[Pathological Lesions and Fractures of the Proximal Femur]. / Patologická loziska a zlomeniny proximálního femuru.

PURPOSE OF THE STUDY The aim of the study was to determine the incidence of primary malignancies metastasizing to the area of the proximal femur, to evaluate the localization of the lesions and fractures, to compare the results of the selected surgical therapy, survival time of the patients and postoperative complications. MATERIAL AND METHODS We retrospectively evaluated the group of patients operated on from 2012 to 2021. The study included 45 patients (24 women and 21 men) with a pathological lesion or a pathological fracture in the area of the proximal femur. The average age was 67 years (38-90). There were 30 (67%) cases of pathological fracture and 15 (33%) cases of pathological lesions in the cohort. In each patient, the perioperative biopsy or resected sample was sent for histological examination. The type of primary malignancy with the localization of lesions and fractures was assessed. Furthermore, we evaluated the outcomes of the surgical method chosen and its complications. We monitored the patients' functional score using the Karnofsky performance status and survival interval. RESULTS The most common primary malignancy was multiple myeloma in 10 cases (22%), followed by seven cases (16%) of breast and lung cancer and 6 cases (13%) of clear cell renal cell carcinoma. Internal fixation was used in 15 cases (33%). Tumor resection with hip joint replacement was performed in 29 patients (64%). One patient was treated with percutaneous femoroplasty. Out of a total of 45 patients, 10 patients (22%) survived for less than three months. The survival rate of more than one year was observed in 21 patients (47%). A total of seven complications occurred in six patients (15%). Fewer complications occurred in the group of patients with a pathological fracture compared to the group with an impending fracture. DISCUSSION Pathological lesions in the bone or an already existing pathological fracture are signs of advanced cancer. Better outcomes are reported in patients who underwent prophylactic surgery, which was, however, not confirmed by our study. The incidence of individual primary malignancies, the postoperative complications and the patient survival corresponded to the statistical data reported by the other authors. CONCLUSIONS In patients with a pathological lesion of the proximal femur, operative treatment will increase the quality of life, either when choosing osteosynthesis or joint replacement, while prophylactic treatment is usually associated with a better prognosis. As a less invasive procedure with lower blood loss, osteosynthesis is indicated for palliative therapy in patients with a limited expected survival time or in patients with a prognosis of healing of the lesion. Reconstruction of the joint with an arthroplasty is indicated in patients with a better prognosis or in cases excluding safe osteosynthesis. Our study confirmed good outcomes with the use of an uncemented revision femoral component. Key words: metastasis, osteolysis, pathological fracture, proximal femur.

[Intra-operative periprosthetic fractures during THA in the period 1995-2009]. / Peroperacní periprotetické zlomeniny u TEP kycelního kloubu v letech 1995-2009.

PURPOSE OF THE STUDY: The aim of this prospective study was to investigate whether female gender and revision surgery were significant risk factors for intra-operative periprosthetic fractures during total hip arthroplasty (THA). MATERIAL AND METHODS: The group investigated comprised the patients who, in the period 1995-2009, sustained an intra-operative periprosthetic fracture during primary or revision THA. The patients were treated by a therapeutic procedure based on the Vancouver system. The results were related to the total number of patients undergoing THA in that period, Statistical analysis was performed using Pearson's x2 test at the 5% significance level. RESULTS: Intra-operative periprosthetic fractures occurred in 110 patients (89 women, 21 men). The average age of the patients was 69 years (70 in women and 62 in men). The women significantly outnumbered the men (p < 0.001). In the period under study, 2936 primary and 791 revision THAs were performed; the incidence of all intra-operative fractures was 3%. Intra-operative fractures during primary THA were recorded in 95 patients (3.2%; range in individual years, 0.4 to 5.9%); fractures during revision THA were found in 15 patients (1.9%; range, 0 to 8.0%). This difference was slightly above the set significance level (p = 0.057). The majority of intra-operative fractures were minimal Vancouver type-A fractures in the greater trochanter region. They were recorded in 95 of the 110 patients (86%) with either primary or revision THA. Of the 15 type-B fractures, eight were shown by a detailed evaluation to occur during revision THA. An independent analysis of type-B fractures in relation to all replacements showed that their occurrence was significantly higher in revision than in primary THA (p = 0.006). DISCUSSION Intra-operative periprosthetic fractures have primarily been studied in terms of their frequency and the cause of their occurrence. Revision surgery and female gender are regarded as risk and predisposing factors. Our results, in accordance with other relevant data, confirmed that serious intra-operative type-B fracture occurred more frequently during revision THA than during primary surgery. It further showed a significantly higher number of periprosthetic fractures in women than in men. However, this finding is affected by the fact that women in general undergo more THAs than men and that the female median life span is longer. The authors consider a careful pre-operative planning and thorough evaluation of all risk factors related to surgery as basic preventive measures. CONCLUSIONS This continuous 15-year study on patients with intra-operative periprosthetic fractures of the hip has allowed us to conclude that these fractures occur more frequently in women than in men, and that more serious fractures (Vancouver type-B) are significantly more frequent during revision than primary THA. The higher incidence in women is, to a great part, accounted for by osteoporosis of the skeleton in elderly people. In revision THA, poor bone quality plays a role as well as osteolysis due to polyethylene granuloma which may be present.

