The evolving role of radiofrequency ablation therapy of breast lesions.

BACKGROUND: The potential for radiofrequency ablation (RFA) therapy is an area of increasing interest in the context of breast conserving therapy for breast cancer. This non surgical technique potentially provides a non invasive, cosmetically pleasing result that is preferable to surgeon and patient. MATERIALS AND METHODS: A literature review was carried out facilitated by PubMed and Medline databases. Cross referencing of the obtained articles was used to identify other relevant studies. A total of 17 studies were reviewed. RESULTS: RFA is emerging as a promising treatment for breast cancer. Pilot and phase II studies have shown RFA to be effective at ablation with few complications or adverse effects experienced by patients. However, complete ablation of tumours is still not achieved in all patients. CONCLUSION: RFA represents a promising therapeutic modality for breast lesions. However, there is a clear need for further research and refinement of the procedure before it can be offered as a therapeutic alternative to surgical excision for operable breast cancer.

[Jones fracture.]. / Jonesova zlomenina.

The authors deal with the issues of traumatology of proximal part of 5th metatarsus and evaluate their experience in the treatment of a specific type of fracture in this region, i.e. the Jones fracture. From the anatomical and biomechanical viewpoints they classify the fractures into fractures of diaphysis, extra-articular fractures of proximal metadiaphysis - i.e. the actual Jones fractures - and intra-articular avulsion fractures of the base. While the fractures of diaphysis may be successfully treated using walking plaster cast for 4 to 6 weeks and in case of auvulsion fractures of the base for 3 to 5 weeks (they may be treated also without rigid fixation), the treatment of metadiaphyseal fractures still poses a problem. The latter group the authors subdivide (not only with regard to the method of treatment) after Torg et al (1984) into acute type of Jones fracture, delayed healing or refracture in chronic complaints of patients and the actual typical stress fracture with a developed non-union. In the first case of acute fracture non-walking plaster cast for the period of 6 to 8 weeks is recommended. In case the period of fixation without weight-bearing was observed the authors recorded in their study no nonunion necessitating a surgical treatment. In delayed healing or re-fractures it was often necessary to prolong the cast plaster immobilization. As a result they recommend in case of physically active patients and professional sportsmen to choose surgical treatment. In case of clinically and radiographically evident non-union with the nature of fatigue fracture they indicate surgical treatment in all cases. The operation consists in decortication, local wide resection of non-union, excochleation of residual fibrous mass and implantation of autologous cortico-cancellous bone graft and with cancellous bone onlaygraft. For fixation they use a simple but stable tension wire loop without further fixation by plaster cast. The evaluation of results of the surgical treatment shows that in all cases clinical asymptomatic healing was achieved in 3 to 6 months (on average 4 months). There was only one case of dehiscence of the wound and irritation by migrated K-wire. After immediate extraction the wound healed without further coplications. Key words: Jones fracture, non-union of 5th metatarsus, stress fracture of 5th metatarsus, extraarticular fracture of 5th metatarsus, fixation of the fracture of 5th metatarsus.

[Internal Fixation of Sacro-iliac Joint in Unstable Fractures of the Pelvic Ring.]. / Osteosyntéza sakroilického kloubu u nestabilních zlomenin pánevního kruhu.

Unstable fractures of the pelvic ring are always serious injuries posing problems from many aspects. Among the most serious are definitely unstable fractures of the pelvic ring with both vertical and rotational instability, i. e. type C fractures according to AO classification scheme. The recent therapeutic concept recommends in case of these fractures an active reconstruction on the dorsal SI complex which evidently improves the final perspective of patients with such a severe injury. The author presents his own clinical experience and literary data relating to the treatment of 11 patients who underwent reconstruction in the region of dorsal sacro-iliac complex due to type C unstable fracture. Clinical results achieved on the basis of the evaluation of a group of 11 patients are favourable and promising despite a significant complexity of the problems of unstable pelvic fractures. In 9 patients the anatomical result on radiograph was excellent, 9 patients regained full mobility after the proper physiotherapy, 10 patients resumed their work and 6 patients resumed even professional sports activity. In the conclusion the author states that in suitable, mainly young and fully stabilized patients the reconstruction surgery on the dorsal pelvic SI segment is fully justified which is documented both by the literary data and his own experience. Key words: unstable pelvic fractures.

