[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.

[Reliability of the Evaluation of MRI Examinations after the Treatment of Chondral Defects in the Knee Joint]. / Spolehlivost hodnocení vysetrení na magnetické rezonanci po osetrení chondrálních defektu kolenního kloubu.

PURPOSE OF THE STUDY This study is a component part of the project focused on cartilage imaging after the treatment of a defect. It aims to compare the evaluation of postoperative status performed by two radiologists with the use of 2D MOCART scoring system and to determine whether this method is a reliable tool for the evaluation of postoperative changes. MATERIAL AND METHODS The study evaluated 78 MRI examinations from 25 patients (one patient had two defects treated), each of whom underwent 3 MRI examinations at 6, 12 and 18 months after surgery. The MRI examinations were performed on Philips Ingenia 3T scanner with 8-channel knee coil, in line with the routine protocol (coronal, sagittal and transversal PD SPAIR, coronal T1, sagittal PD HR, sagittal bFFE). The MRI examinations were evaluated independently by two radiologists using the 2D MOCART (Magnetic Resonance Observation of Cartilage Repair Tissue) score. RESULTS The raters agreed in a total of 592 of 702 evaluations, therefore the inter-rater reliability is high, namely 84.3%. The highest inter-rater agreement was in assessing subchondral lamina and subchondral bone. Whereas the lowest inter-rater agreement was achieved in assessing effusion. The total score showed a very strong and statistically significant correlation (r = 0.893). In eight out of nine questions there was no statistically significant difference between the raters. A significant difference was seen only in the assessment of repair tissue structure. Excellent reliability of the total score was also confirmed by the intraclass correlation coefficient. DISCUSSION The high degree of agreement in assessing the signal intensity of repair tissue was considered very positive as it is generally viewed as the major pitfall in evaluations. On the contrary, subjective perception was confirmed in the evaluation of tissue homogeneity, especially when comparing homogeneity with the adjacent tissue in close vicinity that could have changed already. Surprisingly, the lowest inter-rater concordance was reported in the evaluation of effusion, where in some cases, its volume was underestimated, when traced back retrospectively. CONCLUSIONS The results of this study confirm that despite certain doubts regarding subjective perception of some of the evaluation criteria the 2D MOCART scoring system is a very good and objective tool to evaluate the effects of surgery. Key words: magnetic resonance imaging , hyaline cartilage, classification.

[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.

[Current Options and Importance of Imaging of the Hyaline Articular Cartilage of the Knee Prior to the Surgery - a Different Perspective of an Orthopaedic Surgeon and a Radiologist]. / Soucasné moznosti a význam zobrazování hyalinní chrupavky kolenního kloubu pred operacním zákrokem ­ rozdílný pohled ortopeda a radiologa.

The authors present an overview of the commonly used techniques and new trends of the cartilage imaging, especially postoperatively, and also discuss the potential of MRI imaging of the cartilage from the perspective of an experienced orthopaedic surgeon. In conclusion, the authors propose possible explanations for the potential discrepancies between the MRI and the arthroscopic findings. Hyaline cartilage damage and subsequent reparation of this tissue is one of the topical issues of orthopaedics and traumatology. Due to the expanding possibilities of treatment of this tissue and a relatively good effect of the surgery, the number of patients indicated for magnetic resonance imaging prior to the surgery has been on an increase. To make a decision concerning the subsequent type of treatment, it is necessary to get an idea of the cartilage cover condition, articular surfaces and also of the associated pathologies. The degree of cartilage damage can be assessed by arthroscopy or magnetic resonance imaging, which provides also the possibility of the subchondral lesion detection. Thanks to the noninvasive nature of the MRI examination, it has become the most important method in full imaging of the articular cartilage. The MRI of the cartilage has many options and at present the evaluation of the hyaline cartilage should be an integral part of each MRI examination of joints. For a more accurate assessment of the cartilage there are several advanced techniques available that can be used not only for preoperative diagnostics, but also for monitoring after the surgery. Key words: hyaline cartilage, magnetic resonance, arthroscopy.

[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.

[Generalised Form of Synovial Chondromatosis of the Knee Joint]. / Generalizovaná forma synoviální chondromatózy kolenního kloubu.

