[Tibiotalocalcaneal Arthrodesis: Comparison of Fixation Methods, Mid-Term Clinical Results]. / Tibiotalokalkaneální artrodéza: srovnání metod fixace, strednedobé klinické výsledky.

PURPOSE OF THE STUDY The authors focused on the topic of tibiotalocalcaneal arthrodesis. It is a surgical procedure used to manage severe comprehensive ankle and hindfoot pathology. The scope of surgery and the negative impact on the walking stereotype are offset by preserving a weight-bearing and pain-free limb. The purpose of the study was to evaluate the group of patients who had undergone surgery at the First Department of Orthopaedic Surgery, St. Anne s University Hospital Brno and to identify the most suitable fixation for arthrodesis. It also aimed to compare the outcomes achieved by the authors with those reported by other departments. MATERIAL AND METHODS The group included patients operated on at the authors department between 2011 and 2021. The surgery was indicated in patients with severe concomitant arthritis of the upper and lower ankle, complex hindfoot instability, Charcot arthropathy. Contraindications included acute infection, decompensated diabetes and heavy smoking. The study compares fixation using a lateral plate, a retrograde nail and a retrograde nail with fibula acting as biological plate. The patients were scored preoperatively and postoperatively using the AOFAS Ankle-Hindfoot Score. Statistical analysis of the results was also carried out. RESULTS The group included 23 patients, of whom a lateral plate was opted for in 7 patients, a retrograde nail in 8 patients and a retrograde nail with fibula used as a biological plate in 8 patients. The patients of the group were followed up for the period ranging from 0.5 to 9 years after surgery. Serious complications were observed by the authors in 6 patients of the group. The failure of osteosynthesis material was reported in 2 cases with lateral plating fixation. A stress fracture above the apex of the nail developed in 2 cases. A serious infection was observed by the authors in 1 patient. The method associated with the lowest incidence of complications was the fixation with a retrograde nail and fibula used as a biological plate. DISCUSSION The forms of fixation for tibiotalocalcaneal arthrodesis have recently advanced considerably, the methods of fixation for arthrodesis in particular. The modern implants enable to compress the individual structures, to provide stable fixation and potentially to avoid long-term plaster cast fixation. Nonetheless, these surgical procedures are associated with a high complication rate. Currently, there is no consensus in international studies on the optimal fixation for arthrodesis. Numerous papers describe complications including postoperative infections, failure of osteosynthesis material and fractures close to osteosynthesis material. The number and the type of complications observed by the authors in their group of patients were similar to those reported by other authors. CONCLUSIONS Tibiotalocalcaneal arthrodesis is a surgical procedure reserved exclusively for patients indicated based on strict criteria and should be performed by an experienced team able to cope with potential complications. In the followed-up group of patients, the optimal method of fixation for arthrodesis appeared to be the fixation with a retrograde nail and fibula used as a biological plate. Key words: tibiotalocalcaneal arthrodesis, retrograde nail, lateral ankle plate, ankle instability, ankle arthrosis, biological plate.

[Intramedullary Nailing in Managing Diaphyseal Metastases of Long Bones: Retrospective Study Comparing the Expected Survival and the Actual Survival of Patients]. / Intramedulární hreb v lécbe metastatického postizení diafýz dlouhých kostí: retrospektivní studie s ohledem na srovnání prognózy doby dozití a reálné prezití pacientu.

