[Evaluation of the Clinical Outcomes of Autologous Chondrocyte Implantation in the Management of Chondral Lesions of the Knee after 10+ Years]. / Vyhodnocení klinických výsledku metody implantace solidního chondrograftu v lécbe chondrálních lézí kolenního kloubu po více nez 10 letech.

PURPOSE OF THE STUDY: The authors present the outcomes of more than ten-year clinical follow-up of patients who underwent surgical treatment of deep chondral defect of the knee (medial or lateral condyle). The method of treatment was the implantation of autologous cultured chondrocytes in the form of a solid chondral graft. The aim was also to compare the mid-term and long-term outcomes and to evaluate how the knee condition affects the everyday life and sports activities more than 10 years after surgery. MATERIAL AND METHODS Thirty patients of the total of 56 patients (26 patients dropped out of the long-term follow-up) operated in the period between 2001 and 2012 were available for retrospective evaluation of the clinical condition before surgery, at 1, 2, 5 years after surgery and at 10+ years after surgery. The mean follow-up period of patients was 14.5 years (10 - 20.5 years) after surgery. The clinical evaluation was performed using the Lysholm Knee Scoring Scale and the Tegner Activity Scale. RESULTS The mean preoperative Lysholm score of the followed-up study population was 37.5. During the fi rst two years, improvement was achieved to the maximum value of 83.1. At 5 years and subsequently also at more than 10 years after surgery, a slight decline was reported to the mean value of 78.6. When comparing the outcomes at 5 years and at more than 10 years after surgery, the decline in the value was statistically non-signifi cant. The mean value of the Tegner Activity Scale at more than 10 years after surgery was 4.5 points out of 10 points. DISCUSSION Management of a chondral defect especially in younger patients constitutes a common challenge in everyday orthopaedic practice. There are multiple methods at hand, all of which have their pros and cons. The size of the chondral lesion appears to be the limiting and decisive factor. The greatest pitfall are large chondral lesions (>4cm2 ), where many methods fail to yield satisfactory outcomes. One of the suitable options is the autologous chondrocyte implantation method. CONCLUSIONS The clinical outcomes of patients followed-up for more than 10 years after surgery do not show a statistically signifi cant decline compared to the mid-term outcomes. Based on the data obtained, we continue to consider the autologous chondrocyte implantation as an effective method to manage deep chondral defects in the knee. The patients were mostly able to get back to normal life, including their sports activities, with a signifi cant improvement of its quality compared to that before surgery. KEY WORDS: knee joint, chondrocytes, autologous cartilage implantation, long-term.

[Comparison of the Outcomes of Revision Anterior Cruciate Ligament Reconstruction Using Cadaverous BTB Graft with the Outcomes of Primary ACL Reconstruction with Filtering out the Effects of Age and Sex]. / Srovnání výsledku revizní rekonstrukce predního zkrízeného vazu kolenního kloubu kadaverózním BTB stepem s výsledky po primární rekonstrukci LCA s odfiltrováním efektu veku a pohlaví.

