[Comparison of Clinical Outcomes of Displaced Diaphyseal Clavicle Fractures]. / Porovnání klinických výsledku lécení dislokovaných zlomenin diafýzy klícní kosti.

PURPOSE OF THE STUDY The aim of this retrospective study was to assess the subjective evaluation of treatment by patients with respect to their return to work and recreational sport following the fracture of clavicle diaphysis with posttraumatic shortening of 1.5 cm, or more, treated non-operatively and surgically. MATERIAL AND METHODS Our group of patients consisted of 51 patients (14 females, 37 males) aged between 18 and 89 years (average age 46 years). We concentrated on the parameters of sex, age, side of injury, extent of posttraumatic shortening, method of treatment, return to work or recreational sport, DASH score at one year post non-operative or surgical treatment. Patients who sustained a pathological fracture, fractures of the clavicle combined with an injury of the acromioclavicular joint or simultaneous fracture of the humerus or the ribs were excluded from the study. Patients with open fractures or re-fractures were excluded as well. The indication for treatment selection was based on pre-operative discussion of the doctor with the patient and the Informed Consent was signed. The patient was informed about different treatment options. A shorter period of fixation of the arm and post-operative physiotherapy was mentioned in connection with surgical treatment as well as potential surgical complications. A statistical analysis comparing the data in both groups was conducted using the Fisher exact test. The p-value of 0.05 or less was considered as statistically significant. RESULTS The right side was affected 26 times, the left side 25 times. The shortening ranged from 1.5 to 3.7 cm. 24 patients (8 females, 16 males) aged 21 to 89 years (average 54 years) were treated non-operatively. 27 patients (6 females, 21 males) aged 18 to 74 years (average 38 years) underwent surgery. The difference in sex distribution in both groups was not statistically significant (p = 0.5311). According to the Robinson classification, there were 17 patients with type 2A2 fractures, of whom 8 underwent surgery and 9 were treated non-operatively, 19 patients with type 2B1 fractures, of whom 9 underwent surgery and 10 were treated non-operatively, and 15 patients with type 2B2, of whom 10 underwent surgery and 5 were treated non-operatively. The surgically treated patients prevailed in type 2B2 only, but this difference was not statistically significant (p = 0.2350). In the non-operatively treated group, 23 out of 24 patients returned to pre-injury activities in 3 months on average. Ten patients (48%) reported reaching the same function as on the other side. In the DASH score evaluation, 11 patients reached the value of 0-3.3, five patients 3.4-10, six patients 10.1-30.0 and two reached the score of more than 30. In the evaluation of capacity to work, 15 out of 24 patients were able to work, 11 of them without any restrictions or difficulties. In the evaluation of the sport and playing musical instrument module, 9 out of 24 patients did not engage in sports activities or do not play any musical instruments. In the surgically treated group, 26 out of 27 patients returned to pre-injury activities within 6 weeks. 19 (70%) patients reported reaching the same function as on the other side. In the DASH score evaluation, 19 patients reached the value of 0-3.3, two patients 3.4-10, 5 patients 10.1-30.0 and one patient with nonunion 72.5. Comparison of the average values of the DASH score demonstrated slightly better results achieved by surgical treatment (9.03 vs 6.77). When assessing the work module, 24 out of 27 patients returned to work, 20 of them without any restrictions or difficulties. Out of 27 patients, 4 patients were no longer able to engage in sports activities or to play a musical instrument. Of the 23 remaining patients, 18 did not have any problems, 5 suffered from minimal problems. The group of patients treated non-operatively included one case of non-union and the same applies to the surgically treated group. In 3 patients the removal of hardware was performed, 3 patients underwent revision of the surgical wound because of infection. DISCUSSION The recommendation of the weight-bearing of the upper extremity was similar in both groups, 12 weeks post injury/surgery on average. It is clear that sooner return to work or sports activities in the surgically treated group was preferred by younger patients who expected quicker recovery. Younger patients were less patient and more eager to return to work and sports, while the older patients, on the other hand, were more cautious about possible complications of surgery. CONCLUSIONS The results of our study did not identify any correlation between the clavicle shortening and the indication for surgical treatment. Surgical treatment was preferred by younger patients, more frequently by males. The rationale was supported by the perspective of sooner return to work and favourite sports activities. Their decision was not affected by the known risks of surgical treatment. Evaluation of the DASH score at one year after injury/surgery showed similar results. A higher incidence of complications in the surgically treated group did not lead to negative evaluation of the selected treatment modality by the highly motivated group of patients either. Key words: fractures of the clavicle diaphysis, non-operative treatment, surgical treatment, return to work, return to sports activities, functional results at 1 year.

[Risk Factors for the Development of Distal Tibiofibular Synostosis after Unstable Ankle Fractures]. / Rizikové faktory pro vznik distální tibiofibulární synostózy po luxacních zlomeninách hlezna.

