[Eleven-Year Experience with Total Ankle Arthroplasty]. / Jedenáctileté zkusenosti s náhradou hlezna.

UNLABELLED: PURPOSE OF THE STUDY Total joint replacement is one of the options in surgical treatment of advanced ankle arthritis. It allows the ankle to remain mobile but, unfortunately, it does not provide the same longevity as total knee or hip replacements. Therefore, decisions concerning the kind of treatment are very individual and depend on the clinical status and opinion of each patient. MATERIAL AND METHODS A total of 132 total ankle replacements were carried out in the period from 2004 to 2015. The prostheses used included the Ankle Evolutive System (AES) in 52 patients, Mobility Total Ankle System (DePuy) in 24 patients and, recently, Rebalance Total Ankle Replacement implant in 53 patients. Three patients allergic to metal received the Taric prosthesis. Revision arthroplasty using the Hintegra prosthesis was carried out in four patients. The outcome of arthroplasty was evaluated on the American Orthopaedic Foot and Ankle Society (AOFAS) scoring scale. Indications for total ankle arthroplasty included post-traumatic arthritis in 83 patients, rheumatoid arthritis in 37 and primary arthritis in 12 patients. There were 78 women and 54 men, with an average age of 55.6 years at the time of surgery. RESULTS The average follow-up was 6.1 years (1-11 years). The average AOFAS score of the whole group increased from 33.2 before surgery to 82.5 after it. The primary indication had an important role. Arthroplasty outcomes were poorer in patients with post-traumatic arthritis than in those with rheumatoid arthritis or primary arthritis. In patients with post-traumatic arthritis, the average AOFAS score rose to 78.6 due to restricted motion of the ankle, and some patients continued to have pain when walking. The average AOFAS score in a total of 49 patients who had rheumatoid arthritis or primary arthritis reached a value of 86.4. Post-operative complications were recorded in ten patients (7.6%) in whom part of the wound was healing by second intention. Ossification was also a frequent complication and had to be removed in six patients (4.5%). No early infection was recorded and late infection was treated in three patients. The prosthesis had to be removed and ankle arthrodesis performed in seven patients (5.3%). All had necrosis of the talus with ankle instability. In five, the retrograde nail Medin was used and extensive defects remaining after talar necrosis were filled with massive bone grafts obtained from a bone bank. One patient required tibio-calcaneal arthrodesis with external fixator; surgery in one case involved the use of a Zimmer Trabecular Metal Ankle Fusion Spacer with retrograde nail fixation. The development of cystic radiolucencies adjacent to tibial or talar components presents another post-operative complication. It was recorded mostly in the patients after AES implantation, in whom eight of 52 (15.3%) had these findings. DISCUSSION Total ankle arthroplasty is a complicated surgical procedure potentially associated with various technical problems. The occurrence of complications is indirectly related to the experience of the orthopaedist performing surgery; literature data show that the number of complication decreases with an increased frequency of ankle replacements done. CONCLUSIONS Total ankle arthroplasty, as every orthopaedic surgery, has its advantages and disadvantages. The positive aspects are pain relief and improved mobility of the ankle allowing for physiological gait. However, it shows a lower survivorship rate that the other large joint replacements. A successful outcome depends on the correct indication. The ankle should be stable, the talus without signs of necrosis and valgus or varus deviations of the ankle should not exceed 10 to 15 degrees. KEY WORDS: total ankle arthroplasty, re-implantation, aseptic loosening, retrograde nail, Trabecular Metal spacer, revision arthroplasty.

The National Register of Joint Replacements of the Czech Republic.

The National Register of Joint Replacements of the Czech Republic was established as part of the National Health Information System in 2002. The register's administrator is the Institute of Health Information and Statistics of the Czech Republic, the Czech Society for Orthopaedics and Traumatology acts as its guarantor of scientific quality. The register is financed from governmental sources. It was launched into full operation in 2003 and it currently focuses on hip joint replacements. Register of knee and shoulder joint replacements is in the process of preparation. The register provides aggregate epidemiological data and other statistics, including the Revision Rate (RR) and curves of cumulative survival probability (Kaplan-Meier) for the main monitored groups of patients and implants used. In years 2003-2012 there were 101,734 primary implantations and 13,459 revision surgeries registered. In terms of gender distribution there is a predominance of females amounting to 59.4% in primary implantations and to 63.49% in revision surgeries. The age structure covers the entire range of adult population; however, more than 50% of the replacements are being implanted between 60-74 years of age. Most frequent indications for primary implantation are primary coxarthrosis (69.85%), post-fracture conditions (13.41%) and post-dysplasia arthritis (8.73%). The most frequent indications for revision surgery are aseptic loosening of acetabular component (38.15%), aseptic loosening of femoral component (22.01%) and recurrent dislocation (6.5%). 45,450 (44.68%) of primary implantations were cemented, 36,477 (35.86%) uncemented, 16,559 (16.28%) hybrid with cemented femur and 656 (0.64%) hybrid with cemented acetabulum. There were also records of 2,592 cervicocapital prostheses (2.55%). Most commonly used is the classic anterolateral approach 75.86% in primary implantations and 50.06% in revision surgeries. Mini-invasive approaches in primary implantations did not exceed 3.2% of all cases. Bone grafts were used in 23.89% of primary implantations and 39.55% of revisions. Most widely used implants in primary implantations were cemented PE cup type Muller (Aesculap) 14,000 pcs, original Czech cemented steel Stem with conical neck 12/14 AK (Beznoska) 13,433 pcs, from uncemented models Plasmacup SC (Aesculap) 9,762 pcs and Stem SL "Zweymüller Alloclassic" (Zimmer) 4,337 pcs. Generally most widely used implants in revision surgeries are uncemented Czech Oval cup MO (Medin) with titanium & hydroxyapatite porous coat 956 pcs and uncemented Stem SL WAGNER, lateralised, cone 12/14 (Zimmer) 712 pcs. The Revision Rate for primary implants due to infection for period 2003-2012 represented 0.06% at the end of the followup as of June 30, 2013. Cumulative survival probability (Kaplan-Meier) in year 11 of the follow-up is 95.69% in cemented implants, 94.55% in uncemented, 92.90% in hybrids with cemented femur and 84.11% in hybrids with cemented cup.

