[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.

[Anatomical ACL reconstruction by a double- versus a single-bundle technique. Prospective randomised study of short-term clinical results]. / Anatomická rekonstrukce LCA double- versus single-bundle technikou - zhodnocení krátkodobých klinických výsledku prospektivní randomizované studie.

PURPOSE OF THE STUDY: The aim of the study is to present a comparison of short-term results of double- versus single-bundle anatomical reconstruction of the anterior cruciate ligament (ACL) using hamstring endons and their fixation with absorbable interference screws. MATERIAL AND METHODS: A total of 110 patients with an isolated ACL lesion and the healthy contralateral knee who met the indication criteria for ACL double bundle reconstruction (TISL, 14 mm; ICNW, 12 mm) were intra-operatively allocated at random to either double-bundle group (DB, n=55) or single-bundle group (SB, n=55). At 12 months after surgery, 97 patients (DB group, n=49; SB group, n=48), comprising 68 men and 29 women, were evaluated; the average age was 29.1 years and the injury-to-surgery interval was 15.9 weeks. Pre- and post-operative subjective criteria involved the IKDC and Lysholm score. Objectively, the occurrence of graft failure, range of motion deficit, return to pre-injury sports activity, side-to-side difference in anterior laxity of both knees in 20° flexion on a GNRB laximeter at an applied pressure of 124 N and 250 N, and pivot shift phenomenon were assessed. RESULTS: No statistically significant difference was found in pre-operative values between the two groups. Post-operatively, there were no significant differences in the occurrence of complete graft failure (p=0.0755; DB group, n=0; SB group, n=3), range-of-motion deficit (p=0.2277-0.9788) or return to pre-operative sports activity (p=0.2322). In the DB group, side-to-side anterior tibial shifts at a pressure of 124 N (medians=1.3 mm and 2.1 mm for DB and SB groups, respectively; p=0.0007) and at a pressure of 250 N (DB group =2.1 mm; SB group = 3.1 mm; p<0.0001) were significantly different from the corresponding values in the SB group. Positive results for the pivot shift test (PST) were significantly less frequent in the DB than the SB group (Chi-square test =0.0112). The SB group patients had a 2.9-times (odds ratio, 2.8704) higher risk of positive postoperative PST results than the DB group patients. In both groups, a comparison of pre- and post-operative criteria showed significant improvement in both the subjective and the objective results. DISCUSSION: The results of this study, in accordance with other authors' conclusions, suggest that the double-bundle technique provides better control over rotational and anterior knee laxity and therefore restores knee biomechanics better. However, other literature data do not confirm any significantly better outcomes of this method. Since only short-term results have been obtained so far, the study will continue because only the long-term results can provide conclusive evidence of an advantage of one technique over the other. CONCLUSIONS: Our study showed significantly better restoration of knee rotational and anterior laxity in the patients undergoing anatomical reconstruction of the ACL by the double-bundle technique. The other evaluated criteria did not differ in relation to the technique used.

[Arthroscopic transcapsular iliopsoas tenotomy from the peripheral versus the central compartment in internal snapping hip syndrome. Short-term results of a prospective randomised study]. / Artroskopická transkapsulární tenotomie iliopsoatu u vnitrního typu syndromu lupavé kycle z periferního versus centrálního kompartementu: krátkodobé výsledky prospektivní randomizované studie.

PURPOSE OF THE STUDY: In this prospective randomised study, the short-term results of arthroscopic transcapsular iliopsoas tenotomy approached from the peripheral versus the central compartment for internal snapping hip syndrome are presented. MATERIAL AND METHODS: A group of 19 patients (15 women and four men; mean age, 24.3 years) who underwent arthroscopic transcapsular iliopsoas tenotomy for internal snapping hip syndrome in the period between September 2010 and December 2011 were prospectively evaluated. No injury, hip surgery or feeling of hip instability was recorded in their personal histories. Radiographs did not show any dysplasia, retroversion of the acetabulum or cam lesions. The patients were allocated to two groups using sealed envelope randomisation: Group 1 patients (n=10) were treated by tenotomy from the peripheral compartment and group 2 patients (n=9) underwent tenotomy from the central compartment during traction of the lower extremity. The evaluation included pre-operative 3T MRI findings, arthroscopically detected intra-articular lesions, duration of traction and post-operative complications. The pre-operative WOMAC scores were compared with those at one-year follow-up. In comparison of the two groups, the Mann-Whitney exact test was used for WOMAC scores and Fisher's exact test for post-operative complications. Statistical significance was set at a 0.05 level. RESULTS: In comparing post-operative complications, a significant difference (p=0.0468) between the groups was found only for genital paresthesia, which did not occur in group 1. The other differences were not statistically significant. The pre-operative WOMAC scores did not differ significantly between the groups (p=0.79). The post-operative WOMAC scores were significantly higher in group 1 (p=0.02). In each group the change in WOMAC scores was different and was statistically significant in group 1 (p=0.0014). Associated intra-articular hip pathologies, most frequently synovitis of the peripheral compartment, acetabular chondropathy, or labral lesions, were diagnosed in 90% of group 1 patients and in 66.7% of group 2 patients. DISCUSSION: Most of the authors comparing the results of two different ilioproas tenotomy techniques at one-year follow-up did not report any statistically significant differences in WOMAC scores between them. In accordance with the data reported, an increase in the post-operative WOMAC score, i.e., improvement of clinical outcome, was achieved in all our patients and, in group 1, it was significantly higher (p=0.0015), as compared with a similar study by Ilizaliturri. However, further follow-up of the patients and evaluation of long-term results will be necessary. CONCLUSIONS: The technique of arthroscopic ilioproas tenotomy approached from the peripheral compartment resulted in significantly fewer cases of genital paresthesia and provided significantly better clinical outcomes in comparison with tenotomy from the central compartment.

