Stemless Hemiarthroplasty of the Shoulder Using the SMR® System: Summary of Six-Year Experience and Surgical Technique.

PURPOSE OF THE STUDY In the last number of years, the anatomic hemiarthoplasty has gradually been pushed out of clinical practice by modern reverse shoulder arthroplasty (RSA) designs. This is due to the clear excellent functional results of RSAs in a wide spectrum of indication criteria. Nevertheless, RSAs have several possible complications that cannot occur in an anatomic hemiarthroplasty. In anatomic hemiarthoplasty, the importance of correct indication criteria and observing correct operative technique including soft tissue reconstruction is much more important than in RSA. Furthermore, there is a clear recent trend of increased use of humeral components fixed only in the proximal metaphyseal cancellous bone. Our aim was to summarise our six-year experience with the SMR® Stemless (LimaCorporate, Italy) system which is one of the most modern ones. MATERIAL AND METHODS Twenty cases of SMR® Stemless anatomic shoulder hemiarthroplasty performed between 2016 and 2021 were included in the study. All patients were followed up prospectively. The function was evaluated preoperatively and at the last follow-up. We evaluated the range of active elevation, classic Constant Score (CS) and pain level according to the visual analogue scale (VAS). Statistical evaluation was performed by using basic statistical methods and the statistical significance of the results was assessed with a paired t-test. Level of statistical significance was set at p= 0.01. RESULTS The mean follow-up in our cohort was 3.01 years (range 0.32-5.69, Median 2.82, SD 1.56) All cases were indicated for surgery due to primary osteoarthritis with a limitation of movement and pain. The mean postoperative CS was 85.7 (range 70-96, Median 86, SD 6.83). The mean active elevation postoperatively was 143° (range 100-170°, Median 150°, SD 20.76). Mean postoperative pain according to VAS was 1.05 (range 0-4, Median 1, SD 1.02). The mean preoperative elevation was 60.5° (range 30-100°, Median 65°, SD 18.83). After surgery the mean elevation increased to 143° (range 100-170°, Median 150°, SD 20.76). Statistical evaluation showed a statistically significant increase in the CS (41.7 preoperatively to 85.7 postoperatively), range of active elevation (60.5° preoperatively to 143° postoperatively) and a statistically significant decrease in pain (VAS 6.95 preoperatively to 1.05 postoperatively). We observed no cases of failure or loosening of the implant. A statistically significant increase in post-operative range of motion was demonstrated. DISCUSSION Most modern shoulder arthroplasty designs now include implants allowing for proximal humerus metaphyseal fixation in hemiarthroplasty and even RSA designs. The advantage of metaphyseal fixation without the use of a longer stem is clear. Notably, treatment of periprosthetic humeral fractures is simpler, extraction of the implant for any reason is easier and the preoperative anatomic position of the humeral head can be respected. As with any anatomic shoulder arthroplasty, the functional result is dependent on correct indication criteria, precise surgical technique, correct humeral head position and soft tissue reconstruction - primarily the rotator cuff. CONCLUSIONS Between 2016 and 2021, we performed 20 SMR® stemless shoulder hemiarthroplasties for primary osteoarthritis. The mean follow up was 3 years. The shoulder function improved significantly post-operatively in all patients. There were no cases of implant loosening or failure. Radiographic evaluation showed no implant loosening or change in implant position in the humeral metaphysis. Key words: shoulder joint replacement, reverse shoulder arthroplasty, SMR, stemless, total shoulder arthroplasty, shoulder hemiarthroplasty, EPOCA, wear.

Does the Femoral CCD Angle Measurement in a Standard AP Projection Correlate with the True Anatomical Shape of the Femur?

PURPOSE OF THE STUDY This study aims to ascertain whether a high anteversion of the femoral neck can influence the measurement of the caputcollum-diaphyseal (CCD) angle on a plain anteroposterior (AP) radiograph of the proximal femur. MATERIAL AND METHODS We developed a new method of measuring the CCD angle and femoral neck version of the femur. This was done with the use of a computer program that utilised the measurement of the entire visualised area of femoral neck and shaft to calculate their long axis. Using this method, we measured the CCD angle and femoral neck version (FNV) of 100 photographed cadaveric femurs in two projections: The condylar line (CL) projection and the femoral neck (FN) projection. The same method was applied to 50 radiographs of the same femurs. The femurs were divided into three groups depending on the femoral neck version: Retro (FNV of <0°), Normal (FNV of 0-15°) and Ante (FNV of >15°) RESULTS We found a statistically significant difference in the CCD angle measured in the FN and CL projections in the Normal and Ante groups but not in the Retro group. There is a significant correlation between the increase in FNV and the difference between the measured CCD values in the FL and CL projections. The femoral neck version of our cadaveric femurs varied from -14. 4° to 31. 5° which is a range of more than 35°. CONCLUSIONS From the results, it is clear that with an increase in femoral neck anteversion, there is a statistically significant difference in the CCD angle measured between the two projections. This difference can be up to almost 10°. Surgeons should be aware of the limitation of the AP projection when planning for surgery on the hip. Key words: femoral neck anteversion, CCD angle, templating, preoperative planning.

