[Total Replacement of the First Metatarsophalangeal Joint by Medin PH-Flex and Its Effect on Forefoot Biomechanics in the Propulsion Phase of the Gait Cycle]. / Totální náhrada prvního metatarzofalangeálního skloubení Medin PH-Flex a její vliv na biomechaniku prednozí v propulzní fázi krokového cyklu.

PURPOSE OF THE STUDY Total arthroplasty of the first metatarsophalangeal joint is one of the surgical treatment options for patients with advanced hallux rigidus. This study evaluates the pressure changes in the propulsion phase of the gait cycle using dynamic pedobarography after the total arthroplasty of the first metatarsophalangeal joint by Medin PH-Flex and their comparison with the control groups of patients with hallux rigidus and with asymptomatic patients. MATERIAL AND METHODS Dynamic pedobarograph was used to evaluate 15 first MTP joint replacements by Medin PH-Flex implants in 12 female patients, the average time since joint replacement was 3.5 years (1.5 to 5.5 years). The control group consisted of 13 forefeet in 12 patients with hallux rigidus of Grade 3 and Grade 4 according to the Coughlin classification and 17 healthy patients with no clear foot deformity, i.e. of a total of 34 forefeet. A zone for each metatarsal (M1-M5) and the big toe area (T1) were defined with the use of an integrated software. The difference between the pressure under the big toe area and the first metatarsal bone - hallux stiffness (T1-M1) and the forefoot balance parameter, i.e. the difference between the pressures under the medial and lateral half of the forefoot ((M1+M2)-(M3+M4+M5)), was obtained. The parameters were evaluated for each group during the propulsion phase of the gait, i.e. from 55% to 100% of the stance phase and from 75% to 100% of the stance phase, i.e. that part of propulsion when the greatest pressure is exerted on the big toe. RESULTS For the HS parameter (T1-M1) in 55% to 100% of the stance phase, the median value was -0.66 ± 1.22 (-1.90 to 1.45) in the control group, -0.85 ± 1.94 (-1.40 to 3.80) in patients with hallux rigidus, and -0.10 ± 1.48 (-1.30 to 2.40) in patients after the first MTP joint replacement. The median forefoot balance parameter from 55% of the stance phase was -3.48 ± 2.45 (-6.90 to 0.68) in healthy patients and -4.43 ± 2.72 (-6.98 to 0.23) in hallux rigidus patients. In patients after the joint replacement, the value was -3.00 ± 2.46 (-6.20 to 0.40). The data were statistically analysed by the Dunnett's and Tukey's multiple comparison tests. The hallux stiffness parameter showed a significant improvement after the joint replacement compared to patients with hallux rigidus (p<0.0001). No statistical significance was confirmed when comparing the joint replacement cases and the healthy patients from the control group (p=0.0007 and p=0.0010, respectively). As concerns the forefoot balance parameter, a significant difference was reported in patients with joint replacement compared to healthy patients from the control group and patients with hallux rigidus (p <0.0001). DISCUSSION The published pedobarographic studies differ in terms of the methodology used, the patient population and the parameters examined. The pedobarographic studies after the replacement of the first MTP joint or after its arthrodesis present inconclusive outcomes. According to the available literature, the joint replacement has the potential to improve mediolateral forefoot loading and to partially restore the weight-bearing function of the first ray. Our analysis of the HS parameter suggests that the MTP joint replacement can improve the big toe function compared to patients with hallux rigidus but fails to achieve the functional outcomes of healthy patients. When evaluating the forefoot balance (FB) parameter, we can observe less loading on the lateral half of the forefoot in the propulsion phase compared to hallux rigidus. Nonetheless, the joint replacement is unable to restore the physiological loading of the foot. CONCLUSIONS The first MTP joint replacement has the potential to improve forefoot function and to bring it closer to that of a healthy person, even though achieving physiological loading of the forefoot is unrealistic. Additional studies will be needed to confirm that the indication for the first MTP joint replacement is justified in hallux rigidus in terms of the effect on forefoot biomechanics. Key words: hallux rigidus, total replacement of the first MTP joint, dynamic pedobarography, footscan.

Long-term results of total joint arthroplasty and phalangeal hemiarthroplasty of the first metatarsophalangeal joint using the ToeFit Plus™ system.

BACKGROUND: This paper compares long term success rate of MTP joint replacement for hallux rigidus. We provide long term results of MTP joint replacement with the use of the ToeFit Plus™ System. MATERIALS AND METHODS: Our group consisted of 19 total joint replacements and 12 hemiarthroplasties in 18 and 11 patients respectively, performed between 2005-2009. The average follow-up period was 12.2 years (range 9.8-13.7, SD 1.1) for total arthroplasty group and 11.1 years (range 9.5-13.9, SD 1.7) for hemiarthroplasty group. In all followed patients AOFAS score was calculated along with the range of motion assessment. RESULTS: Average AOFAS score improved from 37 preoperatively to 79 at the time of last follow-up in total arthroplasty group and from 45 to 86 in the hemiarthroplasty group, with consideration to the statistically considerable difference of both groups. The total range of motion improved on average from 14° to the current 32° in patients with total arthroplasty and from 15° to 32° with hemiarthroplasty. The total number of cases that required surgical revision was 7 (37%) in total arthroplasty group and 2 (17%) in hemiarthroplasty group. CONCLUSION: Due to the high percentage of failure that was shown in our long term results, we no longer utilise the ToeFit Plus™ System.

Does the Femoral CCD Angle Measurement in a Standard AP Projection Correlate with the True Anatomical Shape of the Femur?

