[Technique Optimization of Interposition Arthroplasty During Proximal Row Carpectomy with Regard to the Vascularity of the Capsule in Carpal Joint: Cadaverous Study]. / Optimalizace techniky interpozicní artroplastiky pri proximální karpektomii s ohledem na vaskularizaci dorzální kapsuly karpu: kadaverózní studie.

PURPOSE OF THE STUDY The study aimed to propose an optimal based fl ap creation with the view to ensure long-term survival of the interposition arthroplasty. MATERIAL AND METHODS A total of 28 dorsal wrist capsules were collected from 16 cadavers (with age range at death 18 to 80 years, with no visible wrist pathology). Altogether 112 histological specimens were obtained from these 28 samples. Post-hoc Dunn's tests were used to analyse the percentage of vascularisation of individual sides of the dorsal capsule (circumference and area) at the 0.05 level of signifi cance. Spearmann's correlation analysis was used to assess the effect of age on vascularization of the dorsal wrist capsule. In cadavers in whom both capsules were collected, the limbs were compared. For the sake of comparison, the Wilcoxon matched pairs test was used. RESULTS Regarding statistical signifi cance, the largest share of the total circumference and area of the measured vessels of the dorsal capsule is constituted by the distal side (35.2% of the circumference and 30.9% of the area). The blood supply of the dorsal capsule received on the ulnar side is the lowest (12.9% of the circumference and 17.6% of the area). There was no signifi cant effect of age on vascularization of the dorsal wrist capsule confi rmed. Also, the comparison of vascularization of both limbs from a single cadaver did not yield any statistically signifi cant results. DISCUSSION Proximal row carpectomy is a long-established surgical technique used to manage the degenerative changes in the wrist. Our results showed the best vascularization on the distal and radial sides of the dorsal wrist capsule. In this light, the distally-based fl ap or the fl ap described by Berger, which respects the clinically important ligaments, appear to be the least invasive and help maintain the future stability of the wrist. CONCLUSIONS In clinical practice, we advise that a radially-based fl ap according to Berger is created and the distal side of the dorsal capsule, the most vascularized portion based on our results, is preserved as much as possible. The fl ap created in this manner also preserves the important carpal ligaments and appears to the authors of this study to be the most benefi cial, also with respect to the presence of the largest arteries, contrary to the distal side. Another option is to use a distally-based fl ap for interposition arthroplasty. Key words: interposition arthroplasty, proximal row carpectomy, vascularization, degenerative changes, wrist.

[Reconstruction of Lower Extremity Palsy after Pelvic Fractures with the Muscle Transfers]. / Rekonstrukce paréz dolní koncetiny po zlomeninách pánve svalovými transfery.

PURPOSE OF THE STUDY The prevalence of nerve structure injuries accompanying pelvic and acetabular fractures is stated to be 5-25 %, with most frequent injuries to motor nerve structures associated with fractures of the posterior wall of the acetabulum. Prognostically worse outcomes of regeneration are documented mainly in iatrogenic, intraoperative injuries to nerve structures. This study aims to document the functional effect of muscle transfers restoring the movement of lower extremities with irreversible nerve lesion caused by the pelvic and acetabular fracture. MATERIAL AND METHODS A total of 18 patients with irreversible palsy of lower extremities in L4-S1 segments underwent a reconstruction surgery in the period 2006-2016, of whom 13 patients with the mean age of 42 (21-79) years arrived for a follow-up. The group included 10 patients with the loss of function of peroneal portion of the sciatic nerve, one patient sustained femoral nerve lesion and two patients suffered complete sciatic nerve lesion (both the peroneal and tibial portion). The patients were evaluated at the average follow-up of 77 (24-129) months after the reconstruction surgery. The average time interval from pelvic fracture to reconstruction by muscle transfer was 47 (18-151) months. Due to a wide spectrum of functional damage, the patients were evaluated in terms of the overall effect of the reconstruction surgery on the activities of daily living using the LEFS (The Lower Extremity Functional Scale). The surgical techniques used transposition of tensor fascie latae for femoral nerve lesion, transposition of tibialis posteriormuscle for palsy of the peroneal division of the sciatic nerve and tenodesis of tibialis anterior tendon and peroneus longustendon for the palsy of the peroneal and tibial portion of sciatic nerve. RESULTS The effect of movement restoration on daily living evaluated using the LEFS achieved 65 points (53-79) which is 85% of the average value of LEFS in healthy population. The transposition of active muscles tibialis posterior and tensor fasciae latae resulted in all the patients in active movement restoration. A loss of correction of foot position following the performed tenodesis of the paralysed tibialis anterior muscle was observed in one patient, with no significant impact on function. No infection complication was reported in the group. In 78% of patients the intervention was performed as day surgery. DISCUSSION There is a better prognosis for restoration in incomplete nerve lesion than in complete lesions and also in the loss of sensation than in the loss of motor function. The mini-invasive stabilisation of pelvic ring according to literature does not increase the risk of nerve lesions, while on the other hand a higher incidence of femoral nerve damage by INFIX fixator is documented. The type of muscle transfer is selected based on the availability of active muscles suitable for transposition and also with respect to functional requirements of the patient. CONCLUSIONS Irreversible palsy of lower extremity after the pelvic fracture is easily manageable as to the restoration of function. Surgical interventions using the preserved active muscles to restore the lost movement should be a component part of comprehensive surgical care for patients who sustained a pelvic fracture and should be performed centrally at a centre availing of comprehensive expertise. Key words: nerve lesion, tendon transfer, acetabulum, pelvis, fracture.

[Our Initial Experience with Radial Head Replacement]. / První zkusenosti s náhradou hlavice radia.