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.

[Our Initial Experience with Radial Head Replacement]. / První zkusenosti s náhradou hlavice radia.

PURPOSE OF THE STUDY A single treatment procedure for multi-fragmented non-reconstructible radial head fractures has not been established as of yet. One of the available treatment methods can be the implantation of an endoprosthesis, but there is no consensus in available publications. We therefore decided to trial their use and to obtain our own experience. This study includes the evaluation of the outcomes of treatment at one year postoperatively. MATERIAL AND METHODS Our group included eight patients (six men and two women with the mean age of 46.1 years, ranging from 24 to 80 years) with an implanted ExploR® (Biomet, U.S.A.) radial head endoprosthesis. The radial head fractures were of three to six fragment type, in six cases there was an associated dislocation. In one case, there was a concomitant diaphyseal fracture of the ulna which was stabilised using the Würzburger intramedullary nail (TRUE-Instrumente GmbH, Germany). The surgical approach through Kocher's interval was used in all cases. Fixation using a plaster splint from metacarpophalangeal joints up to the shoulder was applied postoperatively for a period of two to three weeks in all patients. RESULTS The assessment was carried out on average at 13 months (range 12-15 months) after the surgery. The mean elbow flexion was 7.5° to 136.9°, forearm supination was 0° to 86.3° and forearm pronation was 0° to 80.0°. The elbow joint maintained its stability in all cases. Neurological deficit did not develop in any of the patients. The DASH score reached the mean value of 11.2. The mean value of the Mayo Elbow Performance Score (MEPS) was 92.5. Radiological signs of implant loosening were observed in three cases. In two of these cases, bone resorption occurred surrounding the stem of endoprosthesis. In two patients, heterotopic ossification were found and in one case, an oversized endoprosthesis head was implanted. No recurrent elbow dislocation was seen in any of the patients. DISCUSSION The application of radial head endoprosthesis is indicated for comminuted radial head fractures and concurrent ligamentous injuries (fracture-dislocations, terrible triad, Essex-Lopresti injuries). Equally good functional outcomes may be achieved with the use of an endoprosthesis as by osteosynthesis. The complications of arthroplasty tend to be late, at ten or more years postoperatively. Further follow-up of our patients will be necessary, along with a further expansion of our group of patients. Complications may be prevented with the use of longer-stem implants and more up-to-date cemented bipolar endoprostheses which, according to recent studies, achieve equally good functional outcomes and reduce the number of necessary revision surgeries - implant removal in particular. CONCLUSIONS In treating the comminuted radial head fractures, the implantation of endoprosthesis helps to achieve a quick restoration of the elbow joint function along with good functional outcomes and prevents instabilities in case of associated ligamentous injuries. A basic precondition for successful treatment is the choice of an adequate size head. The radiological signs of stem loosening do not necessarily have to affect the functional outcomes. Key words: fracture, radial head, endoprosthesis, Kocher approach.

[Longterm Results of Non-Anatomical Reconstruction of Proximal Humerus]. / Dlouhodobé výsledky neanatomické rekonstrukce proximálního humeru.

