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M Krbec

Publications and source records attributed to M Krbec.

At least 19 recordsLinked to original sources
PubMed2005

Predictive factors for spondylotic cervical myelopathy treated conservatively or surgically.

A prospective 3-year randomized study comparing conservative and surgical treatment of spondylotic cervical myelopathy to establish predictive factors for outcome after conservative treatment and surgery. The clinical, electrophysiological and imaging parameters were examined to reveal how they characterized the clinical outcome. The patients with a good outcome in the conservatively treated group were of older age before treatment, had normal central motor conduction time (CMCT), and possessed a larger transverse area of the spinal cord. The patients with a good outcome in the surgically treated group had a more serious clinical picture (expressed in mJOA score and slower walk). Patients should rather be treated conservatively if they have a spinal transverse area larger than 70 mm2, are of older age and have normal CMCT. Surgery is more suitable for patients with clinically worse status and a lesser transverse area of spinal cord.

Adult↗
PubMed2005

Predictive factors for mild forms of spondylotic cervical myelopathy treated conservatively or surgically.

A prospective 3-year randomized study comparing conservative and surgical treatment of spondylotic cervical myelopathy to establish predictive factors for outcome after conservative treatment and surgery. The clinical, electrophysiological and imaging parameters were examined to reveal how they characterized the clinical outcome. Statistically, pair-wise and multiple comparisons of different were used with the independent t-test and on one-way anova models followed by Tukey multiple-range tests. The patients with a good outcome in the conservatively treated group were of older age before treatment, had normal central motor conduction time (CMCT), and possessed a larger transverse area of the spinal cord. The patients with a good outcome in the surgically treated group had a more serious clinical picture (expressed in mJOA score and slower walk). Patients should rather be treated conservatively if they a spinal transverse area larger than 70 mm2, are of older age, and have normal CMCT. Surgery is more suitable for patients with clinically worse status and a lesser transverse area of spinal cord.

Adult↗
PubMed2005

[Treatment of talar chondral lesions by solid chondral graft -- first experience].

The aim of this report is to draw attention to new possibilities of treating chondral lesions of the talus, using a solid chondral graft consisting of autologous chondrocytes grown on a three-dimensional matrix of the tissue glue Tissucol. This method is used in grade II to grade IV chronic lesions and grade IV acute lesions, as classified according to the Berndt and Harty system. Patients' age at implantation should not exceed 40 years. When a lesion is found by arthroscopy on the talar dome, a part of cartilage from a non-weight-bearing surface, most frequently the neck of the talus or the anterior edge of the tibia, is collected. The cartilage is sent to the tissue bank. The preparation of a chondral graft (fragmentation, isolation and cultivation of chondrocytes) takes from 15 to 35 days. After shaping the graft from chondrocytes and Tissucol tissue glue in a special mould, transplantation is carried out. In 2003 we used this method in two patients. They both were male sportsmen, football players, aged 35 and 30 years, respectively. At the time of this report, the former patient was 8 months and the latter 3 months after implantation. The first patient, aged 35, was without complaints at 8 months after implantation. The other patient, a 30-year-old football player, who was still followed up, was without complaints and continued with rehabilitation and full weight-bearing of the extremity. Magnetic resonance imaging performed 3 months post-operatively showed good incorporation of the chondral graft in both patients.

Adult↗
PubMed2004

[Transarticular fixation of C1-C2: a multicenter retrospective study].

PURPOSE OF THE STUDY: Transarticular C1-2 fixation is a surgical alternative in treatment of atlantoaxial instability. Although the method provides very good immediate and long-term stability, it still involves several disadvantages. The group of patients as reported from various institutions are usually very small and hardly comparable. In order to objectively compare the results of the method, we collected the groups of patients treated in four institutions dealing with surgery of the cervical spine in Czech Republic. MATERIAL AND METHODS: During the 9-years period (1993-2001), the transarticular C1/2 fixation was performed in 80 patients (mean age 45.6 years, range 4-85 years). The procedure was indicated for atlantoaxial instability due to rheumatoid arthritis in 32 cases, pseudoarthrosis of the odontoid process in 15 cases, fracture of the odontoid in 8 cases, complex C1-C2 fracture in 7 cases, tumour in 5 cases, C1 fracture in 4 cases, os odontoideum in 3 cases, purulent osteolysis of the odontoid in 3 cases and instability due to tuberculosis in one case, respectively. Two patients underwent surgery for painful arthrosis of atlantoaxial joints only. Transarticular fusion was combined with posterior interlaminar fixation using autologous graft and wire in most of the cases. Clinical and radiological results were evaluated in the early postoperative period and 3, 6 and 12 months after surgery, respectively. The position of the screws in relation to lateral mass of the atlas was evaluated according to our own criteria as optimal, suboptimal, and misplaced. Long-term postoperative stability and bone fusion were also followed. The follow-up ranged from 3 to 99 months (mean 29.1 months). There were 72 patients available for long-term follow-up (i.e. more then 6 months). RESULTS: We inserted 150 screws; two screws were used in 72 patients, one screw in 6 patients while in two patients, the surgery had to be aborted without screwing. Optimal placement was achieved in 103 cases (68.7%), suboptimal because of too medial or lateral placement of the screws in 26 cases (17.3%), suboptimal due to a short screw in 9 case (6%) and a long screw in 8 cases (5.3%). Four screws (2.7%) were found misplaced (i.e. out of the lateral masses). Fusion was confirmed in 51 cases out of 72 operated on (70.8%) at 6-months follow-up, and in 55 cases out of 63 available for follow-up (87.3%) at 12 months, respectively. Segmental stability was achieved in all patients, even in cases with incomplete fusion as seen on radiograph. Furthermore, six screws in four patients were discovered to be broken, nevertheless without any clinical consequences. There were 4 cases of peroperative injury to th vertebral artery (i.e. 5% of patients, 2.7% of screws), one case of dural tear and one case of excessive blood loss from epidural venous plexus. These complications, however, did not cause any significant clinical consequences, either. Other postoperative complications included wound dehiscence in 3 cases, 2 cases of hardware failure due to wrong indication for surgery and 2 cases of persistent neck pain. DISCUSSION: Transarticular C1/2 fixation is known to be universal and stable technique suitable for the treatment of atlantoaxial instability. According to biomechanical studies, this method provides the best stability mainly in rotation and lateral flexion (inclination) when compared to other described methods of atlantoaxial fixation. The fusion rate is reported to vary between 90 to 100% if the posterior interlaminar fusion using bone graft and wire is simultaneously performed. The rare incidence of pseudarthrosis is usually considered to be related to a poor surgical technique as even only one screw should provide bone fusion if properly placed. Using strict evaluation criteria, the fusion rate in our sample of patients was 87.3% at 12 months, or, 92.1% if also controversial radiographs were included. The injury to the vertebral artery is the most serious complication of the method; its incidence in our group (5% of patients) is comparable to data from literature. We believe that most of these events happened because of individual anatomical variations of axis and vertebral artery were not adequately respected. CONCLUSION: Transarticular technique of instrumental atlantoaxial fusion is an effective method with multiple application in treatment of craniocervical and upper cervical spine instability. The gain of immediate stability with acceptable risk of possible complications is the major advantage of this procedure. The results of our multicentric retrospective study confirm the expected high fusion rate and are comparable to previously published reports.

