Nemocnice Znojmo

ObjectivePersistent Genital Arousal Disorder (PGAD) is a rare and distressing condition characterized by persistent genital arousal in the absence of sexual desire. We present a unique case of a menopausal woman who developed PGAD after combined pharmacotherapy with trazodone, pregabalin, vaginal estriol, and depot medroxyprogesterone acetate (DMPA).MethodsThe patient underwent comprehensive gynecological, neurological, and psychiatric evaluation. Menopausal status was confirmed by laboratory findings. A detailed pharmacological review was conducted to assess possible interactions affecting serotonergic, neuronal, and hormonal regulation.ResultsPGAD symptoms emerged shortly after initiating the combination of these medications. Each drug has been individually associated with alterations in sexual function, but their concurrent use may have produced synergistic effects on neuroendocrine pathways. Gradual discontinuation of all medications resulted in complete remission of symptoms.ConclusionThis case supports the hypothesis that combined modulation of serotonergic, neuronal, and hormonal systems can trigger PGAD in predisposed menopausal women. Recognition of potential pharmacological interactions is crucial for diagnosis and management of PGAD.

Tissue fixation is an essential step in the performance of ancillary studies, including immunohistochemistry. The aim of this study was to compare the effect of various fixatives and fixative times on immunohistochemistry (IHC) in bovine and porcine endometrium using progesterone receptors and SOX2 antibodies. Immunohistochemical staining with progesterone receptors and SOX2 was performed on tissue samples fixed in formalin, Antigenfix, Greenfix, Bouin’s solution and methacarn at 1.5, 8.5, 15.5, 29.5, 64.5, 189.5, 249.5, 309.5 and 369.5 days of fixation. Formalin and Antigenfix proved to be the best fixative for both short-term and long-term fixation for IHC. Bouin’s solution was partially applicable for short-term (24 h) fixation. Greenfix and methacarn were absolutely inappropriate fixatives for IHC (completely negative staining using methacarn). These results were obtained on an automated immunostainer using EDTA buffer pH 8.4 as the antigen retrieval solution. When the staining procedure was performed manually and citrate buffer with different pH values was used, weakly positive results were obtained with both progesterone receptors (pH 8 and 9) and SOX2 (pH 7.2); however, significantly lower staining quality was obtained using the methacarn fixative compared to aldehyde fixatives. The reported findings demonstrated the superiority of aldehyde fixatives (formalin and Antigenfix) over alcohol fixatives (methacarn) and fixatives combining both denaturing and cross-linking proteins (Greenfix and Bouin’s solution) for IHC. Antigen retrieval-IHC using EDTA buffer was found to be excellent for aldehyde fixatives, but proved to be completely unsuitable for methacarn, Greenfix, and Bouin’s solution.

Open pelvic fractures are devastating injuries with high mortality and morbidity that require aggressive treatment and multidisciplinary approach to achieve the best results. We present three cases of open pelvic fracture with a Faringer I zone injury, which were treated at our level I trauma centre in 2020. The patients were treated with external fixation without the need for fecal diversion. None of the patients died. Early control of bleeding, appropriate treatment of soft tissues and prevention of fecal contamination are critical for the treatment of patients with open pelvic fractures. A multidisciplinary approach relying on an experienced and trained team is essential for successful treatment of these injuries. Key words: pelvis fracture, open fracture, trauma.