PURPOSE OF THE STUDY Treatment of comminuted three- and four-part displaced proximal humerus fractures continues to be discussed in daily trauma practice. In fractures with metaphyseal comminuted fractures the anatomical reconstruction is often technically unfeasible. For cases of comminuted metaphyseal proximal humerus fractures we proposed the so called non-anatomical reconstruction with simple osteosynthesis. Even today, when nailing and plating are commonly used in osteosynthesis, the non-anatomical reconstruction plays an irreplaceable role. Its application is conditioned by at least partially preserved vascular blood supply of the head fragment. This paper describes our original technique to manage these fractures and provides an evaluation of results of the group of patients in whom this procedure was performed. MATERIAL AND METHODS Our group included a total of 72 patients (who underwent surgery in the period from 1 January 1989 to 22 March 2016), of whom 57 were clinically assessed (8 patients died, 7 patients failed to be traced back). The mean age at the time of procedure was 53.61 years (range 19-81 years). The mean follow-up was 14.3 years (range 0.3-26.3 years) after the surgery. The method consists in removing the comminution zone, impacted modified diaphyseal fragment to head spongiosis and osteosynthesis of greater and lesser tubercle or their remainders to diaphyseal fragment using tensile cerclage. RESULTS The mean post-operative Constant score was 81.4 (range 30-100 points). The mean abduction was 120.4 degrees (range 60-165 degrees) and ventral flexion was 129.2 degrees (range 70-170 degrees). Excellent clinical outcome according to the Constant score was achieved in 19 patients, good outcome in 23 patients, fair in 8 patients and poor in 7 patients. DISCUSSION We have been using our original method for 27 years. Compared to osteosynthesis by locking plates, minimally invasive procedures and trauma shoulder joint replacement, our method helps achieve very good clinical outcomes. Its main advantage, however, is the fact that by this technique the specific type of fractures can be treated, otherwise manageable exclusively by arthroplasty. CONCLUSIONS At our clinic, the non-anatomical reconstruction belongs to irreplaceable methods for treating certain proximal humerus fractures. The clinical outcomes of this method can be described as very good. The method of non-anatomical reconstruction eliminates the disadvantages and risks of arthroplasty. Nonetheless, it shall be stressed that this method can be successful exclusively when applied to precisely indicated types of fractures and when performed with technical precision. Its another advantage are the minimal financial requirements. Key words: non-anatomical reconstruction, osteosynthesis, proximal humerus, cerclage.

[Long-Term Results of the Ludloff Procedure in Relation to the Intraoperative Finding on Acetabular Labrum]. / Dlouhodobé výsledky operace dle Ludloffa ve vztahu k operacnímu nálezu na labrum acetabulare.

PURPOSE OF THE STUDY Developmental dysplasia of the hip still remains one of the most discussed topics in paediatric orthopaedics. The comprehensive care of paediatric patients with congenital developmental dysplasia of the hip at our department in the period from 1970 to 1985 included, among other things, the open reduction using Ludloff s approach in hip joints where closed reduction was not possible. This technique was supported by some of our own previous observations, such as the original classification of intraoperative findings on acetabular labrum (limbus). This study aims to evaluate the long-term results of treatment of our patients where Ludloff s open reduction was used and seeks to establish a conclusive correlation between the final result and the method of treatment of individual types of limbus, possibly confirming or ruling out that the dependence of later development of the acetabulum is dependent on correct and sparing treatment of this barrier to reduction. MATERIAL AND METHODS In the period from 1970 to 1985, the Ludloff s open reduction was performed in 70 patients. In 8 cases bilateral surgery was carried out. A total of 78 hip joints were operated on. The patients underwent the surgery at the age of 5-23 months. Postoperatively, the Hanausek biomechanical apparatus was applied to complete the treatment. In total, documentation of 21 surgeries performed in 20 patients was successfully tracked down. Two patients were removed from the group for incomplete documentation. The final group of patients included a total of 18 patients, of whom there were 13 women and 5 men. In one female patient the surgery was performed bilaterally. The shape of the femoral head, the center-edge (CE) angle and the degree of osteoarthritic changes were assessed on the pelvic radiograph of each patient. The functional result was evaluated using the Harris Hip Score (HHS). RESULTS For the purpose of assessment, the patients were divided into sub-groups based on the intraoperative finding on acetabular labrum. Type I limbus was found in a total of 5 cases. The mean HHS was 93, the mean CE angle was 22.5°. Aseptic necrosis occurred in one patient. Type II limbus was found in a total of 3 patients. The mean HHS was 84, the mean CE angle was 22°. Aseptic necrosis was observed in one patient. Type III limbus was found in 8 patients. The mean HHS was 79, the mean CE angle was 19.4°. Osteoarthritic changes of degree II-III were identified. Necrosis of the femoral head was recorded in 2 patients. Type IV limbus was found three times. The mean HHS was 73, the mean CE angle was 13.3°. Osteoarthritic changes of type III were present. Necrosis of the femoral head was recorded altogether in 2 patients. DISCUSSION The results of the Ludloff procedure reported in the available literature differ markedly as to the resulting function of the hip joint and the incidence of avascular necrosis. No author gave a description of the actual acetabular labrum deformity or showed a detailed description of individual vessel ligations. The advantage of this method is beyond any doubt its low invasiveness and when correctly performed also the minimal burden to the child. Its disadvantage is a certain degree of difficulty in performing this surgery, a worse visualisation of all barriers to reduction and a more challenging treatment of the posterior portion of the hip joint compared to techniques using the anterior approach. CONCLUSIONS Our outcomes indicate that the resulting Harris Hip Score was best in patients with the intraoperative finding of type I limbus. All the other types (II-IV) showed worse HHS results. From the current perspective, it is in all likelihood more advantageous to use surgical approaches that enable better visualisation of the anatomical deformities and allow for better options for their treatment. Key words: congenital hip dislocation, surgical treatment, open reduction, Ludloff procedure, acetabular labrum.

