Complex, atypical clubfoot: follow-up after up to 16 years reveals a high risk of relapse but good functional and radiological outcomes.

INTRODUCTION: The treatment of complex atypical clubfoot poses many challenges. In this paper, we report on the course of complex clubfoot, primary correction using the modified Ponseti method and midterm outcomes. Special consideration is given to clinical and radiological changes in cases of relapse. MATERIALS AND METHODS: Twenty-seven cases of complex, atypical, non-syndromic clubfoot were treated in 16 children between 2004 and 2012. Patient data, treatment data, functional outcomes and, in the relapse cohort, radiological findings were documented during the course of treatment. The radiological findings were correlated with the functional outcomes. RESULTS: All atypical complex clubfeet could be corrected using a modified form of the Ponseti method. Over an average study period of 11.6 years, 66.6% (n = 18) of clubfeet relapsed. Correction after relapse showed an average dorsiflexion of 11.3° during a 5-years' follow-up period. Radiological results showed residual clubfoot pathologies such as a medialized navicular bone in four clubfeet. There were no instances of subluxation or dislocation of the talonavicular joint. Extensive release surgery was not necessary. Nevertheless, after 2.5 preoperative casts (1-5 casts), bone correction was performed in n = 3 feet in addition to Achilles tendon lengthening and tibialis anterior tendon transfer. CONCLUSION: Good primary correction of complex clubfoot using the modified Ponseti technique results in a high recurrence rate in the medium term. Relapse treatment without peritalar arthrolysis procedures produces good functional results even though minor residual radiological pathologies did persist in a minor number of cases.

[Medical assessment in the field of Social Act VII: pre-existing damage and causality of apophyseal injuries and detachments]. / Begutachtung im Bereich des SGB VII: Vorschaden und Kausalität bei apophysären Verletzungen und Lösungen.

The medical assessment of affections of the apophyses frequently presents the assessor with problems in causality testing and estimation of functional impairment. Apophyses are the insertion of tendons and are therefore at the center of an acting parallelogram of forces. They fuse via an apophyseal plate in the second decade of life. Depending on the age there is a reduced mechanical load-bearing capacity of the apophyseal plates in the last 1-2 years before complete mineralization of the joint. Two types of injury must be distinguished in an expert opinion: apophyseal detachment as a result of repetitive microtrauma in the event of chronic overload and apophyseal avulsion fracture as an acute injury due to sudden maximum muscle tension. While chronic overload leads to exclusion from insurance cover by the statutory accident insurance, apophyseal avulsion fractures fulfil the necessary requirements for acceptance as an insurance case. The apophyseal avulsion fracture is subject to a time-limited force, which directly leads to damage to health and avulsion of the tibial tuberosity including its tension system. The sudden jerky maximum muscle pull leads to an overload of the tension system and avulsion of the apophysis in cases of an age-related vulnerable apophyseal plate. Once the mineralization is complete, this type of fracture no longer occurs. Osgood-Schlatter disease, an insertion tendinosis of the patellar tendon, occurs in around 20% of all sport-active adolescents but it is questionable whether it can be associated with the acute avulsion fracture. Knowledge of the pathogenesis of affections and injuries of the apophysis can provide the assessor with good foundations for the estimation of a causal association.

Nonunion of the radial neck in children: a rare but severe complication after fractures of the radial neck.

PURPOSE: Nonunion of the radial neck poses an enormous challenge for treating surgeons. It is a very rare complication of the radial neck with limited experiences. In this current major study, the authors report of their own experiences concerning this problem. METHODS: 11 patients with severe displaced radial neck fracture Metaizeau type IV with elbow dislocation and 2 ongoing fractures. 9 fractures had to be treated with open reduction, six with intramedullary nailing, two with K-wires and one with periosteal suture fixation. In two children, aged 4 and 5, the fracture was not diagnosed initially. The patients showed a successful reduction intraoperatively. RESULTS: All patients developed nonunion of the radial neck. 9 out of 11 children presented with pain and 5 out of 11 with valgus deformity. All children underwent surgical management of the complications. 3 children received a debridement of the elbow joint with resection of the fragmented radial head. 7 cases needed a following reduction, spongiosa-plasty and periosteal flap reconstruction and plate osteosynthesis. One patient received radial intramedullary pinning. All nonunions showed reunion. All patients with obtained radial head showed significant improvement concerning complaints and range of motion. Only one child showed a slight deterioration in range of motion. Children with resected radial head showed good range of motion but complaints and instability in loaded joint needing further surgical treatment. CONCLUSION: Treatment of radial neck nonunion in children should not be delayed until pain, deformity and limited function occurs because this goes along with severe transition of the radial head right up to bone atrophy.

