[Sonographic screening of the newborn hip at the university hospital Marburg--a long-run analysis]. / Sonografisches Screening der Neugeborenenhüfte am Universitätsklinikum Marburg--eine Langzeitanalyse.

BACKGROUND: Since 1985 the hips of the newborns have been sonographically screened at the University Hospital Marburg by staff of the Orthopaedic Department. This study was conducted to collect data on the local incidence of DDH (developmental dysplasia of the hip). Moreover, the diagnostic findings were checked critically to detect weak points. Another aim was to analyse the influence of investigators' experience on the treatment recommendation. MATERIAL AND METHODS: In a retrospective study, 18 247 hip sonograms in a treatment period from 1985 to 2009 were analysed. The following parameters were evaluated: perinatal incidents (e.g., breech presentation, Caesarean section, premature delivery), orthopaedic findings (e.g., club foot, limitation of hip abduction). Bony roof, superior bony rim and cartilaginous roof were analysed; α- and ß-angles and hip type according to Graf were documented. Comparisons between variables were calculated by means of adequate statistic tests. χ(2)-values and coefficients of correlation were used to detect significance. RESULTS: All in all 55 physicians of our Orthopaedic Department conducted 350 measurements on average (min. 1; max. 1993). Accuracy of documentation improved over time. In particular in the beginning of the screening, the hip angles according to Graf were not completely determined and sonograms were classified by "visual diagnosis". The ß-angle was not measured at the outset. In the course of time we measured a decrease of the diagnosis hip type II a according to Graf. In the years 1985-1989 more than 40 % of the hips were described as physiologically immature. We evaluated a numerical regression of hip type II a to 16 % in time period 1990-1994 and 9 % in time period 2005-2009. There was a significant correlation between breech presentation and decentering and eccentric hips. Inexperienced physicians recommend more often therapeutic interventions (p ≤ 0.01). Treatment of hip type II a according to Graf was inconsistent over time. CONCLUSION: This study demonstrates the necessity of standardised hip sonography. Treatment according to measured hip type should be concise. Training programmes both for instructors and medical assistant staff is mandatory. "Bedside teaching" is not constructive.

[Paediatric hip sonography: current status at German university hospitals]. / Sonographie der Säuglingshüfte: Aktueller Status an den deutschen Universitätskliniken.

BACKGROUND: This study was conducted to evaluate the current status of pediatric hip sonography at German university hospitals. MATERIAL AND METHODS: A questionnaire was sent to all heads of orthopedic departments in Germany. They were asked to give details of the technique and instrumentation used for hip ultrasound examination, local organization of consultation and options for advanced training of students and staff. RESULTS: The return rate of the questionnaires was 93.9 %. Pediatric hip ultrasonography was performed at every university hospital by staff of the orthopedic and trauma departments (n = 31, 100 %). A well-established tradition of teaching both medical students and physicians on this topic was reported by many departments. Courses with a focus on pediatric hip sonography were organized in 25.8 % of the German university hospitals. In the majority of the responding orthopedic and trauma departments a 7.5 MHz linear transducer for ultrasound examination (93.5 %), a foot switch for rapid freezing of the ultrasound image (93.5 %) and a cradle for positioning the infant (100 %) were used. A guided probe device recommended by Graf was only used in 35.5 % of the departments. Evaluation of the sonograms was performed in 19 of the clinics (61.3 %) in the classical way on printed paper strips. CONCLUSIONS: This survey documented the high importance of pediatric hip sonography in German university hospitals. Quality controls in the orthopedic departments are carried out internally. For this reason both the implementation of standardized training courses and the schooling of well-trained instructors are mandatory.

[Characteristics in treatment of the hip in patients with Down syndrome]. / Besonderheiten in der Behandlung des Hüftgelenks bei Kindern mit dem Down-Syndrom.

