Growth of methicillin-resistant Staphylococcus aureus during raw milk soft cheese-production and the inhibitory effect of starter cultures

The consumption of raw milk or raw milk products might be a potential risk factor for the transmission of methicillin-resistant Staphylococcus aureus (MRSA). Therefore, we studied MRSA growth during raw milk soft cheese-production. Furthermore, we investigated the inhibitory effect of four starter cultures (Lactococcus lactis, Lacticaseibacillus rhamnosus, Lactiplantibacillus plantarum, Lactobacillus helveticus) on the growth of MRSA in a spot-agar-assay and in raw milk co-culture following a cheesemaking temperature profile. During the initial phases of raw milk cheese-production, MRSA counts increased by 2 log units. In the ripening phase, MRSA counts only dropped slightly and remained high up to the end of the storage. Comparable MRSA counts were found in the rind and core and strain-specific differences in survival were observed. In the spot-agar-assay, all four starter cultures showed strong or intermediate inhibition of MRSA growth. In contrast, in raw milk, only Lactococcus lactis strongly inhibited MRSA, whereas all other starter cultures only had minor inhibitory effects on MRSA growth. Our results indicate that MRSA follow a similar growth pattern as described for other S. aureus during raw milk soft cheese-production and illustrate the potential use of appropriate starter cultures to inhibit MRSA growth during the production of raw milk cheese.

[Current Options of Rheumatosurgery of the Hand and Wrist]

Rheumatosurgery is a discipline managing the symptoms of rheumatoid arthritis of the musculoskeletal system. In a vast number of patients this disease starts in the wrist and hand. The portfolio of surgical procedures performed on the skeleton and soft tissues in these regions can be divided into two groups that, however, often times overlap in practice. Commonly, a combination of these surgical interventions is used. The surgical management should commence with prophylactic interventions that aim to slow down the development of rheumatoid deformities. These are followed by reconstructive surgery which shall manage the already developed rheumatoid deformities and their complications. The prophylactic interventions include early and late synovectomy, peritenosynovectomy, tenodeses, tendon transpositions and limited arthrodeses. The reconstructive surgery procedures comprise osteotomy, resection procedures, alloplasties, total arthrodesis and tendon reconstructions. Key words: rheumatoid arthritis, rheumatosurgery, hand, wrist.

[Our Initial Experience with Radial Head Replacement]

PURPOSE OF THE STUDY A single treatment procedure for multi-fragmented non-reconstructible radial head fractures has not been established as of yet. One of the available treatment methods can be the implantation of an endoprosthesis, but there is no consensus in available publications. We therefore decided to trial their use and to obtain our own experience. This study includes the evaluation of the outcomes of treatment at one year postoperatively. MATERIAL AND METHODS Our group included eight patients (six men and two women with the mean age of 46.1 years, ranging from 24 to 80 years) with an implanted ExploR® (Biomet, U.S.A.) radial head endoprosthesis. The radial head fractures were of three to six fragment type, in six cases there was an associated dislocation. In one case, there was a concomitant diaphyseal fracture of the ulna which was stabilised using the Würzburger intramedullary nail (TRUE-Instrumente GmbH, Germany). The surgical approach through Kocher's interval was used in all cases. Fixation using a plaster splint from metacarpophalangeal joints up to the shoulder was applied postoperatively for a period of two to three weeks in all patients. RESULTS The assessment was carried out on average at 13 months (range 12-15 months) after the surgery. The mean elbow flexion was 7.5° to 136.9°, forearm supination was 0° to 86.3° and forearm pronation was 0° to 80.0°. The elbow joint maintained its stability in all cases. Neurological deficit did not develop in any of the patients. The DASH score reached the mean value of 11.2. The mean value of the Mayo Elbow Performance Score (MEPS) was 92.5. Radiological signs of implant loosening were observed in three cases. In two of these cases, bone resorption occurred surrounding the stem of endoprosthesis. In two patients, heterotopic ossification were found and in one case, an oversized endoprosthesis head was implanted. No recurrent elbow dislocation was seen in any of the patients. DISCUSSION The application of radial head endoprosthesis is indicated for comminuted radial head fractures and concurrent ligamentous injuries (fracture-dislocations, terrible triad, Essex-Lopresti injuries). Equally good functional outcomes may be achieved with the use of an endoprosthesis as by osteosynthesis. The complications of arthroplasty tend to be late, at ten or more years postoperatively. Further follow-up of our patients will be necessary, along with a further expansion of our group of patients. Complications may be prevented with the use of longer-stem implants and more up-to-date cemented bipolar endoprostheses which, according to recent studies, achieve equally good functional outcomes and reduce the number of necessary revision surgeries - implant removal in particular. CONCLUSIONS In treating the comminuted radial head fractures, the implantation of endoprosthesis helps to achieve a quick restoration of the elbow joint function along with good functional outcomes and prevents instabilities in case of associated ligamentous injuries. A basic precondition for successful treatment is the choice of an adequate size head. The radiological signs of stem loosening do not necessarily have to affect the functional outcomes. Key words: fracture, radial head, endoprosthesis, Kocher approach.