[Osteosynthesis by means of a corrugated splint.]. / Osteosyntéza vlnitou dlahou.

The authors submitted the clinical results of an investigation of 43 patients where in 1986 - 1995 at the Orthopaedic Clinic of the Institute for Postgraduate Training in Prague, Bulovka osteosynthesis by means of a corrugated splint was implemented. The predominating part of the patients was formed by men - 29 (67 %), women 14 (33 %). The mean age of the patients at the time of osteosynthesis war 36.7 years (12-77 years). The time interval between primary osteosynthesis and osteosynthesis by means of a corrugated splint was on average 23 months (4 - 65 months). The mean total period of treatment, i. e. the time from primary osteosynthesis to complete cure after osteosynthesis with the corrugated splint was 35.2 months (9 - 74 months). The primary diagnosis was in the majority of patients comminutive diaphyseal fracture of the femur - 39 times (91 %), in 32 instances (77 %) closed, 7 times open (14 %). In 4 instances the corrugated splint was used when osteosynthesis of prolonged femurs failed. The major part of patients did not have, before ostesynthesis with a corrugated splint, more than 1-2 operations (31 patients, i. e. 72 %). There were, however, also patients with five to six operations. Osteosynthesis with a corrugated splint was indicated mainly on account of the diagnosis of pseudoarthrosis of the femur (18 times, i. e. 42 %), splitting of the splint with refracture of the femur 22 times, i. e. 51 %. In one third of the patients (15, i. e. 34 %) the osteosynthesis with a corrugated splint was supplemented by compression, always in case of the diagnosis of hypertrophic pseudoarthrosis of the femur. In the final clinical evaluation 40 patients were included. As to complications, in particular failure of the corrugated splint was investigated. The authors recorded four cases (9 %). In these patients re-osteosynthesis with a corrugated splint was performed and after that after the usual intervals cure of the complication occured. The mean period of recovery in the investigated group of patients was 6.9 months (3-15 months). The authors evaluated also the difference in time between osteosynthesis with a corrugated splint with compression and without compression. The difference between the mean time of recovery in osteosynthesis with compression (6.1 months) and without compression (7.2 months) was 1.1 months. The authors conclude that compression in osteosynthesis with a corrugated splint is not the dominating factor for healing of the osteosynthesis. They evaluate osteosynthesis with a corrugated splint as a safe and reliable method suitable in particular for diaphyseal pseudoarthroses or in failure or failing osteosynthesis in the diaphyseal area of the femur. Key words: plate osteosynthesis, ostheosynthesis of femur.

[The role of osteotomy in the treatment of pseudoarthroses.]. / Uloha osteotomie v lécbe pakloubu

Osteotomies in the area of pseudoarthroses ensue from the necessity to correct biomechanical conditions at these sites. Depending on the site of osteotomy, we speak of intrafocal osteotomies, i. e. wedge-shaped resection (total or partial) of the pseudoarthrosis. The second type of osteotomy is transfocal osteotomy which is normal to the longitudinal axis of each fragment. The third type is parafocal osteotomy which is several centimeters from the pseudoarthrosis and the correction of biomechanical conditions is implemented in this osteotomy. The implementation of osteotomy markedly facilitates the procedure and shortens the time of operation. Healing of the pseudoarthrosis after osteotomy takes on average 5 months, of the osteotomy 7 months. The authors evaluate a group of 27 patients operated in 1982-1995. In all patients the pseudoarthrosis was cured. Key words: osteotomy, treatment of pseudoarthroses.

[Osteosynthesis by Unreamed Interlocking Nail UTN of the Tibial Shaft Fractures Caused by High Energy Injuries.]. / Osteosyntéza nepredvrtaným hrebem UTN zlomenin diafýzy bérce zpusobených velkou energií poranení

