Results of 198 primary total hip arthroplasties using the Delta PF-FIT system with ceramic-on-ceramic articulating surfaces with average seven years follow up.

BACKGROUND: The lifetime implants is a key parameter that the surgeon should take into account at the time of the primary total hip arthroplasty (THA). The aim of this study was a clinical and radiographical evaluation of the Delta PF-FIT (LimaCorporate, Italy) THA system with ceramic-on-ceramic articulations. We have not found a clinical or radiographical assessment of this implant in available published literature. METHODS: A total of 197 (F = 94, M = 103) primary THAs were evaluated in 163 patients with a mean follow-up of 7.7 years (range 5.1-11.2 years (SD ± 1.5)) Harris hip Score (HHS) and the Western Ontario and McMaster Universities Arthritis index (WOMAC) were used for the clinical evaluation. The statistical evaluation was processed by standard statistical methods. The study was approved by Ethic Committee of the University Hospital Motol (Reference No. EK-73/19). RESULTS: The mean HHS score was found to be 97.59 points (61-100 range with a ± 5.13 SD, preoperative HSS was 51.21, range 28-73 with a ± 4,77 SD). 186 THAs were evaluated as excellent (90-100 points), 9 THAs rated as good (80-89 points), 1 THA was rated as fair (70-79) points and 1 THA rated as poor (less than 70 points). The mean WOMAC score was 97.38 points (65-100 range with a ± 5.18 SD, preoperative was 50,12, range 27-69 with a ± 4.85 SD). We documented an overall 99.49% Kaplan-Meier survival with a mean follow-up of 7.7 years with the FIT (LimaCorporate) stem revision and any component revision as the endpoint. With the Delta PF (LimaCorporate) cup revision as the endpoint, the survival was 100%. We have not found a previously published clinical or radiographical review of this THA system, the study shows a comparison with other THA implants. CONCLUSION: Evaluation of the Delta-PF-FIT (LimaCorporate, Italy) THA system with the use of ceramic-on-ceramic BIOLOX®Delta articulation surfaces shows very good outcomes.

Study of the variability of scapular inclination and the glenoid version - considerations for preoperative planning: clinical-radiological study.

BACKGROUND: Preoperative planning with the aid of imaging methods is a principal factor in successful surgery on the shoulder. This work aims to evaluate the variability of glenoid version, spiralling twist and scapular inclination in relation to the frontal axis. Studies focusing on measuring the variability of scapular inclination in the standardised rest position are lacking in the literature. METHODS: We evaluated 104 CT scans of the shoulder. We measured the glenoid version with respect to the scapular axis at three levels. We measured the scapular inclination angle in relation to the sagittal plane and we determined scapular inclination in relation to the frontal axis. Statistical evaluation was performed using the marginal linear model and parameters were estimated using the generalised least squares method, which enables the dependency of measurements performed on the same subject to be taken into consideration. RESULTS: The highest values of retroversion are attained by the glenoid in the cranial section (average -9.96°, range -29.7 to +13.2°). Proof of the spiralling twist is the decline in retroversion at the centre of the glenoid (average -2.09°, range -16.7 to +11.6°). Retroversion decreases further in the inferior direction (average -0.5°, range -20.9 to +17.5°). The average thoracoscapular angle is 45.46°, ranging from 13.1 to 69.0°. The average scapular inclination in relation to the frontal plane is 44.54°, ranging from 21.0 to76.9°. CONCLUSIONS: During preoperative planning, the surgeon should take into consideration not only the glenoid version in relation to the scapular axis, but also the value of the scapular inclination so as to eliminate possible surgical errors, optimise prosthesis implantation and thus decrease the risk of functional restrictions of the joint. CLINICAL TRIAL REGISTRATION: Ethics Committee for Multi-Centric Clinical Trials (EK-554/14,29thApril 2014).

[UHMWPE - polyethylene for articulating surfaces of joint replacements]. / UHMWPE - polyethylen pro artikulacní povrchy kloubních náhrad.

The introduction of artificial joint replacement constitutes a breakthrough method of treatment for severe joint disease for millions of people worldwide.Annual increase in the number of primary replacement and also increasing demands on the longevity of joint replacements are leading to increased demands on wear resistance of articular surface. Ultra-high molecular weight polyethylene (UHMWPE) is still most commonly used material for the production of articular surface. It was introduced into clinical practice in the 60s of the 20th century. Physical-chemical properties of UHMWPE are subject of many studies. These lead gradually to its improvement in terms of higher wear resistance while maintaining the stability against oxidative degradation.The main objective of this review is to summarize the basic properties of high-molecular weight polyethylene which are important for its use in orthopaedic practice and to explain the possibilities of its modification and sterilization. Knowledge of the latest trends about this material helps to orthopaedic surgeons get oriented in the issues and then to choose for their patients implants with the highest implant longevity.

