Additional Akin Proximal Phalanx Procedure Has a Limited Effect on the Outcome of Scarf Osteotomy for Hallux Valgus Surgery

BACKGROUND

One of the most common supplementary techniques for hallux valgus (HV) surgery is proximal phalanx correction proposed by Akin. This study aims to determine the influence of the Akin procedure on the outcome of scarf osteotomy for HV correction.

METHODS

This prospective randomized study on 145 patients diagnosed with moderate to severe HV who underwent a scarf corrective osteotomy was carried out between 2011 and 2016. Patients were divided into two groups based on the additional Akin correction of the proximal phalanx. Postoperative follow-up was 2 years. The patients underwent an examination performed by two orthopedic surgeons twice-at the primary visit (qualification for the surgery and the study) and at the final follow-up. In between, the patients remained under the care of one of the physicians. Data collected included biometric records, radiographs (eg, hallux valgus angle [HVA]), intermetatarsal angle, American Orthopaedic Foot & Ankle Society Hallux Metatarsophalangeal Index, and visual analog scale score for pain and satisfaction.

RESULTS

There was a significant difference in comparison of the HVA between the groups at the final follow-up. Other collected parameters were similar (American Orthopaedic Foot & Ankle Society Hallux Metatarsophalangeal Index, level of pain, and satisfaction). The complication rate was also similar between the groups. We observed comparable rates of reconsent to the treatment and foot appearance satisfaction in both groups.

CONCLUSIONS

Regardless of additional Akin correction, the outcome was comparable. Despite a significant difference in HVA score, pain and satisfaction level were similar. Based on our results, the Akin procedure may not provide substantial benefit as an adjunct to the scarf procedure.

Smoking is associated with prolonged time of the return to daily and sport activities and decreased knee function after meniscus repair with outside-in technique: Retrospective cohort study

BACKGROUND

Arthroscopic repair of post-traumatic meniscal lesion is one of the most common procedures in the orthopedics. Although algorithm of the treatment of meniscal lesion, this procedure is rarely discussed in combination with smoking as a risk factor for the meniscal healing.

PURPOSE

The aim of this study was to assess the knee function, and the amount of time needed to return to daily and sport activities after the non-bucket-handle meniscal outside-in repair depending on Tobacco use.

METHODS

Retrospective chart review identified 99 patients after isolated outside-in meniscal repair within a series of 292 consecutive patients who underwent meniscus repair during a 3 years period. Ninety-two patients were available for follow-up and were divided into smokers and non-smokers group. Demographic data were collected from their medical records which included: age and body mass index, gender, side of index knee, duration of symptoms prior to surgery, meniscal involvement. At the time of the minimum 2 years follow-up examination: KOOS, time of the return to daily activities, time of the return to sport activities, and Tegner scale were collected.

RESULTS

The smoking and non-smoking groups were similar in age, sex, BMI, side, meniscus involved, Tegner scale, and duration of symptoms. Smokers population was 3.5 years older on average. The knee function was significantly better in non-smokers group with average KOOS score 80.2 vs 67.4 in smokers group. In smokers population delayed time of return to daily activities (5.4 vs 4.2 months) and prolonged time of the return to sport activities (9.4 vs 7.6 months) were observed.

CONCLUSIONS

Smoking is associated with significantly prolonged time of the return to daily and sport activities and decreased knee function after meniscus repair with outside-in technique. Level of evidence: III.

Electrostimulation has a positive effect on the knee function after knee arthroscopic surgery: A randomized trial

BACKGROUND

There is a wide range of rehabilitation protocols after knee arthroscopic procedures, mainly based on specialist exercises. They comprise of specific stages and key moments but should also be individualized and adjusted to the patient's needs.

OBJECTIVE

The aim of the study was to evaluate the BodyFlow device impact on physical and psychological functioning of the subjects after knee arthroscopy.

METHODS

Ninety three patients were randomly divided into the study and control group. Each study group subject performed mild electrostimulation using the BodyFlow device for three weeks, five times a day for 20 minutes along with the standard rehabilitation protocol. Control group subjects were treated according to the standard rehabilitation protocol after knee arthroscopy. Healthy and operated lower limb size, a range of the knee joint motion, and the flexor and extensor strength were measured 3, 6, and 9 weeks after arthroscopy. At each measurement, the SF-36 and KOOS surveys were collected.

