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UVOD: Bol glavni je ograničavajući faktor rane rehabilitacije nakon ugradnje totalne endoproteze (TEP) koljena. Bol nakon ugradnje TEP-a koljena opisuje se kao umjereno jaki i jaki te zahtijeva korištenje jakih analgetika u liječenju bola. Multimodalna analgezija podrazumijeva kombinaciju dvaju ili više lijekova koji će utjecati na centralnu i perifernu komponentu bola, a s ciljem bolje kontrole bola uz manje nuspojava lijekova. Dok su tijekom 24 do 48 sati poslijeoperacijski ispitane razne metode analgezije, podaci o optimalnoj kombinaciji lijekova tijekom prva četiri tjedna rehabilitacije i utjecaj na rehabilitaciju su nedostatni. ----- CILJ: Cilj ovog istraživanja je ispitati utjecaj multimodalne analgezije metamizolom na poslijeoperacijski bol u usporedbi prema multimodalnoj analgeziji s meloksikamom tijekom prva četiri tjedna rehabilitacije nakon ugradnje TEP-a koljena. Specifični ciljevi bili su utvrditi ima li razlike među skupinama ispitanika u funkcionalnom ishodu i zadovoljstvu bolesnika te ispitati korelaciju intenziteta bola i veličine poslijeoperacijskog hematoma s postignutim opsegom pokreta koljena tijekom 28 dana rehabilitacije. ----- MATERIJALI I METODE: Istraživanje je bilo prospektivno randomizirano otvoreno. Uključeni su bolesnici hospitalizirani zbog operacije ugradnje TEP-a koljena radi uznapredovalog osteoartritisa. Svi bolesnici dobivali su redovito od prvog poslijeoperacijskog dana (POD1) do POD20 oksikodon u terapijskoj dozi s time da je jedna skupina dobivala meloksikam, a druga skupina metamizol u terapijskim dozama. Kao dodatni analgetici korišteni su paracetamol i tramadol na zahtjev bolesnika tijekom cijelog ispitivanog razdoblja. Na pregledu prije operacije zabilježeni su opći demografski podaci o bolesniku, intenzitet bola u mirovanju, aktivnosti i tijekom noći, razina zadovoljstva, fleksija i ekstenzija koljena te opseg koljena. Te varijable mjerene su svakodnevno tijekom rehabilitacije. Bilježena je i ukupna količina dodatnih analgetika tijekom ispitivanog razdoblja. Prije operacije i nakon 4 tjedna rehabilitacije ispunjeni su specifični upitnici (WOMAC, KSS) i izmjerena hodna pruga (6MWT). ----- REZULTATI: Između rujna 2013. godine i prosinca 2014. godine uključeno je 135 bolesnika. Podaci su analizirani za njih 127 podijeljenih u dvije ispitivane skupine, 63 u skupini s metamizolom i 64 u skupini s meloksikamom. Tijekom 4 tjedna svakodnevno mjeren intenzitet bola je u obje ispitivane skupine usporediv i smanjuju se proporcionalno s vremenom. Fleksija i ekstenzija, nakon inicijalno uzlazne dinamike, gube postignute vrijednosti krajem prvog i početkom drugog tjedna da bi krajem drugog tjedna ponovno počele rasti. Bol tijekom prva dva tjedna nakon operacije u najvećoj mjeri utječe na postizanje fleksije, ali tek od desetog dana rehabilitacije nadalje. Naši rezultati upućuju da je upravo progresija veličine poslijeoperacijskog hematoma povezana s gubitkom postignutog opsega pokreta koljena. Nakon 4 tjedna rehabilitacije nismo našli razlike u postignutom funkcionalnom ishodu, intenzitetu bola niti u razini zadovoljstva među promatranim skupinama bolesnika. ----- ZAKLJUČAK: Poslijeoperacijski bol tijekom prva 4 tjedna rehabilitacije nakon ugradnje TEP-a koljena jednako dobro je liječen multimodalnom analgezijom metamizolom u usporedbi s multimodalnom analgezijom s meloksikamom, čime je potvrđena hipoteza. Dobra kontrola bola i mjere prevencije krvarenja u području koljena mogu ubrzati oporavak tijekom rehabilitacije unutar prvih mjesec dana nakon operacije ugradnje TEP-a koljena., INTRODUCTION: Pain is a major limiting factor of early rehabilitation after total knee replacement (TKR). Pain after TKR is described as severe and very severe and it requires the use of strong analgesics in the treatment of pain. Multimodal analgesia involves a combination of two or more drugs that will treat the central and peripheral component of pain, with the aim of better control of pain with less side effects of the medication. Data regarding the optimal drug combination regimen during the first four weeks of rehabilitation in patients after TKR are insufficient. ----- OBJECTIVES: The aim of this study is to demonstrate equally effective control of the acute postoperative pain and functional outcome in patients receiving metamizole as compared to meloxicam in multimodal analgesic regimens during the first four weeks of rehabilitation after TKR. The specific objective were to determine whether the differences between the groups in the functional outcome and patient satisfaction, and to test the correlation of the pain intensity and the size of the postoperative hematoma with the knee motion range during the 28 days of rehabilitation. ----- MATERIALS AND METHODS: This prospective open randomized study included patients hospitalized for the TKR because of severe knee osteoarthritis. From the first postoperative day (POD1) to POD20, all patients regularly received oxycodone in therapeutic dose, with one group receiving meloxicam, and the other group metamizole in therapeutic doses. As an additional analgesic, paracetamol and tramadol were used at the patient's request throughout the whole study period. At the examination before surgery were recorded the general demographic dana of the patient, the intensity of pain at rest, in activity and during the night, the level of general satisfaction, flexion and extension of the knee and the suprapatellar knee circumference. These variables are measured daily during rehabilitation. The total amount of additional analgesics was recorded during the study period. Prior to surgery and after 4 weeks of rehabilitation, specific questionnaires (WOMAC, KSS) and the length of the walk (6MWT) were measured. ----- RESULTS: In our study 135 patients were included between September 2013. and December 2014. Data were analyzed for 127 divided into two study groups, 63 in metamizole and 64 in the meloxicam group. During the 4 weeks, daily measured pain intensity in both groups was comparable and were reduced proportionately over time. The flexion and extension after initial upward dynamics lost the achieved values at the end of the first and at the beginning of the second week to restart again at the end of the second week. Pain during the first two weeks after surgery largely affects the achievement of flexion, but only after 10th day of rehabilitation. Our findings indicate that postoperative hematoma progression is associated with loss of knee movement. After 4 weeks of rehabilitation, we did not find differences in the achieved functional outcome, the intensity of pain or the satisfaction level between the observed groups of patients. ----- CONCLUSION: Postoperative pain during the first 4 weeks of rehabilitation after TKR was equally well treated in patients receiving metamizole as compared to meloxicam in multimodal analgesic regimens, which was confirmation of the hypothesis. Proper pain control and bleeding prevention measures in the knee area can accelerate recovery during the first month of rehabilitation after TKR.

