[Orthopaedic Treatment for Patients with Myelomeningocele]. / Orthopädische Behandlung bei Myelomeningozele.

BACKGROUND: Due to prenatal diagnostic and folic acid prophylaxis less children with myelomeningocele are now being born. But they become older and need increasingly more orthopaedic care. The orthopaedic care is aimed at the improvement or the preservation of function. METHOD: In this review the current knowledge from the literature and our approach are presented. This is done in the context of the functional aspects within certain periods of life. Treatment Concept: In the first two years of life, the mobility of MMC children is supported by physiotherapy and orthoses irrespective of the level of the lesion. Afterwards, the optimal orthoses are chosen depending on the muscle power, emerging bone deformities, associated CNS malformation, shunt revisions, obesity and limitations in perception as well as the child's motivation. At school age, it is paramount to encourage independence. Orthotic treatment should be continued as long as the children benefit from it. Orthopaedic operations serve the orthosis fitting and the avoidance of pressure sores. Pathological fractures are common. They should be rapidly recognised in order to avoid further bony deformities. CONCLUSION: The aim of any orthopaedic treatment consists of the avoidance of musculoskeletal deformities in order to support the patient's self employment.

[Epiphyseolysis of the femoral head: new aspects of diagnostics and therapy]. / Epiphyseolysis capitis femoris : Neue Aspekte in Diagnostik und Therapie.

BACKGROUND: Slipped capital femoral epiphysis (SCFE) is the most common hip disease in adolescents and is always surgically treated with the aim to avoid further slippage and to reduce the risk of degenerative arthritis at young age. OBJECTIVES: A summary of the etiology, pathogenesis, clinical features, radiographic imaging and current therapy concepts is given. MATERIAL AND METHODS: A selective review of the literature was performed. RESULTS: With an increasing body mass index in adolescents the incidence of SCFE also increases. The diagnostic routine is comprised of a clinical examination with the evaluation of Drehmann's sign and a radiographic evaluation including anterior-posterior aspect and frog's legs view. In situ stabilization with a single screw is the standard treatment for the most prevalent mild or moderate stable slippages. In cases of acute slippage a gentle reduction maneuver may be attempted. Hardware removal must not be performed before epiphyseal closure. Common bilateral but not simultaneous occurrence of the disease requires prophylactic pinning of the unaffected side by default, at least in central Europe. Various surgical treatment options exist to reduce the femoroacetabular impingement caused by the slippage. CONCLUSIONS: Current treatment algorithms result in satisfactory long-term outcomes. If the risk of developing degenerative arthritis after SCFE may be reduced even more with modern arthroscopic or open surgical procedures to restore the anatomic pre-slip conditions has to be confirmed through further long-term studies. The implementation of programs to prevent obesity in adolescents may also reduce the incidence of SCFE.

[Congenital hip dysplasia in newborns : Clinical and ultrasound examination, arthrography and closed reduction]. / Kongenitale Hüftluxation bei Neugeborenen : Klinische und sonographische Untersuchung, Technik der Arthrographie und geschlossenen Reposition.

