[Assessment of Reduction Abilities of an Expandable Stent in Treating Osteoporosis-Related Fractures of Th/L (Thoracolumbar) Spine]. / Zhodnocení repozicních schopností expandibilního stentu pri osetrení osteoporotických zlomenin Th/L pátere.

PURPOSE OF THE STUDY The method of stabilising the osteoporosis-related spinal fractures using an expandable stent (vertebral body stent - VBS) and bone cement is generally accepted for its minimal invasiveness, a low risk of complications and confirmed analgesic effect. The efficiency of reduction of a compressed vertebra is, however, still discussed in the literature. Our hypothesis was that the stent expansion in the vertebral body can achieve a statistically significant reduction in the anterior, middle and posterior part of the vertebra. MATERIAL AND METHODS The patients in whom the VBS technique was used to treat an osteoporosis-related fracture of Th/L spine in the period 2010-2014 were included in the study, namely 29 patients with 31treated fractures. The following radiographic parameters were monitored - anterior, middle and posterior vertebral body height, kyphotic angle between the upper and lower endplates of the vertebral body. Also, the radiation burden, painfulness according to VAS score and occurrence of complications were monitored. The minimum follow-up was 12 months. RESULTS The mean height of the anterior part of the vertebral body before the surgery, on the 1st postoperative day and at 6 weeks, 3 months, 6 months and 12 months was 23.5/25.4/23.9/23.6/23.6 mm respectively. The mean height of the middle part of the vertebral body at the same intervals was 17.9/24.0/23.4/22.9/22.9/22.9 mm. The mean height of the posterior part of the vertebral body was 29.6/29.8/29.4/29.3/29.2/29.2 mm. The kyphotic angle between the endplates of the vertebral body was 8.6/5.3/7.4/7.9/8.0/8.0°. The mean VAS values were 8.2/2.4/2.0/1.9/1.8/1.7. The mean duration of surgery was 54.3 minutes. The mean time of fluoroscopy was 33.4 s. The mean radiation dose was 443.1 cGycm2. The observed complications comprised 2 cases of dilatation balloon rupture, one case of a failure to expand the stents in a healed fracture due to incorrect indication. In total, four cases of cement leakage outside the vertebral body were reported, always with no clinical response. DISCUSSION All the authors agree that the method brings immediate analgesic effect, comparable to kyphoplasty or vertebroplasty. In our cohort, good reduction ability of the implant in the middle part of the vertebral body was confirmed. This has been confirmed also by other authors. Nonetheless, at a longer time interval the loss of correction was observed, which was reported only by Hartmann (5). The other authors mostly did not take into account the longer-term outcomes. CONCLUSIONS The hypothesis that the stent is capable of a statistically significant reduction in the anterior, middle and posterior portion of the vertebral body was only partially confirmed. A statistically significant reduction was seen only in the middle portion of the vertebral body. In the anterior portion of the vertebral body the reduction was demonstrable only immediately after the surgery, while the later follow-up checks revealed the loss of correction. The statistically significant improvement of the kyphotic angle between the endplates of the injured vertebra was also seen only on the first postoperative radiographs and at later follow-up checks the improvement was no more significant. The change in the height of the posterior portion of the vertebral body was not statistically significant at any of the follow-up intervals. Key words:osteoporosis, vertebral fracture, vertebral body augmentation, stentoplasty, vertebral body stent.

[Talar Neck Fractures Treated Using Percutaneous Screw Fixation]. / Zlomeniny krcku talu lécené perkutánne zavedenými srouby.

