[Management Strategy and Evaluation of Surgical Outcomes in Patients with Recurrent Patellar Instability between 2010-2020]. / Strategie lécby a vyhodnocení výsledku operací recidivujících patelárních nestabilit mezi roky 2010­2020.

PURPOSE OF THE STUDY The study retrospectively reviews the outcomes of patella stabilisation surgeries performed at our department in the period 2010-2020. It aimed to provide a more thorough evaluation, to compare the respective types of MPFL reconstruction and to confirm the beneficial effect of tibial tubercle ventromedialization on patella height. MATERIAL AND METHODS In the period 2010-2020, a total of 72 stabilisation surgeries of patellofemoral joint in 60 patients with objective patellar instability (OPI) were performed at our department. The surgical treatment outcomes were evaluated retrospectively using a questionnaire, including the postoperative Kujala score. A comprehensive examination was carried out in 42 patients (70%) who had completed the questionnaire. In case of distal realignment, the TT-TG distance and a change in the InsallSalvati index which serve as an indication for surgery, were assessed. RESULTS Altogether 42 patients (70%) and 46 surgical interventions (64%) were evaluated. The follow-up period was 1-11 years, with the mean follow-up of 6.9 years. In the studied group of patients, only 1 case (2%) of new dislocation was seen, in 2 cases (4%) the patients reported a subluxation episode. The mean score using the school grades was 1.76. Thirty-eight patients (90%) were satisfied with the surgical outcome, 39 patients would undergo a surgery in case of identical problems with the other limb. The mean postoperative Kujala score was 76.8 points, range 28-100 points. The mean TT-TG distance in the studied group with the preoperative CT scan (33x) was 15.4 mm (12-30 mm). The mean TT-TG distance in the cases indicated for tibial tubercle transposition was 22.2 mm (15-30 mm). The mean Insall-Salvati index prior to the performance of tibial tubercle ventromedialization was 1.33 (1-1.74). Postoperatively, the index decreased by 0.11 on average (-0.00 to -0.26) to 1.22 (0.92-1.63). No infectious complications were presented in the studied group. DISCUSSION In patients with recurrent patellar dislocation, the instability is often times caused by pathomorphologic anomalies of the patellofemoral joint. In patients with clinically expressed patellar instability and physiological values of the TT-TG distance, an isolated proximal realignment is performed by medial patellofemoral ligament (MPFL) reconstruction. In the case of pathological values of the TT-TG distance, distal realignment is performed by tibial tubercle ventromedialization to achieve physiological values of the TT-TG distance. In the studied group, tibial tubercle ventromedialization helped decrease the Insall-Salvati index by 0.11 points on average. This has a positive side effect on the patella height, thus on increasing its stability in the femoral groove. In patients with both proximal and distal malalignment, a two-stage surgery is performed. In the isolated cases of severe instability or if symptoms of lateral patellar hyperpressure are present, musculus vastus medialis transfer or arthroscopic lateral release are performed as well. CONCLUSIONS When correctly indicated, proximal, distal realignment or their combination can bring very good functional outcomes with a low risk of recurrent dislocation and postoperative complications. The importance of MPFL reconstruction is confirmed by low incidence of recurrent dislocation in the group investigated in this study, namely when compared with studies referred to in this paper, in which the patients underwent patellar stabilisation using the Elmslie-Trillat procedure. Conversely, leaving the bone malalignment untreated during the isolated MPFL reconstruction increases the risk of its failure. Judging from the obtained results, tibial tubercle ventromedialization also has a positive effect on the patella height through its distalization. Provided the stabilisation procedure is correctly indicated and performed, the patients can get back to their normal activities, often even sports activities. Key words: objective patellar instability, patellar stabilisation, MPFL, tibial tubercle transposition.

[Benefit of Arthroscopy in Differential Diagnostics and Therapy of Lateral Epicondylitis]. / Prínos artroskopie v diferenciální diagnostice a lécbe radiální epikondylitidy.

PURPOSE OF THE STUDY The aim of this study is to confirm that the involvement of arthroscopy in the surgical treatment of painful elbow syndrome, when proper and long enough conservative treatment failed, has better results than open radial epicondylitis surgery alone. MATERIAL AND METHODS A total of 144 patients included 65 men and 79 women, with the mean age of 45.3 years, namely 44.4 years (range 18-61 years) in men and 45.8 years (range 18-60 years) in women. Each patient was clinically examined, an anteroposterior and lateral X-ray of the elbow were performed, and proper therapy was chosen - either primary diagnostic and therapeutic arthroscopy followed by open epicondylitis surgery or primary open epicondylitis surgery alone. The treatment effect was evaluated by using the QuickDASH (Disabilities of the Arm, Shoulder and Hand) scoring system at 6 months after surgery. RESULTS Out of the total group of 144 patients, 114 (79%) patients completed the questionnaire. All the results of the QuickDASH score in our group of patients are in the better half (0-5 very good, 6-15 good, 16-35 satisfactory, over 35 poor), with the mean value 5.63 (in men the mean value was 2.95-2.27 for the combination of arthroscopic and open procedure of LE, 4.55 for open procedure of LE, while in women the mean value was 7.50-6.82 for the combination of arthroscopic and open procedure of LE, 9.09 for open procedure of LE only). Altogether 96 patients (72%) experienced full pain relief. In patients treated with a combination of arthroscopic and open surgery, a higher percentage of patients reported full relief (53 patients, 85%) compared to the patients treated with the open method alone (21 patients, 62%). DISCUSSION By involving arthroscopy in the surgical treatment of patients with lateral elbow pain syndrome after unsuccessful conservative treatment, a successful and early solution to the problem was achieved in 72% of patients. The advantage of elbow arthroscopy over the conventional approach to the treatment of lateral epicondylitis consists mainly in the opportunity to observe intraarticular structures, thus provide a detailed view of the entire joint without the need for direct extensive joint opening, which makes it possible to exclude other causes of problems (e. g. chondromalacia of the radial head, loose body and other intraarticular abnormalities). At the same time, we can treat this source of problems with minimum burden placed on the patient. CONCLUSIONS Arthroscopic examination of the elbow joint makes it possible to diagnose all potential intraarticular sources of difficulties. Simultaneous elbow arthroscopy and open treatment of radial epicondylitis (release of ECRB or EDC, ECU, necrotic tissue excision, deperiostation and radial epicondyle microfractures) is a safe method with low morbidity, faster rehabilitation and return to the original activities based on subjective evaluation of patients and objective scoring. Key words: lateral epicondylitis, radiohumeral plica, elbow arthroscopy.

[Native Joint Septic Arthritis in Adults: Incidence in Our Group of Patients and Antibiotic Therapy Guidelines]. / Infekcní artritidy nativních kloubu u dospelých: výskyt v nasem souboru pacientu a doporucení antibiotické lécby.

