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Intolerance of gluten containing cereals (wheat, rye, and barley) is an etiopathogenetically heterogeneous and relatively common problem of modern man. It occurs as an adverse immune-mediated condition in genetically predisposed individuals. According to the pathogenetic mechanism of intolerance to the components of these cereals, it is classified into celiac disease as an autoimmune disease, wheat allergy as an allergic disease, and non-celiac gluten sensitivity as a non-autoimmune and non-allergic disease. Each of these disorders is characterized by specific intestinal and/or extraintestinal manifestations, which resolve on a gluten-free diet. This review article presents the basic characteristics of these disorders in accordance with modern knowledge.

Celiac disease is a multisystemic autoimmune disease induced by gluten in wheat, rye, and barley. It is characterized by polygenic predisposition, prevailing prevalence in members of the white population (1%), especially in close relatives (5–15%), very heterogeneous expression and frequent association with other autoimmune diseases (3–10%), as well as selective deficiency of IgA and Down, Turner, and Williams syndromes. The basis of the disease and the key finding in its diagnostics is gluten-sensitive enteropathy, i.e., non-specific inflammation of the small intestinal mucosa which resolves by gluten-free diet. In addition to enteropathy, whether symptomatic or asymptomatic, the disease is also characterized by various extraintestinal manifestations, and even very serious complications. Therapy is based on a lifelong glutenfree diet, so that the disorder, if diagnosed in time and treated consistently, has an excellent prognosis.

Introduction/Objective. Celiac disease (CD) is the result of a polygenic predisposition and gluten-containing diet. The aim of this study was to determine the prevalence and clinical forms of CD in siblings of children with verified disease. Methods. The study included 83 siblings, aged 1.5–27 (11.77 ± 6.2) years, of 64 children with CD diagnosed according to ESPGHAN criteria (1990/2012). In addition to a detailed history and clinical examination, serum levels of IgA and antibodies to tissue transglutaminase (AtTG) IgA and IgG classes were determined in all subjects. All with elevated AtTG levels underwent multiple duodenal enterobiopsy. The diagnosis of CD was confirmed by the finding of characteristic histological changes. Results. The diagnosis of CB was made in 13 of 83 subjects (15.67%). Nine of them had an asymptomatic form of the disease, while in the others the disease was clinically manifested – in three the form was classical, in one it was accompanied by severe malnutrition (-26.80%), and in one the manifestation was nonclassical (only short stature). Except for sideropenia and hypoferritinemia in four patients, of which two with hemoglobin below the reference value, standard laboratory findings were within normal limits. Conclusion. Our research shows that the prevalence of CD in siblings of children with verified disease is 15.67%. It is mostly detected in its asymptomatic form. In accordance with this, routine application of serological screening for CD in this population group is necessary for its timely diagnosis and treatment.

Introduction/Objective. Gilbert syndrome (GS) is the most common hereditary hyperbilirubinemia. As well as mild unconjugated hyperbilirubinemia, it is characterized by the excess of bilirubin monoglucuronide over diglucuronide in the bile and thus increases the risk of biliary calculosis. The aim of the study was to determine the importance of GS as a risk factor in the development of cholelithiasis in children. Methods. The study included a sample of 31 children (14 male and 17 female, mean age 12.16 ± 4.11 years, range 3–16.75 years) with symptomatic cholelithiasis. The diagnosis of cholelithiasis was based on an ultrasonographic finding, and for GS the diagnosis was based on at least a double increase of unconjugated bilirubin fraction after a three-day hypocaloric diet (400 kcal per day). Results. GS was confirmed in five or 16.13% of patients (three male and two female, mean age 14.71 ± 0.55 years, range 14–15.3 years). In addition to GS, in the history of the disease they all had some of the additional risk factors for the development of cholelithiasis. One of them had an identical problem as its mother, one had hereditary elliptocytosis, one had sudden weight loss, one was overweight, and one had premature birth and sepsis. Conclusion. GS registers in one-sixth of children with cholelithiasis, but in none of them as the only risk factor for developing this disease. This finding suggests that GS is a risk factor for the development of cholelithiasis, but not sufficient in itself in that respect.

