Novel Cu(II)-based metal-organic framework STAM-1 as a sulfur host for Li-S batteries.

Due to the increasing demand for energy storage devices, the development of high-energy density batteries is very necessary. Lithium-sulfur (Li-S) batteries have gained wide interest due to their particularly high-energy density. However, even this type of battery still needs to be improved. Novel Cu(II)-based metal-organic framework STAM-1 was synthesized and applied as a composite cathode material as a sulfur host in the lithium-sulfur battery with the aim of regulating the redox kinetics of sulfur cathodes. Prepared STAM-1 was characterized by infrared spectroscopy at ambient temperature and after in-situ heating, elemental analysis, X-ray photoelectron spectroscopy and textural properties by nitrogen and carbon dioxide adsorption at - 196 and 0 °C, respectively. Results of the SEM showed that crystals of STAM-1 created a flake-like structure, the surface was uniform and porous enough for electrolyte and sulfur infiltration. Subsequently, STAM-1 was used as a sulfur carrier in the cathode construction of a Li-S battery. The charge/discharge measurements of the novel S/STAM-1/Super P/PVDF cathode demonstrated the initial discharge capacity of 452 mAh g-1 at 0.5 C and after 100 cycles of 430 mAh g-1, with Coulombic efficiency of 97% during the whole cycling procedure at 0.5 C. It was confirmed that novel Cu-based STAM-1 flakes could accelerate the conversion of sulfur species in the cathode material.

Mesh fixation in laparoscopic reconstruction of inguinal hernias.

INTRODUCTION: Laparoscopic inguinal hernia repair is a widely used surgical technique, although not exempt from potential complications. The aim of our study was to compare our postoperative results according to the fixation method of the prosthetic material. METHODS: This is a retrospective study. We looked up 167 patients who underwent laparoscopic inguinal hernioplasty between 01 Jan 2015 and 31 Dec 2016 at the Surgical Department of Vsetin Hospital. The patients were invited for a follow-up visit after 46 weeks and a questionnaire was sent them after 933 months. We evaluated any development of postoperative hematoma, recurrent hernia and pain after one month and during the first year from the surgery in dependence on the fixation method (stapler Pro Thick, acrylic glue Glubran, 3D light mesh). RESULTS: In total, 120 patients were enrolled in the study, 22 in the Glubran group, 59 in the stapler group and 39 in the 3D group. A hematoma developed in 10% in the stapler group, while there was none in the other groups; the difference was statistically significant (p=0.0382). Recurrent hernia was found in 5% in the Glubran group, 3% in the stapler group, and 0% in the 3D group; no statistically relevant difference was found. No difference was demonstrated for postoperative pain, either. CONCLUSION: Long-term postoperative results after TAPP were not found to differ in recurrence rates and pain based on the used fixation material in our set of patients. The stapler was associated with a higher risk of postoperative hematoma, but it was a preferred method in all cases of large hernias.

[Trochanteric femoral fractures]. / Trochanterické zlomeniny femuru.

At the present time proximal femoral fractures account for 30% of all fractures referred to hospitals for treatment. Our population is ageing, the proportion of patients with post-menopausal or senile osteoporosis is increasing and therefore the number of proximal femoral fractures requiring urgent treatment is growing too. In the age category of 50 years and older, the incidence of these fractures has increased exponentially. Our department serves as a trauma centre for half of Prague and part of the Central Bohemia Region with a population of 1 150 000. Prague in particular has a high number of elderly citizens. Our experience is based on extensive clinical data obtained from the Register of Proximal Femoral Fractures established in 1997. During 14 years, 4280 patients, 3112 women and 1168 men, were admitted to our department for treatment of proximal femoral fractures. All patients were followed up until healing or development of complications. In the group under study, 82% were patients older than 70 years; 72% of those requiring surgery were in their seventies and eighties. Men were significantly younger than women (p<0.001) and represented 30% of the group. The fractures were 2.3-times more frequent in women than in men. In the category under 60 years, men significantly outnumbered women (p<0.001). The patients with pertrochanteric fractures were, on the average, eight years older than the patients with intertrochanteric fractures, which is a significant difference (p<0.001). The mortality rate within a year of injury was about 30%. Trochanteric fractures accounted for 54.7% and femoral neck fractures for 45.3% of all fractures. The inter-annual increase was 5.9%, with more trochanteric than femoral neck fractures. There was a non-significant decrease in intertrochanteric (AO 31-A3) fractures. On the other hand, the number of pertrochanteric (AO 31-A1+2) fractures increased significantly (p<0.001). A total of 1 394 fractures were treated with a proximal femoral nail; a short nail was used in 1260 and a long nail in 134 of them. A dynamic hip screw (DHS) was employed to treat 947 fractures. Distinguishing between pertrochanteric (21-A1, 31-A2) and intertrochanteric (31-A3) fractures is considered an important approach because of their different behaviour at reduction. Pertrochanteric fractures occurred more frequently (81.5%); the patients' age was higher (80 years on the average) and women outnumbered men at a ratio of 3:1. Intertrochanteric fractures were found in significantly younger patients (average, 72 years), with a women-to-men ratio of 1.3:1. Stable pertrochanteric fractures (31-A1) were preferably indicated for DHS surgery. Unstable pertrochanteric (31-A2) and intertrochanteric (31- A3) fractures were treated with a nail. The patients underwent surgery on the day of injury or the next day. In the case of contraindications to an urgent intervention, surgery was performed after the patient's medical condition had stabilised. The number of complications was largely related to technical errors, such as insufficient reduction or an incorrectly inserted implant. Intertrochanteric fractures were associated with a higher occurrence of complications. No implant can compensate for errors due to surgery. Serious complications can be reduced by the correct assessment of fracture type, the use of an appropriate operative technique and early treatment of potential complications. The necessity of restoring continuity in the medial cortex of the femoral neck (Adams' arch) is the requirement that should be observed. Pseudoarthrosis or varus malalignment in a healed hip should be managed by valgus osteotomy. When the femoral head or the acetabulum is damaged, total hip arthroplasty is indicated. A prerequisite for successful surgical outcome is urgently and correctly performed osteosynthesis allowing for early rehabilitation and mobilisation of the patient.