PURPOSE OF THE STUDY The purpose of the study is to analyse the number of adult patients treated in our department for native joint septic arthritis and to outline guidelines for antibiotic therapy. MATERIAL AND METHODS From the beginning of 2003 to the end of 2020, a total of 36,342 surgeries were performed at our department. We retrospectively reviewed and analysed all surgeries for native joint septic arthritis (a total of 538 surgical interventions). The study included all adult patients who were operated for native joint septic arthritis in our department in 2003-2020. We included all revision surgeries for ongoing infection (excluding the management of post-infectious findings) as well as all operations performed in patients with multiple joint involvement. Based on the analysis of our data and review of published guidelines for antibiotic treatment of septic arthritis, we have outlined our own antibiotic therapy guidelines for the treatment of native joint septic arthritis. RESULTS From 2003 to 2020 we performed a total of 36,342 surgeries, of which 538 (1.5%) in 461 patients was indicated for native joint septic arthritis. The cohort consisted of 292 men (63%), who underwent 344 surgeries, and 169 women, in whom 194 surgeries were performed. The mean age of patients irrespective of the arthritis location was 62.4 years. Altogether, 19 patients (4.1%) suffered from multi-joint arthritis. The most frequently operated joint was the knee with 252 (54%) patients and 300 surgeries (56%), followed by the shoulder with 68 (14.7%) patients and 78 (14.5%) surgeries, the hip with 38 (8.2%) patients and 42 surgeries (8%), the carpal with 30 (6.5%) patients and 35 (6.5%) surgeries, the ankle with 25 patients (5.4%) - 31 (6%) surgeries, the small finger joints with 22 (4.75%) patients and 23 (4%) surgeries, the elbow with 14 (3%) patients and 14 (2.6%) surgeries, the sternoclavicular joint with 9 (1.9%) patients and 12 (2.2%) surgeries and the acromioclavicular joint with 3 patients and 3 (0.5 %) surgeries, respectively. DISCUSSION The management of septic arthritis relies heavily on early diagnosis, early surgical intervention and adequate antibiotic therapy. The diagnostic process and surgical treatment have their specifics related to the affected location, therefore, respective guidelines will be published separately for each location including the results. On the other side, antibiotic management is not dependent on the location and therefore the guidelines are included in this first analysis septic arthritis in the whole cohort. CONCLUSIONS Septic arthritis in adults in an ongoing issue with rising incidence. Early diagnosis, urgent and adequate surgical treatment, and optimal antibiotic therapy are preconditions for successful outcome. Key words: native joint septic arthritis, incidence, antibiotic therapy, guidelines.

[Accuracy of Alignment of Femoral and Tibial Component of the Oxford Medial Unicompartmental Knee Arthroplasty Using Zimmer Microplasty® Instrumentation]. / Presnost centrace femorální a tibiální komponenty mediální unikompartmentální náhrady kolenního kloubu Oxford za pouzití instrumentária Zimmer Microplasty®.

PURPOSE OF THE STUDY The purpose of the study is to verify the correct alignment of components of the Oxford medial unicompartmental knee arthroplasty using the Zimmer Microplasty® instrumentation at the beginning of the learning curve. The implantation of prosthetic components of partial knee arthroplasty in proper alignment has an effect on long-term survival of the prosthesis and should eliminate the occurrence of frequent complications. MATERIAL AND METHODS The study group includes 20 patients, 9 men with the mean age of 68 years (range 62-78 years) and 11 women with the mean age of 69 years (range 52-81 years). 13 patients underwent surgery on the right knee and 7 patients on the left knee. The mean length of symptoms was 13 months (range 7-20 months), the mean varus knee deformity was 7° (range 4-12°). The selected patients met both the clinical and radiological criteria for enrolment in the study. In all of them medial unicompartmental knee arthroplasty was performed in 2019 by the same surgeon. After surgery, the parameters of accuracy of alignment of individual prosthetic components were measured on the full-length radiograph of the limb under load. The WOMAC score was recorded preoperatively and one year after surgery and subsequently compared. The knee joint flexion preoperatively and one year after surgery was evaluated. RESULTS The analysis of radiographs revealed that in 12 cases the femoral component was implanted in the mean valgus angle of 1.6° (range 1-3°) and in 8 cases in the mean varus angle of 3° (range 1-5°). All femoral components were implanted in the mean flexion of 7.3° (range 3-11°), no component was implanted in extension. As concerns the tibial component, 19 components were implanted in a neutral or minimum varus angle with the mean value of 1.1° (range 0.3-4°). One component only was implanted in the valgus angle of 1°. All tibial components were implanted with the mean dorsal slope of 6.5° (range 4-8°). The incision was 5 mm deep on average (range 3-6 mm). There was a slight divergence between the components, namely 2.8° on average (range 2-7°) and the distance between the components was 4mm on average (range 3-5 mm). The mean knee joint flexion achieved preoperatively by patients was 115° (range 110-123°), whereas postoperatively the mean flexion achieved was 126° (range 111-138°). The preoperative Womac score was 84.5 points on average (range 64-96 points), whereas postoperatively it was 26.4 points on average (range 7-52 points). None of the components was implanted outside the permitted range, no early complications of the partial replacement (luxation of polyethylene mobile bearing insert, early loosening of the prosthesis, tibial fracture) were observed. DISCUSSION Our radiographic measurements show that when Zimmer Microplasty® instrumentation is used correct alignment of the femoral and tibial component can be achieved and the individual components were correctly aligned within the recommended range. Every single component met the required criteria for alignment. When comparing the values obtained by us in measurements with those obtained by other authors from abroad, similar results regarding the alignment of components were achieved. CONCLUSIONS When using Zimmer Microplasty® instrumentation, excellent results can be achieved also at the beginning of the learning curve of partial knee replacement. Key words: medial gonarthrosis, unicompartmental arthroplasty, hemiarthroplasty, alignment of components.

[Outcomes of Revisions of the Acetabular Component of THA with Paprosky Type 3a and 3b Defects Using Tantalum Trabecular Metal Implants 2-10 Years Postoperatively]. / Výsledky revizí acetabulární komponenty TEP kycle s defekty Paprosky 3a a 3b pomocí trabecular metal tantalových implantátu 2­10 let po operaci.

