[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.

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.

[Biomechanika osteosyntézy periprotetických zlomenin femuru po aloplastice kycelního kloubu]. / Biomechanics of Osteosynthesis in Periprosthetic Femoral Fractures Following Total Hip Arthroplasty.

Periprosthetic femoral fractures around the femoral stem of a hip prosthesis constitute a serious challenge. The number of these fractures, associated with a high failure rate and a high number of overall complications, including higher mortality, has been on an increase worldwide. Stable femoral stems are indicated for osteosynthesis, while in case of loosening the method of choice is the replacement by a revision implant. The aim of osteosynthesis of periprosthetic femoral fractures is a stable fixation with soft tissue preservation which results in faster union allowing the patient to return to pre-injury activities. Biomechanical studies on cadavers or on synthetic models and computer simulations make it possible to evaluate the fixation strength in various types of implants in dependence on fracture characteristics and bone quality, but cannot be substituted for clinical trials since there is no direct proportion between fixation rigidity and fracture union. Fundamental principles that shall be followed in osteosynthesis of periprosthetic fractures can be deduced from the available studies. Proximal fixation by screws or a combination of screws and cables are biomechanically more advantageous than the Ogden fixation by cerclage wires or cables. Bicortical fixation enabled by state-of-the-art implants of LAP-LCP or NCB type represents a significantly more stable construction compared to monocortical fixation and led to reduced use of structural allografts. Better stability can be achieved by "double plating" technique which is applied especially in revision surgeries, but also in osteoporotic periprosthetic fractures with a defect zone. In these cases, osteosynthesis with long plates is recommended, bridging the entire femur, i.e. distally with femoral condyles fixation since this prevents the risk of a fracture below the plate. In shorter plates, this risk created by stress concentration at the end screw is amplified when a distal bicortical locking screw is used. That is why it is beneficial to reduce this stress by a monocortical screw or with the use of a conventional screw. Adherence to the principles regarding the position, type and number of screws constitutes the key parameter of successful osteosynthesis of periprosthetic fractures. Key words: hip joint, arthroplasty, periprosthetic fractures, biomechanics of osteosynthesis.

Excess mortality in the United States during the first three months of the COVID-19 pandemic.

Deaths are frequently under-estimated during emergencies, times when accurate mortality estimates are crucial for emergency response. This study estimates excess all-cause, pneumonia and influenza mortality during the coronavirus disease 2019 (COVID-19) pandemic using the 11 September 2020 release of weekly mortality data from the United States (U.S.) Mortality Surveillance System (MSS) from 27 September 2015 to 9 May 2020, using semiparametric and conventional time-series models in 13 states with high reported COVID-19 deaths and apparently complete mortality data: California, Colorado, Connecticut, Florida, Illinois, Indiana, Louisiana, Massachusetts, Michigan, New Jersey, New York, Pennsylvania and Washington. We estimated greater excess mortality than official COVID-19 mortality in the U.S. (excess mortality 95% confidence interval (CI) 100 013-127 501 vs. 78 834 COVID-19 deaths) and 9 states: California (excess mortality 95% CI 3338-6344) vs. 2849 COVID-19 deaths); Connecticut (excess mortality 95% CI 3095-3952) vs. 2932 COVID-19 deaths); Illinois (95% CI 4646-6111) vs. 3525 COVID-19 deaths); Louisiana (excess mortality 95% CI 2341-3183 vs. 2267 COVID-19 deaths); Massachusetts (95% CI 5562-7201 vs. 5050 COVID-19 deaths); New Jersey (95% CI 13 170-16 058 vs. 10 465 COVID-19 deaths); New York (95% CI 32 538-39 960 vs. 26 584 COVID-19 deaths); and Pennsylvania (95% CI 5125-6560 vs. 3793 COVID-19 deaths). Conventional model results were consistent with semiparametric results but less precise. Significant excess pneumonia deaths were also found for all locations and we estimated hundreds of excess influenza deaths in New York. We find that official COVID-19 mortality substantially understates actual mortality, excess deaths cannot be explained entirely by official COVID-19 death counts. Mortality reporting lags appeared to worsen during the pandemic, when timeliness in surveillance systems was most crucial for improving pandemic response.

