The Use of Bovine Xenogeneic Bone Graft for Dega Pelvic Osteotomy in Children with Hip Dysplasia: A Retrospective Study of 147 Treated Hips.

BACKGROUNDS: Dega pelvic osteotomy is commonly used to correct acetabular dysplasia in children with open triradiate cartilage. The use of bovine xenogeneic bone graft (Tutobone®) for Dega osteotomy has not been reported so far. This study aimed to determine the clinical and radiological outcome in a large series of children with hip dysplasia who were treated by Dega osteotomy using a bovine xenogeneic block for stabilisation. METHODS: A retrospective, single-centre study was conducted including 101 patients (147 hips) with different underlying diseases. The acetabular angle of Hilgenreiner (AA) and the lateral center-edge angle (LCA) were analysed to quantify the correction of acetabular indices. Graft incorporation was assessed using the Goldberg scoring system. RESULTS: the mean preoperative AA improved from 28.1 (SD: 6.7) to 14.7 (SD: 5.1) after surgery (p < 0.001). The mean preoperative LCA improved from 9.9 (SD: 6.7) to 21.8 (SD: 6.8) postoperatively (p < 0.001). Both indices remained stable at the one-year follow-up examination. Graft incorporation was excellent with a mean Goldberg score of 6.6. Heterotopic ossification occurred in one hip without clinical relevance. Graft-related complications were not noted. CONCLUSIONS: Dega osteotomy using Tutobone® is safe and effective in the treatment of acetabular dysplasia in children independent of the underlying disease.

Correction of Recurrent Equinus Deformity in Surgically Treated Clubfeet by Anterior Distal Tibial Hemiepiphysiodesis.

BACKGROUND: Residual or recurrent equinus deformity is a common problem in surgically treated clubfeet. This deformity may occur due to soft tissue-related reasons or due to bony deformity. An increased anterior distal tibial angle (ADTA) was previously found in 48% of the operated clubfeet. This study aimed to determine the efficacy and safety of anterior distal tibial hemiepiphysiodesis (ADTE) in the treatment of recurrent equinus deformity in patients with an increased ADTA. METHODS: Eighteen children (23 feet) treated by ADTE to correct recurrent equinus deformity in surgically treated clubfeet were included in this retrospective, single-center study. ADTE using 8 plates was performed in children with an increased ADTA (>82 degrees) and inability to dorsiflex the ankle (≤0 degree of dorsiflexion). The mean patient age was 11.3 years (range: 10.2 to 12.9 y). All patients had completed treatment with implant removal after an average of 20.3 months (range: 9 to 37 mo). RESULTS: The mean preoperative ankle dorsiflexion significantly improved from -3.3 degrees (range: -20 to -0 degrees) to 6.1 degrees (range: -15 to 10 degrees) at the time of 8-plate removal (correction rate: 9.4 degrees; P<0.0001). The ADTA was a mean of 87.5 degrees (range: 83 to 110 degrees) before surgery and significantly improved to 75.8 degrees (range: 63 to 106 degrees) at the time of implant removal (correction rate: 11.7 degrees; P<0.0001). Average follow-up was 43.9 months (range: 10 to 76 mo). Follow-up examinations were continued in 11 patients (13 feet) after implant removal. Changes of ankle dorsiflexion (mean: -2.5 degrees) and ADTA (mean: 3.6 degrees) occurred in this group. CONCLUSIONS: ADTE was safe and effective in the treatment of recurrent equinus deformity in surgically treated clubfeet with increased ADTA. Deterioration of ankle dorsiflexion and ADTA occurred after implant removal in some cases. The results of this study have to be analyzed with caution due to the limited number of included patients and its retrospective nature. LEVEL OF EVIDENCE: Level IV-retrospective case series.

Spinal posture changes using dynamic rasterstereography during the modified Matthiass test discriminate between postural weak and strong healthy children (10-14 years): a pilot study.