The authors present their own two-year experience with osteosynthesis of 54 fractures of the diaphysis of the leg in 51 patients, using a UTN nail without predrilling, at the Orthopaedic Clinic of the Institute for Postgraduate Medical Training in Prague Bulovka Hospital. After a one-year interval they included in the group 28 complicated fractures of the leg in 26 patients where the fractures were caused by a high energy impact. In nine instances (34.6 %) the fracture was in a polytraumatized patient and in eight patients (50,8 %) with multiple injuries. There were 14.3 % grade 1 open fractures (four fractures) and 21.4 % (four fractures) were grade 2 fractures. The other fractures were closed with major soft tissue contusion. In 11 instances (42.9 %) a secondary operation had to be performed: in 9 instances dynamization, in one instance a supplementary spongioplasty, in one case dynamization combined with osteotomy of the fibula and in one instance a rotational malposition was corrected. In three cases UTN osteosynthesis was supplemented by plaster fixation. Full burdening was possible after an average period of three months. Healing was recorded after an average period of 6.4 months, i.e after 27.7 weeks. As to complications, in one instance an infection was recorded, three times instability of the short proximal fragment, twice Sudeck's algoneurodystrophy, twice neurological complications and once a dry dermal necrosis at the site of the surgical wound. The authors did not record thromboembolic disease or compartment syndrome. As to subjective symptoms oedema and intermittent pain on burdenig were most frequent (32.1 %). Fracture of the nail did not occur. Breaking of the supporting screws was found in 17.9 % (20 screws). In the investigated group of patients the authors evaluated the results in 21 patients (80.8 %) as excellent or good. Satisfactory results were recorded in 11.5 % (3 patients). Unsatisfactory results were recorded in two patients (7.7 %) where surgical revision was necessary because of infection and fifteen degree valgus malposition. In the discussion the authors compare their results with patient groups selected according to similar criteria and they confirm the conclusions of indication of UTN in all fractures of the diaphysis of the leg caused by high energy of violence, incl. grade 1 and 2 open fractures according to Gustil's classification. Key words: unreamed interlocking nailing of the tibial shaft fractures, UTN, fractures of the tibial shaft caused by high energy injury.

[Initial experience with the treatment of diaphyseal fractures of the leg by an intramedullary nail.]. / První zkusenosti s lécením diafyzárních zlomenin bérce nepredvrtávaným zajisteným hrebem.

The authors present an account on their clinical experience with the treatment of diaphyseal fractures of the leg using an intramedullary nail not drilled in advance. During the period between May 1994 and August 1995 they treated at the Orthopaedic Clinic of IPVZ in Prague Bulovka hospital a total of 28 patients, 22 men and 6 women, mean age 36 years, follow up period six months. The final clinical evaluation comprised 26 patients with 27 fractures. In 93% the authors recorded complete cure of the fracture of the leg, on average within five months after operation. The group of patients comprised 7 (25%) patients with multiple injuries and 5 (17%) with open fractures of the crus. According to the AO classification of skeletal injuries type B fractures were most frequent -18 (64%). The operation was implemented on average on the seventh day after the accident. In 8 (28%) the authors recorded bending or breaking of the nails, in all instances without any effect on the healing of the fracture. As to local complications the authors recorded four times instability of the nail -three times proximal and once distal instability. The position was successfully managed in all instances by application of a plaster bandage of the Sarmient type. There was only one typical deep infection. The final clinical evaluation was made in 26 patients, where minimal axial deviations were found, minimal restructions as regards the mobility of the knee or talar joint, and the majority of patients were satisfied with the operation. Initial experience with treatment of diaphyseal fractures of the leg using an intramedullary nail without previous drilling revealed a high percentage of completely healed fractures with a minimal number of local or systemic complications. Key word: intramedullary nailing without previous drilling.

[Osteosynthesis of fractures of the ulnar olecranon.]. / Osteosyntéza zlomenin olekranonu ulny.

The problem of fractures of the ulnar olecranon has been, due to the relatively frequent incidence and character of the injury, dealt with for more than 100 years. Various types of osteosynthesis are recently the subject of investigations published in experimental studies. Due to the not quite uniform conclusions of this work the authors processed and evaluated in a retrospective study a group of patients treated at the Orthopaedic Clinic of the Institute of Postgraduate Medical Training, Bulovka Hospital in 1984-1993. In the course of these ten years 70 patients with 71 fractures were treated. The group comprised a total of 29 patients with 30 fractures. In four instances an open fracture was involved. On operation in half the patients major or minor comminution was found. In 23 patients the authors treated the fracture by traction AO cerclage which they supplemented in another seven cases by accessory osteosynthetic material. Twenty-eight fractures, i. e. 93% healed. Excellent and good results were recorded in 83%.The most frequent complications comprised irritation by Kirschner wires (20%), which were the cause of their early removal. Osteosynthesis failed in one instance. Reosteosynthesis was indicated and the result was good. A deep infection was treated in one instance (3.3%). The method of treatment of dislocated fractures of the ulnar olecranon by means of AO traction cerclage is sufficiently stable even when a minimum of osteosynthetic material is used while respecting requirements of biological osteosynthesis. Due to frequent comminution is must be sometimes supplemented by more screws or wires or for a short time by additional plaster fixation. The patients recover and can resume work usually within three months after surgery. Key words: fracture of ulnar olecranon, AO traction cerclage.

