[Radial Head Replacement: Management of Elbow and Forearm Instability after Comminuted Radial Head Fractures Associated with Elbow Dislocation]. / Endoprotéza hlavice radia: resení nestability lokte a predloktí pri trístivých zlomeninách hlavice radia spojených s luxací lokte.

PURPOSE OF THE STUDY: This manuscript aims to identify an indication algorithm for the surgical treatment of radial head fractures associated with elbow dislocation. The study compares the mid-term functional outcomes of patients with multifragment radial head fracture treated by resection with the outcomes of patients treated with radial head replacement. MATERIAL AND METHODS: The cohort of 34 patients who sustained a radial head fracture at the mean age of 42.5 years (age range 20-81 years) was broken down into two groups by type of surgery. The EXT group consists of 20 patients with the radial head fracture treated by radial head resection. The END group includes 14 patients treated with the radial head replacement. In all patients, the radial head fracture was associated with elbow dislocation (type IV fracture according to the Mason-Johnston classification). The modified Kocher's surgical approach was used in all patients of both the groups. In the EXT group, resection of the fragmented radial head was performed. In the END group, the ExploR® Modular Radial Head System (Zimmer, Biomet, USA) was used, consisting of a CoCr (cobalt chromium) alloy head and a titanium stem. The pain and the range of motion of the elbow and forearm were evaluated after the completion of the outpatient rehabilitation (the mean follow-up period was 2.4 years). Simultaneously, the elbow joint stability was assessed. Radiographs were taken to detect heterotopic ossifications, proximalization of the radius, and any signs of prosthesis loosening. The frequency of reoperations was followed-up. The MEPS (Mayo Elbow Performance Score) was calculated. RESULTS: In the EXT group, the mean elbow flexion was 117.5° and the mean pronation/supination was 166.9°. In 50% of patients, the MEPS obtained was greater than 90 points, which means an excellent functional outcome. In 1 patient (5%), recurrent elbow dislocation occurred which was the reason for revision surgery (elbow transfixation with the Kirschner wires and medial collateral ligament suture). Revision surgery was also performed in 2 patients (10%) in whom not all the radial head fragments were removed. Moreover, also observed was elbow joint instability (2 patients) and temporary radial nerve paralysis (1 patient). In 1 case discrete proximalization of the radius developed. The patients in the END group showed the mean elbow flexion of 112° and the mean pronation/supination of 135°. The MEPS obtained from 69% of patients was greater than 90 points, which means an excellent outcome. The pain under load was reported by 3 patients (21%). In 5 patients (35%), the X-rays showed radiolucent zone around the stem of the prosthesis. Neither revision surgery, nor prosthesis removal has been performed yet in any patient. No instability, neurological complications or infections have been reported. In both EXT and END group heterotopic ossifications have developed in 4 patients. CONCLUSIONS: Radial head replacement compared to the radial head resection in the management of multifragment fractures associated with elbow dislocations increase the elbow and forearm stability. The group of patients with an implanted radial head prosthesis shows a higher percentage of patients achieving excellent functional outcome than the group of patients with radial head resection. KEY WORDS: radial head, elbow, fracture, dislocation, resection, prosthesis.

[Total Replacement of the First Metatarsophalangeal Joint by Medin PH-Flex and Its Effect on Forefoot Biomechanics in the Propulsion Phase of the Gait Cycle]. / Totální náhrada prvního metatarzofalangeálního skloubení Medin PH-Flex a její vliv na biomechaniku prednozí v propulzní fázi krokového cyklu.

