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Uvod Pertesova bolest je idiopatska avaskularna osteonekroza proksimalne epifize femura koja se javlja kod dece. Etiologija ove bolesti je nepoznata. Tokom razvoja Pertesove bolesti zastupljen je proces zapaljenja, za koji je pokazano da utiče na remodelovanje koštanog tkiva. Cilj rada S obzirom na to da genetički faktori koji utiču na proces zapaljenja dosad nisu ispitivani kod Pertesove bolesti, cilj ovog istraživanja je bio da se utvrdi povezanost učestalosti varijanti u genima koji učestvuju u inflamatornom odgovoru, TLR4 (engl. toll-like receptor 4) i IL-6 (interleukin 6), i ove bolesti. Metode rada Ispitano je 37 dece s Pertesovom bolešću i 50 zdravih osoba. Metodom PCR-RFLP određeni su polimorfizmi medijatora zapaljenja TLR4 (Asp299Gly, Thr399Ile) i IL-6 (G-174C, G-597A). Rezultati Pokazano je da su polimorfizmi IL-6 G-174C i G-597A u našem ispitivanju bili u potpunoj gametskoj neravnoteži vezanosti. U kontrolnoj grupi je bilo statistički značajno više nosilaca heterozigotnog genotipa IL-6 G-174C/G-597A u poređenju sa grupom ispitanika s Pertesovom bolešću (p=0,047; OR=2,49; 95% CI=1,00-6,21). Takođe, grupa bolesnika nije bila u Hardi- Vajnbergovoj ravnoteži za polimorfizme IL-6 G-174C/G-597A. Nije primećena statistički značajna razlika u raspodeli genotipova za polimorfizme analizirane u TLR4 genu. Raspodela genotipova među grupama bolesnika formiranih na osnovu uzrasta kada se bolest pojavila nije pokazala statistički značajnu povezanost s analiziranim polimorfizmima. Zaključak Naše istraživanje je pokazalo da su nosioci heterozigotnog genotipa za IL-6 G-174C/G-597A polimorfizme bili značajno češći u kontrolnoj grupi nego u grupi dece obolele od Pertesove bolesti. Na osnovu toga zaključili smo da je kod dece koja su nosioci heterozigotnog genotipa za ove polimorfizme manja verovatnoća za razvoj Pertesove bolesti nego kod nosilaca oba homozigotna genotipa., Introduction Perthes disease is idiopathic avascular osteonecrosis of the hip in children, with unknown etiology. Inflammation is present during development of Perthes disease and it is known that this process influences bone remodeling. Objective Since genetic studies related to inflammation have not been performed in Perthes disease so far, the aim of this study was to analyze the association of frequencies of genetic variants of immune response genes, toll-like receptor 4 (TLR4) and interleukin-6 (IL-6), with this disease. Methods The study cohort consisted of 37 patients with Perthes disease and 50 healthy controls. Polymorphisms of well described inflammatory mediators: TLR4 (Asp299Gly, Thr399Ile) and IL-6 (G-174C, G- 597A) were determined by polymerase chain reaction restriction fragment length polymorphism method. Results IL-6 G-174C and G-597A polymorphisms were in complete linkage disequilibrium. A statistically significant increase of heterozygote subjects for IL-6 G-174C/G-597A was found in controls in comparison to Perthes patient group (p=0.047, OR=2.49, 95% CI=1.00-6.21). Also, the patient group for IL-6 G-174C/G- 597A polymorphisms was not in Hardy-Weinberg equilibrium. No statistically significant differences were found between patient and control groups for TLR4 analyzed polymorphisms. A stratified analysis by the age at disease onset also did not reveal any significant difference for all analyzed polymorphisms. Conclusion Our study revealed that heterozygote subjects for the IL-6 G-174C/G-597A polymorphisms were significantly overrepresented in the control group than in the Perthes patient group. Consequently, we concluded that children who are heterozygous for these polymorphisms have a lower chance of developing Perthes disease than carriers of both homozygote genotypes.

