[Short-Term Results of the Carpometacarpal Joint Arthroplasty Using the Ivory® Prosthesis]. / Krátkodobé výsledky náhrady korenového kloubu palce ruky Ivory®.

PURPOSE OF THE STUDY Trapeziometacarpal osteoarthritis affects primarily postmenopausal middle-aged and older women. Total joint replacement is one of the surgical treatment options for symptomatic advanced degenerative changes of the carpometacarpal joint. This study aims to evaluate the short-term functional and radiological results of the Ivory ® prosthesis with the minimum followup period of three years after the surgery. MATERIAL AND METHODS Presented are the results of 48 total trapeziometacarpal joint replacements in the group of 40 patients composed of 36 women and 4 men. The age of patients ranges from 41 to 75 years (median 56 years), with the ratio between the dominant and non-dominant upper extremity 23:25. The follow-up period ranged from 36 to 63 months (median 52 months). The surgery was indicated in patients with symptomatic trapeziometacarpal arthrosis of stage II, III and early stage IV according to Eaton-Glickel once the conservative therapy had failed. In all the patients, the evaluation of the function and pain of the operated joint by DASH score, the range of motion -thumb opposition by Kapandji score were carried out at regular intervals pre- and postoperatively, the radiological evaluation of the stage of degenerative joint condition was done preoperatively, whereas the position of the implant and the lengthening of the first column of the finger were assessed postoperatively. RESULTS Subjectively, the patients were satisfied with the result of the surgery. After the joint replacement, in 65% of cases the patients reported full satisfaction with no difficulties present, in 31% of cases the patients suffered from pain during loading, in 4% of cases the patients reported also occasional pain at rest. Postoperatively, the total DASH score values decreased from the mean preoperative value of 52.79 to 10.4 points at a three-year follow-up. The average value of pain dropped from 3.46 to 1.44 points 3 years after the surgery. The average range of motion - thumb opposition by Kapandji score increased from 8.57/10 to 9.85/10 one year after the surgery. The difference between the values of average increase in length of the first column of the finger was 0.14 mm in favour of the sub-group of symptomatic cases. In the evaluated group, the need for revision was determined in 4 implants. In 1case for aseptic loosening of the cup and three times for dislocation. After 36 months, 47 of 48 implants were in situ, the overall three-year survival was achieved in 97.9%. The most frequent postoperative complication was the occurrence of De Quervain s tenosynovitis (10%). DISCUSSION Currently, most of the newer types of modular uncemented hydroxyapatite-coated total "ball and socket" joint replacements present acceptable medium-term, and in some cases even long-term, results regarding the survival. The most pressing issue continues to be the survival of implants, particularly the failure of the trapezial component and the associated risk of revision surgery. Good postoperative results can be achieved by accurate indication, carefully applied cup implant and good postoperative cooperation of patients. The complementary study did not confirm that the lengthening of the thumb causes the postoperative development of De Quervain s tenosynovitis. CONCLUSIONS The uncemented first carpometacarpal joint total replacement using the Ivory ® prosthesis brings about very good shortterm functional and radiological results, with no occurrence of early aseptic loosening of the implant. Key words:rhizarthrosis, arthroplasty, carpometacarpal joint prosthesis, uncemented.

[Analysis of Costs Associated with Revision Total Knee Arthroplasty]. / Analýza nákladu spojených s reoperacemi TEP kolena.