Pandemija koronavirusne bolesti, COVID-19 (engl. coronavirus disease 19), uzrokovana novim koronavirusom SARS-CoV2 (engl. severe acute respiratory syndrome coronavirus 2) postala je jedna od najsloženijih međunarodnih zdravstvenih i ekonomskih kriza posljednjih godina. Globalni utjecaj COVID-19 posljedica je nagle pojave bolesti o kojoj se prethodno nedovoljno znalo te velikog broja bolesnika (18, 5 % od ukupno oboljelih) koji zahtijevaju liječenje u jedinicama intenzivne skrbi. COVID-19 dominantno zahvaća respiratorni sustav, no danas je poznato da se radi o multisistemskoj bolesti sa često teškim i raznolikim kliničkim slikama zbog oštećenja ne samo respiratornog, već i kardiovaskularnog, neurološkog i mišićno-koštanog sustava te fizičkog dekondicioniranja organizma, što u konačnici dovodi do smanjenja kvalitete života i emocionalnih poremećaja. Stoga je Hrvatsko društvo za fizikalnu i rehabilitacijsku medicinu Hrvatskog liječničkog zbora preporuke za akutnu COVID-19 i post-COVID-19 rehabilitaciju. Preporuke su pripremljene za specijaliste fizikalne i rehabilitacijske medicine, kao vodič u kreiranju rehabilitacijskog programa individualno prilagođenog za svakog pojedinog bolesnika. Rehabilitacijski program provodi multiprofesionalni tim na čelu sa specijalistom fizikalne i rehabilitacijske medicine, a uz njega su uključeni i fizioterapeuti, radni terapeuti, psiholozi, logopedi, socijalni radnici i ostali članovi tima te liječnici drugih specijalnosti ovisno o kliničkoj slici bolesnika.

