Biomedical subjects

D Musil

Publications and source records attributed to D Musil.

At least 19 recordsLinked to original sources

PubMed2006

[Arthroscopic stabilization of the shoulder].

PURPOSE OF THE STUDY: Minimally invasive technique have recently gained importance because of their apparent advantages. One of them is arthroscopic stabilization of the shoulder used for treatment of traumatic anterior glenohumeral dislocation with subsequent instability. In this study we describe the results of and experience with this technique. MATERIAL: Conventional treatment of glenohumeral dislocation, which includes reduction and subsequent immobilization for 4 weeks, has a high risk of recurrent dislocation particularly in young patients.Therefore surgical treatment lowering this risk is preferred. Arthroscopic stabilization is effective in patients with post-traumatic anterior instability of the glenohumeral joint. This technique involves fixation of the torn glenoid labrum and reduction of the anterior articular space. The evaluation of 77 patients treated by this method is presented here. METHODS: The arthroscopic method of labrum fixation with Mitek anchors (Mitek, Norwood, Mass., USA) was used. Arthroscopic stabilization is carried out in a lateral recumbent position with an extension device, using two standard arthroscopic ports. After preparation of the glenoid rim, the torn labrum is sutured to GII anchors inserted in pre-drilled tunnels in the edge of the glenoid. Insertion of three anchors appears optimal, because the use of fewer anchors may result in failure and repeat dislocation. The anchors have to be inserted in a manner ensuring fixation of maximum of the torn labrum. RESULTS: A total of 90 shoulder joints were treated by arthroscopic stabilization and 77 patients were followed up. Excellent results were achieved in 58 patients (75.4 %). Good results in 14 joints (18.2 %) and poor in 4 patients (5.2 %). Three repeat dislocations were recorded and one patient experienced restriction of motion in the treated shoulder. DISCUSSION: The three repeat dislocations (3.9 %) correlate with the results reported in the recent relevant literature. CONCLUSIONS: Arthroscopic shoulder joint stabilization is a reliable method. It is a surgical procedure suitable for treatment of shoulder instability and is also indicated in patients with acute traumatic dislocation, because it significantly reduces the risk of recurrent dislocation that is high in conventional treatment. In the hands of an experienced surgeon this technique is fast and simple and, because of its minimal invasiveness, convenient for the patient. In comparison with open stabilization techniques, arthroscopy is associated with higher failure, but a classical open procedure can still be used for treatment of recurrent dislocations.

Adolescent↗

PubMed2006

[Z-plasty for valgus deformity in total knee arthroplasty].

PURPOSE OF THE STUDY: Several options for treatment of valgus deformity in total knee arthroplasty (TKA) have been described. In 2002 the lateral approach to the valgus knee with Z-plasty of the articular capsule involving part of Hoffa's fat pad started to be used in our department. In this study the surgical technique, including steps for gradual deformity correction, is described and shortterm results are evaluated. MATERIAL: A total of 1136 TKAs were carried out in the period from 1994 to 2004; of these 131 (11 %) were performed on valgus knee. After a visit to the Schulthess Klinik and personal communication with Dr. med. T. Drobny, we began to use the lateral approach to the valgus knee, with Z-plasty of the articular capsule and involvement of Hoffa's fat pad. Forty-two patients (35 women and 7 men) were treated by this technique. The average age of this group was 71 years, and the average preoperative valgus deformity was 20.5 degrees. METHODS SURGICAL TECHNIQUE: A skin incision is made along the midline and, in its lower part, it is led toward the lateral border of the tibial tubercle. The joint capsule is incised in the superficial layer at about 2 cm lateral to the patella. Dissection of the superficial and deep layers of the capsule is made laterally, extending up to 4 cm. After joint exposure, the fat pad is separated from the medial attachment and preserved, on a lateral pedicle, with the patellar ligament. If needed, this flap can be used to close a defect in the distal articular capsule. By including both parts of the joint capsule produced by Z-plasty, medial transposition of the patella is achieved after suture. The deformity is corrected in a sequential manner according to its severity and the effect of release in each step, as follows: 1) Point incisions of the iliotibial band at a 5-cm distance above the articular fissure (piecrusting). 2) Subperiosteal elevation of the iliotibial band attachment from Gerdy's tubercle. 3) Release of the posterolateral capsule. 4) Subperiosteal release of the femoral attachment of the lateral collaterall ligament and dissection of the popliteal muscle. 5) Release of the lateral head of the gastrocnemius muscle. The evaluation of patients was based on the Knee Society Clinical Rating System. RESULTS: Using this surgical technique, correction of deformity was achieved in all patients. The knee axis after surgery improved to 6.6 degrees on the average. The more extensive dissection of lateral structures resulted in larger blood losses, which were on average 1150 ml, and the procedure also required a longer tourniquet application (55 min). The patients were followed up on average for 22 months. The Knee Score assessment in the whole group (42 knees) was on average 90.6 points, with 92.0, 93.3 and 87.9 for rating system categories A, B and C, respectively. The average range of motion was 0 to 118 degrees , and none of the patients reported femoropatellar problems. Revision surgery for hematoma was performed in one patient and puncture of the knee joint had to be done in several patients. Redress for postoperative motion restriction was carried out in three patients and one patient underwent repeat surgery for infection. DISCUSSION: The lateral approach with Z-plasty of the capsule and fat pad involvement provides maximal release of and access to the lateral structures, reduces the risk of insufficient blood supply of the patella and also resolves patellar subluxation. This technique thus allows us to reduce the probability of developing femoropatellar problems that are frequently responsible for poor TKA outcomes in the valgus knee. CONCLUSIONS: The technique described here is an effective approach to the valgus knee requiring total replacement. It provides good access to exposed lateral structures and, with the use of Z-plasty, permits correct alignment and tracking of the patella. In addition, it minimally interferes with blood supply to the patella and completely avoids problems associated with suture of the articular capsule.

