Scoliosis and Adolescence

Idiopatska adolescentna skolioza (AIS) trodimenzionalno je postranično iskrivljenje kralježnice i razmjerno česta pojava u adolescentnoj dobi koju valja razlikovati od skoliotičnoga “lošeg” držanja. Tehnika kliničkog pregleda bolesnika i mogućnosti slikovnog prikaza deformacije opisane su u tekstu. Zbog progresivne i kompleksne naravi bolesti te nepoznatog uzroka liječenje AIS nije uvijek uspješno i uzrok je prijepora. Mogućnost progresivnosti bolesti u pojedinog bolesnika teško je utvrditi. Mnoga se pitanja vežu za potrebu i opravdanost probira na skoliozu (“screening”) u populaciji adolescenata. Konzervativno liječenje AIS danas izaziva mnoge dileme. Iako su razvijene vrlo sofisticirane i uspješne tehnike kirurškog liječenja, smatra se da operacijski postupak u većine bolesnika samo zbog medicinskih razloga nije opravdan. Naime, operacija bitno ne mijenja kvalitetu i eventualni morbiditet u bolesnikovoj kasnijoj dobi. U tekstu su navedena pitanja potanko razrađenas posebnim naglaskom na tranzicijsko, tj. adolescentno doba.Adolescent idiopathic scoliosis (AIS) is a threedimensional lateral curvature of the spine and it is quite often in adolescence. Scoliosis should be differentiated from a bad scoliotic posture. This article describes the technique of clinical examination and imaging possibilities. Due to the progressive and complex nature of the disease and its unknown cause, the treatment of AIS is not always successful and it gives rise to controversies. Possibility of the progression of the disease in individual patients is difficult to establish. There is a number of issues related to the necessity and justifiability of screening in adolescents. The conservative treatment of AIS is nowadays the cause of many dilemmas. Although very sophisticated and practical surgical techniques have been developed, in most patients surgery is not justified on the basis of medical indications only. The surgery does not substantially change the quality and any morbidity in later life. The article discusses these issues in detail, placing a special emphasis on transitional, i.e. adolescent period

Prvih 100 godina nastave ortopedije na Medicinskom fakultetu Sveučilišta u Zagrebu

In Croatia, hospitals where patients with diseases of the locomotor system were cared for date from more than 100 years ago. However, we consider the beginning of orthopaedics in Croatia to be the year 1908 when Božidar Špišić (1879 - 1957) founded the first Orthopaedic Institute in Zagreb. In 1917, the School of Medicine, University of Zagreb was founded, and when the first students were in their fifth year of studies, the Department of Orthopaedic Surgery was established on December 15, 1922, and Božidar Špišić became an Assistant Professor. From that date until today, Orthopaedics has been an independent department within the School of Medicine. The Department of Orthopaedic Surgery was primarily established for the education of medical students. Another important activity of the Department was the training of orthopaedic surgeons and specialists in overlapping fields with orthopaedics. In 1973, the department made a program of postgraduate studies in orthopaedics. The department also participated in postgraduate studies of other professions overlapping with orthopaedics and held numerous post-graduate courses and continuous medical education for doctors. Also, the department organised both domestic and international meetings, symposia, and congresses. Within the scientific post-graduate and doctoral studies, the Department of Orthopaedic Surgery members are lecturers in many courses. This article presents the work and development of the Department of Orthopaedic Surgery in the first 100 years of orthopaedics education at the School of Medicine, University of Zagreb and clinical work as a part of the University Hospital Centre Zagreb. It is a presentation of time periods under nine heads of the department, starting from Professor Božidar Špišić all to the current head Professor Domagoj Delimar.Premda su i ranije u Hrvatskoj postojale bolnice u kojima su se zbrinjavali bolesnici s bolestima i ozljedama lokomotornog sustava, organiziranim početkom rada ortopedije u Hrvatskoj smatra se 1908. godina kada je Božidar Špišić (1879. - 1957.) u Zagrebu osnovao prvi Ortopedski zavod na slavenskom jugu. 1917. godine utemeljen je Medicinski fakultet Sveučilišta u Zagrebu, i kada prvi studenti dolaze na petu godinu studija medicine, utemeljuje se i Katedra za ortopediju, a dr. Božidar Špišić postaje docent 15. 12. 1922. godine. Od tog datuma pa sve do danas ortopedija je samostalan predmet i Katedra u okviru Medicinskog fakulteta. Katedra za ortopediju prvenstveno je osnovana za edukaciju studenata medicine, dok je slijedeća značajna djelatnost Katedre za ortopediju bila i ostala izobrazba specijalista ortopeda i specijalista struka koje se preklapaju s ortopedijom. 1973. godine Katedra za ortopediju započela je provoditi plan i program postdiplomskog studija iz ortopedije, a održava i mnogobrojne postdiplomske tečajeve te tečajeve trajnog usavršavanja liječnika. Također, Katedra organizira domaće i međunarodne sastanke, simpozije i kongrese. Na znanstvenom postdiplomskom i doktorskom studiju članovi Katedre za ortopediju voditelji su mnogih kolegija. Prikaz rada i razvoja Katredre za ortopediju u proteklih 100 godina djelovanja u okviru Medicinskog fakulteta Sveučilišta u Zagrebu i Klinike za ortopediju Kliničkog bolničkog centra Zagreb podijeljen je na više vremenskih odsječaka, počevši od prvog pročelnika profesora Božidara Špišića sve do današnjeg, devetog pročelnika Katedre za ortopediju i predstojnika Klinike za ortopediju Kliničkog bolničkog centra Zagreb profesora Domagoja Delimara