[All-polyethylene tibial component in Walter-Motorlet total knee arthroplasty. Long-term outcomes]. / ALL-POlY standardní tibiální komponenta náhrady kolenního kloubu Walter-Motorlet v dlouhodobém hodnocení

PURPOSE OF THE STUDY: An analysis of long-term results of the all-polyethylene tibial component in Walter-Motorlet cemented condylar knee arthroplasty, with a standard tibial plateau (STP) of our own design. MATERIAL AND METHODS: A total of 49 patients underwent knee replacement; of them, 35 (71.4%) with 38 Walter-Motorlet implants using the STP were evaluated. The average age at the time of evaluation was 87.3 years. The follow-up ranged from 18 to 27 years (average, 24.6 years). Mechanical properties of the STP were tested by experimental measurements and in a photoelasticimetric study. The clinical results were evaluated according to the EULAR Knee Assessment Chart (EKACH). Twenty-four patients (26 knees; 49%) had osteoarthritis (OA) and 11 (12 knees; 23%) had rheumatoid arthritis (RA). Of the 14 (28.6%) patients not included in evaluation, seven (14.3%), with seven knees, required revision arthroplasty and seven (14.3%), with 10 knees, were lost to follow-up. RESULTS: Of the 38 implants evaluated by the EKACH at an average of 24.6 years, subjectively, 14 (36.8%) knees were free from pain and 14 (36.8%) were mildly painful. The remaining 10 (26.4%) joints were acutely painful on walking up or down the hill. In 14 (36.8%) cases the patients experienced their knees as stable. Light domestic chores were routinely performed by 17 patients (10 OA and 7 RA; 48.6%). One (2.9%) OA patient had a full-time job, and nine (25.7%) patients were socially independent. The functional outcome was significantly related to the patient's age at the time of evaluation. Complications included STP aseptic loosening in five (13.1%) and late infection in two (5.2%) knees. Radiography showed translucent zones below an all-polyethylene component in 14 (36.8%) knees. DISCUSSION The five cases of aseptic loosening may have been due to insufficient hardness of a U-shaped polyethylene component and long-term stress at the bone-implant interface. In the majority of knees the anterior cruciate ligament was defective or missing completely. Maintenance of the posterior cruciate ligament facilitates absorption of the greater part of forces at the cement-bone interface, as also reported by other authors. The high incidence of complications associated with patellar components, as described in the literature of the late 1970s and the early 1980s, led us to avoid the primary use of a patellar implant. CONCLUSIONS: Our evaluation showed that, in 73% of the cases, the all-polyethylene tibial component was a suitable and inexpensive implant with very good or good long-term results on average at 24.6 years of follow-up. Since the quality of currently produced polyethylene is high, we recommend the use of all-polyethylene tibial components in all indicated cases.

[Tibio-talo-calcaneal arthrodesis with the retrograde intramedullary nail MEDIN]. / Tibiotalokalkaneální artrodéza retrográdním hrebem MEDIN.

PURPOSE OF THE STUDY: When the talus and the talocalcaneal joint are both affected, their fusion is the method of treatment. Ankle arthrodesis is carried out using various osteosynthetic materials such as external fixators, screws and plates. One of the options is retrograde nailing. Tibio-talo-calcaneal arthrodesis is frequently indicated in patients with rheumatoid arthritis (RA) in whom both the talus and the subtalar joint are often affected. MATERIAL AND METHODS: A retrograde nail for tibio-talo-calcaneal arthrodesis was developed at our department in cooperation with MEDIN Company. This is a titanium double-curved nail, with the distal part bent at 8 degrees ventrally and 10 degrees laterally. It is inserted from the transfibular approach. RESULTS: Sixty-two patients, 35 women and 27 men, were treated at our department from 2005. Since one patient had bilateral surgery, 63 ankles were included. The indications for arthrodesis involved rheumatoid arthritis in 42, post-traumatic arthritis in 10, failed ankle arthrodesis in two and failed total ankle arthroplasty in five ankles; tibial stress fractures close above the ankle in two RA patients, one patient with dermatomyositis and one with lupus erythematodes. The average age at the time of surgery was 64.2 years (range, 30 to 80). The average follow-up was 4.5 years (range, 1 to 9 years), Satisfaction with the treatment outcome and willingness to undergo surgery on the other side were reported by 82% of the patients. The AOFAS score improved from 35 to 74 points. Three (4.8%) patients complained of painful feet due to the fact that exact correction of the calcaneus was not achieved and the heel after arthrodesis remained in a slightly varus position. Of them, two had a failed total ankle arthroplasty. Post-operative complications included early infection managed by antibiotic treatment and early surgical revision with irrigation.in two (3.2%) RA patients, who were undergoing biological therapy. Late infection developed at 2 to 3 years after surgery in three (4.3%) patients (two had RA). The infection was managed by revision surgery with nail removal and irrigation. All patients healed well. Necrosis of the talus and development of a pseudoarthrosis were recorded in four (6.4%) patients, who subsequently underwent nail removal and repeat fusion using an external fixator. DISCUSSION: Retrograde nailing for tibio-talo-calcaneal arthrodesis is used by many authors. Its complication rate is comparable with the other methods of arthrodesis. CONCLUSIONS: The use of tibio-talo-calcaneal arthrodesis aims at a painless and stable joint. Arthrodesis of the talus and the subtalar joint using a retrograde nail is an effective surgical treatment of the joints affected. It is especially recommended for RA patients who have severe deviations. Retrograde nailing provides a stable osteosynthesis which does not require plaster cast immobilisation. The double-curved nail allows for its insertion in the solid part of the calcaneus and helps avoiding injury to the neurovascular bundle.

[Multidirectional screw fixation in the treatment of distal radius fractures using angle-stable plates]. / Význam multidirekcionálního zavedení sroubu pri osetrení zlomenin distálního radia úhlove stabilní dlahou.

