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Introduction: Open lower leg fractures are the most common open fractures of the locomotor system and their treatment is associated with a number of complications., Objective: The aim of the paper was to present the results of the treatment of 68 patients with open lower leg fractures, as well as the complications that accompany the treatment of these fractures., Methods: In the analyzed group, there were 45 (66.18%) men and 23 (33.82%) women. The majority of patients – 33 (48.53%) of them – were injured in motor vehicle accidents, whereas 24 (35.29%) patients sustained injuries due to falls from heights. In two (2.94%) patients the cause of open tibial fractures was gunshot injuries. In the analyzed group, there were 18 (26.47%) type I open fractures, 21 (30.88%) type II open fractures, 19 (27.94%) type IIIA open fractures, seven (10.29%) type IIIB open fractures, and three (4.41%) type IIIC open fractures., Results: The tibial shaft fracture healed without serious complications in 50 (73.53%) patients, whereas in 18 (26.47%) patients we observed some complications. Nonunion was found in 10 (14.71%) patients, osteitis in four (5.88), malunion in two (2.94%) patients. Milder complications such as soft tissue pin tract infection developed in 13 (19.12%) patients, infection of the open fracture wound soft tissue was observed in four (5.88%) patients., Conclusion: Basic principles in the treatment of open lower leg fractures in this study are thorough primary open fracture wound treatment followed by the delayed wound closure, stable fracture fixation using unilateral external skeletal device, proper antibiotic treatment and tetanus prophylaxis. The results correlate with similar studies.

Introduction: Tibia fracture caused by high velocity missiles is mostly comminuted and followed by bone defect which makes their healing process extremely difficult and prone to numerous complications., Case Outline: A 34-year-old male was wounded at close range by a semi-automatic gun missile. He was wounded in the distal area of the left tibia and suffered a massive defect of the bone and soft tissue. After the primary treatment of the wound, the fracture was stabilized with an external fixator type Mitkovic, with convergent orientation of the pins. The wound in the medial region of the tibia was closed with the secondary stitch, whereas the wound in the lateral area was closed with the skin transplant after Thiersch. Due to massive bone defect in the area of the rifle-missile wound six months after injury, a medical team placed a reconstructive external skeletal fixator type Mitkovic and performed corticotomy in the proximal metaphyseal area of the tibia. By the method of bone transport (distractive osteogenesis), the bone defect of the tibia was replaced. After the fracture healing seven months from the secondary surgery, the fixator was removed and the patient was referred to physical therapy., Conclusion: Surgical treatment of wounds, external fixation, performing necessary debridement, adequate antibiotic treatment and soft and bone tissue reconstruction are essential in achieving good results in patients with the open tibial fracture with bone defect caused by high velocity missiles. Reconstruction of bone defect can be successfully treated by reconstructive external fixator Mitkovic.

Background: Large defects of the abdominal wall caused by incisional hernia still represent a challenging problem in plastic, reconstructive, and abdominal surgery. For their successful tension-free repair a proper selection of reconstructive material is essential. In the last decades, the use of synthetic meshes was dominant while biological autodermal grafts were rarely used. The aim of the study was to comparatively analyse efficacy and safety of autodermal graft and polypropylene mesh in surgical treatment of large abdominal wall defects., Methods: This prospective comparative clinical study enroled 40 patients surgically treated for large incisional hernia repair in a 10-year period. The patients were divided into two equal groups consisting of 20 subjects and treated either by biological autodermal graft or by synthetic polypropylene mesh. The surgical techniques of reconstruction, duration of surgery, the occurrence of early, minor, and major (severe) and delyed complications and hospital stay were analysed. The average follow-up took 2 years., Results: Statistically significant differences in demographic characteristics of patients and in size of defects were not found. The surgical technique of reconstruction with an autodermal graft was more complicated. The duration of surgery in patients treated with autodermal grafts was significantly longer. There was no statistically significant difference regarding occurrence of early, minor postoperative complications and hospital stay in our study. Two severe complications were registered in the synthetic mesh group: intestinal obstruction and enterocutaneous fistula. The recurrence rate was 10% in the autodermal graft group and 15% in the group with a synthetic mesh., Conclusion: Tension-free repair of large incisional hernia with autodermal grafts was unjustly neglected despite the fact that it is safe and effective. It can be applied in all cases where synthetic mesh are not indicated (presence of infection, immunodeficient patients, after radiotherapy). They are especially important in war surgery and in lack of funds when commercial grafts cannot be purchased.

