[Total hip arthroplasty after femoral neck fracture in patients with acquired neurological deficit]. / Implantace totální endoprotézy kycelního kloubu pro zlomeninu krcku femuru u pacientu se získaným neurologickým deficitem.

PURPOSE OF THE STUDY: To evaluate the outcome of total hip arthroplasty (THA) performed for femoral neck fracture in patients with a paralytic hip. MATERIAL AND METHODS: Between 1997 and 2004, total hip arthroplasty was performed in 301 patients with a medio-cervical or sub-capital fracture of the femoral neck. In 17 of them there was also neurological deficit due to a stroke in 11, multiple sclerosis in four, and conditions following cranial injury in two. The degree of neurological deficit was assessed pre-operatively and its effect on the outcome was evaluated, in particular that on the overall results of THA, implant stability and post-operative complications. RESULTS: At an average follow-up of 61 months, 15 out of the 17 patients were examined, because one died and one failed to turn up. Four patients had a dislocation and two had a post-operative infection and para-articular ossification. Seven patients could walk with the use of walking aids, eight had serious difficulties or were in a wheelchair. DISCUSSION: The incidence of post-operative complications is much more frequent in patients with neurological deficit than in the other THA patients. Some possibilities to improve the prospects of neurologically affected patients are discussed, such as fall prevention, rational drug therapy, etc. Options for operative techniques and implant use are also dealt with as well as post-operative care to prevent complications. CONCLUSIONS: In patients with medio-cervical or sub-capital fracture of the femoral neck and co-existent neurological deficit, operative considerations should also involve further surgical techniques, such as osteosynthesis or Girdlestone arthroplasty. To achieve a good outcome it is necessary to choose a correct operative procedure with an optimal combination of acetabular and femoral components, to perform additional periarticular surgery and to indicate post-operative comprehensive rehabilitation.

[Arthrodesis of the carpometacarpal joint of the thumb]. / Artrodéza karpometakarpálního kloubu palce ruky.

PURPOSE OF THE STUDY: Arthrodesis of the carpometacarpal (CMC) joint of the thumb is an option for treatment of degenerative and post-traumatic conditions affecting the CMC thumb joint. This procedure is indicated most frequently in patients with primary or secondary stage III rhizarthritis (by the Eaton classification of basal joint arthritis) of idiopathic, rheumatic or post-traumatic etiology. Patients with multidirectional CMC instability, usually traumatic in origin, undergo this surgery only occasionally. In our institution, the treatment is based on the Carroll technique. MATERIAL AND METHODS: Between 1990 and 2005 a total of 14 arthrodeses of the CMC joint of the thumb were performed in 12 patients. The Carroll technique used in all cases involved a conical shaping of the first metacarpal base and a corresponding shaping of the trapezium articular surface, their subsequent set-up and fixation with Kirschner's wires. The patients were assessed for the presence of pain, changes in mobility and muscle strength before and after surgery. The comprehensive evaluation of the whole group was carried out by means of the Cooney score. RESULTS: Arthrodesis resulted in complete union of the CMC joint of the thumb in all cases. The patients were followed up for 5 years on average. The initial painful hand grip subsided in most of them. The initial restriction of motion remained, but was painless in almost all cases. However, broad grip strength improved on average by 35 %. The comprehensive Cooney score showed 64 % of excellent and very good results. DISCUSSION: All characteristics of the patient group and the results achieved by this technique, including the Cooney score evaluation, are discussed. It is concluded that this technique is indicated particularly in middle-aged male patients with stage III rhizarthritis (Eaton classification) who do hard manual work, and in whom rhizarthritis of the other thumb joints can be excluded. Also, unstable CMC joints are indicated for this treatment. The resulting position of arthrodesis and methods of joint fixation are discussed. Different methods of osteosynthesis and their advantages are described. From a comparison with the relevant literature results it appears that the absence of postoperative pseudoarthrosis, a marked reduction of grip pain, improvement of grip strength and the values of Cooney score are encouraging results of arthrodesis for the CMC thumb joint performed by the Carroll method. CONCLUSIONS: It is concluded that the Carroll arthrodesis is an effective technique which, if correctly indicated, alleviates pain, restores the axis of the thumb and, consequently, its stability necessary for thumb function in achieving a hand grip.

[Arthrodesis of interphalangeal joints by means of external frame fixation]. / Artrodéza drobných kloubu prstu ruky zevní rámovou fixací.

