INTRODUCTION

Management of neglected residually displaced acetabular fractures is a big challenge. ORIF is often doomed to failure so a primary total hip replacement is usually kept in mind as a method of choice. However THR is a technically difficult and results are quiet unpredictable. OBJECTIVE. To present our experience with THR in maltreated grossly displaced acetabular fractures and to discuss operative technique and prognostic factors in that complicated surgery.

Objective: To compare anatomical and functional results after treatment of unstable C-type pelvic fractures with percutaneous iliosacral screws (PISS) and anterior sac-roiliac plating (ASIP) in order to verify the proper indications for both techniques.

Material And Methods: The series consists of 37 patients sustained C-type pelvic lesions with dislocation or fracture-dislocation of SI joint of witch 23 were treated by PISS and 14 by APIS. There were 24 males and 12 females of an average age 33 years (16–64 years). The average ISS in both groups was 26.5 and 23 respectively. The surgery was performed 1 – 18 days after trauma (mean 7 days). Screw fixation was carried out with 2 cannulated screws in the S1 body after close reduction in prone or supine position. ASIP was realised with 2 recon plates or DSP through iliac approach. Simultaneous anterior internal fixation was done in 16 PISS patients and 9 ASIP patients.

RESULTS: Average operative duration was 42 min (25–85) in PISS group and 105 min (70–130) in ASIP group (p< 0.001). The average perioperative blood loss was 50 ml (0–150 ml) and 560 ml (400–950) respectively (p< 0.01). The quality of reduction was evaluated according to Leung criteria. The excellent and good results were 17/23 after PISS (74%) and 13/14 after ASIP (93%): p< 0.005. One patient of each group died due to reasons unrelated to pelvic surgery and the remains were followed up for an average 28 months (10–64). Functional results were rated according Pohlemann et al. In PISS group excellent and good results were 17/22 (74%) and in ASIP group 12/13 (82%): p> 0.005. Except one case of fixation failure and nonunion after PISS without anterior stabilisation there was no major complication in every group.

Discussion: The both methods provide effective dorsal fixation and may be used succesfully in C-type injuries. PISS is much faster and bloodless procedure, but is in lower in respect of acceptable anatomical results. ASIP better reduction and is more suitable for fracture-dislocations. Fair functional results and complications in our series were slightly more common after PISS than after ASIP, but the differences were statistically insignificant. The single major comlication occured when anterior fixation was ignored.

Conclusions: Early after trauma when adequate reduction may be done by close manner PISS is prefferable as less traumatic intervention. When acceptable closed reduction can not be obtained, especially in delayed surgery, we consider ASIP as a method of choice for C-type pelvic fractures.

Objectives: To evaluate and compare the results of interlocking nailing (ILN) and plating (PL) in fresh humeral shaft fractures (HSF)

Material and Methods: During 7 years period 145 patients with HSF (84 males and 61 females) were operated and followed up for 8 – 60 months (mean 18 months). According to AO there were 64 Type A, 53 Type B and 28 Type C fractures. Of 18 open injuries there were 10 grades I, 5 grades II and 3 grades IIIA. There were 33 patients with polytrauma, 11 cases with associated limb injuries, 9 cases with floating elbow and 22 patients with primary neurological deficit. In 75 fractures ILN was performed and PL in rest 70.

Results: The mean operative time was 85 min for ILN vs./117 min for PL and the mean blood loss 100ml vs./250 ml. Healing occurred in 139(95.6%) fractures with mean healing time 75 days vs./85 days. Functional results according to Rommens score were as follows. Shoulder: excellent 62(82.6%) vs./55(78.5%), good 11(14.6%) vs./11(15.7%), poor 2(2.8%) vs./4(5.8%).

Elbow: excellent 69(92%) vs./52(74.3%), good 6(8%) vs./16(22.8%), poor 0 vs./2(2.9%). Complications noted were iatrogenic nerve palsy 1(1.3%) vs./12(17%), delayed union 5(7%) vs./2(3%), non union 1(1.3%) vs./5(7%), infection 0 vs./1(1.4%), fixation failure 1(1.3%) vs./5(7%) and reosteosynthesis 1(1.3%) vs./1(1.4%), shoulder impingement 8(11%) vs./2(3%).

