[Migration of the Tips of Metal Implants during Treatment of Coxa Vara Adolescentium (Slipped Capital Femoral Epiphysis)]

PURPOSE OF THE STUDY This paper aims to detect, through a retrospective study, the migration of the tips of used metal implants (K-wires or a screw) in the direction out from the proximal femoral epiphysis as a part of studied basic radiometric characteristics of the cohort, with no intention of the authors to evaluate the therapy outcomes. MATERIAL AND METHODS It was a retrospective multicentre study including patients of two orthopaedic clinics and one department of orthopaedics treated in the period 2005-2018. The same treatment procedure was used in all three centres. The "in situ" fixation was indicated in patients, in whom the Southwick angle in anteroposterior and Lauenstein views was not much greater than 30°, whether primarily due to a mild slip or thanks to careful reduction either in acute or acute-on-chronic forms. All X-rays were measured by a single author (M.S.). In AP and Lauenstein view, overlap of the implant tip (K-wire or a screw) above the subcapital growth plate, the height of epiphysis and Southwick angle are measured at the beginning and at the end of treatment. In a smaller group of patients, also the inter-observer error (M.S. and J.P.) was identified. RESULTS K-wire transfixation was used in 43 patients (50 joints), with the mean age of 11.7 years and the mean duration of transfixation of 18.2 months. The slip of the implant tip out of the head, assessed separately for each introduced K-wire and then averaged, was in both views considered statistically significant (in AP view the level of significance was 5% (p-value = 1.393 x 10^(-6) < 0.05) , in Lauenstein view the level of significance was also 5% (p-value = 0.0001652 < 0.05)). The Wilcoxon signed rank test with continuity correction was used. Transfixation by screw alternatively with one K-wire was used in 23 patients (28 joints), with the mean age of 12.4 years and the mean duration of transfixation of 14.4 months. The slip of the screw tip outside the head was assessed as significant (in AP view at the level of significance of 5% (p-value = 9.41 x 10^(-5) < 0.05), in Lauenstein view at the level of significance of 5% (p-value = 0.003557 < 0.05)). The Wilcoxon signed rank test with continuity correction was used. DISCUSSION This paper aims to detect, through a retrospective study, the so-called migration of the tips of used metal implants (K-wires or a screw) outside the femoral head. Smooth and thin implants such as Kirschner wires should not compromise the continuing growth from subcapital growth plate contrary to the AO screw with threads in the femoral head, the screw head rested against the lateral cortical bone and the screw inserted as a compression one. Nonetheless, with some exceptions, the literature confirms the continued growth of the femoral neck even in the case of screws. In general, implants that do not compromise femoral neck growth provide an opportunity to remodel the anterolateral prominence of the femoral metaphysis, especially in younger patients. In agreement with other authors, the data from our study confirmed, even after a short period of time, a certain degree of proximal femoral remodelling expressed by changes in the Southwick angle. CONCLUSIONS Our study confirmed that in the case of "smooth" K-wires as well as cannulated screws the tips of both implants migrate outside the head. The differences were statistically significant. Therefore, the introduction of a conventional cannulated screw cannot be claimed to immediately produce the effect of epiphyseodesis. Yet, smooth implants less compromise the growth of the femoral neck, which is why they have recently been preferred. Key words: coxa vara adolescentium, metal implants, migration.

[Simultaneous Bilateral Femoral Osteotomies in Neurogenic Hip Instability: a Feasibility Study]

PURPOSE OF THE STUDY The study aimed to evaluate the intraoperative and early postoperative response to simultaneous bilateral femoral osteotomy usually accompanied by soft tissue release of hip joints, or open reduction, capsuloplasty, pelvic osteotomy or extraarticular shelf procedure. MATERIAL AND METHODS A bilateral surgery was performed in 16 children. Twelve children suffered from (spastic) cerebral palsy and there was one case of paralytic dislocation in a patient with myelomeningocele, while the remaining patients suffered from chromosome I aberrations, Dandy-Walker syndrome and merosin-deficient muscular dystrophy. GMFCS Level IV and V prevailed. The patients with femoral head deformity or severe adduction contracture were removed from the study group. In all cases the LCP Pediatric Hip Plate 3.5 or 5.0 (Synthes) was used for osteosynthesis. The postoperative fixation by a hip spica cast was applied for 6 weeks, after which in most cases SWASH orthosis was used at night. The age of the patient, the hip joint finding, the GMFCS level and the type of procedure were recorded. RESULTS The evaluation took into account the use of general anaesthesia only or a combination of general and epidural anaesthesia, most often through caudal block, duration of surgery, time when blood transfusion was necessary and the volumes of blood needed, duration of stay in the Anaesthesiology and Resuscitation Unit, or Intensive Care Unit. As a response to surgery, the changes in haemoglobin levels in g/l and VAS pain score were studied. In four patients only the operative time exceeded 3 hours. Blood transfusion was necessary in 13 patients, with one blood unit being always sufficient. Two patients were admitted to the Anaesthesiology and Resuscitation Unit, the remaining patients spent 1-3 days after surgery in the ICU. The average length of hospital stay did not exceed a week. The postoperative decrease in haemoglobin levels quickly improved. The pain intensity was regularly recorded postoperatively and on day 3-4 it was evaluated as moderate, with patients responding well to common analgesics (VAS 4-7). DISCUSSION The evaluation of duration of simultaneous bilateral procedure, postoperative recovery based on the need for blood transfusion, changes in blood count and VAS scores indicated that the procedure performed on both hip joints simultaneously does not significantly exceed the reasonable limits in terms of the patient s burden. In literature, we found only a single article on a topic of this sort, the conclusions of which are very similar. CONCLUSIONS The simultaneous bilateral femoral osteotomy can be considered a fairly safe procedure. Key words: hip joint instability, simultaneous femoral osteotomy, cerebral palsy.

[Gait Analysis in Patients with Hip Disorders]

Recent studies have shown that the evaluation of both conservative and surgical therapy cannot do without gait analysis. Orthopaedic textbooks, with some exceptions, deal in great detail with a thorough clinical examination of the patient but gait assessment is mentioned only marginally. More attention is paid to gait analysis in rehabilitation medicine. Motion and gait analysis laboratories equipped with optoelectronic cameras and force platforms were first developed for cerebral palsy children. Recently, several studies have been published on the use of these methods in disorders of hip and knee joints or spine diseases. Key words: gait analysis, hip joint.

[Accuracy of proximal femur correction achieved with LCP paediatric hip plates]

PURPOSE OF THE STUDY

The aim of the study was to evaluate, in comparison with the pre-operative planning, the accuracy of proximal femur correction achieved with the use of locking compression paediatric hip plates (LCP) in children and adolescents and to assess pre- and post-operative complications.

MATERIAL AND METHODS

A group of 52 patients in whom proximal femoral osteotomy using the LCP was performed on a total of 55 hips between September 2009 and February 2013 were retrospectively evaluated. The following diagnoses were treated: unstable hip in cerebral palsy, 18 operations; Legg-Calvé-Perthes disease, 10 operations; coxa vara of aetiology other than coxa vara adolescentium (CVA), eight operations; true CVA, six operations; femoral shortening by the Wagner method, six procedures; proximal femoral derotation osteotomy, four procedures; and post-traumatic pseudoarthrosis of the proximal femur, three operations.

