[How Does Affect the Type of Instability after Total Hip Arthroplasty the Outcomes? Our Experience between 1999 and 2020]. / Jak ovlivnuje typ luxace TEP kycle výsledek lécby? Analýza souboru pacientu za období 1999­2020.

PURPOSE OF THE STUDY Dislocation is one of the most common early complications of total hip arthroplasty (THA). In this manuscript, 20 years of experience with the management of this complication are presented, particularly in relation to the type of instability. MATERIAL AND METHODS In the period between January 1999 and December 2020, at least one dislocation occurred in 157 of 8 286 (1.9%) THA patients, of which 117 dislocations (1.6%) in primary and 40 (3.4%) in revision THAs. Almost all patients were operated on from the anterolateral approach during the follow-up period. The type of dislocation was evaluated using the modified Dorr classification. In the first dislocations, conservative approach was usually opted for, except for cases with a clear malposition, irreducible or unstable hips after the reduction. The minimum follow-up period was 18 months (18-240). The success rate of the chosen treatment approach was assessed by means of standard statistical methods. RESULTS The total dislocation rate in the follow-up period was 1.6% for primary THAs and 3.4% for revision THAs. The dislocation rate was slightly higher between 1999 and 2009 compared to the following decade (2.1% versus 1.3% for primary THAs; p=0.009). The most common type of dislocation was the positional dislocation (62%), followed by dislocations due to a combination of causes (17%) and component malposition (11%). Treatment of dislocation was successful in a total of 130 patients (130/157; 83%). Even though a stable hip was achieved in 21 patients (13%), the functional outcome was unsatisfactory, and in 6 patients (4%) we failed to achieve a stable hip. In the positional type of dislocation, the success rate of closed reduction following the first-time dislocation was 86.4% and a similar success rate was reported for reoperations in the first-time dislocations due to the malpositioned components (85.7%). In the second-time dislocation, the surgical therapy was significantly more reliable compared to closed reduction regardless of the type of dislocation (78.6% versus 46%). The treatment of dislocations following primary THAs showed comparable outcomes to those of the treatment of dislocations following revision THAs. Overall, the worst outcomes were achieved in patients with a combined type of dislocation. In total, the THA had to be removed in 11.5% of hips (18/157). The probability of final THA removal increased with the increasing order of dislocation. DISCUSSION In our group of patients, the dislocation rate in THA was comparable or lower than the published data. With the use of preventive measures, i.e. dual mobility cup or larger head diameters in high-risk patients, we managed to reduce the dislocation rate over time. The positional type of dislocation prevails in our group of patients just as in the previously published series, followed by instability from malposition of components. The modified Dorr classification is used to guide the treatment since it allows us not only to make good decision about the treatment modality but to some extent also to estimate the final outcome, particularly with respect to restoring a functional and stable hip. CONCLUSIONS The total dislocation rate was 1.6% for primary THAs and 3.4% for revision THAs. The first-time dislocation of the positional type shall be treated conservatively. Conversely, in the other types of dislocations and in recurrent dislocations, surgical treatment is more likely to achieve a good clinical outcome. The worst outcomes are to be expected in an instability due to combination of multiple causes, which leads to the removal of THA more often than in other types of dislocations. Also, the benefit of preventive measures in high-risk patients over time has been confirmed. Key words: total hip arthroplasty, dislocation, Dorr's classification, treatment strategy, outcomes, complications.

[Arthroscopic Bankart Repair with Remplissage for Anterior Instability: Functional Outcomes, Risk of Failure]. / Artroskopická Bankartova operace se soucasnou remplissage: funkcní výsledky, riziko selhání.

PURPOSE OF THE STUDY This study aimed to evaluate the clinical outcomes and the rate of recurrence in patients who had undergone arthroscopic Bankart repair with remplissage for anterior instability of the glenohumeral joint. MATERIAL AND METHODS The study included 96 arthroscopic Bankart procedures with remplissage performed between 2013 and 2019 at our department in 93 patients (81 men and 12 women; with the mean age of 33 years). We gathered and analysed preoperative data, including a 3D-CT scan of the affected shoulder. Apart from stability, the functional results were assessed postoperatively using the WOSI, SSV, Rowe score, and by measuring the strength of shoulder girdle muscles. The non-parametric MannWhitney U-test was used to identify the predisposing factors for recurrence of glenohumeral instability. RESULTS The arthroscopic Bankart repair with remplissage was indicated in 74 shoulders for primary TUBS and in 22 shoulders as a revision procedure. The recurrent instability was observed in 13 of 96 operated shoulders (13.5%). Subjective instability (positive apprehension test in the extreme positions of the shoulder joint, in abduction and external rotation in particular) was reported by 10 patients (10/13; 77%), three patients experienced a redislocation of the glenohumeral joint in the postoperative follow-up (3/13 patients; 23%). The risk of recurrence of the glenohumeral instability was not correlated with either the number of previous stabilisation procedures, or any other preoperative or intraoperative parameters. Conversely, a new postoperative injury was a factor of key importance. The patients with recurrent instability (subjective instability or glenohumeral dislocation) achieved a significantly lower Rowe score, SSV, postoperative VAS, and worse overall satisfaction with the procedure compared to the group with no recurrent instability. The remplissage induced minor limitations of external rotation at 0° abduction and internal rotation at 90° abduction. After rehabilitation, the muscle strength of the operated shoulder in both groups was comparable to that of the untreated shoulder in all planes of the shoulder range of motion. DISCUSSION Our study confirms the clinical relevance of the addition of remplissage to the arthroscopic Bankart procedure for reducing the rate of recurrent glenohumeral instability in TUBS with a clinically significant Hill-Sachs lesion. Satisfaction with the surgical outcome is high; the functional outcomes are very good, including muscle strength. Surprisingly, though, the risk of recurrent instability does not correlate with the number of implants used in the stabilisation procedure. CONCLUSIONS Addition of remplissage to the arthroscopic Bankart stabilisation in patients with a clinically significant Hill-Sachs lesion shows a low risk of recurrence of glenohumeral instability after surgery compared to the conventional arthroscopic Bankart repair alone. The remplissage does cause minor restrictions in the glenohumeral joint external rotation, but it was not reflected in the satisfaction of patients or a lower clinical score of the shoulder joint. The preoperative assessment of the HillSachs lesion using the "glenoid track" on a 3D-CT scan helps improve the preoperative planning and prediction of outcomes of the stabilisation procedure. Key words: glenohumeral instability, Bankart defect, Hill-Sachs lesion, Bankart repair, remplissage, arthroscopy.

