[Assessment of Clinical Outcomes of Surgically Treated Rockwood Type III Acromioclavicular Dislocation with or without Coracoclavicular Ligament Suture]. / Zhodnocení klinických výsledku operacne resených akromioklavikulárních luxací typu Rockwood III se suturou ci bez sutury korakoklavikulárního vazu.

PURPOSE OF THE STUDY Acromioclavicular (AC) joint dislocation and its surgical treatment still raises a number of questions that remain to be answered. In some types of dislocations, Rockwood type III in particular, the indication for surgical treatment as such is relative. There are numerous techniques and implants available for the reconstruction of AC joint. In our research we focused on the necessity of coracoclavicular (CC) joint reconstruction. MATERIAL AND METHODS In this paper, a cohort of 56 patients with Rockwood type III AC joint injury who underwent surgical treatment at our department in 2010-2016 period was retrospectively evaluated. The patients were treated with open reduction with AC joint stabilisation using hook plate or tension band. The patients were divided into 2 groups, namely group 1 with CC ligament reconstruction and group 2 without CC ligament reconstruction. The assessment was done at 6 months, 1 year and 2 years after surgery. The clinical outcomes were assessed based on the absolute Constant score (CS) and coracoclavicular distance (CCD) on the X-ray. Subsequently, the outcomes were statistically processed and compared using the Student s ttest. RESULTS The least invasive surgical intervention, as to the length of incision, was the reconstruction using the hook plate without CC ligament suture, whereas the longest incision was performed in tension band with CC ligament suture. In the CC ligament suture group, the mean operative time was 10 minutes longer. When evaluating the CS of the compared groups with and without CC ligament reconstruction, no statistically significant difference (p > 0.05) was found between the two groups. Similarly, the CCD values at 2-year follow-up did not show any statistically significant difference between the two groups (p > 0.05). CONCLUSIONS The available outcomes suggest that the surgical methods used by us are adequately safe and reliable. Good clinical outcomes can be achieved by open reduction and fixation of Rockwood type III AC joint dislocation even without CC ligament reconstruction. Key words: acromioclavicular dislocation, classification, reconstruction, coracoclavicular ligament.

[Rare Vascular Complication after ACL Reconstruction]. / Vzácná cévní komplikace po náhrade predního zkrízeného vazu.

The anterior cruciate ligament reconstruction is currently one of the most commonly performed arthroscopic procedures of knee joint. Overall, it is a reliable and sophisticated procedure associated with a relatively low complication rate. In the available literature, less severe complications are reported in 3-7% of cases. The most frequent complications are intractable pain not manageable using analgesic therapy (6.7%), hemarthrosis requiring puncture (4.4%), fever (3.2%) and other complications related in particular to immobilisation (1.2%). The percentage of severe complications is very low (less than 1%). These include deep vein thrombosis (0.6%), cellulitis (0.6%) and infectious complications requiring arthroscopic or surgical revision (0.3%). Vascular injuries around the knee joint are rare and are described in case studies only. The authors present a patient with reduced mobility of the knee and significant pain, haematoma and swelling in the calf, which developed within a short time span after the reconstruction of anterior cruciate ligament. It was caused by bleeding into the medial gastrocnemius muscle. This rare vascular complication was diagnosed angiographically and coiling was used to stop the arterial bleeding, once deep vein thrombosis, congenital haemostasis, gonitis and compartment syndrome were excluded. Key words: ACL reconstruction, angiography, anterior cruciate ligament, arthroscopy, inferior medial genicular artery, vascular complications.

[Our Experience with RM Pressfit Vitamys Cup and Cementless Optimys Short Stem]. / Nase zkusenosti s jamkou RM Pressfit Vitamys a s krátkým necementovaným dríkem Optimys.