RESULTS

Compared with the pre-operative plan, the average deviation of the colodiaphyseal angle was 5.2° (1° to 11°) in 18 unstable hips; 4.7° (1° to 10°) in 10 cases of Legg-Calvé-Perthes disease; 4.5° (3° to 6°) in eight hips with coxa vara of aetiology other than CVA; 6.5° (2° to 13°) in six CVA hips; 4.5° (1° to 10°) in six cases of femoral shortening; 3.5° (1° to 5°) in four derotation osteotomies; and 3.7° (0° to 6°) in three corrections of pseudoarthrosis. In one patient, osteosynthesis failed due to screws being pulled out from the proximal fragment; re-osteosynthesis was carried out using a conventional angled blade plate.

DISCUSSION

As in other international studies, our results confirmed a high accuracy of proximal femur correction with use of the LCP instrumentation. The reported higher time requirement for this technique seems to be related to the learning curve and, with more frequent use, will probably be comparable to the time needed for application of conventional hip angled plates.

CONCLUSIONS

The up-to-date LCP fixation system using the principle of angular stability for correction of the proximal femur in children is a clear advancement and its higher costs are certain to be outweighed by its higher accuracy and thus better results.

[Exactness of correction of proximal femoral deformities using conventional angled blade plates and the cannulated paediatric osteotomy system. Comparison of two methods]

PURPOSE OF THE STUDY

The aim of the study was to compare the exactness of correction of proximal femoral deformities between the patients treated with AO angled blade plates and those managed by the cannulated paediatric osteotomy system (CAPOS).

MATERIAL AND METHODS

In the period from 1994 to 2003, corrective osteotomy of the proximal femur using the conventional AO angled blade plate (90°, 120°, 130°) was performed on 57 hips in 42 children. In the period 2004-2012, 68 hips in 59 children were treated by the CAPOS method. In each child, the pre- and post-operative X-ray views were compared and a real deviation from the pre-operative plan was determined. A deviation larger than 10° in the frontal plane was recorded as an error. Penetration of the blade into either the posterior or the anterior femoral neck cortex seen on axial views was regarded as an error as well.

RESULTS

Corrective osteotomy with AO angled blade plates performed on 57 hips failed in 12 (21.1%) on anteroposterior views and six hips (10.5%) on axial views. Of 68 hips treated by the CAPOS, failure was recorded in four (5.9%) and one (1.5%) on anteroposterior and axial views, respectively. DISCUSSION No information on the CAPOS technique is available in either international or national literature, with the exception of our preliminary report. On the other hand, locking compression plates for paediatric hips, developed later, have been described in several publications. The authors appreciate a higher accuracy of bone correction and higher stability for the whole fixation, which results in earlier mobilisation of the treated extremity. These advantages are also true for CAPOS instrumentation.

CONCLUSIONS

The CAPOS can be seen as an intermediate stage of development between conventional angled blade plates and locking compression plates for paediatric hips. However, it should be noted that surgery involving insertion of an angled blade plate takes less time than insertion of a locking compression plate. For this reason, in procedures combining femoral osteotomy with, for instance, triple pelvic osteotomy the use of CAPOS instrumentation is still preferred.

[Results of the Ponseti treatment evaluated at four to six years after it started]

PURPOSE OF THE STUDY

To assess outcomes of the Ponseti method for treatment of talipes equinovarus in relation to patient age at its start.

MATERIAL AND METHODS

In the 2006-2010 period, 115 children (163 feet) with talipes equinovarus were treated using the principles of Ponseti. The right foot was affected in 44, the left foot in 23, and the bilateral form was treated in 48 patients. In order to obtain results for at least 3 years of follow-up, we included the patients treated by the Ponseti method between 2006 and 2008, in whom 83 affected feet were analysed (23 isolated right feet, 14 left feet, 23 bilateral forms). According to the Dimeglio scoring system used to assess the severity of clubfoot deformity, there were four feet in group II, 37 feet in group III and 42 feet in group IV.

RESULTS

Subtalar release was performed in 29 feet (34.9%), in two feet being only posterior. Moreover, foot deviations, e.g. adduction of the forefoot less than 10° (5 feet, 6%), varus deformity of the heel less than 5° (6 feet, 7.2%), and failure to complete the Ponseti treatment (3 feet, 3.6%) were recorded. For assessment of the effect of age at start of casting on the outcome, two patient subgroup were distinguished: group 1, the treatment stared and continued in the first 8 postnatal weeks; group 2, the treatment was initiated and carried out between 9 and 20 weeks postnatally. Subsequently, subtalar release was performed in 18 of 61 feet (29.5%) in group 1, and in 11 of 21 feet (52.4 %) in group 2. Using Fischer's exact test, the difference was found statistically significant. (p<0.05). Of the three patients with an unfinished course of initial treatment, two underwent subtalar release later and one was lost to follow-up.

DISCUSSION

Contrary to many recent reports, the frequency of Ponseti treatment failure in this study is substantially higher. Nevertheless, we adhered strictly to the Ponseti protocol of treatment, tenotomy was performed under general anaesthesia and Ponseti splinting was maintained properly in all but seven patients (8.4%).

CONCLUSIONS

Irrespective of rather frequent failure of the initial Ponseti treatment, its contribution for the patient is beneficial as it can reduce the extent of subtalar release required. However, a modern family will hardly accept several years of applying splints every night, irrespective of maximally sophisticated bracing. This becomes critical usually at the age when the child starts walking. Nowadays, families cooperate quite well due to the fact that a new method with high mass-media coverage has been offered to them.

[Femoral lengthening. A critical review of ten-year results]

PURPOSE OF THE STUDY

To evaluate the results of femoral lengthening in the patients treated from 2000 to 2009 in whom complete radiographic data were available and the lengthening procedure involved mainly the use of a Mephisto fixator.

MATERIAL AND METHODS

A total of 28 femoral lengthening procedures were carried out in 26 patients,16 girls and 10 boys. The external fixator Mephisto was used in 24 cases; fixators Prospon and Orthofix in one and three cases, respectively. Fifteen patients were treated for congenital short femur, the rest had secondary femoral shortening due to following pathologies: distal femoral epiphysiolysis in five children, proximal femoral osteomyelitis in one child, avascular necrosis of the femoral head in one, diaphyseal femur fracture in one, enchondromatosis of the distal femur with growth plate destruction in one, and contralateral femur overgrowth following a fracture in one child. The average age at the beginning of treatment was 11 (range, 4-16) years. Complications were classified as mild, serious and critical. The results were statistically analysed using several statistical tests.

RESULTS

The average parameter values for the group included: total femoral lengthening, 40.2.mm (SD±11.1); osteotomy index (OI), 41 % (SD±9.8); lengthening percentage (LP), 10.9 % (SD±3.8); lengthening index (LI), 14.5 (SD±3.5) days/cm; hea- ling index (HI), 52.6 (SD±20.1) days/cm; and consolidation index (CI), 93.3 (SD±40.0) days/cm. Mild complications were recorded in 11 (39.2 %), and serious and critical in eight patients (28.6 %). Fourteen patients (53.8 %) were free of any complications. Two complications were concurrently found in five patients (17.9 %). There was a statistically significant difference in the LP values related to the number of complications (p=0.019). No significant relationship was recorded on comparison of the HI value with the patient's age at the time of surgery (p=0.836) and patient's gender (p=0.546) (Mann- Whitney test). The relationship of the OI value to the HI value was non-significant (p=0.492), as was the relationship between the osteotomy technique (oscillating or Gigli saw osteotomy) and the occurrence of complications (p=1.000) (Fisher's exact test). Correlation between the LI and HI values was significant (p<0.001).

DISCUSSION

The results of healing after lengthening, as assessed by the healing and the consolidation index, were in agreement with other authors' data. The lower number of complications, particularly fractures of bone regenerate, can be explained by the facts that, in our study, the lengthening percentage was lower and that the post-operative care was strictly observed, including dynamic axial loading which stimulates bone consolidation at the lengthened section, with adherence to the proof of three developed cortices.

