[Two-Stage Revision for Periprosthetic Infection of the Total Hip Arthroplasty: a Comparison of Two Methods]. / Srovnání klinických výsledku skupiny pacientu neartikulovaného a artikulovaného spaceru pri dvoudobé reimplantaci TEP kycelního kloubu pro periprotetický infekt.

PURPOSE OF THE STUDY The purpose of the study is a retrospective comparison of results of the two-stage revision total hip arthroplasty using a non-articulating and an articulating spacer to treat periprosthetic joint infection (PJI). Two basic hypotheses are evaluated: (1) the clinical outcomes of the patients treated with "hand made" articulating cement spacer are better than in non-articulating patient's group in two-stage revision for PJI of the total hip arthroplasty and (2) PJI recurrence is higher in the group of patients treated with an articulating spacer group. MATERIAL AND METHODS The evaluated group consists of a total of 57 patients (23 women, 34 men) with the mean age of 61.2 years. Group A of 39 patients were treated by two-stage revision using the "hand-made" articulating cement spacer and Group B of 18 patients were treated using the non-articulating spacer. Both the groups were evaluated retrospectively in the reference period: preoperatively and two years after the surgery using the Harris Hip Score (HHS) clinical assessment. The revision surgery for acute and chronic complications of treatment, length of hospitalization, and the PJI recurrence were evaluated for both the groups. RESULTS The resulting HHS clinical reviews were pre-operatively 43.59 points in both the groups with postoperative improvement up to 81.74 points. The mean preoperative HHS scores were 41.67 points (Group A) and 47.77 points (Group B) and two years after the surgery they were 83.43 points (Group A) and 78.08 points (Group B) (two-tailed t-test, p-value = 0.042). In Group A a total of seven revisions were performed in the interval between the two-stage revision (4x recurrent dislocation, 2x persistent infection, 1x spacer fracture). In Group B one patient was revised for persistent infection. In the two-year period after the operation, a relapse of PJI was recorded in 5 patients in Group A (12.8%) and in 1 patient in Group B (5.6%) (Chi-square test, p-value = 0.41). The average time of hospitalization was 51.58 days, whereby 49.72 days and 55.61 days on average for Group A and B respectively (p-value = 0.53). DISCUSSION According to recent studies, the advantage of motion preservation in articulating cement spacers can be complicated by recurrent dislocations, implant migration, periprosthetic fractures or recurrent joint replacement infections, which can further prolong the treatment and worsen the final clinical results. An alternative treatment option is the application of a nonarticulating spacer maintaining the advantage of local administration of antibiotics and reducing the dead space formed by the infected implant removal. Discussed is mainly the choice of the method in case of muscle disorder or presence of segmental bone defects. CONCLUSIONS The results demonstrate the better clinical outcomes and the higher revision rate of patients with an articulating cement spacer in two stage revision. We didn't find any differences between the risk of PJI recurrence in both groups. Key words:periprosthetic infection, total hip replacement, cement spacer, two stage revision, articulating spacer, nonarticulating spacer.

[Periprosthetic Infection of the Knee Megaprosthesis following a Resection of Malignant Tumours around the Knee]. / Periprotetické infekce megaprotéz po resekcích kostních nádoru oblasti kolene.

