[Predictive Factors and Treatment of Aseptic Pseudoarthrosis of the Humeral Shaft]. / Prediktívne faktory a liecba aseptickej pseudoartrózy diafýzy humeru.

PURPOSE OF THE STUDY Aseptic pseudoarthrosis (nonunion, PSA) of the humeral shaft is one of the serious complications in the treatment of fractures in this area. In a retrospective study, the authors described different methods of treating patients with this complication using predictive factors. MATERIAL AND METHODS Based on the definition of nonunion and the criteria, 14 patients (N=14) with the mean age of 56 years (32-78), namely 8 men and 6 women were included in the study. All patients were followed up clinically and radiologically at 1, 3, 6, 9, 12 months and every 3 months until the condition stabilized. The follow-up period was 11-72 months, with the average of 22 months. According to the AO classification, the fractures were classified as: 4-A1, 1-A2, 4-A3, 1-B1, 3-B2 and 1-C2. Based on the Weber-Cech classification, 2 cases of pseudoarthrosis were hypertrophic, 4 oligotrophic and 8 atrophic. According to the Non-Union Scoring System (NUSS), 5 patients reached the score under 25 points, 3 patients received 25-50 points, 4 patients 51-75 points and two patients over 76 points. In five cases, the fracture displacement index (FDI) was above 100%. In 11 patients, PSA was in the proximal and middle third and in three patients in the distal third of the humerus. METHODS Of the whole group (N=14), the nail was used in 5 cases (36%) - in 3 cases NUSS of up to 50 points and in 2 cases over 76 points. The plate was used in 9 cases (64%). In patients with NUSS of up to 50 points - in 1 case after conservative treatment, in 1 case for augmentation of nail, in 3 cases for augmentation of Prévot nails. In 4 cases with NUSS of 51-75 points a plate was replaced. Osteosynthesis was always supplemented by Judet's decortication or resection of atrophic bone and spongioplasty by autologous graft. RESULTS Shoulder function measured by the Constant Murley score (C-M) improved from 53 to 89 points (from the range of 36-76 points to the range of 75-100 points). The function of the elbow joint also improved, namely from the Mayo Elbow Performance Score (MEPS) of 65 points to 90 points (from the range of 45-70 points to the range of 80-100 points). In 11 cases (79%) the nonunion was healed and in 3 cases (21%) the failure to heal was reported. In the group with unhealed nonunions, in one case with NUSS of 51-75 points a thermoplastic casting was used and in two patients with NUSS above 76 points a palliative surgery was performed using a 12mm interlocking intramedullary nail. DISCUSSION The results of our study focused on the treatment of aseptic nonunion of the humeral shaft confirm the conclusions arrived at by other authors. As to the osteosynthesis materials, the plate remains the gold standard and provides sufficient stability for bone healing. For unhealed treatment-resistant PSA, we offer a stable intramedullary nail instead of prosthetic replacement or amputation, which provides good stability required for limb function. CONCLUSIONS When planning the treatment of aseptic pseudoarthrosis of the humeral shaft, it is necessary to have a thorough knowledge of etiopathogenesis with all predictive factors. The NUSS classification provides good guidance in treating this complication. Key words: aseptic nonunion, NUSS classification, predictive factors.

[Current Concepts in the Treatment of Intra-Articular Calcaneal Fractures]. / Súcasné trendy v liecbe intraartikulárnych zlomenín pätovej kosti.

PURPOSE OF THE STUDY The aim of this study was to evaluate and present the current concepts in the treatment of intra-articular calcaneal fractures. MATERIAL AND METHODS During the period of ten years (1/2007-12/2016) 162 dislocated intra-articular calcaneal fractures in 145 patients were treated and evaluated at the Trauma Department of University Hospital in Bratislava. The study group included 97 male (67%) and 48 (33%) female patients. The mean age was 42 years (10-66). 17 cases (11.7%) were bilateral calcaneal fractures. Twelve patients suffered a calcaneal fracture associated with polytrauma (8%), and 15 (10.3%) of such fractures were associated with a spinal injury. All of the avaluated fractures n=162 were classified according to Essex-Lopresti -101 (62.5%) were depression type, 38 (23.5%) were tongue type and 23 (14%) were comminutive. The other used classification was according to Sanders - 95 fractures (59 %) were Sanders type II, 44 (27 %) Sanders type III and 23 (14 %) Sanders type IV. In operative treatment the indication criteria considered were fracture morphology, soft tissue involvement, age and overal patient physical condition. Plate osteosynthesis was used in 80 cases (49%) - in 34 fractures of Sanders type II, 44 in Sanders III and two cases Sanders IV type. Palmer s modified approach (limited lateral approach) was used in 21 fractures (13%) - where 7 fractures (4.3%) were treated by screws, 12 (7.4%) with the C-nail and K-wires were used in 2 pediatric patients (1.2%). In 38 patients (23%) in tongue-type fractures we performed percutaneous reduction (Essex-Lopresti/Westhues) and osteosynthesis with three or four 6.5 mm cancelous screws. 21 fractures Sanders type IV (13%) were treated with the external fixator. RESULTS The regular follow-up period was 6-36 months, with various functional results evaluated according to two scoring systems, namely the Creighton-Nebraska Health Foundation Assessment Score (C-N scoring system) and the AOFAS Ankle-Hindfoot Scale (A-H scoring system). In the whole study group in 125 (77%) treated fractures good and excellent results achieved, in 21 (13%) cases the results were satisfactory and in 16 (10%) cases they were poor. No deep infection complications were recorded, but in 14 cases (8.6%) iatrogenic complications such as incomplete reduction or mal-reduction, inproper indication or misdiagnosed compartment syndrome and 15 (9.2%) superficial infection were observed. DISCUSSION Despite the controversy as to the proper treatment of intra-articular calcaneal fractures, mainly in simpler types of Sanders type IIA and IIB it is of benefit to use a combination of percutaneous reduction of calcaneal body along with the posterior articular surface from the Palmer s modified approach. CONCLUSSIONS At our department we prefer percutaneous reduction and osteosynthesis as a method of choice in tongue-type fractures, and the Palmer s modified approach is the preferred method in Sanders type IIA and IIB fractures. In Sanders type III fractures we advise to use the plate osteosynthesis and for Sanders type IV fractures an external fixator is recommended. Key words:individual treatment concept.

