Lengthening of the ulna by callotasis in children with multiple hereditary exostoses: comparison of methods with and without internal fixation.

PURPOSE: The goal of this retrospective study was to compare the gradual lengthening of the ulna in children with multiple hereditary exostoses with and without an elastic intramedullary nail. METHODS: Between 1998 to 2018, the ulna was lengthened in 28 forearms in 21 patients (aged 7.1 to 16.6 years) using a monolateral external fixator when relative ulnar shortening exceeded 15 mm. In total, 16 forearms were lengthened with the external fixator (group I) and 12 forearms with the addition of an intramedullary elastic nail (group II). Subjective assessment of function, range of movement (ROM) of the wrist and elbow and complications were compared. Ulnar shortening, radial head dislocation, radial articular angle (RAA) and percentage of carpal slip and radial bowing were followed radiographically. The difference between the groups has been evaluated statistically. RESULTS: The function of the extremity improved partially in 81% of patients in group I and in 83% of patients in group II. ROM was not improved except for radial deviation. Radial head position did not change. The values in group II in comparison with group I are higher for gain of length and lower for bone lengthening index and for bone healing index. Carpal slip decreased insignificantly. The RAA and radial bowing decreased, the comparison of values between groups and age under and over ten years were not statistically significant. Complications were more common in group I. No permanent complications were noted. CONCLUSION: The addition of an intramedullary nail during the gradual ulnar lengthening improves the gain, bone healing index and rate of complications. LEVEL OF EVIDENCE: III.

Effects of the '11+ Kids' injury prevention programme on severe injuries in children's football: a secondary analysis of data from a multicentre cluster-randomised controlled trial.

BACKGROUND: To assess the effects of the injury prevention programme '11+ Kids' on reducing severe injuries in 7 to 13 year old football (soccer) players. METHODS: Football clubs (under-9, under-11 and under-13 age groups) from the Czech Republic, Germany, the Netherlands and Switzerland were cluster-randomised (clubs) into an intervention (INT) and a control group (CON). INT replaced their usual warm-up by '11+ Kids' two times a week. CON followed their regular training regime. Match and training exposure and injury characteristics were recorded and injury incidence rates (IRs) and 95% CIs calculated. For the present analysis, only severe injuries (absence from training/match ≥28 days) were considered. Hazard ratios (HR) were calculated using extended Cox models. RESULTS: The overall IR of severe injuries per 1000 football hours was 0.33 (95% CI 0.25 to 0.43) in CON and 0.15 (95% CI 0.10 to 0.23) in INT. There was a reduction of severe overall (HR 0.42, 95% CI 0.24 to 0.72), match (0.41, 0.17 to 0.95) and training injuries (0.42, 0.21 to 0.86) in INT. The injury types that were prevented the most were: other bone injuries 66%, fractures 49% and sprains and ligament injuries 37%. Severe injuries located at the knee (82%), hip/groin (81%), the foot/toe (80%) and the ankle (65%) were reduced tremendously. CONCLUSIONS: '11+ Kids' has a large preventive effect on severe injuries by investing only 15 to 20 min per training session. The present results should motivate coaches to implement effective injury prevention programmes such as the '11+ Kids' in children's football. TRIAL REGISTRATION NUMBER: NCT02222025.

A Multinational Cluster Randomised Controlled Trial to Assess the Efficacy of '11+ Kids': A Warm-Up Programme to Prevent Injuries in Children's Football.

