SURGICAL TREATMENT OF THE RHEUMATOID FOOT

Cilj je ovog članka prikazati činjenice vezane uz kirurško liječenje stopala kod pacijenata s reumatoidnim artritisom. Reumatski upalni proces pogađa vezivno tkivo, zglobove, ligamente, tetive, hrskavicu i kosti uzrokujući deformaciju, bol i gubitak funkcije. Osobito je razoran na stopalima. Deformacije zbog reumatoidnog artritisa veće su nego u drugim reumatskim bolestima. Česta deformacija prednjeg dijela reumatoidnog stopala jest haluks valgus. Na metatarzofalangealnim zglobovima ostalih prstiju, osobito drugom, česte su subluksacija i potpuna dislokacija, a na prstima se razvijaju fleksija proksimalnog interfalangealnog zgloba te fleksija ili ekstenzija distalnog interfalangealnog zgloba. Stražnji dio stopala postupno, poslije i u manjoj mjeri biva zahvaćen bolešću. Učinjen je velik napredak u liječenju reumatskih bolesti lijekovima i kirurški. Primjenjuje se nekoliko rekonstruktivnih metoda. Za deformacije prvog traka stopala: artrodeza prvoga metatarzofalangealnog zgloba, Kellerova resekcija ili resekcija Mayova tipa, implantacijska artroplastika, sinoviektomija, osteotomija prve metatarzalne kosti. Za ostale metatarzofalangealne zglobove: tenotomije i produživanje tetiva ekstenzora, otvoreno opuštanje metatarzofalangealnih zglobova, sinoviektomija, resekcija baze proksimalne falange, metatarzalna kondilektomija, resekcija metatarzalne glavice, osteotomija metatarzalne kosti. Za prste: proksimalna interfalangealna resekcija, proksimalna interfalangealna artrodeza, distalna interfalangealna resekcija, stabilizacija prstiju sindaktilijom. Resekcijske artroplastike, skraćujući koštane strukture, poboljšavaju pokretljivost, ali je njihov rezultat nepredvidiv. Za stražnji dio stopala: artrodeza talonavikularnog, suptalarnog, kalkaneokuboidnog zgloba i zgloba gležnja ili aloartroplastika gležnja. Na vrijeme indicirano, dobro planirano i provedeno kirurško liječenje obično daje dobre rezultate. Ono nalaže intenzivnu suradnju pacijenta, reumatologa i ortopeda.The aim of this article is to present certain facts associated with rheumatoid foot surgery. Arthritic disease processes attack the joints, ligaments, tendons, cartilage, and bones, causing deformity, pain, and loss of function. Their effect on the feet can be devastating. Deformities secondary to rheumatoid arthritis are more severe than those in other forms of arthritic diseases. A common deformity of the forefoot is hallux valgus. The lesser metatarsophalangeal joints, especially the second one, commonly show lateral subluxation and total dislocation, and the toes develop flexion of the proximal interphalangeal joint and flexion or extension of the distal interphalangeal joint. The hindfoot is less affected by the disease process, most oft en only in the late stage of the disease. Great progress has been made in the medical and surgical treatment of arthritic diseases. Several reconstructive procedures can be performed. For first ray deformities: first metatarsophalangeal joint fusion, Mayo or Keller resection, implant arthroplasty, synovectomy, proximal osteotomy of the first metatarsal, and metatarsocuneiform fusion. For lesser metatarsophalangeal joints: extensor tenotomies, open metatarsophalangeal joint release, synovectomy, base resection, metatarsal condylectomy, metatarsal head resection, base and metatarsal head resection, and lesser metatarsal osteotomy. For the toes: proximal interphalangeal joint arthroplasty, proximal interphalangeal joint fusion, distal interphalangeal joint arthroplasty, proximal phalangeal base resection, and digital stabilization by syndactylization. Resection arthroplasty improves motion by shortening skeletal structures and providing new gliding surfaces, but the results are unpredictable. For the rheumatoid hindfoot, arthrodesis of the talonavicular, subtalar, calcaneocuboid, and tibiotalar joints or ankle arthroplasty can be performed. The results of a well-planned and performed surgical treatment, indicated in time, are usually good. Co-operation between the patient, rheumatologist, and surgeon is required

Disekantni osteohondritis na koljenu adolescenta iz starohrvatskoga groblja Gluvine kuće (deveto stoljeće n.e.)

