Treatment of Large Cartilage Defects in the Knee by Hydrogel-Based Autologous Chondrocyte Implantation: Two-Year Results of a Prospective, Multicenter, Single-Arm Phase III Trial.

OBJECTIVE: To evaluate the clinical outcome of a hydrogel-based autologous chondrocyte implantation (ACI) for large articular cartilage defects in the knee joint. DESIGN: Prospective, multicenter, single-arm, phase III clinical trial. ACI was performed in 100 patients with focal full-thickness cartilage defects ranging from 4 to 12 cm2 in size. The primary outcome measure was the responder rate at 2 years using the Knee Injury and Osteoarthritis Outcome Score (KOOS). RESULTS: Two years after ACI treatment, 93% of patients were KOOS responders having improved by ≥10 points compared with their pre-operative level. The primary endpoint of the study was met and demonstrated that the KOOS response rate is markedly greater than 40% with a lower 95% CI (confidence interval) of 86.1, more than twice the pre-specified no-effect level. KOOS improvement (least squares mean) was 42.0 ± 1.8 points (95% CI between 38.4 and 45.7). Mean changes from baseline were significant in the overall KOOS and in all 5 KOOS subscores from Month 3 (first measurement) to Month 24 (inclusive) (P < 0.0001). The mean MOCART (Magnetic Resonance Observation of Cartilage Repair Tissue) score after 24 months reached 80.0 points (95% CI: 70.0-90.0 points) and 92.1 points in lesions ≤ 5 cm2. CONCLUSIONS: Overall, hydrogel-based ACI proved to be a valuable treatment option for patients with large cartilage defects in the knee as demonstrated by early, statistically significant, and clinically meaningful improvement up to 2 years follow-up. Parallel to the clinical improvements, MRI analyses suggested increasing maturation, re-organization, and integration of the repair tissue. TRIAL REGISTRATION: NCT03319797; EudraCT No.: 2016-002817-22.

[Derotational Intertrochanteric Osteotomy in Habitual Dislocation of the Patella]. / Derotacní intertrochanterická osteotomie u habituální luxace pately.

PURPOSE OF THE STUDY The preoperative planning in habitual dislocation of the patella should take into account all pathologies and the procedure should address all abnormalities. One of them might be also the rotational deformity of the femur. The purpose of this prospective study was to confirm the hypothesis that the only correction of pathological femoral anteversion by derotational intertrochanteric osteotomy (in the absence of another pathology) or the correction of femoral anteversion with simultaneous reconstruction of the patellofemoral joint provide adequate stability for the patellofemoral joint, with respect to the elimination of the risk of recurrent dislocation of the patella. MATERIAL AND METHODS In the course of 15 years, 17 patients (20 knee joints) with habitual dislocation of the patella were included in the study, in whom the CT scan also confirmed the femoral anteversion of 35° and greater. The group was female-dominant, often with BMI > 30. The mean age was 26 years. In 4 cases only derotational intertrochanteric osteotomy was performed, in 16 patients the osteotomy was followed by the stabilization of the patella in the knee region (always individually in dependence on the diagnosed pathology), of whom in 2 cases as the second step procedure because of thrombophilic disorders detected earlier. Immediately after the surgery, or at 6 weeks postoperatively (depending on the knee procedure done), individual rehabilitation was commenced. Partial weight bearing was recommended for the period of 3 months after the surgery. The mean follow-up period was 39 months (minimum of 36 months). RESULTS In one case a failure of osteosynthesis was observed and revision osteosynthesis with an intramedullary nail was performed. In all the other cases, primary healing of the osteotomy was achieved. The other complications were less significant (1 case of asymptomatic deep vein thrombosis of the lower limb, evacuation of subcutaneous haematoma in 1 case, 3 cases of the knee stiffness solved by manipulation under general anaesthesia at 6 weeks after surgery). Recurrent patellar dislocation was not observed in any of the patients. No pain in the upper thigh was reported by patients during the last follow-up control (at least 3 years postoperatively). Three female patients reported an isolated feeling of patellar instability. DISCUSSION There are very few studies focusing on the femoral derotational osteotomy for habitual dislocation of the patella in world literature. If any at all, they concern supracondylar and not intertrochanteric femoral osteotomy and the groups of patients were smaller than the group evaluated by us. CONCLUSIONS Preoperative planning for habitual dislocation of the patella should definitely reflect all pathologies. Therefore, the femoral derotational osteotomy should certainly be mastered by the orthopaedic surgeon, though it is a larger and more exacting procedure than patellar stabilizations in the knee region. Indications for this type of osteotomy should include anteversion greater than 30°, or 35°. The derotational intertrochanteric osteotomy alone or its combination with the stabilization of the patella in the knee region brings reliable results with no risk of recurrent dislocation. Key words: patella, habitual dislocation, femur, anteversion, derotational osteotomy.

Fourniers gangrene as Amyands hernia complication.

INTRODUCTION: Fourniers gangrene is a rare but fast deteriorating and serious condition with high mortality. In most cases, it is characterized as necrotizing fasciitis of the perineum and external genitals. Amyands hernia is a rare condition where the appendix is contained in the sac of an inguinal hernia. Inflammatory alterations in the appendix account only for 0.1 % of the cases when Amyands hernia is verified. Fourniers gangrene as a complication of a late diagnosis of appendicitis located in the inguinal canal is described in the literature as rare case reports.   Case report: The case report of a 70-year-old patient with Fourniers gangrene resulting from gangrenous appendicitis of Amyands hernia.  Conclusion: Fourniers gangrene as a complication of Amyands hernia is a rare condition. Only sporadic case reports thereof can be found in the literature. Because of the rarity of this pathology and the lack of randomized controlled studies, it is difficult to determine the optimal treatment according to the principles of evidence-based medicine. An appropriate approach for this condition appears to be the combination of guidelines developed in Amyands therapy according to Losanoff and Basson, along with the recommended “gold standard” therapy for Fourniers gangrene. This means early and highly radical surgical debridement, adequate antibiotic therapy and intensive care.