PURPOSE OF THE STUDY The study presents the monocentric retrospective study of a group of patients with malignant tumours around the knee, treated by a wide resection and a reconstruction with megaprosthesis due to infectious complications. Provided is a detailed analysis of each operative treatment due to the manifestation and process of periprostethic infection of the knee megaprosthesis and the use of external fixator during a two-stage revision. MATERIAL AND METHODS Between 01/1993 and 12/2013, a total of 67 cemented megaprostheses were assessed, with a detailed analysis of 12 patients with periprosthetic infection. The Kaplan-Meier method and MSTS for lower extremity clinical assessment were used and a range of motion was evaluated. RESULTS The endoprosthesis failed due to all kinds of complications (mechanical, biological, infection) in 27 (40.3%) patients. The estimated one-year survival rate from the surgery was 94%, the five-year survival rate was 72%, and the ten-year survival rate was 46%. Based on the statistical analysis of the implant survival due to infection, the one-year survival rate was 94%, the five-year survival rate was 75%, and the ten-year survival rate was 57%. Three patients were treated with radical surgical debridement. Five patients were treated with a two-stage revision with a cement spacer and external fixator, and three patients underwent nail fixation. Clinical values before and two years after the revision surgery for periprosthetic infection using MSTS were assessed. The mean of the difference of clinical values was 1.91 and the p value of paired t-test was 0.24, therefore there was no prove of the clinical result difference using MSTS before and after the revision surgery. DISCUSSION The acute radical debridement and lavage is preferred, if the surgery can be done up to three weeks after the first clinical signs of infection under the condition of good retention of the implant. In case of extensive infectious damage, when abscess, fistula and loosening of the implant are present and when the patient has a good oncological prognosis, we prefer a twostage revision with a cement spacer stabilized by an external fixator. In patients with mitigated infection or uncertain oncological prognosis we prefer a two-stage revision with the combination of a cement spacer and intramedullary nail fixation. CONCLUSIONS The study presents the results of operative treatment of periprosthetic infection of megaprosthesis and the modification of the two-stage replantation of infected MP with the use of external fixation for stabilisation of a non-articulated cement spacer allowing the patient to remain active during the time before the second stage. Key words: periprosthetic infection, megaprosthesis, bone tumour, external fixator, two-stage revision.

[Results of Surgically Treated Patients for Hip Fracture - Complications, Mortality]. / Výsledky po operacích zlomenin proximálního femuru ­ komplikace, letalita.

PURPOSE OF THE STUDY Our main objective was to evaluate the mortality and complications of patients following surgical treatment of hip fractures and to identify the associated risk factors for postoperative mortality. MATERIAL AND METHODS We retrospectively reviewed all patients over the age of 50 who underwent surgical treatment for femoral neck and peritrochanteric fractures at our institution in 2003 and 2013. Mortality was compared between subgroups classified by age, gender, fracture type, method of treatment. Correlation between mortality and postoperative complications, time to surgery, and blood transfusion need were evaluated. Chi-square was used for categorical variables and two-tailed student's t-test for continuous variables. Survival curves were compared by the log-rank test. Mortality rates were adjusted for patient age and compared to the mortality rates of Prague's population in the given years. RESULTS Altogether 425 patients were surgically treated for proximal femoral fracture in 2013, while 229 patients were treated in 2003. The overall 1-year mortality decreased by 10% over the study period (38% in 2003 and 28% in 2013), despite the higher average age in 2013. Survival was better in all subgroups broken down by diagnosis and method of treatment, statistically relevant in the subgroup of femoral neck fractures, notwithstanding the method of treatment and in the subgroup treated with total hip arthroplasty. The strongest prognostic factor for survival was the advanced age. The mortality rate rises significantly over the age of 75. The largest age group was between 85-89 years, with 1-year mortality rate of 32%. The annual mortality of the general population in Prague aged 85-89 years was 13% and has improved only by 1% in the decade. The reoperative rate was 4% and did not affect mortality. There was no significant relationship between mortality and complications or delay of surgery for up to 4 days. DISCUSSION The factors that might have contributed to better survival are the introduction of guidelines for hip fracture care to our unit, better prophylaxis of venous thromboembolism, improvement of surgical skills due to the growing volume of these cases, and a higher rate of discharges to aftercare units. CONCLUSIONS Mortality has significantly decreased between 2003 and 2013 (p < 0.001). We didn't find a correlation between mortality and delay of surgery up to 4 days. That means that a complicated operation such as hip arthroplasty could be postponed and operated in more comfortable conditions (in superaseptic OR) by orthopedic surgeons. Although we haven't identified any modifiable risk factor, we believe that the reasons for better survival are multifactorial as discussed. Key words: hip fracture, proximal femoral fracture, mortality, complications, time to surgery.

[Operative Treatment for Saddle-Shaped Femoral Heads]. / Operacní resení sedlovité deformity hlavice kosti stehenní.