UNLABELLED: This study describes a diagnostic and therapeutic algorithm in a 53-year-old male patient who was diagnosed with a synovial chondromatosis of the knee joint extending to the popliteal fossa and soft tissues around the knee. Because of the presence of massive nodules, the patient was indicated for total synovectomy, with removal of pathologically changed cartilaginous tissue, performed by combined anterior and posterior approaches to the knee joint. Despite complete removal of the synovium and loose cartilage bodies and the patient's pain relief in the post-operative time, three years after the operation new problems appeared. Magnetic resonance imaging (MRI) confirmed a relapse of synovial chondromatosis and the patient was indicated for revision surgery of the knee joint. The results of physical examination and MRI scans, and intra-operative findings in the patient are reported. KEY WORDS: synovial chondromatosis, total synovectomy, direct anterior and posterior approaches to the knee joint.

[High-Resolution MR Examination of the Scapholunate Ligament using a Microscopic Coil: Comparison with Direct MR Arthrography and Arthroscopy Findings]. / MR vysetrení skafolunátního vazu ve vysokém rozlisení s pouzitím mikroskopické cívky: srovnání s prímou MR artrografií a artroskopickými nálezy.

PURPOSE OF THE STUDY Scapholunate dissociation is a clinically most frequently diagnosed form of carpal instability. The aim of this study was to compare high resolution MRI using a microscopic coil with direct MRI arthrography in patients with suspected scapholunate ligament lesions and compare the results with arthroscopy findings and Geissler's arthroscopy classification. MATERIAL AND METHODS A prospective study was carried out in 47 patients (average age, 30.7 years) with clinical symptoms of wrist instability from 2013 to 2014. The patients were examined with the MR device Philips Achieva 1.5T using a microscopic coil and subsequently by direct MR arthrography. The results of examination were evaluated independently by two groups of physicians using a modified arthroscopic classification. The results were verified arthroscopically. For evaluation, an adjusted Geissler's classification was used. The study was approved by the Multicentre Ethics Committee of the Faculty of Medicine in Brno and informed consent was obtained from each patient. RESULTS A total of The MRI examination was evaluated and included in the study in 44 patients (three were excluded for the presence of motion artefacts). Only 20 patients underwent arthroscopy. Examination with a microscopic coil correctly classified 14 of them; an accuracy of 70 % (95 % CI: 45.7 % - 88.1 %) and p = 0.021. Direct MR arthrography correctly classified 16 of 20 injured ligaments, i.e., an accuracy of 80 % (95 % CI: 56.3 % - 94.3 %) and p = 0.002. DISCUSSION Currently, the diagnosis of pathological changes in the wrist is made by routine MRI especially when there is the possibility of using sequences with high spatial resolution. Even though we achieved poorer results by native examination using these techniques, when they were compared with the results of direct MR arthrography, they were still better than those reported in the recent literature. CONCLUSION The optimal method for an examination algorithm of scapholunate ligament lesions is direct MR arthrography. In our study correct findings of direct MR arthrography using Geissler's classification were shown in 80 % of the patients. Key words: scapholunate ligament, scapholunate ligament lesion, direct MR arthrography, microscopic coil, Geissler's classification.

[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.

[Aseptic necrosis of the capitulum of the humerus (Panner's disease) treated by solid chondrograft implantation]. / Aseptická nekróza hlavicky humeru (Morbus Panner) resena implantací solidního chondrograftu.

The authors present the case of aseptic necrosis of the humeral capitulum in a top female gymnast. She was referred to our department with the diagnosis of aseptic necrosis already made and after repeated arthroscopic treatment of the elbow including removal of a loose body in another institution. Exercise-related pain and swelling of the elbow became permanent and did not allow her to pursue her sports activities. After thorough examination, the treatment by implantation of autologous cultured chondrocytes, as a solid chondrograft, was chosen. At the first stage of arthroscopic surgery, a loose body was removed and a sample of healthy cartilage from an articular region not subject to strain was collected. The sample was sent to the Tissue Bank for cultivation and chondrocyte formation into a solid chondrograft, a procedure taking 4 to 5 weeks. At the second stage, the chondrograft was implanted into the lesion site and fixed with tissue glue (Tissucol). The arm was immobilised in a plaster cast for 4 weeks. The patient was followed up clinically and examined with magnetic resonance imaging at 6 month after implantation. The examination showed full graft integration and the arm's return to full mobility without pain at exercise. Even with this rare lesion site within the elbow joint, the implantation of a solid chondrograft proved to be a method achieving very good outcomes.

