Does Convergent Placement of Interlocking Iliosacral Screws into the Body of Vertebra S1 Prevent Screw Migration?

PURPOSE OF THE STUDY To compare the outcomes of parallel and convergent iliosacral screw insertion into the body of vertebra S1 in the treatment of posterior pelvic arch injuries. MATERIAL AND METHODS Radiographs of 120 patients (43 women, 77 men), aged between 14-79 years, treated with iliosacral screw fixation for posterior pelvic ring fractures between 1.1.2009 and 31.12.2019 were reviewed for inclusion in the study. In each case two screws were inserted into the body of vertebra S1. The screws were inserted in either parallel or convergent orientation. Convergent orientation allows the threads of both screws to be interconnected. In this technique, the first screw is inserted into the centre of the body of vertebra S1 as a compression screw. The second screw is inserted as a positioning screw and is placed so that the threads of both screws lock together. We believe that the interlocking of the threads of both screws and contact of the second screw with three cortices (two of the iliac bone and one of the sacrum) increase the stability of the fixation. Migration of loosened screws was measured on radiographs of the pelvis obtained at six weeks and at three, six and twelve months postoperatively. Migration of five millimetres or more within the first six weeks was considered to be clinically significant. Only patients after primary fracture treatment and with a complete one-year follow-up were included in the study. Cases of non-union and failure of osteosynthesis of the anterior pelvic arch and patients with incomplete follow-up were excluded. The incidence of significant screw migration between the two techniques was compared using Fisher's exact test with a 5% level of significance. RESULTS Sixty-three patients (23 women, 40 men) aged 17 to 79 years were included in the study. Parallel screws were used in 24 patients (8 women, 16 men) and convergent screws were used in 39 patients (15 women, 24 men). Clinically significant migration occurred in nine (38%) patients after parallel insertions. In two of these cases there was unstable fixation of the anterior pelvic arch. Migration of convergently placed iliosacral screws occurred in four (10%) cases. In three of these cases this was due to unstable fixation of the anterior pelvic arch. The difference in screw migration between the two groups was shown to be significant (p = 0.0219). DISCUSSION Iliosacral screws ensure sufficient stability of the posterior arch in type B and C pelvic fractures provided that the anterior pelvic arch is stable. Convergent insertion of iliosacral screws may increase the stability of fixation. Minimally invasive surgery with sufficient stability may be advantageous for early treatment of patients after multiple trauma and in elderly patients. The weaknesses of this study are its relatively small number of patients, which prevented reliable statistical analysis of screw migration according to the type of pelvic fractures. The second main limitation is the failure to perform densitometric examination of the skeleton in patients with X-ray proven screw migration for confirmation of osteoporosis as one of the possible causes of fixation failure. CONCLUSIONS The results of the study suggest that convergent insertion of iliosacral screws into S1 is associated with a lower risk of screw migration and subsequent failure of fixation of the posterior pelvic arch. Key words: pelvic fracture, pelvic injury, iliosacral screw, parallel screws, convergent screws, migration of iliosacral screws.

[Comparison of Clinical Outcomes of Displaced Diaphyseal Clavicle Fractures]. / Porovnání klinických výsledku lécení dislokovaných zlomenin diafýzy klícní kosti.

PURPOSE OF THE STUDY The aim of this retrospective study was to assess the subjective evaluation of treatment by patients with respect to their return to work and recreational sport following the fracture of clavicle diaphysis with posttraumatic shortening of 1.5 cm, or more, treated non-operatively and surgically. MATERIAL AND METHODS Our group of patients consisted of 51 patients (14 females, 37 males) aged between 18 and 89 years (average age 46 years). We concentrated on the parameters of sex, age, side of injury, extent of posttraumatic shortening, method of treatment, return to work or recreational sport, DASH score at one year post non-operative or surgical treatment. Patients who sustained a pathological fracture, fractures of the clavicle combined with an injury of the acromioclavicular joint or simultaneous fracture of the humerus or the ribs were excluded from the study. Patients with open fractures or re-fractures were excluded as well. The indication for treatment selection was based on pre-operative discussion of the doctor with the patient and the Informed Consent was signed. The patient was informed about different treatment options. A shorter period of fixation of the arm and post-operative physiotherapy was mentioned in connection with surgical treatment as well as potential surgical complications. A statistical analysis comparing the data in both groups was conducted using the Fisher exact test. The p-value of 0.05 or less was considered as statistically significant. RESULTS The right side was affected 26 times, the left side 25 times. The shortening ranged from 1.5 to 3.7 cm. 24 patients (8 females, 16 males) aged 21 to 89 years (average 54 years) were treated non-operatively. 27 patients (6 females, 21 males) aged 18 to 74 years (average 38 years) underwent surgery. The difference in sex distribution in both groups was not statistically significant (p = 0.5311). According to the Robinson classification, there were 17 patients with type 2A2 fractures, of whom 8 underwent surgery and 9 were treated non-operatively, 19 patients with type 2B1 fractures, of whom 9 underwent surgery and 10 were treated non-operatively, and 15 patients with type 2B2, of whom 10 underwent surgery and 5 were treated non-operatively. The surgically treated patients prevailed in type 2B2 only, but this difference was not statistically significant (p = 0.2350). In the non-operatively treated group, 23 out of 24 patients returned to pre-injury activities in 3 months on average. Ten patients (48%) reported reaching the same function as on the other side. In the DASH score evaluation, 11 patients reached the value of 0-3.3, five patients 3.4-10, six patients 10.1-30.0 and two reached the score of more than 30. In the evaluation of capacity to work, 15 out of 24 patients were able to work, 11 of them without any restrictions or difficulties. In the evaluation of the sport and playing musical instrument module, 9 out of 24 patients did not engage in sports activities or do not play any musical instruments. In the surgically treated group, 26 out of 27 patients returned to pre-injury activities within 6 weeks. 19 (70%) patients reported reaching the same function as on the other side. In the DASH score evaluation, 19 patients reached the value of 0-3.3, two patients 3.4-10, 5 patients 10.1-30.0 and one patient with nonunion 72.5. Comparison of the average values of the DASH score demonstrated slightly better results achieved by surgical treatment (9.03 vs 6.77). When assessing the work module, 24 out of 27 patients returned to work, 20 of them without any restrictions or difficulties. Out of 27 patients, 4 patients were no longer able to engage in sports activities or to play a musical instrument. Of the 23 remaining patients, 18 did not have any problems, 5 suffered from minimal problems. The group of patients treated non-operatively included one case of non-union and the same applies to the surgically treated group. In 3 patients the removal of hardware was performed, 3 patients underwent revision of the surgical wound because of infection. DISCUSSION The recommendation of the weight-bearing of the upper extremity was similar in both groups, 12 weeks post injury/surgery on average. It is clear that sooner return to work or sports activities in the surgically treated group was preferred by younger patients who expected quicker recovery. Younger patients were less patient and more eager to return to work and sports, while the older patients, on the other hand, were more cautious about possible complications of surgery. CONCLUSIONS The results of our study did not identify any correlation between the clavicle shortening and the indication for surgical treatment. Surgical treatment was preferred by younger patients, more frequently by males. The rationale was supported by the perspective of sooner return to work and favourite sports activities. Their decision was not affected by the known risks of surgical treatment. Evaluation of the DASH score at one year after injury/surgery showed similar results. A higher incidence of complications in the surgically treated group did not lead to negative evaluation of the selected treatment modality by the highly motivated group of patients either. Key words: fractures of the clavicle diaphysis, non-operative treatment, surgical treatment, return to work, return to sports activities, functional results at 1 year.

