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

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

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

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

[Augmentation of the Anterior Cruciate Ligament in Patients with Symptomatic Isolated Tear of Anteromedial or Posterolateral Bundle: Evaluation of Two-Year Clinical Results]. / Augmentace predního zkrízeného vazu u pacientu se symptomatickou izolovanou rupturou anteromediální nebo posterolaterální porce: zhodnocení dvouletých klinických výsledku.

PURPOSE OF THE STUDY: We present the results of a prospective study of patients with symptomatic partial ACL tears comparing the pre-operative findings with the clinical results at two years after anterior cruciate ligament (ACL) augmentation. MATERIAL AND METHODS: A total of 29 patients (7 women, 22 men; average age, 27.8 years) who were diagnosed with an isolated tear of the posterolateral (PL) bundle (18 patients) or the anteromedial (AM) bundle (11 patients) at 9 to 24 weeks after injury, and underwent ACL augmentation by isolated PL or AM bundle replacement, were evaluated. The characteristics assessed before surgery and at two years after it included the Lysholm and subjective IKDC scores and knee laxity measurement with a GNRB arthrometer (at 134 N and 250 N) and its assessment by the Lachman, anterior drawer and pivot shift tests. In addition, the presence of cyclop syndrome, graft failure and post-operative complications were evaluated. RESULTS: The patients with isolated reconstruction of the PL bundle showed post-operatively statistically significant improvement in the degree of rotational knee laxity (p < 0.05) and the ventral knee laxity assessed by the Lachman test (p < 0.05). Postoperative improvement in the anterior drawer test results was not statistically significant (p = 0.07). The median value of side-to-side difference in knee laxity measured with the GNRB arthrometer decreased at 134 N from 1.7 mm pre-operatively to 0.8 mm at two years post-operatively (p < 0.05) and, at 250 N, from 2.8 mm to 1.5 mm (p < 0.05). The median Lysholm score increased from 74 to 91 points at two post-operative years and the median IKDC score improved from 76 to 92 points (p < 0.05). Graft failure was reported in one patient (5.6%) and 14 subjects (77.8%) reported return to pre-injury sports activities. The patients undergoing isolated reconstruction of the AM bundle achieved, at two years after surgery, a statistically significant decrease in positivity of the Lachman and anterior drawer tests (p < 0.05), while the results of the pivot shift test did not improve significantly (p = 0.09). The decrease in median values of side-to-side difference in knee laxity measured with the GNRB arthrometer was from pre-operative 3.1 mm to 1.2 mm at 134 N (p < 0.05) and from 6.2 mm to 1.9 mm at 250N (p < 0.05). The median Lysholm and IKDC scores increased from 68 to 92 points and from 70 to 94 points, respectively (p < 0.05). Nine patients (81.9%) reported return to pre-injury participation in sports. Apart from early wound bleeding in one patient, no complications were recorded. DISCUSSION: By permitting maintenance of a healthy bundle and replacement of only a torn one, ACL augmentation provides several benefits. It allows for accelerated revascularization and re-innervation of the graft through mechanoreceptors of the healthy portion; it enables the surgeon to get a good anatomical orientation and achieve precise tunnel reaming; in addition the healthy bundle provides protection for the graft in the early post-operative period. Thus rehabilitation can be faster and also return to sports activities. CONCLUSIONS: Our results show that ACL augmentation using isolated replacement of either the AM or the PL bundle brings about statistically significant improvement of all subjective and most of the objective criteria by two years after surgery.

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

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

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

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

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

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

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

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

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

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

[Massive tears of the rotator cuff--comparison of mini-open and arthroscopic techniques. Part 2. Arthroscopic repair]. / Masivní ruptura rotátorové manzety - srovnání mini-open a artroskopické rekonstrukce. Cást 2: artroskopická rekonstrukce.