Adolescent↗
PubMed2004

[Infection complications of total hip arthroplasty].

The authors present an overview of the current views on etiology and diagnostics of infectious complications of total hip arthroplasty and analyze the possibilities of individual therapeutic procedures (debridement with the preservation of total hip arthroplasty, revision of the endoprosthesis, long-term antibiotic therapy, final resection arthroplasty, arthrodesis). They discuss the pending issues relating to the therapy of infectious complications of total hip arthroplasty (the duration of antibiotic therapy, the interval between the extraction and revision surgery of the endoprosthesis, the use of antibiotic-containing cement). Based on their own experience they recommend the revision surgery with the preservation of the implant, debridement and irrigation as the first step only in case of an early post-operative infection and in case of a late hematogenous acute infection. In case of chronic infection they recommend a two-step revision surgery using the cement spacer and the antibiotic therapy for 3 to 6 months. During this period the laboratory and clinical signs of the infection must be back to their normal. Long-term antibiotic therapy in dependence on microbial sensitivity is recommended.

Anti-Bacterial Agents↗
PubMed2004

[Treatment of patellar cartilage defects by solid chondral graft: first experience].

PURPOSE OF THE STUDY: To present the results of a new method for treatment of cartilage defects of the patella, using a solid graft produced by chondrocytes on a three-dimensional matrix. MATERIAL AND METHODS: Chondrocyte transplantation is indicated in deep and extensive chondral and osteochondral defects of all large joints in patients at 18 to 40 years of age. When, on arthroscopic examination, a defect of patellar cartilage was found, healthy cartilage was collected from a non-weight-bearing surface, i. e., the intercondyllar fossa. In the tissue bank, the cartilage was fragmented, chondrocytes were isolated enzymatically and cultivated in vitro under a permanent assessment for cell quality. The cultivation period ranged from 15 to 35 days. Subsequently, a solid graft was prepared with the use of Tissucol glue, a three-dimensional matrix. The graft was transplanted after arthroscopic verification of the defect by an open, minimally invasive procedure with tourniquet application, with the patient receiving antibiotics. The result of chondral graft implantation was checked by second-look arthroscopy involving removal of a small sample of the integrated chondral graft taken for histological and morphological examination. Another method of post-operative assessment was examination by magnetic resonance imaging (MRI). Solid chondral graft transplantation was used in three patients (two men and one women) treated in the Department of Orthopedics, University Hospital Brno, between May 2001 and December 2003. Their average age at the time of surgery was 31 years (range, 27 to 38 years). The average follow-up was 22 months (range, 2 to 33 months). The post-operative stage of he cartilage was assessed by MRI in one patient and by second-look arthroscopy also in one patient. RESULTS: Two patients fully resumed their daily activities, sports including, at 6 months after the treatment, with one reporting mild chondropathic problems and the other being without complaints. In the third patient at 2 months after surgery, the treatment had not been completed yet. The patella examined by MRI at 18 months after surgery showed a confluent, high layer of hyaline cartilage covering the articular surface. Second-look arthroscopy and histological examination also revealed healthy hyaline cartilage. No serious complications were recorded. DISCUSSION: Autologous chondrocyte transplantation is indicated in younger, active patients with cartilage defects exceeding 2 cm2 and in patients undergoing revision surgery for any defect. The success rate of this procedure has been reported to be over 90 %. One year after transplantation, the cartilage had characteristics of a healthy tissue, as assessed by MRI. Biopsy examination showed that the grafts, chondrocytes as well as osteocytes maintained their integrity at 2 to 12 months after surgery. CONCLUSIONS: The aim of this paper was to define and check indications, to develop the surgical technique, to improve post-operative management and to evaluate mid-term results of the treatment of cartilage defects on the patella.