PURPOSE OF THE STUDY A single treatment procedure for multi-fragmented non-reconstructible radial head fractures has not been established as of yet. One of the available treatment methods can be the implantation of an endoprosthesis, but there is no consensus in available publications. We therefore decided to trial their use and to obtain our own experience. This study includes the evaluation of the outcomes of treatment at one year postoperatively. MATERIAL AND METHODS Our group included eight patients (six men and two women with the mean age of 46.1 years, ranging from 24 to 80 years) with an implanted ExploR® (Biomet, U.S.A.) radial head endoprosthesis. The radial head fractures were of three to six fragment type, in six cases there was an associated dislocation. In one case, there was a concomitant diaphyseal fracture of the ulna which was stabilised using the Würzburger intramedullary nail (TRUE-Instrumente GmbH, Germany). The surgical approach through Kocher's interval was used in all cases. Fixation using a plaster splint from metacarpophalangeal joints up to the shoulder was applied postoperatively for a period of two to three weeks in all patients. RESULTS The assessment was carried out on average at 13 months (range 12-15 months) after the surgery. The mean elbow flexion was 7.5° to 136.9°, forearm supination was 0° to 86.3° and forearm pronation was 0° to 80.0°. The elbow joint maintained its stability in all cases. Neurological deficit did not develop in any of the patients. The DASH score reached the mean value of 11.2. The mean value of the Mayo Elbow Performance Score (MEPS) was 92.5. Radiological signs of implant loosening were observed in three cases. In two of these cases, bone resorption occurred surrounding the stem of endoprosthesis. In two patients, heterotopic ossification were found and in one case, an oversized endoprosthesis head was implanted. No recurrent elbow dislocation was seen in any of the patients. DISCUSSION The application of radial head endoprosthesis is indicated for comminuted radial head fractures and concurrent ligamentous injuries (fracture-dislocations, terrible triad, Essex-Lopresti injuries). Equally good functional outcomes may be achieved with the use of an endoprosthesis as by osteosynthesis. The complications of arthroplasty tend to be late, at ten or more years postoperatively. Further follow-up of our patients will be necessary, along with a further expansion of our group of patients. Complications may be prevented with the use of longer-stem implants and more up-to-date cemented bipolar endoprostheses which, according to recent studies, achieve equally good functional outcomes and reduce the number of necessary revision surgeries - implant removal in particular. CONCLUSIONS In treating the comminuted radial head fractures, the implantation of endoprosthesis helps to achieve a quick restoration of the elbow joint function along with good functional outcomes and prevents instabilities in case of associated ligamentous injuries. A basic precondition for successful treatment is the choice of an adequate size head. The radiological signs of stem loosening do not necessarily have to affect the functional outcomes. Key words: fracture, radial head, endoprosthesis, Kocher approach.

Image Possibilities of the Peripheral Nerve Tumor Using Magnetic Resonance Imaging - Case Report.

Magnetic resonance imaging (MRI) plays a crucial role in the diagnosis and morphological analysis of peripheral nerve tumours (PNTs). In recent years, a number of novel MRI sequences such as MR neurography (MRN), diffusion tensor imaging (DTI) or MR tractography (MRT) have emerged extending the range of conventional MRI techniques. These advanced sequences are able to provide detailed information concerning PNTs structure, including the course and function of individual neural fascicles. This data can then be utilized in tailoring a suitable surgical procedure, reducing the risks of postoperative neurological deficit. The following case report of a median nerve tumour demonstrates the range and practicality of current MRI techniques. With continuing advancement and perfection of these MRI techniques, we can expect their integration into standard diagnostic protocols of PNTs.

[Penetrating Injuries of the Heart and Great Vessels - Fifteen Years of Experience of the Cardiac Surgery Service as a Part of the Major Trauma Centre]. / Penetrující poranení srdce a velkých cév ­ patnáctiletá zkusenost kardiochirurgického servisu v rámci primárního traumacentra.

PURPOSE OF THE STUDY Outcome analysis of penetrating cardiac and great vessels injury within the 15-year existence of the cardiac surgery service as a part of the major trauma centre of the University Hospital Olomouc MATERIAL AND METHODS Retrospective analysis of a group of a total of 16 patients who underwent a surgery for penetrating cardiac and great vessels injury since II/2002 to XI/2016. The dominant causes of penetrating trauma were stab injuries (15 patients, 94%), in one patient only (6%) it was a gunshot injury. The mean age of the patients included in the group was 42.9 ± 16.1 years, with men significantly prevailing (13 patients, 81%). A total of 7 injured persons (44%) were haemodynamically stable when admitted, 9 injured persons (56%) were unstable or in critical condition. The average transfer distance was 48.8 ± 34.5 km; the injured were admitted on average 115.9 ± 154.8 minutes after being injured. Preoperatively, all the injured suffered from pericardial effusion (>5 mm) confirmed by TTE (81%) or CTA (19%). In 4 patients (25%) pericardial drainage for cardiac tamponade was performed before surgery. RESULTS All the penetrating cardiac and great vessels injuries were repaired by cardiac surgeon, in one case only (6%) the extracorporeal circulation support was used. The injury of coronary arteries was in one case managed by CABG and in the other case by ligation of the peripheral part of the coronary artery. In 4 patients (25%) also a penetrating injury of other organs was simultaneously managed. The mean ICU stay reached 85.8 ± 91.9 hours, on average 5.6 ± 9.3 units of red blood cells were administered during the in-hospital stay which lasted on average 7.1 ± 2.4 days. In the group a nonsignificant increase of left ventricular ejection fraction (44.1 ± 4.7 vs. 49.3 ± 3.2, p = 0.882) was reported at discharge of the injured patients. One patient died on the 78 th day of hypoxic brain damage (6% three-month mortality). The long-term survival analysis showed 94% one-year and 88% five-year cumulative survival in the group. DISCUSSION The incidence of the penetrating cardiac and great vessels injury is directly dependent on the crime level in the respective countries and regions. A cardiac arrest, severe hemodynamic instability, unconsciousness, serious concomitant injury, gunshot injury, multiple or atrial injury represent independent predictors of death in these injuries. The total three-month mortality in penetrating cardiac and great vessels injury ranges from 18 to 42%, the presence of vital signs at the time of hospital admission is associated with 78-92% probability of survival. The surviving patients show excellent long-term results with the exception of those who suffered a severe damage to valve apparatus or with significantly depressed left ventricular function. CONCLUSIONS Our experience proves a high survival rate of patients with penetrating cardiac and great vessels injury. The centralisation of the care into the major trauma centre with a cardiac surgery background, a unified treatment algorithm, and a vital interdisciplinary cooperation are the key goal of successful management of these injuries. Key words:penetrating injury, cardiac injury, great vessel injury, outcome. Práce byla podporena programem institucionální podpor.