Introduction: Open segmental fractures of the tibia are rare but severe injuries. In these fractures the wide zone of injury (damage of all structures of the lower leg) creates very unsuitable biological conditions for healing of the fracture., Objective: The aim of our work was to present the results of treatment of patients with segmental open fractures of the tibia treated by external fixation., Methods: We analyzed treatment results of 21 patients with open segmental tibial fractures who were treated using the method of external fixation at the Clinical Center Nis from January 1, 1995 to July 31, 2010. The average age of the patients was 53 years; the youngest patient was 27 years and the oldest one 80 years. According to the Gustilo open fracture classification, there were 3 (14.3%) type 1, 6 (28.6%) type 11, 8 (38.1%) type IIIA, and 4 (19.0%) type IIIB. All the patients were treated by a unilateral type Mitković external fixator by Traffix Company., Results: Union was attained in 16 (76.2%) fractures without severe complications (pseudoarthrosis, chronic osteitis and angular deformities of over 10 degrees). Among severe complications associated with open segmental tibial fractures, in two cases we registered septic pseudoarthrosis, in one aseptic pseudoarthrosis and in two large angular deformities of the tibia after union, with a valgus of over 10 degrees and extremity shortening of over 2 cm which required additional surgery., Conclusion: External fixation by the use of Mitković external fixator is one of the methods of choice in the treatment of open segmental tibial fractures, which incorporated with antibiotic therapy provides good biomehanical conditions for segmental fracture healing that enables good stability of the segmental tibial fracture and decreases the risk of deep infections.

Introduction: The missiles of modern firearms can cause severe fractures of the extremity. High velocity missile fractures of the tibia are characterized by massive tissue destruction and primary contamination with polymorphic bacteria. Treatment of these fractures is often complicated by delayed healing, poor position healing, nonhealing and bone tissue infection., Case Outline: We present the management of tibial nonunion after wounding by high velocity missile and primary treatment by external fixation in a 25-year-old patient. The patient was primarily treated with external fixation and reconstructive operations of the soft tissue without union of the fracture. Seven months after injury we placed a compression-distraction external fixator type Mitkovic and started with compression and distraction in the fracture focus after osteotomy of the fibula and autospongioplasty. We recorded satisfactory fracture healing and good functional outcome., Conclusion: Contamination and devitalization of the soft-tissue envelope increase the risk of infection and nonunion in fractures after wounding by high velocity missile. The use of the compression-distraction external fixator type Mitkovic may be an effective method in nonunions of the tibia after this kind of injury.

Introduction: Shooting injuries of shoulder with destruction of proximal humerus are rare and severe orthopaedic injuries., Case Outline: A 74-year-old patient was wounded at close range by a shotgun. He was wounded in the left shoulder and suffered a massive defect of the proximal humerus and soft tissue. The neurocirculatory finding of the injury extremity was normal. After a short resuscitation, x-ray of the thorax and the left shoulder registered a complete destruction of humeral head. After the primary treatment of the wound under general endotracheal anesthesia, the shoulder was stabilized with an external fixator type Mitkovic, with convergent orientation of the pins, where two pins were placed in the neck of scapula and two in the humeral shaft, because the left scapular acromion was fractured by shotgun projectiles., Conclusion: After radical wound debridement, external fixation is the method of choice for shoulder stabilisation in shooting injury of shoulder with bone defect. If this is not possible, pins of the left external skeletal fixator should be placed into the coracoid process and acromion. The pins can be also placed into the humeral shaft, as done in the presented case, and by which a good stability of the injured proximal humerus, easy approach to the wound for bandaging and reconstructive surgery can be achieved.

