[Multidirectional screw fixation in the treatment of distal radius fractures using angle-stable plates]. / Význam multidirekcionálního zavedení sroubu pri osetrení zlomenin distálního radia úhlove stabilní dlahou.

PURPOSE OF THE STUDY: Intra-articular fractures of the distal radius are treated predominantly by open reduction and internal fixation with various types of angle-stable plates. In this study we compare functional and radiographic outcomes in patients with intra-articular distal radius fractures treated with either angle-stable plates with rigid-direction screw insertion or multidirectional angle-stable plates. MATERIAL AND METHODS: The LCP group included 37 patients with an average age of 50 years (range 20-81 years) who were treated using angle-stable plates with rigid-direction screw insertion (LCP, Synthes). The APTUS group comprising 41 patients with an average age of 48.9 years (range 22-77 years) was treated by angle-stable implants in which screws can pivot freely in all directions (Aptus, Medartis). There was no significant difference between the groups in relation to fracture severity, age or other relevant characteristics. In all cases we used the volar approach. The final evaluation of treatment outcome was made at 12 months after surgery. We measured the range of wrist motion and hand grip strength, and compared the values with those obtained in the contralateral wrist. The results evaluated on the scoring systems of Gartland and Werley and of Castaing, and the DASH score were compared between the groups. The findings on radiographs were compared with the anatomical standard in the distal radius region. RESULTS In the LCP group, the average values, as compared with the contralateral side, were as follows: volar flexion, 84.2 %; dorsal flexion, 82.4 %; radial deviation, 83.2 %; ulnar deviation, 89.1 %; pronation, 98.6 %; supination, 97.4 %. In the APTUS group, the values in comparison with the other wrist were: volar flexion, 84.1 %; dorsal flexion, 91.8 %; radial deviation, 95.1 %; ulnar deviation, 92.8 %; pronation, 99.0 %; supination, 98.1 %. The values statistically comparable with the contralateral side were those in pronation, supination and hand grip strength in both groups. In addition, in the APTUS group, the values corresponding to the healthy wrist function were achieved in both radial and ulnar deviation. There were no differences in the values based on the scoring systems between the LCP and APTUS groups. As for the radiographic parameters, only the reconstruction of radial length was optimal. The other parameters differed from the anatomical standard. However, all patients met the criteria of successful healing of a distal radius fracture. Secondary fragment displacement during healing was recorded in two patients of the LCP group and in one of the APTUS group. Transient irritation of the median nerve was observed in five LCP group patients and in only one APTUS group patient. One patient in each group had an extensor tendon rupture. Reflex sympathetic dystrophy syndrome was diagnosed in two LCP group patients and in three APTUS group patients. DISCUSSION The surgical treatment of complex fractures of the distal radius using the angle-stable implants has generally achieved very good functional and radiographic outcomes with a low rate of complications. In the APTUS group, in contrast to the LCP group, the extent of radial and ulnar deviation corresponded to that found in the healthy wrist. The reason was a low-profile design of the plate and the screws, and the system with multidirectional angle-stable screws. The fewer cases of median nerve irritation in the APTUS group can be explained by the use of a different operative approach reducing the risk of direct mechanical nerve injury. In contrast to other authors, flexor tendon ruptures were not recorded in our groups. CONCLUSIONS The treatment of distal radius fractures by the angle-stable locking plate system from the volar approach achieved comparable functional and radiographic outcomes with both rigid-direction screw insertion and multidirectional screw insertion.

[Chronic lunotriquetral instability of the wrist. Presentation of our method of treatment]. / Chronické lunotriquetrální nestability zápestí--vlastní metoda osetrení

PURPOSE OF THE STUDY: One of the causes of pain on the ulnar side of the wrist is post-traumatic lunotriquetral (LTq) instability, which is difficult to detect on radiographs. For diagnosis, arthroscopic examination is most reliable. The methods for treatment of LTq instability include mere immobilization, ligament reconstructions and LTq joint stabilization with Kirschner's wires in acute conditions, and stabilization of the LTq joint by tenodesis or arthrodesis. In this study our method of treating chronic isolated injury to the lunotriquetral ligament is described. MATERIAL: The group comprised 43 wrists with isolated lunotriquetral ligament injuries diagnosed by arthroscopy. In 19 patients with persisting complaints, stabilization was performed using our original method. At 4 months after surgery, the results were evaluated by the method of Green and O'Brien. METHODS: Access to the LTq joint was gained through the fifth extensor compartment. At about 3 cm proximal to the ulnar head, one third of the extensor capri ulnaris (ECU) tendon was detached, without doing damage to the tendinous sheath on the ulnar head, and stretched distally up to the triquetrum-hamate joint level. Using a 3.2-mm drill, a tunnel was made on the dorsal side of the triquetrum, starting at the distal third of the ulnar side of the triquetrum and opening at the attachment site of the dorsal LTq ligament. In the middle part of the dorsal side of the lunate, a groove 4 mm deep and 6 mm long was made with a cutter and a two-suture Mitek anchor was inserted in its radial side. The graft was passed through the tunnel in the triquetrum, tightened up and inserted in the groove on the lunate, and sutured to the anchor. The rest of the tendon was reinserted to the ECU tendon. After suturing the dorsal structures and skin, a high plaster cast reaching up above the elbow was applied for 4 weeks, followed by application of a short plaster splint for another 2 weeks. RESULTS: Using the method of Green and O'Brien, we assessed pain, function (return to full activity), range of motion and grip strength. An excellent result was recorded in 48%, good in 42% and satisfactory in 10% of the patients; there were no poor results. DISCUSSION: Our method gives better results than the published methods of tenodesis, because it secures stability of both the triquetrum and lunate bones. Also, these methods restrict motion to a lesser degree than LTq joint arthrodesis. CONCLUSIONS: LTq instability of the wrist is a limiting condition for the patient's daily activities. It appears when, for gripping, the hand is positioned in dorsal flexion and ulnar duction. The diagnosis and therapy are complicated and only arthroscopy is reliable for LTq instability detection. The method described here provides an option for treating this disorder with good outcome and, in case of failure, does not interfere with a subsequent LTq joint arthrodesis.

