Fasciotomy closure using negative pressure wound therapy in lower leg compartment syndrome.

BACKGROUND: Fasciotomy wounds can be a major contributor to length of stay for patients as well as a difficult reconstructive challenge. OBJECTIVES: To evaluate lower leg fasciotomy wound closure outcomes comparing treatment with combined dressing fabric (COM) and negative pressure wound therapy (NPWT) in combination with elastic dynamic ligature (EDL). METHODS: Retrospective study of 63 patients who underwent lower leg fasciotomy due to injury treated from January 2008 to December 2015 at the Department of Trauma Surgery, University Hospital Brno. Of these fasciotomy wounds 42 received a NPWT treatment in combination with EDL, 21 were treated only with COM. Fasciotomy wounds were closed either with primary suture or in case of persisting oedema and skin retraction the defect was covered with split thickness skin graft. RESULTS: There was statistically significantly higher rate of primary wound closure using the NPWT versus traditional dressing (p = 0.015). Median time to definitive wound closure or skin grafting was shorter in the NPWT group. Number of dressing changes was lower in the NPWT group (p=0.008). CONCLUSION: NPWT combined with elastic dynamic ligature offers many advantages for fasciotomy wound closure in comparison with traditional techniques (Tab. 5, Fig. 3, Ref. 21).

Traumatic haemarthrosis of the knee -- indication to acute arthroscopy.

BACKGROUND AND AIMS: The most common mechanisms of the knee injuries are distortions and contusions. Fairly often they will result in hemarthrosis. The purpose of this study was to evaluate the findings in patients with acute traumatic hemarthrosis of the knee and based on these findings estimate the necessity of acute artroscopic examination with therapeutic procedure. MATERIAL AND METHODS: In the years 2007 and 2009 a total of 266 patients underwent acute arthroscopic examination in Department of Traumatology the Faculty Hospital Brno after the acute knee trauma. Patients with other intraarticular bone fractures were excluded. RESULTS: The ruptures of the ACL were the most common findings (52 %), meniscal tear (27 %), dislocation of the patella (11 %) and chondral or subchondral fractures were (13 %). In 224 (84 %) cases was performed artroscopic therapeutic procedure and in only 43 (16 %) case was performed routine arthroscopic examination. CONCLUSIONS: Based on our findings we believe that arthroscopic examination is necessary in patients with acute traumatic haemarthrosis of the knee and it is better methods like NMR examination because is provided to execute therapeutic procedure (Tab. 1, Fig. 2, Ref. 8). Full Text in PDF www.elis.sk.

[Minimally invasive thoracoscopic transdiaphragmatic approach to thoracolumbar junction fractures]. / Minimálne invazivní torakoskopicky asistovaný transdiafragmatický prístup pri osetrování predního sloupce torakolumbálního prechodu.

