Mid-term outcomes of arthroscopic Latarjet procedure in chronic anterior shoulder instability after failed Bankart surgery or with significant glenoid bone loss.

INTRODUCTION: Arthroscopic Latarjet surgery is a technique developed to minimize invasive surgical treatment of anterior shoulder instability. However, compared to an open Latarjet operation, it is considered more technically demanding. The aim of our study was to assess its mid-term success rate in the hands of a surgeon with sufficient experience. PATIENTS AND METHODS: We included 32 patients with recurrent anterior shoulder instability in the analysed cohort who had undergone arthroscopic intervention according to Latarjet as a revision after a previous failed Bankart operation or in the case of the significant bone loss of the glenoid. Patients were followed-up according to a defined protocol for an average of 30.2 months (range 12‒60 months). In this study, we present clinical and radiological results of a long-term follow-up evaluated using Rowe, UCLA, and SST scoring systems, comparing ranges of motion, and thorough analysis of CT examinations performed no earlier than 6 months after surgery. Rowe, UCLA and SST scores were determined pre- and postoperatively; the range of motion was compared to the contralateral side. RESULTS: The postoperative score was significantly improved in accordance with the clinical finding in the followed-up group (Rowe: preOP 22.1 points ‒ postOP 97.6 points, UCLA: preOP 19.50 points ‒ postOP 33.30 points, SST: preOP 8.2 points ‒ postOP 11.5). However, the postoperative external rotation remains significantly smaller as compared to the contralateral side. The feared neurovascular damage did not occur in our cohort; one patient (3 %) had an infection in the access portal, which was managed conservatively; one patient (3 %) required revision surgery. CONCLUSION: Our results demonstrated that when in the hands of experienced surgeon, the arthroscopic Latarjet surgery is an effective surgical method with a low incidence of complications and excellent mid-term clinical outcomes (Fig. 17, Ref. 25).

[Evaluation of a Combination of Waveform Amplitude Latency and Decrease of Waveform Amplitude Magnitude during Spinal Surgery in Intraoperative Neurophysiological Monitoring of Transcranial Motor Evoked Potentials and Its Incidence on Postoperative Neurological Deficit]. / Vplyv predlzenia latencie transkraniálnych motorických evokovaných potenciálov v korelácií so znízením amplitúdy pocas spinálnych operácií s pouzitím intraoperacného neurofyziologického monitoringu na prognózu pooperacného neurologického deficitu.

PURPOSE OF THE STUDY This retrospective study investigated the significance of a combination of peak latency of waveform amplitude and waveform amplitude in association with spinal deformities. The correlation with postoperative neurologic deficit was evaluated too. MATERIAL AND METHODS Between January 2007 and January 2018, a group of 113 patients was evaluated in the study who underwent spine surgery using intraoperative neurophysiological monitoring (IONM) focusing on transcranial motor evoked potential (tc-MEP) monitoring. The average age of the patients was 30 years. Tc-MEPs were recorded bilaterally from tibialis anterior muscle and the abductor hallucis muscle in 88 patients without neurological deficit and in 25 patients with neurological deficit. The peak latency of waveform amplitude was defined as the period from stimulation until the waveform amplitude reached its peak. The correlation with postoperative neurological deficit was examined separately for latency delays of 5% and 10% or more and in combination with a decrease in amplitude of 70% or more. We used the presence-absence paradigm to evaluate the disappearance of previously present tc-MEPs and amplitude latency delays. The correlation with the deterioration of amplitudes from baseline or the elevation of thresholds was not used. Statistical tests were used to investigate the changes. The cases in our study with significant tc-MEP alerts were reviewed against the evidence-based response checklist. RESULTS Of 113 patients, the decrease in amplitude of 70% or more was identified in the neurological deficit group in 64% vs. 36% in the normal neurological group (p < 0.001). The neurological deficit was observed in 7.96% of patients postoperatively. A decrease in intraoperative amplitude of 70% or more from previously present tc-MEP occurred in 40 cases, with 89% sensitivity, 64% specificity, 36% false positive rate (FPR), and 20% positive predictive value (PPV) for prediction of postoperative neurological deficit. The amplitude latency peak delay of 10% or more was observed in 41 cases from the group of patients with postoperative neurological deficit, with 100% sensitivity, 64% specificity, 36% FPR and 22% PPV. A combination of a decrease in amplitude of 70% or more from the previously present tc-MEP and a delay in amplitude latency peak of 10% or more resulted in 100% sensitivity, 49% specificity, 51% FPR and 10% PPV in the group of postoperative neurological deficit patients. DISCUSSION Intraoperative tc-MEP alarm points have previously focused mainly on waveform amplitude. In our series, a criterion of an amplitude decrease of 70% or more from previously present tc-MEP was set as the alarm point. No alarm criterion for delay of peak latency of waveform amplitude was set before. We set a latency peak delay of 5% or more and 10% or more of waveform amplitude compared with the previously present tc-MEP as alarm criteria. This is the first study exploring the issue. We demonstrated the efficacy of latency peak of waveform amplitude together with the decrease of waveform amplitude. Another study found similarities in the decrease of amplitude of 70 % or more from baseline and the delay in amplitude latency of 10% or more from baseline; with 86% sensitivity, 98% specificity, 2% FPR and 86% PPV (1). CONCLUSIONS In conclusion, we investigated the efficacy of a change of peak latency delay of waveform amplitude in tc-MEP monitoring. The utilizing of the peak latency delay of waveform amplitude value resulted in high sensitivity up to 100 % and allows reduction of the FPR and an increase of the PPV. Further studies should set the alarm criteria more precisely for the waveform amplitude latency peak delay to achieve more effective spinal cord tc-MEP monitoring. Our concept of findings supports the neurophysiological monitoring findings in other studies. Key words: monitoring, IONM, intraoperative neurophysiological monitoring, tc-MEP, motor evoked potential, transcranial, amplitude, latency, peak.