PURPOSE OF THE STUDY Closed reduction and percutaneous fixation of nondisplaced talar neck fractures have been applied by some authors. The aim of this paper is to assess the results and complications of this minimally invasive technique. MATERIAL AND METHODS In the period from 2009 to 2014, twenty-one patients with a talar neck fracture were observed after closed reduction and percutaneous screw fixation in the Traumatological Hospital in Brno. The mean age of the patients was 38 years (range 18-56 years). The mechanism of injury was a motor vehicle accident in 11 cases, a fall from height in six cases, a sports injury in 3 cases, and a fall from stairs in one case. Injuries were classified according to the Hawkins classification. Conventional preoperative 3-dimensional CT scans of the fractures were analysed. Under the guidance of C-arm fluoroscopy, Kirscher wires were used for closed reduction and temporary percutaneous fixation. Subsequently, 3.5 and 4.5 mm diameter cannulated screws were inserted. The outcome was evaluated on the American Orthopaedic Foot and Ankle Society (AOFAS) scoring scale. RESULTS The average follow-up was 32 months (21-42 months). The average healing time was 15.5 weeks (13-19 weeks). The average AOFAS score was 82.3 points (69-96 points). 75% of patients with type I injury achieved excellent results and 72% of patients with type II injury achieved excellent or good results. None of the patients developed wound complications. Two patients developed partial avascular necrosis and three patients subtalar traumatic arthritis after surgery. DISCUSSION Talar neck fractures are relatively uncommon fractures. Most of the published studies are small. Tenuous blood supply and displaced talar neck fracture predispose to avascular necrosis of the talus. Closed reduction and percutaneous fixation can reduce the soft tissue damage and disturbance to the blood supply. CONCLUSIONS Preoperative 3D CT scans, early surgery, anatomic articular surface reduction and percutaneous screw fixation increase the fracture healing rate and reduce the incidence of talar avascular necrosis. Key word: talus, closed reduction, percutaneous fixation, screw.

[Management of Odontoid Fractures with Compression Screw and Anterior Transarticular Screw Fixation in Elderly Patients]. / Osetrení zlomeniny zubu cepovce u starsích pacientu metodou kompresní osteosyntézy a prední transartikulární stabilizací.

PURPOSE OF THE STUDY In the management of dens axis fractures in patients older than 65 years of age the posterior approach is preferred due to osteoporosis and the risk of a failure of anterior osteosynthesis. The posterior approach, however, is associated with a higher incidence of complications. A combination of anterior transarticular fixation of C1/2 (ATS) with compression osteosynthesis of dens axis significantly increases the stability of osteosynthesis. MATERIAL AND METHODS In the period from 2009 to 2015 our hospital admitted 13 patients older than 65 years of age with a diagnosed type III dens axis fracture based on AO classification. 8 patients sustained a dens axis fracture combined with a stable atlas fracture. The cohort consisted of 13 women aged 67 to 90 years, with the mean age of 82.3 years. None of the female patients were affected neurologically. The dens axis fracture was treated by anterior approach. Once the screw was inserted in the dens axis, two more screws were added, the entrance points of those screws were medial and lateral to the odontoid screw and direction was divergently via C1/2 joints in order to reinforce stability. The patients were monitored at 6-week, 3-, 6- and 12-month follow-ups. Bone healing was confirmed by CT scan. RESULTS No complications were recorded during the surgery in any of the 13 patients. In one female patient the stabilization failed in the early postoperative period. A reoperation from anterior approach with the use of the same method was necessary. In eleven patients bone healing occurred after 6 to 12 months. In two patients pseudoarthrosis was formed with no clinical symptoms. No neurological deterioration or a patient s death was reported in the monitored period within 12 months after the treatment. DISCUSSION Where dens axis fractures in elderly patients are managed operatively, the posterior approach and transarticular fixation of C1/2 with sublaminar loop are preferred. This procedure is considered more reliable, owing to the fears of a failure of osteosynthesis by anterior approach. The most frequent cause of a failure is the pulling out of the screw through the anterior wall of dens axis base in patients with osteoporosis. Concurrently, the anterior approach is regarded as more considerate. The ATS fixation increases stability compared to isolated compression osteosynthesis, which makes it possible to manage the dens axis fractures by a more considerate anterior approach. CONCLUSIONS The ATS is a method that increases stability of compression osteosynthesis in managing dens axis in elderly patients. Key words: dens axis, upper cervical spine fracture, elderly, triple screw technique, anterior transarticular C1/2 stabilization.

[Bilateral Asymmetric Traumatic Dislocation of Hip Joints]. / Bilaterální asymetrická traumatická luxace kycelních kloubu.

