[Arthroscopic therapy of septic hip infections in childhood]. / Arthroskopische Therapie des septischen Hüftgelenksinfekts im Kindesalter.

OBJECTIVE: The treatment goal is to rapidly make a diagnosis and establish an effective arthroscopic therapy in order to allow the hip joint to develop normally throughout childhood with respect to anatomical and functional development. INDICATIONS: Coxarthritis suspected of being septic arthritis CONTRAINDICATIONS: No experience with arthroscopy, osteomyelitis of the dorsal femoral neck requiring an intervention. Relative contraindication: absence of cannulated systems. SURGICAL TECHNIQUE: Arthroscopic lavage of the hip joint, including revision of the femoral neck and debridement of osteomyelitis of the femoral neck with placement of an antibiotic carrier if necessary. The arthroscopy is performed using the two portal technique, placing the patient supine on a normal operation table (traction table not required). POSTOPERATIVE MANAGEMENT: Drain for 2-3 days with mobilization after removal of the drainage. A second look arthroscopy is not normally planned but may become necessary in cases without improvement of the clinical or laboratory test parameters and after follow-up magnetic resonance imaging (MRI). RESULTS: The two portal hip joint arthroscopy using an irrigation volume of 6-9 l is an efficient minimally invasive method to safely treat septic arthritis of the hip joint with or without concomitant femoral neck osteomyelitis. It is associated with low morbidity and offers all advantages of an arthroscopic procedure. Out of 23 children 19 could be sufficiently treated by a single arthroscopic lavage of the hip joint. In three patients an additional osseous component required a second intervention. Out of 23 children 22 achieved an excellent Harris hip score, with one girl only achieving a moderate outcome. The 22 children had an unrestricted hip function at follow-up and could return fully to previous activity levels.

[Treatment of septic arthritis of the hip in children and adolescents]. / Arthroskopische Behandlung von septischen Hüftgelenksinfekten im Kindes- und Jugendalter.

GOAL: Irrigation of the hip joint by hip arthrotomy represents the standard treatment for septic arthritis of the hip in childhood and adolescence. Arthroscopic lavages for treating a septic knee, elbow, ankle and glenohumeral joints are well established, but have only reached little acceptance in the therapy of septic hip arthritis in children. The goal of this study is to evaluate the advantages of the minimally invasive arthroscopic high-volume lavage for septic hip arthritis with regards to treatment safety and complication frequency. PATIENTS AND METHODS: 20 children aged 6.4 years on average (2-14 years) with obvious signs of septic arthritis of the hip proven clinically and by blood tests were arthroscopically treated in a 2-portal technique. In a prone position on a standard table the patient had the arthroscopic lavage procedure followed by insertion of a Redon tube. In all cases a histological sample and a bacterial swab were taken. A traction table was not used. In three children there was a stage I according to Stutz and Gächter, in thirteen a stage II and in four patients a stage III. Because of a concomitant femoral neck osteomyelitis in three cases and an osteomyelitis of the os pubis in a single patient, PMMA mini chains were locally administered. The histological samples were reported as purulent in 16 and as non-specific synovitis in four patients. In ten children a positive bacterial result was given, with Staphylococcus aureus found in 7 cases and single cases with Meningococci, Salmonella and Staphylococcus warneri. All patients received an intravenous antibiotic treatment for 14 days followed by four weeks of oral antibiotics. RESULTS: 16 out of 20 children were sufficiently treated by one single arthroscopic lavage. In three cases with additional osteomyelitis a secondary procedure was needed for removal of the antibiotic chain. During follow-up after an average of 2.9 years 19 of 20 children demonstrated a free range of hip joint motion and a full sporting activity without any restrictions. One girl with stage III arthritis and a preoperative duration of symptoms of seven days developed a femoral head necrosis and chondrolysis with hip joint subluxation. The other 19 patients regained an excellent Harris hip score at follow-up, whereas the girl only produced moderate score values. So, 19 children had an unrestricted function of their hips on the same activity level as before. CONCLUSION: The 2-portal hip arthroscopy with high-volume lavage represents a safe and minimally invasive method in order to successfully treat septic arthritis of the hip and concomitant femoral neck osteomyelitis in children and adolescents. This technique leads to a very low morbidity offering all advantages of arthroscopic procedures. The use of cannulated instruments through well established safe portals makes this arthroscopic lavage procedure a simple and easily adoptable technique.