PURPOSE OF THE STUDY The failure of arthroplasties and above all the issue of infection and its detection have become an ever more frequently discussed problem. The purpose of our study was to determine the frequency and the type of complications after revision total knee arthroplasties and to compare them with the frequency of complications after primary implantations. MATERIAL AND METHODS In our group of patients followed up in the period from January 2007 to December 2016, in 50 patients the revision surgery was performed for aseptic loosening and in 24 patients for deep infection. In the case of revision surgery for aseptic loosening, in 18 patients original sterilised components were used as a spacer, in 6 patients an articulating cement spacer was applied. Only the complications resulting in the performance of further revision were included in the statistics. A total of 13 patients underwent a primary implantation at another centre. The number of revisions and the reason for implant failure were monitored. The results were compared with the frequency of revision surgeries after primary total knee arthroplasty, of which 2,436 were carried out in the referred to period. RESULTS Of 2,436 primary endoprostheses, altogether 3.1 % failed. In 50 (2.1 %) patients aseptic loosening was reported, 24 patients (1 %) suffered from infection. The median time from primary implantation to revision was 11 years for aseptic loosening, 2 years for infection. The most frequent cause of failure was aseptic loosening. In the group of patients who underwent a revision surgery for aseptic loosening, another revision was necessary in 6 cases (12 %), in the group of patients after the two-stage revision surgery for infection, in 9 cases (37.5 %). The most frequent reason for revision surgery was infection - in both the groups this was the reason for 67 % of revision surgeries. DISCUSSION Our results obtained with respect to primary as well as revision surgeries for aseptic loosening correspond with the results reported by other authors. In the case of two-stage revision implantation, the reported frequency of recurrent infections is the same, the frequency of revision surgeries for aseptic causes is slightly lower in our group. The most frequent causes of revision surgery are also in agreement. In the case of primary implantation, the patients most frequently suffer from aseptic loosening, after revision surgeries another revision surgery is most often performed due to infection. The literature refers to studies suggesting the potential use of original components as a spacer with the same success rate as that achieved with the cement spacer. The original components produced good results in two thirds of two-stage revision implantations, which is why we can agree with these studies. CONCLUSIONS The results clearly show a noticeable increase in the frequency of complications in revision surgeries compared to primary surgeries. In comparison with primary implantations, a subsequent revision after the revision implantation for aseptic loosening was necessary three times more frequently, after the two-stage revision implantation for infection it was ten times more frequently. As the most problematic complication can be considered the infection in case of primary as well as revision interventions. It is obvious that aseptic loosening of the primary implant usually occurs later (the median of 11 years) than the development of deep infection (the median of 2 years). Key words: total knee arthroplasty, revision, failure, complications, aseptic loosening, infection, spacer.

PURPOSE OF THE STUDYThe number of patients who underwent total knee replacement is on an increase globally.According to the current literature, 10-30% of patients is dissatisfied with the outcome of surgery.The purpose of this study was to focus on preoperative planning of femoral components position relative to the original anatomy and to find out how it affects the satisfaction of patients after the surgery. MATERIAL AND METHODSA total of 74 total knee replacements were examined at the authors' department one year after the surgery in order to determine the function of knee replacement.The patients underwent a preoperative and postoperative CT scan of the knee joint in order to determine the rotation of the dorsal line of femoral condyles relative to the transepicondylar line, the socalled condylar twist angle (CTA).The study did not explore the absolute value of CTA, but the difference between the preoperative and postoperative angle.The patients were divided into two groups.In Group 1 composed of 53 knees, the difference of the CTA was lower than 3°, Group 2 included the cases with the difference greater than 3°.After 1 year, the patients filled in the Knee Society Clinical Rating Score and WOMAC questionnaires.The statistical significance was evaluated with the use of the unpaired T-test. RESULTSGroup 1 where the original anatomy of the knee joint was respected, reported the mean value of Part 1 of the KSCRS of 83.5 points, the mean value of Part 2 of this questionnaire was 83.5 points.The mean WOMAC score was 86.4 and the mean VAS score was 2.6.In Group 2, with a difference in rotation as against the preoperative status of 3° or more, the mean value of Part 1 and Part 2 of the KSRCS was 72.4 points and 72.1 points, respectively, the mean WOMAC score was 75.5 points and the mean VAS score was 4.7.The comparison by the Student's t-test, in all the monitored values at the level of significance of p < 0.05 the patients' satisfaction and the implant's function depend on respecting the original anatomy of the distal femur. DISCUSSIONIt is generally accepted that the internal rotation of the femoral component causes patellar hyperpression, thus reduces the satisfaction of patients.There are several ways how to determine the rotation of the femoral component.An error is inherent in all of them, inversely proportional to the surgeon's experience.The purpose of our study was to show that in case of appropriately selected preoperative planning the postoperative outcome and the patients' satisfaction can improve. CONCLUSIONSOur study confirms that for the patient's satisfaction after total knee replacement it is fitting to perform preoperative planning regarding the rotation of the femoral component and to seek to maintain the original anatomy, even if the femoral component is implanted in slight internal rotation.