[Bilateral Dislocation of the Hip Joints after a Car Accident?] / Bilaterálna traumatická luxácia bedrových klbov po autonehode?

The authors describe a case report of a 5-year-old foreign girl with a rare bilateral hip dislocation after a car accident. Young surgeons at the emergency department performed an unsuccessful closed reduction. Since the clinical and ultrasound screening of DDH of all newborns in the Slovak Republic is carried out until the age of 4-6 weeks, the treatment of dislocated hips starts early and the late diagnosed dislocations occur rarely. The aim of the study is to point at differences in DDH screening all over Europe resulting in an increased risk of misdiagnosed patients. Key words:hip dislocation, childhood, trauma, DDH, screening.

[Vascularised Fibula and Tendon Transfer in the Comprehensive Treatment of Forearm Fracture with Gas Gangrene Complication]. / Vaskularizovaná fibula a slachový transfer v komplexnej liecbe otvorenej zlomeniny predlaktia komplikovanej plynnou snetou.

Vascularized bone grafting was for the first time described in the 1970s. It has become a crucial component in the reconstruction of long bone defects and non-unions in a poorly vascularised environment. Although the vascularized bone is well described for the lower extremity and mandibular reconstructions, it started to be used for the upper extremity bone defects only recently. This publication presents a case of a young man with an open fracture of both the forearm bones. The treatment of the injury has been complicated with anaerobic gas gangrene of the forearm. This resulted in a non-union, radius shortening and necrosis of both the thumb extensors and flexors muscles. Once the acute infection was managed, the patient received a two-step treatment provided jointly by orthopaedic and plastic surgeons at the University Hospital in Bratislava. At the first stage auto transplantation of the vascularized fibula into the defect of radius was performed, with radial artery and radial veins being the recipient vessels. One year later, a tendon transfer was made in order to reconstruct the extension and flexion of the thumb. Donor tendons were the following: extensor indicis proprius and flexor digitorum superficialis for ring finger. The result of the reconstruction is the full incorporation of the fibular transplant (6 months after the primary operation) and the excellent range of motion of the hand and wrist. Thanks to the tendon transfer the function of the thumb, including the opposition, was achieved two months after the secondary surgery. Key words: defect of radius, tendon transfer, anaerobic infection, gas necrosis, microsurgery.

Bone metastases in neuroendocrine tumors.

Neuroendocrine tumors arise from various cells that form a part of the endocrine system and account for a small number of cases encountered by oncologists in clinical practice. The clinical incidence of these tumors used to be low, and newer imaging modalities have now begun to be used for detecting bone metastases at an earlier stage. Bone metastases arising from neuroendocrine tumors are a well-recognized complication. Their presence carries along a poor prognosis. Clinical symptoms are similar to those encountered in other forms of cancer that are complicated by bone metastasis. Over the last decade or so, the clinical detection, diagnostic methods and treatment strategies have changed dramatically, and new treatments are emerging slowly. The indolent course of neuroendocrine tumors and the development of bone metastasis have limited our current knowledge on how to best prevent and manage the condition. Current information available from clinical studies is marred by paucity and small sample sizes, making further clinical trials an absolute necessity. In this review, we discuss the current status in the diagnosis and management of bone metastases arising from neuroendocrine tumors (Fig. 3, Ref. 28).