OBJECTIVE: Early diagnosis and rapid closed reduction under arthrographic control to initiate retention in a new position during the interval of maximum subsequent maturation power. This allows a (nearly) physiological ripening of the femoral head and acetabulum (AC) with restoration of the congruence of the joint partners (containment) and joint stability. INDICATIONS: Clinically- and ultrasound-proven dislocation of the hip in the newborn. CONTRAINDICATIONS: Increased bleeding, increased risk of anesthesia due to immaturity/prematurity, inability to use a retention cast due to malformations of the urogenital system, spinal deformities, or hernias requiring treatment or supervision. SURGICAL TECHNIQUE: Palpation of the tuberosity of the ischium in 110° flexion and 40-50° abduction of the leg and then puncture lateral to this point. Advance the needle parallel to the plane of the table in the direction of the empty acetabulum and x-ray control. Control of intra-articular needle position by injection of isotonic saline solution. Test reflux by disconnection. Cautious instillation of 0.2-0.4 ml of contrast medium under X-ray control. Closed reduction under X-ray control by pulling slightly, flexion and abduction of the hip joint. Cast applied in approximately 110° hip flexion and 40° abduction. POSTOPERATIVE MANAGEMENT: MRI control on postoperative day 1. Spica cast for 4 weeks. Then cast removal, clinical and ultrasound examination and immediate start of further treatment with a hip splint in 110° hip flexion and 30-40° abduction. Ultrasound follow-up every 3-4 weeks. RESULTS: A total of 40 patients (female:male = 33:7) with 49 hip dislocations were analyzed. The mean age at reduction was 73 days (range 1-334 days). In 21 cases, treatment was started at another hospital. Intra- or immediate postoperative complications were not detectable. According to the control MRI on the first postoperative day, the cast had to be removed in 7 cases (17.7 %) due to insufficient reduction, although no classical need for repositioning could be identified in the MRI analysis. Instead, compared to cases with sufficient hip reduction, significantly reduced acetabular articular surfaces were found, so that in these cases, a lack of stability due to the lack of congruency between the femoral head and the AC must be considered. Signs of a fulminant avascular necrosis (AVN, grade 3 and 4 according to Kalamchi) and a pathological acetabular angle (grade 3 and 4 according to Tönnis) were observed during follow-up in 17.3 and 40.7 % of cases, respectively.

[Growth and deformity after in situ fixation of slipped capital femoral epiphysis]. / Wachstum und Deformität nach In-situ-Fixation der Epiphyseolysis capitis femoris.

BACKGROUND: For mild to moderate slipped capital femoral epiphysis (SCFE) in situ fixation is the current treatment standard. However, concerning the implant selection (screw versus k-wires) as well as the prophylactic stabilisation of the non-affected hip, controversies still exist. The aim of this study was to analyse femoral residual growth and femoral deformities after in situ fixation of SCFE either with k-wires or screws. PATIENTS AND METHODS: We conducted a retrospective analysis of the radiographs of adolescents treated for SCFE in our department between 01/2003 and 02/2011. To evaluate femoral growth the articulo-trochanteric distance, centro-trochanteric distance, caput-collum-diaphyseal angle, pin-joint ratio and pin-physis ratio were determined. The femoral deformity was assessed by measuring the sphericity of the femoral head. Degenerative changes were evaluated in the final radiographs. Statistical analysis was performed concerning differences between therapeutically and prophylactically treated hips as well as stabilisations with k-wires and screws. RESULTS: A total of 22 patients (female : male = 14 : 8, mean age girls: 11 ± 1 years, boys: 13 ± 2 years) with 26 slipped capital femoral epiphyses was analysed. K-wires were used for fixation in 4 hips each therapeutically and prophylactically, 22 hips with SCFE and 14 non-affected hips were stabilised with screws. Treatment with screws did not lead to significantly earlier physeal closure than k-wire pinning. Regarding the femoral growth parameters a significant decrease in the articulo-trochanteric distance and CCD angle was detectable in all groups. The pin-joint ratio revealed an adequate residual growth in 58 % of the therapeutically and in 72 % of the prophylactically treated hips without significant difference between k-wires and screws. The pin-physis ratio demonstrated similar values. Regarding the femoral deformity the SCFE hips resulted in a significantly reduced sphericity, which remained unchanged during follow-up. The prophylactic stabilisation did not result in any deterioration of sphericity. CONCLUSION: The results of this study imply that further growth of the proximal femur after insertion of a sliding screw for in situ stabilisation of mild to moderate slipped capital femoral epiphysis does occur. Furthermore, an increase of deformity during follow-up through screw fixation as compared to pinning was not noticed. Hence, the assumption that screw fixation leads to permanent physeal impairment cannot be confirmed. The consideration of these results may be helpful for implant selection as well as indicating prophylactic surgery for non-affected hips.

