[Modified Salter innominate osteotomy in adults]. / Modifizierte Salter-Innominatum-Osteotomie für Erwachsene.

OBJECTIVE: The dysplastic acetabulum is shifted three-dimensionally outwards and forwards. INDICATIONS: Symptomatic residual hip dysplasias and hip subluxations in skeletally mature patients up to the age of 50 years. Sharp's acetabular up to 60°, as an exception above 60°. CONTRAINDICATIONS: Acetabular retroversion. Radiographic joint space at the lateral acetabular edge that is less than half the normal thickness for the patient's age. Relative contraindication: Elongated leg on the affected side. SURGICAL TECHNIQUE: Ilioinguinal approach in a supine position. Division of the innominate bone. Pivoting the distal osteotomy fragment outwards and forwards with the aid of the Salter maneuver. Fixing the fragments with a guide wire. Final correction of the osteotomy fragments. Force fitting of a dovetail grooved, wedge-shaped bone graft. Insertion of a cannulated compression screw and two further threaded rods. Wound closure. POSTOPERATIVE MANAGEMENT: Unloaded 3­point walking for 4 weeks. Increasing weight bearing from week 4. Full weight bearing from week 10-12. RESULTS: A total of 45 consecutive patients (7 men, 38 women, 49 hips) underwent surgery. Average age at surgery was 27.6 years. The Sharp acetabular angle improved from preoperatively 45.7°â€¯± 4.2° by 13.8° to 32.0°â€¯± 6.4°; the Wiberg (LCE) angle increased from 15.4°â€¯± 9.3° by 19.5° to 34.9°â€¯± 10° postoperatively. The anterior center edge (ACE) angle increased from 28.9°â€¯± 10.4° by 8.6°â€¯± 2.3° to 37.5°â€¯± 8.1°. Complications requiring surgical intervention occurred in 7 patients.

[The great apophyses: Functional strain and relevance]. / Die großen Apophysen: Funktionelle Beanspruchung und Bedeutung.

BACKGROUND: The structure of apophyses and apophyseal growth plates is not substantially different from those of epiphyses and epiphyseal growth plates. In contrast to epiphyseal growth plates, apophyses and apophyseal growth plates do not contribute to the longitudinal growth of the extremity. They are associated with their adjacent joints, triggering the lengths of their lever arms and influencing their external shape and internal architecture. The formative stimulus on apophyses is given by muscles and tendons inserting at the apophysis or canopying the apophsis. APOPHYSIS OF THE GREATER TROCHANTER: The apophysis of the greater trochanter significantly contributes to the lever arm length of the hip joint. Its growth activity triggers the neck-shaft angle and finally the centration of the hip joint. TIBIAL APOPHYSIS: The tibial apophysis interacts with the slope of the proximal tibia and hereby influences the sagittal stability of the knee joint. A damage to the growth plate of the tibial tubercle leads to an anteverted tibial slope and a genu recurvatum difficult to treat. CALCANEAL APOPHYSIS: The calcaneal apophysis determines the length and position of the calcaneus and herewith influences the torque of the ankle joint. In a nutshell you may regard the apophyses as adjusting screws acting on their adjacent joints and influencing their growth, form and structure.

Dysplasia epiphysealis hemimelica of the distal ulna: a case report and review of the literature.

Dysplasia epiphysealis hemimelica (DEH) or Trevor's Disease is a very rare disease with an estimated incidence of one in 1.000.000. The majority of cases reported affect the lower limb and only 25 case reports of 33 cases with affection of the upper limb have been published. Here we present a case of DEH affecting the distal ulnar epiphysis and the lunate in an eleven-year-old girl, a DEH location described extremely rarely before. We firstly do not only present clinical and radiological findings (plane radiographs, CT, MRI), but also the surgical approach and the histopathological results of DEH in this uncommon location. Although extremely rare, DEH should be considered also in non-typical locations.

[Atypical course in Stickler syndrome]. / Ungewöhnlicher Verlauf eines Stickler-Syndroms.