[Arthroscopic Resection and Spongioplasty of Scapholunate Joint in Treating Chronic Dynamic Scapholunate Instability]. / Artroskopická resekce a spongioplastika skafolunátního kloubu v lécbe chronické dynamické skafolunátní nestability.

PURPOSE OF THE STUDY The study evaluated the method of arthroscopic stabilisation of dynamic scapholunate (SL) instability by scapholunate joint resection using bone graft to create synarthrosis between the scaphoid and lunate. MATERIAL AND METHODS Twenty-six patients with chronic dynamic SL instability of Geisler-Messina - EWAS grade IIIB, C and IV were treated by artificial synarthrosis of SL joint using an arthroscopic technique. The mean follow-up period of the patients was 32.2 months (28-39 months, when the range of motion and grip strength were assessed. The functional results were evaluated through the Mayo wrist score. RESULTS Post-operatively, a statistically significant improvement in grip strength was reported, with the mean improvement of 9 kg. On the other hand, significant worsening of flexion with a mean change of -6°, a mean change in extension of -5° and ulnar deviation -2° were identified. According to the visual analogue scale, there was a significant reduction in pain associated with everyday activity (mean change -4) as well as with heavy manual work (mean change -4). According to the Mayo wrist score, the overall results in 3 patients were excellent, in 16 patients good, in 6 patients satisfactory, and in one patient poor. DISCUSSION A limited range of motion significantly influencing the overall results of the functional assessment on the Mayo wrist score does not have a substantial subjective impact on patients and their routine activities. All the studies evaluating the operative techniques restoring stability of proximal row of the carpal bones report limited range of motion in the wrist. These interventions aim at a strong, pain-free grip with preserved wrist function. CONCLUSIONS This study illustrates that the arthroscopic stabilisation of scapholunate joint by synarthrosis is a reliable, minimally invasive surgical method to treat the higher grade of dynamic SL instability. This method makes it possible to achieve good stability of the damaged joint and leads to satisfactory functional results. Key words:wrist, instability, scapholunate joint, arthroscopy, bone graft.

[Indication for Radial Head Resection in Traumatology]. / Indikace resekcí hlavic radia v traumatologii.

PURPOSE OF THE STUDY The aim of our study was to determine the indications for radial head resection at the present day. MATERIAL AND METHODS The radial head resection was performed in the period from 2008 to 2015 in 63 patients divided into three groups. The first group marked "CR" consisted of 33 patients with the Mason type III fracture. The second group marked "CRLUX" included 20 patients with the Mason-Johnston type IV fracture, i.e. a fracture of the proximal end of the radius with a dislocation of the elbow joint. Within this group, in 8 cases also the coronoid process of the ulna was fractured. The third group marked as "CRFR " was composed of 10 patients, in whom concomitant proximal radial fracture and proximal ulna fracture occurred, and in all the cases osteosynthesis of the proximal ulna fracture was performed. For subjective evaluation of the upper limb function the DASH score was used. The functional outcomes were expressed using the Mayo Elbow Performance Score (MEPS). Moreover, the range of motion in the elbow and forearm (flexion and extension of the elbow, pronation and supination of the forearm), elbow joint stability and presence of neurological lesions were assessed. The radiological assessment consisted of measuring the proximalization of the radius, monitoring the heterotopic ossifications, signs of arthrosis, recurrent re-dislocation of elbow and proximal ulna fracture healing. RESULTS The mean follow-up period was 17.6 months (range of 13.2 - 81.0 months, SD 11.5). The mean DASH score was 15.6 (range of 0 - 60, SD 15.3) in the CR group, 12.0 (range of 0 - 52.7, SD 16.7) in the CRLUX group and 17.5 (range of 0 - 62.3, SD 12.8) in the CRFRgroup. A considerably limited mobility was seen in the CR group in three cases (9.1%), in the CRLUX group in four cases (20.0 %) and in the CRFRgroup in two cases (20.0 %). The MEPS score showed similar results in all the groups, excellent and good results were always achieved in more than ¾ of patients. Elbow stiffness did not develop in any of the patients. In the CRLUXgroup, one case a re-dislocation of the elbow occurred. In the CRFRgroup, in one case an injury to the interosseous membrane and distal radioulnar joint ligaments failed to be diagnosed and a clinically significant proximalization of the radius (9 mm shift) occurred, which subsequently required ulnar shortening osteotomy. Additional two proximalization of the radius with a minor shift (2 and 3 mm) in the group CR and CRLUX were not associated with major mobility limitations. Heterotopic ossification occurred in a total of 11 cases (17.5 %) and in four cases it caused major mobility limitations (two cases in the CR group, one case in the CRLUX and CRFRgroups). Surgical treatment was indicated in one case with a good functional effect, in one case the range of motion improved after actinotherapy. In the CR group, one case of neuroma of the radial nerve developed and the condition was treated by sural nerve transplantation. DISCUSSION The current papers view simple proximal radial resection positively unless elbow instability is present. In literature, references are made to serious, mainly late complications (arthrosis, valgus deformity, considerable limitation of elbow range of motion, proximal radial-ulnar synostosis, proximalization of the radius and symptomatic radioulnar joint subluxation). Resection of the radial head is contraindicated in the so called "terrible triad" of the elbow, i.e. the combination of a radial head fracture, a coronoid process fracture and elbow dislocation, and in the Essex-Lopresti injury, i.e. a radial head fracture with a concomitant tear of the interosseous membrane of the forearm and radioulnar joint dislocation. The Essex-Lopresti injury is often overlooked during the initial examination, proximalization of the radius can occur gradually only after several months. CONCLUSIONS The evaluation of our groups of patients showed that the radial head resection can be a good treatment option with no serious early complications in the Mason type III fractures. Serious complications occurred only in cases when the fracture was accompanied by a concomitant injury, i.e. in the Mason-Johnson type IV fractures and in concomitant proximal ulna fracture. When an indication for radial head resection is made, it is essential to correctly diagnose the injury which is clearly a contraindication to this method, i.e. the Essex-Lopresti and the "terrible triad" injuries. Key words: fracture, radial head, resection.