PURPOSE OF THE STUDY A saddle-shaped deformity of the femoral head has a poor prognosis due to rapid development of secondary changes. A new method of treatment by intra-articular anteromedial wedge reduction osteotomy (AWRO) of the femoral head may preserve the hip for the future. This study was designed to ascertain that this invasive technique was safe and effective and to confirm our hypothesis that AWRO significantly improved functional and radiological parameters of the hip joint. MATERIAL AND METHODS Patients who underwent AWRO between 2010 and 2013 were enrolled in this study. The indication criteria for the procedure included Stulberg grade V hips on AP radiographs, hinged abduction with pain, limping and a limited range of movement. Values of the Stulberg grading, capital diaphyseal index, caput-collum-diaphyseal angle and Harris hip score were recorded before and after surgery and the results were statistically evaluated using the paired t-test. The AWRO procedure was performed from the anterolateral approach after subperiosteal protection of the vessels had been ensured. The central necrotic part of the femoral head was removed, and the medial segment was mobilised and fixed to the intact lateral segment. Either a hip spica cast or bed-rest for six weeks was indicated. Full weight bearing was allowed at 3 months after surgery. RESULTS Twelve patients with an average follow-up of 55 months were evaluated. There were eight boys and four girls with an average age of 14 years at the time of surgery. The average Harris hip score improved from 54.52 before to 73.58 after surgery. The post-operative outcomes according to the Stulberg classification included one grade II hip, seven grade III hips, three grade IV hips and one grade V hip. The average capital-diaphyseal index dropped from 1.56 (1.19-1.92) to 1.28 (0.95-1.67) and the average caput-collum-diaphyseal angle increased from 134 degrees (121-143) to 140 degrees (130-155) after surgery. Avascular necrosis developed in two patients. All the differences were statistically significant. DISCUSSION Reduction osteotomies of the femoral head reported in the literature differ from the AWRO procedure used in this study in both the approach and the performance. The results presented here are in agreement with those published in the relevant literature. They showed no significant deterioration in comparison with the outcomes of our short-term study reported earlier. The outcome of treatment is related to the disease aetiology, functional parameters and previous procedures involving the hip joint. CONCLUSIONS AWRO is a salvage procedure that prolongs the longevity of joints in incongruent hips with very high morbidity. This procedure gave significantly better results in years after surgery, which confirmed our hypothesis. Level of evidence IV Key words: hinge abduction, Perthes disease, Stulberg, femoral head reduction osteotomy, avascular necrosis, arteria circumflexa femoris medialis.

[Treatment of deep cartilage defects of the knee with autologous chondrocyte transplantation on a hyaluronic Acid ester scaffolds (Hyalograft C)]. / Osetrení hlubokých defektu chrupavky kolena transplantací autologních chondrocytu fixovaných na nosici z esteru kyseliny hyaluronové (Hyalograft C).

