[Avascular Necrosis of Femoral Head and Coxarthrosis Progression after Acetabular Fractures]. / Avaskulární nekróza hlavice femuru a progrese koxartrózy po zlomeninách acetabula.

PURPOSE OF THE STUDY Non-operative and operative treatment of acetabular fractures is associated with a risk of development of posttraumatic avascular necrosis of femoral head or with the development of posttraumatic coxarthrosis. The purpose of the study was to identify the occurrence of these two complications in patients in our group and to determine the risk factors for the development of these complications. MATERIAL AND METHODS The retrospective study was conducted in two Level I trauma centres in the period from 2009 to 2014. The group included patients with an acetabular fracture. The inclusion criteria were the following: outpatient follow-up for the period of 3 years after the injury, full radiology and CT documentation. The exclusion criteria were the following: pathological fractures, missing documentation after the union, insufficient follow-up period or dissent of the patient. The inclusion criteria were met by 192 patients, 48 women and 144 men, with the mean age of 48.9 years. The following basic epidemiological data were monitored: age, sex, cause of injury, type of fracture according to the Letournel classification, occurrence of associated injuries and type of therapy. The patients undergoing non-operative treatment as well as patients undergoing operative treatment underwent clinical and radiological examinations at 3 and 6 weeks after the injury, then at 3, 6 and 12 months after the injury, subsequent follow-up checks were done at a year-interval up to 3 years after the injury. RESULTS The posttraumatic avascular necrosis of femoral head developed in 22 patients (11.7%, 17 men, 5 women, p = 0.1159), with the mean age of 55.3 years (STDEVP 15.5, range from 22 to 82). The average time to the development of femoral head necrosis was 13.1 months (STDEVP 17.0, range from 1 to 80), median 6 months, 95% percentile 34 months. In a total of 16 patients necrosis developed within 18 months after injury, while in 6 patients after a longer period of time. Progression of coxarthrosis was observed in 63 patients (33.5%, 44 men and 19 women, p = 0.0447). Within 24 months progression was seen in 55 patients, beyond 2 years in 8 patients. Confirmed as risk factors for the development of posttraumatic avascular necrosis of femoral head and progression of posttraumatic coxarthrosis were the age 60 years and above (p = 0.0023), posttraumatic medialisation of the femoral head greater than 2 mm (p < 0.0001), displacement in the weight bearing area within the acetabulum greater than 2 mm (p < 0.0001), operative treatment (p = 0.0014), combined surgical approach (p = 0.0044), and higher caput-collum-diaphyseal (CCD) angle of proximal femur (p = 0.0142). At risk for the development of avascular necrosis were the A5 type fractures (p = 0.0214) and B2 type fractures (p = 0.0218), at risk for the development of coxarthrosis were the C1 type fractures (p = 0.0122). The isolated fractures of the anterior column were by contrast associated with a significantly lower risk for development of both the AVN (p = 0.0052) and posttraumatic coxarthrosis (p = 0.0006), the isolated fractures of the posterior wall were associated only with a higher risk for AVN and coxarthrosis summation (p = 0.0399), and the same applies to the T fractures (B3, p = 0.0200). DISCUSSION Majority of current studies regarding acetabular fractures focuses on operative treatment, short-term complications and comparison of outcomes of operative and non-operative treatment. Only a few studies are dedicated to epidemiological data, or risk factors for the development of medium-term and long-term complications. In the presented study attention was paid to two main complications arising from these fractures and requiring subsequent operative treatment: posttraumatic avascular necrosis of femoral head and posttraumatic coxarthrosis. The limitations of the study are its retrospective nature, summation of groups from two trauma centres (potential bias in patient enrolment or in assessing radiographs), lower frequency of clinical surveillance in non-operatively treated patients after healing, a fairly low number of non-operatively treated patients - especially those with osteoporosis-related insufficiency fractures. Ranking among the relative limitations is also the Letournel classification which, though most commonly used at present, shows a low level of correlation in comparisons by more evaluators. CONCLUSIONS Confirmed as significant risk factors for the development of posttraumatic avascular necrosis of the femoral head and posttraumatic coxarthrosis progression were the age of 60 and above, posttraumatic medialisation of the femoral head greater than 2 mm, displacement involving the weight bearing area of the acetabulum greater than 2 mm, operative treatment, combined operative approach. At risk are also the transverse fractures (A5 according to the Letournel classification), transverse posterior wall fractures (B2 according to the Letournel classification) and at risk for the development of coxarthrosis are both-column fractures with the high fracture line of the anterior column (C1 according to the Letournel classification). Femoral neck valgosity was a risk factor for the development of femoral head necrosis. Conversely, sex and instability of osteosynthesis detected on the radiograph within 3 months postoperatively were not confirmed as the risk factors for the development of aforementioned complications. To verify the results of this retrospective study other multicentric and prospective studies should be conducted. Key words: complications of treatment of acetabular fractures, risk factors for avascular necrosis of femoral head, risk factors for coxarthrosis.