CONCLUSIONS

Our results did not confirm the assumption that slower lengthening will have a favourable effect on the healing index. Key words: femoral lengthening, external fixator, complications.

[A contribution of instrumental gait analysis to the establishment of surgical indications in cerebral palsy]

PURPOSE OF THE STUDY

To evaluate our experience with indications for surgery based on instrumental gait analysis in cerebral palsy children, and to compare them with those drawn from the results of clinical examination.

MATERIAL AND METHODS

The gait analysis laboratory was built in the Paediatric Hospital of the Faculty of Medicine in Brno in the 2008/09 period with support of the Norwegian funds. It is equipped with eight optical cameras, two auxiliary motion-picture video came- ras, two force platforms and a telemetry system for electromyography. Between June 2009 and March 2010 a total of 297 children with spastic cerebral palsy, 66 with hemiparesis and 231 with diparesis were examined.

RESULTS

On the basis of instrumental gait analysis, indications for surgery were established in 19 hemiparetic and 88 diparetic patients, which meant a new indication in 107 children. In 14 children, the results of gait analysis led to abandoning former indications for surgery based on clinical examination only while, in 13 children, they backed up the surgical indications in spite of the negative results of clinical examination. In six children a so-called superclinical decision was made, i.e., the results of repeated clinical examinations over-weighed those of instrumental gait analysis either in favour of or against surgery.

DISCUSSION

Based on the gait analysis results, a change in treatment plans was made in 27 out of 297 children (9 %). This is in contrast with the findings of other authors who report a much higher rate of treatment planning changes (52-70 %) In our stu- dy the use of instrumental gait analysis allowed us to decrease the frequency of surgical indications by 4.7 %. Other authors have achieved a higher value, up to 13 %. Unlike other studies, ours did not confirm the effect of gait analysis outcomes on an increase in the number of one-stage multi-level surgical procedures.

CONCLUSIONS

Instrumental gait analysis is a great contribution to the diagnosis of movement disorders in children with cerebral palsy.

[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.

[Subtalar stabilization of pes equinovalgus by conventional open surgery using bicortical iliac crest bone graft (mid-term results)]

PURPOSE OF THE STUDY

The aim of the study was to analyze the results of subtalar stabilization of the foot by conventional open surgery with the use of bicortical graft in cerebral palsy patients with pes equinovalgus and to compare our results with those of other authors.

MATERIAL

A total of 193 operations were performed, with bilateral surgery in 84, surgery on the right foot in nine and surgery on the left foot in 16 patients. The average follow-up was 5 years and 2 months.

METHODS

Before and after surgery, the clinical presentation in each patient was evaluated according to our subjective, description- based classification using a I-to-III scale (I, normal foot; II, moderate deformity; III, severe deformity). On lateral radiographs of the foot in a standing position, the talocalcaneal (TC) angle and that between the longitudinal calcaneus axis and foot-supporting surface (CS) were measured. The data was analyzed by statistical methods.

RESULTS

The pre-operative findings were compared with the post-operative ones on the basis of our I-III classification system. In all results obtained with the McNemar test, p-values were lower than 0.001; therefore, at a 5 % level, the null hypothesis can be ruled out and a conclusion can be drawn that this surgery has an effect on the change in foot shape, as defined by our classification. Surgery failed in 13 feet (6.7 %), i.e., it did not produce any change in the degree of deformity. Similarly, values of the TC and CS angles were compared. The null hypothesis of Wilcoxon's test is that the patient's condition (TC and CP angles) remains the same before and after surgery. In all cases, the p-values were lower than 0.001; therefore, at a 5 % level, the null hypothesis can be ruled out, with the conclusion that differences between pre- and postoperative conditions were statistically significant.

DISCUSSION

The results of this study, as compared with the relevant data, show that, for correction of pes equinovalgus, subtalar stabilization with bicortical iliac crest graft is a sufficiently reliable method even without metal fixation. The failure rate is only 6.7 %.

CONCLUSIONS

The method described here achieves good results, the validity of which is supported by statistical analysis. Key words: cerebral palsy, pes equinovalgus, subtalar extra-articular arthrodesis.

[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.

[Treatment of congenital pseudarthrosis of tibia by vascularized fibular graft]

PURPOSE OF THE STUDY

The aim of the study was to evaluate the results in a group of patients with congenital pseudarthrosis of the tibia treated by transfer of a vascularized fibular graft from the contralateral extremity.

MATERIAL

The group included three boys and two girls aged 2 to 8 years at the time of surgery. In two patients, the vascularized graft transfer was preceded by other operations. All patients but one had Crawford type IV pseudarthrosis. The signs of peripheral neurofibromatosis were found in four of the five patients.

METHODS

The operation was carried out by two surgical teams, i. e., orthopedic and microsurgery (plastic surgery) specialists. Deep dissection of the pseudarthrosis was performed down to healthy, well vascularized tissue; a vascularized pedicle bone graft was harvested from the contralateral fibula. The graft was inserted and anchored intramedullarily in both tibial fragments, and stability was provided with a K-wire introduced through the calcaneus. Subsequently, the vascular pedicle of the fibular graft was joined to the surrounding vessels (anterior tibial artery and anterior tibial vein). The extremity was immobilized in plaster cast and later a KAFO brace was applied.

RESULTS

Graft union partially failed in the proximal end of the graft due to bone resorption of both the graft and the proximal tibial fragment in two patients. This was successfully treated by additional spongioplasty. In all patients bony union was achieved at an average time of 9.8 months (range, 6 to 21 months). An increase by more than 100 % in the diameter of the transplanted fibula was recorded in four patients. The increase, which was of course related to follow-up time, was a clear proof of primary graft vascularization.

DISCUSSION

The use of vascularized fibular graft harvested from the contralateral extremity showed high effectiveness in comparison with other methods. This was in agreement with the relevant literature reports.

CONCLUSIONS

This method can be used regardless of patients' age and our experience showed that, even in small children, union can be achieved and can thus allow for early weight-bearing and prevention of crus atrophy.

[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.

[Video-assisted tenotomy of the triceps muscle of the calf in cerebral palsy patients]

PURPOSE OF THE STUDY

The aim of the study was to demonstrate the outcomes of video-assisted tenotomy of the gastrocnemius and soleus muscles in children with the spastic form of cerebral palsy.

MATERIAL

In the period from September 2003 to March 2004, 18 lower extremities in 14 patients were operated on.A set for endoscopic plastic surgery with a 4-mm trocar was used. Aponeurotomy was carried out with a scalpel no. 11 or arthroscopic scissors. The treated limb was immobilized in plaster cast for 6 weeks. METHODS The inclusion criteria were: an equinus gait free from a valgus or a varus deviation, preferably unilateral, and the age range between 4 and 10 years. The patients were examined before surgery and followed up at 3-month intervals.

RESULTS

In 16 out of 18 treated extremities, simple aponeurotomy of the gastrocnemius and soleus muscles was sufficient to achieve 20 degrees dorsiflexion. In two cases it was necessary to complete the procedure at the same stage by video-assisted sliding double-point tenotomy of the Achilles tendon. The short-term follow-up did not reveal complications such as failure of wound healing or neurological or vascular disturbance.

DISCUSSION

The international literature data show that this method has largely been developed on cadavers. Much attention has been given to potential injury to the sural nerve. However, the ultimate goal of this operation, i. e., sufficient correction, should be regarded as a much more important factor. In older children, simple aponeurotomy may not achieve this objective and therefore the authors developed a procedure combining video-assisted aponeurotomy with sliding double-point tenotomy of the Achilles tendon.

CONCLUSIONS

Video-assisted tenotomy of the gastrocnemius and soleus muscles proved a fully effective method in our group evaluated at short-term follow-up.