Hypermobility of the first metatarsal bone in patients with rheumatoid arthritis treated by Lapidus procedure.

BACKGROUND: Foot deformities and related problems of the forefoot are very common in patients with rheumatoid arthritis. The laxity of the medial cuneometatarsal joint and its synovitis are important factors in the development of forefoot deformity. The impaired joint causes the first metatarsal bone to become unstable in the frontal and sagittal planes. In this retrospective study we evaluated data of patients with rheumatoid arthritis who underwent Lapidus procedure. We evaluated the role of the instability in a group of patients, focusing mainly on the clinical symptoms and X-ray signs of the instability. METHODS: The study group included 125 patients with rheumatoid arthritis. The indications of the Lapidus procedure were a hallux valgus deformity greater than 15 degrees and varus deformity of the first metatarsal bone with the intermetatarsal angle greater than 15 degrees on anterio-posterior weight-bearing X-ray. RESULTS: Data of 143 Lapidus procedures of 125 patients with rheumatoid arthritis, who underwent surgery between 2004 and 2010 was evaluated. Signs and symptoms of the first metatarsal bone instability was found in 92 feet (64.3%) in our group. The AOFAS score was 48.6 before and 87.6 six months after the foot reconstruction. Nonunion of the medial cuneometatarsal joint arthrodesis on X-rays occurred in seven feet (4.9%). CONCLUSION: The Lapidus procedure provides the possibility to correct the first metatarsal bone varus position and its instability, as well as providing the possibility to achieve a painless foot for walking. We recommend using the procedure as a preventive surgery in poorly symptomatic patients with rheumatoid arthritis in case of the first metatarsal bone hypermobility.

Ankle block implemented through two skin punctures.

BACKGROUND: Recently, peripheral nerve blocks have increasingly been used in orthopedic surgery. The foot block is an alternative for anesthesia in cases of forefoot and midfoot operations. We propose a modification of the block technique due to potential difficulties concerning the tibial nerve. MATERIALS AND METHODS: The spatial position of the tibial nerve in the neurovascular bundle, proximal to entering the tarsal tunnel and sural nerve behind lateral malleolus was measured on 60 dissected preparations. Modification of the block technique was proposed. A tibial nerve block was administered by inserting a needle, at an area above the upper edge of the heel bone, tangential to the Achilles tendon. The needle was then withdrawn and redirected to the frontal plane and inserted through the tissue, anterior to the Achilles tendon and laterally behind the lateral malleolus to block the sural nerve. A block of the saphenous nerve superficial and deep peroneal nerves was implemented by needle insertion subcutaneously two centimeters proximal to the crest of the ankle joint. The technique was then evaluated in the clinical part of the study in 84 operative procedures. RESULTS: The tibial nerve is located 21.1 mm +/- 2.1 mm from the medial aspect of the Achilles tendon and 11.6 mm +/- 1.3 mm deep in the neurovascular bundle. The distance from the posterior margin of the lateral malleolus to the sural nerve is 18.3 mm +/- 1.9 mm. We achieved a 93% success rate in implementation of the complete foot block in 84 operations. CONCLUSION: The technique, proposed in the anatomical portion of the study and evaluated in the clinical part, had a similar success rate when compared to techniques published in the literature. Though comparable to currently used techniques, this technique provides easier positioning of a patient and a complete block of the foot can be done with two skin injection sites.

Isolated talonavicular arthrodesis in patients with rheumatoid arthritis of the foot and tibialis posterior tendon dysfunction.

BACKGROUND: The foot is often affected in patients with rheumatoid arthritis. Subtalar joints are involved more frequently than ankle joints. Deformities of subtalar joints often lead to painful flatfoot and valgus deformity of the heel. Major contributors to the early development of foot deformities include talonavicular joint destruction and tibialis posterior tendon dysfunction, mainly due to its rupture. METHODS: Between 2002 and 2005 we performed isolated talonavicular arthrodesis in 26 patients; twenty women and six men. Tibialis posterior tendon dysfunction was diagnosed preoperatively by physical examination and by MRI. Talonavicular fusion was achieved via screws in eight patients, memory staples in twelve patients and a combination of screws and memory staples in six cases. The average duration of immobilization after the surgery was four weeks, followed by rehabilitation. Full weight bearing was allowed two to three months after surgery. RESULTS: The mean age of the group at the time of the surgery was 43.6 years. MRI examination revealed a torn tendon in nine cases with no significant destruction of the talonavicular joint seen on X-rays. Mean of postoperative followup was 4.5 years (3 to 7 years). The mean of AOFAS Hindfoot score improved from 48.2 preoperatively to 88.6 points at the last postoperative followup. Eighteen patients had excellent results (none, mild occasional pain), six patients had moderate pain of the foot and two patients had severe pain in evaluation with the score. Complications included superficial wound infections in two patients and a nonunion developed in one case. CONCLUSIONS: Early isolated talonavicular arthrodesis provides excellent pain relief and prevents further progression of the foot deformities in patients with rheumatoid arthritis and tibialis posterior tendon dysfunction.