[Comparison of Tension Banding and Modified Orthocord Sling in Acromioclavicular Dislocation Treatment - Non-Randomized Retrospective Study]. / Stabilizace akromioklavikulární luxace tahovou cerklází ve srovnání s jedním Kirschnerovým drátem doplneným klickou z cástecne vstrebatelného materiálu ­ nerandomizovaná retrospektivní studie.

PURPOSE OF THE STUDY Acromioclavicular joint dislocations (AC) represent one of the most frequent injury to the shoulder gridle. Low grade injuries type Rockwood I-II are treated non-operatively. Whereas high grade injuries type Rockwood III-VI are usually treated operatively. At present a wide spectrum of surgical techniques is used: Bosworth screw, hook plate, pinning and tension banding, PDS-sling. In our study the pinning and tension banding technique and the modified orthocord sling technique were compared. The goal of this study was to determine whether there are any clinical and radiological differences between these two techniques. MATERIAL AND METHODS This retrospective non-randomized level 3 evidence study included 58 patients. All of them have sustained a Tossy III AC dislocation. Of the 58 patients, 31 were treated with pinning and tension banding. Modified orthocord (absorbable knitted strand) sling technique (One 2.0-2.5 mm Kirchner wire, orthocord tension banding and coraco-clavicular ligament suture) was used in 27 patients. The same regime was used in postoperative follow up. For the clinical assessment the ASES and Constant score were used. The presence of calcification, degenerative changes, clavicular dislocation were assessed during the X-ray follow-ups. RESULTS The mean treatment time was 18.7 ± 4.9 weeks in the pinning and tension band group (Group A), whereas 15.8 ± 2.8 weeks in the modified orthocord sling technique (Group B). There was a significantly shorter period of healing in Group B. There were no statistically significant differences in the K wire removal time (Group A: 12.6 ± 3.7, Group B: 11.9 ± 3.2). No significant difference was observed between Group A and Group B on the ASES score (Group A: 95 ± 5.8, Group B: 98 ± 3.1) and on the Constant score (Group A: 97.7 ± 3.2, Group B: 97.9 ± 2.9). There were significant differences in both groups between the injured and non-injured shoulder on the Constant score. The mean secondary clavicular dislocation in Group A was 7.2 ± 1.8 mm in the operated shoulder and 4.8 ± 2.0 mm in the non-operated shoulder. The secondary dislocation in Group B was 7.5 ± 2.0 mm in the injured shoulder and 4.2 ± 1.2 mm in the non-injured shoulder. There was a significant difference between the injured and the non-injured shoulder in both groups. Calcification in coraco-clavicular ligament was observed in 15 (48.4%) Group A cases and in 13 (48.1%) Group B cases. Secondary AC joint arthrosis was observed in 8 (25.8%) Group A cases and in 1 (3.7%) Group B case. DISCUSSION No significant difference in clinical outcomes between both the surgical techniques was found. These results are comparable with other, recently published studies. On the other hand, we observed a significantly decreased treatment time with the modified orthocord sling technique. One, centrically inserted Kirschner wire, might better tolerate small rotation movements in the AC joint. Secondary clavicular dislocation, Kirschner wire dislocations and wound complications were similar in both groups and comparable to other, recently published studies. CONCLUSIONS Even though the tension banding and orthocord modified sling rank among the oldest and the cheapest techniques available for AC dislocation treatment, their results are comparable with modern and costly techniques. The orthocord modified sling technique has an advantage of fast and cheap material extraction in outpatient conditions. Key words: AC dislocation, acromioclavicular joint dislocation, orthocord sling, tension banding, AC disruption, acromioclavicular joint disruption.

[Assessment of Reduction Abilities of an Expandable Stent in Treating Osteoporosis-Related Fractures of Th/L (Thoracolumbar) Spine]. / Zhodnocení repozicních schopností expandibilního stentu pri osetrení osteoporotických zlomenin Th/L pátere.

PURPOSE OF THE STUDY The method of stabilising the osteoporosis-related spinal fractures using an expandable stent (vertebral body stent - VBS) and bone cement is generally accepted for its minimal invasiveness, a low risk of complications and confirmed analgesic effect. The efficiency of reduction of a compressed vertebra is, however, still discussed in the literature. Our hypothesis was that the stent expansion in the vertebral body can achieve a statistically significant reduction in the anterior, middle and posterior part of the vertebra. MATERIAL AND METHODS The patients in whom the VBS technique was used to treat an osteoporosis-related fracture of Th/L spine in the period 2010-2014 were included in the study, namely 29 patients with 31treated fractures. The following radiographic parameters were monitored - anterior, middle and posterior vertebral body height, kyphotic angle between the upper and lower endplates of the vertebral body. Also, the radiation burden, painfulness according to VAS score and occurrence of complications were monitored. The minimum follow-up was 12 months. RESULTS The mean height of the anterior part of the vertebral body before the surgery, on the 1st postoperative day and at 6 weeks, 3 months, 6 months and 12 months was 23.5/25.4/23.9/23.6/23.6 mm respectively. The mean height of the middle part of the vertebral body at the same intervals was 17.9/24.0/23.4/22.9/22.9/22.9 mm. The mean height of the posterior part of the vertebral body was 29.6/29.8/29.4/29.3/29.2/29.2 mm. The kyphotic angle between the endplates of the vertebral body was 8.6/5.3/7.4/7.9/8.0/8.0°. The mean VAS values were 8.2/2.4/2.0/1.9/1.8/1.7. The mean duration of surgery was 54.3 minutes. The mean time of fluoroscopy was 33.4 s. The mean radiation dose was 443.1 cGycm2. The observed complications comprised 2 cases of dilatation balloon rupture, one case of a failure to expand the stents in a healed fracture due to incorrect indication. In total, four cases of cement leakage outside the vertebral body were reported, always with no clinical response. DISCUSSION All the authors agree that the method brings immediate analgesic effect, comparable to kyphoplasty or vertebroplasty. In our cohort, good reduction ability of the implant in the middle part of the vertebral body was confirmed. This has been confirmed also by other authors. Nonetheless, at a longer time interval the loss of correction was observed, which was reported only by Hartmann (5). The other authors mostly did not take into account the longer-term outcomes. CONCLUSIONS The hypothesis that the stent is capable of a statistically significant reduction in the anterior, middle and posterior portion of the vertebral body was only partially confirmed. A statistically significant reduction was seen only in the middle portion of the vertebral body. In the anterior portion of the vertebral body the reduction was demonstrable only immediately after the surgery, while the later follow-up checks revealed the loss of correction. The statistically significant improvement of the kyphotic angle between the endplates of the injured vertebra was also seen only on the first postoperative radiographs and at later follow-up checks the improvement was no more significant. The change in the height of the posterior portion of the vertebral body was not statistically significant at any of the follow-up intervals. Key words:osteoporosis, vertebral fracture, vertebral body augmentation, stentoplasty, vertebral body stent.

