[Temporary Hemiepiphysiodesis in the Correction of Axial Deformities for Genua Valga: Retrospective Assessment and Comparison of Outcomes Achieved with the Use of Eight-Figure Plates and Blount Staples]

PURPOSE OF THE STUDY Axial deformities of the lower limbs of various aetiologies are relatively common orthopaedic diagnoses in paediatric population. Fixed deformity is an indication for correction in order to reduce the pain and to delay the early osteoarthrosis of adjacent joints and pain. Temporary hemiepiphysiodesis is technically a fairly simple method for modulating growth at the level of the growth plate and thus correcting the skeletal axis. MATERIAL AND METHODS 59 patients who underwent axial deformity correction of lower limbs at KDCHOT FN Brno were retrospectively analysed. Group 1 consisted of 21 patients with Blount staples implantation, Group 2 consisted of 38 patients to whom eight-figure plates had been applied. Anthropometric parameters (BMI, age, gender, intermalleolar distance (IMD)), duration of therapy, X-ray parameters (anatomical lateral distal femoral angle (aLDFA), anatomical medial proximal tibial angle (aMPTA)) and complications were recorded. The rate of correction was evaluated as the difference in X-ray parameters before and after surgery with respect to the time interval of the therapy. RESULTS The groups were comparable in terms of anthropometric parameters (BMI (p=0.800), IMD (p=0.334), gender (p=0.87)). The only statistically significant difference was found when comparing the mean age of the groups (p=0.005), with Group 1 (12.7±0.7) containing patients with a higher mean age than Group 2 (11.6±1.5). The groups were also comparable in terms of the average rate of correction over a one-month interval (aLDFA p=0.393; aMPTA p=0.831). The mean correction rate for Group 1 was: aLDFA 0.52±0.20/month, aMPTA 0.12±0.08/month; for Group 2: aLDFA 0.56±0.28/month, aMPTA 0.12±0.20/month. Individual implants differed in the type of complications, but no significant statistical difference in the incidence of complications was found between the analysed groups (p=0.526). DISCUSSION Recently, the system of eight-figure plates has been adopted as a standard method for correction of axial deformities of limbs. Although the benefits of this system are indisputable, when comparing the average monthly correction rate, no significant difference was found between the system of eight-figure plates and Blount staples in our study. Another monitored parameter was the occurrence of complications, which was evaluated fairly strictly. Even in this case, no statistically significant difference was found. We believe that the issue of using eight-figure plates is still open, as evidenced by studies, which often produce different results and conclusions. Therefore, a precise evaluation of the indication for correction, including individual characteristics of patients, is needed. CONCLUSIONS Based on the results, it can be concluded that the use of eight-figure plates in comparison with Blount staples provides neither faster correction of axial deformities nor lesser occurrence of complications. It can therefore be argued that the Blount staples still have their place in the indication of correction of axial deformities. The use of eight-figure plates represents a suitable solution for children of younger age to whom anchoring of the screws of eight-figure plates is a suitable solution in the cartilaginous epiphysis of long bones of younger children. Key words: temporary hemiepiphysiodesis, growth plate, Blount staples, eight-figure plates.

Inflammatory cloacogenic polyp in an adolescent - case report and review of the literature

Inflammatory cloacogenic polyp is a rare lesion arising in the anal transitional zone. It is usually benign, but rare cases of malignant transformation are known. It is most commonly seen in the adult population from the fourth to the sixth decade of life, but it can be found among children and adolescents as well. The most common clinical symptoms include rectal bleeding and altered bowel habits, although some patients may be asymptomatic. Treatment involves transanal endoscopic microsurgery followed by a bowel regimen with stool softeners. We present the case report of a 14-year-old boy presenting with intermittent rectal bleeding in whom a polypoid lesion was found during digital rectal examination. The patient underwent proctosigmoidoscopy during which the suspicious lesion was removed by transanal endoscopic microsurgery and the histological diagnosis of inflammatory cloacogenic polyp was established. In the postoperative period, the patient was without any further problems. In this case report, we want to raise awareness of this rare diagnosis and emphasize its place in the differential diagnosis of rectal bleeding across all age groups.

Retrospective analysis of necrotizing pneumonia in children between 2015-2019

INTRODUCTION

An increased incidence rate of cases of complicated pneumonia, reaching up to the stage of necrotizing pneumonia was observed at University Hospital Brno in the past period. The aim of this study was to perform a single-center retrospective analysis of patients with acquired inflammatory lung disease requiring surgical treatment, comprising a long-term follow-up group.

METHODS

Patients hospitalized for community-acquired pneumonia and surgically treated in the years 2015-2019 were analyzed. The rates of necessary chest drainages, decortications and lung resections in relation to the whole group and individual years were monitored. Clinical and X-ray examinations were performed one year after hospitalization and the prognosis was determined for individual types of required treatments. The age, gender and etiological agents were also monitored.

RESULTS

A total of 688 patients were included in the study with the incidence rising until 2018 and decreasing slightly in 2019. A statistically significantly higher number of community-acquired pneumonias and complications was recorded between 2017 and 2018 (p.

[Comparison of Two Minimally Invasive Osteosynthesis Techniques for Radial Head Fractures in Paediatric Patients]