Lesser tuberosity is more reliable than bicipital groove when determining orientation of humeral head in primary shoulder arthroplasty.

PURPOSE: The objective of the study was to provide statistical evaluation of position of bone landmarks of proximal humerus in relation to transepicondylar line and find out which one is the most suitable for setup of the head retroversion in case of humeral head destruction. METHODS: We measured 185 dry humeral preparations (92 left, 93 right). Structures of interest on the proximal humerus were marked with pointers of custom made steel frame. Angular relationships between the humeral head axis and medial margin of the greater tuberosity, lateral margin of the lesser tuberosity, bicipital groove, and crest of the greater tuberosity were evaluated with respect to intramedullary axis of the proximal humeral shaft. RESULTS: The angle between the humeral head axis and medial margin of greater tuberosity was 11.5 +/- 9.0 degrees , the angle between the lateral margin of the lesser tuberosity and the axis was 47.5 +/- 7.4 degrees , the angle between the bicipital groove and the axis was 31.6 +/- 8.8 degrees at the level of the humeral head. The angle between the crest of the greater tuberosity and the axis was 26.6 +/- 9.6 degrees in plane of the surgical neck. CONCLUSIONS: We statistically proved that the lateral margin of lesser tuberosity is more reliable than the bicipital groove; medial margin of the greater and transepicondylar line for reconstruction of humeral head retroversion. We suggest that the lesser tuberosity should be used to determine the retroversion, especially in cases when the margin of humeral head was destructed.

Attachments of muscles as landmarks for implantation of shoulder hemiarthoplasty in fractures.

BACKGROUND: The attachments of muscles and the position of the humeral head are important for a good functional outcome of shoulder hemiarthroplasties after displaced fractures of the proximal humerus. Deviations in the attachments and changes in their spatial position with respect to the humeral head during surgical reconstruction change the biomechanics and reduce the range of motion of the should joint postoperatively. METHODS AND RESULTS: We used 198 humerus preparations and using 3-dimensional analysis measured the angular relationships between the humeral head axis and medial margin of the greater tuberosity (11.9 degrees +/- 9.1 degrees ), lateral margin of the lesser tuberosity (48.0 degrees +/- 7.8 degrees ), and the crest of the greater tuberosity (27.1 degrees +/- 9.6 degrees ). CONCLUSION: This study provides average values of the positions of the greater and lesser tuberosities with respect to the humeral head axis. We show that the greater and lesser tuberosities are more reliable than the transepicondylar line for reconstruction of humeral head retroversion. LEVEL OF EVIDENCE: Basic Science.

Cell surface and relative mRNA expression of heat shock protein 70 in human synovial cells.

