FORTY YEARS OF TOTAL HIP REPLACEMENT IN CROATIA AT THE DEPARTMENT OF ORTHOPAEDIC SURGERY ZAGREB – ORTHOPEDIC SURGERY OF THE 20TH CENTURY

Četrdeset je godina prošlo od prve ugradnje totalne endoproteze zgloba kuka (TEP) u Hrvatskoj, što je revolucioniralo liječenje niza stanja koja za posljedicu imaju disfunkciju kuka i rezultiralo znatnim poboljšanjem sposobnosti i kvalitete života oboljelih. Suvremeni napredak u razvoju endoproteza zgloba kuka usko je vezan s rastućom primjenom biotehnologije u ortopediji, što rezultira implantatima koji su biološki, konstrukcijski i biomehanički prihvatljiviji nego što je to bilo na samom početku. Također, razvijaju se i operacijske tehnike, poput mini invazivne kirurgije ili kompjutorski asistirane operacije koje omogućuju gotovo idealnu ugradnju endoproteze. U Hrvatskoj se, od 1970. godine kada je ugrađena prva totalna endoproteza, razmjerno mogućnostima prate noviteti u primjeni endoproteze zgloba kuka.Forty years have elapsed since the first total hip arthroplasty in Croatia, a procedure that has revolutionized treatment of a whole range of states resulting in hip dysfunction and has brought about significant improvements in restoring functional ability and quality of life of the affected patients. Modern progress in the development of the hip joint endoprosthetics is closely connected to a growing application of biotechnology resulting in implants with greatly improved biological, constructional and biomechanical properties as compared to the pioneering efforts. Additionally, developments of the surgical techniques, such as mini-invasive surgery or computer-assisted surgery enable almost ideal arthroplasty. Since 1970, when the first total hip arthroplasty was performed in Croatia, constant endeavor is being made in order to follow-up the ever evolving progress in the total hip endoprosthetics

Anesteziološki pristup kod akutne ozljede vratne kralježnice u trudnoći

The incidence of traumatic spinal cord injury is 11,000 per year, with 55% of the injuries occurring between the age of 16 and 33, 18% of these in women of reproductive age. Diagnostic and early spinal decompression along with maintaining the mean arterial pressure to improve spinal cord perfusion and a high progesterone level in pregnancy for its neuroprotective and anti-inflammatory effect have the leading role in neurological recovery and clinical outcome. We present a case of a patient in the 17th week of pregnancy who sustained luxation fracture of the C5 and C6 vertebrae and tetraplegia as passenger in a road accident. The early operative treatment and appropriate anesthetic procedure resulted in good clinical outcome with complete neurological recovery.Učestalost traumatskih ozljeda kralježnice je 11.000 na godinu, a 55% ozljeda nastaje u dobi od 16 do 33 godine, od toga 18% u žena reproduktivne dobi. Radiološka dijagnostika, uz ranu kiruršku dekompresiju kralježnice s održavanjem srednjeg arterijskog tlaka za očuvanje perfuzije leđne moždine, uz progesteron kao neuroprotektivni i protuupalni faktor u akutnoj traumi leđne moždine, ima vodeće mjesto u neurološkom oporavku i dobrom kliničkom ishodu. Donosimo prikaz slučaja trudnice u 17. tjednu trudnoće koja je zadobila luksacijsku frakturu petog i šestog vratnog kralješka s razvojem tetraplegije, kod koje su rano operacijsko liječenje i odgovarajući anesteziološki postupak doveli do dobrog kliničkog ishoda

