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Lateral subtalar dislocations are rare and severe injuries caused by high-energy trauma, and they require urgent treatment. We reported two cases of lateral subtalar dislocation, which were treated with different methods. In case of open lateral subtalar dislocation, we used the method of distractional external fixation; the final outcome was good, without avascular necrosis of the talus. The case of closed subtalar dislocation has been treated with open reduction and K-wires fixation. The final outcome was poor, with avascular necrosis of the talus. Our opinion is that ligamentotaxis of the ankle and subtalar joint with unilateral external fixation unloads the talus and reduces the possibility of the development of avascular necrosis of the talus.

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A mangled extremity is the most devastating limb injury and presents a challenge for the orthopedic surgeon. There are two main treatment options, reconstruction or amputation, but sometimes indications for either are not clear. There are many pro and contra arguments for both options. To make the decision easier numerous score systems have been introduced, but the final decision is based on the judgment and experience of the treating surgeon. Early extremity reconstruction appears to give better results than delayed or late reconstruction and should be the treatment of choice where possible. The goal in reconstruction of a lower extremity is to restore and maintain balance and ambulation, while restoration of an upper extremity's numerous functions is more demanding. In this paper the authors describe and suggest treatment approaches in patients with a severely mangled extremity, including assessment and treatment of all injured tissues, using defined protocols, with special attention to bone stabilization, revascularization, soft-tissue coverage and nerve reconstruction. These have a great impact on the outcome and function of the injured extremity. Rehabilitation and return to the preinjury level is slow and sometimes uncertain.

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BACKGROUND: The aim was to evaluate the analgesic efficacy and safety of the dexketoprofen/tramadol 25 mg/75 mg fixed-dose combination vs dexketoprofen (25 mg) and tramadol (100 mg) in moderate-to-severe acute pain after total hip arthroplasty. METHODS: This was a randomized, double-blind, parallel-group study in patients experiencing pain of at least moderate intensity on the day after surgery, compared with placebo at first administration to validate the pain model. The study drug was administered orally every 8 h throughout a 5 day period. Rescue medication, metamizole 500 mg, was available during the treatment period. The evaluation of efficacy was based on patient assessments of pain intensity and pain relief. The primary end point was the mean sum of the pain intensity difference values throughout the first 8 h (SPID8). RESULTS: Overall, 641 patients, mean age 62 (range 29-80) yr, were analysed; mean (sd) values of SPID8 were 247 (157) for dexketoprofen/tramadol, 209 (155) for dexketoprofen, 205 (146) for tramadol, and 151 (159) for placebo. The primary analysis confirmed the superiority of the combination over dexketoprofen 25 mg (P=0.019; 95% confidence interval 6.4-73) and tramadol 100 mg (P=0.012; 95% confidence interval 9.5-76). The single components were superior to placebo (P<0.05), confirming model sensitivity. Most secondary analyses supported the superiority of the combination. The incidence of adverse drug reactions was low and similar among active treatment groups. CONCLUSION: The efficacy results confirmed the superiority of dexketoprofen/tramadol over its single components, even at higher doses (tramadol), with a safety profile fully in line with that previously known for these agents in monotherapy. CLINICAL TRIAL REGISTRATION: EudraCT 2012-004548-31 (https://www.clinicaltrialsregister.eu/ctr-search/search?query=eudract_number:2012-004548-31);ClinicalTrials.gov NCT01902134 (https://www.clinicaltrials.gov/ct2/show/NCT01902134?term=NCT01902134&rank=1).

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Polytrauma remains a major social, economic and medicine affliction. Successful surgical treatment of polytrauma patient's requires an approach predicated on prioritizing injuries. An isoleted fractures rarely poses any threat but in association with multiple injuries, a fractures assumes greater significance. Proper management of femur fractures in po-lytrauma can gretly reduce the mortality and morbidity. In this work the results of the operative treatments of the femoral shaft fractures in polytrauma patients using Mitkovic type internal fixator (14 patients) and Kuntscher nail (9 patients) are compared. The average patients age was 28.43 years (range 16 to 61). Internal fixation using Mitkovic type internal fixator can be method of choose in treatment of femur fractures in polytrauma patient's. Its application is relatively simple. It doesn't damage the periosteal and meduullary bone vascularization, which favors osteosynthesis and provides considerable contribution in osteogensis.

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The fracture of tibia shaft is one of the most common fracture of long bones. The authors bring out the results of the treatment of 90 patients with unstable closed tibial shaft fractures treated by the use of Mitkovic external fixation systems. Within the analayzed group there were 66 (73%) male and 24 (27%) female. The average patients age was 43.9 years (range 15 to 82). Excellent result in treatment of unstable closed tibial shaft fractures with external fixation were achieved in 15 (16,7%) patients, very good in 38 (42,2%) patients, good in 24 (26,7%), poor in 9 (10%) and bad in 4 (4,4%) patients. With 4 (4,4%) patients pseudoarthrosis was formed. Additional treatment of patients with pseudoarthrosis (spongioplastic and placing of CD device) led to pseudoarthrosis healing. Within the analyzed group in all patients treated with extenal fixation there were no registered cases of postoperative osteitis. External fixation by the use of Mitkovic external fixation is one of the method of choose in the treatment of unstable closed tibial fractures, providing dynamic and balanced biomehanical conditions for fracture healing.

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The article describes injuries of soft and bone structures of the shoulder region, with special emphasis on the following clinical forms: instabilities and luxations of the glenohumeral joint, fractures of the proximal humerus, clavicle and the states of painful shoulder. Fractures and dislocations, but also significant entities - painful states caused not only by fractures but also by minor trauma such as tendinitises and m.supraspinatus tendon and bicipital tendon ruptures are discussed in more detail. Moreover, their consequences - painful and stiff shoulder - as well as modern diagnostic and therapeutic procedures applied in the painful shoulder treatment are also discussed.

