Unstable intertrochanteric fractures may be treated by several types of implants, most frequently by dynamic sliding hip screw or some form of intramedullary implant. Intramedullary implants began to be used in cases with an expectation of further improvement of osteosynthesis stability. A need to determine the advantages of single implants for selected types of fractures in randomized trials was defined. In addition to biomechanical principles, bone quality is considered, together with increasing possibilities in recent years of further improving density measurements, especially qCT with respect to local specificity. A series of 86 patients (24 men, 62 women, average age 77,6 years) was operated on from September 6, 2005 to June 30, 2009 for unstable intertrochanteric fracture (31 A2.1, A2.2, A2.3), either by DHS of PFN osteosynthesis after randomization. A CT examination of both hip joints in a predefined manner was performed before surgery. Using special software the relative density of the central spherical part of the femoral head 2 and 3 centimetres in diameter was determined. After fracture healing, the dynamization of the neck screw of both implants and the reduction of vertical distance between the tip of the neck screw and subchondral bone of the femoral head were determined. In addition to evaluation of osteosynthesis stability and osteosyntheis failure, clinical parameters such as surgical time, blood loss and length of hospital stay were compared between the two groups of patients. Survival of patients was evaluated with respect to April 21, 2010. In the patient series, 4 failures of DHS osteosynthesis (cut out) and 2 failures of PFN osteosynthesis (cut out) were noted. Sliding of the DHS was on average 11,9 mm, and was significantly higher in comparison to dynamization of the PFN neck screw, which was 6,9 mm (p=0,005). When comparing the vertical distance between the tip of the neck screw and subchondral bone of the femoral head immediately after surgery and after fracture healing the average reduction of the vertical distance was 1,6 mm in DHS osteosynthesis and 0,8 mm in PFN osteosynthesis. The difference was statistically significant (p=0,025). PFN seems to provide a more stable fixation, based on the measurements. The number of failed DHS osteosyntheses is higher in comparison to the number of failed PFN osteosyntheses but the difference is not statistically significant. The influence of femoral head density on osteosynthesis failure could not be determined due to a low number of failed osteosyntheses in both patient groups. At the same time, after statistical analysis, influence of the relative femoral head density on vertical distance reduction between the screw tip and femoral head subchondral bone in healed fractures was not proven. Statistically, average length of surgical time, length of hospital stay, mean blood loss and survival did not differ significantly between the two patient groups.

The ability of patients to return to their home environment after treatment of proximal femoral fractures is influenced to a significant extent by their level of independence and mobility prior to injury. In order to define independence and mobility precisely, we used the Harris Hip Score Questionnaire, the Barthel Index Questionnaire and the EQ-5D Questionnaire in patients with proximal femoral fractures. We followed 294 patients aged 50 or over, hospitalized from April 1, 2008, to April 28, 2009. The average time of follow-up was 7.3 months after injury. We compared the results for patients returning to their home environment and those staying in facilities providing consecutive care, in relation to the results of the questionnaires. As well as the results of the questionnaires, we looked at the influence of dementia and the presence of relatives at home on the ability of the patients to return to their home environment. We also looked at mortality in relationship to the same factors. 74.6 per cent of the 233 patients who were hospitalized from a home environment, eventually returned home. In all three questionnaires the scores were statistically significantly higher in the group of patients who finally returned home than in the group of patients who did not return home or died: in HHS, p = 0,003, in Barthel Score, p = 0,007 and in EuroQol, p < 0,001. Of those patients who returned home, more had been living with a relative prior to injury, than in the group of patients who did not return home. Dementia was observed significantly less in the group of patients who returned home (p< 0,001) Patients with a higher mobility score within the Harris Hip Score were found to have significantly higher survival rates (p = 0,004). The survival rates of patients with a higher Harris Hip Score, Barthel Score and EQ-5D did not show significant statistical differences.

Introduction: The purpose of this study was to evaluate the results 9 to 12 years after the transfer of 3 distal parts of pectoralis major muscle to restore active elbow flexion in patient with arthrogryposis.

Material and methods: From 1996 to 1999, elbow flexion was reconstructed in 9 upper extremities by 5 patient aged 4.3–9 years. The patients were clinically evaluated according to the subjective and objective assessment and examined electromyographically before the surgery and during the follow up. Last clinical examination was provided 8 to12 years after the surgery in patients aged 15 to 18 years.

