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Based on case histories, the authors draw attention to important infectious complications in patients surgically treated for pelvic injuries. These complications were recorded in four out of 75 patients (5.3%) undergoing surgery for pelvic fracture in the period from 2001 to 2005. The chief risk factors for the development of infection included the poor state of health of a polytraumatized patient in combination with a long stay in an acute care unit, and severe trauma and bleeding of soft tissue structures in B and C types of pelvic injury. Bacteriological findings showed the presence of several pathogenic species (Enterobacter cloacae, Citrobacter koseri, Pseudomonas aeruginosa and Klebsiella oxytoca) or multi-resistant bacteria (methicillin-resistant Staphylococcus aureus).

Gradual particularization of medicine, as witnessed during the second half of the 20th century, resulted in a detailed development of individual subspecializations. Association of therapeutic options resulting from enormous development of these subspecialization brought a new dimension to the treatment of formerly unmanageable conditions. The closest cooperation between a plastic surgeon and a traumatologist is required in the management of patients with serious extremitiy injuries. The conditions include, in particular, amputations of extremities without skeletal and soft tissue devastation, where replantation may be considered, and extensive soft tissue and skeletal injuries, requiring replacement of the missing soft tissue cover following the treatment of the skeletal parts. A new aspect of the cooperation includes common care for infected long bone fractures and osteomyelitides, where primary and extensive skeletal and soft tissue debridement is followed by covering the defect with a muscular or a musculocutaneous flap, facilitating reperfusion and infection management.

The authors analyze the results of their long-term follow-up of basic epidemiological characteristics in fractures of proximal humerus (1,464 patients), distal radius (2,514 patients), proximal femur (3,340 patients) and fracture-dislocation of the ankle (1 195 patients). In fractures of the proximal femur, the average age was 78 years; 71.6 years in men and 80.3 years in women; male-female ratio was 27:73. In fractures of the proximal humerus, the average age was 67 years; 58.8 years in men and 71.2 years in women; male-female ratio was 30:70. In fractures of the distal radius, the average age was 59 years; 45.8 years in men and 64.7 years in women; male-female ratio was 29:71. In fracture-dislocation of the ankle the average age was 49 years; 43.4 years in men and 54.7 years in women; male-female ratio was 50:50. Until 5th decade men had higher representation in all groups of fractures, starting from 6th decade the ratio changed. Introduction of new implants (locking plate, new generation of nails) for fractures of the distal radius and proximal humerus increased significantly the percentage of patients operated on.

The authors evaluate the role of imaging methods used in the diagnostics of pelvic fractures with the aim to suggest the most effective way of their use. The exact diagnosis of an injury is achieved most quickly if, in hemodynamically stable patients, CT scan is the initial examination and, based on the findings, conservative, invasive (laparotomy) or miniinvasive (angiography with bleeding artery embolization) procedures are used. In hemodynamically unstable patients, the diagnostic procedure always begins with plain X-ray and FAST (ultrasound) examination of the pelvis. When large hemoperitoneum is diagnosed, laparotomy is indicated. When only a small amount of hemoperitoneum is detected, a primary, minimally invasive procedure (angiography with bleeding artery embolization) can be carried out by an experienced interventional radiologist. If this fails to result in stabilization of the circulation, laparotomy should follow. Key words: pelvic ring injury, diagnosis, plain radiography, FAST, MDCT, angiography, embolization.

Purpose: Infection is considered one of the most serious complications of the surgical treatment of musculoskeletal injuries. The aim of the study was to evaluate known risk factors and etiological agents of infectious complications in patients surgically treated for musculoskeletal injuries within 6 years., Methods: In a group of 5 234 patients followed in 2000-2005 the early or delayed infectious complication developed in 65 patients (26 women, 39 men, age 22-83 years). In every patient with infectious complication the important risk factors related to personal history, type of the injury, surgery and other treatment were recorded and microbiological culture results were collected., Results: In 60 patients (92.3%) at least one of the following risk factors was registered: diabetes mellitus, age above 75 years, abuse of alcohol and drugs, distant infectious focus or severe skin disease at the time of surgery, polytrauma requiring long-termed stay in intensive care unit, extensive soft tissue injury associated with closed or opened fracture. In 27 patients (41.5%) grampositive cocci and in 17 patients (26.2%) gramnegative bacteria were isolated, in 12 patients (18.5%) mixed bacterial flora was identified and 9 patients (13.8%) had negative cultures. The most severe findings from microbiological view occurred in patients with extensive soft tissue injury associated with fracture, diabetes or long-termed stay in intensive care unit., Conclusion: The infectious complications after the surgical treatment of musculoskeletal injuries occurred predominantly in patients with risk factors. The extensive soft tissue injury associated with fracture, diabetes and long-termed stay of the polytrauma patient in intensive care unit were identified as the most frequent risk factors. The patients of these risk groups also presented with the most serious microbiological findings.

The aim of the paper was analysis of the basic demographic and epidemiologic data of the patients treated for a pelvic fracture. The group comprised 204 patients (74 women, 130 men) hospitalized in the Traumacentre of the University Hospital of 3rd Faculty of Medicine, Charles University in Prague in the period of 2002-2006. Higher incidence of this fracture in men as compared to women was significant (p = 0.001). The age of the patients ranged between 15-93 years, with the mean age of 42.8 years. Prevailing cause of the injury were car accidents (128 patients - 63%), fall from height (61 patients - 30%), of this in 20 patients (10%) it was a case of suicide attempt. Higher representation of women in suicide attempts was significant (p = 0.044). Type A fracture was found in 42 patients (21%), Type B in 101 patients (49%) and Type C was identified in 61 patients (30%). Surgical treatment was indicated in 10% of Type A fractures, in 32% of Type B and in 50% of Type C fractures. The difference in the number of operated on patients with Type A and Type C fractures was significant (p = 0.008). In Type A fracture 15% of patients died, in type B it was 13% of patients and in Type C fracture 40%. The difference in the number of deceased patients between Type A and type C was significant (p < 0.001).

