Jan Bartoníček

Valgus intertrochanteric osteotomy for malunion and nonunion of trochanteric fractures

Objective To evaluate the results of valgus intertrochanteric osteotomy for varus nonunion and malunion of trochanteric fractures. Setting University hospital. Design Retrospective clinical study. Patients Fifteen patients (age range 29–84 years) with varus malunion (11 cases) or varus nonunion (4 cases). Indication for surgery was nonunion or varus malunion with limb shortening greater than 2 cm associated with limp, abductor muscle insufficiency, hip pain, and back pain. Intervention The patients were treated by a valgus intertrochanteric osteotomy fixed with a 120° double-angled blade plate. Results Average follow-up was 5.5 years (range 2–10 years). Fourteen patients healed without complications: 12 patients within 4 months; 2 delayed unions within 6 months. One patient required revision surgery for a loss of fixation due to a fall 6 weeks after surgery. This osteotomy also healed. Average lengthening achieved by osteotomy was 2 cm (range 1–5 cm). In all patients, the resulting range of flexion in the hip joint was greater than 90°, Harris hip score before surgery was 73 points (range 61–83), and after surgery 92 points (range 76–98). Osteoarthritis or avascular necrosis of the femoral head did not develop in any of the cases. Conclusion Valgus intertrochanteric osteotomy is an effective procedure that reliably restores hip function in trochanteric malunion or nonunion.

Avascular necrosis of the femoral head in pertrochanteric fractures: a report of 8 cases and a review of the literature.

Objective: To evaluate patients with pertrochanteric fractures (Type 31A1 + 2 ASIF/OTA classification) treated surgically and who subsequently developed avascular necrosis of the femoral head (ANFH). Setting: University hospital. Design: Retrospective clinical study and analysis of the literature. Patients: From 1995 to 2003 the authors operated on 1,373 patients with pertrochanteric fractures. Eight patients with a mean age of 69 years (range, 52-78 years) subsequently developed ANFH. Intervention: Five patients were treated with a dynamic hip screw (DHS), and 3 were treated with an intramedullary hip nail (IMHN). Results: All fractures in these 8 patients healed without complications in 3 to 4 months. Avascular necrosis of the femoral head developed 4 months to 4 years after the operation. Detailed analysis of these cases did not reveal any risk factors or errors in surgical technique to account for the ANFH. Results of a literature review of 41 cases in addition to our 8 cases give us reason to believe the etiology of postoperative AFNH following surgical treatment of pertrochanteric fractures is probable injury to the deep branch of the medial circumflex artery at time of fracture. Other possible risk factors include high-energy trauma, comminution, displacement of the fragments, and atypical fracture line. Conclusions: ANFH develops in approximately 0.5-1% of all pertrochanteric fractures, mostly within 4 years after the injury and predominantly in patients older than 50 years of age. The diagnosis should be considered in patients who have undergone an operation previously and have symptoms that are unclear. Prevention of ANFH in these fractures includes an early reduction, stable fixation, and correct surgical technique.

Bosworth-type fibular entrapment injuries of the ankle: the Bosworth lesion. A report of 6 cases and literature review.

Objectives: To evaluate patients with Bosworth-type fibular entrapment injuries of the ankle. Design: Retrospective clinical study and analysis of the literature. Setting: University hospital. Patients: Six cases treated for Bosworth-type fibular entrapment injuries (the Bosworth lesion) in the period 2001 to 2004. Intervention: Five patients were treated with open reduction and internal fixation (ORIF), and 1 patient was treated with closed reduction and cast. Results: All patients treated by ORIF healed without complications with a good subjective outcome. In 1 case treated nonoperatively, an ankle fusion had to be performed 2 years after injury for severe osteoarthritis. Additionally, we have recorded 3 cases, 2 not previously described in the literature, in which the fracture of the fibula was located at the middle or proximal third of its shaft. In the literature we found another 54 cases with dislocation of the fibula behind the posterior tubercle of the distal tibia. The analysis showed that morphology of the Bosworth lesion, as we prefer to refer to this complex fracture-dislocation, changes with age and may be divided into 3 basic types. In children and adolescents the dislocation of the distal fibula is associated with epiphyseolysis of the distal tibia; in young adults the fibula dislocates without fracture; in middle-aged and older adults, the dislocated fibula fractures, probably because of the decreased elasticity. Conclusions: The Bosworth lesion is a severe injury of the ankle, and its successful treatment requires a correct diagnosis based on careful initial clinical and radiographic evaluation and early surgical treatment.