PURPOSE OF THE STUDY Tantallum trabecular metal implants (Trabecular Metal Technology - TMT) considerably changed the acetabular reconstruction options in revision surgeries with extensive bone defects and distorted pelvic ring integrity. The purpose of this study is to ascertain the short-term to medium-term outcomes of acetabular reconstruction through TMT implants in patients with Paprosky type 3a and 3b acetabular defects and in case of pelvic discontinuity. MATERIAL AND METHODS The prospective monocentric study included patients in whom the revision of acetabular components in total hip arthroplasty was performed, the acetabular defect was classified as Paprosky 3a and higher, a TMT implant was used for reconstruction, and the follow-up period was at least 2 years after surgery. In total, 87 patients who had met the inclusion criteria were operated on and followed-up. The patients in the study group underwent a clinical examination, an X-ray and also an assessment using the Harris hip score. Moreover, the patients were asked about their satisfaction with the surgical outcome, their willingness to undergo the same procedure again in case of difficulties, and they were also asked to rate the outcome in percentage term and by assigning grades. Also, an analysis of the reasons for revision and subsequent complications was carried out. Implant integration and its migration were evaluated on an X-ray. RESULTS 32 men and 55 women were subjects to evaluation, with a balanced number of operated sides (44:43 in favour of the right side). One-stage procedures prevailed, which were performed in a total of 74 cases, while two-stage revisions were performed in 13 cases in the study group. In three patients (3.5%) pelvic discontinuity was diagnosed, 69 patients (79%) suffered from Paprosky 3a defect and 15 patients (17%) from Paprosky 3b defect. The first patients underwent surgery in 2009 and the mean follow-up period in the study group was 48 months. In 1 patient the TMT implant was removed for infectious complications, in the remaining part of the group the TMT implant was fully integrated with no signs of loosening or migration in the monitored period. In the assessment using the Harris hip score, the mean score of 80.4 (range 36-99) was achieved. When assessing the satisfaction with the surgical outcome, the mean value achieved was 94.4%, and the mean assigned grade was 1.26 (on a school grading scale). DISCUSSION Extensive bone defects and pelvic discontinuity represent an issue in revisions of the acetabular component in total hip arthroplasty. There are several options how to address these conditions. State-of-the-art TMT implants thanks to their shortterm and medium-term outcomes appear as one of the most beneficial option with a low failure rate both in our study group and in published papers. CONCLUSIONS Evaluation of this monocentric prospective study reveals encouraging short-term and medium-term outcomes of the use of TMT implants in managing extensive acetabular bone defects of Paprosky 3a and 3b type and supports their further introduction into practice at our department. Key words: total hip arthroplasty (THA), revision implantation, TMT implant.

[Economic Analysis of the Costs of Hospital Stay of Patients with Infection as a Complication of Total Replacements - Part 2: Total Hip Arthroplasty]. / Ekonomická analýza nákladu na hospitalizaci pacientu s infekcní komplikací totální náhrady - 2. cást: totální náhrada kycelního kloubu.

PURPOSE OF THE STUDY The study aims to quantify the costs of a hospital stay of patients with periprosthetic joint infection after total hip arthroplasty throughout the period of treatment. MATERIAL AND METHODS The group included patients who have been treated at our department for infection as a complication of total hip replacement since 1 January 2011, who have been provided with treatment (including complications) exclusively at the departments of Nemocnice Ceské Budejovice, a.s. and whose treatment can be considered completed in 2019. The patients were included in the study regardless of the type of infection and method of treatment. The group consisted of 36 patients (16 men and 20 women). There were 3 cases of early postoperative infection, 14 cases of late postoperative infection and 19 cases of hematogenous infection. The group includes 8 patients treated by a one-stage reimplantation, 19 patients managed by a two-stage reimplantation, 6 patients treated by a revision surgery with implant retention, and 3 patients in whom only the implant removal was possible. In selected patients, all the reported points for all the hospital stays and costs incurred on a separately charged material were ascertained and the final sum was compared with the reimbursement obtained by the hospital in the DRG system valid for the respective year of treatment. The total costs were analysed and also an analysis by type of infection and method of treatment was carried out. RESULTS The average costs of managing infection as a complication of total hip arthroplasty at our department amounted to CZK 320 065 (CZK 56 995 - CZK 953 614), the reimbursement in respect of the monitored cases in the DRG system equalled CZK 220 503 (CZK 89 149 - CZK 589 974). The aforementioned suggests that the average loss per treated patient is CZK 99 562 (CZK + 63 372 - CZK -428 499). DISCUSION Care associated with infections as a complication of total hip arthroplasty is very costly and these costs are not fully covered by the reimbursement from the health insurance companies. In the Czech Republic, these costs have not been quantified as yet, therefore it is only possible to compare the costs with international publications arriving at similar conclusions and with own monitoring of the costs of periprosthetic joint infections after total hip arthroplasty. The most economically efficient is the one-stage replacement which, however, is not suitable for all the patients, and the two-stage reimplantation continues to be the gold standard. In our study, the most expensive was found to be the treatment of periprosthetic joint infection after total hip arthroplasty, in which also the highest financial loss is reported. CONCLUSIONS Due to the very high costs of treatment for periprosthetic joint infections after total hip arthroplasty, it is necessary to exert maximum efforts to prevent periprosthetic joint infections and to consider a change in the method of financing, particularly in centres to which patients are referred from other centres in order to make this treatment economically viable. Key words:total hip arthroplasty, PJI - periprosthetic joint infection, economic analysis.

[Economic Analysis of the Costs of Hospital Stay of Patients with Infection as a Complication of Total Replacements - Part 1: Total Knee Arthroplasty]. / 1. cást: totální náhrada kolenního kloubu - 1. cást: totální náhrada kolenního kloubu.

PURPOSE OF THE STUDY The study aims to quantify the costs of a hospital stay of patients with total knee periprosthetic joint infection throughout the period of treatment. MATERIAL AND METHODS The group included patients who have been treated at our department for infection as a complication of total knee replacement since 1 January 2011, who have been provided with treatment (including complications) exclusively at the departments of Nemocnice Ceské Budejovice, a.s. and whose treatment can be considered completed in 2018. The patients were included in the study regardless of the type of infection and method of treatment. The group consisted of 24 patients (11 men and 13 women). There were 2 cases of early postoperative infection, 6 cases of late postoperative infection and 16 cases of hematogenous infection. The group includes 17 patients treated by a two-stage reimplantation, 6 patients treated by a revision surgery with implant retention, and 1 patient treated by a one-stage replacement. In selected patients, all the reported points for all the hospital stays and costs incurred on a separately charged material were ascertained and the final sum was compared with the reimbursement obtained by the hospital in the DRG system valid for the respective year of treatment. The total costs were analysed and moreover, an analysis by type of infection and method of treatment was carried out. RESULTS The average costs of managing infection as a complication of TKA in our department amounted to CZK 405 864 (CZK 66 768-CZK 181 17). The average cost of a two-stage revision was CZK 497 487, the cost of a revision surgery with original implant retention was CZK 175 312. The reimbursement in respect of the monitored cases in the DRG system equalled CZK 276 230 (CZK 40 943-CZK 848 401). The aforementioned suggests that the average loss per a treated patient is CZK 129 635 (CZK + 26 066Kc-CZK -332 774). DISCUSION Our study is in agreement with recent literature, when confirming that the care associated with infections as a complication of TKA is very costly (especially in case of a two-stage reimplantation) and also that this care is not fully covered by the health insurance company. The reimbursement made by the health insurance companies does not cover on average 1/3 of the costs of care for an infectious patient. Theoretically, the reasons behind the reduced reimbursement may be sanctions which, however, cannot be accepted in case of late hematogenous infections which constituted more than 50% in our group. CONCLUSIONS Our study presented the actual costs associated with the care of TKA infection. It makes sense that the most expensive is the two-stage reimplantation, which is nevertheless still considered to be the gold standard procedure in chronic TKA infection. High costs of therapy together with the requirement of expert care would justify the introduction of care provided by specialised centres. In this case, centralisation could result in a more efficient use of funds and improvement of the quality of provided care. Key words:total knee arthroplasty, PJI - periprostetic joint infection, economic analysis. ÚVOD.