Conclusions: Interlockimg nailing reduces risk of nerve injury and infection, provides more stability in segmental, complex and osteoporotic HSF. No significant differences in the term of healing in the both methods. Plating should be preferred in open Fx with incidental nerve palsy or vascular injury and juxtaarticular Fx, especially distally located. The method provides anatomical reduction, but requires extended approach and increases risk of iatrogenic nerve palsy.

Introduction: For a period of 7 years were treated in Emergency Hospital Pirogov 205 patients with humeral shaft fracture (HSF)–125 with interlocking nailing (ILN), 80 with AO plates, these include 55 delayed unions (DU) and nonunions (NU).

Material and methods: We treated 15 DU (2–4 months), 19 NU after conservative treatment (4–12 months), 15 NU after operative treatment and 6 recalcitrant NU. 23 of the cases were men at the average age of 43.9 (18–74) and 32–women, at the average age of 64.7 (43–88). NU according to Weber-Cech were–2 hypertrophic, 18 olygotrophic and 20 atrophic, as 7 of them were infected. The initial trauma in 14 cases was high energy. The most common predisposing factors at DU are: poor bone contact–distraction 11 cases, soft tissue interposition 8 cases. At NU after conservative treatment: soft tissue interposition 13 cases and inadequate vascularity–severe injury 6 cases, and at NU after operative treatment: mechanical instability–inadequate fixation 18 cases and excessive soft tissue striping 11 cases. The usual contributing factors are: metabolic bone disease 23 cases; obesity 18 cases; poor functional level 14 cases; smoking 14 cases; advanced age 11 cases. Osteosynthesis with AO plate were 23 cases and the remaining 32–interlocking nails. Bone grafting was done in 23 cases, decortications in 12 cases, and channel reaming–in 20 cases.

Results: All the cases that were treated with AO plates consolidated for the average period of 103 days (70–150) and the cases with interlocking nails (with the exception of 3–9%) for the average period of 108 days (160–240). As post-operative complications we had 6 (26%) cases of iatrogenic neurological injury with plate ostheosynthesis, 3 (10%) cases of shoulder impingements with ILN, one case of shaft fracture and infection in both methods. The patients were followed for minimum 12 months after bone union–clinical and X-ray examinations (12–60) months. We rated the final functional result according to Rommens score: excellent–29, very good–13, good–8, satisfactory–2, bad–3.

Conclusion: We think that DU are more appropriate for interlocking nailing. The cases that NU are a result of unsuccessful conservative treatment, because intramedullary channel was obstructed, is better to be treated by ostheosynthesis with plate. And the contrary–it is suitable to replace ostheosynthesis with AO plate with interlocking nails after extraction of the implants in addition to bone grafting.

Objective: A floating hip, e.i. combination of pelvic or acetabulat fracture with ipsilateral femoral fracture is uncommon condition, but posing considerable problems such as how to manage each component of the injury and what are the treatment priorities. The aim of the syudy is to report our experience with surgical treatment of traumatic floating hip.

Material and methods: For the 4-year period in our institution 15 patients with floating hips (10 mails, 5 females, average age 38 years) were treated operatively. There were 10 unstable pelvic ring disruptions B and C types and 5 displaced acetabular fractures, combined with 2 neck, 11 shaft and 2 supracondylar femoral fractures. Six patients were operated simultaneously for both components and in the rest definitive pelvic surgery were done at a second stage. pelvic girdle was stabilized by a variety of methods: anterior sacro-iliac plates, iliosacral lag screws, transsacral posterior plaates. Acetabular fractures were all treated by ORIF. For femoral fractures nailing was done in 8 cases, plating in 5 and cervical screw fixation in 2.

Results: All fractures healed in time. Two superficial femoral infections resolved after local care. Results for pelvic injuries were estimated according to Pholemann score and for acetabular fractures – to Matta scale. In respect to pelvic fractures 5 ecxellent, 3 good and 2 poor results were noted, and regarding acetabular fractures 3 exccelent, 1 satisfactory and 1 poore results. All femoral fractures united in good position. Overall final outcome was excellent in 8, good in 3, fair in 1 and poor in 3 patients.

