Martin Krbec

Distal tibiofibular synostosis after surgically resolved ankle fractures: An epidemiological, clinical and morphological evaluation of a patient sample

INTRODUCTION Ankle fractures comprise a highly morphologically and etiologically diverse group of injuries, which includes various degrees of impairment of bone and ligamentous structures. The complete synostosis and incomplete bony bridging of tibiofibular syndesmosis are among the local late complications after surgically treated ankle fractures. PATIENTS AND METHOD 269 patients were evaluated, including 203 patients with Weber type-B fractures, and 66 patients with Weber type-C fractures. All patients underwent ankle radiography at standard intervals (post-operatively, 6 and 12 weeks, 6 and 12 months). The final assessment one year after osteosynthesis was performed. The study analyzed age, sex, fracture morphology, the location and morphology of ossification, functional outcomes and subjective evaluations of patient status. RESULTS As risk factors there were found male sex, tibiotalar dislocation, syndesmotic screw fixation and Weber type-C fractures. The severity of subjective difficulties and objective status were not dependent on the size of distal tibiofibular synostosis. DISCUSSION AND CONCLUSION Despite relatively extensive imaging findings of complete synostosis or incomplete bony bridging, they only limited functional outcomes to a minimal extent.

Distal locking in short hip nails: Cause or prevention of peri-implant fractures?

OBJECTIVES The most common cause of femoral fractures after osteosynthesis of trochanteric fractures with short nails is weakening of the femoral cortex via distal locking and stress concentrations at the tip of the nail. The aim of the study was to verify whether the incidence of peri-implant fractures is dependent upon the distal locking technique. METHODS We prospectively analysed a group of 849 pertrochanteric fractures (AO/ASIF 31-A1+2) managed with short nails from 2009 to 2013. Unlocked nailing was performed in 70.1% and distal dynamic locking was performed in 29.9%. The mean age was 82.0 years. Peri-implant fractures were divided into 3 groups according to the height of the fracture in relation to the tip of the nail. RESULTS In total 17 fractures (2.0%) were detected. One peri-implant fracture occurred after locked nailing, whereas 16 cases occurred after unlocked nailing (p=0.037). Patients without distal locking had an 85.7% greater risk of peri-implant fracture. Fractures of the proximal femur (Type I) occurred significantly earlier than fractures at the tip of the nail (Type II) (p=0.028). CONCLUSION Unlocked nails do not guarantee sufficient stability. Distal locking serves to prevent postoperative femoral fractures. We recommend the routine use of distal locking when utilizing short nails.

Antithrombotic therapy of patients with atrial fibrillation discharged after major non-cardiac surgery. 1-year follow-up. Sub-analysis of PRAGUE 14 study

Background The study investigated the discharge antithrombotic medication in patients with atrial fibrillation (AF) after major non-cardiac surgery and the impact on one-year outcomes. Methods A subgroup of 366 patients (mean age 75.9±10.5 years, women 42.3%, acute surgery 42.9%) undergoing major non-cardiac surgery and having any form of AF (30.6% of the total population enrolled in the PRAGUE-14 study) was followed for 1 year. Results Antithrombotics (interrupted due to surgery) were resumed until discharge in 51.8% of patients; less frequently in men (OR 0.6 (95% CI 0.95 to 0.35); p = 0.029), and in patients undergoing elective surgery (OR 0.6 (95% CI 0.91 to 0.33); p = 0.021). Dual antiplatelet therapy was resumed more often (91.7%) in comparison to aspirin monotherapy (57.3%; p = 0.047), and vitamin K antagonist (56.3%; p = 0.042). Patients with AF had significantly higher one-year mortality (22.1%) than patients without AF (14.1%, p = 0.001). The causes of death were: ischaemic events (32.6% of deaths), bleeding events (8.1%), others (N = 51; 59.3%, 20 of them died due to cancer). Non-reinstitution of aspirin until discharge was associated with higher one-year mortality (17.6% vs. 34.8%; p = 0.018). Conclusion Preoperatively interrupted antithrombotics were re-administrated at discharge only in half of patients with AF, less likely in male patients and those undergoing elective surgery. The presence of AF was recognized as a predictor of one-year mortality, especially if aspirin therapy was not resumed until discharge. Trial registration ClinicalTrials.gov NCT01897220

ID 113 – Neurophysiology and biopsy of paraspinal muscles in idiopathic scoliosis

Objective The pathogenesis of idiopathic scoliosis (IS) remains poorly understood. Local changes in deep paraspinal muscles and/or dysfunction of spinal inhibitory circuits are not fully elucidated. We compared the morphological and functional changes of paraspinal muscles on both sides of the scoliosis curve. Methods Before corrective surgery we performed EMG and muscle biopsy of paraspinal muscles at convexity and concavity of scoliotic curve in 10 subjects with IS (8 women, 11–29years). Cutaneous silent period (CSP) induced by noxious digit II stimulation in thenar muscles was recorded in IS patients and in healthy volunteers. Results Right curve convexity had 8 subjects. All of them presented changes in muscle fiber distribution with numerical predominance of type I on the curve convexity. Seven subjects have increased MUP amplitude on this side (range 10–62%). CSP did not significantly differ between concavity and convexity but shortening of CSP duration was observed in more pronounced scoliotic curve. Conclusion Our findings demonstrate a significant asymmetry in fiber type distribution corresponding with an altered function in paraspinal muscles with predominance on convexity of scoliotic curve. Spinal inhibitory reflex is preserved; however, it could be modulated in more progressive IS. Supported by Grants PRVOUK P34, IGA-NT 13693.