Reamed versus unreamed nail in the treatment of tibia shaft fractures.

PURPOSE: The aim of the prospective randomized study was to compare the results of the treatment of tibia shaft fractures (TSF) by reamed or unreamed intramedullar nail. METHODS: There were 103 patients with 104 TSF enrolled in the study within the period from December 2005 to June 2010. Seven patients were excluded from the study. Factors of injury severity, course of surgery and hospitalization, and incidence of early and delayed complications were recorded. X-ray was performed every 4 weeks until the fracture was healed. Functional results were evaluated at least 1 year after the surgery. Closed fractures were classified according to Tscherne classification and the open ones according to Gustilo classification. RESULTS: Forty-eight patients with 49 TSF were treated by unreamed tibial nail. There were 15 women and 33 men in this group. Injury severity score (ISS) ranged from 4 to 25 (ø 6.63). There were 45 closed fractures (0 16; I 22; II 7) and four open fractures (I 2; II 1; IIIA 1). In the reamed nail group there were 48 TSF. ISS ranged from 4 to 18 (ø 6.13). There were 35 closed (0 17; I 13; II 5) and 13 open (I 5; II 5; IIIA 3) fractures in this group. The time of operation was on average 15 min shorter in the unreamed nail group. X-ray healing was the same in both groups (18.12 versus 17.92 weeks). We had four patients in the unreamed nail group and six patients in the reamed nail group with delayed healing (28-44 weeks). We recorded no infection, loss of reduction or re-operation in both groups. Follow-up of functional results was 90 %. CONCLUSIONS: There was no statistically significant difference in clinical and functional results between the groups. We suggest that both methods are comparable.

[Surgical treatment for proximal humerus fracture]. / Operacní lécba zlomenin proximálního humeru.

PURPOSE OF THE STUDY: The aim of the study was to compare the medical aspects of alternative surgical methods for treatment of proximal humerus fractures in specific indications (two- and three- fragment fractures). MATERIAL AND METHODS: A prospective randomised study on surgical treatment of two- and three-fragment fractures of the proximal humerus was carried out at the Department of Surgery, University Hospital in Hradec Králové, from January 2006 till January 2010. The study comprised patients with proximal humerus fractures indicated for surgical treatment. Study inclusion criteria were as follows: informed consent, AO fracture types A2, A3, B1 or C1, age between 18 and 80 years, and patient compliance. Exclusion criteria included open fracture, associated injury (AIS . 2), open growth plates, or such state of the patient's health that would limit the extent of surgery. Two groups were compared. One included patients treated by the Zifko method of minimally invasive osteosynthesis with intramedullary K-wire insertion (MIO group) and the other (ORIF group) consisted of patients undergoing open reduction with angle-stable osteosynthesis using a Philos plate (Synthes, Switzerland). The patients were randomised to the groups by a computer programme which facilitates the maintenance of homogeneity of the groups compared. The procedure in each patient was based on the sealed-envelope method. RESULTS: The ORIF group comprised 28 patients. It took them an average of 27.2 weeks (9-72) to regain normal upper limb function. The final CM score was 86.6% (64-100%) as compared with the healthy limb. Excellent and good results were achieved in 89% of the patients; complications were recorded in 39% of them. The MIO group included 27 patients. The fractures healed in all of them. Normal upper limb function was regained at an average of 21.4 weeks (13-36). The final CM score was 87.5% (52-100%) in comparison with the healthy limb. Excellent and good results were achieved in 89% and complications developed in 33% of the patients. CONCLUSIONS: The statistical evaluation of the results, using the unpaired t-test, did not show any significant differences either in functional outcomes or the number of complications between the two groups. The only significant difference was found in operative times (117 min and 72 min in ORIF and MIO groups, respectively). The difference in time needed to regain limb function (27 and 21 weeks) was at a marginal level of statistical significance. With both methods 89% of excellent and good results were achieved, and a similar number of patients had complications (11 and 9).

