[Intercondylar eminence fracture in children. Results of long-term follow-up]. / Fraktura interkondylické eminence v detském veku. Výsledky dlouhodobého sledování.

PURPOSE OF THE STUDY: An intercondylar eminence fracture is injury more common in children and adolescents than in adults. Also if it is considered a benign lesion, a displaced medial spine fracture can result in cruciate ligament laxity. We report the evaluation of long-term results of conservative and arthroscopic stabilisation in children and adolescents with different types of intercondylar eminence fracture. MATERIAL AND METHODS: Flirty-eight patients with intercondylar eminence fractures, 31 boys and 17 girls, were included in our retrospective study. Of them, 33 were at the end of skeletal growth. According to the Meyers and McKeever classification, 11 fractures were type I, 20 were type II and 17 were type III. The first step in the treatment was an attempt at conservative reduction. If it failed, arthroscopic reduction with crossed K-wire fixation was used. At clinical follow-up, the patients were examined for pain, range of motion, level of activity, and the laxity tests were done. RESULTS: Conservative treatment was used in all type I cases (100 %), in eight type II cases (40%) and three type III cases (18%). The remaining patients were treated by arthroscopic reduction with crossed K- wires (type I, 0%; type II, 60%; type III, 82%). Six patients (12.5%) had symptoms of persistent anterior instability and five of them (10.4%) were indicated for anterior ligament reconstruction at the end of skeletal growth. We did not see serious complications. DISCUSSION: Most of the authors recommend that type I and type II fractures should be treated conservatively; type III is better treated by arthroscopic reduction. Some of type II and type III fractures are indicated for minimally invasive surgical treatment at once. At the present time at our department, type II and some type III fractures are indicated first for conservative reduction and, when this fails, arthroscopic reduction with K-wire fixation is used. CONCLUSIONS: The aim of our report was to report the results of our study and present our relatively conservative way of treatment as the method of choice for treating intercondylar eminence fractures in children and adolescents.

[Knee arthroscopy in children and adolescents with trauma histories]. / Artroskopie kolenního kloubu u detí a adolescentu s úrazovou anamnézou.

PURPOSE OF THE STUDY: In this retrospective study we analysed the major indications for knee arthroscopy and the diagnoses made using it in children and adolescents who had sustained knee joint injuries. MATERIAL AND METHODS: A total of 731 knee joint artroscopies were performed and retrospectively evaluated in patients under 19 years of age. The group included patients with knee joint injuries treated at our department in the 2000-2010 period. There were 413 boys (58%) and 300 girls (42%) with an average age of 14 years and 2 months. The clinical diagnosis was compared with the arthroscopic diagnosis. RESULTS: The results of our comparative study were divided into three groups. The clinical diagnosis was fully confirmed in 62%, partially confirmed in 17% (combined injuries) and was wrong in 21% of the patients. In this group, the most frequent diagnosis made by arthroscopy was injury to the lateral meniscus. Arthroscopy revealed patellar dislocations in 18%, osteochondral and cartilage lesions in 16%, plica injuries in 15 %, medial meniscus injuries in 14%, anterior cruciate ligament lesions in 12% and lateral meniscus injury in 8% of the patients. DISCUSSION: With the number of knee injuries in children and adolescents increasing every year, the role of arthroscopy in their diagnosis and treatment is becoming increasingly important. The results of our analysis showed gradual improvement in clinical outcomes and subjective evaluation of the arthroscopic technique in children and adolescents with the history of knee injury. Some authors report difficulties with the pre-operative diagnosis at this age; our results were notably better. CONCLUSION: Knee arthroscopy is a safe and effective method of a high diagnostic and therapeutic value and its use in children and adolescents should be recommended.

[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.

[Analysis of the results of bone healing in femurs lengthened by the gradual distraction method in children and adolescents]. / Analýza výsledku kostního hojení prodluzovaných femuru metodou postupné distrakce u detí a dospívajících.

PURPOSE OF THE STUDY: Treatment of leg length inequality via lengthening of the shorter extremity is an infrequent orthopedic procedure due to the requirement of special distraction devices and possible serious complications. Essential qualitative changes in operative technique development are associated with the name of G. A. Ilizarov, who paved the way for the autoregenerate gradual distraction method in the 1950s. MATERIAL AND METHODS: In the years 1990 through 2007 a total of 67 patients underwent femur lengthening via gradual distraction using various types of external fixators at the Department of Pediatric Surgery, Orthopedics, and Traumatology, Faculty Hospital in Brno. The quality of bone healing was monitored and a number of parameters followed and statistically evaluated using regularly scheduled X-ray examinations. RESULTS: In 13 cases we had to remove the external fixator following the distraction phase, perform an osteosynthesis via a splint and fill the distraction gap via spongioplasty. The bone healing was satisfactory in the remaining 54 patients and the lengthened bone required no other fixation method. The analysis showed statistically significant deceleration in bone healing following distraction in female patients over 12 years of age, and in boys over 14 years of age. Lack of periosteal callus five weeks after surgery always signified serious problems in further healing. Severe complications were recorded in 11 cases during the distraction phase, and in 12 cases after the removal of the distraction apparatus. DISCUSSION: Our results fully correspond with the data and experience of others cited authors. In addition our study showed deceleration in bone healing in girls over 12 years and in boys over 14 years of age and serious problem in healing when is lack of periostal callus five weeks after surgery. CONCLUSIONS: The aim of this report was to present the results of our study of distraction gap bone healing using the gradual lengthening approach. Key words: leg lengthening, gradual distraction, external fixation, leg discrepancy, complication.

