Spinal tumours: recommendations of the Polish Society of Spine Surgery, the Polish Society of Oncology, the Polish Society of Neurosurgeons, the Polish Society of Oncologic Surgery, the Polish Society of Oncologic Radiotherapy, and the Polish Society of Orthopaedics and Traumatology

PURPOSE

The purpose of these recommendations is to spread the available evidence for evaluating and managing spinal tumours among clinicians who encounter such entities.

METHODS

The recommendations were developed by members of the Development Recommendations Group representing seven stakeholder scientific societies and organizations of specialists involved in various forms of care for patients with spinal tumours in Poland. The recommendations are based on data yielded from systematic reviews of the literature identified through electronic database searches. The strength of the recommendations was graded according to the North American Spine Society's grades of recommendation for summaries or reviews of studies.

RESULTS

The recommendation group developed 89 level A-C recommendations and a supplementary list of institutions able to manage primary malignant spinal tumours, namely, spinal sarcomas, at the expert level. This list, further called an appendix, helps clinicians who encounter spinal tumours refer patients with suspected spinal sarcoma or chordoma for pathological diagnosis, surgery and radiosurgery. The list constitutes a basis of the network of expertise for the management of primary malignant spinal tumours and should be understood as a communication network of specialists involved in the care of primary spinal malignancies.

CONCLUSION

The developed recommendations together with the national network of expertise should optimize the management of patients with spinal tumours, especially rare malignancies, and optimize their referral and allocation within the Polish national health service system.

Kinematic parameters after tibial nonunion treatment using the Ilizarov method

Background

Analysis of the outcomes of Ilizarov treatment of tibial nonunion shows functional deficits in the lower limbs of some patients. Biomechanical gait parameters are an important measure for assessing musculoskeletal disorder treatments that aim to restore normal gait. The purpose of our study was to compare the kinematic parameters in patients with tibial nonunion treated using the Ilizarov method and those in a control group of healthy volunteers.

Methods

The study population consisted of 23 patients (age 54.9 ± 16.4 years) who were treated for tibial nonunion using the Ilizarov method, as well as 22 healthy adult controls (age 52.7 ± 10.6 years). Kinematic parameters were measured using a Noraxon MyoMOTION System. We measured hip flexion and abduction, knee flexion, ankle dorsiflexion, inversion, and abduction during walking.

Results

Our analysis showed significant differences between the patients’ operated limbs (OLs) and the controls’ nondominant limbs (NDLs) in the ranges of hip flexion, hip abduction, and knee flexion. We observed no significant differences in knee flexion between the OL and the NOL in patients or between the dominant limb (DL) and NDL in controls. Our evaluation of the kinematic parameters of the ankle joint demonstrated significant differences between the patients’ OLs and the controls’ NDLs in the ranges of ankle dorsiflexion, ankle inversion, and ankle abduction. There were also significant differences in the range of ankle dorsiflexion and ankle abduction between the patients’ NOLs and the controls’ DLs.

Conclusion

Tibial nonunion treatment using the Ilizarov method does not ensure complete normalization of kinematic parameters assessed 24–48 months following the completion of treatment and rehabilitation.

Dynamic Gait Parameters in Patients With Nonunion of the Tibia Following Treatment With the Ilizarov Method

The purpose of this study was a comprehensive assessment of the dynamic parameters of gait in patients who underwent Ilizarov treatment for nonunion of the tibia. The experimental group consisted of 24 individuals treated with the Ilizarov method for nonunion of the tibia. The control group comprised 31 healthy individuals, matched for BMI, sex, and age. The dynamic gait parameters in patients and in the control group were measured with a Zebris pedobarographic platform. The treatment group and the control group showed statistically significant differences in terms of the following gait parameters: maximum force during braking nonoperated-limb (NOL), time maximum force during braking operated-limb (OL), time maximum force during braking NOL, maximum force during push-off NOL, time maximum force during push-off OL, and maximum force forefoot OL. Most of the evaluated gait parameters were bilaterally similar in patients group. The only significant differences between the operated and nonoperated limb were seen in terms of Time maximum force during push-off and Maximum force forefoot. The most pronounced abnormalities in dynamic gait parameters were observed in the forefoot (maximum force forefoot OL was 13.3% lower than in the control group, maximum force forefoot OL was 12.4% lower than in NOL). The patients treated with the Ilizarov method did not achieve a complete normalization of dynamic gait parameters, as their gait parameters did not equal those measured in the control group. The Ilizarov method for the treatment of tibial nonunion helps restore a symmetrical distribution of gait parameter values between the affected limb and the healthy limb. Patients continue to show the following abnormalities in their dynamic gait parameters after treatment: higher values maximum force during braking NOL, Time maximum force during braking OL, time maximum force during braking NOL, maximum force during push-off NOL, contact time forefoot NOL, contact time midfoot NOL, contact time heel NOL and smaller values of time maximum force during push-off OL.