PURPOSE OF THE STUDY This study aims to ascertain whether a high anteversion of the femoral neck can influence the measurement of the caputcollum-diaphyseal (CCD) angle on a plain anteroposterior (AP) radiograph of the proximal femur. MATERIAL AND METHODS We developed a new method of measuring the CCD angle and femoral neck version of the femur. This was done with the use of a computer program that utilised the measurement of the entire visualised area of femoral neck and shaft to calculate their long axis. Using this method, we measured the CCD angle and femoral neck version (FNV) of 100 photographed cadaveric femurs in two projections: The condylar line (CL) projection and the femoral neck (FN) projection. The same method was applied to 50 radiographs of the same femurs. The femurs were divided into three groups depending on the femoral neck version: Retro (FNV of <0°), Normal (FNV of 0-15°) and Ante (FNV of >15°) RESULTS We found a statistically significant difference in the CCD angle measured in the FN and CL projections in the Normal and Ante groups but not in the Retro group. There is a significant correlation between the increase in FNV and the difference between the measured CCD values in the FL and CL projections. The femoral neck version of our cadaveric femurs varied from -14. 4° to 31. 5° which is a range of more than 35°. CONCLUSIONS From the results, it is clear that with an increase in femoral neck anteversion, there is a statistically significant difference in the CCD angle measured between the two projections. This difference can be up to almost 10°. Surgeons should be aware of the limitation of the AP projection when planning for surgery on the hip. Key words: femoral neck anteversion, CCD angle, templating, preoperative planning.

[Minimally Invasive Hallux Valgus Surgery: First Experience]. / Miniinvazivní operace hallux valgus: první zkusenost.

PURPOSE OF THE STUDY The Minimally Invasive Chevron Akin (MICA) is a percutaneous technique used to correct hallux valgus deformity. The combination of distal osteotomy of the first metatarsal and the proximal phalanx of the big toe stabilized with internal fixation was used over the last decade. The retrospective study presents the results of measurements performed on preoperative and postoperative X-rays and offers a comparison with conventional osteotomies. MATERIAL AND METHODS The study population consists of 76 patients who underwent 93 operations between 2015 and 2018 at the Department of Orthopaedics, 1st Faculty of Medicine, Charles University in Prague. The mean age of patients was 50.2 years (range 18-74 years). The study evaluates and measures the parameters and the attributes of interest on weight-bearing X-rays of the foot before and after the operation at 6-week or 3-month follow-ups. The first intermetatarsal angle was measured according to the mechanical and the anatomic axis of the first metatarsal bone. Apart from that, the displacement of the first metatarsal head in the osteotomy, hallux valgus angle and distal metatarsal articular angle were analysed. The position of the medial sesamoid bone and the congruency of the first metatarsophalangeal joint were evaluated as well. RESULTS The mean hallux valgus angle was 33.2° ± 7.3° and 10.2° ± 5.8° postoperatively. The mean value of the first mechanical intermetatarsal angle decreased from 12.4° ± 2.8° to 7.4° ± 2.5° postoperatively. The mean value of the first anatomic intermetatarsal angle increased from 13.7° ± 3.6° to 17.4° ± 4.6°. The used technique restored the congruency of the first metatarsophalangeal joint in 85 cases (91%). The mean lateral displacement of the metatarsal head fragment was 50% of its width (range 18% to 84%). The mean X-ray exposure during the operation was 0.58 mGy and the personnel were exposed to radiation for 79 seconds on average. DISCUSSION One of many questions raised with regard to hallux valgus surgery is the choice of the right technique in order to achieve proper position of the big toe. The surgeon should have the opportunity to use a technique that provides the possibility to change orientation of the metatarsal head articular surface in three anatomic planes. Our study found out that the displacement of the metatarsal head using the MICA technique in transversal plane is from 4 mm to 18 mm (in 20 mm diameter of the head). The method thus offers a possibility to correct mild, moderate and partially severe deformities as well. The main disadvantage of the method is the necessity to use a C-arm at the operating theatre. CONCLUSIONS The Minimally Invasive Chevron Akin (MICA) is a percutaneous technique to correct hallux valgus deformity based on two extraarticular osteotomies of the proximal phalanx of the big toe and the distal part of the first metatarsal bone. The method using stable internal fixation with two screws offers a possibility to change the orientation of the articular surface of the metatarsal head in sagittal, transversal, and even in frontal plane, and is useful to correct mild and moderate deformities. Key words: hallux valgus, minimally invasive technique, percutaneous technique, chevron osteotomy, Akin osteotomy.

[Long-Term Results of the Ludloff Procedure in Relation to the Intraoperative Finding on Acetabular Labrum]. / Dlouhodobé výsledky operace dle Ludloffa ve vztahu k operacnímu nálezu na labrum acetabulare.

