Reamed versus unreamed nail in the treatment of tibia shaft fractures.

PURPOSE: The aim of the prospective randomized study was to compare the results of the treatment of tibia shaft fractures (TSF) by reamed or unreamed intramedullar nail. METHODS: There were 103 patients with 104 TSF enrolled in the study within the period from December 2005 to June 2010. Seven patients were excluded from the study. Factors of injury severity, course of surgery and hospitalization, and incidence of early and delayed complications were recorded. X-ray was performed every 4 weeks until the fracture was healed. Functional results were evaluated at least 1 year after the surgery. Closed fractures were classified according to Tscherne classification and the open ones according to Gustilo classification. RESULTS: Forty-eight patients with 49 TSF were treated by unreamed tibial nail. There were 15 women and 33 men in this group. Injury severity score (ISS) ranged from 4 to 25 (ø 6.63). There were 45 closed fractures (0 16; I 22; II 7) and four open fractures (I 2; II 1; IIIA 1). In the reamed nail group there were 48 TSF. ISS ranged from 4 to 18 (ø 6.13). There were 35 closed (0 17; I 13; II 5) and 13 open (I 5; II 5; IIIA 3) fractures in this group. The time of operation was on average 15 min shorter in the unreamed nail group. X-ray healing was the same in both groups (18.12 versus 17.92 weeks). We had four patients in the unreamed nail group and six patients in the reamed nail group with delayed healing (28-44 weeks). We recorded no infection, loss of reduction or re-operation in both groups. Follow-up of functional results was 90 %. CONCLUSIONS: There was no statistically significant difference in clinical and functional results between the groups. We suggest that both methods are comparable.

[Percutaneous fixation of anterior column acetabular fractures--first experience]. / Perkutánní osteosyntéza predního pilíre acetabula: první zkusenosti.

PURPOSE OF THE STUDY: Percutaneous fluoroscopy-assisted fixation of acetabular fractures is not a widely used technique. Its advantage lies particularly in percutaneous placement of screws in the anterior column of the acetabulum. The operative procedure is described and the first experience of the authors with this minimally invasive technique at their department is reported. MATERIAL: Between December 2007 and April 2009, 10 fractures of the anterior column of the acetabulum were treated by percutaneous stabilisation in 10 patients. There were six men and four women aged 25 to 76 (average, 46) years. Retrograde screw fixation was used in three, anterograde screw fixation in two and anterograde screw placement following retrograde guide wire insertion in five patients. METHODS: The minimally invasive method of acetabular stabilization using 6.5-mm or 7.3-mm cannulated screws was facilitated by the use of intra-operative fluoroscopic imaging. Following fracture reduction, a percutaneous guide wire, aided by a C-arm, was placed in the upper pubic ramus and the anterior column of the acetabulum in either an anterograde or a retrograde mode. Subsequently, a traction cannulated screw was inserted. When anterograde guide wire placement was difficult to do, the retrograde guide wire placement was used for anterograde screw insertion. The quality of fracture reduction and the placement of screw were evaluated by a post-operative CT examination. RESULTS: The average follow-up was 11 (range, 2-19) months. The average operative time necessary for percutaneous screw insertion in the anterior column of the acetabulum was 26.4 (range, 15-45) min, and the average X-ray exposure time for the screw placement was 3 min and 13 sec (range, 40-448 sec). The average time needed for screw insertion following the retrograde guide wire was 2 min and 30 sec (range, 40-242 sec). The average post-operative fragment dislocation leading to incongruency was 1.3 mm (range, 0-4 mm). The results of reduction assessed as excellent (<2 mm) and poor (>or=2 mm) were achieved in six and four patients, respectively. No screw malplacement was recorded. Post-operative infectious complications occurred in one (10 %) patient. DISCUSSION: Important factors for avoidance of intra-operative complications included a thorough pre-operative planning on the basis of CT diagnostic examination, meeting the indication criteria and using a safe stabilisation technique. However, the percu- taneous fluoroscopy-assisted method requires a longer exposure to X-ray than do the techniques utilising computerised navigation. The occurrence of infectious complications was not lower than with the use of open reduction and internal fixation methods. CONCLUSIONS: After the operative technique has been mastered, the minimally invasive method of osteosynthesis is likely to become a method of choice for certain kinds of acetabular fractures. The current, most frequent indications are minimally displaced transverse fractures, T-shaped fractures and anterior column acetabular fractures. A limiting factor of this technique is reduction. It is certain that further evolution of this technique and its more frequent use will be associated with computerised navigation.

[Surgical management of proximal humeral fractures using the Hackethal (Zifko) method--a case review]. / Operacní lécba zlomenin proximálního humeru metodou podle Hackethala (Zifka)--case serie.