PURPOSE OF THE STUDY Evaluation of the success rate of revision ACL reconstruction using the cadaverous BTB allogeneic graft and comparison of the outcomes achieved with the data of patients after the primary ACL reconstruction using the autologous BTB graft with filtering out the potential effect of diversity of the groups of patients as concerns sex and age. MATERIAL AND METHODS The evaluated outcomes of 34 patients operated in the period 2004-2017, i.e. with the minimum follow-up period of three years, were compared with the outcomes of 34 patients selected individually so that in pairs the age and sex are identical - 10 women and 24 men in the range of age from 20 to 44 years, with the median of 29 years at the time of surgery. The assessment and comparison of the outcomes achieved are done according to the Lysholm and Tegner scores. RESULTS The mean Lysholm score of the patients after the revision ACL reconstruction using the cadaverous BTB allograft achieved 54.7 points preoperatively, 72.3 points at the 1-year follow-up and 77.4 points at the 3-year follow-up. The Tegner score at the time of full performance before the injury was 7.7 points, whereas it was 5.8 points after the injury and 6.5 points three years after the surgery. In the group of patients after the primary ACL reconstruction using the autologous BTB graft, the Lysholm score was 64.4 points preoperatively, 85.1 points one year postoperatively and 88.2 points three years postoperatively. The results according to the Tegner score achieved by the primary control group at respective follow-up periods were 6.7 points, 5.1 points and 6.2 points respectively. DISCUSSION The increase in the number of performed ACL reconstructions leads also to an increase in the number of revision surgeries. This trend is also fuelled by the change in the lifestyle, the shift in age-related indication criteria for surgery, and other factors. The realistic expectations regarding the outcome of the revision ACL reconstruction shall take into account the effect of multiple insults that the knee must withstand. Even though subjective improvement of the knee condition is usually experienced postoperatively, the achieved outcomes tend to be less positive than in primary reconstructions. The return to the original pre-injury level of sports activities is achieved less frequently after revision surgeries. CONCLUSIONS The revision surgery of ACL rupture using the cadaverous BTB graft is a safe and reliable technique. It has a potential to improve the subjective satisfaction of the patient, nonetheless the mean postoperative Lysholm score is not so high as that achieved in patients after primary ACL reconstruction. Key words: anterior cruciate ligament, revision ACL reconstruction, cadaverous BTB graft, ACL graft rerupture.

[Two-Year Results of Modified AMIC Technique for Treatment of Cartilage Defects of the Knee]. / Dvouleté výsledky modifikované AMIC techniky v lécbe chondrálních defektu kolenního kloubu.

PURPOSE OF THE STUDY Damage to hyaline cartilage represents a serious problem due to its limited capacity of regeneration. Currently, there are several treatment options available. The purpose of this study is to evaluate the success rate of treatment of chondral and osteochondral defects of the knee joint using the modified AMIC (Autologous Matrix-Induced Chondrogenesis) technique, combining microfractures of the base and the implantation of the type I collagen-based cell-free implant over a two-year period. MATERIAL AND METHODS The prospective study of the success rate of treatment by the modified AMIC technique included 15 patients (13 men and 2 women) with a defect confirmed by MRI and appropriate indication criteria. The mean age at the time of implantation was 33.4 years (range 19-47 years). The mean size of a treated defect was 3.66 ± 1.71 cm2 (range 2.00-7.05 cm2). The clinical outcomes were monitored through the Knee Injury and Osteoarthritis Outcome Score (KOOS), the Lysholm score and the Tegner activity scale preoperatively and subsequently at 6, 12 and 24 months postoperatively. Control MRI was conducted at 6, 12 and 18 months postoperatively. The MRI finding was evaluated using the Magnetic Observation of Cartilage Repair Tissue (MOCART) score. RESULTS The total KOOS score was 44.69 ± 7.71 preoperatively, while postoperatively it gradually increased up to 80.45 ± 8.97 (p < 0.001) at 24 months. The Lysholm score significantly rise from 43.47 ± 11.87 preoperatively to the mean value of 81.60 ± 13.07 (p < 0.001) at 24 months postoperatively. The preoperative Tegner score was 3.53 ± 1.41. At 24 months, there was a statistically significant increase to 5.40 ± 1.70 (p = 0.003). The mean MOCART score at 18 months postoperatively was 74.67 ± 14.08. At the end of the monitored period, a complete filling of the defect site by tissue was achieved in 73.33% patients. A complete integration with adjacent cartilage was seen in 66.67% patients and homogenous structure of newly formed tissue was reported in 80% of patients. DISCUSSION In recent years, cell-free implants (the so-called scaffolds or carriers) have been used ever more frequently in treating localised cartilage defects. Their main effect should consist in helping the cells penetrate the defect site and support new cartilage tissue formation. In order to improve the efficacy of cell-free implants, a new therapeutic technique was developed, combining the microfractures of the base with the use of cell-free scaffold AMIC (Autologous Matrix-Induced Chondrogenesis). Our modification of the original AMIC technique consists in the use of a type I collagen-based scaffold instead of the original collagen membrane constituted by collagen type I and III. Based on the statistical processing of results, the modified AMIC technique has shown a statistically significant improvement compared to the preoperative values of the KOOS questionnaire and all its sub-groups, the Lysholm core and the Tegner activity scale. These good clinical outcomes correlate with the results obtained by other authors using both the original method and the modified AMIC technique. CONCLUSIONS The modified AMIC technique using the cell-free type I collagen-based implant appears to be a safe, accessible and onestage technique to treat localised chondral and osteochondral defects of the knee joint up to the size of 8 cm2. Key words: hyaline cartilage, chondral defect, AMIC, scaffold, knee.

