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PURPOSE OF THE STUDY This article presents the evidence and the rationale for the recommendations for surgical treatment of degenerative lumbar stenosis (DLS) and spondylolisthesis that were recently developed as a part of the Czech Clinical Practice Guideline (CPG) “The Surgical Treatment of the Degenerative Diseases of the Spine”. MATERIAL AND METHODS The Guideline was drawn up in line with the Czech National Methodology of the CPG Development, which is based on the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. We used an innovative GRADE-adolopment method that combines adoption and adaptation of the existing guidelines with de novo development of recommendations. In this paper, we present three adapted recommendations on DLS and a recommendation on spondy-lolisthesis developed de novo by the Czech team. RESULTS Open surgical decompression in DLS patients has been evaluated in three randomized controlled trials (RCTs). A recommendation in favour of decompression was made based on a statistically significant and clinically evident improvement in the Oswestry Disability Index (ODI) and leg pain. Decompression may be recommended for patients with symptoms of DLS in the event of correlation of significant physical limitation and the finding obtained via imaging. The authors of a systematic review of observational studies and one RCT conclude that fusion has a negligible role in the case of a simple DLS. Thus, spondylodesis should only be chosen as an adjunct to decompression in selected DLS patients. Two RCTs compared supervised rehabilitation with home or no exercise, showing no statistically significant difference between the procedures. The guideline group considers the post-surgery physical activity beneficial and suggests supervised rehabilitation in patients who have undergone surgery for DLS for the beneficial effects of exercise in the absence of known adverse effects. Four RCTs were found comparing simple decompression and decompression with fusion in patients with degenerative lumbar spondylolisthesis. None of the outcomes showed clinically significant improvement or deterioration in favour of either intervention. The guideline group concluded that for stable spondylolisthesis the results of both methods are comparable and, when other parameters are considered (balance of benefits and risks, or costs), point in favour of simple decompression. Due to the lack of scientific evidence, no recommendation has been formulated regarding unstable spondylolisthesis. The certainty of the evidence was rated as low for all recommendations. DISCUSSION Despite the unclear definition of stable/unstable slip, the inclusion of apparently unstable cases of DS in stable studies limits the conclusions of the studies. Based on the available literature, however, it can be summarized that in simple degenerative lumbar stenosis and static spondylolisthesis, fusion of the given segment is not justified. However, its use in the case of unstable (dynamic) vertebral slip is undisputable for the time being. CONCLUSIONS The guideline development group suggests decompression in patients with DLS in whom previous conservative treatment did not lead to improvement, spondylodesis only in selected patients, and post-surgical supervised rehabilitation. In patients with degenerative lumbar stenosis and spondylolisthesis with no signs of instability, the guideline development group suggests simple decompression (without fusion). [ABSTRACT FROM AUTHOR]

PURPOSE OF THE STUDY In this randomized prospective study, we monitored and compared perioperative changes in skeletal muscle enzymes blood levels in open and mini-invasive stabilization of thoracolumbar spine fractures. The established hypothesis was to confirm higher blood levels of muscle enzymes in open stabilization. MATERIAL AND METHODS This study included 38 patients with the mean age of 46.4 years. 19 injuries were managed in an open procedure and 19 procedures were mini-invasive. Venous blood was taken intermittently at short intervals to determine the levels of skeletal muscle enzymes. The catalytic concentration of creatine kinase was determined via an enzymatic UV-test, and the concentration of myoglobin via electro-chemiluminescent immunoassay. Enzyme levels were processed statistically. The Wilcoxon test was used. RESULTS The median increase in the values of both enzymes is higher in the mini-invasive method than in the open method in both the surgery phase for the injury and in the extraction phase. The median increase in the values of both enzymes is higher in both methods for the primary procedure phase compared to the extraction phase. All results are statistically significant at p of <0.05. All tests were calculated using the MATLAB Statistics Toolbox. DISCUSSION A very surprising finding, when testing the hypothesis of the levels increasing mainly in open stabilization, was confirming the opposite. Both enzymes were higher in the mini-invasive approach to stabilising the spine after the injury, but also after the extraction. This contradicts the available literature. However, this can be explained by the methodology of enzyme levels determination in the previously published studies. We believe that this phenomenon can be partially caused by an iatrogenic mini-compartment of muscles in the postoperative period, absence of wound drainage, but also by higher muscle contusion when inserting bolts through the tubes via small incisions, when the tubes penetrate to the entry points relatively violently and the muscles in this area are affected more than in the classical skeletization. CONCLUSIONS Analysis of biochemical changes in open and mini-invasive surgery did not confirm the hypothesis that levels of creatine kinase and myoglobin enzymes increase especially in open stabilization. On the contrary, they were statistically significantly higher in mini-invasive procedures. [ABSTRACT FROM AUTHOR]

Objective: To determine the efficacy of adding instrumented spinal fusion to decompression to treat degenerative spondylolisthesis (DS)., Design: Systematic review with meta-analysis., Data Sources: MEDLINE, Embase, Emcare, Cochrane Library, CINAHL, Scopus, ProQuest Dissertations & Theses Global, ClinicalTrials.gov and WHO International Clinical Trials Registry Platform from inception to May 2022., Eligibility Criteria for Study Selection: Randomised controlled trials (RCTs) comparing decompression with instrumented fusion to decompression alone in patients with DS. Two reviewers independently screened the studies, assessed the risk of bias and extracted data. We provide the Grading of Recommendations, Assessment, Development and Evaluation assessment of the certainty of evidence (COE)., Results: We identified 4514 records and included four trials with 523 participants. At a 2-year follow-up, adding fusion to decompression likely results in trivial difference in the Oswestry Disability Index (range 0-100, with higher values indicating greater impairment) with mean difference (MD) 0.86 (95% CI -4.53 to 6.26; moderate COE). Similar results were observed for back and leg pain measured on a scale of 0 to 100, with higher values indicating more severe pain. There was a slightly increased improvement in back pain (2-year follow-up) in the group without fusion shown by MD -5·92 points (95% CI -11.00 to -0.84; moderate COE). There was a trivial difference in leg pain between the groups, slightly favouring the one without fusion, with MD -1.25 points (95% CI -6.71 to 4.21; moderate COE). Our findings at 2-year follow-up suggest that omitting fusion may increase the reoperation rate slightly (OR 1.23; 0.70 to 2.17; low COE)., Conclusions: Evidence suggests no benefits of adding instrumented fusion to decompression for treating DS. Isolated decompression seems sufficient for most patients. Further RCTs assessing spondylolisthesis stability are needed to determine which patients would benefit from fusion., Prospero Registration Number: CRD42022308267., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