[Pseudarthrosis following surgically treated forearm fractures in children and adolescents]. / Unterarmpseudarthrosen im Kindes- und Jugendalter.

AIM: Due to the changing attitude of treating paediatric forearm fractures increasingly towards the surgical stabilisation rather than conservatively by the method of elastic stable intramedullary nailing (ESIN), we are confronted with complications which have not been described in childhood previously. Pseudarthrosis following surgically treated forearm fractures in children is only found in single reports with none in the German-speaking area. The goal of this study is to define predisposing factors which may lead to pseudarthrosis after surgery for forearm fractures. METHOD: From 1990 to 2011 all children having sustained a pseudarthrosis following forearm fractures treated in our institution were included. All children who did not demonstrate a complete consolidation of the forearm fractures after 6 months from injury were considered for the study. Those pseudarthroses which were caused through systemic diseases were excluded. RESULTS: During the time period of 21 years, fourteen children were treated who fulfilled the criteria of having a pseudarthrosis. Nine of the fourteen children had primarily been treated in an outside hospital, five in our institution. The average age was 10.8 years (7-15 years). There were thirteen ulnar shaft and one radius shaft pseudarthroses. In 11 children the pseudarthrosis was located in the middle third and there was one child each with a pseudarthrosis in the proximal and distal third of the ulna. There were 13 ulnar shaft fractures and one monteggia lesion. Twelve of the fractures were primarily closed and there were two open cases. In nine cases an open reduction of the ulna was necessary, the radius was openly reduced in four patients. In five children technical mistakes of the osteosynthesis were identified to contribute to the formation of the pseudarthrosis. Five of the 14 children had experienced a re-fracture. Nine children had revision surgery. These children were treated by plate osteosynthesis or ESIN. In five patients the pseudarthrosis healed spontaneously without interference. There were 13 hypertrophic and one hypotrophic pseudarthroses. CONCLUSION: Pseudarthrosis of the forearm following surgical treatment of forearm fractures in children and adolescents mainly occurred in the middle third of the ulna. In primarily open fractures or in cases which needed to be openly reduced the risk of pseudarthrosis formation was higher. Inadequate osteosynthetic stabilisation is another factor to contribute to difficulties in fracture healing. Despite of the possibility of pseudarthrosis, the indication to ESIN treatment in paediatric forearm fractures is not doubted. It is important to keep the surgical trauma as small as possible if open reduction is required in order to not disturb the perfusion of the bone.

[Clubfoot associated with tibial and fibular hemimelia]. / Der Klumpfuß bei tibialer und fibularer Hemimelie.

AIM: Clubfoot is rarely associated with tibial or fibular hemimelia. Treatment is complex and in most of the cases extensive surgery is required. At present experience with Ponseti casting is limited. We describe casting and surgical treatment of 10 clubfeet associated with tibial and fibular hemimelia. MATERIAL AND METHOD: Between 1.1.2004 and 31.12.2009 398 clubfeet were treated with casting in our institution. In the same period 10 clubfeet were associated with fibular or tibial hemimelia. Treatment started in 9 clubfeet with Ponseti manipulation and casting. We used the classification of Weber for tibial hemimelia and the Kalamchi-Achterman classification and Paley classification for fibular hemimelia. Data of all patients were prospectively documented and the result of the foot deformity was evaluated before a first lengthening procedure. Documentation included patient data, associated foot pathologies, surgical procedures, functional results. Functional results were evaluated before the first lengthening procedure started. RESULTS: Three patients had tibial hemimelia, two Weber type 1, one Weber type 2, one Weber type 3. five patients had fibular hemimelia, Paley type IV or Kalamchi-Achterman Type IA. One child had bilateral fibular hemimelia. The prospective leg length discrepancy ranged from 3.2 cm to 14 cm. Four feet had initially a successful treatment with casting. In a type 2 according to Weber we performed an ankle reconstruction procedure to correct tibiofibular diastases. Four feet underwent PMR. We had four relapses. Two equinus relapses were treated with a posterior release. Two severe relapses were finally corrected with resection of the coalition and midfoot osteotomies. In a Weber type 3 case a complex reconstruction was performed using an Ilisarov and a TSF frame. Functional results showed in a mean follow-up of 42.2 months (24-72 months) a dorsiflexion between 5 and 20° (Ø 7.7°) and a plantarflexion between 10 and 40° (Ø 26.1°). CONCLUSION: Treatment of clubfoot associated with tibial or fibular hemimelia with the Ponseti technique is limited because of complex hindfoot deformities including tarsal coalitions. Nevertheless treatment after birth starts with casting. Only mild cases of hemimelia without coalition can be corrected with the Ponseti technique. In a case of tibiofibular diastasis successful casting is possible, but extensive surgery is often necessary. In more severe cases we do not recommend casting. In these cases surgical treatment, including posteromedial release, osteotomies for the hindfoot, resection of coalitions or complex osteotomies with Ilisarov or TSF frame is the treatment of choice.