Results: 3–4 years after pectoralis major transfer, 6 very good and good results were achieved, the average active ROM of elbow ranged 15 to 95 degrees. The power of elbow flexion was graded as 4 and 4+. This method was unsuccessful in the remaining 3 cases, the patients were not able to reach the mouth with the hands because of limited elbow flexion. 9 to12 years after the surgery, the results were similar. 5 extremities remain very good and good. One deterioration was obvious. The ROM of elbow changed, namely the extension was mostly reduced even in very good and good evaluations (the average decrease was 13.8 degrees, the range −20 to +10 deg.). The active flexion was not changed in 5 elbows, or it was increased (the average increase 4,4 deg., the range 0–15 deg.). The final limitation of extension (30 – 50 degrees) does not restrict using the hands for perineal hygiene and the final active flexion (85–100 degrees) allows elevating the hands to the head for feeding and toilet.

Discussion and Conclusions: From the analysis of unsuccessful results 3–4 years after the surgery it was obvious that all cases were related to very limited preoperative passive flexion of the elbow; restricted movement of the shoulder and failed distal fixation of the transferred muscle. After 9–12 years, the active elbow flexion and extension for raising the hands to the mouth and for toilet needs, respectively, remain in majority previously successful cases. Because most children reached the skeletal maturity, no further shortening of the transferred muscle and limitation of extension is expected. These findings do not concur with the literature reports. According to our results, the transfer of the pectoralis major represents the efficient method for permanent restoring of bilateral active elbow flexion with the remaining functional extension. The ROM does not change significantly after having reached the plateau 2 years postoperatively. The prerequisites for successful results are a minimum of 90 degrees of passive flexion of the elbow before the surgery, the active shoulder abduction of 80–90 degrees, long-term rehabilitation and successful fixation of the transferred muscle to the forearm.

Alloys of titanium, aluminium, vanadium, iron and other metals are traditional materials used in bone tissue surgery. The anchorage of the metallic materials into the surrounding tissue depends of their mechanical and other physical and chemical properties. The integration of metallic material with the surrounding tissue can be markedly improved by appropriate physicochemical surface properties of the material, such as roughness, topography, wettability or presence of certain chemical functional groups. In the present study the first step the surface roughness of samples of pure Ti or Ti6Al4V alloy. In order to influence the adhesion, growth and presence of bone differentiation markers in human osteoblast-like MG 63 cells, we modified as machining or subsequent polishing by diamond paste was performed. In addition, we investigated the interaction of these cells with a newly developed material for construction of bone-anchoring parts of bone implants. These tested materials were treated either with electro-erosion or plasma-spraying with Ti. After the cells seeding (MG63, human osteoblast-like cells of the line MG 63, derived from osteosarcoma of a 13-year-old boy, on different surfaces, the basic parametrs of adhesion and the viability of bone cells were detected, the cell were analysed and cultered for 1–8 days, during 3 different time intervals(expl.1. 4. and 7 day). Cells number, were detected and analyzed in a ViCell XR analyzer. The concentration of molecules participating in cell adhesion, osteoblastic differentiation, was determined semi-quantitatively by the enzyme-linked immunosorbent assay (ELISA) in cell. In addition we performed a reconstruction curve of population density of human osteoblast-like MG 63 cells on day 1, 4 and 8. including calculation of doubling time(DT)in human osteoblast-like MG 63 cells grown on metallic materials with different surface treatments. From the tested surfaces Ti Alloys electroerosion surfaces seem promising materials. They show the best osteointegration parameters in vitro. Nevertheles further in vivo experiments must be performed prior to clinical use.

Aims: In spite of approved methods of osteosynthesis of proximal femoral fractures using modern implants stabilisation still may fail especially in unstable osteoporotic fractures which is a cause of revision surgeries and unsatisfactory functional results. The goal of our study was to determine predisposing factors of failure of either DHS or PFN osteosynthesis with respect to the degree of osteoporosis. At the same time we evaluated clinical results one year after surgery and evaluated occurrence of further osteoporotic fractures.