PURPOSE OF THE STUDY The study analyses a cohort of patients with surgically treated ankle fractures who developed complete distal tibiofibular synostoses. It focuses on their occurrence and association with the extent of tibiotalar dislocation of the ankle joint on the trauma X-ray and its relation to the choice of surgery. MATERIAL AND METHODS The cohort of a total of 824 patients with type B and C fractures according to Weber classification was followed up for 9 years. The cohort consisted of 403 (48.9%) men and 421 (51.1%) women. The exclusion criteria included associated talus fractures, calcaneus fractures and fractures of the other bones of the foot. The studied data were obtained retrospectively from medical documentation and by evaluation of trauma X-rays and X-rays obtained during the postoperative checks. The ankle fractures were classified based on the Weber classification and the basic epidemiologic data (age and gender), type of fracture and extent of tibiotalar dislocation of ankle fractures on the trauma X-ray were evaluated. Posttraumatic ankle dislocation was divided into tibiotalar dislocation > 10 mm, tibiotalar dislocation < 10 mm and the group with regular ankle joint. When evaluating the treatment method, the cohort was divided into three groups: Group 1 with one-stage osteosynthesis, Group 2 with temporary K-wire transfixation or external fixation and subsequent secondary conversion to internal osteosynthesis, and Group 3 with definitive transfixation or external fixation of the ankle. The results were statistically evaluated using the Pearson s chi-square test, or the Fisher s exact test for low frequencies. A multivariant logistic regression model was created to identify statistically significant factors contributing to the development of synostosis. The results with the p-value < 0.05 were considered statistically significant. RESULTS In the whole cohort, the synostosis of distal tibiofibular joint was observed in a total of 131 (15.9%) patients. In men it was in 85 (21.1%) cases and in women in 46 (10.9%) cases, which was statistically significant (p < 0.0001). There was a statistically significant difference (p = 0.0020) between the mean age in the group of patients with synostosis (54.4 years) and the mean age in the group of patients without synostosis (49.1 years). Complete distal tibiofibular synostoses were found in 78 (12.7%) fractures classified as type B according to the Weber classification and in 53 (25.5%) type C fractures. When taking into account the gender, synostoses occurred more frequently in men in both types of fractures classified based on the Weber classification, only in type C fractures no statistical significance was established (p = 0.3026). Various size of posttraumatic tibiotalar dislocation was present in both types of fractures. The group with less severe type B ankle fractures showed a statistically significant dominance of synostosis development in cases with large tibiotalar dislocation of more than 10 mm (p<0.0001). In the group with type C fractures different results were obtained. The highest frequency of cases with synostosis was reported in the group with dislocation smaller than 10 mm (p = 0.0698). In the entire cohort, 615 (74.6%) one-stage osteosyntheses were performed and synostoses developed in 77 (12.5%) cases. In 165 (20.0%) patients, transfixation with K-wires or external fixation with subsequent conversion to secondary osteosynthesis were used and synostoses were identified in 50 (30.3%) cases (p < 0.0001). The open fractures showed an insignificantly smaller number of synostoses than the closed fractures (p = 0.5902). DISCUSSION Posttraumatic distal tibiofibular synostoses have varied morphology. A number of studies confirmed that they do not affect much the functional status of the ankle, even despite their extensive finding in the area of syndesmosis is evident on the Xray. Etiologically, a certain role in their development is reported to be played by posttraumatic hematoma in case of damage to deep soft and bony structures of the ankle. CONCLUSIONS A higher occurrence of synostoses was observed in male population, older age patients and also in type C fractures according to the Weber classification. Larger tibiotalar dislocation showed statistical significance in the development of synostoses in type B fractures according to the Weber classification, whereas in type C fractures it was not the main factor contributing to the development of synostosis. In cases where one-staged osteosynthesis was performed, the occurrence of synostoses was statistically significantly lower than in secondary osteosynthesis after temporary stabilisation. Key words: ankle fracture, distal tibiofibular synostosis, ankle joint dislocation, Weber classification, acute surgery, delayed surgery.

Does Convergent Placement of Interlocking Iliosacral Screws into the Body of Vertebra S1 Prevent Screw Migration?

PURPOSE OF THE STUDY To compare the outcomes of parallel and convergent iliosacral screw insertion into the body of vertebra S1 in the treatment of posterior pelvic arch injuries. MATERIAL AND METHODS Radiographs of 120 patients (43 women, 77 men), aged between 14-79 years, treated with iliosacral screw fixation for posterior pelvic ring fractures between 1.1.2009 and 31.12.2019 were reviewed for inclusion in the study. In each case two screws were inserted into the body of vertebra S1. The screws were inserted in either parallel or convergent orientation. Convergent orientation allows the threads of both screws to be interconnected. In this technique, the first screw is inserted into the centre of the body of vertebra S1 as a compression screw. The second screw is inserted as a positioning screw and is placed so that the threads of both screws lock together. We believe that the interlocking of the threads of both screws and contact of the second screw with three cortices (two of the iliac bone and one of the sacrum) increase the stability of the fixation. Migration of loosened screws was measured on radiographs of the pelvis obtained at six weeks and at three, six and twelve months postoperatively. Migration of five millimetres or more within the first six weeks was considered to be clinically significant. Only patients after primary fracture treatment and with a complete one-year follow-up were included in the study. Cases of non-union and failure of osteosynthesis of the anterior pelvic arch and patients with incomplete follow-up were excluded. The incidence of significant screw migration between the two techniques was compared using Fisher's exact test with a 5% level of significance. RESULTS Sixty-three patients (23 women, 40 men) aged 17 to 79 years were included in the study. Parallel screws were used in 24 patients (8 women, 16 men) and convergent screws were used in 39 patients (15 women, 24 men). Clinically significant migration occurred in nine (38%) patients after parallel insertions. In two of these cases there was unstable fixation of the anterior pelvic arch. Migration of convergently placed iliosacral screws occurred in four (10%) cases. In three of these cases this was due to unstable fixation of the anterior pelvic arch. The difference in screw migration between the two groups was shown to be significant (p = 0.0219). DISCUSSION Iliosacral screws ensure sufficient stability of the posterior arch in type B and C pelvic fractures provided that the anterior pelvic arch is stable. Convergent insertion of iliosacral screws may increase the stability of fixation. Minimally invasive surgery with sufficient stability may be advantageous for early treatment of patients after multiple trauma and in elderly patients. The weaknesses of this study are its relatively small number of patients, which prevented reliable statistical analysis of screw migration according to the type of pelvic fractures. The second main limitation is the failure to perform densitometric examination of the skeleton in patients with X-ray proven screw migration for confirmation of osteoporosis as one of the possible causes of fixation failure. CONCLUSIONS The results of the study suggest that convergent insertion of iliosacral screws into S1 is associated with a lower risk of screw migration and subsequent failure of fixation of the posterior pelvic arch. Key words: pelvic fracture, pelvic injury, iliosacral screw, parallel screws, convergent screws, migration of iliosacral screws.

