[Comparison of Modifications of Femoral and Tibial Lengthening in Children]. / Srovnání modifikací prolongace femuru a bérce u detí.

PURPOSE OF THE STUDY Limb lengthening has always belonged to the most complex surgical techniques in paediatric orthopaedics. In our study, we compared the results of femoral and tibial lengthening using three different surgical techniques. The presented study aimed to shorten the duration of external fixation to a minimum and to reduce the complication rate. MATERIAL AND METHODS The retrospective study compared 74 patients (38 boys, 36 girls) who had undergone stepwise progressive lengthening of the femur or tibia between the years 2007 and 2019. The most frequent indication was the proximal focal femoral deficiency (PFFD, 33 patients). The total number of lengthening procedures was 130 (femur 72, tibia 58), the follow-up period was 2-14 years. The following modifications of surgical techniques were used: (i) standard approach, i.e. corticotomy with a two-stage removal of the fixator, (ii) preventive fixation with elastic stable intramedullary nails (ESIN) and also with a two-stage removal of the fixator, and (iii) standard approach with an early removal of the external fixator and plate osteosynthesis. RESULTS The mean lengthening achieved was 56 ± 18 (27-114) mm in femur and 54 ± 16 (25-110) mm in tibia. There was no statistical difference in the lengthening achieved by different modifications. The mean duration of external fixation in femur and tibia lengthening was comparable (166 and 164 days). The complications were observed in 60% of lengthening procedures, the most frequent being the pin release or axial malalignment of the lengthening (33 cases, 25%). The patients with ESIN displayed statistically the lowest complication rate (26%), the highest complication rate was seen in children with osteosynthesis using a plate (80%). CONCLUSIONS It follows from our results that fixation with intramedullary nails in comparison with the standard approach and plate osteosynthesis helped decrease the number of complications by more than 50%. The plate osteosynthesis is indicated in patients with repeated lengthening (achondroplasia, hypochondroplasia or PFFD with pronounced shortening) since it significantly reduces the duration of external fixation. Key words: limb lengthening, femur, tibia, surgical techniques, complications.

[Scanning Technique in Shoulder Ultrasonography]. / Sonografické vysetrení ramena.

This guide to ultrasound examination of the shoulder describes the basic scanning planes and contains corresponding high-resolution ultrasound images. The patient and probe positionings are explained in a simplified step-by-step manner using schematic drawings. This standard and simple examination technique seems to be an appropriate way to improve the learning curve of novice musculoskeletal sonographers. In this manuscript, an emphasis is placed on the rotator cuff, biceps tendon, subacromial-subdeltoid bursa, and joint recesses evaluation. This article also describes some common pitfalls to avoid when starting with shoulder ultrasonography (e.g. always determine the relevance of ultrasound findings in the context of clinical examination). Key words: tendons, bursa, synovial, shoulder, musculoskeletal, protocol, examination, ultrasound imaging, sonography, rotator cuff, acromioclavicular joint, shoulder impingement syndrome, learning curve.

[Scanning Technique in Elbow Ultrasonography]. / Sonografické vysetrení lokte.

This introduction to ultrasound evaluation of the elbow describes the basic scanning planes and contains corresponding high-resolution ultrasound images. The patient and probe positionings are explained in a simplified step-by-step manner using schematic drawings. This standard and simple examination technique seems to be an appropriate way to improve the learning curve of novice musculoskeletal sonographers. In this manuscript, an emphasis is placed on effusion detection, ulnar nerve imaging, and commonly injured tendons assessment. This article also describes some common pitfalls to avoid when starting with musculoskeletal ultrasonography (e.g. positioning issues, unsolicited artifacts). Key words: tendons, elbow tendinopathy, golfer's elbow, tennis elbow, musculoskeletal, protocol, ultrasound, common extensor tendon, common flexor tendon, ulnar nerve.

[Scanning Technique in Hip Ultrasonography]. / Sonografické vysetrení kycle.

This guide to ultrasound imaging of the hip describes the basic scanning planes and contains corresponding highresolution ultrasound images. The patient and probe positionings are explained in a simplified step-by-step manner using schematic drawings. This standard and simple examination technique seems to be an appropriate way to improve the learning curve of novice musculoskeletal sonographers. In this manuscript, an emphasis is put on hip effusion detection and on how to diagnose tendon and muscle injuries. Key words: tendons, hip tendinopathy, hip joint, athletic injuries, musculoskeletal, protocol, ultrasound, adductor tendon, trochanteric bursa, sciatic nerve.

