[Very late effects of radiotherapy -  limiting factor of current radiotherapy techniques]. / Velmi pozdní následky radioterapie -  limitující faktor soucasných radioterapeutických technik.

BACKGROUND: Very late effects of radiotherapy occur within decades after the initial exposure. Their development is induced by low doses of ionizing radiation (from 4 Gy per radiation series) and their clinical manifestations are difficult to distinguish from other independent diseases diagnosed in individuals not formerly treated with radiation. A long time period from the exposure confounds any causal relationships between radiation and adverse events. Still, these side effects not only reduce the patients quality of life but also lead to an early morbidity and mortality, hence generating significant costs in health care and social systems. PURPOSE: This article summarizes findings about the most common very late consequences of radiotherapy, which include cardiotoxicity, CNS toxicity, pneumotoxicity, renal toxicity and secondary malignancies. This issue is crucial in the group of children cancer patients, malignant lymphomas, testicular tumors and CNS tumors. Generally, the risk of very late effects of radiotherapy (RT) should be considered in all patients irradiated at a relatively early age with a high chance of long term survival. The risk of very late effects of RT is also one of the key limiting factors in the use of RT in the treatment of patients with benign lesions with longterm survival expectation, e. g. in patients with glomus tumors, neurofibromas, desmoid tumors or hemangiomas or other benign lesions (arterio venous malformations). Currently, the only known prevention of these very late adverse effects is to minimize the dose to critical structures to the lowest achievable level.

Cardiac conduction system as a new organ at risk in radiotherapy.

BACKGROUND: Cardiovascular diseases represent the most common non-oncologic cause of death in patients following radiotherapy (RT) in the thoracic region. Radiation-induced heart disease (RIHD) can manifest as various heterogeneous clinical entities. However, the influence of RT on the cardiac conduction system has only recently gained more attention. Arrhythmogenic toxicity, i.e., conduction disorders and arrhythmias, constitutes a significant part of these adverse effects. The cardiac conduction system is not routinely monitored as an organ at risk (OaR). Its specific histological nature and function suggest different sensitivity and response to radiation. The heart is a highly heterogeneous organ, and the routinely monitored dose to the whole heart may not adequately characterize the risk of increased arrhythmogenic toxicity from RT. Cardiac structures, including the conduction system, appear to be additional OaRs for which dose distribution should be monitored. MATERIAL AND METHODS: For the systematic selection of studies, we utilized the PubMed database with keywords derived from the analysis of existing literature. The search was limited to English-language publications, and the selection criteria included relevance to the topic and the quality of methodology. PURPOSE: This article summarizes the impact of RT on the cardiac conduction system. CONCLUSION: Radiotherapy-induced cardiotoxicity significantly affects morbidity and mortality. The heart exhibits heterogeneity in terms of radiosensitivity. Certain cardiac subregions in the dose distribution show a higher correlation with poorer overall survival than routinely monitored doses to the whole heart and derived parameters (the volumes irradiated with the doses of 5 or 30 Gy - V5 or V30, respectively). The most radiosensitive subregions appear to be the base of the heart, including the beginning of the conduction system. Higher doses to the conduction system, especially the sinoatrial (SA) node, are associated with a higher incidence of a wide range of arrhythmias and poorer overall survival. However, dose limits (Dmean and Dmax) for the conduction system have not yet been established. Dosimetric studies have identified cutoff doses to the SA node, exceeding which there is a significant increase in mortality and the occurrence of arrhythmias.

[Allofit cementless acetabular component: five-year experience]. / Necementovaná jamka Allofit--petileté zkusenosti.

