Synovial fluid alpha-defensins in Lyme arthritis-a useful marker.

Lyme arthritis, one of the possible late manifestations of Lyme borreliosis, predominantly affects the supporting joints and in adults most often occurs in the form of monoarthritis of the knee. Early diagnosis is based on clinical findings and serology. PCR detection of Borrelia in synovial fluid has become an integral part of the laboratory testing algorithm. The clinical presentation and inflammatory markers in Lyme arthritis can resemble septic arthritis. Determining the levels of alpha-defensins (human neutrophil peptide (HNP 1-3)) in synovial fluid by liquid chromatography is a highly sensitive method revealing the presence of inflammatory process. Between 2020 and 2022, we examined eleven patients with Lyme arthritis of the knee. We measured levels of HNP 1-3 from synovial fluid by HPLC in patients, and we compared it with the corresponding C-reactive protein (CRP) levels in paired serum samples. In patients diagnosed with Lyme arthritis, HNP 1-3 levels in synovial fluid ranged from 2.5 to 261 mg/L, with a median of 46.5 mg/L. Average serum CRP was 43 mg/L. The results show that elevated HNP 1-3 can be consistent with not only septic arthritis or systemic disease, but also with Lyme arthritis, especially in patients with negative culture and 16S PCR from synovial fluid. Final diagnosis must be verified by examination for anti-Borrelia antibodies from serum and synovial fluid. The aim of this work is to introduce an HPLC method for the determination of alpha-defensins as one of the possible diagnostic markers.

Anatomy of the iliopsoas notch and its relationship with morphology of the proximal femur.

PURPOSE: Discrepancy between the morphology of the acetabular margin and the design of hemispheric acetabular cups used in total hip arthroplasty may produce postoperative hip pain due to an iliopsoas impingement at the iliopsoas notch. This study aimed to determine the anatomical features of the iliopsoas notch in the Central European sample, and to test whether the morphology of the proximal femur affects the size of the iliopsoas notch. METHODS: The sample was composed of 40 matched pairs of dry hip bones and corresponding femora. The depth and length of the iliopsoas notch were measured and correlated with the available demographic data. The anthropometric parameters of the proximal femur were calculated using image-analysis software, and their association with the measurements of the iliopsoas notch was tested. RESULTS: The iliopsoas notch was present in all specimens and featured four morphological configurations: curved (61.3%), angular (16.2%), irregular (16.2%), and straight (6.3%). Its size was found to be larger in males (P = 0.014 for depth, P < 0.001 for length). No significant difference existed between the sides. The height and age of the specimens did not correlate with the size of the iliopsoas notch. Furthermore, neither the femoral neck version, the lesser trochanteric version, nor the angle between the neck of the femur and the lesser trochanter influenced the dimensions of the iliopsoas notch. CONCLUSION: The iliopsoas notch is a consistent landmark of the acetabulum, although its anatomical appearance is widely variable. The iliopsoas notch arrangement cannot be predicted perioperatively based on the morphology of the proximal femur. The various shapes and sex-related differences detected in this study could be used for designing new hip implants or could be utilized during cup positioning in total hip arthroplasty.

Update on Focal Infection Management: A Czech Interdisciplinary Consensus.

BACKGROUND: The focal infection theory has been used to explain several chronic systemic diseases in the past. Systemic diseases were thought to be caused by focal infections, such as caries and periodontal diseases, and dentists were held responsible for these diseases due to the spread of oral infections. As knowledge of the interrelationship between oral microorganisms and the host immune response has evolved over the last few decades, the focal infection theory has been modified in various ways. The relationship between oral and systemic health appears to be more complex than that suggested by the classical theory of focal infections. Indeed, the contribution of the oral microbiota to some systemic diseases is gaining acceptance, as there are strong associations between periodontal disease and atherosclerotic vascular disease, diabetes, and hospital-associated pneumonia, amongst others. As many jurisdictions have various protocols for managing this oral-systemic axis of disease, we sought to provide a consensus on this notion with the help of a multidisciplinary team from the Czech Republic. METHODS: A multidisciplinary team comprising physicians/surgeons in the specialities of dentistry, ear-nose and throat (ENT), cardiology, orthopaedics, oncology, and diabetology were quetioned with regard to their conceptual understanding of the focal infection theory particularly in relation to the oral-systemic axis. The team also established a protocol to determine the strength of these associations and to plan the therapeutic steps needed to treat focal odontogenic infections whenever possible. RESULTS: Scoring algorithms were devised for odontogenic inflammatory diseases and systemic risks, and standardised procedures were developed for general use. CONCLUSIONS: The designed algorithm of the oral-systemic axis will be helpful for all health care workers in guiding their patient management protocol.