PURPOSE OF THE STUDY: Intra-articular fractures of the distal radius are treated predominantly by open reduction and internal fixation with various types of angle-stable plates. In this study we compare functional and radiographic outcomes in patients with intra-articular distal radius fractures treated with either angle-stable plates with rigid-direction screw insertion or multidirectional angle-stable plates. MATERIAL AND METHODS: The LCP group included 37 patients with an average age of 50 years (range 20-81 years) who were treated using angle-stable plates with rigid-direction screw insertion (LCP, Synthes). The APTUS group comprising 41 patients with an average age of 48.9 years (range 22-77 years) was treated by angle-stable implants in which screws can pivot freely in all directions (Aptus, Medartis). There was no significant difference between the groups in relation to fracture severity, age or other relevant characteristics. In all cases we used the volar approach. The final evaluation of treatment outcome was made at 12 months after surgery. We measured the range of wrist motion and hand grip strength, and compared the values with those obtained in the contralateral wrist. The results evaluated on the scoring systems of Gartland and Werley and of Castaing, and the DASH score were compared between the groups. The findings on radiographs were compared with the anatomical standard in the distal radius region. RESULTS In the LCP group, the average values, as compared with the contralateral side, were as follows: volar flexion, 84.2 %; dorsal flexion, 82.4 %; radial deviation, 83.2 %; ulnar deviation, 89.1 %; pronation, 98.6 %; supination, 97.4 %. In the APTUS group, the values in comparison with the other wrist were: volar flexion, 84.1 %; dorsal flexion, 91.8 %; radial deviation, 95.1 %; ulnar deviation, 92.8 %; pronation, 99.0 %; supination, 98.1 %. The values statistically comparable with the contralateral side were those in pronation, supination and hand grip strength in both groups. In addition, in the APTUS group, the values corresponding to the healthy wrist function were achieved in both radial and ulnar deviation. There were no differences in the values based on the scoring systems between the LCP and APTUS groups. As for the radiographic parameters, only the reconstruction of radial length was optimal. The other parameters differed from the anatomical standard. However, all patients met the criteria of successful healing of a distal radius fracture. Secondary fragment displacement during healing was recorded in two patients of the LCP group and in one of the APTUS group. Transient irritation of the median nerve was observed in five LCP group patients and in only one APTUS group patient. One patient in each group had an extensor tendon rupture. Reflex sympathetic dystrophy syndrome was diagnosed in two LCP group patients and in three APTUS group patients. DISCUSSION The surgical treatment of complex fractures of the distal radius using the angle-stable implants has generally achieved very good functional and radiographic outcomes with a low rate of complications. In the APTUS group, in contrast to the LCP group, the extent of radial and ulnar deviation corresponded to that found in the healthy wrist. The reason was a low-profile design of the plate and the screws, and the system with multidirectional angle-stable screws. The fewer cases of median nerve irritation in the APTUS group can be explained by the use of a different operative approach reducing the risk of direct mechanical nerve injury. In contrast to other authors, flexor tendon ruptures were not recorded in our groups. CONCLUSIONS The treatment of distal radius fractures by the angle-stable locking plate system from the volar approach achieved comparable functional and radiographic outcomes with both rigid-direction screw insertion and multidirectional screw insertion.

[Comparison of in vivo characteristics of polyethylene wear particles produced by a metal and a ceramic femoral component in total knee replacement]. / Srovnání oterových charakteristik polyetylenu in vivo u náhrad kolena s kovovou a keramickou femorální komponentou.

PURPOSE OF THE STUDY: The aim of the study was to evaluate in vivo and compare, in terms of the quality and number of ultra high-molecular polyethylene (UHMWPE) wear particles, total knee replacements of identical construction differing only in the material used for femoral component production, i.e., CoCrMo alloy or ZrO2 ceramics. MATERIAL AND METHODS: Samples of peri-prosthetic granuloma tissue were collected in two patients with total knee replacement suffering from implant migration, who were matched in relevant characteristics. The primary knee replacement in Patient 1 with a CoCrMo femoral component was done 7.2 years and in Patient 2 with a ZrO2 implant 6.8 years before this assessment. The polyethylene wear-induced granuloma was analysed by the MORF method enabling us to assess the shape and size of wear debris and the IRc method for assessment of particle concentration. RESULTS: In the granuloma tissue samples of Patient 1, on the average, particles were 0.30 mm in size and their relative volume was 0.19. In the Patient 2 tissue samples, the average size of particles was 0.33 mm and their relative volume was 0.26. There was no significant difference in either particle morphology or their concentration in the granuloma tissue between the two patients. DISCUSSION: One of the options of how to reduce the production of polyethylene wear particles is to improve the tribological properties of contacting surfaces in total knee replacement by substituting a cobalt-chrome femoral component with a zirconia ceramic femoral component. The previous in vitro testing carried out with a mechanical simulator under conditions approaching real weight-bearing in the human body did show a nearly three-fold decrease in the number of UHMWPE wear particles in zirconia components. The evaluation of granuloma tissue induced by the activity of a real prosthetic joint for nearly seven years, however, did not reveal any great difference in either quality or quantity of polyethylene debris between the two replacements. The difference of surface roughness between CoCrMo (Ra = 0.05) and ZrO2 (Ra = 0.02) components did not play any role in in vivo conditions. CONCLUSIONS In accordance with a previous clinical study, this evaluation of the quality and quantity of UHMWPE wear particles produced by a ceramic femoral component in vivo failed to demonstrate any advantage of zirconia ceramic components over the cobalt-chrome femoral components so far used.

[Total elbow replacement in patients with rheumatoid arthritis]. / Totální náhrada loketního kloubu v lécbe nemocných s revmatoidní artritidou.