[Minimally invasive plate osteosynthesis (MIPO) in the humeral diaphysis fractures]. / Minimálne invazivní dlahová osteosyntéza (MIPO) zlomenin diafýzy humeru.

INTRODUCTION: Most of the humeral shaft fractures can be successfully treated conservatively. Due to increasing number of multiple and high-energy injuries, necessity of patient's compliance and restriction of his selfcare is conservative treatment in background. Humeral shaft fractures indicated to operation treatment are mostly solved by closed reposition and internal fixation with intramedullar nail (CRIF) or open reposition and internal fixation (ORIF). AIM: The aim is to prove that miniinvasive plate osteosynthesis (MIPO) of the humeral shaft fractures combines advantages of the both currently used methods. In other words, to use a plate osteosynthesis with minimal invasiveness and to exclude unexpected complications of radical operation approach by open reposition and problems related to nailing. MATERIAL AND METHOD: From March 2007 to August 2008 we operated on 20 patients with humeral shaft fractures using MIPO technique. Fractures were classified according to AO-classification: A - 9x, B - 5x, C - 6x. There were monotraumas and multiple injuries, as well. RESULTS: The results were evaluated by Constant-Murley test and Liverpool elbow scoring system. The mean value was 92/9.1 points. In 75% of patients we have reached good and excellent results. Complications were observed in 5 patients (20%). All patients have been healed. CONCLUSION: In spite of the limited number of patients in case serie our results are in accordance with current published data. Minimally invasive plate osteosynthesis is in our opinion safe and effective operation method for humeral shaft fractures treatment.

[Rupture of the interventricular septum after the blunt trauma of thorax]. / Traumatická ruptura mezikomorového septa jako následek tupého poranení hrudníku--kazuistika.

Authors present the case of little patient with the dissection, pseudoaneurysm and finally a rupture of the interventricular septum after the blunt thracic injury. The patient was smitten as a pedestrian by a car and during the whole period of her stay in the hospital she was showing signs of circulatory instability. Due to the current intraabdominal injuries this circulatory decompensation was first assigned to hemoperitoneum, for which the girl was operated on about 3 hours after admission. Nevertheless, even after the abdminal cavity check, after the treatment of supreficial liver lacerations and intensive volume resuscitation the patient showed signs of insufficiency. Diagnosis was finally determined on the base of the transthoracic echocardiography (TTE), which proved the traumatic rupture of interventricular septum. The operation followed correcting the defect, which was performed with a good result according to the TTE postoperatively. Nevertheless, 27 hours after the admission the patient died due to the electromechanical dissociation. In the discussion the authors then evoke a number of papers concerning the same topic.

[Surgical management of proximal humeral fractures using the Hackethal (Zifko) method--a case review]. / Operacní lécba zlomenin proximálního humeru metodou podle Hackethala (Zifka)--case serie.

BACKGROUND: Fractures of the proximal humerus actually represent 5% of all fractures and 45% of all humeral fractures with the highest incidence in women over 60 years of age. The outcomes of the greatest concern at these patients (pain, function of the shoulder and activities of daily living) get worse with age, osteoporosis, grading of fracture type and of initial fracture displacement. According to the literature (Evidence Based Medicine--EBM level II-III) operative treatment of displaced fractures reduces pain and need for assistance in activities of daily living, but open reduction with internal fixation by conventional screws and plates was connected with implant loosening, infection and avascular necrosis, whereas closed reduction with different methods of miniinvasive percutaneous stabilisation is threatened by primary malreduction. AIM: Evaluation of clinical and functional outcomes and analysis of results of proximal humerus fractures treated by closed or percutaneous reduction and intramedullary fixation by means of bundle of Kirschner wires after Zifko. DESIGN: Retrospective descriptive study--case serie. MATERIAL AND METHODS: Within January 1, 2005 - December 31, 2005 there were 87 patients with 87 two- and three-fragments fractures of proximal humerus (according to Neers classification) operated at our institution, from which 76 by the method after ZiFko. 36 patients from these 76 came to final evaluation (follow-up rate 47%). AO fracture types were: A2-36%, A3-33%, B1-19%, C1-12%. RESULTS: The resulting Constant-Murley (CM) score reached in mean 89 points with 89% of excellent--good functional results. Complications were recorded in 30% of cases and were represented mainly by proximal migration of K-wires. Avascular necrosis of humeral head occured in two cases (5.5%). CONCLUSION: In spite of low follow-up rate we conclude, that the method of closed reduction and intramedullary fixation of two- and three-part fractures of proximal humerus after Zifko offers above-average final results with acceptable rate of complications, mostly not severe ones. The essential pre-condition of good result is proper reduction--closed of percutaneous one. On the contrary, suboptimal results correlate with primary and secondary malreductions. The incidence of latter increases in intraarticular fracture types with small fragment of head and thus with insuficient implant retention. To evaluate the merit of the method in relation to angle-stable extra-/or intramedullary implants, the prospective trials are needed.