PURPOSE OF THE STUDY Transposition of tibialis posterior muscle ranks among the methods of dorsiflexion restoration in patients with peroneal nerve palsy. Even though this method is commonly used, anatomical variations are still encountered which make us modify the established procedures. The purpose of this study is to evaluate the functional outcomes of operated patients and based on the clinical experience to define by cadaver preparation the anatomical causes preventing the use of the standard transposition technique. MATERIAL AND METHODS The clinical group includes 21 patients (15 men, 6 women) with the mean age of 34.2 years and with common peroneal nerve palsy confirmed by EMG. In 20 patients, transposition of the tendon of the tibialis posterior muscle (MTP) through the interosseous membrane of the leg was performed. In one patient the tendon was transposed ventrally to the distal end of the tibia and fixed in the lateral cuneiform bone due to an extremely narrow space of the interosseous membrane of the leg distally between the lower limb bones. In 18 patients the tendon was fixed by osteosuture to the base of 3rd metatarsal bone, in three patients to the lateral cuneiform bone. The outcomes were evaluated at 6 months after the surgery, when active ankle dorsiflexion (DF) range of motion greater than 5° was considered an excellent outcome, active position at 90° up to DF less than 5° a satisfactory outcome, and any plantigrade position as a poor outcome. The anatomical study included 20 extremities fixed by formalin (10 cadavers, 5 men and 5 women with the mean age of 71.3 years). The length of the individual parts of tibialis posterior muscle was measured and the variations of the muscle attachment were evaluated. The measurement was concluded by a simulation of surgical procedure. RESULTS When evaluating the clinical group, an excellent outcome was reported in 12 patients (57%), a satisfactory outcome in 8 patients (38%) and a poor outcome in one patient (5%). When evaluating the anatomical group, a division of the attaching part of the tendon into three main strips was observed. The thickest middle strip attached to the tuberosity of navicular bone and medial cuneiform bone was reported in all the specimens. The thinner lateral strip (originating from the tendon in 90% of specimens) was attached to the intermediate and lateral cuneiform bone, the cuboid bone, metatarsal bones II-V, and moreover it grows into the origin of the flexor hallucis brevis muscle. The third strip of the tendon attached to the sustentaculum tali, plantar calcaneonavicular ligament and fibrocartilago navicularis was missing in one specimen (5%). When the passing the tendon through the interosseous space between the lower limb bones was simulated in order for the tendon to go in the direction of the planned traction, in two specimens (10%) the pulling through was impossible due to the tendon being thicker than the interosseous space. In two specimens (10%) it was not the tendon, but already the muscular belly which passed through the given space. DISCUSSION In our group, 95% of the functional outcomes were excellent or satisfactory. A poor result was reported in one patient, in whom the EMG examination was not performed as a standard procedure and in whom the muscular strength was insufficient to achieve full dorsiflexion of the ankle. The anatomical study indicates that the narrow space between the lower limb bones can prevent the pulling through of the tendon, which can be addressed intraoperatively by the transposition of the tendon ventrally to tibia. The study reveals that the tendon necessary for transposition can be elongated by the strips of the tendon attached to the sole of the foot. CONCLUSIONS The knowledge of the anatomical conditions may help us better manage potential complications intraoperatively. Key words: tibialis posterior muscle, peroneal nerve palsy, transposition of tibialis posterior muscle, anatomy of tibialis posterior muscle, common fibular nerve palsy.