PURPOSE OF THE STUDY: A retrospective analysis of patients with thoracolumbar junction fractures who underwent video-assisted thoracoscopic surgery via a minimally invasive approach (minithoracotomy) for reconstruction of the anterior spinal column. MATERIAL: Between 2002 and 2006, a total of 127 patients were treated by this technique. The age of the group, including 75 men and 52 women, ranged from 18 to 75 years (average, 45.9 years). L1 and Th12 fractures were treated in 71 and 66 patients, respectively. Based on CT scans and operative findings, the fractures were assessed as type A in 81, type B in 42 and type C in four patients. The causes of injury were a fall from height in 72, a pedestrian's fall in 29, a traffic accident in 23 and other in three patients. On admission 19 patients had a neurological deficit of varying degree: Frankel grade A, eight patients; grade B, four; grade C, five; and grade D, two patients. METHODS: The patients were treated by either posterior stabilization and, at the second stage, the minimally invasive technique via an anterior approach, or the minimally invasive anterior procedure alone. Transpedicular posterior stabilization was performed in 52 patients. All of them had an anterior procedure completed with screw-rod-screw stabilization, and the vertebral body was replaced with an allograft or an expandable titanium cage in 50 and two patients, respectively. The anterior approach alone was used in 75 patients, who received a bisegmental angle-stable implant in 43 and a monosegmental plate in 32 cases. To replace the vertebral body, allografts were used in 71 and an expandable titanium cage in four patients. RESULTS: The average follow-up period was 3.9 years (range, 1 to 6 years). In the anterior procedure, the average operative time was 90 min (range, 50 to 130 min) and blood loss ranged from 200 ml to 2300 ml. A complication due to deep infection occurred in one patient and required removal of both the anterior and posterior implants. Bony fusion without complications was achieved in all patients within a year of surgery. The loss of correction after the anterior procedure with an allograft or titanium cage was up to 2 degrees at 1-year follow-up. No conversion of the minimally invasive technique to a conventional approach due to visceral or vascular injury was necessary; nor was revision surgery for fluidothorax needed. No loosening of an anterior implant or cage dislocation was recorded. Hypesthesia in the operative wound area was found in four patients (3.1%). Improvement in neurological status by at least one Frankel grade was found in 10 of the 19 affected patients. DISCUSSION: The anterior approach is recommended for reconstruction of the anterior spinal column in burst fractures of the thoracolumbar junction in particular. An isolated posterior approach may result in implant failure during bony union or in the loss of correction after implant removal that can lead to the recurrence of kyphosis. Conventional thoracotomy is often associated with significant morbidity and hence there is a need for a minimally invasive approach to treat thoracolumbar junction injury. CONCLUSIONS: The minimally invasive approach (minithoracotomy up to 6-7 cm) combined with thoracoscopy is an alternative to an exclusively endoscopic technique enabling us to provide safe surgical treatment of the anterior spinal column.

[Transplantation of deep frozen menisci]. / Transplantace hluboce mrazených menisku.

PURPOSE OF THE STUDY: Subtotal or total meniscectomy will increase weight-bearing per square unit of the cartilage surface approximately threeand- half-times. A long-term overloading of cartilage is clinically manifested by pain, swelling and a rapid onset of early arthritic lesions discernible on radiograms. One of the options for the treatment of degenerative changes in the joint is meniscal transplant. The authors present their first experience with the transplantation of deep frozen meniscal tissue in the Czech Republic. MATERIAL: By September 2006, we had treated 26 patients with clinical problems following subtotal or total meniscectomy. The patients, 15 women and 11 men, were between 24 and 46 years of age. Eighteen patients underwent transplantation of the medial meniscus and eight received a lateral meniscal transplant. Concomitant repair of the anterior cruciate ligament (ACL) was indicated in 11 patients, of whom 10 were treated with semitendinosus tendon graft and one with patellar ligament allograft. One patient with a lateral meniscal transplant and ACL reconstruction also had suture of the medial meniscus for a previously sustained injury. In 16 patients, chondromalacia was at the level of Outerbridge grade II and, only in five patients, the finding was Outerbridge grade I. Five patients with grade III chondromalacia were treated using the microfracture technique. Valgus or varus osteotomy was not indicated at all. METHODS: The goal of meniscal transplant surgery is: 1) to relieve pain after meniscectomy; 2) to prevent degenerative changes of cartilage; 3) to eliminate or reduce the risk of development of osteoarthritic lesions; 4) to restore normal mechanics of the knee joint. Patient selection is important and it is necessary to take into consideration: 1) level of cartilage degenerative changes; 2) knee alignment; 3) knee joint stability; 4) graft size. In patients with instability of the knee and indications for meniscal graft, it is necessary to stabilize the joint by ligament reconstruciton prior to transplantation; in the case of malalignment corrective osteotomy is required. RESULTS: All patients healed without complications. At the end of the third follow-up month, the range of motion was S-0-0-130 in 22 patients and S-0-0-120 in three patients. Only one patient had the range of motion restricted to S-0-0-110. Evaluation showed improvement from pre-operative values to those at 6 months and two years post-operatively as follows: IKDS score, 57-64 to 73-80 to 76-84; Lysholm score, 50-76 to 80-90 to 85-95; and Tegner score, 2-4 to 4-7 to 5-8. No complications associated with meniscal transplant incorporation were recorded. Also in five patients with Outbridge grade III degenerative changes, meniscal transplantation was successfully carried out. In four patients, of which two had a cartilage defect treated, second-look arthroscopy showed that the lesions healed with healthy fibrocartilaginous tissue. CONCLUSIONS: All patients reported resolution of subjective complaints, as seen from the results of the IKDC, Lysholm and Tegner scoring systems. It was obvious that when biomechanics of the knee joint were restored, conditions facilitating healing of chondral defects were provided. Based on this experience, the authors conclude that meniscal transplantation improves the quality of life in biologically young patients with clinical problems after meniscectomy.

