Coxarthrosis is a common problem. Changes in all articular structures during coxarthrosis were described extensively, besides labrum. This study was designed to:

describe histological changes in the labrum during coxarthrosis, and correlate them with radiographic changes

Methods: Consecutive patients scheduled for THR were analyzed. Cases of systemic disorders, septic arthritis of the hip, previous hip surgeries were excluded. All hips were assessed radiographically, and staged according to Hip Osteoarthrosis Radiographic Grading System (HORGS) and for etiology to: dysplastic, idiopathic and avascular necrosis (AVN) groups. From the group of 90 patients in 77 hips we were able to harvest hip labrum during THR. All labra were examined by histological techniques for the presence of: labral matrix degeneration of, granular matrix breakdown, pseudocysts formation, matrix calcifications, chondrocyte apoptosis, macrophage and lymphocyte infiltration, vascular ephiteliar cell and blood vessel formation. After analysis labral histological degeneration score (LHDS) (0–11 points) was designed and computed.

Results: Degeneration of the labral matrix was found in all specimens, granular matrix breakdown in 98%, pseudocysts in 91%, calcifications in 22 %, apoptosis in 19%, macrophage infiltration in 30%, lymphocyte infiltration in 19 %, vascular ephiteliar cell in 39 % and blood vessel formation in 35 % of specimens. Average LHDS for all cases was 5.4, and was the highest (6.1) in dysplastic coxarthrosis, followed by idiopathic changes (LHDS 5.7). Significantly lower (p=0.02) values were found in AVN group (LDHS 3.7). In 35 randomly selected patients anterior, middle and posterior portion of labrum was evaluated separately. The highest LDHS was found in middle portion 5.9, comparing to anterior (LDHS 3.5) and posterior (LDHS 4.25) portion, and this difference was significant (p=0.002). Radiographic assessment showed that 10 % of patients had grade 1 changes according to HORGS, 28 % grade 2, and 62% grade 3 changes. Strong correlation (p=0.0002) was found between LDHS and radiographic HORGS scores. Labra of the patients with severe coxathrosis showed more degeneration changes.

Conclusions: Hip labrum shows various degenerative changes in the course of coxarthrosis like other structures in the joint. Degree of histological degeneration correlates well with radiographic changes. Small labral changes were found in AVN group with no destruction of acetabulum, the highest labral degeneration was found in cases of dysplastic coxarthrosis. The biggest changes were noted in the middle portion of the labrum. The results of this study proved that degeneration of the labrum is simultaneous with other articular structures and labral degeneration itself promotes coxarthrosis.

In the last decades the number of anterior cruciate ligament (ACL) injury in skeletally immature patients (SIP) increased as a result of the participation in competitive sports at younger age and improved diagnostic tools allowing early diagnosis of ACL injury. Although the eminence avulsion fracture is more frequent in SIP and considered the ACL injury pediatric equivalent, intra-substance ACL injury in children is a growing problem. With torn ACL injured knee remains unstable. This instability is poorly tolerated in teens since it is difficult to limit their activity and leads to meniscal and chondral tears and causes resignation from sport carrier. Intraarticular transphyseal ACL reconstruction seems to be effective technique to restore knee stability despite potential iatrogenic complications such as epiphisiodesis, leg length discrepancy and axial malalignment. The main aim of this study was to evaluate the efficacy and results of this method and assess frequency of potential complications.

Material: From 2006 to 2007 we performed 15 reconstructions (7 boys, 8 girls) of ACL in skeletally immature patients (Tanner 3). All patients were athletes. Average age of girls was 11,2 years and boys 12,3 years. The period from injury to reconstruction were shorter than 10 months. All patients were operated by the same surgeon using the same surgical technique – gracilis-semitendinosus autograft, with transphyseal tibial and femoral tunnels and extraarticular fixation with AO screws. Average tunnel diameter was 7 mm. All beside one ACL injuries were isolated, with 1 meniscus tear.

