[Surgical treatment of congenital muscular torticollis]. / Operative Behandlung des Torticollis muscularis congenitus.

OBJECTIVE: Surgical treatment of congenital muscular torticollis with tripolar release of the sternocleidomastoid muscle, followed by modified postoperative treatment with a special orthosis. INDICATIONS: Muscular torticollis due to contracture of the sternocleidomastoid muscle; failure of conservative therapy. CONTRAINDICATIONS: Torticollis due to bony anomaly or other muscular contractures. SURGICAL TECHNIQUE: Tenotomy of the sternocleidomastoid muscle occipitally and resection of at least 1 cm of the tendon at the sternal and clavicular origin. POSTOPERATIVE MANAGEMENT: Orthosis must be worn for 6 weeks 24 h/day, then for another 6 weeks 12 h/day. RESULTS: A total of 13 patients were treated with tripolar release of the sternocleidomastoid muscle and modified postoperative management. Average follow-up time was 25.7 months. One patient presented with recurrence after 3 years. No intra- or postoperative complications were observed.

Preoperative embolization of renal cell carcinoma metastases to the bone prior to stabilization procedures does not result in reduction in intraoperative blood loss.

PURPOSE: The effect of preoperative embolization of bone metastases prior to stabilization procedures in reducing intraoperative blood loss remains controversial. This study aimed to analyze the effect of preoperative embolization on orthopedic stabilization procedures of the extremities and spine in cases with bone metastases from renal cell carcinomas. In particular, do these patients suffer less blood loss during the operation and do they need lesser fluid replacements or packed red cell bags intra- and perioperatively? Does preoperative embolization reduce the duration of surgery? METHODS: We retrospectively reviewed stabilization procedures of the spine and extremities at our institution between 2011 and 2021 for group differences (embolization vs. no embolization) in terms of blood loss, fluid substitution, need for packed red cell transfusions, tumor size, and duration of surgery. RESULTS: We reviewed 79 stabilization procedures of the spine (n = 36) and extremities (n = 43), of which 30 included preoperative embolization procedures. Surprisingly, the embolization group showed a statistically significant increase in blood loss, the need for fluid substitution, and red cell transfusions. Subgroup analysis revealed a significant negative effect of preoperative embolization on stabilization procedures of the extremities. CONCLUSION: Based on our data, preoperative embolization of renal cell carcinoma metastases of the extremities had a negative effect on intraoperative blood loss and the need for fluid substitution and should therefore be avoided. Our data did not show an effect on stabilization procedures of the spine.

Intramedullary Nailing Versus Compound Plate Osteosynthesis in Pathologic Diaphyseal Humerus Fractures: A Retrospective Cohort Study.

BACKGROUND AND OBJECTIVES: Pathologic fractures of the extremities due to carcinoma metastases require individual and patient prognosis-related stabilization procedures. Considering the anatomic features of the humerus, implant material stability is less critical than femoral fractures because of less weight-bearing stress. Therefore, operation length, blood loss, and quick recovery of function are of greater interest. In this retrospective cohort study, we evaluated and compared the outcomes of compound plate osteosynthesis and intramedullary (IM) nailing while managing diaphyseal pathologic fractures of the humerus. METHODS: We retrospectively reviewed patients treated at our institution for pathologic fractures of the diaphyseal humerus between 2010 and 2021 for group differences (plate osteosynthesis vs. IM nailing) in terms of blood loss, length of operation, implant survival, and upper extremity function. RESULTS: We reviewed 42 stabilization procedures due to pathologic diaphyseal humerus fractures, with a mean follow-up of 8.5±15.4  months. IM nailing (n=20) showed a significantly lower blood loss (266.7±23.7 mL) than plate osteosynthesis (n=22, 571.1±92.6 mL). We did not detect statistically significant differences in the complication rate, length of operation, or Musculoskeletal Tumor Society score. CONCLUSION: Our findings suggested that diaphyseal fractures of the humerus should be stabilized using an IM nail rather than plate osteosynthesis due to lower blood loss, while complication rate, implant survival, and length of operation remain indifferent.

[Minimally invasive tibialis anterior tendon transfer in shuttle technique for the treatment of clubfoot recurrence in adolescent patients]. / Minimalinvasiver Tibialis-anterior-Sehnentransfer in Shuttle-Technik zur Behandlung des Klumpfußrezidivs im Wachstumsalter.

