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J Stehlík

Publications and source records attributed to J Stehlík.

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↗
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

[Total knee arthroplasty with the Beznoska S.V.L. implant: short-term results].

PURPOSE OF THE STUDY: To present and evaluate short-term clinical results of total knee arthroplasty using the Beznoska S. V. L. implant and to compare them with the results of other authors. MATERIAL: In the period from April 1997 to October 2002, 197 total knee replacements with a S. V. L. implant were carried out of these, 164 implants were evaluated in 146 patients. This group comprised 116 women (78 %) and 48 men (22 %), with an average age of 73.6 years (range, 63 to 83) at the time of surgery. The patients were evaluated on average at 4.3 years (range, 1.5 to 6.5) after surgery. Indications for replacement were primary knee arthritis in 151, rheumatoid arthritis in nine, secondary post-traumatic arthritis in two and conditions following tibial osteotomy in two cases. METHODS: The results were evaluated using the Knee Society Clinical Rating System which consists of three parts: Knee Score (100 points), Knee Function Score (100 points) and Categorical Score (allocating patients to three groups according to function deficiencies of other joints). X-ray images were examined for implant position, the presence of radiolucent lines and patellar position, and assessed on the basis of the Knee Society Total Knee Arthroplasty Roentgenographic and Scoring System. RESULTS: No or mild pain in the treated joint was reported by 90.2 % of the patients. Severe pain was not recorded at all. The average maximal range of flexion increased from 94 degrees preoperatively to 104 degrees post-operatively. The range of motion more than 90 degrees and that of more than 100 degrees were recorded in 96 % and 76.8 % of the operated-on knees, respectively. An anteroposterior mild instability of 5 to 10 mm was objectively found in nine knees (5.5 %) a medial laxity of 6 to 9 degrees was detected in 36 knees (22 %) and that of 10 to 15 degrees only in one patient. Severe instability was not recorded. The leg axis achieved after surgery was on average 6.4 degrees valgus, compared to 5.5 degrees varus before surgery. The total Knee Score was 85.1 points (range, 53 to 100), with excellent or good outcomes in 151 knee replacements (92 %). Six patients (4.6 %) reported failure to walk a distance of more than 500 m on an even terrain, six (4.6 %) could not manage the stairs and five (3 %) required a permanent use of two crutches or a walking frame. The average function score, which also included the effect of concomitant diseases of other joints, was 64.9 points (range, 40 to 100), with excellent or very good outcomes being achieved in 64 implants (39 %). On X-ray examination of implant position in anteroposterior projection, the average valgus angle of the femoral component was 94.8 degrees (range, 92 to 100) and the tibial angle was 90.3 degrees (range, 85 to 94). In lateral projection the flexion angle of the femoral component was 2.5 degrees (-1 to 6) and the average dorsal tilt of the tibia was 3 degrees. Distinct radiolucent lines up to 1 mm in width were seen in the femoral component in 10 (6 %) cases and in the tibial component in 27 (16.5 %) cases, this occurred in zones 1, 2 or 4. Wider lines of 2 mm were present in both components in 6 (3 %) cases. Radiolucent lines were recorded in 43 (26 %) implants. The patella examined in axial projection was correctly centered in 140 (85 %) total knee replacements. Eleven patients reported femoropatellar problems and, in three of them, patella replacement was subsequently performed. No aseptic loosening occurred and one deep infection (0.6 %) was treated by a two-stage reimplantation. DISCUSSION: Excellent to very good outcomes, with an average Knee Score of 85.1 points, were achieved in 92 % of the implants. The total outcome characterized by an average Functional Score of 64.9 points was related to a higher average age of our patients and a high proportion of patients with diseases of other joints, which interfered with overall mobility and self-sufficiency. The results of implant position evaluation, based on X-ray examination, showed good values, which testifies to the use of an appropriate surgical technique and accuracy of the instrumentation applied. The occurrence of radiolucent lines was low, as was the number of complications. Our results are comparable with those reported in the literature. CONCLUSIONS: Our short-term evaluation shows that the S. V. L. implant is fully useful for total knee replacement in patients of higher age categories.

Aged↗
PubMed2002

[Combined method of treating dislocated fractures of the calcaneus].