[Infectious Inflammation of Pubic Symphysis (Symphysitis Pubis Purulenta): Five Case Reports and Literature View]. / Infekcní zánet symfýzy (symphysitis pubis purulenta): pet kazuistik a prehled literatury.

Purulent inflammation of the pubic symphysis is a rare condition involving the symphysis and parasymphyseal parts of the pubic bones. It is usually found in immuno-compromised patients and its most frequent cause is Staphylococcus aureus. Conservative treatment is based on long-term administration of antibiotics and has been efficient, as reported, in about 50% of the patients. The authors treated five patients with a late diagnosis of purulent infection of the pubic symphysis in whom the antibiotic therapy had to be completed by surgical intervention. Three patients undergoing surgery with removal of the infected necrotic tissue healed fast and well. One patient required repeated surgery because of recurrent purulency; eventually, the infection cleared up. One patient was treated only conservatively because she refused surgical treatment. Consequently, pubic diastasis developed and she suffered from persistent pelvic pain. One year after treatment her condition became complicated by pelvic fracture following a fall. The patient refused surgery again. However, the development of non-union and progression of complaints made her agree to a surgical treatment; fixation of the non-union had a satisfactory outcome. In the literature, infection in the symphysis region is referred to by several different names. One - in the authors' opinion incorrect use - is "arthritis" (septic arthritis of the pubic symphysis; pubic symphysis septic arthritis; infectious osteoarthritis of the pubis). Another term is "osteomyelitis" (acute pubic osteomyelitis; pubic osteomyelitis; osteomyelitis of the pubis; osteomyelitis pubis; osteomyelitis of the pubic symphysis; osteomyelitis of the symphysis pubis). None of the names shows clearly whether it is primary an infection of the symphysis or of the parasymphyseal bone. A combination of the term "osteitis" with "infectious" (infectious osteitis pubis) is an attempt to distinguish purulent symphysitis pubis from osteitis pubis. The authors completed both the Czech and English title of this paper with the Latin designation symphysis pubis purulenta. A possibility of using a new name, such as "pubosymphysitis", in analogy to "spondylodiscitis" can also be discussed. However, the use of simple terms "infection of symphysis" or "infection of pubic symphysis" seems to be most practicable. Based on the experience with the treatment of five patients with infection of the pubic symphysis, the authors suggest that the late phase with abscess formation or purulent discharge should be managed by surgery. This treatment has good clinical outcomes although it may be complicated by slow healing of soft tissues around the symphysis and instability of the anterior pelvic segment with its sequelae. Key words: infection of the symphysis, infection of the pubic symphysis, septic arthritis of the pubic symphysis, pubic osteomyelitis.

[Risk of death in patients with unstable pelvic fracture and large vessel injury]. / Riziko úmrtí pacienta s nestabilní zlomeninou pánve a poranením velkých cév.

