[Tricalcium phosphate mixed with autologous bone marrow in the treatment of benign cystic bone lesions in children]. / Trikalciumfosfát v kombinaci s autologní kostní drení v lécbe cystických kostních defektu v detském veku.

PURPOSE OF THE STUDY: To test the hypothesis that the application of tricalcium phosphate (TCP) mixed with autologous bone marrow can achieve better and faster healing of benign bone lesions than the application of tricalcium phosphate granules alone. MATERIAL AND METHODS: The prospective study included two groups, each consisting of 10 patients, treated for benign cystic bone lesions at the Department of Paediatric Surgery, Orthopaedics and Trauma Surgery from July 1, 2008 to June 30, 2010. The bone cysts involved non-ossifying fibroma, enchodroma, fibrous dysplasia, aneurysmal bone cyst and juvenile bone cyst. One group was treated using ChronOS(TM) Beta-Tricalcium Phosphate (Synthes GmbH, Switzerland) granules mixed with autologous bone marrow harvested during surgery (BM group). The other (CH group) received treatment with ChronOS granules alone. Relevant clinical data were obtained from all 20 patients treated for one of the bone cyst forms mentioned above. The patients were followed up till the end of 2010. RESULTS: TCP application was a one-step procedure in both groups. In the BM group, bone regeneration ad integrum (Neer 1) was achieved, with only an occasional very small residue of the cyst seen on radiographs (Neer 2). None of the patients reported any problems, not even at 6 months after surgery. In the CH group, two patients required further surgical treatment because of insufficient bone healing (Neer 3) and two other patients reported pain persisting at the site of the lesion at 6 months post-operatively. In these patients TCP was used to fill a defect after excochleation of an aneurysmal bone cyst or fibrous dysplasia. The rest of the patients showed satisfactory healing. DISCUSSION: The main objective of the use of synthetic biocompatible materials in surgical treatment of benign bone cysts requiring filling of the lesion is to reduce the post-operative stress of paediatric patients as much as possible. Although our first results were not statistically significant to give unambiguous support to our hypothesis that lesions would heal better with the use of synthetic tricalcium phosphate mixed with autologous bone marrow, there is plenty of evidence that further development of cell technologies will result in a more exact definition of bone substitute materials in both their components, i.e., well-defined cells and non-biological scaffolds close in structure to inorganic compounds of bone, i.e., biodegradable osteoinductive materials. CONCLUSIONS: The patients with benign bone lesions treated by TCP mixed with autologous bone marrow showed neither recurrent disease nor complications. The group treated with TCP alone had recurrent lesions in two and persisting pain also in two patients. Other complications were not recorded.

[A contribution of instrumental gait analysis to the establishment of surgical indications in cerebral palsy]. / Prínos instrumentální pohybové analýzy pro indikaci chirurgické lécby u detské mozkové obrny.

PURPOSE OF THE STUDY: To evaluate our experience with indications for surgery based on instrumental gait analysis in cerebral palsy children, and to compare them with those drawn from the results of clinical examination. MATERIAL AND METHODS: The gait analysis laboratory was built in the Paediatric Hospital of the Faculty of Medicine in Brno in the 2008/09 period with support of the Norwegian funds. It is equipped with eight optical cameras, two auxiliary motion-picture video came- ras, two force platforms and a telemetry system for electromyography. Between June 2009 and March 2010 a total of 297 children with spastic cerebral palsy, 66 with hemiparesis and 231 with diparesis were examined. RESULTS: On the basis of instrumental gait analysis, indications for surgery were established in 19 hemiparetic and 88 diparetic patients, which meant a new indication in 107 children. In 14 children, the results of gait analysis led to abandoning former indications for surgery based on clinical examination only while, in 13 children, they backed up the surgical indications in spite of the negative results of clinical examination. In six children a so-called superclinical decision was made, i.e., the results of repeated clinical examinations over-weighed those of instrumental gait analysis either in favour of or against surgery. DISCUSSION: Based on the gait analysis results, a change in treatment plans was made in 27 out of 297 children (9 %). This is in contrast with the findings of other authors who report a much higher rate of treatment planning changes (52-70 %) In our stu- dy the use of instrumental gait analysis allowed us to decrease the frequency of surgical indications by 4.7 %. Other authors have achieved a higher value, up to 13 %. Unlike other studies, ours did not confirm the effect of gait analysis outcomes on an increase in the number of one-stage multi-level surgical procedures. CONCLUSIONS: Instrumental gait analysis is a great contribution to the diagnosis of movement disorders in children with cerebral palsy.