Methods: Within the framework of a research plan (2005–2009) patients with low energy fractures of trochanteric area with qCT proven osteoporosis have been randomised. Unstable intertrochanteric fractures were operated by either DHS or PFN osteosynthesis after adequate reduction. During surgery one bone sample was taken from the femoral head prior to insertion of head screw located at the tip of the screw and the second sample was taken from iliac crest. Samples from the femoral head were examined by histomorphometry. Relationship between histomorphometry and migration of osteosynthetic material was evaluated. After surgery patients were examined in osteology department including DEXA and received appropriate treatment of osteoporosis. Orthopaedic follow up was performed 6 weeks, 3, 6 and 12 months after surgery when patients were evaluated by Harris hip score. Results were evaluated statistically.

Results: From September 1. 2005 to August 31. 2006 55 patients with unstable intertrochanteric fractures had been randomised. DHS was used in 26 patients and PFN in 29 patients. The average age of the patients was 75,6 years. Only patients who were able to sign informed consent were elegible for randomisation. The average qCT T-score was −3,2 and the qCT Z-score was −1,1. In addition to osteoporosis osteomalacia was proven histologically in one patient. Secondary osteoporosis was proven in 15 per cent of all patients. 49 patients were examined 1 year after operation. Failure of osteosynthesis was observed in four cases (7,3 per cent, 2x DHS and 1x PFN cut out phenomenon, 1 case of PFN head screw migration). Migrating PFN screw was removed. There were no other revision surgeries. The average qCT T-score in patients with failure of osteosynthesis was −4,3, Z-score −2,1. The average HHS one year after surgery was 67,3.

Conclusions: In patients with proven osteoporosis in spite of correct surgical technique risk of osteosynthesis failure is increased. Optimized surgical techniques and implants may still improve surgical results in patients with severe osteoporosis (qCT T-score lower than −4).

Type IIb, so called mobiled pseudoarthrosis according to Paley classification, is characterized by congenital pseudoarthrosis of proximal femur with an isolated small and stiff femoral head. We are unable to create a moveable hip joint but appropriate length of the affected extremity can be reached by gradual lengthening. In previous classification it is known as Type Aitken C or Pappas III.

Type IIIa, with diaphysial deficiency of femur, corresponds to Type D according to Aitken or to Type I and II according to Pappas.

In Type IIIa, the knee joint is developed and functional with the ROM more than 45 degrees. In Type IIIb the knee joint is more or less stiff and functionally unuseable.

These three groups present the most severe congenital short femur deformities, but their occurrence is fortunately very seldom – less than 1 in 300 thousand live births. Among 41 cases of congenital short femur Pappas I–IV which were collected during 30 years from the Czech population of 10 million – Pappas I was seen in one case, Pappas II in five cases, Pappas III in 16 cases and Pappas IV in 19 cases. From the 16 cases of Pappas III deformity was found in three of them – stiffness of isolated femoral head was found and these three patients were added to this group.

Method of Treatment: In Type IIb we use complex treatment consisting of six consecutive steps:

Distraction of the distal part of femur up to acetabular level

Lengthening between 15 and 39 cm was reached.

In Type IIIa, ilio-femoral fusion (knee-for-hip procedure) was performed in five cases. The functional results are excellent. There was no need for Syme amputation or rotationplasty. The prerequisite is at least 60 degrees arc of motion in the knee joint. Severe restricted ROM in the knee joint may lead to pseudoarthrosis.

In Type IIIb (2 cases), the residual fragment of distal femur with unfunctional knee joint was stabilized in socket formed after pelvic osteotomy in the level of original acetabulum. The removal of telescopic proximo-distal movement stabilized the supportive function of the extremity.

Purpose of the study. To evaluate the changes of the wrist by arthroscopy without distraction in patient with multiple hereditary osteochondromatosis (MHO) and enchondromatosis in relation to the forearm deformity and the combination with following surgical procedure.

Introduction. Wrist arthroscopy was used to evaluate the changes in the wrist in patients with MHO and enchondromatosis and to correlate these changes to specific deformities of the forearm bones.

Material and Methods The new technique of wrist arthroscopy without distraction was used in 16 children in 20 wrist joints, with MHO (12 patients) and enchondromatosis (4 patients). Conventional 2.4mm arthro-scope and the III/IV, VI/R and MCU approaches were used in combination mostly with the following surgical procedures according to present deformities (15 times). The arthroscopical findings were correlated to the conventional X-ray examinations of the wrist (radial articular angle, carpal slip, and relative ulna shortening).