Osteogenesis imperfecta: mogućnosti kirurškog liječenja s naglaskom na današnji ortopedski pristup

The treatment of osteogenesis imperfecta should be multidisciplinary and personalized. The best option for surgical treatment is implantation of an intramedullary telescopic nail, in many specialized hospitals the preferable method is Fassier-Duval telescopic nail. The main advantages of the Fassier-Duval intramedullary nail are fewer surgical scars, reduced blood loss, decreased time of operation, less pain, and better postoperative mobility. Orthopedic surgeons who are dealing with osteogenesis imperfecta have to answer two main questions, i.e. when to start with surgical procedures and which type of intramedullary nailing to use. There are a few things that are necessary for a satisfactory outcome of the surgical procedure: precise preoperative planning, all sizes of Fassier- Duval nail available in the operating room during the surgery, and intraoperative radiologic C-arm guidance.Liječenje bolesti osteogenesis imperfecta treba biti multidisciplinsko i personalizirano. Najbolji način kirurškog liječenja je ugradnja intramedularnog teleskopskog čavla, pri čemu većina specijaliziranih bolnica prednost daje metodi Fassier-Duvalova teleskopskog čavla. Glavne prednosti Fassier-Duvalova intramedularnog čavla su manje kirurških ožiljaka, manji gubitak krvi, skraćeno vrijeme operacije, manja bolnost i bolja poslijeoperacijska mobilnost. Ortopedski kirurzi koji se bave liječenjem osteogenesis imperfecta moraju odgovoriti na dva glavna pitanja: kada započeti kirurške zahvate i koji tip intramedularnog čavla primijeniti. Nekoliko je stvari neophodno ispuniti da bi ishod kirurškog zahvata bio zadovoljavajući: precizno prijeoperacijsko planiranje, dostupnost svih veličina Fassier-Duvalova čavla u operacijskoj sali za vrijeme operacije te intraoperacijsko radiološko vođenje pomoću C-ruke