[Treatment of the Shoulder Impingement Syndrome with PRP Injection]. / Lécba impingement syndromu ramena pomocí injekce PRP.

PURPOSE OF THE STUDY This study aimed to explore the effects of new therapeutic procedures in patients with shoulder impingement syndrome. The primary goal of the study was to confirm the hypothesis that the application of the platelet-rich plasma (PRP) in patients with shoulder impingement syndrome will have a positive effect on both the subjective and objective evaluation of their condition. The clinical condition before and after the treatment was evaluated. The secondary goal was to compare the effect achieved by a series of 3 PRP injections and that achieved by treating the impingement syndrome with a standard single depot corticosteroid injection. MATERIAL AND METHODS The randomized prospective blinded study carried out in the period 2013-2015 included 25 patients (Group I), to whom 3 PRP injections were applied in the subacromial (SA) space at a 1-week interval at the outpatient department. The control group of 25 patients (Group II) was treated by a standard single depot corticosteroid injection applied in the SA space. The subjective and objective conditions were evaluated immediately before the treatment, at 6 weeks, 3 months and 6 months after the administration of the injection. The evaluation comprised a physical examination, an evaluation using the Visual Analogue Scale (VAS), ASES (American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form) and the Constant score. A part of the study was the statistical processing of the results. RESULTS Both the groups were comparable when assessing the mean age of patients as well as the share of both sexes in the groups; Group I with the mean age of 48.7 years (15 men and 10 women), Group II with the mean age of 50.1 years (16 men and 9 women), but also when assessing the baseline mean VAS score, Constant score and ASES score. In Group I, the baseline mean VAS score improved from 2.96 (range: 1-5; median: 3.0; SD: 0.77) to 2.0 (range: 1-3; median: 2.0; SD: 0.49) at 3 months after the administration and to the mean value of 1.16 (range: 0-2; median: 1.0; SO: 0.67) at 6 months after the last PRP injection. In Group II, the baseline mean VAS score improved from 3.12 (range: 2-5; median: 3.0; SD: 0.82) to the mean value of 2.16 (range: 1-4; median: 2.0; SD: 0.73) at 3 months after the administration of the depot corticosteroid injection and to 1.8 (range: 1-3; median: 2.0; SD: 0.57) at 6 months after the administration. In both the groups of patients, the p-value obtained by the Student s t-test was statistically significant (p < 0.05) when comparing the results of all the three scoring systems before the treatment and 6 months after the treatment. DISCUSSION Although the treatment of musculoskeletal disorders with the concentrate of a platelet-rich plasma (PRP) is a frequently used method, particularly in private medical practice, the scientific literature can offer just a very few studies studying in depth the use of this method of treatment in humane medicine. CONCLUSIONS Based on the results of our study, the hypothesis can be accepted that the concentrate of platelet-rich plasma administered through a series of 3 injections applied in the subacromial space in patients with shoulder impingement syndrome has positive effects on the daily activities of patients as well as on the objective evaluation via the selected scoring systems. Key words:platelet-rich plasma, shoulder impingement syndrome.

[Surgical Treatment of the Achilles Insertional Tendinopathy Using the Augmentation with the BT Graft from M. Quadriceps Femoris]. / Augmentace BT stepem z m. quadriceps femoris pri resení úponové tendinopatie Achillovy slachy.

PURPOSE OF THE STUDY The aim of the prospective study was to evaluate the effectiveness of the Achilles insertion tendinopathy treatment, focusing on the evaluation of results in patients treated for retrocalcaneal pain, and to review the outcomes following the surgical treatment by means of Achilles tendon reinforcement with the bone-tendon autograft (BT). MATERIAL AND METHODS The group comprised 18 patients, 10 men and 8 women, who were surgically treated with in line with the described surgical protocol. The group was treated at the author s department in the period 2013-2016. The patients were evaluated using the FAOS, VAS, and Kitaoka scores. The diagnosis of the Achilles insertion tendinopathy was confirmed by the MRI examination (changes at the Achilles tendon attachment to the calcaneus). The patients underwent surgery if the pain persisted after the conservative therapy lasting more than half a year. The mean follow-up was 12 months after the surgery. RESULTS The mean FAOS score improved from 4 preoperatively to 1 at the 12-month postoperative follow-up. The mean VAS and Kitaoka score improved from high level of pain preoperatively to low pain level. DISCUSSION Our study evaluated the results of surgical treatment of the diagnosis that may be difficult to treat effectively solely by non-surgical procedures. There are not many studies published in the literature regarding this issue. CONCLUSIONS The method of surgical treatment of the Achilles insertional tendinopathy using the augmentation with the BT graft was found to be an effective procedure with a low risk of complications and reliable results. Key words:Achilles tendon; insertional tendinopathy.

[Arthroscopic Treatment of Chronic Retrocalcaneal Bursitis - Endoscopic Calcaneoplasty]. / Artroskopická terapie chronické retrokalkaneární burzitidy ­ endoskopická kalkaneoplastika.

