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INTRODUCTION: Irrigation suction drainage (ISD) is an additional method in treatment of infected bones. Two liters of saline solution daily with an antibiotic is usually recommended for ISD, although some authors suggest that more fluid should be used without antibiotics, stressing the importance of the mechanical effect. Although the method is nowadays accepted as a routine procedure, the reported results of ISD are based on treatment of a limited number of patients and the only criteria for assessment have been clinical and bacteriologic findings. The aim of this prospective study is to show the importance of the mechanical effect of an increased fluid run and the optimal time necessary for cleaning of the osteomyelitic cavity by follow-up the C-reactive protein (CRP) levels as an indicator of an acute inflammation of the affected bone. METHODS: The prospective study was an open, centralized and randomized clinical investigation including over 105 patients with bone infection treated in the period 1986-1996. Two parameters with possible influence on the CRP levels were determined during investigation: 1. patients were divided in three groups depending on the duration of the irrigation suction drainage (3-6 days, 7-10 days and over 10 days) and 2. quantity of the liquid used for the irrigation suction drainage (two groups: 2000 ml per day and 6000 ml per day). Groups were similar in regard to age, sex, bacteriologic agents, duration of infection, localization and previous operations. C-reactive protein (CRP) is a nonspecific, but extremely sensitive indicator of an acute inflammatory disease. The erythrocyte sedimentation rate is not always a reliable indicator of infection. CRP as a protein of an acute phase appears and disappears quickly. Decreased values are a sign of a healing process used in this study for the estimation of the efficacy of the ISD. The CRP level was controlled semiquantitatively before operation and every third day over three weeks. If the values were below 6 mg/l, the results were classified as negative. RESULTS: There were not significant statistical differences in different groups as far as a preoperative average CRP values were concerned neither in the quantity of employed liquid nor in the duration of the ISD and interaction between these two groups. It was the same on the third postoperative day. The differences appear in the significantly lower average values of the CRP in patients of the second group (6000 ml/day) where the ISD lasted for seven or more days. During further follow up, (6th to 21st day) one can observe a significant statistical difference in average CRP values between the first (2000 ml/day) and second group (6000 ml/day) but there is not difference when the duration and sort of employed liquid is concerned. There is not significant difference in average statistical values of the CRP in blood for interaction of fluid quantity and time of ISD as well. DISCUSSION: The main disadvantage in the function of ISD is nonuniform rinsing of the osteomyelitic cavity. Prolonged ISD has no influence on the clinical result as well as on the average values of the CRP. Starting from the third postoperative day results indicate that the quantity of employed liquid has an important influence on the average level of the CRP, while the duration of ISD is not important. Prolonged ISD can not compensate for an inappropriate surgical intervention because it is only an additional method in the treatment of an osteomyelitic process. CONCLUSION: By observing changes in CRP levels during treatment one can conclude that the efficacy of ISD is based mostly on mechanical rinsing and the removal of debris. This points to the importance of the quantity of fluid employed in irrigation suction drainage. Application of 6000 ml liquid per day without antibiotics during 5-7 days gives opportunity of better rinsing increasing the effect of ISD and reducing the incidence of complications.

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In orthopedic reconstructive surgery infection is a fatal complication which compromises not only the functional result and worsens the starting, initial state, but sometimes, endangers the patient's life, especially when it is an elder person. In the literature there are data which state that in orthopedic reconstructive surgery there are certain risk factors, but there are no data about the following: which factors affect the infection incidence and how. It gets even a greater problem because various types of described infections are not well defined as characteristics of certain infections (superficial or deep) and they are not described in the same way by certain authors. That is why the goal of this paper was to enlighten these problems and to clear up the connection among risk factors and certain infections. That is how risk factors may be divided into factors typical for 1. infected tissue, 2. patient, 3. applied intervention, 4. direct postoperative period and 5. presence of a foreign body. In the conclusion it may be pointed out that the decrease in percentage of infections in orthopedic surgery cannot be achieved if all mechanisms and factors which affect it are not known. It is the characteristic of bone tissue that if it is once infected it cannot be healed spontaneously. However, there is no guarantee that there will be no relapse after an adequate therapy. Treatment of postoperative infections remains an open and one of the leading problems of the orthopedic septic surgery. First signs of infection should be promptly reacted to, because every deepening of infection and surgery prolongation prolongs the treatment to months and years, often without results.