OBJECTIVE: The objective of this study was to assess the efficacy of a newly developed warm-up programme ('11+ Kids') regarding its potential to reduce injuries in children's football. METHODS: Children's football teams (under 9 years, under 11 years, and under 13 years age groups) from Switzerland, Germany, the Czech Republic and the Netherlands were invited. Clubs were randomised to an intervention group and a control group, and followed for one season. The intervention group replaced their usual warm-up by '11+ Kids', while the control group warmed up as usual. The primary outcome was the overall risk of football-related injuries. Secondary outcomes were the risks of severe and lower extremity injuries. We calculated hazard ratios using extended Cox models, and performed a compliance analysis. RESULTS: In total, 292,749 h of football exposure of 3895 players were recorded. The mean age of players was 10.8 (standard deviation 1.4) years. During the study period, 374 (intervention group = 139; control group = 235) injuries occurred. The overall injury rate in the intervention group was reduced by 48% compared with the control group (hazard ratio 0.52; 95% confidence interval 0.32-0.86). Severe (74% reduction, hazard ratio 0.26; 95% confidence interval 0.10-0.64) and lower extremity injuries (55% reduction, hazard ratio 0.45; 95% confidence interval 0.24-0.84) were also reduced. Injury incidence decreased with increasing compliance. CONCLUSION: '11+ Kids' is efficacious in reducing injuries in children's football. We observed considerable effects for overall, severe and lower extremity injuries. The programme should be performed at least once per week to profit from an injury preventive effect. However, two sessions per week can be recommended to further increase the protective benefit. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02222025.

Hereditary Multiple Exostoses: Clinical, Molecular and Radiologic Survey in 9 Families.

Hereditary multiple exostoses (HME) represents a heterogeneous group of diseases often associated with progressive skeletal deformities. Most frequently, mutations in EXT1 and EXT2 genes with autosomal dominant inheritance are responsible for HME. In our group of 9 families with HME we evaluated the clinical course of the disease and analysed molecular background using Sanger sequencing and MLPA in EXT1 and EXT2 genes. The mean age in our group of patients, when the first exostosis was recognised was 4.5 years (range 2-10 years) and the number of exostoses per one patient documented on X-ray ranged from 2 to 54. Most of the exostoses developed before the growth was completed and they were dominantly localised in the distal femurs, proximal tibia, proximal humerus and distal radius. In all patients, at least one to 8 surgeries were necessary due to complaints and local complications, but neither patient developed malignant transformation. In half of the patients, the disease resulted in short stature. DNA analyses were positive in 7 families. In five probands, different EXT1 gene mutations resulting in premature stop-codon (p.Gly124Argfs*65, p.Leu191*, p.Trp364Lysfs*11, p.Val371Glyfs*10, p.Leu490Profs*31) were found. In two probands, nonsense mutations were found in EXT2 gene (p.Val187Profs*115, p.Cys319fs*46). Five mutations have been novel and two mutations have occurred de novo in probands. Although the risk for malignant transformation is usually low, especially in patients with low number of exostoses, early diagnostics and longitudinal follow up of patients is of a big importance, because early surgery can prevent progression of secondary bone deformities.

Soccer Injuries in Players Aged 7 to 12 Years: A Descriptive Epidemiological Study Over 2 Seasons.

BACKGROUND: As part of a risk-management approach, sound epidemiological data are needed to develop prevention programs. A recent review on soccer injuries of players younger than 19 years concluded that prospective data concerning children are lacking. PURPOSE: To analyze the incidence and characteristics of soccer injuries in children aged 7 to 12 years. STUDY DESIGN: Descriptive epidemiological study. METHODS: The present survey was a prospective descriptive epidemiological study on soccer injuries over 2 seasons in the Czech Republic and Switzerland. Exposure of players during training and match play (in hours) and injury data were reported by coaches via an Internet-based registration system. Location, type, and severity of injuries were classified according to an established consensus. Injury characteristics are presented as absolute numbers and injury incidence rates (injuries per 1000 hours of soccer exposure). An injury was defined as any physical complaint sustained during a scheduled training session or match play resulting in at least 1 of the following: (1) inability to complete the current match or training session, (2) absence from subsequent training sessions or matches, and (3) injury requiring medical attention. RESULTS: In total, 6038 player-seasons with 395,295 hours of soccer exposure were recorded. The mean (±SD) age of the players was 9.5 ± 2.0 years, and 3.9% of the participants were girls. A total of 417 injuries were reported. Most (76.3%) injuries were located in the lower limbs, with 15.6% located in the upper limbs. Joint and ligament injuries comprised 30.5%, contusions 22.5%, muscle and tendon injuries 18.5%, and fractures and bone injuries 15.4% of all injuries; 23.7% of injuries led to more than 28 days of absence from sport participation. The overall injury incidence was 0.61 (95% CI, 0.53-0.69) injuries per 1000 hours of soccer exposure during training sessions and 4.57 (95% CI, 4.00-5.23) during match play. Injury incidence rates increased with increasing age. CONCLUSION: The observed injury incidences were lower compared with studies in youth players. Children showed a relatively high proportion of fractures and bone stress and of injuries to the upper limbs. CLINICAL RELEVANCE: The study provides an evidence base for injury incidence rates and injury characteristics in children's soccer. These data are the basis to develop an age-specific injury-prevention program.

