[Latarjet procedure for the treatment of inveterated shoulder dislocations]. / Pouzití operace podle Latarjeta pri inveterované luxaci ramene.

PURPOSE OF THE STUDY: Transfer of the tip of the coracoid process to the anterior margin of the glenoid is a procedure indicated in shoulder instability due to bone lesion. However, it is also used in inveterated shoulder dislocations refractory to conservative treatment that require open reduction of the joint. The bone block thus created allows for more effective and safer rehabilitation than does a temporary rigid Ki-wire fixation of the humeral head. The aim of this retrospective study was to evaluate the group of patients treated for irreducible inveterated shoulder dislocations by the Latarjet procedure. MATERIAL: Between 2005 and 2009, 16 patients with inveterated anterior shoulder dislocations were operated on. The group comprised 11 men and five women with an average age of 58 years. In all patients the duration of shoulder dislocation was longer than 3 days and reduction that would keep the humeral head in the glenoid socket was not possible even under general anaesthesia. The reasons for the late treatment included a delayed visit to the doctor's because the injury was not considered serious, the dislocation being missed in the presence of other more serious conditions, and even an overlooking by the attending physician. The longest time between the dislocation and its treatment was 23 days. Alcohol abuse was evident in some of the patients. METHODS: In the patients with irreducible inveterated shoulder dislocations who were referred to us, closed reduction was attempted in the first place.When this failed or when spontaneous dislocation subsequently occurred, open revision surgery was carried out. After coagula and synovia were removed from the glenoid socket, the head still had a tendency to dislocate spontaneously. Subsequently, the Latarjet procedure ;was performed this involved osteotomy of the coracoid process, retaining the attachment of the short head of the biceps brachii, and its transposition, through a split in the subscapularis ten- don, to the anterior lower margin of the glenoid. The process was fixed with two traction screws to create a firm bone barrier preventing dislocation. RESULTS: The functional outcome was assessed at 6 months after surgery, ;using the Constant score its average value was 60 points (35 to 85). From the evaluation of individual cases it appeared that the longer the time of shoulder dislocation, the worse the functional outcome of treatment. In comparison with the patients treated by open reduction with a temporary rigid Ki-wire fixation, the Latarjet procedure was clearly beneficial. DISCUSSION: Before the Latarjet procedure has been adopted, inveterated dislocations were treated by open reduction and a temporary fixation of the head in the socket by means of Ki-wires for three weeks. The functional outcomes following inveterated dislocation and rigid fixation were pitiable. Although the shoulder was articulated, its motion was restricted and painful. The procedure described here allows the patient to start early rehabilitation while maintaining shoulder stability. CONCLUSIONS: Inveterated irreducible shoulder dislocation is a rare diagnosis which is usually associated with the patient's personality disorder or is missed in patients with a disorder of consciousness. The treatment is difficult, but with the use of the procedure described here it is possible, with some limitation, to restore the shoulder function and its range of motion.

[Arthroscopic stabilization procedure for multidirectional shoulder instability]. / Artroskopická stabilizace ramene pri multidirekcionální nestabilite.

PURPOSE OF THE STUDY: The authors describe an arthroscopic procedure for multidirectional shoulder instability and its results in a group of their patients. They present a new argument to the widely accepted view that multidirectional instability of the shoulder is not an indication to surgical treatment. MATERIAL: A total of nine shoulders in seven patients were indicated to surgical intervention because of multidirectional shoulder instability. The average age of the patients was 19 years. Two patients underwent a bilateral procedure. Based on the preoperative clinical findings, two groups were distinguished: the patients with loose shoulders who, with overhead use of the arm, suffered from recurrent subluxations dorsally or caudally, and those who were able to voluntarily dislocate the glenohumeral joint as well as to reduce it spontaneously (habitual posterior dislocation). The patients were evaluated at one year follow-up using the Rowe and Zarins criteria. Patients with unidirectional instability of the shoulder were not included in the study. METHODS: All patients diagnosed with multiple recurrent posterior dislocations of the shoulder were indicated for surgery. After clinical examination, arthroscopy was carried out in a lateral recumbent position and, according to the findings, first capsulorrhaphy of the posterior capsule of the joint and reattachment of the labrum were performed, and then a similar intervention was carried out on the anterior part of the joint. For the operation, only two incisions were made, one for insertion of the arthroscope, the other for the instruments, and they were used interchangeably. Both absorbable and non-absorbable anchors were used and the capsule was fixed with a sliding knot. Subsequently, the shoulder was immobilized in a Desault bandage for 6 weeks, then rehabilitation was carried out. Full activity including sports was allowed beginning with the third month after surgery. RESULTS: Shoulder stability was achieved in all patients. After the procedure, no voluntary dislocation of the joint in the posterior direction or subluxations of the shoulder with overhead use of the arm were recorded. All patients, who had had serious problems pre-operatively, were satisfied with the results and would undergo the arthroscopic procedure again. Therefore, the therapy can be regarded as very effective. DISCUSSION: Our results of operative treatment contradict the generally accepted view that multidirectional shoulder instability is not indicated for surgical treatment, and the only therapy recommended to the patients is shoulder muscle strengthening, with avoidance of excessive motion range. This approach has persisted since the time when open surgery permitted either an anterior or a posterior intervention, but not both at the same stage. Today, arthroscopic reconstruction of the whole capsule is possible, with only a minimal interference with the shoulder muscles. Therefore, its benefits for the patients are undisputable. CONCLUSIONS: Arthroscopic stabilization of the shoulder for the treatment of multidirectional instability is a demanding procedure; however, if performed technically well, it is very efficient and provides good outcomes for patients with this diagnosis.

[Treatment of chondral and osteochondral defects of the knee]. / Soucasné moznosti resení chondrálních a osteochondrálních defektu kolene.

Chondral and osteochondral defects play an important role in the knee surgery. The knee traumas are often followed by preterm development of osteoarthritis due to limited reparative processes in the cartilage. Today's diagnostic possibilities and progress in arthroscopic techniques promote the early diagnostic and exact classification of osteochondral defects. The prognosis of these injuries is improved by following early treatment. Authors present therapeutic ways of solving the defects of cartilage and adjacent part of the subchondral bone. The new possible method of solving the deep chondral defects on the weight-bearing site of the knee by combined mosaic plasty and autologous cultivated chondrocytes is described.

[Mosaicplasty in treatment of deep chondral knee defects - first experience.]. / Resení hlubokých chondrálních defektu kolene mozajkovou plastikou - první zkusenosti.

The mosaicplasty as a method for solving the deep chondral defects is a one-stage technology with autogenous osteochondral graft application. The small cylinder's forming graft are obtained from a nonweightbearing site of knee cartilage and graft is further applied by press-fit technique to former prepared cartilage defects on the weightbearing site. Authors analyse the indications of this method and mention the possible risk and technical troubles during the treatment of the first group of patients. Key words: mosaicplasty, deep chondral defects, autologous osteochondral transplantation.