Recently, secondary life-threatening inflammatory reactions have been identified with molecular biological techniques in patients with multi-system injuries who were submitted to immediate or early intramedullary fixation of their fractured femora. This phenomenon was called “The second hit”, and it caused ARDS, PE, and Renal Failure.

In a consecutive series of 135 trauma patients with high energy long bone fractures, 40 had sustained multiple-injuries. All fractures were reduced and stabilized on admission by AO-Tubular External Fixation systems. After 72–96 hours, this system was converted to an hybrid-ring-tubular system, which had three dimensional stability. They commenced partial weight bearing 24 hours later, and were followed by bony union.

One patient developed DVT, none developed ARDS, PE, Renal Failure.

Superficial pin-tract infection was common, but no-deep infection and’or osteomyelitis were encountered.

With this minimal-invasive surgical technique, life threatening complications were avoided while preserving the integrity of the soft tissue envelope, the critical contributing biological factor for fracture healing.

Purpose of Study: Current knowledge links the biological cascade of fracture healing to the fracture muscle envelope and to the preservation of stable, perpetual axial micromovements. The active biological compounds in the initiation of osteoneogenesis are cytokines. The current study correlates the latter by their molecular weight to their osteoneogenetic activity.

Materials and Methods: Under GA and strict aseptic conditions, experimental fractures were produced in the mid-diaphysis of the left tibia in 60 adults Wistar rats. They were stabilized by an intramedullary no 20 needle. They were split into for equal groups:

Group A: Fractures were left to heal spontaneously. This was the control group.

Groups B,C,D: Using meticulous dissection, a sterile nitrocellulose membrane was wrapped around the fracture between the periosteum and muscle envelope.

The membranes pore sizes were: 3.5 kDa in group G; 12–14 kDa in group C; and 50 kDa in group D. The rats were euthanized at weeks 2, 5, 10 by an overdose of pentobarbital. Fracture healing was assessed by radiographies, histologic examinations and immunohistochemical localization of bone specific genes [IGF-1, IGF-1 receptor, cartilage proteoglycans, type II collagen, osteocalcin].

Results: In group A, callus formation was present at 2 weeks and progressed to full fracture healing by 5 weeks. In group B, no callus was detectable even at 10 weeks. In group C, most rats did not develop any callus, while a few started to develop calluses at 10 weeks. In group D, callus development was comparable to group A.

A good correlation was found between the radiological and morphological results.

Immunohistochemical localization of gene expression revealed a high level of PCNA [proliferating cellular nuclear antigen] with high local levels of IGF-1, and high levels of type II collagen as well as osteocalcin. In group B, this level of activity was very mild and did not reach bone healing level. In groups A and D, the results were comparable. They developed both medullary and periosteal callus, the former being persistently absent in groups B and C.

Conclusions: Extensive direct contact between fractured bone and it’s muscle envelope is essential for the biological sequence of new bone formation, i.e. fracture healing. Preventing the diffusion of cytokines with a molecular weight higher than 14 kDa from muscle to fractured bone effectively interrupts the biological cascade of osteoneogenesis.

Aims: To evaluate the clinical outcome of the treatment of severe high-energy war injuries to limbs using circular external þxation frames. Metods: 43 patients after war injuries with 57 high-energy fractures were treated. According to Gustilo and Anderson all fractures were open grade 3B and 3C. There was other major organ trauma in 52,8% of patients. On admission, the fractured bones were stabilized with an AO tubular external þxation frame followed by thorough extensive soft tissue debridement, vascular reconstruction if needed. After 5 to 7 days the tubular þxator is exchanged for a circular frame that allows receiving stability, sufþcient for full weight bearing by minimal invasive þxation and freeing the previously bridged joints, in order to preserve their range of movement. Closed reduction of fractures was performed in most patients by successful implementation of ligamentotaxis and use thin wires with olives. In patients with high-energy Ç ßoating joint È injuries the circular devices were connected by hinges to permit early initiation of joint motions and functional treatment. In patients with upper limb injuries a separate bone þxation was used to allow early ßexion/ extension and pronation/supination motions. Results: In all patients the circular external þxation was the deþnitive treatment. Bone grafting was not necessary in any patient because of compression-distraction possibility. Fracture union was achieved at median time of 8 months (range 3 60). Throughout the period of fracture healing the patients were ambulatory, living at home. Conclusion: The circular þxation frame allows perform successful skeletal stabilization and functional restoration of limbs in patients with extensive bone and soft tissue loss, even in limbs of the risk.

Topical treatment of infected wounds has a crucial role as an adjuvant to surgical debridement. Solutions currently used for local would treatment have either low antiseptic properties with low irritating effect, such as physiologically balanced solutions acting mostly by a mechanical irrigating effect, or antiseptic solutions which cause chemical irritation of the surrounding tissues. The use of topical substance with effective antiseptic properties, which is also not irritating to surrounding healthy tissues, should improve significantly the effectiveness of infected wound treatment.

