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PURPOSE OF THE STUDY The study aimed to evaluate the results of closed reduction and epiphyseodesis of unstable slips of the proximal femoral epiphysis. The hypothesis was that the clinical and radiological results of this method and incidence of avascular necrosis are comparable to the results of closed reduction and open reduction using surgical hip dislocation reported by literature. MATERIAL AND METHODS In the period 2013–2023, 20 patients were treated for unstable slips in one institution. Whereas the boys were older (mean age of 13.4 years) than girls (mean age of 11.6 years), the gender distribution was equal. Acute on chronic slips prevailed over the acute slips (ratio 3:1). The slips were treated using the closed reduction, transphyseal fixation and capsular decompression at 6 to 240 hours after slip (81 hours on average). All patients were treated concurrently on the contralateral side as the prevention of the slip or to treat the grade I slips (two patients). The follow-up ranged from 7 months to 7 years. Clinical results were evaluated according to two scores: 1) own score (Bulovka University Hopspital score) based on the reduction of ROM, shortening of extremity and limitations of activities; 2) D’Aubigne-Postel score. In the radiological evaluation, correction of slip angle, alpha-angle, avascular necrosis (AVN) and the prominence of the anterior margin of the femoral neck on axial radiographs were evaluated. RESULTS According to the Bulovka University Hospital score, there were 10 excellent results (50%) with no limitation of activity, including sport, in tree cases the results were very good (15%) and in five cases good (25%), respectively, with some limitation of activity, and two results were unsatisfactory (10%) with severe limitation of activity due to the AVN. According to the D’Aubigne-Postel score, there were 14 excellent results (70%), four good results (20%), and two unsatisfactory results (10%). The slip reduction was as follows: under 20 deg. in five patients; under 30 deg. in 10 patients, and over 30 deg. in five patients, respectively. Alfa-angle was greater than 63 degrees (range 45-88 deg.) on average. Prominence of the off-set epiphysis-femoral neck and femoroacetabular impingement (FAI) were observed in six patients. Remodelling of this prominence was seen in one patient four years after surgery. Shortening of the femoral neck over 1 cm was reported in two patients. Complete AVN with severe deformity of the hip was noted in two patients. DISCUSSION Our hypothesis was confirmed because the results of treatment of the unstable slips by closed reduction are comparable with the published results of the same method and with surgical hip dislocation. The results correspond with those of large published cohorts of patients concerning the correction as well as rate of complications. CONCLUSIONS According to our results, urgent gentle closed reduction, transphyseal fixation and capsular decompression represent efficient and relatively safe methods of treatment of unstable slips with low incidence of complication. Residual deformity of the off-set epiphysis-femoral neck and FAI represent limitations of this method. [ABSTRACT FROM AUTHOR]

PURPOSE OF THE STUDY The study aimed to propose an optimal based fl ap creation with the view to ensure long-term survival of the interposition arthroplasty. MATERIAL AND METHODS A total of 28 dorsal wrist capsules were collected from 16 cadavers (with age range at death 18 to 80 years, with no visible wrist pathology). Altogether 112 histological specimens were obtained from these 28 samples. Post-hoc Dunn’s tests were used to analyse the percentage of vascularisation of individual sides of the dorsal capsule (circumference and area) at the 0.05 level of significance. Spearmann’s correlation analysis was used to assess the effect of age on vascularization of the dorsal wrist capsule. In cadavers in whom both capsules were collected, the limbs were compared. For the sake of comparison, the Wilcoxon matched pairs test was used. RESULTS Regarding statistical significance, the largest share of the total circumference and area of the measured vessels of the dorsal capsule is constituted by the distal side (35.2% of the circumference and 30.9% of the area). The blood supply of the dorsal capsule received on the ulnar side is the lowest (12.9% of the circumference and 17.6% of the area). There was no significant effect of age on vascularization of the dorsal wrist capsule confirmed. Also, the comparison of vascularization of both limbs from a single cadaver did not yield any statistically significant results. DISCUSSION Proximal row carpectomy is a long-established surgical technique used to manage the degenerative changes in the wrist. Our results showed the best vascularization on the distal and radial sides of the dorsal wrist capsule. In this light, the distally-based flap or the flap described by Berger, which respects the clinically important ligaments, appear to be the least invasive and help maintain the future stability of the wrist. CONCLUSIONS In clinical practice, we advise that a radially-based fl ap according to Berger is created and the distal side of the dorsal capsule, the most vascularized portion based on our results, is preserved as much as possible. The flap created in this manner also preserves the important carpal ligaments and appears to the authors of this study to be the most beneficial, also with respect to the presence of the largest arteries, contrary to the distal side. Another option is to use a distally-based flap for interposition arthroplasty. [ABSTRACT FROM AUTHOR]

