[Osteosynthesis of intracapsular femoral neck fractures by dynamic hip screw (DHS) fixation]. / Osteosyntéza intrakapsulárních zlomenin krcku stehenní kosti metodou DHS.

PURPOSE OF THE STUDY: The treatment of femoral neck fractures shows a relatively high number of poor outcomes, usually due to late complications, such as avascular necrosis of the femoral head or pseudoarthrosis. The latter may develop when the osteosynthesis of osteoporotic bone fails. The aim of this retrospective study was to evaluate a group of patients treated by osteo- synthesis for intra-capsular femoral neck fractures at our department, and to verify indication criteria and identify the therapeutic procedures that are best suited to our conditions. MATERIAL: In the 1997-2001 period, a total of 81 patients with intra-capsular femoral neck fractures were operated on. Of these, 64 treated by dynamic hip screw (DHS) fixation were followed up for at least 5 years. There were 33 women and 31 men; the average age was 21.5 years (range, 21 to 74 years). METHODS: The Garden classification was used to evaluate the displacement of femoral neck fractures. Preferably, osteosynthesis was carried out by closed reduction; only exceptionally was an extension device for the operating table used. A 135-degree sliding hip screw, with a short thread, directed to the head centre and a two-hole side plate were used most often.The average follow-up was 6.9 years. Evaluated were: the occurrence of late complications in relation to the length of time between injury and surgery, quality of fracture reduction, use of an anti-rotation screw and necessity of repeat surgery. RESULTS: Garden I or II fractures were diagnosed in 13 patients, 51 had Garden III or Garden IV fractures. Bone union without complications was achieved in 73.4 % of the patients within 12 months of surgery. Late complications were found in 26.6 %; of these, only one had Garden I fracture and the rest were Garden III and IV fractures. An anti-rotation screw was used in 39 patients (60.9 %) and its use had no effect on the development of late complications. Of the seven patients who developed pseudoarthrosis, the screw was used in four (57.1%); out of the nine patients with avascular necrosis, it was used in six (66.7 %). In the whole group, an unsatisfactory outcome of post-operative reduction was recorded in 29.7 %. In the patients with late complications this was found in 52.9 %, which was a statistically significant difference. Of the 17 patients with poor outcomes, 14 underwent total hip arthroplasty; in the patients with necrosis, arthroplasty was carried out at an average of 26 months post-operatively, in those with pseudoarthrosis it was at 7 months post-operatively. DISCUSSION: For the treatment of intra-capsular fractures of the femoral neck, surgery is the most frequent approach, but there are controversial views on various relevant issues. An important factor affecting the treatment outcome is the patient's bone quality. CONCLUSIONS: Our results show a direct relationship between the extent of fracture displacement and late complications, i.e., avascular necrosis and non-union. The quality of fracture reduction had a greater effect on fracture non-union than on the development of femoral head necrosis. The length of time between injury and surgery played a lesser role than it is believed. The use of an anti-rotation screw was not significantly related to the occurrence of late complications. The DHS method is economical and available, and provided sufficient results whose comparisons with the literature data show that this therapeutic approach is correct.

[Ipsilateral traumatic dislocation of hip and knee joints. Case report]. / Ipsilaterální traumatická luxace kycelního a kolenního kloubu - kazuistika.

Traumatic obturator dislocation of the hip without fracture associated with antero-lateral knee dislocation is considered to be an extreme injury. Such a case, which has never been treated in our department, is reported here. The patient was a 40-year-old man who suffered his injury in a motorcycle accident. He had ipsilateral traumatic obturator hip dislocation and anterior knee dislocation.Within two hours of injury dislocation reduction was carried out under general anaesthesia, the anterior cruciate ligament was reconstructed using BTB allograft and a CT scan was obtained. In this type of trauma CT-angiography is always indicated to detect any possible threat to limb vitality. The functional results were excellent and were directly dependent on the correct use of arthroscopy. At 3 years post-operatively, his hip and knee joints were examined. The Harris hip score was 98 points and the International Knee Documentation Score (IKDC) was also excellent. There was no neurological deficit, although this type of trauma is usually associated with neurological complications. At the time of examination the patient was symptom free.

[Fractures of the tibial pylon: treatment options and outcomes]. / Zlomeniny pylonu tibie--moznosti osetrení a výsledky.