Introduction/Objective. Nonclassical celiac disease (CD) is characterized by a very heterogeneous and non-specific clinical presentation. The aim of this study was to determine the basic symptoms and clinical signs of this CD subtype in children and adolescents Methods. The study was based on a sample of 58 children and adolescent, 38 female and 20 male, ages 1.75 to 17.75 (10.01±4.62) years with a nonclassical CD diagnosed according to the European Society for Pediatric Gastroenterology, Hepatology and Nutrition criteria from 1990 and 2012. Results. Except four patients who were between the ages of 1.75 to 2.50 years, all others were older than three years. The main clinical symptoms and signs suggestive of non-classical CD were anemia caused by iron deficiency (48.28%), short stature (34.48%), and intermittent abdominal pain (18.97%), anorexia with stagnation or weight loss (13.79%), and chronic constipation (6.9%). Thirty patients had one symptom or sign of the disease, 15 had two and 13 had three. In addition, 12 patients had dental enamel hypoplasia, 18 sideropenia without anemia and five mild isolated hypertransaminasemia. A gluten-free diet, apart from the dental enamel hypoplasia, has resulted in the withdrawal of all indicators of the disease. Conclusion. The main symptoms and clinical signs of nonclassical CD in children and adolescents were iron deficiency anemia, short stature and intermittent abdominal pain, and less frequently anorexia with stagnation or weight loss and chronic constipation. Excluding dental enamel hypoplasia, a gluten-free diet leads to a complete recovery of the patient.

Introduction/Objective. Benign transient hyperphosphatasemia (BTH) is a pathogenetic insufficiently clear clinical entity that is mostly seen in infants and young children. The objective of this paper is to present our experience regarding the age of occurrence, the conditions of the discovery, and the length of duration of BTH in children. Methods. The study was realized on a sample of 18 children, nine boys and nine girls, aged 10–42 (21.06 ± 9.35) months with BTH. The diagnosis of BTH is based on the absence of bone and hepatobiliary diseases, and its spontaneous disappearance over the course of several months. Results. One patient was in the first year, 13 in the second, three in the third, and one in the fourth. Isolated high activity of serum alkaline phosphatase, which was 2.04–21.9 (8.05 ± 5.31) times above the upper reference value for the corresponding age, in 14 cases it was found during the acute diarrhea, and in four with acute rhinopharyngitis, of which in two complicated with otitis media. The cause of diarrhea in six cases was rotavirus, in two Campylobacter, and in one adenovirus, and otitis media in one case was caused by Streptococcus pneumoniae, while in others, etiologic factors of infection were not identified. Spontaneous normalization of serum alkaline phosphatase activity was recorded between one and three months after the onset. Conclusion. BTH is a harmless biochemical disorder that spontaneously subsides within three months after initial observation. It is found randomly as a routine laboratory finding most often within the treatment of acute gastrointestinal and respiratory infections.

Introduction. Recurrent aphthous stomatitis (RAS) is a relatively common oral mucosal lesion of unclear etiology. It occurs in otherwise healthy people, but also in various infectious and non-infectious diseases, including celiac disease (CD). We present an obese adolescent with RAS as the only clinical sign of CD. Case outline. An adolescent aged 15 2/12 years come with very pronounced RAS in previous five months. He had no other difficulties. The patient was obese from the age of 12. Other data were without peculiarities. On admission he was 165 cm tall (P25), obese (BMI 27 kg/m2), in the final stage of puberty, with stretch marks in the distal areas of the abdomen, thighs and gluteus and very pronounced pain-sensitive aphthae in the buccal and labial mucosa accompanied by swelling of the lips and perioral region. Except for lower serum iron levels (8 μmol/l), routine laboratory blood tests were within the reference range. The serological test for CD was positive (antibodies to tissue transglutaminase IgA 78.5 U/ml, anti-endomysial antibodies IgA positive). Endoscopy revealed reflux esophagitis, without any other pathological findings. Stereomicroscopic and pathohistological analysis of the duodenal mucosa samples showed mild destructive enteropathy (Marsh IIIa). Pathohistological examination of the gastric mucosa revealed grade I-II lymphocytic gastritis. The urease test for Helicobacter pylori was negative. A gluten-free diet resulted in the withdrawal of aphthous stomatitis and no recurrence later. Conclusion. Within the differential diagnostic analysis of the RAS causes, CD should also be considered. Additionally, obesity does not exclude the presence of CD.

Introduction/Objective. The purpose of this study was to compare two methods of treatment and to evaluate the advantages in the final outcome of transcervical fixation of the femoral head using one cannulated screw in the treatment of slipped capital femoral epiphysis. Methods. This study included 65 pediatric patients (35 boys and 30 girls), aged 6–16 years (average 11.86), during a 12-year period (2000–2012). We compared the slipping degree before and after the treatment (Southwick angle), the range of motion before and after treatment, and complication occurrence between two groups of children. The first group of children (26 patients) underwent closed reduction and cast immobilization (Group I). The other group (39 patients) was treated with transcervical fixation using one cannulated screw (Group II). Results. Comparing preoperative and postoperative Southwick angle, we found much better improvement in Group II, but without statistical significance between the two groups of patients (p = 0.09). Observing the range of motion of the hips before and after treatment, we found improvement in both groups of patients, especially in patients treated using transcervical fixation with cannulated screw (Group II). In complication occurrence, the patients in Group II had less complication occurrence compared to Group I (p = 0.02). Conclusion. The transcervical fixation using one cannulated screw has better clinical outcome and lower complication rate in relation to closed reduction and cast immobilization in the treatment of slipped capital femoral epiphysis.