[The Use of BTB Allograft in Revision Reconstruction of the Anterior Cruciate Ligament and Its Success Rate in Terms of Subjective Patient Satisfaction]. / Úspesnost kadaverózních náhrad predního zkrízeného vazu kolenního kloubu se zamerením na subjektivní spokojenost pacientu.

PURPOSE OF THE STUDY A retrospective evaluation of the success rate of revision ACL reconstruction performed using BTB allograft in terms of the life expectancy of the procedure up to and over five years from surgery. MATERIAL AND METHODS Over a ten-year period, from 2003 to 2013, we performed 47 revision ACL reconstruction surgeries. The majority of the primary ACL reconstructions using BTB autografts were not performed at our site. The group observed included 16 women (34%) and 31 men (66%). The women were aged between 25 and 48 years, the median age being 32.5, and the men were aged between 25 and 46 years with the median age of 35. We were able to make a full pre- and post-operative evaluation of 22 out of 47 patients who underwent secondary ACL reconstruction surgery using a cadaverous BTB graft. This evaluation included an objective clinical testing and a subjective evaluation of the function and stability of the knee joint using the Tegner activity score, Lysholm score, and a modified Cincinatti score. The set of 22 patients was split into two groups: up to five years from revision surgery and over five years from the procedure. RESULTS In the group of patients who were fully evaluated within five years of revision reconstruction there was an average improvement of 16.4 points on the Cincinatti score, 19.9 points on the Lysholm score, and an upward movement averaging 1.5 levels on the Tegner activity score. In the over five years from surgery category the average improvement was 15.5, 15.9, and 1.2 levels upward movement, respectively. We were unable to prove a significantly increased level of failure in BTB allografts after five and more years from revision ACL reconstruction. DISCUSSION The two strongest factors affecting the life expectancy of ACL replacements are the age of the patient and the type of the graft used, allograft or autograft. The most at risk, in terms of how long the graft will last, is the age group of 10 - 19 years old. With each ten-year increase in age the risk of rupture is reduced more-or-less by half. Patients with ACL allograft replacement show a fourfold increased risk of the graft rupturing. The younger and more active the patient requiring revision ACL reconstruction is, the greater the need for an autograft. If an allograft has been used in revision reconstruction on an athlete, a great emphasis must be placed on the necessity of delaying the return to previous sporting activities for at least nine months. CONCLUSIONS The mid-term results of revision ACL reconstruction show that, subject to reasonable levels of stress, a correctly performed procedure using cadaverous BTB grafts is a good option to restore the stability of the knee joint over a period of five years and more from surgery. An increased incidence of reruptures or greater insufficiency of the cadaverous graft were not evident in our group after five and more years. The risk of cadaverous grafts failure is just like in the autologous replacement directly linked to the return to sport interval, frequency and intensity of stress to which the graft is subjected over a long period of time. The risk of rerupture is always higher in allograft reconstructions that have already stood in need of restructuring for a longer period of time. For this reason, a delay in returning to sports activity must be emphasized. As a rule, we recommend a return to full athletic training only after nine months to a year after surgery. Key words: anterior cruciate ligament, revision ACL reconstruction, tendon graft insufficiency, BTB autograft insufficiency, BTB allograft of the ACL, cadaverous BTB graft, ACL graft rerupture.

[Management of Osteochondral Lesions of the Ankle Joint by Implantation of Autologous Chondrocytes]. / Lécba osteochondrálních lézí hlezenního kloubu metodou implantace autologních chondrocytu.