PURPOSE OF THE STUDY Developmental dysplasia of the hip still remains one of the most discussed topics in paediatric orthopaedics. The comprehensive care of paediatric patients with congenital developmental dysplasia of the hip at our department in the period from 1970 to 1985 included, among other things, the open reduction using Ludloff s approach in hip joints where closed reduction was not possible. This technique was supported by some of our own previous observations, such as the original classification of intraoperative findings on acetabular labrum (limbus). This study aims to evaluate the long-term results of treatment of our patients where Ludloff s open reduction was used and seeks to establish a conclusive correlation between the final result and the method of treatment of individual types of limbus, possibly confirming or ruling out that the dependence of later development of the acetabulum is dependent on correct and sparing treatment of this barrier to reduction. MATERIAL AND METHODS In the period from 1970 to 1985, the Ludloff s open reduction was performed in 70 patients. In 8 cases bilateral surgery was carried out. A total of 78 hip joints were operated on. The patients underwent the surgery at the age of 5-23 months. Postoperatively, the Hanausek biomechanical apparatus was applied to complete the treatment. In total, documentation of 21 surgeries performed in 20 patients was successfully tracked down. Two patients were removed from the group for incomplete documentation. The final group of patients included a total of 18 patients, of whom there were 13 women and 5 men. In one female patient the surgery was performed bilaterally. The shape of the femoral head, the center-edge (CE) angle and the degree of osteoarthritic changes were assessed on the pelvic radiograph of each patient. The functional result was evaluated using the Harris Hip Score (HHS). RESULTS For the purpose of assessment, the patients were divided into sub-groups based on the intraoperative finding on acetabular labrum. Type I limbus was found in a total of 5 cases. The mean HHS was 93, the mean CE angle was 22.5°. Aseptic necrosis occurred in one patient. Type II limbus was found in a total of 3 patients. The mean HHS was 84, the mean CE angle was 22°. Aseptic necrosis was observed in one patient. Type III limbus was found in 8 patients. The mean HHS was 79, the mean CE angle was 19.4°. Osteoarthritic changes of degree II-III were identified. Necrosis of the femoral head was recorded in 2 patients. Type IV limbus was found three times. The mean HHS was 73, the mean CE angle was 13.3°. Osteoarthritic changes of type III were present. Necrosis of the femoral head was recorded altogether in 2 patients. DISCUSSION The results of the Ludloff procedure reported in the available literature differ markedly as to the resulting function of the hip joint and the incidence of avascular necrosis. No author gave a description of the actual acetabular labrum deformity or showed a detailed description of individual vessel ligations. The advantage of this method is beyond any doubt its low invasiveness and when correctly performed also the minimal burden to the child. Its disadvantage is a certain degree of difficulty in performing this surgery, a worse visualisation of all barriers to reduction and a more challenging treatment of the posterior portion of the hip joint compared to techniques using the anterior approach. CONCLUSIONS Our outcomes indicate that the resulting Harris Hip Score was best in patients with the intraoperative finding of type I limbus. All the other types (II-IV) showed worse HHS results. From the current perspective, it is in all likelihood more advantageous to use surgical approaches that enable better visualisation of the anatomical deformities and allow for better options for their treatment. Key words: congenital hip dislocation, surgical treatment, open reduction, Ludloff procedure, acetabular labrum.

[Our Experience with the Total Replacement of the First Metatarsophalangeal Joint by Medin PH-flex]. / Nase zkusenosti s totální náhradou prvního metatarzofalangeálního kloubu palce PH-flex Medin.

PURPOSE OF THE STUDY: The first metatarsophalangeal (MTP) joint replacement ranks among the treatment methods of patients with hallux rigidus. The paper aims to evaluate the short-term to mid-term outcomes and to present clinical experience with our Medin PH-flex implant. MATERIAL AND METHODS In the period from January 2011 to 2016 we performed total replacement of the first MTP joint in 31 patients, in 4 cases bilaterally. In total, 35 implants were evaluated. The mean age of the patient at the time of surgery was 57.7 years (39-72 years). The surgery was conducted in 29 women and 2 men. The patients were evaluated using the AOFAS score (American Orthopaedic Foot and Ankle Society score), the radiographs were assessed as to the potential occurrence of radiolucent lines, with major stress put on the assessment of the mobility in MTP joint and its position. The pain was assessed based on the VAS score. RESULTS Prior to the joint replacement surgery, the mean AOFAS score in patients was 55.6 (35-65). Postoperatively, the mean AOFAS score was 80.8 (65-95). The pain suffered by patients was evaluated with the use of the Pain Visual Analogue Scale (VAS score). The preoperative mean VAS score was 5 (2-8), whereas the postoperative score improved to mean VAS 2 (0-4). The range of motion was clinically assessed with a goniometer. The mean range of motion of plantar flexion and dorsiflexion was 16.00° (5-35°) and 28.60° (10-55°), respectively. The mean range of motion was 36° (15-60°). No intraoperative complications were observed. In all the patients, the surgical wound healed per primam. In 2 female - (5.7 %) of the whole group of patients who underwent surgery a deep infection occurred, namely 10 and 21 months following the implantation. In both the female patients their condition was managed by joint revision operation and by a simple removal of the implant. DISCUSSION Joint replacement related matters were repeatedly discussed in professional literature. There are many papers published in the literature on this topic. A whole range of the first MTP joint implants of different shapes have been developed, with extremely different clinical results. CONCLUSIONS An appropriately chosen type of the implant, a fitting indication and a correctly applied implantation technique can lead to the desired good outcome. The first MTP joint replacement should be indicated after careful consideration since the management of a potential joint replacement failure can often be very technically challenging and quite mutilating for the patient. The mid-term outcomes of the Medin a.s. first MTP implant seem to be promising. It will, however, be necessary to wait for long-term outcomes in order to evaluate the final benefits of this type of implant in patients with hallux rigidus. Key words: hallux rigidus, arthroplasty of the MTP joint, hemiarthroplasty, silicone implant.

[Eleven-Year Experience with Total Ankle Arthroplasty]. / Jedenáctileté zkusenosti s náhradou hlezna.