Aged↗

PubMed2006

[Prevalence and causes of reflux in deep venous system of the leg in patients with insufficiency of superficial veins].

UNLABELLED: The aim of the prospective study was to find out the following: 1. What is the prevalence of deep vein reflux of the leg in patients with superficial vein reflux detected by ultrasonography? 2. What are the possible causes of deep vein insufficiency of the leg retrospectively detectable on the basis of targeted medical history? 3. Is the incidence of identified deep vein insufficiency of the leg gender specific? The sample consisted of 100 legs with superficial vein reflux detected on ultrasonography (C1 - C4 / CEAP) of 79 randomized patients (59 women aged 45 +/- 12 years and 20 men aged 52 +/- 15 years). We collected the medical history of all patients and examined them for any vascular diseases of the leg. Superficial and deep venous system of the leg was examined by routine duplex ultrasonography with 7.5 a 10 MHz linear probe in B-mode, colour flow mapping and pulse Doppler using Valsalva manoeuvre and manual compression of thigh. During the examination, patients lay both prone and on their back. RESULTS: Prevalence of deep vein reflux in patients with superficial vein reflux detected by ultrasonography was 43 %. Prevalence of deep vein reflux in patients only with primary venous insufficiency (i.e. personal medical history without phlebothrombosis of the leg, trauma, surgery or plaster fixation) was 35.4% in our sample. The possible causes of deep vein reflux in our patients are the following: overweight and obesity (58.6%), primary valvular insufficiency (35.4%), secondary valvular insufficiency--post-thrombotic, post-traumatic (34.9%) and various combinations of these factors. Deep vein insufficiency increased with the BMI. Deep vein reflux was significantly more frequent in men (80%) as compared with women (54.2%).

Body Mass Index↗

PubMed2005

[Our experience with revision total knee arthroplasty].