Mimicry of lyme arthritis by synovial hemangioma.

To report on the differential diagnosis of lyme arthritis and synovial hemangioma due to similar clinical and radiological signs and symptoms. A 15-year-old boy presented at the age of 9 with recurrent rather painless swelling of the right knee. Altogether four episodes lasting for 1-2 weeks each occurred over a period of 18 months before medical advice was sought. Physical examination revealed only a slightly limited range of motion. Living in an endemic area of borreliosis, he reported a tick bite 6 months prior to onset of his symptoms with erythema migrans and was treated for 10 days with amoxicillin. Serology revealed two positive unspecific bands in IgG immunoblot (p41 and 66) with slight positivity for ELISA. Ultrasound revealed synovial thickening and increased fluid. Despite the weak positive serology a diagnosis of lyme arthritis could not be excluded and intravenous antibiotic treatment with ceftriaxone was started. After two further relapses antiinflammatory therapy including intraarticular steroids were introduced with no long lasting effect. A chronical disease developed with alternate periods of swelling and almost complete remission. Ultrasound as well as MRI demonstrated ongoing signs of synovitis, therefore after further progression, a diagnostic arthroscopy was performed showing an inconspicuous knee joint. A second MRI showed focal suprapatellar enhancement and was followed by open arthrotomy revealing a histopathological proven synovial cavernous juxtaarticular hemangioma. To our knowledge, the differential diagnosis of lyme arthritis and synovial hemangioma has not yet been reported despite obvious clinical similarities. In conclusion, in children and adolescents synovial hemangioma has to be considered in differential diagnosis of recurrent knee swelling. Early diagnosis is important to prevent prolonged suffering from chronic joint swelling with probable joint damages, unnecessary treatment procedures and as well school and sports absenteeism.

Combined dynamic contrast-enhancement and serial 3D-subtraction analysis in magnetic resonance imaging of osteoid osteomas.

The purpose of this study was to retrospectively correlate the results of dynamic contrast-enhanced magnetic resonance imaging (MRI) with histological and clinical diagnoses in patients with osteoid osteomas. Fifty-four patients with the MR diagnosis of osteoid osteoma were studied. MRI (1.5 Tesla) consisted of thin-section STIR sequences, dynamic 3D T1 gradient echo sequences during application of contrast material, and high-resolution postcontrast T1 spin echo sequences with fat saturation (maximum voxel size 0.6 x 0.6 x 3.0 mm). Evaluation was focused on serial image subtraction during the early phase after contrast injection and on time-intensity curves. The surrounding edema was helpful in finding the nidus in each lesion. In 49 of 54 patients (90.7%), the diagnosis of osteoid osteoma was certain or highly probable (sensitivity 1.0, positive predictive value 0.91). A total of 38 of 54 osteoid osteomas were histologically proven. Five MRI diagnoses were regarded as false positives. A similar proportion has been reported for computed tomography. Tailored high-resolution MR examinations with dynamic contrast enhancement can reliably diagnose osteoid osteomas and exactly localize the nidus without radiation exposure. We propose a stepwise approach with STIR sequences, dynamic contrast-enhanced scanning, and high-resolution postcontrast T1 spin echo sequences with fat saturation.