[Incidence, Diagnosis and Risk Factors for Fracture-Related Infection (FRI): 3-Year Experience of Level I Trauma Centre]. / Incidence a diagnostika infektu pri zlomenine (FRI) a rizikové faktory jeho vzniku: tríleté zkusenosti traumacentra I. stupne.

PURPOSE OF THE STUDY The study aims to determine the incidence of fracture-related infection (hereinafter referred to as the FRI) at a Level I trauma centre over a three-year period. It also aimed to determine the risk factors, to observe confirmatory and suggestive criteria in line with the applicable recommendations, and to evaluate the bacterial spectrum in a diagnosed FRI. MATERIAL AND METHODS It is a retrospective-prospective study carried out through studying the documentation. The study included all patients diagnosed with FRI and treated between 2019 and 2021, except for the patients with hand fractures since minor phalangeal fractures of the fingers were largely treated by the outpatient department, no osteosynthesis was performed in the operating room, and these patients were not followed up at our department. RESULTS The FRI incidence was 2.33% of all osteosyntheses performed at the Level 1 trauma centre in the period 2019-2021. The FRI was most often caused by pyogenic cocci agents and the FRI developed most frequently within 6 months after osteosynthesis. The site at risk was the lower limb region. The FRI incidence was most often indicated by suggestive clinical criteria (redness, secretion, pain) and radiological criteria (delayed healing, non-union). Overall, 42.19% of treated nonunions were later diagnosed as FRI. At the time of FRI diagnosis, the CRP values were normal in 21.7% of patients. DISCUSSION The FRI incidence rate in 2019-2021 was 2.33%, which corresponds with the values reported in other papers focusing on the incidence of infectious complications after osteosynthesis. Fang and Depypere reported 1-2% of infectious complications. The most common risk factors are open fractures, which account for 20.16% in our cohort. Ktistakis and Depypere describe the incidence of osteomyelitis in 30% of treated open fractures. In our cohort, the incidence of FRI was significantly higher in lower limb fractures. Bezstarosti, Wang and Pesch published similar results, with some deviations. The time from osteosynthesis to final FRI diagnosis varied from a few weeks to several years. In more than half of the patients the FRI developed within 6 months after performed osteosynthesis. Metsemakers and Fang refer to the very same trend. The CRP levels in the study population varied a lot. Xing-qi Zhao describes CRP as a less sensitive (sensitivity 65.6%) but more specific marker (specificity 75.4%). According to the available literature, the most common agents causing infectious complications of osteosynthesis are gram-positive cocci, S. aureus in particular. In our study, G+ pyogenic cocci were clearly the most commonly detected, which is consistent with the results of studies by Fang and Depypere, focused on the incidence of infectious complications. The most common FRI clinical manifestations included wound secretion, redness, swelling and pain. Furthermore, suggestive radiological criteria, especially delayed healing and non-union also indicated the FRI occurrence. According to Fang, the most common clinical manifestations of infectious complications include pain, swelling, redness and wound dehiscence. Fang reports that the most common radiologic findings are the periosteal reaction, loosening of the implant and delayed healing or non-union, which is consistent with our cohort. In the cohort of non-unions surgically treated at our department, FRI was subsequently confirmed in 42.19% of cases. CONCLUSIONS The incidence of FRI at Level 1 trauma centre was 2.33% of operated fractures in 2019-2021, with pyogenic cocci being the most common infectious agents. The FRI usually developed within 6 months after osteosynthesis. The typical site for the FRI development was the lower limb region, the ongoing FRI was indicated by suggestive clinical criteria (redness, secretion, pain) and radiological criteria (delayed healing and a non-union). Overall, 42.19% of treated non-unions were later diagnosed as FRI. Key words: fracture-related infection, FRI, suggestive criteria, confirmatory criteria, FRI diagnosis, microbial, microbiology spectrum, osteosynthesis, complications, non-union.

[Minimally Invasive Cancellous Bone Graft Harvesting in Trauma Indication - Clinical Part of the Study]. / Miniinvazivní odber spongiózních stepu v traumatologické indikaci ­ klinická cást studie.