[Patient Triage in Disasters and Mass Casualty Incidents]. / Triage pacientu pri katastrofách a hromadných nestestích.

Disasters (more than 50 people affected) and mass casualty incidents (more than 10 people affected) which are the result of natural or civilisation disasters, traffic accidents or terrorist attacks are characterised by a large number of injured persons. In these critical situations, triage - prioritisation of patients based on the severity and type of the injury must be performed. Patients are sorted into those who need immediate medical intervention and those whose care can wait. Triage is a generally accepted tool assisting the health-care professionals in treating large numbers of injured people following mass casualty incidents. It is a stressful situation requiring not only professional expertise, but also experience and the ability to stay on top of things. Fortunately, such situations do not occur very often in our country. This paper aims to present experience gained during humanitarian missions abroad (Iraq, Kurdistan, Nepal), internships in hospitals in Israel and in Chris Hani Baragwanath Hospital in Johannesburg, South Africa. Key words: mass casualty incidents, triage priority schemes, triage labels.

[The Injury-Treatment Time Interval of the Most Frequent Limb Fractures - 1-Year Monocentric Study]. / Interval úraz-osetrení u nejcastejsích zlomenin skeletu koncetin ­ jednoletá monocentrická studie.

INTRODUCTION The purpose of the study was to evaluate the injury-treatment time interval in a group of patients with limb bone fractures over the period of one year; and to compare this interval in the most frequent fractures of the upper and lower limb. MATERIAL AND METHODS The followed-up group of the prospective one-year monocentric study included 3,148 patients treated consecutively for 3,909 fractures. For the purpose of sub-analysis of the injury-treatment time interval in limb bone fractures, excluded from the group were the patients with multiple fractures (520 pts), patients with spinal fractures (356 pts) and pelvic fractures (210 pts). The statistical significance of the achieved results was tested with the use of contingency tables (chi-square test of independence). The significance level for the quantified tests was set at 5%. RESULTS The sub-analysis covered 1,727 patients whose medical records mentioned the exact time of injury and first examination. Within the first 6 hours after the injury, 536 (56.0%) patients with an upper limb bone fracture and 429 (55.7%) patients with a lower limb bone fracture were treated. Within 24 hours after the injury, 683 (71.4%) patients with an upper limb bone fracture and 572 (74.3%) patients with a lower limb bone fracture were treated. Within the first 24 hours after the injury, 104 (76.4%) patients with a proximal humerus fracture, 240 (84.5%) patients with a distal radius fracture and only 174 (55.5%) patients with metacarpal and phalanx fractures were treated. In the first hours after the injury, most frequently treated were the patients who sustained a distal radius fracture, and the longest injurytreatment time interval was seen in patients with hand bone fractures. The difference in the 24hour injury-treatment interval was significant when comparing distal radius fractures and proximal humerus fractures (p = 0.047) and when comparing distal radius fractures and hand bone fractures (p < 0.001). Within 24 hours after the injury, 166 (83.3%) patients with a proximal humerus fracture, 128 (79.1%) patients with an ankle fracture and 142 (63.4%) patients with metatarsal and phalanx fractures were treated. The shortest injury-treatment interval was reported in patients with a proximal femoral fracture and an ankle fracture, and relatively the lowest number of treated patients in the first hours after the injury was reported among patients with metatarsal and toe fractures. When evaluating the 24hour injury-treatment time interval, this difference was significant only when comparing proximal femoral fractures and metatarsal and phalanx fractures (p < 0.001), while when comparing proximal femoral fractures and ankle fractures the difference was not significant (p = 0.283). DISCUSSION There are not many studies of other authors focused on monitoring the injury-treatment time interval in the most frequent limb bone fractures. They also confirm that the treatment is sought out most quickly by patients with fractures that make walking or self-care impossible. CONCLUSIONS The results of the study confirmed that the fastest treatment was requested in patients with fractures which made the selfcare (distal radius) or walking (proximal femur, ankle) impossible; less painful fractures (metacarpal, phalanx fractures) and fractures that do not compromise walking (metatarsal fractures) were treated in the first 24 hours after the injury significantly less frequently. The patients with ankle fractures sought out treatment the most quickly compared to the patients with other fractures; it concerned largely occupational or sports injuries sustained by young men who were brought for treatment immediately after the injury, directly from their workplace or sports ground. The treatment of osteoporotic fractures (proximal humerus, distal radius, proximal femur) was spread over the first 6 hours due to the lack of independence of elderly patients after sustaining a fall at home; in majority of them transport to treatment was arranged for by relatives or neighbours only with a certain delay, once they became aware of their injury. Key words: fracture epidemiology, limb bone fractures, trauma-treatment time interval.

