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Bumbaširević M, Matić S, Palibrk T, Glišović Jovanović I, Mitković M, Lesić A. Mangled extremity- Modern concepts in treatment. Injury 2021; 52:3555-3560. [PMID: 33766434 DOI: 10.1016/j.injury.2021.03.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 03/09/2021] [Indexed: 02/02/2023]
Abstract
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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Affiliation(s)
- M Bumbaširević
- School of Medicine, University of Belgrade; Clinic for orthopedic surgery and traumatology, Clinical Centre of Serbia; Serbian Academy of Sciences and Arts, Belgrade
| | - S Matić
- School of Medicine, University of Belgrade; Clinic for orthopedic surgery and traumatology, Clinical Centre of Serbia
| | - T Palibrk
- School of Medicine, University of Belgrade; Clinic for orthopedic surgery and traumatology, Clinical Centre of Serbia
| | | | - M Mitković
- Clinic for orthopedic surgery and traumatology, Clinical Centre Nis
| | - A Lesić
- School of Medicine, University of Belgrade; Clinic for orthopedic surgery and traumatology, Clinical Centre of Serbia
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Bumbaširević M, Lešić A, Palibrk T, Georgescu AV, Matei IR, Tabaković D, Matić S, Glišović Jovanović I, Petrović A, Manojlović R. Lower limb replantation: 27 years follow up. Injury 2020; 51 Suppl 4:S77-S80. [PMID: 32122628 DOI: 10.1016/j.injury.2020.02.113] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 02/19/2020] [Accepted: 02/21/2020] [Indexed: 02/02/2023]
Abstract
Replantation of lower extremity is a very complex and difficult procedure. There are still a lot of controversies about indications, even numerous scoring systems are now available that can facilitate the surgeon's decision. We present the functional results of a replanted below-knee amputation in an elderly patient, 27 years after the injury and discuss the indication for replantation.
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Affiliation(s)
- Marko Bumbaširević
- Orthopedic and Traumatology University Clinic, Clinical Center of Serbia, Belgrade, Serbia; Faculty of Medicine, University of Belgrade, Belgrade, Serbia; SANU - Serbian Academy of Sciences and Arts, Serbia.
| | - Aleksandar Lešić
- Orthopedic and Traumatology University Clinic, Clinical Center of Serbia, Belgrade, Serbia; Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Tomislav Palibrk
- Orthopedic and Traumatology University Clinic, Clinical Center of Serbia, Belgrade, Serbia; Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Alexandru Valentin Georgescu
- Department of Plastic Surgery and Reconstructive Microsurgery, University of Medicine Iuliu Hatieganu Cluj Napoca, Romania; Clinic of Plastic Surgery and Reconstructive Microsurgery, Clinical Hospital of Recovery, Cluj Napoca, Romania
| | - Ileana Rodica Matei
- Department of Plastic Surgery and Reconstructive Microsurgery, University of Medicine Iuliu Hatieganu Cluj Napoca, Romania; Clinic of Plastic Surgery and Reconstructive Microsurgery, Clinical Hospital of Recovery, Cluj Napoca, Romania
| | - Dejan Tabaković
- Orthopedic and Traumatology University Clinic, Clinical Center of Serbia, Belgrade, Serbia
| | - Slađana Matić
- Orthopedic and Traumatology University Clinic, Clinical Center of Serbia, Belgrade, Serbia; Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | | | - Aleksandra Petrović
- Orthopedic and Traumatology University Clinic, Clinical Center of Serbia, Belgrade, Serbia
| | - Radovan Manojlović
- Orthopedic and Traumatology University Clinic, Clinical Center of Serbia, Belgrade, Serbia; Faculty of Medicine, University of Belgrade, Belgrade, Serbia
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Abstract
Amputations have a devastating impact on patients' health with consequent psychological distress, economic loss, difficult reintegration into society, and often low embodiment of standard prosthetic replacement.The main characteristic of bionic limbs is that they establish an interface between the biological residuum and an electronic device, providing not only motor control of prosthesis but also sensitive feedback.Bionic limbs can be classified into three main groups, according to the type of the tissue interfaced: nerve-transferred muscle interfacing (targeted muscular reinnervation), direct muscle interfacing and direct nerve interfacing.Targeted muscular reinnervation (TMR) involves the transfer of the remaining nerves of the amputated stump to the available muscles.With direct muscle interfacing, direct intramuscular implants record muscular contractions which are then wirelessly captured through a coil integrated in the socket to actuate prosthesis movement.The third group is the direct interfacing of the residual nerves using implantable electrodes that enable reception of electric signals from the prosthetic sensors. This can improve sensation in the phantom limb.The surgical procedure for electrode implantation consists of targeting the proximal nerve area, competently introducing, placing, and fixing the electrodes and cables, while retaining movement of the arm/leg and nerve, and avoiding excessive neural damage.Advantages of bionic limbs are: the improvement of sensation, improved reintegration/embodiment of the artificial limb, and better controllability. Cite this article: EFORT Open Rev 2020;5:65-72. DOI: 10.1302/2058-5241.5.180038.
