Preliminary results of two surgical techniques in the treatment of recurrent patellar dislocation : Medial patellofemoral ligament reconstruction versus combined technique of vastus medialis advancement, capsular plasty and Roux-Goldthwait procedure in treatment of recurrent patellar dislocation.

PURPOSE: Recurrent patellar dislocation is defined as a dislocation occurring more than once. There is no consensus as to the choice of operative technique for recurrent dislocation in adolescents. Recently, great importance has been attributed to MPFL reconstruction. The aim of this study is to evaluate the value of MPFL reconstruction (group A) in adolescents by comparing MPFL reconstruction with combined soft tissue proximal and distal alignment (group B). METHODS: MPFL reconstruction by means of Avikainen's technique was performed on 32 knees. Another 33 knees were subject to the techniques combining retinacular plasty, vastus medialis advancement, and Roux-Goldthwait procedure. The results were assed clinically (Lyscholm scale and the Kujala Anterior Knee Pain Scale) and using X-rays (axial and lateral knee view). Isokinetic assessment of the quadriceps and hamstring was performed. RESULTS: No statistically significant differences between the two groups were observed regarding the Lyscholm and Kujala scales, the presence of redislocation (9.3 % for group A versus 12.1 % for group B), apprehension test, abnormal patellofemoral angle, abnormal Caton index (p > 0.05). A statistically significant difference between the groups was observed regarding the rate of pain complaints, the incidence of an abnormal congruence angle, patellar medialization and deficits in the peak torque of the hamstring between the two angular velocities (p < 0.05). CONCLUSIONS: The redislocation rates risk is similar in both groups. However, a lower incidence of pain complaints in the group of patients with MPFL reconstruction favours the use of MPFL reconstruction as the first choice technique. LEVEL OF EVIDENCE: III.

Predictive characteristic of simple bone cyst treated with curettage and bone grafting.

BACKGROUND: The efficiency of treating simple bone cyst (SBC) is low. Depending on the choice of treatment, a positive response occurs in 20 to 80 % of cases. These rates are unacceptable, particularly considering they concern the treatment of benign lesions affecting children. Although cyst curettage is one of the first known ways of treating SBC, no precise qualification criteria exists for this procedure. The aim of our study is to identify which type of cyst may be most effectively treated using curettage with grafting. METHODS: A retrospective analysis was performed on 24 patients referred to our clinic for SBC treatment. To identify predictive factors, the group of patients who positively responded to treatment (Neer stages I and II, n = 14) were compared with the group in which recurrences occurred (Neer stages III and IV, n = 10). RESULTS: Significantly fewer patients with lesions located in the humerus (chi(2) = 9.351; p < 0.05) and without pathological facture at the time of diagnosis (p = 0.017) were found in the group with no recurrence. The following radiological parameters were found to vary significantly between groups: cyst area (z = 3.121; p < 0.01), cyst index (z = 2.213; p < 0.05) and cyst diameter ratio (z = 2.202; p < 0.05). In the group with no recurrences, the mean values of these parameters were found to be lower than in group with poor response to treatment. No statistically significant differences regarding age, sex or type of bone graft (p > 0.05) were found. Recurrences were experienced by 10 patients (41.7 %) during the 3-year period after surgery CONCLUSION: In the group treated with curettage, associations were identified between worse treatment results and the location in the humerus, pathological fractures at the time of diagnosis, large cyst area, large cyst index and large cyst diameter.

AbobotulinumtoxinA (Dysport®) Improves Function According to Goal Attainment in Children With Dynamic Equinus Due to Cerebral Palsy.

This secondary analysis of a large (n = 241), randomized, double-blind study evaluated the efficacy of 2 doses of abobotulinumtoxinA + standard of care (SOC) versus placebo + SOC in enabling children with dynamic equinus due to cerebral palsy to achieve their functional goals using Goal Attainment Scaling. Most parents/caregivers selected goals targeting aspects of gait improvement as most relevant. Mean (95% confidence interval) Goal Attainment Scaling T scores at week 4 were higher for both abobotulinumtoxinA groups versus placebo (treatment difference vs placebo: 10 U/kg/leg: 5.32 [2.31, 8.32], P = .0006, and 15 U/kg/leg 4.65 [1.59, 7.71], P = .0031). Superiority of both abobotulinumtoxinA doses versus placebo was maintained at week 12. Best goal attainment T scores were higher in the abobotulinumtoxinA groups versus placebo for the common goals of improved walking pattern, decreased falling, decreased tripping, and improved endurance. These findings demonstrate that single injections of abobotulinumtoxinA (10 and 15 U/kg/leg) significantly improved the ability of pediatric cerebral palsy patients to achieve their functional goals.