Currently, conventional diagnosis of acetabular fractures is often supplemented and even replaced by CT examination, as this can provide a more detailed image of the extent of fracture and its morphology. Supported by developmental anatomy, Harris et al. proposed a new classification for acetabular fractures in which the pubic bone component of the acetabulum is shown to coincide with the anterior column of the acetabulum. There is no need to abandon the generally accepted and much used Letournel-Judet classification, but changes in the algorithm of acetabular fracture examination will certainly require that the CT classification of acetabular fractures is included. The Harris classification, based on evaluation of simple and unambiguous axial CT scans, is readily understood by both radiologists and orthopedic trauma surgeons and thus the use of it will foster greater interdisciplinary cooperation resulting in a better care for patients with acetabular fractures. Key words: acetabular fracture, CT-based classification, CT-based diagnosis.

Purpose of the Study: The aim of the study was to evaluate the results of treatment in patients with infected fractures or chronic osteomyelitis in the tibial and ankle regions by radical debridement of skeletal and soft tissues and coverage of the defect, using free flap transfer or muscle flap transposition., Material: Between January 1, 2002 and December 31, 2004, 26 patients were treated by this method; 13 had infected tibial or ankle fractures and 13 showed osteomyelitis of the tibia. All patients, in the case of failure, would have been indicated for below-knee amputation. The group comprised six women and 20 men at an average age of 46 years (range, 10 to 67 years)., Methods: In this retrospective study, the following data were recorded: type of injury (multiple trauma, combined trauma, single trauma), fracture type according to the AO classification, grade of injury in open fractures by the Gustillo and Anderson classification, number of previous operations in patients with infected fractures, microbiological findings in all patients before defect coverage with a flap, interval between the injury and flap coverage, number of post-operative complications, number of subsequent operations, period of relief for the treated limb, actual weight-bearing of the limb, patient's satisfaction with the therapy., Results: Since one patient died of heart attack during follow-up, 25 patients (5 women and 20 men) were included in the final evaluation. The average follow-up was 27 months (range, 15 to 49 months). The healing of infection and union of bone were recorded in 21 patients (84 %). Healing with pseudoarthrosis development occurred in three patients (12 %). One patient (4 %) had to undergo leg amputation due to persistent secretion. The duration of treatment before coverage of the defect was on average 10 weeks (range, 4 weeks to 6 months) in the patients with infected fractures, and 9 years (range, 2 to 20 years) in the patients with osteomyelitis. Post-operative complications were recorded in seven patients (27 %). Impaired vascularization of the flap in the early post-operative period was found in two patients (8 %). In two patients (8 %) residual infected tissue under the flap resulted in purulent secretion. In three patients (12 %), at the time of evaluation, the lower extremity could not bear weight due to non-union of fractured bone., Discussion: The use of free or transposition muscle is regarded as the optimal method for the treatment of extensive defects of soft tissues in limb traumatology. The advantages include: good quality coverage of the defect; ability of vascularized flap tissue to transport antibiotic to the defect area; long-term improved perfusion in the fracture region is important for fracture healing., Conclusions: The treatment of infected tibial and malleolar fractures by debridement and subsequent coverage of soft tissue defects, using muscle flap transfer, permits elimination of infection in most of the patients, but often requires subsequent surgery in order to provide biological stimulation for healing of defective fractures. Treatment of osteomyelitis of the tibia by this method is demanding, but has a good prospect of healing in a period shorter than is necessary for treatment without muscle flap transfer.

Purpose of the Study: The authors present a group of patients treated for pelvic fractures in a period of 6 years and they evaluate radiographic findings and clinical outcomes following surgical management of type B and type C fractures., Material and Methods: Between July 1998 and June 2004, a total of 271 patients with pelvic fractures, 162 men and 109 women (average age, 42 years; range, 15 to 93 years) were hospitalized at the authors' departments. Of these, 141 patients were operated on (94 men, 47 women; average age, 37 years; range, 15 to 72 years) and 130 were treated conservatively (average age, 47 years; range, 15 to 93 years). The clinical outcome assessment in patients with type B and type C fractures treated surgically was based on the Majeed scoring system, and the radiographs were evaluated as described by Matta and Tornetta., Results: In 85 % of the patients, pelvic fractures were due to a high-energy trauma caused by traffic accidents in 63 % (pedestrian injury, 30 %; injury of the driver or passenger, 28 %; motorcycle injury, 5 %), by falls from heights in 20 % (occupational injury, 10 %; suicidal attempt, 10 %) and by other causes in 2 %. Sports accidents, usually due to a low-energy trauma, accounted for 8 % of the injuries (falls from a bicycle, violent kicks) and ordinary falls of elderly persons for 7 %. Type A injury was in 56 patients (21 %), type B in 103 patients (38 %) and type C in 112 patients (41 %). In 27 % of the patients, pelvic ring injury was part of a multiple trauma, in 58 % it was a combined injury and in 15 % it presented as a single trauma. Primary neurological deficit was found in nine patients (9 %) with type B fracture and in 20 patients (18 %) with type C fracture; this difference was statistically significant (p = 0.005). Urogenital injury was co-existent with type B fracture in 12 patients (12 %) and with type C fracture in 15 patients (13 %); the difference was not significant (p = 0.734). In seven patients (3 %), the injury involved an open fracture. Thirty-three patients (12 %) died during hospitalization. The difference in death rate between the patients with type C and those with type B fractures was significant (p = 0.021). Excellent and good clinical outcomes were achieved in 83 % and 70 % of the patients with type B and type C fractures, respectively. The difference was not significant (p = 0.236). Radiographs showed excellent reduction in 83 % of type B fractures and in 61 % of type C fractures; the difference was not significant (p = 0.271). Intra-operative complications were recorded in 22 %, early post-operative ones in 13 % and late complications in 11 % of the patients., Discussion: The significant difference in primary neurological deficit between the patients with type C fractures and those with type B fractures was attributed to more severe injury and vertical dislocation of the posterior segment in type C fractures. On the other hand, the fact that urogenital involvement was not significantly higher in type C fractures can be explained by an equal presence of anterior segment injury in both type B and type C fractures. The significantly higher number of deaths in patients with type C fractures, as compared with those with type B fractures, was related more to severe injuries of other organ systems in polytraumatized patients than to injuries of the pelvis itself, although severe injury to the posterior segment in type C fractures can result in massive bleeding into the retroperitoneum., Conclusions: An active approach to the treatment of patients with unstable pelvic fractures, which is based on the correct diagnosis, comprehensive multi-disciplinary care, urgent primary stabilization and early definitive fixation by internal osteosynthesis, offers a prospect of survival and a good functional outcome for the patient. However, a high proportion of lasting sequelae due to altered biomechanics of the pelvic ring, and irreversible injuries to neural structures and the urogenital system may lessen good results achieved by a demanding surgical procedure on the skeleton.