Nepotpuna natkrovljenost glave butne kosti se karakteriše poremećenim anatomskim odnosima u zglobu kuka i predstavlja stanje između pozicija apsolutne podudarnosti i potpunog odsustva kontakta dveju zglobnih površina. U mlađoj životnoj dobi najčešće je asimptomatska i predstavlja uzgredan radiografski nalaz. Osteotomija ilijačne kosti po Chiari-ju predstavlja jednu od takozvanih osteotomija “spasavanja“ koje imaju za cilj smanjivanje tegoba, pre svega bola, kod pacijenata sa nepopravljivo narušenim oblikom zglobnih površina. Bila je veoma rasprostranjena i često korišćena metoda u lečenju razvojnog poremećaja kuka i drugih ortopedskih stanja praćenih nepotpunom natkrovljenošću glave butne kosti. Kod velikog broja takvih pacijenata vremenom su se razvile degenerativne promene koje zahtevaju nove hirurške intervencije, pre svega zamenu zgloba veštačkim. Aloartroplastične hirurške procedure su kod pacijenata sa značajno izmenjenim anatomskim odnosima u zglobu kuka izuzetno složene i nepredvidljive, a broj intraoperativnih komplikacija i kasnijih reintervencija nije zanemarljiv. CILJEVI • Utvrditi i uporediti funkcionalni status nakon ugradnje totalne bescementne endoproteze kuka u grupi pacijenta kod kojih je prethodno učinjena osteotomija ilijačne kosti metodom po Chiari-ju u odnosu na grupu pacijenata kod kojih takva procedura nije učinjena, iako je postojala indikacija; • Dokazati opravdanost osteotomije ilijačne kosti metodom po Chiari-ju u smislu očuvanja funkcije zgloba kuka i odlaganja daljih hirurških procedura, pre svega ugradnje veštačkog zgloba; • Ustanoviti tehničke poteškoće prilikom ugradnje i definisati najčešće komplikacije nakon ugradnje totalne bescementne endoproteze kuka kod pacijenata prethodno operisanih metodom po Chiari-ju; • Uporediti radiografske parametre totalne endoproteze kuka između dve grupe ispitivanih pacijenata radi procene trajnosti implantata..., Insufficient femoral head coverage is characterized by altered anatomic hip correlations. It represents condition between absolute joint congruency and complete absence of contact between the two joint surfaces. In the younger age group is usually asymptomatic and an incidental radiographic finding. Chiari surgery is one of so-called „salvage“ osteotomies aimed at reducing symptoms, especially pain, in patients with insufficient femoral head coverage when a full reconstruction of anatomic correlations cannot be expected even by utilization of other more efficient and technically more challenging pelvic osteotomies. It was very frequently used method in the treatment of developmental dysplasia of the hip and other orthopedic conditions followed by insufficient femoral head coverage. A large number of such patients eventually have developed degenerative changes that require a new surgical procedure, primarily total hip replacement. Total hip arthroplasty in patients with significantly altered anatomic correlations in the hip joint is extremely complex and unpredictable, and the number of intraoperative complications and subsequent reinterventions is not negligible. OBJECTIVES • Identify and compare the functional status after implantation of noncemented total hip endoprosthesis in a group of patients who had previous Chiari osteotomy in relation to the group of patients in whom this procedure was not performed, although there was an indication; • Prove justification of Chiari pelvic osteotomy in terms of preserving the function of the hip joint and delay of further surgical procedures, primarily the total hip arthroplasty • Establish technical difficulties during total hip arthroplasty and define the most common complications after implantation of noncemented total hip endoprosthesis in patients previously operated on by the Chiari method; • Compare radiographic parameters of total hip replacement between the two groups of patients to assess the durability of the impl

Introduction. Hip joint incongruence is found in a number of hip joint disorders in childhood and adolescence. Altered hip joint compression force overcomes the adaptive capacity of joint cartilage, inevitably leading to degenerative joint changes and early invalidity. Most utilized method for operative treatment of this impairment that we use in adolescent age is Tennis triple pelvic osteotomy. The effects of operative treatment can be objectively analyzed by numeric and analytic hip joint mathematical models. The mathematical model most used in hip joint biomechanical functional analysis is three-dimensional radiography-based model. It has been widely applied to normal hips and hips operated by various methods. However, it has not been applied to Tennis triple pelvic osteotomy. Goals. To apply three-dimensional radiography-based mathematical model of the hip joint to standard anterioposterior pelvis and hip radiography, before and after triple pelvic osteotomy, to calculate parameters of contact hip stress distribution (direction, angle and intensity of resultant hip force, angle and magnitude of peak contact hip stress, the index of the hip stress gradient), and to analyze the relationship of biomechanical parameters to patients’ standard clinical and radiographic data. Material and method. Out of 92 patients with hip joint incongruence in adolescent age (due to developmental disease of the hip, postreductional avascular necrosis of femoral head or Leg-Calvé-Perthes disease), operated by Tönnis triple pelvic osteotomy at the Institute for Orthopaedic Surgery “Banjica” in Belgrade in the period from 1996. to 2011, 75 hips (60 patients) were included in the test group, with average Wiberg CE angle of 15,18+/-9,310. All contralateral hips were also analyzed, and then divided in negative control group (healthy hips, 19 cases) and positive control group (deformed hips, 56 cases). The three-dimensional radiography-based mathematical model of the hip joint described by

Objective: To define productivity indicators in healthcare department which reflect department functioning and enable productivity measurements over years. Methods: A combination of two methodologies, the Seven Steps of Determining Productivity Indices and the Objectives Matrix Method, was applied at the Department for Pediatric Orthopedics and Traumatology of the Institute for Orthopedic Surgery "Banjica" in Belgrade in order to determine and analyze productivity indicators during the period from 2005 to 2010. Results: Based on Departments' measurable inputs and outputs, productivity indicators were defined, divided in three categories: department, surgeons and nurses. By observing single indicators in Objectives Matrix, the score increased for average length of hospital days which shortened over the observed six years. The relationship between the number of surgeries and the number of working hours in the operating theater increased, as well as the indicators of the productivity of nurses. Productivity indicators of the Department regarding ambulatory working hours were constant in case of ultrasound exams, while those regarding emergency and consultative exams were decreased. Conclusion: Although the methods of the Seven Steps of Determining Productivity Indices and Objectives Matrix have been developed for the needs of industrial organizations, the paper shows that their application is possible in healthcare services as well. Productivity follow-up using indicators and total weighted score during years, enables healthcare managers to analyze low-productivity fields where improvements are needed.