Assessment of Lower Limb Load Distribution in Patients Treated with the Ilizarov Method for Tibial Nonunion

Background

Successful treatment of tibial nonunion should lead to a complete bone union, lack of pain, and pathological mobility of the lower extremity, as well as to the achievement of satisfactory joint mobility and muscle strength, which in turn improves its biomechanics. The objective of this study was to assess the load placed on the lower limbs in patients subjected to treatment with the Ilizarov method due to aseptic tibial nonunion.

Material/Methods

This research involved 24 participants (average age, 55 years). All were diagnosed with aseptic tibia nonunion and treated with the Ilizarov external fixator between 2000 and 2017. The control group was matched to the treated group in terms of sex and age. This study used pedobarography evaluation to assess lower limb load distribution.

Results

No differences were found in the distribution of the load over the entire foot or of the forefoot and hindfoot of the treated limb in comparison to the non-dominant limb of the controls, or in the healthy limb of the treated group compared to the dominant limb of the control group. Similarly, differences in load distribution between the operated and healthy limbs of the treated group were insignificant.

Conclusions

Patients subjected to treatment with the Ilizarov external fixator for aseptic tibial nonunion show symmetrical load distribution on both lower limbs following treatment, which does not differentiate them in this respect from healthy individuals. Treated patients presented with a symmetrical distribution of the load on the lower extremities over the entire foot surface, including the forefoot and hindfoot. Finally, the Ilizarov external fixator enables restoration of correct static biomechanics of the treated limbs over the period of aseptic tibial nonunion therapy.

A new criterion for assessing Ilizarov treatment outcomes in nonunion of the tibia

INTRODUCTION

The purpose of this study was to assess a population of patients with nonunion of the tibia treated with the Ilizarov method in terms of achieved union rates and maintained union rates, determination of re-fracture factors, with a subsequent comparison of our findings with those reported in the available literature.

MATERIALS AND METHODS

This study was a retrospective assessment of 102 patients with nonunion of the tibia treated with the Ilizarov method in the period 2008-2015. The assessed parameters were bone union achieved during treatment, duration of stabilization with an Ilizarov external fixator, and maintained bone union at the last follow-up visit.

RESULTS

The mean age at the start of treatment was 46.7 years (11-84 years). The mean follow-up period was 7 years (2-12 years). Bone union was achieved in all patients. The mean duration of Ilizarov stabilization in the study group was 7.9 months (2.8-20.7 months). The rate of union maintained at the last follow-up visit was 95.1%.

CONCLUSIONS

All patients in our study achieved bone union, which constitutes a better outcome than those reported on average in the literature (73.7-100%). The mean length of time which the Ilizarov external fixator was in place in our patients was 8.3 months, which is consistent with the data from literature. Infection, atrophic nonunion, nonunion in 1/3 distal of tibia, and close surgery technique are risk factors of re-fracture. None of the analyzed studies assessed the proportion of patients with maintained bone union. In our study, maintained bone union was observed in 95.1% of patients at the follow-up visit at least 2 years after treatment, which indicates excellent long-term treatment outcomes in nonunion of the tibia treated with the Ilizarov method.

