Kazuistika popisuje případ pacienta přijatého po autohavárii se sdruženým poraněním, u kterého dominovala zlomenina horního konce stehenní kosti, s výrazným, hrubě posunutým meziúlomkem. Potíže s úlomkem vedly po čase k rozhodnutí o jeho vyjmutí. Při plánování operace bylo zjištěno cévní poranění, které bylo cévním chirurgem při vyjmutí úlomku řešeno.

In this case study, the patient was admitted to a hospital with a multiple trauma. Proximal femoral fracture was dominant with a considerably displaced fragment. The trouble with the fragment led to a decision to extract it. When planning the operation, a vascular injury was discovered. It was treated at the same time as the fragment was removed.

• Klíčová slova
• kostní fragment, meziúlomek, úlomek kosti,
• MeSH
• dopravní nehody MeSH
• fraktury femuru * chirurgie   komplikace   radiografie   MeSH
• lidé MeSH
• mladiství MeSH
• paréza etiologie   MeSH
• pooperační komplikace MeSH
• poranění cév * etiologie   chirurgie   komplikace   MeSH
• tříštivé fraktury chirurgie   komplikace   radiografie   MeSH
• trombektomie MeSH
• vena femoralis * chirurgie   zranění   MeSH
• vnitřní fixace fraktury MeSH
• výkony cévní chirurgie metody   MeSH
• Check Tag
• lidé MeSH
• mladiství MeSH
• mužské pohlaví MeSH
• Publikační typ
• kazuistiky MeSH

PURPOSE OF THE STUDY: The aim of the study was to analyse causes of impaired bone healing in femoral fractures and to present options of their management. MATERIAL AND METHODS: This is a retrospective study of the data on complications prospectively collected between 2008 and 2013. The patients admitted for primary treatment at the Trauma Centre of the Faculty of Medicine in Hradec Kralove from January 2008 to December 2013 included 1186 patients with injury severity scores (ISS) > 15 and 1340 patients with new injury severity scores (NISS) >15, all older than 16 years. With the exception of two patients, the primary treatment involved the application of an external fixator as part of damage control surgery. Definitive surgery, regardless of the site of fracture, was performed using unreamed femoral nails (UFN) in 51, distal femoral nails (DFN) in 33, plates in 26, long proximal femoral nail antirotation (PFNA-long) in 14 and nails combined with dynamic hip screw (DHS) plates in five fractures. The analysis revealed both mechanical and biological causes of poor bone healing. RESULTS: Of the 124 patients whose multiple injuries included a fracture of the femur, 11 died within 24 hours in spite of intensive resuscitation. In the remaining 113 patients there were 16 bilateral fractures, 20 fractures of the proximal femur (extraarticular), 72 diaphyseal femur fractures and 26 distal femur fractures. Nine patients sustained segmental femoral shaft fractures. Ten diaphyseal and 14 distal femur injuries were open fractures (13.5% and 54%, respectively). Pseudarthrosis developed in a total of 12 fractures (9.3%); six (7.2%) were diaphyseal fractures, of which three were initially open fractures, and six (21.4%) were distal femur fractures with two initially open injuries. All proximal femur fractures healed completely. DISCUSSION: The frequency of non-union femoral diaphyseal fractures in our patients treated by unreamed intra-medullary nailing is in agreement with the literature data. The frequency of non-union distal femur fractures in our group was slightly higher than is published in the literature. This can be accounted for by the characteristics of our group consisting of patients with multiple severe injuries in whom fractures are due to high-energy trauma; the overall severity of injuries negatively affects the biological potential of a human organism for bone healing. CONCLUSIONS: A successful outcome of femoral fracture repair is based on an understanding of the biomechanical principle, i.e., correct fracture reduction and stable osteosynthesis fitting the morphology of the fracture. Comminuted femoral fractures heal well with the use of a narrow long nail whose working length allows for even distribution of movement at a fracture line amongst the fragments and thus fracture motion load does not exceed 20%. On the other hand, short oblique and transverse fractures are examples of problematic fractures which require maximum possible stability provided by a thick nail with a short working length; this is achieved by reaming the medullary cavity or adding lag screws. In our group of patients these fractures were also the most problematic ones. Generally, nailing remains the golden standard in the management of femoral fractures.

