[Poldi-Cech cemented femoral stem in total hip arthroplasty after 25 years]. / Cementovaný drík TEP Poldi-Cech po 25 letech.

PURPOSE OF THE STUDY: The aim of the study was to evaluate the results of Poldi-Cech femoral stem implantation in primary total hip arthroplasty after 25 years. MATERIAL AND METHODS: A group of 65 patients (90 hips) with Poldi-Cech total hip arthroplasty carried out between 1974 and 1984 was evaluated at the end of 2009. The mean follow-up of all patients was 28 years (25 to 35). There were seven men and 58 women. The mean age at the time of implantation was 43 years (26 to 60) and at the latest follow-up it was 72 years. In all patients the cemented UHMW PE acetabular component (RCH 1000) was used together with AKV Ultra 2 Poldi steel femoral stems (1st, 2nd and 3rd generations). The stem was a monoblock with a 32-mm head. The evaluation of the results was based on the Harris hip score and X ray with an A-P view of the pelvis and the affected hip. Statistical analysis was made using the life-table method. RESULTS: At the latest follow up the mean Harris score was 69.7 points (40 to 88). There were 69 hips with an original Poldi-Cech femoral component still in situ, 64 of them were stable and five with radiological evidence of aseptic loosening. Five patients had undergone Girdlestone resection arthroplasty for septic loosening. Thirteen patients (16 hips) had femoral stem revision. The cumulative proportion of clinical survivorship of the Poldi-Cech femoral stem, with revision for any reason as the endpoint, .was 0.93 at 6 years, 0.84 at 12 years, and 0.77 at 18, 24 and 30 years after the index surgery. Radiographic findings revealed 64 hips with stable stems, five hips with ;aseptic loosening (probable, 0 possible, 2, definite, 3). Six- teen hips were after revision surgery for aseptic loosening of the stem and five hips were after Girdlestone resection arthroplasty for septic failure. The cumulative proportion of radiological survivorship of the Poldi-Cech femoral stem with any reason as the endpoint was 0.92 at 6 years, 0.78 at 12 years, 0.72 at 18 years, 0.69 at 24 years and 0.69 at 30 years. DISCUSSION: The Poldi-Cech stem with its anatomical shape and a highly polished surface meets the principles of successful composite beam stems. Its disadvantage is a valgus neck- shaft angle of 140° giving lower femoral offset and the risk of development of valgus deformity of the ipsilateral knee. In most cases osteolysis, radiolucent lines and bone rarefaction of the femur resulted from polyethylene wear of the acetabular component. CONCLUSIONS: This study demonstrates a long-term survivorship of the Poldi-Cech femoral component in patients undergoing total hip arthroplasty 25 to 35 years ago.

[Proximal femoral varus osteotomy in adults after developmental dysplasia of the hip: long-term results]. / Varizacní osteotomie proximálního konce femuru u dospelých po vývojové dysplazii kycle--dlouhodobé výsledky.

PURPOSE OF THE STUDY: The aim of this retrospective study was to assess the results of varus osteotomy of the proximal femur in adults with coxa valga after developmental dysplasia of the hip (DDH) and to evaluate the efficacy of this method. MATERIAL AND METHODS: Thirty hips in 28 patients treated by proximal femoral varus osteotomy in the period from 1983 to 1990 were evaluated. The indication for surgery involved coxa valga (145°-168°) with grade I- III of osteoarthritis and mild acetabular dysplasia. The patient group comprised twenty six women and two men with an average age of 28 years (18 to 42) at the time of surgery. The mean follow-up was 22 years (19 to 26). The preoperative radiographic examination included an AP view of the pelvis, AP views of the hip in neutral and in frog-leg position and AP views of the hip in 30° of abduction and neutral rotation. Varus osteotomy was indicated when the best position of the hip joint was achieved in abduction. The procedure was performed according to M. Müller. Hip assessment was based on the grade of osteoarthritis, CCD angle, Wiberg angle and AHI index. The results were statistically evaluated using the life table analysis of clinical survivorship of osteotomy and the Kaplan- Meier curve. Clinical failure was defined as conversion of osteotomy to total hip replacement (THR). RESULTS: At the latest follow-up of 22 years on the average, 18 patients (19 hips) still had osteotomy and 10 patients (11 hips) had undergone conversion to THR. The life table analysis showed the cumulative proportion of osteotomy with a clinical survivorship of 0.97 at 5 years, 0.75 at 10 and 15 years, and 0.68 at 20 and 25 years after surgery. The cumulative rate of clinical survivorship of osteotomy, as shown by the Kaplan-Meier curve, was 0.89 at 10 years, 0.75 at 20 years and 0.67 at 25 years after surgery. Nineteen patients were satisfied with the osteotomy outcome. The median of Harris hip scores in the patients with osteotomy was 48 points before surgery and 78 points at the latest follow-up. Conversion to THR in 10 patients (11 hips) was done at an average of 12 years after osteotomy. The median values before surgery and at the latest follow-up were: CCD angle, 158° and 118°; Wiberg angle, 13° and 20°; and AHI index, 56 % and 79 %, respectively. DISCUSSION: The prerequisite for a good result of proximal femoral varus osteotomy is the correct indication, i.e., younger age (18 to 30 years), a lower grade of osteoarthritis, mild dysplasia and a spherical shape of the femoral head. A disadvantage of the procedure is a shortening of the limb. The best indication for femoral varus osteotomy is unilateral coxa valga with a longer leg. CONCLUSIONS: This study shows favourable long-term results after isolated proximal femoral varus osteotomy in young adults with developmental dysplasia of the hip. A good function had been preserved in 18 of 28 DDH patients for an average of 22 years.

