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PURPOSE OF THE STUDY The prevalence of nerve structure injuries accompanying pelvic and acetabular fractures is stated to be 5-25 %, with most frequent injuries to motor nerve structures associated with fractures of the posterior wall of the acetabulum. Prognostically worse outcomes of regeneration are documented mainly in iatrogenic, intraoperative injuries to nerve structures. This study aims to document the functional effect of muscle transfers restoring the movement of lower extremities with irreversible nerve lesion caused by the pelvic and acetabular fracture. MATERIAL AND METHODS A total of 18 patients with irreversible palsy of lower extremities in L4-S1 segments underwent a reconstruction surgery in the period 2006-2016, of whom 13 patients with the mean age of 42 (21-79) years arrived for a follow-up. The group included 10 patients with the loss of function of peroneal portion of the sciatic nerve, one patient sustained femoral nerve lesion and two patients suffered complete sciatic nerve lesion (both the peroneal and tibial portion). The patients were evaluated at the average follow-up of 77 (24-129) months after the reconstruction surgery. The average time interval from pelvic fracture to reconstruction by muscle transfer was 47 (18-151) months. Due to a wide spectrum of functional damage, the patients were evaluated in terms of the overall effect of the reconstruction surgery on the activities of daily living using the LEFS (The Lower Extremity Functional Scale). The surgical techniques used transposition of tensor fascie latae for femoral nerve lesion, transposition of tibialis posteriormuscle for palsy of the peroneal division of the sciatic nerve and tenodesis of tibialis anterior tendon and peroneus longustendon for the palsy of the peroneal and tibial portion of sciatic nerve. RESULTS The effect of movement restoration on daily living evaluated using the LEFS achieved 65 points (53-79) which is 85% of the average value of LEFS in healthy population. The transposition of active muscles tibialis posterior and tensor fasciae latae resulted in all the patients in active movement restoration. A loss of correction of foot position following the performed tenodesis of the paralysed tibialis anterior muscle was observed in one patient, with no significant impact on function. No infection complication was reported in the group. In 78% of patients the intervention was performed as day surgery. DISCUSSION There is a better prognosis for restoration in incomplete nerve lesion than in complete lesions and also in the loss of sensation than in the loss of motor function. The mini-invasive stabilisation of pelvic ring according to literature does not increase the risk of nerve lesions, while on the other hand a higher incidence of femoral nerve damage by INFIX fixator is documented. The type of muscle transfer is selected based on the availability of active muscles suitable for transposition and also with respect to functional requirements of the patient. CONCLUSIONS Irreversible palsy of lower extremity after the pelvic fracture is easily manageable as to the restoration of function. Surgical interventions using the preserved active muscles to restore the lost movement should be a component part of comprehensive surgical care for patients who sustained a pelvic fracture and should be performed centrally at a centre availing of comprehensive expertise. Key words: nerve lesion, tendon transfer, acetabulum, pelvis, fracture.

The aim of the study was to compare results of the Burton-Pellegrini trapeziectomy with ligamentoplasty using the flexor carpi radialis tendon with those of trapeziometacarpal joint replacement in the treatment of advanced rhizarthrosis.A group of 17 patients, 15 men and two women, underwent trapeziectomy with ligamentoplaty; in 12 of them, the dominant hand was involved. The trapeziometacarpal joint prosthesis Beznoska was implanted in 11 patients (10 men and one woman) with seven dominant and four non-dominant hands. All patients pre-operatively experienced pain during thumb movement and hand grip. They were examined before surgery and at 3, 6 and 12 months after it; the values obtained before and at 1 year after surgery were compared. The methods of evaluation included pain intensity assessed using the visual analogue scale (VAS), the Kapandji thumb opposition test and the disabilities of the arm, shoulder and hand (DASH) score (total DASH score and its thumb-targeted module).In the group treated by the Burton-Pellegrini procedure, the average pre- and post-operative Kapandji scores were 6.4 and 8.9, respectively. The average VAS scores were 5/10 pre-operatively and 1/10 post-operatively. The average values for the total pre- and post-operative DASH scores were 58 and 19 points, respectively. The DASH score in a thumb-targeted module assessing basal joint-loading in the thumb was 63 points before and 21 points after surgery. In the patients with total joint replacement, the average pre- and post-operative values were as follows: Kapandji score, 7.4 and 9.8; VAS score, 5/10 and 1/10; total DASH score, 56 and 7 points; thumb module DASH score, 60 and 11 points. Two serious complications were recorded, an infection in resection interposition arthroplasty and a trauma associated with total joint replacement loosening. Four patients showed transient paresthesia.Several methods for surgical treatment of rhizarthrosis are available today. Arthrodesis is still a widely used procedure although it inhibits thumb movements. Resection arthroplasty provides sufficient pain-free thumb motion, but radial shortening and a loss of grip strength are its disadvantages. Resection interposition arthroplasty results in sufficient painless motion. Tendon interposition provides enough stability for the thumb and for sufficient grip and pinch strength. The disadvantages of this method include a potential for failure of the suspensory tendon during over exercising or a weakened attachment of the autologous tendon to the bone and thus a risk of rupture. Total joint replacement respects the thumb anatomy, preserves the articular capsule and fibrous structures during conservative resection of joint surfaces and keeps the biomechanics of the basal joint of the thumb. It combines advantages of the other surgery procedures, by allowing for a painless range of motion in the joint and vital pinching and gripping abilities, while avoiding their disadvantages such as movement restriction and loss of grip strength. However, the technique may still bear any of the risks associated with foreign material implantation (dislocation, replacement failure, infection, etc.).The two techniques present valuable contributions to the treatment of advanced rhizarthrosis. In our patients, better outcomes are shown in trapeziometacarpal joint replacement though, in comparison with resection interposition arthroplasty, the indication criteria for this surgery are limited by factors such as the height of the trapezium bone and bone quality necessary for good osseointegration.