Biomechanical Study Concerning the Types of Resection in Arthrodesis of First Metatarsophalangeal Joint.

This work concerns a biomechanical study aiming to ascertain the optimal type of joint resection when performing a joint arthrodesis. A 3-dimensional digital model of the first metatarsophalangeal joint including the entire first metatarsal bone and proximal phalanx using CT scans of the forefoot was created. Using this computer model, 4 types of resections; ball-and-socket, flat-on-flat, wedge 90°, and wedge 100° were simulated. Parameters measured using this model were the force necessary to separate the 2 fused surfaces, the surface area of the resected surfaces and the shortening of the first ray. By measuring the reactive force necessary to separate the phalanx from the first metatarsal, the 90° wedge resection was found to be the most stable, with comparable results in the case of the 100° wedge resection. Wedge resections are also more favorable when comparing the shortening of the first ray. Wedge resections, though being more technically difficult to perform prove to be the most stable for metatarsophalangeal joint-1 arthrodesis using this model.

Lateral release in hallux valgus deformity: from anatomic study to surgical tip.

The important part of hallux valgus deformity operations, especially in the case of an incongruent joint, is the release of the soft tissue on the lateral side of the first metatarsophalangeal joint. The purpose of the present anatomic study was, with preparation of the lateral structures of the joint and lateral conjoined tendon, to provide a background for a surgical tip of the release of the joint for an additional metatarsal osteotomy. For the present study, we used 30 specimens (15 left and 15 right) from 19 cadavers at the Institute of Anatomy, First Faculty of Medicine, Charles Faculty (Prague, Czech Republic). Only specimens that met the criteria of hallux valgus were included in the present study. The technique was based on the incision of the lateral sesamoid ligament and partial tenotomy of the lateral conjoined tendon from the first interdigital web space. The release was done gradually with supination and abduction of the big toe to achieve the smallest size of the tenotomy. The median of the tenotomy size of the conjoined tendon was 6.5 (range 5 to 14) mm. The median size of the conjoined tendon in the frontal plane just ventral to the sesamoid bone was 10.6 (range 8 to 14) mm. The technique of the release, in which the big toe was abducted and supinated, can minimize the size of the lateral conjoined tendon release and can minimize the possibility of a postoperative deformity.

Hypermobility of the first metatarsal bone in patients with rheumatoid arthritis treated by Lapidus procedure.

BACKGROUND: Foot deformities and related problems of the forefoot are very common in patients with rheumatoid arthritis. The laxity of the medial cuneometatarsal joint and its synovitis are important factors in the development of forefoot deformity. The impaired joint causes the first metatarsal bone to become unstable in the frontal and sagittal planes. In this retrospective study we evaluated data of patients with rheumatoid arthritis who underwent Lapidus procedure. We evaluated the role of the instability in a group of patients, focusing mainly on the clinical symptoms and X-ray signs of the instability. METHODS: The study group included 125 patients with rheumatoid arthritis. The indications of the Lapidus procedure were a hallux valgus deformity greater than 15 degrees and varus deformity of the first metatarsal bone with the intermetatarsal angle greater than 15 degrees on anterio-posterior weight-bearing X-ray. RESULTS: Data of 143 Lapidus procedures of 125 patients with rheumatoid arthritis, who underwent surgery between 2004 and 2010 was evaluated. Signs and symptoms of the first metatarsal bone instability was found in 92 feet (64.3%) in our group. The AOFAS score was 48.6 before and 87.6 six months after the foot reconstruction. Nonunion of the medial cuneometatarsal joint arthrodesis on X-rays occurred in seven feet (4.9%). CONCLUSION: The Lapidus procedure provides the possibility to correct the first metatarsal bone varus position and its instability, as well as providing the possibility to achieve a painless foot for walking. We recommend using the procedure as a preventive surgery in poorly symptomatic patients with rheumatoid arthritis in case of the first metatarsal bone hypermobility.