INTRODUCTION The authors evaluate the results of endoscopic treatment and analyse the causes of persisting difficulties in retrocalcaneal bursitis unresponsive to conservative treatment. Stated as one of the causes is the possible chronic irritation of minor/partial tears of anterior parts of the distal portion of the Achilles tendon, which have no chance to heal due to continued overload and impingement syndrome of the superior prominence of the calcaneal tubercle. MATERIAL AND METHODS The authors evaluate the group of 24 patients (10 women and 14 men) diagnosed with retrocalcaneal bursitis, who reported more than 12 months of difficulties and in whom the conservative therapy options have already been exhausted. The decision to perform a revision arthroscopy was made by the authors based on chronic long-lasting difficulties, clinical examination, calcaneus radiograph, ultrasound examination and negative response to the performed conservative treatment. The MRI scan was obtained in 4 patients. In 11 patients during arthroscopy the Achilles tendon was intact, in 13 patients (54.2%) minor tears were detected on the anterior aspect of the distal Achilles tendon, not diagnosed preoperatively (by ultrasound examination). In all the patients, resection of the prominence of the calcaneal tubercle was performed, whereas in patients with affected Achilles tendon also the loose tendon fragments were resected. RESULTS A total of 23 patients reported an improvement of their condition, the pain subsided at 21-43 days. Altogether 21 patients returned to activities carried out before the onset of pain. The AOFAS score values measured preoperatively in patients with an intact tendon were 59.5 ± 15.0, in patients with an injured tendon it was 45.57 ± 9.6, while 6 months after the surgery the values were 95.7 ± 6.2, or 88.71 ± 7.8 respectively. In 1 female patient, with one prior surgery, diagnosed with a partial tear of the Achilles tendon, the effect of the surgery was unsatisfactory. After six months the patient underwent an open revision surgery and the Achilles tendon reinsertion. No intraoperative or postoperative complications were observed. DISCUSSION The endoscopic technique facilitates a more visible bone resection, with better control of resection, which is less invasive than the open technique. The source of irritation can be removed, which is not always only the prominence of the calcaneal tubercle, but another cause of persisting problems can also be a microtrauma affecting the anterior portion of the Achilles tendon, with a reactive hyperaemia in bursal tissue. Compared to literature and also based on the results of the authors of this retrospective study, the endoscopic calcaneoplasty is less invasive than the open surgery. It is always necessary to properly diagnose the causes of difficulties and to timely respond to persisting symptoms in patients, not responding satisfactorily to conservative therapy. CONCLUSIONS The findings presented by the authors provide a new perspective on the causes of chronic problems such as the "posterior heel pain" and tend to give preference to the active endoscopic approach in patients with persisting problems, not responding to conservative treatment, predisposed based on the radiological examination and with a positive finding on ultrasound or MRI scan. Key words:retrocalcaneal bursitis, endoscopic calcaneoplasty, arthroscopy.

Aplikace plazmy obohacené o trombocyty a leukocyty k laterálnímu epikondylu humeru.

PURPOSE OF THE STUDY The aim of the study was to evaluate the safety and efficacy of the application of platelet- and leukocyte-rich plasma (L-PRP) in the treatment of lateral humeral epicondyle (ERH) as compared to the administration of corticosteroid therapy. MATERIAL AND METHODS It was a prospective, double-blind and randomized clinical trial. It included a total of 25 cases of ERH in 23 patients aged 18 to 60 years. They were divided into two arms: L-PRP arm with 10 cases and corticosteroid arm with 15 cases. The therapy of L-PRP group: first application: 3 ml of native L-PRP without activation, second application: after 6 weeks, 3 ml of thawed L-PRP. Therapy of the corticosteroid arm patients: first and second application (both after 6 weeks) of 3.5 mg of Betamethasonum. The follow-up period was 12 months. The safety evaluation was carried out based on the number of adverse events. The efficacy was evaluated using the DASH score and the Visual Analogue Scale (VAS). The time series outcomes were analysed statistically by percentile graphs and repeated measures ANOVA. RESULTS The ascertained values of blood elements in the received L-PRP as against the original blood were the following: platelets around 400%, white blood cells around 200%, red blood cells around 30%. The differences in individual subpopulations of white blood cells: neutrophils 74%, lymphocytes 424%, monocytes 385%, eosinophils 43%, basophils 337%. The product was classified as L-PRP group based on the POSEIDO classification. Safety evaluation: both the groups reported no adverse and also no serious adverse events. One patient withdrew from the corticosteroid group on the grounds of a subjective feeling of treatment failure. Efficacy evaluation: for both the general DASH score and Work Module a statistically better effect of L-PRP was proven in the first 6 months at p < 0.05. For the general DASH score, the L-PRP group reported a decrease of difficulties from approximately 50% to 20% on DASH score and in the corticosteroid group the difficulties returned to more or less the initial value. In the Work Module, the L-PRP group showed a decline in difficulties from approximately 46% to 18% and the corticosteroid group from approximately 43% only to 38%. The Sports and Music Module was evaluated by percentile graphs only. The VAS assessment proved that an effect was achieved only after the administration of the first dose of L-PRP and corticosteroid, with a more significant effect reported in L-PRP. The overall statistical evaluation using the VAS showed no difference between these two therapies at the level of significance of p<0.05 (p = 0.08). DISCUSSION The product used by us was classified as a L-PRP subcategory. The application of the native and subsequently frozen L-PRP is rare as compared to the corticosteroid therapy. CONCLUSIONS According to our results, the application of L-PRP is suitable to treat lateral humeral epicondyle. The benefits can be foreseen in the form of a better functional score, whereas the analgesic effect equals the effect of corticosteroid. A slightly additive effect was seen in the thawed second dose. Key words: platelet- and leucocyte-rich plasma, epicondylitis radialis humeri.

[Bilateral Asymmetric Traumatic Dislocation of Hip Joints]. / Bilaterální asymetrická traumatická luxace kycelních kloubu.