PURPOSE OF THE STUDY: The indications for arthrodesis of interphalangeal joints include pain, instability, deformity or irreparable damage to the relevant flexor or extensor tendon. The general principle of arthrodesis is to resect the affected joint ends in the flexion desired so that a highest possible surface of contact may be provided. Subsequently, retention by means of internal or external fixation is performed. The aim of this study is to evaluate our method of interphalangeal joint arthrodesis, using an external frame fixator, to present the results and to point out the advantages of this method, thus showing its applicability for relevant surgical indication. MATERIAL: Arthrodesis by external fixation was carried out in 37 patients. The group included 21 men and 16 women at an average age of 49.6 years (range, 30 to 67 years). The method was used in the patients who differed in the etiology of lesions of interphalangeal joints. Twenty-two patients had previously experienced purulent arthritis, six had post-traumatic arthritis and joint instability, five had rheumatoid arthritis, two had primary arthritis and two had an inveterate rupture of the extensor aponeurosis. METHODS: We used a simple frame fixator whose stability was based on two to four Kirschner's wires inserted and maintained in clamps on rods, 4 cm or 7.5 cm long, each having a double anti-clockwise thread that facilitates compression, distraction and correction in one plane. The surgical procedure was carried out under axillary block with the use of a tourniquet. It involved making an S-shaped incision dorsally, severing the extensor apparatus, resecting articular surfaces in the desired flexion position, inserting parallel wires and fixing them in clamps on rods, achieving compression, checking the position of articular surfaces and suturing. Included in the group assessment were the gender and age of the patients, etiology of articular disease, number of the digits and joints affected, limb laterality, wound healing, stability of fixation, maintenance of a correct arthrodesis position and signs of healing on X-ray images. Time required for bony union and the shortening of the digit due to surgery were also included in the evaluation. RESULTS: The 35 followed-up patients showed healing of the wound and arthrodesis, with firm bony union being achieved at an average of 6.7 weeks. In one patient after removal of the fixator, septic pseudoarthrosis developed at the site of the resected distal interphalangeal joint. Another patient developed ischemia of the distal phalanx of the thumb treated, which required release and subsequent removal of the external fixator, with vasodilatation therapy. After a prolonged topical therapy, painless fibrous ankylosis developed in that interphalangeal joint and the thumb was salvaged. DISCUSSION: The aim of arthrodesis is to achieve firm and painless bony union in a correct functional position at a reasonable time. Arthrodesis in our patients healed at an average time of 6.7 weeks. The high effectivity of the compression technique in achieving firm bony fusion is the factor emphasized in the literature, particularly in situations where there is a reduced contact surface, poor coverage by soft tissue, infection or the presence of a systemic disease, such as rheumatoid arthritis or diabetes mellitus. This all is in agreement with the results of this study. CONCLUSIONS: This study shows advantages of the compression technique of arthrodesis by means of external frame fixation based on insertion of wires beyond the site of inflammation. Compression and stability result in rapid osseous union, immobilization in plaster cast is not necessary, free joints of the hand can be exercised, the fixator is removed in an outpatient department and the minimal presence of metal material does not interfere with good healing of soft tissues. Therefore this method has all merits to be used for surgery in a terrain affected by rheumatic, inflammatory or potentially inflammatory lesions.

[Results of Menon's arthroplasty in basal joint osteoarthritis]. / Výsledky artroplastiky podle Menona u rizartrózy.

PURPOSE OF THE STUDY: Osteoarthritis of the basal joints is a frequent degenerative disease. The wide range of arthritic lesions of the first carpal metacarpal joint should be treated by targeted surgical techniques. These methods, including arthroplasty, arthrodesis and alloplasty, for use in relevant indications are available in the Department of Orthopedics at the Medical Faculty Teaching Hospital in Hradec Králové. In this study, the results of Menon's arthroplasty modified by the authors are evaluated. MATERIAL AND METHODS: The interpositional arthroplasty, first used and published by Menon in 1955, was introduced in January 2002 by the authors in the treatment of arthritic lesions, classified as stage III disease by the Eaton radiological rating system, in middle-aged, manually working women. The procedure consists of resection of the trapezium articular surface affected by osteoarthritis, tendon interposition, and the reconstruction of the articular capsule soft tissues using tenodesis of the abductor pollicis muscle tendons. Sixteen female patients were treated by our modified technique. The post-operative outcome of arthroplasty was evaluated by comparison of both hands' efficiency, with the use of the Cooney score system. RESULTS: At 2 years of follow-up, in 14 treated hands there was pain relief, improved mobility and an increase in grip strength; excellent and very good outcomes, as evaluated by the Cooney score, were achieved in 80% of the operated hands. In one patient, conversion of Menon's arthroplasty to an alloplasty with a Rubena prosthesis had to be carried out due to persistent complaints. DISCUSSION: The authors evaluate the surgical procedure used and present the reasons for their modification of the Menon's technique with the use of the long palmar muscle tendon. The choice of operative techniques for specific indications, as available in the authors' department, is discussed. The outcomes reported in this study are compared with the results published in the foreign literature. Complications and risks of this treatment are mentioned. The advantage of a partial over a total trapeziectomy is emphasized. CONCLUSIONS: The early outcomes of Menon's arthroplasty, which was indicated in manually working, middle-age female patients with stage III basal-joint osteoarthritis, are satisfactory. This precisely indicated and correctly performed technique has so far fulfilled the authors' expectations.