INTRODUCTION: The aim of the study was to provide accurate data regarding the incidence of large vessel injury as part of pelvic trauma in patients treated during a 12-year period. METHODS: In total, 715 patients admitted and treated for pelvic fractures from 2001-2012 were analyzed. Data on large vessel injuries (aorta, inferior vena cava, common iliac artery and vein) reported in perioperative or autopsy findings were obtained from the patient database. The statistical significance of achieved results was tested using contingency tables (chi-square test of independence or Fisher factorial test). The significance level for the calculated tests was chosen to be 5%. RESULTS: Sixty six (9%) patients died in the first hours after admission, 43 (6%) of them prior to surgery. Seventy (10%) underwent urgent surgeries, 47 (7%) of whom survived and 23 (3%) died. A large vessel injury in the pelvic region was detected in 13 (2%) patients. In the surviving surgical patients, a serious injury of pelvic venous plexus, as the only source of bleeding, was found only once (2%), while in patients who deceased post-surgically and pre-surgically, serious vascular injury in the pelvic region was diagnosed in 5 and 7 patients in both subgroups (22% and 41%, resp.). This difference was significantly higher in comparison with surviving patients (p=0.0002 and p=0.0109, resp.). CONCLUSION: The incidence of large vessel injury with severe bleeding associated with pelvic trauma was low in our study; however, the risk of death in patients with this injury was significantly higher. The results of our study support the hypothesis that in most patients a large artery or vein injury in combination with massive bleeding from the venous plexus due to a dislocated pelvic fracture results in death even before arrival of emergency services. This hypothesis could be verified in a study including also autopsy findings in persons who died even before hospital admission. KEY WORDS: unstable pelvic injury vascular injury risk of death.

[Intraoperative CT navigation in spinal and pelvic surgery: initial experience]. / Peroperacní CT navigace u operací pátere a pánve: první zkusenosti.

INTRODUCTION: The authors describe their first experience with virtually navigated pelvic and spine screws based on perioperative CT navigation. MATERIAL AND METHODS: From 22 October 2012 (launching the device) to 9 January 2013, a total of 15 CT-navigated pelvic and spine operations were performed in 14 patients. Nerve root compression, scoliosis, vertebral fracture and spondylodiscitis were the indications for spine procedures; B-type and C-type fractures according to the AO classification were the indications in pelvic surgical procedures. The preparation and the course of the procedures were in accordance with current standards and recommendations in all the cases. Perioperative navigation and subsequent examination of the screw trajectory were performed via O-arm imaging system (Medtronic Navigation, Louisville, Colorado) instead of the standard C-arm fluoroscopy. RESULTS: A total of 73 screws were inserted (60 transpedicular screws into cervical, thoracic and lumbar vertebrae, 9 iliosacral screws into the first sacral vertebra and 4 pubic screws). Only one of the pubic screws (1.4% of all screws) was found malpositioned at the subsequent perioperative examination and was extracted immediately and replaced. Further complications were not observed and none of the procedures had to be converted into a standard fluoroscopy guided operation. CONCLUSION: A short but intensive experience with perioperative CT navigation allows us to state: 1. CT navigation shortens the operating time and minimalizes the risk of screw malposition in multiple screw spine procedures; 2. CT navigation improves the introduction of iliosacral and pubic screws in pelvic fixations; 3. there is virtually no radiation load to the staff using the CT navigation; 4. mastering this technique will allow a wider use of miniinvasive screw insertion in the pelvis and other regions where minimal dislocation will enable miniinvasive internal fixation.

[Pelvic injuries and acetabular fractures: differences in their severity]. / Poranení pánve a zlomeniny acetabula: rozdíly v závaznosti techto poranení