[Long-term results of the CLS acetabular cup in primary total hip replacement]. / Dlouhodobé výsledky CLS jamky u primární náhrady kycle.

PURPOSE OF THE STUDY To evaluate the results of primary total hip replacement with the CLS acetabular cup at a minimum of 15 years of follow- up. MATERIAL AND METHODS A total of 105 patients, with 112 hips, undergoing hip arthroplasty with the use of CLS acetabular cup between 1991 and 1993 were evaluated. The group comprised of 33 men and 72 women with an average age of 51.3 years (range, 28 to 66) at the time of surgery. All patients received the CLS expansion cup with a polyethylene Sulen-type liner. Cemented femoral stems were used in 75 hips and uncemented CLS stems were implanted in 37 hips. Ceramic heads of the femoral component were used in 86 hips and metal heads were used in 26 hips. The clinical outcome was assessed by the Merle dAubignnd Postel score and the Harris hip score, and the radiological results were evaluated on anterior posterior X-ray films of the pelvis and the affected hip. RESULTS The average follow-up was 16.2 years (range, 15 to 17). The average Merle dAubignnd Postel score increased from 8.1 (range, 5.7 to 9.8) pre-operatively to 14.6 (range, 14.1 to 16.8) post-operatively. The average Harris hip score improved from 42 to 86 points (range, 71 to 99). The complications requiring revision arthroplasty included aseptic loosening in two hips, fracture of the CLS shell in three, dislocation in three and replacement of the liner due to high wear in two hips. The cumulative proportion of clinical survivorship with revision for any reason was 92 %. Fixation by bone ingrowth, assessed by the method of Engh et al. occurred in 98 cases, fibrous tissue fixation was found in ten hips. Unstable fixation was recorded in four hips (two with aseptic loosening and two with fracture of the shell). There were no signs of rarefaction of bone along acetabular shell in 98 hips. No noticeable migration was found in the stable cups. Only in ten cups from 112, polyethylene wear exceeded 4 mm. Cumulative probability of radiological survivorship of the CLS acetabular cup with any radiological sign of loosening was 86.6 %. DISCUSSION The causes of fracture of the CLS cup can be explained by insufficient bone support or bone resorption in the proximallateral part of the acetabulum in patients with developmental hip dysplasia, by low bone quality due to severe osteoporosis or by insufficient primary stability of the cup. The advantages of the CLS cup include removal of a small amout of bone and favourable force distribution in circumferential anchorage. The cup showed good osteointegration even in a bone of lower quality and with defects of the acetabular bottom. CONCLUSIONS The CLS acetabular cup shows good results at 16-year follow-up period. No increase in fractures of the shell, migration or radiolucent lines, or in bone rarefaction or osteolysis was recorded with time. The reliability of this implant has been recently increased with the use of cross-linked polyethylene (Durasul). Key words: primary total hip replacement, uncemented cup.

[Revision knee arthroplasty due to aseptic loosening]. / Revizní náhrada kolena po aseptickém uvolnení.

PURPOSE OF THE STUDY: Anatomic changes associated with aseptic loosening make conditions for revision of total knee arthroplasty more diffi-cult. The aim of this study was to evaluate the results of revision total knee replacement at an average follow-up of 6.1 years. MATERIAL AND METHODS: A total of 97 revision knee replacements due to aseptic loosening carried out in the years 1992 to 2003 were evalua-ted. The group included 46 men and 51 women at an average age of 66.8 years. The average preoperative Knee Society Score (KKS) was 31 points and the Functional Score (FS) was 22 points. There were 41 minor operations for AORI type I defects, 49 moderately serious procedures for AORI type II defects and seven major operations for AORI type III defects. In minor procedures standard components were implanted in 14 patients, standard components with cemented stems with extension were used in nine, and polyethylene plateau exchange was carried out in 18 patients. For moderately serious procedures, posterior stabilized components with extended cemented stems were used in 15 patients, revision implants with cementless stems in 26 patients and standard components with cemented stems in eight patients. In seven patients with major surgery, the hinged type of prosthesis was employed. Radiographic results were evaluated on the basis of Ewald's classification. RESULTS: Clinical findings showed improvement of the average KKS from 31 to 74 points at follow-up of 6.1 years. Functional out-comes improved, as shown by the average FS, from 22 to 67 points. Fifteen patients were not satisfied with the outcome of surgery, the causes being aseptic loosening in four, deep infection in eight and pain due to progression of radiolucent lines of the tibia in three patients. DISCUSSION: The results of revision surgery with component replacement because of aseptic loosening are worse in comparison with those of primary total knee replacement. The average KSS score after revision surgery was 74 points at 6.1-year follow--up, whereas after primary surgery it was 92 points at 6.5 years. The average FS score after revision was 67 points, as compared with 86 points at 6.5 years after primary surgery. Complications involving infection occurred in 8.2 % of the revi-sion cases, but only in 0.8 % of the primary operations. The authors used modular systems because these provide more options. Good outcomes were achieved with morselized bone grafting for filling cavitary defects. In patients with large defects in tibial or femoral metaphyses, posterior stabilized components and cementless intramedullary stems were used with good results. CONCLUSIONS: The authors recommend to avoid filling large bone defects with bone cement. They prefer bone grafting. In the case of good quality metaphyseal bone, they use standard components or posterior stabilized components with or without additi-onal cemented or cementless short stem extensions. In the case of poor quality metaphyseal bone with defects, they use revision implants with cementless long stems. The authors have achieved good results with off-set stems.