PURPOSE OF THE STUDY This article presents the evidence and the rationale for the recommendations for surgical treatment of degenerative lumbar stenosis (DLS) and spondylolisthesis that were recently developed as a part of the Czech Clinical Practice Guideline (CPG) "The Surgical Treatment of the Degenerative Diseases of the Spine". MATERIAL AND METHODS The Guideline was drawn up in line with the Czech National Methodology of the CPG Development, which is based on the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. We used an innovative GRADE-adolopment method that combines adoption and adaptation of the existing guidelines with de novo development of recommendations. In this paper, we present three adapted recommendations on DLS and a recommendation on spondylolisthesis developed de novo by the Czech team. RESULTS Open surgical decompression in DLS patients has been evaluated in three randomized controlled trials (RCTs). A recommendation in favour of decompression was made based on a statistically significant and clinically evident improvement in the Oswestry Disability Index (ODI) and leg pain. Decompression may be recommended for patients with symptoms of DLS in the event of correlation of significant physical limitation and the finding obtained via imaging. The authors of a systematic review of observational studies and one RCT conclude that fusion has a negligible role in the case of a simple DLS. Thus, spondylodesis should only be chosen as an adjunct to decompression in selected DLS patients. Two RCTs compared supervised rehabilitation with home or no exercise, showing no statistically significant difference between the procedures. The guideline group considers the post-surgery physical activity beneficial and suggests supervised rehabilitation in patients who have undergone surgery for DLS for the beneficial effects of exercise in the absence of known adverse effects. Four RCTs were found comparing simple decompression and decompression with fusion in patients with degenerative lumbar spondylolisthesis. None of the outcomes showed clinically significant improvement or deterioration in favour of either intervention. The guideline group concluded that for stable spondylolisthesis the results of both methods are comparable and, when other parameters are considered (balance of benefits and risks, or costs), point in favour of simple decompression. Due to the lack of scientific evidence, no recommendation has been formulated regarding unstable spondylolisthesis. The certainty of the evidence was rated as low for all recommendations. DISCUSSION Despite the unclear definition of stable/unstable slip, the inclusion of apparently unstable cases of DS in stable studies limits the conclusions of the studies. Based on the available literature, however, it can be summarized that in simple degenerative lumbar stenosis and static spondylolisthesis, fusion of the given segment is not justified. However, its use in the case of unstable (dynamic) vertebral slip is undisputable for the time being. CONCLUSIONS The guideline development group suggests decompression in patients with DLS in whom previous conservative treatment did not lead to improvement, spondylodesis only in selected patients, and post-surgical supervised rehabilitation. In patients with degenerative lumbar stenosis and spondylolisthesis with no signs of instability, the guideline development group suggests simple decompression (without fusion). Key words: degenerative lumbar stenosis, degenerative spondylolisthesis, spinal fusion, Clinical Practice Guideline, GRADE, adolopment.

•Surgical correction of AARD is an appropriate method of treatment after failed non-operative therapy.•The technique of surgical reduction and C1-C2 fixation using Harms/Goel technique provides excellent clinical outcomes.•In case of traumatic AARD we recommend to consider temporary fixation., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2022 The Authors.)

Introduction: Surgical treatment of high-grade developmental spondylolisthesis remains controversial with paucity of data reporting complete reduction of the deformity, especially in pediatric patients., Research Question: To assess efficacy and safety of complete reduction and circumferential L5-S1 fusion in children with high-grade high-dysplastic spondylolisthesis. Emphasis was placed on fusion rates, correction of lumbosacral deformity and long-term clinical outcomes by means of patient-reported outcome measures (PROMs)., Material and Methods: Consecutive series of 18 pediatric patients referred to surgery over an 11-years period. Several radiographic variables and PROMs were collected pre- and post-surgery with minimum follow-up of 2-years., Results: The mean age of cohort was 12.9 years with a mean follow-up of 7.8 years. Postoperatively, the mean slip was reduced from 64.4±9.8% to 4.5±5.9% with no loss of correction during follow-up. PROMs significantly improved following the index procedure (p<0.0001). Lumbo-pelvic parameters improved after surgery, including SS, but not PT. Development of adjacent level spondylolisthesis was noted in eight subjects (44%), two of these patients required additional surgery. Posterolateral and anterior fusion was obtained in 100% and 78% of cases, respectively. One patient developed a transient right-sided L5 nerve paresis after surgery that gradually resolved within one year post-surgery. Preoperatively, we recorded three patients with L5 nerve root motor deficit, which resolved completely in two cases and in one patient remained unchanged., Discussion and Conclusion: Complete reduction can safely be accomplished without an increased risk of nerve root injury. Coupled with single-level circumferential fusion, it provides high fusion rates with satisfactory spino-pelvic alignment., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2022 The Authors.)

