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Opisani su kirurški zahvati i komplikacije u pacijenata na biološkoj terapiji.

In the past 60 years, primary THA has been one of the most successful and most performed orthopaedic procedure. Over the years, hip arthroplasty has changed, and research continues to improve its results. Better materials and design provide patients with an increased range of motion with enhanced stability and very low wear. In recent years, there have been a number of reports describing the performance of THA through smaller incisions using minimally invasive surgical techniques, aimed to spare the soft tissue, especially the abductor musculature. These techniques allow less post- operative pain, reduced blood loss, shorter hospitalization, better functional recovery and faster return to everyday routine. However, tissue sparing techniques can result in numerous complications related to the learning curve. Today four minimally invasive approaches have been described and many of their modifications. All of them are technically demanding, and may require specialized instruments and equipments. This article describes in detail the surgical technique of a minimally invasive anterolateral hip approach with patients in the supine position, including the preoperative setting, with pearls and tips based on the authors’ experience.

Zadnjih 60-ak godina primarna zamjena zgloba kuka predstavlja jednu od najučinkovitijih i najizvođenijih operacija u ortopediji. Tijekom godina navedeni zahvat doživio je značajne promjene s ciljem unaprijeđenja kvalitete života pacijenata. Upotreba boljih materijala i promjena dizajna implantata omogućili su bolju stabilnost, veću pokretljivosti te veću trajnost proteze kuka. Kako bi se smanjila kirurška trauma, očuvala abduktorna muskulatura te ubrzao oporavak bolesnika počelo se s korištenjem minimalno invazivnih tehnika. Pri uporabi takvih tehnika smanjen je gubitak krvi, smanjena poslijeoperacijska bol, skraćen je boravak u bolnici i postignut bolji funkcionalni oporavak i povratak svakodnevnim aktivnostima. Krivulja učenja je nešto dulja pri savladavanju takvih tehnika, koje sa sobom nose i neke komplikacije. Do danas su opisane četiri osnovne tehnike minimalno invazivne kirurgije, te njihove brojne modifikacije. Za većinu ovih tehnika potrebni su posebni instrumenti konstruirani za tu namjenu. U ovom radu detaljno je opisana tehnika minimalno invazivnog antero-lateralnog pristupa s pacijentom na leđima pri ugradnji totalne proteze kuka uključujući i prijeoperacijsko namještanje pacijenta te ostale tehničke detalje., In the past 60 years, primary THA has been one of the most successful and most performed orthopaedic procedure. Over the years, hip arthroplasty has changed, and research continues to improve its results. Better materials and design provide patients with an increased range of motion with enhanced stability and very low wear. In recent years, there have been a number of reports describing the performance of THA through smaller incisions using minimally invasive surgical techniques, aimed to spare the soft tissue, especially the abductor musculature. These techniques allow less post-operative pain, reduced blood loss, shorter hospitalization, better functional recovery and faster return to everyday routine. However, tissue sparing techniques can result in numerous complications related to the learning curve. Today four minimally invasive approaches have been described and many of their modifications. All of them are technically demanding, and may require specialized instruments and equipments. This article describes in detail the surgical technique of a minimally invasive anterolateral hip approach with patients in the supine position, including the preoperative setting, with pearls and tips based on the authors’ experience.

Osteoarthritis, as the most common form of arthritis, affects predominantly middle-aged and elderly population worldwide. This chronic, degenerative, progressive and multifactorial joint disease can affect different joints in the body. One of the most commonly affected joints with osteoarthritis is the hip joint. Hip osteoarthritis is characterized by the presence of pain, stiffness, and limping which ultimately results with inability to perform activities of daily living. Thus, hip osteoarthritis significantly affects patients’ quality of life and represents a major public health problem. Because of its high incidence, prevalence and significant medical, social, and economic impact on society as a whole, in this review article we will describe and discuss terminology, classification, epidemiology, etiopathogenesis, clinical presentation, diagnosis, treatment, and prevention of hip osteoarthritis.

Family with sequence similarity 46, member A (FAM46A) gene VNTR and BCL2-Associated Athanogene 6 (BAG6) gene rs3117582 polymorphisms were genotyped in a case-control study with 474 large-joint (hip and knee) osteoarthritis (OA) patients and 568 controls in Croatian population by candidate-gene approach for association with OA. We found that BAG6 rs3117582 SNP genotypes were associated with protection (major allele homozygote) and susceptibility (major-minor allele heterozygote) to OA. BAG6 rs3117582 major allele (A) was associated with reduced risk to OA while the minor allele (C) was associated with increased risk to OA. We identified 6 alleles harboring 2 to 7 repeats making 20 genotypes for FAM46A. A rare FAM46A VNTR genotype comprising VNTR alleles with four and seven repeats (c/f) was associated with increased OA risk in both genders. The genotype with four and six repeats (c/e) was also associated with increased risk to OA in males. A polymorphic FAM46A allele with six repeats (e) was associated with reduced risk to OA in females. Our results suggest association between the FAM46A gene, BAG6 gene and OA in Croatian population, respectively. This is the first study to show associations between these genetic loci and OA.

Prekrivajući zglobne površine zglobna hrskavica osigurava pravilno raspoređivanje i prenošenje mehaničke sile u zglobu te omogućuje pokretanje uz niski stupanj trenja. Ima specifičnu makroskopsku, mikroskopsku i molekularnu građu, što uključuje izuzetno mali broj stanica – hondrocita (2 do 10 % ukupnog volumena tkiva) koje proizvode i održavaju integritet velike količine međustaničnog matriksa i to u relativno hipoksičnim i hiponutricijskim uvjetima zbog nedostatka krvnih žila. Uz to, mitotička aktivnost i regeneracijski potencijal hondrocita izuzetno su niski, pa nakon oštećenja zglobne hrskavice ne nastupa potpuna tkivna regeneracija, već je zamjenjuje biomehanički manje kvalitetna vezivna hrskavica. Unatoč razvoju brojnih farmakoloških i kirurških procedura liječenja oštećenja zglobne hrskavice, pokazala su se brojna ograničenja i trenutno ne postoji idealna terapijska procedura koja bi dovela do potpune morfološke i funkcionalne restauracije oštećene zglobne hrskavice. Ipak, zahvaljujući napretku stanične i molekularne biologije kostiju te tkivnog inženjerstva, učinjeni su značajni pomaci u razumijevanju mehanizama održavanja integriteta tkiva i organa koji su doveli do stvaranja novih koncepata liječenja koji se baziraju na temeljnim principima odnosa elemenata regenerativnog trijasa. U ovom članku kratko je opisana uloga svakog pojedinog elementa trijasa: stanica kao produktivnog, nosača kao konduktivnog i signalnih molekula kao induktivnog elementa regeneracije., Covering articular surfaces, articular cartilage ensures load bearing and low frictional movement in synovial joints. Articular cartilage has a specific macroscopic, microscopic and molecular structure characterized by an extremely small number of cells – chondrocytes (2 to 10% of the total volume of tissue), which produce and maintain the integrity of the large amount of extracellular matrix in the relatively hypoxic and hyponutritional conditions, due to the lack of blood vessels. In addition, mitotic activity and regeneration potential of chondrocytes are extremely low, which is why articular cartilage does not show its complete tissue regeneration after damage, but it is replaced by the biomechanically poorer bonding cartilage. Despite the development of numerous pharmacological and surgical procedures for treatment of the damaged articular cartilage, they have shown a number of limitations, and currently there is no ideal therapeutic procedure that would lead to a complete morphological and functional restoration of damaged articular cartilage. However, thanks to advances in cellular and molecular biology and tissue engineering, significant progress in understanding mechanisms of maintaining the integrity of tissues and organs have been made, which led to the creation of new concepts of treatment, based on the fundamental principles of relations between elements of regenerative trias. This article briefly describes the role of each element of the trias: productive cells, conductive carrier and signaling molecules as an inductive element of the articular cartilage regeneration.