Two tendons, i.e., the extensor indicis proprius (EIP) and the extensor carpi radialis longus (ECRL), are commonly used to reconstruct the function of a ruptured extensor pollicis longus (EPL) tendon. We reviewed a group of patients with EPL ruptures treated by ECRL tendon transfer to the EPL tendon, which was the method of choice. The aim was to evaluate the results and to assess the effect of ECRL detachment on hand function.Twenty patients were treated surgically for a subcutaneous rupture of the EPL tendon between 2003 and 2007. Each patient was examined at 2 years after surgery. The range of motion (ROM) of both the injured and the contralateral hand was recorded and evaluated with a modified Geldmacher scoring system; a response to the DASH questionnaire was obtained. The mean follow-up was 24 months (19-31 months).For the ROM of the operated hand, the mean Total Active Motion (TAM) of 98.75 degrees (60-140, SD 22.74) was calculated. The mean extension lag at the interphalangeal (IP) joint was 5.42 degrees (0-25, SD 8.77) and the mean IP flexion was 65.8 degrees (40-80, SD 13.2). In order to evaluate body side differences, the ROM of the contralateral thumb was recorded. The values were as follows: mean TAM, 141.3 degrees (115-190, SD 20.43); mean IP extension lag, 0 degrees (0-0, SD 0); mean IP flexion, 68.8 degrees (50-80, SD 9.6).The extension lag at the IP joint was detected in both the operated and the contralateral hands. The patients examined at a longer interval after surgery showed an increase in extension lag. This may have been caused by undesired adaptation of the donor muscle, the presence of adhesions or suture loosening.The results showed increased adaptation of thumb motion to the extension lag at the IP joint, which had a mild effect on the patient's hand function. The difference in wrist extension between the operated and the contralateral hand corresponded to the pre-operative condition.

Common peroneal nerve palsy is the commonest lower extremity peripheral paresis. The foot drop and inability or difficulty to move the ankle and toes dorsally and inability to perform foot pronation is a debilitating condition for the patient. Tendon transfer is a treatment option often used to restore the foot function after the peroneal palsy in cases when reinervation is not clinically satisfactory.The study group included 14 patients treated in the Trauma department of FNO either for common or deep peroneal nerve paresis, or for isolated lesion of the anterior tibial muscle. Active muscles, i.e.the posterior tibial muscle (13 patients) or long peroneal muscle (1 patient) were used for the movement restoration procedure. The tendons were anchored to the cuneiform bone.In all the patients, active foot extension was restored, with the average range of motion of 12.3 degrees (4-20) and with sufficient muscle strength. Based on the Stanmore score assessment, the subjects showed good results, reaching 87-100 points.The posterior tibial muscle tendon transfer, or peroneus longus muscle tendon transfer lead to restoration of active extension of the foot. The reconstruction procedure results in a minor restriction of the ankle range of motion. Considering the foot functionality, it is better to perform the transfer with a slight preload of the tendon, in order to achieve adequate postoperative ankle extension.