Lesion of gluteal nerves and muscles in total hip arthroplasty through 3 surgical approaches. An electromyographically controlled study.

PURPOSE: Three surgical approaches in total hip arthroplasty (THA) were compared concerning: 1) clinical and radiological results; 2) innervation of the tensor fasciae latae and gluteal muscles; 3) clinical outcome of the nerve lesions; 4) sensitivity of the EMG analysis. METHODS: A total of 70 patients aged 39-79 years were evaluated clinically and electromyographically before and 3-9 months after THA in 2 centres using the anterolateral approach in 22, transgluteal approach in 33 and posterior approach in 15 patients, respectively. RESULTS: 1) Hip flexion, external rotation and Trendelenburg lurch were reduced and the centre of the rotation was higher after the anterolateral approach. 2) The inferior branch of the superior gluteal nerve of the tensor fasciae latae muscle was mostly damaged in the anterolateral approach (73% of lesions), whereas innervations of gluteus medius (9% of lesions) and maximus muscles (no lesion) were preserved. The transgluteal approach most often caused a partially denervated gluteus medius (81.8%) and the tensor fasciae latae (48%) and the gluteus maximus muscle only in 29%, respectively. After the posterior approach, partial denervation in the gluteus medius and maximus muscles were noted in 53.3% and 71.4%, respectively, whereas in the tensor fasciae latae muscle in only 14%. 3) The power of the abductors was not significantly reduced in partially denervated muscles. 4) The EMG examination is not sensitive enough to determine the relevant power of hip abductors. CONCLUSIONS: Despite some disadvantages associated with the anterolateral approach, the transgluteal and posterior approaches are often connected with a partial lesion of the gluteus medius and maximus muscles. In all approaches, clinical sequelae are not significant in primary THA.

Proteomic analysis of the extracellular matrix in idiopathic pes equinovarus.

Idiopathic pes equinovarus is a congenital deformity of the foot and lower leg defined as a fixation of the foot in adduction, supination, and varus. Although the pathogenesis of clubfoot remains unclear, it has been suggested that fibroblasts and growth factors are involved. To directly analyze the protein composition of the extracellular matrix in contracted tissue of patients with clubfoot. A total of 13 infants with idiopathic clubfoot treated with the Ponseti method were included in the present study. Tissue samples were obtained from patients undergoing surgery for relapsed clubfeet. Contracted tissues were obtained from the medial aspect of the talonavicular joint. Protein was extracted after digestion and delipidation using zip-tip C18. Individual collagenous fractions were detected using a chemiluminescent assay. Amino acid analysis of tissue samples revealed a predominance of collagens, namely collagen types I, III, and VI. The high content of glycine and h-proline suggests a predominance of collagens I and III. A total of 19 extracellular matrix proteins were identified. The major result of the present study was the observation that the extracellular matrix in clubfoot is composed of an additional 16 proteins, including collagens V, VI, and XII, as well as the previously described collagen types I and III and transforming growth factor ß. The characterization of the general protein composition of the extracellular matrix in various regions of clubfoot may help in understanding the pathogenesis of this anomaly and, thus, contribute to the development of more efficacious therapeutic approaches.

Reconstruction of elbow flexion in arthrogryposis multiplex congenita type I: results of transfer of pectoralis major muscle with follow-up at skeletal maturity.