[Operation treatment of the humeral shaft fractures]. / Operacní lécba zlomenin diafýzy humeru.

INTRODUCTION: Nowadays the humeral shaft fractures represent about 4% of all fractures. Most of them can be treated conservatively. In this type of treatment the cooperation of the patient is necessary, treatment is long lasting and needs the extremity to be immobilized. That's why still more fractures are indicated for the operation treatment, which enables an early rehabilitation and selfcare of the patient. AIM: The aim of our work was to assess the functional and clinical results in patients after the operation of the humeral shaft fractures treated by closed reposition and intramedullary fixation or by open reposition and plate osteosynthesis (ORIF). DESIGN: Retrospective descriptive study--case serie MATERIAL AND METHODS: In our department within the years 2001-2006 we operated on 101 patients with humeral shaft fractures. 65 patients came to be checked, the follow up rate--65%. Fractures were classified according AO: A--50%, B--29%, C--21%. The ORIF was used in 18 patients, closed reduction and locked intramedullary nail in 21 patients, and closed reduction and K-wires bundle (Hackethal) in 26 patients. RESULTS: The resulting conditions we evaluated by Constant-Murley and Liverpool elbow scoring system. The mean value reached 86/8.9. In 82% of patients we have reached good to excellent results. Complications were noted in 34 CONCLUSION: In spite of limited number of patients in our study the results of ours generally are not in contradiction to the current literature data. The best results were achieved by ORIF. On the contrary, the worst outcomes with greatest number of complications were in Hackethal group.

[Traumatic pseudoaneurysm of arteria femoralis profunda--the case report]. / Poúrazové pseudoaneuryzma hluboké stehenni tepny. Kazuistika.

Authors present the case report of the pseudoaneurysm of deep femoral artery caused by the injury of the vessel wall during the open femur fracture. This fracture was primarly treated by repoisition and stabilization by the external fixator (Rohr system, Synthes GmbH, Switzerland), which was nine days later converted into the intramedullar osteosynthesis by the unreamed nail UFN (Synthes GmbH, Switzerland). The first clinical signs of the pseudoaneurysm occurred several days after the patient had been dismissed. In the clinical picture there dominated the painful swelling of thigh but no perfusion or innervation disorders in the periphery of the extremity were noticed and the finding was concluded as myositis ossificans. Proper diagnosis was set only 6 weeks later on the basis of the ultrasound and angiographic investigations. The situation was then solved by the angiographic embolization of pseudoaneurysm. In the discussion also other opinions from the literature are presented.

[Echinococcal cysts in the liver and lungs]. / Echinokoková cysta jater a plic.

The authors present the case of a patient with relapsing parasitic cyst of the liver and a parasitic cyst of the lungs. The patient was treated by surgery. The cystectomy of the echinococcus cyst in the liver was made in the first stage and subsequently a resection of the lung tissue containing another echinococcus cyst was made. Pharmacological therapy by the anti-helmintic drug albendazol was a part of the treatment. There were no complications during both surgical interventions and the subsequent treatment. In the scolocidal liquid of the liver cyst, echinococcus organisms were diagnosed by microscopy and documented by photography.