Tumori kosti u djece: učestalost, dijagnoza, kirurško liječenje i komplikacije

Bone tumor treatment changed considerably during past decades. Due to improvements in basic research in the areas of tumor biology, tumor detection and imaging, surgical procedures and development of modern surgical instruments, discovery and use of new technical equipment, and especially in the use of chemotherapy and radiotherapy, significant progress has been achieved. About 100 new patients with primary bone tumor (both benign and malignant) are discovered in Croatia and treated at the Department of Orthopedic Surgery, Clinical Hospital Center Zagreb and Zagreb University School of Medicine per year, and almost a half of them (45%) are younger than 20 years. The most common benign bone tumors are osteochondroma, simple (juvenile) bone cyst, and osteoid osteoma, and the most common malignant bone tumors are osteosarcoma and Ewing’s sarcoma. Bone tumors are localized mostly in the long bones (femur, tibia, humerus), and the knee joint region is the most common site of tumors. Patient history and examination with laboratory and imaging methods remain the essence in tumor diagnosis. A conventional X-ray examination must be the first and the most important part in tumor imaging, followed by bone scan, CT, MRI, ultrasound, and histological or cytological analysis. The biopsy, as the most accurate method in tumor diagnosis must be performed as the last diagnostic procedure. Cytological analysis is useful in tumors with soft tissue. An individual approach to patient is essential in order to choose the most suitable surgical treatment for bone tumor. Depending on the tumor type, location and other patient-related risk factors, one of the various forms of surgical therapy should be chosen. Limb salvage surgery means “en-bloc” tumor resection with the affected part of the bone through a healthy tissue and defect reconstruction, with preservation of the affected limb; this procedure is performed nowadays in about 85% of patients with malignant bone tumors. Reconstruction can be biologic (with bone auto- or homotransplant) or with foreign material (i.e. endoprosthesis or bone cement). Soft tissue reconstruction is a great challenge in this part of a treatment, and complications are not rare. Amputation still has and will have in the future an important place in treating patients with malignant bone tumor. Decision on additional chemo- and/or radiotherapy should be made between pediatric, oncology and orthopedic surgeons, according to international guidelines. Future devolvement in treating patients with bone tumors points into supporting and/or establishing reparative procedures. Bone and surrounding tissue regeneration is always better than defect reconstruction.Liječenje tumora kosti posljednjih se desetljeća znatno promijenilo. Zahvaljujući napretku temeljne znanosti u području biologije tumora, boljoj mogućnosti otkrivanja i snimanja tumora, kirurškim metodama i suvremenim kirurškim instrumentima, otkriću i primjeni nove tehničke opreme, a posebice kemoterapiji i radioterapiji postignuto je mnogo. U Hrvatskoj se godišnje otkrije oko 100 novih bolesnika s primarnim tumorom kosti (dobroćudnih i zloćudnih) i toliko ih se liječi u Klinici za ortopediju Kliničkog bolničkog centra Zagreb i Medicinskog fakulteta Sevučilišta u Zagrebu, a gotovo polovica tih bolesnika (45%) mla|a je od 20 godina. Najčešći dobroćudni tumori kosti su osteohondrom, jednostavna (juvenilna) koštana cista i osteoidni osteom, dok su najčešći zloćudni tumori kostiju osteosarkom i Ewingov sarkom. Tumori kostiju uglavnom se nalaze u dugim kostima (femur, tibija, humerus), a najčešće sijelo tumora je područje koljenoga zgloba. Povijest bolesti i pregled upotpunjen laboratorijskim i radiološkim nalazima i dalje su temelj za postavljanje dijagnoze tumora. Konvencionalni rtg pregled mora biti prvi i najvažniji dio snimanja tumora, nakon čega slijede scintigrafija, CT, MRI, ultrazvuk te histološka ili citološka analiza. Biopsija je najtočnija metoda u dijagnozi tumora i zadnji dijagnostički postupak koji se mora obaviti. Citološka analiza je korisna kad je riječ o tumorima mekog tkiva. Individualni pristup bolesniku nužan je za izbor najprikladnijeg oblika kirurškog liječenja tumora kosti. Izbor - kirurške terapije ovise o vrsti tumora, sijelu i ostalim čimbenicima rizika svakog pojedinog bolesnika. Kirurgija spašavanja ekstremiteta znači resekciju tumora ’en bloc’ sa zahvaćenim dijelom kosti kroz zdravo tkivo i rekonstrukcijom defekta, uz sačuvanje zahvaćenog ekstremiteta; taj se postupak danas primjenjuje u oko 85% bolesnika sa zloćudnim tumorima kosti. Rekonstrukcija se može izvesti biološki (auto- ili homotransplantatom) ili stranim materijalom (endoprotezom ili koštanim cementom). Rekonstrukcija mekog tkiva velik je izazov u tome dijelu liječenja i komplikacije nisu rijetka pojava. Amputacija još uvijek ima i ubuduće će imati važno mjesto u liječenju bolesnika sa zloćudnim tumorima kosti. Odluku o naknadnoj primjeni kemo- i/ili radioterapije zajedno trebaju donijeti pedijatar, onkolog i ortopedski kirurg u skladu s me|unarodnim smjernicama. Daljnja zadaća u liječenju bolesnika s tumorima kosti jest podupirati i/ili odrediti reparativne postupke. Regeneracija kosti i okolnoga tkiva uvijek je bolja solucija od rekonstrukcije defekta

Croatian rotatory oblique three-dimensional osteotomy (CROTO) - a modified Wilson's osteotomy for adult hallux valgus intended to prevent dorsal displacement of the distal fragment and to reduce shortening of the first metatarsal bone