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The ankle fractures continue to be a topical issue in orthopedic surgery. X-ray diagnostics, but primarily also other modem diagnostic procedures such as CT, MRI, and arthroscopy enable detection of not only fractures but also osteocartilaginous fractures and soft-tissue ligamentary lesions, which are frequent causes of pain and instability of the ankle. The key segment is the posterio-lateral segment and tibio-fibular syndesmosis whose integrity is sometimes only surgically establishable. In the ankle treatment, stable fixation - since recently by means of resorptive osteofixation materials - and early rehabilitation of the operated ankle are aimed at. The open and pylon fractures, as the most severe forms of ankle fractures, are treated by external fixation with minimum internal fixation (hybrid fixation) of the ankle with conversion of the rigid into a dynamic (articulated) external fixator enabling movement and nutrition of the damaged articular cartilage.

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A new concept in external skeletal fixation is presented. A 3D unilateral system developed by Mitkovic has widely been investigated biomechanically in AO institute in Davos (Switzerland). Consists of three components only providing extremely simple application and dynamic fixation of bones and different joints. This simple external fixator functions as an accurate reduction device at the same time, minimizing need for fluoroscopy. Clinically this system has been applied to mere then 13 thousand patients in 43 clinics. This paper presents the results of its application for treatment of open fractures, war wounds with fractures and for comminuted and intraarticular closed fractures in the series of 597 patients. Overall average time for union time was 3.2 months. Overall success of fracture healing was 96.8% including open and closed fractures. Our study suggests that the use of this 3D unilateral system is suitable for routine use.

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One of the main goals in fracture treatment is reservation of both intramedular and periosteal vascularisation. The aim of this paper is to show a new method of internal fixation which accomplishes these goals. The paper presents the results of clinical application of Mitkovic Internal Fixator, new self-dynamisable device, which provides fixation of the femur using minimally invasive technique. This device has been investigated experimentally on 60 animals. It has been applied to 267 patients. Here is presented a series of 92 fixations of femoral diaphyses after fresh fractures and after unsuccessful treatment using other methods. Follow-up was 3.1 years (2 to 7 years). Bone healing was achieved in all patients within 3.5 months (2.7-9 months) with big amount of periosteal callus formation. There were no complications in all patients seen. It can be concluded that this method and device meet biological and biomechanical requirements for safe fracture treatment.

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The results of limb lengthening, correction of limb deformities and solving of bone loss, by the use of Mitkovic external fixation system and minimally invasive technique on the series of 96 operations in 89 patients are shown. Only lower extremities were included in this series. The advantages of this external fixation system in comparison to other systems are pointed out. The main advantages are the optimal biomechanical conditions including unilateral but 3-dimensional frame, which provides conditions very similar to natural biomechanical features of the human long bones, simplicity of application and low cost. The received result was excellent or very good in 98.4%. Maximal limb lengthening was 18 cm (at the same time in the femur and the tibia). Angular deformity correction is extremely simplified with minimized possibility of complications. The frame for bone transport is very simple. It can be concluded that presented methods are suitable for routine use.

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Periprosthetic fractures of the femur after total hip arthroplasty are a big orthopaedic problem, particularly in elderly patients and quite a challenge for orthopaedic surgeons. There is no universal method in treating these fractures. Rigid plates fixation can be limited and aggravated especially in the proximal part of the femur where the endoprosthesis stem does not allow for an undisturbed fixation of both femur cortexes by means of screws. Mitkovic's dynamic internal fixator is an original implant allowing for an undisturbed fixation of both femur cortexes regardless of the presence of the endoprosthesis stem. Fixation is made possible by means of movable clamps and a convergent possibility to place screws. A dynamic internal fixator can fix all types of periprosthetic femoral fractures. The paper shows the early experience in fixating periprosthetic femoral fractures after total hip arthroplasty in 14 patients, average age 69.7. According to Vancouver classification, 3 patients had the type A fracture, 9 patients had the type B fracture, and 2 patients had the type C fracture. All fractures were fixed by Mitkovic's dynamic internal fixator. The fracture occurred 2-12 years after primary total hip arthroplasty. The follow-up of the operated patients was 12 months. The method is less invasive than the methods described in books. Mechanical complications are not likely to appear due to the fracture dynamics along the femoral shaft axis, which is made possible by this implant. Our initial experience in femur fracture fixation after hip arthroplasty ahows that it is modern and effective dynamic implant which will contribute significantly to the improving of the treatment of these often very complicated fractures.

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We report 26 patients with 28 type C3, distal intraarticular tibial (pilon) fractures treated by dynamic external fixation. Follow-up was at least two years, and the results (subjective and objective) were classified according to the Ovadia system. The mean to fracture union was 14 weeks (range: 12 to 20 weeks). There were three cases with angulation deformity (from 7 degrees to 20 degrees). There were no cases with nonunion or deep infection. Based on these results, this treatment with closed reduction and dynamic external fixation allowing early motion appears as a suitable method for treatment of comminuted intraarticular tibial pilon fractures.

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In the period from January 1st, 1969, to December 31st, 1988, 585 osteosyntheses of the closed bone fractures of lower limbs were performed at the Orthopedic department at the Military Hospital in Nis. At the same period 25 postoperative osteomyelitis were registered, i.e., 4.27%. The average duration of osteosynthesis in the tested group of patients was 84.6 minutes, and 54 minutes in control group. The difference of the average duration of osteosynthesis between groups was significant. The type and size of metal implants did not directly affect the evolution of postoperative bone infection unless the correct implantation was done and unless they were made of standardized leaguers.

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