[The Effect of Activation of the Shoulder Girdle Muscles on Functional Outcomes of Rehabilitation in Patients with Surgically Treated Distal Radius Fractures]. / Vliv aktivace pletencového svalstva na funkcní výsledek rehabilitace po frakturách distálního radia osetrených operacne.

PURPOSE OF THE STUDY The aim of the study was to assess the functional outcomes of rehabilitation in patients with surgically treated distal radius fractures in the early postoperative period. We compared the functional outcomes of patients undergoing standard rehabilitation with the group of patients whose postoperative rehabilitation was extended with shoulder girdle exercises of the affected upper limb while the wrist was immobilized. Several indices and variables were used for the assessment of the functional therapeutic outcomes of the affected wrist. MATERIAL AND METHODS Forty patients (32 females and 8 males, the mean age 60.5 years) with distal radius fractures treated by internal fixation using volar surgical approach were involved in the study between 2013-2016. The tested subjects were randomized and split into two groups according to the selected method of rehabilitation. The tested subjects with standard rehabilitation extended with shoulder girdle muscles activation were labelled as group I. It included patients (n = 20) of the mean age 59.8 (age range 42-73 years) with immobilized wrist (i.e. for 3-4 weeks) performing shoulder girdle muscles exercises at the same time. Furthermore, standard kinesiotherapy continued after their fixation was removed. The other tested group, labelled as group II (n = 20), the mean age 61.3 (variation 40-74 years of age) involved patients with distal radius fractures. Only standard rehabilitation was performed in this group as late as their forearm fixation was removed. The following indices and parameters were assessed in the early postoperative period (i.e. by 8 weeks after the fixation removal): wrist and fingers range of motion (ROM), hand grip strength (dynamometry), local swelling, pain, scores of a nine hole peg test (NHPT), and a DASH score. RESULTS After the fixation had been removed, the group I reported statistically significantly higher values of movement compared to the values of the contralateral limb in the following directions: dorsal flexion, palmar flexion, MP joints flexion, flexion of PIP joints (proximal interphalangeal), and flexion of DIP joints (distal interphalangeal). After eight weeks, the group I manifested significantly higher values in dorsal flexion, palmar flexion and ulnar deviation in the wrist. There were no significant differences in other movement directions. The hand grip strength mean value examined with a dynamometer was significantly higher in the group I in the sixth and eighth week of testing (group I - 58.9% strength of a healthy limb after six weeks, or 66.5% after eight weeks). The results in the group II were 49.9% strength of a healthy limb after six weeks, or 56.6% after eight weeks. The group I showed statistically significantly lower values of wrist swelling and higher finger dexterity in the NHPT in all measured weeks. Lower pain intensity in the group I during the measurements was observed. At the same time, this group showed significantly better results in the DASH score. DISCUSSION The results of this study are useful for clinical practice. They confirm a functional relation between the activity of hand muscles and the shoulder muscle activity. The differences in the functional ability of the hand and the functional state of the injured wrist were detected as early as in the early postoperative period. It could be stated that the tested subjects in the group I showed a greater and faster improvement in the physical function of the injured hand. This was also accompanied by a positive psychological effect. We had not found a study of a similar type in the available literature that we could have compared our submitted results to. CONCLUSIONS Shoulder girdle muscles exercises after a distal radius fracture, while wrist is immobilized, can evidently enhance functional capability and accelerate the hand-function restitution. Early functional outcomes of the injured wrist after the rehabilitation with shoulder girdle muscles exercises support the efficiency of this broadened rehabilitation protocol. Key words: distal radius frac,ture, hand, shoulder, functional treatment, rehabilitation.

[High-Resolution MR Examination of the Scapholunate Ligament using a Microscopic Coil: Comparison with Direct MR Arthrography and Arthroscopy Findings]. / MR vysetrení skafolunátního vazu ve vysokém rozlisení s pouzitím mikroskopické cívky: srovnání s prímou MR artrografií a artroskopickými nálezy.