[Outcomes and Complications of Surgical Treatment for LSS at 1-Year Follow-up - Prospective Study]. / Výsledky a komplikace po operacním resení LSS v horizontu jednoho roku ­ prospektivní studie.

PURPOSE OF THE STUDY Lumbar spinal stenosis (LSS) is a serious and fairly frequent disorder with prevalence increasing with age which often results in a disability. The surgical procedures are often very risky due to the greater age of patients with severe stenosis and their comorbidities. The study aimed to assess the functional outcomes and complications in patients who underwent surgical treatment for LSS at one year postoperatively and to identify the differences in the functional outcomes, if any, in dependence on the number of operated segments. MATERIAL AND METHODS It was a prospective study which included 33 patients who underwent surgery at the authors department from 1 November 2015 to 1 October 2016 for LSS, the mean age of patients was 69.5 (43-83) years. The surgery was indicated based on the clinical examination, radiography and MR imaging and consisted in posterior decompression with or without stabilisation and fusion. Pre- and post-operatively, a neurological examination and evaluation of patient difficulties were performed by: VAS - particularly for low back pain (VAS-LB) and lower limb pain (VAS-LL), Oswestry Disability Index (ODI) and Swiss Spinal Stenosis Questionnaire (SSSQ). The evaluation was done at a half year and one year after the surgery. The authors made comparisons in dependence on the number of treated segments (1-2, 3-5 and Th-S stabilisation). RESULTS A significant improvement of all the followed-up parameters was reported at one year postoperatively. At one year after the surgery, the VAS-LB score showed a decrease by 2.39 (p = 0.001), the VAS-LL by 3.26 (p < 0.001), while a decrease by 2 or more points is considered clinically significant. When evaluating the SSSQ questionnaire, a decrease in subjective difficulties (SSSQ-S) was by 0.89 (p < 0.001), in physical function (SSSQ-F) by 0.87 (p < 0.001). In this questionnaire, the satisfaction rate with the surgery was 2 - i.e. somewhat satisfied. Altogether 76% of patients were very or somewhat satisfied, no one was very dissatisfied. When evaluating the ODI, an improvement by 20.6% (p < 0.001) was reported. The authors identified neither any significant differences in the outcomes at a one-year follow-up in dependence on the length of stabilisation, nor any significant differences between the six-months and one-year follow-up. Intraoperative complications occurred in 18%, early postoperative complications in 6% of patients. The ASD developed in 9% within one year. DISCUSSION The authors confirmed a significant improvement of the followed-up parameters (VAS-LB, VAS-LL, SSSQ, ODI) which corresponds with recent literature. The decrease in VAS and ODI in the authors study is more marked than the outcomes stated in literature. The authors outcomes clearly show that there is no correlation with the length of stabilisation and the number of decompressed segments. Conversely, the rate of complications was higher in this group than the rates stated in literature, but majority of complications had no consequences for the patients. CONCLUSIONS In the group of patients with a one-year follow-up the authors confirmed that surgical procedures will result in reduced subjective difficulties of patients, reduced pain and improvement of physical function. A significant improvement of all the followed-up parameters was reported. The authors did not confirm the correlation between the postoperative improvement and the number of treated segments. Key words:lumbar spinal stenosis, quality of life, post-operative outcomes, complications.

[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.

Supramolecular Assembly of Human Pulmonary Surfactant Protein SP-D.