PURPOSE OF THE STUDY: In this study the results of arthroscopic repair of massive rotator cuff tears are evaluated and compared with those of mini-open surgery published in Part 1. MATERIAL: By the year 2006, of 176 patients undergoing the reconstruction of massive rotator cuff tears in our department, 77 were treated by arthroscopy. In this group there were 50 men; the dominant arm was operated on more frequently (60x). The average age of the patients was 55 years (range, 37-74). METHODS: Surgery is carried out under combination of general anesthesia and an interscalene brachial plexus block, in a lateral recumbent position, with traction applied to the axis of the limb abducted at 40 degrees. Standard arthroscopic portals are used. After exploration of the glenohumeral joint and thorough bursectomy, the torn rotator cuff tendons are mobilized and an insertion site is prepared. Using Spiralok (Mitek) anchors loaded with two strands of Orthocord suture, the tendons are re-attached with mattress stitches by means of an arthroscopic grasper (Mitek). We use the standard single-row technique with re-insertion at the original site. In indicated cases we carry out tenotomy or tenodesis of the long head biceps tendon. Acromionplasty follows only in type III acromion cases. After surgery the limb is immobilized in a Gilchrist bandage for 5 weeks during which, in accordance with the strength of re-attachment, passive exercise is carried out. Rehabilitation therapy should continue for 6 months at least. The results were evaluated on the basis of the UCLA (University of California at Los Angeles) shoulder rating system and the Constant scoring system. Using the school marking system (1, best; 5, worst) we asked about patients' satisfaction with surgery and their willingness to undergo the same operation again. RESULTS: Of the 77 patients treated for massive rotator cuff tears by arthroscopic repair up to 2006, 40 were fully evaluated. The average pre-operative Constant score was 48.4 (26-83) points and the UCLA score was 13.8 (6-25) points; post-operatively, these values increased up to 85.45 and 30.35 points, respectively. In addition to rotator cuff repair, we performed tenotomy or tenodesis of the long head biceps tendon (31x; in seven cases a tendon rupture was present), acromioplasty (17x), acromioclavicular joint resection (3x), subscapular muscle reconstruction (5x) and treatment for shoulder instability (3x). In four patients we recorded the following complications: transient paresis of the upper extremity one, infection in one, and long-term secretion from the ventral portal in two patients. They were completely treated. All patients were satisfied with the treatment outcome and expressed willingness to undergo the surgery again, if needed. DISCUSSION: Although the arthroscopic repair of a massive rotator cuff tear is a technically demanding procedure with a long learning curve, since 2005 all rotator cuff repairs at our department have been carried out arthroscopically. The results achieved are comparable with those of the mini-open surgery and, in addition, this method allows us to treat all co-existent pathologies at one stage. The Spiralock anchor (Mitek) proved to be an optimal implant for re-attachment of the rotator cuff tendons. No evaluation of a similar patient group is available in the relevant Czech literature, but the results are in agreement with those of published international studies. CONCLUSION: Arthroscopic rotator cuff repair can be recommended as the procedure fully comparable with the open technique. Because of the possibility to diagnose and treat all shoulder pathologies at one stage, all rotator cuff repairs at present carried out at our department are arthroscopic procedures.

[Intra-articular analgesia after anterior cruciate ligament reconstruction]. / Intraartikulární analgetická smes po rekonstrukci predního zkrízeného vazu.