PURPOSE OF THE STUDY No study has so far been published in the Czech Republic that would try to at least estimate the costs associated with revision total knee arthroplasties (TKA). The purpose of our study was to determine the total costs of primary and revision TKA for aseptic and septic failure and to determine the structure of costs, all with respect to a single workplace in the Czech Republic. MATERIAL AND METHODS The group included a total of 43 patients aged 55 to 82 years, of whom 23 (53.5%) with primary TKA implantation, 10 (23.3%) patients with revision surgery for aseptic failure, and 10 patients for septic failure of TKA. The costs of TKA were calculated retrospectively, factoring in all the items of reported care sent to the health insurance company system. The resulting costs reflected the appropriate payments in CZK based on the point value in the year concerned. RESULTS The average costs of uncomplicated primary TKA implantation amounted to CZK 136,279; the surgical treatment of aseptic failure of TKA was CZK 189,634; and the surgical treatment of septic failure of TKA was CZK 296,189. In all the evaluated cases, the highest cost item was the material of the implant (43.5 to 54.2% of the total costs), followed by the bed costs (19.8 to 21.6%), and the third highest cost item being the performance of surgery (13.6 to 16.5%). The costs of the physician's services represented 12.8 to 14.7% of the total costs and 23.6 to 33.8% of the costs of the implants. The costs associated with the treatment of infection by multiple-stage reimplantation were 5.4 times higher than when DAIR (revision surgery with debridement, irrigation, original implant retention) was used. The average costs of inpatient rehabilitation accounted for CZK 23,046 and the insurance company reimbursed on average CZK 33,544 for a 4-week therapeutic spa treatment. DISCUSSION The finding that the revision TKA is several times more expensive than the primary TKA and that the multiple-stage total knee reimplantation is the most expensive corresponds with the literature. In the Czech Republic, the dominant cost item is the cost of the implant, namely in the total costs of both the primary and revision TKA, with the revision implants in our study being on average 2.1 times more expensive than the implants used for primary implantation. Besides, the costs of implants also considerably differ across countries. The costs of the physician's services ranked 4th in the list of cost items, which does not correspond with the data reported in Western Europe or the US. Conversely, the least difference was observed in the costs of preoperative preparation and auxiliary examinations. CONCLUSIONS We have concluded in our study that the average costs of the total knee replacement for aseptic failure were 1.9 times higher than the costs of primary surgery. The average costs of treatment for septic failure (two-stage procedure) were 2.7 times higher compared to primary surgery. In case of aseptic failure, the costs of total knee reimplantation were 2.7 times higher compared to the replacement of only polyethylene liner in case of instability and osteosynthesis in case of periprosthetic fracture, with components retention. The costs of septic failure therapy were 5.4 times higher in multiple-stage reimplantation compared to revision surgery with debridement, irrigation and original implant retention. Key words: total knee arthroplasty; total knee replacement; revision total knee arthroplasty; aseptic failure; septic failure; cost analysis.

[Occurrence and Progression of Early Radiolucent Lines around Total Knee Arthroplasty]. / Výskyt a progrese casných radiolucentních linií kolem TEP kolenního kloubu.

PURPOSE OF THE STUDY Radiolucent (RL) lines may appear around the total knee arthroplasty (TKA); they occur much more frequently under the tibial component than under the femoral one. The RL lines are gaps between the TKA and the cement, or between the cement and the bone bed. They are clearly visible immediately after the surgery or may appear later. They constitute pathology of the interface and are subject to research mainly due to their potential association with aseptic loosening. The aim of this study was to assess how often they are clearly visible on the first postoperative radiograph in everyday clinical practice, how they develop during the following two years, and to compare the results with the available professional literature. Another aim was to assess the relation between RL lines and the alignment of components, the patient's habitus and clinical outcomes of the surgery. MATERIAL AND METHODS The group included 62 patients with a total number of 69 TKA implants, of which 28 were men (45.2%) and 34 women (54.8%) aged 46 to 79 years of age. The occurrence of RL lines was monitored on the first postoperative radiograph and subsequently at a one-year interval during the following 2 years. The location of RL lines and the placement of components were assessed radiographically in terms of the concept by Meneghini et al. The evaluation of surgical outcomes was done using the Knee Society Score (KSS), and the habitus was assessed with the BMI index. Subjective evaluation of the surgical outcome was done using the 4-point satisfaction scale. RESULTS The first postoperative radiographs showed a RL line at 9 (0.8%) locations in 9 (13.0%) TKAs. The control radiographs made 1 year after the surgery showed a RL line at 42 (3.8%) locations in 29 (42.0%) TKAs. During the last check conducted 2 years after the surgery, a RL line was detected at 60 (5.4%) locations in 33 (47.8%) TKAs. Throughout the follow-up period, progression of the existing RL line occurred at 6 locations in 6 (8.7%) TKAs. On the very contrary, the RL line disappeared at 8 locations in 6 (8.7%) TKAs. An association was found between the RL line occurrence and postoperative limb axis (a higher risk was posed by the varus deformity). Moreover, the frequency of RL lines increased with the growing BMI value. No relation was found between the KSS and satisfaction with the surgery and the occurrence of RL lines. DISCUSSION AND CONCLUSIONS The occurrence of RL lines corresponds roughly with the frequency stated in literature. Some lines show progression, other disappear. So far, we have been unable to distinguish the predictively significant RL lines from the insignificant ones. Important will undoubtedly also be the size of surface of RL lines and their cause. More frequent RL lines were observed in the postoperative varus deformity of TKA and with the growing BMI value. The RL lines under the anterior part of the femoral component showed a tendency to progress. In order to avoid them we recommend modifying the cementing technique. Clinically significant is the fact that the RL lines occurrence correlates neither with subjective nor with clinical outcomes of the surgery. Key words: total knee arthroplasty; total knee replacement; radiolucent lines; progression; alignment; Knee Society Score; BMI.

[Validity of the Morawietz classification for evaluation of periprosthetic tissue]. / Prínos Morawietzovy klasifikace k hodnocení periprotetických tkání.