INTRODUCTION: Pain is a major limiting factor of early rehabilitation after total knee replacement (TKR). Pain after TKR is described as severe and very severe and it requires the use of strong analgesics in the treatment of pain. Multimodal analgesia involves a combination of two or more drugs that will treat the central and peripheral component of pain, with the aim of better control of pain with less side effects of the medication. Data regarding the optimal drug combination regimen during the first four weeks of rehabilitation in patients after TKR are insufficient. ----- OBJECTIVES: The aim of this study is to demonstrate equally effective control of the acute postoperative pain and functional outcome in patients receiving metamizole as compared to meloxicam in multimodal analgesic regimens during the first four weeks of rehabilitation after TKR. The specific objective were to determine whether the differences between the groups in the functional outcome and patient satisfaction, and to test the correlation of the pain intensity and the size of the postoperative hematoma with the knee motion range during the 28 days of rehabilitation. ----- MATERIALS AND METHODS: This prospective open randomized study included patients hospitalized for the TKR because of severe knee osteoarthritis. From the first postoperative day (POD1) to POD20, all patients regularly received oxycodone in therapeutic dose, with one group receiving meloxicam, and the other group metamizole in therapeutic doses. As an additional analgesic, paracetamol and tramadol were used at the patient's request throughout the whole study period. At the examination before surgery were recorded the general demographic dana of the patient, the intensity of pain at rest, in activity and during the night, the level of general satisfaction, flexion and extension of the knee and the suprapatellar knee circumference. These variables are measured daily during rehabilitation. The total amount of additional analgesics was recorded during the study period. Prior to surgery and after 4 weeks of rehabilitation, specific questionnaires (WOMAC, KSS) and the length of the walk (6MWT) were measured. ----- RESULTS: In our study 135 patients were included between September 2013. and December 2014. Data were analyzed for 127 divided into two study groups, 63 in metamizole and 64 in the meloxicam group. During the 4 weeks, daily measured pain intensity in both groups was comparable and were reduced proportionately over time. The flexion and extension after initial upward dynamics lost the achieved values at the end of the first and at the beginning of the second week to restart again at the end of the second week. Pain during the first two weeks after surgery largely affects the achievement of flexion, but only after 10th day of rehabilitation. Our findings indicate that postoperative hematoma progression is associated with loss of knee movement. After 4 weeks of rehabilitation, we did not find differences in the achieved functional outcome, the intensity of pain or the satisfaction level between the observed groups of patients. ----- CONCLUSION: Postoperative pain during the first 4 weeks of rehabilitation after TKR was equally well treated in patients receiving metamizole as compared to meloxicam in multimodal analgesic regimens, which was confirmation of the hypothesis. Proper pain control and bleeding prevention measures in the knee area can accelerate recovery during the first month of rehabilitation after TKR.

INTRODUCTION: Cotyloplasty is a technique that involves making a perforation of the medial wall of a dysplastic acetabulum and then inserting an acetabular cup with the medial aspect of it’s dome beyond the Kohler’s line. Although this method is in use since 1976., so far no one has not defined how much cotyloplasty can be performed to remain acetabular component stablity. In this study we measured acetabular component stability depending on the diameter of cotyloplasty. MATERIALS AND METHODS: On the 24 pigs pelvis models iatrogenic medial wall defect in different diameters (10, 20, 25, 30mm) was made followed with acetabular component placement (size 44). Acetabulum was loaded for determining to which diameter of cotyloplasty acetabular component remains stable, or at which point the remaining medial wall of the acetabulum can´t withstand the load and acetabular cup moves through the pelvis for more than 2 mm or breaks through acetabulum. RESULTS: In our study we found that in the average person (weighing 70 kg), we can make acetabular defect that is between 25 and 30 mm if we use the acetabular component size 44. If it is a person with higher body weight, up to 100 kg, this defect should not exceed the diameter of 25 mm. CONCLUSION: For the first time maximal diameter of cotyloplasty which ensures the primary stability of acetabular component is determed. We confirmed our hypothesis that THA will have sufficient stability to ensure secondary bone ingrowth around it, if amount of cotyloplasty does not exceed half of the acetabular component diameter. This information will help orthopedic surgeons in preoperative planning of total hip arthroplasty and postoperative rehabilitation patients with hip dysplasia.