Heterotopic Ossifications after Fractures of the Anterior Pelvic Segment: Overview of Morphology and Clinical Correlations.

PURPOSE OF THE STUDY In certain patients after treated pelvic fractures, heterotopic ossifications can be observed in the area of the pubic bone, which protrude ventrally, and often also laterally and distally into surrounding soft tissues of the groin or even medially into the proximal thigh. These ossifications are shaped like sharp spikes of various lengths, which is why the authors refer to them as "spicules". In some patients, these ossifications are also associated with pain. The aim of this study was to provide an overview of the morphology of heterotopic ossifications of the anterior segment of the pelvis and to discuss the etiology of their origin, and further to determine the incidence, risk factors and clinical significance of these "spike-like" ossifications. MATERIAL AND METHODS X-ray images of patients treated for pelvic injuries between 2009 and 2018, in whom radiological documentation was available at least 12 months after the injury or surgery were evaluated. Patients with acetabular fractures or combined pelvic and acetabular injuries were not included in the study. Possible risk factors studied included gender, severity of injury, type of fracture according to the AO / ASIF classification, concomitant bladder injury, method of treatment and type of osteosynthesis of the anterior segment of the pelvis. The categorial data concerning risk factors for the observed "spicule" type ossifications was statistically evaluated using the chi-square test at the 5% level of significance. RESULTS The studied group consisted of 218 patients (121 women, 97 men) aged 13 to 92 years of age (mean age was 54 years, median age was 55 years). Heterotopic "spicule" type ossifications occurred in 21 patients (4 females, 17 males) aged 18 to 76 years (mean 39 years, median 41 years). Significant risk factors in the observed ossification group included male sex (p = 0.0004), severity of trauma (predominance of "spicules" was seen in multiple trauma patients, (p = 0.0024), unstable pelvic injury according to AO / ASIF classification (predominance of "spicules" in type B and C fractures over type A fractures, (p = 0.0013), concomitant bladder injury (p = 0.0009) and in patients undergoing surgical treatment of the fracture (p < 0.0001), where all the observed spicules were seen in patients undergoing anterior pelvic segment osteosynthesis. A statistically significant difference was also evident when comparing the osteosynthetic material used in the anterior segment (a increased incidence of ossifications was seen in patients undergoing plate fixation compared to patients in whom pubic screws were used, p = 0.0050). DISCUSSION Heterotopic ossifications are described as relatively common consequences of pelvic fractures, but are not considered a major problem because they usually do not produce any clinical correlations. The causes of post-traumatic and postoperative ossifications in the pelvic area include the effects of high energy traumas, extensive surgical procedures, prolonged artificial lung ventilation, and post-infectious states after complications of surgical treatment. CONCLUSIONS The study identified risk factors for heterotopic "spicule" type ossifications. The identified risk factors include male sex, severity of injury, unstable type of fracture, concomitant bladder injury, surgical treatment, and the use of massive implants. Only the effect of bladder injuries can be partially influenced by performing less invasive surgical techniques during combined pelvic and bladder injuries. Key words: pelvic fracture, pelvic injury, complications, heterotopic ossifications, multiple trauma, unstable pelvic trauma, urinary bladder injury.

[The Injury-Treatment Time Interval of the Most Frequent Limb Fractures - 1-Year Monocentric Study]. / Interval úraz-osetrení u nejcastejsích zlomenin skeletu koncetin ­ jednoletá monocentrická studie.

INTRODUCTION The purpose of the study was to evaluate the injury-treatment time interval in a group of patients with limb bone fractures over the period of one year; and to compare this interval in the most frequent fractures of the upper and lower limb. MATERIAL AND METHODS The followed-up group of the prospective one-year monocentric study included 3,148 patients treated consecutively for 3,909 fractures. For the purpose of sub-analysis of the injury-treatment time interval in limb bone fractures, excluded from the group were the patients with multiple fractures (520 pts), patients with spinal fractures (356 pts) and pelvic fractures (210 pts). The statistical significance of the achieved results was tested with the use of contingency tables (chi-square test of independence). The significance level for the quantified tests was set at 5%. RESULTS The sub-analysis covered 1,727 patients whose medical records mentioned the exact time of injury and first examination. Within the first 6 hours after the injury, 536 (56.0%) patients with an upper limb bone fracture and 429 (55.7%) patients with a lower limb bone fracture were treated. Within 24 hours after the injury, 683 (71.4%) patients with an upper limb bone fracture and 572 (74.3%) patients with a lower limb bone fracture were treated. Within the first 24 hours after the injury, 104 (76.4%) patients with a proximal humerus fracture, 240 (84.5%) patients with a distal radius fracture and only 174 (55.5%) patients with metacarpal and phalanx fractures were treated. In the first hours after the injury, most frequently treated were the patients who sustained a distal radius fracture, and the longest injurytreatment time interval was seen in patients with hand bone fractures. The difference in the 24hour injury-treatment interval was significant when comparing distal radius fractures and proximal humerus fractures (p = 0.047) and when comparing distal radius fractures and hand bone fractures (p < 0.001). Within 24 hours after the injury, 166 (83.3%) patients with a proximal humerus fracture, 128 (79.1%) patients with an ankle fracture and 142 (63.4%) patients with metatarsal and phalanx fractures were treated. The shortest injury-treatment interval was reported in patients with a proximal femoral fracture and an ankle fracture, and relatively the lowest number of treated patients in the first hours after the injury was reported among patients with metatarsal and toe fractures. When evaluating the 24hour injury-treatment time interval, this difference was significant only when comparing proximal femoral fractures and metatarsal and phalanx fractures (p < 0.001), while when comparing proximal femoral fractures and ankle fractures the difference was not significant (p = 0.283). DISCUSSION There are not many studies of other authors focused on monitoring the injury-treatment time interval in the most frequent limb bone fractures. They also confirm that the treatment is sought out most quickly by patients with fractures that make walking or self-care impossible. CONCLUSIONS The results of the study confirmed that the fastest treatment was requested in patients with fractures which made the selfcare (distal radius) or walking (proximal femur, ankle) impossible; less painful fractures (metacarpal, phalanx fractures) and fractures that do not compromise walking (metatarsal fractures) were treated in the first 24 hours after the injury significantly less frequently. The patients with ankle fractures sought out treatment the most quickly compared to the patients with other fractures; it concerned largely occupational or sports injuries sustained by young men who were brought for treatment immediately after the injury, directly from their workplace or sports ground. The treatment of osteoporotic fractures (proximal humerus, distal radius, proximal femur) was spread over the first 6 hours due to the lack of independence of elderly patients after sustaining a fall at home; in majority of them transport to treatment was arranged for by relatives or neighbours only with a certain delay, once they became aware of their injury. Key words: fracture epidemiology, limb bone fractures, trauma-treatment time interval.