Methods: In prospective study without control group patients were examined before reconstruction, and 6, 12, 24 months after surgery IKDC, Lysholm and Tegner score. We assessed the growth, leg length and axial disturbances by clinical and radiological assessment and the return to prior level of sport activity.

Results: In 12 and 24 months follow-up no disturbance of angular and longitudinal growth were observed, 11/12 patients returned to previous sport activity after mean of 7 months post- op with scores: IKDC 96,5 after 12 months and 97 after 24 months, Lysholm 95 after 12 months and 96 after 24 months. Average gain of growth was 5,5cm/12 months on average.

Conclusion: The use of complete transphyseal reconstruction is a safe, reliable technique in patients who have significant growth remaining, providing adequate knee stability, good satisfaction and allowing return to sport activity.

Introduction: One of the most challenging problems in total hip arthroplasty (THA) is implantation of the prothesis in the dysplastic hip. The purpose of the study is to evaluate the long-term results of uncemented total hip) in patients below 50 years of age.

Material and Methods: In the last twenty years, 862 primary uncemented hip endoprosthesis were implanted in our Institution. This surgery was performed in 459 patients. From this group 220 hips in 177 patients (167 women and 10 men), who had dysplastic coxarthrosis, were included in our study. The left hip was operated in 66 and the right one in 68 patients. Bilateral surgery was performed in 43 patients. The means age at the time of hip surgery was 38,3 years (range from 18 to 49 years). The mean follow-up was 9,3 years ( range from 2 years to 18,6 years). In 167 (75,8%) patients the operative treatment of DDH was performed during the childhood. Only 39 (17,7%) patients were treated in the childhood conservatively. All patients were evaluated clinically and radiological. For clinical evaluation the classification system proposed by Merle d’Aubigne and Postel with Charnley modification was used. For radiological evaluation of the steam implantation the classification system proposed by De Lee and Charnley was used and for the cup implantation the system by Gruen and Moreland. The femoral head displacement prior to THA surgery was classified according to Crowe at all. classification.

Results: Based on above mentioned criteria in 26 hips (11,8%) the final result was graded as very good, in 61 cases (27,7%) as good, in 94 hips (42,7%) as satisfactory and in the remaining 39 cases (17,8%) the final result was poor. We observed a very strong correlation between clinical and radiological results. According to Crowe and all. classification, in class I we noted 19 (61,3%) very good , 11 (35,5%) good, 1 (3,2%) satisfactory results. In class II % (6,6%) very good, 25 (32,9%) good, 39 (51,3%) satisfactory results. In class III only in 2 cases the final result was graded as very good, and good in 23 hips (25,8%). In class IV there was no very good result, and we observed 19 (21,4%) poor results. In analyzed group in 37 (16,8%) patients the revision hip surgery was necessary because of aseptic prosthesis loosening.

Discussion and Conclusion: The treatment of dysplastic coxarthrosis by means of THA is difficult. The high level of experience is necessary to perform this type of surgery. This type of THA should be done only in special orthopaedic centers. Starting the surgery one has to think about complications.

Introduction: One of the most important factors, to improve the primary prosthesis stability is the bearing surface between the femoral head and the cup. The connection metal-metal and ceramic-ceramic seems to be one of the best to reduce the loosening rate. The purpose of the study is to evaluate the long-term results of uncemented total hip replacement using the ceramic Mittelmeier enoprosthesis (ceramic cup – ceramic head).

Material and Methods: In the last twenty years, 258 primary ceramic, Mittelmeier type hip endoprosthesis were implanted in our Institution. This surgery was performed in 222 patients (116 women and 106 men), at the average age at the surgery of 45,6 years (range from 18 years to 70 years). In 36 patients the surgery was performed on both hips. The means follow-up was 10,2 years ( range from 4 years to 18,6 years). The most frequent indication for surgery was: in 105 cases idiopathic, in 81 dyspalstic and in 25 posttraumatic coxarthrosis. All patients were evaluated clinically and radiological. For clinical evaluation the classification system proposed by Merle d’Aubigne and Postel with Charnley modification was used. For radiological evaluation the classification system proposed by De Lee and Charnley ( steam) and system by Gruen and Moreland (cup) was used.