[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.

[Effect of sterilisation with formaldehyde, gamma irradiation and ethylene oxide on the properties of polyethylene joint replacement components]. / Vliv sterilizace formaldehydem, gama zárením a etylenoxidem na vlastnosti polyetylenových komponent kloubních náhrad.

PURPOSE OF THE STUDY: Each method of sterilisation has some effect on the structure and properties of UHMWPE and thus also on joint replacement longevity. This study was designed to compare, using objective methods of measurement, several kinds of sterilisation and to recommend the one which has the best prospect for making joint replacements last longer. MATERIAL AND METHODS: Two groups of UHMWPE samples were tested. Group 1 included virgin GUR 1020 polyethylene, non-modified and non-sterilised (Meditech, Germany). Group 2 comprised of three sets of samples sterilised with formaldehyde, gamma irradiation and ethylene oxide, respectively. In both groups, physicochemical properties were assessed by infrared spectroscopy (IR), and the oxidation (OI) and trans-vinyl (VI) indices, which show the degree of oxidation of a material, were determined. Free-radical concentrations were measured by the method of electron spin resonance (ESR). The mechanical properties of each sample were studied using small punch tests (SPT) and testing microhardness (MH). Any change in mechanical properties can affect, to various degrees, the quality and longevity of a prosthetic joint. RESULTS: The samples sterilised by gamma irradiation showed higher values of both the OI (0.37) and the VI index (0.038) than the other samples (OI, 0.02 to 0.05 and VI, 0). Also, the free-radical concentration was detectable only in the gamma-sterilised sample. Values obtained for mechanical properties were as follows: peak load in the range of 58.48 N (gamma irradiation) to 59.60 N (ethylene oxide); ultimate load in the range of 46.69 N (gamma irradiation) to 57.50 N (ethylene oxide); ultimate displacement in the range of 4.29 mm (gamma irradiation) to 4.58 mm (virgin polyethylene and formaldehyde); and work to failure in the range of 185.18 mJ (gamma irradiation) to 205.89 mJ (virgin polyethylene). Microhardness values were obtained in the following ranges: 41.2 to 44.6 MPa (virgin polyethylene); 40.2 to 44.1 MPa (formaldehyde); 46.1 to 49.3 MPa (gamma irradiation); and 40.3 to 44.2 MPa (ethylene oxide). DISCUSSION: The samples sterilised with formaldehyde and ethylene oxide have mechanical properties very similar to virgin polyethylene, they are not damaged by oxidation and do not contain free radicals. Owing to these characteristics, the immediate and long-term oxidation stability of the three samples is higher. The sample sterilised by gamma irradiation showed the presence of free radicals and immediate and long-term oxidative degradation. This results in the deterioration of mechanical properties and the growth of crystallinity due to enhanced oxidation and leads to higher polyethylene microhardness. CONCLUSIONS: Sterilisation with gamma irradiation results in oxidative degradation and mechanical property deterioration, which is one of the potential risks of a shorter life span of joint replacements. The use of ethylene oxide or formaldehyde does not change polymer properties nor has any effect on oxidation of materials. Therefore, a longer life expectancy of the joint replacements sterilised with ethylene oxide can be expected. The life span of their joint replacements is a key issue for the patients. Prosthetic joint loosening is painful and the patient often requires re-implantation. A higher number of re-implantations is associated with higher costs for the institution involved and, consequently, for the whole health care system. Although this study basically deals with chemical issues, it informs the surgeon of the latest developments leading to the improvement of implanted materials, which can increase the life expectancy of joint replacements and patients' satisfaction.

Mathematical modelling for the comparison of plate and intramedullary osteosynthesis stability in intraarticular distal radius fractures.

BACKGROUND: A comparison between plate and intramedullary osteosynthesis techniques in terms of the biomechanical stability of distal radius fracture fixation. METHODS: Mathematical modelling was used to simulate distal radius fractures, type C1 and type C2, and to compare the stability of osteosynthesis in both techniques under several wrist joint load conditions: axial compressive loading of the radius, bending loads in volar and dorsal flexion and radial and ulnar deviation, and axial torsional loading of the forearm. RESULTS: For both type C1 and type C2 fractures, the stability of intramedullary osteosynthesis was comparable with plate osteosynthesis in dorsal flexion. Plate osteosynthesis proved to be more stable only in ulnar deviation. The intramedullary X-screw technique provided more stability when loads were applied in volar flexion, radial deviation, pronation and supination, and in axial loading of the radius. CONCLUSIONS: The result of mathematical simulations was comparable for both types of fracture. It showed a higher stability of intramedullary osteosynthesis. Although when lower force intensity was applied, both techniques were comparable (Fig. 8, Ref. 16).