An evaluation of surgical outcomes in luxation and subluxation of the hip joint in children with cerebral palsy.

The goal of this work is to evaluate the suitability of the surgical operations used in severe forms of cerebral palsy with luxation or subluxation of the hips. The research involved 32 children with cerebral palsy and subluxation or luxation of the hip joint. 28 of these children had a severe form of quadriplega, and 4 had diplegia. In all cases, surgery was performed on the adductors, and in most cases on the bone system as well. Derotational-varizing osteotomies were performed 24 times, pelvic osteotomies using Dega's method 10 times, Salter's method seven times, Schanz's method 2 times, and triple pelvic osteotomy using Steele's method once. In three cases the femoral head was resected. The Salter and Dega osteotomies were evaluated as favorable in relation to the proper centering of the hip and securing it against renewed dislocation. On the other hand, over-correction of the increased neck-diaphysis angle caused a limitation in abduction, thus intensifying nursing difficulties. This method was evaluated particularly negatively in cases of pelvic tilt. In view of these outcomes in the surgical treatment of spastic hip luxations and subluxations, it would seem best to prevent dislocation by the appropriate rehabilitation and nursing procedures, and by early detection of dislocation.

Surgical treatment of spastic equino-varus deformity.

Spastic equino-varus deformity is one of more frequent deformation detected in cerebral palsy. Between 1994 and 2000, 45 feet in 34 patient were treated by split posterior tibial transfer to peroneus brevis combined with an Achilles tendon lengthening or gastrocnemius recession described by Vulpius. The average time interval from the surgical treatment to follow up was 3 (1/2) years (range 4-96 months). The results of examination were grouped according to the Green's classification. Excellent results 68,4%, good results 20,1% and poor results 11,5%. To our opinion this method gives good results and it is recommended one.

Long-term outcome lengthening and axis correction with the Ilizarov method in post-inflammatory shortening and deformity of the humerus.

Background. Post-inflammatory shortening and deformation of the humerus results from damage to the epiphyseal cartilage of this bone, and in particular to the proximal growth plate, most commonly caused by neonatal staphylococcemia. This is frequently accompanied by shortening of the femur, deformation of the hip and knee joints, the temporo-mandibular joint, and occasionally other joints as well. In the present article the authors present their own experiences with the application of osteogenesis in the post-inflammatory shortening and axis deformation of the humerus.
Material and methods. The clinical material consisted of 23 patients treated during the period 1995-2000 at the institutions represented by the authors in Wroclaw and Lodz. The average shortening was 8,5 cm (31,3%), and the average follow-up period was 2 years.
Results. The average lengthening achieved was 7,5 cm (40,5%), and the average lengthening index was 22,7 days/cm. complete axis correction was achieved in all patients with deformities of the humerus. More exact monitoring of the distraction process is necessary in the arm than in the lower limbs. Only 2 problems and 2 obstacles (according to Paley's classification of complications) were encountered in the course of treatment.
Conclusions. The results obtained indicate that the Ilizarov method is a safe and effective technique for the treatment of shortening and axis deformity of the humerus.

[Analysis of treatment results of humeral lateral condyle fractures in children]. / Analiza wyników zlaman klykcia bocznego kosci ramiennej u dzieci.