Previous reports on the use of Hexamethylenebiguanide solution for local antiseptic treatment in infected wounds indicated on a good curative effect without any local or systemic side effects. Unfortunately none of these reports is based on well designed statistical data which is essential for the safe and skilled use of any pharmaceutical agent.

We present the results of controlled prospective double-blind study comparing the topical use of 0.1% Hexamethylenbiguanide solution with non lactated Ringer solution as agents for a topical treatment of infected wounds in extremities. The group of 104 patients with ischemic, combat, post surgical or due to open fracture wounds treated by either of these solutions following surgical debridement without additional systemic antibiotic use. According to the strict follow-up protocol, wounds’ healing was evaluated on a weekly basis. In the group of patients treated by the 0.1% Hexamethylenbiguanide solution, 75% rate of a complete wound healing was observed. In the control group the rate of healing was 52% [p=0.026, Chi square test, Figure 1]. These results indicate the high effectiveness of the Hexamethylenbiguanide as a topical agent for infected wound treatment.

We immobilised the right hindlimbs of six-month-old female Wistar rats for four weeks using a biplanar external fixation bridging the knee. The untreated left limbs served as a control group. An additional group of rats was allowed to recover for four weeks after removal of the frame.

Immobilisation caused reduction in the wet weights of approximately 50% in the gastrocnemius, quadriceps, soleus and plantaris muscles; this was not restored completely after remobilisation. There was an increase in the activity of acid phosphatase of approximately 85% in the gastrocnemius and quadriceps muscles whereas that of creatine phosphokinase was reduced by about 40%. These values returned to nearly normal after remobilisation. Histological and ultrastructural examination showed a marked myopathy of the gastrocnemius muscle after immobilisation although the morphology was largely restored after remobilisation.

We conclude that after four weeks of remobilisation, hind-limb muscles do not return to preimmobilisation weights, although biochemical activities and ultrastructural appearance are largely restored.

We reviewed 31 of 33 consecutive patients with intra-articular fractures of the knee at 6 to 22 years (average 14). Of these, 77% had excellent or good results; the others had various degrees of degenerative osteoarthritis. There was no significant difference between the results after surgical or conservative treatment. Secondary degeneration was not related to cause or type of fracture, but its incidence increased with the patient's age at the time of injury, though not with the length of follow-up. Early mobilisation appeared to be beneficial in preventing later degenerative changes.

Specimens of tissue from haemophilic synovium and articular cartilage were collected from 39 patients during reconstructive surgery. They were studied by histochemistry, electron microscopy and microprobe analysis. The detailed findings are presented and discussed. It is suggested that haemophilic arthropathy is the result of a number of mechanisms affecting the synovial lining which becomes progressively fibrotic and the hyaline cartilage which disintegrates and is eventually lost. Mechanical and chemical processes cause degeneration of cells but enzymatic processes appear to be primarily responsible for the degradation of the matrix of the articular cartilage.

This study shows that after intra-articular injection, aurothiomalate and colloidal gold of small (200 A) particle size were rapidly absorbed from joints while the larger, 300 A, particle size colloidal radioactive gold could not be found outside them. Larger particle size suspensions seem therefore more likely to remain localised in the joint and its lining synovium after intra-articular injection, the systemic absorption from the joint cavity diminishing with increasing particle size. It was also found that the intra-articular injection of small amounts of aurothiomalate, of colloidal gold and of colloidal radioactive gold produces identical degenerative lesions in the lining cells of the proximal convoluted tubules of the kidneys. These lesions were always found, although gold particles were demonstrated only in sampled kidney tissues of the animals injected with the soluble gold preparation whereas no gold could be detected in the tissues of animals injected with colloidal non-radioactive or radioactive gold. Electron microscopic evidence is presented to suggest the possibility that the mitochondria are the "target" organelles of the gold-induced cellular damage. Mitochondrial damage was demonstrated in liver and spleen in addition to the already described kidney damage. The correlation between structure and function of the mitochondrial changes is not clear, and ionic shifts may be both a cause and a result of damage.

The results of ten excision arthroplasties of the elbow for rheumatoid disease are described. The operation may afford good relief of pain and a useful increase both of hinge motion and of forearm rotation. Instability is not a serious problem unless the patient has to bear weight on crutches. To increase stability after arthroplasty it appears that Kirschner wire fixation is advisable as well as a plaster cast. For advanced rheumatoid disease unilateral excision arthroplasty has a definite value, especially for patients confined to a wheelchair.

An attempt to produce scoliosis in young baboons by excision of the heads of ribs failed in thirteen growing animals observed for up to a year after operation. Other investigators have failed to produce scoliosis in primates by similar and other techniques that had successfully produced scoliosis in quadruped animals. The possible reasons for this are discussed, especially in the light of clinical trials that are being carried out with techniques transposed from the quadruped experimental animal to the scoliosis clinic.