[Leukocyte esterase testing for examination of exudate associated with skeletal system diseases. Comparison with cytological and microbiological examinations]

PURPOSE OF THE STUDY

Leukocyte esterase is an enzyme in neutrophils from which it is released into exudate; its detection by colorimetric test strips indicates the presence of neutrophils. This is a rapid method to find whether exudate is of infectious or non-infectious aetiology. The aim of the study was to determine the sensitivity and specificity of leukocyte esterase testing with use of AUTION Sticks (Arkray) for examination of exudates obtained in inflammatory diseases of the skeletal system.

MATERIAL AND METHODS

Exudates associated with skeletal system diseases were collected from 45 patients in the period from July 1st to December 31 st , 2012. Aspirates obtained under sterile conditions were examined for leukocyte esterase; cytological and microbiological examinations were also carried out. For the detection of leukocyte esterase, a drop of aspirate was placed on the reagent zone of a test strip and the resulting colour reaction was read after 90 minutes. Changes in colour were compared with a reference strip provided by the manufacturer. The results were assessed on a five-shade scale as follows: 0, no colour change; 1 to 4, gradual change from light pink to deep purple. The results were compared with those of cytological and microbiological examinations. Shade 4 on the strip corresponded to a positive cytological finding of bacterial infection, and shades 3 and 4 correlated with a positive microbial finding. The sensitivity and specificity of leukocyte esterase testing were statistically evaluated for both comparisons.

RESULTS

Based on the results of cytological and microbiological examinations, an infectious aetiology of exudate was diagnosed in 21 (44.4%) and non-infectious aetiology in 24 (63.6%) patients. With leukocyte esterase reagent strips when shade 4 was taken as a positive result, the sensitivity and specificity of examination was assessed as 0.6190 and 0.9583, respectively. When taking both shade 3 and shade 4 for a positive result, sensitivity and specificity were 0.8571 and 0.8750, respectively. Shades 0 and 1 corresponded to the number of leukocytes in exudate that was no higher than 2 x 10⁹/ml.

DISCUSSION

The detection of leukocyte esterase is a quick and easy examination. It is useful for readily excluding or confirming an infectious aetiology of exudate and can, to some extent, substitute a cytological examination. It can also help to make a quick decision whether one- or two-stage joint reimplantation should be performed and thus eliminate the need of intra-operative histological examination of frozen tissue samples. A drawback of the method was that exudate samples contaminated with blood interfered with an assessment of colour shades. However, this can be avoided by centrifugation of the sample and use of a supernatant free from erythrocytes.

CONCLUSIONS

Diagnosing infectious aetiology of joint exudate or exudate from an abscess using leukocyte esterase reagent strips appears, according to our results, to be a promising, semi-quantitative method with high specificity and sensitivity which is rapid, simple and affordable. It can be useful particularly in out-patient institutions for a quick diagnosis of arthritis; intraoperatively, it can serve as an additional method to other exudate examinations.

[Bone healing capacity in patients undergoing total hip arthroplasty]

PURPOSE OF THE STUDY

To identify some characteristics of bone repair capacity in elderly patients who undergo total hip arthroplasty, which requires good healing ability of bone for implant osteointegration and bone defect repair, particularly if revision arthroplasty is necessary.

MATERIAL AND METHODS

In a group of 27 patients (mean age, 70 ± 7 years; range, 60 to 81 years) a coincidence of osteoarthritis and osteopenia/ osteoporosis was assessed, and mesenchymal stem cells (MSC) were isolated and their numbers, viability and proliferative capacity were evaluated. The MSC populations were examined for their behaviour on bone tissue scaffolds used in orthopaedic surgery for treatment of bone lesions. Each patient underwent bone densitometry examination before total hip arthroplasty. Bone marrow was harvested intra-operatively from the trochanteric region of the femur. From a portion of bone marrow, MSCs were isolated and cultured, and a mononuclear cell concentrate was obtained. Either whole bone marrow or a mononuclear cell concentrate was applied to selected matrices (allograft, demineralised bone matrix, porous beta-tricalcium phosphate (-TCP), pressed hydroxyapatite or calcium sulphate). The production of new collagen and extracellular mineralized matrix were first assessed in expansion medium and, when the production was low, differentiation medium was used.