PURPOSE OF THE STUDY: In this double-blind prospective study, pain after reconstruction of the anterior cruciate ligament (ACL) was evaluated using the visual analogue scale (VAS). Comparisons were made between patients administered an intra-articular analgesic mixture of adrenaline, morphine and bupivacaine (Marcaine) and those without it, between patients surgically treated by the BTB technique and those undergoing hamstring tendon ACL reconstruction, and between men and women undergoing the same procedure. MATERIAL: Eighty-five randomly selected patients were allocated by five groups according to the surgery performed: 1. ACL reconstruction by the BTB technique, without administration of the analgesic mixture (20 patients); 2. hamstring tendon ACL reconstruction, without the analgesic mixture (20 patients); 3. ACL BTB technique with intra-operative, intra-articular analgesia (20 patients); 4. hamstring tendon ACL reconstruction, with intra-operative, intra-articular analgesia (20 patients), 5. ACL reconstruction using a cadaver graft, without intra-operative analgesia (5 patients). METHODS: ACL reconstruction was carried out, in tourniquet-induced ischemia, by one of the standard techniques mentioned above. An analgesic mixture of adrenaline (1 ml/1 mg), morphine (1 ml/10 mg) and Marcaine (0.5 %/20 ml) was administered into the joint under arthroscopic control before the procedure was terminated. In all cases, the drain was released at 30 min. after the end of surgery. The limb was immobilized in a brace and the joint was cooled with ice. When requested, intramuscular analgesics (Dolmina and Dipidolor) were given.VAS pain scores were recorded at 30 min, 1, 2, 4, 8, 12 and 24 h after surgery. The range was from 0 (no pain) to 10 (maximum pain) scores. In addition, the amount of intramuscular analgesics and the time of their administration after surgery were noted. RESULTS: VAS pain scores were lowest in the patients with ACL reconstruction by cadaver BTB grafting, the highest scores were reported by the patients with autologous BTB graft reconstruction. Women perceived the operation as more painful than men. When the intra-operative analgesic mixture was used, the amount of post-operative opiate analgesics was reduced by 29 % and 46 % in group 3 and group 4 patients, respectively, and in group 3 its administration was postponed (first administration after an interval 1.7-times longer than in group 4). The number of patients not requiring any opiate drugs increased markedly in both these groups. Intra-operative analgesia resulted in only a slight decrease in VAS pain scores, more in group 3 than group 4. DISCUSSION: Several analgesics are used for intra-articular administration in order to alleviate post-operative pain. The most frequently used drugs include bupivacaine, morphine or epinephrine, but their mixtures are more effective than any of the drug administered alone. The most apparent evidence of the effect was the reduced amount of opiate drugs required after surgery, which was significant in all patients treated with intra-articular analgesia (groups 3 and 4) and particularly in men. However, VAS pain scores in the two groups decreased only slightly. Since maximum pain is experienced at the graft donor site, the effect of the evaluated mixture is regarded as complementary and multi-modal analgesic therapy is recommended. CONCLUSIONS: The use of intra-articular analgesia has a significant effect on the reduction of opiate amounts administered to patients during the 24-hour post-operative period after ACL reconstruction, regardless of the surgical technique used. These patients also reported slightly lower perception of pain, as assessed by the VAS pain score. The effect was higher in men than in women.

[Arthroscopic stabilization of the shoulder]. / Artroskopická stabilizace ramenního kloubu.

PURPOSE OF THE STUDY: Minimally invasive technique have recently gained importance because of their apparent advantages. One of them is arthroscopic stabilization of the shoulder used for treatment of traumatic anterior glenohumeral dislocation with subsequent instability. In this study we describe the results of and experience with this technique. MATERIAL: Conventional treatment of glenohumeral dislocation, which includes reduction and subsequent immobilization for 4 weeks, has a high risk of recurrent dislocation particularly in young patients.Therefore surgical treatment lowering this risk is preferred. Arthroscopic stabilization is effective in patients with post-traumatic anterior instability of the glenohumeral joint. This technique involves fixation of the torn glenoid labrum and reduction of the anterior articular space. The evaluation of 77 patients treated by this method is presented here. METHODS: The arthroscopic method of labrum fixation with Mitek anchors (Mitek, Norwood, Mass., USA) was used. Arthroscopic stabilization is carried out in a lateral recumbent position with an extension device, using two standard arthroscopic ports. After preparation of the glenoid rim, the torn labrum is sutured to GII anchors inserted in pre-drilled tunnels in the edge of the glenoid. Insertion of three anchors appears optimal, because the use of fewer anchors may result in failure and repeat dislocation. The anchors have to be inserted in a manner ensuring fixation of maximum of the torn labrum. RESULTS: A total of 90 shoulder joints were treated by arthroscopic stabilization and 77 patients were followed up. Excellent results were achieved in 58 patients (75.4 %). Good results in 14 joints (18.2 %) and poor in 4 patients (5.2 %). Three repeat dislocations were recorded and one patient experienced restriction of motion in the treated shoulder. DISCUSSION: The three repeat dislocations (3.9 %) correlate with the results reported in the recent relevant literature. CONCLUSIONS: Arthroscopic shoulder joint stabilization is a reliable method. It is a surgical procedure suitable for treatment of shoulder instability and is also indicated in patients with acute traumatic dislocation, because it significantly reduces the risk of recurrent dislocation that is high in conventional treatment. In the hands of an experienced surgeon this technique is fast and simple and, because of its minimal invasiveness, convenient for the patient. In comparison with open stabilization techniques, arthroscopy is associated with higher failure, but a classical open procedure can still be used for treatment of recurrent dislocations.