We report about a 12-year-old boy with a Stickler syndrome. Because of osteonecrosis in the femoral head in MRI the initial diagnosis was dysplasia epiphysealis capitis femoris. The patient developed a progressive stiffness of the hip and a retinal detachment. A molecular investigation showed a Stickler syndrome. Stickler syndrome is an autosomal dominant hereditary disease. It has a very low incidence and a rare association with hip disease. Usually the patients suffer from hypermobility. In our case the course was atypical and diagnosis delayed.

[Ultrasound in the early diagnosis of congenital dislocation of the patella]. / Sonographische Frühdiagnose der kongenitalen Patellaluxation.

INTRODUCTION: Congenital dislocation of the patella is defined as lateral dislocation of the patella present at birth, impossibility of closed reduction and diagnosis before the age of 10 years. We report about a rare case of a bilateral congenital dislocation of the patella. CASE REPORT: Physical examination of an eight-month- old boy showed bilateral knee flexion contractures associated with moderate genu varum. On both sides the patella could not be palpated easily. Radiographic diagnosis could not show the patella as the patella normally ossifies later. Ultrasound examination located the patella lateral to the lateral femoral condyle on both sides. Closed reduction was impossible. An open reduction with division of the lateral soft tissues, lateral release, and derotation of the quadriceps femoris and refining of the medial structures was performed. After cast removal the patellae were both located in the intercondylar grooves as confirmed by clinical and ultrasound examinations of both knees. Active and passive exercises were started. CONCLUSION: Failure of internal rotation of the myotome which contains the quadriceps femoris and the patella is the etiology of congenital dislocation of the patella. The quadriceps acts as flexor, exerting a valgus stress on the knee, causing external rotation of the tibia. Diagnosis is often delayed because of the lack of pathological findings on plain radiographs. Early diagnosis is enabled by ultrasonography. Surgical treatment is necessary and results are good, as long as there are no secondary changes.

Neuromuscular function and radioanatomical form of the myelomeningocele hip.

The aim of this study was to describe variants in neuromuscular function and radioanatomical form of the myelomeningocele hip based on the level of spinal paralysis. For this purpose, 84 hip joints of 44 children with myelomeningocele age 1 to 10.75 years were classified into five spinal paralysis groups. Using anteroposterior pelvic radiographs, the position of the capital epiphysis, represented by the epiphyseal angle, and the position of the greater trochanter apophysis, represented by the apophyseal angle, were evaluated. The epiphyseal angle of the five paralysis groups showed three categories of average values. The thoracic/thoracolumbar group had an average of 0 degree, groups 2 (distal L1/L2) and 3 (distal L3/L4) had average values of 5 degrees to 6 degrees, and groups 4 (distal L5) and 5 (distal S1) had average values of 13 degrees to 14 degrees. The average values of the apophyseal angle showed a characteristic curve: the values dropped from group 1 (67 degrees) to groups 2 (45 degrees) and 3 (34 degrees) and then rose in groups 4 (44 degrees) and 5 (52 degrees). The authors concluded that the insufficiency of the hip abductors leads to a reduction of the epiphysis angle, and the relative insufficiency of the small glutei compared with the knee extensors leads to a reduction of the apophysis angle.

[Transfer of the psoas tendon to the, at its origin detached, rectus femoris muscle in infantile cerebral palsy]. / Verpflanzung der Sehne des Musculus psoas auf den abgelösten Ursprung des Musculus rectus femoris bei infantiler Zerebralparese.

OBJECTIVES: Correction of flexion contracture of hip allowing an erect position while standing and walking. The gain in function helps to prevent a neurogenic dislocation of the coxofemoral joint. INDICATIONS: In infants with cerebral palsy unable to straighten the body before they can stand or walk. In ambulatory spastic children and adolescents with bothersome hip flexion contracture. CONTRAINDICATIONS: Severe retardation of motor development in patients with cerebral palsy in whom walking and standing cannot be anticipated. Marked spastic-dystonic muscle weakness. SURGICAL TECHNIQUE: In general, soft tissue releases at hip and knee are performed at the same sitting. Anterior approach to the hip. Detachment of the sartorius from the anterior superior iliac spine and mobilization in a distal direction. Detachment of the rectus femoris from the anterior inferior iliac spine and retraction distally. Exposure of the femoral nerve in the lacuna musculorum. Exposure of the psoas and detachment from the lesser tuberosity. The tendon is mobilized in a proximal direction. Transfer of the rectus tendon on the divided psoas tendon. Reattachment of the sartorius or distal displacement into the fascia of the thigh. RESULTS: A clinical and radiological follow-up of 71 bilaterally operated patients. A pertinent complete radiographic documentation was possible in all but 1 patient. 49.3% (n=35) of patients were able to walk preoperatively compared to 80.3% (n=57) at the time of follow-up. The average migration percentage according to Reimers amounted to 28.4% preoperatively; it had regressed to 18.2% at the time of follow-up. In none of the patients did a subluxation or dislocation occur.