BACKGROUND: The treatment of hip instability in patients with Down syndrome is challenging. We have performed different pelvic osteotomies and corrections at the proximal femur for this indication. This retrospective study was conducted to evaluate the clinical and radiological outcome of each intervention. MATERIAL AND METHODS: All in all, 166 patients with Down syndrome were treated at our orthopaedic department in the observation period. Problems related to the hip joint were diagnosed in 63 of those patients. Only patients who underwent surgery were included in this study. The charts and X-rays of these 31 patients were evaluated with respect to the following parameters: incidence of the hip problem, concomitant diseases, temporal progress, kind of operation method and date, duration of stay in the hospital, after-care, follow-on surgery related to complications, AC angle, CE angle, ACM angle, CCD angle, index of migration according to Reimers, classification of Bauer and Kerschbauer and general morphology of the femoral head. The group was compared with an age-matched group of 21 patients with hip dysplasia. Those patients underwent the same sort of operation in the same year. RESULTS: In the Morbus Down group, we performed surgery for preservation of the hip in 49 cases. This included 13 osteotomies according to Chiari, 11 triple osteotomies according to Tönnis, 10 corrections by femoral varus derotation osteotomy, 8 pelvic osteotomies according to Pemberton, 5 pelvic osteotomies according to Salter and 2 open reductions of the hip. With respect to the moment of surgery, we detected three peaks of age. There was no difference in course of disease and quantity of complications between the groups. Satisfactory results concerning clinical and radiological outcome were achieved predominantly by complete redirectional acetabular osteotomies. Half of the patients who were solely treated by femoral varus derotation osteotomy needed follow-on surgery in the form of pelvic osteotomy. Comparison of preoperative and postoperative range of motion of the hip joint between groups detected capsular insufficiency, increased ligamentous laxity and muscular hypotonia in patients with Down syndrome. Comparison of pelvic radiographs demonstrated significant improvement concerning measured angles in both groups. Preoperative values with respect to AC angle and CE angle were demonstrated to be lower in the hip dysplasia group (p < 0.01); whereas values for ACM angle were comparable between groups. CONCLUSION: Hypermobility and secondary dislocation of the hip joint is a common problem in patients with Down syndrome, which often requires surgical intervention at an early stage. According to our data and clinical results we suggest a complete redirectional acetabular osteotomy in combination with capsular plication for treatment of this challenging condition.

[Measurement on printed paper strips or on the ultrasound device with computer assistance - which technique is more accurate in paediatric hip ultrasound?]. / Ausmessung auf Papier oder computergestützt am Ultraschallgerät - Welches Verfahren ist genauer in der Sonografie der Säuglingshüfte?

AIM: Two different measurement techniques of ultrasonograms of the infant hip were evaluated with respect to reproducibility of the Graf classification and variation of α- and ß-angles. MATERIAL AND METHODS: In a cross-sectional, blinded study, the hips of 207 consecutive newborn babies (101 male; 106 female) were sonographically screened at an average of 2.64 days after birth. Each hip was measured twice by three investigators with different levels of experience - a paediatric orthopaedic surgeon, a senior surgeon and a trained medical student. A mobile ultrasound system (SONOLINE G60S®, Siemens, Erlangen, Germany), equipped with a 7.5 MHz linear transducer, was used. Both hip joints were measured twice by all three investigators. The measurement was performed 6-8 weeks later in a blinded manner. The sonograms were initially printed out on high-quality paper strips and measured by pencil, ruler and goniometer. Finally, each investigator evaluated the same sonograms computer-assisted, using the trackball and dashboard of the ultrasound system. RESULTS: Concerning intraobserver reliability, we observed a significant reduction of variation both for α- and ß-angles in favour of the classic measurement on printed strips (p < 0.05). The interobserver calculation also detected a trend for higher angle variation when the angles were measured electronically. The reproducibility of Graf classification was not influenced by the kind of measurement technique. The outcome was not affected by investigator's level of experience (p > 0.05). CONCLUSIONS: This study demonstrated considerable advantages for the classic measurement of paediatric hip ultrasonograms with pencil and goniometer on printed paper strips compared to computer-aided measurement concerning variation of α- and ß-angles.