Introduction: Injuries caused by aircraft bombs cause severe damages to the human body. They are characterized by massive destruction of injured tissues and organs, primary contamination by polymorph bacterial flora and modified reactivity of the body. Upon being wounded by aircraft bombs projectiles a victim simultaneously sustains severe damages of many organs and organ systems due to the fact that a large number of projectiles at the same time injure the chest, stomach, head and extremities., Case Report: We presented a patient, 41 years of age, injured by aircraft bomb with hemo-pneumothorax and destruction of the bone and soft tissue structures of the foot, as well as the treatment result of such heavy injuries. After receiving thoracocentesis and short reanimation, the patient underwent surgical procedure. The team performed thoracotomy, primary treatment of the wound and atypical resection of the left lung. Thoracic drains were placed. The wounds on the lower leg and feet were treated primarily. Due to massive destruction of bone tissue of the right foot by cluster bomb splinters, and impossibility of reconstruction of the foot, guillotine amputation of the right lower leg was performed. Twelve days after the wounding caused by cluster bomb splinters, soft tissue of the left lower leg was covered by Tirsch free transplant and the defect in the area of the left foot was covered by dorsalis pedis flap. The transplant and flap were accepted and the donor sites were epithelized. Twenty-six days following the wounding reamputation was performed and amputation stump of the right lower leg was closed. The patient was given a lower leg prosthesis with which he could move., Conclusion: Upon being wounded by aircraft bomb splinters, the injured person sustains severe wounds of multiple organs and organ systems due to simultaneous injuries caused by a large number of projectiles. It is necessary to take care of the vital organs first because they directly threaten the life of the wounded patient. Despite adequate surgical treatment of war wounds of the feet, because of massive defect of bone and soft tissue, amputation may be the only rational solution of the treatment. The resection of the lung may be succesfull method for the severe destruction of the lung.

Introduction: Aircraft bombs can cause severe orthopaedic injuries. Tibia shaft fractures caused by aircraft bombs are mostly comminuted and followed by bone defects, which makes the healing process extremely difficult and prone to numerous complications. The goal of this paper is to present the method of treatment and the end results of treatment of a serious open tibial fracture with soft and bone tissue defects resulting from aircraft bomb shrapnel wounds., Case Outline: A 26-year-old patient presented with a tibial fracture as the result of a cluster bomb shrapnel wound. He was treated applying the method of external bone fixation done two days after wounding, as well as of early coverage of the lower leg soft tissue defects done on the tenth day after the external fixation of the fracture. The external fixator was removed after five months, whereas the treatment was continued by means of functional plaster cast for another two months. The final functional result was good., Conclusion: Radical wound debridement, external bone fixation of the fracture, and early reconstruction of any soft tissue and bone defects are the main elements of the treatment of serious fractures.

Background/aim: Soft tissue defects of the lower leg, especially in its distal third, still remain a challenging problem in reconstructive surgery. The aim of this study was to examine septocutaneous system of lower leg vascularization, quantitatively and qualitatively, which is the basis of fasciocutaneous and neurocutaneous flaps., Methods: Septocutaneous systems a. tibialis posterior and a. peroneae were examined by anatomical suprafascial lower leg microdissection of 40 fresh cadavers. Septocutaneous perforators located intermusculary, in deep crural fascia duplicature, were followed from its origin (at main arterial trunks of the lower leg) till the point they reach the deep crural fascia. The number and localization of emergence of the septocutaneous perforators were examined for both above mentioned arterial trunks, and the obtained data were documented by photographs, tables and graphics. Statistical analysis (especially cluster analysis), was used for establishing reliable septocutaneous perforators levels., Results: Septocutaneous perforator systems of the lower leg have constant and reliable pattern of existance. Lower leg length was 36 cm in average, (between 33 and 43 cm). Lower leg was divided in 10 equal segments, 3.6 cm each. A. tibialis posterior and a. peronea had 5 septocutaneous perforators. Cluster analysis of a. tibialis posterior perforators (with diameter > or = 0.5 mm), discovered 5 reliable levels of septocutaneous perforators. These levels are at 3.6-10.8 cm; 14.4--21.6 cm and 25.2-28.8 cm. For a. peronea reliable perforators were found at 3.6-10.8 cm, 14.4--18 cm and 21.6-25.2 cm. Posterior tibial artery perforators had the greatest diameter (from 0.5-1.8 mm; mean value 1.14 mm and SD = 0.26 mm). A mean diameter for peroneal artery perforators was 0.9 mm. Conclusion. Existance of reliable levels of septocutaneous perforators of the lower leg enables and makes reconstruction of the soft tissue defects of the lower leg, especially its distal third and foot, much easier.