[Lateral approach to pediatric femoral neck fractures]. / Lateraler Zugang zur Fixation von Schenkelhalsfrakturen im Kindesalter.

OBJECTIVE: Illustration of surgical treatment of all types of femoral neck fractures other than type AO 31-E/2.1 (Delbet type IB) through the lateral approach INDICATIONS: Femoral neck fractures: a) transcervical (type AO 31-E/1.1) or Delbet type IA, respectively; b) medial femoral neck fracture (type AO 31-M/3.1 I) or Delbet type II, respectively; c) lateral femoral neck fracture (type AO 31-M/3.1 II) or Delbet type III, respectively; d) intertrochanteric (type AO 31-M/3.1 III) or Delbet type IV, respectively. CONTRAINDICATIONS: Transepiphyseal fracture with dislocation (type AO 31-E/2.1) or Delbet type IB, respectively SURGICAL TECHNIQUE: Open reduction of femoral neck fractures using lateral approach. POSTOPERATIVE MANAGEMENT: Early functional treatment with full range of motion of the hip joint immediately postoperatively. Amount of weight bearing depending on the geometry of the fracture. RESULTS: In a retrospective study, 33 children (19 boys and 14 girls) with a femoral neck fracture were followed-up for at least one year (average follow-up was 1.6 years). Average age of the included patients was 9.7 years (range 1-16 years). Three fractures were treated conservatively with pelvic leg plaster and 30 were openly reduced and stabilized. The fractures were classified according to Delbet. There were 2 type I fractures (transepiphyseal), 12 type II fractures, 10 type III fractures and 9 type IV fractures. A very good result was achieved in 29 children (88%). The most common complication was avascular necrosis (AVN), which was observed in 3 patients, all of whom showed an unsatisfactory result. Another complication was a screw breakout that resulted in a screw change. This child also showed an unsatisfactory result. Lateral access is a standard access in traumatology as well as pediatric orthopedics which can be used safely and with few complications even in children.

Respuesta a: «Asterixis como forma de presentación atípica de hipercalcemia» / Answer to: «Asterixis as an atypical expression of hypercalcemia»

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Frequency of Secondary Dislocations of Initially non Displaced and Minimally Displaced Fractures of the Lateral Humeral Condyle in Children - Surveillance of a Treatment Algorithm. / Häufigkeit sekundärer Dislokationen von initial nicht dislozierten und minimal dislozierten Condylus-radialis-Frakturen bei Kindern ­ Kontrolle eines Therapiealgorithmus.

AIM OF THE STUDY: The treatment of undisplaced fractures of the lateral humeral condyle is conservative. However, it is problematic that it is not possible to differentiate between a stable and an unstable, non-displaced fracture. A pragmatic approach is to X-ray the elbow without a cast 5 days after trauma and to compare those images with the initial ones. If there is a central increase of dislocation, then there is an indication of an unstable fracture. The dislocation can also be indicated by a translational movement, which is best observed in the border area. The aim of the study was to retrospectively determine the incidence of secondary dislocations of initially undisplaced and minimally dislocated fractures of the lateral humeral condyle in infants between 2010 and 2015. METHODS: We performed a retrospective, non-randomized analysis of 75 children with initially undisplaced and minimally displaced fractures of the lateral humeral condyle between 2010 and 2015. The strategy for the evaluation of a stable and an unstable fracture of the lateral humeral condyle was carried out by means of an X-ray without a cast 5 days after trauma. Further radiological controls were performed after 14 days, 4 weeks and after 10 to 12 weeks in operated children. RESULTS: Seven initially undisplaced and minimally dislocated fractures (9,3%) showed a secondary dislocation 5 days after trauma when a radiological control without a cast was performed. At the control 14 days after trauma there was no further secondary dislocation. The immobilization took place in an upper arm cast for a period of 4 weeks. CONCLUSION: 90% of all non-dislocated fractures of the lateral humeral condyle can be treated conservatively. It is important to find out which about 10% of children will experience a secondary dislocation safely and effectively. It has been shown that the strategy for the evaluation of a stable and an unstable fracture of the lateral humeral condyle by means of a radiological control after 5 days without a cast can be effective and cost-saving. With a high degree of certainty, the unstable fracture can be detected at the radiological control 5 days after trauma. If, after 5 days, the radiological control reveals unsure finding regarding the dislocation, it is advisable to recheck the fracture in the second radiological control after 14 days.