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Affiliation(s)
- Marko Bumbaširević
- School of Medicine, University of Belgrade, Serbia
- University Clinic for Orthopaedic Surgery and Traumatology, Clinical Centre of Serbia, Serbia
| | - Aleksandar Lesic
- School of Medicine, University of Belgrade, Serbia
- University Clinic for Orthopaedic Surgery and Traumatology, Clinical Centre of Serbia, Serbia
| | - Tomislav Palibrk
- School of Medicine, University of Belgrade, Serbia
- University Clinic for Orthopaedic Surgery and Traumatology, Clinical Centre of Serbia, Serbia
| | - Darko Milovanovic
- School of Medicine, University of Belgrade, Serbia
- University Clinic for Orthopaedic Surgery and Traumatology, Clinical Centre of Serbia, Serbia
| | | | | | - Stanisa Raspopovic
- ETH Zürich, Department of Health Sciences and Technology, Institute for Robotics and Intelligent System, Zurich, Switzerland
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Bumbaširević M, Lešić A, Palibrk T, Georgescu AV, Matei IR, Vučetić Č, Pierluigi T, Matić S, Damjanović D, Raspopović S. What microsurgeon, orthopaedic and plastic surgeon should know about bionic hand. Injury 2019; 50 Suppl 5:S137-S140. [PMID: 31690497 DOI: 10.1016/j.injury.2019.10.065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Hand loss is a catastrophic event that generates significant demands for orthopedics and prosthetics. In the course of history, prostheses evolved from passive esthetic replacements to sophisticated robotic hands. Yet, their actuation and particularly, their capacity to provide patients with sensations, remain an unsolved problem. Sensations associated with the hand, such as touch, pain, pressure and temperature detection are very important, since they enable humans to gather information from the environment. Recently, through a synergistic multidisciplinary effort, medical doctors and engineers have attempted to address these issues by developing bionic limbs. The aim of the bionic hands is to replace the amputated hands while restoring sensation and reintroducing hand-motor control. Recently, several different approaches have been made to interface this sophisticated prosthesis with residual neuro-muscular structures. Different types of implants, such as intramuscular, epineural and intraneural, each have their own complementary advantages and disadvantages, which are discussed in this paper. After initial trials with percutaneous leads, present research is aimed at making long-term implantable electrodes that give rich, natural feedback and allow for effortless control. Finally, a pivotal part in the development of this technology is the surgical technique which will be described in this paper. The surgeons' insights into this procedure are given. These kinds of prostheses compared with the classic one, hold a promise of dramatic health and quality of life increase, together with the decrease the rejection rate.
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Affiliation(s)
- Marko Bumbaširević
- Orthopedic and Traumatology University Clinic, Clinical Center of Serbia, Serbia; Faculty of Medicine, University of Belgrade, Serbia.