[Indication for Radial Head Resection in Traumatology]

PURPOSE OF THE STUDY The aim of our study was to determine the indications for radial head resection at the present day. MATERIAL AND METHODS The radial head resection was performed in the period from 2008 to 2015 in 63 patients divided into three groups. The first group marked "CR" consisted of 33 patients with the Mason type III fracture. The second group marked "CRLUX" included 20 patients with the Mason-Johnston type IV fracture, i.e. a fracture of the proximal end of the radius with a dislocation of the elbow joint. Within this group, in 8 cases also the coronoid process of the ulna was fractured. The third group marked as "CRFR " was composed of 10 patients, in whom concomitant proximal radial fracture and proximal ulna fracture occurred, and in all the cases osteosynthesis of the proximal ulna fracture was performed. For subjective evaluation of the upper limb function the DASH score was used. The functional outcomes were expressed using the Mayo Elbow Performance Score (MEPS). Moreover, the range of motion in the elbow and forearm (flexion and extension of the elbow, pronation and supination of the forearm), elbow joint stability and presence of neurological lesions were assessed. The radiological assessment consisted of measuring the proximalization of the radius, monitoring the heterotopic ossifications, signs of arthrosis, recurrent re-dislocation of elbow and proximal ulna fracture healing. RESULTS The mean follow-up period was 17.6 months (range of 13.2 - 81.0 months, SD 11.5). The mean DASH score was 15.6 (range of 0 - 60, SD 15.3) in the CR group, 12.0 (range of 0 - 52.7, SD 16.7) in the CRLUX group and 17.5 (range of 0 - 62.3, SD 12.8) in the CRFRgroup. A considerably limited mobility was seen in the CR group in three cases (9.1%), in the CRLUX group in four cases (20.0 %) and in the CRFRgroup in two cases (20.0 %). The MEPS score showed similar results in all the groups, excellent and good results were always achieved in more than ¾ of patients. Elbow stiffness did not develop in any of the patients. In the CRLUXgroup, one case a re-dislocation of the elbow occurred. In the CRFRgroup, in one case an injury to the interosseous membrane and distal radioulnar joint ligaments failed to be diagnosed and a clinically significant proximalization of the radius (9 mm shift) occurred, which subsequently required ulnar shortening osteotomy. Additional two proximalization of the radius with a minor shift (2 and 3 mm) in the group CR and CRLUX were not associated with major mobility limitations. Heterotopic ossification occurred in a total of 11 cases (17.5 %) and in four cases it caused major mobility limitations (two cases in the CR group, one case in the CRLUX and CRFRgroups). Surgical treatment was indicated in one case with a good functional effect, in one case the range of motion improved after actinotherapy. In the CR group, one case of neuroma of the radial nerve developed and the condition was treated by sural nerve transplantation. DISCUSSION The current papers view simple proximal radial resection positively unless elbow instability is present. In literature, references are made to serious, mainly late complications (arthrosis, valgus deformity, considerable limitation of elbow range of motion, proximal radial-ulnar synostosis, proximalization of the radius and symptomatic radioulnar joint subluxation). Resection of the radial head is contraindicated in the so called "terrible triad" of the elbow, i.e. the combination of a radial head fracture, a coronoid process fracture and elbow dislocation, and in the Essex-Lopresti injury, i.e. a radial head fracture with a concomitant tear of the interosseous membrane of the forearm and radioulnar joint dislocation. The Essex-Lopresti injury is often overlooked during the initial examination, proximalization of the radius can occur gradually only after several months. CONCLUSIONS The evaluation of our groups of patients showed that the radial head resection can be a good treatment option with no serious early complications in the Mason type III fractures. Serious complications occurred only in cases when the fracture was accompanied by a concomitant injury, i.e. in the Mason-Johnson type IV fractures and in concomitant proximal ulna fracture. When an indication for radial head resection is made, it is essential to correctly diagnose the injury which is clearly a contraindication to this method, i.e. the Essex-Lopresti and the "terrible triad" injuries. Key words: fracture, radial head, resection.

[Surgical treatment of midshaft clavicular fractures using intramedullary nail]

INTRODUCTION

The aim of our study was to assess treatment outcomes in fractures of the middle part of the clavicle using an intramedullary nail.

METHODS

We have evaluated a total of 58 patients with a clavicle bone fracture stabilized by the Hofer Clavicula Pin implant (HCP, Hofer GmbH & Co KG, Fürstenfeld, Germany). A static implant was used in 43 cases, and a dynamic implant was used in the remaining 15. The mean age of patients was 39.1 years (range 1871, SD 4.4), the male-to-female ratio being 43:15. The right collarbone was broken in 26 patients, the left one in 32. The average time between accident and surgery was 10.2 days (range 2-19, SD 4.4). The set included 24 two-, 14 three- and 20 four-fragment fractures of the clavicle midshaft. Open reduction was used in all the cases. The implant was introduced by the indirect method: first, insertion of the pin from the fracture antegrade into the lateral fragment took place, then it was inserted retrogradely into the medial fragment.

RESULTS

The average patient follow-up was 7.1 months (range 623, SD 5.5). X-ray signs of healing were evident in all cases, with healing occurring at 8.4 weeks on average (range 620, SD 4.1). In one case (1.7%), however, healing did not occur - refracture was diagnosed 18 days following pin extraction with no clear mechanism of injury; two more refractures were caused by a new accident. The apex of the pin was broken in four cases (6.9%). In two cases (3.4%), angulation of the pin occurred; however, full fracture healing was satisfactorily achieved. Pin prominence was observed in a total of 23 cases (39.7%), requiring premature extraction of the implant due to perforation or irritation of skin and pain in 13 (22.4%) cases. 10 cases (17.2%) of prominence were asymptomatic. Six cases with skin perforation by the implant developed clinical signs of infection, wound healing was always achieved after extraction of the pin and application of antibiotics. A very good functional finding in the shoulder joint was observed in 57 patients (98.2%). The DASH score reached an average of 8.1 points (range 0.8-30.8, SD 4.4). Constant score was 93.1 (range 42.8-98.1, SD 3.2).

CONCLUSION

Intramedullary stabilization of two-, three- and four-fragment fractures of the middle part of the clavicle using the Hofer Clavicula Pin provides very good stability during healing and leads to good healing of fractures. The complications of the method are soft tissue irritation or even skin perforation in the region of the lateral end of the implant. Preventive insertion of the pin closer to the bone may prevent such complications, but also result in difficult pin extraction.Key words: fractures - clavicle - osteosynthesis - intramedullary complications.