• MeSH
• dospělí MeSH
• externí fixátory MeSH
• fraktury femuru radiografie   chirurgie   MeSH
• hojení fraktur * MeSH
• intramedulární fixace fraktury metody   MeSH
• lidé středního věku MeSH
• lidé MeSH
• mladiství MeSH
• mladý dospělý MeSH
• nezhojené fraktury etiologie   prevence a kontrola   MeSH
• polytrauma radiografie   chirurgie   MeSH
• retrospektivní studie MeSH
• rizikové faktory MeSH
• senioři MeSH
• skóre závažnosti úrazu MeSH
• vnitřní fixace fraktury přístrojové vybavení   metody   MeSH
• Check Tag
• dospělí MeSH
• lidé středního věku MeSH
• lidé MeSH
• mladiství MeSH
• mladý dospělý MeSH
• senioři MeSH
• Publikační typ
• anglický abstrakt MeSH
• časopisecké články MeSH

Recent reports have found a relationship between long-term bisphosphonate therapy and the occurrence of low-energy subtrochanteric or diaphyseal atypical femoral fractures. These fractures usually occur at only one site in the same bone. We report a rare case of a patient with sequential atypical femoral fractures (first, a diaphyseal fracture, and second, an ipsilateral subtrochanteric fracture) after low-energy trauma. We present the clinical and operative findings and discuss how to prevent subsequent atypical femoral fractures. This case indicates that an atypical subtrochanteric femoral fracture can occur after an atypical diaphyseal fracture in a long-term bisphosphonate user. Doctors should be aware of the possibility of a second fracture and explain the risk to the patient. Key words: bisphosphonate, atypical femoral fracture, low-energy trauma, subtrochanteric and diaphyseal femoral fractures.

• MeSH
• bisfosfonáty škodlivé účinky   MeSH
• diafýzy zranění   chirurgie   MeSH
• fraktury femuru radiografie   chirurgie   MeSH
• inhibitory kostní resorpce škodlivé účinky   MeSH
• intramedulární fixace fraktury MeSH
• lidé MeSH
• postmenopauzální osteoporóza farmakoterapie   MeSH
• senioři MeSH
• úrazy pádem MeSH
• Check Tag
• lidé MeSH
• senioři MeSH
• ženské pohlaví MeSH
• Publikační typ
• časopisecké články MeSH
• kazuistiky MeSH

x

• MeSH
• časové faktory MeSH
• exprese genu MeSH
• fraktury femuru farmakoterapie   radiografie   MeSH
• hojení fraktur * účinky léků   MeSH
• kostní morfogenetické proteiny genetika   terapeutické užití   MeSH
• kostní morfogenetický protein 2 * aplikace a dávkování   genetika   MeSH
• kostní morfogenetický protein 4 genetika   MeSH
• kostní morfogenetický protein 6 genetika   MeSH
• kostní morfogenetický protein 7 genetika   MeSH
• kostní svalek MeSH
• krysa rodu rattus MeSH
• kvantitativní polymerázová řetězová reakce statistika a číselné údaje   MeSH
• messenger RNA MeSH
• mezibuněčné signální peptidy a proteiny genetika   MeSH
• osteogeneze účinky léků   MeSH
• potkani Sprague-Dawley MeSH
• regenerace kostí genetika   účinky léků   MeSH
• rekombinantní proteiny MeSH
• stanovení celkové genové exprese MeSH
• TNF-alfa genetika   MeSH
• uzavřené fraktury MeSH
• výzkum MeSH
• zvířata MeSH
• Check Tag
• krysa rodu rattus MeSH
• ženské pohlaví MeSH
• zvířata MeSH

This study was designed to investigate effects of insulin on fracture healing and expression of vascular endothelial growth factor (VEGF) in diabetic rats. Wister rats were randomly divided into diabetic control (n=66), diabetic insulin (=66) and non-diabetic control group (n=66). Diabetes was established by peritoneal injection of alloxan. Tibia fracture was surgically created and was allowed to heal. Radiological and biomechanical examinations were performed on the healing tibia. Immuohistochemistry was used to assess VEGF expression in the healing fracture tissues. Cortical reconstruction of the fracture sites in non-diabetic control and diabetic insulin groups was more rapid than in diabetic control group within 6 weeks of the fracture. Mechanical strength of the affected tibia in the diabetic insulin and non-diabetic control group was superior to diabetic control group. Histological examination of the fracture sites revealed a delay in chondrocyte maturation and hypertrophy in diabetic control group. VEGF expression was widely distributed in fracture sites within the first 4 weeks in control and diabetic insulin treatment group. However VEGF expression in the callus and periosteum in diabetic control group was much less than in diabetic insulin or non-diabetic control group. In conclusion, diabetes delays fracture healing and adversely affects callus formation with a reduced VEGF expression at the fracture sites. Insulin therapy improves fracture healing in diabetes rats, possibly through enhancing VEGF expression in the fractured bones.