[Reconstruction of severe acetabular bone defects using Burch-Schneider cage]. / Rekonstrukce závazných acetabulárních defektu pomocí Burchova-Schneiderova prstence.

PURPOSE OF THE STUDY: The Burch-Schneider cages (BSC) are designed to manage severe acetabular defects by bridging large bone gaps and preventing medial and superior migration of the prosthetic cup. The purpose of the study was to evaluate the results of such revisions after prolonged follow-ups. MATERIAL AND METHODS: From 1985 to 2000 sixty-nine acetabular revisions with BSC were performed in 68 patients with an acetabular defect classified as type Paprosky 3A (32) and 3B (37) at our institutions. After meticulous debridement of the entire acetabulum cancellous chips were pressurized into the bone defects to restore the hemispherical shape. The cage flange for the ischium was then placed after slight contouring into the foramen obturatum or inside the ischium. Finally, the cage was fixed against the ilium with at least three screws. The average age at the time of surgery was 67.9 years (range, 51-78), the mean follow-up equalled 8.3 years (range, 5-20), and the mean Harris hip score was 48 points (range, 29-76). A clinical follow-up study was performed with using conventional measures such as Harris hip score, x-ray analysis, strength of the abductor muscles, and ability to walk without support. RESULTS: A total of 55 patients (80.9 %) remained without any revision until the latest follow-up. Six components were removed due to aseptic loosening (8.7 %); five for septic loosening (7.2 %), and two revisions had to be performed for recurrent instability (2.9 %). Moreover, there were another six hips definitely or probably loose according to x-ray analysis resulting in a 17.4 % (12/69) rate of aseptic failure. Successful cage re-replacement was achieved only in two cases while the remaining nine hips ended as resection arthroplasties. At the time of follow-up examinations the average Harris hip score was 74 points (range, 51-91), only twelve patients were able to walk without support (12/68, 17.6 %), and insufficiency of the abductor muscles was found in fifteen hips (15/69, 21.7 %). Consolidation of the bone graft was observed in 79.7 % (55/69) of our hips. DISCUSSION: The severe acetabular bone defect reconstructions have been deteriorating with time as reported by most of the published studies. The results of the current study are no exception. On the other hand, the rate of complications observed in our study was comparable or even lower than in similar studies. CONCLUSIONS: Despite relatively worse results with prolonged follow-ups, the BSC remains a considerable part of the current orthopaedic armamentarium especially when extensive acetabular bone loss is countered. Loosening belongs to the most common complications of the BSC.

Revision hip surgery using the CLS expansion shell.

The aim of our study is to assess the outcomes using the uncemented CLS expansion shell in revision hip surgery for aseptic loosening of the acetabular component. Between 1991 and 2000 we used the CLS expansion shell in revision hip surgery in 215 patients (230 hips). We were able to evaluate 196 patients (211 hips) with failed acetabular components. The male/female ratio was 82/114 and the mean age of the patients was 63 years (range 38-71). The main reason for revision was aseptic loosening of the PE cup (184 patients). There were 79 hips with Paprosky defect of the acetabulum type I, 62 hips with type 2A, 57 hips with type 2B and 13 hips with type 2C in the study. The mean follow-up was 8.5 years (range 5-14). Plain radiographs using an AP view of the pelvis and AP and lateral views of the affected hip were taken immediately after surgery and at the latest follow-up. Clinical outcomes were determined using the Merle dAubigne' and Postel score and the Harris Hip score. The mean preoperative Merle dAubigne' score was 7.8 points (range 6.9 to 9.9); at the latest follow-up it was 14.9 points (range: 12.5 to 15.9). The mean preoperative Harris Hip score was 38.6 points (range: 32 to 59); at the latest follow-up it was 82.5 points (range: 38 to 95). Osteointegration of the CLS expansion shell was present in 149 hips (70.6%) at the latest follow-up. There were 31 complications (15%) requiring a second revision. Clinical survivorship of the CLS expansion shell was 90% at five years and 84% at 8.5 years after revision surgery. Radiological survivorship was 78% at five years and 70% at 8.5 years after revision surgery. The CLS expansion shell offers a viable alternative for revision hip surgery with lower bone quality, insufficient bone at the bottom and cavitary defects of the acetabulum.;

[Resection of head and neck of the femoral bone according to Girdlestone]. / Resekce hlavice a krcku kosti stehenní podle Girdlestona.