PURPOSE OF THE STUDY The clinical prospective study presents the results of minimally invasive harvesting of cancellous bone tissue in trauma indications. We focused on evaluating the clinical outcomes of this technique, particularly on the amount of cancellous bone harvested, the effectiveness of its use and complications. The pain in the bone graft harvest site is evaluated and compared with the pain after a standard harvest from the iliac crest. MATERIAL AND METHODS All the patients aged 18-90 years, in whom cancellous bone was harvested by minimally invasive technique using a bone cutter were included prospectively in the study. It was used to fill the defect in treating a fracture or in surgical treatment of non-union. The patients, in whom the grafts harvested in this manner were combined with another substitute, were not included in the study. Thus, 57 adult patients (40 men, 17 women) were included in the group in the period from March 2012 to March 2016. 37 patients, i.e. 65% of the total number of 57 patients, arrived for the evaluation of the clinical outcome. The minimally invasive graft harvesting was performed using the Aesculap® cutters. The graft was harvested either from the skeleton directly in the area of surgical wound or by a mini incision above the harvest site in the area under surgical drapes. The diameter of the cutter was selected based on the planned necessary number of grafts and with account taken of the harvest site. There were 6 harvest sites selected - proximal humerus, proximal ulna, iliac crest, greater trochanter of femur, distal femur and proximal tibia. The age and gender of patients, harvest site, type of the used cutter and the total number of harvested grafts were recorded in the study. The patients underwent a clinical follow-up at 6 weeks, 3 months, 6 months and 1 year postoperatively. The healing of the fracture or non-union was assessed on radiographs and in case of any doubt a CT scan was indicated. The pain at the graft harvest site was quantified with the use of the VAS score. A possible correlation between the age and the harvest site pain was explored by means of the Pearson s correlation coefficient. RESULTS In surgical management of fractures, 10.98 cm³ of bone marrow (σ 5.32) was harvested on average, in non-unions it was 10.85 cm³ (σ 5.52). With the above described technique, the mean healing time of lower extremity fractures was 26 weeks, in upper extremity it was 22 weeks. The non-unions of lower extremity and upper extremity healed after 28 weeks and 19 weeks, respectively. The average pain at the harvest site was 4.08 (σ 2.21, p ˂ 0.001). By calculating the Pearson's correlation coefficient it was confirmed that there is no correlation between the age and pain VAS score at the harvest site (r = -0.05). No early complications at the graft harvest site were observed in our group of patients. DISCUSSION On average, 10.98 cm³ of bone marrow was harvested in treated fractures, which in comparison to standard harvests from the iliac crest offers sufficient amount of tissue to treat complicated fractures and non-unions. Technically, the standard harvest site of cancellous bone tissue from the iliac crest is replaceable. The harvesting technique offers an interesting alternative also in terms of the duration of surgery and material. CONCLUSIONS Our study confirmed that by the minimally invasive technique of bone graft harvesting adequate amount of tissue to treat defect fractures and non-unions can be harvested. Spongioplasty using grafts harvested in this manner is effective, with a minimum percentage of non-unions. The advantage of this technique is the proximity of the harvest site and the operative field and low level of pain. The minimally invasive graft harvesting represents a technique with a low risk of postoperative and late complications. Key words: bone graft, autografts, minimally invasive surgery, ilium, pain.

[Minimally Invasive Cancellous Bone Graft Harvesting in Trauma Indication - Experimental Part of the Study]. / Miniinvazivní odber spongiózních stepu v traumatologické indikaci ­ experimentální cást studie.

PURPOSE OF THE STUDY Our experimental study presents a set of bone grafts harvested by a minimally invasive procedure from selected deceased donors. Our objective was to compare the concentration of red bone marrow in the cancellous bone harvested in this way from selected regions with the reference harvesting from the iliac crest. Thus, the potential of grafts to heal complicated fractures or non-unions is assessed. MATERIAL AND METHODS The Hospital Department of Pathology provided 10 cadaver preparations - 7 male and 3 female for the experiment. In the process of selection, the age limit was 18-50 years, the other exclusion criteria were severe injuries and burning to death as mechanisms affecting the condition of the skeletal system, bone diseases except for osteoporosis, and malignant diseases. From each preparation, a total of 12 samples of cancellous bone tissue were harvested from pre-defined 6 harvest sites bilaterally - proximal humerus, proximal ulna, greater trochanter of proximal femur, distal femur, proximal tibia and from the reference region of the iliac wing. The grafts were harvested using a 10 mm bone cutter. In total, 120 samples of cancellous bone of the determined diameter and uniform length of 30 mm were obtained. The obtained preparations were laboratory processed, fixed, decalcified and hematoxylin-eosin stained. The samples were assessed microscopically. The share of the bone tissue and cancellous bone was expressed as a percentage. Determined as a healing potential parameter was the concentration of red bone marrow and its ratio to the yellow bone marrow was stated. The hypothesis was tested using the ANOVA analysis of variance. RESULTS The highest concentration of red bone marrow was observed in cancellous grafts harvested from the iliac wing with 34.95%, followed by greater trochanter of proximal femur with 31.7%, distal femur with 26.9% and proximal humerus with 21.9%. Its concentration was negligible in proximal tibia with 2.55% and proximal ulna with 0.15%. By ANOVA statistical method the values of reference samples from the iliac wing and greater trochanter of the femur, distal femur and proximal humerus were compared. The differences are not statistically significant - P 0.60, 0.48 and 0.34 (p < 0.05). No significant differences were found in the concentration of red bone marrow. Statistically compared were also the values of reference samples from the iliac wing and proximal tibia, proximal ulna. This difference is statistically significant - P 0.0008 and 0.0002 (p <0.05). Thus, the difference in the concentration of red bone marrow is obvious. DISCUSSION The aforementioned results suggest that the greatest potential to heal will be achieved with the use of bone grafts from the iliac wing region, followed by greater trochanter of the femur, distal femur and proximal humerus. When testing the hypothesis by the ANOVA method, the detected differences between the selected harvest regions are not statistically significant. Therefore, the iliac wing grafts can be used in practice just as the material from greater trochanter of the femur, distal femur or proximal humerus, which is of equal quality. The other regions, proximal tibia and ulna, contain only minimum concentration of red bone marrow. CONCLUSIONS The experimental study comparing the concentration of red bone marrow in grafts harvested using a minimally invasive procedure from the region of greater trochanter, distal femur and proximal humerus concluded that these samples are comparable with the grafts from the iliac wing. The grafts harvested from proximal tibia and proximal ulna show only negligible concentration of red bone marrow and their use in clinical practice is disputable. The benefits of our experimental study for treatment shall be further evaluated in a clinical study. Key words: bone marrow, stem cells, bone healing/orthobiologics, new technology assessment, autograft harvesting.