[Massive tears of rotator cuff - comparison of mini-open and arthroscopic techniques. Part 1. Mini-open technique]. / Masivní ruptura rotátorové manzety - srovnání mini-open a artroskopické rekonstrukce. Cást 1. Mini-open technika.

PURPOSE OF THE STUDY: In Part 1 of this study we evaluate the results of surgical repair of massive rotator cuff tears by a "mini-open" technique. In Part 2 we will compare them with the results of reconstructions performed by arthroscopic surgery. MATERIAL: Between 1995 and 2006, 99 repairs of massive rotator cuff (RC) tears were carried out in our department. The patient group included 73 men and 23 women at an average age of 55.7 years (range, 37 to 74 years). In 69 cases surgery was performed on the dominant (right) upper extremity. Surgical repair was indicated on the basis of clinical, radiological and arthrographic examination of the patients. Those who underwent surgery by the mini-open technique and in whom the RC tear was massive but repairable (grades 3 and 4 on the Bateman classification or grade III /a, b/ on the Gschwend classification) were included in the group evaluated here (N = 63). The RC re-attachment was done by several techniques, i. e., intraosseous sutures, Mitek RC anchors and Spiralok anchors (Mitek). METHODS: Surgery is carried out in a beach-chair position. Using deltoid splitting we expose the shoulder joint. At present we use Neer's acromioplasty only when a type II or a type III acromion is present. After releasing and mobilizing RC muscles and preparing the bone for re-attachment, we reduce the size of tear with end-to-end suture and re-attach the RC tendons to the humerus. We close the incision in two layers. The arm is then immobilized in a brace for 4 to 6 weeks and a long-term (6 months) rehabilitation is recommended. During the period of study, we first employed intraosseous sutures, then Mitek RC anchors and finally Spiralok anchors (Mitek). After the initial "single-row" technique using simple sutures we adopted a "double-row" technique with mattress sutures and, subsequently, the modified Mason-Allen technique combining mattress and simple vertical sutures. The double- row technique allowed us to extend the area of contact for re-attachment and increased the strength of fixation. The results were evaluated on the basis of the UCLA (University of California at Los Angeles) shoulder rating system and the Constant scoring system. Using the school marking system (1, best; 5, worst) we asked about patients' satisfaction with surgery and their willingness to undergo the same operation again. RESULTS: Out of the 63 patients undergoing surgery by the mini-open technique, 51 were available for follow-up. The pre-operative average Constant score was 39 points (range, 26 to 79) and UCLA score was 13 points (range, 6 to 22). The average follow-up was 51.6 months (range, 15 to 131 months). The post-operative average Constant score was 84.8 points (56 to 100) and by this criterion there were 70.6 % of excellent and 17.6 % of good results. The average UCLA score was 29.14 points (range, 22 to 35) and, based on this evaluation, there were 15.7 % of excellent and 54.9 % of good results. Satisfaction with the operation was reported by 96 % of the patients. DISCUSSION: Although with the mini-open technique we can achieve very good outcomes even in massive tears of the rotator cuff, the results are nevertheless worse than in small or medium RC tears. Our results are comparable with those of other authors. In the open procedure we prefer the mini-open deltoid splitting technique, because it does not require detachment of the deltoid from the acromion. For fixation, anchors loaded with two sutures seem more convenient, as well as the double-row suture anchor technique with modified Mason-Allen suture that, according to Gerber, is stronger and provides better conditions for healing. CONCLUSION: Repair of massive rotator cuff tears by the mini-open technique, if indicated early, gives very good results on condition that an adequate surgical technique is used and good-quality post-operative care, including rehabilitation, is provided. This approach can be fully recommended. Its results are comparable with those achieved by arthroscopy. This, in addition, permits inspection of the glenohumeral joint for co-existing pathologies. However, since 2005 we have preferred doing all RC repairs by arthroscopic surgery.

[Allograft for surgical reconstruction of the cruciate ligaments of the knee - part 1]. / Pouzití alogenních stepu v chirurgii zkrízených vazu kolenního kloubu - Cást 1.