Although osteochondritis dissecans of the knee has been known for a long time, we still do not fully understand why it develops. This prompted us to present and describe an example of osteochondritis dissecans identified in the Osteological Collection of the Croatian Academy of Sciences and Arts. The case of osteochondritis dissecans described in this report was recovered from the Gluvine kuće cemetery in the Dalmatian hinterland, approximately 28 km north-east of Split. A total of 77 graves were excavated and the individual exhibiting osteochondritis dissecans was recovered from grave number 16 that belongs to the younger phase of the cemetery that lasted during the second half of the 9th century A.D. Osteochondritis dissecans was noted in a subadult individual. The pathological changes consistent with osteochondritis dissecans are present on both medial femoral condyles. The lesion on the right femoral condyle is an oval crater-like defect with well defined margins and a porous floor of rough trabecular bone. The lesion on the left femoral condyle is basically, with two small provisions, identical to the one on the right side. The first is that it is slightly smaller, while the second is that unlike its antimere, it has a well preserved bone fragment that fits perfectly into the ostechondritic pit. Radiographic analyses of the femoral condyles support a diagnosis of osteochondritis dissecans and show a well-demarcated radiolucent defect in the articular surfaces of both joints surrounded by a thin sclerotic repair zone. According to the classification systems this degree of change corresponds to stage 3 or grade 3 osteochondritis dissecans – a detached but non-displaced fragment. Returning, for a second, to the opinion that prompted us to present this case, it is clear that during the last 1100 years there have been no significant morphological or radiological changes in the characteristics of osteochondritis dissecans.Disekantni osteohondritis, osobito onaj u području femoralnih kondila, poznat je stoljećima, ali se još uvijek raspravlja o uzrocima njegova nastanka. To nas je potaknulo da prikažemo slučaj osteohondritisa u području kondila femura iz Osteološke zbirke Zavoda za arheologiju Hrvatske akademije znanosti i umjetnosti. Kostur na kojem je nađen disekantni osteohondritis otkopan je na arheološkom nalazištu Gluvine kuće u Dalmatinskom zaleđu oko 28 kilometara sjeveroistočno od Splita. Na nalazištu je ukupno otkopano 77 grobova, a kostur s patološkim nalazom nađen je u grobu broj 16 koji se vremenski datira u drugu polovinu 9. stoljeća poslije Krista. Disekantni osteohondritis je nađen na kosturu osobe koja je u trenutku smrti imala 13,5 do 15 godina. Kostur je dobro očuvan, sa svijetlo smeđim kostima čiji je korteks imao relativno malo post-mortalnih oštećenja. Patološke promjene u smislu nalaza disekantnog osteohondritisa prisutne su na medijalnim kondilima obaju koljena. Lezija na desnom medijalnom kondilu femura imala je jasno omeđene rubove, a dno mu je činila gruba trabekularna kost. Gotovo jednaka lezija nađena je i na lijevom medijalnom kondilu, samo što je ova bila nešto manjeg promjera i, što je naročito zanimljivo, posjedovala je slobodni fragment kosti koji je točno odgovarao defektu na kondilu femura. Radiografska analiza medijalnih kondila obaju femura pokazala je karakterističnu radiolucentnu demarkacijsku liniju na zglobnoj ploštini obaju kondila okruženu sklerotičnom zonom kosti, što je tipičan radiološki nalaz kao i kod današnjih nativnih rendgenograma. U skladu s postojećim klasifikacijama u stupnjeve patoloških promjena pri postojanju disekantnog osteohondritisa u prikazanom slučaju radilo se o 3. stupnju, tj. stupnju s demarkiranim fragmentom. Na temelju našeg prikazanog slučaja može se zaključiti da u proteklih 1100 godina nije došlo do morfoloških i radioloških promjena u slici disekantnog osteohondritisa u području koljena