PURPOSE OF THE STUDY: To evaluate the mid-term results of using the Allofit cementless acetabular cup for primary hip replacement. MATERIAL AND METHOD: The Allofit cup is a cementless hemispherical acetabular component. The macrostructure on the external surface, including 1200 concentrically arranged teeth, and the rough-blasted surface of the biocompatible pure titanium provide good conditions for press-fit fixation. From 1998 to 2005 we used it in 182 cases of primary total hip replacement (THR) in 164 patients. (18 patients had bilateral THRs) The average age at the time of surgery was 58.3 years in men (range, 39-74 years) and 64.1 years in women (range, 33-80 years). We used the Bauer anterolateral approach as our standard procedure. The cup was combined with one of six types of cemented or cementless stems and a 28-mm ceramic head. At a minimum follow-up of five years, we evaluated clinical and radiological findings, i.e., the Harris hip score, radiological signs of loosening, migration and polyethylene wear. The average follow-up was 7.4 years (range, 5-11 years). For more accurate reading of X-ray films, the photographs were zoomed to 115%. RESULTS: The final evaluation included 147 primary THRs in 129 patients. We recorded no intra-operative complications. The average Harris hip score increased from pre-operative 44 to post-operative 87 points (range, 31-100). The loosening of a cup occurred in three patients (2.1%), of which two were infected (1.4%) and one was aseptic (0.7%). We had to replace the polyethylene insert in three patients, in one for abnormally high polyethylene wear and, in two, because of a ceramic head fracture due to a fall. Cup migration was not recorded. Eight cups (5.4%) had a thin (less than 1 mm) radiolucent line without signs of loosening. Polyethylene wear indicated by an asymmetric position of the head was detected by the Dorr method in 32 cups (21.8%). A shift of the head centre towards the proximal pole of the titanium shell ranged from 0.4 to 6.0 mm. The average polyethylene wear of all cups was 0.29 mm in 5 years, which is 0.06 mm per year. DISCUSSION: The Allofit acetabular cup is suitable for younger patients with good bone quality. In elderly patients or in those with severe osteoporosis, we preferably indicate cemented components. Press-fit cups can also be used in patients with postdysplastic osteoarthritis of the hip on condition that enough bone is left around the cup margin for press-fit fixation. CONCLUSIONS: Cementless press-fit cups have very good outcomes, even in a long-term follow-up. Our experience gives support to these results because of a low number of hips with loosening, both septic and aseptic, or polyethylene wear of the primary implanted acetabular cup, and no cup migration in our patients. The five-year survival rate of the Allofit acetabular cup was 95.8%.

Treatment of high risk prostate cancer with combined radiotherapy and hormonal treatment- results and identification of factors influencing outcome.

PURPOSE: The aim of this work was to prospectively analyze the outcome of combined hormonal treatment and radical radiotherapy in high risk non metastatic prostate cancer patients (T1=4, N0-1, M0). METHODS: Between April 2003 and December 2007 196 patients with high risk prostate cancer were treated with curative intent. The treatment consisted of 2-month neoadjuvant hormonal treatment (LHRH analog), radical radiotherapy (68-78 Gy, conformal technique) and an optional 2-year adjuvant hormonal treatment. RESULTS: The median follow up time was 59 months. Fiveyear overall survival was 86% and 5-year biochemical disease free survival (DFS) 70%. Factors found to be statistically significant relative to outcomes were Gleason score (p=0.017), initial PSA value (p=0.039) and adjuvant hormonal treatment (p=0.035). There was no significant association between radiotherapy dose or volume and biochemical DFS (bDFS). Late genitourinary and gastrointestinal toxicity was acceptable. CONCLUSION: Treatment combining hormonal therapy and radical radiotherapy can be recommended for this subgroup of prostate cancer patients. Adjuvant hormonal treatment should also be used.

[Radiobiological pitfalls of new techniques in radiotherapy]. / Radiobiologická úskalí nových technik v radioterapii.

Radiotherapy techniques in the last decade evolved to the stage where the potential dose distribution significantly differs from earlier practices. Rotational IMRT, robotic radiotherapy or proton radiotherapy enables extremely precise dose delivery to target volumes, on the other hand, these techniques can yield a number of problems. As for photon radiotherapy, this concerns primarily the effect of large volume irradiation with doses of 0.10.5 Gy. In this range, the hypersensitivity to low doses and the bystander effect may play an important role. Proton therapy is upredictable in its radiobiological effect at the end of the Bragg curve and there is also uncertainty about the peaks exact location. These effects should be taken into account when choosing among the irradiation techniques or when applying tolerance doses to critical organs in clinical practice, especially in younger patients with long survival expectation.

Radiation induced lymphopenia - a possible critical factor in current oncological treatment.

BACKGROUND: The effect of ionizing radiation on the immune system during the treatment of malignant tumors has long remained a point of great interest. This issue is currently gaining importance, especially in connection with the advancing development and availability of immunotherapeutic treatment. During cancer treatment, radiotherapy has the ability to influence the immunogenicity of the tumor by increasing the expression of certain tumor-specific antigens. These antigens can be processed by the immune system, stimulating the transformation of naïve lymphocytes into tumor-specific lymphocytes. However, at the same time, the lymphocyte population is extremely sensitive to even low doses of ionizing radiation, and radiotherapy often induces severe lymphopenia. Severe lymphopenia is a negative prognostic factor for numerous cancer dia-gnoses and negatively impacts the effectiveness of immunotherapeutic treatment. AIM: In this article, we summarize the possible influence of radiotherapy on the immune system, with a particular emphasis on the impact of radiation on circulating immune cells and the subsequent consequences of this influence on the development of cancer. CONCLUSION: Lymphopenia is an important factor influencing the results of oncological treatment, with a com-mon occurrence during radiotherapy. Strategies to reduce the risk of lymphopenia consist of accelerating treatment regimens, reducing target volumes, shortening the beam-on time of irradiators, optimizing radiotherapy for new critical organs, using particle radiotherapy, and other procedures that reduce the integral dose of radiation.

