Introduction: Aim of this study is to evaluate the results of the treatment using the technique of dual cortical graft.

Material and Methods: Twenty-one patients (13 boys, 8 girls, age 3–8 years) were treated in period 1996–2008 in our institution. In seventeen patients, dual cortical graft harvested from tibia of parents was used for reconstruction of pseudarthrosis. NF type I was the cause of pseudarthrosis in 13 patients. After resection of the hamartomatous fibrous tissue, sclerotic bone ends and periosteum and reduction of angulations, the cortical grafts are placed on lateral and medial side of the tibia and are fixed thru the tibia proximally and distally with conventional screws. Cast immobilization follows for 9–12 weeks. In concomitant fibular pseudarthrosis, intra-medullary fixation and cancelous bone grafting treat the pseudarthrosis. In 11 patients, this technique represented the 1st surgical procedure, whereas in 6 cases (including 2 failed vascularised fibular transfers), 1–15 previous surgical procedures were used in treatment. Further surgical procedures followed for correction of the leg length discrepancy and deformity of the ankle.

Results: The fusion of non-union was achieved in 16 patients. 12 patients reached skeletal maturity (59%) whereas 4 patients (24%) did not finished the growth and are still in treatment. 10 patients use the protection brace and intramedullar nail was used in 2 patients to prevent refracture. One patient refused further treatment and amputation followed in another institution. Concerning functional outcome, 14 patients walk unlimited, 2 patients walk more then 1 hour and 1 patient walks less then 1 hour. 13 patients did not use the walking aid, 2 patients use 1 cane a 2 patients the crutches. The complication rate of this method is similar to the other methods, mainly due to the refractures. Only in one patient, the pseudarthrosis primarily fused after single procedure. In 3 patients, second procedure was necessary. In remaining 12 patients, 3–6 further surgical procedures were used for the healing of pseudarthrosis due the delayed-union of grafts or refracture of the tibia. In these cases, cancelous bone grafting and various techniques of fixation were used to achieve the union.

Discussion: and conclusion: The results of the dual cortical grafting technique are comparable to other effective methods like Ilizarov method and the method is useful also after previous failed procedures. The complication rate is similar to other methods. The prevention of the refracture by bracing or rodding is recommended in all patients. This surgical procedure should be delayed until 4 years of age.

Significance: The method of dual cortical grafting represents still effective method of treatment of CPT.

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.

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.

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 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.