[Intramedullary Nailing in Managing Diaphyseal Metastases of Long Bones: Retrospective Study Comparing the Expected Survival and the Actual Survival of Patients]. / Intramedulární hreb v lécbe metastatického postizení diafýz dlouhých kostí: retrospektivní studie s ohledem na srovnání prognózy doby dozití a reálné prezití pacientu.

PURPOSE OF THE STUDY The paper focuses on the potential use of nail osteosynthesis in diaphyseal metastases of long bones. The purpose of the paper is to assess the outcomes of intramedullary osteosynthesis in pathologic and impending pathologic fractures, to evaluate patient survival and potential complications. MATERIAL AND METHODS The retrospective study evaluated a cohort of 42 patients (19 men and 23 women) in whom intramedullary osteosynthesis was performed for complete pathologic fracture (28 patients) or impending pathologic fracture (14 patients) between 2010 and 2019. Of the total number of 42 patients, 31 patients' lower limbs were affected, namely by 17 pathologic fractures and 14 impending fractures. There were 11 humerus fractures. The mean age was 61.8 years (range 41-84 years). In the followed-up cohort, the patient survival after osteosynthesis with intramedullary nails, complications occurred and post-operative mobility of the patient were assessed. The functional outcomes were evaluated using the Musculoskeletal Tumor Society (MSTS) scoring system. The unpaired Mann-Whitney test was used to test the significance of the difference in functional outcomes and survival between the followed-up groups. Survival longer than 6 months was evaluated using Fisher's exact test. The level of statistical significance used for the test was p 0.05. RESULTS The investigated indicator was patient survival, which was 11.3 months (range 1-50 months) on average. In the group of impending fractures, the mean survival was 13.5 months. In the group of pathologic fractures, the survival was 10 months. The functional outcome in 16 followed-up patients at three months after intramedullary osteosynthesis according to the MSTS score was 46.9% (30-66.7%). At the level of significance of p 0.05, the statistically significant difference in the functional outcomes between the group with preventive intramedullary osteosynthesis and the group with nail osteosynthesis of the pathologic fracture was not confirmed (p=0.952). When comparing the patient survival after nail osteosynthesis with impending pathologic fracture and the survival of patients with pathologic fracture, a statistically significant difference in survival between these two groups (p=0.520) was not confirmed. The patient survival of longer than 6 months was 71% in the group of impending fractures and 40% in the group of pathologic fractures. DISCUSSION The occurrence of pathologic fracture is associated with increased pain, loss of function, and according to some authors, a higher risk of death. Surgical treatment options include intramedullary osteosynthesis, plate osteosynthesis with cement filling, implantation of an intercalary spacer, and implantation of tumor endoprostheses. When deciding on a surgical procedure, an account is taken of the expected survival of the patient. In patients with an expected survival of up to 6 months, intramedullary osteosynthesis is indicated as a palliative surgical intervention. The most common complications include implant failure and metastatic progression. CONCLUSIONS Intramedullary osteosynthesis is the method of choice in treating pathologic fractures or impending pathologic diaphyseal fractures of long bones in patients with an expected predicted survival of up to 6 months. Intramedullary osteosynthesis aims to reduce pain and enable early verticalization. The study confirmed the importance of preventive intramedullary osteosynthesis and its effect on survival compared to the survival of patients with a pathologic fracture. Key words: skeletal metastases, diaphyseal metastases, intramedullary osteosynthesis, pathologic fracture, impending fracture.

[Changes in Cognitive Functions after Total Hip Arthroplasty]. / Zmeny kognitivních funkcí po totální náhrade kycelního kloubu.

PURPOSE OF THE STUDY The postoperative delirium is a frequent, oftentimes underestimated complication of total hip arthroplasty. Its occurrence is reported to be between 10% and 50%. The postoperative delirium increases mortality, the length of hospital stay and leads to worse functional results. Even though there is evidence of efficiency of preventive measures and effectiveness of treatment interventions, inadequate attention has been paid so far to this serious complication related to inpatient hospital care. This paper aimed to determine the incidence of cognitive function impairment in relation to the total hip replacement, to determine the influence of the defined parameters on changes in cognitive functions and to draft practice guidelines for the care of patients after a total hip replacement in the framework of prevention and early detection of changes in cognition of patients after total hip replacement. MATERIAL AND METHODS Prospective observational descriptive study, the evaluated parameters included: type of anaesthesia, duration of surgical procedure (operation), type of analgesia, O2 saturation, haemoglobin levels, changes in the ionogram, body temperature, presence of concomitant diseases, polypragmasia, abuse, level of self-sufficiency of patients evaluated by ADL. In order to obtain the data, the Mini Mental State Examination (MMSE), the Abbreviated Mental Test Score (AMTS), Recall and naming test, and the Activities of Daily Living Test (ADL) were used. The monitored group of patients included a total of 116 persons, of whom 68 men and 48 women. The mean age was 71.16 years; the range from 65 to 86 years; median - 72.36 years. RESULTS A statistically significant dependence was revealed between the change in cognitive functions and all the monitored parameters, except for the haemoglobin levels after 120 hours postoperatively, ion levels after 120 hours and sex by the 10-point Mini Mental Test score. A statistically significant dependence was revealed between the change in cognitive functions and 02 saturation, ion levels, elevated body temperature after 120 hours postoperatively, age, diabetes, polypragmasia and in correlation with the ADL 120 hours postoperatively by the MMSE test. A statistically significant dependence was revealed between the change in cognitive functions and all the monitored parameters, except for anaesthesia and analgesia, haemoglobin levels after 24 and 120 hours, ion levels after 120 hours, renal insufficiency and in correlation with the ADL after 24 hours by the "Recall and naming" test. DISCUSSION The correlation between delirium and long-term cognition impairment was described by several studies. Both the recent literature and our study clearly indicate a correlation between the postoperative cognitive impairment on the one hand and polypragmasia, age, presence of concomitant diseases on the other hand. In some parameters such as the sex of the patient its influence was not clearly established by the relevant literature or our study. The perioperative factors influencing the onset of delirium referred to in literature are anaesthesia and its duration. Our study reveals the correlation between the anaesthesia and the onset of cognitive impairment when evaluated by the Abbreviated Mental Test Score. As regards the monitored postoperative parameters, the influence of postoperative hyposaturation, decreased haemoglobin level, changes in ionogram, elevated body temperature, lower self-sufficiency of the patient was established. Also our study shows the correlation between the change in the aforementioned parameters and the cognitive impairment, even though not quite clearly in all the parameters. The most sensitive evaluation tool turned out to be the Abbreviated Mental Test Score. CONCLUSIONS Our study clearly showed that a highly sensitive test to detect the current changes in cognition in a short-term horizon is the Abbreviated Mental Test Score. Based on the statistically significant factors determining the onset of the change in cognition that we had revealed, we elaborated a clearly arranged scheme of identified risk factors and interventions for the prevention and early identification of the onset of changes in cognitive functions and potential delirium. Key words:total hip arthroplasty, cognitive impairment, delirium.