Pulmonary surfactant protein D (SP-D) is a glycoprotein from the collectin family that is a component of the lung surfactant system. It exhibits host defense and immune regulatory functions in addition to contributing to the homeostasis of the surfactant pool within the alveolar airspaces. It is known that the SP-D monomer forms trimers, which further associate into higher-order oligomers. However, the pathway and the interactions involved in the assembly of SP-D oligomers are not clearly understood. In the current study, a recombinant form of full-length human SP-D (rhSP-D) has been qualitatively and quantitatively studied by atomic force microscopy (AFM) and electrophoresis, with the aim to understand the conformational diversity and the determinants defining the oligomerization of the protein. The rhSP-D preparation studied is a mixture of trimers, hexamers, dodecamers and higher-order oligomeric species, with dodecamers accounting for more than 50% of the protein by mass. Similar structures were also found in hSP-D obtained from proteinosis patients, with the largest fuzzy-ball-like oligomers being more abundant in these samples. The proportion of dodecamer is increased under acidic conditions, accompanied by a conformational change into more compact configurations. Two hexamers appear to be the minimal necessary unit for dodecamer formation, with stabilization of the dodecamer occurring via non-covalent, ionic, and hydrophobic interactions between the individual N-terminal domains and the proximal area of the SP-D collagen stems.

The use of disposable skin staples for intestinal resection and anastomosis in 63 dogs: 2000 to 2014.

OBJECTIVE: To describe the use of disposable skin staples for intestinal resection and anastomosis in dogs and report associated dehiscence and mortality rates. METHODS: Retrospective evaluation of medical records of dogs that underwent intestinal resection and anastomosis using disposable skin staples between 2000 and 2014. Data regarding patient signalment, indication for surgery, location of the resection and anastomosis, number of procedures performed, evidence of peritonitis at the time of surgery, surgeon qualifications, dehiscence, and mortality were obtained from the medical records. Mortality was defined as failure to survive beyond 10 days following resection and anastomosis. RESULTS: The overall mortality rate of patients undergoing intestinal resection and anastomosis was 12·7% (8/63). The most common indication for resection and anastomosis was neoplasia (20/63 [31·7%]), followed by foreign body removal (19/63 [30·2%]). The overall dehiscence rate was 4·8% (3/63). No difference in mortality associated with indication for surgery, whether multiple procedures were performed, surgeon qualifications, or evidence of peritonitis at the time of surgery was identified. CLINICAL SIGNIFICANCE: In this retrospective study, the overall mortality and dehiscence rates using disposable skin staples were similar to previously reported outcomes following resection and anastomosis.

American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network 2015: recommendations for the treatment of ankylosing spondylitis and nonradiographic axial spondyloarthritis

OBJECTIVE: To provide evidence-based recommendations for the treatment of patients with ankylosing spondylitis (AS) and nonradiographic axial spondyloarthritis (SpA). METHODS: A core group led the development of the recommendations, starting with the treatment questions. A literature review group conducted systematic literature reviews of studies that addressed 57 specific treatment questions, based on searches conducted in OVID Medline (1946-2014), PubMed (1966-2014), and the Cochrane Library. We assessed the quality of evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) method. A separate voting group reviewed the evidence and voted on recommendations for each question using the GRADE framework. RESULTS: In patients with active AS, the strong recommendations included use of nonsteroidal antiinflammatory drugs (NSAIDs), use of tumor necrosis factor inhibitors (TNFi) when activity persists despite NSAID treatment, not to use systemic glucocorticoids, use of physical therapy, and use of hip arthroplasty for patients with advanced hip arthritis. Among the conditional recommendations was that no particular TNFi was preferred except in patients with concomitant inflammatory bowel disease or recurrent iritis, in whom TNFi monoclonal antibodies should be used. In patients with active nonradiographic axial SpA despite treatment with NSAIDs, we conditionally recommend treatment with TNFi. Other recommendations for patients with nonradiographic axial SpA were based on indirect evidence and were the same as for patients with AS. CONCLUSION: These recommendations provide guidance for the management of common clinical questions in AS and nonradiographic axial SpA. Additional research on optimal medication management over time, disease monitoring, and preventive care is needed to help establish best practices in these areas.(AU)

Observed Incidence of Uveitis Following Certolizumab Pegol Treatment in Patients With Axial Spondyloarthritis.