Adolescent↗
PubMed2003

[Bone grafts in hip prosthesis revisions].

PURPOSE OF THE STUDY: We describe the collection, storage and examination of allogenic bone grafts and their use in revision hip arthroplasty, indicated because of acetabular loosening, that involved either an uncemented cup or an augmentation device with a cemented cup according to the extent and nature of acetabular defects. MATERIAL: Allogenic bone grafts, usually long bones, were collected from deceased humans within 12 hours of death. They were processed according to the standards of US tissue banks. Using ELISA, the blood of each donor was serologically examined for antibodies against selected antigens (HIV I, HIV II, syphilis, HbsAg, HCV, and p24HIV I, HTLV I and II, and HbcAg, if required). Microbiological examination of each bone sample was also included. The samples were kept in a quarantine box until the examination results were known. When these were negative, the bones were cut, under aseptic conditions, to obtain parts (condyle, metaphysis, diaphysis, patella, etc.) weighing from 80 to 150 gr. Subsequently, another quality check, involving microbiological and histological examination, was performed. The allografts were stored at -80 degrees C. METHODS: Between October 1999 and October 2000, 67 revision total hip replacements were performed. Of these, allogenic bone grafting was used for acetabular reconstruction in 30 cases (45%). The average amount of graft tissue per operation was 107 gr (range, 43 to 163 gr). Eleven grafts had been harvested from the tibial condyle, nine from the trochanters, eight from the femoral condyle and two from the patella. The graft bone, ground into coarse chips, was washed with an antibiotic solution. Two techniques were used in graft implantation. 1) Impaction grafting, under pressure, of the acetabulum whose surface was free from any granulation tissue and scratched to make the bone bleed, and implantation of a cemented cup (LOR or Spotorno CLS). 2) Filling of large defects with a bulk of allograft bone chips, using an augmentation ring, mesh or Burch-Schneider cage, and implantation of a cemented polyethylene acetabular component. Uncemented implants were used in 17 and cemented cups with an augmentation device in 13 cases. The hips were checked by X-ray at 3, 6 and 12 months and then at yearly intervals. RESULTS: In the postoperative period of 26 to 38 months, an early recurrent infection led to temporary removal of the implant in one case, one hip showed superficial infection that responded to therapy and there was one case of aseptic acetabular loosening. A recurrent dislocation led to femoral stem exchange for a modular component with a longer neck in one case. The remaining 28 cases showed good incorporation of the graft without any signs of implant migration. DISCUSSION: Segmental defects of the acetabulum can be treated by implantation of specific types of acetabular cups or by massive bone grafting. Cavitary defects can be filled with cancellous allograft bone or bioactive, artificial materials. We prefer morselized allograft bone from the tissue bank and this was used in 45% of repeat surgeries for failure of the acetabular component. An uncemented cup is more convenient, supposing sufficient primary stability can be ensured. When defects are extensive, augmentation devices and filling with graft bone are necessary. Cadaver allografts offer advantages over autologous bone because they are available at any amount and thus enable us to avoid extensive damage to the iliac crest by autologous tissue harvesting. Cadaver grafts are bones of good quality, free from degenerative or dystrophic changes because they are usually taken from young subjects. The size of 7 to 10 mm is optimal because it permits the grafts to maintain both structure and strength. The strict procedure of sample collection and examination minimizes the risk of infection transfer. The progress of graft bone ingrowth was evaluated on radiographs that showed incorporation of allograft into the surrounding bone during 3 to 6 months and no radiolucent areas at host bone-implant contact. CONCLUSIONS: Our patients showed good allogenic bone ingrowth in relation to the acetabular bed and good bone restructuring and incorporation in relation to the implant. Neither mechanical failure of implants nor graft rejection were recorded. The risk of infection transfer was low and comparable with routine blood transfusion. The necessary prerequisite for revision hip arthroplasty is a well-operating bone tissue bank.

Acetabulum↗
PubMed2003

[Injuries of the lower cervical vertebrae--the monocortical stabilization technique].