Objective: In order to measure patients' satisfaction in the Institute of Orthopaedic Surgery "Banjica" there was study about quality of healthcare services, quality of employees practice, as well as, quality of healthcare treatments and other services. Methodology: The questionnaires, focus group interviews, were conducted with 90 patients, consumers of healthcare services in Institute of Orthopaedic Surgery "Banjica" from August to November 2010. Interviews were anonymous, which gives freedom of opinion in patients' population. Results: The results show that patients' satisfaction with healthcare services in this Institute is very high. According to the results, it is 85.8% patients which are very satisfied with healthcare services. Evaluation of general satisfaction, 70.1% of patients have opinion that this Institute is more competitive then others on healthcare orthopaedic market place in Serbia. Patients will choose this Institute again for their healthcare problems (85.6%), which show that this Institute has very satisfied patients and patients which will give good recommendation for the Institute. Conclusions: Satisfaction of patients is key point in healthcare organizations, because their satisfaction is real measure of healthcare institutions work and measure of branding institutions in patients' mind. Also, patients' satisfaction shows real position of healthcare institutions on market place. The truth is that healthcare organizational strength comes from within the team of people that work there, which fulfils patients' satisfaction with their practices as doctors, nurses, technicians and others medical staff. This research present that the Institute of Orthopaedic Surgery "Banjica" is well positioning on healthcare marketplace and that patients are very satisfied with healthcare services in this Institute. According to research, Institute in further work have to follow modern approaches in medicine and management field, in order to keep leader position o

Hallux valgus je kompleksan deformitet prednjeg stopala. Pored lateralne devijacije prvog metatarzofalan-gealnog zgloba veće od 15-20 stepeni i intermetatrzalnog varusa većeg od 8-9 stepeni, odlikuje se i opsežnim promenama u mekim tkivima svoda, sezamoidnom mehanizmu i metatarzokuneiformnom zglobu. Javlja se gotovo isključivo kod ljudi koji nose obuću. Iako se donekle može tretirati neoperativno, korektivnim separatorima i ulošcima, dominantno lečenje je operativno. Opisan je veliki broj operativnih postupaka čiji je cilj korekcija deformiteta i uspostavljanje normalne biomehanike prednjeg stopala. Postoji sedam konceptualno različitih procedura počevši od jednostavne buniektomije, preko raznih mekotkivnih procedura, metatarzalnih i falangealnih osteotomija, do resekcione artoplastike i metatatrzofalan-gealne artrodeze. Sve imaju jasne indikacije i nijedna od njih nema prednost nad ostalima. U skladu sa etiopatogenezom bolesti prevencija je jednostavna: nošenje udobne obuće., Hallux valgus is a complex deformity of the forefoot. Beside the lateral deviation of the first metatarsophalangeal joint angle exceeding 15-20 degrees and intermetatarsalvarus exceeding 8-9 degrees, it is also characterized by extensive changes of the soft tissue arch, sesamoid mechanism and metatarsocuneiform joint. It occurs almost exclusively in humans wearing shoes. Although in some measure it can be treated non-operatively, by corrective separators and inserts, operative treatment is predominant. There are numerous operative procedures aimed at the correction of the deformity and inducing normal biomechanics of the forefoot. There are seven conceptually different procedures starting from simple bunionectomy, through various soft tissue procedures, metatarsal and phalangeal osteotomies, to resection arthroplasty and metatarsophalangeal arthrodesis. All have clear indications, and none of them has advantages over the others. In accordance with the etiopathogenesis of the disease prevention is easy; wearing comfortable shoes.