The authors present a rare case of bilateral asymmetric traumatic dislocation of hip joints, where the left joint was treated conservatively after the reduction, while the right joint, with an acetabular fragment interposition, was treated surgically - by arthroscopically assisted reduction and fixation of an osteochondral fragment of posterior wall of the acetabulum. The female patient healed with no complications, showing an excellent clinical outcome with no signs of instability or limited mobility of hip joints, and also with no signs of para-articular calcification or necrosis of the hip at 1 year after the injury and treatment. Bilateral asymmetric dislocation of hip joint is a rare injury with the total incidence of 150 cases as reported by the literature. Recently, its incidence is higher due to the increased traffic and the associated accident rate. A precise and prompt reduction of the injured hip joint is always necessary, if possible under general anesthesia. Also, it is always necessary to carry out a complete examination of the patient since this type of injury is always caused by a strong force and is often accompanied by injuries of other parts of the body. Key words: bilateral asymmetric dislocation of hip joints, hip arthroscopy, acetabular fracture.

[Open talar dislocation]. / Otevrená luxace talu.

PURPOSE OF THE STUDY: Total talar extrusion is a rare injury. It is frequently associated with severe soft tissue injury. There is no consensus about an appropriate treatment for an extruded talus. Total extrusion of the talus has a high possibility of avascular necrosis of the talus or infection. The primary goal of this study is a retrospective evaluation of the patients with open total talar dislocation treated by immediate reimplantation. MATERIALS AND METHODS: We evaluated six patients (mean age, 29.6 years) with an open total talar dislocation treated in the Traumatological Hospital Brno. The dislocated talus, after debridement, was reduced, held in the correct position by Kirschner wires and spanned by external fixation, with two pins placed in the calcaneus and two in the distal tibia. The patients were evaluated on the basis of clinical and radiographic examination. Two patients underwent secondary reconstruction procedures. The four remaining patients were evaluated using the AOFAS score. RESULTS: The mean follow-up period was 24.2 months (range, 18-32). Two patients had an infection and one developed avascular necrosis of the talus. One patient required arthrodesis of the subtalar joint and one talectomy with tibiocalcaneal arthrodesis and callus distraction of the tibia. CONCLUSIONS: A primary reimplantation of the talus can produce good functional outcome. It is reasonable to replace an extruded talus as soon as possible after debridement. Infection and avascular necrosis of the talus seem to be difficult to predict.

[Mid-term radiographic results in Th12 and L1 fractures after anterior column reconstruction with tibial shaft bone allograft]. / Radiologické stredne-dlouhé výsledky u Th12 a L1 zlomenin, kde prední sloupec byl rekonstruován alogenním diafyzárním tibiálním stepem.

PURPOSE OF THE STUDY: Frozen tibial shaft bone allografts filled with autologous cancellous bone chips were used for anterior column reconstruction in Th12 and L1 fractures. The aim of this retrospective study was to evaluate the five-year results of the treatment on the basis of radiographic findings. MATERIAL AND METHODS: Twenty-six patients treated in 2005 and 2006 for isolated Th12 or L1 fractures, with no neurological deficit, were evaluated. In all patients, the spine was stabilised from an isolated anterior approach or through a combined posterior and anterior approach, and angle-stable implants were used. On radiographic examination the loss of correction and lateral compression of the segment involved were measured on standard X-ray views. Data on bone union at graft-bone interfaces were obtained from spiral CT scans. For assessment of the stage of bone healing, a scale of 0-25-50-75-100 % was established, and each patient was evaluated by two independent radiologists. Based on the average results, bone union was defined as non-union, 0-24 %; incomplete union, 25-74 %; complete union, 75-100 %. RESULTS: The average loss of correction measured by Beck's method was 0.77 degree. In four patients, the lateral compression angle deteriorated on the average by 1.1 degree (range, 0.7°-1.8°) during the treatment. The proximal graft-bone interface showed complete union in 19 patients (73 %), and the distal interface was completely healed in 20 patients (77 %). Incomplete bone union at the proximal and the distal interface was found in seven (27 %) and six (23 %) patients, respectively. Nonunion was not recorded. No complications occurred. CONCLUSIONS: The use of tibial shaft bone allografts filled with autologous cancellous bone chips resulted in stable reconstruction of the anterior column of the thoracolumbar spine which showed a low loss of correction and good bone union.

