[Open Heel Spur Surgery - Our Experience]. / Resekce patní ostruhy operacní cestou ­ nase zkusenosti.

PURPOSE OF THE STUDY The plantar calcaneal spur (inferior calcar calcanei) is a frequent source of foot pain. The study presents the results of calcaneal spur excision by open surgery. It covers the indication, surgical approach, postoperative care, and presents the results reported at least one year after the surgery. MATERIAL AND METHODS The group consists of 42 heel spurs in 41 patients operated on in the period 2000-2016. The mean age was 44.5 years, with the age range 37-75 years. In 18 cases the surgery was performed on the right side, in 24 cases on the left side, the group was composed of 24 women and 17 men. Difficulties were suffered for the period of 8 months to 10 years before the surgery, the conservative treatment always continued for at least 6 months. The patients were assessed by the AOFAS questionnaire and the VAS score preoperatively and at 6 and 12 months postoperatively. Also, control radiographs were used to assess any potential recurrence. The surgical approach, the surgery per se and the postoperative care are described in detail. RESULTS The AOFAS score was 56 (45-75) preoperatively, 89.8 (82-98) at 6 months postoperatively and 90.4 (82-98) at one year after the surgery. The VAS score was 7 (5-9) preoperatively, 2 (0-4) at 6 months postoperatively, and 2 (0-3) at one year after the surgery. The average operative time was 35 minutes (20-50). The average length of stay in hospital was 3.8 days (2-5). The average duration of postoperative treatment was 16 weeks (12-26). Early complications involved one case of paresthesia experienced along the outside of the foot, which faded away. In one case the control radiograph at a one-year follow-up revealed recurrence of a heel spur. DISCUSSION Removal of plantar calcaneal spur is indicated after the conservative treatment options have been exhausted. By open surgery, results comparable to arthroscopy are achieved, but with fewer complications, while providing a better view of the surgical wound, a possibility to perform additional interventions in this region under visual control, a considerably lower exposure to X-ray, and it is also inexpensive. The scar is of minimum size and comparable to those after arthroscopy. CONCLUSIONS Heel spur surgery is a safe procedure with minimum complications. Nonetheless, it is indicated only once the conservative treatment options have been exhausted. Key words:calcaneus bone, plantar calcaneal spur.

Assessment of the Effectiveness of Combat Eyewear Protection Against Blast Overpressure.

It is unclear whether combat eyewear used by U. S. Service members is protective against blast overpressures (BOPs) caused by explosive devices. Here, we investigated the mechanisms by which BOP bypasses eyewear and increases eye surface pressure. We performed experiments and developed three-dimensional (3D) finite element (FE) models of a head form (HF) equipped with an advanced combat helmet (ACH) and with no eyewear, spectacles, or goggles in a shock tube at three BOPs and five head orientations relative to the blast wave. Overall, we observed good agreement between experimental and computational results, with average discrepancies in impulse and peak-pressure values of less than 15% over 90 comparisons. In the absence of eyewear and depending on the head orientation, we identified three mechanisms that contributed to pressure loading on the eyes. Eyewear was most effective at 0 deg orientation, with pressure attenuation ranging from 50 (spectacles) to 80% (goggles) of the peak pressures observed in the no-eyewear configuration. Spectacles and goggles were considerably less effective when we rotated the HF in the counter-clockwise direction around the superior-inferior axis of the head. Surprisingly, at certain orientations, spectacles yielded higher maximum pressures (80%) and goggles yielded larger impulses (150%) than those observed without eyewear. The findings from this study will aid in the design of eyewear that provides better protection against BOP.

[Dynamic Hip Screw Osteosynthesis for Proximal Femoral Fractures in Patients with Coxarthrosis]. / Osteosyntéza zlomenin proximálního femuru metodou DHS v terénu koxartrózy.

PURPOSE OF THE STUDY: Evaluation of a group of patients with coxarthrosis who sustained fractures of the proximal femur and were treated by dynamic hip screw (DHS) osteosynthesis. MATERIAL AND METHODS: The group comprised 23 DHS osteosyntheses in 22 patients treated between the years 1997 and 2012. The indication to osteosynthesis in all 23 cases was a stable pertrochanteric fracture of the femur; all patients had grade III or grade IV coxarthrosis (assessed on the Kellgren & Lawrence scale) and their physical health was classified as ASA 3 or 4. Preventive antibiotic therapy was administered within 48 hours of surgery. The evaluated factors included operative time, blood loss, specific complications such as infection, osteosynthetic material fractiure or osteosynthesis failure, requirement of revision surgery, post-operative mobility and patient survival. The follow-up was 2 years. RESULTS: The operative time was 35 min to 85 min (average, 49 min); blood losses ranged from 50 ml to 450 ml (average, 189 ml). Of the 23 hips, infectious complication was found in one (4.3%) and osteosynthetic material fractiure also in one (4.3%). There was no necessity of revision surgery due to osteosynthesis failure, nor any conversion to total hip arthroplasty. Postoperative mobility (with use of walking aids or forearm crutches) was achieved in 17 (77.3%) patients. The average survival of the patients was 6.3 months, the range from 7 days to 3 years. DISCUSSION: DHS osteosynthesis is a reliable method for the treatment of proximal femoral fractures due to osteoporosis. These fractures in patients with coxarthosis are primarily indicated to total hip arthroplasty. However, this is questionable in polymorbid elderly patients in whom hip replacement carries high risk. In such patients DHS osteosynthesis is preferred as a less risky procedure. CONCLUSIONS: DHS osteosynthesis is indicated for stable pertrochanteric fractures of the femur in a limited number of patients with advanced coxarthrosis in whom total hip replacement would be associated with an undue risk. The majority of patients after surgery became mobile, but with short-term survival.