[Treatment of deep cartilage defects of the knee with autologous chondrocyte transplantation: long-term results]. / Lécba osteochondrálních defektu kolenního kloubu metodou implantace solidního chondrograftu - dlouhodobé výsledky.

PURPOSE OF THE STUDY: The authors present the long-term results of surgical treatment of deep chondral defects of the knee (medial or lateral femoral condyle). They used the transplantation of autologous cultured chondrocytes in the form of a solid chondral graft. MATERIAL AND METHODS: Indications for autologous chondrocyte transplantation most frequently included acute trauma to the knee. Patients with chondral lesions categorized as grades IIIa and IIIb by the Noyes-Stabler classification were indicated for this treatment. A small sample of healthy cartilage was harvested arthroscopically from the non-weight-bearing area of the knee and was sent to the Tissue Bank for chondrocyte cultivation. After 4 to 5 weeks the cultured chondrocytes were formed into a solid chondral graft, implanted at the damaged site of the medial or lateral femoral condyle and fixed with fibrin glue (Tissucol). RESULTS: Fifty-two patients, 34 males and 18 females (average age, 29 years range, 17 to 45 years) were treated using this method in the period from 2001 to 2009. Follow-up was 6 to 84 months, with an average of 46 months. Thirteen patients were examined by magnetic resonance imaging (MRI) 7 to 39 months (average, 19 months) after the implantation. Full incorporation the chondrograft was observed in 12 patients (92.3%). The clinical results were evaluated by the Lysholm scoring system (1, 2 and 5 years after the operation) and showed significant improvement. In 24 patients, the chondrograft quality was evaluated by immunohistochemical methods in samples taken by second-look arthroscopy from the borders of implantation sites. Hyaline chondral tissue was detected in 100% samples by microscopic examination, and collagen type II was present in 100% samples examined by imnunohistochemistry using haematoxylin-eosin staining. CONCLUSIONS: A significant improvement in knee function was recorded when the pre-operative and final follow-up stages were compared. The autologous chondrocyte transplantation showed a potential for the treatment of large cartilage defects. The excellent results achieved allowed the patients to return to normal activity levels.This method is also convenient when ligament reconstruction is necessary during one operation.

[Surgical management of posterior cruciate ligament avulsion fracture]. / Operacní resení avulzního poranení tibiálního úponu zadního zkrízeného vazu.

PURPOSE OF THE STUDY: Injury to the posterior cruciate ligament (PCL) is relatively rare and, if combined with avulsion fracture of the PCL insertion site, it accounts for only a small number of knee injuries. This is why PCL avulsion fracture is an easily missed diagnosis resulting in knee instability and arthritis development. The aim of this study was to show the necessity of surgical treatment of these injuries. MATERIAL: Between January 2004 and September 2005, four patients with PCL injury underwent surgery. Three had avulsion fracture at the PCL insertion site, and in one the avulsion fracture involved also the intercondylar eminence. The average follow- up was 15 months, with a range of 5 to 20 months. METHODS: The diagnosis was based on clinical examination, plain X-ray and MRI results. After arthroscopic treatment of the anterior compartment, the posterior compartment was treated from the posteromedial and the posterolateral approach. Using a K-wire for guidance, a tunnel was drilled and the fragment was fixed with an absorbable cannulated screw. Postoperatively, the limb was immobilized in a rigid brace at a 20 degrees flexion for 4 weeks followed by passive exercise rehabilitation. Within 10 weeks of surgery full weight-bearing was possible in all patients. Outcome evaluation was based on clinical, radiographic and MRI examination shortly after surgery and at 3-month follow-up. RESULTS: None of the four treated knee joints had any post-operative instability. The PCL was in a correct position and showed appropriate tension on MRI scans. DISCUSSION: Today arthroscopically-assisted operations are preferred to conservative treatment or open osteosynthesis. An exact diagnosis is best made on the basis MRI examination. To fix the bony fragment, various techniques can be used, such as hooked nail, screw, K-wire or traction suture through the proximal tibia. The method used usually depends on the size of a bony fragment. CONCLUSIONS: The advantages of arthroscopic surgery include faster healing and rehabilitation and less pain and trauma associated with the operative procedure. A readily performed arthroscopic procedure prevents knee joint instability and arthritis development. The outcomes achieved in our patients give support to the indication for surgical treatment in this kind of knee injury.

