[Radial Head Replacement: Management of Elbow and Forearm Instability after Comminuted Radial Head Fractures Associated with Elbow Dislocation]. / Endoprotéza hlavice radia: resení nestability lokte a predloktí pri trístivých zlomeninách hlavice radia spojených s luxací lokte.

PURPOSE OF THE STUDY: This manuscript aims to identify an indication algorithm for the surgical treatment of radial head fractures associated with elbow dislocation. The study compares the mid-term functional outcomes of patients with multifragment radial head fracture treated by resection with the outcomes of patients treated with radial head replacement. MATERIAL AND METHODS: The cohort of 34 patients who sustained a radial head fracture at the mean age of 42.5 years (age range 20-81 years) was broken down into two groups by type of surgery. The EXT group consists of 20 patients with the radial head fracture treated by radial head resection. The END group includes 14 patients treated with the radial head replacement. In all patients, the radial head fracture was associated with elbow dislocation (type IV fracture according to the Mason-Johnston classification). The modified Kocher's surgical approach was used in all patients of both the groups. In the EXT group, resection of the fragmented radial head was performed. In the END group, the ExploR® Modular Radial Head System (Zimmer, Biomet, USA) was used, consisting of a CoCr (cobalt chromium) alloy head and a titanium stem. The pain and the range of motion of the elbow and forearm were evaluated after the completion of the outpatient rehabilitation (the mean follow-up period was 2.4 years). Simultaneously, the elbow joint stability was assessed. Radiographs were taken to detect heterotopic ossifications, proximalization of the radius, and any signs of prosthesis loosening. The frequency of reoperations was followed-up. The MEPS (Mayo Elbow Performance Score) was calculated. RESULTS: In the EXT group, the mean elbow flexion was 117.5° and the mean pronation/supination was 166.9°. In 50% of patients, the MEPS obtained was greater than 90 points, which means an excellent functional outcome. In 1 patient (5%), recurrent elbow dislocation occurred which was the reason for revision surgery (elbow transfixation with the Kirschner wires and medial collateral ligament suture). Revision surgery was also performed in 2 patients (10%) in whom not all the radial head fragments were removed. Moreover, also observed was elbow joint instability (2 patients) and temporary radial nerve paralysis (1 patient). In 1 case discrete proximalization of the radius developed. The patients in the END group showed the mean elbow flexion of 112° and the mean pronation/supination of 135°. The MEPS obtained from 69% of patients was greater than 90 points, which means an excellent outcome. The pain under load was reported by 3 patients (21%). In 5 patients (35%), the X-rays showed radiolucent zone around the stem of the prosthesis. Neither revision surgery, nor prosthesis removal has been performed yet in any patient. No instability, neurological complications or infections have been reported. In both EXT and END group heterotopic ossifications have developed in 4 patients. CONCLUSIONS: Radial head replacement compared to the radial head resection in the management of multifragment fractures associated with elbow dislocations increase the elbow and forearm stability. The group of patients with an implanted radial head prosthesis shows a higher percentage of patients achieving excellent functional outcome than the group of patients with radial head resection. KEY WORDS: radial head, elbow, fracture, dislocation, resection, prosthesis.

Autonomic Nervous System Function in Newly Diagnosed Multiple Sclerosis: Association With Lipid Levels and Insulin Resistance.

Autonomic nervous system (ANS) disorders are common in multiple sclerosis (MS). Previous studies showed differences in insulin resistance (IR) and lipoprotein levels in MS subjects compared to controls. Lipolysis caused by increased sympathetic activity could be one of the possible linking mechanisms leading to dyslipidemia in MS. Our study aimed to evaluate ANS activity in the context of glucose and lipid metabolism in people with MS. We prospectively measured short-term heart rate variability (HRV), fasting lipoprotein concentrations, and calculated IR indices based on plasma glucose and insulin levels during oral glucose tolerance test (oGTT) in 32 patients with MS and 29 healthy controls matched for age, sex and body mass index in our study. There was no significant difference in HRV parameters and lipoprotein levels between MS and controls. A significant positive correlation was found between low/high-frequency power ratio (LF/HF) and triglycerides (r=0.413, p=0.021) in MS subjects but not in controls. A significantly lower whole-body insulin sensitivity index (ISIMat) was found in patients with MS compared to the control group (7.3±3.7 vs. 9.8±5.6, p=0.041). No significant correlations were found between LF/HF and IR parameters. In MS subjects, the positive correlation of LF/HF with triglycerides could reflect the effects of sympathetic activity on lipolysis. Positive correlations of sympathetic activity with increased lipoprotein levels could rather reflect processes associated with immune system activation/inflammation, than processes involved in glucose homeostasis maintenance.