Pulmonary metastases in pseudomyxoma peritonei - case report and review of the literature.

Pseudomyxoma peritonei is a rare disease caused by dissemination of cancer forming mucous and gelatinous masses in the peritoneal cavity. Local recurrence is frequent; however, dissemination outside the peritoneal cavity is rare.  Case report: We present the case report of a female patient treated for bilateral pulmonary metastases from pseudomyxoma peritonei. We removed 1 metastasis from her left lung and 12 metastases form her right lung. The patient remained in a good clinical state; however, additional lung metastases developed, as well as a metastasis in L2 vertebra for which the patient underwent a surgical procedure. Conclusion: Cytoreductive surgeries for intrathoracic involvement in pseudomyxoma peritonei with additional hyperthermic cytostatic intrapleural lavage in case of pleural involvement can lead to a longer lifespan in indicated patients.

[Injury of Medial Structures in Ankle Fractures - Epidemiological Aspects and Outcomes of Treatment]. / Poranení mediálních struktur u zlomenin hlezna ­ epidemiologické aspekty a hodnocení výsledku lécby.

PURPOSE OF THE STUDY Ankle fractures are characterised by a high variability of damage to bone and ligament structures which leads to diverse clinical conditions. This study aims to analyse a group of patients with surgically treated ankle fractures, with a focus on evaluating the outcomes of treatment of ankle joint medial structure injuries (medial malleolar fracture, ligament lesions). MATERIAL AND METHODS The analysed group included 186 patients (102 men and 84 women), in whom an ankle fracture surgery was performed in 2015 and 2016. The outcomes of the treatment were evaluated in 111 patients with type B and type C fractures, who underwent a follow-up examination at one year after the surgery consisting in subjective and objective assessment of the condition and an ankle radiograph. The obtained outcomes were processed using the techniques of descriptive statistics and subsequently evaluated through the Pearson´s chi-square test at 5% significance level, or the Fisher´s exact test for low frequencies. RESULTS The mean age of patients in the group was 48.6 years, while it was lower in men than in women (42.8 years compared to 53.9 years). According to Weber classification, 1 % of fractures were classified as a type A fracture, 68 % as a type B, 27 % as a type C. The group of isolated medial malleolar fractures represented 4 % of cases. The medial side of the ankle joint more frequently suffered a ligament lesion (56 %) than a medial malleolar fracture (44 %). The mean age of the patients with a medial malleolar fracture was 51.9 years, whereas the mean age of the patients with a ligament lesion on the medial side of the ankle was 44.2 years. When evaluating the outcomes using the OMA score at one year postoperatively, a statistically significant difference was found (p = 0.002) between the patients with a medial malleolar fracture (OMA 79.9) and the patients with a ligament lesion at the medial side of the ankle joint (OMA 91.2). DISCUSSION The aim of the study was to add more information on medial structures of ankle joint that are of major importance for ensuring stability of ankle fractures. In agreement with the literature, when managing the ankle fractures with an injury suffered on the medial side there is obviously a more uniform approach in cases with medial malleolar fractures. The situation is different in case of the deltoid ligament lesion, when historically there is a certain level of non-uniformity in indications for revision surgeries and treatment of the injured ligament structures. In our group, in the case of ligament lesion on the medial side of the ankle joint an emphasis is put on the fluoroscopy control of the symmetry of tibiotalar joint space before the beginning of the surgery and also after the fibular fracture stabilisation. The revision surgery was indicated in cases where asymmetry of ankle fork was found. The patients considered the treatment outcome better in cases with a ligament lesion than in cases with a medial malleolar fracture. CONCLUSIONS Proper treatment of medial structures of the ankle joint is important for ensuring the stability of ankle fractures. The patients with type B fractures reported better results at one year postoperatively compared to the patients with type C fracture according to the Weber classification. A statistically significantly better results after the ankle fracture surgery were achieved in patients with the presence of a medial ligament lesion compared to the patients with a medial malleolar fracture. Key words:ankle fracture, injury of medial structures, epidemiology, outcomes of treatment.

Splenic abscess as a rare symptom of the extrapulmonary tuberculosis - case report.

INTRODUCTION: Extrapulmonary tuberculosis can involve any organ or tissue. It is a rare disease in the Czech Republic with an incidence rate of 0.62 cases per 100.000 persons. It affects mostly immunocompromised patients. The most common sites include lymph nodes, the urogenital system, skin, joints, bones and serous epithelium - the peritoneum, pleura, and pericardium. Splenic involvement is rare. Mycobacterium is a slow growing intracellular parasite. The diagnostic process is very difficult; microbiological diagnosis is critical. CASE REPORT: An 84 years old female patient with subcapsular splenic rupture with no trauma history as a cause of anemia. Splenic abscess was diagnosed during surgical revision and splenectomy. Tuberculosis was suspected based on subsequent histological analysis, which was confirmed after nine weeks of peritoneal fluid culture. The surgical procedure and postoperative hospitalization were not associated with any complications. The patient was referred to the respiratory clinic for further treatment. CONCLUSION: The diagnosis of extrapulmonary tuberculosis including splenic localization should always be considered. A sample from the affected tissue or effusion must be collected in the case of unclear perioperative findings and sent for complete bacteriological testing, including mycobacterial culture. If a tuberculous splenic abscess is found, the therapeutic process should involve its complete drainage in combination with long-term anti-TB medication.