OBJECTIVE: Axial spondyloarthritis (axial SpA) is characterized by inflammation of the spine and sacroiliac joints and can also affect extraarticular sites, with the most common manifestation being uveitis. Here we report the incidence of uveitis flares in axial SpA patients from the RAPID-axSpA trial, including ankylosing spondylitis (AS) and nonradiographic (nr) axial SpA. METHODS: The RAPID-axSpA (NCT01087762) trial is double-blind and placebo-controlled to week 24, dose-blind to week 48, and open-label to week 204. Patients were randomized to certolizumab pegol (CZP) or placebo. Placebo patients entering the dose-blind phase were re-randomized to CZP. Uveitis events were recorded on extraarticular manifestation or adverse event forms. Events were analyzed in patients with/without history of uveitis, and rates reported per 100 patient-years. RESULTS: At baseline, 38 of 218 CZP-randomized patients (17.4%) and 31 of 107 placebo-randomized patients (29.0%) had past uveitis history. During the 24-week double-blind phase, the rate of uveitis flares was lower in CZP (3.0 [95% confidence interval (95% CI) 0.6-8.8] per 100 patient-years) than in placebo (10.3 [95% CI 2.8-26.3] per 100 patient-years). All cases observed during the 24-week double-blind phase were in patients with a history of uveitis; in these patients, rates were similarly lower for CZP (17.1 [95% CI 3.5-50.1] per 100 patient-years) than placebo (38.5 [95% CI 10.5-98.5] per 100 patient-years). Rates of uveitis flares remained low up to week 96 (4.9 [95% CI 3.2-7.4] per 100 patient-years) and were similar between AS (4.4 [95% CI 2.3-7.7] per 100 patient-years) and nr-axial SpA (5.6 [95% CI 2.9-9.8] per 100 patient-years). CONCLUSION: The rate of uveitis flares was lower for axial SpA patients treated with CZP than placebo during the randomized controlled phase. Incidence of uveitis flares remained low to week 96 and was comparable to rates reported for AS patients receiving other anti-tumor necrosis factor antibodies.

[Surgical Correction of Scoliosis: Does Intraoperative CT Navigation Prolong Operative Time?] / Operacní korekce skoliózy: prodluzuje peroperacní CT navigace trvání operace?

PURPOSE OF THE STUDY The aim of the study was to compare the duration of corrective surgery for scoliosis in relation to the intra-operative use of either fluoroscopic or CT navigation. MATERIAL AND METHODS The indication for surgery was adolescent idiopathic scoliosis in younger patients and degenerative scoliosis in middleage or elderly patients. In a retrospective study, treatment outcomes in 43 consecutive patients operated on between April 2011 and April 2014 were compared. Only patients undergoing surgical correction of five or more spinal segments (fixation of six and more vertebrae) were included. RESULTS Transpedicular screw fixation of six to 13 vertebrae was performed under C-arm fluoroscopy guidance in 22 patients, and transpedicular screws were inserted in six to 14 vertebrae using the O-arm imaging system in 21 patients. A total of 246 screws were placed using the C-arm system and 340 screws were inserted using the O-arm system (p < 0.001). The procedures with use of the O-arm system were more complicated and required an average operative time longer by 48% (measured from the first skin incision to the completion of skin suture). However, the mean time needed for one screw placement (the sum of all surgical procedures with the use of a navigation technique divided by the number of screws placed using this technique) was the same in both techniques (19 min). DISCUSSION With good teamwork (surgeons, anaesthesiologists and a radiologist attending to the O-arm system), the time required to obtain one intra-operative CT scan is 3 to 5 minutes. The study showed that the mean time for placement of one screw was identical in both techniques although the average operative time was longer in surgery with O-arm navigation. The 19- minute interval was not the real placement time per screw. It was the sum of all operative times of surgical procedures (from first incision to suture completion including the whole approach within the range of planned stabilization) which used the same navigation technique divided by the number of all screws inserted during the procedures. The longer average operative time in procedures using O-arm navigation was not related to taking intra-operative O-arm scans. The authors consider surgery with an O-arm imaging system to be a safer procedure and use it currently in surgical correction of scoliosis. CONCLUSIONS The study focused on the length of surgery to correct scoliosis performed using either conventional fluoroscopy (C-arm) or intra-operative CT scanning (O-arm) showed that the mean placement time for one screw was identical in both imaging techniques when six or more vertebrae were stabilised. The use of intra-operative CT navigation did not make the surgery longer, and the higher number of inserted screws provides evidence that this technique is safer and allows us to achieve good stability of the correction procedure. Key words: virtual CT guidance, O-arm, scoliosis, transpedicular screw.