On the basis of 60 cases authors analyze treatment results of the humeral lateral condyle fractures in children. This type of fracture is a second most common elbow fracture in children after supracondylar fracture of the humerus. Authors consider this fracture to be the most difficult to diagnose among all elbow injuries. Analyzed cohort of patients consists of 54 at age between 1.5 to 10 years and 6 patients between 12 to 17 years of age. In 75% of cases operative treatment was delayed due to late referral from other hospitals. According to appearance of the fracture line on X-rays there were 53 cases of type II and 7 cases of type 1 according to Milch classification system. The amount of displacement was evaluated according to Jakob scale and there were 35 cases of III degree, 17 cases of II degree and 8 cases of I degree of displacement. All patients were evaluated with antero-posterior and lateral distal humerus x-rays. In some cases other diagnostic techniques were used. In older children computerized tomography and in younger children ultrasound examination was performed. The treatment results were evaluated according to Hardacre scale. Follow-up time was 1 to 13 years. There were 27 very good and 27 good results in a 54 cases group of patients who underwent surgery within 15 days since injury. In other group which consists of 6 patients who underwent surgery more than 5 weeks after injury there were 2 cases of very good, 2 cases of good; and 2 cases of bad results. Authors believe that putting a proper diagnosis of humeral lateral condyle fracture in children and performing an operative treatment results in a good and a very good outcomes. Basing on the analysis of treatment results of authors cohort of patients, they claim that precise diagnosis and proper determining of degree of displacement increases the number of patients qualified to operative treatment.

[Early results of congenital clubfoot using Ponseti method]. / Wczesne wyniki leczenia stopy konsko-szpotawej wrodzonej metoda Ponsetiego.

Congenital clubfoot is one of the most common congenital skeletal defects. Its aetiology remains unclear. Due to its high incidence and social consequences, the therapy of congenital clubfoot presents an important medical issue. Non-surgical treatment methods are preferred. Many publications confirmed the efficacy of the Ponseti method. The aim of this study was to present early results of congenital clubfoot treatment using the Ponseti method in a one-year follow-up. The therapy protocol was in accordance with guidelines presented by the inventor. The necessity of surgical treatment was a criterion for negative treatment outcome. One hundred and sixteen feet of 92 children were analysed. A Dimeglio-Bensahel classification was used for the evaluation of the defect advance. Seventy-one feet (61.2%) were assessed as grade II, 43 feet as grade III (37.1%) and 2 feet as grade IV deformation. No patients with grade I deformation were included into the study. A positive treatment outcome was observed for 96 feet (82.7%), whereas a negative result for the remaining 20 feet (17.3%). Our results are therefore not consistent with the literature data. It could have resulted from the too precipitate qualification for surgery by the physician and problems with compliance. The Ponseti method is an effective and less straining treatment modality of the congenital clubfoot. In most cases it allows for avoiding extensive surgery and associated complications. A necessity of wearing an orthosis and a risk treatment failure, if not worn systematically, should be emphasised. A longer follow-up period is required for complete result analysis.

[Split posterior tibial tendon transfer as a selected technique of treatment of spastic equino-varus deformity in children]. / Przeniesienie polowy sciegna miesnia piszczelowego tylnego na miesien strzalkowy krôtki jako wybrana technika leczenia deformacji stopy konsko-szpotawej spastycznej u dzieci.

Equinovarus deformity is one of the most common deformities seen in patients with cerebral palsy. During years between 1993 and 2004 in 36 patients with cerebral palsy 46 operative procedures of split posterior tibial tendon transfer to peroneus brevis muscle were performed to correct varus deformity of the foot. Additionally equinus was corrected by lengthening lengtheninglengthening of the calcaneal tendon in 42 cases and in 4 cases by gastrocnemius recession according to Baker modification of Vulpius procedure. Children's age at the time of operation was between 3.5 and 16 years of age (average 7.5). In our cohort of 36 patients there were 10 cases of quadriplegia (28%), 12 cases of hemiplegia (33%), 12 cases of paraparesis inferior (33%) and 2 cases of monoplegia (6%). 25 patients with 34 operated feet (73.9%) reported for final examination. Follow-up period was from 18 months to 11 years (average 5.5 years). At final examination we evaluated clinical effectiveness of gait, passive and active range of movement, plantograms, and subjective evaluation of patient and patients' parents. Wearing of orthoses and orthopaedic footwear was noted. The results were divided into groups according to Green's classification. There were 67.6% of very good results, 23.6% of good results and 8.8% of poor results. Basing on our experience in treatment of spastic equinovarus deformity of the foot in children with cerebral palsy we stand, that split posterior tibial tendon transfer can bring good results and is a valuable surgical technique in treatment of equinovarus deformity.

[Results of treatment of the intercondylar eminence of tibia in children]. / Ocena wyników leczenia zlaman wynioslosci miedzyklykciowej kosci piszczelowej u dzieci.

