Deep Venous Thrombosis after Conservative Treatment of Clavicular Fracture in COVID-19 Negative Children: Two Case Reports.

A 13-year-old girl suffered fracture of her left clavicle. A figure-of-8 bandage was placed during initial treatment. Six days after trauma her distal arm, elbow and proximal forearm were swollen, pain and tenderness of distal part of brachial vein was recognized during clinical examination. Duplex ultrasonography revealed partial thrombosis of the brachial vein. Bandage was immediately removed and administration of LMWH (enoxaparin) was started. Complete recanalization was achieved after a few days. The fracture was healed without further complication, patient was without sonographic and clinical signs of post-thrombotic syndrome. The second case report describes a 14-year-old boy. Initially, the fixation was a figure-of-8 bandage. 5 days after the injury he had swollen arm and elbow on the injured side, according to duplex ultrasonography deep venous thrombosis of the axillary and the brachial vein was recognized. There was only partial recanalization at the first sonographic follow up, the patient was converted to Warfarin for 3 months after injury after initial LMWH therapy. At the last follow-up, fracture of the left clavicle was healed and there were no DUSG or clinical signs of post-thrombotic syndrome. Key words: clavicle, deep venous thrombosis of the upper extremity, anticoagulant therapy.

[Periprosthetic Femoral Fractures after Total Hip Replacement: Our Results and Treatment Complications]. / Periprotetické zlomeniny femuru po implantaci aloplastiky kycelního kloubu: nase výsledky a komplikace pri lécení.

PURPOSE OF THE STUDY The study consists of a retroactive evaluation of results of surgical treatment in patients with periprosthetic femoral fracture after total hip replacement and a comparison with results reported in the literature. MATERIAL AND METHODS In the period from 2003 to 2013, a total of 83 patients with periprosthetic femoral fracture after total hip replacement were treated at our clinic, namely 69 women and 14 men. The mean age in the cohort was 74 years (range 47-87). The Vancouver classification was used to grade the fractures. The cohort included 31 patients with type B1 fracture, 25 patients with type B2 fracture, 8 patients with type B3 fracture, and 19 patients with type C fracture. Altogether 80 patients underwent a surgery, 3 patients with non-displaced type B1 fracture were treated conservatively. The mechanism of injury was a simple fall in 75 % of primary endoprostheses and in 56% of revision endoprostheses. The average time to fracture was 7.6 years in primary implant and 3.6 years in revision endoprosthesis. In fractures with a well-fixed stem (type B1 and C) plate osteosynthesis was used. In case of a comminution zone, osteosynthesis was followed by spongioplasty. In patients with a loose stem (type B2 and B3), the fracture was treated with a revision uncemented stem. In two cases a combination of a revision stem and a massive corticocancellous bone graft was used. The evaluation was performed using the Harris Hip Score and the minimum follow-up from the surgery was 3 years. RESULTS In the group of patients with type B1 fracture, 28 patients were treated surgically. An excellent result was achieved in 22 patients (84%), in 4 patients (16%) the result was very good. The remaining 2 patients failed to meet the requirement of the minimum follow-up of 3 years. In the group of patients with type B2 fractures, composed of 25 patients, the femoral component was replaced with a revision uncemented stem with cerclage wires or titanium tapes or cables. Osseointegration of the stem was recorded in 24 patients, one female patient died 4 months after the surgery. An excellent result was achieved in 16 patients (64%), a very good result in 4 patients (16%). The remaining 5 patients (20%) failed to meet the minimum follow-up of 3 years. In 8 patients with type B3 trauma, the reimplant of a revision stem was supplemented by spongioplasty, in 2 cases by solid corticocancellous bone grafts with cerclage. In this group osseointegration occurred in all the cases within 6-9 months. The follow-up was affected by the older age of patients and 6 patients died during the follow-up period. The requirement of a follow-up longer than 3 years was met in 2 patients (25%) only and the result was considered very good. In the group of 19 patients with type C fracture, plate osteosynthesis was performed, which was in 12 cases complemented with spongioplasty. Healing occurred within 6 months in 13 patients (72%), within 9 months in 3 patients (17%) and in 2 patients (11%) reoperation was carried out due to fixation failure. One female patient died 16 days after the surgery. An excellent result was achieved in 15 patients (83%), in the remaining three patients the follow-up was shorter than three years due to their death. DISCUSSION Periprosthetic femoral fractures after total hip replacement is a rare but feared complication. Its incidence ranges from 0.1 to 4%. It occurs most frequently 7 to 8 years after the primary implant and 3 to 4 years after the revision of endoprosthesis implantation. The main risk factor is the loosening of stem of endoprosthesis. Another risk factor is osteoporosis. Age, sex and obesity do not constitute significant risk factors. Stem stability and presence of bone defects are the main criteria in favour of surgical treatment. If the stem remains well fixed, the osteosynthesis is opted for, whereas if the stem is loose, its replacement has to be performed. The management of bone defects is an integral part of femoral reconstruction and restoration of endoprosthesis stability. CONCLUSIONS Surgical treatment of periprosthetic fractures, thanks to the introduction of new implants for osteosynthesis and development of new stems for revision endoprostheses, helps achieve ever better results. Of major importance for choosing the treatment method is correct classification of fracture and stem stability. Poor bone quality is a common feature, therefore a perfect mechanical fixation is necessary. The long-term results are affected primarily by the patient s age. Key words: periprosthetic femoral fractures, surgical treatment, results, complications.

