[Treatment of recurrent clubfoot and residual deformities after congenital clubfoot]. / Therapie des Rezidivklumpfußes und residueller Deformitäten nach kongenitalem Klumpfuß

Relapse and residual deformity after treatment of congenital clubfoot are common problems. Recurrences occur in up to 48 % of cases after successful initial treatment using Ponseti's technique. By casting and anterior tibial tendon transfer as recommended by Ponseti a flexible and well functioning foot can be achieved in most cases. Neglected clubfoot remains a demanding challenge. Depending on the severity of the deformity, the impairment of function and patient age, conservative and/or different operative treatment options can be considered. Manipulation and casting according to Ponseti is also recommended in toddlers with relapses even after peritalar joint release. Thus the need and extent of operative treatment can be reduced. Additional osteotomy may be indicated in more rigid feet and older children. An accurate evaluation of the existing deformity and functional impairment is mandatory for the individual choice of treatment. The number of previous operative procedures reduces the amount of improvement and mobility of the foot. Therefore, the best and most efficient treatment for recurrent clubfoot is prevention in the form of consistent primary treatment, consistently wearing braces and regular follow-up examinations.

[Spastic equinus foot]. / Spastischer Spitzfuß

Pes equinus is the most common deformity in cerebral palsy. A primarily dynamic pes equinus without shortening of the calf muscle in many cases turns into a structural pes equinus. This is due to insufficient linear growth of the calf muscle compared to bone growth. Structural pes equinus has to be distinguished from marked, compensatory and forefoot pes equinus. Conservative as well as operative treatment options are often applied in combination or sequentially. In dynamic pes equinus botulinum toxin A is the therapy of choice. Only slight structural pes equinus may improve under botulinum toxin A injection with and without additional casting. Usually, structural pes equinus requires operative treatment or lengthening of the gastrocnemius and/or soleus muscle (operation according to Baumann). Because of its side effect of inducing loss of power of the calf muscle, lengthening of the Achilles tendon should only be performed with caution. Especially in bilateral spastic cerebral palsy, the increased risk of causing talipes calcaneovalgus and crouch gait has to be considered.

[Congenital clubfoot]. / Kongenitaler Klumpfuss

Congenital clubfoot is one of the most common congenital skeletal deformities with an incidence of 1-2/1000 newborns. The deformity is characterized by pathological changes of joints, bones (especially the talus), muscles, tendons and soft tissues which result in subtalar malpositions known as talipes equinus, varus adductus and cavus. Secondary clubfoot is always part of an underlying systemic or neurologic disease and can occur at birth or develop over time. The treatment of clubfoot should start early after birth and is primarily conservative, involving manipulation and serial casting. Among conservative techniques available today, the Ponseti method is the treatment of choice. Applying this treatment protocol surgical therapy can be reduced in amount and extent. Extensive surgical therapy is only necessary in exceptional cases.

[Indications and results of corrective pelvic osteotomies in developmental dysplasia of the hip]. / Indikation und Ergebnisse hüftnaher Osteotomien bei Dysplasie.

BACKGROUND: Joint-preserving reconstructive surgeries in children and adolescents remain challenging for orthopaedists with regard to indication and surgical technique. Besides skeletal maturity and tissue quality at the time of surgery, the kind and degree of deformity, the causative pathologies in secondary dysplasias, and the prognosis have to be considered when deciding for or against a surgical procedure. Developmental dysplasia of the hip (DDH) is the most frequent deformity that indicates reorienting surgery on the hip joint in children and adolescents. The aim of these procedures is to prevent early secondary osteoarthritis. For patients and families as well as for the orthopaedist, risk-benefit analysis is of major interest. METHODS: In this study, the surgical techniques and specialties of different reconstructive operations are presented. Based on a review of the literature, the results of defined surgical methods are discussed and compared with own experiences. RESULTS: Only limited information is available about the clinical long-term outcome after defined reconstructing surgery on the hip joint in children and adolescents. The degree of the deformity, the age of onset, and the surgical experience of the orthopaedist are crucial factors in decision making for or against a surgical treatment. In early childhood, acetabuloplasty and Salter osteotomy are widely accepted to correct DDH. Triple and periacetabular osteotomies are preferred and have shown promising results in late adolescence and young adults. When the triradiate cartilage (growth plate) is closed, good outcomes can be achieved by the Ganz osteotomy. Intertrochanteric varus and derotation osteotomies of the femur may serve as additional procedures for pelvic osteotomies and are rarely indicated as a single procedure today. CONCLUSION: Reconstructive surgery on the hip joint improves function and may prevent early osteoarthritis and delay progression of cartilage degeneration in most patients when the indication and surgical technique are appropriate.