[Treatment of congenital clubfoot with the Ponseti method]. / Die Behandlung des kongenitalen Klumpfusses mit der Ponseti-Methode.

AIM: The primary therapy for congenital clubfoot is non-surgical involving manipulation and serial casting. With traditional casting, relatively large numbers of feet require extensive surgery to achieve full correction. The purpose of this study was to evaluate the efficacy of the Ponseti method. METHODS: Between 1.1.2004 und 31.12.2005, 29 patients with 41 clubfeet were treated with the Ponseti method. Only patients without any prior treatment were included. Classification followed Pirani's score. The number of casts to full correction, tenotomies, number of posteromedial releases, dorsi-, plantarflexion and hindfoot position were documented. The follow-up time was 1-9 months, the average follow-up time was 9.1 months. RESULTS: 39 clubfeet were successfully treated with the Ponseti method. The average Pirani score was 4.9. Percutaneous tenotomies were necessary in 34 of the clubfeet. Average dorsiflexion was 19 degrees and plantarflexion 42 degrees . After failed Ponseti treatment 2 feet were treated with a posteromedial release. CONCLUSION: With the Ponseti method the need for extensive corrective surgery is greatly reduced. We recommend the Ponseti method as standard therapy in clubfoot management.

Complications at screw removal in slipped capital femoral epiphysis treated by cannulated titanium screws.

INTRODUCTION: Various modes of fixation are proposed for the treatment of slips of the capital femoral epiphysis (SCFE). We describe our experience with the use and removal of a new, cannulated titanium screw (Asnis III, Stryker, Howmedica). PATIENTS AND METHODS: Single cannulated titanium screws had been inserted in 101 hips of 65 patients in the 3-year period from 2001 to 2003. These pins were used for in situ fixation of minor chronic slips in 41 patients and for prophylactic fixation on the contralateral side in patients with open physis in 60 patients. RESULTS: The insertion of these screws was achieved without any real problem. The mean surgical time was 25 min (13-46 min). Problems came up when we started to remove the pins. Hardware retrieval was attempted in 27 patients with 43 pins. The mean surgical time for removal was double the average time of insertion with 51 min (26-107 min). The hexagonal Allen sockets proved to be too weak to overcome the necessary torque for loosening the pin from bone and applying the reverse-cutting-force, necessary to extract the pin. Eleven patients needed extensive chiselling. Two adolescents sustained a subtrochanteric fracture 5 and 7 weeks after hardware removal. Seven pins could not be totally removed. CONCLUSION: Due to the considerable disadvantages encountered in our series we conclude that Asnis III cannulated screws should be suspended from further use in SCFE.

[Ultrasound diagnosis of congenital knee dislocation]. / Sonographie der angeborenen Knieluxation.

Since 1990, more than 50 children with hyperextended knee joints have been treated based on sonographic assessment. Ultrasound imaging has been useful for primary diagnosis, classification, and follow-up of conservative treatment. The image quality of sonographic documentation more or less equates the more expensive magnetic resonance imaging (MRI) and has become the golden standard of imaging hyperextended knee joints. There is almost no more need for plain X-rays.

Follow-up study after treatment of knee flexion contractures in spina bifida patients.

Knee flexion contractures in spina bifida patients are seen in all levels of paralysis. The majority is encountered in children with thoracolumbar lesions. Positional deformation, spinal reflex activity, fractures around the knee joint and a weak quadriceps are the main causes of the flexion deformity of the knee. One hundred and forty-five knee flexion contractures in 80 children have been treated between 1980 and 1995; 15 with unilateral contracture, 65 with bilateral involvement. The age at the time of correction in 38 patients with thoracolumbar lesions was between 24 months and 11 years (average, 7.7 years). In 42 patients with sacral or lumbosacral lesions, the age at the time of correction was between 10 and 19 years (average, 16.3 years). Associated surgery was mainly carried out on hip flexors, adductors and triceps surae. Complete posterior release was practiced in thoracolumbar lesions including posterior capsulotomy and release of the posterior cruciate ligament. In lumbosacral lesions, the lengthened tendons are sutured to prevent flexor weakness in the postoperative course. Vascular and neurologic structures are spared. Postoperative serial casts are helpful to achieve full extension without vascular or skin troubles. The long-term results were very good in 59 patients with 106 knees, good in 16 patients with 29 knees, and unsatisfactory in 5 patients with 10 knees. Slow deterioration years after surgery can be anticipated. The main causes are lack of personal initiative to stand and to walk, and obesity.

