Drukčiji pristup liječenju oštećenog meniska – sačuvajmo menisk

Menisci su vezivno-hrskavične strukture koje imaju važnu ulogu u zaštiti zglobne hrskavice i stabilnosti koljena. Puknuće meniska predstavlja najčešću intraartikularnu patologiju koljenskog zgloba te je najčešći razlog izvođenja operacijskih zahvata na koljenu. Razvojem artroskopskih tehnika, artroskopska djelomična meniscektomija postala je metodom izbora u liječenju puknuća meniska. Iako je minimalno invazivan zahvat kojim se odstranjuje samo dio meniska, a nakon kojeg se bolesnici brzo vraćaju svakodnevnim aktivnostima, artroskopska djelomična meniscektomija dugoročno ima nepovoljan utjecaj na hrskavicu koljena, što rezultira ubrzanim razvojem osteoartritisa. Stoga se od devedesetih godina prošlog stoljeća sve više promovira metoda artroskopskog šivanja meniska kojom se nastoji sačuvati anatomska cjelovitost, a time i funkcionalnost meniska. Premda kliničke studije pokazuju zadovoljavajuće dugoročne rezultate nakon takvih zahvata, nažalost, i dalje se šivanje meniska ne izvodi dovoljno često. Cilj ovoga preglednog rada jest naglasiti važnost meniska u očuvanju hrskavice i stabilnosti koljena te na temelju podataka iz literature prikazati suvremene spoznaje o etiologiji, klasifikaciji, dijagnostici i liječenju puknuća meniska

Veća učestalost revizijskih zahvata i aseptičkog razlabavljenja totalnih endoproteza koljena sa stražnjom stabilizacijom u usporedbi s totalnom endoprotezom koljena s očuvanim stražnjim križnim ligamentom istog tipa endoproteze – retrospektivna studija jednog centra na 580 koljena

The purpose of this study was to evaluate the 4-year survivorship of total knee arthroplasty (TKA) of a single manufacturer and determine whether failure rates differ between the cruciate-retaining (CR) and the posterior-stabilised (PS) type of implant. In addition, possible causes of revision were analysed as well. A retrospective analysis of 580 TKAs, with either the CR or the PS type of the Biotech Future Knee endoprosthesis (BIOTECH GmbH, Garbsen-Berenbostel, Germany) was performed. The 4-year survivorship for revision of any cause in all cases was 89.14%, with aseptic loosening being the most common cause of revision (53.9%). Regarding the type of implant model, the revision rate was higher in the PS group compared to the CR group (13.7% to 8.0%, respectively, p=0.027). The Cox regression models suggested that the type of prosthesis was a significant predictor of the need for revision (HR, 0.442; 95% CI, 0.234-0.833). In conclusion, our study has shown higher revision rates with the PS implant type when compared to the CR implant type with a higher rate of aseptic loosening in the PS group. Further studies are needed to determine the cause of these results and to investigate whether the problem is specific to the implant.Primarne endoproteze koljena razlikuju se u dizajnu s obzirom je li stražnja ukrižena sveza održana (CR) ili žrtvovana (PS). Cilj istraživanja bio je ispitati 4-godišnje preživljenje totalne endoproteze koljena jednog proizvođača te utvrditi postoje li razlike s obzirom na CR ili PS dizajn endoproteze. Također, analizirani su mogući uzroci revizijskih zahvata. Retrospektivno je analizirano 580 koljenskih (PS i CR) endoproteza Biotech Future Knee (BIOTECH GmbH, Garbsen-Berenbostel, Germany). Ukupno 4-godišnje preživljenje ispitivanih endoproteza je 89.14%, a kao najčešći uzrok revizijskog zahvata zabilježeno je aseptičko razlabavljenje endoproteze (53.9%). S obzirom na dizajn endoproteze, postotak revizijskih zahvata je bio viši u PS nego u CR grupi(13.7% i 8.0%, p=0.027). Coxov regresijski model upućuje na dizajn endoproteze kao značajan prediktor potrebe za revizijskim zahvatom (HR, 0.442; 95% CI, 0.234-0.833). U zaključku, ovo istraživanje utvrdilo je viši postotak revizijskih zahvata kod PS dizajna u usporedbi s CR dizajnom endoproteze. Potrebne su dodatne studije kako bi se utvrdilo je li opažena razlika specifična za dizajn endoproteze ili ispitivani implantat