CILJ: Prikazati primjenjivost personalizirane medicine u svakodnevnom kliničkom radu Specijalne bolnice Sv. Katarina kao regionalnom centru izvrsnosti i lideru u primjeni inovativnih metoda dijagnostike i liječenja. METODE: Liječnici različitih specijalnosti: radiolozi, neurolog, neurokirurg i vertebrolog, ortopedi, fizijatar, anesteziolog te molekularni biolog, medicinski biokemičar i pedijatar, u ovome su radu na konkretnim primjerima naveli osnovne principe primjene personalizirane medicine u svome svakodnevnom kliničkom radu kritički se pri tome osvrćući na relevantne radove o navedenoj temi publicirane u recentnoj medicinskoj literaturi. ZAKLJUČCI: Nedvojbeno je da će načela personalizirane medicine odrediti smjernice razvoja dijagnostičkih i terapeutskih postupaka. Isto tako, stanična terapija, liječenje matičnim stanicama, stanično reprogramiranje, tkivni inženjering ili genska terapija postati će metode izbora u liječenju niza bolesti koje smo do sada više ili manje bezuspješno liječili standardnim metodama i postupcima.

Ugradnja totalne endoproteze kuka bolesnicima s osteoartritisom kuka znatno smanjuje bol i povećava kvalitetu života. Bitan parametar kvalitete života o kojem liječnici rijetko razgovaraju s bolesnicima jest seksualna aktivnost, a interes bolesnikâ za tu temu postoji. Dapače, bolesnici koji su prije operacije imali otežane seksualne aktivnosti uzrokovane bolnošću i ograničenjem kretnja u zahvaćenom kuku nakon operacije ponovo imaju bezbolne i pokretljive kukove. Operater nakon ugradnje totalne endoproteze kuka najčešće preporučuje ograničen opseg pokreta u kuku kako bi se prevenirala luksacija endoproteze. To stvara ograničenja u aktivnostima svakodnevnog života, sportskim aktivnostima te naravno u seksualnoj aktivnosti. Cilj je ovog rada dati smjernice o osobitostima seksualnih odnosa kod bolesnica i bolesnika s ugrađenom totalnom endoprotezom kuka. Rehabilitacija ovih bolesnika trebala bi sadržavati i edukaciju o mogućnostima i ograničenjima tijekom seksualne aktivnosti.

median nerve, bifid

Podvojeni živac medijanus kod bolesnice sa sindromom karpalnog kanala ‐ prikaz slučaja

Cilj je ovoga rada prikazati raspodjelu i zastupljenost patomorfoloških promjena ramenog zgloba otkrivenih ultrazvučnim pregledom bolesnika s radnom dijagnozom humeroskapularnog periartritisa (PHS). Retrospektivno su analizirani ultrazvučni nalazi 141 bolesnika, odnosno 147 simptomatskih ramena kod bolesnika s uputnom dijagnozom PHS. Nalazi su podijeljeni u skupine prema anatomskoj lokalizaciji i ultrazvučno otkrivenoj patomorfologiji te po dobnim skupinama. Podaci su analizirani deskriptivno. Ukupno je nađeno 87 (59, 2%) pozitivnih i 60 (40, 8%) urednih ultrazvučnih nalaza. Najčešće su promjene na tetivi supraspinatusa (55, 3%), potom tenosinovitis duge glave bicepsa (15, 2%), burzitisi (12, 6%), tendinitis supskapularisa (10, 6%) i tendinitis infraspinatusa (0, 7%). Najveći broj patomorfoloških promjena, a ujedno i urednih nalaza, nađen je u dobnoj skupini od 40 do 65 godina. Najmanji je broj urednih nalaza u skupini starijih od 65 godina gdje je otkriveno najviše kompletnih ruptura supraspinatusa. Ultrazvuk je zbog svoje visoke specifičnosti i osjetljivosti za otkrivanje promjena rotatorne manšete, subakromijalo-subdeltoidne burze i tetive duge glave bicepsa, a s druge strane dostupnosti, neinvazivnosti i relativno niske cijene, metoda izbora za procjenu mekotkivnih struktura kod bolnog ramena. Ciljana anamneza i klinički pregled smanjit će broj neadekvatno indiciranih pretraga.

In this case report we present a patient with bifocal pubic rami stress fractures after contralateral total hip arthroplasty for congenital hip dysplasia and longstanding ipsilateral hip fusion. Treatment protocol for patients with various degrees of hip arthritis on one side and contralateral longstanding hip fusion are proposed based on the literature and our and previously published cases.