INTRODUCTION The purpose of our study was to evaluate the clinical outcomes in patients at 3-6 years follow-up after primary implantation of RM Pressfit Vitamys cementless elastic cup and cementless Optimys short stem, including bone tissue remodelling around both the components. MATERIAL AND METHODS The evaluation covered 49 joint replacements in patients who had undergone surgery at our department between 2012 and 2015. The age at the time of primary surgery ranged from 29 to 71 years, with the mean value of 59.2 years. Postoperatively, the position of endoprosthesis, changes in femoroacetabular offset, signs of osseointegration of the implant, bone tissue remodelling around both the components and potential signs of aseptic loosening were assessed. The functional status of the joint was evaluated according to the Harris scale. RESULTS The mean follow-up time of Vitamys cup and Optimys stem was 5.6 years and 4.6 years, respectively. We focused on the combination of RM Pressfit Vitamys (49x), Optimys (28x) and Bionit 2 (41x) implants. All the cups showed good osseointegration. Based on the comparisons with a postoperative X-ray, at least mild osteoporosis in the acetabular roof was confirmed in 6 cases. All Optimys femoral components were in direct contact with the Adams arch and with the endosteal side of lateral cortex of proximal femoral metadiaphysis. Femoroacetabular offset was slightly decreased in 5 patients only. The final evaluation in 2018 did not confirm any radiolucent lines or signs osteolysis around any of the components. In 2 stems only, distal migration less than 2 mm was obvious, with subsequent good osseointegration. Signs of stress shielding were present in 2 femoral components in the form of mild cortical atrophy in the region of the Adams arch. Distal femoral cortical hypertrophy was not observed, the greater trochanter did not show the loss of bone tissue in any of the patients. There were no signs of polyethylene wear. The mean value of HHS increased from 53 to 97 points. An excellent result was achieved in 44 total hip replacements, of which 100 points in 28 cases. In the remaining 5 patients the result was good. The survival rate of both the components was 100% according to the Kaplan-Meier analysis. DISCUSSION The successful functioning of cementless total hip arthroplasty is the correct placement of both components with good primary fixation. Excessive proximal and lateral shift of the centre of rotation results in increased load of endoprosthesis and risk of earlier aseptic loosening, its reduction leads to the weakening of pelvitrochanteric muscles. The shift of the centre of rotation from the original anatomical position should therefore not exceed 5 millimetres. Insufficient cup fixation always results in mechanical failure of an endoprosthesis. Distal migration of stems without contact with external femoral cortex with full weight-bearing of the operated lower extremity in the postoperative period does not constitute a sign of instability, but only its placement enables good osseointegration. Bone remodelling can be assessed by imaging techniques at 2 years after the primary implantation at the earliest. At places with lower load, the bone loss occurs and the loss of bone trabeculae can lead to the failure of fixation of the component. At places with load accumulation, the bone hypertrophy occurs that can be manifested by thigh pain. In case of cementless press-fit cup, the degree of bone remodelling depends on its elasticity, in case of stem on the used material, shape and fixation site. CONCLUSIONS The RM Pressfit Vitamys monobloc cup through its mechanical properties approximates the best the elasticity of bone tissue. The stress distribution around the implant is more symmetrical as against other conventional cementless cups. The Optimys stem enables the reconstruction of anatomical conditions corresponding a healthy hip joint. Respecting the rule of at least three-point fixation is a precondition for good and fast secondary stability of components. Minimising the wear of articulating surfaces and physiological remodelling of adjacent bone tissue are the main factors that help prolong the survivorship of both the components, while also securing more favourable conditions and better outcomes in case of necessity of reimplantation. Key words: cementless elastic cup, short cementless stem, femoroacetabular offset, stress shielding, osseointegration of the implant.

[Rare Vascular Complication after ACL Reconstruction]. / Vzácná cévní komplikace po náhrade predního zkrízeného vazu.