PURPOSE OF THE STUDY Total arthroplasty of the first metatarsophalangeal joint is one of the surgical treatment options for patients with advanced hallux rigidus. This study evaluates the pressure changes in the propulsion phase of the gait cycle using dynamic pedobarography after the total arthroplasty of the first metatarsophalangeal joint by Medin PH-Flex and their comparison with the control groups of patients with hallux rigidus and with asymptomatic patients. MATERIAL AND METHODS Dynamic pedobarograph was used to evaluate 15 first MTP joint replacements by Medin PH-Flex implants in 12 female patients, the average time since joint replacement was 3.5 years (1.5 to 5.5 years). The control group consisted of 13 forefeet in 12 patients with hallux rigidus of Grade 3 and Grade 4 according to the Coughlin classification and 17 healthy patients with no clear foot deformity, i.e. of a total of 34 forefeet. A zone for each metatarsal (M1-M5) and the big toe area (T1) were defined with the use of an integrated software. The difference between the pressure under the big toe area and the first metatarsal bone - hallux stiffness (T1-M1) and the forefoot balance parameter, i.e. the difference between the pressures under the medial and lateral half of the forefoot ((M1+M2)-(M3+M4+M5)), was obtained. The parameters were evaluated for each group during the propulsion phase of the gait, i.e. from 55% to 100% of the stance phase and from 75% to 100% of the stance phase, i.e. that part of propulsion when the greatest pressure is exerted on the big toe. RESULTS For the HS parameter (T1-M1) in 55% to 100% of the stance phase, the median value was -0.66 ± 1.22 (-1.90 to 1.45) in the control group, -0.85 ± 1.94 (-1.40 to 3.80) in patients with hallux rigidus, and -0.10 ± 1.48 (-1.30 to 2.40) in patients after the first MTP joint replacement. The median forefoot balance parameter from 55% of the stance phase was -3.48 ± 2.45 (-6.90 to 0.68) in healthy patients and -4.43 ± 2.72 (-6.98 to 0.23) in hallux rigidus patients. In patients after the joint replacement, the value was -3.00 ± 2.46 (-6.20 to 0.40). The data were statistically analysed by the Dunnett's and Tukey's multiple comparison tests. The hallux stiffness parameter showed a significant improvement after the joint replacement compared to patients with hallux rigidus (p<0.0001). No statistical significance was confirmed when comparing the joint replacement cases and the healthy patients from the control group (p=0.0007 and p=0.0010, respectively). As concerns the forefoot balance parameter, a significant difference was reported in patients with joint replacement compared to healthy patients from the control group and patients with hallux rigidus (p <0.0001). DISCUSSION The published pedobarographic studies differ in terms of the methodology used, the patient population and the parameters examined. The pedobarographic studies after the replacement of the first MTP joint or after its arthrodesis present inconclusive outcomes. According to the available literature, the joint replacement has the potential to improve mediolateral forefoot loading and to partially restore the weight-bearing function of the first ray. Our analysis of the HS parameter suggests that the MTP joint replacement can improve the big toe function compared to patients with hallux rigidus but fails to achieve the functional outcomes of healthy patients. When evaluating the forefoot balance (FB) parameter, we can observe less loading on the lateral half of the forefoot in the propulsion phase compared to hallux rigidus. Nonetheless, the joint replacement is unable to restore the physiological loading of the foot. CONCLUSIONS The first MTP joint replacement has the potential to improve forefoot function and to bring it closer to that of a healthy person, even though achieving physiological loading of the forefoot is unrealistic. Additional studies will be needed to confirm that the indication for the first MTP joint replacement is justified in hallux rigidus in terms of the effect on forefoot biomechanics. Key words: hallux rigidus, total replacement of the first MTP joint, dynamic pedobarography, footscan.

Antimicrobial efficacy and activity perseverance in arthroplasty of calcium sulfate beads containing vancomycin prepared ahead of time and stored in ready-to-use formula.

The use of local therapy with antibiotics in a suitable carrier is essential in the treatment and prevention of infections in orthopedic surgery and traumatology. In our orthopedic surgery department, a synthetic calcium sulfate hemihydrate (CaSO4·½H2O) is used as an antibiotic carrier, enabling the application of most types of intravenous antibiotics in the form of powder and liquid. This type of carrier with antibiotics is prepared in the theater during the procedure. During a surgical procedure, a small dead space is created (hand and foot area), which must be filled with an antibiotic carrier, and the situations arise where a large amount of the carrier is not used and thrown away. Therefore, we verified the efficacy of vancomycin in the pre-prepared carrier by an orientation microbiological method and by measuring the concentrations of the vancomycin released in active form and its two crystalline degradation products. Based on the agar diffusion test, we did not measure any difference in the effectiveness of the antibiotic in the carrier after its 12-day storage. Although vancomycin concentrations decreased by approximately 32% at the end of 12 days of storage, the concentrations of the released active form of vancomycin are many times higher than the minimum inhibitory concentrations for resistant strains of Staphylococcus aureus. Thus, the calcium sulfate carrier with vancomycin can be prepared several days in advance before its application, certainly up to 12 days.

Reverse Total Shoulder Arthroplasty: 14-Year Clinical Experience with 496 Performed Arthroplasties.

PURPOSE OF THE STUDY Reverse total shoulder arthroplasty (RSA) can be considered a proven method for the treatment of the most severe shoulder joint affections. In this study, we present 14-year experiences of the authors with the LimaCorporate SMR® RSA system in 496 cases. MATERIAL AND METHODS Included in the study are 496 RSAs performed between 2007 and 2020. We successfully followed up 368 shoulders in 358 patients. This was a prospective study with function being evaluated preoperatively and at the last follow-up in 2020. We evaluated the range of motion in active elevation and the classic Constant Score (CS). According to this score, the pain level was also evaluated. Standard statistical methods were used with a paired t-test used for comparisons of values. RESULTS The mean follow-up in our group was 5.5 years (0.7-13.6, SD 3.22, median 4.96). Indications were: primary osteoarthritis (84), acute trauma (69), posttraumatic sequelae (79), cuff tear arthropathy (37), RA (29), chronic dislocations (18), final treatment of infectious complications (7), avascular necrosis (6), tumours (4) and TSA revisions (9). The mean post-operative CS of all patients was 71.9 (2-94, SD 11.26, median 73). The mean post-operative active elevation was 127.35° (30°-180°, SD 28.36, median 130°). The mean pain level at final follow-up was 0.65 (0-3, SD 0.65, median 1). There was a statistically significant improvement In the CS (26.9 to 71) and the final achieved elevation (48.5° to 127.35°) in all groups except acute traumas for obvious reasons. A significant decrease in pain (2.8 to 0.65) was observed in all groups. We saw no implant failures or UHMWPE component wear. DISCUSSION We compared our results with those published by other authors. When considering the functional outcomes, our results are comparable with those published previously. Compared to other studies, an interesting result is the low incidence of scapular notching. In our cohort of patients, it was only present in 10 (2.7%) cases. We attribute this to the design of the SMR® implant which meets the main criterium of a modern shoulder arthroplasty system: modularity of both glenoid components. The glenospheres are available in 36, 40 and 44mm sizes with standard and distalised options. Furthermore, the system also contains the Axioma® revision glenoid component. Humeral stems are available in a range of sizes and lengths including revision stems. The humeral body is also available in two sizes. The short variant is optimal for revision with hemiarthroplasty to reverse conversion. CONCLUSIONS During a period of 14 years, we performed 496 implantations of RSAs using the SMR® system. We evaluated 368 cases with an average follow-up of 5.5 years. During long-term follow-up we experienced no implant failures or complications indicative of any constructional insufficiencies. We saw no signs of UHMWPE liner wear. The SMR® system allows for treatment of even the most complex shoulder affections due to its high modularity. Key words: shoulder joint replacement, reverse shoulder arthroplasty, SMR®, Axioma®, outcomes, ROM, scapular notching, complication, polyethylene wear, UHMWPE.