The aim of this pilot study was to investigate whether the clinical Matthiass test can be objectified by means of dynamic rasterstereography in children. We aimed at discriminating between postural weak and strong children. Dynamic rasterstereography was used to capture sagittal spinal posture changes during the modified Matthiass test (mMT). Primary outcomes were spinal posture changes (trunk inclination, kyphotic and lordotic angles) during the test. Two-step cluster analysis was run jointly on the three primary outcomes. Data of 101 healthy children (10-14 years, 46% girls) were assessed. Cluster analysis identified two groups of participants with significantly different postural performance levels during the mMT (low vs. high performers). Low performers showed a higher increase in backward lean, as well as kyphosis and lordosis (4°-5°, respectively) when compared to high performers. The two performance groups were age-, BMI-, and activity-matched.Conclusion: This pilot study established preliminary normative data on spinal posture changes during the Matthiass test (high performers) and provided corresponding cutoff values for postural weakness (low performers). These results could provide a basis for future longitudinal and interventional studies targeting long-term consequences of childhood postural weakness and the prevention of back pain. What is Known: • The prevalence of postural insufficiencies in children is high. • No consensus exists about the postural assessment in children. • A common clinical test to identify postural insufficiency is the Matthiass test yet criticized for its subjective assessment. What is New: • This pilot study objectified the modified Matthiass test by rasterstereography and statistically identified two groups of healthy children with different postural performance levels. • It established preliminary normative data on spinal posture changes and provided corresponding cutoff values for postural weakness.

Anterior distal femoral hemiepiphysiodesis can reduce fixed flexion deformity of the knee: a retrospective study of 83 knees.

Background and purpose - Fixed knee flexion deformity in children is a common problem in various diseases including myelomeningocele and cerebral palsy. Until now, only a few studies focusing on the surgical procedure of anterior distal femoral hemiepiphysiodesis have been published. We analyzed outcome and correction rate in the largest case series to date of patients treated by staples or 8-plates. Patients and methods - We reviewed the medical records of all patients with fixed knee flexion deformity who were treated with anterior distal femoral hemiepiphysiodesis using either staples or 8-plates between the years 2002 and 2017 (73 patients; 130 knees). 49 patients (83 knees) had completed treatment with implant removal at the time of full correction of the deformity or at skeletal maturity and were included. The average age at operation was 12 years (6-20). Patients were assigned to 3 different groups based on their diagnosis: cerebral palsy, myelomeningocele, and the "other" group.d Results - Mean fixed knee flexion deformity improved from 21° (10-60°) to 8° (0-50°) (p < 0.001) with an average correction rate of 0.44° per month (range -2.14° to 1.74°). The correction rate per month was lowest for patients with cerebral palsy (0.20°), followed by the myelomeningocele group (0.50°), and the "other" group (0.58°). Implant loosening occurred in 10% of the treated knees with consecutive re-implantation in 5% of the cases. Interpretation - Anterior distal femoral hemiepiphysiodesis is an effective and safe method for the treatment of fixed knee flexion deformity in children. The optimal timing depends on the remaining individual growth potential, the underlying disease, and the extent of the deformity.

Spinal postural changes during the modified Matthiass test in healthy children : Interday and interrater reliability of dynamic rasterstereographic measurements.

OBJECTIVE: The Matthiass test serves to identify postural insufficiencies by evaluating the sagittal posture but this subjective assessment may be responsible for different reports on the prevalence of postural insufficiencies in children. Previously, rasterstereography was used to objectify this clinical test. Until now, the coupling of the Matthiass test with rasterstereography has not yet been applied to children and the reliability is unknown; therefore, the objective of our study was to provide interday and interrater reliability of rasterstereographic measurements during dynamic (modified Matthiass test) and static trials (only interday) in healthy children. METHODS: Trunk inclination, kyphotic, and lordotic angles were measured using rasterstereography during static and dynamic trials (modified Matthiass test: 90° shoulder flexion, hand-held load, 5% of body weight). Intraclass correlation coefficients (ICC) were calculated using a two-way mixed model (absolute agreement, average measure). RESULTS: In this study 21 healthy children were assessed (age range 10-12 years). Dynamic rasterstereographic measurements showed fair to good interday and interrater reliability (ICC 0.46-0.70) and static measurements good to excellent interday reliability (ICC 0.63-0.91). CONCLUSION: Dynamic rasterstereography during the modified Matthiass test furnishes reliable data serving to objectify spinal changes of healthy children and detect postural insufficiencies. Additional efforts are needed to investigate how the early detection of postural insufficiencies can help to prevent back pain in children, adolescents and adults.