[Four-Corner Arthrodesis of the Wrist with Dorsal Circular Plate - a Retrospective Monocentric Study]

PURPOSE OF THE STUDY Our study aimed to evaluate a group of patients who in the period from 2005 to 2014 underwent a four-corner arthrodesis of the wrist in our department. We also wanted to verify the hypothesis as to whether the use of conventional dorsal plate without the application of bone grafts leads to comparable results as the use of dorsal locking plates and routine application of bone grafts. MATERIAL AND METHODS Throughout the years 2005 to 2014 the four-corner arthrodesis of the wrist was performed in our department in a total of 62 patients, in two cases bilaterally. The indication was the diagnosis of SLAC/SNAC grade III. Normed RondoFix implant was used in all the cases. Following the surgery, the wrist was immobilized by a volar plaster splint for the period of 2 weeks and subsequently orthosis was applied for additional 4 weeks. The wrist mobilisation started in week seven when the orthosis was removed, the patients were allowed full load on the wrist 3 months after the surgery. Our group of patients was evaluated retrospectively, a total of 53 operated wrists in 51 patients were assessed. The assessment was carried out based on a radiograph of the wrist, range of motion, Mayo Modified Wrist Score, DASH Score and grip strength test. RESULTS The mean range of motion in sagittal plane was 63.7°, in frontal plane the mean value was 32.1°. According to the Mayo Modified Wrist Score 37 patients were rated "excellent" or "good". Due to the presence of moderate pain, the result in other 10 patients was assessed as "satisfactory". In a total of 4 patients the result was assessed as "weak", in two of them for a presence of non-union and in other two for severe pain under load. One of these patients underwent bilateral surgery and reported severe pain in both the wrists. Regarding DASH score, the best result equalled 0, the worst 65.83, with the mean of 20.5. The grip strength ranged from 8 to 54 kg, with the mean value of 27.5 kg. In two patients, a non-union occurred. In the first case the extraction of implant and re-arthrodesis was performed due to severe pain and screw migration. The patient is now 22 months after the surgery and the radiographs show that the arthrodesis has healed and the patient has no clinical difficulties. The second patient did not report any difficulties, therefore he is only subject to follow-up. No cases of screw or plate breakage were reported. In one case, the patient reported pain in the region of radial styloid process. A revision was indicated with radial styloidectomy and decompression of tendons of m. extensor pollicis brevis and m. abductor pollicis longus. As a result the patient had no clinical difficulty. One case of wrist radial deviation was recorded. It was managed by corrective wedge osteotomy and reosteosynthesis using a circular dorsal plate. In one patient dorsal impingement occurred, accompanied by limited range of motion and pain. Extraction of OS material was indicated and the patient was relieved of any difficulties. We have recorded aseptic necrosis of lunate bone in one case. DISCUSSION When comparing the functional results such as the range of motion and grip strength, our results are fully comparable to previously published papers. In papers where DASH was referred to, its value ranges from 13 to 29.82, which is fully consistent with our observations with the final value of 20.5. The incidence of non-union and the degree of complications is not deviating from the values included in other publications either. In all the mentioned publications the authors refer to routine use of bone grafts. The publications evaluating the use of locking plates do not report different results either. CONCLUSIONS In case of correct indication, the four-corner arthrodesis of the wrist represents a very good solution. In our group of patients, we confirmed the hypothesis that equally good results as with the use of locking plates can be achieved when using a non-locking plate system. Essential is the proper correction of DISI and primary good congruence between fused carpal bones instead of the use of bone grafts. Key words: SLAC wrist, SNAC wrist, four-corner arthrodesis, partial wrist fusion.

[Spontaneous Tendon Ruptures in the Rheumatoid Hand]

A spontaneous tendon rupture is a direct consequence of rheumatoid inflammation and can appear without any noticeable impact, often during sleep. The patient then presents with inability to flex or extend metacarpophalageal or interphalangeal joints. Multiple ruptures resulting in impaired function of several fingers can also occur and markedly limit the hand's grip strength. A tear may arise from either mechanical injury to the tendon along its course over bone or connective tissues, or by biochemical action of lysosomal enzymes, released during the inflammation process, on the connective tissue of the tendon. Ischaemic damage to a part of the tendon due to constriction of vessels supplying the peritenonium is found in hypertrophic peri-tenosynovitis. Spontaneous ruptures can be prevented, in the first place, by early synovectomy and then by a number of prophylactic procedures on soft tissues and carpal bones, which can stop or at least slow down the development of severe axial deformities of the wrist and hand. Simple end-to-end suture of the stumps is usually not possible; tendon repair surgery using free grafts or, more often, intact tendon transfer is necessary. In the flexor part, transfer of the superficial flexor tendon to a stump of the deep flexor tendon is frequently performed; a free graft can also be used at a two-stage tendon reconstruction. The repair of flexor tendons is technically more demanding and the results are less satisfactory compared to repair surgery on the extensor tendon. Key words: rheumatoid arthritis, metacarpophalageal joint, interphalangeal joint, tendon rupture.

[Conservative and Surgical Treatment for Distal Ulna Fractures Associated with Distal Radius Fractures]

PURPOSE OF STUDY

Fractures of the distal radius and distal ulna require anatomical reconstruction for good restoration of wrist and hand function. In this study we compared the results of conservative treatment with those of plate osteosynthesis management in distal ulna fractures of patients who had concomitant fractures of the distal radius indicated for plate osteosynthesis. Our objective was to specify indications for plate osteosynthesis of a distal ulna fracture in the case of an associated distal radius fracture.