[Efficacy and safety of solifenacin in daily clinical practice--clinical study phase IV]. / Efektivita a bezpecnost solifenacinu v bezné praxi--klinické hodnocení fáze IV.

OBJECTIVE: Symptoms of urinary urgency, frequency, nocturia with/or without urge incontinence, are reffered to as the overactive bladder (OAB). Main option for the treatment of the OAB are anticholinergic agents. The aim of the paper is to evaluate the efficacy and safety of the solifenacin in the daily clinical practice. MATERIAL AND METHODS: 344 patients with OAB symptoms (311 women, 33 men, average age 57.04 years) were enrolled into the study. Patients were treated with solifenacin 5 mg or solifenacin 10 mg in the flexible dosing regimen. Efficacy data were obtained from the validated questionnaries and micturion diaries. Safety assessment was based on adverse event reporting. RESULTS: We observed a highly significant reduction of bladder problems caused by OAB (Patient Perception of Bladder Condition--PPBC/PBC score 4.83 at baseline to 3.29 at endpoint). The decrease of micturion frequency from baseline to endpoint was 31.19%, decrease of episodes of nocturia was 54.65 % and decrease of incontinence episodes was 90.19%. Average number of urgency episodes decresed from 12.46/day at baseline to 7.28/day at endpoint (41.6%). Average urgency severity decreased from 2.43 at baseline to 1.55 at endpoint (-37.4%). Adverse events were reported in 19 patients (5.52%) between visits 1 and 2 and in 16 patients (4.68%) between visits 2 and 3. CONCLUSIONS: Results of our phase IV. study showed the excellent efficacy and safety profile of solifenacin in the treatment of OAB in accordance with results of published phase III. clinical studies.

[Treatment of talar chondral lesions by solid chondral graft -- first experience]. / Osetrení defektu chrupavky hlezna solidním chondrograftem -- první informace.

The aim of this report is to draw attention to new possibilities of treating chondral lesions of the talus, using a solid chondral graft consisting of autologous chondrocytes grown on a three-dimensional matrix of the tissue glue Tissucol. This method is used in grade II to grade IV chronic lesions and grade IV acute lesions, as classified according to the Berndt and Harty system. Patients' age at implantation should not exceed 40 years. When a lesion is found by arthroscopy on the talar dome, a part of cartilage from a non-weight-bearing surface, most frequently the neck of the talus or the anterior edge of the tibia, is collected. The cartilage is sent to the tissue bank. The preparation of a chondral graft (fragmentation, isolation and cultivation of chondrocytes) takes from 15 to 35 days. After shaping the graft from chondrocytes and Tissucol tissue glue in a special mould, transplantation is carried out. In 2003 we used this method in two patients. They both were male sportsmen, football players, aged 35 and 30 years, respectively. At the time of this report, the former patient was 8 months and the latter 3 months after implantation. The first patient, aged 35, was without complaints at 8 months after implantation. The other patient, a 30-year-old football player, who was still followed up, was without complaints and continued with rehabilitation and full weight-bearing of the extremity. Magnetic resonance imaging performed 3 months post-operatively showed good incorporation of the chondral graft in both patients.

[Treatment of patellar cartilage defects by solid chondral graft: first experience]. / Náhrada defektu chrupavky pately solidním chondrograftem -- první zkusenosti.