PURPOSE OF THE STUDY: The treatment of dislocated intraarticular fractures of calcaneus is still an unsolved chapter of traumatology. Our own poor long-term results of a purely conservative procedure has led us to develop a combined method of a direct and indirect reduction of calcaneus with the subsequent stabilization which we have been using since 1994. The basic principle of the method consists in the combination of a direct reduction of dislocated fragments of articular surfaces and indirect of calcaneus as a whole with the subsequent transfixation of calcaneus by K-wires. MATERIAL: In the period of 1994-2001 we have treated in total 261 patients with 302 fractures of calcaneus, of which 218 were men (83.5%) and 43 women (16.5%) in the age range from 13 to 82 years (average age 45.1 years). By our own surgical method we treated 213 patients with 248 fractures, of which 180 were men (84.5%) and 33 women (15.5%) in the age range of 13-79 years (average age 44.8 years). Conservatively handled were 54 fracture in 48 patients. In the long-term followed up group we included 160 patients with 187 fractures operated on by identical method observing a minimum two-year interval after the operation. Of them 134 were men (83.8%) and 26 women (16.2%) in the age range of 15-75 years (average age 44.3 years). Of 248 operated on fractures of calcaneus 159 were joint-depression type (64.1%), 61 tongue type (24.6%) and 28 comminuted (11.3%) types of fractures. The time interval between the injury and operation ranged between 6 hours and 3 weeks (average 18.5 hours), however most patients we operated on on the day of injury. METHODS: The basic principle of the method was a combination of a direct reduction of dislocated fragments of articular surfaces and indirect reduction of the calcaneus as a whole with a subsequent transfixation of the calcaneus by K-wires. After draping and setting of the image intensifier we proceeded to the actual surgery and divided the whole procedure of reduction and subsequent stabilization into 4 phases: Phase I--traction Phase II--elevation Phase III--compression Phase IV--transfixation In the first traction phase we inserted K-wire transversely through the distal-posterior edge of the calcaneus and connected it to the U-handle in order to achieve a proper effect of the traction. By traction distally along the long axis of the limb we restored the height and length of the calcaneus. Simultaneous pendular movements in eversion/inversion direction released the fragments and considerably facilitated the subsequent reduction. In the second, elevation phase the procedure differed according to individual types of fracture. In joint-depression type we inserted a blunt Steinmann pin or better a curved transpedicular elevator under the dislocated posterior articular surface through skin plantar stab incision and an ever-present primary transverse line of the fracture. In the tongue type of fracture we first introduced in the second phase a thick K-wire (3 mm) along the long axis of the tongue fragment and reduce the fragment by leverage elevation with a simultaneous continuous U-handle traction. After obtaining the desirable position we fixed the fragment by a K-wire vertically introduced from the upper part of calcaneal tuberosity (anteriorly and laterally from the origin of the Achilles tendon) towards the planta. If the medial part of the posterior articular surface remained dislocated we finished its reduction by means of elevator as in the preceding type of the fracture. The third and fourth phases of the surgical procedure was again identical for both types of fractures. In the third, compression phase we performed manually lateral compression of fragments under permanent traction. In the fourth, transfixation phase we first transfixed the reduced position of fragments formed by the primary longitudinal and transverse line. Under continuous radiograph checking in the lateral projection we inserted K-wires gradually from the lateral aspect, about 1.5 cm beneath the lateral malleolus into sustentacular fragment. Additional, mostly 2 K-wires we inserted under continuous traction and counter-traction along the long axis of the calcaneus and as the last step we drilled K-wires from the plantar side from calcaneal tuberosity into the fragments of the posterior articular surface. RESULTS: In the group of long-term followed up patients we evaluated the Creighton-Nebraska Health Foundation score in 160 patients who were on average 43.4 months after operation. The obtained values of the score ranged between 63-100 points with the average of 83.9 points. In 27 patients the result was very good (16.9%), in 89 patients good (55.6%), in 24 patients fair (15.0%) and in 20 patients the result was poor (12.5%). DISCUSSION: The first results of our method of 1998 have proved that it is necessary to combine the basic procedures of direct reduction of joint fragments, i.e. restoration of the calcaneus as a whole, namely in a strictly recommended sequence with a subsequent transfixation by K-wires. We do not use surgical procedures with open reduction and internal fixation (ORIF) differing mutually by the chosen surgical approach and the type of internal fixation used. As compared to ORIF our method has a significantly broader indication range. It can be used for the operation of patients regardless of the age, presence of associated diseases (diabetes, vascular affection) or local affection (a marked oedema, haematoma, non-infected skin blisters). The comparison of the general outcomes of the treatment in our group of patients, 72.5% of excellent and good results and only 12.5 of poor results, corresponds with the values of equally extensive foreign group of patients. In addition, as concerns the number of the incidence of deep infects in closed fractures (0.8%) the values in our group are in comparison several times lower and amputation of the limb was not necessary in any of the cases. It should be also noted that our group of patients has only a minimal indication limitation and operated on are also risk patients who never get in "filtered" groups treated by open method. Therefore it may be stated that the general results are in case of our method markedly better. CONCLUSION: The proposed method requires neither a specialist nor any expensive technical equipment and as a result it may be used both at orthopaedic and surgical departments and due to its undemanding nature and short hospitalization it is also very acceptable from the economic viewpoint.