Articular cartilage repair techniques exploiting intrinsic healing capacity – which one is the best?

In this review article articular cartilage structure and organization is explained, followed by brief discussion on articular cartilage focal lesion development and subsequent endogenous regeneration, which mainly relies on presence of intrinsic healing capacity. In case of full thickness focal chondral defects intrinsic healing ability is insufficient and full spontaneous repair is almost never achieved. In those cases, cartilage repair techniques are indicated. Currently, the most commonly used articular cartilage repair techniques include three groups of techniques such as: bone marrow stimulation, osteochondral allografting/autografting and autologous chondrocyte implantation. These groups are further divided to specific cartilage repair techniques, discussed in detail and compared to other approaches. The information provided is intended to allow proper critical judgment and to answer the question “Which articular cartilage repair technique is the best for the particular patient?”

Primjene i kritička evaluacija bloka odjeljka fascije iliace i quadratus lumborum bloka u ortopedskim zahvatima

Anterior section of the hip joint capsule is innervated by femoral nerve and obturator nerve, and posterior section is innervated by the nerve to quadratus femoris muscle and occasionally by the superior gluteal (posterolateral region) and sciatic nerve (posterosuperior region). One of the regional anesthesia options for hip surgery is the fascia iliaca compartment block (FICB) that affects nerves important for hip innervation and sensory innervation of the thigh - femoral, obturator and lateral femoral cutaneous nerve. FICB can be easily performed and is often a good solution for management of hip fractures in emergency departments. Its use reduces morphine pre-operative requirement for patients with femoral neck fractures and can also be indicated for hip arthroplasty, hip arthroscopy and burn management of the region. Quadratus lumborum block (QLB ) is a block of the posterior abdominal wall performed exclusively under ultrasound guidance, with still unclarified mechanism of action. When considering hip surgery and postoperative management, the anterior QLB has shown to reduce lengthy hospital stay and opioid use, it improves perioperative analgesia in patients undergoing hip and proximal femoral surgery compared to standard intravenous analgesia regimen, provides early and rapid pain relief and allows early ambulation, thus preventing deep vein thrombosis and thromboembolic complications etc. However, some nerve branches responsible for innervation of the hip joint are not affected by QLB , which has to be taken into consideration. QLB has shown potential for use in hip surgery and perioperative pain management, but still needs to be validated as a reliable treatment approach.Prednji dio čahure zgloba kuka nerviraju n. femoralis i n. obturatorius, dok stražnji dio čahure inervira n. musculi quadratus femoris i povremeno n. glutealis superior (posterolateralni dio) i n. ischiadicus (posterosuperiorni dio). Jedna od mogućnosti za primjenu regionalne anestezije u kirurgiji zgloba kuka je blok odjeljka fascije iliace (FICB), koji zahvaća živce bitne za inervaciju kuka te senzornu inervaciju bedra – n. femoralis, n.obturatorius i n. cutaneus femoris lateralis. FICB se može izvesti relativno jednostavno i predstavlja dobru opciju za zbrinjavanje fraktura kuka u hitnim situacijama. Dokazano je kako smanjuje upotrebu morfija preoperativno u pacijenata s frakturom vrata femura, a može biti indicirani za artroplastiku kuka, artroskopije kuka te sanaciju opeklina u regiji bedra. Quadratus Lumborum blok (QLB ) spada u blokove stražnjeg abdominalnog zida te se provodi isključivo pod kontrolom ultrazvuka. Još uvijek nije razjašnjen točan mehanizam njegovog djelovanja. Dokazano je kako prednji QLB dovodi do smanjenja trajanja boravka u bolnici i smanjenja upotrebe opioida nakon operacija kuka. Također, pokazao se kao uspješnija metoda perioperativne analgezije u bolesnika u kojih se provodi zahvat na kuku ili proksimalnom femuru u usporedbi sa standardnom intravenskom analgezijom, te omogućuje ranu mobilizaciju pacijenata, što smanjuje pojavnost duboke venske tromboze i tromboembolijskih komplikacija. S druge strane, neki živčani ogranci koji sudjeluju u inervaciji zgloba kuka nisu zahvaćeni s QLB , što također treba uzeti u obzir. QLB se pokazao kao potencijalna opcija za anesteziju u kirurgiji kuka, no tek se treba dokazati njegova pouzdanost