[Subtalar stabilization of pes equinovalgus by conventional open surgery using bicortical iliac crest bone graft (mid-term results)]. / Strednedobé výsledky subtalární stabilizace pes equinovalgus klasickou otevrenou metodou bikortikálním stepem z pánve.

PURPOSE OF THE STUDY: The aim of the study was to analyze the results of subtalar stabilization of the foot by conventional open surgery with the use of bicortical graft in cerebral palsy patients with pes equinovalgus and to compare our results with those of other authors. MATERIAL: A total of 193 operations were performed, with bilateral surgery in 84, surgery on the right foot in nine and surgery on the left foot in 16 patients. The average follow-up was 5 years and 2 months. METHODS: Before and after surgery, the clinical presentation in each patient was evaluated according to our subjective, description- based classification using a I-to-III scale (I, normal foot; II, moderate deformity; III, severe deformity). On lateral radiographs of the foot in a standing position, the talocalcaneal (TC) angle and that between the longitudinal calcaneus axis and foot-supporting surface (CS) were measured. The data was analyzed by statistical methods. RESULTS: The pre-operative findings were compared with the post-operative ones on the basis of our I-III classification system. In all results obtained with the McNemar test, p-values were lower than 0.001; therefore, at a 5 % level, the null hypothesis can be ruled out and a conclusion can be drawn that this surgery has an effect on the change in foot shape, as defined by our classification. Surgery failed in 13 feet (6.7 %), i.e., it did not produce any change in the degree of deformity. Similarly, values of the TC and CS angles were compared. The null hypothesis of Wilcoxon's test is that the patient's condition (TC and CP angles) remains the same before and after surgery. In all cases, the p-values were lower than 0.001; therefore, at a 5 % level, the null hypothesis can be ruled out, with the conclusion that differences between pre- and postoperative conditions were statistically significant. DISCUSSION: The results of this study, as compared with the relevant data, show that, for correction of pes equinovalgus, subtalar stabilization with bicortical iliac crest graft is a sufficiently reliable method even without metal fixation. The failure rate is only 6.7 %. CONCLUSIONS: The method described here achieves good results, the validity of which is supported by statistical analysis. Key words: cerebral palsy, pes equinovalgus, subtalar extra-articular arthrodesis.

[Treatment of congenital pseudarthrosis of tibia by vascularized fibular graft]. / Lécba vrozeného pakloubu bérce vaskularizovaným kostním stepem.

PURPOSE OF THE STUDY: The aim of the study was to evaluate the results in a group of patients with congenital pseudarthrosis of the tibia treated by transfer of a vascularized fibular graft from the contralateral extremity. MATERIAL: The group included three boys and two girls aged 2 to 8 years at the time of surgery. In two patients, the vascularized graft transfer was preceded by other operations. All patients but one had Crawford type IV pseudarthrosis. The signs of peripheral neurofibromatosis were found in four of the five patients. METHODS: The operation was carried out by two surgical teams, i. e., orthopedic and microsurgery (plastic surgery) specialists. Deep dissection of the pseudarthrosis was performed down to healthy, well vascularized tissue; a vascularized pedicle bone graft was harvested from the contralateral fibula. The graft was inserted and anchored intramedullarily in both tibial fragments, and stability was provided with a K-wire introduced through the calcaneus. Subsequently, the vascular pedicle of the fibular graft was joined to the surrounding vessels (anterior tibial artery and anterior tibial vein). The extremity was immobilized in plaster cast and later a KAFO brace was applied. RESULTS: Graft union partially failed in the proximal end of the graft due to bone resorption of both the graft and the proximal tibial fragment in two patients. This was successfully treated by additional spongioplasty. In all patients bony union was achieved at an average time of 9.8 months (range, 6 to 21 months). An increase by more than 100 % in the diameter of the transplanted fibula was recorded in four patients. The increase, which was of course related to follow-up time, was a clear proof of primary graft vascularization. DISCUSSION: The use of vascularized fibular graft harvested from the contralateral extremity showed high effectiveness in comparison with other methods. This was in agreement with the relevant literature reports. CONCLUSIONS: This method can be used regardless of patients' age and our experience showed that, even in small children, union can be achieved and can thus allow for early weight-bearing and prevention of crus atrophy.