UNLABELLED: PUPOSE OF THE STUDY The treatment of osteochondral lesions of weight-bearing joints remains a serious therapeutic challenge, largely due to the minimal ability of articular hyaline cartilage to regenerate. The authors present the long-term clinical and MRI results of treating deep chondral and osteochondral defects of the ankle joint by the method of implantation of autologous chondrocytes in the form of a solid chondrograft. MATERIAL AND METHODS The method of solid chondrograft implantation in the ankle joint was used in our Department from the year 2003. Between 2003 and 2013, this method was used in 31 patients, 16 men and 15 women. Their average age at the time of implantation was 29 years (16 to 50 years). The follow-up period ranged from 16 to 145 months (average, 57 months). The clinical outcome was evaluated using the Mazur questionnaire. At follow-up all patients underwent regular MRI examinations and the results were assessed on the basis of Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) scores. Twelve patients required a second-look arthroscopy. RESULTS A comparison of the Mazur pre-operative scores with those obtained at 1, 2 and 5 years post-operatively showed marked improvement of ankle joint function. The average pre-operative value of 30.0 (based on responses of 31 patients) increased to the average of 89.7 (based on results of 11 patients). At 1 year post-operatively, the average MOCART score for a group of 18 patients was 78.3; at 5 post-operative years, the average value for nine patients examined was 77.0. Complete filling of defects at 1 year of follow-up was found in 88.1% and , at 5 years, it was recorded in 83.3% of the patients examined. DISCUSSION The articular hyaline cartilage is a highly differentiated tissue and its ability of repair is very limited. Therefore every damage to the articular surface should be regarded as a pre-arthritic condition// disease. Currently, there are several options of treating a damaged articular cartilage, but none of them makes its complete healing certain. A lot of studies concerned with longterm results of implanting autologous chondrocytes in the knee are available in the literature, but only few authors present long-term clinical and radiographic outcomes of ankle joint treatment similar to ours. CONCLUSIONS Based on our clinical and MRI results, the method of autologous chondrocyte implantation can be recommended since it has good long-term results, provides repair of articular cartilage and allows for patients' return to activities of daily living. KEY WORDS: chondral defect, hyaline cartilage, autologous chondrocyte, ankle joint.

[Most frequent causes of autologous graft failure in anterior cruciate ligament replacement]. / Nejcastejsí príciny selhání autologních náhrad predního zkrízeného vazu kolenního kloubu.

PURPOSE OF THE STUDY: The aim of this retrospective study was to present a comprehensive overview of the causes of bone-tendon-bone (BTB) autograft failure after primary anterior cruciate ligament (ACL) reconstruction. MATERIAL AnD METHODS: Between 2003 and 2013, we performed revision ACL replacement in 47 patients who had undergone primary BTB autograft ACL reconstruction in other hospitals. The group consisted of 16 women (aged 25 to 48 years) and 31 men (25 to 46 years). Surgery was performed on the right knee in 26 and on the left knee in 21 patients. In each of the 47 patients, two different assessments were made: 1. Analysis of causes of failure based on surgical protocols and/or intra-operative video records taken during most of the procedures. 2. Evaluation of bone tunnel location on lateral knee radiograms, using the method described by Harner for femoral tunnels and that reported by Stäubli and Rauschning for tibial tunnels. RESULTS: The most frequent cause of knee instability, occurring in 51.1% of the patients, was new trauma to the knee. nontraumatic instability in the remaining 48.9% was due to insuffiiency of the graft, and resulted from an incorrect surgical technique (42.5%) or biological causes (6.4%). The most common surgical mistake found was incorrect bone tunnel placement in the tibia or femur, with a malpositioned femoral tunnel being most frequent. This was diagnosed in 32 patients (68.1% of all patients) and, in 17, was the main or major cause of BTB graft failure. DISCUSSION: Based on relevant literature data and our experience, principles for prevention of graft failure after ACL reconstruction can be summarised as follows: 1. harvest of a suffiiently strong BTB autograft 2. accurate anatomical bone tunnel placement 3. appropriate tension of the BTB autograft 4. preventing graft impingement 5. secure graft fiation 6. early functional rehabilitation with an accent on delaying full weight-bearing on the knee (6 to 9 months post-operatively) CONCLUSIONS: New trauma to the knee is the most frequent cause of BTB autograft failure after ACL reconstruction. This can be avoided by participating in a professionally guided rehabilitation programme and not returning to sports activities earlier than 9 months after ACL reconstruction. The most common technical error in ACL reconstruction is non-anatomical tunnel placement in the tibia and femur. Femoral tunnel malposition is most frequent while incorrect tibial tunnel placement, which does not inflence graft failure so much, is less common.