[Release of the lateral structures of the first metatarsophalangeal joint during hallux valgus surgery]. / Uvolnení laterálních struktur prvního metatarzofalangeálního skloubení pri operaci pro hallux valgus.

PURPOSE OF THE STUDY: Operations of hallux valgus deformity are very well known in orthopaedic surgery. The important part of these procedures is the release of soft tissue on the lateral side of the first metatarsophalangeal joint. Soft tissue procedures became routinely used in the 1920s and 1930s and several techniques of soft tissue release have been published in the past seventy years. We found several inaccuracies between the anatomy published and the routine clinical performance. The purpose of the study was to describe the anatomy of the first metatarsophalangeal joint's lateral part, especially the adductor hallucis muscle attachment, and to assess to what extent the lateral structures of the first metatarsophalangeal joint should be released to correct hallux valgus deformity. MATERIAL: We described and compared the anatomy of the lateral part of the first metatarsophalangeal joint on 30 dissected specimens obtained from cadavers that met the criteria of hallux valgus deformity. METHODS: The standard preparation method was used for anatomical dissection; whole leg specimens including the pelvic girdle were fixed in formaldehyde, acetone, ethyl-alcohol and glycerol. The detailed course and shape of the adductor muscle attachment was described as well as its relation to the lateral sesamoid bone, lateral portion of the flexor hallucis brevis and the transverse metatarsal ligament. Dissection of the joint's lateral capsule was used to show the course of the lateral collateral ligament, sesamoid ligament and conjoined tendon of the adductor hallucis and flexor hallucis brevis muscles. Subsequently, we released the lateral sesamoid ligament with a standard longitudinal cut and then released the conjoined tendon and lateral collateral ligament at the level of the joint gap in the frontal plane. We evaluated the proposed technique in terms of the extent of soft tissue release and the size of tenotomy necessary to correct the deformity. RESULTS: The mean valgus deformity was 32° (range, 18° to 50°). We were not able to define space between the medial border of the adductor hallucis and the flexor hallucis brevis in 23 cases (77%). The mean size of release was 6.4 mm (range, 5 to 15 mm) and the width of a conjoined tendon at the level of release was 11.2 mm (range, 8 to 15 mm). We did not achieve satisfactory release with our technique in two cases (7%, deviation 45° and 50°). DISCUSSION: We compared our results with those of similar anatomical studies. We found several inaccuracies in anatomical descriptions of the adductor hallucis attachment. We confirmed the difficulty in separation of the adductor hallucis from the lateral head of the flexor hallucis brevis in total tenotomy of the adductor. Our technique was successful in releasing the first metatarsophalangeal joint's lateral structures. CONCLUSIONS: Our study showed than even partial tenotomy of the conjoined tendon of the adductor hallucis and flexor hallucis brevis muscles is successful in correcting hallux valgus deformity. The release has to be combined with release of the lateral sesamoid ligament.

Bone grafts as vancomycin carriers in local therapy of resistant infections.

The level of an antibiotic capable of inhibiting the etiological agent at the site of infection is an essential prerequisite for successful antibiotic therapy. In some cases, locally applied antibiotics may compensate for limitations of systemic administration and shorten systemic therapy. We aimed at verifying to what extent vancomycin (Van) bound to ground bone grafts is usable in the treatment of serious infections. The levels of released Van significantly exceeded the Van minimum inhibitory concentration, which can suppress Van-sensitive staphylococci and Van intermediate Staphylococcus aureus, for the whole period of a 16-day measurement. Our results indicate that bone grafts can be used as Van carriers in therapy of osteomyelitis caused by Van-sensitive Staphylococcus strains.

[MEDIN implant of the first metatarsophalangeal joint]. / Náhrada prvního metatarzofalangeálního skloubení Medin.