[Recommendations for Crisis Management in Mass Casualty Incidents, with a Focus on a Terrorist Attack]. / Doporucení resení krizového stavu pri hromadném nestestí se zamerením na teroristický útok.

Recently, there has been an apparent increase in terrorism-related incidents. The security experts believe that the risk of terrorist attacks cannot be fully ruled out in the Czech Republic either. For this reason, it is appropriate to obtain information from regions with more experience with terrorism and to learn from their mistakes. Based on the analysis of terrorist attacks in Madrid (2004), Israel (2001-2012) and Paris (2015) and our own experience gained during the humanitarian missions in Libya, Syria, Iraq and Ukraine, adequate recommendations for crisis management are presented. An integral part of the preparedness is also a regular training of activation of disaster management plan and simulation of reaction to a mass casualty incident. Key words: mass casualty incident, terrorist attack, disaster management plan.

[Comparison of Hospital Preparedness to Deal with Crisis Situations in Mass Casualty Incidents According to the UN Human Development Index]. / Porovnání pripravenosti nemocnic na resení krizového stavu pri hromadném nestestí v závislosti na indexu lidského rozvoje dané zeme.

PURPOSE OF THE STUDY This thesis presents the very current topic of general hospital preparedness to deal with crisis situations in mass casualty incidents. MATERIAL AND METHODS The key part of the work consists in a questionnaire survey of 26 foreign and domestic respondents, which provides a very good description of this issue in various countries of the world. The group is divided into health facilities in developed and developing countries of the world according to the UN Human Development Index. Another sub-group consists of hospitals in areas with a higher frequency of terrorist attacks and a separate group is formed by 5 hospitals in the Czech Republic. Based on the results of the questionnaire survey, the preparedness of hospitals for dealing with mass casualty incidents is compared in both the groups according to the advancement of the country and also in the subgroup of hospitals in the Czech Republic and in countries with frequent terrorist attacks. The maximum achievable score evaluating the hospital readiness is 20 points. The data obtained by the questionnaire survey is evaluated using statistical methods. RESULTS Higher preparedness of hospitals was found in developed countries, with a hospital preparedness score of 12.9 points compared with 5.9 points in developing countries' hospitals. Hospitals in the Czech Republic show a similar readiness for mass casualties as the other hospitals in developed countries, with the mean score of 12.2 points. Hospitals in countries with a higher number of terrorist attacks did not show a higher readiness to deal with crisis situations associated with mass casualties - the mean score of 9.4 points. DISCUSSION The following discussions and evaluations, together with personal experience and thorough knowledge of real-life solutions, became the basis for recommendations of triage procedures, organization of surgery and traumatology departments and material equipment of medical facilities in the Czech Republic. CONCLUSIONS By applying the results of the habilitation thesis it is possible to achieve an optimal solution and increase the reliability in the preparedness of hospitals in dealing with crisis situations, especially to eliminate the discrepancy between theory and practice. Key words: mass casualty incidents, triage, hospital preparedness, disaster management response.

[Outcomes and Complications of Surgical Treatment for LSS at 1-Year Follow-up - Prospective Study]. / Výsledky a komplikace po operacním resení LSS v horizontu jednoho roku ­ prospektivní studie.

PURPOSE OF THE STUDY Lumbar spinal stenosis (LSS) is a serious and fairly frequent disorder with prevalence increasing with age which often results in a disability. The surgical procedures are often very risky due to the greater age of patients with severe stenosis and their comorbidities. The study aimed to assess the functional outcomes and complications in patients who underwent surgical treatment for LSS at one year postoperatively and to identify the differences in the functional outcomes, if any, in dependence on the number of operated segments. MATERIAL AND METHODS It was a prospective study which included 33 patients who underwent surgery at the authors department from 1 November 2015 to 1 October 2016 for LSS, the mean age of patients was 69.5 (43-83) years. The surgery was indicated based on the clinical examination, radiography and MR imaging and consisted in posterior decompression with or without stabilisation and fusion. Pre- and post-operatively, a neurological examination and evaluation of patient difficulties were performed by: VAS - particularly for low back pain (VAS-LB) and lower limb pain (VAS-LL), Oswestry Disability Index (ODI) and Swiss Spinal Stenosis Questionnaire (SSSQ). The evaluation was done at a half year and one year after the surgery. The authors made comparisons in dependence on the number of treated segments (1-2, 3-5 and Th-S stabilisation). RESULTS A significant improvement of all the followed-up parameters was reported at one year postoperatively. At one year after the surgery, the VAS-LB score showed a decrease by 2.39 (p = 0.001), the VAS-LL by 3.26 (p < 0.001), while a decrease by 2 or more points is considered clinically significant. When evaluating the SSSQ questionnaire, a decrease in subjective difficulties (SSSQ-S) was by 0.89 (p < 0.001), in physical function (SSSQ-F) by 0.87 (p < 0.001). In this questionnaire, the satisfaction rate with the surgery was 2 - i.e. somewhat satisfied. Altogether 76% of patients were very or somewhat satisfied, no one was very dissatisfied. When evaluating the ODI, an improvement by 20.6% (p < 0.001) was reported. The authors identified neither any significant differences in the outcomes at a one-year follow-up in dependence on the length of stabilisation, nor any significant differences between the six-months and one-year follow-up. Intraoperative complications occurred in 18%, early postoperative complications in 6% of patients. The ASD developed in 9% within one year. DISCUSSION The authors confirmed a significant improvement of the followed-up parameters (VAS-LB, VAS-LL, SSSQ, ODI) which corresponds with recent literature. The decrease in VAS and ODI in the authors study is more marked than the outcomes stated in literature. The authors outcomes clearly show that there is no correlation with the length of stabilisation and the number of decompressed segments. Conversely, the rate of complications was higher in this group than the rates stated in literature, but majority of complications had no consequences for the patients. CONCLUSIONS In the group of patients with a one-year follow-up the authors confirmed that surgical procedures will result in reduced subjective difficulties of patients, reduced pain and improvement of physical function. A significant improvement of all the followed-up parameters was reported. The authors did not confirm the correlation between the postoperative improvement and the number of treated segments. Key words:lumbar spinal stenosis, quality of life, post-operative outcomes, complications.