[Arthroplasty for intracapsular fractures of the femoral neck. Current concept review]. / Aloplastika u intrakapsulárních zlomenin krcku femuru.

The authors discuss arguments concerning indications and selection of implants and operative techniques for arthroplasty in the treatment of femoral neck fractures. Their analysis is based on long-term experience with surgical treatment of patients with hip fractures and on the evaluation of a large number of publications by well-known specialists. The assessed group included 4795 patients treated at their institution between 1997 and 2010, of whom 1532 underwent hip replacement, with 1032 receiving hemiarthroplasty (HA) and 500 having total hip replacement (THR) indicated for femoral neck fractures. A painful hemiarthroplasty due to acetabular cartilage erosion and subsequent head protrusion is still a challenging clinical problem. The most important factor in prevention of this complication remains strict adherence to indication criteria. A metal monoblock hemiarthroplasty should be indicated only in very old patients with serious co-morbidities or in patients whose pre-operative mobility has been greatly restricted. For the other cases, a modular prosthesis is preferred because it allows for more exact alignment and, if necessary, its conversion to a total hip prosthesis is relatively easy. The stem to be implanted should be the one used in standard THR procedures. A ceramic modular head then enables hemiarthroplasty to function for long with a low risk of cartilage erosion and head protrusion. Even if the choice of an optimal prosthesis, in terms of its biomechanical and biological properties, has been correct, the prosthesis' long life span and good functioning still depends on the surgeon's adherence to the principles of the correct operative technique (the head centre situated 1 to 2 mm below the level of the apex of the greater trochanter, 12- to 15-degree anteversion, articular capsule suture, and re-insertion of external rotator tendons if the Koch-Langenbeck approach is used. This is the only way of minimising acetabular erosion and other complications. Indications for total replacement include, in addition to fractures at joints affected by arthritis, most often a displaced fracture of the femoral neck found in younger patients still in good general health with a good prospect for a long life. Even if dislocation and loosening occur in these patients more often than in those with a THR procedure indicated for other reasons (primary or post-dysplastic arthritis), this therapy offers fewer complications and longer functioning in comparison with other methods of treating femoral neck fractures. A cemented prosthesis can be regarded as the standard implant; however, if the proximal femur shows good quality cortical bone, an uncemented implant can be used without a greater risk of future loosening. In the absence of hip arthritis which leads to the development of subchondral sclerosis required for the correct acetabular cup fixation, a hybrid THR with an expansion cup or a screw-in cup is recommended.

[Reccurent tibial osteomyelitis after the segmental bone transport: a radical interdisciplinary treatment]. / Rekurentní osteomyelitida tibie po transportu kosti a její radikální interdisciplinární lécba.

Long-term or recurrent osteomyelitis results in the deterioration of soft tissue quality at the site of an infectious process. An insufficient perfusion of the scar tissue contributes to difficult treatment of osteomyelitis. A local transpositional or free muscle flap used to replace the vulnerable scar tissue will enhance perfusion of the affected bone and will help to control osteomyelitis. The authors present the case of a patient who had been treated by bone transport for a 14-cm-long segmental defect of the tibia after post-traumatic osteomyelitis. Recurrent osteomyelitis was found nine years after the primary surgery. The whole tibial cavity was opened leaving a 12-mm-wide trepanation opening, and debridement of all necrotic and inflammatory tissue including dystrophic skin was performed. The Orr technique was used for further treatment. There was no relapse and granulation tissue samples repeatedly gave negative culture results. Therefore, at the second stage, the soft tissue defect was covered with a free latissimus dorsi muscle flap. Anastomoses to the recipient vessels were technically difficult to carry out in the tissue greatly affected by previous chronic inflammation. Ten days after the surgery the patient was allowed to stand and walk, full weight-bearing was allowed at 2 months post-operatively when the flap was completely integrated. At 6-year follow-up the extremity was fully weight-bearing, with no recurrence of infection, and the patient was satisfied with the outcome. The authors regard this interdisciplinary management (extensive bone and soft tissue debridement, free muscle flap transfer) as a method indicated for the treatment of recurrent tibial osteomyelitis.