Background: Alcoholism is a major threat to public health in both developed and developing countries. Alcohol has many effects on lipid profile, including inducing de novo fatty acid synthesis and inhibiting fatty acid oxidation in liver. Aim of this study was to study the effect of alcohol consumption on serum lipid profile in alcoholics and to compare with those of non-alcoholic controls.Methods: 100 cases and 100 age and sex matched controls were selected. These subjects were classified into, 1. Moderate alcoholics: Consuming ≤210 g per week 2. Heavy alcoholics: Consuming &gt;210 g per week. Blood was taken in fasting state and lipids were estimated.Results: Among 200 subjects, 94% were male. 58.5% of the male and 83.3% of the female were heavy drinkers. Maximum number of alcoholics were seen in the age group of 41-50 years. The height correlated well with both control and study group. The moderate dose alcoholics had a higher weight when compared to control group and heavy dose alcoholics. The heavy dose alcoholics had a lower BMI when compared with the control group and moderate dose alcoholics. Heavy dose alcohol consumption was associated with a higher increase in triglyceride level. The total cholesterol level was significantly higher in the heavy dose alcoholics when compared with the control group. The HDL level was highest in the moderate dose alcoholics. The LDL level was highest in heavy dose alcoholics whereas, the moderate dose alcoholics had a lesser LDL level when compared with the control group. The VLDL level steadily increased with alcohol consumption.Conclusions: Patients with heavy alcohol consumption had significant increase in total cholesterol, triglycerides, LDL and VLDL. The moderate alcohol consumers had significantly increased HDL and decreased LDL. These protective effects declined after heavy alcohol consumption.

