[Congenital pseudarthrosis of lower leg treated by almost outdated method--case report].

INTRODUCTION: Congenital pseudarthrosis of tibia is a rare congenital deformity with progressive evolution. Treatment is vague and difficult, and many methods have been used--from once mandatory early amputation to contemporary operative (Ilizarov method, free microvascular fibular graft) and adjuvant methods (electrostimulation, biphosphonates, bone morphogenetic protein). We present the usage of once popular method of homologous graft insertion and intramedullary fixation. CASE OUTLINE: This is a case report of male patient with pseudarthrosis involving both crural bones (Boyd type 5), diagnosed in neonatal age. Early conservative treatment was unsuccessful, so child never initiated gait. At the age of three and a half years, operative treatment was applied: resection of pseudarthrosis on both tibia and fibula, and osteoplasty of tibia using cylindric homologous graft and intramedullary fixation with transtarsal Steinman pin, followed by long leg cast immobilization. Pin was removed after ten months, and physical therapy was initiated 1.5 year after surgery, with initial to partial weight bearing and short leg cast throughout another year. Two and a half years after surgery complete union of graft was documented, and then full weight bearing was allowed. At final visit, five years and three months after surgery, shin axis was correct, leg lengths were equal, and child had normal walk with full range of motion. X-ray showed complete union of both tibia and fibula. CONCLUSION: Despite bad prognostic factors (young age, severe deformity), utilization of obsolete and almost forgotten treatment methods can provide excellent result.

[Treatment of infantile tibia vara - 18-year follow-up: A case report].

INTRODUCTION: Blount disease is developmental disorder of the lower leg, manifested by multiplanar deformity. Surgical treatment includes corrective osteotomy, lateral hemiepiphisyodesis, distraction of the proximal tibial physis, physeal bar resection and elevation of the medial tibial plateau. CASE OUTLINE: A case of a 4-year-old girl with bow legs is presented. Condition was recognized as Blount disease, type five. Both lower legs were operated by medial methaphyseal semi-osteotomy of the proximal tibia with the elevation of the medial tibial plateau. Prospectively, bilateral proximal hemiepiphysiodesis was done. Total follow-up period was eighteen years.The patient has no disturbances, clinical and radiographic findings are excellent. Improvement of the femoro-tibial angle is 22 degrees on the right side, and 21 degrees on the left side. Improvement of the varus angle is 7 degrees on the right side, and 27 degrees on the left side. Medial plateau depression is completely bilaterally reduced; improvement on the right side is 46 degrees, and 51 degrees on the left side. CONCLUSION: It is known today that multiplanar deformity is a part of the disease; varus, antecurvatum and internal rotation of the lower leg. By elevation of the medial plateau varus of the lower and antecurvatum component of deformity can be solved, while internal torsion cannot be solved. This deformity has to be either skillfully neglected, or corrected by an additional osteotomy by the elevation of the medial tibial plateau. Lateral hemiepiphysiodesis serves as extra stabilisator of the achieved result, and it is recommended to be done in combination with surgical elevation of the medial tibial plateau and derotative corrective osteotomy of the tibia.

[Treatment of the femoral neck pseudoarthrosis in childhood: case report].

INTRODUCTION: Femoral neck fractures in children and adolescents are rare. However, their complications are frequent - avascular necrosis, femoral neck pseudoarthrosis, premature physeal closure with consequent growth disturbance and coxa vara deformity. CASE OUTLINE: A 9.5-year-old boy was injured in a car accident, and femoral neck fracture was diagnosed. Prior to admission at our hospital he was surgically treated several times. He was admitted at our hospital eight months following the accident. On the X-ray transcervical pseudoarthrosis of the femoral neck was found, as well as coxa vara deformity and metaphyseal avascular necrosis. He was operated at our hospital; all previously placed ostefixation material was removed, valgus osteotomy of 30 degrees was done as well as additional local osteoplasty using the commercial osteoindactive agent (Osteovit). Postoperatively, we applied skin traction, bed rest and physical therapy. At the final follow-up, the patient was recovered completely. He is now painless, the legs are of equal length, range of movements in the left hip is full, life activity is normal.The X-ray shows that the femoral neck pseudoarthrosis is fully healed. CONCLUSION: This case is presented in order to encourage other colleagues to challenge the problematic situation such as this one. Also, we would like to remind them what one should think about and what should be taken into consideration in the primary treatment of femoral neck fractures in children. Valgus femoral osteotomy, as a part of the primary treatment of femoral neck fracture in children (identically as in the adults) can prevent the occurrence of femoral neck pseudoarthrosis.