[Options for correction of post-traumatic length discrepancies in forearm bones in children (case reports)]

Correction of radius length after a premature complete or partial closure of the distal epiphyseal plate is important for both the correction of radial deviation of the hand and the restoration of normal function of the radiocarpal articulation. This study comprised four patients. Two children with complete closure of the epiphyseal plate of the distal radius underwent callotaxis. One patient was treated for atrophic pseudoarthrosis of the distal radial metaphysis by external fixation and subsequent spongioplasty. One patient with partial closure of the epiphyseal plate was treated by physeal distraction. In each patient an Ilizarov's external fixator was applied. The full correction of radius length was achieved in all cases. No complications were recorded with the exception of tissue irritation around Kirchner's wires, which occurred mainly on the volar side. In the therapy of injuries suffered during adolescent growth acceleration, it is necessary to perform a certain overdistraction of the radius. An alternative method includes epiphyseodesis of the distal ulna. Key words: post-traumatic closure of the epiphyseal plate, callotaxis, physeal distraction, chondrodiatasis.

[Bone surgery for unstable hips in patients with cerebral palsy]

PURPOSE OF THE STUDY

The aim of this retrospective study was to compare the efficacy of femoral osteotomy alone with that of osteotomy combined with an acetabular procedure in patients with unstable hips due to spastic cerebral palsy.

MATERIAL

Sixty-one hip joints in 50 patients who had shown distinct subluxation or dislocation of the joint were operated on. Eleven patients underwent bilateral surgery. Before bone surgery, soft-tissue release involving both the flexors and adductors was performed on 19 hips. Femoral osteotomy alone was performed on 29 hip joints and combined femoral and pelvic osteotomy was carried out on 32 joints.Twelve resections of the proximal femur in seven patients were evaluated as a separate group. All treated hip joints were assessed by clinical and radiographic examination at a follow-up of more than 5 years.

METHODS

The skiagraphs taken in a strictly neutral position of the lower limbs before surgery and at the final examination were evaluated on the basis of Reimers's migration index and Wiberg's centre-edge angle. The locomotor abilities of each child were categorized according to the Vojta scoring system for locomotor development. The range of motion in the treated hip joint was assessed using the standard S. F. T. R. method. The results obtained were statistically analyzed by the Kruskal- Wallis, one-way ANOVA test.

RESULTS

A comparison of the results of femoral osteotomy alone with those of combined femoral and pelvic osteotomy showed that the post-operative values of the migration index and centre-edge angle, as compared with the pre-operative ones, were statistically higher (p<0.05) in the latter. In a long-term perspective, the surgery had no adverse effects on a natural development of locomotor abilities of the child. The children had higher scores by the modified Vojta rating system. There was no change in the range of motion in the treated hip joints after the operation.

DISCUSSION

In 28, out of the 32 joints treated by combined femoral and pelvic osteotomy, Salter osteotomy was performed and it showed a high efficacy in providing hip joint stability. The main emphasis during surgery was placed on the maximum acetabular rotation laterally. Femoral osteotomy alone was less effective in providing hip joint stability; in addition, in order to achieve this, tilting of the proximal fragment to a varus position was generally higher than in combined operations. In three patients this treatment resulted in fixed adduction of the hip joint with negative consequences for movement.

CONCLUSIONS

In the treatment of unstable hip joints a combination of varus derotation femoral osteotomy and pelvic osteotomy provides better containment of the joint than femoral osteotomy alone.

[Periosteal tethering of growth plates in long bones (focal fibrocartilaginous dysplasia)]

PURPOSE OF THE STUDY

Another three cases of periosteal tethers (focal fibrocartilaginous dysplasia) are reported. Until now only 54 children affected by this entity were described. Analysis of these three cases concerning clinical appearance, x-ray deformity, preoperative and histologic findings and the end-results of the own method of surgical treatment was undertaken to categorise the proper diagnosis.

MATERIAL

The studied group involved distal posteromedial femoral lesion (Boy aged 11 months, Epiphysis-diaphysis angle 68 degrees, femoro-tibial angle 27 degrees). Another case with proximal tibial lesion on the lateral side (Boy aged 18 months, Epiphysis-diaphysis angle 75 degrees, femoro-tibial angle 18 degrees). Third case with proximal tibial lesion, localised typically medially (Boy aged 17 months, Epiphysis-diaphysis angle 70 degrees, femoro-tibial angle 19 degrees).

METHODS

All three cases were routinely followed for short time, before surgical correction was performed. AP and lateral x-rays were undertaken. Surgical correction involved curretage of the lesion and a half-circumferential excision of the periost between the lesion and the physis. Short-term immobilisation followed. In no case an osteotomy was needful.

RESULTS

Limited surgical approach consisting of curretage and periost excision resulted in slow but full correction of the long bone angulation. In the distal femoral lesion the normal value of limb axis was achieved in 9 years, in proximal and lateral tibial lesion in 7 years and in proximal and medial tibial lesion in 3 years. Persisting shortening of the limb length was found only in femoral lesion involving 10 millimetres. Histologic findings comprised areas of dense fibrous tissue, of fibrocartilage and of sclerotic bone. Bacterial cultivation was negative.

DISCUSSION

It seems, that there is almost no difference between clinical, x-ray and preoperative findings of periosteal tethers and focal fibrocartilaginous dysplasia. A real fibrous band between the cortical lesion and the physis was not found in this study, however the periost was roughened and adhered firmly to the bone. Limited surgical exposure consisting of curretage and half-circumferential excision of periost quaranteed in all three cases full correction of the former deformity.

CONCLUSION

Osteotomy is not an absolutely necessary surgical solution in these cases.

[Causes of development of genu recurvatum after surgical treatment in spastic forms of childhood cerebral palsy]

PURPOSE OF THE STUDY

To evaluate the contribution of different surgical techniques of lengthening of distal hamstrings on the development of hyperextension deformity of the knee in spastics.

MATERIAL

Totally 51 patients of age 7.6 + 3.7 years at operation. Follow-up after surgical release for 4-10 years. Basically two surgical techniques were used: 1. Simple division of gracilis and semitendinosus, fractional lengthening of semimembranosus and biceps femoris. 2. Gracilis and semitendinosus were anchored after its transverse division to fractionally lengthened semimembranosus.

METHODS

Pre-operative and post-operative Bleck popliteal angles were estimated. Hyperextension was tested in lying and standing positions.

RESULTS

Type of surgery (1 or 2) did not influence the development of hyperextension deformity of the knee (tested by Fisher exact test). Nevertheless the relation between type of surgery (1 or 2) and the stratified value of Bleck popliteal angle was statistically significant. In the subgroup 2, in which the superficial tendons were anchored to semimebraneous, the occurrence of values of Bleck angle less than 20 degrees, was lower than in the subgroup 1.

DISCUSSION

It seems, that the type of described two different surgical techniques is not so much decisive for development of hyperextension deformity.

CONCLUSION

Authors surmise, that principal role play stronger deep knee flexors (semimembranosus and biceps femoris). Its fractional lengthening must be very careful.

[Percutaneous aponeurotomy of the triceps surae muscle in cerebral palsy in children]

PURPOSE OF THE STUDY

To assess the short-term results of percutaneous aponeurotomy of gastrocnemius including the possible complications and effects of the treatment.

MATERIAL

Totally 88 procedures were performed in 61 patients in the period 1998-2001. Re-examination in 2002 involved 44 patients with 66 procedures.

METHODS

The procedure was done from one-point incision. Six weeks immobilisation followed. Re-examination concerned the shape of the calf, the testing for palpable defect, US examination of calf muscles and aponeurosis, neurological and vascular examination.

