Midterm Development of Ultrasound-unstable Hip Joints After Overhead Traction and Treatment With Tübingen Splint and Fettweis Plaster: A Radiologic Follow-up Analysis Over 5.5 Years.

PURPOSE: The aim of this study was to determine the success rate for treatment of ultrasound unstable hips (type D, III and IV) with Fettweis plaster in terms of a midterm follow-up from the very beginning in the neonatal period until the age of 4 to 8 years. METHODS: In total, 69 unstable hips, which were successfully treated with Fettweis plaster and after with a flexion-abduction splint, were included into the study. Hip delvelopment was followed by determining the acetabular index (ACI) on routine pelvic radiographs at the age of 12 to ≤24, 24 to ≤48 and 48 to ≤96 months and the center edge angle on the latter, and classifying both angles according to Tönnis. RESULTS: After initially successful treatment, the first radiograph at the age of 12 to ≤24 months showed 39.1% (n=27) hips with normal findings, 33.2% (n=23) hips with slightly dysplastic findings, and 27.5% (n=19) hips with severe dysplastic findings. Comparison between first and second radiograph showed improvement of the ACI in 9/69 hips and between the second and third time point in 20/69 hips. Overall, 20 hip joints showed deteriorations. Hereby, 16 deteriorations took place after the first radiograph and 4 after the second radiograph. Deteriorations were observed independently of the initial hip type (D, III, and IV). CONCLUSIONS: Midterm results indicate that radiologic controls should be provided to detect deteriorations after finishing treatment. ACI and center edge angle are helpful parameters in the assessment of hip joint development in the age range of 4 to 8 years. LEVEL OF EVIDENCE: Level III.

Radiological long-term follow-up up to 12 years of initially ultrasound unstable hip types D, III and IV after treatment with the Tübingen splint worn as a plaster.

INTRODUCTION: The treatment of ultrasound unstable hips with the Tübingen splint is currently under discussion. However, there is a lack of long-term follow-up data. This study presents to the best of our knowledge first radiological mid-term to long-term data of the successful initial treatment with the Tübingen splint of ultrasound unstable hips. MATERIALS AND METHODS: From 2002 to 2022 the treatment of ultrasound unstable hips type D, III and IV (age ≤ 6 weeks, no severe limitation of abduction) with the Tübingen splint worn as a plaster is evaluated. Based on data derived from routine X-rays during the follow-up period, a radiological follow-up (FU) analysis until the age of 12 years was performed. The acetabular index (ACI) and center-edge angle (CEA) were measured and classified according to Tönnis as normal findings (NF), slightly (sliD) or severely dysplastic (sevD). RESULTS: 193 of 201 (95.5%) unstable hips could be successfully treated showing normal findings with an alpha angle > 65°. The few patients showing treatment failures were successfully treated applying a Fettweis plaster (human position) under anesthesia. The radiological FU of 38 hips showed a favorable trend with increase of normal findings from 52.8% to 81.1% and decrease of 38.9% to 19.9% of sliD respectively 8.3% to 0% of sevD hips. The analysis of avascular necrosis of the femoral head showed 2 cases (5.3%) of grade 1 according to Kalamchi and McEwen, which were improving over time in the further course. CONCLUSIONS: The Tübingen splint as alternative to replace a plaster has proven a successful therapeutic option for ultrasound unstable hips type D, III and IV with favorable and over time improving radiological parameter up to the age of 12 years.

Outcome after subtalar screw arthroereisis in children with flexible flatfoot depends on time of treatment: Midterm results of 95 cases.

OBJECTIVES: The subtalar screw arthroereisis (SSA) is a treatment option for painful pediatric flexible flatfeet (PFF). Hence, the optimal time point for a SSA is discussed controversially. Therefore the present study evaluates the influence of the patient's age at surgery on the radiological outcome to provide further evidence in this matter. METHODS: From 08/2007 to 12/2015 50 patients with 95 PFF were included. Inclusion criteria were: 1) Patients with PFF under or equal 15 years of age, 2) treatment with SSA and 3) presence of pre-op, post-op and follow up (FU) routine biplane radiographs. A subdivision was made into group A: 5-8 years, group B: 9-12 years and group C: 13-15 years. The radiographs were analyzed for: 1) calcaneal-pitch (CP), 2) lateral talocalcaneal angle (lat. TCA), 3) a.p. talocalcaneal angle (a.p. TCA, kite angle) and 4) navicular-cuboidal-index (NCI) and meary angle. RESULTS: Our study showed the best deformity correction when surgery was conducted between 9 and 12 years of age (group B), with significant improvement in all measured parameters without secondary deterioration during FU. In group A, the SSA show inferior results with poorer long-term success with only an improvement in the a.p. TCA. Group C showed mixed results. While CP and NCI improved, the lat. TCA deteriorated in FU. In conclusion, the ideal age for surgical intervention by SSA is between 9 and 12 years. Surgery before the age of 8 years did not show long-term success and delayed treatment at the age of 13-15 was only partially successful with deterioration during FU period. LEVEL OF EVIDENCE: IV.