PURPOSE OF THE STUDY: The growing numbers of anterior cruciate ligament (ACL) reconstructions performed by an increasing number of surgeons have resulted in an increased number of failed reconstructed ligaments. For repeat surgery, autologous tissues are most frequently used, namely BTB graft, hamstring tendons or quadriceps tendon construct. However, these alternative methods have certain disadvantages and therefore we decided to use BTB allografts from cadaverous donors. The risk of disease transmission due to allograft implantation has been reported to be low, but a thorough serological screening of donors is the prerequisite. We used BTB allografts first in revision ACL surgery only, but because of good results we started using theme for reconstruction of both cruciate ligaments and, in some cases, also for primary reconstruction. MATERIAL: In the period from 2002 to 2004, patellar ligaments harvested from 23 cadaverous donors were used at the orthopedic ward of the Ceské Budejovice hospital to prepare 87 BTB grafts, of which 42 were implanted. In 57 % of the procedures, an allograft was used in revision surgery carried out for the failure of a ;previously reconstructed ACL in 10 % it was used in complete reconstruction of both cruciate ligaments, and in 14 % it was used for primary ACL reconstruction in indicated cases. In 19 % of the cases, allograft was used when autologous graft failed or was damaged during the primary operation. METHODS: Graft harvesting, storage, handling and implantation have been carried out in accordance with the practices included in Act no. 285/2002 Coll. Serological examination of the donors and bacteriological assays of the grafts were performed according to the current regulations. The implantation of BTB allografts in ACL reconstruction was carried out by the standard method used in reconstructive procedures. RESULTS: Out of 87 BTB allografts prepared, 16 were discarded because of positive culture findings. Two allografts could not be used because the screening was positive for CMV infection. No infectious complications, poor healing or a systemic response to the allograft implanted were recorded in any of the patients. DISCUSSION: The use of allografts is a method suitable for revision surgery in failed ACL reconstruction. It allows us to avoid further weakening of the structures associated with the knee joint. The size of allograft bony blocks permits treatment of defects in the tibial or the femoral tunnel. CONCLUSIONS: The use of a BTB allograft is a reliable and safe procedure. It has advantages not only in revision ACL reconstruction, but also in reconstruction of both cruciate ligaments. Also primary ACL reconstruction in indicated cases achieved good results.

[BTB allograft for revision surgery of the anterior cruciate ligament - part 2]. / Reoperace predního zkrízeného vazu kadaverózním B-T-B stepem - Cást 2.