[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.

[Comparison of Plaster Fixation and Kirschner Wire Transfixation as Temporary Fixation of Displaced Ankle Fractures - Randomised Prospective Study]. / Porovnání sádrové fixace a transfixace Kirschnerovými dráty pri docasné fixaci dislokovaných zlomenin hlezna ­ randomizovaná prospektivní studie.

PURPOSE OF THE STUDY The purpose of the study was to assess two therapeutic procedures of temporary fixation of displaced ankle fractures, namely the plaster fixation or Kirschner wire (KW) transfixation via the sole of the foot. MATERIAL AND METHODS Group of patients The randomised prospective study conducted in the period 02/2016-02/2017 compared two methods of temporary fixation of displaced ankle fractures. In total, 38 patients were included in the study (18 patients treated with plaster fixation, 20 patients treated with KW). Methods During the randomisation (by envelopes, drawing of lots by the patient), in one group of patients, temporary stabilisation by plaster fixation was performed, whereas the other group was treated by percutaneously inserted KWs. The attention was focused on the quality of achieved reduction, its retention until the final treatment, and soft tissue status. After one year, the final examination was performed, in which we focused on the assessment of the clinical condition of the ankle joint with the use of the Olerud-Molander Ankle Score (OMAS), the AOFAS (American Orthopedic Foot and Ankle Society) score, and the Visual Analogue Scale (VAS) measuring the overall satisfaction. Moreover, in both the methods potential incidence of arthritic changes was monitored on radiographs. RESULTS Both the methods achieved 100% successful reduction rate. The group with plaster fixation reported a loss of reduction in six patients (33.3%) as against the KW group where no loss of reduction occurred. This difference was significant (p = 0.007). In plaster fixation method, after its removal local complications occurred on skin in 56%, of which skin necrosis in 16.7%, and it always occurred in association with the loss of reduction, which was statistically significant (p = 0.245). In KW method, local complications on skin were present in 25% only. In the group of patients with KW, there was not a single case of surface or deep infection reported. No KW migration was observed. DISCUSSION Potential complications of conservative treatment of displaced fractures with plaster fixation include the migration of fragments and widening of the ankle fork during the further course which may threaten the vitality of soft tissues. A total of six patients (33.3%) treated with plaster fixation showed a failure of reduction, which is by approximately 10% more than described in literature. In seven cases after the plaster fixation removal bullae were observed (38.9%) and in three cases skin necrosis was present (16.7%), which occurred in re-displaced fractures only. The bullae were present whether the reduction was successfully maintained or not. In literature, local complications after plaster fixation removal are reported in roughly 14%. Temporary percutaneous ankle KW transfixation is applied to maintain the reduced fracture in a favourable position and to facilitate monitoring and treating the soft tissues. Prior to the final surgical solution, bullae were observedin four cases (20%), of which skin necrosis in one case (5%). Bullae formation and necrosis are most likely related to the initial damage to soft tissues due to the injury and were not caused by the KW insertion. The literature describes local complications in 7% with respect to the KW technique, however, the type of complications is not specified. In our group, at a one-year follow-up arthritic changes grade I and II according to Kellgren and Lawrence scale were reported in 70% of cases with KW technique. Whether the osteoarthritis was caused by fixation or the fracture itself and what would be the percentage of individual types of osteoarthritis after several years of follow-up is a question. CONCLUSIONS Plaster fixation or Kirschner wires for temporal fixation of displaced ankle fractures shall be applied on a case by case basis. Based on our findings, the application of plaster fixation to displaced ankle fractures does not provide adequate stability of the reduced fracture and in case of re-displacement the status of soft tissues deteriorates. The impossibility to control the status of soft tissues in plaster fixation and the lower complication rate in fixation with K wires constitute additional reasons why this fixation technique via the sole of the foot appears to reap more benefits. Key words:displaced ankle fractures, temporal fixation, plaster fixation, Kirschner wire transfixation, complications.

[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.

[Arthroscopic Finding of Knee Joint in Relation to Age and Its Comparison with Pre-Operative Clinical Finding - a Retrospective Study]. / Artroskopický nález kolenního kloubu v závislosti na veku a jeho srovnání s predoperacní klinikou ­ retrospektivní studie.

