[Suprapatellar Nailing of Tibial Fractures - Evaluation of Clinical and Radiological Results]. / Suprapatelární hrebování zlomenin bérce ­ hodnocení klinických a rentgenologických výsledku.

PURPOSE OF THE STUDY The locked nailing of diaphyseal fractures of the tibia currently represents a method of choice for treating the closed diaphyseal fractures, some of the tibial metaphyseal fractures and open tibial diaphyseal fractures classified as grade I and II according to Gustilo-Anderson (GA) classification. The suprapatellar (SP) approach is an alternative technique of insertion of the nail in semi-extension of the lower extremity with easier reduction, namely of multiple fractures and proximal diaphyseal fractures of the tibia in particular. This study aims to evaluate the group of patients in whom the suprapatellar approach was used and who were followed up for the period of at least 12 months. MATERIAL AND METHODS The prospective study included 55 cases of osteosynthesis of diaphyseal fractures of the tibia with the surgery performed in the period from January 2013 to June 2015, of which in 53 patients (17 women and 36 men) with the mean age of 49.6± 16.7 years the ETN nail by DePuy Synthes ® was inserted through a suprapatellar approach. In 38 cases (70.1%) an isolated trauma was involved, 15 patients (29.9%) were treated for multiple injuries or polytrauma. In nine cases (17%) it was an open fracture (2times - GA grade I, 7times - GA grade II). A multiple fracture or a fracture of the proximal third was recorded in 19 cases (34.5%). The functional and radiological results of the treatment were assessed prospectively at 12 months after the surgery using the Lysholm (LS) score. RESULTS The final functional results were successfully assessed in 49 performed osteosyntheses (89.1%). The mean duration of surgery was 72.7± 19.57 min (40-140 min, median 65 min). A total of 48 (98%) fractures healed by primary intention. In five cases (10.2%) a delayed healing occurred and in one case (2 %) non-union was reported, requiring a revision surgery. In three cases (6.1%) complete implant was removed (twice by SP and once by IP approach). The mean Lysholm score was 93.4 ± 8.39 points (59-100 points, median score of 95 points). An excellent or a good result was observed in 45 patients (91.8%), a satisfactory result in three patients (6.2%), and a poor result in one patient (2%). A statistically significant correlation (p = 0.006) between the LS score values and the age of the patients was confirmed. In patients up to 60 years of age the LS score was 96.2 ± 4.51 points (89-100, median 96), at the age of more than 60 years it was 86.9 ± 11.46 (59-100, median 89). CONCLUSIONS The suprapatellar approach in treating the tibial diaphyseal fractures represents a safe alternative nail insertion technique. If an appropriate surgical technique is applied, the risks inherent in this approach are negligible. The approach allows for an easy reduction of challenging fractures of the proximal third diaphyseal fracture of the tibia and multiple fractures of the tibia and facilitates an easy check of the axial position of the extremity. The functional results of the knee joint are comparable to those achieved with the infrapatellar nailing technique. The final LS score correlates with the age of the patients. Key words:tibial fractures, suprapatellar approach, intramedullary nailing, knee pain.

[Osteosynthesis of Anterior Pelvic Segment: New Symphyseal Plate - First Clinical Experience]. / Osteosyntéza predního segmentu pánve: nová symfyzeální dlaha ­ první klinické zkusenosti.

PURPOSE OF THE STUDY The aim of this study is to evaluate the first experience gained with the new type of anatomical symphyseal plates intended to stabilise ruptured symphysis and closely located fractures. MATERIAL AND METHODS A retrospective evaluation was performed in 5 patients who had undergone surgery in the period from July 2015 to the end of 2016 using a new anatomical symphysial plate for pelvic ring injury. In four cases a stabilisation of symphyseolysis was carried out and in one case osteosynthesis of bilateral rami fracture near the symphysis was performed. The posterior pelvic segment was fixed 3 times by iliosacral screws and 2 times by a transsacral bar. All the surgeries in symphysis region were performed via a modified anterior suprapubic approach. A total of 3 men and 2 women with the mean age of 54.6 years (range 19-77 years) were operated. The mean follow-up period of five patients was 12.6 months. Also, preliminary evaluation of postoperative clinical and radiological outcomes was conducted on a very heterogenous group of patients. RESULTS The postoperative radiological outcome assessed by Pohlemann score was excellent in all the cases. After 3-6 months, screw loosening was reported in 3 cases, with no impact on the overall result of the surgery, in one case the symphysis widened 2 mm with simultaneous loosening of two screws, with no impact on the clinical result either. Clinical evaluation of the results was conducted in 4 patients using the Majeed score with the mean follow-up of 12.6 months, the score achieved was 98, 86, 72 and 49 points. In one patient the results could not be evaluated due to concurrent spinal cord injury with quadriplegia. Nonetheless, even this patient has no difficulty in sitting in a rehabilitation wheelchair. No serious intraoperative or early postoperative complications were reported. As regards late complications, one female colostomy patient developed deep infection three months after the primary surgery. DISCUSSION The first clinical as well as radiological outcomes in our small group of patients are comparable to the outcomes of larger groups using multi-hole plates to stabilise the anterior segment, or the application of 2 plates. In agreement with other authors, the new plates can be applied through a less invasive operative approach avoiding the necessity to transect rectus abdominis muscles. The results of earlier biomechanical studies suggest that their strength will equal 2 inserted plates, or will be comparable to multi-hole plates. CONCLUSIONS The first experience with the use of new anatomical symphysial plates are promising. The new types of plates intended for anterior pelvic segment facilitate fixation by screws inserted at two levels. They significantly improve the stability of fixation and can replace the commonly used 2 plates. The only limiting factor of our group of patients is its small size. Comparative weight-bearing tests shall be performed in the future. Key words:symphysis pubic disruption, pelvic ring fractures, pelvic instability, new symphyseal plates.