A case review of laparoscopic management of the uterovaginal descent and rectal prolaps in one step in a young female following her complicated pelvic fracture.

The authors compare their experience with the treatment of pelvic ring injuries with the literature data concerning the etiology, diagnosis and classification of this trauma, co-existing pathologies, primary therapeutic procedures, timing of the definitive treatment, surgical approaches, osteosynthesis of the posterior and anterior segments, complications and lasting sequelae. The authors regard the issue of surgical treatment as an independent discipline in the field of musculoskeletal system traumatology. They see the reason for it in the variability and complexity of primary therapeutic procedures and the necessity of following up and attending to the patients in whom treatment of complications and lasting sequelae requires multi-disciplinary co-operation.

Purpose of the Study: The aim was to evaluate the diagnostic value of plain X-ray images in the diagnosis of pelvic ring injury in comparison with CT findings., Material and Methods: The group evaluated consisted of 30 patients, 11 women and 19 men, at an average age of 46 years (range, 20-81 years; women, 20-68 years, men, 20-81 years; average age, 49 and 44 years in women and men, respectively) in whom plain radiography and CT scans were done as part of the initial examination. A retrospective assessment of plain X-ray images was carried out by two independent specialists (radiologist and trauma surgeon). The authors together evaluated CT scans and carried out the final assessment of all medical records. Pelvic radiography was taken with a mobile X-ray unit; CT scans were done according to the standard trauma scanning protocol, using a CT scanner with either one row (CT) or 16 rows (multidetector/MDCT) of detectors., Results: Based on the evaluation of X-ray and CT findings, a total of 133 fractures or displacements in the sacroiliac joint or pubic symphysis were detected. The radiologist identified 99 (74 %) injured structures and the trauma surgeon 111 (83 %) ones. This difference was not significant on the whole (p = 0.536), nor when individual structures were assessed. False negative findings were made by the radiologist on 10 occasions and by the trauma surgeon on seven occasions; the evaluation of image data sets by both observers was associated with only one false positive finding. The overall sensitivity of plain X-ray images, when compared to CT scans, was 83 %, but it was considerably lower on evaluation by one observer only (radiologist, 67 %; trauma surgeon, 78 %)., Discussion: The biggest difference between the findings of two independent specialists existed in the assessment of injuries to the posterior ring of the pelvis (SI joint, sacrum) on plain X-ray images. However, trauma in this region was identified without any doubt on CT scans. To diagnose the type of pelvic injury from CT scans without a possibility to evaluate standard anteroposterior (AP) radiographs or good-quality 2D or 3D reconstructions was found difficult in over one third of the patients. A validity comparison of standard AP radiography and high-quality 2D or 3D CT reconstructions showed that both had an equal value for the exact detection of pelvic injury type. For correct evaluation of the type of injury, scans from the MDCT were easier to read than those from the CT scanner., Conclusions: There is no doubt about the role of standard AP X-ray in the identification of pelvic injury type in polytraumatized, hemodynamically unstable patients. The validity of CT examination for identification of injury to the posterior ring of the pelvis in particular is so high that, in the primary diagnostic procedure, inlet and outlet radiography of the pelvis has lost its importance. The information on the stability and type of injury provided by 2D and 3D CT reconstructions is so exact that, at present, CT examination can reliably replace AP radiography, particularly if, for various reasons, good-quality X-ray images cannot be guaranteed.

Objective: Evaluation of the influence of vaginal childbirth on the integrity of the puborectalis muscle with the help of real-time 3D ultrasound., Design: Prospective pilot study., Setting: Institute for Care for Mother and Child, Prague, Czech Republic., Material and Methods: We examined 20 primigravid women in the third trimester and on the third day after vaginal delivery. The transperineal 3D ultrasound examination was performed and the data were evaluated afterwards in the 4D view software. The VCI (Volume Contrast Imaging) mode with slice thickness 3 millimeters was used for analysis. We evaluated the integrity of the puborectalis muscle on both sides, the quality of the images and the presence of hematomas., Results: The examination before delivery did not show any abnormal anatomy of the examined region. We found four (20%) unilateral defects and one (5%) bilateral puborectalis avulsion after the delivery. The bilateral defect was after the forceps delivery, the other defects occurred after normal uncomplicated vaginal deliveries, where only left mediolateral episiotomy was performed and the birth weight did not exceed 3700 g. In our series, 25% of women suffered an injury of a major muscle of pelvic floor. No defect was diagnosed during the delivery and did not show any connection with the episiotomy., Conclusions: 3D ultrasound can detect major birth trauma to the puborectalis muscle. The puborectalis muscle avulsion is usually not recognized during the delivery and does not cause immediate problem to the patient.