Hyperfractionated accelerated radiotherapy with concomitant integrated boost of 70-75 Gy in 5 weeks for advanced head and neck cancer. A phase I dose escalation study.

BACKGROUND AND PURPOSE: The present study was performed to evaluate the feasibility of a new, 5-week regimen of 70-75 Gy hyperfractionated accelerated radiotherapy with concomitant integrated boost (HARTCIB) for locally advanced, inoperable head and neck cancer. METHODS AND MATERIALS: A total of 39 patients with very advanced, stage IV nonmetastatic head and neck squamous cell carcinoma (median gross tumor volume 72 ml) were included in this phase I dose escalation study. A total of 50 fractions intensity-modulated radiotherapy (IMRT) were administered twice daily over 5 weeks. Prescribed total dose/dose per fraction for planning target volume (PTV(tumor)) were 70 Gy in 1.4 Gy fractions, 72.5 Gy in 1.45 Gy fractions, and 75 Gy in 1.5 Gy fractions for 10, 13, and 16 patients, respectively. Uninvolved lymphatic nodes (PTV(uninvolved)) were irradiated with 55 Gy in 1.1 Gy fractions using the concomitant integrated boost. RESULTS: Acute toxicity was evaluated according to the RTOG/EORTC scale; the incidence of grade 3 mucositis was 51% in the oral cavity/pharynx and 0% in skin and the recovery time was ≤ 9 weeks for all patients. Late toxicity was evaluated in patients in complete remission according to the RTOG/EORTC scale. No grade 3/4 late toxicity was observed. The 1-year locoregional progression-free survival was 50% and overall survival was 55%. CONCLUSION: HARTCIB (75 Gy in 5 weeks) is feasible for patients deemed unsuitable for chemoradiation. Acute toxicity was lower than predicted from radiobiological models; duration of dysphagia and confluent mucositis were particularly short. Better conformity of radiotherapy allows the use of more intensive altered fractionation schedules compared with older studies. These results suggest that further dose escalation might be possible when highly conformal techniques (e.g., stereotactic radiotherapy) are used.

Postoperative radiochemotherapy with weekly cisplatin in patients with head and neck cancer single-institution outcome analysis.

The objective of this study was to evaluate the feasibility, toxicity and efficacy of postoperative radiochemotherapy with weekly cisplatin in locoregionally advanced or high risk head and neck cancer in a single institutional setting. Patients with head and neck cancer of stage III/IV or patients with insufficient margins of resection were included in the study. Radiotherapy consisted of 70 Gy/ 7 weeks/ 35 fraction after R1/2 resection and 60-64 Gy/ 6-6,5 weeks/ 30-32 fraction after R0 resection, respectively. All patients received concurrent cisplatin 40 mg/m2 weekly. Between 7/2002 and 12/2008, 100 consecutive patients [WHO ≤ 2, male to female ratio 84/16, median age 54 years] were treated. Tumors of the oropharynx were the most frequent (49%) and stage IV was predominant (86%). 96% patients received the full radiation treatment as planned, median total tumor dose was 66 Gy. Omission of weekly cisplatin had been occurring frequently, the most frequent reason for its early cessation were hematological toxicities (34%). Grade 3/4 mucosal toxicity developed in 32%. No death was observed during the treatment. The late toxicities were acceptable, predominantly subcutaneous fibrosis and xerostomia in most of the cases. We recorded six cases of osteonecrosis. Two and half year overall survival, locoregional control, time to progression and disease free survival were 64%, 88%, 79% and 59%, respectively. Postoperative radiochemotherapy with weekly cisplatin is toxic, but tolerable and highly effective in terms of locoregional control and survival. Multivariete analysis revealed that the only prognostic factor for survival was primary surgery at the University centre.

Definitive radiochemotherapy with weekly cisplatin in patients with head and neck cancer; single institution outcome analysis.