OBJECTIVE: Tibialis anterior transfer in shuttle technique using the tunnelator is an atraumatic surgical technique without injuring the extensor retinaculum. The technique allows for postoperative treatment with pain-adapted full weight-bearing for 6 weeks in a lower leg cast which is simplified compared to the current literature. INDICATIONS: Passive, correctable clubfoot recurrences in the event of muscular imbalance (overbalanced anterior tibial muscle). CONTRAINDICATIONS: Structural movement restrictions of the foot, muscular insufficiency of the anterior tibial muscle, infection or cancerous lesions in the surgical site. SURGICAL TECHNIQUE: Loosen the tibialis anterior muscle at the base of the first metatarsal. Guide the tendon proximally out of the extensor retinaculum, then shuttle the tendon below the retinaculum with the help of the "tunnelator" and transosseous fixation at the lateral cuneiform. POSTOPERATIVE MANAGEMENT: Pain-adapted full weight-bearing in a lower leg walking cast for 6 weeks postoperatively. RESULTS: In the course of a retrospective study, the above-mentioned surgical procedure was carried out in 20 patients (total n = 26 surgeries) between 2013 and 2019. After a follow-up of 12 months, complete correction of the clubfoot relapse was found in 88.5% of cases. There were no general or specific surgical complications.

Mid-term Follow-Up after Closed Reduction in Developmental Dysplastic Hips.

PURPOSE: Closed reduction and subsequent spica casting is the gold standard for treatment of unstable or dislocated developmental dysplastic hips (DDHs). There are few data on mid-term results after treatment of DDH, especially on closed reduction. METHODS: Thirty-one consecutive patients with unstable or dislocated hips (n = 36) that were treated by fluoroscopic, contrast agent-supported closed reduction and spica casting were included and evaluated clinically and radiologically 2 and 5 years after treatment. RESULTS: After 2 and 5 years, there were no significant differences between healthy and successfully treated hips that were detectable with respect to acetabular coverage (AC) angle, center-edge angle, and clinical stability of the hip. There was a significant difference at the 2-year follow-up between healthy hips and hips that needed to undergo secondary open reduction surgery (n = 4) with respect to the AC angle (p < 0.001). CONCLUSION: Closed reduction in DDHs results in acceptable clinical and radiological results in the mid-term follow-up. It remains unclear why some patients with subsequent sonographically matured hips show secondary deterioration and recurrence of dysplasia.

Is Prematurity a Protective Factor Against Developmental Dysplasia of the Hip? A Retrospective Analysis of 660 Newborns.

PURPOSE: In Middle Europe developmental dysplasia of the hip (DDH) has an incidence of up to 5.9 %. The rate of congenital hip dislocation as the worst complication of a growth disorder of the hip is between 1.5 % and 2.5 %. Among known risk factors of DDH are breech position, multiples, foot deformities and family history. The aim of this retrospective study was to investigate prematurity as a risk factor for developmental dysplasia of the hip (DDH). MATERIALS AND METHODS: The hips of 283 infants who were born before the 38th week of gestation or earlier, and those of 377 infants who were born after the 37th week of gestation, none of whom had other risk factors for DDH, were compared using the ultrasound technique according to Graf et al., within the first week after birth. Both hips of all infants were included in the study. RESULTS: Surprisingly, the difference in alpha angles between the two groups was statistically extremely significant, favoring the preterm infants. Moreover, we found a physiological curve of alpha angle development with a peak after the 31st week of gestation. The incidence of pathological dysplasia was not significantly different in the two groups. CONCLUSION: Our results suggest that prematurity is not a predisposing factor for DDH, but rather is protective for hip development.

[Extension osteotomy of the lateral distal femur using the contralateral TomoFix® plate]. / Laterale distale femorale Extensionsosteotomie mit der kontralateralen TomoFix®-Platte.

OBJECTIVE: Supracondylar distal femoral osteotomy. Fixation with the contralateral TomoFix® (Fa. DePuy Synthes, Oberdorf, Switzerland) lateral distal femur plate. Use of the laterally reversed plate to improve the reconstruction of the sagittal anatomical axis of the leg. INDICATIONS: To correct knee flexion contractures with a deficiency of extension >20° at the age of 10 years. CONTRAINDICATIONS: Surgical site infections or tumors. SURGICAL TECHNIQUE: Ventral closed wedge osteotomy of the distal femur. Implantation of the locking compression TomoFix® lateral distal femur plate. POSTOPERATIVE MANAGEMENT: Full weight bearing. RESULTS: In all, 16 distal femoral osteotomies were performed in 9 patients. All patients had knee flexion contraction due to neurological disease. Patients with cerebral palsy showed a better GMFCS (gross motor function classification scale) level after surgery. Hardware was removed after 11.5 months (range: 9-18 months).

