[Intra-operative periprosthetic fractures during THA in the period 1995-2009]. / Peroperacní periprotetické zlomeniny u TEP kycelního kloubu v letech 1995-2009.

PURPOSE OF THE STUDY: The aim of this prospective study was to investigate whether female gender and revision surgery were significant risk factors for intra-operative periprosthetic fractures during total hip arthroplasty (THA). MATERIAL AND METHODS: The group investigated comprised the patients who, in the period 1995-2009, sustained an intra-operative periprosthetic fracture during primary or revision THA. The patients were treated by a therapeutic procedure based on the Vancouver system. The results were related to the total number of patients undergoing THA in that period, Statistical analysis was performed using Pearson's x2 test at the 5% significance level. RESULTS: Intra-operative periprosthetic fractures occurred in 110 patients (89 women, 21 men). The average age of the patients was 69 years (70 in women and 62 in men). The women significantly outnumbered the men (p < 0.001). In the period under study, 2936 primary and 791 revision THAs were performed; the incidence of all intra-operative fractures was 3%. Intra-operative fractures during primary THA were recorded in 95 patients (3.2%; range in individual years, 0.4 to 5.9%); fractures during revision THA were found in 15 patients (1.9%; range, 0 to 8.0%). This difference was slightly above the set significance level (p = 0.057). The majority of intra-operative fractures were minimal Vancouver type-A fractures in the greater trochanter region. They were recorded in 95 of the 110 patients (86%) with either primary or revision THA. Of the 15 type-B fractures, eight were shown by a detailed evaluation to occur during revision THA. An independent analysis of type-B fractures in relation to all replacements showed that their occurrence was significantly higher in revision than in primary THA (p = 0.006). DISCUSSION Intra-operative periprosthetic fractures have primarily been studied in terms of their frequency and the cause of their occurrence. Revision surgery and female gender are regarded as risk and predisposing factors. Our results, in accordance with other relevant data, confirmed that serious intra-operative type-B fracture occurred more frequently during revision THA than during primary surgery. It further showed a significantly higher number of periprosthetic fractures in women than in men. However, this finding is affected by the fact that women in general undergo more THAs than men and that the female median life span is longer. The authors consider a careful pre-operative planning and thorough evaluation of all risk factors related to surgery as basic preventive measures. CONCLUSIONS This continuous 15-year study on patients with intra-operative periprosthetic fractures of the hip has allowed us to conclude that these fractures occur more frequently in women than in men, and that more serious fractures (Vancouver type-B) are significantly more frequent during revision than primary THA. The higher incidence in women is, to a great part, accounted for by osteoporosis of the skeleton in elderly people. In revision THA, poor bone quality plays a role as well as osteolysis due to polyethylene granuloma which may be present.

[Radiographic evaluation of scapula fractures]. / Radiodiagnostika zlomenin lopatky.

The authors use both radiographic and CT examination for diagnosing fractures of the scapula. The standard trauma series consists of chest radiograph, ap radiograph of injured shoulder girdle, ap and lateral radiographs of the scapula (Neer I and II views). According to our experience, the axillary view is not very helpful. Chest radiograph allows for assessment of the thoracic wall, lungs and of both of the shoulder girdles, particularly the position of both scapulas with regard to the spine (thoracoscapular dissociation). The radiograph of the shoulder girdle should cover the entire scapula, the clavicle, acromioclavicular and sternoclavicular joints, and the proximal humerus. Where a scapula fracture is found, Neer I and II views are used. Neer I view is used to evaluate the joint line of the glenohumeral joint, medial displacement of the glenoid and to determine the value of the glenopolar angle. Neer II view, also called Y-view, allows assessing translation, angulation and overlapping of fragments of the lateral borders of the scapular body. CT scans are helpful for evaluation of the glenoid fossa and, where necessary, of the processes of the scapula. They, however, do not allow for correct determining of the fracture types, those of the scapular body in particular. Three-dimensional CT reconstruction is the only method that is able to determine the personality of the scapula fracture. In these reconstructions it is necessary to image the scapula from the anterior, posterior, medial and lateral aspects. Evaluation of the glenoid fossa and of the adjacent parts of the lateral border of the scapula requires subtraction of the proximal humerus and the clavicle. The authors verified the contribution of this radiodiagnostic method on a group of 25 patients with a fracture of the scapula, operated on between 2005 and 2008.