[Video-assisted tenotomy of the triceps muscle of the calf in cerebral palsy patients]. / Video-asistovaná tenotomie m. tricipitis surae u pacientu s detskou mozkovou obrnou.

PURPOSE OF THE STUDY: The aim of the study was to demonstrate the outcomes of video-assisted tenotomy of the gastrocnemius and soleus muscles in children with the spastic form of cerebral palsy. MATERIAL: In the period from September 2003 to March 2004, 18 lower extremities in 14 patients were operated on.A set for endoscopic plastic surgery with a 4-mm trocar was used. Aponeurotomy was carried out with a scalpel no. 11 or arthroscopic scissors. The treated limb was immobilized in plaster cast for 6 weeks. METHODS The inclusion criteria were: an equinus gait free from a valgus or a varus deviation, preferably unilateral, and the age range between 4 and 10 years. The patients were examined before surgery and followed up at 3-month intervals. RESULTS: In 16 out of 18 treated extremities, simple aponeurotomy of the gastrocnemius and soleus muscles was sufficient to achieve 20 degrees dorsiflexion. In two cases it was necessary to complete the procedure at the same stage by video-assisted sliding double-point tenotomy of the Achilles tendon. The short-term follow-up did not reveal complications such as failure of wound healing or neurological or vascular disturbance. DISCUSSION: The international literature data show that this method has largely been developed on cadavers. Much attention has been given to potential injury to the sural nerve. However, the ultimate goal of this operation, i. e., sufficient correction, should be regarded as a much more important factor. In older children, simple aponeurotomy may not achieve this objective and therefore the authors developed a procedure combining video-assisted aponeurotomy with sliding double-point tenotomy of the Achilles tendon. CONCLUSIONS: Video-assisted tenotomy of the gastrocnemius and soleus muscles proved a fully effective method in our group evaluated at short-term follow-up.

Smoking and pregnancy: prevalence, knowledge, anthropometry, risk communication.

Information about smoking impact on pregnancy as well as clear advice to stop and a treatment offer should be included into the health care of pregnant women. We contacted them within the first 3 days after delivery. In the sample of 265 women 23.8% (63/265) smoked during their pregnancy (51.9% with basic education only, 25.8% with high school and 5.0% with university education), and 7% of the sample (19/265) did not quit by the delivery. Only 68% of smokers (43/63) were asked about their smoking habits during the pregnancy by their gynaecologist, and both smokers and non-smokers had insufficient information about the impact of smoking on their baby (40% of smokers and 32% of non-smokers had no idea at all), the doctor was the source of this kind of information only in 5% (13/265) cases. Smokers' children had a lower average birth weight (3.084 g in smokers vs. 3.325 g in non-smokers, p=0.02) and were smaller (49.3 cm vs. 50.5 cm respectively, p=0.02). Smokers' bodyweight increased more than non-smokers' during their pregnancy (gaining 14.8 kg vs. 12.9 kg respectively, p=0.02), they also underwent the delivery at a lower age (27.6 vs. 30.0 years respectively, p<0.01) and after a non-significantly shorter duration of pregnancy (38.7 weeks vs. 39.0 weeks respectively, p=0.53). If 23.8% of pregnant women smoke and 90.6% of them would like to stop, it is a missed opportunity for education and treatment of tobacco dependence by their physicians.

Early diagnosis of congenital dislocation of the hip.