PURPOSE OF THE STUDY Limb lengthening has always belonged to the most complex surgical techniques in paediatric orthopaedics. In our study, we compared the results of femoral and tibial lengthening using three different surgical techniques. The presented study aimed to shorten the duration of external fixation to a minimum and to reduce the complication rate. MATERIAL AND METHODS The retrospective study compared 74 patients (38 boys, 36 girls) who had undergone stepwise progressive lengthening of the femur or tibia between the years 2007 and 2019. The most frequent indication was the proximal focal femoral deficiency (PFFD, 33 patients). The total number of lengthening procedures was 130 (femur 72, tibia 58), the follow-up period was 2–14 years. The following modifications of surgical techniques were used: (i) standard approach, i.e. corticotomy with a two-stage removal of the fixator, (ii) preventive fixation with elastic stable intramedullary nails (ESIN) and also with a two-stage removal of the fixator, and (iii) standard approach with an early removal of the external fixator and plate osteosynthesis. RESULTS The mean lengthening achieved was 56 ± 18 (27–114) mm in femur and 54 ± 16 (25–110) mm in tibia. There was no statistical difference in the lengthening achieved by different modifications. The mean duration of external fixation in femur and tibia lengthening was comparable (166 and 164 days). The complications were observed in 60% of lengthening procedures, the most frequent being the pin release or axial malalignment of the lengthening (33 cases, 25%). The patients with ESIN displayed statistically the lowest complication rate (26%), the highest complication rate was seen in children with osteosynthesis using a plate (80%). CONCLUSIONS It follows from our results that fixation with intramedullary nails in comparison with the standard approach and plate osteosynthesis helped decrease the number of complications by more than 50%. The plate osteosynthesis is indicated in patients with repeated lengthening (achondroplasia, hypochondroplasia or PFFD with pronounced shortening) since it significantly reduces the duration of external fixation. [ABSTRACT FROM AUTHOR]

PURPOSE OF THE STUDY Hemiepiphyseodesis is commonly used to correct a coronal plane knee deformity during childhood. Since 2007 Blount staple method has been replaced by the eight-Plate Guided Growth System. We retrospectively analysed the indications, results and complications of the older Blount staple method so as to compare them with the newer eight-Plate Guided Growth system. MATERIAL AND METHODS In the period from 2009 to 2019, a total of 98 lower extremities of 54 patients were treated by hemiepiphyseodesis. Lateral distal femoral angle (LDFA), medial proximal tibial angle (MPTA) and mechanical axis deviation (MAD) were measured before and after the correction. We focused on the location of hemiepiphyseodesis (distal femur/proximal tibia/both), the operative time and compared the results of implanting 2 or 3 Blount staples. RESULTS The primary correction of valgus knee deformity was achieved in 97%, of which only partial correction was observed in 9.2% and slight overcorrection in 6.1%. A total of 4 patients (4.1%) underwent subsequent corrective osteotomy. The mean LDFA increased from 80° to 86°, while the mean MPTA decreased from 94° to 92°. The mean MAD decreased from 23 mm to 3 mm. The reported complication rate was 5.1%, including four cases of loosening of staples and one case of superficial infection. DISCUSSION It has been verified that the LDFA reduction correlates with staple implantation into the distal femur, conversely the increase in the MPTA correlated with the implantation of staples into the proximal tibia or into both locations. The number of implanted staples (2 or 3) did not affect the size of the resulting correction, but the operative time was statistically significantly shorter when 2 instead of 3 staples were implanted. CONCLUSIONS Blount staple hemiepiphyseodesis is an older method, but it still gives very good results with a low rate of complications. The operating time can be shortened by using 2 staples only, with the same correction effect. The LDFA and MPTA parameters are helpful in identifying the location of hemiepiphyseodesis. The key to success of treatment still remains in correct timing of the implantation of staples with sufficient growth potential. [ABSTRACT FROM AUTHOR]