PURPOSE: The objective of this study was to evaluate the feasibility, toxicity and efficacy of definitive radiochemotherapy with weekly cisplatin in head and neck cancer in a single institutional setting. METHODS: Previously untreated patients with stage II-IV head and neck cancer were included. Radiotherapy consisted of 70 Gy/7 weeks/35 fractions. All patients received concurrent cisplatin 40 mg/m(2) weekly. RESULTS: Between 2/2002 and 8/2009, 148 consecutive patients (WHO ≤ 2, male to female ratio 6/1, median age 56 years) were treated. The mean follow-up was 40 months. Tumors of the oropharynx were the most frequent (46%) and stage IV predominated (80%). Eighty-nine percent of the patients had received the full radiation treatment as planned. Omission of weekly cisplatin occurred frequently, mainly because of hematological toxicity. Only 64% of the patients completed at least 5 cycles of chemotherapy. Grade 3/4 mucosal toxicity developed in 32% of the patients. The late toxicities were acceptable: 74% of the patients were able to eat solid food during the 1st post-treatment year, 4 patients were not able to swallow at all during the 1st post-treatment year, requiring thus permanent feeding tube. Five cases of osteoradionecrosis of the mandible were reported. Three-year overall survival, locoregional control, time to progression and disease free survival were 34, 60, 52 and 29%, respectively. CONCLUSION: Definitive radiochemotherapy with weekly cisplatin was toxic, with high rate of morbidity and mortality in this patient population. Five weekly cycles of 40 mg/m(2) cisplatin seem to be the dose limit for most patients. Three-year survival was significantly reduced despite the promising high initial response and locoregional control.

[Treatment for volume upgrading of the low-grade supratentorial glioma after the subtotal neurosurgical resection]. / Lécba nízkostupnového gliomu supratentoriální oblasti mozku po neurochirurgické subtotální resekci s projevy objemového up-gradingu.

BACKGROUND: Low-grade gliomas WHO II (LGG) are mostly detected in patients with neurological symptomatology between 20 and 45 years of age very often as secondary epilepsy. We present two cases in which low-grade gliomas attacked neurological zones. Neurosurgical resection was subtotal because of the risk of the damage in neurocognitive functions in both these patients. After the operation, both patients were followed at neurosurgery department in regular intervals using different imaging methods (MRI, MRS and PET). After resections, the MRI detected the enlargement of the volumes of the tumor residua in both patients. PATIENTS AND METHODS: Owing to the risk of up-grading to high-grades glial tumors (overexpression of EGFR and VEGF), both patients were indicated for curative treatment by external beam radiotherapy combined with chemotherapy (Temodal®) and adjuvant chemotherapy. RESULTS: After the end of this treatment, the MRI proved considerable partial regressions in both patients. Moreover, three months later, the MRI did not prove any residual disease. CONCLUSION: Radiotherapy combined with the administration of Temodal should prolong the OS and TTP in patients with a high risk of up-grading of low-grade gliomas of the brain. Both the patients are in a follow-up program, also because of the risk of duplicite brain tumor.

[Our results of the Brandes-Keller procedure and Helal metatarsal osteotomy in patients with forefoot deformity]. / Nase zkusenosti s operacní rekonstrukcí prednozí u pacientu s hallux valgus a metatarzalgiemi pri pes transversoplanus.

PURPOSE OF THE STUDY: The most frequent valgus deformity of the big toe is often associated with a collapse of the traverse arc of the foot. The purpose of the present study was to assess the results of forefoot reconstruction by the Brandes-Keller resection arthro- plasty of the first metatarsophalangeal joint and the Helal metatarsal osteotomy when this deformity was present. MATERIAL: A retrospective study of 40 consecutive patients with severe forefoot deformities was performed.The patients were treated at our department in the period from 1997 to 2003.The average age at the time of surgery was 54.7 years.Twelve patients underwent bilateral surgery. The results of 52 operations were evaluated. RESULTS: Each patient returned for a personal interview by an independent investigator and a clinical examination. A post-operative forefoot score was calculated according to the system of the American Orthopaedic Foot and Ankle Society (AOFAS). This 100-point scale includes items related to pain, level of activity, deformity and motion. The average AOFAS score was 85.5 points post-operatively. No pain was reported in 38 (75 %) forefeet, mild pain in 12 (23 5 %) forefeet and moderate pain in 1 (2 %) forefoot. The complications included slow healing of the wound in two patients (3.8 %) and asymptomatic pseudoarthrosis after metatarsal osteotomy in two patients (3.8 %). Five patients (9.6 %) reported persisting swelling of the foot dorsum for a period longer than 3 months. DISCUSSION In agreement with the majority of the published data we are of the opinion that the Brandes-Keller resection arthroplasty is a surgical method suitable to treat valgus deformities of the big toe with concomitant arthritis of the first metatarsophalangeal joint (MTP) in elderly patients whose weight-bearing demands are low. This treatment permits early post-operative weight-bearing. In younger patients with valgus deformity of the big toe without arthritis it is preferred to use techniques preserving the joint. The use of total replacement of the first MTP joint is open to discussion. CONCLUSIONS: The Brandes-Keller procedure with the Helal metatarsal osteotomy, if correctly performed in indicated cases, results in painless walking in patients with forefoot deformity.