[Mid-term results of idiopathic clubfeet treated with the Ponseti method]. / Mittelfristige Ergebnisse der Behandlung des idiopathischen Klumpfußes mit der Ponseti-Methode.

AIM: The Ponseti method is accepted worldwide for the treatment of congenital clubfoot. We report about our experience in a 7-year period. The purpose of the study was to evaluate the history of well treated feet between primary correction and the age of 5-6 years with relapse rate and functional results. MATERIAL AND METHOD: Between 1.1.2004 and 31.12.2005 we treated 71 patients with 102 idiopathic clubfeet with the Ponseti method. All patients were prospectively evaluated. We used the Pirani score. The patients' results were documented when the children started to walk and before primary school. The results were compared and statistically evaluated. We used the McKay score and measured the talocalcaneal angle on lateral and a. p. radiographs. RESULTS: 89 % clubfeet were successful treated with the Ponseti method. At walking age plantar flexion was between 30° und 50° (∅ 42°) and dorsiflexion between 5° and 30° (∅ 25°). Before primary school plantar flexion was between 30° and 50° (∅ 37,8°) and dorsiflexion between 0° and 25° (∅ 13,9°). Using the McKay score we had 91 % excellent or good results. 31 % cases had surgical treatment of a relapse. In the relapse group 82 % had an excellent or good result according to the McKay score. CONCLUSION: The Ponseti method is a very effective technique to treat idiopathic clubfeet. In the first 5 to 6 years of age there is a significant loss of range of motion. The relapse rate is comparable to those of other clubfoot treatment concepts. The relapse treatment of the Ponseti technique, with recasting, tibialis anterior tendon transfer and Achilles tendon lengthening leads to good functional results.

[Operative and follow-up treatment of rotator cuff tears--the current situation]. / Operative Therapie und Nachbehandlung der Rotatorenmanschettenruptur--Aktueller Stand.

AIM: The aim of this study was to evaluate the current situation of rotator cuff repair and follow-up treatment in German hospitals. METHODS: An evaluated survey, enquiring about the year 2006, was sent to all 777 German orthopaedic and/or trauma surgery departments. The hospitals were chosen using the official index of hospitals from the German Federal Statistical Office. RESULTS: 44 % of the surveys were sent back, whereby 40 % were of use. Within the 309 departments, 26 % of the total number of 59,957 shoulder operations were rotator cuff repairs. Mini-open was the operation method in 49 %, open in 29 % and arthroscopic in 22 % of cases. Regarding the operational methods, there were differences between the departments and level of care. The arthroscopic technique was used sometimes in 48 % of the departments, whereas 52 % never used it. Specialised shoulder departments employed the total arthroscopic procedure more often. A set follow-up treatment occurred in 79 % of departments. CONCLUSION: Rotator cuff repair is mainly carried out using the mini-open method, which is nowadays regarded as gold standard.

[Parental enquiries before frequenting the outpatient paediatric orthopaedic consultation--focus Internet]. / Elterliche Recherche vor Aufsuchen der kinderorthopädischen Sprechstunde--Schwerpunkt Internetinformationen.