Aim: The cellular and molecular sequences of the osteogenesis induced by rhBMP-7 bound to inactive rat bone residue (IRBR) as a carrier implanted in rats have been studied at calvarial defect. Methods and experimental design: To create a parcial defect of calvarial rat bone, periosteum and bone of the frontoparietooccipital complex were grinded with dental burr and special care was taken to avoid cranial wall opening. The implants were harvested at day 7th, 12th and 21th. Tissue samples were analysed by histology, histochemistry and histomorphometry. Results: The results of this study showed different initial tissue response in relation to control samples of implants (contain no active osteoinductive BMP-7). On rat calvarial deffect BMP-7 induced direct bone formation (intramembranous bone formation) and fuses with the underlying bone deffect. In the underlying bone remodeling is active as early as day 12th and is completely fused with the impalnt by day 21st.The results of histomorphometry showed more prounanced and rapid osteogenesis in relation to control animals. Conclusion: The results of this study suggest that rhBMP-7 induced early bone formation and promote osteogenesis to deffect healing. The bone forming process is manly direct ie. intramembranous bone formation.

The osteophytes are bone spurs overgrowing the edge of the articular cartilage during the course of osteoarthritis (OA). Although the cellular mechanism of their development and growth is revealed and resemblin normal bone development, there is still debate concerning molecular mechanism of their growth. Since the role of bone morphogenetic proteins family members (BMPs) in bone development is well established and documented, the members of the BMPs as an important member of the local grpwth factor network and their extracellular inhibitors were recognized as an important factors that could modulate, even cease development and growth of osteophytes. The aim of our study was to analyse expression and localization of the most potent osteoinductive BMP-2, -4 and -7, and their extracellular inhibitors gremlin, chordin, follisatin and noggin. The study was performed on tissue collection of 25 osteophytes collected during total knee joint replacement surgery due to severe OA, and on 10 samples of normal knee joint tissues from individuals undergoing autopsy. The expression of molecular factors was analysed using immunohistochemistry and Western blot analysis. Our result demonstrate the significant differences in BMPs and their antagonists expression between normal and OA affected joint tissue and suggest the potent role of these molecular factors in pathogenesis and / or mechanism of growth and development of human knee joint osteophytes.

Artroskopija ručnog zgloba je minimalno invazivna endoskopska metoda koja omogućuje dijagnosticiranje i liječenje pojedinih bolesti i ozljeda ručnog zgloba (RZ), mediokarpalnog zgloba (MKZ) i distalnog radioulnarnog zgloba (DRUZ). Ovu minimalno invazivnu kiruršku metodu prvi je opisao Yung-Cheng Chen 1979., no njezina šira primjena u kliničkoj praksi počinje tek nakon 1986., kada je Terry Lane Whipple preporučio distrakciju RZ-a i precizne lokalizacije ulaznih mjesta (portala), kako bi se učinila pravilna i potpuna evaluacija RZ-a prilikom izvođenja artroskopije. Iako je prvotno artroskopija RZ-a bila samo dijagnostička metoda, tijekom vremena, zahvaljujući kontinuiranom napretku tehnologije i uvođenju inovacija u instrumentaciji i operativnoj tehnici, artroskopija RZ-a postaje i terapeutska metoda. Cilj ovog rada prikazati je osnove o artroskopiji RZ-a, a one uključuju: povijesni razvoj, indikacije i kontraindikacije, evaluaciju i probir bolesnika za artroskopiju RZ-a na temelju anamneze, fizikalnog pregleda i slikovne obrade, pripremu za artroskopiju RZ-a, potrebnu opremu, poznavanje izvanzglobne anatomije, portale (ulazna mjesta), poznavanje unutarzglobne anatomije, preduvjete, tehniku artroskopije RZ-a, prednosti i nedostatke ove operativne metode, komplikacije i zaključak., Wrist arthroscopy is minimally invasive endoscopic procedure which enables the diagnosis and treatment of certain diseases and injuries of the wrist joint (WJ), midcarpal joints (MCJs) and distal radioulnar joint (DRUJ). This minimally invasive surgical procedure was first described by Yung-Cheng Chen in 1979. However, its widespread application in clinical practice began after 1986, when Terry Lane Whipple recommended wrist distraction and precise localization of portals to do proper and complete evaluation of the wrist when performing arthroscopy. Although initially wrist arthroscopy was only a diagnostic tool, during time due to the continuous advancement of technology and the introduction of innovations in instrumentation and surgical technique, wrist arthroscopy became a therapeutic method. The aim of this professional paper is to present the basics of wrist arthroscopy, which include: historical development, indications and contraindications, evaluation and selection of patients for wrist arthroscopy on the basis of history, physical examination and diagnostic imaging procedures, wrist arthroscopy setup, the necessary equipment, superficial anatomy, portals, intraarticular anatomy, preconditions, technique of wrist arthroscopy, the advantages and disadvantages of this surgical procedure, complications, and conclusion.

Liječenje oštećenja tetiva rotatorne manšete ovisi o veličini rupture i dobi bolesnika. Sve akutne ozljede u mlađih i radno sposobnih bolesnika trebalo bi odmah operativno liječiti. U većih ozljeda rupturirane tetive retrahiraju se, pa je rekonstrukcija nakon više mjeseci otežana. Kod bolesnika koji imaju preko 70 godina prvo pokušamo s konzervativnim liječenjem. Rekonstrukcija većih ruptura u starijih ljudi neizvjesna je, ovisi o dubini retrakcije tkiva i stupnju masne degeneracije mišića. Ako palijativna terapija ne zadovoljava, treba se odlučiti na ugradnju posebne vrste endoproteze. Operativne metode dijele se na otvorene i artroskopske. Svaka metoda ima svoje prednosti, ali su funkcionalni rezultati podjednaki., The treatment of rotator cuff tears depends of tear size and patient’s age. Acute tears in younger and active patients should be operated immediately. In large tears, the tendon will retract and with time it will loose the elasticity, so the repair after several months will be difficult. In patients over 70 years of age, it is wise first to start with conservative treatment. The cuff reconstruction in large tears is uncertain, due to the retraction and poor tissue quallity. Furthermore, these patients have often severe co-morbidity and will not easily accept sugery with uncertain result. If primary repair is not possible, special prosthetic replacement is considered. Rotator cuff repair can be done arthroscopically or by open, but mini invasive sugery. Both methods have advantages and difficulties, but overall long term results show comparable results.