Fracture of the tibial eminence in children is a condition in which there is no widely accepted and approved therapeutic scheme. The greatest divergence of treatment options concerns type II according to Mayers and McKeever classification. Described therapeutic options range from cast immobilisation of the lower extremity without attempt of closed reduction to open reduction with internal fixation. Paper shows the results of treatment of tibial emienence fractures in children treated at our institution. Cohort of patients consists of 21 children at age 7 to 16 years of age (mean 12.2 years). There were three cases of type I, five cases of type II and thirteen cases of type III fracture according to Mayers and McKeever classification. Operatively 16 patients were treated with type II and III fracture, and the rest of them were treated nonoperatively. Open reduction and internal fixation was performed according to modified technique described in 1937 by H. Lee. The results were evaluated by X-ray, clinical examination of stability and range of motion of the affected knee and by subjective clinical outcome with use of modified Lysholm knee scale. All patients treated operatively presented very good and good clinical outcome. Nonoperatively treated patients was a small and no homogenous group. Results of treatment ranged from very good to poor. Worse outcomes were associated with additional injuries to the affected knee (poor result in patient with type II fracture) and qualification for the conservative treatment in patient with type III fracture.

[The efficacy assessment of cuboid and medial cuneiform bone wedge ostetomy in the treatment of metatarsus adductus]. / Ocena skutecznosci osteotomii klinowej kosci szesciennej i klinowatej przysrodkowej w leczeniu przywiedzenia przodostopia.

Metatarsus adductus is usually a morphologic feature of the clubfoot or occurs as an isolated defect. Such deformation causes shortening of the medial foot column and lengthening of the lateral. The purpose of the study is a retrospective evaluation of long-term therapeutic effects in a group of patients, who underwent closing wedge cuboid osteotomy and opening wedge medial cuneiform osteotomy. Surgery was performed in 19 persons, procedure was applied to 26 feet, of which 3 presented congenital metatarsus adductus and 23 presented recurrent clubfoot. During ostoetomy we performed additional corrective procedures on soft tissues. Foot and gait deformation, pain associated with activities, presence of calluses on the lateral plantar surface of the foot, difficulty in footwear were evaluated before and after surgery on clinical examination. The pre- and post operative X-rays were used to determine: in AP view the Kite's angle and the angle between the calcaneal bone and the 5th metatarsalbone (forefoot adduction evaluation), in lateral view the Kite's angle, the angle between the calcaneal bone and the 1st metatarsal bone (forefoot supination evaluation) and the angle between the talus and the 1st metatarsal bone (cavus evaluation). An early recurrence of the deformation after the removal of wire fixation occurred in 2 patients. Late complications taking the form of adduction and supination of the forefoot occurred in 5 cases. In general recurrences of adduction of the metatarsus occurred in 27 % operated feet. Radiographic evaluation proved a significant statistical effect of the "plus-minus" osteotomy limited to the reduction of the adduction angle of the forefoot and not affect improvement of the supination of the forefoot and the foot excavation.

[Treatment of the femoral, tibia and humeral shaft fractures in children with the use of intramedullary nailing or external fixation, a long term study]. / Ocena wyników leczenia zlaman kosci udowej, piszczelowej i ramiennej u dzieci leczonych metodami zespolenia sródszpikowego i stabilizacji zewngtrznej.

The treatment of long bones shaft fractures with intramedullary nailing and external fixation is gaining popularity nowadays. The aim of this study was to analyze operative methods of treatment of the long bones shafts fractures in children. We compared outcomes of surgical treatment with the use of external fixation and flexible nails. The study group consisted of 127 patients (4 to 18 years old) who were operated on in our hospital during the period 1990-2005: 90 patients with femoral shaft fractures, 31 with tibia fractures and 6 with humeral fractures. In 81 children we performed fixation with Wagner's tool and in 46 cases we used Prevot or Ender nails. The follow up (performed at least one year after treatment cessation) included clinical examination and X-ray imaging. Union in an almost anatomical position was obtained in 126 patients. There was one fracture-healing complication ( nonunion- due to to early hardware removal). The study showed many advantages of the surgical treatment: minimal invasiveness, short hospitalization period, early rehabilitation. In our group both methods of management were comparable. We recommend intramedullary nailing in closed, transverse fractures and external fixator in open, multifragmentary and possibly unstable fractures.