[Epidemiology and economic implications of fractures of proximal femur, proximal humerus, distal radius and fracture-dislocation of ankle]. / Epidemiologie a ekonomie zlomenin proximálního femuru, proximálního humeru, distálního radia a luxacních zlomenin hlezna.

The authors analyze the results of their long-term follow-up of basic epidemiological characteristics in fractures of proximal humerus (1,464 patients), distal radius (2,514 patients), proximal femur (3,340 patients) and fracture-dislocation of the ankle (1 195 patients). In fractures of the proximal femur, the average age was 78 years; 71.6 years in men and 80.3 years in women; male-female ratio was 27:73. In fractures of the proximal humerus, the average age was 67 years; 58.8 years in men and 71.2 years in women; male-female ratio was 30:70. In fractures of the distal radius, the average age was 59 years; 45.8 years in men and 64.7 years in women; male-female ratio was 29:71. In fracture-dislocation of the ankle the average age was 49 years; 43.4 years in men and 54.7 years in women; male-female ratio was 50:50. Until 5th decade men had higher representation in all groups of fractures, starting from 6th decade the ratio changed. Introduction of new implants (locking plate, new generation of nails) for fractures of the distal radius and proximal humerus increased significantly the percentage of patients operated on.

[Fractures of sternal end of the clavicle--current concept review]. / Zlomeniny mediálního klíku--Souhrnný referát.

Fractures of the medial end of the clavicle are still an outstanding issue with only minimum information available. Their diagnosis requires a special care both in isolated fractures of the clavicle and in polytrauma. An accurate diagnosis is impossible without CT scanning, preferably with a 3D reconstruction. Non-displaced fractures are indicated for non-operative treatment. In displaced fractures, sustained particularly by younger or active individuals, operative treatment should be considered. Best suitable for fixation is a cerclage, K-wires are strictly contraindicated. Formulation of a more specific opinion on the method of treatment, long-term outcomes and complications will be possible only on the basis of a greater number of reported cases.

[Diagnosing occult pertrochanteric fractures of proximal femur with MRI]. / Diagnostika okultních pertrochanterických zlomenin proximálního femuru magnetickou rezonancí.

A group of 9 patients with a suspected fracture of the hip underwent radiography and subsequently magnetic resonance imaging (MRI) diagnosis. Radiographic findings were in 2 cases negative and in 7 cases the radiographs revealed a fissure or fracture of the greater trochanter. MRI proved a complete pertrochanteric fracture in 1 case, an incomplete pertrochanteric fracture in 8 cases and in all the 9 cases a fracture of the greater trochanter. Occult pertrochanteric fractures were readily demonstrated with frontal scans. Sagittal and transversal scans showed only more precisely the course of the fracture line and involvement of the intertrochanteric crest, if any. Among the 9 patients, 6 were managed conservatively and 3 patients were treated with a 2-hole DHS (dynamic hip screw). Indication for surgery was based primarily on the scope of the patients' subjective complaints and on their general condition. All the 9 patients healed without complications. The authors indicate MR imaging diagnosis in clinically suspected fractures of the proximal femur where the radiographic finding is negative. Fractures with a radiographic finding of a fissure or fracture of the greater trochanter should be examined by MRI that in most cases reveals an occult pertrochanteric fracture.

[Unreamed locking intramedullary nailing of humeral fractures--basic evaluation of a patient group]. / Nepredvrtané zajistené nitrodrenové hrebování zlomenin humeru--základní hodnocení souboru.

