Ochronóza neboli alkaptonurie patří mezi metabolická systémová onemocnění. Jedná se o vzácnou autosomálně recesivně dědičnou chorobu. Její podstata spočívá v poruše metabolismu aminokyseliny tyrosinu. V důsledku ukládání kyseliny homogentisové ve tkáních dochází k poškození kardiovaskulárního, urogenitálního a pohybového aparátu. Popis případu dokumentuje ošetření subtrochanterické zlomeniny obou proximálních femurů s následným selháním osteosyntézy vlevo. Pakloub byl řešen z důvodu progrese koxartrózy implantací totální náhrady. Až histologickým vyšetřením hlavice femuru byla stanovena přesná diagnóza. Po následné implantaci totální endoprotézy kolenního kloubu s rozsáhlým poškozením chrupavek a okolních měkkých tkání byla ochronóza histologicky znovu potvrzena. Snížená kvalita měkkých tkání jako jeden z faktorů přispěla k rozvoji hlubokého infektu, který vedl k rozvoji septického stavu. I přes intenzivní antibiotickou léčbu a amputaci končetiny došlo k srdečnímu a renálnímu selhání s úmrtím pacienta.
Ochronosis or alkaptonuria is a metabolic systemic disorder. It is a rare disease with autosomal recessive inheritance pattern, characterized by a faulty metabolism of the amino acid tyrosine. In an alternative metabolic pathway, homogentisate oxidizes to a brown-red pigment alkapton, which is being excreted to urine while damaging the kidney. Other tissues and organs are also being damaged, including the heart valves, spine, and major joints. Case study involves pseudo-joint after osteosynthesis of subtrochanteric femoral fracture and severe coxarthrosis in the field of ochronosis. Ochronosis was not diagnosed exactly until the implantation of total hip endoprosthesis and histological examination. Ochronosis was also confirmed during the subsequent implantation of total knee endoprosthesis, the damage to cartilages and adjacent soft tissues being extensive. Due to the inferior quality of soft tissues deep infection developed, which had to be managed with amputation. Severe decompensation of heart and kidney damage and death occurred, the patient died, the cause of death being heart failure accompanying a septic state.
- Klíčová slova
- hojení tkání,
- MeSH
- alkaptonurie * diagnóza komplikace patofyziologie MeSH
- amputace MeSH
- artróza kolenních kloubů etiologie chirurgie MeSH
- artróza kyčelních kloubů etiologie chirurgie MeSH
- fatální výsledek MeSH
- fraktury femuru chirurgie MeSH
- hojení fraktur MeSH
- hojení ran MeSH
- infekce měkkých tkání diagnóza farmakoterapie komplikace MeSH
- lidé MeSH
- náhrada kyčelního kloubu MeSH
- nekróza etiologie MeSH
- ochronóza * diagnóza komplikace MeSH
- pooperační komplikace MeSH
- progrese nemoci MeSH
- senioři MeSH
- sepse MeSH
- terapie neúspěšná MeSH
- totální endoprotéza kolene MeSH
- vnitřní fixace fraktury MeSH
- Check Tag
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- Publikační typ
- kazuistiky MeSH
The most complex topic is represented by operative treatment of type IV lesions of rotator cuff. Palliative arthroscopic resection of rotator cuff did not produce optimal results. We thus intend to evaluate the newly implemented surgical techniques at our department. Fifty-six patients with type IV rotator cuff lesions were treated surgically between October 2007 and December 2010. In 6 patients, combined operations had to be performed because of their pathology, and these were not included in detailed evaluation. The population selected for detailed evaluation of new surgical techniques included 50 patients (mean age: 59 years, range: 41–73 years). The patients were randomized into two subpopulations, each formed by 25 people. Both subpopulations can be considered representative and comparable. All operations were performed in the “beach-chair” position in general anesthesia or/and in interscalenic block. After type IV lesion was diagnosed, the prespecified surgical procedure followed – partial muscle transfer of subscapularis muscle tendon (Karas) or partial non-anatomic rotator cuff reconstruction (Burkhart). The results were evaluated after 6 months using the modified Constant Functional Score. The following parameters were assessed: sex, age, side of the operation, dominance of the limb, Constant Functional Score pre-operatively and post-operatively, subjective and objective evaluation, pain, activities, movement and muscle strength, Constant Score improvement, improvement in its individual items and subitems, pain pre-operatively and post-operatively. In older patients with type IV lesions, we have good experience with Karas method while in younger and more active patients, Burkhart method seems to be more useful.