Fractional CO2 laser therapy of hypertrophic scars - evaluation of efficacy and treatment protocol optimization.

INTRODUCTION: Hypertrophic scars are an unwanted and mutilating consequence of deep burns, and are further exacerbated by extensive burn injuries. Fractional CO2 laser therapy is one of the methods for complex treatment of hypertrophic scars, it has been used since 2007 [1]. Although its effectiveness has been objectively proven in clinical practice, the optimal settings parameters have not been determined. To evaluate the effect of laser therapy, previously designed evaluation tools are used, which evaluate the quality of scars well, but fail to capture specific changes for the performed laser therapy. MATERIAL AND METHODS: Fractional CO2 laser therapy of hypertrophic scars is performed at the Department of Plastic and Esthetic Surgery, University Hospital Olomouc, since 2017 and the systematic study took place in 2019-2020. In common, 25 hypertrophic scars were treated in 13 patients; each scar was treated by fractional CO2 laser therapy more than once. RESULTS: Statistical analysis detected statistically significant improvement of the texture of the scars and the improvement of overall functional and esthetic result. We found significant reduction of the height under 2 mm (62,5% of scars) in scars with the height > 2 mm before the initiation of laser therapy. Correlation analysis detected a statistically significant positive correlation between the energy of laser beam and the reduction volume of the scar protruding above the niveau of healthy surrounding tissue. Fractional CO2 laser therapy showed statistically significant efficacy in the reduction of the risks associated with full-format CO2 laser-therapy. Fractional treatment was very well tolerated by the patients. Topical 5% lidocaine gel was effective in 24 out of 25 patients. Further healing was without complications in all patients. CONCLUSION: Fractional CO2 laser therapy has achieved statistically significant improvement of the texture and reduction of hypertrophic scars and overall improvement of functional and esthetic result in our study.

Superior Role of Waist Circumference to Body-Mass Index in the Prediction of Cardiometabolic Risk in Dyslipidemic Patients.

Coronary risk evaluation by conventional factors (age, gender, smoking, blood pressure and cholesterol) may further be specified by facets of the metabolic syndrome, namely insulin resistance, hypertriglyceridemia and obesity. Although obesity is usually defined as elevated body mass index (BMI), recent data indicate a superior role of waist circumference or hypertri-glyceridemic waist (HTGW) over BMI in the assessment of cardiometabolic risk. In dyslipidemic patients, the specific contributions of risky waist, HTGW or BMI have not been evaluated as yet. 686 dyslipidemic subjects (322 males and 364 females) were enrolled into a cross-sectional study. In each subject basic antropometry (i.e. waist circumference, HTGW, BMI) and laboratory parameters of lipid profile and insulin resistance were determined. Cardiometabolic risk was given by fulfilling the criteria (harmonized definition) of metabolic syndrome. The significance of risky waist, HTGW and BMI were assessed by comparing the respective predictive values for the presence of metabolic syndrome. Dyslipidemic patients with risky waist, HTGW or high BMI have a more atherogenic lipid profile and higher insulin resistance compared to those without risky waist, HTGW or high BMI. Risky waist is stronger predictor of metabolic syndrome (PPV 66 %, NPV 90 %) and thus posesa greater cardiometabolic risk than higher BMI per se does (PPV 42 %, NPV 97 %). The contribution of triglycerides (i.e. HTGW) to these predictive values is marginal (PPV 66 %, NPV 92 %). The present results highlight the superior role of waist circumference as a screening tool over BMI for the evaluation of cardiometabolic risk in dyslipidemic subjects. HTGW brings little additional benefit in risk stratification. Lower BMI proved to be optimal for identifying the subjects with inferior risk.

Robotic paraaortic lymphadenectomy in oncogynecology. Double side docking of daVinci S system increases the success rates of high paraaortic lymph node dissection in endometrial cancer.

OBJECTIVE: To present an overview of minimally invasive approaches to suprapelvic lymphadenectomy and compare two different methods of staging robotic transperitoneal paraaortic lymphadenectomies in patients with early stages of endometrial cancer. DESIGN: Retrospective study and literature review. SETTING: Department of Obstetrics and Gynecology, Faculty of Medicine and Dentistry, Palacky University Olomouc, University Hospital Olomouc. METHODS: In this retrospective study we enrolled 70 patients with early stages of endometrial cancer undergoing staging robotic surgery at the Department of Obstetrics and Gynecology, University Hospital Olomouc from January 2016 to March 2018. Primary systematic pelvic and paraaortic lymphadenectomy was suggested in all patients. In 39 out of 70 patients single docking was used for robotic staging surgery, whereas in 28 patients the procedure was done using double side docking approach. Number of patients with total and infra-renal suprapelvic lymphadenectomy, number of para-aortic lymphonodes retrieved and the rate of lymphadenectomy complications were compared. RESULTS: Robotic surgery was performed in 67 (96%) out of 70 patients. In three cases (0,4%) laparoscopy was converted to laparotomy. Single side docking was used in 39 cases (58%), whereas in 28 patients (42%) double side docking was used. Paraaortic lymhadenectomy was performed in 45 cases (67%). In 16 patients (24%) the upper limit of the left renal wein was reached. Upper limit of paraaortic lymphadenectomy was above inferior mesenteric artery but did not reach left renal vein in 19 cases (28%). Inferior mesenteric represented upper limit of paraaortic lymphadenectomy in 10 patients (15%). Number of paraaortic lymphonodes retrived (4,9 ± 3,3 vs 3,7 ± 4,9, p = 0,028) as well as number of paraaortic lymphadenectomies with upper limit at the left renal vein (p < 0,0001) was higher in double side docking cases. Complication rates were low in both groups and the differences were not significant. CONCLUSION: Number of lymphonodes retrieved as well as the number of paraaortic lymphadenectomy cases with upper limit at the left renal vein was higher in double side docking group. Operating time, complication and conversion rates were low without differences between both groups.