PURPOSE OF THE STUDY Radial head fractures in paediatric patients account for 5-19% of all elbow injuries and approximately 1% of all fractures in children. Non-displaced fractures are treated with plaster cast fixation. If the fracture is displaced, we proceed to closed reduction, or to osteosynthesis in case of unstable fragments. If closed reduction fails, we opt for open reduction and osteosynthesis. The prospective randomised clinical study aims to compare the two methods of minimally invasive osteosynthesis using the pre-bent Kirschner wire or Prévot nail and to identify differences between them. MATERIAL AND METHODS The prospective randomised clinical study was conducted in 2015-2019. The final cohort included 32 patients who met the inclusion criteria. The patients in whom other osteosynthesis implants had been used or in whom open reduction had to be performed were excluded from the study. Also excluded were the patients with serious concomitant injuries of elbow. For patients included in the cohort, demographic data, precise evaluation of the displacement and location of the fracture as well as the duration of plaster cast fixation and osteosynthesis implants used were recorded. In the clinical part, the methods were compared based on the achievement of full range of motion in dependence on the degree of original displacement, use of osteosynthesis implant, and occurrence of early and delayed complications. Clinical and radiological outcomes were compared. In both types of minimally invasive osteosynthesis, Métaizeau surgical technique was used. RESULTS Based on the clinical trial criteria, 26 (81%) excellent, 4 (13%) good and 2 (6%) acceptable outcomes were achieved. In 3 cases the loss of rotation was up to 20°, in 1 case the loss of flexion was up to 10°. In one patient the loss of flexion was 15° and rotation up to 30°. In another patient the loss of rotation was up to 40°. The radiological assessment showed 14 (44%) excellent outcomes, 15 good (47%) and 3 (9%) acceptable outcomes. The statistical analysis of both the groups of the cohort using non-parametric tests revealed no statistically significant differences in individual demographic parameters. The comparisons of both types of osteosynthesis in dependence on the degree of displacement by non-parametric Fisher's exact test showed no statistically significant difference in the radiologic or clinical results. The only statistically significant difference was observed in the duration of metal implant placement. DISCUSSION Comparable studies report excellent or good clinical outcomes in 80-95% of cases (1,13,16). In our cohort, excellent or good clinical outcomes were achieved in 30 patients (94%). In two patients, in whom Prévot nail was used, the outcomes were acceptable. Nonetheless, this fact did not result in any statistical significance when comparing the two methods separately or in comparisons based on the degree of displacement. CONCLUSIONS The comparison of the two methods of minimally invasive osteosynthesis revealed no statistically significant difference, namely not even when both the methods were compared based on the degree of displacement. When Kirschner wire is used, the possibility to remove the metal implant in the outpatient setting is considered to be an advantage. The drawback consists in potential penetration of the sharp Kirschner wire in the radiocapitellar joint, which we did not encounter when the second technique of osteosynthesis was used. The advantage of Prévot nail includes a lower risk of pin-tract infection. Key words: minimally invasive osteosynthesis, radial head, fracture, child.

Myofibroblastic tumor of the esophagus - a case report of long-term follow-up and literature review

BACKGROUND

Inflammatory myofibroblastic tumor (IMT) is a rare mesenchymal neoplasm with intermediate malignant potential. Although most often seen in the lungs, it can occur at multiple anatomical locations, including the gastrointestinal tract. An esophageal lesion is extremely rare, however. IMTs present most commonly in children and young adults. The main therapeutic approach is surgical resection.

CASE REPORT

We report on the follow-up of a case in a 13-year-old boy with IMT in the esophagus. He underwent surgical resection in 2013 and is free of disease to date.

CONCLUSION

Surgical resection is the most preferred therapy. If the resection is complete, the risk of recurrence is low. Nevertheless, every patient should be carefully followed up after the resection.

Management of ileocolic intussusception in the Czech Republic

INTRODUCTION

Ileocolic intussusception is one of the most frequent causes of acute abdomen in infants and toddlers. The purpose of this study was to evaluate the treatment of ileocolic intussusception in the Czech Republic in 2019.

METHODS

Fourteen departments of paediatric surgery participated in this multicentre retrospective study. A SurveyMonkey Inc. questionnaire was used for anonymous data collection of patients with ileocolic intussusception.

RESULTS

In 2019, ileocolic intussusception was diagnosed in 162 patients; median age was 30 months (3 months to 9.5 years). Contrast enema was indicated in 133 patients, primary surgery in 14 patients and spontaneous reduction was found in 15 patients. All departments using contrast enema had a success rate of 89.5%; 12 departments approached the contrast enema procedure under general anaesthesia (including myorelaxation at 7 departments) and 2 departments under sedation. Contrast enema under general anaesthesia with/without myorelaxation was significantly more successful than contrast enema under sedation (108/113, 95.6% vs 11/20, 55%; p.

[Laparoscopy at the pediatric surgery department for a five-year period]

INTRODUCTION

Laparoscopy in small children was developed only after the adoption and verification of basic principles in adult patients and is mostly concentrated in specialized facilities due to the possible complications and necessity of follow-up specialized anesthesiological and post-operative care. In the 1990s, the Clinic of Paediatric Surgery, Orthopaedics and Traumatology at University Hospital Brno was one of the first in the Czech Republic to begin operating on children laparoscopically. The presented study informs about the development of these minimally invasive methods, the frequency of their use, and the spectrum of patients at the pediatric surgery facility where laparoscopy in children has been systematically developed over many years.

METHODS

Retrospective analysis of children operated upon laparoscopically at the clinic of Paediatric surgery, Orthopaedics and Traumatology of University Hospital Brno over the five-year period from 1 January 2012 to 31 December 2016. A list of surgical procedures was prepared which was then first divided into procedures specific exclusively for children and those common to adult patients surgery. Separately, an overview was prepared of operated patients under 50 kg, which was the boundary criterion defined by the authors for laparoscopy in children as opposed to adults. For all procedures, the frequency of the completed cases performed laparoscopically was precisely ascertained. The source for this data was the hospital system and surgical documentation.

RESULTS

In the evaluated period, a total of 995 laparoscopic procedures were performed, more than half of which (56.8%) were in patients under 50 kg. The majority of those were procedures performed also in adults. The group of surgical operations exclusively specific to children was characterized by low frequencies of the individual procedures.

CONCLUSION

The presented analysis confirms that laparoscopy in children is based on standard procedures common to surgery on adults. These procedures are adopted the most quickly, and they can be disseminated across a large group of surgeons who are then able to perform these routinely on child patients. Surgical procedures exclusively specific for children, on the other hand, are performed less frequently, their adoption is slower, and laparoscopic approach is less common. Therefore, laparoscopy specific to children needs to be performed on a long-term basis, systematically, and within a small group of surgeons. Otherwise, it is better not to perform it at all.Key words: laparoscopy - child frequency.