Results. 1. Wrist arthroscopy without distraction offers the sufficient information about wrist anatomy in children and it was possible to continue with the surgical procedure in the same session. 2. The arthroscopic findings in the radiocarpal and mediocarpal space were normal in all wrist joints, with exception of one patients with cartilage lesions. 3. The articular disc of triangular fibrocartilage complex failed in 11 wrists, where shortening of the ulna was present or head of ulna was not centred to incisura radii. 4. The normal or reduced disc was found in 5 and 4 wrists, respectively, where ulna was not shortened or where normal position of head of ulna was re-established after lengthening. No correlation was obtained between discus anatomy and radial articular angle and carpal slip.

Conclusions. Shortening of the ulna by MHO or encho-dromatosis leads to elimination of the articular disc and later to degenerative changes in wrist joint. Lengthening of the ulna to distal radioulnar joint leads probably to re-establishment of the articular disc. Arthroscopy without distraction evaluates the wrist conditions and the results of treatment and enables a surgical procedure in the same session in children of the school age.

Purpose: To give the review of the foot deformities in the patients with myelomeningocele (MMC), their relationship to the level of the neurological lesion and therapeutic possibilities.

Material & Methods: Since 1998 till 2004 there were 20 patients with myelomeningocele treated in our clinic, in 19 patients was noted the foot deformity (total 34 feet). The deformity was unilateral in 4 patients, asymmetric in 2 patients (equinovarus + calcaneovalgus or planovalgus). The most frequent was equinovarus deformity (16 feet, 47%), next planovalgus deformity (9 feet, 26,5%), calcaneovalgus (7 feet, 20,6%) and equinovalgus (2 feet, 5,9%). In 28 feet the surgery was done. For the correction of the various deformities of the feet were used soft tissue releases or tendons transfer, in the older patient or after failed soft tissue release the bony operation was done (tarsal osteotomy, talo-calcaneal stabilisation, artrodesis).

Results: The aim of every type of surgery was to achieve the acceptable foot shape, with plantigrade step and possibility of weigh bearing, with minimal risk of the pressure necrosis. In the most patients the purpose was achieved, although some of them passed several surgeries. In 18 deformities only one surgery obtained the correction of the deformity, the but for the 10 feet subsequent surgery was required because of the residual or relapsing deformity. In 3 patients was noted the pressure necrosis, in 1 patient appeared the fracture of the distal tibia (epiphyseolysis) after the removal the postoperative plaster.

Conclusion: The orthopaedic care about the patients with MMC is only a part of the interdisciplinary approach of several specialists. The procedures for the correction of the neurogenic deformities of the feet, belong to the delicate surgery and is necessary very careful indication in relation with the type of deformity, which is dependent on the high of the lesion, and with the expectancy of walking. In the patients with good prognosis of walking is necessary to choose the procedure which guarantee weight-bearing and plantigrade step without the risk of ischemic skin defects.

Purpose: To analyse middle-term outcomes of treatment of patients with congenital luxation of hip using modified overhead traction.

Material and Methods: During the years 1991–2001, a total of 116 patients (138 hip joints) were treated. The group comprised 99 girls and 17 boys with the average age 4.7 months (ranging from 1.5–11 months). Patients were divided into two subgroups: patients who have been treated at our department from the determination of the diagnosis and those referred to our department from other facilities after unsuccessful conservative therapy. Only those patients were evaluated in whom the traction therapy was completed at least 2 years ago, the mean follow-up period was 4.5 years (2–10). After the initial preparatory horizontal traction, we moved to a 4-week overhead regimen wherein we increased the abduction by 10 degrees every five days. After completing the dystraction, every hip joint was examined using arthrography and where the reposition was possible, the therapy continued with the fixation in plaster spike for 6 weeks. Pavlik harnes were used for the final phase of the treatment.

Results: In the group of primarily treated patients, reposition was successful in 78 out of 91 hip joints (85.7%). In another 4 hip joints (4.4%), reluxation occurred after an average period of 3.5 weeks after the removal of the spike. Nine hip joints (9.9%), 7 of type IV and 2 of type IIIB, were non-repositionable. Much worse results were achieved in the group of patients who received previous treatment. Only 12 hip joints (25.5%) were maintained permanently repositionable but neither of them was of type IV. Reluxation within two weeks after the removal of the fixation occurred in another 5 hip joints (10.6%). A total of 30 hip joints (63.9%) could not be reposed due to arthrographic findings of reposition obstacles. All these patients were admitted for treatment after the 6th month of age. We have observed no case of avascular head necrosis in the group of 90 patients who received conservative treatment.