[Tibio-Calcaneal Arthrodesis with Vertically Placed Tricortical Bone Graft after Traumatic Talar Extrusion - a Case Report]. / Tibio-kalkaneárna artrodéza pomocou vertikálne ulozeného trikortikálneho stepu po traumatickej extrúzii talu ­ kazuistika.

The aim of this publication is to present a case report of a 38-year-old patient with traumatic astragalectomy and resultant foot reconstruction surgery using a combination of talus compensation by vertically placed tricortical autograft and pantalar arthrodesis with a retrograde calcaneotibial nail (hindfoot nail). The advantage of this treatment is based on a solid, stable osteosynthesis, while maintaining the length of the limb. Key words: traumatic talar extrusion, tibiocalcaneal arthrodesis, hindfoot nail, bone graft, pantalar arthrodesis.

[Chronic Locked Posterior Shoulder Dislocation Treated by Anatomical Total Shoulder Arthroplasty]. / Liecba inveterovanej zadnej luxácie ramena anatomickou totálnou protézou.

The aim of this study was to present the results of surgical treatment in two male patients with chronic locked posterior dislocation of the shoulder, who underwent total shoulder arthroplasty due to destruction of more than 45% of the humeral head articular surface and glenoid impairment. The deltopectoral approach was used in both cases. Total shoulder arthroplasty (Epoca-Synthes) was carried out in the standard manner. Case one: A 29-year-old, extremely obese patient suffered injury to his shoulder during an epileptic seizure. At 11 months after injury, surgery was performed using an interscalene plexus block because general anaesthesia presented a high risk for the patient. The total follow-up period was 4 years. Between the 2nd and the 3rd follow-up year, the patient lost about 46% of his body weight. At the first year, when the patient maintained his initial overweight, shoulder elevation was 170° and range of motion was not restricted. The overall Constant Score (CS) was 96. Due to a massive weight loss, muscle strength was reduced and the CS decreased to 82. Case two: A 41- year-old man injured his shoulder in a fall and, due to a late diagnosis, underwent surgery under general anaesthesia at 11 months after injury. At 3-year follow-up the overall result was excellent, with only slightly limited internal rotation of the shoulder.

[Conservative treatment of acetabular fractures: epidemiology and medium-term clinical and radiological results]. / Konzervatívna liecba zlomenín acetabula: epidemiológia a strednodobé klinické a rádiologické výsledky.