PURPOSE OF THE STUDY: The aim of the study was to assess differences in the number and severity of associated injuries between patients with pelvic injury and those with acetabular fracture. MATERIAL AND METHODS: The patients treated in the period from January 1, 2008, to December 31, 2010, were enrolled. The group comprised 249 patients (130 women and 119 men) with pelvic injuries and 58 patients (14 women and 44 men) with acetabular fractures. In the patients with pelvic injury, the average age was 52 years, 61 in women and 43 in men, in the range of 17 to 91 years. In the patients with acetabular fracture, the average age was 54 years, 59 in women and 53 in men, in the range of 21 to 96 years. The relevant data including age, sex, cause of injury, associated injuries and the overall severity of injury were obtained from the patient database. The results were statistically analysed using Pearson's .2 test at a 5% level of significance. RESULTS: Acetabular fractures were recorded in more men than women and this difference was significantly higher (p = 0.002) than in the patients with pelvic injury in whom similar numbers of men and women were affected. A fall from height was significantly more frequent as a cause of pelvic injury than that of acetabular fracture (p = 0.034). The patients with pelvic injury also had significantly more associated injuries (p = 0.016) and the number of these patients with an Injury Severity Score (ISS) higher than 16 was significantly higher compared with the number of patients with acetabular fractures (p < 0.001). DISCUSSION: Little published information is available on comparison of the severity of injuries in patients with pelvic injuries and those with acetabular fractures because these conditions are in fact two nosological units. In pelvic injuries, as conditions usually accompanied by multiple trauma, associated injuries, risk factors for death, requirements for primary life-saving measures, complications and treatment outcomes have been studied. Less attention has been paid to these issues in patients with acetabular fractures; the authors focused on determining the quality of intra-articular fracture treatment in relation to a subsequent risk of avascular necrosis of the femoral head or early arthritis. CONCLUSIONS: The study comparing the patients with pelvic injury with those having acetabular fracture showed a significantly higher proportion of men in the group with acetabular fractures. A fall from height significantly more often caused a pelvic injury than an acetabular fracture. In traffic accidents, drivers usually suffered acetabular fractures while pedestrians and cyclists had pelvic injuries. However, a significantly higher number of associated injuries and multiple trauma with an ISS > 16 recorded in the patients with pelvic injury in comparison with those with acetabular fractures was the most important difference between these two groups.

[Tendon-splitting approach for the surgical treatment of Haglund's deformity and associated condition. Evaluation and results]. / Transachiální prístup pri operacní lécbe Haglundovy deformity a pridruzených afekcí: hodnocení vlastního souboru pacientu

PURPOSE OF THE STUDY: To evaluate the results of the dorsal longitudinal tendon-splitting approach for surgical treatment of Haglund's deformity and associated conditions. MATERIAL: The group comprised patients who underwent surgery for Haglund's deformity and related conditions between January 2003 and June 2007. There were 15 patients, six women and nine men, with 17 treated heels (one man and one woman had bilateral surgery). METHODS: Using the tendon-splitting approach, a prominence of the posteriosuperior border of the calcaneus was resected and the associated conditions were treated. The evaluation was based on a 1-to-5-degree scale and included the patient's clinical state before and after surgery (pain, shoe-wearing and load tolerance), and pre-operative radiography (presence of Haglund's deformity, ossification of the Achilles tendon and/or adjacent tissues). The study was retrospective. RESULTS: The average age of the patients at the time of surgery was 44.5 years (range, 16 to 60). The minimum follow-up was 6 months (range, 6 to 65 months). X-ray and intra-operative findings showed Haglund's deformity in 13 cases, calcaneal bursitis in six, ossified mass at the insertion of the Achilles tendon in six, intratendinous ossification in two, and partial tendon degeneration and subcutaneous bursitis in one case each. Post-operative relief was recorded in 16 treated heels. The condition in one patient deteriorated, as manifested by heel swelling after exercise and a feeling of tension at the insertion site of the Achilles tendon in forced dorsiflexion of the ankle. An average preoperative score of 4.1 improved to 2.1 post-operatively. No serious complications either overall or at the site of surgery (Achilles tendon rupture, poor wound healing) were found. Three heels retained a slight restriction of motion (up to 10 degrees). One heel showed impaired sensitivity in the region treated. DISCUSSION: The tendon-splitting approach provides a good view of and easy access to the structures to be operated on. The risk of incomplete resection of the prominence or of leaving sharp edges because of an insufficient view is small. Compared with other methods, this approach allows for concurrent treatment of other conditions that may be present at the insertion site of the Achilles tendon. The tendon-splitting approach does not result in any structural changes of the Achilles tendon. CONCLUSIONS: The dorsal longitudinal tendon-splitting approach for surgical treatment of Haglund's deformity is an efficient, undemanding and safe method alternative to lateral or medial approaches used more often. It allows for concurrent treatment of several pathological conditions at the insertion site of the Achilles tendon, such as subcutaneous bursitis, ossified mass at the tendon insertion, tendon degeneration, intratendinous ossification, calcaneal bursitis and Haglund's deformity.