Ekstendirani anterolateralni pristup kroz jedan rez za liječenje bolesti kuka bolesnika s cerebralnom paralizom

Cerebral palsy often carries a high risk of hip involvement, especially in patients with a higher degree of body involvement. Hip subluxations and dislocations are commonly seen in non-ambulatory patients. We report on a single skin incision anterolateral approach to the hip that provides excellent visualization of all relevant anatomical structures and allows for a broad range of operative procedures needed to complete the San Diego operation. From 2005 to 2020, 50 patients (56 hips) were treated using the San Diego procedure. There were 22 male and 28 female patients, with 28 dislocated and 28 subluxated hips. The average patient age at the time of surgery was nine (range, 4 – 22 years). A San Diego or Dega pelvic osteotomy was done in 49 hips, and seven hips underwent a Brunner-type pelvic osteotomy. The mean follow-up was seven years (range, 2 – 13 years). The median preoperative AI measured at 40° (range, 35° – 50°). The median postoperative AI at the time of the most recent follow-up was 22,5° (range, 5° – 40°). The average head migration index at the last follow-up was 10% (range, 0% – 60%). Two infections, three recurring adduction contractures, four redislocations, one fracture, and one pseudarthrosis were encountered. All patients were eventually able to sit pain-free, with significantly better sitting balance.Cerebralna paraliza nosi sa sobom visok rizik od bolesti kuka, osobito u bolesnika s višim stupnjevima zahvaćenosti tijela. Subluksacije i dislokacije su učestale u bolesnika koji ne hodaju. Ovdje predstavljamo kohortu bolesnika liječenu kirurški upotrebom jednog reza i ekstendiranog anterolateralnog pristupa na kuk. Ovaj rez i pristup na zglob kuka omogućuju odličnu vizualizaciju svih važnih anatomskih struktura kao i izvođenje svih potrebnih zahvata unutar San Diego procedure. Od 2005. do 2018. godine 50 bolesnika (56 kukova) liječeno je San Diego operacijom. Bilo je 22 muških i 28 ženskih bolesnika, 28 dislokacija i 28 subluksacija. Prosječna dob bolesnika prilikom operacije bila je 9 godina (4 – 22 god.). San Diego, odnosno Dega osteotomija zdjelice učinjene su na 49 kukova, a na 7 osteotomija po Brunneru. Prosječno praćenje trajalo je 7 godina (2 – 13 god.). Srednja vrijednost preoperativno mjerenog AI iznosila je 40° (35° - 50°), a postoperativno AI je mjerio 22,5° (5° – 40°). Prosječna vrijednost migracijskog indeksa glave na posljednjem pregledu iznosila je 10% (0% – 60%). Od komplikacija uočene su 4 redislokacije, 2 slučaja infekcije aduktorne regije, 3 povratne aduktorne kontrakture, 1 subtrohanterna fraktura te 1 slučaj pseudartroze femura. Svi bolesnici su na posljednjoj kontroli pokazali bolji balans u sjedećem položaju te su sjedili bez bolova

Arthroscopic Treatment of Localized and Diffuse Pigmented Villonodular Synovitis of the Knee

Pigmented villonodular synovitis (PVNS) is a rare proliferative synovial disorder of uncertain etiology. Two forms of this disorder, a localized (LPVNS) and diffuse (DPVNS) form, are well differentiated. The therapy of choice for LPVNS is arthroscopic partial synovectomy with excision of the lesion. Total synovectomy, whether done arthroscopically or through an open arthrotomy, is the recommended treatment for DPVNS. During an eight-year period 13 patients, six male and seven female, average age 28 years (range, 16 to 60 years) were treated for PVNS of the knee with arthroscopic synovectomy. Average follow-up was 84 months (range, 28 to 127 months). Four patients were affected by localized PVNS and were subjected to partial arthroscopic synovectomy (two to three portals) with a complete lesion excision. The remaining nine patients presented with the diffuse form of PVNS and all of them underwent total arthroscopic synovectomy (five portals). The diagnosis was confirmed by synovial biopsy. Each patient was evaluated before treatment and at final follow-up. Results were assessed clinically, radiographically and subjectively and were rated as excellent, good, fair, or poor. No complications or recurrences were noted in the LPVNS group, and all four patients were rated as excellent. In the DPVNS group, eight patients were rated as excellent and one patient was rated as fair and it was the patient who suffered the only recurrence in our case series. No relevant complications were encountered. No cases of infection, joint stiffness or neurovascular lesions were seen. Arthroscopy has become the golden standard in treatment of LPVNS, and can undoubtedly give results that are as good as with open synovectomy when treating DPVNS, if performed by an experienced arthroscopic surgeon