[Scanning Technique in Wrist and Hand Ultrasonography]. / Sonografické vysetrení zápestí a ruky.

This guide to ultrasound examination of the wrist and hand describes the basic scanning planes and contains corresponding high-resolution ultrasound images. The patient and probe positionings are explained in a simplified step-by-step manner using schematic drawings. This standard and simple examination technique seems to be an appropriate way to improve the learning curve of novice musculoskeletal sonographers. In wrist section, an emphasis is placed on the carpal tunnel and extensor tendons evaluation. In the hand region, the scanning of the flexor pulley system and the flexor pollicis longus is described. Key words: hand, wrist joint, ultrasound, tendons, carpal tunnel syndrome, De Quervain disease, trigger finger disorder, hand injuries, musculoskeletal, protocol.

[Scanning Technique in Knee Ultrasonography]. / Sonografické vysetrení kolena.

This guide to ultrasound imaging of the knee describes the basic scanning planes and contains corresponding high-resolution ultrasound images. The patient and probe positionings are explained in a simplified step-by-step manner using schematic drawings. This standard and simple examination technique seems to be an appropriate way to improve the learning curve of novice musculoskeletal sonographers. In this manuscript, an emphasis is placed on Baker's cyst and knee effusion detection and on how to diagnose collateral ligament injuries. Key words: tendons, knee joint, tendinopathy, Baker's cyst, popliteal cyst, menisci, tibial, medial collateral ligament, musculoskeletal, protocol, ultrasound.

[Scanning Technique in Ankle nad Foot Ultrasonography]. / Sonografické vysetrení hlezna a nohy.

This guide to ultrasound imaging of the ankle and foot describes the basic scanning planes and contains corresponding high-resolution ultrasound images. The patient and probe positionings are explained in a simplified step-by-step manner using schematic drawings. This standard and simple examination technique seems to be an appropriate way to improve the learning curve of novice musculoskeletal sonographers. In this manuscript, an emphasis is placed on joint effusion detection, plantar fasciitis, Achilles tendinopathy, and ligamentous injuries around the ankle. Key words: tendons, ankle joint, tendinopathy, Achilles tendon, fasciitis, plantar, anterior talofibular ligament, musculoskeletal, protocol, ultrasound.

[Correction of Valgus Knee Deformity by Hemiepiphyseodesis: a Restrospective Analysis]. / Korekce valgózní deformity kolena u detí pomocí hemiepifyzeodézy: retrospektivní analýza.

PURPOSE OF THE STUDY Hemiepiphyseodesis is commonly used to correct a coronal plane knee deformity during childhood. Since 2007 Blount staple method has been replaced by the eight-Plate Guided Growth System. We retrospectively analysed the indications, results and complications of the older Blount staple method so as to compare them with the newer eight-Plate Guided Growth system. MATERIAL AND METHODS In the period from 2009 to 2019, a total of 98 lower extremities of 54 patients were treated by hemiepiphyseodesis. Lateral distal femoral angle (LDFA), medial proximal tibial angle (MPTA) and mechanical axis deviation (MAD) were measured before and after the correction. We focused on the location of hemiepiphyseodesis (distal femur/proximal tibia/both), the operative time and compared the results of implanting 2 or 3 Blount staples. RESULTS The primary correction of valgus knee deformity was achieved in 97%, of which only partial correction was observed in 9.2% and slight overcorrection in 6.1%. A total of 4 patients (4.1%) underwent subsequent corrective osteotomy. The mean LDFA increased from 80° to 86°, while the mean MPTA decreased from 94° to 92°. The mean MAD decreased from 23 mm to 3 mm. The reported complication rate was 5.1%, including four cases of loosening of staples and one case of superficial infection. DISCUSSION It has been verified that the LDFA reduction correlates with staple implantation into the distal femur, conversely the increase in the MPTA correlated with the implantation of staples into the proximal tibia or into both locations. The number of implanted staples (2 or 3) did not affect the size of the resulting correction, but the operative time was statistically significantly shorter when 2 instead of 3 staples were implanted. CONCLUSIONS Blount staple hemiepiphyseodesis is an older method, but it still gives very good results with a low rate of complications. The operating time can be shortened by using 2 staples only, with the same correction effect. The LDFA and MPTA parameters are helpful in identifying the location of hemiepiphyseodesis. The key to success of treatment still remains in correct timing of the implantation of staples with sufficient growth potential. Key words: hemiepiphyseodesis, guided growth, valgus knee deformity, Blount staple.