[Personal experience with the basal wedge closed osteotomy of the first metatarsus in hallux valgus]. / Nase zkusenosti s bazální sikmou uzavrenou osteotomií I. metatarzu u hallux valgus.

PURPOSE OF THE STUDY: The authors present their philosophy of the surgical treatment of metatarsus primus varus by oblique basal closed osteotomy of 1st metatarsal, evaluate and generalize the results achieved also with regard to the age of patients. MATERIAL: The evaluation covers a group of patients operated on for the mentioned static defect since 1995 with a minimal interval of 12 months after the surgery. From this general group a subgroup has been subsequently singled out of children and adolescents up to the age of 18. The general group included 24 patients in which 31 surgeries were performed. The subgroup of children and adolescents comprised 10 patients in which the surgery was performed in 12 feet. METHODS: Monitored in both group was age, sex, osteotomy laterality, the presence of distal operation. Post-operative monitoring focussed on the following data: the time interval after the operation, subjective satisfaction, range of motion of Ist metatarsophalangeal joint, the incidence of complications. Evaluation covered post-operative correction of individual angles and the shortening of Ist metatarsal by comparison of pre- and post-operative radiograph. RESULTS: Evaluated in the whole group were 22 patients, in the group of children and adolescents 8 patients, with average time interval of 3 years after the operation. On the basis of the surgery average correction of intermetatarsal angle by 10.5 degrees was achieved in both groups, average correction of valgosity by 18 degrees in the basic group and by 10 degrees in the group of adolescents. DISCUSSION: The results are evaluated globally on the basis of specialized literature. The authors present their philosophy of the solution of the issues of metatarsus primus varus as a static defect by different surgical techniques, formulate a clear strategy of the use of distal surgery and discuss its efficiency in relation to the patient's age. CONCLUSION: Oblique basal closed osteotomy of Ist metatarsal within a comprehensive solution of the static defect of hallux valgus is recommended to the broad orthopaedic public as a surgery which in view of the authors can bring good results in children and adolescents. In adults they recommend to indicate this surgery in the mentioned cases in combination with a distal operation.

[Personal experience with treatment of pseudoarthrosis of the navicular bone of the carpus]. / Nase zkusenosti s lécbou pakloubu navikulárnni kosti karpu.

PURPOSE OF THE STUDY: A displaced fracture of the scaphoid bone of the hand may result, according to some authors, in the development of pseudoarthrosis in 10 to 50% of the patients and aseptic necrosis of the proximal bone fragment may develop in 30 to 50% of them. Them surgical treatment of scaphoid bone pseudoarthrosis has recently made great progress and the results achieved by the authors in this field are reported in this paper. These results are discussed in light of the results and opinions presented at the 8th Congress of the World Federation for Hand Surgery held in Istambul in June 2001 and are compared with the achievements made by other authors and published in the most recent relevant literature. MATERIAL AND METHODS: At our department, two standard surgical procedures are available to treat pseudoarthrosis of the scaphoid bone that is free from deforming changes due to arthritis. One approach involves resection of the pseudoarthrosis and subsequent cancellous bone grafting, using osseous tissue from the styloid process of the radius and osteosynthesis with a navicular screw. The other procedure is a modified arthroplasty according to Dwyer and is applied to cases which show aseptic necrosis of the proximal bone fragment. The follow-up study of the patients treated between 1997 and 2001 included patients in whom the follow-up period was at least six months. The results were evaluated according to Pechlaner's rating system. RESULTS: A total of 26 patients were examined; the average time from the operation was 17 months. Of them, 24 underwent the primary treatment that involved resection of pseudoarthrosis followed by cancellous bone grafting and osteosynthesis with a screw. This primary operation healed the condition in 17 patients, but the rest of them had to undergo one or two more surgical procedures. Evaluation by Pechlaner's scoring system showed 14 excellent, five good, two sufficient and three poor outcomes of the treatment. DISCUSSION: The pseudoarthrosis of the scaphoid bone, its diagnosis, surgical treatment and different operative techniques are discussed. Special attention is paid to the use of either vascularized rotatory grafts or pedicled vascularized grafts. The follow-up results are compared with those of other orthopedic clinics and hospitals. Various aspects of further improvement in the treatment of this disease under current conditions are considered. CONCLUSIONS: The results achieved in the treatment of pseudoarthrosis of the scaphoid bone of the hand are comparable with those of other orthopedic hospitals. Adoption of more recent types of osteosyntheses in considered. For a potential introduction of the vascularized graft technique, the use of a vascularized graft collected from the dorsum of the distal radius is suggested. This method is also regarded as suitable for treatment of certain cases of aseptic necrosis of the lunate bone.