PURPOSE OF THE STUDY: Our objective is to introduce our simplified, easy-to-use classification of rotator cuff (RC) lesions, describe the frequency of individual findings in a considerably large series of shoulder joints examined by arthroscopy, evaluate the results of the operative management of individual lesion types, and recommend optimal surgical approaches. MATERIAL: Over the course of 10 years (between October 1st, 2000 and December 31st, 2009), 756 arthroscopic operations on the shoulder joint were performed. RC lesions were identified in 516 cases. We categorized the lesions using our own classification. Patient characteristics were as follows: the mean age was 43 years, 69% of the patients were men, and the right shoulder was affected in 61% of the cases (with the dominant upper limb being affected in 71% of the cases). The patients were followed up for a minimum period of 6 months. METHODS: All operations were performed in the "beach-chair" position under general anesthesia or in an interscalenic block. The arthroscope was introduced into the shoulder joint through the "soft-spot". Continuous lavage via an arthroscopic pump was used. The glenohumeral joint was examined first; an examination of the subacromial space followed. Once the lesion type was identified, other procedures were performed. In standard situations, type I lesions were managed with ASK sub- acromial decompression (SAD). As to type II lesions, we initially performed open RC reconstruction with acromioplasty, which we later replaced with ASK-assisted RC reconstruction with SAD; we are currently managing these lesions with ASK RC reconstruction + SAD. As for type III lesions, we initially used to treat them with open RC reconstruction with acromio - plasty; we are now performing ASK-assisted RC reconstruction with mini-incision + SAD. We are trying to use "double-row" sutures in certain cases. The initial management of type IV lesions consisted of ASK palliative resection of RC remnants combined with SAD. Currently, we are performing partial muscle transfer of the intact subscapularis muscle tendon (Karas) or partial non-anatomical RC reconstruction (Burkhart). A combination of both methods described above was required in some cases. If delamination of the RC was found, partial reconstruction using the "double-layer" technique took place. Open acromioplasty was added during all operations. Type V lesions are managed with ASK palliative resection of RC remnants + SAD; when this approach proves unsuccessful, which is a rare phenomenon, resurfacing follows. The results were evaluated after 6 months using a modified Constant functional score. Besides clinical examination, self-assessment questionnaires filled in by the patients were also evaluated. RESULTS: Out of a total of 516 RC lesions, type I was the most prevalent (54%), followed by type V (16%). The prevalence of lesion types II, III and IV was about 10% each. In type I, the mean improvement measured by the Constant score was 36 points. As for type II, open reconstruction, ASK-assisted reconstruction and ASK reconstruction resulted in mean improvements of 31, 34, and 35 points, respectively. While open reconstruction of type III lesions was associated with a 27-point improvement on the Constant score, the use of ASK-assisted reconstruction resulted in a 29-point improvement. In type IV, the use of ASK palliative resection of RC remnants, muscle transfer (Karas), partial reconstruction (Burkhart), and a combination of the last two methods led to the mean 19-, 25-, 22-, and 22- point improvements respectively. Following ASK palliative resection, the mean Constant score improvement in type V lesions was 17 points, while the use of resurfacing, if performed, was associated with a 21-point improvement. DISCUSSION In type I lesions, favourable long-term outcomes are achieved through ASK SAD, which removes RC irritation within the narrowed subacromial space. RC reconstruction or sutures, which can be performed arthroscopically quite easily, are indicated in type II lesions. The situation is similar in type III lesions, where, from a technical point of view, reconstruction is facilitated by ASK-assisted reconstruction with mini-incision. Since type IV lesions are the most complex ones, the largest number of surgical management methods is described here. As for muscle transfer, the subscapularis and latissimus dorsi muscles are used most often, the latter requiring wider surgical access. Partial non-anatomical reconstruction is useful, too. New synthetic prostheses, as well as biosynthetic or biologic prostheses prepared with cultures of pluripotent stem cells, have been developed recently. Unlike some other authors, we prefer open surgery. Attempts at ASK reconstruction increase surgical time considerably, while the cosmetic effect is negligible if many ASK ports are used. Reconstruction is contraindicated in type V lesions; good outcomes are being achieved with ASK palliative resection of RC remnants (Apoil). Type I lesions are successfully managed with ASK SAD. The method of choice in type II lesions is ASK reconstruction. In type III lesions, we have been getting good results with ASK-assisted RC reconstruction with mini-incision. As for type IV lesions in older patients, we have good experience with muscle transfer of a part of the intact subscapularis muscle tendon (Karas); partial non-anatomial reconstruction (Burkhart) is deemed more beneficial in younger and more active patients. For anatomical reasons, a combination of both above-mentioned methods had to be used in some cases. ASK palliative resection of RC remnants, rarely followed by resurfacing when unsuccessful, remains the method of choice in treating type V lesions. Key words: shoulder arthroscopy, rotator cuff lesions, classification, subacromial decompression, reconstruction, open surgery, palliative resection, Constant Functional Score.