Assessment of complications depending on the sliding screw position - finite element method analysis.

OBJECTIVES: The study was aimed at the assessment of specific complications depending on the sliding hip screw position. BACKGROUND: The finite element method in the biomechanical analysis of this implant may be used to predict the mechanical failure due to the screw position. METHODS: 380 sliding screw osteosyntheses for stable pertrochanteric fractures of 365 patients were included in the study. We divided and analysed the osteosyntheses with five various screw positions and focused on the specific complications development. For the construction of the finite element model of the femur, the program ABAQUS 6.9 was used. Analyses were performed with evaluation of the bone response to the different screw locations (strain and stress) with maximum low-cycle high stress loading. RESULTS: The specific complication rate was 10 %, with the re-operation rate of 4.2 %. If placing the screw in the middle third of the neck it reduced significantly strain patterns of the plate and screw. A screw position in the superior third of the neck significantly increased the strain of the plate and screw by more than 63 %. CONCLUSIONS: The conformity in the clinical and biomechanical analyses was observed. The finite element model can be considered as valid in predicting sliding screw failures (Tab. 4, Fig. 8, Ref. 30).

[DHS osteosynthesis for proximal femoral fractures: infectious complications]. / Osteosyntéza zlomenin proximálního femuru metodou dhs: infekcní komplikace.

PURPOSE OF THE STUDY: Evaluation of infectious complications in patients with proximal femoral fractures treated by osteosynthesis using dynamic hip screws (DHS). MATERIAL: The group included 501 patients with 532 DHS procedures performed in the years 1996-2010. In 31 patients osteosynthesis was carried out bilaterally. METHODS: Osteosynthesis was indicated for femoral neck fracture in 18 hips and for pertrochanteric fracture in 514 hips. Prophylactic antibiotic therapy was administered within 48 hours of surgery. The occurrence of infectious complications (surface and deep wound infection), presence of infectious agents, risk factors, and the course of treatment and its outcome were investigated. RESULTS: Of 532 fractures treated by DHS osteosynthesis, seven were infected (1.3%) as follows: one fracture of the femoral neck with methicillin-resistant Staphylococcus aureus, and, of six pertrochanteric fractures, four with Staphylococcus aureus, one with Escherichia coli and one with Staphylococcus epidermidis. Surface wound infection was diagnosed in one case (0.2%) and deep infection in six cases (1.1%). Five revision DHS procedures were carried out in five patients. One or more risk factors were found in each patient with infected DHS. The treatment of infection included wound dressing and abscess drainage without reoperation in two cases, implant removal in three, and implant removal with femoral head resection and spacer insertion in two cases. Second-stage total hip arthroplasty (THA) was performed in one case. Of the seven infected fractures, five (71%) healed successfully. DISCUSSION DHS osteosynthesis is a reliable method for treating proximal femoral fractures. The 1.3% infection rate in our group is comparable with other relevant studies. This complication is serious and requires prolonged treatment but is not as devastating as an infected THA. For the treatment of infected DHS osteosynthesis, standard methods from screw removal to second-stage THA were employed. CONCLUSIONS: Infectious complications following osteosynthesis with dynamic hip screws are rare events in the treatment of proximal femoral fractures. Staphylococcus aureus was the most frequently isolated infectious agent. Each infectious complacation was associated with one or more risk factors. Antibiotic prophylaxis is important particularly in patients at risk.

[Joint dislocation after total knee arthroplasty as an ankle fracture complication. Case report]. / Luxace TEP kolenního kloubu jako komplikace zlomeniny hlezna - kazuistika.