PURPOSE OF THE STUDY: To present our experience with resection arthroplasty of the hip joint according to Girdlestone, as the primary surgical technique used to treat various hip disorders. MATERIAL: During 1990 to 1999, 28 hips in 26 patients were treated in our department by resection arthroplasty according to Girdlestone. The most frequent indications for resection arthroplasty included pyogenic arthritis of the hip, tuberculous arthritis of the hip, post-traumatic pseudoarthrosis and avascular necrosis of the head, hip ankylosis following injury to the thoracic spine, and painful restriction of motion in cerebral palsy. In 2000, 20 hips were evaluated in 19 patients (11 men and 8 women; mean age at the time of surgery, 59.4 years; range, 18 to 79 years). The average time between the operation and evaluation was 3 years and 7 months. Seven patients were lost to follow-up; two died from unrelated causes, four underwent reimplantation of the hip prosthesis at an average of 13 months after the primary resection, and one patient failed to turn up. METHODS: Each patient was examined for the range of motion in the hip joint and limb length, and the questionnaire was completed. The Harris hip scores were used to evaluate joint function. RESULTS: Of the 19 patients, six (33%) were free from pain, ten (53%) occasionally used analgesics for relief of mild to moderate pain, and three (16%) reported severe pain restricting their daily activities. All patients were using walking aids, five (26%) had one French crutch and 11 (58%) had two crutches. Two patients (11%) were able to move only with a walking frame and one patient was confined to a wheel chair because of paraplegia due to thoracic spine injury. The shortening of affected limbs ranged from 1.5 cm to 6.5 cm (mean, 3.8 cm). All patients showed the Trendelenburg sign. Passive flexion in the treated hip ranged from 40 degrees to 130 degrees. The average Harris score was 64 points (range, 25 to 83 points). None of our patients achieved an excellent outcome. DISCUSSION: The use of the Girdlestone resection arthroplasty aims at pain alleviation, improvement in hip function, cure of infection, if this is present, and patients' satisfaction. The results described in the literature vary from bad to excellent. The evaluation of patients' satisfaction ranges from 14% in the study by Petty et al. to 100% described by Böhler and Salzer. In our group, 74% of the patients were satisfied with the surgical outcome, which is in agreement with 74%, 79% and 77% reported by Ballard et al., Bourne et al., and Haw and Gray, respectively. Most authors agree that the Girdlestone technique provides alleviation of pain in the treated hip; 84% of our patients reported pain relief. Although resection of the femoral head resulted in a considerable shortening of the affected limb (up to 4 cm), 84% of all our patients were able to walk with the use of some support. The issues open to dispute are the duration and method of post-operative extension. We do not consider skeletal traction to be necessary. We found no difference in functional outcomes or limb shortening between the patients who underwent skeletal traction for 3 weeks and those who had early mobilization without skeletal traction. CONCLUSIONS: Young and active patients with a single affected joint usually do not want to accept pseudoarthrosis as a definitive outcome. On the other hand, older patients with concomitant disorders or diseases are often willing to come to terms with pain-free hip pseudoarthrosis.

[Total hip replacement in osteoarthritis with acetabular protrusion]. / Totální náhrada kycle pri osteoartróze s protruzí acetabula.

PURPOSE OF THE STUDY: The acetabular protrusion changes anatomical conditions for implantation of a cup in total hip replacement. The aim of this study was to evaluate different approaches to implantation of acetabular components in patients with this condition. MATERIAL: A total of 50 hips in 33 patients who had surgery for osteoarthritis with acetabular protrusion between 1992 and 2000 were evaluated. Their initial diagnoses were: idiopathic rotrusio acetabuli in 20 patients, rheumatoid arthritis in nine, arthropathy due to psoriasis in two and Bekhterev's disease in two patients. The average age of the patients was 64.1 years (range, 27 to 74 years). In group I including 18 hips, cemented polythylene cups were used (11 Poldi, 5 Ultima and 2 Weber prostheses). In group II involving 32 hips, uncemented cups were employed (29 CLS, 2 Morscher and 1 Balgrist prostheses). Bone grafts inserted in the acetabular bottom were used in eight and 25 cases of groups I and II, respectively. The mean follow-up was 7.1 years. METHODS: The following parameters were evaluated: Wiberg's angle, protrusion grades according to Sotelo-Garzy, Charnley scores, teardrop collapse, angle of acetabular inclination, approximate femoral head center and center of the femoral prosthesis head, and the distance between them in both horizontal and vertical directions, deviation of the center of the femoral component head from the anatomical center of rotation in horizontal and vertical directions, radiolucent zones according to de Lee and Charnley, position of the femoral head center inside or outside the TAR triangle and aseptic loosening of the acetabular component. RESULTS: At a follow-up of 7.1 years in group I, 10 hips showed full osteointegration, five underwent revision arthroplasty for aseptic loosening and three showed some degree of aseptic loosening. All failures occurred in the acetabular cups implanted without bone grafting of the acetabular bottom. In group II, 29 hips showed full clinical survival with complete osteointegration of the acetabular cup and three were found to have a radiolucent zone of 1 mm in width. DISCUSSION: The complete osteointegration of a cemented acetabular cup was achieved in 10 out of 18 hips, with eight having spongioplasty of the acetabular bottom. The use of uncemented cup resulted in full clinical survival and complete osteointegration in 29 cases out of 32. The best outcome was achieved with the use of an expansion, uncemented CLS cup. This is designed for peripheral fixation, which is useful in the protrusion of an acetabulum with a thin bottom and permits acetabular bottom grafting and positioning of the femoral component head in the center of hip rotation. It provides full osteointegration even with low bone quality. CONCLUSION: Prerequisites for successful arthroplasty in hips with acetabular protrusion include the firm implantation of an acetabular component, placement of the femur lateral to Köchler's line, location of the center of the femoral component head inside the TAR triangle and an agreement between the approximate center of the femoral head and the center of the femoral component head. The firm and lasting implantation of a cemented cup requires spongioplasty of the acetabular bottom. At an average of 7.1 years after surgery, uncemented cups in conjunction with bone grafting of the acetabular bottom showed better outcomes than cemented acetabular components.

Chiari pelvic osteotomy in the management of developmental hip dysplasia: a long term follow-up.