Injury to the spinal chord at the C5 level results in a severe handicap to the patient because of a loss of active motion of the wrist and hand. Selected surgical procedures can effectively restore active extension of the wrist and provide conditions for some vital pinching and gripping abilities. The deltoid muscle also has a potential for restoration of upper limb function, because its posterior portion can be used to restore elbow extension. The aim of this clinical retrospective study was to describe and evaluate the techniques used to improve the quality of life in patients with spinal chord lesions at the C5 level.The group studied consisted of 15 patients (3 women and 12 men; average age, 34 years) with a spinal chord lesion at the C5 segment who had zero wrist extension or in whom wrist extensor muscle force was equal to the third degree of muscle strength or less. The procedures to restore active extension of the wrist involved the radiobrachialis muscle, the reconstruction of elbow extension was activated by the posterior portion of the deltoid muscle, and a fixed supination posture of the forearm was corrected by elongating the distal tendon of the biceps muscle which was derotated and attached to the proximal radius. The interval between injury and reconstructive surgery was 36 months on the average.The reconstructive surgery described resulted in restoration of hand and wrist function with sufficient muscle strength in all patients, which had a favourable effect on many aspects of their daily lives. The average values of muscle strength were 4.1° (3° to 5°). for wrist extension and 3.3° (2° to 4°) for elbow extension. Key-pinch force was on average 1.2 kg (0.2 to 2.1). A failure of thumb carpometacarpal arthrodesis was the most frequent complication and occurred in two patients. On clinical evaluation, all patients reported satisfaction with the restored function of their upper extremities and expressed their willingness to undergo the same procedure again.Reconstructive surgery of the upper extremity in tetraplegic patients has been performed with success in several countries, namely USA and Sweden, for many years. Since 2003 the results in the Czech Republic have also shown positive effects of reconstructive procedures on better quality of life in patients with cervical spinal chord injury at the lower levels, in whom the goal is to restore vital pinching and gripping abilities. A good outcome of surgical treatment requires good quality post-operative care provided by a team of physical therapists fully informed of the reconstructive procedures involved.A restored function of the upper extremity in the patients with spinal chord injury at the C level plays a decisive role in the whole spectrum of the patient's daily activities, such as dressing, communication, etc., and thus improves their self- care. The restoration of active elbow extension has a positive effect on the patient's mobility.

Latissimus dorsi transfer is a relatively complicated procedure subsequently requiring an active, long-term physical therapy. The surgeon's performance and a patient's effort are therefore of worth consideration. However, sutures of massive rotator cuff tears do not always produce good results. The aim of the study is to evaluate the role of latissimus dorsi transfer in the treatment of these shoulder pathologies.A total of 21 patients were evaluated. Their age at the time of surgery ranged from 48 to 63 years, with an average of 54.8 years. A minimum follow-up was three years, the average was 47 months (70-36 months). The indication for surgery included a massive rotator cuff tear, without symptoms of arthropathy and with normal subscapularis muscle function, which had been resistant to conservative treatment for 6 months at least. In 13 patients, transfer was performed after previous surgery on the rotator cuff.The procedure was carried out in a lateral position. The latissimus dorsi tendon was cut off just at its attachment to the humerus, the muscle was mobilised and the musculo-tendinous flap was released to reach the proximal operative wound and to cover the greater tuberosity of the proximal humerus. A shoulder abduction splint was used to immobilise the upper extremity for 6 weeks. Active and supervised individual physical therapy followed.Subjective evaluation was excellent in 10, good in 9, and poor in 2 patients. The average Constant-Murley score improved by 32.25 points as compared before surgery (from 38.50 to 70.75). The evaluation of active arm elevation in the frontal plane showed improvement in 16 patients (77 %) by 40 degrees on average, no change in five patients (23%), and no deterioration in any of the patients. Active external rotation with the arm held at the body side improved by 14 degrees on average. Progression of radiographic changes indicating arthropathy was recorded in five patients.Post-operative haematoma, developed three patients it was treated by needle aspiration in one, and drainage in two patients.The results presented here are in agreement with those reported in the international literature.The method of latissimus dorsi transfer shows poorer outcomes after previous attempts to suture of massive rotator cuff tears. In patients with a restricted range of motion before surgery, the post-operative shoulder motion achieved at the final evaluation is also lower.When based on a correct indication, latissimus dorsi transfer with an uncomplicated post-operative therapy will result in improvement of shoulder function and pain relief, and it is therefore justified. One of the prerequisites for good results is the initial patient's consent with a supervised, active and long-term post-operative physical therapy. The transfer itself is a demanding surgical procedure associated with several risks and it should therefore be performed by an experienced and competent surgeon with a deep knowledge of shoulder girdle anatomy.