Introduction: In pernicious anemia besides the presence of megaloblasts in the bone marrow, changes in myeloid series were seen; being the most evident among the metamyelocyte. The aim of this study was to perform the quantification of metamyelocyte of the bone marrow in pernicious anemia., Material and Methods: Between 2000-2006 in the Clinic of Hematology-Nis, 68 patients with pernicious anemia were examined and 30 with dyspeptic syndrome (control group). The group of patients with pernicious anemia in relation to pathohistologic changes of gastric mucosa was divided into three sub-groups. Morphometrical analysis of metamyelocyte of the bone marrow was carried out by the application of the double netlike system (B100). The following parameters were used: relative surface, contour length, absolute surface of nucleus and cytoplasm, absolute contour nucleus and cytoplasm density, shaped nucleus and cytoplasmic factor and nuclear-cytoplasmatic ratio of metamyelocytes., Results: Relative surface, contour length, absolute surface and contour density of nucleus and cytoplasm of metamyelocytes increased simultaneously with the degree of atrophic gastritis. Shaped nucleus and cytoplasmic factor and nuclear-cytoplasmatic ratio of metamyelocytes decreased in all examined groups in relation to the control group., Conclusion: Not only are bone marrow erythroid elements scoped with megaloblastic changes but the changes on the level of leukocyte cells as well. The result of this is the phenomena of giant metamyelocytes.

Introduction: Polytrauma remains a major social, economic and medicine affliction. A successful surgical treatment of polytrauma patients requires an approach predicated on prioritizing injuries. An isolated femur fractures rarely poses any threat but in association with multiple injuries, this fracture assumes greater significance. The proper management of femur fractures in polytrauma can greatly reduce the mortality and morbidity., Material and Methods: We present our results in the treatment of 24 femur shaft fracture in 22 polytrauma patients treated by Mitkovic external fixator in 5 year period (2000-2004) on Orthopeadic and Traumatology Clinic--Clinical Center Nis. The average of patients age was 32.8 years (ranging from 17 to 62). There were 11 (46%) closed and 13 (54%) open fractures., Results: Eighteen fractures were treated by external fixation until union. The remaining six fractures were treated by conversion of the external fixation to internal fixation. Sixteen fractures (88.88%), in which the external fixation was the definitive method of treatment, healed completely. The average healing time was 6.29 (4-9) months. There were three pin-track infections (16.66%), one nonunion (5.55%) and only one deep infection (5.55%)., Conclusion: The external fixation by the use of Mitkovic external fixator in the treatment of femur fractures is a safe procedure to achieve temporary rigid stabilisation in polytrauma patients before the subsequent internal fixation (damage control orthopaedics). The external fixation using Mitkovic external fixator can be definitive method of choice in treatment of open and comminutive femur fractures in polytrauma patients until union.

Background/aim: Besides the conquasant fractures, open tibia shaft fractures belong to the group of the most severe fractures of tibia. Open tibia shaft fracture is one of the most common open fractures of long bones. They most frequently occur as a result of traffic accidents caused by the influence of a strong direct force., Methods: Within the period from January, 2000 to December 31, 2005 at the Clinic for Orthopaedics and Traumatology, Clinical Center Nis, 107 patients with open tibial fractures were treated. We analyzed 96 patients with open tibial fracture. In the series analyzed, the male sex was prevalent--there were 74 men (77.08%). The mean age was 47.3 years. The youngest patient was 17 years old, while the oldest patient was 79. According to the classification of the Gustilo et al. in the analysed group there were 30 (31.25%) open tibial fractures of the I degree, 31 (32.29%) of the II degree, 25 (26.05%) of the III A degree, 8 (8.33%) of the III B degree and 2 (2.08%) of the III C degree. In 95 of the patients the treatment of open tibia shaft fractures consisted of the surgical treatment of wound and the external fixation of the fractured bone using "Mitkovic" type external fixator with a convergent method of pin applications. One primary amputations had been done in patients with grade IIIC open tibial fracture with large soft tissue defect., Results: Of the 96 open tibial fractures available for follow-up, 73 (76.04%) healed without severe complications (osteitis, pseudoarthrosis, valgus malunion and amputation). There were nine (9.38%) soft tissue pin track infections and six (6.25%) superficial wound infections. The mean time of union was 21 (14-36) week. Among severe local complications associated with open tibial fractures, in eight patients (8.33%) was registered osteitis, and in nine patients (9.38%) fracture nonunion and the development of pseudoarthrosis. Three of the patients (3.13%) had more than 10 degree valgus malunion. In one patients (1.04%) deep pin track infection developed. Two patients (2.08%) had below the knee amputation (one primary in patient with type III C open fracture and one secondary after the development of deep infections)., Conclusion: Surgical treatment of wounds, external fixation, leaving the wounds open and performing necessary debridements, adequate drug therapy administration are essential for obtaining good results in patients with open tibial shaft fractures.

