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The new osteomyelitis classification was worked out on the strength of treatment results of 361 patients. Four types of long bones lesions are marked out: medullar, superficial, focal and diffuse. The kind of surgical treatment is determined according to the lesion type. Authors worked out a modification of osteoplastic trepanation--a "grip-sack" technique, which is used for medullar and focal femoral and tibial osteomyelitis. Long term follow-up results are obtained in 271 (77,7%) cases. The developed classification eases the standardization of follow-up results and permits treatment planning.

Follow-up results of 162 patients with necrotic suppurative forms of the diabetic foot syndrome (DFS) are studied in a period of 6 months to 7 years. 51.35% of patients with neuropathic form of DFS (NPDFS) relapsed, whereas among patients with neuroischemic form (NIDFS) relapse was reported in 61.36% of cases. High amputations were performed in 31.58% of patients with NPDFS and in 34.09% in patients with NIDFS. Lethality after five years of follow-up was 25.81% after shank-level amputation and 50% after hip-level amputation in patients with NPDFS, and in the group of NIFDS these numbers amount 57.84% and 72.12%, respectively. Authors conclude that compensation of diabetes and its late complications is crucial for patients with DFS. Surgical treatment should be maximal sparing, with possible foot preservation. Vascular reconstructive surgery should be preferred in NIDFS for critical limb ischemia reduction. The level of high limb amputations in patients of both groups should be limited by shank when possible.

During 2005-2007 128 patients at the age from 21 to 80 years with extensive trophic ulcers of legs were treated in the contaminated surgery department of A.V. Vishnevsky Surgery Institute and Korolenko Hospital. In 87 patients (69.9%) varicosity was the cause of venous insufficiency, in 41 patients--post-thrombotic disease. 23 patients (17.97%) had double-sided throphic ulcers. In 50 patients (39.1%) ulcer area exceeded 40 cm2. In microscopical analysis fungi were discovered in 87 patients (89.06%). In the remaining 15 patients diagnosis was verified culturally. System etiotropic antimycotic antibacterial treatment including hyposensitizative, anti-inflammatory, antihistamine drugs was carried out. 34 patients (26.57%) received broad spectrum antibiotic from terbinafine group (Terbizil) in dosage 250 mg once a day during 3 moths with concurrent use of topical antimycotics. 34 patients (26.56%) recieved pulse therapy with broad spectrum antibiotic Rumicoz 400 mg a day during 7 days in combination with topical antimycotics. Nizoral 400 mg a day during 30 days was prescribed to 26 patients (20.3%). 34 patients (26.56%) were treated only with topical antimycotics. After preoperative preparation and reduction of inflammatory process 64 patients had underwent excision of trophic ulcers whereupon the therapy was continued. In these patients regress of varicose eczema manifestation was achieved on the 10th day. In patients who hadn't received surgical cure regress of varicose eczema was signed on the 23-25th day after onset of treatment. Question of plastic closing of throphic ulcers and wounds after their excision was solved particularly. 14 patients needed recurring surgical management becose inflammatory process was continued. Comprehensive approach to therapy taking into account mycotic semination appears to be appropriate and effective. Proactive surgical tactics (excision of throphic ulcer) allows to quicken preoperative preparation for correction of venous blood flow.

Severe hypercoagulation syndrome was diagnosed in patients with various forms of diabetic foot. Pathology at coagulogram parameters reflects systemic metabolic and inflammatory disturbances. Anticoagulant therapy should be combined with correction of glycemia, treatment of infection and critical ischemia. Only this complex therapy can normalize coagulation parameters and reduce the risk of thrombotic complications.

Endoscopic subfascial dissection was performed in patients with chronic venous insufficiency of CEAP class 4-6. 76 surgeries were performed in 68 patients. Mean age of the patients was 56 years. The causes of chronic venous insufficiency were varicose (37) and postthrombotic diseases. Trophic ulcers were in 46 patients. Thirty patients underwent earlier various phlebectomies, including Linton's surgery (6 patients). In 33 patients endoscopic subfascial dissection of venous perforants was combined with various phlebectomy, in 37 patients -- with excision of ulcer with following autodermoplasty few days after surgery. Endoscopic subfascial dissection was carried out with special surgical R.Wolf endoscope with 6 mm instrumental canal, and also standard laparoscopic optical devices "Olympus". Complications during surgery were seen in 2 patients: bleeding in subfascial space (1.3%) and perforation of tissues in ulcer zone (1.3%). In postoperative period long (up to 14 days) lymphorrhea and suppuration of surgical wound were in 2 (2.6%) patients. It is concluded that endoscopic approach is optimal for elimination of pathological reflux through venous perforants in complicated forms of chronic venous insufficiency of the lower extremities, including trophic ulcers resistant to treatment.