Zastarjeli Monteggini prijelomi u djece

Results of surgical treatment for chronic Monteggia\u27s lesions in 16 children were retrospectively analyzed. The mean age at the time of reconstructive surgery was 7 years and 8 months. Using Bado\u27s classification, there were 12 type I, 3 type III lesions, and 1 type IV lesion. In 11 cases, operative procedures consisted of a combination of corrective ulnar osteotomy and open reduction of radial head. Corrective ulnar osteotomy alone was required in 2 cases. Another two cases required a combination of corrective osteotomy of both radial and ulnar shafts. Annular ligament reconstruction had to be performed in only 1 case initially submitted to open reduction of radial head. The patients were examined at 9 years and 6 months of the initial reconstructive procedure on an average. Using the scale proposed by Morrey, there were 9 good, 4 satisfactory, and 3 poor results. Eleven complications were recorded including 2 radial nerve lesions, 2 nonunions at the site of ulnar osteotomy, 5 redislocations and 1 subluxation, and 1 ulnar fracture below the site of osteotomy. Seven of 11 patients with complications underwent repeat operative procedures. These seven patients included both children previously submitted to combined osteotomies of both the ulna and radius as well as both children who had undergone corrective ulnar osteotomy alone. Thus, a very high rate of complications was recorded in our series of patients undergoing operative treatment for the sequels of Monteggia\u27s lesions. In our opinion, the main reason for this was inappropriate choice of operative treatment. Reporting on this very high rate of complications may hopefully draw attention to the fact that reconstructive procedures to correct the sequels of Monteggia\u27s lesions should not be attempted before learning the basic principles that need to be addressed. These are reconstructive procedures that should only be performed after a thorough study of the possible complications. Based upon this survey of our experience, we conclude that in addition to ulnar deformity correction, open reduction and stabilization of radial head are mandatory to achieve a satisfactory result.Provedena je retrospektivna analiza rezultata kirurškog liječenja zastarjelih Montegginih prijeloma u 16 djece, 6 djevojčica i 10 dječaka. Prosječena dob u vrijeme rekonstruktivne operacije bila je 7 godina i 8 mjeseci (raspon od 5 godina i 2 mjeseca do 12 godina i 10 mjeseci). Prema Badoovoj klasifikaciji bilo je 12 slučajeva tipa I, 3 tipa III i 1 tipa IV. U 11 slučajeva primijenili smo kombinaciju korektivne osteotomije ulne i krvave repozicije glavice radijusa, u 2 slučaja učinjena je samo korektivna osteotomija ulne, u 2 slučaja kombinacija korektivne osteotomije ulne i radijusa, a u jednom krvava repozicija glavice radijusa uz rekonstrukciju anularnog ligamenta. Vrijeme praćenja iznosilo je prosječno 9 godina i 6 mjeseci (raspon od 3 godine i 10 mjeseci do 17 godina). Prema Morreyevih ljestvici bilo je 9 dobrih, 4 zadovoljavajuća i 3 loša rezultata. Zabilježeno je 11 komplikacija: 2 lezije radijalnog živca, 2 pseudoartroze na mjestu osteotomije ulne, 5 reluksacija i 1 subluksacija, 1 prijelom ulne ispod mjesta ostetomije. Zbog komplikacija ponovno je operirano 7 djece, uključujući oba djeteta kod kojih je bila primijenjena kombinacija osteotomije ulne i radijusa i te oba djeteta kod kojih je bila primijenjena samo korektivna osteotomija ulne. Kirurško liječenje zastarjelih Montegginih prijeloma u našoj seriji je bilo povezano s velikim brojem komplikacija. Smatramo da je glavni uzrok tome bio neprimjeren izbor kirurškog zahvata. Uz ispravljanje deformacije ulne neophodna je i krvava repozicija i stabilizacija glavice radijusa

Novi način liječenja bilateralnog varus deformiteta kuka korištenjem „pločice osmice“ kod djece s kongenitalnom spondiloepifizealnom displazijom

