Cannabinoids and Pain: New Insights From Old Molecules

Cannabis has been used for medicinal purposes for thousands of years. The prohibition of cannabis in the middle of the 20th century has arrested cannabis research. In recent years there is a growing debate about the use of cannabis for medical purposes. The term ‘medical cannabis’ refers to physician-recommended use of the cannabis plant and its components, called cannabinoids, to treat disease or improve symptoms. Chronic pain is the most commonly cited reason for using medical cannabis. Cannabinoids act via cannabinoid receptors, but they also affect the activities of many other receptors, ion channels and enzymes. Preclinical studies in animals using both pharmacological and genetic approaches have increased our understanding of the mechanisms of cannabinoid-induced analgesia and provided therapeutical strategies for treating pain in humans. The mechanisms of the analgesic effect of cannabinoids include inhibition of the release of neurotransmitters and neuropeptides from presynaptic nerve endings, modulation of postsynaptic neuron excitability, activation of descending inhibitory pain pathways, and reduction of neural inflammation. Recent meta-analyses of clinical trials that have examined the use of medical cannabis in chronic pain present a moderate amount of evidence that cannabis/cannabinoids exhibit analgesic activity, especially in neuropathic pain. The main limitations of these studies are short treatment duration, small numbers of patients, heterogeneous patient populations, examination of different cannabinoids, different doses, the use of different efficacy endpoints, as well as modest observable effects. Adverse effects in the short-term medical use of cannabis are generally mild to moderate, well tolerated and transient. However, there are scant data regarding the long-term safety of medical cannabis use. Larger well-designed studies of longer duration are mandatory to determine the long-term efficacy and long-term safety of cannabis/cannabinoids and to provide definitive answers to physicians and patients regarding the risk and benefits of its use in the treatment of pain. In conclusion, the evidence from current research supports the use of medical cannabis in the treatment of chronic pain in adults. Careful follow-up and monitoring of patients using cannabis/cannabinoids are mandatory

Liječenje periprotetskih prijeloma bedrene kosti nakon totalne proteze kuka kod Vankuverskog tipa B

