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BACKGROUND Heparin-induced thrombocytopenia (HIT) is a disease in which the immune response elicited by heparin results in a state of hypercoagulability and platelet activation, leading to thrombocytopenia and thromboembolism. Gustilo-Anderson type IIIC open fractures of the extremities are defined as open fractures presenting with arterial injuries that require repair and result in treatment challenges and complications. The diagnosis of HIT can be difficult in patients with severe trauma with consumptive thrombocytopenia associated with heavy bleeding and the use of heparin after vascular anastomosis. CASE REPORT A 48-year-old man was injured in a car accident, pinching his right lower leg and sustaining a Gustilo-Anderson type IIIc open fracture, for which he underwent emergency revascularization surgery. Heparin was administered continuously immediately after the surgery. On postoperative day 9, ischemic changes were observed in the right foot, and we performed suture re-anastomosis; however, the blood circulation in the right lower leg did not resume, and right lower leg amputation was performed due to ischemic necrosis with the onset of HIT. Postoperatively, the patient was switched to edoxaban after the recovery of his platelet count. Thereafter, the patient experienced no new thrombus occlusion or wound trouble, and was able to walk on a prosthetic leg and return to daily life. CONCLUSIONS It is important to consider the possibility of HIT as soon as thrombocytopenia appears in patients with Gustilo-Anderson type IIIC open fracture who are receiving heparin after vascular anastomosis, as a delayed diagnosis of HIT can make it difficult to save the limb.

Objective: Diagnostic/therapeutic accidents Background: Heparin-induced thrombocytopenia (HIT) is a disease in which the immune response elicited by heparin results in a state of hypercoagulability and platelet activation, leading to thrombocytopenia and thromboembolism. Gustilo-Anderson type IIIC open fractures of the extremities are defined as open fractures presenting with arterial injuries that require repair and result in treatment challenges and complications. The diagnosis of HIT can be difficult in patients with severe trauma with consumptive thrombocytopenia associated with heavy bleeding and the use of heparin after vascular anastomosis. Case Report: A 48-year-old man was injured in a car accident, pinching his right lower leg and sustaining a Gustilo-Anderson type IIIc open fracture, for which he underwent emergency revascularization surgery. Heparin was administered continuously immediately after the surgery. On postoperative day 9, ischemic changes were observed in the right foot, and we performed suture re-anastomosis; however, the blood circulation in the right lower leg did not resume, and right lower leg amputation was performed due to ischemic necrosis with the onset of HIT. Postoperatively, the patient was switched to edoxaban after the recovery of his platelet count. Thereafter, the patient experienced no new thrombus occlusion or wound trouble, and was able to walk on a prosthetic leg and return to daily life. Conclusions: It is important to consider the possibility of HIT as soon as thrombocytopenia appears in patients with Gustilo- Anderson type IIIC open fracture who are receiving heparin after vascular anastomosis, as a delayed diagnosis of HIT can make it difficult to save the limb. [ABSTRACT FROM AUTHOR]

We present a 71-year old patient admitted to Plastic and Reconstructive Surgery Clinic, Clinical Center Niš for the right leg conquasation. The patient was injured accidentally by a petrol tiller. On admission, both thigh and lower leg conquasation was observed with large wound on anteromedial thigh and one on medial side of the lower leg. Soft tissue and bones were covered with dirt and pieces of clothing. The wounds were thoroughly rinsed and dirt was removed followed by detailed debridement. After primary surgical treatment of the wound, open proximal lower leg fracture was stabilized with external skeletal fixation using two nails in the proximal and two nails in the distal fragment. Soft tissue defect was treated by plastic surgeon. The patient was administered anti-tetanus protection, antibiotic treatment and anticoagulant prophylaxis of deep vein thrombosis and pulmonary thromboembolism. Physical therapy was initiated subsequent to successful healing of the soft tissue wounds. External skeletal fixation was removed after three months for infection around the proximal nails and the treatment was contuinued using functional Sarmiento’s plaster imobilization leading to full recovery of open lower leg fracture.

Open lower-leg fractures are usually associated with broken skin and soft tissue damages. The main aim is to establish results of surgical medical treatment of open fractures with external fixation. The patients with open lower-leg fraction were immediately after the admission to hospital primarily surgically treated and then underwent the blood reposition and external fixation. External fixation was applied from 4 to 8 weeks and after it was taken off, a PTB cast was applied until the fracture healed. 56 (45,16%) patients with open lower-leg fracture, out of total 124 injured were treated in this way. After a four-month treatment, we had 8 (14,29%) pseudoarthroses (false joints) of the lower- leg and 48 (85,71%) regularly healed fractures which was established clinically and radiologically. Pseudoarthroses were treated with surgical osteotomy of fibula and then with application of PTB cast, after that were healed regularly. After rehabilitation, all patients had a satisfactory function of knee and ankle joint -- movement amplitudes were within the optimum value limits. Based on results of medical treatment of open lower-leg fractures in a described way, the same may be recommended as a standard one. [ABSTRACT FROM AUTHOR]