The outcomes of Ilizarov treatment in aseptic nonunions of the tibia stratified by treatment strategies and surgical techniques

Nonunions of the tibia, particularly those located in the distal third of the bone, are relatively common in clinical practice. There is no gold standard for the treatment of nonunions of the tibia. The purpose of our study was to assess the results of treatment with the Ilizarov method in patients with aseptic nonunions of the tibia, depending on the employed treatment strategies and surgical techniques. A total of 75 patients with Ilizarov treatment of aseptic nonunions of the tibia were evaluated in the study. The patients's mean age at the beginning of treatment was 46 years. The mean follow-up period was 10 years and 11 months. The evaluated patients underwent either closed technique or open technique. The operators used one of two treatment strategies: neutral fixation without compression or continued compression. The following were assessed: rates of union, ASAMI bone scores, ASAMI functional scores, treatment time, complications, duration of hospital stay. Bone union was achieved in all of the 75 evaluated patients. The results of most analyses showed no significant differences in the assessed variables, except for the ASAMI functional scores, which were higher in the group of patients who underwent closed surgery (Me = 6.00 vs. Me = 4.00). We observed better ASAMI functional score outcomes in the patients who underwent closed fixation than in the open fixation group. The different surgical techniques and treatment strategies had no effect on the number of complications, rates of bone union, length of hospital stay, duration of Ilizarov treatment, or ASAMI bone scores. For managing nonunions of the tibia we recommend the technique of closed fixation without continued compression. The Ilizarov method in the treatment of nonunions of the tibia gives good outcomes.

Surgical treatment outcomes of the Ilizarov and internal osteosynthesis methods in posttraumatic pseudarthrosis of the tibia-a retrospective comparative analysis

Introduction

This study compared surgical treatment outcomes of the Ilizarov and internal osteosynthesis methods in posttraumatic pseudarthrosis of the tibia.

Material and methods

In a retrospective comparative study, 75 patients were treated with the Ilizarov technique for aseptic posttraumatic pseudarthrosis of the tibia in the period 2000–2016. We compared them with the 51 patients from the control group, treated for tibial bone union disturbances using internal osteosynthesis methods, i.e., internal-fixation plates and intramedullary nails. The study groups were compared in terms of the rates of union, time to union, and the baseline-to-postoperative difference in lower leg deformity.

Results

Union rate in the Ilizarov group was 100% and the control group was 51.92% (p < 0.001). The median time to union suggests that patients from the Ilizarov group needed a shorter time to achieve bone union (203.00 days vs. 271.00 days) (p = 0.091). The effect size in the Ilizarov group was larger both in terms of reducing both limb deformity and shortening (it is worth noting, however, that the Ilizarov treatment was used in patients with higher baseline values of both these parameters). We observed no significant difference in terms of time to union between the group of patients with at least one risk factor for disturbance in fracture healing and the group with no risk factors. The following risk factors were considered: diabetes mellitus, corticosteroid therapy, smoking, alcohol dependence, and advanced lower-extremity vascular disease (p = 0.827).

Discussion

Our study demonstrated a high effectiveness of the Ilizarov method in the treatment of aseptic posttraumatic pseudarthroses of the tibia. The Ilizarov method seems to be worth considering in all cases where either the patient or the nature of injury is associated with additional risk factors and whenever there is a need for leg deformity correction or leg elongation.

Assessment of body balance of patients treated with the Ilizarov method for tibial nonunion

Purpose: The biomechanics of the musculoskeletal system in patients after tibial nonunion treatment using the Ilizarov method have not yet been fully explored. From the orthopaedic and patient point of view, after the treatment, an assessment should be carried out of the biomechanics of the musculoskeletal system. The aim of this study was to assess the body balance of patients treated with the Ilizarov method for tibial nonunion. Methods: The research group included 24 individuals with a mean age of 55 years, who were treated for aseptic tibial nonunion with the Ilizarov method. The control group was matched to the study group in terms of gender and age, and consisted of 32 subjects with a mean age of 50.5 years and no significant medical history. This study evaluated the balance of patients with the use of pedobarography. Results: In the control group, a statistically significantly shorter path of centre of gravity was observed. There were no statistical differences between the study and control groups for the field area of the centre of gravity. There were no statistical differences between the study and control groups for the minor axis length or major axis length of the centre of gravity. There was a relationship between the centre of pressure path length and the age of the participants in both the control group and the study group. Conclusions: Treatment of patients with tibial nonunion with the Ilizarov fixator achieves similar balance to healthy volunteers. In the pedobarographic evaluation, patients treated for tibial nonunion using the Ilizarov method had similar statics of the musculoskeletal system to healthy volunteers.