Joint dislocation after total knee arthroplasty is a rare complication. It is described as the result of ligamentous instability. Here we report the case of an 82-year-old women who underwent primary total knee arthroplasty (TKA) for advanced primary grade III gonarthrosis. At 3 post-operative months the joint was stable and painless, with radiographic evidence of good TKA alignment and integration. At 4 months the patient suffered injury to the ankle involving a bimalleolar fracture and damage to knee soft tissues. The fracture was surgically treated. Subsequently, dorsal tibial dislocation was manifested. This was managed by individual intramedullary nail arthrodesis. At 8 months following the operation, the knee condition was satisfactory, with rigid arthrodesis and leg shortening of 4 cm. The patient was satisfied because she was free of pain and able to walk. Arthrodesis of the knee joint with an individual nail is an option for a definitive treatment of TKA instability. When other joints, such as ankle or hip joints, are injured, it is recommended to pay attention also to any TKA implanted previously because of potential development of instability or infection.

[Osteosynthetic material breakage in patients treated with DHS for proximal femoral fracture]. / Zlomení osteosyntetického materiálu u pacientu se zlomeninou proximálního femuru osetrenou DHS.

INTRODUCTION: In the literature, there are only few articles about the metal breakage after the Dynamic Hip Screw (DHS) osteosynthesis. We have evaluated our group of patients focusing on these specific complications. MATERIAL AND METHODS: We have evaluated a group of 428 patients (321 female and 107 male subjects) who underwent a total of 456 135 degrees 1"-collar DHS osteosyntheses, for primary proximal femoral fractures. The patients were aged 82.3 years on average, the procedures were performed during 1996-2009. We focused on the ostesynthetic material breakage (K-wire, sliding screw, hip plate, cortical screws). The follow-up period was 2 years. RESULTS: Out of 16 DHS used for intracapsular femoral neck fractures, metal breakage was recorded in one case (6.25%)-(K-wire) and no reoperation was required. Out of a total of 436 DHS procedures performed for stable pertrochanteric fractures, metal breakage complications were recorded in 8 cases (1.8%)-(3 times K-wire, 3 times cortical screws, 2 times sliding screw), and reoperation was indicated in 4 cases (2 times sliding screw, 2 times cortical screws). Out of a total of 4 DHS procedures used for subtrochanteric fractures, osteosynthetic material breakage was recorded in two cases (50%)-(1 times K-wire, 1 times cortical screws) and no reoperation was required. No cases of hip plate breakage were recorded. Out of a total of all 456 DHS procedures metal breakage was recorded in 11 cases in total (2.4%), reoperation was required in 4 cases (0.9%). CONCLUSION: In the literature, the authors found only several articles related to the osteosynthetic material breakage after DHS surgery. Correct indication and operation technique can reduce occurence of this specific complication and the reoperation rates. In future, the authors plan to employ computer modelling methods and biomechanic analysis.

[Shortening scarf osteotomy of the fifth metatarsal: mid-term results]. / Zkracovací scarf osteotomie 5. metatarzu - strednedobé výsledky.

PURPOSE OF THE STUDY: To present the results of shortening scarf osteotomy of the fifth metatarsal as an option for the treatment of forefoot deformities with calluses and associated pain around the fifth metatarsal head. MATERIAL: In nine patients, 12 osteotomies were performed between 2004 and 2007.The results were evaluated at the end of 2009. One patient had one-stage bilateral surgery two had two-stage bilateral surgery. METHODS: Surgical treatment was indicated in patients in whom conservative treatment had failed, and after the evaluation of load radiographs of the forefoot. The operation (sec. Barouk) is standardly performed from a longitudinal incision and involves the excision of two bone blocks, 3 to 4 mm in width, from both fifth metatarsal fragments after the osteotomy. Fixation is achieved with two Poldi screws from mini-instrumentation.The procedure can be combined with surgery on the other metatarsals. The lower extremity is then immobilised in a cast for 3 weeks. Partial weight-bearing on the heel is allowed from the second post-operative day and full weight-bearing is permitted after X-ray examination at 6 weeks. The average hospital stay is four days. RESULTS: Nine patients (12 feet) underwent surgery. The average follow-up was 3.8 years (2 to 5). The average inter-metatarsal angle was 13 degrees before surgery and 4 degrees after it. The average valgus angle of the fifth metatarsophalangeal joint was 25 degrees pre-operatively and 5 degrees post-operatively. The average metatarsal shortening was 6.5 mm. DISCUSSION: Shortening shaft osteotomy allows for maximal medial translation of the fifth metatarsal and maximal correction of the angle between the fourth and fifth metatarsals. At one stage it permits metatarsal head medialisation, as does chevron osteotomy, as well as proximal translation of the head achieved by Weil osteotomy. The results of shortening scarf osteotomy have been better than those of an isolated Weil procedure, chevron osteotomy or bunionectomy. Percutaneous Krammer's method, BRT, shaft and proximal osteotomies are still discussed. CONCLUSIONS: Shortening scarf osteotomy of the fifth metatarsal is indicated when conservative treatment is unsuccessful in management of calluses and fifth metatarsal head deformities, particularly in flat-footedness. It can also be used in salvage procedures following failed surgery or in digitus quintus supraductus in adults. It requires experience with first metatarsal osteotomy and a precise operative technique.