[Minimal Invasive Fixation of Pelvic Injury: CT-Study of the Pelvic Bone Dimensions]. / Miniinvazivní osteosyntéza poranení pánve: CT studie rozmeru skeletu pánve.

UNLABELLED: PURPOSE OF THE STUDY This radiographic study was focused on measuring the dimensions of pelvic bones at sites of minimally invasive screw insertion with the aim to assess the risk of damage to vascular and nervous structures. MATERIAL AND METHODS The group consisted of 77 patients (39 women and 38 men) aged between 19 and 85 years (average, 65; women, 65; men, 64) who underwent CT examination of the pelvis because of reasons other than injury. On the left side, a total of 14 dimensions of the superior pubic ramus, supraacetabular region, retroacetabular region, quadrilateral surface of the acetabulum and lateral foraminal sides of the S1 and S2 vertebral bodies were measured. The results were evaluated using descriptive statistics. RESULTS The inner antero-posterior dimension of the isthmic area of the superior pubic ramus was 8 mm or less in four women (10.3%) and 9 or 10 mm in further 14 women (35.9%). The inner cranio-caudal dimension of the superior pubic ramus was 8 mm or less in 14 women (35.9%) and 9 or 10 mm in further 16 women (41.0%). These dimensions obtained in men were as follows: 8 mm and less in three men (7.9%) (7 mm in one, 8 mm in two), and 9 or 10 mm in nine men. Sizes of the other pelvic bones were large enough to allow for safe insertion of single screws. DISCUSSION Single screws most frequently used in minimally invasive treatment of pelvic fractures are cannulated screws 7.3 mm or 6.5 mm in diameter; less frequently used are 4.5-mm cancellous screws (e.g. in treatment of avulsion injuries) or long 3.5-mm cortical "creeping" screws to be inserted in the superior pubic ramus. The use of "creeping" screws reported by several authors indicates problems associated with placement of standard screws (diameter, 7.3 mm and 6.5 mm) through the isthmus into the superior ramus. In slim high pelvises of some patients with gracile skeletons or in low pelvises of small women, the screws can protrude over the cortical margin. However, the risk of injury to nervous or vascular structures is low when the intraosseous screw is exactly inserted and it is so even in case its thread cuts into cortical bone. Neither the femoral artery nor the femoral nerve is situated too close to the superior pubic ramus. The "corona mortis" may potentially be jeopardised because of its contact with both the superior and posterior cortical bones of the superior ramus, but it usually follows a course more lateral to the isthmus of the ramus. CONCLUSIONS The results of the study showed that the size of the superior pubic ramus in its isthmic area may cause difficulties during insertion of cannulated screws with standard diameters (7.3 mm and 6.5 mm) in the majority of women and in some men. The risk of damage to vascular and nervous structures during screw insertion is associated only with the superior and posterior walls of the superior pubic ramus and with the area of the S2 foramen in case the correct procedure of intraosseous screw insertion is not strictly followed. KEY WORDS: retrograde pubic screw, iliosacral screw, supraacetabular screw, retrograde posterior column screw.

[Swimming pool suction injury: etiology, profylaxis and management]. / Úraz podtlakem v bazénu: etiologie, prevence a management.

Swimming pool suction injuries are unique and rare with a substantive risk of fatal consequences. Little children under the age of 8 are the most frequent victims with serious injuries. Drownings of different seriousness are also a usual part of accidents. The case of a 19 year old man trapped in the gluteal area by a unsecured suction drainage hole illustrates the uniqueness of this problem in an interesting way. Prophylactic arrangements are well known but the problem is with their strict application. Fatal causes excluding drowning include hypovolemic shock from the sudden redistribution of intersticial fluid and blood and also the evisceration of the bowel and other abdominal organs. Localised often bizarre and large swellings and sufusions can be treated nonoperatively in the vast majority of cases. For the prevention of these injuries it is important to inform the public and increase their awareness to these injuries. It is also crucial for the correct management of these injuries a deeper awareness of this issue and a sharing of experiences and solutions with other experts.Key words: vacuum - accident - entrapment - compartment syndrome.

[Fixation of acetabular fractures. a novel method of pre-operative Omega plate contouring]. / Osteosyntéza zlomeniny acetabula: nová metoda predoperacní modelace Omega dlahy.