The authors present a rare case of bilateral asymmetric traumatic dislocation of hip joints, where the left joint was treated conservatively after the reduction, while the right joint, with an acetabular fragment interposition, was treated surgically - by arthroscopically assisted reduction and fixation of an osteochondral fragment of posterior wall of the acetabulum. The female patient healed with no complications, showing an excellent clinical outcome with no signs of instability or limited mobility of hip joints, and also with no signs of para-articular calcification or necrosis of the hip at 1 year after the injury and treatment. Bilateral asymmetric dislocation of hip joint is a rare injury with the total incidence of 150 cases as reported by the literature. Recently, its incidence is higher due to the increased traffic and the associated accident rate. A precise and prompt reduction of the injured hip joint is always necessary, if possible under general anesthesia. Also, it is always necessary to carry out a complete examination of the patient since this type of injury is always caused by a strong force and is often accompanied by injuries of other parts of the body. Key words: bilateral asymmetric dislocation of hip joints, hip arthroscopy, acetabular fracture.

[Treatment of Extensive Chondral Defects of the Patella after Patellar Dislocation]. / Terapie rozsáhlých chondrálních defektu pately po akutní luxaci pately.

PURPOSE OF THE STUDY Patellar dislocation is a fairly frequent knee joint injury in young patients. In most cases, this injury can be treated conservatively or surgically. In many cases, patellar cartilage or lateral femoral condyle or both these parts of articular surface are injured, and in conservative treatment this chondral damage very often remains undiagnosed. The purpose of this study is to evaluate the outcomes of treatment in patients who underwent surgery for patellar dislocation and in whom extensive traumatic cartilage lesions of the patella were found. MATERIAL AND METHODS The authors carry out a retrospective evaluation of outcomes in 34 patients from the period 2005-2014, in whom extensive chondral defect of the posterior side of the patella after its traumatic dislocation with the mean size of 4.1 cm2 (the maximum size was 28x18 mm) was found, namely in 21 women and 13 men aged 13-28 years. The patients were indicated for arthroscopic surgery based on the clinical examination which revealed a clear traumatic patellar dislocation. In 2 radiographs only, an osteochondral fragment was found, and in these patients a CT scan of the injured knee was made. The patients were retrospectively broken down into 3 sub-groups by the method of treatment of the chondral defect. The mean size of the defect in the debridement group was 2.7 cm2 compared to 4.6 cm2 in the group with cartilage fixation. In group I reinsertion through MiniSynthes 2.0 screws (5 patients) was performed, in group II reinsertion of the chondral fragment was done using transosseous PDS sutures (19 patients), in group III debridement of injured cartilage was carried out (10 patients). RESULTS The patients were assessed postoperatively using Kujala score and IKDC score. The mean age of patients at the time of injury was 19.6 years, with mean follow-up of 30.2 months. No group reported limitations of range of motion at the time of evaluation. Knee pain under load was present in 3 patients in group I, in 1 patient in group II and in 7 patients in group III. No patient suffered from another patellar dislocation. The mean Kujala score was 84.7 (group I), 89.3 (group II), and 78.5 (group III). The IKDC was 84.6 in group I, 87.2 in group II, and 74.3 in group III. At the time of evaluation, pre-injury activities were resumed by 72% of patients from group I, 82% of patients from group II, and 69% of patients from group III. DISCUSSION Treatment of primary patellar dislocation is still subject to discussions on whether to pursue conservative or surgical treatment. The main topic of studies is the subsequent rate of patellar re-dislocation and the rate of cartilage damage in patellofemoral joint, examined is also the scope of performed surgery, while only very few papers focus on treating the injured cartilage of the patella. Despite numerous studies, the optimal method of treatment of this injury has been identified as yet. CONCLUSIONS Where a serious, extensive fragment of patellar cartilage is found, the fixation of cartilage with the use of transosseous PDS sutures brings very good and good results, without the necessity of another surgery, while the simultaneous treatment of medial patellar retinacula considerably decreases the risk of patellar re-dislocation, thus reducing the risk of further damage to cartilage of patelofemoral joint. The use of transosseous suture fixation is considered by the authors to be more appropriate than the use of screws, mostly because no further surgery to remove fixation screws is necessary. Key words: acute patellar dislocations, chondral lesions, chondral repair, arthroscopy.

[Quantitative Analysis of Power Doppler Images in Lateral Humeral Enthesopathy]. / Kvantitativní analýza power Doppler obrazu laterální entezopatie humeru.

PURPOSE OF THE STUDY The evaluation of efficiency of power Doppler sonography in the diagnosis of lateral humeral enthesopathy, role of correct assessment of Doppler sonographic images with the method of quantitative analysis, assessment of statistical differences between a group of patients with lateral humeral enthesopathy and a control group of healthy subjects and assessment of the diagnostic power of this test. In addition, consideration of the relevance of each area of the lateral compartment for assessment and diagnosis making in lateral humeral enthesopathy. MATERIAL AND METHODS A total of 41 subjects, aged 18 to 60 years, entered the study. Thirteen patients were diagnosed with lateral humeral enthesopathy on the basis of clinical tests and a positive reaction of the lateral humeral epicondylus to administration of local anaesthetic. The control group consisted of 28 subjects without clinical signs of lateral humeral enthesopathy and subjective complaints. Power Doppler activity was evaluated in the whole region studied and in sub-regions involving the enthesis of the common extensor tendon and the periosteum of the lateral epicondyle with the area distal to it. The evaluation was based on calculating the overall surface with power Doppler activity using the method of quantitative image analysis. Each patient was measured on three occasions and the median of values obtained was used in calculation. To assess the diagnostic power of this test, all values obtained from the whole power Doppler region measured were used. The optimal dividing criterion at which the method had a maximum of sensitivity and specificity was determined. RESULTS The most evident, statistically significant difference between the patient and the control group was recorded in the whole "Range of Interest" (ROI) region (p=1.34x10-6). A significant difference was also found in sub-regions corresponding chiefly to the tendon of the extensor carpi radialis brevis muscle and to the periosteum of the lateral epicondyle (p=0.0043). On the other hand, no significant difference was recorded in the sub-region of the proximal common extensor tendon (p=0.066). A Receiver Operating Characteristic (ROC) was performed to evaluate the sensitivity and specificity for a colour representation of each power Doppler image (a cut-off level). Calculation of the diagnostic power of the test gave a value of 0.915 (p=0.05) below the ROC curve. The optimal marginal value, at which both sensitivity and specificity were highest, was determined to be 455 pixels (sensitivity, 80.5%; specificity, 93.8%). DISCUSSION Power Doppler sonography has already been investigated in view of its potential for the diagnosis of lateral humeral enthesopathy. The results, however, have so far been assessed chiefly categorially, based on the examining physician's opinion. The problematic step in the whole procedure is the technique of power Doppler examination. It is necessary to maintain a constant setting and an examination technique eliminating artefacts. When these conditions are met, the method has both high sensitivity and specificity. In addition, because of being non-invasive, the method is convenient for routine use. CONCLUSIONS Power Doppler sonography is a method convenient to confirm or exclude the diagnosis of lateral humeral enthesopathy. Our results showed its statistical significance and diagnostic power (sensitivity and specificity). In the future, the quantitative image analysis could become a valuable adjunct method of evaluation not only for power Doppler images. Key words: Doppler sonography, quantitative image analysis, lateral humeral enthesopathy.