PURPOSE OF THE STUDY: The study evaluates our experience with revision anterior cruciate ligament (ACL) surgery, with emphasis placed on the use of allografts. MATERIAL: In the 2002-2004 period, 421 reconstructions of the anterior cruciate ligament, using patellar BTB or hamstring tendon autografts, were carried out in our orthopedic ward. In the same period we performed 24 revision ACL reconstructions (6 %) with BTB allografts; 19 were in men and five in women. Revision surgery after ACL reconstruction with a BTB graft fixed with a non-absorbable interference screw and with a hamstring tendon graft was performed in 18 and 5 patients, respectively. METHODS: We distinguish four steps in the revision procedure: 1) diagnosis and analysis of the ACL reconstruction failure; 2) preoperative planning and surgery timing (one- or two-stage procedure, graft type, fixation method); 3) operative procedure; 4) postoperative care including rehabilitation. Revision surgery is indicated on the basis of subjective complaints (instability), and the results of clinical examination (Lachman's and pivot-shift tests) and imaging methods (X-ray, MRI, arthroscopy). Causes of failure are categorized as 1) traumatic (major trauma, too early weight-bearing, minor trauma due to rehabilitation); 2) surgery-related (erroneous position of the tibial and/or femoral tunnels, insufficient tensioning of the graft and its insufficient fixation); 3) biological (poor ;graft incorporation and restructuring, infection); and 4) combination of all previous causes. Errors in tunnel position are differentiated according to the part of the tunnel (tibial, femoral or both) tunnel direction (ventral, dorsal, lateral or medial) and the degree of malposition (mild, moderate or serious). We perform one-stage surgery when the position of tunnels is correct, with the exception of revision due to infection, and in all malpositions but for a dorsally positioned tibial tunnel. In a moderate degree of femoral tunnel ventral malposition, we make decisions individually. A two-stage procedure consists of removal of the failed graft and fixation material and spongioplasty followed by revision surgery. The results of revision reconstruction greatly depend on a correct isometric position. We extend the tunnel, if it is in a mild-degree malposition, and create a new, smaller tunnel, if the malposition is severe. Fixation, with either the Rigidfix system or interference screws, is also selected according to the direction and degree of malposition. In the last 3 years, we used exclusively grafts harvested from cadavers. RESULTS: In the group of 24 patients undergoing revision ACL reconstruction, the right knee was treated in 13. The previous ACL reconstruction was done with BTB grafts in 18 patients, with hamstring tendons in 5 patients and one patient underwent reconstruction by Harnach's method in an outside institution. The average time between the primary reconstruction and revision surgery was 27 months (range, 4 to 169 months). We found a surgery-associated error in 12 cases. poor graft restructuring in 3 and involvement of traumatic etiology in 11 cases. One patient underwent revision surgery because of infection. We used one-stage procedures in 20 patients and two-stage procedures in four patients. We fixed the graft with femoral interference screws and the Rigidfix system in 17 and 7 patients, respectively, and with tibial interference screws in 23 patients (absorbable screw completed with cancellous screw in one patient). Only in one patient did we use the tibial Rigidfix system. The average follow-up was 16 months. No infection, thromboembolic disease or synovialitis were recorded. One patient experienced a recurrent failure of the graft and one patient was treated for the Cyclops lesion. The average Lysholm scores were 78.25 (range, 48-97); 87.5 % of the patients were satisfied with the results and the same proportion of patients would undergo the surgery again. The overall results appeared poorer due to the patients in whom revision ACL reconstruction was performed on arthritic joints. DISCUSSION: The outcomes of revision surgery are worse than those in primary reconstruction. We regard allografts with massive bony blocks, adjusted as required, as an optimal method. The risk of disease transmission is low, operative time is shorter, incision is smaller and further trauma to the treated or the other, healthy knee due to graft harvest is avoided. Only patients without signs of gonarthrosis who have motivation are indicated for revision surgery, because they can be expected to cooperate well in the postoperative period. CONCLUSIONS: Revision ACL surgery should be performed by surgical teams with sufficient experience in this field. The crucial point is the analysis of ACL reconstruction failure with further procedure planning. The use of BTB allografts from the local tissue bank proved efficient in our hospital. In the hands of experienced surgeons, allograft offer great prospects for ACL reconstruction with good outcome.

[Reconstruction of the anterior cruciate ligament: comparison of patellar bone-tendon-bone and hamstring tendon graft methods. Part 1. Evaluation of patients treated by the patellar bone-tendon-bone graft technique]. / Rekonstrukce predního zkrízeného vazu: srovnání metod B-T-B a slachami hamstringu. Cást 1: Rekonstrukce predního zkrízeného vazu B-T-B technikou--hodnocení naseho souboru.

PURPOSE OF THE STUDY: Reconstruction of the anterior cruciate ligament (ACL) by means of a patellar bone-tendon-bone (B-T-B) graft is currently one of the most frequent arthroscopic procedures. Progress in alternative techniques, particularly the use of hamstring tendon grafts and different methods for graft anchorage, was the reason for evaluation of our group of patients. The results were assessed at 18 months of follow-up. MATERIAL: We evaluated 137 surgically treated knees in 136 patients, 20 female and 117 male, on the basis of the Lysholm score system completed with a clinical examination of knee joint stability by Lachman's test and the pivot shift test and the ability of assuming a squatting position. We completed the evaluation with the patient's report on their satisfaction with the outcome and willingness to undergo the surgery again in the case of the other knee instability. METHODS: We carried out surgery under general anesthesia with the extremity in flexion and application of a tourniquet. Arthroscopy is performed from the anterolateral portal and graft is harvested, though a longitudinal incision, from the middle third of the patellar ligament and with the bony blocks from the patella and tibial tubercle. The graft width is 9 to 10 mm. Tibial or femoral tunnels are drilled by means of a tibial of femoral reamer and the inserted graft is fixed with metal interference screws. Cefazolinum with low-molecular heparin is administered during surgery. Rehabilitation of the extremity on a continuous passive motion (CPM) device begins on the first day. Full weight-bearing is allowed from the sixth week. RESULTS: The average Lysholm score of the group was 86.9. Excellent, good and satisfactory outcomes were achieved in 46.38%, 23.91% and 14.49% of the knees, respectively; 14.49% showed poor outcomes. Satisfaction with the outcome of surgery was reported by 90.5% of the patients, 75.18% complained of problems with knee-bend and pain at the donor site and scar. DISCUSSION The results of our evaluation are similar to those reported in the relevant literature. There are no differences in Lysholm scores from literature data or from the results recorded in a group of patients operated on with the use of the Rigidfix system and hamstring tendon grafts, in whom the average score was 84.3. The patients treated by the B-T-B technique, however, experience more problems at the graft harvest site, with subsequent femoropatellar complaints. CONCLUSIONS: ACL reconstruction with a patellar B-T-B graft is a surgical technique which resolves the patient's existing complaints due to knee instability, but may also have a preventive effect. This technique is suitable for sportsmen and sportswomen. Because of frequent postoperative complaints of pain at the donor site, it is not indicated for persons with femoropatellar problems, elderly persons and those who have kneeling jobs.