Suradljivost bolesnika s adolescentnom idiopatskom skoliozom tijekom konzervativnog liječenja – pregled istraživanja i iskustva multidisciplinarnog tima Klinike za ortopediju Kliničkoga bolničkog centra Zagreb

Konzervativno liječenje skolioze uključuje nošenje korektivne ortoze u propisanom vremenu, nerijetko potpomognuto režimom fizikalne terapije. Djelotvornost liječenja ortozom dokazana je brojnim kliničkim ispitivanjima te predstavlja “zlatni standard” konzervativnog liječenja. Suradnja bolesnika u liječenju ortozom bît je uspješnosti tretmana. Liječenje je učinkovito samo u vrijeme rasta, a najčešće se odvija u periodu adolescencije. Adolescencija je psihološki vrlo burno razdoblje pa suradnja s adolescentnim bolesnikom može biti otežana iz više razloga. Zato je važno razumijevanje i uvažavanje psihosocijalnih aspekata u liječenju ove skupine bolesnika, kao i razumijevanje i uvažavanje dinamike cijele obitelji. Unaprjeđivanje suradnje važno je za tijek i ishod liječenja, a postupci unaprjeđivanja suradnje i pružanja psihološke potpore trebaju biti kontinuirani i strukturirani. Bolesnici koji dobivaju adekvatnu psihološku potporu koja uključuje i edukaciju o važnosti tretmana bolje surađuju te se općenito bolje osjećaju od onih bolesnika koji navedenu potporu nisu primili

Osobitosti anestezije kod ortopedskih zahvata u bolesnika s osteogenesis imperfecta [Characteristics of anesthesia in patients with osteogenesis imperfecta undergoing orthopedic surgical procedures]

The aim is to show our experience in anesthesia of patients with osteogenesis imperfecta (OI) who have undergone orthopedic surgical procedures. This is a retrospective analysis of OI patients treated at our Department from 1980 to 2012. We analyzed demographics, comorbidities, preoperative characteristics, anesthesia types, anesthetics and intraoperative and postoperative complications. In the given period, 26 OI patients were treated, using 103 surgeries, and 103 anesthesia procedures. Most procedures, a total of 68, were used in children aged 0-10 years. According to the diagnosis, OI type III was mostly encountered. The rating of the American Society of Anesthesiologist (ASA) physical status was II in most cases, a total of 99. General anesthesia was used in 89 cases, and regional anesthesia in 14. Fourteen intraoperative complications were seen, mostly difficult intubation, and six postoperative cardiovascular instability cases. With careful preparation, and knowledge of pitfalls, anesthesia in these patients should be a safe procedure

CHARACTERISTICS OF ANESTHESIA IN PATIENTS WITH OSTEOGENESIS IMPERFECTA UNDERGOING ORTHOPEDIC SURGICAL PROCEDURES

Prikazujemo svoje iskustvo u anesteziranju bolesnika s osteogenesis imperfectom u sklopu ortopedskoga kirurškog liječenja prijeloma i deformacija kostiju. Učinjena je retrospektivna analiza dokumentacije bolesnika liječenih u našoj Klinici od 1980. do 2012. godine. Analizirani su demografski podaci, komorbiditeti, prijeoperacijske osobitosti, vrste anestezije, anestetika i lijekova te intraoperacijske i poslijeoperacijske komplikacije. U navedenom razdoblju liječeno je 26 bolesnika s navedenom dijagnozom. Zabilježene su 103 operacije, odnosno 103 anesteziološka postupka. Najviše zahvata, njih 68, učinjeno je u dobnoj skupini od 0 do 10 godina. Najviše bolesnika bolovalo je od tipa III osteogenesis imperfecte, najtežeg oblika ove bolesti spojivog sa životom. U 99 operacija zabilježen je ASA (American society of anesthesiologists) status II bolesnika. U 89 slučajeva učinjena je opća anestezija, u 14 regionalna. Zabilježeno je 14 intraoperacijskih komplikacija, najviše otežanih intubacija te 6 slučajeva poslijeoperacijske kardiovaskularne nestabilnosti. Uz kvalitetnu pripremu i predviđanje mogućih komplikacija anestezija u ovih bolesnika sigurna je procedura.The aim is to show our experience in anesthesia of patients with osteogenesis imperfecta (OI) who have undergone orthopedic surgical procedures. This is a retrospective analysis of OI patients treated at our Department from 1980 to 2012. We analyzed demographics, comorbidities, preoperative characteristics, anesthesia types, anesthetics and intraoperative and postoperative complications. In the given period, 26 OI patients were treated, using 103 surgeries, and 103 anesthesia procedures. Most procedures, a total of 68, were used in children aged 0–10 years. According to the diagnosis, OI type III was mostly encountered. The rating of the American Society of Anesthesiologist (ASA) physical status was II in most cases, a total of 99. General anesthesia was used in 89 cases, and regional anesthesia in 14. Fourteen intraoperative complications were seen, mostly difficult intubation, and six postoperative cardiovascular instability cases. With careful preparation, and knowledge of pitfalls, anesthesia in these patients should be a safe procedure

