Metaizeau Technique for Treatment of Paediatric Isolated Radial Neck Fracture - Clinical and Radiological Outcomes - Case Control Study

BACKGROUND

Radial neck fractures account for 5-17% of elbow fractures and about 1% of all fractures in children. The subject of the presented research is assesment of clinical and radiological outcomes of the Metaizeau technique for treatment of isolated radial neck fractures in children.

MATERIAL AND METHODS

Retrospective analysis of clinical and radiological data of patients treated with the Metaizeau technique in our Department between 2015 and 2020. Twenty children with isolated radial neck fracture met the inclusion criteria.

RESULTS

Excellent outcomes of operative treatment were achieved in 95% of children. None of the complications described in the literature (e.g. avascular necrosis of radial head (AVN), malunion, nonunion) were observed in our case series.

CONLCUSIONS

1. The Metaizeau technique for reduction and stabilisation of the radial neck fracture using a TEN is a safe and effective method in the paediatric population and produces good clinical and radiological results. 2.Furthermore, the minimal demands it places on surgical equipment make it possible for this technique to be recommended to orthopaedic surgeons managing paediatric trauma patients.

Is the Synovium the First Responder to Posttraumatic Knee Joint Stress? The Molecular Pathogenesis of Traumatic Cartilage Degeneration

OBJECTIVE

The aim of this study was to evaluate if a similar catabolic and inflammatory gene pattern exists between the synovium, hyaline cartilage, and blood of patients with the knee joint tissues and if one precedes the other.

DESIGN

A total of fifty-eight patients (34 females and 24 males) with a mean age of 44.7 years (range, 18-75) underwent elective knee arthroscopy due to previously diagnosed pathology. Full blood samples were collected preoperatively from synovium and cartilage samples intraoperatively. Real time PCR with spectrophotometric analysis was performed. Following genes taking part in ECM (extracellular matrix) remodeling were selected for analysis: MMP-1, MMP-2, MMP-8, MMP-9, MMP-13, MMP-14, ADAMTS-4 (Agg1) and ADAMTS-5 (Agg2) proteases, TIMP-1, and TIMP-2 - their inhibitors - and IL-1 and TNF-α cytokines.

RESULTS

Analysis revealed a strong and significant correlation between gene expression in synovial and systemic blood cells (p <0.05 for all studied genes) with ADAMTS-4, ADAMTS-5, IL-1, TNF-α and TIMP-2 expression most positively correlated with an R>0.8 for each. An analysis between chondrocytes and systemic blood gene expression shown no significant correlation for all genes. Bivariate correlation of International Cartilage Repair Society grading and genes expression revealed significant associations with synovial MMP-1, MMP-2, MMP-8, MMP-9, IL-1, TNF-α and TIMP-2.

CONCLUSION

We suggest that the synovial tissue is the first responder for knee joint stress factors in correlation with the response of blood cells. The chondrocyte's genetic response must be further investigated to elucidate the genetic program of synovial joints, as an organ, during OA development and progression.

Association between Polymorphism eNOS4, tPA, Factor V Leiden, Prothrombin, and Methylenetetrahydrofolate Reductase and the Occurrence of Legg-Calvé-Perthes Disease

BACKGROUND

Legg-Calvé-Perthes (LCPD) disease is a complex condition affecting the femoral head's epiphysis in children. It occurs with a prevalence ranging from 0.4 to 29.0 cases per 100,000 children under the age of 15. It involves various factors, including genes associated with coagulation and fibrinolysis, pro-inflammatory factors, and vasoactive substances.

METHODS

We investigated the relationship between genetic mutations associated with coagulation and vascular disorders and the occurrence of LCPD in Polish patients. We performed a study involving 25 patients with LCPD and 100 healthy controls. All subjects were genotyped for eNOS4, Factor V Leiden, prothrombin, tPA25, and MTHFR polymorphism.

RESULTS

The analysis revealed that the frequencies of eNOS4 genotypes were significantly different in LCPD patients than in the control group (p = 0.018). The frequencies of 4a allele were significantly higher in patients with LCPD than in the healthy population (26% vs. 9%, p = 0.0012). There were no significant differences in genotype and allele frequencies for Factor V Leiden, prothrombin tPA 25, and MTHFR gene polymorphisms between patients with LCPD and the controls.

CONCLUSIONS

Genotype and allele frequencies of eNOS4 were significantly higher in patients with LCPD. These findings suggest a potential association between the eNOS gene polymorphism and an increased risk of developing LCPD.

The significance of the Dega osteotomy

Wiktor Dega has significantly impacted contemporary pediatric orthopedics by developing transiliac osteotomy - Dega's pelvic osteotomy. The global implementation of the surgery technique gained dynamism in the 2000s after being published by Ward and Grudziak. Since then, derivative operative techniques called Dega, Dega-like or Dega family osteotomies have been developed. We analyzed the original articles published by Dega between 1929 and 1974 concerning transiliac osteotomy technique development and articles about its derivatives. The epidemiological significance of developmental hip dysplasia focused Wiktor Dega's attention in the 1920s. At that time, he treated patients according to König's idea of acetabular roof plastic surgery. The osteotomy depth gradually increased, which allowed deeper graft placement to perform what we nowadays call acetabuloplasty. In 1958, Dega coined the name 'supraacetabular semicircular osteotomy'. It differed from the final concept of the transiliac osteotomy by not assuming the cut of the inner cortex of the iliac bone. The hinge for the acetabular rotation was located at the inner cortex's whole length, disallowing the excessive redirection. The final concept of osteotomy allows for simultaneous acetabuloplasty and redirection to change the shape, location and acetabular volume. Dega derivatives are Mubarak (San Diego) and high Dega osteotomies. Dega osteotomy and its derivates are routinely implemented to treat developmental hip dysplasia and spastic hip disorders. It might be considered an option in Legg-Calve-Perthes disease, congenital deficiencies, and flaccid hip displacement in neurological conditions.

Dega transiliac osteotomy in the treatment of advanced forms of Perthes' disease: a literature review

The work aims to revise the current views on the effectiveness of Dega's pelvic osteotomy in preventing femoral head deformity in the course of Perthes' disease in patients with late symptoms >8 years of age and withsignificant changes in the radiographic image (Catterall III/IV or Herring B, B/C, C). We did a literature review. Four articles from six found in 'PubMed' which combine Dega acetabuloplasty and Perthes' disease words were fully read and analyzed. Kamegaya (2018), with a 9.5-year follow-up period, described differences comparing the group treated with femoral varus osteotomy with the group that was treated with a combined Dega acetabuloplasty and femoral varus osteotomy. A series of papers by Napiontek from 2004, with an average 8-year follow-up, also describes satisfactory results after Dega's osteotomy, with 27 hips in groups I/II according to Stulberg. Another paper in the series, which analyzed operatively and non-operatively treated patients, shows no differences in the period of time of Perthes disease treatment between the analyzed groups. The last paper in the series from 2001, describes 10 patients treated primarily due to hip dysplasia, who was diagnosed with Perthes disease. Five of them underwent Dega acetabuloplasty obtaining a Stulberg score of I/II in the long-term follow-up. We think it seems reasonable to return to the treatment planning of Perthes' disease using Dega acetabuloplasty as a method to improve the hip congruence in late-diagnosed and advanced forms of the disease.

Results of treatment of congenital vertical talus by the Dobbs method

Congenital vertical talus is a rare foot deformity. The hindfoot is valgus and equinus, the midfoot is dorsiflexed and forefoot is abducted due to a fixed dorsal dislocation of the navicular on the head of the talus and the cuboid on the anterior part of the calcaneus. The epidemiology and etiology of vertical talus is unknown. Dobbs et al. (J Bone Joint Surg Am 88(6):1192-200, 2006) described a minimally invasive alternative which allowed to avoid the need for extensive soft tissue release procedures in treatment of congenital vertical talus. Eleven congenital vertical talus feet (group 5 according to Hamanishi) in eight children (four boys and four girls) constituted the study material. Upon the diagnosis, the patients' age ranged from 5 to 26 months old (the mean - 14.6). The treatment involved serial manipulation and casting according to the reverse Ponseti method (from 4 to 7 casts) followed by a minimally invasive approach consisting in temporary stabilization of the talonavicular joint with the use of K-wire and Achilles tenotomy according to the Dobbs technique. Then patients continued the shoe and bar program for 2 years. The X-ray measurements on lateral radiographic included the talocalcaneal angle, tibiotalar angle and talar axis-first metatarsal base angle whereas AP radiographic images-the talocalcaneal angle and talar axis-first metatarsal angle. The Wilcoxon test was used to compare dependent variables. The final clinical assessment made during the last follow-up (the mean: 35.8 months, the range: 25-52) revealed that neutral position of the foot and normal range of motion were observed in ten cases and recurrence of foot deformity in one case. The last X-ray examination showed normalization all of radiological parameters, except for one case, and examined parameters were statistically significant. The minimally invasive technique described by Dobbs should be the first option in treatment of congenital vertical talus. It allows to reduce the talonavicular joint, brings good results and preserves foot mobility. The attention should be put on early diagnosis.