[Revision of Infected Total Knee Arthroplasties with DAIR Method - Factors Affecting the Two-Year Survival Rate]. / Revize infektu totální náhrady kolenního kloubu metodou DAIR ­ faktory ovlivnující dvouleté prezití.

PURPOSE OF THE STUDY Periprosthetic joint infections in total knee arthroplasty (TKA) represent one of the most limiting factors of implantation. Frequency of this complication is up to 2.5% in primary implantation. Revision TKA with the use of DAIR (Debridement, Antibiotics and Implant Retention) procedure is a widely accepted method in treating infection, but the indication criteria have not been clearly defined as yet. The lack of uniformity prevails also with respect to the surgical technique and the importance of respective techniques for successful treatment. The purpose of this study was to evaluate the factors affecting the twoyear survival of TKA after treating the infection by DAIR. MATERIAL AND METHODS We conducted a monocentric retrospective analysis involving 52 cases of infected TKA managed with DAIR in the period between 2007 and 2016. The evaluation took into account such factors as the sex, age, history of revision surgery for aseptic or septic reasons, and pathogens. The patients were divided into groups based on the McPherson criteria. As to the procedure, we monitored the effect of administered antibiotics, time interval between the manifestation of symptoms of TKA infection and surgery, exchange of modular parts, and use of pulse lavage, continual lavage, local antibiotic carrier, or combination of these techniques. Treatment failure was defined as persistent infection and transition to chronic suppressive antibiotic therapy or need for revision surgery of the respective joint due to recurrent infection of TKA, or death directly associated with the treatment of infected TKA in the follow-up period of 2 years after DAIR. The R software (Team Development Core, 2017) was used to carry out the statistical analysis. The target variable was the failure at two years after surgery. The Generalized Linear Model (GLM) was used for the binary dependent variable - the socalled logistic model with a logit link function. RESULTS 32 of 52 patients (61.5%) were successfully treated, of whom 18 women (62.1%) and 14 men (60.9%). The effect of causative agent, administered antibiotics, polyethylene insert exchange, McPherson score or history of revision surgery of the respective joint for aseptic reasons was not confirmed. The history of revision surgery for infection of the affected joint had a strong negative impact on treatment success, 10 of 13 (76.9%) implants failed as against 10 of 39 (25.6%) implants with negative history of infection. The mean time from surgery to the manifestation of infection was 5.9 weeks (0.5-47.5). When surgery was performed within 2 weeks from the manifestation of infection, 1 of 15 (6.7%) cases failed. In case of a later surgery, 19 of 37 (51.4%) cases failed. As concerns the used surgical technique, 60% (9/15) failure was reported in case of the combination of pulse lavage and continual lavage, 36.4% (4/11) in case of the combination of pulse lavage and local antibiotic carrier, 25% (4/16) in case of separate continual lavage, and 66.7% (2/3) in case of continual lavage with local antibiotic carrier. DISCUSSION The importance of individual factors in revision surgery of periprosthetic joint infections of TKA remains unclear. The world literature indicates as a major negative effect the time factor, the positive history of infection of the affected implant, or other previous revision surgery for aseptic reasons. Ambiguous results are achieved in assessing the effect of the pathogen, administered antibiotics or presence of fistula, the statistical significance of which has not been confirmed in our study. Questionable is also the importance of individual surgical techniques. CONCLUSIONS DAIR is a suitable method in treating infections of stable TKA without the history of revision surgery for infection. The surgery should be performed within 2 weeks from the manifestation of symptoms. Key words: debridement, antibiotics, infection, implant retention, total knee arthroplasty.

[Current Options of Rheumatosurgery of the Hand and Wrist]. / Soucasné moznosti revmatochirurgie zápestí a ruky.

Rheumatosurgery is a discipline managing the symptoms of rheumatoid arthritis of the musculoskeletal system. In a vast number of patients this disease starts in the wrist and hand. The portfolio of surgical procedures performed on the skeleton and soft tissues in these regions can be divided into two groups that, however, often times overlap in practice. Commonly, a combination of these surgical interventions is used. The surgical management should commence with prophylactic interventions that aim to slow down the development of rheumatoid deformities. These are followed by reconstructive surgery which shall manage the already developed rheumatoid deformities and their complications. The prophylactic interventions include early and late synovectomy, peritenosynovectomy, tenodeses, tendon transpositions and limited arthrodeses. The reconstructive surgery procedures comprise osteotomy, resection procedures, alloplasties, total arthrodesis and tendon reconstructions. Key words: rheumatoid arthritis, rheumatosurgery, hand, wrist.