PURPOSE OF THE STUDY The aim of this retrospective study was to assess the subjective evaluation of treatment by patients with respect to their return to work and recreational sport following the fracture of clavicle diaphysis with posttraumatic shortening of 1.5 cm, or more, treated non-operatively and surgically. MATERIAL AND METHODS Our group of patients consisted of 51 patients (14 females, 37 males) aged between 18 and 89 years (average age 46 years). We concentrated on the parameters of sex, age, side of injury, extent of posttraumatic shortening, method of treatment, return to work or recreational sport, DASH score at one year post non-operative or surgical treatment. Patients who sustained a pathological fracture, fractures of the clavicle combined with an injury of the acromioclavicular joint or simultaneous fracture of the humerus or the ribs were excluded from the study. Patients with open fractures or re-fractures were excluded as well. The indication for treatment selection was based on pre-operative discussion of the doctor with the patient and the Informed Consent was signed. The patient was informed about different treatment options. A shorter period of fixation of the arm and post-operative physiotherapy was mentioned in connection with surgical treatment as well as potential surgical complications. A statistical analysis comparing the data in both groups was conducted using the Fisher exact test. The p-value of 0.05 or less was considered as statistically significant. RESULTS The right side was affected 26 times, the left side 25 times. The shortening ranged from 1.5 to 3.7 cm. 24 patients (8 females, 16 males) aged 21 to 89 years (average 54 years) were treated non-operatively. 27 patients (6 females, 21 males) aged 18 to 74 years (average 38 years) underwent surgery. The difference in sex distribution in both groups was not statistically significant (p = 0.5311). According to the Robinson classification, there were 17 patients with type 2A2 fractures, of whom 8 underwent surgery and 9 were treated non-operatively, 19 patients with type 2B1 fractures, of whom 9 underwent surgery and 10 were treated non-operatively, and 15 patients with type 2B2, of whom 10 underwent surgery and 5 were treated non-operatively. The surgically treated patients prevailed in type 2B2 only, but this difference was not statistically significant (p = 0.2350). In the non-operatively treated group, 23 out of 24 patients returned to pre-injury activities in 3 months on average. Ten patients (48%) reported reaching the same function as on the other side. In the DASH score evaluation, 11 patients reached the value of 0-3.3, five patients 3.4-10, six patients 10.1-30.0 and two reached the score of more than 30. In the evaluation of capacity to work, 15 out of 24 patients were able to work, 11 of them without any restrictions or difficulties. In the evaluation of the sport and playing musical instrument module, 9 out of 24 patients did not engage in sports activities or do not play any musical instruments. In the surgically treated group, 26 out of 27 patients returned to pre-injury activities within 6 weeks. 19 (70%) patients reported reaching the same function as on the other side. In the DASH score evaluation, 19 patients reached the value of 0-3.3, two patients 3.4-10, 5 patients 10.1-30.0 and one patient with nonunion 72.5. Comparison of the average values of the DASH score demonstrated slightly better results achieved by surgical treatment (9.03 vs 6.77). When assessing the work module, 24 out of 27 patients returned to work, 20 of them without any restrictions or difficulties. Out of 27 patients, 4 patients were no longer able to engage in sports activities or to play a musical instrument. Of the 23 remaining patients, 18 did not have any problems, 5 suffered from minimal problems. The group of patients treated non-operatively included one case of non-union and the same applies to the surgically treated group. In 3 patients the removal of hardware was performed, 3 patients underwent revision of the surgical wound because of infection. DISCUSSION The recommendation of the weight-bearing of the upper extremity was similar in both groups, 12 weeks post injury/surgery on average. It is clear that sooner return to work or sports activities in the surgically treated group was preferred by younger patients who expected quicker recovery. Younger patients were less patient and more eager to return to work and sports, while the older patients, on the other hand, were more cautious about possible complications of surgery. CONCLUSIONS The results of our study did not identify any correlation between the clavicle shortening and the indication for surgical treatment. Surgical treatment was preferred by younger patients, more frequently by males. The rationale was supported by the perspective of sooner return to work and favourite sports activities. Their decision was not affected by the known risks of surgical treatment. Evaluation of the DASH score at one year after injury/surgery showed similar results. A higher incidence of complications in the surgically treated group did not lead to negative evaluation of the selected treatment modality by the highly motivated group of patients either. Key words: fractures of the clavicle diaphysis, non-operative treatment, surgical treatment, return to work, return to sports activities, functional results at 1 year.