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An open, controlled, randomized clinical investigation was carried out in 33 patients suffering from osteomyelitis. In the first group, 17 patients, a through drainage with sterile physiologic solution was applied, while in the second group, 16 patients, antibiotic was added to the sterile physiologic solution. In all patients values of C reactive protein (CRP) in the blood were examined, and later on every third day after the operation. A significant difference of average values of CRP between the 3rd and 21st day in both groups of patients was established, as well as the similarity in average values of CRP, which points to the fact that the mechanical effect of through drainage is dominant, speaking about rinsing focus of infection and eliminating necrotic tissues and small sequesters.

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The retrospective study comprised 23 patients with infected pseudoarthrosis after osteosynthesis of of the lower log fracture treated at the Clinic of Orthopedic Surgery and Traumatology in Novi Sad. Staphylococcus aureus has been the most common causative agent of infection. In all patients debridment of infection foci was performed and reosteosynthesis with the external fixator and in 10 patients spongioplasty was performed in addition. At the control examination good results were achieved in 4, satisfying in 3 and poor in 16 patients. Amputation was performed in 5 patients.

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An experimental study on transplantation validity of patella's ligament, when transplanting front crossed ligament, was performed on 106 knees in 53 grown-up dogs. The investigation had three stages. Three months after the transplantation of the front crossed ligament with the medial third part of the patella's ligament animals were sacrificed and in one group the static resistance and the resistance to elongation, by using special tweezers (Alfred Amsler Co., Schafhausen, Switzerland), was investigated. The results showed that the patella's ligament is very suitable for transplantation because its resistance and strength were almost identical with the same parameters of intact front crossed ligament. Revascularization of the new ligament using Spaltenholz's technique was done in the second group, and three months after the operation, complete revascularization of transplants took place. The synovial membrane which covers the new ligament represents the main source of fresh blood vessels on one side, while similar process takes place along the bone tunnels where the new ligament was fixed. The new ligament histologic analysis carried out in the third group of experimental animals showed that after three months the transplant acquires the structure which is very similar to the front crossed ligament. The obtained results of the investigation show that the patella's ligament is a very good biologic material for transplantation of the crossed ligament.

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Over a ten-year period, 485 patients suffering from malleous fracture were operated at the Department for Orthopaedic Surgery and Traumatology in Novi Sad. Postoperative infection appeared in ten cases (2.06%). Eight of these patients primarily had open fractures, and two of them had closed ones. Osteosynthesis of the lateral malleous had most frequently been treated by the use of panel and screws. Staphylococcus aureus was isolated as symptom of the infection in eight cases. In treatment of malleous osteomyelitis, the debridement of focus of infection together with fixation material extraction was the most frequently performed operative method. During a two-year period no exacerbation, seven patients was observed while at control examination three patients had secretion from fistula. Mobility of ankle joint was limited in most cases, while walking imposed no pain.

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A radiogrametric assessment of the patellar height performed by three measurement methods, in the lateral views of radiograms of 136 patients with chondromalacia of the patella was aimed at the establishment of certain parameter values in the studied population and the assessment of the influence the altered patellofemoral ratio has upon the onset of the disease. The results of the study verified the remarkable advantages of the method by Insall and Salvati for the measurement of the patellar height and showed a significant involvement of patellofemoral incongruity in the development of chondromalacia, since in 15-16% of the cases the patella was not properly placed.