The impact of ECG synchronization during acquisition of left­atrium computed tomography model on radiation dose and arrhythmia recurrence rate after catheter ablation of atrial fibrillation - a prospective, randomized study.

BACKGROUND: The impact of ECG gating during computed tomography (CT) acquisition of left atrium (LA) model on radiation dose, image quality and ablation event-free survival rate after catheter ablation (CA) of atrial fibrillation (AF) is not well defined. METHODS: Sixty-two patients with paroxysmal atrial fibrillation were randomized for two types of LA CT (with vs without ECG gating) before CA. Pulmonary veins isolation was performed in all patients. Patients were followed for 12 months after CA. RESULTS: There was no difference between the groups in CA length (131.61±32.57 vs 119.84±33.18 min; p=0.108), CA fluoroscopy time (4.48±2.19 vs 3.89±1.83 min; p=0.251), CA fluoroscopy dose (3.99±2.79 vs 3.91 vs2.91 Gy*cm2; p=0.735), visual data quality (1.77±0.88 vs 2.0±0.63; p=0.102) and registration error (2.42±0.72 vs 2.43±0.46 mm; p=0.612). We found a significant difference in CT Dose index (89.55±5.99 vs 19.19±4.33 mGy; p<0.0001) and Dose Length product (1438.87±147.75 vs 328.21±73.83 mGy*cm; p<0.0001). Twelve months after CA, 25 of 31 patients in the gated group and 24 of 31 patients in the non-gated group were free of AF (80.65 vs 77.42 %; p=0.838). CONCLUSION: ECG gating of computed tomography of LA before AF ablation burdens patients with a four times higher radiation dose while improving neither the quality of CT model or fusion of CT with the electroanatomic map. As a result, it has no significant impact on arrhythmia recurrence rate after ablation (Tab. 3, Fig. 3, Ref. 25).

[Local Application of Tranexamic Acid in Total Hip Arthroplasty Decreases Blood Loss and Consumption of Blood Transfusion]. / Lokální aplikace kyseliny tranexamové u TEP kycle snizuje krevní ztráty a spotrebu krevních transfuzí.

PURPOSE OF THE STUDY The primary aim of our study was to identify the effects of local application of tranexamic acid (TXA, Exacyl) on the amount of postoperative blood loss and blood transfusion requirement in primary total hip arthroplasty. We also recorded the levels of postoperative haemoglobin and its drop in early period after surgery. In each patient, we monitored in detail the incidence of early complications (haematoma, wound exudate). Lastly, the economic aspect of TXA administration was also taken into account. MATERIAL AND METHODS The prospective study included a total of 312 patients (122 men and 190 women) undergoing primary total hip arthroplasty (THA) at our department between January 2012 and November 2015. The patients enrolled in the study were divided into the intervention group with local (intra-articular) application of TXA and the control group without using TXA. Each group had 156 patients. The mean age of patients in the group with TXA was 65.6 years and the most frequent indication for THA surgery was primary osteoarthritis (59.0 %). The groups did not show any differences in basic characteristics, which was statistically verified. In each patient the volume of postoperative drainage, total blood loss, including the hidden loss, was recorded. In postoperative period, we monitored the haemoglobin levels and haematocrit. On discharge of each patient from the hospital, the size and site of a haematoma, wound exudate if still present even after postoperative day 4 and early surgical revision were evaluated. RESULTS In the group with TXA the blood losses from drains were significantly lower compared to the control group (493.4 ± 357.1 ml vs. 777.3 ± 382.5 ml; p < 0.0001). The median value for total blood loss (i.e. drainage volume and hidden loss) in the group with TXA was by 29.5 % lower than the median in the group without TXA (689.2 vs. 977.1 ml). The mean total blood loss (intraoperative + postoperative) was 783.8 ± 478.6 ml (mean ± standard deviation) in the patients with TXA and 1079.7 ± 487.1 ml in the second group without TXA. The difference in the total blood loss volume was significant (p < 0.0001). In the group with TXA the consumption of blood transfusion was significantly lower by 50 % (20 vs. 40 units), (p = 0.0004). The patients with TXA also reported a significantly lower consumption of allogeneic blood (p = 0.004), a higher level of postoperative haemoglobin (p < 0.0001) and a lower mean drop of haemoglobin (p < 0.0001). We did not observe any significant differences in the incidence of haematomas (p = 0.644). No higher volume of wound drainage and joint swelling after postoperative day 4 in patients with TXA was found (p = 0.565; p = 0.242). The TXA group did not show a higher rate of surgical revision (p = 1.000). The total economic costs of blood transfusion requirements were significantly lower in the TXA group than in the control group (p = 0.004), including consumption of autologous transfusions and blood salvage (p < 0.0001). DISCUSSION The main effect of the local application of TXA is to reduce bleeding which should result in lower postoperative blood loss and consumption of allogenic blood transfusion. The advantage of the local application of TXA is its easy application and maximum concentration of TXA at the surgical site. In addition, a potential harm associated with a systemic administration of a higher TXA dose is reduced because of only minimal TXA resorption into the circulation. According to a number of recent studies, the local application of TXA achieves comparable results to its intravenous application. The economic benefit of TXA intervention is also worth considering. CONCLUSIONS The local application of TXA is an effective and, simultaneously, safe method to reduce perioperative blood loss and consumption of blood transfusions and also to decrease the costs of hospital stay in the patients after THA. Another advantage of the local application is the need to administer one dose only, whereas at least two doses need to be administered intravenously in order to achieve the same effect. No significant complications were observed in the patients with TXA. According to the recent literature, it is therefore appropriate to include the local application of TXA among the recommended procedures for THA, as is the case in total knee arthroplasty. Key words: tranexamic acid, local application, blood loss, hidden blood loss, THA, total hip arthroplasty, complications.