[Medial opening-wedge high tibial valgus osteotomy, using a stable TomoFix plate, in genu varum arthritis: surgical technique]. / Valgizacní vysoká osteotomie tibie u genu varum arthroticum rozevrením klínu z vnitrní strany stabilizovaná úhlove stabilní dlahou TomoFix: Operacní technika.

The authors present the technique of high tibial correction osteotomy by the medial opening procedure, with the use of an angle-stable TomoFix plate. The prerequisite for a long-term good outcome of corrective osteotomy in genu varum is to achieve limb alignment permitting transfer of weight-bearing from the affected medial compartment to the healthy lateral compartment of the knee. The development of implants that maintain a stable angle has facilitated corrective osteotomy with an opening wedge on the medial side of the proximal tibia. These implants provide stable fixation even when a high correction of the mechanical axis is needed. The authors present the case of a patient with varus malalignment following a fracture of the tibia. In order to achieve correction of the limb's mechanical axis, it was necessary to open the proximal tibia osteotomy with a wedge that was 2.5 cm on the outer side.

The European school of total hip arthroplasty and 35 years of total hip arthroplasty in the Czech Republic.

The development of the European total hip arthroplasty in the sixties of 20th century is associated mainly with the names of G. K. McKee, J. Charnley and M. E. Muller. The SICOT meeting in Paris in 1966 introduced THA as a new method of treatment of osteoarthritis of the hip and paved the way for the commercialization of the manufacturing of prostheses. The success of this method consisted primarily in the fixation of individual components by bone cement and application of metal-to-polyethylene and metal-to-metal joints. The book presents these historical events as they have been reflected in the development of THA in the countries of the former Czechoslovakia and in the development of implants of domestic provenance. The development of THA in the former Czechoslovakia started in 1969 and was based on the Swiss school established by M. E. Muller. The Muller component with the "banana-shaped" stem was implanted using the Watson-Jones approach, the proximal femur canal was prepared by a rasp and the Palacos cement was used. This prosthesis served also as the model for the first Czech implant Poldi-Cech of I generation (the Chirulen cup available in three sizes, the "banana- shaped" femoral component with a 32 mm head-diameter and 130 degree neck-shaft angle) the development of which started in 1969 and the serial production began in 1972 in the Poldi Kladno steel company. Fatigue fractures of the "banana-shaped" stem led to the development of the concept of a femoral component with an "anatomical" stem. In Switzerland, this concept was developed by B. G. Weber. In the former Czechoslovakia the development of a new femoral component with an "anatomical" stem following the shape of the intramedullary canal with an ovoid profile and without sharp edges started in 1972. Due to the incidence of fatigue fractures of the "banana-shaped"stem and material that was not sufficiently strong (steel used for the production of osteosynthetic components), 144 degree neck-shaft angle was chosen. Reduction of the effect of bending forces on the valgus stem had eliminated fatigue fractures. This Poldi-Cech prosthesis of II generation was provided in nine sizes. The diameter of the head remained the same. Three Chirulen cups were supplemented with a "flat" cup for implantation in a dysplastic acetabulum. The prosthesis was implanted with an exact instrument set (reamer for acetabular preparation, rasp for proximal femoral preparation, alignment device for accurate positioning of both the cup and the femoral component) with the use of the Palacos cement. The production of the Poldi-Cech prosthesis of II. generation started in 1974 with the fabrication of a monoblock. Since 1986 it has been developed into a modular system (14/16 cone) with the possibility to use a ceramic head of 32 mm diameter (only in the nineties the cone size was changed to 12/14 and the heads were provided also in the 28 mm diameter). The Poldi-Cech prosthesis of II generation with the "anatomical" stem has been implanted since 1974 (i. e. during 30 years) in more than 140 000 patients in the Czech and Slovak Republics. In the same year cemented monoblock hemiarthroplasty was developed on the same basis as THA using the same "anatomical" stem and 36 to 60mm head diameter. Until now more than 35,000 of these hemiarthroplasty systems have been implanted. Until 1992 the Poldi-Cech implant was practically the only available cemented total hip replacement in the former Czechoslovakia and retrospectively it may be considered a highly successful implant. In the authors' view, the further development of THA will lead in the following years to the use of implants proved by a long-term follow-up. Preference will be given to prostheses the implantation of which will require a minimal loss of the bone stock during primary surgery and which will allow a technically easy reimplantation. The continental Europe has been recently preferring hybrid prostheses while Scandinavia witnesses an evident increase in the number of implanted cemented prostheses to the detriment of the cementless and hybrid ones. Naturally, cementless prostheses will keep dominating in young patients.

[Infection complications of total hip arthroplasty]. / Infekcní komplikace TEP kycelního kloubu.

