INTRODUCTION: Autologous stem cell transplantation (ASCT) became standard of care for patients with multiple myeloma (MM) under the age of 65 years. We routinely perform ASCT for newly diagnosed MM since 1996 in our department. PATIENTS AND METHODS: We retrospectively analyzed all 285 transplants in 185 patients done for MM from January 1996 till December 2010. We analyzed overall survival (OS) and progression-free survival (PFS) regarding conditioning, stage, complete or very good partial remission (CR, VGPR) achievement, renal impairment, single vs. double transplant. RESULTS: Estimated 10-years survival of the whole set of patients is 39% (median survival 95 months). Patients with renal impairment show same OS as those without (p = 0.22). Patients show similar overall survival and event free survival regardless of type of transplant. We observed better outcome in terms of overall survival in patients treated with new drugs (p = 0.0014). Reaching CR or VGPR was not translated into better OS (p = 0.30) and EFS (p = 0.10). Also stage of the disease and whether single or double transplant was used did not make any significant difference in the outcome. CONCLUSION: Stem cell transplantation greatly improved outcome of patients with MM. Poor outcome of allogeneic transplantation in our group of patients is related to high transplant related mortality (20% vs. 0%) and unexpected high relapse rate. There is a trend towards better survival, when new drugs are incorporated at any time in the course of the disease. This fact supports hypothesis that use of these drugs with ASCT should translate into better long-term outcome. and J. Radocha, V. Maisnar, A. Zavrelová, M. Cermanová, M. Lánská, M. Kmonícek, L. Jebavý, M. Bláha, J. Malý, P. Zák
Osteochondritis dissecans(OCD) of the knee is identified with increasing frequency in the adolescent patient. Left untreated, OCD can cause significant impairment and restriction in physical activity and development of osteoarthritis at an early age. The diagnosis of lesions of OCD can be confirmed on plain radiographs. MRI has emerged as the gold standard to evaluate the stability of the lesion and the integrity of the overlying articular cartilage. Treatment of OCD lesions depend on the stability of the lesion. Stable lesions can be treated conservatively by physical activity modification and immobilization. Unstable lesions and stable lesions not responding to conservative measures should be treated surgically. Surgical options range from arthroscopic drilling, either transarticular or extra-articular drilling for stable lesions or salvage procedures such as autologous chondrocyte transplantation (ACT), mosaicplasty to restore joint and cartilage congruency. and H. H. Shaikh, J. Vícha, T. Proček, J. Pavlata, T. Kučera
BACKGROUND: Though mid-term survival rates of over 95% in several series have been published, there is still a paucity of related literature regarding the role of vertical stem instability in the osteointegration of fluted tapered stems. This paper presents a comprehensive and prospective assessment on short-term experiences with uncemented modular femoral stem in the treatment of defective femur during revision surgery of total hip replacement. MATERIALS AND METHODS: Clinical and radiological monitoring of 20 consecutive patients with implanted tapered fluted revision stem (Lima Corporate, Udine, Italy) was of 27 months in average (20-35 months). The average pre-operative Merle d'Aubigné and Postel method score was 6.3 points (3-10 points). The frequency of femur defects, classified according to Paprosky, was IIIA = 9 and IIIB = 11. RESULTS: During last follow-up, the Merle d'Aubigné and Postel hip score was on average 11.7 (6-16 points). Compared to post-operation radiograph, stem migration of 1.9 mm (0-11 mm) on average was found. This vertical stem migration was observed only when comparing hip radiographs immediately after surgery, and at 6 weeks post-surgery. The Paprosky IIIA defects group, presented a subsided stem by an average of 1.5 mm. In the group of Paprosky IIIB defects, the stem subsidence was on average 2.3 mm. All 20 patients in the study showed excellent osteointegration of the uncemented revision modular stem. CONCLUSIONS: This study found and excellent osteointegration of the Lima uncemented tapered fluted revision modular stem in defective femur with a cortical bone segment present in the diaphyseal isthmus area. The initial vertical instability leading to stem migrating during the first six weeks following surgery did not, however, affect its osteointegration. and P. Šponer, T. Kučera, K. Urban, D. Zítko, D. Diaz-Garcia, M. Grinac
The clinical outcome of 153 Graves' disease patients treated with a wide dose range of radioactive iodine-131 (RAI) was analyzed retrospectively. Six to nine months after the first dose of RAI 60 patients (39%) were hypothyroid (or rather thyroxine-substituted) and 26 (17%) were euthyroid, while 67 patients (44%) did not respond properly: in 32 (21%) their antithyroid drug (ATD) dose could be reduced but not withdrawn (partial response) and 35 (23%) remained hyperthyroid or the same dose of ATD was necessary (no response). The outcome did not correspond significantly to the administered activity of RAI (medians 259, 259, 222, and 259 MBq for hypothyroid, euthyroid, partial, and no response subgroups, respectively), or the activity retained in the gland at 24 h (medians 127, 105, 143, and 152 MBq). The effect was, however, clearly, and in a stepwise pattern, dependent on initial thyroid volume (17, 26, 33 and 35 ml, P < 