• MeSH
• biomechanika MeSH
• chondrocyty patologie   účinky léků   MeSH
• experimentální diabetes mellitus farmakoterapie   komplikace   patofyziologie   MeSH
• femur patologie   radiografie   účinky léků   MeSH
• fraktury femuru * farmakoterapie   patofyziologie   patologie   radiografie   MeSH
• hojení ran účinky léků   MeSH
• imunohistochemie MeSH
• inzulin * terapeutické užití   MeSH
• kostní svalek patofyziologie   účinky léků   MeSH
• modely nemocí na zvířatech MeSH
• potkani Wistar MeSH
• studie případů a kontrol MeSH
• vaskulární endoteliální růstové faktory * analýza   účinky léků   MeSH
• zvířata MeSH
• Check Tag
• mužské pohlaví MeSH
• zvířata MeSH
• Publikační typ
• práce podpořená grantem MeSH

PURPOSE OF THE STUDY Both column fractures, defined as an acetabular fracture with no articular fragment in connection with the axial skeleton account for approximately 20% of all acetabular fractures. The typical type of a both column acetabular fracture is the C1.2 fracture with a multifragmentary anterior column fracture extending to the iliac crest and a large posterior column fragment in more than half of the patients. MATERIAL AND METHODS The analysis of 135 surgically treated patients with both column fractures showed that more than half of these patients had associated injuries. The mean age was 40 years, and two thirds of these patients were male. A high energy trauma was the trauma mechanism in 87.4%. The mean ISS was 14.2 points. The mean articular fracture displacement was 14.8 mm. 65.9% of the patients showed a central femoral head dislocation. An associated posterior wall fracture was present in 34.8% and an acetabular roof comminution in 34.1%. 8.9% of patients had a fracture related nerve damage. RESULTS Osteosynthesis was performed 9.6 days after trauma. Several approaches were used for stabilization with a combination of plate and screw fixation in 71.9%. The mean operative time was 287 minutes with a blood loss of 1796 ml. Postoperatively the hip joint was congruent in 94.7% with anatomical or near-anatomical joint reconstruction in 75.6%. latrogenic nerve injury occurred in 12 patients (8.9%). 89 patients (66.4%) could be followed after a mean of 54.6 months. The average subjective Visual Analog Scale pain score was 27.6. Mild or no pain was seen in 60.7%. The mean Merle d'Aubigné score was 15 with 60.7% of patients having a functionally perfect or good result. 61.8% had no post-traumatic osteoarthritic changes of their hip joint. A joint failure was diagnosed in 25.8% of the patients. DISCUSSION Analysing only patients with anatomically reconstructed hip joints patients had better results with 69,8% having no or mild pain and a good or excellent functional result. Post-traumatic arthrotic changes occued in only 17.5% of these patients. A joint failure was present in 25.4%. In this group, a joint failure was significantly more likely to be present with an additional lesion of the femoral head and severe primary articular fracture displacement. CONCLUSIONS In contrast to other acetabular fracture types, both column fractures show worser results regarding joint reconstruction, and functional and radiological long-term results. The optimal results can be achieved with anatomic joint recontsruction.

• MeSH
• acetabulum chirurgie   radiografie   zranění   MeSH
• fraktury femuru chirurgie   komplikace   radiografie   MeSH
• intramedulární fixace fraktury metody   MeSH
• lidé MeSH
• pánevní kosti zranění   MeSH
• pooperační komplikace epidemiologie   etiologie   MeSH
• výsledek terapie MeSH
• Check Tag
• lidé MeSH

This paper describes current treatment strategies of distal femoral fractures as well as their evidence based rationale. The treatment of distal femoral fractures has improved with the evolution of plating and nailing technologies. The commonly selected surgical approaches are outlined and surgical treatment techniques including both internal and external fixation are discussed.

• MeSH
• externí fixátory využití   MeSH
• fraktury femuru chirurgie   klasifikace   radiografie   MeSH
• hojení fraktur MeSH
• intramedulární fixace fraktury metody   MeSH
• kostní destičky využití   MeSH
• lidé MeSH
• nezhojené fraktury chirurgie   MeSH
• poranění kolena etiologie   chirurgie   radiografie   MeSH
• prognóza MeSH
• vnitřní fixace fraktury metody   MeSH
• výsledek terapie MeSH
• Check Tag
• lidé MeSH
• Publikační typ
• přehledy MeSH