Biomechanical evaluation of temporary epiphysiodesis at the femoral epiphysis using established devices from clinical practice.

The aim of this study is to compare biomechanical features of different devices used in clinical routine for temporary epiphysiodesis (eight-Plate® and FlexTackTM). The tested implants were divided into four different groups (eight-Plate® vs. FlexTackTM for lateral and anterior implantation) á 10 samples for testing implanted eight-Plate® vs. FlexTackTM in fresh frozen pig femora for maximum load forces (Fmax) and axial physis distance until implant failure (lmax). A servo hydraulic testing machine (858 Mini Bionix 2) was used to exert and measure reproducible forces. Statistical analyses tested for normal distribution and significant (p < 0.05) differences in primary outcome parameters. There were no significant differences between the eight-Plate® lateral group and the FlexTackTM lateral group for neither Fmax (p = 0.46) nor lmax (p = 0.65). There was a significant higher Fmax (p < 0.001) and lmax (p = 0.001) measured in the eight-Plate® group compared to the FlexTackTM group when implanted anteriorly. In anterior temporary ephiphysiodesis, eight-Plate® demonstrated superior biomechanical stability. At this stage of research, there is no clear advantage of either implant and the choice remains within the individual preference of the surgeon.

Proximal Femoral Osteotomies in the Adolescence: Indications and Treatment Strategies. / Proximale Femurosteotomien im Wachstumsalter: Wann indiziert? Wie operieren?

Proximal femoral osteotomies are common surgical interventions to treat hip deformities in pediatric orthopedics. The aim of proximal femoral osteotomies is to optimise hip containment by using varus or valgus osteotomy, flexion or extension osteotomy with shortening, lengthening or derotation of the femoral neck. Furthermore improved muscular dysbalance by enhancing the femoral offset, extension of the range of motion and pain reduction are important surgical intentions. In the long term, a proximal femoral osteotomy is meant to minimize the probability of an early osteoarthritis of the hip. In the current literature many different types of proximal femoral osteotomies are described. They can be divided concerning their anatomical localization into subcapital, base of the femoral neck, intertrochanteric and subtrochanteric osteotomies. A profound knowledge about the deformity and the anatomical situation is essential to choose the appropriate osteotomy. The aim of this review is to show the different ways of proximal femoral osteotomies and their indications after having done a selective literature research. Furthermore over the last years the osteosynthesis materials have changed from blade plates (non-locking) to locking compression plates which allow an early re-mobilization without hip spica casts.

Risk factors for failed closed reduction in dislocated developmental dysplastic hips.

AIM OF THE STUDY: The present study aimed to identify risk factors for unsuccessful CR. INTRODUCTION: Closed reduction (CR) represents the gold standard for treatment of developmental dysplasia of the hip (DDH), but to a minor percentage, it fails to reduce dysplastic hips successfully. METHODS: Seventy-three dysplastic hips underwent closed reduction and post-interventional MRI of the pelvis. MRIs were evaluated for successful reduction of the hip, volumes of femoral heads, and acetabular diameter. Initial treatment results were correlated to AC angles at two years of follow-up. Contralateral, healthy hips served as control. RESULTS: Out of 73 instable, dysplastic hips, there were nine cases of CR failure. These cases showed significantly increased femoral head volumes (p = 0.002) and a significantly (p = 0.02) larger ratio of femoral head volume to acetabular opening area. There was no significant difference (p = 0.15) in acetabular diameter between both groups. At two years of follow-up, AC angles were significantly (p = 0.003) larger and pathologic in cases of CR failure. CONCLUSION: Exclusive enlargement of the femoral head is a risk factor for unsuccessful reduction and its ratio to the acetabular opening surface is predictive for CR success in DDH.

Infantile scurvy: Still a relevant differential diagnosis in Western medicine.