PURPOSE OF THE STUDY: Fractures of a tibial pylon are serious problems in traumatology. The methods of their therapy have not been unified yet and treatment outcomes are not satisfactory. This is often due to extensive comminution of the distal tibia, bone defects or a thin coverage of soft tissue. The objective of this study is to compare the literature data and, on the basis of this and our own experience, to present guidelines for the treatment of fractures of tibial pylons. MATERIAL: In the period from 1998 to June 2002, 60 patients (average age, 42 years) underwent surgery for a fracture of the tibial pylon in the Department of Orthopedics, IPVZ, and in the hospital Na Bulovce, First Faculty of Medicine, Charles University in Prague. In most of the patients, the injury was caused by falling from a height. Thirteen patients failed to turn up for follow-up. METHODS: Plate osteosynthesis or MIO, usually combined with plaster cast, were used in 42 patients. External fixation, with individual screws or Kirschner's wires in some cases, was employed in 18 patients. External fixation was applied in open fractures and in serious comminutions of the distal tibia. RESULTS: A total of 47 patients were followed up for a period of 6 months to 5 years. Infectious complications occurred in 12 patients (20%), of whom five had to undergo repeat surgery. Twenty-five patients (53%) reported good results of treatment, with no or only very minor restriction of motion in the ankle joint. In 13 patients, the outcome was satisfactory and nine patients were not satisfied because of serious restriction of motion or ankylosis of the ankle joint. Three patients underwent a delayed arthrodesis of the ankle joint. The fractures healed completely in all patients. DISCUSSION: The results achieved in our patients were comparable with those described in the international literature. The very good and satisfactory outcomes in 53% and 28% of the patients, respectively, are in agreement with the studies reporting good rates of success. Also the number of infectious complications (20%; 8% serious) was in the range generally reported. The initial method of treating fractures of the tibial pylon by plate osteosynthesis has gradually been abandoned. The major prognostic factors for the outcome of treatment are the extent of injury to soft tissues and the kind of surgical procedure used. Therefore, it appears that external fixation, usually in combination with semi-closed reduction and fixation of fragments with screws and Ki-wires, has a better prognosis not only in open fractures but also in closed comminuted fractures with seriously injured soft tissues. CONCLUSIONS: Fractures of the tibial pylon are serious injuries and their therapy requires good experience in the field and appropriate technical facilities. The method of treatment should be chosen according to not only fracture type but also soft tissue involvement and the patient's overall state.

[Treatment of calcaneal fractures using the medial approach for open reduction]. / Lécba zlomenin patní kosti otevrenou repozicí z mediálního prístupu.

PURPOSE OF THE STUDY: A comprehensive evaluation of the treatment of calcaneal fractures by open reduction is presented. The long-term results are compared with the relevant literature data. MATERIAL: In the period from 1987 to 2000, 60 displaced fractures of the calcaneus were treated in 51 patients. Of these, 49 patients suffered the fracture by falling from a height, which is generally the most common cause. Only two patients were injured during sports activities. Thirty eight injuries were classified as fractures of the joint depression type and 22 as fractures of the tongue type. The patients had surgery on the day they sustained the injury or after edema had subsided, if this was present on admission. The interval between injury and surgery was 4.6 days on the average. The fracture was fixed with Kirschner's wires (Kw) in 53 cases, a Kirshcner's wire and a hook-nail in five cases and a Kirchner's wire and a spongious screw in two patients. In May 2001, 23 patients were available for evaluation after a follow-up period of 6 to 120 months. METHODS: The patients underwent clinical and radiographic examination and filled a questionnaire. The fracture type was defined on the basis of the Essex-Lopresti classification system. Outcomes were scored according to the Creighton-Nebraska Health Foundation rating system that assessed pain, range of motion, edema, a change in shoe size, patient's activity after therapy termination and return to a job. RESULTS: In May 2001, 23 patients, with a follow-up ranging from 6 to 120 months were checked up. Of them, 20 (86.9%) had neither clinical manifestations nor subjective complaints. Three patients retired because of persisting complaints, two with disability pensions and one with an old-age pension. A total of 19 patients were evaluated by the Creighton-Nebraska Health Foundation rating system. The average score was 90.8 points. The results were excellent in 15 patients, good in three and poor in one patient. The complications reported by the patients included superficial infection in two, thromboembolic disease in one, and hypesthesia on the medial side of the leg in two patients. DISCUSSION: The optimal mode of treatment in dislocated intra-articular fractures of the calcaneus still remains open to discussion. Should conservative or surgical therapy be used? In agreement with others, the authors preferred early surgical intervention. This facilitated a better congruence of the dorsal articular surface. The average remaining dislocation of the articular surface was 1.1 mm in surgically treated as against the average of 4.7 mm in conservatively treated patients. It was possible to restore the length, height and width, and the correct axial position of the calcaneus by this surgery from the medial approach. However, in indicated cases, the procedure required an additional intervention from the lateral approach through a mini-incision. As reported in the literature, other authors have achieved comparable, or even better results but on the basis of either the lateral or the plantar approach. The application of primary spongioplasty or primary arthrodesis of the subtalar joint is discussed. The advantages of preoperative examination by computer-assisted tomography are emphasized. CONCLUSIONS: Good outcomes of the treatment of intra-articular, dislocated calcaneal fractures depend on a correct shape and position of the dorsal articular surface of the calcaneus. The open reduction procedure from the medial approach based on the principles of McReynold's technique allowed us to accomplish both these criteria.