BACKGROUND: Fractures of the proximal humerus actually represent 5% of all fractures and 45% of all humeral fractures with the highest incidence in women over 60 years of age. The outcomes of the greatest concern at these patients (pain, function of the shoulder and activities of daily living) get worse with age, osteoporosis, grading of fracture type and of initial fracture displacement. According to the literature (Evidence Based Medicine--EBM level II-III) operative treatment of displaced fractures reduces pain and need for assistance in activities of daily living, but open reduction with internal fixation by conventional screws and plates was connected with implant loosening, infection and avascular necrosis, whereas closed reduction with different methods of miniinvasive percutaneous stabilisation is threatened by primary malreduction. AIM: Evaluation of clinical and functional outcomes and analysis of results of proximal humerus fractures treated by closed or percutaneous reduction and intramedullary fixation by means of bundle of Kirschner wires after Zifko. DESIGN: Retrospective descriptive study--case serie. MATERIAL AND METHODS: Within January 1, 2005 - December 31, 2005 there were 87 patients with 87 two- and three-fragments fractures of proximal humerus (according to Neers classification) operated at our institution, from which 76 by the method after ZiFko. 36 patients from these 76 came to final evaluation (follow-up rate 47%). AO fracture types were: A2-36%, A3-33%, B1-19%, C1-12%. RESULTS: The resulting Constant-Murley (CM) score reached in mean 89 points with 89% of excellent--good functional results. Complications were recorded in 30% of cases and were represented mainly by proximal migration of K-wires. Avascular necrosis of humeral head occured in two cases (5.5%). CONCLUSION: In spite of low follow-up rate we conclude, that the method of closed reduction and intramedullary fixation of two- and three-part fractures of proximal humerus after Zifko offers above-average final results with acceptable rate of complications, mostly not severe ones. The essential pre-condition of good result is proper reduction--closed of percutaneous one. On the contrary, suboptimal results correlate with primary and secondary malreductions. The incidence of latter increases in intraarticular fracture types with small fragment of head and thus with insuficient implant retention. To evaluate the merit of the method in relation to angle-stable extra-/or intramedullary implants, the prospective trials are needed.

[Treatment of deep chondral defects of the knee using autologous chondrocytes cultured on a support--preparation of the cartilage graft]. / Terapie hlubokých chondrálních defektu kolena pomocí autologních kultivovaných chondrocytu na nosici--príprava chondrograftu.

PURPOSE OF THE STUDY: Chondral and osteochondral defects represent an important topic in the knee surgery. The knee traumas are often followed by premature development of osteoarthritis due to limited reparative processes in the cartilage. Today's diagnostic possibilities and progress in arthroscopic techniques promote the early diagnostics and exact classification of osteochondral defects. Authors present therapeutic ways for treatment of cartilage injuries and adjacent part of the subchondral bone. New possible method for treatment of deep chondral defects on the weight-bearing area of the knee is the application of autologous cultivated chondrocytes in Tissucol (Baxter, Austria). MATERIAL AND METHODS: Chondrocyte retrieval and in vitro cultivation is today a commonly known method. The goal of the knee surgery is to find a suitable three-dimensional bearer for chondrocyte culture. After serial laboratory tests we decided to use the tissue fibrin glue Tissucol (Baxter, Austria) as a chondrocyte carrier. Very good cell viability and capability of cell migration and outgrow in Tissucol were documented. Authors describe a new chondrograft type, its characteristics. They focused on quality control and documentation of key parameters necessary for graft use in humans. Following methods for quality control were used: Sterility control Determination of cells number Determination of cell viability by trypan blue staining. Viability between 90-95% was demonstrated. Determination of proliferative activity was tested using growth quality control. Migration and outgrowth of chondrocytes was documented. The morphological characteristics were studied by: Light microscopy (haematoxylin-eosin staining). Electron microscopy (transmission and scanning). A good stage of cellular organelles and production of extracellular matrix with protocollagenic fibrils were found in all cases. Immuno-fluorescence microscopy (using monoclonal antibodies against vimentin). RESULTS: Preclinical testing on pigs and cadaverous was provided following laboratory investigations. Testing on cadaverous demonstrated a chondrograft ability to fill up completely the chondral defect to renovate the anatomic surface of the joint cartilage. Tests on pigs described hyaline-like cartilage. Publication contains detailed description of chondrograft preparation to allow reproducibility of described technique. Chondrograft transplantation consists of following phases: Arthroscopic diagnostic of defect. Arthroscopic sampling of cartilage for in vitro cultivation. Transport of samples to tissue bank. Enzymatic isolation, in vitro cultivation of chondrocytes. Graft formation (combination of fibrin glue Tissucol with chodrocytes), quality control. Transplantation (chondrograft agglutination into defect). DISCUSSION: The goal of the nowadays tissue engineering is to find an optimal three-dimensional carrier for autologous chondrocyte culture. A new type of carrier based on hyaluronic acid--Hyalograft C was presented by Marcani et al in 2001 year. Published results from the first 20 clinical cases using Hyalograft C do not report any method complications. Our chondrograft technique represents an alternative option when compared to method described by Marcani. CONCLUSIONS: Based on the successful preclinical outcomes observed in this study, authors conclude that autologous chondrocyte transplantation in Tissucol offers an important treatment option for large full thickness chondral lesions located on the weight-bearing surfaces of the femur.

[Treatment of chronic anal fissure with lateral sphincterotomy]. / Lécení chronické anální fisury laterální sfinkterotomií.

This paper presents a group of 134 patients, who underwent treatment of chronic anal fissure by internal lateral sphincterotomy (ILS) within the period of 12 years (1985-1996). This number of patients where those in whom conservative treatment (anal divulsion) was not successful. From the total number of 134 patients 110 were treated successfully by surgery (82.08%). In 19 patients even after fissure healing slight discomfort persisted. Moderate and more severe complaints were reported in 5 patients. In 4 cases the chronic anal fissure failed to heal, in 1 patient due to ILS perianal fistula developed. No other complications, like incontinency etc., were found within the short time interval of follow-up. ILS is a simple and safe surgical procedure performed under general anaesthesia after precise differentitation of the internal sphincter. The results of surgical treatment are very satisfactory, marked painfulness relieves immediately after operation, the fissure heals rapidly after relaxation of the internal sphincter spasm. Postoperative treatment is simple, the percentage of complications is low. None of the patients operated on in the authors department developed incontinence. (Tab. 3, Ref. 25.)