RESULTS

A coincidence of osteoarthritis and osteopenia/osteoporosis was found in 50% of the patients. All were women with a low body mass index and had been post-menopausal for an average of 23 years. The isolated MSCs contained a high percentage of viable cells (mean, 95%). The mesenchymal cells of patients with osteopenia, as compared with those having normal bone density, showed markedly lower numbers of fibroblastic colony forming units (CFU-F) per ml and had a lower proliferative capacity because the population doubling time during the first four passages was much longer. Of the scaffolds tested, allografts showed the most marked collagen and extracellular mineralized matrix production in expansion medium with either whole bone marrow or a monocyte concentrate; porous -TCP was the best of bone graft substitutes in collagen and extracellular mineralized matrix production by both whole bone marrow and a monocyte concentrate, but this was only in differential medium.

DISCUSSION

The coincidence of ostearthritis with osteopenia/osteoporosis was found in a higher number of our patients than is reported in the literature. Also, a lower MSC proliferative capacity and a low number of CFU-F/ml in the patients with low bone density were interesting findings. Better bone regeneration would generally be achieved with higher MSC numbers and the use of growth factors for stimulation of osteoinduction and angiogenesis. Bone marrow harvesting for MSC isolation, cultivation and subsequent transplantation is currently feasible only in an experiment. A bone marrow aspirate can be applied, but it may not provide a sufficient number of MSCs. In addition to autologous bone grafts, the best collagen production was on allografts. In bone graft substitutes, the porous structure played an important role because on a non-porous material (calcium sulphate) the formation of collagen was very low. There was no difference in collagen and extracellular mineralized matrix production between whole bone marrow and monocyte concentrates.

CONCLUSIONS

Elderly patients have reduced bone healing capacity also because of osteopenia/osteoporosis that occurs more often than it is generally diagnosed, including its coincidence with osteoarthritis. The mesenchymal stem cells isolated from osteopenic bone give a lower number of CFU-F/ml and have a lower proliferative capacity. Of the matrices for new bone formation, allografts showed the best results because collagen was produced already in expansion medium. Of the graft substitutes, porous -TCP was the best, but with collagen production in differential medium. The use of bone marrow aspirate is currently a method of choice in order to increase MSC numbers at the site of bone healing. The use of growth factors is an expensive treatment. To achieve the goal of reliable promotion of osteogenesis with cultured MSC transplantation and use of composite materials with pro-osteogenic and pro-angiogenic factors will still require many experimental and clinical studies.

[Venous thromboembolism prophylaxis after total hip arthroplasty]

PURPOSE OF THE STUDY The authors compare the frequency of thromboembolic disease in the patients receiving prophylactic therapy for 10 days with that in the patients having a prolonged course of preventive treatment recommended for up to 35 days after total hip arthroplasty (THA). MATERIAL The group first evaluated comprised patients undergoing total hip replacement in 2005 and 2006 when enoxaparin was administered for 10 days after surgery. Patients with revision THA were not included. The other group included patients operated on in 2008 who received preventive treatment for 35 post-operative days either with enoxaparin for the whole time, or with enoxaparin for 10 days of hospital stay and then warfarin up to the 35th day after surgery. Patients under going revision THA and those taking other prophylactic agents were not evaluated. METHODS The evaluation of the 2005/6 group included retrospective reviews of medical records, questionnaires sent to the patients and information received from their general practitioners. The 2008 group assessment was based on the information obtained at the patient's follow-up visit at 3 months and completed with data from the questionnaires and medical notes. We focused on the records of distal or proximal deep vein thrombosis in lower extremities and of pulmonary embolism including cases with a fatal outcome. Complications associated with pharmacological prevention were also recorded. RESULTS In the 2005/6 group including 478 patients with an average age of 67.2 years, 23 (4.8 %) patients developed thrombo- embolic disease within 3 months of surgery, six patients had pulmonary embolism of which two of them died. The thromboembolic complication developed at a median of 30.5 post-operative days, i.e., after patient discharge from hospital. In the 2008 group comprising 289 patients with an average age of 63.8 years, three patients (1 %) developed thromboembolic disease within 3 months of surgery. Of them, one woman had deep vein thrombosis in relation to a high factor VIII level; and one developed pulmonary embolism with no fatal outcome. Only the minority of patients (6.9 %) continued enoxaparin therapy, the majority (93.1 %) preferred conversion to warfarin after discharge from hospital. Of the total number of 289 patients evaluated, complications associated with prophylactic treatment were recorded in 52 patients (18 %), name- ly, in 35 patients (12.1 %) it was difficult to establish the correct dosage of warfarin, in 13 patients (4.5 %) warfarin caused minor bleeding or dyspepsia and in 4 patients (1.4 %) major bleeding was recorded. DISCUSSION In our study the patients receiving a 10-day prophylactic therapy showed a slightly higher occurrence of thromboembolic disease within 3 months of THA surgery (4.8 %) than the patients reported by Eikelboom et al. (4.3 %). The results of prolonged prophylactic treatment for at least 35 days were similar, thromboembolic disease was found in 1 % of the patients. The development of thromboembolic event was recorded in our study at a median of 30.5 post-operative days, as compared with a median of 17 days in the study by Liebermann et al. In both studies, most of the thromboembolic complications developed after the patients had been discharged from hospital. The majority of patients chose warfarin for prolonged preventive treatment. There was a high complication rate (18 %) due to not finding the correct warfarin dosage or because of its overdose CONCLUSIONS Patients undergoing THA are at high risk of developing deep vein thrombosis. The risk can be markedly reduced by prolonged pharmacological ophylaxis It is recommended that the use of warfarin for this prolonged therapy should be care- fully considered, because its optimal dose is difficult to establish and its overdose may cause serious complications.