[Synthetic biocompatible degradable material for juvenile bone cyst treatment]. / Syntetický biokompatibilní degradabilní materiál v lécbe juvenilních kostních cyst.

PURPOSE OF THE STUDY: Owing to advances in operative techniques and biotechnology, bone replacement biocompatible materials have recently come into focus for orthopaedic and trauma surgeons. Bone lytic lesions, such as tumorous bone defects, diseases simulating cancer, chronic inflammatory lesions or skeletal injuries, often require stabilisation of the skeleton and treatment of the bone affected. Juvenile bone cysts are benign lytic lesions posing a threat to bone compactness in childhood. They are benign, fluid containing bone cavities, lined with a membrane consisting of thin vascularised connective tissue with scattered osteoclast-like cells. These cysts are usually diagnosed between; five and twenty years of age outside this age range their occurrence is rare. MATERIAL: The group comprised the patients treated for juvenile bone cysts at the Department of Paediatric Surgery, Orthopaedics and Traumatology between 2001 and 2007. In the 2001-2003 period, 24 patients were treated with Depo-Medrol. Between January 2005 and December 2007, 31 patients with the same diagnosis were treated by minimally invasive application of chronOs Inject. METHODS: The aim of the study was to compare these two methods of juvenile cyst therapy, i.e., the most widely used method of repetitive Depo-Medrol applications against the novel method based on filling the cyst with chronOs Inject, a synthetic biocompatible resorbable material. An alternative hypothesis assumed that the new method would result in fewer necessary operations in patients with juvenile cyst and better treatment outcomes, as evaluated by Neer's criteria for bone cyst therapy. RESULTS: A total of 20 surgical interventions were performed in 18 patients treated by chronOs Inject and 100% cyst healing without necessity of additional surgery was achieved. Of the 24 patients treated with Depo-Medrol, 12 patients (50%) showed cyst healing wit no further surgery required. A total of 69 applications were needed. DISCUSSION: An impetus to introduce the novel method of juvenile cyst treatment stemmed from the unsatisfactory results of the previous treatment with repetitive Depo-Medrol applications requiring additional open surgery and spongioplasty to fill the cyst. For filling cysts and other benign bone defects jeopardizing bone stability, such as deep metaphyseal fibrous defect, non-ossifying fibroma, enchondroma or fibrous dysplastic lesion, synthetic tricalcium phosphate in the form of chronOs granules was used, but without the possibility of minimally invasive percutaneous application. As soon s the resorbable chronOs Inject became available, the minimally invasive method of filling cysts with this material was adopted. CONCLUSIONS: The results showed that, in the patients treated by the chronOs Inject method, the outcomes achieved were significantly better than those in the patients treated with Depo-Medrol. The difference was in the number of operations needed, which were significantly fewer in the chronOs Inject method, as well as in the overall treatment outcome, with significantly more frequent excellent results in the chronOs Inject method.

[The use of biodegradable materials in the management of bone cysts in children]. / Pouzití biodegradabilních materiálu v lécbe kostních cyst u detí.

AIM: The commonest benign lytic bone disorders, which compromise the bone robustness include juvenile bone cysts. Provided the cysts do not undergo spontaneous healing, which is commonly facilitated by pathological fracturing or introduction of osteosynthetic material into the cyst, the cystic cavity must be filled in. Numbers of potential defect management procedures, including use of corticoids, autografts, allografts or recently introduced methods of application of synthetic anorganic biomaterials, have been used. The aim of this study is to assess a possibility of the biomaterials use in the management of benign cysts in children. MATERIAL AND METHODOLOGY: The study included 20 juvenile bone cysts patients aged 10-17, treated with tricalcium phosphate during 2004-2007 in the KDCHOT. The authors assessed rates of the procedures, therefore a number of required hospitalizations and total anesthesias, intraoperative complications, postoperative complications, durations of hospitalization and treatment outcomes, based on Neer criteria, including the cyst's time-to-heal interval. In addition, evaluation of the results was related to the cyst's location. RESULTS: The treatment results, assessed according to the Neer criteria, show that 90% of the cysts healed and did not require further surgical intervention. Poor outcome was recorded in 2 subjects, who required further surgery due to skeletal instability. Intraoperative and perioperative complications were insignificant, the average duration of hospitalization was 4 days and the average time-to-heal period following primary or secondary percutanneous cyst filling was 15 months (ranging from 13 to 20 months). CONCLUSION: The studied method of the tricalcium phosphate application resulted in reduced rates of surgical procedures required for the defect healing. Furthermore, it is not associated with serious perioperative or intraoperative complications and the hospitalization duration may be very short.

[Synovial sarcoma in child -- case report]. / Synoviální sarkom u dítete -- kazuistika.

