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

• MeSH
• artroplastika metody   MeSH
• dospělí MeSH
• karpální klouby * chirurgie   MeSH
• kosti zápěstní * chirurgie   MeSH
• lidé středního věku MeSH
• lidé MeSH
• mladiství MeSH
• mladý dospělý MeSH
• mrtvola MeSH
• rozsah kloubních pohybů MeSH
• senioři nad 80 let MeSH
• senioři MeSH
• zápěstní kloub chirurgie   MeSH
• Check Tag
• dospělí MeSH
• lidé středního věku MeSH
• lidé MeSH
• mladiství MeSH
• mladý dospělý MeSH
• senioři nad 80 let MeSH
• senioři MeSH
• Publikační typ
• anglický abstrakt MeSH
• časopisecké články MeSH

PURPOSE OF THE STUDY This study aims to evaluate the results of patients treated by proximal row carpectomy at a follow-up of at least 5 years after the surgery. MATERIAL AND METHODS A total of 25 patients were treated by proximal row carpectomy for degenerative changes of the wrist as a consequence of the previous trauma or avascular necrosis of the lunate bone, of whom 21 patients underwent a follow-up examination at least 5 years postoperatively. Proximal row carpectomy was indicated in 15 patients for SLAC wrist, in 4 patients for avascular necrosis of the lunate bone, in 1 patient for SNAC wrist, and in 1 patient for inveterate dislocation of the wrist. The follow-up clinical and radiological examinations were performed at least 5 years after the surgery. The range of wrist motion, grip strength, presence of pain at rest or pain under loads, total clinical score according to the Green and O'Brien scoring system, patient satisfaction with the outcome of surgery were assessed. By fluoroscopy the range of wrist motion, degenerative changes of the radiocapitate joint, and translation of the capitate bone with respect to the distal radius were evaluated. RESULTS Postoperative improvements in the range of motion and grip strength were confirmed. Also, the pain relief at rest and under loads was achieved. Five years after the surgery, most of the patients (85.6%) reported an overall improvement. The total clinical score according to the Green and O'Brien scoring system improved from 35.8 preoperatively to 63.1 postoperatively. DISCUSSION The advantage of this procedure is a low percentage of complications, relative technical simplicity, maintenance of functional motion of the wrist, satisfactory grip strength, and pain relief. There are no complications related to the implant, no risk of a non-union. CONCLUSIONS As shown by our results obtained 5 years after the surgery as well as the published data, in the indicated cases the proximal row carpectomy is an appropriate surgical technique to treat the degenerative changes of the wrist. In most of the patients, favourable functional results and pain relief can be expected. Key words:proximal row carpectomy, SLAC wrist, SNAC wrist, avascular necrosis of the lunate bone, dislocation of the wrist.

• MeSH
• artralgie prevence a kontrola   MeSH
• dislokace kloubu chirurgie   MeSH
• kosti zápěstní diagnostické zobrazování   zranění   patologie   chirurgie   MeSH
• lidé MeSH
• následné studie MeSH
• nekróza MeSH
• ortopedické výkony škodlivé účinky   metody   MeSH
• poloměsíčitá kost patologie   chirurgie   MeSH
• pooperační komplikace MeSH
• radiografie MeSH
• rozsah kloubních pohybů MeSH
• síla ruky MeSH
• výsledek terapie MeSH
• Check Tag
• lidé MeSH
• Publikační typ
• časopisecké články MeSH