Rekonstrukcija prednjeg križnog ligamenta i anterolateralnog ligamenta koljena tetivama kvadricepsa i plantarisa

Anterior cruciate ligament (ACL) reconstructions with quadriceps tendon (QT) grafts are gaining popularity, both in primary and revision procedures. Recently, the role of the anterolateral ligament (ALL) of the knee in improving rotational knee stability has been emphasised and concurrent ACL and ALL reconstruction is advocated. In this paper, a new technique utilising the QT and the plantaris tendon (PLT) for combined ACL and ALL reconstruction is analysed. Patients that underwent combined ACL and ALL reconstruction using QT and PLT grafts in a 3-years period were prospectively analysed. A total of 9 patients with 6 months minimum follow-up were assessed with Lachman and Pivot shift clinical tests, International Knee Documentation Committee (IKDC) score, Knee injury and Osteoarthritis Outcome Score (KOOS), Lysholm score, and Tegner activity scale. One patient had reconstructed ACL re-rupture at the final follow-up visit, leaving 8 patients with a mean follow-up of 19±8 months. There was a significant improvement in anteroposterior and rotational stability in all the patients. The IKDC, KOOS, and Lysholm scores improved as well. The Tegner activity scale increased postoperatively, however, it did not reach preinjury values. QT and PLT grafts are valuable alternatives for currently used grafts in combined ACL and ALL reconstructive procedures. This new technique is a reasonable option in ACL revision surgery and a good alternative in primary ACL and ALL reconstruction, especially when hamstring grafts are not advised or they are missing.Rekonstrukcija prednjeg križnog ligamenta (ACL) presatkom tetive kvadricepsa (QT) kod primarnih i revizijskih zahvata postaje sve učestalija. Nedavno je istaknuta uloga anterolateralnog ligamenta (ALL) u poboljšanju rotacijske stabilnosti koljena te se zagovara istodobna rekonstrukcija ACL-a i ALL-a. U ovom radu analizirana je nova kirurška tehnika kombinirane rekonstrukcije ACL-a i ALL-a koja koristi QT i tetivu plantarisa (PLT). Prospektivno su praćeni pacijenti kojima je učinjena udružena rekonstrukcija ACL-a i ALL-a presadcima QT i PLT u razdoblju od 3 godine. Ukupno je analizirano 9 pacijenata s minimalno 6 mjeseci praćenja. Koristili su se klinički testovi Lachman i Pivot shift te upitnici procjene ishoda: International Knee Documentation Committee (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS), Lysholm i Tegnerova ljestvica aktivnosti. Kod svih pacijenata je došlo do značajnog poboljšanja u anteroposteriornoj i rotacijskoj stabilnosti. Rezultati IKDC, KOOS i Lysholm upitnika također su se poboljšali. Tegnerova ljestvica aktivnosti se postoperativno poboljšala, ali nije dosegla vrijednosti prije ozljede. Jedan je pacijent zadobio rerupturu ACL-a u vrijeme posljednjeg pregleda, ostavljajući 8 pacijenata s prosječnim praćenjem od 19±8 mjeseci. Presadci QT i PLT vrijedna su alternativa za trenutno korištene presatke u zahvatima udružene rekonstrukcije ACL-a i ALL-a. Ova nova tehnika razumna je opcija u revizijskim zahvatima rekonstrukcije ACL-a i dobra alternativa u primarnoj rekonstrukciji ACL-a i ALL-a, osobito kada se ne preporuča koristiti tetive fleksora koljena ili one nedostaju