UNLABELLED: PURPOSE OF THE STUDY Total joint replacement is one of the options in surgical treatment of advanced ankle arthritis. It allows the ankle to remain mobile but, unfortunately, it does not provide the same longevity as total knee or hip replacements. Therefore, decisions concerning the kind of treatment are very individual and depend on the clinical status and opinion of each patient. MATERIAL AND METHODS A total of 132 total ankle replacements were carried out in the period from 2004 to 2015. The prostheses used included the Ankle Evolutive System (AES) in 52 patients, Mobility Total Ankle System (DePuy) in 24 patients and, recently, Rebalance Total Ankle Replacement implant in 53 patients. Three patients allergic to metal received the Taric prosthesis. Revision arthroplasty using the Hintegra prosthesis was carried out in four patients. The outcome of arthroplasty was evaluated on the American Orthopaedic Foot and Ankle Society (AOFAS) scoring scale. Indications for total ankle arthroplasty included post-traumatic arthritis in 83 patients, rheumatoid arthritis in 37 and primary arthritis in 12 patients. There were 78 women and 54 men, with an average age of 55.6 years at the time of surgery. RESULTS The average follow-up was 6.1 years (1-11 years). The average AOFAS score of the whole group increased from 33.2 before surgery to 82.5 after it. The primary indication had an important role. Arthroplasty outcomes were poorer in patients with post-traumatic arthritis than in those with rheumatoid arthritis or primary arthritis. In patients with post-traumatic arthritis, the average AOFAS score rose to 78.6 due to restricted motion of the ankle, and some patients continued to have pain when walking. The average AOFAS score in a total of 49 patients who had rheumatoid arthritis or primary arthritis reached a value of 86.4. Post-operative complications were recorded in ten patients (7.6%) in whom part of the wound was healing by second intention. Ossification was also a frequent complication and had to be removed in six patients (4.5%). No early infection was recorded and late infection was treated in three patients. The prosthesis had to be removed and ankle arthrodesis performed in seven patients (5.3%). All had necrosis of the talus with ankle instability. In five, the retrograde nail Medin was used and extensive defects remaining after talar necrosis were filled with massive bone grafts obtained from a bone bank. One patient required tibio-calcaneal arthrodesis with external fixator; surgery in one case involved the use of a Zimmer Trabecular Metal Ankle Fusion Spacer with retrograde nail fixation. The development of cystic radiolucencies adjacent to tibial or talar components presents another post-operative complication. It was recorded mostly in the patients after AES implantation, in whom eight of 52 (15.3%) had these findings. DISCUSSION Total ankle arthroplasty is a complicated surgical procedure potentially associated with various technical problems. The occurrence of complications is indirectly related to the experience of the orthopaedist performing surgery; literature data show that the number of complication decreases with an increased frequency of ankle replacements done. CONCLUSIONS Total ankle arthroplasty, as every orthopaedic surgery, has its advantages and disadvantages. The positive aspects are pain relief and improved mobility of the ankle allowing for physiological gait. However, it shows a lower survivorship rate that the other large joint replacements. A successful outcome depends on the correct indication. The ankle should be stable, the talus without signs of necrosis and valgus or varus deviations of the ankle should not exceed 10 to 15 degrees. KEY WORDS: total ankle arthroplasty, re-implantation, aseptic loosening, retrograde nail, Trabecular Metal spacer, revision arthroplasty.

PCR diagnostic system in the treatment of prosthetic joint infections.

In our prospective study, we examined whether a multiplex PCR diagnostic method is suitable for the primary detection of pathogens. We also examined the possibility and sensitivity of detecting genes responsible for biofilm production and methicillin resistance. From 2007 to 2009, 94 patients were included in the study. A UNB (universal detection of 16S ribosomal bacterial DNA) and UNF (universal detection of pathogenic fungi) were used in the primary detection. A multiplex assay for biofilm production, methicillin resistance allowed us to distinguish between Gram positivity and negativity and to detect Staphylococci. From all the samples, the culture was positive in 53.2 % of cases, and by using the UNB method, we detected bacteria in 79.8 % of cases-the UNF detection of fungi was positive in 10.6 % of cases. In 75 % of positive findings, we detected a Gram-negative bacterium in 65.3 % of cases. In 47.2 % of Staphylococci detected, the ability to produce biofilm was confirmed. 61.1 % of the Staphylococci exhibited a methicillin resistance. Our multiplex scheme cannot yet fully replace microbial cultivation but can be a rational guide when choosing an appropriate antibiotic therapy in cases where the microbial culture is negative.

[Tumour-like lesion of the forefoot due to a retained toothpick fragment. Case report]. / Tumoru podobná afekce prednozí na podklade retence dreveného párátka. Kazuistika.

The case of a 17-year-old patient with a pseudotumour of the forefoot caused by a retained toothpick fragment is reported. The patient had several examinations in a two-year period and was treated for synovialitis of the first and third metatarsophalangeal joints. However, radiography of the plantar surface was the only examination done during these two years. Therapy was unsuccessful. After admission to our department, ultrasonography was performed and a foreign body in granulation tissue was detected. Computed tomography and MRI confirmed the finding. The foreign body granuloma was removed by surgery and the patient healed successfully. Options for visualising wooden foreign bodies not detected on X-ray images are discussed. Key words:pseudotumour, forefoot, toothpick, retained.

[Release of the lateral structures of the first metatarsophalangeal joint during hallux valgus surgery]. / Uvolnení laterálních struktur prvního metatarzofalangeálního skloubení pri operaci pro hallux valgus.