Anaerobic infection is one of the most complicated problems of pyosurgery. The algorithm of examination of patients with anaerobic infection including intraoperative diagnosis is proposed. Surgical treatment playing also diagnostic role is the basis of combined treatment of soft tissues anaerobic infection. Early diagnosis and active surgical policy is one of the main ways of problem solving.

Three hundred and fifteen patients with necrotic forms of diabetic foot were examined and treated. Neuropathic infected form of diabetic foot was diagnosed in 45.7% patients, neuro-ischemic form--in 54.3%. Mixed aerobic-anaerobic infection in foot's necrotic focus was detected in 87.6% diabetic patients, only aerobic--in 12.4%. High level of intoxication was seen in these patients. Algorithm of complex surgical treatment of different forms of diabetic foot is presented.

Long-term and severe pyonecrotic processes in diabetic patients testify to severe disorders of immune system in this disease. High titer of antibodies to tested autostrain demonstrated its etiologic role in infectious process. The study group consisted of 29 patients (with diabetic pyonecrotic foot lesions), control group--17 patients with burns of III a, b--IV stage affecting from 20 to 60% of body surface. In diabetic patients antibodies titer to the most encountered infectious agents Staphilococcus aureus and Pseudomonas aeroginosa was lower than in burn patients with immunity deficiency. Decrease of antibodies titer in diabetic patients testifies to high insufficiency of B-immunity.

Early studies have demonstrated that the unique phenomenon ATP aerobic synthesis on neutrophilic plasma membranes is observed when neutrophils are activated with the chemoattractive peptide FMLP. This paper presents the results of the study of a possible association of ATP plasma membranous synthesis with priming, with the occurrence of respiratory explosion and apoptosis of the neutrophils isolated from the blood of donors and patients with surgical infection of different severity. The interaction of neutrophilic plasma membranes with FMLP and with hTNF (was attended by ATP synthesis. Examining the level of FMLP-stimulated production of superoxide in patients with surgical infection revealed that the amount of the superoxide produced by neutrophils noticeably decreased and droppped by more than 5 times in sepsis. The FMLP-stimulated plasma membranous synthesis of ATP was determined in the same patients. A decrease in the production of superoxide was simultaneously accompanied by a reduction in the plasma membranous synthesis of ATP. Both the plasma membranous synthesis of ATP and the production of superoxide declined in sepsis at the most. The neutrophils isolated from peripheral blood of the same patients showed DNA damage whose degree was directly related to the condition of a patient. The maximum DNA damages were observed in sepsis. The findings suggest that apoptosis is induced in surgical infection in the peripheral neutrophils. The DNA damage and the FMLP-stimulated plasma membranous synthesis of ATP was estimated in the neutrophils isolated from the inflammation focus. It turned out that in local surgical infection, there were the maximum DNA damages and the FMLP-stimulated plasma membranous synthesis of ATP was lower than that in the peripheral neutrophils. It can be suggested that the FMLP-stimulated plasma membranous synthesis of ATP may be a regulators of neutrophilic functional states in surgical infection and sepsis.

Aim: To evaluate effectiveness of sulodexide in patients with pyonecrotic complications of diabetic foot., Material and Method: Sulodexide was given to 15 patients which were examined for blood fibrinogen, foot tissues saturation with oxygen, microbic contamination of the wound tissue. In addition, ultrasound dopplerography of foot arteries, laser doppler flowmetry were performed., Results: Fibrinogen in peripheral blood fell, arteriovenous shunting diminished, capillary blood flow and oxygen saturation of the tissues improved., Conclusion: Even early sulodexide treatment is effective at different stages of the pathological process in diabetic patients with severe pyonecrotic lesion of the lower limbs as it recovers microcirculatory blood flow.