[Value of ultrasound in differential diagnosis of pediatric hip joint effusion (Perthes disease, C. fugax, epiphysiolysis coapitis femoris]. / Stellenwert der Sonographie in der Differentialdiagnose des kindlichen Hüftgelenksergusses (M. Perthes, C. fugax, Epiphysiolysis coapitis femoris).

UNLABELLED: Hip pain during infancy is frequently harmless by nature and hardly demands any therapeutic intervention. A careful differential diagnosis is of great importance. AIM: In our study we attempted to evaluate the significance of sonography as a non-radiant and economical aid in the differential diagnosis of hip diseases during infancy. METHODS: The study population consisted of children aged from 2 to 14 years, who visited our clinic with hip complaints and evident capsular distension (more than 2 mm compared to the contralateral hip joint) and without preceeding diagnosis. The study period was from 1988 to 1995. From the 82 children enrolled in this study we diagnosed Coxitis fugax (n = 54), Morbus Perthes (n = 19), Epiphysiolysis capitis femoris (n = 5), rheumatic Arthritis (n = 2), septic Arthritis (n = 1) and femoral Osteoid-Osteoma (n = 1). All patients with Coxitis fugax were scheduled for clinical and sonographic re-examination. RESULTS: Coxitis fugax is the most frequent disease of the hip during infancy. Perthes disease is the most important differential diagnosis up to the age of 10 years. Epiphysiolysis capitis femoris and rheumatic diseases proved to be most common differential diagnosis among elderly children. As a result of our study we were able to establish a diagnostic algorithm of hip diseases during infancy. Sonographic examination proves to be of great value especially in the differential diagnosis of Coxitis fugax and M. Perthes. In many cases the X-ray examinations which were previously mandatory could even be dispensed with. RELEVANCE: Although this concept requires careful supervision of the patients, it spares 60% of the children from undergoing X-ray examinations or MRI.

[Bilateral congenital radio-ulnar synostosis with hyperpronation--findings and surgical therapy]. / Beiderseitige angeborene radioulnare Synostose mit Hyperpronation--Befund und operative Therapie.

Congenital proximal synostoses of the ulna and radius do not require surgery in most of the cases, since the proximal synostosis can be sufficiently compensated by the wrist joint. In cases of considerable functional deficit, the synostosis has to be separated to enable re-ossification in a more advantageous position. We report on a patient with bilateral synostosis and a significant functional deficit due to the grotesque hyperpronation of the forearms. Following operative longitudinal separation and redressive casts, a good correction was obtained. X-ray imaging in lateral view documented the improved forearm position.

[Recurrent Perthes disease in a 6-year-old boy]. / Rezidiv eines M. Perthes bei einem 6-jährigen Jungen.

Two episodes of avascular necrosis in the same femoral capital epiphysis have been reported in Gaucher's disease and in six cases of Legg-Calvé-Perthes disease. The present case report is an additional example of a recurrent avascular necrosis in a six years old boy two years after complete healing of the first occurrence had been documented clinically and radiologically.

[Protrusion of a calcified cervical intervertebral disk in a 5-year-old boy]. / Protrusion einer verkalkten zervikalen Bandscheibe bei einem 5-jährigen Jungen.

Herniation of the calcified nucleus pulposus is a complication of intervertebral disc calcification. The herniated nucleus pulposus may assume an intraspinal location which may lead to cord compression and produce alarming neurological symptoms and radiographic images. Surgical intervention is, however, rarely necessary as complete resorption of the calcified disc material will generally occur. We report the case of a five years old boy with the symptoms of an acute tortcollis, radiographs of the cervical spine revealed calcification of C5/C6 intervertebral disc and MRI narrowing of the spinal canal. With conservative treatment his symptoms resolved within three weeks, three months later X-rays and MRI showed complete resolution of the calcification and herniation.