BACKGROUND: The purpose of this study was to analyze the results of a pectoralis major transfer to restore active elbow flexion in patients with extension elbow contracture in arthrogryposis. The hypotheses were: (1) this transfer ensures permanent useful elbow flexion; and (2) flexion elbow deformity will not progress during growth and after its cessation. METHODS: Unipolar transfer of the 3 distal parts of the pectoralis major muscle was used in 9 extremities of 5 patients (age range, 5 to 9 y; average age, 6.3 y) and the results were prospectively followed in the period of 13 to 16 years. Posterior elbow release was necessary in 5 extremities to achieve passive flexion of 90 degrees before the transfer. The subjective evaluation of daily living activities and data on the physical examination of the range of movement of the elbow, muscle strength, and electrical activity of the transferred muscle were assessed. Two specimens from transferred muscles were histologically examined. RESULTS: All extremities achieved the active elbow flexion. Significant improvement of function for daily living activities was achieved in 5 extremities (55.5%). It includes the following results: 1 very good with flexion of 90 degrees and a deficit of extension of 35 degrees; 2 good with flexion of 92 and 100 degrees and a lack of extension of 42 and 45 degrees; and 2 satisfactory with a limited arc of motion between 20 and 45 degrees. Four extremities remained unsatisfactory with the arc of motion of 5 to 15 degrees. Significant elbow flexion contracture of 70 to 80 degrees developed in 4 extremities. Extremities with a necessity of posterior elbow release achieved a limited range of movement or significant elbow flexion contracture. Electromyography corresponded to a partial denervation of the transferred muscle followed by reinervation. Histologic examinations showed partial atrophy with signs of ongoing regeneration. CONCLUSIONS: The hypotheses of the study were not confirmed, because this muscle transfer restores useful elbow flexion without flexion deformity if the passive flexion at children's age exceeds 90 degrees without a necessity of posterior release. In these cases, bilateral pectoralis to biceps transfer is recommended. LEVEL OF EVIDENCE: Level II.

Surgical treatment of lumbar spondylodiscitis: a comparison of two methods.

PURPOSE: This study evaluates two basic hypotheses: (1) the risk of an isolated dorsal approach to ventral lumbar spondylodiscitis based on clinical and radiographic results and (2) the risk of anterior radical debridement due to using a titanium implant in the site of bone infection. METHODS: Group A consisting of 23 patients was treated only by a dorsal transmuscular approach and group B consisting of eight patients was treated by two-stage posteroanterior surgery. Both evaluated groups were assessed before surgery, six weeks and one year after surgery with the Japanese Orthopaedic Association (JOA) score, visual analogue scale (VAS) and Kirkaldy-Willis functional criteria. To evaluate the sagittal balance restoration, measurement by the Cobb modified angle of the affected segment was performed. RESULTS: Differences (p < 0.001) in group A were found between JOA values before surgery (average 9.30) and at six weeks after surgery (average 11.82) and 12 months after surgery (13.27) and VAS differences before surgery (average 7.39), six weeks after surgery (average 3.82) and 12 months after surgery (average 2.36) in group A. According to the Kirkaldy-Willis functional criteria, 11 patients were evaluated as excellent, nine patients as good and two patients as poor. The values of the JOA score in group B showed an improvement compared with the JOA values before surgery (average 9.38) at six weeks after surgery (average 11.75) and 12 months after surgery (average 13.63), and the VAS score before surgery (average 7.38) was found to have improved six weeks after surgery (average 4.63) and 12 months after surgery (average 2.25). The functional evaluation according to the Kirkaldy-Willis functional criteria assessed three patients as excellent, four patients as good and one patient as fair. Radiographic examinations of group A revealed the following findings before surgery (average 1.75), six months after surgery (average -3.73) and 12 months after surgery (average -0.79) and in group B before surgery (average 3.71), six weeks after surgery (average -8.21) and 12 months after surgery (average -6.45). CONCLUSIONS: The results demonstrate the minimum serious surgical complications and greater loss of sagittal balance without clinical correlation in group A. We did not find any relapse or persistence of the infection in the post-operative period in group B.

The influence of triple pelvic osteotomy on birth canal size.