[Treatment of acetabular fractures. 1. Indications for surgical approaches]. / Lécení zlomenin acetabula. 1. cást: Indikace operacních prístupu.

The results of surgical treatment of fractures of the acetabulum depend on the selection of the surgical approach. Therefore the authors focused their attention on the surgical approaches which are best known and used most frequently at present. They present a review and brief characteristic of different surgical approaches. On a group of 70 fractures in the region of the acetabulum they demonstrate their own practical experience with the application of different approaches. Based on their experiences and analysis of data reported in the literature, they submit indications of these approaches when dealing with actual traumatological situations in the region of the injured acetabulum.

[Results of surgical treatment of dislocation fractures of the ankle joint]. / Výsledky operacního lécení luxacních zlomenin hlezna.

The authors have made evaluation of the surgical treatment of luxation fractures of the ankle in the period 1979-1987 in 105 patients (60 female, 45 male patients) in the age range from seventeen to eighty-one years, with the most frequent representation of the age group ranging from thirty-five to forty-five years. The group comprised 2,70 percent of fractures of type Weber A, 31.53 percent of fractures of type Weber B and 65.77 percent of fractures of type Weber C. 53 percent of patients were operated on the day of injury, 24.8 percent of patients were transferred with a delay from other clinics and in the rest of the patients the timely operation was contraindicated because of the poor local or general condition. The results were processed according to a uniform worksheet by the computer. On the basis of the evaluation there were found out 87.62 percent of successful and 12.38 percent of poor results. 93.3 percent of patients resumed their original jobs and there was no patient eligible for a full disability pension. The main cause of failure was the osteoarthritis of the ankle joint found out in connection with the inaffestable factors (such as defects of cartilage, nature of the bone lesion, luxation of talus, age and sex of the patient) and affectable factors (infection, failure of osteosynthesis, pseudoarthrosis of medial malleolus, non-anatomical position in the area of tibiofibular syndesmosis). The incidence of these negative factors may be reduced by a timely operation, precise surgical strategy and technique and proper post-operative treatment.

[Compartment syndrome in fractures of the shin]. / Kompartment syndrom pri zlomeninách bérce.

Compartment syndrome represents the most serious complication in the treatment of the fractures of the shin. In the period 1979-1987 17 patients with variously developed form of the compartment syndrome were treated at the Orthopaedic clinic of the Institute for In-service Education of Physicians. 7 patients, i. e. 40 per cent were transported from other clinics. There were 8 open fractures in the group, i. e. 47 per cent, and they were classified according to Allgöwer. All patients were primarily operated on for the fracture of the shin and the compartment syndrome occurred in 11 cases after plate osteosynthesis and in 6 cases as a result of the implementation of an external fixation device. Early fasciotomy in the interval up to two hours after the manifestation of the syndrome was done only in two patients, in three cases fasciotomy was not done at all. From the viewpoint of the types of decompression bilateral incision was done in five cases and parafibular decompression in 7 cases. Restitutio ad integrum after the syndrome does not exist. Results of the treatment range from the healing with the defect of soft tissues to the amputation which was performed in two patients. In the evaluation of surgical errors resulting in the development of the syndrome primary closure of operational wound ranks the first place. In the evaluation of the general biological condition of the organism in 66 per cent polyglobulia and hypalbuminemy were found as an expression of a poor biological condition of the organism and chronic hypoxy. The necessity was stressed of the evaluation of the condition of soft tissues and their contamination and their adequate treatment. The possibility was pointed out of hyperbaric oxygenation as a still neglected component of the causal therapy.