PURPOSE OF THE STUDY: In contrast to the thoracolumbal spine, the cervical spine bears a lower biomechanical load and, therefore, anterior stabilization of a fracture is a definitive procedure in the majority of cases. What remains the matter of choice is screw fixation in the body of the vertebra involved. This may be either monocortical or bicortical. In this study, we evaluate a group of patients in whom fractures of the lower cervical spine were treated using the CSLP monocortical system (Synthes). MATERIAL: We included 68 patients in whom complete radiographic data were available and the surgery was performed more than 6 months earlier. This group comprised 49 men and 19 women with the mean age of 37.6 years and range of 12 to 79 years. In the first stage, all patients were operated on from the anterior approach. In 11 (16.2%) patients with type B or C injury, according to the AO classification, the procedure was completed by dorsal stabilization. The definite indication for surgery was any involvement of nerve structures or open fractures; kyphosis greater than 15 degrees, reduction by more that 50% of the proximal edge of the vertebral body, narrowing of the spinal canal by more than 50%, multiple wedge fractures and disc and ligament injuries associated with instability were considered conditional indications. METHODS: Any locked dislocation was reduced manually under X-ray guidance in the shortest possible time. Subluxations or fractures of the vertebral body were reduced by positioning the patient's body on the operating table. The standard procedure for subluxation management was distraction of the segment by applying a Caspar's distractor and subsequent microscopic discectomy up to the posterior longitudinal ligament. A tricortical bone graft was collected from the iliac crest. After its implantation, the distractor was released and the segment was fixed by a CSLP system (Synthes) with monocortical screws 14 mm long, usually used in a 2 + 2 configuration. In locked dislocation, in addition, the discission of the posterior longitudinal ligament and inspection of the dural sac were performed, and completed by dorsal stabilization with hook plates or a Cervifix fixator (Synthes) in one procedure under anesthesia. When the body of the vertebra was fractured, either partial or subtotal excision of it was carried out according to the type of fracture or when displaced fragments protruded into the spinal canal. A tricortical graft taken from the iliac crest was larger than in the treatment of subluxation but a plate was applied as in monosegmental fixation. In addition, the graft was fixed with special screws that had a porous surface and holes in the shank. Dorsal stabilization with hook plates or a Cervifix fixator was used for severe instability in type B or C injury. RESULTS: The normal range of cervical spine motion (flexion, extension, inclination, rotation) was found in 44 patients. Slightly limited movement (75% to 90% normal motion) was in 17 patients and seven were affected more seriously (50% to 75% normal motion). Of the 19 patients with neurological deficit, 13 showed improvement by 1, 2 or 3 grades of Frankel's classification in seven, four and two patients, respectively. The first signs of bone remodeling between the graft and covering plate, usually at the distal graft border, were found in 16 patients at 6 weeks and in the remaining 52 patients at 12 weeks. By 6 months postoperatively, all patients showed complete healing and incorporation of the tricortical graft. The cranial screws broke in one case (1.5%) but this had no effect on the treatment outcome. No complication related to the surgical procedure occurred intraoperatively. DISCUSSION: The very good results achieved with the use of the CSLP monocortical system in this study (98.5% fusion without broken screws or plates) are in agreement with relevant data reported in the Czech and foreign literature. The principal condition is a careful preparation of both the endplates of vertebral bodies and the graft. After insertion, this should stay in place without any tendency to extrude. If the graft is too long, it imposes an increased load on plates or screws that consequently act ventrally. CONCLUSION: Our experience and literature data suggest that the CSLP monocortical system is fully capable to stabilize the lower cervical spine after injury, supposing all procedures described above are completed. In more serious trauma and type B or C instability, the additional dorsal instrumented fusion is indicated.

Adolescent↗
PubMed2003

[Injuries of the atlas].

PURPOSE OF THE STUDY: Injuries of atlas account for 1-2% of all injures of the spine and for 7% of the injuries of the cervical spine. Fractures of atlas occur either as isolated fractures or in combination with the injury of the axis or occipital condyles. The aim of the work is to evaluate a group of patients with the injury of the atlas treated both conservatively and surgically. MATERIAL: Between January 1996 and October 2001 we treated at the Orthopaedic Department of 3rd Medical Faculty, Carles University in Prague 10 patients with the injury of atlas. Between November 2001 and December 2002 we treated at the Orthopaedic Department and Spondylosurgical Department of the Medical Faculty Motol another 5 patients with the injury of atlas. In 10 cases the fracture of atlas was isolated (anterior arch--once, 4 time Jefferson fracture, twice--fracture of massa lateralis), in 5 cases the fracture was associated with the injury of epistropheus (dens type II/posterior arch--twice, dens type II/Jefferson fracture--once, dens type II/massa lateralis--once, hangman fracture type II/posterior atlas arch--once). Teh group of patients included 9 men and 6 women of the average age of 46.6 years (range, 27-85 years). Eight patients were treated conservatively, 7 patients surgically. The most frequent cause of the injury was fall on the head or a severe downward violence in 7 cases, car accident in 4 cases, other causes vere identified in 4 cases. Neurological deficit upon admission was found out only in one patient (Frankel D). METHODS: In isolated injuries of the anterior or posterior arch of atlas we always proceeded conservatively. The cervical spine was fixed for 12 weeks in the Philadelphia collar. One isolated fracture of massa lateralis was also treated conservatively for 12 weeks in the Philadelphia collar. Another case of the same type of fracture was treated surgically by C1-C2 by the Magerl technique supplemented on the intact side by the Gallie wire loop. Two stable Jefferson fractures were treated by the halo vest applied for 12 weeks. Two unstable fractures were handled surgically, once by C1-C2 by the Magerl technique and once by C0-C2 occipitocervical fixation. C1-C2 associated injuries were treated in four cases surgically, three times by a direct dens fixation and once by C1-C2 fixation after Magerl supplemented with the Gallie wire loop. A patient with the associated hangman fracture type II and fracture of the posterior atlas arch refused the surgery and therefore was treated by the halo fixation for 12 weeks. Philadelphia collar was applied to the patients operated on. RESULTS: In the group of the conservatively treated, 3 patients complained of pain in the upper part of cervical spine and head requiring from time to time the administration of analgesics. All fractures healed within 12 weeks and the functional radiographs showed stable C0-C2 segments. As for complications, during the conservative treatment in one case a pyogenic secretion was recorded around the fixation elements of the halo apparatus requiring its removal after 8 weeks. The patient was further treated by a pelot fixation. In one case it was necessary to adjust twice the halo apparatus due to re-dislocation of the hangman fracture (associated hangman fracture of type II and posterior atlas arch). In spite of this the injury healed in C2-C3 subluxation, however, the fracture of atlas healed in a favourable anatomical position. In the group of the operated on, 2 patients complained of pain in the upper cervical spine requiring from time to time the administration of analgesics and one patient complained of a marked limitation of the range of motion by 50% (C0-C2 occipitocervical fixation). Also in this group stable C0-C2 segments were found out 12-14 weeks after the surgery. DISCUSSION: In our group of 15 patients the fracture healed, i.e. stable C0-C1 and C1-C2 segments, in all patients treated both conservatively and surgically. In the group of conservatively treated patients there occurred in one case re-dislocation of the fracture. However, the patient refused the surgery repeatedly. Apart from these case we found in neither group any severe complication. The ratio of conservative and surgical treatment was 8:7. CONCLUSION: Based on our own experience and the literary data we believe that suitable for the treatment of stable injuries of the atlas is conservative treatment, i.e. fixation in the Philadelphia collar for 12 weeks. In unstable injuries or intraarticular injures with dislocation we prefer surgical fixation of C1-C2 or C0-C2 in dependence on the type of injury. All associated injuries are indicated for surgical treatment.