Ankle Arthrodesis with Simultaneous Lengthening of the Lower Limb Using the Ilizarov Fixator

BACKGROUND

Patients with advanced ankle arthrosis or joint deformities and co-existing lower limb shortening present a complex therapeutic problem. This paper presents the Ilizarov treatment as a comprehensive method of simultaneous ankle arthrodesis and equalisation of lower limb length in 18 patients.

MATERIAL AND METHODS

Eighteen patients with arthrosis, deformities or other conditions of the ankle joint and ipsila-teral lower limb shortening were treated with the Ilizarov method. The patients were assessed with the Foot and Ankle Outcomes Questionnaire before the treatment and one year after Ilizarov Fixator removal.

RESULTS

The Ilizarov Fixator allows early weight-bearing of the operated limb, which is undoubtedly convenient for the patient. The mean treatment duration was 8.2 months (range 4-18 months). Lower limb lengthening was 4.1 cm on ave-rage (range 2.5-8.5 cm). Bone union was achieved in all cases. Radiological and clinical outcomes were satisfactory in all 18 cases. Prolonged regenerate calcification was recorded in 1 patient. Ten patients developed soft tissue pin-tract infec-tions and in 1 patient the Kirschner wire broke. According to the Foot and Ankle Outcomes Questionnaire, patients achiev-ed a notable improvement in daily functioning and quality of life.

CONCLUSIONS

1. The outcomes of a comprehensive treatment con-sisting of ankle arthrodesis and lower-leg leng-then-ing using the Ilizarov method confirm its effec-tiveness. 2. The Ilizarov Fixator allows early weight-bearing of the operated limb and evaluation at all treat-ment stages, creating an optimal biological envi-ron-ment for bone healing. 3. The patient recovers functionally to allow satis-fac-tory and pain-free functioning as well as re-sum-ption of daily responsibilities. The low inci-den-ce of complications adds to the attractiveness of the method.

Comminuted Fractures of the Distal Femur Treated with Ilizarov External Fixator. Case Series Study

BACKGROUND

Distal femoral fractures constitute a type of lower limb injuries that is rare and difficult to treat. Despite advances in surgical technique and development of implants used for internal fixation of fracture fragments, the treatment continues to result in numerous complications. The Ilizarov External Fixator reduces the risk of complications and allows for bone union.

MATERIAL AND METHODS

Six men with distal femoral fractures resulting from multisite and multiorgan injuries were treated at the Department of Orthopaedics and Musculoskeletal Traumatology of the Medical Uni-versity of Warsaw between 2008 and 2016. Mean age of the patients was 42.6 years. Four of them were mana-ged with the Ilizarov method as a primary treatment and two wore the apparatus as a second-line treatment following unsuccessful plate osteosynthesis.

RESULTS

Mean treatment duration with the Ilizarov apparatus was 29 weeks. Bone union was achieved in all patients. After the treatment, the patients ambulated unassisted, without orthopaedic aids. All patients re-turned to work.

CONCLUSIONS

1. The Ilizarov method allows for efficient fixation of comminuted distal femoral fractures, in-clud-ing C2 and C3 intra-articular fractures (AO/ASIF classification). 2. The use of the Ilizarov apparatus re-duces soft tissue laceration, preserves blood supply to the bone fragments, and allows for easier skin care, which is particularly important in the case of open fractures. 3. Early rehabilitation with the patient fully loading the operated limb reduces muscle atrophy and stimulates bone union.

Stress Fractures of Tibia Treated with Ilizarov External Fixator

BACKGROUND

Stress fractures are the result of cyclic loading of the bone, which gradually becomes damaged. Most often they are treated by rest or plaster cast and, in rare cases, by internal fixation. There is little published data on initial reposition followed by stabilization with the Ilizarov apparatus in such fractures.

MATERIAL AND METHODS

Six patients were treated with an external fixator according to the Ilizarov method for a stress fracture of the tibia between 2007 and 2015. Three patients were initially treated conservatively. Due to increasing tibial deformation, they were qualified for surgical treatment with external stabilization. In the other patients, surgery was the first-line treatment. All patients demonstrated risk factors for a stress fracture. After the surgery, they fully loaded the operated limb.

RESULTS

No patient developed malunion, nonunion, infection or venous thrombosis. The average time from the first operation to the removal of the external fixator was 19 weeks. Radiographic and clinical outcomes were satisfactory in all patients.