Lukovi stopala su definisani položajem kostiju i stabilizovani aktivnim i pasivnim mekotkivnim strukturama. Najznačajniji lukovi stopala su longitudinalni, medijalni i lateralni. Oni se tokom života razvijaju i menjaju, a najčešći poremećaj predstavlja ravno stopalo. U prve dve godine života oslonac punim stopalom se smatra fiziološkom pojavom, a nakon toga predstavlja deformitet koji zahteva dijagnostiku i terapiju. Fleksibilno ravno stopalo je uzrokovano ligamentarnom labavošću, najčešće je bezbolno i leči se simptomatski (propisivanje odgovarajuće obuće i kineziterapija). Rigidno ravno stopalo najčešće nastaje usled koštanih promena (vertikalni kongenitalni talus, tarzalna koalicija) nastalih idiopatski ili u sklopu neuromuskularnih patoloških stanja, a bolne tegobe su najčešće prisutne. I ovde se lečenje počinje neoperativnim metodama, ali je najčešće neophodno primeniti neku od vrsta operativnog lečenja., Foot arches are defined by the position of bones and stabilized by active and passive soft tissue structures. The most significant foot arches are longitudinal, medial and lateral. During lifetime they develop and change, while the most significant disorder represents the flatfoot. During the first two years of life, the flatfoot in full weight bearing position is considered a normal physiological condition, while in later age it represents a deformity requiring additional diagnostics and treatment. The flexible flatfoot is caused by ligamentous laxity, it is mostly pain-free and is treated symptomatically (prescription of adequate shoes and kinesitherapy). The rigid foot is most often caused by bone changes (tarsal coalition, vertical congenital talus) occurring idiopathically or within neuromuscular pathological conditions, with mostly present pain problems. In such cases treatment is also initiated by non-surgical methods, however, some type of surgical treatment is most frequently necessary to be used.

Uvod. SWOT analiza je menadžerski instrument za analiziranje unutrašnjeg i spoljašnjeg okruženja kroz snage i slabosti, mogućnosti i pretnje. Cilj rada. Cilj rada je bio da se prikaže primena SWOT analize u Službi za dečju ortopediju i traumatologiju Instituta za ortopedsko- hirurške bolesti 'Banjica' u Beogradu. Metode rada. Kvalitativno istraživanje je urađeno u decembru 2008. godine primenom tzv. fokusgrupa čiji su učesnici bili zaposleni zdravstveni radnici i bolesnici ove službe. Proces rada u fokus-grupi odvijao se u dve faze. U prvoj fazi je primenjena tehnika za prikupljanje ideja, 'vrtlog ideja' o faktorima unutrašnjeg i spoljašnjeg okruženja, odnosno prepoznate su snage i slabosti, mogućnosti i pretnje Službe. U drugoj fazi je primenjena nominalna grupna tehnika i smanjena je lista faktora, koji su, prema svom uticaju na Službu, procenjivani na trostepenoj Likertovoj (Likert) skali, od faktora sa najvećim (rang 3) do faktora s najmanjim uticajem (rang 1). Rezultati. Najveću snagu Službe čine: stručan i iskusan kadar, visokokvalitetne usluge, prosečna zauzetost postelja, činjenica da je Služba nastavna baza, zadovoljni korisnici, prijatan ambijent i dopunski rad. Slabosti su: prostorna organizacija, nemotivisanost kadra za stalno usavršavanje, nedostatak pojedinih profila zaposlenih, neadekvatan sanitarni čvor, nemogućnost pružanja usluga koje ne pokriva Fond osiguranja, duga prosečna dužina bolničkog lečenja i nizak materijalni status većeg dela korisnika. Mogućnosti su: zakonska regulativa, formiranje pedijatrijske traumatološke službe u Beogradu, dobra regionalna pozicija Instituta i nova tržišta. Pretnje su: izostanak autonomije Službe u kadrovskoj politici i kadrovska politika Instituta, organizacija Instituta po službama i odeljenjima, konkurencija unutar Instituta, nemogućnost povećanja kapaciteta odeljenja, ishrana neprilagođena bolesnicima, male mogućnosti za stručno usavršavanje zaposlenih, zastarelost opreme Instituta i neformalni oblici plaćanja, Introduction. SWOT analysis is a managerial tool used to evaluate internal and external environment through strengths and weaknesses, opportunities and threats. Objective. The aim was to demonstrate the application of the SWOT analysis on the example of the Department for Paediatric Orthopaedics and Traumatology at the Institute of Orthopaedic Surgery 'Banjica' in Belgrade. Methods. Qualitative research was conducted during December 2008 at the Department for Paediatric Orthopaedics and Traumatology of the Institute of Orthopaedic Surgery 'Banjica' by applying the focus group technique. Participants were members of the medical staff and patients. In the first