[The German version of parents' postoperative pain measure (PPPM-D). Validation on children 2-12 years old]. / Die deutsche Version des Parents' Postoperative Pain Measure (PPPM-D). Validierung an Kindern im Alter von 2 bis 12 Jahren.

BACKGROUND: Parents become increasingly more responsible for the postoperative pain management of their children. Useful and valid pain assessments for parents may improve pain measurement. The aim of this study was to evaluate a German version of the parents' postoperative pain measure (PPPM-D). METHODS: After translation of the PPPM into German 52 children between 2 and 12 years of age, undergoing orthopedic and trauma surgery, were included in a prospective study. At least one of the parents completed the PPPM-D on the preoperative day and the day of surgery until postoperative day 5. Both, the children's and infants postoperative pain scale (CHIPPS) for children between 2 and 4 years and the faces pain scale revised (FPS-R) for children between 5 and 12 years were also assessed. Moreover, the acceptance of the PPPM-D by the parents was assessed. RESULTS: The PPPM-D showed satisfactory reliability (Cronbach's α values = 0.77-0.87). Construct validity was demonstrated with strong correlations with the CHIPPS and the FPS-R. Discriminative validity was shown by both statistically and clinically significant differences between minor, medial and major surgeries on the first 3 days after surgery. The examination of sensitivity to change yielded promising results. The PPPM-D was well accepted by the participating parents. CONCLUSIONS: The results of this study provide evidence of the reliability, validity and high acceptance of the PPPM-D as an assessment tool of postoperative pain among children aged 2 through to 12 years of age after orthopedic or trauma surgery.

Midterm results following revision surgery in clubfeet.

Relapse rates of surgically treated clubfeet are about 25%. We reviewed 43 patients (57 feet) treated for relapsed clubfoot deformity between 1992 and 2001 in our department. The average age of the patients at the time of revision surgery was 5.1 years, the mean follow-up was 6.6 years. Surgical therapy was performed using an algorithm according to age groups. The mean Atar score at follow-up was 77 points, representing a good outcome. Out of 57 feet, 20 (35%) were rated excellent, 24 (42%) good, 5 (9%) fair, and 8 (14%) poor. The number of previous surgical interventions had no influence on the outcome. Using an age related surgical algorithm, good postoperative results could be achieved in most of our patients, thus improving their functional situation. This emphasises the usefulness of the proposed algorithm in the difficult situation of recurrent clubfoot, while thorough analysis of the underlying deformity remains essential.

[Intra-acetabular localisation of an osteochondroma causing subluxation of the hip joint]. / Intraazetabuläre Lokalisation eines Osteochondroms mit Subluxation des Hüftgelenkes -- Eine seltene Entität bei Kindern mit multipler kartilaginärer Exostosenkrankheit.

INTRODUCTION: Intra-acetabular localisation of an osteochondroma causing subluxation of the hip joint is a rare entity in children suffering from multiple hereditary exostoses. In literature only 6 operatively treated cases have been reported. CASE: We add the case of an 8-year-old boy with an intraarticular exostosis of the left acetabulum causing subluxation of the hip. Using an anterolateral approach to the hip joint this exostosis was removed surgically together with some extraarticular exostoses of the proximal femur. The hip could be re-centered in combination with an additional varus derotation osteotomy of the proximal femur. Intraoperatively the femoral head was only subluxated to minimise the risk of avascular necrosis. After a follow-up of two years the patient has complete remission of symptoms and there is no evidence of avascular necrosis radiologically with good remodelling of the left hip. CONCLUSION: The operative treatment of an intraarticular exostosis of the hip joint is a difficult and risky surgical procedure. The reported open surgical procedure allowed resection of the intraarticular exostosis in combination with therapy of additional pathologies of the proximal femur.

Surgical treatment of congenital pseudarthrosis of the clavicle: a report of three cases and review of the literature.

Congenital pseudarthrosis of the clavicle is a rare entity of unknown aetiology with predominance of the right side. Our therapeutic concept is discussed with special reference to surgical therapy, histopathological findings and the most recent literature. Two girls and one boy, aged 4, 6, and 8 years, presenting with congenital pseudarthrosis of the clavicle were surgically treated between 1994 and 2000. A resection of the pseudarthrosis and internal fixation with a small reconstruction plate was performed. A bone graft from the iliac crest was used for restoration of clavicular length. Histological examination revealed a false joint with the ends of the clavicle covered by hyaline cartilage. The patients showed radiographic healing after 12 weeks. At follow-up (mean 44 months), all patients showed excellent clinical and radiological results without functional impairment. The clinical features and histological examination of the resected pseudarthroses clearly proved the diagnosis of a true congenital pseudarthrosis of the clavicle. According to our clinical and radiological results and considering the recent literature, we recommend surgical therapy with resection, bone grafting, and osteosynthesis with a reconstruction plate around the age of 4 - 6 years.

[Correction of forearm deformities in children with multiple cartilaginous osteochondromas]. / Deformitätenkorrektur am Unterarm bei Kindern mit multipler kartilaginärer Exostosenkrankheit.