[Complications of dynamic hip screw treatment for proximal femoral fractures]. / Komplikace operacní lécby zlomenin proximálního femuru metodou DHS.

PURPOSE OF THE STUDY: To present the results of Dynamic Hip Screw (DHS) osteosynthesis for the treatment of proximal femoral fractures with a focus on specific complications of this method. MATERIAL From 1997 till 2007, the authors performed 367 DHS osteosyntheses to treat 341 patients with fractures of the proximal femur. The average patient age was 81.8 years (21-101). Twenty-six patients had surgery for bilateral fractures. METHODS: Osteosynthesis was always carried out using a 135° DHS (Medin, Nové Mesto na Morave, Czech Republic) to manage fractures of the femoral neck (13 ); trochanteric and basic cervical fractures (349 ) and subtrochanteric fractures (5). At the end of 2009 the group was evaluated in terms of specific complications, i.e., intra-operative, early and late post-operative complications, and reoperation incidence. Hip radiographs were made before the patient was discharged, at 6 weeks, then at 3, 6 and 12 months post-operatively.When there were no complications, X-ray examination was repeated every 12 months. RESULTS: A total of 39 specific complications of the DHS system (11 %) were recorded. The 17 intra-operative complications included: insufficient reduction (10), broken tip of a K-wire (3), faulty technical procedure (2) and fracture of the distal fragment during surgery (2). In addition, 22 post-operative complications (both early and late) were recorded: "cut-out" phenomenon (6), avascular necrosis of the femoral head (5), progression of coxarthrosis (4), screw breakage (2) , femoral fracture under the plate (2), pseudoarthrosis (2) and late infection (1). Complications in relation to the fracture site were as follows: femoral neck fractures, 3/13 (23 %) all requiring revision surgery; trochanteric fractures, 35/349 (10 %), of these 12 reoperated; subtrochanteric factures, 1/5 (20 %) no revision surgery required. Of the 367 fractures treated by DHS osteosynthesis, 15 (4 %) required revision surgery for specific complications. The mortality rate within one year of surgery was 49 %. DISCUSSION: Enough information on treatment options for proximal femoral fractures can be found in the literature. However, less attention is paid to their complications. The authors used DHS osteosynthesis to treat 367 fractures during 11 years, and recorded 11 % of complications. These can be prevented by the correct indication (the final decision of the implant to be used is sometimes made only after a fracture reduction under an X-ray image intensifier on the operating theatre), correctly performed procedure and thorough post-operative care. The high one-year mortality was due to the high average age in the group. CONCLUSIONS: The authors regard DHS as an effective method to treat stable pertrochanteric fractures and fractures of the femoral neck in younger patients. Complications most often occur as a result of technical mistakes made by surgeons.

[Evaluation of surgical repair of distal biceps tendon ruptures]. / Hodnocení operacní lécby rupt.

PURPOSE OF THE STUDY To present the results of surgical repair of ruptures of the distal tendon of the biceps brachii muscle and thus show the adequacy of this treatment. MATERIAL Between 1987 and 2006, 19 patients had surgery for distal biceps tendon rupture. Only one side was affected in each patient. All patients were men between 28 and 69 years (average age, 47.5 years) at the time of injury (surgery). When the patients were evaluated at the end of 2007, 18 patients were included, because one died a year after surgery. METHODS The surgical repair always included a single-incision anatomical reattachment into the radial tuberosity. In 11 patients, a modified Mac Reynolds method with screw and washer fixation was used; in seven patients the insertion was fixed with Mitek anchors and, in one, it was sutured to the adjacent soft tissues. The average follow-up was 7 years (range, 1 to 20.5 years). The patients were evaluated for the cause of injury, their physical activity, age, dominance of the injured arm, surgical procedure and complications. RESULTS In 18 patients surgical repair was done early and, in one, at 16 days after injury. In all of them the tendon was detached from its site of insertion, but never torn. The intra-operative complications included, in one patient, bleeding owing to iatrogenic damage to a branch of the brachial artery, and difficult separation of the tendon due to its previous healed injury in another patient. Early post-operative complications included superficial skin necrosis in one patient and transient neurological deficit of the dorsal brand of the radial nerve and of the lateral cutaneous nerve of the forearm in two and one patient, respectively. The late complications were heterotropic ossification in three patients and screw migration in the one treated by the Mac Reynolds method. Excellent results were recorded in 11 patients (61 %), and good outcomes with a slight restriction of motion or muscle strength not limiting the patient's physical activities were in six (33.5 %) patients; only one patient (5.5 %) experienced pain on moderate exercise and had recurrent heterotropic ossification. Apart from this condition, there was no difference in the frequency of complications associated with the method used. DISCUSSION Only sparse information on distal biceps tendon ruptures has been available in the relevant Czech literature and, if so, only small groups with short follow-ups have been involved. Conservative treatment or the methods of non-anatomical reattachment have poor functional outcomes. Much better results are achieved by anatomical reattachment. Based on our experience with the Mac Reynolds technique, an anterior single-incision approach using fixation with Mitek anchors can be recommended. CONCLUSIONS Early surgical repair involving anatomical reattachment from the anterior singleincision approach with two Mitek anchors is recommended when a rupture of the distal tendon insertion of the biceps brachii is diagnosed. Key words: biceps radii muscle, biceps tendon injury, tendon fixation, bone screw and washer use.