[Treatment of Fractures of the Distal Third of Tibia Diaphysis by MIPO Technique]. / Lécba zlomeniny distální tretiny diafýzy tibie pomocí MIPO techniky.

PURPOSE OF THE STUDY MIPO (Minimally Invasive Plate Osteosynthesis) technique is currently a commonly used method to treat fractures of the distal third of tibia diaphysis. At the same time, it is just like other methods accompanied by a relatively high complication rate. The purpose of this study was to determine whether the use of this technique at our department is effective and whether the complication rate does not differ considerably from values reported by literature. MATERIAL AND METHODS In the period 2014-2016, minimally invasive plate osteosynthesis was performed in a total of 42 patients, who had suffered a fracture of the distal third of tibia diaphysis. They sustained a low-energy trauma. The mean age of patients was 50 years (range 27-86 years) and the mean follow-up period was 11.8 months (range 1.5-38 months). All the patients were treated with a minimally invasive technique with the use of subcutaneous LCP. In 41 patients (98%) it was inserted via anteromedial approach. In one patient only (2%), the LCP was inserted via anterolateral approach due to the unfavourable local finding on the medial side of the distal lower limb. RESULTS Of the total number of operated patients, 35 patients (83%) underwent surgery within 24 hours of injury, including two patients in whom an external fixator was used. The mean operative time was 61 minutes (range of 30-150 minutes). The primary healing occurred in 93% of patients with radiological signs of healing within 5.6 months on average (range of 1.5-16 months). Time to full weight bearing was 4.2 months on average (range of 1.5-16 months). Delayed healing was observed in four patients. In three patients, a non-union developed, necessitating revision surgery. Infectious complications were reported in seven patients, in three of whom deep wound infection developed. In one case, the chronic infection resulted in a lower limb amputation. In five patients mal-union occurred. DISCUSSION The outcomes achieved by the authors in treating fractures of the distal third of tibia diaphysis with a minimally invasive technique do not considerably differ from the outcomes reported by other authors in literature. In terms of the outcomes and the complication rate, the MIPO method is comparable to the treatment of these fractures with the use of nails. Limiting for fracture healing is the vascular supply. Therefore, in treating these injuries it is necessary to proceed with minimum invasiveness and carefulness and to seek to limit any additional trauma to soft tissues, thus also to vascular supply. In case of syndesmosis failure, the concurrent treatment of distal fibula fractures is clearly indicated. In case of intact syndesmosis, fibular osteosynthesis and the sequence of procedures are to be decided by the surgeon. At present, rigid osteosynthesis is being abandoned for potential slower healing up to development of non-unions. CONCLUSIONS The treatment of fractures of the distal third of tibia diaphysis remains an unsolved issue despite the development of stateof-the art materials, implants and surgical techniques. The MIPO technique can be considered an effective method of treatment of these types of fractures, achieving a high success rate of healing and acceptable rate of complications. Key words: minimally invasive plate osteosynthesis (MIPO), distal third of tibia diaphysis, locking compression plate (LCP).

Analysis of Gene Expression of Pseudoarthrosis Tissue in Congenital Short Femur, Initial Study and First Exprerience.