Introduction/Objective Isolated hypertransaminasemia (IHTS) is a common, benign, and transient appearance in patients with celiac disease (CD). The aim of this study is to determine the frequency of IHTS in children up to two years old with clinically classical CD, as well as its connection with the onset of the first symptoms of the disease, the age of diagnosis, the clinical and laboratory nutritional parameters, and the degree of damage of small intestinal mucosa. Methods The study was based on a sample of 82 children, 55 female and 27 male, ages 7–24 (14.28 ± 4.41) months. The diagnosis of CD was based on the revised ESPGHAN criteria and the activity of serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) by standard laboratory methods. Results IHTS was found in 39 (47.56%) patients, 27 of whom (69.23%) had elevated levels of both transaminases and 12 of only one – eight of AST and four of ALT. The increase in relation to the aforementioned reference value for ALT was 1.1–10.08 (1.67 ± 1.73), and for AST it was 1.08–7.91 (1.56 ± 1.29) times. In patients with IHTS compared to those with normal transaminasemia, the age of onset of CD was significantly lower (9.83 ± 3.69 vs. 12.95 ± 4.43 months, p = 0.001), as well as the age of diagnosis (12.97 ± 3.88 vs. 15.47 ± 4.56 months; p = 0.01), while the differences in the other observed parameters were not significant. Conclusions IHTS occurs in almost half of children up to two years old with classical CD. Hypertransaminasemia is in most cases mild and significantly more frequent in patients with earlier clinical expression of the CD.

Introduction/Objective. The classic type of celiac disease (CD) is most common in children under two years of age. The aim of this study was to investigate whether breastfeeding, particularly breastfeeding during gluten introduction, and timing of gluten introduction, influence the onset of CD at this age. Methods. We retrospectively analyzed medical records of 93 children, 40 in the first and 53 in the second year, with a classic CD diagnosed at the University Children’s Hospital, Belgrade between 2000 and 2010. The diagnosis of CD was based on the criteria of the European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) from 1989. Results. Duration of breastfeeding reduced the onset of the CD in the first year p = 0.039 (OR = 1.43 95% CI 1.019–1.899). Also, breastfeeding at the time of gluten introduction significantly delayed the age at diagnosis (F = 1.671, t = 2.39, p = 0.029). The timing of gluten introduction did not affect the age of occurrence of CD in these group of children. Conclusion. Longer breastfeeding, and breastfeeding at the time of gluten introduction, postponed the onset of classic CD in patients up to two years. The association between the occurrence of CD and the time of introduction of gluten in this age group of patients has not been established.

Introduction/Objective. Anemia is the most common extraintestinal manifestation of celiac disease (CD) in children. The aim of this study was to determine the frequency, severity and type of anemia in children with a classical CD, as well as the differences between anemic and non-anemic patients in their age, duration of illness, percentile body length or height, percentage of body weight (BW) deviation compared to ideal, and the degree of damage to the small intestine mucosa. Methods. The study was based on a sample of 90 children, 56 females and 34 males, ages 7–90 (18.23 Ѓ} 12.7) months with classical CD. The diagnosis of CD is based on the ESPGHAN criteria from 1990 and 2012, and of anemia on the 2011 WHO reference values. Results. Anemia was found in 47 (52.22%) patients, of which it was mild in 23 cases [hemoglobin (Hb) 100–109 g/L] and moderately severe in 24 (Hb 70–99 g/L), in 34 (72.34%) it was microcytic [mean cell volume (MCV) < 70 fl] and normocytic (MCV 70–87 fl) in 13 patients. Low serum iron levels (< 10.7 μmol/L) were found in 68 (75.56%), and hypoferritinemia (< 16 ng/ml) in 77 (85.56%) patients. Except for a greater deficit of BW in patients with anemia compared to those without anemia (-14.64 ± 9.60 vs. -8.56 ± 11.87%, p < 0.01), differences in other defined features were not significant. Conclusion. Mild or moderate iron deficiency anemia occurs in slightly more than half of children with a classical type CD. In anemic compared to non-anemic patients, there is a significantly higher BW deficit, while differences in other characteristics typical for this type of disease are not significant.