[Floating Hip Injuries: Treatment Outcomes and Complications]. / Ipsilaterální zlomeniny pánve, acetabula a femuru ­ floating hip: nase výsledky a komplikace pri lécení.

PURPOSE OF THE STUDY The aim of this retrospective study was to evaluate the results of surgical management of patients with ipsilateral injuries to the femur and the pelvis or acetabulum (floating hip). MATERIAL AND METHODS A total of 54 patients with injury to the pelvic ring or acetabulum concomitant with an ipsilateral femoral fracture were treated at our Department in the period from 2005 to 2013. The group consisted of 35 men and 19 women with an average age of 36.5 (22 to 72) years. Only patients undergoing surgery were included. Excluded were patients who died within 48 hours of injury, those whose pelvic injury was treated conservatively and patients with Pipkin type IV fracture. The average follow-up was 6.1 (2 to 10) years. The mechanism of injury included a traffic accident in 36 patients, fall from a height in 15 patients and fall off a horse in two patients; one patient was buried under a collapsed trench wall. Functional outcomes were evaluated using the Harris Hip Score and the Majeed scoring system. RESULTS Of 15 patients with type A fractures (pelvic ring and diaphyseal femur fractures), 12 (80%) had excellent and three (20%) had good results. The outcomes of type B fractures in 28 patients (acetabular and femoral fractures) were excellent in 12 (43%), very good in 10 (36%), good in four (14%) and poor in two (7%) patients. In the sub-group of seven patients with type C fractures (fractures of the pelvic ring and acetabulum with concomitant femoral fracture), the results were satisfactory in five patients (72%), good in one (14%) and poor also in one patient (14%). DISCUSSION The general health status of a patient after traumatic injury is decisive for choosing amongst treatment options of damage control surgery, primary temporary stabilisation and definitive stabilisation. Early definitive stabilisation of fractures gives best results. Primary external fixation of a diaphyseal femur facture with subsequent conversion to internal osteosynthesis, in relation to a change in the patient's general health state within the concept of damage control surgery, has no effect on the functional results of femoral or pelvic fracture treatment. Delayed definitive fixation of an acetabular fracture, however, makes reduction of the fracture more difficult and results in a poorer functional outcome. CONSLUSIONS Injuries to the femur concomitant with pelvic and/or acetabular fractures are serious traumatic events requiring a correct evaluation of the patient's general health status and soft tissue conditions as well as an appropriate treatment timing. The results do not differ from those of treatment for each isolated injury. They are related to types of fracture and experience of the operating team. Complications in floating hip injuries are not higher in number, but their combination may have unpleasant consequences. Key words: floating hip, surgical treatment, complications, outcomes.

[Minimally invasive stabilization of posterior pelvic ring injuries with a transiliac internal fixator and two iliosacral screws: comparison of outcome]. / Miniinvazivní stabilizace poranení zadního pánevního segmentu transiliakálním vnitrním fiátorem a dvema iliosakrálními srouby: srovnání funkcních výsledku