[Rotational Laxity of the Knee Joint - In Vivo MRI Study]. / Rotacní laxita kolenního kloubu ­ in vivo NMR studie.

PURPOSE OF THE STUDY The purpose of the study was to evaluate tibio-femoral rotation during a simulated squat and to investigate the relationship between the rotational position of the femur in full extension and the amount of external rotation of the femur on the tibia during flexion. MATERIAL AND METHODS Part 1: MRIs of volunteers Data on healthy knees of 10 volunteers were obtained using 2D MRI measurements. The foot and the ankle were fixed to prevent rotation and adduction/abduction movements. Sagittal MRIs of the knees have been performed in 4 positions of flexion. The amount of longitudinal rotation in each position of flexion was calculated. Part 2: Mathematical model experiment a) The model of the femur has been positioned in the 3D coordinate system in full extension and at 12.8° of internal rotation and then flexed to 90° without longitudinal rotation. The distance between the centre of the femoral head and the sagittal plane passing through the centre of the knee was then measured. b) Subsequently, the femur was flexed and rotation allowed to retain femoral head within the sagittal plane. The amount of femoral rotation was then calculated. RESULTS Part 1: In full extension the femur was on average in 12.8° of IR relative to the tibia. By 90° flexion femur rotated on average 12.2° externally. Part 2: a)From full extension to 90° flexion the femoral head moved 93.1 mm laterally from the sagittal plane. b)Between full extension and 90° flexion the femur rotated 12.8° externally, a degree which corresponds to the amount of initial internal rotation of the femur in full extension. DISCUSSION The most important finding of the presented in vivo study lies in the fact that in normal knees with tibia rotationally fixed flexion is always coupled with femoral external rotation in order to keep the femoral head in the acetabulum. This rotation is obligatory. CONCLUSIONS We have demonstrated that if the tibia is rotationally fixed, the knee flexion is possible only when accompanied by femoral external rotation to keep the femoral head in the acetabulum. A mathematical description of the experiment has been proposed, the results of which confirm the stated premise. This finding can be explained by initial internal rotation of the femur in full extension of the knee and is allowed by the shape of articulating bones and tension of soft tissues Key words: knee, terminal extension, knee rotation, knee movement, MRI, hip joint.

[Anterior Cruciate Ligament Tears - Influence on Terminal Extension]. / Ruptury predního zkrízeného vazu ­ vliv na terminální extenzi.

PURPOSE OF THE STUDY The aim of this paper was to compare terminal extension in normal and anterior cruciate ligament (ACL) deficient knees, and therefore to determine the role of the ACL during this motion. MATERIAL AND METHODS Ten knees with ACL tears (7 knees with recent ACL tears, 3 knees with long-standing tears) and 10 normal contralateral knees have been examined using MRI in passive hyperextension, 20° flexion and 20° flexion with a 9 kg posteriorly directed load on the femur. Movements of the femoral condyles on the tibia were calculated using previously described methods. RESULTS 1. Under the load at 20° flexion, knees with ACL tear showed posterior femoral subluxation (equivalent to a Lachman test), chronic tears being more unstable. Contralateral normal knees were antero-posteriorly stable. In hyperextension, both femoral condyles subluxed posteriorly in ACL tears but not in normal knees. 2. In all knees with ACL tear, the lateral femoral condyle moved posteriorly from hyperextension to 20°, equating to femoral external rotation. 3. The longitudinal rotation axis during terminal extension in normal knees was medial but in ACL tears it was central causing the medial femoral condyle to move forward from hyperextension to 20°. In normal knees, the medial femoral condyle did not move antero-posteriorly from hyperextension to 20° flexion. DISCUSSION Internal rotation of the femur during terminal extension has been recognized for 150 years. The question remains: what causes the usual combination of longitudinal rotation and extension? In the current literature ACL is considered to be responsible for internal rotation of the femur during terminal extension of the knee. So far, as we are aware, the kinematics of terminal extension, including hyperextension, have not been reported after ACL tear in the living knee. CONCLUSIONS Results of this study imply that: 1. The ACL prevents anterior tibial subluxation in hyperextension. 2. The ACL does not cause rotation in terminal extension. 3. The ACL locates the axis of longitudinal rotation in terminal extension. We hope that by studying living knees with and without ACL tear we may not only clarify the nature and mechanism of rotation in terminal extension, and hence the role of the ACL, but do so in a context of direct clinical relevance. Key words: knee, terminal extension, ACL tear, axis of longitudinal rotation, antero-posterior instability, MRI.

[Indication for Radial Head Resection in Traumatology]. / Indikace resekcí hlavic radia v traumatologii.