Arthroscopic Latarjet Procedure With 2-Screw Stabilization: Results of Treatment of 156 Cases with a Minimum of 2-Year Follow-Up. Multicenter Study

BACKGROUND

Various arthroscopic stabilization procedures are associated with recurrence rates ranging from 10.8% to 21.1%. Recurrences occur especially in young male patients participating in contact sport activities. Bony defects of the humeral head and the glenoid predispose not only to subsequent dislocations but also to failure of surgical treatment. This is the group where &quot;bony&quot; procedures such as arthroscopic Latarjet are recommended to provide better stability as the primary treatment.

MATERIAL AND METHODS

Patients with traumatic unidirectional anterior shoulder instability treated from 2009 to 2016 with an arthroscopic Latarjet procedure operated on in two centres. Clinical results, including range of motion, Subjective Shoulder Value and Walch-Duplay score, and postpoperative complications were evaluated.

RESULTS

156 patients were available for follow-up at a minimum of 2 years after surgery. The mean follow-up was 4318 months. Mean age at the time of surgery was 27.9 (16-53) years. At final follow-up, 8 cases of recurrent instability were identified, including 6 cases of recurrent dislocation and two cases of recurrent subluxation. Mean Walch-Duplay score increased from 3019 preoperatively to 8316 (p&lt;0.05) at the last follow-up. An average loss of external rotation of 11.8 (0-70) (p&lt;0.05) when compared with the contralateral shoulder was observed at the last follow-up. Mean Subjective Shoulder Value score was 92.89.4%. 8 (5%) patients presented with loss of shoulder stability. 25 (15.8%) patients reported subjective return to sport anxiety. Eleven (7%) patients complained of anterior compartment pain. The total number of revision surgeries was 14 (8.9%).

CONCLUSIONS

1. The arthroscopic Latarjet procedure can achieve satisfactory clinical outcomes for the treatment of anterior shoulder instability 2. The rate of complications and recurrence does not increase with time and is comparable at a minimum of 2 years follow-up to early results described in literature.

Pediatric Monteggia Fracture Outcome Assessment - Preliminary Report

BACKGROUND

The term Monteggia fracture refers to a class of injuries encompassing the fracture of the proximal end of the ulna with subluxation or dislocation of the radial head. These injuries account for 0.4-1% of all forearm fractures in children. Despite its low incidence, Monteggia fractures require particular attention, since as much as 30-50% of the cases may be unrecognized, which subsequently leads to complications. The purpose of this paper is to evaluate treatment outcomes of Monteggia fractures in children. Both conservative treatment and surgery were analyzed.

MATERIAL AND METHODS

15 children (7 boys and 8 girls) between the ages of 4-16.3 years (mean age 8.3 years) with Monteggia fractures were hospitalized at our center in the years 2015-2020. Closed reduction and immobilization in a cast were performed in 12 patients, while three children underwent surgical treatment with internal fixation of the ulna. The radial head dislocation was reduced successfully in every patient.

RESULTS

Every child from the study group who received conservative treatment regained full elbow mobility as well as normal forearm supination and pronation. Only one of the patients who underwent the surgery demonstrated a 20° deficit in elbow flexion that did not affect limb function.

CONCLUSIONS

1. Our experience shows that closed reduction together with immobilization in a cast is usually a sufficient treatment in Monteggia fractures. 2. However, the dislocated radial head should be properly reduced in all patients. 3. Correct diagnosis and treatment followed by appropriate rehabilitation result in full recovery and no mobility limitations in children and teenagers.

Effectiveness of conservative treatment of multidirectional instability of the shoulder joint. Literature review and meta-analysis

<br><b>Introduction:</b> Multidirectional shoulder instability (MDI) occurs when the shoulder is dislocating in at least two directions. The patient usually experiences pain with apprehension and a clicking sensation inside the joint. So far, a few classification scales of shoulder instability have been made. Despite this fact, MDI is highly problematic for clinicians in diagnosis and treating.</br> <br><b>Aim:</b> This article presents the current trends in the conservative treatment of multidirectional instability, assess effectiveness of rehabilitation and indicates the directions of MDI research.</br> <br><b>Material and methods:</b> In order to find current literature and conduct a critical analysis, the following scientific database was used: Cochrane Library, Physiotherapy Evidence Database (PEDro), MEDLINE and PubMed. We chose four articles which included a comparison of conservative and operative treatment, and four which evaluate the effectiveness of rehabilitation.</br> <br><b>Results:</b> Low quality evidence shows priority of surgical treatment over conservative treatment. The protocol developed by Watson obtains a statistically significant advantage over the Burkhead and Rockwood protocol. Discussion: The effectiveness of rehabilitation reaches different levels. Rehabilitation should last from 3 to 12 months. If rehabilitation does not achieve a sufficient effect, arthroscopic methods of reducing the volume of the articular capsule should be considered. Due to the small number of scientific reports and their quality, the obtained data should be interpreted with caution. Much further research is required to create a precise and most effective algorithm.</br> <br><b>Conclusion:</b> Rehabilitation exercises play an important role in the treatment of multidirectional instability of the shoulder joint, especially when the patient has not had an injury. Exercise types and load should be dosed individually. At present, the protocol described by Watson is the most effective.</br>

Acetabular shape and orientation of the spastic hip in children with cerebral palsy

AIM

To see if three-dimensional (3D) methods could bring new understanding to acetabular changes in shape and orientation in the spastic hip and in which direction(s) acetabular orientation might change, which is crucial for planning appropriate hip correction surgery.

METHOD

We performed a retrospective study of pelvic computed tomography (CT) examinations in 20 consecutive patients (10 females, 10 males). The mean age of patients was 12 years 9 months (SD 2y; range: 9-16y) at the time of the CT examination. The control group consisted of 18 consecutive pelvic CT examinations (36 acetabula) of deceased individuals (six females, 12 males) aged 4 to 17 years (mean age: 10y 6mo; SD 5y 2mo) whose whole-body CT scans were taken shortly after their death. We compared 3D CT reconstructions of 28 unstable and dislocated hips in children with bilateral cerebral palsy (Gross Motor Function Classification System levels IV and V) with the unaffected side and typically developing controls to assess spatial orientation (inclination, anteversion, and tilt), acetabular volume, and surface area. Additionally, we analysed the multiple factors that may lead to structural and spatial changes of the acetabulum.

RESULTS

Patients with dislocated and spastic hips had significantly lower anteversion (-3.2° and -1.4° respectively, p<0.001), increased inclination (85.2° and 85.3° respectively, p<0.001), and decreased tilt (24.6° [p=0.014] and 20.7° [p=0.013] respectively) compared with typically developing individuals. Regarding acetabular volume and surface area, dislocated and unstable hips had significantly lower volume (17.6ml vs 31.5ml respectively, p<0.001) and surface area (28.9cm² vs 36.2cm² respectively, p<0.001) than unaffected hips. Among several factors, only Reimer's migration index had an influence on acetabular orientation (i.e. anteversion, p=0.01), volume (p<0.001), and surface (p=0.004).

INTERPRETATION

Acetabula in patients with spastic hip disease were severely retroverted with increased steepness; acetabular orientation was distorted superoposteriorly. In rare cases, acetabular orientation was distorted only superiorly or superoanteriorly.

WHAT THIS PAPER ADDS

Acetabular orientation was distorted superoposteriorly in most patients with severe bilateral cerebral palsy. More pronounced acetabular changes were found in hips with a higher Reimer's migration index.

Analysis of Outcomes of Total Cementless Hip Joint Arthroplasty in the Treatment of Advanced Hip Osteoarthritis Following Childhood Perthes' Disease

BACKGROUND

The aim of this study is to analyse the outcomes of total cementless hip joint arthroplasty in the treatment of advanced hip osteoarthritis following Perthes' disease in childhood.

MATERIAL AND METHODS

The study enrolled 56 patients (15 women and 41 men) who underwent a total of 61 hip joint arthroplasties for coxarthrosis following Perthes' disease. The mean age of the patients at surgery was 46.7 years (range 21-67 years). The mean follow-up period was 13.7 years.

RESULTS

Pre-operative Merle d'Aubigne-Postel scores (modified by Charnley) of the study group were poor in all patients. Mean post-operative improvement was 6.7 points. The outcomes were classified as excellent in 25 cases, good in 16, satisfactory in 16 and poor in 9 cases. Poor results were always related to loosening of the acetabular cup. Heterotopic ossification was noted in 7 cases. According to the Kaplan-Meier estimator, 10 years' survival probability was 85.24% for the whole implant and 100% for the stem.