Ankle block implemented through two skin punctures.

BACKGROUND: Recently, peripheral nerve blocks have increasingly been used in orthopedic surgery. The foot block is an alternative for anesthesia in cases of forefoot and midfoot operations. We propose a modification of the block technique due to potential difficulties concerning the tibial nerve. MATERIALS AND METHODS: The spatial position of the tibial nerve in the neurovascular bundle, proximal to entering the tarsal tunnel and sural nerve behind lateral malleolus was measured on 60 dissected preparations. Modification of the block technique was proposed. A tibial nerve block was administered by inserting a needle, at an area above the upper edge of the heel bone, tangential to the Achilles tendon. The needle was then withdrawn and redirected to the frontal plane and inserted through the tissue, anterior to the Achilles tendon and laterally behind the lateral malleolus to block the sural nerve. A block of the saphenous nerve superficial and deep peroneal nerves was implemented by needle insertion subcutaneously two centimeters proximal to the crest of the ankle joint. The technique was then evaluated in the clinical part of the study in 84 operative procedures. RESULTS: The tibial nerve is located 21.1 mm +/- 2.1 mm from the medial aspect of the Achilles tendon and 11.6 mm +/- 1.3 mm deep in the neurovascular bundle. The distance from the posterior margin of the lateral malleolus to the sural nerve is 18.3 mm +/- 1.9 mm. We achieved a 93% success rate in implementation of the complete foot block in 84 operations. CONCLUSION: The technique, proposed in the anatomical portion of the study and evaluated in the clinical part, had a similar success rate when compared to techniques published in the literature. Though comparable to currently used techniques, this technique provides easier positioning of a patient and a complete block of the foot can be done with two skin injection sites.

[Os Pisiforme transposition in the treatment of Kienböck's disease - long term results]. / Transpozice os pisiforme pri resení rozvinutých stadií morbus Kienböck - dlouhodobé výsledky.

PURPOSE OF THE STUDY: One of the methods used for treatment of Kienböck's disease is based on transposition of the pisiform bone into free space created by removal of the lunate bone. It is performed in patients with stage IIIB to IV, as assessed by Lichtmann's score. However, this operative procedure has so far lacked an unequivocal assessment of its therapeutic value. The aim of our work was to assess the therapeutic effect of the Kuhlmann method in the treatment of advanced stages of Kienböck's disease. MATERIAL: From January 1996, eighteen patients (18 wrists) diagnosed with Kienböck's disease were operated on, using the Kuhlmann method, and the group of these patients was included in this follow-up study. The average follow-up time was 7.6 +/- 2.3 years. METHODS: The results were evaluated on the basis of subjective (VAS) and functional criteria (ROM, grip force, DASH questionnaire and combined Cooney score questionnaires) and radiological assessment (arthritis evaluation, C.H.I., Natrass index, RSA). RESULTS: All patients experienced pain relief. The average pain assessment by VAS (10-point scale) before and after the procedure was 8.76 +/- 0.9 and 2.94 +/- 1.59, respectively. The range of motion was reduced on the operated extremity (70% compared to non-operated) as well as the grip test (57%). The average DASH score at the time of study was 20.9 +/- 12.2 and the average Cooney score was 67.6 +/- 17.4. Before the operation, eleven wrists showed signs of osteoarthritis. At the follow-up evaluation, arthritis was present in fifteen patients.We found a significant difference in average radiological parameters characterizing a carpal collapse deformity (C.H.I., Natrass index, RSA) - all parameters showed deteriorating tendencies. DISCUSSION: In nine patients, necrotic changes of the lunate occurred. In the patients whose pisiforme was not affected, a moderate retardation of carpal collapse occurred. However, the discrepancy between relevant indicators (C.H.I, Natrass index, RSA) was not statistically significant when comparing both groups. Therefore, we cannot conclude as to whether or not a vital transposed pisiforme bone impedes the development of carpal collapse. The only proved difference between these two groups was in pain evaluation, measured by VAS, after the procedure CONCLUSION: Although there was a good subjective assessment of the operation results, we are of the opinion that this method should not be used as a routine surgical procedure for advanced Kienböck disease. In view of a large number of failed cases we believe that this method should be considered very carefully.