Purpose of the Study: Radical resection of a vertebra is reserved only for specific tumors that invade the surrounding tissues and recur when not removed completely. The vertebra may be removed using a piecemeal technique or en bloc, using only two (in thoracolumbar spine) or more osteotomies (in cervical spine). We present our technique of en bloc resection of subaxial cervical vertebra for Ewing's sarcoma of C3, with preservation of all nerve roots and both vertebral arteries. To our knowledge, this surgical technique has not been reported in the English literature. The aim of this study is to describe the new technique of radical resection of subaxial cervical vertebra., Material and Methods: A transoral biopsy of tumor tissue anterior to C2-C3 was performed in 8-year old boy, revealing a diagnosis of Ewing's sarcoma. The patient was started on neoadjuvant chemotherapy. After 6 chemotherapy cycles with the VIDE regimen, the soft-tissue component completely regressed, with the only a residual deposit in C3 vertebral body. Based on further multidisciplinary meeting, an en bloc spondylectomy of C3 was recommended, preferably with preservation of nerve roots and vertebral arteries. In August 2014, prior to the planned surgery, we performed another thorough examination of the patient using plain films, CT and MRI. Neither angiography nor embolization was performed. DESCRIPTION OF SURGICAL TECHNIQUE: The first stage of the operation consisted of resection of the posterior structures. We exposed the posterior elements of C2 to C4 by the mid-line incision. The C3 arch was without pathological changes. After partial resection of the C2 inferior and C4 superior articular processes we performed bilateral osteotomy in the region of the pedicle adjacent to the arch with a chisel and removed the whole of the C3 posterior arch. Subsequently we perforated the transverse foramina close to the pedicle, using fine Kerrison rongeurs. The lateral parts around vertebral arteries were left in situ. In the next step we used instrumentation with polyaxial screws to stabilize the C2-C4 section. After 19 days we performed the second stage surgery from an anterior approach with the removal of the anterior and lateral parts of the vertebra. We made a transverse incision anterior to the sternocleidomastoid between the internal carotid artery and the trachea on the right side at the level of C3 to expose the spine. We resected C2-C3 and C3-C4 intervertebral discs and then performed osteotomy with fine Kerrison rongeurs on both sides, again, close to the vertebral body. Subsequently, the vertebral body was released and extracted en bloc. In the next step, both vertebral arteries were mobilized and shifted medially and the lateral portions of the transverse processes were released and removed en bloc. The empty space was filled with solid allograft and the C2-C4 levels were bridged by the cervical plate in 2+1+2 configuration., Results: There were no complications during both surgeries. The follow-up CT examination 4 months after the operation revealed a clear bone fusion of C2-C4, both anteriorly between vertebral bodies and posteriorly between the arches. Clinically the patient has reached 8 month follow up and had no complaints, both he and his parents were satisfied. Physiotherapy is proceeding according to plan. The patient remains under supervision at our centre., Discussion: Total en bloc resection of a subaxial cervical vertebra with preservation of neural and vascular structures has been described in the English literature only once. In 2007 was published a total en bloc resection of C5 for chordoma, preserving the above mentioned structures. Authors removed the lamina en bloc after bilateral osteotomy. Transverse foramina were perforated by the Gigli saw and removed in piecemeal fashion, including the posterior tubercle. In the next step, they removed the vertebral body and the anterior tubercle from the anterior approach. However, their treatment differs from the technique described here and does not correspond fully to the principle of en bloc resection. Our surgical technique is based on a similar principle of performing several osteotomies without the use of high speed burr, while preserving all neural and vascular structures. The difference can be particularly seen in the approach to remove lateral parts of the transverse foramen, which are surrounding the vertebral arteries. We consider it as ideal to split the cervical vertebra by smooth cuts into four parts and remove them en bloc., Conclusion: Total en bloc spondylectomy of a subaxial cervical vertebra with preservation of vertebral arteries and nerve roots is a radical surgery that should be used to treat only the most serious conditions. The risk of neurological deficit is outweighed by the benefits of oncological radicality. This new surgical technique has not yet been described and it is clear, that a larger cohort of patients is necessary to assess and potentially modify this technique so that it can be used more frequently in the future.

Purpose of the Study: Although great advances have been made in both radiological diagnosis and antibiotic therapy of microbial infections, the treatment of spinal infections remains a major clinical challenge. Many of the patients affected are referred to spinal units with long delays. The general population is ageing and the number of immunocompromised patients, as well as the number of operative procedures for spinal disorders are increasing. The aim of our study was to evaluate the clinical presentations of spinal infections, options for their diagnosis, indications for treatment and their risk factors and the results of surgery., Material and Methods: The group of 112 patients evaluated after the treatment of spinal infection comprised 63 men and 49 women at an average age of 59.4 years (range, 17 to 84). The average follow-up was 3.2 years (range, 6 months to 8 years). Of these, 82 patients had primary hematogenous infection, 29 had post-operative infection,and one had an infected gun shot wound. Thirty-six patients showed neurological deficit and six were paraplegic. The diagnostic methods included FBC, CRP and EST tests, examination of blood cultures, aspirates and biopsy samples from the infected site, bone scintigraphy, MRI and CT scanning. Indications for surgery included an infection not responding to conservative treatment,with existing or impending spinal instability, and with or without neurological deficit. The surgical management involved transpedicular drainage of the abscess, wound debridement from the posterior approach and instrumented spondylodesis. Surgery which included spinal decompression with radical excision of infected tissue was augmented with posterolateral instrumented fusion and/or anterior stabilization, as indicated., Results: Of the 112 patients treated, seven died of uncontrollable sepsis after surgery; the remaining 105 were followed up. Another four patients died of causes unrelated to the spinal problem treated within 12 months. All patients recovered except for two in whom the infection persisted, but 13 required more than one surgical procedure. One patient with CSF leakage failed to heal after five interventions. The most frequently isolated infectious agents were Staphylococus aureus, Staphylococus epidermidis and E. coli. Of the 33 patients with neurological deficit, 24 improved by one or two Frankel grades. The neurological status of six paraplegic patients did not improve, but their functional findings did after stabilization of the spine. Clinical evaluation showed 47 (44.7 %) very good, 40 (38 %) good, eight (7.6 %) unchanged and 10 (9.5 %) poor outcomes., Conclusion: Early diagnosis is a prerequisite for good treatment outcomes. Clinical examination, results of laboratory tests, and scintigraphy and MRI findings play the key role. When progressing osteolysis is suspected, a CT scan is necessary. Debridement should be as radical as possible, but always in compliance with the patient's health state. At an advanced stage of disease, spinal stabilization is important because it allows us to remove infected tissue. Intravenous and then oral antibiotic therapy at 2 to 4 and 6 to 12 weeks of follow-up is mandatory. The management of spinal infections is a complex process requiring good multidisciplinary cooperation.

Objective: The aim of this study was to investigate the expression of several cytokines, matrix metalloproteinases (MMPs), and tissue inhibitor of matrix metalloproteinases (TIMP)-1 in osteoarthritis (OA) and control sera and different joint tissues., Methods: Serum, synovial fluid, cartilage, synovial and subchondral bone tissues were examined in OA and control subjects. The protein level of tumor necrosis factor (TNF)-alpha, interleukin (IL)-1alpha, IL-8, IL-10 and MMP-2, MMP-3, MMP-9, and TIMP-1 were measured by immunoanalysis., Results: Serum levels of TNF-alpha, MMP-3 and -9 were significantly higher in OA patients than in controls. Conversely, serum IL-10 was decreased in OA patients. CRP was elevated when compared to healthy controls and decreased significantly 6 months after the surgery. In contrast to control samples, OA cartilage and synovium revealed significantly higher MMP-2, -3, -9 and IL-10. IL-1alpha was significantly higher in OA cartilage and IL-8 in OA synovium. Interestingly, MMP-3, -9, TIMP-1 and all tested cytokines were up-regulated in OA subchondral bone., Discussion: This study demonstrates pro-inflammatory condition of OA pathology and supports the idea that vascularized subchondral region may increase the synthesis of cytokines and MMPs leading to degradation of adjacent cartilage.