[Total hip replacement from a MIS-AL approach (comparison with a standard anterolateral approach)]. / Totální endoprotéza kycelního kloubu z MIS-AL prístupu - porovnání se standardním anterolaterálním prístupem.

PURPOSE OF THE STUDY: Minimally invasive surgery (MIS) techniques have recently become a powerful and effective marketing instruments that are often perceived by the patient as the criterion of the surgeon's and institution's standard. In addition to studies reporting the benefits of minimally invasive procedures, some authors have recently found no such benefits or even pointed out some disadvantages. In this paper we present our own view of this issue. Our definition of minimally invasive surgery: a minimally invasive procedure is such that an optimally placed incision using anatomical intervals without damage to muscle insertions allows us to gain a good view of the operating field and to safely perform the planned surgery. Because of this optimal approach it is possible to make skin incisions shorter. MATERIAL: Between April 21, 2005, and December 28, 2006, the first 40 MIS hip procedures were performed at the Department of Orthopaedic Surgery of the ILF Bulovka. Forty patients who, in the same period, were operated on from an anterolateral standard approach and who met the same indication criteria, including age, comprised a control group. In both groups all routinely used types of implants were included. METHODS: For objective assessment of potential differences between surgical outcomes of the two techniques, the following para- meters were recorded: operating time, peri-operative blood loss, pre- and post-operative Hb levels, Hb level on the first post- operative morning, amount of blood drained away with a Redon drain, number of anodyne applications (indirect evaluation of post-operative pain) and length of hospital stay. The parameters were compared for the cemented and the uncemented implants separately. The results were evaluated using the paired t-test, with the significance level set at a value of p<0.05. RESULTS: A comparison of the MIS-AL results with those of the standard total hip replacement procedure did not show any significant differences, not even during further follow-up; by the end of 2008 no implant failure or necessity of revision arthro- plasty was reported. DISCUSSION: So far the only indisputable fact is that all the benefits of minimally invasive techniques described until now are merely related to time, as they facilitate a faster rate of soft tissue repair; therefore, these techniques only shorten recovery and thus speed up return of the operated hip to full function. CONCLUSIONS: Based on comparison of the standard anterolateral and minimally invasive techniques it can be concluded that the MIS- AL approach is effective even without the use of special instrumentation. However, the results of this study failed to give unambiguous support to its advantage over the classical technique.

[Proton therapy for head and neck squamous cell carcinomas: From physics to clinic]. / Protonthérapie des carcinomes épidermoïdes des voies aérodigestives supérieures : de la physique à la clinique.

Intensity-modulated radiation therapy (IMRT) is presently the recommended technique for the treatment of locally advanced head and neck carcinomas. Proton therapy would allow to reduce the volume of irradiated normal tissue and, thus, to decrease the risk of late dysphagia, xerostomia, dysgeusia and hypothyroidism. An exhaustive research was performed with the search engine PubMed by focusing on the papers about the physical difficulties that slow down use of proton therapy for head and neck carcinomas. Range uncertainties in proton therapy (±3 %) paradoxically limit the use of the steep dose gradient in distality. Calibration uncertainties can be important in the treatment of head and neck cancer in the presence of materials of uncertain stoichiometric composition (such as with metal implants, dental filling, etc.) and complex heterogeneities. Dental management for example may be different with IMRT or proton therapy. Some uncertainties can be somewhat minimized at the time of optimization. Inter- and intrafractional variations and uncertainties in Hounsfield units/stopping power can be integrated in a robust optimization process. Additional changes in patient's anatomy (tumour shrinkage, changes in skin folds in the beam patch, large weight loss or gain) require rescanning. Dosimetric and small clinical studies comparing photon and proton therapy have well shown the interest of proton therapy for head and neck cancers. Intensity-modulated proton therapy is a promising treatment as it can reduce the substantial toxicity burden of patients with head and neck squamous cell carcinoma compared to IMRT. Robust optimization will allow to perform an optimal treatment and to use proton therapy in current clinical practice.

Immunological response in the mouse melanoma model after local hyperthermia.