PURPOSE OF THE STUDY: Hemiarthoplasty or total replacement of the first metatarsophalangeal (MTP) joint has been used in orthopaedic surgery for the last 60 year, but good post-operative outcomes have been achieved only in the last ten years. Joint replacement is mainly used in stage 3 and stage 4 hallux rigidus conditions for which arthrodesis is not indicated. The operation on the first MTP joint has its place in the present-day orthopaedics. This study describes anatomical measurements and the development of the first Czech implant (MEDIN Orthopaedics) to replace this joint. MATERIAL AND METHODS: Thirty cadaver specimens were used to develop basic shapes of phalangeal and metatarsal components. A standard technique was used for anatomical dissection of the first MTP joint. Fifteen specimens were cut in the sagittal plane and fifteen in the transverse plane in order to open the intramedullary cavity of the proximal phalanx of the great toe and the first metatarsal bone. The basic shapes of phalangeal and metatarseal components were designed based on the shape of cortical bone of their inner surfaces. Data for the shape, size and scale of articular components were obtained by measurement on 58 dry bone specimens of the first metatarsus and on 30 calibrated X-ray images. In order to adjust the scale and size of components, the final shape and the range of implant size were tested on 50 specimens of dissected lower extremities fixed in formaldehyde, acetone, ethyl-alcohol and glycerol. RESULTS: The new type of a first MTP implant designed by us was based on cone-shaped anchor components coated with hydroxyapatite. The implants can be used in hemiarthroplasty or total joint replacement. The metatarsal insert was designed with a declination angle of 20 degrees to facilitate good dorsiflexion and with a flattening to ensure good function of the sesamoid bones, The phalangeal articular insert was made of either CoCr alloy or low-weight polyethylene for use in hemiarthroplasty and total joint replacement, respectively. DISCUSSION: The new implants are designed for treatment of stage 3 or stage 4 hallux rigidus. We recommend to use hemiarthroplasty or total joint replacement only in the case of first metatarsal head destruction or severe joint destruction due to rheumatoid arthritis. CONCLUSIONS: Our anatomical study of the first MTP joint, proximal phalanx of the great toe and first metatarsal bone was used to design the first Czech implant of this joint.

[Bilateral arthrodesis of the medial foot joints in a patient with rheumatoid arthritis]. / Oboustranná artrodéza mediální cásti nohy u pacientky s revmatoidní artritidou.

Patients with rheumatoid arthritis (RA) often have foot problems. The subtalar and particularly talonavicular joints are affected most frequently. The posterior tibial tendon has an important role in mid-foot stability. In RA patients, chronic inflammation of this tendon or talonavicular joint arthritis can results in posterior tibial tendon rupture. This leads to a collapsed talonavicular joint and forefoot instability, first with talonavicular and later Chopart's joint involvement. This shows as a planovalgus foot, with the forefoot in pronation and the heel in valgus deviation. In a 61-year-old RA patient, ruptures of the posterior tibial tendon due to rheumatoid inflammation occurred bilaterally, with subsequent deviation and instability of the forefoot. Arthrodesis with a medial column screw-Midfoot Fusion Bolt was carried out on the left foot and 4 months later on the right foot. At 7 months after the left and 4 months after the right foot surgery, the patient was free from pain, both feet were stable under loading and the forefoot was firm. The planovalgus deformity was corrected, as well as a valgus deviation of the great toe. Radiography showed a good position of the screws and complete healing of the medial foot joints.

[Cement-within-cement femoral stem reimplantation technique]. / Reimplantace náhrady kycelního kloubu metodou docementování dríku do puvodního cementového luzka.

PURPOSE OF THE STUDY: The reimplantation of a cemented femoral component at revision is always a challenge for the orthopaedic surgeon, particularly when the cement mantle is intact. The aim of this study was to provide evidence that the recementing of a femoral stem into the original cement mantle can be included in routine surgical procedures. MATERIAL AND METHODS: A group of 104 patients with femoral stem revision, followed-up for an average of 50.2 months, were retrospectively reviewed. The outcome evaluation was focused, in the first place, on survivorship of the femoral component, acetabular migration, and dislocation and infection after revision arthroplasty. Hip function evaluation was based on the Harris hip scores before surgery and at the latest follow-up. On radiographs Gruen zones were assessed pre-operatively and at the latest follow-up. The results were statistically evaluated using the Kaplan-Meier survival analysis (Statistica 8.0). RESULTS: Of the 104 patients, only three (2.9 %) had stem re-revision due to its loosening. Further 16 patients underwent revision for other post-operative complications. The success rate of reimplantation in our group including all post-operative complications was 81.7 %. The average Harris scores were 56 before surgery and 87 at the latest follow-up. Radiolucent lines in Gruen zones were on average 0.45 mm in width before revision and 0.15 mm at the latest follow-up. Fourteen patients had second revision within 20 months of the first and only five were revised after a long period. DISCUSSION: The cement-within-cement exchange of a femoral component is a relatively frequent orthopaedic procedure. Despite this frequency, however, there have not been enough literature reports based on large patient groups to give support to its routine use. The aim of this study was to demonstrate on a large patient group that recementing a femoral stem into the original intact cement mantle can be considered an established operative technique. Our results suggest that the list of indications for this technique, as described by Lieberman and Nelson, can be extended by the following: broken stem with an intact distal cement mantle, replacement of a monoblock femoral component due to severe head damage, loosening of the femoral component without impairment of the distal cement mantle, conversion of a cervico-capital to a total hip replacement and the need of removing all bone cement. No risk is associated with reimplantation of the original component if there is no need for a different implant to correct angle or length stability. A new implant is always used when any part of the femoral component has been damaged mechanically. If only the proximal stem requires recementing, the use of the original component is preferred because of absolute cement/stem cohesion. The number of our patients in which the technique failed was generally in agreement with the results of other authors. CONCLUSIONS: Utilisation of the original cement mantle of a femoral component is one of the options at revision arthroplasty. It requires rational considerations based on the type of surgery, state of the cement mantle, and type of material used for the femoral stem. The method is indicated preferably in the hips with an intact cement mantle treated for loosening of the acetabular component, recurrent dislocation or unequal leg-length in monoblock femoral components. In such situations the removal of well-fixed cement would also involve a considerable loss of bone tissue. The follow-up outcomes showed that the involvement of the cement-within-cement technique in routinely used surgical procedures is fully justified.