0.001) or activity per gram tissue retained at 24 h (6.02, 4.95, 4.75, and 4.44 MBq/g, P = 0.002). Also, higher residual level of thyrotoxicosis at the time of RAI treatment was connected with worse outcome. The dose-dependency of outcome was further analyzed. When our sample was divided into tertiles, according to the adjusted dose, the same modest success rates (47%) were seen in the lower and middle tertiles. However, doses higher than 5.88 MBq/g (the upper tertile) resulted in success rate of 75%. Finer division into decils has shown a threshold-like increase in cure rate between the 7th and the 8th decil. In the first 7 decils (doses ≤ 6 MBq/g) the complete response rate was 45 to 50%, in the 8th decil (6.0 to 7.8~MBq/g) it rose to 80% and was not further increased with increasing dose. Direct comparison of higher (> 6 MBq/g, cure rate 80%) and lower (≤ 6 MBq/g, cure rate 46%) doses gave highly significant difference (P < 0.001). With our dosing range we found a dose-dependent clinical outcome that suggests an optimum delivered dose near 6.5 MBq/g, resulting in successful treatment of ca 80% patients. and J. Čepková, J. Horáček, J. Vižďa, J. Doležal
Periprosthetic fractures are the third most common reason for revision total hip arthroplasty. Surgical treatment of periprosthetic fractures belongs to the most difficult procedures due to the extensive surgery, elderly polymorbid patients and the high frequency of other complications. The aim of this study was to evaluate the results of operatively treated periprosthetic femoral fractures after total hip arthroplasty. We evaluated 47 periprosthetic fractures in 40 patients (18 men and 22 women) operated on between January 2004 and December 2010. The mean follow-up period was 27 months (within a range of 12-45 months). For the clinical evaluation, we used modified Merle d'Aubigné scoring system. In group of Vancouver A fractures, 3 patients were treated with a mean score of 15.7 points (good result). We recorded a mean score of 14.2 points (fair result) in 6 patients with Vancouver B1 fractures, 12.4 points (fair result) in 24 patients with Vancouver B2 fractures and 12.7 points (fair result) in 7 patients with Vancouver B3 fractures. In group of Vancouver C fractures, we found a mean score of 16.2 points (good result) in 7 patients. Therapeutic algorithm based on the Vancouver classification system is, in our opinion, satisfactory. Accurate differentiation of B1 and B2 type of fractures is essential. Preoperative radiographic images may not be reliable. If in doubt, checking the stability of the prosthesis fixation during surgery should be performed. and M. Korbel, P. Sponer, T. Kucera, E. Procházka, T. Procek
Our case-based review focuses on limb salvage through operative management of Charcot neuroarthropathy of the diabetic foot. We describe a case, when a below-knee amputation was considered in a patient with chronic Charcot foot with a rocker-bottom deformity and chronic plantar ulceration. Conservative treatment failed. Targeted antibiotic therapy and operative management (Tendo-Achilles lengthening, resectional arthrodesis of Lisfranc and midtarsal joints, fixation with large-diameter axial screws, and plaster cast) were performed. On the basis of this case, we discuss options and drawbacks of surgical management. Our approach led to healing of the ulcer and correction of the deformity. Two years after surgery, we observed a significant improvement in patient's quality of life. Advanced diagnostic and imaging techniques, a better understanding of the biomechanics and biology of Charcot neuroarthropathy, and suitable osteosynthetic material enables diabetic limb salvage. and T. Kučera, P. Šponer, J. Šrot
The aim of this study is to evaluate the results of total hip arthroplasty in patients with Parkinson's disease during a period of five years, focusing on the assessment of the risks and benefits of surgery. During this period we performed total hip arthroplasty in 14 patients (15 hips) with Parkinson's disease. Patients were evaluated by subjective symptoms and objective findings, with a focus on the use of support while walking and walking distance, severity of Parkinson's disease before surgery and at the time of the last follow-up. During the postoperative period, the following parameters were assessed: length of ICU stay, mobilization, complications, the total duration of hospitalization and follow-up care after discharge. Of the 11 patients (12 hips) followed-up 1-5 years with an average of 3 years after operation 8 cases showed progression of neurological disability. 5 patients (6 hips) showed an increased dependence on the use of support when walking and reduced distance that the patient was able to walk. Subjectively, 10 hip joints were completely painless and 2 patients complained of only occasional mild pain in the operated hip. Complications that were encountered were urinary tract infection (5 patients), cognitive impairment (3 patients) and pressure ulcer (2 patients). We did not observe any infection or dislocation of the prosthesis. Three patients fell and fractured the femur and 3 patients in our cohort died during follow up. Implantation of total replacement is possible with judicious indication after careful evaluation of neurological finding in patients with minimal or mild functional impairment of the locomotor system. Prerequisite for a good result is precise surgical technique and optimal implant position with balanced tension of the muscles and other soft tissues around the hip. and PG. Mathew, P. Sponer, T. Kucera, M. Grinac, J. Knízek