Signal protein-functionalized gold nanoparticles for nuclear targeting into osteosarcoma cells for use in radiosensitization experiments.

The standard therapy for malignant primary bone tumors such as osteosarcoma involves major surgeries. For tumors located in difficult regions such as the pelvis, surgical intervention could lead to serious side effects for example loss of a limb and/or function, loss of bowel, bladder and sexual function as well as problems with wound healing and surgical complications. Therefore, exploring other approaches that can improve or complement current surgical techniques is important. Hence, sensitizing primary bone tumors to radiation could offer an additional strategy that could complement surgery and significantly improve survival and quality of life. Gold nanoparticles (AuNPs) have been shown to enhance radiosensitivity by increasing the local dose of radiation inside tumors. Therefore, the referred procedure of preparation and functionalization of gold nanoparticles may be used for investigation whether DNA repair inhibition in the presence of AuNPs leads to an effective radiosensitizing strategy for primary bone tumor cells and explore the mechanism of how this may be happening. In our work, we prepared gold nanoparticles and verified the relation between the size of the AuNPs and their uptake in tumor 143B cells and also investigated whether the optimal size of the AuNPs should not be smaller than the size of nuclear envelope pores (20-50 nm). Hence, two different AuNPs systems were prepared: the first one with AuNPs core size of about 5 nm (BS) and the second one with AuNPs core size of about 50 nm (ZA). For cellular AuNPs uptake enhancement, we functionalized the AuNPs with signaling peptides. For this purpose we prepared PEG-coated AuNPs functionalized with signal peptides for targeted transport into the cytoplasm (CPP) and into the cell nucleus (CPP + NLS). The toxicity of the AuNPs systems was assessed by MTS assay. We prepared stable functionalized AuNPs systems of both sizes. With the functionalizing of the AuNPs using signal peptides (CPP, NLS), the AuNPs penetrated into the cell nucleus. The referred procedure of preparation and functionalization of gold nanoparticles may be used for investigating inhibition of DNA repair in the presence of AuNPs and it could lead to new understanding in overcoming radioresistance in primary bone tumor cells.

The density, nanohardness and some optical properties of As-S and As-Se chalcogenide bulk glasses and thin films.

Amorphous As2S3, As2Se3 and As1Se99 bulk glasses and thin films were prepared by the melt quenching technique and vacuum thermal evaporation, respectively, on different substrates. The density (ρ) - determined by the simple and cheap method of precise weighting, refractive index (n), structural arrangement - inferred from Raman spectroscopy, and nanohardness (H ind) were determined for all the studied materials in both bulk and thin film states. It is found that regardless of the chemical composition, the bulk glass density, refractive index and nanohardness are higher in comparison with those of the corresponding virgin and by annealing relaxed thin films, and the observed differences are discussed. The almost negligible influence of the substrate on the thin films density, structural arrangement and nanohardness, was observed.

[Current Options of Rheumatosurgery of the Hand and Wrist]. / Soucasné moznosti revmatochirurgie zápestí a ruky.

Rheumatosurgery is a discipline managing the symptoms of rheumatoid arthritis of the musculoskeletal system. In a vast number of patients this disease starts in the wrist and hand. The portfolio of surgical procedures performed on the skeleton and soft tissues in these regions can be divided into two groups that, however, often times overlap in practice. Commonly, a combination of these surgical interventions is used. The surgical management should commence with prophylactic interventions that aim to slow down the development of rheumatoid deformities. These are followed by reconstructive surgery which shall manage the already developed rheumatoid deformities and their complications. The prophylactic interventions include early and late synovectomy, peritenosynovectomy, tenodeses, tendon transpositions and limited arthrodeses. The reconstructive surgery procedures comprise osteotomy, resection procedures, alloplasties, total arthrodesis and tendon reconstructions. Key words: rheumatoid arthritis, rheumatosurgery, hand, 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.

[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.

[Surgical treatment of midshaft clavicular fractures using intramedullary nail]. / Operacní resení zlomenin strední cásti klícní kosti pomocí nitrodrenového hrebu.