UNLABELLED: Heat shock proteins (Hsps) have been repeatedly implicated to participate in the pathogenesis of rheumatoid arthritis (RA). METHODS: Herein, Hsp70 cell surface and mRNA expression were studied in human fibroblast-like synovial cells, dermal fibroblasts and peripheral blood leukocytes derived from 24 RA patients, who underwent synovectomy by using flow-cytometric analysis and real-time quantitative reverse-transcriptase polymerase chain reaction. For comparison, peripheral blood leukocytes of 17 healthy controls were tested. RESULTS: Significantly higher Hsp70 membrane positivity was found on fibroblast-like synovial cells in RA patients (average 18.3%, median 16.5%) than on autologous and healthy control peripheral blood lymphocytes (RA patients: average 4.7%, median 2.9%, p = 0.002; healthy controls: average 6.0%, median 4.5%, p = 0.002) and/or autologous dermal fibroblasts (average 5.1%, median 4.3%, p < 0.001). Strong Hsp70 cell surface expression was also found on peripheral blood monocytes of RA patients (average 53.0%, median 58.1%) and healthy controls (average 49.4%, median 47.5%, p = 0.52). Peripheral blood granulocytes of healthy controls (average 41.8%, median 41.4%) showed significantly increased Hsp70 expression comparing with RA patients (average 10.7%, median 6.4%, p = 0.005). Significantly higher Hsp70 gene expression was observed in synovial cells of RA patients (average 2.04, median 1.7) when compared with autologous peripheral blood leukocytes (average 0.75, median 0.68; p < 0.001). However, the difference in Hsp70 gene expression between RA-derived synovial cells and healthy control peripheral blood leukocytes (average 1.69, median 1.64) was not observed (p = 0.83). We also found significantly lower relative gene expression in peripheral blood leukocytes of RA patients in comparison with healthy controls (p < 0.001). Interestingly, we found that Hsp70 gene expression in RA non-affected skin dermis gained from the operation wound was 3.7-fold higher in average (average 7.6, median 8.3) when compared to autologous RA-affected synovial tissue (p < 0.001); 10.1-fold higher in average when compared to autologous peripheral blood leukocytes (p < 0.001) and 4.5-fold higher in average comparing to control peripheral blood leukocytes (p < 0.001). CONCLUSION: Hsp70 gene expression in RA-affected synovial tissue is followed by Hsp70 cell surface expression on fibroblast-like synovial cells growing from RA synovial tissue. Hsp70 may be translocated to the cell surface from the cytosol and/or Hsp70 released from inflamed synovial tissue may be captured onto the membrane of synovial cells from the extracellular space via Hsp receptors. As a physiological response to potentially harmful enviromental stress factors, skin dermis produces higher levels of Hsp70 comparing to the cells of internal organs and tissues.

Fetal cells of mesenchymal origin in cultures derived from synovial tissue and skin of patients with rheumatoid arthritis.

The transplacental cell transfer naturally takes place during pregnancy and occurs bi-directionally between the mother and fetus. Using real-time polymerase chain reaction (PCR) assay and sex determining region Y (SRY) gene as a marker, we examined the presence of male fetal cells in cell cultures derived from synovial tissues and skin dermis in women with prior pregnancy history suffering from rheumatoid arthritis (RA) who underwent synovectomy. Male DNA was detected in synovial cell samples derived from carpal, hip, metacarpophalangeal and metatarsophalangeal joints in five out of 13 (38.5%) patients with RA in a frequency range of 0.02-62.55 (mean 12.17) male cells per 10,000,000 total cells. SRY gene positivity was found as well in skin fibroblast cultures in four out of 10 (40.0%) RA patients in a frequency range of 3.26-43.47 (mean 15.42) male cells per 10,000,000 total cells, respectively. The difference in a frequency of fetal-derived male cells between both the cohorts did not achieve the statistical difference (p=0.77). We conclude that persisting male fetal cells are able to grow from non-inflamed tissues as well as from those which have many features characteristic of a stressed tissue. We conclude that persisting male fetal cells are also able to proliferate in cell culture since their presence was detected even in consecutive passages.

Expression of heat shock protein receptors on fibroblast-like synovial cells derived from rheumatoid arthritis-affected joints.

We examined the membrane expression of inducible Hsp70 and HSP receptors like TLR2, TLR4, CD14, CD36, CD40 and CD91 on fibroblast-like synovial cells (SC) derived from synovial tissue in 23 patients with rheumatoid arthritis (RA), who underwent synovectomy by using flow cytometric analysis. For comparison, autologous skin fibroblasts (SF) derived from the operation wound were tested. Significantly higher Hsp70 expression was found on synovial cells than on skin fibroblasts (median SC 21.4% x SF 5.0%, P < 0.001). Both synovial cells and skin fibroblasts expressed high levels of cell surface CD91 (median SC 80.2% x SF 79.2%), however, no or low levels of CD14, CD40, TLR2, TLR4 and CD36. Further, we observed high co-expression of CD91 and Hsp70 on RA synovial cells (median 18.6%), while skin fibroblasts showed only background Hsp70 expression (median 3.9%, P < 0.001). Since we demonstrated the high prevalence of inducible Hsp70 in RA synovial fluids, we speculate that Hsp70 might be captured onto the membrane of synovial cells from the extracellular space via the CD91 receptor. The significance of the Hsp70 interaction with synovial cells via CD91 remains undefined, but may mediate other non-immune purposes.

Hydroxyapatite porous coating and the osteointegration of the total hip replacement.