[Ipsilateral fractures of the proximal femur and the femoral shaft]. / Ipsilaterální zlomeniny proximálního konce a diafýzy femuru.

PURPOSE OF THE STUDY: The aim of the study was a retrospective evaluation of the surgical treatment of 171 fractures of the proximal femur and the femoral shaft. MATERIAL AND METHODS: Between the years 1994 and 2008, 171 ipsilateral fractures were operatively treated in 169 patients with an average age of 56 years (range, 21-97 years). The group comprised 108 men and 61 women. The fracture was fixed by the long Gamma nail (Howmedica) in 18 cases, by the long PFN (Synthes) in 147 cases and by the long PFH (Medin) in three cases. In two patients with a bilateral fracture, a reconstruction nail was used on one side and a combination of DHS and condylar plate on the other. External fixation was used in a patient with severe burns. In one case the fracture was fixed by a LCP Proximal Femoral Plate. Types of fractures were evaluated on the basis of the authors' own classification of 1998. Type I (concomitant femoral neck and femoral shaft fractures) accounted for 13 %, Type II (pertrochanteric fracture and femoral shaft fracture) for 23 %, Type III (complex fracture of the proximal femur extending from the femoral neck base to the femoral shaft) for 21 %, Type IV (high subtrochanteric fracture extending from the tuberculum innominatum to the femoral shaft) for 40 % and Type V (Type I or II with a fracture of the distal femur) for 3 % of fractures. In 68 % of cases the injury was caused by high-energy trauma. In Types I and V it involved all the patients, in Type II 95 % of them. These fractures occurred primarily within a polytrauma or as an associated injury (91 %). Types III and IV included mainly monotrauma cases (78 %). The minimum follow-up period was 12 months (1-15 years). RESULTS: Of 129 fractures, 127 (98 %) healed within 12 months after the injury. In one patient, non-union healed after re-nailing 15 months after the injury. In another case, infected non-union healed 18 months after the injury. In the whole group, 14 intraoperative and 9 early postoperative complications (14 %) were encountered. In the group of 129 patients followed up minimally for 1 year, 16 late complications (12 %) were recorded. In 125 cases treated with a reconstruction nail there were 13 complications (10 %) and in four patients treated by another method, complications occurred in three cases. The highest number of complications was recorded in Type V fractures (3 of 5). Excellent results were achieved in 63 %, good in 29 %, fair in 6 % and poor results in 2 % of the patients. DISCUSSION: There is no generally accepted classification of ipsilateral fractures of the femur. Therefore, we used our own classification that proved useful in evaluation of the group of patients.We only slightly modified it in terms of the findings. Type III and type IV fractures have a number of characteristic features in common and so we decided to cover them by one type of complex fractures extending from the femoral neck base as far as the femoral shaft. There is no consensus concerning the treatment. In addition, the percentage of complications is quite high. The group was treated almost exclusively with the reconstruction nail. In 2 % we used another method of internal fixation. Our results do not differ from those reported by other authors. CONCLUSIONS: In case of fractures of the femoral shaft, in high-energy trauma particularly, it is necessary to check the patient for a potential proximal femur fracture. The diagnosis should be made on the basis of a radiograph of the pelvis in internal rotation and axial projection and CT scans for evaluation of the proximal femur, including 2D CT reconstructions. Prior to nailing of the femoral shaft, sciascopic examination must be made of the hip in both projections. Fixation by a reconstruction nail is a suitable method for treatment of ipsilateral fractures.We consider the risk of complications adequate to the mechanism of injury and its severity.