[Use of Solid Intercalary Allografts for Reconstruction Following the Resection of Primary Bone Tumors]. / Vyuzití solidních interkalárních allostepu k rekonstrukci po resekcích primárních kostních nádoru.

PURPOSE OF THE STUDY There are several treatment options for bone tumors at diaphyseal/metadiaphyseal sites of long bones (with joint preservation) including massive intercalary allografts, autografts (vascularized or non-vascularized fibular autograft, devitalised tumor bearing bone), endoprosthetic replacement (intercalary spacer), cementoplasty with ostheosynthesis and distraction osteogenesis. Reconstruction using massive intercalary bone allografts is for us the method of choice in case of curable primary bone tumors at the diaphyseal/metadiaphyseal region. The purpose of this study is to evaluate our results and complications. MATERIAL AND METHODS Our retrospective study reviewed 41 patients after intercalary allograft reconstruction following the resection of primary bone tumors in the years 2000 - 2014. The group consists of 27 men and 14 women with the mean age at the time of diagnosis 27 years and the mean follow-up (from primary surgery) was 7 years. The patients were diagnosed with the Ewing sarcoma (14), chondrosarcoma (9), osteosarcoma (8), adamantinoma (6), OFD-like adamantinoma (2) and aneurysmatic bone cyst (2). The site of tumor were tibia (18), femur (16), humerus (5), radius (1) and ulna (1). We retrospectively evaluated the results of this intercallary allograft reconstructions, the incidence of failures and complications as well as the role of risk factors. RESULTS 14 patients (34.1%) successfully healed without complications. In the same number of patients (14 patients, 34.1%) the allograft reconstruction failed. 7 of these patients underwent amputation (17.1%), 6 of whom for oncological complications (local recurrence) and only 1 for complications of the reconstruction (infection). Other 7 patients with an allograft-related failure were successfully treated with a limb salvage procedure and underwent a new reconstruction. The remaining 13 patients (31.7%) suffered from complications that did not result in a failure of the reconstruction. The major complications of the reconstruction were the non-union (53.7%), fractures and allograft resorption (14.6%) and infection (7.3%). By statistical evaluation of common risk factors a statistically significant relationship was found between uncomplicated healing and stable bridging osteosynthesis (p = 0.014), between allograft fractures/resorptions and non-bridging osteosynthesis (p = 0.018), and the lowest reoperation rate was connected with plate osteosynthesis (0.037). DISCUSSION AND CONCLUSIONS The intercalary allograft reconstruction is an important biological method in orthopaedic tumor surgery. Even though it is connected with a high rate of complications (non-union, fracture and resorption, infection), in the vast majority of cases they can be solved, while achieving limb-salvage and good function of extremity. The essential prerequisite for successful uncomplicated healing of reconstruction is the stable bridging osteosynthesis, preferably with a plate. In high risk patients with a combination of recognized important risk factors described in literature (adult patients, large resection (more than 15 cm), femoral location and aggressive oncological treatment) we nowadays try to reduce the complication rate with a primary combination of an allograft with vascularized fibular autograft. Key words:biological bone reconstruction, massive intercallary allograft, stable bridging osteosynthesis, primary bone tumors.

[Kombinovaná lécba mekkotkánového sarkomu v oblasti pánve]. / Kombinovaná lécba mekkotkánového sarkomu v oblasti pánve.

Soft tissue sarcomas (STS) constitute a heterogeneous group of rare malignant tumors of mesenchymal cell origin and they may develop in any part of the body. They can form enormous masses in certain localizations. A case report of a young woman with locally advanced liposarcoma in the pelvic cavity is presented. This example emphasizes the significance of early diagnosis, as only radical surgery can be potentially curative in sarcoma therapy.Key words: advanced pelvic sarcoma multimodal treatment multidisciplinary.