[Treatment of Acute Periprosthetic Infections with DAIR (Debridement, Antibiotics and Implant Retention) - Success Rate and Risk Factors of Failure]. / Lécba akutních periprotetických infekcí postupem DAIR (debridement, antibiotics and implant retention) ­ úspesnost a rizikové faktory selhání.

PURPOSE OF THE STUDY Revision surgery with implant retention and exchange of mobile prosthetic parts is considered to be the method of first choice in acute periprosthetic infections with a stable endoprosthesis and good condition of soft tissues, where the symptoms did not last longer than 3 weeks. The aim of the study was to evaluate the long-term outcomes and to identify the factors affecting the success rate of this procedure. MATERIAL AND METHODS This unicentric retrospective study evaluated the results of 18 surgeries with implant retention performed at the Department of Orthopaedics of Ceské Budejovice Hospital in the period 2009-2016. The failure of the procedure was defined as the presence of at least one of the following criteria: removal or replacement of endoprosthesis within 2 years after the DAIR procedure, detection of the same pathogen during the DAIR procedure and in the later performed revision surgery, necessity of chronic suppressive antibiotic therapy, death related to periprosthetic infection. The cured patients were invited for a clinical check-up. The postoperative condition was assessed using the Knee Society Score and the Harris Hip Score. RESULTS The overall success rate of the procedure reached 61.1%. Hematogenic dissemination was the cause of periprosthetic infection in 13 followed-up cases (72.2%), with the average time after the implantation of 153.2 weeks. Treatment through the DAIR procedure was successful in 53.8%. Early postoperative complications were observed in 5 cases (27.8%), in 4 of which, i.e. 80%, they were successfully managed by a surgery with implant retention. The most frequently identified etiological agents were Staphylococcus aureus and Staphylococcus epidermidis strains. In primo-implanted endoprostheses the success rate reached 90.9% (in case of early postoperative infections even 100%), whereas surgeries in repeatedly operated joints were successful in 14.3% only. The mean value of the Knee Society Score in patients after a successful knee joint surgery was 81.2 of the maximum score of 100 (σ= 8.5), the Function Knee Society Score was 70 of 100 (σ= 34.6). In the case of the Harris Hip Score in patients after the hip replacement, the mean hip function score was 89.8 of the maximum of 100 (σ= 7.3). The patients with knee and hip joint endoprosthesis after the performed DAIR procedure were satisfied on average to the level of 82.5% and 90%, respectively, while 28.6% of patients experienced certain functional decline during daily activities. Postoperatively, 25% of patients reported continuing stronger pain as compared to the past medical history. No patient experienced any change in terms of a limited range of motion or decreased joint stability. DISCUSSION The overall success rate of the DAIR procedure of 61.1% corresponds with the values stated in the literature. A significantly higher success rate was achieved in early postoperative complications. This can be explained by a lower specificity in determining the actual pathogenesis of late periprosthetic infections and potentially longer lasting colonisation of endoprosthesis. The medical history of previous surgeries performed on the affected joints for septic arthritis or with a surgical instrument retention was identified as an important risk factor of failure of the subsequently performed DAIR procedure. Significant effects of pathogenicity of the detected agent or systemic comorbidities on the success rate of the procedure were not confirmed in our group. Successful performance of the DAIR procedure results in maintaining a very good function of endoprosthesis as well as subjective satisfaction of patients. CONCLUSIONS The DAIR technique is an ideal solution in correctly and early diagnosed acute periprosthetic infections. The results suggest that it is particularly appropriate in early postoperative infections of primary total joint replacements. Its indication in late periprosthetic infections, especially of repeatedly operated joints, shall be carefully considered. Key words:acute periprosthetic joint infections, PJI, DAIR, implant retention, risk factors, success rate.

[Endoprosthesis Infections - Guidelines for Antibiotic Therapy Common Guidelines of the Czech Society for Orthopaedics and Traumatology and the Society for Infectious Diseases of the Czech Medical Association of J. E. Purkyne]. / Infekce endoprotéz ­ doporucení antibiotické lécby Spolecné doporucení Ceské spolecnosti pro ortopedii a traumatologii a Spolecnosti infekcního lékarství Ceské lékarské spolecnosti J. E. Purkyne.