[Osteosynthesis for periprosthetic supracondylar fracture above a total knee arthroplasty using a locking compression plate]. / Osteosyntéza periprotetické suprakondylické zlomeniny kolenního kloubu s pouzitím LCP dlahy.

PURPOSE OF THE STUDY: The frequency of periprosthetic fractures related to total knee arthroplasty is increasing, with a prevalence of 1.3% on the average and with women being affected more often (4 out of 5 patients). Fractures of the distal femur are common, while tibial fractures are rare. Crucial for treatment is to distinguish fractures of the metaphysis above the femoral component, which remains firmly fixed, from those involving the knee joint replacement and component loosening. Supracondylar periprosthetic fractures are almost always managed surgically, using methods of osteosynthesis with an angle condylar or DCS plate, or a short retrograde- inserted supracondylar intramedullary nail. The recent use of implants such as LCPs with angle-stable screws has offered good prospects. This retrospective study presents our first experience with an LCP for treatment of supracondylar periprosthetic fractures of the knee joint. MATERIAL AND METHODS: Between 2005 and 2008, a total of 13 supracondylar periprosthetic knee fractures were treated by the LCP technique. The patient group included 10 women and three men the average age was 67.4 (range, 56-81) years. The fractures were classified using the system proposed by Su et al. and the AO classification system. According to the Su classification, 12 types I and II fractures and one type III fracture were indicated for osteosynthesis. Based on the AO classification, there were four type 33 A1 fractures, five 33 A2 fractures, three 33 A3 fractures and one 33 C2 initially incorrectly classified as type 33 A3 fracture. The average time between total knee arthroplasty and injury was 6.8 years. In all patients fractures occurred after primary implantation of a cemented condylar total knee replacement without a femoral stem.The fractures were treated by a less invasive technique of LCP implantation within an average of 2.5 days of injury. The patients were followed up until radiographic fracture union, and complications were recorded. RESULTS: The 13 patients were treated by LCP osteosynthesis through a less invasive approach. One patient had primary spongioplasty, two had spongioplasty after an interval of 7 weeks. One patient died of a disease unrelated to trauma and surgery at 3 months after osteosynthesis. In one patient, osteosynthesis failed with fragment dislocation shortly after the operation. The case analysis showed that the initial indication was marginal and the comminuted zone was too low above the implant, with the fracture line extending to the component. Subsequently, conversion to revision total knee arthroplasty involving a stem was carried out. In nine patients, bone union was achieved in an average of 18 weeks, with radiographic evidence of fracture union. No complications such as wound infection, delayed wound healing or thromboembolic disease were recorded. No bone union failure and pseudoarthrosis development occurred. DISCUSSION: There are only few reports on the treatment of supracondylar periprosthetic knee fractures and evaluation of its results in the literature, and the groups evaluated are small. In a meta-analysis of cases from the 1981 to 2006 period, Herrera et al. have found only 29 assessable studies with a total of 415 cases, i.e., an average of 14 cases per study. The usual method of treatment was DCS plate osteosynthesis. Complications associated with conventional osteosynthesis techniques, as reported by various authors, may reach up to 30% (pseudoarthrosis development, 9% osteosynthesis failure, 4% necessity of revision surgery, 13% fracture malunion, 47%).Good results have been achieved with a retrograde-inserted intramedullary nail. The use of an LCP has been reported in the literature only occasionally. The classification system described by Rorabeck et al. is most widely used, but the system proposed by Su et al. seems more convenient to us, because fractures are placed in three groups, according to the localisation of a fracture line and its distance from the femoral component, as follows: type 1 fracture, fracture line is proximal to the femoral component type 2 fracture, fracture line starts at the level of a proximal edge of the femoral component and runs proximally type 3 fracture, fracture line extends below the upper end of the femoral component. Type 1 fracture is indicated for a retro- grade-inserted intramedullary nail, type 2 fracture for LCP osteosynthesis, and type 3 fracture for revision total knee arthroplasty. The use of LCPs in the treatment of supracondylar fractures of total knee arthroplasty, with a success rate of 86%, is described by Ricci et al. Other authors also report better outcomes with the use of LISS or LCP methods than with conventional osteosynthesis techniques. CONCLUSIONS: Osteosynthesis with an angle-stable table LCP is an efficient method suitable also for the treatment of periprosthetic fractures of the distal femur above total knee arthroplasty. It offers all advantages of angle-stable implants. It is more effective for osteoporotic bone than a DCS implant or a condylar plate, because it provides better fixation stability for the distal fragment. However, further studies are needed to compare its efficiency with that of an IM nail.