PURPOSE OF THE STUDY In the retrospective study of two South Bohemian centres we present the comparison of pre-operative anamnestic clinical signs in relation to the arthroscopic intraoperative finding. The obtained data is used also to evaluate the arthroscopic finding in relation to age and sex. MATERIAL AND METHODS The arthroscopic findings of patients who underwent surgery in 2013-2014 period (1.1.2013-31.12.2014) at the Department of Trauma Surgery of Ceské Budejovice Hospital, a.s. and in 2014 (1.1.-31.12.2014) at the Department of Orthopaedics and Traumatology of Písek Hospital, a.s. were evaluated. In total, 1 021 patients underwent surgery, with the mean age of 44 years. The patients were not selected. The group includes all the patients who underwent surgery, including those in whom repeat arthroscopy was performed, in the respective period of time, regardless of the mechanism of difficulties. A preoperative MRI scan was carried out in 470 patients. The referring physician was present during the examination. In all the patients undergoing surgery, the main clinical preoperative sign was examined based on the documentation, namely in the following order - hemarthros, locked knee, hydrops or merely a pain. In the arthroscopic finding, the medial meniscal lesion - anterior and posterior horn, and complete tear was assessed. The same was done for lateral meniscus. In anterior cruciate ligament - ACL - partial or complete tear was assessed. We identified the frequency of findings in relation to age and evaluated the correlations between the clinical signs and the arthroscopic finding. We calculated the sensitivity and specificity of hemarthros as a sign of ACL tear. The analysis was conducted based on the medical history in medical record documentation and the surgical protocol. The cartilage was not assessed. RESULTS Analysis of clinical and anamnestic signs in relation to arthroscopic findings 1. Negative arthroscopic findings (potential cartilage damage with no damage to other soft structures and normal arthroscopic findings) are in 83% accompanied by a mere knee pain. 2. High percentage of isolated locked joint (15%) in negative findings 3. Complete ACL tears are most frequently reported in the under-35 age category - 43% of 191 men who underwent surgery and 33% of 102 women. 4. Isolated injuries to ACL without the meniscus tear are frequent in younger patients - 30% - 40% of the total number of patients with injured ACL. 5. In patients older than 56 years of age the ACL damage is accompanied by concurrent meniscus tear (96% in men, 100% in women). 6. Sensitivity of hemarthros (68%) for complete ACL tear. Specificity of the presence of hemarthros in complete ACL lesions (91%) indicates that there are also complete ACL tears with no hemarthros whatsoever in the medical history. For partial tears the values of sensitivity and specificity are 27% and 67%, respectively. In partial tear, the presence of hemarthros is not a diagnostic lead. 7. In 15% of negative findings a "locked knee" was present. It was not a genuinely locked knee, but rather an antalgic position. Not every locked knee must necessarily mean a meniscus lesion or ACL tear. 8. Isolated meniscus tear is in 75% accompanied only by pain. 9. In our group of patients, isolated osteoarthrosis or malacic cartilage without any damage to ligaments or menisci was rare - only in 22 cases (2% of the entire group). DISCUSSION There are lots of studies which focus on comparing the clinical findings with perioperative pathology of knee joint and the importance of pre-operative clinical examination. Our extensive retrospective study proved that in 56-plus age category virtually each ACL injury is accompanied by a meniscal lesion, which can be explained by a possible ACL damage at a young age and subsequent instability resulting in meniscus tear or frequent presence of degenerative meniscal changes at an older age. A small number of isolated degenerative cartilage damage was established (2%). We fully agree with the authors who prove that the degenerative cartilage changes are ever since the very beginning accompanied by changes of the other soft structure of the knee. We revealed a high percentage of locked knee joint in negative arthroscopic findings. According to the clinical pre-operative examination, the locked knee does not automatically mean the meniscal lesion or ACL tear. In agreement with the others we prove a close association between hemarthros and ACL injury. CONCLUSIONS 1. A clinical examination, a detailed medical history is necessary 2. With hemarthros in medical history, there is a likelihood of complete ACL tear. Conversely, even a seemingly trivial knee sprain without hemarthros or locked knee can mean the ACL tear. 3. Where a mere pain is present, it mostly indicates an isolated meniscal damage or a negative finding. 4. Degenerative cartilage changes are accompanied by degeneration of menisci and ligaments. 5. Our group of patients did not include any case of hemarthros in the medical history with a negative arthroscopic finding. Hemarthros always indicated a more serious damage to knee soft structures. Key words: knee joint injuries, knee arthroscopy, sensitivity, specificity, hemarthros.

[Treatment of Displaced Patellar Fractures with Multiple Circular Cerclage]. / Lécba dislokovaných zlomenin césky etázovou cerklází.