PURPOSE OF THE STUDY The paper focuses on the potential use of nail osteosynthesis in diaphyseal metastases of long bones. The purpose of the paper is to assess the outcomes of intramedullary osteosynthesis in pathologic and impending pathologic fractures, to evaluate patient survival and potential complications. MATERIAL AND METHODS The retrospective study evaluated a cohort of 42 patients (19 men and 23 women) in whom intramedullary osteosynthesis was performed for complete pathologic fracture (28 patients) or impending pathologic fracture (14 patients) between 2010 and 2019. Of the total number of 42 patients, 31 patients' lower limbs were affected, namely by 17 pathologic fractures and 14 impending fractures. There were 11 humerus fractures. The mean age was 61.8 years (range 41-84 years). In the followed-up cohort, the patient survival after osteosynthesis with intramedullary nails, complications occurred and post-operative mobility of the patient were assessed. The functional outcomes were evaluated using the Musculoskeletal Tumor Society (MSTS) scoring system. The unpaired Mann-Whitney test was used to test the significance of the difference in functional outcomes and survival between the followed-up groups. Survival longer than 6 months was evaluated using Fisher's exact test. The level of statistical significance used for the test was p 0.05. RESULTS The investigated indicator was patient survival, which was 11.3 months (range 1-50 months) on average. In the group of impending fractures, the mean survival was 13.5 months. In the group of pathologic fractures, the survival was 10 months. The functional outcome in 16 followed-up patients at three months after intramedullary osteosynthesis according to the MSTS score was 46.9% (30-66.7%). At the level of significance of p 0.05, the statistically significant difference in the functional outcomes between the group with preventive intramedullary osteosynthesis and the group with nail osteosynthesis of the pathologic fracture was not confirmed (p=0.952). When comparing the patient survival after nail osteosynthesis with impending pathologic fracture and the survival of patients with pathologic fracture, a statistically significant difference in survival between these two groups (p=0.520) was not confirmed. The patient survival of longer than 6 months was 71% in the group of impending fractures and 40% in the group of pathologic fractures. DISCUSSION The occurrence of pathologic fracture is associated with increased pain, loss of function, and according to some authors, a higher risk of death. Surgical treatment options include intramedullary osteosynthesis, plate osteosynthesis with cement filling, implantation of an intercalary spacer, and implantation of tumor endoprostheses. When deciding on a surgical procedure, an account is taken of the expected survival of the patient. In patients with an expected survival of up to 6 months, intramedullary osteosynthesis is indicated as a palliative surgical intervention. The most common complications include implant failure and metastatic progression. CONCLUSIONS Intramedullary osteosynthesis is the method of choice in treating pathologic fractures or impending pathologic diaphyseal fractures of long bones in patients with an expected predicted survival of up to 6 months. Intramedullary osteosynthesis aims to reduce pain and enable early verticalization. The study confirmed the importance of preventive intramedullary osteosynthesis and its effect on survival compared to the survival of patients with a pathologic fracture. Key words: skeletal metastases, diaphyseal metastases, intramedullary osteosynthesis, pathologic fracture, impending fracture.

[Treatment of Giant Cell Tumor of Bone in the Distal Radius and Ulna]. / Lécba obrovskobunecného kostního nádoru distálního radia a ulny.

PURPOSE OF THE STUDY The preferred treatment of giant cell tumor of bone is curettage with the use of local adjuvant. If the tumor spreads beyond the bone into soft tissues, en bloc excision should be performed. Intralesional curettage allows joint preservation, but it is associated with a high recurrence rate. The purpose of the study was to identify the risk factors for local recurrence and to compare the functional outcomes after both types of surgical procedures. MATERIAL AND METHODS The group included 16 patients (5 women, 11 men) with giant cell tumor of bone in distal forearm treated at the First Department of Orthopedic Surgery, St. Anne s University Hospital Brno in 2005-2019. The mean age of patients was 38 years (22-53). The follow-up period was 6.75 years (2-15) on average. The most common location of the tumor was distal radius (14). In 6 patients denosumab treatment was indicated. Based on the obtained data, we compared the effects of gender, Campanacci grade, type of surgery and administration of denosumab on the risk of local recurrence. The functional outcomes were evaluated retrospectively based on the Musculoskeletal Tumor Society scoring system for upper limb salvage surgeries. RESULTS Resection and reconstruction using an osteocartilaginous allograft was performed in 9 patients. Seven patients were treated with tumor curettage with bone cement used to fill the cavity. The group of patients who underwent curettage showed a significantly higher mean MSTS score 89% compared to the group of patients with resection with the mean MSTS score 66% (P < 0.05). Local tumor recurrence was reported in 3 patients (18.75%). No statistically significant difference was found in gender, tumor grade, radicality of surgery or administration of targeted therapy with respect to the incidence of local recurrence. Altogether 6 complications (37.5%) were observed in the group. DISCUSSION The treatment of a giant cell tumor of bone aims to completely remove the tumor and to preserve the best possible function of the limb. The complications in distal forearm involve particularly an increase incidence of local recurrence and painful or limited range of motion of the wrist. Whereas curettage with the use of local adjuvant is burdened with a higher recurrence rate, resection with allograft reconstruction of bone defect is usually associated with poorer functional outcomes. CONCLUSIONS Tumor curettage using local adjuvant is preferred in a well-circumscribed tumor and offers an excellent functional outcome. En bloc tumor resection and reconstruction using an osteocartilaginous allograft is a suitable treatment option for a locally advanced tumor with a low risk of local recurrence. Key words: giant cell tumor of bone, distal radius, distal ulna, curettage, osteocartilaginous allograft.