[Treatment for Periprosthetic Femoral Fractures after Total Hip Arthroplasty]. / Terapie periprotetických zlomenin femuru po implantaci totální endoprotézy kycelního kloubu.

PURPOSE OF THE STUDY To give a description of the patient group, risk factors, classification, therapeutic procedures and treatment outcomes in periprosthetic femoral fractures after total hip arthroplasty treated in the Trauma Hospital in Brno. MATERIAL AND METHODS This retrospective study comprised of 51 patients treated for a periprosthetic femoral fracture between 2003 and 2013. This included 19 (37%) intra-operative and 32 (63%) post-operative fractures. According to the Vancouver classification, the types of fractures were as follows: 9 patients A; 21 B1; 9 B2; 6 B3 and 6 with type C. RESULTS Type A fractures were treated conservatively. Although pseudoarthrosis of the greater trochanter occurred, the patients had no clinical problems. The intra-operative type B1 fractures were managed by cerclage tapes in nine patients and the post-operative B1 fractures were treated by plate osteosynthesis in 10 patients and femoral stem reimplantation in two patients. All post-operative type B2 and type B3 fractures were managed by reimplantation of the femoral stem and type C fractures were treated by plate osteosynthesis. Serious complications requiring revision surgery were recorded in five patients; they included plate failure in two B1 fractures, dislocation of a B2 fracture, a dislocation with femoral component rotation in a B3 fracture and failure of the plate in a type C fracture. CONCLUSIONS The treatment of a periprosthetic fracture can affect the patient's life. In view of the fracture type, implant type, general health of the patient and all risk factors, the authors prefer one-stage surgical treatment. The Vancouver classification is a guidleine for the therapeutic plan. Osteosynthesis as a single procedure is indicated only if the femoral component is stable and well fixed. When the stem in B2 and B3 fractures is loose, revision surgery with stem replacement is necessary. Key words: periprosthetic fracture, total hip atrhroplasty, Vancouver classification.

[Dislocation of the clavicle: case report]. / Luxace klícní kosti.

A traumatic dislocation of the clavicle is a rare injury. So far 37 reports of this trauma have been found in the relevant literature; they are most often treated by surgery. A 32-year-old woman was admitted to local hospital for polytraumata sustained in a motor car accident. Once the patient had been stabilised, at three months after injury, stabilisation of the left dislocated clavicle was undertaken. The medial end was stabilised, using a strip dissected from the ligament of the sternoclavicular (SC) joint capsule, with Orthocord sutures, and laterally by coracoacromial ligament transfer (Weaver and Dunn technique) and K-wire fixation through the acromioclavicular (AC) articulation. The K-wire was removed 10 weeks after stabilisation. At 6 months after the repair surgery, the patient was free of any complaint, with no motion restriction and with good configuration of the SC and AC joints. The mean scores according to the University of California at Los Angeles (UCLA) rating system were 14 points before surgery and 28 points at 6 months after surgery; the mean Constant scores were 56 and 92 at the respective intervals. The clinical outcome of surgical stabilisation in this patient was very good. She had no signs of instability and no restriction of motion at the joints treated.

[Inveterated posterior glenohumeral dislocation treated surgically from the anterior approach]. / Inveterované zadní glenohumerální luxace a jejich operacní resení predním prístupem.