Remodelling of the femoral head after proximal femoral osteotomy for avascular necrosis associated with slipped capital femoral epiphysis

Avascular necrosis is the most devastating complication associated with slipped capital femoral epiphysis. In this case report, we present the clinical and radiological outcome of two patients after proximal femoral osteotomy for avascular necrosis associated with slipped capital femoral epiphysis. The Iowa hip score was used to assess the function. Periodic radiographic observations showed no progression of the collapse, and bone remodelling of the necrotic femoral head. Our evaluation of patients who underwent proximal femoral osteotomy for avascular necrosis prior to collapse of the femoral head suggests that its use resulted in acceptable clinical outcome with bone remodelling of the necrotic area (Fig. 4, Ref. 16).

Mid-term results of one-stage surgical correction of congenital vertical talus

OBJECTIVE

Congenital vertical talus is a rare condition but a well-known cause of severe rigid flatfoot in children. The aim of this study was to evaluate the mid-term clinical and radiological results of one-stage surgical correction in children with congenital vertical talus.

METHODS

Five feet in three children diagnosed with congenital vertical talus who had undergone surgical correction were followed up for a mean period of seven and half years. During this period they were clinically evaluated for subjective complaints and objective findings focused on the range of movement at the ankle joint, position of the hindfoot, and weight-bearing ability of the treated extremity. They were also evaluated on the basis of radiographs of foot and ankle made in standard projections.

RESULTS

All the children had a good functional range of movement and normally shaped foot. The range of movement remains restricted and decreased during the follow-up period without causing any functional disability. All radiological measurements were within normal limits. There was no evidence of necrosis of talus.

CONCLUSION

We recommend operative treatment for congenital vertical talus by the end of first year of age. The range of movement remains restricted and seems to decrease during follow-up, which had a little effect on the functional outcome of the ankle joint (Fig. 3, Tab. 1, Ref. 18). Full Text (Free, PDF) www.bmj.sk.

[Congenital pseudoarthrosis of the clavicle in a boy with Prader-Willi's syndrome]

The authors present the case of a boy with congenital pseudoarthrosis of the right clavicle who met all clinical and auxologic criteria of Prader-Willi's syndrome. Poor cooperation due to mental retardation was the reason for the primary conservative treatment. During this, deformity of the middle clavicle progressed, but without development of subjective complaints and functional deficit. At his 16 years, this cosmetic defect became unacceptable for his parents and, later than it is usually recommended, resection of pseudoarthrosis with plate osteosynthesis and autologous spongioplasty was indicated. The sufficient skeletal maturation and size of both fragments allowed us to perform stable osteosynthesis with the use of a contoured reconstruction plate, without the risk of insufficient osteosynthesis or clavicle fracture after the removal of osteosynthetic material.

[Restricted motion after total knee arthroplasty]

PURPOSE OF THE STUDY

The aim of the study was to ascertain what proportion of patients undergoing total knee arthroplasty (TKA) complain of restricted knee joint motion, and to investigate options for improvement of this situation.