Conclusion: Traction therapy is a safe and mild method of treatment for congenital luxation of the hip joint. The rate of success of the therapy depends on the sonographic findings and age of patients at the beginning of therapy. Considerably worse results are achieved in the group of patients who have already received unsuccessful inadequate treatment.

Purpose of the study. To evaluate the changes of the wrist by arthroscopy without distraction in patients with multiple hereditary osteochondromatosis (MHO), and enchon-dromatosis in relation to the forearm deformity, and the combination with the following surgical procedure.

Introduction. Arthroscopy of the wrist in childhood was not published previously. Wrist arthroscopy was used to evaluate the changes in the wrist in patients with MHO and enchondromatosis and to correlate these changes to specific deformities of the forearm bones.

Material and Methods. The arthroscopy without distraction was used in 11 children in 13 wrist joints, with MHO (nine patients) and enchondromatosis (two patients). Conventional 2.4 mm arthroscope and the III/IV, VI/R and MCU approaches were used in combination mostly with the following surgical procedures according to the presented deformities (11 times). The arthroscopic find-ings were correlated to the conventional X-ray examinations of the wrist (radial articular angle, carpal slip, and relative ulna shortening).

Results. 1. Wrist arthroscopy without distraction offers sufficient information about wrist anatomy in children to make it possible to continue with the surgical procedure in the same session. 2. The arthroscopic findings in the radiocarpal and mediocarpal space were normal in all wrist joints. 3. The articular disc of the triangular fibro-cartilage complex failed in seven wrists where shortening of the ulna was present or the head of ulna was not centered to the incisura radii. 4. A normal or reduced disc was found in six wrists where the ulna was not shortened or a normal position of the head of the ulna was re-established after lengthening. No correlation was obtained between discus anatomy and the radial articular angle and the carpal slip.

Conclusions. Shortening of the ulna by MHO or enchon-dromatosis leads to the disappearance of the articular disc. Centering the ulna to the distal radioulnar joint can lead to re-establishment of the articular disc. Arthros-copy without distraction permits evaluation of the condition of the wrist, the results of treatment, and enables the surgical procedure to be performed in the same session.

Introduction: The incidence of DDH has decreased dramatically during the last thirty years. The first reason was the introduction of targeted examination of all newborn babies (in the Czech Republic since 1977) and then our system was adopted by all of the other European countries. In the 1960s about 15% of all children were treated for different stages of hip dysplasia and there were 3% of true dislocations. These very high numbers of less serious grades of DDH are partially due to over-diagnosis and over-treatment. In the 1980s, the numbers had been reduced to 5% of dysplasias and 0.8% of dislocations. The introduction of ultrasound examination according to Graf within the first week of life has contributed to further reduction of DDH cases.

Material and Methods: Open reduction is indicated only for congenitally dislocated hip joints in which tender, conservative reduction cannot be done. As a tender reduction, this can only be made by continuous overhead traction with a gradual increase of hip abduction from 10 to 60 degrees. When reduction cannot be considered as harmless, the surgical procedure consisting of open reduction and derotational osteotomy should be performed before the age of one year. In children older than the age of eighteen months a pelvic osteotomy must be added

Results: From 1980 to the end of 2000 (a period of 21 years), 147 dislocated hip joints in 128 children were operatively treated. The average follow-up was 11 years (2 – 21). In the age group of up to 15 months of age, 68 hip joints (62 patients) had open reduction and a derotational osteotomy was added in 32 cases (47%).

An additional pelvic osteotomy in cases of simple open reduction was performed on 17 hips (47%) and on 10 hips (31%) in cases of open reduction and derotation.

Aseptic necrosis developed in 5 cases (7.3%), but it is difficult to distinguish between pre-existing necrosis after conservative treatment and postoperative necrosis.

In the age group of 15 months to 36 months, there were 47 hip joints in 42 children. The surgery consisted of open reduction, varus and derotational osteotomy plus Salter (exceptionally Pemberton) osteotomy. The rate of necrosis was 12.8% (6 cases).