[Mid-term results of cementless ultima cups in primary total hip replacement]. / Strednedobé výsledky necementované jamky TEP kycelního kloubu Ultima u primoimplantací

PURPOSE OF THE STUDY: To present the results of primary total hip arthroplasty (THA) with use of the hemispheric threaded Ultima cup at 8.5-year follow-up. MATERIAL: Between 1996 and 1999, a total of 40 Ultima acetabular components were used in 33 patients (15 men and 18 women). The average age at the time of surgery was 61.2 years (range, 45 to 71). By the end of 2006, 36 cups were assessed. Indications for the primary THA procedure included primary arthritis in 32 hips, post-traumatic arthritis in three, post-dysplastic arthritis in two, femoral neck fracture in two and rheumatoid arthritis in one. METHODS: The average follow-up was 8.5 years (range, 7 to 10). The indication criteria for primary implantation were evaluated, i.e., body mass index, patients' activity and their age. THA outcome was evaluated on the basis of clinical rating (Harris hip score) and pain assessment and on radiographic findings on which the acetabulum before and cup position after THA were compared, and potential changes in cup position, acetabular cup loosening or para-articular ossifications were observed. RESULTS: Good outcomes were found in 88.9 % of the hips. In most, cup position was satisfactory. One acetabular component was implanted in a varus position (34 degrees ). An intraoperative complication included fracture of the greater trochanter, which was left untreated for spontaneous healing. The early-postoperative complications were one dislocation, two wounds with serous secretion not requiring revision surgery, and one large haematoma. Stem fracture as a late complication was recorded in two THAs. Radiolucencies were found in six hips and paraarticular ossifications in four. Migration of the cup with protrusion into the acetbulum occurred in one patient 3 years after THA. Four cups showed aseptic loosening within 3 to 7 years of surgery. No infection was recorded in this THA group. DISCUSSION: Information on mid- and long-term outcomes of the use of cementless acetabular cups in the relevant literature is sparse. The Ultima cup is dealt with only in the report by Pazdírek et al., whose results are in agreement with ours, but involve a lower number of implanted cups and a shorter follow-up. In this study, loosening was recorded only in cups larger than 32 mm in diameter. In comparison with our group of cementless BMT acetabular components, the use of cementless Ultima cups gives better results at mid-term follow-up. CONCLUSIONS: At 8.5-year follow-up, 88.9 % of the Ultima acetabular components were without radiographic signs of loosening. Attention should be paid primarily to THA patients with a thin wall acetabulum requiring a larger cup and a 32-mm liner.

[Use of uncemented Beznoska acetabular cup - mid-term results at the orthopedic ward in Pelhrimov]. / Zkusenosti s pouzitím necementované jamky Beznoska typu "jezek" na ortopedickém oddelení nemocnice pelhrimov.

PURPOSE OF THE STUDY: The authors evaluated the mid-term results in 133 patients to whom 143 uncemented Beznoska (BMT) acetabular cups were implanted. MATERIAL: A total of 143 acetabular cups were implanted to 133 patients in the period from 1994 to 2002. Thirteen patients died or dropped out of the study during follow-up. METHODS: The patients were followed up at 3, 6 and 12 months after surgery and then, according to their conditions, every one or two years. In each patient, the following information was recorded: age at the time of implantation, gender, pre-operative diagnosis, physical activity, body mass index, Harris hip score, acetabular cup size, stem type, cup and stem alignment immediately after arthroplasty, intra-operative complications, early complications during hospital stay, and late complications. Attention was paid to infection, aseptic loosening and polyethylene wear. Loosening of both the cup and the stem was evaluated in each zone, using the criteria of Krbec and Cech. Malalignment of the stem and cup as well as thinning of the acetabular wall, as signs of loosening, were also recorded. RESULTS: Of the 133 patients treated, 35 had poor results (24.5 %) and 17 of them underwent revision surgery. Deep wound infection was recorded in seven hips, the prosthesis was removed from six, and subsequently three of them had reimplantation. Loosening of the stem occurred in nine patients and two were revised. In three patients with a thin acetabular wall, indication for surgery was not correct; in another patient an operative fault occurred. All of them underwent revision arthroplasty. One hip showed asymmetric wear of the polyethylene liner without sings of acetabular cup loosening. Aseptic loosening was found in 15 patients (10.5 %), eight were revised. In the group of patients who had surgery 5 and more years before, 13 cups out of 81 implanted ones were loosened (16 %). In the group operated on at 8 and more years earlier, aseptic loosening was found in nine hips out of 49 (18.4 %). DISCUSSION The mid-term results of the use of uncemented Beznoska acetabular cups are fully comparable with those of cemented Beznoska acetabular cups. However, the outcomes initially hoped for in relation to this component have not been achieved. CONCLUSIONS: The uncemented BMT acetabular cup cannot be recommended for the same indications as are those for which other uncemented components are used. It is not suitable for young and active patients under 70 years of age and for patients who have a thin wall of the acetabulum. Also, it is not recommended to combine this component with an uncemented femoral component. In our opinion, it is not suitable for revision hip arthroplasty, either.