PURPOSE OF THE STUDY The aim of our study was to determine the indications for radial head resection at the present day. MATERIAL AND METHODS The radial head resection was performed in the period from 2008 to 2015 in 63 patients divided into three groups. The first group marked "CR" consisted of 33 patients with the Mason type III fracture. The second group marked "CRLUX" included 20 patients with the Mason-Johnston type IV fracture, i.e. a fracture of the proximal end of the radius with a dislocation of the elbow joint. Within this group, in 8 cases also the coronoid process of the ulna was fractured. The third group marked as "CRFR " was composed of 10 patients, in whom concomitant proximal radial fracture and proximal ulna fracture occurred, and in all the cases osteosynthesis of the proximal ulna fracture was performed. For subjective evaluation of the upper limb function the DASH score was used. The functional outcomes were expressed using the Mayo Elbow Performance Score (MEPS). Moreover, the range of motion in the elbow and forearm (flexion and extension of the elbow, pronation and supination of the forearm), elbow joint stability and presence of neurological lesions were assessed. The radiological assessment consisted of measuring the proximalization of the radius, monitoring the heterotopic ossifications, signs of arthrosis, recurrent re-dislocation of elbow and proximal ulna fracture healing. RESULTS The mean follow-up period was 17.6 months (range of 13.2 - 81.0 months, SD 11.5). The mean DASH score was 15.6 (range of 0 - 60, SD 15.3) in the CR group, 12.0 (range of 0 - 52.7, SD 16.7) in the CRLUX group and 17.5 (range of 0 - 62.3, SD 12.8) in the CRFRgroup. A considerably limited mobility was seen in the CR group in three cases (9.1%), in the CRLUX group in four cases (20.0 %) and in the CRFRgroup in two cases (20.0 %). The MEPS score showed similar results in all the groups, excellent and good results were always achieved in more than ¾ of patients. Elbow stiffness did not develop in any of the patients. In the CRLUXgroup, one case a re-dislocation of the elbow occurred. In the CRFRgroup, in one case an injury to the interosseous membrane and distal radioulnar joint ligaments failed to be diagnosed and a clinically significant proximalization of the radius (9 mm shift) occurred, which subsequently required ulnar shortening osteotomy. Additional two proximalization of the radius with a minor shift (2 and 3 mm) in the group CR and CRLUX were not associated with major mobility limitations. Heterotopic ossification occurred in a total of 11 cases (17.5 %) and in four cases it caused major mobility limitations (two cases in the CR group, one case in the CRLUX and CRFRgroups). Surgical treatment was indicated in one case with a good functional effect, in one case the range of motion improved after actinotherapy. In the CR group, one case of neuroma of the radial nerve developed and the condition was treated by sural nerve transplantation. DISCUSSION The current papers view simple proximal radial resection positively unless elbow instability is present. In literature, references are made to serious, mainly late complications (arthrosis, valgus deformity, considerable limitation of elbow range of motion, proximal radial-ulnar synostosis, proximalization of the radius and symptomatic radioulnar joint subluxation). Resection of the radial head is contraindicated in the so called "terrible triad" of the elbow, i.e. the combination of a radial head fracture, a coronoid process fracture and elbow dislocation, and in the Essex-Lopresti injury, i.e. a radial head fracture with a concomitant tear of the interosseous membrane of the forearm and radioulnar joint dislocation. The Essex-Lopresti injury is often overlooked during the initial examination, proximalization of the radius can occur gradually only after several months. CONCLUSIONS The evaluation of our groups of patients showed that the radial head resection can be a good treatment option with no serious early complications in the Mason type III fractures. Serious complications occurred only in cases when the fracture was accompanied by a concomitant injury, i.e. in the Mason-Johnson type IV fractures and in concomitant proximal ulna fracture. When an indication for radial head resection is made, it is essential to correctly diagnose the injury which is clearly a contraindication to this method, i.e. the Essex-Lopresti and the "terrible triad" injuries. Key words: fracture, radial head, resection.

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.

Current treatment procedures for civilian gunshot wounds.

INTRODUCTION: This work provides an overview of the incidence of gunshot wounds during peace conditions in a civilian population and aims to assess the principles of their treatment. METHOD: We evaluated a total of 104 patients with gunshot wounds with an average age of 38.7 years (range 1871). 84 men (80.8%) and 20 women (19.2%) were involved. The head was affected 7 times (6.7%). Out of those, penetrating injury occurred only once (1.0%). The throat was hit three times (2.9%). The chest was injured 15 times (14.4%), penetrating injury at this site was observed in 10 cases (9.6%). In five cases the lungs were affected and the heart once. Gastric injury occurred 13 times, penetration into the peritoneal cavity occurred seven times (6.7%). The intestine was injured five times, the liver three times and the gall-bladder once. Limb injury was present in 66 (63.5%) cases and in 19 of those, the injury was associated with a fracture. In 50 cases (48.1%), the patient was attacked by another person. 45 patients (43.3%) injured themselves unintentionally, five patients (4.8%) were injured in a suicidal attempt and four (3.8%) were accidentally shot by someone else. The weapons used were: pistol in 57 (54.8%) cases, air rifle in 20 cases (19.2%), a rifle in 10 cases (9.6%), two patients (1.9%) were injured with a detonator and one (1.0%) with an assault rifle. In 14 cases (13.5%), the type of firearm used was not established. RESULTS: Surgical treatment was indicated in all cases. The first step was always a thorough wound irrigation. Single surgical treatment was performed in 48 cases (46.2%) while the other 56 patients (53.8%) required multiple surgeries. Specialized surgical procedures were performed in a total of 30 cases: seven laparotomies, five thoracotomies, five fracture stabilizations using external fixator, four amputations of limbs, two intramedullary osteosyntheses, two stabilizations with the use of Kirchner wires, two vascular surgeries, one craniotomy and one suture of a peripheral nerve. Complications of healing were not frequent: wound infection was observed in two cases (1.9%), wound dehiscence in one case (1.0%), osteomyelitis in two cases (1.9%), nonunion of the fracture (1.0 %) occurred once and in one case (1.0%), pulmonary embolism was diagnosed which was not fatal. CONCLUSION: Consistent debridement, fasciotomy, and complete drainage of the wound are only indicated in deep gunshot wounds. A surgical revision of the abdominal cavity is indicated for all penetrating abdominal gunshot injuries. The watch-and-wait approach with surgical wound management and hospitalization is only allowed for unambiguously non-penetrating abdominal injuries. Complications of gunshot wound healing in civilian settings are not common and are most often infectious. Key words: gunshot wound - civilian settings surgical treatment.