PURPOSE OF THE STUDY: The aim of the study was to describe a novel Omega plate and the procedure for obtaining an accurate pelvic inlet view, the mode of pre-operative plate contouring, the surgical procedure used and the evaluation of results in the first 15 patients treated using this method. MATERIAL AND METHODS: In the period 2009-2011, a total of 232 patients underwent osteosynthesis for pelvic fractures. Out of them, 52 were treated by the modified Stoppa approach and 12 with the original Omega plate. Between July 2010 and January 2014, a novel 3.5-mm Omega plate was used in 12 men and 3 women. The average duration of follow-up was 8.5 months in 11 patients; four were shortly after surgery. The multi-functional Omega plate is described in detail. An exact pelvic inlet projection, named the "computer tomography-defined (CTD) view", was based on pre-operative CT examination. It facilitates pre-operative contouring of the plate according to a mirror image of the uninjured half of the pelvis. The surgical procedure enables us to apply the contoured plate to the correct position; the plate completes reduction, restores normal pelvic anatomy and makes operative time shorter. The radiographic evaluation of post-operative results was done using the Matta classification and functional outcome was assessed by the Harris Hip Score. RESULTS: Surgery using the isolated Stoppa approach was carried out in 11 patients and a procedure combining the Stoppa approach with another method was used in four patients. All operations were successfully completed, during two of them the external iliac vein was injured and treated by vascular suturing. No other vascular or nerve injury occurred. One deep wound infection successfully healed was recorded. The post-operative radiographic results were excellent or satisfactory in 12 and poor in three patients. At follow-ups of 6 to 12 months, no failure of fracture reduction or osteosynthesis was recorded in 11 patients. Neither avascular necrosis of the femoral head nor heterotopic ossification was found. One patient showed signs of post-injury arthritis at 6 months after surgery. The functional result assessed by the Harris Hip Score was excellent in seven patients, good in two (one of them with gonarthrosis), satisfactory in one patient with contralateral total hip replacement and ipsilateral gonarthrosis, and poor in one patient with hemiparesis after a stroke. DISCUSSION: Shape and size variability in CTD pelvic inlet views do not allow us to create a unified anatomically correct implant. Contouring during the operative procedure may not be accurate enough and significantly prolongs the time of surgery. Therefore, a custom-made plate for each patient seems to be an optimal method. It has been demonstrated on a group of 50 patients that CTD images of the right and left halves of the pelvis are identical in 68% and very similar (variation in length up to 5 mm and in curvature up to 3 mm) in 18%. At present plate contouring according to a mirror image of the acetabulum, which will be obtained by 3D printing, is prepared. CONCLUSIONS: Pre-operative contouring of an Omega plate based on a post-injury CT scan of the uninjured half of the pelvis is over 80% accurate or almost accurate. The multi-functional 3.5-mm pelvic plate Omega allows us to stabilise complicated fractures of the superior ramus of the pubic bone, anterior acetabular column or quadrilateral plate as well as fractures above the linea arcuata or uncomplicated fractures of the posterior column. The stabilisation of all fragments of the anterior column and quadrilateral plate is very firm and the Omega plate is resistant to fragment redisplacement. Also, it is its advantage that it can remain in situ if total hip arthroplasty is required later.

[Use of the Omega plate for stabilisation of acetabular fractures: first experience]. / Uzití Omega dlahy pri stabilizaci zlomenin acetabula--první zkusenosti.

PURPOSE OF THE STUDY: The aim of our study is to solve the problem of insufficient fixation of comminuted fractures of the quadrilateral plane and the iliopectineal line. These fixation problems occur while using the standard narrow 3.5 mm fixation plate applied from a modified Stoppa approach. A new plate developed by the authors--the Omega plate--fulfils the requirements. MATERIAL AND METHODS: In the period 2010-2012, we performed 156 stabilisations of pelvic ring fractures and acetabular fractures. We used the modified Stoppa approach applying the standard fixation plate in 24 patients and the Omega plate in 15 patients. The patient group with the Omega plate included 10 male and five female patients with the average age of 61 years (range, 30-72). Only 11 patients were followed up, with an average period of 13.3 months, because one patient was lost to followup and three patients were shortly after surgery. The surgical technique of Omega plate application is described in detail. The clinical evaluation of post-operative results was based on the Harris Hip Score; the graphical results were rated using the Matta and Pohlemann criteria. RESULTS: The Stoppa approach alone was used in four patients, combination of two approaches (Stoppa and Kocher-Langenbeck approach) was used in six cases and three approaches were employed in five patients. No adverse intra- or post-operative events were recorded. Excellent or satisfactory graphical results were obtained in 12 patients and an unsatisfactory graphical outcome was recorded in three cases. In the follow-up period ranging from 8 to 22 months, 11 patients healed. Late complications included avascular femoral head necrosis in two and severe post-traumatic coxarthrosis in three patients. Due to these complications, all five patients underwent total hip arthroplasty without previous Omega plate removal at an average interval of 15 months from the primary pelvic surgery. They were not included in the follow-up evaluation. The remaining six patients had an average Harris Hip Score of 88 points (range, 81-98). DISCUSSION: The novel plate, shaped as a reverse omega letter, enables fixation of the quadrilateral area of the acetabulum through pressure of the arc of the plate against this area. Hitches, with holes for screw insertion, attached to the Omega plate in its middle part allow for fixation of fragments above the linea arcuata simply by pressure. Hitches in the ventral part provide for plate fixation to the ventral acetabular column and the superior pubic ramus. Hitches in the posterior segment of the plate facilitate insertion of a long screw in the posterior acetabular column from an additional iliac approach for stabilisation of simple acetabular fractures. The Omega plates are manufactured in several modifications. CONCLUSIONS: The Omega plate enables us to fix fractures of the superior pubic ramus, fractures of the anterior acetabular column, fractures of the quadrilateral acetabular plate, fractures in the iliopectineal line and simple fractures of the posterior column. A CT-defined projection of the pelvic inlet based on pre-operative CT scans allows us to choose the appropriate plate size and to shape the plate pre-operatively. After a technically well performed Stoppa approach and good fragment reduction, the application of an Omega plate is easy if our recommendations are followed. Fixation of all fragments of the anterior column and the quadrilateral plate is very stable and the Omega plate is highly resistant to secondary loss of reduction. A potential total hip arthroplasty does not require Omega plate removal.

[Timing of surgical intervention in acute spinal cord injury and post-operative neurological recovery]. / Timing operací pátere pri akutním poskození míchy a jeho vliv na vývoj neurologického nálezu.