[Surgical Correction of Scoliosis: Does Intraoperative CT Navigation Prolong Operative Time?] / Operacní korekce skoliózy: prodluzuje peroperacní CT navigace trvání operace?

PURPOSE OF THE STUDY The aim of the study was to compare the duration of corrective surgery for scoliosis in relation to the intra-operative use of either fluoroscopic or CT navigation. MATERIAL AND METHODS The indication for surgery was adolescent idiopathic scoliosis in younger patients and degenerative scoliosis in middleage or elderly patients. In a retrospective study, treatment outcomes in 43 consecutive patients operated on between April 2011 and April 2014 were compared. Only patients undergoing surgical correction of five or more spinal segments (fixation of six and more vertebrae) were included. RESULTS Transpedicular screw fixation of six to 13 vertebrae was performed under C-arm fluoroscopy guidance in 22 patients, and transpedicular screws were inserted in six to 14 vertebrae using the O-arm imaging system in 21 patients. A total of 246 screws were placed using the C-arm system and 340 screws were inserted using the O-arm system (p < 0.001). The procedures with use of the O-arm system were more complicated and required an average operative time longer by 48% (measured from the first skin incision to the completion of skin suture). However, the mean time needed for one screw placement (the sum of all surgical procedures with the use of a navigation technique divided by the number of screws placed using this technique) was the same in both techniques (19 min). DISCUSSION With good teamwork (surgeons, anaesthesiologists and a radiologist attending to the O-arm system), the time required to obtain one intra-operative CT scan is 3 to 5 minutes. The study showed that the mean time for placement of one screw was identical in both techniques although the average operative time was longer in surgery with O-arm navigation. The 19- minute interval was not the real placement time per screw. It was the sum of all operative times of surgical procedures (from first incision to suture completion including the whole approach within the range of planned stabilization) which used the same navigation technique divided by the number of all screws inserted during the procedures. The longer average operative time in procedures using O-arm navigation was not related to taking intra-operative O-arm scans. The authors consider surgery with an O-arm imaging system to be a safer procedure and use it currently in surgical correction of scoliosis. CONCLUSIONS The study focused on the length of surgery to correct scoliosis performed using either conventional fluoroscopy (C-arm) or intra-operative CT scanning (O-arm) showed that the mean placement time for one screw was identical in both imaging techniques when six or more vertebrae were stabilised. The use of intra-operative CT navigation did not make the surgery longer, and the higher number of inserted screws provides evidence that this technique is safer and allows us to achieve good stability of the correction procedure. Key words: virtual CT guidance, O-arm, scoliosis, transpedicular screw.

[Nailing of pertrochanteric fractures - operative technique]. / Hrebování pertrochanterických zlomenin - operacní technika.

Nailing of pertrochanteric fractures is indicated when DHS is associated with high rate of complications. Thus in unstable comminuted fractures, mainly with posterolateral defect and instability, with Adam´s arch defect and medial instability and in cases when fracture line extends into the subtrochanteric region. The increase in number of nailed pertrochanteric fractures has both its rational and irrational reasons; irrational, as until now there is no clear evidence, that nailing is a faster, safer and easier procedure with a lower rate of complications compared with DHS, a rational, as a proven increase in number of unstable and comminuted fractures has to be reflected in treatment changes. Thus, with respecting the operative techniques principles, intramedullary nailing provides evident biomechanical advantages with the possibility of full weight-bearing and a very low rate of complications.

[Nailing of inter- and subtrochanteric fractures - operative technique]. / Hrebování inter- a subtrochanterických zlomenin - operacní technika.

Intertrochanteric and subtrochanteric fractures are a quite heterogeneous and imprecisely defined group of fractures. These fractures can be essentially divided into two basic groups. The first one belongs to trochanteric fractures. In the AO/ASIF classification; these fractures are called intertrochanteric (31A3). In the second group, the term subtrochanteric fracture is used by most authors for fractures about 5 cm distally from lesser trochanter. In both intertrochanteric and subtrochanteric fractures, the proximal fragment is formed by femoral head, neck and greater trochanter including its base with vastus ridge (tuberculum vastoadductorium or innominate tubercle). On this tubercle, the gluteus medius muscle (proximally) and the origin of the vastus lateralis muscle (distally) are attached. Tension of these muscles may cause dislocation of the proximal fragment. For this reason, reduction of the fracture can be troublesome and it is more difficult than in pertrochanteric fractures It seems that intramedullary nailing will remain the favorite technique of most of the surgeons dealing with intertrochanteric and subtrochanteric fractures. We use short reconstruction nail in intertrochanteric fractures. It is useful to use long reconstruction nail in subtrochanteric fractures. Distal locking of the nail is necessary. Dynamic distal locking is preferred because the two main fragments are compressed along the axis of the nail. The number of complications was largely related to technical errors, such as insufficient reduction or an incorrectly inserted implant. No implant can compensate for errors due to surgery. Serious complications can be reduced by the correct assessment of fracture type, the use of an appropriate operative technique and early treatment of potential complications. The necessity of restoring continuity in the medial cortex of the femoral neck (Adams arch) is the requirement that should be observed. Pseudoarthrosis or varus malalignment in a healed hip should be managed by valgus osteotomy. When the femoral head or the acetabulum is damaged, total hip arthroplasty is indicated. A prerequisite for successful surgical outcome is urgently and correctly performed osteosynthesis allowing for early rehabilitation and mobilisation of the patient.

[Intraoperative CT navigation in spinal and pelvic surgery: initial experience]. / Peroperacní CT navigace u operací pátere a pánve: první zkusenosti.