In this prospective study, 35,550 neonates were examined shortly after birth by a team of orthopaedic surgeons. They diagnosed 775 unstable or dislocated hips in 656 babies; there were two teratological dislocations. Treatment was first with a Frejka pillow and, if this failed to give a normal hip, a Pavlik harness at three months. Early clinical examination did not identify 21 infants who were found to have subluxation or dislocation of the hip at the three-month review. The number of missed cases declined during the study, however, reflecting the increasing experience of the examiners. One case of avascular necrosis occurred in the group treated from birth and one in the late-diagnosed group. Open reduction was necessary only in the two teratological dislocations. Experienced examiners are needed for accurate clinical diagnosis; and treatment should be started before the baby is discharged from the maternity ward.

Selective treatment program for developmental dysplasia of the hip in an epidemiologic prospective study.

Over 1 year of ultrasound (US) mass screening, 4,568 newborns were examined consecutively at age 3-4 weeks using both clinical and ultrasonographic examination methods. The US examination involved both the static and dynamic scanning. In total, 25 babies were treated early (5.5 per 1,000), and 6 babies were given late treatment for postnatally developing acetabular dysplasia (1.3 per 1,000). Early treatment was instituted only for hips remarkably distorted anatomically, as could be seen from their shape on the static scan, and for those that were sonographically unstable with an apparent stress displacement. Clinical examination at age 3-4 weeks failed in more than half of all sonographically abnormal cases. In one case, the postnatal development of the hip joint was associated with the worsening of its formation and a developing subluxation despite its primary normal characteristics.

[Late results of conservative treatment of perthes disease.]. / Pozdní výsledky konzervativní lécby Perthesovy choroby.

The objective of the submitted work was to assess the long-term prognosis of Perthes disease. From the originally invited 142 patients 72 attended the check-up examination, complete X-ray documentation was assembled only in 32 patients with 38 affected hip joints. The time interval which had elapsed since the onset of the disease was on average 17 years. The authors evaluated the clinical and X-ray picture of the hip joints and assessed retrospectively the affection of the head according to Catterall's method, incl. signs of a head associated with risk. Treatment provided during the sixties and beginning of the seventies did not meet the principles of modern "containment" therapy. It comprised bed rest, application of a plaster spike and aftertreatment with a Thomas splint. During late check-up examinations Wiberg's angle, the epiphyseal index, the index of overlapping of the head, the distance of the head from the floor of the acetabulum and the height of the peak of the greater trochanter above the centre of the head of the femur were assessed. In addition to assessment of these partial X-ray parameters the authors evaluated the spherical properties of the head by Mose's method and subjectively the X-ray picture, using a three grade scale (satisfactory, feasible, poor). In the majority of assessed parameters the authors found a statistically significant correlation with the retrospective classification of the original X-ray pictures classified according to Catterall. The clinical picture was satisfactory in the majority, the authors did not find painful restriction of movement, while almost half the patients reported occasional subjective complaints as regards the hip joint. On the X-ray changes in the overgrowth of the greater trochanter were more marked than changes of the spherical character of the head and the extent of decentering. The follow-up of the group will continue to obtain a longer time interval from the onset of the disease. Key words: Perthes disease, late results, Catterall's classification.

[Clinical and ultrasonic diagnosis of congenital hip dislocation (dynamics of changes in early therapy)]. / Klinická a ultrasonografická diagnostika vrozeného vykloubení kycelních kloubu (dynamika zmen pri vcasné terapii).