INTRODUCTION: The main purpose of this study is to evaluate the efficacy of the plasma sprayed, combined porous titanium alloy/HA coating in promoting bony ingrowth and mechanical stabilization of total hip implants. The performance of the titanium alloy/HA type coated hip prostheses and the one of the same shape but without any coating, is compared in this paper. MATERIAL AND METHODS: The implants were manufactured from titanium alloy VT-6 (ASTM F-136). The hip stems utilized in the control group were identical to those subsequently coated. The coating consists of a plasma deposited first layer of porous titanium alloy (TiAl(6)V(4)), similar in composition to the forged substrate and a plasma deposited second layer of over-sprayed hydroxyapatite, Ca(10)(PO(4))6(OH)2. Coating is located in the critical area of the hip stems, where high fixation interface strength is desired, i.e. in the proximal area of the stem where the highest stresses occur. The porous titanium alloy/hydroxyapatite (HA) coated femoral stems were implanted in 50 patients. The results were compared with a control group of 50 patients with the same type of endoprosthesis, but without the porous titanium alloy/HA coating. Both groups of patients were operated on and evaluated by the same orthopedic surgeons with a mean follow up of 11.4 years in the HA group and 10.6 years in the control group. RESULTS: HHS in the control group was preoperatively 35.5 points (range 26-49) and 85.1 points (range 54-100) in the time of the last control. HHS in the HA group was preoperatively 34.1 points (range 27-56) and 94.4 points (range 89-100) in the time of the last control. In 28 cases (56%) of the control group a range of translucencies were obvious. These translucent lines, however, did not appear with any of the patients in the coated implant group except one infection stem migration. CONCLUSION: Experience with the HA-type coated hip implants demonstrates substantially higher degree and quality of osteointegration in the porous titanium alloy/HA type implants.

Topographic variations of the relationship of the sciatic nerve and the piriformis muscle and its relevance to palsy after total hip arthroplasty.

The aim of this paper was to study the anatomical relationship between the piriformis muscle and the sciatic nerve with regard to the possibility of neurological deficit after THA. The incidence of anatomical variation of both structures is 15-30% in the literature. The authors studied 91 cadavers and found an atypical relationship in 19 cases (20.9%). In this study individual variations were found with the following frequency: The sciatic nerve exits below the piriformis muscle in 79.1% of the cases. The sciatic nerve separates into two divisions above the piriformis, one branch passing through the muscle, the other below it (14.3%). An unsplit nerve passes through the piriformis muscle in 2.2%. The nerve separates into two divisions above the piriformis, one branch exiting above the muscle and passing along its dorsal aspect, the second exiting distally below the muscle in 4.4%. The most common reasons for sciatic nerve injury in surgery of the hip joint are direct injuries, ischemia of the nerve tissue, compression or excessive distraction of the nerve, compression by bone cement, thermal damage during cement polymerization, injury during THA dislocation, compression by hematoma, bone prominence or an implanted acetabular component. According to the presented anatomical study, overstretching of the nerve itself or its branches in the area of the pelvitrochanteric muscles after their release from their origin can be another mechanism. Such overstretching can appear in the presence of some of the aforementioned anatomical variants.

Primera experiencia con un método propio en la artrodesis total de muñeca / The first experience on a personal surgery technique of arthrodesis

Se enfatiza sobre la importancia de un carpo estable y no dolorosa para la función de los dedos. Las reflexiones sobre nuestro propio método de osteosintesis están basados en hallazgos anatómicos y biomecanicos, enfatizando el concepto, funcional del pilar central de la muñeca donde la flexión y la extensión maxima ocurre. En este sentido se aplica la placa en la línea formada por la porción distal del radio, semilunar, hueso grande y la base del tercer metacarpiano. La placa es comparada con la clasica placa AO, baja, (solo 2,7 mm) con forma de L y ligeramente convexa dorsalmente en su sección transversal. Esto sigue el arco natural del carpo y metacarpianos no aumentando la tensión de las estructuras blandas ni de la piel que la cubre. Por la focalización de los agujeros ovales permite una ligera autocompresión y asegura una adecuada fijación en tres puntos del metacarpo. La abertura oval en la rama corta de la placa sirve para localizar en centro de la sección transversa del segundo metacarpiano y asegura una correcta colocación del tornillo, haciéndose así posible una operación plástica de los extensores los cuales en sinovitis reumática y destrucción del carpo son frecuentemente lesionados. Se presentan los resultados de 29 operaciones. La consolidación ósea adecuada fue lograda en todos los pacientes con un promedio de 2 meses y medio. El inicio de altura del carpo (CIH) aumento y el agarre de la mano mejoro. En 11 pacientes se encontró ruptura de los extensores, los cuales se repararon. En todos los casos se realizo sinovectomia y resección de la cabeza del cubito. Se realizo la artrodesis bilateral en 3 pacientes. En un caso se observó infección de la herida cicatrizando por segunda intención