Introduction. Isolated dislocation of the pisiform bone is a very rare condition due to robust ligamentous attachments that stabilize the pisiform to the carpus. This type of injury is usually a result of direct trauma to the ulnar and volar aspect of the wrist. Case outline. We present an isolated dislocation of the pisiform, with no other carpal bone injuries, treated successfully with closed reduction. Diagnosis was based on clinical findings, plain radiographs, and computer tomography examination of the wrist. Elongation and partial rupture of the pisometacarpal ligament was found on magnetic resonance imaging. Conclusion. Fracture and dislocation of the pisiform is an extremely rare injury in children, which could be easily neglected or misdiagnosed. Closed reduction with plaster cast immobilization should always be considered as the first method of treatment in the pediatric population, since the conservative approach provides excellent results.

Introduction. Guillain–Barre syndrome (GBS) is the most common cause of acute flaccid paralysis in healthy infants and children. Acute motor axonal neuropathy (AMAN) is a type of GBS characterized by motor syndrome with no sensory symptoms. Case outline. Authors describe a six-and-a-half year old girl with atypical clinical presentation of AMAN with severe painful lower limbs and refusal of the leg reliance with typical findings on nerves conduction studies. Conclusion. Despite the nerve conduction study findings, atypical forms of AMAN and GBS are possible. Pain symptoms must be taken very seriously and treated careful by the clinicians.

Introduction/Objective. Child abuse is a significant public health problem in modern society. Many cases of violence against children remain undetected. Serbia has no official protocols for medical examination of abused children. The aim of the study is an analysis of the social, clinical and radiological characteristics of physical abuse of children under three years of age that required hospital treatment. Methods. This retrospective study included 98 physically injured children admitted to the University Children’s Hospital in the period from 2013 to 2015, with suspected physical abuse. In addition to the history of injuries, complete clinical examinations and standard laboratory analyses were performed in all children, as well as X-ray examination in children with apparent or suspected skeletal injury. Ultrasound examination and computerized tomography or magnetic resonance imaging were performed in selected patients. Final diagnosis of abuse was established by multidisciplinary assessment team. The children were divided into two groups – those with proven and those with suspected abuse. Results. Most of 98 children who were suspected of being abused (92%) were from one or both unemployed parents, 68% were male, 60% were first-born, and 44% younger than one year. Ninety-two percent of the children had skeletal fractures, 19% of whom had two or more fractures. The commonest fracture was a linear skull fracture, which was detected in 51% of the cases. Abuse was confirmed in only five of 98 suspected cases. Conclusion. Among the known social risk factors for abuse of children, the low economic status of the family was the most frequent one in our analyzed sample. The most common injury is a linear skull fracture. A national guideline for medical investigating of abused children is required.

Introduction. Closed reduction and percutaneous pinning are the most widely used treatment options for displaced supracondylar humerus fractures in children, but there is still no consensus concerning the most preferred technique in injuries of the extension type. Objective. The aim of this study was to compare three common orthopaedic procedures in the treatment of displaced extension type supracondylar humerus fractures in children. Methods. Total of 93 consecutive patients (66 boys and 27 girls) referred to our hospital with Gartland type II or III extension supracondylar humeral fractures were prospectively included in the study over a six-year period. At initial presentation 48 patients were classified as Gartland type II and 45 as Gartland type III fractures. The patients were subdivided into three groups based on the following treatment modality: closed reduction with percutaneous pinning, open reduction with Kirschner wires (K-wires) fixation, and closed reduction with cast immobilisation. The treatment outcome and clinical characteristics were compared among groups, as well as evaluated using Flynn’s criteria. Results. Excellent clinical outcome was reported in 70.3% of patients treated with closed reduction with percutaneous pinning and in 64.7% of patients treated with open reduction with K-wire fixation. The outcome was significantly worse in children treated with closed reduction and cast immobilisation alone, as excellent outcome is achieved in just 36.4% of cases (p=0.011). Conclusion. Closed reduction with percutaneous pinning is the method of choice in the treatment of displaced pediatric supracondylar humeral fracture, while open reduction with K-wire fixation is as a good alternative in cases with clear indications. [Projekat Ministarstva nauke Republike Srbije, br. 175095]