CONCLUSIONS

1. Total cementless hip joint arthroplasty is an effective method in the treatment of advanced hip osteoarthritis following Perthes' disease in childhood. 2. With good surgical technique and in the absence of complications, the risk of aseptic loosening is minimal. 3. Due to the patients' young age, there may be more cases of loosening over time, requiring regular long-term follow-up.

Variation in pelvic shape and size in Eastern European males: a computed tomography comparative study

Background

The significantly accelerated development of human society in the last millennium has brought about changes in human behavior and body mass that may have influenced human bone morphology. Our objective was to analyze the variation in pelvic shape and size in males from modern and medieval populations.

Methods

We obtained 22 pelvic girdles of adult males from a medieval cemetery located in Cedynia, Poland. The control group comprised 31 contemporary male pelves from individuals inhabiting the same region. The analyzed parameters were: interspinous distance (ISD), intercristal distance (ICD), intertuberous distance (ITD), anatomic conjugate of the pelvis, height of the pelvis (HP), iliac opening angle (IOA), iliac tilt angle (ITA), and ISD/ITD/HP ratio. Geometric morphometrics was used to analyze differences in shape in the pelves. All analyses were carried out on three-dimensional CT reconstructions of pelves.

Results

ISD, ICD, and IOA were significantly greater in modern pelves than in those from Cedynia, but no significant differences were seen between the two groups in ITD, anatomical conjugate, HP, or ITA. ISD/ITD/HP ratios were significantly lower in the Cedynia group. Geometric morphometrics revealed significant differences in pelvic shape between the analyzed groups.

Discussion

The pelves of modern males are larger, wider, and flatter than those of medieval males. Changes in the set of daily activities that produce mechanical loading and estimated body mass may constitute the main factors explaining pelvic variability. However, differences in ontogenesis should also be taken into consideration, especially since growth in past populations is often found to be reduced relative to modern populations.

Radial Extracorporeal Shockwave Therapy and Ultrasound Therapy in the Treatment of Tennis Elbow Syndrome

BACKGROUND

Both ultrasound and radial shockwave therapies are used to treat tennis elbow syndrome. The aim of this study was to compare the therapeutic efficacy of both therapies by assessing the reduction in pain intensity and frequency, restoration of mobility, and reduction in the need for pain medication.

MATERIAL AND METHODS

The study enrolled 60 people, who were randomly divided into two groups of 30 patients: those treated by radial shockwave therapy and those treated by ultrasound therapy. Radial shockwave therapy consisted of 3 sessions at weekly intervals. Ultrasound therapy consisted of 10 treatments performed daily. The clinical status of the patients before treatment, just after treatment, and after 8 weeks was assessed with the Leitinen questionnaire and a visual analogue scale (VAS).

RESULTS

Pain reduction, as assessed by VAS scores, was observed in both groups, who were not different at baseline (p=0.807). While both therapies were effective (p&lt;0.005), mean pain intensity assessed by VAS scores in patients treated by radial shockwave therapy was significantly lower compared to those treated by ultrasound therapy; this relationship was present just after treatment completion (p=0.001) and at 8 weeks after treatment completion (p=0.002).

CONCLUSIONS

1. Both radial shockwave and ultrasound therapies cause a reduction in the intensity and frequency of pain that persists for at least 8 weeks, reducing the need for pain medication and improving the function of the treated upper limb. 2. Ultrasound therapy is less effective than radial shockwave therapy.

Bilateral hypermobility of ulnar nerves at the elbow joint with unilateral left ulnar neuropathy in a computer user: A case study

Occupational ulnar neuropathy at the elbow joint develops in the course of long term direct pressure on the nerve and a persistently flexed elbow posture, but first of all, it is strongly associated with "holding a tool in a certain position" repetitively. Therefore, computer work only in exceptional cases can be considered as a risk factor for the neuropathy. Ulnar hypermobility at the elbow might be one of the risk factors in the development of occupational ulnar neuropathy; however, this issue still remains disputable. As this condition is mostly of congenital origin, an additional factor, such as a direct acute or chronic professional or non-professional trauma, is needed for clinical manifestations. We describe a patient - a computer user with a right ulnar nerve complete dislocation and left ulnar nerve hypermobility, unaware of her anomaly until symptoms of left ulnar neuropathy occurred in the course of job exposure. The patient was exposed to repetitive long lasting pressure of the left elbow and forearm on the hard support on the cupboard and desk because of a non-ergonomically designed workplace. The additional coexistent congenital abnormal displacement of the ulnar nerve from the postcondylar groove during flexion at the elbow increased the possibility of its mechanical injury. We recognized left ulnar neuropathy at the ulnar groove as an occupational disease. An early and accurate diagnosis of any form of hypermobility of ulnar nerve, informing patients about it, prevention of an ulnar nerve injury as well as compliance with ergonomic rules are essential to avoid development of occupational and non-occupational neuropathy.

Comparison Analysis of Autologous Conditioned Plasma

BACKGROUND

Autologous Conditioned Plasma (ACP) has a wide range of potential uses in modern orthopaedics. The aim of this study was to examine the characteristics of proprietary ACP and compare them with those of ACP produced using a commercially available kit.

MATERIAL AND METHODS

In the hospital laboratory, 20 samples of ACP taken from patients and prepared according to the commercially available kit protocol with a double syringe system were compared with 40 ACP preparations made using disposable sterile equipment available in the hospital.

RESULTS

The mean platelet concentration in the ACP samples prepared according to the Arthrex protocol was 2.02 (range 1.16 to 2.64) times greater than in peripheral blood, while the concentration in the proprietary preparation was 1.61 (range 0.82 to 2.52) times higher. However, the mean platelet density in the proprietary preparation (n = 24) was 1.98 (range 1.48 to 2.52) times that of peripheral blood within 20 minutes of collection, and 1.41 (range 0.84 - 1.87) times after 20 minutes (n = 16). Therefore, the proprietary method of producing ACP is comparable to that of the commercial kit with regard to platelet density (p>0.05).

CONCLUSION

Using disposable hospital equipment and with a relatively short time between ACP preparation and testing, it is possible to obtain a suitable proprietary platelet-rich preparation comparable to one produced using a commercial system.

Anterior Cruciate Ligament Reconstruction Using the Transphyseal Technique in Prepubescent Athletes: Midterm, Prospective Evaluation of Results

PURPOSE

To evaluate the efficacy, results, and complications of transphyseal technique of anterior cruciate ligament (ACL) reconstruction in prepubertal patients and to assess a possible influence of children's growth on the outcome.

METHODS

Between 2005 and 2009, 22 (16 boys and 6 girls) prepubescent patients, Tanner stage 1 and 2, underwent ACL reconstruction and the follow-up 6, 12, and 24 months after surgery and after growth plate closure. The average age of the girls was 11.2 years, and of the boys, 12.3 years. The average follow-up period was 77.2 months. Clinical outcome was evaluated by Lysholm, Tegner, and International Knee Documentation Committee (IKDC) objective and subjective knee scores. Standard radiograms were performed for potential axial growing disturbance.

RESULTS

The average follow-up period was 77.2 months (range, 54 to 102 months), and IKDC subjective scores changed from 58 (range, 44 to 69) before surgery to 87 (range, 86 to 87; P = .00) at 6 months, 93 (range, 88 to 97; P = .00) at 12 months, and 95 (range, 92 to -98; P = .5) at final examination. Lysholm score increased from 58 (range, 53 to 64) before surgery to 89 (range, 85 to 92; P = .00) at 6 months and 96 (range, 94 to 100; P = .00) at 12 months, 24 months (P = .9), and final examination (P = .8). Before injury, all patients were graded 7 on the Tegner scale. Nineteen athletes reached at least grade 7 and returned to the level of activity a mean of 9 months after the surgery. No patient had deformity or growth disturbances observed clinically.

CONCLUSIONS

Arthroscopic-assisted transphyseal ACL reconstruction in prepubescent patient is a promising technique, provided that all technical details are respected. It gives excellent subjective and objective knee scores and provides a very good function of the knee joint in the midterm period with no or only minor effect on the leg length. The rate of growth after surgery did not influence the results.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Does hemipelvis structure and position influence acetabulum orientation?

Background

Although acetabulum orientation is well established anatomically and radiographically, its relation to the innominate bone has rarely been addressed. If explored, it could open the discussion on patomechanisms of such complex disorders as femoroacetabular impingement (FAI). We therefore evaluated the influence of pelvic bone position and structure on acetabular spatial orientation. We describe this relation and its clinical implications.