PURPOSE OF THE STUDY: Developmental hip dysplasia in adults causes several anatomical changes which can lead to premature and progressive secondary osteoarthritis. The principle of Chiari osteotomy is the medialisation of the subluxated femoral head. This improves the biomechanics of the hip. The goal of the study was to assess the long term results of Chiari innominate osteotomy. MATERIAL: The authors evaluated 130 hips after Chiari ostetomy from 230 patients operated on in the sears 1969-1985 at the Ist Orthopaedic Department of St. Anna University Hospital in Brno, Czech Republic. The mean follow-up was 22.3 years (15-30) and there were 125 women and 5 men. The average age at the time of the procedure was 29 years (15-52). METHODS: We assessed the Harris hip score, daily activities, the length of the improvement after the procedure and asked the patients if they would undergo again the same procedure. We also assessed the CE angle, the Sharp angle, AHI index, the CCD angle, the Shenton's line, Crowe type of dysplasia, the shape of the femoral head and Kellgren-Lawrence grades of the osteoarthritis. There were 5 types of hip dysplasia in the study: coxa valga subluxans, coxa valga luxans, coxa plana brevis, coxa magna and severe deformity of the femoral head. There were 26 cases of hip dysplasia alone, 87 cases of hip dysplasia with a subluxation of the femoral head and 13 cases of dysplasia with a false acetabulum. We searched for the factors influencing the end results. We measured the medial shift of the distal pelvic fragment and the level of the osteotomy. RESULTS: The mean nmedial shift of the distal fragment was 22 mm e.g. 48.6%. There was a correct level of the osteotomy in 113 patients. Radiological features improved: the CE angle (-12 degrees to +37.2 degrees), the Sharp angle (48 degrees to 41 degrees), AHI index (51 to 96.3%). The Harris hip score improved from 42 points to 67.5 points an average. 65 patients have been satisfied with the procedure, 49 were partialy satisfied and 16 were not satisfied. There were 80 patients without any other procedure (the first group) and there were 50 patients with the conversion to total hip replacement at the time of the latest follow-up (the second group). The mean age at the time of the operation was 24.2 years in the first group and 33.7 years in the second group. 62 patients in the first group had no osteoarthritis or grade 1 osteoarthritis at the time of the operation. 43 patients in the second group had grade 2 or 3 osteoarthritis at the time of the operation. The favourable results of the operation lasted 17.6 years in the first group and 11.1 years in the second group. The time between Chiari osteotomy and the conversion to total hip replacement was 12.2 years in the second group. DISCUSSION: The favourable factors are the age up to 30 years, no osteoarthritis or the grade 1 of osteoarthritis, coxa valga subluxans of Crowe type I and type II of hip dysplasia with a normal Shenton line, the spherical and ovoid shape of the femoral head, the correct level of the osteotomy and full coverage of the femoral head (medial shift 40%). The unfavourable factors for long term results were older age (over 35 years) of the patient at the time of the operation, grade 2 and 3 of osteoarthritis, severe deformity of the femoral head, Crowe type III of hip dysplasia with broken Shenton's line more than 20 mm, an angular shape of the femoral head, a CE angle bellow -15 degrees, a high CCD angle (near to 180 degrees) and incorrect procedure technique. CONCLUSION: The study approved a favourable effect of Chiari pelvic osteotomy in patients with residual developmental hip dysplasia. The authors evaluated 130 patients operated on in the years 1969-1985 with a mean follow-up 22.3 years. In the first group (80 patients) a favourable result lasted an average of 17.6 years (3-30). 37 patients are still painfree, 35 patients have conservative treatment for osteoarthritis, 8 patients are planning a conversion to total hip replacement. Radiological signs have improved substantialy. Harris hip score has improved from 42 points to 67.5 points on average. In the second group (50 patients) a favourable result lasted for average 11.1 years (0-29). All of them had a conversion to total hip replacement at the average of 12.2 years. Chiari osteotomy gives the patients with residual developmental hip dysplasia and a correct indication favourable long-term results. It diminishes pain, prevents further subluxation and reduces the development of secondary osteoarthritis of the hip joint. (Tab. 6, Ref. 23.).

[Total knee replacement following high tibial osteotomy]. / Totální náhrada kolenního kloubu po vysoké osteotomii tibie.

PURPOSE OF THE STUDY: The objective of the study was to find out to what extent anatomical changes due to high osteotomy of the tibia affect knee function after total knee arthroplasty. MATERIAL: Of the patients with knee osteoarthritis treated by cemented total PFC prostheses in 1995, two groups were selected. Group I consisted of 50 patients who had knee replacement without previous tibial osteotomy; the average age of the patients was 71.2 years and the average follow-up was 5.7 years. Group II comprised 50 patients with high tibial osteotomy before total knee replacement. The average age was 73.5 years and average follow-up was 5.4 years. Before arthroplasty, all patients showed knee motion in the range from 10 degrees valgus to 15 degreEs varus, flexion of the knee was up to 20 degrees and there was no marked instability. METHODS: The results of knee arthroplasty were evaluated, in terms of function, according to the Knee Society Clinical Rating System, using the knee scoring system (KSS) and functional system (FS). The length of the patella and patellar ligament were measured, the Insall-Salvati index was calculated and the height of the patella was determined. RESULTS: The average KSS scores were 86.6 and 84.2 points for groups I and II, respectively. Excellent and good outcomes were achieved in 38 group I patients and in 37 group II patients. The average FS scores were 82.7 and 81.4 points in groups I and II, respectively. The average Insall-Salvati indices in groups I and II were 1.09 and 0.91, respectively. No patella infera was recorded in group I but it was found in 21 (42%) patients of group II. DISCUSSION: There was no difference in knee function, as shown by KSS and FS scores, between the two groups. This is in agreement with the results of Billings et al. and Meding et al. who studied 21 and 81 patients with knee arthroplasty, respectively. On the other hand, Windsor et al. and Katz et al., in groups of 45 and 21 patients, respectively, found that high tibial osteotomy prior to knee replacement adversely affected the outcome of arthroplasty in terms of knee function. The authors draw attention to the fact that, after high osteotomy, the detachment of soft tissues around the proximal tibia is more difficult. The surgeon has to deal with changes in shape and sloping of the proximal part of the tibia and its altered position in relation to the diaphysis. CONCLUSIONS: The outcomes of total knee arthroplasty, as assessed by functional scores, were similar in the patients both without and with preceding high tibial osteotomy. This condition had some effect on the development of a patella infera (present in 21 out of 50 patients) but only to a mild degree (Insall-Salvati Index, 0.91).