PURPOSE OF THE STUDY Although the congenital short femur is morphologically well characterized, changes at the molecular level have not been described in the literature so far. The absence of such information, along with the unknown aetiology of the defect, was the motivation for analysing angiogenesis and osteogenesis in the pseudoarthrosis (false joint) tissue in PFFD patients compared to physiological bone. The authors expected differences in gene expression, particularly in the quantity of expressed genes. MATERIAL AND METHODS A piece of bone was removed during an elective surgery procedure, placed in an RNA stabilization reagent, which prevents RNA degradation, and deep frozen. Thereafter, RNA was isolated and the profile of transcription was analysed by biochip analysis (SuperArray Bioscience Corporation). In total, it is possible to detect 113 genes of osteogenesis and angiogenesis. From the end of 2005 until the end of 2008, samples of 7 patients with PFFD and 3 physiological bone samples were examined. Several analyses were repeated to confirm the results; in total 13 chips for osteogenesis and 11 chips for angiogenesis expression were used. RESULTS Differences in the quantity and representation of the genes were noted. Some genes were considered over-expressed in PFFD tissue compared with the control sample (e.g. the gene for calcitonin receptor, collagen XII, I alpha 2, collagen II, IX, FGFR2, fibronectin, integrin) and other genes under-expressed (e.g. the gene for annexin A5, collagen XVIII alpha1, collagen I alpha1, cathepsin K, FGFR1, FGFR3, IGF2, VEGFB). CONCLUSIONS The differences in gene expression confirmed the authors' hypothesis. So far, the results cannot be generalized; this is the first step for follow-up experiments to confirm the suggested information and to integrate it with clinical findings, such as the alternative blood supply of affected extremity in some patients. Key words: proximal femoral focal deficiency, gene expression, microarray analysis, angiogenesis, osteogenesis.

[Mid-Term Results of Treatment of Severe Grades of Slipped Capital Femoral Epiphysis without Surgical Hip Dislocation]. / Strednedobé výsledky lécení skluzu tezkého stupne pri coxa vara adolescentium bez chirurgické luxace kycelního kloubu.

PURPOSE OF THE STUDY To evaluate the results of treatment of acute and chronic severe slips of slipped capital femoral epiphysis. The tested hypothesis was that the results will be comparable with the methods using surgical hip dislocation. MATERIAL AND METHODS In the period 1996-2014, 26 patients were treated for severe slips ( >60°). Boys prevailed (2:1) and were older on average (the mean age 13.8 vs.12 years). Chronic stable slips prevailed (16 patients) and were followed by acute-on-chronic slips (7 patients) and with acute slips (3 patients). The acute unstable slips were treated using closed reduction and transphyseal fixation. The acute-on-chronic slips were treated using closed reduction and fixation (2 patients) and subcapital osteotomy (5 patients), respectively. Chronic slips were treated as follows: with subcapital osteotomy (10 patients); with intertrochanteric femoral osteotomy (5 patients); and with transphyseal fixation without correction (1 patient). 22 patients were treated concurrently on the contralateral side as a prevention or to treat the slips. The follow-up ranged from 20 months to 13 years. The clinical results were evaluated according to four scores: 1) our own score (NB score) based on the reduction of ROM, shortening of extremity and limitations in activities; 2) Merle d'Aubigne score; 3) Harris hip score (HHS); 4) non arthritic hip score (NAHS). In the radiological evaluation, correction of slip angle, alpha-angle, avascular necrosis (AVN) and grade of arthrosis according to Toennis were observed. RESULTS According to the NB score 10 excellent results (38%), 11 very good results (42%), one good and one satisfactory result (4%) and 3 unsatisfactory results (11%) were achieved. According to the other scores the following results were reported: a) excellent: D'Aubigne-Postel - 19 (73%); HHS - 20 (77%); NAHS - 21(81%), b) good: D'Aubigne and HHS- 3 (11%); NAHS - 2 (8%), c) satisfactory: D 'Aubigne - one (4%), HHS and NAHS 0, d) unsatisfactory: D'Aubigne, HHS and NAHS - 3 (11%). The evaluation of surgical methods shows that the best results were achieved by closed reduction of acute slips (with 80% excellent results). The result of transphyseal fixation without reduction was satisfactory only. The intertrochanteric osteotomy led mostly to very good results (80%) and then to the excellent results (20%). After subcapital osteotomy, mostly excellent and very good results (40% each) were reported, followed by two unsatisfactory results (13%) and one good result (7%). As concerns the slip reduction and alfa angle, the best results were achieved by closed reduction and subcapital osteotomy. The FAI was observed/ in 10 patients. Arthrosis was observed as follows: grade I in 8 patients, grade II in 3 patients. The AVN was present as segmental in 4 patients (15%) and as complete in two patients (8%), namely in one after closed reduction and in one after subcapital osteotomy. Dislocations of the hip occurred twice after subcapital osteotomy. Chondrolysis and hip ankylosis were reported in one patient after subcapital osteotomy. DISCUSSION The hypothesis was confirmed because the results of treatment of severe slips without hip dislocation are comparable with procedures using the surgical hip dislocation. The results correspond with large published cohorts of patients in terms of correction as well as the rate of complications. CONCLUSIONS The best results were achieved by closed reduction of acute slips where no complications were present. Subcapital osteotomy without surgical dislocation is comparable with modified osteotomy with surgical hip dislocation. Intertrochanteric osteotomy represents an efficient method in treating grade II slips. Transphyseal fixation without slip correction cannot be recommended in treating severe slips. Key words: slipped capital femoral epiphysis, severe grades of slip, subcapital femoral osteotomy, intertrochanteric femoral osteotomy, closed reduction of slip.