phase of the focus group brainstorming was applied to collect the factors of internal and external environment, and to identify strengths and weaknesses, opportunities and threats, respectively. In the second phase the nominal group technique was applied in order to reduce the list of factors. The factors were assessed according to their influence on the Department. Factors ranked by the three point Likert scale from 3 (highest impact) to 1 (lowest impact). Results. The most important strengths of the Department are competent and skilled staff, high quality of services, average hospital bed utilization, the Department providing the educational basis of the School of Medicine, satisfied patients, pleasant setting, and additional working hours. The weaknesses are: poor spatial organization, personnel unmotivated to refresh knowledge, lack of specifically trained personnel, inadequate sanitary facilities, and uncovered services by the Insurance Fund, long average hospital stay, and low economic status of patients. The opportunities are: legislative regulations, formed paediatric traumatology service at the City level, good regional position of the Institute, and extension of referral areas. The threats are: absent Department autonomy in the personnel policy of the Institute, competitions within the Institute, impo

Uvod. Institut za ortopedsko-hirurške bolesti 'Banjica' u Beogradu pruža tercijarne zdravstvene usluge na nacionalnom nivou. Nakon decenija neprekidnog razvoja, tokom poslednjih godina, u uslovima velikih socijalnih i državnih promena, perioda tranzicije i raspada bivše Jugoslavije, došlo je do slabljenja Instituta. Cilj rada. Radi prevazilaženja krize, primenili smo moderne metode menadžmenta, kako bismo definisali probleme u vođenju ustanove i predložili odgovarajuće strategije oporavka. Metode rada. Sprovedena je anketa na 100 ispitanika (17,67%) zaposlenih u Institutu. Rezultati su obrađeni metodama deskriptivne statističke analize, PEST i SWOT analizom. Rezultati Ocenjen je uticaj političkih fluktuacija, starenja stanovništva, finansijskog modela i tehnološke zastarelosti. Ispitivani su brojni personalni i interpersonalni faktori: kvalitet medicinske usluge (3,59±0,76, skala 1-5), odnos između učesnika u procesu zdravstvene zaštite (3,39±0,78), uslovi rada (opisani kao neodgovarajući u 91% slučajeva), ljudski, finansijski i drugi resursi, profesionalna saradnja, stimulacija, konkurencija i mobing (zabeležen u 56% slučajeva), javno informisanje, ugled institucije (ocena 3,70±0,88) i PR aktivnosti (neprepoznate u 78% slučajeva). Skoro svi ispitanici (93%) su se izjasnili da na poslu ulažu maksimalni napor. Zaključak. Na osnovu rezultata istraživanja definisano je nekoliko strateških ciljeva. Oni obuhvataju jačanje naučnih aktivnosti, opštu orijentaciju ka specifičnim i ekskluzivnim patološkim stanjima i metodama lečenja, poboljšanje transparentnosti u rukovođenju ustanovom, uvođenje sistema stimulacije zaposlenih na osnovu kvaliteta, podršku promociji i PR aktivnosti Instituta., Introduction. The Institute for Orthopaedic Surgery 'Banjica' in Belgrade provides tertiary healthcare services on national level. After decades of constant development, a recent decline coincided with the decade of great social and governmental disturbance, the transition period after the dissociation of former Yugoslavia. Objective. In order to overcome the crisis, we used modern management methods to define problems in the institution management, and to propose appropriate strategies. Methods. A survey that included 100 employees (17.67%) was carried out, followed by descriptive statistical analysis, PEST and SWOT analyses. Results The impact of political fluctuations, ageing of population, financing model, obsolete medical technology was evaluated. Various personal and interpersonal factors were assessed: the quality of medical service (3.59±0.76, mark 1-5); relations among health service participants (3.39±0.78); occupational conditions (not good-91%); human, financial and other resources; professional cooperation, stimulation; rivalry and mobbing (declared in 56%); public informing, institution image (rank 3.70±0.88) and PR activities (new to 78%). 93% declared to give maximum effort at work. Conclusion. Using these results, we defined several strategic objectives. These include strengthening scientific activities, general orientation to specific and exclusive pathological conditions and treatment methods, improvement of management transparency, introduction of quality-based stimulation of workers, support of promotional and PR activities.