Introduction. Alpha-1-antitrypsin deficiency (AATD) is a relatively rare and clinically very heterogeneous autosomal recessive disorder. Objective. Presentation of clinical characteristics of AATD in the first months after birth, as well as the significance of testing brothers and sisters for its presence. Methods. Objectives of the study were analyzed on a sample of eight children (four male and four female, aged 63 months (mean14.81±23.96 months; range 1-63 months) with AATD confirmed based on its low serum value and pathological phenotype. Results. Of the total of eight patients, six manifested cholestasis syndrome (three male and three female, mean age 2.25±1.37 months; range 1-4.5 months), while two patients, a 3.5-year-old girl and a 5.25-year-old boy, were without symptoms and clinical-laboratory signs of the disease, disclosed during family testing. Serum alpha-1-antitrypsin level rated 0.30-0.66 g/L (0.37±0.12), among which seven were with ZZ phenotype 0.30-0.39 (0.33±0.04), and in a boy with FZ the phenotype was disclosed on family screening, 0.66 g/L. In the group of patients with cholestasis syndrome (serum GTT 444.80±203.15 U/L; range 201-676 U/L), three had mild to moderate hepatomegaly, one had longitudinal growth delay (

Introduction. X-linked hypophosphatemic rickets (XLHR) is a dominant inherited disease caused by isolated renal phosphate wasting and impairment of vitamin D activation. We present a girl with X-linked hypophosphatemic rickets (XLHR) as a consequence of de novo mutation in the PHEX gene. Case Outline. A 2.2-year-old girl presented with prominent lower limb rachitic deformity, waddling gait and disproportionate short stature (79 cm, A (p.G579R) (exon 17), XLHR was diagnosed. Analysis of the parental PHEX gene did not show the abnormality, which indicated that the child’s XLHR was caused by de novo mutation of this gene. Conclusion. Identification of genetic defects is exceptionally significant for diagnosis and differential diagnosis of hereditary HR.

Introduction. Intraventricular hemorrhage occurs in almost one fifth of prematurely born children. Due to present complications, such as hydrocephalus and neurological deficit, it endangers the child’s life, therefore there is the need for understanding and prevent risk factors as well as the need for finding most optimal methods of treatment. Objective. The aim of the study was to point out the current therapeutic modalities of the treatment of posthemorrhagic hydrocephalus in prematurely born children. Methods. The study included 60 patients divided into two groups of 30 patients treated at the University Children’s Hospital of Belgrade in the period 2003-2008. Results. Treatment outcome of the control group of patients treated by standard methods was influenced by gestational age (p=0.024), head circumference on birth (p=0.043), body mass on birth (p=0.006), Apgar score on birth (p

Introduction. Pseudoachondroplasia (PSACH) is an autosomal dominant osteochondrodysplasia due to mutations in the gene encoding cartilage oligomeric matrix protein. It is characterized by rhizomelic dwarfism, limb and vertebral deformity, joint laxity and early onset osteoarthrosis. We present the girl with the early expressed and severe PSACH born to clinically and radiographically unaffected parents. Case Outline. A 6.5-year-old girl presented with short-limbed dwarfism (body height 79.5 cm,

Introduction. Hypospadias is a congenital anomaly of the penis, characterised by ectopically positioned urethral meatus and associated anomalies (cryptorchidism, inguinal hernia, penile curvature). Proximal forms of hypospadias, as severe cases, are particularly accompanied by penile curvature (chordee). Distal types are considered to be mild degrees. Objective. To determine the incidence of congenital curvature within various forms of hypospadias in order to signify preoperative and intraoperative diagnosis of chordee as a part of hypospadias repair. Methods. The total of 454 patients with hypospadias were treated surgically in a five-year period (2001-2006.) at the University Children's Hospital of Belgrade. The patients were divided into two groups according to the surgeon who had treated them. Only the first group of patients was tested for chordee as a part of standard procedure and complete treatment. In both groups we analyzed the number of patients treated for penile curvature within various types of hypospadias. We also compared scores in the two groups using Fisher test and χ2-test. Results. Scanning retrospective, 104 cases (22.9%) of diagnosed and surgically corrected chordee were determined. In 31.6% of patients from the first group and 11.6% of patients from the second group we diagnosed and corrected some form of penile curvature was. Chordee was significantly more frequent in the first group, regarding hypospadias in general (p