Th e rate of periprosthetic femoral fractures following total hip replacement has been growing steadily in the last 20 years and ranges from 0.1% to 2.1%. These fractures are mostly related to older patients with the presence of chronic diseases and frequently poor bone quality. Th e treatment is surgically very complex and demanding, followed by a series of complications. Th e evaluation in this retrospective study included 23 patients who were medically treated from January 2004 to December 2015 with the mean follow-up of 14.5 (range, 9-25) months. Th ere were 17 patients with cement total hip arthroplasty (THA) and 6 with cementless THA. During treatment of fractures, different techniques were implemented including the use of wire cerclage, dynamic compression plates (DCP), a locking compression plate (LCP) system, and long revision stem. For the purpose of distinguishing fractures, we used the Vancouver classifi cation by Duncan and Masri. For clinical evaluation, we used the modifi ed Merle d’Aubigne score system and monitored complications during treatment. Th e aim is to show treatment results of the type B periprosthetic femoral fractures by using diff erent operative treatment techniques. According to the Vancouver classifi cation within type B, 10 (43.47%) patients had type B1 fractures, another 10 (43.47%) patients had type B2 fractures, and three (13.04%) patients had type B3 fractures. According to gender distribution, there were eight (34.8%) male and 15 (65.2%) female patients, mean age 59.5 (range, 47-86) years. Twelve (52.2%) and 11 (47.8%) patients had left- and right-sided fractures, respectively. Th e mean length of hospital stay was 16 (range, 9-26) days. According to the Merle d’Aubigne score system, 10 patients with type B1 fractures had the mean score of 11.5 points, which is poor result. Poor result was also recorded in patients with type B2 fractures, with the mean score of 10.6 points. Th e three patients with type B3 fractures had the mean score of 12 points, which is considered fair score. In conclusion, Vancouver classifi cation has been widely accepted and using the protocols makes decision making during treatment much easier. During treatment of this type of fracture, we used various implants, wire cerclage, DCP and LCP, as well as long stem revision. In certain cases, we applied surgical techniques, implants that are not recommended by the Vancouver protocol by which we treated periprosthetic femoral fractures; in these case, we recorded nonunion bone, malunion and breaking of implants, which resulted in poor treatment outcome.Incidencija periprotetskih prijeloma bedrene kosti kod totalne proteze kuka (TPK) je u stalnom porastu u posljednja dva desetljeća i kreće se u opsegu od 0,1%-2,1%. Ovi su prijelomi karakteristični za osobe starije životne dobi s prisutnim kroničnim bolestima, često slabijom kvalitetom kosti, a samo liječenje je kirurški složeno i zahtjevno te praćeno nizom komplikacija. Ova retrospektivna studija je obuhvatila 23 bolesnika liječenih u razdoblju od siječnja 2004. do prosinca 2015. godine. Srednje vrijeme praćenja je bilo 14,5 (od 9 do 25) mjeseci. Bilo je 17 bolesnika s cementnom i šest s bescementnom TPK. U rješavanju prijeloma rabili smo različite tehnike: uporabu žičanih serklaža, DC ploče, LCP sustava i dugog revizijskog stema. Za podjelu prijeloma služili smo se Vankuverskom klasifi kacijom po Duncanu i Masriju. Za kliničku evaluaciju rabili smo modifi cirani Merle d’Aubigneov sustav bodova i pratili komplikacije tijekom liječenja. Cilj je prikazati rezultate liječenja periprotetskih femoralnih prijeloma tipa B nakon uporabe različitih operativnih tehnika i implantata u rješavanju ovoga tipa prijeloma. Prema Vankuverskoj klasifi kaciji unutar tipa B zabilježena je podklasifi kacija na B1 s 10 (43,47%) bolesnika, B2 s 10 (43,47%) bolesnika i B3 s 3 (13,04%) bolesnika. Distribucija bolesnika prema spolu bila je: 8 (34,8%) muškog spola i 15 (65,2%) ženskog spola. Srednja životna dob ispitanika bila je 59,5 (47-86) godina. Od ukupnog broja ispitanika bilo ih je 12 (52,2%) s prijelomom na lijevoj i 11 (47,8%) na desnoj strani. Srednje vrijeme hospitalizacije je bilo 16 (9-26) dana. Primjenom Merle d’Aubigneova sustava bodova kod 10 bolesnika s prijelomom B1 dobivena je srednja ocjena od 11,5 bodova (loš rezultat). Kod 10 bolesnika s prijelomom B2 dobivena je srednja ocjena od 10.6 bodova (loš rezultat). Kod 3 ispitanika s prijelomom B3 dobivena je srednja ocjena od 12 bodova (dovoljan rezultat). Vankuverska klasifikacija i protokol liječenja za periprotetske femoralne prijelome kod TPK je opće prihvaćena i daje sigurne smjernice u donošenju odluke pri liječenju, odnosno korištenju implantata. U našem radu rabili smo različite implantate, žičane serklaže, DC ploču, LCP sustav i dugi revizijski stem u kiruškom liječenju ovoga tipa prijeloma. U određenom broju slučajeva primijenili smo kirurške tehnike odnosno implantate koje ne preporučuje Vankuverski protokol; u ovim slučajevima zabilježen je izostanak cijeljenja kosti, pomicanje i lomljenje implantata, što je rezultiralo nezadovoljavajućim ishodom liječenja

Flat feet in children

The authors describe flatfoot, as one of very frequent deformities in everyday medical practice. A special condition of the deformity associated with a calcaneal valgus position and complicated by a knee valgus position (as a consequence of non-treatment) is described. Also, the precise anatomy of the longitudinal foot arches (medial and lateral), definition and classification of the deformity, clinical findings and therapeutic protocols are proposed. The authors especially emphasise that the need for having extensive knowledge on the differences between a flexible and rigid flatfoot, having in mind that the treatment of flexible flat foot is usually not necessary, while the treatment of rigid flatfoot is usually unavoidable

