[Comparison of the Arthroscopic Finding in the Knee Joint and the MRI - Retrospective Study]. / Porovnání artroskopického nálezu kolenního kloubu s magnetickou rezonancí ­ retrospektivní studie.

PURPOSE OF THE STUDY Our retrospective study presents the comparison of the preoperative magnetic resonance imaging of the knee joint - MRI - and the arthroscopic finding - ASC. Its aim is to find out how a positive or a negative finding of MRI corresponds with the operative finding and how much the experience of radiologist contributes to the conformity. MATERIAL AND METHODS The MRI findings of knee joints treated surgically at two departments in 2013 and 2014 were assessed. The MRI was performed in a total of 470 patients who subsequently underwent an arthroscopic surgery. A conformity or a non-conformity in anterior, posterior horn and complete rupture of both menisci and in partial or complete tear of anterior cruciate ligament - LCA was searched for. The sensitivity, specificity and accuracy of MRI were established. The difference between experienced and less experienced radiologists was evaluated. The analysis of the radiology report, surgical protocol of ASC and medical history in the documentation was performed. The cartilage was not subject to evaluation. The finding of Grade 1 meniscus tear on MRI was evaluated as negative. Grade 2 and Grade 3 were evaluated as positive. RESULTS Comparison of the preoperative MRI and the arthroscopic finding 1. The group with MRI reported 3 % of diagnostic arthroscopies. The control group without MRI (551 ASC) reported 15 % diagnostic arthroscopies. 2. Low sensitivity of MRI (0.67) in negative findings of ASC. It concerned 7 cases in which a pathological finding was identified on a MRI scan, but not by ASC. In two cases the repeated arthroscopy confirmed that a pathology inside the knee joint was overlooked by the arthroscopist. In the remaining five cases, the clinical finding improved without a repeated surgery. 3. High sensitivity of MRI is shown in the most frequent finding - posterior horn of medial meniscus (0.94). 4. Lower sensitivity (0.76) in partial and (0.83) in complete ACL tear. It increases to 0.93 if partial and complete tear are put together. Both MRI and ASC detect the pathology of ligament, but do not agree in terms of terminology. 5. Lower sensitivity (0.78) was seen in posterior horn of lateral meniscus, most likely due to its complicated anatomy. 6. Specificity of complete tear of medial meniscus tear is 0.99. Lower specificity in the posterior horn of medial meniscus (0.81) shows a higher number of positive MRI findings in negative ASC findings. Some posterior horn tear can be overlooked by an inexperienced surgeon. The MRD findings need to be studied. 7. High specificity (0.99) was described in negative findings. In three cases only, the surgeon discovered a pathological finding, not revealed by MRI scan. It always concerned a tear within the posterior horn of the medial meniscus. 8. Specificity (0.88, 0.93 or 0.86, respectively) in partial, complete and all ACL damages in total. 9. We concluded that contributing to the degree of agreement between MRI and ASC is also the experience of a radiologist. The most experienced radiologist evaluated 190 of 470 MRI scans, the remaining twelve radiologists assessed 280 scans. The posterior horn of the medial meniscus - sensitivity or specificity evaluated by an experienced radiologist (0.98 and 0.88, respectively) and inexperienced radiologist (0.91 and 0.79). The specificity and sensitivity in complete ACL tears - by experienced radiologist (0.91 and 0.94, respectively) and inexperienced radiologist (0.81 and 0.90, respectively). The test accuracy of the experienced radiologist in evaluating the most frequent injuries of soft knee structures was by 9-10 % higher than of the inexperienced radiologist. DISCUSSION The results obtained by the other authors show that the sensitivity and specificity range from 0.6 to 0.9. They agree that the MRI is unsuitable for assessing the cartilage. We confirm that the results are worse when evaluating the posterior horn of the lateral meniscus. We have also proven that the radiologist s experience does play an important role. It can be the reason for a high degree of difference between the results of various authors. Some of them give preference to a clinical examination or a diagnostic arthroscopy instead of the MRI. At our department, MRI is indicated if we are convinced it can help with the indication or where it will suggest what to focus on during the surgery. CONCLUSIONS A preoperative MRI scan can prevent an unnecessary arthroscopy. It displays structures to the surgeon which shall be reviewed in detail during the surgery. We recommend paying attention to Grade 2 MRI findings, positive MRI findings on the posterior horn of medial meniscus and to MRI findings on partial ACL tears. Such menisci and ligaments shall be carefully reviewed. Clinical preoperative examination and cooperation between the surgeon, the "arthroscopist", and the radiologist is essential. The experience of the radiologist also plays a role when evaluating the MRI scan. We have introduced MRI ward rounds. Key words: MRI, knee joint, knee arthroscopy, sensitivity, specificity, accuracy.