The arthroscopic debridement in the management of osteoarthritis of the knee joint by high tibial osteotomy.

THE AIM OF THE STUDY: The authors evaluated the benefits of the arthroscopic debridement performed in the same session with the high tibial osteotomy in the management of the knee joint of osteoarthritis connected with varus or valgus deformity. MATERIAL AND METHODS: Arthroscopy was indicated in 52 patients from 96 patients with high tibial osteotomy in the years 1996-2001. RESULTS: Significant intraarticular disorders were found in all 52 patients. 34 patients were fully satisfied, 10 were partialy satisfied and 8 were not satisfied with the outcome. Twenty from 22 patients with meniscal tears had a marked improvement. 4 patients with loose bodies and 5 patients with chondral flaps causing blockages had no further blockages or irritation of the knee. The arthroscopic findings of chondral lesions were in 10 cases from 13 more significant than it was expected from weightbearing X-ray films. CONCLUSION: The arthroscopy performed before high tibial osteotomy in the same session helped to detect a significant intraarticular disorder and the arthroscopic debridement improved the end results after high tibial osteotomy. (Ref. 16.)

The effect of alendronate in the treatment of postmenopausal osteoporosis.

OBJECTIVES: The aim of the study was the evaluation of the effect of alendronate in the treatment of postmenopausal osteoporosis on subjective criteria and on bone mineral density after two years. MATERIAL AND METHODS: The authors collected data from 44 women by questionaire and analysed the data from DEXA examination. The patients were given Fosamax 10 mg and calcium 500 mg per day in the years 2001-2002. RESULTS: The compliance of alendronate was good in 42 women (95.5%). 15 patients were very satisfied with the treatment, 22 were satisfied and 5 patients claimed no improvement at the end of the study. A positive effect of the treatment was seen in 37 patients (88.1%). 21 patients claimed to have no pain and 15 patients suffered mild intermitent pain at the end of the study. 24 patients used no analgetics and 9 patients used them irregularly. 11 patients claimed to have normal activity and 22 patients had mildly diminished activity in daily life. The authors encountered no symptomatic vertebral or nonvertebral fracture during the study. The mean BMD in the lumbar spine improved in T score by 0.38 SD after one year and 0.35 SD after the second year. The mean BMD has improved in the neck region in T score by 0.21 SD after the first year and 0.21 SD after the second year. The mean BMD in lumbar spine has improved in Z score by 0.31 SD after one year and 0.02 SD after the second year. The mean BMD in the neck region has improved in Z score by 0.31 SD after the first year and 0.16 SD after the second year. The mean change of bone mineral density in lumbar spine was +4.17% after the first years and +4.19% after the second year. The mean change of BMD in the femoral neck region was +4.46% after the first years and + 3.71% after the second year. According to student t-test all the data of increased BMD were statisticaly significant at the 5% level of the significance (p < 0.05). CONCLUSION: Alendronate therapy significantly reduced the pain and the need for analgesics. It improved the daily activity and mobility of the spine in the patients with postmenopausal osteoporosis. It resulted in a positive change of BMD in vertebral region of +8.36% and +8.17% in the femoral neck region after two years. The fracture risk in vertebral region was diminished by 31% and in the femoral neck region by 38% at the end of the study. (Tab. 11, Ref. 14.).

[Preoperative planning and surgical technic in achieving stability and leg length equality in total hip joint arthroplasty]. / Predoperacní plánování a operacne-technické resení stability a vyrovnání délky koncetin u totální náhrady kycelního kloubu.

One of the prerequisites for a good outcome of total hip arthroplasty is preoperative planning. Using a roentgenogram, the size of an implant, incision level on the femoral neck, depth required for fitting the cup, restoration of the center of hip rotation and, if necessary, correction of length descrepancy between the legs are determined. The preoperative planning based on an X-ray image was introduced by M. E. Müller and, in 1976, was modified by R. Schneider who used a transparent sheet for a template on which all relevant points guiding the surgical procedure are marked, i.e., the right position for implantation of the cup and stem, and incision lines. In uncomplicated cases, however, this approach is not necessary and the "planning principle of parallel lines" developed by L. Spotorno in 1988 can be used instead. The determination of length discrepancy between the legs is derived from a drawing of three reference lines on the roentgenogram. The lines parallel to each other indicace the same length for both legs. If the legs differ in length, the lines will diverge from each other in a way typical for this condition.

[Complications with the acetabular cup in the CLS total hip joint endoprosthesis]. / Komplikace jamky totální endoprotézy CLS kycelního kloubu.