[Age-related force distribution at the proximal end of the femur in normally growing children]. / Die altersabhängige Kräfteverteilung am koxalen Femurende des normal wachsenden Kindes.

In a group of normally developed children and adolescents the age dependent distribution of forces at the proximal end of the femur was to be described. The results should explain why the shape of the proximal end of the femur changes significantly during the time of growth and why the neck shaft angle decreases. The method applied was the biomechanical computation analyzing in the coronal plane according to Pauwels' biomechanical hip model. The necessary age relevant data was derived from 675 anteroposterior pelvis radiographs of healthy children of both sexes and of varying age. The following can be put down as a result: 1. The proximal end of the femur is stressed by two resultant forces: the hip resultant force R controls the growth of the capital growth plate, the trochanteric resultant force RT regulates the growth of the greater trochanter growth plate. 2. During the growing period the hip resultant force R adjusts itself less vertically: during the second year of life it inclines at an average of 11,6 degrees towards the vertical, towards the end of the growing period it is incident with an inclination angle of 20 degrees. With the older child the magnitude of the hip resultant force R decreases in relation to the exerting body weight. 3. During the time of growth the trochanteric resultant force RT maintains its direction stability with inclination angles of 50-52 degrees towards the vertical. Its magnitude increases significantly (in relation to the exerting body weight). 4. From age 2 to 10 the projected neck shaft angle decreases from an average of 148.2 degrees to 133.7 degrees and usually remains stable. It can be concluded that the shape of the proximal end of the femur is determined by the muscle forces stimulating the greater trochanter apophysis and by gravity. With increasing age the growth of the greater trochanter apophysis shifts the insertions of abductor muscles laterally. As a result the directions of the hip abductors and the hip resultant force R incline. The neck shaft angle decreases consecutively.

[Peroneus tertius tendon repair following old traumatic rupture of the anterior tibial tendon (casuistry)]. / Peronaeus-tertius-plastik nach veralteter traumatischer ruptur der tibialis-anterior-sehne (kasuistik).

The etiology of anterior tibial tendon rupture and the results after secondary operation are described in one patient. A new operative technique using his peroneus tertius tendon as a free graft was performed. Follow-up after only 5 months showed almost normalized function in comparison to the uninjured leg. No additional loss of function owing to the operative method was noted. Ultrasound is of the highest diagnostic value in detecting the injury and in controlling the course of healing.

[Treatment of congenital tibial pseudarthrosis using a free vascularized fibula transfer and plate osteosynthesis. Case report]. / Die Behandlung der angeborenen Tibiapseudarthrose mittels freiem vaskularisiertem Fibulatransfer und Plattenosteosynthese. Fallbericht.

Congenital pseudarthrosis of the tibia is a rare disorder of unknown etiology. The free vascularized fibula-pro-tibia-transplant permits correction of the defect and the leg length-discrepancy during one surgical procedure. A 5 year old girl with congenital pseudarthrosis underwent a free vascularized fibular-pro-tibia-transplant. At a follow-up examination 5 years post surgery she had no subjective complaints, she walked without external orthopaedic support, there was no leg length-discrepancy. As stated in the literature the rates of bony unions are much higher than after conventional methods.

[Biomechanics of the hip joint in children]. / Studien zur Biomechanik des kindlichen Hüftgelenkes.

Based on the data derived from the examination of 16 infantile and juvenile anatomical hip specimens as well as the radiological examination of 1350 hip joints of healthy children, a biomechanical model of the developing hip was computed. This two-dimensional vector model describes the forces acting on the growth plates of the head and the greater trochanter during the one-legged stance. It could be proven that the apophysis of the greater trochanter is subject to compressive stress by lateral-cranial traction bands and therefore corresponds with a "pressure apophysis". The muscle forces acting on the trochanter apophysis can be combined as a trochanteric resultant RT. This stimulates a lateral-cranial growth of the trochanter apophysis. The direction of the hip abductors and, as a result, also the direction and the length of Pauwels' hip resultant R are influenced by this mechanism.