OBJECTIVE: Infantile scurvy or Moller-Barlow's disease appears to be of no further importance in Western countries; however, this is a careless assumption. In severely disabled children especially, this malady manifests itself in a broad range of symptoms such as delayed or suppressed bone healing, minor traumatization leading to bruises or fractures, and epiphysiolysis. METHODS: The aim of this article was to present the required daily uptake of vitamin C and the biochemical pathways in the human body leading to the typical symptoms of scurvy. Two cases of chronic scurvy with prolonged bone healing and bleeding, epiphysiolysis, and gingival hyperplasia are presented. Both patients were chronically ill with one having cerebral palsy and the other a neuroblastoma of the adrenal gland. RESULTS: After diagnosis, the substitution of vitamin C via percutaneous endoscopic gastrostomy in both patients was necessary to treat them. Both patients quickly achieved a full recovery. CONCLUSION: The two patients presented show the importance of infantile scurvy in daily medical care. The prevalence of scurvy is often underestimated in severely disabled or chronically ill children.

Closed Reduction as Therapeutic Gold Standard for Treatment of Congenital Hip Dislocation. / Die geschlossene Reposition der Säuglingshüfte als therapeutischer Goldstandard der kongenitalen Hüftluxation.

BACKGROUND: Congenital hip dislocation (luxation) has an incidence of 0.4 - 0.7% and is regarded as a prearthrotic deformity. Thus, if not being diagnosed and treated at a very early age, extensive surgical measures are inevitable in childhood and early adulthood. METHODS: In the time between 01/2013 and 02/2019 we performed 28 600 hips sonographies in babies as part of general screening measures at U2 or U3. There were 71 instable, dysplastic or dislocated hips diagnosed that were treated by arthrographic, closed reduction. After a hip spica cast was applied, reposition was controlled by MRI, estimating the acetabular head index (ACI), the head coverage index (HCI) as well as the femoral head's sphericity or by sonography using the Graf method. RESULTS: Overall success rate was 91.6% for primary closed reduction. Patients with primarily irreducible hips were significantly older (p < 0.003) than patients with primarily successful reducible hips. Congenital dislocated hips had significantly higher ACIs (p < 0.001) and HCIs (p = 0.03) as well as significantly less well rounded femoral heads (sphericity; p < 0.001) compared to stable hips. CONCLUSION: Early diagnosis and treatment of congenital dislocated hips by closed reduction is essential for a sufficient and regular maturation of the hips without further surgical interventions.

The Phenomenon of the Apparent (Double) Femoral Head in Infant Hip Sonography According to Graf-Description, Incidence and Clinical Relevance. / Das Phänomen des scheinbar (ver)doppelten Hüftkopfes bei der Säuglingssonografie nach Graf-Beschreibung, Inzidenz und klinische Relevanz.

PURPOSE: Hip screening sonography according to Graf in rare cases yields the appearance of a double femoral head, aptly named the Double-Head-Sign. The goal of this retrospective study is to offer a definition of this rare sign, evaluate its incidence of occurrence and compare the sonographic findings with the clinical findings. MATERIALS AND METHODS: This Double-Head-Sign is caused by the overlap of the trochanter major with the actual head of the femur in cases of coxa vara. This was observed in 13 of 2800 neonates we screened as part of our sonographical neonatal hip screening. RESULTS: 13 neonates presented themselves with ultrasound findings in accordance with our description, yielding an incidence of 0,46% in our patient cohort. In correlation, these neonates also exhibited increased external and decreased internal rotation of the hip. Two had an underlying condition (achondroplasia). CONCLUSION: In these rare cases, clinical examination of hip rotation in 90° hip flexion has proved helpful and further interdisciplinary examination of such infants to distinguish a possible underlying primary condition is recommended.

Outcome evaluation of new calcium titanate schanz-screws for external fixators. First clinical results and cadaver studies.

OBJECTIVE: External fixators are important for correcting length discrepancies and axis deformities in pediatric or trauma orthopedic surgery. Pin loosening is a common pitfall during therapy that can lead to pain, infection, and necessary revisions. This study aims to present clinical data using calcium titanate (CaTiO3) Schanz screws and to measure the fixation strength. PATIENTS AND METHODS: 22 titanate screws were used for external fixators in 4 pediatric patients. Therapy was initiated to lengthen or correct axial deformities after congenital abnormalities. The maximum tightening torque was measured during implantation, and the loosening torque was measured during explantation. In addition, screws of the same type were used in a cadaver study and compared with stainless steel and hydroxyapatite-coated screws. 12 screws of each type were inserted in four tibias, and the loosening and tightening torque was documented. RESULTS: The fixation index in the in vivo measurement showed a significant increase between screw insertion and extraction in three of the four patients. The pins were in situ for 91 to 150 days, and the torque increased significantly (P = 0.0004) from insertion to extraction. The cadaveric study showed lower extraction torques than insertion torques, as expected in this setting. The calculated fixation index was significantly higher in the CaTiO3 group than in the other groups (P = 0.0208 vs. HA and P < 0.0001 vs. steel) and in the HA group vs. plain steel group (P = 0.0448). CONCLUSION: The calcium titanate screws showed favorable fixation strength compared to HA and stainless steel screws and should be considered in long-term therapy of external fixation.

