritic articular cartilage whereas BMP-3 expression was absent. BMPR-IA and BMPR-II were strongly expressed in both normal and osteoarthritic articular cartilage. BMPR-IB was not expressed in osteoarthritic (OA) cartilage. BMPs and CDMPs with intact signalling play an important role in articular cartilage homeostasis, preventing cartilage degeneration.

Sunlight and incidence of pterygium on Croatian Island Rab--epidemiological study

The aim of this epidemiologic study, on small island Rab, in North Adriatic Sea, is to estimate correlation between climatic factors, specially chronic exposure to strong visible and UV light, and appearance of pterygium and exfoliation syndrome. In the first group of population which live in a village and who are agriculturists and fishermen (480 persons) appearance of pterygium is in 23% (16% in males and 7% in females), but 0.0% in urban people (61 people). The appearance of exfoliation syndrome was in the first group of agriculturists and fishermen population in 21%, of which 19% of males and 2% of females, and in urban people 0.0%. The higher intraocular pressure in exfoliation syndrome was 92%. All population in this examination were in the highest age (mean age is 65-80 years). Chronic exposure to sunlight caused the high percentage appearance of pterygium and exfoliation syndrome.

Anthropometric characteristics of high level European junior basketball players

The purpose of the research was to assess anthropometric status of European high-level junior basketball players and to determine anthropometric differences between the players playing in different game positions (guards, forwards, centers). The sample consisted of 132 young basketball players, participants of the European Junior Basketball Championship, Zadar, 2000. Participants were measured with 31 measures (anthropometric variables), on the basis of which two body composition measures (BMI and relative body fat) and somatotype were calculated. The basic statistical parameters were computed. The analysis of variance and discriminant canonical analysis were employed to determine the differences between positions in play. Results indicate that prominent longitudinal and transversal skeletal dimensions as well as circumference measures characterize players on the position of centers, but they do not have significantly larger skinfold measures in relation to forwards. Centers are also predominantly ectomorphic compared with other players. Guards achieved significantly lower values in all spaces and they are predominantly mesomorphic. Further investigations are necessary in order to assess potential changes in status of these parameters when the participants will reach the age of senior players and afterwards, as well as to determine relations between anthropometric status and skill related variables.

Position specific morphological characteristics of top-level male handball players

With the aim of determining the common morphological features of senior male handball players and of analyzing their specificities i.e. the probable variation between the four playing positions (back court players, wings, pivots, goalkeepers), 25 anthropometric measures were applied to the sample of 49 players, members of three top-quality handball teams. The basic descriptive parameters were calculated and then an analysis of variance and a cluster analysis were performed. A mesomorphic, athletic body- type was obtained with a marked longitudinal skeleton dimensionality, but also with a balanced ratio between the skeletal system and muscle mass and with low values of subcutaneous fat tissue. Back court players and goalkeepers are superior in terms of outstanding skeletal dimensions and circumferences. Line players, i.e. wings and pivots, have somewhat lower longitudinal measures, whereas pronounced voluminosity and a slightly higher fat tissue value differentiate pivots from players in other positions. Cluster analysis revealed a greater homogeneity in the morphological profiles of the samples of line players (wings and pivots) than in the profiles of backs or goalkeepers. The obtained position-related differences in morphological characteristics of players suggest that the experienced players from the sample were earlier successfully subjected to the selection process and oriented to a particular playing position because of the observed correspondence between their body-type and specific kinesiological demands of the position in question. Therefore, in top-quality team-handball it would be recommendable to select players whose morphological profiles are as compatible as possible with positional specificities in the demand for the game.