Legg-Calvé-Perthes disease: Diagnostics and contemporary treatment

Legg-Calvé-Perthes disease represents avascular necrosis of the femoral head in a growing child. It commonly affects children aged 2-14 years, mostly boys, and has familiar pattern. The etiology of this disease is unknown. It is based on avascular necrosis due to variations of the femoral head vascular supply, trauma, coagulation of endocrine disturbances. The disease presents with limping and pain localized in the hip with projection to thigh and knee, frequently accompanied by the limitation of abduction and internal rotation, as well as slight limitation in flexion of about 20 degrees. Plain radiography is most informative additional diagnostic procedure, enabling assessment of the stage of disease, containment of the femoral head within the acetabulum, acetabular coverage and the extent of disease. Main treatment goal is obtaining the spherical congruity of the hip joint. This can be achieved by abduction bracing, varization femoral osteotomies and various innominate osteotomies (sometimes combined with femoral osteotomies). Children younger than four years of age, with minimal femoral head involvement, do not need any treatment. These children with a larger involvement, older than four years of age, with possible containment in hip abducion, should be treated by one of the following procedures: Salter innominate osteotomy, Salter innominate osteotomy with femoral shortening, or triple pelvic osteotomy. The patients with containment of the hip is not possible in abduction (related to subluxation and femoral head crush), should be treated by Chiari pelvic osteotomy

Forearm reconstruction after loss of radius: Case report

Introduction. Osteomyelitis of the radius resulting in the radial clubhand is a very rare condition and few studies have been published about its prognosis and treatment. Case Outline. This is a case report of hematogenous osteomyelitis of the radius with a complete loss of the radius leaving only the distal radial metaphysis to carry the carpus. In order to achieve best functional results, four-step operative protocol was performed for reconstruction; lengthening of the forearm by external fixator, radioulnar transposition to create a one-bone forearm, plate removal and transposition of brachioradialis to the extensor pollicis longus as well as proximal row carpectomy. After nine years of the last operation, the function of the elbow and hands is good with acceptable cosmetic result. The forearm is 5 cm shorter and there has been a persistent mild limitation of palmar flexion. Conclusion. Creation of the one-bone forearm normalizes the elbow and wrist function, corrects forearm malalignment, and improves forearm growth potential

Infected tibial nonunions: Treatment by the Ilizarov method - multicentric study

Introduction. Associated bone tissue defect and infection, commonly result in non-healing, i.e. by the development of infected tibial nonunion. Objective. The aim of the paper was to present experiences acquired in the treatment of this problem by the application of the Ilizarov method. Methods. The analyses enrolled 16 patients diagnosed with infected tibial nonunion. The Ilizarov method was used in all the patients, of type bilocal synchronous compressive-distractive or bilocal alternating compressive-distractive. Bone and functional results were classified as excellent, good, fair and poor. Total follow-up period of the patients was 48.77±41.57 months on the average. Results. Fifteen (93.75%) cases of nonunions were successfully healed. According to the laboratory findings of inflammation, the same patients were also successfully treated for local infection. The inequality of the lower limbs was also resolved by new bone formation of average length of 5.75±3.29 cm. Poor result was verified in one (6.25%) patient only. The patient satisfaction was scored 3.73±1.33 and physician’s satisfaction 4.33±1.11. Conclusion. The Ilizarov method with bone transport, because of being capable to solve simultaneously a local infection and tibial malalignement, and by substituting bone and soft tissue defects, thus enabling healing of until then unhealed bone, has shown as the best method in the treatment of this complex problem, infected tibial nonunions

Treatment of Periprosthetic Femoral Fractures after Total Hip Arthroplasty Vancouver Type B