[Comparison of treatment results of idiopathic and non-idiopathic congenital clubfoot : prospective evaluation of the Ponseti therapy]. / Vergleich der Behandlungsergebnisse bei kongenitalen idiopathischen und nichtidiopathischen Klumpfüßen : Prospektive Evaluation der Ponseti-Therapie.

BACKGROUND: Clubfoot deformity is one of the most common congenital musculoskeletal deformities and occurs in newborns with different neuromuscular diseases. To date the Ponseti method is the gold standard for the treatment of idiopathic clubfeet but not for non-idiopathic clubfeet which are associated with neuromuscular diseases. The results of the treatment for congenital idiopathic and non-idiopathic clubfeet according to Ponseti performed in our department since 2004 were compared concerning results and relapse surgery with particular reference to the compliance of the parents concerning the use of an abduction splint. PATIENTS AND METHODS: A total of 101 children (28 female and 73 male) with 159 clubfeet were treated with the Ponseti method and included in this prospective non-randomized cohort study. Of these children 27 with 48 affected feet suffered from neuromuscular diseases which are associated with clubfoot deformity, such as myelomeningocele (n=4), arthrogryposis (n=9) and various other syndromes (n=14). The degree of the deformity was evaluated with the Pirani score initially, after casting and at follow-up. Parents were asked at follow-up to state subjectively how compliant they were with the abduction splint treatment. The necessity of surgical treatment of relapses was recorded. Statistical analysis was performed applying χ(2) and Kruskal-Wallis tests for the comparison of idiopathic and non-idiopathic clubfeet. RESULTS: The average period of follow-up was 36 month (range 6-75 months) and non-idiopathic clubfeet were initially significantly more severely deformed according to the Pirani-score (p=0.013). Treatment of non-idiopathic clubfeet was started significantly later than that of idiopathic clubfeet (p=0.003) and took significantly longer (p <0.001). A correlation between the initiation of casting and the duration of casting was not found (p=0.399). At the end of the casting period no significant differences were found between correction of idiopathic and non-idiopathic clubfeet with respect to the Pirani score (p=0.8). The mean score after casting was 0.1 in both groups. At mid-term follow-up the score increased in both groups but stayed below 0.5 with non-idiopathic clubfeet showing a significantly higher score than idiopathic clubfeet (p=0.014). Relapse surgery was necessary in 11% of the patients. No significant difference in the revision rate was found between the two groups (p=0.331) and peritalar release was not necessary in either group. The rate of revisions correlated with the compliance concerning the use of the abduction splint (p <0.001). Only 61% of the parents stated that they adhered strictly to the abduction splint treatment recommendations with no significant difference between the groups (p=0.398). CONCLUSION: This study shows good initial results after Ponseti treatment for idiopathic as well as non-idiopathic clubfeet. Based on the good functional results all clubfeet should initially be treated with the Ponseti method regardless of the etiology.

[Do German-speaking paediatric orthopaedic surgeons agree on diagnostics and treatment of the neonatal hip?]. / Diagnostik und Therapie der Säuglingshüfte - sind sich die deutschsprachigen Kinderorthopäden einig?