PURPOSE OF THE STUDY This study aims to articulate regional guidelines for curative and suppressive antibiotic therapy of total joint replacement infections. MATERIAL AND METHODS When developing the standard, used as source materials were the published foreign guidelines for antibiotic therapy of prosthetic joint infections, the analysis of resistance of bacterial strains conducted in the Hospital in Ceské Budejovice, a.s. and the assessment of strain resistance for the Czech Republic published by the European Antimicrobial Resistance Surveillance Network (EARS-Net). Considered was also the availability of individual antibiotics in the Czech Republic and restricted prescription according to the Summary of Product Characteristics as specified in the State Institute for Drug Control marketing authorisation. The expert group composed of orthopaedists, microbiologists and infectious disease specialists elaborated the basic antibiotic guideline for choosing an appropriate antibiotic/antifungal drug based on the usual susceptibility, its dose and dosage interval for initial and continuation therapy. The comments of individual specialists were gradually incorporated therein and in case of doubts majority rule was applied. The drafted document was sent for peer reviews to clinical orthopaedic, infectious disease and microbiological centres, whose comments were also incorporated and the finalised document was submitted for evaluation to specialised medical societies. RESULTS The outcome is the submitted guideline for antibiotic curative and suppressive therapy suitable for managing the prosthetic joint infections, which was approved by the committee of the Czech Society for Orthopaedics and Traumatology andthe Society for Infectious Diseases of the Czech Medical Association of J. E. Purkyne. DISCUSION Curative therapy of total joint replacement infections consists primarily in surgical treatment and has to be accompanied by adequate antibiotic therapy administered initially intravenously and later orally over a sufficient period of time. Bearing in mind the wide spectrum of pathogens that can cause infections of a joint replacement and their capacity to form a biofilm on foreign materials, the correct choice of an antibiotic, its dose and dosage interval are essential for successful treatment. Such standard should respect regional availability of antibiotics, regional pathogen resistance/susceptibility and ensure the achievement of sufficiently high concentrations at the requested location including anti-biofilm activity. CONCLUSIONS The submitted guideline is not the only treatment option for joint total replacement infections, but it makes the decisionmaking easier when treating these complications in the form of infections. The final choice of an antibiotic, its dose and duration of therapy shall be based on a critical assessment of results of microbiological (blood culture and molecular genetic) tests and reflect the patient s clinical condition. Since these are multidisciplinary issues, we consider useful for this guideline to be commented upon and approved by the committee of both the Society for Orthopaedics and Infectious Diseases so that it can become the starting point for treatment. Key words: total joint replacement infection, TEP, ATB, antibiotic therapy, consensus meeting, guideline.

[Use of Patient Specific Instruments at Total Knee Arthroplasty. One-Year Results of a Prospective Randomised Study]. / Pacient Specific Instruments (PSI) pri implantaci TEP kolenního kloubu - rocní výsledky prospektivní randomizované studie.

UNLABELLED: PURPOSE OF THE STUDY The aim of this prospective study was to evaluate, at one year of follow-up, radiographic and clinical results of total knee arthroplasty (TKA) performed with use of Zimmer® Patient Specific Instruments (PSIs) which allow for planning and customising each patient's TKA. MATERIAL AND METHODS Of the patients with knee arthritis who were eligible for joint replacement, 23 were randomly selected and included in this study. There were 11 men and 12 women, with 11 right and 12 left knee joints. On the basis of pre-operative CT scans, PSI custom-made pin guides, which conformed to the individual patient's anatomy, were produced and then used in the THA surgery involving a NexGen (CR) system. All patients were examined before surgery and at 1 year after THA. The evaluation at a follow-up visit included standing full-length radiographs (antero-posterior and lateral), Knee Score results, range of motion (ROM), patient's satisfaction report, and post-operative complications. The X-ray views were examined for mechanical leg axis alignment, TKA alignment in antero-posterior and lateral projection and signs of potential loosening. RESULTS At 1 post-operative year, the average Knee Society Score (KSS) was 85.5 points and the average functional score was 82.6 point. The satisfaction rate was 94% and, on a school rating system, the average mark was 1.3. The average postoperative ROM value was 116°. All patients were willing to undergo the surgery again. The only complication was thrombosis in one patient. Radiographic findings of knee alignment were optimal in 18, correct (up to 3° deviation) in three and incorrect (above 3° deviation) in two patients. Radiographic signs of loosening were not recorded. DISCUSSION Correct knee alignment is one of the requirements for achieving a good TKA outcome. Various techniques are used to improve the total knee process (computer-aided surgery, customised guides). Zimmer Patient Specific Instruments provide advanced pre-operative planning and more accurate implant sizing and alignment. An experienced surgeon can achieve the same good results with conventional planning under standard conditions but the use of PSIs is clearly more beneficial in patients with extra-articular deformities and in patients in whom femoral intramedullary guides cannot be employed. To produce a custom-made pin guide requires a CT scan of the whole leg and is also associated with additional paperwork. The PSIs simplify the total knee process from start to finish and surgeons have complete flexibility to make fine-tuning adjustments during the procedure. CONCLUSIONS Zimmer Patient Specific Instruments allow for exact alignment of both the femoral and the tibial component in a TKA process. Under standard circumstances, clinical and radiographic outcomes are comparable with those of conventional planning. However, the use of PSIs is clearly more beneficial in patients with extra-articular deformities and in patients in whom femoral intramedullary guides cannot be employed. KEY WORDS: total knee arthroplasty, TKA, Patient Specific Instruments, PSIs.

Recurrent varicose veins: causes and neovascularisation. A 17-year experience.

AIM: The aim of the paper was to determine the causes of varicose vein recurrence and, when neovascularisation is suspected, to confirm or exclude its presence and to establish its contribution to the recurrence of varicose veins. METHODS: A retrospective analysis of a set of 217 legs reoperated in our department over a period of 17 years with a two-year prospective histological and histochemical (nestin) analysis of resected veins. RESULTS: Reflux as a cause of varicose vein recurrence was identified in 93% of the limbs. It was most commonly found in the area of the saphenofemoral junction, followed by the area of the saphenopopliteal junction. Reflux in the perforating veins was almost invariably linked to that in the saphenofemoral junction or saphenopopliteal junction; an isolated damage to the perforating veins was only present in three limbs. Histological and histochemical analysis was performed for the samples of eleven veins in which neovascularisation was suspected based on preoperative duplex ultrasonography evaluation. Neovascularisation was confirmed in none of these veins and none of them was the cause of recurrence. CONCLUSION: The major cause of varicose vein recurrence is a reflux left unresolved during the primary surgery, particularly in the area of the saphenofemoral junction. A less common cause is progression of the disease and the occurrence of a new reflux. Neovascularisation is of no importance for the recurrence of varicose veins.

[The Effect of Tranexamic Acid on Blood Loss after Primary Unilateral Total Knee Arthroplasty. Prospective Single-Centre Study]. / Vliv podání kyseliny tranexamové na krevní ztráty po primární jednostranné náhrade kolenního kloubu - prospektivní studie.