[Arthroscopic Finding of Knee Joint in Relation to Age and Its Comparison with Pre-Operative Clinical Finding - a Retrospective Study]. / Artroskopický nález kolenního kloubu v závislosti na veku a jeho srovnání s predoperacní klinikou ­ retrospektivní studie.

PURPOSE OF THE STUDY In the retrospective study of two South Bohemian centres we present the comparison of pre-operative anamnestic clinical signs in relation to the arthroscopic intraoperative finding. The obtained data is used also to evaluate the arthroscopic finding in relation to age and sex. MATERIAL AND METHODS The arthroscopic findings of patients who underwent surgery in 2013-2014 period (1.1.2013-31.12.2014) at the Department of Trauma Surgery of Ceské Budejovice Hospital, a.s. and in 2014 (1.1.-31.12.2014) at the Department of Orthopaedics and Traumatology of Písek Hospital, a.s. were evaluated. In total, 1 021 patients underwent surgery, with the mean age of 44 years. The patients were not selected. The group includes all the patients who underwent surgery, including those in whom repeat arthroscopy was performed, in the respective period of time, regardless of the mechanism of difficulties. A preoperative MRI scan was carried out in 470 patients. The referring physician was present during the examination. In all the patients undergoing surgery, the main clinical preoperative sign was examined based on the documentation, namely in the following order - hemarthros, locked knee, hydrops or merely a pain. In the arthroscopic finding, the medial meniscal lesion - anterior and posterior horn, and complete tear was assessed. The same was done for lateral meniscus. In anterior cruciate ligament - ACL - partial or complete tear was assessed. We identified the frequency of findings in relation to age and evaluated the correlations between the clinical signs and the arthroscopic finding. We calculated the sensitivity and specificity of hemarthros as a sign of ACL tear. The analysis was conducted based on the medical history in medical record documentation and the surgical protocol. The cartilage was not assessed. RESULTS Analysis of clinical and anamnestic signs in relation to arthroscopic findings 1. Negative arthroscopic findings (potential cartilage damage with no damage to other soft structures and normal arthroscopic findings) are in 83% accompanied by a mere knee pain. 2. High percentage of isolated locked joint (15%) in negative findings 3. Complete ACL tears are most frequently reported in the under-35 age category - 43% of 191 men who underwent surgery and 33% of 102 women. 4. Isolated injuries to ACL without the meniscus tear are frequent in younger patients - 30% - 40% of the total number of patients with injured ACL. 5. In patients older than 56 years of age the ACL damage is accompanied by concurrent meniscus tear (96% in men, 100% in women). 6. Sensitivity of hemarthros (68%) for complete ACL tear. Specificity of the presence of hemarthros in complete ACL lesions (91%) indicates that there are also complete ACL tears with no hemarthros whatsoever in the medical history. For partial tears the values of sensitivity and specificity are 27% and 67%, respectively. In partial tear, the presence of hemarthros is not a diagnostic lead. 7. In 15% of negative findings a "locked knee" was present. It was not a genuinely locked knee, but rather an antalgic position. Not every locked knee must necessarily mean a meniscus lesion or ACL tear. 8. Isolated meniscus tear is in 75% accompanied only by pain. 9. In our group of patients, isolated osteoarthrosis or malacic cartilage without any damage to ligaments or menisci was rare - only in 22 cases (2% of the entire group). DISCUSSION There are lots of studies which focus on comparing the clinical findings with perioperative pathology of knee joint and the importance of pre-operative clinical examination. Our extensive retrospective study proved that in 56-plus age category virtually each ACL injury is accompanied by a meniscal lesion, which can be explained by a possible ACL damage at a young age and subsequent instability resulting in meniscus tear or frequent presence of degenerative meniscal changes at an older age. A small number of isolated degenerative cartilage damage was established (2%). We fully agree with the authors who prove that the degenerative cartilage changes are ever since the very beginning accompanied by changes of the other soft structure of the knee. We revealed a high percentage of locked knee joint in negative arthroscopic findings. According to the clinical pre-operative examination, the locked knee does not automatically mean the meniscal lesion or ACL tear. In agreement with the others we prove a close association between hemarthros and ACL injury. CONCLUSIONS 1. A clinical examination, a detailed medical history is necessary 2. With hemarthros in medical history, there is a likelihood of complete ACL tear. Conversely, even a seemingly trivial knee sprain without hemarthros or locked knee can mean the ACL tear. 3. Where a mere pain is present, it mostly indicates an isolated meniscal damage or a negative finding. 4. Degenerative cartilage changes are accompanied by degeneration of menisci and ligaments. 5. Our group of patients did not include any case of hemarthros in the medical history with a negative arthroscopic finding. Hemarthros always indicated a more serious damage to knee soft structures. Key words: knee joint injuries, knee arthroscopy, sensitivity, specificity, hemarthros.