[Failed compression osteosynthesis of the dens axis treated by anterior C1-C2 transarticular stabilisation. Case report]. / Selhání kompresní osteosyntézy zubu cepovce resené prední transartikulární stabilizací C1/2. Kazuistika.

We describe the case of an 80-year-old female patient who had undergone anterior C1-C2 transarticular stabilisation and was subsequently treated by the triple-screw method for failed compression osteosynthesis of a AO type III dens axis fracture. Key words: dens axis, upper cervical spine fracture, eldery, triple screw technique, anterior transarticular C1-C2 stabilisation.

[Treatment of intra-articular proximal tibial evaluation of two- to seven-year follow-up]. / Výsledky lécby niktrokloubních zlomenin proximální tibie v UN Brno v letech 1997 az 1999: hodnocení po 5-7 letech od terapie.

PURPOSE OF THE STUDY: Intra-articular fractures of the proximal tibia always present a complicated therapeutic problem. In this retrospective study, the results of both conservative and surgical treatment of these fractures are evaluated. MATERIAL: In the period from 1997 to 1999, 114 patients with proximal tibial fractures were treated in the Traumatological Hospital in Brno-Traumacenter. Of these, 34 (30 %) were treated conservatively and 80 (70 %) by a surgical procedure. A total of 80 patients were included in follow-up (70 %). Of these, 61 had surgery, which involved arthroscopically-assisted intervention in 25 patients, arthrotomy in 27 patients and open reduction with external fixation in nine patients who had an open fracture (eight had type C3 fracture). Minimally invasive fixation with a cancellous screw and washer was used in 25, and a buttress plate in 27 patients. Spongioplasty was carried out in 11 patients. METHODS: Clinical and questionnaire-based evaluation was undertaken at 5 to 7 years after the injury and following therapy. The outcome was assessed on the basis of two classification systems, i.e., the IKDC (International Knee Documentation Committee) score and the Lansinger score designed particularly for the evaluation of proximal tibial fractures. The outcomes were evaluated in relation to fracture type, conservative or surgical treatment, method of osteosynthesis, and use of arthroscopic control and spongioplasty. RESULTS: In each of the evaluated patients, radiographs were obtained after injury and then at the completion of therapy. The fractures classified according to the AO system were as follows: type A1 fractures - 9 patients; types B1, B2, B3 - 46 patients; types C1, C2, C3 - 34 patients. The average IKDC and the Lansinger scores achieved at 5- to 7-year follow-up were 70 and 24 points, respectively. This can be regarded as a very good result. Within 5 years of injury, four patients underwent total knee arthroplasty; all of them were over 50 years and had a type C3 fracture. The type B3 and C3 treated by arthrotomy showed similar outcomes on both classification systems (IKDC/Lansinger: 69/67 and 24/24, respectively). The B3 fractures operated on under arthroscopic control had better outcomes (77/69) than those treated by arthrotomy (27/25), because this approach combines advantages of inner fracture fixation with a minimally invasive surgical technique. Better results were also achieved in fractures treated by minimally invasive fixation with cancellous screws. DISCUSSION: The outcomes of therapy in intra-articular fractures of the proximal tibia related to how serious the fracture was and how well it was reduced and stabilized. Both the approach to fracture reduction and the method of its stabilization (buttress plate, minimally invasive screws, external fixator) are selected according to fracture type and soft tissue state. Spongioplasty is indicated if subchondral bone is affected. Reduction and stabilization performed under arthroscopic control permit more precise reconstruction of the articular surface, but can be used only for certain fractures (type A1 and B1, B2 and B3). For reduction and stabilization of all fracture types, with the exception of AO type 41A-1 fracture, an Y-ray image intensifier system is necessary. The meniscus above the injured bone should be preserved in order to maintain good function of the joint. CONCLUSIONS: In intra-articular fractures of the proximal tibia, treatment outcomes depend on the type of fracture as well as correct reduction and use of appropriate fixation. When accurate alignment, joint stability and well reduced articular surfaces are achieved, outcomes are very good. At mid-term follow-up, reduction under arthroscopic control gives better results than stabilization performed by arthrotomy.