CONCLUSION

1. The Ilizarov method allows for successful stabilization of stress fractures of the tibia. 2. It may be a good alternative to internal stabilization, especially in patients with multiple comorbidities which affect bone quality and may impair soft tissue healing.

Atypical Fractures of the Femur Associated with Chronic Treatment with Bisphosphonates

BACKGROUND

The problem of atypical fractures, such as subtrochanteric or diaphyseal femoral fractures, associated with long-term treatment with bisphosphonates (BPs) has recently been given increasingly more attention. These fractures develop as stress fractures and are characterised by diaphyseal cortical thickening and a transverse or slightly oblique fracture line. The use of bisphosphonates has been documented to reduce the risk of osteoporotic fractures. However, an increasing number of papers verify the safety and benefits of the administration of these drugs over more than 3-5 years.

MATERIAL AND METHODS

This paper presents 13 cases of atypical femoral fractures in 11 patients of the Department of Orthopaedics and Traumatology of the Musculoskeletal System of the Warsaw Medical University.

RESULTS

All patients had been taking BPs for a mean period of over 13 years (between 2 and 25 years) before the fracture.

CONCLUSIONS

1. The authors stress that these fractures differ from "classic" osteoporotic fractures. 2. The authors indicate surgical treatment of these fractures (even incomplete ones) as a method of choice. 3. The authors suggest that the need for further BP therapy should be assessed after 3-5 years of treatment.

Open Trimalleolar Fractures Treated with Ilizarov External Fixator

BACKGROUND

Open trimalleolar fractures are some of the most severe fractures of the ankle joint region and some of the most difficult in trauma surgery. Repositioning with internal fixation is the most common surgical treatment method. There is little published data on primary repositioning and external fixation.

MATERIAL AND METHODS

Five patients with open trimalleolar were fitted with Ilizarov external fixators in single-stage procedures.

RESULTS

Full weight bearing was possible following surgical treatment in all five patients. None of the patients developed malunion, infections or vein thrombosis. For all patients, the Ilizarov apparatus was remodelled after six weeks to allow movement in the ankle. Three patients developed posttraumatic arthrosis requiring joint fusion. Arthrodesis was performed in two patients, and another patient will require it in the future. None of the patients developed any inflammatory complications. The mean duration of treatment with an external fixator was 11.6 weeks (range: 9-15 weeks). Radiological and clinical outcomes were satisfactory in all patients.

CONCLUSIONS

The Ilizarov method allows for early and definitive treatment of open trimalleolar fractures with a low risk of complications and a good clinical outcome.

Bilateral fatigue fractures of the bones of both crura in a patient with a history of abuse of alcohol and psychoactive substances treated with Ilizarov external fixator apparatus

BACKGROUND

Fatigue (slow) fractures are a result of cyclic burden on the affected bones. At the same time, regeneration processes are disturbed or appropriate mechanical environment to promote healing is lacking. Fatigue fractures are classified into two types: stress fractures and deficiency fractures. The former occur as a result of excessive training in healthy individuals with normal bone structure, e.g. in sportsmen and soldiers. Deficiency-related fractures are most common in individuals with metabolic disorders that affect bone mineralization, such as osteomalacia or osteoporosis.

CASE REPORT

The article presents a case of a 37-year-old male with fatigue fractures within both crura. During the interview, the patient reported the abuse of alcohol and benzodiazepines and the history of using other psychoactive substances.

CONCLUSIONS

Fractures were treated using Ilizarov external fixator apparatus. Bone union was achieved after several months of external fixation.

Percutaneous thermoablation of osteoid osteoma--a case study

Osteoid osteoma has been traditionally treated by curettage and en bloc resection. These methods are now being replaced by low-invasive techniques. We present the description of a percutaneous thermoablation of a femoral neck osteoid osteoma performed under CT guidance in a 22-year-old female patient.