PURPOSE OF THE STUDY: In the period from 1990 and June 2003, 885 total knee replacements were performed at the orthopedic ward of the Ceske Budejovice Hospital. Of these, 19 (2.14 %) patients underwent revision surgery; in addition, 25 patients who had had primary surgery in other hospitals were operated on. Of these 44 patients, 25 were followed up and evaluated. The aim of the study was to evaluate the pre-operative treatment including examination for bacterial infection by cultivation, the selection of an optimal procedure (one- or two-stage operation, surgical approach and implantation technique) and postoperative therapy. MATERIAL: The 25 evaluated patients were followed up for an average of 34.5 months (range, 6-109 months) after reimplantation. Loosening occurred in most of the commonly used types of primary implants. The group comprised five men and 19 women; the average age at the time of reoperation was 70 years (range, 51-78 years). Ten patients had repeat surgery on the left and 14 on the right knee at an average of 43.5 months (range, 4-120 months) after primary surgery. Fourteen patients were treated by one-stage and 10 patients by two-stage surgery. The Genesis system (Smith Nephew) was used in 13 patients, Sigma PFC revision implant (Johnson and Johnson) in eight, Walter-Motorlet implant (reuse of the primary implant at the time when a revision system was not available) in one and external fixator in five patients. METHODS: Revision arthroplasty was indicated on the basis of clinical symptoms and X-ray, scintigraphic and biochemical (CRP, WBC, FW) examinations. The use of recently adopted methods (procalcitonin, orosomucoid, alpha-1-antitrypsin, beta-2- macroglobulin, ceruloplasmin, PCR and PET) was not evaluated because of short-term applications. Patients in whom infection or colonization of the implant was suspected were treated by two-stage reimplantation, using a canalized spacer with a stem and a patellar pelota made of antibiotic-loaded cement. The average time between implant removal and reimplantation was 108 days (range, 60-244 days). Each removed implant was placed in a culture medium for 5 to 7 days. This resulted in a high occurrence of positive cultivation results even in the patients who, on the basis of previous examination, were first considered to have had aseptic loosening and had undergone one-stage surgery. All patients with positive tests received long-term antibiotic therapy, usually a combination of ciprofloxacin and rifampicin, according to the cultivation results. RESULTS: Out of 14 one-stage reimplantations (indicated for by the negative results of all laboratory examinations), implant colonization was recorded in five cases, with a coagulase-negative staphylococcus being the most frequent infectious agent. No recurrent infection was found after the long-term antibiotic course. One patient with the implant infected with Staphylococcus aureus underwent primary arthrodesis. Out of 10 two-stage reimplantations (in patients with positive laboratory tests), recurrent infection was found in two cases and was caused by a pathogen different from the original one. The patients were treated by arthrodesis. Good outcomes, defined as a functional total knee replacement free from infection at least 6 months after reimplantation, were achieved in 79 % of the patients. Better functional results were obtained by onestage surgery. Patients with concomitant rheumatoid arthritis had aseptic loosening more frequently, and patients with impaired immunological status, due to diabetes mellitus, cytostatic drug or corticosteroid administration, more often showed septic loosening. DISCUSSION: The 2.14 % loosening of total knee arthroplasty in our patients (19 out of 885) can be considered a good result. A functional joint was achieved in all patients (100 %) with aseptic loosening and in 69 % of those with infected or colonized implants. The results of routine biochemical tests and bacteriological cultivation did not allow us to distinguish aseptic from septic loosening with certainty. Therefore, we adopted new screening markers (PCR and PET) and a new method of microbiological examination of the removed implant and collected tissue. However, we could evaluate the role of these specialized tests only on the basis of literature data, since we had only short-term experience with them ourselves. Our results with the treatment of early loosening of total knee arthroplasty suggest that patients benefit more from the two-stage procedure. CONCLUSIONS: We strongly emphasize the employment of all possible means to prevent loosening, i. e., to use an appropriate surgical technique for primary implantation, to observe aseptic principles and to administer antibiotic therapy in conditions suspected of bacteremia. The shorter the interval between the onset of complaints and the reimplantation, the better results. Early loosening should be treated by two-stage surgery. Our method of bacteriological examination gives good results. Because of complexity of the problem, patients with a loose knee prosthesis should be referred to orthopedic departments with experienced and skilled surgical teams and high-quality examination facilities.With the observation of appropriate procedures, there is a great chance of achieving good results. Arthrodesis is still regarded as a justified "salvage" operation, particularly in cases with pre-operative findings of Staphylococcus aureus. Procedures for repeat surgery following the failure of a reimplanted joint have so far yielded doubtful results and still await further development.

Aged↗

PubMed2005

[Reconstruction of the anterior cruciate ligament: comparison of patellar bone-tendon-bone and hamstring tendon graft methods. Part 1. Evaluation of patients treated by the patellar bone-tendon-bone graft technique].

PURPOSE OF THE STUDY: Reconstruction of the anterior cruciate ligament (ACL) by means of a patellar bone-tendon-bone (B-T-B) graft is currently one of the most frequent arthroscopic procedures. Progress in alternative techniques, particularly the use of hamstring tendon grafts and different methods for graft anchorage, was the reason for evaluation of our group of patients. The results were assessed at 18 months of follow-up. MATERIAL: We evaluated 137 surgically treated knees in 136 patients, 20 female and 117 male, on the basis of the Lysholm score system completed with a clinical examination of knee joint stability by Lachman's test and the pivot shift test and the ability of assuming a squatting position. We completed the evaluation with the patient's report on their satisfaction with the outcome and willingness to undergo the surgery again in the case of the other knee instability. METHODS: We carried out surgery under general anesthesia with the extremity in flexion and application of a tourniquet. Arthroscopy is performed from the anterolateral portal and graft is harvested, though a longitudinal incision, from the middle third of the patellar ligament and with the bony blocks from the patella and tibial tubercle. The graft width is 9 to 10 mm. Tibial or femoral tunnels are drilled by means of a tibial of femoral reamer and the inserted graft is fixed with metal interference screws. Cefazolinum with low-molecular heparin is administered during surgery. Rehabilitation of the extremity on a continuous passive motion (CPM) device begins on the first day. Full weight-bearing is allowed from the sixth week. RESULTS: The average Lysholm score of the group was 86.9. Excellent, good and satisfactory outcomes were achieved in 46.38%, 23.91% and 14.49% of the knees, respectively; 14.49% showed poor outcomes. Satisfaction with the outcome of surgery was reported by 90.5% of the patients, 75.18% complained of problems with knee-bend and pain at the donor site and scar. DISCUSSION The results of our evaluation are similar to those reported in the relevant literature. There are no differences in Lysholm scores from literature data or from the results recorded in a group of patients operated on with the use of the Rigidfix system and hamstring tendon grafts, in whom the average score was 84.3. The patients treated by the B-T-B technique, however, experience more problems at the graft harvest site, with subsequent femoropatellar complaints. CONCLUSIONS: ACL reconstruction with a patellar B-T-B graft is a surgical technique which resolves the patient's existing complaints due to knee instability, but may also have a preventive effect. This technique is suitable for sportsmen and sportswomen. Because of frequent postoperative complaints of pain at the donor site, it is not indicated for persons with femoropatellar problems, elderly persons and those who have kneeling jobs.