[Scarf osteotomy for the treatment of forefoot deformity]. / Scarf osteotomie a její pouzití pri postizení predonozí

PURPOSE OF THE STUDY: The outcome of surgical treatment in hallux valgus is sometimes unsatisfactory for both the patient and the surgeon. The valgus position of the big toe in the metatarsophalangeal joint is associated with a deviation to varus of the first metatarsal, resulting in the space between the first and second metatarsals called the intermetatarsal (IMT) angle. In most patients the angle is between 10 and 20 degrees. These patients were indicated for scarf osteotomy as this method has been reported to achieve good outcomes. The results are compared with the relevant literature data on foot osteotomy. MATERIAL: Our group involved 62 scarf osteotomies carried out on 49 patients who were followed up for an average of 18 months (range, 6-36 months). Three patients underwent surgery on both feet in one stage, five had bilateral surgery in two stages. The average pre-operative IMT angle was 16 degrees (range, 9-21 degrees) and the average hallux valgus angle was 37 degrees. METHODS: The patients were indicated for surgery on the basis of subjective complains and weight-bearing radiographs. Scarf osteotomy was performed by the Barouk technique. From a signle incision in the first intermetatarsal space, the lateral articular capsule was released, adductor tendon was dissected and sesamoid bones were reduced. The first metatarsal was exposed from an incision along its medial axis, the bunion was excised and Z-osteotomy of the metatarsal was performed. The distal fragment was shifted laterally, fixed with two 3.5 mm Poldi screws, and the capsule was closed under tension with transosseal suture. If necessary, an additional procedure on the big toe phalanges or osteotomy of the other metatarsals are carried out. From the second post-operative day the patients were allowed to walk on the heel, after removal of sutures they walked wearing a special sandal and, from the third week onwards, full weight-bearing was allowed. The average hospital stay lasted 4 days. The evaluation of post-operative results was based on radiograms, subjective feelings of the patients and clinical assessment of the range of big toe motion. RESULTS: Out of 62 operations carried out on 49 patients (average age, 41.5 years), 23 were performed on the right and 23 on the left foot; bilateral surgery was carried out in three patients in one stage and in five patients in two stages. Simultaneously, the Weil osteotomy was performed on six feet, Akin osteotomy of the big toe phalanges on five feet, Braggard surgery of the second toe on three feet, and scarf osteotomy of the fifth metatarsal on three feet. All feet were indicated for scarf osteotomy because of pain and, in 56 feet, also esthetic reasons were involved. The patients' subjective post-operative assessments were as follows: satisfaction with the outcome in 58 feet, pain associated with tight shoes in two feet, pain while walking in six feet, and dissatisfaction with the big toe shape in one patient.The average IMT angle of 16 degrees and hallux valgus angle of 37 degrees on the pre-operative radiograms showed improvements to 9 degrees and 18 degrees, respectively, on the post-operative X-ray. The sesamoid bones were reduced in all cases. After surgery the average range of motion was restricted as follows: plantar flexion by 7 degrees (to 23 degrees) and dorsal flexion by 6 degrees (to 54 degrees). The complications included one fracture of the head requiring osteosynthesis, one failure of fixation with repeat valgus osteotomy, three cases of insufficient correction of a valgus position that had to be treated by additional osteotomy of the first toe phalanges. DISCUSSION: Out of other types of osteotomy (Funk, Dega, spike osteotomy), outcomes similar to scarf osteotomy have been achieved only by the Austin procedure. However, in this, shifting of the distal fragment is limited and the results show that the Austin method should be preferred in deformities with an IMT angle of about 10 degrees. Scarf osteotomy in addition allows for early weight-bearing, does not produce shortening of the first metatarsal but permits its elongation and elevation by oblique osteotomy, if necessary. It can also be used for the fifth metatarsal. The drawbacks include a more complicated surgical technique and higher risk of complications; shifting of the distal fragment is also limited and, for this reason, scarf osteotomy is not effective in deformities with an IMT angle higher than 20 degrees. CONCLUSIONS: Scarf osteotomy is an effective procedure for a moderate valgus deformity of the big toe with an IMT angle between 10 and 20 degrees. It permits early weight-bearing of the treated extremity. It requires exact pre-operative planning and strict adherence to the operative technique.