PURPOSE OF THE STUDY: Operations of hallux valgus deformity are very well known in orthopaedic surgery. The important part of these procedures is the release of soft tissue on the lateral side of the first metatarsophalangeal joint. Soft tissue procedures became routinely used in the 1920s and 1930s and several techniques of soft tissue release have been published in the past seventy years. We found several inaccuracies between the anatomy published and the routine clinical performance. The purpose of the study was to describe the anatomy of the first metatarsophalangeal joint's lateral part, especially the adductor hallucis muscle attachment, and to assess to what extent the lateral structures of the first metatarsophalangeal joint should be released to correct hallux valgus deformity. MATERIAL: We described and compared the anatomy of the lateral part of the first metatarsophalangeal joint on 30 dissected specimens obtained from cadavers that met the criteria of hallux valgus deformity. METHODS: The standard preparation method was used for anatomical dissection; whole leg specimens including the pelvic girdle were fixed in formaldehyde, acetone, ethyl-alcohol and glycerol. The detailed course and shape of the adductor muscle attachment was described as well as its relation to the lateral sesamoid bone, lateral portion of the flexor hallucis brevis and the transverse metatarsal ligament. Dissection of the joint's lateral capsule was used to show the course of the lateral collateral ligament, sesamoid ligament and conjoined tendon of the adductor hallucis and flexor hallucis brevis muscles. Subsequently, we released the lateral sesamoid ligament with a standard longitudinal cut and then released the conjoined tendon and lateral collateral ligament at the level of the joint gap in the frontal plane. We evaluated the proposed technique in terms of the extent of soft tissue release and the size of tenotomy necessary to correct the deformity. RESULTS: The mean valgus deformity was 32° (range, 18° to 50°). We were not able to define space between the medial border of the adductor hallucis and the flexor hallucis brevis in 23 cases (77%). The mean size of release was 6.4 mm (range, 5 to 15 mm) and the width of a conjoined tendon at the level of release was 11.2 mm (range, 8 to 15 mm). We did not achieve satisfactory release with our technique in two cases (7%, deviation 45° and 50°). DISCUSSION: We compared our results with those of similar anatomical studies. We found several inaccuracies in anatomical descriptions of the adductor hallucis attachment. We confirmed the difficulty in separation of the adductor hallucis from the lateral head of the flexor hallucis brevis in total tenotomy of the adductor. Our technique was successful in releasing the first metatarsophalangeal joint's lateral structures. CONCLUSIONS: Our study showed than even partial tenotomy of the conjoined tendon of the adductor hallucis and flexor hallucis brevis muscles is successful in correcting hallux valgus deformity. The release has to be combined with release of the lateral sesamoid ligament.

Bone grafts as vancomycin carriers in local therapy of resistant infections.

The level of an antibiotic capable of inhibiting the etiological agent at the site of infection is an essential prerequisite for successful antibiotic therapy. In some cases, locally applied antibiotics may compensate for limitations of systemic administration and shorten systemic therapy. We aimed at verifying to what extent vancomycin (Van) bound to ground bone grafts is usable in the treatment of serious infections. The levels of released Van significantly exceeded the Van minimum inhibitory concentration, which can suppress Van-sensitive staphylococci and Van intermediate Staphylococcus aureus, for the whole period of a 16-day measurement. Our results indicate that bone grafts can be used as Van carriers in therapy of osteomyelitis caused by Van-sensitive Staphylococcus strains.

[MEDIN implant of the first metatarsophalangeal joint]. / Náhrada prvního metatarzofalangeálního skloubení Medin.

PURPOSE OF THE STUDY: Hemiarthoplasty or total replacement of the first metatarsophalangeal (MTP) joint has been used in orthopaedic surgery for the last 60 year, but good post-operative outcomes have been achieved only in the last ten years. Joint replacement is mainly used in stage 3 and stage 4 hallux rigidus conditions for which arthrodesis is not indicated. The operation on the first MTP joint has its place in the present-day orthopaedics. This study describes anatomical measurements and the development of the first Czech implant (MEDIN Orthopaedics) to replace this joint. MATERIAL AND METHODS: Thirty cadaver specimens were used to develop basic shapes of phalangeal and metatarsal components. A standard technique was used for anatomical dissection of the first MTP joint. Fifteen specimens were cut in the sagittal plane and fifteen in the transverse plane in order to open the intramedullary cavity of the proximal phalanx of the great toe and the first metatarsal bone. The basic shapes of phalangeal and metatarseal components were designed based on the shape of cortical bone of their inner surfaces. Data for the shape, size and scale of articular components were obtained by measurement on 58 dry bone specimens of the first metatarsus and on 30 calibrated X-ray images. In order to adjust the scale and size of components, the final shape and the range of implant size were tested on 50 specimens of dissected lower extremities fixed in formaldehyde, acetone, ethyl-alcohol and glycerol. RESULTS: The new type of a first MTP implant designed by us was based on cone-shaped anchor components coated with hydroxyapatite. The implants can be used in hemiarthroplasty or total joint replacement. The metatarsal insert was designed with a declination angle of 20 degrees to facilitate good dorsiflexion and with a flattening to ensure good function of the sesamoid bones, The phalangeal articular insert was made of either CoCr alloy or low-weight polyethylene for use in hemiarthroplasty and total joint replacement, respectively. DISCUSSION: The new implants are designed for treatment of stage 3 or stage 4 hallux rigidus. We recommend to use hemiarthroplasty or total joint replacement only in the case of first metatarsal head destruction or severe joint destruction due to rheumatoid arthritis. CONCLUSIONS: Our anatomical study of the first MTP joint, proximal phalanx of the great toe and first metatarsal bone was used to design the first Czech implant of this joint.

[Bilateral arthrodesis of the medial foot joints in a patient with rheumatoid arthritis]. / Oboustranná artrodéza mediální cásti nohy u pacientky s revmatoidní artritidou.

Patients with rheumatoid arthritis (RA) often have foot problems. The subtalar and particularly talonavicular joints are affected most frequently. The posterior tibial tendon has an important role in mid-foot stability. In RA patients, chronic inflammation of this tendon or talonavicular joint arthritis can results in posterior tibial tendon rupture. This leads to a collapsed talonavicular joint and forefoot instability, first with talonavicular and later Chopart's joint involvement. This shows as a planovalgus foot, with the forefoot in pronation and the heel in valgus deviation. In a 61-year-old RA patient, ruptures of the posterior tibial tendon due to rheumatoid inflammation occurred bilaterally, with subsequent deviation and instability of the forefoot. Arthrodesis with a medial column screw-Midfoot Fusion Bolt was carried out on the left foot and 4 months later on the right foot. At 7 months after the left and 4 months after the right foot surgery, the patient was free from pain, both feet were stable under loading and the forefoot was firm. The planovalgus deformity was corrected, as well as a valgus deviation of the great toe. Radiography showed a good position of the screws and complete healing of the medial foot joints.