Cilj: Uznapredovala artroza gležnja kod koje se bol i smanjena pokretljivost zgloba ne poboljšavaju na konzervativnu terapiju predstavlja indikaciju za artrodezu gležnja. Cilj ovog rada bio je analizirati rezultate liječenja uznapredovale artroze gležnja artroskopskom artrodezom gležnja. Metode: U Klinici za ortopediju Lovran u razdoblju od 2000. do 2010. godine 8 bolesnika liječeno je artroskopskom artrodezom gležnja. Prosječna dob bolesnika bila je 55,5 godina. Kod svih bolesnika radilo se o artrozi četvrtog stupnja po Kellgren-Lawrenceovoj podjeli. Fiksacija mjesta artrodeze učinjena je u 6 bolesnika unutarnjom fiksacijom vijcima, dok je u 2 bolesnika korišten vanjski fiksator. Svi su bolesnici radiološki obrađeni prije i poslije operacijskog zahvata standardnim stojećim snimkama gležnja u dva smjera. Mjereni su tibiotalarni kutovi te je praćeno vrijeme zaraštavanja artrodeze zgloba. Rezultati: Radiološki su rezultati pokazali da je prosječni postoperacijski kut između anatomske uzdužne osi tibije i talusa bio na antero-posteriornim snimkama gležnja 93,85°, a na latero-lateralnim snimkama 107,5°. Koštano cijeljenje na mjestu artrodeze završeno je u razdoblju od 12 tjedana kod svih bolesnika. Zaključak: Dobiveni rezultati, iako analizirani na maloj skupini bolesnika, potvrđuju uspješnost primjene kirurške tehnike artroskopske artrodeze gležnja., Aim: End-stage ankle arthrosis with pain and contracted articulation not responding to conservative therapy procedures represents indication for ankle arthrodesis. This paper was aimed at analysing the outcome of end-stage ankle arthrosis treatment by way of arthroscopic ankle arthrodesis. Methods: The analysis dealt with 8 patients treated at the Clinic for orthopaedic surgery Lovran who underwent arthroscopic ankle arthrodeses in the period from 2000 to 2010. Their mean age was 55.5 years. All of them had sufferred from arthrosis grade four using the scale of Kellgren and Lawrence. At the point of arthrodesis, fixation was performed by means of internal screws in 6 patients and by external fixators in 2 patients. All of them were taken their ankle pre- and post-operation radiographs in standard standing positions in two directions. Their tibiotalar angles were measured and their arthrodesis time to union was followed up. Results: As the radiological results showed, the mean postoperative angle between the tibial and talar anatomical horizontal axes in the antero-posterior ankle radiographs was 93.85°, whereas the one in the latero-lateral radiographs was 107.5°. In all the patients the bone union was completed in 12 weeks. Conclusion: Notwithstanding the small sized group of followed-up patients, the results achieved have confirmed the efficiency of the arthroscopic ankle arthrodesis.

Artroskopija ručnog zgloba je minimalno invazivna endoskopska metoda koja omogućuje dijagnosticiranje i liječenje pojedinih bolesti i ozljeda ručnog zgloba (RZ), mediokarpalnog zgloba (MKZ) i distalnog radioulnarnog zgloba (DRUZ). Ovu minimalno invazivnu kiruršku metodu prvi je opisao Yung-Cheng Chen 1979., no njezina šira primjena u kliničkoj praksi počinje tek nakon 1986., kada je Terry Lane Whipple preporučio distrakciju RZ-a i precizne lokalizacije ulaznih mjesta (portala), kako bi se učinila pravilna i potpuna evaluacija RZ-a prilikom izvođenja artroskopije. Iako je prvotno artroskopija RZ-a bila samo dijagnostička metoda, tijekom vremena, zahvaljujući kontinuiranom napretku tehnologije i uvođenju inovacija u instrumentaciji i operativnoj tehnici, artroskopija RZ-a postaje i terapeutska metoda. Cilj ovog rada prikazati je osnove o artroskopiji RZ-a, a one uključuju: povijesni razvoj, indikacije i kontraindikacije, evaluaciju i probir bolesnika za artroskopiju RZ-a na temelju anamneze, fizikalnog pregleda i slikovne obrade, pripremu za artroskopiju RZ-a, potrebnu opremu, poznavanje izvanzglobne anatomije, portale (ulazna mjesta), poznavanje unutarzglobne anatomije, preduvjete, tehniku artroskopije RZ-a, prednosti i nedostatke ove operativne metode, komplikacije i zaključak., Wrist arthroscopy is minimally invasive endoscopic procedure which enables the diagnosis and treatment of certain diseases and injuries of the wrist joint (WJ), midcarpal joints (MCJs) and distal radioulnar joint (DRUJ). This minimally invasive surgical procedure was first described by Yung-Cheng Chen in 1979. However, its widespread application in clinical practice began after 1986, when Terry Lane Whipple recommended wrist distraction and precise localization of portals to do proper and complete evaluation of the wrist when performing arthroscopy. Although initially wrist arthroscopy was only a diagnostic tool, during time due to the continuous advancement of technology and the introduction of innovations in instrumentation and surgical technique, wrist arthroscopy became a therapeutic method. The aim of this professional paper is to present the basics of wrist arthroscopy, which include: historical development, indications and contraindications, evaluation and selection of patients for wrist arthroscopy on the basis of history, physical examination and diagnostic imaging procedures, wrist arthroscopy setup, the necessary equipment, superficial anatomy, portals, intraarticular anatomy, preconditions, technique of wrist arthroscopy, the advantages and disadvantages of this surgical procedure, complications, and conclusion.

Artroza koljena je najčešća degenerativna bolest zglobova čija se incidencija povećava starenjem populacije. U uznapredovaloj fazi bolesti liječenje artroze koljena obuhvaća ugradnju totalne endoproteze koljena. Dugotrajnost preživljenja totalne endoproteze koljena ovisi o ispravnoj pozicioniranosti komponenata endoproteze u sve tri ravnine, odnosno o rekonstrukciji biomehaničkih odnosa donjeg ekstremiteta. Pogreške u kirurškoj tehnici najčešći su razlog nepreciznosti ugradnje komponenti totalne endoproteze koljena. Razvojem instrumentarija poboljšavaju se rezultati ugradnje endoproteze koljena, a značajan napredak postiže se uvođenjem računalne navigacije u kirurgiju koljena 1997. godine. Virtualnim povezivanjem anatomskih struktura, prvenstveno koštane anatomije pacijenta, s računalnom slikom istoga, koristeći podatke slikovnih pretraga ili anatomske intraoperativne podatke, svaka je kirurška akcija prikazana na ekranu u realnom vremenu na računalno oblikovanom modelu. Virtualna trodimenzionalna reprodukcija koljena uz pomoć računala omogućava preciznije reseciranje zglobnih površina i ugradnju komponenti endoproteze koljena. Precizna pozicioniranost dijelova endoproteze i rekonstrukcija biomehaničkih odnosa omogućava brži oporavak, agresivniju fizioterapiju, a i sam vijek endoproteze je produljen, čime se smanjuju troškovi zdravstvenog sustava i povećava zadovoljstvo pacijenta., Knee osteoarthritis is the most common degenerative joint disease, whose incidence increases as populations age. In advanced stages, knee osteoarthritis disease treatment considers the implantation of a total knee endoprosthesis. Longterm survival of total knee endoprosthesis depends on the correct positioning of prosthesis components in all three planes, with respect to the reconstruction of the biomechanical relations of the lower extremities. Mistakes in surgical technique are the most common reason for inaccurate implantation of the total knee endoprosthesis components. The development of instruments for total knee arthroplasty enhanced the results of total knee arthroplasty and significant progress was achieved with the introduction of the computer navigation system in knee surgery in 1997. Virtual linking of anatomical structures, primarily the bone anatomy of the patient, with computer images of the same, using image search data or intraoperative anatomic data, each surgical action is displayed on the monitor in real time on a computer-shaped model. Virtual three-dimensional reproductions of the knee using a computer system enable accurate resection of the articular surface and precise implantation of total knee endoprosthesis components. The precise positioning of total knee endoprosthesis components and the reconstruction of the biomechanical relations allow faster recovery, aggressive physiotherapy, and longer survival of endoprosthesis which reduce the cost of the health system and increase patient satisfaction.

Acute coronary syndrome (ACS) presents today the leading group of post-operative cardiovascular complications, while endothelial dysfunction (ED) is one of the key elements in its development. The chronic ED represents thus the basis for the gradual development of atherosclerotic changes, while its sudden aggravation leads to ACS. The persistent ED occurs due to the effects of chronic cardiovascular risk factors, while according to the available studies it can also develop or aggravate under the impact of different acute events. We have directed this study to the investigation of the dynamic of endothelial function before and after a major orthopaedic surgical intervention. This randomised prospective study included 19 patients that underwent the intervention of total knee replacement and 20 healthy examinees of the adequate age and gender. High-resolution ultrasound test based on the flow mediated dilatation of the brachial artery is what at we carried out at the beginning of the research, respectively 12, 24 48 and 72 hours, as well as 7 days after the surgical intervention. The starting values of the FMD test were within the normal range in both groups, although the ability of dilatation upon stimulus was significantly lower in the investigated group. The FMD percentage change in the total sample was negatively connected with the body weight, not having shown additional connections with other cardiovascular risk factors. During the early post-operative period, a significant transitory lowering of the FMD percentage change was recorded, having reached the lowest value 24 hours after the surgery. During the seven-day prospective surveillance, no significant cardiovascular complications were recorded. Further research is necessary in order to confirm these results as well as the testing of the possible connection of the described post-operative transitory endothelial dysfunction with the development of cardiovascular complications and the adverse event.

