Epidemiology and injury morphology of traumatic hip dislocations in children and adolescents in Germany: a multi-centre study.

OBJECTIVE: Traumatic hip dislocations are very rare in childhood and adolescence. The aim of this multi-centre study is to analyse the current epidemiology and injury morphology of a large number of traumatic hip dislocations in children. This can provide a better understanding of childhood hip dislocations and contribute to the development of a therapeutic approach in order to prevent long-term impacts. METHODOLOGY: This retrospective, anonymised multi-centre study included patients, aged up to 17 years, with acute traumatic hip dislocations and open growth plates. The patients came from 16 German hospitals. Exclusion criteria included insufficient data, a positive history of hip dysplasia, or an association with syndromal, neurological or connective tissue diseases predisposing to hip dislocation. An analysis was carried out on the patients' anthropometric data and scans (X-ray, MRI, CT), which were collected between 1979 and 2021. Gender, age at the time of dislocation, associated fractures, mechanism of injury, initial treatment including time between dislocation and reduction, method of reduction, treatment algorithm following reduction and all documented complications and concomitant injuries were evaluated. RESULTS: Seventy-six patients met the inclusion criteria. There were two age peaks at 4-8 years and 11-15 years. There was an increased incidence of girls in the under-eight age group, who had mild trauma, and in the group of over-eights there were more boys, who had moderate and severe trauma. Dorsal dislocation occurred in 89.9% of cases. Mono-injuries dominated across all age groups. Concomitant injuries rarely occurred before the age of eight; however, they increased with increasing ossification of the acetabulum and appeared as avulsion injuries in 32% of 11-15-year-olds. Of the 76 patients, 4 underwent a spontaneous, 67 a closed and 5 a primary open reduction. A reduction was performed within 6 h on 84% of the children; however, in around 10% of cases a reduction was not performed until after 24 h. Concomitant injuries needing intervention were identified in 34 children following reduction. Complications included nerve irritation in the form of sensitivity disorders (n = 6) as well as avascular necrosis (AVN) of the femoral head in 15.8% of the patients (n = 12). CONCLUSIONS: Traumatic hip dislocations are rare in childhood and adolescence and have high complication rates. The most severe complication, femoral head necrosis, occurred in 16% of cases. Minor injuries, especially in younger children, are enough to cause a dislocation. Posterior dislocation was more frequent and primarily occurred as a mono-injury; however, concomitant injuries must be considered with increasing age. Children continue to experience delayed reductions. The length of time until reduction, age and the severity of the concomitant injury play a role in the development of femoral head necrosis; however, this topic requires additional investigation.

Fractures of the Humeral Ulnar Condyle in Children - a Rare but Complicated Injury. / Die Condylus-ulnaris-humeri-Fraktur des Kindes ­ eine seltene, aber komplikationsträchtige Verletzung.

BACKGROUND: Ulnar humeral condyle fractures are rare paediatric elbow fractures, classified as Salter-Harris IV paediatric elbow injuries. Due to constant radiological changes in the elbow with varying manifestation of ossification centres as well as late ossification of the trochlea, diagnosis of these injuries is challenging. To avoid long-term complications, the treating surgeon should be familiar with the rare injury picture, diagnostics and adequate therapeutic measures. MATERIAL AND METHODS: The present retrospective study includes data on all paediatric cases from 2002 to 2019 with primary or secondary treatment at a paediatric traumatology centre for ulnar condyle fracture with a minimum follow-up of 12 months. Range of motion, joint stability under valgus and varus stress as well as axial ratios of the injured and uninjured side were evaluated in a clinical follow-up examination. The Mayo Elbow Performance Score was used to objectify functional results. RESULTS: 20 children, average age 8.6 years (4 - 13) and average follow-up time 25 months, were included. Radiological evaluation based on Jakob and Fowles classification revealed a type I fracture in three cases, a type II fracture in one case and a type III fracture in 16 cases. Three cases were treated nonoperatively with an upper arm cast. 17 children were treated with open reduction and internal fixation. Diagnosis of three fractures was delayed. No postoperative complications such as infections, nerve damage or nonunions. 15 children showed free elbow function. Three children showed slightly restricted elbow extension by less than 10° and two by 10°-20°. All children showed free pro/supination. 18 children showed a physiological and bilaterally identical arm axis compared to the uninjured side. Two children showed a slightly increased cubitus valgus with a 5 - 10° difference between sides. Radiologically, two children with delayed fracture treatment showed partial necrosis of the trochlea. The Mayo Elbow Score showed good (2) to excellent results in all children (18). CONCLUSION: Very good clinical and functional results can be expected if the injury is diagnosed without delay followed by adequate therapy. Misdiagnosis of ulnar condyle fractures can be associated with the development of nonunions and functional restrictions as well as, after operative therapy, trochlear necrosis. Children up to the age of 6 in particular are at risk of misdiagnosis due to faulty assessment of the cartilaginous trochlea.

Juvenile osteochondritis dissecans of the talus: predictors of conservative treatment failure.