MATERIAL AND METHODS

A total of 27 patients were evaluated. In 17 of them, distal radius fractures were treated by plate osteosynthesis and distal ulna fractures conservatively (CONS group). In 12 patients, both distal radius and distal ulna fractures were treated by plate osteosynthesis (SURG group). Osteosynthesis was carried out using an APTUS variable-angle locking system (Medartis, Basel, Switzerland). In two SURG group patients with distal radioulnar joint (DRUJ) instability, the radius and ulna in anatomical position were secured with two Kirschner wires.

RESULTS

Fracture union of the distal radius was achieved in all patients. Non-union of the distal ulna was recorded in one patient of each group. No secondary displacement of distal radius fragments during bone union was found in either group. Displacement of fragments during the healing of distal ulna fracture occurred in one (6.7%) patient of the CONS group. Out of the parameters evaluated, the restriction of motion below 80% of the original range in volar flexion, dorsal flection and supination was recorded in three CONS patients (20.0%) and two SURG patients (16.7%). No DRUJ instability was found. Intra-operative swelling preventing closure of surgical wounds was managed by secondary wound suture in one SURG patient (8.3%). There were no other complications.

DISCUSSION

Views vary on whether the distal ulna should be treated by plate osteosynthesis when, after distal radius fixation, its fracture managed by closed reduction heals well. A distal ulna plate often causes pain and has to be removed. The acute cases of DRUJ instability caused by comminuted distal ulna fracture can be treated by osteosynthesis of the distal ulna and two Kirschner wires inserted into the fracture site in an ulnar-to-radial direction. For chronic radioulnar instability, various methods involving free tendon grafts and dynamic tenodesis are used. Other options include the Sauvé-Kapandji procedure based on inducing artificial non-union of the distal ulna diaphysis and radioulnar arthrodesis; in our modification of this technique we use a single cancellous malleolar screw. In severely comminuted fractures of the distal ulna with injury to articular cartilage, ulnar head replacement can be indicated. CONCLUSIONS Distal ulna fractures can be treated conservatively if osteosynthesis of the distal radius in the anatomical position is achieved together with anatomical reduction of bone fragments of the distal ulna. When a distal radius fracture managed by osteosynthesis is not accompanied by anatomical reduction of distal ulna fragments, or the ulna is shorter or longer than the contralateral bone, an open reduction and stabilisation using an angle-stable locking plate, set at an adequate radius-toulna length ratio, is the method of choice.

[Shape-memory osteosynthesis for trapeziometacarpal joint arthrodesis]

PURPOSE OF THE STUDY

Arthrodesis of the trapeziometacarpal joint is the method of choice in the treatment of degenerative arthritis of this joint. This procedure was indicated most frequently in middle-age patients doing hard manual labor. Methods for achieving a solid fusion of the trapeziometacarpal joint are known and often reported in the literature. Frequently, they are associated with some failure rate, particularly as concerns bone union. Our study presents a simple and effective method verified in cadaver specimens and then currently used at our department.

MATERIAL AND METHODS

The procedure for arthrodesis of the trapeziometacarpal joint was verified fist in fixed wrist and hand specimens at the Institute of Anatomy, 1 st Faculty of Medicine, Charles University in Prague. If the original shape of the basal thumb joint between the trapezium and the metacarpal is maintained, it allows for correct reduction and subsequent arthrodesis in a required position. In patients, surgical treatment included the use of implants, two DePuy shape-memory staples, which facilitate sufficient fragment compression and provide stable fixation. The staples were inserted in pre-drilled and gauged tunnels in the body of the trapezium and in the proximal metaphysis of the fist metacarpal.

RESULTS

Between 2011 and 2014, the procedure was used in 14 patients diagnosed with primary arthritis of the trapeziometacarpal joint. The group comprised nine women and five men, the average age was 52 years and the range was 44 to 69 years. Surgery was most frequently carried out on the dominant upper extremity (85%); there was no bilateral surgery. The average follow-up was 18.3 months (range, 5 to 39 months). Solid fusion was recorded at 7 weeks after surgery in all patients except for the one still treated at the time of this paper submission. All patients were free of pain, ten reported satisfaction with grip strength and hand function, the rest would have preferred improvement in fine motor skills of the thumb. All of them found the cosmetic appearance of the hand satisfactory..

DISCUSSION

The methods generally used for trapeziometacarpal joint arthrodesis are reported to carry some risk of pseudarthrosis development. A lot of modifications have been described, from conventional procedures using AO lag screws or Kirschner wires to up-to-date plate systems involving angle-stable fixation. Total fusion of the trapeziometacarpal joint is disputable in patients with rheumatoid arthritis from the technical point of view as well as the relevance of indication criteria. Some authors consider this procedure a contraindication for patients with rheumatoid arthritis. The use of joint replacement in treating trapeziometacarpal joint arthritis is another complex issue.

CONCLUSIONS

An arthrodesis of the trapeziometacarpal joint based on careful assessment of indication criteria proved to be a simple, effective and low-cost method of stable osteosynthesis that provided good conditions for solid fusion of the trapezium with the base of the fist metacarpal. It allowed for sufficient abduction and opposition of the thumb, thus permitting satisfactory hand grip strength and full involvement in everyday life activities and occupations. It provided stability of the thumb, its painless movement and good cosmetic looks.

[ToeFit-Plus system for replacement of the first metatarsophalangeal joint]

PURPOSE OF THE STUDY

Hallux rigidus is a frequent disease of the first metatarsophalangeal (MTP) joint. It is a painful condition markedly reducing joint motion. For grade-3 and grade-4 disease, as classified by Coughlin, first MTP joint replacement is another option of surgical treatment, in addition to resection arthroplasty or arthrodesis.