[Risk of death in patients with unstable pelvic fracture and large vessel injury]. / Riziko úmrtí pacienta s nestabilní zlomeninou pánve a poranením velkých cév.

INTRODUCTION: The aim of the study was to provide accurate data regarding the incidence of large vessel injury as part of pelvic trauma in patients treated during a 12-year period. METHODS: In total, 715 patients admitted and treated for pelvic fractures from 2001-2012 were analyzed. Data on large vessel injuries (aorta, inferior vena cava, common iliac artery and vein) reported in perioperative or autopsy findings were obtained from the patient database. The statistical significance of achieved results was tested using contingency tables (chi-square test of independence or Fisher factorial test). The significance level for the calculated tests was chosen to be 5%. RESULTS: Sixty six (9%) patients died in the first hours after admission, 43 (6%) of them prior to surgery. Seventy (10%) underwent urgent surgeries, 47 (7%) of whom survived and 23 (3%) died. A large vessel injury in the pelvic region was detected in 13 (2%) patients. In the surviving surgical patients, a serious injury of pelvic venous plexus, as the only source of bleeding, was found only once (2%), while in patients who deceased post-surgically and pre-surgically, serious vascular injury in the pelvic region was diagnosed in 5 and 7 patients in both subgroups (22% and 41%, resp.). This difference was significantly higher in comparison with surviving patients (p=0.0002 and p=0.0109, resp.). CONCLUSION: The incidence of large vessel injury with severe bleeding associated with pelvic trauma was low in our study; however, the risk of death in patients with this injury was significantly higher. The results of our study support the hypothesis that in most patients a large artery or vein injury in combination with massive bleeding from the venous plexus due to a dislocated pelvic fracture results in death even before arrival of emergency services. This hypothesis could be verified in a study including also autopsy findings in persons who died even before hospital admission. KEY WORDS: unstable pelvic injury vascular injury risk of death.

[Double incision laparoscopic surgery]. / Laparoskopická chirurgie ze dvou incizí.

INTRODUCTION: Single incision laparoscopic surgery (SILS) is a common alternative to classical laparoscopic surgery. However, material costs of SILS significantly limit the spreading of this method to most of surgical departments in the Czech Republic. Therefore we introduced DILS, which is technically more difficult than 3- to 4-incision laparoscopy but comparable cost-wise and its result approaches the cosmetic effect of SILS. METHODS: We describe the technical approach for DILS. We evaluate our own group of patients who were operated on in 2012-2014. RESULTS: Nine minor complications evaluated as Clavien-Dindo grade I-IIIb were seen in the group of 64 patients undergoing laparoscopic cholecystectomy, appendectomy or TAPP operation of groin hernias using DILS method. DILS-cholecystectomy was converted to multiple-ports laparoscopy 4 times. CONCLUSION: In our group, DILS did not present a higher complication rate than laparoscopic surgery using multiple incisions. This method is well-regarded by the patients in terms of its aesthetic results, and economically it is more advantageous than SILS. KEY WORDS: minimally invasive surgery - SILS - double incision laparoscopic surgery.

[Kirschner wire transfixation of unstable ankle fractures: indication, surgical technique and outcomes]. / Transfixace nestabilních zlomenin hlezna Kirschnerovými dráty: indikace, technika provedení a výsledky.

PURPOSE OF THE STUDY The aim of the study was to assess treatment outcomes in patients undergoing K-wire transfixation of unstable ankle fractures and compare the results with those of patients in whom it was possible to perform primary one-stage osteosynthesis. MATERIAL AND METHODS Between 2009 and 2012, a total of 358 patients (191 women and 167 men) had surgery for unstable ankle fracture. At 1-year follow-up, their subjective feelings, objective findings and ankle radiographs were evaluated. The fractures were categorised according to the Weber classification. A patient group treated by one-stage osteosynthesis, a group with definitive transfixation and a group of patients in whom temporary transfixation was converted to definitive osteosynthesis were assessed and compared. RESULTS The group treated by one-stage osteosynthesis included 278 patients with an average age of 47 years; the group of 20 patients with definitive transfixation had an average age of 67 years, and the group of 60 patients who had temporary transfixation with subsequent conversion to internal osteosynthesis were 55 years on average. In the group with one-stage osteosynthesis, 223 (80%) ankle fractures on post-injury radiographs were associated with minor joint dislocations and 55 (20%) with major dislocations. On the other hand, the radiographs of the patients treated by temporary transfixation and delayed open reduction with internal fixation showed major dislocations in 38 (63%) and minor dislocations in the rest of the patients (37%); the difference between the two groups was statistically significant (p<0.001). Posterior malleolar fractures were most frequent in the group with temporary transfixation (60%) and least frequent in the group with primary osteosynthesis (44%); also this difference was statistically significant (p=0.032). At one-year follow-up, in the group with one-stage osteosynthesis, 220 patients (79%) had no radiographic signs of posttraumatic ankle osteoarthritis while, in the group with temporary transfixation, no radiographic evidence of ankle osteoarthritis was recorded in 25 (42%) patients. While tibiofibular synostosis was recorded in only few patients (9%) of the group with one-stage osteosynthesis, it showed a high occurrence in the group with temporary transfixation (35%). The patients with one-stage osteosynthesis (188/68%) had a higher proportion of excellent outcomes measured on the Olerund-Molander ankle scoring scale than the other two groups (temporary transfixation, 47%; definitive transfixation,10%); in both cases the difference was significant (p < 0.001 and p = 0.003, respectively). DISCUSSION In this study the morphological and clinical aspects of surgically treated ankle fractures were assessed. The patients with one-stage osteosynthesis were compared with those treated by temporary or definitive transfixation. The majority of patients undergoing temporary transfixation had a fractured posterior margin of the tibia and major ankle joint dislocation, which suggested serious injuries to bone and ligament structures. Generally, the use of only two K-wires inserted through the calcaneus and talus into the distal tibia is recommended. Patients with K-wire transfixation usually require a longer hospital stay because of the serious nature of their injuries. CONCLUSIONS The therapy of choice for unstable ankle fractures is one-stage osteosynthesis. Temporary transfixation is an effective method of primary management when an unstable fracture cannot be treated by definitive osteosynthesis at the early stage due to local or general health conditions of the patient. The temporary transfixation provides good alignment of the ankle joint necessary for successful healing of soft tissues. A higher occurrence of post-traumatic ankle osteoarthritis, ossification and distal tibiotalar synostosis found in the patients treated by temporary transfixation is more related to serious types of ankle fractures the patient had suffered than to the method itself. Key words: unstable ankle fracture, soft tissue condition, indications for transfixation, treatment outcome.