ANTERIOR COMPARTMENT SYNDROME OF THE LEG: A CASE REPORT

Sindrom prednjeg odjeljka potkoljenice može se javiti kao akutni oblik s brzim razvojem ishemičnih promjena, osobito u prednjem tibijalnom mišiću, zbog čega se i naziva "sindrom m. tibialis anteriora" ili "tibialis anterior syndrome", ili u kroničnom obliku koji nastaje postepeno i koji se ubraja u sindrome prenaprezanja i jedan je od uzroka nastanka tegoba poznatih pod imenom „trkačka potkoljenica“. Iznosimo prikaz slučaja akutnog oblika sindroma prednjeg odjeljka potkoljenice u sportaša rekreativca, a osim toga po zanimanju poštara koji je prije nastanka sindroma učestalo nosio terete po stepenicama. Bolesnik u dobi od 40 godina javio se u ortopedsku ambulantu zbog otoka i nesnosnih bolova u području prednjeg dijela lijeve potkoljenice. Odmah je postavljena klinička dijagnoza početnog akutnog sindroma prednjeg odjeljka potkoljenice s još uvijek očuvanom arterijskom cirkulacijom i bez neuroloških ispada..Rutinski laboratorijski nalazi su bili u granicama normale osim nalaza kreatin-kinaze koja je iznosila 1124 U/L (referentne vrijednosti do 177). Indicirana je hitna fasciotomija,tj. dekompresija prednjeg odjeljka potkoljenice, koja je izvedena otvorenim pristupom. Intraoperativno bile su vidljive početne ishemične promjene mišića,ali bez znakova nekroze mišićnog tkiva. Nakon provedene fasciotomije stavljeni su rijetki adaptacijski šavovi kože. Postoperacijski tijek je protekao uredno,a kontrolirani laboratorijski nalazi kreatin -kinaze drugi postoperacijski dan iznosili su 422 U/L dok su peti dan već bili na normali,tj. inosili su 112 U/L. Nakon uredno zaraslog postoperacijskog ožiljkas i provedene ambulantne fizikalne terapije bolesnik se vratio sportskim aktivnostima i redovnom poslu 5 tjedana nakon početka liječenja. Za akutni sindrom prednjeg odjeljka potkoljenice bitno je posumnjati na postojanje sindroma i postaviti ranu dijagnozu, a nakon potvrđene dijagnoze hitno izvesti fasciotomiju kao metodu izbora u liječenju. Nalaz povišenih vrijednosti kreatin –kinaze doprinosi potvrđivanju sumnje na akutni oblik sindroma, a dinamika vrijednosti kreatin-kinaze može pomoći u praćenju i procjeni tijeka poslije operacijeAnterior compartment syndrome of the leg may appear in an acute form characterized by a rapid development of ischemic changes, especially in the anterior tibial muscle, which is why it is called “syndrome m. tibialis anteriora” or “tibialis anterior syndrome,” or in a chronic form which develops gradually and is considered an overuse injury and can lead to the condition known as shin splints or “runner\u27s leg.” We present a case involving an acute form of anterior compartment syndrome in a recreational sportsman, a postman who often had to climb stairs carrying heavy packages prior to the onset of the syndrome. The patient, 40 years of age, checked into the orthopedics clinic complaining of swelling and unbearable pain in the anterior part of the left lower leg, He was immediately diagnosed with an early stage of acute anterior compartment syndrome with arterial circulation still intact and no neurological incidents. Routine laboratory tests showed normal results except the creatine kinase value, which was 1124 U/L (the upper limit of the reference range is 177). He was processed for an urgent fasciotomy, a decompression of the anterior compartment, which was performed as an open procedure. During the surgery we found ischemic muscle changes, but no signs of muscle tissue necrosis. After the fasciotomy the skin was sutured using adaptive stitches. Postoperatively the patient was well, and control laboratory tests revealed creatine kinase values of 422 U/L on the second day following the surgery and 112 U/L, or normal, on the fifth day after the surgery. After the scar healed nicely and the patient completed physical therapy, he went back to work and resumed his athletic activities five weeks after starting the treatment. With regard to anterior compartment syndrome, the condition should be suspected and diagnosed as early as possible. After confirmation of the diagnosis, an urgent fasciotomy should be performed as a first-line treatment option. The presence of elevated creatine kinase levels may be used, at least in part, to confirm a suspected acute form of the syndrome, while changes in creatine kinase levels may be used to help monitor and evaluate a patient’s postoperative progress