The authors present an overview of the current views on etiology and diagnostics of infectious complications of total hip arthroplasty and analyze the possibilities of individual therapeutic procedures (debridement with the preservation of total hip arthroplasty, revision of the endoprosthesis, long-term antibiotic therapy, final resection arthroplasty, arthrodesis). They discuss the pending issues relating to the therapy of infectious complications of total hip arthroplasty (the duration of antibiotic therapy, the interval between the extraction and revision surgery of the endoprosthesis, the use of antibiotic-containing cement). Based on their own experience they recommend the revision surgery with the preservation of the implant, debridement and irrigation as the first step only in case of an early post-operative infection and in case of a late hematogenous acute infection. In case of chronic infection they recommend a two-step revision surgery using the cement spacer and the antibiotic therapy for 3 to 6 months. During this period the laboratory and clinical signs of the infection must be back to their normal. Long-term antibiotic therapy in dependence on microbial sensitivity is recommended.

[Long-term results of the Schenker cementless femoral component]. / Dlouhodobé výsledky necementované femorální komponenty Schenker.

PURPOSE OF THE STUDY: The aim of the work is to evaluate the results achieved in the group of patients with implanted Schenker cementless femoral component (Schenker, Switzerland) and discuss the method of solution of loosening of these components in the group of patients who underwent revision surgery. MATERIAL: The first part of the followed-up group comprised 16 patients (11 women, 5 men) with the total of 18 operated on hips who underwent primary hip arthroplasty between 1989 and 1992 (Poidi cemented cup, Schenker cementless femoral component). The average follow-up period was 140 months (range 120 to 156 months). The second part of the group included patients who underwent revision for loosening of the Schenker cementless femoral component. This part consisted of 18 patients (11 women, 7 men) with 20 operated on hips. The average interval after primary hip arthroplasty was 65 months (range 36 to 118 months). METHODS: In the period between May and December 2002, 34 patients were examined in the out-patient department. The evaluation involved only patients who did not undergo revision surgery. The clinical condition was evaluated on the basis of the Harris Hip Score and a radiograph was made to monitor any signs of linear wear of the cup, the extent of the radiolucent zone in both components and a potential migration of components. RESULTS: Results were evaluated in 16 patients (11 women, 5 men) with 18 operated on hips. The average follow-up period was 140 months. Harris Hip Score averaged 76 points (range, 56 to 97 points). The linear wear up to 1 mm was recorded in 4 cups and that of up to 2 mm in 2 cups. The radiolucent line surrounding the cup in zone III after DeLee and Charnley was present in 5 cups, in zones II and III in another 1 patient. No cup showed any signs of migration. The radiolucent line surrounding the femoral component was present in 9 hips. The progress of subsiding as compared to the preceding radiograph check (interval of 1 to 2 years) was evident in 3 femoral components. At the time of the check 20 femoral components had been already revised, of this 7 hips were after repeated revision. DISCUSSION: Between 1986 and 1992, 74 primary hip arthroplasties in 61 patients were performed at the authors' department using Schenker cementless femoral component always in combination with Poldi cemented cup. Of 61 patients, the follow-up was not completed in 27 (10 patients died, 6 of them underwent a revision surgery at other hospitals, 11 patients were lost for the follow-up). In the evaluated 18 hips only 7 were without pain, another 3 patients from suffered occasional pain which responded to common analgesics. The results of clinical evaluation after Harris are unconvincing. During the follow-up 29 joints (39% of the original cohort) had been revised or indicated for revision surgery. Repeated revision surgery was performed in 7 hip joints where the Schenker cementless femoral component was originally replaced by cemented stem and this cemented component loosened within 3 to 7 years after the first revision. With regard to the success rate of other double tapered femoral components, the authors consider the material of the component (vitalium) as the main cause of failure. The surface of this stem did not provide for a long-term osteointegration and is at present successfully used only for production of femoral heads rather than for cementless femoral components. CONCLUSION: A favourable clinical finding and a good integration of the cementless femoral component Schenker were recorded within the average follow-up of 12 years only in 5 patients. All of them were young at the time of surgery and had a very good quality of bone. As a conclusion authors state that in general, Schenker cementless femoral component has not proved to be successful in clinical practice. For revision surgery of the loosened Schenker cementless femoral component it is necessary to use a titanium cementless component with a surface allowing long-term osteointegration.

[Evaluation of results after reimplantation of total hip arthroplasty cemented cup]. / Hodnocení výsledku po reimplantaci cementované jamky TEP kycelního kloubu.