MATERIAL AND METHODS

In a group of 27 patients with symptomatic hallux rigidus, 28 MTP joint replacements using a TOEFIT-PLUS implant were carried out in the 2005-2009 period. There were 24 women and three men, with an average age of 56.3 years. The average follow-up was 24 months (range, 4 to 48). Indication for surgery included hallux rigidus in 20, conditions following Keller's arthroplasty in five, necrosis of the first metatarsus head in two cases and a condition after the Austin procedure in one patient. Pain, assessed by the Kitaoka score, and the range of joint motion; were evaluated before the surgery and at the final follow-up visit this also included the radiographic assessment of implant position and its integration.

RESULTS

Of the 28 implants used, nine were hemiprosthetic and 19 total joint replacements. The average time between surgery and full weight-bearing was 6.6 weeks (range, 5 to 8) in both groups. The post-operative Kitaoka score was 87.1 (68-100) as compared with the preoperative value of 36.3 (24-52), and this difference was statistically significant.The range of motion at the first MTP improved from 14.7 degrees pre-operatively to 38.5 degrees post-operatively. There was no statistically significant difference in joint function, as assessed by the Kitaoka score and range of motion, between the two groups (hemiprosthetic vs. total joint replacements). The complications included prolonged skin healing with minor dehiscence in four cases. Revision surgery was required in three cases because of restricted joint motion associated with pain. In three cases of the total joint replacement group, there was radiographic evidence of asymptomatic osteolysis around both the phalangeal and the metatarsal component. In the hemiarthroplasty group, no osteolysis was recorded.

DISCUSSION

Up to now several types of implants have been developed to alleviate pain and restore and maintain the first MTP motion in patients with hallux rigidus.The TOEFIT-PLUS implant belongs to the most recent ones. Our results are in agreement with those of other currently used replacements in terms of clinical and functional evaluation. The complications recorded in our study are also similar to those reported in the literature, which include aseptic loosening, dislocation and mechanical failure of the implant. There is no consistent approach to their treatment. Arthrodesis with tricortical graft seems to be an option, but it carries a considerable risk of failure. Since in our patients aseptic loosening was recorded only in the total joint replacement group, hemiarthroplasty has recently been preferred, because it has clinical and functional outcomes as good as total joint replacement.

CONCLUSIONS

Our results with the use of TOEFIT-PLUS replacement show that this implant is effective in the treatment of hallux rigidus advanced stages and has good clinical outcomes, i.e., maintenance of motion at the MTP joint of the big toe, pain alleviation and early weight bearing. Since hemiarthroplasty is associated with fewer complications whose potential treatment is easier, this approach seems to have a better prospect than total joint replacement.

[Our experience with AES total ankle replacement]

PURPOSE OF THE STUDY

The method of choice for the treatment of severe ankle arthritis is either arthrodesis or joint arthroplasty. Each has its advantages and disadvantages. Arthrodesis is the definitive therapy for severe ankle destruction and instability. Joint arthroplasty has an advantage in maintaining ankle mobility. However, its range of indications and its reliability and durability are more limited. The aim of this study is to present our experience with the AES prosthesis and draw attention to some drawbacks of this surgical treatment.

MATERIAL

From September 2003 till June 2008, 51 AES ankle replacements were carried out in 51 patients (33 women and 18 men). Their average age at the time of surgery was 53.8 years. The youngest patient was 23 and the oldest was 88 years old. The indication for surgery was rheumatoid arthritis in 10, primary arthritis in six and post-traumatic ankle arthritis in 35 patients.

METHODS

The patients were evaluated in 2008. The follow-up ranged from 4 months to 5 years. The patients were examined for ankle joint mobility and pain. Radiographs were assessed for potential signs of component loosening.

RESULTS

The results presented here are short-term ones. The pre-operative AOFAS score of 33.7 increased to 82.3 points post-operatively. The range of motion was on average 20 degrees of plantar flexion and 5 to 10 degrees of dorsiflexion. Thirty- five patients (68.7 %) were free from pain, 11 (21.5 %) experienced slight pain while walking, and five (9.8 %) patients reported more intensive pain in the joint treated. Intra-operative complications included a fracture of the medial malleolus in two (3.9 %) patients subsequently treated with screw osteosynthesis. Post-operatively, seven (13.7 %) patients experienced slow healing of the operative wound. One patient had dislocation of the polyethylene liner at 3 months after surgery. Revision surgery was carried out in seven (13.7 %) patients. Two patients suffering from increasing pain around medial malleolus underwent revision and removal of ossifications. One patient developed necrosis of the talus at 1 year after surgery. She underwent extraction of the prosthesis and ankle arthrodesis with a retrograde locking nail inserted through the heel. A large bony effect arising due to extraction of the necrotic talus was repaired using bone graft. Three (5.8 %) patients developed post-operative instability of the ankle that required revision surgery. The radiographs of another three (5.8 %) patients showed bone cysts and signs of tibial component loosening. Of these, one patient underwent surgical revision with replacement of the polyethylene liner. Cavities were freed from granuloma induced by polyethylene wear debris, and filled with bone graft from the iliac crest.

DISCUSSION

Total ankle replacement is a complicated surgical procedure that may results in various technical difficulties and complications. These are inversely proportional to the surgeon's experience, as also shown by literature data.

CONCLUSIONS

The longevity of a total ankle replacement depends, much more than in other joint replacements, on an accurate implantation technique and correct indication.

[Os Pisiforme transposition in the treatment of Kienböck's disease - long term results]

PURPOSE OF THE STUDY

One of the methods used for treatment of Kienböck's disease is based on transposition of the pisiform bone into free space created by removal of the lunate bone. It is performed in patients with stage IIIB to IV, as assessed by Lichtmann's score. However, this operative procedure has so far lacked an unequivocal assessment of its therapeutic value. The aim of our work was to assess the therapeutic effect of the Kuhlmann method in the treatment of advanced stages of Kienböck's disease.