RESULTS

Recurrence of mild degree of equinus deformity was found in 3 out from 66 procedures. No neurological or vascular complications were registered.

DISCUSSION

Rate of recurrence in this study is comparable with the figures after open aponeurotomy.

CONCLUSION

Operation is reserved for skilled surgeon, however in short future, most of operations on spastics will be done like video-assisted procedures.

[Rotational acetabular osteotomy in the treatment of Legg-Calve-Perthes disease]

PURPOSE OF THE STUDY

The material of prospective study involving 57 surgically treated hips in 55 patients suffering with a severe form of Legg-Calvé-Perthes disease (LCPD) was analysed by the use of statistical methods to depict the influence of age, of sex, of the amount of head involvement on the outcomes of surgical treatment by rotational acetabular osteotomy (Salter or Steel osteotomy from 9 years of age).

MATERIAL

During the period 1990-2000 rotational acetabular osteotomy for Legg-Calvé-Perthes disease was performed totally in 124 patients. Excluded were cases, in which the operation was done for residual subluxation as a definitive outcome of former LCPD, cases which did not return for controls, cases with not yet completed consolidation after surgery and cases operated by me abroad. Totally were analysed stastistical sheets from 57 rotational acetabular osteotomies, including basis dates from medical history, clinical and x-ray examinations. Special concern was given to the evaluation of remodellation of the affected femoral head chronologically.

METHODS

All patients were operated by the group of three senior orthopaedic surgeons. Indication for surgery was based on the evidence of the progressive collapse of the femoral head issuing in the lateral and anterior head extrusion. As the Mose as well as Stulberg classification are showing inter-rater discrepancies, authors measured as well head-neck index, epiphyseal index and acetabulum-head index to eliminate subjectives errors.

RESULTS

Age at operation and sex did not affect the results expressed in epiphyseal quotient and acetabulum-head index. With the increasing age the head-neck index dropped down depicting the progressive shortening of the femoral neck the older kids. The periods from the operation till the consolidation of the lateral pillar of the femoral head were longer in younger than in older children. Although the evaluation of results in Mose classification showed poorer results generally and also specifically in relation to the increasing age, distribution of results in Stulberg classification showed excellent and fair results in almost 90% of all treated patients.

DISCUSSION

Prospective study based on the use of rotational osteotomy, avoiding the routine combination with varisation of the proximal femur in older kids using in them Steel triple osteotomy, showed promising results especially in Stulberg classification. Contrary to Salter and others prerequisiting for the indication of operation only slight deformity of the affected femoral head, many of the enrolled cases appeared with the remarkable deformity of the femoral head before the operation. Rotational acetabular osteotomy showed its potential to involve the enlarged head and follow-up depicted its subsequent slow remodellation.

CONCLUSIONS

Submitted study was prepared to be matched nextly with the conservative group, which will be published in another publication. Internal analysis of the presented cohort disclosed that presented surgical treatment (Salter or Steel osteotomy respectively) assured, that irrespective of higher age, the important parameters like epiphyseal quotient and acetabulum-head index did not become worse than in younger groups. Even in the group over 9 years of age, 87.5% were categorised like excellent and fair results in Stulberg classification.

[Results of lengthening 20 humeri]

PURPOSE OF THE STUDY

The aim of the retrospective study was to evaluate the results of 20 performed lengthenings of the humerus in children and adolescents.

MATERIAL

Assessment involved totally 20 lengthening procedures having been done in 18 patients, twice as a repeated procedure, in the period 1983-1999. The indication was shortening of humerus approaching at least the amount of 50 millimeters. Proportion of boys and girls was 7/13. The shortening arouse on the base of pyogenic infection in 12, post-traumatically in 3, congenitally in 2 and in one case it was caused by a bone cyst expansion. Mean value of shortening was 83 millimeters. Mean value of age was 12 years, ranging from 7 till 16 years.

METHODS

Lengthening procedure was performed by the use of different types of external fixation. In most cases Wagner unilateral fixator was used (13 cases). The choice of external fixator was based more on its availability determined by economical reasons. Contrary to Wagner and Orthofix, Ilizarov fixator did not need the common replacement of different sizes of apparatus during lengthening. Osteotomy was routinely performed at the point between the distal and middle thirds of the length of humerus, approach was always associated with visualisation of the radial nerve.

RESULTS

Serial x-rays were consecutively studied to specify the mean value of lengthening--71 millimeters, the mean value of distraction phase--91 days, the mean value of total period of fixation--197 days and the mean value of period determined at its end by the full re-canalisation of the lengthening zone--355 days. Mean value of bone lengthening index was calculated on 13.2 days/1 centimeter, mean value of bone healing index on 28.6 days/1 centimeter, and a modified bone healing index based on full recanalisation of the lengthening zone with a mean value of 44.5 days/1 centimeter. In no one case an additional bone grafting or plate osteosynthesis was necessary. Complications involved 3 cases of transient radial nerve palsy, which spontaneously resolved.

DISCUSSION

As other reports of humerus lengthening respecting "callotasis method", this study showed almost uneventful distraction and healing This cohort involves a big sample of lengthenings resembling in its size the cohort of Cattaneo et al., the world's biggest group.

CONCLUSIONS

It was proved, that the humerus lengthening is a safe method solving successfully the cosmetic problem of length deficiency. It seems, that presumably the keeping up the principle of "callotasis" brings about uneventful treatment programme.

[Prevention of development of hip joint instability in patients with the spastic form of juvenile cerebral palsy]

PURPOSE OF THE STUDY

How effective are the hip adductors and flexors tenotomies for the correction of unstable hip joint in cerebral palsy?

MATERIAL

The study included 45 children with contractures of the hip adductors and flexors and hip subluxations due to spastic cerebral palsy. Thirty three of them were boys and 12 were girls. Their ages ranged from 2 to 13 years. Preoperative and postoperative roentgenograms of 82 hip joints were investigated.

METHODS

Open tenotomies of m. adductor longus and brevis, m. gracilis, m. rectus femoris and m. psoas major. The immobilisation by POP casts lasted for 6 weeks. Abduction and extension bracing followed the plaster removal in all children. The hip joints were radiographed in neutral rotation both before and at least 6 months after the operation. Reimers migration percentage (MP) and Wiberg angle (CE angle) known as the parameters of hip instability were assessed. The obtained data were statistically analysed.

RESULTS

The preoperative MP was below 25% in 25 hips, between 25 and 39% in 33 hips, between 40 and 59% in 14, and over 59% in 10 hips. The analysis of postoperative roentgenograms showed the following MP distribution: 56 less than 25%, 23 between 25 and 39%, and 3 greater than 40%. No postoperative MP was higher than 49%. 54% formerly subluxated hips achieved normal MP. The difference between preoperative and postoperative MP was statistically significant (P < 0.001). Before the tenotomies 24 hips were normal with CE angle over 20 degrees. It was between 20 degrees and 11 degrees in 28 cases and between 10 degrees and 1 degree in 17 cases. The preoperative CE angle was negative in 13 cases. Postoperatively CE angle was higher than 20 degrees in 53 hips. It was between 20 degrees and 11 degrees in 22 cases and between 10 degrees and 1 degree in 7 cases. The minimum CE angle after soft-tissue release was 4 degrees. The difference between preoperative and postoperative CE angles was statistically significant (P < 0.001). MP improved in 93% and CE angles in 96% of cases.

DISCUSSION

Classical tenotomies of the spastic hip adductors used to be recommended in prevention of the hip subluxation in cerebral palsy patients. MP improved in 70% of cases in the Reimers' study (1980) based on selective adductors tenotomies. If the soft tissue release was unsuccessful bony operation was indicated. Kalen and Black claimed in 1985 that if psoas tenotomy was performed in addition to adductors tenotomies MP improvement was attained in 80-100% of cases.