PURPOSE OF THE STUDY: The effect of an early surgical intervention in the traumatised spine on resolution of neurological deficit still remains a topic of professional discussions. The aim of this retrospective study was to find a correlation between the length of an injury-to-surgery interval and the development of a post-operative neurological deficit, and thus to answer the question of whether early surgical decompression and stabilization gives better chance of neurological recovery. MATERIAL AND METHODS: Medical records of consecutive surgical patients admitted between 2007 and 2010 with traumatic spinal cord injury were reviewed and the injury-to-surgery interval and post-operative development of neurological deficit at a minimum follow-up of 6 months was evaluated. The initial neurological finding and the finding at 6 months of follow-up were classified on the Frankel scale and the outcome was assessed as improved or unimproved. The patients were allocated to four subgroups according to the time that elapsed between injury and surgery, i.e., time up to 24 h, 24-72 h, 72 h -1 week, and longer than 1 week. The percentage of improved patients was calculated in each subgroup and the results were statistically evaluated using the Kruskal-Wallis test at a significance level of 0.1. RESULTS: Out of the total number of 32 evaluated patients, 28 had at least partial neurological recovery. In the subgroup treated within first 24 h, improvement was found in 93 % of the patients, in the 24-72 h subgroup it was 80%, in the 72 h-1 week subgroup it was 60% and surgery later than a week after injury resulted in improvement in 42% of the patients. Based on statistical evaluation, the time between injury and surgery appeared to be a significant prognostic factor. When a paired comparison of subgroups was made, the only significant difference was found between the subgroup treated within 24 hours of injury and that operated on later than a week after injury. The other paired comparisons failed to show a significant difference due to a small number of patients; however, a tendency to better functional results was observed in all earlier- treated subgroups. DISCUSSION: The authors are aware of few limitations of the study. Its retrospective character, a relatively small number of patients and a single institution setup may limit the interpretation. Despite this fact, the message is clear. Similar studies carried out prospectively at several institutions may, however, provide results with a higher validity. CONCLUSIONS: Patients with traumatic spinal cord injury who undergo early decompression and stabilisation have a higher chance of at least partial neurological recovery.

[Current role of methylprednisolone in the treatment of acute spinal cord injury]. / Soucasný pohled na uzívání methylprednisolonu v lécbe akutního poskození míchy.

High doses of methylprednisolone (MPSS) came into use as part of a therapeutic protocol for acute spinal cord injuries following the published results from the NASCIS II study in 1992; they soon became a standard of care around the world. However, the results of this study have been critically reviewed and questioned by many authors since the beginning. The major argument is based on the fact that its effectiveness in reducing post-injury neurological damage has not been conclusively proved; in addition, there has been increasing evidence of serious side effects of steroids administered at high doses. In the Czech Republic, as part of pre-hospital care, MPSS according to the NASCIS II (or NASCIS III) protocol is used in all regional centres of emergency medical service. In the Czech spinal surgery centres involved in treating acute spinal cord injuries, there are 19 of them, attitudes towards the use of MPSS vary. In 16% of the centres a certainty of its beneficial effect is still maintained, faith in its effect together with fear of a "non-lege artis" procedure is the reason for MSPP use in 21%, and the fear of sanctions only leads to its use in 63% of the centres. There is no standard practice in application of the NASCIS II and NASCIS III protocols and no standard exclusion criteria exist. The two protocols are used equally, and one institution has its own modification. The recommended MPSS dose is administered with no exception in 63% of the centres; dose adjustment is employed according to the form of spinal cord lesion in 11%, the level of spinal cord injury in 5%, associated diseases in 16% and patient age in 11% of the spinal surgery centres. After the results of studies on MPSS administration in acute spinal cord injury have been analysed, many medical societies have changed their recommendations. In view of later relevant publications it is no longer possible to regard MPSS administration as a standard of cure for acute spinal cord injury. Current evidence suggests that MPSS administration in a 24-hour regimen after an initial dose given within 8 hours of injury is the therapeutic procedure that needs individual consideration in each patient according to their state of health and potential complications. MPSS administration at an interval longer than 8 hours after injury and for more than 24 hours is not justified, nor is it justified to use a high MPSS dose at the place of injury by an emergency ambulance crew. Key words: corticosteroids, methylprednisolone, spinal cord trauma, neurological damage.

[Non-union after a vertical fracture of the sacral central zone with a conical dislocation of the pelvic ring]. / Pakloub po longitudinální zlomenine centrální zóny sakra s kónickou instabilitou pánevního kruhu.

A longitudinal (vertical) fracture of the sacrum passing through the central sacral canal is a very rare injury, reported in the literature mostly as case reports. Out of 24 reference found, non-union associated with this fracture has been reported only once. A longitudinal fracture of the sacrum is always associated with injury to the anterior pelvic ring. Conical instability of the pelvis, little known so far, occurs if only the anterior ring of the pelvis is stabilised and early weight-bearing is established. It is demonstrated by opening of the distal part of a sacral fracture and, in the case of symphyseolysis, also by opening of the distal part of the symphysis. Therefore, in this type of fracture, both the anterior and posterior pelvic arches should be stabilised at the same time. Iliosacral screws applied percutaneously are optimal for osteosynthesis of sacral longitudinal fractures; sacral bars could be used as well. By means of this procedure, painful instability of the posterior pelvic segment and non-union in this area can be prevented. This case report describes the successful treatment of a 46-year-old male patient injured in a motorbike accident. Despite stabilisation of the pubic symphysis using a plate and locking screws, the patient developed a pseudoarthrosis of the sacrum with implant failure within 6 months of surgery. For that reason, the sacrum was stabilised by two iliosacral screws in a combination with a sacral bar at the S1-S2 level. The implants were introduced percutaneously using CT guidance. Stabilisation of the anterior part of the pelvis was performed by using a supra-acetabular external pelvic fixator; the original implant was left in situ. Consequently, the sacral non-union healed within one year.

[Single cannulated screws for stabilisation of pelvic ring and acetabular fractures]. / Samostatné kanylované srouby pri stabilizaci zlomenin pánevního kruhu a acetabula.

