[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.

[Diclofenac 75mg. and 30 mg. orfenadine (Neodolpasse) versus placebo and piroxicam in postoperative analgesia after arthroscopy]. / Diklofenak 75 mg s orfenadinem 30 mg (NEODOLPASSE) versus placebo a piroxikam v pooperacní analgezii u artroskopií.

PURPOSE OF THE STUDY: Arthroscopy is often performed in an out-patient department or as one-day surgery. Opioids often used as postoperative analgesics may have unwanted side effects that may postpone the patient's discharge from hospital. This study was designed to evaluate a substitute for the most frequently used opioid pethidine. For pain relief, non-steroid anti-inflammatory drugs are recommended, but they offer a limited choice for parenteral administration. We used a new agent (Neodolpasse) based on diclophenac and orphenadine, and compared its efficacy with piroxicam and placebo. METHODS: A total of 119 patients scheduled for knee joint arthroscopy were included in this prospective study. In a randomized, double-blind manner, they received piroxicam (P), Neodolpasse (combining 75 mg diclophenac and 30 mg orphenadine; N) or placebo (C). The number of patients in groups P, N and C were 44, 35 and 40, respectively. The effect of therapy was evaluated on the basis of the following criteria: duration of post-operative analgesia until a request for another analgesic, pain intensity (0-10 VAS), side effects and the patient's satisfaction with analgesia. The efficacy was evaluated for 24 hours after arthroscopy; premedication and analgesia induction and administration followed the same anesthetic protocol in all groups. The ethic committee approved the study and patients gave their informed consent. The results were statistically evaluated using the ANOVA analysis of variance completed by a multiple comparison of levels of significance according to Bonferroni. The presence of side and unwanted effects was analyzed by the chi-square of Fisher's exact test. A p value les than 0.05 was regarded as statistically significant. RESULTS: There were significant differences in the number of patients not requiring further analgesic medication after arthroscopy (P 52.3% vs. C (11.7%) p < 0.05, N (68.6%) vs. C p < 0.001), lower average postoperative pain (0 to 10-point scale, P 2.4 vs. C 2.9 p < 0.05, N 1.5 vs. C p < 0.05) and fewer side effects (N vs. both P and C, p < 0.05). DISCUSSION: The combination of diclophenac with orphenadine for intravenous application has only recently been available in the Czech Republic. The addition of a central muscle relaxant to a peripheral analgesic has a better effect than diclophenac alone. This may also account for a longer duration of analgesia in comparison with piroxicam reported to have significantly longer analgesic effects. The new medication also had fewer side effects. It was interesting to record that even the patients who had more pain and shorter postoperative analgesia were satisfied with the therapy provided. CONCLUSIONS: The main result of this study is the finding that Neodolpasse significantly reduces the intensity of postoperative pain and increases the duration of postoperative analgesia after knee joint arthroscopy.

[The proximal femoral nail (PFH)--another alternative for osteosynthesis of trochanteric fractures]. / PFH (proximální femorální hreb)--dalsí alternativa osteosyntézy trochanterických zlomenin.

The aim of the study was to test a new intramedullary implant PFH-Medin on internal fixation of trochanteric fractures. The basic group comprised 35 patients (average age 79.2 years). Indicated for the surgery were patients with all types of trochanteric fractures, i.e. 13 stable (AO 31A1), 15 unstable (AO 31A2) peritrochanteric fractures and 7 intertrochanteric (AO 31A3) fractures. Final outcomes were evaluated in 21 patients with the minimal follow-up of 6 months. From the viewpoint of the type of the fracture 9 cases were stable peritrochanteric, 7 cases unstable peritrochanteric and 5 intertrochanteric fractures. Duration of surgery was measured from the incision until wound closure and in the whole group of 35 patients it was on average 50 min. (range, 25-90 min.). X-ray exposure was recorded including the period necessary for the reduction of the fracture and was on average 80 sec. (range, 25-120 sec.). In the whole group we encountered only two complications. The first complication resulted from the insertion of the distal locking screw outside of the nail and the patient healed without problems. The second case involved aseptic necrosis of the femoral head eight months after the surgery and five months after the fracture had healed. All 21 patients followed up minimally for sixth months healed in anatomical position.

[Duration of surgery in osteosynthesis of fractures of the trochanter]. / Operacní cas pri osteosyntéze zlomenin trochanterického masivu.