Risk factors for football injuries in young players aged 7 to 12 years.

Football (soccer) is very popular among children. Little is known about risk factors for football injuries in children. The aim was to analyze potential injury risk factors in 7- to 12-year-old players. We collected prospective data in Switzerland and the Czech Republic over two seasons. Coaches reported exposure of players (in hours), absence, and injury data via an Internet-based registration system. We analyzed time-to-injury data with extended Cox models accounting for correlations on team- and intra-person levels. We analyzed injury risk in relation to age, sex, playing position, preferred foot, and regarding age-independent body height, body mass, and BMI. Further, we analyzed injury risk in relation to playing surface. In total, 6038 player seasons with 395 295 hours of football exposure were recorded and 417 injuries occurred. Injury risk increased by 46% (Hazard Ratio 1.46 [1.35; 1.58]; P < .001) per year of life. Left-footed players had a higher injury risk (Hazard Ratio 1.53 [1.07; 2.19]; P = .02) for training injuries compared to right-footed players. Injury risk was increased in age-adjusted taller players (higher percentile rank). Higher match-training ratios were associated with a lower risk of match injuries. Injury risk was increased on artificial turf (Rate Ratio 1.39 [1.12; 1.73]; P < .001) and lower during indoor sessions (Rate Ratio 0.68 [0.52; 0.88]; P < .001) compared to natural grass. Age is known as a risk factor in older players and was confirmed to be a risk factor in children's football. Playing surface and leg dominance have also been discussed previously as risk factors. Differences in injury risks in relation to sex should be investigated in the future.

Head injuries in children's football-results from two prospective cohort studies in four European countries.

Head injuries are considered harmful in children. We analyzed head and neck injuries in organized football in 7- to 12-year-old children. Data for this analysis were obtained from a prospective cohort study over two consecutive football seasons in two European countries, and a randomized intervention trial over one season in four European countries. Football exposure and injuries were documented through an online database. Detailed information regarding injury characteristics and medical follow-up was retrieved from coaches, children and parents by phone. Thirty-nine head injuries and one neck injury (5% of all 791 injuries) were documented during 9933 player-seasons (total football exposure 688 045 hours). The incidence was 0.25 [95%CI 0.15, 0.35] head/neck injuries per 1000 match hours (N=23 match injuries) and 0.03 [95%CI 0.02, 0.03] per 1000 training hours. Eleven concussions (27.5%), nine head contusions (22.5%), eight lacerations or abrasions (20%), two nose fractures (2.5%), and two dental injuries (2.5%) occurred. The remaining eight injuries were nose bleeding or other minor injuries. Thirty injuries (75%) resulted from contact with another player, and ten injuries were due to collision with an object, falling or a hit by the ball. Whereas 70% of all head injuries (N=28) were due to frontal impacts, 73% of concussions (N=8) resulted from an impact to the occiput. The incidence and severity of head injuries in children's football are low. Coaches and parents, however, should be sensitized regarding the potential of concussions, particularly after an impact to the occiput.

[Operative Treatment for Saddle-Shaped Femoral Heads]. / Operacní resení sedlovité deformity hlavice kosti stehenní.