Spondyloepiphysal dysplasia congenita (SEDc) is a rare autosomal dominant genetic disorder. Femoral head ossification delay and the proximal femur varus deformity i.e. coxa vara (CV) are the major features of SEDc. The accepted treatment is a valgus femoral osteotomy. The data on hip surgery in SEDc are scarce. In our database from 2006 to 2020, there were 6 SEDc patients. Four patients had surgery on 8 hips. Surgical treatment was indicated due to progressive CV deformity i.e. a decreasing neck-shaft angle (NSA), pain, limited hip abduction, and gait disturbances. In three patients, a novel surgical treatment was applied – a greater trochanter apo-physiodesis using “Eight-plate”. The patients were evaluated clinically and radiologically. The median age at first surgery was 6.3 years (range, 3.2 to 9.5 y) and the median follow-up period was 7 years (range, 5.6 to 14 y). The postoperative NSA was significantly improved with a mean increase of 13 degrees (P<0.001). Additional surgeries were needed in two patients. Overall, our results showed improved clinical and radiological parameters. The purpose of this study was to determine whether a method using an “Eight- plate” applied early to greater trochanter apophysis in SEDc patients with bilateral CV could reduce the need for more aggressive surgery in near future.Spondiloepifizna displazija kongenita (SEDc) je rijedak autosomno dominantan genetski poremećaj. Glavna značajka SEDc je odgoda okoštavanja glave bedrene kosti i varusna deformacija proksimalnog femura, tj. coxa vara (CV). Prihvaćeno liječenje je valgus osteotomija proksimalnog femura. Podaci o operaciji kuka u SEDc pacijenata su oskudni. U našoj bazi od 2006. do 2020. bilo je 6 SEDc pacijenata. Četiri pacijenta imala su 8 operacija kukova. Indikacija za kirurško liječenje bila je progresivna CV deformacija tj. smanjenje vratno-dijafizičnog kuta (NSA), bol, ograničena abdukcija kuka i poremećaji hoda. Kod tri pacijenta primijenjeno je novo kirurško liječenje - apofiziodeza velikog trohantera pomoću “pločice osmice”. Bolesnici su praćeni klinički i radiološki. Medijan dobi kod prve operacije bio je 6,3 godine (raspon od 3,2 do 9,5 godina), a medijan praćenja 7 godina (raspon od 5,6 do 14 godina). Postoperativni NSA je značajno poboljšan s prosječnim povećanjem od 13 stupnjeva (P<0,001). Dva pacijenta su trebala dodatne operacije. Sve u svemu, naši su rezultati pokazali poboljšane kliničke i radiološke parametre. Svrha ove studije bila je utvrditi može li metoda koja koristi “pločicu osmicu”, rano primijenjena na apofizu velikog trohantera kod SEDc pacijenata s obostranom CV-om, smanjiti potrebu za ekstenzivnijom operacijom u bliskoj budućnosti

Osteogenesis imperfecta - multi-systemic and life-long disease that affects whole family [Osteogenesis imperfecta - više-sustavna, doživotna bolest i njen utjecaj na obitelj]

Osteogenesis imperfecta or brittle bone disease, a heritable disorder of connective tissue, is the most common of the inherited disorders primarily affecting bone. There are approximately 400 individuals with OI in Croatia alone. It is estimated that twice that number is present, represented by individuals with mild OI in whom the diagnosis has not been made. Due to the relatively low number of patients in the general population, treating physicians have limited experience with this disease, either with children or adults. The basis of this disease in European populations is mostly the result of defects in the structure or processing of collagen type I, an important protein of the extracellular matrix of many tissues. Presently, molecular defects in 16 different genes have been discovered to result in at least one type of OI of which 14 are not COL1 mutation loci. Although fractures occurring with no injury or minor injury are the hallmark of OI, other non-mineralized tissues can be affected as well and the pathological changes can be present in skin, tendons, eyes, teeth and blood vessels. Clinical manifestations are very heterogeneous and numerous signs and symptoms such as blue sclera, deafness, abnormal teeth development, joint hypermobility, increased risk of hernias, capillary fragility, aneurysms etc. Although there is no cure for this disease, there are specific therapies that can reduce the pain and complications associated with OI. The purpose of this review is to provide a brief overview of the molecular basis of this disease, describe clinical presentations, as well as to present orthopaedic therapeutic modalities for the patients with OI