[Jones fracture.]. / Jonesova zlomenina.

The authors deal with the issues of traumatology of proximal part of 5th metatarsus and evaluate their experience in the treatment of a specific type of fracture in this region, i.e. the Jones fracture. From the anatomical and biomechanical viewpoints they classify the fractures into fractures of diaphysis, extra-articular fractures of proximal metadiaphysis - i.e. the actual Jones fractures - and intra-articular avulsion fractures of the base. While the fractures of diaphysis may be successfully treated using walking plaster cast for 4 to 6 weeks and in case of auvulsion fractures of the base for 3 to 5 weeks (they may be treated also without rigid fixation), the treatment of metadiaphyseal fractures still poses a problem. The latter group the authors subdivide (not only with regard to the method of treatment) after Torg et al (1984) into acute type of Jones fracture, delayed healing or refracture in chronic complaints of patients and the actual typical stress fracture with a developed non-union. In the first case of acute fracture non-walking plaster cast for the period of 6 to 8 weeks is recommended. In case the period of fixation without weight-bearing was observed the authors recorded in their study no nonunion necessitating a surgical treatment. In delayed healing or re-fractures it was often necessary to prolong the cast plaster immobilization. As a result they recommend in case of physically active patients and professional sportsmen to choose surgical treatment. In case of clinically and radiographically evident non-union with the nature of fatigue fracture they indicate surgical treatment in all cases. The operation consists in decortication, local wide resection of non-union, excochleation of residual fibrous mass and implantation of autologous cortico-cancellous bone graft and with cancellous bone onlaygraft. For fixation they use a simple but stable tension wire loop without further fixation by plaster cast. The evaluation of results of the surgical treatment shows that in all cases clinical asymptomatic healing was achieved in 3 to 6 months (on average 4 months). There was only one case of dehiscence of the wound and irritation by migrated K-wire. After immediate extraction the wound healed without further coplications. Key words: Jones fracture, non-union of 5th metatarsus, stress fracture of 5th metatarsus, extraarticular fracture of 5th metatarsus, fixation of the fracture of 5th metatarsus.

[Resection of radial head for traumatological indication.]. / Resekce hlavicky vretenní kosti z traumatologické indikace.

Authors evaluate a group of 35 patients who underwent in the period 1987-1996 a resection of radial head for traumatological indication. They review the results after an early resection in 16 patients, 81 % of which are without complaints. Late resection in 19 patients significantly increased the range of motion and in 75 % it contributed to easing of pain. In the conclusion the authors emphasize the difficult indication of an early and late resection. Key words: injury of elbow, fractures of radial head, resection of radial head.

[Conversion of external fixation to an intramedullary nail in complicated fractures.]. / Konverze zevní fixace na nitrodrenový hreb u komplikovaných zlomenin diafýzy - první zkusenosti.

The authors present the method of conversion of external fixation to an intramedullary nail in treatment of complicated fractures of the diaphysis of the leg. This procedure is useful in particular in open fractures and in fractures associated traumatological issue. Conversion gives very satisfactory therapeutic result with a minimum of complications. The purpose of the present paper is to elucidate the procedure and make the readers familiar with the autors' experience assembled with the method in the first six patients. Key words: external fixation, conversion, intramedullary nail.

[Osteosynthesis by means of a corrugated splint.]. / Osteosyntéza vlnitou dlahou.