BACKGROUND: Ultrasound examination of the neonatal hip has been an integral part of the German programme for the "early detection of disease in childhood" since 01.01.1996. The aim of this study is to determine if any consensus exists among German-speaking paediatric orthopaedic specialists concerning diagnosis and treatment of the neonatal hip 15 years after legal implementation of hip ultrasound screening by the Graf technique. MATERIALS AND METHODS: A questionnaire was sent to all members of the German speaking Association of Paediatric Orthopaedic Surgeons (Vereinigung für Kinderorthopädie - VKO). The query included questions concerning education and field of activity of the member as well as information on the diagnostics of neonatal hip with regard to examiner, technical equipment, and type of screening. In addition, four cases were presented with clinical history, clinical findings, and rateable Graf sonogram (case 1: 3 days old ♀, type D; case 2: 2 days old ♀, type IV; case 3: 4 weeks old ♀, type II a; case 4: 4 months old ♀, type III a) and a treatment recommendation was requested for each case. RESULTS: 78 of 179 contactable VKO members participated in this survey. 75.6 % of the participants are specialists with additional qualification in paediatric orthopaedic surgery. 68 % of the participants work in a hospital. As stated by 61.5 % of the participants the ultrasound examination of the neonatal hip is primarily done by orthopaedic surgeons. One participant stated that the examination is performed primarily by medical-technical assistants. The majority of participants use a 7.5-MHz linear transducer for ultrasound examination, a positioning device according to Graf and a foot switch as technical equipment. State-of-the-art equipment as recommended by Graf including in addition to the above mentioned an upright image display and a transducer guiding arm system is available to only 21.8 % of the participating VKO members. 23 of 50 participants stated that a general screening is performed at their institution where all newborns get an ultrasound examination within the first week of life regardless of medical history and clinical findings. Therapeutic recommendations for the first case (type D hip) were in 15.4 % wait and check by some colleagues, supplemented by double diapering. 56.4 % would use a flexion-abduction splint and 26.9 % would perform reduction with consecutive retention. To treat case 2 (type IV hip) 3.8 % of participants suggest a flexion-abduction splint and 88.5 % reduction and retention. Concerning the type of reduction the participants do not agree. Pavlik harness as well as closed reduction under anaesthesia or without anaesthesia is recommended. In case 3 (type II a hip) 67.9 % of the colleagues suggest to wait and check, some with supplementary double diapering. 25.6 % suggest a flexion-abduction splint. One colleague would prescribe a Pavlik harness. In case 4 (type III a hip) 14.1 % of the participants suggest a flexion-abduction splint, 80.8 % reduction and retention as described before with disagreement concerning the preferred type of reduction. On combining the therapeutic suggestions for all four cases, 66 % of the participants recommend a type of treatment that is concordant with Graf's guidelines. CONCLUSION: Despite the existence of clear recommendations the German-speaking paediatric orthopaedic surgeons are quite discordant concerning diagnostics and treatment of the neonatal hip. Uncertainty particularly concerning the evaluation of sonograms of physiologically immature and dysplastic-unstable hips bears the risk of overtreatment as well as of delayed diagnosis of hip dysplasia.

[Locking plates for osteosyntheses of corrective osteotomies in paediatric orthopaedic and neuroorthopaedic patients]. / Winkelstabile Implantate zur Osteosynthese nach Korrekturosteotomien in der Kinder- und Neuroorthopädie.

