5th Metatarsal Jones Fracture - To Treat Conservatively, or Surgically Using Headless Double-Threaded Herbert Screw?

PURPOSE OF THE STUDY Fifth metatarsal fractures, in particular so-called Jones fractures, are relatively common injuries both in the general population and athletes. Although discussions about whether the surgical or conservative solution should be preferred are ongoing for decades, there is no clear consensus. Here, we aimed to prospectively compare the results of osteosynthesis using the Herbert screw with the conservative solution in patients from our department. MATERIAL AND METHODS Patients 18-50 years presenting to our department with Jones fracture and meeting further inclusion/exclusion criteria were offered participation in the study. Those willing to participate signed informed consent and were randomized by flipping the coin into surgically and conservatively treated groups. After six and twelve weeks, X-ray was performed in each patient and AOFAS score was determined. Conservatively treated patients who showed no signs of healing and whose AOFAS was below 80 after six weeks were offered surgery again. RESULTS Of 24 patients in total, 15 were assigned to the surgically treated group and nine were treated conservatively. After six weeks, AOFAS score of all but two patients (86%) in the surgically treated group ranged between 97 and 100, while this score exceeded 90 points only in three patients (33%) from the conservatively treated group. On X-ray, successful healing after six weeks was observed in seven patients (47%) from the surgically treated group but in none of the patients from the conservatively treated group. Three out of five patients in the conservative group whose AOFAS was below 80 after six weeks opted for surgery at that time and all improved significantly by the twelfth week. DISCUSSION Although studies on surgical treatment of Jones fracture using various screws or plates are not rare, we present an uncommon method of surgical treatment of this injury - the use of the Herbert screw. The results of this method are excellent and even on a relatively small sample yielded statistically significantly better results than conservative treatment. Moreover, the surgical treatment facilitated early loading of the injured limb, which allows an earlier return of the patients to normal life. CONCLUSIONS Osteosynthesis using Herbert screw in Jones fracture yielded significantly better results than conservative treatment. Key words: Jones fracture, AOFAS, Herbert screw, 5th metatarsal fracture, surgical treatment.

[Comparison of Two Minimally Invasive Osteosynthesis Techniques for Radial Head Fractures in Paediatric Patients]. / Porovnání dvou metod miniinvazivní osteosyntézy u zlomenin hlavicky vretenní kosti u detí.

PURPOSE OF THE STUDY Radial head fractures in paediatric patients account for 5-19% of all elbow injuries and approximately 1% of all fractures in children. Non-displaced fractures are treated with plaster cast fixation. If the fracture is displaced, we proceed to closed reduction, or to osteosynthesis in case of unstable fragments. If closed reduction fails, we opt for open reduction and osteosynthesis. The prospective randomised clinical study aims to compare the two methods of minimally invasive osteosynthesis using the pre-bent Kirschner wire or Prévot nail and to identify differences between them. MATERIAL AND METHODS The prospective randomised clinical study was conducted in 2015-2019. The final cohort included 32 patients who met the inclusion criteria. The patients in whom other osteosynthesis implants had been used or in whom open reduction had to be performed were excluded from the study. Also excluded were the patients with serious concomitant injuries of elbow. For patients included in the cohort, demographic data, precise evaluation of the displacement and location of the fracture as well as the duration of plaster cast fixation and osteosynthesis implants used were recorded. In the clinical part, the methods were compared based on the achievement of full range of motion in dependence on the degree of original displacement, use of osteosynthesis implant, and occurrence of early and delayed complications. Clinical and radiological outcomes were compared. In both types of minimally invasive osteosynthesis, Métaizeau surgical technique was used. RESULTS Based on the clinical trial criteria, 26 (81%) excellent, 4 (13%) good and 2 (6%) acceptable outcomes were achieved. In 3 cases the loss of rotation was up to 20°, in 1 case the loss of flexion was up to 10°. In one patient the loss of flexion was 15° and rotation up to 30°. In another patient the loss of rotation was up to 40°. The radiological assessment showed 14 (44%) excellent outcomes, 15 good (47%) and 3 (9%) acceptable outcomes. The statistical analysis of both the groups of the cohort using non-parametric tests revealed no statistically significant differences in individual demographic parameters. The comparisons of both types of osteosynthesis in dependence on the degree of displacement by non-parametric Fisher's exact test showed no statistically significant difference in the radiologic or clinical results. The only statistically significant difference was observed in the duration of metal implant placement. DISCUSSION Comparable studies report excellent or good clinical outcomes in 80-95% of cases (1,13,16). In our cohort, excellent or good clinical outcomes were achieved in 30 patients (94%). In two patients, in whom Prévot nail was used, the outcomes were acceptable. Nonetheless, this fact did not result in any statistical significance when comparing the two methods separately or in comparisons based on the degree of displacement. CONCLUSIONS The comparison of the two methods of minimally invasive osteosynthesis revealed no statistically significant difference, namely not even when both the methods were compared based on the degree of displacement. When Kirschner wire is used, the possibility to remove the metal implant in the outpatient setting is considered to be an advantage. The drawback consists in potential penetration of the sharp Kirschner wire in the radiocapitellar joint, which we did not encounter when the second technique of osteosynthesis was used. The advantage of Prévot nail includes a lower risk of pin-tract infection. Key words: minimally invasive osteosynthesis, radial head, fracture, child.