The case of an 11-year-old boy with recurrent abdominal pain is presented. Physiological findings were found normal during a clinical investigation, as well as many laboratory tests, ultrasonography and CT of abdomen. Only a high level of sedimentation rate and the focus of increased activity in the sacral region on scintigraphy using 99mTc-HMPAO (hexamethypropyleneaminooxime) labelled leukocytes were found. The other findings on bone scintigraphy, X-ray and MRI led to a deflection of the correct diagnosis. The real culprit proved to be an ingested foreign body (a piece of a wooden skewer) that the patient failed to reveal.

Fractures of the sacrum in children are rare. In the 17 cases described in the past 25 years, surgery was indicated only for treatment of the consequences of the primary injury. We present the case of a 10-year-old girl who sustained the following injuries as a result of a fall from a swing: posterior angulation of S2/3 with suspected injury of anterior ligamentous structures, fracture of the proximal part of the S4 body with a displacement by the bone width anteriorly and contraction of 5 mm, posterior angulation of S5/Co1 also with a suspected injury of anterior ligamentous structures. After an unsuccessful attempt at closed reduction, open reduction and fixation by two K-wires was indicated. The fracture healed in 8 weeks. Two years after the treatment, the patient is without complaints and limitations. The question is whether surgery was necessary for treatment of this fracture or whether spontaneous healing and subsequent remodelling of the sacral bone in such a young patient may be expected which would be also fully satisfactory. In our view, the described surgical treatment was appropriate and is definitely indicated for patients with a similar injury associated with a neural lesion.

Hemiarthroplasty has still its place in the therapeutic algorithm of the treatment of dislocated intracapsular femoral neck fractures. As compared to internal fixation it is accompanied by less complications and allows an immediate postoperative weight bearing. In contrast to total hip arthroplasty, this operation is not so demanding for the patient. However in the long-term perspective it is often associated with erosion of acetabulum. Therefore it is indicated mainly for biologically older patients with less physical activity without osteoarthritis of the hip. In these patients we usually prefer a cemented monoblock hemiarthroplasty. In case of biologically younger patients where it is impossible to use total hip arthroplasty due to general or local condition, modular hemiarthroplasty is indicated with a removable head allowing in case of acetabular erosion an easy conversion to total hip arthroplasty. Hemiarthroplasty must be correctly indicated and technically properly performed. First of all it is necessary to respect the relation between the centre of the prosthetic head and the apex of the greater trochanter, i.e. the head centre should be 1-2 mm below the level of apex of the greater trochanter. Further, it requires a correct anteversion and suture of the articular capsule as a prevention of postoperative dislocation.

The development of the European total hip arthroplasty in the sixties of 20th century is associated mainly with the names of G. K. McKee, J. Charnley and M. E. Muller. The SICOT meeting in Paris in 1966 introduced THA as a new method of treatment of osteoarthritis of the hip and paved the way for the commercialization of the manufacturing of prostheses. The success of this method consisted primarily in the fixation of individual components by bone cement and application of metal-to-polyethylene and metal-to-metal joints. The book presents these historical events as they have been reflected in the development of THA in the countries of the former Czechoslovakia and in the development of implants of domestic provenance. The development of THA in the former Czechoslovakia started in 1969 and was based on the Swiss school established by M. E. Muller. The Muller component with the "banana-shaped" stem was implanted using the Watson-Jones approach, the proximal femur canal was prepared by a rasp and the Palacos cement was used. This prosthesis served also as the model for the first Czech implant Poldi-Cech of I generation (the Chirulen cup available in three sizes, the "banana- shaped" femoral component with a 32 mm head-diameter and 130 degree neck-shaft angle) the development of which started in 1969 and the serial production began in 1972 in the Poldi Kladno steel company. Fatigue fractures of the "banana-shaped" stem led to the development of the concept of a femoral component with an "anatomical" stem. In Switzerland, this concept was developed by B. G. Weber. In the former Czechoslovakia the development of a new femoral component with an "anatomical" stem following the shape of the intramedullary canal with an ovoid profile and without sharp edges started in 1972. Due to the incidence of fatigue fractures of the "banana-shaped"stem and material that was not sufficiently strong (steel used for the production of osteosynthetic components), 144 degree neck-shaft angle was chosen. Reduction of the effect of bending forces on the valgus stem had eliminated fatigue fractures. This Poldi-Cech prosthesis of II generation was provided in nine sizes. The diameter of the head remained the same. Three Chirulen cups were supplemented with a "flat" cup for implantation in a dysplastic acetabulum. The prosthesis was implanted with an exact instrument set (reamer for acetabular preparation, rasp for proximal femoral preparation, alignment device for accurate positioning of both the cup and the femoral component) with the use of the Palacos cement. The production of the Poldi-Cech prosthesis of II. generation started in 1974 with the fabrication of a monoblock. Since 1986 it has been developed into a modular system (14/16 cone) with the possibility to use a ceramic head of 32 mm diameter (only in the nineties the cone size was changed to 12/14 and the heads were provided also in the 28 mm diameter). The Poldi-Cech prosthesis of II generation with the "anatomical" stem has been implanted since 1974 (i. e. during 30 years) in more than 140 000 patients in the Czech and Slovak Republics. In the same year cemented monoblock hemiarthroplasty was developed on the same basis as THA using the same "anatomical" stem and 36 to 60mm head diameter. Until now more than 35,000 of these hemiarthroplasty systems have been implanted. Until 1992 the Poldi-Cech implant was practically the only available cemented total hip replacement in the former Czechoslovakia and retrospectively it may be considered a highly successful implant. In the authors' view, the further development of THA will lead in the following years to the use of implants proved by a long-term follow-up. Preference will be given to prostheses the implantation of which will require a minimal loss of the bone stock during primary surgery and which will allow a technically easy reimplantation. The continental Europe has been recently preferring hybrid prostheses while Scandinavia witnesses an evident increase in the number of implanted cemented prostheses to the detriment of the cementless and hybrid ones. Naturally, cementless prostheses will keep dominating in young patients.