Regeneration of the Skeleton by Recombinant Human Bone Morphogenetic Proteins

Recombinant human bone morphogenetic proteins (rhBMPs) have past a long journey in human orthopaedic surgery during the last 15 years. From the first reports of the use of rhBMPs in hostile environments such as critically-sized bone defects, avascular femoral head necrosis, unstable thoracolumbar vertebral fractures, instability between the atlas and axis due to rheumatoid arthritis; over the use for nonunions of long bones and the scaphoid, reconstructive and revision surgeries of the hip, acute fractures, allograft nonunions, congenital pseudarthrosis, and various approaches of lumbar and cervical spine fusions, rhBMPs overgrow to a safe and reliable device in the treatment of open tibial shaft fractures, nonunions of long bone fractures, anterior lumbar interbody fusion and revision posterolateral lumbar fusions. Systematic review of the published literature of rhBMPs is presented

Distribucija sialoglikokonjugata - gangliozida i PSA-NCAM u mozgu dviju zmija otrovnica: Vipera ammodytes i Vipera berus bosniensis

The Bosnian adder (Vipera berus bosniensis) and the horned viper (Vipera ammodytes) are two venomous snake species with different ecological preferences. The Bosnian adder occurs in a range of habitats and is endemic to the Balkan Peninsula, while the horned viper thrives in dry, rocky areas with little vegetation. The horned viper is best known for its highly venomous venom, making it the most dangerous of the European vipers. The aim of this study was to compare the expression and distribution of complex gangliosides and to identify migratoryzones in the brain of Bosnian adder and horned viper. Immunohistochemistry was performed using specific antibodies for the major brain gangliosides (GM1, GD1a, GD1b, GT1b) and PSA NCAM and analysed in different brain regions. Both snake species showed expression of all four complex gangliosides with similar distribution patterns. GD1b was the most prominent ganglioside expressed in all brain structures, while GM1 showed varying distribution between the species. The strongest expression of PSA NCAM was observed in the periventricular zones of the telencephalon, suggesting that these areas are associated with neurogenesis, whereas other regions with lower expression may serve as migratory zones. In addition, it is important to note that the specific distribution of gangliosides and PSA NCAM may be influenced by factors such as brain region, developmental stage, and species-specific characteristics.Bosanska riđovka (Vipera berus bosniensis) i poskok (Vipera ammodytes) dvije su otrovne vrste zmija različitih ekoloških preferencija. Bosanska se riđovka javlja u različitim staništima i endem je Balkanskog poluotoka, dok poskok obitava u suhim, stjenovitim područjima s malo vegetacije i najpoznatija je zmija po vrlo otrovnom otrovu, što ga čini najopasnijom od europskih zmija. Cilj je ovog rada bio usporediti ekspresiju i distribuciju složenih gangliozida i identificirati migracijske zone u mozgu bosanske riđovke i poskoka. Imunohistokemija je provedena pomoću specifičnih protutijela za glavne gangliozide mozga (GM1, GD1a, GD1b, GT1b) i PSA NCAM čija je ekspresija i distribucija analizirana u različitim regijama mozga. Obje vrste zmija pokazale su ekspresiju sva četiri složena gangliozida sa sličnim obrascima distribucije. GD1b je bio najistaknutiji gangliozid izražen u svim moždanim strukturama, a GM1 je pokazao različitu raspodjelu između dviju vrste. Najjača ekspresija PSA NCAM uočena je u periventrikularnim zonama telencefalona, a to sugerira da su ta područja povezana s neurogenezom, dok druge regije s nižom ekspresijom predstavljaju migracijske zone. Važno je napomenuti da na specifičnu distribuciju gangliozida i PSA NCAM mogu utjecati i drugi čimbenici kao što su: regija mozga, razvojna faza životinje i karakteristike specifične za vrstu. Stoga proučavanje njihove distribucije u različitim životinjskim vrstama pruža uvid u raznolikost i evoluciju sialoglikokonjugata u kontekstu razvoja i funkcije neurona