[Management of diaphyseal forearm fractures using LCP angle- stable fixation devices and intramedullary nailing]. / Resení diafyzárních zlomenin predloktí pomocí uhlove stabilní dlahy LCP a nitrodrenového hrebování.

AIM OF THE STUDY: The aim of this study is to assess treatment outcomes of diaphyseal radial and ulnar fractures using angle- stable LCP device (Synthes, Svýcarsko), compared to ForeSight intramedullary nailing (Smith&Nephew, USA). MATERIAL AND METHODS: The prospective study included 80 patients with 115 forearm fractures, assigned to two equal groups, based on the fixation method. The group included 53 males and 27 females, the mean age was 36.6 years of age (range 18-77). the mean folow up period was 18 months (range 12-32 months). The patients were repetitevely x-rayed and their functional assessment was performed at the same time. Furthermore, treatment- related complications were also evaluated. RESULTS: Two cases of prolonged healing were recorded in the LCP device treatment group. Four cases of prolonged healing were recorded in the intramedullary nailing group, which healed within 18 months and did not require reoperation. The mean fracture healing time was 20.5 weeks (range 9-80 weeks) in the group with intramedullary nailing, and 19.0 weeks (range 12-46 weeks) in the LCP group. No significat differences in surgery time, healing time, postoperative pain scores or final 1-year functional outcomes were detected between the both treatment groups. Statistically significant prolonged healing was demonstrated in the intramedullary nailing group in cases, where fragment dislocation exceeded 3 mm, compared to a group of patients with anatomical repositioning and dislocation of less than 2 mm (p = 0.015; Anova). No cases of deep infections were recorded. Complications, recorded in the intramedullary nailing group, included the following: partial migration of securing nails in two subjects and incomplete synostosis in two subjects. Complications, recorded in the LCP device group, included: early re-fracturing in the original fracture location in a single subject (3 weeks after extraction). DISCUSSION: The results correspond with outcomes of other recent studies. Although open repositioning and internal fixation is considered a standard treatment method in forearm diaphyseal fractures, recently changing opinion on the use of nails in this indication is apparent. Considering ongoing improvements of these implants, the trend of nailing should be more widely accepted. CONCLUSION: Although their concept of fracture fixation is different, the both implants appear indicated for the management of forearm diaphyseal fractures.

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.

[Tibiotalocalcaneal arthrodesis using a retrograde nail locked in the sagittal plane]. / Tibiotalokalkaneální artrodéza retrográdním hrebem jisteným v rovine sagitální.

PURPOSE OF THE STUDY: To evaluate our experience with the use of a retrograde nail locked in the sagittal plane for tibiotalocalcaneal arthrodesis indicated in severe post-traumatic arthritis of the ankle. MATERIAL: Twenty patients, 16 men and four women at an average age of 58.7 years (range, 23 to 72) were evaluated. All patients had severe post-traumatic changes in the talocrural and talocalcaneal joints. Five patients also had an equinus deformity. In two patients arthrodesis followed the treatment of purulent arthritis of the talocrural joint. A local fasciocutaneous flap was used for soft tissue reconstruction in three patients. All patients were operated on using the standard surgical technique. METHODS With the patient in a supine position, reamed by hand with the use of a driving rod, a straight retrograde AAN Orthofix nail was inserted through the heel bone and talus into the distal tibia and locked in these bones in the sagittal plane. RESULTS: No complications such as injury to the neurovascular plexus or pseudoarthrosis were recorded. Four patients showed a reaction to the proximal locking screw on the proximal tibial surface, which was treated by earlier screw removal under topical anaesthesia. Due to infectious complications, the nail had to be removed prematurely in one patient. The average Foot Function Index was 12 points (range, 10 to 15) and the average ankle-hindfoot score was 67.6 points (range, 59 to 84). Thirteen patients (65 %) were not limited in their daily activities or recreational sports, six (30 %) experienced pain in sports but not daily activities and one patient (5 %) reported pain even when walking. All fusions healed in the correct position within 18 weeks. DISCUSSION: Tibiotalocalcaneal arthrodesis is not a frequent surgical procedure in either trauma surgery or orthopaedics. For this complicated procedure, rather than intramedullary nails, internal fixation with screws or plates or external fixation are preferred. The high rate of bony healing can be explained by maintenance of exact nail locking in the sagittal plane. The antero- posterior approach provides a more secure locking in the bone and assists in neutralizing sagittal forces at the site of arthrodesis. The use of reamed interlocking nails can therefore be accepted not only for treatment of long-bone fractures, but also for treating pseudoarthrosis and in complicated or failed arthrodesis. CONCLUSIONS: Patients' satisfaction is the primary goal we strive to achieve in severe post-traumatic conditions of the talus and foot. Repeat surgery, spongioplasty, external fixation revision for pin-tract infection, persistent pain, activity restriction and poor clinical results reduce patients' satisfaction. In our group, the rate of healed arthrodesis was high and the number of complications was low, therefore our patients' satisfaction was high.