CONCLUSION

Adductors and flexors tenotomies can correct the spastic hip joint instability fully and permanently if the operation is performed prior to bony changes of the hip. The operation being followed by appropriate immobilisation and physiotherapy increases the percentage of good results.

Triple osteotomy of the pelvis in children and adolescents

PURPOSE OF THE STUDY

To assess the results of Steel triple osteotomy on Developmental hip displacement (DDH) and Legg-Calvé-Perthes Disease (LCPD) cases utilising objective criteria based on measurements. All measurements were done by a co-author in a blind way. What concerns DDH, triple osteotomy was used in all cases in which authors felt to obtain a profit for a patient, so that hips with non-spherical head were operated on, too. On the other hand, as far as the experience with Steel osteotomy in LCPD is very limited, authors used this method presuming to obtain similar effect like with Salter osteotomy in younger patients.

MATERIAL

41 Steel osteotomies carried out in 29 cases of developmental dislocation of the hip (DDH), (age ranging 14-23 years) and in 12 cases of Legg-Calvé-Perthes disease (LCPD), (9-12 years of age) have been analysed. The follow-up duration was 4-12 years.

METHODS

Differently to the postulations of Dr. Steel, the inaugurator of triple osteotomy for DDH cases, indications in this study were also extended to aspherical congruencies and even incongruencies in DDH. Besides measuring CE, Sharp angles and Reimer's index, there was used subjectively descriptive classification of both initial conditions and results. The reached medialization and caudalization of the femoral head to Shenton line played an important role at the evaluating classification of the results. All obtained data were processed by the statistical methods to ascertain the influence of the operation. The same measuring methods were used for assessment of LCPD cases.

RESULTS

Fisher's exact test has shown the dependence of the results in DDH on the preoperative finding, reflecting the fact, that the triple osteotomy did not improve substantially the parameters of the more distorted hip joints. With the greater degree of joint deformity, the chance to obtain postoperative correction was less. Complete correction in all the DDH group was obtained in 20, partial correction in 7 cases and failure was found in 2 cases. Fisher exact test in LCPD demonstrated that results are not statistically dependent on the initial state. Complete correction in LCPD group was obtained in 10, partial correction in 1 and failure in 1 case.

DISCUSSION

It seems that the indication of Steel triple osteotomy in DDH must be highly well-considered concerning especially the containment of aspherical femoral head. Indication should be based on careful pre-operative planning using dynamic contrast arthrography helping to find the best position of femoral head through the additional femoral osteotomy. Hitherto rare application of Steel osteotomy for LCPD everywhere seems to be little irrespective of the fact that this operation can secure the containment of even deformed femoral head with the perspective of its subsequent remodelling as showed this study.

CONCLUSION

The historical postulate of inaugurator of triple osteotomy, concerning the sphericity of the femoral head as a condition sine qua non, seems to be broken especially in Legg-Calvé-Perthes disease. Even sattle deformity of femoral head can be corrected. What concerns the DDH the greater degree of joint deformity, especially aspherical incongruency brings about the risk of failure of surgical procedure. Nevertheless, in this study five out from seven cases of that degree of distortion obtained at least partial correction.

[Contemporary possibilities of the ultrasound diagnosis of developmental hip dislocation.]

The report is focussed on the last report of Graf et al., which was published in Stolzalpe as a manual for hip sonography in relation to the other contemporary publications from all the world, dealing with the same problem. It seems, that the assessment of hip joint abnormalities in Graf's classification is basically valid, not however the mode of the estimation of dynamic hip sonography. Not only due to the technically improper testing of the hip stability in extension of hip and knee, but as well as for the over-estimation of the displacement of the femoral head, which can produce false-positive findings. Graf's categorisation is still characterised by the over-categorisation of all abnormalities to many subgroups, which do not show always significant differences among themselves. The attitude to the treatment involving POP cast from D group including also newborns differs from all the experience summarised before in the world literature concerning the neonatal age, being limited usually on soft bandages and functional treatment. The recommendation to use overhead traction for subluxating newborn's hip (Graf's group III) does not correspond with the experience and results of many studies, which were performed yet before the era of ultrasound screening. Several reports of the other Czech authors were mentioned, which comply with the Graf's attitude and are even more aggressive in treatment program, starting the over-head traction from Graf's D group. Review of English, French and American literature is here counterweighted to the clinically improper appplica-tion of Graf's diagnostic scheme which however from the point of imaging is basically a good system.

Comparative in vitro and in vivo assessment of genotoxic effects of etoposide and chlorothalonil by the comet assay

The alkaline single cell gel electrophoresis (comet) assay was used to assess in vitro and in vivo genotoxicity of etoposide, a topoisomerase II inhibitor known to induce DNA strand breaks, and chlorothalonil, a fungicide widely used in agriculture. For in vivo studies, rats were sacrificed at various times after treatment and the induction of DNA strand breaks was assessed in whole blood, bone marrow, thymus, liver, kidney cortex and in the distal part of the intestine. One hour after injection, etoposide induced DNA damage in all organs studied except kidney, especially in bone marrow, thymus (presence of HDC) and whole blood. As observed during in vitro comet assay on Chinese hamster ovary (CHO) cells, dose- and time-dependent DNA effects occurred in vivo with a complete disappearance of damage 24 h after administration. Even though apoptotic cells were detected in vitro 48 h after cell exposure to etoposide, such a result was not found in vivo. After chlorothalonil treatment, no DNA strand breaks were observed in rat organs whereas a clear dose-related DNA damage was observed in vitro. The discrepancy between in vivo and in vitro models could be explained by metabolic and mechanistic reasons. Our results show that the in vivo comet assay is able to detect the target organs of etoposide and suggest that chlorothalonil is devoid of appreciable in vivo genotoxic activity under the protocol used.

Selective treatment program for developmental dysplasia of the hip in an epidemiologic prospective study

Over 1 year of ultrasound (US) mass screening, 4,568 newborns were examined consecutively at age 3-4 weeks using both clinical and ultrasonographic examination methods. The US examination involved both the static and dynamic scanning. In total, 25 babies were treated early (5.5 per 1,000), and 6 babies were given late treatment for postnatally developing acetabular dysplasia (1.3 per 1,000). Early treatment was instituted only for hips remarkably distorted anatomically, as could be seen from their shape on the static scan, and for those that were sonographically unstable with an apparent stress displacement. Clinical examination at age 3-4 weeks failed in more than half of all sonographically abnormal cases. In one case, the postnatal development of the hip joint was associated with the worsening of its formation and a developing subluxation despite its primary normal characteristics.

[Ultrasonography in legg-calvé-perthes disease]

Several last reports showed a very good utility of US visualisation in Legg-Calvé-Perthes disease especially in the assessment of the lateral extrusion of the femoral head and the subchondral fracture. Prospective analysis of 43 patients with 53 affected hip joints in this study showed that the hip joint effusion and synovitis have to be differentiated. Effusion occured only in the early stages of the disease. Sensitivity of US detection of the femoral head deformity was 87,3 % in this group compared with X-ray diagnosis. Assessment of the lateral extrusion seems to be rather inaccurate due to the high inter-observer error. A new approach which was suggested, posterior scanning of the flexed hip joint can be effective only if the femoral head is fragmented. US could replace classical X-ray, hopefully, only very partially. Key words: ultrasonography, Legg-Calvé-Perthes disease.

[Congenital posteromedial angulation of tibia and fibula.]