[Judet posterior approach to the scapula]. / Judetuv zadní prístup k lopatce.

PURPOSE OF THE STUDY: A detailed description of the Judet posterior approach to the scapula. MATERIAL AND METHODS: The authors used this approach in 24 patients operated on for fractures of the scapular body and neck and for combined fractures of the scapula. In 23 patients the surgical site healed without complications, in 1 case revision was required due to a haematoma. DESCRIPTION OF THE APPROACH: The approach has three phases. The first of them consists in a boomerang skin incision along the scapular spine and the medial scapular border producing a skin flap, and identification of the posterior border of the deltoid. In the next phase, the posterior deltoid is dissected off the scapular spine and reflected laterally. In the final phase, the infraspinatus is mobilized and reflected proximally. During the whole procedure the neurovascular bundle passing from the spinoglenoid notch to the infraspinatus must be handled with maximum caution. In certain types of fractures of the scapula, this approach may be limited using a medial and a lateral window to expose the respective borders of the scapular body, without full mobilization of the infraspinatus. On the other hand, where the fracture of the scapula is associated with a fracture of the lateral clavicle or dislocation of the AC joint, the approach may be extended using a saber cut incision starting from the proximolateral angle of the Judet incision and passing over the AC joint. This modification was used in a fracture of the scapular body associated with dislocation of the AC joint. DISCUSSION: The advantage of the Judet approach is an excellent exposure of the infraspinousus fossa. The main disadvantage of this approach is considered its extensiveness and atrophy of the infraspinatus that is most probably caused by its mobilization. However, there may be more causes of this atrophy. The first of them is injury to the suprascapular nerve in fractures of the surgical neck of the scapula by its entrapment in the fracture line. In these fractures the whole course of the nerve in the spinoglenoid notch should be revised. Another cause may be overstretching of the nerve during the operation, when the mobilized muscle is retracted too far proximally, medially or laterally. Therefore a continuous visual control of the nerve is of vital importance. The third cause is inadequate reinsertion of the muscle. A certain role may be played also by insufficient postoperative rehabilitation. Clinical experience gained in the treatment of our patients and a personal experience of one of the authors (injury to the suprascapular nerve during arthroscopy of the shoulder and complete atrophy of the muscle) prove that even after dennervation of the infraspinatus the function of the shoulder is almost normal. Performance of a limited approach using a lateral and a medial window requires sufficient experience in both the Judet approach and internal fixation of the scapula fractures. This modification is indicated in transverse two-part fractures of the scapular body and exceptionally in three-part T- or Y-fractures of the scapular body with a minimal displacement in the vertical fracture line. Its use depends also on the type of the fracture of the lateral border of scapula. Where an interfragment is broken off the lateral border, the fracture line passes close below the glenoid or involves it, the use of a limited approach is questionable. Of great importance in this respect is also the trauma-operation interval. After one week the reduction of the fragments from the limited approach is difficult and there is a potential risk of injury to the suprascapular nerve. An alternative lateral direct approach to the lateral border of the scapula, described for the first time by Dupont and Evrard in 1932, provides only limited exposure and cannot be, where necessary, extended to the entire infraspinous fossa. Therefore it is not suitable for treatment of the scapular body and neck. The posterosuperior approach is indicated in isolated fractures of the posterior glenoid. It uses the horizontal part of the Judet incision and passes along the posterior edge of the acromion and the lateral portion of the scapular spine. After dissection of the spinal and partially the acromial portion of the deltoid off the bone, the muscle can be retracted distally providing access to a more deeply located tendon of the infraspinatus. The tendon may be either retracted or cut and carefully elevated medially thus providing access to the posterior surface of the glenoid and the scapular neck. Where necessary, this approach may be converted to the Judet approach. CONCLUSION: The discussed disadvantages of the Judet approach are relative and its benefits clearly prevail. Therefore it is recommended as the basic posterior approach for operative treatment of fractures of the scapula. Key words: scapula fractures, operative treatment, Judet approach.