MATERIAL

Our evaluation included a group of 796 patients treated with TKA at our department in the period from January 1, 1990, to December 31, 2004. In all cases, a condylar implant with preservation of the posterior cruciate ligaments was used.

METHODS

In addition to medical history, the range of motion, knee joint malalignment and radiological findings were assessed before surgery. After THA, the type of implant and complications, if any, were recorded, and improvement in joint motion was followed up. Based on the results of Kim et al., flexion contracture equal to or higher than 15 degrees and/or flexion less than 75 degrees were made the criteria of stiffness after THA. Patients with restricted THA motion who had aseptic or septic implant loosening were not included.

RESULTS

Of the 796 evaluated patients, 32 (4.14 %) showed restricted motion after total knee arthroplasty, as assessed by the established criteria. In 16 patients, stiffness defined by these criteria had existed before surgery, and three patients showed an excessive production of adhesions and heterotopic ossifications. In three patients, the implantation procedure resulted in an elevated level of the original joint line and subsequent development of patella infera and increased tension of the posterior cruciate ligament. Four patients declined physical therapy and, in six, the main cause of stiffness could not be found. Seventeen patients did not require surgical therapy for restricted motion; TKA provided significant pain relief and they considered the range of motion achieved to be sufficient. One patient underwent redress 3 months after surgery, but with no success. Repeated releases of adhesions, replacement of a polyethylene liner and revision surgery of the extensor knee structures were performed in 15 patients. In these, the average value of knee flexion increased by 17 degrees only and, in the patients suffering from excessive adhesion production, this value remained almost unchanged. Revision TKA was carried out in four patients, in whom knee joint flexion increased on average by 35 degrees to achieve an average flexion of 83 degrees.

DISCUSSION

Restricted motion after TKA has been reported to range from 1.3 % to 12.0 %, but consistent criteria have not been set up. In our study it was 4.14 %. In agreement with the literature data, one of the reasons was pre-operative restricted motion, which was recorded in 16 of 32 patients. Similarly, also in our patients, biological predisposition to excessive production of fibrocartilage associated with adhesions in all knee joint compartments was the major therapeutic problem. Intra-operative fractures, ligament tears requiring post-operative fixation and unremoved dorsal osteophytes lead to the restriction of knee joint motion. By inadequate resection of articular surface, the original joint line may be at a higher level; this results in an increased tension of the posterior cruciate ligament and patella infera development, both influencing knee flexion. In our study, three patients were affected. Knee joint stiffness can also develop in patients declining physical therapy or in whom this is not correctly performed, often for insufficient analgesia. In contrast to the data reported in the literature, 17 of 32 patients in this study had no need for surgical treatment of restricted knee joint motion. Redress under general anesthesia was not effective. For markedly restricted motion of the knee joint, reimplantation can be recommended or, in less severe cases, an intervention on adjacent soft tissues.

CONCLUSIONS

Restricted motion of the knee joint after TKA is difficult to treat and, therefore, prevention is recommended. This should include thorough conservative treatment of gonarthrosis, early indication for surgery, prevention of elevation in the joint line and consistent rehabilitation with appropriate analgesia. For severe stiffness of the knee joint, as evaluated by the criteria of Kim et al., revision arthroplasty can be recommended.

[Scintigraphic detection of osteoblast activity after implantation of BAS-0 bioactive glass-ceramic material into long bone defects]

PURPOSE OF THE STUDY

The aim of the study was to demonstrate, by three-phase bone scintigraphy, radionuclide uptake at the site of defects in long bones filled with the non-resorbable bioactive glass-ceramic material BAS-0 at a long follow-up.

MATERIAL

Twenty patients, 14 men and 6 women, operated on between 1990 and 2000 for benign bone tumors or tumor-like lesions localized in the femur, tibia or humerus were comprised in the study. Their average age at the time of operation was 14 years (range, 8 to 24). The diagnoses based on histological examination included juvenile bone cysts in 11, aneurysmal bone cyst in five, non-ossifying fibroma in two, and fibrous dysplasia in two patients. The lesions were localized in the femur, humerus and tibia in 11, five and four patients, respectively. The metaphysis was affected in eight and the diaphysis in 12 patients.