Arch index and running biomechanics in children aged 10-14 years.

BACKGROUND: While altered foot arch characteristics (high or low) are frequently assumed to influence lower limb biomechanics and are suspected to be a contributing factor for injuries, the association between arch characteristics and lower limb running biomechanics in children is unclear. RESEARCH QUESTION: Therefore, the aim of this study was to investigate the relationship between a dynamically measured arch index and running biomechanics in healthy children. METHODS: One hundred and one children aged 10-14 years were included in this study and underwent a biomechanical investigation. Plantar distribution (Novel, Emed) was used to determine the dynamic arch index and 3D motion capture (Vicon) to measure running biomechanics. Linear mixed models were established to determine the association between dynamic arch index and foot strike patterns, running kinematics, kinetics and temporal-spatial outcomes. RESULTS: No association was found between dynamic arch index and rate of rearfoot strikes (p = 0.072). Of all secondary outcomes, only the foot progression angle was associated with the dynamic arch index (p = 0.032) with greater external rotation in lower arched children. SIGNIFICANCE: Overall, we found only few associations between arch characteristics and running biomechanics in children. However, altered foot arch characteristics are of clinical interest. Future studies should focus on detailed foot biomechanics and include clinically diagnosed high and low arched children.

Hip Morphology in MPS-1H Patients: An MRI-based Study.

BACKGROUND: Hip dysplasia is common in mucopolysaccharidosis type-1H (MPS-1H) patients, but its morphology is not completely understood. No magnetic resonance imaging (MRI)-based studies have been reported in the literature. The purpose of this study was to improve knowledge of hip dysplasia pathology by describing the hip morphology of these patients in MRI scans, plain radiographs, and arthrograms. METHODS: We performed a retrospective chart review of 18 MPS-1H patients. Supine anteroposterior pelvic radiographs of 36 hips and MRI scans of 18 hips were analyzed. Six arthrographs were also available. RESULTS: Plain radiographs were available for 18 patients. The mean age was 6.0 (SD=3.8) years. The mean acetabular index (AI) was 36.2 degrees (SD=5.8), and the mean migration percentage was 59.0% (SD=17.2). MRI data were available for 9 patients. The MRI findings were compared with the radiographs of the same patient. The mean AI (39.3 degrees, SD=5.8) was confirmed by the MRI findings (39.1 degrees, SD=5.5). The migration percentage was lower in the MRI scans than in the radiographs. Radiologically, the center-edge angle was negative in all patients, with a mean of -16.8 degrees (SD=7.9), and the MRI images produced a more negative value (-19.6 degrees, SD=7.6). The soft tissue coverage of the femoral head was described with the inclusion of the cartilaginous roof and labrum. The cartilaginous AI was 22.4 degrees (SD=7.5), and the labral AI was 13.5 degrees (SD=6.7). All 6 arthrograms revealed stability during dynamic testing. CONCLUSIONS: This study provides the first description of hip morphology in MPS-1H patients through MRI-based data. The cartilaginous coverage of the hip was increased compared with that of healthy children. The use of radiography alone may lead to a misunderstanding of hip morphology. MRI and arthrogram is highly recommended if surgery is considered.

Recombinant Human Bone Morphogenetic Protein-2 (rhBMP-2) for the Treatment of Nonunion of the Femur in Children and Adolescents: A Retrospective Analysis.