Adult↗
PubMed2002

Rare presentation of non-Hodgkin lymphoma of the thoracolumbar spine in pregnancy with 7 years' survival.

A rare, so far unpublished, case of non-Hodgkin lymphoma in 26-year-old pregnant woman is presented. As X ray examination and other investigations were avoided during her pregnancy, the discrete signs of spinal cord compression led to sudden severe neurological deterioration after delivery. This necessitated emergency decompression and stabilization of the spine. Acute surgical treatment resulted in complete functional recovery. It was followed by chemotherapy and radiotherapy, which led to disease-free survival 7 years after the surgery. Magnetic resonance imaging is the examination of choice when long-lasting back pain during pregnancy does not resolve with bed rest.

Adult↗
PubMed2002

[Atlanto-axial rotation dislocation (case report)].

The authors present a female patient 45 years old, who had a car accident as a driver of a passenger car. Her car was hit from the left side by another car and the women hurt her head, neck and left shoulder. Due to pain in the region of the head and neck she was taken to the respective surgical out-patient department where they diagnosed the concussion of the brain of II degree and distortion of the cervical spine. The patient was treated conservatively by bed rest with the cervical spine fixed in the soft Schanz collar. After ten days she was discharged from the hospital and further followed up by a neurologist in the out-patient department. She underwent physical therapy focussed on the relaxation of muscles in the region of the cervical spine. Due to persisting pain in the region of upper cervical spine the patient was sent to the department of the first author six weeks after the injury. On clinical examination the head was inclined to the right and rotated to the left with pain in the region of the occipitocervical passage. Radiographs were made in the lateral and Sandberg projection. In the lateral projection the atlantodental distance was normal, the Sandberg projection showed an evidently asymmetrical location of the dens between the lateral masses of the atlas, asymmetrical size of the lateral masses and inclination of the head to the left. These basic projections alone showed an evident rotational atlantoaxial dislocation of I degree according to Fielding. The authors further added CT examination which showed rotation of C1 against C2 and asymmetrical location of the dens without dislocation from the anterior arch of the atlas. A conservative physical therapy was not successful and the patient felt worse. Twelve months after the injury a pre-operative traction by Glisson sling was introduced for five days with a gradual weight bearing up to 5 kg. A reduction followed from the dorsal approach and fixation of C1-C2 after Magerl combined with Gallie technique. The surgery was without complications and the post-operative radiographs showed a good position of the C1-C2 complex and a correct insertion of screws through atlantoaxial joints. The patient wore for six weeks a Philadelphia collar and another six weeks the Schanz collar. Standard and functional radiographs in flexion and extension made 12 weeks after the surgery showed bone bridging between C1-C2 arches and a stable atlantoaxial fusion. At the check one year after the surgery the patient had a limited rotation of the head by 25%, however, she was without pain and the inclination and rotation of the head was compensated. In the authors' view the use of Magerl technique of C1-C2 fixation is possible in case of a rotational atlantoaxial dislocation but difficult with regard to the changed anatomical conditions.

Atlanto-Axial Joint↗
PubMed2002

[Marginal indications for the Magerl method of fixation of C1-C2 (case report)].

The authors present a 4-year old girl who had a car accident as a passenger and hurt her head, chest and limbs as well as upper cervical spine. The patient with multiple injuries was taken to the FTN Centre of Children's traumatology, Prague. Here the basic vital functions were ensured and a diagnosis was made of contusion of the brain with quadriparesis and inhibition of the respiratory centre, contusion of the chest, epiphysiolysis of the distal femur and later also instability of C1-C2. A censor for measuring or intracranial pressure was immediately inserted with a subsequent reduction of the distal femur and elastic fixation. External lumbar drainage was performed in the next week instability of C1-C2 was not found out and therefore not treated. Three months after the injury a ventriculoperitoneal shunt for intracranial hypertension was inserted. MRI showed stenosis in the region of occipitocervical passage and dorsal decompression of craniocervical passage was performed which consisted in the removal of the posterior arch of C1 and a significant extension of foramen magnun dorsally and laterally to both sides. Due to persisting ligamentous instability of C1-C2 with a spastic quadriparesis and inhibition of the respiratory centre a surgical atlantoaxial stabilization was indicated, i.e. causal treatment of instability. Seven months after the injury Magerl fixation of C1-C2 was performed by 2.7 mm titanicum screws (Synthes). Preoperative stability of C1-C2 in the reduced position was satisfactory but with regard to iatrogenic instability the C0-C1 fixation was combined with occipitocervical fussion by Ransford loop extending over C0-C3. Further, the triangular flap of periost was overturned from the external occipital protuberance to C3 and all this was bridged by cortical cancellous bone grafts from iliac crest. After two months a check simple and functional x-ray examination showed a stable fusion of C0-C2. The neurological finding remained the same even after one year, i.e. a severe quadriparesis with the inhibition of the respiratory centre requiring artificial lung ventilation.