Allogeneic stem cell transplantation after fludarabine, melphalan and thymoglobulin followed by early withdrawal of prophylactic immunosuppression in patients with acute lymphoblastic leukemia - update of single center study.

Presented are updated results of allogeneic hematopoietic stem cell transplantations (HSCTs) in 25 adult patients with acute lymphoblastic leukemia (ALL) in complete remission (CR) after a reduced intensity conditioning (RIC) combining fludarabine (150 mg/m2) and melphalan (140 mg/m2) with thymoglobulin (4.5 mg/kg or recently 4.0 mg/kg) followed by early initiation of reduction and withdrawal of prophylactic posttransplant immunosuppression. The median post-transplant follow-up was 32 (range, 4-87) months. Stable engraftment of donor's hematopoiesis was achieved in all patients. Acute graft versus host disease (GVHD) as well as the chronic one were equally observed in four cases (16%). Five patients (20%) relapsed with ALL in the median of 9 (range, 3-15) months after HSCT. During the above post-transplant follow-up, 4 recipients (16%) died. Disease progression and posttransplant complications were the cause of death in three (12%) and one (4%) of them, respectively. The probabilities of 2-year event-free (EFS) and overall survival (OS) were 70.3% (95% CI 51.9-88.7%) and 86.1% (95% CI 71.6-100%), respectively. Presented study confirmed our previously reported promising results and this approach may be considered as an alternative to traditional HSCTs performed in high-risk patients with ALL.

[Comparison of vaginal use of micronized progesterone for the luteal support. Randomized study comparison of Utrogestan and Crinone 8]. / Srovnání vaginálního uzití mikronizovaného progesteronu k luteální podpore. Randomizovaná studie porovnávající Utrogestan a Crinone 8.

OBJECTIVE: The study was focused on comparison of efficiency, safety and tolerance of vaginal use of micronized progesterone in preparations Utrogestan and Crinone 8%. DESIGN: Prospective randomized study. SETTING: Department of Gynecology and Obstetric, University Hospital, Olomouc, Faculty of Medicine and Dentistry, Palacky University, Olomouc. MATERIAL AND METHODOLOGY: Into a prospective randomized study was, after calculation of 80% of the power of the study, α = 0,05, included 111 women in age between 18-40 with a basal value FSH < 10 IU/l and a normal finding in uteral cavity. After evaluation of efficiency of both preparations there was selected a fertilization rate, an implantation rate, a pregnancy rate and a take-home baby rate. Comparison of tolerance was made from evaluation of 21 parameters which were obtained through a questionnaire. RESULTS: There were not been proven any significant differences in efficiency between both preparations. Crinone 8% was in patients better tolerated. CONCLUSION: Luteal support within the IVF/ICSI-ET remains an integral part of the treatment. According to the outcomes of the study it seems to be more suitable to use a vaginal gel for the luteal support with micronized progesterone.

[Influence of Enhanced Recovery Regime on Early Outcomes of Total Knee Arthroplasty]. / Vliv intenzifikovaného pooperacního rezimu na casné výsledky TEP kolena.

PURPOSE OF THE STUDY Our study compared early outcomes of total knee arthroplasty performed in conventional and enhanced perioperative care regimes, i.e. without the use of Redon drain, with intensified perioperative analgesia and more frequent and intensive rehabilitation regime in the latter. MATERIAL AND METHODS The prospective study included 194 patients (76 men and 118 women) implanted with primary knee endoprosthesis. The mean age was 68.8 (44.7 - 88.0 years). The patients were divided into two groups - the "enhanced" and "conventional" procedures. In the first group, Redon suction drain was not inserted at the end of the surgery, and the patients commenced passive knee mobility exercise of the operated knee immediately after being brought back from the operating theatre. The general anaesthesia was supplemented by a combined femoral nerve block and wound infiltration with local anaesthetics. The second group comprised the patients who underwent conventional surgery, i.e. with the use of drain, without femoral nerve block, with no wound infiltration with local anaesthetics, and without immediate post-operative mobilization of the joint. The evaluation was carried out using regular clinical tools (subjective evaluation, objective examination, questionnaire and Knee Society Score (KSS)). Standard statistical methods were applied to data processing. RESULTS The patients under the "conventional regime" showed a significantly sharper drop in haemoglobin and haematocrit levels, higher consumption of blood transfusion and analgesics during the first three days after the surgery. The patients under the "enhanced regime" showed a better range of joint motion at hospital discharge, flexion in particular (p = 0.001). During the hospital stay no frequent swelling, secretion or wound reddening was reported in any of the monitored groups. In the "conventional" group, however, haematomas were more frequently present. The postoperative checks did not reveal any differences in satisfaction of the patients with the surgery. At the first follow-up examination at the outpatient department the "conventional" group patients more often reported knee pain and a feeling of a swollen knee. Nonetheless, their statements did not correspond with the VAS score. In the period between the 6th and 12th months following the surgery, the differences in the range of motion disappeared. The KSS showed a noticeable improvement in both the groups as against the preoperative values. In the "enhanced" group patients, the score increased dramatically at the beginning, whereas in the "conventional" group, the score was growing slowly and gradually until the last follow-up check after the surgery. The "conventional" group patients more frequently reported infectious complications (surface and deep wound infections: 4 vs. 2 patients) requiring a revision surgery (p = 0.024). DISCUSSION Recently, attention has been drawn to the rapid recovery approach, which eliminated postoperative immobilization and enabled the patient to start exercising already on the day of the surgery, with some patients even walking independently. The individual enhanced recovery regimes differ in details but mostly result in achieving the aim much sooner when compared to the conventional approaches. The patients under the enhanced recovery regimes can accomplish better functional outcomes in the first few months after the surgery than the patients undergoing the surgery under the conventional regime. The routine use of Redon drains in TKA is obviously unnecessary; it tends to be associated with a higher blood loss and a higher risk of prosthetic joint infection. CONCLUSIONS The TKA implant without suction drains combined with intensified perioperative analgesia and intensive postoperative rehabilitation is a safe way to earlier recovery of the function of the operated knee, or, by extension, the lower limb. The described approach is not associated with a higher risk of perioperative complications (bleeding, healing disorders or early infections). Patients also benefit from lower blood losses. Based on the results of our study, we recommend performing the TKA surgeries routinely without drains, with perioperative analgesia and immediate postoperative joint mobilization. Key words: total knee arthroplasty; perioperative care; rapid recovery; drainage; active movement; postoperative outcomes; pain; infection.