PURPOSE OF THE STUDY: The vast majority of studies on fractures of the acetabulum are concerned with surgical treatment. All displaced fractures are presented as surgically treated. The purpose of this study was to evaluate the results of surgical and conservative treatment of patients with acetabular fractures in relation to the degree of fracture displacement. MATERIAL AND METHODS: We analysed 140 fractures of the acetabulum treated in our institution by different methods between 2009 and 2013. In addition to the use of Letournel´s classification, we allocated each fracture to one of six groups: 1. Sixty displaced fractures treated surgically, 2. Twenty three fractures with a displacement of more than 6 mm, 3. Eighteen slightly displaced fractures (2-3 mm in the acetabular roof or 4-5 mm in other parts of the acetabulum), 4. Twenty non-displaced fractures, 5. Six pelvic fractures involving the acetabulum and 6. Thirteen fractures of old people, mostly displaced but not examined by CT. Groups 2 to 6 were treated conservatively. In all patients, demographic and epidemiologic factors were analysed in relation to the patient's group assignment. In 107 patients, hip function was assessed using the Matta clinical grading system at a minimum follow-up of 12 months (average 3.16 years). Radiological status, time of admission, start of weight-bearing after the accident, working ability, mortality and complications were also evaluated. RESULTS: Non-displaced fractures were often associated with serious injury or polytrauma in 20 patients; not all of them had excellent functional outcome. (mean score, 17.25). Excluding two patients who developed avascular necrosis, fourteen slightly displaced fractures had a fixal score of 16.92. Sixteen patients with displaced fractures were managed conservatively due to their poor medical condition and other circumstances. Their functional outcome (mean score, 15.25) was significantly worse than that of the patients with non-displaced fractures (p=0.02) and worse than the outcome in patients with slightly displaced fractures, but the difference was not significant (p=0.32). No occurrence of accelerated post-traumatic arthritis was observed in these groups. The mean clinical score of 14.80 and 60% of excellent and good results were achieved in surgically treated patients. Eight of them were treated by primary hip arthroplasty and osteosynthesis. A total of 11 patients required total hip arthroplasty because of post-traumatic osteoarthritis, but only one from the group of slightly displaced fractures, all others from the group of surgically treated patients. DISCUSSION: Displaced fractures of the acetabulum are best treated by open reduction and internal fixation. The type of fracture and the quality of reduction influence the functional outcome. There are a few studies reporting long-term outcomes in conservatively treated acetabular fractures. Although conservative treatment continues to be the mainstay of treatment in most centres in the developing countries, it is obvious that not all of acetabular fractures can or must be treated surgically or identically. We found that, in many cases, surgery was too dangerous for the patient and his/her medical condition or that the result of surgery was doubtful, mostly because of a late presentation. In some cases, primary hip arthroplasty is a solution. Secondary total hip replacement is technically more demanding and has a higher rate of failure. CONCLUSIONS: Conservative treatment is the method of choice for the treatment of non-displaced acetabular fractures. Excellent or very good results can also be expected in slightly displaced fractures if acetabular roof involvement is minor. In displaced fractures, if the result of surgery is doubtful under various circumstances or if high-risk medical conditions are present in the patient, conservative treatment can be the method of choice with satisfying results. Key words: acetabular fractures, conservative treatment, degree of displacement, epidemiology of acetabular fractures.

[Surgical treatment of intra-articular calcaneal fractures]. / Operacná liecba intraartikulárnych zlomenín pätovej kosti.

PURPOSE OF THE STUDY The calcaneus is one of the most complex bones in the human body. If fractured, restoration of its anatomy is demanding and displaced fractures may have permanent consequences affecting both daily living and work activities of the patient. In this prospective study, the authors present the results of surgical treatment of 48 dislocated intra-articular fractures of the heel bone. MATERIAL In the period from September 2006 to September 2009, 48 dislocated intra-articular fractures in 41 patients were surgically treated at the Department of Trauma Surgery in Bratislava-Kramare. Seven (17 %) patients, six men and one woman, had bilateral calcaneal fractures. In the group of 41 patients, 32 (78 %) were men and nine (22 %) were women. The average age of the group was 41 years (range, 16 - 64 years). METHODS Based on computed tomography scans, the fractures (n=48) were classified according to the Sanders system into Sanders II to IV subgroups. This included 26 Sanders II fractures (54 %), 15 Sanders III fractures (31 %) and seven Sanders IV fractures (15 %). Minimally invasive reduction and osteosynthesis (MIOS) was used to treat 16 Sanders II fractures (33.33 %) and two Sanders IV fractures (4.16 %). Open reduction and internal fixation (ORIF) was employed in 10 Sanders II fractures (20.83 %), all 15 Sanders III fractures (31 %) and one Sanders IV fracture (2.08 %). Four comminuted fractures (8.33 %) classified as Sanders IV fractures were stabilised with an external fixator. The surgical technique was selected in accordance with the bone morphology, soft tissue condition and patient's overall state. RESULTS The patients were followed up for 6 to 36 months and clinical assessment was based on the Creighton Nebraska Health Foundation scoring system (C-N score) and the AOFAS Ankle-Hindfoot Scale (A-H score). The functional outcomes were excellent in 25 fractures (52 %), good in nine (18.75 %), less satisfactory in eight (16.6 %) and poor in six fractures (12.5 %). Complications of wound healing were recorded in three fractures (6.25 %) treated by ORIF, and only involved superficial marginal wound necrosis. There was no deep wound infection. Algodystrophic syndrome developed in two cases (4.16 %). X-ray measurements were used to assess the final Böhler's angle, whose value after treatment ranged from 8° to 38°, with an average of 27°. DISCUSSION At present the selection of an operative technique is being discussed. The advocates of MIOS emphasise a lower com- plication rate associated with wound healing and the possibility of using this technique when the treated tissues are in a critical condition. The advantage of ORIF lies in exact open reduction and stable osteosynthesis. CONCLUSIONS The method of percutaneous reduction and osteosynthesis is the optimal treatment for Sanders II dislocated fractures. Severely dislocated fractures (Sanders II and III) require open reduction and plate osteosynthesis. Comminuted fractures should be treated first by external fixation and by arthrodesis at the second stage if problems arise.