| | - Aleksandar Lešić
- Orthopedic and Traumatology University Clinic, Clinical Center of Serbia, Serbia; Faculty of Medicine, University of Belgrade, Serbia
| | - Tomislav Palibrk
- Orthopedic and Traumatology University Clinic, Clinical Center of Serbia, Serbia; Faculty of Medicine, University of Belgrade, Serbia
| | - Alexandru Valentin Georgescu
- Department of Plastic Surgery and Reconstructive Microsurgery, University of Medicine Iuliu Hatieganu, Cluj-Napoca, Romania; Clinic of Plastic Surgery and Reconstructive Microsurgery, Clinical Hospital of Recovery, Cluj-Napoca, Romania
| | - Ileana Rodica Matei
- Department of Plastic Surgery and Reconstructive Microsurgery, University of Medicine Iuliu Hatieganu, Cluj-Napoca, Romania; Clinic of Plastic Surgery and Reconstructive Microsurgery, Clinical Hospital of Recovery, Cluj-Napoca, Romania
| | - Čedomir Vučetić
- Orthopedic and Traumatology University Clinic, Clinical Center of Serbia, Serbia; Faculty of Medicine, University of Belgrade, Serbia
| | - Tos Pierluigi
- UOD Reconstructive Microsurgery, AOU Città della Salute e della Scienza di Torino, Torino, Italy
| | - Sladjana Matić
- Orthopedic and Traumatology University Clinic, Clinical Center of Serbia, Serbia; Faculty of Medicine, University of Belgrade, Serbia
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Bumbaširević M, Palibrk T, Georgescu AV, Soucacos P, Matei IR, Vučetić Č, Manojlović R, Marković D, Tos P, Nikolić S, Glišović Jovanović I, Petrović A, Lešić A. "Close-open-close free-flap technique" for the cover of severely injured limbs. Injury 2019; 50 Suppl 5:S29-S31. [PMID: 31706589 DOI: 10.1016/j.injury.2019.10.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The treatment of severely injured extremities still presents a very difficult task for trauma orthopaedic surgeons. Despite improvements in technology and surgical/microsurgical techniques, sometimes a limb must be amputated, otherwise severe and potentially fatal complications may develop. There is a well-established belief that severe open fractures should be left open. However, Godina proved wound coverage in the first 72 h (after an injury) to be safe and to bring good final results. So early wound cover (no later than one week after an injury) with well vascularized free flaps became the gold standard. Yet for many patients (some of whom have serious health problems), operative treatment needs to be postponed when they arrive to specialized microsurgical departments for microsurgical reconstruction much later than one week after incurring an injury. As the definite wound cover period from one week to 3 months seems to be hazardous, especially due to the potential of infection, we developed a safe, original flap technique that prevents infection and covers important structures such as exposed bones, tendons, nerves and vessels. We named this technique the "close-open-close free flap technique". It enables difficult wound cover in any biological phase of the wound, by combining complete flap cover first, with the removal of stitches from one side of the flap after 6-12 h. This technique works very well for borderline cases as well; where even after a complete debridement, dead tissue still remains in the wound - making wound cover very dangerous. Closing completely severe open fractures with free (or pedicled) flaps and removing the stitches on one side after 6-12 h, enables orthopaedic surgeons to safely cover any kind of wound in any biological phase of the wound. Additional debridements, lavages and reconstructions can easily be performed under the flap and after the danger of a serious infection has disappeared, definitive wound closure can be carried out.
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Affiliation(s)
- Marko Bumbaširević
- Orthopedic and Traumatology University Clinic, Clinical Center of Serbia, Serbia; Faculty of Medicine, University of Belgrade, Serbia.