Methods

This retrospective study was based on computed tomography scanning of three-dimensional models of 31 consecutive male pelvises (62 acetabulums). All measurements were based on CT spatial reconstruction with the use of highly specialized software (Rhinoceros). Relations between acetabular orientation (inclination, tilt, anteversion angles) and pelvic structure were evaluated. The following parameters were evaluated to assess the pelvic structure: iliac opening angle, iliac tilt angle, interspinous distance (ISD), intertuberous distance (ITD), height of the pelvis (HP), and the ISD/ITD/HP ratio. The linear and nonlinear dependence of the acetabular angles and hemipelvic measurements were examined with Pearson’s product − moment correlation and Spearman’s rank correlation coefficient. Correlations different from 0 with p < 0.05 were considered statistically significant.

Results

Comparison of the axis position with pelvis structure with orientation in the horizontal plane revealed a significant positive correlation between the acetabular anteversion angle and the iliac opening angle (p = 0.041 and 0.008, respectively). In the frontal plane, there was a positive correlation between the acetabular inclination angle and the iliac tilt angle (p = 0.025 and 0.014, respectively) and the acetabular inclination angle and the ISD/ITD/HP ratio (both p = 0.048).

Conclusions

There is a significant correlation of the hemipelvic structure and acetabular orientation under anatomic conditions, especially in the frontal and horizontal planes. In the anteroposterior view, the more tilted-down innominate bone causes a more caudally oriented acetabulum axis, whereas in the horizontal view this relation is reversed. This study may serve as a basis for the discussion on the role of the pelvis in common disorders of the hip.

NERVE ENDINGS AND VASCULAR SUPPLY IN SEMITENDINOSUS TENDON OF CEREBRAL PALSY CHILDREN

Objective: To evaluate the distribution of SP (substance P) and S-100 peptide immunoreactivity, as well as the vascular supply of tissues commonly used as grafts for anterior cruciate ligament (ACL) reconstruction. A second aim was to compare the above mentioned distribution in the semitendinosus muscle tendons of cerebral palsy (CP) patients with the semitendinosus muscle tendons and patellar tendons of patients without CP. Methods: The first group consisted of 14 children with cerebral palsy with a mean age of 11.7 years old. At the time of hamstring lengthening operation, a sample of semitendinosus muscle was taken for analysis. The second group comprised 20 patients treated for isolated ACL rupture of the knee (mean age 32 years old). Group three comprised ten patients in the mean age of 14.3 years old treated for recurrent lateral patellar dislocation, and from whom a sample of patellar tendon was obtained. Results: No statistically significant differences were demonstrated with regard to the amount of immunopositive nerve fibers expressing SP or S-100 in all 3 groups of patients. A significant difference was noted in the number of blood vessels between the adult and child semitendinosus muscles, but not between the semitendinosus muscles and patellar tendon of children. Conclusion: The number of nociceptors as well as proprioceptive fibers is similar in patients with CP and patients from a neurologically healthy population. Level of Evidence IV, Cases Series.

The variable morphology of suprascapular nerve and vessels at suprascapular notch: a proposal for classification and its potential clinical implications

PURPOSE

The most common place for suprascapular nerve entrapment is the suprascapular notch. The aim of the study was to determine the morphological variation of the location of the suprascapular nerve, artery and vein, and measure the reduction in size of the suprascapular opening in each type of the passage.

METHODS

A total of 106 human formalin-fixed cadaveric shoulders were included in the study. After dissection of the suprascapular region, the topography of the suprascapular nerve, artery and vein was evaluated. Additionally, the area of the suprascapular opening was measured using professional image analysis software.

RESULTS

Four arrangements of the suprascapular vein, artery and nerve were distinguished with regard to the superior transverse scapular ligament: type I (61.3 %) (suprascapular artery was running above ligament, while suprascapular vein and nerve below it), type II (17 %) (both vessels pass above ligament, while nerve passes under it), type III (12.3 %) (suprascapular vessels and nerve lie under ligament) and type IV (9.4 %), which comprises the other variants of these structures. Statistically significant differences regarding the suprascapular opening were observed between the specimens with types II and III. Anterior coracoscapular ligaments were present in 55 from 106 shoulders.

CONCLUSION

The morphological variations described in this study are necessary to better understand the possible anatomical conditions which may promote suprascapular nerve entrapment (especially type III). They may be useful during open and endoscopic procedures at the suprascapular notch to prevent such complications as unexpected bleeding.

An accurate method of radiological assessment of acetabular volume and orientation in computed tomography spatial reconstruction

Background

Two-dimensional (2D) measurements of acetabular morphology and orientation are well known; there is less information on these acetabular characteristics in three dimensions. One important reason is the lack of standardized reference planes for the pelvis, especially in relation to the spinopelvic unit; another is that no method precisely assesses the acetabulum in three-dimensional (3D) orientation based on its axis rather than on the directions of the edges of the acetabular rim. We present an objective, highly reliable and accurate, axis-based approach to acetabular anthropometry in the measurement of acetabular volume and spatial orientation in both normal and pathologic hips. This was done using reference planes based on the sacral base (SB) and true acetabular axis in 3D computed tomography (CT) pelvic reconstruction.

Methods

Radiological examinations of 30 physiologic pelves (60 acetabula) were included in the study. Reliability and accuracy of the method were verified by comparing acetabular angles in 2D pelvic scans with 3D reconstructions. We also applied the method to two pathologic acetabula.

Results

Comparison of axis position in the horizontal plane revealed significant positive correlations between 2D angle measurements (acetabular anteversion angle [AAA] and anterior acetabular index [AAI]) and 3D measurement of anteversion angle (p < 0.001 and p = 0.012, respectively). In the frontal plane, there was no difference between abduction angle, measured on topogram, and inclination angle, obtained from a 3D model (p = 0.517). In the sagittal plane, there was a significant negative correlation between AAA and acetabular tilt (p < 0.001). Inter- and intra-observer reproducibility was excellent for determination of the sacral-base plane and assessment of volume, with Fleiss κ coefficients of 0.850 and 0.783, respectively, and intraclass correlation coefficients of 0.900 and 0.950, respectively. Inter-observer reproducibility for evaluation of acetabular axis ranged from 0.783 to 0.883, and intra-rater reliability ranged from 0.850 to 0.900 for all 3D angles.

Conclusions

Our method is a new, reliable diagnostic tool for assessing the acetabula in both normal and pathologic hip joints. The sacral-base plane can be used as a stable reference that takes the relationship of the acetabulum to the spinopelvic unit into consideration.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-015-0503-8) contains supplementary material, which is available to authorized users.

Phenomenon of painless knee in recurrent patellar dislocation in children

INTRODUCTION

Cartilage lesion with patellar malalignment may be correlated with pain. Situations in which patients with recurrent patellar dislocation are painless between episodes of luxation can be approached with considerable curiosity. We evaluated the distribution of substance-P and S-100 protein expression in soft tissue of the knee in children with recurrent patellar dislocation, in order to evaluate the distribution of nociceptors and determine tissue origins of this situation.

MATERIAL AND METHODS

Samples were collected from the medial and lateral synovial membrane, medial and lateral patellar retinaculum, Hoffa's body, patellar ligament, and quadriceps' aponeurosis in 10 children during the Blauth procedure and 10 adults with idiopathic osteoarthritis during total joint alloplasty. The density of nociceptive fibres was compared in the children and adults using S-100 and substance-P monoclonal antibodies.

RESULTS

Statistical differences between groups were demonstrated for S-100 expression in synovial membrane of the medial knee compartment (p < 0.05) and for substance-P expression in the medial patellar retinaculum (p < 0.05) and synovial membrane of the lateral (p < 0.05) and medial (p < 0.05) knee compartment in favour of children.

CONCLUSIONS

Lack of pain sensations in patients with recurrent patellar dislocation may be associated with non-increased expression of nerve endings in Hoffa's body. Increased expression of either S-100 protein or substance-P in synovial membrane and the medial retinaculum did not induce pain development in the knee joints of that group of patients.

Do gene expression changes in articular cartilage proteases of the synovial membrane correlate with expression changes of the same genes in systemic blood cells?

PURPOSE

The aim of our study was to find whether an injury of the knee joint tissues increases gene expression of selected hyaline cartilage degenerating enzymes such as matrix metaloproteinases (MMP) and aggreacaneses (Agg).

METHODS

A total of 138 patients (81 female, 57 male) were admitted for knee arthroscopy with a mean age of 38.8 years. Full blood samples were collected preoperatively and synovium samples intraoperatively. Joint tissue lesions such as menisci, anterior cruciate ligament (ACL) and hyaline cartilage were estimated. Real time PCR with spectrophotometric analysis was performed.

RESULTS

An ACL lesion was found in 56 patients, medial menisci (MM) in 65, and lateral menisci (LM) in five. Chondral lesions were estimated according to Outerbridge's grading system. In laboratory tests correlation between ACL tear and gene expression was seen except TIMP1 in serum (p < 0.05). In MM lesions MMP9, Agg2 elevation in serum was observed. LM lesions erased MMP13, MMP14 in serum and MMP8 in synovium. Chondral lesions revealed that many genes had higher expression in patients without hyaline degeneration. All of the gene expressions correlated between serum and synovium.