INTRODUCTION: The aim of this study was to investigate the influence of triple pelvic osteotomy on the internal pelvic dimensions and thus on the potential for normal vaginal delivery. METHODS: Data were acquired by processing fixed anatomical specimens of 19 female pelves with maintained sacrotuberous and sacrospinous ligaments after unilateral and bilateral osteotomy, respectively. The specimens were measured and x-ray images and photographs were taken. RESULTS: The dimensions in the plane of the pelvic inlet and the plane of the greatest pelvic dimension after unilateral osteotomy increased in 51%, remained unchanged in 34% and in 15% of cases they decreased. The most critical locations for the passage of fetus decreased in average from 0.016 cm in distantia interspinalis in the plane of the least pelvic dimension to 0.695 cm in distantia intertuberositas in the plane of the pelvic outlet. After bilateral osteotomy are decreases more significant from 0.226 cm (2.05%) to 1.00 cm (9.51%). Decreases we observed in the monitored dimensions were not so big in comparison to other published studies. CONCLUSION: Results of this study confirm our hypothesis that unilateral triple pelvic osteotomy does not significantly narrow the bony birth canal and so it does not impede the ability to deliver per vias naturales in female patients with this surgical procedure in anamnesis. After bilateral triple osteotomy we would rather recommend Caesarean section.

Muscle transfers in children and adults improve external rotation in cases of obstetrical brachial plexus paralysis: a comparative study.

PURPOSE: Latissimus dorsi and teres major transfers to the lateral side of the humerus with lengthening of the pectoralis major and subscapularis muscles for residual shoulder deformity were compared in children and skeletally mature patients. METHODS: Fifteen patients (nine children, six skeletally mature patients aged three to 30 years, follow-up one to 22 years) were treated for internal shoulder contracture after birth plexus lesions: C5-C6 (seven patients); C5-7 (five patients); C5-C8-T1 (three patients, respectively). Range of movement, Mallet shoulder function score and radiographs were assessed. RESULTS: Pre-operatively, shoulder function restrictions were comparable in all patients. Postoperatively, external rotation, abduction and Mallet function score improved significantly (p < 0.05) in all patients except one. There were no differences in improvement between children and skeletally mature patients (p = 0.24-1.0). CONCLUSIONS: This technique improves external rotation and abduction of the shoulder for daily living activities in children and young, skeletally mature, patients.

Comparison of the short-term and long-term results of the Ponseti method in the treatment of idiopathic pes equinovarus.

PURPOSE: Congenital club foot is one of the most common birth defects involving the musculoskeletal system. At present two methods are used for the treatment of this deformity: French and Ponseti method. The purpose of this study was to compare the short-term (up to three years) and long-term (three to seven years) results of treatment with the Ponseti method. METHODS: A total of 195 consecutive infants (143 boys and 52 girls) with idiopathic club foot treated with the Ponseti method in the period of 2005-2012 were included in this study; the total number of feet was 303. The severity of the foot deformity was classified according to Diméglio. When relapse occurred up until three years of age, we started with the casting again. If conservative treatment was unsuccessful we proceeded to surgical treatment. RESULTS: Primary correction was attained in all cases. Surgical correction of relapses was performed in 30 % of patients according to the Ponseti method (re-tenotomy of the Achilles tendon and transposition of the tibialis anterior) and in 70 % by alternative techniques. The number of relapses indicated for surgery increased with increasing period of follow-up: whereas in patients where the treatment started already in 2005 relapses occurred in 72 %, in patients included in 2011 the number of recurrences only reached 3 %. CONCLUSIONS: It follows from our results that it is impossible to cure all club feet with casting, tenotomy of the Achilles tendon and transposition of the tibialis anterior only.

Anteromedial wedge reduction osteotomy for the treatment of femoral head deformities.

Aspherical femoral head deformity has poor a prognosis which can lead to early arthritic changes in young adults. The intraartricular anteromedial wedge reduction osteotomy restores sphericity of the femoral head.
We performed seven anteromedial wedge reduction osteotomies. Clinical indications were pain, limp and restriction of movement of the hip joint. The mean age at time of the surgery was 13.3 years. The aetiology of the femroal head deformity was Perthes disease in six patients and in one patient, multiple epiphyseal dysplasia. All seven hips were classified as Stulberg V before surgery.
At a mean follow-up of 17.4 months the Harris hip score increased from a mean of 55.4 preoperatively to a mean of 84.8 postoperatively. The final results were Stulberg IV in one hip, Stulberg III in four hips and Stulberg II in two hips postoperatively. The capital diaphyseal ratio dropped from average of 1.57 preoperatively to 1.21 postoperatively. No signs of osteonecrosis were recorded. One patient suffered a subluxation of the femoral head.
The anteromedial wedge reduction osteotomy has good short-term results in aspherical incongruent hips.