LIGAMENT WHICH DESERVES ATTENTION – MEDIAL PATELLOFEMORAL LIGAMENT

Istraživanja medijalnoga patelofemoralnog ligamenta (MPFL) došla su u žarište interesa tijekom posljednjih petnaestak godina. Razlog tomu su činjenice što je MPFL primarni medijalni pasivni stabilizator patele i što je gotovo uvijek ozlijeđen nakon primarne luksacije patele. Mehanička su mu svojstva nakon ozljede narušena i nikada se ponovno ne postiže njegova puna funkcija. Brojne kirurške tehnike rekonstrukcije MPFL-a opisane su u literaturi. U ovom članku dan je detaljan pregled suvremenih spoznaja o anatomiji i biomehanici MPFL-a. Prikazane su različite tehnike rekonstrukcije MPFL-a s posebnim osvrtom na metodu rekonstrukcije MPFL-a dijelom tetive kvadricepsa koju i rabimo u svojoj ustanovi.There has been increasing interest in investigating the medial patellofemoral ligament (MPFL) during the last fifteen years. This is due to the recognition of the MPFL as the primary static soft-tissue restraint to lateral patellar displacement and the association of MPFL injury with primary traumatic patellar dislocation. The MPFL often heals poorly and thus rarely regains its full function. Numerous surgical techniques have been described for reconstruction of this important structure. This paper reviews the relevant anatomy and biomechanics, published reconstruction options, and describes the surgical technique performed at our institution – that of using a quadriceps autograft to reconstruct the MPFL

Plantaris muscle tendon – a novel graft in new operation technique for combined anterior cruciate and anterolateral ligament reconstruction of the knee

Mišić plantaris je mali mišić površnog stražnjeg odjeljka noge karakteriziran najdužom tetivom u ljudskom tijelu. Istraživanja ukazuju da je plantaris rudimentarni mišić sa zanemarivom biomehaničkom funkcijom. Tetiva mišića plantarisa odavno je prepoznata kao lako dostupan presadak kod raznih rekonstruktivnih zahvata u ortopediji. Anterolateralni ligament koljena predstavlja važan čimbenik uspostave rotacijske stabilnosti kod koljena kojem nedostaje funkcija prednjeg križnog ligamenta. Tetiva mišića plantarisa ima odlična biomehanička svojstva za rekonstrukciju anterolateralnog ligamenta. U ovom kratkom preglednom radu prikazana je nova operacijska tehnika zajedničke rekonstrukcije prednjeg križnog ligamenta i anterolateralnog ligamenta koljena uz presatke tetiva mišića semitendinozusa i plantarisa.Plantaris muscle is a fusiform muscle of the superficial posterior leg compartment. It is characterized by the longest tendon in humans. Reports suggest that plantaris muscle is rudimentary with a minor biomechanical function. Plantaris tendon is a well known and accessible graft for various reconstructive procedures. The anterolateral ligament has recently been recognized as an important structure in restoring the rotational stability of the anterior cruciate ligament deficient knee. Plantaris tendon has excellent biomechanical properties for anterolateral ligament reconstruction. The present study describes a new combined anterior cruciate ligament and anterolateral ligament reconstruction technique using plantaris tendon and semitendinosus tendo