Th e rate of periprosthetic femoral fractures following total hip replacement has been growing steadily in the last 20 years and ranges from 0.1% to 2.1%. These fractures are mostly related to older patients with the presence of chronic diseases and frequently poor bone quality. Th e treatment is surgically very complex and demanding, followed by a series of complications. Th e evaluation in this retrospective study included 23 patients who were medically treated from January 2004 to December 2015 with the mean follow-up of 14.5 (range, 9-25) months. Th ere were 17 patients with cement total hip arthroplasty (THA) and 6 with cementless THA. During treatment of fractures, different techniques were implemented including the use of wire cerclage, dynamic compression plates (DCP), a locking compression plate (LCP) system, and long revision stem. For the purpose of distinguishing fractures, we used the Vancouver classifi cation by Duncan and Masri. For clinical evaluation, we used the modifi ed Merle d’Aubigne score system and monitored complications during treatment. Th e aim is to show treatment results of the type B periprosthetic femoral fractures by using diff erent operative treatment techniques. According to the Vancouver classifi cation within type B, 10 (43.47%) patients had type B1 fractures, another 10 (43.47%) patients had type B2 fractures, and three (13.04%) patients had type B3 fractures. According to gender distribution, there were eight (34.8%) male and 15 (65.2%) female patients, mean age 59.5 (range, 47-86) years. Twelve (52.2%) and 11 (47.8%) patients had left- and right-sided fractures, respectively. Th e mean length of hospital stay was 16 (range, 9-26) days. According to the Merle d’Aubigne score system, 10 patients with type B1 fractures had the mean score of 11.5 points, which is poor result. Poor result was also recorded in patients with type B2 fractures, with the mean score of 10.6 points. Th e three patients with type B3 fractures had the mean score of 12 points, which is considered fair score. In conclusion, Vancouver classifi cation has been widely accepted and using the protocols makes decision making during treatment much easier. During treatment of this type of fracture, we used various implants, wire cerclage, DCP and LCP, as well as long stem revision. In certain cases, we applied surgical techniques, implants that are not recommended by the Vancouver protocol by which we treated periprosthetic femoral fractures; in these case, we recorded nonunion bone, malunion and breaking of implants, which resulted in poor treatment outcome

Extremity replantations: Possibilities and limitations

Amputated parts of extremities can be replanted under some convenient conditions. Replantations have been done for over four decades. The long way of technological development has been passed and today the great results of recovering are reached. Replantations are challenge with many possibilities, but also with many limitations, because the operation is very complexive. Our research shows that traumatic amputations on extremities in Serbia are mostly caused by circular saw (41%), by ax (14,6%), by shelter (12,5%), by press and in traffic (10,4%), by cable, rope, chain and derrick (9%) and by wedding ring (2,1%). General recovery of replanted fingers, according Tamai criteria, on our clinical material was excellent in 29,8% of cases, good (42,5%), satisfying (22,9%) and bad (4,6%). Every patient was satisfied with operation, according the subjective patients' estimation. During the past decades the huge experience has been collected and various technological development in medicine suggest redefinition of indications and also suggest accepting particular, individual indications in some cases of amputated parts of extremity and replantations

Evaluation of reversal osteofixation using K-wires in digital replantation

Introduction. Modified, reversal technique of fixation in digital replantation using K-wires was analyzed. The results obtained from the standard technique and reversal technique of fixation using K-wires were compared. Objective. The aim was to compare the results of osteofixation using K-wires in digital replantation when either standard or reversal, modified technique was used. Methods. A retrospective study included 103 replanted fingers in 72 patients. The first group included standard fixation using K-wires and the second group included fixation using K-wires, but with a modified technique. Modification consisted of the opposite order of moves during the phalanges fixation compared to the standard technique: first, K-wire was introduced intramedullary in the proximal phalanx and the top of the wire was drawn out through the skin in proximal part of the finger or hand. Second, distal part of the wire was introduced in the phalanx of the amputated part of the finger intramedullary until the wire entered the cortex. Results. Duration of bone healing after digital replantation was shorter in cases where reversal technique was used in comparison with standard technique (7.2 weeks compared to 7.5 weeks). Conclusion. The comparison of standard and reversal technique of phalangeal fixation with K-wires in digital replantation shows that both techniques are useful. Reversal technique expands the choice of operative techniques for bone fixation during the replantation. It shows some advantages and enables avoidance of vein injuries. [Projekat Ministarstva nauke Republike Srbije, br. III 41004 i br. 175095

The treatment of subtrochanteric fractures

Subtrochanteric fractures of the femur have a special place because of a significant number of complications following treatment. Powerful loading forces asymmetrically acting to this bone segment, as well as poor vascularization interfere with bone union. There are basically two current approaches in the fixation of subtrochanteric fractures; the first involves a plate with a compression screw and another one is intramedullary (IM) nail, with two options: centromedullary (standard interlocking femoral nail) and cephalomedullary femoral nail with two modifications, reconstructive and trochanteric. All IM nails may be used by open technique or closed minimal invasive method. IM nailing is favoured in view of a shorter operative time, shorter hospitalisation and complications. Indirect fracture reduction and knowledge of biology of bone fracture may result in full success without any bone graft