MATERIAL

From January 1996, eighteen patients (18 wrists) diagnosed with Kienböck's disease were operated on, using the Kuhlmann method, and the group of these patients was included in this follow-up study. The average follow-up time was 7.6 +/- 2.3 years.

METHODS

The results were evaluated on the basis of subjective (VAS) and functional criteria (ROM, grip force, DASH questionnaire and combined Cooney score questionnaires) and radiological assessment (arthritis evaluation, C.H.I., Natrass index, RSA).

RESULTS

All patients experienced pain relief. The average pain assessment by VAS (10-point scale) before and after the procedure was 8.76 +/- 0.9 and 2.94 +/- 1.59, respectively. The range of motion was reduced on the operated extremity (70% compared to non-operated) as well as the grip test (57%). The average DASH score at the time of study was 20.9 +/- 12.2 and the average Cooney score was 67.6 +/- 17.4. Before the operation, eleven wrists showed signs of osteoarthritis. At the follow-up evaluation, arthritis was present in fifteen patients.We found a significant difference in average radiological parameters characterizing a carpal collapse deformity (C.H.I., Natrass index, RSA) - all parameters showed deteriorating tendencies.

DISCUSSION

In nine patients, necrotic changes of the lunate occurred. In the patients whose pisiforme was not affected, a moderate retardation of carpal collapse occurred. However, the discrepancy between relevant indicators (C.H.I, Natrass index, RSA) was not statistically significant when comparing both groups. Therefore, we cannot conclude as to whether or not a vital transposed pisiforme bone impedes the development of carpal collapse. The only proved difference between these two groups was in pain evaluation, measured by VAS, after the procedure

CONCLUSION

Although there was a good subjective assessment of the operation results, we are of the opinion that this method should not be used as a routine surgical procedure for advanced Kienböck disease. In view of a large number of failed cases we believe that this method should be considered very carefully.

[First experience with total wrist replacement using an implant of our design]

PURPOSE OF THE STUDY

To present the results of total wrist replacement with a cementless prosthesis designed by us.

MATERIAL AND METHODS

A group of five men and 27 women treated between 2004 and 2007 was evaluated. The average age was 51.6 years and follow-up ranged from 4 to 38 months, with an average of 9.4 months. Indications for surgery included wrist destruction due to rheumatoid arthritis, arthritis or psoriatic arthropathy. Subjective evaluation recorded satisfaction of the patients with the wrist range of motion, cosmetic appearance of the hand and pain relief. The range of motion was assessed with a goniometer at 4 months of follow-up on average. Radiographs were made immediately after surgery and then at 6 and 12 months post-operatively.

RESULTS

All patients reported pain relief, 23 were satisfied with wrist mobility and hand appearance, and seven were only partly satisfied and would have preferred a greater range of motion. Two patients were dissatisfied with an ulnar deviation of the carpal axis and therefore revision arthroplasty of the radial ligamentary and tendinous structures was planned. No aseptic or septic loosening of the implant or its migration was found.

DISCUSSION

The current total wrist arthroplasty has evolved from Swanson silastic implants to prostheses with a metal-on-polyethylene bearing whose active surfaces are firmly fixed in bone. In today's Europe, the most frequently used prostheses are Meuli implants or the latest modification of the Guepar implant, which is very close to the Universal 2 implant. In the USA since 1985, Professor's Beckenbaugh's BIAX implant has continuously been improved. The implant designed by us is based on all well-tired implant components and aims at being as similar to the anatomical wrist structures as possible. The socket is fixed in the distal radius. The carpal components involve the main fixation shaft for the third metacarpal and a short antirotation pin for the second metacarpal base. A metal head is assembled onto a tapered shaft extending from the carpal component transversal zone. The implant is made of titanium alloy, in some parts coated with hydroxyapatite; the sockets has a polyethylene liner.

CONCLUSION

Total wrist replacement is usually preceded, particularly in surgery for rheumatoid arthritis, by operations intended to prevent or slow down gradual wrist destruction. The usual salvage procedures include surgery on soft tissues (synovectomy, tenodesis, tendon reconstruction) and/or bone (limited wrist arthrodesis, Sauve-Kapandji procedure). These procedures usually have a temporary effect and total replacement will be the next step in surgical treatment. For the most severe destruction associated with subluxation and wrist instability, total arthrodesis in a neutral wrist position still remains the method of choice. The first results with use of the implant of our design show that this total wrist replacement allows us to preserve or restore the wrist range of motion and to improved grip strength.

[Silastic implant arthroplasty of the second to fifth metacarpophalangeal joints in rheumatoid arthritis]

PURPOSE OF THE STUDY

The authors evaluate the long-term results of metacarpophalangeal joint (MCP) arthroplasty of the second to fifth digits in the rheumatoid hand in relation to the factors that have a long-term effect on implant function.

MATERIAL

In a group of 41 patients, 52 hands were treated with a total of 166 Swanson silastic MCP implants in the period from 1988 to 2005. The average follow-up was 3.2 years (range, 6 months to 17 years). Arthroplasty was carried out exclusively for the indication of rheumatoid destruction of MCP joints.

METHODS

The patients were assessed for the range of motion, MCP joint alignment and functional and radiographic findings. Xray images were examined for osseous lesions at the margins of resected parts, implant position and its state and joint alignment. Radiography was performed from the standard distance in anteroposterior and oblique projections. Subjective satisfaction of the patients was evaluated on the basis of a questionnaire, in which hand function, pain and cosmetic appearance were recorded.

RESULTS

The function and mobility of the fingers improved after surgery, with an increased range of motion in MCP joints towards extension (average range, 3 degrees to 51 degrees flexion), and correction of an ulnar drift of the MCP joint of each finger (average, 5.8 degrees ). Radiographs showed destruction of silastic implants in 13.3 % of the fingers treated. The subjective evaluation by patients was satisfactory. Long-lasting pain relief was reported by 79 % and satisfaction with hand function by 90 % of the patients. Improvement in a cosmetic appearance of the hand was also significant.