PURPOSE OF THE STUDY The aim of the study was a retrospective evaluation of the surgical treatment of 171 fractures of the proximal femur and the femoral shaft. MATERIAL AND METHODS Between the years 1994 and 2008, 171 ipsilateral fractures were operatively treated in 169 patients with an average age of 56 years (range, 21-97 years). The group comprised 108 men and 61 women. The fracture was fixed by the long Gamma nail (Howmedica) in 18 cases, by the long PFN (Synthes) in 147 cases and by the long PFH (Medin) in three cases. In two patients with a bilateral fracture, a reconstruction nail was used on one side and a combination of DHS and condylar plate on the other. External fixation was used in a patient with severe burns. In one case the fracture was fixed by a LCP Proximal Femoral Plate. Types of fractures were evaluated on the basis of the authors' own classification of 1998. Type I (concomitant femoral neck and femoral shaft fractures) accounted for 13 %, Type II (pertrochanteric fracture and femoral shaft fracture) for 23 %, Type III (complex fracture of the proximal femur extending from the femoral neck base to the femoral shaft) for 21 %, Type IV (high subtrochanteric fracture extending from the tuberculum innominatum to the femoral shaft) for 40 % and Type V (Type I or II with a fracture of the distal femur) for 3 % of fractures. In 68% of cases the injury was caused by high-energy trauma. In Types I and Vit involved all the patients, in Type II 95% of them. These fractures occurred primarily within a polytrauma or as an associated injury (91 %). Types III and IV included mainly monotrauma cases (78 %). The minimum follow-up period was 12 months (1-15 years). RESULTS Of 129 fractures, 127 (98 %) healed within 12 months after the injury. In one patient, non-union healed after re-nailing 15 months after the injury. In another case, infected non-union healed 18 months after the injury. In the whole group, 14 intraoperative and 9 early postoperative complications (14 %) were encountered. In the group of 129 patients followed up minimally for 1 year, 16 late complications (12%) were recorded. In 125 cases treated with a reconstruction nail there were 13 complications (10 %) and in four patients treated by another method, complications occurred in three cases. The highest number of complications was recorded in Type V fractures (3 of 5). Excellent results were achieved in 63 %, good in 29 %, fair in 6 % and poor results in 2 % of the patients. DISCUSSION There is no generally accepted classification of ipsilateral fractures of the femur. Therefore, we used our own classification that proved useful in evaluation of the group of patients. We only slightly modified it in terms of the findings. Type III and type IV fractures have a number of characteristic features in common and so we decided to cover them by one type of complex fractures extending from the femoral neck base as far as the femoral shaft. There is no consensus concerning the treatment. In addition, the percentage of complications is quite high. The group was treated almost exclusively with the reconstruction nail. In 2 % we used another method of internal fixation. Our results do not differ from those reported by other authors. CONCLUSIONS In case of fractures of the femoral shaft, in high-energy trauma particularly, it is necessary to check the patient for a potential proximal femur fracture. The diagnosis should be made on the basis of a radiograph of the pelvis in internal rotation and axial projection and CT scans for evaluation of the proximal femur, including 2D CT reconstructions. Prior to nailing of the femoral shaft, sciascopic examination must be made of the hip in both projections. Fixation by a reconstruction nail is a suitable method for treatment of ipsilateral fractures. We consider the risk of complications adequate to the mechanism of injury and its severity.

• MeSH
• dospělí MeSH
• fraktury femuru chirurgie   radiografie   MeSH
• fraktury krčku femuru chirurgie   radiografie   MeSH
• lidé středního věku MeSH
• lidé MeSH
• mladý dospělý MeSH
• senioři nad 80 let MeSH
• senioři MeSH
• vnitřní fixace fraktury metody   MeSH
• Check Tag
• dospělí MeSH
• lidé středního věku MeSH
• lidé MeSH
• mladý dospělý MeSH
• mužské pohlaví MeSH
• senioři nad 80 let MeSH
• senioři MeSH
• ženské pohlaví MeSH

