[Osteosynthesis of intracapsular femoral neck fractures]. / Osteosyntéza intrakapsulárních zlomenin krcku femuru.

PURPOSE OF THE STUDY: To evaluate outcomes of internal fixation of intracapsular femoral neck fractures. MATERIAL AND METHODS: Between the beginning of 1998 and end of 2002 the authors performed internal fixation of intracapsular fracture of the femoral neck in 47 patients (21 women, 26 men). The average age of patients was 56 years, range, 17 to 86 years (men 54.5 years, women 58.2 years). Forty patients (18 women, 22 men) went through the follow-up at the minimal interval of 1 year after the surgery. Their average age was 56 years. The remaining 7 patients were lost to follow-up. In 21 patients the case was Garden 1 and 2 fractures, in 19 patients Garden 3 and 4 displaced fractures. Internal fixation by three lag screws was performed in 16 cases, fixation by DHS with antirotational screw in 24 cases. RESULTS: The fracture healed in 70% of cases, non-union occurred 3times and avascular necrosis developed 9times. Garden 1 and 2 fractures were associated with 14.3% and Garden 3 and 4 fractures with 47.4% of complications. Of fractures treated by lag screws, 71% of cases healed, while in those treated by DHS the percentage was 69%. Both duration of surgery and x-ray exposure was in lag screws by 50% longer than in DHS. In terms of the development of avascular necrosis, the study did not prove any advantage of a shorter interval between the injury and surgery. However, development of avascular necrosis was influenced also by other factors and therefore the significance of urgent surgery within 6 hours after injury should not be questioned. CONCLUSION: Garden 3 and 4 displaced fractures have a worse prospect than Garden 1 and 2 fractures. Duration of surgery and x-ray exposure in DHS is shorter than in lag cancellous screws with the same percentage of good results. Of great importance is an exact reduction of the fracture in both projections, a correct position of implants and evacuation of intracapsular haematoma as a prevention of avascular necrosis of the femoral head.

[Evaluation of results after reimplantation of total hip arthroplasty cemented cup]. / Hodnocení výsledku po reimplantaci cementované jamky TEP kycelního kloubu.

PURPOSE OF THE STUDY: The aim of the study is to evaluate the results achieved after the replacement of a loosened or broken cemented cup by another cemented cup and to specify conditions under which such procedure may be successful. MATERIAL: In the period of 1992-1997, 158 revision surgeries of total hip arthroplasty were performed at the authors' Department. In 69 patients (57 women, 12 men) the cemented cup was replaced by another cemented cup and the original femoral monocomponent with the 32 mm head diameter the surface of which was not damaged was left in place. METHODS: The indication for operation was loosening of Degree 2 or 3 of the classification after Krbec et al. The surgery was performed from the Watson-Jones or Bauer approach. The cup was always revised with the use of the Palacos cement in combination with antibiotics by the cementing technique of 2nd generation. Augmentation was used in 11 cups. The original femoral component was always returned to the original cemented bed and a cement mantle was added in the proximal part in 15 patients. Poldi cups were replaced in all patients of the followed up cohort (63 times loosening--91%, 6 times breakage--9%) using 3 types of cups for revision surgery (Poldi--44 times, Ultima--20 times, SPC--5 times). During the period of March through December 2001, 48 patients were followed up in the out-patient department. The clinical condition was evaluated on the basis of the Harris Hip Score and a radiograph was made to monitor changes in the position of the cup, linear wear, the presence and size of the radiolucent zone. RESULTS: The results were evaluated in 48 patients (40 women and 8 men) with the average interval of 63 months after revision of the cup (range, 46 to 112 months). However, the clinical and radiograph evaluation of the condition was made only in 45 patients. Three patients re-operated on in 2001 were not included in the evaluation. The Harris Hip Score was on average 78 points (range, 51 to 97 points). Radiographs did not show any change in the position of the cup. The linear wear up to 1 mm was revealed in 4 cups and above 1 mm in 1 cup (11% of the evaluated patients). The radiolucent line in zone III after DeLee and Charnley was present in 4 cups, in zones II and III in another 4 patients, i.e. in total in 8 of 45 cups (18%). DISCUSSION: The group of 45 followed-up patients may be considered a sufficiently representative sample of the original 69-member cohort (minimally 7 patients died in the follow-up period, 3 patients were not included in the evaluation). With regard to the average follow-up of 63 months the results may be considered as medium-term. The average interval between primary total hip arthroplasty and revision of 130 months is comparable with the results of similar studies by other authors. The results of the clinical evaluation on the basis of Harris Hip Score are not convincing (range, 51 to 97 points, average 78 points). Radiographs showed a radiolucent zone in 8 cups (18%). Another 3 patients were at the time of evaluation after a repeated revision of the cup for loosening (at the interval of 22 to 34 months). CONCLUSION: A good integration of the cemented cup used in revision of the loosened cemented cup of total hip arthroplasty was evident only in infrequent cases of a perfectly preserved acetabulum both from the viewpoint of shape and structure. The evaluation of other patients of the followed-up cohort, however, produced rather unconvincing results. On this basis and also on the basis of their experience in the use of cementless cups in revision of total hip prostheses the authors recommend to prefer a cementless implant in the revision of the cup.