[Evaluation of the clinical results in patients with symptomatic partial tears of the anterior cruciate ligament diagnosed arthroscopically]. / Zhodnocení klinických nálezu u pacientu s artroskopicky prokázanou symptomatickou parciální rupturou predního zkrízeného vazu.

PURPOSE OF THE STUDY: The study presents a retrospective evaluation of clinical data and arthroscopic findings in a group of our patients with symptomatic knee instability due to a partial tear of the anterior cruciate ligament (ACL). MATERIAL AND METHODS: The group included 31 patients diagnosed with symptomatic partial ACL tears, i.e. an isolated tear of the posterolateral (PL) or the anteromedial (AM) bundle. The patients' average age was 26.5 years. A side-to-side difference in ventral knee laxity was assessed using the anterior drawer test and the Lachman test under general anaesthesia before arthroscopy was commenced; rotational knee laxity was evaluated by the pivot shift test. An objective evaluation of side-to-side ventral laxity differences in both knees was performed on the GNRB® arthrometer with an applied pressure of 134 N and 250 N in the conscious patient. During arthroscopic examination, findings on the two ACL bundles were recorded. RESULTS: All 31 patients were diagnosed with symptomatic partial ACL tears, of them 22 had a PL bundle lesion and nine had an AM bundle tear. All patients with PL bundle lesions only reported problems in association with pivot sports, and all patients with AM bundle tears had problems regardless of any sports activities. In all patients with isolated AM bundle tears, the lesion was located close to its femoral attachment. In the patients with PL bundle tears, femoral location was found in 68% and tibial location in 32% of the patients. In the patients with partial PL bundle lesions, + and ++ results in the pivot shift test were recorded in 32% and 68% of the treated patients, respectively. The Lachman test showed + and ++ results in 71% and 9% of the patients, respectively. The anterior drawer test had negative results in 87% and positive + results in 13% of the patients. The side-to-side difference on the GNRB arthrometer ranged from 0.4 to 2.3 mm at a pressure of 134 N and from 1.2 to 4.2 mm at 250 N in the patients with isolated PL bundle lesions. In the patients with AM bundle lesions, the results were as follows: pivot shift test, 89% negative. 11% positive +; Lachman test, 56% negative, 44% positive +; anterior drawer test, 89% +, 11% ++; GNRB test, 2.2 to 4.4 mm at 134 N, and 4.3 to 7.1 at 250 N. DISCUSSION: The diagnosis of partial ACL lesions, i.e., isolated tears of the AM or the PL bundle, requires accurate knowledge of knee anatomy and its biomechanics. In accordance with other authors our results showed that an arthroscopic examination of both bundles of the ligament as well as knee laxity evaluation under general anaesthesia are most essential for making the definite diagnosis in partial ACL tears. They also confirmed that, in isolated AM bundle lesions, ventral laxity is present more often particularly at a higher degree of knee flexion while, in PL bundle lesions, rotational laxity is more frequent and ranges from 0 to 30 degrees of knee flexion. CONCLUSIONS: To make the definite diagnosis of partial ACL tears, patient medical history, clinical knee examination including instability type and degree assessment under general anaesthesia and, most importantly, arthroscopic findings on both ACL bundles are necessary.

[Comparison of patellar pain after total knee arthroplasty with conventional versus individual femoral rotational alignment]. / Srovnání výskytu patelární bolesti po aloplastice kolenního kloubu u konvencne nebo individuálne nastavené rotace femorální komponenty.

PURPOSE OF THE STUDY: The aim of the study was to find out whether the frequency and intensity of patellar pain can be affected by individual rotational alignment of the femoral component in total knee arthroplasty, as compared with the standard 3 degrees of external femoral rotation in conventional procedures. MATERIAL AND METHODS: In randomly selected patients treated for knee osteoarthritis by total joint replacement between January 2007 and January 2011, the occurrence of patellar pain was assessed. The evaluated knees were allocated to two groups. Group 1 included 350 knee joints with conventional femoral rotational alignment, i.e., 3 degrees of external rotation. Group 2 comprised 380 knee joints with an individual rotational alignment of the femoral component based on the condylar twist angle. Post-operative anterior knee pain was assessed on the following scale: 1, no pain; 2, occasional mild pain; 3, moderate pain; 4, severe pain. RESULTS: In group 1, 312 knee joints were free from pain, 15 occasionally experienced mild pain, 15 had moderate and eight had severe pain. A total of 23 revision operations were performed for patellar pain at the anterior knee and pain around the patella refractory to non-steroidal anti-rheumatic and rehabilitation therapy. In group 2, there were 331 pain-free knees, 48 with occasional mild pain, one with moderate pain and no knee with severe pain. No revision surgery was required. One patient with moderate patellar pain underwent surgery for spinal canal stenosis; after that knee pain was only mild. The groups were compared, as to pain assessment results, using the test of equality of relative frequencies, i.e., score categories 1+2 versus 3+4 of 350 (group 1) equalled 23 (6.57%) were compared with 1 (0.26%) of 380 (group 2); the difference was significant (p < 0.001). Using the same test for comparison of the frequency of repeat operations, i.e., 23 (0.57%) of 350 (group 1) versus 0 (0%) of 380 (group 2), also gave a significant result (p = 0.001). DISCUSSION: Mild and occasional pain was recorded in both groups, suggesting that femoral component malrotation is not the only cause of patellar pain following total knee arthroplasty. A markedly lower incidence of moderate and severe pain and no need for revision surgery found in group 2 provides evidence that the use of individual rotational alignment of the femoral component is fully justified. CONCLUSIONS: An individual rotational alignment of the femoral component can significantly reduce the incidence of moderate to severe patellar pain or even need for revision surgery.

