[Peripheral Factures of the Talus. Mid-Term Results]. / Periferní zlomeniny talu ­ strednedobé výsledky operacní lécby.

PURPOSE OF THE STUDY Peripheral fractures of the talus (lateral talar process and posterior talar process) are rare injuries, easy to miss on examination due to their location and clinical manifestation. They account for 0.3% to 1.0% of all fractures of the talus. An incorrect or late treatment of talar process fractures can result in permanent pain, impingement syndrome, healing in malposition, pseudoarthrosis development and also, due to joint instability, in a potential development of severe subtalar arthritis. The aim of this retrospective study was to evaluate the results of surgical management of these fractures in our department. MATERIAL AND METHODS The study included 14 adult patients with fractures of the peripheral talar processes who met the criteria of the retrospective study and were treated in our department between 2008 and 2014. All patients underwent clinical examination with evaluation based on the AOFAS Ankle-Hindfoot score, VAS score and radiographic evidence of arthritis. Follow-up ranged from 24 to 95 months. The average age of the patients at the time of surgery was 34 years (range, 21-59 years); there was one woman and 13 men. All underwent pre-operative CT scanning. The surgical procedure included open reduction and internal fixation (ORIF) which, in indicated cases, was preceded by partial or total removal of the processes. RESULTS Of the 14 patients, seven were treated for fractures of the lateral talar process (LTP group) and seven for the posterior talar process (PTP group). All fractures healed completely. The median AOFAS score was 87 (72-100) points in the LTP group, and 84 (58-100) points in the PTP group. Excellent and good results on the AOFAS Ankle-Hindfoot scale were achieved in 10 (72%), satisfactory in two (14%) and poor in two (14%) patients. Of the LTP group, six patients (86%) showed the VAS score ≤ 3, and one (14%) had the VAS score = 4. In the PTP group, the VAS score ≤ 3 was reported by three (43%) and values of up to 5 by four (57%) patients. Arthritis in the talocrural and subtalar joints was evaluated as zero or grade 1 in 11 (79%) of all patients; of these 11 patients only two (14%) had a VAS score higher than 3. Only one patient had marginal wound necrosis; no deep wound infection was recorded. DISCUSSION The majority of fractures in our group were due to falls from a height or traffic accidents, which is in accordance with the literature data. In about 70% of these injuries, more parts of the leg are affected and, therefore, a thorough medical inspection is necessary. These mechanisms of injury most frequently produce type II LTP fracture (Hawkins classification). Four patients with a LTP fracture, who had the process partially removed, achieved good results on the AOFAS scale and the VAS score less than or equal to 3. As also published in the literature, the removal of small fragments has no crucial effect on ankle stability. CONSLUSIONS An adequate surgical treatment of displaced peripheral fractures of the talar processes provides good functional outcomes. In fractures with associated leg injuries or high-energy traumata, the prognosis is poorer. Fractures of talar processes often show symptoms and signs similar to those of more serious forms of dislocation of the talus and therefore a careful assessment of standard X-ray images taken for a "swollen ankle" is necessary. If the findings are not clear, CT examination is indicated. Key words: fracture, talus, processus lateralis tali, processus posterior tali.

[Long-term results of nailing of extra-articular proximal humerus fractures]. / Dlouhodobé výsledky hrebování extraartikulárních zlomenin proximálního humeru.

PURPOSE OF THE STUDY To evaluate the long-term results of intramedullary nailing of extra-articular proximal humerus fractures. MATERIAL AND METHODS Thirty-six patients with 36 extra-articular fractures, types 11-A2 and 11-A3, treated by intramedullary nailing were reassessed after an average follow-up of 54 (30-86) months. The group included five type 11-A2 and 31 type 11-A3 fractures according to the AO/OTA classification. Radiographic and clinical outcomes - the absolute Constant score (CSabs) and the relative Constant score (compared to the contralateral side, CSrel) were evaluated. The rate of complications was assessed. RESULTS All fractures healed. The mean long-term CSabs was 73 pts, the mean CSrel was 89% of the unaffected side. Thirty (83%) patients achieved excellent or good results (CSrel higher than 80%), four (11%) had satisfactory and two patients (5.5%) had poor results (CSrel less than 60%). No significant difference was observed in functional results between different age groups. No non-union, loss of reduction or deep infection was encountered. Two cases of prolonged healing were observed, one implant-related complication happened due to locking screw breakage. Conclusion Nailing can be recommended for the safe treatment of extra-articular fractures of the proximal humerus. If the procedure is performed properly, the possibility of excellent functional results is high and the rate of complications is minimal. Age does not influence the final functional result. Key words: proximal humerus, extra-articular fractures, intramedullary nail, long-term results.

[AO type 13-C distal humerus fractures. Results of surgical treatment]. / Zlomeniny distálního humeru AO 13 C - výsledky operacní lécby.

PURPOSE OF THE STUDY: The aim of this retrospective study was to evaluate the results of surgical treatment in 41 fractures of the distal humerus classified as type C according to the AO system using conventional versus angle-stable locking plates. MATERIAL: Fifty-one patients were treated by the open reduction and internal fixation method at our department between 2005 and 2008. The group included 28 women and 23 men with an average age of 52.5 years. Forty-one patients came to the final treatment evaluation. The average follow-up was 19 months. Of the 41 injuries, 34% were open fractures. METHODS: All patients were operated on from the standard dorsal approach. Olecranon osteotomy was performed in 83% and the Bryan-Morrey procedure was used in 17% of the patients. Stable osteosynthesis with two reconstruction plates was used in 14 patients (34%), two locking distal humeral plates (DHP) in 21 patients (51%) and a reconstruction plate combined with a DHP was employed in six patients (15%).Controlled early passive rehabilitation was started as soon as acute pain after surgery had resolved. Follow-up at 4, 8 and 12 weeks and at 6 and 12 months included clinical and radiographic examination. The functional outcome was assessed using the Mayo Elbow Performance Score (MEPS) system. RESULTS: The average MEPS was 83.6 points. Excellent results were recorded in 19 (46%), good in 14 (34%), satisfactory in five (12%) and poor in three (8%) patients. Healing was achieved within 3 months of surgery in 82% and within 4 months in 12% of the patients. Non-union due to failure of osteosynthesis was recorded in 5 % of the patients. No differences were found in the duration of healing in relation to the implant used. The average flexion/extension range of motion (ROM) at the elbow was 108 degrees (range, 40 to 145 degrees). The complications included failure of osteosynthesis in three patients, deep wound infection in two, superficial infection in one and heterotopic ossification in five patients. Of 16 patients (39%) with ulnar nerve irritation, 15 had impairment in sensory function and one in motor function. The average operative time was 163 min. DISCUSSION: The results of our study correspond to relevant data reported in the present-day literature. There is an agreement in excellent and good functional outcomes, as assessed using the MEPS, in ROM values and operative time as well as in complications such as non-union, infection or heterotopic ossification. Compared with other studies, the proportion of ulnar nerve irritation in our group was higher. As reported, excellent results are achieved with the use of locking compression plates, particularly in comminuted fractures of the distal humerus in osteoporotic bone. CONCLUSIONS: The method of open reduction and internal fixation with two plates performed by an experienced surgeon brings about good results in the treatment of AO type C fractures of the distal humerus.