Cruciate ligaments in proximal femoral focal deficiency: arthroscopic assessment.

BACKGROUND: Because there is limited information concerning the cruciate ligaments in proximal femoral focal deficiency, knee arthroscopy was used to identify the changes of cruciate ligaments and their relation to the different types of this deficiency. METHODS: Knee arthroscopy was performed in 21 consecutive patients with deficiency types III, IV, VII-IX using the Pappas classification. A new classification of the knee was created. It contains types I, II, III according to the findings of the anterior cruciate ligament (ACL) (type I: normal, type II: hypoplasia, type III: aplasia) and 3 subtypes A, B, C according to the findings of the posterior cruciate ligament (PCL) (type A: normal, type B: hypoplasia, type C: aplasia), respectively. Instrumented and radiologic drawer testing was provided additionally in 2010. RESULTS: The changes of the cruciate ligaments were found in all but 1 patient. Type I was found in only 2 patients. In 1, both cruciate ligaments were intact (type IA). In the other patient, the ACL was intact, but the PCL was absent (type IC). Hypoplastic ACLs (type II) were found in 4 patients, namely in 3 patients with normal PCLs (type IIA), whereas in 1 patient the PCL was absent (type IIC). In the majority of patients, the ACLs completely failed (type III, 15 patients). Absence of both cruciate ligaments was found in 8 patients (type IIIC). PCLs were intact in 4 patients (IIIA) or were hypoplastic in 3 patients (IIIB), respectively. Instrumental drawer testing was not reliable in patients of our group. Radiologic testing showed a posterior shift of the tibia in the majority of patients on the affected side. Anterior and posterior drawer tests were increased in a majority of patients, but did not directly correlate to the presence/absence of cruciate ligaments. CONCLUSIONS: Variable changes of the cruciate ligaments were found in all but 1 patient with proximal femoral focal deficiency. These changes were not related to the type of Pappas classification. Despite the lower clinical relevance of the changes in majority of patients, imaging of cruciate ligaments is recommend before lengthening of the extremity to avoid dislocation of the knee. LEVEL OF EVIDENCE: I - Testing of previously developed diagnostic criteria in series of consecutive patients.

Computed tomographic angiography in proximal femoral focal deficiency.

BACKGROUND: Because there is limited information concerning the vascular pattern and the role of vessels in patients with proximal femoral focal deficiency, the vascular supply of the lower extremities was studied systematically with use of computed tomographic angiography in order to identify vascular changes, relate any vascular changes to the classification of the deficiency, and establish that there are no major changes in the topographical anatomy of the vessels. METHODS: Standardized computed tomographic techniques were used in twenty-one patients (thirteen boys and eight girls who ranged from one to nineteen years old) with proximal femoral focal deficiency types I through IV and VII, VIII, and IX, according to the Pappas classification. RESULTS: A common anatomical vascular pattern, in which the hypoplastic extremity was supplied through the femoral artery, was detected in nineteen patients. In patients with Pappas type-I through IV disease, the external iliac, femoral, and deep femoral arteries were substantially reduced in length and diameter and the deep femoral artery arose more proximally in comparison with that in the contralateral extremity; however, in the patients with Pappas type-VII, VIII, or IX disease, the diameters of the arteries and the origin of the deep femoral artery were similar to those of the contralateral extremity. In two patients with Pappas type-III disease, atypical anatomy of the vessels was found. The anterior part of the thigh and the pseudarthrosis were supplied through the femoral artery (the external iliac artery) as a terminal branch, while the remainder of the extremity was supplied from the internal iliac artery, which entered the thigh posterior to the hip as the inferior gluteal artery and continued as the artery to the sciatic nerve to the popliteal artery. No substantial anastomoses were found between the femoral and the posterior arteries in these vascular patterns. CONCLUSIONS: Computed tomographic-angiographic reconstruction can be used to depict the spatial configuration of the pseudarthrosis and the vascular pattern of the extremity in patients with proximal femoral focal deficiency. We found distinct vascular changes in the majority of the involved thighs, but there were no typical changes related to the Pappas classification. Because we found atypical vascular patterns in two patients, evaluation of the vessels with use of various diagnostic methods is recommended in patients with severe types of proximal femoral focal deficiency.