V období od ledna 2000 do prosince 2006 jsme na našem pracovišti provedli celkem 326 artroskopických výkonů na ramenním kloubu s nálezem poškození rotátorové manžety. Z celkového počtu bylo 21 pacientů vojáků z povolání. Poškození rotátorové manžety jsme klasifikovali podle vlastní modifikace Gschwendovy klasifikace. Jednotlivé typy lézí jsme pak léčili určenými postupy a hodnotili s odstupem času pomocí Constantova funkčního skóre. Zaměřili jsme se na vojáky z povolání a jejich zdravotní klasifikaci. Závěrem se pokoušíme vytvořit doporučení zdravotní klasifikace u jednotlivých typů s ohledem na individuální výsledky léčby. U lézí rotátorové manžety I. typu by při adekvátní léčbě nemělo docházet k funkčnímu postižení ani ke změně zdravotní klasifikace – odpovídá „A“. U lézí II. typu je situace stejná jako u typu I. Při neodpovídající léčbě by v některých případech protrahované poruchy mohlo přetrvávat funkční omezení a nález by pak mohl odpovídat zdravotní klasifikaci „C“. U lézí III. typu i při adekvátní léčbě výsledek závisí na funkčním deficitu po ukončení léčení – odpovídá „A“ nebo „C“. U lézí IV. typu rozsah poškození a rozsah event. operačního zákroku předpokládá výslednou funkční poruchu a zdravotní klasifikace tudíž odpovídá „C“. Pacienti s lézí V. typu i po provedeném paliativním ošetření by vzhledem k přítomnosti funkčního omezení a zejména těžších degenerativních změn měli být klasifikováni stupněm „D“.
In the period from January 2000 to December 2006 we performed together 326 arthroscopic operations on the shoulder joint with finding of rotator cuff tear on our department. In a total number of patients there was 21 professional soldiers. Rotator cuff lesions were categorized on the basis of our modification of the Gschwend classification. Particular types were treated by definite procedures and evaluated by the Constant Functional Score in the time interval. We focused on the professional soldiers and theirs health classification. In the conclusion we attempt to form recommendation of the health classification in cases of particular types of lesions in the respect of individual results of treatment. Type I lesions of rotator cuff – in case of adequate treatment there would be no functional handicap and no change of the health classification – corresponds to „A“. Type II lesions – the situation is the same as in the case of type I lesions. In some cases of inadequate treatment and prolonged disorder there can be functional deficit and the finding can correspond to health classification „C“.Type III lesions – as well as in the case of adequate treatment the result depends on the functional handicap after finishing of treatment – corresponds to „A“ or „C“. Type IV lesions – the extent of disorder and operation treatment presumes resulting functional deficit and so the health classification corresponds to „C“. The patients with type V lesion as well as after the paliative surgery would be classified by the grade „D“ of the health classification in the respect of serious functional handicap and above all attendance of the serious degenerative changes.