The immunological study was made in which the drug sensitivity index according to S. M. Demyanenko was estimated in 76 patients (24 women and 52 men aged 17-73 years): in patients with soft tissue purulent infection (group 1, n = 46) and surface thermal burns (degree III-IV) of 40% body surface (group 2, n = 30). Patients with satisfactory drug tolerance served control (16 patients of group 1 and 10 ones of group 2). Correlations between humoral and cellular immunity parameters and drug sensitivity index were studied. The results may serve a basis for development of early and adequate correction of immunological disorders in the above patients, of drug-related complications caused by immunological imbalance.

Objective rapid morphological and hemostasiological methods for evaluating the reparative process in the wound making use of PC software have been developed for identification of stages of reparative process in the wound under conditions of modern surgical service. Cytran consultative software has been developed for evaluation of phases of reparative reaction in the wound. Coagulogram consultative software was used for identification of reparative reaction phases in the wound from hemostasiological changes in tissue factors of granulation tissue in the wound. Cytran and Coagulogram software were used under clinical conditions in 105 patients with open, suppurative, and burn wounds for characterization of the reparative reaction phases.

Experiences with surgical treatment of 269 patients with chronic osteomyelitis of long bones based on the principles of active surgical treatment of purulent wounds were summarized. Certain aspects of surgical treatment of patients with chronic osteomyelitis were revised and supplemented. Different variants of surgical treatment of the osteomyelitis focus were shown depending on the volume and character of the injury and the methods of plastic substitution of defects of the bones and soft tissues. Main principles of antibacterial therapy for chronic osteomyelitis are described.

Clinical and bacteriological efficacies of vancomycin (Edicin, LEK) in the treatment of 17 patients with wound infection and 13 patients with thermal affections were studied. The clinical efficacy in the group of the patients with purulent wounds of the soft tissues amounted to 94.1 per cent and that in the patients with thermal affections was 92.3 per cent. The bacteriological effect was recorded in 86.6 per cent of the patients with purulent wounds of the soft tissues and in 69.3 per cent of the patients with burn infections. The drug intolerability was observed in two cases.

The experience in surgical treatment of 269 patients with long bone chronic osteomyelitis based on the principles of active surgical policy for purulent wounds is summarized. Some aspects of osteomyelitis surgical treatment are reconsidered and complemented. Variants of osteomyelitic focus surgical debridement dependent on severity the lesion as well as methods of plastic replacement of bones' and soft tissues' defects are demonstrated.

Two groups of patients with a grave form of diabetes mellitus type I and II with diabetic foot syndrome have been examined. Group 1 (21 cases) consisted of patients whose foot was amputated. The cause of the necrotic process was ischemia produced by alteration of the arterial vessels aggravated by infection. Patients of group 2 (18 cases) were treated with resultant wound healing and foot preservation. The material was subdivided into two subgroups: 1) tissue from the "infectious" foot with great amount of bacteria and inflammation reaction; 2) tissue from the "ischemic" foot with considerable alterations of microvessels structure. In both groups well developed granulation tissue was observed after the treatment; almost all the cells of this tissue included 3H-uridin and labelling with 3H-thymidine was increased in fibroblasts, endotheliocytes and pericytes.

The problems of terminology are discussed, as well as classification and definition of sepsis. Comparative analysis of traditional for our country and up-to-date foreign classifications is carried out. The criteria for diagnosis of sepsis are discussed. On the basis of 20-year experience in examination and treatment of patients with sepsis, the authors set forth their own stand, suggesting two varieties of sepsis for consideration: common complication of surgical infection, a rare disease.

Application of gas-liquid chromatography methods and mass-spectrometry enabled the authors to develop objective criteria, which provided prompt acceptance of quantity information about the stage ams severity of the wound process, its influence on the organism and prognosis of expectant complications (taking into account aerobic or anaerobic components of microflora) and early correction of surgical policy.