[Comparison of Two Methods of Minimally Invasive Osteosynthesis for Proximal Radius Fractures in Paediatric Patients]

PURPOSE OF THE STUDY The presented study was construed as a retrospective multicentric clinical study focused on paediatric skeletal injuries of the proximal radius. As a general rule, the Type I displaced fractures (Judet classification) are treated conservatively, with no reduction. In the case of Type II-IV displacement, the fracture necessitates reduction or is also transfixed by a Kirschner wire (K-wire) or a Prevot nail (P-nail) where subsequent fragment instability occurs. The comparison aimed to ascertain whether there is a statistically significant difference between the two methods. No difference was expected by the authors, therefore a null hypothesis was set. MATERIAL AND METHODS The patients were treated at the Clinic of Paediatric Surgery, Orthopaedics and Traumatology (CPSOT) of the Faculty of Medicine of the Masaryk University and at the Clinic of Orthopaedics and Traumatology of the Musculoskeletal System of the University Hospital in Pilsen in the period from 2006 to 2015. Two methods of closed reduction and minimally- invasive osteosynthesis were evaluated. The first method was the elastic stable intramedullary nailing (ESIN) with a P-nail, the second method was an osteosynthesis using a K-wire. In the clinical part of the study, comparisons were made based on the monitoring of the same parameters - final restriction of movement, time to full weight bearing of the extremity and incidence of serious complications. RESULTS The final group comprised a total of 31 patients, of whom 7 boys and 24 girls aged 3-16 years with the median of 9-10 years. Some restriction of movement following the treatment occurred in a total of seven patients (44%) with the K-wire and in four patients (27%) with the P-nail. When comparing the movement at 5% level of significance using the Chi-Square tests, no significant difference was found (p = 0.446). When evaluating the serious complications at 5% level of significance using the Chi-Square tests, the difference between the two methods of treatment was again insignificant (p = 0.365). When the full weight bearing was compared (median K-wire 8 weeks, median P-nail 10 weeks), a statistically significant difference was obtained at 5% level of significance using the Fischer exact test (p = 0.003). DISCUSSION In these fractures, usually the metaphysis or the physis are involved in the injury, in which case the fractures are classified according to Salter and Harris, with the most frequent occurrence of SHII epiphyseal separation and rare SHIII and SHIV epiphyseal fractures. The radial head fractures are mostly caused by valgus force. Therefore, the individuals with a higher elbow valgosity are more prone to injuries. The girls strongly prevail (77%) also in our study. In general, our results as well as the literature have proven that as the displacement increases, the necessity of closed reduction and osteosynthesis grows. The post-treatment complications in our group were observed in 35.5% of patients, namely most often in the form of limited movement. The literature refers to complications in 26.5-53% of patients. CONCLUSIONS The clinical results clearly show that when comparing the complications after the radial head fracture in children there is no statistically significant difference between the methods of osteosynthesis. This study shall serve as a starting point for the currently ongoing prospective multicentric study evaluating the modified ESIN technique using a pre-bent Kirschner wire. Key words:children, fracture, radius, proximal, osteosynthesis.

[Verification of the Necessity for the Open Reduction and Tension Band Wiring of the Displaced Olecranon Fracture in Younger Children]

PURPOSE OF THE STUDY Olecranon fractures in skeletally immature patients are rather rare and represent up to 7% of elbow skeletal injuries. Although the majority of olecranon fractures is constituted by undisplaced fractures treated conservatively with good outcomes, a few of them require surgery. The aim of the study was to compare two different approaches of surgical treatment - the open reduction with tension band wiring - cerclage (ORCe) and the closed reduction and percutaneous pinning (CRPP). MATERIAL AND METHODS 37 patients (28 boys, 9 girls) were included in the retrospective multicentric study. The patients were treated at two different institutions (the Clinic of Paediatric Surgery, Orthopaedics and Traumatology, the University Hospital Brno and the Department of Paediatric Surgery and Traumatology, the University Hospital Hradec Králové, Czech Republic). 17 patients underwent the ORCe procedure, while 20 patients were treated using the CRPP method. Different parameters were statistically compared in the groups (demographic data, data concerning the course of the therapy, outcome of the therapy in terms of movements' restrictions and complications such as osteosynthesis failure and infection). RESULTS Both the groups were comparable in terms of demographic data because no statistically significant difference was observed in terms of the age (p = 0.082), the affected site (p = 1.000) and the gender (p = 0.462). Statistically significant difference between these two groups was found in the interval between the implementation and the removal of the osteosynthetic material (p < 0.001) and in the length of cast immobilisation (p = 0.047). The number of patients with movement restriction up to 10° was statistically significantly higher in patients who underwent the CRPP procedure (p = 0.040), but no statistically significant difference was seen between these two groups in terms of movement restriction more than 10° (p = 0.609). One revision surgery was performed in the CRPP group, however with no statistical significance (p = 0.350). DISCUSSION The multicentric study included 37 children, who underwent surgical treatment of a displaced olecranon fracture. Compared to the studies dealing with this topic the number of patients included in this study is relatively high. It advocates the possibility of using the CRPP method as a good alternative to the gold-standard ORCe technique because no difference in terms of the number of revision surgeries and the clinically important movement restriction of more than 10° were seen. It also brings along advantages such as a simple surgical technique, good functional and cosmetic effects, reducing the risk of ischemic insult of growth plate and the possibility of osteosynthetic material removal at an outpatient department with no need for general anaesthesia. The risk of a higher radiation exposure of both the patient and the surgical team should be considered as a disadvantage of the closed method. CONCLUSIONS The mini-invasive CRPP appears to be a good alternative option to the ORCe method for the treatment of isolated olecranon fractures in children offering the advantages such as avoiding extensive open procedure and simple implants removal. Key words:children, olecranon, fracture, tension band wiring - cerclage, percutaneous pinning, elbow.

[Laparoscopic cholecystectomy in children and adolescents]

INTRODUCTION

In the treatment of cholelithiasis in adults, laparoscopic cholecystectomy is the method of first choice. There is plentiful literary evidence of the low complication incidence in this age group, but similar assessment is lacking in the paediatric population. In this work, the authors focus on cholelithiasis in children and the possible use of laparoscopy in the diagnostic - therapeutic scheme.

MATERIAL AND METHODS

The study group consisted of 148 patients operated on by laparoscopic cholecystectomy between 2002 and 2011 at the Department of Paediatric Surgery, Orthopaedics and Traumatology of University Hospital Brno. The first objective of the study was to evaluate the length of surgery; the second one was the occurrence of complications which were divided into intraoperative and postoperative. Intraoperative complications were subdivided into severe and moderate, postoperative complications into early and late. The last objective was to evaluate the benefit (number of complications, treatment outputs) of intraoperative cholangiography for obstructive jaundice before the surgery.