[Comparison and statistical evaluation of two methods of condylar twist angle measurement in total knee arthroplasty]. / Komparace a statistické zhodnocení dvou metod merení "condylar twist angle" u aloplastiky kolenního kloubu.

PURPOSE OF THE STUDY: The aim of this prospective randomised study was to compare and statistically analyse two methods of condylar twist angle (CTA) measurement in total knee arthroplasty in order to assess their applicability in routine practice. MATERIAL AND METHODS: The study included 238 patients with 256 sites undergoing total knee arthroplasty (TKA) in the period from January 2009 to May 2011. There were 93 men (nine with bilateral TKA) and 145 women (nine with bilateral TKA) with an average age of 69.3 years and a range of 47 to 88 years. The implants NexGen (Zimmer) and ADVANCE® Medial-Pivot Knee (Wright) were used. In each patient, CTA was measured before surgery by the radiologist on a multidetector CT SOMATOM 64 (Siemens) using the Yoshioki method. The other CTA measurement was made intra-operatively by the surgeon using our modification of the Hofmann method which involved the identification of a reference line for optimal rotational alignment of the femoral component. A STATISTICA 9.0 software package was used for statistical analysis. In addition to basic statistical data, selected data were presented in graphical forms as Box and Whisker's plots and histograms. Changes in CTA and differences between the groups were evaluated using the Wilcoxon signed-rank test. Relationships among the variables were studied using Spearman's correlation coefficient. RESULTS: The statistical analysis showed that the pre-operative CTA value obtained from CT scans was, on the average, higher by 0.5 degrees than the value from intra-operative measurement, as assessed at the level of significance p = 0.001 (signed- rank test). The intra-individual variability was lower than the inter-individual one (14.4% and 30.8%, respectively). This means that both methods are suitable for CTA measurement in the knee joint replacement procedures. Spearman's correlation coefficient was 0.6, which is the value of medium strong correlation. The post-operative CTA assessed on CT scans was in the range of 0 to 2 degrees in 87.5% of the patients. Both the pre-operative and intra-operative CTA values were significantly higher in women than in men (Wilcoxon two-sample test). There was no statistical difference between the left and the right side. DISCUSSION: Malrotation of the femoral component is one of the causes leading to patellar subluxation and pain in the front part of the knee. The post-operative CTA value should be zero. Optimal rotational alignment of the femoral component varies with each patient; in our study it was found in the range of 0 to 7 degrees on the basis of CTA values. We do not recommend 7 degrees of external rotation to be exceeded because of the risk associated with balancing the flexion gaps; nor do we recommend to set internal rotation of the femoral component for the risk of patellar complications. The difference of 0.5 degree found in the CTA value between the two measuring methods can be explained by individual differences in the anatomy of the medial epicondylar region, and by the use of only selected whole numbers (0, 3, 5, 7) in intra-operative measurements. This difference does not play any role in routine surgical procedures. CONCLUSIONS: The statistical evaluation of the results of CTA measurement with the two methods showed that both were equally suitable for routine total knee arthroplasty. The results of intra-operative CTA measurements are comparable with those obtained on CT scans; in addition, the intra-operative method is less expensive and eliminates exposure of the patient to radiation. CT-based CTA measurements are useful in the patients with chronic problems after TKA in whom femoral component malrotation needs to be either confirmed or ruled out.

[Inveterate dislocation fracture of the sternoclavicular joint]. / "Inveterovaná" luxacní zlomenina sternoklavikulárního kloubu

We present the case report of a 21-year-old man with a late diagnosis of retrosternal dislocation of the sternoclavicular joint with a fractured sternal end of the clavicle. The first symptom leading to the diagnosis was dysphagia associated with physical activity. The diagnosis was based on computed tomography examination. In the first place, the fragment of the medial clavicular end was fixed with two screws. During surgery the sternoclavicular joint was wrongly identified; this fact was revealed by the following radiographic examination. On revision surgery, the sternoclaviculr ligament was reconstructed using a semitendinosus tendon graft. The reconstructed ligament was augmented with two Orthocord sutures running between the clavicle and the first rib. At 2 years after surgery the functional outcome and sternoclavicular joint stability were excellent.

[Primary Pyomyositis of the muscles around the hip. case reports and literature review]. / Primární pyomyozitida svalu v oblasti kycelního kloubu: kazuistiky a prehled literatury.

The authors present three case reports of primary pyomyositis, a severe but rare disorder involving the muscles around the hip. In three boys, with an average age of 16 years, the disease developed suddenly in association with strenuous sporting activities. The boys had fever, pain and restricted motion at hip joints, haemoculture tests positive for Staphylococcus aureus and the presence of inflammatory markers. Magnetic resonance findings showed infiltrates and abscesses in the muscles around the hip. X-ray and computed tomography (CT) examination of the pelvis revealed bone irregularities near the pubic symphysis due to repeated avulsion injury to the medial group of the thigh muscles in two boys, and a fresh avulsion of the anterior inferior iliac spine in one boy. This patient developed reactive synovitis of the hip and iliopectineal bursitis. All three patients received intravenous antibiotic therapy, first with broad-spectrum and then with specific anti-staphylococcus antibiotics, for 2 to 3 months. Repeated puncture and drainage of the abscesses under CT guidance was performed in one patient; repeated surgery with abscess removal was necessary in two patients. The early diagnosis and combined conservative and surgical treatment prevented development of the third, septic stage of this disease which is commonly associated with serious complications.