PURPOSE OF THE STUDY: Current trends in minimally invasive surgery together with advances in computed tomography and fluoroscopic guidance allow us to perform close reduction and percutaneous fixation also in non-displaced or minimally displaced fractures of the pelvic ring and acetabulum. Authors report the method of percutaneous screw fixation. MATERIAL AND METHODS: During the period from 1998 to 2010, a total of 568 patients were surgically treated for fractures of the pelvic ring and acetabulum. The patient series included 132 men and 46 women with an average age of 41.6 years (from 15 to 88 years). In this cohort, 225 single screws were placed at various sites of the pelvis. Of the screws, 197 were applied percutaneously and 28 in open procedures. A definition of six screw categories is proposed as well as the list of indications for their use. A detailed description of the techniques for screw placement, including the associated risks, is also presented. A novel method of minimally invasive stabilisation of the ruptured symphysis by means of two pubic screws and a two-hole plate is reported. A total of 157 patients were followed for the average period of 11.9 months (from 3 to 144 months). The navigation methods used in pelvic fracture stabilisation are described. RESULTS: It is difficult to provide an overall evaluation of the results in such a heterogeneous group of patients and therefore the outcome was assessed according to the placement of single screws. The types of injury with the use of appropriate screws are described in detail. Complications and the final graphical and clinical outcomes are reported. As the pelvic ring and acetabular injuries vary too much, it was not easy to assess the clinical outcome for each screw category. DISCUSSION: Percutaneous screw fixation is indicated in non-displaced fractures having a potential for displacement as well as in minimally displaced fractures that can be fixed with precisely placed screws. Dislocated fractures have to be reduced before surgery. Percutaneous screw placement can be performed as a single surgical procedure and this technique can also be part of a limited open approach. Percutaneous or open placement of cannulated screws facilitates stabilisation of individual fragments and allows for low surgical invasivity. This type of screw fixation in pelvic surgery provides all benefits of minimally invasive procedures. In this respect, some authors' view that the advantages outweigh a less successful result of fracture reduction can be accepted. A relatively high risk of iatrogenic complications is a disadvantage of this technique. The correct placement of screws has the highest priority because all percutaneous pelvic screws described here are inserted into the sites known as "narrow safe zones". CONCLUSIONS: In specific localisations, the percutaneous fixation of pelvic ring and acetabular fractures using single screws presents a new surgical technique for which the indications have not been exactly defined yet. The procedure should be performed by an experienced surgeon ready to convert surgery from a minimally invasive procedure to an open one, if the navigation technique used does not provide a reliable guidance or when the fracture reduction or stabilisation fails.

[Surgical treatment of pelvic ring and acetabular fractures using the Stoppa approach]. / Zlomeniny pánevního kruhu a acetabula operované prístupem podle Stoppy.

PURPOSE OF THE STUDY: The Stoppa approach used in acetabular and pelvic ring fractures provides an excellent visualisation of the anterior column, quadrilateral plate and part of the posterior column for its exact reduction. Our first experience of this surgical approach and preliminary results are reported. MATERIAL AND METHODS: Between April 2008 and September 2009, the Stoppa approach was used 15 times in 14 patients. This series includes 13 males and one female with an average age of 47.7 years. The mean follow-up was 6.8 months (range from 3 to 15) in 11 patients. In three patients, the post-operative period was too short for evaluation. The surgical procedure is described in detail and associated risks are rated. The Harris hip score was used for clinical evaluation. Radiographic results were assessed according to the criteria described by Matta and Pohlemann. RESULTS: Ten patients suffered from an isolated acetabular fracture, two displayed an acetabular fracture combined with the pelvic ring injury. An isolated pelvic ring fracture was identified in one patient. One patient sustained an acetabular and pelvic ring fracture at one side associated with a simple pelvic ring injury contra-laterally. In five cases, surgery was carried out using three approaches; two approaches were used in another five patients. In remaining five cases, an isolated Stoppa approach was used. An exact anatomical or satisfactory reconstruction of the acetabulum was achieved in 10 patients; in three patients a poor result with 5-mm displacement was found. The pelvic ring fractures were anatomically reduced in two patients. The average Harris hip score in nine patients was 85 points (range from 70 to 95). No serious intra-operative vascular or nerve damage was detected, deep wound infection was revealed in one case. DISCUSSION: The Stoppa approach makes the surgery of the anterior column and quadrilateral plate easier. It can be combined with other surgical techniques, usually with an approach using an "iliac window" over the iliac crest or with a Kocher-Langenbeck's approach. Indications for this type of surgery include acetabular fractures, combined acetabular and pelvic ring fractures and pelvic ring fractures without an injury to the acetabulum as well. Compared to the conventional ilioinguinal approach, the Stoppa approach is less extensive and does not endanger integrity of the lateral femoral cutaneous nerve. It facilitates the treatment of fractures in the posterior part of the quadrilateral plate because the visual control of reduction allows us to restore anatomical conditions. Some technical problems may occur if the screws inserted from the posterior approach into the fracture line of the inner acetabular surface, in order to stabilise the posterior column, interfere with an exact reduction. The use of a narrow plate for stabilisation of comminuted fractures of the quadrilateral plate may create problems as well. CONCLUSIONS: The Stoppa approach changes the conditions for treatment of acetabular and pelvic ring fractures fundamentally. It affords an excellent visualisation of the anterior column and quadrilateral plate and allows for an exact reduction and stable fixation of their fractures. In combination with other approaches it permits anatomic reconstruction of the most serious fractures of the acetabulum and pelvic ring.

[Nonunions or malunions of pelvic fractures]. / Paklouby pánve.