Aim: To evaluate biomechanical and clinical outcomes of a newly developed modification of the Wilson's osteotomy for hallux valgus: a three-dimensional subcaptial correction of the metatarsal head position with a simultaneous lateral and plantar shift with derotation intended to reduce displacement of the distal fragment and shortening of the first metatarsal bone. ----- Methods: Thirty four feet (28 female patients) underwent the new procedure and were evaluated before and 12 to 84 months (median=25.5) after the surgery. ----- Results: Plantar shift of the distal fragment was achieved in all feet. Shortening of the first metatarsal was moderate: ≤6 mm in 32/34 feet, 7 and 10 mm in the remaining two. Median difference in metatarsal index post- vs. pretreatment was -4.0. The hallux valgus angle, intermetatarsal and distal metatarsal articular angles were reduced in all feet. The American Orthopaedic Foot and Ankle Society score improved in all feet (median increase= 51.5). ----- Conclusion: The method allows for a lateral and plantar shift with derotation of the distal fragment and a mild/moderate shortening of the first metatarsal bone

Utjecaj preoperativne fizioterapijske pripreme kod pacijenata upućenih na ugradnju totalne enduproteze kuka

Uvod: Artroza zglobova jedan je od vodećih uzroka boli i nesposobnosti u svijetu, a najčešće zahvaćeni zglobovi su koljena i kukovi. Pacijenti se odlučuju na operativni zahvat ugradnje totalne endoproteze kuka kako bi se smanjila bol, povećala mobilnost i poboljšalo izvođenje aktivnosti svakodnevnog života te na taj način poboljšala kvaliteta života. Preoperativna fizioterapija je potencijalan način ubrzanja vremena oporavka i općenitog poboljšanja pacijentova stanja koji je upućen na ugradnju totalne endoproteze. Cilj: Utvrđivanje razlike u funkcionalnim sposobnostima nakon ugradnje totalne endoproteze kuka između ispitanika s kojima je provedena preoperativna fizioterapijska priprema i kod kojih nije provedena preoperativna fizioterapijska priprema. Materijali i metode: Uzorak čini 30 ispitanika za operativni zahvat ugradnje totalne endoproteze kuka. U ispitivanoj skupini (N=15) nalaze se ispitanici koji su imali preoperativnu fizioterapijsku pripremu i postoperativnu fizioterapijsku intervenciju, dok su ispitanici u kontrolnoj skupini (N=15) imali samo postoperativnu fizioterapijsku intervenciju, Provedeno je mjerenje opsega pokreta fleksije kuka i abdukcije kuka pomoću goniometra, Numerička skala za procjenu intenziteta boli te 10 Meter Walk Test, Timed Up and Go Test i upitnici Oxford Hip Score i Harris Hip Score za procjenu funkcionalne sposobnosti. Mjerenje je provedeno u preoperativnom danu te treći i deseti postoperativni dan. Rezultati: Nije dobivena statistički značajna razlika u preoperativnom mjerenju između skupina. Prisutna je statistički značajna razlika treći postoperativni dan kod ispitivane skupine u abdukciji kuka (p=0,001) i Harris Hip Score testu (p=0,021), te desti postoperativni dan u abdukciji kuka (p=0,042), 10 Meter Walk Test (p=0,047), Timed Up and Go Test (p=0,028) te Oxford Hip Score (p=0,035) i Harris Hip Score (p=0,006). Zaključak: Properativna fizioterapijska priprema utječe na povećanje funkcionalne sposobnosti nakon operativnog zahvata ugradnje totalne endoproteze kuka