CONCLUSION

An ACL lesion provokes elevation in expression of proteases genes, while the influence of other lesions remains elusive. Gene expression in synovium correlates with peripheral blood.

Comparison of knee function in patients with a healed fracture of the femoral shaft fixed with retrograde and antegrade intramedullary nailing

BACKGROUND. Despite extensive current knowledge about fractures of the femoral shaft, the choice between antegrade and retrograde intramedullary (IM) nailing with respect to the future function of the joint serving to introduce the nail continues to raise controversy. To compare knee function in patients with a healed fracture of the femoral shaft fixed by antegrade vs. retrograde IM nailing. MATERIAL AND METHODS. The study involved a group of 65 individuals with traumatic fractures of the femoral shaft who underwent stabilisation with IM nails in the years 2001-2010. Thirty-two cases were retrograde nails (Group R) and 33 antegrade nails (Group A). Patient age at trauma ranged from 19 to 91 years (mean: 47). Knee function was assessed in both groups with the KOOS, KSS1 and KSS2 scoring systems. RESULTS. Knee function as assessed with KOOS differed significantly between retrograde and antegrade nailing, with a greater incidence of poor and fair results in the former and more excellent outcomes in the latter group (p=0.0133). As regards KSS1 and KSS2, there were no significant differences between the groups (p=0.1947, p=0.4038). The range of motion was 86-125 degrees in Group R and 121-125 degrees in Group A. Knee pain was reported by 37.5% of the patients treated with retrograde nailing and 39.4% of those who had the IM nail inserted via the antegrade approach (p=0.22). The mean time to bone union was 180 days in Group R and 219 days in Group A (p=0.25). Age and presence of osteoarthritis at trauma significantly lowered the KOOS (p=0.0027, p= 0.005) and KSS (p=0.0002, p=0.002) scores, as well as the knee range of motion (p=0.0014, p=0.004) CONCLUSIONS. 1. Knee function following retrograde and antegrade IM nailing to stabilise femoral shaft fractures was comparable. 2. The choice of IM nailing method should not be based solely on orthopaedic indications, but also on the severity of osteoarthritis present at trauma.

Variation in morphology of suprascapular notch as a factor of suprascapular nerve entrapment

PURPOSE

The shape and size of the suprascapular notch (SSN) is one of the most important risk factors in suprascapular nerve entrapment. The aim of the study was to perform a morphological study of SSN variations.

METHODS

A total of 616 computer tomography scans of scapulae were retrospectively analysed in 308 patients. The examination focused on the suprascapular region. The type of suprascapular notch was determined by using a classification based on three geometrical measurements: maximal depth (MD), superior (STD) and middle (MTD) transverse diameters.

RESULTS

In the scans, five types of SSN were noted. In type I (24.18%) maximal depth was greater than superior transverse diameter. Type II (1.95%) has equal MD, STD and MTD. In type III (56.16%) the superior transverse diameter was greater than the maximal depth. Scapulae with bony foramen were classified as type IV (4.72%). In type V a discrete notch (12.99 %) was found. Additionally, types I and III were divided into three subtypes: A, B and C. The frequency of type I and IV was lower in females than in males, but type III was more common in females than males. Distribution of other types of SSN in both groups was similar.

CONCLUSION

Knowledge of the anatomical variations of the suprascapular notch described in this study should be helpful in endoscopic and open procedures of the suprascapular region and also may increase the safety of operative decompression of the suprascapular nerve.

Reliability of clinical evaluation of meniscus repair with the all-inside technique

INTRODUCTION

The study aimed to compare questionnaire data and clinical evaluation with an assessment of meniscal morphology conducted at arthroscopic anterior cruciate ligament (ACL) reconstruction following meniscal repair.

MATERIAL AND METHODS

The study involved a selected group of 17 subjects (5 women and 12 men) aged 14-33 years, who underwent meniscal repair with the Fast-Fix system followed by ACL reconstruction. The mean interval between the procedures was 9 months. Prior to each procedure, the patients were requested to fill in the Lysholm Knee Questionnaire.

RESULTS

At review, 14 patients met the criteria of a healed meniscal repair, whereas the remaining 3 subjects presented with signs of meniscal injury. These observations were confirmed at repeat arthroscopy. The Lysholm score for the entire study group increased from a baseline value of 57.3 to 92.2 points postoperatively, with the patients with reruptured menisci also improving, from 58 to 75.3 points.

CONCLUSIONS

1) Our results show that clinical examination is reliable to evaluate the healing of meniscal lesions following all-inside repair, as confirmed by repeat arthroscopy. 2) A far greater increase in the Lysholm score seen in patients whose menisci were confirmed to have healed by repeat arthroscopy indicates that such questionnaires may be of help in the evaluation of treatment outcomes.

Development of human hip joint in the second and the third trimester of pregnancy; a cadaveric study

Background

The purpose of the study was an evaluation of fetal hip joint morphology during the second and the third trimester of pregnancy. Serial sections were performed on 23 cadaver infants.

Results

The mean lunar age was 6.6 months. Femoral shaft length (FSL) and width of the proximal and distal epiphysis were x-rayed to determine fetal age. The neck shaft angle (NSA), the femoral antetorsion angle (FAA), the acetabulum anteversion angle (AAA) and the acetabulum slope angle (ASA) were measured. Hip development ratios were plotted for all cadaveric species and revealed: flat FSL/NSA slope pattern, upward FSL/FAA slope pattern and downward slope pattern for FSL/ASA and FSL/AAA ratios. The changes, observed during the developmental period, were not statistically significant. NSA did not change during the second or the third pregnancy trimester. FAA increased during pregnancy but the changes were not statistically significant. AA, as well as ASA, showed a decreasing trend during the second and the third pregnancy trimester, however, with no correlations to age.

Conclusion

Despite an increasing depth and growing dimensions of the acetabulum in the uterus, its orientation does not change in any significant way.

Hip joint pain in spastic dislocation: aetiological aspects

AIM

Children with severe forms of cerebral palsy (CP) are at high risk of hip joint displacement. Various studies have found that the pain from affected joints occurs in 40 to 84% of studied individuals. The purpose of this study was to establish a correlation between the density of nociceptors localized in selected areas of the spastic dislocated hip joint and clinical evidence of hip joint pain in children with CP.

METHOD

Nineteen samples of articular capsule and 19 samples of teres ligaments, collected during open hip joint reduction from 19 non-ambulatory children with spastic CP (Gross Motor Function Classification System level V; mean age 9y 6mo; 10 males, nine females), were studied. Pain was assessed using the numeric rating scale completed by caregivers. The density of nociceptive fibres was compared between the children with painful and children with painless hip joints, using S-100 and substance P monoclonal antibodies.

RESULTS

The presence of S-100 protein and substance P were significantly increased (p=0.024 and p=0.02 respectively) in the children with painful hip joints. There were significantly positive correlations between the intensity of pain and the density of nerve fibres with S-100 protein (teres ligament, p=0.001; joint capsule, p=0.032) as well as substance P (teres ligament, p=0.001).

INTERPRETATION

Direct and indirect inflammatory factors, present in dislocated hip joints with cartilage damage in children with spastic CP, lead to hip joint sensitization.

Evaluation of adductor myotomy versus adductor transfer to ischiadic tuber in the treatment of spastic hip in cerebral palsy

BACKGROUND

The muscle imbalance associated with the spastic type of infantile cerebral palsy may result in subluxations or dislocations of the hip. The aim of the study was to compare the clinical and radiological results of myotomy of the hip adductor muscles versus adductor transfer to the ischiadic tuber in the prevention of hip subluxation and dislocation in infantile cerebral palsy.

MATERIAL AND METHODS

The study involved 36 ambulant children with spastic diparetic CP treated at our Department in the years 1987-2002. Group I consisted of 21 children (41 hip joints) who underwent myotomy of the adductor longus, adductor brevis and gracilis muscles. Mean age at the time of surgery was 10 years (3 to 17 years). Group II consisted of 15 children (28 hip joints) who underwent transfer of the tendons of the adductor muscles to the ischiadic tuber. Mean age at the time of surgery in this group was 8 years (3 to 16 years). The mean duration of hospital stay was 6 days in Group I and 9 days in Group II. Rehabilitation was carried out for an average of 3 months in Group I and 4 months in Group II.

RESULTS

The follow-up examination showed improvement in the hip range of motion in both groups and no radiographic differences.

CONCLUSIONS

Adductor myotomy is superior to adductor transfer because of easier surgical technique, shorter duration of hospital stay and no need to immobilize the hip.