TARSAL TUNNEL SYNDROME IN ATHLETES

Sindrom kompresije nervus tibialisa ili njegovih ogranaka n.plantaris medialis et lateralis u području tarzalnog kanala (tunela) poznat je od 1962. godine kao sindrom tarzalnog kanala (tunela). Tarzalni kanal je koštano-vezivni kanal (tunel) smješten ispod medijalnog gležnja (maleola) stopala, a koji kanal se naziva i „hilus stopala“, jer kroz taj tunel na taban dolaze sve anatomske strukture od tetiva do živaca i krvnih žila. Kanal se dijeli na dva dijela, tj. na lacuna tendinum za prolaz tetiva m.tibialis posterior, m.flexor hallucis longus i m. flexor digitorum longus i na lacuna vasonervorum za prolaz neurovaskularnog snopa. Lacuna vasonervorum dijeli se opet u dva kanala i to medijalni (gornji) za prolaz n. plantaris medialis i istoimene arterije i vena te lateralni (donji) za prolaz n.plantaris lateralis te arterije i vena. Medijalni (gornji) kanal je u neposrednom odnosu s lacuna tendinum što je i jedan od uzroka češće kompresije n.plantaris medialis. Uzroci nastanka sindroma tarzalnog kanala su zauzimanje prostora u kanalu (ganglion, anomalni mišić i sl.) ili zbog izvanjskog pritiska na strukture u kanalu. Postoje i idiopatski oblici sindroma tarzalnog kanala kada se ne može otkriti izravni uzrok nastanka karakterističnih simptoma u smislu žarenja, pečenja, bockanja i smanjene osjetljivosti osobito u prva tri prsta tabana. Uz kliničku dijagnostiku nove mogućnosti MRI i ultrazvučne dijagnostike smanjuju broj tzv. idiopatskih oblika sindroma tarzalnog kanala, a korisne su i za evaluiranje eventualnog neuspješnog kirurškog liječenja . Sindrom tarzalnog kanala u športaša opisuje se relativno rijetko, a češće se javlja u sportovima gdje su prisutni sprintanje, skokovi ili neki specifični pokreti (judo), a pojava simptoma povezana je i s biomehaničkim promjenama u području gležnja i stopala. Idiopatske oblike sindroma tarzalnog kanala koji se češće nalaze u športaša može se objasniti učestalim ponavljajućim istezanjima (trakcijom) živaca ili tendinitisima u području lacuna tendinum, a što se sve može svrstati u sindrome prenaprezanja. Iako se nešto rjeđe opisuje nego u općoj populaciji potrebno je misliti na mogućnost pojave sindroma tarzalnog kanala u športaša, a ne postojeće tegobe pripisivati spuštenom stopalu ili proširenim venama.Tibial nerve compression syndrome or its affiliate\u27s branches n. plantaris medialis and lateralis in the fragment of tarsal canal (tunnel) are known since 1962. as tarsal tunnel syndrome. Tarsal channel is bone-connective tissue tunnel located under medial part of the ankle, and that channel is called the "hilum foot", because through that tunnel all the anatomical structures from tendon to the nerves and blood vessels are coming to the sole. The tunnel is divided into two parts – on lacuna tendinum for passage of m. tibialis posterior tendon, m. flexor hallucis longus and m. flexor digitorum longus and on lacuna vasonervorum for passage of the neurovascular bundle. Lacuna vasonervorum is divided again into two parts – into medial (upper tunnel) for the passage of n. plantaris medialis and homonymous artery and veins and to lateral (lower tunnel) for passage of n. plantaris lateralis, artery and veins. Medial (upper) tunnel is in direct relation with lacuna tendinum, which is one of the most common causes of compression of n. plantaris medialis. Causes of tarsal tunnel syndrome onset are found in possible space engagement in the tunnel (by ganglion, anomalous muscle or similar) or due to external pressure on the structures in the tunnel. There are also idiopathic forms of the tarsal tunnel syndrome, when you cannot detect a direct cause of the characteristic symptoms in terms of firing, burning, picking and reduced sensitivity especially in the first three fingers of the feet. Besides the clinical diagnosis, new opportunities of MRI and ultrasound diagnosis procedures reduce the number of so-called idiopathic forms of tarsal tunnel syndrome, and are useful for the evaluation and for eventual failure of surgical treatment. Tarsal tunnel syndrome is relatively rare described in athletes and does occur more often in sports where sprinting, jumping, or some specific movements (like in judo) are present. The occurrence of symptoms is also associated with biomechanical changes in the ankle and foot. Idiopathic forms of tarsal tunnel syndrome, which are more often found in athletes, may be explained by frequent repetitive stretching (traction) of the nerve or by tendinitis in the lacuna tendinum and can be classified as overuse injuries. Although less frequently described than in the general population, it is necessary to think of the possibility of tarsal tunnel syndrome in athletes, and not attribute present symptoms to the foot deformities or varicose veins