PURPOSE OF THE STUDY: The aim of the study is to present complications of acetabular component of CLS total hip replacement and their solution. MATERIAL: In the period of 1986-1999 in total 219 cementless CLS total hip replacements and 2012 CLS cups in hybrid replacements were implanted at 1st Orthopaedic Department in Brno--primary surgeries--2026, revision surgeries--205. Of 2231 CLS cups we encountered 25 complications requiring a revision surgery (1.1% of all cases): 2 cases of the broken metal shell, 3 cases of cup penetration into pelvis, 4 cases of cup migration, 5 cases of aseptic loosening, 5 cases of dislocations and 6 cases of deep infections. METHOD: Broken metal shells were treated by Müller and Eichler ring, cancellous bone grafting with a cemented PE cup. Penetration of cups into pelvis were managed by Girdlestone procedure. Migration of the cup was solved in 1 case by Burch-Schneider ring, other cases with a good function were left in situ. Aseptic loosening with defects of acetabulum was solved by means of metal rings, cancellous bone grafting and cemented PE cup. Dislocation was managed by adjustment of CLS cup in the correct position, longer or closed reduction and orthesis. In infections a two-step procedure was used with a repeated application of CLS cup, Prostalac technique or Girdlestone procedure. RESULTS: The results of cases solved by means of acetabular metal rings, cancellous bone grafting and cemented PE cup are after 2-5 years good. The patients are capable of full weight bearing and have no pains, Harris score is 83-89 points. The radiograph shows in all but one patients a stable implant without radiolucent interface. The function of all patients with dislocations of CLS implant is now very good or good. No recurrence was recorded in patients with infections. The function of the hip with Girdlestone procedure is in 2 patients low--Harris score is 58 and 63 points. Harris score in patients after a two-step revision with a repeated application of CLS cup is 80-89 points. DISCUSSION: In cases of the broken metal shell there occurred a proximolateral defect of the acetabular bone as a result of development dysplasia of the hip. The cup had inadequate circumferential support. The cases of cup penetration into pelvis are connected with a marked primary or subsequent deficiency of the acetabular floor, excessive reaming of subchondral bone and osteoporosis. Revision surgery with a metal ring requires a careful extensive cancellous bone grafting with a complete filling of all defects, support of the ring by the bone and development of a stable bone-ring-cemented PE cup composite. The best results in infections were achieved by a two-step revision with a repeated application of CLS cup. CONCLUSION: Of the total number of 2231 implanted CLS cups in the period of 1986-1999 only 25 complications were recorded requiring a revision surgery, i.e. 1.1% of all cases. Complications relating to the cup were treated in case of acetabular defects by means of metal acetabular rings, cancellous bone grafting and cemented cups. In infections a two-step procedure was used with a repeated application of CLS cup, Prostalac technique or Girdlestone procedure.

[Structural Bone Grafting in THR with Cup for Dysplastic Hip.]. / Strukturální kostní step a CLS jamka u postdysplastické artrózy kycle.

The authors present results of THR with cementless CLS cup and massive structural bone grafting for dysplastic hip in 42 patients at the average 7,3 years after surgery. They used an autogenous graft from the femoral head in all cases. Crowe type of dysplasia: group I. 14 patients, group II. 20, group III. 5 and group IV. 3 patients. Harris hips score has improved from 37 to 79 points.The cup was placed into anatomic hip centre in 14 patients. There was proximal position up to 15 mm from the hip centre in 27 patients and lateral position up to 10 mm from the hip centre in 18 patients. Osteointegration of the CLS cup has occured in all cases. Clinical survivorship was 100 percent. There was no definite or probable aseptic loosening of the cup. There was no revision. The average of the support of the cup by the structural graft was 30 percent. All grafts have healed to the iliac bone. There was bridging trabeculisation, remodelling and trabecular reorientation at the interface between the iliac bone and the graft. Key words: developmental dislocation of the hip, total endoprosthesis.

[THR in Osteoporotic Fractures of the Femoral Neck.]. / Resení osteoporotických zlomenin krcku stehenní kosti totální náhradou kycle.

The authors present a group of 49 patients with a fracture of femoral neck with the symptoms of evident osteoporosis treated by THR. The group comprised 44 females and 5 males, average age 70 years (62-88 age range). Tha authors evaluated 42 patients on average 18 months after the surgery (9 to 29 months). Indicated to THR were 36 acute fracteures and 13 early failures of fixation. The degree of osteoporosis after Singh: grade 4-4 patients, grade 3-22 patients, grade 2-19 patients, grade 1-4 patients.The type of fracture after Garden: type II - 5, type III - 26, type IV - 18 fractures. The authors used in 39 patients (Singh 1-3) the cemented type of THR with polyethylene cup, in 6 of which they reinforced the acetabular cup with a metal ring (Eichler, Miiller). In 4 cases they used a hybrid type of THR with Spotorno cup (Singh - 4). They applied the cementing technique of 2nd generation. Forty-five patients evaluated their condition after operation as very good or good, 38 patients were equally active as before the operation, 44 reported a good range of motion. Harris average score was 88 (75-99). In one female patient the authors found a deep infect. In 41 patients (of 42 evaluated) firm osteointegration of both components was achieved. The authors indicate total replacement in active patients with dislocated fracture of femoral neck and osteoporosis Singh 4-1 older then 62 years. They prefer it to internal fixation in order to avoid known complications. They refer to good results of their group of 84 total replacements evaluated during the average period of 5,5 years (from 1981-1986) and to the extensive recent study of the Mayo Clinc. Key words: fracture of femoral neck, THR.