The effect of spinopelvic parameters on the development of proximal junctional kyphosis in early onset scoliosis

Pre- and postoperative spinopelvic anatomy can influence results of distraction treatment in early onset scoliosis. I hypothesize patients with abnormal spinopelvic alignment have increased risk of proximal junctional kyphosis (PJK) during distraction treatment. Patients were treated between April 1997 and August 2014. A subsegment of patients were evaluated for quality of life. 135 patients were treated at an average age of 5.3 ± 2.83 years (range, 0.97-12.18), with minimum 2-year follow-up (average, 4.5 ± 2.6 years). 96 of 135 were included in the radiographic PJK study. 89 rib- and 46 spine-based distraction implants were used.Radiographic PJK developed in 38%, and clinical PJK in 18% of patients. Only pre-operative TK >50º increased risk for radiographic PJK (RR: 1.667, P=0.04). Pre-operative spinopelvic parameters did not increase risk for clinical PJK. Regarding quality of life, pelvic incidence –lumbar lordosis (PI-LL) mismatch > ±20o increased risk for poor outcomes through multiple domains while pelvic tilt (PT) >30°, implant type or fusion to pelvis had no effect. Preoperative TK >50º and spine-based distraction construct increased risk of radiographic PJK, and postoperative PI-LL >20º and PT ≥30º increased risk for clinical PJK. Preoperative PI >60° was shown to increase pain.Pre- i postoperativna spinopelvina anatomija utječu na rezultate liječenja djece s ranopojavnom skoliozom. Hipoteza predmnijeva da bolesnici s abnormalnom spinopelvinom anatomijom imaju veći rizik od nastanka kifoze proksimalnog spoja (KPS) u tijeku liječenja rastućim instrumentacijama. Ova studija obuhvatila je bolesnike liječene od travnja 1997. do kolovoza 2014. Kod dijela bolesnika evaluirana je i kvaliteta života. 135 bolesnika liječeno je u prosječnoj dobi od 5,3 ± 2,83 godina (raspon, 0,97-12,18) s minimalnim praćenjem od 2 godine (prosjek, 4,5 ± 2,6 godina). 96 bolesnika uključeno je u ispitivanje radiografske kifoze. Ukupno je upotrijebljeno 89 kralježničnih i 46 rebrenih instrumentacija. Radiografska KPS pronađena je u 38% (36/96), dok je ona klinički značajna otkrivena u 18% (24/135) bolesnika. Preoperativna torakalna kifoza (TK) >50° povećala je rizik za radiografsku KPS (RR: 1.667, P=0.04), dok preoperativni spinopelvini parametri nisu utjecali na razvoj klinički značajne kifoze. Utjecaj navedenih anatomskih varijanti na kvalitetu života bio je slijedeći: razlika incidence zdjelice i lordoze (eng. pelvic incidence lumbar lordosis mismatch (PI-LL)) >20° uzrokuje loš rezultat u multiplim domenama, nagib zdjelice (eng. pelvic tilt (PT)) >30°. Preoperativna TK >50° i kralježnične instrumentacije povećavaju rizik pojave radiografske kifoze, a postoperativni PI-LL >20° i PT ≥30º povećavaju rizik od klinički značajne kifoze. Preoperativna PI >60° uzrokuje bolove