[Analysis of prognostic factors in osteosarcoma adult patients, a single institution experience]. / Prognostické faktory konvencního osteosarkomu dospelých pacientu

BACKGROUND: The objective of this report was to estimate long-term outcome and prognostic factors in adult patients with high-grade osteosarcoma. The intended therapeutic strategy included preoperative and/or postoperative chemotherapy as well as surgery of all operable lesions. PATIENTS AND METHODS: We reviewed the clinical data of 36 newly diagnosed adult patients (aged 19-82, average 37.5, median 28.5 years) with high-grade osteosarcoma of the trunk or limbs evaluated by a multidisciplinary team and treated between 1999 and 2010 in Brno. Forty-five percent of patients were over thirty, more than 36% over forty. Thirty-one percent of patients had metastasis at the time of diagnosis. Demographic parameters, tumor-related and treatment-related variables included possible prognostic factors and their impact on response, overall survival (OS) and event-free survival (EFS) were analyzed. RESULTS: All the patients were followed up after treatment. Seventy-three percent of patients were poor responders to chemotherapy. Sixteen patients are alive, and twenty patients died. The survival time ranged from 2 to 177 months (average 45 months, median survival 23 months). The 5-year OS of all patients was 52.4%. OS of patients without metastasis was 68.12%, while 2-year OS with metastasis was 26% only. 5-year EFS was 38.7%. Univariate analysis revealed that the prognosis of adult osteosarcoma patients was significantly related to distant metastasis (p = 0.006), surgical stage (p = 0.00582), serum alkaline phosphatase (ALP) level (p = 0.00841) and serum lactatdehydrogenase (LD) level (p = 0.047). The other analyzed prognostic factors including age had no statistically significant influence on outcome of osteosarcoma in adult patients. CONCLUSION: The prognosis of osteosarcoma in adult patients was significantly correlated to surgical stage, distant metastasis, serum ALP and LD.

[Resection and reconstruction of the chest wall for primary or metastatic tumours]. / Resekce a rekonstrukce hrudní steny pro primární ci metastatické nádorové onemocnení.

PURPOSE OF THE STUDY: The aim of the study was to assess mortality and the complication rate after the extensive resection of chest wall tumour and subsequent soft tissue reconstruction. We wanted to evaluate the justification for major surgery in the group of patients with primary or secondary tumours, including those with an advanced stage of disease. MATERIALS AND METHODS: A total of 35 patients after major chest wall resection within an eight-year period (2000-2008) were analysed retrospectively. A major resection was defined as resection of 75 cm2 or more of full thickness of the chest wall. There were 19 cases of primary malignant tumour of the chest wall, 10 cases of secondary tumour, and 6 cases of benign or semi-malignant lesions. The chest was stabilised with the help of either polypropylene or a double layer mesh of polyester covered with polyurethane. For soft tissue reconstruction, a musculocutaneous flap was used in 18 cases. The number of resected ribs ranged from two to seven. The vertebral body was partially resected in four cases, and total sternectomy was performed in two cases. This surgery was carried out with potentially curative intent in 30 (85.7%) and with palliative intent in five patients (14.3%). RESULTS: No post-operative mortality occurred. The complication rate was 17.1 %. The one-year survival rate was 88.6 %. There were seven long-term survivors at 5 or more years after resection of the chest wall for soft tissue sarcoma. Local recurrence occurred in six patients (17.1%). Neither the type of prosthesis nor the type of surgical procedure influenced the complication rate. DISCUSSION: Chest wall resection is an established surgical procedure in the treatment of primary chest wall tumours and, occasionally, solitary metastatic disease. The groups of patients reported in the literature have been heterogeneous and usually small, and thus an estimation of the true risk of the major procedure is difficult. Three studies involving large patient groups published in the last 11 years have shown morbidity in 24.4%, 33.2% and 46.0% of patients and mortality in 7.0%, 3.8% and 4.1% of patients, respectively. The results in our group of unselected patients are comparable with these studies; however, we did not perform extensive procedures like pneumonectomy and chest wall resection, or extended fore quarter amputation. CONCLUSIONS Complete resection of the chest wall is feasible even in advanced tumours without significant peri-operative morbidity and mortality. Major chest wall resection as a palliative procedure remains selective for motivated patients in a good physical condition but with low quality of life caused by a chest wall tumour.

[Poldi-Cech cemented femoral stem in total hip arthroplasty after 25 years]. / Cementovaný drík TEP Poldi-Cech po 25 letech.

PURPOSE OF THE STUDY: The aim of the study was to evaluate the results of Poldi-Cech femoral stem implantation in primary total hip arthroplasty after 25 years. MATERIAL AND METHODS: A group of 65 patients (90 hips) with Poldi-Cech total hip arthroplasty carried out between 1974 and 1984 was evaluated at the end of 2009. The mean follow-up of all patients was 28 years (25 to 35). There were seven men and 58 women. The mean age at the time of implantation was 43 years (26 to 60) and at the latest follow-up it was 72 years. In all patients the cemented UHMW PE acetabular component (RCH 1000) was used together with AKV Ultra 2 Poldi steel femoral stems (1st, 2nd and 3rd generations). The stem was a monoblock with a 32-mm head. The evaluation of the results was based on the Harris hip score and X ray with an A-P view of the pelvis and the affected hip. Statistical analysis was made using the life-table method. RESULTS: At the latest follow up the mean Harris score was 69.7 points (40 to 88). There were 69 hips with an original Poldi-Cech femoral component still in situ, 64 of them were stable and five with radiological evidence of aseptic loosening. Five patients had undergone Girdlestone resection arthroplasty for septic loosening. Thirteen patients (16 hips) had femoral stem revision. The cumulative proportion of clinical survivorship of the Poldi-Cech femoral stem, with revision for any reason as the endpoint, .was 0.93 at 6 years, 0.84 at 12 years, and 0.77 at 18, 24 and 30 years after the index surgery. Radiographic findings revealed 64 hips with stable stems, five hips with ;aseptic loosening (probable, 0 possible, 2, definite, 3). Six- teen hips were after revision surgery for aseptic loosening of the stem and five hips were after Girdlestone resection arthroplasty for septic failure. The cumulative proportion of radiological survivorship of the Poldi-Cech femoral stem with any reason as the endpoint was 0.92 at 6 years, 0.78 at 12 years, 0.72 at 18 years, 0.69 at 24 years and 0.69 at 30 years. DISCUSSION: The Poldi-Cech stem with its anatomical shape and a highly polished surface meets the principles of successful composite beam stems. Its disadvantage is a valgus neck- shaft angle of 140° giving lower femoral offset and the risk of development of valgus deformity of the ipsilateral knee. In most cases osteolysis, radiolucent lines and bone rarefaction of the femur resulted from polyethylene wear of the acetabular component. CONCLUSIONS: This study demonstrates a long-term survivorship of the Poldi-Cech femoral component in patients undergoing total hip arthroplasty 25 to 35 years ago.