Cervical Vertebrae↗
PubMed2002

[Primary osteosynthesis of the odontoid process: a multicenter study].

PURPOSE OF THE STUDY: Direct osteosynthesis is a method of choice for the treatment of odontoid process fractures. It is based on insertion, from the anterior approach, of one or two screws from the C2 body into the apex of the odontoid across the fracture line. The tensile action of screws results in compression of fragments and stabilization of the fracture. The aim of the study was to evaluate a group of patients treated by this method and to compare our results with those reported in the foreign literature. MATERIAL: A total of 99 patients were treated by direct osteosynthesis of the odontoid in the departments involved in the study between 1994 and 2001. METHODS: Patients indicated for this surgery were those with fractures of type II according to Anderson and D'Alonzo and those with type III fractures but only when the fracture line went across the articulation surfaces of C1-C2, when closed reduction was not possible or the patients were not indicated for halo fixation. Direct osteosynthesis was not applied to fractures with comminution at the base of the odontoid, irreducible fractures, odontoid fractures combined with dislocated fractures of the atlas or pathological fractures. Severe kyphosis of the cervical spine or a large thoracic cage was also regarded as a contraindication. RESULTS: All the 99 patients were followed up from 3 up to 102 months, with an average of 28.5 months; only in seven patients, the follow-up period was shorter than 6 months. The most frequent subjective complaint was a painful operation wound. This usually resolved within two weeks of surgery. Except for four patients, alle were satisfied with the outcome. Type II fractures were diagnosed in 84 and type III fractures in 15 cases. A total of 174 screws were inserted into the odontoid processes of 99 patients. A single screw was used in 25 and two screws in 73 patients. In one case, three screws had to be inserted. Screw lenght ranged from 36 to 44 mm, diameter was 40.9 mm. Three months after surgery, X-ray examination, both in flexion and extension, did not reveal any instability in any of the patients. No morphological change in the C2-C3 intervertebral space was observed Of 92 (92.9%) paitents under longterm follow-up, 84 (91.3%) showed complete healing of the fracture, three died and five patients eventually developed pseudoarthrosis, which was due to a broken screw in three of them. This condition was treated by dorsal fixation of C1-C2 according to Magerl or by one of the dorsal cerclage techniques. The group was free of any perioperative complications related to the anterior approach or injury to nerve structures by screws. DISCUSSION: The most frequent subjective complaint was a painful operation wound. Treatment of odontoid fractures varies according to the type of injury, bone quality and also practice at each department. Type II injuries are highly unstable and, because of the small fracture surface, their healing ability is much lower than in type III fractures. Previously, most of the patients with odontoid injuries were treated conservatively by immobilization in a plaster cast or a brace or, later, by a halo device. In the long term, however, they showed a high proportion of pseudoarthroses (10 to 100%). Direct osteosynthesis of the odontoid by screws permits the maintenance of rotation of the C1-C2 mobile segment. We followed the scheme of indications used abroad but did not perform osteosynthesis to correct pseudoarthrosis. The number of osteosyntheses healed (91.3%) was also in agreement with the literature data. Earlier, we used two screws for all types of fractures. Recently, we have preferred insertion of a single screw in type II and III fractures in narrow odontoids. In the later, there is no danger of rotational dislocation during screw insertion; to insert one screw from the centre of the C2 base is easy and speeds up the procedure. However, in displaced type II and type II T fractures, two screws are a necessity. Similarly to other authors, we recorded a slight limitation of cervical spine rotation in patients at long-term follow-up, particularly in elderly subjects with advanced osteochondrosis. No complications leading to deterioration of the patient's state were recorded. CONCLUSIONS: Direct osteosynthesis is a method of choice for most of the type II and indicated cases of type III fractures of the odontoid process of the axis. This surgical procedure facilitates restoration of anatomical conditions of the spine and its immediate stability. Consequently, patients can be readily mobilized and rehabilitated.

Adolescent↗
PubMed2002

[Replacement of the vertebral body with an expansion implant (Synex)].