[Posttraumatic avascular necrosis of the scaphoid bone, our arthroplasty modification after dwayer.]. / Posttraumatická avaskulární nekróza proximální cásti navikulární kosti karpu, nase modifikace artroplastiky podle Dwayera.

In the introduction the authors present this unit from the viewpoint of its incidence. With regard to its etiology and pathoanatomy its development is compared to the aseptic necrosis of femoral head. A scheme illustrates the basic surgical solutions of this condition. The modified method after Dwayer was performed at the authors' department in three cases since 1995. The authors emphasize the principle not to remove a greater portion of the bone than one quarter of the total size. Discussion deals with the Preiser disease which represents an idiopathic aseptic necrosis of the scaphoid bone. Apart from the outcomes of standard surgical methods the authors describe also their experience with new, non-traditional techniques of the treatment of posttraumatic aseptic necrosis of the proximal part of the scaphoid bone. Key words: Aseptic necrosis of the proximal fragment of the scaphoid bone, resection arthroplasty.

[Surgical treatment of the dislocation of acromioclavicular joint, therapeutic results in acute and inveterate injuries.]. / Operacní lécba luxace akromioklavikulárního kloubu, terapeutické výsledky u akutních a inveterovaných úrazu

The authors present an outline of the current literary sources which broaden the view of the issues of acromioclavicular dislocation. They compare the results of surgical treatment in acute and inveterate iniuries and state that the surgical treatment in indicated cases of acute injuries brings better results as compared to conservative treatment and that the results of surgical treatment of inveterate cases are markedly better than pre-operation findings, however, worse in comparison with the surgical treatment of acute dislocation. Surgical procedure is determined for the incidence of calcification in the injured coracoclavicular ligament in inveterate dislocations. Key words: acromioclavicular dislocation, acute and inveterate dislocation, calcification of injured ligament.

[Treatment of the rupture of ulnar collateral ligament of metacarpophalangeal ligament of the thumb, surgical treatment of chronic instability.]. / Lécba ruptury ulnárního kolaterálního vazu metakarpofalangeálního kloubu palce ruky, operacní resení chronické nestability.

The author presents possible solutions of both acute rupture and chronic lesion of metacarpophalangeal ligament of the thumb of the hand. Chronic post-trauma instability is indicated by the author for modified reconstruction of the ligament after Strandell. Since 1991 such operation was performed in 12 patients who were followed with an average interval 3 years after the surgery. The mentioned evaluation scheme showed 8 excellent and 4 good results of the operation. Key words: metacarpophalangeal joint, ulnar collateral ligament, reconstruction of ligament rupture.

[Development and Implantation of the Endoprosthesis Rubena CMC in Rhizarthritis.]. / Vývoj a implantace endoprotézy Rubena CMC u rizartrózy.

The author describes the development and production of a new endoprosthesis, Rubena CMC, which is used by the author to deal with advanced stages of rhizarthritis. He mentions in detail the surgical and postoperative procedure. In the discussion he explains in detail problems associated with size and shape of the product and advocates special stages of the surgical procedure. Key words: rhizarthritis, endoprosthesis Rubena CMC, implantation.

[Extraabdominal Desmoid (12-Year Follow-up of a Group).]. / Extraabdominální desmoid (sestava za dobu 12 let).