Background: It is known that outcomes after injury care in low-and-middle income countries (LMICs) are poorer than those in high income countries. However, little is known about healthcare provider competency to deliver quality injury care in these settings. We developed and used clinical vignettes to evaluate injury care quality in an LMIC setting.Method: Four serious injury scenarios, developed from agreed best practice, testing diagnostic and management skills, were piloted with high and low-income setting clinicians. Scenarios were used with primary and referral facility clinicians in Malawi. Participants described their clinical course of action (assessment, diagnostic, treatment and management approaches) for each scenario, registering one point per agreed best practice response. Mean percentage total scores were calculated and univariable and multivariable comparison made across provider groups, facility types, injury care frequency and training level.Results: Fourteen Doctors, 51 Clinical Officers, 20 Medical Assistants from 11 facilities participated. Mean percentage total vignette scores varied significantly with clinician provider group (Doctors 63.1% vs Clinical Officers 49.6%, p<0.001, Clinical Officers vs Medical Assistants 39.4% p=0.001). Important care aspects most frequently included or omitted were: following chest injury, 88.2% reported chest drain insertion, 7.1% checked for tracheal deviation; following penetrating abdominal injury and shock, 98.8% secured IV access, 0% mentioned tranexamic acid; following severe head injury, 88.2% proposed CT or neurosurgical transfer, 7.1% ensured normotension; and following isolated open lower leg fracture, 90.1% arranged orthopaedic consultation, 2.4% assessed distal neurological status.Conclusion: These clinical vignettes proved easy to use and collected rich data. This supports their use for assessing and monitoring clinical care quality in other similar settings. [ABSTRACT FROM AUTHOR]

The infection rate of open lower leg fracture is extremely high. Surgical treatment guarantees a reduced risk of infection when compared with conservative treatments. But even osteosynthetic methods such as screw or compression plate fixation show unsatisfactory results because of the additional traumatization of the primarily injured soft tissue combined with a reduction of blood circulation. From July 1973 till September 1976 we treated 57 2nd and 3rd degree open shank fractures with osteosynthetic methods: 46 with compression plate osteosynthesis and 11 primarily or secondarily with external fixation. The osteitis-rate was 14%, in addition to that there was a soft-tissue infection rate of 5%. In order to change our therapeutical procedure we stabilized 2nd and 3rd degree open lower limb fractures and lower leg fractures complicated by soft-tissue damages consequently by external fixation. From October 1976 till May 1978 we treated 39 open shank fractures; 25 of them were 2nd and 3rd degree open fractures. They were treated by external fixation. This change in our surgical treatment resulted in an osteitis-rate of 2.6%, there was no case of soft-tissue inflammation. These results underline the superiority of treating 2nd and 3rd degree open lower leg fractures and fractures combined with soft-tissue injuries consequently and chiefly with AO external fixation. [ABSTRACT FROM AUTHOR]

Copyright of Timocki Medicinski Glasnik is the property of Timocki Medicinski Glasnik and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Septic nonunion of the pilon region with ankle joint infection is challenging for orthopedic surgeons to treat and is associated with a high risk of limb loss. Therefore, the aim of this study was to evaluate the effectiveness of bone transport for ankle arthrodesis in salvaging the limp after septic ankle destruction of the pilon region. We conducted a single-center, retrospective study including 21 patients treated for septic pilon nonunion with accompanying septic ankle destruction via Ilizarov bone transport between 2004 and 2018. In all cases, the complete excision of the nonunion and the resection of the ankle joint were carried out, followed by treating the bone and joint defect with a bone transport into the ankle arthrodesis. In 12/21 patients an additional flap transfer was required due to an accompanying soft tissue lesion. The overall healing and failure rate, final alignment and complications were recorded by the patients' medical files. The bone-related and functional results were evaluated according to the Association for the Study and Application of Methods of Ilizarov (ASAMI) scoring system and a modified American Orthopedic Foot and Ankle Society (AOFAS) scale. After a mean follow-up of 30.9 ± 15.7 months (range 12–63 months), complete bone and soft tissue healing occurred in 18/21 patients (85.7%). The patients had excellent (5), good (7), fair (4), and poor (3) results based on the ASAMI functional score. Regarding bone stock, 6 patients had excellent, 7 good, and 6 fair results. The modified AOFAS score reached 60.6 ± 18 points (range, 29–86). In total, 33 minor complications and 28 major complications occurred during the study period. In 2 cases, a proximal lower leg amputation was performed due to a persistent infection and free flap necrosis with a large soft tissue defect, whereas in one case, persistent nonunion on the docking side was treated with a carbon orthosis because the patient refused to undergo an additional surgery. Bone transport for ankle arthrodesis offers the possibility of limb salvage after septic ankle destruction of the pilon region, with acceptable bony and functional results. However, a high number of complications and surgical revisions are associated with the treatment of this severe complication after pilon fracture. [ABSTRACT FROM AUTHOR]