PURPOSE OF THE STUDY: Total elbow arthroplasty is associated with a higher occurrence of complications than is usual for large-joint replacements. Two kinds of prostheses, unconstrained and semi-constrained, are currently used and each has its supporters or opponents. In this study the results of the two techniques used in our patients are evaluated and compared. MATERIAL: Two groups of elbows in patients with rheumatoid arthritis were evaluated. One comprised 58 elbows treated by Souter-Strathclyde total elbow arthroplasty (S-S group). The mean age of the patients at the time of surgery was 53 years (range, 22 to 71) and the mean follow-up was 9.5 years (range, 0.7 to 16.7). The other group included 63 elbows treated by Coonrad-Morrey elbow arthroplasty (C-M group). The mean age of the patients at the time of surgery was 54 years (range, 26 to 75) and the mean follow-up was 4.21 years (range, 0.28 to 7.87). METHODS: The Kaplan-Meier analysis was used to estimate implant survival in each group. Clinical assessment included range of motion and pain experience. The Mayo Elbow Performance Score (MEPS) was used as a clinical rating scale for the whole group. Radiographs were taken in two basic projections. The elbows with an implant removed or re-implanted were excluded from the evaluation. The patients were studied prospectively. The results were statistically analysed, with the level of significance set at 0.05. RESULTS: All patients experienced pain relief after surgery. In the S-S group, 35 elbows were free from pain (77.7 %), in the C-M group this was 53 elbows (88.3 %). The range of motion improved after arthroplasty in both groups. Flexion more than 110° was achieved in twice as many elbows in the C-M group than in the S-S group. Flexion contracture in the S-S group did not improve significantly. MEPS values after surgery improved in both groups, with significantly better results in the C-M group. In the S-S group, four elbow arthroplasties (6.9 %) showed instability, which was treated by replacement with a semi-constrained implant in one case and managed by articulated external fixation of the elbow for 6 weeks in three cases. Radiolucent lines were detected in five replacements (11.1 %) along the whole ulnar component width, in 12 (26.6 %) in the olecranon region and in 14 (31.1 %) in the distal humeral component. In the C-M group no radiolucency was recorded around the component. In the S-S group, revision surgery was carried out in 13 arthroplasties (22.4 %); of these, 10 (17.2%) were due to aseptic loosening, one (1.7 %) due to instability and one (1.7%) because of deep infection. In the C-M group, three elbows required revision (4.8 %), one for periprosthetic fracture (1.6 %) and two for deep infection (3.2 %). The results of survival analysis did not differ between the two groups. DISCUSSION: The weak point of Souter-Strathclyde total elbow arthroplasty is the ulnar component whose impairment and subsequent wear are involved in all cases of aseptic loosening. An insufficient length of the humeral component is another risk factor. Even natural movements of the elbow joint produce concentration of stresses on a small surface; this gradually weakens component fixation in bone and results in aseptic loosening. A higher risk of failure in Coonrad-Morrey elbow arthroplasty is associated with polyethylene lining of the hinge mechanism. CONCLUSIONS: The Coonrad-Morrey total elbow replacement is at present considered the method of choice. It is easier to perform and provides better functional outcomes than the Souter-Strathclyde elbow implant.

[Our experience with AES total ankle replacement]. / Nase zkusenosti s náhradou hlezna AES.

PURPOSE OF THE STUDY: The method of choice for the treatment of severe ankle arthritis is either arthrodesis or joint arthroplasty. Each has its advantages and disadvantages. Arthrodesis is the definitive therapy for severe ankle destruction and instability. Joint arthroplasty has an advantage in maintaining ankle mobility. However, its range of indications and its reliability and durability are more limited. The aim of this study is to present our experience with the AES prosthesis and draw attention to some drawbacks of this surgical treatment. MATERIAL: From September 2003 till June 2008, 51 AES ankle replacements were carried out in 51 patients (33 women and 18 men). Their average age at the time of surgery was 53.8 years. The youngest patient was 23 and the oldest was 88 years old. The indication for surgery was rheumatoid arthritis in 10, primary arthritis in six and post-traumatic ankle arthritis in 35 patients. METHODS: The patients were evaluated in 2008. The follow-up ranged from 4 months to 5 years. The patients were examined for ankle joint mobility and pain. Radiographs were assessed for potential signs of component loosening. RESULTS: The results presented here are short-term ones. The pre-operative AOFAS score of 33.7 increased to 82.3 points post-operatively. The range of motion was on average 20 degrees of plantar flexion and 5 to 10 degrees of dorsiflexion. Thirty- five patients (68.7 %) were free from pain, 11 (21.5 %) experienced slight pain while walking, and five (9.8 %) patients reported more intensive pain in the joint treated. Intra-operative complications included a fracture of the medial malleolus in two (3.9 %) patients subsequently treated with screw osteosynthesis. Post-operatively, seven (13.7 %) patients experienced slow healing of the operative wound. One patient had dislocation of the polyethylene liner at 3 months after surgery. Revision surgery was carried out in seven (13.7 %) patients. Two patients suffering from increasing pain around medial malleolus underwent revision and removal of ossifications. One patient developed necrosis of the talus at 1 year after surgery. She underwent extraction of the prosthesis and ankle arthrodesis with a retrograde locking nail inserted through the heel. A large bony effect arising due to extraction of the necrotic talus was repaired using bone graft. Three (5.8 %) patients developed post-operative instability of the ankle that required revision surgery. The radiographs of another three (5.8 %) patients showed bone cysts and signs of tibial component loosening. Of these, one patient underwent surgical revision with replacement of the polyethylene liner. Cavities were freed from granuloma induced by polyethylene wear debris, and filled with bone graft from the iliac crest. DISCUSSION: Total ankle replacement is a complicated surgical procedure that may results in various technical difficulties and complications. These are inversely proportional to the surgeon's experience, as also shown by literature data. CONCLUSIONS: The longevity of a total ankle replacement depends, much more than in other joint replacements, on an accurate implantation technique and correct indication.

[Custom-designed 3D tibial augmentation for knee replacement]. / Individuální 3D tibiální augmentace pro náhrady kolenního kloubu.

Reconstruction with the use of custom-made implants aims at optimal replacement of lost or damaged bone structures and restoration of their funkction. In this study the development and construction of a custom-made implant and the operative technique used for the treatment of an extensive tibial defect are described. The patient was a 65-year-old man treated for over 20 years for psoriatic arthritis and severe instability of the right knee, particularly in the frontal plane, with a worsening varus deformity. The radiogram showed an extensive destruction of the medial tibial condyle that also deeply involved the lateral condyle. The extent of defect made it impossible to use any commercial tibial augmentation. The geometry of the custom-designed implant for the medial tibial condyle was constructed on the basis of a 3D defect model and the shape of the medial tibial condyle of the collateral knee seen on CT scans. After its correct shape was verified on a plastic model, its coordinates were set in the software of a machine tool, and a titanium augmentation otherwise compatible with a standard knee replacement was produced.The use of such a custom implant to complete standard total knee arthroplasty has so far been demanding in terms of organisation and manufacture. Its production in the future could be facilitated by substituting titanium for plastic material such as poly-ether-ether-ketone (PEEK). Key words: custom-made implant, tibial augmentation, knee prosthesis.

[Medin modular implant for total knee arthroplasty--mid-term results]. / Strednedobé výsledky u náhrad kolenního kloubu Medin Modular.

