[Femoral Fractures in Children Younger than Two Years. Are We Considering Abusive Etiology?] / Fraktury femuru u detí do dvou let. Pomýslíme na moznost týrání?

PURPOSE OF THE STUDY: The primary aim is to assess the proportion of children younger than two years with a femoral fracture who underwent a skeletal survey. The secondary aim of the study is to evaluate the patients' demographics, reported trauma mechanism, type of fracture, type of treatment and complication rate. MATERIAL AND METHODS This was a retrospective study of children younger than two years examined at the Department of Imaging Methods for a femoral fracture between 2015-2022. The type and site of the fracture were assessed on radiographs. The patients' medical records were used to assess which steps had been taken to evaluate for possible abusive etiology of the fracture. The data were correlated with the published guidelines for performing skeletal survey in young children with fractures. The patients' demographics, medical history, time interval from trauma or symptoms onset to medical examination, type of treatment, duration of orthopaedic follow-up in addition to the clinical fi ndings at the last orthopaedic follow-up visit were also retrieved from the patients' medical records. RESULTS A total of 40 children were included in the study, 21 of whom were girls (52.5%). The mean age was 13.8 months. 5 children (12.5 %) were younger than 6 months. 36 children (90%) had a history of trauma, the vast majority of whom suffered a fall. 21 patients (52.5%) sustained a distal metaphyseal fracture, 19 patients (47.5%) suffered a diaphyseal fracture. A spica cast was used in 12 patients (30%), which was applied under general anaesthesia in most cases. 28 patients (70%) received a long leg cast. A certain degree of stiffness following cast removal was the only documented complication. Based on the published guidelines, it was estimated that in 23 patients (57.5%) a skeletal survey should have been performed. However, this investigation was performed in 2 patients (5%) of the study population only. DISCUSSION Femoral fractures in young children are rare, especially in those younger than six months of age. The fractures were located in femoral diaphysis and in distal femoral metaphysis. Surgical treatment was not required, and no signifi cant complications were observed. Nonetheless, the study showed that the rate of child abuse screening was low. The skeletal survey was performed in two cases only, both children were younger than six months and had no history of trauma. Based on the published guidelines, however, it may be assumed that the skeletal survey should have been performed in more than half of the patients in the study. The failure to perform this investigation might have led to the abuse not being detected and the child being returned to the abusive environment. CONCLUSIONS Management of femoral fractures in patients younger than two years does not usually require hospitalisation and is not associated with the risk of complications. However, potential further harm may be caused if abusive etiology of the femoral fracture fails to be discovered. This study has shown that the rate of abuse evaluation is low. It is essential to initiate a multidisciplinary discussion on this topic to raise the physicians' awareness and to implement the screening for child abuse among young children with femoral fractures. This scientifi c paper also includes a summary of necessary steps to be taken in the evaluation of a young child with a femoral fracture. KEY WORDS: fractures, femur, children, infant, child abuse, radiography.

[Our Experience with ICON Hip Resurfacing System]. / Nase zkusenosti s povrchovou náhradou kycelního kloubu ICON.

PURPOSE OF THE STUDY Our study aimed to assess the mid-term outcomes and complications with the ICON hip resurfacing system and to carry out a detailed analysis of pitfalls and risks associated with pairing the bearing surfaces of metal-on-metal hip implants. MATERIAL AND METHODS A total of 52 hip joints were assessed in 43 patients who received the ICON hip resurfacing system at our department between 2009 and 2013. The cohort included 34 men and 9 women. Their age at the time of primary surgery ranged from 34 to 67 years, with the mean age of 51.8 years. The mean follow-up was 7.6 years. The evaluation focused on the position and osseointegration of both components, bone remodelling around the implant, and signs of potential aseptic loosening. The functional status of the hip was assessed by Harris Hip Score. RESULTS The primary stability of both components was always good, there were no femoral neck fractures reported in our cohort. All the acetabular components were stable, showing appropriate osseointegration, with no radiolucent zones or signs of osteolysis around them. There was not a single case of the femoral component stem being in a biomechanically disadvantageous varus position. In zone I and III according to Beaulé, cancellous bone osteolysis developed in two patients. The narrowing of the femoral neck below the end of the femoral component, compared to postoperative X-rays, achieved the mean value of 1.3% according to Grammatopolouse. The HHS increased from 64 to 95.5 points. An excellent outcome was observed in 48 joints, whereas the outcome of the remaining 4 joints was very good. The mean survival rate of the resurfacing hip implant calculated using the Kaplan-Meier analysis achieved 100%. The cobalt and chromium levels in the blood of patients did not exceed the reference physiological value. DISCUSSION The resurfacing system enables to preserve the bone tissue of the metaphysis and a part of the femoral head. The reduced mechanical endurance of the peripheral part of femoral components smaller in size caused by implant malposition resulted in fatal consequences in the ASR system. Greater range of motion conditioned by the design of the resurfacing system led to a mechanical wear, with a significant increase in the concentration of metal particles in the effective joint space. The elevated levels of cobalt and chromium ions in some patients induced delayed-type hypersensitivity with subsequent development of aseptic lymphocyte-dominated vasculitis associated lesions presented as peri-acetabular changes (pseudotumors to osteolysis) with subsequent failure of implant fixation. We have not observed this complication in the ICON system as yet. In patients suffering from hip pain after the resurfacing hip arthroplasty and simultaneous high chromium and cobalt blood levels, pelvic CT/MRI is indicated with reduction of artefacts around the metal material. Surgical treatment of soft tissue affections, bone defects and reimplantation using conventional or revisioncementless components is a possible treatment option. CONCLUSIONS The ideal patient indicated for hip resurfacing is a physically active man under 60 years of age (with a femoral head size of 54-60 mm), with primary or secondary osteoarthritis, no joint deformity, with a good quality bone tissue in the femoral neck and head region. As for the functional performance, the resurfacing system allows the patients a large range of motion with very good joint stability immediately after surgery. Despite that, the metal-on-metal tribological pairing must be approached with caution. The risk of developing lesions associated with ALVAL is unpredictable. In our cohort of patients with ICON hip resurfacing system, mostly excellent outcomes with minimum complications were reported provided the indication criteria and the correct surgical procedure had been complied with. Key words: hip resurfacing system, metal articulating surfaces, adverse reaction to metal particles, aseptic lymphocytedominated vasculitis associated lesions, pseudotumor.