INTRODUCTION: The authors describe their first experience with virtually navigated pelvic and spine screws based on perioperative CT navigation. MATERIAL AND METHODS: From 22 October 2012 (launching the device) to 9 January 2013, a total of 15 CT-navigated pelvic and spine operations were performed in 14 patients. Nerve root compression, scoliosis, vertebral fracture and spondylodiscitis were the indications for spine procedures; B-type and C-type fractures according to the AO classification were the indications in pelvic surgical procedures. The preparation and the course of the procedures were in accordance with current standards and recommendations in all the cases. Perioperative navigation and subsequent examination of the screw trajectory were performed via O-arm imaging system (Medtronic Navigation, Louisville, Colorado) instead of the standard C-arm fluoroscopy. RESULTS: A total of 73 screws were inserted (60 transpedicular screws into cervical, thoracic and lumbar vertebrae, 9 iliosacral screws into the first sacral vertebra and 4 pubic screws). Only one of the pubic screws (1.4% of all screws) was found malpositioned at the subsequent perioperative examination and was extracted immediately and replaced. Further complications were not observed and none of the procedures had to be converted into a standard fluoroscopy guided operation. CONCLUSION: A short but intensive experience with perioperative CT navigation allows us to state: 1. CT navigation shortens the operating time and minimalizes the risk of screw malposition in multiple screw spine procedures; 2. CT navigation improves the introduction of iliosacral and pubic screws in pelvic fixations; 3. there is virtually no radiation load to the staff using the CT navigation; 4. mastering this technique will allow a wider use of miniinvasive screw insertion in the pelvis and other regions where minimal dislocation will enable miniinvasive internal fixation.

[Trochanteric femoral fractures]. / Trochanterické zlomeniny femuru.

At the present time proximal femoral fractures account for 30% of all fractures referred to hospitals for treatment. Our population is ageing, the proportion of patients with post-menopausal or senile osteoporosis is increasing and therefore the number of proximal femoral fractures requiring urgent treatment is growing too. In the age category of 50 years and older, the incidence of these fractures has increased exponentially. Our department serves as a trauma centre for half of Prague and part of the Central Bohemia Region with a population of 1 150 000. Prague in particular has a high number of elderly citizens. Our experience is based on extensive clinical data obtained from the Register of Proximal Femoral Fractures established in 1997. During 14 years, 4280 patients, 3112 women and 1168 men, were admitted to our department for treatment of proximal femoral fractures. All patients were followed up until healing or development of complications. In the group under study, 82% were patients older than 70 years; 72% of those requiring surgery were in their seventies and eighties. Men were significantly younger than women (p<0.001) and represented 30% of the group. The fractures were 2.3-times more frequent in women than in men. In the category under 60 years, men significantly outnumbered women (p<0.001). The patients with pertrochanteric fractures were, on the average, eight years older than the patients with intertrochanteric fractures, which is a significant difference (p<0.001). The mortality rate within a year of injury was about 30%. Trochanteric fractures accounted for 54.7% and femoral neck fractures for 45.3% of all fractures. The inter-annual increase was 5.9%, with more trochanteric than femoral neck fractures. There was a non-significant decrease in intertrochanteric (AO 31-A3) fractures. On the other hand, the number of pertrochanteric (AO 31-A1+2) fractures increased significantly (p<0.001). A total of 1 394 fractures were treated with a proximal femoral nail; a short nail was used in 1260 and a long nail in 134 of them. A dynamic hip screw (DHS) was employed to treat 947 fractures. Distinguishing between pertrochanteric (21-A1, 31-A2) and intertrochanteric (31-A3) fractures is considered an important approach because of their different behaviour at reduction. Pertrochanteric fractures occurred more frequently (81.5%); the patients' age was higher (80 years on the average) and women outnumbered men at a ratio of 3:1. Intertrochanteric fractures were found in significantly younger patients (average, 72 years), with a women-to-men ratio of 1.3:1. Stable pertrochanteric fractures (31-A1) were preferably indicated for DHS surgery. Unstable pertrochanteric (31-A2) and intertrochanteric (31- A3) fractures were treated with a nail. The patients underwent surgery on the day of injury or the next day. In the case of contraindications to an urgent intervention, surgery was performed after the patient's medical condition had stabilised. The number of complications was largely related to technical errors, such as insufficient reduction or an incorrectly inserted implant. Intertrochanteric fractures were associated with a higher occurrence of complications. No implant can compensate for errors due to surgery. Serious complications can be reduced by the correct assessment of fracture type, the use of an appropriate operative technique and early treatment of potential complications. The necessity of restoring continuity in the medial cortex of the femoral neck (Adams' arch) is the requirement that should be observed. Pseudoarthrosis or varus malalignment in a healed hip should be managed by valgus osteotomy. When the femoral head or the acetabulum is damaged, total hip arthroplasty is indicated. A prerequisite for successful surgical outcome is urgently and correctly performed osteosynthesis allowing for early rehabilitation and mobilisation of the patient.

[Calcaneal fractures treated by open reduction and internal fixation with a locking compression plate (LCP). A prospective study. part I: basic analysis of the group]. / Zlomeniny patní kosti lécené otevrenou repozicí a dlahovou osteosyntézou - prospektivní studie. Cást I: Základní analýza souboru pacientu