PURPOSE OF THE STUDY To evaluate the mid-term results of total knee arthroplasty (TKA) using a Medin Modular joint prosthesis in a standard design preserving the posterior cruciate ligament. MATERIAL The study comprised 206 consecutive total knee arthroplasties, 10 bilateral, 60 in men and 136 in women. Twelve patients died of causes unrelated to the surgery and 14 knee replacements were lost to follow-up. A total of 180 were evaluated at an average follow-up of 6.5 years (range, 5 to 8.7 years). The patients ranged in age from 43 to 84 years (average, 69.5 years). The basic indication for surgery was osteoarthritis in 179 and rheumatoid arthritis in 37 cases. METHODS Pain, range of motion, stability and function were scored on a 100-point scale of the Hospital for Special Surgery (HSS) Scoring System. Subjective satisfaction was essessed by the patient's willingness to undergo the surgery again. At yearly intervals, radiographs in two projections were examined for radiolucent lines around the implant. The Kaplan-Meier survival curve was evaluated for the whole group and compared with that for non-infected cases only. The mechanical properties of the implant were most reliably shown by the survival curve for the subgroup of knee replacements free of infection. RESULTS At the final follow-up out of 180 knees, 169 were fully functioning and 11 required revision arthroplasty for the following reasons: polyethylene wear, one knee; instability, two; infection, six; patellar fracture, one; and problems associated with the femoro-patellar joint, one knee. The Kaplan-Meier curve for the whole group showed survival of 92 % of the implants at the end of the 9-years follow-up time. In the infection-free subgroup, in which aseptic loosenings were only included, there was a 95 % survival. The average range of flexion was over 106 degrees, and only 11 knees had flexion below 90 degree lack of. Extension from 5 to 10 degrees was found in four knees. Thirteen knees showed instability that did not interfere with function. In 191 knees, after surgery alignment was optimal, between 0 and 5-degree valgus; in 11 knees varus up to 5 degrees and valgus up to 10 degrees were found. No pain was recorded in 123 knees, occasional pain with no effect on function in 36 cases, and moderate pain after weight-bearing in 10 knees. By the HSS score, 136 knees had excellent and very good (over 90 points) outcomes and 21 had unsatisfactory or poor outcomes (below 85 points); the remaining 23 had satisfactory outcomes (between 89 and 85 points). The subjective evaluation was positive for 156 knees. Of 169 TKA evaluated radiographs, 141 were without signs of radiolucency, 17 showed a slight marginal radiolucent line and 11 had a more pronounced radiolucent line up to 1 mm in width, but without progression. DISCUSSION A total of 93 % of total replacements were evaluated and 7 % were lost to follow-up. Therefore, the number of remaining patients is big enough to make the group valid for assessment. The rate of complications, including 2.9 % of infected knees, is in agreement with the reported values. The occurence of polyethylene wear was negligible. A comparison of the cumulative survival curve for the whole group with that for the infection-free subgroup showed that the effect of infection on the TKA outcome was statistically significant (p=0.0431), and that late infection remains the most serious complication. Aseptic loosening plays a less important role in implant survival evaluated at mid-term intervals. CONCLUSIONS The rate of complications for Medin Modular implants evaluated at an average follow-up of 6.5 years is not different from the values reported for similar prostheses. The most serious complication is late infection. Persistent pain is usually located to the femoro-patellar articulation, but it seldom markedly affects joint function. The cumulative survival curve for the whole group was 92 % at a 9 years. The HSS evaluation of the whole group showed that 75 % of the knees achieved mor than 90 points.

[Oblong implants for revision total hip arthroplasty]. / Oválné implantáty v problematice revizí totálních náhrad kycelního kloubu.

PURPOSE OF THE STUDY: A prerequisite for the successful implantation of an acetabular component in a defective bone tissue is, in addition to providing sufficient primary fixation of the implant, reconstruction of the acetabular bone bed. To achieve this, one of the options involves the use of an oblong implant. Data published on this topic are sparse and therefore the aim of this study was to gain a deeper insight into this issue. In addition, we wanted to compare the results achieved with the oblong component with those obtained using its original model. MATERIAL: One group comprised 111 patients with 133 sides who underwent acetabular revision for aseptic loosening or extraction of an infected acetabular component with subsequent implantation of an oblong cup (Langs-Ovale Revisionspfanne [L.O.R.], Allopro, Switzerland). The average age of this group at the time of surgery was 62.2 (range, 31-83) years, and average follow-up was 9.7 (range, 0.6-13.9) years. The other group consisted of 134 patients with 152 sides who for the same indications as the L.O.R. group received a Walter Oval cup (Medin Orthopaedics, Czech Republic). The average age at the time of surgery was 64.6 (22-86) years, and average follow-up was 7.3 (range, 1.1-9.8) years. The proportion and nature of defects and underlying clinical diagnoses in the two groups were statistically comparable. The patients requiring replacement or removal of the acetabular component were not included in clinical evaluation, but their data were used for survival analysis. The clinical evaluation included: in the L.O.R. group, 115 hip joints at an average follow-up of 10.8 (range, 4.5-13.9) years and, in the Walter Oval group, 144 hip joints at an average follow-up of 7.5 (range, 2.3-9.8) years. The data of patients who died during ;the study (L.O.R., 7 Walter Oval, 11) were included in the clinical evaluation as of the date of the final follow-up. METHODS: The results for each group were evaluated using the Kaplan-Meier survival analysis, with a simple survival curve and a"worst case" survival curve. The statistical difference between the curves was calculated by the Gehan-Wilcoxon test. Survival tables were constructed for 12 or 8 years. A comparison of the initial and the final Harris hip score (HHS) was made using the t-test. Radiographs were inspected for the signs of implant migration, the presence of translucent lines surrounding the implant and screws and screw breaks. The results were evaluated by the Chi-square and Fisher's exact tests, with the level of significance set at 0.05. RESULTS: In the I.O.R. group, 18 implants (13.5%) were reimplanted or removed in the Walter Oval group it was eight cups (5.3%). Aseptic loosening was the cause of reimplantation in 8.3% and 3.9% of the hips in the L.O.R. and Walter Oval groups, respectively. Deep infection required revision surgery in 5.3% of the L.O.R hips, and in 1.3% of the Walter Oval hips. The Walter Oval group showed a longer implant survival, but this was not confirmed by the "worst case" analysis. The final HHS markedly improved in comparison with the initial one in both groups. No radiographic difference between the groups was found. DISCUSSION: The comparison of our results with those of other methods used in the indications described here provides evidence in favour of oblong implants. The major advantage, as well as the condition of success, is the anchoring of an oblong cup in the patient's own load-bearing bone. CONCLUSIONS: Acetabular defects in the range of Paprosky types IIB to IIIA are indicated for the use of oblong implants in a basic position. The Arbond hydroxyapatite coating providing an osteoactive surface for the oblong cup described significantly improves the survival of this implant in comparison with the original model.