[Hemiarthroplasty for treatment of comminuted trochanteric fractures in elderly patients]

Successful operative stabilization of the comminuted, trochanteric fractures in elderly patients is problematic due to advanced osteoporosis and poor physical activity excluding the cooperation in the postoperative rehabilitation. Stable fixation with dynamic hip screw or gamma nail, or flexible Ender nailing requires relieve of load during forthcoming several postoperative weeks needed for bone union, that reduced their usefulness in elderly patients. The aim of study was to analyze the usefulness of the cemented hemiartrhoplasty for the treatment of patients with comminuted trochanteric fractures. We analyzed 18 patients (16 women and 2 men, aged 69- 93-years-old (mean 83.3 years) treated in our Department in 2007 with cemented hemiathroplasty due to comminuted trochanteric fractures. Patients were intensively rehabilitated bearing their body weights from 3rd-5th, and consequently discharged on 9th-12th postoperative day. Due to the possibility of almost immediate mobilization in the postoperative period, cemented hemiathroplasty could be a method of choice for the treatment of the comminuted trochanteric fractures in elderly patients.

The evaluation of social awareness of osteoporosis, based on the aimed questionnaire

BACKGROUND

Osteoporosis is the most common osteopathy. Osteoporosis is recognized by World Health Organization as a civilization disease. Still, the awareness of osteoporosis in polish society is unknown. The aim of the study is demographic evaluation of people who are interested in diagnosis and treatment of osteoporosis. Another aim is to analyze data such as age, sex, fracture occurrence, style of life of people who have phoned to Osteoporosis Information Telephone (OIT).

MATERIAL AND METHODS

The analysis was based on 501 individuals (446 women, 55 men). The evaluated parameters were age, sex, place of living, education, risk factor awareness, fracture occurrence and the source of knowledge about OIT. The auxiliary questions concerned previous diagnosis and treatment.

RESULTS

In 83,3 % of analyzed group the general information about osteoporosis was acquired from newspapers, 13,11% from books and folders, 3 % from radio programmes, 0,4 % from TV, and 0,19% from internet. 23,5% of people acquired information about OIT from magazines including weekly TV programme. 148 people (29,5%) were examined by densitometry. 57 people (11,3%) had a previous history of bone fractures.

CONCLUSIONS

Our study helps to evaluate the social awareness of osteoporosis in people interested in this problem. We hope that our results will help to rise social awareness of osteoporosis thanks to new medial advertising companies in the future and will become the base for others analyzes of osteoporosis.

[Comparison of the Ender's nailing and Dynamic Hip Screw (DHS) fixation in the treatment of trochanteric fractures in elderly patients]

The aim of this study was an evaluation which operative method of treatment: stabilisation with the Dynamic Hip Screw or with Ender's nails is less invasive procedure in elderly patients with trochanteric fractures. 100 consecutive patients with trochanteric fracture were enrolled into the study, of which 53 patients (49 women, 4 men; mean age 89 years) were stabilised intramedullarily with the use of Ender's nails and 47 patients (26 women, 21 men; mean age 76 years) were treated operatively with the use of Dynamic Hip Screw. The factors compared the mean length of hospital stay, the mean duration of the surgery, post-operative blood loss, early local and general complication rate and mortality in both groups. We took into account their general health and coexisting illnesses according to the American Society of Anesthesiologists (ASA) classification, type of fracture according to AO and Evan's classifications and the surgeon's experience. The mean duration of the surgery was 27 minutes longer in the case of DHS stabilisation. The complication rate was higher and the mean length of postoperative hospital stay was longer after Ender nailing. The mean blood loss: the drop in Red Blood Cells (RBC), Haematocrit (Ht) and the Mean Haemoglobin Concentration (Hb) was also higher in patients treated with the use of Ender nails. The mean rate of blood units that had to be transfused postoperatively was also higher in "Ender" group. The difference was statistically significant, especially in the group of patients treated as emergency procedure at the day of admission (p < 0.05). The operative treatment of trochanteric fractures in elderly patients with the use of DHS device showed to be a less invasive procedure in comparison to Ender nailing. In conclusion, the indications for this method of trochanteric fractures' treatment should be expanded, especially in the case of unstable fractures.

The application of spinal orthoses in the treatment of scoliosis

This article presents the most commonly used types of spinal orthoses, their effectiveness in the prevention of progression of scoliosis, and the impact of various factors on treatment outcome in patients qualified for conservative treatment. Spinal orthoses achieved the apex of their popularity in the 1960s, but in later years their role in the treatment of scoliosis has diminished. Nevertheless, the results of long-range observation of the outcome of conservative treatment with spinal orthoses have shown that this is the only treatment method other than surgery that can stop the progression of curvature of the spine.