INTRODUCTION: The aim of our study was to assess treatment outcomes in fractures of the middle part of the clavicle using an intramedullary nail. METHODS: We have evaluated a total of 58 patients with a clavicle bone fracture stabilized by the Hofer Clavicula Pin implant (HCP, Hofer GmbH & Co KG, Fürstenfeld, Germany). A static implant was used in 43 cases, and a dynamic implant was used in the remaining 15. The mean age of patients was 39.1 years (range 1871, SD 4.4), the male-to-female ratio being 43:15. The right collarbone was broken in 26 patients, the left one in 32. The average time between accident and surgery was 10.2 days (range 2-19, SD 4.4). The set included 24 two-, 14 three- and 20 four-fragment fractures of the clavicle midshaft. Open reduction was used in all the cases. The implant was introduced by the indirect method: first, insertion of the pin from the fracture antegrade into the lateral fragment took place, then it was inserted retrogradely into the medial fragment. RESULTS: The average patient follow-up was 7.1 months (range 623, SD 5.5). X-ray signs of healing were evident in all cases, with healing occurring at 8.4 weeks on average (range 620, SD 4.1). In one case (1.7%), however, healing did not occur - refracture was diagnosed 18 days following pin extraction with no clear mechanism of injury; two more refractures were caused by a new accident. The apex of the pin was broken in four cases (6.9%). In two cases (3.4%), angulation of the pin occurred; however, full fracture healing was satisfactorily achieved. Pin prominence was observed in a total of 23 cases (39.7%), requiring premature extraction of the implant due to perforation or irritation of skin and pain in 13 (22.4%) cases. 10 cases (17.2%) of prominence were asymptomatic. Six cases with skin perforation by the implant developed clinical signs of infection, wound healing was always achieved after extraction of the pin and application of antibiotics. A very good functional finding in the shoulder joint was observed in 57 patients (98.2%). The DASH score reached an average of 8.1 points (range 0.8-30.8, SD 4.4). Constant score was 93.1 (range 42.8-98.1, SD 3.2). CONCLUSION: Intramedullary stabilization of two-, three- and four-fragment fractures of the middle part of the clavicle using the Hofer Clavicula Pin provides very good stability during healing and leads to good healing of fractures. The complications of the method are soft tissue irritation or even skin perforation in the region of the lateral end of the implant. Preventive insertion of the pin closer to the bone may prevent such complications, but also result in difficult pin extraction.Key words: fractures - clavicle - osteosynthesis - intramedullary complications.

Nutritional intervention as an essential part of multiple sclerosis treatment?

Multiple sclerosis (MS) is a chronic inflammatory and demyelinating disease of the central nervous system. In addition to the genetic, epigenetic and immunological components, various other factors, e.g. unhealthy dietary habits, play a role in the MS pathogenesis. Dietary intervention is a highly appealing approach, as it presents a simple and relatively low risk method to potentially improve outcomes in patients with brain disorders in order to achieve remission and improvement of clinical status, well-being and life expectancy of patients with MS. The importance of saturated fat intake restriction for the clinical status improvement of MS patients was pointed for the first time in 1950s. Recently, decreased risk of first clinical diagnosis of CNS demyelination associated with higher intake of omega-3 polyunsaturated fatty acids particularly originating from fish was reported. Only few clinical trials have been performed to address the question of the role of dietary intervention, such is e.g. low saturated fat diet in MS treatment. This review summarizes current knowledge about the effect of different dietary approaches (diets low in saturated fat and dietary supplements such as fish oil, lipoic acid, omega-3 polyunsaturated fatty acids, seeds oils, high fiber diet, vitamin D, etc.) on neurological signs, patient's well-being, physical and inflammatory status. So far the results are not conclusive, therefore much more research is needed to confirm and to understand the effectiveness of these dietary interventions in the long term and well defined studies.

Current treatment procedures for civilian gunshot wounds.