PURPOSE OF THE STUDY The study aims to conduct a mid-term evaluation of results of the treatment of patellar fractures with multiple circular cerclage. MATERIAL AND METHODS The retrospective clinical study with its own group of patients who underwent surgery in our centre in the period from 2008 to 2014. The study included a total of 29 patients with displaced patellar fractures treated with multiple circular cerclage. The available radiographic documentation was assessed and the quality of perioperative reposition, fracture healing, loss of reposition and potential failure of osteosynthesis material was considered. During the clinical examination, the range of motion (ROM) of the operated knee was measured. The current pain was evaluated on the Visual Analogue Scale for Pain (VAS). For evaluation of functional outcomes, the KOOS and LEFS scoring systems were used. RESULTS A total of 27 fractures (93.1%) healed after a mean period of 10.3 weeks after the primary surgery. In 23 cases two circular loops and in six cases 3 loops were used. The mean follow-up period was 66.6 months (range 22-100). The mean duration of the surgery was 59.6 minutes with the mean length of the incision of 11.8 cm (range 9-15). The quality of reposition was evaluated as exact in 23 patients, as adequate in six patients. The mean extension and flexion was 0.2° and 135°, respectively. The individual mean KOOS scores were the following: pain 75.0, symptom 74.5, knee function in daily living 76.7, knee function in sports and recreational activities 48.1, quality of life 57.8. The mean LEFS score was 68.7. The mean VAS score was 2.4. Extraction of osteosynthesis material was done in a total of seventeen cases (58.6%) at a mean of 10 months after osteosynthesis (range 5-14). In altogether five cases (17.2%) the loss of reposition occurred. In two patients pseudoarthrosis developed. Osteosynthesis material failure was reported in two cases (6.9%). DISCUSSION In our study population, by using the technique of multiple circular cerclage 27 fractures (93.1%) healed. In two cases the fractures failed to heal and pseudoarthrosis developed. In one case it was due to non-adherence to the postoperative regimen by the patient. According to the literature, 15-30% of patients suffer from functional limitations. In our study population the mean values of extension and flexion were 0.2° and 135°, respectively. Compared to the group of 17 patellar fractures managed with the modified Pyrford technique where the mean extension and flexion was 0.5° and 131.1°, respectively. According to the data referred to in literature, in up to 80 % cases post-operative pain of anterior knee is reported. In our population the current pain was assessed on the VAS and the mean value of 2.4 was ascertained in comparison to the set of different ORIF surgical procedures and a partial patellectomy, when the final mean VAS score was 2.8. In our population the values of LEFS and KOOS scores are comparable to the values of populations where different surgical techniques were assessed. The post-operative loss of reposition in up to 20% cases is reported by the literature, compared to our population, where it was recorded in a total of 5 cases (17.2%). CONCLUSIONS Multiple circular cerclage is a simple and inexpensive surgical method for treating displaced patellar fractures. It can be used for majority of types of fracture, including comminuted fractures, in which, however, there is a slightly higher risk of loss of reposition. The functional outcomes and the number of complications are comparable to other surgical techniques used. Key words: displaced patellar fracture, multiple circular cerclage, functional outcomes.

[Long-Term Outcomes of the Treatment of Pediatric Femoral Shaft Fractures Treated with Bryant's Vertical Traction]. / Dlouhodobé výsledky lécby zlomenin diafýzy femuru u detí lécených Bryantovou vertikální trakcí.

PURPOSE OF THE STUDY The paper aimed to evaluate the long-term outcomes of the treatment of diaphyseal femur fractures in children treated with Bryant's vertical traction. Moreover, we also assessed the size of overgrowth in the injured femur. MATERIAL AND METHODS The study included 23 patients with 23 femoral shaft fractures treated with Bryant's vertical traction at our department in 2009-2014. The following parameters were assessed: sex, ïnjured side, weight, age, mechanism of injury, potential abuse, type of fracture, duration of traction, and total length of hospital stay. The healing time of the fracture was the same as the duration of traction. Also assessed was the size of femoral shortening after the removal of traction, the presence of skin complications in the course of treatment and potential development of compartment syndrome. At the mean follow-up of 47.8 months (range 22-85 months) from the date of injury the patients were evaluated clinically and radiologically for: length of limbs, presence of rotational deformity, range of motion of knee and hip joints, potential pain or limping, potential scoliosis of the spine and presence of scars after traction. Finally, through a questionnaire we learned about the opinions of parents as to the treatment method and about the possibility of home traction. RESULTS All the fractures healed. There was a total of 17 injured boys and 6 injured girls. Whereas 12 patients sustained a fracture of the left femur, 11 patients sustained a fracture of the right femur. The mean weight of patients at the time of injury was 13.9 kg (range 5-20 kg). The mean age at the time of traction was 30.8 months (range 1-70 months). The injury most frequently occurred from various falls, altogether in 15 cases (65.2%). Traffic accidents were registered as the cause of injury in 3 cases (13%). No abuse was confirmed. The average duration of traction was 19.8 days (range 8-26 days). The total length of hospital stay took on average 23.6 days (range 9-33 days). Skin excoriation and bullae due to irritation by the traction occurred in 21 children (91.3% cases). All the bullae healed, in 4 (17.4%) patients minor scars of 1x1 cm in size were formed around ankles. Not a single patient developed the compartment syndrome. The average femoral shortening after the removal of traction was 0.8 cm (range 0-2.3 cm). The follow-up examination, performed on average 47.8 months (range 22-85 months) from the date of injury revealed the average discrepancy of spinomalleolar distances in both the lower limps of 0 cm (range -1 to 1 cm). Radiographically measured lengths of both the femurs showed the average difference of 0 cm (range -1.4 to 0.9 cm). The resulting average overgrowth of injured femur was 0.9 cm (range 0.1 to 3.2 cm). Scoliosis of the spine was not reported in any of the patients. In 3 patients femur alignment demonstrated rotation, namely an external rotation of 10° in all the cases. All the children demonstrated full hip and knee joint mobility, identical to the uninjured side. After a heavy load one patient reported pain in the thigh and one walked with limp. The other patients showed no problems whatsoever. Treatment with the use of Bryant's traction was well tolerated by parents. Altogether 15 parents (65.2%) would opt for the same treatment method in case of a recurrent injury. The home traction option would be welcomed by 17 parents (73.9%). DISCUSSION The treatment by Bryant's vertical traction is condemned in Anglo-Saxon countries due to the risk for developing compartment syndrome, described in earlier studies. Neither our cohort, nor more recent studies reported the occurrence of compartment syndrome. The most frequent complication faced in our study was the skin complications underneath the traction, namely in a total of 91.3% of patients. In the literature, the other authors only make references to bullae occurrence, but do not provide any further specifications. Overgrowth after femoral shaft fractures is a very well described phenomenon. The size of femoral overgrowth described in our study was similar to that referred to in the available literature. A method frequently used abroad is the so-called home traction. This method, however, has so far failed to take root in our country, even though this therapeutic technique would be appreciated by parents. CONCLUSIONS The treatment of femoral shaft fractures by Bryant's vertical traction, in children up to the weight of 15 kg, is a simple and safe method with excellent functional outcomes and minimum serious complications. When treating the children with the body weight more than 15 kg, the risk of bullae formation increases, therefore in this weight category treatment shall be decided upon on a case by case basis. The resulting average overgrowth of injured femur was 0.9 cm which corresponds with the findings of other authors. The treatment method using the Bryant's traction is well tolerated by parents, even though most of them would welcome the option of home traction. Key words: traction, femur fracture, overgrowth, children.