BACKGROUND: Modern locking plates are widely used for the treatment of adult orthopaedic and trauma patients. Sporadic descriptions of their advantages now exist for paediatric trauma patients. Publications concerning their implantation in paediatric orthopaedic and neuroorthopaedic patients are still scarce even though it is well known that the compliance of children and adolescents is limited and that rapid mobilisation is essential for patients with disorders of neurological origin or bone metabolism to avoid developmental setbacks and perioperative fractures. PATIENTS AND METHODS: The principle of the locking plate system also described as internal fixateur is based on the thread bolting of the screwheads within the plate. This results in high initial stability and thus high initial loading capacity. Furthermore, it is possible to preserve soft tissue and periosteum which leads to less impaired biological bone healing. Between February 2008 and March 2010 locking plates were used for osteosynthesis in our department in 16 paediatric patients with 20 corrective osteotomies. All patients suffered from either neurological disorders or diseases with alteration of the bone metabolism. The outcome was analysed concerning safety, complications, practicability, mobilisation, consolidation of the osteotomy, loss of correction, as well as complications with the removal of the implants. RESULTS: Seven of the treated patients suffered from neurological disorders such as cerebral palsy or spina bifida, 9 patients had diseases with local or systemic alteration of their bone metabolism such as vitamin D deficiency and phosphate diabetes. The average age of the patients at the time of surgery was 11.18 (5-18) years. Implant-associated complications were not seen in this patient group, especially no implant failures. Mobilisation was achieved without cast treatment with at least partial weight-bearing within the first postoperative week in most cases. Loss of correction or problems with implant removal did not occur. 18 of the 20 osteotomy sites were completely healed at the 12 week follow-up. CONCLUSION: Locking plates are a safe and effective treatment device not only for adult trauma patients but also for the treatment of children and adolescents. When stabilisation of corrective osteotomies is performed with locking plates especially young patients benefit from this technique since mobilisation can be started earlier as compared to the use of non-angle stable plates or wires and cast immobilisation becomes unneccessary. The surgeon needs to know the range of products to pick the best implant regarding the growing skeleton's special anatomy. When choosing implants for patients with reduced bone density or impaired motor abilities as in cerebral palsy, spina bifida, and other systemic disorders, locking plates have to be taken into account to facilitate mobilisation and to avoid setbacks in motor development as well as pressure ulcers from casts. Clinical studies have to evaluate if early mobilisation combined with shorter inpatient treatment and less time and cost consuming postoperative physiotherapy or rehabilitation justify the use of the more expensive locking plates for the treatment of otherwise healthy patients.

[Modified acetabuloplasty using bioresorbable screws and lyophilised allogenic bone]. / Modifizierte Azetabuloplastik unter Verwendung von bioresorbierbaren Schrauben und lyophilisiertem allogenem Knochen.

AIM: Various pericapsular procedures are available to surgically improve the acetabular coverage of the femoral head prior to closure of the triradiate cartilage. In this study the acetabuloplasty with the modification according to Westin (Pember-Sal) was applied. Indications for surgery were congenital hip dysplasia or luxation as well as Perthes' disease. To date, the standard procedures for acetabuloplasty include the transplantation of an autologous iliac crest bone graft and the fixation with K-wires. The aim of this study was to investigate if a modification of the operative procedure with the use of resorbable screws and allogenic bone transplants can minimise the operative trauma, avoid a second procedure, and permit MRI follow-ups without increasing the risk of the operation. METHOD: 15 patients with a mean age of 6.7 years were included in this case series and treated with a modified acetabuloplasty for the indication hip dysplasia or Perthes' disease. The modification of the standard procedure included the transplantation of allogenic bone wedges customised from lyophilised femoral grafts. The fixation was performed with bioresorbable polylactide screws. Clinical and radiographical follow-ups were conducted. RESULTS: Procedure-related complications occurred neither in the intra- nor the postoperative period. The allogenic bone graft was remodelled successively as seen on radiographic controls. Dislocations of the bone wedges were not detectable. Subsiding of the allograft did not occur to a noticeable extent as the acetabular index showed no increase during follow-up. CONCLUSION: This study presents a gentle method of acetabuloplasty which avoids iliac crest bone harvesting with its known complications as well as a second procedure under anaesthesia for the removal of implants.

[Promotion of bone healing through clinical application of autologous periosteum derived stem cells in a case of atrophic non-union]. / Klinische Anwendung von autologen Periostzellen zur Förderung der Knochenheilung bei atropher Pseudarthrose--Kasuistik.

This case report describes the application of periosteum-derived mesenchymal stem cells in a patient with atrophic non-union of the distal femur after correction osteotomy. While biomechanical treatment devices for various bone defects are available in abundance, biological promoters for clinical application in situations of critical bone healing are still scarce. We showed radiographically that cultivated autologous periosteal bone precursor cells on a three-dimensional matrix can promote bone healing in a defect where numerous established methods had failed to lead to consolidation. To the best of our knowledge, this is the first clinical application of in-vitro cultivated autologous periosteum-derived cells for the healing of a large bone defect in humans.