Critical-size bone defects after compound fractures, infection, or tumor resection are challenging to treat. The same is true for fractures in patients with impaired bone healing due to metabolic diseases and cancer. Despite considerable progress over the last decade in surgical techniques, material design, and dedicated imaging approaches, these scenarios represent unsolved clinical problems. The high socioeconomic burden of such conditions justifies increasing interest in novel osteoinductive drugs for adjuvant therapeutic approaches. There is an increasing body of experimental and clinical literature on potentially promising effects of growth factors, anti-resorptive, and anabolic agents. The true clinical efficacy of these, however, is discussed controversially. Therefore, we aimed to critically examine the hypothesis that targeted adjuvant therapies have the potential to enhance bone regeneration in critical-size bone defects and under systemic conditions that impair bone healing. This first approach to the topic deals with small molecule drugs and compounds that influence the immune response and inflammatory processes. In particular, literature reporting on selective cyclooxygenase-2 inhibitors has been reviewed with respect to their local and systemic mode of action and to stimulate further research on bone healing under critical conditions. [ABSTRACT FROM AUTHOR]

Copyright of Acta Medica Medianae is the property of Acta Medica Medianae and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Acta Facultatis Medicae Naissensis is the property of Nis University, Faculty of Medicine and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background: The care of severely injured patients remains a challenge. Their initial treatment in the emergency room is the essential link between first aid in the field and definitive in-hospital treatment. Methods: We present important elements of the initial in-hospital care of severely injured patients on the basis of pertinent publications retrieved by a selective search in PubMed and the current German S3 guideline on the care of severely and multiply traumatized patients, which was last updated in 2016. Results: The goal of initial emergency room care is the rapid recognition and prompt treatment of acutely life-threatening injuries in the order of their priority. The initial assessment includes physical examination and ultrasonography according to the FAST concept (Focused Assessment with Sonography in Trauma) for the recognition of intraperitoneal hemorrhage. Patients with penetrating chest injuries, massive hematothorax, and/or severe injuries of the heart and lungs undergo emergency thoracotomy; those with signs of hollow viscus perforation undergo emergency laparotomy. If the patient is hemo- dynamically stable, the most important diagnostic procedure that must be performed is computerized tomography with contrast medium. Therapeutic decision-making takes the patient's physiological parameters into account, along with the overall severity of trauma and the complexity of the individual injuries. Depending on the severity of trauma, the immediate goal can be either the prompt restoration of organ structure and function or so-called damage control surgery. The latter focuses, in the acute phase, on hemostasis and on the avoidance of secondary damage such as intra-abdominal contamination or compartment syndrome. It also involves the temporary treatment of fractures with external fixation and the planning of definitive care once the patient's organ functions have been securely stabilized. Conclusion: The care of the severely injured patient should be performed in structured fashion according to the A-B-C-D-E scheme, which involves the securing of the airway, breathing, and circulation, the recognition of neurologic deficits, and whole-body examination by the interdisciplinary team. [ABSTRACT FROM AUTHOR]

Complex limb trauma are extremely severe and pose a threat both to the patient's life, because of their systemic impact, as well as to the vitality of the traumatized limb, because of potentially severe septic complications. Post-traumatic (post fracture) osteitis is most often a consequence of an open fracture (always contaminated) or a closed operated fracture which was contaminated by pathogenic germs, the most common of which is Staphylococcus aureus (but Gram-negative bacteria, such as Klebsiella, Pseudomonas and Proteus are also worth mentioning). The consequence of an acute osteitis which was incompletely or inadequately treated is chronic osteitis, which requires long-term treatment, with inconsistent outcome results. To describe this topic, we present the case of a 15 year old pacient, which presents at the hospital as a surgical emergency, following a complex high energy trauma cause by a smash-up, whose survival and then healing, in spite of complete and correct approach, were extremely problematic/challenging, and called for a massive amount of human, financial and temporal resources. [ABSTRACT FROM AUTHOR]

The article presents papers presented at the Regensburg Conference on topics such as ultrasound contrast agents as markers of vascularity and microcirculation, perfusion imaging of tissue transplants with Contrast Harmonic Ultrasound Imaging (CHI) and Magnetic Resonance Imaging (MRI) as compared to laser-induced Indocyanine Green (ICG) fluorescence angiography, and the use of antithrombotic agents in microvascular surgery.