Adolescent↗
PubMed2001

[Personal experience with the Wagner revision stem in hip joint reoperations].

PURPOSE OF THE STUDY: Since 1993 we have been using the Wagner revision stem, initially in the length of 265 mm and 305 mm and later also the short stem of 190 mm and 225 mm, for revision surgery with the destruction of proximal femur. This technique provided for primary fixation of the stem in the unaffected femoral bone and creates prerequisites for the bone regeneration and bone formation of the destructed host bone by the loosened implant in the metaphysis and proximal part of diaphysis. MATERIAL AND METHODS: In the period of 1993-1998 we operated on and followed a group of 35 patients (18 men and 17 women), average age 69 years (age range, 52-89). In 32 patients we performed revision surgery of Poldi-Cech stem, twice CF-30 stem and once cementless J + J stem. The average time interval between the primary operation and revision surgery was 10 years (range, 2-22 years). Thirty patients had to be reoperated due to aseptic loosening of the implant and five patients due to infection. Wagner stem was applied no sooner than 6 months after the infect had healed. In the application of the short stem (190 mm or 220 mm) we use Bauer approach (4 times) or extended Bauer approach (4 times), in long stems we use transfemoral approach in our modification: osteotomy is performed from the extended Bauer approach in the frontal plane and the anterior part of femoral cortex is retracted. The retracted anterior part of the femoral cortex femoral bone is fixed back only by hemi-wire loops. RESULTS: Of the total number of 35 operated on 2 patients required revision surgery due to the subsidence of the stem and one removal of the stem in case of complete protrusion of the cup into pelvis. In short stems there were no post-operative complications. Dislocation of the hip occurred in three patients after the implantation of the long stem. After the closed reduction the surgery was not necessary. In one patient there developed an infection 5 months after operation. It was a hematogenous infect resulting from a pyogenic affection of the operated on limb. A two-step revision surgery was performed with a spacer and a subsequent reimplantation of a stem of greater diameter. DISCUSSION: Wagner presents results of 69 patients after the application of his own stem 265 mm and 305 mm long. In 62 patients of the total number no subsidence was encountered, in two cases post-operative dislocation was recorded. Isakson et al. do not consider subsidence resulting in fixation of the stem as a significant factor and correct the difference in the length by shoes. They point out that this method is suitable for the solution of defects of proximal femur in such a way that the implant has a stable fixation and provides for bone formation, restoration of the destructed part of proximal femur in the extent of the original loosened stem. We consider the Wagner technique a significant contribution to the solution of these severe complications. As compared to Wagner, instead of the sagittal plane we perform transfemoral approach in the frontal--horizontal plane which allows operation in the supine position of the patient and a more precise replacement of the cup. In our group of patients we incorrectly used the long stem without transfemoral approach in 3 patients, one patient required revision surgery, in the remaining two patients the period of osteointegration of the stem was substantially longer. CONCLUSION: The Wagner revision stem allows treatment of the destructed proximal part of femur caused by loosening of the stem and polyethylene granuloma. Of great importance is the preservation of the contact of muscles and residual parts of the destructed femoral bone. The short version of the Wagner stem (190 mm and 225 mm) has fully justified itself in revision surgeries of the replacement of the stem in cases of a preserved bone stock. Wagner stem sufficiently bridges the trepanation hole and is safely engaged in the femoral shaft. The long Wagner stem (265 mm and 305 mm) has proved suitable in revision surgeries in cases of thinner cortex and defects in the whole length of the loosened implant. This stem requires a transfemoral approach and a perfect stable anchoring of the stem in the stable skeleton of the femoral shaft. Bone formation and remodelling of proximal femur does not affect the length of the limb. Of great importance is its accurate planning. This procedure is a considerable contribution to the solution of these severe complications.

Aged↗
PubMed1998

[Our method of treatment of dislocated fractures of the heel bone (preliminary report)].

The authors present first experience with their method of treatment of displaced fractures of calcaneus. The method is based on the combination of direct and indirect reposition of fragments and exact fixation with K-wires. Axial and AP X-ray and 2 plane CT scan are indispensible conditions for operation planning. The procedure can be divided into 4 phases: traction, elevation, compression, transfixation. Up till now 65 patients have been treated with this method. 20 patients with 24 fractures were evaluated according to the Creighton-Nebraska Health Foundation score in the interval 24 months after the operation. The average value of the score was 96.6 points, 16 patients were evaluated as excellent, in 2 patients the result was good.

Adolescent↗
PubMed1997

Application of numerical modelling of osteotomy to orthopaedic practice.