Controversy persists concerning posterior cruciate ligament retention in total knee arthroplasty for patients with rheumatoid arthritis (1). Posterior instability which develops as a result of the destruction of the retained PCL following disease progression (2), is considered a source of persistent pain and functional impairment following total knee arthroplasty (3, 4). The aim of the study is to compare functional and radiological outcomes of cruciate sacrificing (PCL stabilising)and cruciate retaining of cemented total knee prosthesis in patients with rheumatoid arthritis knee destruction. We analysed 60 knees in patients with rheumatoid arthritis with implanted cemented total knee prosthesis. The patients were divided in two groups. The 30 patients in the first group were implanted with posterior cruciate retaining knee prosthesis (DePuy, PFC Sigma CR), while the posterior cruciate ligaments of patients in the second group of 30 were sacrificing (DePuy, PFC Sigma CS). The average age in both groups was 67 years (57- 75) and the average follow-up period 5 years (3-­8). We evaluated the Hospital for Special Surgery Knee score, knee flexion, correction of deformity, patient satisfaction with surgery and radiographic analysis of radiolucency. The mean Knee Society functional scores improved, rising from 36 points (range 25 - 60) to 73 points (range 60 - 90) for the cruciate- retaining group, and from 34 points (range 23 - 58) to 75 points (range 60 - 100) for the cruciate-sacrificing group. Final follow-up revealed that knee flexion was approximately 1050 (range 70 - 120°) and 110° (range 70 - 125°) in the cruciate-retaining and posterior-stabilized groups, respectively. In both groups we achieved an average 60 of valgus. In both groups the patients reported major pain relief and satisfaction with surgery. We did not observe significant radiolucency in the follow-up period in either group, nor any other clinical signs of loosening. On the basis of our study we could not observe the superiority of one knee arthroplasty design over the other. We thus suggest using PCL retaining knee prosthesis design in patients with rheumatoid arthritis, because this model preserves much more bone stock, which is important in potential knee revision arthroplasty. References: 1.Dorr LD, Oschner JL, Gronley J, Perry J. Functional comparison of posterior cruciate retained versus sacrificed total knee arthroplasty. Clin Orthop 1988 ; 236:36-43. 2.Nelissen RGHH, Hogendoorn PCW. Retain or sacrifice the posterior cruciate ligament in total knee arthroplasty? A histopathological study of the cruciate ligament in osteoarthritic and rheumatoid disease. J Clin Pathol 2001 ; 54:381–4. 3. Laskin RS, O'Flynn HM. Total knee replacement with posterior cruciate ligament retention in rheumatoid arthritis. Problems and complications. Clin Orthop 1997 ; 345:24–8. 4. Pagnano MW, Hanssen AD, Lewallen DG, Stuart MJ. Flexion instability after primary posterior cruciate retaining total knee arthroplasty. Clin Orthop 1998 ; 356:39–46.

Among the predisposing factors to osteoarthritis (OA), a frequent destructive joint disease, is the complex genetic heritage including the interleukin‐1 family members like the IL1β (IL1B) and the IL1 receptor antagonist (IL1RN) genes. The aim of this study was to investigate allelic and genotypic frequencies of the IL1B gene single nucleotide polymorphism (SNP) at −511(G>A) and the variable number tandem repeat (VNTR) in the IL1RN gene in a Croatian Caucasian population of hip OA (HOA) cases and healthy controls. A total of 259 HOA patients with total hip replacement (THR) and 518 healthy blood donors as controls were genotyped for IL1B gene SNP −511(G>A) and the VNTR in the IL1RN gene associated with HOA. The genotype G/A (1/2) at IL1B was significantly associated with the protection of the HOA (p A) and IL1RN (VNTR) were found associated with the HOA. The haplotype 1–2 at these loci had only a trend to susceptibility (p = 0.065). Haplotype 1–3 had a significant male bias in diseased. Furthermore, genotype comprising 2–1/2–2 haplotypes was found significantly associated with predisposition to HOA (p = 0.027, OR = 2.23, 95% CI = 1.03–4.88), whereas genotype 1–1/2–2 with protection to disease (p = 0.028, OR = 0.65, 95% CI = 0.43–0.97). Our findings suggest that HOA in Croatian population might have a different genetic risk regarding the IL1 locus than has been reported for other Caucasian populations previously.

Trochanteric femoral fractures are a major problem in the elderly because of higher bone fragility due to osteoporosis. Numerous chronic illnesses, which usually affect the elderly, aggravate and complicate their surgical treatment. Trochanteric femoral fractures results in high morbidity and mortality in elderly patients. The aim of our study is to evaluate the effectiveness of hemiarthroplasty in the treatment of unstable trochanteric femoral fractures in elderly patients. Between 2000 and 2005, 50 patients with unstable trochanteric femoral fractures (41 women) aged 75 to 92 years (mean 86 years) underwent cemented hemiarthroplasty. The surgical procedure was performed within first 48 hours after the fracture (out of which 14 in the first 12 hours, 27 in the first 24 hours and 9 in the first 48 hours), with minimal blood loss. Hemiarthroplasty was indicated in patients where stability was important to allow early mobilization. In forty patients (80%) early ambulation with full weight bearing was achieved during the short period of hospitalization (9–14 days). Given that the affected population is predominantly the elderly, who are less mobile and demanding and thus put less strain on the endoprosthesis, we believe that this kind of treatment is the treatment of choice for unstable trochanteric femoral fractures in these patients. This assumption is corroborated by the fact that we did not have any endoprosthesis luxation, apparent acetabular protrusion or instability during the mean follow up period of 15 months (range 12–18 months).

OBJECTIVE: The aim of this study was to investigate influences of new clinical guidelines for LMWHs therapy and new trends in the usage after introducing oral LMWHs. Oral LMWHs were introduced into the Croatian drug list in 2009. METHODS: The data were obtained from pharmaceutical wholesalers for the ten-year period (2001-2010) (IMS Health database). Financial expenditure data are presented in Croatian Kuna, while drug utilization data are presented in defined daily doses per 1000 inhabitants per day (DDD/1000). We calculated total and hospital consumption of LMWHs and compared shares of oral and subcutaneous LMWHs in hospital and out hospital consumption. RESULTS: In the period 2001-2010 total expenditure increased 3.37 times (11.4 to 38.5 millions) while the related utilization of LMWHs increased 4.66 times (0.42 DDD/1000 to 1.96 DDD/1000). In hospitals 97% of subcutaneous LMWHs were used, while only 46% of oral LMWHs were prescribed in hospitals. A share of oral in total LMWHs usage and expenditure is 1.41%, but increased during one year period for approximately 5 times. CONCLUSION: The usage and financial expenditure of LMWHs in Croatia increased during the investigated period, especially with the introduction of new clinical guidelines for the prevention of thromboembolic incidents. Subcutaneus LMWHs were mostly prescribed in hospitals because its usage required professional application and monitoring. The introduction of oral LMWHs changed that trend and provided self medication at home. That could lead to better patient compliance and decrease of thromboembolic incidents and medical costs in the treatment of medical complications.