PURPOSE OF THE STUDY: This paper describes replacement of the vertebral body with the expansion implant Synex. Usually, autologous bone graft is used to replace the vertebral body. In patients with bone cancer or multiple injuries to the spine, cement filling is preferred whereas, in other indicated cases, implants are inserted, of which Harms' titanium cage has been the most common one. However, this needs filling with a large amount of bone tissue and it is often difficult to adjust its size into the space available. Telescopic devices, on the other hand, are easier to implant and their application requires only a minimum amount of autologous bone tissue. MATERIAL: In the period from January 2000 to June 2001, we used telescopic implants Synex to replace vertebral bodies in 34 patients. Indications for treatment were: vertebral fractures in 14, post-traumatic kyphosis in six, vertebral metastatic tumours in eight and a primary tumour in six patients. METHODS: In 25 cases, the vertebral body replacement was completed by posterior stabilization using internal fixation and, in nine cases, by anterior stabilization with a Ventrofix fixator. In 32 patients, the implant was inserted from the anterior approach and, in two, from the posterior approach following complete spondylectomy. RESULTS: The L1 vertebra was replaced most frequently (nine patients), then T 12 (seven patients) and L2 (six patients). For treatment of fresh fractures, the Synex implant was used in 14 cases. Of these one was inserted from the posterior approach in the L1 region where trauma had caused severe injury to the spinal cord. In spinal tumours. Synex was used in 14 patients, i.e., in six with diagnosed plasmacytoma, in two with metastatic dissemination from prostate carcinoma, in four with vertebral metastases from breast cancer and in two patients with non-differentiated metastases. The anterior approach was performed by conventional thoracotomy or combined thoracotomy and lumbotomy in 20 patients and a less invasive retroperitoneal approach was used in 12 patients. One patient died of multiple metastases at 7 months after surgery and one patient had relapse of a local tumour resulting in paraparesis that required a repeat decompression of the spinal canal. The operation took 1 h and 50 min when the anterior approach and anterior stabilization with a Ventrofix fixator were used; the operation lasted from 3 h 20 min to 6 h 10 min when complementary posterior stabilization was involved. The patients were followed up for 2 to 24 months. No failure of the implant in terms of migration, change in position or penetration into adjacent vertebral bodies occurred. DISCUSSION: The replacement of a vertebral body has conventionally been performed with the use of a massive bone graft. However, collection of an autologous bone graft large enough to suit this purpose is not always possible. Complications at the donor site have been described. A homologous bone graft carries a risk of disease transmission and the reconstruction ability of a massive graft has not been confirmed for certain. Cement filling augmented with Kirschner's wires is usually used in cancer patients. Titanium cages require application of a large amount of spongiose bone tissue into their interior. Consequently, bone in the centre fails to remodel. A sharp edge of the mesh may induce migration of the cage towards the vertebral body and failure of the implant. Mechanical failure and collapse of cages have also been described. Telescopic cylindrical implants, on the other hand, need only a small amount of spongiose bone tissue to fill. They can be adapted directly to the implantation site by means of a special distractor and, therefore, before adjusting its final length, the exact position and orientation of the implant can be achieved in the space prepared. This facilitates close contact with the endplates of adjacent vertebral bodies and the development of osteointegration. The use of telescopic implants enabled us to avoid the force that is often necessary to apply during insertion of Harms' cages in the patients whose spines had already been stabilized with posterior fixation or to avoid the need of a triple surgical procedure in order to achieve better stability of the implant. In two patients, Synex was inserted from a non-standard posterior approach. Indications for Synex implantation should be evaluated in view of disease prognosis in each patient. If only limited survival is expected, cement filling with K-wires should be preferred. CONCLUSIONS: Synex is a sophisticated implant to replace severely damaged vertebral bodies regardless of the nature of lesion. Its application required additional stabilization by either posterior or anterior fixation (internal transpedicular fixator and Ventrofix or Kaneda, respectively). Its use is indicated in post-traumatic defects of vertebrae in acute or poorly healed scervical.

Bone Transplantation↗
PubMed2002

[Use of bioceramics in the treatment of fractures of the thoraco-lumbar spine].

PURPOSE OF THE STUDY: The primary reduction and stabilization of all types of injury to the thoracolumbar spine is currently performed from the posterior approach by an internal, transpedicular fixator. The exceptions are type A fractures, according to the AO classification, that can primarily be treated from the anterior approach. The aim of the study was to assess the effect of BAS-O bioceramic granules, inserted by transpedicular approach, on the development of post-operative kyphosis of the segments injured. MATERIAL: Between 1997 and 2001 we treated anterior spinal column fractures, using bioceramic granules in combination with an internal fixator, in 53 patients (40 men, 13 women: age 26 to 69 years; average, 42.3 years) at the Department of Orthopedics and Traumatology of the Third Faculty of Medicine and FNKV in Prague. However, only 42 patients (33 men, 9 women; age 28 to 67 years; average, 41.6 years) who had had the metal fixator removed more than six months previously were included in the study. The fixator was removed in the range of 10 to 24 months after the primary operation. The sample was divided into two groups; one with bioceramic material inserted in the body of the damaged vertebra (20 patients) and the other bioceramic granules implanted in both the vertebral body and the intervertebral space (22 patients). METHODS: In all the patients, the standard procedure included transpedicular application of Schanz's screws and an USS FS fixator (Synthes). If necessary, distraction of the segment injured and the correction of lordosis were carried out. Further transpedicular procedures to treat the anterior spinal column were as follows: If the vertebral body was injured without destruction to the intervertebral disc, a bent elevator was inserted through the vertebral foramen and the intervertebral joints were reduced. At the same time, a cavity for application of bioceramic granules was created. These were inserted, using a funnel and a pusher, in the anterior part of the injured body. If the fracture involved a destroyed intervertebral disc, the disc was removed, the vertebral end plate of the adjacent vertebra was perforated and bioceramic granules were inserted in both the vertebral body and intervertebral space. Subsequently, spongeous bone grafts were harvested from the ilium and massively applied to the previously decorticated transverse and articular processes. RESULTS: In the group of patients who had bioceramic granules inserted in only the vertebral body, the kyphotic angle was on average 10.36 degrees after injury and 2.86 degrees after surgery; therefore, a correction by 13.22 degrees was achieved. At 3 and 6 months after surgery, the kyphotic angle was 2.71 degrees and 2.68 degrees, respectively; at 3 and 6 months after fixator removal, it was 0.67 degree in both instances. In the group of patients with bioceramic granules implanted in both the vertebral body and intervertebral space, the kyphotic angle was on average 9.16 degrees after injury and 4.26 degrees after, surgery; therefore, a correction by 13.43 degrees was achieved. At 3 and 6 months after surgery, the kyphotic angle was -4.11 degrees and -4.00 degrees, respectively; at 3 and 6 months after fixator removal, it was 2.38 degrees and 2.44 degrees, respectively. DISCUSSION: Our results revealed differences between the patients who had bioceramic granules inserted in only the vertebral body and those who had them also in the intervertebral space. At 6 months after surgery, the first group showed the loss of correction per two segments to be 3.53 degrees on the average, whereas the second group had a loss of 6.70 degrees, i.e., twice as high. This may be explained by a more serious damage to the intervertebral disc in the latter group. Only small differences between the groups were found in the kyphotic angle at both 6 months after surgery and 3 to 6 months after fixator removal. This implied that, in both groups, the loss of correction occurred in the period up to 3 months after removal of the fixator. CONCLUSIONS: Bioceramic granules provide material for replacement of osseous tissue in the body of the vertebra as well as conditions necessary for bone restructuring. The loss of correction per segment is lower by about half in patients treated with bioceramic granules than in those who received a spongeous bone grafts.