The anterior cruciate ligament reconstruction is currently one of the most commonly performed arthroscopic procedures of knee joint. Overall, it is a reliable and sophisticated procedure associated with a relatively low complication rate. In the available literature, less severe complications are reported in 3-7% of cases. The most frequent complications are intractable pain not manageable using analgesic therapy (6.7%), hemarthrosis requiring puncture (4.4%), fever (3.2%) and other complications related in particular to immobilisation (1.2%). The percentage of severe complications is very low (less than 1%). These include deep vein thrombosis (0.6%), cellulitis (0.6%) and infectious complications requiring arthroscopic or surgical revision (0.3%). Vascular injuries around the knee joint are rare and are described in case studies only. The authors present a patient with reduced mobility of the knee and significant pain, haematoma and swelling in the calf, which developed within a short time span after the reconstruction of anterior cruciate ligament. It was caused by bleeding into the medial gastrocnemius muscle. This rare vascular complication was diagnosed angiographically and coiling was used to stop the arterial bleeding, once deep vein thrombosis, congenital haemostasis, gonitis and compartment syndrome were excluded. Key words: ACL reconstruction, angiography, anterior cruciate ligament, arthroscopy, inferior medial genicular artery, vascular complications.

Perspectives of 3D printing technology in orthopaedic surgery.

Using most widespread technology of rapid prototyping (RP) in medicine focus on the development of models for diagnosis, for training and planned surgery, as well as the direct manufacture of implants for bone reconstruction. The applications of 3D printing in the field of medicine are giving extraordinary results and tissue and prosthetic 3D printing, medical and engineering research professionals are conducting 3D printing organ bind. Researchers worldwide are pursuing the creation of artificial bone using 3D printers, bones that can be later implanted to humans. In near future, many body parts could be manufactured in a turn and successfully implanted to patients. Although medical advances in 3D printing are used in orthopaedic field, research in 4D printing has already started. Flat objects made with 3D printing, using a regular plastic, combined with smart material, were able to become a hub without an external intervention. In nutshell, the future of additive manufacturing (AM) in trauma and orthopedic surgery is relatively bright with the inclusion of 3D printing in medicine. Bioprinting in this area will be focused on fractures, nonunions, deformities and bone, cartilage and soft tissue reconstruction. CONCLUSION: The innovative technology not only assists the medical staff but is also beneficial for the patients because the medical problems, which were not curable in the past, are now possible with modern technology (Fig. 4, Ref. 52) Keywords: bone defect, tissue engineering, 3D printing, biomaterials, bone, porous scaffold.

Reduced focal fiber collinearity in the cingulum bundle in adults with obsessive-compulsive disorder.

Obsessive-compulsive disorder (OCD) is a disabling condition, often associated with a chronic course. Given its role in attentional control, decision-making, and emotional regulation, the anterior cingulate cortex is considered to have a key role in the pathophysiology of the disorder. Notably, the cingulum bundle, being the major white matter tract connecting to this region, has been historically a target for the surgical treatment of intractable OCD. In this study, we aimed to identify the extent to which focal-more than diffuse-abnormalities in fiber collinearity of the cingulum bundle could distinguish 48 adults with OCD (mean age [SD] = 23.3 [4.5] years; F/M = 30/18) from 45 age- and sex-matched healthy control adults (CONT; mean age [SD] = 23.2 [3.8] years; F/M = 28/17) and further examine if these abnormalities correlated with symptom severity. Use of tract-profiles rather than a conventional diffusion imaging approach allowed us to characterize white matter microstructural properties along (100 segments), as opposed to averaging these measures across, the entire tract. To account for these 100 different segments of the cingulum bundle, a repeated measures analysis of variance revealed a main effect of group (OCD < CONT; F[1,87] = 5.3; P = 0.024) upon fractional anisotropy (FA, a measure of fiber collinearity and/or white matter integrity), in the cingulum bundle, bilaterally. Further analyses revealed that these abnormalities were focal (middle portion) within the left and right cingulum bundle, although did not correlate with symptom severity in OCD. Findings indicate that focal abnormalities in connectivity between the anterior cingulate cortex and other prefrontal cortical regions may represent neural mechanisms of OCD.