PURPOSE OF THE STUDY Scapholunate dissociation is a clinically most frequently diagnosed form of carpal instability. The aim of this study was to compare high resolution MRI using a microscopic coil with direct MRI arthrography in patients with suspected scapholunate ligament lesions and compare the results with arthroscopy findings and Geissler's arthroscopy classification. MATERIAL AND METHODS A prospective study was carried out in 47 patients (average age, 30.7 years) with clinical symptoms of wrist instability from 2013 to 2014. The patients were examined with the MR device Philips Achieva 1.5T using a microscopic coil and subsequently by direct MR arthrography. The results of examination were evaluated independently by two groups of physicians using a modified arthroscopic classification. The results were verified arthroscopically. For evaluation, an adjusted Geissler's classification was used. The study was approved by the Multicentre Ethics Committee of the Faculty of Medicine in Brno and informed consent was obtained from each patient. RESULTS A total of The MRI examination was evaluated and included in the study in 44 patients (three were excluded for the presence of motion artefacts). Only 20 patients underwent arthroscopy. Examination with a microscopic coil correctly classified 14 of them; an accuracy of 70 % (95 % CI: 45.7 % - 88.1 %) and p = 0.021. Direct MR arthrography correctly classified 16 of 20 injured ligaments, i.e., an accuracy of 80 % (95 % CI: 56.3 % - 94.3 %) and p = 0.002. DISCUSSION Currently, the diagnosis of pathological changes in the wrist is made by routine MRI especially when there is the possibility of using sequences with high spatial resolution. Even though we achieved poorer results by native examination using these techniques, when they were compared with the results of direct MR arthrography, they were still better than those reported in the recent literature. CONCLUSION The optimal method for an examination algorithm of scapholunate ligament lesions is direct MR arthrography. In our study correct findings of direct MR arthrography using Geissler's classification were shown in 80 % of the patients. Key words: scapholunate ligament, scapholunate ligament lesion, direct MR arthrography, microscopic coil, Geissler's classification.

[Scaphoid excision and four-corner fusion using the variable angle locking intercarpal fusion plate for treatment of post-traumatic degenerative changes of the wrist]. / Excize clunkové kosti a ctyrrohá fúze zápestí pomocí VA-LIF v lécbe degenerativních poúrazových zmen zápestního kloubu.

PURPOSE OF THE STUDY: The aim of this study is to compare functional and X-ray results before and after four-corner arthrodesis using an angular stable dorsal circular plate in patients with post-traumatic degenerative changes of the wrist. METHODS: Nine consecutive patients with scapholunate advanced collapse (SLAC) or scaphoid nonunion advanced collapse (SNAC) of the wrist, stage III, underwent scaphoid excision and four-corner fusion using angular stable plate fixation. The wrists were immobilised using a split for two weeks and then a removable wrist brace with assisted physiotherapy for four weeks. Minimal followup was 18 months. Clinical assessment before and after surgery included the wrist range of motion (ROM), grip strength, presence of pain, disabilities of the arm, shoulder and hand (DASH) scores, and radiographic findings of the carpal height and ulnar translation ratios. Differences were statistically tested. In addition, patients' satisfaction with functional outcomes was evaluated. RESULTS: In the post-operative period the patients experienced less pain during daily activities and had a better carpal height ratio than before surgery; these differences were statistically significant. In the other criteria, although showing better post-operative results, improvement was not statistically significant. Eight patients were satisfied with the final outcome. One patient required limited denervation of the wrist for pain relief. There was no non-union. DISCUSSION The functional outcomes (ROM, grip strength) in our patients at follow-up were fully comparable with the previously published studies. Although, by most postoperative treatment protocols, physical therapy is started at four to eight weeks of rigid fixation of the wrist, no non-union was found in our group of patients who had a shorter period of post-operative fixation. CONCLUSIONS: Four-corner arthrodesis of the wrist using angular stable dorsal circular plate fixation provides pain relief with acceptable preservation of the range of motion and no consolidation problems. Long-term follow-up and a larger group of patients would be necessary to confirm these hopeful results.

[Restoration of active foot extension following peroneal nerve palsy]. / Obnova aktivní extenze nohy pri paréze peroneálních nervu.

INTRODUCTION: Common peroneal nerve palsy is the commonest lower extremity peripheral paresis. The foot drop and inability or difficulty to move the ankle and toes dorsally and inability to perform foot pronation is a debilitating condition for the patient. Tendon transfer is a treatment option often used to restore the foot function after the peroneal palsy in cases when reinervation is not clinically satisfactory. MATERIAL AND METHODS: The study group included 14 patients treated in the Trauma department of FNO either for common or deep peroneal nerve paresis, or for isolated lesion of the anterior tibial muscle. Active muscles, i.e.the posterior tibial muscle (13 patients) or long peroneal muscle (1 patient) were used for the movement restoration procedure. The tendons were anchored to the cuneiform bone. RESULTS: In all the patients, active foot extension was restored, with the average range of motion of 12.3 degrees (4-20) and with sufficient muscle strength. Based on the Stanmore score assessment, the subjects showed good results, reaching 87-100 points. CONCLUSION: The posterior tibial muscle tendon transfer, or peroneus longus muscle tendon transfer lead to restoration of active extension of the foot. The reconstruction procedure results in a minor restriction of the ankle range of motion. Considering the foot functionality, it is better to perform the transfer with a slight preload of the tendon, in order to achieve adequate postoperative ankle extension.