Purpose: The incidence of developmental dysplasia of the hip (DDH) is higher in Eastern Europeans and Middle Easterners. This study aimed to establish consensus among experts in this geographical area on the management of DDH before walking age., Methods: Fourteen experienced orthopedic surgeons agreed to participate in a four-round online consensus panel by the Delphi method. The questionnaire included 31 statements concerning the prevention, diagnosis, and treatment of DDH before walking age., Results: Consensus was established for 26 (84%) of 31 statements. Hip ultrasonography is the proper diagnostic tool under six months in DDH; universal newborn hip screening between three and six weeks is necessary; positive family history, breech presentation, female gender, and postnatal swaddling are the most important risk factors; Ortolani, Barlow tests, and limitation of abduction are the most important clinical findings; Pavlik harness is the first bracing preference; some Graf type IIa hips and all Graf type IIb and worse hips need abduction bracing treatment; the uppermost age limit for closed and open reductions is 12 months and 12-24 months, respectively; anatomic reduction is essential in closed and open reductions, postoperative MRI or CT is not always indicated; anterior approach open reduction is better than medial approach open reduction; forceful reduction and extreme positioning of the hips (> 60° hip abduction) are the two significant risk factors for osteonecrosis of the femoral head., Conclusion: The findings of the present study may be useful for clinicians because a practical reference, based on the opinions of the multinational expert panel, but may not be applicable to all settings is provided., (© 2023. The Author(s) under exclusive licence to SICOT aisbl.)

Background and Objectives : Idiopathic anterior knee pain is a common condition in adolescents and is mostly of unknown cause. The aim of this study was to examine the influence of the Q-angle and muscle strength on idiopathic anterior knee pain. Materials and Methods : Seventy-one adolescents (41 females and 30 males) diagnosed with anterior knee pain were included in this prospective study. The extensor strength in the knee joint and the Q-angle were monitored. The healthy extremity was used as a control. The Student's paired sample t -test was applied for testing the difference. Statistical significance was set at 0.05. Results : There was no statistically significant difference in the Q-angle value between the idiopathic AKP and the healthy extremity ( p > 0.05) within the entire sample. A statistically significant higher Q-angle of the idiopathic AKP knee ( p < 0.05) was obtained in the female subgroup. No statistically significant difference ( p > 0.05) was found in the male subgroup. Within the male subgroup, the strength of the extensors within the knee joint of the healthy extremity had statistically significant higher values than the strength of these muscles in the affected extremity ( p < 0.05). Conclusion : A greater Q-angle is a risk factor linked to anterior knee pain within the female population. Decreased muscle strength of knee joint extensors is a risk factor linked to anterior knee pain in both sex subgroups.

Treating complicated wounds in the pediatric population using traditional wet to moist wound dressing methods is not always appropriate due to the frequent need to change dressings daily or even a number of times a day, causing distress to the patient. Topical negative pressure is a method that allows for fewer dressings and provides localized benefits, thus accelerating wound healing. The merits of this therapy have been proven in studies on adults, but research on the pediatric population is scarce. Here we intend to present the results of negative pressure wound therapy (NPWT) on 34 pediatric patients (study group) and compare them with 24 patients (control group) treated with the traditional wet to moist dressing for complicated wounds. The results show that topical negative pressure wound therapy is a safe method that downgrades a wound from a complicated to a simple one and allows definitive coverage using a simpler technique with fewer wound dressings. The scars of the patients in the study group exhibited a better result on a visual scar scale. The patients in the control group had a shorter hospital stay. Based on the recorded results, we were able to make treatment recommendations.

Aim: This study aimed to improve osteosarcoma chemoresponsiveness prediction by optimization of computational analysis of MRIs. Patients & methods: Our retrospective predictive model involved osteosarcoma patients with MRI scans performed before OsteoSa MAP neoadjuvant cytotoxic chemotherapy. Results: We found that several monofractal and multifractal algorithms were able to classify tumors according to their chemoresponsiveness. The predictive clues were defined as morphological complexity, homogeneity and fractality. The monofractal feature CV for Λ'(G) provided the best predictive association (area under the ROC curve = 0.88; p <0.001), followed by   Y-axis intersection of the regression line  for  box fractal dimension, r²  for  FD M and tumor circularity. Conclusion: This is the first full-scale study to indicate that computational analysis of pretreatment MRIs could provide imaging biomarkers for the classification of osteosarcoma according to their chemoresponsiveness.

Purpose: The goal of this study is to evaluate the treatment outcomes of anterolateral bowing and residual deformities of distal tibia in patients with CPT using circular external fixation and hydroxyapatite coated flexible intramedullary nailing without excision of affected part of tibia., Patients and Methods: Six patients (4 boys and 2 girls, mean age 12.4 ± 4.1 years) were included in the study. Mean follow-up is 2.1 years. In 4 patients with early onset of disease initial surgical treatment (at age of 5-8 years) was dysplastic zone or pseudarthrosis resection with proximal metaphyseal osteotomy for bone transport. Children with unbroken bowed tibia (2 cases of type II according to Crawford classification) had no previous surgery. Neurofibromatosis type I was diagnosed in 4 cases. Surgical technique for residual deformity correction consisted of percutaneous osteotomy, application of circular external frame and composite hydroxyapatite-coated intramedullary nailing., Results: Mean external fixation time was 95.3 ± 17.5 days. All patients never get fractured after frame removal. At the present time, they are considered to be healed, in 2.1 years, in average, without fractures or deformity recurrence. Mean lower limb length discrepancy varied from 2 to 10 mm at the latest follow-up control. After realignment procedure, patients didn't require additional surgery but one. Intramedullary nails were removed in two years after deformity correction for individual reason., Conclusion: Correction of anterolateral bowing or residual deformity in children with CPT is indicated. Association of external fixation with intramedullary nailing/rodding left in situ after frame removal ensure stability and accuracy of deformity correction. Biological methods of stimulation of bone formation in dysplastic zone are obligatory to ensure bone union. Intramedullary nailing with composite hydroxyapatite-coated surface provides mechanical and biological advantages in patients with CPT., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2019 Professor P K Surendran Memorial Education Foundation. Published by Elsevier B.V. All rights reserved.)