PAG: a potential tumour suppressor and how it all started. From immune signalling to neoplastic transformation.

Phosphoprotein associated with glycosphingolipid-enriched microdomains (PAG) also known as Csk-binding protein was first fully characterized in 2000. It was initially recognized as a ubiquitously expressed adaptor protein recruiting cytoplasmic C-terminal Src-kinase to the close proximity of plasma membrane-anchored Src-kinases thereby allowing Csk to impose its inhibitory potential on these kinases. A role of PAG was initially seen in negative regulation of immune reactions. Since the year 2000 other Csk-dependent and independent interactions have been discovered and some of them showed anti-oncogenic effects in experiment. According to current opinions, these findings place PAG in a position of tumour suppressor candidate.

Functional results in patients with sarcoma around the knee joint.

Authors evaluated functional outcomes after three different surgical procedures for sarcoma around the knee joint. Sixteen patients with sarcoma were given four to six preoperative courses of chemotherapy. Patients were separated into three groups according to the pattern of tumour excision. The first group underwent the resection of proximal fibula and tibialis anterior muscle resection, the second group underwent resection of distal femur or proximal tibia with total knee replacement, and the third group underwent radical amputation. The mean functional evaluations were 100, 95 and 80%. All marginal resections of proximal fibula resulted in excellent function. No local evidence of tumour recurrence was seen at mean follow-up of 24 months (Tab. 1, Fig. 2, Ref. 7).

Rafting in the membrane. A lesson learnt from lymphoproliferative disorders.

Lipid rafts are chemically distinct compartments of the plasma membrane. Their integrity is a prerequisite for vital cellular functions particularly for signalling and trafficking. Their perturbation is associated with development of a broad spectrum of diseases. Lipid rafts are also important for therapeutic effects of some drugs. Moreover, some of the raft associated molecules are useful immunohistochemical markers in routine histopathology.

Re-fixation in a lymph node revealing solution is a powerful method for identifying lymph nodes in colorectal resection specimens.

AIM: To verify an impact of a lymph node revealing solution (LRS) on the number of lymph nodes (LN) revealed in colorectal resection specimens. MATERIAL AND METHOD: Fifty-nine cases of rectosigmoid carcinomas divided into two subgroups-stage pT2&3 (20 cases) and ypT2&3 (with pre-operative radiotherapy-39 cases)-were formalin fixed for 42-72 h, serially sectioned and re-fixed in LRS containing ethanol, diethyl ether, glacial acetic acid, and formalin for 24 h. The number of LNs was matched to a control group consisting of 34 cases of colorectal carcinoma, 14 pT2&3 and 20 ypT2&3 rectosigmoid carcinomas examined routinely. Results were statistically tested by Student's t-test. RESULTS: In the study group the total number of revealed LNs was 869, range 1-48, average 14.7 per specimen, median 15. In the control group the number of LNs was 200, range 0-13, average 5.9 per specimen, median 6. The difference between the study and the control group was statistically significant (P = 0.05). CONCLUSION: Using LRS leads to a significant increase in the number of revealed LNs in colorectal resection specimens and makes it possible to find more than 12 LNs in a majority of stage pT2 and pT3 adenocarcinomas.

[Matrix-producing breast carcinoma with myoepithelial differentiation--description of 11 cases and review of literature aimed at histogenesis and differential diagnosis]. / Matrix produkující karcinom prsu s myoepiteliální diferenciací--popis 11 prípadu a prehled literatury se zamerením na histogenezi a diferenciální diagnostiku.