Our study was aimed to characterize the phenotype and functional endpoints of local microwave hyperthermia (LHT, 42 degrees C) on tumor infiltrating and spleen leukocytes. The effectiveness of LHT applied into the tumor of B16F10 melanoma-bearing C57/BL6 mice was compared with anesthetized and non-treated animals. Subpopulations of leukocytes were analyzed using the flow cytometry, and the cytotoxic activity of splenocytes against syngeneic B16F10 melanoma and NK-sensitive YAC-1 tumor cell lines was evaluated in (51)Cr-release assay. Similarly, the in vitro modification of the heat treatment was performed using healthy and melanoma-bearing splenocytes. We found a 40 % increase of activated monocytes (CD11b+CD69+) infiltration into the tumor microenvironment. In the spleen of experimental animals, the numbers of cytotoxic T lymphocytes (CTLs-CD3+CD8+) and NK cell (CD49b+NK1.1+) raised by 22 % and 14 %, respectively, while the NK1.1+ monocytes decreases by 37 %. This was accompanied by an enhancement of cytotoxic effector function against B16F10 and YAC-1 targets in both in vivo and in vitro conditions. These results demonstrate that LHT induces better killing of syngeneic melanoma targets. Furthermore, LHT evokes the homing of activated monocytes into the tumor microenvironment and increases the counts of NK cells and CTL in the spleen.

[Scapholunate instability of the wrist following distal radius fracture]. / Skafolunátní nestability zápestí po zlomeninách distálního radia.

PURPOSE OF THE STUDY: Scapholunate (SL) ligament disruption frequently occurs together with distal radius fractures. If it is not diagnosed and treated, instability develops and will eventually be manifested as arthritic lesions known as scapholunate advanced collapse (SLAC) of the wrist. The aim of this study was to record the occurrence of SL ligament disruption in the patients treated conservatively for displaced fractures of the distal radius and to find out which fracture types are most often associated with injury to the SL ligament. MATERIAL AND METHODS: A total of 75 patients treated conservatively for distal radius fractures in 1997-98 were included in the study. The group comprised 41 women and 34 men, with fractures of the right upper limb in 44 and fractures of the left upper limb in 31 patients. They all were at active age, i. e., between 18 and 60 years, and came for a check-up 3 years after injury. They were examined for radiographic findings of SL instability and signs of SLAC development. Radiographs obtained after injury and images taken after reduction and then after bone union were retrospectively evaluated to look for signs of SL instability. The initial fractures were categorized on the AO classification and, for each fracture type, the percent of patients with co-existent SL instability was assessed. RESULTS: In the group of 75 patients examined at 3 years after injury, 16 (27 %) wrists showed radiographic signs of instability, with SLAC development in 13 patients and no arthritic lesions in three. All patients with SL instability reported pain, restricted range of motion in the wrist or reduced grip strength. The distribution of instability in relation to AO fracture type, expressed as percent, was as follows: SL instability associated with type A2 fracture was found in 38 %, with type A3 fracture in 17 %, and with type B in 25 % of the patients. SL instability was associated with type C1, type C2 and type C3 in 21 %, 27 % and 8 % of the patients, respectively. In radiographs taken after reduction, signs of damage to the SL ligament were apparent in 56 % of these patients. Radiographic findings at 6 weeks after injury showed signs of SL instability in as many as 81 % of the patients. DISCUSSION: Our results show that SL instability is found in association with type A2 and type A3 fractures, in which trauma force is "used" to break the distal radius and subsequently, due to carpal supination, to disrupt the SL ligament. In type B1 fractures, SL disruption results from an avulsion fracture of the radial styloid process due to ulnar deviation of the wrist. The retrospective evaluation of radiographs revealed that, immediately after reduction, signs of SL instability were obvious in 56 % of the cases. At that stage the condition could have been treated by K-wire transfixation and reattachment of the SL ligament. At 6 weeks, radiographic evidence of SL ligament disruption was found in 81 % of the patients. Even at that stage repair would have been possible by either reattachment or reconstruction of the ligament. It is apparent from these results that the evaluation of radiographic findings after reduction and during follow-up should also focus on other changes in the wrist in addition to signs of bone union. CONCLUSIONS: Fractures of the distal radius are no longer frequent only in elderly women, as has recently been common, but they are found more and more often in active young persons. Because their bones are healthier, soft tissues are affected more frequently. Injury to the SL joint results in the development of arthritic lesions which may rapidly progress in active patients. SLAC development can be prevented by early diagnosis of soft tissue lesions on X-ray images, because these are usually apparent after reduction or at follow-up. If doubts arise, arthroscopy or another examination should be done, even though these may not be sufficiently reliable.