First detection of Chlamydia trachomatis LGV biovar in the Czech Republic, 2010-2011.

We present four cases of proctitis in HIV-infected men having sex with men (MSM) living in the Czech Republic. The causative agent in all cases was the lymphogranuloma venereum (LGV) biovar of Chlamydia trachomatis. The spread of proctitis caused by C. trachomatis serovars L1­3 among MSM has been observed in several European countries, the United States and Canada since 2003. To our knowledge, no LGV cases in eastern Europe have been published to date.

[Epidemiological, morphological and clinical aspects of ankle fractures]. / Epidemiologické, morfologické a klinické aspekty zlomenin v oblasti hlezna.

PURPOSE OF THE STUDY: The study presents the evaluation and comparison of two groups of patients surgically treated for ankle fractures at our department in 2007 and in 2010, respectively. Our analysis included patients' age, the mechanism of injury, fracture morphology and the method of osteosynthesis. The aim of the comparison was to ascertain recent trends in the development of the selected characteristics. MATERIAL AND METHODS: The 2007 group comprised 62 patients, 31 men and 32 women, the 2010 group had 123 patients, 55 men and 68 women. The ankle fractures were classified according to the Weber and Lauge-Hansen systems. The selected characteristics were analysed in each group and the results were compared to obtain information on changes during the interval of 4 years. The data were evaluated using the methods of descriptive statistics; categorical data were analysed by the chi-square test with the level of significance set at 5%. RESULTS: The average age was 44 years in men and 59 in women in the 2007 group and 40 years in men and 56 in women in the 2010 group; in the whole patient group, the average age decreased from 52 years in 2007 to 47 years in 2010. Based on the Weber classification, the incidence of fractures in 2007 and 2010 was as follows; type A, 5% in both years; type B, 68% and 72%; type C, 27% and 23%. There was no significant difference between the groups in the incidence of either type B or type C fractures (p = 0.823 and p = 0.659, respectively). The majority of fractures were caused by low-energy mechanisms. High-energy injuries due to falls from a height or traffic accidents did not exceed 6 %. In men, who sustained sports-related injury more often, fractures were found in 23% and 16% in 2007 and 2010, respectively; this difference approached statistical significance (p = 0.050). Most of the fibular fractures were managed by plate osteosynthesis, often in combination with lag screws. Medial malleolar fractures were usually fixed with two cancellous screws, or with a screw and a K-wire. The number of surgical inspections of the medial structures of an injured ankle with no medial malleolar fracture decreased from 68% in 2007 to 37% in 2010. Osteosynthesis of a fractured posterior margin of the distal tibia was carried out in 7% of the patients in 2007 and in 23% in 2010. DISCUSSION: The morphological and epidemiological characteristics described were selected to obtain a comprehensive notion of the patients studied. Only the patients who had surgery were included. An increase in the number of ankle fractures managed surgically during a four-year period of our study was due to a growing number of patients and the fact that surgery was indicated more frequently because stricter criteria for assessment of post-reduction findings or secondary displacement were adopted. In surgical treatment, the recent trend preferring primary osteosynthesis to transfixation or external fixation has been evident because it allows for early rehabilitation and return to normal activities. CONCLUSIONS: The number of ankle fractures treated by primary osteosynthesis grew between 2007 and 2010. There was also an increase in the number of fractured posterior margins of the distal tibia managed by osteosynthesis. The results of the Weber and Lauge-Hansen classifications were in agreement with the relevant literature data. In the majority of cases the ankle fracture occurred as a single trauma.

[The NanoKnife and two successful cases of intracavitary irreversible electroporation of main bronchus tumours]. / NanoKnife a dva úspesné prípady intrakavitální ireverzibilní elektroporatizace nádoru hlavního bronchu.

We have used the method of irreversible electroporation (IRE) twice to treat central non-small cell lung tumours. Both tumours obstructed the right main stem bronchus. Due to a high risk of right-sided pneumonectomy we chose to apply the tissue sparing device called NanoKnife and an alternative IRE method. The first surgery was performed in August 2011 and the second one in June 2012. The first case was an epidermoid carcinoma, 3 cm in size, which completely obstructed the right main stem bronchus on the boundary line with the upper lobar bronchus and caused lung atelectasis. The second case was a carcinoid, 2 cm in size, which grew from the main stem bronchus to the carina. Pneumonectomy was contraindicated due to lung function in the first case, and the other patient preferred the IRE method to radical but risky resection with bronchoplasty. IRE was performed through open thoracotomy. No complications were detected after the surgery in both cases. The first patient was discharged on the 12th postoperative day and the second one on the 5th postoperative day. 98% regression of the tumour was detected by CT scan in the first patient, and complete regression occurred in the case of the second one. 100% apoptosis and "disparition" of the carcinoma in the first case was verified by bronchoscopy and cytology after 6 months. Both patients remain in follow-up after surgery using the IRE method and are without subjective or objective complaints and without any signs of tumour recurrence. NanoKnife and IRE without lung resection resulted in the destruction of lung tumours while preserving the lung parenchyma and pulmonary functions.