PURPOSE OF THE STUDY: The aim of the work is to provide an overview of the existing experience in Synthes unreamed humeral nail (UHN). MATERIAL: Between August 1996 and February 2000 we treated by means of UHN a group of 37 patients (12 men and 25 women), average age 55 years (range, 18-87 years) with a fracture of humeral shaft. According to AO classification in 10 patients it was a case of a fracture of proximal humerus involving the shaft (11B-3) and in 27 cases a fracture of the shaft (12 A, B, C). The whole group was operated on by 11 surgeons. METHOD: In 26 cases we used the antegrade method and in 11 cases the retrograde one, in dependence on the type and location of the fracture. The assessment was performed in the form of a prospective study. The follow-up including radiograph checks was carried out at the intervals of 6 weeks, 3, 6, 9 and 12 months after the operation or at another 6 weeks or 3 months after the extraction of the nail, if any. In addition we invited the whole group, i.e. 37 patients for the final control examination which all of them attended. This examination was performed by the first author of the work. The average follow-up was 38 months (range, 12-55 months). RESULTS: The average duration of the surgery in the whole group was 80 minutes, the average duration of x-ray exposure was 3.1 minutes. Peroperative complications occurred in total 42 times in 23 patients. Seven cases required a supplementary incision, i.e. open reduction of the fracture; insufficient nail placement (not into the proper depth) in the humeral head and its prominence into joint line evaluated on the post-operative radiograph) in antegrade nailing occurred 6 times. Problems with locking were encountered 15 times in 10 patients. Comminution of the fragments peroperatively during the insertion of the nail occurred 3 times, peroperative injury of the radial nerve was recorded in total 4 times, always in the antegrade method of the insertion during distal locking from the lateral side. A postoperative complication occurred 16 times in 12 patients, 6 times the radiograph showed penetration of the end of the nail into the shoulder and 6 times the locking screws loosened. No infect was recorded. The mentioned complications required in total 10 revision surgeries in 6 patients (5 of them were treated by the antegrade method). The fracture healed in a good anatomical position in 33 cases. In 4 cases there occurred non-union which was 3 times treated with a plate re-fixation and cancellous bone grafting of which twice successfully. In 2 cases the healing required another revision surgery. A good subjective as well as objective result was achieved almost in 90% of patients. A risk factor from the viewpoint of the limitation of the range of motion in the shoulder proved to be the fracture of 11B3 type and also the antegrade method of nailing, in case of the elbow the retrograde method of nailing. However, the greatest risk was posed by the necessity of a longer post-operative immobilisation of the limb in the case of a not quite stable internal fixation. DISCUSSION: A relatively high number of complications in our group results from strict criteria we have set. However, also literary data present a relatively high number of variously serious complications. Our results as well as the average duration of the surgery is comparable with other authors. CONCLUSION: The main indication of UHN are comminuted or multi-level fractures of humerus in the central three fifths of its length. If possible we prefer the retrograde method of nailing, in the antegrade method we recommend distal locking from the anterior aspect of the arm. Transverse or short oblique fractures can be successfully treated by a simpler Hackethal technique. Long spiral fractures are ideally treated conservatively or by plate fixation.

[S-ROM Modular THR System -Three and Half Years of Experience.]. / S-ROM systém totální náhrady kycelního kloubu: 3,5 roku zkuseností

UNLABELLED: PURPOSE OF THE STUDY Presentation of the first 3,5-year experience with the application of S-ROM system in total hip arthroplasty. MATERIAL A retrospective study evaluating 33 patients (14 men, 19 women), average age 57 years (25-84 years) operated on in the period betwen December 1996 and June 2000. In 5 cases we performed primary implantation and in 28 cases revision surgery. Indications to primary surgery included once primary osteoarthritis, twice postdysplastic osteoarthritis and twice trauma. Of revision surgeries, there were 19 cases of aseptic loosening, 8 cases of septic loosening and once malposition of the stem. In 10 cases the revision surgery consisted in a mere replacement of the stem, complete replantation including the acetabular cup was performed in 18 cases. In 24 cases it was the first revision of the stem, in 4 cases the second revision. In 19 patients the revised stem was originally cemented, in 8 patients cementless and in 2 patients it was impossible to identify the original type of the stem. Acetabular cup was replanted in 18 cases with two exceptions by means of a cementless component. METHOD The evaluation concentrated mainly on peroperative and postoperative complications and symptoms of loosening.The follow-up ranged between 4 and 45 months with the average of 30 months. Twenty-four patients were followed for more than 2 years, 16 patients for more than 3 years, 4 patients for less than one year. OUTCOMES We recorded in total 15 complications, of which 8 peroperative and 6 postoperative. Of 8 peroperative complications we evaluated 6 cases as specific for S-ROM. In 5 cases the introduction of the stem resulted in the calcar split which was treated by wire cerclage. In 1 case when we applied in the revision surgery a longer straight stem the tip of the stem got to a close contact, even perforated the anterior cortex of the femoral shaft. A nonspecific complication was represented by a spiral fracture of femoral shaft during the perforation of the pedestal formation below the tip of the original cementless loosened stem. The fracture was treated by a plate. For a similarly non-specific complication we consider partial reaming of the medial cortex during the revision surgery of a loosened cemented stem. Both the calcar splits and the fracture of the shaft healed without any complications. The cases of the perforation of the anterior cortex and the above mentioned reaming of the medial cortex were not associated with any subjective complaints or objective problems, either. Six postoperative complications included three dislocations (twice treated by open reduction), one paraarticular heterotopic ossification (Brooker III type), once pain in the thigh and once recurrence of the infection. In 24 patients with the follow-up longer than two years we did not record any signs of loosening or localized osteolysis or signs of metal wear betwen the stem and the conical sleeve. In 30 cases we evaluate the result of the operation as very good. As a failure we consider the case of a recurring dislocations, the case of paraarticular ossifications and thigh pain and the case of the recurrent infection. DISCUSSION Our results prove the existing literary data on good medium-term results of the application of S-ROM system, mainly in case of revision surgery. Its specific complication is a peroperative calcar (Adam's arch) split and perforation of the anterior diaphyseal cortex when using the long stem. CONCLUSION S-ROM represents a perspective system for revision surgeries. It is contraindicated in case of extensive defects of the proximal femur which do not allow to anchor the conic sleeve and in case of severe osteoporosis. KEY WORDS: total hip arthroplasty, S-ROM, revision surgery.