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

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

[Vascular injuries in joint replacement surgery]. / Problematika cévních poranení u operací kycelního kloubu.

Iatrogenic injuries to blood vessels in joint replacement surgery are rare events that occur as few per thousand. However, their sequelae are serious. The patient may either bleed to death, because vascular injury is not obvious and therefore difficult to diagnose, or lose the limb due to ischaemia. The highest risk of vascular injury is associated with repeat surgery and loosening of the acetabular component. We distinguish sharp and blunt force injuries. The former are caused by implants, sharp instruments, bone fragments or bone cement debris. The latter arise from stretching over a part of implanted material. Bleeding can be inapparent or apparent. Inapparent bleeding is difficult to diagnose and is recognized from the dynamics of blood losses. Haemodynamic instability or, in a worse case, even hypovolaemic shock may be the only signs of bleeding. Occlusion of an artery is manifested by limb ischaemia. The seriousness and progression of ischaemia depends on the rate of arterial occlusion, potential pathways for collateral circulation and the degree of atherosclerotic vascular disease. The patient with conduction anaesthesia does not feel pain and therefore the diagnosis must primarily be based on arterial pulsation in the limb and its skin colour. A pseudoaneurysm can develop due to a partially weakened vascular wall and its rupture is a life-threatening complication. Its presence is recognized as a pulsating mass in the groin. An arterio- venous fistula which arises from traumatic communication between the two vessels may lead to cardiac failure. The diagnosis is based on examination by sonography and digital subtraction angiography. The results of CT angiography and MR angiography are difficult to evaluate because of the presence of metal implants. In apparent bleeding it is sometimes difficult to locate the source. It is recommended to perform digital compression and gain access to the vessels from the extraperitoneal approach. When an expanding haematoma or ischaemia is present, the artery can be treated by surgical exploration or percutaneous transluminal angioplasty. A possibility of vascular injury should be taken into account particularly in revision arthroplasty. To check blood flow in the limb before surgery is advisable. If the procedure entails a significant risk of post-operative complications, a vascular surgeon should be available. In the case of acute intra-operative bleeding, the source should be localised as soon as possible, the site compressed and an expert assistance called in. When the source is not obvious, it should not be attempted to apply vascular clamps or clips at random; this may do even more damage to the vessel.

[Anatomical study of flexor hallucis brevis insertion: Implications for clinical practice]. / Anatomická studie úponové cásti m. flexor hallucis brevis pro klinickou praxi.