[Six-month functional and X-ray outcomes of distal radius fractures managed using multidirectional locking plates]. / Sestimesícní funkcní a rentgenové výsledky zlomenin distálního radia osetrených multidirekcionálními zamykatelnými dlahami.

INTRODUCTION: Distal radius fractures remain the commonest fractures in the human body. Developed countries have recorded increasing rates of these fracures. MATERIAL AND METHODS: The authors assess results of distal radius osteosynthesis procedures using the Aptus Radius 2.5 mm (Medartis, Schweiz) system, consisting of 18 types of multidirectional, locking plates, designated for osteosyntheses and corrective osteotomies of the distal radius. The authors evaluate six-month results in 66 patients operated from January to September 2007. All AO types of fractures were included in the study group.The mean age of the patients was 49.5 years. RESULTS: According to X-ray, the mean healing time was 7 weeks. 6 moths following the procedure, the radius length was +0.4 mm (ranging from +4 mm to -4 mm), the radial inclination was 21 degrees (ranging from 13 degrees to 29 degrees) and the palmar tilt of the articular surface was 7 degrees (ranging from 0 degrees to 10 degrees of the palmar tilt). The range of motion, compared to the other extremity, was as follows: palmar flexion 87.5%, dorsal flexion 91.5%, radial duction 90.5%, ulnar duction 88.2%, pronation 98.1% and supination 94.3%. The mean grip strength reached 85% of that of the contralateral extremity. DISCUSSION: Fragment-specific fixation using the Aptus radius system, provides enough stability to prevent secondary loss of correction. Functional and radiological outcomes were similar to those with other types of locking plates. The results obtained from this study correspond to data presented in other recent studies assessing multidirectional locking plates. CONCLUSION: Central, targeted fixation of the fracture fragments and introduction of locking screws provide stability, which minimizes duration of additional fixation and facilitates early rehabilitation. It can be used for osteosynthesis of all types of fractures according to AO classification and, in particular, optimizes fixation of the C.2. and C.3. fracture types.

[Treatment of intracapsular femoral neck fractures with the use of a proximal femoral nail]. / Resení intrakapsulárních zlomenin krcku femuru pomocí proximálního femorálního hrebu.

PURPOSE OF THE STUDY: The management of intracapsular femoral neck fractures remains an unsolved issue of the present-day trauma surgery of the musculoskeletal system. These fractures are conventionally treated with the use of spongious screws or a dynamic hip screw combined with an antirotational spongious screw. The aim of this study was to evaluate the outcomes of surgical therapy using a different type of implant (proximal femoral nail) for intracapsular femoral neck fractures. MATERIAL: From January 2000 to March 2004, intracapsular fractures were treated with the use of a proximal femoral nail in 70 patients. In this retrospective study, 56 patients (28 men and 28 women) were evaluated at a minimum of 12 months after surgery. The average follow-up was 22.4 months. According to the AO classification, the fractures were categorized as 31- B1 in 20, 31-B2 in 12 and 31-B3 in 24 patients. METHODS: The implant used was a bi-axial proximal femoral nail (Targon PF, B. Braun Aesculap, Germany) inserted by the standard surgical procedure. RESULTS: In 33.3 % of the patients the operative stabilization was performed early, within 6 hours of injury, in 51.8 % the operation was carried out within 24 hours, and 14.3 % of the patients underwent surgery later than 24 hours after injury. At one year after injury, fracture union without complications was recorded in 45 patients (80 %). Complications included avascular necrosis of the femoral head in seven patients (12.5 %), pseudoarthrosis in two patients (3.6 %) and other serious complications in two patients (3.6 %). Reoperations were indicated in five patients, and these underwent total hip replacement. No refracture occurred in the vicinity of the implant. No or little pain after the implantation procedure, as assessed at 12 months and later, was reported by 83 % of the patients. The patients in whom fracture union was achieved without complications were allowed to walk with full weight-bearing at 13.8, 16.4 and 20.4 weeks, when their injury was 31-B1, 31-B2 and 31-B3, respectively. CONCLUSIONS: Our results show that the bi-axial proximal femoral nail (Targon PF, B. Braun Aesculap, Germany) is useful for management of intracapsular femoral head fractures because of the following advantages: it eliminates the risk of lateral protrusion of the implant, it allows for even distribution of weight bearing and thus reduces the risk of pseudoarthrosis development, it has a low probability of the sliding screw getting jammed.