PURPOSE OF THE STUDY A saddle-shaped deformity of the femoral head has a poor prognosis due to rapid development of secondary changes. A new method of treatment by intra-articular anteromedial wedge reduction osteotomy (AWRO) of the femoral head may preserve the hip for the future. This study was designed to ascertain that this invasive technique was safe and effective and to confirm our hypothesis that AWRO significantly improved functional and radiological parameters of the hip joint. MATERIAL AND METHODS Patients who underwent AWRO between 2010 and 2013 were enrolled in this study. The indication criteria for the procedure included Stulberg grade V hips on AP radiographs, hinged abduction with pain, limping and a limited range of movement. Values of the Stulberg grading, capital diaphyseal index, caput-collum-diaphyseal angle and Harris hip score were recorded before and after surgery and the results were statistically evaluated using the paired t-test. The AWRO procedure was performed from the anterolateral approach after subperiosteal protection of the vessels had been ensured. The central necrotic part of the femoral head was removed, and the medial segment was mobilised and fixed to the intact lateral segment. Either a hip spica cast or bed-rest for six weeks was indicated. Full weight bearing was allowed at 3 months after surgery. RESULTS Twelve patients with an average follow-up of 55 months were evaluated. There were eight boys and four girls with an average age of 14 years at the time of surgery. The average Harris hip score improved from 54.52 before to 73.58 after surgery. The post-operative outcomes according to the Stulberg classification included one grade II hip, seven grade III hips, three grade IV hips and one grade V hip. The average capital-diaphyseal index dropped from 1.56 (1.19-1.92) to 1.28 (0.95-1.67) and the average caput-collum-diaphyseal angle increased from 134 degrees (121-143) to 140 degrees (130-155) after surgery. Avascular necrosis developed in two patients. All the differences were statistically significant. DISCUSSION Reduction osteotomies of the femoral head reported in the literature differ from the AWRO procedure used in this study in both the approach and the performance. The results presented here are in agreement with those published in the relevant literature. They showed no significant deterioration in comparison with the outcomes of our short-term study reported earlier. The outcome of treatment is related to the disease aetiology, functional parameters and previous procedures involving the hip joint. CONCLUSIONS AWRO is a salvage procedure that prolongs the longevity of joints in incongruent hips with very high morbidity. This procedure gave significantly better results in years after surgery, which confirmed our hypothesis. Level of evidence IV Key words: hinge abduction, Perthes disease, Stulberg, femoral head reduction osteotomy, avascular necrosis, arteria circumflexa femoris medialis.

[Complications after femoral lengthening with ring fixators in congenital femoral deficiency]. / Komplikace po prolongaci femuru kruhovým fixátorem pri vrozeném defektu femuru.

PURPOSE OF THE STUDY: Congenital femoral deficiency (CFD) is a rare and complex deformity. The results and complications of surgical correction of this deformity using ring fixators (Ilizarov/Taylor Spatial Frame) have been evaluated. MATERIAL AND METHODS: We retrospectively reviewed a consecutive series of 30 patients with CFD, between the ages of 3.3 and 17 years (mean, 9.3 years), with 35 lengthening procedures. Ten cases were treated with an Ilizarov frame, 25 cases with a Taylor Spatial Frame (TSF). RESULTS: The average lengthening at femoral osteotomy was 44.3 mm. Nine patients underwent an additional tibial lengthening by an average of 24.2 mm. The total lengthening was 50.5 mm (28-85 mm). A fracture after removal of the fixator occurred in 25.7% of the cases, and a pin-site infection with the subsequent need of operative revision was found in 8.5%. A subluxation of the knee joint was observed in 11.4% and a persistent limitation of the knee joint range of motion in 22.8%. CONCLUSIONS: Despite several complications, the use of ring fixators, especially the TSF, is an effective method for treatment of this complex deformity. The complication rate was similar with the use of either ring fixator. Some complications can be decreased with experience. The risk of knee dislocation can be reduced by joint bridging and fractures after frame removal can be avoided by prophylactic rodding.

[Efficiency of conservative treatment by overhead traction in developmental dysplasia of the hip]. / Úspesnost konzervativní lécby vývojové kycelní dysplazie metodou "over-head trakce"