Evaluation of satisfaction with surgical treatment for musculoskeletal dysfunction in children with cerebral palsy

BACKGROUND

The variety of symptoms in cerebral palsy (CP) points to the advisability of using the term 'cerebral palsies' to underline the complex nature of the associated musculoskeletal dysfunctions. The incidence of CP is estimated at 1 to 5 in 1000 live born infants. This makes CP one of the main causes of hospitalization in paediatric orthopaedic wards. The complicated nature of the musculoskeletal dysfunctions entails the necessity of employing multiple surgical procedures: starting from multilevel soft tissue operations, to multiple corrective osteotomies, to spinal surgery with implantation of baclofen pumps for subarachnoid administration. The aim of the study was to evaluate the level of satisfaction following surgery in CP children.

MATERIAL AND METHODS

The study group was composed of 52 children (27 males and 25 females) surgically treated between 1988 and 2001. There were 18 children with hemiparesis, 19 with diparesis and 15 with tetraparesis. A subjective evaluation of the level of the satisfaction of the patient and the parent/guardian after the surgical treatment was carried out during a follow-up examination.

RESULTS

Forty-three parents (82.6%) reported improvement after the surgery and declared that they would take the same decision again. Five parents reported no significant change in the quality of life of their children (9.6%), and two (3.8%) reported a deterioration.

CONCLUSION

1. Multilevel soft tissue release in children with CP significantly improved their quality of life and was associated with a high level of parents'/guardians' satisfaction.

Radiological evaluation of hip joint congruency in children with cerebral palsy

BACKGROUND

Disturbed muscle balance in the hip joints of children with cerebral palsy (CP) shifts the pivoting point from the middle of the femoral head to the lesser trochanter. Forces that dislocate the femoral head progressively change acetabular shape, producing inadequate femoral head covering. The aim of the study was to carry out a radiological evaluation of hip congruency in children with CP after surgical treatment.

MATERIAL AND METHODS

The study group consisted of CP patients operated on due to lower limb dysfunction between 1988 and 2001. All patients had undergone multilevel soft tissue release. A total of 52 children reported for follow-up examinations. There were 18 patients with hemiparesis (32%), 19 with diparesis (36%), and 15 with tetraparesis (29%). The age at surgery was between 2 and 19 y.o. (average age 7.33 y.o.). Radiological evaluation of the hip joints focused on changes in the migration index and the shaft-neck angle.

RESULTS

The mean migration index before surgery was 30.4% in the group of diparetic and tetraparetic children. At the last follow-up examination, the average migration index was 32.5% on the right side and 25.6% on the left side (p>0.05). There was a statistically significant decrease in the value of the migration index in children operated on before the age of 8 years (p=0.007). In children operated on after the age of 8, the change in the migration index value did not exceed 0.5% (p>0.05).

CONCLUSIONS

1. The mean migration index did not change significantly in the study group of surgically treated CP children. 2. Surgery had no influence on the shaft-neck angle 3. Surgery prevented progression of the migration index.

[Evaluation of distal radius fracture treatment--non-operative vs. operative with percutaneous pinning]

The aim our study was retrospective analysis of distal radius fracture treatment. We compared conservative treatment (closed reduction, cast immobilization) with operative treatment--percutaneous K-wire pinning.

MATERIAL AND METHODS

52 patients--39 female (75%) and 13 male (25%), with mean age of 58 years (range 25-77 years), that underwent displaced distal radius fracture in years 2002-2008. The number of evaluated groups is equal--26 patients, mean follow-up time is 40 months (range 4-79 months). Type of fracture has been evaluated on the X-ray film according to Frykman classification. The final X-ray film was estimated according to Lidström classification (based on radial inclination, volar angulation, radial shortening). Both groups of patient were statistically equal by means of sex, age and initial type of fracture according to Frykman classification. Range of motion of affected and contralateral radio-carpal joint after treatment has been evaluated using goniometer. Results were analyzed with statistical methods.

RESULTS

Group of patients that underwent non-operative treatment had better range of motion only by means of ulnar deviation (statistical significance, p < 0.05). There were no statistical differences between patients who underwent operative and non-operative treatment in radiological evaluation using Lidström classification.

SUMMARY

Our study has not proved statistically significant differences between patient treated non-operatively and operatively (functional and radiological evaluation), except for one radio-carpal joint range of motion parameter.

[Hand deformity in adult rheumatoid arthritis and juvenile chronic arthritis]

Adult rheumatoid arthritis (RA) is the most common of rheumatoid diseases, that may cause hand dysfunction in some patients. Its equivalent in children is juvenile chronic arthritis (JCA). The aim of our study was to evaluate differences in hand deformity between children with JCA and adults with RA. The prospective study was performed on two groups of patients: 15 with JCA (average age 13.1 years, range from 9 to 18 years) and 15 with RA (average age 53.6 years, range from 42 to 60 years). Both groups were similar in terms of Seyfried classification system and duration of the disease--7.9 years for children and 8.6 for adults. Clinical assessment was performed according to Swanson and Seyfrieda classification system. Patients with RA had only radial wrist "deviation" and those with JCA had both radial and ulnar wrist deviation. In MCP joints in adult's group fingers were always in ulnar position and in children's group finder position was opposite to wrist position. "Swan neck" deformity of fingers from II to V was found in both groups. "Buttonhole deformity" was more often seen in older group. Pain of wrist and in IP joints was more often found and was more severe in RA group. Hypertrophy of synovium and subluxation of IP and wrist joust were found with similar frequency in both groups. In other joints subluxation was rare. Concluding, radial wrist deviation is typical for RA patients. Children with JCA had both radial and ulnar wrist deviation. In MCP joints deformity is always opposite to wrist deviation.

[Results evaluation of children flexible flatfoot operative treatment according to Mittelmeier method]

The aim of the study is to evaluate results of the operative treatment of children flexible flatfoot. The investigative material consisted of 16 children (7 girls, 9 boys) treated between 1995-2004. The age at the time of operation was 9-15 years (mean 11.5 year). The average follow up period was 4.5 year (from 1 to 10 years). Clinical examination consisted of physical and subjective examination performed before and after operation. Subjective examination was performed on the basis of questinnaire. Physical examination was completed with hindfoot valgus angle measurement and with podoscopy (Clark's angle and Godunow-Sztriter index measurement). We decided to do surgery in children when conservative treatment failed. Operation was performed according to Mittelmeier method. After surgery we applied short leg cast with 10 degrees foot supination for 4 weeks. We allowed patients to walk without weight bearing by using elbow crutches for 8 weeks, and recommended rehabilitation 2-6 weeks after cast removing. According to static foot parameter we obtained 4 very good, 8 good and 4 sufficient results. According to patients subjective evaluation we obtained 5 very good, 8 good and 3 sufficient results. In two cases we had postoperative complications (prolonged wound healing). On the basis of presented material we can state that surgery according to Mittelmeier method at children above 9 years old could be benefit and should be take into consideration in treatment flexible flatfoot.

[The use of small diameter cups in total uncemented hip replacement]

The aim of the study was to analyze early results of total uncemented hip replacement with use of small diameter acetabular components. In the group of 13 patients (15 hips) with severe dysplastic coxarthrosis mean age at surgery was 43.6 years. There were 8 right and 7 left hips operated. For clinical assessment Merle d'Aubigné and Postel classification modified by Charnley was used. Radiographs were evaluated according to Engh and Massini, De Lee and Charnley as well as Gruen classification system. The mean follow up was almost 18 months. There were 11 good and 4 satisfactory results. No very good and poor results were found. Subjective assessment of patients was much better than with use of Merle d'Aubigné and Postel classification. The use of small uncemented cups in a valuable method witch allows good positioning of acetabular component. Implantation of this type of cups gives satisfactory fixation without use of bone grafts but limits possibility of limb length inequality correction.

[How to avoid complications after surgery in children with cerebral palsy?]

The authors reviewed most common complications and the way to avoid problems in the surgical treatment of children with cerebral palsy, with a focus on making the proper diagnosis, age at the time of surgery, and approach to nonoperative and operative treatment.

[The role of the ossific nucleus in the treatment of developmental dislocation of the hip joint]

The aim of the study was to compare long-term radiological results and appearance of avascular necrosis in hips with and without ossific nucleus of femoral head at the beginning of treatment. We retrospectively reviewed radiographs of 155 hips in 107 children treated for developmental dislocation of the hip. The age of children at the onset of treatment was 14.2 months. Minimal age at last follow-up was 14 years. Statistical analysis showed no correlation between presence or size of ossific nucleus and avascular necrosis of femoral head or final radiological outcomes. We do not recommend delay in the treatment of dislocated joint on the bases of presence and size of ossific nucleus. This delay may result in lost of optimal time for remodeling of affected hip joint.