[PCCP--first choice of the treatment of trochanteric fractures in our orthopaedic department]. / PCCP--metoda volby v lécení trochanterických zlomenin na nasem pracovisti.

INTRODUCTION: The authors present their experiences with the treatment of trochanteric fractures (31A1.1-31A3.3) using the Gotfried's percutaneous compression plate (PCCP). The authors evaluate some parameters at other kinds of osteosynthesis in the same indication. MATERIAL: We made 230 osteosynthesis of trochanteric fractures in the period from August 2004 to December 2008. The PCCP was used 179x (72x type 31A1.1-3, 90x type 31A2.1-3, 17x type 31A3.1-3). The other kinds of osteosynthesis were used 51x (DHS 40x, PFN 9x and condylar plate 2x) in the same indication. The mean age, the hospitalization time, the interval admission - operation, wound complications and the lethality within 30 days, 90 days and 1 year were evaluated. Some patients were lost to follow up or died. The bone healing was evaluated at 119 PCCP and 43 other osteosynthesis, which remained in the study. METHOD: The stabilisation is done via two 2-3 cm long incisions. The plate, assembled on a introducer, is inserted through the proximal incision. The special hook for the plate fixation to the bone, two angular stable self-cutting neck screws and three diaphyseal screws are inserted from the distal incision. RESULTS: The first value concerns the PCCP, the value in brackets concerns the other osteosynthesis. Number 179 (51).The mean age 78.9 (76.2) years, the interval admission - operation 0.95 (1.12) days, the hospitalization time 15.3 (16.5) days, the wound hematoma and revision 3 (1), the wound infection and revision 1 (1). Died within 30 days 8.4% (5.9%), within 90 days 13 % (13.7%), within 1 year 33.9% (29.2%). All 119 patients with PCCP (including 15 type AO 31A3) were healed within 8 months. No pseudoarthrosis, collaps or cut-out were noted at the PCCP group. Four failures, caused by an unsuitable indication or by a surgeon error, were noted in the group of the other osteosynthesis. DISCUSSION: The advantage of the PCCP is minimally invasive technique and rotation stability. The authors proved that the PCCP reduces and fixes the fractured lateral wall at high subtrochanteric fractures (31 A3.1-3). The wall is healed and prevents collapse. The authors indicate AO type 31A3 fractures to the PCCP unlike the author of the method. CONCLUSION: The study confirmed that the PCCP is a minimally invasive osteosynthesis suitable for all types of trochanteric fractures. All 119 followed up patients including 15 with 31 A3.1-3 fractures were healed.