AIM: Deformity of the forearm with shortening and bowing is common in children with multiple cartilaginous osteochondromas. The objective of this study was to evaluate the benefit of ulnar lengthening using an external fixateur in these patients. METHOD: 9 patients (10 cases) underwent surgery of the forearm between 1995 and 2001 and were evaluated using a standard protocol. The mean follow-up was 33.6 months, the mean age at operation 8.9 years. All patients were treated with ulnar lengthening, in 6 cases combined with an excision of the osteochondromas. RESULTS: Four out of ten patients did show an improvement in postoperative forearm rotation, two deteriorated and 4 presented unchanged. Wrist motion improved in 7 patients and remained unchanged in 3. The postoperative radial articular angle showed an improvement in 6, the carpal slip in 9 of the patients. The preoperative radial head dislocation in one patient remained unchanged postoperatively. CONCLUSION: The authors advocate this therapeutic concept for the correction of forearm deformity in multiple hereditary osteochondromas to prevent a progression of the deformity and to establish carpal stability. A significant improvement of forearm and wrist function could not be reached.

[Osteochondral lesions of the talus -- indications for MRI with a contrast agent]. / Osteochondrale Läsionen am Talus - Indikationen zur MRT mit Kontrastmittel.

AIM: This study aims to establish the indication for a pre- and postoperative MRI examination with an intravenous contrast agent in patients with an osteochondral lesion of the talus. METHODS: 20 patients with an osteochondral lesion of the talus in the different stages according to DiPaola were prospectively examined preoperatively and 6 months postoperatively by an MRI investigation with an i. v. contrast agent. The Weber ankle score was determined pre- and postoperatively. A correlation was calculated between MRI and arthroscopic findings of an osteochondral lesion (Spearman-rho). RESULTS: There was a significant correlation among the radiological, the MRI and the arthroscopically determined locations. With regard to staging only 12 out of 20 lesions were staged correctly by MRI using arthroscopy as a gold standard. Due to metal artifacts and morphological changes the postoperative MRI could not be used for staging. CONCLUSION: A preoperative MRI investigation is indicated in patients with ankle pain of unknown origin, a normal radiograph and a suspected osteochondral lesion of the talus. MRI is not indicated to determine the localization and the stage of an osteochondral lesion. A postoperative MRI is only necessary for the exclusion of a secondary pathology.

Epidermoid cyst mimicking monoarticular arthritis of the great toe.

Local swellings of the foot are a common presentation in rheumatological practice. In the following case report, an epidermoid cyst presenting with the typical features of monoarticular arthritis is described in a 27-year-old woman. The differential diagnosis of forefoot swelling is discussed, with particular emphasis on epidermoid cysts and monoarticular arthritis.

Arthrodesis in the treatment of hallux rigidus.

We reviewed 34 patients (38 joints) with hallux rigidus treated from 1989 to 1999 with arthrodesis of the first metatarsophalangeal joint. Average patient age at time of surgery was 52 (24-71) years, and the mean follow-up was 54 (18-116) months. There were six superficial infections, and all arthrodeses united. There was a good functional result with a significant pain reduction. The mean postoperative American Orthopaedic Foot and Ankle Society (AOFAS) score was 53 (5-84) points.

Transient bone marrow oedema of the foot.

We treated ten patients who on the basis of MRI were suspected to have transient bone marrow oedema. In eight cases the talus was affected, in one the cuboid and in one the navicular bone. All patients had acute onset pain at the ankle. Four were treated with core decompression and had an immediate pain relief. Six were treated conservatively and became also pain-free but with considerable delay.

[The role of MRI in therapy and follow-up after surgical treatment of osteochondrosis dissecans of the talus]. / Die Rolle der MRT in der Therapie- und Verlaufskontrolle nach operativ therapierter Osteochondrosis dissecans des Talus.

AIM: Our study was designed to evaluate the use of magnetic resonance imaging (MRI) in the follow-up of surgically treated osteochondrosis dissecans (OCD) of the talus. METHOD: We investigated 16 patients (18 joints) with OCD of the talus, surgically treated in our department between 1990 and 1997. All of them had preoperative MRI scans of the affected ankle. The mean follow-up was 40 months (8-82). All patients were evaluated by clinical examination, plain radiography and MRI using a standard protocol. RESULTS: The clinical Bray score improved significantly from 58 preoperative to 82 postoperative. Using a visual analogue scale we saw a significant reduction of the patients pain level post-op. In 72% of the patients the preoperative MRI was able to predict the accurate stage of the cartilage. Postoperative MRI showed no more lesion in 3, intact articular cartilage in 11, and disrupted cartilage in 4 joints. There was no correlation between clinical, plain radiographical, and MRI findings postoperative. CONCLUSION: Arthroscopy remains the golden standard in evaluating articular cartilage. Using our data, MRI is not the method of choice in the follow-up of surgically treated OCD lesions of the talus. Postoperative use of intravenous contrast media gave no additional information. Postoperative MRI should be reserved only for symptomatic patients to gather additional information about the actual state of the OCD. Afterwards a prompt arthroscopy of the symptomatic ankle should be performed.