Cerebral palsy is a serious world-wide problem; its incidence ranges from one to five per thousand of live-born children and is much influenced by gestation age and birth weight. In orthopaedic treatment of lower extremity motor disorders, one of the options for contracture or deformity elimination and for stiff leg gait improvement is rectus femoris tendon transfer. The aim of this study was to evaluate the results of this surgical technique.In the period from 1993 to 2003, 15 patients of both sexes, aged 5 to 13 years, were treated by the Gage method (22 operations) in our department. The indication for surgery was excessive spasticity of the femoral quadriceps muscle at the beginning of the swing phase of the gait cycle. The spastic syndromes included quadruparesis in seven patients, diparesis in seven patients and hemiparesis in one patient. After surgery, a circular plaster cast was applied for 4 weeks. Following immobilization, all patients received a short-term inpatient and long-term outpatient physical therapy. They were followed- up for 1 to 10 years and gait improvement was analyzed on the basis of three criteria in the swing phase: quality of the initial swing, frequency of tripping over the toe and the degree of knee flexion. The results were evaluated on a 1-to-4 scale (best to worst), categorizing the patients into four groups.The first, second and third categories included eight, five and two patients, respectively. None of the patients was placed in the fourth category. Surgery did not increase the initial range of inner hip rotation. Patients with milder forms of cerebral palsy (diparesis and hemiparesis) achieved better results.Our results showed that distal rectus femoris tendon transfer significantly improved knee flexion during the swing phase of the gait cycle. The prerequisite for a good outcome of surgery is a pre-operative potential for passive knee extension and stable function of the other lower extremity joints. Key words: cerebral palsy, surgical treatment, quadriceps tendon transfer.

The authors deal with surgical treatment of osteoarthritis of carpometacarpal joint of the thumb. They present results of three different techniques of interposition arthroplasty.Thirteen operations were carried out in the period of 1997-1999 in 12 patients (9 women and 3 men). In seven cases the dominant right hand was affected, in 4 cases the left hand was involved. The average age was 56 years (range, 48-91 years). In none of the patients any extreme activity of the operated on hand is expected in future.The surgical treatment consists in resection of damaged articular surface and interposition of soft tissue. In Nalebuff-Millender operation the graft is taken from the tendon of m. palmaris longus (PL). In the operation after Burton and Pellegrini the graft is formed by the longitudinal half of the tendon of m. flexor carpi radialis (FCR). The tendon is fixed to the Ist metacarpal by its pulling through a channel drilled in the base of the metacarpal. In Wulle operation the interposition tissue is harvested from the longitudinal half of tendon of m. abductor pollicis longus (APL) wound around FCR tendon. During the operation after Nalebuff-Millender we performed in the first 3 patients partial resection of trapezium, in all other cases total resection of trapezium. The thumb was fixed for three weeks with a subsequent physiotherapy. The results were evaluated according to a three-grade classification--excellent, good, poor (fully functional, partially functional and non-functional hand) according to tenderness, strength of grip and abduction range of the thumb.In 7 patients after Nalebuff-Millender operation the result was twice excellent and five times good. Among 5 good results were three patients with partial resection of trapezium. The condition was stabilized after 4-9 months. In patients after Burton and Pellegrini operation we achieved an excellent result in 4 cases and in 2 cases a good result. Recovery lasted for 3-6 months. In the female patient after Wulle operation the result is good, stabilized after 4 months.The authors make a mutual comparison of the results of individual applied procedures. Burton and Pellegrini procedure provides good results which are certainly enhanced by stabilization of base I by MT tendon pulled through the channel. Better results were achieved by using total resection of trapezium. The authors compare the interposition arthroplasty with other surgical procedures which they present in a short overview (arthrodesis, arthroplasty, osteotomy).Interposition arthroplasty is a suitable solution of osteoarthritis of carpometacarpal joint after the failure of conservative treatment in patients in whom no extreme activity of the affected hand is expected. Burton-Pellegrini procedure is technically more demanding, however, it provides the best results and the fastest recovery. Total resection of trapezium proved efficient as it contributes to a better orientation during operation and to good results.

Habitual luxation of the patella is as a rule considered an indication for a stabilizing operation. As regards approaches to the surgical solution of this problem we can differentiate between operations of the proximal part of the extension apparatus, i.e. operations of the soft tissues and operations on the distal part of the extension apparatus, above all plastic operations and transposition of the insertion of the lig. patellae on the tuberositas tibiae. In the present paper the authors submit their own modification of transposition of the tuberositas tibiae, suitable in severe affections after closure of the epiphyseal space. The described technique makes it possible to anchor the transposed tuberosity by an autofixation mechanism without using osteosynthetic material. The basis of the method is removal of a small block of bone with the insertion of the lig. patellae, size 2 x 4 cm, and its insertion beneath the corticalis at a site selected in advance into an opening 2 x 2 cm with subsequent covering and stitching of the periosteum. The extent of medialization depends on testing during flexion and extension. To prevent the development of the syndrome of patellar hyperpression it is important to avoid excessive distalization of the insertion of the ligament. During the preoperative period it is recommended to apply a plaster splint for two weeks, followed by functional rehabilitation and gradual burdening; complete burdening should be attained by the third month after operation. The surgical technique was tested in a group of 16 patients at the First Orthopaedic Clinic and with regard to its simplicity and reliability the method can be recommended.