International Interdisciplinary Consensus Meeting on the Evaluation of Developmental Dysplasia of the Hip.

In September 2018, an international meeting of doctors of various disciplines, with expertise in the detection and treatment of DDH, was held in Csolyospalos, Hungary. The aim was to achieve consensus on the detection and early treatment of the condition and to develop a standardized system of teaching and training for hip ultrasound. There was strong agreement that US screening is essential. Specifically the Graf technique was selected as the technique of choice. Universal US screening was strongly favored. Screening should be carried out as soon as possible, but not later than the sixth week of age. US screening is cost-effective, does not result in overtreatment, and contributes to a reduction of long-term consequences. The essential principle of treatment is timely application of a device to achieve reduction, retention and maturation, by holding the hips in flexion, and a safe degree of abduction. It was agreed that the effectiveness of any screening policy depends on the correct scanning technique. Therefore, standardization of teaching and training of the Graf technique is mandatory. A unified teaching policy and materials should be developed for this purpose. Certification, re-certification and audit were discussed. The group, which has been formalized as the International Interdisciplinary Consensus Committee On DDH Evaluation (ICODE), will continue to meet and work towards establishing international consensus on DDH, standardizing and developing teaching and training of the Graf technique for hip US, and maintaining standards for detection and management.

Avoiding drainage after major hip surgery in children is a viable option: results from a retrospective comparative study.

PURPOSE: The use of closed-suction drainage systems to evacuate haematomas after surgical procedures is still common practice in many orthopaedic departments. However, no evidence to support the routine use of closed-suction drains in orthopaedic surgery exists. Post-operative handling and removal of the drain is particularly complicated in children. We hypothesised that the use of surgical drains in major hip procedures in children does not reduce the complication rate. METHODS: The records of 63 children undergoing 97 major hip procedures managed with closed-suction drains (centre A), and 75 children undergoing 130 major hip procedures without application of wound drains (centre B) were retrospectively reviewed in this dual-centre study. Demographic data, pre-existing conditions, surgical indications and procedures, duration of hospitalisation and complication rates were analysed. RESULTS: Children (mean age, 8.3 ± 4 years) in both groups presented similar demographics, medical histories, surgical indications and procedures. No intra-operative complications occurred in either group. In the undrained group a significant shorter hospitalisation time was observed. Overall, there were 31 complications (31.9 %) in the drained group and 26 complications (20 %) in undrained group (p = 0.05). Applying the Clavien-Dindo grading system, both groups had mainly minor grade I and grade II complications. No differences regarding the rate of wound-related complications were observed between the two groups. CONCLUSIONS: The use of wound drains in our study cohorts has been shown to have no positive impact on complications rates after corrective osteotomies around the hip joint in children. In the light of our results and of the poor evidence of drainage use in adults, we do not recommend the routine use of drains in children undergoing orthopaedic hip procedures.

Best clinical practice in botulinum toxin treatment for children with cerebral palsy.

Botulinum toxin A (BoNT-A) is considered a safe and effective therapy for children with cerebral palsy (CP), especially in the hands of experienced injectors and for the majority of children. Recently, some risks have been noted for children with Gross Motor Classification Scale (GMFCS) of IV and the risks are substantial for level V. Recommendations for treatment with BoNT-A have been published since 1993, with continuous optimisation and development of new treatment concepts. This leads to modifications in the clinical decision making process, indications, injection techniques, assessments, and evaluations. This article summarises the state of the art of BoNT-A treatment in children with CP, based mainly on the literature and expert opinions by an international paediatric orthopaedic user group. BoNT-A is an important part of multimodal management, to support motor development and improve function when the targeted management of spasticity in specific muscle groups is clinically indicated. Individualised assessment and treatment are essential, and should be part of an integrated approach chosen to support the achievement of motor milestones. To this end, goals should be set for both the long term and for each injection cycle. The correct choice of target muscles is also important; not all spastic muscles need to be injected. A more focused approach needs to be established to improve function and motor development, and to prevent adverse compensations and contractures. Furthermore, the timeline of BoNT-A treatment extends from infancy to adulthood, and treatment should take into account the change in indications with age.