Úvod: Kolektiv autorů prezentuje případ osmnáctiletého pacienta, který v rámci závažného polytraumatu (ISS 41) utrpěl vzácné těžké poranění zápěstí, jehož chirurgické ošetření bylo modifikováno časově odloženým řešením. Materiál: Kazuistika popisuje klinický průběh, diag-
nostiku a timing péče o výše uvedeného pacienta v časové posloupnosti. Transskafoid-transtriquetro-perilunátní luxace byla chirurgicky řešena s odstupem osm týdnů od úrazu kvůli pozdnímu stanovení diagnózy poranění a nutnosti odložení operačního výkonu pro reaktivní perikarditidu rozvinutou v důsledku kontuze srdce, která vedla k časné fázi srdeční tamponády. Vzhledem k předpokládanému rozvoji avaskulární nekrózy proximálního pólu os scaphoideum v důsledku malpozice fragmentů a dislokace radiokarpálního kloubu, nebyla již primární rekonstrukce kloubu možná a pacient byl indikován k proximální karpektomii – princip metody je podrobně psán v textu, terapeutickou rozvahu shrnuje diskuze. Po 18 měsících od operačního výkonu byl pacient bez reziduální bolesti zápěstí, nevykazoval známky nestability radiokapitátního kloubu, zaznamenaný rozsah hybnosti poraněného zápěstí a předloktí dosahoval 80 % rozsahu hybnosti nepostižené končetiny a síla stisku ruky činila 95 % síly stisku nepostižené končetiny. Výsledek léčby lze hodnotit jako velmi dobrý. Diskuze: Přidružená poranění kostí karpu a perilunátní luxace bývají často při závažných poraněních a polytraumatu primárně nezjištěny, proto je důležité na ně mys-
let a časně diagnostikovat, aby se předešlo závažným komplikacím rezultujícím z odloženého ošetření, které vedou k trvalým funkčním následkům. Při závažném poranění způsobeném vysokoenergetickým mechanismem lze úraz horních končetin předpokládat a bylo by vhodné v rámci primární diagnostiky provádět rentgenové snímky zápěstí ve dvou projekcích, vyšetření lze provést po překlenutí akutní fáze polytraumatu. Závěr: Proximální karpektomie je chirurgickou metodou volby v léčbě inveterovaných perilunátních luxací a zlomenin s dobrými funkčními výsledky.

Introduction: Authors present a case report of 
eighteen years old patient with serious multiple trauma (ISS 41), who suffered a rare severe injury of the wrist, the surgical treatment was modified by delayed diagnosis. Material: Case report describes the clinical course, diagnosis and timing of the treatment of the patient. Transscaphoid-transtriquetro-perilunate dislocation was treated surgically 8 weeks after injury. Delay was caused by late diagnosis of the wrist injury and the necessity to postpone the surgery due to reactive pericarditis deve-loped as a result of a heart contusion, which led to early stage of cardiac tamponade. Because of avascular necrosis of the scaphoideum caused by dislocation of the fragments and radiocarpal joint, primary joint reconstruction was not possible and the patient was indicated for proximal row carpectomy – treatment principles are described in the text, indication is summarised in the discussion. 18 months after surgery the patient was free of residual wrist pain, he showed no signs of wrist instability, recorded range of motion of injured wrist and forearm was 80 % of the unaffected limb and hand grip strength was 95 % of unaffected limb. Treatment outcomes can be assessed as very good. Discussion: Associated perilunate dislocations and perilunate fracture dislocations are often primarily unde-
tected in cases of serious multiple trauma. It is important to think of them and diagnose them early to prevent on set of severe complications resulting from delayed treatment, especially permanent functional consequences. Injury of the upper extremities can be expected in cases of high 
energy trauma, where plain wrist radiographs in two projections should be performed for primary diagnosis. Examination can be performed after overcoming of the acute phase of multiple trauma. Conclusion: Proximal row carpectomy is a surgical method of choice in the treatment of the most serious pe-rilunate dislocations and perilunate fracture dislocations with good functional results.

• MeSH
• dislokace kloubu chirurgie   radiografie   MeSH
• kosti zápěstní chirurgie   MeSH
• lidé MeSH
• mladý dospělý MeSH
• mnohočetné fraktury etiologie   chirurgie   radiografie   MeSH
• poloměsíčitá kost chirurgie   radiografie   zranění   MeSH
• polytrauma etiologie   chirurgie   radiografie   MeSH
• poranění zápěstí * chirurgie   radiografie   MeSH
• výsledek terapie MeSH
• Check Tag
• lidé MeSH
• mladý dospělý MeSH
• mužské pohlaví MeSH