RESULTS

On study day 21, a positive, statistically significant, difference in the knee joint size, range of flection and extension, flexor and extensor strength as well as all KOOS survey subscales and physical functioning categories included in the SF-36 survey was observed. On study day 63, positive effects persisted and significant differences in other categories included in the SF-36 survey were observed.

CONCLUSION

Application of mild electrostimulation using the BodyFlow device has a positive impact on the swelling in the knee joint region, range of motion, extensor and flexor strength as well as physical, psychological, and social functioning.

Snapping Plantaris Tendon as Cause of Pain in an Amateur Runner: A Case Report

A rare case of painful snapping around the Achilles tendon without reported injury in a healthy 30-year-old male amateur runner is reported. The plantaris tendon was firmly attached to the Achilles tendon by adhesions, and its movement was restricted and impaired. All adhesions were removed and the plantaris tendon was liberated during surgery, with an excellent outcome. This case showed that previously described removal of the snapping tendon is not necessary because liberation of the plantaris tendon restored function of both the plantaris and the Achilles tendons.

Morphology of Spring Ligament Fibrocartilage Complex Lesions

BACKGROUND

The spring ligament fibrocartilage complex (SLFC) is an important static foot stabilizer comprising the superomedial ligament (SML) and the inferior ligament, with anatomical variations (third ligament). The aim of this study was to describe the patterns of the lesions found during SLFC surgery, to allow direct comparison between the results with various surgical techniques.

METHODS

Fourteen consecutive patients with SLFC lesions were analyzed during surgical treatment. The mean patient age was 37.3 years, and the mean time from injury was 6.9 months. Intraoperative assessments and anatomical descriptions of the lesions were collected.

RESULTS

Three types of lesion were found. In 13 of 14 cases, only the superomedial ligament was involved: five superomedial ligament distentions and eight superomedial ligament ruptures. In one case, total SLFC (superomedial and inferior ligaments) rupture was observed.

CONCLUSIONS

The first classification of SLFC lesions is presented, which is simple, consistent, and based on anatomical description.

Management of an iatrogenic injury to the tibial nerve in a 24-year-old hurdle runner

According to previously published papers, neurovascular injuries seem to be the most unfortunate complications after surgical procedures. In this report, we present our therapeutic approach to iatrogenic injury of the posterior tibial nerve that occurred during ankle arthroscopy in a 24-year-old patient. The outcome of the therapy was a full sensory return and partial motor return (S4 and M3 according to the Medical Research Council Grading System for Nerve Recovery). Our patient was able to resume her typical training. In comparison with available reports, our therapeutic approach enabled earlier functional recovery after nerve injury. While sensory return is beneficial, motor improvement is also important. However, we are conscious of the poor functional outcomes reported by other researchers.

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.

Thickening of the knee joint cartilage in elite weightlifters as a potential adaptation mechanism

Thickening and increase of area of cartilage have been proposed as two alternative mechanisms of cartilage functional adaptation. The latter has been reported in endurance sportsmen. In weightlifters, extreme strain applied to the articular surfaces can result in other forms of adaptation. The aim of this research is to determine whether cartilage thickness is greater in elite weightlifters than in physically inactive men. Weightlifters (13) and 20 controls [age and body mass index (BMI) matched] underwent knee Magnetic Resonance Imaging (MRI). A single sagittal slice of the knee was taken and cartilage thickness was measured in five and six regions of the medial and lateral femoral condyles, respectively. The analyzed segments represented weight-bearing and nonweight-bearing regions. The tibia cartilage in the weight-bearing area was also measured. The time of training onset and its duration in the weightlifter group were recorded. The cartilage was found to be significantly thicker in weightlifters in most of the analyzed regions. The distribution of cartilage thickness on the medial and lateral femoral condyles was similar in both groups. The duration of training was not associated with cartilage thickness, but the time of training onset correlated inversely with cartilage thickness. It is possible that in high-strain sports, joint cartilage can undergo functional adaptation by thickening. Thus, mechanical loading history could exert a postnatal influence on cartilage morphology.

Effects of Hydrostatic Loading on a Self-Aggregating, Suspension Culture-Derived Cartilage Tissue Analog

OBJECTIVE

Many approaches are being taken to generate cartilage replacement materials. The goal of this study was to use a self-aggregating suspension culture model of chondrocytes with mechanical preconditioning.