PURPOSE OF THE STUDY: The treatment of chondral defects by transplantation of autologous chondrocytes has recently shown further development. Various biomaterials are used as carriers facilitating attachment and even distribution of chondrocytes in the defect. Since 2003 Hyalograft C, hyaluronan-based scaffolds, has been used, in a clinical study, for implantation of autologous chondrocytes in the treatment of deep chondral lesions of the knee at our department. MATERIAL: Eight patients (7 men and 1 woman; average age, 31 years) followed up for at least 9 months were evaluated. The lesions with an average size of 3.9 cm2 were localized on femoral condyles. METHODS: The outcome of surgery was evaluated on the basis of the IKDC Subjective Knee Evaluation Form, Knee Injury and Osteoarthritis Outcome Score (KOOS) and Lysholm knee score. The patients underwent MR examination preoperatively and at 3, 6 and 12 months after surgery. The newly-formed cartilage was assessed by International Cartilage Repair Society (ICRS) visual scores at second-look arthroscopy carried out at 9 to 12 months following transplantation. Consistency of the new cartilage developing in the defect and that of healthy cartilage around the defect was compared by means of a special indentation probe in three patients. A biopsy sample was collected from the grafted site for histological, histochemical and immunohistochemical examination. RESULTS: All patients reported improvement in knee function on average at 10 months after surgery. The average IKDC subjective score increased from 46 points preoperatively to 74 points postoperatively. The KOOS evaluation showed pain relief and improved function. In quality of life evaluation the average score of 35 points before surgery increased to 70 points after it. The average Lysholm knee score was 61 points before and 83 points after surgery. MR findings correlated well with arthroscopic findings. Second-look arthroscopy showed a normal appearance of the newly-formed cartilage in six, and an abnormal appearance in two patients. The average ICRS visual score was 9.4 points. No graft failure was recorded. The newly-produced tissue had the histological characteristics of a mixed hyaline and fibrous cartilage in seven patients, and of hyaline-like cartilage in one patient. DISCUSSION: The ICRS visual repair assessment of the newly-formed tissue showed that our results were better than the one-year outcomes reported by Bartlett et al. (11 patients after transplantation of a collagen bilayer seeded with chondrocytes), but worse than the results of an Italian multi-center study (55 patients with Hyalograft C-based grafts followed up on average for 14 months). At almost one year, implantation of on a Hyalograft C resulted in the production of mixed cartilage incorporated well in the subchondral bone. Only one patient had mature hyaline cartilage. One year is too short to allow for complete remodeling of the newly formed cartilage into a mature hyaline cartilage. This is in agreement with other studies suggesting that the new cartilage continues to mature and remodel for a time longer than one year. CONCLUSIONS: Based on our results we suggest that the use of Hyalograft C is a safe and effective option for treatment of deep chondral defects of the knee; it is particularly useful in patients in whom the primary defect treatment has failed. The application of Haylograft C is relatively quick and easy; this is convenient when surgery involves more than one procedure (ligament reconstruction, osteotomy). However, a definite evaluation of this method will be possible only after long-term results are available. Key words: deep cartilage defects, chondral defects, cartilage repair, autologous chondrocyte transplantation, hyaluronan- based scaffold, Hyalograft C, cartilage repair assessment, ICRS.

[Initial experience with implantation of the cemented Beznoska/S.V.L. total knee joint endoprosthesis]. / První zkusenosti s implantací cementované totální endoprotézy kolenního kloubu typu Beznoska/S. V. L.

PURPOSE OF THE STUDY: The authors present the results of their first trial of a new, Beznoska/S. V. L. type, knee prosthesis in order to introduce it to a broad orthopedic public. MATERIAL: Clinical and radiological evaluation was carried out on 34 knee prostheses implanted in 31 patients between September 1997 and October 1999. The average patient age at the time of surgery was 71.3 years and the average interval between surgery and assessment was 22.4 months (range 6 to 31 months). All patients underwent implantation due to primary or secondary gonarthosis. A brief description of the implant and the instrumentation and used surgical technique is provided. METHODS: Clinical outcomes were evaluated according to the "Knee-Society Clinical Rating System" by John N. Insall. The system classifies both knee joint parameters and knee function. X-ray films were assessed on the basis of the "Knee-Society Total Knee Arthroplasty Roentgenographic Evaluation and Scoring System" by Frederic C. Ewald. In standardized X-ray projections, this allowed us to evaluate the implant position as well as radiolucent lines. RESULTS: On stability evaluation, we found anteroposterior instability up to 5 mm in 85% of the implants and mediolateral instability up to 9 degrees in 97% of them. A maximum flexion of 90 degrees to 120 degrees was achieved in 91% of the implants. The final outcome in terms of knee score was on average 80.3 points (range, 40 to 97 points), which was a very good result. Evaluation by function score showed that only 17% of the patients were not able to walk farther than 500 meters. Although 82% of them had to hold on a railing when going upstairs, all were able of stair ascent and descent; 13% had to use a walking stick permanently. The average function score was 68.4 points (range, 30 to 100), which was a good outcome. Radiograms in anteroposterior projection, assessed according to Ewald, showed the average femoral flexion angle (alpha) to be 95.2 degrees, the average tibial angle (beta) to be 89 degrees and the total valgus angle (omega) to be 3.2 degrees. In lateral projection, the femoral flexion angle (gamma) was on average 2.5 degrees and the average tibial angle (delta) was 86.7 degrees. An optimal position of the patella was achieved in 27 implants. Five radiolucent lines, up to 1 mm, were found in zone 1 of the femoral component and further lines were observed in zones 1, 2 and 4 of the tibial component. DISCUSSION: When assessing the results by the knee and function scores, it had to be taken into consideration that the average age of the patients was 71.3 years. At this age, walking without a stick, or stair ascent or descent without the use of a railing can hardly be expected. The average result of 68.4 points achieved can, therefore, be considered a very satisfactory outcome. The values shown by X-ray examination were close to the normal condition. The patients were also asked for their subjective opinion of the effect of arthroplasty; 97% of them regarded the effect as good or very good, only one patient reported no benefit. CONCLUSIONS: The results of the first trial of the use of a cemented prosthesis, type Beznoska/S. V. L., in total knee arthroplasty are presented, together with practical recommendations. Although the patient sample was small and the follow-up period short, the results are promising and suggest excellent prospects for this implant.