PURPOSE OF THE STUDY: Periprosthetic fracture is one of the most serious complication of total knee arthroplasty. In our retrospective clinical study we designed our classification with rules for treatment of those fractures. MATERIAL AND METHODS: During the last thirty years we treated 53 distal femoral periprosthetic fractures in our orthopaedic department. In our clinical study we reviewed our group of distal femoral periprosthetic fractures with on the basis of X-ray findings, the treatment method used and treatment outcomes. RESULTS: According to our findings we divided distal femoral periprosthetic fractures into six groups: Type I Nondisplaced fractures, 5.7%; treatment failure rate, 33%. Type II a Fractures with lateral comminution (the most often type of fractures), 37.7%; treatment failure rate, 20%. Type II b Fractures with medial comminution, 7.5%; treatment failure rate, 60%. Type II c Fractures above TKA (the second most often type), 34%; treatment failure rate, 18%. Type II d Comminuted fractures, 5.7%; treatment failure rate, 18%. Type IIIFractures with loosening of TKA, 9.4%; treatment failure rate, 20%. For the treatment of fractures we used various methods according to the type of fracture: Plate osteosynthesis in 32 cases, with failure in seven. Three failures in IIa group due to incorrect osteosynthesis with condylar plate, treated by reosteosteosynthesis with same implant. One in IIb group treated primarily with cement plomb, after second failure treated with revision total knee arthroplasty. Two failures in IIc group, treated by reosteosynthesis with spongioplasty using the same implant. One failure in III group solved with revision TKA. Intramedullary nail in nine cases , with failure in two. One failure in IIb group treated by reosteosynthesis with condylar plate and cement plombage. One in IIc group due to infection, solved with extraction of material and second stage revision TKA. Conservative treatment in three cases,with failure in two. One in I group treated with condylar plate. One in IId group solved with revision TKA. Miniosteosynthesis in three cases, with failure in two.One failure in IIa group treated with condylar plate, one in IIb group treated with intramedullary nail and additional hydroxyapatite plombage. Revision total knee arthroplasty in five cases with no failure. Extraction of TKA, external fixation, and arthrodesis in 1 case with no failure. DISCUSSION: The rules for treatment of distal femoral periprosthetic fractures are not definite yet. For fractures above TKA is recommended nail osteosynthesis; for fractures at the level of femoral component is preferable to use osteosynthetic material, condylar plate or LCP. Bone grafts, bone cement, and artificial bone are used to augment osteosynthesis in comminuted fractures. Fractures at the site of loosening are indicated for revision TKA. CONCLUSIONS: According to our results: Type I: Conservative treatment possible. Osteosynthesis with condylar plate is recommended. Type IIa: Indication for condylar plate osteosynthesis. Type IIb: The most problematic group. Osteosynthesis with condylar plate with augmentation or condylar plate placed from medial side. Type IIc: Plate osteosynthesis possible, intramedullary nail is recommended. Type IId: Osteosynthesis with augmentation is possible in some cases; revision TKA is recommended. Type III: Indication for revision TKA.

• MeSH
• fraktury femuru etiologie   chirurgie   radiografie   MeSH
• lidé středního věku MeSH
• lidé MeSH
• protézy kolene MeSH
• senioři nad 80 let MeSH
• senioři MeSH
• totální endoprotéza kolene škodlivé účinky   MeSH
• vnitřní fixace fraktury MeSH
• Check Tag
• lidé středního věku MeSH
• lidé MeSH
• senioři nad 80 let MeSH
• senioři MeSH

This study appears from an experiment previously carried out in New Zealand white rabbits. Allogenic mesenchymal stem cells (MSCs) were transplanted into an iatrogenically-created defect in the lateral section of the distal physis of the left femur in 10 miniature pigs. The right femur with the same defect served as a control. To transfer MSCs, a freshly prepared porous scaffold was used, based on collagen and chitosan, constituting a compact tube into which MSCs were implanted. The pigs were euthanized four months after the transplantation. On average, the left femur with transplanted MSCs grew more in length (0.56±0.14 cm) compared with right femurs with physeal defect without transplanted MSCs (0.14±0.3 cm). The average angular (valgus) deformity of the left femur had an angle point of 0.78°, following measurement and X-ray examination, whereas in the right femur without transplantation it was 3.7°. The initial results indicate that preventive transplantation of MSCs into a physeal defect may prevent valgus deformity formation and probably also reduce disorders of the longitudinal bone growth. This part of our experiment is significant in the effort to advance MSCs application in human medicine by using pig as a model, which is the next step after experimenting on rabbits.

• MeSH
• autologní transplantace MeSH
• časové faktory MeSH
• femur chirurgie   radiografie   růst a vývoj   MeSH
• financování organizované MeSH
• fixace fraktur metody   škodlivé účinky   MeSH
• fraktury femuru chirurgie   patofyziologie   radiografie   MeSH
• kultivované buňky MeSH
• miniaturní prasata MeSH
• modely nemocí na zvířatech MeSH
• nestejná délka dolních končetin MeSH
• osteogeneze MeSH
• prasata MeSH
• tkáňové podpůrné struktury MeSH
• transplantace mezenchymálních kmenových buněk škodlivé účinky   MeSH
• zvířata MeSH
• Check Tag
• zvířata MeSH