Results: Based on above mentioned criteria in 87 hips (33,7%) the final result was graded as very good, in 96 cases (37,3%) as good, in 47 hips (18,2%) as satisfactory and in the remaining 28 cases (10,9%) the final result was poor. The very good and good results were noted in patients older than 50 years with idiopathic coxarthrosis. The poor results were observed in young patients with dysplastic coxarthrosis, especially in cases with poor developed hip joint after the previous hip surgery in the childhood, because of DDH (type III and IV according to Crowe at all. classification system). Only 13 hips (5%) required revision procedures. In 2 cases (0,8%) revision was directed only to the cup, in 6 hips (2,3%) to the steam and in 5 cases (1,9%) it was necessary to exchange both elements.

Conclusion: The long term results and our experience with ceramic uncemented hip endoprosthesis type Mittelmeier are promising. This type of hip prosthesis should be indicated in young patients with idiopathic or posttraumatic coxarthrosis. This indication could give long lasting good clinical and functional results.

Introduction: Late diagnosed developmental dysplasia of the hip joint (DDH) is now a very rare case in an orthopaedic practice. It is mostly because of early ultrasound screenings of baby’s hips. Two ultrasound techniques are most popular and widely used in the world – the Graf’s technique in Europe and Harcke’s in the USA. The purpose of this study was to establish a value of Harcke’s technique which is not very popular in Europe.

Material and Methods: During the last 10 years, 25 000 ultrasound hip examinations of newborns hips because of early DDH screening were performed in our Clinic. In every child both hips were examined using two techniques (Graf’s and Harcke’s). The mean age during the first hip ultrasound examination was 5 weeks (from 10 days to 8 weeks). The Siemens SL1 equipment with linear transducer of 7.5 MHz was used for examination. The position of the hip during examination followed all requirements indicated by Graf or Harcke. All ultrasound examination were performed and analyzed by two orthopaedic surgeons.

Results: In this study the DDH was diagnosed in 5,6% of all examined hips. Most common type of dysplastic hip was type II according to Graf’s classification, or laxity with stress according to Harcke’s classification. The cases with decentration (subluxation or dislocation) were diagnosed in 2% of all dysplastic hips. In Graf’s technique there were some differences in measuring the beta or alfa angles between examiners, however, this did not influenced the type of hip dysplasia. Harcke’s method was easy to perform because the measuring of the angles was not necessary. The time which was required for examination of a child’s hips did not extend 2 minutes.

Conclusions: Both methods are very useful in early diagnosis of DDH and could be used for general hip screening for newborn hips. Harcke’s method gives a better visualization of the hip in two planes and gives dynamic pictures.

Aims: The purpose of this study was to evaluate the late results after total hip arthroplasty in young patients with dysplastic coxarthrosis. Methods: In our Institution between the years 1985 Ð 2001, 949 total hip arthroplasties (THA) were performed because of severe hip arthrosis. From this group, 186 patients (231 hips) were diagnosed as dysplastic coxarthrosis and this group (176 female and 10 male) was selected for further evaluations. The average age at the time of surgery was 38,1 years (from 18 to 52 years). In the early childhood 141 patients (75,8%) were surgically treated because of hips dysplasia, non-surgical treatment was applied in 33 patients (17,7%) and no treatment at all in 12 cases. The uncemented THA was performed in 208 hips (90%) before the age of 50 years. We used the Crowe classiþcation to group dysplastic hips before the surgery. To the Crowe class 1 were classiþed 57 hips (24,7%), to class 2 Ð 78 hips (33,8%), class 3 included 69 hips (29,9%) and class 4 Ð 27 hips (11,6%). The clinical outcome was rated according to the Harris hip-scoring system. Radiological appearance based on de Lee and Gruen classiþcation and overall placement of prosthesis. Results: In our material we noted excellent results in 103 hips, good in 64, fair in 45 and poor results in 19 hips. Poor results were mostly connected to aseptic loosening of the prosthesis. The clinical results were slightly better than radiological. Conclusions: Treatment of dysplastic coxarthrosis is difþcult and connected with high rate of complication and technical problems during the surgery. The most common complications occurred in hips class 3 and 4 according to Crowe classiþcation. In 8% of all treated hips, revision THA was necessary because of different type of complications.