PURPOSE OF THE STUDY Although the congenital short femur is morphologically well characterized, changes at the molecular level have not been described in the literature so far. The absence of such information, along with the unknown aetiology of the defect, was the motivation for analysing angiogenesis and osteogenesis in the pseudoarthrosis (false joint) tissue in PFFD patients compared to physiological bone. The authors expected differences in gene expression, particularly in the quantity of expressed genes. MATERIAL AND METHODS A piece of bone was removed during an elective surgery procedure, placed in an RNA stabilization reagent, which prevents RNA degradation, and deep frozen. Thereafter, RNA was isolated and the profile of transcription was analysed by biochip analysis (SuperArray Bioscience Corporation). In total, it is possible to detect 113 genes of osteogenesis and angiogenesis. From the end of 2005 until the end of 2008, samples of 7 patients with PFFD and 3 physiological bone samples were examined. Several analyses were repeated to confirm the results; in total 13 chips for osteogenesis and 11 chips for angiogenesis expression were used. RESULTS Differences in the quantity and representation of the genes were noted. Some genes were considered over-expressed in PFFD tissue compared with the control sample (e.g. the gene for calcitonin receptor, collagen XII, I alpha 2, collagen II, IX, FGFR2, fibronectin, integrin) and other genes under-expressed (e.g. the gene for annexin A5, collagen XVIII alpha1, collagen I alpha1, cathepsin K, FGFR1, FGFR3, IGF2, VEGFB). CONCLUSIONS The differences in gene expression confirmed the authors’ hypothesis. So far, the results cannot be generalized; this is the first step for follow-up experiments to confirm the suggested information and to integrate it with clinical findings, such as the alternative blood supply of affected extremity in some patients. [ABSTRACT FROM AUTHOR]

Purpose of the Study: The study aimed to evaluate the results of closed reduction and epiphyseodesis of unstable slips of the proximal femoral epiphysis. The hypothesis was that the clinical and radiological results of this method and incidence of avascular necrosis are comparable to the results of closed reduction and open reduction using surgical hip dislocation reported by literature., Material and Methods: In the period 2013-2023, 20 patients were treated for unstable slips in one institution. Whereas the boys were older (mean age of 13.4 years) than girls (mean age of 11.6 years), the gender distribution was equal. Acute on chronic slips prevailed over the acute slips (ratio 3:1). The slips were treated using the closed reduction, transphyseal fixation and capsular decompression at 6 to 240 hours after slip (81 hours on average). All patients were treated concurrently on the contralateral side as the prevention of the slip or to treat the grade I slips (two patients). The follow-up ranged from 7 months to 7 years. Clinical results were evaluated according to two scores: 1) own score (Bulovka University Hopspital score) based on the reduction of ROM, shortening of extremity and limitations of activities; 2) D'Aubigne-Postel score. In the radiological evaluation, correction of slip angle, alpha-angle, avascular necrosis (AVN) and the prominence of the anterior margin of the femoral neck on axial radiographs were evaluated., Results: According to the Bulovka University Hospital score, there were 10 excellent results (50%) with no limitation of activity, including sport, in tree cases the results were very good (15%) and in five cases good (25%), respectively, with some limitation of activity, and two results were unsatisfactory (10%) with severe limitation of activity due to the AVN. According to the D'Aubigne-Postel score, there were 14 excellent results (70%), four good results (20%), and two unsatisfactory results (10%). The slip reduction was as follows: under 20 deg. in five patients; under 30 deg. in 10 patients, and over 30 deg. in five patients, respectively. Alfa-angle was greater than 63 degrees (range 45-88 deg.) on average. Prominence of the off-set epiphysis-femoral neck and femoroacetabular impingement (FAI) were observed in six patients. Remodelling of this prominence was seen in one patient four years after surgery. Shortening of the femoral neck over 1 cm was reported in two patients. Complete AVN with severe deformity of the hip was noted in two patients., Discussion: Our hypothesis was confirmed because the results of treatment of the unstable slips by closed reduction are comparable with the published results of the same method and with surgical hip dislocation. The results correspond with those of large published cohorts of patients concerning the correction as well as rate of complications., Conclusions: According to our results, urgent gentle closed reduction, transphyseal fixation and capsular decompression represent efficient and relatively safe methods of treatment of unstable slips with low incidence of complication. Residual deformity of the off-set epiphysis-femoral neck and FAI represent limitations of this method., Key Words: slipped proximal femoral epiphysis, unstable slips, closed reduction, transphyseal fixation.