[Scapholunate instability of the wrist following distal radius fracture]. / Skafolunátní nestability zápestí po zlomeninách distálního radia.

PURPOSE OF THE STUDY: Scapholunate (SL) ligament disruption frequently occurs together with distal radius fractures. If it is not diagnosed and treated, instability develops and will eventually be manifested as arthritic lesions known as scapholunate advanced collapse (SLAC) of the wrist. The aim of this study was to record the occurrence of SL ligament disruption in the patients treated conservatively for displaced fractures of the distal radius and to find out which fracture types are most often associated with injury to the SL ligament. MATERIAL AND METHODS: A total of 75 patients treated conservatively for distal radius fractures in 1997-98 were included in the study. The group comprised 41 women and 34 men, with fractures of the right upper limb in 44 and fractures of the left upper limb in 31 patients. They all were at active age, i. e., between 18 and 60 years, and came for a check-up 3 years after injury. They were examined for radiographic findings of SL instability and signs of SLAC development. Radiographs obtained after injury and images taken after reduction and then after bone union were retrospectively evaluated to look for signs of SL instability. The initial fractures were categorized on the AO classification and, for each fracture type, the percent of patients with co-existent SL instability was assessed. RESULTS: In the group of 75 patients examined at 3 years after injury, 16 (27 %) wrists showed radiographic signs of instability, with SLAC development in 13 patients and no arthritic lesions in three. All patients with SL instability reported pain, restricted range of motion in the wrist or reduced grip strength. The distribution of instability in relation to AO fracture type, expressed as percent, was as follows: SL instability associated with type A2 fracture was found in 38 %, with type A3 fracture in 17 %, and with type B in 25 % of the patients. SL instability was associated with type C1, type C2 and type C3 in 21 %, 27 % and 8 % of the patients, respectively. In radiographs taken after reduction, signs of damage to the SL ligament were apparent in 56 % of these patients. Radiographic findings at 6 weeks after injury showed signs of SL instability in as many as 81 % of the patients. DISCUSSION: Our results show that SL instability is found in association with type A2 and type A3 fractures, in which trauma force is "used" to break the distal radius and subsequently, due to carpal supination, to disrupt the SL ligament. In type B1 fractures, SL disruption results from an avulsion fracture of the radial styloid process due to ulnar deviation of the wrist. The retrospective evaluation of radiographs revealed that, immediately after reduction, signs of SL instability were obvious in 56 % of the cases. At that stage the condition could have been treated by K-wire transfixation and reattachment of the SL ligament. At 6 weeks, radiographic evidence of SL ligament disruption was found in 81 % of the patients. Even at that stage repair would have been possible by either reattachment or reconstruction of the ligament. It is apparent from these results that the evaluation of radiographic findings after reduction and during follow-up should also focus on other changes in the wrist in addition to signs of bone union. CONCLUSIONS: Fractures of the distal radius are no longer frequent only in elderly women, as has recently been common, but they are found more and more often in active young persons. Because their bones are healthier, soft tissues are affected more frequently. Injury to the SL joint results in the development of arthritic lesions which may rapidly progress in active patients. SLAC development can be prevented by early diagnosis of soft tissue lesions on X-ray images, because these are usually apparent after reduction or at follow-up. If doubts arise, arthroscopy or another examination should be done, even though these may not be sufficiently reliable.

[Callus distraction lengthening of the tibia with the intramedullary kinetic nail (case report)]. / Prolongace bérce pomocí kalus-distrakce s vyuzitím kinetického intramedulárního hrebu (kazuistika).

In this report the first experience with callus distraction lengthening using the intramedullary kinetic nail is described. This was performed on a left tibia with a total shortening of 34 mm. The distraction phase lasted 36 days and the rate of distraction was 0.95 mm per day. The full weight-bearing of the treated lower extremity was allowed at 12 weeks after surgery. Complete consolidation of the callus was achieved at 112 days and the consolidation index was 3.21 days/mm. No serious complications were recorded during the post-operative period. At 12 months after surgery, the patient showed a full range of motion in the knee, his ankle range of motion was S 15-0-35, and he achieved an excellent functional outcome on evaluation by Paley's classification.