[Proximal femoral varus osteotomy in adults after developmental dysplasia of the hip: long-term results]. / Varizacní osteotomie proximálního konce femuru u dospelých po vývojové dysplazii kycle--dlouhodobé výsledky.

PURPOSE OF THE STUDY: The aim of this retrospective study was to assess the results of varus osteotomy of the proximal femur in adults with coxa valga after developmental dysplasia of the hip (DDH) and to evaluate the efficacy of this method. MATERIAL AND METHODS: Thirty hips in 28 patients treated by proximal femoral varus osteotomy in the period from 1983 to 1990 were evaluated. The indication for surgery involved coxa valga (145°-168°) with grade I- III of osteoarthritis and mild acetabular dysplasia. The patient group comprised twenty six women and two men with an average age of 28 years (18 to 42) at the time of surgery. The mean follow-up was 22 years (19 to 26). The preoperative radiographic examination included an AP view of the pelvis, AP views of the hip in neutral and in frog-leg position and AP views of the hip in 30° of abduction and neutral rotation. Varus osteotomy was indicated when the best position of the hip joint was achieved in abduction. The procedure was performed according to M. Müller. Hip assessment was based on the grade of osteoarthritis, CCD angle, Wiberg angle and AHI index. The results were statistically evaluated using the life table analysis of clinical survivorship of osteotomy and the Kaplan- Meier curve. Clinical failure was defined as conversion of osteotomy to total hip replacement (THR). RESULTS: At the latest follow-up of 22 years on the average, 18 patients (19 hips) still had osteotomy and 10 patients (11 hips) had undergone conversion to THR. The life table analysis showed the cumulative proportion of osteotomy with a clinical survivorship of 0.97 at 5 years, 0.75 at 10 and 15 years, and 0.68 at 20 and 25 years after surgery. The cumulative rate of clinical survivorship of osteotomy, as shown by the Kaplan-Meier curve, was 0.89 at 10 years, 0.75 at 20 years and 0.67 at 25 years after surgery. Nineteen patients were satisfied with the osteotomy outcome. The median of Harris hip scores in the patients with osteotomy was 48 points before surgery and 78 points at the latest follow-up. Conversion to THR in 10 patients (11 hips) was done at an average of 12 years after osteotomy. The median values before surgery and at the latest follow-up were: CCD angle, 158° and 118°; Wiberg angle, 13° and 20°; and AHI index, 56 % and 79 %, respectively. DISCUSSION: The prerequisite for a good result of proximal femoral varus osteotomy is the correct indication, i.e., younger age (18 to 30 years), a lower grade of osteoarthritis, mild dysplasia and a spherical shape of the femoral head. A disadvantage of the procedure is a shortening of the limb. The best indication for femoral varus osteotomy is unilateral coxa valga with a longer leg. CONCLUSIONS: This study shows favourable long-term results after isolated proximal femoral varus osteotomy in young adults with developmental dysplasia of the hip. A good function had been preserved in 18 of 28 DDH patients for an average of 22 years.

[Long-term results of use of the CLS stem in primary total hip arthroplasty]. / Dlouhodobé výsledky CLS dríku u primární náhrady kycle.

PURPOSE OF THE STUDY: The aim of the study was to evaluate the results of primary total hip arthroplasty with the use of the CLS stem at 11 to 17 years after implantation. MATERIAL AND METHODS: A total of 108 patients (122 hips) in whom a CLS stem was used in the 1991-1996 period were evaluated. The group included 34 men and 74 women, with an average age of 48 years (range, 28-63). The CLS stem with a neck-shaft angle of 145 degrees and the CLS expansion cup were used in all patients. Clinical outcomes were evaluated by Merle d'Aubigné-Postel score and Harris hip score, radiological examination was completed on AP and lateral views of the pelvis and the operated hip. RESULTS: The average follow-up was 16.4 years (range, 11-17). The average Merle d'Aubigné-Postel score was 14.5 (range, 13.9-17.0) points and the average Harris hip score was 84.8 (range, 70-99) points. Very good or good outcomes were found in 81% of the patients. Three patients underwent revision surgery, in one for septic loosening, in one for aseptic loosening and in one for varus stem position leading to instability. The radiographs evaluated as described by Engh showed 116 stable stems, three fibrous stable and three unstable stems. Subsidence of more than 3 mm, without any further deterioration, was found in five hips at 12 months post-operatively. Seven hips showed one radiolucent line, four showed two radiolucent lines and three hips showed three radiolucent lines, all of them being less than 2 mm wide. DISCUSSION: Radiographic evidence of a stable stem in 116 hips (116/122) suggests a high reliability of the implant. Assessment of radiolucent lines showed 108 hips without radiographic demarcation and 11 hips with slight demarcation. The signs of stress-shielding grade 1 were found in 28 hips. Good results of arthroplasty with the CLS stem can be attributed to its three-dimensional wedge-shaped design that allows for an optimal press-fit in the metaphyseal region. The porous surface provides reliable osteointegration. Stress-shielding is prevented by optimal stress distribution in the metaphyseal region and by a modulus of elasticity of titanium alloy which closely approximates the modulus of elasticity of bone. CONCLUSIONS: At 15 years post-operatively, the cumulative probability of clinical survivorship of the CLS stem was 98.3 %, and cumulative probability of radiographic survivorship was 87.7 %. The advantages of this stem include a technically simple implantation, reliable osteointegration and long-term stability even in high demanding patients.