[Current treatment options of osteoporotic thoracolumbal spinal fractures]. / Soucasné moznosti osetrení osteoporotických fraktur torakolumbální pátere.

AIM OF THE STUDY: Retrospective assessment of a patient group, including patients with osteoporotic thoracolumbal fractures. Only patients over 65 years of age were included in the study. METHODS: During IX/2005 VII/2006, 45 patients with osteoporotic fractures were managed: 28 females, 17 males aged 65-85 y.o.a, their mean age was 72.6 y.o.a. The mechanisms of the injury included falls in 39 subjects, car- motocycle accidents in 5 subjects, a submerge accident in a single subject. Three patients sufferred from neurological symptoms. TI-TI0 injury was diagnosed in 8 subjects, T11-L2 in 43 subjects, L3-L5 in 5 subjects. Type A injuries prevailed--in 47 subjects, type B injury were diagnosed in 4 subjects, type C in 2 subjects. Conservative therapy was indicated in 25 subjects; transpedicular stabilization in 15 subjects, stabilization using isolated anterior approach in one patient, vertebroplasty in 5 patients. The majority of the injuries were monotraumas--31 subjects, associated traumas in 12 subjects, polytraumas in 2 subjects. RESULTS: The authors assessed data collected from 25 patients. 6 patients exited, 14 failed to turn up for their follow up examination at 12 months. GDW (Grunddeckplattenwinkel), VAS (Visual Analog Scale) and Oswestry score and complication rates were assessed. Prior to the therapy, the mean VAS score in the conservative group, surgical management and vertebroplasty groups was 7.0: 8.2 and 7.9, respectively; at 12 months the score was reduced to 3.8; 3.4 and 3.7, respectively. The Oswestry score figures in the respective treatment groups were 25.3%, 27.1% and 23.5%. There were no statistically significant differencies between the results. At the time of the injury, the mean GDW in the conservative group was -2 degrees, at 12 months -6 degrees. Prior to vertebroplasty it was +4 degrees, following the procedure +6 degrees, and at 12 months +2 degrees. Prior to surgical stabilization it was -10 degrees, postoperatively +3 degrees and at 12 months 0 degrees. An early infectious complication, a wound absces, was recorded in one patient. A late complication, implant failure, was recorded in the same patient at 6 months postoperatively. CONCLUSION: Treatment of osteoporotic thoracolumbal spinal fractures requires individual thorough assessment of therapeutical options.

[Arthroscopic management of traumatic luxation of the patella]. / Artroskopické osetrení traumatické luxace pately.