Purpose of the Study: Transarticular C1-2 fixation is a surgical alternative in treatment of atlantoaxial instability. Although the method provides very good immediate and long-term stability, it still involves several disadvantages. The group of patients as reported from various institutions are usually very small and hardly comparable. In order to objectively compare the results of the method, we collected the groups of patients treated in four institutions dealing with surgery of the cervical spine in Czech Republic., Material and Methods: During the 9-years period (1993-2001), the transarticular C1/2 fixation was performed in 80 patients (mean age 45.6 years, range 4-85 years). The procedure was indicated for atlantoaxial instability due to rheumatoid arthritis in 32 cases, pseudoarthrosis of the odontoid process in 15 cases, fracture of the odontoid in 8 cases, complex C1-C2 fracture in 7 cases, tumour in 5 cases, C1 fracture in 4 cases, os odontoideum in 3 cases, purulent osteolysis of the odontoid in 3 cases and instability due to tuberculosis in one case, respectively. Two patients underwent surgery for painful arthrosis of atlantoaxial joints only. Transarticular fusion was combined with posterior interlaminar fixation using autologous graft and wire in most of the cases. Clinical and radiological results were evaluated in the early postoperative period and 3, 6 and 12 months after surgery, respectively. The position of the screws in relation to lateral mass of the atlas was evaluated according to our own criteria as optimal, suboptimal, and misplaced. Long-term postoperative stability and bone fusion were also followed. The follow-up ranged from 3 to 99 months (mean 29.1 months). There were 72 patients available for long-term follow-up (i.e. more then 6 months)., Results: We inserted 150 screws; two screws were used in 72 patients, one screw in 6 patients while in two patients, the surgery had to be aborted without screwing. Optimal placement was achieved in 103 cases (68.7%), suboptimal because of too medial or lateral placement of the screws in 26 cases (17.3%), suboptimal due to a short screw in 9 case (6%) and a long screw in 8 cases (5.3%). Four screws (2.7%) were found misplaced (i.e. out of the lateral masses). Fusion was confirmed in 51 cases out of 72 operated on (70.8%) at 6-months follow-up, and in 55 cases out of 63 available for follow-up (87.3%) at 12 months, respectively. Segmental stability was achieved in all patients, even in cases with incomplete fusion as seen on radiograph. Furthermore, six screws in four patients were discovered to be broken, nevertheless without any clinical consequences. There were 4 cases of peroperative injury to th vertebral artery (i.e. 5% of patients, 2.7% of screws), one case of dural tear and one case of excessive blood loss from epidural venous plexus. These complications, however, did not cause any significant clinical consequences, either. Other postoperative complications included wound dehiscence in 3 cases, 2 cases of hardware failure due to wrong indication for surgery and 2 cases of persistent neck pain., Discussion: Transarticular C1/2 fixation is known to be universal and stable technique suitable for the treatment of atlantoaxial instability. According to biomechanical studies, this method provides the best stability mainly in rotation and lateral flexion (inclination) when compared to other described methods of atlantoaxial fixation. The fusion rate is reported to vary between 90 to 100% if the posterior interlaminar fusion using bone graft and wire is simultaneously performed. The rare incidence of pseudarthrosis is usually considered to be related to a poor surgical technique as even only one screw should provide bone fusion if properly placed. Using strict evaluation criteria, the fusion rate in our sample of patients was 87.3% at 12 months, or, 92.1% if also controversial radiographs were included. The injury to the vertebral artery is the most serious complication of the method; its incidence in our group (5% of patients) is comparable to data from literature. We believe that most of these events happened because of individual anatomical variations of axis and vertebral artery were not adequately respected., Conclusion: Transarticular technique of instrumental atlantoaxial fusion is an effective method with multiple application in treatment of craniocervical and upper cervical spine instability. The gain of immediate stability with acceptable risk of possible complications is the major advantage of this procedure. The results of our multicentric retrospective study confirm the expected high fusion rate and are comparable to previously published reports.

The authors present an overview of the current views on etiology and diagnostics of infectious complications of total hip arthroplasty and analyze the possibilities of individual therapeutic procedures (debridement with the preservation of total hip arthroplasty, revision of the endoprosthesis, long-term antibiotic therapy, final resection arthroplasty, arthrodesis). They discuss the pending issues relating to the therapy of infectious complications of total hip arthroplasty (the duration of antibiotic therapy, the interval between the extraction and revision surgery of the endoprosthesis, the use of antibiotic-containing cement). Based on their own experience they recommend the revision surgery with the preservation of the implant, debridement and irrigation as the first step only in case of an early post-operative infection and in case of a late hematogenous acute infection. In case of chronic infection they recommend a two-step revision surgery using the cement spacer and the antibiotic therapy for 3 to 6 months. During this period the laboratory and clinical signs of the infection must be back to their normal. Long-term antibiotic therapy in dependence on microbial sensitivity is recommended.