The authors submitted the clinical results of an investigation of 43 patients where in 1986 - 1995 at the Orthopaedic Clinic of the Institute for Postgraduate Training in Prague, Bulovka osteosynthesis by means of a corrugated splint was implemented. The predominating part of the patients was formed by men - 29 (67 %), women 14 (33 %). The mean age of the patients at the time of osteosynthesis war 36.7 years (12-77 years). The time interval between primary osteosynthesis and osteosynthesis by means of a corrugated splint was on average 23 months (4 - 65 months). The mean total period of treatment, i. e. the time from primary osteosynthesis to complete cure after osteosynthesis with the corrugated splint was 35.2 months (9 - 74 months). The primary diagnosis was in the majority of patients comminutive diaphyseal fracture of the femur - 39 times (91 %), in 32 instances (77 %) closed, 7 times open (14 %). In 4 instances the corrugated splint was used when osteosynthesis of prolonged femurs failed. The major part of patients did not have, before ostesynthesis with a corrugated splint, more than 1-2 operations (31 patients, i. e. 72 %). There were, however, also patients with five to six operations. Osteosynthesis with a corrugated splint was indicated mainly on account of the diagnosis of pseudoarthrosis of the femur (18 times, i. e. 42 %), splitting of the splint with refracture of the femur 22 times, i. e. 51 %. In one third of the patients (15, i. e. 34 %) the osteosynthesis with a corrugated splint was supplemented by compression, always in case of the diagnosis of hypertrophic pseudoarthrosis of the femur. In the final clinical evaluation 40 patients were included. As to complications, in particular failure of the corrugated splint was investigated. The authors recorded four cases (9 %). In these patients re-osteosynthesis with a corrugated splint was performed and after that after the usual intervals cure of the complication occured. The mean period of recovery in the investigated group of patients was 6.9 months (3-15 months). The authors evaluated also the difference in time between osteosynthesis with a corrugated splint with compression and without compression. The difference between the mean time of recovery in osteosynthesis with compression (6.1 months) and without compression (7.2 months) was 1.1 months. The authors conclude that compression in osteosynthesis with a corrugated splint is not the dominating factor for healing of the osteosynthesis. They evaluate osteosynthesis with a corrugated splint as a safe and reliable method suitable in particular for diaphyseal pseudoarthroses or in failure or failing osteosynthesis in the diaphyseal area of the femur. Key words: plate osteosynthesis, ostheosynthesis of femur.

[Osteosynthesis by Unreamed Interlocking Nail UTN of the Tibial Shaft Fractures Caused by High Energy Injuries.]. / Osteosyntéza nepredvrtaným hrebem UTN zlomenin diafýzy bérce zpusobených velkou energií poranení

The authors present their own two-year experience with osteosynthesis of 54 fractures of the diaphysis of the leg in 51 patients, using a UTN nail without predrilling, at the Orthopaedic Clinic of the Institute for Postgraduate Medical Training in Prague Bulovka Hospital. After a one-year interval they included in the group 28 complicated fractures of the leg in 26 patients where the fractures were caused by a high energy impact. In nine instances (34.6 %) the fracture was in a polytraumatized patient and in eight patients (50,8 %) with multiple injuries. There were 14.3 % grade 1 open fractures (four fractures) and 21.4 % (four fractures) were grade 2 fractures. The other fractures were closed with major soft tissue contusion. In 11 instances (42.9 %) a secondary operation had to be performed: in 9 instances dynamization, in one instance a supplementary spongioplasty, in one case dynamization combined with osteotomy of the fibula and in one instance a rotational malposition was corrected. In three cases UTN osteosynthesis was supplemented by plaster fixation. Full burdening was possible after an average period of three months. Healing was recorded after an average period of 6.4 months, i.e after 27.7 weeks. As to complications, in one instance an infection was recorded, three times instability of the short proximal fragment, twice Sudeck's algoneurodystrophy, twice neurological complications and once a dry dermal necrosis at the site of the surgical wound. The authors did not record thromboembolic disease or compartment syndrome. As to subjective symptoms oedema and intermittent pain on burdenig were most frequent (32.1 %). Fracture of the nail did not occur. Breaking of the supporting screws was found in 17.9 % (20 screws). In the investigated group of patients the authors evaluated the results in 21 patients (80.8 %) as excellent or good. Satisfactory results were recorded in 11.5 % (3 patients). Unsatisfactory results were recorded in two patients (7.7 %) where surgical revision was necessary because of infection and fifteen degree valgus malposition. In the discussion the authors compare their results with patient groups selected according to similar criteria and they confirm the conclusions of indication of UTN in all fractures of the diaphysis of the leg caused by high energy of violence, incl. grade 1 and 2 open fractures according to Gustil's classification. Key words: unreamed interlocking nailing of the tibial shaft fractures, UTN, fractures of the tibial shaft caused by high energy injury.

