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PURPOSE OF THE STUDY Lumbar spinal stenosis (LSS) is a serious and fairly frequent disorder with prevalence increasing with age which often results in a disability. The surgical procedures are often very risky due to the greater age of patients with severe stenosis and their comorbidities. The study aimed to assess the functional outcomes and complications in patients who underwent surgical treatment for LSS at one year postoperatively and to identify the differences in the functional outcomes, if any, in dependence on the number of operated segments. MATERIAL AND METHODS It was a prospective study which included 33 patients who underwent surgery at the authors department from 1 November 2015 to 1 October 2016 for LSS, the mean age of patients was 69.5 (43-83) years. The surgery was indicated based on the clinical examination, radiography and MR imaging and consisted in posterior decompression with or without stabilisation and fusion. Pre- and post-operatively, a neurological examination and evaluation of patient difficulties were performed by: VAS - particularly for low back pain (VAS-LB) and lower limb pain (VAS-LL), Oswestry Disability Index (ODI) and Swiss Spinal Stenosis Questionnaire (SSSQ). The evaluation was done at a half year and one year after the surgery. The authors made comparisons in dependence on the number of treated segments (1-2, 3-5 and Th-S stabilisation). RESULTS A significant improvement of all the followed-up parameters was reported at one year postoperatively. At one year after the surgery, the VAS-LB score showed a decrease by 2.39 (p = 0.001), the VAS-LL by 3.26 (p0.001), while a decrease by 2 or more points is considered clinically significant. When evaluating the SSSQ questionnaire, a decrease in subjective difficulties (SSSQ-S) was by 0.89 (p0.001), in physical function (SSSQ-F) by 0.87 (p0.001). In this questionnaire, the satisfaction rate with the surgery was 2 - i.e. somewhat satisfied. Altogether 76% of patients were very or somewhat satisfied, no one was very dissatisfied. When evaluating the ODI, an improvement by 20.6% (p0.001) was reported. The authors identified neither any significant differences in the outcomes at a one-year follow-up in dependence on the length of stabilisation, nor any significant differences between the six-months and one-year follow-up. Intraoperative complications occurred in 18%, early postoperative complications in 6% of patients. The ASD developed in 9% within one year. DISCUSSION The authors confirmed a significant improvement of the followed-up parameters (VAS-LB, VAS-LL, SSSQ, ODI) which corresponds with recent literature. The decrease in VAS and ODI in the authors study is more marked than the outcomes stated in literature. The authors outcomes clearly show that there is no correlation with the length of stabilisation and the number of decompressed segments. Conversely, the rate of complications was higher in this group than the rates stated in literature, but majority of complications had no consequences for the patients. CONCLUSIONS In the group of patients with a one-year follow-up the authors confirmed that surgical procedures will result in reduced subjective difficulties of patients, reduced pain and improvement of physical function. A significant improvement of all the followed-up parameters was reported. The authors did not confirm the correlation between the postoperative improvement and the number of treated segments. Key words:lumbar spinal stenosis, quality of life, post-operative outcomes, complications.

The authors describe their first experience with virtually navigated pelvic and spine screws based on perioperative CT navigation.From 22 October 2012 (launching the device) to 9 January 2013, a total of 15 CT-navigated pelvic and spine operations were performed in 14 patients. Nerve root compression, scoliosis, vertebral fracture and spondylodiscitis were the indications for spine procedures; B-type and C-type fractures according to the AO classification were the indications in pelvic surgical procedures. The preparation and the course of the procedures were in accordance with current standards and recommendations in all the cases. Perioperative navigation and subsequent examination of the screw trajectory were performed via O-arm imaging system (Medtronic Navigation, Louisville, Colorado) instead of the standard C-arm fluoroscopy.A total of 73 screws were inserted (60 transpedicular screws into cervical, thoracic and lumbar vertebrae, 9 iliosacral screws into the first sacral vertebra and 4 pubic screws). Only one of the pubic screws (1.4% of all screws) was found malpositioned at the subsequent perioperative examination and was extracted immediately and replaced. Further complications were not observed and none of the procedures had to be converted into a standard fluoroscopy guided operation.A short but intensive experience with perioperative CT navigation allows us to state: 1. CT navigation shortens the operating time and minimalizes the risk of screw malposition in multiple screw spine procedures; 2. CT navigation improves the introduction of iliosacral and pubic screws in pelvic fixations; 3. there is virtually no radiation load to the staff using the CT navigation; 4. mastering this technique will allow a wider use of miniinvasive screw insertion in the pelvis and other regions where minimal dislocation will enable miniinvasive internal fixation.