[Long-Term Results of Total Knee Replacement Using P.F.C. Sigma System with an All-Polyethylene Tibial Component]. / Dlouhodobé výsledky totální náhrady kolenního kloubu P.F.C. Sigma s celopolyetylenovou tibiální komponentou.

PURPOSE OF THE STUDY Use of an all-polyethylene (all-poly, AP) tibial component in primary total knee arthroplasty is still an attractive option considering the durability of replacement, the elimination of backside wear and the lower cost compared to modular metalbacked tibia. The purpose of the study was to evaluate the long-term results of the total knee replacement using the P.F.C. Sigma system with a monoblock all-polyethylene tibial component implanted at the 1st Orthopedic Department of the St. Anne's University Hospital and Masaryk University Brno in the period 1999-2010. MATERIAL AND METHODS In the monitored period, 911 total knee replacements using P.F.C. Sigma with an all-polyethylene tibial component were performed. This cohort of patients was evaluated at least 10 years after the primary replacement surgery. Altogether 323 knee replacements in 289 patients were evaluated. The clinical outcomes were assessed according to the Knee Society Clinical Rating System (KSS) and the Total Knee Arthroplasty Roentgenographic Evaluation and Scoring System. The replacement survival was evaluated using the Kaplan-Meier survival analysis. RESULTS In the evaluated group, the average KS was 82.6 points and the average functional score was 74.7 points. Excellent results were recorded in 213 cases, good results in 78 and satisfactory in 23 replacements. Poor clinical results were reported in 9 patients. The average range of motion was 105.8°. In 5 knees (1.5%) revision surgery was performed for infection complications, 3 cases were complicated due to periprosthetic fractures, 4 replacements were revised due to anterior knee pain and 8 knees showed a limited range of motion. Only 1 replacement was revised for aseptic loosening, with no need for reimplantation of the component. The survivorship of the implant was 98.5 % at the follow-up of 12.8 years, including the reasons of reimplantation. DISCUSSION Total knee replacement with an all-polyethylene tibial component is not so popular as the metal-backed modular implants. The all-polyethylene tibial component has certain advantages: lower unit costs, no backside wear, no liner dislocation, possibility of conservative bone resection. On the other hand, this type of implant is not modular and augmentations or longer stems cannot be used. Even though this type of endoprosthesis is recommended exclusively for elderly patients with a lower level of activity, the current mid- and long-term results show that indications for all-poly implants are much broader. CONCLUSIONS The total knee replacement with an all-polyethylene tibial component shows very good long-term clinical outcomes with an excellent survival rate. The all-poly design is cost-effective and may be used not only in elderly patients. Key words: total knee replacement, all-polyethylene tibial component, long-term results.

[Open Incisional Biopsy and Ultrasound-Guided Core Needle Biopsy of Extremity-Localized Musculoskeletal Tumors]. / Otevrené incizní biopsie a ultrazvukove navigované punkcní biopsie nádoru pohybového aparátu v oblasti koncetin.

PURPOSE OF THE STUDY To evaluate the results of incisional open biopsies and ultrasound-guided core needle biopsies for musculoskeletal lesions in extremity and limb girdle locations. MATERIAL AND METHODS In 2019, 176 open incisional biopsies were performed at our department, 113 from bone lesions and 63 from soft tissue lesions. In the period of September 2019 to February 2020, we started performing also ultrasound-guided core needle biopsies from soft tissue lesions in limited indications, namely in 23 cases. The diagnostic accuracy, complications and pain associated with the procedure were evaluated. RESULTS Of 113 open incisional biopsies of bone, 91.1% was fully representative and 6.2% non-representative with an indication for re-biopsy. In 53 cases another surgical procedure followed, which fully confirmed the diagnosis made based on the biopsy in 79.2%. In 7.5% the diagnosis slightly changed, with no therapeutic impact, in 5.7% the histological grade was changed, and in 7.5% the diagnosis was substantially modified. Complications appeared in 9.8% of cases. The procedure was associated with pain expressed by an increase in VAS score by 2.7 points. Of 63 soft tissue open incisional biopsies, 100% was fully representative. In 30 cases another surgical procedure followed, which fully confirmed the diagnosis made based on the biopsy in 96.7%, in one case the diagnosis was changed from aggressive benign lesion to a low-grade sarcoma. Complications appeared in 6.4% of cases. The procedure was associated with pain expressed by an increase in VAS score by 1.4 points. Of 23 ultrasound-guided core needle biopsies from soft tissues in limited indications, 100% was representative. In 11 cases another surgical procedure followed, which fully confirmed the diagnosis made based on the biopsy in 81.8%, in 2 cases the diagnosis was slightly changed, with no therapeutic impact or a change of histological grade. No complications were reported. The procedure was associated with minimal pain expressed by an increase in VAS score by 0.1 points. When comparing the group of soft tissue open incisional biopsies and ultrasound-guided core needle biopsies, a statistically significant less pain associated with the procedure was found in the group of core needle biopsies. CONCLUSIONS The biopsy of musculoskeletal tumors should be performed at specialty centers for treatment of these rare conditions. In that case it produces good results and is associated with a low rate of complications. Indications for open biopsy or core needle biopsy must be assessed individually. Key words: musculoskeletal tumors, bone and soft tissue sarcomas, open incisional biopsy, core needle biopsy, fine needle aspiration biopsy, ultrasound-guided core needle biopsy.