Cilj istraživanja: Analizirati preoperativne i postoperativne RTG snimke zdjelice s oba kuka te utvrditi stvarnu razliku u dužini nogu i položaj femoralnog dijela proteze. Materijal i metode: Obrađeno je 40 bolesnika kod kojih je ugrađena bescementna endoproteza, te 40 bolesnika kod kojih je ugrađena cementna endoproteza. Podaci su uzeti retrospektivnim pretraživanjem za razdoblje od 1. 1. 2007. do 31. 12. 2008. Rezultati: U našem istraživanju nakon ugradnje bescementne proteze 26 ispitanika ima dužu nogu nakon operacije, ali niti jedan nema odstupanja veća od 2 centimetra; 4 ispitanika ima kraću nogu, dok 10 ispitanika ima jednaku dužinu nogu prije i poslije operacije. Najveći broj bolesnika (92 %) ima ugrađenu endoprotezu tipa Intraplant, dok je kod 8 % ugrađena endoproteza Zimmer. Najveći broj endoproteza Intraplant ugrađen je u valgus položaju (18 endoproteza), 10 proteza u varusu, te 9 u neutralnom položaju. Kod Zimmera su 2 endoproteze ugrađene u valgus, te 1 u neutralnom položaju. Kod ugradnje cementnih endoproteza 34 ispitanika ima dužu nogu, od toga dva bolesnika imaju odstupanje veće od 2 centimetra, jedan kraću nogu, a kod 5 ispitanika se dužina nogu prije i poslije operacije nije mijenjala. Od tog je broja 75 % bolesnika bilo s ugrađenom endoprotezom Surgival, te 21,5 % bolesnika s protezom Zimmer i 3,5 % s protezom ZweiMuller. Najveći broj endoproteza po tipu Surgival (50 %) postavljeno je u valgus položaj femoralnog dijela komponente, 30 % u neutralan, te 20 % u varus položaj, a kod tipa Zimmer 50 % endoproteza ugrađeno je u neutralan položaj femoralne komponente. Zaključak: Jedan od ciljeva ugradnje totalne endoproteze kuka potpuna je rekonstrukcija biomehaničkih odnosa čime se postiže dugovječnost endoproteze. Nejednakost dužine nogu jedna je od potencijalnih komplikacija ugradnje endoproteze kuka, što može utjecati na zadovoljstvo bolesnika operacijom. Iako ponekad nije moguće u potpunosti rekonstruirati biomehaničke odnose, pravilnom preoperativnom pripremom te odgovarajućim pozicioniranjem femoralne komponente može se značajno utjecati na nejednakost dužine nogu., Aim: The goal was to analyze hip joint by RTG before and after the surgery and to find out the real difference in leg length as well as to determine the position of the femoral part of endoprosthesis. Material and methods: 40 patients had implanted noncement endoprosthesis and another 40 cement endoprosthesis. Data were calculated for the period from 1.1.2007. to 31.12.2008., retrospectively. Results: In our research, upon implanting noncement prosthesis 26 of examined patients had longer leg after the procedure, but none had the deviations larger than 2 centimeters. Furthermore, 4 had shorter leg, and 10 had equal leg length before and after the surgery. 92 % of all patients had Intraplant type endoprosthesis implanted and remaining 8 % had Zimmer type endoprosthesis. Intraplant endoprosthesis were mostly implanted in valgus position – 18 cases, 10 were implanted in varus position and 9 in neutral position. In Zimmer case however 2 endoprosthesis were implanted in valgus position and 1 in neutral position. In case of cement endoprosthesis implantation 34 of patients had on leg longer, two of them deviation more than 2 cm. One patient had shorter leg and in 5 cases the length of leg were not changed before and after the surgery. 75 % of all patients had implanted Surgival endoprosthesis and 21,5 % of them had Zimmer and ZweiMuller endoprosthesis. 50 % of Surgival endoprosthesis were implanted in valgus position of phemoral part, 30 % in neutral position and remaining 20 % in varus position. In Zimmer case 50 % of all endoprosthesis were implanted I neutral position of femoral component. Conclusion: One of main goals of total hip arthroplasty is a complete reconstruction of normal hip biomechanics which influence longevity of endoprosthesis. Leg length discrepancy is one of the potential complications after total hip arthroplasty that can affect patient satisfaction with the operation. Although, sometimes it is not possible to fully reconstruct the normal hip biomechanics, proper preoperative preparation, and appropriate positioning of femoral components can significantly affect the leg length discrepancy.

The patella is a sesamoid bone and, because of poor vascular supply, it is considered that metastases are not usual. Only about 30 cases of patellar metastasis originating from different primary tumours, mostly lung and breast have been reported in the literature. In only eight cases was patellar metastasis the only sign of distant tumour. Here, we present a unique case of patellar metastasis of lung adenosquamous carcinoma, with the anterior knee pain as the first and only sign of the disease.

The aim of this study is to detect changes in total drug usage and financial expenditure according to legal changes in Croatia, especially considering pricing policy. The data were obtained from the Croatian National Health Insurance Institute for the eight-year period (2001-2008). Financial expenditure data are presented in Euros, while drug utilization data are presented in defined daily doses/1000 inhabitants/day (DDD/1000). During the investigated period drug usage increased 81.33%, while financial expenditure increased 77.23%. ATC C-group (cardiovascular drugs) represents approximately 30% of annual financial expenditure and 50 % of total DDD/1000. While total DDD/1000 increased for approximately 10% every year, financial expenditure increased 10-20% annually until 2006, but since then there have been no significant changes. After the introduction of the new pricing system, at the end of 2005, there was a decrease in price which is calculated in Euro/DDD. This decrease differs from 2-20 % relating to diferent ATC groups, i.e. for C-group is 15.85%. Drugs usage and financial expenditure increased during the investigated period. As a result of the introduction of the new pricing system, which regulates prices of the new original drugs and also stimulates generics prescription, there has been a significant decrease in total financial expenditure.

This study explores the influence of test repetition on bipodal visually controlled balance, both static and dynamic. Our goal was to get an insight into the pattern of changes in posture maintanance results during repeated balance tests. Fifteen young, healthy male recreational athletes were tested for static and for dynamic balance using KAT 2000 balance platform. The subjects first performed three trial tests of static and dynamic balance to get used to the platform followed by seven repetitions of static as well as dynamic test which were recorded. During the repeated tests we could not determine any significant improvements of static balance test resulting from number of test repetitions neither in static nor in dynamic balance (Friedman ANOVA: Static balance p=0.497, Dynamic balance p=0.393). Correlating static and dynamic balance results we found that only one third of the dynamic balance was related to static balance abilities (r2=0.36). Posible patterns in front-back and left-right directions were analyzed as well, however, none of these balance scores were found to be related to the number of repetitions. In conclusion, this study found no significant influence of limited number of repetitions (seven) on test results in static and dynamic posture. However, as large number of repetitions might still influence test results we discourage the use of KAT 2000 as a training tool in patients in which it will be used as an instrument to validate postoperative rehabilitation or investigation results.

Kontrolni mehanizmi koji nadziru temperaturu tijela, složeni su i nastoje da se unutarnja fiziološka temperatura tijela ne mijenja u većem rasponu od 0,5 oC . Ukoliko se temperatura tijela ne održi, mjereno rektalno iznad 32°C , dolazi do progresivnog usporavanja svih fizioloških procesa. Rizik od hipotermije dodatno se povećava u slučaju nedostatka znanja o mogućim tegobama i komplikacijama koje prate ovo stanje, što je u sportaša naročito izraženo, pri nedostatku komunikacije s ostalim sudionicima takmičenja ili trenerom. Nedovoljna psihološka i fizička priprema, potiskivanje znakova iscrpljenosti i neadekvatna zaštita od vremenskih nepogoda doprinose pogoršanju rezultata u hladnim uvjetima, pa i opasnošću od ozbiljnog narušavanja zdravlja. Iznosimo zato mjere prevencije hipotermije kao i postupke zagrijavanja, s osvrtom na ulogu odjeće u hladnim uvjetima., Body temperature is controlled by complex thermoregulatory mechanisms which maintain core body temperature within 0, 5 o C. Lowering rectal temperature below 32o C significantly decreases level of human body performance. Due to the lack of knowledge about first symptoms and usually poor communication with other competitors, athletes are prone to hypothermia and its complications. Insufficient protection from cold combined with poor physical and psychological fitness can further endanger athletes' health. This paper presents measures of prevention of hypothermia and warming-up procedures with special attention paid to clothing in cold conditions.