[The surgical treatment of proximal humerus fractures in children and adolescent]. / Leczenie operacyjne zlaman i zluszczen blizszej czesci kosci ramiennej u dzieci i dorastajacych.

The aim of his study was to evaluate outcomes of the surgical treatment of proximal humerus fractures in children. The studied group consisted of 24 patients who were operated on during the period 1997-2006. Operative and postoperative complications were evaluated. For the follow up evaluation Constant-Murley Score and Oxford Shoulder Score in own modification were employed. The scores assessed the following characteristics: pain, activity level in daily living, range of motion and shoulder strength. In all reported cases a correct union was obtained as well as the anatomical axis of the bone (only in one child 20 degrees varus curve of the bone remained but without limitation in the shoulder motion range). The total of 21 patients were evaluated during follow-up visits, 13 patients obtained the result "very good" and 8 "good" in the Consant-Murley Score. According to the Oxford Schoulder Score 18 patients obtained maximum results, and 3 children results above 95% of the maximum score. In the study group the results of the surgical treatment of proximal humerus fractures were very good. We can therefore recommend this type of treatment in patients with proximal humerus fracture with large dislocation and angulation.

[Fracture of the femoral neck in children]. / Zlamania szyjki kosci udowej u dzieci.

The femoral neck fractures in children are very rare. It is difficult to elaborate a standard of treatment of this disorder in children, because of a little amount of publications on this subject. The common complications which occur are physis premature closure, coxa vara, avascular necrosis of the head and neck of femur and ocasionally nonunion. The paper analyses 18 cases of fracture in children at the age of 4 to 16 years old (average 8 years old) who were treated at the clinic since 1990 to 2003. Cohort of patients included 7 boys and 11 girls. Fractures were classified according to Delbet: 4 cases of type II and 14 cases of type III. In 17 cases left and in 1 case right femur was involved. Operative treatment was performed by means of open reduction (anterior approach), and internal fixation: in 10 cases fixation with lag screws for cancellous bone; in 2 cases with lag screw and Kirschner wire; in 1 case fixation with angular blade. Postoperatively patients were placed in hip spica cast for 6 weeks. Full weightbearing was allowed after fracture united and AVN was excluded. Follow up time was from 1.5 to 12 years (average 6 years). Outcomes were analysed according to the fracture type and treatment kind. Functional and radiologic results were evaluated according to Ratliff's score. Basing on the analysed material, the authors of the essay conclude that patients with femoral neck fracture type II and type III according to Delbet, who had dislocation of the part of bone femur should have a surgical treatment applied, while the non-surgical treatment should be applied with the patients who have femoral neck fracture with no dislocation of the part of bone femur.

[Feet deformation treatment in children with arthrogryposis multiplex congenita (AMC)--evaluation of the results]. / Leczenie deformacji stóp u dzieci z artrogrypoza--ocena wyników.

In Arthrogryposis Multiplex Congenita (AMC) feet deformations are frequent. They have form of talipes equinovarus, or less frequently of plano-valgus. The study included influence of various surgical techniques on final result of foot treatment in arthrogryposis. The aim of the study was to analyse errors in classification and surgical technique influencing the final result. Between 1986 and 2004 21 AMC children were surgically treated. In all of the patients the disease was accompanied by heavy feet deformations: 38 talipes equinovarus deformations and 1 plano-valgus. Age of the treated children was between 7 months and 4 years. All feet required surgery. Follow-up period was 3 to 20 years, mean 12.5 years. During the follow-up examination the following elements were evaluated: foot appearance, gait mechanics, foot load level, wearing commercial shoes or orthopaedic equipment. Additionally radiography of feet in AP and lateral projection was performed. Posterior liberation was performed in 21 feet, peritarsal reposition in 18 feet. In case of 13 feet the primary correction was satisfactory. In the remaining 26 feet re-surgeries were necessary, including astrogolectomy in 9 feet. 13 good results were obtained--in which feet were properly loaded, adapted to common shoes and painless. 15 satysfying results were obtained--the feet required orthopaedic shoes; and 11 bad results, where temporary foot pain additionally occurred. Excessively conservative primary surgery in case of heavy foot deformations was a cause for multiple re-surgeries.