PURPOSE OF THE STUDY: In a prospective study of patients with calcaneal fractures treated by open reduction from an extensile lateral approach and LCP osteosynthesis, the authors evaluated the basic epidemiological data, mechanism of injury, type of fracture, essential data on surgery, days of hospital stay and the number of complications. MATERIAL AND METHODS: In the period from September 1, 2006 to July 31, 2010, a total of 230 patients with 243 calcaneal fractures were treated. The fractures were classified as either open or closed and according to the Essex-Lopresti system. Of the total number of patients, 135 (55.6 % of all fractures) were indicated for conservative treatment and 108 (44.4% of all fractures) for surgical intervention. Indications for surgery based on the generally accepted criteria enabled us to select 77 patients with 82 fractures (33.7 % of all fractures) for treatment by the method of open reduction and LCP osteosynthesis. These patients constituted the group evaluated here. The other patients were treated using other techniques (21 fractures, i.e., 8.6 % of all fractures, by the Stehlík-Stulík transfixation method and further five [2.1 %] by screw osteosynthesis). Six surgeons were involved in the treatment of this group. For the diagnosis of fractures, plain radiographs in lateral and axial projection and axial and coronal CT images were used. All fractures were treated after subsidence of oedema by the method of open reduction and LCP fixation from an extensile lateral approach, with the use of a tourniquet. The follow-up period for the evaluation of functional outcome and bone union was 3 to 48 months. Fifty patients were followed up for over one year. RESULTS: The group evaluated comprised 58 men (75.3 %) with 63 fractures (76.8 %) and 19 women (24.7 %) with 19 fractures (23.2 %). The average age of the group was 42 years, with 41 years (range, 22-61 years) in men and 47 years (range, 30-70 years) in women. The most frequent cause of injury was a fall from a height below 1 metre and this was recorded in 38 patients (49.4 %); 18 patients (24.3 %) had a fall from a height below 3 metres. Eight fractures were caused by a fall from the window, seven calcaneal fractures, as part of .polytrauma, were sustained in road accidents (9.1 %) and six calcaneal bones were injured due to ankle sprain in walking on a flat surface (7.8 %). Bilateral fractures occurred in five (6.5 %) patients, the right and left heel bones were injured in 31 (40.3 %) and 41 (53.2 %) fracture cases, respectively. An open fracture was recorded on three occasions (3.7 %). Of the 82 evaluated fractures, 23 were type IIa fractures (28 %) and 59 were type IIb fractures (72 %) according to the Essex-Lopresti classification system. The average injury-surgery interval was 10 days (range, 1 - 23 days). The average operative time was 77 minutes (range, 45-175 min) and the average duration of tourniquet application was 61 minutes (range, 20-130 min). The average length of hospital stay was 18 days (range, 7-61 days). In 15 patients (18.3 % of osteosynthesis cases) wound healing was delayed. Deep wound infection developed in three cases (3.7 %); these required revision surgery which involved implant removal before bone union in two cases and healing of the wound after revision without implant removal in one case. A necrotic lesion in one case (1.2 %) was treated by muscle flap transfer. Complications which varied in type and severity were recorded in 22 % of the patients. The Rowe score was used to evaluate functional outcomes, which were excellent in 44 %, good in 46 %, satisfactory in 4 % and poor in 6 % of the surgically treated patients.. DISCUSSION: Only about one-third of the patients with calcaneal fractures were indicated for open LCP osteosynthesis. This is in agreement with the strict indication criteria established by the foreign authors with Professors Zwipp and Sanders at the head. It appears that this fracture chiefly occurs in the population of young active men (Kocis reported only men and no woman with this fracture in his study). The authors focus on exact radiographic diagnosis including CT examination, as recommended by Stehlík and Stulík in their book. They recommend to use the Essex-Lopresti system for primary classification and, because of the frequency of LCP osteosynthesis procedures performed, also recommend to carry out this treatment in specialised institutions. The rate of serious complications in this study was relatively low and in accordance with the findings of Zwipp, Zeman and others. CONCLUSIONS: The analysis of basic data on the group of patients with calcaneal fractures treated by open reduction and LCP fixation showed the following: chiefly young active men sustained this fracture; calcaneal fracture was usually due to a fall or jump from a level not too high; X-ray examination (lateral and axial projection) was sufficient to make a diagnosis; for a decision to operate it was useful to complete the diagnosis by CT examination; the prerequisite for minimising post-operative complications was strict adherence to the established indication criteria, surgery only after oedema had subsided and use of the correct surgical technique. The number of complications and their nature did not differ from the data reported by other authors.

[Ipsilateral fractures of the proximal femur and the femoral shaft]. / Ipsilaterální zlomeniny proximálního konce a diafýzy femuru.

PURPOSE OF THE STUDY: The aim of the study was a retrospective evaluation of the surgical treatment of 171 fractures of the proximal femur and the femoral shaft. MATERIAL AND METHODS: Between the years 1994 and 2008, 171 ipsilateral fractures were operatively treated in 169 patients with an average age of 56 years (range, 21-97 years). The group comprised 108 men and 61 women. The fracture was fixed by the long Gamma nail (Howmedica) in 18 cases, by the long PFN (Synthes) in 147 cases and by the long PFH (Medin) in three cases. In two patients with a bilateral fracture, a reconstruction nail was used on one side and a combination of DHS and condylar plate on the other. External fixation was used in a patient with severe burns. In one case the fracture was fixed by a LCP Proximal Femoral Plate. Types of fractures were evaluated on the basis of the authors' own classification of 1998. Type I (concomitant femoral neck and femoral shaft fractures) accounted for 13 %, Type II (pertrochanteric fracture and femoral shaft fracture) for 23 %, Type III (complex fracture of the proximal femur extending from the femoral neck base to the femoral shaft) for 21 %, Type IV (high subtrochanteric fracture extending from the tuberculum innominatum to the femoral shaft) for 40 % and Type V (Type I or II with a fracture of the distal femur) for 3 % of fractures. In 68 % of cases the injury was caused by high-energy trauma. In Types I and V it involved all the patients, in Type II 95 % of them. These fractures occurred primarily within a polytrauma or as an associated injury (91 %). Types III and IV included mainly monotrauma cases (78 %). The minimum follow-up period was 12 months (1-15 years). RESULTS: Of 129 fractures, 127 (98 %) healed within 12 months after the injury. In one patient, non-union healed after re-nailing 15 months after the injury. In another case, infected non-union healed 18 months after the injury. In the whole group, 14 intraoperative and 9 early postoperative complications (14 %) were encountered. In the group of 129 patients followed up minimally for 1 year, 16 late complications (12 %) were recorded. In 125 cases treated with a reconstruction nail there were 13 complications (10 %) and in four patients treated by another method, complications occurred in three cases. The highest number of complications was recorded in Type V fractures (3 of 5). Excellent results were achieved in 63 %, good in 29 %, fair in 6 % and poor results in 2 % of the patients. DISCUSSION: There is no generally accepted classification of ipsilateral fractures of the femur. Therefore, we used our own classification that proved useful in evaluation of the group of patients.We only slightly modified it in terms of the findings. Type III and type IV fractures have a number of characteristic features in common and so we decided to cover them by one type of complex fractures extending from the femoral neck base as far as the femoral shaft. There is no consensus concerning the treatment. In addition, the percentage of complications is quite high. The group was treated almost exclusively with the reconstruction nail. In 2 % we used another method of internal fixation. Our results do not differ from those reported by other authors. CONCLUSIONS: In case of fractures of the femoral shaft, in high-energy trauma particularly, it is necessary to check the patient for a potential proximal femur fracture. The diagnosis should be made on the basis of a radiograph of the pelvis in internal rotation and axial projection and CT scans for evaluation of the proximal femur, including 2D CT reconstructions. Prior to nailing of the femoral shaft, sciascopic examination must be made of the hip in both projections. Fixation by a reconstruction nail is a suitable method for treatment of ipsilateral fractures.We consider the risk of complications adequate to the mechanism of injury and its severity.