AIM: The authors present a restrospective assessment of acute traumatic patellar luxation. MATERIAL: From 1999 to 2003, the authors treated 57 patients with acute traumatic patellar luxations, including 36 females and 21 males, the age range was 16-40 years. In cases of marked lateralization of the patella, the injured medial retinaculum was sutured under arthroscopic control. Furthermore, should the lateralization persist, lateral release of the patella was conducted. Early patellar cartillage injuries were detected in 34 subjects (59%), injuries of the lateral femoral condyle in 19 subjects (33 %). Patellar chondromalacia, grade 1-2 was diagnosed in 16 subjects. Free cartillagenous particles within the joint were detected in 18 subjects. Reconstruction of the cartillage was conducted in extensive injuries in 13 subjects. RESULTS: The subjects were assessed 1-4 years after the injuries and surgery. In one case (2%), a relaps of the patellar luxation, due to a new contact sport injury (a direct impact), was recorded. Assessment results, using the Lysholm score, were defined as follows: 93%-excellent and good, 7% fair. CONCLUSION: Sparing surgical techniques, followed by appropriate rehabilitation care, may optimalize the healing process of the injured tissue and prevent relapses of patellar luxations, as well as further wearing of femoropatellar cartillages.

[Anterior spondylodesis using a corticospongious allograft in the combined management of Th-L spinal fractures]. / Prední spondylodéza kortikospongiózním allostepem pri kombinovaném postupu osetrení zlomenin Th-L prechodu pátere.

AIM: The authors introduce a group of patients with thoracolumbar spinal fractures, following their combined management. The aim of this work is to retrospectively assess the allograft bone reconstruction and loss of spinal axis correction rate in the fused segments, following extraction of the posterior instrumentation. MATERIAL: During the period from 2002 to 2005, the authors managed 71 patients with spinal fractures in Th 11-12 segments, using the combined procedure, excluding anterior fixation, in the Traumatology Clinic of LF MU Brno. The study group included 37 patients, at least 6 months after extraction of the posterior stabilizator. The patient group included 12 females and 25 males, aged between 17 to 62 years. The mean age was 29.7 years. METHODS: The patients were managed with transpedicular stabilization method as the first step and with anterior monosegmental spondylodesis using coticospongious allografts, excluding futher use of metal implants, as the second step. Assessment of the bone reconstruction and incorporation of the allograft at the anterior spondylodesis site, was based on x-ray and CT examinations. Loss of correction in the fused segment was assessed based on measurement of GDW angles (Grund-Deckplattenwinkel) on x-rays following extraction of the implant. The findings were compared to those following stabilization. Upon CT examination, bone structure of the implanted allograft and its reconstruction and incorporation between the two vertebrae, was assessed. Furthermore, the concerned bone density was measured. RESULTS: Out of our patient group, no loss of correction was detected in five subjects, only. In 32 subjects, the correction loss ranged from 1 degrees up to 34 degrees. The mean was 7.08 degrees. Based on the CT examination, partial resorption of the graft edge occured in all subjects, in 32 subjects the allograft was fragmented, particullarly in its central part, with densities ranging from 122 HU to 246 HU, the mean of 158 HU. The graft's outline was partially undetectable in 20 subjects. Outer hypodense zone surrounding the allograft was detected in all subjects. DISCUSSION: Injured discs next to the injured vertebra undergo degeneration and, later on, collaps, which results in the correction loss. Therefore, fusion of the segments is an essential part of stabilization procedures. Either posterolateral fusion, inter-intraarticular fusion or anterior intercorporal fusion methods may be applied. The authors concentrate primarily on adequate completion of the anterior fusion, which may prevent a serious secondary complication--posttraumatic kyphosis. However, opinions on management of the anterior segments and anterior spondylodesis, are not uniform. Also, best methods which would result in firm spondylodeses, are currently under discussion. CONCLUSION: The aim of the anterior column therapy is to create anterior spondylodesis firm enough to prevent future onset of a posttraumatic kyphosis. Anterior fusion based on conticospongious allografts without anterior instrumentation may frequently result in kyphotic spinal deformities, due to its partial resorption and fragmentation. Therefore, the authors would not recommend using corticospongious allografts without anterior instrumentation.