PURPOSE OF THE STUDY: To present the results of a new method for treatment of cartilage defects of the patella, using a solid graft produced by chondrocytes on a three-dimensional matrix. MATERIAL AND METHODS: Chondrocyte transplantation is indicated in deep and extensive chondral and osteochondral defects of all large joints in patients at 18 to 40 years of age. When, on arthroscopic examination, a defect of patellar cartilage was found, healthy cartilage was collected from a non-weight-bearing surface, i. e., the intercondyllar fossa. In the tissue bank, the cartilage was fragmented, chondrocytes were isolated enzymatically and cultivated in vitro under a permanent assessment for cell quality. The cultivation period ranged from 15 to 35 days. Subsequently, a solid graft was prepared with the use of Tissucol glue, a three-dimensional matrix. The graft was transplanted after arthroscopic verification of the defect by an open, minimally invasive procedure with tourniquet application, with the patient receiving antibiotics. The result of chondral graft implantation was checked by second-look arthroscopy involving removal of a small sample of the integrated chondral graft taken for histological and morphological examination. Another method of post-operative assessment was examination by magnetic resonance imaging (MRI). Solid chondral graft transplantation was used in three patients (two men and one women) treated in the Department of Orthopedics, University Hospital Brno, between May 2001 and December 2003. Their average age at the time of surgery was 31 years (range, 27 to 38 years). The average follow-up was 22 months (range, 2 to 33 months). The post-operative stage of he cartilage was assessed by MRI in one patient and by second-look arthroscopy also in one patient. RESULTS: Two patients fully resumed their daily activities, sports including, at 6 months after the treatment, with one reporting mild chondropathic problems and the other being without complaints. In the third patient at 2 months after surgery, the treatment had not been completed yet. The patella examined by MRI at 18 months after surgery showed a confluent, high layer of hyaline cartilage covering the articular surface. Second-look arthroscopy and histological examination also revealed healthy hyaline cartilage. No serious complications were recorded. DISCUSSION: Autologous chondrocyte transplantation is indicated in younger, active patients with cartilage defects exceeding 2 cm2 and in patients undergoing revision surgery for any defect. The success rate of this procedure has been reported to be over 90 %. One year after transplantation, the cartilage had characteristics of a healthy tissue, as assessed by MRI. Biopsy examination showed that the grafts, chondrocytes as well as osteocytes maintained their integrity at 2 to 12 months after surgery. CONCLUSIONS: The aim of this paper was to define and check indications, to develop the surgical technique, to improve post-operative management and to evaluate mid-term results of the treatment of cartilage defects on the patella.

[Arthroscopic stabilization of the shoulder using anchors]. / Stabilizace remenního kloubu artroskopicky za pouzití kotvicek.

PURPOSE OF THE STUDY: The purpose of the current report was to present our initial experience with an arthroscopic technique for anterior stabilization of the shoulder with an anchor in 64 patients who had recurrent anterior glenohumeral instability. MATERIAL: The application of arthroscopic techniques for the operative treatment of recurrent anterior instability of the glenohumeral joint has generated widespread interest. The goal of all arthroscopic techniques for stabilization of the shoulder is the re-establishment of a functioning inferior glenohumeral ligament. This is achieved by reattaching the avulsed anteroinferior aspect of the labrum or capsule to the anterior aspect of the glenoid neck with one of a variety of methods. Arthroscopically assisted repair of the anterior aspect of the labrum with use of a bioabsorbable/nonabsorbable suture with an anchor was performed in 64 consecutive patients who had chronic anterior instability of the shoulder. The average age of the patients was twenty-seven years (range, sixteen to fifty-two years). The etiology of the instability was a traumatic injury in 53 patients. All fifty-three shoulders had a Bankart lesion. The patients were evaluated at an average of 18 months (range, 3 to 36 months) after the procedure. METHODS: During shoulder arthroscopy in typical laying position with traction applied on upper extremity we made diagnosis of capsule defect or laxity in all the cases. Using anchor technique we sutured capsule defect, or tightened loose capsule to glenoid rim. Two or three sutures were used. The anchors were Mitek GII implants, or Arthrex screws, with non-absorbable sutures in most cases. RESULTS: Fifty (78 per cent) of the patients were asymptomatic and were able to participate in sports without restriction. The repair was considered to have failed in three (4.5 per cent) of the patients. In one of them, the failure resulted from a single traumatic reinjury during participation in a contact sport, and was treated operatively. The remaining two failures occurred atraumatically. DISCUSSION: It is difficult to compare the results from the present study with those from other reports on arthroscopic techniques of anterior stabilization because of variation among the indications, the techniques, and the implants that were used. The degree of capsular laxity is central to the success or failure of arthroscopic stabilization. CONCLUSION: Anterior stabilization of the shoulder with an anchor may be indicated for patients who have anterior instability with or without Bankart lesion and need suture of the lesion and capsulorrhaphy or capsular imbrication to reduce the joint volume.