[Revision of Infected Total Knee Arthroplasties with DAIR Method - Factors Affecting the Two-Year Survival Rate]. / Revize infektu totální náhrady kolenního kloubu metodou DAIR ­ faktory ovlivnující dvouleté prezití.

PURPOSE OF THE STUDY Periprosthetic joint infections in total knee arthroplasty (TKA) represent one of the most limiting factors of implantation. Frequency of this complication is up to 2.5% in primary implantation. Revision TKA with the use of DAIR (Debridement, Antibiotics and Implant Retention) procedure is a widely accepted method in treating infection, but the indication criteria have not been clearly defined as yet. The lack of uniformity prevails also with respect to the surgical technique and the importance of respective techniques for successful treatment. The purpose of this study was to evaluate the factors affecting the twoyear survival of TKA after treating the infection by DAIR. MATERIAL AND METHODS We conducted a monocentric retrospective analysis involving 52 cases of infected TKA managed with DAIR in the period between 2007 and 2016. The evaluation took into account such factors as the sex, age, history of revision surgery for aseptic or septic reasons, and pathogens. The patients were divided into groups based on the McPherson criteria. As to the procedure, we monitored the effect of administered antibiotics, time interval between the manifestation of symptoms of TKA infection and surgery, exchange of modular parts, and use of pulse lavage, continual lavage, local antibiotic carrier, or combination of these techniques. Treatment failure was defined as persistent infection and transition to chronic suppressive antibiotic therapy or need for revision surgery of the respective joint due to recurrent infection of TKA, or death directly associated with the treatment of infected TKA in the follow-up period of 2 years after DAIR. The R software (Team Development Core, 2017) was used to carry out the statistical analysis. The target variable was the failure at two years after surgery. The Generalized Linear Model (GLM) was used for the binary dependent variable - the socalled logistic model with a logit link function. RESULTS 32 of 52 patients (61.5%) were successfully treated, of whom 18 women (62.1%) and 14 men (60.9%). The effect of causative agent, administered antibiotics, polyethylene insert exchange, McPherson score or history of revision surgery of the respective joint for aseptic reasons was not confirmed. The history of revision surgery for infection of the affected joint had a strong negative impact on treatment success, 10 of 13 (76.9%) implants failed as against 10 of 39 (25.6%) implants with negative history of infection. The mean time from surgery to the manifestation of infection was 5.9 weeks (0.5-47.5). When surgery was performed within 2 weeks from the manifestation of infection, 1 of 15 (6.7%) cases failed. In case of a later surgery, 19 of 37 (51.4%) cases failed. As concerns the used surgical technique, 60% (9/15) failure was reported in case of the combination of pulse lavage and continual lavage, 36.4% (4/11) in case of the combination of pulse lavage and local antibiotic carrier, 25% (4/16) in case of separate continual lavage, and 66.7% (2/3) in case of continual lavage with local antibiotic carrier. DISCUSSION The importance of individual factors in revision surgery of periprosthetic joint infections of TKA remains unclear. The world literature indicates as a major negative effect the time factor, the positive history of infection of the affected implant, or other previous revision surgery for aseptic reasons. Ambiguous results are achieved in assessing the effect of the pathogen, administered antibiotics or presence of fistula, the statistical significance of which has not been confirmed in our study. Questionable is also the importance of individual surgical techniques. CONCLUSIONS DAIR is a suitable method in treating infections of stable TKA without the history of revision surgery for infection. The surgery should be performed within 2 weeks from the manifestation of symptoms. Key words: debridement, antibiotics, infection, implant retention, total knee arthroplasty.

[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.

[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.

[Tibio-talo-calcaneal arthrodesis with the retrograde intramedullary nail MEDIN]. / Tibiotalokalkaneální artrodéza retrográdním hrebem MEDIN.