[Reconstruction of the anterior cruciate ligament: comparison of patellar bone-tendon-bone and hamstring tendon graft methods. Part 2. Short-term evaluation of the hamstring tendon graft technique with use of the Rigidfix system]. / Rekonstrukce predního zkrízeného vazu: srovnání metod B-T-B a slachami hamstringu. Cást 2: Rekonstrukce predního zkrízeného vazu--hamstringy--Rigidfix.

PURPOSE OF THE STUDY: The high number of patients with femoropatellar complaints following ACL reconstruction with bone-tendon-bone (B-T-B) autograft led us to use and subsequently evaluate hamstring tendon grafts fixed with the Rigidfix system. In this study we present the evaluation of short-term results. MATERIAL: We evaluated 85 patients (51 male and 34 female) at an average follow-up of 14 months. The average age of the group was 29.7 years (range, 16 to 59 years). In 46 patients we treated the right knee and in 39 patients the left knee. Fifty-five patients in this group also had an associated injury to the soft knee tissues. For reconstruction, a semitendinosus tendon graft was used in 56 knees and a semitendinosus-gracilis tendon graft in 29 patients. METHODS: The operation was carried out with tourniquet application to the extremity in a flexed position. The tendon of the semitendinosus muscle was harvested through an oblique incision and, in some cases, when its width and length was not sufficient for graft construction, the gracilis muscle tendon was harvested too. The graft, at least 75 mm by 8 mm in size, was prepared on a graft board. After having drilled the both tunnels, the femoral Rigidfix reamer was inserted in a routine manner and protective sleeves for Rigidfix cross pins were introduced. With the extremity in semiflexion, the inserted graft was fixed to the cortical bone by absorbable cross pins on the femur and absorbable interference screws on the tibia. The postoperative treatment involved procedures as in the B-T-B technique. RESULTS: The group was evaluated by the Lysholm score system, with an average of 84.3 scores achieved. The men showed better outcomes than women, i. e., 85.7 and 81.4, respectively. The scores in the patients with a single tendon did not differ significantly from the patients with a combined tendon (semitendinosus, 83.2 vs. semitendinosus-gracilis, 84.2), nor did they greatly differ between the patients with injury to ACL alone and those with ACL and associated soft tissue injuries (ACL, 83.9 vs. ACL+ associated injury, 85.5). Most of the patients (94 %) were satisfied with the outcome of treatment. The complications involved thrombosis of the operated lower extremity in three patients and repeat surgery for hematoma in two patients. Knee instability was found in five patients. One graft failed to restructure and incorporate, in two knee tunnels were incorrectly centered and two grafts ruptured due to trauma. Three of these patients underwent repeat surgery. DISCUSSION: Our results, as evaluated by the Lysholm score system, were in agreement with those of other authors. We did not find any difference in knee stability between the patients treated by the hamstring tendon technique and those undergoing reconstruction with a patellar B-T-B autograft. However, the patients with hamstring tendon reconstruction reported a considerably lower number of femoropatellar problems. CONCLUSIONS: ACL reconstruction with a hamstring tendon autograft fixed with the Rigidfix system is a suitable alternative technique to ACL reconstruction carried out with a patellar B-T-B graft. It provides equal knee stability but has significantly lower donor site morbidity. It is suitable for patients who have contraindications for the B-T-B technique and in persons practicing little or no sports.