Purpose of the Study: The aim of the study is to evaluate the results achieved after the replacement of a loosened or broken cemented cup by another cemented cup and to specify conditions under which such procedure may be successful., Material: In the period of 1992-1997, 158 revision surgeries of total hip arthroplasty were performed at the authors' Department. In 69 patients (57 women, 12 men) the cemented cup was replaced by another cemented cup and the original femoral monocomponent with the 32 mm head diameter the surface of which was not damaged was left in place., Methods: The indication for operation was loosening of Degree 2 or 3 of the classification after Krbec et al. The surgery was performed from the Watson-Jones or Bauer approach. The cup was always revised with the use of the Palacos cement in combination with antibiotics by the cementing technique of 2nd generation. Augmentation was used in 11 cups. The original femoral component was always returned to the original cemented bed and a cement mantle was added in the proximal part in 15 patients. Poldi cups were replaced in all patients of the followed up cohort (63 times loosening--91%, 6 times breakage--9%) using 3 types of cups for revision surgery (Poldi--44 times, Ultima--20 times, SPC--5 times). During the period of March through December 2001, 48 patients were followed up in the out-patient department. The clinical condition was evaluated on the basis of the Harris Hip Score and a radiograph was made to monitor changes in the position of the cup, linear wear, the presence and size of the radiolucent zone., Results: The results were evaluated in 48 patients (40 women and 8 men) with the average interval of 63 months after revision of the cup (range, 46 to 112 months). However, the clinical and radiograph evaluation of the condition was made only in 45 patients. Three patients re-operated on in 2001 were not included in the evaluation. The Harris Hip Score was on average 78 points (range, 51 to 97 points). Radiographs did not show any change in the position of the cup. The linear wear up to 1 mm was revealed in 4 cups and above 1 mm in 1 cup (11% of the evaluated patients). The radiolucent line in zone III after DeLee and Charnley was present in 4 cups, in zones II and III in another 4 patients, i.e. in total in 8 of 45 cups (18%)., Discussion: The group of 45 followed-up patients may be considered a sufficiently representative sample of the original 69-member cohort (minimally 7 patients died in the follow-up period, 3 patients were not included in the evaluation). With regard to the average follow-up of 63 months the results may be considered as medium-term. The average interval between primary total hip arthroplasty and revision of 130 months is comparable with the results of similar studies by other authors. The results of the clinical evaluation on the basis of Harris Hip Score are not convincing (range, 51 to 97 points, average 78 points). Radiographs showed a radiolucent zone in 8 cups (18%). Another 3 patients were at the time of evaluation after a repeated revision of the cup for loosening (at the interval of 22 to 34 months)., Conclusion: A good integration of the cemented cup used in revision of the loosened cemented cup of total hip arthroplasty was evident only in infrequent cases of a perfectly preserved acetabulum both from the viewpoint of shape and structure. The evaluation of other patients of the followed-up cohort, however, produced rather unconvincing results. On this basis and also on the basis of their experience in the use of cementless cups in revision of total hip prostheses the authors recommend to prefer a cementless implant in the revision of the cup.

The authors present an overview of the current views on etiology and diagnostics of infectious complications of total hip arthroplasty and analyze the possibilities of individual therapeutic procedures (debridement with the preservation of total hip arthroplasty, revision of the endoprosthesis, long-term antibiotic therapy, final resection arthroplasty, arthrodesis). They discuss the pending issues relating to the therapy of infectious complications of total hip arthroplasty (the duration of antibiotic therapy, the interval between the extraction and revision surgery of the endoprosthesis, the use of antibiotic-containing cement). Based on their own experience they recommend the revision surgery with the preservation of the implant, debridement and irrigation as the first step only in case of an early post-operative infection and in case of a late hematogenous acute infection. In case of chronic infection they recommend a two-step revision surgery using the cement spacer and the antibiotic therapy for 3 to 6 months. During this period the laboratory and clinical signs of the infection must be back to their normal. Long-term antibiotic therapy in dependence on microbial sensitivity is recommended.

Background: Congenital pseudarthrosis of the clavicle is a rare disease. There are about 200 individual cases reported so far in world literature, mainly in the form of case reports. The majority of authors recommend surgical. An analysis of 103 cases published since 1980 shows only a few post-surgical complications., Case Report: The authors present a female patient operated at the age of 4.5 years. During surgery both cartilaginous ends were resected and internal fixation was performed by a one-third semitubular plate fixed by 3.5 mm cortical screws. Ten days after hardware removal, a fracture occurred in the screw-hole following a minor impact. Surgery to heal the congenital pseudarthrosis was successful, but a new fracture occurred, resulting from bone weakening. This simple fracture was treated conservatively. At present (5 years after the first surgery) the patient's parents are completely satisfied with both the functional result and the cosmetic appearance., Conclusions: The authors have not found in the literature any reports of similar complications after surgical treatment of this condition. The use of more delicate osteosynthetic material might prevent the complication described here.