[Conservative treatment of Malgaigne fracture in young female--case report].

INTRODUCTION: Pelvic ring injuries usually result from high-energy trauma, and cranial and abdominal multiple injuries are frequently present. Malgaigne fracture is referred to pelvic ring disruption at two sites, and is often treated surgically for its instability. We present a case of nonoperative treatment of Malgaigne pelvic fracture. CASE OUTLINE: A 17-year-old girl sustained a Malgaigne fracture falling off a horse. After ruling out urgent multiple trauma in local hospital, she was then transferred to Pediatric Orthopedic and Trauma Service at the Institute of Orthopedic Surgery "Banjica" Belgrade, with provisional cutaneous traction of 2 kg applied to her right leg. After the status evaluation, the supracondylar femoral traction was applied for three months, combined with pelvic cradle for first 73 days. Weight of traction was gradually adjusted according to x-ray check-up, ranging from 1-16 kg (1/4 of body weight). Antibiotic prophylaxis was administered for 10 days, and thromboprophylaxis for two months. After the removal of traction, physical therapy was applied and the patient achieved full weight bearing four months after the injury. Treatment outcome was a symmetric and stable pelvic ring, equal leg length, full range of motion in both hip joints and normal walking. CONCLUSION: Traction therapy, combined with gravitational suspension in pelvic cradle, resulted in excellent clinical result. Although significantly longer and more loaded than usual, normal weight bearing and walking were promptly achieved using intensive physical therapy.

Impact of triple pelvic osteotomy on contact stress pressure distribution in the hip joint.

PURPOSE: We studied changes of contact stress distribution in the hip joint after Tonnis triple pelvic osteotomy applied in the treatment of dysplasia and hip joint incongruence in adolescents. METHODS: In a group of 75 patients, 54 (72 %) female, who underwent surgery by triple pelvic osteotomy in adolescence for developmental disorder of the hip and avascular necrosis of the femoral head, a three-dimensional hip joint model was used based on the radiography of the pelvis with hips. The following biomechanical parameters were calculated: resultant hip force normalised to body weight (R/Wb), inclination of the resultant hip force (θ-R), the position of the stress pole (θ), peak contact hip stress (Pmax), and peak contact hip stress normalised to body weight (Pmax/Wb). Gait quality was also assessed. RESULTS: After surgery the Wiberg CE angle was increased by 17.85° (114 %), resultant hip force normalised to body weight (R/Wb) was decreased by 0.107 (3.3 %), the position of the stress pole was shifted medially by 27.59° (63.5 %), and peak contact hip stress normalised to body weight (Pmax/Wb) was decreased by 2249.74 (55.9 %). Waddling gait was reduced from 17 (23.9 %) to four cases (5.6 %). All changes were statistically highly significant (p<0.01). CONCLUSIONS: The effect of Tonnis triple pelvic osteotomy lies in the improvement of stress distribution across the acetabular cartilage of the hip joint, thus slowing down the degenerative damage of the hip joint.

[Infected tibial nonunions--treatment by the Ilizarov method: multicentric study].

INTRODUCTION: Associated bone tissue defect and infection, commonly result in non-healing, i.e., by the development of infected tibial nonunion. OBJECTIVE: The aim of the paper was to present experiences acquired in the treatment of this problem by the application of the Ilizarov method. METHODS: The analyses enrolled 16 patients diagnosed with infected tibial nonunion.The Ilizarov method was used in all the patients, of type bilocal synchronous compressive-distractive or bilocal alternating compressive-distractive. Bone and functional results were classified as excellent, good, fair and poor. Total follow-up period of the patients was 48.77 +/- 41.57 months on the average. RESULTS: Fifteen (93.75%) cases of nonunions were successfully healed. According to the laboratory findings of inflammation, the same patients were also successfully treated for local infection. The inequality of the lower limbs was also resolved by new bone formation of average length of 5.75 +/- 3.29 cm. Poor result was verified in one (6.25%) patient only. The patient satisfaction was scored 3.73 +/- 1.33 and physician's satisfaction 4.33 +/- 1.11. CONCLUSION: The Ilizarov method with bone transport, because of being capable to solve simultaneously a local infection and tibial malalignement, and by substituting bone and soft tissue defects, thus enabling healing of until then unhealed bone, has shown as the best method in the treatment of this complex problem, infected tibial nonunions.

[Neonatal hip dysplasia--differential diagnosis].