Background. The aim of this study was to examine clinical and radiographic healing after rhBMP-2 application in children and adolescents presenting with nonunion of the femur and to investigate the safety of rhBMP-2 use in these cases. Materials and Methods. We reviewed the medical records of five patients with a mean age of 11 years (5.4 to 16.2) with nonunion of the femur who were treated with rhBMP-2 and internal fixation using a locking plate at a single institution. Particular attention was paid to identify all adverse events that may be due to rhBMP-2 use. Results. Union occurred in four of five patients at a mean of 12.1 months (7.9 to 18.9). The locking plates were removed after a mean of 16 months (11 to 23). One patient had nonunion due to deep infection. After a mean follow-up of 62.5 months (17 to 100), union was still evident in all four patients and they were fully weight-bearing without pain. Discussion. In this retrospective study, rhBMP-2 combined with a locking plate has been used successfully to treat children and adolescents with nonunion of the femur in four of five cases. One major complication was thought to be possibly related to its use.

Bone morphogenetic protein-2 for the treatment of congenital pseudarthrosis of the tibia or persistent tibial nonunion in children and adolescents: A retrospective study with a minimum 2-year follow-up.

There is a lack of studies reporting on rhBMP-2 application in pediatric orthopaedics, although few reports demonstrated promising results of the use of rhBMP-2 in children, especially for spine fusion and for the treatment of congenital pseudarthrosis of the tibia. The objectives of this study were (1) to examine clinical and radiographic healing after rhBMP-2 application for the treatment of congenital pseudarthrosis of the tibia (CPT) or persistent tibial nonunion in children and adolescents, and (2) to investigate the safety of rhBMP-2 use in these cases. Therefore we reviewed the medical records of ten patients with a mean age of 8.6 years (2.3-21) with CPT (n = 7) or persistent tibial nonunion for at least six months (n = 3) who had been treated with rhBMP-2. Nine of ten patients had union at final follow-up, after a mean of 72.9 months (25-127). In the CPT group, primary healing of the pseudarthrosis occurred in six of seven patients at a mean of 5.2 months (3-12). Repeat rhBMP-2 application was performed in three patients; two patients had one additional application each, and one patient had three additional applications. Complications that may be attributed to the use of rhBMP-2 were seen in two of fifteen applications, including a compartmemt syndrome and a hematoma. In this retrospective case series rhBMP-2 has been used successfully to treat CPT or persistent tibial nonunion in pediatric patients. However, prospective randomized controlled trials are warranted to investigate the long-term efficacy and safety of rhBMP-2 use in these cases.

Evaluation of complications associated with off-label use of recombinant human bone morphogenetic protein-2 (rhBMP-2) in pediatric orthopaedics.

The off-label use of recombinant human bone morphogenetic protein-2 to promote bone healing in adults has significantly increased in recent years, while reports of recombinant human bone morphogenetic protein-2 application in children and adolescents are very rare. The aim of this study was to evaluate the safety of single and repetitive recombinant human bone morphogenetic protein-2 use in pediatric orthoapedics. Therefore we reviewed the medical records of 39 patients who had been treated with recombinant human bone morphogenetic protein-2 at our institution. Their mean age was 10.9 years. Recombinant human bone morphogenetic protein-2 was used in 17 patients for spine fusion, in 11 patients for the treatment of congenital pseudarthrosis of the tibia or tibial nonunion, in 5 patients for the management of femoral nonunion, in 5 patients for nonunions at other locations, and in 1 case for tibial shortening. Special attention was paid to identify all adverse events that may be attributed to recombinant human bone morphogenetic protein-2 use, including local inflammatory reactions, allergic reactions, systemic toxicity, excessive wound swelling, hematoma, compartment syndrome, infection, heterotopic ossification, excessive bone growth, carcinogenicity, and the consequences of repeated applications of recombinant human bone morphogenetic protein-2. Follow-up was a mean of 39 months. Forty-six operations with application of rhBMP-2 were performed. Complications that may be due to application of recombinant human bone morphogenetic protein-2 were seen after 18 operations including swelling, increase in temperature, wound secretion, redness and hyperthermia. We consider the three cases of necessary revisions, one due to hematoma, one due to development of a compartment syndrome, and one due to deep infection, to be the only complications related to the use of recombinant human bone morphogenetic protein-2. In conclusion, we found few complications attributable to application of recombinant human bone morphogenetic protein-2 in pediatric patients.