[Osteosynthesis for periprosthetic supracondylar fracture above a total knee arthroplasty using a locking compression plate]. / Osteosyntéza periprotetické suprakondylické zlomeniny kolenního kloubu s pouzitím LCP dlahy.

PURPOSE OF THE STUDY: The frequency of periprosthetic fractures related to total knee arthroplasty is increasing, with a prevalence of 1.3% on the average and with women being affected more often (4 out of 5 patients). Fractures of the distal femur are common, while tibial fractures are rare. Crucial for treatment is to distinguish fractures of the metaphysis above the femoral component, which remains firmly fixed, from those involving the knee joint replacement and component loosening. Supracondylar periprosthetic fractures are almost always managed surgically, using methods of osteosynthesis with an angle condylar or DCS plate, or a short retrograde- inserted supracondylar intramedullary nail. The recent use of implants such as LCPs with angle-stable screws has offered good prospects. This retrospective study presents our first experience with an LCP for treatment of supracondylar periprosthetic fractures of the knee joint. MATERIAL AND METHODS: Between 2005 and 2008, a total of 13 supracondylar periprosthetic knee fractures were treated by the LCP technique. The patient group included 10 women and three men the average age was 67.4 (range, 56-81) years. The fractures were classified using the system proposed by Su et al. and the AO classification system. According to the Su classification, 12 types I and II fractures and one type III fracture were indicated for osteosynthesis. Based on the AO classification, there were four type 33 A1 fractures, five 33 A2 fractures, three 33 A3 fractures and one 33 C2 initially incorrectly classified as type 33 A3 fracture. The average time between total knee arthroplasty and injury was 6.8 years. In all patients fractures occurred after primary implantation of a cemented condylar total knee replacement without a femoral stem.The fractures were treated by a less invasive technique of LCP implantation within an average of 2.5 days of injury. The patients were followed up until radiographic fracture union, and complications were recorded. RESULTS: The 13 patients were treated by LCP osteosynthesis through a less invasive approach. One patient had primary spongioplasty, two had spongioplasty after an interval of 7 weeks. One patient died of a disease unrelated to trauma and surgery at 3 months after osteosynthesis. In one patient, osteosynthesis failed with fragment dislocation shortly after the operation. The case analysis showed that the initial indication was marginal and the comminuted zone was too low above the implant, with the fracture line extending to the component. Subsequently, conversion to revision total knee arthroplasty involving a stem was carried out. In nine patients, bone union was achieved in an average of 18 weeks, with radiographic evidence of fracture union. No complications such as wound infection, delayed wound healing or thromboembolic disease were recorded. No bone union failure and pseudoarthrosis development occurred. DISCUSSION: There are only few reports on the treatment of supracondylar periprosthetic knee fractures and evaluation of its results in the literature, and the groups evaluated are small. In a meta-analysis of cases from the 1981 to 2006 period, Herrera et al. have found only 29 assessable studies with a total of 415 cases, i.e., an average of 14 cases per study. The usual method of treatment was DCS plate osteosynthesis. Complications associated with conventional osteosynthesis techniques, as reported by various authors, may reach up to 30% (pseudoarthrosis development, 9% osteosynthesis failure, 4% necessity of revision surgery, 13% fracture malunion, 47%).Good results have been achieved with a retrograde-inserted intramedullary nail. The use of an LCP has been reported in the literature only occasionally. The classification system described by Rorabeck et al. is most widely used, but the system proposed by Su et al. seems more convenient to us, because fractures are placed in three groups, according to the localisation of a fracture line and its distance from the femoral component, as follows: type 1 fracture, fracture line is proximal to the femoral component type 2 fracture, fracture line starts at the level of a proximal edge of the femoral component and runs proximally type 3 fracture, fracture line extends below the upper end of the femoral component. Type 1 fracture is indicated for a retro- grade-inserted intramedullary nail, type 2 fracture for LCP osteosynthesis, and type 3 fracture for revision total knee arthroplasty. The use of LCPs in the treatment of supracondylar fractures of total knee arthroplasty, with a success rate of 86%, is described by Ricci et al. Other authors also report better outcomes with the use of LISS or LCP methods than with conventional osteosynthesis techniques. CONCLUSIONS: Osteosynthesis with an angle-stable table LCP is an efficient method suitable also for the treatment of periprosthetic fractures of the distal femur above total knee arthroplasty. It offers all advantages of angle-stable implants. It is more effective for osteoporotic bone than a DCS implant or a condylar plate, because it provides better fixation stability for the distal fragment. However, further studies are needed to compare its efficiency with that of an IM nail.

Specific aspects of the treatment of patients with multiple mechanical and burn injuries.

Fewer than 5 percent of all burn patients sustain other traumatic injuries before, during, or immediately after their accident. Multiple traumas associated with a burn injury create special problems during the care of the thermally injured patients. Conversely, the burn injury often complicates the diagnosis and treatment of the trauma. The combination of mechanical and burn injuries can be divided into two types: a) any associated fracture located outside the burned area, or b) fractured bones within the burned area. This situation represents a critical factor which must be taken into account during treatment procedures. The following options should be considered: in fractures outside the burned area, there would be no difference in standard, skeletal treatment procedures. For the treatment of fractures in burned areas (mostly on the extremities), the optimal procedure is osteosynthesis within 48 hours of the burn trauma, when the burn wound is nearly sterile (without significant bacterial colonisation). We prefer two-team surgery. Firstly, a trauma surgeon performs osteosynthesis and, after that, burn surgeons treat the burns. The optimal approach in full-thickness burns would be necrectomy and autografting. This is, however, not always possible, because of the overall condition of the patient who has been continuously resuscitated during the shock period. All individual factors must be considered during the decision-making process.

[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.

[The proximal femoral nail (PFH)--another alternative for osteosynthesis of trochanteric fractures]. / PFH (proximální femorální hreb)--dalsí alternativa osteosyntézy trochanterických zlomenin.