RESULTS

In the above mentioned period, 143 laparoscopic cholecystectomies and five laparoscopic cholecystectomies including splenectomy were performed. The average age of the patients was 13.9 years; the average length of laparoscopic surgery was 52 minutes. One major, serious intraoperative complication (0.7%) was recorded - injury to the ductus hepaticus communis. Moderate intraoperative complications occurred in 4.5%. Furthermore, one serious early postoperative complication (0.7%) - bleeding from the cystic artery --and one minor (0.7%) - in a patient with acute pancreatitis after endoscopic retrograde cholangiopancreatography - was recorded. Late postoperative complications occurred in 4% of the patients. Conversion of laparoscopic operation with a definitive resolution of the serious condition was performed in one patient because of the aforementioned serious intraoperative complications. Eleven patients underwent intraoperative cholangiography; extraction of stones from the bile duct was performed in six cases.

CONCLUSION

Intraoperative cholangiography in children and adolescents can be recommended as a safe and effective imaging modality for patients with preoperative evidence of biliary obstruction. Laparoscopic cholecystectomy in children and adolescents can be clearly recommended as an effective and safe surgical technique convenient for paediatric patients.

[Failure of the primary treatment of displaced supracondylar humerus fractures in children]

PURPOSE OF THE STUDY

The aim of the study was to retrospectively evaluate the treatment outcomes of displaced supracondylar humerus fractures, including potential complications, in children treated at the Department of Paediatric General Surgery, Orthopaedics and Trauma Surgery of the Faculty of Medicine in Brno between 2000 and 2011.

MATERIAL AND METHODS

The study comprised 564 children, 321 (57%) boys and 243 (43%) girls, who were allocated to two groups according to the method of primary treatment. The average age at the time of injury was 6.8 years (range, 1 to 16). In group 1, all 499 patients were indicated for primary closed reduction and percutaneous osteosynthesis with crossed K-wires under general anaesthesia. In group 2, all 65 patients underwent closed reduction under general anaesthesia and immobilisation in a high plaster cast. The per cent failure of primary treatment requiring either repeat surgery or a change in treatment strategy was evaluated. The duration of follow-up ranged from 14 to 150 months.

RESULTS

Open fractures were recorded in eight (1.4%) patients. Twenty-five (4.4%) children had further injury to the ipsilateral limb. Three (0.5%) patients underwent open reduction because it was not possible to achieve adequate reduction by the closed method. In group 1, percutaneous osteosynthesis was performed using two crossed K-wires in 484, three K-wires in 13 and four K-wires in two patients. Re-displacement of fracture fragments requiring repeat reduction and percutaneous osteosynthesis occurred in 10 (2%) patients. One patient had two re-operations. In group 2, the primary treatment failed in 13 (20%) children who needed repeat reduction and conversion to percutaneous osteosynthesis. The difference in the occurrence of failure between the two groups was significant (p<0.001). Nerve injury was recorded in 92 patients (16.3% of all children and 18% of those treated with percutaneous osteosynthesis). Neurosurgical intervention was necessary for injury to the ulnar nerve in five patients and to the radial nerve in one patient. Three children had vascular injury requiring vascular surgery. Two patients underwent corrective osteotomy of the distal humerus for cubitus varus deformity. Volkmann's contracture as a complication was not recorded.

DISCUSSION

Minimally displaced fractures can be treated by closed reduction and plaster cast immobilisation but this method fails in up to 20% of cases. A poor result is related to the extent of dorsal displacement before reduction; on the other hand, degrees of flexion in a plaster cast have no effect. The most frequent technical errors resulting in re-displacement after primary osteosynthesis include incomplete reduction and primary fixation in displacement, or failure of both K-wires to pass through the opposite cortex or to fix both fragments firmly. A K-wire diameter smaller than 1.6 mm may also be a reason for failure. The main problem of the method of two crossed K-wires is a frequent injury to the ulnar nerve.

CONCLUSIONS

Supracondylar humerus fracture is, regardless of advancements in therapy, an injury with an uncertain treatment outcome and a high percentage of complications. Since primary osteosynthesis failed in 20% of the patients treated by simple reduction under general anaesthesia and plaster cast immobilisation, for the patients requiring fracture reduction under general anaesthesia, the authors recommend one-stage primary treatment including K-wire transfixation. Re-displacement after primary osteosynthesis was always due to a technical error during the surgical procedure and can, therefore, be avoided by a precise operative technique.

[Treatment of a bone bridge by transplantation of mesenchymal stem cells and chondrocytes in a composite scaffold in pigs: experimental study]

PURPOSE OF THE STUDY

The presented experimental study describes the results of using a combination of allogeneic mesenchymal cells (MSCs) with chondrocytes (CHCs) and a novel scaffold based on type I collagen and chitosan fibres. This biocomposite was transplanted into a defect produced by excision of a bone bridge to induce new cartilaginous tissue formation. The left femur was treated by transplantation into a defect of distal epiphysis; the right femur with implantation of the scaffold only served as control. A better therapeutic result was therefore expected in the left femur - the reduction of growth and angular deformities, and the histological finding of a tissue similar to the cartilage excised from the left femur..

MATERIAL AND METHODS

The miniature pig was selected as an experimental model and 10 pigs were used. Mesenchymal stem cells derived from femoral bone marrow and chondrocytes derived from a sample harvested from the non-weight-bearing articular surface of the distal end of the femur were cultured in medium. The novel scaffold was based on collagen containing chitosan nanofibres. To make manipulation during implantation easier, the cilindrical scaffolds after lyophilisation were again placed in 96-well plates for seeding. The scaffolds before implantation were seeded with 2x106 allogeneic MSCs and 1x106 allogeneic CHCs. The outcomes of treatment were assessed by measuring the length of bone and the degree of distal femoral valgus deformity, and by the histological findings obtained (properties and maturity of the newly-formed tissue, detection of type II collagen, PAS reaction).