[Use of Solid Intercalary Allografts for Reconstruction Following the Resection of Primary Bone Tumors]. / Vyuzití solidních interkalárních allostepu k rekonstrukci po resekcích primárních kostních nádoru.

PURPOSE OF THE STUDY There are several treatment options for bone tumors at diaphyseal/metadiaphyseal sites of long bones (with joint preservation) including massive intercalary allografts, autografts (vascularized or non-vascularized fibular autograft, devitalised tumor bearing bone), endoprosthetic replacement (intercalary spacer), cementoplasty with ostheosynthesis and distraction osteogenesis. Reconstruction using massive intercalary bone allografts is for us the method of choice in case of curable primary bone tumors at the diaphyseal/metadiaphyseal region. The purpose of this study is to evaluate our results and complications. MATERIAL AND METHODS Our retrospective study reviewed 41 patients after intercalary allograft reconstruction following the resection of primary bone tumors in the years 2000 - 2014. The group consists of 27 men and 14 women with the mean age at the time of diagnosis 27 years and the mean follow-up (from primary surgery) was 7 years. The patients were diagnosed with the Ewing sarcoma (14), chondrosarcoma (9), osteosarcoma (8), adamantinoma (6), OFD-like adamantinoma (2) and aneurysmatic bone cyst (2). The site of tumor were tibia (18), femur (16), humerus (5), radius (1) and ulna (1). We retrospectively evaluated the results of this intercallary allograft reconstructions, the incidence of failures and complications as well as the role of risk factors. RESULTS 14 patients (34.1%) successfully healed without complications. In the same number of patients (14 patients, 34.1%) the allograft reconstruction failed. 7 of these patients underwent amputation (17.1%), 6 of whom for oncological complications (local recurrence) and only 1 for complications of the reconstruction (infection). Other 7 patients with an allograft-related failure were successfully treated with a limb salvage procedure and underwent a new reconstruction. The remaining 13 patients (31.7%) suffered from complications that did not result in a failure of the reconstruction. The major complications of the reconstruction were the non-union (53.7%), fractures and allograft resorption (14.6%) and infection (7.3%). By statistical evaluation of common risk factors a statistically significant relationship was found between uncomplicated healing and stable bridging osteosynthesis (p = 0.014), between allograft fractures/resorptions and non-bridging osteosynthesis (p = 0.018), and the lowest reoperation rate was connected with plate osteosynthesis (0.037). DISCUSSION AND CONCLUSIONS The intercalary allograft reconstruction is an important biological method in orthopaedic tumor surgery. Even though it is connected with a high rate of complications (non-union, fracture and resorption, infection), in the vast majority of cases they can be solved, while achieving limb-salvage and good function of extremity. The essential prerequisite for successful uncomplicated healing of reconstruction is the stable bridging osteosynthesis, preferably with a plate. In high risk patients with a combination of recognized important risk factors described in literature (adult patients, large resection (more than 15 cm), femoral location and aggressive oncological treatment) we nowadays try to reduce the complication rate with a primary combination of an allograft with vascularized fibular autograft. Key words:biological bone reconstruction, massive intercallary allograft, stable bridging osteosynthesis, primary bone tumors.

[Kombinovaná lécba mekkotkánového sarkomu v oblasti pánve]. / Kombinovaná lécba mekkotkánového sarkomu v oblasti pánve.

Soft tissue sarcomas (STS) constitute a heterogeneous group of rare malignant tumors of mesenchymal cell origin and they may develop in any part of the body. They can form enormous masses in certain localizations. A case report of a young woman with locally advanced liposarcoma in the pelvic cavity is presented. This example emphasizes the significance of early diagnosis, as only radical surgery can be potentially curative in sarcoma therapy.Key words: advanced pelvic sarcoma multimodal treatment multidisciplinary.