Conclusions: Surgical treatment is a method of choice for a floating hip. ORIF of pelvic ring and locking nailing of the femur result in best outcome. Simultaneous procedure provides more rapid recovery, but should be carried out only in stable patients. If staged surgery is planned, stabilisation of the femur should be done prior to definitive pelvic fixation in order to facilitate later pelvic surgery.

Aim: In order to determine the reliability of the ORIF of bicondylar fractures in elderly patients, we will present the results of the patients aged above 60 years in which ORIF with plates is a method of choice. Materials & Method: For the period 1996–2001 year, 20 patients with dislocated bicondylar fractures were operated with mean age Ð 70.7 (63.8). All of them were followed up Ð 14 women and 6 men. The AO types were: C1 Ð 7; C2 Ð 5; C3 Ð 8. Five patients were with þrst and second type open fractures.

Fifteen patients were operated immediately and the rest Ð between the 5th and the 10th day. The average operative time was 335 minutes. The patients were operated by the standard technique of AO. Osteotomy of the olecranon was used in all patients except for 3 patients. All the fractures were stabilised with 2 plates except for 2 patients (1 plate). The osteotomy was þxated with a tension wire and K-wires. Carefully assisted rehabilitation was started at average on the 9th day. Results: The patients were monitored for 13 to 56 months. None had serious infections. One case resulted in failure of þxation and nonunion. In order to assess the function of the elbow joint we used Morrey& Chao, DASH, and average arch of movement. Scoring: 83,02 (±24,59); 20,10 (±21,66); 97û(±37,83).Conclusions: We consider that the operative treatment with plates of the bicondylar fractures in the elderly can provide good clinical results in the hands of the experienced surgeon.

Objective: To evaluate the results of operative treatment of complex fractures of the acetabulum. Material and methods: For the period 1992 Ð 2001 þfty one patients with complex acetabular fractures were treated surgically and followed up for an average 4 years 3 months (range, 1 Ð 11 years). There were 34 males and 17 females of an average age of 39 years (range, 18 Ð 64 years). Thirty one of the patients sustained multiple trauma. The mean operation time was 9 days (range, 3 Ð 22 days). According to Judet-Letournel classiþcation there were 2 posterior clolumn/posterior wall fractures, 10 Ð transversal/posterior wall, 7 Ð T-type, 9 Ð T-type/posterior wall, 11 Ð anterior column/posterior hemitransversal and 12 Ð both column injuries. Posterior Koher-Langenbeck, ilioinguinal, extended iliofemoral or combined approaches were used depending of fracture pattern. Internal þxation was done with lag column screws, column shaped plates, brim plates or buttress plates. Spring plating with stright or T plates was widely used in cases of comminution. Ealy weight-protected motion was conducted after surgery. Results: Average operative time was 3.5 h (range 1.5 Ð 8 h), and average blood loss was 1200 ml (range 450 Ð 2300 ml). According to Mattañs criteria anatomical reduction was achieved in 23 cases, good Ð in 13, fair Ð in 11 and poor Ð in 4. Late outcome was evaluated according to Merl dñAubigne-Postel-Matta scale. Nineteen ecxellent, 16 good, 11 fair and 5 poor results were recorded. The last were due to arthritis, avascular necrosis or chondrolysis. The late results correlated strongly with quality of reduction and initial cartilage damage. Early complications were 1 case of operative bleeding, 1 intraarticular screw penetration, 5 jatrogenic nerve palsies (2 of femoral cutaneus nerve and 3 of peroneal nerve) and 1 superþcial inection. Late complications were 1 case of chondrolysis, 2 avascular necroses and 2 Grade III heterotopic ossiþcations. Conclusion: ORIF provides high prevalance of excellent and good results in complex acetabular fractures and should be considered as a method of choice. The quality of reduction is of most importance for þnal outcome. Initial cartilage condition, fracture type and degree of comminution should also be taken in mind for late prognosis. As the surgery is demanding perfect surgical skills, special experience and adequate equipment are required for þnal success.