DESIGN

Our model differs from others in that it is based on a scaffold-less, self-aggregating culture model that produces a cartilage tissue analog that has been shown to share many similarities with the natural cartilage phenotype. Owing to the known loaded environment under which chondrocytes function in vivo, we hypothesized that applying force to the suspension culture-derived chondrocyte biomass would improve its cartilage-like characteristics and provide a new model for engineering cartilage tissue analogs.

RESULTS

In this study, we used a specialized hydrostatic pressure bioreactor system to apply mechanical forces during the growth phase to improve biochemical and biophysical properties of the biomaterial formed. We demonstrated that using this high-density suspension culture, a biomaterial more consistent with the hyaline cartilage phenotype was produced without any foreign material added. Unpassaged chondrocytes responded to a physiologically relevant hydrostatic load by significantly increasing gene expression of critical cartilage molecule collagen and aggrecan along with other cartilage relevant genes, CD44, perlecan, decorin, COMP, and iNOS.

CONCLUSIONS

This study describes a self-aggregating bioreactor model without foreign material or scaffold in which chondrocytes form a cartilage tissue analog with many features similar to native cartilage. This study represents a promising scaffold-less, methodological advancement in cartilage tissue engineering with potential translational applications to cartilage repair.

Risk factors for Anterior Cruciate Ligament injury in skeletally immature patients: analysis of intercondylar notch width using Magnetic Resonance Imaging

The necessity for identification of risk factors for Anterior Cruciate Ligament, ACL injury has challenged many investigators. Many authors have reported lower Notch Width Index, NWI measured on radiographs in patients with midsubstance ACL lesions compared to control groups. Since a narrow intercondylar notch has been implicated as a possible risk factor related to ACL injury we decided to compare NWI measured on MRI scans between age-matched groups with acute ACL injury with those of the normal population. The purpose of this study was to measure intercondylar notch width on MRI scans in an immature population to determine if there was a difference between the population with ACL tears and a control group. We also wanted to assess age as a risk factor in an ACL injury population. We retrospectively analysed the MRI scans of 46 patients with ACL injuries and 44 patients with normal MRI findings who served as a control group for NWI measurements. For the ACL injury group we collected information from medical charts including age at the time of injury, gender, mechanism of injury, type of activity practised at the time of injury and prevalence of meniscal injury. Demographic data of the control group were comparable with those from the study group. We found a statistically significant (p < 0.001) difference in the mean value of the intercondylar notch width between normal knees (0.2691) and the ACL injury population (0.2415). In the ACL injury group we did not find differences in NWI values with regard to gender, involved side, mechanism of injury and type of sport practised at the time of injury. A narrower intercondylar notch was found to be associated with the risk of ACL rupture in an immature population. The young group of athletes with ACL injury needs further study to prospectively assess the risk of knee injuries.

[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.

Incomplete transiliac osteotomy in skeletally mature adolescents with cerebral palsy

Incomplete transiliac osteotomy is commonly used in the surgical treatment of spastic hip disease in children with cerebral palsy. The osteotomy hinges through an intact sciatic notch and an open triradiate cartilage. We asked whether incomplete transiliac osteotomy, combined with varus osteotomy of the femur and soft tissue reconstruction, performed after skeletal maturity could improve hip coverage and acetabular shape and provide pain relief in patients with spastic hip disease. We retrospectively evaluated 27 consecutive adolescent patients (33 hips) with cerebral palsy in whom an incomplete transiliac osteotomy was performed after closure of the triradiate cartilage. The mean age at surgery was 15 years. Five hips were dislocated and 28 hips were subluxated preoperatively. The minimum followup was 2 years (mean, 3.3 years; range, 2 years-7.5 years). The subluxated hips had a minimum Reimers' migration index of 23% (mean, 52%; range, 23-95%), which was reduced to 0% (mean, 7%; range, 0-39%) at followup. The minimum preoperative Sharp's angle was 34 degrees (mean, 52 degrees ; range, 34 degrees -70 degrees ), which was reduced to 20 degrees (mean, 35 degrees ; range, 20 degrees -50 degrees ) at followup. A painless hip was achieved in 26 of 33 hips at followup. An incomplete transiliac osteotomy can be performed after skeletal maturity, resulting in a painless and stable hip in the majority of patients.