BACKGROUND: The ideal treatment for juvenile osteochondritis dissecans of the talus (ODT) is still unclear. To determine predictors of failure of conservative treatment, children admitted for ODT were retrospectively analyzed. METHODS: Patient files were analyzed to search for children treated for an ODT between 2000 and 2011. X-rays and MRI at baseline were evaluated for grading of lesions and the patient history was obtained. Final follow-up evaluation was performed via questionnaire and complementary telephone interview. Outcome was measured using the AOFAS and the Olerud/Molander scores. Conservative treatment consisted of out of sports and modification of activity under full weight-bearing. In case of persisting pain, full load removal on crutches was initiated. For further analysis, two groups were formed: (1) successful conservative treatment; (2) converted to surgical therapy. A logistic regression was used to determine potential predictors of conservative treatment failure. RESULTS: Seventy-seven lesions in 67 children with a mean age of 11.4 years (range 4-15 years) at the time of diagnosis were identified. Every patient received conservative treatment as a first-line treatment after diagnosis of ODT except for one single patient with a grade IV lesion at time of diagnosis who received operative treatment directly after diagnosis. Sixty-one percent of the lesions failed conservative treatment. A higher age as well as a grade III lesion at time of diagnosis was predictive for failure of the conservative treatment (p = 0.03 and p = 0.02, respectively). Regarding the functional outcome, a higher grade lesion in general was predictive for an inferior outcome as measured by clinical score. CONCLUSION: Grade III ODT especially in older children leads significantly more often to treatment failure when treated non-surgically. No other predictors for treatment failure could be identified. LEVEL OF EVIDENCE: Level III (retrospective comparative study).

Arthroscopic reduction and acetabuloplasty for the treatment of dislocated hips in children of walking age: a preliminary report.

INTRODUCTION: This paper presents our initial findings on the use of arthroscopic hip reduction in conjunction with acetabuloplasty to treat patients of walking age who had congenital dislocation of the hip. MATERIALS AND METHODS: Arthroscopic reduction with acetabuloplasty was performed on nine children of walking age with nine dislocated hips. The average age of the patients was 21.4 months (14-41 months). Arthroscopic reduction was performed using a two-portal method with a 2.7-mm mini cannulated arthroscopic instrument. We used a subadductor portal and a high anterolateral portal. The obstacles preventing reduction-hypertrophic teres ligament, pulvinar, capsular constriction, hypertrophic transverse ligament-were eliminated. RESULTS: We treated one grade 4 hip, four grade 3 hips and four grade 2 hips, as classified by Tönnis. We were able to perform arthroscopic reduction on all of the hips. The main obstacles preventing reduction were a capsular constriction and a hypertrophic teres ligament. During the investigation period, which averaged 15.4 months (6-29 months), no repeat dislocation occurred. According to the Tönnis classification system for avascular necrosis, there were two cases of a grade 2 necrosis of the femoral head. The average preoperative AC angle was 40° (34°-47°). The average AC angle at the follow-up examination was 18.7° (11°-27°). CONCLUSIONS: We can conclude that the standardized arthroscopic surgical technique presented here can also be used to safely perform arthroscopic reduction in toddlers. The new arthroscopic method is an alternative to open reduction for selective hip dislocations. We believe this approach can be used to treat dislocated hips that are classified as grades 2 and 3 dislocations according Tönnis. Early results are promising. Medium-term results are needed to make a definitive statement on the rates of necrosis of the femoral head.

The talar axis-first metatarsal base angle in CVT treatment: a comparison of idiopathic and non-idiopathic cases treated with the Dobbs method.

PURPOSE: Congenital vertical talus (CVT) appears as an idiopathic or non-idiopathic deformity. In this study, we analysed the talar axis-first metatarsal base angle (TAMBA) values of idiopathic and non-idiopathic CVT cases treated with the Dobbs method. MATERIALS AND METHODS: Between January 2007 and July 2012, 20 cases of CVT were treated, starting with a manipulation, casting and a minimally invasive surgical approach. We analysed retrospectively the TAMBA values in idiopathic and non-idiopathic CVT. As a new indicator for the mobility in the talonavicular complex, we used the difference of the TAMBA in neutral position and the TAMBA in plantarflexion. TAMBA measurements of CVT successfully treated with the Dobbs method were compared to TAMBA values of CVT unsuccessfully treated using a minimally invasive approach. RESULTS: Out of 20 CVT, 14 were successfully treated with the Dobbs method. Of these 14, five feet were non-idiopathic and nine feet were idiopathic. Six feet did not have complete correction following the Dobbs protocol, and were associated with arthrogryposis or caudal regression syndrome. The initial TAMBA in idiopathic feet ranged from 70 to 110° (mean 88°). The TAMBA in non-idiopathic feet ranged from 75 to 128° (mean 105). Feet successfully treated with the Dobbs method had an initial TAMBA between 74 and 110° (mean 87°). Feet unsuccessfully treated with the Dobbs method had an initial TAMBA between 95 and 128° (mean 118°).The measurement difference between the TAMBA in neutral and plantarflexion positions in cases unsuccessfully treated with the Dobbs method were smaller compared to values of feet successfully treated with the Dobbs method. These differences were statistically significant (p < 0.0001). CONCLUSION: In our series, the success of the Dobbs method in CVT treatment depended on the flexibility in the talonavicular complex. The TAMBA value and TAMBA difference (TAMBA neutral minus TAMBA plantarflexion) express the flexibility in the talonavicular joint and could be predictive for the success of a minimally invasive treatment. Only in a few cases is the success of the Dobbs method limited. These feet are associated with a TAMBA greater than 120° in neutral position and, particularly, a TAMBA difference smaller than 25°.