[Four-Corner Arthrodesis of the Wrist with Dorsal Circular Plate - a Retrospective Monocentric Study]. / Ctyrrohá déza karpu pomocí dorzální cirkulární dlahy ­ retrospektivní monocentrická studie.

PURPOSE OF THE STUDY Our study aimed to evaluate a group of patients who in the period from 2005 to 2014 underwent a four-corner arthrodesis of the wrist in our department. We also wanted to verify the hypothesis as to whether the use of conventional dorsal plate without the application of bone grafts leads to comparable results as the use of dorsal locking plates and routine application of bone grafts. MATERIAL AND METHODS Throughout the years 2005 to 2014 the four-corner arthrodesis of the wrist was performed in our department in a total of 62 patients, in two cases bilaterally. The indication was the diagnosis of SLAC/SNAC grade III. Normed RondoFix implant was used in all the cases. Following the surgery, the wrist was immobilized by a volar plaster splint for the period of 2 weeks and subsequently orthosis was applied for additional 4 weeks. The wrist mobilisation started in week seven when the orthosis was removed, the patients were allowed full load on the wrist 3 months after the surgery. Our group of patients was evaluated retrospectively, a total of 53 operated wrists in 51 patients were assessed. The assessment was carried out based on a radiograph of the wrist, range of motion, Mayo Modified Wrist Score, DASH Score and grip strength test. RESULTS The mean range of motion in sagittal plane was 63.7°, in frontal plane the mean value was 32.1°. According to the Mayo Modified Wrist Score 37 patients were rated "excellent" or "good". Due to the presence of moderate pain, the result in other 10 patients was assessed as "satisfactory". In a total of 4 patients the result was assessed as "weak", in two of them for a presence of non-union and in other two for severe pain under load. One of these patients underwent bilateral surgery and reported severe pain in both the wrists. Regarding DASH score, the best result equalled 0, the worst 65.83, with the mean of 20.5. The grip strength ranged from 8 to 54 kg, with the mean value of 27.5 kg. In two patients, a non-union occurred. In the first case the extraction of implant and re-arthrodesis was performed due to severe pain and screw migration. The patient is now 22 months after the surgery and the radiographs show that the arthrodesis has healed and the patient has no clinical difficulties. The second patient did not report any difficulties, therefore he is only subject to follow-up. No cases of screw or plate breakage were reported. In one case, the patient reported pain in the region of radial styloid process. A revision was indicated with radial styloidectomy and decompression of tendons of m. extensor pollicis brevis and m. abductor pollicis longus. As a result the patient had no clinical difficulty. One case of wrist radial deviation was recorded. It was managed by corrective wedge osteotomy and reosteosynthesis using a circular dorsal plate. In one patient dorsal impingement occurred, accompanied by limited range of motion and pain. Extraction of OS material was indicated and the patient was relieved of any difficulties. We have recorded aseptic necrosis of lunate bone in one case. DISCUSSION When comparing the functional results such as the range of motion and grip strength, our results are fully comparable to previously published papers. In papers where DASH was referred to, its value ranges from 13 to 29.82, which is fully consistent with our observations with the final value of 20.5. The incidence of non-union and the degree of complications is not deviating from the values included in other publications either. In all the mentioned publications the authors refer to routine use of bone grafts. The publications evaluating the use of locking plates do not report different results either. CONCLUSIONS In case of correct indication, the four-corner arthrodesis of the wrist represents a very good solution. In our group of patients, we confirmed the hypothesis that equally good results as with the use of locking plates can be achieved when using a non-locking plate system. Essential is the proper correction of DISI and primary good congruence between fused carpal bones instead of the use of bone grafts. Key words: SLAC wrist, SNAC wrist, four-corner arthrodesis, partial wrist fusion.

[Our Experience with the Total Replacement of the First Metatarsophalangeal Joint by Medin PH-flex]. / Nase zkusenosti s totální náhradou prvního metatarzofalangeálního kloubu palce PH-flex Medin.

