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.