[Anatomical study of flexor hallucis brevis insertion: Implications for clinical practice]. / Anatomická studie úponové cásti m. flexor hallucis brevis pro klinickou praxi.

PURPOSE OF THE STUDY: The flexor hallucis brevis (FHB) is one of the short muscles of the foot. It divides in front into two portions, which are inserted into the medial and lateral sides of the base of the first phalanx of the great toe. The detailed knowledge of its insertion into the proximal phalangeal base is decisive in any surgery involving the first metatarsophalangeal (MTP) joint, such as implant arthroplasty, resection arthroplasty or amputation. Complications resulting from injury to this insertion are commonly known. The aim of this study was to describe in detail the morphology of FHB insertion sites and to determine a safe extent of resection to be done at the base of the proximal phalanx. MATERIAL AND METHODS: In 36 cadaver specimens we measured FHB insertion length from the plantar side of the proximal phalangeal base and from the plane perpendicular to the long axis of the phalanx and passing through the base of the concave articular surface of the phalanx. RESULTS: Measured from the plantar base of the proximal phalanx, the mean length of the medial insertion site was 11.5 ± 0.9 mm (range, 9.5 to 13.0 mm) and that of the lateral insertion site was 9.5 ± 1.1 mm (range, 8.0 to 11.5 mm). After resection, the mean values for medial and lateral FBH insertion sites were 8.5 ± 1.7 mm (range, 6.5 to 11.0 mm) and 7.1 ± 1.4 mm (ran- ge, 5.5 to 9.5 mm), respectively. The mean total proximal phalangeal length was 33.1 ± 2.2 mm (range, 28.5 to 37.0 mm), reduced after resection to 30.5 ± 2.1 mm (range, 26.0 to 34.5 mm). DISCUSSION: Our results show that the medial insertion site, where the medial FHB tendon and distal part of the abductor hallucis muscle are joining, is longer than the lateral site. Therefore the length of the lateral site is decisive for preserving FHB function. Since the plane perpendicular to the long axis of the phalanx and passing through the base of the concave articular surface of the phalanx is almost identical with the beginnings of FHB insertions, it seems optimal for clinical practice to perform the initial resection along this plane. CONCLUSIONS: To preserve at least one third of the FHB insertion, the final resection should not exceed 4 mm or 13 % of the proximal phalangeal length, as measured from the reference plane defined above.

[Long-term results of the SVL total knee arthroplasty]. / Dlouhodobé výsledky náhrady kolenního kloubu SVL.

PURPOSE OF THE STUDY: The aim of the study was to evaluate the long-term results of the total knee replacement Beznoska SVL implanted at the 1st Department of Orthopaedic Surgery, 1st Faculty of Medicine, Charles University and Motol University Hospital Prague, in the 1997/2009 period. MATERIAL AND METHODS: The SVL implant is a non-constrained knee replacement, anatomically similar to the bone it replaces, which preserves the posterior cruciate ligament. A total of 1101 knee joint replacements were evaluated in 973 patients, of whom 128 underwent bilateral arthroplasty. Kaplan-Meier curves were used to estimate the cumulative survival of implants. Clinical outcomes were assessed using the Knee Society clinical rating system (KS score) and radiographic data evaluation was also included. RESULTS: Using KS scores, the results were excellent in 997, good in 75, satisfactory in 19 and poor in 10 knees. The average range of motion was 0.16 to 106.31 degrees. The complications included flexion contracture, as the most frequent problem (13 knees), 10 knees were infected, aseptic loosening due to polyethylene granuloma was found in eight knees and anterior knee pain was experienced in six cases. At follow-up of 12.5 years implant survivorship was 98 %, as evaluated by the Kaplan-Meier analysis. DISCUSSION: A comparison of SVL implant survivorship with other knee replacement designs is discussed. It should be emphasized that the clinical outcome depends not only on implant quality, but also on the operative technique used and the surgeon's experience and skills. It is the SVL system that allows for the balancing of knee joint stability and thus enables even less experienced surgeons to make use of a more sophisticated implantation technique. CONCLUSIONS: Total knee replacement using the SVL Beznoska implant is a safe, reliable and economic treatment with excellent clinical outcomes.

[In vitro assessment of vancomycin released from bone grafts]. / Monitoring vankomycinu uvolnovaného z kostních stepu v pokuse in vitro.