PURPOSE OF THE STUDY: The aim of the study is to evaluate the results achieved after the replacement of a loosened or broken cemented cup by another cemented cup and to specify conditions under which such procedure may be successful. MATERIAL: In the period of 1992-1997, 158 revision surgeries of total hip arthroplasty were performed at the authors' Department. In 69 patients (57 women, 12 men) the cemented cup was replaced by another cemented cup and the original femoral monocomponent with the 32 mm head diameter the surface of which was not damaged was left in place. METHODS: The indication for operation was loosening of Degree 2 or 3 of the classification after Krbec et al. The surgery was performed from the Watson-Jones or Bauer approach. The cup was always revised with the use of the Palacos cement in combination with antibiotics by the cementing technique of 2nd generation. Augmentation was used in 11 cups. The original femoral component was always returned to the original cemented bed and a cement mantle was added in the proximal part in 15 patients. Poldi cups were replaced in all patients of the followed up cohort (63 times loosening--91%, 6 times breakage--9%) using 3 types of cups for revision surgery (Poldi--44 times, Ultima--20 times, SPC--5 times). During the period of March through December 2001, 48 patients were followed up in the out-patient department. The clinical condition was evaluated on the basis of the Harris Hip Score and a radiograph was made to monitor changes in the position of the cup, linear wear, the presence and size of the radiolucent zone. RESULTS: The results were evaluated in 48 patients (40 women and 8 men) with the average interval of 63 months after revision of the cup (range, 46 to 112 months). However, the clinical and radiograph evaluation of the condition was made only in 45 patients. Three patients re-operated on in 2001 were not included in the evaluation. The Harris Hip Score was on average 78 points (range, 51 to 97 points). Radiographs did not show any change in the position of the cup. The linear wear up to 1 mm was revealed in 4 cups and above 1 mm in 1 cup (11% of the evaluated patients). The radiolucent line in zone III after DeLee and Charnley was present in 4 cups, in zones II and III in another 4 patients, i.e. in total in 8 of 45 cups (18%). DISCUSSION: The group of 45 followed-up patients may be considered a sufficiently representative sample of the original 69-member cohort (minimally 7 patients died in the follow-up period, 3 patients were not included in the evaluation). With regard to the average follow-up of 63 months the results may be considered as medium-term. The average interval between primary total hip arthroplasty and revision of 130 months is comparable with the results of similar studies by other authors. The results of the clinical evaluation on the basis of Harris Hip Score are not convincing (range, 51 to 97 points, average 78 points). Radiographs showed a radiolucent zone in 8 cups (18%). Another 3 patients were at the time of evaluation after a repeated revision of the cup for loosening (at the interval of 22 to 34 months). CONCLUSION: A good integration of the cemented cup used in revision of the loosened cemented cup of total hip arthroplasty was evident only in infrequent cases of a perfectly preserved acetabulum both from the viewpoint of shape and structure. The evaluation of other patients of the followed-up cohort, however, produced rather unconvincing results. On this basis and also on the basis of their experience in the use of cementless cups in revision of total hip prostheses the authors recommend to prefer a cementless implant in the revision of the cup.

[Preoperative planning and surgical technic in achieving stability and leg length equality in total hip joint arthroplasty]. / Predoperacní plánování a operacne-technické resení stability a vyrovnání délky koncetin u totální náhrady kycelního kloubu.

One of the prerequisites for a good outcome of total hip arthroplasty is preoperative planning. Using a roentgenogram, the size of an implant, incision level on the femoral neck, depth required for fitting the cup, restoration of the center of hip rotation and, if necessary, correction of length descrepancy between the legs are determined. The preoperative planning based on an X-ray image was introduced by M. E. Müller and, in 1976, was modified by R. Schneider who used a transparent sheet for a template on which all relevant points guiding the surgical procedure are marked, i.e., the right position for implantation of the cup and stem, and incision lines. In uncomplicated cases, however, this approach is not necessary and the "planning principle of parallel lines" developed by L. Spotorno in 1988 can be used instead. The determination of length discrepancy between the legs is derived from a drawing of three reference lines on the roentgenogram. The lines parallel to each other indicace the same length for both legs. If the legs differ in length, the lines will diverge from each other in a way typical for this condition.

[Personal experience with the Wagner revision stem in hip joint reoperations]. / Nase zkusenosti s revizním Wagnerovým dríkem pri reoperacích kycelního kloubu.