For the period from 1996 to 1998 in the Division of wounds and wound infection of A.V. Vishnevsky Institute of Surgery 92 patients with pyonecrotic forms of "diabetic foot" underwent thorough examination and treatment. The patients were divided into groups by the form of "diabetic foot": with pyonecrotic forms of "diabetic foot" without critical ischemia (group 1) and with it (group 2). In 18 patients of both groups the data of electron autoradiography were used to reveal peculiarities of the wound process. Group 1 patients had at admittance a large number of neutrophiles in various stages of destruction in biopsies of the wound. In patients of group 2 a great majority of the vessels in biopsies of the wound were in different stages of destruction with lost connections between their separate cells or some of their part absent. Separate cells (endotheliocytes and pericytes) which make up the walls of destroying vessels, were synthesizing RNA and were functionally active. In both groups, the studied parts of the wound before plastic repair of its defect usually represented as well developed granulation tissues with a number of microvessels and cells. Intensive synthesis of PNA in the cells of microvascular wall evidenced of their high functional activity, and the synthesis of DNA in them showed their ability for proliferation, i.g.--for growth. Thus, microangiopathy was reversible, and the solution of the problem of critical ischemia should be considered in the light of macroangiopathy. Thus, in patients of group 1 the cause of pyonecrotic damage consists in infection process, while in patients of group 2--in combination of infection with ischemia of the extremity. In both groups pyonecrotic disease of the extremity ruses at the background of severe disturbances of cellular immunity.

The analysis of the treatment of 900 patients with large festered wounds of various genesis and location for the period from 1973 to 1998 years in the intensive care department has shown, that infection of respiratory ways is encountered in 30% of cases (in patients with nonsporeforming anaerobic bacteria--in 11-12%), bacteriuria--in 70-80%, bacteriamia--in 75% of patients with sepsis. In acute pyogenous diseases of soft tissues microbes from the wounds in monoculture were isolated out in 83.3% of cases, associations of gram-positive and gram-negative bacteria--in 16.7%, in chronic pyogenous diseases of soft tissues--in 60 and 40% of cases, respectively. In sepsis associations of gram-positive and gram-negative microbes were isolated in 55.6% of cases. Most often (91%) pathogenic staphylococcus was found in hemocultures. Uring in 62% of cases contained association of gram-positive and gram-negative microorganisms, in sputum gram-positive microflora in monoculture (69%) prevailed. In the group of patients with peritonitis, phlegmon of the anterior abdominal wall, diabetic phlegmon and gangrene, crush syndrome the association of anaerobic and aerobic microflora (from 57.1 to 98.8%) prevailed in the wounds. Application of up-to-date antimicrobial means in the intensive care unit resulted in a decrease of mortality rate in sepsis and complicated course of wound infection up to 23%, and in anaerobic nonsporeforming infection--up to 15%.

The 25-year experience with the underbandage treatment of soft tissue purulent wounds of various location and genesis with modern ointments with polyethylene glycol as the basis was analyzed. Levocin, levomecole, dioxycole, 5-percent dioxydinic, 1-percent iodopyronic, 0.5-percent quinifuryl and furagel ointments proved to preserve their high activity against aerobic grampositive and gramnegative flora. 10-percent mafenide acetate ointment had a high selective effect on Pseudomonas aeruginosa. The new ointments nitacid and streptonitole containing nitazole and white streptocide were highly active against both aerobic and anaerobic infections. The use of the ointments with the polyethylene glycol as the basis made it possible to decrease 2 times the period of the patient hospitalization in surgical units and to shorten the terms of the systemic antibacterial therapy. The marked therapeutic effect of such ointments due to their high dehydrating capacity and broad antibacterial spectrum enabled to consider them as the drugs of choice in the local treatment of purulent wounds during the 1st phase of the wound process, trophic and decubic ulcers, infected burns, diabetic and atherosclerotic gangrene, furuncles, carbuncles, mastitis, etc. The ointments in the water soluble vehicle can be as well used with success for the prophylactic treatment of infected wounds after the suture. The multitarget effect of the ointments in the water soluble vehicle and their ability to prevent severe purulent complications permitted to consider them as the 1st order drugs in cases of emergency.

