[Topographic localisation of insertion of the anterior cruciate ligament]

INTRODUCTION

Determining the center of tibial insertion of the anterior cruciate ligament is important during reconstruction ligament.

AIM

Determining the center of insertion of the anterior cruciate ligament on the anterior intercondylar area relate to anterior and medial edge of the upper end of tibia.

MATERIAL AND METHODS

The messurement has been done on 102 tibia. We measured distance from the center of ACL to anterior and medial edge of the uper part of tibia, and the lenght and the width of the tibial insetion. Also, we showed the procentual ratio these distances with medio-lateral and anteroposterior diametar of upper tibial part.

RESULTS

The distance between the centre of attachment and medial edge is at 39% from entire latero-medial diametar, while the distance from anterior edge is at 31% from entire anterio-posterior diametar. The possitive correlation between the distance of centar of the anterior cruciate ligament from anterior and inner edge (r = 0.366, p) was found.

CONCLUSION

The center of the attachment of the ACL at anterior intercondylarl area is at 1/3 of antero-posterial diametar behind the anterior edge of the upper part of tibia and 2/5 of latero-medial diametar inside from the medial edge.

[Current trends in surgical treatment of radial nerve injuries associated with injuries of the humerus]

Radial nerve is the most common injured peripheral nerve after bone and wrist injuries in human body. Radial nerve can be injured by force causing fracture of the humeral shaft, due to compound fracture of the bone or by direct injury with small fragments of the bone. This happen in of cases and in remaining caseswas caused by manipulation during the treatment of the fracture of the humeral shaft. Because of the possibility of spontaneous recovery, indication and timing of surgical treatment of the radial nerve still remain controversial. There is contradictory approach in the treatment of the injured radial nerve. In a period betwen 1979 and 2005 year we have operated 193 patients with injury of radial nerve. Among them, 97 (50.2%) have had combined injury of the humeral shaft or proximal part of radius. Rest of injuries of the radial nerve were associated with manipulation during treatment. Surgical treatment has been performed in a period between three and four months after neurological deficit. Analysing our result regarding recovery of the motor function we have used combination of gradation including British Medical Council Score and modified Highet Scale to obtain satisfactory analysis of useful functional recovery of motor function after surgical procedure. We have classified results as bad M O-2 for all muscles innervated by the radial nerve; satisfactory M3, for extensors of the wrist and fingers and M O-2 for abductor of the thumb, good M 4-5 extensors of the wrist and fingers and M3 for abductor of the thumb, and excellent M 4-5 for all muscles.

[Influence of morphometric intercondylar notch parameters in ACL ruptures]

The most important anatomic risk factors in ACL lesions are the morphometric parameters of intercondylar notch. In the morphometric studies index of notch width and index of notch shape (NWI and NSI) are commonly used. The certain morphologic parameters of distal femoral part are used in calculation. Beside standard parameters we measured the maximal width of intercondylar notch and distal part of femur, which we used for calculation of maximal index of notch width and maximal index of notch shape (NWI max and NSI max). We compared two different methods of calculation of intercondylar notch indexes to find out which one represent anatomic risk factor and influence the ACL lesions. The indexes were measured in the two groups of patients (33) who have the history of knee injuries, the first group has document of ACL injuries and the second without ACL injuries (control one). The important difference between two groups was founded in NWI (p < 0.01) and NSI (p < 0.05). NWImax and NSImax do not show the difference (p > 0.05). The NWI and NSI importance is higher in males, and smaller in females. There is no difference in NWImax and NSImax (p > 0.05) comparing to the gender.

[Posterior femoral cortex perforation unrecognised during arthroscopic LCA reconstructive surgery]

One of the most important technical demands in ACL surgery is good fixation of the graft. Integrity of the posterior femoral cortex is necessary for Interference screws fixation. The femoral tunnel, placed as posterior as possible, is also mandatory for good graft position and potentially leads to violation of the cortex. The divergence between screw and tunnel could result in perforation of the posterior wall. Without intraoperative x-ray it is difficult to be sure that position of the screw is correct, even with good graft tension. Still, the problem exists with absorbable screws. The aim of the study is to show results of 6 patients with this complication treated without revision of the femoral fixation with mean follow up of 1.5 year. Potential pitfall in ACL reconstruction is posterior cortex breakout and loss of fixation. If it is recognized during surgery changing the type of fixation can solve the problem, but if not, in the early phase of rehabilitation and weight bear, graft failure is feasible. The tibia tunnel angle and length, the footprint of femoral tunnel reamer and hyper flexion of the knee during screw insertion are methods for preventing the breakout of the posterior wall and screw-tunnel divergence. Modification of the early postoperative treatment and less aggressive rehabilitation protocol reduced the need for revision surgery. Even with best surgical technique, skill and experience this complication is possible to occur.