PURPOSE OF THE STUDY A consensual classification of the periprosthetic interface membrane obtained at revision total joint arthroplasty was published by Morawietz et al. in 2006. Based on histomorphological criteria, four types of periprosthetic membrane were proposed: type I, aseptic failure; type II, septic failure; type III, combined type (carrying signs of both type I and II); and type IV, indeterminate type. The aim of this study was to find out whether and to what extent the Morawietz system would be suitable for use at an independent institution involved in the evaluation of periprosthetic membranes for a long time. Should it appear that the institution achieved an equally good or even better agreement between the clinical diagnosis and the histopathological finding, this consensus classification could be recommended for routine use. MATERIAL AND METHODS The samples of periprosthetic tissue evaluated in this study were obtained during surgery from the following groups of patients: 66 patients with aseptic loosening of total hip (THA) or knee arthroplasty, 15 patients with infection of THA, 16 patients with THA without any signs of aseptic loosening, osteolysis or infection; 8 patients with hip osteoarthritis and 8 patients with knee osteoarthritis. Sample collection and processing (for purposes of histomorphological evaluation and immunohistochemical staining) was performed according to the established protocol. The tissue samples evaluation was made by an experienced pathologist hand in hand with the method described in the original paper by Morawietz et al. For a more detailed tissue analysis, selected antibodies (CD4, CD8, CD20, IFN-γ and Hsp-60) were visualized by immunohistochemistry. RESULTS The majority of samples from aseptic reoperations were classified as membranes of the type I (79%) and III (16%). Specimens retrieved from septic cases were mostly classified as membranes of type II and III (60% together). The septic membranes showed a significantly higher expression of CD20 protein when compared with both the aseptic (p < 0.0001) and control THA samples (p = 0.003). The membranes retrieved from the surroundings of a stable THA without osteolysis and infection had lower expression levels of Hsp60 and IFN-γ, when compared with those from both aseptic and septic loosening. Finally, Hsp-60 expression was significantly higher in osteoarthritic tissue than in samples from stable THA (p = 0.041). DISCUSSION Morawietz et al. proposed a standardized classification system for evaluation of periprosthetic tissue. As any attempt at generalization of a complex issue, this proposal has certain shortcomings. One of these is poor detection of chronic and low-grade infections. A method that would improve the conventional counting of polymorphonuclear leukocytes is still being sought. In this connection, immunostaining for CD20 combined with an assessment of antimicrobial peptides may be a promising option. The supplementary specimen staining showed that pseudosynovial tissue is much more active in patients carrying infection and the least active in samples from stable THA in which certain tolerance and thus tissue homeostasis might be expected. CONCLUSIONS 1. In this study the distribution of findings classified according to the Morawietz system was similar to the results published in the original study from 2006. 2. The definition of an aseptic membrane (type I) in the Morawietz system meets the requirements of clinical practice (agreement, about 80%). 3. An increased sensitivity for infectious membrane detection can be achieved by using supplementary immunohistochemical staining effective particularly in chronic and low-grade infections. 4. Painless and stable THAs typically have very low expression levels of CD4, CD20 and Hsp-60 proteins, and interferon- -gamma (IFN-γ) as well. Key words: total hip arthroplasty, total knee arthroplasty, aseptic loosening, prosthetic joint infection, tissue analysis, membranes, CD receptors, Hsp-60 protein, IFN-γ.

Osteolysis around total knee arthroplasty: a review of pathogenetic mechanisms.

Aseptic loosening and other wear-related complications are some of the most frequent late reasons for revision of total knee arthroplasty (TKA). Periprosthetic osteolysis (PPOL) pre-dates aseptic loosening in many cases, indicating the clinical significance of this pathogenic mechanism. A variety of implant-, surgery- and host-related factors have been delineated to explain the development of PPOL. These factors influence the development of PPOL because of changes in mechanical stresses within the vicinity of the prosthetic device, excessive wear of the polyethylene liner, and joint fluid pressure and flow acting on the peri-implant bone. The process of aseptic loosening is initially governed by factors such as implant/limb alignment, device fixation quality and muscle coordination/strength. Later, large numbers of wear particles detached from TKA trigger and perpetuate particle disease, as highlighted by progressive growth of inflammatory/granulomatous tissue around the joint cavity. An increased accumulation of osteoclasts at the bone-implant interface, impairment of osteoblast function, mechanical stresses and increased production of joint fluid contribute to bone resorption and subsequent loosening of the implant. In addition, hypersensitivity and adverse reactions to metal debris may contribute to aseptic TKA failure, but should be determined more precisely. Patient activity level appears to be the most important factor when the long-term development of PPOL is considered. Surgical technique, implant design and material factors are the most important preventative factors, because they influence both the generation of wear debris and excessive mechanical stresses. New generations of bearing surfaces and designs for TKA should carefully address these important issues in extensive preclinical studies. Currently, there is little evidence that PPOL can be prevented by pharmacological intervention.