Purpose: Evaluation of post-surgery tissue perfusion of free flaps of the lower leg with contrast enhanced harmonic imaging (CHI), laser-induced indocyanine green (ICG) fluorescence angiography and magnetic resonance imaging (MRI). Materials and methods: 10 patients with free flaps of the lower limb were evaluated with CHI, ICG-fluorescence angiography and perfusion weighted MRI. Perfusion weighted MRI was performed after intravenous bolus injection of 25 ml Gd-DTPA. The ICG fluorescence was detected by a near-infrared-laser device (λem = 780 nm). Ultrasound was carried out by an experienced examiner with a linear probe after intravenous bolus injection of 2.4 ml SonoVue®. For MRI time intensity curves as well as color-coded blood volume maps of the whole free flap were qualitatively evaluated. For CHI and ICG time intensity curves in selected regions of interest were analyzed. A score from 1–5 (1 = low, 5 = excellent) was used for analysis of perfusion images by three independent readers. Results: In 3 cases (radialis, parascapular and lateral thigh flap) CHI, MRI and ICG perfusion imaging showed an excellent (score 4–5) contrast enhancement of the cutaneous and subcutaneous part of the free flaps. In 2 cases of osteocutaneous flaps perfusion in central and distal parts of the free flaps was reduced (score 2). Correlation between CHI, MRI and ICG was 0.69–0.83 for the distal parts of the free flaps and 0.74–0.87 for the center of the flaps (Spearman test). Perfusion in the center of the free flaps was significantly different for MRI and ICG and also for MRI and CHI (p<0.05, Wilcoxon test). Conclusion: These first results introduce CHI and MRI perfusion imaging as a promising post-surgery monitoring in patients with free flaps. [ABSTRACT FROM AUTHOR]

Background: We present nine patients with progressive sclerosing cholangitis after septic shock. Patients: All nine patients had previously required long term treatment in an intensive care unit for septic shock: two patients with polytrauma, five with burn injury, and two with extensive surgery. They were admitted to our hospital because of cholangitis. Endoscopic retrograde cholangiography revealed severe intrahepatic stenoses in all patients and liver biopsies showed typical signs of sclerosing cholangitis. No patient had pre-existing liver disease. Results: Mean follow up time was 35 months. In patients with major bile duct stenoses (3/9), 12 endoscopic dilations were performed in total. In one patient, concrements were extracted and intermittent stenting was necessary. To date, 4/9 patients have rapidly developed liver cirrhosis. During follow up, 5/9 patients died: two after fulminant cholangitis, one after liver failure, one due to liver transplantation associated problems, and one after cerebral ischaemia. One patient has been registered for transplantation and the remaining three patients show no acute signs of liver failure. Conclusions: Patients with sclerosing cholangitis, following septic shock, represent a new variant of vanishing bile duct disorders. In such patients liver disease rapidly progresses to cirrhosis. Endoscopic treatment may only transiently improve the course of the disease. Orthotopic liver transplantation is indicated in end stage disease. [ABSTRACT FROM AUTHOR]

Alternatives to internal fixation of long-bone fracture comprise, depending on location, external fixation or joint replacement. Limitations comprise risk of infection and functional outcome quality, which vary according to technique. The present study examines these limitations, based on comparative or large-scale studies from which certain significant results emerge. Four main questions are dealt with: (1) the present role of locking plates; (2) conditions for intramedullary nailing in Gustilo grade IIIb open fracture; (3) the limitations of conversion from external fixation to intramedullary nailing in open lower leg fracture; (4) and the limitations of definitive anterograde femoral nailing in multiple trauma. Locking plate fixation has yet to prove clinical superiority in any of the anatomic sites for which good-quality comparative analyses are available. Infection risk in Gustilo grade IIIb open lower leg fracture is equivalent when treated by intramedullary nailing or external fixation, if wound care and debridement are effective, antibiotherapy is initiated rapidly and skin cover is restored within 7days. Conversion from primary external fixation to intramedullary nailing is possible if the external fixator was fitted less than 28days previously and skin cover was restored within 7days. The pulmonary and systemic impact of peripheral lesions or definitive anterograde intramedullary nailing of femoral fracture in multiple trauma calls for caution and what is known as "damage-control orthopedics" (DCO), a term covering the general consequences of both the initial trauma and its treatment. Femoral intramedullary nailing is thus contraindicated in case of hemorrhagic shock (blood pressure<90mmHg), hypothermia (<33°C), coagulation disorder (platelet count<90,000) or peripheral lesions such as multiple long-bone fractures, crushed limb or primary pulmonary contusion. In such cases, external fixation or retrograde nailing with a small-diameter nail and without reaming are preferable., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)