Intradermal running suture versus 3M™ Vetbond™ tissue adhesive for wound closure in rodents: a biomechanical and histological study.

BACKGROUND: Although tissue adhesives and traditional sutures were compared in numerous studies during the early stages of healing, it has to be clarified, from the histological and biomechanical point of view, how the differences develop during the later phases. METHODS: Twenty-four male Sprague-Dawley rats were used and divided into 2 groups: the IRS (intradermal running suture) and G (glue) groups. Two parallel full-thickness skin incisions were made on the back of each rat. Wounds in the IRS group were closed by an IRS, whereas wounds in the G group were closed using tissue adhesive (n-butylcyanoacrylate). Rats were sacrificed 7 and 22 days after surgery. RESULTS: Similar wound tensile strengths of glued and sutured wounds were measured on days 7 (IRS = 10.3 ± 1.7 g/mm(2) vs. G = 12.9 ± 4.0 g/mm(2), p = 0.9612) and 22 (IRS = 95.6 ± 15.7 g/mm(2) vs. G = 85.6 ± 16.4 g/mm(2), p = 0.2502) after surgery. Histology revealed a significantly increased amount of granulation tissue formation in glued wounds on day 7. The difference in granulation tissue formation was reduced until day 22. CONCLUSIONS: Tissue adhesive based on n-butylcyanoacrylate presents a fair alternative to traditional suture wound closure techniques.

Simple interrupted percutaneous suture versus intradermal running suture for wound tensile strength measurement in rats: a technical note.

BACKGROUND: In this experimental study, simplicity of measurement and wound tensile strength of wounds fixed by simple interrupted percutaneous suture (SIPS) and intradermal running suture (IRS) were compared. METHODS: Twenty-eight male Sprague-Dawley rats were used for the experiment and separated into two groups: SIPS group and IRS group. Under general anesthesia, two parallel full-thickness (4-cm) skin incisions were made on the back of each rat. Wounds in the SIPS group were closed using 4 interrupted percutaneous sutures, whereas wounds in the IRS group were closed by intradermal running suture. Seven animals from each group were sacrificed at 2 and at 5 days after surgery for tensile strength testing. RESULTS: The wound tensile strength of IRS wounds was significantly higher than that of SIPS wounds at 2 days (SIPS = 2.9 +/- 0.8 vs. IRS = 3.7 +/- 0.9 g/mm(2), p < 0.05) and at 5 days (SIPS = 5.6 +/- 1.3 vs. IRS = 7.1 +/- 1.2 g/mm(2), p < 0.01). In addition, the measurement of IRS wounds was easier and faster due to removal of only one suture. CONCLUSIONS: These findings highlight the advantages of expanding the use of IRS suturing in experimental studies conducted on rats.

[EPI-LASIK--2 years' clinical results]. / EPI-LASIK--2-rocné klinické skúsenosti.

PURPOSE: To evaluate the clinical results of Epi-LASIK, a new surface ablation surgical technique for the treatment of low and middle myopia. METHODS: Twenty eyes of 10 patients had Epi-LASIK for the correction of low and middle myopia. Mean preoperative spherical equivalent of the refractive error was 3.64 diopters (D) +/- 1.9 D, and the best spectacle-corrected visual acuity was from 1.0 to 0.8 in 100 % of eyes. All epithelial separations were performed with the Krumiech-Barraquer microkeratome (Lasitome Gebauer). In the postoperative period the patients filled out a questionnaire grading pain score of the treated eyes. RESULTS: The mean uncorrected visual acuity at 1 month after the operation was from 1.0 to 0.8 in 90 % of eyes. After 12 months, the mean spherical equivalent of the refractive error of the treated eyes was -0.262 +/- 0.15 D (from -0.25 to +0.25 D). One hundred percent of eyes had clear corneas at 6 months after the treatment. After 24 months, the mean spherical equivalent of the refractive error was -0.258 I 0.14 D, no "haze" was observed. CONCLUSIONS: The first clinical results suggest that Epi-LASIK is a safe, less painful and efficient method for the correction of low and middle myopia. We suppose, further studies will establish this method as a very good alternative surface ablation procedure.