Cilj: Cilj istraživanja bio je ispitati pokretljivost koljena nakon ugradnje totalne cementne endoproteze koljena. Metode: U razdoblju od rujna 2007. do prosinca 2008. kliničkim pregledom, odnosno mjerenjem opsega pokretljivosti goniometrom, analizirana je preoperativna pokretljivost koljena, pokretljivost koljena 14. postoperativni dan, te godinu dana nakon ugradnje totalne endoproteze koljena. Analizirane su one endoproteze kod kojih su komponente postavljene u neutralnom položaju, te kod kojih je uspostavljen dobar balans mekih česti. Analizirana je pokretljivost koljena 45 bolesnika operiranih u našoj ustanovi. Svim bolesnicima ugrađen je isti tip endoproteze i operirao ih je isti operacijski tim. Rezultati: Postoji statistički značajna razlika u prisutnosti preoperativne fleksorne kontrakture te fleksorne kontrakture godinu dana od operacije, no opsezi fleksije preoperativno i godinu dana nakon operacije su bez statistički značajne razlike, iako trend ukazuje na veću mogućnost fleksije godinu dana nakon operacije. Rasprava: Odgovarajućom operativnom tehnikom te provođenjem rehabilitacijskog postupka po standardnom protokolu postiže se pokretljivost dovoljna za svakodnevne životne aktivnosti. Pokretljivost godinu dana nakon operacije ukazuje na važnost fizikalne terapije po otpustu iz bolnice. Iako postoperativna pokretljivost koljena većinom ovisi o preoperativnoj pokretljivosti, a djelomično o tipu i pozicioniranosti endoproteze, rezultati naše studije ukazuju na značajnost kirurške tehnike i rane postoperativne kineziterapije. Zaključak: Najčešći razlog zbog kojeg se bolesnici odlučuju na ugradnju endoproteze koljena je bol i smanjena pokretljivost. U svih bolesnika bol je bio značajnije manjeg intenziteta, a postignuta pokretljivost godinu dana nakon operacije bila je dovoljna za ostvarivanje svakodnevnih životnih aktivnosti., Aim: To determine the range of motion after implantation of total cement knee endoprosthesis. Methods: In the period form Septemer 2007 to December 2008 range of motion was measured during clinical exam with protractor. Range of motion was analysed preoperatively, 14th day postoperatively and a year postoperatively. We analysed the prosthesis where the components were placed in a neutral position, and where a good balance of soft tissue was established. Mobility of the knee of 45 patients operated in our institution was analyzed. Same type of prosthesis was implanted to all patients, and the same operating team performed the surgeries. Results: There are signifi cant diff erences in the presence of preoperative flexion contracture and flexion contracture a year after the surgery. The extent of flexion preoperative and one year after surgery were without significant differences, although the trend indicates a greater ability of flexion one year after surgery. Discussion: Appropriate operative technique and rehabilitation process by standard protocol enable mobility which is suffi cient for daily life activities. Mobility one year after surgery indicates the importance of physical therapy after discharging from hospital. Although postoperative mobility of the knee mainly depends on preoperative mobility, and partly on the type and position of endoprosthesis, the results of our study indicate the importance of surgical technique and early postoperative kinesiotherapy. Conclusion: The most common reasons for patients to decide for total knee arthroplasty are pain and reduced mobility. In all patients, pain was of signifi cantly lower intensity, and mobility achieved one year of operations was sufficient to overcome daily living activites.

The paper presents an operative technique proposed for treating severe Hallux Valgus deformity with arthrosis of the first metatarsal joint in elderly people. The procedure consists of the Keller's arthroplasty in combination with basal osteotomy of the first metatarsal bone, whereby the head of the metatarsal is displaced laterally and plantarward. The osteotomy is fixed with a reconstructive plate. The results show a significant improvement in the hallux valgus angle, the first metatarsal angle, as well as in the plantar pressure distribution.

Full knee extension is necessary for bearing full body weight with minimum muscular action, while flexion of various degrees is needed for walking, climbing the stairs or rising from a chair. Flexion contracture of the knee can affect the functional performance of the knee joint for everyday activities, especially if it is combined with angular deformity in the frontal plane, which is usually seen in RA patients. The flexion deformity in RA is multifactorial and is a result of osseous, muscular, ligamentous and capsular changes, as well as of fibrous adhesion among these structures. We measured the range of motion after total knee arthroplasty in RA patients with preoperative flexion contracture of 30-40 degrees, associated with valgus deformity. Range of motion in 25 female RA patients with valgus deformity and flexion contracture was measured. The range of motion was measured by goniometer and plain radiography preoperatively, as well as on the 14th day and one year postoperatively. We analysed the patients in whom components of prosthesis were placed in the proper position as well as in whom proper soft tissue balance and full range of motion were achieved during operation. All patients were operated on by the same surgical team and the same type of cemented knee prosthesis with sacrifice of posterior cruciate ligament was implanted in all the patients. The patella was also replaced. All patients had the same postoperative rehabilitation protocol. On the 14th postoperative day 15 patients had full extension and 10 had flexion contracture of no more than 10 degrees. The result was statistically significant compared to preoperative flexion contracture. Further flexion was 70 degrees in 13 and 90 degrees in 12 patients. We could not find any dependence between preoperative and postoperative flexion degree in the same patient. One year postoperatively full extension was achieved in all patients, but average improvement of flexion ranged from 5 to15 (average 10) degrees in comparison with the 14th postoperative day. We observed that patients with better flexion early in the postoperative period exhibited better improvement of flexion one year postoperatively. The results of this study showed that severe flexion contracture in RA patients can successfully be corrected with knee arthroplasty. The higher the flexion in the early postoperative period, the better the improvement in flexion one year postoperatively. References: Chiu, K Y, Ng, T P, Tang, W M, Yau Review article: Knee flexion after total knee arthroplasty. J Orthop Surg (Hong Kong). 2002 Dec ; 10(2):194-202.

It is well known that the periosteumis capable of bone formation. In the present study the value of the vascularized periosteal graft in healing the long-bone defect filled with allogenous bone graft was studied.The aim was to verify the efficiency of the rotational vascularized periosteal graft as a optional surgical method as well as to prove its advantage in comparison with the nonvascularized periosteal graft.

Despite increasing knowledge of etiopathogenesis, therapy and the recurrence rate of the popliteal cyst, it nevertheless occasionally represents a clinical enigma. We thus report the case of a 58-year old rheumatoid arthritis patient in whom a giant recurrent cyst developed very shortly after primary excision. Reports of such large popliteal cysts are rare and very few cases were reported in RA patients. Moreover, no such giant recurrent cysts formed so shortly after primary excision. Thus, its occurrence may be partially ascribed to the specific dynamics of fluid flows caused by the absence of a valve-like mechanism. Regarding the treatment, it appears that synoviectomy may reduce the production of synovial fluid, but reinforcement of the thin tissue can be estimated only after posterior capsula closure and capsuloplasty. Immobilization is necessary so that initiation of the healing process is not disturbed.