[Longterm results of poldi hip replacement.]. / Dlouhodobé výsledky totální endoprotézy kycelního kloubu Poldi.

The authors evaluated 124 patients operated on by means of cemented Poldi THR in the period 1980-1986 on average 14,2 years after the primary implantation (12,2-18,0). Average age of patients was 55 years (in the range of 33 to 75). Pre-operative diagnosis was osteoarthritis in 78 cases and rheumatoid arthritis in 46 patients. All patients had normal anatomical relations. The implants applied included a 49 mm polyethylene cup and a bananashaped CoCr polished stem with 32 mm head with the use of 1st generation method of cementing. Harris Hip Score averaged prior to the surgery 49 (19-52) and after the surgery 68 (49-98). In 59 patients Harris Hip Score was above 70 points. In total, 10 revision surgeries were performed of which 9 due to aseptic loosening (the cup - 6times, the cup and the stem - twice, the stem - once) and 1 due to septic loosening. There were 23 cases of evident loosening of the cup (of which 8 symptomatic and 15 asymptomatic one) and 8 probable. The number of potential operations of the cup is 46 and that of the stem 11. Combined prevalence of revision surgeries accomplished and potential is 54 (43,5 %) in case of the cup and 14 (11,2 %) in case of the stem. The survival rate after 14 years is 81,5 % in the acetabular cup and 95,2 % in case of the stem. Authors found out an increased number of THR failure after 12 years due to aseptic loosening of the acetabular cup. After the Kaplan-Maier curve the survival rate of THR after 4 years is 99 %, after 8 years 97 %, after 10 years 94 %, after 12 years 91 % and after 15 years 76 %. Linear polyethylene wear of the cup is on average 0,14 mm annually, and the volumetric one amounts to 189 cubic mm annually. Key words: THR, longterm results.

[Burch-Schneider Ring in Revision Surgery of THR.]. / Burchuv-Schneideruv prstenec u revizních náhrad kycle.

The authors evaluate the results of 16 revision surgeries of the hip joint with the application of Burch-Schneider ring in 3A and 3B Paprosky type of acetabular defect on average 4 years after the primary surgery. According to the subjective evaluation 9 of them were very good, 6 of them were good and 1 result was satisfactory. The average Harris Hip Score was 88 points. They did not encounter any evident or probable loosening of the cup. In all patients bone allografts were fully integrated. The new bone created under the Burch-Schneider ring can be in future used for the revision surgery, if need be. Burch-Schneider ring can be successfully used for the treatment of significant defects of acetabulum in revision surgery of the hip joint. Key words: THR, revision surgery.

[Polymerase chain reaction in diagnosis of infection of total knee replacement.]. / Polymerázová retezová reakce v diagnostice infekcí totální náhrady kolena.

Polymerase chain reaction allows a direct detection of DNA of bacterial pathogens in synovial fluid. With the help of artificially synthetized nucleotides, the so called primers, and in the presence of DNA polymerase enzyme it is possible to produce a great number of copies of the DNA being investigated and subsequently detect them. Authors used this method in 32 symptomatic knees after TKR (P.F.C. cemented type - Johnson and Johnson). Group I (pyogenic infection) comprised 14 patients. Their clinical condition required operation - extraction of TKR, debridement, spacer, lavage. All of them were PCR positive. Only 6 patients had a positive bacteriological cultivation, 8 of them were bacteriologically negative. Group II (synovialitis) included 18 patients. All of them had a negative bacteriological cultivation. Group II.a showed a slightly positive PCR reaction (mitigated infection, detection of DNA microbes incapable of reproduction). After the treatment by antibiotics the patients were without complaints. Group IIb included patients who were all PCR negative. Their case was non-bacterial irritation of synovial membrane. They had a good response to non-steroid antiflogistics. The sensitivity of PCR method is 100%, it can detect also microbes in patients treated by antibiotics. PCR method is fast providing results within 24 hours. It reliably detects the presence of bacteria in the punctate, it specifies diagnosis and contributes to the distinguishing between pyogenic infection from non-bacterial synovialitis. Key words: total knee replacement, infection.

[Non-cemented CLS Spotorno Socket and Cemented Polyethylene Socket in Revised Replacements of the Hip Joint.]. / Necementovaná CLS jamka Spotorno a cementovaná polyetylenová jamka u revizních náhrad kycelního kloubu.

The objective of the presented work was to evaluate the results of revised replacements of the hip joint using non-cemented CLS Spotorno sockets and cemented polyethylene sockets of 1992 - 1993. The baseline situation was identical: an aseptically loosened polyethylene socket, intact pillars and preserved acetabular margins. In the group of CLS Spotorno sockets there were 56 patients, 52 were evaluated after an average period of 42 months following revision. In the CLS Spotorno group the mean Harris hip score was at the end of the study 84.6 points. The authors recorded complete osteointegration of the socket in 45 instances. There were 7 sockets with radiolucent margins. In the group of cemented polyethylene sockets the mean Harris hip score was 74.3 points. The total number of radiolucent margins was 24. Three patients had already a second surgical revision, five patients had symptomatic and six asymptomatic loosening of the socket. Complete osteointegration of the socket was recorded in 28 patients. The cumulative probability of clinical non-failure of the cemented polyethylene socket after 43 months was 79.34 %. The cumulative probability of non-failure of the non-cemented socket CLS Spotorno after 42 months was 94.44 %. Key words: alloplasty of the hip joint, revised replacements of the socket.