[Early suture versus ligamentoplasty of scapholunate ligament injury: comparison of clinical results]. / Casná sutura versus ligamentoplastika léze skafolunátního vazu - srovnání klinických výsledku

PURPOSE OF THE STUDY: The aim was to evaluate subjective and objective criteria of wrist, hand and arm function in a group of patients with acute static scapholunate dissociation treated by acute suture or ligament reinsertion, and in a group of patients with chronic static scapholunate dissociation treated by ligament reconstruction using ligamentoplasty. MATERIAL AND METHODS: Of a total number of 70 patients treated surgically for scapholunate instability at the Department of Trauma Surgery, University Hospital in Olomouc and the Department of Trauma Surgery, University Hospital in Brno, from 2002 till the end of 2008, 37 patients with acute or chronic static scapholunate dissociation treated by suture, ligament reinsertion or ligamentoplasty were selected. Of them, 17 patients with chronic scapholunate dissociation and 10 patients with acute scapholunate dissociation appeared at the final follow-up. The assessment of subjective criteria was based on the Disabilities of the Arm, Shoulder and Hand Score, the Wrightington Wrist Function Score and the Visual Analogue Scale. The objective criteria included range of motion and grip strength, and radiographic parameters, such as scapholunate gap and scapholunate and scaphocapitate angles. Satisfaction of the patients and their return to work were also evaluated. The results were statistically analysed using the Chi-square, Mann-Whitney-U and Wilcoxon tests, with the level of significance a=0.05. RESULTS: In the group with acute static scapholunate dissociation, the objective criteria showed an improved range of flexion- extension. The range of radial and ulnar bending and grip strength were almost identical with those of the healthy wrist. In both evaluated groups the self-rated criteria had almost the same values in all three rating systems used. No statistically significant difference in any of the values compared was recorded. DISCUSSION: The results of subjective and objective assessments were comparable in the two groups. Paradoxically, some items of the subjective evaluation were better in the patients undergoing ligament reconstruction - ligamentoplasty. This can probably be explained by different subjective comparison of pre- and post-operative conditions in each group. Even though the subjective assessment was almost identical in both groups, we definitely find an advantage in acute treatment of a scapholunate ligament tear by suture. A technically easier procedure, a shorter period of restricted hand and arm function for the patient, no degenerative changes due to instability and a lower risk of complications - they all give support to this technique. Later conversion to another type of stabilisation if ligamentoplasty fails may bring problems and give much worse results than a failure of acute sutures CONCLUSIONS: An acute operative treatment of scapholunate ligament injury is regarded as a more suitable method for scapholunate dissociation. Ligamentoplasty, because of technical demands and risk of post-operative complications, can be used as a method of choice if the acute sutures of a torn scapholunate ligament fail or scapholunate dissociation is diagnosed at a late stage.

[A Palmar percutaneous volar versus a dorsal limited approach for the treatment of non- and minimally-displaced scaphoid waist fractures: an assessment of functional outcomes and complications]. / Palmární perkutánní nebo dorzální limitovaný operacní prístup v lécbe minimálne dislokovaných a nedislokovaných zlomenin strední tretiny clunkové kosti: funkcní výsledky a rozbor komplikací.

PURPOSE OF THE STUDY: Non-displaced or minimally displaced scaphoid waist fractures can be surgically treated using either the percutaneous volar or the limited dorsal approach.These techniques provide a possibility of early wrist physiotherapy throughout the healing period, better functional outcomes and a shorter sick leave duration.Many reports cite low complication rates.The purpose of this study is to compare both techniques based on the complication rate and functional outcomes. MATERIAL AND METHODS: The authors compared 42 patients treated for an acute scaphoid waist fracture by percutaneous osteosynthesis and 38 patients treated by osteosynthesis using a limited dorsal approach after a follow-up of at least 12 months. The differences between the groups were tested statistically. RESULTS: The overall complication rate was 11.9% for the percutaneous approach and 15.8% for the dorsal approach. There was one case of non-union in each group. The differences in the complication rates as well as in the range of wrist motion and in persistent complaints were statistically insignificant. We found significantly (p=0.042) better grip strength for the percutaneous approach. DISCUSSION: Most of the complications detected were due to a technical error during surgery and can be minimized by meticulous adherence to the technique. The difference in grip strength is very close to the significance level set for the study, and this will be necessary to clarify in a planned prospective study. CONCLUSIONS: Based on the statistical analysis of the results of our clinical data, the two techniques are comparable.

[Restoration of upper-limb function in patients with cervical spinal cord lesion]. / Obnova pohybu horní koncetiny u pacientu s vysokou mísní lézí.

PURPOSE OF THE STUDY: Injury to the spinal chord at the C5 level results in a severe handicap to the patient because of a loss of active motion of the wrist and hand. Selected surgical procedures can effectively restore active extension of the wrist and provide conditions for some vital pinching and gripping abilities. The deltoid muscle also has a potential for restoration of upper limb function, because its posterior portion can be used to restore elbow extension. The aim of this clinical retrospective study was to describe and evaluate the techniques used to improve the quality of life in patients with spinal chord lesions at the C5 level. MATERIAL AND METHODS: The group studied consisted of 15 patients (3 women and 12 men; average age, 34 years) with a spinal chord lesion at the C5 segment who had zero wrist extension or in whom wrist extensor muscle force was equal to the third degree of muscle strength or less. The procedures to restore active extension of the wrist involved the radiobrachialis muscle, the reconstruction of elbow extension was activated by the posterior portion of the deltoid muscle, and a fixed supination posture of the forearm was corrected by elongating the distal tendon of the biceps muscle which was derotated and attached to the proximal radius. The interval between injury and reconstructive surgery was 36 months on the average. RESULTS: The reconstructive surgery described resulted in restoration of hand and wrist function with sufficient muscle strength in all patients, which had a favourable effect on many aspects of their daily lives. The average values of muscle strength were 4.1° (3° to 5°). for wrist extension and 3.3° (2° to 4°) for elbow extension. Key-pinch force was on average 1.2 kg (0.2 to 2.1). A failure of thumb carpometacarpal arthrodesis was the most frequent complication and occurred in two patients. On clinical evaluation, all patients reported satisfaction with the restored function of their upper extremities and expressed their willingness to undergo the same procedure again. DISCUSSION: Reconstructive surgery of the upper extremity in tetraplegic patients has been performed with success in several countries, namely USA and Sweden, for many years. Since 2003 the results in the Czech Republic have also shown positive effects of reconstructive procedures on better quality of life in patients with cervical spinal chord injury at the lower levels, in whom the goal is to restore vital pinching and gripping abilities. A good outcome of surgical treatment requires good quality post-operative care provided by a team of physical therapists fully informed of the reconstructive procedures involved. CONCLUSIONS: A restored function of the upper extremity in the patients with spinal chord injury at the C level plays a decisive role in the whole spectrum of the patient's daily activities, such as dressing, communication, etc., and thus improves their self- care. The restoration of active elbow extension has a positive effect on the patient's mobility.