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Lesions of the anterior cruciate ligament of the knee are very frequent misfortune and the results of their suture being insufficient yet, made us to explore the possibility to replace the damaged ligament with the fascia lata as an autologous transplant. Surgical operation was performed on dogs. Instead of the anterior cruciate ligament removed, we used a piece of a rolled fascia lata. Six months after transplantation being performed, samples of the fascia lata were extracted for histological analysis to assess their structure and to evaluate the transplant as a neoligament, on the basis of its similarity with the normal structure of the ligament. After degeneration of a part of transplant because of the insufficient supply of nutrients, the invasion of the synovial blood vessels into the fascia lata was established and the young granulation tissue formed on the account of the nondifferentiated adventitial cells. In the mosaic of the transplant structure there were present parts of a more mature, dense connective tissue with longitudinal orientation of the cells, the fibers and the vascular elements, which partially made structure similar to that in ligaments. In the attachment region fibrocartilage was noticed, gradually passing into the hyaline one, to merge with the hyaline cartilage of the joint surface. After the histological analysis follows the conclusion that fascia lata functionally could replace the anterior cruciate ligament if a role was supplied with sufficient collagenic fibers on the cross-section. Time is of a high importance, too.(ABSTRACT TRUNCATED AT 250 WORDS)

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Late results of radial head excision were studied in 60 patients who had isolated fractures of the radial head. Symptomatic elbows were found in 43% of the patients, osteoarthritis in 52%, and valgus deformity in 30%. Elbow motion was restricted in 63%, and new bone formation at the surgical site was noted in 57% of the patients. Forearm rotation was limited in 58%. A proximal radioulnar synostosis was found in 7%, and proximal migration of the radius was present in 47%. A definite and symptomatic subluxation of the distal radioulnar joint was found in 25%. Overall results were unsatisfactory (fair and poor) in 50% of the patients. Excision of the radial head is a serious operation and is followed by a high proportion of complications. The indications for this operation should be relatively limited.

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The photometric latex test (PLT) for the detection of rheumatoid factors (RF), developed and clinically evaluated in adult rheumatoid arthritis, was applied in a study of juvenile rheumatoid arthritis (JRA). A total of 40 individuals with JRA, 27 with other collagen diseases and 24 in a control group were examined. The incidence of seropositives by PLT was 50% in JRA, 33% in collagen diseases and 17% in controls. The percentage of JRA was significantly higher than in the controls, and also higher than values in the literature claiming that only about 20% of JRA patients are seropositive. These findings were discussed concerning the diagnostic capability of PLT as compared with other serologic tests for RF. The increase in PLT titer values was found to indicate an aggravation of the inflammatory process and could help estimate the clinical stage of the disease. A follow-up of patient titer values could be of great diagnostic value. The data on serum immunoglobulins and complement fractions levels could not confirm the findings on a significant increase in JRA patients, but following of "level profiles" of each patient could add to the estimation of patient's clinical status. In cases of seropositives when other laboratory parameters did not indicate a clear transition from the chronic active to acute stage of disease, the only parameter which often showed such a transition is the RF titer determined by PLT testing, which could be of importance for a timely change of the therapy.

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In the period of 1966-1975 the authors treated 228 patients with a fractures of diaphysis of humerus, 103 of whom underwent surgery; in 36 of them a paralysis of the radial nerve occurred. These 36 patients were divided into two groups: primary lesions (22 cases) which were discovered during hospitalization, and secondary lesions which occurred in postoperative course. The aim of clinical research with the primary lesion (respectively 22 patients) was to ascertain which method would have the best effect. In 77,2% of these patients, a radial nerve was not interrupted, while in 13.6% its continuity was partially preserved, and only in 9.09% a complete interruption occurred. Complete recovery of the nerve was in 50% of patients, 22.7% had a small conduction deficit, while its paralysis was further present in 18.8% of cases. Accordingly to this, the authors attained an excellent and very good results in 59% of patients, while in the remaining 41% of cases the results was satisfactory. It has been established that primary lesions of radial nerve has been occurring in 7.64% of cases (similar date do exist in reviewed reports), and in the majority of patients a spontaneously recovery will occur in the course of 2-3 months. Therefore the authors are not for a primary exploration of n.radialis if it is a question of closed fractures. In rare cases with interruption of the radial nerve with extensive contusions of both simultaneously interrupted nervous stumps a primary suture is not indicated. Therefore an eventual surgical exploration to establish whether an interruption of the nerve exists, does not contribute to attain recovery.

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