Nitazole, a drug from the nitrotiazole group, was shown to be active in vitro against bacteroides, peptococci, peptostreptococci, clostridia, staphylococci, colibacilli and streptococci. By its activity and antibacterial spectrum nitazole had some advantages over metronidazole, a drug from the nitroimidazole group. Experimental study of nitazole aerosole formulation in 4 models of purulent wounds of rabbits infected by Bacteroides fragilis, B. melaninogenicus, Clostridium perfringens 27 and Staphylococcus aureus 209P revealed its high therapeutic efficacy. In the treatment of 37 patients with purulent wounds of the soft tissues including 12 cases isolating anaerobic microbes, the clinical process of the acute suppuration in all the patients at the average reduced to the 5th-7th day. By the data of the bacteriological and cytological examinations the wound surface was ready for putting in stitches or free perforated cutaneous graft by the 10th-12th day. The drug tolerance was good. No adverse reaction were observed under the nitazole dressing in any case during the treatment of the wounds.

The method of estimation of lysozyme activity in serum when chitin azure is used as substrate is described. The basis of incubation medium is 0.1 M acetate buffer, pH 5.0. It was judged about activity of lysozyme by fluorescence of azure in incubation medium at the end of three hour incubation at 37 degrees C after separation on non-reacted chitin azure by short time centrifugation. It was shown that development of wound infection is accompanied by increasing of chitinase activity of lysozyme in serum.

Piperacillin/tazobactam (P/T) or tazocin was used in the treatment of 40 patients with soft tissue purulent necrotic wounds of various genesis and localization. In the majority of the patients the affection was of recurring nature. P/T was administered in a dose of 4.5 g 3 times a day for 1 to 14 days (mainly for 8 to 10 days) as 30-minute intravenous infusions. The clinical effect of the treatment was stated in 36 patients (90 per cent). In 3 out of 8 patients with diabetes mellitus the treatment failed. In 1 patient the treatment was discontinued after the first dose because of asphyxia and a short-term decrease of the arterial pressure. Among 105 microbial strains isolated from 75 patients 64 were highly susceptible to P/T, 33 were moderately susceptible and 8 were resistant. 76.3 per cent of the isolates produced beta-lactamase, 66.3 per cent of them were susceptible to P/T. 54 gram-positive and gram-negative strains were isolated from 40 patients. 16 out of the 54 strains were isolated as monocultures and the others as associations. After the treatments the pathogen eradication and the pathogen eradication followed by superinfection were stated in 26 patients (66.7 per cent). In 11 patients (28.2 per cent) the pathogen persistence was observed at the background of the clinical improvement in the majority of the patients. The relapses were recorded in 2 patients (5.1 per cent).

The efficacy of cefpirome was estimated in the treatment of 25 patients: 15 patients with pyo-necrotic wounds of the soft tissue of various genesis and localization and 10 patients with deep thermal burns involving 8 to 40 per cent of the body surface. The clinical and bacteriological efficacies of the treatment in the patients with the wound infection amounted to 100 and 80 per cent respectively. In the patients with the burn infection the respective values were 90 and 80 per cent. The drug tolerance was good. Adverse reactions were observed in 1 patient. Bolus intravenous administration of the drug was preferable by comparison with the injections.

128 cases of artificially caused purulent diseases have been analysed. All the cases were masked as chronic septicemia, recurrent abscesses, nonhealing wounds and fever of the unclear origin. The specific features of artificial diseases have been pointed out: social status, occupation, provoking factors, specific clinical signs--multiple hospitalizations, dominating location of postoperative scars and abscesses. Diagnostic principles, including psychological ang psychiatric testing are discussed. The neuro-psychiatric disorders were detected in most cases. Prevention of such diseases is analysed.

The experience with ofloxacin used for 10 years from 1986 to 1995 in the complex therapy of 208 patients with wound infection complicated in 51 patients (24.5 per cent) by respiratory tract infection such as purulent tracheobronchitis or pleuropneumonia was generalized. In 28 patients (13.5 per cent) persistent bacteriuria not susceptible to the routine drugs was stated. The clinical and bacteriological efficacies of ofloxacin in the group of the patients with noncomplicated purulent wounds of the soft tissues amounted to 85-91 and 74-80 per cent respectively. In the group of the patients with wound infection complicated by respiratory or urinary tract infection the clinical and bacteriological efficacies equaled 94-100 per cent. The appetite disorder, epigastric pain or nausea were rare. Only in 3 cases the adverse reactions required the treatment discontinuation. Despite the use of ofloxacin for many years, the susceptibility of the main causative agents of surgical infections to the drug remained high: Staphylococcus epidermidis 93.3 per cent, Staph.aureus 94.5 per cent, Pseudomonas aeruginosa 96.5 per cent, Escherichia coll 100 per cent, Proteus spp. 100 per cent, Enterobacter spp. 100 per cent, Acinetobacter spp. 82.3 per cent and Klebsiella spp. 88.8 per cent. The successive use of ofloxacin, at first intravenously for 3-5 days and then orally in the form of tablets for 3-5 days, in the treatment of 15 patients with wound infections of various genesis and localization subjected to osteoplastic reconstructive operations provided positive effects in all the cases and was economically advantageous.