The author has based his article on all available literature dealing with a rare congenital clinical unit "congenital posteromedial angulation of tibia and fibula". Congenital kyphoscoliosis of tibia is a synonym for the same disease. In contrast to other angulations of the tibia and fibula the above mentioned clinical unit is characterized by a spontaneous remodeling of the bone deformity. Persisting is only the shortening of tibia. The author describes in the study his own follow-up of four cases. In one case it was necessary to correct valgus deformity of tibia in 8th month of age. Angulation in all four children spontaneously corrected itself before the 3rd year of age. Documentation is supplemented with a developmental series of x-rays in both projections. The medial component of angulation persists longer than the dorsal component. Discrepancy of the length of lower limbs in our cases where the growth has not finished yet ranges between 2-4 cm. Key words: congenital posteromedial angulation of tibia and fibula.

Ultrasound examination of neonate's hip joints

In a mass screening project, 872 neonates were examined clinically and by ultrasound. Hip joint stability was assessed in the ultrasound stress test showing a normal or physiologic instability, in the range of 0 to 2 mm. Along with the dynamic examination, a modified Graf's method was used. All obtained sonograms were submitted to careful assessment by one of authors, including regular measurement of alpha and beta angles. This relatively small group in the low-risk population served as a model of normality. White newborns compared with an black Caribbean group did not show the presence of apparent primary acetabular dysplasia. Both methods--dynamic ultrasound test and Graf's scanning--seemed to us to be valuable.

[Chronic recurrent multifocal osteomyelitis.]

The authors discuss the diagnostic and prognostic problem of chronic recurrent osteomyelitis (CRMO) described for the first time in 1972 by Giedione. This relatively rare disease of unknown origin is characterized by a slow onset with oedema and pain at several sites of the locomotor apparatus which occur concurrently or consecutively and are followed by relapses. The body temperature is normal or slightly elevated. CRMO is sometimes associated also with palmoplantar pustulosis. The authors evaluate six patients wih CRMO treated in 1988-1994 (4 boys and 2 girls), age 7-13 years at the onset of the disease. There were at least 2 and not more the 4 foci per patient. The clinical symptoms before the first orthopaedic examination persisted for 1-5 weeks. Concurrent skin disease was not observed. Relapses of symptoms were described in the patients at 8 sites with remissions lasting 4-16 weeks. The most frequent site in the investigated group is the distal metaphysis of the femur and proximal metaphysis of the tibia (11 times), the medial portion of the clavicle (twice) and the short bones of the toes (three times). Classical X-ray diagnosis revealed skeletal changes consistent with the appearance of acute or chronic haematogenic osteomyelitis. All-body scintigraphy 99mTc revealed an increased cumulation of the radiopharmaceutical preparation in the focus sooner than the classical X-ray picture. Bacteriological examination of specimens obtained from blood and material from the osseous foci does not identify the causal agent. FW and CRP examination gave elevated values and frequently also leucocytosis. Antibiotics administered for 4-32 weeks produced no detectable effect, non-steroid antiphlogistics mitigated subjective complaints. Sequestration was not observed in the investigated patients. Post-inflammatory premature closing of the growth zones on the short bones of the feet are found as a rule. Key words: chronic multifocal recurrent osteomyelitis, child age.

[Deformity of the forearm caused by benign bone tumours treated by external fixation.]

A developed deformity of the forearm is usually due to an osteochondroma and has a typical clinical and X-ray appearance. Patients suffering from this disease have a restricted function of the forearm due to shortening of the bones, usually both bones, and in particular girls are aware of the cosmetic and aesthetic loss. The X-ray symptomatology of the deformity is as follows: dislocation of the head of the radius, multiple tumours on both bones which dislocate the bones, ulnar angulation of the radius and ulna, shortening of the ulna, ulnar inclination of the articulation surface of the distal radius, ulnar subluxation of the wrist and shortening of the metacarpal bones. The therapeutic procedure used by the authors is stagewise and comprises the following operations: ablation of the osteochondromas, gradual extension of the ulna, reposition of the head of the radius and correction osteotomy of the distal radius. The objective of the submitted paper is long-term clinical and X-ray evaluation of the forearm deformity after operation. In the majority of patients after treatment radial duction in the wrist remains restricted but this is not important from the functional aspect. The X-ray finding of ulnar subluxation of the wrist frequently improves after extension of the ulna. Key words: osteochondromas, deformities of the forearm, gradual extension of the ulna.

[Legg-calvé-perthes disease.]

The author summarizes basic findings on the etiology and epidemiology of Legg-Calvé-Perthes disease (LCP). Attention is paid to its pathogenesis, and the relationship of transient synovitis to LCP is discussed. Attention is paid to pathological findings in LCP and the relationship of growth to the development of LCP. The author analyzes work devoted to clinical and radiological findings, arthrography and scintigraphy of the hip joints, incl. MR, CT and US examinations. He deals also with the differential diagnosis of LCP and prognostic factors which have an impact on therapeutic results. Therapy is discussed from the aspect of conservative treatment (Atlanta splints did not prove very effective in severe forms of LCP), as well as from the aspect of surgical treatment. Special attention is paid to varus osteotomy and osteotomy of the pelvis according to views of various authors, and on the other hand to valgusextension osteotomy in patients where so-called abduction on a hinge with excentric rotation of the head of the femur develops. Special attention is devoted to therapeutic possibilities in severe forms of LCP. The latest views on classification of so-called abduction on a hinge are given corresponding to the grade of lateral extrusion of the head, incl. possibilities of suitable treatment. Key words: Legg-Calvé-Perthes disease, diagnosis, treatment.

[Possibilities to Visualize the Non-ossified Patella by Ultrasound.]

The patella ossifies between the second and third year of life. Inborn dislocation of the patella must be, however, diagnosed as soon as possible. The basis is naturally clinical diagnosis, but the possibillity of imaging of the patellofemoral joint is welcome, as it provides graphic documentation. Apart from the financially and otherwise pretentious NMR examination, documentation can be obtained by ultrasound. The author demonstrates two cases of dislocation of the patella in Down's disease. Key words: congenital dislocation of the patella, ultrasound.

[Late results of conservative treatment of perthes disease.]

The objective of the submitted work was to assess the long-term prognosis of Perthes disease. From the originally invited 142 patients 72 attended the check-up examination, complete X-ray documentation was assembled only in 32 patients with 38 affected hip joints. The time interval which had elapsed since the onset of the disease was on average 17 years. The authors evaluated the clinical and X-ray picture of the hip joints and assessed retrospectively the affection of the head according to Catterall's method, incl. signs of a head associated with risk. Treatment provided during the sixties and beginning of the seventies did not meet the principles of modern "containment" therapy. It comprised bed rest, application of a plaster spike and aftertreatment with a Thomas splint. During late check-up examinations Wiberg's angle, the epiphyseal index, the index of overlapping of the head, the distance of the head from the floor of the acetabulum and the height of the peak of the greater trochanter above the centre of the head of the femur were assessed. In addition to assessment of these partial X-ray parameters the authors evaluated the spherical properties of the head by Mose's method and subjectively the X-ray picture, using a three grade scale (satisfactory, feasible, poor). In the majority of assessed parameters the authors found a statistically significant correlation with the retrospective classification of the original X-ray pictures classified according to Catterall. The clinical picture was satisfactory in the majority, the authors did not find painful restriction of movement, while almost half the patients reported occasional subjective complaints as regards the hip joint. On the X-ray changes in the overgrowth of the greater trochanter were more marked than changes of the spherical character of the head and the extent of decentering. The follow-up of the group will continue to obtain a longer time interval from the onset of the disease. Key words: Perthes disease, late results, Catterall's classification.