[Intra-Articular Application of Tranexamic Acid Significantly Reduces Blood Loss and Transfusion Requirement in Primary Total Knee Arthroplasty]. / Lokální aplikace kyseliny tranexamové významne snizuje mnozství krevních ztrát a spotrebu krevních transfuzí po primární TEP kolena.

PURPOSE OF THE STUDY The aim of this prospective study was to investigate the effect of topical application of tranexamic acid (TXA, Exacyl) on the amount of post-operative blood loss, and blood transfusion requirement in patients undergoing primary total knee arthroplasty (TKA). Attention was paid to early complications potentially associated with TXA administration, such as haematoma, wound exudate, or knee swelling. In addition, the economic benefit of TXA treatment was also taken into account. MATERIAL AND METHODS The study included 238 patients (85 men and 153 women) who underwent primary total knee arthroplasty (TKA) at our department between January 2013 and November 2015. A group of 119 patients (41 men and 78 women) received intraarticular TXA injections according to the treatment protocol (TXA group). A control group matched in basic characteristics to the TXA group also consisted of 119 patients. The average age in the TXA group was 69.8 years, and the most frequent indication for TKA surgery was primary knee osteoarthritis (81.5%). In each patient, post-operative volume of blood lost from drains and total blood loss including hidden blood loss were recorded, as well as post-operative haemoglobin and haematocrit levels. On discharge of each patient from hospital, the size and site of a haematoma; wound exudate, if present after post-operative day 4; joint swelling; range of motion and early revision surgery, if performed, were evaluated. Requirements of analgesic drugs after surgery were also recorded. RESULTS In the TXA group, blood losses from drains were significantly lower than in the control group (456.7 ± 270.8 vs 640.5 ±448.2; p = 0.004). The median value for blood losses from drains was lower by 22% and the average value for total blood loss, including hidden losses, was also lower than in the control group (762.4 ± 345.2 ml vs 995.5 ± 457.3 ml). The difference in the total amount of blood loss between the two groups was significant (p = 0.0001), including hidden blood loss (p = 0.030). The TXA patients had significantly fewer requirements for allogeneic blood transfusion (p < 0.0004), higher post-operative haemoglobin levels (p = 0.014), lower incidence of haematomas (p = 0.0003), and a significantly higher flexion degree on discharge from hospital (p < 0.0001). No higher volume of wound drainage was found (p = 1.000). Only one patient of the TXA group underwent revision surgery due to wound healing disturbance. The total costs of blood transfusion requirements were significantly lower in the TXA group than in the control group (p = 0.0004). DISCUSSION Topical administration allows the antifibrinolytic effect of TXA to act directly at a bleeding site. Its advantages involve easy application, maximum TXA concentration at the site of application, no danger associated with administration of a higher TXA dose and minimal TXA resorption into the circulation. On the other hand, there are no exact instructions for an effective and safe topical application of TXA and some authors are concerned that a coagulum arising after TXA application might affect soft tissue behaviour (healing, swelling, rehabilitation) or result in infection. CONCLUSIONS The study showed the efficacy and safety of topical TXA administration resulting in lower peri-operative bleeding, fewer blood transfusion requirements and higher haemoglobin levels after TKA. The patients treated with TXA had less knee swelling, lower incidence of haematomas and used fewer analgesic drugs in the early post-operative period. The economic benefit is also worth considering. In agreement with the recent literature, it is suggested to add topical TXA application to the recommended procedures for TKA surgery. Key words: tranexamic acid, Exacyl, topical application, intra-articular application, blood loss, hidden blood loss, total knee arthroplasty, complications.

Allogeneic stem cell transplantation after fludarabine, melphalan and thymoglobulin followed by early withdrawal of prophylactic immunosuppression could be an effective approach to patients with acute lymphoblastic leukemia.

Presented are results of allogeneic hematopoietic stem cell transplantations (HSCTs) in 13 patients with high-risk acute lymphoblastic leukemia (ALL) in the first complete remission after a reduced intensity conditioning combining fludarabine (150 mg/m2) and melphalan (140 mg/m2) with thymoglobulin (4.5 mg/kg). The immunosuppressive effect of T-cell depletion reducing the risk of graft-versus-host disease (GVHD) and non-relapse mortality was compensated by early initiation of reduction and withdrawal of prophylactic immunosuppression aimed at maintaining effective immunological antileukemic control. The median post-transplant follow-up was 23 (range, 10-65) months. Stable engraftment of donor's hematopoiesis was achieved in all patients. Acute GVHD was observed in two cases (15.4%); the chronic form was not noted. Two patients (15.4%) relapsed with ALL at 3 and 16 months after transplantation. During the above post-transplant follow-up, all 13 recipients were alive, with a probability of 2-year disease-free survival of 76.9% (95% CI 51-100%). Although the results were obtained with a small pilot study group it may be assumed that, given the prognostic risk of most patients and the nearly 2-year median post-transplant follow-up, the approach may be considered as an alternative to HSCTs after traditional myeloablative or reduced conditioning regimens with standard GVHD prophylaxis.