Osteochondritis dissecans shows a severe course and poor outcome in patients with juvenile idiopathic arthritis: a matched pair study of 22 cases.

Juvenile osteochondritis dissecans (JOCD) and juvenile idiopathic arthritis (JIA) are both common diseases which may affect joints and bony structures in pediatric patients. In some cases, JOCD and JIA occur at the same time. In this study, the course of JOCD in patients with JIA was therefore evaluated to provide possible recommendations for further treatment opportunities and control examinations. From 06/2012 to 03/2018 55 children with JOCD with or without JIA were examined. Inclusion criteria were: (1) age ≤ 16 years, (2) diagnosis of a JOCD with or without JIA and (3) two routine MRI controls. The JOCD evaluation based on the classification according to Bruns and the measurement of the largest extent via MRI. 18 of these 55 children met our criteria: 11 JOCD findings of 7 patients with JIA (group A) were matched according to age and localization of JOCD to 11 patients without JIA (group B). Mean age of disease onset of JIA was 8.2 years (oligo JIA) and of JOCD 11.6 years. The mean time follow-up was 17.7 months. At all observation time points more JOCD findings (with stage III° and IV°, respectively) along with a significant deterioration was seen in group A compared to group B. The comparison of the last MRI control between group A and group B shows a significant smaller defect size (decrease of 54.5%, p = 0.028) in group B (97.9 ± 48.9 mm2) as in group A (185.1 ± 102.9 mm2). In comparison of first (169.7 ± 84.2 mm2) and last MRI (97.9 ± 48.9 mm2) a significant decrease in lesion size of JOCD in group B was seen (decrease of 58.4%, p = 0.048). Patients with JIA show a more progressive and severe course of JOCD. Therefore, we recommend (1) the early use of MRI in patients with JIA and persistent joint pain to detect potential JOCD and (2) in presence of JIA and JOCD regular MRI follow-up controls to identify deteriorating JOCD findings and prevent early joint destruction in pediatric patients.

Improving results in rat fracture models: enhancing the efficacy of biomechanical testing by a modification of the experimental setup.

BACKGROUND: Animal fracture models, primarily performed in rats, are crucial to investigate normal and pathological bone healing. However, results of biomechanical testing representing a major outcome measure show high standard deviations often precluding statistical significance. Therefore, the aim of our study was a systematical examination of biomechanical characteristics of rat femurs during three-point bending. Furthermore, we tried to reduce variation of results by individually adapting the span of bearing and loading areas to the bone's length. METHODS: We examined 40 paired femurs of male Wistar-rats by DXA (BMD and BMC of the whole femur) and pQCT-scans at the levels of bearing and loading areas of the subsequent biomechanical three-point bending test. Individual adjustment of bearing and loading bars was done respecting the length of each specimen. Subgroups of light (< 400 g, n = 22) and heavy (> 400 g, n = 18) animals were formed and analysed separately. We furthermore compared the results of the individualised bending-setting to 20 femurs tested with a fix span of 15 mm. RESULTS: Femurs showed a length range of 34 to 46 mm. The failure loads ranged from 116 to 251 N (mean 175.4 ± 45.2 N; heavy animals mean 221 ± 18.9 N; light animals mean 138.1 ± 16.4 N) and stiffness ranged from 185 N/mm to 426 N/mm (mean 315.6 ± 63 N/mm; heavy animals mean 358.1 ± 34.64 N/mm; light animals mean 280.8 ± 59.85 N/mm). The correlation of densitometric techniques and failure loads was high (DXA R2 = 0.89 and pQCT R2 = 0.88). In comparison to femurs tested with a fix span, individual adaptation of biomechanical testing homogenized our data significantly. Most notably, the standard deviation of failure loads (221 ± 18.95 N individualized setting vs. 205.5 ± 30.36 N fixed) and stiffness (358.1 ± 34.64 N/mm individualized setting vs. 498.5 ± 104.8 N/mm fixed) was reduced by at least one third. CONCLUSIONS: Total variation observed in any trait reflects biological and methodological variation. Precision of the method hence affects the statistical power of the study. By simply adapting the setting of the biomechanical testing, interindividual variation could be reduced, which improves the precision of the method significantly.

Development of unstable hips after treatment with the Tübingen splint: mid-term follow-up of 83 hip joints.