Unicameral bone cysts (UBC) are benign bone tumor-like lesions. Mostly they are located in the metaphyseal-diaphyseal region of long bones in children and adolescents. The etiology of UBC is still unclear. There is no consensus about the protocol of UBC treatment. The aim of this study was to evaluate the effectiveness of three different techniques for the treatment of UBC. This study included 129 pediatric patients with UBC treated at University Children's Hospital in Belgrade during the 8-year period. The mean follow up was 7.14 years. The following parameters were observed: gender, age, site, length of cyst, cyst index, cortical thickness, presentation of pathologic fracture, healing of cyst, treatment complications and length of hospitalization. These parameters were correlated to three treatment modalities, i.e. intracystic methylprednisolone acetate injection (group 1), curettage with bone grafting (group 2) and osteoinductive procedure using demineralized bone matrix (group 3). We found statistically significant differences in healing of the cysts and length of hospital treatment between groups 1 and 2, and between groups 2 and 3. In conclusion, complete healing of UBC can be achieved only using open surgery procedure. Intracystic methylprednisolone acetate instillation can be considered a good option for initial treatment of UBC.

Flexible intramedullary nailing (FIN) provides multiple advantages in limb lengthening and progressive deformity correction in combination with external fixation. The article presents brief literature review and authors' experience in limb lengthening of abnormal bone (Ollier's disease, fibrous dysplasia, osteogenesis imperfecta). Titanium and, especially, hydroxyapatite-coated bent elastic nails in combination with external fixator are appropriate in limb lengthening of abnormal bone in children. FIN left in situ after lengthening procedure and external frame removal should be applied for long-term reinforcement of lengthened bone in patients with abnormal bone (metabolic bone disorders, skeletal dysplasias with compromised bone tissue development). The FIN respects bone biology, which is mandatory for good bone consolidation. Osteoactive properties of intramedullary elastic implants are favorable for bone formation and as well as for stable position of nails without risks of migration in long-term follow-up., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Postoperative analgesia is imperative in the youngest patients. Pain, especially if experienced during childhood, has numerous adverse effects-from psychological, through complications of the underlying disease (prolonged treatment, hospital stay, and increased costs of the treatment) to an increase in the incidence of death due to the onset of the systemic inflammatory response. Peripheral blocks provide analgesia for 12-16 h, and are safer due to rare side effects that are easier to treat. The continuous peripheral block (CPNB) has been increasingly used in recent years for complete and prolonged analgesia of pediatric patients, as well as a part of multidisciplinary treatment of complex regional pain syndrome. It has been shown that outpatient CPNB reduces the need for parenteral administration of opioid analgetics. It has also been proved that this technique can be used in pediatric patients in home conditions. Safety of CPNB is based on the increasing use of ultrasound as well as on the introduction of single enantiomers local anesthetics (ropivacaine and levobupivacaine) in lower concentrations. It is possible to discharge patient home with catheter, but it is necessary to provide adequate education for staff, patients, and parents, as well as to have dedicated anesthesiology team. Postoperative period without major pain raises the morale of the child, parents. and medical staff.