[Dega transiliac acetabular osteotomy in cerebral palsy hip joint]

Untreated hip joint in cerebral palsy children leads to subluxation or dislocation caused by muscle imbalance often with associated painful arthritis. The very strong hip joint flexors and adductors muscles overpower the abductors and extensors muscles, moving the hip joint's rotation center to shift from center of the femoral head to the lesser trochanter. The forces gradually change the shape of the acetabulum, which becomes more elliptical. Between 1994 and 2000, 136 cerebral palsy children were treated by multilevel soft tissue surgery. Among them 95 children required surgical interventions for hip problems. In 18 cases (7 girls, 11 boys) with average adduction of 10 degrees and migration index over 60%, osteotomy of proximal femur (varus and derotation osteotomy) combine with Dega pelvic osteotomy was performed. Mean age at the time of surgery was 11.2 years. The study was based on clinical examination, parents' questionnaire and radiological findings (mean follow up 8 years). The functional improvement was observed. Correction of the position of femoral head into acetabulum allowed for sufficient abduction of the leg with mean increase of 18 degrees. In ambulatory patients, gait pattern had change to less energy. In non-ambulatory patients improved ability of perineal care. Migration index decreased to an average of 25%. Hip pain decreased in all. The unsatisfactory results were noted in two cases, redislocation. Dega's acetabular osteotomy allows for correction deficiency of the acetabulum with a good coverage of femoral head. With a properly planned approach, bone surgery can bring good clinical and functional results.

[Facial asymmetry in children with congenital muscular torticollis after surgical treatment]

Asymmetrical position of facial skeleton and movement restriction in the cervical spine in young children could be caused by torticollis mainly muscle origin. We observe miofibrosis of sternocleidomastoid muscle. This face deformation is seen from 0.3 to 1.5% children. Torticollis could be associated with malocclusion, facial asymmetry, vision defect or vertebral body deformation. Muscle stretching is a main type of treatment at infantile age. In the case of faille and in older children sternocleidomastoid myotomy is indicated. The purpose of our study is to analyze facial asymmetry in children after torticollis surgery and determination if surgery performed after 3 years of age is associated with higher risk of facial deformity in long follow up. The study population consisted of 16 patients who underwent sternocleidomastoid tenotomy in proximal and distal part. The control group consisted of 13 persons. Booth groups underwent subjective and objective analysis consisted of computer facial symmetry analysis and measurements of range of motion in the cervical spine. The study group was divided into two subgroups--patients operated before and after 3 years of age. The follow up was 2 to 26 years (mean 13.4 years). The statistical analysis of objective evaluation revealed significant difference in horizontal face axis between subgroups (p<0.05). Range of motion at cervical vertebral column was the same in both groups. Facial asymmetry caused by muscle torticollis is persistent in horizontal axis in long follow up and is more often observed in children operated after 3 years of age, but statistical analysis does not support this thesis.

[The role of the ossific nucleus in the treatment of developmental dislocation of the hip joint]

The aim of the study was to compare long-term radiological results and appearance of avascular necrosis in hips with and without ossific nucleus of femoral head at the beginning of treatment. We retrospectively reviewed radiographs of 155 hips in 107 children treated for developmental dislocation of the hip. The age of children at the onset of treatment was 14.2 months. Minimal age at last follow-up was 14 years. Statistical analysis showed no correlation between presence or size of ossific nucleus and avascular necrosis of femoral head or final radiological outcomes. We do not recommend delay in the treatment of dislocated joint on the bases of presence and size of ossific nucleus. This delay may result in lost of optimal time for remodeling of affected hip joint.

[Treatment of physeal fractures in children]

The aim of the study was to determine final clinical and radiological results of epiphyseal fractures treated in our hospital. Thirty-five patients were included in the study (6 girls and 29 boys) aged from 5 to 17 years (mean 12.1 years). Follow up ranged from 2 to 20 years. According to Salter and Harris classification system 15 patients had type I and 20 had type II fracture. According to the Neer-Horowitz classification system of the proximal end of humerus one patient had grade III and three had grade IV fracture. Physeal fractures included: proximal end of humerus (n = 4), distal end of radius (n = 16) (with coexistent distal end of ulna fractures in 6 cases), distal end of femur (n = 4), distal end of tibia (n = 3) and distal end fibula (n = 8). Six patients were treated with open reduction and K-wire fixation, three with skeletal traction and cast, one with closed reduction and K-wire fixation and twenty five with closed reduction and cast. Neurovascular deficit was noted in any of our patients at admission and after reduction. During follow-up we did not notice physeal arrest, changes in limbs axis or limb shortening in any of our patients. All our patients had good clinical results. In 2 cases in early postoperative follow-up limitation of shoulder abduction after physeal fracture of proximal humerus was observed. Restoration of proper anatomical conditions is conducive to restore function of growth plate. Kirschner wire fixation did not increase the risk of growth arrest. Physeal injuries at the end of growth did not cause limb axis changes.

Early clinical results of open and arthroscopic synovectomy in knee inflammation

BACKGROUND

The authors compared early results of open and arthroscopic knee joint synovectomy in patients with nonspecific exudative synovitis and rheumatoid arthritis.

MATERIAL AND METHODS

The study comprised two groups of patients matched for age, preoperative range of motion in the involved knee and etiology of synovitis. Group I included patients after open synovectomy and group II consisted of subjects following an arthroscopic procedure. Blood loss, analgesic intake, duration of hospitalization, range of flexion and extension in the involved knee at discharge as well as 3 and 6 months following surgery were compared, together with respective recurrence rates.

RESULTS

A statistically significant decrease in blood loss and a shorter duration of hospitalization were found in group II compared to group I; no differences were observed in postoperative analgesic use. Mean flexion range was significantly greater before surgery than in the 3 analyzed time intervals in both study groups except for knee flexion in group II compared before and 6 months following the intervention. However, mean flexion range in the operated joint at discharge and 3 months postoperatively was significantly greater in group II as compared with group I. A comparison of the knee extension range between the groups revealed significantly higher values in group II at discharge, but no statistically significant differences were found in the subsequent follow-up assessments. However, flexion contractures developed 6 months after surgery in 5 patients from group I and in 1 patient from group II. No recurrence of effusion was observed in either group.

CONCLUSIONS

According to the authors, arthroscopic synovectomy reduces blood loss following surgery, shortens duration of hospitalization and permits faster recovery.

[Split tibialis posterior tendon transfer on peroneus brevis for equinovarus foot in CP children]

Equinovarus deformity of the foot is a result of the muscles imbalance in which inventors of the foot, mostly posterior and anterior tibialis muscle, overpower evertors. In children with cerebral palsy untreated spastic equinovarus deformity may cause severe fixed foot deformity and painful callosities under metatarsal heads and on the lateral side of the foot. The gait pattern becomes less effective and needs more energy. The study group consisted of 154 children with cerebral palsy treated in our Clinic by the multilevel soft tissue surgery. For foot problems 136 children needed surgical intervention. In 19 ambulatory patients, with hemiplegia or diplegia, split tibialis posterior tendon transfer together with tendo Achilles lengthening and plantar aponeurectomy were performed. The study was based on clinical examination, parents' questionnaire, radiology and gait analysis at least one year after surgery. The mean follow up was 4.6 years. The functional improvement was observed in 17 (89%) children with tendon transfer. At the last follow up those patients were brace free, with plantigrade foot while walking (without DAFO orthesis) and normal shoes were used. All painful callosities disappeared. On a standing AP X-ray adequate correction of the hindfoot-forefoot relation was achieved in 14 (74%) cases. Persistent equinovarus deformity over 10 degrees was observed in 2 cases. Those patients underwent additional bone surgery. With a properly planned approach the split tibialis posterior tendon transfer can bring good clinical and functional results in CP children with equinovarus deformation. We recommend this procedure in early stage of the deformity what can eliminate more harmful triple arthrodesis in severe deformities.

The role of the acetabulum in Perthes disease

The purpose of this study is to evaluate the changes in the shape of acetabulum from the onset of the disease to the skeletal maturity in Legg-Calvé-Perthes disease. The study population consisted of 243 patients with unilateral involvement who had reached skeletal maturity at last follow-up. All hips were treated by containment methods (which included bed rest and traction in abduction, Petri cast, brace, varus osteotomy, Salter osteotomy, and shelf acetabuloplasty). Necrosis of the femoral head was estimated according to the lateral pillar classification and late results according to the Stulberg classification. Changes in the shape of the acetabulum were divided into 3 groups: type I-normal, concave lateral acetabulum margin; type II-flat, horizontal lateral acetabulum margin; and type III-convex, sloping acetabular margin. Roentgenograms performed during the fragmentation stage revealed type I changes in 78 (32.1%) hips, type II in 136 (55.7%), and type III in 29 (12.2%). At the last follow-up, there were type I changes in 124 (51.2%) hips, type II in 81 (33.5%), and type III in 38 (15.3%). The statistical analysis revealed no significant statistical difference between the age at the onset and gender with regard to acetabular changes. There was significant statistical correlation between the lateral pillar classification, subluxation of the femoral head, the range of hip abduction, and the Stulberg classification with regard to acetabular changes. A type III was statistically associated with lateral pillar classification group C, major subluxation of the femoral head, limited hip abduction, and in Stulberg group 3, 4, or 5. Only surgical methods of treatment improved the acetabular shape at the last follow-up (P<0.05). In our opinion, the lateral acetabulum shape plays a very important role during the remodeling of the deformed proximal femoral epiphysis.