The authors present a group of three female patients treated on account of an extraabdominal desmoid during the last 12 years at the Orthopaedic Clinic of the Faculty Hospital in Hradec Králové. The age of one patient was 27 years, the others were 30 years old. They reported mild pain of the soft tissue tumour on touch or during active movement. The tumour was in one instance in the area of the back and twice in the area of the shoulder. Preoperative examinations include X-ray pictures in the basic projections and ultrasound. It is useful to supplement them by CT examination which gives more detailed information on the relationship of the tumour and surrounding tissues. Most important for establishment of the diagnosis is histological examination where in particular in proliferating varieties the differentiation from fibrosarcoma is difficult. In all instances treatment was by surgery, i. e. wide excision of the tumour into sound tissue. This procedure alone was sufficient in patient no. 2. The marked tendency of local relapses of the tumour called in the remaining two patients for repeated reoperations, in patient no. 3 after several relapses actinotherapy was used. In the discussion the authors mention hormonal influences and injuries which according to data in the literature can play a part in the etiology of this relatively rare disease affecting mainly women in fertile age. The long-term prognosis is very favourable and with advancing age relapses are less frequent. Key words: extraabdominal desmoid, diagnosis, treatment.

[Our approach to metacarpophalangeal joints of the long fingers in patients with rheumatoid arthritis.]. / Nase resení deformity metakarpofalangeálních kloubu dlouhých prstu u pacientu s revmatoidní artritidou.

In the submitted paper the author describes the surgical indication scheme in deformities of the metacarpophalangeal joint of the long fingers caused by rheumatoid arthritis, as used at the Orthopeadic Clinic, Faculty Hospital, Hradec Králové. The author evaluated a group of patients treated in 1984-1996 where a total of 43 joints were operated. The mean time interval after surgery was 3.5 years. As compared with the world literature, comparable results were achieved, the only complication was a dislocation of the endoprosthesis Rubena II in one patient during the postoperative period. It was found that the final effect of surgery of deformities affecting the metacarpophalangeal joints of the long fingers in patients with rheumatoid arthritis is complete or partial functional painlessness, marked improvement of the cosmetic appearance, partial increase of the range of functional movements and the muscular strength of the grip and "pinch". Key words: rheumatoid arthritis, ulnar drift of the metacarpophalangeal joints, implantation arthroplasty.

[Pathological fracture of a lumbar vertebra in psoriatic spondylarthropathy.]. / Patologická zlomenina bederního obratle u psoriatické spondylartropatie.

The paper deals with a rare case of fracture of the lumbar vertebra in psoriatic arthropathy which finally led in a 39-year old female patient with a 14-year-old history of the disease to straightening of the spine. The fracture of the vertebral body L2 with straightening of the lumbar section by 25 degrees healed after conservative treatment without any complications. The case is discussed from the aspect of the cause of the fracture, mechanism of the episode. The resulting position of the spine is compared with the results of surgery, i. e. rachotomy. Key words: psoriatic spondylarthropathy, pathological fracture of the lumbar vertebra, rachotomy.

[Personal experience with treatment of Pipkin fractures of the femoral head]. / Nase zkusenosti s lécbou zlomenin hlavice femuru Pipkinova typu.

In the introduction the authors analyze the classification and incidence of fractures of the Pipkin type. This is a rare injury which develops as a rule in 10% of posterior type dislocations during motor car crashes. The authors present a theoretical review of all therapeutic possibilities in specific types of fractures. The group comprises 17 patients during a follow-up period of 16 years, mean age of the patients 39.6 years. In 82% the cause of the injury was a car accident. Type IV fractures were most frequent, consistent with data in the literature only one type III fracture was recorded. Sixteen patients were operated incl. three operated after a long time interval following the injury. The authors evaluate nine patients who were at least one year past the injury. The average period which had elapsed since the injury was 7.3 years. From the evaluation patients were eliminated who had primary or secondary prostheses of the hip joint. According to the score based on modified evaluation of Thompson, Epstein and Motta 44 excellent and very good results were achieved, one poor result. Two patients were granted full invalid pensions. In the discussion the authors compare their views and results with those reported in the literature. In the conclusion the authors state that treatment of these fractures should be provided at highly specialized departments.

[Helal's oblique subcapital metatarsal osteotomy]. / Sikmá subkapitální osteotomie metatarzu podle Helala.

The authors present four-year surgical experience using Helal's oblique metatarsal subcapital osteotomy to manage metatarsalgy of various etiology. A total of 109 patients (131 feet) were operated on during the observance period. The amount of 79 patients (108 feet) were revised on the average 21 months after the surgery. According to Gainor's score excellent results were achieved in 76.9 per cent of cases, 3 patients were re-operated on for a relapsing preoperational condition. The indication for Helal's metatarsal osteotomy is the finding of metatarsalgy with reducible metatarsal capitula.