In recent decades an increase in the number of fractures of the proximal femur was recorded in this country and world-wide. The majority of patients with this diagnosis is above 70 years of age and their treatment comprises in addition to the medical aspect also economic and social problems. The objective of the present work is to summarize briefly the results achieved during the five-year trial focused on socio-economic problems of treatment of patients with fractures of the proximal femur. The investigated group comprised 244 patients hospitalized at the Orthopaedic Department of the Third Faculty of Medicine Charles University in 1997 with 248 fractures of the proximal femur. Thirty-nine fractures were treated conservatively, 116 by internal fixation and in 93 cases an arthroplasty was implanted. In the course of the first year of treatment 85 patients died. The therapeutic results after one year were evaluated in 159 patients. The total annual costs of the investigated group were 15.9 million crowns. The mean annual costs of treatment of one fracture of the proximal femur was 64,000 crowns. The ratio of deaths rose with age (p = 0.003), it did not depend on the social background of the patient (p = 0.16) and the quality of locomotor activity before the injury (p = 0.16). No type of fracture was associated with a higher or lower mortality (p = 0.09). A statistically significant higher mortality was recorded in patients included in the higher class of the ASA score (p < 0.001) and in conservatively treated patients (p < 0.001). The type of anaesthesia did not affect the mortality. The functional results were significantly worse in patients living before the injury in a dependent position (0.01 < p < 0.05) and with restricted physical activity (p < 0.01). The type of fractures did not affect significantly the functional results (p > 0.05). Poorer functional results were recorded in patients with ischaemic heart disease (p < 0.001) and neurological disease in their history (p < 0.001). Also inclusion into a higher class of surgical risk according to the ASA score was associated with poorer functional results (p < 0.001). Different types of anaesthesia and different methods of surgical treatment did not affect the quality of functional results. However the functional results were better in operated patients as compared with conservatively treated patients (p < 0.001).

In recent years there are in particular in the daily press discussions on the publication of data concerning the number of deaths in different hospitals. Without comments on the structure of the group of hospitalized patients and their morbidity these data may be confounding. The objective of the work is to inform on the number of deaths and spectrum of the deceased at the Orthopaedic-Traumatological Department in course of three years and analyze the data. The investigated group was formed by patients who died in the course of hospitalization at the Orthopaedic-Traumatological Clinic of the Third Medical Faculty Charles University and Vinohrady Faculty Hospital Prague in 1998-2000. In 1998 16 men and 15 women died (mean age 85 years), in 1990 29 women and 10 men (mean age 81 years) and in 2000 14 women and 6 men (mean age 78 years). Patients after injuries predominated, only 5 patients died after a planned orthopaedic operation during this period. The most frequent diagnosis of the deceased patients was fracture of the proximal femur which in 1998 and 1999 accounted for more than 90% and in 2000 for 100% of the patients who died after an injury. According to post-mortem diagnoses death caused by acute myocardial infarction and other complications of ischaemic heart disease predominated (55%).

Purpose of the Study: The authors present an overview of mortality of patients with proximal femur fractures treated at the authors' Department in 1997 in dependence on different factors relating to the preinjury condition and the treatment itself. The aim of the work was to determine the impact of these factors on the risk of mortality and compare the findings with the data published by other authors dealing with the same issue., Material: In the given year 244 patients with 248 proximal femur fractures, 58 men (24%), 186 women (76%), average age 77 years were treated. There were 115 (47%) fractures of femoral neck, 117 (47%) pertrochanteric fractures and 16 (6%) intertrochanteric (high subtrochanteric) fractures. Thirty-nine fractures (16%) were treated conservatively, internal fixation was performed in 116 fractures (47%), i.e. 6 times by a plate, 94 times by a DHS, 16 times by the Gamma nail, and 93 fractures (37%) were treated by arthroplasty (62 times by hemiarthroplasty and 31 times by total hip arthroplasty)., Methods: The following data was recorded in all patients of the monitored group: age, sex, social environment and physical activities of the patient prior to the injury, mechanism of the injury, type of fracture, surgical risk expressed by the respective class of the ASA score, therapeutic procedure, type of anesthesia and interval between the injury and operation. Recorded was also the number of mortality in the course of primary hospitalisation and one year after the injury or operation. At the end of the one-year monitoring statistical evaluation was made of the relation between mortality and the above mentioned monitored factors and the results were compared with those published in similar types of study., Results: In the period of one year after the injury or operation 85 patients died of the total number of 244 (56 women and 29 men). The number of decreased patients was increasing in individual age decades and the highest number was recorded in case of men in 9th decade (80%) and 10th decade (100%). The lowest number of mortality related to patients who lived with their families prior to the injury (26.5%) and the highest number was in patients from social care institutes (43.8%). Patients with impaired mobility already prior to the injury and not leaving their homes accounted for 46.7% of mortality. In the course of one year after the injury 33.0% died of fracture of femoral neck, 30.7% of pertrochanteric and 35.7% of intertrochanteric (high subtrochanteric) fracture. Dependence of mortality on ASA score was as follows: ASA I-0%, ASA II-4.3%, ASA III-21.3%, ASA IV-42.1%, ASA V-68.9%. The highest number of mortality of operated on patients was in the group treated by hemiarthroplasty (41.1%). After spinal anesthesia 26.6% of patients died within one year and after general anesthesia 26.7% of them. There was an evident increase in the number of mortality in patients operated on in the interval longer than 3 days after the injury., Discussion: The mortality in the followed up group was statistically significantly influenced by the age (p = 0.003), sex (p < 0.01) and ASA score (p < 0.001). This corresponds to the results of other studies. The dependence of mortality on environment and mobility prior to the injury, type of the fracture, type of surgical treatment and type of anesthesia has not been proved., Conclusion: Based on the evaluation of the data monitored in the group a conclusion was made that absolute mortality risk in the first year after the injury related to patients with pathological fractures due to metastasis. A higher risk related to male patients older than 80 years with the surgical risk of ASA IV and higher and this risk rate was the highest in the time interval within 3 months after the injury or operation.

We present a case of lunate dislocation with total disruption of all ligaments and, consequently, nutrient vessels. The injury was handled by fusion of the lunate with the scaphoid, capitate and triquetrum. This 'anchor fusion' has led to a very good long-term result.