[Anatomical double-bundle anterior cruciate ligament reconstruction - transtibial versus anteromedial reaming of femoral tunnels]. / Anatomická rekonstrukce predního zkrízeného vazu double bundle technikou - moznosti cílení femorálních kanálu

PURPOSE OF THE STUDY: The aim of the study was to compare two options of how to get the correct anatomical position of both femoral tunnels, using the transtibial or the anteromedial portal technique, during anatomical double-bundle anterior cruciate ligament (ACL) reconstruction. MATERIAL AND METHODS: A total of 36 patients, 29 men and seven women, underwent double-bundle ACL reconstruction between October 2009 and December 2010. Their average age was 26.5 years. The average interval between ACL injury and reconstruction was 7.4 months. A diagnostic arthroscopy for the treatment of cartilage and meniscal lesions was performed in 21 patients and one-stage ACL reconstruction with diagnostic arthroscopy was carried out in the remaining 15 patients. In all 36 patients, the position of the tip of the guide wire in relation to the anatomical insertion sites of both the anteromedial (AM) and posterolateral (PL) bundles was assessed intra-operatively. Three guide wire positions were found: the tip was in the centre of the native insertion site, the tip was within the insertion site but not in its centre, and the tip was outside the insertion site. RESULTS: Using the transtibial technique through the AM tunnels, the tip of the guide wire was centred within the femoral AM insertion site only in one patient (2.8%), out of the centre but within the AM insertion site in four patients (11.1%) and outside the insertion site in the remaining 31 patients (86.1%). With this technique, the position of the femoral PL tunnels was outside the native PL insertion site in all 36 patients. With the transtibial technique using the PL tunnels, the tip of the guide wire was centred within the femoral AM native insertion in 11 patients (30.5%), out of the centre but still within the AM insertion site in 16 (44.5%) and outside the AM insertion site in nine patients (25%). Aiming for the femoral PL tunnel resulted in the tip of the guide wire being outside the native femoral PL insertion site in all cases. Using the technique of guide wire insertion through an accessory AM portal it was possible to achieve the centres of both the AM and PL native anatomical insertion sites in all 36 patients (100%). DISCUSSION: We agree with the many authors who recommend the reaming of PL femoral tunnels through an accessory AM portal because the transtibial technique does not allow for the placement of their precise native anatomical positions. Our intraoperative findings showed that the transtibial technique was effective to get the correct anatomical position of AM femoral tunnels just in 30.5% of the patients. In view of the fact that the same results can be achieved with the AM transportal technique in 100% of the patients, we prefer this technique in accordance with the majority of other authors. CONCLUSIONS: In anatomical double-bundle ACL reconstruction, the native anatomical position of PL tunnels was achieved in all patients and the native AM tunnels in most of them using the accessory AM portal technique. The transtibial technique proved to be unsatisfactory.

[Arthroscopic stabilisation of post-traumatic ventral instability of the shoulder by use of bioknotless anchors]. / Artroskopická stabilizace ventrální posttraumatické instability ramenního kloubu pomocí bioknotless kotev.

PURPOSE OF THE STUDY: Post-traumatic ventral shoulder instability is a frequent disorder resulting from ventral and caudal dislocation of the humeral head. The aim of this retrospective study is to evaluate the long-term results of arthroscopy-assisted reinsertion of the ventral labrum using absorbable bioknotless suture anchors. MATERIAL AND METHODS: A group of 129 patients with unidirectional ventral instability of the shoulder was evaluated for the results of treatment involving labrum reinsertion with use of absorbable bioknotless anchors. This arthroscopy-assisted method is performed from two minimal incisions, with the patient in a beach-chair position. The shoulder rating scale of Rowe and Zarins was used to compare the pre-operative status with the treatment outcomes during follow-up ranging from 12 months to 5 years. RESULTS: Return to the pre-injury level of activities was recorded in 93.8 % of the patients. The methods failed and dislocation recurred in 4.6 % of the patients. These underwent repeat surgery with the same technique and implants. DISCUSSION: Arthroscopy-assisted stabilisation of the shoulder is a minimally invasive technique allowing for anatomically exact and complete treatment of traumatic injury to the intra-articular structures. It results in faster convalescence and provides better results than open methods. It requires short hospital stay and is performed as one-day surgery in our department; consequently, the costs of care for one patient are reduced. The use of absorbable suture anchors permits reimplantation of other anchors, either when suture material at primary stabilisation fails or at a potential repeat operation. The cosmetic effect of only two minimal incisions also plays a role. CONCLUSIONS Arthroscopic labrum repair with absorbable knotless anchors is, after a perfect mastering of the surgical technique, an effective treatment and, based on the results achieved, also the method of choice used at our department for managing labral lesions caused by traumatic unidirectional instability of the glenohumeral joint.

[Total knee arthroplasty in severe valgus deformity in a patient with achondroplasia]. / Aloplastika kolenního kloubu totální endoprotézou u tezké valgózní deformity pri achondroplazii.

The authors present the results of total knee replacement in a 66-year-old woman with achondroplasia. The condition was diagnosed on the basis of clinical and radiographic findings; molecular genetic examination confirmed that the patient was heterozygous for the G1138A mutation responsible for substitution of an arginine for a glycine residue at position 380 (G380R). The patient presented with an unusual finding of severe fixed 20-degree valgus deformity, so far not published, which did not conform with the clinical features of achondroplasia. The authors presumed that the deformity had developed due to asymmetric growth of the distal femoral diaphysis resulting in a hypoplastic lateral femoral condyle and, consequently, valgus deformity. They put emphasis on thorough pre-operative radiography in order to define the size of components according to the templates, and on measurement of the valgus angle and femoral mechanical axis. They also drew attention to the problem of an extra-articular tibial alignment guide and recommended the use of its alternative or computer navigation. The surgery restored the mechanical axis, range of motion and stability of the knee, relieved pain and improved walking, which afforded a better quality of life for the patient.