[Our Experience with Treatment of Fractures of the Proximal Femur by Gamma-nail.]. / Nase zkusenosti s resením zlomenin proximálního femuru pomocí gamma-hrebu.

The authors present their own experience with the use of a standard and long gamma-nail, indications for surgery and advantages of its use. They draw attention to some imortant steps of the surgical technique. During the period from May 1995 to December 1996 they evaluated a group of eight patients, mean age 56 years (18-89 years), with an unstable pretrochanteric fracture fixed by a standard nail and a group of seven patients, mean age 42.2 years (21 - 72 years), with a complicated fracture of the proximal femur and diaphysis fixed by a long gamma-nail. Of fifteen operated patients eleven evaluated the result as excellent, two as good and one as poor. One female patient was not mobilized because of medical complications. Key words: gamma-nail, long gamma-nail, fractures of the proximal femur.

[Initial experience with the treatment of diaphyseal fractures of the leg by an intramedullary nail.]. / První zkusenosti s lécením diafyzárních zlomenin bérce nepredvrtávaným zajisteným hrebem.

The authors present an account on their clinical experience with the treatment of diaphyseal fractures of the leg using an intramedullary nail not drilled in advance. During the period between May 1994 and August 1995 they treated at the Orthopaedic Clinic of IPVZ in Prague Bulovka hospital a total of 28 patients, 22 men and 6 women, mean age 36 years, follow up period six months. The final clinical evaluation comprised 26 patients with 27 fractures. In 93% the authors recorded complete cure of the fracture of the leg, on average within five months after operation. The group of patients comprised 7 (25%) patients with multiple injuries and 5 (17%) with open fractures of the crus. According to the AO classification of skeletal injuries type B fractures were most frequent -18 (64%). The operation was implemented on average on the seventh day after the accident. In 8 (28%) the authors recorded bending or breaking of the nails, in all instances without any effect on the healing of the fracture. As to local complications the authors recorded four times instability of the nail -three times proximal and once distal instability. The position was successfully managed in all instances by application of a plaster bandage of the Sarmient type. There was only one typical deep infection. The final clinical evaluation was made in 26 patients, where minimal axial deviations were found, minimal restructions as regards the mobility of the knee or talar joint, and the majority of patients were satisfied with the operation. Initial experience with treatment of diaphyseal fractures of the leg using an intramedullary nail without previous drilling revealed a high percentage of completely healed fractures with a minimal number of local or systemic complications. Key word: intramedullary nailing without previous drilling.

[Osteosynthesis of fractures of the ulnar olecranon.]. / Osteosyntéza zlomenin olekranonu ulny.

The problem of fractures of the ulnar olecranon has been, due to the relatively frequent incidence and character of the injury, dealt with for more than 100 years. Various types of osteosynthesis are recently the subject of investigations published in experimental studies. Due to the not quite uniform conclusions of this work the authors processed and evaluated in a retrospective study a group of patients treated at the Orthopaedic Clinic of the Institute of Postgraduate Medical Training, Bulovka Hospital in 1984-1993. In the course of these ten years 70 patients with 71 fractures were treated. The group comprised a total of 29 patients with 30 fractures. In four instances an open fracture was involved. On operation in half the patients major or minor comminution was found. In 23 patients the authors treated the fracture by traction AO cerclage which they supplemented in another seven cases by accessory osteosynthetic material. Twenty-eight fractures, i. e. 93% healed. Excellent and good results were recorded in 83%.The most frequent complications comprised irritation by Kirschner wires (20%), which were the cause of their early removal. Osteosynthesis failed in one instance. Reosteosynthesis was indicated and the result was good. A deep infection was treated in one instance (3.3%). The method of treatment of dislocated fractures of the ulnar olecranon by means of AO traction cerclage is sufficiently stable even when a minimum of osteosynthetic material is used while respecting requirements of biological osteosynthesis. Due to frequent comminution is must be sometimes supplemented by more screws or wires or for a short time by additional plaster fixation. The patients recover and can resume work usually within three months after surgery. Key words: fracture of ulnar olecranon, AO traction cerclage.