[Massive hemorrhage and mechanisms of coagulopathy in trauma]

Trauma is disease of the young, mainly affecting people between 15-40 years of age. Uncontrolled massive bleeding is the leading cause of early in-hospital mortality, within 48h of admission, and the second leading cause of prehospital death in victims of both military and civilian trauma, accounting for 40-45% of the total fatalities. Coagulopathy develops early after injury and is present in 25-36% of trauma victims upon admission to the emergency department. Coagulopathy correlates to the severity of trauma and is associated with an increased risk of mortality. The aim of this paper is to explain pathophysiology of developing coagulopathy in trauma. The coagulopathy in the trauma patient is complex and multifactorial. It includes: dilutional coagulopathy, hypothermia, acidosis, hyperfibrinolysis, anemia and consumption coagulopathy. When the patient develops the so called "lethal triad" of hypothermia, acidosis and coagulopathy, surgical restoration of vascular integrity may be insufficient to achieve a deffinitive control of blood loss and non-mechanical bleeding from small vessels, usually terminated by spontaneous coagulation, becomes a life-threatening condition.

[Treatment of unreduced posterior dislocations of the shoulder]

Unreduced posterior dislocations of the shoulder are rare and difficult to treat. Treatment depends of defect of the humeral head. Since 1997 to 2002 eleven patients were referred to us for treatment unreduced posterior dislocations of shoulder with impressed fracture of the humeral head. Dislocations have lasted between two to eight months. All patients were treated with open reduction. Allograft reconstruction of the defect was used in six and hemiarthroplasty in two cases. As assessed with the scoring system of Constant, patients were rated excellent (9), satisfactory (1), unsatisfactory (1). Allograft reconstruction is the optimal choice for defects involving 20% to 45% of the humeral head. Prosthetic replacement is preferred for larger defects. Reconstruction of the defects involving less than 20% of the humeral head is not necessary. The observation is only ment to serve as a guide during decision making. The surgeon must make his own surgical choice based on the individual patient factors and on the intraoperative findings.

[Effect of resection of the lateral retinaculum of the knee in surgical treatment of symptomatic patello-femoral incongruency]

Biomechanical malfunction of the knee extensor mechanism in the patello femoral joint is regarded as patella malalignment but major patients complaints are anterior knee pain and patellar slipping. Lateral retinacular release is one of the basic surgical procedures in the treatment of patellar malalignment. The aim of the study was to estimate the achievements of the lateral retinacular release in solving particular biomechanical disorders of the patello femoral joint, as well as individual patients complaints. Evaluation of objective parameters x-ray and clinical findings before and after the operation, shows statistically highly significant difference, thus confirming implementation of the fore mentioned surgical procedure. Despite the fact that anterior knee pain subsided postoperatively in the number of patients, statistically significant values, comparing to the preoperative findings, could not be obtained. Incidence of the patellar slipping has shown statistically significant reduction two years following the surgery. Achieving proper biomechanical alignment of the patello femoral joint is obviously not sufficient to provide relief of subjective complaints, especially concerning anterior knee pain, although considerable improvements were registered in the number of patients.

Low back pain--differential diagnosis, prognosis and treatment

From January 2002 to February 2003, 137 patients complaining of low back pain were treated at the Institute for Orthopedic Surgery "Banjica", Belgrade, Serbia. There were 89 male and 48 female patients aged 13 to 77, mean age 42.2. Their condition was diagnosed through use of radiography, CT, MRI, EMNG, standard battery of neurological tests, and laboratory analyses (urine and blood analysis). Surgical treatment was performed on 39 patients; all other patients received some form of non-surgical care (physical therapy, medication or corset). Treatment efficacy was evaluated by use of the visual analog scales (VAS) and the Oswestry index, before and after treatment. The use Wilcoxon's pair test revealed statistically significant difference between before and after treatment data on VAS and Oswestry index for all patients.

[Arthroscopy of the hip--surgical treatment of synovial osteochondromatosis]

The hip arthroscopy is an efficient procedure in treatment of synovial chondromatosis in selected patients. The advantages compared to open procedures are lesser operative moribidity and faster postoperative recovery.