[Comprehensive diagnosis of infection in revision total replacements of large joints]. / Komplexní diagnostika infekce u revizních operací totálních endoprotéz velkých kloubu

PURPOSE OF THE STUDY: To make comprehensive diagnoses of the infections associated with revision total knee and hip arthroplasties in our group of patients MATERIAL AND METHODS: From September 2002 till November 2004, a group of 69 patients undergoing revision total joint replacement (65 hips and four knees) were evaluated. The period between primary and revision surgery ranged from 6 months to 25 years. The patients were examined for CRP, erythrocyte sedimentation rate (ESR) and white blood cell (WBC) counts. The samples of their periprosthetic tissue were assessed for biopsy and microbial findings. The removed prosthetic components were sonicated.The samples were cultured in both aerobic and anaerobic conditions for 16 days. A finding of more than 10 neutrophils per viewing field was taken as a positive biopsy result. The definition of an infection was based on the detection of a microorganism with the identical phenotype in two or more samples. RESULTS: Before surgery, 13 patients had a suspected infection which was subsequently diagnosed. A positive culture result in at least one of the collected samples was found in 48 patients; of these, a positive culture finding of a phenotypically identical microorganism in two or three samples was in 32 patients, who thus met the definition of infection. The average values for the whole group were: CRP, 16 mg/L (1-109); ESR, 25 mm/h (3-110); peripheral WBC count, 6.2 x 109/L (3.6-11.6). The microorganisms most frequently growing in culture were coagulase-negative staphylococci and propionibacteria accounting for 41% and 29% of the total isolates obtained, respectively. From the total number of samples, positive culture results were obtained in 36% of sonicate femoral components; 40% of sonicate acetabular cups, 51% of periprosthetic tissues and 48% of swabs. In these positive microbial cultures strictly anaerobic microorganisms were found in 41% of femoral component, 49% acetabular component and 42% periprosthetic tissue samples and in 27% of swabs taken at arthrotomy. Prolonged cultivation of the 151 isolates initially obtained yielded 81 (54%) isolates which would have failed to be detected by primary culture. The results of laboratory tests in the patients with negative culture findings, in those with a phenotypically identical micro- organism found in one sample, and in those with positive findings in two or more samples were: CRP, 4.3 mg/L; 9.8 mg/L; and 21.7 mg/L, respectively; ERS, 13.5mm/h; 20.1 mm/h; and 33.0 mm/h, respectively; and WBC counts, 6.27 x 109/L; 6.25 x 109/L; and 6.16 x 109/L, respectively. The t-test was used for the statistical analysis of CRP, ESR and WBC count values, and it revealed a significant differences between the patients with negative microbial findings and those with positive microbial findings in two and more samples in all three values, i.e., CRP (p = 0.01), ESR (p = 0.01) and WBCs (p = 0.96). Biopsy findings showed a sensitivity of 62.5 % and a specificity of 91% in relation to the microbial findings. DISCUSSION: Our results as well as relevant literature data suggest that microorganisms may survive on implant surfaces even in the cases regarded as aseptic. They often grow slowly and, theoretically, can have an adverse effect on the longevity of revision arthroplasty. However, because of current endoprosthetic practices and the ubiquitous presence of microorganisms, contamination of some samples cannot be excluded. CONCLUSIONS: In our group of patients, the CRP and ESR values proved to be useful in making the diagnosis of infection. For this pur- pose, WBC counts in blood samples were not sensitive enough. Biopsy findings had low sensitivity, but appeared to be a specific marker of infection. Prolonged cultivations of samples and cultivation under anaerobic conditions resulted in a marked increase in isolates obtained, as compared with the routine cultivation technique.

[Radiographic measurements in total knee arthroplasty and their role in clinical practice]. / Radiologická merení u aloplastiky kolenního kloubu a jejich význam pro praxi.

PURPOSE OF THE STUDY: The aim of the study was to present the use of digital sciagraphy and computed tomography for pre- and post-operative measurements in total knee arthroplasty. The authors were interested, in the first place, in the optimal adjustment of femoral component rotation and a valgus angle if extra-articular deformities of the femur and/or the tibia were present. MATERIAL AND METHODS: Digital sciagraphic examination was carried out on an AXIOM ARISTOS (Siemens) apparatus using the software designed by us. In group 1 comprising 269 knee joints, in a standing and weight-bearing position with lower extremity neutral rotation, the valgus angle was measured and the entry point for the intramedullary rod of a femoral cutting block was deter- mined. Subsequently, the mechanical axis and extra-articular deformities of the femur and/or the tibia were found and the patella position in 30-degree flexion of the knee joint was assessed on axial images. Based on radiographic evaluation, relevant treatment for different types of disorders, including extra-articular deformity, was proposed. In group 2 consisting of 204 knee joints, the values of a condylar twist angle were measured on axial sections, using a Siemens Somatom Sensation 64 CT Scaner.The method of condylar twist angle measurement was developed and the values for men and women were obtained. RESULTS: In group 1, the mean values obtained for valgus knee deformity were: valgus angle, 5.4°; median, 5.5°; modus, 6.0°. Those for varus knee deformity were: valgus angle, 7.2°; median, 7.0; modus, 7.0. A normal knee joint alignment (mechanical axis of 0° to 5°) had the respective mean values of 6°; 6.0° and 6.0°. This group showed 76 extra-articular deformities (33.9 %). In group 2, for women the mean ± SD value of the condylar twist angle was 5.25° ± 1.68; and median and modus values were 5.0° and 4.0 °, respectively. For men, the respective values were 4.69° ± 1.33; 4.0° and 4.0°. DISCUSSION: The mean values of valgus angle and CTA found in this study are in agreement with the literature data. In the pre-operative planning it is necessary to take extra-articular deformities in consideration, to respect the entry point for the intra- medullary rod and to take a compromise solution for adjustment of the valgus angle of the femur and for tibial deformities. Also, in severe valgus and varus deformities of the knee, the maintenance of a neutral mechanical axis should be strictly observed. The optimal adjustment of femoral component rotation is individual and depends on the type of deformity and femoro-patellar joint pathology. The external rotation of a femoral component should be set in the range of 0° to 7°. CONCLUSIONS: Digital sciagraphy with suitable software and computed tomography contribute to radiographic measurements before and after total knee arthroplasty. They facilitate an accurate and quick measurement together with data storage. On examination in a standing weight-bearing position it is necessary to keep standard lower extremity neutral rotation. Computed tomography is recommended when more severe valgus and varus deformities and/or femoro-patellar pathology are present. The results of radiographic measurement analysis will allow the surgeon to plan the operative strategy and select a suitable type of implant.