[Reability of clinical assesment of injury of intraarticular structures of the knee joint verified by arthroscopic examination]

The aim of this paper is an evaluation of specificity, sensitivity and accuracy of clinical examination in intraarticular disorders of the knee joint. Study was performed on 100 patients (31 female, 69 male) (age 15-61 years) treated by arthroscopy. Our study showed the high sensitivity and specificity in assessment of leasions of the medial meniscus and leasions of the anterior cruciate ligament. Leasions of the medial meniscus and of the anterior cruciate ligamnet one. Leasions of the medialis meniscus may be painless and may not be associated with trauma.

[The role of plantar calcaneonavicular ligament complex in the development of the adult flat foot--anatomical study]

Acquired adult flat foot, despite numerous research projects, is a controversial clinical entity. Recently the role of plantar calcaneonavicular ligament complex (spring ligament) in stabilization of the longitudinal arch of the foot has drawn an attention. Since there are differences in anatomical description of his complex in the literature, the main aim of our study was to anatomically evaluate this complex. Ten cadaver feet were examined. In four cases spring ligament complex comprised two components: superomedial calcaneonavicular ligament and inferior calcaneonavicular ligament. In six cases complex was composed of three ligaments and we were able to identify structure of the third ligament. In this subgroup in two cases the spring ligament had its own fibrocartilage surface connected by tiny fibrous band with fibrocartilage articular surface. In summary, the spring ligament complex comprises superomedial calcaneonavicular ligament and inferior calcaneonavicular ligament. In majority of cases one can distinguish structure of the third ligament.

Pectoralis major release to improve shoulder abduction in children with cerebral palsy

The aim of our study was to evaluate the surgical results after pectoralis major muscle release in children with cerebral palsy and to assess a caregiver's satisfaction in patient's care after this procedure.Twenty-one shoulders in 13 patients were analyzed at least 12 months after surgery. All but 1 patient involved in our study had quadriplegic type of cerebral palsy involvement. In 17 limbs, only pectoralis release was performed; in 4 limbs, latissimus dorsi release was added. After clinical examination, a questionnaire was used to determine the caregiver's assessment. The passive range of abduction and flexion was maintained at an angle greater than 90 degrees in 10 patients. External rotation was restricted in 6 patients. All caregivers would recommend this surgery to another patient. All but one reported improvement in care of the patients after surgery. The indication for this surgical procedure is limited only to the selected cerebral palsy cases in which custodial care is impaired by shoulder adduction contracture. The 2 main indications for the procedure are the limitations in the ability to bathe the axilla and the difficulty in dressing.

[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.

Unilateral versus bilateral peri-ilial pelvic osteotomies combined with proximal femoral osteotomies in children with cerebral palsy: perioperative complications

The purpose of this study is to evaluate if bilateral peri-ilial pelvic osteotomies (PIPO) combined with proximal femoral varus derotation osteotomies (VDRO) influenced postoperative complications in children with spastic quadriplegia. Bilateral and unilateral hip subluxation or dislocation secondary to spasticity was present in 29 and 61 patients, respectively. The children were divided into 2 groups: group 1 were to be performed a surgery for unilateral PIPO associated with bilateral VDRO, and group 2 were to be performed a surgery for bilateral PIPO and VDRO. The average age of patients at initiation of surgery was 11.7 years (range, 5-20 years) for group 1 and 10.7 years (range, 5-19 years) for group 2. The hospital stay was similar for group 1 and 2 (P = 0.797), which was 9 days. In group 1, 11 (18%) of 61 children needed an average of 2 days (range, 1-7 days) in the intensive care unit postoperatively, and 4 of these 11 patients were reintubated because of respiratory problems. In group 2, 6 (20%) of 29 children were transferred to the intensive care unit postoperatively for an average of 2 days (range, 1-4 days) and 3 of these 6 children were reintubated because of respiratory problems. In conclusion, respiratory problems and anemia were the most common early postoperative complications, which occur with a similar rate in children with spastic quadriplegia who underwent bilateral or unilateral peri-ilial pelvic osteotomy(ies) combined with proximal femoral osteotomies. We believe that bilateral hip procedures including PIPO, proximal femoral osteotomies, and soft-tissue release can be performed safely in 1 stage and, based on this data, the staged procedure would probably have the same risk as the first procedure.