METHODS

Clinical, radiological and scintigraphic examinations were carried out at 2 to 12 years (7 years on average) after surgery. The clinical evaluation included subjective complaints and objective findings. Radiographs were made in standard projections and the osteo-integration of glass-ceramic material was investigated. Three-phase bone scans were made and the healthy and the affected limbs in each patient were compared by means of an index. Radionuclide uptake was considered normal when the index value was equal to 1.0, mildly increased at an index value of 1.2, moderately increased at 1.2-1.5 and markedly increased at an index value higher than 1.5.

RESULTS

The clinical evaluation showed that, in the patients with glass-ceramic filling of metaphyses, six had no subjective complaints and two reported transient pain. In the patients with implants in diaphyses, subjective complaints were recorded in nine and no complaints in three patients. No inflammatory changes in soft tissues were found. No restriction in weightbearing of the limb treated was reported by any of the patients. On radiography, 18 patients were free from any disease residue or recurrence. Two patients had a residual defect. The bioactive glass-ceramic material BAS-0 was completely incorporated in all patients. On three-phase bone scans, radionuclide distribution on the flow phase and soft tissue phase was symmetrical in both limbs of all patients. For the metaphyseal location of implants, the delayed images demonstrated physiological radionuclide distribution in one patient, mildly increased distribution (index up to 1.2) in four, increased uptake (index up to 1.5) in two patients, and highly increased uptake (index above 1.5) in one patient. For the diaphyseal location of implants, the delayed scans demonstrated slightly increased radionuclide distribution in two, markedly increased in two and highly increased uptake in eight patients.

DISCUSSION

The tissue during incorporation of a non-resorbable synthetic material is influenced by stress-shielding. This changes local mechanical signals, which has a negative effect on the adjacent bone tissue. Stress accumulating at the interface of a rigid implant and bone tissue may result in pain, and is detected by scintigraphy as an increased nucleotide uptake, particularly in diaphyseal grafts.

CONCLUSIONS

This paper presents problems associated with implantation of the non-resorbable bioactive glass-ceramic material BAS-0 in the treatment of diaphyseal defects of long bones. The results show that, for filling of the defects described herein, non-resorbable glass-ceramic materials are not suitable.

[Musculoskeletal vascular malformations in children]

PURPOSE OF THE STUDY

This study on vascular malformations of the musculoskeletal system in children is concerned with the disease diagnosis and evaluation of treatment results in a group of pediatric patients.

MATERIAL

Eighteen children with musculoskeletal vascular malformations, treated at the Department of Orthopedics in Hradec Králové, were assessed. The relevant data were obtained from their medical notes and the children were examined at the outpatient department.

METHODS

The initial complaints leading to examination at our department, diagnostic methods used and outcomes of vascular malformation treatment were investigated. Special attention was paid to the results of treatment for unequal leg length.

RESULTS

The most frequent initial complaint was a painful, growing, hard tissue mass on either an upper or a lower extremity. In addition to clinical and angiographic diagnostic methods, also Doppler sonography and magnetic resonance imaging were used. Therapy by intervention radiology (selective embolization or sclerotherapy) resulted in reduction of the lesion and subsidence of the signs in 76 % of the patients. In the rest (24 %), the clinical findings did not change. It was necessary to repeat these methods twice to four-times. The best results were achieved by combining intervention radiology and a subsequent excision of the malformation. Of the four patients, only one experienced recurrence after 11 years. Four children were successfully treated for unequal leg length by temporary epiphyseodesis of the proximal tibia which, in one, had to be completed with shortening osteotomy of the proximal femur performed after skeletal maturation.

DISCUSSION

There is great inconsistency in the classification of vascular malformations as well as in views on their therapy. The increasing role of magnetic resonance imaging for the diagnosis of vascular malformations is apparent, and our results fully support this fact. Intervention radiology techniques still remain the prevailing methods of treatment. In our experience, the best results are achieved by their combination with an excision of the lesion. When unequal leg length is treated, temporary epiphyseodesis is recommended; if this is preceded by treatment of the malformation, the final discrepancy in leg length is smaller.

CONCLUSIONS

The correct diagnosis and treatment of vascular malformations and their sequelae are based on inter-disciplinary cooperation. The use of magnetic resonance imaging for diagnosis is recommended. Good results are achieved by a combination of intervention radiology methods with lesion excision. Temporary epiphyseodesis is the method of choice for treatment of unequal leg length.