[Proximal row carpectomy in the treatment of degenerative arthritis of the wrist]. / Proximální karpektomie v lécbe poúrazových degenerativních zmen zápestního kloubu.

PURPOSE OF THE STUDY: To evaluate the outcome in patients treated by proximal row carpectomy at a follow-up of at least 12 months. MATERIAL: A total of 28 patients were treated by proximal row carpectomy for degenerative arthritis of the wrist due to previous trauma to the wrist or avascular necrosis of the lunate. Of them, 24 underwent a follow-up examination at least 12 months post-operatively. Proximal row carpectomy was indicated in 11 patients for scaphoid non-union advance collapse (SNACwrist), in five patients for scapholunate advanced collapse (SLAC-wrist), in four patients for inveterate dislocation of the wrist, and in four patients for avascular necrosis of the lunate. Ten patients with proximal row carpectomy were simultaneously treated by partial resection of the posterior interosseous nerve and two patients by limited radial styloidectomy. In one patient we performed distraction resection arthroplasty of the wrist using the Fitzgerald method. METHODS: The follow-up clinical and radiological examinations were performed after a minimum of 12 months post-operatively.We evaluated the range of wrist motion, grip strength, the presence of resting pain and pain dusing physical activities and the patient's satisfaction with the treatment outcome. By radiological examination we assessed radiocapitate joint degeneration and translation of the capitate bone in relation to the lunate facet of the radius. The differences between the results of pre- and post-operative clinical examinations were statistically evaluated using the Student's t-test, Sign test, Mann-Whitney test, and Wilcoxon signed rank test. The results were considered to be significant if p < 0.05. RESULTS: Improvements in the range of motion in the flexion-extension arch, dorsal flexion, radial deviation and grip strength, expressed as percentages of these values for the opposite, unaffected wrist, were statistically significant. The differences in palmar flexion and ulnar deviation were statistically insignificant. Pain relief at rest and during physical activities was statistically significant. At the follow-up examination most patients (87.5%) reported an overall improvement. The difference in overall improvements between the patients with and without partial resection of the posterior interosseous nerve was not statistically significant. DISCUSSION: The advantages of this procedure involve its technical simplicity, maintenance of wrist motion, satisfactory grip strength and pain relief, and a relatively low occurrence of post-operative degenerative wrist changes. These changes are not in correlation with functional complaints. CONCLUSIONS: As shown by our results as well as published data, proximal row carpectomy is an effective surgical procedure for the treatment of degenerative arthritis of the wrist for its technical simplicity and favourable functional outcomes. Key words: proximal row carpectomy, SNAC-wrist, SLAC-wrist, avascular necrosis of the lunate, dislocation of the wrist, posterior interosseous nerve resection.

Complications during and after surgery of the lower cervical spine by isolated anterior approach with CSLP implant.

BACKGROUND: The merits of different operative approaches in the management of spinal injury is debated. The aim of this study was to assess, retrospectively, the outcome of treatment of injuries of the lower cervical spine by an anterior approach, in terms of fusion rate and complications. MATERIALS AND METHODS: Between 1995 and 2004, 270 patients with an injury of the lower cervical spine were operated on by an anterior approach in our hospital. There were 67 females and 203 males. Using the Aebi and Nazarian classification, 22% of patients had a type A injury, 23% of patients had a type B injury and 55% of patients had a type C injury. All had an anterior approach with monocortical stabilisation using a cervical spine locking plate [Synthes]. RESULTS: Radiological evidence of fusion was found in all but one patient at 6 months. Complications occurred in a small proportion of the series. Recurrent laryngeal nerve injury was noted in seven patients, an abscess in the wound in one patient, a haematoma requiring re-operation for evacuation in two patients. The cervical locking plate broke in one patient and this patient went on to develop a pseudoarthrosis from failure to fuse. In another patient there was release of the plate osteosynthesis. CONCLUSIONS: Treatment of the injured lower cervical spine by an anterior operation and plate fixation was successful in achieving bone fusion in almost every patient and was followed by a complication in only a small proportion of our series. Similar results in other reports indicate that this approach is a safe and effective procedure.

Interlocking nailing of forearm fractures.

AIM OF THE STUDY: The aim of this retrospective study is to evaluate the results after treating diaphyseal fractures of the radius and ulna with an interlocking intramedullary nail. MATERIALS AND METHODS: Between 2001 and 2005, 78 patients with 118 fractures were treated using the ForeSight intramedullary nail (Smith & Nephew, Memphis, USA). The average patient age was 37.02 years. In the postoperative period, early and late complications were evaluated through radiological and functional methods. The average period of follow-up was 25 months (range: 12-58 months). RESULTS: The average length of time to demonstrated bone healing was 14.2 weeks. Four cases of prolonged healing were observed. Pseudo-arthrosis formation did not occur. Assessment of function according to Anderson gave the following results: full range of movement in 88.6% of patients; mild restriction of movement in 10.1%; severe restriction of movement in 1.3% of patients. The implanted material was extracted from 27 patients. Refractures did not occur. Postoperative complications included: 1 superficial infection, 3 cases of incomplete radio-ulnar synostosis; one case of compartment syndrome. CONCLUSIONS: Upon comparing the techniques of using plates with those of nailing in the treatment of forearm fractures, we have achieved comparable results with nailing. We therefore regard it as advantageous, in particular for treating open, serial and grossly comminuted fractures of the forearm bones.