[Plantar fibromatosis (Ledderhose's disease)]. / Plantární fibromatóza (Ledderhoseova nemoc).

The authors describe the concomitant presence of plantar fibromatosis and Dupuytren's disease in a 33-year-old man. A lesion located under the sesamoid bones of the first metatarsophalangeal joint on the right showed an aggressive tendency (rapid growth, pain, impossibility to put weight on the medial side of the foot). Another lesion located proximal to the first one was smaller and painless. Neither plain radiography nor computed tomography showed any structural changes of the skeleton. Contrast-enhancement on magnetic resonance imaging revealed two lesions on the sole of the foot. Since a concurrence of plantar fibromatosis and malignant tumour could not be ruled out, an excision of both lesions and the adjacent plantar aponeurosis was made for biopsy examination. The operative procedure was carried out from two incisions.The intra-operative findings included proliferative growth and bleeding in the lesion located under the first metatarsophalangeal joint, and delimited growth without noticeable bleeding in the other lesion. Based on histological examination, the diagnosis of plantar fibromatosis was made for both lesions.The differential diagnosis and therapy of plantar fibromatosis is discussed.

[Bursitis iliopectinea]. / Iliopectineal Bursitis.

PURPOSE OF THE STUDY To present clinical and radiographic findings of iliopectineal bursitis and draw attention to some related etiopathogenetic factors. MATERIAL AND METHODS Six patients followed up between 2005 and 2007 were evaluated. They included four women and two men (average age, 58 years; range, 35 to 80 years) who presented with a tender mass in the hip region (four right and two left sides). Each patient underwent an examination involving a clinical check-up, imaging methods (CT, MR, angio-CT) and standard laboratory tests. RESULTS Iliopectineal bursitis clinically manifested as a tender mass in the groin and hip region in five patients; in one it was pulsating. The sixth case was asymptomatic. In three patients iliopectineal bursitis was found in association with steroid therapy and subsequent avascular necrosis of the femoral head and chronic synovitis. It followed tularemia with hip joint involvement in one patient, salmonella arthritis in one, and kidney transplant rejection in one. Also, iliopectineal bursitis was diagnosed in a patient with rheumatoid arthritis treated with steroids, but without femoral head avascular necrosis, and was incidentally found in another patient examined for digestive problems. Of the six cases of swollen bursa detected by the imaging methods used, five were found to communicate with the hip joint cavity, with four being so large that the bursa extended into the retroperitoneum. Two patients underwent excision or resection of the bursa; in addition, one of them had revitalizing graft surgery for femoral head necrosis. The patient with salmonella arthritis had to undergo a Girdlestone procedure. One patient was treated by draining of the bursa and, after inflammation resolved, total hip replacement surgery was carried out during which the iliopectineal bursa was removed. The patient with rheumatoid arthritis was treated by bursa draining and refused further surgical therapy (total hip replacement). DISCUSSION In our group of six patients, bursitis was symptomatic in five and was associated with chronic hip synovitis accompanying femoral head necrosis following steroid therapy or inflamation, either non-specific or arthitic. Bursitis was asymptomatic in one patient and was diagnosed only incidentally on CT examination done for another reason. The communication between the bursa and the hip joint cavity, found on CT scans and magnetic resonance images, was a radiographic factor important for differential diagnosis. The underlying disease of the hip joint plays a key role in the etiopathogenesis of iliopectineal bursitis. Therefore, surgical treatment should be comprehensible and, in addition to bursa resection or excision, should also include treatment of the affected joint (alloplasty, femoral head resection or revitalization). CONCLUSION Iliopectineal bursitis is associated with chronic hip synovitis present in degenerative, infectious or rheumatic joint diseases. When a lump is diagnosed in the inguinal or hip region, iliopectineal bursitis should always be considered in addition to conditions such as abscess, cyst, hernia, pseudoaneurysm, lymphocele, etc. The finding of communication beteen the bursa and hip joint cavity, made on CT scans or magnetic resonance images, is a radiographic factor important in terms of differential diagnosis. The surgical treatment of iliopectineal bursitis includes excision or resection of the bursa and therapy for the hip joint (alloplasty, femoral head resection or revitalization).

[Secondary pyomyositis of hip muscles (non-tropical pyomyositis)]. / Sekundární pyomyozitida kycelních svalu (nontropical pyomyositis).

