[Intra-articular calcaneal fractures]. / Nitrokloubní zlomeniny patní kosti.

PURPOSE OF THE STUDY: In this retrospective evaluation the authors present the group of patients with intraarticular calcaneal fractures that were treated from an extended lateral approach. MATERIAL: In the period from 2001 to 2003, 32 patients with intra-articular calcaneal fractures were treated by osteosynthesis, using a plate, from the extended lateral approach. All patients were men at an average age of 41.7 years (range, 20 to 63 years). The most frequent cause of injury was a fall from height. A combined injury was recorded in eight patients. The right calcaneus was broken in 11 and the left one in 21 patients. Patients with bilateral calcaneal fractures were not included in the evaluation. METHODS: Preoperative X-ray and CT examinations of the fractured calcaneus were carried out in all patients. The Sanders classification of calcaneal fractures was used for fracture evaluation. All patients were treated from the extended lateral approach by osteosynthesis with the use of a plate. Spongioplasty using an autologous graft from the iliac crest or an allogenous graft was carried out in 21 and 11 patients, respectively. The patients were operated on within an average of 7.3 days of admission (1 to 16 days), and were followed up for at least one year (average, 30 months) after surgery. Postoperative evaluation was based on radiographs and the results of the Kerr rating system obtained from questionnaires. RESULTS: The outcomes were excellent, 36 %; very good, 44 %; good, 17 %; and poor, 3 %. The Böhler angle postoperatively assessed on radiographs was on average + 28.5 degrees. All patients showed bone union, and no pseudoarthrosis was recorded. One patient had to be treated for a late purulent complication requiring metal removal. One patient underwent early wound revision due to postoperative hematoma. The metal was removed on average at 13 months postoperatively (range, 2.5 to 26 months). DISCUSSION: The treatment of intra-articular calcaneal fractures is determined by the type of injury, state of soft issues in the limb injured, patient's status and surgeon's experience. CONCLUSIONS: Our results as well as literature data show that exact reduction of the posterior subtalar joint with internal osteosynthesis can achieve good clinical outcomes in patients with intraarticular calcaneal fractures, particularly when the fractures are classified as Sanders II and III types.

[Implantation of a non-cemented acetabulum with the use of a navigation system]. / Implantace necementované jamky s vyuzitím navigacního systému.

PURPOSE OF THE STUDY: To compare, on the basis of clinical and radiographic findings, the results of non-cemented acetabulum implantation involving the use of a CT-free navigation system with those of implantation without its use. MATERIAL: A total of 50 patients undergoing implantation of a non-cemented acetabulum in the period from April 2002 to September 2003 were evaluated. Twenty-five patients operated on without the navigation system were included in group 1 on a random basis and 25 patients treated with the use of the system constituted group 2. METHODS: Both groups were evaluated on the basis of clinical and X-ray findings. The radiographic measurement of acetabulular inclination was based on anteroposterior projection of both hips made on films on films equal in size. Anteversion of the acetabulum was assessed according to the Ackland system. The Merle d'Aubigne and Postel scores were used for clinical evaluation. The results were compared statistically. RESULTS: In group 1, the average inclination was 50.6 degrees (range, 38-62) and the average anteversion was 9.4 degrees (range, 3-18). In group 2, the values were 43.0 degrees (32-55) and 10.4 degrees (8-16) for the average inclination and anteversion, respectively. The difference in acetabular inclination between the two groups was statistically significant. When accuracy was evaluated, the difference in acetabular anteversion was statistically significant. DISCUSSION: The achievement of an optimal position of the acetabular component is one of the important factors for good, long-term outcomes of hip replacement. The optimal position that, as suggested by many authors, involves an inclination of 45 +/- 10 degrees and an anteversion of 15 +/- 10 degrees provides sufficient stability, low wear and a satisfactory range of motion in the hip joint. The results close to these values were achieved in the patients included in group 2. CONCLUSIONS: A comparison of the groups showed that the computer-assisted navigation system used in implantation resulted in an optimal position of the acetabular component.

[Resection of head and neck of the femoral bone according to Girdlestone]. / Resekce hlavice a krcku kosti stehenní podle Girdlestona.

PURPOSE OF THE STUDY: To present our experience with resection arthroplasty of the hip joint according to Girdlestone, as the primary surgical technique used to treat various hip disorders. MATERIAL: During 1990 to 1999, 28 hips in 26 patients were treated in our department by resection arthroplasty according to Girdlestone. The most frequent indications for resection arthroplasty included pyogenic arthritis of the hip, tuberculous arthritis of the hip, post-traumatic pseudoarthrosis and avascular necrosis of the head, hip ankylosis following injury to the thoracic spine, and painful restriction of motion in cerebral palsy. In 2000, 20 hips were evaluated in 19 patients (11 men and 8 women; mean age at the time of surgery, 59.4 years; range, 18 to 79 years). The average time between the operation and evaluation was 3 years and 7 months. Seven patients were lost to follow-up; two died from unrelated causes, four underwent reimplantation of the hip prosthesis at an average of 13 months after the primary resection, and one patient failed to turn up. METHODS: Each patient was examined for the range of motion in the hip joint and limb length, and the questionnaire was completed. The Harris hip scores were used to evaluate joint function. RESULTS: Of the 19 patients, six (33%) were free from pain, ten (53%) occasionally used analgesics for relief of mild to moderate pain, and three (16%) reported severe pain restricting their daily activities. All patients were using walking aids, five (26%) had one French crutch and 11 (58%) had two crutches. Two patients (11%) were able to move only with a walking frame and one patient was confined to a wheel chair because of paraplegia due to thoracic spine injury. The shortening of affected limbs ranged from 1.5 cm to 6.5 cm (mean, 3.8 cm). All patients showed the Trendelenburg sign. Passive flexion in the treated hip ranged from 40 degrees to 130 degrees. The average Harris score was 64 points (range, 25 to 83 points). None of our patients achieved an excellent outcome. DISCUSSION: The use of the Girdlestone resection arthroplasty aims at pain alleviation, improvement in hip function, cure of infection, if this is present, and patients' satisfaction. The results described in the literature vary from bad to excellent. The evaluation of patients' satisfaction ranges from 14% in the study by Petty et al. to 100% described by Böhler and Salzer. In our group, 74% of the patients were satisfied with the surgical outcome, which is in agreement with 74%, 79% and 77% reported by Ballard et al., Bourne et al., and Haw and Gray, respectively. Most authors agree that the Girdlestone technique provides alleviation of pain in the treated hip; 84% of our patients reported pain relief. Although resection of the femoral head resulted in a considerable shortening of the affected limb (up to 4 cm), 84% of all our patients were able to walk with the use of some support. The issues open to dispute are the duration and method of post-operative extension. We do not consider skeletal traction to be necessary. We found no difference in functional outcomes or limb shortening between the patients who underwent skeletal traction for 3 weeks and those who had early mobilization without skeletal traction. CONCLUSIONS: Young and active patients with a single affected joint usually do not want to accept pseudoarthrosis as a definitive outcome. On the other hand, older patients with concomitant disorders or diseases are often willing to come to terms with pain-free hip pseudoarthrosis.