[Fascial closure of the abdominal wall by dynamic suture after topical negative pressure laparostomy treatment of severe peritonitis--results of a prospective randomized study]. / Uzáver steny brisní po laparostomii s pouzitím negativníiho tlaku pro tezkou peritonitidu pomocí dynamické fasciální sutury--výsledky prospektivní randomizované studie.

INTRODUCTION: Severe peritonitis is a frequent condition characterized by high morbidity and mortality rates. Topical negative pressure (TNP) laparostomy could improve the results of the treatment, provided that the adverse events of this method are reduced. The aim of our study was to prove, in a prospective randomized study, that the primary use of TNP laparostomy reduces morbidity and mortality when compared to primary abdominal wall closure after the index surgery for severe peritonitis. The possibility of the abdominal wall fascial closure significantly influencing morbidity was the main topic of this study. MATERIAL AND METHODS: Between 9/2009 and 9/2011,57 patients with severe peritonitis were included in the study at the Department of Surgery of the Bulovka Faculty Hospital; 28 of them were randomized to the TNP laparostomy group and 29 to the primary closure group. The two groups did not differ in age, gender, polymorbidity and severity of peritonitis. RESULTS: The length of hospital stay was similar in both groups (median: 22 days; range 10-171 days) in the intervention group and 23 days (range 3-71) in the control group (p = 0.89). The mortality rate was significantly lower in the TNP laparostomy group in comparison with the primary closure group (3 patients, 11% vs. 12 patients, 41%; p = 0.01). A complete closure of the abdominal wall including fascia and complete abdominal wall healing was achieved in 80% of survivors in the TNP group, compared to 29% in the primary closure group (p = 0.01). No enteral fistula occurred in any surviving patients from both groups. The overall length of abdominal wall healing was significantly shorter in the TNP group (median: 7; 7-94 days, versus 30; 7-223; p = 0.04). CONCLUSIONS: Primary TNP laparostomy is an effective and safe method in the treatment of severe peritonitis. Keeping good clinical practice, especially using dynamic suture as early as after the index surgery and the timely closure of laparostomy as soon as the indication disappears (according to relevant criteria) leads to a significantly higher abdominal wall healing rate, icluding fascial closure, than after peritonitis treatment without laparostomy.

[Sacral nerve stimulation in the treatment of fecal incontinence--initial experience in the Czech Republic and assessment of functional outcomes]. / Stimulace sakrálního nervu v lécbe fekální inkontinence--první zkusenosti v Ceské republice a hodnocení funkcních výsledku.

INTRODUCTION: During the last decade, sacral nerve stimulation (SNS) has become a new perspective and effective method in the treatment of fecal incontinence. In the Czech Republic, SNSs have been used since 2010. METHODS: From May 2010 to August 2011, sacral nerve stimulation was performed in 15 patients in FN Na Bulovce Surgical Clinic in Prague. All of the subjects were female patients and their mean age was 59 (46-68 years of age). The first phase of the treatment included the following procedures: percutaneous sacral nerve (S2-S4) examination, electrode implantation and subchronic stimulation. Permanent neurostimulator implantation was indicated in 14 out of the 15 subjects and over 50% of them experienced reduction in incontinence episodes. The following neurostimulators were used: Medtronic InterStim 3023 or InterStim II 3058. Stimulation parameters included 15 Hz frequency, pulse width of 210 micros and the stimulation range was between 1-3 V. The patients' follow up period was 1-15 months after the procedure. OUTCOMES: After the first phase of SNS, the morbidy rate was 7%. The morbidity rate after the permanent neurostimulator implantation was 0 %. Permanent neurostimulators were implanted in 14 out of the total of 15 subjects, i.e. the success rate was 93 %. Based on the incontinence recording sheet (diary) data collected from all the 14 subjects, the mean number of incontinence epizodes was 24 epizodes/week (+/- 13.0) before the stimulation and 4 epizodes/week (+/- 3.8) after the stimulation procedure. Cleveland Clinic Incontinence Score was assessed in the first 8 subjects and its mean value was 20 (+/- 0.7) before the procedure, vs. 7 (+/- 1.2) after the stimulation procedure. The both values were significantly lower after the stimulation procedure (p <0.05). No significant differences between the manometric values before the procedure and after the stimulation procedure were detected. SF-36 showed improvement in the quality of life, in particular in the parameters assessing social and mental functions. Nevertheless, there were no significant differences in any of the studied parameters. CONCLUSION: The initial experience with SNS in the Czech Republic showed over 50% improvement in continence rates in 93% of the subjects with introduction of stimulation electrodes and subchronic stimulation and over 50% improvement in 100% of the subjects, who underwent permanent neurostimulator implantations, and full continence was achieved in 33% of the subjects.

The membrane-bound quinohemoprotein alcohol dehydrogenase from Gluconacetobacter diazotrophicus PAL5 carries a [2Fe-2S] cluster.