Identifying management competencies for health care executives: review of a series of Delphi studies.

This analysis reviews a selected body of research that identifies the essential areas of management expertise required of future health care executives. To ensure consistency, six studies are analyzed, utilizing the Delphi technique, to query a broad spectrum of experts in different fields and sites of health care management. The analysis identifies a number of management competencies, i.e., managerial capabilities, which current and aspiring health care executives, in various settings and with differing educational backgrounds, should possess to enhance the probability of their success in current and future positions of responsibility. In addition, this review identifies the skills (technical expertise), knowledge (facts and principles) and abilities (physical, mental or legal power) required to support achievement of these competencies. Leadership and resource management, including cost and finance dimensions, are the highest-rated requisite management competencies. The dominant skills, knowledge and abilities (SKAs) are related to interpersonal skills. The lowest-rated SKAs are related to job-specific, technical skills. Recommendations include the review of this research by formal and continuing education programs to determine the content of their courses and areas for future research. Similarly, current health care executives should assess this research to assist in identifying competency gaps. Lastly, this analysis recommends that the Delphi technique, as a valid and replicable methodology, be applied toward the study of non-executive health care managers, e.g., students, clinicians, mid-level managers and integrated systems administrators, to determine their requisite management competencies and SKAs.

Trends in managed care organizations: implications for the physician executive.

The rapid change in the managed health care industry is placing substantial demands on the managerial and leadership skills of physician executives. These changes are forcing a reevaluation of the fundamental principles of managed care organizations, specifically in terms of patient satisfaction, cost containment, and quality health care. Additionally, the physician executive will be confronted with substantial issues concerning future staffing needs. This article assesses the health care industry's environment to suggest where managed care is going and how physician executives should position themselves to optimize their position in the marketplace.

Variables affecting Army physical disability processing.

This research identifies variables affecting the length of time to process a soldier through the U.S. Army Physical Disability Evaluation System (PDES). The subjects are 8,301 soldiers whose disability records were processed in fiscal year 1996. The dependent variable examined was the average number of days a soldier remains in the disability processing system. Independent variables included age, component, compensation award, Congressional involvement, gender, grade, retirement eligibility, race, length of service, formal Physical Evaluation Board (PEB), and regional PEB. Statistical analysis using linear regression and SPSS yielded an average length of stay (ALOS) of 155 days and a range of 1 to 2,052 days. The research shows that the most significant variables affecting ALOS are Congressional involvement, component, compensation, formal PEB, and regional PEB. The authors recommend a program of disability case management and increasing emphasis on transition assistance programs to reduce ALOS in the PDES.

Management competencies required in ambulatory care settings.

A study was conducted to identify the most important competencies physician executives in medical groups and other ambulatory settings will need to have in the next five years. The specific job skills, knowledge, and abilities (SKA) that physician executives will need to acquire these competencies were also explored. The Delphi techniques were used to analyze responses from two surveys from members of the American College of Medical Practice Executives. The most important competencies were grouped into 13 management domains, each with specific SKAs. "Managing health care resources to create quality and value" and "fundamentals of business and finance" were rated as the most important competencies. The most frequently rated SKA was the "ability to build and maintain credibility and trust."

Competency in health care management: a training model in epidemiologic methods for assessing and improving the quality of clinical practice through evidence-based decision making.

This article describes a training model that focuses on health care management by applying epidemiologic methods to assess and improve the quality of clinical practice. The model's uniqueness is its focus on integrating clinical evidence-based decision making with fundamental principles of resource management to achieve attainable, cost-effective, high-quality health outcomes. The target students are current and prospective clinical and administrative executives who must optimize decision making at the clinical and managerial levels of health care organizations.