[Osteochondritis Dissecans in Children - Treated with Arthroscopic Drilling]. / Osteochondritis dissecans u detí ­ osetrení pomocí artroskopické techniky fokálních návrtu.

PURPOSE OF STUDY Osteochondritis dissecans (OCHD) is an increasingly diagnosed disease among adolescent patients. It is a condition affecting subchondral bone and the lining cartilage. If left untreated, it can cause destruction of cartilage of the affected joint leading to early development of arthrosis. Mostly affected joints are knees and ankles, but affected elbow and other joints have been described too. The purpose of our study is to present the patients diagnosed and treated surgically at our clinic with arthroscopic drilling in the period 2010-2015, and subsequently the clinical findings obtained at follow-up checks after the surgery. MATERIAL AND METHODS Between 2010 and 2015, a total of 34 patients (36 joints) underwent surgical treatment at our clinic. Their age ranged from 6 to 19 years at the time of surgery, 17 girls and 17 boys underwent the surgery. All the patients were treated with transarticular antegrade arthroscopic drilling. Each patient was diagnosed based on the clinical finding, radiographs, or MRI. The patients were followed after 6 weeks, thereafter 3, 6, and 12 months after the surgery. Each patient was evaluated based on the clinical findings (presence of swelling, range of motion, and pain according to VAS), and radiographs. RESULTS The preoperative VAS was 2.9 and dropped down to 1.5 at the first follow-up visit. None of the patients complained of pain at 1-year follow-up. 34 (out of 36) patients suffered joint swelling preoperatively, 6 weeks after the surgery only 9 patients presented with ongoing swelling, at 1-year follow-up no patient reported this problem. The X-ray findings showed regression in 35 of 36 patients one year after the surgery. One female patient underwent redo surgery because of an ongoing restriction of movement and X-ray finding persistence. DISCUSSION Majority of patients with OCHD can be treated conservatively. Physical activity modification and temporary immobilization are commonly used treatment methods of this condition. If conservative treatment is unsuccessful, arthroscopy should be considered. Stable lesions have a high chance of spontaneous healing without surgery. There is a variety of arthroscopic treatment methods. Mostly transarticular transchondral drilling is used to treat this condition. CONCLUSION Treatment of OCHD with arthroscopic drilling shows promising results in our cohort of patients. We recommend to use arthroscopic drilling in patients in stage I to III according to X-ray when 3 months of conservative treatment do not improve the clinical symptoms, swelling and restriction of movement. Antegrade drilling is the most frequently used treatment method in OCHD at our clinic, we consider this technique a simple and effective, with short surgical time needed. Key words: osteochondritis dissecans, treatment, arthroscopy, drilling.

Autologous Mesenchymal Stromal Cells Immobilized in Plasma-Based Hydrogel for the Repair of Articular Cartilage Defects in a Large Animal Model.

The treatment of cartilage defects in trauma injuries and degenerative diseases represents a challenge for orthopedists. Advanced mesenchymal stromal cell (MSC)-based therapies are currently of interest for the repair of damaged cartilage. However, an approved system for MSC delivery and maintenance in the defect is still missing. This study aimed to evaluate the effect of autologous porcine bone marrow MSCs anchored in a commercially available polyglycolic acid-hyaluronan scaffold (Chondrotissue®) using autologous blood plasma-based hydrogel in the repair of osteochondral defects in a large animal model. The osteochondral defects were induced in twenty-four minipigs with terminated skeletal growth. Eight animals were left untreated, eight were treated with Chondrotissue® and eight received Chondrotissue® loaded with MSCs. The animals were terminated 90 days after surgery. Macroscopically, the untreated defects were filled with newly formed tissue to a greater extent than in the other groups. The histological evaluations showed that the defects treated with Chondrotissue® and Chondrotissue® loaded with pBMSCs contained a higher amount of hyaline cartilage and a lower amount of connective tissue, while untreated defects contained a higher amount of connective tissue and a lower amount of hyaline cartilage. In addition, undifferentiated connective tissue was observed at the edges of defects receiving Chondrotissue® loaded with MSCs, which may indicate the extracellular matrix production by transplanted MSCs. The immunological analysis of the blood samples revealed no immune response activation by MSCs application. This study demonstrated the successful and safe immobilization of MSCs in commercially available scaffolds and defect sites for cartilage defect repair.