PURPOSE OF THE STUDY: The first metatarsophalangeal (MTP) joint replacement ranks among the treatment methods of patients with hallux rigidus. The paper aims to evaluate the short-term to mid-term outcomes and to present clinical experience with our Medin PH-flex implant. MATERIAL AND METHODS In the period from January 2011 to 2016 we performed total replacement of the first MTP joint in 31 patients, in 4 cases bilaterally. In total, 35 implants were evaluated. The mean age of the patient at the time of surgery was 57.7 years (39-72 years). The surgery was conducted in 29 women and 2 men. The patients were evaluated using the AOFAS score (American Orthopaedic Foot and Ankle Society score), the radiographs were assessed as to the potential occurrence of radiolucent lines, with major stress put on the assessment of the mobility in MTP joint and its position. The pain was assessed based on the VAS score. RESULTS Prior to the joint replacement surgery, the mean AOFAS score in patients was 55.6 (35-65). Postoperatively, the mean AOFAS score was 80.8 (65-95). The pain suffered by patients was evaluated with the use of the Pain Visual Analogue Scale (VAS score). The preoperative mean VAS score was 5 (2-8), whereas the postoperative score improved to mean VAS 2 (0-4). The range of motion was clinically assessed with a goniometer. The mean range of motion of plantar flexion and dorsiflexion was 16.00° (5-35°) and 28.60° (10-55°), respectively. The mean range of motion was 36° (15-60°). No intraoperative complications were observed. In all the patients, the surgical wound healed per primam. In 2 female - (5.7 %) of the whole group of patients who underwent surgery a deep infection occurred, namely 10 and 21 months following the implantation. In both the female patients their condition was managed by joint revision operation and by a simple removal of the implant. DISCUSSION Joint replacement related matters were repeatedly discussed in professional literature. There are many papers published in the literature on this topic. A whole range of the first MTP joint implants of different shapes have been developed, with extremely different clinical results. CONCLUSIONS An appropriately chosen type of the implant, a fitting indication and a correctly applied implantation technique can lead to the desired good outcome. The first MTP joint replacement should be indicated after careful consideration since the management of a potential joint replacement failure can often be very technically challenging and quite mutilating for the patient. The mid-term outcomes of the Medin a.s. first MTP implant seem to be promising. It will, however, be necessary to wait for long-term outcomes in order to evaluate the final benefits of this type of implant in patients with hallux rigidus. Key words: hallux rigidus, arthroplasty of the MTP joint, hemiarthroplasty, silicone implant.

[Analysis of Oxidative Damage to Components Removed from Beznoska/Poldi Total Hip Replacements]. / Analýza oxidacního poskození explantovaných komponent náhrady kycelního kloubu Beznoska/Poldi.

UNLABELLED: PURPOSE OF THE STUDY Ultrahigh molecular weight polyethylene (UHMWPE) is today the most frequently used bearing surface in total joint replacements (TJR) because of its properties, i.e., excellent biocompatibility, good mechanical and tribological performance and high wear resistance. UHMWPE liners are the most loaded TJR components and, therefore, their properties are decisive for TJR longevity. This study had three objectives: 1) to evaluate the oxidative degradation of explanted UHMWPE components; 2) to look for a statistically significant relationship between the extent of oxidative degradation and the durability of joint replacements; and 3) to investigate whether the durability of a TJR was related to the type of sterilisation used in manufacture. MATERIAL AND METHODS The study included 26 acetabular components obtained at revision arthroplasty between 2004 and 2013 from patients in whom a Beznoska/Poldi total hip replacement was used in the period from 1977 to 2002. The average age of the patients at the time of primary implantation was 57.9 years, the average longevity of the components removed was 18.63 years (range, 6.9 to 27.9 years). Samples of worn out and unworn areas from explanted components were processed in a three-step procedure in order to finally obtain 2-mm microtome sections. These were studied by infrared microspectroscopy. Oxidative damage to UHMWPE was determined as the oxidation index (OI); radiation damage to UHMWPE during sterilization was evaluated as the transvinylene index (VI); oxidation-induced changes in the polymer structure and its properties were characterised as the crystallinity index (CI); and local changes in mechanical properties due to oxidative degradation were assessed as microhardness (MH). Spearman's correlation coefficient and the Wilcoxon two-sample test were used for statistical analysis. RESULTS The OI values (average and maximum) in both worn out and unworn surface areas were related to component longevity. The difference between the oxidation index of ruptured components and that of the other components was statistically significant. Significant differences were also found between the average and maximum OI values of worn out areas and those of unworn surfaces. The relationship between the average oxidation index in both the unworn and worn out areas of UHMWPE components and the longevity of cracked components was statistically significant. DISCUSSION Our results show that the OI values obtained by microspectroscopy correlated with both the microscopic damage and the longevity of UHMWPE liners and the correlation was statistically significant also in relation to the longevity of total replacements. Relationships amongst OI, VI, CI and MH values as well as their relation to failure and longevity of total replacements are discussed. CONCLUSIONS It can be concluded that infrared microspectroscopic measurement of OI values is a simple and fast method to characterise UHMWPE liners. In addition, the IR spectra also show other supplementary characteristics, such as VI and CI indices. These values provide information on the quality of various UHMWPE types currently used in TJR surgery. The types of UHMWPE which exhibit high oxidative degradation should be avoided in clinical practice due to increased risk of early TJR failure. Responsible orthopedic surgeons should be aware of this fact and, if possible, collaborate with an independent, noncommercial laboratory in order to evaluate the quality of various UHMWPE liners used in their hospitals. KEY WORDS: UHMWPE, oxidation, total joint replacement, infrared spectroscopy, microhardness.