Adolescent↗

PubMed2005

[Reconstruction of the anterior cruciate ligament: comparison of patellar bone-tendon-bone and hamstring tendon graft methods. Part 2. Short-term evaluation of the hamstring tendon graft technique with use of the Rigidfix system].

PURPOSE OF THE STUDY: The high number of patients with femoropatellar complaints following ACL reconstruction with bone-tendon-bone (B-T-B) autograft led us to use and subsequently evaluate hamstring tendon grafts fixed with the Rigidfix system. In this study we present the evaluation of short-term results. MATERIAL: We evaluated 85 patients (51 male and 34 female) at an average follow-up of 14 months. The average age of the group was 29.7 years (range, 16 to 59 years). In 46 patients we treated the right knee and in 39 patients the left knee. Fifty-five patients in this group also had an associated injury to the soft knee tissues. For reconstruction, a semitendinosus tendon graft was used in 56 knees and a semitendinosus-gracilis tendon graft in 29 patients. METHODS: The operation was carried out with tourniquet application to the extremity in a flexed position. The tendon of the semitendinosus muscle was harvested through an oblique incision and, in some cases, when its width and length was not sufficient for graft construction, the gracilis muscle tendon was harvested too. The graft, at least 75 mm by 8 mm in size, was prepared on a graft board. After having drilled the both tunnels, the femoral Rigidfix reamer was inserted in a routine manner and protective sleeves for Rigidfix cross pins were introduced. With the extremity in semiflexion, the inserted graft was fixed to the cortical bone by absorbable cross pins on the femur and absorbable interference screws on the tibia. The postoperative treatment involved procedures as in the B-T-B technique. RESULTS: The group was evaluated by the Lysholm score system, with an average of 84.3 scores achieved. The men showed better outcomes than women, i. e., 85.7 and 81.4, respectively. The scores in the patients with a single tendon did not differ significantly from the patients with a combined tendon (semitendinosus, 83.2 vs. semitendinosus-gracilis, 84.2), nor did they greatly differ between the patients with injury to ACL alone and those with ACL and associated soft tissue injuries (ACL, 83.9 vs. ACL+ associated injury, 85.5). Most of the patients (94 %) were satisfied with the outcome of treatment. The complications involved thrombosis of the operated lower extremity in three patients and repeat surgery for hematoma in two patients. Knee instability was found in five patients. One graft failed to restructure and incorporate, in two knee tunnels were incorrectly centered and two grafts ruptured due to trauma. Three of these patients underwent repeat surgery. DISCUSSION: Our results, as evaluated by the Lysholm score system, were in agreement with those of other authors. We did not find any difference in knee stability between the patients treated by the hamstring tendon technique and those undergoing reconstruction with a patellar B-T-B autograft. However, the patients with hamstring tendon reconstruction reported a considerably lower number of femoropatellar problems. CONCLUSIONS: ACL reconstruction with a hamstring tendon autograft fixed with the Rigidfix system is a suitable alternative technique to ACL reconstruction carried out with a patellar B-T-B graft. It provides equal knee stability but has significantly lower donor site morbidity. It is suitable for patients who have contraindications for the B-T-B technique and in persons practicing little or no sports.

Adolescent↗

PubMed2005

[Allograft for surgical reconstruction of the cruciate ligaments of the knee - part 1].