[Peripheral Factures of the Talus. Mid-Term Results]. / Periferní zlomeniny talu ­ strednedobé výsledky operacní lécby.

PURPOSE OF THE STUDY Peripheral fractures of the talus (lateral talar process and posterior talar process) are rare injuries, easy to miss on examination due to their location and clinical manifestation. They account for 0.3% to 1.0% of all fractures of the talus. An incorrect or late treatment of talar process fractures can result in permanent pain, impingement syndrome, healing in malposition, pseudoarthrosis development and also, due to joint instability, in a potential development of severe subtalar arthritis. The aim of this retrospective study was to evaluate the results of surgical management of these fractures in our department. MATERIAL AND METHODS The study included 14 adult patients with fractures of the peripheral talar processes who met the criteria of the retrospective study and were treated in our department between 2008 and 2014. All patients underwent clinical examination with evaluation based on the AOFAS Ankle-Hindfoot score, VAS score and radiographic evidence of arthritis. Follow-up ranged from 24 to 95 months. The average age of the patients at the time of surgery was 34 years (range, 21-59 years); there was one woman and 13 men. All underwent pre-operative CT scanning. The surgical procedure included open reduction and internal fixation (ORIF) which, in indicated cases, was preceded by partial or total removal of the processes. RESULTS Of the 14 patients, seven were treated for fractures of the lateral talar process (LTP group) and seven for the posterior talar process (PTP group). All fractures healed completely. The median AOFAS score was 87 (72-100) points in the LTP group, and 84 (58-100) points in the PTP group. Excellent and good results on the AOFAS Ankle-Hindfoot scale were achieved in 10 (72%), satisfactory in two (14%) and poor in two (14%) patients. Of the LTP group, six patients (86%) showed the VAS score ≤ 3, and one (14%) had the VAS score = 4. In the PTP group, the VAS score ≤ 3 was reported by three (43%) and values of up to 5 by four (57%) patients. Arthritis in the talocrural and subtalar joints was evaluated as zero or grade 1 in 11 (79%) of all patients; of these 11 patients only two (14%) had a VAS score higher than 3. Only one patient had marginal wound necrosis; no deep wound infection was recorded. DISCUSSION The majority of fractures in our group were due to falls from a height or traffic accidents, which is in accordance with the literature data. In about 70% of these injuries, more parts of the leg are affected and, therefore, a thorough medical inspection is necessary. These mechanisms of injury most frequently produce type II LTP fracture (Hawkins classification). Four patients with a LTP fracture, who had the process partially removed, achieved good results on the AOFAS scale and the VAS score less than or equal to 3. As also published in the literature, the removal of small fragments has no crucial effect on ankle stability. CONSLUSIONS An adequate surgical treatment of displaced peripheral fractures of the talar processes provides good functional outcomes. In fractures with associated leg injuries or high-energy traumata, the prognosis is poorer. Fractures of talar processes often show symptoms and signs similar to those of more serious forms of dislocation of the talus and therefore a careful assessment of standard X-ray images taken for a "swollen ankle" is necessary. If the findings are not clear, CT examination is indicated. Key words: fracture, talus, processus lateralis tali, processus posterior tali.