PURPOSE OF THE STUDY: Since 1993 we have been using the Wagner revision stem, initially in the length of 265 mm and 305 mm and later also the short stem of 190 mm and 225 mm, for revision surgery with the destruction of proximal femur. This technique provided for primary fixation of the stem in the unaffected femoral bone and creates prerequisites for the bone regeneration and bone formation of the destructed host bone by the loosened implant in the metaphysis and proximal part of diaphysis. MATERIAL AND METHODS: In the period of 1993-1998 we operated on and followed a group of 35 patients (18 men and 17 women), average age 69 years (age range, 52-89). In 32 patients we performed revision surgery of Poldi-Cech stem, twice CF-30 stem and once cementless J + J stem. The average time interval between the primary operation and revision surgery was 10 years (range, 2-22 years). Thirty patients had to be reoperated due to aseptic loosening of the implant and five patients due to infection. Wagner stem was applied no sooner than 6 months after the infect had healed. In the application of the short stem (190 mm or 220 mm) we use Bauer approach (4 times) or extended Bauer approach (4 times), in long stems we use transfemoral approach in our modification: osteotomy is performed from the extended Bauer approach in the frontal plane and the anterior part of femoral cortex is retracted. The retracted anterior part of the femoral cortex femoral bone is fixed back only by hemi-wire loops. RESULTS: Of the total number of 35 operated on 2 patients required revision surgery due to the subsidence of the stem and one removal of the stem in case of complete protrusion of the cup into pelvis. In short stems there were no post-operative complications. Dislocation of the hip occurred in three patients after the implantation of the long stem. After the closed reduction the surgery was not necessary. In one patient there developed an infection 5 months after operation. It was a hematogenous infect resulting from a pyogenic affection of the operated on limb. A two-step revision surgery was performed with a spacer and a subsequent reimplantation of a stem of greater diameter. DISCUSSION: Wagner presents results of 69 patients after the application of his own stem 265 mm and 305 mm long. In 62 patients of the total number no subsidence was encountered, in two cases post-operative dislocation was recorded. Isakson et al. do not consider subsidence resulting in fixation of the stem as a significant factor and correct the difference in the length by shoes. They point out that this method is suitable for the solution of defects of proximal femur in such a way that the implant has a stable fixation and provides for bone formation, restoration of the destructed part of proximal femur in the extent of the original loosened stem. We consider the Wagner technique a significant contribution to the solution of these severe complications. As compared to Wagner, instead of the sagittal plane we perform transfemoral approach in the frontal--horizontal plane which allows operation in the supine position of the patient and a more precise replacement of the cup. In our group of patients we incorrectly used the long stem without transfemoral approach in 3 patients, one patient required revision surgery, in the remaining two patients the period of osteointegration of the stem was substantially longer. CONCLUSION: The Wagner revision stem allows treatment of the destructed proximal part of femur caused by loosening of the stem and polyethylene granuloma. Of great importance is the preservation of the contact of muscles and residual parts of the destructed femoral bone. The short version of the Wagner stem (190 mm and 225 mm) has fully justified itself in revision surgeries of the replacement of the stem in cases of a preserved bone stock. Wagner stem sufficiently bridges the trepanation hole and is safely engaged in the femoral shaft. The long Wagner stem (265 mm and 305 mm) has proved suitable in revision surgeries in cases of thinner cortex and defects in the whole length of the loosened implant. This stem requires a transfemoral approach and a perfect stable anchoring of the stem in the stable skeleton of the femoral shaft. Bone formation and remodelling of proximal femur does not affect the length of the limb. Of great importance is its accurate planning. This procedure is a considerable contribution to the solution of these severe complications.

[The uncemented cup of the CLS Spotorno joint endoprosthesis--5-years' results]. / Necementovaná jamka endoprotézy kloubu CLS Spotorno--petileté výsledky.

PURPOSE OF THE STUDY: Authors report on five-year results in patients after THR operated on between 1994 and 1995 in which a cementless CLS Spotorno cup was used. MATERIAL: In the given period 59 patients were operated on (35 women and 24 men). The average age at the time of implantation was 54.6 years. The most frequent causes of the indication for THR was primary osteoarthritis of the hip in 27 patients and postdysplastic osteoarthritis in 16 patients. Applied were 46-62 mm cups for 28 mm and 32 mm diameters of the head. The femoral component used was a cementless Poldi--42 times, cemented MS-30--16 times and cementles CLS--once. The surgical approach was first anterolateral, later Bauer transgluteal approach which allows a better visualization of the location during the reaming of acetabulum and cup positioning. The reaming of acetabulum and implantation of the cup were performed in a standard way. Prior to incision Kefzol (cefazolin) was administered intravenously in the dosage of 2 g. In patients with a preceding operation on the hip joint the administration of Kefzol was extended to 24 to 72 hours (3 x 1 g each 8 hours intravenously). Standard antithrombotic prevention by miniheparinization was applied in all patients until they were able to walk with the help of crutches (7 to 10 days). In case of an increased risk of thromboembolic complications heparin with a low molecule weight (Fraxiparine) was applied over the same period. METHODS: In the period between autumn 1999 and spring 2000 clinical examination of the patients operated on was performed together with a radiograph of the hip joint involved. Clinical findings were evaluated after Harris hip score. Radiograph findings were compared to the postoperative and the control ones made one year after the operation. Evaluated were the position of components and signs of their loosening, if any. RESULTS: After the average follow-up of 59 months 57 patients were checked. Excellent results according to Harris were achieved in 40 patients, good results in 13 patients and satisfactory results in 4 patients. No poor result was recorded. Radiographs proved a full integration of CLS Spotorno cups without any signs of loosening in all checked patients. DISCUSSION: Not very numerous works in both foreign and domestic literature list according to the experience of individual authors the following advantages of CLS Spotorno cup: a small bone loss during reaming of acetabulum, excellent primary stability, excellent secondary stability and its easy reimplantation as compared to all types of cementless cups. Only in one female patient after a peroperative fissure of proximal femur the control examination showed a lower value of Harris score than was the average value of the whole group. Similarly, the Harris score was lower in female patients who postoperatively experienced complications of neurological and internal nature (1 temporary paresis of n. ischiadicus, 1 phlebothrombosis of veins of the limb operated on). Control radiograph examination proved a full bone integration without signs of loosening in both components of the implant in all 57 checked patients. CONCLUSION: After five years the authors have a good experience with CLS Spotorno cup and recently they have started to indicate it more often in postdysplastic coxarthrosis in younger patients and in revision surgery for aseptic loosening of a cup. In young patients they recommend its matching with CLS Spotorno cementless femoral component and in middle-aged patients its matching with MS-30 (Morscher-Spotorno) cemented femoral component the centralizer of which allows an ideal anchoring of the stem in the cement mantle.