Gluconacetobacter diazotrophicus stands out among the acetic acid bacteria as it fixes dinitrogen and is a true endophyte. It has a set of constitutive enzymes to oxidize ethanol and acetaldehyde which is upregulated during N(2)-dependent growth. The membrane-bound alcohol dehydrogenase (ADH) is a heterodimer (subunit I approximately 72 kDa, subunit II approximately 44 kDa) and constitutes an important component of this organism. ADH of Ga. diazotrophicus is a typical quinohemoprotein with one pyrroloquinoline quinone (PQQ) and four c-type cytochromes. For the first time, a [2Fe-2S] cluster has been identified by EPR spectroscopy in this type of enzyme. This finding is supported by quantitative chemical analysis, revealing 5.90 +/- 0.15 Fe and 2.06 +/- 0.10 acid-labile sulfurs per ADH heterodimer. The X-band EPR spectrum of ADH (as isolated in the presence of dioxygen, 20 K) showed three broad resonances at g 2.007, 1.941, and 1.920 (g(av) 1.956), as well as an intense narrow line centered at g = 2.0034. The latter signal, which was still detected at 100 K, was attributed to the PQQ semiquinone radical (PQQ(sq)). The broad resonances observed at lower temperature were assigned to the [2Fe-2S] cluster in the one-electron reduced state. The oxidation-reduction potentials E(m) (pH 6.0 vs SHE) of the four c-type cytochromes were estimated to E(m1) = -64 (+/-2) mV, E(m2) = -8 (+/-2) mV, E(m3) = +185 (+/-15) mV, and E(m4) = +210 (+/-10) mV (spectroelectrochemistry), E(mFeS) = -250 (+/-5) mV for the [2Fe-2S] cluster, and E(mPQQ) = -210 (+/-5) mV for the PQQ/PQQH(2) couple (EPR spectroscopy). We propose a model for the membrane-bound ADH of Ga. diazotrophicus showing hypothetical intra- and intermolecular electron pathways. Subunit I binds the PQQ cofactor, the [2Fe-2S] cluster, and one c-type cytochrome. Subunit II harbors three c-type cytochromes, thus providing an efficient electron transfer route to quinones located in the cytoplasmic membrane.

[Malignant ascites--optional management using hyperthermic peroperative chemotherapy (HIPEC)]. / Maligní ascites--moznost ovlivnení tvorby pomocí hypertermické peroperacní chemoterapie (HIPEC).

UNLABELLED: 146 procedures using hyperthermic intraoperative peritoneal chemotherapy (HIPEC) were performed in 121 patients in the FNB Surgical Clinic, during 2000-2008. During these procedures, ascites was detected in 30 subjects (24.8%) and its volume was 250-11,000 ml. The patients concerned could not undergo radical surgery for their GIT or gynecological tumors. The patient group was divided into two subgroups. Subgroup A (22 subjects) included subjects, in whom at least palliative debulking of the tumors (usually total omentectomy) was feasible, and the procedure was followed by HIPEC. Subgroup B (8 patients) included subjects who could not undergo even the minimum debulking procedure because of extensive tumorous spread in their abdominal cavity, underwent only HIPEC. Out of the total of 22 subjects in Subgroup A, ascites was not postoperatively recorded in 17 patients. In 5 patients, ascites was gradually formed from month 6.3 onwards, however, it only reached subclinical levels. In this subgroup, 7 patients exited (at the mean postoperative month 11.7), the remaining 15 patients were surviving at that time, out of whom 9 patients were surviving for more than 1 year after the procedure, 4 subjects were surviving for over 2 years after the procedure and 2 patients for over 4 years. The geometric mean survival time 16.49 months, standard deviation of 1.57. In Subgroup B (8 patients), no ascites was detected in 3 subjects until their death (37.5%), further 5 subjects presented with ascites at the mean postoperative month 7.25. These patients survived for 2-23 months. The geometric mean survival time was 6.83 months, standard deviation of 2.12. There was a statistically significant difference between the two subgoups in the survival time parametres (p = 0.009), thereas, the difference in ascites relapse rates was statistically insignificant (p = 0.12). In the whole study group, in-hospital morbidity was 16.6% and lethality 3.3%. CONCLUSIONS: HIPEC with/without debulking is an efficient method for controlling, managing or preventing the development of malignant ascites, it extends the mean survival time of the patients (especially when bulking is feasible) with low morbidity and lethality rates of the procedure.

[Tolerance of accelerated postoperative rehabilitation following intestinal resections]. / Tolerance akcelerované pooperacní rehabilitace po strevních resekcních výkonech.

INTRODUCTION: Modern procedures in peri-operative care arising from evidence-based medicine improve postoperative results. Their acceptance is however not a common clinical practice at most surgical centers. AIM: The aim of our study was to design a protocol and introduce it into the praxis. The subject of announcement is tolerance of protocol in our conditions. PATIENTS AND METHOD: Prospective randomized study included patients who were operated on (open bowel resection) at Department of Surgery in period 4/2005-12/2007. They were randomized in fast track group (n=53) and non-fast track group (n=52). Protocol with accelerated recovery was used in the fast track group (FTG) and we used traditional approach in the not-fast track (non-FTG). Results were statistically evaluated, 2 patients (FTG) were excluded from analysis for protocol failure (protocol was non kept by anesthesiologist in 1 patient and by the nurse in the second patient). Protocol and informed consent form was approved by the Hospital Ethics Committee. RESULTS: Both groups did not differ in age, diagnosis and length of surgery. Analgesia was controlled significantly better in FTG; similarly oral intake tolerance was higher in this group (day of surgery--mean value 634 ml versus 304 ml). Restoration of bowel functions was also faster in interventional group (mean time 2.1 versus 3.9 days). Frequency of postoperative complications was lower and hospital stay was shorter (median 7.0 versus 9.0 days, p < 0.001). CONCLUSION: Designed fast track protocol of postoperative recovery could be introduced in clinical praxis in terms of study. Patients' tolerance was very good. Application of accelerated recovery procedures is possible in our conditions but it means primarily to overcome worse tolerance of attending personnel.

[New types of diamond whetstones (Chirana State Enterprise Nove Mesto). 2. Diamond-coated whetstones with different grain size]. / Nové typy diamantovaných brousku Chirana, státní podnik Nové Mesto na morave. Cást II. Diamantované brousky s jemnejsí a hrubsí zrnitostí.

The selection of diamond-coates whetstones manufactured by Chirana for turbine drills is extended at present by two new types of toods with a different size of diamond particles. In practice they prove useful in more effective in the final stages of the final preparation of the ground surface.