[Revision surgery in diaphyseal forearm fractures]. / Revizní operace diafyzárních zlomenin predloktí

PURPOSE OF THE STUDY: The aim of the study was to compare the results of revision surgery in diaphyseal fractures of the ulna and radius treated by intra-medullary interlocking nailing or plate osteosynthesis. MATERIAL AND METHODS: The group included 36 patients who, in the period from 2000 to 2005, were treated with the use of the intra-medullary ForeSight nail system (Smith & Nephew, USA) or a small, 3.5 mm auto-compression plate (different manufacturers). Pseudoarthrosis developed in 25 patients and recurrent fractures were found in 11 patients (six of these suffered fractures along the original fracture line after minimal trauma and five showed a recurrent fracture at the site of screw tunnels). The average age of the patients was 37.3 years. The average period between injury and revision surgery was 16 months (range, 4 to 32 months). The follow-up included examination for early and late complications and the evaluation of X-ray findings and functional outcomes. RESULTS: The average follow-up was 21 months (range, 12 to 36 months). For revision surgery, an intra-medullary nail was used in 28 and a plate in 8 patients. The average operative time was 85 min (range, 30 to 180 min). Radiographic union was achieved by 6 months in 30, by 12 months in three and by 18 months in three patients. The average fusion time in the 30 patients healing by 6 months (nailing, 23x, 7x plate osteosynthesis) was 16.05 weeks. The range of motion in the wrist, forearm and elbow was evaluated by the Anderson method. The outcomes were excellent, good and satisfactory in 11, 15 and 10 patients, respectively. Poor results or wrist or elbow stiffness were not recorded. Pain was recorded at rest and in activity, taking requirements for analgesic therapy into account. After revision surgery, 22 patients were free from pain, 10 reported occasional pain during activity and four experienced pain at rest. None of the patients required permanent analgesic therapy. CONCLUSIONS: The results of our study show the effectiveness of plate and nailing techniques in revision forearm surgery. The corrective procedure must be chosen with regard to the type of pseudoarthrosis, and individual therapy respecting the principles of stable osteosynthesis is necessary. A differentiated operative approach, infection control and stimulation of bony union also play important roles.

[Treatment of gunshot wounds and prevention of complications during the healing process]. / Osetrení strelných poranení a prevence vzniku komplikací v prubehu hojení.

INTRODUCTION: The objective of the research is the assessment of the way and results of a case-series of treatment of gunshot wounds and to remain of the requirement of complete wound treatment in peace time. MATERIALS AND METHODS: During the period from 1997 to 2006, we treated 60 patients who had penetrating gunshot wounds. The case series included 12 female and 48 male patients ranging in ages from 18 to 71 years (average age 37 years). Weapons that caused injuries included pistol (33), rifle (5), assault rifle AK-47 (1), air gun (9), firecrackers (2), and unknown weapons (10). We assessed outcomes of different therapeutic approaches by monitoring early and late postoperative complications and by total recovery time. RESULTS: Two patients died within the first 24 hours; no other patients die after the first 24 hours of initiation of treatment. Thirty-nine patients were hospitalized with hospital stays ranging from 1 to 40 days (average length of stay 13.2 days). Total recovery time varied from 3 to 330 days averaging 65.7 days until full recovery and ability to work. Fifteen patients had bone injury, eight of which needed osteosyntesis. Four patients received external fixators, two were treated by titanium intramedullar nail, and two by transfixation with Kirchner wire eighteen patients (30%) had secondary sutures. Perioperative complications were osteomyelitis (two patients), pseudoarthrosis of upper extremity proximal phalange (one patient) and non-lethal pulmonary embolism (one patient). CONCLUSION: Standard treatment of penetrating gunshot wounds should consist of primary and prompt detailed debridement, sufficient fasciotomy, and complete drainage of the wound.

[Treatment of proximal humeral fractures by angular stabile, antegrade, interlocking intramedullar nail]. / Osetrení zlomenin proximálního humeru pomocí úhlove stabilního antegrádního zajisteného nitrodrenového hrebu--prospektivní studie.

INTRODUCTION: The objective of our study is evaluation of clinical and radiological results of dislocated proximal humeral fractures, treated by direct, angular stabile, antegrade and interlocking implants Targon PH (Aesculap, Tuttlingen, Germany). METHODS: We evaluated 102 patients (76 female and 26 male), average age was 67.3 years (26-87 years). The standard nail was used in 73 cases; the long one was used in 29 cases. We interpreted functional results (Constant's score and relative Constant's score), radiological results and postoperative complications. RESULTS: Constant's score achieved average 51.3 points--3 weeks after operation, 67.4 points--after 6 months and 75.8 points--after 1 year. Value of the relative Constant's score was 59.3%, 75.9% and 83.5%. We have found trend to the poorer functional outcomes in all complicated four-part fractures; especially in cases with disarticulation. The complete bone healing was reached in: 63.7% up to 3 months, 95.1% up to 6 months and 99% up to 1 year. We detected lecase of the pseudoarthrosis. We had 37 complications in our 102 patients group in the first year after operation. The migration of the proximal fixation screws was most frequent complication--12 patients. Eight times the humeral head aseptic necrosis appeared (5x partial, 3x complete), 3 times redislocation of tuberculum maius was found. We made reoperation 2 times by Phillos plate (1x for pseudoarthrosis, 1x for broken screws). CONCLUSIONS: Targon PH is intramedullary nail stabilisation of proximal humeral fractures by angular stabile, antegrade, interlocking system. We consider it for mini-invasive technique that provides high stability in osteoporotic bone and allows immediate postoperative shoulder mobilisation.