[Long-term experience with the combined ARBOND hydroxyapatite coating in implant osteointegration]. / Dlouhodobé zkusenosti s kombinovaným hydroxyapatitovým povrchem ARBOND v osteointegraci implantátu.

PURPOSE OF THE STUDY: The hydroxyapatite coating of an implant surface provides osteoactive conditions that can support osteointegration of cementless joint arthroplasties. However, the possibilities of hydroxyapatite degradation, resorption and delamination that may become responsible for failure of total hip arthroplasty (THA) have been reported. The aim of the study was to assess the properties of Arbond hydroxyapatite coating by comparing the long-term survival of implants identical in construction but different in surface coating. MATERIAL: One group (HA) comprised 86 patients (100 THAs) with an average age of 45.14 years (range, 22.3 to 77.4 years) at the time of surgery who received a femoral stem (Walter) with a coating of Arbond sprayed over the proximal half. The other group (control) included 92 patients (100 THAs) with an average age of 49.7 years (range, 33 to 68.7) who had an identical femoral component without coating. In both groups the conical-shaped acetabular cup (Walter) and femoral head made of sintered ceramics were used. The patients in whom one or both components were replaced or extracted were not included in the final clinical evaluation (Harris Hip Score). For the statistical analysis of survival, a stable component still in place at the date of the revision procedure was regarded as surviving; a lose component at the same date was considered a failure. Finally, 71 hips of the HA group followed up for an average of 15.51 (range, 5.6 to 18.56) years and 39 control hips at an average follow-up of 14.19 (range, 6.24 to 18.48) years were clinically evaluated. The data of patients who died in the course of study (HA group, 11; control group, 14) were included in the clinical evaluation with the date of their last follow-up. METHODS: For both groups, the Kaplan-Meier survival curves were constructed for overall survival and for the survival of acetabular and femoral components separately. Differences in survival curves were evaluated with the use of Gehan's Wilcoxon test. Component survival was also calculated using 15-year life-table survivorship analysis. Differences in variables under study were assessed with the use of the two-tailed Student's t-test. A p value of less than 0.05 was considered significant. RESULTS: A total of 29% hips were revised in the HA group, 27% for aseptic loosening of the acetabular cup, in 2% both components were removed because of deep infection. In the control group revision procedures were performed in 61% of the hips. Except for one case of deep infection (1%), the reason was cup loosening in 30%, stem loosening in 12% and both components loosening in 18% of the hips. The HA group showed a significantly longer survival of both total hip prostheses and individual components. The final HHS was significantly better than the initial score in both groups. There was no difference in the degree of improvement between the two groups. The radiographic data showed full osteointegration of stems in the HA group. The control group, on the other hand, had 87% of the stems with translucent lines in zone I and zone VII according to Gruen's classification. DISCUSSION: The significantly longer survival of hips in the HA group gives support to the use of hydroxyapatite coating in total hip arthroplasty. The poorer results in grit-blasted implants, as compared with the literature data, can be explained by allow degree of roughness of the Walter implant surfaces. CONCLUSIONS: The combined Arbond hydroxyapatite coating improves conditions for implant osteointegration in the bone.

[New metod for quantification of UHMWPE wear particles around joint replacements]. / Nová metoda kvantifikace oterových cástic UHMWPE v okolí kloubních náhrad.

PURPOSE OF THE STUDY: The orthopaedic community has unanimously adopted the view that ultra high molecular weight polyethylene (UHMWPE) wear particles are a very frequent cause of aseptic implant loosening. Some studies have tried to provide objective evidence for this.We have found descriptions of particle distribution or morphology, but no report that would objectively cor- relate the number of particles in zones surrounding an implant with the extent of damage to these zones. The aim of this study was to develop a method allowing us to evaluate a number of samples with polyethylene abrasive wear large enough to find association between the extent of damage around a THA and the number of biologically active UHMWPE wear particles, 0.1 to 10 microm in size. MATERIAL AND METHODS: In 28 patients undergoing revision total hip arthroplasty (THA) at the 1st Orthopaedic Clinic, 1st Faculty of Medicine, Char- les University, we took samples of typical osteoaggressive granuloma from defined zones around the implant; the zones corresponded to those described by Gruen and DeLee. The extent of tissue damage in each zone was evaluated on the basis of pre-operative radiographs and by the extent of osteolysis and damage to soft tissues actually observed during revision THA. The volume of wear particles in each zone was assessed by the IRc method developed by us; this is based on a quantitative evaluation of infrared spectra. To verify the methodology, a comparison between tissue damage and the number of particles in each zone was made in three randomly selected patients. RESULTS: We introduced a method of detailed orthopaedic evaluation which enabled us to categorize zones around a revised THA according to the extent of damaged tissue. As a result, a series of zones ranked by the extent of damaged tissue, or an "orthopaedist's statement" (OS), was obtained. At the same time we adopted a method, based on infrared spectroscopy and termed IRc, by which the number of particles in the samples of damaged tissues and osteoaggressive granulomas collected from the area around a revised THA was determined.The results of evaluation were presented as numerical data that, in a defined way, were converted into a series of zones ranked according to the number of wear particles, i.e., the "result of measurement" (RM). In this study we verified the methods described above and made a comparison of OSs and RMs for three randomly selected patients. The very good agreement found confirmed the reliability of both methods which will soon be used to evaluate a group of patients large enough to provide statistically significant results. DISCUSSION: The IRc method determines a total volume of UHMWPE wear particles, 0.1 to 10 microm in size, which are generally considered to be most biologically active. This study suggests that the distribution of particles around a THA is uneven and that relation between tissue damage and the number of wear particles in individual zones surrounding a THA does exist. The major conclusion from the orthopaedic point of view is a confirmation of the assumption that UHMWPE wear particles are one of the chief causes of THA failure. Although this fact is generally accepted, studies correlating the number of particles with tissue damage and osteolysis in individual zones are very scarce. CONCLUSIONS: The quick and simple IRc method offers a possibility to quantify polyethylene wear particles in soft tissues. The number of 0.1 to 10 microm wear polyethylene particles correlated with pre-operative radiographic findings and orthopaedic evaluation of revision THAs in three randomly selected patients. The confirmed correlation between the extent of tissue damage in individual zones surrounding a THA and the volume of wear particles detected in these zones supports the view that UHMWPE wear particles are one of the main causes of THA failure.