PURPOSE OF THE STUDY: Developmental dysplasia of the hip (DDH) is a disorder affecting the development of the acetabulum, proximal femur and joint capsule. The objective of this study was to analyse the results of closed reduction by overhead traction in subluxated and dislocated hips. MATERIAL AND METHODS: In the period from 2002 to 2007, a total of 109 patients (124 hips) were treated by overhead traction. The indication criteria included adductor contracture and misalignment of the hip joint assessed as classes III A, III B or IV according to the Graf ultrasonographic classification. There were 96 (88 %) girls and 13 (12 %) boys. The left side was more frequently affected, at a ratio of 83 to 41, and bilateral DDH was found in 15 patients. Teratologic dislocations were not included in the study. The patients were divided into two groups according to age and the place of primary diagnosis. The children primarily diagnosed at our hospital Na Bulovce where placed in group 1, the patients diagnosed outside our hospital fell in group 2. The average age at the beginning of treatment was 2.2 months in the first group and 6 months in the second group. Our method of overhead traction consists of two phases. Horizontal traction is applied for two weeks in phase 1; the hips are then flexed beyond 90 degrees and gradually abducted for another 4 weeks in phase 2.The outcome of traction is examined by arthrography and a spica cast is applied in the safe zone.We observed the relation between the Graf classification and arthrograpy. The outcome of closed reduction was compared between the groups and the development of avascular necrosis was observed. The hips treated by open reduction were assessed in a different study. RESULTS The efficiency of closed reduction was 84 % in group 1 and 60 % in group 2 in which also two cases of recurrent dislocation were found. No significant differences between the Graf classification and the final arthrographic findings were recorded in either group (p ≥ 0.05). Avascular necrosis as defined by the Salter criteria was not diagnosed. DISCUSSION: Early reduction is essential to ensure normal development of the hip joint. Overhead traction therapy for misalignment of the hip joint is a safe method reducing damage to the femoral head. Its principle lies in gradual distraction of the contracted muscles and joint capsule with a concomitant change in traction direction in order to achieve a reduction manoeuvre without placing increased stress on the femoral head. CONCLUSIONS: Overhead traction is the method of choice for management of Graf's class III A, III B and IV hips. For the efficiency of treatment, an early diagnosis and a correct indication are essential. To avoid complications such as avascular necrosis, it is necessary to observe the principle of a safe zone.

[The Ponseti method of treatment of congenital clubfoot--first experiences]. / Ponsetiho metoda v lécení pes equinovarus congenitus--první zkusenosti.

PURPOSE OF THE STUDY: To provide a detailed description of the Ponseti method and report the first results of its use, including factors that played a role. MATERIAL AND METHODS: In the 2005-2007 period, 91 patients with idiopathic rigid clubfoot (133 feet) were treated by the Ponseti method. The group comprised 62 boys and 29 girls. In most patients the Ponseti method was used as primary treatment, or by 3 months of age when previous treatment failed. In five children this treatment was started between the 3rd and 8th months of age. The result were evaluated by the criteria described by Richards et al., who distinguished four groups. The result was regarded as good when a permanent plantigrade foot was achieved (group 1). Plantigrade feet likely to require posterior release later were considered indeterminate rusults (group 2). Feet that needed posterior release, anterior tibial muscle transfer or lateral column shortening fell in the fair result group (3). Feet requiring complete subtalar release were classified as poor results (group 4). The results achieved in each year were statistically evaluated using Fisher's test (p<0.05). RESULTS: The overall evaluation for 3 years showed good results in 70%, indeterminate in 7.5%, fair in 6.76% and poor in 15.8% of the treated feet. A detailed analysis for each year revealed that, in 2005, good results (50%) were recorded in a significantly lower number of feet than in 2006 (72.2%; p=0.032) and 2007 (93%; p<0.001). On comparison of the years 2006 and 2007, good results in 2007 were found in a significantly higher number of feet than in 2006 (p=0.019). The poor results were due to 1) very rigid feet (6%); 2) initial problems with availability of Denis-Brown splints (19 feet; 14.5%); 3) problems with shoes not made to custom and not fitting patient's little feet (20 feet; 15%) 4) faulty techniques of correcting the deformity (4 feet); 5) poor family cooperation in compliance with the bracing protocol (15 feet; 11.2%). Some of the factors were combined. A delayed beginning of the treatment had no significant effect on the results. DISCUSSION: Our 3-year results of clubfoot treatment, by which plantigrade foot position was acheved on average in 77.5% of the patients, are in agreement with those achieved outside Ponseti centres. However, there were clear differences, with the worst results in 2005. The results comparable with those of Ponseti and his co-workers were achieved by us only in 2007. In accordance with the findings of Richards et al. we suggest that the percentage of short-term good results can change insignificantly within 4 years because of increased recurrence of deformities. CONCLUSIONS: Although our initial results were worse than reported in the literature, it can be concluded that the Ponseti method of treating idiopathic clubfoot is more efficient that the methods used previously and can be recommended as an efficient, safe and economical technique. Good compliance with the protocol improves the therapeutic results.