The treatment of infected diaphyseal femoral defects by lengthening one of the bone fragments by Ilizarov

We analyzed 30 patients with infected diaphyseal defect of femur, which have been treated by lengthening one of the bone fragments with Ilizarov apparatus. The mean length of the bone defect was 6 cm. Substitution of the defect, bone healing and elimination of the infection was achieved in 27 patients. The mean time of apparatus fixation was 10 months. According to Palley scoring system, 10 patients had excellent functional results.

[Minimal incision total hip joint arthroplasty]

"Minimaly-invasive" total joint arthroplasty have been widely introduced to the orthopaedic community several years ago. The concept has received a great attention and has been greeted variably with enthusiasm, concern, and skepticism. Numerous meetings, scientific exibits, symposia and congreses has been taking place all around the world. Whether this represents the future of orthopaedic surgery or just a fad, the term "minimaly-invasive" or "minimaly-incision" are yet to be clear and establish. Our intention is to present 72 of first 100 cases of total hip arthroplasty performed by "minimaly-incision" surgery. In our opinion first results are positve and we intend to continue with this kind of surgery.

Ucestalost ortopedskih povreda kod politraume

Trauma is one of the leading causes of mortality in the world. Traumatic injury has a significant impact on the patient, socially, functionally and financially. Orthopedic injuries are generally not life-threatening unless they result in significant hemodynamic instability. The outcome of the orthopedic injuries might lead to mild or severe disability and lost quality of life. Therefore, the orthopedic surgeon has significant role in treatment of trauma patient. In order to control and prevent traumatic injuries, to improve quality of trauma treatment and outcome, including the costs the National trauma registry is essential. The aim of the study was to collect the dates about the frequency of orthopedic injuries in polytraumatised patients who were treated in intensive care unit of Emergency Center of Serbia in last two years. There were significant number of orthopedic injuries (53,2%) in polytraumatised patients. The major cause of the injuries is traffic (78,6%) and most patients were between 30-50 years (30%).

[Anterior cruciate ligament reconstruction: comparison of male and female athletes using the patellar tendon and hamstring autografts]

Few authors have studied the effects of gender on the outcome of ACL reconstruction in athletes. This retrospective-prospective study compared the treating results using the patellar tendon (LP) and hamstring (StG) techniques in men and women. We followed 40 athletes (23 males, 17 females) from population of 120 patients operated at Institute for Orthopaedic Surgery Banjica. There were 13 males and 7 females in the LP group and 11 males and 9 females in the StG group. Patients were operated by the same surgeons within 6 month from injury and underwent the same rehabilitation program. After an average of 24 months they were assesed by clinical evaluation, knee laxity analysis and standard knee scores. Among LP patients there were no significant differences between males and females regarding knee evaluation form, laxity or functional tests. Females in the hamstring group had significantly grater laxity and significantly higher deficit in flexion and extension. We suggest further studies on the clinical significance of these findings, particularly on their ramifications of return to sports and rehabilitation of female athletes.

[Functional and radiographic results in partial unipolar hip joint arthroplasty after 6-15 years]

Due to extreme conditions during civil war in early 1990's we were forced to deviate from accepted guidelines in treatment of intracapsular fractures of the femoral neck. Therefore, majority of patients were treated non-operatively. In those that were subjected to surgery, unipolar hemiarthroplasty was treatment of choice, since conditions permitted us to attempt osteofixation in very few, youngest of our patients. As a result of this practice born of necessity, we can now look back and learn from this unique experience.

[Differences in the rehabilitation period following two methods of anterior cruciate ligament replacement: semitendinosus/gracilis tendon vs ligamentum patellae]

In this study we have analyzed outcome during the early rehabilitation period phase following two different methods of anterior cruciate ligament (ACL) reconstruction: ligamentum patellae (LP) and semitendonosus/gracilis tendon (SG) based reconstruction. This study included 40 patients treated by each method, examined 6 weeks and 3, 6 and 12 months after surgery. Patients in the SG group showed significantly better Lysholm scores at 6 and 12 months, Tegner Activity Scale scores at 3 months, and pain profile assessments at 6 weeks and 3 months than those in the LP group. Significant differences were observed in LP group in range-of-motion at 6 weeks and 3 and 6 months post-surgery. Stability tests revealed no significant differences between patients in the two groups. SG-based reconstruction of the ACL thus demonstrated advantages over LP-based reconstruction regarding pain and function, while LP-based reconstruction was associated with an earlier return of motion.