INTRODUCTION: This work provides an overview of the incidence of gunshot wounds during peace conditions in a civilian population and aims to assess the principles of their treatment. METHOD: We evaluated a total of 104 patients with gunshot wounds with an average age of 38.7 years (range 1871). 84 men (80.8%) and 20 women (19.2%) were involved. The head was affected 7 times (6.7%). Out of those, penetrating injury occurred only once (1.0%). The throat was hit three times (2.9%). The chest was injured 15 times (14.4%), penetrating injury at this site was observed in 10 cases (9.6%). In five cases the lungs were affected and the heart once. Gastric injury occurred 13 times, penetration into the peritoneal cavity occurred seven times (6.7%). The intestine was injured five times, the liver three times and the gall-bladder once. Limb injury was present in 66 (63.5%) cases and in 19 of those, the injury was associated with a fracture. In 50 cases (48.1%), the patient was attacked by another person. 45 patients (43.3%) injured themselves unintentionally, five patients (4.8%) were injured in a suicidal attempt and four (3.8%) were accidentally shot by someone else. The weapons used were: pistol in 57 (54.8%) cases, air rifle in 20 cases (19.2%), a rifle in 10 cases (9.6%), two patients (1.9%) were injured with a detonator and one (1.0%) with an assault rifle. In 14 cases (13.5%), the type of firearm used was not established. RESULTS: Surgical treatment was indicated in all cases. The first step was always a thorough wound irrigation. Single surgical treatment was performed in 48 cases (46.2%) while the other 56 patients (53.8%) required multiple surgeries. Specialized surgical procedures were performed in a total of 30 cases: seven laparotomies, five thoracotomies, five fracture stabilizations using external fixator, four amputations of limbs, two intramedullary osteosyntheses, two stabilizations with the use of Kirchner wires, two vascular surgeries, one craniotomy and one suture of a peripheral nerve. Complications of healing were not frequent: wound infection was observed in two cases (1.9%), wound dehiscence in one case (1.0%), osteomyelitis in two cases (1.9%), nonunion of the fracture (1.0 %) occurred once and in one case (1.0%), pulmonary embolism was diagnosed which was not fatal. CONCLUSION: Consistent debridement, fasciotomy, and complete drainage of the wound are only indicated in deep gunshot wounds. A surgical revision of the abdominal cavity is indicated for all penetrating abdominal gunshot injuries. The watch-and-wait approach with surgical wound management and hospitalization is only allowed for unambiguously non-penetrating abdominal injuries. Complications of gunshot wound healing in civilian settings are not common and are most often infectious. Key words: gunshot wound - civilian settings surgical treatment.

[Spontaneous Tendon Ruptures in the Rheumatoid Hand]. / Spontánní slachové ruptury v oblasti revmatické ruky.

A spontaneous tendon rupture is a direct consequence of rheumatoid inflammation and can appear without any noticeable impact, often during sleep. The patient then presents with inability to flex or extend metacarpophalageal or interphalangeal joints. Multiple ruptures resulting in impaired function of several fingers can also occur and markedly limit the hand's grip strength. A tear may arise from either mechanical injury to the tendon along its course over bone or connective tissues, or by biochemical action of lysosomal enzymes, released during the inflammation process, on the connective tissue of the tendon. Ischaemic damage to a part of the tendon due to constriction of vessels supplying the peritenonium is found in hypertrophic peri-tenosynovitis. Spontaneous ruptures can be prevented, in the first place, by early synovectomy and then by a number of prophylactic procedures on soft tissues and carpal bones, which can stop or at least slow down the development of severe axial deformities of the wrist and hand. Simple end-to-end suture of the stumps is usually not possible; tendon repair surgery using free grafts or, more often, intact tendon transfer is necessary. In the flexor part, transfer of the superficial flexor tendon to a stump of the deep flexor tendon is frequently performed; a free graft can also be used at a two-stage tendon reconstruction. The repair of flexor tendons is technically more demanding and the results are less satisfactory compared to repair surgery on the extensor tendon. Key words: rheumatoid arthritis, metacarpophalageal joint, interphalangeal joint, tendon rupture.

Nitric oxide as an indicator for severity of injury in polytrauma.

BACKGROUND: Patients with injuries to multiple organs or organ systems are in a serious risk of shock, multiorgan failure and death. Although there are scoring systems available to assess the extent of polytrauma and guide the prognosis, their usefulness is limited by their considerably subjective nature. As the production of nitric oxide (NO) by many cell types is elevated in tissue injury, we hypothesized that serum concentration of NO (and its oxidation products, NOx) represents a suitable marker of polytrauma correlating with prognosis. We wanted to prove that nitric oxide could serve as an indicator for severity of injury in polytrauma. METHODS: We measured serum NOx and standard biochemical parameters in 93 patients with various degrees of polytrauma, 15 patients with minor injuries and 20 healthy volunteers. RESULTS: On admission, serum NOx was higher in patients with moderate polytrauma than both in controls and patients with minor injury, and it was even higher in patients with severe polytrauma. Surprisingly, NOx on admission was normal in the group of patients that required cardiopulmonary resuscitation or died within 48 hours after admission. In the groups, where it was elevated on admission, serum NOx dropped to normal values within 12 hours. Blood lactate levels on admission were elevated in proportion to the severity of subsequent clinical course. CONCLUSION: Elevated serum NOx and blood lactate in patients with polytrauma are markers of serious clinical course, while normal NOx combined with a very high lactate may signal a fatal prognosis (Fig. 4, Ref. 8).