RESULTS

The right and left legs were examined for longitudinal bone growth and the valgus angle and compared. The treated left leg showed a higher average value for longitudinal growth than the untreated right leg (p = 0.004). The average degree of angular deformity was lower in the left leg than in the right leg (p = 0.008). The microscopic findings showed that a tissue similar to hyaline cartilage was more frequently present in the femoral bone defect of the left leg, as compared with that of the right leg. Type II collagen was detected more frequently and at higher amounts on the left than the right side (p = 0.033). The PAS reaction was positive in all left limbs, with a high degree of positivity in 80 % of them, while this was not achieved in any of the right limbs (p = 0.001).

DISCUSSION

The use of stem cells in the indication reported here has only been the matter of time since the information on encouraging results in neurology and cardiology was published. First studies with positive results have soon been reported. The initial hydrogel scaffolds were based on tissue adhesives. However, they were not stable enough and were difficult to handle during surgery. In further studies, therefore, the use was made of a three-dimensional scaffold with a self-supporting structure of collagen fibres. This structure also facilitated its hydrodynamic seeding with MSCs and CHCs, which is an effective and sparing procedure for the transplanted cells. Studies concerned with MSCs and/or CHCs transplantation for re - pair of a physeal defect following bone bridge excision, i.e. for bone bridge treatment, in a broader experimental design, however, are still missing.

CONCLUSION

Transplantation of a composite scaffold seeded with mesenchymal stem cells and chondrocytes into a physeal defect following bone bridge excision prevented growth disturbance and angular deformity development in the distal femoral epi - physis. In comparison with the control group, it resulted in a more frequent production of a tissue similar to hyaline cartilage, with a cell formation reminiscent of a typical columnar arrangement of the growth plate. Key words: mesenchymal stem cells, growth plate, bone bridge, scaffold.

[Magnetic resonance imaging for detection of rotational deformities in children with femoral shaft fractures treated by the ESIN method]

PURPOSE OF THE STUDY

The aim of the study was to evaluate the results of elastic stable intramedullary nailing (ESIN).used in the treatment of children with femoral shaft fractures, with a focus on post-traumatic rotational deformity assessed by magnetic resonance imaging (MRI). An alternative hypothesis was established assuming a significantly high incidence of this post-traumatic complication. Also, the advantages of MRI for the diagnosis of rotational deformity were assessed in comparison with ultra- sonography and physical examination.

MATERIAL AND METHODS

A total of 26 patients, 18 boys and 8 girls, between 6 and 14 years of age (average, 12.5), were included. The range of knee and hip motion was evaluated and the length of both lower extremities was measured. The radiograph of each patient contained a contrast, marked scale to facilitate an exact determination of femur length. In these 26 patients, MRI examination was included as a novel approach in this system of evaluation. On the basis of transversal sections through the proximal and the distal femoral epiphysis, the angle formed by the femoral neck axis and a dorsally led line tangential to both femoral condyles was measured The difference in this anteversion angle between the injured and the healthy extremity was taken as a value of post-traumatic rotational deformity. The difference equal to or larger than 10 degrees was regarded as a pathological finding. The results were evaluated using the Wilcoxon signed-rank test.

RESULTS

The average value of the difference was 5.8 degrees. A pathological persistent post-traumatic rotational deformity of 10 and more degrees was found in three patients (15 %). The results of statistical analysis did not confirm our alternative hypothesis that use of the ESIN method for femoral shaft fractures might be associated with a significantly increased probability of rotational deformity development (p=0.450).

DISCUSSION

As described in the literature, post-traumatic rotational deformity following a femoral shaft fracture can be up to 20 degrees in 10 % to 20 % of the patients.The results of this study are notably better. Routinely, measurement of the angle of anteversion is based on physical examination of hip range of motion. This finding was completed by X-ray examination in semi-axial projection, as described by Schulz whose error of measurement was 10 or more degrees. The angle of femoral anteversion and the difference between the extremity after femoral shaft fracture and the contralateral one can also be determined by ultrasonography, but the error of measurement can be about 5 degrees. An exact measurement of the angle of anteversion can be achieved with computed tomography, but this examination means radiation exposure for the patient. The method which combines exact measurement and no risk of exposure for the child is magnetic resonance imaging.

CONCLUSIONS

The method of measuring rotational deformity after femoral shaft fracture using MRI gave exact results and posed no risk for the child, and is therefore presented as a novel and important part of post-traumatic follow-up of children with this injury. In the ESIN- treated patients, this diagnostic method did not reveal any statistically significant occurrence of serious post-traumatic rotational deformity during the healing of a femoral shaft fracture.

[The Czech Republic Register of Injuries (URCR)--experience with the database management in the Brno Faculty Hospital]

INTRODUCTION

Injuries are the leading cause of mortality in age group of people junior to 45 years. Central data collection is important to survey basic injury causation and trauma care quality. The Czech Trauma Registry was started in 2004. The aim of study was to discover valid statistic analysis from current data collection and its clinical practice contribution.

PATIENTS AND METHODS

Doctors working in the Centre of trauma care (University hospital Brno) collect and enter data to the Trauma Registry. Data collection is practiced continuously through the hospitalization. Abbreviated Injury Scale and Injury Severity Score are used for injury severity determining. In the University hospital Brno 161 patients (159 patients met validity criterion) were entered in trauma registry.

RESULTS

159 patients were evaluated, Injury Severity Score was 16-75, demographically from 6 regions. Traffic accident was the most frequent cause of injury. Average inpatient age was 43 years. Mortality in our patient file was 10.7%. Investing sum for 1 patient who was returned to Trauma Registry was 209 019 Czech crowns.

DISCUSSION

Authors confront their results with the German Trauma Registry, results in basic parameters are analogous. Data collection should be proceeding correctly. Czech Trauma Registry should be the instrument of quality management and is waiting for its statutory provision.

CONCLUSION

Trauma registry is going to afford plenty information for pre-hospital and hospital care improvement.