PURPOSE OF THE STUDY: The flexor hallucis brevis (FHB) is one of the short muscles of the foot. It divides in front into two portions, which are inserted into the medial and lateral sides of the base of the first phalanx of the great toe. The detailed knowledge of its insertion into the proximal phalangeal base is decisive in any surgery involving the first metatarsophalangeal (MTP) joint, such as implant arthroplasty, resection arthroplasty or amputation. Complications resulting from injury to this insertion are commonly known. The aim of this study was to describe in detail the morphology of FHB insertion sites and to determine a safe extent of resection to be done at the base of the proximal phalanx. MATERIAL AND METHODS: In 36 cadaver specimens we measured FHB insertion length from the plantar side of the proximal phalangeal base and from the plane perpendicular to the long axis of the phalanx and passing through the base of the concave articular surface of the phalanx. RESULTS: Measured from the plantar base of the proximal phalanx, the mean length of the medial insertion site was 11.5 ± 0.9 mm (range, 9.5 to 13.0 mm) and that of the lateral insertion site was 9.5 ± 1.1 mm (range, 8.0 to 11.5 mm). After resection, the mean values for medial and lateral FBH insertion sites were 8.5 ± 1.7 mm (range, 6.5 to 11.0 mm) and 7.1 ± 1.4 mm (ran- ge, 5.5 to 9.5 mm), respectively. The mean total proximal phalangeal length was 33.1 ± 2.2 mm (range, 28.5 to 37.0 mm), reduced after resection to 30.5 ± 2.1 mm (range, 26.0 to 34.5 mm). DISCUSSION: Our results show that the medial insertion site, where the medial FHB tendon and distal part of the abductor hallucis muscle are joining, is longer than the lateral site. Therefore the length of the lateral site is decisive for preserving FHB function. Since the plane perpendicular to the long axis of the phalanx and passing through the base of the concave articular surface of the phalanx is almost identical with the beginnings of FHB insertions, it seems optimal for clinical practice to perform the initial resection along this plane. CONCLUSIONS: To preserve at least one third of the FHB insertion, the final resection should not exceed 4 mm or 13 % of the proximal phalangeal length, as measured from the reference plane defined above.

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

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

Heat shock protein gene expression profile may differentiate between rheumatoid arthritis, osteoarthritis, and healthy controls.

OBJECTIVE: Heat shock proteins (Hsps) have been repeatedly implicated in the pathogenesis of rheumatoid arthritis (RA). The aim of this work was to study Hsp mRNA and protein levels to determine whether they can be used to differentiate between RA, osteoarthritis (OA), and healthy controls. METHODS: Hsp27, Hsp60, Hsp70, Hsp90α, and HspBP1 mRNA expression was analysed using real-time quantitative reverse transcription polymerase chain reaction (qRT-PCR) in 24 RA, 11 OA, and 21 healthy controls. Hsp70 and HspBP1 protein levels were measured in serum using an enzyme-linked immunosorbent assay (ELISA). RESULTS: Hsp gene expression profiles differ significantly between inflammatory (RA) and non-inflammatory (OA) joint diseases, showing significantly increased Hsp27 and Hsp90α mRNA levels in RA synovial tissues. Up-regulated Hsp60 and Hsp90α together with down-regulated Hsp70 and elevated HspBP1/Hsp70 mRNA ratios can be used to differentiate between RA patients and healthy individuals through analysis of peripheral blood samples. Despite increased HspBP1 levels in RA sera, Hsp70 levels and the HspBP1/Hsp70 protein ratio remained identical in the RA patients and healthy individuals, which may contribute to the inhibition of Hsp70 anti-apoptotic activity. CONCLUSION: Hsp gene expression analysis can be implemented as a new diagnostic approach to facilitate differentiation between RA, OA, and healthy controls.

[Long-term results of the SVL total knee arthroplasty]. / Dlouhodobé výsledky náhrady kolenního kloubu SVL.

PURPOSE OF THE STUDY: The aim of the study was to evaluate the long-term results of the total knee replacement Beznoska SVL implanted at the 1st Department of Orthopaedic Surgery, 1st Faculty of Medicine, Charles University and Motol University Hospital Prague, in the 1997/2009 period. MATERIAL AND METHODS: The SVL implant is a non-constrained knee replacement, anatomically similar to the bone it replaces, which preserves the posterior cruciate ligament. A total of 1101 knee joint replacements were evaluated in 973 patients, of whom 128 underwent bilateral arthroplasty. Kaplan-Meier curves were used to estimate the cumulative survival of implants. Clinical outcomes were assessed using the Knee Society clinical rating system (KS score) and radiographic data evaluation was also included. RESULTS: Using KS scores, the results were excellent in 997, good in 75, satisfactory in 19 and poor in 10 knees. The average range of motion was 0.16 to 106.31 degrees. The complications included flexion contracture, as the most frequent problem (13 knees), 10 knees were infected, aseptic loosening due to polyethylene granuloma was found in eight knees and anterior knee pain was experienced in six cases. At follow-up of 12.5 years implant survivorship was 98 %, as evaluated by the Kaplan-Meier analysis. DISCUSSION: A comparison of SVL implant survivorship with other knee replacement designs is discussed. It should be emphasized that the clinical outcome depends not only on implant quality, but also on the operative technique used and the surgeon's experience and skills. It is the SVL system that allows for the balancing of knee joint stability and thus enables even less experienced surgeons to make use of a more sophisticated implantation technique. CONCLUSIONS: Total knee replacement using the SVL Beznoska implant is a safe, reliable and economic treatment with excellent clinical outcomes.