Názor na chirurgickou léčbu izolované scapho-trapezio-trapezoidní artrózy není doposud jednotný a ani etiologie vzniku izolované artrózy tohoto kloubu není dostatečně objasněna. Nejčastěji užívaná léčebná metoda u symptomatické scapho-trapezio-trapezoidní artrózy je artrodéza, která způsobuje omezení pohybu zápěstí a je zatížena komplikacemi především v podobě vzniku bolestivého pakloubu a rozvojem radioscaphoidního impingementu. Další metodou operačního řešení je resekce distálního pólu scaphoidea, která často způsobí zvýraznění midkarpální malpozice mezi proximální a distální karpální řadou a v některých případech dochází k progresivním změnám charakteru midkarpální destrukce kloubu. Popsaný případ upozorňuje na stav, kdy izolovaná scapho-trapezio-trapezoidní artróza není ve své podstatě primární, ale je sekundárním důsledkem chronické, asymptomatické, dorzální midkarpální nestability. Četnost těchto stavů a vhodný způsob léčby není dostatečně literárně dokumentován.

The opinions on the surgical treatment of isolated scapho-trapezoid trapeziometacarpal arthritis remain divided, and even the aetiology of the origin of osteoarthritis of the joint has not been sufficiently explained. The most commonly used method of treatment for symptomatic scapho-trapezoid-trapeziometacarpal arthritis is arthrodesis, which uses restriction of movement in the wrist and is burdened with complications, especially in the form of painful pseudo-arthritis and development of radioscaphoid impingement. Another method of surgical treatment is the resection of the distal pole of the scaphoid, which often causes the disparity in midcarpal malposition between the proximal and distal carpal row and in some cases leads to progressive changes in the character of midcarpal joint destruction. This case highlights the condition where isolated scapho-trapezoid-trapeziometacarpal arthrosis is not inherently primary, but secondary consequence of chronic, asymptomatic, dorsal midcarpal instability. The frequency of these conditions and suitable method of treatment is not sufficiently documented in literature.

• Klíčová slova
• karpectomie, distální resekce scaphoidea, midkarpální nestabilita,
• MeSH
• artralgie MeSH
• člunkovitá kost chirurgie   MeSH
• kosti zápěstní * abnormality   chirurgie   patofyziologie   MeSH
• kostní dráty MeSH
• lidé středního věku MeSH
• lidé MeSH
• nestabilita kloubu * chirurgie   patofyziologie   radiografie   MeSH
• ortopedické výkony metody   MeSH
• osteoartróza * diagnóza   chirurgie   komplikace   MeSH
• poloměsíčitá kost chirurgie   MeSH
• progrese nemoci MeSH
• reoperace MeSH
• rozsah kloubních pohybů MeSH
• trapézová kost chirurgie   MeSH
• trapézovitá kost chirurgie   MeSH
• zápěstní kloub * chirurgie   patofyziologie   MeSH
• Check Tag
• lidé středního věku MeSH
• lidé MeSH
• ženské pohlaví MeSH
• Publikační typ
• kazuistiky MeSH
• práce podpořená grantem MeSH

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

• MeSH
• artrodéza metody   MeSH
• bolest prevence a kontrola   MeSH
• člunkovitá kost chirurgie   MeSH
• kosti zápěstní chirurgie   MeSH
• kostní destičky * MeSH
• lidé MeSH
• obnova funkce MeSH
• poranění zápěstí komplikace   patofyziologie   MeSH
• síla ruky MeSH
• Check Tag
• lidé MeSH
• Publikační typ
• anglický abstrakt MeSH
• časopisecké články MeSH

An overview about current concepts in treating carpal injuries is presented. These injuries are more commonly seen in young, active individuals after a fall on an outstretched hand. Conventional radiographs and a thorough examination are important. The scaphoid is the most affected bone. Scaphoid fractures can be classified in accordance to OTA, AO, and other classification systems, but mostly to Herbert. It can be treated non-operatively if undisplaced, however a percutaneous internal fixation can be discussed to achieve earlier return to work and shorter time to union, but hazarding the consequences of an operation. Unstable, proximal pole, or delayed diagnosed scaphoid fractures should be treated surgically. Nonunion is seen in 5 - 40% of scaphoid fractures depending mainly on displacement and localization of the fracture. The gold standard in non-osteoarthritic scaphoid nonunion is debridement of the nonunion site, bone grafting, realignment, stable fixation and rehabilitation. The treatment of scaphoid-nonunion advanced collapse is more complex. Proximal row carpectomy or arthrodesis (four-corner or complete wrist) can be mandatory. Other carpal bone fractures are rare. Perilunate dislocations are also uncommon but can be disabling. They usually originate in high-energy trauma. The Mayfield stages help to understand the injury pattern. Open reduction through both volar and dorsal approaches, repair of the volar capsule as well as volar and dorsal ligaments, and internal fixation is commonly the standard treatment. However osteoarthritis and carpal instability are often encountered.