PURPOSE OF THE STUDY: The growing numbers of anterior cruciate ligament (ACL) reconstructions performed by an increasing number of surgeons have resulted in an increased number of failed reconstructed ligaments. For repeat surgery, autologous tissues are most frequently used, namely BTB graft, hamstring tendons or quadriceps tendon construct. However, these alternative methods have certain disadvantages and therefore we decided to use BTB allografts from cadaverous donors. The risk of disease transmission due to allograft implantation has been reported to be low, but a thorough serological screening of donors is the prerequisite. We used BTB allografts first in revision ACL surgery only, but because of good results we started using theme for reconstruction of both cruciate ligaments and, in some cases, also for primary reconstruction. MATERIAL: In the period from 2002 to 2004, patellar ligaments harvested from 23 cadaverous donors were used at the orthopedic ward of the Ceské Budejovice hospital to prepare 87 BTB grafts, of which 42 were implanted. In 57 % of the procedures, an allograft was used in revision surgery carried out for the failure of a ;previously reconstructed ACL in 10 % it was used in complete reconstruction of both cruciate ligaments, and in 14 % it was used for primary ACL reconstruction in indicated cases. In 19 % of the cases, allograft was used when autologous graft failed or was damaged during the primary operation. METHODS: Graft harvesting, storage, handling and implantation have been carried out in accordance with the practices included in Act no. 285/2002 Coll. Serological examination of the donors and bacteriological assays of the grafts were performed according to the current regulations. The implantation of BTB allografts in ACL reconstruction was carried out by the standard method used in reconstructive procedures. RESULTS: Out of 87 BTB allografts prepared, 16 were discarded because of positive culture findings. Two allografts could not be used because the screening was positive for CMV infection. No infectious complications, poor healing or a systemic response to the allograft implanted were recorded in any of the patients. DISCUSSION: The use of allografts is a method suitable for revision surgery in failed ACL reconstruction. It allows us to avoid further weakening of the structures associated with the knee joint. The size of allograft bony blocks permits treatment of defects in the tibial or the femoral tunnel. CONCLUSIONS: The use of a BTB allograft is a reliable and safe procedure. It has advantages not only in revision ACL reconstruction, but also in reconstruction of both cruciate ligaments. Also primary ACL reconstruction in indicated cases achieved good results.

Adult↗

PubMed2005

[BTB allograft for revision surgery of the anterior cruciate ligament - part 2].

PURPOSE OF THE STUDY: The study evaluates our experience with revision anterior cruciate ligament (ACL) surgery, with emphasis placed on the use of allografts. MATERIAL: In the 2002-2004 period, 421 reconstructions of the anterior cruciate ligament, using patellar BTB or hamstring tendon autografts, were carried out in our orthopedic ward. In the same period we performed 24 revision ACL reconstructions (6 %) with BTB allografts; 19 were in men and five in women. Revision surgery after ACL reconstruction with a BTB graft fixed with a non-absorbable interference screw and with a hamstring tendon graft was performed in 18 and 5 patients, respectively. METHODS: We distinguish four steps in the revision procedure: 1) diagnosis and analysis of the ACL reconstruction failure; 2) preoperative planning and surgery timing (one- or two-stage procedure, graft type, fixation method); 3) operative procedure; 4) postoperative care including rehabilitation. Revision surgery is indicated on the basis of subjective complaints (instability), and the results of clinical examination (Lachman's and pivot-shift tests) and imaging methods (X-ray, MRI, arthroscopy). Causes of failure are categorized as 1) traumatic (major trauma, too early weight-bearing, minor trauma due to rehabilitation); 2) surgery-related (erroneous position of the tibial and/or femoral tunnels, insufficient tensioning of the graft and its insufficient fixation); 3) biological (poor ;graft incorporation and restructuring, infection); and 4) combination of all previous causes. Errors in tunnel position are differentiated according to the part of the tunnel (tibial, femoral or both) tunnel direction (ventral, dorsal, lateral or medial) and the degree of malposition (mild, moderate or serious). We perform one-stage surgery when the position of tunnels is correct, with the exception of revision due to infection, and in all malpositions but for a dorsally positioned tibial tunnel. In a moderate degree of femoral tunnel ventral malposition, we make decisions individually. A two-stage procedure consists of removal of the failed graft and fixation material and spongioplasty followed by revision surgery. The results of revision reconstruction greatly depend on a correct isometric position. We extend the tunnel, if it is in a mild-degree malposition, and create a new, smaller tunnel, if the malposition is severe. Fixation, with either the Rigidfix system or interference screws, is also selected according to the direction and degree of malposition. In the last 3 years, we used exclusively grafts harvested from cadavers. RESULTS: In the group of 24 patients undergoing revision ACL reconstruction, the right knee was treated in 13. The previous ACL reconstruction was done with BTB grafts in 18 patients, with hamstring tendons in 5 patients and one patient underwent reconstruction by Harnach's method in an outside institution. The average time between the primary reconstruction and revision surgery was 27 months (range, 4 to 169 months). We found a surgery-associated error in 12 cases. poor graft restructuring in 3 and involvement of traumatic etiology in 11 cases. One patient underwent revision surgery because of infection. We used one-stage procedures in 20 patients and two-stage procedures in four patients. We fixed the graft with femoral interference screws and the Rigidfix system in 17 and 7 patients, respectively, and with tibial interference screws in 23 patients (absorbable screw completed with cancellous screw in one patient). Only in one patient did we use the tibial Rigidfix system. The average follow-up was 16 months. No infection, thromboembolic disease or synovialitis were recorded. One patient experienced a recurrent failure of the graft and one patient was treated for the Cyclops lesion. The average Lysholm scores were 78.25 (range, 48-97); 87.5 % of the patients were satisfied with the results and the same proportion of patients would undergo the surgery again. The overall results appeared poorer due to the patients in whom revision ACL reconstruction was performed on arthritic joints. DISCUSSION: The outcomes of revision surgery are worse than those in primary reconstruction. We regard allografts with massive bony blocks, adjusted as required, as an optimal method. The risk of disease transmission is low, operative time is shorter, incision is smaller and further trauma to the treated or the other, healthy knee due to graft harvest is avoided. Only patients without signs of gonarthrosis who have motivation are indicated for revision surgery, because they can be expected to cooperate well in the postoperative period. CONCLUSIONS: Revision ACL surgery should be performed by surgical teams with sufficient experience in this field. The crucial point is the analysis of ACL reconstruction failure with further procedure planning. The use of BTB allografts from the local tissue bank proved efficient in our hospital. In the hands of experienced surgeons, allograft offer great prospects for ACL reconstruction with good outcome.