PURPOSE OF THE STUDY: Infections of the musculoskeletal system present a serious problem in orthopaedic and trauma medicine because, typically, they are often recurrent and associated with the development of resistance to antibiotics. The aim of this study was to ascertain whether the local concentration of vancomycin released from cancellous bone grafts exceeded the minimum inhibitory concentration (MIC) for vancomycin-resistant Staphylococcus aureus (VRSA ≥ 16 mg/L) during a 16-day in vitro experiment. MATERIAL AND METHODS: Morselised grafts of spongy bone were selected as ideal local carriers of antibiotic. They were impregnated with vancomycin (Edicin®). Its concentration was assessed by Agilent 1200 high performance liquid chromatography coupled with a diode array detector (Agilent Technologies, USA). Morselised bone was impregnated with vancomycin at 0.1 g antibiotic per 10 g bone, and 20 samples each weighing 1 g were prepared. They were placed in test tubes with phosphate buffer at pH = 7.4 and maintained in a thermostat at 37°C. During the 16-day period, buffer samples were taken at intervals and examined for vancomycin concentration by the above-described method. RESULTS: During the whole experimental period, the level of released vancomycin was high above the MIC for VRSA. The maxi- mum average concentration was obtained between day 2 and day 4 and it reached 507.68 mg/L. At this interval the vancomycin level was stable, because there was no significant difference (p >.0.005) between the values of the 2nd and the 4th day. Then a gradual decrease in antibiotic levels was detected, with an average concentration of 332.29 mg/L recorded at 16 days. DISCUSSION: Recently, the occurrence of methicilin-resistant Staphylococcus aureus (MRSA) infections has been increasing as well as the risk of VRSA infections, and therefore our experiment was set up to assess the releasing properties of bone grafts impregnated with vancomycin The levels of released vancomycin were much higher than the MIC for VRSA for the whole period of measurement. This finding is different from the results of an in vitro study by Witso et al., in which the vancomycin level dropped below the MIC after 2 weeks. The decrease in vancomycin levels following its maximum values was greater than it had been expected although the samples were diluted only minimally..There are several explanations for this finding. However, from the clinical point of view it is important that, for a sufficiently long period, vancomycin is maintained at a level exceeding the MIC for VRSA. CONCLUSIONS: In an in vitro experiment under conditions simulating a human internal environment, the elution of antibiotic from vancomycin-impregnated cancellous bone grafts was investigated. The local vancomycin concentrations much exceeded the MIC for VRSA for more than 2 weeks. The highest levels, i.e. the total vancomycin amount, were recorded at 2 to 4 days after carrier application. Based on the experimental results, vancomycin-loaded bone grafts can be recommended for local treatment of the musculoskeletal system infected with antibiotic-sensitive staphylococci, MRSA strains or possibly also for VRSA infections.

[ToeFit-Plus system for replacement of the first metatarsophalangeal joint]. / Nase zkusenosti s náhradou I. MTP kloubu palce implantátem ToeFit Plus.

PURPOSE OF THE STUDY: Hallux rigidus is a frequent disease of the first metatarsophalangeal (MTP) joint. It is a painful condition markedly reducing joint motion. For grade-3 and grade-4 disease, as classified by Coughlin, first MTP joint replacement is another option of surgical treatment, in addition to resection arthroplasty or arthrodesis. MATERIAL AND METHODS: In a group of 27 patients with symptomatic hallux rigidus, 28 MTP joint replacements using a TOEFIT-PLUS implant were carried out in the 2005-2009 period. There were 24 women and three men, with an average age of 56.3 years. The average follow-up was 24 months (range, 4 to 48). Indication for surgery included hallux rigidus in 20, conditions following Keller's arthroplasty in five, necrosis of the first metatarsus head in two cases and a condition after the Austin procedure in one patient. Pain, assessed by the Kitaoka score, and the range of joint motion; were evaluated before the surgery and at the final follow-up visit this also included the radiographic assessment of implant position and its integration. RESULTS: Of the 28 implants used, nine were hemiprosthetic and 19 total joint replacements. The average time between surgery and full weight-bearing was 6.6 weeks (range, 5 to 8) in both groups. The post-operative Kitaoka score was 87.1 (68-100) as compared with the preoperative value of 36.3 (24-52), and this difference was statistically significant.The range of motion at the first MTP improved from 14.7 degrees pre-operatively to 38.5 degrees post-operatively. There was no statistically significant difference in joint function, as assessed by the Kitaoka score and range of motion, between the two groups (hemiprosthetic vs. total joint replacements). The complications included prolonged skin healing with minor dehiscence in four cases. Revision surgery was required in three cases because of restricted joint motion associated with pain. In three cases of the total joint replacement group, there was radiographic evidence of asymptomatic osteolysis around both the phalangeal and the metatarsal component. In the hemiarthroplasty group, no osteolysis was recorded. DISCUSSION: Up to now several types of implants have been developed to alleviate pain and restore and maintain the first MTP motion in patients with hallux rigidus.The TOEFIT-PLUS implant belongs to the most recent ones. Our results are in agreement with those of other currently used replacements in terms of clinical and functional evaluation. The complications recorded in our study are also similar to those reported in the literature, which include aseptic loosening, dislocation and mechanical failure of the implant. There is no consistent approach to their treatment. Arthrodesis with tricortical graft seems to be an option, but it carries a considerable risk of failure. Since in our patients aseptic loosening was recorded only in the total joint replacement group, hemiarthroplasty has recently been preferred, because it has clinical and functional outcomes as good as total joint replacement. CONCLUSIONS: Our results with the use of TOEFIT-PLUS replacement show that this implant is effective in the treatment of hallux rigidus advanced stages and has good clinical outcomes, i.e., maintenance of motion at the MTP joint of the big toe, pain alleviation and early weight bearing. Since hemiarthroplasty is associated with fewer complications whose potential treatment is easier, this approach seems to have a better prospect than total joint replacement.

[Regional anaesthesia of the foot achieved from two cutaneous points of injection: an anatomical study]. / Bloková anestezie nohy provedená ze dvou kozních vpichu (anatomická studie).