[Juvenile unstable severe slip of the proximal femoral epiphysis: case report and review of treatment options]

The authors present the case of a severe unstable slip of the proximal femoral epiphysis in a 14-year-old boy. A serious metabolic disorder diagnosed in the boy led to postponement of necessary surgical intervention. The primary development of necrosis of the proximal femoral epiphysis during the 6 months following the slip is reported here. A good outcome was eventually achieved by three-plane valgus, flexion and derotational osteotomy of the femur at second-stage surgery. The authors emphasize the prognostic importance of stability assessment in the displaced epiphysis.

[Treatment of juvenile bone cysts by curettage and filling of the cavity with BAS-0 bioactive glass-ceramic material]

PURPOSE OF THE STUDY

The aim of the study was to evaluate the long-term results of using the bioactive, glass-ceramic material BAS-0 for bone tissue replacement after removal of juvenile bone cysts by curettage.

MATERIAL

Between 1990 and 2000, BAS-0 material was used to fill the cavity after removal of a juvenile bone cyst in 21 patients, 15 males and 6 females, with an average age of 15 years (range 4 to 44 years). Surgical treatment was indicated only in juvenile bone cysts meeting the following criteria: 1) subjective complaints, i. e., pain at activity; 2) X-ray findings of either a) thinning cortical layer with a potential for pathological fracture, particularly in the proximal femur, b) recurrent pathological fractures without apparent healing of the cyst or c) increase in cyst size by 25% within 6 months. In all patients, the diagnosis of a juvenile bone cyst was confirmed by histological examination. Cyst localization was as follows: eight in the humerus, eight in the femur, two in the fibula and one in the ulna, iliac bone and tibia each.

METHODS

After careful curettage of a soft tissue lining from the inner surface of the cystic cavity, the space was filled completely with 2- to 4-mm BAS-0 granules in 15 patients; in the rest granules were applied in a mixture with cancellous bone graft, which was either autologous or allogenic. The former was implanted in one patient, the latter, taken from either the mother or father, was used in four and one patients, respectively. All patients were clinically and radiologically examined during the follow-up period of 3 to 12 years, with an average of 7 years. The clinical evaluation was based on subjective complaints, and on the state of soft tissues in the region of lesion, range of motion in the adjacent joints and the loading capacity of the limb treated. Radiological evaluation was based on standard X-ray images assessed according to the classification system of Neer.

RESULTS

The clinical examination showed that 10 patients were free from subjective complaints, one patient had rest pain, three patients experienced pain when using the limb, four patients reported mild and intermittent pain, two patients were in pain when the whether changed and one patient complained of pain during pregnancy. Objectively, no inflammatory changes of soft tissues were found. Both passive and active motion of the adjacent joints was possible in the full range and the treated limb retained its complete function in all patients. X-ray examination showed excellent results, i. e., no residuum or cysts recurrence, in 16 patients. A residual lesion was present in one patient and cyst recurrence was recorded in four patients.

DISCUSSION

The currently used methods of treatment include corticoid instillation in the cyst, injection of autologous bone marrow, multiple drilling and drainage of the cyst and removal of the cyst with subsequent filling of the cavity with bone graft. In our patients, the bioactive, glass-ceramic material BAS-0 was used to replace either autogenous or allogenic bone grafts. Complete healing of the cyst was achieved in 76% of our patients, which is the result comparable with the literature data.

CONCLUSIONS

Although the therapy of juvenile bone cysts has changed from extensive surgical procedures to less invasive techniques, the curettage of a cyst with subsequent filling of the residual cavity still remains the method of choice in selected patients. Instead of autogenous cancellous bone grafts or allogenic grafts predominantly used for this procedure, the bioactive, glass-ceramic material BAS-0 can be recommended, particularly when the cavity to be filled is located in the metaphysis of a long bone, i. e., in the region subject to great compression.

[Surgical treatment of multiple epiphyseal dysplasia in the hip joints in childhood--short-term results]

PURPOSE OF THE STUDY

The presentation of our results of surgical treatment of the hip joints affected by multiple epiphyseal dysplasia, using the Steel technique of triple osteotomy of the innominate bone in children.