| | - Tomislav Palibrk
- Orthopedic and Traumatology University Clinic, Clinical Center of Serbia, Serbia; Faculty of Medicine, University of Belgrade, Serbia
| | - Alexandru Valentin Georgescu
- Department of Plastic Surgery and Reconstructive Microsurgery, University of Medicine Iuliu Hatieganu Cluj Napoca, Romania; Clinic of Plastic Surgery and Reconstructive Microsurgery, Clinical Hospital of Recovery, Cluj Napoca, Romania
| | - Panayotis Soucacos
- First Department of Orthopedics, National and Kapodistrian University of Athens, School of Medicine, ATTIKON University Hospital, Athens, Greece
| | - Ileana Rodica Matei
- Department of Plastic Surgery and Reconstructive Microsurgery, University of Medicine Iuliu Hatieganu Cluj Napoca, Romania; Clinic of Plastic Surgery and Reconstructive Microsurgery, Clinical Hospital of Recovery, Cluj Napoca, Romania
| | - Čedomir Vučetić
- Orthopedic and Traumatology University Clinic, Clinical Center of Serbia, Serbia; Faculty of Medicine, University of Belgrade, Serbia
| | - Radovan Manojlović
- Orthopedic and Traumatology University Clinic, Clinical Center of Serbia, Serbia; Faculty of Medicine, University of Belgrade, Serbia
| | - Dragan Marković
- Faculty of Medicine, University of Belgrade, Serbia; Vascular surgery University Clinic, Clinical Center of Serbia, Serbia
| | - Pierluigi Tos
- UOD Reconstructive Microsurgery, AOU Cittàdella Salute e dellaScienza di Torino, Torino, Italy
| | - Slobodan Nikolić
- Faculty of Medicine, University of Belgrade, Serbia; Institute of Forensic Medicine "Milovan Milovanovic", Belgrade, Serbia
| | | | - Aleksandra Petrović
- Orthopedic and Traumatology University Clinic, Clinical Center of Serbia, Serbia
| | - Aleksandar Lešić
- Orthopedic and Traumatology University Clinic, Clinical Center of Serbia, Serbia; Faculty of Medicine, University of Belgrade, Serbia
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Abstract
As a result of its proximity to the humeral shaft, as well as its long and tortuous course, the radial nerve is the most frequently injured major nerve in the upper limb, with its close proximity to the bone making it vulnerable when fractures occur.Injury is most frequently sustained during humeral fracture and gunshot injuries, but iatrogenic injuries are not unusual following surgical treatment of various other pathologies.Treatment is usually non-operative, but surgery is sometimes necessary, using a variety of often imaginative procedures. Because radial nerve injuries are the least debilitating of the upper limb nerve injuries, results are usually satisfactory.Conservative treatment certainly has a role, and one of the most important aspects of this treatment is to maintain a full passive range of motion in all the affected joints.Surgical treatment is indicated in cases when nerve transection is obvious, as in open injuries or when there is no clinical improvement after a period of conservative treatment. Different techniques are used including direct suture or nerve grafting, vascularised nerve grafts, direct nerve transfer, tendon transfer, functional muscle transfer or the promising, newer treatment of biological therapy. Cite this article: Bumbasirevic M, Palibrk T, Lesic A, Atkinson HDE. Radial nerve palsy. EFORT Open Rev 2016;1:286-294. DOI: 10.1302/2058-5241.1.000028.
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Affiliation(s)
- Marko Bumbasirevic
- Orthopaedic and Traumatology University Clinic, Clinical Center of Serbia, Serbia.,School of Medicine, University of Belgrade, Serbia
| | - Tomislav Palibrk
- Orthopaedic and Traumatology University Clinic, Clinical Center of Serbia, Serbia
| | - Aleksandar Lesic
- Orthopaedic and Traumatology University Clinic, Clinical Center of Serbia, Serbia.,School of Medicine, University of Belgrade, Serbia
| | - Henry DE Atkinson
- Department of Trauma and Orthopaedics, University College, London Medical School, North Middlesex University Hospital, UK
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Andjelković S, Lesić AR, Palibrk T, Vucković C, Sudjić V, Bumbasirević MZ, Jakovljević A, Djukić VR. [Digital nerve injury of the hand-epidemiologic and clinical analysis]. Acta Chir Iugosl 2010; 57:95-98. [PMID: 21449143 DOI: 10.2298/aci1004095a] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
The aim of this study was to show the significance of epidemiologic factors of digital nerve injury and their social influence. 108 patients were operated with primary suture within first 48 h after injury. We record factors as sex, age, etiology, dominance and level of injury. Results of sensory recovery were measured by Medical Research Council scale (MCR). Males predominantly sustain this injury (83.3%) and we seen more frequently in the young adults. Average age is 34.7 years (from 16 to 70). These injuries rarely isolated and most of them are in the zone II (48.1%). The full recovery we have only in nine patients. Digital nerve injury of the hand are more often found in young mail adults who are work active. They are out of work even six months, and sometimes even more. Some of these injuries leaves permanent disability which have a socio-economic importance.
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Affiliation(s)
- Sladjana Andjelković
- Klinika za ortopedsku hirurgiju i traumatologiju KCS, Medicinski fakultet, Beograd
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