PURPOSE OF THE STUDY: When the talus and the talocalcaneal joint are both affected, their fusion is the method of treatment. Ankle arthrodesis is carried out using various osteosynthetic materials such as external fixators, screws and plates. One of the options is retrograde nailing. Tibio-talo-calcaneal arthrodesis is frequently indicated in patients with rheumatoid arthritis (RA) in whom both the talus and the subtalar joint are often affected. MATERIAL AND METHODS: A retrograde nail for tibio-talo-calcaneal arthrodesis was developed at our department in cooperation with MEDIN Company. This is a titanium double-curved nail, with the distal part bent at 8 degrees ventrally and 10 degrees laterally. It is inserted from the transfibular approach. RESULTS: Sixty-two patients, 35 women and 27 men, were treated at our department from 2005. Since one patient had bilateral surgery, 63 ankles were included. The indications for arthrodesis involved rheumatoid arthritis in 42, post-traumatic arthritis in 10, failed ankle arthrodesis in two and failed total ankle arthroplasty in five ankles; tibial stress fractures close above the ankle in two RA patients, one patient with dermatomyositis and one with lupus erythematodes. The average age at the time of surgery was 64.2 years (range, 30 to 80). The average follow-up was 4.5 years (range, 1 to 9 years), Satisfaction with the treatment outcome and willingness to undergo surgery on the other side were reported by 82% of the patients. The AOFAS score improved from 35 to 74 points. Three (4.8%) patients complained of painful feet due to the fact that exact correction of the calcaneus was not achieved and the heel after arthrodesis remained in a slightly varus position. Of them, two had a failed total ankle arthroplasty. Post-operative complications included early infection managed by antibiotic treatment and early surgical revision with irrigation.in two (3.2%) RA patients, who were undergoing biological therapy. Late infection developed at 2 to 3 years after surgery in three (4.3%) patients (two had RA). The infection was managed by revision surgery with nail removal and irrigation. All patients healed well. Necrosis of the talus and development of a pseudoarthrosis were recorded in four (6.4%) patients, who subsequently underwent nail removal and repeat fusion using an external fixator. DISCUSSION: Retrograde nailing for tibio-talo-calcaneal arthrodesis is used by many authors. Its complication rate is comparable with the other methods of arthrodesis. CONCLUSIONS: The use of tibio-talo-calcaneal arthrodesis aims at a painless and stable joint. Arthrodesis of the talus and the subtalar joint using a retrograde nail is an effective surgical treatment of the joints affected. It is especially recommended for RA patients who have severe deviations. Retrograde nailing provides a stable osteosynthesis which does not require plaster cast immobilisation. The double-curved nail allows for its insertion in the solid part of the calcaneus and helps avoiding injury to the neurovascular bundle.

[Resistance of the the coraco-clavicular ligaments to traction: clinical application]. / Etude de la résistance à la traction des ligaments coraco-claviculaires: applications cliniques.

One method for treating chronic incapacitating acromioclavicular dislocation is to resect the external extremity of the clavicle and to stabilise the stump by ligamentoplastic procedures, using the coracoclavicular ligament. The purpose of this work was to evaluate the mechanical quality of the ligamentoplastic approach. Twelve fresh cadavers, average age 80 years, were studied. The samples taken were 24 coracoclavicular ligaments, 24 coraco-acromial ligaments, 9 tendons from the palmaris longus muscle and 9 iliotibial tracts. The ligaments removed were tested in a Instron traction machine at a speed of 10 cm/mn. The mechanical properties of the coracoclavicular and coraco-acromial ligaments were studied. For comparison, those of the tendon of the palmaris longus muscle and the iliotibial tract were also studied. The results show the pre-rupture resistance of the coraco-acromial ligament to be 50% lower than that of the trapezoid and conoid parts of the coracoclavicular ligaments taken together. These results suggest the validity of ligamentoplastic treatment using the coraco-acromial ligament, but that reinforcement, using a tendon from the palmaris longus muscle or a piece of the iliotibial tract, may also be necessary, especially for subjects taking part in sports or with well-developed musculature.