[The prognostic factors in perthes disease]

The purpose of this study was to evaluate the role of selected factors which may play role in the estimation of late result during Perthes disease and which one can be eliminated during treatment period. The study population consisted of 311 patients (50 patients with bilateral disease, 361 hips joint) who had reached skeletal maturity at last follow up. All hips were treated by containment methods (bed rest and traction in abduction, Petri cast, brace, varus osteotomy, Salter osteotomy and shelf acetabuloplasty). Both clinical and radiological parameters (taken during fragmentation stage) were included in our study: gender, age at the onset, hip joint abduction, type of treatment, extend of the femoral head necrosis according to the Herring and Catterall classification, LLD, premature growth plate arrest, ATD and ATD index, lateral acetabulum shape - type I - normal, concave lateral acetabulum margin, type II--flat, horizontal and type III--convex, sloping, femoral head subluxation, femoral head sphericity disturbance according to the Mose, risk factors according to the Catterall, Wiberg angle, Eyre-Brook index. Long-term results were evaluated according to the Stulberg classification and were divided into two groups: good result--Stulberg group 1 or 2 and poor and bad result--Stulberg group 3, 4 or 5. The unilateral and bilateral Perthes disease was estimated separately. The statistical analysis revealed in unilateral Perthes disease that next risk factors may lead to poor or bad late result: age at the onset 9 and more years, group 3 or 4 according to Catterall and group C according to Herring classification, type III lateral acetabulum shape, hip joint abduction less than 10 degrees, premature growth plate arrest, ATD index less than 0.8, femoral head subluxation more than 20%, femoral head sphericity disturbance more than 5mm, Gage sign, calcification laterally to the femoral head (sensitivity 85.0%, specificity 98.7%). Bilateral Perthes disease: age at the onset over 6 years, group 3 or 4 according to Catterall and group C according to Herring classification, hip joint abduction less than 10 degrees and calcification laterally to the femoral head (sensitivity 81.8%, specificity 92.3%). The statistical analysis showed which clinical and radiological factors may play an important role in estimation of late results during Perthes disease. Additionally during fragmentation stage of Perthes disease we have possibility to correct or eliminate some of the risk factors - femoral head subluxation, lateral acetabulum shape and hip joint abduction and improve the late result.

[Hip joint development after treatment the developmental dislocation with overhead traction]

Despite the fact that ultrasound of children's hips is widely used for screening, late diagnosed cases of developmental dislocation of the hip are still a common problem in the orthopaedic practice. The aim of the study is to review final clinical and radiological outcomes of treatment of DDH with overhead traction and closed reduction after skeletal growth. Clinical records and radiograms of 107 hips (81 children) were retrospectively reviewed. All of them were treated according to the same program: overhead traction (about 2 weeks), followed by closed reduction, modified Lorenz cast (2 months) and finally cast in Lange position (3 months). Average age of children was 14.2 months at the beginning of treatment and 20.7 years at last visit. Good and very good results were found in 80% of cases according to final radiological assessment of Severin and in 91% according functional classification of Harris. Avascular necrosis of femoral head according to Bucholz-Ogden classification system was identified in one third of patients. Functional results are better than radiological, but deteriorated with time especially in hips with residual dysplasia and AVN due to development of early, secondary degenerative changes.

[Perthes disease with onset after nine years of age]

The aim of this study is to evaluate and compare selected clinical and radiological hip joint parameters in Perthes disease with onset before and after 9 years of age. Analysis was based on 261 patients with unilateral Perthes disease. Patient with bilateral changes ware excluded because of earlier onset before 9 years old. The average age of patients at the time of initial symptoms was 7,1 years ( 2,5 - 13 years). The follow-up ranged from 16 to 50 years (average 20, 2 years). The clinical analysis was based on evaluation of age, gender and range of passive abduction. The radiological assessment was based on Catterall and Herring classifications, lateral subluxation, premature physeal closure by Bowen classification, limb length discrepancy, shape of the lateral acetabulum rim, ATD distance and index, center-edge angle, the Mose Classification, epiphyseal index and quotient. Assessments of final results were based on The Mose Classification and the Stulberg Classification. We affirmed that, in children with the onset of disease after 9 years of age, asymmetrical premature physeal closure, major lateralization, grater contour of the head deviation (Mose) and trochanteric overgrowth were more frequent occurred than in children with Perthes disease before 9 years of age. Patients who were over the age of 9 years at the time of onset and have a hip in Catterall 3 group and 4 group together with the lateral pillar B group or C group get a poor outcome. There were not any differences in the outcomes in Catterall 1 and 2 group together with Hering A group depending on age at the time of onset. Both age at the time of onset after 9 and quantity of femoral head necrosis have the most significant impact on the outcome, leading to poor final results. In accordance with our observation we do advise caution in older children's treatment with femoral varus osteotomy.

Leg length discrepancy in Legg-Calve-Perthes disease

The purpose of this study was to determine the incidence of the leg length discrepancy (LLD) in Legg-Calve-Perthes disease and whether there is any correlation between LLD and age at onset, gender, type of treatment, and severity of disease. The study population consisted of 261 patients with unilateral involvement who had reached skeletal maturity at last follow-up. All hips were treated by containment methods (bed rest and traction in abduction, Petri cast, brace, varus osteotomy, Salter osteotomy, and shelf acetabuloplasty). The late results were classified according to the Stulberg classification. LLD was found in 33 patients and ranged from 1 to 5.2 cm (average 2.51 cm). The limb shortening was observed in Herring group B (average 2.18 cm) and C (average 2.82 cm) and was statistically significant more common in group C. The statistical analysis revealed no statistical difference between the age at onset, sex, and type of treatment with regard to LLD; nevertheless, patients in Herring group C with LLD were younger than patients in group B, and LLD was seen more often after varus osteotomy. The amount of residual shortening of the affected limb in Legg-Calve-Perthes disease at the end of skeletal growth seems to depend on the extent of involvement and the presence of a growth arrest. A varus osteotomy produces more significant shortening than other methods of treatments. The age at the onset of symptoms and sex do not influence the amount of LLD, but early onset of the disease can result in more severe limb shortening.

[Long-term results of uncemented hip arthroplasty for dysplastic coxarthrosis]

The purpose of the study was to evaluate the long-term results of uncemented total hip arthroplasty (THA) in young patients (below 50 years of age) with dysplastic coxarthrosis. In the last 20 years, 862 primary uncemented THA, were implanted in our Institution. This surgery was performed in 459 patients. From this group 220 hips in 177 patients (167 women and 10 men), who had dysplastic coxarthrosis, were included in our study. The left hip was operated in 66 and the right one in 68 patients. Bilateral surgery was performed in 43 cases. The means age at the time of hip surgery was 38.3 years (range from 18 to 49 years). The mean follow-up was 9.3 years (range from 2 years to 18.6 years). In 167 (75.8%) patients the operative treatment of DDH was performed during the early childhood (Colonna-Zahradnicek procedures, Dega, Pemberton and Salter pelvic osteotomies). Only 39 (17.7%) patients were treated in the childhood conservatively by means of overhead extension, Frejka pillow or Pavlik harness. All patients were evaluated clinically and radiological. For clinical evaluation the classification system proposed by Merle d'Aubigne and Postel with Chamley modification was used. For radiological evaluation of the steam implantation the classification system proposed by De Lee and Chamley was used and for the cup implantation the system by Gruen and Moreland. The femoral head displacement prior to THA surgery was classified according to Crowe at all. classification. Based on above mentioned criteria in 26 hips (11.8%) the final result was graded as very good, in 61 cases (27.7%) as good, in 94 hips (42.7%) as satisfactory and in the remaining 39 cases (17.8%) the final result was poor. We observed a very strong correlation between clinical and radiological results. According to Crowe and all. classification, in class I we noted 19 (61.3%) very good, 11 (35.5%) good, 1 (3.2%) satisfactory results. In class II in 5 cases (6.6%) the results was very good, 25 (32.9%) good and in 39 (51.3%) satisfactory results. In class III only in 2 cases the final result was graded as very good, and good in 23 hips (25.8%). In class IV there was no very good result, and we observed 19 (21.4%) poor results. In analyzed group in 37 (16.8%) patients the revision hip surgery was necessary because of aseptic prosthesis loosening.

CONCLUSIONS

The treatment of dysplastic coxarthrosis by means of THA is difficult. The high level of experience is necessary to perform this type of surgery. This type of THA should be performed only in selected orthopaedic centers. Starting the surgery one has to think about complications.