The review of outcome measures in the shoulder surgery

The article contains the review of outcome measures frequently used in the shoulder surgery. The genesis, structure and scoring of each instrument has been presented. Underlying of advantages and disadvantages should help with selection of clinically useful measure.

[Evaluation of femoral neck fracture treatment with hemiarthroplasty in elderly patients]

The authors reviewed the medical records of 457 patients who underwent a hemiarthroplasty procedure for the treatment of displaced femoral neck fracture. The age of the patients ranged from 60 to 103 years (mean age: 83 years). Follow-up evaluation of 331 patients was done 4-114 months post-op (mean follow-up time 52 months). 19 patients (4.2%) died in hospital, 67 patients (14.6%) developed systemic conditions during hospitalisation. 12 months post-op the mortality rate was 15.7%. Mean survival was 36.5 months. According to the Merle d'Aubigne-Postel evaluation system there were 154 satisfactory results (75.9%). Cemented or uncemented implantation techniques had no influence on long term results. 94 patients (4.2%) achieved pre-injury mobility. The reoperation rate was 8.1%. Poor general conditions at admission that postponed surgery and impaired mobility were strong negative prognostic factors.

Influence of intraoperative using of recombinant tissue plasminogen activator on the development of cerebral angiospasm after subarachnoid haemorrhage in patients with ruptured intracranial aneurysms

For a few years conducted experimental studies and clinical trials set one's hopes on the role of the fibrynolytic treatment using recombinant tissue plasminogen activator (rt-PA) in preventing cerebral vasospasm. In our study the target population was 45 patients with ruptured saccular aneurysms causing severe SAH. In the group of 24 patients treatment consisted of a single intraoperative injection of 10 mg of rt-PA into the opened basal subarachnoid cisterns following aneurysm clipping. The patients underwent surgery with aneurysm clipping within 72 hours from subarachnoid haemorrhage in all patients. Control group of 21 patients underwent early operation after SAH and rt-PA was not given. All patients had significant basal cistern blood accumulation seen on CT scans preoperatively according to Fisher's grade III. Patients in our study were classified in clinical grade I and II according to classification of Hunt/Hess. Transcranial Doppler Daily examinations in postoperative course were performed in all patients. The postoperative results were evaluated according to Glasgow Outcome Scale. Postoperatively patients were evaluated by daily transcranial Doppler and serial CT scans. TCD demonstrated reduction in the development of vasospasm to a greater degree in the rt-PA treated group. Serial CT examinations demonstrated radical blood clot removal in all rt-PA treated patients. The postoperative results according to the Glasgow Outcome Scale in the rt-PA treated group were as follow: 22 patients were grades I and II, 2 patients were grade III. In the control group 13 patients were grades I and II, 6 patients were grade III, and 2 patients died. In the rt-PA treated group only one patient presented delayed ischemic deficit.

[Contribution to the microanatomy of the proximal part of the arteria centralis longa (Heubner's artery)]

The anterior communicating artery complex is one of the most frequent intracranial aneurysm sites. Pterional craniotomy is the usual way to expose this region. While exposing of the aneurysmal dome, the posterior part of the gyrus rectus is frequently resected. In this stage of the procedure and later during clipping of the aneurysm, the surgeon's manipulation is closely related to the proximal part of the Heubner's artery. This vessel feeds important structures in the region of the basal ganglia. The anatomy of the Heubner's artery was described by many authors. However the intraoperative identification of this artery is still not clear. Therefore we performed detailed microanatomical investigation of the proximal part of the Heubner's artery in 40 brain hemispheres. It was found that during resection of the posterior part of the gyrus rectus two arteries are exposed. The recurrent Heubner's artery runs posteriorly to the gyrus rectus. The second artery runs on the medial and inferior surface of gyrus rectus supplying cerebral cortex. This artery frequently originates from the A1/A2 junction or the proximal part of the A2 segment of the anterior cerebral artery. Because of it, this cortical artery is difficult to distinguish from the recurrent Heubner's artery. This artery can branch out from the recurrent Heubner's artery or the frontopolar artery. In conclusion, the greatest probability of the injury to the recurrent Heubner's artery may occur during resection of the posterior part of the gyrus rectus.