Role of ultrasound in the diagnosis and management of developmental dysplasia of the hip: an international perspective

Early diagnosis of developmental dysplasia of the hip is very important for proper treatment. Different ultrasound techniques have been used for early diagnosis of developmental dysplasia of the hip, but two of them are widely used in orthopedic practice: Graf's technique in Europe and Harcke's method in the United States. Our experience has led us to use an ultrasound technique that combines the two methods. Use of ultrasound has reduced the number of late-presenting cases, shortened treatment time, and decreased the number of surgical procedures of the hip joint in Poland.

Hamstring anterior cruciate ligament reconstruction: is it necessary to sacrifice the gracilis?

PURPOSE

The purpose of this study was to determine if there was a difference in the clinical results of anterior cruciate ligament (ACL) reconstruction when using the semitendinosus tendon (ST) alone versus the semitendinosus and gracilis (STG) construct.

TYPE OF STUDY

Prospective randomized study.

METHODS

We prospectively followed up a group of 97 patients who underwent reconstruction with either an ST graft (50 patients) or STG graft (47 patients). The patients were evaluated according to standard knee scales (IKDC, Noyes, Lysholm, Tegner), self-evaluation score (SANE), clinical findings, computerized knee laxity analysis, and functional tests. Isokinetic flexion, extension, and internal rotation-external rotation testing were also performed. The results were subjected to statistical analysis.

RESULTS

We did not find any significant difference between the 2 groups according to the standard knee scores; self-evaluation score; clinical findings; computerized knee laxity analysis; flexion, extension, and external rotation strengths; or functional tests. However, we did note that the internal rotation torque deficit was significantly higher in the STG group (P = .039). Likewise, the external-to-internal rotation ratio was significantly greater in the STG group (P = .006).

CONCLUSIONS

Although there is not much clinical difference when using the ST alone versus the STG construct, internal rotation weakness following harvest of 2 tendons may need to be evaluated further. We suggest that, whenever possible, only 1 tendon should be used when performing anterior cruciate ligament reconstruction with hamstring tendons.

LEVEL OF EVIDENCE

Level I, Randomized Controlled Study.

Comparison of anterior cruciate ligament reconstruction in male and female athletes using the patellar tendon and hamstring autografts

Despite the higher incidence of anterior cruciate ligament (ACL) injuries in female than in male athletes few authors have studied the effects of gender on the outcome of ACL reconstruction. This prospective study compared the results of ACL reconstruction using the patellar tendon and hamstring techniques in men and women. We prospectively followed 80 comparable athletes (46 males, 32 females) from a population of 287 patients operated on at our institution for ACL reconstruction using either patellar tendon or hamstring graft. There were 26 males and 14 females in the patellar tendon group, and 22 males and 18 females in the hamstring group. All patients were operated on by the same surgeon within 6 months from injury and underwent the same rehabilitation program at the same center. After an average of 36 months the patients were assessed by clinical evaluation, computerized knee laxity analysis, and isokinetic and functional strength tests; standard knee scores were also used. Among patellar tendon patients there were no significant differences between males and females regarding knee evaluation form, laxity, or isokinetic and functional tests. Females in the hamstring group had significantly greater laxity, and isokinetic tests at 1 year revealed a significantly higher deficit of peak torque at 60 degrees /s in flexion and extension. We suggest further studies on the clinical significance of these findings particularly on their possible ramifications in the areas of return to sports and rehabilitation of female athletes.

Avascular necrosis after surgical treatment for development dysplasia of the hip

We reviewed the medical records of 101 patients with developmental dysplasia of the hip who were treated with Dega's (102 hips), or Salter's (42 hips)osteotomy preceded by open reduction and femoral intertrochanteric osteotomy. The minimal follow-up was 17 years. At the last follow-up, there were proximal fem-oral growth disturbances in 52 hips (36%). In 20 hips, the disturbances were graded as mild and in six as severe. We found significantly better clinical and radiological results in hips without avascular changes. Risk factors for the development of avascular necrosis were: involvement of the left side and surgical treatment initiated after 2 years of age without pre-operative traction and without femoral shaft shortening. We found that the incidence of avascular necrosis increased with the length of follow-up. The avascular necrosis influenced both clinical and radiological results.