[Osteosynthesis of the pseudoarthrosis of the navicular bone with the herbert screw - own modification with the usage of the tricortical bone graft.]. / Osteosyntéza pakloubu navikulární kosti Herbertovým sroubem - vlastní modifikace s pouzitím trikortikálního stepu.

Authors in their a short report are presenting possibility of scaphoid reconstruction for nonunion with a modeled tricortical corticocancellous bone graft from the illiac crest after resection of pseudoarthrosis back to the healthy bone in their's own modification. This operation with the possibility of stable osteosyntesis with the use of Herbert screw gives ideal opportunity for restoration of full length and thus also function of navicular bone without use of any postoperative immobilization. Also detailed operation technique is described including a bone graft harvesting and its final modelation. Finally authors are presenting a case of 5 years old pseudoarthrosis of navicular bone in 20 years old women successfully treated by this technique. Key words: pseudoarthrosis of the navicular bone, Herbert screw, tricortical corticocancellous bone graft.

[Biopsy in orthopaedic surgery.]. / Probatorní operace v ortopedii.

At the begging of the article the authors are giving the explanation and definition of the terms of biopsy in orthopedic surgery. Then they are in details explaining all types of biopsy - closed and open, which is further divided into excisional and incisional. Prior to the performance of a biopsy procedure, all necessary clinical and radiological evaluations must be performed and a biopsy procedure must be planned as carefully as the definitive procedure. The details of all biopsy techniques are well-described. Biopsy should be done meticulously, with emphasis on proper placement of incision, avoidance of excessive dissection and hemorrhage, receiving proper amount and quality of pathologic tissue and must be finished with tight closure; and done in such a way that biopsy tract re-excision as part of an en bloc excision is later possible. Finally, possible complications of these procedures are discussed. Key words: aspiration biopsy, biopsy, excisional biopsy, final operation, incisional biopsy, needle biopsy, open biopsy, percutaneous biopsy, trephine biopsy.

[Personal experience with the use of the Herbert screw in orthopedics and traumatology]. / Nase zkusenosti s pouzitím Herbertova sroubu v ortopedii a traumatologii.

The authors present in the submitted paper their initial experience as well as theoretical possibilities of using Herbert's screw. This is a relatively new type of implant developed originally for stable compressive osteosynthesis of small bones. This screw is made from a titanium alloy in sizes of 16-32 mm and is based on the principle of traction screws. It has, however, compared with the latter some advantages and thus makes a reduction of the period of postoperative fixation possible. It is supplied along with the insertion instruments which facilitate peroperative reposition and retention of fragments for easier insertion of the screw. In the authors' department this screw was used in 1988-1991 for osteosynthesis in 18 patients incl. 12 with fractures of the navicular bone, head of the radius, the patella, Bennett's fracture, osteochondral fractures of the femoral condyle and it was also used for osteosynthesis of scapholunatal desis and desis of the interphalangeal articulations of the hand. In the authors' so far not very numerous group Herbert's screw proved useful--only in one patient the X-ray and clinical finding was not satisfactory and called for further surgical operation. It is, of course, essential to respect the surgical principles for its application, in particular in fractures of the navicular bone. The implant is an advance in the treatment of selected recent injuries as well as their late sequelae.