[Unstable pertrochanteric fractures, biomechanic, classification and therapy.]. / Nestabilní pertrochanterické zlomeniny -jejich biomechanika, klasifikace a terapie.

The authors deal with unstable pertrochanteric, intertrochanteric and subtrochanteric fractures extending as far as calcar femorale. The treatment of pertrochanteric issues is a serious issue as their total number in the Czech Republic exceeds 5.000 annually and with the exception of those which are contraindicated due to their health condition, all patients are indicated to surgery. In the treatment of unstable pertrochanteric fractures there occurs failure of internal fixation also with the use of implants such as dynamic hip screw or Gamma nail. The cause of unsuccessful treatment of unstable fractures is the defect in calcar femorale - impairment of the weightbearing area of proximal femur and failure of the implant as a result of its cyclic overloading - breakage of the nail, cutting out of the screw from the head in the osteoporotic bone or breaking out of screws fixing the plate to the femoral shaft. For a causal procedure the authors consider the reconstruction of the calcar femorale by a wedge valgus osteotomy of the comminuted zone after the original design of Debrunner and Cech (1969). Simultaneously with reconstruction of the medial cortical support in the calcar femorale the 160 degrees valgization is performed. In the AO classification the authors consider for unstable the fractures of types 31.A2.1, A2.2, A3.3. Significant from the therapeutic viewpoint is the classification of stable fractures (with open reduction the anatomic reconstruction of weight-bearing calcar femorale is possible) and unstable fractures - where with open reduction the defect of calcar femorale persists. For stabilization of unstable the authors recommend fixation by DHS at 150 degrees angle. If need be, this fixation may be combined with lag screws and in case of a simultaneous fracture of greater trochanter and in reverse fractures a trochanteric buttress plate has to be added. Key words: unstable pertrochanteric fractures, nonanatomic valgus reduction, DHS fixation.

[Valgus Osteotomy in the Treatment of the Ischemic Necrosis of Femoral Head in Children: Part II - Clinical Evaluation of the Group.]. / Valgizující osteotomie pri lécení následku ischemické postdysplastické nekrózy hlavice kosti stehenní u detí- II. cást: klinické hodnocení souboru.

The authors present long-term results of the surgical treatment of ischemic necrosis of proximal femur resulting from the treatment of the developmental dysplasia. They used their own technique of intertrochanteric valgus osteotomy in 77 hip joints. The surgical technique was published in the first part of the work. It consists in valgus osteotomy which lengthens femoral neck and, consequently also the whole limb. At the same time a fusion of the physis of the greater trochanter was performed and the pathological antetorsion of the femoral neck corrected. Osteotomy was fixed with a special valgus angled blade plate. In cases where dysplastic acetabulum persists the authors supplement the operation with the shelf operation after Bosworth. All patients operated on for the ischemic necrosis of femoral head were originally treated conservatively. Of the operated on group of 77 hip joints, 69 hip joints were classified in type III after Bucholz-Ogden and 8 hip joints in type II (type II B after Thomas et al.). Valgus operation was performed in children at the age of 3 to 15 years. The patients were further followed up on average 15,4 years, the average age upon the termination of the follow-up was 24,7 years. Eight patients of the group underwent a revision surgery by the same technique for inadequate primary correction or for the loss of correction in the course of the further growth of the hip joint. In 4 patients the authors equalized the length of both limbs by shortening the contralateral femur, in 3 patients additional fusion of the physis of the greater trochanter was performed. In case of dysplastic acetabulum the shelf arthroplasty after Bosworth proved to be very suitable. On the basis of their experience and clinical results the authors recommend to perform the surgery at the age between 7 and 10 years as in earlier operations there may occur a loss of correction during the following period and in children operated on later the adaptation of the operated on hip joint decreases. A prerequisite of a good long-term result is a precise preoperative planning of the operation and its exact technical performance. Key words: developmental dysplasia of the hip joint, ischemic necrosis, valgus intertrochanteric osteotomy of femur.

[Protrusion of Acetabular Cup in THR.]. / Protruze umelé jamky kycelního kloubu.

The authors report on a case of a complete protrusion of the cup of the hip joint into pelvis. Angiographic examination documents a considerable displacement of iliac vessels caused by the pressure of the displaced acetabular cup which poses a great risk of the injury of vessels during the revision surgery. As a solution of this complication the authors used a separate extraperitoneal approach described in literature as an approach to iliac vessels after Leitz allowing a safe removal of the acetabular cup and the ball of the prosthesis. For the removal of the stem the transgluteal approach was used. Key words: Pelvic protrusion of the acetabular cup, angiography, extraperitoneal release of iliac vessels.

[Spotorno CLS Cup in Revision Arthroplasty of the Hip.]. / Pouzití standardní necementované jamky CLS v revizních indikacích.