Long-term outcome of surgical treatment of developmental dyplasia of the hip using the Dega and Salter method of pelvic osteotomy with simultaneous intratrochanteric femoral osteotomy

Background. Developmental dysplasia of the hip is still an important issue in orthopedic practice. Even though the number of patients who require surgical correction has decreased in the last 20 years, we still have patients with early dysplastic coxarthriosis. The aim of our study was to assess at maturity the reconstruction of the hip joint among patients surgically treated in childhood using Dega and Salter pelvic osteotomies. Material and methods. Our material consisted of 102 patients who were surgically treated in our clinic for DDH using Dega and Salter osteotomy, with a minimum of 15 years of follow-up. All medical records and radiographs were evaluated through the whole period of treatment until the final follow-up. Clinical results were evaluated using the McKay/ Barrett clasification, and radiological results with Severin criteria. Results. Surgical treatment of DDH gives satisfactory long-term results. We found better outcomes among patients treated at less than 3 years of age and with shorter follow-up. Conclusion. The Dega and Salter pelvic osteotomies are a good choice in the treatment of DDH. In our opinion the Severin classification does not foresee the future of the hip joint, since the criteria are too optimistic.

Risk factors for avascular necrosis after closed hip reduction in developmental dysplasia of the hip

Background. Avascular necrosis of the femoral head occurring after surgery for developmental dysplasia of the hip can negatively affect the long-term prognosis of the involved hip. The purpose of our study was to evaluate a number of clinical and radiological risk factors for AVN after non-operative treatment of DDH. Material and methods. Clinical data and radiographs of 77 patients (103 hips) treated for DDH by closed reduction followed by cast immobilization were reviewed retrospectively. The average age at the time of reduction was 16 months (range 4 to 28), and the average final follow-up was at age 22.4 years (range 13 to 47). The Kalamchi and MacEwen classification system was used to evaluate AVN. Results. Avascular necrosis was found in 35.9% of the treated hips (37 cases). Comclusions. We established the impact of several kinds of radiological and clinical data on the incidence and severity of AVN. In our analysis the degree of initial dislocation (Tönnis classification) and age at the onset of treatment are important risk factors for AVN. The presence and size of the ossific nucleus, the use and duration of preliminary traction, previous treatment with Frejka pillow or Pavlik splint, and lateralization were not associated with the incidence and severity of ischemic necrosis.

The classification systems used in the diagnosis and evaluation of treatment results of developmental dysplasia of the hip

Authors presented the classification systems common used for diagnosis and evaluation of end results of treatment of developmental dysplasia of the hip. The most frequent used classifications for evaluation of clinical and radiological results were discuss in this paper with description of classification systems used for avascular necrosis of the capital head.

[Premature femoral head growth plate closure in Perthes' disease]

The study population consisted of 311 patients (50 female and 261 male) who had reached skeletal maturity at last follow up (361 hips). The mean age at the onset of symptoms was 6 years and 10 months (range: 2.5-13 years). All patients were treated by containment methods (bed rest and traction in abduction, brace, Petri cast, varus osteotomy, Salter osteotomy and shelf operation). Premature growth plate closure was estimated according to Bowen (central and lateral). Necrosis of the femoral head was classified according to Herring and Catterall, late results according to Stulberg and Mose and leg length discrepancy on scanograms. Article-trochanter distance (ATD) was estimated according to the Edgren methods. Premature femoral head growth plate closure was found in 61 hips (central--41 and lateral--20). Statistical analysis did not reveal any correlation between the gender and type of treatment and premature growth plate closure. The central pattern of growth plate closure was more often seen to 6 years of age at the onset and the lateral over 9 years of age at the onset (p = 0.0176). Premature growth plate closure was observed more often in Herring group C and Catterall group 4 (p = 0.0001). Disturbances in femoral head sphericity according to Mose increased (except with bilateral Perthes' disease) and ATD decreased in patients with premature growth plate closure. Also premature growth plate closure increased the leg length discrepancy in Perthes' disease. Thirty two (52.5%) hips with abnormal physeal growth were classified into type I or II according to Stulberg classification, 16 (26.2%) into type III and 13 (21.3%) into type IV or V. Premature growth plate closure in Perthes' disease is more common in huge necrosis of the femoral head. The central pattern of growth plate closure is more often in younger children (to 6 years of age) and the lateral in older (over 9 years of age). With abnormal physeal growth the greater trochanter overgrow and ATD decreased, the leg length discrepancy and disturbances in sphericity of the femoral head increased. Premature growth plate closure increased satisfactory and poor results according to Stulberg classification.