PURPOSE OF THE STUDY Surgery for the nonunion or malunion of pelvic fractures is not common even at specialised departments. This article presents the authors experience with this procedure, completed with case studies and a review of relevant literature. MATERIAL AND METHODS From 1998 to 2007, a total of 359 patients underwent surgery for pelvic trauma. In the same period, eight surgeries on nonunions or malunions of the pelvis were performed, three in men and five in women. The average age of the patients was 37.3 years (range from 15 to 68). The primary treatment included conservative therapy (two patients), external fixation (three patients) and osteosynthesis of the anterior pelvic segment in another three patients. Reconstructive surgeries were always executed for nonunion or malunion or for both conditions together. Patients suffered most often from pain, limping, from the need of using crutches or leg shortening; no diffuculties occurred while sitting. Surgery for nonunion or malunion was performed at the average period of 29.3 months (range from 6 to 84) after injury. Surgical techniques and risks are described in detail. RESULTS Two patients suffer from persistent pain after surgery. In one patient, it is due to partial sacroiliac ankylosis with pathological mobility of the remaining part of the sacroiliac joint together with nonunion of the fractured dorsal part of the ilium. In the other one, pain comes from muscular dysbalance, as well as from chronic lesions in the sacroiliac joint and from scoliosis, despite the fact that the pelvis was successfully reconstructed 7 years after the initial injury. Four patients have no or only transient pain. In four patients limping disappeared after surgery; in two it is still persisting. One of these is the patient with partial sacroiliac joint ankylosis, while symphysis pubic diasthesis persists in the other. Leg length difference, sitting problems or other complaints following surgery are not observed. Four patients developed union detected radiologically, widening of the symphysis persists in one patient and sacroiliac joint problem in another one. Excellent results with anatomic integrity in all three x-ray projections were achieved in only two patients. Satisfactory outcome with a residual deformity of less than 1 cm of the vertical or posterior displacement or up to 15-degree rotation in any plane was achieved in three patients. A poor outcome involving more than 1-cm dislocation was found in one case. DISCUSION The most common cause of poorly healed pelvic fractures is a misdiagnosis of the primary injury and a subsequent conservative way of treatment. Injuries to the posterior pelvic segment are repeatedly underestimated. A frequent error in pelvic ring fracture therapy is that only the anterior pelvic segment is treated surgically, often with only a simple external fixator inserted in the iliac crests. In addition, the treatment strategy is often decided on in hospitals whose surgeons have not enough in pelvic trauma surgery. The most frequent complaints associated with an inadequate treatment are pain, walking problems and limping. Sitting can be difficult in some patients. Urinary bladder can be compressed with the result of frequent and urgent miction, and vaginal compression could bring about dyspareunia. Additionally, pelvic deformations in women can aggravate delivery. Cosmetic changes due to a prominent sacrum, a prominent greater trochanter or distal spine scoliosis are also of concern. The method of an accurate measurement of anatomic alterations of the pelvis is presented. CONCLUSIONS Early surgery of the pelvic trauma enables an adequate restoration of pelvic anatomy and provides conditions for good and reliable stability of both the posterior and anterior pelvic segments. Late repairs of nonunions or malunions are demanding and associated with a high risk of serious complications, often with long-term sequelae. Key words: pelvic fracture, malunion, nonunion.

[Use of angle-stable implants for proximal humeral fractures: prospective study]. / Pouzití úhlove stabilních implantátu pri osetrení zlomenin proximálního humeru - prospektivní studie.

PURPOSE OF THE STUDY: To evaluate and compare proximal humeral fractures treated either by plate osteosynthesis with angular-stable screws or by intramedullary nailing, and to define the indications optimal for use of either technique. MATERIAL: The study comprised 97 patients. The proximal humeral internal locking system (PHILOS) plate was used in 49 patients (31 women and 18 men); with age average 57.4 years (women, 64.5 and men, 45.3 years). By the AO classification, 12 patients with type A, 15 with type B, and 22 with type C fractures. The Targon PH nail was used in 48 patients (32 women and 16 men) at an average age of 65.3 years (women, 72.2 and men, 51.4 years). Type A fractures were in 18, type B in 18 and type C in 12 patients. METHODS: The patients were prospectively evaluated and placed into the two groups. The post-operative range of motion was assessed by the Constant-Murley (CM) score at 6 weeks, and at 3, 6 and 12 months. The CM value was related to the healthy collateral limb and recorded as a relative CM score. RESULTS In the PHILOS group, the average values were: operative time, 76.2 min; X-ray exposure, 4.2 min; and relative CM score, 74.5 points. The Targon PH group showed the average operative time of 50.2 min., X-ray exposure for 4 min. and the relative CM score 78.3 points. There were no significant differences between the groups, with the exception of shorter operative time in intramedullary nailing. DISCUSSION: Nailing is the method of choice for two-fragment fractures. In comminutive metaphyseal fractures particularly, the use of nailing is more effective than plate osteosynthesis that carries the risk of plate detachment from the diaphysis. In fractures with a long fracture line extending into the metaphysis, plate osteosynthesis with open reduction is a better option. The results in three-fragment fractures are comparable and the choice of an implant is the matter of surgeon's preference. The standard technique for four-fragment fractures involves the use of angular-stable plate fixation through the deltoid- pectoral approach. Intramedullary nailing is a borderline indication requiring a modified surgical procedure, with tubercles being fixed with osteosuture. CONCLUSIONS: No statistically significant differences in functional results occurred between the observed groups at one year of followup. In four-fragment proximal humerus fractures, the patients treated with Targon PH nails had more complications and worse relative CM scores than those treated with PHILOS plates; however, this was not statistically significant and the number of complications decreased after the technique of tubercle osteosuture had been introduced. Finally, the only significant difference between the groups was a shorter operative time with the use of intramedullary nailing.

[Hemiarthroplasty for management of proximal humeral fractures]. / Hemiartroplastika v lécbe zlomenin proximálního humeru.