MATERIAL

Twelve hip joints in 11 patients were treated by the Steel technique of triple osteotomy of the innominate bone at our department in the period from 2000 to 2001. However, the evaluation involved only children who also had multiple epiphyseal dysplasia, i.e., two boys and one girl. One of the boys had bilateral surgery with 6.5 months between the operations. The average age at the time of operation was 7.5 years, with a range of 6.5 to 8.5 years. The indication for the Steel osteotomy included severe conditions characterized by flattening and fragmentation of the proximal femoral epiphysis that was insufficiently covered by a dysplastic acetabulum.

METHODS

The clinical evaluation was based on a classification system according to Merle d'Aubigné and Postel. Assessment was made on X-ray films before and after surgery. The follow-up was 17 to 29 months with an average of 2 years.

RESULTS

The average Merle d'Aubigné and Postel score for the operated-on hips was 17.5 points. The maximum attainable value is 18 points; therefore all hips showed excellent clinical outcomes. Radiological examination showed an improvement in Wiberg's center-edge (CE) angle, i.e., from 15 degrees preoperatively to 44 degrees postoperatively (range, 10 to 25 and 41 to 48 degrees, respectively). The surgical treatment resulted in an average increase in the CE angle by 29 degrees, with the range between 21 and 33 degrees according to correction extent.

DISCUSSION

A comparison of our results with those of other authors was not possible since no literature data were available on the Steel osteotomy in patients with multiple epiphyseal dysplasia. In our opinion these children constitute a specific category of patients with this disorder but the size of our group was too small to draw conclusions with a more general validity.

CONCLUSIONS

The Steel triple osteotomy of the innominate bone permits correction of abnormal anatomical conditions of hip joints in severe multiple epiphyseal dysplasia. The nature of this disorder, however, requires a long-term follow-up of the patients treated.

[Personal experience with the basal wedge closed osteotomy of the first metatarsus in hallux valgus]

PURPOSE OF THE STUDY

The authors present their philosophy of the surgical treatment of metatarsus primus varus by oblique basal closed osteotomy of 1st metatarsal, evaluate and generalize the results achieved also with regard to the age of patients.

MATERIAL

The evaluation covers a group of patients operated on for the mentioned static defect since 1995 with a minimal interval of 12 months after the surgery. From this general group a subgroup has been subsequently singled out of children and adolescents up to the age of 18. The general group included 24 patients in which 31 surgeries were performed. The subgroup of children and adolescents comprised 10 patients in which the surgery was performed in 12 feet.

METHODS

Monitored in both group was age, sex, osteotomy laterality, the presence of distal operation. Post-operative monitoring focussed on the following data: the time interval after the operation, subjective satisfaction, range of motion of Ist metatarsophalangeal joint, the incidence of complications. Evaluation covered post-operative correction of individual angles and the shortening of Ist metatarsal by comparison of pre- and post-operative radiograph.

RESULTS

Evaluated in the whole group were 22 patients, in the group of children and adolescents 8 patients, with average time interval of 3 years after the operation. On the basis of the surgery average correction of intermetatarsal angle by 10.5 degrees was achieved in both groups, average correction of valgosity by 18 degrees in the basic group and by 10 degrees in the group of adolescents.

DISCUSSION

The results are evaluated globally on the basis of specialized literature. The authors present their philosophy of the solution of the issues of metatarsus primus varus as a static defect by different surgical techniques, formulate a clear strategy of the use of distal surgery and discuss its efficiency in relation to the patient's age.

CONCLUSION

Oblique basal closed osteotomy of Ist metatarsal within a comprehensive solution of the static defect of hallux valgus is recommended to the broad orthopaedic public as a surgery which in view of the authors can bring good results in children and adolescents. In adults they recommend to indicate this surgery in the mentioned cases in combination with a distal operation.

[Our experience with the removal of infected hip arthroplasty.]

In total 67 infected hip arthroplasties in the group of 26 men and 41 women were removed at the Orthopaedic Clinic in Hradec Králové in the period of 1984-1998.Twenty three patients (11 men and 12 women) showed up for the follow up with an average period of 5 years after the removal of the implant.The follow up consisted in the examination of the range of movements and a protocol was filled in. The acquired data then served for the calculation of the Haris score of the hip joints operated on. Seven patients had no pain, slight or moderate pain not affecting the daily routine activities were reported by 10 patients. However, none of the patients was able to walk without support and a significant shortening of the lower limb operated on was found with the average value of 5 cm. The average rating based on the total evaluation of the hip joint according to the Harris Hip Score was 57,5 points, no hip joint after the removal of arthroplasty was assessed as excellent. Removal of hip arthroplasty as a final solution of periprothetic infect remains at present one of the possibilities of the treatment, however, not even this operation is quite without a risk of the recurrence of infect. In the group of 61 patients followed up after the removal of infected hip arthroplasty we recorded retrospectively in the average interval of 3 years and 4 months after the extraction 11 cases of the recurrence of infect (i. e. 18 %). Key words: infected hip arthroplasty, removal of infected hip arthroplasty.