[Complications and risks associated with an anticoagulation therapy combining low molecular weight heparin and Warfarin after total replacement of large joints--our experience]. / Komplikace a rizika profylaktické antikoagulacní lécby provádené kombinací nízkomolekulárního heparinu (LMWH) a Warfarinu po implantaci TEP velkých kloubu--nase zkusenosti.

PURPOSE OF THE STUDY: This study deals with the efficacy and safety of anticoagulation therapy, using a combination of low molecular weight heparin (LMWH) and Warfarin, administered after total arthroplasty (TA) of large joints. Patients with a high rate of complications due to bleeding comprised the first evaluated group. After the causes had been analyzed and eliminated (or reduced), the second group of patients was evaluated. The aim of the study was to ascertain whether risks and complications did not overweight the benefits of Warfarin administration in the prophylaxis of deep venous thrombosis (DVT) and whether this combined anticoagulation therapy, which is cheaper than LMWH alone, was generally applicable. MATERIAL: Group 1 comprised 100 consecutive patients undergoing surgery in 2001. Group 2 consisted of 122 consecutive patients operated on in 2002. Only patients with elective either total knee or hip arthroplasties were included. In all of them, Warfarin therapy was initiated at 2 days after surgery and preoperative LMWH administration was carried on until 6 to 7 days postoperatively. METHODS: Both groups were examined for the frequency and extent of postoperative hematomas, INR (international normalized ratio) fluctuation at the time of Warfarin initiation and during its long-term administration, and thrombotic and bleeding complications associated with anticoagulation therapy. The results were statistically evaluated and compared between the groups, and conclusions were drawn for further treatment policy. RESULTS: In group 1, 20% of hospitalized patients and 21% within 10 weeks of discharge from hospital experienced bleeding or thrombotic complications. A markedly high INR at Warfarin initiation was found in 8% of the patients. After discharge, 11% were not followed up, 5% were found underdosed and 12% overdosed. In group 2, 3.2% of the patients had bleeding complications during hospitalization, but no thrombotic events occurred; at 10 weeks of follow-up, bleeding or thrombotic complications were recorded in 10.6% of the patients. Extreme values of INR at Warfarin initiation were found in 5.7% of the patients. After discharge, 5% were not followed up, 30% were found underdosed and 8.1% overdosed. The distinctly better results in group 2 were attributed to the measures taken to eliminate most of the factors increasing hazards of Warfarin anticoagulation therapy, i. e., pre-operative administration of non-steroid antirheumatic drugs (NSA), high initial Warfarin doses, strict requirement for INR values in the range of 2-2.5, failure to keep the recommended diet after discharge, poor compliance with taking the prescribed Warfarin dose and insufficient INR monitoring by general practitioners. DISCUSSION: In patients undergoing total arthroplasty of large joints, the authors compare the anticoagulation therapy based on LMWH and Warfarin with other treatments for DVT prevention in terms of efficacy, safety and economy. They prefer LMWH administration as early as 12 h before surgery. Although Warfarin administration has proved a safe therapy with regard to bleeding complications in a number of conditions, this is not the case in patients undergoing total knee or hip replacements. These procedures result in great stress for the organism, particularly after long-term preoperative NSA treatment, and this is associated with a risk of gastric ulcer development or manifestation of existing mucosal lesions. The risk of bleeding may be increased by unexplained fluctuation of INR values at Warfarin initiation. CONCLUSIONS: The results of this study suggests that correctly administered, preventive drug treatment of thromboembolic events is an important adjunct to other measures, such as early rehabilitation including standing and walking, compression of the lower extremities or sufficient liquid intake, taken to prevent the development of deep venous thrombosis. The combination of LMWH with Warfarin was used as an anticoagulation therapy in this study. The effective and safe Warfarin treatment should be based on the experience of an attending physician, who starts and monitors the therapy. Warfarin administration requires careful and relatively complex follow-up, with frequent INR check-ups. However, the use of appropriate dosage and thorough follow-up do not make Warfarin administration completely safe in all cases. For instance, a high INR value at Warfarin initiation, which is difficult to influence, carries a high risk of bleeding for patients with occult gastrointestinal lesions. The authors do not routinely use preventive treatment with LMWH alone, primarily for its high cost.