Allergic reactions to latex in myelodysplasia: a review of the literature.

Current research has identified clinically relevant allergens in natural latex. Children with myelodysplasia are especially considered to be at risk for the development of immunoglobulin E-mediated hypersensitivity, which can lead to life-threatening intraoperative anaphylaxis. A careful medical history is mandatory to identify patients who might be predisposed to anaphylactic reactions. Preventive measures involve primarily the avoidance of latex contact at home and in hospitals for all patients with myelodysplasia. The effectiveness of additional pharmacologic prophylaxis has to be determined further.

[Concomitant vascular complications in supracondylar humerus fractures in children]. / Begleitende Gefässkomplikationen bei suprakondylären Humerusfrakturen des Kindes.

From January 1st 1990 to December 31st 1997, 614 children were treated for supracondylar humerus fracture at the Department of Orthopedic Surgery in the Olga Hospital, Stuttgart. Ten of these children had concomitant vascular complications. The concept of treatment we had chosen was analysed retrospectively. The median patient age of the seven girls and three boys with vascular complications was six years. The vascular injuries were diagnosed after admission to the hospital by palpation of the wrist pulse, clinical appraisal of the vascularity and by registration of the Doppler signal via the arteries of the wrist. The emergency operations carried out initially comprised fragment reposition and fixation with crossed K wires via an access route on the extensor side in all ten children. The subsequent appraisal of the blood flow revealed a pulse restoration (transient vascular occlusion due to dislocation) in two out of the ten children. In eight out of the ten children, the pulse did not return, which is why the vessel had to be explored under emergency conditions. Intraoperatively, we saw a vascular spasm with functional vascular occlusion in one of these eight children. Mechanical vascular occlusion were diagnosed in five of these eight children. In adventitial strangulation (two of these five children), the pulse transmission to the hand occurred immediately after severance of the strangulation connective tissue. In intimal damage (three of these five children), the vascular segment concerned was resected and reconstructed, mostly in the form of an end-to-end-anastomosis with venous patch grafting. We observed a combined vascular occlusion (mechanical-functional occlusion) in two out of these eight children. In the follow-up investigation, the wrist pulses could be palpated in nine children. Nine children had a physiological signal in color duplex sonography, and one child had a pathological monophasic signal over the brachial artery, radial artery as well as the ulnar artery. Late ischemic damage (cold intolerance, claudicatio, Volkmann's contracture) were not detected in any of the children. Appraisal of elbow joint mobility revealed a median extension deficit of 0 degrees (range 0-10 degrees ), a median flexion deficit of 0 degrees (range 0-15 degrees ) and a normal pronation and supination equal on each side. The load-carrying joint axis was normal in a comparison of the sides in all children.

Intertrochanteric corrective osteotomy for moderate and severe chronic slipped capital femoral epiphysis.

A total of 299 acute, acute on chronic, and chronic slips were treated from 1975 to 1997. The patients were reviewed in three cohorts: 75 patients with slipped capital femoral epiphysis (SCFE) were treated between 1975 and 1982, 101 patients with 107 slips were treated from 1983 to 1991, and 110 patients with 117 slips were treated from 1992 to 1997. The authors have corrected 130 hips with chronic slips by intertrochanteric osteotomy. Of these 130 hips, 111 were moderate slips between 20 and 50 degrees, 19 hips with a slipping angle of more than 50 degrees were classified as severe chronic slips. During the same period, 92 chronic slips less than 20 degrees were treated by fixation in situ, and 77 acute or acute on chronic slips had an open and exceptionally a closed reduction followed by fixation. Eight postoperative fractures caused by inadequate plate fixation were observed after these 130 intertrochanteric osteotomies. They all necessitated plate replacement followed by uneventful healing. Three patients with major displacement developed chondrolysis after the corrective osteotomy, two were transient, and one patient developed avascular necrosis (AVN). The midterm clinical results showed a satisfactory outcome in all three cohorts. In 47 patients in the series from 1975 to 1982, the clinical outcome was measured using Imhäuser's score: 43 patients had good and very good results, 4 patients had a moderate or bad result. In the second and third series, the IOWA hip score was used to measure the clinical outcome. The 49 patients with osteotomies for chronic slips treated from 1983 to 1991 had an average score of 90.3 points, and 1 patient had AVN. In the latest series from 1992 to 1997 with 34 corrective osteomies, there was no chondrolysis or AVN and the average IOWA score was 93.9 points.