PURPOSE OF THE STUDY: Tranexamic acid is an antifibrinolytic agent which blocks plasmin-mediated fibrin degradation. It is used in surgery to reduce intra-operative and post-operative blood loss. The aim of our study was to assess the effect of tranexamic acid administration on blood loss after elective primary unilateral total knee arthroplasty. MATERIAL AND METHODS: A total of 119 patients (50 men, 69 women) with an average age of 69.2 years were included. The patients were randomised into two groups: Group A received a single dose of tranexamic acid (Exacyl, 1.5 g i.v.) before the operation; Group B (control) did not receive any antifibrinolytic agent. All patients underwent surgery under spinal anaesthesia with a tourniquet applied to the operated leg. The intra-operative blood loss, post-operative blood loss based on drainage, pre- and post-operative levels of haemoglobin and haematocrit, and the number of administered blood transfusions were analysed. RESULTS: The administration of tranexamic acid led to a reduction in post-operative blood loss at all intervals tested, including the total blood loss (504 ± 214 vs 815 ± 231 ml; p < 0.001), and to reduced requirements for blood transfusion (1.18 ± 0.51 vs 1.54 ± 0.84 transfusion units; p < 0.05). A similar effect was observed in the subgroups of men and women; the total blood loss was higher in men than in women in both group B (non-significant) and group A (p < 0.05) patients. There was a gradual decline in haemoglobin and haematocrit levels during the post-operative period, with no significant differences between the two groups. Nor were there any differences in intra-operative blood losses either. No severe complications such as stroke, acute myocardial infarction or thromboembolic disease were recorded. DISCUSSION The administration of tranexamic acid before the application of a tourniquet resulted in reducing post-operative, but not intra-operative, blood losses in patients undergoing elective total knee arthroplasty. Transfusion requirements were reduced as well. CONCLUSIONS: Our study confirmed the efficacy and safety of tranexamic acid administration in relation to blood loss after total knee arthroplasty. In this indication, the administration is in accordance with the literature data.

[Minimally invasive anterolateral surgical approach for total hip arthroplasty: seven-year results]. / Náhrada kycelního kloubu MIS-AL technikou--sedmileté výsledky.

PURPOSE OF THE STUDY: To evaluate the results of using the minimally invasive surgical-anterolateral approach (MIS-AL) for total hip arthroplasty at 7-year follow-up. MATERIAL: A total of 188 patients operated on between January 2005 and March 2006 were invited to come for check-up. Of them, 132 had a complete follow-up including examination at one and 7 years post-operatively. Forty-seven patients did not respond, four had died and five underwent revision arthroplasty. The evaluation was based on the Harris Hip Score, percent and school markings and radiographic analysis. METHODS: The patient was operated on in the lateral position. A short incision (5 to 8 cm) was made above the junction of the greater trochanter and the anterior superior iliac spine. The hip was accessed through a natural separation between the gluteus medius and the tensor fasciae latae. After joint capsule resection, femoral elevators were applied and femoral neck osteotomies were performed. The first was done on the leg in an orthograde position and the other as well as femoral head extraction were carried out on the leg with the knee flexed 90 degrees and hip external rotation of 90 degrees. Using reamers and rasps, the bone of both the acetabulum and the femur was prepared for implantation of a cementless or cemented prosthesis. A standard antibiotic prophylaxis and an antithrombotic therapy were administered. The patients were allowed to walk with 30 kg of weight on the operated leg from the 2nd post-operative day; walking with full weight-bearing without external support was allowed in patients with cemented implants at 6 weeks and in those with cementless implants at 3 months after surgery. RESULTS: The group evaluated consisted of 69 men and 63 women, with an average age of 64.75 years at surgery. The average pre-operative Harris Hip Score was 46. At 7 years after surgery the average hip score increased to 89.125. Of the 132 patients, 128 were satisfied with the outcome; the average rating was 94% and the average school mark was 1.34. The outcome assessment by the same patients at 1 post-operative year included the average values of 90.55 for the hip score, and 97% and 1.17 for percent and school marking of satisfaction, respectively. Better outcomes were achieved in the patients with cementless hip replacement. DISCUSSION: Our results, which are in agreement with the published data, show that the results of mid-term assessment of MIS-AL procedures are not superior to those achieved by the conventional approach. Even well documented prospective randomised studies comparing minimally invasive and standard techniques have failed to report any advantages of one method over the other in any of the characteristics studied, which included haemoglobin levels, X-ray findings, patient mobilisation, length of hospital stay, pain intensity, and scoring system results (Harris Hip Score, McMaster University Osteoarthritis Index or Short Form-12). Many studies have focused on looking for characteristics of better early results after minimally invasive techniques but, so far, the findings have been comparable for both methods or are of no great importance. CONCLUSIONS: The minimally invasive technique for total hip replacement is no revolution in this field but is an alternative for a selected category of patients whose condition in the early post-operative period would benefit from less-invasive surgery. The MIS-AL approach does not replace the conventional total hip arthroplasty. It may play a role early after surgery but has no superior outcomes in the long-term post-operative period. In well indicated cases it is the method of choice with good mid-term results.

A method for estimating population sex ratio for sage-grouse using noninvasive genetic samples.

Population sex ratio is an important metric for wildlife management and conservation, but estimates can be difficult to obtain, particularly for sexually monomorphic species or for species that differ in detection probability between the sexes. Noninvasive genetic sampling (NGS) using polymerase chain reaction (PCR) has become a common method for identifying sex from sources such as hair, feathers or faeces, and is a potential source for estimating sex ratio. If, however, PCR success is sex-biased, naively using NGS could lead to a biased sex ratio estimator. We measured PCR success rates and error rates for amplifying the W and Z chromosomes from greater sage-grouse (Centrocercus urophasianus) faecal samples, examined how success and error rates for sex identification changed in response to faecal sample exposure time, and used simulation models to evaluate precision and bias of three sex assignment criteria for estimating population sex ratio with variable sample sizes and levels of PCR replication. We found PCR success rates were higher for females than males and that choice of sex assignment criteria influenced the bias and precision of corresponding sex ratio estimates. Our simulations demonstrate the importance of considering the interplay between the sex bias of PCR success, number of genotyping replicates, sample size, true population sex ratio and accuracy of assignment rules for designing future studies. Our results suggest that using faecal DNA for estimating the sex ratio of sage-grouse populations has great potential and, with minor adaptations and similar marker evaluations, should be applicable to numerous species.

[Relationship of acromial morphology and rotator cuff tears]. / Vztah tvaru akromia a ruptury rotátorové manzety.

PURPOSE OF THE STUDY: To evaluate the effect of acromial morphology, as assessed on radiographs, on rotator cuff tears. MATERIAL: A total of 200 patients surgically treated for shoulder disorders were enrolled. All were older than 40 years and had good quality shoulder radiographs. Two groups were composed: First, a clinical model group of 136 patients to be investigated for three parameters of rotator cuff injury that was divided into two subgroups. One included 68 patients, with an average age of 53.5 years, in whom surgery revealed no injury to the rotator cuff; the other subgroup of 68 patients, with an average age of 58 years, had a ruptured supraspinatus tendon. Subsequently, a control group of 64 patients (32 with rotator cuff injury and 32 without it) was used to verify the results of the model group. METHODS: Three parameters describing the acromion, i.e., acromion index (AI), lateral acromion angle and acromial slope, were measured on standard radiographs. Tangential antero-posterior and scapular "Y" (supraspinatus outlet) views were taken, the images were digitalised and evaluated using a TomoCon 3.0 Viewer programme, and the results of the two groups were statistically analysed and compared. RESULTS: The difference between the patients with rotator cuff injury and those without it was best shown, in both groups, by significant differences in the acromion index. This was true for both the men and women. The AI values for the patients with rotator cuff injury were 0.66 and 0.65 in the model and control groups, respectively. The same AI value of 0.76 was found for uninjured rotator cuffs in both groups. The two other parameters investigated did not appear to be of any significant validity for assessment of rotator cuff tears. DISCUSSION: The aetiology of injury to the rotator cuff has not been fully understood yet but, undoubtedly, the causes will be many. The shape of the acromion is regarded as one of the important factors. We agree with Nyffeler et al. that a lateral extension of the acromion is most often associated with rotator cuff tears and that the acromion index proposed by these authors is a good parameter to assess this morphological change. CONCLUSIONS: A lateral extension of the acromion plays an important role in the aetiology of degenerative tears of the supraspinatus tendon. The acromion index appears to be the best instrument for assessing this morphological change.