PURPOSE OF THE STUDY Limb lengthening has always belonged to the most complex surgical techniques in paediatric orthopaedics. In our study, we compared the results of femoral and tibial lengthening using three different surgical techniques. The presented study aimed to shorten the duration of external fixation to a minimum and to reduce the complication rate. MATERIAL AND METHODS The retrospective study compared 74 patients (38 boys, 36 girls) who had undergone stepwise progressive lengthening of the femur or tibia between the years 2007 and 2019. The most frequent indication was the proximal focal femoral deficiency (PFFD, 33 patients). The total number of lengthening procedures was 130 (femur 72, tibia 58), the follow-up period was 2-14 years. The following modifications of surgical techniques were used: (i) standard approach, i.e. corticotomy with a two-stage removal of the fixator, (ii) preventive fixation with elastic stable intramedullary nails (ESIN) and also with a two-stage removal of the fixator, and (iii) standard approach with an early removal of the external fixator and plate osteosynthesis. RESULTS The mean lengthening achieved was 56 ± 18 (27-114) mm in femur and 54 ± 16 (25-110) mm in tibia. There was no statistical difference in the lengthening achieved by different modifications. The mean duration of external fixation in femur and tibia lengthening was comparable (166 and 164 days). The complications were observed in 60% of lengthening procedures, the most frequent being the pin release or axial malalignment of the lengthening (33 cases, 25%). The patients with ESIN displayed statistically the lowest complication rate (26%), the highest complication rate was seen in children with osteosynthesis using a plate (80%). CONCLUSIONS It follows from our results that fixation with intramedullary nails in comparison with the standard approach and plate osteosynthesis helped decrease the number of complications by more than 50%. The plate osteosynthesis is indicated in patients with repeated lengthening (achondroplasia, hypochondroplasia or PFFD with pronounced shortening) since it significantly reduces the duration of external fixation. Key words: limb lengthening, femur, tibia, surgical techniques, complications.

Purpose: The goal of this retrospective study was to compare the gradual lengthening of the ulna in children with multiple hereditary exostoses with and without an elastic intramedullary nail., Methods: Between 1998 to 2018, the ulna was lengthened in 28 forearms in 21 patients (aged 7.1 to 16.6 years) using a monolateral external fixator when relative ulnar shortening exceeded 15 mm. In total, 16 forearms were lengthened with the external fixator (group I) and 12 forearms with the addition of an intramedullary elastic nail (group II). Subjective assessment of function, range of movement (ROM) of the wrist and elbow and complications were compared. Ulnar shortening, radial head dislocation, radial articular angle (RAA) and percentage of carpal slip and radial bowing were followed radiographically. The difference between the groups has been evaluated statistically., Results: The function of the extremity improved partially in 81% of patients in group I and in 83% of patients in group II. ROM was not improved except for radial deviation. Radial head position did not change. The values in group II in comparison with group I are higher for gain of length and lower for bone lengthening index and for bone healing index. Carpal slip decreased insignificantly. The RAA and radial bowing decreased, the comparison of values between groups and age under and over ten years were not statistically significant. Complications were more common in group I. No permanent complications were noted., Conclusion: The addition of an intramedullary nail during the gradual ulnar lengthening improves the gain, bone healing index and rate of complications., Level of Evidence: III., (Copyright © 2021, The author(s).)