OBJECTIVE: Presentation of variable morphology of the so-called matrix-producing carcinoma, the rare variant of metaplastic breast carcinoma. Establish the extent of myoepithelial phenotype by immunohistochemistry and assess behaviour of the lesion. DESIGN: Review of clinicopathologic data of 11 cases. SETTING: Private Biopsy Lab s.r.o., Pilsen and Sikl's Department of Pathology, Charles University and Faculty Hospital, Pilsen. METHODS: Included are eleven cases from Breast Registry, Biopsy Lab s.r.o., Pilsen and Pathology Department, Faculty Hospital in Hradec Králové and Martin and from Biopsy Lab in Horovice. Analyzed were morphology, stage, grade and follow up. Myoepithelial phenotype was demonstrated immunohistochemically by LSAB+ system (DAKO) and seven conventional myoepithelial markers (GFAP, aktin S, calponin, cytokeratin 14, p63, CD10 and P-cadherin) were used. Oncogene p53 and Her2/neu were also detected. RESULTS: Matrix-producing carcinoma is an extremely rare type of metaplastic carcinoma of the breast, where high-grade epithelial component continually merges with heterologous mesenchymal chondroid component without overt spindle cell sarcomatoid pattern in between. There were all women at the age of 32 to 86-years (average 54 years, median 52 years) and the maximum tumor diameter ranged from 18 to 60 mm (average 32 mm). The axillary LN was positive in six cases in the time of diagnosis. The follow up available in 9 women ranged from three months to ten years (average 24 months); dissemination of the disease was observed in three cases; 2 of these patients died of disease after three and ten years, respectively. The heterologous mesenchymal chondroid component was produced in two different ways; one displayed typical structure of low-grade hyaline cartilage, in the second one the epithelial tumorous cells were embedded in the homogenous eosinophilic extracellular matrix giving appearance of chondroid aura. Metaplastic component constituted 5-75% of the tumor volume. Immunohistochemical evidence of myoepithelial differentiation in all neoplasms was demonstrated, with at least two conventional myoepithelial markers (actin S, calponin, GFAP, CK14, CD10, p63 and P-cadherin) being positive in every case. Expression of p53 was identified in six cases, all tumors were Her2/neu negative. Histologically the metastases were formed either by carcinoma cells only, or more frequently, they replicated the structure of primary lesion. CONCLUSION: As a rare entity, matrix-producing carcinoma of breast displaying myoepithelial phenotype, deserves separate position in tumor classification. It differs from conventional myoepithelial carcinoma and from heterologous metaplastic carcinoma, where the matrix emanate from undifferentiated sarcomatous tissue, but precise histogenesis in not clear yet. This is a very aggressive lesion and our findings show that previous reports of indolent behaviour were preliminary. Spectrum of differential diagnosis, namely benign mixed tumor, phylloid tumor, primary breast sarcoma and colloid carcinoma warrant clear knowledge about this unique entity.

Osteoid osteoma of olecranon process of ulna in subchondral location.

We present a case of a 15-year-old girl with osteoid osteoma in an unusual subchondral localization of the olecranon. Unspecific complaints and minimal X-ray findings at the onset of the disease led to an incorrect diagnosis and more than 2 years of inefficient treatment.

Cardiac rhabdomyosarcoma.

Cardiac sarcoma is a very rare neoplasm and is difficult to diagnose. The case of a 51-year-old man with a left atrial tumour, locally recurrent three months after its surgical removal, is presented. Computed tomography showed metastatic spread to the lung parenchyma. On revised histology, the mass extirpated was a sarcoma. Because of the metastatic spread, further therapy was symptomatic only; the patient died 15 months after the first manifestation of his problems. Immunohistochemical staining confirmed cardiac rhabdomyosarcoma with metastatic spread to the lungs. Difficulty in diagnosing and treating cardiac tumours is discussed.

[Our Experience in the Revision Surgery of THR.]. / Nase skúsenosti s reimplantáciou TEP koxy.

The authors present their experience in the revision surgery of THR. Most often it was the case of aseptic loosening of the acetabulum, the femoral component or both components (67 %), lytic radioluscence or even lysis in the region of implants, fissures even fractures of the femur and septic loosening. They evaluate the results of revision surgeries of THR for a 5-year period in 106 patients after Merle dAubigne and Postel: excellent result was achieved in 33 %, good in 39 %, average in 19 % and a poor result in 9 %. The authors emphasize in case of primary surgery the importance of indication criteria, age of the patient, appropriate choice of the type of implant, evaluation of the immunological condition of the patient. In revision surgeries of aseptic loosening of the implant and bone defects of the medial acetabular wall efficient was mainly the application of bone grafts and cementless acetabular cup of the Harris-Galante, Zweymüller or Balgrist type. Periprothetic fractures of the femur should be treated by internal fixation and Wagner revision stem. In case of septic loosening the endoprosthesis was extracted or a two-phase revision surgery performed. Key word: THR revision surgery, aseptic loosening, bone defects, Wagner revision stem.

Pigmented microcystic chromophobe cell carcinoma: a unique variant of renal cell carcinoma.