PURPOSE OF THE STUDY Our retrospective study presents the comparison of the preoperative magnetic resonance imaging of the knee joint - MRI - and the arthroscopic finding - ASC. Its aim is to find out how a positive or a negative finding of MRI corresponds with the operative finding and how much the experience of radiologist contributes to the conformity. MATERIAL AND METHODS The MRI findings of knee joints treated surgically at two departments in 2013 and 2014 were assessed. The MRI was performed in a total of 470 patients who subsequently underwent an arthroscopic surgery. A conformity or a non-conformity in anterior, posterior horn and complete rupture of both menisci and in partial or complete tear of anterior cruciate ligament - LCA was searched for. The sensitivity, specificity and accuracy of MRI were established. The difference between experienced and less experienced radiologists was evaluated. The analysis of the radiology report, surgical protocol of ASC and medical history in the documentation was performed. The cartilage was not subject to evaluation. The finding of Grade 1 meniscus tear on MRI was evaluated as negative. Grade 2 and Grade 3 were evaluated as positive. RESULTS Comparison of the preoperative MRI and the arthroscopic finding 1. The group with MRI reported 3 % of diagnostic arthroscopies. The control group without MRI (551 ASC) reported 15 % diagnostic arthroscopies. 2. Low sensitivity of MRI (0.67) in negative findings of ASC. It concerned 7 cases in which a pathological finding was identified on a MRI scan, but not by ASC. In two cases the repeated arthroscopy confirmed that a pathology inside the knee joint was overlooked by the arthroscopist. In the remaining five cases, the clinical finding improved without a repeated surgery. 3. High sensitivity of MRI is shown in the most frequent finding - posterior horn of medial meniscus (0.94). 4. Lower sensitivity (0.76) in partial and (0.83) in complete ACL tear. It increases to 0.93 if partial and complete tear are put together. Both MRI and ASC detect the pathology of ligament, but do not agree in terms of terminology. 5. Lower sensitivity (0.78) was seen in posterior horn of lateral meniscus, most likely due to its complicated anatomy. 6. Specificity of complete tear of medial meniscus tear is 0.99. Lower specificity in the posterior horn of medial meniscus (0.81) shows a higher number of positive MRI findings in negative ASC findings. Some posterior horn tear can be overlooked by an inexperienced surgeon. The MRD findings need to be studied. 7. High specificity (0.99) was described in negative findings. In three cases only, the surgeon discovered a pathological finding, not revealed by MRI scan. It always concerned a tear within the posterior horn of the medial meniscus. 8. Specificity (0.88, 0.93 or 0.86, respectively) in partial, complete and all ACL damages in total. 9. We concluded that contributing to the degree of agreement between MRI and ASC is also the experience of a radiologist. The most experienced radiologist evaluated 190 of 470 MRI scans, the remaining twelve radiologists assessed 280 scans. The posterior horn of the medial meniscus - sensitivity or specificity evaluated by an experienced radiologist (0.98 and 0.88, respectively) and inexperienced radiologist (0.91 and 0.79). The specificity and sensitivity in complete ACL tears - by experienced radiologist (0.91 and 0.94, respectively) and inexperienced radiologist (0.81 and 0.90, respectively). The test accuracy of the experienced radiologist in evaluating the most frequent injuries of soft knee structures was by 9-10 % higher than of the inexperienced radiologist. DISCUSSION The results obtained by the other authors show that the sensitivity and specificity range from 0.6 to 0.9. They agree that the MRI is unsuitable for assessing the cartilage. We confirm that the results are worse when evaluating the posterior horn of the lateral meniscus. We have also proven that the radiologist s experience does play an important role. It can be the reason for a high degree of difference between the results of various authors. Some of them give preference to a clinical examination or a diagnostic arthroscopy instead of the MRI. At our department, MRI is indicated if we are convinced it can help with the indication or where it will suggest what to focus on during the surgery. CONCLUSIONS A preoperative MRI scan can prevent an unnecessary arthroscopy. It displays structures to the surgeon which shall be reviewed in detail during the surgery. We recommend paying attention to Grade 2 MRI findings, positive MRI findings on the posterior horn of medial meniscus and to MRI findings on partial ACL tears. Such menisci and ligaments shall be carefully reviewed. Clinical preoperative examination and cooperation between the surgeon, the "arthroscopist", and the radiologist is essential. The experience of the radiologist also plays a role when evaluating the MRI scan. We have introduced MRI ward rounds. Key words: MRI, knee joint, knee arthroscopy, sensitivity, specificity, accuracy.

Background: The objective of the study was to demonstrate the effect of concentrated bone marrow stem cells (MSCs) to the healing of sutured tendon of the supraspinatus muscle in comparison to the same procedure performed without MSCs. We have postulated the hypothesis that MSCs enhance the healing of the sutured supraspinatus tendon to its humeral footprint. Methods and findings: None of the patients had to be excluded from our prospective randomized study. 50 patients met the indication criteria for isolated supraspinatus surgery. 25 patients (Group I) received MSCs into the supraspinatus footprint. 25 patients (Group II) was treated without the use of MSCs. Patients were examined pre-operatively, 6, 12 and 24 months after the surgery and assessment included physical examination, visual analogue scale (VAS), ASES (American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form) and Constant score. Patients underwent MRI 2 years postoperatively. Findings were compared with the preoperative results. We have found no statistically significant differences between both groups pre-operatively. After a 24-month follow-up period there were significant differences observed in all clinical outcomes. When compared results between both groups two years postoperatively, p-value (p=0.05) for the VAS score was 0.0176 and for the Constant score 0.0355. The only statistically non-significant was p-value for the ASES score comparing results from both groups at two years follow-up (p=0.085). The MRI findings at 2 years showed fully healed tissue of the rotator cuff tendon in 17 patients in the Group I, but only in 9 patients in the Group II. Conclusions: We have accepted the hypothesis that MSCs enhance the healing of the sutured supraspinatus tendon to its humeral footprint.