PURPOSE OF THE STUDY: By presenting the results of treatment of secondary pyomyositis of deep hip muscles, to draw attention to the seriousness of this complication occurring in association with pelvic and lumbo-sacral infections. MATERIAL AND METHODS: The course of disease was evaluated retrospectively in a group of 13 patients with an average age of 65.8 years treated in the period from April 2004 to June 2007. The imaging methods used included native radiography, ultrasonography (SONO), computed tomography (CT) and magnetic resonance imaging (MRI). Markers of inflammation, i.e., C-creative protein, erythrocyte sedimentation rate and WBC differential count, were used to assess the intensity of inflammation. At stage 1, patients were treated conservatively, with appropriate antibiotic therapy. At stages 2 and 3, surgical procedures were used (incision, abscess evacuation and drainage) or abscess was treated by CT-guided needle puncture and pigtail drain insertion. The evaluation took into account survival of the patients in relation to the stage of their disease, early detection of origin of infection, therapy initiation, and other factors putting patients at risk. RESULTS: Of the 13 patients treated, 10 had stage 3 pyomyositis with beginning or developed multiple-organ failure when they were referred to our institution from outside hospitals; three admitted at stage 2 pyomyositis were in relatively good state. Ten patients were cured, two died due to multiple-organ failure and one due to pulmonary embolism after lower-extremity phlebothrombosis. The success of treatment appeared to be related to early surgical intervention. DISCUSSION: A good outcome of therapy depends on an early diagnosis and treatment of the underlying infection and pyomyositis. To establish the diagnosis of pyomyositis, repeated clinical, laboratory and bacteriological examinations are necessary, as well as the use of imaging methods, namely SONO, CT and MRI. Treatment may be complicated when small multiple abscesses develop deep in the hip muscles where surgical intervention is difficult. CONCLUSIONS: Secondary pyomyositis is a serious, life-threatening complication of the underlying infection. The outcome of the disease depends on early diagnosis, therapy and the patient's overall state. Stage 1 pyomyositis (muscle oedema) is treated conservatively with antibiotics. Stage 2 pyomyositis needs surgical intervention with abscess aspiration and drainage; in some cases CT-guided needle puncture with pigtail drain insertion is sufficient. An appropriate antibiotic course is obligatory. Stage 3 pyomyositis associated with septic shock or multiple-organ failure requires a comprehensive care in an acute medicine department. In polymorbid patients prognosis is poor and treatment is expensive and often unsuccessful.

[Long-term results of calcaneal fracture treatment by open reduction and internal fixation using a calcaneal locking compression plate from an extended lateral approach]. / Strednedobé zkusenosti s lécbou zlomenin patní kosti otevrenou repozicí a vnitrní fixací kalkaneární LCP z rozsíreného laterálního prístupu.

PURPOSE OF THE STUDY: To report on the surgical treatment of intra-articular calcaneal fractures by open reduction and internal fixation with a calcaneal locking compression plate (LCP) from an extended lateral approach, and to retrospectively analyze the mid-term results in a group of patients treated by this technique. MATERIAL: In the period from August 2005 till March 2007, a total of 49 patients with 61 calcaneal fractures were treated. Of these, 11 (18 %) were treated conservatively. Reduction combined with Kirschner-wire fixation was used in four fractures (6.6 %). Open reduction with internal calcaneal LCP fixation (ORIF- calcaneal LCP) from an extended lateral approach was carried out to treat 46 fractures (75.4 %) in 38 patients. The group evaluated here comprised 29 patients with 33 calcaneal fractures treated by ORIF-calcaneal LCP at a follow-up longer than 6 months. The fractures were classified on the basis of computer tomography (CT) findings as Sanders types I to IV. The group had two woman (6.9 %) and 27 men (93.1 %) with an average age of 34.2 years (range, 19-55 years). In 11 fractures (33.3 %), the primary treatment included filling a central cancellous bone defect area. Calcium phosphate bone substitute material (resorbable ChronOS) was used in nine cases (27.3 %), a self-solidifying hydroxyapatite implant was injected in two (6.1 %) cases (X3 Wright and Norian SRS, respectively), and a bone allograft was implanted in one case (3 %). METHODS: Indicated for surgery were patients with an intra-articular calcaneal fracture, Sanders type II or type III, with articular surface displacement by more than 1 mm. Contraindications included age over sixty years, poor cooperation, smoking habits, peripheral vascular disease or skin infection. Surgery was performed only after oedema had resolved. The aim of our treatment was to achieve anatomical reconstruction of all articular surfaces, to restore the height, length, width and axis of the heel bone, to carry out primary stable osteosynthesis, and to enable the patient to begin rehabilitation with early mobilization. A passive rehabilitation usually started on the first post-operative day, and full weight-bearing of the extremity was allowed not earlier than 3 months post-operatively. Regular check-ups were at 6 weeks, 3, 6 and 12 months and then every year. The mid-term results were evaluated by the system of Rowe et al., scoring rest pain, possibility of return to preinjury jobs, use of walking aids, restriction of physical activity and limping. RESULTS The most frequent cause of injury was a fall or jump from height; this was recorded in 27 patients (93.1 %). An open fracture was diagnosed on two occasions (6.9 %). Bilateral calcaneal fractures were found in six patients (20.7 %); four (13.8 %) were treated by bilateral ORIF-calcaneal LPC and two (6.9 %) underwent closed reduction on one and Kirschnerwire transfixation on the other extremity. A combined injury to the musculoskeletal system was diagnosed in 11 patients (38 %), in whom four (13.8 %) had a tibial pylon fracture of the contralateral limb and four (13.8 %) had a thoracolumbar spine fracture. The surgical procedure was performed on average within 11.7 days of injury, and the average hospital stay was 18.2 days (range, 6 to 18 days). Early post-operative complications were recorded in six patients (20.7 %). Wound dehiscence was found in two (6.9 %), necrosis of wound edges in two (6.9 %), and early superficial infection responding to antibiotic therapy also in two patients (6.9 %). Deep infection, non-union or post-operative compartment syndrome were not recorded. Excellent Rowe scores were achieved in 10 patients (34.5 %), good in 15 (51.7 %) and satisfactory in two (6.9 %). Only two patients (6.9 %) reported poor outcome. DISCUSSION: The methods of classification and treatment of calcaneal fractures continue to be a frequently discussed topic. The technique of ORIF-calcaneal LCP from an extended lateral approach has recently been preferred for patients with displaced Sanders type II or III calcaneal fractures. In agreement with other literature references, this approach allowed us to observe the fracture, to reduce both the subtalar and calcaneocuboid articulations, to stabilize the fracture by internal fixation and to begin early rehabilitation. Because of the risk of early complications, the timing of surgery and a thorough consideration of indications and contraindications are of principal importance.We agree with other authors that filling calcaneal bone defects is not necessary. Pre- and post-operative CT scans are necessary. In accordance with literature data, fractures developing compartment syndrome are indicated for urgent fasciotomy and ORIF-calcaneal LCP should be postponed. In patients with multiple trauma and also in those with open calcaneal fractures, a temporary stabilization with an external fixator medially is performed first, and then converted to a second-stage, ORIF-LCP procedure. CONCLUSIONS: The surgical treatment of displaced intra-articular fractures that involves open reduction from an extended lateral approach and internal fixation with a calcaneal LCP shows very good preliminary results. A CT examination is required for the diagnosis and classification of fractures and a correct indication for surgery. Good timing is of principal importance. An urgent surgical intervention is necessary in open fractures or in those in which soft tissues are squashed by bone fragments. In the other fractures, surgery is carried out after oedema subsidence. Foot compartment syndrome is a serious complication of calcaneal fractures and urgent fasciotomy is the only adequate therapy. Full weight-bearing of the operated extremity depends on the rate of bone healing; it is usually allowed at 3 months after surgery.