Five cases of pigmented chromophobe renal cell carcinoma are presented. The patients included four men and one woman between the ages of 60 and 73 years (median age, 66.5 years), who presented with symptoms due to their renal mass. Surgical resection of the renal mass was performed in all patients. Grossly, the tumors were well encapsulated, yellow to dark gray, with a vague nodular pattern on cut surface. The tumors varied between 2.5 and 9 cm in greatest diameter. Histologically, all tumors shared similar features, namely, a malignant cellular proliferation composed of deeply eosinophilic to clear cytoplasm with round nuclei and inconspicuous nucleoli. The cellular proliferation was arranged in a microcystic and/or microalveolar pattern. In one tumor, conventional areas of clear cell carcinoma in association with the chromophobe component were present. In addition, all tumors contained pigmented areas, which were shown by light microscopy to have features of lipochrome pigment. Ultrastructural studies of these areas demonstrated the presence of intracytoplasmic polygonal to round, electron-dense pigment granules, which in some areas seemed to coalesce to form larger granules. In addition, numerous mitochondria and cytoplasmic vesicles were present. The cases described herein highlight an additional morphologic variant of chromophobe renal cell carcinoma.

[Primary intraosseous liposarcoma - case report.]. / Primárny kostný liposarkóm - kazuistika.

Primary intraosseous liposarcoma belongs to exceptional tumors rarely found on the sceleton. There are only several tens of cases described in literature and they are published as case reports. Because there is not enough experience, especially with diagnostics of this illness, it happens that it is considered as malignant fibrous histiocytoma, malignant mesenchymoma or with secondary infiltration of liposarcoma of soft tissue into the bone. Authors tried (in correlation with the clinical outcome studies of macroscopic samples with detailed histologic examination) to overcome diagnostic uncertainities of this case. Key words: primary intraosseous liposarcoma, maligant bone tumors.

[Acetabular Replacements in THR in Dysplastic Osteoarthritis of the Hip.]. / Náhrady acetábula pri totálnych endoprotézach u dysplastických koxartróz.

The authors present different options of the surgical treatment of dysplastic osteoarthritis of the hip. For the acetabular replacement they use Harris-Galante, Zweymúller and Balgrist cementless cups. They evaluate results for a five-year postoperative period in 182 patients. On the basis of Merle d'Aubigne and Postel evaluation system the results were excellent in 79,6 % and very good in 12,1 %.The authors recorded only a relatively small percentage of complications (10,9 %) relating to the wound infect, loosening of the cup, trombophlebitis and palsy of n. peronaeus com. or n. femoralis. The authors emphasise the importance of CT examination of the hip joint in the preoperative preparation and of the knowlege of biomechanics of pelvis for the insertion of the cementless cup. The replacement of acetabulum in dysplastic osteoasthritis of the hip is an open issue - there exists no ideal cup for each case. Key words: dysplastic osteoarthritis of the hip, cementless cup, THR, acetabuloplasty.

[Austin's Operation at the First Orthopaedic Clinic in Bratislava.]. / Austinova operácia na I. ortopedickej klinike v Bratislave.

There are more than 200 types of surgical treatment of hallux valgus, but new modifications still appear. At the authors' Clinic during the last four years some of the patients are operated by Austin's operation. The operation is made under anaesthesia type "foot block". The operation is performed in a bloodless field, achieved by an Esmarch bandage. The incision is dorsomedial above the 1st MTP joint and is about 5 cm long. The incision of the bursa is Y shaped, with the base on the proximal phalanx of the hallux. We ablate the exostosis, deliberate the fibular portion of the articular capsule of MT and in case of more difficult redressibility of the hallux tenotomy of the m. adductor hallucis is performed. Osteotomy of the distal metatarsus is made transversally in a V--shaped manner at an agle of 60 degrees . The distal osteo-tomized fragment is lateralized by one to two thirds of the metatarsal width. This position is fixed by a Kirschner wire inserted by the percutaneous paraosseous route through the hallux, the space between the first and second MT and fixed in the tarsus. Y-shaped bursotomy and artrotomy is sutured in such as way to achieve stability of the osteotomy and redressing of the hallux. The stitches are removed 14 days after operation. The Kirschner wires are left for four weeks. Postoperation treatment proceeds in a specially shaped postooperation sandal. By this method since the beginning of 1992 till the end of 1995 at the authors' Clinic 48 feet of 36 patients were operated (42 women, 6 men). The mean age at the time of surgery was 44.5 years (22 to 58 years). The mean period of work inability was 9.7 weeks. The patients were examined at least 6 months after surgery and 40 excellent results were recorded (83%), 7 (15%) good results and 1 (2%) poor result. Complications were rare. In two patients there was secondary healing of the surgical wound, in two instances infection of the wound occurred. Key words: hallux valgus, Austin's operation, chevron osteotomy.