[Effect of femoral shaft fracture for growth of the lower extremity in children]

On the material of 15 children aged from 1.5 to 15 years (mean 6.6), who were treated conservatively the influence of fracture of the femoral shaft for growth of the lower extremity was assessed. In the follow-up from 1 to 14 years (mean 6.2) 2 patients had shortened of the fractured limb 5 mm, 5 patients had equal extremity and 8 had lengthened limb from 5 mm to 15 mm, at the same time 6 had overgrowth 10 mm and more. The overgrowth of the limb was observed only within of the femur, the legs were equal in every case. The overgrowth was remarked in the cases of spiral fracture with overriding, in fracture of the opposite site to dominant hand, in boys and in the cases which were treated by direct traction.

[The comparison of the results of treatment of displaced supracondylar humeral fractures by skeletal traction and percutaneous K-wire fixation in children]

The aim of the study was to compare of the results of treatment of displaced supracondylar humeral fractures by skeletal traction and percutaneous K-wire fixation in children. We assessed retrospectively the type and result of treatment of 23 children. We obtained very good results in all cases treated by closed reposition secured by percutaneous K-wire fixation. In the group treated by skeletal traction, in 5 cases reposition was inadequate with subsequent limitation of range of motion in the elbow joint. According to our results closed reposition and percutaneous fixation should be the method of choice in displaced supracondylar humeral fractures in children.

[The use of Bicontact hip prosthesis in treatment of coxarthrosis]

The issue of a stabile, long lasting bone-implant interface is still very valid. One of the new models of uncemented hip prosthesis is the Bicontact prosthesis made by Aesculap. This four-part endoprosthesis offers two types of cups: threaded München type and spherical Plasmacup type. The prosthesis stem is a wedged type stem, porous in the proximal type. The aim of this paper was to evaluate the value of Bicontact prosthesis in treatment of coxarthrosis. Our material consisted of 69 patients (38 female and 31 male) with 72 operated hips. Average age of the patients was 50.8 years. The mean follow-up was 24.5 months. Clinical and radiological evaluation according to Merle d'Aubine-Postel classification with Charnley's modification yielded 88% very good and good results. In 11 hips a similar complication was noted--fracture of the femur during final hammering of the prosthesis stem into the medullary canal. This was immediately repaired by circular wire fixation without any influence on the final result. This complication was observed during the first procedures. The learning curve of surgical technique allowed us to avoid this complication during subsequent procedures. We concluded that type of hip prosthesis was is very useful in in treatment of coxarthrosis.

[Intervate dislocation of the distal interphalangeal joint of the annular finger in a child]

The paper presents a good cosmetic and functional result of surgical treatment of distal interphalangeal joint dislocation of the annular finger in a 14 year old boy. The mechanism and pathology of this rare lesion of the hand are discussed. Factors affecting final outcome are: preserved joint cartilage, careful surgical approach and proper post-op treatment.

[Corrective surgical procedures as repeated treatment of residual clubfoot]

The authors present an analysis of failed surgery in 139 patients with congenital clubfeet. There were 72 feet, which required repeated surgical procedures after primary treatment. Twelve feet were treated by posterior release, and 65 by postero-medial release. The repeated reconstruction was performed at a mean age of 3.6 years. No very good results were found in either group at final follow-up, done according to the Magone et al. classification. In the first group treated by posterior release god results were noted in 53.3% of the cases, sufficient in 43.1% and poor in 38.5%. The authors underline that the final results depend on early consequent conservative treatment, use of adequate operating techniques and cooperation between child, parents, physician and orthotic specialist.

[Long term results of the treatment of clubfoot with postero-medial fibular graft]

The authors present long term results of treatment of congenital clubfoot by postero-medial release. Our material consisted of 82 patients, with 103 clubfeet, 5 months to 9 years old (mean age 22 months) at the time of surgery. The age at the time of the final follow-up ranged from 6.3 to 27 years. Final results were evaluated according to the Magone classification. Basing on this classification we achieved very good results in 9 feet, good results in 20, sufficient results in 28 and poor results in 46 feet. In the analyzed group most of the results were either sufficient or poor--71.84% of the cases. These feet required further surgical procedures. The authors stress that incorrect classification for this type of surgery and inadequate surgical technique caused a high percentage of poor and sufficient results.