Conservative versus surgical treatment of displaced midshaft clavicle fracture in adolescents.

INTRODUCTION: Midshaft clavicle fractures are common in childhood and their conservative treatment predominates. The indication for surgical treatment of adolescents with significantly displaced fractures remains controversial. The aim of this study was to compare the results of conservative or surgical treatment (intramedullary nailing) of these fractures. METHODS: Retrospective clinical study of patients aged 1117 years with significantly displaced clavicle fractures treated at the Department of Pediatric Surgery and Traumatology, University Hospital Hradec Králové in 20112020. RESULTS: In this period, 696 patients with a clavicle fracture (excluding neonatal fractures) were treated. Of these, only 90 (13%) adolescent patients had significantly displaced diaphyseal fractures. Conservative approach was adopted in 52 (58%) of them; the remaining patients underwent a surgical procedure, while an intramedullary inserted and fixed titanium nail (TEN) was used in 20 (22%) cases. Supportive fixation was necessary in 4 of the operated patients. The duration of supportive fixation (basic therapeutic procedure for conservative treatment) was significantly shorter in operated patients (18 vs. 29 days, p=0.0001). No statistically significant difference was found in terms of the time interval of complete healing and return to full activity (74 vs. 85 days, p=0.051). There was one complication in the healing of the surgical wound; all patients healed without sequelae. CONCLUSION: According to the study, intramedullary osteosynthesis using a fixed titanium nail reduced the need for supportive fixation and allowed to shorten its time. Overall cosmetic and functional results were comparable to the conservative procedure. Therefore, this method can be recommended, especially for active adolescents.

Management of ileocolic intussusception in the Czech Republic.

INTRODUCTION: Ileocolic intussusception is one of the most frequent causes of acute abdomen in infants and toddlers. The purpose of this study was to evaluate the treatment of ileocolic intussusception in the Czech Republic in 2019. METHODS: Fourteen departments of paediatric surgery participated in this multicentre retrospective study. A SurveyMonkey Inc. questionnaire was used for anonymous data collection of patients with ileocolic intussusception. RESULTS: In 2019, ileocolic intussusception was diagnosed in 162 patients; median age was 30 months (3 months to 9.5 years). Contrast enema was indicated in 133 patients, primary surgery in 14 patients and spontaneous reduction was found in 15 patients. All departments using contrast enema had a success rate of 89.5%; 12 departments approached the contrast enema procedure under general anaesthesia (including myorelaxation at 7 departments) and 2 departments under sedation. Contrast enema under general anaesthesia with/without myorelaxation was significantly more successful than contrast enema under sedation (108/113, 95.6% vs 11/20, 55%; p.

Foreign body ingestion in children.

INTRODUCTION: Evaluation of results of the group of paediatric patients treated for swallowed foreign bodies in the digestive tract. METHODS: Retrospective analysis of patients treated for foreign bodies in the digestive tract, managed at the University Hospital of Hradec Králové between 2011-2018. RESULTS: 365 patients (182 boys, 183 girls) with a foreign body in the digestive tract have been evaluated. The mean age was 2.4 years. Most of the children were treated as outpatients (280 children, 76.7%) and only 85 children (23.3%) were hospitalized. The most commonly swallowed frequent bodies included coins (26%) and batteries (14.5%); sharp objects occurred in 5.2%. Unusual foreign bodies were noticed, too. We can mention for example a pen or a plant nutrition product. In 302 cases (82.7%) the foreign bodies passed easily per vias naturales. Endoscopy was necessary in 63 cases (17.2%) - in 51 children the object had to be removed from the oesophagus and in 12 children the object had to be removed from the stomach. None of the swallowed bodies caused complications such as digestive tract perforation or bowel obstruction. No patient in the group was indicated for laparotomy to remove the foreign body. CONCLUSION: Foreign bodies entrapped in the oesophagus have to be removed endoscopically. In most cases, foreign bodies in the stomach require only observation in the outpatient setting because they leave the stomach easily, without complications, per vias naturales. If a battery remains at the same place of the digestive tract for more than 24 hours, endoscopic removal is indicated at our department. In addition, endoscopy is done in cases of swallowed multiple magnets or bodies that are too large and remain in stomach for several weeks or months. Surgical removal of foreign bodies should be reserved only for complicated cases.

[Verification of the Necessity for the Open Reduction and Tension Band Wiring of the Displaced Olecranon Fracture in Younger Children]. / Overení nutnosti otevrené repozice a tahové cerkláze u dislokované zlomeniny okovce u mensích detí.