[Long-term results of the CLS acetabular cup in primary total hip replacement]. / Dlouhodobé výsledky CLS jamky u primární náhrady kycle.

PURPOSE OF THE STUDY To evaluate the results of primary total hip replacement with the CLS acetabular cup at a minimum of 15 years of follow- up. MATERIAL AND METHODS A total of 105 patients, with 112 hips, undergoing hip arthroplasty with the use of CLS acetabular cup between 1991 and 1993 were evaluated. The group comprised of 33 men and 72 women with an average age of 51.3 years (range, 28 to 66) at the time of surgery. All patients received the CLS expansion cup with a polyethylene Sulen-type liner. Cemented femoral stems were used in 75 hips and uncemented CLS stems were implanted in 37 hips. Ceramic heads of the femoral component were used in 86 hips and metal heads were used in 26 hips. The clinical outcome was assessed by the Merle dAubignnd Postel score and the Harris hip score, and the radiological results were evaluated on anterior posterior X-ray films of the pelvis and the affected hip. RESULTS The average follow-up was 16.2 years (range, 15 to 17). The average Merle dAubignnd Postel score increased from 8.1 (range, 5.7 to 9.8) pre-operatively to 14.6 (range, 14.1 to 16.8) post-operatively. The average Harris hip score improved from 42 to 86 points (range, 71 to 99). The complications requiring revision arthroplasty included aseptic loosening in two hips, fracture of the CLS shell in three, dislocation in three and replacement of the liner due to high wear in two hips. The cumulative proportion of clinical survivorship with revision for any reason was 92 %. Fixation by bone ingrowth, assessed by the method of Engh et al. occurred in 98 cases, fibrous tissue fixation was found in ten hips. Unstable fixation was recorded in four hips (two with aseptic loosening and two with fracture of the shell). There were no signs of rarefaction of bone along acetabular shell in 98 hips. No noticeable migration was found in the stable cups. Only in ten cups from 112, polyethylene wear exceeded 4 mm. Cumulative probability of radiological survivorship of the CLS acetabular cup with any radiological sign of loosening was 86.6 %. DISCUSSION The causes of fracture of the CLS cup can be explained by insufficient bone support or bone resorption in the proximallateral part of the acetabulum in patients with developmental hip dysplasia, by low bone quality due to severe osteoporosis or by insufficient primary stability of the cup. The advantages of the CLS cup include removal of a small amout of bone and favourable force distribution in circumferential anchorage. The cup showed good osteointegration even in a bone of lower quality and with defects of the acetabular bottom. CONCLUSIONS The CLS acetabular cup shows good results at 16-year follow-up period. No increase in fractures of the shell, migration or radiolucent lines, or in bone rarefaction or osteolysis was recorded with time. The reliability of this implant has been recently increased with the use of cross-linked polyethylene (Durasul). Key words: primary total hip replacement, uncemented cup.

[Revision knee arthroplasty due to aseptic loosening]. / Revizní náhrada kolena po aseptickém uvolnení.

PURPOSE OF THE STUDY: Anatomic changes associated with aseptic loosening make conditions for revision of total knee arthroplasty more diffi-cult. The aim of this study was to evaluate the results of revision total knee replacement at an average follow-up of 6.1 years. MATERIAL AND METHODS: A total of 97 revision knee replacements due to aseptic loosening carried out in the years 1992 to 2003 were evalua-ted. The group included 46 men and 51 women at an average age of 66.8 years. The average preoperative Knee Society Score (KKS) was 31 points and the Functional Score (FS) was 22 points. There were 41 minor operations for AORI type I defects, 49 moderately serious procedures for AORI type II defects and seven major operations for AORI type III defects. In minor procedures standard components were implanted in 14 patients, standard components with cemented stems with extension were used in nine, and polyethylene plateau exchange was carried out in 18 patients. For moderately serious procedures, posterior stabilized components with extended cemented stems were used in 15 patients, revision implants with cementless stems in 26 patients and standard components with cemented stems in eight patients. In seven patients with major surgery, the hinged type of prosthesis was employed. Radiographic results were evaluated on the basis of Ewald's classification. RESULTS: Clinical findings showed improvement of the average KKS from 31 to 74 points at follow-up of 6.1 years. Functional out-comes improved, as shown by the average FS, from 22 to 67 points. Fifteen patients were not satisfied with the outcome of surgery, the causes being aseptic loosening in four, deep infection in eight and pain due to progression of radiolucent lines of the tibia in three patients. DISCUSSION: The results of revision surgery with component replacement because of aseptic loosening are worse in comparison with those of primary total knee replacement. The average KSS score after revision surgery was 74 points at 6.1-year follow--up, whereas after primary surgery it was 92 points at 6.5 years. The average FS score after revision was 67 points, as compared with 86 points at 6.5 years after primary surgery. Complications involving infection occurred in 8.2 % of the revi-sion cases, but only in 0.8 % of the primary operations. The authors used modular systems because these provide more options. Good outcomes were achieved with morselized bone grafting for filling cavitary defects. In patients with large defects in tibial or femoral metaphyses, posterior stabilized components and cementless intramedullary stems were used with good results. CONCLUSIONS: The authors recommend to avoid filling large bone defects with bone cement. They prefer bone grafting. In the case of good quality metaphyseal bone, they use standard components or posterior stabilized components with or without additi-onal cemented or cementless short stem extensions. In the case of poor quality metaphyseal bone with defects, they use revision implants with cementless long stems. The authors have achieved good results with off-set stems.