GENETIC BACKGROUND OF ASEPTIC INSTABILITY AFTER TOTAL HIP ARTHROPLASTY

Ugradnja totalne endoproteze zgloba kuka dramatično je unaprijedila liječenje niza bolesti zgloba, no ta je metoda, s druge strane, pogodovala nastanku nove bolesti – periprostetske osteolize s posljedičnom aseptičkom nestabilnosti endoproteze. Aseptička nestabilnost najčešća je kasna komplikacija ugradnje endoproteze i glavni uzrok njezine nestabilnosti, odnosno nefunkcionalnosti. Molekularni i stanični mehanizmi ove komplikacije vrlo su opsežno istraženi i jasno je pokazana važnost protetskog materijala i oblikovanja u njezinu nastanku. No, prepoznata je i činjenica da postoji određena individualna sklonost njezinu nastanku koja nije određena ni svojstvima endoproteze ni demografskim ili morbiditetnim svojstvima bolesnika. Posljednjih je godina provedeno nekoliko manjih studija koje su pokušale definirati »genetsku podlogu individualne sklonosti« aseptičkoj nestabilnosti. Sve su slijedile istu logiku – tražena je veza između komplikacije i gena koji kodiraju za medijatore upale i/ili koštanog remodeliranja, posebice onih s poznatim polimorfizmima koji utječu na ekspresiju/aktivnost. Do sada su pronađene neke združenosti, što ovom pristupu daje, barem teorijski, potencijal da rezultira sustavom razmjerno pouzdanog predviđanja individualnog rizika, koji bi pak mogao utjecati na individualizaciju u odabiru protetskih materijala, programa postoperativne terapije ili terapije lijekovima. Međutim ova su istraživanja u ranoj fazi. Budući napori trebali bi biti usmjereni prema a) definiranju genskih markera – pouzdanih prediktora i b) definiranju funkcionalnih veza između određenih genskih markera i aseptičke nestabilnosti. Ti su ciljevi neostvarivi bez primjene tehnika proteomske analize.Total hip arthroplasty (THA) has dramatically improved the treatment of an entire range of hip joint diseases. On the other hand, however, it has favored the development of a new disease – periprosthetic osteolysis with a consequent instability of THA. Aseptic instability is the major late complication of THA and the main reason of its malfunction. Molecular and cellular mechanisms of this complication have been thoroughly studied. The importance of prosthetic materials and design have been clearly demonstrated. However, existence of individual susceptibility to development of this complication that is determined neither by endoprothesis properties nor by demographic or morbidity characteristics of a patient has also been recognized. In the recent years, several smaller studies have tried to define the »genetic background of the individual susceptibility« towards the development of aseptic instability. All these studies followed the same logic – they searched for a link between the complication and genes coding for mediators of inflammation and/or bone remodeling, particularly those with known polymorphisms that influence expression/activity. Several associations have been found indicating, at least theoretically, a potential of developing a system of relatively reliable individual risk prediction, which in turn could result in individualized choice of prosthetic material, postoperative therapy programs and medication therapy. However, this research is at an early stage and future efforts should be focused on a) identification of genetic markers – reliable predictors and b) identification of functional links between particular genetic markers and aseptic instability. It is impossible to meet these goals without application of techniques of proteomic analysis

Carpal tunnel syndrome - modern diagnostic and therapy

Sindrom karpalnog tunela najcešca je kompresivna neuropatija na ljudskom tijelu koja se manifestira ispadima u inervacijskom podrucju živca medianusa s ucestalošcu izmedu 50 i 150 slucajeva na 100.000 stanovnika. Simptomatika ovisi o trajanju i jacini kompresije živca. Smetnje senzibilnosti prvi su i najstalniji simptom, dok motoricke smetnje nastaju u bolesnika s dugotrajnom kompresijom živca. Elektroneurofiziološka dijagnostika "zlatni je standard” u postavljanju dijagnoze, a potrebno ju je uciniti kod svake klinicke sumnje na sindrom karpalnog tunela. Kao dodatna dijagnosticka sredstva u atipicnim slucajevima mogu poslužiti ultrazvuk i magnetska rezonancija karpalnog tunela. Neoperacijsko lijecenje rezervirano je za lakše oblike kompresije živca, te kod pojave sindroma u tranzitornim stanjima, kao što su trudnoca, laktacija, korištenje oralnih kontracepcijskih sredstava i sl. Metoda izbora za perzistentne i progresivne oblike sindroma karpalnog tunela, kao i za one koji ne reagiraju na konzervativnu terapiju, operacijsko je lijecenje. Dekompresija živca medianusa efikasan je i siguran zahvat koji u najvecem broju slucajeva oslobada pacijenta od tegoba. Sam zahvat može se izvršiti metodom "otvorenog polja” ili endoskopski, iako za sada nema pokazatelja o prednosti endoskopske tehnike u odnosu na klasicnu tehniku "otvorenog polja”, a jatrogena oštecenja živca medianusa daleko su cešca pri endoskopskoj tehnici. U svakodnevnoj praksi najvece znacenje ima rano prepoznavanje sindroma karpalnog tunela, te njegovo pravodobno i adekvatno lijecenje. U suprotnom dolazi do nepotrebno dugog trajanja smetnji za pacijenta i težeg oštecenja živca, što smanjuje izglede uspješnog lijecenja, te dovodi do nepotrebnih ekonomskih gubitaka.Carpal tunnel syndrome is the most common compressive neuropathy in the human body, which is expressed by a deficit in the median nerve innervation area, with prevalence of 50 to 150 cases per 100.000 inhabitants. Symptoms depend on nerve compression duration and intensity. Sensibility disorders are the first and one of the most persistent symptoms, while motoric disorders arise in patients with prolonged nerve compression. Electroneurophysiological diagnostics is a "golden standard” in diagnosis setting, and it is necessary to be done in every patient with a clinical doubt on carpal tunnel syndrome. Additional diagnostics means in atypical cases can be performed by ultrasound and magnetic resonance of the carpal tunnel. Non-surgical treatment is reserved for mild forms of nerve compression, and in cases of syndrome in temporary conditions like pregnancy, lactation, taking oral contraceptives etc. The method of choice for persistent and progressive forms of carpal tunnel syndrome, as well for those who don\u27t respond to the conservative treatment, is surgery. Decompression of median nerve is an efficient and secure procedure, which, in most cases, releases the patient from its symptoms. Procedure can be performed by an "open field” method or via endoscopy, although, for now, no indicators on advantages of endoscopic technique vs. classical technique of an "open field” have been found, and iatrogenous damage of the median nerve are much more frequent in surgery via endoscopy. In everyday practice, the most important is early recognition of the carpal tunnel syndrome, and its timely and adequate treatment. On the contrary, unnecessaryprolongation of the condition leads to much more severe nerve damage, which diminishes chances for a successful treatment and causes necessary economy losses