[Distal rectus femoris tendon transfer in cerebral palsy patients]. / Transfer distálního úponu m. rectus femoris u pacientu s detskou mozkovou obrnou.

PURPOSE OF THE STUDY: Cerebral palsy is a serious world-wide problem; its incidence ranges from one to five per thousand of live-born children and is much influenced by gestation age and birth weight. In orthopaedic treatment of lower extremity motor disorders, one of the options for contracture or deformity elimination and for stiff leg gait improvement is rectus femoris tendon transfer. The aim of this study was to evaluate the results of this surgical technique. MATERIAL AND METHODS: In the period from 1993 to 2003, 15 patients of both sexes, aged 5 to 13 years, were treated by the Gage method (22 operations) in our department. The indication for surgery was excessive spasticity of the femoral quadriceps muscle at the beginning of the swing phase of the gait cycle. The spastic syndromes included quadruparesis in seven patients, diparesis in seven patients and hemiparesis in one patient. After surgery, a circular plaster cast was applied for 4 weeks. Following immobilization, all patients received a short-term inpatient and long-term outpatient physical therapy. They were followed- up for 1 to 10 years and gait improvement was analyzed on the basis of three criteria in the swing phase: quality of the initial swing, frequency of tripping over the toe and the degree of knee flexion. The results were evaluated on a 1-to-4 scale (best to worst), categorizing the patients into four groups. RESULTS: The first, second and third categories included eight, five and two patients, respectively. None of the patients was placed in the fourth category. Surgery did not increase the initial range of inner hip rotation. Patients with milder forms of cerebral palsy (diparesis and hemiparesis) achieved better results. CONCLUSIONS: Our results showed that distal rectus femoris tendon transfer significantly improved knee flexion during the swing phase of the gait cycle. The prerequisite for a good outcome of surgery is a pre-operative potential for passive knee extension and stable function of the other lower extremity joints. Key words: cerebral palsy, surgical treatment, quadriceps tendon transfer.

Incidence of football injuries in youth players. Comparison of players from two European regions.

Several authors have investigated the frequency of football injuries in youth players. However, the results of these studies are inconsistent because of the different age groups investigated and the different methods applied. The aim of the present study was to compare the incidence and characteristics of football injuries in youth players of two European regions. A total of 444 youth players from the Czech Republic and the Alsace region of France and Germany were followed weekly for 1 year. In 311 players (70%), complete weekly follow-ups over the 1-year period were available. The comparison of injury data revealed no substantial differences between players from the Alsace region and the Czech Republic in injury incidence per 1000 hours of exposure, degree of injury severity, or the circumstances in which the injuries occurred. However, players from the Czech Republic spent more time in training and playing football than did players from the Alsace region, and in the Czech Republic a higher proportion of injuries was caused by foul play. With only a few exceptions, the statistics were similar in the amount of football played as well as in the incidence of injury between different age and skill levels in both European regions.

Severe injuries in football players. Influencing factors.

The aims of this prospective study were to analyze factors related to the occurrence of severe football injuries in players of different ages (14 to 42 years) and different skill levels (local teams to first league teams). In the Czech Republic, 398 players were followed up for 1 year, during which time they sustained 686 injuries. Of these, 113 (16.5%) were severe injuries. Ninety-seven severe injuries (86%) were able to be documented in detail. Trauma was the cause of 81.5% of the injuries and overuse was the cause of 18.5%. Joint sprains predominated (30%), followed by fractures (16%), muscle strains (15%), ligament ruptures (12%), meniscal tears and contusions (8%), and other injuries. Injuries to the knee were most prevalent (29%), followed by injuries to the ankle (19%) and spine (9%). More injuries occurred during games (59%) than in practice. Twenty-four percent of the injured players had suffered a previous injury of the same body part. Forty-six percent of injuries were caused by contact and 54% involved no body contact. Thirty-one percent of severe injuries were caused by foul play. From these results and the analysis of injuries in specific body parts, the following factors were determined to influence the occurrence of severe injuries: 1) personal factors (intrinsic): age of player, previous injuries, joint instability, abnormality of the spine, poor physical condition, poor football skills, or inadequate treatment and rehabilitation of injuries; 2) environmental factors (extrinsic): subjective exercise overload during practices and games, amount and quality of training, playing field conditions, equipment (wearing of shin guards and taping) and violations of existing rules (foul play).