PURPOSE: Every day several million people are seeking for answers to medical problems via the internet. In particular parents, whose children are affected by systemic diseases, orthopaedic defective positions, anomalies or deformities, use the internet to increase their knowledge. Concerning this situation there is a lack of studies in the current literature. METHODS: We investigated parental preparation to the outpatient paediatric orthopaedic consultation at our University Hospital with respect to internet enquiries or further sources of information using a standardised questionnaire. We assessed age and educational background of the parents, local hardware equipment and general habits of internet use. In particular, we retrieved parental use of search machines (e.g., Google.de, Yahoo.de), general medical websites (e.g., netdoktor.de) and websites from self-help groups (e.g., klumpfusskinder.de). RESULTS: In total, 288 out of 300 questionnaires (96%) were evaluated. More than half of the parents (57%) were over 35 years of age and 78% were women. 82% of the study population had access to the internet at home and 70% used the internet regularly. More than 80% obtained information about the orthopaedic diseases of their child beforehand. Age and educational background of the parents were not significantly correlated with the extent of enquiries (p > 0.05). 90% of the parents, using the internet as source of information, frequented internet search machines; approximately one third used general medical websites. In particular in clubfeet we observed a highly significant (p < 0.001) tendency of parents to frequent websites from self-help groups. 60% of the study population assessed the internet information as useful; 92% will frequent the internet as source of information again. One third of the respondents is going to discuss the obtained internet information with the physician. CONCLUSIONS: The internet is an important source of information for parents in the field of paediatric orthopaedics. Treating physicians will be increasingly confronted with the results of parental internet enquiries.

[Radial head prosthesis - treatment of comminuted radial head fractures combined with elbow instability]. / Radiuskopfprothese - Behandlung von Radiuskopftrümmerfrakturen mit begleitender Bandinstabilität.

AIM: This cohort study shows the results after treatment of comminuted radial head fractures combined with elbow instability, using radial head arthroplasty. METHOD: Between 2001-2003, 25 patients with an unreconstructible comminuted fracture of the radial head and elbow instability were treated with a bipolar radial head prosthesis. Using the Mason/Johnston classification there were 15 type III and 10 type IV radial head fractures. In 17 cases the operation took place within a week. In 8 cases the prosthesis was implanted after 129 +/- 113 days. The mean follow-up time was 21 +/- 6 months. RESULTS: The range of elbow movement showed a loss of mean extention of 13 +/- 8 degrees and a mean flexion of 126 +/- 12 degrees . The mean pronation was 72 +/- 13 degrees and supination 76 +/- 12 degrees . According to the Morrey score there were 8 excellent results, 13 good, 3 fair and 1 poor. The mean DASH score was 21.3 (0-74). Compared to a reference group, similar in age and gender, the patients showed no notable differences in quality of life. In one case the prosthesis dislocated and another patient experienced an aseptic loosening of the stem. Seven patients were diagnosed with heterotopic ossification, stage I and II on the Ilahi scale. 96 % of patients were able to return to their preoperative working life. A comparison of acute and chronic radial head fractures, treated with prosthesis showed no difference in results. CONCLUSION: An arthroplasty with a radial head prosthesis can be recommended for unreconstructible comminuted radial head fractures with ligament injury.

[Arthroscopically-assisted combined anterior and posterior cruciate ligament reconstruction]. / Arthroskopisch assistierter simultaner vorderer und hinterer Kreuzbandersatz.

BACKGROUND: The best treatment of a combined rupture of the anterior and posterior cruciate ligaments is still unclear. METHODS: Nine patients with unilateral traumatic ruptures of both the anterior and posterior cruciate ligaments were treated by arthroscopically-assisted simultaneous reconstruction. The operation was done using hamstring tendon and patellar tendon autografts, an average of 235 days (range 52-567) after the initial trauma. Patients were followed up for an average of 37 months (range 24-58) after surgery. For this retrospective cohort study, we used the Lysholm knee score, the Tegner activity score, and the SF-36 questionnaire as a means of assessment. RESULTS: The evaluation at follow-up showed an average score of 74 points on the Lysholm scale. Using the IKDC evaluation, four patients could be placed in group B and five patients in group C. A significant increase, from 1.9 points before trauma to 5.0 points at follow-up, was observed on the Tegner activity score. Comparing the operated with the healthy knees, with respect to stability and isokinetic muscle strength, we noted significantly better scores in the healthy knees. Using the SF-36 questionnaire, patients showed a reduced level of physical well-being. CONCLUSION: The treated patients were able to carry out their activities of everyday life. However, none of them returned to their preinjury activity level.