Objective The pathogenesis of idiopathic scoliosis (IS) remains poorly understood. One of the hypothesis of the development of IS could be an abnormal sensorimotor integration. Cutaneous silent period (CSP) is a plurisegmental spinal inhibitory reflex, which occurs after painful stimulation of small diameter A-delta fibers. To date, CSPs have not been extensively studied in patients with idiopathic scoliosis. Materials and methods We recorded CSPs induced by noxious digit II stimulation in both thenar muscles while the subject maintains a moderately strong voluntary muscle contraction in 6 patients with idiopatic scoliosis before surgery (1 male; age 14–28 years) and in 9 healthy volunteers (4 males; age 20–34 years). The beginning, duration and end of the CSP have been measured in individual traces. Results CSP onset, duration and end latencies in IS did not significantly differ between concavity and convexity of the scoliotic curve. Moreover, there was not any significant difference in CSP onset, duration and end latencies in IS as compared to controls. Conclusion We conclude that plurisegmental spinal inhibitory reflex is well preserved in idiopatic scolioisis. These findings did not support the hypothesis of disturbances in sensorimotor integration at the spinal level. Supported by Research Projects of Charles University PRVOUK P34, Grant Project of Czech Ministry of Health NT12282, NT13693.

The authors present analysis of a group of 75 patients with the fracture of proximal femur treated by the Gamma nail. The group consisted of 24 male and 51 female patients, average age 74 years (ranging from 24 to 91 years). Most frequent were intertrochanteric unstable fractures (Kyle III) - 41 %, subtrochanteric fractures accounted for 27 %. The average duration of the surgery was 70 minutes, the duration of x-ray exposure was 2,6 minutes. Healing in anatomical position was achieved in 91 %. Recorded were 8 peroperative complications (rotation of the head, inadequate reduction - 3 times, cut-out of the screw from the head - twice, breaking of the femoral shaft by the nail, erroneous distal locking). Early postoperative complications were represented twice by haematoma in the surgical wound. Late complications occurred 8 times (aseptic necrosis of the head - twice, cut-out of the screw from the head - twice, breaking of the nail, breaking of distal locking screws, migration of the distal locking screw - twice, mitigated infection - once). Most complications related to subtrochanteric fractures. The comparison with the authors group of patients treated by Ender nail shows in case of the Gamma nail a slightly higher percentage of final good results (88 % versus 91 %), but significantly lower percentage of complications. In the group treated by Ender nailing the mortality within 3 months after operation amounted to 37 % while in case of the Gamma nail only to 25 %. Key words: proximal femur fractures, Gamma nail, outcomes and complications.

Based on the analysis of their group of 75 patients treated for the fracture of proximal femur by means of the Gamma nail and on the analysis of data from the literature the authors present a comprehensive list of all complications resulting from this technique: inadequate reduction, -jamming of nail, fracture displacement by nail isertion, perforation of the head, incorrect length of the lag screw, problems with distal locking, fracture of the femoral shaft, rotation of head on the lag screw, rotation of diaphysis on the nail, failure of the healing of the wound and infection, breaking of the nail, non-union, healing in the varus position, aseptic necrosis of the head, incorrect rotational position of the limb, unequal length of lower limbs, problems with the set of instruments, migration of the set screw. Ensuing from the analysis are the main principles of the surgical technique.unstable intertrochanteric fractures, comminuted fractured (Kyle IV) of trochanteric regions and some subtrochanteric fractures. Reduction: in case of unstable fractures it is advantageous to correct them in a slightly valgus position, in the lateral projection it is necessary to achieve linear position of fragments. Antibiotics: recommended in case of elderly patients, in younger patients, only in risk involving cases. Position: the leg to be operated on has to be in adduction with regard to the body. Selection of the nail: diameter 12 mm, angle 130 degrees . Reaming: in the distal direction it is necessary to ream medullary cavity by 2 mm more than is the diameter of the nail, in the proximal direction it must be reamed up to 17 mm. Insertion of the nail: should be done manually, never use a hammer! If too much resistance is felt when advancing the nail, it is necessary to ream a larger hole or choose a thinner nail. Insertion of the lag screw: in AP projection along the longitudinal axis of the neck and head or slightly below, in the axial one exactly along the axis of the neck and head. Compression: only in cases where there is a diastasis between the fragments alignment with the tro-chanteris region. Compression: only in cases where there is a diastasis between the fragments alignment with the trochanteris region. Fixation of the set screw: should be done in such a way to prevent rotation but at the same time to allow free sliding of the lag screw, i. e. to screw it and subsequently unscrew by one quarter of a turn. Releasing of the traction after the insertion of the lag screw: in cases where there is diastasis between the femoral shaft and trochanteric region, special care should be taken in case of subtrochanteric fractures. Distal locking: is performed by one screw inserted in the proximal hole, care should be taken not to lever the targeting device or the guide sleeve, slipping of the drill bit should be avoided. The use of a short screw is not suitable. Tightening should be done carefully, checking by image intensifier is recommendend. R-drainage: always into the nail wound, in case of the lag screw incision it should be considered from the viewpoint of bleeding. Key words: proximal femur fracture, Gamma nail, summary of complications.