PURPOSE OF THE WORK: To analyze duration of surgery in individual types of internal fixation of fractures of the trochanteric massif and identify factors which have an impact on it. MATERIAL: Analysis covered a group of 137 patients treated with Ender nailing (EN), 314 patients by means of Dynamic Hip Screw (DHS), 74 patients by means of Gamma nail, 37 patients by means of Proximal Femoral Nail (PFN) and 13 patients by means of 130 degrees angled blade plate. The groups of patients included basicervical femoral neck fractures (29 cases), peritrochanteric and subtrochanteric fractures. Peritrochanteric fractures were evaluated according to Kyle classification, types I and II as stable (174 cases), type III unstable (159 cases) similarly as type IV (peri/subtrochanteric fractures or comminuted fractures of the whole trochanteric massif--35 cases). High subtrochanteric fractures (55 cases) were evaluated after Seinsheimer. From the viewpoint of AO/ASIF classification they were 31A1, 31A2, 31A3 fractures. EN was indicated mainly in Kyle I through IV fractures, DHS for basicervical fractures and Kyle I through III fractures, Gamma nail for Kyle I through IV fractures and high subtrochanteric fractures, PFN mainly for high subtrochanteric fractures and Kyle III fractures, 130 degrees angled blade plate was indicated only for stable peritrochanteric Kyle I fractures. RESULTS: The average duration of surgery, i.e. starting from the skin incision until the suture of the wound, was in DHS 47 min., in EN 52 min., in 130 degrees angled blade plate 54 min., in PFN 58 min. and in Gamma nail 70 min. The shortest time intervals were achieved in stable peritrochanteric fractures of Kyle I and II (EN, DHS, Gamma), the longest ones in high subtrochanteric fractures (Gamma, PFN). The impact of the learning curve was analyzed in DHS. In 1995 the average duration was 70 min. (35 patients/year), in 2000 already only 39 min. (123 patients/year). DISCUSSION: If we wish to make a serious evaluation of the duration of surgery of any method we must not forget that apart from it there is a whole number of other factors by which it is influenced. In case of proximal femur it is the type of fracture, the number and experience of surgeons, mastering the learning curve, annual frequency of surgeries at the respective Department as well as variation within the surgical technique (e.g. in DHS the number of distal locking and the number of locking screws, etc.) A significant role in this study was also played by the development of internal fixation at the Department of the authors. For instance, considerably shorter duration of surgery as well as minimum of complications in PFN were achieved thanks to mastering of the learning curve on the Gamma nail which we had started to use 3 years before. An objective evaluation requires also a sufficient number of cases in order to eliminate errors caused by low numbers and other variable factors. CONCLUSION: Surgery duration data which we present are comparable with the values included in the world literature. It applies not only to the duration of surgery in individual implants but also in individual types of proximal femur fractures. At present at our Department the average duration of surgery ranges in dependence on the applied implant, type of fracture and skills of the surgeon between 30 and 60 minutes. Relatively shortest duration can be achieved in DHS, in Gamma nail and PFN the duration is slightly longer. However, the duration of surgery is only a supporting factor. Of much greater importance for the patient is the quality of the surgery. Thus favouring any method only on the basis of the duration of surgery is absolutely irrelevant.

[Unstable pertrochanteric fractures, biomechanic, classification and therapy.]. / Nestabilní pertrochanterické zlomeniny -jejich biomechanika, klasifikace a terapie.

The authors deal with unstable pertrochanteric, intertrochanteric and subtrochanteric fractures extending as far as calcar femorale. The treatment of pertrochanteric issues is a serious issue as their total number in the Czech Republic exceeds 5.000 annually and with the exception of those which are contraindicated due to their health condition, all patients are indicated to surgery. In the treatment of unstable pertrochanteric fractures there occurs failure of internal fixation also with the use of implants such as dynamic hip screw or Gamma nail. The cause of unsuccessful treatment of unstable fractures is the defect in calcar femorale - impairment of the weightbearing area of proximal femur and failure of the implant as a result of its cyclic overloading - breakage of the nail, cutting out of the screw from the head in the osteoporotic bone or breaking out of screws fixing the plate to the femoral shaft. For a causal procedure the authors consider the reconstruction of the calcar femorale by a wedge valgus osteotomy of the comminuted zone after the original design of Debrunner and Cech (1969). Simultaneously with reconstruction of the medial cortical support in the calcar femorale the 160 degrees valgization is performed. In the AO classification the authors consider for unstable the fractures of types 31.A2.1, A2.2, A3.3. Significant from the therapeutic viewpoint is the classification of stable fractures (with open reduction the anatomic reconstruction of weight-bearing calcar femorale is possible) and unstable fractures - where with open reduction the defect of calcar femorale persists. For stabilization of unstable the authors recommend fixation by DHS at 150 degrees angle. If need be, this fixation may be combined with lag screws and in case of a simultaneous fracture of greater trochanter and in reverse fractures a trochanteric buttress plate has to be added. Key words: unstable pertrochanteric fractures, nonanatomic valgus reduction, DHS fixation.