Purpose of the Study: Patients with rheumatoid arthritis (RA) often suffer from instability of the upper cervical spine. The most common instability is anterior atlanto-axial subluxation (AAS). Instability may lead to neurologic deficits from spinal cord compression and intractable pain, decreasing quality of life and its length., Material and Methods: This prospective study analyzed different fixation methods and the influence of atlanto-axial and occipito-cervical fusion on clinical and radiological outcome. 41 patients with RA with instability of the upper cervical spine were treated surgically for progressive instability, pain and neurological deficit. Average age of our patients was 52.4 years (21-76 years). At the time of surgery, duration of the disease was in average 18.6 years (2-47 years). Patients had advanced stage of the disease according to Steinbroker, on hands stage 3.7 and feet stage 2.9. Atlanto-axial fixation was done for AAS in 27 (24 Magerl transarticular fixations and Brooks-Jenkins technique in 3 patients). Occipito-cervical fusion was done in 13 patients (3 with Ransford loop and sublaminar wires and 9 with CerviFix). One patient was managed in halo-cast fixation. Spinal fusion was performed in all patients using autologenous bone graft. Patients were evaluated by using Functional Rating Index (FRI), Health Assessment Questionnaire (HAQ) and visual pain analogue scale (VAS) before and after surgery in set intervals, when radiological examination was also performed including dynamic films., Results: Three patients died in the postoperative period (3 weeks, 11 and 18 months). 38 patients remained for follow up, which was in average 28.4 months. Fusion was considered when hardware was intact and patient was satisfied, no motion was detected on dynamic X rays or bony fusion was clearly visible. Fusion was assessed in 40 patients, 32 fused, 8 had fibrous non-union. 3 of these patients had hardware failure. 9 patients had preoperatively verified panus formation peridentally, which resorbed after the surgery. FRI evaluation was done in 40 patients, 30 improved (14 patients by more than 10 points), 6 patients did not change and 4 worsened. The improvement after 3 and 12 months was statistically significant (p < 0.001). Average HAQ score decreased after surgery, but the change was not statistically significant (p > 0.05). Average VAS score decreased significantly after surgery (p < 0.05). There were 5 hardware related complications including one vertebral artery injury. None of these complications required subsequent surgery nor had any influence on good clinical outcome., Discussion: Results of FRI and VAS show the benefit from early indication of surgical stabilization of upper cervical spine in patients with RA. Based on our experience, as well as other authors, fixation of AAS by transarticular screw fixation according to Magerl is the preferred method in the younger patient group. Once destruction of the atlanto-axial joints, lateral subluxation or cranial migration of the dens is present, occipito-cervical fusion using titanium malleable implant (CerviFix) is necessary., Conclusion: Positive clinical outcomes advocate early surgical intervention as described in recent literature. Surgery prevents subsequent neurological damage life quality deterioration and shortening of life expectancy.

Purpose of the Study: Both synovial and bone forms of osteoarthritis (OA) are characterized by inflammatory processes in the articular compartment. Increasing evidence suggests that changes in bone tissue are important for the deterioration or loss of joint function. Therefore it is reasonable to shift emphasis from research on cartilage to that on other articular tissues, particularly on subchondral bone. The aim of the study was to demonstrate the involvement of several cytokines in OA development and, on the basis of changes of joint markers, to assess the extent of inflammatory process., Material: A total of 60 patients with an osseous form of osteoarthritis of the knee joint (28 patients) or the hip joining (32 patients) underwent total knee or hip arthroplasty. The mean age of our patients was 66.7 +/- 10.4 years. Preoperative clinical and radiographic examinations were carried out as well as routine laboratory tests on blood and urine. Samples of urine, blood serum (BS) and synovial fluid (SF), extracts from cartilage (CA) and synovial membrane (SM) and granulation bone tissue were analysed for markers indicating the presence of inflammatory processes in joints., Method: The following markers of inflammatory activity in the bone compartment were investigated: pyridinoline (PYR), deoxypyridinoline (D-PYR), bone alkaline phosphatase (BAP) and chondrex (CHON). The levels of cytokines IL-1 alpha, IL-8, IL-10 and TNF-alpha were assayed by immunoanalysis (ELISA and IMMULITE system) in BS, CA, SM, GT and SF. The tissue samples were obtained during arthroplasty., Results: In the patients with osteoarthritis, the urinary levels of PYR and D-PYR were higher than control values (70.33 +/- 34.93 vs (41.6 +/- 10.6 nmol/mmol creatinine). No significant differences were found between pre- and post-operative levels. Similarly, the serum levels of BAP and CHON compared with control values were higher (27.65 +/- 12.21 vs 12.2 +/- 2.7 U/L and (96.35 +/- 58.83 vs 43.2 +/- 14.5 ng/ml, respectively). In all articular compartments and in synovial fluid, the level of cytokine IL-8 exceeded concentrations of the other cytokines. In blood serum, only IL-10 levels were markedly increased as against the control group (17.35 +/- 5.82 vs 9.80 +/- 4.40 pg/ml)., Discussion: Primary osteoarthritis is the most common joint disease that deteriorates with age. Its symptoms are pain and a lower range of motion in the joint affected. The initial involvement of articular cartilage progresses to degenerative changes involving synovial and bony structures. This degenerative disease gradually develops into an inflammatory disease. At this stage, osseous tissue shows an increase in metabolism and bone destruction results. In the control of inflammatory reactions by the immune system, cytokines, among other proteins, play an important role: some may enhance inflammation by activating leukocytes (IL-1, TNF-alpha, IL-8) while others, such as IL-10, have anti-inflammatory effects., Conclusion: During osteoarthritis, the articular compartment shows high metabolic processes that, in some patients, may increase and even persist some time after arthroplasty.

Based on their group of 52 patients the authors analyze the complications they encountered in the treatment of crural fractures by a not predrilled intramedullary nail. Consistent with the literature they found that this method is successful in the treatment of closed and open fractures of the crural diaphysis. They mention, however, a relatively high percentage of complications which in the long run are not a impediment for healing of the fracture but influence it. In the discussion these complications are analyzed in detail in an attempt to find a solution and to avoid them in future patients. They conclude that even this relatively simple and effective method of fractures of the crural diaphysis has its pitfalls and its indication and implementation call for much attention.