Soft tissue tumors occur rarely and account for 7 to 10% of all malignant neoplasms in children under 15 years of age. They constitute a heterogeneous group of tumors arising from primitive mesenchymal tissue. According to their origin they are classified as rhabdomyosarcomas and non-rhabdomyosarcomas of soft tissues. Synovial sarcoma is a rare fibroblastic tumor of soft tissue. In children under 5 years it is found only exceptionally. This study reports on a synovial sarcoma localized on the right lower extremity in a boy aged 4 years and 5 months. Differential diagnosis, prognostic factors and the role of imaging methods are discussed.

[Malignant tumors of long bones in children: differential diagnosis and the role of imaging methods]. / Maligní tumory dlouhých kostí u detí, diferenciální diagnostika, prínos zobrazovacích metod.

PURPOSE OF THE STUDY: The aim of the study was to analyze primary malignant tumors and tumor-like lesions of long bones, in relation to their localization, characteristics and distribution in age groups, in children and young adults, and to assess the role of radiography and magnetic resonance imaging (MRI) in their diagnosis. MATERIAL: Sixty-four patients, aged between 3 and 20 years, who were referred to us with the diagnosis of a suspected malignant long-bone tumor of osseous or cartilage origin in the period from 2000 to 2004 were included in the study. METHODS: Plain radiography and MRI were carried out on the same day. For MRI, the Magnetom Open Viva system (magnetic field strength of 0.2 T) was used and examination comprised a conventional STIR (corresponding to fat saturation) and a T-weighed sequence. Most patients also underwent post-contrast examination with paramagnetic contrast medium infusion. RESULTS: In 26 children (40.6 %) a primary malignant tumor of osseous or cartilage origin was diagnosed; one child (1.5 %) had a giant-cell tumor. The definitive diagnoses in 37 children (57.9 %) included osteomyelitis in 12, fatigue fracture in 11, posttraumatic myositis ossificans in three children, and miscellaneous diagnoses in the remaining 11 children (one, cartilaginous exostosis; three, unicameral bone cyst; two, non-ossifying fibroma; one, fibrous dysplasia; one, subperiosteal abscess; one, histiocytosis; one, foreign body; one, negative MRI findings). CONCLUSIONS: To confirm the diagnosis of a malignant long-bone tumor, high quality X-ray and MRI are essential; CT examination is recommended in specific indications. The results of imaging methods cannot be assessed without reference to each other. Primary malignant tumors of long bones usually involve a large soft-tissue mass, and an exclusively intraosseous localization is rare. Osteosarcoma often invades the epiphysis. In making the differential diagnosis of primary malignant bone tumors, special attention must be paid to differentiation from osteomyelitis or fatigue fractures. The majority of juvenile bone lesions of any origin are usually detected between 10 and 13 years of age. These pathologic lesions are most frequently localized in the distal or proximal transition zones between the diaphysis and metaphysis.

Illusory correlations in patient stereotyping.

Two experiments document one basis of patient stereotyping: the relative frequency of people's contact with medical patients. Experiment 1 demonstrated that illusory correlations formed based on the infrequency of target patients and their non-cooperative behaviors. Participants read about two groups of patients with two similar diseases (labelled A and B). One group appeared less often than the other and performed fewer non-cooperative behaviors; however, the proportion of non-cooperative and cooperative behaviors was the same for both groups. Participants overestimated the number of non-cooperative behaviors performed by the infrequently appearing group, evaluated the group negatively and believed that these patients would be unlikely to cooperate in the future. Experiment 2 attempted to address the relationship between illusory correlations and memory for the infrequent group's non-cooperative behaviors. Implications for how people perceive medical non-adherence in patients with stigmatized medical conditions were discussed.

[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.

ChronOS inject in children with benign bone lesions--does it increase the healing rate?

OBJECTIVE: Benign bone lesions in children although rare, can result in a pathological fracture. Although their etiology and pathogenesis are not yet entirely clear, the phenomenon of spontaneous healing is well known. Nevertheless, some benign bone lesions are unlikely to heal spontaneously due to the patient's age or high risk of fracture and deformity due to the lesion's location or size. The following study presents our results after treatment of these bone cysts with chronOS Inject. METHODS: From June 2004 to May 2007 23 patients with 24 benign bone cysts were treated with chronOS Inject, an injectable tricalcium phosphate, using a minimally invasive technique at two pediatric surgery departments. Postoperative follow-up examined bone healing, remodeling, chronOS Inject resorption and adverse effects. RESULTS: 15 males and 9 females, mean age 11 years at time of diagnosis, were treated with chronOS Inject. The humerus was affected 13 times, the femur 7 times, the tibia twice and the radius, the fibula and talus once each. Except for one case, all pathological fractures healed within five weeks post-injection. Two children had cystic residues. No severe adverse effects were seen. CONCLUSIONS: These preliminary results indicate that chronOS Inject could provide an alternative treatment for benign bone cysts that are unlikely to heal spontaneously due to the patient's age, high risk of instability or pathological fracture due to the lesion's size or location, or lesions that have already been treated several times using other methods without success.