Local action transcutaneous flurbiprofen in the treatment of soft tissue rheumatism

The objective of the present study was to establish the efficacy and tolerability of local action transcutaneous flurbiprofen (flurbiprofen LAT) in the treatment of soft tissue lesions. A randomized, double-blind, parallel-group placebo-controlled study was carried out in two hospital outpatient rheumatology clinics. One hundred and four patients aged 18-75 yr were randomized to receive a non-woven polyester-backed patch supporting a formulation containing 40 mg flurbiprofen 12-hourly over 14 days; or a non-medicated (but otherwise identical) control. Statistically significant differences in favour of the active preparation were seen at both days 7 (P = 0.02) and 14 (P = 0.009) for the investigator's overall opinion of severity of the condition, and at day 7 for the investigator's assessment of pain severity (P = 0.04 intention-to-treat; P = 0.052 N.S. eligible data). The need for further treatment in the form of steroid injections after the trial was greater in the controls (29/44, 66%) than in the flurbiprofen LAT group (17/46, 37%) (chi 2 = 7.54 on 1 d.o.f., P = 0.006). Plasma flurbiprofen levels in 11 patients ranged from 13.4 to 338.7 ng/ml (mean 116; median 57.9). Eight out of 53 (15%) patients receiving flurbiprofen LAT reported a total of 10 adverse events, compared with three out of 51 (6%) reporting seven events among controls. Patients found the patch convenient and soothing. We conclude that flurbiprofen LAT is an effective and acceptable treatment for soft tissue lesions, and should be considered as an alternative therapy to local steroid injection.

[Cooperation between the pediatrician and orthopedist in the diagnosis of congenital hip dislocation]

The author summarizes the principles of clinical diagnosis, referring to experience assembled in an investigation comprising more than 35,000 neonates during past years. The submitted pattern could be a practical instruction for examination of the hip joints by paediatricians--neonatologists. The author emphasizes the fact that the diagnosis of complete dislocation unless irreponible is very easy, and being a clinically very obvious defect, it should not be missed. In other countries the trend predominates to ensure examination of the hip joints of neonates by paediatricians-neonatologists for whom this examination is a matter of routine. The author outline possibilities of ultrasonographic examination, static as well as dynamic. In large towns it proved useful to establish an ultrasonographic examination room where some 4000 infants aged 2-3 weeks are examined. The hitherto used classification of ultrasonic examination is not quite reliable in view of "over-diagnosis" and thus to unnecessary therapy which can lead--as any abduction therapy--to complications such as avascular necrosis. Paediatricians-neonatologists should master the clinical problem and be aware of the responsibility for early clinical diagnosis to enable orthopaedists to specify indication for early treatment based on ultrasonographic examination.

Early diagnosis of congenital dislocation of the hip

In this prospective study, 35,550 neonates were examined shortly after birth by a team of orthopaedic surgeons. They diagnosed 775 unstable or dislocated hips in 656 babies; there were two teratological dislocations. Treatment was first with a Frejka pillow and, if this failed to give a normal hip, a Pavlik harness at three months. Early clinical examination did not identify 21 infants who were found to have subluxation or dislocation of the hip at the three-month review. The number of missed cases declined during the study, however, reflecting the increasing experience of the examiners. One case of avascular necrosis occurred in the group treated from birth and one in the late-diagnosed group. Open reduction was necessary only in the two teratological dislocations. Experienced examiners are needed for accurate clinical diagnosis; and treatment should be started before the baby is discharged from the maternity ward.

[Early therapy of congenital hip dislocation and ultrasonic studies of clinically positive cases--results of a prospective epidemiological study in Brünn]

The early diagnosis of CDH in CSFR an in other countries is discussed from different views. To our opinion only the orthopaedic surgeons are able to ensure the high sensitivity and specificity of the clinical tests. In the Brno-prospective epidemiologic study we have examined 19,879 neonates. The frequency of dislocation and instability was 368 cases (18%). The early treatment with Frejka pillow or Pavlik harness has failed only in one case. The systematic second (6 weeks) and third examination (3 months) discovered 19 late diagnosed cases (0.95%). In the era of conventional diagnosis the usual frequency of CDH in CSFR was 20-30%. The ultrasonographic examination of all neonates is not yet possible in our country; we have examined only clinically positive cases.

[Neonatal osteomyelitis is still a reality]

The authors draw attention to the fact that it is essential to consider osteomyelitis of children under 1 year as a separate nosological unit with regard to the anatomical features of the vascular supply of epimetaphyses. The authors discuss the diagnostic difficulties. In addition to the basic examination they emphasize also the importance of whole-body scintigraphy and examination by ultrasound. They indicate surgery where clinical symptoms do not recede within 24-48 hours after the onset of antibiotic treatment and where on probatory puncture pus is revealed and if during establishment of the diagnosis the X-ray finding is already positive. As to antibiotics they use Oxacillin first. The authors evaluate the results of treatment of 25 neonates after a 2-10-year interval following the onset of the disease. The process was found most frequently in the proximal and distal metaphysis of the femur (56%) and in the proximal metaphysis of the tibia (24%). They operated 18 patients in the acute stage (72%). Staphylococcus aureus was cultivated in 60% from pus and in 50% from haemocultures. The authors found a satisfactory state in 17 patients (68%) and an unsatisfactory one in 8 patients (32%).

[Clinical and ultrasonic diagnosis of congenital hip dislocation (dynamics of changes in early therapy)]

The authors present part of their prospective epidemiological study of congenital dysplasia of hip joints within which newborns were examined by ultrasonogram prior to the beginning of the therapy. Apart from the standard examination in the frontal plane after Graf they examined on principle also the ultrasonographic stability by the dynamic test after Schuler as well as by the application of the probe anteriorly with the simultaneous provocation according to Palmén. The authors have processed pathological ultrasonographic findings in 53 newborns (64 hip joints). The technique of the examination by ultrasound from the anterior approach is explained in detail. The comparison of both dynamic tests has shown that the examination from the anterior approach is considerably more sensitive than Schuler's dynamic test and also fully correlates with the clinical finding. It is a fact that the shift of the head in the flexion dorsally represents the most important component of the movement in unstable hip joint during provocation, it is far more noticeable than the lateralization of the head or the shift in the cranial direction. After achieving ultrasonographic stability the classical Graf method is sufficient for the registration of residual changes on the acetabular rim. The follow-up of patients until their complete healing has shown a surprisingly rapid remodellation of hip joints. The whole complex of clinically unstable hip joints has been divided into subgroups according to Graf classification. In type IIc or IId on the basis of ultrasonographic examination from the anterior approach the stable joints from the ultrasonographic viewpoint have been distinguished from unstable ones. The follow-up carried out in short intervals has shown that of longest duration is the remodellation of total dislocation and, on the contrary, of shortest duration is the healing of joints in the IIc or IId type. An absolute majority of affected hip joints have become normal until 3rd month of the age. The complex does not include two patients with teratological dislocation, the incidence of which has been determined in our study by the ratio of 2 cases in 35,550 of timely examined newborns. The role of the factor of spontaneous stabilization cannot be in this part of the study completely discounted. However, herewith we present part of an accomplished epidemiological study where the number of timely diagnosed patients including late diagnoses corresponds to the number of dislocations and subluxations determined within the conventional late diagnosis.

[Generalized laxity of the ligaments in children]

Authors reviewed the literature about the nomenclature and classification of ligamentous laxity syndrome. They are using the term "Generalized ligamentous laxity". They prefer the methods, with total body points-system to the extensometry of the fingers. On the basis of 890 healthy children they determined the statistic characteristics of the score of the generalized ligamentous laxity in relation to age and sex. They suggest, on the basis of the obtained data, the way of clinical application.