Osteogenesis imperfecta type III – a short review and an example of personalized surgery approach

Osteogenesis imperfecta (OI) or brittle bone disease, a heritable disorder of connective tissue, is the most common of the inherited disorders primarily affecting bone. There are approximately 400 individuals with OI in Croatia alone. The basis of this disease in European populations is mostly the result of defects in the structure or processing of collagen type I, an important protein of the extracellular matrix in many tissues. Although fractures occurring with no injury or minor injury are the hallmark of OI, other non-mineralized tissues can be affected as well. Four different types of the disease are commonly distinguished, ranging from a mild condition (type I) to a lethal one (type II). Types III and IV patients present with severe forms. Due to the relatively low prevalence in the general population, treating physicians have limited experience with this disease, both with children or adults. As an example of personalized surgery approach, we present an 11-year-old patient with OI type III. Before referral to our hospital, she was treated with 18 cycles of bisphosphonates as well as with several different surgical procedures. The patient underwent two surgeries at our hospital with a 5-month interval between them. Using the Fassier-Duval intramedullary telescoping nail, correction osteotomies of both femurs and lower legs in two separate settings were performed, with a very good final result

Osteogenesis Imperfecta – Multi-Systemic and Life-Long Disease that Affects Whole Family

Osteogenesis imperfecta or brittle bone disease, a heritable disorder of connective tissue, is the most common of the inherited disorders primarily affecting bone. There are approximately 400 individuals with OI in Croatia alone. It is estimated that twice that number is present, represented by individuals with mild OI in whom the diagnosis has not been made. Due to the relatively low number of patients in the general population, treating physicians have limited experience with this disease, either with children or adults. The basis of this disease in European populations is mostly the result of defects in the structure or processing of collagen type I, an important protein of the extracellular matrix of many tissues. Presently, molecular defects in 16 different genes have been discovered to result in at least one type of OI of which 14 are not COL1 mutation loci. Although fractures occurring with no injury or minor injury are the hallmark of OI, other non-mineralized tissues can be affected as well and the pathological changes can be present in skin, tendons, eyes, teeth and blood vessels. Clinical manifestations are very heterogeneous and numerous signs and symptoms such as blue sclera, deafness, abnormal teeth development, joint hypermobility, increased risk of hernias, capillary fragility, aneurysms etc. Although there is no cure for this disease, there are specific therapies that can reduce the pain and complications associated with OI. The purpose of this review is to provide a brief overview of the molecular basis of this disease, describe clinical presentations, as well as to present orthopaedic therapeutic modalities for the patients with OI

Osteogenesis imperfecta type III – a short review and an example of personalized surgery approach

Osteogenesis imperfecta (OI) or brittle bone disease, a heritable disorder of connective tissue, is the most common of the inherited disorders primarily affecting bone. There are approximately 400 individuals with OI in Croatia alone. The basis of this disease in European populations is mostly the result of defects in the structure or processing of collagen type I, an important protein of the extracellular matrix in many tissues. Although fractures occurring with no injury or minor injury are the hallmark of OI, other non-mineralized tissues can be affected as well. Four different types of the disease are commonly distinguished, ranging from a mild condition (type I) to a lethal one (type II). Types III and IV patients present with severe forms. Due to the relatively low prevalence in the general population, treating physicians have limited experience with this disease, both with children or adults. As an example of personalized surgery approach, we present an 11-year-old patient with OI type III. Before referral to our hospital, she was treated with 18 cycles of bisphosphonates as well as with several different surgical procedures. The patient underwent two surgeries at our hospital with a 5-month interval between them. Using the Fassier-Duval intramedullary telescoping nail, correction osteotomies of both femurs and lower legs in two separate settings were performed, with a very good final result