Purpose of the Study: Direct osteosynthesis is a method of choice for the treatment of odontoid process fractures. It is based on insertion, from the anterior approach, of one or two screws from the C2 body into the apex of the odontoid across the fracture line. The tensile action of screws results in compression of fragments and stabilization of the fracture. The aim of the study was to evaluate a group of patients treated by this method and to compare our results with those reported in the foreign literature., Material: A total of 99 patients were treated by direct osteosynthesis of the odontoid in the departments involved in the study between 1994 and 2001., Methods: Patients indicated for this surgery were those with fractures of type II according to Anderson and D'Alonzo and those with type III fractures but only when the fracture line went across the articulation surfaces of C1-C2, when closed reduction was not possible or the patients were not indicated for halo fixation. Direct osteosynthesis was not applied to fractures with comminution at the base of the odontoid, irreducible fractures, odontoid fractures combined with dislocated fractures of the atlas or pathological fractures. Severe kyphosis of the cervical spine or a large thoracic cage was also regarded as a contraindication., Results: All the 99 patients were followed up from 3 up to 102 months, with an average of 28.5 months; only in seven patients, the follow-up period was shorter than 6 months. The most frequent subjective complaint was a painful operation wound. This usually resolved within two weeks of surgery. Except for four patients, alle were satisfied with the outcome. Type II fractures were diagnosed in 84 and type III fractures in 15 cases. A total of 174 screws were inserted into the odontoid processes of 99 patients. A single screw was used in 25 and two screws in 73 patients. In one case, three screws had to be inserted. Screw lenght ranged from 36 to 44 mm, diameter was 40.9 mm. Three months after surgery, X-ray examination, both in flexion and extension, did not reveal any instability in any of the patients. No morphological change in the C2-C3 intervertebral space was observed Of 92 (92.9%) paitents under longterm follow-up, 84 (91.3%) showed complete healing of the fracture, three died and five patients eventually developed pseudoarthrosis, which was due to a broken screw in three of them. This condition was treated by dorsal fixation of C1-C2 according to Magerl or by one of the dorsal cerclage techniques. The group was free of any perioperative complications related to the anterior approach or injury to nerve structures by screws., Discussion: The most frequent subjective complaint was a painful operation wound. Treatment of odontoid fractures varies according to the type of injury, bone quality and also practice at each department. Type II injuries are highly unstable and, because of the small fracture surface, their healing ability is much lower than in type III fractures. Previously, most of the patients with odontoid injuries were treated conservatively by immobilization in a plaster cast or a brace or, later, by a halo device. In the long term, however, they showed a high proportion of pseudoarthroses (10 to 100%). Direct osteosynthesis of the odontoid by screws permits the maintenance of rotation of the C1-C2 mobile segment. We followed the scheme of indications used abroad but did not perform osteosynthesis to correct pseudoarthrosis. The number of osteosyntheses healed (91.3%) was also in agreement with the literature data. Earlier, we used two screws for all types of fractures. Recently, we have preferred insertion of a single screw in type II and III fractures in narrow odontoids. In the later, there is no danger of rotational dislocation during screw insertion; to insert one screw from the centre of the C2 base is easy and speeds up the procedure. However, in displaced type II and type II T fractures, two screws are a necessity. Similarly to other authors, we recorded a slight limitation of cervical spine rotation in patients at long-term follow-up, particularly in elderly subjects with advanced osteochondrosis. No complications leading to deterioration of the patient's state were recorded., Conclusions: Direct osteosynthesis is a method of choice for most of the type II and indicated cases of type III fractures of the odontoid process of the axis. This surgical procedure facilitates restoration of anatomical conditions of the spine and its immediate stability. Consequently, patients can be readily mobilized and rehabilitated.

The aim of this study was to test C/C material (carbonized, graphitized or covered with pyrolytic carbon) designated for the use in orthopaedic and bone surgery. Using an in vitro assay we confirmed, that the cell proliferation was exhibited the mostly on the C/C composite coated with pyrolitic carbon and afterwards polished. The two latest of subsequent water extracts of this material had a slightly inhibiting effect on the cells metabolic activity. Biocompatibility test in vivo performed subcutaneously on rats did not show big differences between three tested implants (C/C composite, epoxy resine, titanium alloy), on the other hand the plates tested on pigs demonstrated foreign-body reaction induced by wear C/C composite material. Such debris were found both in the neighborhood of the implant as well as in the lymphatic node., (Copyright 2000 Kluwer Academic Publishers)

The authors describe in a group of 22 patients their experience with Sauvé-Kapandji's operation in posttraumatic damage of the distal radioulnar joint. They analyze the causes of affection of the distal radioulnar joint, discuss the functional anatomy of this joint and describe the technique of operation. In the discussion they deal with possible complications and analyze in detail their results. They suggest a pattern of evaluation of the results of surgery based on objective and subjective findings. In the conclusion they mention the satisfactory results of this operation if the correct surgical technique is used and careful indication of the operation is made.

The authors present short-term results of a 360 degrees fusion together with the experience in their own modification of minimally invasive retroperitoneal approach to the lumbar spine. In the course of 1998 and 1999 they operated on the total number of 21 patients using this approach. The anterior approach was considered as part of the combined operation on the lumbar spine which was indicated for degenerative, traumatic, tumorous and iatrogenic instability of the lumbar spine. They evaluated blood loss, duration of the surgery, duration of image intensifier exposure, restoration of the peristalsis, satisfaction of the patient with the operation by means of Visual Analog Scale and in 12 patients who exceeded a twelvemonth of the follow-up also healing of the fusion on dynamic radiographs of the lumbar spine. The results are very optimistic. As compared to a classical approach they achieved low blood loss, short duration of the surgery, a quick restoration of peristalsis and a reduction of postoperative morbidity. An undoubted advantage of the presented technique is the economic thriftiness as concerns special endoscopic devices, retraction frames, microscope, special instruments or expansion devices. During the evaluation of the fusion no development of a nonunion or migration of grafts or cages was recorded. Also the satisfaction of patients after the operation was high and in the following period it even increased. Key words: lumbar spine fusion, retroperitoneal approach, minimally invasive surgery.