PURPOSE OF THE STUDY: The aim of the study is to remind the medical community of the occurrence of rare dorsal glenohumeral dislocations and of the need to pay increased attention to radiographic and clinical examination in the patients in whom signs of this injury are also supported by medical history. When this dislocation becomes a chronic disorder, it can frequently be managed only by surgical intervention. The treatment algorithm used at the authors' institutions is described. MATERIAL: In the period from 2000 to 2008, a total of l7 patients (9 women and 8 men) with an average age of 65.5 years (51 to 89 years) had surgery for inveterated dorsal glenohumeral dislocation. The average injury-surgery interval was 5.6 weeks (1 to 18 weeks). The average follow-up was 38 months (101 to 13 months). METHODS: Surgery was performed via an anterior deltoideopectoral approach. Under pathological conditions, the subscapular muscle was identified. When a large reverse Hill-Sachs defect was present, the lesser tuberosity with the subscapular tendon was osteomited (10 patients). After scar and granulation tissue had been removed, the humeral head was reduced. Using Neer's modification of the McLaughlin procedure, the excised lesser tuberosity fragment was transferred into the antero-medial defect in the humeral head and fastened with a screw. In the case of an unstable humeral head, this was held in the reduced position by two Kirschner wires either passed through the acromion or fixed to the glenoid (11 patients). The arm was immobilized in a brace for four weeks. Then the wires were removed and rehabilitation was started with avoidance of internal rotation. RESULTS: None of the patients had recurrent dislocation. All were satisfied with the outcome and capable of resuming their daily activities sufficiently. Six patients complained of occasional pain. The average value of active elevation was 113° (40° to 160°). Reduced muscle strength in abduction, as compared with the contralateral arm, was observed in two patients. Injury to the axillary vein was recorded in one patient. Two patients had a large haematoma of the arm with swelling of the whole extremity. Two of the 11 patients treated with Kirschner wires developed infection around the wires that healed after their removal at four weeks after surgery. DISCUSSION The open reduction and stabilization of a posterior inveterated glenohumeral dislocation can be regarded as a rare procedure performed only occasionally even in specialized institutions. The international literature also provides information on only a few tens of such cases over a number of years. Causal procedures, performed through both an anterior and posterior approach, as well as extrafocal (rotational) osteotomy have been recommended. Currently, surgery from an anterior approach is preferred, because a reverse Hill-Sachs defect, if present, can be managed either by transfer of the lesser tuberosity with the subscapular tendon or by massive allograft. CONCLUSIONS The authors' experience suggests that Neer's modification of the McLaughlin procedure is the optimal treatment for posterior inveterated glenohumeral dislocation with an anteromedial defect of the humeral head. The excision of the lesser tuberosity with the subscapular tendon provides good access to the shoulder joint and thus allows for its reliable reduction. The fastening of a tuberosity fragment into the compression defect resolves one of the major risks for recurrent dislocation, without necessity to use allogenic material. Transfixation of the humeral head with Kirschner wires for four weeks is a reliable method of holding the head in the glenoid without risk of significantly restricting shoulder motion in the future.

[Clinical outcomes of surgical management of acromioclavicular dislocation with and without ligament suturing]. / Klinické výsledky operacního resení acromioclaviculárni luxace se suturou a bez sutury vazu.

INTRODUCTION: The aim of the study was to present a retrospective assessment of clinical outcomes of acromioclavicular (AC) dislocation surgery with and without suturing of the coracoclavicular ligament (CC). MATERIAL AND METHODS: Patients regardless of their age and gender were included in the study. All the subjects were operated by the same surgeon using the same surgical technique--traction cerclage. Every odd-numbered patient's procedure included ligament suturing and every even-numbered patient was operated without ligament suturing. The patients underwent clinical follow up at identical time intervals, had Pruban (elastic net bandage) fixation applied for one week and had the same rehabilitation regime for 6 weeks. The wires were extracted at 6-8 months. A total of 42 patients were included in the study. All the subjects were classified according to Tossy III, based on x-ray findings. The study group included 36 males and 6 females. The average age was 31.8 years (17-55). In 14 cases, preoperative stress x-rays of the upper extremity were performed. CC ligmanet suture was completed in 21 patients and 21 patients underwent procedures without CC suturing. The clinical outcome was assessed after wire extraction. RESULTS: Painful complications were recorded in 2 subjects and they reported the pain to be intermittent. The pain was classified as maximum grade 4, based on VAS (Visual analogue score). In one patient, the authors recorded pain sensation in the area of Kirschner's wires endings. In this particular patient, the wires were extracted 6 weeks after the procedure and following that, the patient was symptom-free. CONCLUSION: Based on the findings, the authors recorded no differences in the clinical outcomes of AC surgery with or without CC ligament suturing.

[Transplantation of deep frozen menisci]. / Transplantace hluboce mrazených menisku.

PURPOSE OF THE STUDY: Subtotal or total meniscectomy will increase weight-bearing per square unit of the cartilage surface approximately threeand- half-times. A long-term overloading of cartilage is clinically manifested by pain, swelling and a rapid onset of early arthritic lesions discernible on radiograms. One of the options for the treatment of degenerative changes in the joint is meniscal transplant. The authors present their first experience with the transplantation of deep frozen meniscal tissue in the Czech Republic. MATERIAL: By September 2006, we had treated 26 patients with clinical problems following subtotal or total meniscectomy. The patients, 15 women and 11 men, were between 24 and 46 years of age. Eighteen patients underwent transplantation of the medial meniscus and eight received a lateral meniscal transplant. Concomitant repair of the anterior cruciate ligament (ACL) was indicated in 11 patients, of whom 10 were treated with semitendinosus tendon graft and one with patellar ligament allograft. One patient with a lateral meniscal transplant and ACL reconstruction also had suture of the medial meniscus for a previously sustained injury. In 16 patients, chondromalacia was at the level of Outerbridge grade II and, only in five patients, the finding was Outerbridge grade I. Five patients with grade III chondromalacia were treated using the microfracture technique. Valgus or varus osteotomy was not indicated at all. METHODS: The goal of meniscal transplant surgery is: 1) to relieve pain after meniscectomy; 2) to prevent degenerative changes of cartilage; 3) to eliminate or reduce the risk of development of osteoarthritic lesions; 4) to restore normal mechanics of the knee joint. Patient selection is important and it is necessary to take into consideration: 1) level of cartilage degenerative changes; 2) knee alignment; 3) knee joint stability; 4) graft size. In patients with instability of the knee and indications for meniscal graft, it is necessary to stabilize the joint by ligament reconstruciton prior to transplantation; in the case of malalignment corrective osteotomy is required. RESULTS: All patients healed without complications. At the end of the third follow-up month, the range of motion was S-0-0-130 in 22 patients and S-0-0-120 in three patients. Only one patient had the range of motion restricted to S-0-0-110. Evaluation showed improvement from pre-operative values to those at 6 months and two years post-operatively as follows: IKDS score, 57-64 to 73-80 to 76-84; Lysholm score, 50-76 to 80-90 to 85-95; and Tegner score, 2-4 to 4-7 to 5-8. No complications associated with meniscal transplant incorporation were recorded. Also in five patients with Outbridge grade III degenerative changes, meniscal transplantation was successfully carried out. In four patients, of which two had a cartilage defect treated, second-look arthroscopy showed that the lesions healed with healthy fibrocartilaginous tissue. CONCLUSIONS: All patients reported resolution of subjective complaints, as seen from the results of the IKDC, Lysholm and Tegner scoring systems. It was obvious that when biomechanics of the knee joint were restored, conditions facilitating healing of chondral defects were provided. Based on this experience, the authors conclude that meniscal transplantation improves the quality of life in biologically young patients with clinical problems after meniscectomy.