Background/aim: Autoimmune atrophic fundic gastritis induces the pernicious anemia (PA), as well as the changes in both epithelium and endocrine cells of gastric mucosa. The most important complications are: achlorhydria, hypergastrinemia, gastric cancer and enterochromaffin-like (ECL) carcinoid. The aim of this study was to examine ECL carcinoid histogenesis in A-gastritis associated with PA., Methods: During the period from 2000-2006, 65 patients with PA and 30 patients of the control group were examined. Histopathological examination was done in endoscopical biopsies of gastric mucosa fixed in 10% formaldehyde. Paraffin sections were stained with classic hematoxylin-eosin (HE); histochemical AB-PAS (pH 2.5), cytochemical argyrophilic Servier-Munger's and immunocytochemical PAP methods for G cell identification and chromogranin A antibodies - specific marker for neuroendocrine ECL cells. Both G and ECL cells were counted per 20 fields, of surface 0.0245312 mm2 by a field. Basal gastrin serum levels were also examined by using radioimmunoassay (RIA) method. The obtained results were statisticaly calculated by using Student's t test., Results: Marked antral G cell hyperplasia associated with corporal ECL hyperplasia was found. ECL cell hyperplasia was of simplex, linear, adenomatoid type to the pattern of intramucous ECL cell carcinoid. An average number of G cells was statistically significant in the patients with PA as compared to the control group (p < 0.05) as well as an average number of ECL cells., Conclusion: We concluded that antral G cell hyperplasia accompanied by gastrinemia induces ECL hyperplasia and ECL corporal carcinoid in A-gastritis and that their histogenesis develops trough simple, linear and adenomatoide hyperplasia.

Introduction: Trochanteric fractures are extracapsular fractures of the proximal femur. The increasing number of trochanteric fractures is a great sociomedical problem. These fractures usually occur in elderly people (older than 65 years) with osteoporosis. Lateral and frontal falls are the most frequent cause of trochanteric fractures in the elderly. The aim of this paper is to present our results of applying the Mitković selfdynamisable internal fixator (SIF)., Material and Methods: From January 2001 to December 2005, 238 patients with trochanteric femoral fractures were treated operatively using the Mitković selfdynamisable internal fixator at the Clinic of Orthopeadics and Traumatology in Nis. The average patient age was 69, 11 years (range 17 to 88). In the analyzed group there were 152 (64%) female and 86 (36%) male patients, whereas patients in the eighth 101 (43%) and seventh 65 (27%) decade of life prevailed., Results: Excellent results in the treatment of trochanteric femoral fractures with a Mitković dynamic internal fixator were achieved in 143 (60%) patients, good in 49 (21%) patients, poor in 41 (17%) and unsatisfactory in 5 (2%) patients., Discussion and Conclusion: The treatment of trochanteric fractures may be operative and nonoperative. The aim of the operative treatment, considered to be the "gold standard" for these fractures, is to restore the patient's pretraumatic activity level and to reduce life-threatening complications. The operative stabilization is performed using various types of implants. Surgical treatment by using dynamic implants is a method of choice in the treatment of trochanteric fractures. Internal fixation using the Mitković selfdynamisable internal fixator is a method of choice in the treatment of trochanteric femoral fractures, providing dynamization and compression of the fracture site in two axes (axis of the femoral neck and femoral diaphyseal axis) and balanced biomechanical 3D.