[Rigid-fix pins fixation and LCA reconstruction with semitendinosus/gracilis autograft]

ACL reconstruction techniques highly developed during the decades and biomechanical tests for hamstrings graft showed much in advance loading and stiffness comparing BPTB grafting. We have made joint analysis of 30 patients with semitendinosus / gracilis ACL reconstruction. Choice for proximal fixation was Mitek Rigid-fix Pins technique and bioactive screws for distal fixation; in 18 cases bioactive screws were used for femoral and tibial graft fixation. Lysholm score and knee clinical tests were parameters used for outcome evaluation. Follow up averaged 6 months with assessment after 1, 3, 6 and 12 months. Our results showed excellent postoperative Lysholm score in 85% and very good in 15% of cases. Postoperative Lachman was 1+ in 15% and postoperative pivot shift was 0%. Full rehabilitation achieved 85% and with modifications in everyday activities 15% of patients. Donor localization morbidity was markedly reduced and we have no complications. On the basis of the improved results in graft compression as well as stability with this technique, applied method is highly recommended for the reconstruction in ACL deficient knees.

[ACL reconstruction with BTB graft--unusual evolution of knee arthrofibrosis case report]

Knee arthrofibrosis, which usually occurs after trauma or surgery, can inhibit joint biomechanics. An elaborated interaction of growth factors and other inflammatory mediators initiates and coordinates this deleterious tissue proliferation. Knowledge of risk factors can aid clinicians in helping patients avoid knee arthrofibrosis. Once the condition is present, a history and examination are imperative to institute the most appropriate treatment regimen. Nonoperative measures can be used as therapy, though surgery is often necessary for optimal results. We have analyzed problems in patient with uncommon evolution of knee arthrofibrosis following ACL recontruction with BTB autograft.

Pregnancy is not associated with altered morphology of the femoral artery

While pregnancy is associated with adjustments in cardiovascular function, the morphology of the vascular system during pregnancy has been generally viewed as being very stable. However, recently we have demonstrated that pregnancy remodels the aorta and the carotid artery. In the present study, we assessed the morphological characteristics of the guinea-pig femoral artery during different stages of pregnancy using light and electron microscopy. There were no significant differences between external and internal diameters, wall thickness, total cross-sectional area and cross-sectional areas of lumen, intima, media, and adventitia of femoral arteries from non-pregnant and early-, mid- and late-pregnant guinea-pigs (n = 8-10). In previous studies, we have shown that the morphology of vascular smooth muscle and endothelial cells in the aorta and the carotid artery may be altered by pregnancy. Therefore, to test this possibility we measured diameters as well as cross-sectional areas of femoral arterial muscle and endothelial cells using electron microscopy. These parameters, at the electron microscopy level, were also not significantly changed by pregnancy (n = 8-10). It is concluded that the morphology of the guinea-pig femoral artery is not altered during pregnancy. In this regard, this study demonstrated that pregnancy-induced vascular remodelling varies between blood vessels that undergo the same functional alterations. Therefore, this may suggest that pregnancy-induced changes in blood flow through different vascular beds are not the most important factor involved in vascular remodelling observed during pregnancy. Rather, it is possible that haemodynamic-independent factors regulate pregnancy-mediated structural changes of the vascular wall.

Effect on neonatal oestrogen and hCG treatment on the genital organs of adult female rats

The ovaries and the uterine as well as vaginal mucous membranes of 80-, 180- and 365-day-old intact female rats and females neonatally treated with a single dose of oestrogen and repeated doses of human chorionic gonadotropin (hCG) were studied. Numerous follicles, interstitial cells and corpora lutea (CL) were present on the ovary of intact females from 80 up to 365 days of age. The number of primary and secondary follicles decreased in the intact female rats between Day 180 and Day 365 of life. On the ovaries of 180- and 365-day-old female rats neonatally treated with oestrogen, interstitial glandular cells and cystic follicles predominated. No CL were present on these ovaries. The height of epithelial cells of the uterine and vaginal mucous membranes increased in intact female rats from 80 to 365 days of age, whereas in oestrogen-treated females the height of epithelium decreased. From 80 up to 365 days of age, the height of epithelial cells of uterine and vaginal mucous membranes of rats neonatally treated with repeated doses of hCG was similar to that in the corresponding control animals.