Adult↗

PubMed2004

[Chronic venous insufficiency--outpatient study of risk factors].

The aim of the clinical study was to monitor and analyse possible causes of chronic venous insufficiency (CVI) in a randomised sample of patients with diagnosed CVI. There were 100 patients in the investigated sample, 82 women of an average age of 40.4 years and 18 men of an average age of 42.7 years. Monitoring of risk factors of development and advancement of CVI in our sample of patients showed following results: 1. frequent overweight and obesity (BMI > 25 kg/m2) in women (47.6%) and men (83%) with relatively frequent cases when a patient put on weight more than 5 kg within the last 5 years before development of CVI signs (24.4% of women and 22% of men); 2. a predominance of multiparas (68.3%) over women who have not given a birth or gave birth to 1 child (31.7%), we have found a big percentage of multiparas among both women younger than 40 (40%) and especially older women (> or = 40 years) where the percentage was 75.4%); 3. a positive family history in the majority of our patients with CVI (71%), in 88.7% in a first grade relative; 4. the major part of people in the sample were standing when working (59%), the number of people with sedentary work was high too (32%); 5. smoking admitted only minor part of the CVI patients (27%); 6. significant history of hormonal treatment in the female patients (37.8%), especially among women younger than 40 (48%); 7. other risk factors (accidents and surgeries of lower extremities, recurrent thrombophlebitis) appeared either in a very small percentage of the patients (lower limbs surgeries) or in significantly smaller percentage compared to risks in points 1 to 4 (accidents of lower extremities 20%), recurrent thrombophlebitis 22%).

Adult↗

PubMed2004

[Recurrence of varices in lower extremities].

Authors have done a retrospective analysis of 94 lower extremities in 88 patients examined from 1996 to 2002 for recurrence of varices in lower extremities. The goal was to find out the most frequent causes of recurrence of varices in lower extremities in patients with history of varices surgery referred to venous guidance clinic because of another onset of varices in lower extreminites or clinical signs of chronic venous insufficiency. Reflux was proved in 78 lower extremities from the total number of 94 (83%) in our sample. Isolated reflux was discovered in 59 extremities in saphenofemoral junction (39 extremities), in saphenopopliteal junction (14 extreminies), and in perforators (6 extremities). Combined reflux detected simultaneously in two or three places (SFJ, SPJ, perforators) was found in 19 extremities. In 11 cases the reflux was proved in two places and in 8 cases even in 3 places simultaneously. The main cause of recurrence of varices in lower extremities in our sample was reflux especially in saphenofemoral junction and saphenopopliteal junction. Reflux in perforators was usually accompanied with saphenofemoral and/or saphenopopliteal junctions incompetence. Isolated reflux in perforators was found very rarely (6.4%). The cause of varices recurrence was not disclosed in 17% of cases.

Female↗

PubMed2004

[Can the position of a patient influence the result of an ultrasound examination of venous valve insufficiency?].