[Fracture Type and Injury-to-Surgery Interval as Risk Factors for Avascular Necrosis of the Femoral Head after Internal Fixation of Intracapsular Femoral Neck Fracture]. / Typ zlomeniny a interval úraz-operace jako rizikové faktory pro vznik avaskulární nekrózy hlavice femuru po osteosyntéze intrakapsulárních zlomenin krcku.

PURPOSE OF THE STUDY: The aim of the study was to investigate the occurrence of avascular necrosis (AVN) of the femoral head following the osteosynthesis of intracapsular fracture of the femoral neck in relation to the time interval between injury and surgery and the type of fracture. MATERIAL AND METHODS: The data of patients with intracapsular fractures of the femoral neck surgically treated in the period from 2001 to 2011 were reviewed. Of 1555 patients treated for this fracture, 125 (7%) underwent osteosynthesis. The evaluated group included 115 patients who came for examination at one-year follow-up. There were 59 (52%) women and 56 (48%) men. Dynamic hip screw (DHS) osteosynthesis with an anti-rotation screw was performed in 103 patients and lag-screw osteosynthesis involving three parallel cannulated cancellous screws was employed in 12 patients. The patients were allocated to groups according to the injury-to-surgery interval and to sub-groups on the basis of the Garden classification of femoral fracture stage. RESULTS: In the group of 58 patients treated within 6 h of injury, AVN developed in 10 (17%). When the type of fracture was considered, 4% of the non-displaced fractures and 30% of the displaced fractures developed AVN. The patients with Garden stage I and II (non-displaced) fractures treated within 6 h of injury had a significantly lower risk of AVN development than those with Garden stage III or IV (displaced) fractures. The group treated between 6 and 24 post-injury hours comprised 21 patients, of whom four (19%) had AVN. In non-displaced and displaced fracture sub-groups, 25% of the patients in the former and 16% in the latter had AVN. The stage of displacement had no effect on AVN development. The two groups together (patients treated by 24 h) had a significantly lower AVN incidence than the patients treated after 24 h (p = 0.0025). In this group of 36 patients, 16 had AVN (44%) and the fracture stage made no significant difference (p = 0.6985; nondisplacement sub-group, 41%; displacement sub-group, 55%). CONCLUSIONS: The study showed a significantly lower AVN occurrence in the patients surgically treated within 24 h of injury. In the patients treated within 6 h of injury, AVN incidence was significantly lower in the patients with non-displaced fractures, as compared with those who had displaced fractures. This was not true for the two patient groups treated later (6-24 and later than 24 h) in which the differences between AVN development after non-displaced fractures and that after displaced fractures were similar.

Behavioral inhibition in childhood predicts smaller hippocampal volume in adolescent offspring of parents with panic disorder.