Koštana banka predstavlja složen sustav koji u svom radu ujedinjuje prikupljanje, pohranu i raspodjelu koštanih presadaka. Da bi se presadak adekvatno upotrijebio u koštano- -zglobnoj kirurgiji mora se mikrobiološki testirati i nadzirati, te, uz prateću dokumentaciju, obilježiti kada je spreman za upotrebu. Koštani presadci prikupljaju se ili od živućih donora koji daruju odstranjene dijelove glave bedrene kosti tijekom rutinskog zahvata ugradnje totalne endoproteze kuka, ili od kadavera, u sklopu multiorganske eksplantacije. Potencijalni živući davatelji daju svoj pristanak na donaciju za potrebe koštane banke, koja se potpisuje zajedno s pristankom na operacijski zahvat. Prethodno su anamnestički ispitani i klinički pregledani uz provedene odgovarajuće laboratorijski testove. U sklopu multiorganske eksplantacije izvršena je analiza heteroanamnestičkih podataka i poduzete su sve potrebne laboratorijske pretrage i testovi na osnovi kojih regrutiramo davatelja kao povoljnog za uzimanje tkiva i organa. U praksi je običaj da se obavi razgovor s obitelji o donaciji određene anatomske cjeline, te pristankom i potpisom legalizira davateljstvo. Presadci se, nakon uzimanje obriska za bakteriološku analizu, pakiraju i obilježavaju, te spremaju u zamrzivač na -80°C. Metoda dubokog smrzavanja predstavlja najdostupniju i pouzdanu tehniku pohranjivanja koštanih presadaka. U takvim uvjetima pohranjeni presadak može se uspješno upotrijebiti i nakon pet godina., Bone bank is a complex system which unifies collection, storage and distribution of bone grafts. In order to adequately use bone graft in bone and joint surgery, it must be tested microbiologically monitored and marked when ready for use with the accompanying documentation. Collection of bone grafts is carried out either from the living donors, who are giving away parts removed from the femur head during routine procedure of mounting total hip endoprosthesis or from cadaver within multiorgan explantation. Potential providers give their consent to the donation for the purpose of bone bank, which is signed along with agreement for surgery. They were previously anamnestically tested, clinically reviewed and adequate laboratory tests were conducted. Within multiorgan explantation heteroanamnestic data analysis was performed and all the necessary laboratory tests were taken under which we elected donors as favorable for donation of tissues and organs. It is custom in practice to conduct talks with the family regarding the donation of specific anatomical zones and agreeing and signing legalizes donation. After taking smears for bacteriological analysis grafts are packed and marked, and then saved in the freezer at -80°C. Method of deep freezing represents the most available and reliable technology for storage of bone grafts. In such conditions stored graft can be successfully used even after five years.

Open total dislocation of a talus with extrusion (missing talus) is an extremely rare injury. We present a case of a 63-year-old male who sustained an open total lateral dislocation of the right talus with extrusion and without a concomitant fracture after a fall from a small height. Tibiocalcaneonavicular arthrodesis was performed. Arthrodesis failed, and due to painfull and unstable ankle, rearthrodesis was performed two years later, successefully. Because of rarity of this kind of injury, hers importance for foot function, previously described various treatment options and absence of guidelines, herewith we propose, according to our experience and review of literature, the algoritham for the treatment of this rare injury.

The aim of this study was to detect changes in bisphosphonates usage and the effects of new pricing regulation concerning generic and new original bisphosphonates introduction on the national reimbursement list. Drug utilization and financial expenditure data were analysed for the bisphosphonates prescribed by general practitioners. The data were obtained from the Croatian National Health Insurance Institute for the period 2001–2007. Utilization data are presented in DDD/1000 inhabitants/ day (DDD/1000), while expenditure data are presented in Euros and Euros/DDD. In the period 2001–2007, the usage of bisphosphonates increased 2.62 times (from 1.58 to 5.72 DDD/1000). The usage increased until 2005 but since then there have not been any significant differences. The related expenditure increased 2.21 times from 2001–2006, and in 2007 decreased 30%, so the overall growth in expenditure was 1.22 times. For the entire period original alendronate remained the most frequently prescribed bisphosphonate (ranging from 50.05% in 2001 to 95.9% in 2004.), it had the highest financial share (96.75% in 2001 to 60.06% in 2007). After the introduction of new original and generic bisphosphonates the expenses decreased ; for original alendronate 38.93% (1.13 Euro/DDD in 2001 to 0.69 Euro/DDD in 2007) and for other original bisphosphonates 82.73% (6.66 Euro/DDD in 2005 to 1.15 Euro/ DDD in 2007). The usage of bisphosphonates in Croatia increased during the investigated period, but financial expenditure decreased after 2006 with introduction of the new pricing system which regulates prices of the new original bisphosphonates and also stimulates generics with lower prices on the Croatian drug market.

The aim of this study was to detect changes in non-steroidal anti-inflammatory drugs (NSAIDs) financial expenditure and consumption according to the legal changes especially considering pricing policy (restrictive comparative pricing). Further, to analyze possible influences of new studies (connection between NSAIDs and increased cardiovascular risks) on NSAIDs utilization. The data was obtained from the Croatian National Health Insurance Institute and from pharmaceutical wholesalers for the seven-year period (2001-2007). Financial expenditure data are presented in Euros, while drug utilization data are presented in defined daily doses/1000 inhabitants/day (DDD/1000). In the investigated period the total expenditure of the group increased 10.39% while the related consumption of NSAID increased 1.95% (41.404 DDD/1000 to 42.224 DDD/1000). During the first part of the investigated period (from 2001-2005), before new pricing policy was introduced, the expenditure of NSAIDs increased 15.72% and the related consumption 5.92%. After the new measures were introduced (2005), in the period from 2005-2007 the financial expenditure of NSAIDs decreased 24.04% while usage decreased 4.03%. For the entire period diclofenac was the most frequently prescribed NSAID, but its share in the total consumption of NSAIDs decreased from 54.33 % in 2001 to 41.84% in 2007. The usage of NSAIDs in Croatia increased during the investigated period, so in 2005 new pricing policy was introduced to slow down the financial expenditure. This resulted in a considerable financial decrease and the usage was almost on the same level. The decrease of diclofenac usage in 2007 could be explained as the result of the published studies (the end of 2006) concerning its cardiovascular side effects.

Meningocele may be asymptomatic and incidentally discovered. Presenting as a retrorectal mass, sacral meningocele may produce urinary, rectal, and menstrual pain. Anterior sacral meningocele may be the cause of tethered cord syndrome. This article presents a case of a previously healthy 39-year-old man with large meningeal herniation that occupied the entire pelvis who developed symptoms of bacterial meningitis. A 39-year-old man was admitted with fever, chills, headache and photophobia. Escherichia coli was isolated from cerebrospinal fluid culture. Moderate improvement regarding meningeal symptoms was noted due to intravenous antibiotic therapy, but intense pain in the lower back associated with constipation, fecal and urinary incontinence, and saddle anesthesia developed. Abdominal ultrasound was negative. Plain radiographs and computed tomography demonstrated sacral bone defect and retrorectal expansive mass. MRI confirmed anterior sacral meningocele with cord tethering. After posterior laminectomy and dural opening, communication between meningocele and intrathecal compartment was obliterated. Computed tomography-guided percutaneous drainage through the ischiorectal fossa was performed to treat residual presacral cyst. Delayed diagnosis in our patient was related to misleading signs of bacterial meningitis without symptoms of intrapelvic expansion until the second week of illness. In our patient, surgical treatment was unavoidable due to resistive meningitis, acute back pain, and symptoms of space-occupying pelvic lesion. Neurosurgical approach was successful in treatment of meningitis and neurological disorders. Computed tomography-guided evacuation of the residual retrorectal cyst was less invasive than laparotomy, resulting in normalization of defecation and miction despite incomplete evacuation. Further follow-up studies may provide insight into the most effective treatment of such conditions.