Efficiency of amino acid utilization in the growing pig at suboptimal levels of intake: branched-chain amino acids, histidine and phenylalanine + tyrosine.

Five balance experiments on growing pigs were carried out to study the marginal efficiency of utilization of isoleucine, leucine, valine, histidine and phenylalanine + tyrosine and to estimate their requirements for maintenance. Purified diets based on casein and crystalline amino acids as the sole source of N contained graded levels of each amino acid, corresponding to protein accretion rates of 0, 33, 66, 99 and 132 g/day, respectively. All other essential amino acids were given in a 30% excess. N retention increased linearly (p < 0.01) as the dietary concentration of the limiting amino acid increased. Based on linear regression equations relating amino acid deposition in body protein to amino acid intake, marginal efficiencies of ileal digestible amino acid utilization were calculated to be isoleucine - 0.81, leucine - 0.81, valine - 0.82, histidine - 1.17 and phenylalanine + tyrosine - 0.67. Extrapolating the regression equations to zero N retention, the daily requirements of amino acids for N equilibrium were estimated to be (mg/kg0.75) isoleucine - 18, leucine - 33, valine - 23, histidine - 14 and phenylalanine + tyrosine - 43.

Effect of nonessential amino acids on nitrogen retention in growing pigs fed on a protein-free diet supplemented with sulphur amino acids, threonine and tryptophan.

Two N balance experiments were conducted on growing pigs to study the effect of essential and nonessential amino acids added to a protein-free diet on N retention. In Expt. 1, the addition of sulphur amino acids, threonine and tryptophan to a protein-free diet at levels two times the maintenance requirements reduced (p > 0.1) daily N loss from -131 to -108 mg/kg(0.75). A further addition of nonessential amino acids equivalent to 250 mg N/kg(0.75)/d resulted in a marked increase (p < 0.01) in daily N retention to 28 mg/kg(0.75). In Expt. 2, nonessential amino acids were added to a protein-free diet supplemented with sulphur amino acids, threonine and tryptophan at levels corresponding to 100, 200 and 300 mg N/kg(0.75)/d. N retention increased linearly as dietary nonessential N increased. The slope of the best-fit regression line indicated that the marginal efficiency of nonessential N utilization for protein accretion was 0.26. The results suggest that nonessential amino acids may be a limiting factor for the re-utilization of amino acids released by body protein breakdown or that they may serve as precursors for de novo synthesis of amino acids by gut microorganisms, thus contributing to the amino acid requirements of the pig.

[Valgus osteotomy of the first metatarsal by a bone graft.]. / Valgizacní osteotomie prvního metatarzu kostním stepem.

The authors describe their experience of valgus osteotomy of the first metatarsal in hallux valgus - metatarsus primus varus (HV-MTPV). It is based on the Stamm technique consisting in the resection of one third of the base of the proximal phalanx of the great toe. From the resected part they make a wedge-shaped bone graft. Subsequently, they extend the section and perform a two-third transversal osteotomy of the first metatarsal (MT) 1 cm distal to the cuneometatarsal joint. The rest of the bone is broken into valgus position by pressure. Afterwards, the bone graft is inserted in the open osteotomy line from the medial side. Valgus position is fixed a wire loop. In contrast to the Stamm procedure the authors perform no additional operations on the tendon apparatus. They put emphasis on a stable fixation and an early rehabilitation of the metatarsal joint. Since 1991 they have performed in total 69 valgus osteotomies on 51 patients. In eight cases only osteotomy was performed without the resection of the base, the bone graft was made from the resected bone prominence of the head of the first metatarsal and the adductor of the great toe was released. In case of metatarsalgia this procedure is combined with Helal or Wolf osteotomy. The operation has proved successful in the most severe defects with hallux valgus angle (HVA) exceeding 40 degrees , intermetatarsal angle (IMA) above 16 degrees and incongruency of the MTP joint. Lateralisation of sesame bones is spontaneously corrected after the surgery. Six months after operation 90 % of patients were satisfied with the result. In four patients the surgery did not bring the expected effect. The first after valgus revision of the great toe and varus revision of the metatarsal. In his case osteotomy was combined with Silver operation without resection of the base. Insufficient release of the adductor of the great toe resulted in the recurrence of the defect. In the second patient there occurred necrosis of the head and in the third patient the MTP joint got rigid as a result of the inadequate resection of the base of the phalanx of the great toe. The fourth patient was lost to follow-up. The surgical lengthening of the first metatarsal is 1 mm. The authors evaluated its relative length together with HVA and IMA angles and compared the group of patients with healthy population. They came to the conclusion that a longer first metatarsal potentiates the development of the defect. A detailed statistic analysis of these measurements will be presented in the next publication. Key words: hallux valgus, metatarsus primus varus (HV-MTPV), osteotomy of the first metatarsal.