Histomorphometric diagnostics of renal osteopathy in chronic dialysis patients at high risk of cardiovascular disease.

UNLABELLED: Chronic kidney disease-mineral and bone disorder (CKD-MBD) ranks among clinically and pathogenetically significant complications in patients with CKD. Numerous factors are involved in its development, and histomorphometric analysis of the bone tissue is still necessary for accurate diagnosis. METHODS: The open, pilot, prospective study aimed at performing a comprehensive histomorphometric bone analysis in 26 dialysis patients and assessing the relationships of different types of CKD-MBD to selected parameters of calcium and phosphate metabolism, densitometry, activity of parathyroid glands, presence of diabetes mellitus, and duration of dialysis treatment. RESULTS: Comparison of the histomorphometric characteristics demonstrated statistically significant correlations between the volume of bone trabeculae and s-procollagen 1 (.754) as well as s-calcitonin (.856). Similarly, there was a positive correlation between the size of tetracycline lines and volume of bone trabeculae (.705) and a strong negative correlation with the thickness of trabeculae (-.442). When assessing the serum levels of s-osteoprotegerin and serum RANKL, there was a correlation with osteoid thickness and bone trabeculae thickness. In case of s-osteoprotegerin, a statistical power was demonstrated in relation to osteoid thickness (.880); in case of s-RANKL, a statistical power was demonstrated in relation to the thickness of trabeculae (.830). When assessing the influence of dialysis duration, relationships to the volume of trabecular bone (.665) and volume of bone trabeculae (.949) were demonstrated. Finally, a relationship between s-1,25-hydroxyvitamin D and s-osteoprotegerin was observed (.739); also the relationships demonstrated were significantly lower volume of bone trabeculae in men (p = 0.067) and lower values of s-osteocalcin and s-procollagen 1 in diabetic patients (p = 0.014). CONCLUSION: The results provide new noninvasive possibilities of CKD-MBD detection that are based on selected serum parameters of bone metabolism. Presented are possibilities of noninvasive assessment of different types of CKD-MBD using serum osteomarkers in relation to comprehensive CKD-MBD histomorphometry.

Randomized clinical trial comparing neurological outcomes after carotid endarterectomy or stenting.

BACKGROUND: Silent infarction in the brain can be detected in around 34 per cent of patients after carotid endarterectomy (CEA) and 54 per cent after carotid angioplasty and stenting (CAS). This study compared the risk of new infarctions in the brain in patients undergoing CEA or CAS. METHODS: Consecutive patients with internal carotid artery (ICA) stenosis exceeding 70 per cent were screened for inclusion in this prospective study. Patients with indications for intervention, and eligible for both methods, were allocated randomly to CEA or CAS. Neurological examination, cognitive function tests and MRI of the brain were undertaken before and 24 h after intervention. RESULTS: Of 150 randomized patients, 73 (47 men; mean age 64·9(7·1) years) underwent CEA and 77 (58 men; 66·4(7·5) years) had CAS. New infarctions on MRI were found more frequently after CAS (49 versus 25 per cent; P = 0·002). Lesion volume was also significantly greater after CAS (P = 0·010). Multiple logistic regression analyses identified intervention in the right ICA as the only independent predictor of brain infarction (odds ratio 2·10, 95 per cent c.i. 1·03 to 4·25; P = 0·040). Stroke or transient ischaemic attack occurred in one patient after CEA and in two after CAS. No significant differences were found in cognitive test results between the groups. CONCLUSION: These data confirm a higher risk of silent infarction in the brain on MRI after CAS in comparison with CEA, but without measurable change in cognitive function. REGISTRATION NUMBER: NCT01591005 ( http://www.clinicaltrials.gov).

[Surgery for degenerative spondylolisthesis of the lumbar spine using intra-articular fusion. A prospective study]. / Operace degenerativní spondylolistézy bederní pátere metodou intraartikulární fúze: prospektivní studie.

PURPOSE OF THE STUDY: The aim of the study is to present our surgical method of treating degenerative spondylolisthesis, which includes radical bilateral laminectomy to relieve compression on the spinal cord, transpedicular fixation of the segment and arthrodesis by bilateral intra-articular fusion. MATERIAL AND METHODS: This surgery was indicated in patients with grade I or grade II of degenerative sponylolisthesis with a 4-mm or more slippage. Our prospectively studied group consisted of 46 patients (17 men, 29 women; average age, 64.2 years; range, 39-84 years). Before surgery and at 1 year after the procedure, the intensity of axial pain and that of radicular pain were each assessed using the visual Analogue Scale (VAS). Difficulty in performing daily living activities was measured by the Oswestry Disability Index (ODI). The surgical procedure included laminectomy, partial medial facetectomy, foraminotomy to relieve pressure on the spinal nerve roots and transpedicular fixation to provide stability. Using a cutter, cartilage was separated off the cortical bone and, in order to facilitate fusion, bone cavities thus produced were filed with corticospongious grafts harvested from the removed vertebral arch with Kerrison forceps. At 1-year follow-up, dynamic X-ray was used to evaluate spine alignment and, on a CT scan, the degree of intra-articular fusion was assessed. Fusion was achieved when bone density measurement showed more than 350 Hounsfield Units (HU). For the measurements, the authors used their own modified method by means of a Region of Interest (ROI) analysis. The clinical and radiographic results were statistically evaluated. RESULTS: At 1 year after surgery, lumbar flexion-extension bending X-ray films revealed stability of the treated segments in all patients (100%). CT examination showed bone density higher than 350 HU at both joints, i.e., complete bone fusion, also in all 46 patients. The mean post-operative ODI score was significantly lower than its mean pre-operative value (23.6 vs 55.4), which was improvement by 57.4%. The differences in pre- and post-operative VAS scores were also statistically significant. The mean VAS score for low back pain decreased from 7.61 to 1.74, i.e., improvement by 77.1%, and the mean vAS score for radicular pain dropped from 6.98 to 1.24, i.e., improvement by 82.2%. Assessed by Odom's outcome criteria, the results were excellent in 26 patients and very good in 20 patients, and they were not related to age, gender or the spinal level treated. Any complications associated with the operative procedure or wound healing and requiring repeated surgical treatment were not recorded. DISCUSSION: The surgical technique described here has advantages over other methods in reliable achieving nerve decompression, joint fusion and spinal stability at low costs and short operative time. In addition, it avoids the necessity of harvesting bone from the iliac crest. CONCLUSIONS: At 1-year follow-up all patients showed better health conditions, with improvement in average scores for the ODI by 57%, for low back pain by 77% and for radicular and claudication pain by 82%. The technique of intra-articular fusion for treatment of degenerative spondylolisthesis resulted in solid bone fusion and spinal stability in all patients.