[Treatment of intracapsular fractures of the femoral neck with a biaxial proximal femoral nail]. / Versorgung der Schenkelhalsfrakturen mit einem biaxialen proximalen Femurnagel.

BACKGROUND: Intracapsular fractures of the femoral neck are mostly treated using individual cancellous screws or a dynamic hip screw in combination with anti-rotational cancellous screws. The goal of this study was to evaluate the possibility of using proximal femoral nails for the surgical stabilisation of intracapsular fractures of the femoral neck. METHODS: A total of 58 patients (30 male, 28 female) were evaluated in a retrospective study after a minimum postoperative follow-up of 24 months. The average length of time after surgery was 33.1 months. According to the AO classification, the following numbers of type 31B intracapsular fractures of the femoral neck were included in the study: by number, 20 cases of type 31B1, 12 cases of type 31B2 and 26 cases of 31B3. The biaxial proximal femoral nail (Targon PF, B. Braun, Aesculap(R), Germany) was the tested implant and was inserted using standard surgical techniques. RESULTS: No complications in healing were noted in 48 patients (82.8% of the study group) 2 years following injury. The most frequent complication found was avascular necrosis of the head in seven patients (12.1%). Pseudoarthrosis formation was seen in two patients (3.4%), and other severe peroperative complications were observed in two other patients (3.4%). Reoperations were indicated in five patients, all of whom received a total hip endoprosthesis. We did not observe any refracture in the area of the implant. After 12 months 83% of the patients stated that they felt no or little pain. CONCLUSION: The results of our study have proven that the Targon PF biaxial proximal femoral nail may be used in treating intracapsular fractures of the femoral neck.

[Open posterior dislocation of the elbow with fractures of the radial head and coronoid process and multiple diaphyseal fractures of the ulna]. / Offene posteriore Dislokation des Ellbogens mit Frakturen des Caput radii, des Processus coronoideus und mehrfachen Diaphysenfrakturen der Ulna.

A healthy, right-handed 34-year-old man was injured by repeated direct blows delivered to his left upper arm with a baseball bat. These blows led to a posterior dislocation of the elbow joint, associated with fractures of the radial head and the coronoid process. There was bone loss on the fractured joint surface of the olecranon, with simultaneous ipsilateral trauma to the ulna. The correct surgical approach in the case of such fractures is still the subject of some controversy. The treatment can have serious complications. The results of treatment are often poor, especially because of persisting instability and stiffness of the elbow following a long period of immobilisation. Few studies have been concentrated on this topic up to now. We report on the functional and radiological results 24 months after the treatment of this rare, open "shock triad in the elbow."

[Trauma to the triangular fibrocartilaginous complex (TFCC)]. / Traumatická poskození triangulárního fibrokartilaginózního komplexu (TFCC).

PURPOSE OF THE STUDY: The triangular fibrocartilaginous complex (TFCC) can be injured either due to trauma or by chronic strain. Based on these findings, Palmer devised a classification system distinguishing traumatic (I) and degenerative (II) TFCC lesions. Traumatic TFCC injury may be single or involved in a combined injury of the distal radius. The aim of this study was to evaluate the results of surgical treatment in patients with traumatic TFCC injury at six-month follow-up. MATERIAL AND METHODS: In the years 2000 to 2004, 23 patients with injury to the wrist were treated. The group comprised 16 men and 7 women at an average age of 34 years (range, 17 to 54 years). Nine patients were diagnosed with a distal radial fracture and 14 had no damage to the bony structures. Of these, seven showed clinical signs of TFCC injury and were indicated to acute arthroscopy of the wrist. The remaining seven, due to persisting complaints, were examined by arthroscopy within 3 months of injury. During the arthroscopic procedure, the Palmer type of injury was identified and arthroscopic treatment, open or closed, was carried out at the same stage. All patients were followed up for 6 months for pain relief and return to full physical activity. RESULTS: The arthroscopic examination revealed the following TFCC lesions: 11 central ruptures (I.A), 6 ulnar tears (I.B), 4 palmar (I.C) and 2 radial (I.D) avulsions. During arthroscopy, partial resection of the disc was performed in 13 cases (I.A, I.D), and reattachment of the disc to the styloid process of the ulna was carried out in six cases (I.B). In four of these patients the intervention was done at the stage of acute lesion within 4 weeks of injury, and in two within a longer period. Four patients with type I.C injuries underwent open disc reattachment from the palmar approach. Subjective evaluation showed that 65 % of the patients had no complaints, 26 % reported pain after excessive activity and 9 % had pain associated with daily activities. Nome of the patients reported rest pain. DISCUSSION: In our group, 91 % of the patients reported excellent and very good results at six months of follow-up. The two patients experiencing pain in daily activities (9 %) had type I.B. injury and were indicated for arthroscopy at a time longer than 6 weeks after injury. CONCLUSIONS: TFCC lesions are wrist injuries which, if diagnosed early and treated appropriately, show good healing. If the triangular fibrocartilage complex is damaged by a central tear, disc resection gives good results. However, if the distal radioulnar ligaments are torn, their reattachment is necessary in order to prevent instability of the distal radioulnar joint. Open surgical procedures interfere with integrity of the distal radioulnar joint ligaments, which may lead to joint instability and prolonged healing.