[Endoprosthesis of the shoulder joint designed by the authors - surgical technique.]. / Vlastní endoprotéza ramenního kloubu - operacní technika.

Endoprostheses of the shoulder joint are nowadays already standard procedures in the surgical repertoir of orthopaedic and traumatological departments. Indication for the operation are degenerative diseases with destruction of the articular surface, non-reconstructible fractures of the upper end of the humerus, in particular in elderly patients and tumours in the area of the proximal portion of the humerus. The main cause of inadequate function of endoprostheses of the shoulder joint is insufficiency of the rotator cuff. This may be due either to its primary destruction by the basic disease (e. g. rheumatoid arthritis) or imperfect reconstruction during surgery. The majority of authors use during reconstruction of the rotator cuff a simple procedure, i. e. suture to the proximal portion of the endoprosthesis. In some instances the implementation of the suture is difficult or there is the risk the stiches will cut through during rehabilitation. Favourable experience with reconstruction of the rotator cuff during non-anatomical reconstruction of fractures of the proximal humerus by screwing of the insertion lamellae of the greater and lesser tubercle made the authors try to use this principle in the construction of a new type of endoprosthesis, which is described in detail in the submitted paper. Subsequently the authors describe also differences in the surgical technique during implantation of the endoprosthesis in patients with degenerative diseases and in traumatological indications. In their opinion the advantage is that in traumatic indications of replacement of the shoulder joint the suggested implant makes reliable and relatively easy fixation of both tubercles with insertions of the rotator cuff to the endoprosthesis possible and simultaneously also attachment to the fragment of the diaphysis. In fragments of the greater tubercle this can be achieved by the use of a clawed splint which is fixed by one screw inserted via the corticalis of the diaphysis into the stem of the endoprosthesis. This ensures the stability of the endoprosthesis in the proximo-distal direction as well as against rotation. The fragment of the lesser tubercle is fixed by one screw to the body of the endoprosthesis. The authors assume that reconstruction of the rotator cuff and at the same time stabilization of the shank of the endoprosthesis by one screw and a clawed splint differs fundamentally and is a new approach to the solution of this very complicated problem. Despite the initial clinical experience the authors are aware of certain technical shortcomings of the implant and instrumentarium and continue to work on their elimination. Key words: endoprosthesis of the shoulder joint, reconstruction of the rotator cuff.

[Contribution to the problem of classification of fractures of the proximal end of the humerus in adults.]. / Príspevek k problematice klasifikací zlomenin proximálního konce humeru u dospelých.