[Long-term results of nailing of extra-articular proximal humerus fractures]. / Dlouhodobé výsledky hrebování extraartikulárních zlomenin proximálního humeru.

PURPOSE OF THE STUDY To evaluate the long-term results of intramedullary nailing of extra-articular proximal humerus fractures. MATERIAL AND METHODS Thirty-six patients with 36 extra-articular fractures, types 11-A2 and 11-A3, treated by intramedullary nailing were reassessed after an average follow-up of 54 (30-86) months. The group included five type 11-A2 and 31 type 11-A3 fractures according to the AO/OTA classification. Radiographic and clinical outcomes - the absolute Constant score (CSabs) and the relative Constant score (compared to the contralateral side, CSrel) were evaluated. The rate of complications was assessed. RESULTS All fractures healed. The mean long-term CSabs was 73 pts, the mean CSrel was 89% of the unaffected side. Thirty (83%) patients achieved excellent or good results (CSrel higher than 80%), four (11%) had satisfactory and two patients (5.5%) had poor results (CSrel less than 60%). No significant difference was observed in functional results between different age groups. No non-union, loss of reduction or deep infection was encountered. Two cases of prolonged healing were observed, one implant-related complication happened due to locking screw breakage. Conclusion Nailing can be recommended for the safe treatment of extra-articular fractures of the proximal humerus. If the procedure is performed properly, the possibility of excellent functional results is high and the rate of complications is minimal. Age does not influence the final functional result. Key words: proximal humerus, extra-articular fractures, intramedullary nail, long-term results.

Internal fixation of fractures of the proximal humerus with the MultiLoc nail.

OBJECTIVE: Anatomical reduction of two- to four-part fractures of the proximal humerus using indirect reduction techniques. Intramedullary fixation with a short humerus nail. Restoration of a stable bone-implant construct that enables early functional after-treatment. INDICATIONS: Displaced and unstable two- to four-part fractures of the proximal humerus. Fractures of the proximal humerus extending in the humeral diaphysis (use a long nail). Ipsilateral combined lesions of the proximal humerus and the humeral diaphysis (use a long nail). CONTRAINDICATIONS: Poor physical and/or mental status. Critical soft tissue conditions in the area near the surgical site. Local soft tissue infection. Pre-existing severe osteoarthritis of the shoulder joint; severe shoulder stiffness. Head-split fractures of the humerus head that cannot be reduced. SURGICAL TECHNIQUE: Exposure of the fracture using an anterior acromial approach and determination of the correct nail entrance point. Anatomic fracture reduction using indirect reduction techniques. Stable fixation using an intramedullary MultiLoc® nail. Determination of the proximal locking configuration depending on the fracture morphology. Distal locking with angle-stable option. POST-OPERATIVE TREATMENT: Post-operative radiographs for documentation of the surgical result and implant position. Use of an arm sling for 7-10 days. Active and passive exercises of the shoulder joint starting on day 1. Shoulder abduction limited to 60° for 2 weeks. Subsequent abduction to 90° until the 4th week. Subsequent active mobilisation without restrictions. Weight bearing and sporting activities after 3 months. Radiological evaluation after 2, 6 and 12 weeks. RESULTS: During a 6-month period, 160 patients were documented in a prospective clinical multicentre study. According to the AO classification, there were 36% A-type fractures, 41% B- and 23% C-type injuries. A 6-month follow-up was available for 17 patients. The mean age of these patients was 67 years. One patient had an A-type fracture. There were ten B- and six C-type fractures. At the time of follow-up, the mean Constant score was 66 points. Radiographically, all fractures had healed. Intra-articular screw penetration and loss of reduction were both observed once.

[AO type 13-C distal humerus fractures. Results of surgical treatment]. / Zlomeniny distálního humeru AO 13 C - výsledky operacní lécby.

PURPOSE OF THE STUDY: The aim of this retrospective study was to evaluate the results of surgical treatment in 41 fractures of the distal humerus classified as type C according to the AO system using conventional versus angle-stable locking plates. MATERIAL: Fifty-one patients were treated by the open reduction and internal fixation method at our department between 2005 and 2008. The group included 28 women and 23 men with an average age of 52.5 years. Forty-one patients came to the final treatment evaluation. The average follow-up was 19 months. Of the 41 injuries, 34% were open fractures. METHODS: All patients were operated on from the standard dorsal approach. Olecranon osteotomy was performed in 83% and the Bryan-Morrey procedure was used in 17% of the patients. Stable osteosynthesis with two reconstruction plates was used in 14 patients (34%), two locking distal humeral plates (DHP) in 21 patients (51%) and a reconstruction plate combined with a DHP was employed in six patients (15%).Controlled early passive rehabilitation was started as soon as acute pain after surgery had resolved. Follow-up at 4, 8 and 12 weeks and at 6 and 12 months included clinical and radiographic examination. The functional outcome was assessed using the Mayo Elbow Performance Score (MEPS) system. RESULTS: The average MEPS was 83.6 points. Excellent results were recorded in 19 (46%), good in 14 (34%), satisfactory in five (12%) and poor in three (8%) patients. Healing was achieved within 3 months of surgery in 82% and within 4 months in 12% of the patients. Non-union due to failure of osteosynthesis was recorded in 5 % of the patients. No differences were found in the duration of healing in relation to the implant used. The average flexion/extension range of motion (ROM) at the elbow was 108 degrees (range, 40 to 145 degrees). The complications included failure of osteosynthesis in three patients, deep wound infection in two, superficial infection in one and heterotopic ossification in five patients. Of 16 patients (39%) with ulnar nerve irritation, 15 had impairment in sensory function and one in motor function. The average operative time was 163 min. DISCUSSION: The results of our study correspond to relevant data reported in the present-day literature. There is an agreement in excellent and good functional outcomes, as assessed using the MEPS, in ROM values and operative time as well as in complications such as non-union, infection or heterotopic ossification. Compared with other studies, the proportion of ulnar nerve irritation in our group was higher. As reported, excellent results are achieved with the use of locking compression plates, particularly in comminuted fractures of the distal humerus in osteoporotic bone. CONCLUSIONS: The method of open reduction and internal fixation with two plates performed by an experienced surgeon brings about good results in the treatment of AO type C fractures of the distal humerus.