[Prebioptic methods in the cervical cancer screening]. / Prebioptické metody pri screeningu karcinomu delozního hrdla.

OBJECTIVE: To evaluate the agreement between Pap smears, colposcopic findings and definitive excisional specimen in patients with abnormal Pap smears. DESIGN: Retrospective study. SETTING: Center of outpatient gynecology and primary care, Brno; Department of Obstetrics and Gynecology, University Hospital, Olomouc; Department of Medical Biophysics, Palacky University, Olomouc.Subjects and methods of the study: This retrospective study assessed the correlation between colposcopy and histopathology of woman who had abnormal Pap smears. Colposcopic chart review included participants from 2008 to 2012 who attended colposcopic clinic, center of outpatient gynecology care, Brno. RESULTS: One thousand nine hundred and twenty five patients screened by cytology, submitted to colposcopy and subjected to cone biopsy were selected. Cytopathological results were compared with colposcopic findings and results obtained on the basis of histological analyses of cone biopsy specimen. Agreement of cytology and histopathological diagnosis was in 1199 patients (62.3%). Agreement of colposcopic diagnosis and cervical pathology was matched in 1492 (93.5%). Agreement of colposcopy and cytology was found in 1022 pacientek (64.1%). False negatives of cytology in high grade lesions were in 36.4%. CONCLUSION: Strength of agreement between colposcopic diagnosis and cervical pathology was found to be very good while for cytology high percentage of false negative results was seen. Expert colposcopists and high quality standard cytopathologic and bioptic laboratories are necessary for nationwide cervical screening programmes. KEYWORDS: cervical cancer, colposcopy, oncological cytology, histology, CIN, cone biopsy.

Correlation of lipid parameters and markers of insulin resistance: does smoking make a difference?

Insulin resistance associated with dyslipidemia enhances cardiovascular risk. Several atherogenic indexes have been suggested to give more precise information about the risk. The aim of our study was to estimate, which atherogenic index correlates better with parameters of insulin resistance. Furthermore, we compared the parameters of lipid metabolism and insulin resistance between smokers and non-smokers. In our cross-sectional study we enrolled 729 patients with dyslipidemia which were divided into two groups - non-smokers (586) and smokers (143). We measured lipid profile, parameters of insulin resistance (fasting glycemia, insulin, HOMA-IR, C-peptide, proinsulin) and calculated atherogenic indexes - atherogenic index of plasma (log (TAG/HDL-C), AIP), ApoB/ApoA1 index and nonHDL-C. AIP was found out to show stronger correlations with parameters of insulin resistance (p<0.001, correlation coefficients ranging between 0.457 and 0.243) than other indexes (ApoB/ApoA1 or nonHDL cholesterol). AIP correlated with parameters of insulin resistance both in smokers and non-smokers, but after adjustment (for age, body mass index, waist circumference) persisting only in non-smokers. Smokers had a wider waist circumference and a proatherogenic lipid profile. Smoking increases the risk of developing metabolic syndrome. AIP can be used in daily praxis for predicting insulin resistance in patients with dyslipidemia, predominantly in non-smokers.

[Surgery of the pulmonary metastases]. / Chirurgie plicních metastáz.

INTRODUCTION: Surgical resection of lung metastases of epithelial and mesenchymal tumors has an irreplaceable position in the complex treatment of advanced stages of these malignancies. Among the most significant prognostic factors affecting longterm survival of these patients are: parameter of complete resection, number and size of metastases, histological type of primary tumor, lymph node involvement, DFI (Disease Free Interval) and biological aggressiveness of the tumor or TDT (Tumor Doubling Time). AIM: retrospective analysis of patients with lung metastases of epithelial and mesenchymal tumors operated on at the I. Department of Surgery from 2005 to 2011. MATERIAL AND METHODS: The authors present a set of 50 patients and evaluation of their age, gender, type of primary tumor, number of metastases, occurrence of bilateral metastases, repeat metastasectomies, duration of DFI, type of operation and selected approach and performance of mediastinal lymphadenectomy. The probability of five-year survival, relationship between survival on DFI, difference in survival between metastases of colorectal cancer versus renal cancer and the influence of repeated metastasectomies and number of metastases on survival were statistically analyzed. RESULTS: Sixty operations were performed on a set of 50 patients (average age 61.2 years). Forty-two procedures were performed by thoracotomic approach. A solitary metastasis was discovered in 43 patients; in 8 patients, more than 3 metastases were resected. Repeated metastasectomies were performed 10 times. Mediastinal lymphadenectomy was performed in 21 cases. The most frequent procedure was extraanatomic resection (28×). Fourteen patients had DFI < 12 months, 19 patients had DFI 12-36 months and 17 patients had DFI > 36 months. Average survival was 66.9 months; the probability of five-year survival was 0.549 (54.9%). A relationship between DFI and survival was not discovered. There was no statistically significant difference in survival after metastasectomy for colorectal cancer and renal cancer. A relationship between survival interval and number of metastases and repeated metastasectomies was not discovered. CONCLUSION: Surgical resection of lung metastases plays an important role in multidisciplinary care, assuming a precise selection of patients indicated for this treatment. When properly adhering to the indication criteria, very positive results of long-term survival may be expected.