Background/aim: Intraarticular fractures of the tibial plafond (pilon fractures) belong to the group of most severe fractures. They are usually caused by high-energy trauma and frequently associated with a marked soft-tissue damage. Surgical treatment has replaced the traditional nonoperative treatment. The aim of this study was to present the results of the treatment of distal tibial intraarticular fracture by the use of internal fixation, as well as the combination of minimal internal fixation and external fixation., Methods: The study included 47 patients with pilon tibia fractures who went through at the Clinic for Orthopedics and Traumatology, School of Medicine, Nis (1995-2004). Within the analayzed group there were 33 (70.2%) males and 14 (29.8%) females. The patients mean age was 45.8 years. In the first group, which consisted of 22 patients, open reduction and internal fixation of both the tibia and the fibula was performed in the two separate incisions. The second group consisted of 25 patients managed with external fixation by external fixator "Mitković" with limited internal fixation. Besides external fixation, a minimal internal fixation was performed by the use of Kirschner wires and screws. The patients were followed-up inside a 24-months-period. Results. The obtained was a substantially high number of complications after open reduction and internal fixation in the group of patients. There was no difference in a long-term clinical outcome. Postoperative osteitis, as the most severe complication in the management of closed pilon tibia fractures, was not registered in the second group., Conclusion: Considering the results obtained in this study, it can be concluded that external fixation by the "Mitković" external fixator with the minimal internal fixation is a satisfactory method for the tratment of fractures of the tibial plafond causing less complications than internal fixation.

Whether laparoscopic appendectomy is superior to open appendectomy for simple and perforated appendicitis in children is still debatable. To answer this question, surgical experience of three experienced pediatric surgeons in a single institution was studied during one year in all cases of laparoscopic appendectomy. From January 2003 to January 2004, all laparoscopic appendectomies were reviewed for operative technique, advantages, disadvantages, operative time and length of stay. There were 44 laparoscopic appendectomies in children aged 4 to 19 years. Operating time dropped from 52 minutes at the beginning to less than 25 minutes at the end of year. Operating time in perforated appendicitis was slightly longer, from 58-65 minutes. Length of stay was 1-2 days for simple cases, and maximum 5 days for perforated ones. There were no postoperative complications such as abscess, bowel obstruction, bleeding, wound infection or mortality. Laparoscopic appendectomy is at least as safe and effective, if not superior to, as open appendectomy for both, simple and perforated appendicitis. Postoperative pain is less, and recovery is faster. Laparoscopic appendectomy is our procedure of choice in pediatric surgery.

Neutropenic enterocolitis (NE) is an unusual acute complication of neutropenia, associated with leukemia and lymphoma. It has been observed mainly in the first phase of therapy when drugs are used in maximally tolerated dose. This is a case report of neutropenic enterocolitis in a patient with acute lymphoblast leukemia who received prednisone, vincristine, daunorubicin and L-asparaginase, with perforation of cecal and terminal ileum. Perforation and defect intestine wall was excised and sutured directly in two layers. Protective proximal loop ileostomy was performed at that time.

From January 2003 to January 2004, laparoscopy was performed in 100 cases, aged from 10 months to 19 years. Diagnostic laparoscopy was applied in 39 patients, most often in nonpalpable testes (29), ovarian cysts (4), abdominal trauma (1), abdominal cysts (2) and intersex states (3). Ninety patients underwent operative laparoscopy: appendectomy (44), orchiopexy (2), orchiectomy (1), herniorrhaphy (1), varicocelectomy (8), adnexectomy (2), cholecystectomy (8), Fowler-Stephens procedure (1), abdominal cysts (2), ovarian cystectomy (6), subdiaphragmatic abscess (1), adhesiotomy (11), liver cysts (2) and splenectomy (1). Diagnostic laparoscopy has proved to be more reliable and less invasive method in comparison to previously used methods. Our conclusion is that operative laparoscopy has many advantages compared with some of the classical surgical procedures.

The use of fasciocutaneous flaps for the reconstruction of lower leg soft-tissue defects inflicted during the bombing of our country is presented in this case report. The experience with 9 patients with soft-tissue defects of the lower leg is presented with the aim of examining the possibilities of war-wound reconstruction. The results of the earlier use of fasciocutaneous flaps in the lower leg reconstruction as well as the those obtained during the reconstruction of the lower leg soft-tissue defects in war wounds was proven to be safe and reliable method of the reconstructions of severe lower leg injuries, particularly of its distal segment and the malleolus region.