PURPOSE OF THE STUDY: With the advent of angle-stable implant systems in surgical treatment of proximal humeral fractures, the number of indications to shoulder hemiarthroplasty decreased dramatically, because these modern implants provide certain fixation of osteoporotic bone fragments in elderly patients. MATERIAL AND METHODS: The authors report on their experience with shoulder replacement surgery in 29 patients, of which 26 underwent urgent surgery. The indications for acute hemiarthroplasty included humeral head fractures in which destruction of the articular surface exceeded 40 %, and fractures with evident or suspected insufficient vitality of the humeral head in elderly patients. Other indications included intra-operative osteosynthesis with the necessity of subsequent intra-operative conversion. Two patients with late implant failure and one with bone malunion, after conservative treatment of a fracture, were indicated for second stage hemiarthroplasty. The authors draw attention to the most frequent errors associated with this surgery and describe guidelines used in post-operative care. A total of 20 patients were evaluated by the Constant Score at an average follow-up of 12.5 months (range, 6-39 months). RESULTS: Shortly after the operation, loosening of parts of the modular prosthetic system occurred in two patients. Aseptic loosening of the stem was observed in two patients, and early deep wound infection was found in two patients. The implant was removed in two cases, once for its loosening, and once for persisting infection. None of the patients died due to causes related to shoulder hemiarthroplasty. The functional outcomes corresponded to the choice of patients, because the indications for hemiarthroplasty involved the most serious fractures in elderly patients. Post-operative subjective evaluation usually showed only intermittent and mild pain; only four patients complained of severe pain. Arm elevation in the youngest age group, i.e., up to 59 years, was 100 degrees on the average, with a range of 70 to 140 degrees. In the patients 60 to 69 years old, the average elevation was 95 degrees, with a range of 90 to 110 degrees; in the oldest group, i.e., 70 years and older, the average elevation was 75 degrees and the range was 30 to 130 degrees. Excellent outcomes with elevation over 120 degrees were achieved in four patients only. The average Constant Scores in the three age groups were 68, 54 and 42 points, respectively. DISCUSSION: When deciding the indications for hemiarthroplasty, many factors must be considered. Beside the type of fracture and patient's age, a possible impairment of blood supply, which is associated with avascular bone necrosis, must also be taken into account. Criteria for correlation between vascularisation impairment and X-ray findings, with the analysis of advantages and disadvantages of hemiarthroplasty, are described in this article. In the end, an indication scheme for the treatment of proximal humeral fractures is suggested. CONCLUSIONS: Good results achieved in shoulder hemiarthroplasty are related to both the development of modular prosthetic systems for shoulder replacement and a faultless surgery procedure itself. Careful and long-term post-operative care also plays an important role. Functional outcomes after acute hemiarthroplasty are clearly better than those after a second-stage operation performed when conservative treatment or previous osteosynthesis have failed.

[Application of the Targon PH long nail in storey fractures and metaphyseal fractures of the proximal humerus]. / Pouzití hrebu Targon PH long u etázových zlomenin a zlomenin metafýzy proximálního humeru.

Storey and proximal metadiaphyseal humeral fractures are serious injuries, affecting patients of all age cathegories, however, elderly patients are affected more often. Conservative treatment results in a long-term immobilisation of the extremity, restricts ventilation and reduces the comfort. Former implants did not meet requirements for a stable osteosynthesis and hampered early rehabilitation. The Targon PH long nail (Aesculap, Tuttlingen, SRN) combines advantages of intramedullary fixation within the whole length of the medullary cavity with the use of angle-stable screws in the proximal fixation storey, which extends chances for a reliable osteosynthesis also to the proximal fifth of the humerus. The procedure's prons include the miniinvasive character of the procedure and the possibility of adequate early rehabilitation. The authors assess a patient group of 23 subjects, including 14 females and 9 males, operated in the Traumacentrum of the Liberec Regional Hospital from January 2004 to December 2005. The final functional results assessment could be performed in 20 patients (87%), 13 females and 3 males, aged 65.3 years, on average. The minimal follow-up period lasted 12 months and the result was evaluated using the Constant-Murley score.

Classification-related approach in the surgical treatment of thoracolumbar fractures.

BACKGROUND: Advanced diagnostic tools, classification systems and accordingly selected surgical approaches are essential requirements for the prevention of failure of surgical treatment of thoracolumbar fractures. The present study is designed to evaluate the contribution of classification to the choice of a surgical approach using the current fracture classification systems. MATERIALS AND METHODS: We studied prospectively a group of 64 patients (22 females, 42 males) of an average age of 43 years, all operated on for thoracolumbar fractures during the year 2001. The AO-ASIF classification was used preoperatively with all imaging studies (X-ray, computed tomography (CT) and magnetic resonance imaging (MRI)). When the damage was detected only in the anterior column (A type), an isolated anterior stabilization (n = 22) was preferred. If the MRI study disclosed an injury in the posterior column, a posterior approach (n = 20) using the internal fixator was chosen. Injuries involving the posterior column (B or C type) were classified additionally according to the load-sharing classification (LSC). If LSC gave six or more points, treatment was completed with an anterior fusion. The combined postero-anterior procedure was carried out 22 times. The minimum followup period was 22 months. RESULTS: Neither implant failure and nor significant loss of correction were observed in patients treated with anterior or combined procedures. The average loss of correction (increase of kyphosis) in simple posterior stabilization was 3.1 degree. CONCLUSION: Complex fracture classification helps in the selection of the surgical approach and helps to decrease the chances of treatment failure.

[Classification-based surgical approach in surgical management of thoracolumbar fractures of the spine]. / Klasifikací rízená volba operacního prístupu pri operacním lécení zlomenin torakolumbární pátere.

INTRODUCTION: The decision on the surgical approach in the operative treatment of the fractures of thoracolumbar spine is possible only by following a detailed classification. However, the application of the classification systems is not reliable without a complex imagination of the bony and fibrous structures involved into the fracture. Pre-op investigation should include x-rays, CT-scans and MRI. MATERIAL AND METHODS: Patient series consists of 21 females and 43 males treated surgically for the unstable thoracolumbar fracture during 2001. The average age was 43 years. Patients suffering form osteoporosis, fresh spinal cord injury and multiple spine fractures were excluded. All fractures were examined by plain x-rays, CT-scans and MRI and classified according the AO-ASIF classification system. In patients with A-type fractures the single anterior approach was used. Patients with B- or C-type of fracture were operated by the posterior approach. These fractures were complementary classified according to the Load-sharing classification and those with 6 or more points were additionally operated also from the front. Patients were divided into the three groups: the anterior approach (22 pts), the combined procedure (22 pts) and the posterior approach (20 pts). In the third group, the hardware was removed after 15 months on average. No posterolateral fusion was carried out. Minimum follow-up was 22 months. RESULTS: No implant failure was found in any patient. No significant loss of correction was found in the first and the second group. The loss of correction in the third group was 3.1 degree on average. CONCLUSION: Overall graphical imagination of the thoracolumbar fractures (including MRI) is essential for their classification. The classification helps to choose the optimum surgical approach. The approach related to the fracture classification prevents the treatment failure.