Self-inhibition in Ca2+ -evoked taste responses: a novel tool for functional dissection of salt taste transduction mechanisms.

Rat chorda tympani (CT) responses to CaCl2 were obtained during simultaneous current and voltage clamping of the lingual receptive field. Unlike most other salts, CaCl2 induced negatively directed transepithelial potentials and gave CT responses that were auto-inhibitory beyond a critical concentration. CT responses increased in a dose-dependent manner to approximately 0.3 M, whereafter they decreased with increasing concentration. At concentrations where Ca2+ was self-inhibitory, it also inhibited responses to NaCl, KCl, and NH4Cl present in mixtures with CaCl2. Ca2+ completely blocked the amiloride-insensitive component of the NaCl CT response, the entire KCl-evoked CT response, and the high-concentration-domain CT responses of NH4Cl (>/=0.3 M). The overlapping Ca2+-sensitivity between the responses of the three Cl- salts (Na+, K+, and NH+4) suggests a common, Ca2+-sensitive, transduction pathway. Extracellular Ca2+ has been shown to modulate the paracellular pathways in different epithelial cell lines by decreasing the water permeability and cation conductance of tight junctions. Ca2+-induced modulation of tight junctions is associated with Ca2+ binding to fixed negative sites. This results in a conversion of ion selectivity from cationic to anionic, which we also observed in our system through simultaneous monitoring of the transepithelial potential during CT recording. The data indicate the paracellular pathway as the stimulatory and modulatory site of CaCl2 taste responses. In addition, they indicate that important transduction sites for NaCl, KCl, and NH4Cl taste reception are accessible only through the paracellular pathways. More generally, they show that modulation of paracellular transport by Ca2+ in an intact epithelium has functional consequences at a systemic level.

Chorda tympani responses under lingual voltage clamp: implications for NH4 salt taste transduction.

Rat chorda tympani (CT) responses to NH4Cl, ammonium acetate (NH4Ac), and ammonium hippurate (NH4Hp) were obtained during simultaneous current and voltage clamping of the lingual field potential. Although functional and developmental similarities for gustation have been reported for NH4+ and K+ salts, we report here that significant differences are discernible in the CT responses to both salts. Unlike neural responses to KCl, those to NH4Cl are voltage sensitive, enhanced by submucosa negative and suppressed by positive voltage clamp. In this regard, NH4Cl responses are qualitatively similar to NaCl responses; however, the magnitude of NH4Cl voltage sensitivity is significantly less than that of NaCl. The concentration dependence of the CT response to NH4Cl manifests a biphasic nonlinear relationship not observed with KCl or NaCl. Below 0.3 M, the CT response increases as if to approach a saturation value. However, beyond 0.3 M an inflection appears in the CT-concentration curve because of an abrupt increase in CT responses. This kinetic profile is Cl-dependent and is correlated with an increase in transepithelial conductance that displays similar NH4Cl concentration dependence. The biphasic relation to salt concentration is not observed when acetate or hippurate is substituted for Cl-. As with Na+ and K+ salts, less mobile anions than Cl- (Ac- and Hp-) lower the CT responses. However, like Na+ salts, but in contrast to K+ salts, the onset kinetics of CT responses to NH4Ac or NH4Hp remained rapid, even under positive voltage-clamp conditions. Amiloride (100 microM) partially suppresses CT responses within the concentration range of 0.05-0.3 M (48-20% suppression). Amiloride also suppresses the voltage sensitivity of NH4Cl CT responses, but does not eliminate the sensitivity as it does for Na+ salts. In conclusion, the data suggest that taste transduction for NH4 salts is mediated over two NH+ conduction pathways in the taste bud. This is especially evident with NH4Cl, where the CT-concentration curves show two distinct kinetic regimes. Below 0.3 M the saturation with increasing concentration, clamp voltage response dependence, and amiloride sensitivity suggest an apical membrane transduction conductance. Above 0.3 M, the high anion dependence of the response and its amiloride insensitivity indicate participation of the paracellular pathway in transduction.