Reconstruction of elbow flexion in arthrogryposis multiplex congenita type I. Part I: surgical anatomy and vascular and nerve supply of the pectoralis major muscle as a basis for muscle transfer.

PURPOSE: The anatomy and neurovascular supply of the pectoralis major muscle was studied in order to establish the safe and functional muscle transfer for the reconstruction of elbow flexion in patients with arthrogryposis multiplex congenita (AMC). METHODS: Twenty pectoralis major muscles were dissected in 11 adult cadavers. The distribution of the motor end plates was studied in five pectoralis major muscles in foetuses by the detection of esterases. RESULTS: The pectoralis major muscle consists of clavicular, manubrial, sternocostal, costal and abdominal parts. Each part has a distinct vascular and nerve supply. The motor nerves arise from the medial and lateral pectoral nerves. The motor end plates are localised in one zone in the clavicular and manubrial parts and in two oblique zones in the distal parts of the muscle. In 15 cases, each of the muscle parts were supplied by one nerve branch. In four cases, six nerves were distinguished and the clavicular part was supplied by two nerves. In one case, four nerves were found, with the clavicular and manubrial parts supplied by one common nerve. Three branches (13 cases) or two arterial branches (seven cases) supplied the muscle, arising from thoracoacromial and lateral thoracic arteries, respectively. The superior branch supplied the clavicular and manubrial parts, whereas the dominant pectoral branch supplied the manubrial, sternocostal and costal parts of the muscle. The inferior branch of the lateral thoracic artery supplied the abdominal part in 13 cases. In seven cases, the inferior branch failed and the abdominal part was supplied from the dominant branch. CONCLUSION: This study presents guidelines for the transfer of the distal parts of the pectoralis major muscle for the reconstruction of elbow flexion. The sternocostal, costal and abdominal parts of the muscle can be released as a unit from the chest wall after dissection between the second and third rib and be transferred to the brachium. They are sufficiently supplied from the dominant pectoral branch of the thoracoacromial artery in all cases and inconstantly from the inferior branch of the lateral thoracic artery and from three motor nerves.

Pelvic osteotomy in the neurogenic unstable hip.

Background. The purpose of our study was to evaluate treatment outcome in pelvic osteotomy for neurogenic hip instability, mainly in combination with soft tissue procedures, open reduction in dislocated hips, and proximal femoral osteotomy. Material and methods. 19 patients with neurogenic hip instability were treated from 1996 to 2005, with 29 pelvic osteotomies: 23 for cerebral palsy (15 patients), 5 for meningomyelocoele (3 patients), and 1 for sciatic nerve palsy. There were 19 subluxated and 10 dislocated hips. Results. In the CP patients, 13 patients reported improvement, one patient reported no change, and one patient reported deterioration. In objective assessment, improvement in gross motor function was found in 13 patients, in one patient unchanged, and in one patient walking ability deteriorated. In radiological evaluation, normal or dysplastic hips were achieved in 15 hips (66%). Eight hips (34%) progressively subluxated in follow-up with no redislocation. The subluxations led to repeated surgery in 2 patients. Avascular necrosis of the femoral head occurred in 2 hips (8%). All the MMC and paralytic patients improved in their movement activities. In radiological criteria, all hips were initially improved, but in the follow-up, 3 hips remained dysplastic and 3 hips resubluxated, leading to repeated surgery in one patient. Conclusions. Different types of pelvic osteotomies should be chosen in neuromuscular hip instability according to the hip deformities in order to achieve a stable and congruent hip. The combination with soft tissue release and femoral varus derotation osteotomy offer satisfactory outcomes mainly in the early stage of instability.