[Cementless ceramic-on-ceramic total hip system]. / Necementovaná totální endoprotéza kycelního kloubu, keramika-keramika.

PURPOSE OF THE STUDY: This is an experimental and clinical study on the use of cementless, ceramic-on-ceramic total hip arthroplasty (THA). MATERIAL AND METHODS: In the experimental part, the authors constructed, by means of mathematical analysis of finite elements, surface tension standards for the ceramic liner at various angles of cup inclination, and identified potentials for destruction of the liner. In the clinical trial, they evaluated the outcomes in 50 patients, out of the 249 implanted prostheses, at five-year follow-up. RESULTS: The experiment showed that a slightly steeper inclination the cup provided physical conditions for increased longevity of the ceramic liner. In the clinical study, no post-operative complications, such as fracture of the acetabulum or femur, and dislocation or break of any ceramic part, were recorded. No infection or loosening of the prosthesis occurred. The patients did not complained of any pain in the hip joint, which is typical of non-cemented THA. DISCUSSION: Ceramic-on-ceramic bearing surfaces show the least wear due to high biocompatibility. Computer-assisted surgery can markedly reduce the risk of incorrect positioning of the acetabular component. In this prospective study, the five-year survival of ceramic-on-ceramic THA in 50 patients free from any complications, whose Harris hip score was 97.4 points, suggests that objections to these prostheses, as raised by some authors, are not justified. CONCLUSIONS: In our experience the Plasmacup Bicontact ceramic-on-ceramic prosthesis is one of a few options that has a prospect of remaining the only total hip replacement in one's lifetime. Key words: total hip replacement, ceramic-on-ceramic.

Revision hip surgery using the CLS expansion shell.

The aim of our study is to assess the outcomes using the uncemented CLS expansion shell in revision hip surgery for aseptic loosening of the acetabular component. Between 1991 and 2000 we used the CLS expansion shell in revision hip surgery in 215 patients (230 hips). We were able to evaluate 196 patients (211 hips) with failed acetabular components. The male/female ratio was 82/114 and the mean age of the patients was 63 years (range 38-71). The main reason for revision was aseptic loosening of the PE cup (184 patients). There were 79 hips with Paprosky defect of the acetabulum type I, 62 hips with type 2A, 57 hips with type 2B and 13 hips with type 2C in the study. The mean follow-up was 8.5 years (range 5-14). Plain radiographs using an AP view of the pelvis and AP and lateral views of the affected hip were taken immediately after surgery and at the latest follow-up. Clinical outcomes were determined using the Merle dAubigne' and Postel score and the Harris Hip score. The mean preoperative Merle dAubigne' score was 7.8 points (range 6.9 to 9.9); at the latest follow-up it was 14.9 points (range: 12.5 to 15.9). The mean preoperative Harris Hip score was 38.6 points (range: 32 to 59); at the latest follow-up it was 82.5 points (range: 38 to 95). Osteointegration of the CLS expansion shell was present in 149 hips (70.6%) at the latest follow-up. There were 31 complications (15%) requiring a second revision. Clinical survivorship of the CLS expansion shell was 90% at five years and 84% at 8.5 years after revision surgery. Radiological survivorship was 78% at five years and 70% at 8.5 years after revision surgery. The CLS expansion shell offers a viable alternative for revision hip surgery with lower bone quality, insufficient bone at the bottom and cavitary defects of the acetabulum.;

Perioperative fractionated high-dose rate brachytherapy in the treatment of soft tissue sarcomas.

The purpose of the study was to investigate the viability of perioperative fractionated high dose rate brachytherapy (HDR BT) for primary and reccurent soft tissue sarcomas (STS). From February 1998 through June 2002, 21 adult patients, 11 females and 10 males with either low grade or high grade soft tissue sarcomas were treated by perioperative HDR BT. Surgical margin was negative in 10 cases, close in 4 and positive in 4 in cases. In 3 cases it was not described. BT was used as a part of primary treatment in 10 cases and for the treatment of reccurent tumor in 11 cases. The localisation of the tumor was the extremity in 16 patients and the trunk in 5 patients. Ten patients were treated with HDR BT alone (total mean dose 40 Gy) and 11 were treated with combination of external beam radiotherapy (EBRT) (40-50 Gy) and brachytherapy (total mean dose 24 Gy). Hyperfractionation 2.4-3 Gy twice daily at 10 mm from the source was used for BT. Follow-up periods were between 7--48 months (median: 20 months). Local control in patients treated pro primary STS was 100%.The pulmonal metastases were a cause of death in one case, one patient was alive with dissemination and one patient was disease free after salvage surgery and chemotherapy for lung metastases. Local control was achieved only in 3 of 11 patients treated for reccurent tumor (27%). Six patients were disease free after salvage surgery, 2 patients died of disease progression, one patient died of toxicity of chemotherapy without evidence of disease and 2 patients are alive with distant metastases. Local control was achieved in 5 of 11 (45%) patients with positive, close or not stated surgical margin and in 5 of 10 (50%) patients with negative margin. Local control was 100% in patients treated by EBRT + BT, but only 20% in patients treated by BT alone. No infection or delayed wound healing has occurred after BT. Soft tissue necrosis was seen in 4 cases, subcutanous fistula in one case and peripheral nerve palsy in one case. Despite small number of patients and short follow up our study suggest that perioperative HDR BT is easy and promissing when used as a part of primary treatment for STS. The treatment results for recurrence are poor and in a lot of cases radical surgical approach should have been considered for the salvage.