Simultaneous surgical correction of hallux valgus and lesser toes deformity

Svrha rada je prikazati rezultate istovremenog kirurškog liječenja haluksa valgusa i deformacije ostalih prstiju stopala. U Službi za ortopediju Opće bolnice Karlovac u razdoblju od 2000. do 2009. godine trodimenzionalnom (3-D) osteotomijom za haluks valgus (metoda po Lucijaniću), kombiniranoj s operacijom ostalih prstiju stopala, operirana su 74 pacijenta (87 stopala). Ispravljanje deformacija prstiju uključivalo je proksimalnu interfalangealnu resekcijsku artroplastiku, produživanje tetive dugog ekstenzora, resekciju baze drugog i trećeg prsta sa subtotalnom sindaktilizacijom. Weilova osteotomija je primijenjena u bolesnika s predugim drugim metatarzalnim kostima. Klinička i radiološka evaluacija operiranih bolesnika provedena je nakon prosječno 60,5 mjeseci (raspon 12-127 mjeseci). Prosječna dob pacijenata u vrijeme operacije bila je 56,5 godina (27-70 godina), a 97,3% su bile žene. Prosječni postoperacijski haluks valgus kut je značajno smanjen s 33,5° +- 8 na 11,4° +- 6,8, dok je intermetatarzalni kut značajno smanjen sa 14,3° +- 3,6 na 6,1° +- 3,2. Prosječno smanjenje prve metatarzalne kosti od 7,1 milimetara kompenzirano je plantarnim pomakom glave prve metatarzalne kosti u zoni osteotomije. Klinički parametri su značajno poboljšani prema AOFAS ljestvici s prosječno 37,1 +- 11,2 prijeoperativno na 87,8 +- 9,5 poslijeoperativno (p < 0,001). Rezultat je ocijenjen kao odličan i dobar u 85% slučajeva, uz 10 zadovoljavajućih i 3 loša ishoda. Komplikacije su uključivale recidiv deformacije u šest slučajeva. Jedan slučaj luksacije drugog metatarzofalangealnog zgloba je izazvao pogoršanje već prije prisutne metatarzalgije. Bio je jedan slučaj površne infekcije i jedan venske tromboze, dva tjedna nakon operacije. Rezultat ove studije potvrdio je Lucijanićevu metodu kao vrlo uspješnu u kirurškom liječenju umjerene do teške deformacije haluksa valgusa, a u kombinaciji s različitim postupcima kirurškoga liječenja deformacija ostalih prstiju, osigurava se potpuno ispravljanje glavnine poremećaja prednjega dijela stopala.The purpose of this study was to present results of simultaneous correction of hallux valgus and lesser toes deformity. In the Department of Orthopaedic Surgery, Karlovac General Hospital, between 2000 and 2009, 74 patients (87 feet) underwent new three-dimensional (3-D) osteotomy for hallux valgus (Lucijanić\u27s method) combined with lesser toes surgery or lesser metatarsal osteotomy. Correction deformities included proximal interphalangeal resection arthroplasty, extensor tendon lengthening, resection of both bases of the second and third toes with a subtotal webbing of toes two and three (syndactylisation).The Weil osteotomy on the lesser metatarsal was performed in 11 cases with excess of the lesser metatarsal length. Clinical and radiological evaluation was performed with an average follow up of 60.5 months (range: 12-127 months). The average patient age at the time of surgical treatment was 56.5 years (27-70), 97.3% were women. The average hallux valgus angle significantly decreased from 33.5 +- 8 to 11.4 +- 6.8 while the intermetatarsal angle significantly decreased from 14.3 +- 3.6 to 6.1 +- 3.2. The first metatarsal distal articular surface angle was reduced in average from 16.8 +- 6.7 to -1.4 +- 7.4. The first metatarsophalangeal joint congruence of average 1.3 +- 0.9 grade was corrected to 0.2 +- 0.5. The sesamoid position was corrected from an average preoperative grade of 2.5 +- 0.7 to a grade of 0.4 +- 1.2 at final follow-up. The first metatarsal declination angle was increased from 22.6 +- 3.7 to 28.5 -+ 4.6. The first metatarsal pronation angle was corrected from 7.2 +- 6.9 to 0.2 -+- 5.6. The relative length of the first and the second metatarsals was reduced from 2.4 +- 3.7 to -4.7 +- 3.7 millimetres. The first metatarsal shortened an average of 7.1 millimetres compensated with plantar displacement of the metatarsal head at the osteotomy site. The preoperative AOFAS\u27 hallux-metatarsophalangeal-interfhalangeal score averaged 37.1 +- 11.2 which increased significantly to 87.8 +- 9.4 postoperatively (p < 0.001). The overall outcome was rated as excellent and good in 85% of cases (10 fair, 3 poor). Complication included recurrence of deformity in six cases. Prolonged swelling was found in three cases. There were one case of superficial infection and one case of vein thrombosis two weeks after surgery. The results of this study confirmed the author\u27s procedure as very useful surgical technique for correction of a moderate to sever hallux valgus deformity. Its combination with various procedures for lesser toes ensures complete correction of main forefoot disorders