Purpose of the Study: To present the first 3-5 year experience in primary implantation of the Ultima cementless hemispherical threaded cup., Material: In the period between October 1995 and June 1997 we implanted in total 30 Ultima cementless cups in 28 patients (10 men, 18 women). The average age of the operated on was 60 years (41-74 years). Twenty-four patients, i.e. 26 hips were available for the follow up. From the viewpoint of diagnosis the group of patients included 15 cases of primary osteoarthritis, 9 cases of acute intracapsular femoral neck fracture, 3 cases of postdysplastic osteoarthritis, 2 cases (1 female patient with bilateral affection) of rheumatoid osteoarthritis (RA) accompanied with the protrusion of acetabulum and 1 case of idiopathic necrosis of the head., Methods: The average follow up was 39 months (31-51 months). Subjectively, we followed the patients' satisfaction with the result of the surgery, i.e. subsidence of pain, range of motions and the willingness to undergo the surgery once more on the basis of its result. Radiologically, we assessed the shape of acetabulum prior to operation, the position of the implanted cup in ap projection on the postoperative radiograph, on the last control radiograph we evaluated osteointegration of the cup and also potential particular ossification., Results: Nineteen patients out of 24 were subjectively satisfied with the result of the operation. The primary shape of acetabulum was in 24 cases spherical, 4 times dysplastic slightly lower CE (Wiberg) angle and twice there occurred protrusion of the head (the female patient with RA). The position of the cup in ap projection was evaluated in 25 cases as correct (45 degrees declination), in 2 cases as valgus (more than 55 degrees declination), in 3 cases as varus (less than 35 degrees declination) and in 1 case the cup was inserted too deep. Osteointegration was evaluated in 25 cases. In 22 cases we considered the osteointegration as good, i.e. without signs of a radioluscent line around the circumference of the cup. This line we encountered in 2 patients around the whole circumference of the cup but without any signs of a change in the position of the cup and without subjective complaints (pain in the hip). Both patients operated on for the primary osteoarthritis had a spherical shape of acetabulum and the declination of the cup was assessed as satisfactory. In 1 case we had to re-operate on due to the migration of the cup in the pelvis, namely in the female patient with RA and bilateral affection. The migration occurred on the left side 2.5 year after the primary surgery. Particular ossification was encountered 3 times, one case required extirpation. Complications were recorded in 8 patients. In one case the lateral cortex was peroperatively perforated by the stem of the femoral component. In another patient with a dysplastic acetabulum the cup was inserted to deep in the medial wall of the acetabulum. In the third patient the greater trochanter got broken, remained displaced and only the ligaments healed. Early postoperative complications were recorded twice. In one case it was a serous secretion from the wound which subsided after a few days without the necessity of revision. Revision was required in the second case when the R-drainage broke in the course of its removal. Late complications occurred in 3 patients. In one case there developed a mitigated infection requiring revision surgery, in case of the female patient with RA the cup protruded in the pelvis which necessitated a revision surgery., Discussion: So far there are no literary data on this type of cup. The only existing information relates to the preceding type of a similar design, i.e. Mecring cup, which failed., Conclusion: Despite relatively good but short-term results of this small series the unusual design of the Ultima hemispherical threaded cup requires a great prudence in its application and additional long-term follow-up. Therefore the cup cannot be recommended for a regular use for the time being.

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.

Purpose of the Study: Authors report on five-year results in patients after THR operated on between 1994 and 1995 in which a cementless CLS Spotorno cup was used., Material: In the given period 59 patients were operated on (35 women and 24 men). The average age at the time of implantation was 54.6 years. The most frequent causes of the indication for THR was primary osteoarthritis of the hip in 27 patients and postdysplastic osteoarthritis in 16 patients. Applied were 46-62 mm cups for 28 mm and 32 mm diameters of the head. The femoral component used was a cementless Poldi--42 times, cemented MS-30--16 times and cementles CLS--once. The surgical approach was first anterolateral, later Bauer transgluteal approach which allows a better visualization of the location during the reaming of acetabulum and cup positioning. The reaming of acetabulum and implantation of the cup were performed in a standard way. Prior to incision Kefzol (cefazolin) was administered intravenously in the dosage of 2 g. In patients with a preceding operation on the hip joint the administration of Kefzol was extended to 24 to 72 hours (3 x 1 g each 8 hours intravenously). Standard antithrombotic prevention by miniheparinization was applied in all patients until they were able to walk with the help of crutches (7 to 10 days). In case of an increased risk of thromboembolic complications heparin with a low molecule weight (Fraxiparine) was applied over the same period., Methods: In the period between autumn 1999 and spring 2000 clinical examination of the patients operated on was performed together with a radiograph of the hip joint involved. Clinical findings were evaluated after Harris hip score. Radiograph findings were compared to the postoperative and the control ones made one year after the operation. Evaluated were the position of components and signs of their loosening, if any., Results: After the average follow-up of 59 months 57 patients were checked. Excellent results according to Harris were achieved in 40 patients, good results in 13 patients and satisfactory results in 4 patients. No poor result was recorded. Radiographs proved a full integration of CLS Spotorno cups without any signs of loosening in all checked patients., Discussion: Not very numerous works in both foreign and domestic literature list according to the experience of individual authors the following advantages of CLS Spotorno cup: a small bone loss during reaming of acetabulum, excellent primary stability, excellent secondary stability and its easy reimplantation as compared to all types of cementless cups. Only in one female patient after a peroperative fissure of proximal femur the control examination showed a lower value of Harris score than was the average value of the whole group. Similarly, the Harris score was lower in female patients who postoperatively experienced complications of neurological and internal nature (1 temporary paresis of n. ischiadicus, 1 phlebothrombosis of veins of the limb operated on). Control radiograph examination proved a full bone integration without signs of loosening in both components of the implant in all 57 checked patients., Conclusion: After five years the authors have a good experience with CLS Spotorno cup and recently they have started to indicate it more often in postdysplastic coxarthrosis in younger patients and in revision surgery for aseptic loosening of a cup. In young patients they recommend its matching with CLS Spotorno cementless femoral component and in middle-aged patients its matching with MS-30 (Morscher-Spotorno) cemented femoral component the centralizer of which allows an ideal anchoring of the stem in the cement mantle.