Behavioral inhibition (BI) is a genetically influenced behavioral profile seen in 15-20% of 2-year-old children. Children with BI are timid with people, objects and situations that are novel or unfamiliar, and are more reactive physiologically to these challenges as evidenced by higher heart rate, pupillary dilation, vocal cord tension and higher levels of cortisol. BI predisposes to the later development of anxiety, depression and substance abuse. Reduced hippocampal volumes have been observed in anxiety disorders, depression and posttraumatic stress disorder. Animal models have demonstrated that chronic stress can damage the hippocampal formation and implicated cortisol in these effects. We, therefore, hypothesized that the hippocampi of late adolescents who had been behaviorally inhibited as children would be smaller compared with those who had not been inhibited. Hippocampal volume was measured with high-resolution structural magnetic resonance imaging in 43 females and 40 males at 17 years of age who were determined to be BI+ or BI- based on behaviors observed in the laboratory as young children. BI in childhood predicted reduced hippocampal volumes in the adolescents who were offspring of parents with panic disorder, or panic disorder with comorbid major depression. We discuss genetic and environmental factors emanating from both child and parent that may explain these findings. To the best of our knowledge, this is the first study to demonstrate a relationship between the most extensively studied form of temperamentally based human trait anxiety, BI, and hippocampal structure. The reduction in hippocampal volume, as reported by us, suggests a role for the hippocampus in human trait anxiety and anxiety disorder that warrants further investigation.

Perspectives of paediatric and adult gastroenterologists on transfer and transition care of adolescents with inflammatory bowel disease.

BACKGROUND: Programmes specific to inflammatory bowel disease (IBD) that facilitate transition from paediatric to adult care are currently lacking. AIM: We aimed to explore the perceived needs of adolescents with IBD among paediatric and adult gastroenterologists and to identify barriers to effective transition. METHODS: A web-based survey of paediatric and adult gastroenterologists in Australia and New Zealand employed both ranked items (Likert scale; from 1 not important to 5 very important) and forced choice items regarding the importance of various factors in facilitating effective transition of adolescents from paediatric to adult care. RESULTS: Response rate among 178 clinicians was 41%. Only 23% of respondents felt that adolescents with IBD were adequately prepared for transition to adult care. Psychological maturity (Mean = 4.3, standard deviation (SD) = 0.70) and readiness as assessed by adult caregiver (Mean = 4, SD = 0.72) were prioritised as the most important factors in determining timing of transfer. Self-efficacy and readiness as assessed by adult caregiver were considered the two most important factors to determine timing of transition by both groups of gastroenterologists. Poor medical and surgical handover (Mean = 4.10, SD = 0.8) and patients' lack of responsibility for their own care (Mean= 4.10, SD = 0.82) were perceived as major barriers to successful transition by both paediatric and adult gastroenterologists. CONCLUSIONS: Deficiencies exist in current transition care of adolescents with IBD in Australia and New Zealand. Standardising transition care practices with strategies aimed at optimising communication, patient education, self-efficacy and adherence may improve outcomes.

Pancreatic Neuroendocrine Neoplasms.

Pancreatic neuroendocrine neoplasms (Pan-NENs) are rare but clinically important lesions. Pan-NENs are known for and often categorized by their capacity to produce clinical syndromes mediated by the production of hormones. Despite sometimes presenting dramatically from excessive hormone production, not all Pan-NENs produce functional hormone, and they can pose diagnostic challenges to practicing pathologists. Distinguishing Pan-NENs from mimics can be crucial, because Pan-NENs carry different prognoses and have unique treatments available due to their specific biological properties. This article reviews the current categorization and features of Pan-NENs.

[Nailing of pertrochanteric fractures - operative technique]. / Hrebování pertrochanterických zlomenin - operacní technika.

Nailing of pertrochanteric fractures is indicated when DHS is associated with high rate of complications. Thus in unstable comminuted fractures, mainly with posterolateral defect and instability, with Adam´s arch defect and medial instability and in cases when fracture line extends into the subtrochanteric region. The increase in number of nailed pertrochanteric fractures has both its rational and irrational reasons; irrational, as until now there is no clear evidence, that nailing is a faster, safer and easier procedure with a lower rate of complications compared with DHS, a rational, as a proven increase in number of unstable and comminuted fractures has to be reflected in treatment changes. Thus, with respecting the operative techniques principles, intramedullary nailing provides evident biomechanical advantages with the possibility of full weight-bearing and a very low rate of complications.