[Alloplastic Materials and their Propensity to Bacterial Colonisation]. / Aloplastické materiály z pohledu jejich citlivosti ke kolonizaci bakteriemi.

UNLABELLED: PURPOSE OF THE STUDY The alloplastic materials currently used for protective surface layers on implants were tested in vitro under microbiological laboratory conditions by contamination with microbial agents most frequently found in deep infection of total joint replacements. The objective was to find out how the resistance to bacterial colonisation was related to different surface finishes. MATERIAL AND METHODS Each of 14 samples of alloplastic material currently used in the manufacture of orthopaedic implants was inoculated with each of the group of microorganisms most frequently infecting joint replacements; these were Staphylococcus aureus, Staphylococcus epidermidis, Pseudomonas aeruginosa, Enterococcus faecalis and Escherichia coli. At 24 hours of incubation, biofilms produced on sample surfaces were collected, stained with crystalline violet and assessed by spectrophotometry. The average value of biofilm absorbances (AV595) for the group of microorganism tested was taken as a basic characteristic of each material sample indicating its sensitivity to bacterial. RESULTS Of the metal materials with smooth surface finish, Vitalium (AV595, 0.368) showed the lowest affinity to microbial colonisation; next was titanium (AV595, 0.459) and steel (AV595, 0.505). A significant increase in sensitivity to bacterial colonisation was recorded in all types of surface finish of steel (AV595, 0.571) and in titanium alloy with a rough surface texture (AV595, 0.737 to 1.676); p < 0.05. Porous titanium surfaces significantly increased material affinity to colonisation. DISCUSSION Our study had certain limitations concerning in vitro evaluation of porous surfaces that have high affinity to bacterial colonisation. Porous titanium, and its hydroxyapatite layer in particular, considerably promotes osteoblast colonisation of the surface as well as implant osseointegration in the bone bed. Microorganisms therefore have no room for surface colonisation. Problematic may remain the surface parts outside contact with bone that keep their affinity to bacterial colonisation. CONCLUSIONS The material of choice for cemented implants is Vitalium which, of all metal surfaces, has the lowest sensitivity to bacterial colonisation. The materials of choice for cementless implants are titanium alloys. However, an osteoactive surface not in contact with bone remains a problem. On the one hand, its roughness and porosity are crucial to good osseointegration, on the other hand, its affinity to bacterial colonisation is high. KEY WORDS: alloplastic material, biofilm, joint replacement infection.

[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.

PCR diagnostic system in the treatment of prosthetic joint infections.

In our prospective study, we examined whether a multiplex PCR diagnostic method is suitable for the primary detection of pathogens. We also examined the possibility and sensitivity of detecting genes responsible for biofilm production and methicillin resistance. From 2007 to 2009, 94 patients were included in the study. A UNB (universal detection of 16S ribosomal bacterial DNA) and UNF (universal detection of pathogenic fungi) were used in the primary detection. A multiplex assay for biofilm production, methicillin resistance allowed us to distinguish between Gram positivity and negativity and to detect Staphylococci. From all the samples, the culture was positive in 53.2 % of cases, and by using the UNB method, we detected bacteria in 79.8 % of cases-the UNF detection of fungi was positive in 10.6 % of cases. In 75 % of positive findings, we detected a Gram-negative bacterium in 65.3 % of cases. In 47.2 % of Staphylococci detected, the ability to produce biofilm was confirmed. 61.1 % of the Staphylococci exhibited a methicillin resistance. Our multiplex scheme cannot yet fully replace microbial cultivation but can be a rational guide when choosing an appropriate antibiotic therapy in cases where the microbial culture is negative.

The effect of Vancomycin degradation products in the topical treatment of osteomyelitis.

BACKGROUND: The topical application of Vancomycin is increasingly being used in orthopedics because of the development of methicillin resistant bacteria. Consequently, resistance to Vancomycin has recently been on the rise. One possible explanation for this phenomenon could be the thermal degradation of Vancomycin to antibacterially inactive crystalline degradation products (CDP-1s). The aim of our in vitro experiment was to compare the creation and elution characteristics of CDP-1s and the active form of Vancomycin (factor B) released from bone grafts. METHODS: CDP-1s and the factor B released from bone grafts into the buffer solution were measured using the high-performance liquid chromatography method at progressive intervals. RESULTS: The factor B was released from bone grafts at the highest levels, typically on the first day (618.8 mg/L). CDP-1 levels kept increasing until the end of measurement on day 15, when the concentration of CDP-1s (1280.7 mg/L) was much higher compared to that of factor B (217.5 mg/L). CONCLUSIONS: We confirmed the tendency of Vancomycin to convert to antimicrobially ineffective CDP-1s. Although Vancomycin is decomposed into crystalline degradation products, its active forms are released from bone grafts in sufficient concentration for more than two keks (Tab. 3, Fig. 1, Ref. 15).

[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.

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.