SURGICAL TREATMENT OF HALLUX VALGUS WITH NEW METHOD: OPERATIVE TECHNIQUE AND REVIEW OF 100 CASES

Prikazujemo operacijsku tehniku i rezultate liječenja za novu, trodimenzionalnu metodu korekcije haluksa valgusa razvijenu u OB Karlovac koju je uveo dr. Ivica Lucijanić. Bolesnici obuhvaćeni istraživanjem liječeni su od 2001. do 2008. godine. Klinički i radiološki evaluirani su prije i prosječno 4,5 godina poslije liječenja. Po bodovnoj ljestvici American Orthopaedic Foot and Ankle Society stanje je poboljšano s 48,56 na 92,34 boda. Vrijeme oporavka do povratka na posao bilo je prosječno 7,7 tjedana. Rezultat je bio odličan i dobar u 93%, zadovoljavajući u 5% i loš u 2% stopala. Kut haluksa valgusa smanjen je nakon operacije s prosječno 29,7° na 9,3°. Prvi intermetatarzalni kut smanjen je prosječno s 12,5° na 5,2°. Kut nagiba prve metatarzalne kosti u sagitalnoj ravnini povećan je prosječno za 5,3°. Kongruencija prvog metatarzofalangealnog zgloba i položaj medijalne sezamoidne kosti su ispravljeni. Nova metoda omogućuje korekciju haluksa valgusa u sve tri ravnine u prostoru te rješava problem metatarzalgije.We present the operative technique and treatment results for a new three-dimensional method for hallux valgus correction. Lucijanić procedure was developed at the Department of Orthopaedic Surgery, General Hospital Karlovac, where patients enrolled in this study were treated from 2001 to 2008. Clinical and radiological evaluation was performed in 100 cases with a mean follow-up of 4.5 years. Mean American Orthopaedic Foot and Ankle Society score improved from 48.56 preoperatively to 92.34 points postoperatively. Average recovery time and return to work was 7.7 weeks. Result was excellent or good in 93%, fair in 5% and poor in 2% of feet. On the average hallux valgus angle decreased from 29.7° to 9.3° and on the average intermetatarsal angle decreased from 12.5° to 5.2°. First metatarsal inclination angle on average increased 5.3°. First metatarsophalangeal joint congruence and tibial sesamoid position were corrected. The new method allows for correction of hallux valgus deformity in all three planes and for metatarsalgia attenuatio