[Arthroscopic repair of subscapularis tendon tear]. / Artroskopická rekonstrukce ruptury slachy musculus subscapularis.

PURPOSE OF THE STUDY: In this study the arthroscopic reconstruction of a rupture of the subscapularis tendon is described and the results of the technique are evaluated, with the aim to show the advantages and effectiveness of this surgical procedure. MATERIAL: Between 2006 and 2008, arthroscopic repair of the subscapularis tendon was carried out in 23 patients, 16 men and seven women, with an average age of 55 (range, 37-74) years. The dominant arm was treated more often (15x). All 23 patients treated by this diagnostic arthroscopic technique were included in the evaluation. METHOD: With the patient in a lateral recumbent position, the arthroscope was introduced from a dorsal port, and the procedure was carried out through working ventral and anterosuperolateral ports. Following its identification, the subscapularis tendon was mobilised and an insertion site was prepared. Subsequently, a Fastin anchor (Mitek) was inserted. The tendon was stitched through using the mattress suture technique and firmly reinserted to the lesser tuberosity. If necessary, a coracoplasty was performed and the biceps long head tendon was managed.When more tendons of the rotator cuff were torn, the subscapularis tendon was treated first. A complete tear was treated with two anchors and a partial rupture with one Fastin anchor. Post-operative immobilisation lasted 6 weeks and was followed by a six-month rehabilitation therapy. The tears were assessed according to the system proposed by Lafosse et al. The outcomes were evaluated using the University of California at Los Angeles (UCLA) and Constant scoring systems at a minimum of 1 year after surgery. RESULTS: The 23 patients undergoing arthroscopic repair of the subscapularis tendon were evaluated. The average follow-up was 24 months. The average pre-operative values for the Constant and UCLA scores were 44.4% (25-72%) and 13.8 points (8-24), respectively. Post-operatively, they improved to 84.75% (50-100%) for the Constant score and 28.6 points (17-35) for the UCLA score. The only post-operative complication involving persistent purulent secretion from the posterior port was successfully managed. All patients reported improvement as against the pre-operative condition, all were satisfied with the outcome and expressed their willingness to undergo the same surgery on the other shoulder, if need be. DISCUSSION: Rupture of the subscapularis tendon is an infrequent injury to the rotator cuff and an isolated tear is rare. An exact clinical diagnosis of a subscapularis tendon tear is difficult. However, subscapularis tendon tears can be reliably diagnosed as well as treated by arthroscopy, including partial ruptures that are often misdiagnosed. Our results compare well with those reported in the international literature and are rated as very good. CONCLUSIONS: Arthroscopy is the most suitable method to diagnose as well as manage ruptures of the subscapularis tendon classified as Lafosse grades I to IV. Arthroscopic tear repair results in a significant improvement in function of the shoulder joint and pain relief. Based on these results, the arthroscopic treatment of all Lafosse grade I-IV ruptures in our institution is recommended.

Klippel-Trénaunay syndrome associated with great saphenous vein aplasia.

Klippel-Trénaunay syndrome (KTS) is a rare, sporadic, congenital vascular disease of unknown aetiology. KTS could be associated with infliction of other regions. An association with great saphenous vein aplasia has never been described.

[Arthroscopic capsular release in frozen shoulder syndrome]. / Artroskopický kapsulární release u syndromu zmrzlého ramene.

PURPOSE OF THE STUDY To evaluate the results of arthroscopic capsular release for the treatment of severe frozen shoulder syndrome. MATERIAL Between 2006 and 2008, 27 patients with severe frozen shoulder syndrome were treated by arthroscopic capsular release. The average age of the patients was 54 years (range, 34 to 75), 15 were men and 12 were women. The right shoulder was operated on more frequently (16 patients). The average pre-operative flexion was 73 degrees (range, 10 degrees to 150 degrees ) and pre-operative abduction was 56 degrees (10 degrees to 140 degrees ). The average Constant score was 35 points. METHODS With the patient in a lateral recumbent position, arthroscopic release of the joint capsule is performed with the Mitek VAPR 3 radiofrequency system, using a hook or an LPS electrode. The rotator interval, coracohumeral ligament, superior and middle glenohumeral ligaments and anterior part of the inferior glenohumeral ligament are gradually released, as well as the anterior glenohumeral joint capsule along its full width at the anterior rim of the labrum.To avoid damage to the axillary nerve, the axillary part of the joint capsule is released along the edge of the glenoid cavity. When internal rotation in abduction still remains restricted, release is extended to the posterior glenohumeral joint capsule.The procedure also involves exploration of the subacromial space and, if necessary, subacromial bursectomy or acromioplasty. Subsequently, the range of motion after release is tested and, when necessary, the remaining fibres of the joint capsule are disintegrated by careful manipulation (redress). The surgery is followed by analgesic and rehabilitation therapy. RESULTS All treated patients reported an improved range of motion. The average post-operative flexion and abduction extended to 160 degrees and 155 degrees, respectively, and 23 patients gained the motion range necessary for normal shoulder function.The average Constant score was 80.3 points and the University of California at Los Angeles (UCLA) score was 28.6 points. When using the school marking system, the average result evaluation was 1.75. All patients were satisfied with the outcome and were willing to undergo surgery on the other side if need be. No complications were recorded. DISCUSSION Therapy for frozen shoulder can be conservative or surgical. Most of the cases can be managed by correct conservative treatment. In accordance with the current literature data, we are using arthroscopic capsular release in resistant cases. This technique allows us to release contracted structures without the risk of iatrogenic injury and offers possibilities for the treatment of co-existing lesions. In the majority of patients this procedure can remedy their complaints, although the affected shoulder joint rarely remains asymptomatic. The aim of this approach is to accelerate the treatment of this disability; the long-term results are similar to those of conservative therapy. CONCLUSIONS Arthroscopic capsular release is the method of choice for the treatment of frozen shoulder syndrome in patients who have failed to respond to conservative therapy. It provides marked improvement in the range of motion and is associated with a minimum of post-operative complications. However, some patients may complain of persisting discomfort in the joint treated. Key words: frozen shoulder, arthroscopy, capsular release.