UNLABELLED: PURPOSE OF THE STUDY Revision surgery for the loosening of total hip arthroplasty with the use of cemented implants does not guarantee good long-term results. The current trend prefers the use of cementless implants, particularly of the press-fit type. In our group of patients with aseptic loosening of the acetabular cup with a preserved acetabular bone stock without segmental defects we used for the revision surgery a Spotorno CLS cementless cup. MATERIAL The group comprised 33 patients, 29 women and 4 men, of the average age of 66 years, with the loosened acetabular component, of which 31 had originally a cemented Poldi cup and 2 a cementless threaded Walter-Motorlet cup. Cup revision only was performed in 25 cases, both components (cup and stem) were replaced in 8 cases. METHODS We used a standard cementless Spotorno CLS cup. In case of a preserved circular bone stock of acetabular rim the cup was implanted in the standard position. Cavity defects were filled by cancellous bone grafts. In case of poor anatomical bone stock the cup was implanted deeper in acetabular cavity usually in a more varus position and rarely in valgus position depending on the localisation of segmental defect. RESULTS The average follow-up was 38 months (range, 16-63 months). In one case there occurred aseptic loosening after 12 months and the second revision surgery was necessary in order to replace the implant by the same type of a greater size. In one case after 6 months there developed a hematogeneous infection and the implant was replanted by a two-stage procedure. In the remaining cases osteointegration took place in the course of 12 months after the operation. In 7 cases the cups were implanted in a slightly varus/valgus position necessitated by the acetabular bone stock, without any impact on the osteointegration or function. DISCUSSION The disadvantage of cemented implants in the revision surgery consists in the limited possibility of the integration of cemented mantle and the destructed bone interface. The advantages of cementless implant in the revision surgery of a loosened cup is confirmed by a number of authors but they relate mainly to press-fit cups. The data on the use of Spotorno CLS expansion cup in the revision surgery are rare. Our group with a short follow-up demonstrates that the integration and the function of the CLS cup as a revision implant seems to be reliable. The main prerequisite, however, is a good acetabular bone stock without greater segmental defects. Cavity defects may be filled in by autologous or homologous cancellous bone grafts. The CLS cup may be fixed, if necessary, in a slightly non-anatomical position without any impairment of the function. It includes mainly the cases of the ovoid shape of acetabulum when the cup is implanted in the acetabula roof in greater varus slope than recommended by the author of implant. CONCLUSIONS The Spotorno CLS cementless expansion cup as a revision implant in the right indication brings good short term results on condition of a good primary stability of the implant and a spherical acetabulum without great segmental defects. KEY WORDS: THA, revision surgery, cementless CLS cup.

[Extended Bauer Approach and Transfemoral Approach in THA Revision.]. / Rozsírený Baueruv prístup a prístup transfemorální pouzívaný námi pri revizních operacích TEP kycelního kloubu.

The number of revision surgeries of the hip joint keeps growing and it brings new problems, especially in cases where the skeleton in the region of the loosened stem is destructed. As we have been pursuing total hip arthroplasty in the Czech Republic for 30 years we know that the life of the implants is reduced, the number of aseptic loosening is increasing. This loosening is associated with the loss of the bone stock, mainly the cortex gets thinner. The revision cemented stem cannot be exactly fixed in the destructed proximal femur and, in addition, the bone is further damaged. Wagner introduces a new concept of the treatment of these severe complications: transfemoral approach, cementless implant - a stem which may be fixed distal to the destruction of the proximal femur. This method provides prerequisites for the formation of the new bone - bone regeneration and the regeneration of the destructed femoral bone stock. The author presents an extended Bauer approach he has been using in revision surgeries since 1983 (in cases where the bone stock has been preserved and the broken stem of the implant or the persisting remnants of the bone cement have to be removed). This technique is used also in the transfemoral approach which differs from the Wagner approach by performing transfemoral osteotomy in the coronal rather than sagittal plane. It allows operating on the patient in the supine position - similarly as during primary implantation. It provides the possibility of a reliable replacement and alignment of the loosened cup and the revision of the medullary canal from the transfemoral approach in the coronal plane, removal of the bone cement, polyethylene granuloma and an exact application of the Wagner stem. It means that the stem must be fixed below the osteotomy level, extending over 10 cm, but minimally 7 cm proximally to the isthmus of the medullary canal. This extended transfemoral approach requires the Wagner stems in the length of 265 mm and 305 mm. With the use of the Wagner stems of the length of 190 mm or 225 mm this approach is usually not indicated. Key words: revision surgery, transfemoral approach, Wagner stem.

[Valgus osteotomy in the treatment of sequelae of ischemic post-dysplastic necrosis of femoral head in children. Part I: surgical technique.]. / Valgizující osteotomie pri lécení následku ischemické postdysplastické nekrózy hlavice stehenní kosti u detí: I. cást - operacní technika.

The authors deal with the surgical technique of the reconstruction of coxa vara in children. They present valgus osteotomy on the Pauwels principle with the simultaneous apophyseodesis of the growth plate of greater trochanter, lengthening of fermoral neck fixed by 120 degrees angled blade plate for adolescents allowing a parallel lengthening of the lower limb. The main indication for this technique is postdysplastic coxa vara and congenital coxa vara in children. However, it may be used also in adults. The benefits of the method consist in the possibility of exact planning of the surgery. Key words: valgus osteotomy, reconstruction, DDH, ischemic necrosis of the femoral head.