Adult↗
PubMed2001

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

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

Aged↗
PubMed2001

[Treatment of thoracolumbar spinal fractures using internal fixators (evaluation of 120 cases)].

PURPOSE OF THE STUDY: A group of 120 patients was evaluated with acute injury of Th-L spine who were operated on from posterior approach with the use of Dick AO fixator or USS fixator in the period of 1991-1996. MATERIAL: In the period of 1991-1996, 128 patients were operated on with the acute injury of Th-L spine. Evaluated were 120 patients: 81 men (67.5%) of average age 40.1 years (age range, 16-74 years) and 39 women (32.5%) of average age 35.4 years (age range, 15-66 years). Posterior stabilization using the internal fixator was combined with posterolateral or posterior interarticular fusion. In comminuted fractures of the vertebral body transpedicular cancellous bone grafting was performed and starting for 1995 also intercorporal transpedicular fusion. METHODS: The evaluation covered location and type of fractures, injury of other levels of the spine, other associated injuries, neurological symptomatology prior to the surgery and 3 months after the surgery, duration of surgery and of image intensifier exposure, peroperative and early postoperative complications, radiograph evaluation of the degree of reduction, the loss of correction after 12 months and after the hardware removal. RESULTS: Evaluated were 120 patients. Average interval after the surgery at the time of the evaluation was 43.7 months (range, 24-93 months). The injury was caused in 82 cases (68.3%) by a fall from height, in 26 cases (21.7%) by a car accident and in 12 cases (10%) by another cause. Associated injuries included: calcaneus fracture 18 times, the fracture of ankle 4 times, pelvis fracture 4 times, other fractures 18 times. In 89 cases the injury involved only one vertebra, i.e. one level, 31 cases were multi-level injuries. The angle of the kyphosis of vertebral body was on average 21.8 degrees. Patients with neurological symptoms were on average operated on 2-12 hours after the admission, other patients were operated on in the interval between 5 hours and 7 days. Bilateral transpedicular cancellous bone grafting was performed in 106 affected vertebrae, the canal was revised in 27 injured vertebrae. The surgery took on average 172 minutes (range, 62-430 minutes). Image intensifier exposure lasted on average 2.4 minutes. Average blood loss was peroperatively estimated at 725 ml, postoperatively on average at 815 ml. Postoperative complications: healing of the wound per secundam 6 times, thromboembolic complication in 9 cases--never fatal, pneumonia 3 times, uroinfection 5 times. The total number of these complications was about 8%. Vertebral body was completely restored in 72 cases, incompletely in 34 cases (up to 5 degrees deficit). The correction of kyphosis achieved was on average 6.5 degrees. After 12 months the correction loss with the fixator in place was on average 2.5 degrees. After the removal of the fixator the average correction loss was 5.5 degrees. In 2 cases there occurred a significant re-dislocation which required revision surgery. Transpedicular screws broke 6 times in the total of 4 patients, fixator loosened in 2 cases. DISCUSSION: Surgical treatment of thoracolumbar spine is indicated in unstable injuries and all injuries with neurological lesion and a proved compression of spinal canal. Decompression of the spinal canal is often achieved by reduction, lordotization and distraction. In other cases revision of the canal is indicated. Stabilization is performed by means of a transpedicular internal fixator. Part of the surgery is posterior fusion. The defect in the reduced body is treated by transpedicular cancellous bone grafting. The affected inervertebral disc must be treated by intersomatic fusion. Anterior operation is indicated as a complementary one. CONCLUSIONS: 1. Absolute majority of injuries of thoracolumbar spine may be treated from the posterior approach. In this it is necessary to restore the stability of the anterior column. An indispensable part of the operation is a flawless posterior fusion. 2. Some types of injuries require a complementary anterior approach in the first or second step. This applies mainly to the injuries with a defect of anterior column evaluated on the basis of classification after Gaines. 3. A primary isolated anterior approach to the treatment of the injury of Th-L spine is not in our view suitable as a routine.

Adolescent↗