Posterior malleolar fractures of the ankle

Despite an increasing awareness of injuries to PM in ankle fracture-dislocations, there are still many open questions. The mere presence of a posterior fragment leads to significantly poorer outcomes. Adequate diagnosis, classification and treatment require preoperative CT examination, preferably with 3D reconstructions. The indication for surgical treatment is made individually on the basis of comprehensive assessment of the three-dimensional outline of the PM fracture and all associated injuries to the ankle including syndesmotic instability. Anatomic fixation of the avulsed posterior tibiofibular ligament will contribute to syndesmotic stability and restore the integrity of the incisura tibiae thus facilitating anatomic reduction of the distal fibula. A necessary prerequisite is mastering of posterolateral and posteromedial approaches and the technique of direct reduction and internal fixation. Further clinical studies with higher numbers of patients treated by similar methods and evaluation of pre- and postoperative CT scans will be necessary to determine reliable prognostic factors associated with certain types of PM fractures and associated injuries to the ankle.

Is distal locking with IMHN necessary in every pertrochanteric fracture

Two groups of patients were treated for pertrochanteric fractures (AO/ASIF 31A1+A2) with an intramedullary hip nail. In the first group of 44 patients distal dynamic locking was used, and in the second group of 74 patients the nail was not distally locked. Comparison of the two groups of patients did not show any difference in terms of the period of fracture healing, radiological and functional results or frequency of complications. In the group with a distally locked nail the surgery took 40.4 minutes, while in the group without distal locking only 34.4 minutes. In total, we recorded only seven complications, none of which were caused by absence of distal locking of the nail. This study has shown that distal locking of IMHN is unnecessary in most pertrochanteric fractures (AO/ASIF 31A1+2). The only exceptions are comminution of the lateral wall of the greater trochanter, secondary diaphyseal fracture line, large posteromedial fragment extended distally below the level of the lesser trochanter and broad intramedullary canal.

Femoral neck fracture: The cause of death of Emperor Charles IV

Abstract We present the oldest documented case of femoral neck fracture of a particular person in the history of orthopaedic surgery. Examination of the skeleton of Charles IV, the King of Bohemia and Roman Emperor living in XIVth century has revealed a fracture of the left femoral neck. This fracture was most probably an indirect cause of his death as it resulted in pneumonia, the immediate cause of death. This fact has been confirmed by contemporary chronicles.

Displaced fractures of the medial end of the clavicle: report of five cases.

The authors present a group of five men who sustained a displaced fracture of the medial end of the clavicle. In all cases, the diagnosis was confirmed by computed tomographic scan. Three young men with extra-articular fractures were treated operatively with a very good result. Two older men were treated nonoperatively, one with a good result (intra-articular fracture) and one with a fair result (extra-articular fracture). The method of treatment of fractures of the medial end of the clavicle depends primarily on the type and displacement of the fracture. Treatment decisions should be always based on a computed tomographic scan, because plain radiographs do not adequately image the medial clavicle. Surgical treatment of these fractures should be considered, particularly in young or physically active individuals.

Osteoid osteoma of olecranon process of ulna in subchondral location.

Abstract We present a case of a 15-year-old girl with osteoid osteoma in an unusual subchondral localization of the olecranon. Unspecific complaints and minimal X-ray findings at the onset of the disease led to an incorrect diagnosis and more than 2 years of inefficient treatment.

Early history of scapular fractures

The first to use the term Scapula was Vesalius (1514–1564) and thus it has remained ever since. Probably the oldest injured scapula, from 250 million years ago, was described by Chinese authors of a skeletal examination of a fossilised remains of a dinosaur Yangchuanosaurus hepingensis. In humans, the oldest known scapular fractures date back to the prehistoric and early historic times. In ancient times, a fracture of acromion was described in the treatises of Hippocrates. Early modern history of the treatment of scapular fractures is closely interlinked with the history of the French surgery. The first to point out the existence of these fractures were Petit, Du Verney and Desault in the 18th century. The first study devoted solely to scapular fractures was published by Traugott Karl August Vogt in 1799. Thomas Callaway published in 1849 an extensive dissertation on injuries to the shoulder girdle, in which he discussed a number of cases known at that time. The first radiograph of a scapular fracture was published by Petty in 1907. Mayo Robson (1884), Lambotte (1913) and Lane (1914) were pioneers in the surgical treatment of these fractures, followed in 1923 by the French surgeons Lenormat, Dujarrier and Basset. The first internal fixation of the glenoid fossa, including a radiograph, was published by Fischer in 1939.

Treatment of distal humerus fractures in adults: a historical perspective.

Nonsurgical treatment was the mainstay of management of distal humerus fractures for centuries and nonunions and malunions were common. The 19th century featured the recognition of distinct injury patterns. With advances in radiology, anesthesia, antisepsis, and hardware technology, surgical treatment is now generally preferred, yet loss of elbow joint mobility can still be a vexing problem.