[Synthetic biocompatible degradable material for juvenile bone cyst treatment]

PURPOSE OF THE STUDY

Owing to advances in operative techniques and biotechnology, bone replacement biocompatible materials have recently come into focus for orthopaedic and trauma surgeons. Bone lytic lesions, such as tumorous bone defects, diseases simulating cancer, chronic inflammatory lesions or skeletal injuries, often require stabilisation of the skeleton and treatment of the bone affected. Juvenile bone cysts are benign lytic lesions posing a threat to bone compactness in childhood. They are benign, fluid containing bone cavities, lined with a membrane consisting of thin vascularised connective tissue with scattered osteoclast-like cells. These cysts are usually diagnosed between; five and twenty years of age outside this age range their occurrence is rare.

MATERIAL

The group comprised the patients treated for juvenile bone cysts at the Department of Paediatric Surgery, Orthopaedics and Traumatology between 2001 and 2007. In the 2001-2003 period, 24 patients were treated with Depo-Medrol. Between January 2005 and December 2007, 31 patients with the same diagnosis were treated by minimally invasive application of chronOs Inject.

METHODS

The aim of the study was to compare these two methods of juvenile cyst therapy, i.e., the most widely used method of repetitive Depo-Medrol applications against the novel method based on filling the cyst with chronOs Inject, a synthetic biocompatible resorbable material. An alternative hypothesis assumed that the new method would result in fewer necessary operations in patients with juvenile cyst and better treatment outcomes, as evaluated by Neer's criteria for bone cyst therapy.

RESULTS

A total of 20 surgical interventions were performed in 18 patients treated by chronOs Inject and 100% cyst healing without necessity of additional surgery was achieved. Of the 24 patients treated with Depo-Medrol, 12 patients (50%) showed cyst healing wit no further surgery required. A total of 69 applications were needed.

DISCUSSION

An impetus to introduce the novel method of juvenile cyst treatment stemmed from the unsatisfactory results of the previous treatment with repetitive Depo-Medrol applications requiring additional open surgery and spongioplasty to fill the cyst. For filling cysts and other benign bone defects jeopardizing bone stability, such as deep metaphyseal fibrous defect, non-ossifying fibroma, enchondroma or fibrous dysplastic lesion, synthetic tricalcium phosphate in the form of chronOs granules was used, but without the possibility of minimally invasive percutaneous application. As soon s the resorbable chronOs Inject became available, the minimally invasive method of filling cysts with this material was adopted.

CONCLUSIONS

The results showed that, in the patients treated by the chronOs Inject method, the outcomes achieved were significantly better than those in the patients treated with Depo-Medrol. The difference was in the number of operations needed, which were significantly fewer in the chronOs Inject method, as well as in the overall treatment outcome, with significantly more frequent excellent results in the chronOs Inject method.

Quality of newly formed cartilaginous tissue in defects of articular surface after transplantation of mesenchymal stem cells in a composite scaffold based on collagen I with chitosan micro- and nanofibres

The aim of this study was to evaluate macroscopically, histologically and immunohistochemically the quality of newly formed tissue in iatrogenic defects of articular cartilage of the femur condyle in miniature pigs treated with the clinically used method of microfractures in comparison with the transplantation of a combination of a composite scaffold with allogeneic mesenchymal stem cells (MSCs) or the composite scaffold alone. The newly formed cartilaginous tissue filling the defects of articular cartilage after transplantation of the scaffold with MSCs (Group A) had in 60 % of cases a macroscopically smooth surface. In all lesions after the transplantation of the scaffold alone (Group B) or after the method of microfractures (Group C), erosions/fissures or osteophytes were found on the surface. The results of histological and immunohistochemical examination using the modified scoring system according to O'Driscoll were as follows: 14.7+/-3.82 points after transplantations of the scaffold with MSCs (Group A); 5.3+/-2.88 points after transplantations of the scaffold alone (Group B); and 5.2+/-0.64 points after treatment with microfractures (Group C). The O'Driscoll score in animals of Group A was significantly higher than in animals of Group B or Group C (p<0.0005 both). No significant difference was found in the O'Driscoll score between Groups B and C. The treatment of iatrogenic lesions of the articular cartilage surface on the condyles of femur in miniature pigs using transplantation of MSCs in the composite scaffold led to the filling of defects by a tissue of the appearance of hyaline cartilage. Lesions treated by implantation of the scaffold alone or by the method of microfractures were filled with fibrous cartilage with worse macroscopic, histological and immunohistochemical indicators.

Use of allogenic stem cells for the prevention of bone bridge formation in miniature pigs

This study appears from an experiment previously carried out in New Zealand white rabbits. Allogenic mesenchymal stem cells (MSCs) were transplanted into an iatrogenically-created defect in the lateral section of the distal physis of the left femur in 10 miniature pigs. The right femur with the same defect served as a control. To transfer MSCs, a freshly prepared porous scaffold was used, based on collagen and chitosan, constituting a compact tube into which MSCs were implanted. The pigs were euthanized four months after the transplantation. On average, the left femur with transplanted MSCs grew more in length (0.56+/-0.14 cm) compared with right femurs with physeal defect without transplanted MSCs (0.14+/-0.3 cm). The average angular (valgus) deformity of the left femur had an angle point of 0.78 degrees , following measurement and X-ray examination, whereas in the right femur without transplantation it was 3.7 degrees. The initial results indicate that preventive transplantation of MSCs into a physeal defect may prevent valgus deformity formation and probably also reduce disorders of the longitudinal bone growth. This part of our experiment is significant in the effort to advance MSCs application in human medicine by using pig as a model, which is the next step after experimenting on rabbits.

[Proximal tibial growth plate trauma in childhood and options for its management]

AIM

Traumas to the proximal tibial epiphyseal growth plate account for less than 2% of all physeal injuries, therefore, it may cause diagnostic or therapeutic difficulties. The authors studied a group of patients treated in the Clinic of pediatric surgery, orthopedics and traumatology of the Brno Faculty Hospital (FN Brno) during past 11 years, in order to assess its treatment outcomes and complication rates.

METHODOLOGY

Based on the Salter-Harris (SH) classification, the studied patients with proximal tibia epiphyseolyses were assigned to groups using the following criteria: type of epiphyseolysis and treatment approach, and the authors identified associated complications in individual patients. The follow up assessment of the treatment course and results were performed for each of the groups. The studied parametres included: fixation duration, duration of subsequent rehabilitation care, knee joint mobility and complication rates (angulation, limb shortening, skeletal porosis and eventual reoperation).