The aim of the study was to test a new intramedullary implant PFH-Medin on internal fixation of trochanteric fractures. The basic group comprised 35 patients (average age 79.2 years). Indicated for the surgery were patients with all types of trochanteric fractures, i.e. 13 stable (AO 31A1), 15 unstable (AO 31A2) peritrochanteric fractures and 7 intertrochanteric (AO 31A3) fractures. Final outcomes were evaluated in 21 patients with the minimal follow-up of 6 months. From the viewpoint of the type of the fracture 9 cases were stable peritrochanteric, 7 cases unstable peritrochanteric and 5 intertrochanteric fractures. Duration of surgery was measured from the incision until wound closure and in the whole group of 35 patients it was on average 50 min. (range, 25-90 min.). X-ray exposure was recorded including the period necessary for the reduction of the fracture and was on average 80 sec. (range, 25-120 sec.). In the whole group we encountered only two complications. The first complication resulted from the insertion of the distal locking screw outside of the nail and the patient healed without problems. The second case involved aseptic necrosis of the femoral head eight months after the surgery and five months after the fracture had healed. All 21 patients followed up minimally for sixth months healed in anatomical position.

[The Essex-Lopresti forearm fracture (case report)]. / Essex-Loprestiho zlomenina predloktí (kazuistika).

The radial head fracture associated with dislocation in the distal end of the ulna and tear of interosseous membrane of the forearm with a subsequent proximal migration of the radial shaft is a relatively rare injury. For the first time it was described by Essex-Lopresti in 1951. Our report presents one case together with an analysis of available literature relating to the diagnosis and treatment. A man, 69 years old, hurt his right elbow and forearm in a fall on the outstretched arm. There was a 2 x 1 cm excoriation on the lateral portion of the elbow and a dominating pain and limitation of the range of motion of the right elbow and wrist. The radiograph of the elbow, forearm and wrist showed a dislocated comminuted fracture of the radial head, dorsal subluxation of the ulnar and proximal displacement of radius. The condition was assessed as Essex-Lopresti fracture of the forearm indicated for surgery. The four-fragment fracture of the radial head did not allow reconstruction and therefore the head was resected. Subsequently the distal radio-ulnar joint was revised from dorsal approach with a K-wire inserted transversally. In order to prevent proximal displacement of the radius a K-wire was inserted in the medullary cavity of the radius close to the distal end of the humerus with the elbow in 90 degrees flexion and slight supination. The wounds were sutured and plaster of Paris applied extending across the elbow up to the metacarpal heads. After 6 weeks the plaster fixation and K-wires were removed. Full weight bearing was permitted 4 months after the surgery. Ten months after the surgery the patient was without complaints. Flexion in the elbow ranged between 0-5-130 degrees, pronation-supination was limited by 10 degrees in both extreme positions. The ulnar head became prominent on the dorsal side, dorsiflextion and ulnar duction in the wrist were limited to 10 degrees. The radiograph of the wrist showed and evident proximal displacement of the radius, the dorsally subluxated ulnar head overhung by 7 mm. Our case has confirmed that a mere extirpation of the head with a subsequent stabilization and transfixation of the proximal end of the radius and transfixation of the distal radio-ulnar joint cannot prevent after the extraction of wires a proximal displacement of the radius and development of the "plus variant" resulting in the limitation of both the range of motion of the wrist and the pronation-supination movement of the forearm.

[Osteosynthesis of trochanteric fractures using proximal femoral nails]. / Osteosyntéza trochanterických zlomenin proximálním femorálním hrebem (PFN Synthes).

PURPOSE OF THE STUDY: Presentation of the existing experience in the use of Proximal Femoral Nail Synthes (PFN) in trochanteric fractures. MATERIAL: A prospective study evaluating a group of 41 patients, 12 men and 29 women, average age 68 years (range 21-93 years) operated on between September 1997 and March 2001 by means of PFN. The group comprised 11 unstable peritrochanteric fractures (31-A2), 26 high subtrochanteric fractures (31-A3), 3 low subtrochanteric fractures and 1 pathological fracture. METHOD: Monitored were first of all preoperative and post-operative complications and final results. RESULTS: The average duration of surgery was in the whole group of 41 patients 61 minutes (30-100 minutes), in the group of high subtrochanteris fractures 58 minutes (30-80 minutes). Average X-ray exposure including the time necessary of the reduction of the fracture was 2.9 minutes (1-6 minutes). In the group there occurred 3 complications. In the first case distal fixation of the mail failed. However, the fractures healed with any other complications. The second case was a patient with unstable peritrochanteric fracture when a too short lag screw was inserted to the head during surgery. In spite of this the fracture healed in 3 months, however, the resulting varus deformity caused a 1.5 cm shortening of the limb. In the third case, a female patient with a low subtrochanteric fracture, fragments were left in distraction and a large fragment of medial cortex bearing also lesser trochanter remained significantly displaced. Even after 6 months the fractures did not healed and therefore we performed dynamization of the nail and cancellous bone grafting in the region of the defect of medial cortex. Final results were evaluated in patients with a minimum follow-up of 6 months, i.e. in 22 patients, 9 patients did not come, 8 patients died. Most patients healed in 3 months (in total 20 patients of 28 followed up) but we set the minimum follow-up period of 6 months when we checked 22 patients of 39. Within six months 8 patients died and another 9 patients did not appear for the follow up. There were 17 cases of a high subtrochanteric fracture, 3 cases of unstable peritrochanteric fracture, one case of per-subtrochanteric fracture and one case of a low subtrochanteric fracture. Within 6 months the fracture healed in 21 patients, i.e. in 95% of the followed-up patients, of this in 20 cases (91%) in anatomical position. DISCUSSION: In literature we have found only one publication (Simmermacher et al.--Injury 30, 1999) dealing with PFN which presents very good experience with this implant. Our good results were significantly influenced by preceding experience in the use of Gamma nail. In comparison with it PFN represents an implant of the next generation. However, the basic prerequisite of a good result is a perfect mastering of the surgical technique. CONCLUSION: PFN is a method of choice in trochanteric fractures, namely in high subtrochanteric fractures (31-A3).