The authors present their experience with treatment of scaphoid non-unions by the operation according to Matti-Russe. They compare their results with those of other authors and present a relatively high number of successfully treated patients with stable non-unions localized in the midline of the scaphoid bone as well as a high patient satisfaction rate with this method of treatment. The disadvantage of this treatment is long-term cast immobilization of the wrist and poor results in treatment of unstable non-unions and those localized in the proximal portion of the scaphoid bone. They conclude, that at present, it is more effective to support the surgery by osteosynthesis with an adequate implant and thus shorten the immobilization period in a cast.

Authors are presenting their results of anterior cervical instrumented fusion technique on group of 39 patients who were operated on in traumatic and degenerative indications.They present a 97 % fusion rate with minimal complications. Decompression of neural tissues, meticulous shaping of the tricortical autologous bone graft and respecting the physiological alignment of the cervical spine are presented as the most important steps. Application of the Morscher cervical plate is helpful, since it decreases postoperative neck immobilization in orthosis and increases the fusion rate. Key words: anterior instrumented cervical fusion, autologous bone graft, cervical plate.

The authors are presenting results on minimally-invasive laparoscopic approach to obtain anterior fusion of the lumbar spine on group of 62 patients. 12 patients had to have a conversion to open procedure. 50 patients were included in the follow up and evaluated in average 22 months after surgery. The advantages of the approach were documented by good overall rating of the procedure by the patients themselves, low blood loss, short hospital stay and high fusion rate. More than 50 % of patients had previously at least one spine surgery. The endoscopic retroperitoneal gasless approach (BERG) is very convenient as it enables surgery without gas insuflation in space large enough to treat as many as 3 spine levels at the same time. Key words: anterior interbody lumbar fusion, laparoscopic, minimally-invasive surgery.

On a group of 30 patients authors present the results they have achieved in the treatment of fractures of distal radius by external fixation. They deal with indications to the treatment of this injury by external fixation and describe in detail the method of such treatment. They discuss the pitfalls of this treatment, potential complications and adequacy of individual types of external fixators. They point out the discrepancy in the evaluation of objective achievements and subjective evaluation of patients. In total they evaluate the results as good and recommend a more consistent diagnostic and therapeutic connsidera-tion of the treatment of these injuries in out-patient departments. Key words: fracture of distal radius, external fixator.

The published paper pertains to a group of fullgrown minipigs where under anaesthesia with Narcamone after premedication with Rometar cartilage samples from the medial condyle of the femur in the area of the femoropatellar joint were taken. The collected cartilage samples served subsequently for the preparation of an autologous implant. After its preparation another operation was performed where by means of a bioptic trocar (diameter 3.5 mm) a cylindershaped defect was produced into which the implant was introduced. The animals were killed 8-12 weeks after the operation and part of the joint with the implant was subjected to further examination. The authors investigated three types of implants: 1. an implant based on three-dimensional cultivation of chondrocytes in a cultivation medium enriched with cartilaginous collagen and aggregan, 2. as sub 1 but the cultivation medium was enriched with the GHK tripeptide, 3. chondrocytes in the implant are added to gel prepared from cartilaginous collagens and aggregan. All three types of implants had a stimulating effect on the new formation of hyaline cartilage. When the tripeptide GHK is used, the newly formed tissue contains more cells. Simplest is the preparation of the third implant. Also the peroperative procedure is simplest. Key words: chondrocytes, cartilaginous collagens, cartilaginous implant, tripeptide gly-his-lys, aggregan, minipigs.

The authors prepared 12,5% collagen gel, that they supplemented by tripeptide gly-his-lys. peflacin and hypersulfated glycosaminoglycan (HSGAG). By means of I125 marking they followed up its absorption from small polyurethan sponges placed under the skin of rats. They found out, that absorption of gel without HSGAG is faster. No collagen antibodies (type I., II., III.) against the gel were formed neither in the experiment with rabbits, nor later on with minipigs when gel was placed into bone defects. Further on presence of microorganisms in the gel was looked for with negative results on various bacteriological nutrient media. The gel was used in a model experiment for filling artifically created bone defects in femurs of minipigs. Healing was followed up both histologically and with help of RTG and NMR and compared with healing of defects either unfilled, or filled with gel containing peflacin and HSGAG, but not tripeptide. The authors found out that slowest healing was in case of unfilled defects, on the other hand defects filled with collagen gel and GHK were healing substantially faster than defects filled with gel without GHK, i.e. healing needs approximately half the time less. Key words: healing of bone defects, collagen, tripeptide GHK, peflacin.

In our experimental study we report results of a measurement of the stiffness of different types of external fixators. In model of external fixation of the femur the mechanical properties of Hoffmann, Wagner, Ilizarov and Poldi 7 aparates were evaluated in model of external fixation of the tibia the properties of the different configurations of the unilateral frame and of the combined unilateral frame and bilateral frame were evaluated. Our results have shown the importance: - the stiffness of an applied frame, - the proper interconection of the used configura tion of the apparatus (frame), - the number and placement of an individual im plants screws, pins. Some of the obtained results were applied in our clinical practice. Key words: external fixation, biomechanics.

External fixation undoubtedly represents a great contribution to treatment of fractures. Its development goes back to middle of 19th century and is connected with the name of Joseph Francois Malgaigne, even though this outstanding doctor was probably not the first one to have used it. It is difficult to determine exactly the sequence of individual authors according to their merit, because each of them contributed to the development of external fixation in a different way. Nevertheless there are a few names that deserve special attention as Lambotte, Parkhill, Putti, H. Judet and Klapp with Block, who made significant steps forward in the development. It is obvious that external fixateurs in the time before World War Two were already highly developed devices and in comparison with the present situation in the field we could say that almost everything has been here before, only the precision of manufacturing of components and quality of used materials are on a higher level.

Based on seven-year experience with non-cemented femoral components of total endoprostheses of the hip joint, type Schenker, the authors assume that their use is limited only to a small group of patients under 40 years of age, provided strict principles as regards precision of implantation are respected. The latter are discussed in the submitted paper.