• MeSH
• člunkovitá kost chirurgie   zranění   MeSH
• dislokace kloubu chirurgie   komplikace   MeSH
• fraktury kostí diagnóza   chirurgie   klasifikace   MeSH
• kloubní ligamenta chirurgie   zranění   MeSH
• kosti zápěstní chirurgie   zranění   MeSH
• lidé MeSH
• nestabilita kloubu MeSH
• ortopedické výkony metody   využití   MeSH
• poranění zápěstí diagnóza   chirurgie   klasifikace   MeSH
• pseudoartróza MeSH
• vnitřní fixace fraktury metody   využití   MeSH
• výsledek terapie MeSH
• Check Tag
• lidé MeSH

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

• MeSH
• dospělí MeSH
• kosti zápěstní chirurgie   radiografie   MeSH
• lidé středního věku MeSH
• lidé MeSH
• mladý dospělý MeSH
• osteoartróza chirurgie   radiografie   MeSH
• senioři MeSH
• zápěstní kloub radiografie   MeSH
• Check Tag
• dospělí MeSH
• lidé středního věku MeSH
• lidé MeSH
• mladý dospělý MeSH
• mužské pohlaví MeSH
• senioři MeSH
• ženské pohlaví MeSH

Autoři ve své práci srovnávají výsledky při ošetřování pakloubu člunkové kosti zápěstí s výsledky uváděnými v literatuře. Na souboru 21 pacientů jsou srovnávány výsledky s použitím šroubu Synthes 3,0 mm. Pozornost věnují nejen technickým, ale i biologickým aspektům léčby, zejména vhodné volbě operační techniky, kvalitě opracování ploch pakloubu a významu správného zavedení šroubu. Ve svém souboru nemocných s použitím šroubu Synthes 3,0 mm dosáhli zhojení pakloubu v 85,7 %. V závěru zdůrazňují, že není tak důleležitý použitý implantát, jako biologický stav pakloubu a pečlivost ošetření ploch pakloubu.

The authors compare their results of the management of the pseudoarthrosis of the navicular bone of the wrist with those reported in the literature. The study group included 21 patients and the Synthes 3.0 mm was applied. The authors concentrate on both technical and biological aspects of the therapy, mainly on an appropriate choice of the procedure, quality of the management of the surfaces of the pseudoarthrosis and significance of correct introduction of the device. The rate of the healed pseudoarthroses reached 85.7% in their patient trial group. They conclude that the main prerequisites for a successful outcome are the biological status of the pseudoarthrosis and a thorough management of the pseudoarthrosis surfaces, rather than a type of the implant.

• MeSH
• hojení ran MeSH
• kosti zápěstní chirurgie   patologie   MeSH
• kostní šrouby využití   MeSH
• lidé MeSH
• pseudoartróza chirurgie   klasifikace   radiografie   MeSH
• rehabilitace MeSH
• spokojenost pacientů MeSH
• transplantáty MeSH
• zápěstí patologie   MeSH
• Check Tag
• lidé MeSH

• MeSH
• artroplastika metody   MeSH
• dospělí MeSH
• kosti zápěstní chirurgie   patologie   MeSH
• lidé středního věku MeSH
• lidé MeSH
• metakarpus chirurgie   patologie   MeSH
• osteoartróza chirurgie   MeSH
• výsledek terapie MeSH
• výsledky a postupy - zhodnocení (zdravotní péče) metody   MeSH
• Check Tag
• dospělí MeSH
• lidé středního věku MeSH
• lidé MeSH
• ženské pohlaví MeSH

• MeSH
• artrodéza metody   MeSH
• dislokace kloubu chirurgie   patologie   terapie   MeSH
• kosti zápěstní chirurgie   MeSH
• lidé MeSH
• ortopedické výkony metody   MeSH
• radiografie metody   MeSH
• výsledek terapie MeSH
• Check Tag
• lidé MeSH
• Publikační typ
• kazuistiky MeSH