[Clinical evaluation of the ceramic femoral component used for reconstruction of total knee replacement]. / Klinické zhodnocení pouzití keramické femorální komponenty v konstrukci náhrady kolenního kloubu.

PURPOSE OF THE STUDY: The study evaluates mid-term results of total knee replacement with a zirconia ceramic (ZrO2) femoral component. MATERIAL: The evaluated group comprised 20 knees in 19 patients (4 men and 15 women). In one patient the replacement was performed bilaterally. Two patients had in the contralateral knee the same type of prosthesis with a femoral chrome-cobalt component.The mean age at the time of operation was 65.2 years (range, 38-81 years).The primary indication was 14 times osteoarthritis and 5 times rheumatoid arthritis. The average follow-up period was 6.5 years (range, 2.1-8.5 years). METHODS: Patients included in the study regardless of age, body mass and the basic diagnosis, agreed with the use of the ceramic femoral component. The evaluation covered a range of motion, mechanical axis, joint stability, pain, swelling, ability to walk on level ground and on stairs, subjective satisfaction (EULAR Knee Chart). Radiograph were assessed at one year intervals in two projections to identify the incidence of radiolucency around the implant. The Kaplan-Meier survival curve was used and compared with the survival curve in identical chrome-cobalt implants. RESULTS: At he final follow-up, 14 knees were evaluated, because 3 patients died without any connection with the implant, in one case the tibial component migrated due to necrosis of the tibial condyle in a patient with RA and two implants had to be revised and replaced due to polyethylene wear. No infection or negative tissue reaction was recorded in the evaluated group. The average flexion range was 109 degrees. All knees were stable and without swelling, in two cases there occurred slight femoropatellar pain. Twelve patients were fully satisfied, 2 patients were satisfied with a certain reservation. The differences in the course of the survival curves of chrome-cobalt and ceramic implants were statistically insignificant. DISCUSSION: Although the use of zirconia ceramics in vitro reduces the amount of polyethylene wear, the clinical outcomes of total knee replacements as compared to the hip are not convincing. One of the causes may be the substantially different and more complex biomechanics of the knee. Tribology improvement of the femoral ceramic component cannot compensate the deficiencies in the joint balancing in flexion and extension. The economically and technologically demanding production of these implants may be justified in patients with allergies caused by chrome-cobalt components. CONCLUSIONS: The results of mid-term follow-up of the use of zirconia ceramic femoral components proved no impact on the improvement of the period of survival of the knee implant. No adverse response to the material or mechanical failure of the ceramic components was encountered. Key words: total knee replacement, zirconia ceramic femoral component, TKR mid-term results, ceramic knee survival curve.

Polyarticular Form of Pigmented Villonodular Synovitis. Radiation and Surgical Therapy: Long Term Follow-up.

We describe a case of 30-year old male followed-up since the age of 6 for severe type of rare combination of polyarticular form of pigmented villonodular synovitis with hereditary malformation constellation consistent with Noonan-like syndrome. Within 20 years, the patient underwent repeated synovectomies of large joints with temporary effect only. Radiation therapy with the dose of 30 Gy in 15 sessions has been applied for active aggressive synovitis of both knees associated with pain and progressive joint destruction. Favorable effect lasted for 3 years. Progressive destruction with range-of-motion limitation required successive total joint replacement of both knee joints. Left knee prosthesis has been revised for aseptic loosening after 3.5 years. It is now 5 years since the right knee primoimplantation and 3 years since the left knee reimplantation without signs of component loosening or recurrence, with satisfactory clinical and functional outcome.

SAPHO syndrome - rare case of joint damage treated by knee synovectomy and total hip joint replacement.

This report describes the case of a young male who had been followed-up between the ages of 14-21 years at different health facilities for symptoms initially considered to be caused by tumor, then by chronic osteomyelitis or ankylosing spondylitis and finally diagnosed as the SAPHO syndrome. Musculoskeletal symptoms of the SAPHO syndrome include focal, probably aseptic chronic osteomyelitis, synovitis and formation of hyperostoses. Therapy of the SAPHO syndrome is predominantly conservative. However, in this case we had to employ arthroscopic synovectomy first, for severe synovitis resistant to any conservative therapy approach. Later, left total hip replacement has been performed for advanced hip joint damage accompanied by intense pain and significant range of motion reduction. At the present time, the patient is 51/2 years after synovectomy of the knee and 5 years after the hip joint replacement. The knee joint is without effusion or functional limitations, with intermittent pains only. The hip prosthesis in the risk area is fully integrated without signs of component loosening, with very good functional outcome. While synovectomy can be obviously fully recommended in cases like this, the total joint replacement should be considered unique and indicated only rarely after careful consideration of all circumstances.We consider this approach absolutely exceptional also because we have not found reference to similar case in any national or international professional literature available.

[Our results of the Lapidus procedure in patients with hallux valgus deformity]. / Nase zkusenosti s operací podle Lapiduse u pacientu s hallux valgus.