Background: Outcomes of total knee replacement in cases of hemophilic patients are worse than in patients who undergo operations due to osteoarthritis. Previous publications have reported varying rates of complications in hemophilic patients, such as infection and an unsatisfactory range of motion, which have influenced the survival of prostheses. Our retrospective study evaluated the data of hemophilic patients regarding changes in the development of the range of motion., Methods: The data and clinical outcomes of 72 total knee replacements in 45 patients with hemophilia types A and B were reviewed retrospectively. Patients were operated between 1998 and 2013. All of the patients were systematically followed up to record the range of motion and other parameters before and after surgery., Results: The mean preoperative flexion contracture was 17° ± 11° (range, 0°-40°), and it was 7° ± 12° (range, 0°-60°) postoperatively. The mean flexion of the knee was 73° ± 30° (range, 5°-135°) before the operation and 80° ± 19° (range, 30°-110°) at the last follow-up. The mean range of motion was 56° ± 34° (range, 0°-130°) before the operation and 73° ± 24° (range, 10°-110°) at the last follow-up., Conclusions: Statistical analysis suggested that the range of motion could be improved until the 9th postoperative week. The patient should be operated on until the flexion contracture reaches 22° to obtain a contracture < 15° postoperatively or until the contracture reaches 12° to obtain less than 5°. The operation generally does not change the flexion of the knee in cases of hemophilic patients, but it reduces the flexion contracture and therefore improves the range.

PURPOSE OF THE STUDY A saddle-shaped deformity of the femoral head has a poor prognosis due to rapid development of secondary changes. A new method of treatment by intra-articular anteromedial wedge reduction osteotomy (AWRO) of the femoral head may preserve the hip for the future. This study was designed to ascertain that this invasive technique was safe and effective and to confirm our hypothesis that AWRO significantly improved functional and radiological parameters of the hip joint. MATERIAL AND METHODS Patients who underwent AWRO between 2010 and 2013 were enrolled in this study. The indication criteria for the procedure included Stulberg grade V hips on AP radiographs, hinged abduction with pain, limping and a limited range of movement. Values of the Stulberg grading, capital diaphyseal index, caput-collum-diaphyseal angle and Harris hip score were recorded before and after surgery and the results were statistically evaluated using the paired t-test. The AWRO procedure was performed from the anterolateral approach after subperiosteal protection of the vessels had been ensured. The central necrotic part of the femoral head was removed, and the medial segment was mobilised and fixed to the intact lateral segment. Either a hip spica cast or bed-rest for six weeks was indicated. Full weight bearing was allowed at 3 months after surgery. RESULTS Twelve patients with an average follow-up of 55 months were evaluated. There were eight boys and four girls with an average age of 14 years at the time of surgery. The average Harris hip score improved from 54.52 before to 73.58 after surgery. The post-operative outcomes according to the Stulberg classification included one grade II hip, seven grade III hips, three grade IV hips and one grade V hip. The average capital-diaphyseal index dropped from 1.56 (1.19-1.92) to 1.28 (0.95-1.67) and the average caput-collum-diaphyseal angle increased from 134 degrees (121-143) to 140 degrees (130-155) after surgery. Avascular necrosis developed in two patients. All the differences were statistically significant. DISCUSSION Reduction osteotomies of the femoral head reported in the literature differ from the AWRO procedure used in this study in both the approach and the performance. The results presented here are in agreement with those published in the relevant literature. They showed no significant deterioration in comparison with the outcomes of our short-term study reported earlier. The outcome of treatment is related to the disease aetiology, functional parameters and previous procedures involving the hip joint. CONCLUSIONS AWRO is a salvage procedure that prolongs the longevity of joints in incongruent hips with very high morbidity. This procedure gave significantly better results in years after surgery, which confirmed our hypothesis. Level of evidence IV Key words: hinge abduction, Perthes disease, Stulberg, femoral head reduction osteotomy, avascular necrosis, arteria circumflexa femoris medialis.