SURGICAL TREATMENT OF HALLUX LIMITUS/RIGIDUS IN YOUNG FEMALE ATHLETE

Hallux limitus/ rigidus određuje ograničenje dorzalne fleksije metatarzofalangealnog zgloba palca usljed stvaranja osteofita uokolo dorzalnog ruba glave prve metatarzalne kosti. Navode se mnogi uzroci nastanka uključujući i traumu. Liječenje je konzervativno ili kirurško, a primjenjuje se više vrsta kirurškog liječenja. Autori prikazuju sportašicu s hallux limitusom (drugi stupanj bolesti) operiranu u njezinoj 19. godini života s postoperativnim praćenjem od 10 godina. Bolesnica je operirana metodom po Lucijaniću izvorno opisanom za kirurško liječenje hallux valgusa.Uosnovi primjenjenog kirurškog postupka je 3D distalna osteotomija prve metatarzalne kosti, njeno skraćivanje i plantarizacija glave te osteosinteza kompresivnim vijkom. Opisana je klinička i radiološka slika te nalaz podobarografije prije i nakon operacije. Dorzalna fleksija u prvom metatarzofalangealnom zglobu je prije operacije iznosila 20°. Deset godina nakon operacije pacijentica se bavi rekreacijskim trčanjem i uglavnom je bez bola i s dobrim opsegom kretnji u prvom metatarzofalangealnom zglobu, tj. dorzalna fleksija u zglobu iznosi 55 stupnjeva.Hallux limitus/rigidus is defined as the limitation of dorsiflection in the first metatarsophalangeal joint of the big toe due to the formation of osteophytes around the dorsal aspect of the articular margin of the head of the first metatarsal. Many ethiologies have been proposed including trauma. More types of the conservative and surgical treatment are practised. The autors report a case of the 19 years female sportist with hallux limitus (grade -2 disease) proceeded to open surgery with postoperative follow-up of ten years. The surgical procedure had been described before by Lucijanić originaly for treatment of hallux valgus. In the base of applied procedure is 3D distal osteotomy of the first metatarsal, shortening and plantar displacement of the metatarsal head and osteosynthesis using a compression screw. The clinical, radiological and pedobarography feature before and after surgery is described.The preoperative first metatarsophalangeal joint dorsiflexion was 20°. Ten years after surgery the patient is mainly pain-free and with good range of motion of the first metatarsophalangeal joint and dorsiflexion is 55 degrees. She is capable for recreational long running

Impact of pharmacotherapeutic education on medication adherence and adverse outcomes in patients with type 2 diabetes mellitus: a prospective, randomized study

Aim To evaluate the impact of pharmacotherapeutic education on 30-day post-discharge medication adherence and adverse outcomes in patients with type 2 diabetes mellitus (T2DM). Methods The prospective, randomized, single-center study was conducted at the Medical Department of University Hospital Dubrava, Zagreb, between April and June 2018. One hundred and thirty adult patients with T2DM who were discharged to the community were randomly assigned to either the intervention or the control group. Both groups during the hospital stay received the usual diabetes education. The intervention group received additional individual pre-discharge pharmacotherapeutic education about the discharge prescriptions. Medication adherence and occurrence of adverse outcomes (adverse drug reactions, readmission, emergency department visits, and death) were assessed at the follow-up visit, 30 days after discharge.Results The number of adherent patients was significantly higher in the intervention group (57/64 [89.9%] vs 41/61 [67.2%]; χ2 test, P = 0.003]. There was no significant difference between the groups in the number of patients who experienced adverse outcomes (31/64 [48.4%] vs 36/61 [59.0%]; χ2 test, P = 0.236). However, higher frequencies of all adverse outcomes were consistently observed in the control group. Conclusion Pharmacotherapeutic education of patients with T2DM can significantly improve 30-day post-discharge medication adherence, without a significant reduction in adverse clinical outcomes