[BAS-0 Bioactive Glass-ceramic as a Bony Tissue Replacement (Clinical Experience after a Longterm Interval after Application).]

The authors present evaluation of the application of BAS-0 bioactive glass-ceramics at the Orthopaedic Clinic in Hradec Králové in the period 1990-1997. Bioactive glass-ceramics was implanted in total in 106 patients of which in 38 patients during THR revision surgery and in 20 patients with bone infection. Of 48 patients with bioactive glass-ceramics used as a bony tissue replacement in filling the defects during operations of benign tumours or tumours of similar affections and in the surgical treatment of fractures of tibial plateau, 31 were followed up for the period ranging between 3 months to 6 years (average 3,2 years). In all patients followed the soft tissue surrounding the implanted glass-ceramics shows no reaction, radiographs showed bone trabeculae continuously pass over to the surface of the glass-ceramic particles and in no case we recorded periostal reaction or any other X-ray changes showing irritation, loosening or extrusion of this bone replacement. Key words: bioactive glass-ceramics, benign bone tumours and tumour-like affections, fractures of tibial plateau.

[Recostruction of Extensive Acetabular Defects by Bioactive Glass Ceramics in Re-operations of Total Endoprostheses.]

The authors made 37 revisions on account of aseptic loosening of total endoprostheses of the hip joint using bioactive glass ceramics BAS-0 of Lasak Co. Prague. For reconstruction of large defects of the acetabulum they used a combination of different types of anti-protrusion metal baskets and granules from this material. In some instances the glass ceramic material was combined with autologous spongiosa. The longest follow-up period is over 4 years. In no instance loosening of the glass ceramic material occurred or its expulsion. All reconstructed sockets of hip joints were burdened by the patients from the third month after surgery. Harris Hip Score before operation was on average 52. During the last checkups of the patients it reached the level of 86. The authors mention complications associated with the procedure. The advantages and disadvantages of the procedure are discussed. Key words: bioactive glass ceramics, reconstruction of acetabular defect, aseptic loosening of endoprosthesis.

[Tricalcium Phosphate as a Bone Tissue Substitute (testing of biological properties in animal experiments.]

The authors present the results of implantations of tricalcium phosphate of LASAK Co. Prague into defects of the long bones of 12 experimental dogs after an exposure time of 2,4 and 8 months. Seven modifications of the mentioned material were used in the form of granules, prisms and powder in a total of 18 implantations. In all instances specimens after implantation were taken which did not have macroscopic or microscopic signs of inflammatory reaction. X-ray did not reveal any clear spots round the material, signalizing an inflammatory of fibrous reaction. Microscopic examination confirmed excellent tolerance of the surrounding live tissue and osteoblastic activity in the immediate vicinity of the implants. After 8 months tricalcium phosphate was still present and only a smaller size of the particles suggested its absorbability. In the discussion the authors mention some possibilities of the clinical use of this material and contemplate on the problem of absorption. Key words: bone defect, tricalcium phosphate, bioactive glass ceramics, osteoinduction, absorbability of material.

[Hemiarthroplasty of the knee joint, possibilities and limitations of its use.]

In the submitted paper the authors evaluate the results of hemiarthroplasty of the knee joint at the Orthopaedic Clinic in Hradec Králové in 1985-1992. To a total of 40 patients 53 sledge-shaped endoprostheses of Link Co. were administered. Twenty-five patients with 30 endoprostheses and a mean follow up period of 5.6 years were checked. For evaluation criteria published by Joseph and Kaufman were used. In 60 % the results were excellent or good, in 30 % satisfactory and in 10 % unsatisfactory. Re-operations were performed in two patients. On the postoperative X-rays the authors examined radiological signs of loosening of the endoprostheses. They did not find a statistically significant correlation between clearing round the endoprosthesis nor clinical signs of its loosening. Key word: hemiarthroplasty of the knee joint.