Management competencies for medical practice executives: skills, knowledge and abilities required for the future.

The purpose of this study was to obtain a consensus of opinion from a large and diverse population of experienced ambulatory health care administrators regarding the essential ambulatory health care management competencies, and their related skills, knowledge and abilities (SKA) requirements, that will be required for successful management performance in ambulatory health care delivery settings in the next five years. A literature review suggests limited research in this essential and rapidly developing area for the health care community. The research design and methods employed the Delphi technique. Three hundred and twenty (320) Fellows of the American College of Medical Practice Executives (ACMPE) were asked to respond to two rounds of a Delphi mail survey. The results indicate that the essential ambulatory management competencies could be discretely grouped into six Management Domains, each with related SKAs. The respondents rated leadership and strategic management as the most important Management Domains. The highest rated SKA emphasized interpersonal skills with the next highest SKA relating to ethical and moral dimensions. Patient care management, as well as two SKAs relating to computer skills, were rated lowest.

Tl-201 chloride SPECT imaging of hepatocellular carcinoma.

PURPOSE: Tl-201 chloride has been used to image viable tumors in various sites of the body. There has been limited use of Tl-201 below the diaphragm because of normal uptake in the liver, spleen, kidneys, and intestines. The use of sequential Tl-201 and Tc-99m sulfur colloid in the detection and characterization of suspected hepatocellular carcinoma (HCC) was prospectively evaluated. METHODS: Four patients with indeterminate liver nodules on radiologic imaging studies were studied with sequential Tl-201 and sulfur colloid liver scans on a triple-headed gamma camera with planar and SPECT acquisition. All patients had subsequent pathologic correlation. RESULTS: There were three focal nodular HCC lesions and one case of multicentric HCC, size varying between 1.9 cm and greater than 4.0 cm (multicentric HCC). In all lesions, Tl-201 SPECT images showed abnormal increased uptake at sites of HCC, which corresponded to areas of photopenia on sulfur colloid. Computed tomography detected a lesion in two of four patients, whereas US was positive in all patients. However, US was specific for tumor in only one patient and CT was not specific in any patient. CONCLUSION: We believe that in patients with suspected HCC, Tl-201 SPECT imaging will have an important role in the detection and characterization of HCC, especially in the cirrhotic patient. Planar Tl-201 hepatic images will usually be normal, except in large lesions, and high-resolution SPECT technique is essential in successful liver tumor imaging.

Reengineering medical treatment facilities for TRICARE: the Medical Group Practice Model.

The purpose of this article is to propose a model for reengineering military community hospitals, as well as medical centers, to adapt to the extraordinarily rapid and complex changes that are being made to the Military Health Services System. This article analyzes the changes taking place and discusses how a particular organizational model, the Medical Group Practice Model, can enhance quality and patient satisfaction in a capitated managed care environment. The phased implementation, structure, and performance management of the model are described, as is the model's advantages and disadvantages.

FORECAST 2000: a prediction of skills, knowledge, and abilities required by senior medical treatment facility leaders into the 21st century.

This paper reports results from a Delphi study conducted among the Commanders and Deputy Commanders for Administration of 37 Army medical treatment facilities (MTFs), who identified the most important issues challenging their institutions for the remainder of this decade, and the skills, knowledge, and abilities required by MTF leaders to deal successfully with those challenges. A Delphi mail-out was conducted in two iterations. Respondents identified 187 health care issues which were divided by content into nine domains by a panel of health care experts. The domains, ranked by importance, were cost-finance, health care delivery, access to care, quality and risk management, technology, professional staff relations, leadership, marketing, and ethics. In the second Delphi iteration, MTF leaders agreed upon the necessary skills, knowledge, and abilities of future leaders. Results indicated that future leadership will require enhanced financial, quantitative, and technical skills, as well as competence in a broad array of interpersonal and communication skills. Implications for military medical leader development initiatives are discussed.