PURPOSE OF THE STUDY Regional anaesthesia for the lower extremity distal to the ankle joint, knows as anaesthetic ankle block or foot block, involves a series of injections of local anaesthetic to block the peripheral nerves that supply innervation to the foot. Since the tibial nerve block is not always effective, the aim of this study was to design a modified technique of anaesthetic application. MATERIAL The study was carried out on 30 human cadavers provided by the Institute of Anatomy, 1st Faculty of Medicine, Charles University in Prague, and included data on a total of 60 lower extremities. METHODS Information about position of the tibial nerve (or its branches, i.e., the medial plantar and lateral plantar nerves) and the sural nerve was obtained using a set of special measurement devices designed for this purpose. The following distances were measured; the length of a basic line, i.e., distance between the posterior margin of the medial maleollus and the medial edge of the Achilles tendon (at the level of the upper part of the heel bone); the distance between the medial edge of the Achilles tendon and the tibial nerve; and the distance between the tibial nerve (its deep location) in the neurovascular plexus and the basic line. The location of the sural nerve behind the lateral maleollus was found by measuring the nerve distance from the posterior margin of the lateral maleollus and measuring the distance between this margin and the lateral edge of th Achilles tendon. RESULTS The distance between the posterior margin of the medial maleollus (medial edge of the sulcus for the posterior tibial muscle tenton) and the medial edge of the Achilles tendon (at the level of the upper part of the heel bone) was 46.3 mm +/- 5.2 mm. The depth of tibial nerve location, i.e. distance from the basic line to the neurovascular plexus, was 11.6 mm +/- 1.3 mm. The distance between the posterior margin of the lateral maleollus and the lateral edge of the Achilles tendon (at the level of the upper part of the heel bone) was 37.1 mm +/- 4.3 mm. The sural nerve was located at a distance of approximately 18.3 mm +/- 1.9 mm from the posterior edge of the lateral maleollus. DISCUSSION The study was concluded by proposing a modified technique of local anaesthetic ankle block using two points of anaesthetic injection. The first point is located immediately in front of the medial edge of the Achilles tendon and above the upper edge of the calcaneus. The anaesthetic applied will block the tibial and sural nerves, with the sural nerve being blocked by the anaesthetic delivered with a needle advanced through the soft tissues ventral to the Achilles tendon. The second area of application is located at 2 cm above the ventral fold of the ankle joint on the lateral edge of the anterior tibial muscle tendon and provides subcutaneous infiltration anaesthesia for the superficial and deep peroneal nerves and the saphenous nerve. CONCLUSIONS The results of this anatomical study provided a basis for a modified technique of regional anaesthesia of the foot. Its major clinical attributes involve reduced necessity to manipulate with the patient, and sensory and motor blockage of all nerves supplying innervation to the foot from only two points of injection. Key words: ankle block, foot block, regional anaesthesia.

[First experience with total wrist replacement using an implant of our design]. / První zkusenosti s totální náhradou zápestí nasí konstrukce.

PURPOSE OF THE STUDY: To present the results of total wrist replacement with a cementless prosthesis designed by us. MATERIAL AND METHODS: A group of five men and 27 women treated between 2004 and 2007 was evaluated. The average age was 51.6 years and follow-up ranged from 4 to 38 months, with an average of 9.4 months. Indications for surgery included wrist destruction due to rheumatoid arthritis, arthritis or psoriatic arthropathy. Subjective evaluation recorded satisfaction of the patients with the wrist range of motion, cosmetic appearance of the hand and pain relief. The range of motion was assessed with a goniometer at 4 months of follow-up on average. Radiographs were made immediately after surgery and then at 6 and 12 months post-operatively. RESULTS: All patients reported pain relief, 23 were satisfied with wrist mobility and hand appearance, and seven were only partly satisfied and would have preferred a greater range of motion. Two patients were dissatisfied with an ulnar deviation of the carpal axis and therefore revision arthroplasty of the radial ligamentary and tendinous structures was planned. No aseptic or septic loosening of the implant or its migration was found. DISCUSSION: The current total wrist arthroplasty has evolved from Swanson silastic implants to prostheses with a metal-on-polyethylene bearing whose active surfaces are firmly fixed in bone. In today's Europe, the most frequently used prostheses are Meuli implants or the latest modification of the Guepar implant, which is very close to the Universal 2 implant. In the USA since 1985, Professor's Beckenbaugh's BIAX implant has continuously been improved. The implant designed by us is based on all well-tired implant components and aims at being as similar to the anatomical wrist structures as possible. The socket is fixed in the distal radius. The carpal components involve the main fixation shaft for the third metacarpal and a short antirotation pin for the second metacarpal base. A metal head is assembled onto a tapered shaft extending from the carpal component transversal zone. The implant is made of titanium alloy, in some parts coated with hydroxyapatite; the sockets has a polyethylene liner. CONCLUSION: Total wrist replacement is usually preceded, particularly in surgery for rheumatoid arthritis, by operations intended to prevent or slow down gradual wrist destruction. The usual salvage procedures include surgery on soft tissues (synovectomy, tenodesis, tendon reconstruction) and/or bone (limited wrist arthrodesis, Sauve-Kapandji procedure). These procedures usually have a temporary effect and total replacement will be the next step in surgical treatment. For the most severe destruction associated with subluxation and wrist instability, total arthrodesis in a neutral wrist position still remains the method of choice. The first results with use of the implant of our design show that this total wrist replacement allows us to preserve or restore the wrist range of motion and to improved grip strength.

A new technique for reconstruction of the proximal humerus after three- and four-part fractures.

The results of proximal humeral replacement following trauma are substantially worse than for osteoarthritis or rheumatoid arthritis. The stable reattachment of the lesser and greater tuberosity fragments to the rotator cuff and the restoration of shoulder biomechanics are difficult. In 1992 we developed a prosthesis designed to improve fixation of the tuberosity fragments in comminuted fractures of the proximal humerus. The implant enables fixation of the fragments to the shaft of the prosthesis and the diaphyseal fragment using screws, washers and a special toothed plate. Between 1992 and 2003 we used this technique in 50 of 76 patients referred to our institution for shoulder reconstruction after trauma. In the remaining 26, reconstruction with a prosthesis and nonabsorbable sutures was performed, as the tuberosity fragments were too small and too severely damaged to allow the use of screws and the toothed plate. The Constant score two years post-operatively was a mean of 12 points better in the acute trauma group and 11 points better in the late post-traumatic group than in the classical suture group. We recommend this technique in patients where the tuberosity fragments are large enough to allow fixation with screws, washers and a toothed plate.