INTRODUCTION: Hip dysplasia is the elementary form of the developmental dysplasia of the hip (DDH). The diagnosis may be made by the ultrasound examination (types II a-, II b). OBJECTIVE: The aim of the authors was to define the congenital structural neonatal hip dysplasia, and to differentiate hip hypoplasia, hip dysplasia and teratogenic anomalies. METHODS: In all the cases, the uniform clinical and ultrasound tests were performed. All the patients were examined in the neonatal period of life (the first six weeks). The following clinical tests were used: Le Damany-Ortolany, Coleman-Barlow-Palmen and Weissman-Strinovic. For the ultrasound examination, the Graph's method was used. RESULTS: The investigation was performed in the period 2007-2008. 2,878 neonates were included. The distribution of the sonotypes, according to Graph, was as follows: Ia in 16.17%. Ib in 65.08%; IIa+ in 18.17%, IIc in 0.28%, IId in 0.19%; IIIa in 0.009%, IIIb in 0.02%; and IV in 0.01%. It was found that DDH was 8 times more frequent in girls; located more frequently at the left side than bilaterally. CONCLUSION: Hip sonoscreening has to be performed in all newborns in the first 72 hours. The suggested follow-up period is six weeks: for the diagnosis--the first three weeks, and for the prevention and treatment--all six weeks.

[Treatment of septic pseudoarthrosis of tibia by Ilizarov method: case report].

INTRODUCTION: Septic pseudoarthroses of the tibia represent a relatively frequent complication of open fractures with a large soft tissue damage. They may be localized: in the proximal metaphysis, between the proximal and middle thirds, between middle and distal thirds, in the distal metaphysis. CASE OUTLINE: A case of a 52-year-old man with open fracture of the left tibia is presented. He fell from the height of 30 meters. The external fixation according to Mitkovic was performed in another institution. The patient was referred to our hospital nine months after the accident, with clear clinical and radiological signs of septic pseudoarthrosis of the tibia. The resection of septic pseudoarthrosis was done two weeks after admission. Three weeks later, another operation was performed, bilocal alternating distractive-compressive osteosynthesis according to Ilizarov. After eleven months Ilizarov frame was removed, with clinical, radiological signs of healing of pseudoarthrosis and complete curing of the infection. Five months after removal of the frame, the patient was fully anatomically and functionally recovered. CONCLUSION: Being satisfied with the achieved results and encouraged with the data from the literature, we recommend this method as the method of choice for the treatment of pseudoarthrosis of the tibia. The advantage consists of curing the infection using the natural bactericide power of the tissue and curing the bone defect, at the same time, and finally, producing the equalization of the legs.

[Complicated distal femoral epiphyseolysis treated by Ilizarov method: case report].

INTRODUCTION: Injuries of the distal femur are rare in children; however, they are frequently associated with complications. They are almost always physeal, most frequently Salter-Harris type II epiphyseolysis. The treatment of such injuries is similar in all physeal injuries. It is intended to provide growth plate recovery by gentle reduction and stable fixation thus preventing secondary complications, and also to provide decompression of the segment to solve the compartment syndrome and recover the neurovascular structures. CASE OUTLINE: A seven-year old boy presented with a right knee injury while sleigh riding. He was admitted three weeks following the injury with distal femoral epiphysiolysis associated with peroneal palsy. A day after admission to our institute the reduction was performed using the Ilizarov device. Physical therapy was started immediately after surgery, as well as walking with weight bearing on the operated leg. Five months after surgery the patient was anatomically and functionally recovered. CONCLUSION: The presented method is recommended in the treatment of such injuries because of several reasons; reposition is simple and complete, there is no need to open the fracture site, fixation is stable, the growth plate is preserved, there is no need for additional external immobilisation, and physical therapy involving walking with weight bearing on the operated leg may be started immediately after surgery.

[Hip dislocation following the treatment of femoral neck fracture--case report].

INTRODUCTION: Femoral neck fractures are very rare in young patients and are frequently complicated by femoral head osteonecrosis and femoral neck nonunion. CASE OUTLINE: A 19-year-old girl with hip dislocation following the treatment of the femoral neck fracture is presented. The femoral neck fracture was initially treated by open reduction and three-screw fixation. After detecting the nonunion of femoral neck, valgus osteotomy was done. Secondary, iatrogenic, hip dislocation appeared. The patient had pains, and in iclinical findings a shorter leg and limited range of motion in the hip--altogether 40 degrees. She was then successfully treated by open reduction, together with Chiari pelvic osteotomy and joint transfixation. Transfixation pin was removed three weeks following the operation. After that, the patient was put into the abduction device and physical therapy was started. The mentioned regimen lasted four months after the surgery, then the abduction device was removed and walking started. Full weight bearing was allowed eight months after surgery. CONCLUSION: As we have not found the literature data concerning the above mentioned problem, we solved it in the way that we usually do for the treatment of developmental dislocation of the hip in adolescence.