The frequency of periprosthetic fractures related to total knee arthroplasty is increasing, with a prevalence of 1.3% on the average and with women being affected more often (4 out of 5 patients). Fractures of the distal femur are common, while tibial fractures are rare. Crucial for treatment is to distinguish fractures of the metaphysis above the femoral component, which remains firmly fixed, from those involving the knee joint replacement and component loosening. Supracondylar periprosthetic fractures are almost always managed surgically, using methods of osteosynthesis with an angle condylar or DCS plate, or a short retrograde- inserted supracondylar intramedullary nail. The recent use of implants such as LCPs with angle-stable screws has offered good prospects. This retrospective study presents our first experience with an LCP for treatment of supracondylar periprosthetic fractures of the knee joint.Between 2005 and 2008, a total of 13 supracondylar periprosthetic knee fractures were treated by the LCP technique. The patient group included 10 women and three men the average age was 67.4 (range, 56-81) years. The fractures were classified using the system proposed by Su et al. and the AO classification system. According to the Su classification, 12 types I and II fractures and one type III fracture were indicated for osteosynthesis. Based on the AO classification, there were four type 33 A1 fractures, five 33 A2 fractures, three 33 A3 fractures and one 33 C2 initially incorrectly classified as type 33 A3 fracture. The average time between total knee arthroplasty and injury was 6.8 years. In all patients fractures occurred after primary implantation of a cemented condylar total knee replacement without a femoral stem.The fractures were treated by a less invasive technique of LCP implantation within an average of 2.5 days of injury. The patients were followed up until radiographic fracture union, and complications were recorded.The 13 patients were treated by LCP osteosynthesis through a less invasive approach. One patient had primary spongioplasty, two had spongioplasty after an interval of 7 weeks. One patient died of a disease unrelated to trauma and surgery at 3 months after osteosynthesis. In one patient, osteosynthesis failed with fragment dislocation shortly after the operation. The case analysis showed that the initial indication was marginal and the comminuted zone was too low above the implant, with the fracture line extending to the component. Subsequently, conversion to revision total knee arthroplasty involving a stem was carried out. In nine patients, bone union was achieved in an average of 18 weeks, with radiographic evidence of fracture union. No complications such as wound infection, delayed wound healing or thromboembolic disease were recorded. No bone union failure and pseudoarthrosis development occurred.There are only few reports on the treatment of supracondylar periprosthetic knee fractures and evaluation of its results in the literature, and the groups evaluated are small. In a meta-analysis of cases from the 1981 to 2006 period, Herrera et al. have found only 29 assessable studies with a total of 415 cases, i.e., an average of 14 cases per study. The usual method of treatment was DCS plate osteosynthesis. Complications associated with conventional osteosynthesis techniques, as reported by various authors, may reach up to 30% (pseudoarthrosis development, 9% osteosynthesis failure, 4% necessity of revision surgery, 13% fracture malunion, 47%).Good results have been achieved with a retrograde-inserted intramedullary nail. The use of an LCP has been reported in the literature only occasionally. The classification system described by Rorabeck et al. is most widely used, but the system proposed by Su et al. seems more convenient to us, because fractures are placed in three groups, according to the localisation of a fracture line and its distance from the femoral component, as follows: type 1 fracture, fracture line is proximal to the femoral component type 2 fracture, fracture line starts at the level of a proximal edge of the femoral component and runs proximally type 3 fracture, fracture line extends below the upper end of the femoral component. Type 1 fracture is indicated for a retro- grade-inserted intramedullary nail, type 2 fracture for LCP osteosynthesis, and type 3 fracture for revision total knee arthroplasty. The use of LCPs in the treatment of supracondylar fractures of total knee arthroplasty, with a success rate of 86%, is described by Ricci et al. Other authors also report better outcomes with the use of LISS or LCP methods than with conventional osteosynthesis techniques.Osteosynthesis with an angle-stable table LCP is an efficient method suitable also for the treatment of periprosthetic fractures of the distal femur above total knee arthroplasty. It offers all advantages of angle-stable implants. It is more effective for osteoporotic bone than a DCS implant or a condylar plate, because it provides better fixation stability for the distal fragment. However, further studies are needed to compare its efficiency with that of an IM nail.