[Treatment of diaphyseal forearm fractures with locking intramedullary nail]. / Osetrení diafyzárních zlomenin predloktí pomocí zajisteneho nitrodireniového hrebu.

INTRODUCTION: The aim of this study is to evaluate the results after treating diaphyseal fractures of the forearm with an inter-locking intramedullary nail. METHODS: Between 2003 and 2005, 45 patients with 68 fractures were treated using the ForeSight intramedullary nail (Smith&Nephew, Memphis, USA). The average patient age was 34.12 years. In the postoperative period, early and late complications were evaluated through radiological and functional methods. RESULTS: The average length of time to demonstrated bone healing was 13.2 weeks. 3 cases of prolonged healing were observed, and pseudoarthrosis formation did not occur. Assessment of function according to Anderson gave the following results: full range of movement in 86.9% of patients; mild restriction of movement in 10.9%; and severe restriction of movement in 2.2% of patients. Postoperative complications included: I superficial infection, 2 cases of incomplete radioulnar synostosis; and 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, and we therefore regard it as advantageous foremost for treating open, serial and grossly comminuted fractures of the forearm bones.

An anatomical study of the anterior interosseous nerve and its innervation of the pronator quadratus muscle.

This anatomical study of 40 upper limbs from cadavers investigated the branching pattern of the anterior interosseous nerve in its distal part using the operating microscope. An articular branch to the wrist joint and/or the distal radioulnar joint was only found in seven of the 40 specimens and was always a small terminal continuation of the anterior interosseous nerve after the nerve had passed through the pronator quadratus and innervated it. Therefore, we do not recommend division of the anterior interosseous nerve from the dorsal approach through the interosseous membrane before it gives off its muscular branches to the pronator quadratus. This risks damage of the innervation of this muscle of importance for initiation of hand pronation.

[Our experience with repair of the scapholunate ligament using the MITEK bone anchor]. / Nase zkusenosti s reinzercí skafolunátního vazu pouzitím kostních kotvicek MITEK.

PURPOSE OF THE STUDY: A complete rupture of the scapholunate (SL) interosseal ligament results in palmar flexion of the scaphoid and dorsiflexion of the lunate that leads to disintegration of the carpal circle and the development of scapholunate dissociation with dorsal intercalary segment instability. If the injury is not treated properly or early, the abnormal position of the scaphoid and lunate results in degenerative changes of the wrist shown by X-ray and referred to as scapholunate advanced collapse (SLAC). The aim of this study was to evaluate the results of our method used for reconstruction of the SL ligament by means of MITEK bone anchors in acute injury. MATERIAL AND METHODS: The group included 17 patients, 12 male and 5 female, aged 18 to 49 years, with complete SL ligament ruptures. The dominant hand was affected in 10 patients. After the diagnosis had been confirmed, we performed reconstructive surgery involving re-attachment of the SL ligament to the scaphoid by means of the MITEK Mini G2 anchor. The patients were examined by X-rays at 3, 6, 12 and 24 months after the operation to assess the SL angle, capitolunate (CL) angle, SL distance and signs of SLAC. Hand function and pain were evaluated on the basis of the Wrightington Hospital Wrist Scoring (WHWS) system. RESULTS: The average preoperative value of the SL angle was 79 degrees and was corrected to 38 degrees by surgery. By subsequent physical therapy for 12 months, an SL angle of 51 degrees was achieved and increased to 52 degrees during the following year. The CL angle, showing a preoperative average value of 34 degrees, was corrected by surgery to 6 degrees, further increased to 9 degrees by exercising and then remained unchanged. The average SL distance of 5.25 mm preoperatively was reduced to 2.75 mm by surgery with no further change. At 24 months of follow-up, the results of pain evaluation were excellent, good and satisfactory in 41 %, 47 % and 12 % of the patients, respectively, with no poor outcome indicating restriction of the patient's daily activities. Functioning of the hand was excellent in 47 %, good also in 47 % and satisfactory in 6 % of the patients. The range of motion was excellent, good and satisfactory in 24 %, 64 % and 12 % of the patients, respectively. No stiff wrist was recorded after reconstruction of the SL ligament by our method. The hand grip was evaluated as excellent in 47 %, good in 35 % and satisfactory in 18 % of the patients. DISCUSSION: The results show that by reconstruction of the SL ligament with the use of MITEK anchors, radiographic values of the SL and CL angles and SL distance can reach the normal levels within 24 months of the operation. As assessed by the WHWS system, excellent and good results were achieved in 88 % of the wrists treated. Similarly, at 24 months of followup, excellent or good functional outcomes were reported by 94 % of the patients, and excellent or good results in relation to the range of motion and hand grip were experienced by 88 % and 82 % of the patients, respectively. CONCLUSIONS: When treating complete SL ligament ruptures within 4 weeks of injury, stabilization with Kirschner's wires, re-attachment of the SL ligament and suture of the articular capsule are adequate procedures leading to the best results. The ligament reconstruction with MITEK anchors, as presented here, is a relatively simple method giving good results. For treatment of chronic instability it is necessary to use other surgical procedures that, however, will reduce wrist mobility to a greater extent.