During the development of an osteoarthritic hip joint, osteophytes, cysts as well as arthrosis originate on the contact boundary between the femoral head and the acetabulum in highly loaded human joints. The purpose of proximal femur osteotomy is to bring the femoral head into a new position inside the acetabulum. The corrective options of intertrochanteric osteotomy most frequently used in orthopaedic practice are valgization, varization, displacements, oblique displacements, lateralization, extension, rotation or shortening of the shaft. The present widespread tomographic measurement methods, such as computer tomography (CT), magnetic resonance imaging (MRI) and 2D or 3D reconstruction involve the simulation of surgical problems of osteotomy, as well as the simulation of the reconstruction of the function of the hip joint after the operation. The results of numerical modelling of osteotomy concerning contact problems, will be presented in the contribution.

Acetabulum↗
PubMed1996

Morphological features of bone healing under the effect of collagen-graft-glycosaminoglycan copolymer supplemented with the tripeptide Gly-His-Lys.

The authors prepared 7.5% and 12.5% collagen gel, and supplemented it with the tripeptide Gly-His-Lys (GHK), perfloxacine and hypersulphated glycosaminoglycan (HSGAG). By means of 125l marking, its absorption was followed from small polyurethane sponges placed under the skin of rats. The absorption of gel without HSGAG was found to be faster. Antibodies against collagen (type I, II and III) or collagen gel were generated either in rabbits or in minipigs, in which collagen gel was tested. Microbiological tests proved the sterility of the collagen gel. The collagen gel supplemented with GHK, pefloxacine and HSGAG was named Colladel, and was used in a model experiment in guinea-pigs for filling artificially created bone defects in diaphyses of femurs, and with cementless endoprostheses. The healing process was followed by means of RTG and NMR, and histologically. The slowest healing process was found in unfilled bone defects. Defects filled with Colladel without GHK healed substantially more quickly, and the most accelerated healing was connected with complete Colladel application. When Colladel was used with cementless endoprostheses, vivid osteogenic activity at the interface of trabecular bone and metal stem was detectable in the course of the experiment.

4-Quinolones↗
PubMed1995

Free cross leg flap as a method of reconstruction of soft tissues defects.

Authors demonstrate on clinical cases the possibility of reconstruction of soft leg tissues by the use of the so called free cross flap. This method appears to be convenient in cases where there are no suitable recipient vessels within reach on the injured extremity and where the defect is of such an extent that the conventional cross flap does not provide sufficient amount of tissue.

Adolescent↗
PubMed1994

[Trans-pedicular stabilization of fractures of the thoraco-lumbar spine. I].

Proceeding from the literature survey and on the basis of his own experience the author presents a current concept review of the problems of the transpedicular stabilization in fractures of the thoracolumbar spine. Individual chapters are devoted to the biomechanics and transpedicular screw placement, classification of implants and to the transpedicular operations on the injured vertebral body. Based on both his own experience and survey of the literature the author recommends the following: in order to increase the stability of osteosynthesis to place transpedicular screw in anteromedial direction (Magerl approach) close to the anterior cortex of the vertebral body or (in case of osteoporosis) to performate it by tip of the screw; in fractures with the compression of vertebral body (mainly in case of burst fractures) to perform transpedicular reduction and cancellous bone grafting after Daniaux and Dick. Out of the implants so far used the author considers the best Fixateur intern (Dick) allowing faultless reduction as well as a longterm stabilization of the fracture.

Fracture Fixation, Internal↗
PubMed1994

[Transpedicular stabilization in fractures of the thoracolumbar spine. II].

Proceeding from the literature survey and on the basis of his own experience the author presents a current concept review of the problems of the transpedicular stabilization in fractures of the thoracolumbar spine. Individual chapters are devoted to the biomechanics and transpedicular screw placement, classification of implants and to the transpedicular operations on the injured vertebral body. Based on both his own experience and survey of the literature the author recommends the following: in order to increase the stability of osteosynthesis to place transpedicular screw in anteromedial direction (Magerl approach) close to the anterior cortex of the vertebral body or (in case of osteoporosis) to perforate it by tip of the screw. in fractures with the compression of vertebral body (mainly in case of burst fractures) to perform transpedicular reduction and cancellous bone grafting after Daniaux and Dick. Out of the implants so far used the author considers the best Fixateur interne (Dick) allowing facultless reduction as well as a longterm stabilization of the fracture.

Bone Screws↗
PubMed1993

[Candida sepsis. II. Laboratory methods and their clinical importance].

The authors present experience assembled at the septic station of the infectious department and mycological laboratory as regards interpretation of results of laboratory examinations in invasive Candida infections and they summarize the most important data from the literature on the correct collection of material, evaluation of microscopic and cultivation findings, the importance of examinations and haemocultures, venous catheters, urine, faeces and sputum. They analyze problems of serological examination and direct detection of antigen, they recommend mycological monitoring of patients at risk. In the conclusion they summarize the most frequent mistakes as regards the evaluation of laboratory results and indications of treatment.

Candida albicans↗