[The uncemented self-threading Ultima cup: first 5 years' experience]. / Necementovaná samorezná jamka Ultima: zkusenosti prvních peti let.

PURPOSE OF THE STUDY: To present the first 3-5 year experience in primary implantation of the Ultima cementless hemispherical threaded cup. MATERIAL: In the period between October 1995 and June 1997 we implanted in total 30 Ultima cementless cups in 28 patients (10 men, 18 women). The average age of the operated on was 60 years (41-74 years). Twenty-four patients, i.e. 26 hips were available for the follow up. From the viewpoint of diagnosis the group of patients included 15 cases of primary osteoarthritis, 9 cases of acute intracapsular femoral neck fracture, 3 cases of postdysplastic osteoarthritis, 2 cases (1 female patient with bilateral affection) of rheumatoid osteoarthritis (RA) accompanied with the protrusion of acetabulum and 1 case of idiopathic necrosis of the head. METHODS: The average follow up was 39 months (31-51 months). Subjectively, we followed the patients' satisfaction with the result of the surgery, i.e. subsidence of pain, range of motions and the willingness to undergo the surgery once more on the basis of its result. Radiologically, we assessed the shape of acetabulum prior to operation, the position of the implanted cup in ap projection on the postoperative radiograph, on the last control radiograph we evaluated osteointegration of the cup and also potential particular ossification. RESULTS: Nineteen patients out of 24 were subjectively satisfied with the result of the operation. The primary shape of acetabulum was in 24 cases spherical, 4 times dysplastic slightly lower CE (Wiberg) angle and twice there occurred protrusion of the head (the female patient with RA). The position of the cup in ap projection was evaluated in 25 cases as correct (45 degrees declination), in 2 cases as valgus (more than 55 degrees declination), in 3 cases as varus (less than 35 degrees declination) and in 1 case the cup was inserted too deep. Osteointegration was evaluated in 25 cases. In 22 cases we considered the osteointegration as good, i.e. without signs of a radioluscent line around the circumference of the cup. This line we encountered in 2 patients around the whole circumference of the cup but without any signs of a change in the position of the cup and without subjective complaints (pain in the hip). Both patients operated on for the primary osteoarthritis had a spherical shape of acetabulum and the declination of the cup was assessed as satisfactory. In 1 case we had to re-operate on due to the migration of the cup in the pelvis, namely in the female patient with RA and bilateral affection. The migration occurred on the left side 2.5 year after the primary surgery. Particular ossification was encountered 3 times, one case required extirpation. Complications were recorded in 8 patients. In one case the lateral cortex was peroperatively perforated by the stem of the femoral component. In another patient with a dysplastic acetabulum the cup was inserted to deep in the medial wall of the acetabulum. In the third patient the greater trochanter got broken, remained displaced and only the ligaments healed. Early postoperative complications were recorded twice. In one case it was a serous secretion from the wound which subsided after a few days without the necessity of revision. Revision was required in the second case when the R-drainage broke in the course of its removal. Late complications occurred in 3 patients. In one case there developed a mitigated infection requiring revision surgery, in case of the female patient with RA the cup protruded in the pelvis which necessitated a revision surgery. DISCUSSION: So far there are no literary data on this type of cup. The only existing information relates to the preceding type of a similar design, i.e. Mecring cup, which failed. CONCLUSION: Despite relatively good but short-term results of this small series the unusual design of the Ultima hemispherical threaded cup requires a great prudence in its application and additional long-term follow-up. Therefore the cup cannot be recommended for a regular use for the time being.