[Arthroscopic stabilization of the fractured intercondylar eminence]. / Artroskopická stabilizace odlomené interkondylické eminence.

PURPOSE OF THE STUDY: The authors present the results of arthroscopic reduction of a displaced fracture of the intercondylar eminence and stabilization of the fracture with a tension band wire and absorbable, double PDS sutures. MATERIAL: In the years 1998 to 2002, a fracture of the intercondylar eminence was arthroscopically diagnosed in 34 patients, 21 women and 13 men in the age range of 17 to 46 years. Five patients had type I fracture, 13 had type II fracture and 16 had type III fracture, as classified by the Meyers and McKeever system. Arthroscopic stabilization was used for all type II and type III fractures in a total of 29 patients. Double PDS sutures no. 1 were always applied. One double PDS loop was used in eight patients and, in the rest, two or three double PDS loops were employed. METHODS: PDS no. 1 sutures were inserted, by means of wire loops, through bone tunnels. These were drilled with 2-mm Kirschner's wires, using an anterior cruciate ligament (ACL) reamer, medial to the tibial tuberosity. Double PDS sutures were applied to the distal portion of the ACL, which permits good stabilization even in comminuted fractures of the eminence. The strength of a double PDS loop is sufficient and facilitates speedy recovery. Before terminating surgery it is necessary to check joint mobility and fixation stability. Only good stability allows for early mobilization of the joint. The postoperative treatment involved immobilization of the knee joint with a rigid brace in a semi-flexed position at 20 degrees for 6 weeks. However, from the second postoperative day, the brace was removed during targeted rehabilitation. Exercise on a continuous passive motion device, strengthening of the thigh muscles, patellar mobilization, walking with the use of crutches, while wearing the brace, with partial weight bearing until pain were practised. A treadmill without loading was used from the fifth postoperative week. RESULTS: Twenty-nine patients in whom stabilization with PDS sutures was used were evaluated. Of them 26 were completely free from any complaints and fully healed, always without findings of displacement on X-ray. In one patient, a fragment of the comminuted fracture was loosened and interfered with full extension. It was removed by arthroscopy and full recovery without consequences ensued. One patient underwent repeat surgery for hematoma in the wound; after wound healing and rehabilitation, he achieved a full range of motion. One patient showed signs of fibrosis of Hoffa's fat pad. All patients returned to the style of life as before injury. At follow-up of 1 to 4 years, Lysholm scores were excellent in 23 patients, very good in four patients, satisfactory in one patient (repeat surgery) and one patient was not examined. DISCUSSION: Fracture of the intercondylar eminence is caused by a mechanism similar to that causing rupture of the anterior cruciate ligament but, in addition, the margin of the intercondylar fossa is pressed against the eminence which breaks off. Displaced fractures (types II and III according to the Meyers and McKeever classification) are indicated for surgical stabilization. Fixation of the fractured eminence by means of absorbable material is sufficient, and insertion of metal material and its subsequent removal thus can be avoided. Arthroscopic inspection permits exact reduction; this procedure is minimally invasive. CONCLUSIONS: Arthroscopic stabilization of a fractured eminence by means of PDS sutures is a gentle surgical procedure that provides good mechanical support, facilitates early rehabilitation and achieves good outcomes. The use of absorbable sutures allows us to avoid further surgery in order to remove fixation material.

Treatment of deep cartilage defects of the knee using autologous chondrograft transplantation and by abrasive techniques--a randomized controlled study.

AIM OF THE STUDY: To compare outcomes of surgical treatment of deep cartilage defects of the knee in a group of patients treated by autologous chondrograft transplantation versus patients treated by abrasive techniques. MATERIALS AND METHODS: An original method of chondrograft preparation based on cultivated autologous chondrocytes in a three-dimensional carrier - fibrin glue (Tissucol, Baxter, Austria) has been described. Preclinical tests in human cadavres and porcine models have established the possibility of chondrograft use in humans. Of the 50 patients included in the study, 25 patients (50%) underwent autologous chondrograft transplantation (group I) and 25 patients (50%) were treated using abrasive techniques according to Johnson (group II). These two groups were similar with respect to age, size of defect, depth and localization, and presence of concomitant knee injuries. The Lysholm knee and IKDC (International Knee Documentation Committee) subjective scores were used to evaluate the results. RESULTS: The preoperative value of the Lysholm knee score for patients in group I was 47.60 points; 5 months after surgery 77.20 points; and 12 months after surgery 86.48 points. The values for the Lysholm knee score for patients in group II preoperatively, 5 months postop, and 12 months postop were 52.60, 69.20, and 74.48 respectively. Results 12 months after surgery were significantly better in group I as compared to group II (p < 0.001). The preoperative value of the IKDC subjective score in group I was 41.28 points; 5 months after surgery 67.00 points; and 12 months after surgery 76.48 points. The values for the IKDC subjective score in group II preoperatively, 5 months postop, and 12 months postop were 45.00, 62.28, and 68.08 respectively. Results 12 months after surgery were significantly better in group I when compared to group II (p < 0.05). CONCLUSIONS: The results obtained in this study have confirmed the better outcome in patients treated with autologous chondrograft transplantation. This original method was found to be just as effective as abrasive techniques. We recommend its use in clinical practice.