[Treatment of intra-articular proximal tibial evaluation of two- to seven-year follow-up]. / Výsledky lécby niktrokloubních zlomenin proximální tibie v UN Brno v letech 1997 az 1999: hodnocení po 5-7 letech od terapie.

PURPOSE OF THE STUDY: Intra-articular fractures of the proximal tibia always present a complicated therapeutic problem. In this retrospective study, the results of both conservative and surgical treatment of these fractures are evaluated. MATERIAL: In the period from 1997 to 1999, 114 patients with proximal tibial fractures were treated in the Traumatological Hospital in Brno-Traumacenter. Of these, 34 (30 %) were treated conservatively and 80 (70 %) by a surgical procedure. A total of 80 patients were included in follow-up (70 %). Of these, 61 had surgery, which involved arthroscopically-assisted intervention in 25 patients, arthrotomy in 27 patients and open reduction with external fixation in nine patients who had an open fracture (eight had type C3 fracture). Minimally invasive fixation with a cancellous screw and washer was used in 25, and a buttress plate in 27 patients. Spongioplasty was carried out in 11 patients. METHODS: Clinical and questionnaire-based evaluation was undertaken at 5 to 7 years after the injury and following therapy. The outcome was assessed on the basis of two classification systems, i.e., the IKDC (International Knee Documentation Committee) score and the Lansinger score designed particularly for the evaluation of proximal tibial fractures. The outcomes were evaluated in relation to fracture type, conservative or surgical treatment, method of osteosynthesis, and use of arthroscopic control and spongioplasty. RESULTS: In each of the evaluated patients, radiographs were obtained after injury and then at the completion of therapy. The fractures classified according to the AO system were as follows: type A1 fractures - 9 patients; types B1, B2, B3 - 46 patients; types C1, C2, C3 - 34 patients. The average IKDC and the Lansinger scores achieved at 5- to 7-year follow-up were 70 and 24 points, respectively. This can be regarded as a very good result. Within 5 years of injury, four patients underwent total knee arthroplasty; all of them were over 50 years and had a type C3 fracture. The type B3 and C3 treated by arthrotomy showed similar outcomes on both classification systems (IKDC/Lansinger: 69/67 and 24/24, respectively). The B3 fractures operated on under arthroscopic control had better outcomes (77/69) than those treated by arthrotomy (27/25), because this approach combines advantages of inner fracture fixation with a minimally invasive surgical technique. Better results were also achieved in fractures treated by minimally invasive fixation with cancellous screws. DISCUSSION: The outcomes of therapy in intra-articular fractures of the proximal tibia related to how serious the fracture was and how well it was reduced and stabilized. Both the approach to fracture reduction and the method of its stabilization (buttress plate, minimally invasive screws, external fixator) are selected according to fracture type and soft tissue state. Spongioplasty is indicated if subchondral bone is affected. Reduction and stabilization performed under arthroscopic control permit more precise reconstruction of the articular surface, but can be used only for certain fractures (type A1 and B1, B2 and B3). For reduction and stabilization of all fracture types, with the exception of AO type 41A-1 fracture, an Y-ray image intensifier system is necessary. The meniscus above the injured bone should be preserved in order to maintain good function of the joint. CONCLUSIONS: In intra-articular fractures of the proximal tibia, treatment outcomes depend on the type of fracture as well as correct reduction and use of appropriate fixation. When accurate alignment, joint stability and well reduced articular surfaces are achieved, outcomes are very good. At mid-term follow-up, reduction under arthroscopic control gives better results than stabilization performed by arthrotomy.

[Reconstruction of soft tissue defects of lower leg, ankle and foot using sural flap]. / Rekonstrukce defektiu mekkých tkání dolní tretiny bérce, hlezna a nohy pouzitím suralis laloku.

Covering soft-tissue injuries on the lower third of the leg, ankle joint and on the calcaneal part of the foot has so far been the domain for free flap use. The distally based superficial sural artery flap with vascular axis of the sural nerve was first described by Masquelet. We treated 31 patients after injuries with this method. No flap failed. Necrosis of the edges affected three flaps. Most flaps showed slight venous congestion. The authors present their clinical experience using this technique. The advantages are the following: the blood supply is reliable, elevation is easy and quick and major arteries are not sacrified.

[Arthroscopic management of traumatic luxation of the patella]. / Artroskopické osetrení traumatické luxace pately.

AIM: The authors present a restrospective assessment of acute traumatic patellar luxation. MATERIAL: From 1999 to 2003, the authors treated 57 patients with acute traumatic patellar luxations, including 36 females and 21 males, the age range was 16-40 years. In cases of marked lateralization of the patella, the injured medial retinaculum was sutured under arthroscopic control. Furthermore, should the lateralization persist, lateral release of the patella was conducted. Early patellar cartillage injuries were detected in 34 subjects (59%), injuries of the lateral femoral condyle in 19 subjects (33 %). Patellar chondromalacia, grade 1-2 was diagnosed in 16 subjects. Free cartillagenous particles within the joint were detected in 18 subjects. Reconstruction of the cartillage was conducted in extensive injuries in 13 subjects. RESULTS: The subjects were assessed 1-4 years after the injuries and surgery. In one case (2%), a relaps of the patellar luxation, due to a new contact sport injury (a direct impact), was recorded. Assessment results, using the Lysholm score, were defined as follows: 93%-excellent and good, 7% fair. CONCLUSION: Sparing surgical techniques, followed by appropriate rehabilitation care, may optimalize the healing process of the injured tissue and prevent relapses of patellar luxations, as well as further wearing of femoropatellar cartillages.