Exercise associated hormonal signals as powerful determinants of an effective fat mass loss.

Obesity management for achieving an effective weight loss includes dietary modification and exercise [resistance (strength), endurance (cardiovascular) or intervals training (high-intensity intermittent exercise)]. Regular exercise acutely increases fat oxidation, which induces loss of fat mass and increases energy expenditure. Moreover, it has a positive effect on the physical (improved insulin sensitivity, lipid profile, etc.) and mental health (mood, cognition, memory, sleep, etc.). Endocrine responses to muscle actions are affected by many factors, including the exercise muscle groups (lower and upper body), load/volume, time-under tension, and rest-period intervals between sets, training status, gender, and age. The aim of this review is to summarize, evaluate, and clarify the literature data focusing on the endocrine responses to different types of exercise, including the frequency, intensity, and type of movement with regard to the fat loss strategies. Many studies have investigated anabolic [growth hormone, insulin-like growth factor-1 (IGF-1), testosterone] and gluco- and appetite- regulatory (insulin, cortisol, ghrelin) hormone responses and adaptations of skeletal muscles to exercise. Muscle tissue is a critical endocrine organ, playing important role in the regulation of several physiological and metabolic events. Moreover, we are also describing the response of some other substances to exercise, such as myokines [irisin, apelin, brain-derived neurotrophic factor (BDNF), myostatin, and fibroblast growth factor 21 (FGF21)]. It is proposed that reducing intra-abdominal fat mass and increasing cardiorespiratory fitness through improving nutritional quality, reducing sedentary behavior, and increase the participation in physical activity/exercise, might be associated with clinical benefits, sometimes even in the absence of weight loss.

[Conservative and Surgical Treatment for Distal Ulna Fractures Associated with Distal Radius Fractures]. / Konzervativní a operacní lécba zlomenin distální ulny pri soucasné osteosyntéze zlomenin distálního radia.

PURPOSE OF STUDY: Fractures of the distal radius and distal ulna require anatomical reconstruction for good restoration of wrist and hand function. In this study we compared the results of conservative treatment with those of plate osteosynthesis management in distal ulna fractures of patients who had concomitant fractures of the distal radius indicated for plate osteosynthesis. Our objective was to specify indications for plate osteosynthesis of a distal ulna fracture in the case of an associated distal radius fracture. MATERIAL AND METHODS: A total of 27 patients were evaluated. In 17 of them, distal radius fractures were treated by plate osteosynthesis and distal ulna fractures conservatively (CONS group). In 12 patients, both distal radius and distal ulna fractures were treated by plate osteosynthesis (SURG group). Osteosynthesis was carried out using an APTUS variable-angle locking system (Medartis, Basel, Switzerland). In two SURG group patients with distal radioulnar joint (DRUJ) instability, the radius and ulna in anatomical position were secured with two Kirschner wires. RESULTS: Fracture union of the distal radius was achieved in all patients. Non-union of the distal ulna was recorded in one patient of each group. No secondary displacement of distal radius fragments during bone union was found in either group. Displacement of fragments during the healing of distal ulna fracture occurred in one (6.7%) patient of the CONS group. Out of the parameters evaluated, the restriction of motion below 80% of the original range in volar flexion, dorsal flection and supination was recorded in three CONS patients (20.0%) and two SURG patients (16.7%). No DRUJ instability was found. Intra-operative swelling preventing closure of surgical wounds was managed by secondary wound suture in one SURG patient (8.3%). There were no other complications. DISCUSSION: Views vary on whether the distal ulna should be treated by plate osteosynthesis when, after distal radius fixation, its fracture managed by closed reduction heals well. A distal ulna plate often causes pain and has to be removed. The acute cases of DRUJ instability caused by comminuted distal ulna fracture can be treated by osteosynthesis of the distal ulna and two Kirschner wires inserted into the fracture site in an ulnar-to-radial direction. For chronic radioulnar instability, various methods involving free tendon grafts and dynamic tenodesis are used. Other options include the Sauvé-Kapandji procedure based on inducing artificial non-union of the distal ulna diaphysis and radioulnar arthrodesis; in our modification of this technique we use a single cancellous malleolar screw. In severely comminuted fractures of the distal ulna with injury to articular cartilage, ulnar head replacement can be indicated. CONCLUSIONS Distal ulna fractures can be treated conservatively if osteosynthesis of the distal radius in the anatomical position is achieved together with anatomical reduction of bone fragments of the distal ulna. When a distal radius fracture managed by osteosynthesis is not accompanied by anatomical reduction of distal ulna fragments, or the ulna is shorter or longer than the contralateral bone, an open reduction and stabilisation using an angle-stable locking plate, set at an adequate radius-toulna length ratio, is the method of choice.