[Unreduced elbow dislocation treated by Ilizarov method--a case report].

INTRODUCTION: Unreduced elbow dislocation is every elbow dislocation older than one week. It may be treated non-operatively (with prereduction traction) or surgically. The treatment goals are: to reduce pain, to establish joint stability and movements. There are a lot of techniques described in literature, series are relatively small, mostly case reports. Multicentric studies have not been done. That is why there are no precisely defined therapeutic protocols. Every contribution in the field is valuable. CASE OUTLINE: A 43-year-old patient was admitted for the treatment of a three-month old unreduced elbow dislocation. Treatment has been done by Ilizarov method, using the reduction mechanism. The reduction process lasted two weeks. The Ilizarov device was removed two months after the operation, then physical therapy was started. Normal anatomical and functional findings were established five months following the operation. CONCLUSION: The presented method of treatment has been found as very useful, having in mind that it may solve two problems: difficult reduction and redislocation. Reduction may be done without the joint opening, step by step; retention of the reduced joint may be easily done. Physical therapy may be started without Ilizarov device removal, movements of flexion and extension may be improved without any lateral instability. There is no iatrogenic intraarticular damage, so there are no secondary joint degeneration, pains and invalidity.

[Systematic struggle to eradicate developmental displacement of the hip in newborns in the regions of Kula and Vrbas].

INTRODUCTION: Successful treatment of developmental displacement of the hip (DDH) depends on early diagnosis. Clinical screening of all newborns is a useful tool and should be encouraged in everyday practice, because DDH has a high prevalence and significant morbidity. Clinical exam is an important part of early diagnosis, but insufficient. Ultrasound exam is more sensitive in early diagnosis of DDH. OBJECTIVE: Systematic struggle against DDH by means of early detection and treatment begins in neonatology units, and continues in primary healthcare centres. METHODS: Methodology consists of personal history, clinical exam, ultrasonography and radiography. After these procedures, treatment is advised if necessary. Basically, DDH treatment is atraumatic involving abduction pillow, Von Rosen abduction device, Pavlik harnesses. RESULTS: During 2007 and 2008, screening examination was performed in 769 boys (51.47%) and 725 girls (58.52%), born at the Medical Center "Veljko Vlahovic" in Vrbas. A total of 1,494 neonates or 2,988 hips were examined. Ultrasonographically, a normal type Ia was found in 406 hips (13.60%), intermediate type Ib in 2,014 hips (67.40%), immature type IIa+ in 374 hips (12.50%), unstable type IIg in 39 hips (1.30%), decentering IId in 52 hips (1.70%), and eccentric types III and IV in 35 hips (1.20%). Of 2988 examined hips, normal finding was detected in 2794 (93.50%) and pathological finding (DDH) was found in 194 (6.50%). Ultrasonographical findings were determined according to Graph classification. CONCLUSION: The frequency of DDH in the regions of Vrbas and Kula above 5% (6.50%) presents a social and medical problem in children of these locations. Eradication, early detection and treatment involve systematic examinations (clinical, sonographical and radiographical) in the first year of life. Treatment has to be initiated in a neonatal unit by atraumatic means. The team work including a gynaecologist, neonatologist and paediatric orthopaedic surgeon is crucial.

Triple pelvic osteotomy for the treatment of residual hip dysplasia. Analysis of complications.

The aim of the paper was to present the results achieved with triple pelvic osteotomy in the treatment of residual hip dysplasia, with special interest in identifying recurrences and complications and how to avoid them. 60 patients (76 hips) with developmental dysplasia of the hip (DDH), treated by the triple pelvic osteotomy according to Tönnis and modified by Vladimirov, were included in the study. Hips were evaluated radiologically with the center-edge (CE) angle, break of the Shenton-Menard arch and index of acetabular depth by Heyman-Herndon, and functionally using the Harris Hip Score (HHS). The postoperative results showed an average increase of the CE angle by a mean of 23.5+/-9.28 degrees, with a highly significant difference between the preoperative and final postoperative findings (t-test, t=-20.85, p<0.01). The mean HHS significantly improved (p<0.01). Total complication rate was 13,1%, divided in: 1,3% (one case) of triple nonunion of iliac, pubic and ischial bones, 7,9% (six cases) of double nonunion of pubic and ischial bones, 2,6% (two cases) of peroneal palsy and 1,3% (one case) of infection. In this study the triple pelvic osteotomy showed to be reliable for acetabular dysplasia in adolescent and young adult, alone or in association with proximal femoral osteotomy and/or great trochanter distal advancement.