Bilateral Tibial Tubercle Avulsion Fractures in Children - Clinical Results of a Rare Fracture. / Die bilaterale Avulsionsfraktur der Tuberositas tibiae ­ klinische Ergebnisse einer seltenen Verletzung im Wachstumsalter.

BACKGROUND: Tibial tubercle avulsion fractures are rare, they represent less than 1% of all physeal fractures. Compared to monolateral tibial tubercle avulsion fractures, bilateral occurrence is even rarer. The purpose of this study is to report about the so far largest group of bilateral avulsion fractures and to compare them to unilateral fractures as well as to current literature. METHOD: All patients who suffered from bilateral tibial tubercle fractures between January 2009 and March 2019 were included. All medical records and radiographs were reviewed and a clinical follow-up was performed. The examined criteria were age, gender, mechanism of injury, classification, risk factors, complications, management and outcomes. Clinical outcome was measured using the well established Tegner activity scale and Lysholm-Gillquist score. The same criteria were analyzed in a literature review of bilateral tibial tubercle fractures to compare our results to available literature. RESULTS: We found four children with bilateral tibial tubercle avulsion fractures. All patients were male with a mean age of 14.5 ± 0.7 years (13 - 15). Mean follow-up examination was 13.6 ± 6.5 months (8 - 29) after surgery. The avulsions occurred during jumping activities in all cases. All children could no longer stand or move because of sudden pain in the knee. We found type IV fractures in three cases, type III fractures in four cases and one type V fracture according to the Ogden classification. All children were treated by open or closed reduction and stabilization with screws or K-wires. Follow-up showed complete fracture healing without complications in all patients. There were no changes in Tegner activity scale and Lysholm-Gillquist Score and knee function comparable to prior to the accident was achieved in all cases. CONCLUSION: Good clinical results without restrictions regarding function of the knee joint can be achieved by direct operative treatment of bilateral tibial avulsion fractures. A reduction in sporting activity has not to be expected. There were no differences between bilateral or unilateral tibial tubercle avulsion fractures.

Colitis como forma de presentación de una granulomatosis eosinofílica con poliangitis / Colitis as a form of presentation of eosinophilic granulomatosis with polyangiitis

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Limitation of flatfoot surgery in overcorrected clubfeet after extensive surgery.

INTRODUCTION: Flatfoot is a severe complication of extensive clubfoot surgery. In this retrospective study, we evaluated our results following flatfoot surgery in overcorrected clubfeet. The aim was to analyze the success of different surgical techniques, including tarsal osteotomies and arthrodesis, in correcting different types of flatfeet. MATERIAL AND METHOD: Between January 1, 2011 and December 31, 2015 we treated 25 severe cases of flatfeet after extensive clubfoot surgery. We classified the hindfoot deformities into rotational valgus, hinge valgus or translatory valgus based on AP standing X-rays. Tarsal osteotomies (Mitchell, Evans, Cotton) and arthrodesis were adapted based on age and severity. Age, gender, pain, hindfoot valgus and function were documented. Function and X-rays were compared pre- and postoperatively. RESULTS: There were 17 male and 4 female patients. Age at operation ranged from 11 to 26 years with an average age of 14.3 years. The mean follow-up was 27.6 months (7-60 months). Primary surgical treatment was a tarsal osteotomy in 19 cases and in six cases it was arthrodesis. Hindfoot valgus (Ø 18.6°-3.2°), calcaneal pitch (Ø 6.2°-14.6°), Costa Bartani angle (Ø155°-142°) and Meary angle (Ø 2.0°-8.8°) improved pre- to postoperatively. Range of motion did not improve after surgical correction. 81% were satisfied with the postoperative results. All flatfeet with translatory valgus, initially treated with a tarsal osteotomy, needed further arthrodesis due to primary undercorrection. CONCLUSION: Tarsal osteotomies are successful methods for correcting flatfeet following extensive clubfoot surgery with rotational valgus and mild hinge valgus. Tarsal osteotomies are unable to successfully correct flatfeet that have a translatory valgus. In such cases, we recommend double or triple arthrodesis. The functional outcome is limited by the preop range of motion and the appearance of talus deformities.