[Warfarin-induced hemorrhagic pseudocyst in the pelvis of a woman with an inherited disorder of blood coagulation, complicated by pelvic bone pseudoxanthoma mimicking Erdheim-Chester disease]. / Warfarinem vyvolaná hemoragická pseudocysta malé pánve u zeny s vrozeným genetickým defektem koagulace komplikovaná usuracním pseudoxantomem pánevní kosti napodobujícím Erdheim-Chesterovu nemoc.

A fifty-year-old woman with developmental dysplasia of the hip underwent total hip arhtroplasty, and subsequently developed recurrent venous thrombophilia of the lower extremities. Hematological examination revealed an inherited disorder of blood coagulation (homozygous mutation of the 5,10-methylenetetrahydrofolate reductase gene) and therefore longterm Warfarin anticoagulation therapy was started. A year later she was diagnosed with a large pelvic posthemorrhagic pseudocyst (hematoma) located below the musculus iliacus and adhering to bone in the region of posterior acetabulum. The condition was complicated by usuration and focal osteolysis of the adjacent pelvic bone. Histological examination of the hematoma showed characteristics of an unusual pseudoxanthoma mimicking Erdheim-Chester disease. The differential diagnosis of histological findings is discussed and recent relevant literature is reviewed.

[Peripheral primitive neuroectodermal tumor -- PNET]. / Periferní primitivní neuroektodermový tumor -- PNET.

The authors describe three cases of peripheral primitive neuroectodermal tumor. The tumor was found in soft tissues of the crus, shoulder girdle and perineum, and was also located paravertebrally and epidurally at the level of L1-L2 vertebrae. Radiological findings were not specific for this disease. The results of imaging methods (sonography, CT, MRI, DSA) were important for the assessment of tumor size, its boundary and invasion of the surrounding tissues, and for the evaluation of tumor response to therapy and detection of recurrent disease. The PNET diagnosis was based on immunohistochemical, biochemical and cytogenetic examinations. One patient died 5 months after the first clinical signs were manifested; the two patients surviving for 2 and 1 3/4 years after first sign manifestation, respectively, remained in the care of cancer specialists. Key words: skeletal Ewing's sarcoma, extra-skeletal Ewing's sarcoma, Ewing's sarcoma family of tumors, peripheral primitive neuroectodermal tumor.

[Magnetic resonance imaging for examination of proximal femoral fractures: its contribution to clinical medicine]. / Vysetrení zlomenin horního konce femuru magnetickou rezonancí (MR) - prínos pro praxi.

PURPOSE OF THE STUDY: The aim of the study was to find out, by magnetic resonance (MR) imaging, the degree of blood supply impairment in the femoral head in proximal femur fractures. MATERIAL: Twenty-eight patients, 22 women and six men, aged between 49 and 96 years (average, 75.2 years) were evaluated. Twenty-six patients were examined within 2-48 hours of injury, one patient at 72 hours (3 days) and one at 144 hours (6 days). Two groups were made: A, including 18 patients with an intra-articular fracture of the femoral neck, and B, consisting of 10 patients with an extra-articular fracture (per- to subtrochanteric fractures) for comparison. METHODS: Native and contrast-enhanced (intravenous injection of Magnevist) MR images were obtained. An MR pulse sequence permitting fat signal suppression (T1, TSE, FS) was used in coronal and transversal planes. RESULTS: In all B group patients, enhancement in the femoral head following contrast medium application was seen as even; enhancement was also shown in two group A patients with locked fractures. These results indicated that blood supply to the femoral head remained intact. Five group A patients showed enhancement in some areas of the femoral head only, and this finding corresponded to partial damage to the femoral vasculature. In the remaining 11 patients of group A, no post-contrast enhancement could be distinguished. This finding suggested extensive damage to the femoral vasculature associated with a high risk of post-traumatic avascular necrosis (AVN). In the contralateral femurs of the patients from both groups, contrast enhancement in the femoral head was fully visualized, with the exception of one patient whose contralateral femoral head showed signal alteration typical of advanced AVN (non-traumatic in origin). DISCUSSION: The authors recommend the use of this method in patients with intra-articular fractures of the femoral neck that are between 40 and 65 years of age. For this patient category, MR results have a crucial role in the choice of an appropriate therapy including the surgical procedure to be used (osteosynthesis vs total hip arthroplasty/THA/). To perform osteosynthesis of the femoral neck is less demanding in terms of surgical skills and treatment costs than THA. Since the former method preserves the femoral head, it is preferred if blood supply is not disturbed. THA is the method of choice in hips with impaired blood supply to the femoral head and with a high risk of post-traumatic AVN.