The authors present part of their prospective epidemiological study of congenital dysplasia of hip joints within which newborns were examined by ultrasonogram prior to the beginning of the therapy. Apart from the standard examination in the frontal plane after Graf they examined on principle also the ultrasonographic stability by the dynamic test after Schuler as well as by the application of the probe anteriorly with the simultaneous provocation according to Palmén. The authors have processed pathological ultrasonographic findings in 53 newborns (64 hip joints). The technique of the examination by ultrasound from the anterior approach is explained in detail. The comparison of both dynamic tests has shown that the examination from the anterior approach is considerably more sensitive than Schuler's dynamic test and also fully correlates with the clinical finding. It is a fact that the shift of the head in the flexion dorsally represents the most important component of the movement in unstable hip joint during provocation, it is far more noticeable than the lateralization of the head or the shift in the cranial direction. After achieving ultrasonographic stability the classical Graf method is sufficient for the registration of residual changes on the acetabular rim. The follow-up of patients until their complete healing has shown a surprisingly rapid remodellation of hip joints. The whole complex of clinically unstable hip joints has been divided into subgroups according to Graf classification. In type IIc or IId on the basis of ultrasonographic examination from the anterior approach the stable joints from the ultrasonographic viewpoint have been distinguished from unstable ones. The follow-up carried out in short intervals has shown that of longest duration is the remodellation of total dislocation and, on the contrary, of shortest duration is the healing of joints in the IIc or IId type. An absolute majority of affected hip joints have become normal until 3rd month of the age. The complex does not include two patients with teratological dislocation, the incidence of which has been determined in our study by the ratio of 2 cases in 35,550 of timely examined newborns. The role of the factor of spontaneous stabilization cannot be in this part of the study completely discounted. However, herewith we present part of an accomplished epidemiological study where the number of timely diagnosed patients including late diagnoses corresponds to the number of dislocations and subluxations determined within the conventional late diagnosis.

[Bone Reconstruction of Autolyzed Antigen-free Allogenic /AAA/ Bone in Children and Adolescents with Benign Bone Tumours.]. / Kostní prestavba autolyzované antigenuprosté alogenní /AAA/ kosti u detí a dospívajících s benigními kostními tumory.

The authors describe in detail the preparation of six batches of human AAA/autolyzed antigen-free allogenic bone/ prepared in 1985 to 1988. This bone was administered to a total of 48 children and adolescents aged 6 to 19 years. It was used to fill cavities after metaphyseal connective tissue bone defects /31 x/, solitary bone cysts /10 x/, enchondromas /5 x/ and fibrous dysplasia /2 x/. The observation period was 2 years and 2 months to 5 years and 9 months. The mean volume of the cavities was 21 ml. In all patients the X-ray pictures were evaluated in a chronological sequence and changes on the host s bones in the cavity and the inserted AAA bones were described, and finally also changes of the entire bone complex with incorporated AAA implants. The results were arranged in tables. On the host's bones a periosteal reaction was observed in the area surrounding the focus, the entire cavity was covered with a soft shadow, there was sclerosis of the margins and bottom of the bone bed and gradual diminution of the bone defect from the sides and bottom of the bed. On the AAA bones the following observations were of interest: the connection of AAA bone with the surrounding newly formed bone, less clearly defined outlines of the AAA bone, loss of identity of the AAA bone. Sclerosis or elimination of the AAA bone were not observed. In three patients with batch 5 a "halo" effect was observed. On the entire complex with incorporated AAA bones the following were investigated: sclerosis of the entire portion of the bone, then regression and diminution of sclerosis, differentiation of the corticalis and medullary cavity and formation of a normal bone structure without signs of previous treatment. Preparation of six different batches of AA bone revealed that: 1.The spongious parts are more readily and more rapidly incorporated than the cortical part which is only partly demineralized. 2.Gelatinization with LiCI had a favourable effect on the incorporation of thus prepared implants. X-ray investigation revealed that the course of incorporation and reconstruction of these bones has the following specific features: 1.Reconstruction begins as a rule by the periosteal reaction of the host and its shift above the gap has a favourable effect on healing of the defect. 2.Two months after operation the cavity is covered by a soft shadow when the newly formed vessels and mesenchymal cells of the host infiltrate into the focus. 3.Activation of the bed is manifested by its greater density, sclerotization and by gradual diminution of the volume of the cavity. The greater density is not necessarily associated with diminution of the size of the cavity. 4.Bone implants are connected to the newly formed bone without passing through the stage of densi fication and sclerotization. The newly formed bone infiltrates them, absorbs and replaces the bone proper without signs of the previous stage of scle rosis, as observed in patients with frozen allogenic bones. 5.After incorporation of AAA implants further bone reconstruction takes place, as known from the healing of fractures or bone gaps. Key words: demineralized bone, AAA bone, benign bone tumors, reconstruction of bone transplant.