Background: The number of publications evaluating economic and social aspects of the treatment of proximal femur fractures increased steadily in the last 20 years in the foreign literature. Due to the absence of similar studies in the domestic literature the authors decided to investigate this issue in the Czech Republic and to present outcomes. The aim of the presented study is to inform about the costs of treatment of patients with proximal femur fractures in an orthopaedic department and estimate the costs of such treatment on a nationwide scale., Methods and Results: A detailed follow up of 244 patients treated for a proximal femur fracture was carried out at the Orthopaedic Clinic of the 3rd Medical Faculty and Faculty Hospital, Královské Vinohrady in 1997, including economic aspects and the fate of patients after their discharge from the hospital in the course of one year after their injury or surgery. The average cost of primary treatment of a patient in this group amounted to 38,000 Kc, on a nation-wide scale this sum totalled 29,000. The obtained results were compared with national data acquired from the Institute of Health Care Informations and Statistics and from the General Health Insurance Company. The monitored group accounted for 2% of the national group of patients with this diagnosis., Conclusions: Exact data on the costs of primary treatment of patients with a proximal femur fracture were obtained only in the monitored group of our patients, in 1997 these costs amounted to 9,389,848 CZK. The costs in the whole Czech Republic may be only estimated at approximately 450 million CZK.

The authors present an overview of basic demographic data obtained from the follow up of 248 patients treated for a proximal femur fracture at their clinic in 1977.The average age (77 years) and the predominance of patients older than 70 years (81 %) are comparable with the groups of patients presented in the foreign literature. The group of patients accounts for approximately 2 % of the national group (data acquired from the Institute of Health Care Information and Statistics), the average age is by 5 years higher and the predominance of patients older than 70 years is more significant by approximately 10 %. Also the percentage of mortality in the course of hospitalization is in the authors' group higher (approximately by 4 %) as compared to the national group. The risk of death is, however, high only in the group of patients older than 80 years and the conservatively treated patients. The comparison with similar dat in the group of patients treated for the same diagnosis at the authors' clinic in 1998 shows a significant increase of the number of treated patients (by 33 %), however, basic demographic data (average age and age distribution) has not changed. Key words: proximal femur fractures, basic demographic data.

Legg-Calvé-Perthes disease (LCPD) is considered as avascular necrosis of the proximal femoral epiphysis, that can result in a secondary osteoarthritis. Bone scintigraphy using 99mTc phosphonate complexes is a suitable method for study of changes of LCPD. The authors present a group of 59 children (44 boys, 15 girls), with clinical suspicion of LCPD or with clear diagnosis of LCPD according to X-ray examination, who were examined using scintigraphy. The patological scintigraphic images of the proximal femoral epiphysis are evaluated according to Conway's classification. The correlation of pinhole imaging of the hip X-ray examination is neccessery for the correct diagnosis of stage of LCPD according to Conway's criteria. In author's experience Conway's classification is useful for evaluation of the development of disease; this is important for prognosis and treatment of LCPD. Key words: Legg-Calvé-Perthes disease, bone scintigraphy, scintigraphic classification.

The authors submit their initial experience with the use of the apparatus Artroflow recommended as one possible means to prevent thromboembolic disease in bedridden patients. The strictly defined criteria of the investigation made it possible to include in the group only a limited number of patients, therefore the results are not significant. Seven months' experience, however, convinced the authors that it is useful to use Artroflow for the rehabilitation of geriatric patients after fractures of the proximal part of the femur. Key words: prevention of thromboembolic disease, activation of the venous pump by passive means, Artroflow apparatus.

The authors give a review of imaging techniques used at present in the diagnosis and follow-up of changes in Legg-Calvé-Perthes disease. Based on data in the literature and their own experince, the authors draw attention to the advantages and disadvantages of different diagnostic methods. They discuss possibilities of different imaging techniques in the early diagnosis of the disease. In their opinion a high-standard X-ray examination is still the basic examination. A suitable supplement in particular in a early stages are sonographic, scintigraphic and magnetic resonance examinations. Key words: diagnosis of Legg-Calvé-Perthes disease, X-ray examination, sonography, scintigraphy, magnetic resonance.

The author presents an account of the most frequently used X-ray classifications of morbus Legg-Calvé-Perthes, incl. their description and discusses the advantages and disadvantages of the various methods. He emphasizes in particular Waldenstrom's, Herring's and Stulberg's classification. Key words: morbus Legg-Calvé-Perthes, X-ray classification.

Based on seven-year experience with non-cemented femoral components of total endoprostheses of the hip joint, type Schenker, the authors assume that their use is limited only to a small group of patients under 40 years of age, provided strict principles as regards precision of implantation are respected. The latter are discussed in the submitted paper.

The authors monitored a group of 87 patients after a reoperation of the total replacement of the hip joint due to the so-called aseptic loosening of one of the components. On the basis of the evaluation of clinical complaints and an x-ray finding of the extent and progress of the so-called radioluscent line on the cement-bone interface and their correlation with the peroperative finding of the loosening of the implant they developed an x-ray classification of the loosening of the total endoprosthesis. This three-grade classification facilitates the consideration of the latest state of the fixation of the implant and the prognosis of further development. It is a therapeutical guideline for the determination of the period suitable for reoperation and possible exchange of endoprosthesis. Key words: total endoprosthesis of the hip joint, aseptic loosening, diagnostics.

The authors present a case-history pertaining to the early diagnosis of Perthes' disease by magnetic resonance in a patient with a marked clinical symptomatology and a negative classical skiagram. Typical changes on the X-ray picture developed after a three-month interval. Confirmation of the importance of magnetic resonance for early diagnosis of Perthes' disease is consistent with the quoted literature. Key words: early diagnosis, Perthes' disease, magnetic resonance.