PURPOSE OF THE STUDY: The most frequent deformity of the big toe and forefoot associated with a collapse of the transverse arch of the foot is a valgus deformity. For correction of a hallux valgus, several procedures are described in the literature. A valgus deformity often develops due to a varus deviation of the first metatarsal bone when the intermetatarsal angle between the first and second metatarsals is greater than 10 degrees. When the intermetatarsal angle is larger then 10 degrees or the first ray is hypermobile, a Lapidus procedure is one of the options. The objective of this study was to evaluate the outcomes in patients with hallux valgus deformity treated by the Lapidus procedure. MATERIAL: The group comprised 61 patients, 49 women and 12 men, with an average age of 58.3 years at the time of surgery, who were treated at our department in the period from 2002 to 2006. Fifteen patients had bilateral surgery. The results of 76 operations were evaluated. Indications for surgery were hallux valgus in 22 patients, rheumatoid arthritis in 36 and psoriatic arthritis in three patients. METHODS: Access was gained on the mediodorsal side of the foot through an incision medial to the extensor hallucis longus tendon, over the first tarsometatarsal joint up to the first metatarsophalangeal joint. An arthrodesis was fixed with two Kirschner wires in eight feet and with two screws in 15 feet. Recently, the use of shape memory alloy staples (DePuy Mitek) was adopted and applied in 53 feet with good outcome. In the patients with rheumatoid arthritis the Lapidus procedure together with resection of the heads of the second and fifth metatarsals was used from the plantar approach. RESULTS: The evaluation was focused on the patients' satisfaction and their subjective complaints. No pain was reported on 56 (73%) forefeet, slight pain was experienced on the dorsal side in ten feet (13%) and pain in the transverse arch also in ten feet (13%). Complications included slow healing of the wound in seven feet of the patients with rheumatoid arthritis (9.2%), and infection requiring revision surgery in one patient (1.3%). Five patients (6.5%) reported persisting swelling of the foot dorsum for a period longer than 3 months. Recurrence of hallux valgus was recorded in nine feet. The average American Orthopaedic Foot and Ankle Society score, which was 48.1 points pre-operatively, improved to 89.2 points post-operatively. In one patient, bony union was very slow and was achieved at 5 months after surgery. DISCUSSION: An exact evaluation of the results of a Lapidus procedure is not always possible, particularly in patients with rheumatoid arthritis in whom foot disorders are more complex. A much discussed issue is first metatarsal hypermobility. In our group of 61 patients, this was found in 28. Of these, 18 had rheumatoid arthritis and ten had hallux valgus. The rate of pseudoarthrosis following a Lapidus procedure is reported to range from 3.3% to 9%. In our group only one patient was affected (1.3%). CONCLUSION: A correctly performed: Lapidus procedure enables us, by correcting a varus deviation of the first metatarsal, to repair valgus deformity of the big toe resulting in painless walking.

Rare case of osteomyelitis of tibial shaft caused by Nocardia cyriacigeorgica.

Nocardiosis is a rare infection caused by the aerobic actinomycete of the Nocardia genus. In most cases, nocardiosis manifests as a lung infection or a bone lesion. Due to the nonspecific and mild clinical manifestations of nocardiosis, the establishment of definite diagnosis can be difficult. When antibiotic therapy is incorrectly targeted, only the symptoms of the disease are suppressed. The mainstay in the treatment of Nocardia osteomyelitis has so far been the combined surgical debridement with long-term, initially intravenous, antibiotic administration. We present the successful conservative treatment of a nocardiosis osteomyelitis of the tibia caused by the Nocardia cyriacigeorgica species in an 81-year-old female patient that manifested itself as a secondary affection on top of a primary nocardiosis infection of the lung. From microbiological examination, N. cyriacigeorgica was discovered; the identification was made using matrix-assisted laser desorption/ionization time of flight mass spectrometry (MALDI-TOF MS) with an identification score of 1.9. The sensitivity was evaluated using E test. Sensitivity to trimethoprim/sulfamethoxazole, amikacin, imipenem, and linezolid was demonstrated. The bacteria were shown to be resistant to ciprofloxacin. For treatment, trimethoprim/sulfamethoxazole was used due to the value of minimum inhibitory concentration, which was 0.25 mg/L. The initial dose of 960 mg of trimethoprim/sulfamethoxazole every 8 h was reduced to 960 mg every 12 h after 3 months. The total duration of treatment was 7.5 months. Under the established treatment, the bone and lung lesions healed. Nocardiosis of the long bone is considered a rare disease and its precise diagnosis has not yet been standardized. We used the MALDI-TOF MS method for the identification of the causal organism which is a fast and reliable method according to current world literature even when compared with the rRNA genetic sequencing reference method. Our case study presents a rare case of osteomyelitis of tibial shaft caused by N. cyriacigeorgica and its successful conservative treatment.

Total elbow replacement with the Souter-Strathclyde prosthesis in rheumatoid arthritis. Long-term follow-up.

We assessed the long-term results of 58 Souter-Strathclyde total elbow replacements in 49 patients with rheumatoid arthritis. The mean length of follow-up was 9.5 years (0.7 to 16.7). The mean pre-operative Mayo Elbow Performance Score was 30 (15 to 80) and at final follow-up was 82 (60 to 95). A total of 13 elbows (22.4%) were revised, ten (17.2%) for aseptic loosening, one (1.7%) for instability, one (1.7%) for secondary loosening after fracture, and one elbow (1.7%) was removed because of deep infection. The Kaplan-Meier survival rate was 70% and 53% at ten and 16 years, respectively. Failure of the ulnar component was found to be the main problem in relation to the loosening. Anterior transposition of the ulnar nerve had no influence on ulnar nerve paresthaesiae in these patients.

[Current strategies for prevention of prosthetic joint infection]. / Soucasné moznosti prevence infekcí kloubních náhrad.

Deep sepsis still remains the second most common cause of prosthetic joint failure despite its overall incidence is decreasing. It can be defined as a bacterial growth and replication on the prosthetic joint surface resulting in periprosthetic tissue damage and prosthesis loosening. The implants are colonized by airborne-, skin-, tool-, and/ or surgeon-related bacteria during surgery even though majority of procedures are performed under strictly respected conditions nowadays. After the insertion of the prosthesis into the human body the race between bacteria and host cells begins on what will colonize the prosthetic surface first. If the bacteria are more successful then they develop on formation of biofilm which is the biological correlative for the prosthetic joint infection (PJI) resisting effectively against host immune response and antibiotics. That is why preventative measures are strongly worth to do it, and removal of the prosthesis is the single optimal treatment. Each step in the pathogenesis of prosthetic joint infection may represent relevant targets against which prevention strategies may be directed. Of them the most useful seems to be identification of individual factors predisposing for PJI development, antibiotic prophylaxis given before the surgery, and operating room/ surgical quality parameters. Key words: prevention, prosthetic joint infection, deep sepsis, biofilm, total joint replacement.