[Evaluation of anterior cruciate ligament reconstruction using anterior tibial muscle tendon allograft]. / Hodnocení výsledku náhrady predního zkrízeného vazu pomocí alogenního stepu ze slachy m. tibialis anterior.

PURPOSE OF THE STUDY: Injury to the anterior cruciate ligament (ACL) frequently results in the development of knee instability. This is managed by ACL reconstruction using autogenous or allogeneic grafts. This study presents a comprehensive evaluation of the patients with ACL reconstruction using a tendon allograft harvested from the anterior tibial muscle (ATM). MATERIAL AND METHODS: The group under study comprised 53 patients, 33 men and 20 women, with unilateral ACL reconstruction while the other knee was intact. The average age was 32.4 years (17 to 51) and the average follow-up was 33,4 months (21 to 53). Clinical evaluation included the Tegner and Lysholm scores and questionnaire-based satisfaction rating. Functional assessment included measurements of the range of motion and thigh circumference. Knee stability was determined using the pivot shift test, Lachman test and one-leg hop test. ACL laxity was measured on a GNRB® arthrometer. Placement of the tibial and the femoral tunnel on radiographs was assessed by the method of Harner. RESULTS: All patients reported their willingness to undergo the surgery again. The average pre-operative Tegner score improved from 7.17 (4-10) to 6.45 (2-10; p = 0.0001). The average post-operative Lysholm score was 87 points (47-100). At final follow-up, the full range of motion was recorded in 39 patients (74%), while the remaining patients exhibited only insignificant restriction of knee motion in comparison with the pre-operative status. The results of the Lachman test were negative in 38 patients (71.7%) while the pivot shift test was negative in 52 patients (98.1%). In the one-leg hop test, 44 patients (83%) were able to jump on the treated leg for a distance longer than 90% of the distance done on the healthy leg. The GNRB test at a force of 134N showed an anterior shift of the proximal tibia by 2.2 mm (0.1-9.3) on the average. The tibial tunnel was placed in zone B in 48 patients (90.6%) and the femoral tunnel was most often located to zone D (n = 47; 88.7%). DISCUSSION: The choice of tissue for ACL reconstruction is still being discussed. In some centres an ATM tendon allograft is used only in revision surgery while, in other centres, it is also employed in primary procedures. Recent studies on ACL surgery suggest that outcomes are relatively independent of the material used for reconstruction. In view of evidence-based medicine, more well-conducted multicentre clinical trials are needed to optimise indications for allograft ACL reconstruction. CONCLUSIONS: The ACL reconstruction using an ATM tendon allograft showed good clinical outcome at a minimum follow-up of 21 months. The method can be recommended not only for revision ACL reconstruction but also in primary reconstructions particularly in elderly patients. The present-day technology of producing allografts maintains tissue biomechanical characteristics and reduces risks for transmission of infection to a minimum.

[Comparative study of detection and evaluation of the size of oesophageal varices with the use of 12 and 20 MHz frequency radial endosonography vs. esophagogastroduodenoscopy]. / Srovnávací studie detekce a vyhodnocování velikosti jícnovýh varixu s vyuzitím radiální endosonografie s frekvencí 12 a 20 MHz vs ezofagogastroduodenoskopie.

INTRODUCTION: Portal hypertension is an important marker in the development of life-threatening complications of hepatic cirrhosis. It is the direct cause ofoesophageal varices (OV), liver encephalopathy, and ofascites. One of the most important locations where the junctions between the portal and systemic circulation become dilated is the region of the oesophagus and the stomach. Bleeding from OV can be the cause of death in as many as 1/3 of cirrhosis patients with portal hypertension. Oesophagogastroduodenoscopy (EGD) is a standard procedure to examine gastro-oesophageal varices, but radial endosonography (EUS) allows for precise quantification of the size of oesophageal and stomach varices including their diagnosis at a stage when they still cannot be distinguished by standard EGD. The objective of the study was to assess the benefit of 12 and 20 MHz EUS and EGD in the detection of oesophageal and stomach varices (including varices which still cannot be diagnosed endoscopically) and in determining their size. Another objective was to find out whether there is a link between hepatic functional impairment measured by the Child-Pugh scale and the size of oesophageal varices. We also assessed the incidence and size of varices with respect to portal blood flow measured by Doppler examination. METHOD: The group contained 31 patients with proven hepatic cirrhosis. RESULTS: The sensitivity rate of EGD with respect to EUS expressing the portion of patients with a positive outcome was 92%. The specificity rate expressing the quantity of healthy individuals with a negative result was 83%.