Purpose: Latissimus dorsi and teres major transfers to the lateral side of the humerus with lengthening of the pectoralis major and subscapularis muscles for residual shoulder deformity were compared in children and skeletally mature patients., Methods: Fifteen patients (nine children, six skeletally mature patients aged three to 30 years, follow-up one to 22 years) were treated for internal shoulder contracture after birth plexus lesions: C5-C6 (seven patients); C5-7 (five patients); C5-C8-T1 (three patients, respectively). Range of movement, Mallet shoulder function score and radiographs were assessed., Results: Pre-operatively, shoulder function restrictions were comparable in all patients. Postoperatively, external rotation, abduction and Mallet function score improved significantly (p < 0.05) in all patients except one. There were no differences in improvement between children and skeletally mature patients (p = 0.24-1.0)., Conclusions: This technique improves external rotation and abduction of the shoulder for daily living activities in children and young, skeletally mature, patients.

Purpose: Congenital club foot is one of the most common birth defects involving the musculoskeletal system. At present two methods are used for the treatment of this deformity: French and Ponseti method. The purpose of this study was to compare the short-term (up to three years) and long-term (three to seven years) results of treatment with the Ponseti method., Methods: A total of 195 consecutive infants (143 boys and 52 girls) with idiopathic club foot treated with the Ponseti method in the period of 2005-2012 were included in this study; the total number of feet was 303. The severity of the foot deformity was classified according to Diméglio. When relapse occurred up until three years of age, we started with the casting again. If conservative treatment was unsuccessful we proceeded to surgical treatment., Results: Primary correction was attained in all cases. Surgical correction of relapses was performed in 30 % of patients according to the Ponseti method (re-tenotomy of the Achilles tendon and transposition of the tibialis anterior) and in 70 % by alternative techniques. The number of relapses indicated for surgery increased with increasing period of follow-up: whereas in patients where the treatment started already in 2005 relapses occurred in 72 %, in patients included in 2011 the number of recurrences only reached 3 %., Conclusions: It follows from our results that it is impossible to cure all club feet with casting, tenotomy of the Achilles tendon and transposition of the tibialis anterior only.

Purpose of the Study: Developmental dysplasia of the hip (DDH) is a disorder affecting the development of the acetabulum, proximal femur and joint capsule. The objective of this study was to analyse the results of closed reduction by overhead traction in subluxated and dislocated hips., Material and Methods: In the period from 2002 to 2007, a total of 109 patients (124 hips) were treated by overhead traction. The indication criteria included adductor contracture and misalignment of the hip joint assessed as classes III A, III B or IV according to the Graf ultrasonographic classification. There were 96 (88 %) girls and 13 (12 %) boys. The left side was more frequently affected, at a ratio of 83 to 41, and bilateral DDH was found in 15 patients. Teratologic dislocations were not included in the study. The patients were divided into two groups according to age and the place of primary diagnosis. The children primarily diagnosed at our hospital Na Bulovce where placed in group 1, the patients diagnosed outside our hospital fell in group 2. The average age at the beginning of treatment was 2.2 months in the first group and 6 months in the second group. Our method of overhead traction consists of two phases. Horizontal traction is applied for two weeks in phase 1; the hips are then flexed beyond 90 degrees and gradually abducted for another 4 weeks in phase 2.The outcome of traction is examined by arthrography and a spica cast is applied in the safe zone.We observed the relation between the Graf classification and arthrograpy. The outcome of closed reduction was compared between the groups and the development of avascular necrosis was observed. The hips treated by open reduction were assessed in a different study. RESULTS The efficiency of closed reduction was 84 % in group 1 and 60 % in group 2 in which also two cases of recurrent dislocation were found. No significant differences between the Graf classification and the final arthrographic findings were recorded in either group (p ≥ 0.05). Avascular necrosis as defined by the Salter criteria was not diagnosed., Discussion: Early reduction is essential to ensure normal development of the hip joint. Overhead traction therapy for misalignment of the hip joint is a safe method reducing damage to the femoral head. Its principle lies in gradual distraction of the contracted muscles and joint capsule with a concomitant change in traction direction in order to achieve a reduction manoeuvre without placing increased stress on the femoral head., Conclusions: Overhead traction is the method of choice for management of Graf's class III A, III B and IV hips. For the efficiency of treatment, an early diagnosis and a correct indication are essential. To avoid complications such as avascular necrosis, it is necessary to observe the principle of a safe zone.