[Fractures of sternal end of the clavicle--current concept review]. / Zlomeniny mediálního klíku--Souhrnný referát.

Fractures of the medial end of the clavicle are still an outstanding issue with only minimum information available. Their diagnosis requires a special care both in isolated fractures of the clavicle and in polytrauma. An accurate diagnosis is impossible without CT scanning, preferably with a 3D reconstruction. Non-displaced fractures are indicated for non-operative treatment. In displaced fractures, sustained particularly by younger or active individuals, operative treatment should be considered. Best suitable for fixation is a cerclage, K-wires are strictly contraindicated. Formulation of a more specific opinion on the method of treatment, long-term outcomes and complications will be possible only on the basis of a greater number of reported cases.

[S-ROM Modular THR System -Three and Half Years of Experience.]. / S-ROM systém totální náhrady kycelního kloubu: 3,5 roku zkuseností

UNLABELLED: PURPOSE OF THE STUDY Presentation of the first 3,5-year experience with the application of S-ROM system in total hip arthroplasty. MATERIAL A retrospective study evaluating 33 patients (14 men, 19 women), average age 57 years (25-84 years) operated on in the period betwen December 1996 and June 2000. In 5 cases we performed primary implantation and in 28 cases revision surgery. Indications to primary surgery included once primary osteoarthritis, twice postdysplastic osteoarthritis and twice trauma. Of revision surgeries, there were 19 cases of aseptic loosening, 8 cases of septic loosening and once malposition of the stem. In 10 cases the revision surgery consisted in a mere replacement of the stem, complete replantation including the acetabular cup was performed in 18 cases. In 24 cases it was the first revision of the stem, in 4 cases the second revision. In 19 patients the revised stem was originally cemented, in 8 patients cementless and in 2 patients it was impossible to identify the original type of the stem. Acetabular cup was replanted in 18 cases with two exceptions by means of a cementless component. METHOD The evaluation concentrated mainly on peroperative and postoperative complications and symptoms of loosening.The follow-up ranged between 4 and 45 months with the average of 30 months. Twenty-four patients were followed for more than 2 years, 16 patients for more than 3 years, 4 patients for less than one year. OUTCOMES We recorded in total 15 complications, of which 8 peroperative and 6 postoperative. Of 8 peroperative complications we evaluated 6 cases as specific for S-ROM. In 5 cases the introduction of the stem resulted in the calcar split which was treated by wire cerclage. In 1 case when we applied in the revision surgery a longer straight stem the tip of the stem got to a close contact, even perforated the anterior cortex of the femoral shaft. A nonspecific complication was represented by a spiral fracture of femoral shaft during the perforation of the pedestal formation below the tip of the original cementless loosened stem. The fracture was treated by a plate. For a similarly non-specific complication we consider partial reaming of the medial cortex during the revision surgery of a loosened cemented stem. Both the calcar splits and the fracture of the shaft healed without any complications. The cases of the perforation of the anterior cortex and the above mentioned reaming of the medial cortex were not associated with any subjective complaints or objective problems, either. Six postoperative complications included three dislocations (twice treated by open reduction), one paraarticular heterotopic ossification (Brooker III type), once pain in the thigh and once recurrence of the infection. In 24 patients with the follow-up longer than two years we did not record any signs of loosening or localized osteolysis or signs of metal wear betwen the stem and the conical sleeve. In 30 cases we evaluate the result of the operation as very good. As a failure we consider the case of a recurring dislocations, the case of paraarticular ossifications and thigh pain and the case of the recurrent infection. DISCUSSION Our results prove the existing literary data on good medium-term results of the application of S-ROM system, mainly in case of revision surgery. Its specific complication is a peroperative calcar (Adam's arch) split and perforation of the anterior diaphyseal cortex when using the long stem. CONCLUSION S-ROM represents a perspective system for revision surgeries. It is contraindicated in case of extensive defects of the proximal femur which do not allow to anchor the conic sleeve and in case of severe osteoporosis. KEY WORDS: total hip arthroplasty, S-ROM, revision surgery.