The goal of our work was to test sensitivity of the duplex ultrasound examination in making a sapheno-femoral junction diagnosis in lying patients. For this reason we tried to find out whether in ultrasound examination of lumen diameter of the great saphenous vein (B-mode) the speed of blood flow and reflux detection (CFM, pulse Doppler detection) are influenced by the position of a patient when lying and when standing. We examined 70 lower limbs of 70 different patients (47 women and 23 men) in whom the sapheno-femoral junction was not diagnosed when examined in the lying position. The difference in the lumen diameter of the great saphenous vein measured when lying and when standing was statistically significant in our group of patients (p < 0.01). Decreased blood flow when standing was also statistically significant (p < 0.01). In any of the 50 examined lower limbs with the competent sapheno-femoral junction during the Valsalvov's manoeuvre when lying was not proved reflux nor it was proved when standing ( CFM, pulse Doppler detection). The examination of the venous reflux in the lying position is a physiologic, delicate, and at the same time reliable method. The lying position is comfortable for both the patient and the physician and as we proved, compared to ultrasonography in the vertical position, it does not lack needed sensitivity.

Blood Flow Velocity↗

PubMed2003

[Anatomic and hemodynamic changes in the venous vascular bed in the lower extremities with chronic venous insufficiency].

The authors paid attention to revealing as precisely as possible anatomical and haemodynamic conditions in venous vascular bed in the course of ultrasonographic examination of 309 lower extremities with clinical manifestations of chronic venous insufficiency (CVI). A combined reflux in the superficial and deep venous system (53.7%) or isolated reflux in superficial veins (25.9%) proved to be the most frequent pathogenic bases of CVI. Pathophysiology of varices was mostly based on the venous reflux and the primary idiopathic CVI was mostly present (98.1%). The post-thrombotic partial obstruction of the deep venous system (post-thrombotic venous changes on the walls) was demonstrated exceptionally (1.9%). A high coincidence of reflux in the deep and superficial venous system points out to s.c. secondary reflux in the deep veins originating on the basis of primary reflux in the large or small saphena. An attempt was made to clarify, whether the development and frequency of incompetent perforators is directly connected with the presence and seriousness of reflux in the large and small saphena. The presence and severity of large saphena insufficiency does not univocally indicate the presence of dilated or insufficient perforators on the medical side of the crus, where these anastomoses are present most frequently. The large saphena is a long vein typically suffering from segmental insufficiency, i.e. reflux affecting a certain portion, whereas other parts of the vein may be fully competent. Anatomical venous variability and abnormalities on lower extremities were demonstrated in every fifth extremity (62 extremities, 20.1%). Most of them concerned large saphena (39 extremities, 62.8%), small saphena being second (15 extremities, 25.2%). Other anatomical deviations occurred sporadically as solitary findings. In the large saphena, duplication was present most frequently (54.8%). Insufficient variable superficial veins and anatomical venous anomalies were mostly not the only pathogenic basis of CVI, but were predominantly associated with insufficiently in the area of deep veins and perforators (84%). In our cohort there were altogether 55 extremities (17.8%) after the operation on superficial venous system, where relapses of varices were found. The causes of post-operation relapse of varices may be divided into three groups: 1. insufficiency of the large saphena, 2. insufficiency of the small saphena and 3. insufficiency of the deep veins. A combined simultaneous insufficiency in several venous systems was found most frequently (27 extremities, 49.1%). Even though the reflux in the deep veins was demonstrated in 50.9% of these extremities, a combination with the reflux in superficial veins and perforators (49.1%) was present with the exception of one case of isolated insufficiency. The insufficiency of the large and small saphena was clearly the leading single causes (15 extremities, 27.3%) of varix relapses. The patients should never be operated on the venous system of lower extremities without previous detailed ultrasonographic examination. It is the only way to increase probability of the operation success and to decrease the risk of relapses of CVI manifestations.

Chronic Disease↗

PubMed2001

Factorising ligand affinity: a combined thermodynamic and crystallographic study of trypsin and thrombin inhibition.

The binding of a series of low molecular weight ligands towards trypsin and thrombin has been studied by isothermal titration calorimetry and protein crystallography. In a series of congeneric ligands, surprising changes of protonation states occur and are overlaid on the binding process. They result from induced pK(a) shifts depending on the local environment experienced by the ligand and protein functional groups in the complex (induced dielectric fit). They involve additional heat effects that must be corrected before any conclusion on the binding enthalpy (DeltaH) and entropy (DeltaS) can be drawn. After correction, trends in both contributions can be interpreted in structural terms with respect to the hydrogen bond inventory or residual ligand motions. For all inhibitors studied, a strong negative heat capacity change (DeltaC(p)) is detected, thus binding becomes more exothermic and entropically less favourable with increasing temperature. Due to a mutual compensation, Gibbs free energy remains virtually unchanged. The strong negative DeltaC(p) value cannot solely be explained by the removal of hydrophobic surface portions of the protein or ligand from water exposure. Additional contributions must be considered, presumably arising from modulations of the local water structure, changes in vibrational modes or other ordering parameters. For thrombin, smaller negative DeltaC(p) values are observed for ligand binding in the presence of sodium ions compared to the other alkali ions, probably due to stabilising effects on the protein or changes in the bound water structure.