[Traumatic avulsion of the tuberosity of the ischium]. / Traumatická avulze tuber ossis ischii (kazuistika).

The apophysis of the ischial tuberosity usually becomes united with the hipbone by 25 years of age. The highest incidence of avulsion in this region occurs between 15 and 17 years in young active persons. Apophysitis should be differentiated from apophyseolysis or an avulsion fracture of the ischial tuberosity. Apophysitis may be associated with chronic excessive sports activities in young men and women and is manifested by pain in the region involved. Its presence is confirmed by radiographic findings. The patient with an avulsion fracture of the ischial tuberosity reports an injurious event, usually a sudden movement during sports activities, associated with immediate pain. The diagnosis is again confirmed by radiology. Apophysitis is treated conservatively with no resulting problems. The poor healing of an avulsion fracture may result in chronic complaints, particularly painful sitting. This condition is treated by resection of the fractured apophysis. The authors describe the case of a 28-year-old man who complained of experiencing pain when sitting. At 20 years of age, he suffered an avulsion fracture of the ischial tuberosity that was treated conservatively. He was examined at our department and an unhealed fracture of the ischial tuberosity was diagnosed by radiology and computed tomography. The separated bony fragment was removed and the patient was followed up to 1 year. He remained free from any complaints. An avulsion fracture of the ischial tuberosity is an injury rarely reported in our as well as foreign literature. The available case reports are discussed.

[A less invasive retropleural-retroperitoneal approach to the thoraco-lumbar spine]. / Méne invazivní retropleurální-retroperitoneální prístup k torakolumbální páteri.

UNLABELLED: Authors describe the technique of anterior less invasive approach to the treatment of thoracolumbar spine. The advantage of the mentioned approach is the treatment of the anterior spinal column without opening the thoracic cavity. MATERIAL: In the period between 1996-2000 the described method was used in 46 patients. The average age of patients was 49 years (range, 22 to 67 years). There were 30 men and 16 women. Most frequently affected was L1-fractures in 29 patients, Th12 was handled in 16 patients and Th11 only in one case. METHOD: The surgical technique is based on the anterior approach to thoracolumbar spine without opening of the pleural cavity. RESULTS: The evaluation included 46 patients. The surgical time ranged between 100 minutes and 180 minutes. Blood losses ranged between 300 and 2000 ml. Pleural cavity was opened in three cases. Thoracic drainage was not applied in any patient from the followed-up group. Neither preoperative nor postoperative complications were recorded. In all cases allograft was used without complications. DISCUSSION: The described method is one of the possibilities of treating the anterior spinal column in the region of thoracolumbar spine in addition to the classic Hodgson approach or thoracoscopic treatment. CONCLUSION: In the given group of patients the authors' department introduced the treatment of the anterior column of thoracolumbar spine without opening pleural cavity and without the necessity of draining the thoracic cavity. It is a less invasive method as compared to the classic Hodgson approach. The alternative to the treatment of the anterior spinal column in the thoracolumbar region is the thoracoscopic method.

[Dynamics of cytokines in blood and liquor at the spinal injured patients.]. / Dynamika vzestupu cytokinu v krvi a likvoru u spinálních traumat.

Authors followed the increase of cytokines concentration in blood and liquor at spine injured patients. The degree of the neurological damage was classified according to Frankel scale. Mediators: IL-1, IL-2, IL-6, TNF-alfa, Cortisol were investigated. No significant response of IL-1, IL-2, TNF-alfa to the spinal injury was documented. The Cortisol levels in blood and liquor reached vallues of 100 pg/ml. But no statistical correlation between the Cortisol level and various degrees of spinal neurological damage was identified. The increase in Cortisol concentration can be explained by the stress reaction of the organism. The IL-6 blood and liquor concentrations reached extremly high vallues. We certified a significant relationship between the IL-6 level and the neurological damage of the spinal cord. In prognostic point of view we conclude that the lower increase of IL-6 means: a)lower degree of the neurological damage of the spinal cord classified by Frankel; b)higher percentage of neurological improvement. Key words: cytokines, spinal injury, spinal cord lesion.