The open reduction in children older than the age of 3 was performed in 24 children (32 hip joints). The open reduction, varus and derotational osteotomy of the femur were performed in all cases. The Salter osteotomy was performed in 12 hips, Pemberton in 5, triple pelvic osteotomy in 6 cases, and Chiari was used in primary reduction in 9 cases.

The necrosis rate was 6.2% (2 cases).

In the targeted study regarding the effectivity of overhead traction, we had 90 hip joints in 76 patients. In the group of primary treatment in our institution (57 hip joints), successful reduction was reached in 80.1% of cases, but in the group of 33 hip joints where primary treatment had failed, conservative treatment was successful in only 30% and open reduction was performed in 23 cases.

We used the radiological classification according to Severin and clinical score according to Merle D’Aubigne: Severin I - excellent results − 12%, Severin II – good – 63%, Severin III – fair – 15%, Severin IV – poor – 6%, Severin V – re-dislocation, 6 cases – 4%. The necrosis rate was 9%.

Conclusion: Conservative and operative treatment of DDH are not two competing methods. The treatment of each dislocation starts conservatively. Only when there is no chance for harmless, tender reduction of the femoral head into the acetabular socket, the open reduction should be indicated and performed by experienced specialists. Early open reduction with femoral derotation gives statistically significant better results in comparison with only open reduction. The percentage of excellent results seems to be low, but it must be kept in mind that a hip joint which was operated and had an open reduction heals, in the majority of cases, at least radiologically. Functional results do not correspond in childhood with the radiology. Despite that, the children in the time period of FU do not complain, and the patients with operated DDH in the natural history must be considered as a high risk for the development of secondary coxarthrosis.

We present the treatment protocol of congenital clubfoot in different age groups that has been widely used in Bulovka Orthopedic Clinic since 1984. Conservative treatment begins immediately after delivery and corrects all presented deformities on the principle of subtalar derotation of the calcaneus. The correction is applied and an above-knee cast is changed every 48 hours. After five corrections and changes of casts, the casting and correction is then repeated weekly. After achieving reduction of deformities, the cast is changed at intervals of two to three weeks. Cast immobilisation should be continued for two to three months for postural clubfoot, and six to seven months for congenital clubfoot. After retention in the cast, a polypropylene above-knee splint is applied up to the age of two to three years. In addition, passive stretching exercise and stimulation of the lateral part of the foot should be provided in order to achieve muscle balance between the evertors and invertors.

Surgical treatment: When conservative treatment is unsatisfactory, the goal of operative treatment is to reduce all deformities in a one-step procedure. Posterior capsulotomy at the age of three to six months is indicated when the forefoot has been corrected by conservative treatment but the hindfoot remains fixed in the equinus and mild varus, or at the age of six to 12 months for residual hindfoot equinus.

Complete subtalar release according to McKay is required at the age of over six months to three years. Post-operative treatment is the same as for the abovementioned conservative treatment.

Treatment between the age of three and seven: The choice of surgical procedure must be individual according to the deformity, but surgical correction of severe deformity principally includes extensive subtalar release, and lateral column shortening by cuboid enucleation.

Treatment between the age of seven and ten: Individual procedures (Ilizarov method; Dwyer osteotomy of the calcaneus, or osteotomy of the mid-tarsal bones) are chosen to treat deformities. These procedures are usually combined with soft tissue release, but not with complete subtalar release.

Treatment after the age of ten (skeletal maturity of the foot): The same methods as in the previous group are used. When severe or unsatisfactory results after previous surgical treatment are obvious, a triple subtalar arthrodesis is the appropriate salvage method of correction.

Treatment of residual deformities: For treatment of dynamic deformities due to muscle imbalance after the age of four, a temporary lateral transfer of the whole tendon of the anterior tibial muscle is performed. For the same age group, forefoot adduction and supination are corrected with a ball and socket osteotomy of the base of metatarsals I-V.

This therapeutic concept was applied to 397 operated feet. 60% of the cases were primary surgical corrections, and 40% were repeated surgical corrections. 95% of primary surgical procedures and 75% of secondary surgical procedures were classified as satisfactory, indicating that the foot was sufficiently mobile, with plantigrade weight bearing.

The outcomes of the Berman-Gartland osteotomy in 26 feet (20 children) from 1995 to 1999 were evaluated. Average age at time of operation: 8 years, 3 months (range 37 to 194 months). Average age at follow-up: 2 years, 5 months (range 2 to 70 months).