Ischemic necrosis of the femoral head occurring after the treatment of congenital dysplasia of the hip can negatively affect the long-term prognosis of the involved hip.

The purpose of the study was to evaluate a number of clinical and radiological risk factors for AVN after non-operative treatment of DDH.

Clinical data and radiographs of 77 patients with103 abnormal hips treated because of developmental dysplasia of the hip by closed reduction followed by cast immobilization were reviewed retrospectively. The average age of patients at the time of reduction was 16 months (ranged, 4 to 28) and the average final follow up was 22,4 years (ranged from 13 to 47 years). Kalamchi and MacEwen classification system was used for evaluation of the AVN. Avascular necrosis was found in 35,9% of the treated hips. We established the influence of several radiological and clinical data on the incidence and severity of AVN.

Conclusion: In our analysis the degree of initial dislocation according to Tönnis classification is an important risk factor for AVN. Age at the onset of treatment, presence and size of ossific nucleus, the use and period of preliminary traction, previous treatment with Frejka pillow or Pavlik splint, sex and side were not associated with the incidence and severity of ischemic necrosis. The results have been analysed statistically.

The purpose of this study is to determine how the lateral shape of the acetabulum changes during Perthes disease and if there is any correlation between the lateral acetabulum shape and final result and type of treatment.

The study population consisted of 243 patients with unilateral involvement who had reached skeletal maturity at last follow up. There were 35 (14.4%) female and 208 (85.6%) male patients. The mean age at the onset of symptoms was 7 years and 1 month. AP X-ray films were estimated during fragmentation, reossification and last follow up. Group A consisted of 56 hips, 126 hips were classified as group B and 61 hips as group C according to the Herring classification. For the lateral acetabular shape we proposed a classification: group A – a normal concave acetabular roof, group B – a horizontal flat roof and group C – a roof convexly rounded and up going. All hips were treated by containment methods (bed rest and traction in abduction-78 hips, Petri cast-31 hips, brace-94 hips, varus osteotomy-20 hips, Salter oste-otomy-12 hips and shelf arthroplasty-8 hips). The outcomes of treatment were evaluated according to the Stulberg classification.

During fragmentation stage we found 78 (32.1%) hips with normal lateral acetabular shape-type A. Horizontal roof-type B was noted in 136 (56%) hips and in 29 (11.9%) type C was observed. We observed improvement in the shape of lateral acetabulum after treatment. At the last follow up there were 124 (51%) hips with type A, 81 (33.3%) with type B and 38 (15.7%) with type C. Statistical analysis revealed significant correlation between lateral acetabular shape and Stulberg classification. A normal concave acetabular roof at the fragmentation stage leaded mainly to Stulberg group 1and 2 whereas a roof convexly rounded and up going leaded to Stulberg group 3, 4 or 5 (p< 0.0001). Analysis showed no statistical significant correlation between treatment by using bed rest and traction in abduction, Petri cast, braces and development the lateral acetab-ular shape (p=0.09). Only treatment by using surgical methods improved the lateral acetabular shape at the last follow up (p=0.0015).

The acetabulum is a mould for remodeling of the deformed femoral head in Perthes disease and the lateral acetabulum plays the most important role. We can expect that normal shape of the acetabulum gives good result at final follow up whereas a roof convexly rounded usually follows to Stulberg group 3, 4 or 5. Only surgical treatment improves the shape of the acetabulum.