[Disarticulation of the knee joint]. / Exartikulace v kolenním kloubu.

PURPOSE OF THE STUDY: The authors report their experience with exarticulation in the knee joint, describe the relevant surgical procedure, assess the outcomes of different modifications of the surgical treatment and emphasize the advantages of the stump following exarticulation in the knee joint. MATERIAL: The sample included 19 patients, 13 women and 6 men, operated on in the period from 1987 to 2001. One of the women had bilateral surgery. Their average age at the time of surgery was 48 years, the range was 5 to 82 years. In most of the patients, exarticulation in the knee joint was indicated because of a malignant tumor in the crux region that could not be treated by any radical but, at the same time, limb-saving procedure. Other indications included an infected allograft of the tibia, chronic osteomyelitis of the tibia complicated by spinocellular carcinoma in a fistula, a stump after high amputation in the tibia that could not be fitted with a prosthesis, chronic lymphedema and diabetic microangiopathy. METHODS: Exarticulation is an amputation of the peripheral part of a limb in a joint, i.e., without cutting bone. The authors used a modified Rogers' procedure. Under the use of a tourniquet, a ventral incision, 10 cm long, was run from the articular fissure level distally and a dorsal incision, 5 cm long, was cut distal to the articular fissure. This produced a longer ventral and a shorter dorsal flap. The subsequent procedure included the discission of the ligamentum patellae at the tibial attachments, the articular capsule, m. sartorius, m. gracilis, m. semitendinosus, m. semimembranosus and biceps femoris, all cut at their distal attachments, as well as the tractus iliotibialis. The collateral and cruciate ligaments were incised at their femoral attachments. After dissection of the neuro-vascular bundle, the vessels were incised and double ligated. The n. tibialis and n. peronaeus were infiltrated with mesocaine and cut through. Then the m. popliteus, ligamentum popliteum arcuatum and the two heads of the m. gastrocnemius were incised and the crux separated. After removal of the pneumatic tourniquet, bleeding was arrested. The condyles, patella and synovialis were left intact. The ligamentum patellae was sutured to the tendons of the m. semimemranosus, m. semitendinosus and biceps femoris. The m. satorius and m. tractus iliotibialis were sutured to the extensor apparatus. The layer after layer was sutured with individual stitches and two Redon's drains were inserted below the fascia. RESULTS: Five patients were referred back to the initial hospital. Of six patients who died, five developed complications due to dissemination of the underlying malignant disease and one died of causes unrelated to the major disease. Eight patients were followed up at regular intervals. Of these, seven were satisfied with their stump and only one patient complained of pressure sores and therefore changed prosthetic care. Patients' complaints that would lead to repeat operations or amputation in the femur were not recorded. DISCUSSION: The surgical technique described is fast, gentle in terms of tissue damage and relatively easy to perform. All patients in the group showed good healing. The authors point out that the stump achieved by exarticulation has good weight-bearing qualities because of a large surface controlled by strong musculature that can maintain muscular balance and control the rotation of a prosthesis. The results of this study are in agreement with the data published in the English, German and Russian literature. In the Czech literature, this issue has not been reported yet. CONCLUSIONS: The advantages of exarticulation in the knee joint are as follows: quick, gentle and uncomplicated surgical procedure with low blood losses; good potential for per primam healing; high quality of the stump surface to be fitted with a prosthesis; current availability of good quality prostheses that are easier to fit than those applied after high amputation in the crux with a stump less than 11 cm or after low amputation in the femur.

The effect of alendronate in the treatment of postmenopausal osteoporosis.

OBJECTIVES: The aim of the study was the evaluation of the effect of alendronate in the treatment of postmenopausal osteoporosis on subjective criteria and on bone mineral density after two years. MATERIAL AND METHODS: The authors collected data from 44 women by questionaire and analysed the data from DEXA examination. The patients were given Fosamax 10 mg and calcium 500 mg per day in the years 2001-2002. RESULTS: The compliance of alendronate was good in 42 women (95.5%). 15 patients were very satisfied with the treatment, 22 were satisfied and 5 patients claimed no improvement at the end of the study. A positive effect of the treatment was seen in 37 patients (88.1%). 21 patients claimed to have no pain and 15 patients suffered mild intermitent pain at the end of the study. 24 patients used no analgetics and 9 patients used them irregularly. 11 patients claimed to have normal activity and 22 patients had mildly diminished activity in daily life. The authors encountered no symptomatic vertebral or nonvertebral fracture during the study. The mean BMD in the lumbar spine improved in T score by 0.38 SD after one year and 0.35 SD after the second year. The mean BMD has improved in the neck region in T score by 0.21 SD after the first year and 0.21 SD after the second year. The mean BMD in lumbar spine has improved in Z score by 0.31 SD after one year and 0.02 SD after the second year. The mean BMD in the neck region has improved in Z score by 0.31 SD after the first year and 0.16 SD after the second year. The mean change of bone mineral density in lumbar spine was +4.17% after the first years and +4.19% after the second year. The mean change of BMD in the femoral neck region was +4.46% after the first years and + 3.71% after the second year. According to student t-test all the data of increased BMD were statisticaly significant at the 5% level of the significance (p < 0.05). CONCLUSION: Alendronate therapy significantly reduced the pain and the need for analgesics. It improved the daily activity and mobility of the spine in the patients with postmenopausal osteoporosis. It resulted in a positive change of BMD in vertebral region of +8.36% and +8.17% in the femoral neck region after two years. The fracture risk in vertebral region was diminished by 31% and in the femoral neck region by 38% at the end of the study. (Tab. 11, Ref. 14.).