The osteotomy is performed in tourniquet from three lengthwise incisions and fixed by Kirschner wires and plaster of Paris for six weeks. Only patients with idiopathic PEC were included in this study. Average age at time of primary operation was ten months. For analysis, the type and percentage of preceding operations were: pantalar release (40%), posterior release (12%), and tendo calcaneus elongation (8%). Eight feet (30%) were not primarily surgically treated. Indicated for metatarsal osteotomy were: footwear difficulty (92%), gait instability (65%), and muscle spasm (56%). Average adduction deformity of the forefoot was clinically assessed as 30 degrees (20 to 45 degrees). Forefoot rigidity was evaluated according to Black as grade II (14 feet) and grade III (12 feet).

Radiograph assessment was made by the use of T-I.MTT and C-V.MTT angle changes in the dorsoplantar weight-bearing view. We succeeded in correcting the average values of T-I.MTT angle from 28 degrees (range 20 to 43 degrees) preoperatively to 4 degrees (range 2 to 15 degrees) postoperatively, and C-V.MTT angle from 16 degrees (range 8 to 24 degrees) to 2 degrees (range -5 to 7 degrees). Isolated metatarsal varus deformity was found in 12 feet, in combination with talo-navicalar joint hypercorrection in nine feet, and in combination with residual talo-navicular joint subluxation in five feet.

Calcaneocuboid joint displacement was classified as grade I and II in 16 and 3 feet respectively. Preoperative residual displacement was not found in seven feet.

Complications were noted in three metatarsal nonunions (2% of 130 osteotomized metatarses), four pin migrations, one superficial infection, and one persistent forefoot swelling.

At final follow-up, clinical findings and outcomes were assessed as excellent in 16 feet (62%) and good in 10 feet (38%). We recorded no inferior result. An apparent relationship was not found between the type and timing of preceding operations and varus forefoot deformity persistence. In 19 feet (73%), residual grade I and grade II tibial subluxation of the cuboid bone was found.

We examined a group of 26 patients (28 hip joints) with postdysplastic osteoarthritis who were operated in 1995 and 1996.

The Zweymüller Bicon prosthesis was used in all cases. Only patients with dysplasia Type B and C according to Eftekhar were included. By the method of Ranawat and Pagnana, the true acetabular region and the approximate femoral head centre were determined on preoperative and postoperative radiographs. The patients were controlled in 1999 with HHS. Antero-posterior radiographs of the pelvis and lateral radiographs of the acetabulum according to Zweymüller were made in all hips.

In most of the operated hip joints the true center of the rotation differed from the ideal centre, with the maximal difference being 18 mm cranially. Cranial placement of the cup occurred more frequently in Type C. No patient was reoperated, and as determined by radiographs, there were no indications of loosening in the acetabular and femoral components.

The Zweymüller Bicon total hip joint endoprosthesis is suitable in most cases of postdysplastic osteoarhritis of the hip. No special or individual implant was necessary in 1995 and 1996. Good primary stability and a good result was achieved in all cases. We consider this type of hip implant as especially useful in CDH osteoarthritis.

The authors reviewed a group of 24 patients (26 hips) who had been managed with open reduction through an anterolateral approach from 1981 to 1985. Eight patients with an inadequate clinical (6) or roentgenographic (2) follow-up were excluded from the study. The purpose was to evaluate 18-year results of nine hips operated in pre-walking age up to 12 months and nine hips operated later. All patients were operated by the senior doctor. The goals of management are concentric reduction and its maintenance in order to provide the optimum environment for development of the hip joint.

The average age of the children at the time of operation was seven months (range 3–10 months) in the first group and 32 months (range 15–60 months) in the second group. Open reduction was performed if a stable reduction could not be achieved with traction as demonstrated with arthrography.

Evaluation of the first group: marginal dislocation was found in one hip (11.1%) and in the rest of cases the head was highly dislocated. A simultaneous derotational femoral osteotomy was added in the course of four reductions (44.4%) and in three of these cases a subsequent Salter osteotomy was performed. Five hips (55.6%) were reduced without additional femoral osteotomy and in three of these cases, a subsequent combination of Salter and derotational varisation osteotomy was performed. Average age at the time of the subsequent operation was 31 months (range 19–44 months).