Introduction: Thanks to early ultrasound diagnosis of DDH the number of late diagnosed cases decreased in the last ten years. The surgical intervention because of dislocated hip is also reduced to the few cases a year. We still however have in our practice patients after operative treatment of DDH. One of the methods used for proper hip reduction is transiliacal pelvic osteotomy described by Dega.

The aim of this study is to evaluate the late results of one stage procedure with Dega transiliacal pelvic osteotomy in the treatment of DDH with dislocation.

Material and Methods: In our Institution 256 dislocated hips were treated surgically by means of open hip reduction, femoral directional osteotomy and Dega’s transiliacal osteotomy. From this group 102 patients (91 female and 11 male), presented 144 operated hips were seen for the final follow-up. The left hip was affected in 45 cases, right in 17, and bilateral in 41 patients. The mean age at the surgery was 23,5 months. Mean follow-up was 19.8 years (minimum 15 years after surgery). Patients were evaluated clinically (Barrett modification of McKay classification) and radiologically using Severin classification. All radiograms from whole period of treatment were collected and evaluated.

Results: In 90 hips the final result was classify as very good (57%), good in 36 hips (23%), satisfactory in 10 hips and poor in 8 hips. Radiologically very good result (group IA) was seen in 51 hips, good in 65 hips (group IB, IIA, IIB), satisfactory in 24 hips and poor in 4 hips. It was a good correlation between clinical and radiographic classification.

Conclusions : The late results after one stage hip reconstruction with Dega’s transiliacal osteotomy gives a long lasting good results and is recommended for operative treatment of DDH with dislocation.

Introduction: The knee arthritis is a very common seen chronic disease in an orthopaedic practice. It is mostly seen in patients after 6 decade of life and connected with a severe knee pain. In most of the cases the surgical intervention is indicated because of unicondylar arthritis changes. Because of the costs of the hemiarthroplasty we choose a high tibial osteotomy for tibial axis correction to prevent further gonarthrosis.

The aim of this study was to evaluate the late results after high tibial osteotomy in patients with unicondylar gonarthrosis.

Material and Methods: In our Institution during last 20 years 94 high tibial osteotomy were performed because of unicondylar, medial gonarthrosis. The mean age of the patient at the time of surgery was 56 years (from 19 to 72 years). The mean follow-up was 16 years. Only patients with arthritic changes on the medial compartment of the knee with a “good” lateral part of the knee were scheduled for this type of surgery. In every case the dome type of osteotomy was performed followed by 1cm resection of fibula. After surgery the limb was stabilized with plate in 16 cases, K-wires in 4 cases, Ilizarov frame in 43 cases, orthofix device in 8 cases and other type of external fixator in remaining 23 cases. In patients where external fixator was used the full weight bearing was recommended as soon as patient tolerated the pain. The external fixator was removed after an average period of 6 weeks when bone callus was diagnosed. To assess of the clinical results based on HSS score and radiological results were evaluated using the modified Dihlmann classification.

Results: In 88,8% of all cases the final result was graded as excellent and good, in 1,9% the final results was satisfactory and in 7.8% the final results was poor. From analyzed patients 46% was scheduled for TKR at an average time of 12 years after initial surgical procedure. In 28% after average 16 years after high tibial osteotomy the good shape of the knee joint was observed with good clinical function and radiographic appearance. Pain was reduced in 82% of all cases, increased range of the knee motion was observed in 65% and improved walking ability in 64% of all cases. The poor results were connected with not adequate patients selection for this type of surgery (patients after 7 decade of life) and with advanced arthritic knee changes before the surgery.

Conclusions : The high tibial osteotomy is a good method for preventing gonarthrosis. When early performed gives good long-lasting result. In our opinion is recommended for unicondylar gonarthrosis as an alternative to the knee hemiarthroplasty.