[Nailing of inter- and subtrochanteric fractures - operative technique]. / Hrebování inter- a subtrochanterických zlomenin - operacní technika.

Intertrochanteric and subtrochanteric fractures are a quite heterogeneous and imprecisely defined group of fractures. These fractures can be essentially divided into two basic groups. The first one belongs to trochanteric fractures. In the AO/ASIF classification; these fractures are called intertrochanteric (31A3). In the second group, the term subtrochanteric fracture is used by most authors for fractures about 5 cm distally from lesser trochanter. In both intertrochanteric and subtrochanteric fractures, the proximal fragment is formed by femoral head, neck and greater trochanter including its base with vastus ridge (tuberculum vastoadductorium or innominate tubercle). On this tubercle, the gluteus medius muscle (proximally) and the origin of the vastus lateralis muscle (distally) are attached. Tension of these muscles may cause dislocation of the proximal fragment. For this reason, reduction of the fracture can be troublesome and it is more difficult than in pertrochanteric fractures It seems that intramedullary nailing will remain the favorite technique of most of the surgeons dealing with intertrochanteric and subtrochanteric fractures. We use short reconstruction nail in intertrochanteric fractures. It is useful to use long reconstruction nail in subtrochanteric fractures. Distal locking of the nail is necessary. Dynamic distal locking is preferred because the two main fragments are compressed along the axis of the nail. The number of complications was largely related to technical errors, such as insufficient reduction or an incorrectly inserted implant. No implant can compensate for errors due to surgery. Serious complications can be reduced by the correct assessment of fracture type, the use of an appropriate operative technique and early treatment of potential complications. The necessity of restoring continuity in the medial cortex of the femoral neck (Adams arch) is the requirement that should be observed. Pseudoarthrosis or varus malalignment in a healed hip should be managed by valgus osteotomy. When the femoral head or the acetabulum is damaged, total hip arthroplasty is indicated. A prerequisite for successful surgical outcome is urgently and correctly performed osteosynthesis allowing for early rehabilitation and mobilisation of the patient.

[Intraoperative CT navigation in spinal and pelvic surgery: initial experience]. / Peroperacní CT navigace u operací pátere a pánve: první zkusenosti.

INTRODUCTION: The authors describe their first experience with virtually navigated pelvic and spine screws based on perioperative CT navigation. MATERIAL AND METHODS: From 22 October 2012 (launching the device) to 9 January 2013, a total of 15 CT-navigated pelvic and spine operations were performed in 14 patients. Nerve root compression, scoliosis, vertebral fracture and spondylodiscitis were the indications for spine procedures; B-type and C-type fractures according to the AO classification were the indications in pelvic surgical procedures. The preparation and the course of the procedures were in accordance with current standards and recommendations in all the cases. Perioperative navigation and subsequent examination of the screw trajectory were performed via O-arm imaging system (Medtronic Navigation, Louisville, Colorado) instead of the standard C-arm fluoroscopy. RESULTS: A total of 73 screws were inserted (60 transpedicular screws into cervical, thoracic and lumbar vertebrae, 9 iliosacral screws into the first sacral vertebra and 4 pubic screws). Only one of the pubic screws (1.4% of all screws) was found malpositioned at the subsequent perioperative examination and was extracted immediately and replaced. Further complications were not observed and none of the procedures had to be converted into a standard fluoroscopy guided operation. CONCLUSION: A short but intensive experience with perioperative CT navigation allows us to state: 1. CT navigation shortens the operating time and minimalizes the risk of screw malposition in multiple screw spine procedures; 2. CT navigation improves the introduction of iliosacral and pubic screws in pelvic fixations; 3. there is virtually no radiation load to the staff using the CT navigation; 4. mastering this technique will allow a wider use of miniinvasive screw insertion in the pelvis and other regions where minimal dislocation will enable miniinvasive internal fixation.