Animals↗

PubMed2001

Computational modelling of inhibitor binding to human thrombin.

Thrombin is an essential protein involved in blood clot formation and an important clinical target, since disturbances of the coagulation process cause serious cardiovascular diseases such as thrombosis. Here we evaluate the performance of a molecular dynamics based method for predicting the binding affinities of different types of human thrombin inhibitors. For a series of eight ligands the method ranks their relative affinities reasonably well. The binding free energy difference between high and low affinity representatives in the test set is quantitatively reproduced, as well as the stereospecificity for a chiral inhibitor. The original parametrisation of this linear interaction energy method requires the addition of a constant energy term in the case of thrombin. This yields a mean unsigned error of 0.68 kcal/mol for the absolute binding free energies. This type of approach is also useful for elucidating three-dimensional structure-activity relationships in terms of microscopic interactions of the ligands with the solvated enzyme.

Antithrombins↗

PubMed2001

[Contribution of coloured duplex ultrasonography to preoperative examination of patients with chronic venous insufficiency].

In a prospective study the authors examined by coloured duplex sonography 76 patients (93 extremities) with chronic venous insufficiency (CVI), before a planned operation of the veins of the lower extremities. Attention was focused on the site of the reflux ( superficial, deep venous system, perforators) and the importance of perforators and congenital venous anomalies in CVI. In the investigated group of patients with CVI a combined reflux was present in several venous systems concurrently, confirmed in 69 extremities (74.2%). In 25 extremities the authors found insufficiency of the saphenofemoral junction along with femoropopliteal reflux. This high grade of reflux coincidence in these two neighbouring anatomical areas indicates so-called secondary reflux. Dilated perforators were found in 65 extremities (70%). These insufficient perforators were most frequently on the median side of the leg, regardless whether in the proximal or distal half. Obviously there is direct correlation between the grade of CVI according to the international clinical classification and the number of incompetent perforators. The ratio of inborn venous anomalies in the development of CVI in the authors group of patients was not statistically significant.

Adult↗

PubMed2000

New proline mimetics: synthesis of thrombin inhibitors incorporating cyclopentane- and cyclopentenedicarboxylic acid templates in the P2 position. Binding conformation investigated by X-ray crystallography.

With the aim to prepare nonpeptidic thrombin inhibitors, the amino acids of the thrombin-inhibiting tripeptide chain D-Phe-Pro-Arg were replaced with isosteres. Arg was replaced with the more rigid P1 truncated p-amidinobenzylamine (Pab), Pro with either cyclopentane-1, 2-dicarboxylic acid or cyclopentene-1,5-dicarboxylic acid, and D-Phe with a series of readily available lipophilic amines. One of the most potent compounds (25, pIC(50) = 6.01) in these series was cocrystallized with thrombin where the X-ray crystal structure provide insight to the structure-activity relationship (SAR).

Anticoagulants↗

PubMed2000

Exploring the chiral space within the active site of alpha-thrombin with a constrained mimic of D-Phe-Pro-Arg--design, synthesis, inhibitory activity, and X-ray structure of an enzyme-inhibitor complex.

An indolizidinone motif with strategically placed substitutents was designed and synthesized as a constrained mimic of D-Phe-Pro-Arg. Low nanomolar inhibition of alpha-thrombin validates the design elements in this inhibitor which also exhibits a 20-fold selectivity for thrombin versus trypsin. An X-ray crystal structure of the inhibitor with alpha-thrombin shows the expected interactions with key amino acids within the active site and some notable changes in positions.

Binding Sites↗

PubMed2000

[Chronic venous insufficiency].

The author investigated in a group of 224 patients selected at random (380 extremities), indicated for different reasons for examination of the venous system of the lower extremities by coloured duplex and triplex sonography, the prevalence, site and clinical manifestations of deep venous insufficiency. Only 21.1% patients indicated for examination on account of clinical signs of deep venous thrombosis had objective signs of the disease, while almost half (47.7%) suffered from venous insufficiency. Venous insufficiency was detected also in a large percentage (59.9%) of patients without clinical symptoms. In the great majority of patients (99.8%) combined insufficiency was found affecting concurrently the femoral and popliteal vein and sometimes also the iliac vein.

Adult↗