A classification is useful only if it helps the surgeon to resolve a given fracture. This applies obviously also to fractures of the proximal end of the humerus. In the submitted paper the authors review the problem of classification of fractures of the proximal humerus which could help orthopaedists and traumatologists to decide on the therapeutic approach to these serious injuries. For a long time it did not prove possible to elaborate a classification which meets contemporary theoretical demands and practical needs. Some hitherto used older classifications are based on the course of the fracture line or the mechanism of the injury; they do not assess accurately the types of fractures and are not an effective guideline for treatment. The authors mention, or at least remind of all important attempts of various authors to classify fractures of the proximal end of the humerus. Some of these attempts are historically important (Malgaigne, Kocher, Böhler, Codman, Watson-Jones, Dehne, Typovský, Duparc and Largier). Codman's basic four-fragment classification has become the basis of subsequent more modern classifications which are used at present and which are analyzed in more detail by the authors. This applies to the classifications by Neer, AO, Tile and to Habermeyer's classification. In the discussion their advantages and shortcomings are considered. From the literature it is obvious that Neer's classification is the most widely used one. For the correct enlistment of a fracture into a certain classification pattern it is essential to assess accurately the fracture line between fragments of the fracture. Among commonly available imaging methods Neer's "traumatic series" of three X-ray pictures or an oblique "apical" projection recommended by Richardson et al. is considered most reliable. The most up-to-date imaging methods such NMR, CT and 3D-CT are, no doubt, more instructive but for the given purpose they are too expensive and so far not readily available in this country. The authors conclude that for a problem so varied as fractures of the proximal humerus it is very difficult to find a uniform classification, which will meet all demands (i.e. logical structure, overview, simple procedure, while at the same time complete, reproducible and offering the possibility of prognosis and assessment of the therapeutic procedures). All classifications have in some of the required criteria greater or smaller shortcomings. The mentioned modern classifications meet to a certain extent their purpose and each department which is used to a method will find it difficult to switch over to another one. Because all classifications comprise also therapeutic guidelines for treatment of different types of fractures, the therapeutic results achieved by the given department in the treatment of fractures of the proximal humerus by using a certain classification are decisive. Key words: classification of fractures of the proximal humerus.

[Alloplasty of the shoulder joint - introduction to the problem.]. / Aloplastika ramenního kloubu -úvod do problematiky.

The authors present a review of contemporary views on the problem of alloplasty of the shoulder joint. In the historical introduction they mention the development of surgery of the shoulder joint with the gradual transition from resection or interposition arthroplasties to endoprostheses of varying design which according to the principle of internal constraint can be divided into three groups, i. e. not compressed, semi-constrained and fully-constrained implants. Development revealed that the best results with the least number of complications are achieved with non-constrained implants which predominate nowadays in the production of most firms. The authors describe separately indications for hemiarthroplasties (which implies always implantation of the humeral component) and total replacement of the shoulder joint. Both indication groups overlap to a considerable extent. The spectrum of indications was extended considerably, from the original oncological indications, in particular by degenerative diseases (osteoarthritis, rheumatoid arthritis, systemic diseases etc.) and with regard to the rising number and complexity of fractures of the proximal end of the humerus (or scapula) also by traumatological indications (comminuted dislocated and luxation fractures, poorly healed fractures and fractures of severely osteoporotic bones etc.). Contraindications include nervous lesions with paralysis of the deltoid muscle or the rotator muscles, previous infection, an irreparable defect of bone tissue and a mentally labile, not collaborating patient. During the rehabilitation period a three-stage programme elaborated by Hughes and Neer proved useful. The authors emphasize early positioning of the operated extremity in maximal elevation. In the subsequent part the authors analyze complications associated with surgery of endoprostheses of the shoulder joint. In general it may be stated that the number of complications increases with the degree of constraint of the implant and fully-constrained implants are practically no longer used because of the large number of complications. The most frequent complications are a restricted mobility of the shoulder joint, instability - luxation of the endoprosthesis, impingement syndrome, lack of incorporation of protuberances, pseudoarthroses, infections, loosening of the implants, fractures, nervous and vascular lesions, heterotopic ossifications and permanent postoperative pain. In the conclusion the authors emphasize that replacement of the shoulder joint is not a simple operation and should be carried out by surgeons with great experience with surgery of the shoulder in departments adequately equipped for surgery and rehabilitation. Key words: alloplasty, endoprosthesis, shoulder joint.

[Initial Results with Non-cemented Walter-Motorlet Prostheses of the Hip Joint.]. / První výsledky s necementovanou totální náhradou kycelního kloubu Walter-Motorlet.