[Evaluation of anterior cruciate ligament reconstruction using anterior tibial muscle tendon allograft]. / Hodnocení výsledku náhrady predního zkrízeného vazu pomocí alogenního stepu ze slachy m. tibialis anterior.

PURPOSE OF THE STUDY: Injury to the anterior cruciate ligament (ACL) frequently results in the development of knee instability. This is managed by ACL reconstruction using autogenous or allogeneic grafts. This study presents a comprehensive evaluation of the patients with ACL reconstruction using a tendon allograft harvested from the anterior tibial muscle (ATM). MATERIAL AND METHODS: The group under study comprised 53 patients, 33 men and 20 women, with unilateral ACL reconstruction while the other knee was intact. The average age was 32.4 years (17 to 51) and the average follow-up was 33,4 months (21 to 53). Clinical evaluation included the Tegner and Lysholm scores and questionnaire-based satisfaction rating. Functional assessment included measurements of the range of motion and thigh circumference. Knee stability was determined using the pivot shift test, Lachman test and one-leg hop test. ACL laxity was measured on a GNRB® arthrometer. Placement of the tibial and the femoral tunnel on radiographs was assessed by the method of Harner. RESULTS: All patients reported their willingness to undergo the surgery again. The average pre-operative Tegner score improved from 7.17 (4-10) to 6.45 (2-10; p = 0.0001). The average post-operative Lysholm score was 87 points (47-100). At final follow-up, the full range of motion was recorded in 39 patients (74%), while the remaining patients exhibited only insignificant restriction of knee motion in comparison with the pre-operative status. The results of the Lachman test were negative in 38 patients (71.7%) while the pivot shift test was negative in 52 patients (98.1%). In the one-leg hop test, 44 patients (83%) were able to jump on the treated leg for a distance longer than 90% of the distance done on the healthy leg. The GNRB test at a force of 134N showed an anterior shift of the proximal tibia by 2.2 mm (0.1-9.3) on the average. The tibial tunnel was placed in zone B in 48 patients (90.6%) and the femoral tunnel was most often located to zone D (n = 47; 88.7%). DISCUSSION: The choice of tissue for ACL reconstruction is still being discussed. In some centres an ATM tendon allograft is used only in revision surgery while, in other centres, it is also employed in primary procedures. Recent studies on ACL surgery suggest that outcomes are relatively independent of the material used for reconstruction. In view of evidence-based medicine, more well-conducted multicentre clinical trials are needed to optimise indications for allograft ACL reconstruction. CONCLUSIONS: The ACL reconstruction using an ATM tendon allograft showed good clinical outcome at a minimum follow-up of 21 months. The method can be recommended not only for revision ACL reconstruction but also in primary reconstructions particularly in elderly patients. The present-day technology of producing allografts maintains tissue biomechanical characteristics and reduces risks for transmission of infection to a minimum.

[Percutaneous interspinous dynamic stabilization (in-space) in patients with degenerative disease of the lumbosacral spine - a prospective study]. / Perkutánní interspinózní dynamická stabilizace (In-Space) u nemocných s degenerativním onemocnením lumbosakrální pátere - prospektivní studie.

INTRODUCTION: Interspinous spacers are supposed to reduce the segmental extension with a decrease in the expansion of yellow ligaments into the spinal canal, thus avoiding the dynamic narrowing of the spinal canal and compression of nerve roots. The aim of this study was to evaluate clinical outcomes and post-operative complications during one year in patients mostly having suffered from spinal stenosis and treated by In-Space interspinous spacer (Synthes, USA). MATERIAL AND METHODS: A total of 25 patients aged between 25 and 73 (average age 52.6) years, including 18 males and 7 females, with degenerative disease of the lumbosacral spine were indicated for surgery and prospectively followed up. The patients were operated on under general anaesthesia in the prone position, using a minimally invasive lateral percutaneous approach, under fluoroscopic control. The ODI and VAS values as well as X- rays (Range Of Motion and Sagittal angle of the operated segment) 6 and 12 months after the surgery were compared to each other and to those before surgery. The results were statistically analyzed. RESULTS: The average ODI of the group was 47.2% before surgery and 17.48% 6 months (22.76% 12 months) after surgery, showing a statistically significant improvement by 63% (52% after 12 months). The average VAS of the group was 6.64 points before surgery and 2.96 points 6 months (2.8 points 12 months) after surgery, which showed a statistically significant improvement by 55.4% after 6 months (57.8% after 12 months) when compared to preoperative status. After surgery the lordotic sagittal angle remained in all cases; one year after surgery the angle increased due to the slight sinking of some implants. The extent of segmental motion was minimally changed (6.1° 6 months and 7.24° 12 months after surgery). No serious complications occurred. The effect of interspinous implants proved insufficient in two cases (one year and two years after surgery) and conversion to arthrodesis or decompression was performed. CONCLUSIONS: 1. Percutaneous, minimally invasive insertion of an In-Space interspinous spacer is an effective and safe method of dynamic stabilization not accompanied by any serious complications. 2. ODI improved by 63% 6 months after surgery with a decrease in this effect 12 months after surgery. VAS for axial and radicular pain, as reported by patients, improved on average by 55.4% 6 months and by 57.8% 12 months after surgery. 3. In all cases, the lordotic sagittal angle remained after surgery and the extent of segmental motion from flexion to extension was minimally changed.