Red cell distribution width is a potent prognostic parameter for in-hospital and post-discharge mortality in hospitalized coronavirus disease 2019 patients: a registry-based cohort study on 3941 patients

Aim To investigate clinical and prognostic associations of red cell distribution width (RDW) in hospitalized coronavi - rus disease 2019 (COVID-19) patients. Methods We retrospectively analyzed the records of 3941 consecutive COVID-19 patients admitted to a tertiary-level institution from March 2020 to March 2021 who had avail - able RDW on admission. Results The median age was 74 years. The median Charl - son comorbidity index (CCI) was 4. The majority of pa - tients (84.1%) on admission presented with severe or criti - cal COVID-19. Patients with higher RDW were significantly more likely to be older and female, to present earlier dur - ing infection, and to have higher comorbidity burden, worse functional status, and critical presentation of COVID-19 on admission. RDW was not significantly associated with C-re - active protein, occurrence of pneumonia, or need for oxy - gen supplementation on admission. During hospital stay, patients with higher RDW were significantly more likely to require high-flow oxygen therapy, mechanical ventilation, intensive care unit, and to experience prolonged immobi - lization, venous thromboembolism, bleeding, and bacte - rial sepsis. Thirty-day and post-hospital discharge mortality gradually increased with each rising RDW percent-point. In a series of multivariate Cox-regression models, RDW demon - strated robust prognostic properties at >14% cut-off level. This cut-off was associated with inferior 30-day and postdischarge survival independently of COVID-19 severity, age, and CCI; and with 30-day survival independently of COVID severity and established prognostic scores (CURB-65, 4Cmortality, COVID-gram and VACO-index). Conclusion RDW has a complex relationship with COVID19-associated inflammatory state and is affected by prior comorbidities. RDW can improve the prognostication in hospitalized COVID-19 patients

The associations of age, sex, and comorbidities with survival of hospitalized patients with coronavirus disease 2019: data from 4014 patients from a tertiary-center registry

Aim To investigate how age, sex, and comorbidities affect the survival of hospitalized coronavirus disease 2019 (COVID-19) patients. Methods We retrospectively analyzed the records of 4014 consecutive adults hospitalized for COVID-19 in a tertiarylevel institution from March 2020 to March 2021. Results The median age was 74 years. A total of 2256 (56.2%) patients were men. The median Charlson-comor - bidity-index (CCI) was 4 points; 3359 (82.7%) patients had severe or critical COVID-19. A significant interaction be - tween age, sex, and survival ( P <0.05) persisted after ad - justment for CCI. In patients <57 years, male sex was re - lated to a favorable (odds ration [OR] 0.50, 95% confidence interval [CI] 0.29-0.86), whereas in patients ≥57 years it was related to an unfavorable prognosis (OR 1.19, 95% CI 1.04- 1.37). Comorbidities associated with inferior survival inde - pendently of age, sex, and severe/critical COVID-19 on ad - mission were chronic heart failure, atrial fibrillation, acute myocardial infarction, acute cerebrovascular insult, history of venous thromboembolism, chronic kidney disease, ma - jor bleeding, liver cirrhosis, mental retardation, dementia, active malignant disease, metastatic malignant disease, autoimmune/rheumatic disease, bilateral pneumonia, and other infections on admission. Conclusion Among younger patients, female sex might lead to an adverse prognosis due to undisclosed reasons (differences in fat tissue distribution, hormonal status, and other mechanisms). Patient subgroups with specific co - morbidities require additional considerations during hos - pital stay for COVID-19. Future studies focusing on sex differences and potential interactions are warranted