[Role of ultrasonography in the diagnosis of shoulder joint injury]. / Význam UZ vysetrení v diagnostice poranení ramenního kloubu.

PURPOSE OF THE STUDY: To define the role of ultrasonography in the diagnostic algorithm for patients with shoulder joint injury and to show its potential for the detection of rotator cuff tears and Hill-Sachs lesions. MATERIAL AND METHODS: A group of 52 patients with clinical signs of shoulder disorders following trauma who were treated in the 2005-2006 period. After ultrasonographic examination, all patients were surgically treated by arthroscopy. In 12 of them an additional magnetic resonance imaging was carried out before surgery. The results of ultrasonography were compared with arthroscopic findings in terms of detection of full-thickness rotator cuff tears and Hill-Sachs lesions. These were the two most frequent traumatic lesions detected by ultrasonography. RESULTS: A full-thickness tear of the rotator cuff was correctly diagnosed in 13 patients. In further four the ultrasound finding was incorrectly interpreted as a moderate rotator cuff injury. For the detection of full-thickness tears, the sensitivity of the method was 76 %, its specificity was 94 % and accuracy 88 %. The detection of Hill-Sachs lesions by ultrasonography correlated with arthroscopic findings, with a sensitivity of 86 %, specificity of 93 % and accuracy of 92 %. DISCUSSION: A number of studies report on options for the ultrasonographic detection of various types of traumatic injury to shoulder structures. Examination by ultrasound shows skeletal surfaces, thus permitting detection of a minor bone injury or a Hill- Sachs defect, and reveals soft tissue shoulder structures including tendons, ligaments and bursae. In some studies the possibility of detecting rotator cuff tears by ultrasonography has been described. Although sufficient accuracy of ultrasonographic examination in this region is reported, the results are not consistent. CONCLUSIONS: Our results show high reliability of ultrasonography for the diagnosis of shoulder trauma. The detection of full-thickness rotator cuff tears and Hill-Sachs lesions was possible with sufficient accuracy, which makes this quick, simple and available examination a valuable diagnostic tool. The finding of a rotator cuff tear is important information for the orthopaedist and, in the majority of patients, is also an indication for surgery. An ultrasonographic examination can therefore be regarded as a standard part of the diagnostic algorithm for shoulder trauma.

[Instrumentation of idiopathic scolioses by isola and miami-moss systems.]. / Instrumentace idiopatických skolióz systémy Isola a Miami-Moss.

In our University department 135 patients were operated and followed up for minimally 2 years postoperatively. Isola system was used in 92 patients, Miami-Moss in 43 patients. The average curve magnitude was preoperatively in Isola group 61,0 degrees , in Miami-Moss 54,8 degrees . Isola was used exclusively posteriorly, Miami Moss also anteriorly (16 cases). In more severe curves the rib osteotomy of concavity was added (22 patients), most severe curves were released by anterior discectomy with interbody fusion (24 patients). The average postoperative correction was in Isola 55,6 %, in Miami Moss 64,1 %, loss of correction in Isola 2,8 degrees, in Miami Moss 4,3 degrees. No complications were observed in Miami group. A double severe complications in one patient were recorded in Isola group, one transient monoparesis and 5 wound infections.The achieved correction and its loss of both systems were practically not different. Key words: idiopathic scoliosis, surgery, Miami Moss, Isola.