Background: Closed reduction and percutaneous pinning are the preferred treatment of displaced supracondylar humeral fractures in children. The purpose of this study is to evaluate the non-standard Dorgan's method and compare its results with those of the standard percutaneous cross pinning method in treatment of unstable or irreducible Gartland type II and III supracondylar humeral fractures in children., Patients and Methods: This was a prospective evaluation of 138 consecutive patients with Gartland type II or III extension supracondylar humeral fractures referred to University Children's Hospital during a four-year period. The patients were randomized into two groups: the first group, comprised of 71 patients, was treated with standard pin configuration and the second group, comprised of 67 patients, underwent Dorgan's method. The study included 88 boys and 50 girls aged 1.5-11.4 years (mean 6.5±2). At initial presentation 8.7% (n-12) fractures were classified as Gartland type IIa, 25.4% (n-35) as Gartland type IIb and 65.9% (n-91) as Gartland type III., Results: Flynn's criteria were used to evaluate the results. An excellent clinical outcome was reported in about 90% of patients (n-90) treated with standard pin configuration and 89.5% (n-60) of patients treated with Dorgan's method. There were no statistically significant differences in outcomes between the groups in terms of their gender, age, fracture types, function and cosmetics. Neurological lesions were observed in 9.9% of patients (n=7) who were treated using the standard configuration Kirschner pins, while in those treated by Dorgan's method neurological complications were not observed. However, the procedure time was longer (mean 36.54±5.65min) and radiation exposure significantly higher (mean 10.19±2.70 exposures) in the group that was treated using Dorgan's method, compared to the conventional method (mean 28.66±3.76min and 7.54±1.63 exposures)., Conclusion: Two laterally inserted crossed pins provide adequate stability with good functional and cosmetic outcome for most unstable paediatric supracondylar humeral fractures with no risk of iatrogenic ulnar nerve injury., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Background: Femoral neck fractures in children are very rare and account for about 1% of all paediatric fractures. The aim of this retrospective study was to analyse the clinical and radiographic outcome in paediatric femoral neck fracture and to review the role of early decompression of the hip in the final outcome., Patients and Methods: The study was performed at the Department of Paediatric Orthopaedics and Traumatology, University Children's Hospital in Belgrade, Serbia from January 1996 to January 2010. The study included 28 patients, 12 female and 16 male, aged 4-14 years. Patients who were aged over 14 years or who had pathological femoral neck fractures or metabolic disturbances were excluded from the study. The type of neck fracture was determined according to the Delbet and Colonna classification. The patients were treated using different surgical procedures: closed reduction and cast immobilisation, closed reduction and percutaneous fixation with Kirschner wires (K-wires), closed reduction and fixation with cannulated screws and open reduction with Wagner plate stabilisation. The final outcome was evaluated using the clinical outcome (based on the Howorth-Ferguson scale), radiographic outcome and occurrence of complications., Results: The median age of patients included in the study was 10.75 years and the average follow up was 9 years. According to the Delbet classification, there was one patient with type I, eight patients with type II, 16 patients with type III and three patients with type IV femoral neck fracture. Based on the Colonna classification, there were 23 displaced and five non-displaced femoral neck fractures. Decompression of the hip was performed in 21 patients. Avascular necrosis (AVN) developed as the main complication in 11 patients. The final outcome was excellent in 14 patients, good in four patients and poor in 14 patients., Conclusion: Our study unequivocally confirms the positive effect of urgent treatment on the incidence of AVN as well as on the outcome. We have established a 12-hour interval after injury as an optimal time limit for commencing treatment. Unambiguously positive effects of hip decompression on the incidence of AVN were also noted. We found similar efficiency for open and needle hip decompression., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Background: The purpose of this retrospective study was to evaluate the complications associated with leg lengthening in children treated with the Ilizarov external fixator (IEF) and compare them between two groups of patients: one group was treated using an IEF alone and the other group was treated using an IEF in association with intramedullary alignment (IA)., Patients and Methods: The study was performed at the University Children's Hospital in Belgrade, Serbia during a fourteen-year period (from 2000 to 2014). Complications occurred in 73 paediatric patients who underwent the leg lengthening procedure. Complications were classified according to the Caton classification and compared between two groups. Group I comprised 39 patients who underwent the limb lengthening procedure using IEF alone. Group II consisted of 34 patients who were treated with the combination of IEF and IA using two Kirschner wires (K-wires) or Titanium Elastic Nails (TEN). The duration of hospital treatment was also compared between the two groups and the impact of the type of IA on the occurrence of complications was assessed., Results: There was a high rate of complications in patients treated using an IEF compared with those treated using the combination of IEF and IA, but there was no statistically significant difference between the two groups. There was a statistically significant difference in the duration of initial hospitalisation between the two groups, particularly when comparing TEN usage in IA. A comparison of the group of patients treated using an IEF in association with K-wires and patients treated using IEF and TEN showed there was no statistically significant difference in complication rate and duration of initial hospitalisation., Conclusion: IA has multiple advantages as a method of treatment of leg length inequality. The major effect of applying IA in association with a circular IEF is significantly reduced complication rate and duration of initial hospitalisation, particularly when using TEN as a method of IA. This method of treatment also decreases hospital costs., (Copyright © 2015 Elsevier Ltd. All rights reserved.)