[Minimally invasive total hip replacement--one-year results]. / Náhrada kycelního kloubu MIS-AL technikou--rocní výsledky.

PURPOSE OF THE STUDY: To present a prospective evaluation of one-year results in 162 patients undergoing total hip arthroplasty from a minimally invasive antero-lateral approach (THA MIS-AL). MATERIAL: A total of 249 THA MIS-AL procedures were performed between January 2005 and October 2007. At one year after surgery 162 patients were examined and their conditions evaluated by the Harris score, percent satisfaction assessment, 1-to-5 scale school marking, findings on lateral X-ray images and occurrence of post-operative complications. METHODS: With the patient lying in a lateral recumbent position, access is gained through a short incision (5 to 8 cm) along a line connecting the greater trochanter and the anterior superior iliac spine, between the gluteus medius and tensor fasciae latae muscles. After the articular capsule is removed and neck osteotomy done by a two-step procedures, the head is extracted. Both the acetabulum and the femur are processed with special instruments and a cemented or a cementless implant is inserted. Standard prophylaxis with antibiotics and anticoagulants is administered. The patient is mobilized from the second post-operative day, with individually allowed, partial weight-bearing of the operated extremity. RESULTS: In the 162 evaluated patients, the average Harris score increased from pre-operative 46.8 to post-operative 90.4 points. Excellent and good outcomes were found in 84% of the patients. The average school marking was 1.12 and patient satisfaction expressed in percent was 97%. Of 32 patients who had undergone both standard and minimally invasive hip replacement surgery, 25 considered the MIS AL technique to be better, five found no difference and two regarded is as worse. In two patients (0.8%), exposure had to be extended by the standard antero-lateral approach because of femur damage without displacement. Two patients (0.8%) suffered temporary post-operative peroneal nerve paresis. One patient (0.4%) had functional complications and five (2%) had to undergo surgery for haematoma. Sockets in a position other than the optimal 35 degrees to 55 degrees were recorded in two patients. The stem showed a 5 degrees varus deviation in one patient and that of 4 degrees in eight patients; a 4 degrees valgus deformity was found in three patients. Para-articular ossifications (stage 1 or 2) not affecting joint function were recorded in 20 patients (12%). DISCUSSION: Our results show good subjective evaluation of this technique. Its advantages include less pain and earlier patient mobilization. In our first patients a higher number of slight stem malposition (up to 3 degrees) was recorded. Early complications were rare. The occurrence of paraarticular ossifications was an unexpected finding; these, however, did not influence either joint function or subjective evaluation of the outcome. CONCLUSION: If all indication criteria are met and the operative technique is well mastered, the MIS-AL procedure helps provide successful outcomes with less muscle damage and more rapid rehabilitation for people receiving hip replacement; it has few complications and, in indicated cases, it appears to be an approach preferable to the standard THA technique.

[Indications for and methods of hallux rigidus treatment]. / Indikace a metody lécby hallux rigidus na nasem pracovisti.

PURPOSE OF THE STUDY: In a retrospective study, to evaluate the results of surgical treatment of hallux rigidus on the basis of clinical rating, radiographic findings and visual analogue scale (VAS). MATERIAL: The group included 68 patients, 38 women and 30 men, treated at the orthopaedic ward of the Hospital Ceské Budejovice in the period from April 2004 to June 2007. The average age of the patients was 58.6 years (range, 34 to 79). Right and left feet were affected in 42 and 26 patients, respectively. Follow-up ranged from 3 to 30 months. METHODS: Surgery was undertaken only after all means of conservative treatment had been used. Indications for each type of operation were based on the severity of disorder of the first metatarsophalangeal joint (MTPJ), patient's age, toe's motion restriction and physical stress on the patient's big toe. In patients with moderate degenerative MTPJ disease, in 25 feet, a Moberg dorsal wedge osteotomy of the first proximal phalanx was carried out when plantar flexion was preserved; in 12 feet, a Youngswick sagittal V osteotomy was indicated when both flexion and extension were limited and the first metatarsus was long enough; in 14 cases cheilectomy alone was used. In patients with severe arthritis, the TOEFIT-PLUS modular joint replacement of th first MTPJ was used in seven, the Brandes-Keller resection arthroplasty was carried out in six and arthrodesis of the first MTPJ was performed in four. All patients were examined at 2 and 6 weeks after surgery. Those undergoing osteotomy, arthrodesis or joint replacement were X-rayed after surgery and then at 6 weeks of follow-up. RESULTS: The outcome of treatment was evaluated at 3 to 30 months after surgery by clinical and X-ray examination and using the VAS. The average range of MTPJ motion improved from 5 degrees to 22 degrees in dorsiflexion and from 17.5 degrees to 27 degrees in plantar flexion. Osteotomy or arthrodesis in all patients healed in correct alignment, without loosening or migration of prosthetic components. Based on the VAS (100-point scale), pain assessment was 34 preoperatively and 78 post-operatively; joint motion increased from 51 before to 82 after surgery; and ability for daily activities from 50 to 84. The overall VAS score was 42 before surgery and improved to 83 after surgery. Five patients were dissatisfied; two of them underwent repeat surgery (arthrodesis) with marked improvement and one achieved improvement by shoe modification. The rest of the group reported good or very good outcomes. DISCUSSION: Resection arthroplasty, widely used before, is now performed only in patients exerting minimal physical activity and with severe arthritic disease, because it results in loss of the big toe's supporting function. Osteotomies by Moberg or Youngswick procedures involve the use of screws (Barouk). Stable osteosynthesis allows for early post-operative rehabilitation and weight bearing in appropriate modified shoes. Dorsal wedge osteotomy is the method most frequently used in our department to the full satisfaction of our patients.TOEFIT joint replacement is indicated in elderly patients with severe degenerative disease who wish to maintain toe motion and have adequate weight bearing of the treated foot. Emphasis is placed on good post-operative rehabilitation of the joint and on co-operation with the patient. CONCLUSIONS: The hallux rigidus diagnosis covers several grades of degenerative disease of the first MTPJ and therefore its surgical treatment must necessarily involve more than one operative procedure. Even when an appropriate technique is used, the problems may not resolve completely. When the technique to be used is considered, good communication with the patient is necessary, because they should know the principle of treatment and an anticipated outcome of it. Our results show that the surgical treatment of hallux rigidus has good outcome if it is correctly indicated and technically well performed and completed with good post-operative care.