PURPOSE OF THE STUDY: A comparison of radiological and clinical results between dorsal pelvic segment stabilization with a transiliac internal fixator (TIFI) and that with two iliosacral screws (IS). MATERIAL AND METHODS: In this prospective study, both the TIFI and the IS group had 32 patients. The majority of injuries were assessed as type C1.3 because only patients with a high-energy mechanism of injury were included. Radiological results were evaluated according to the Matta scoring system and clinical outcome using the Majeed score and the Pelvic Outcome Score. Categorical data were evaluated by the two-sided Fisher's exact test or Pearson's χ2 test and continuous data by Student's t-test. A test result with p<0.05 was considered statistically significant. RESULTS: In the TIFI group, the mean posterior displacement was 2.2 mm, in the IS group it was 1.9 mm (p=0.58542). The pelvic outcome scores in the TIFI group were: excellent, 28%; good, 12%; fair, 48.0%; and poor, 4 %; in the IS group they were: excellent, 11.1%; good, 22.2%; fair, 66.7%; and poor, 0.0% (p=0.51731). The Majeed scores were as follows: excellent, 56.0%; good, 16.0%; fair, 20.0%; poor 8.0 % for the TIFI group and excellent, 50.0%; good, 27.8%; fair, 11.1%; and poor, 11.1% for the IS group (p=0.70187). Within the total, average Majeed score was 80.64 points in TIFI, 80.67 in IS (p=0.99654). In a sub-analysis of unilateral transforaminal fractures (Pohlemann type II), the average score for TIFI was 82.8 points and only 53.5 points for IS; the differences were statistically significant (p=0.04517). No intraoperative complications were associated with TIFI and one injury to the superior gluteal artery (3.1%) and two iatrogenic neurological injuries with IS (6.3%; p=0.23810). In the TIFI group, the fixator was removed without complications. In the IS group, post-operative wound bleeding following screw removal occurred in three patients (20.0%; p=0.22414), complete extraction of screws and washers was successful only in seven patients (46.7%), washers were left in situ in six patients (40.0 %) and IS removal was not possible in two patients (13.3%). The difference in complications between the groups was highly significant (p=0.00220). DISCUSSION: The results of our study are in agreement with those of the relevant studies published recently as well as with the outcomes of transiliac plate fixation reported in the literature. TIFI implantation is preferred in transforaminal and central sacral fractures because, unlike iliosacral screws, it carries a low risk of excessive compression of the sacral foramina and iatrogenic neurological injury. There were no significant differences in clinical and radiological findings between TIFI and IS procedures. Only in unilateral transforaminal fracture the TIFI stabilization had better outcome, as shown by the Majeed score. The IS fixation was associated with a higher rate of complications not only in primary implantation, but also at implant removal. CONCLUSIONS: The TIFI technique is superior to the IS procedure in fixation of unilateral transforaminal fractures and provides a reasonable alternative to the existing types of minimally invasive fixation.

[Complications associated with surgical treatment of pelvic ring fractures]. / Komplikace operacního lécení zlomenin pánevního kruhu.

PURPOSE OF THE STUDY: A retrospective analysis of complications associated with surgical treatment of pelvic ring fractures. MATERIAL: Between 2004 and 2011 a total of 257 patients with pelvic ring fractures, 176 men and 81 women with an average age of 36 years, were treated. The average follow-up was 53 months (range, 13 to 108 months). AO type C fractures, which were most frequent, were recorded in 67%, type B fractures in 30% and type A fractures in 3% of the patients. Displaced unstable fractures or markedly displaced type A fractures of the pelvic ring were indicated for surgery. RESULTS: Three types of complications were distinguished, i.e., intra-operative, early and late. Of a total of 40 intra-operative complications in 31 (16%) patients, the most frequent ones included malreduction in 14 patients (5%), nerve injury in 12 (5%), erroneous insertion of an implant in seven (3%) and vascular injury in six (2%) patients. Early post-operative complications requiring repeat surgery that were recorded in 15 patients (6%) were due to failure of osteosynthesis in seven patients, early wound infection in six, and haematoma which needed exploration in two patients. There were 25 late post-operative complications in 18 patients and they included fracture union with pelvic deformity in eight (3%) patients, chronic posterior pelvic pain in seven (3%), inguinal hernia through a scar in six (2%), pseudoarthrosis in three (1%) and late infection in one patient. DISCUSSION: The outcome of surgery depends on the fracture type, method of management and associated injuries; the patient's age and bone quality also play a role. Risk factors for the development of complications include markedly displaced and unstable pelvic ring fractures, open fractures, complex pelvic injury and associated injuries which do not allow for immediate definitive fracture stabilisation. Not every poor outcome is due to a complication per se or, the other way round, is exclusively related to the type of fracture. Many long-term sequelae arise from complex injuries. Because the anatomy of the pelvis is very complex, pelvic fractures are often associated with injury to the nerve structures and their management by reduction and fixation is difficult. CONCLUSIONS: The characterisation and evaluation of complications associated with the management of pelvic ring fractures is problematic because it is difficult to distinguish which of them have been caused by pelvic ring fracture and associated injuries and which are due to surgical treatment. Although most complications arise from injury, the increasing role of surgery in their treatment leads to a higher rate of iatrogenic complications most frequently resulting from an improper surgical technique, including fracture reduction and/or fixation.