[Primary treatment of clubfoot]. / Die primäre Behandlung des Klumpfusses.

Our primary club foot therapy consists of a combination of plaster cast manipulation, physiotherapy and surgical correction. The initial plaster cast method of 4 to 6 weeks is followed by a functional mobilisation of the foot. The main aim being the reduction of the malpositioned talus in the ankle mortise. If there is residual deformity surgery is planned after six month. We use the Cincinnati approach with the possibility of the dorsal, medial and lateral release, enabling a correction of the hind-, mid- and forefoot. The main part of postoperative care is seen in the functional rehabilitation of the foot by physiotherapy, in order to achieve a cosmetic foot with good functions. Physiotherapy is advised until the child enters school in order to preserve function and form into adult life. A high frequency of satisfactory results can be expected using this protocol.

[Prolonged transitory paralysis after pneumatic tourniquet use on the upper arm]. / Prolongierte passagere Paralyse nach pneumatischer Blutsperrenanwendung am Oberarm.

A case of paralysis in a youth lasting 7.5 months caused by application of a tourniquet is described. The paralysis was induced by the brief application of excessive cuff pressure. The function of the arm nerves returned spontaneously.

Primary treatment of talipes equinovarus.

Our primary club foot therapy consists of a combination of plaster cast manipulation, physiotherapy and surgical correction. The initial plaster cast method of 4 to 6 weeks is followed by a functional mobilisation of the foot. The main aim being the reduction of the malpositioned talus in the ankle mortise. If there is residual deformity surgery is planned after six month. We use the Cincinati approach with the possibility of the dorsal, medial and lateral release enabling a correction of the hind-, mid- and forefoot. The main part of postoperative care is seen in the functional rehabilitation of the foot by physiotherapy, in order to achieve a cosmetic foot with good functions. Physiotherapy is advised until the child enters school in order to preserve function and form into adult life. A high frequency of satisfactory results can be expected using this protocol.

Modern trends in internal fixation of femoral shaft fractures in children. A critical review.

Elastic intramedullary (IM) devices, which avoid the physeal region like Nancy and Ender nails do, can be used in children younger than even 4 years without compromising the trochanter physis or risking an avascular necrosis. Intramedullary fixation of femoral shaft fractures leads to satisfactory results of alignment and union. Prerequisites for intramedullary closed nailing are a traction table, especially for older children and adolescents, and an image intensifer. Interlocking IM, Ender, and Nancy nails all have the equal advantage of early weight bearing and reduced hospitalization time compared with traction and cast management. Küntscher or interlocking nails should only be used in adolescents close to the end of growth to avoid growth arrest of the trochanterocervical physis. Küntscher nails and interlocking IM nails are both associated with the small but troublesome risk of avascular necrosis. Ender and Nancy nails, with retrograde or antegrade pinning, have a low complication rate and a short learning curve for surgeons. Overgrowth in late controls after IM rodding of shaft fractures is about the same as the other types of treatment with an average overgrowth of 7 mm. Short hospital stay for children with IM nails reduces cost of treatment to about one half compared with in-hospital traction and cast management.

[Clinical studies in suspected hip dysplasia or dislocation]. / Die Klinische Untersuchung bei Verdacht auf Hüftdysplasie oder -luxation.