DISCUSSION

At long-term follow-up, a gradual decrease in the range of motion of MCP joints and a partial recurrence of ulnar drift usually occur at about 2 years. However, in most cases, they do not result in either subjective complaints or functional restriction. These findings are in agreement with the results published in the relevant literature.

CONCLUSIONS

The silastic implant remains a standard procedure in surgical reconstruction of the MCP joints in the rheumatoid hand. Improvements in the range of motion and joint alignment and alleviation of pain result in a markedly improved hand function and patients' satisfaction. The long-term outcome of MCP joint arthroplasty is significantly influenced by the severity of rheumatoid arthritis.

[Ten years' experience with our method of wrist joint arthrodesis]

PURPOSE OF THE STUDY

Total arthrodesis of the carpal joint is a complex operative procedure that results in the restoration of joint stability in frontal and sagittal planes and improvement in function of the tendons of digits' extensors and flexors. We developed our own method based on the use of a special implant; in this study we report our long-term results.

MATERIAL

Since 1992 we have carried out 54 total carpal arthrodeses, using our method, on 51 patients; three patients were treated bilaterally. Both wrists were treated in. This group comprised 34 women and 19 men, with the average age of 47.6 years. We used the modified method mainly in patients with stage IV rheumatic carpal destruction (Larsen classification) or in those with wrist destruction due to arthritis or psoriasis. In two patients, this method was indicated because of a non-reparable lesion of the nervus radialis. It was also used in two patients who had their wrist replacements removed due to failure.

METHODS

The procedure was carried out, with a tourniquet applied to the upper arm, from the dorsal approach to the carpal joint. After opening the capsule, using an oscillating saw, we resected the facies articularis radii, the carpal bones, which were freed from cartilage and turned into a cancellous in situ filling, and the distal ulna. This procedure prepared the operation field for the application of our plate. This L-shaped plate, only 2 mm thick, with its concave curve fitting the palm, allows for three-point fixation of the metacarpal region and also maintains slight compression.

RESULTS

In all the patients, we achieved osseous fusion detectable by radiography and clinical examination on average at 12 weeks postoperatively. The grasping function of the hand improved in all patients because the carpal axis was adjusted to a functionally convenient position. The resection of the distal ulna, which is a part of our method, removed pain caused by supination or pronation. The patients reported the absence of pain, instability and edema of the wrist.

DISCUSSION

The aim of any method for total wrist arthrodesis is the firm fixation of resection-treated articular surfaces of the radius, carpal bones and metacarpal bases for a period long enough to allow for their complete fusion. These techniques involve intraosseous procedures, the use of plates, osteorrhaphy and external fixation. Most of these methods use massive corticocancellous grafts collected from the hipbone crest. The critical point of all methods is fixation of the metacarpal region.

CONCLUSIONS

The method described here is based on an original implant in the form of an L-shaped plate that permits sufficient fixation without using grafts taken from the pelvis. In patients with rheumatic arthritis, if needed, it facilitates peritenosynovectomy or reconstruction of spontaneous tendon ruptures in one operation. It does not require long-term immobilization in plaster cast and permits early rehabilitation of finger joints.

[Deformities of the forefoot in patients with rheumatoid arthritis--results of surgical treatment]

PURPOSE OF THE STUDY

Rheumatoid arthritis affects the foot very frequently. The transversal arch of the foot gradually declines due to the inflammation, the metatarsal heads protrude in the sole of the foot which is accompanied by painful bunions and sometimes also skin necrosis. The great toe turns into a valgus position and pronation. Walking is very painful.

MATERIAL

The authors evaluate a group of patients operated on for the deformities of the forefoot between 1995 and 2002.

METHODS

In the deformities of the forefoot the authors use resection of the heads of II-V metatarsals. They use a plantar surgical approach during which they remove bunions under the heads of the metatarsals. Then they gradually perform resection of the heads of--V metatarsals. In case of the great toe they prefer resection after Keller. In 5 cases they used fusion of the MTP joint of the great toe. They use fusion only in cases of a marked valgus position of the great toe. Where I MTT was in a significantly varus position, they applied in 3 cases the Lapidus procedure.

RESULTS

Between 1995 and 2002 they operated on 92 patients, in 38 of them the surgery was performed bilaterally. Evaluation covered 130 surgeries. In 85 cases the patients had rheumatoid arthritis, in 7 the basic diagnosis was psoriatic arthritis. The group included 72 women and 20 men. The average age at the time of surgery was 38.4 years. Eighty-two (63.1%) patients were without pain 7 (5.4%) patients had severe pain. The authors monitored the occurrence of revalgization of the great toe after Keller resection arthroplasty--of 77 patients revalgization occurred in 23 cases (29.8%). The complications included 3 times a late infect 1-2 years after the surgery after the protrated infect of the organs, 3 times a skin necrosis between the great toe and 2nd metatarsal, when prior to the surgery there was a significant valgus deformity and after the correction of the great toe there was a skin tension in this region, 6 times a delayed healing of the wound on the sole of the foot.

DISCUSSION

The authors present different surgical techniques of the forefoot and the great toe of the foot used by different authors.

CONCLUSION

As the patients suffer from a polyarticular affection the emphasis is put on the individual approach and a properly timed operation. In this respect of vital importance is the cooperation involving a rheumatologist, orthopaedic surgeon, physical therapist and prosthetic department. Orthopaedic insoles and orthopaedic shoes are an integral part of the comprehensive therapy. Surgical treatment is not very demanding for patients and in most cases it brings a significant relief.

[Physical therapy after shoulder arthroplasty.]