[Joint research on the precise determination of the energy and protein requirements of fattening pigs. 9. The effect of various levels of energy and protein nutrition on the performance and feed expenditure of fattening pigs]. / Gemeinschaftsuntersuchungen zur Präzisierung des Energie- und Proteinbedarfs für Mastschweine. 9. Mitteilung. Einfluss unterschiedlicher Niveaus der Energie- und Proteinernährung auf Leistung und Futteraufwand bei Mastschweinen.

In the scope of a joint international experiment, 2 scientific feeding experiments were carried out in combination with measurings of the metabolism for the determination of the digestibility and the N-balance with hybrid pigs of modern genetic origin in the fattening period between 30 and 100 kg live weight. In the first experiment with isocaloric feeding the influence of 3 levels of protein supply (18, 16 and 14% crude protein in the first fattening period and 16, 14 and 12% crude protein in the second fattening period) on the fattening performance and the expenditure of feed, protein and energy per kg live weight gain and in the 2nd experiment with equal crude protein supply per animal and day the influence of 3 levels of energy supply (100 : 85 : 70%) on fattening performance and expenditure were tested. In addition to that, the composition of the carcass was ascertained of a total of 51 animals. The average live weight gain in the 3 variants and over the complete fattening period between 30 and 100 kg in experiment 1 amounted to 772 g, 753 g and 687 g and in experiment 2 to 778 g, 713 g and 583 g. The best fattening performance was achieved with the highest energy and protein supply, and an energy supply reduced by 15% nevertheless resulted in fattening performance 753 and 713 g resp. per animal and day. The expenditure values are discussed; a detailed evaluation is given in the 10th contribution to this series of publications on the total results of this joint international experiment. The carcass analysis shows the tendency of a decreasing protein content in the carcass caused by a decreasing protein supply and an increasing fat and energy content whereas a decrease of the energy supply has no effect on the protein content but a distinct effect with regard to the decrease of the fat content of the carcass caused by the decreased energy supply.

[Joint research on the precise determination of the energy and protein requirements of fattening pigs. 10. Comparative evaluation of the research for the precise determination of the energy and protein requirements of fattening pigs]. / Gemeinschaftsuntersuchungen zur Präzisierung des Energie- und Proteinbedarfs für Mastschweine. 10. Mitteilung. Vergleichende Auswertung der Untersuchungen zur Präzisierung des Energie- und Proteinbedarfs für Mastschweine.

Institutes from 5 CMEA countries took part in complementary joint investigations in order to ascertain the variance in energy and protein requirement and parameters of nutrient and energy metabolism with such fattening pigs as test animals as characterise the prospective breeding development in each of the countries and in order to establish the bases for the critical revision of the norms of energy and protein requirement for fattening pigs and, if necessary, their more precise determination. The most important conclusion drawn from the comparative assessment of the results presented in 9 articles is that due to wide variations in the energy and protein requirement values between the individual investigators as well as within the institutions themselves, norms of energy and protein requirement for fattening can only be adopted between countries when adequate investigations under the specific conditions of the individual countries justify this.