[Unreamed locking intramedullary nailing of humeral fractures--basic evaluation of a patient group]. / Nepredvrtané zajistené nitrodrenové hrebování zlomenin humeru--základní hodnocení souboru.

PURPOSE OF THE STUDY: The aim of the work is to provide an overview of the existing experience in Synthes unreamed humeral nail (UHN). MATERIAL: Between August 1996 and February 2000 we treated by means of UHN a group of 37 patients (12 men and 25 women), average age 55 years (range, 18-87 years) with a fracture of humeral shaft. According to AO classification in 10 patients it was a case of a fracture of proximal humerus involving the shaft (11B-3) and in 27 cases a fracture of the shaft (12 A, B, C). The whole group was operated on by 11 surgeons. METHOD: In 26 cases we used the antegrade method and in 11 cases the retrograde one, in dependence on the type and location of the fracture. The assessment was performed in the form of a prospective study. The follow-up including radiograph checks was carried out at the intervals of 6 weeks, 3, 6, 9 and 12 months after the operation or at another 6 weeks or 3 months after the extraction of the nail, if any. In addition we invited the whole group, i.e. 37 patients for the final control examination which all of them attended. This examination was performed by the first author of the work. The average follow-up was 38 months (range, 12-55 months). RESULTS: The average duration of the surgery in the whole group was 80 minutes, the average duration of x-ray exposure was 3.1 minutes. Peroperative complications occurred in total 42 times in 23 patients. Seven cases required a supplementary incision, i.e. open reduction of the fracture; insufficient nail placement (not into the proper depth) in the humeral head and its prominence into joint line evaluated on the post-operative radiograph) in antegrade nailing occurred 6 times. Problems with locking were encountered 15 times in 10 patients. Comminution of the fragments peroperatively during the insertion of the nail occurred 3 times, peroperative injury of the radial nerve was recorded in total 4 times, always in the antegrade method of the insertion during distal locking from the lateral side. A postoperative complication occurred 16 times in 12 patients, 6 times the radiograph showed penetration of the end of the nail into the shoulder and 6 times the locking screws loosened. No infect was recorded. The mentioned complications required in total 10 revision surgeries in 6 patients (5 of them were treated by the antegrade method). The fracture healed in a good anatomical position in 33 cases. In 4 cases there occurred non-union which was 3 times treated with a plate re-fixation and cancellous bone grafting of which twice successfully. In 2 cases the healing required another revision surgery. A good subjective as well as objective result was achieved almost in 90% of patients. A risk factor from the viewpoint of the limitation of the range of motion in the shoulder proved to be the fracture of 11B3 type and also the antegrade method of nailing, in case of the elbow the retrograde method of nailing. However, the greatest risk was posed by the necessity of a longer post-operative immobilisation of the limb in the case of a not quite stable internal fixation. DISCUSSION: A relatively high number of complications in our group results from strict criteria we have set. However, also literary data present a relatively high number of variously serious complications. Our results as well as the average duration of the surgery is comparable with other authors. CONCLUSION: The main indication of UHN are comminuted or multi-level fractures of humerus in the central three fifths of its length. If possible we prefer the retrograde method of nailing, in the antegrade method we recommend distal locking from the anterior aspect of the arm. Transverse or short oblique fractures can be successfully treated by a simpler Hackethal technique. Long spiral fractures are ideally treated conservatively or by plate fixation.

[Initial experience with the use of the artroflow apparatus.]. / První zkusenosti s vyuzitím prístroje Artroflow.

The authors submit their initial experience with the use of the apparatus Artroflow recommended as one possible means to prevent thromboembolic disease in bedridden patients. The strictly defined criteria of the investigation made it possible to include in the group only a limited number of patients, therefore the results are not significant. Seven months' experience, however, convinced the authors that it is useful to use Artroflow for the rehabilitation of geriatric patients after fractures of the proximal part of the femur. Key words: prevention of thromboembolic disease, activation of the venous pump by passive means, Artroflow apparatus.