Treatment of fixed knee flexion deformity by anterior distal femoral stapling.

PURPOSE: The treatment of fixed knee flexion deformity through anterior distal femoral stapling has been investigated in only two studies so far, with promising results. The aim of the present study was to determine whether this technique might improve fixed knee flexion deformity in a series of growing children and adolescents with different conditions. Follow-up examinations were continued after staple removal in terms of a possible impairment of this deformity. METHODS: We reviewed the medical records of all patients with fixed knee flexion deformity who had been treated by anterior distal femoral stapling at our institution. Twenty patients (37 knees) with a mean age of 12.7 years met the inclusion criteria (>12 months of follow-up; no additional procedures to correct fixed knee flexion deformity such as hamstring lengthening or posterior capsulotomy) and were evaluated in this study. RESULTS: The mean fixed knee flexion deformity significantly improved from 21.4° (SD = 11.6) preoperatively to 7.0° (SD = 9.8) after a mean follow-up of 35.3 months. Young patients (<12 years) revealed superior improvement of this deformity, and especially children with distinct fixed knee flexion deformity of 30° or greater had benefit from early treatment. Impairment of flexion deformity was only seen in one patient (2 knees) after staple removal. CONCLUSIONS: Our results demonstrate that anterior distal femoral stapling is an effective method for the treatment of fixed knee flexion deformity in growing children and adolescents. Rare complications, immediate mobilization, and a low recurrence rate after staple removal provide obvious advantages of this minimally invasive procedure. LEVEL OF EVIDENCE: Retrospective therapeutic study, Level IV.

Anterior femoral epiphysiodesis for the treatment of fixed knee flexion deformity in spina bifida patients.

BACKGROUND: Fixed knee flexion deformity is a common problem in spina bifida patients. Owing to interference with ambulation, this deformity may lead to anterior knee pain and progressive crouch gait. If conservative treatment fails, surgical procedures including supracondylar femoral extension osteotomy, joint distraction, and posterior capsulotomy have to be considered. Potential complications of these procedures are fractures, neurovascular lesions, knee instability, and recurrent deformity with continued growth. As fixed knee flexion deformity in spina bifida patients frequently occurs bilaterally, this results in higher perioperative and postoperative risks and prolonged recovery, making these relatively invasive methods less appealing. In the skeletal immature patient, anterior femoral stapling is a feasible method to treat fixed knee flexion deformity as could be shown in an earlier study. In this study, anterior femoral stapling was performed in a series of patients with diverse etiologies, and the overall success rate was then calculated. The aim of this study was to determine whether anterior femoral epiphysiodesis may improve fixed knee flexion deformity in a group of spina bifida patients. METHODS: Ten spina bifida patients with bilateral fixed knee flexion deformity (20 knees) were treated by anterior femoral epiphysiodesis through stapling. None of the patients received further knee procedures. The mean preoperative fixed knee flexion deformity was 20.3 ± 9.9 degrees (range: 10 to 40 degrees). Clinical and radiographic follow-up examinations were performed every 3 to 6 months after surgery. RESULTS: All patients except 1 experienced significant improvement with a mean correction rate of 0.9 ± 0.5 degrees per month (range: 0.2 to 1.9 degrees). The residual flexion deformity averaged 5.3 ± 5.3 degrees (range: 0 to 15 degrees; P<0.001). CONCLUSIONS: Anterior femoral epiphysiodesis through stapling is an effective and safe method for the treatment of fixed knee flexion deformity in growing children and adolescents with spina bifida. LEVEL OF EVIDENCE: Therapeutic Study, Level IV.