RESULTS

The studied complications were recorded in 2 subjects in the undislocated epiphyseolysis group treated conservatively, and a single complication was recorded in the traumatic fragment dislocation group. Out of the total of 19 patients, complications were recorded in 3 subjects (16%) and the remaining 16 patients (84%) had no complications or posttraumatic effects recorded.

CONCLUSION

The study results correspond to the literature data. Therefore, minimum complication rates and high treatment success rates using standard treatment procedures were demonstrated.

[The use of biodegradable materials in the management of bone cysts in children]

AIM

The commonest benign lytic bone disorders, which compromise the bone robustness include juvenile bone cysts. Provided the cysts do not undergo spontaneous healing, which is commonly facilitated by pathological fracturing or introduction of osteosynthetic material into the cyst, the cystic cavity must be filled in. Numbers of potential defect management procedures, including use of corticoids, autografts, allografts or recently introduced methods of application of synthetic anorganic biomaterials, have been used. The aim of this study is to assess a possibility of the biomaterials use in the management of benign cysts in children.

MATERIAL AND METHODOLOGY

The study included 20 juvenile bone cysts patients aged 10-17, treated with tricalcium phosphate during 2004-2007 in the KDCHOT. The authors assessed rates of the procedures, therefore a number of required hospitalizations and total anesthesias, intraoperative complications, postoperative complications, durations of hospitalization and treatment outcomes, based on Neer criteria, including the cyst's time-to-heal interval. In addition, evaluation of the results was related to the cyst's location.

RESULTS

The treatment results, assessed according to the Neer criteria, show that 90% of the cysts healed and did not require further surgical intervention. Poor outcome was recorded in 2 subjects, who required further surgery due to skeletal instability. Intraoperative and perioperative complications were insignificant, the average duration of hospitalization was 4 days and the average time-to-heal period following primary or secondary percutanneous cyst filling was 15 months (ranging from 13 to 20 months).

CONCLUSION

The studied method of the tricalcium phosphate application resulted in reduced rates of surgical procedures required for the defect healing. Furthermore, it is not associated with serious perioperative or intraoperative complications and the hospitalization duration may be very short.

[New options for management of posttraumatic articular cartilage defects]

Articular cartilage trauma, in particular due to its poor healing potential remains a complicated problem in both the adult and paediatric traumatology and orthopedics. In older patients, total endoprosthesis of the joint is a method of choice, however, in younger patients, the situation remains more complicated. In case of osteochondral lesions (arthrosis, chondral fractures. osteochoodrosis dissecns) the ideal management should result in complete recovery of the hyaline cartilage on the traumatized joint surface. Contemporary medicine uses some therapeutic procedures resulting in partial recovery of the articular cartilage structure at the lesion site and several techniques of excisionining the articular surface's injured part and of transplantations of biological grafts. Regarding the above first approach, abrasive methods (micro fractures, small drill holes), which are expected to result in recovery of the articular cartilage through progenitor cells that migrate from the bone marrow to the defect site following subchondral fracturing. In case the injury is managed early, the osteochondral fragment may be fixed and the articular congruence be recovered. Mosaicoplasty using osteochondral auto grafts or other autologous grafts, or more recently using transplantations of autologous chond rocytes, which seem to have a major potential in the hyaline cartilage healing process. However, methodology of the transplant retention at the defect site remains a problem. Furthermore, the use of mesenchymal stem cells, so far in the experimental phase, appears prospective. Pivotal articular cartilage treatment research activities have progressed to a level of searching for a suitable scaffold of perfect qualities. This is the task for cooperation with bioengineering. requiring provision of the most exact differentiation protocol for hyline cartilage producing mesenchymal stem cells (MSCs).

Use of 3D geometry modeling of osteochondrosis-like iatrogenic lesions as a template for press-and-fit scaffold seeded with mesenchymal stem cells

Computed tomography (CT) is an effective diagnostic modality for three-dimensional imaging of bone structures, including the geometry of their defects. The aim of the study was to create and optimize 3D geometrical and real plastic models of the distal femoral component of the knee with joint surface defects. Input data included CT images of stifle joints in twenty miniature pigs with iatrogenic osteochondrosis-like lesions in medial femoral condyle of the left knee. The animals were examined eight and sixteen weeks after surgery. Philips MX 8000 MX and View workstation were used for scanning parallel plane cross section slices and Cartesian discrete volume creation. On the average, 100 slices were performed in each stifle joint. Slice matrices size was 512 x 512 with slice thickness of 1 mm. Pixel (voxel) size in the slice plane was 0.5 mm (with average accuracy of +/-0.5 mm and typical volume size 512 x 512 x 100 voxels). Three-dimensional processing of CT data and 3D geometrical modelling, using interactive computer graphic system MediTools formerly developed here, consisted of tissue segmentation (raster based method combination and 5 % of manual correction), vectorization by the marching-cubes method, smoothing and decimation. Stifle- joint CT images of three individuals of different body size (small, medium and large) were selected to make the real plastic models of their distal femurs from plaster composite using rapid prototyping technology of Zcorporation. Accuracy of the modeling was +/- 0.5 mm. The real plastic models of distal femurs can be used as a template for developing custom made press and fit scaffold implants seeded with mesenchymal stem cells that might be subsequently implanted into iatrogenic joint surface defects for articular cartilage-repair enhancement.

Biochemical and biophysical aspects of collagen nanostructure in the extracellular matrix

ECM is composed of different collagenous and non-collagenous proteins. Collagen nanofibers play a dominant role in maintaining the biological and structural integrity of various tissues and organs, including bone, skin, tendon, blood vessels, and cartilage. Artificial collagen nanofibers are increasingly significant in numerous tissue engineering applications and seem to be ideal scaffolds for cell growth and proliferation. The modern tissue engineering task is to develop three-dimensional scaffolds of appropriate biological and biomechanical properties, at the same time mimicking the natural extracellular matrix and promoting tissue regeneration. Furthermore, it should be biodegradable, bioresorbable and non-inflammatory, should provide sufficient nutrient supply and have appropriate viscoelasticity and strength. Attributed to collagen features mentioned above, collagen fibers represent an obvious appropriate material for tissue engineering scaffolds. The aim of this minireview is, besides encapsulation of the basic biochemical and biophysical properties of collagen, to summarize the most promising modern methods and technologies for production of collagen nanofibers and scaffolds for artificial tissue development.