In the second group, only high dislocations were found and each procedure was accompanied with simultaneous and subsequent interventions. At the final follow-up of the first group, the clinical findings were evaluated as Severin class A in eight hips (88.9%) and class B in one hip (11.1%). Three hips (33.3%) were Severin roentgenographic class I, and six hips (66.7%) were class II. Six hips (66.7%) showed avascular necrosis classified as Ogden-Bucholz Type I (3) and Type II (3). No significant degenerative changes were found. In the second group, the results were worse – two patients had already had THAs implanted.

The results are excellent or good in children operated in the pre-walking age. The results in patients operated later are worse. We consider this method to be useful for the treatment of congenital dislocation of the hip.

Postdysplastic ischaemic necrosis of the proximal femoral epiphysis has its origin in the vascular crisis during conservative or operative treatment of DDH and in the majority of cases has an iatrogenic origin. The severity of the symptoms and functional disability is dependent on the anatomic changes of the proximal femur and the whole hip joint respectively, which were caused by previous conservative or operative treatment, including repeated surgery. The symptoms such as limping from leg length discrepancy and abductor insufficiency, pain and restricted ROM are less apparent in small children, but become more conspicuous with the approach of the end of growth. For the classification of the patterns of ischemic necrosis of the femoral head, the classification according to Bucholz and Ogden was used.

Four principal types of this deformity are recognised. There are three main problems which are to be solved by surgical treatment. 1. The acetabular dysplasia with a pelvic osteotomy 2. Improving the bio-mechanics by distalisation of the greater trochanter and by the lengthening of the femoral neck with or without valgisation 3. Lengthening of the shorter extremity.

The decision on the type of surgery to be performed depends on the age of the patient and the severity of the anatomic deformity, as well as the functional disability. A very useful method for treatment was found to be a double intertrochanteric osteotomy with a trochanteric advancement, and almost invariably in combination with a triple or Salter pelvic osteotomy. The lengthening osteotomy of the femoral neck follows the principles of Müller and Wagner. A similar technique was also proposed later by Morscher.

My own contribution has been to modify the operation by an oblique execution of the osteotomy, and a method of fixation of the greater trochanter by means of an angle plate – providing a lengthening of the limb by up to 3 cm. In the case of acetabular dysplasia, a pelvic osteotomy should be performed as a first procedure in order to obtain better stability of the hip joint. A femoral osteotomy can follow at a minimal interval of three months. If the femoral osteotomy is performed as a first step without enlargement of the actabulum, there is the risk of further deterioration of the covering of the femoral head, even in a dislocation. This philosophy of treatment of sequel of postdysplastic necrosis has been used since 1979.

Up to 1984, we operated on 48 hip joints in 46 patients, 39 girls and 7 boys aged 4 to 21, with a follow- up of at least 15 years. In 12 cases, 10 girls and 2 boys aged 4 to 8, a Salter and valgus osteotomy was performed. Thirty-four patients (29 girls and 5 boys) had a triple pelvic osteotomy, with 2 girls being operated bilaterally. In 22 hips, a lengthening osteotomy of the femoral neck was added as a second stage procedure. Five parameters were used for clinical evaluation: pain, limping, range of motion, Trendelenburg sign, and leg length discrepancy. For radiological assessment, we used an AP X-ray of the entire pelvis taken before and after osteotomy, and also during follow-up. CE angle, Sharp’s angle, ACM angle, and lateralisation were recorded. Hip score was measured on all hips, but we found that CE, Sharp and lateralisation were of greater value. In a group of 12 cases operated on up to the age of 8 by combining Salter and valgus osteotomy, a cementless THR was necessary for a young woman of 25. The remaining 11 patients are up to the present time without any major problems. In a group of 14 patients operated for sequel of postdysplastic necrosis Type II deformity (all with triple pelvic osteotomies and five in combination with femoral neck lengthening osteotomy), all have a normal quality of life, including having natural childbirths. From 22 Type III hip joints in 20 patients operated for sequel of postdysplastic necrosis, a cementless THR was implanted in three cases 14, 17 and 18 years after original surgery. Fourteen patients (15 hip joints − 67%) can be considered as good results without needing to have any therapy. Three patients (4 hips) suffer from degenerative arthritis and are candidates for THR.