A properly conducted rehabilitation of the shoulder after arthroplasty is an inseparable part of the total treatment and is a prerequisite for the achievement of a good functional result. It is suitable to begin with the exercises within 48 hours after the surgery. The initial mobilization of the joint and decompression of the subacromial space the passive motion of the shoulder is exercised. Later the passive exercise is followed by active training aimed at the strengthening of the muscles of the shoulder girdle.The rehabilitation programme has to be tailored to individual patients and controlled by the surgeon who is the only one who can evaluate the condition of the musculoskeletal apparatus of the shoulder, the stability of the fixation of fragments or suture of the rotator cuff. During the whole period of exercising it is necessary to emphasize and check the proper movement stereotype during each exercise session. The same rehabilitation programme may be applied not only in after shoulder arthroplasty but also after anatomical or non-anatomical reconstruction of proximal humerus. Key words: rehabilitation, shoulder arthroplasty.

[Technique of transposition of os pisiforme in treatment kienböck disease of the lunate.]

The authors present an overview of surgical treatment of I-IV Degree aseptic necrosis of the lunate. They deal in detail with the transposition of os pisiforme which is indicated in compressive changes of the lunate bone in III and IV degrees of Decoulx classification. They present the surgical procedure verified on anatomical cadavers. Transposition of os pisiforme to the space left after the extirpated lunate preserves the integrity of proximal line of carpal bones, the fundamental geometrical indexes of carpus are fully restored or they are only insignificantly changed. The evaluation of the group of patients operated on by the authors will be published. Key words: Kienbóck disease, lunate bone.

WRIST ARTHRODESIS IN RHEUMATOID ARTHRITIS

Arthrodesis of the wrist is a standard operation which is indicated for severe rheumatoid arthritis in which destruction is too advanced for more conservative procedures, or after failure of previous surgery. We have developed an L-shaped plate designed for this purpose. It provides rigid internal fixation with the wrist in the neutral position and utilises bone grafts obtained from the distal ulna and the carpal bones.

We have carried out 29 successful fusions between 1992 and 1995. In all 29 patients synovectomy and resection of the head of the ulna were performed; 11 also had reconstruction of ruptured extensor tendons. All the patients obtained bony union, pain relief and improved function.

Wrist arthrodesis in rheumatoid arthritis. A new technique using internal fixation

Arthrodesis of the wrist is a standard operation which is indicated for severe rheumatoid arthritis in which destruction is too advanced for more conservative procedures, or after failure of previous surgery. We have developed an L-shaped plate designed for this purpose. It provides rigid internal fixation with the wrist in the neutral position and utilises bone grafts obtained from the distal ulna and the carpal bones. We have carried out 29 successful fusions between 1992 and 1995. In all 29 patients synovectomy and resection of the head of the ulna were performed; 11 also had reconstruction of ruptured extensor tendons. All the patients obtained bony union, pain relief and improved function.

[Reconstruction of the Extensor Apparatus of the Wrist and the Hand in RA.]

Reconstruction of the extensor apparatus of the wrist and the hand is one of the common rheumato-surgical operations. Primary suture of the tendon which produces the best results is only rarely possible. The patient usually attends late, very frequently does not even notice at first an isolated rupture of the extensor. The authors recorded in a group of 39 rheumato-surgical operations of the wrist a disorder of the extensor apparatus in 14 instances. In nine instances the repair of the extensor was part of a total arthrodesis of the carpus, in two instances part of simple synovectomy, in one instance the authors repaired extensors in conjunction with radio-lunate desis and in one instance in conjunction with the solution of a caput ulnae syndrome operation according to Sauvé-Kapandji. Discontinuation of the tendon of the m. extensor pollicis longus was found three times, discontinuation of the tendon of the fourth finger five times, of the fifth finger three times, of the third finger also three times. Repair was achieved by several approaches. In two instances where the retraction of tendinous stumps was minimal they made an "end-to-end" suture. Twice they used a free bridging graft, collected from the m. palmaris longus. Tendon transposition was used five times, five times they used the course of intact neighbouring tendons to fix to them distal stumps of the discontinued extensors by the "end-to-side" or "side-to-side" method. The functional gain was beyond doubt in all patients, the smallerst deficit of extension of the finger, assessed six months after operation, was recorded in direct suture and in tendinous transposition. The greatest deficit of extension was recorded by the authors when they used a free graft. In cases of multiple rupture of tendons the authors used a combination of several methods of repair, depending on the surgical finding. Key words: rheumatic destruction of the carpus, rheumatic synovialitis of the hand, repair of the extensors of the hand.

[Tissue loss injury of the proximal phalanx of the thumb and repair using a rib graft]

In their case report the authors deal with the loss tissue injury of the proximal phalanx of the thumb caused by a circular saw. The first treatment on the day of the injury was carried out at the local clinic, the edges of the wound were trimmed and the residual small bone fragments were removed. Then suture was made of the dorsal aponeurosis and a K-wire was drilled in percutaneously through the distal phalanx into the base of the proximal phalanx in order to maintain the distance between the fragments. Wide-spectrum antibiotics were applied together with antitetanus-toxic injections and anti-gangrenous serum. After 9 weeks when the wound was healed per primam the patient was sent for further treatment to the central clinic. There they introduced extension through the nail of the thumb and left it there for 15 days. 11 weeks after the injury the patients was operated on. A bone graft was made from part of 6th rib and fixed to the residue of the base by a T-shaped plate. The distal phalanx was then transfixed to the bone graft by 2 crossed-K-wires. The wound healed per primam, K-wires were removed after 6 weeks. The grasping function of the hand was preserved, the residual motion was possible in the metacarpophalangeal joint of the thumb, interphalangeal arthrodesis was stable. The patient resumed his original job as a painter.