Microflora of purulent necrotic lesions of the foot in 14 patients with diabetes mellitus was investigated by aerobic and anaerobic procedures. It was shown that the process was due to the same species of pathogenic microorganisms irrespective of the lesion severity. However, the number of the pathogens in the associations and the dissemination level per a patient were higher when the lesions were extended. The tissue microbial dissemination in the purulent foci was also higher in the patients with wounds complicated by marked inflammation of the surrounding tissues and the tissues under the lesion. The time course of the changes in the foot microflora during the target-aimed antibacterial therapy was followed up.

The clinical efficacy of sulperazone (cefoperazone + sulbactam) manufactured by Pfizer (USA) was studied in the treatment of 25 patients with wound infections. By the disease severity and complications 9 patients belonged to the risk group. Insulators with abacterial media or bandages with ointments on the polyethylene glycol base and drugs stimulating reparative processes (methyl-diadioxylin, dioxyzol, gentacycol) were used for the local treatment of the wounds. The clinical efficacy was stated in 92 per cent of the cases and in 76 per cent of the cases the efficacy was bacteriological. The tolerance of sulperazon was good in all the cases. The signs of the drug intolerance or affection of the hepatic or renal function were not detected. 281 clinical isolates of the aerobic microflora were tested for their antibiotic susceptibility. The highest susceptibility to sulperazone was observed in gram-positive organisms, gram-negative bacilli (Proteus mirabilis, Escherichia coli and Klebsiella spp.) and some nonfermenting bacteria.

Neutrophil leucocytes of patients with sepsis, purulent inflammatory processes clinically close to sepsis and those of healthy persons were studied electron-microscopically. Leucocytes with degranulation due to the release of their content into the circulation were found in purulent-inflammatory diseases. Leucocytes with pronounced degranulation, areas with cytoplasma lysis and extracellular organelles (lipid droplets, primary and secondary granules with clear-cut membrane borders and content of granules without membrane borders) were observed in sepsis.

The wounds without healing for a long time (from 1 month to 2 years) were studied histologically and electron-radioautographically. The reduction of the vessel number in such wounds occurs, first, due to degenerative changes in the cells of their walls, and second, due to loss of connection between the cells. Some of these cells retain functional activity (incorporation of 3H-uridine) and capacity for proliferation (incorporation of 3H-thymidine). The latter is particularly characteristic for pericytes, this proving their role as a source of fibroblasts in the stage of organization and formation of the scar.

A clinicolaboratory study on the efficacy of lomefloxacin (maxaquin, Searle, USA) was carried out in the treatment of 31 patients with wound infections. In the complex therapy the clinical efficacy of the drug amounted to 96.7 per cent and its bacteriological activity reached 64.6 per cent. The drug tolerance in the majority of the cases was good. Only in one patient an allergic reaction in the form of multiple skin eruption on the 6th day of the treatment was recorded. One patient showed an insignificant increase in the level of alanine aminotransferase not accompanied by any signs of hepatic insufficiency.

To close extensive infected wounds and to replace long bone defects, along with other methods a method of graded tissue strain (GTS) has been developed and introduced into practice (246 patients). The method differs from all others in that it requires no transfer of elaborate flaps while replacing soft tissue defects; and no graft or foreign body is introduced externally into the wound in replacing long bone defect. Soft tissue defect is gradually replaced by wound-adjacent intrinsic tissues, the wound is closed by related skin and bone defect is filled by an osseous regenerate which is formed during graded transposition of the osteotomized fragment. At the same time good blood supply and tissue innervation retain, which contributes to their resistance to purulent infection. The analysis of the findings has led to the conclusion that GTS is an indispensible contribution to the development of plastic purulent surgery allowing the anatomic and functional integrity of the diseased segment to be restored.