Intraoperacijska navigacija detekcijskom gama sondom kod resekcije osteoidnog osteoma – prikaz dvaju slučajeva

Two cases of osteoid osteoma tumor (OO ) are presented and our early experience with intraoperative gamma probing to localize OO during surgery is reported. The concept of radioguided surgery was developed 60 years ago and the gamma detection probe technology for radioguided biopsy and/or resection of bone lesions has been applied since the early 1980s. Bone scintigraphy is very important for initial diagnosis of OO with almost 100% sensitivity. The bone scan finding is specific, with so called double density appearance, very intense accumulation of radiopharmaceutical in the nidus and therefore great difference between the nidus and the surrounding healthy bone, thus making possible to treat this lesion with probe guided surgery. Three phase bone scintigraphy and single photon emission computed tomography were conducted in our patients for initial diagnosis of OO . A second bone scintigraphy was performed before surgery. The surgery followed 12-15 hours later by intraoperative nidus detection with a hand-held gamma probe. Gamma hand-held probe is a system that detects gamma photons. The count rate in the nidus area on the day of surgery was 3 to 4 times higher than in the healthy bone area. Drilling was performed until the counts decreased to the level of the surrounding bone counts, thereby confirming complete excision. This is the method of choice for minimizing bone resection, the risk of pathologic fracture, the need of bone grafting, and reducing the period of convalescence. Evidence for the treatment efficiency is pain disappearance after the surgery.U radu se prikazuju dva klinička slučaja kod kojih smo koristili detekcijsku gama sondu za intraoperacijsku navigaciju prilikom kiretaže tumora osteoidnog osteoma (OO ). Zahvati su izvršeni na Klinici za traumatologiju Kliničkog bolničkog centra “Sestre milosrdnice”. Koncept radionavigacije u kirurgiji razvijao se zadnjih 60 godina, a primjena tehnologije gama detekcijske sonde za biopsiju ili resekciju koštanih lezija datira od ranih osamdesetih. Uz RTG te kompjutoriziranu tomografiju scintigrafija kosti je jedna od najvažnijih metoda u dijagnostici OO , s gotovo 100%-tnom osjetljivošću. Za početnu dijagnozu učinjena je trofazna scintigrafija kosti i SPE CT – jednofotonska emisijska kompjutorizirana tomografija. Druga scintigrafija kosti učinjena je prije zahvata. Operacija je uslijedila 12-15 sati kasnije uz intraoperacijsko otkrivanje gnijezda ručnom gama sondom. Na dan operacije brojčana vrijednost bila je 3-4 puta viša na mjestu lezije u odnosu na zdravu kost. Kiretaža tumora provođena je sve dok brojčana vrijednost nije pala na razinu vrijednosti okolne kosti, na taj način potvrđujući potpuno uklanjanje lezije. Ovo je jedna od metoda izbora liječenja OO , jer na najmanju mjeru svodi resekciju kosti te time smanjuje rizik od mogućih patoloških prijeloma i skraćuje razdoblje rekonvalescencije. Dokaz uspješnosti kirurškog zahvata bio je nestanak boli u operiranih bolesnika