- MeSH
- artroskopie metody využití MeSH
- lidé MeSH
- ozbrojené síly klasifikace MeSH
- posuzování zdravotní způsobilosti MeSH
- ramenní kloub abnormality patologie zranění MeSH
- rotátorová manžeta abnormality patologie zranění MeSH
- skóre závažnosti úrazu MeSH
- zdravotní stav MeSH
- Check Tag
- lidé MeSH
- Geografické názvy
- Česká republika MeSH
PURPOSE OF THE STUDY The aim of this study is to present a simple rotator cuff lesion classification that provides guidelines as to their treatment, and to evaluate the results of palliative arthroscopic resection of rotator cuff residues known as unreconstructible lesions. In addition, our therapeutic approaches were ascertained in view of their applicability to the types of lesions studied. MATERIAL In a five-year period (January 1, 2000 to December 31, 2004), a total of 181 arthroscopic procedures were performed on the shoulder joints of patients diagnosed with impingement or rotator cuff syndromes. In 130 cases, a tear or irritation of the rotator cuff was recorded. Rotator cuff lesions were categorized on the basis of our modification of the Gschwend classification. In 15 of the patients, in whom unreconstructible lesions were detected, arthroscopic palliative resection of rotator cuff residues was performed. The average age of these patients was 65 years, and they were followed up for 6 to 60 months. METHODS All surgery was carried out in a "beach-chair" position, either under general anesthesia or with an interscalene brachial plexus block. The arthroscope was inserted through the "soft-spot". Continuous irrigation was provided with an arthroscopic pump. In the first place, the glenohumeral joint was explored, and resection of rotator cuff residues was performed via ventral and lateral ports. The procedure was completed by subacromial decompression and partial resection of the acromion.The results were evaluated by the Constant Functional Score, as modified by us. Clinical examination was supplemented with subjective information from questionnaires provided by the patients. RESULTS In a total of 130 shoulder joints with rotator cuff tears examined by arthroscopy, type I lesions were found in 90, and these were treated by arthroscopic subacromial decompression. Twenty-five type II and type III lesions underwent open rotator cuff repair and 15 type IV and type V lesions were treated by palliative arthroscopic resection of residual rotator cuff lesions, using the Apoil method. These fifteen patients were followed up for 6 to 60 months and their outcomes were evaluated. No excellent results were achieved (Constant Score, 80-100 points), but this is implicit in the nature of a palliative operation. Good (65-79 points) and satisfactory (51-64 points) results were recorded in 11 (73.3 %) and four (26.7 %) patients, respectively. No poor results were found. The average improvement in Constant scores was 21 points. DISCUSSION A total of 130 rotator cuff lesions diagnosed arthroscopically were categorized on the basis of a modified classification system. We will continue to treat type I lesions by arthroscopic subacromial decompression, which has provided good results, as reported in our previous study. We consider the arthroscopic repair of rotator cuff tears to be an optimal procedure for type II lesions; for type III lesions we will keep using open repair surgery. The most complex problem is presented by type IV lesions. While palliative arthroscopic resection of the rotator cuff is one option, muscle transfer has also shown satisfactory outcomes, as has partial reconstruction. The use of either allografts or cadaver grafts did not give good results. Type V lesions, in our opinion, are unambiguously indicated for palliative arthroscopic resection of the rotator cuff. Their treatment by the Apoil method and detailed evaluation of the outcomes are described here; the results of this study are in agreement with those reported in the relevant international literature. CONCLUSIONS Good and satisfactory results were achieved by palliative arthroscopic resection of the rotator cuff, in combination with subacromial decompression, in patients with unreconstructible lesions. The average improvement in the Constant Functional Score was 21 points. This suggests that the method can be recommended for wider use in the future. However, exact diagnosis and correct indication, i.e., type V lesion, are essential.
- MeSH
- akromion chirurgie MeSH
- artroskopie metody využití MeSH
- chirurgická dekomprese metody využití MeSH
- dospělí MeSH
- lidé MeSH
- syndrom zhmožděného ramene diagnóza chirurgie MeSH
- Check Tag
- dospělí MeSH
- lidé MeSH
- mužské pohlaví MeSH
- ženské pohlaví MeSH
- Publikační typ
- srovnávací studie MeSH