[Consequennce of nontreatment scapholunate instability of the wrist]. / Následky nelécené skafolunátní nestability zápestí.

Authors evaluate the results of patients with acute rupture of the scapholunate (SL) ligament, demonstrated by arthroscopy, in this study. One group of patients was treated with reinsertion of SL ligament by the help of Mitek anchor. In the other group there were patients with diagnosed total rupture of SL ligament which rejected the reinsertion of the ligament. Authors evaluate results of both groups 24 months after the injury. On the basis of clinical and X-ray results, even after such short time, reasonably worse results for the group without performed reinsertion were determined. Even X-ray documented arthrotic changes of scapholunate advanced collapse (SLAC) type were present.

[Forefoot surgery under regional anesthesia]. / Operace prednozí ve svodné anestezii nohy.

PURPOSE OF THE STUDY: The aim of this study is to present the method of lower limb peripheral nerve block for forefoot surgery and, in comparison with other methods, to evaluate the results in terms of postoperative analgesia and postoperative complications. MATERIAL: Our group included 164 patients, 13 men and 151 women in the age range from 16 to 79 years, who underwent surgery for forefoot deformities during the years 1998-99. Of these, 77 (46 %) were operated on under general anesthesia, 54 (33 %) under infiltration anesthesia and 33 (21 %) under peripheral nerve block. METHODS: When peripheral nerve block was used, the anesthetic Marcain was administered about 1 hour before surgery at the following sites: along the deep branch of the peroneal nerve on the dorsal side of the foot, along the tibial nerve behind the inner ankle, and along the sural nerve in the outer ankle region. After surgery, the duration of requirement for analgesia in all three types of anesthesia was recorded. Complications associated with wound healing were also recorded. Subjective satisfaction of the patients was evaluated as a separate issue. RESULTS: No intraoperative complications were found in the patients operated on under peripheral nerve block. In three patients, regional anesthesia was not sufficient and had to be completed with topical anesthetics administered during the operation. The patients treated under regional anesthesia asked for analgesics after an average of 9.5 hours; those operated on under infiltration and general anesthesia required analgesics at an average of 2.5 hours (range, 2 to 4 hours) and within 30 min of waking up, respectively. Complications associated with wound healing were recorded in 5 %, 11 % and 6 % of the patients treated under general, infiltration and regional anesthesia, respectively. Of the 33 patients operated on under regional anesthesia, 28 would prefer this anesthesia for any other similar surgery and five would rather have general anesthesia. DISCUSSION: Regional anesthesia is associated with fewer complications of wound healing than topical anesthesia, which is apparently due to a lower degree of ischemia produced in the treated limb by peripheral nerve block. Healing after regional anesthesia is only a little worse than after general anesthesia, but with the absence of risks related to general anesthesia. Patients operated on under general anesthesia feel pain immediately after surgery, those receiving infiltration anesthesia ask for painkillers at an average of 2.5 hours and, with well-introduced regional anesthesia, patients are free from pain for 9.5 hour on the average. The duration of postoperative pain absence is also related to the anesthetic used. The use of 1 % Mesocain results in a fast onset of anesthesia but its effect is shorter, while 0.5 % Marcain has a slower onset but a longer effect. CONCLUSIONS: Regional anesthesia for forefoot surgery, if the anesthetic is well administered, is one of the options associated with minimal risks. It apparently reduces complications of wound healing, when compared with infiltration anesthesia. It can be used in situations where general anesthesia would put the patient at risk. It also has a pronounced analgesic effect that persists well after surgery and provides better postoperative comfort for the patient. Key words: lower limb, peripheral nerve block, forefoot surgery.

[Our experience with repair of the scapholunate ligament using the MITEK bone anchor]. / Nase zkusenosti s reinzercí skafolunátního vazu pouzitím kostních kotvicek MITEK.