[Urgent management of the complex pelvic fractures]. / Urgentní osetirení komplexních zlomenin pánve.

AIM OF STUDY: The term "complex pelvic fractures" is reserved for pelvic ring fractures associated with soft tissue injuries in the pelvic region and with haemodynamic instability of the patient. These fractures represent only 10% of all pelvic fractures; however, the morality rate exceeds 33%. This study describes the algorithm of the urgent treatment of serious pelvic ring injuries. METHODS: Urgent application of pelvic clip or external pelvic fixator is considered as a part of the reanimation period. If the external pelvic ring fixation is not followed by stabilization of patient's circulation, the pelvis packing using the lower middle incision without opening of the abdominal cavity must be executed within a short time. The absence of the intraabdominal bleeding is essential. If the pelvis packing does not improve patient's haemodynamic conditions, the bleeding should be controlled by angiography and embolization or by direct ligature of the internal iliac artery. In the most severe cases, hemipelvectomy would be carried out as the life-saving procedure. DISCUSSION: Extreme blood loss associated with complex pelvic ring fractures is possible due to enlarged volume of the injured pelvis. This is caused by a gap within the symphysis or in the region of the pubic rami and by a shift in the posterior pelvic segment. In such situation, waiting for the self-packing of pelvis by haematoma can be dangerous. In case of parapelvic compartments disruption, the effect of the self-packing would not come at all. The management of the pelvic ring fractures should be completed by a surgical procedure, because non-surgical treatment is mostly disappointing. The best results can be achieved only by the early operation of the anterior and posterior pelvic segment aimed at the realignment of pelvic ring and proper anatomical relations. CONCLUSIONS: Complex pelvic ring fractures require the aggressive approach. The basic reanimation procedures include application of the pelvic clip. This is the only way how to control extensive haemorrhage associated with the pelvic ring fractures and how to improve patient's haemodynamic conditions. The final surgical treatment of the pelvis fractures should be completed early after the injury. This is within the competence of specialized centres.

[100 CT-guided pelvic operations]. / 100 CT navigovaných operací pánve.

PURPOSE OF THE STUDY: The authors present their 10-year experience with the computed tomography (CT) assisted insertion of implants in the sacroiliac (SI) region and acetabular region. Indications for these interventions and their detailed descriptions are reported. MATERIAL: A total of 98 patients, with the average age of 40.7 years and prevalence of men (70%), were treated. The most frequent cause of injury was a car accident, second in rank was fall from a height. Of these patients, 86 were followed up from 2 months to 3 years. METHODS: The surgical procedure was carried out in the CT department, in which conditions were provided to meet the criteria of an operating theatre. Computed tomography was used to plan the exact position of the implant and, during the procedure, to guide its precise insertion. These procedures required close cooperation of the surgeon and radiologist. A total of 73 CT-guided operations were performed on the SI region, using iliosacral screws or sacral rods. The operation was always preceded by surgery on the anterior pelvic segment. Iliosacral screws were also used in six patients operated on for pseudoarthrosis of the sacrum or chronic instability of the SI joint. The screws were also used in 19 patients who underwent surgical intervention in the acetabular region; in 14 cases it was for a fracture of the acetabular rim. All procedures were carried out by this minimal invasive technique. RESULTS: In all cases, correct insertion of the implant was achieved. There was only one serious preoperative complication due to the fact that the guidewire deviated from its planned direction without this being shown by CT scan. A late infectious complication following iliosacral screw application was recorded in one patient and, in another patient, a nut loosened on one side of the sacral rod. These implants, temporally immobilizing the SI joint, were removed at periods of 6 to 9 months after the operation. There was no case of secondary dislocation of the SI joint after the implant was removed. Complete bony healing of the fractures treated, including pseudoarthrosis, was achieved in all our patients. A comprehensive evaluation of the clinical results of CT-guided operations was difficult because of large inter-individual differences in the extent of pelvic injuries. DISCUSSION: CT-guided interventions are currently indicated predominantly for fractures of the sacrum or displacement of the SI joint up to a 15 mm distance. It is necessary to re-evaluate the extent of displacement after an exact reconstruction of the anterior pelvic segment and restoration of the anatomical conditions. The displacement in the posterior segment usually becomes markedly reduced. The simultaneous surgical treatment of both the anterior and posterior pelvic segments results in restoration of pelvic girdle continuity and maintenance of good stability of the pelvis. This permits early rehabilitation and mobilization of the patient. Other conditions indicated for CT-guided surgery include simple fractures of the acetabular rim with a distance between the fracture lines up to 7 to 10 mm, usually following hip dislocation, and simple oblique fractures of the acetabular columns. CONCLUSIONS: The CT-guided surgical procedure allows us to assess both the shape and course of fracture lines or distance between the injured structures. It also enables us to choose the optimal direction, in relation to these structures, for an implant to be inserted and to respect important anatomical structures in the surroundings. It helps us to determine the exact length of implants to be used. During the procedure, repeated CT scans facilitate checking the direction and position of both instruments and implants. In the closing phase of the operation, it is possible to assess closeness of the bones screwed together, the definitive placement of the implants and their reliable fixation. This method also permits to check whether a screw did not penetrate through the opposite cortical bone.