The authors present their experience with the use of non-cemented total endoprostheses of the hip joint. During a 5-year period at the First Orthopaedic Clinic of the First Medical Faculty, Charles University, Prague 178 non-cemented hip joint prostheses were implanted. The authors evaluated, using internationally accepted criteria, 69 patiens with non-cemented prostheses of the hip joint Walter-Motorlet after an interval of more than 20 months. The intensity of pain was reduced, the consumption of analgesics lower. The patients' capacity to look after themselves improved. The distance patients are able to cover without resting increased. Heterotopic ossifications were found in 20 patients but only low grades. Translucent X-ray lines at the borderline between the implant and bone were found in 20 patients but they were only 2 mm wide and sharply defined. Subjective evaluation by the patient and surgeon was in all instances favourable. The authors evaluate also complications in the entire group of 178 operated patients and analyze the surgical method used. Walter-Motorlet non-cemented prostheses are indicated in biologically young patients. They are very suitable for patients with acetabular dysplasia and in patients with rheumatic disease. An unequivocal contraindication are severe forms of metabolic diseases which do not create conditions for secondary bone fixation. Key words: non-cemented total prosthesis of the hip joint, results, complications, indications, contraindications.

[Results of reconstructive surgery in fractures of the proximal humerus]. / Výsledky rekonstrukcních operací zlomenin proximálního konce pazní kosti.

In treatment of comminuted dislocation fractures of the proximal humerus the most serious therapeutic problem still remains the 6th group of Neer's classification, in particular fractures with four fragments and with a completely dislocated and devitalized head. The authors present in a retrospective study an overall comparison of results assembled in 30 patients (and 19 checked patients resp.) who were operated by the technique of anatomical reconstruction (13 and 8 patients resp.) or by the authors own technique of non-anatomical reconstruction (17 and 11 patients resp.), all operated on account of comminuted dislocation fractures of the proximal humerus at the orthopaedic clinics of the First and Third Medical Faculty, Charles University, Prague in 1976-1988. Analysis of the results of the checked patients made the authors draw the following conclusions: 1. Fractures of the proximal end of the humerus is a relative frequent injury, in particular in the elderly. About 20% of these injuries call for surgical treatment. 2. In all non-anatomical reconstructions the mobility is very restricted in particular exorotation, in anatomical reconstructions the restriction is much smaller. 3. In all patients operated by the technique of non-anatomical reconstruction within three years necrobiotic reconstruction of the fragment of the head occurred which is the greater, the larger the fragment of the head which was preserved. 4. The result of the reconstruction depends on the preservation of nurture of the fragment of the head and on selection of an adequate technique of osteosynthesis. 5. In anatomical reconstructions the most frequent complication was loosening of the osteosynthetic material, a varus position of the head and pseudoarthrosis.(ABSTRACT TRUNCATED AT 250 WORDS)

[Long-term results of Ludloff's repositioning method]. / Dlouhodobé výsledky krvavé repozice podle Ludloffa.

Authors have evaluated results of the surgical treatment of congenital dysplasia of the hip joint performed at I Orthopaedic Clinic in Prague in the years 1970-1985. In the course of this period open reduction according to Ludloff was performed in seventy children out of which eight times bilaterally. Fifty-six out of the total number of seventy children same for the follow-up check. The age of the children operated on ranged between five and 23 months; in six cases the operation was performed on both hip joints. The follow-up ranged from three to eighteen years with an average of eleven years. In all children the postoperative treatment consisted in the application of the Hanausek biomechanical apparatus. On the basis of clinical and roentgenological criteria the results were divided into fair and poor results. For fair result were considered the hips with a good range of motion (none of the motions was reduced more than by 50 percent of the normal range), patients did not feel any pain, the limb shortening did not exceed 1 cm and the Trendellenburg test was negative. From the roentegonological viewpoint for fair were considered the findings without persisting subluxation and dislocation with the spheric head (the asphercity on the Moose template did not exceed 2 mm) and without evident shape deformities of the proximal end of the femur (coxa vara, overgrowth of the greater trochanter). Only such hips which meeted both the clinical and roentgenological criteria were evaluated in general as fair, the other were assessed as poor. On the basis of these criteria the result of the treatment was evaluated as fair in 76 percent and poor in 24 percent of cases. The authors also observed the incidence of aseptic necrosis of the femoral head from the viewpoint of the types defined by Bucholz and Ogden. Necrosis of Type I was not found in the group, necrosis of Type II occurred 12 times, necrosis of Type III and Type IV three times each. No evident connection was found out between the incidence of the necrosis of head and the ligation of both branches of a. circumflexa femoris medialis. The main cause of the impossibility to perform reduction was the isthmus of the joint capsula in its inferomedial portion in the area of iliofemoral ligament. Of decisive importance for the development of the joint after open reduction was a perfect reduction of the head into acetabulum.(ABSTRACT TRUNCATED AT 400 WORDS)