PURPOSE OF THE STUDY: A complete rupture of the scapholunate (SL) interosseal ligament results in palmar flexion of the scaphoid and dorsiflexion of the lunate that leads to disintegration of the carpal circle and the development of scapholunate dissociation with dorsal intercalary segment instability. If the injury is not treated properly or early, the abnormal position of the scaphoid and lunate results in degenerative changes of the wrist shown by X-ray and referred to as scapholunate advanced collapse (SLAC). The aim of this study was to evaluate the results of our method used for reconstruction of the SL ligament by means of MITEK bone anchors in acute injury. MATERIAL AND METHODS: The group included 17 patients, 12 male and 5 female, aged 18 to 49 years, with complete SL ligament ruptures. The dominant hand was affected in 10 patients. After the diagnosis had been confirmed, we performed reconstructive surgery involving re-attachment of the SL ligament to the scaphoid by means of the MITEK Mini G2 anchor. The patients were examined by X-rays at 3, 6, 12 and 24 months after the operation to assess the SL angle, capitolunate (CL) angle, SL distance and signs of SLAC. Hand function and pain were evaluated on the basis of the Wrightington Hospital Wrist Scoring (WHWS) system. RESULTS: The average preoperative value of the SL angle was 79 degrees and was corrected to 38 degrees by surgery. By subsequent physical therapy for 12 months, an SL angle of 51 degrees was achieved and increased to 52 degrees during the following year. The CL angle, showing a preoperative average value of 34 degrees, was corrected by surgery to 6 degrees, further increased to 9 degrees by exercising and then remained unchanged. The average SL distance of 5.25 mm preoperatively was reduced to 2.75 mm by surgery with no further change. At 24 months of follow-up, the results of pain evaluation were excellent, good and satisfactory in 41 %, 47 % and 12 % of the patients, respectively, with no poor outcome indicating restriction of the patient's daily activities. Functioning of the hand was excellent in 47 %, good also in 47 % and satisfactory in 6 % of the patients. The range of motion was excellent, good and satisfactory in 24 %, 64 % and 12 % of the patients, respectively. No stiff wrist was recorded after reconstruction of the SL ligament by our method. The hand grip was evaluated as excellent in 47 %, good in 35 % and satisfactory in 18 % of the patients. DISCUSSION: The results show that by reconstruction of the SL ligament with the use of MITEK anchors, radiographic values of the SL and CL angles and SL distance can reach the normal levels within 24 months of the operation. As assessed by the WHWS system, excellent and good results were achieved in 88 % of the wrists treated. Similarly, at 24 months of followup, excellent or good functional outcomes were reported by 94 % of the patients, and excellent or good results in relation to the range of motion and hand grip were experienced by 88 % and 82 % of the patients, respectively. CONCLUSIONS: When treating complete SL ligament ruptures within 4 weeks of injury, stabilization with Kirschner's wires, re-attachment of the SL ligament and suture of the articular capsule are adequate procedures leading to the best results. The ligament reconstruction with MITEK anchors, as presented here, is a relatively simple method giving good results. For treatment of chronic instability it is necessary to use other surgical procedures that, however, will reduce wrist mobility to a greater extent.

[Mercurimetric determination of cephalosporin antibiotics]. / Beitrag zur merkurimetrischen Bestimmung der Cephalosporin-Antibiotika.

The conditions for a potenciometric estimation of cefuroxime, cefsulodin, cefotaxime and ceftriaxon with mercury(II) perchlorate after the previous reaction of the antibiotics with hydroxylamine were established. The mercurimetric determination was well reproducible with the relative error of the mean ranging up to 1% and the results are identical with the spectrometric and microbiological determination. There is no need to use a standard. With this technique only the content of effective antibiotic with an intact beta-lactam ring can be estimated. The method did not provide objective results for cefoperazone and cefoxitin. The direct determination of cephalosporin degradation products was verified for cefalexin, cefalothin, cefuroxime, cefsulodin and ceftriaxon.

[Conditions for the mercurimetric determination of the drug content of penicillins]. / Bedingungen für die merkurimetrische Gehaltsbestimmung von Penicillinen.

Mercurimetric determination of penicillins includes direct titration with a solution of mercury (II) perchlorate in the medium of pyridine solvent or acetate buffer, which determines the content of decomposition products, and titration after alkaline hydrolysis, which indicates the total amount of penicillin. The determination which is indicated potentiometrically with continuous addition of the titrant, provides real and reproducible results in the titration rate of 0.6 ml/min with the initial concentration of penicillin 170 mg/30 ml and temperature 25 degrees C. Benzathine and procaine salts of benzylpenicillin and benzathine salt of phenoxymethylpenicillin were dissolved in dimethylformamide (DMF) before the titration in acetate buffer. Titrations of ampicillin, amoxycillin and azlocillin were performed in the mixture of acetate buffer and formamide which ensured real results. Hydrolysis of the lactam ring of azlocillin, mezlocillin, ticarcillin and piperacillin is quantitative in 10 min of action of NaOH (1 mol/l) which was confirmed by comparing with the enzymatic cleavage. Relative standard deviation for all penicillins was less than 1%. The accuracy of the method for the determination of penicillins was proved by comparing with the microbiological and iodometric determination. The mercurimetric determination of penicillins and their decomposition products in acetate buffer was applied to injections, tablets, capsules and dry sirup.