[Clinical examination of menisci in the era of arthroscopy]. / Význam klinického vysetrení menisku v ére artroskopie.

PURPOSE OF THE STUDY: A profound clinical history and examination in case of a soft-tissue injury of the knee joint has a principal significance for the diagnosis and the following treatment. Our aim was to compare the development of surgery of the soft-tissue injury of the knee in our region within a 25-year interval. The most frequently affected structures in the knee joint are the menisci. We have focussed on the evaluation of the extent to which selected clinical history and symptoms are actually associated with the affection of menisci. MATERIAL: First we compared groups of patients operated on for the soft-tissue injury of the knee joint within a 25-year interval. The scope of the care in the out-patient department was in this period almost the same. Then we examined a group of patients with a suspect tear of menisci and focussed on the clinical history and findings which are most often related to the injuries of menisci. METHODS: In a retrospective study aimed at the acquisition of sufficient statistical data and concentrated on the development of the surgery of the soft-tissue knee we compared a group of 91 patients operated on by arthrotomy in the period of 1973-1975 with a group of 780 patients operated on in the years 1996-98 by arthroscopy. In the subsequent prospective study we examined 104 patients sent to arthroscopic examination for a suspect tear of the medial or lateral meniscus. Based on the performed arthroscopy we divided the patients into three group--with the injured medial meniscus, with the injured lateral meniscus and without affection of meniscus. We investigated the diagnostic value of clinical history and clinical symptoms. RESULTS: In the retrospective study comparing the groups of patients in the 25-year interval the number of knee joints operated on increased 9times, the average age decreased by 8 years and the duration of hospitalisation was reduced by 9 days, the period of after-treatment in the out-patient department was reduced by 59 days. In the prospective study focussed on the lesion of meniscus the success rate of clinical history and examinations was 62% in lesions of the medial meniscus, 47% in lesions of the lateral meniscus. Significant in the clinical history of both menisci was a joint effusion and click phenomenon in the knee joint. Of clinical symptoms relating to lesion of the medial meniscus there often (above 60%) occurred pain of the medial joint line, painful bend and positive Steinmann II test, in case of the lateral meniscus painful bend and inability of full bend (nebo flexion--co má autor na mysli termínem "dotazení?) and walking in bend. Their disadvantage is a low specificity. On the contrary lower sensitivity but higher specificity is recorded by the clinical history of the locked knee and the presence of click phenomena during clinical examination. Simultaneous affection of the cartilage of the medial condyle of the femur in the lesion of the medial meniscus was in 64% of cases and of the lateral condyle of the femur in the lesion of the lateral meniscus in 47% of cases. DISCUSSION: Opinion on the clinical history and examination of the injured knee joint has not changed substantially during 25 years as shown by the comparison of the literature, but arthroscopy thanks to its visualisation of the joint cavity and a lower invasiveness contributed to the improvement of the diagnostics of the lesions of the knee joint, a less invasive surgery resulting in a reduced period of treatment. As compared to other authors we achieved in the evaluation of clinical history and examination practically the same success rate of diagnosis in the lesion of the medial meniscus but a lower success rate in the lesion of the lateral meniscus. As concerns clinical history we did not find any significant differences in comparison with other authors, in case of clinical examination we did not achieve such good results in case of McMurray test and as the most significant manoeuvre we consider the Steinmann II test for the medial meniscus. Frequent simultaneous injury of the cartilage and menisci corresponds to the findings of other authors. CONCLUSION: Indication for surgery for the affection of menisci therefore has to be based on a careful analysis of clinical history and examination of the patient, it is not possible to rely on any of the menisci symptoms and their significance is only supportive. As the most significant symptoms we assess the clinical history of the verified knee swelling, click phenomena and locked knee in the knee joint, in the clinical examination pain and click phenomena of the joint lines.

[Solution of Intertrochanteric Fractures of Proximal Femur by 130 degrees Angled Blade Plate - Longterm Results.]. / Resení pertrochanterických zlomenin proximálního femuru 130 degrees dlahou - dlouhodobé výsledky.

Authors summarize their longterm outcomes of the use of 130 degrees angled blade plate in intertrochanteric fractures. The group comprises 110 patients operated on by this technique in the period of 1988-1997. The analysis of the results has proved that this technique was justified in stable fracture classification according to AO/ASIF - A1.1 A1.2. In other fractures A1.3 A2.1 A2.2 A2.3 there occurs after 6 months a varus position and in extreme cases the internal fixation fails. In the second part of the article the authors inform about the results in a group of 24 patients 3 to 6 years after operation. The patients have been subdivided into two groups according to the stability of the fracture; based on the Harris score evidently better results have been recorded in patients with a stable intertrochanteric fracture. Half of these patients reached the score of 81 points and more according to Harris. Key words: intertrochanteric fracture of proximal femur, technique of 130 degrees angled blade plate.