PURPOSE OF THE STUDY Olecranon fractures in skeletally immature patients are rather rare and represent up to 7% of elbow skeletal injuries. Although the majority of olecranon fractures is constituted by undisplaced fractures treated conservatively with good outcomes, a few of them require surgery. The aim of the study was to compare two different approaches of surgical treatment - the open reduction with tension band wiring - cerclage (ORCe) and the closed reduction and percutaneous pinning (CRPP). MATERIAL AND METHODS 37 patients (28 boys, 9 girls) were included in the retrospective multicentric study. The patients were treated at two different institutions (the Clinic of Paediatric Surgery, Orthopaedics and Traumatology, the University Hospital Brno and the Department of Paediatric Surgery and Traumatology, the University Hospital Hradec Králové, Czech Republic). 17 patients underwent the ORCe procedure, while 20 patients were treated using the CRPP method. Different parameters were statistically compared in the groups (demographic data, data concerning the course of the therapy, outcome of the therapy in terms of movements' restrictions and complications such as osteosynthesis failure and infection). RESULTS Both the groups were comparable in terms of demographic data because no statistically significant difference was observed in terms of the age (p = 0.082), the affected site (p = 1.000) and the gender (p = 0.462). Statistically significant difference between these two groups was found in the interval between the implementation and the removal of the osteosynthetic material (p < 0.001) and in the length of cast immobilisation (p = 0.047). The number of patients with movement restriction up to 10° was statistically significantly higher in patients who underwent the CRPP procedure (p = 0.040), but no statistically significant difference was seen between these two groups in terms of movement restriction more than 10° (p = 0.609). One revision surgery was performed in the CRPP group, however with no statistical significance (p = 0.350). DISCUSSION The multicentric study included 37 children, who underwent surgical treatment of a displaced olecranon fracture. Compared to the studies dealing with this topic the number of patients included in this study is relatively high. It advocates the possibility of using the CRPP method as a good alternative to the gold-standard ORCe technique because no difference in terms of the number of revision surgeries and the clinically important movement restriction of more than 10° were seen. It also brings along advantages such as a simple surgical technique, good functional and cosmetic effects, reducing the risk of ischemic insult of growth plate and the possibility of osteosynthetic material removal at an outpatient department with no need for general anaesthesia. The risk of a higher radiation exposure of both the patient and the surgical team should be considered as a disadvantage of the closed method. CONCLUSIONS The mini-invasive CRPP appears to be a good alternative option to the ORCe method for the treatment of isolated olecranon fractures in children offering the advantages such as avoiding extensive open procedure and simple implants removal. Key words:children, olecranon, fracture, tension band wiring - cerclage, percutaneous pinning, elbow.

[Open versus laparoscopic appendectomy for acute appendicitis in children]. / Otevrená versus laparoskopická operace akutní apendicitidy u detí.

INTRODUCTION: Acute appendicitis is a common disease affecting both adults and children. The basic therapeutic procedure is an appendectomy. Open appendectomy has been gradually supplemented and sometimes replaced by a laparoscopic approach in numerous departments. The aim of our work was to compare laparoscopic and open surgery objectively. METHOD: Retrospective analysis of data from patients operated on at the Department of Pediatric Surgery and Traumatology, Teaching Hospital in Hradec Králové in 20092016. Only the precisely evaluated parameters, i.e. the time of anesthesia, the time of surgery and the duration of post-operative pain, were assessed within the scope of objectification. Data were evaluated only in a homogeneous group of patients with phlegmonous appendicitis. RESULTS: During the above period, 261 patients with acute appendicitis were operated on at our department, 166 of whom suffered from phlegmonous appendicitis. 133 children were operated laparoscopically and 33 by open procedure. The results obtained were statistically significantly different only for the time of anesthesia (p=0.00035) which was shorter in open operations. The time of surgery was also shorter in the open operation group, but only at the limit of statistical significance. A statistically significant difference was not found in the time of duration of pain for individual surgical approaches. CONCLUSION: Laparoscopic approach in the surgical treatment of acute appendicitis is a more modern method than open surgery and it has become a standard procedure in some departments. However, the results of our study confirm that the open approach remains an equivalent alternative to the treatment of acute phlegmonous appendicitis.Key words: appendicitis open appendectomy laparoscopy.

[Retrogastric bronchogenic cyst]. / Retrogastrická bronchogenní cysta.

The authors present a case of an incidental finding of an asymptomatic retrogastricaly localized bronchogenic cyst. In a 3.5 year old boy, abdominal US, which was performed because of constipation complains, revealed a cystic mass. MRI study confirmed the presence of a simple cyst, located in the retrogastric region. The patient underwent laparotomy and the cyst, measuring 3 cm in a diameter, was removed from the omental bursa. During the postoperative period, no complications or symptoms were recorded. Histologicaly, the finding was surprisingly identified as a bronchogenic cyst. Occurence of bronchogenic cysts within the abdominal cavity is reported very rarely in the literature.