Background: Rheumatoid arthritis (RA) is the most frequent human chronic inflammatory autoimmune disease characterized by chronic synovitis and bone damages. Joint destruction caused by RA predominantly occurs in hands, feet and knee joints. RA is responsible not only for great deformity of the joint, but also affect the bone quality causing the progressive bone resorption and osteoporosis. Progressive changes can affect the quality of every day life in RA patients. The greatest problem during total knee replacement in RA patients proved to be the lack of strong bone of the tibia and femur, as well as necessity of the soft tissue balancing during surgery due to great deformity. Both factors are very important in longevity of the knee prosthesis. Objectives: The purpose of our research was to assess outcome in RA patients undergoing total knee replacement concerning an incidence of early aseptic loosening. Methods: We analysed the 55 knees in 48 patients (37 women and 18 men) in whom total knee replacement was performed due to advanced arthritic changes and deformity. All changes were due to well estabilished and documented rheumatoid arthritis according to American College of Rheumatology criteria. The average age of these patients was 65.4 years (range 54 to 75) and the average follow up period was 6 years (3– 12). Outcome was evaluated clinically in terms of pain relief and range of motion of the knee. On radiological images we analysed the knee axis and signs of loosening of prosthetic component and bone resorption. Results: A bone stock and bone strength are important for supporting the prosthesis component and with propertly performed soft tissue balancing we achieved optimal biomechanical load in knee prosthesis. In all patients we achieved pain relief and flexion of the knee of 90 degrees and greater. During the final radiological analysis there were no signs of bone resorption or aseptic loosening of the prosthesis components. Moreover, we observed no clinical signs of synovitis in all examined knees. Conclusion: Knees affected by rheumatic changes often show reduction of the bone quality and impairment of bone remodeling that can cause great deformity after years of the disease. After implantation of prosthesis all clinical signs of rheumatoid arthritis of the knee disapeared. Despite severe osteoporosis and deformity there were no signs of aseptic loosening during follow up period in the examined group of patients. This can support the hypothesis that the cartilage is important factor in maintaining the inflammation process in RA.

Povećana tjelesna masa djece se često u literaturi povezuje sa smanjenim sposobnostima vezanima uz sportsku izvedbu. Zbog smanjenih motoričkih sposobnosti takva djeca često izbjegavaju sudjelovanje u sportskim aktivnostima što dovodi do zatvorenog kruga tj.do daljnjeg povećanja tjelesne mase. Cilj ovog rada bio je utvrditi koje motoričke sposobnosti su pod najvećim utjecajem povećane tjelesne mase, te da li postoje razlike prema spolu. Uzorak se sastojao od 224 djece koji su bili polaznici 5, 6, 7 i 8-og razreda osnovne škole (prosječna dob 13, 07± 1, 24). Prije početka istraživanja, detaljna objašnjenja postupka ispitivanja te obrazac za suglasnost roditelja poslana su roditeljima djece. Protokol testiranja je obuhvaćao mjerenje morfoloških karakteristika (visina, težina, postotak masti) i različitih motoričkih sposobnosti (brzina, snaga, vrijeme reakcije, ravnoteža mjereni na Kistler Quattro jump force platformi, ravnotežnim platformama i Newtest Powertimer PC sustavu). Za svako dijete je izračunat indeks tjelesne mase i postotak masti, te je pojedinačno svaki ispitanik uvršten u pojedinu skupinu prema stupnju uhranjenosti (nedovoljno uhranjeni, normalno uhranjeni, poveæ ane tjelesne mase i pretili). U tu svrhu su se koristili grafikoni rasta za dob i spol.ANOVA/MANOVA statistička analiza je ukazala na značajan pad sposobnosti s porastom stupnja uhranjenosti u svim motoričkim testovima osim testovima ravnoteže kod dječaka. Nasuprot tome, neočekivano, sposobnosti djevojaka većeg indeksa tjelesne mase se nisu značajno razlikovale od onih nižeg indeksa. Jedini statistički značajno lošiji rezultat deblje djevojke su postigle na testu repetitivnih pokreta donjih ekstremiteta. U zaključku, sportski programi koji se nude u školama morali bi sadržavati i aktivnosti u kojima se dječaci povećane tjelesne mase neće osjećati nedovoljno sposobnima, a možda čak i neke sportove u kojima je bitna ravnoteža kao pokazatelj koji je najmanje pod utjecajem tjelesne mase kao npr. skateboard i sl.

SAŽETAK Cilj istraživanja: Nesteroidni protuupalni analgetici osnova su multimodalne analgezije i mogu značajno uštedjeti potrošnju opijata pri liječenju jakih poslijeoperacijskih bolova. Preemptivni analgetski učinak redovitom perioperacijskom primjenom diklofenaka nije ispitivan u velikim ortopedskim zahvatima. Ovaj je rad dizajniran da bi se odredilo hoće li preemptivna primjena diklofenaka prijeoperacijski i u 48 poslijeoperacijskih sati unaprijediti postojeći multimodalni program: smanjiti bolove i/ili smanjiti potrošnju opijatnog analgetika fentanila. Ispitanici i metode: Ispitivanje je provedeno u razdoblju od dvije godine na 80 pacijenata koji su se podvrgavali elektivnim rekonstrukcijskim zahvatima na prednjemu križnom ligamentu koljena. Pacijenti su bili podijeljeni u dvije skupnine: jedni su preemptivno večer prije zahvata i u 48 poslijeoperacijskih sati dobivali 150 mg peroralnog diklofenaka, a drugi placebo. Svi su pacijenti poslijeoperacijski primali kombiniranu intraartikularnu analgeziju, kontinuiranu 24-satnu infuziju tramadola 200 mg i metamizola 2500 g te intravenski fentanil, prema potrebi. Četiri puta u 48 sati mjerile su se vizualno- analogne skale bolova u mirovanju i tijekom vježbi te 24-satna potrošnja opijata. Rezultati: Ispitanici u preemptivnoj diklofenak skupini pokazali su statistički značajno manju prosječnu potrošnju opijatnog analgetika fentanila te značajno manji intenzitet bolova u mirovanju i tijekom vježbi u odnosu na kontrolnu skupinu (p, SUMMARY Objectives: Nonsteroidal antiinflammmatory drugs are recommended for the multimodal analgetic management of postoperative pain and may have significant opioid-sparing effect after major surgery. Preemptive analgesic efficacy of nonsteroidal antiinflammatory drug diclofenac have not been evaluated after major orthopedic surgery. This study was designed to determine whether the administration of a preemptive doses of diclofenac to patients who have undergone anterior cruciate ligament reconstruction would enhance analgesia, and/or decrease consumption of opioid analgetic fentanyl. Patients and methods: We evaluated 80 patients undergoing anterior cruciate ligament reconstruction. The patients were divided into two groups: ones preemptively, the night before and for 48 hr after operation, received oral diclofenac and others placebo. All patients postoperatively received combined intraarticular analgesia, continious 24-hr intravenous infusion of 200 mg tramadolum and 2,5 g metamisolum and intravenous fentanyl as needed. The outcome measures included visual-analog pain scores at rest and movements preoperatively and four times during 48 hours and the total dose of fentanyl during 24 horus. Results: The total dose of fentanyl were significantly less in the diclofenac group, and pain scores were significantly less in the diclofenac group at rest and movements than in the control group (p

Neurogenous bone tumours are rare ; however, definite benign neurilemmomas have been described.On radiographs, they are seen as discrete lytic lesions. Their microscopic appearance is similar to that of neurilemmomas of soft tissue.This article reports an aggressive, intraosseous epitheloid malignant schwannoma involvinf the tibial shaft.

There are only a few reported cases of synovial chondromatosis affecting pisotriquetral joint (PT). Osteoarthritis of the PT is also rare and can be as disabling as osteoarthritis of any joint. We report this to be the unique case of synovial chondromatosis of the PT joint with secondary osteoarthritis.

Authors describe undelayed femoral head ossification in Kniest dysplasia, evolution of hip abnormalities and a 30-year patient follow-up.