Genetics of neuroendocrine factors in rheumatoid arthritis.

Inadequate production of cortisol related to inflammation and decrease in adrenal androgen production are hallmarks of hypothalamic-pituitary-adrenal (HPA)-related endocrine findings in rheumatoid arthritis (RA). In particular, lower dehydroepiandrosterone sulfate (DHEAS) levels were consistently found in a subset of premenopausal RA females. Recently, several new gene variants have been identified in association with serum DHEAS concentrations, such as in SULT2A1 and HHEX genes. These DHEAS-related genes and other variants involved in HPA regulation may play a role in the adrenal androgen deficiency in RA. The aim of our study was to review involvement of genetic mechanisms of HPA regulation, with focus on adrenal androgens, in the context of RA pathophysiology. Although, effects of the DHEAS-related gene variants appear to be relatively small compared to other well-known factors such as age, complex interactions between DHEAS-associated genotypes and adrenal androgen hypofunction phenotype may exist in RA. Further studies analyzing specific neuroendocrine phenotype/genotype in RA are needed.

Mathematical modelling for the comparison of plate and intramedullary osteosynthesis stability in intraarticular distal radius fractures.

BACKGROUND: A comparison between plate and intramedullary osteosynthesis techniques in terms of the biomechanical stability of distal radius fracture fixation. METHODS: Mathematical modelling was used to simulate distal radius fractures, type C1 and type C2, and to compare the stability of osteosynthesis in both techniques under several wrist joint load conditions: axial compressive loading of the radius, bending loads in volar and dorsal flexion and radial and ulnar deviation, and axial torsional loading of the forearm. RESULTS: For both type C1 and type C2 fractures, the stability of intramedullary osteosynthesis was comparable with plate osteosynthesis in dorsal flexion. Plate osteosynthesis proved to be more stable only in ulnar deviation. The intramedullary X-screw technique provided more stability when loads were applied in volar flexion, radial deviation, pronation and supination, and in axial loading of the radius. CONCLUSIONS: The result of mathematical simulations was comparable for both types of fracture. It showed a higher stability of intramedullary osteosynthesis. Although when lower force intensity was applied, both techniques were comparable (Fig. 8, Ref. 16).

Complex structural rearrangements in As-Se glasses.

Structural relaxation of As-Se glasses through the glass-to-supercooled liquid transition interval is studied with temperature-modulated differential scanning calorimetry. It is shown that connectivity of glass network and long-term physical ageing change not only the full width at half maximum of the out-of-phase component of complex heat capacity, which is conventionally used for analysis, but also its asymmetry value. The latter is shown to carry very important information on the dynamic heterogeneity in glasses. Raman spectroscopy is used as complementary technique to reveal possible structural rearrangements in the investigated glass network.

Determinants of adrenal androgen hypofunction in premenopausal females with rheumatoid arthritis.

The aim of our study was to investigate adrenocortical function in the context of disease activity and inflammatory status in premenopausal RA females. Adrenal glucocorticoid and androgen responses to the 1 microg ACTH 1-24 test were investigated in 23 premenopausal RA and in 15 age- and BMI-matched healthy females. Twelve RA patients were on low-dose prednisone (<8.5 mg/day). Patients with DAS28>3.2 had lower (p<0.05) total plasma cortisol, 17-hydroxyprogesterone, dehydroepiandrosterone and androstenedione responses in the ACTH test compared to healthy controls. Patients with DAS28>3.2 had lower (p<0.05) dehydroepiandrosterone response in the ACTH test compared to patients with DAS28