Mechanical response of porous scaffolds for cartilage engineering

Mechanical properties of scaffolds seeded with mesenchymal stem cells used for cartilage repair seem to be one of the critical factors in possible joint resurfacing. In this paper, the effect of adding hyaluronic acid, hydroxyapatite nanoparticles or chitosan nanofibers into the cross-linked collagen I on the mechanical response of the lyophilized porous scaffold has been investigated in the dry state at 37 oC under tensile loading. Statistical significance of the results was evaluated using ANOVA analysis. The results showed that the addition of hyaluronic acid significantly (p<<0.05) reduced the tensile elastic modulus and enhanced the strength and deformation to failure of the modified cross-linked collagen I under the used test conditions. On the other hand, addition of hydroxyapatite nanoparticles and chitosan nanofibers, respectively, increased the elastic modulus of the modified collagen ten-fold and four-fold, respectively. Hydroxyapatite caused significant reduction in the ultimate deformation at break while chitosan nanofibers enhanced the ultimate deformation under tensile loading substantially (p<<0.05). The ultimate tensile deformation was significantly (p<<0.05) increased by addition of the chitosan nanofibers. The enhanced elastic modulus of the scaffold was translated into enhanced resistance of the porous scaffolds against mechanical load compared to scaffolds based on cross-linked neat collagen or collagen with hyaluronic acid with similar porosity. It can be concluded that enhancing the rigidity of the compact scaffold material by adding rigid chitosan nanofibers can improve the resistance of the porous scaffolds against compressive loading, which can provide more structural protection to the seeded mesenchymal stem cells when the construct is implanted into a lesion. Moreover, scaffolds with chitosan nanofibers seemed to enhance cell growth compared to the neat collagen I when tested in vitro as well as the scaffold stability, extending its resorption to more than 10 weeks.

[Remodelling ability of the distal radius in fracture healing in childhood]

INTRODUCTION

Distal forearm fractures are among the commonest skeletal injuries in childhood. The aim of this work is to analyze factors determining remodelling abilities of the distal radial metaphysis in dislocated fractures, considering a requirement for eventual non-operative repositioning.

MATERIAL AND METHODOLOGY

The primary patient group included a group of patients treated in 2004 for distal radial metaphysis fractures, left to heal in a dislocated position. The angle of dislocation ranged from 8 to 30 degrees. All patients underwent a follow up x-ray examination 2, or more, years later and a clinical examination of the wrist joint range of motion. The extent of remodellation was studied, considering duration of the healing process, patient's age and the fracture line distance from the growth plate.

RESULTS

The results show that in the majority of the patients included in the study, complete remodellation of the radius nearly to its anatomical position (86%) occurred. The results were significantly better in the patient group aged 0-12 years. Furthermore, significantly less residual dislocations were recorded within 20 mm from the growth plate. Restriction of the wrist joint range of motion resulting from residual dislocation was not recorded.

CONCLUSION

Based on the results, conservative treatment of the condition, especially in cases of multiple injuries or of a polytrauma, is recommended. Also, in cases of deterioration of the positioning or of redislocation after repositioning, repositioning need not be repeated in patients below 12 year of age.

[Data collection and the Czech Republic Trauma Registry]

INTRODUCTION

A trauma registry is an integral part of any thorough traumatological care conception. The essential task of such a data collection is to provide complex information on conditions, treatment, outcomes and trauma treatment costs, considering a region or other registered part of, usually, a state entity.

MATERIAL, METHODOLOGY

Registration of individual trauma characteristics throughout the state territory is a prerequisite for creating a data set, providing information for making valid conclusions applicable for all ranges of human activity. The trauma registry outputs are essential for traffic institutions, police, commercial inspection, commercial and health insurance companies, hospitals, etc. With respect to traffic problematics, the trauma registry plays a significant role in pointing out the most risk places in the region, in assessing the traffic type and use of protective tools. Furthermore, it facilitates exact aiming of preventive and corrective measures.

CURRENT CONDITION

Current legislation does not require reporting data to the trauma database, insufficient data are provided by UZIS only. Our Clinic of Paediatric Surgery, Orthopaedics and Traumatology iniciated a model version of the Czech Republic National Trauma Registry. Our activities were approved by and supported by the Society of Traumatologic Surgery. It is a question of time, when sufficient pressure is exerted and the trauma registry becomes an integral part of the traumatological care in the Czech Republic.

[Results of the elective laparoscopic appendectomy in unexplained pains in the right hypogastrium]

AIM

The aim of this study is to assess results of surgical therapy in female patients with clinical diagnoses of unexplained pains in the right hypogastrium.

STUDY GROUP

The study was conducted with a group of female patients, who were indicated for elective laparoscopic appendectomy. All girls underwent complete laboratory and clinical examinations prior to the procedure, and, later, histological findings and peroperative findings were added. The patient group was then re-examined retrospectively. All procedures were conducted at the Clinic of Paediatric Surgery, Orthopaedics and Traumatology in Brno.

METHODOLOGY

A follow-up examination of clinical symptoms was the primary method in the study. After 3 years of the procedure, the girls were asked to fill in a questionnaire, including 5 questions with pre-defined answers. Complete records of 67 female patients were obtained during the period 1997-2000.

RESULTS AND CONCLUSION

Over 80% of the enquired female patients experienced no further symptoms. The study confirmed positive effects of elective appendectomies in unexplained pains in the right hypogastrium.

[Massive spongioplasty and external fixation in the posttraumatic pseudoarthrosis management--a case review]

The authors of this case review present three cases of posttraumatic pseudoarthroses as complications of open fractures of the forearm and the course of their treatment. External fixation with the Ilizar external fixation apparatus and bridging spongioplasty was applied in all patients. In the first presented case, the external fixation and spongioplasty was required after resection of the atrophic posttraumatic pseudoarthrosis. In the remaining two cases, furthermore, transposition of the distal fragment of the radius using distraction in order to correct its position against the distal part of the ulna, was required. The pseudoarthroses healed in all three subjects. The case review highlights the key significance of the external fixation method and the massive spongioplasty.