[Complications with the acetabular cup in the CLS total hip joint endoprosthesis]. / Komplikace jamky totální endoprotézy CLS kycelního kloubu.

PURPOSE OF THE STUDY: The aim of the study is to present complications of acetabular component of CLS total hip replacement and their solution. MATERIAL: In the period of 1986-1999 in total 219 cementless CLS total hip replacements and 2012 CLS cups in hybrid replacements were implanted at 1st Orthopaedic Department in Brno--primary surgeries--2026, revision surgeries--205. Of 2231 CLS cups we encountered 25 complications requiring a revision surgery (1.1% of all cases): 2 cases of the broken metal shell, 3 cases of cup penetration into pelvis, 4 cases of cup migration, 5 cases of aseptic loosening, 5 cases of dislocations and 6 cases of deep infections. METHOD: Broken metal shells were treated by Müller and Eichler ring, cancellous bone grafting with a cemented PE cup. Penetration of cups into pelvis were managed by Girdlestone procedure. Migration of the cup was solved in 1 case by Burch-Schneider ring, other cases with a good function were left in situ. Aseptic loosening with defects of acetabulum was solved by means of metal rings, cancellous bone grafting and cemented PE cup. Dislocation was managed by adjustment of CLS cup in the correct position, longer or closed reduction and orthesis. In infections a two-step procedure was used with a repeated application of CLS cup, Prostalac technique or Girdlestone procedure. RESULTS: The results of cases solved by means of acetabular metal rings, cancellous bone grafting and cemented PE cup are after 2-5 years good. The patients are capable of full weight bearing and have no pains, Harris score is 83-89 points. The radiograph shows in all but one patients a stable implant without radiolucent interface. The function of all patients with dislocations of CLS implant is now very good or good. No recurrence was recorded in patients with infections. The function of the hip with Girdlestone procedure is in 2 patients low--Harris score is 58 and 63 points. Harris score in patients after a two-step revision with a repeated application of CLS cup is 80-89 points. DISCUSSION: In cases of the broken metal shell there occurred a proximolateral defect of the acetabular bone as a result of development dysplasia of the hip. The cup had inadequate circumferential support. The cases of cup penetration into pelvis are connected with a marked primary or subsequent deficiency of the acetabular floor, excessive reaming of subchondral bone and osteoporosis. Revision surgery with a metal ring requires a careful extensive cancellous bone grafting with a complete filling of all defects, support of the ring by the bone and development of a stable bone-ring-cemented PE cup composite. The best results in infections were achieved by a two-step revision with a repeated application of CLS cup. CONCLUSION: Of the total number of 2231 implanted CLS cups in the period of 1986-1999 only 25 complications were recorded requiring a revision surgery, i.e. 1.1% of all cases. Complications relating to the cup were treated in case of acetabular defects by means of metal acetabular rings, cancellous bone grafting and cemented cups. In infections a two-step procedure was used with a repeated application of CLS cup, Prostalac technique or Girdlestone procedure.

[Low grade malignant fibromyxoid sarcoma]. / Nízce maligní fibromyxoidní sarkom.

Two cases of low-grade fibromyxoid sarcoma are presented. In a 31-year-old male the tumour arouse in the scapular soft tissues and local recurrence occurred. In a female of 45, the neoplasm was located in the thigh. Histologically, the neoplasms with low cellularity of deceptively benign-appearing small fibroblastic spindle cells demonstrated alternating dense fibrous and loose myxoid areas, showing a mainly whorled and swirling growth pattern. In myxoid areas a prominent vascular component was present. Mitoses and cellular atypia were absent. Tumor cells showed staining with anti-vimentin and occasionally anti-actin antibodies. As a distinctive soft-tissue sarcoma, low-grade fibromyxoid sarcoma had to be distinguished from variety of benign and malignant soft tissue tumours such as neurofibroma, liposarcoma, myxoid MFH and others.

[Basic principles of the treatment of metastasis of adenocarcinoma of long bones and pelvis.]. / Základní principy lécby metastázy adenokarcinomu dlouhých kostí a pánve.

Authors evaluated longterm results of the survival of patients with metastasis of adenocarcinoma in long bones and pelvis in 72 cases which were treated and followed at Ist Orthpaedic Clinic of the Faculty Hospital of St. Ann in Brno in the period of 1970-1995. Patients were divided into two groups. One group of patients was treated with intralesional operation and in the second group the metastasis was radically resected. The period of survival in the second group was longer. Authors also present a general survey of adjuvant therapy of metastasis of adenocarcinoma in bones. Key words: metastasis of adenocarcinoma in long bones and pelvis, method of treatment.

[Prosthetic arthroplasty in the region of the knee for musculoskeletal tumours]. / Pouzití modulární totální endoprotézy kolenního kloubu u muskuloskeletálních tumoru

The authors evaluated a group of 23 patients (13 women and 10 men) with resection of the distal end of the femur or proximal part of the tibia for musculoskeletal tumours in the knee joint region. Resected bone was replaced by individually made tumorous total endoprostheses. Most frequently the authors operated on account of osteosarcoma (13 cases) and chondrosarcoma (5 cases). The proximal tibia was replaced in 11 patients, the distal femur in 12 patients. Endoprosthesis of 5 types and from 4 firms were used. Johnson and Johnson implants and Poldi type were most frequent. Hinge endoprostheses of all types exhibited a lower movement range in replacements of the distal part of the femur as compared with a higher movement range in replacements of the proximal part of the tibia. Subjectively best results for patients were achieved wih composite endoprostheses with a highly congruent surface.