Exact and sensitive clinical screening during the neonatal period allows detection of a majority of hip dysplasia and dislocations. Roser-Ortolani-Barlow maneuver promotes early detection of dislocatable hips and therefore opens the perspective for a successful early treatment. Ultrasound allows a good differentiation of suspected clinical abnormalities.

[Coxitis in the newborn infant and infant. Diagnosis and therapy]. / Die Koxitis beim Neugeborenen und Säugling. Diagnose und Therapie.

From 198 o 1996 (12 years) we saw 24 neonates and small infants with septic arthritis of the hip joint. A minority of these infants was simultaneously affected by osteomyelitis of the femoral neck or the acetabulum. Clinical signs are a painful leg, pseudoparalysis, uneasiness and refusal to drink. Quantitative measurements of C-reactive protein (CRP) are more reliable then leucocyte count and sedimentation rate. Ultrasound images yield early information about capsular swelling and septic effusion; in late cases US can visualize femoral neck necrosis. Emergency arthrotomy to relieve the joint from septic effusion, bacteriological specimens and capsular biopsy are mandatory. Intravenous application of a second-generation cephalosporin as antibiotic has proven effective. We have been using cefuroxim for the past 10 years, changed if necessary according to the antibiogram. Parenteral antibiotic treatment is continued for an average of 3 weeks, followed by oral treatment for another 3 weeks. CRP normalisation monitors the cure from the disease. Our 24 cases included 7 with group B streptococci 2 with Staphylococcus aureus, 2 with Staphylococcus epidermidis and 2 with Escherichia coli. In 8 cases no germs could be cultured; 6 of them had outside antibiotic treatment before being transferred. If treatment was initiated within 3 days, healing without residuals was the rule. In 18 cases with early and sufficient treatment no sequelae were observed. With delay of treatment for several days, moderate osteomyelitic changes of the neck and the acetabulum were observed. In a case with delay of surgical treatment for 5 weeks, complete destruction of the hip joint occurred, causing a poor final result.

[Hematogenous multifocal osteomyelitis]. / Hämatogene multifokale Osteomyelitis.

The clinical features, diagnosis and treatment of haematogenous multifocal osteomyelitis, a rare illness, are described. Of clinical note are the pain, pseudoparalyses and restriction of movement. Staphylococcus aureus was the pathogen in both of the cases we described. Sonography is a useful diagnostic tool for the localization of subperiosteal abscesses; scintigraphy is a supplementary examination for cases where it is difficult to establish a diagnosis. MR-tomography is the most reliable method for examination of proximal infected foci (spondylitis, pelvis osteomyelitis). In our view, the earliest possible removal of all infected foci by means of operation and parenteral antibiotics mare the most important treatment.

Coxitis in newborns and infants.

From 1985 to 1996 (12 years) we saw 24 neonates and small infants with septic arthritis of the hip joint. A minority of these infants was simultaneously affected by osteomyelitis of the femoral neck or the acetabulum. Clinical signs are a painful leg, pseudoparalysis, uneasiness and refusal to drink. Quantitative measurements of C-reactive protein (CRP) are more reliable then leucocyte count and sedimentation rate. Ultrasound images yield early information about capsular swelling and septic effusion; in late cases US can visualize femoral neck necrosis. Emergency arthrotomy to relieve the joint from septic effusion, bacteriological specimens and capsular biopsy are mandatory. Intravenous application of a second-generation cephalosporin as antibiotic has proven effective. We have been using cefuroxim for the past 10 years, changed if necessary according to the antibiogram. Parenteral antibiotic treatment is continued for an average of 3 weeks, followed by oral treatment for another 3 weeks. CRP normalisation monitors the cure from the disease. Our 24 cases included 7 with group B streptococci 2 with Staphylococcus aureus, 2 with Staphylococcus epidermidis and 2 with Escherichia coli. In 8 cases no germs could be cultured; 6 of them had outside antibiotic treatment before being transferred. If treatment was initiated within 3 days, healing without residuals was the rule. In 18 cases with early and sufficient treatment no sequelae were observed. With delay of treatment for several days, moderate osteomyelitic changes of the neck and the acetabulum were observed. In a case with delay of surgical treatment for 5 weeks, complete destruction of the hip joint occurred, causing a poor final result.