INTRODUCTION: Early diagnosis and treatment of hip dysplasia are widely accepted as major factors for beneficial outcome. However, modalities for reduction and retention as well as for imaging are currently under clinical investigation. Local and general risk factors, e.g., breech presentation and the family's desire to avoid in-hospital treatment are major concerns in the decision-making process and consultation. For treatment of unstable hips in newborns the treatment with the Tübingen splint has proven good results in recent studies. However, mid- and long-term outcome studies are missing. We report on clinical results and X-ray parameter of initially unstable hips after treatment with the Tübingen splint at two time points: 12-24 and 24-48 months of age. MATERIALS AND METHODS: Included were newborns with 83 unstable hips (type D, III, IV according to Graf) which were successfully treated with the Tübingen splint-used as reduction splint 24 h per day/7 days per week-until type I hips were documented by ultrasound examination. Measurments are based on routine pelvic X-ray control at the age of 12-24 and 24-48 months. The acetabular angle was determined and according to the Tönnis-Classification evaluated into: normal findings (< 1 s), slightly dysplastic findings (1-2 s) and severely dysplastic findings (> 2 s). Children with secondary hip dysplasia were not included in this series. RESULTS: In 2nd year of life, 45 hips (54.2%; initial hip type D: 47.4%, III: 63.2%, IV: 42.9%) of the formerly unstable hips show normal X-ray findings. Although final ultrasound showed normal findings, at this time point 28 hips (33.7%; initial hip type D: 34.2%, III: 31.6%, IV: 42.9%) were slightly dysplastic and 10 (12.0%%; initial hip type D: 18.4%, III: 5.3%, IV: 14.3%) still severely dysplastic. At the age of 24-48 months, the percentage of radiologic normal hips had increased to 61 hips (73.5%; initial hip type D: 68.4%, III: 81.6%, IV: 57.1%), the number of slightly (19 hips) and severely dysplastic (3 hips) hips had decreased 22.9% (initial hip type D: 28.9%, III: 15.8%, IV: 28.6%) respectively 3.6% (initial hip type D: 2.6%, III: 2.6%, IV: 14.3%). At this time no operative intervention was neccessary. CONCLUSIONS: Our mid-term data show on the one hand a good development of unstable hips after successful treatment with the Tübingen splint. On the other hand despite successful therapy and normal ultrasound findings at the end of treatment further imaging by X-ray are mandatory to close follow-up and to detect those which might need surgical correction of residual dysplasia.

Use of the Tübingen splint for the initial management of severely dysplastic and unstable hips in newborns with DDH: an alternative to Fettweis plaster and Pavlik harness.

AIM: Hip dysplasia is one of the most common skeletal disorders. As a late consequence 20-25% of the patients are at risk to develop secondary osteoarthritis and may require total hip replacement early in life. The treatment principles of hip dislocation are (1) concentric reposition, (2) retention, i.e., plaster in human post or Pavlik harness and (3) maturation in abduction flexion orthesis. The Tübingen splint was introduced as a further development of abduction devices for the treatment of (residual) hip dysplasia with stable hips. The advantages are easy handling, adjustment according to growth and safe limitation of abduction. The aim of this study was to determine the success of treatment of unstable hips with use of the Tübingen splint from early diagnosis until final end of therapy hence normal ultrasound findings. METHODS: From January 2003 to August 2016 79 children with 109 sonographic unstable hips were treated with the Tübingen splint initially consequently 24 h/day. Inclusion criteria were diagnosis of type D, type III a/b or type IV hips according to Graf and beginning of treatment at an age of less or equal 6 weeks, without limitation of abduction on clinical examination. RESULTS: At the time of diagnosis 51 type D (46.8%), 46 type III (42.2%) and 12 type IV (11.0%) hips were noticed. In 30 patients (38.0%) bilateral hip dysplasia (type D-IV) was diagnosed. 104 of 109 hips (95.4%) treated with the Tübingen splint could be transferred in a type I hip after a mean treatment period of 88.9 days (SD ± 26.0). In 5 cases (4.6%, 1 type III and 4 type IV hips) the treatment failed. CONCLUSION: Our data show, that successful treatment of unstable hips in neonates with the Tübingen splint is a comparably successful treatment modality relative to the Pavlik harness and Fettweis plaster.

Effects of thromboprophylaxis on mesenchymal stromal cells during osteogenic differentiation: an in-vitro study comparing enoxaparin with rivaroxaban.

BACKGROUND: Low-molecular-weight heparins (e.g. Enoxaparin) are widely used to prevent venous thromboembolism after orthopaedic surgery, but there are reports about serious side effects including reduction in bone density and strength. In recent years new oral antithrombotic drugs (e.g. direct Factor Xa-inhibitor, Rivaroxaban) have been used to prevent venous thromboembolism. However, there is lack of information on the effects of these new drugs on human mesenchymal stromal cells during osteogenic differentiation and, therefore, effects during postoperative bone healing. METHODS: We evaluated the effects of Rivaroxaban and Enoxaparin on the proliferation, mRNA and surface receptor expression as well as differentiation capacity of primary human mesenchymal stromal cells during their osteogenic differentiation. RESULTS: Enoxaparin, but not Rivaroxaban treatment significantly increased human mesenchymal stromal cell (hMSC) proliferation during the first week of osteogenic differentiation while suppressing osteogenic marker genes, surface receptor expression and calcification. CONCLUSIONS: This is the first paper to demonstrate that Rivaroxaban had no significant influence on hMSC differentiation towards the osteogenic lineage, indicating a less affected bone healing process compared with Enoxaparin in vitro. Based on these findings Rivaroxaban seems to be superior to Enoxaparin in early stages of bone healing in vitro.

Customised osteotomy guides and endoprosthetic reconstruction for periacetabular tumours.

PURPOSE: We sought to analyse clinical and oncological outcomes of patients after guided resection of periacetabular tumours and endoprosthetic reconstruction of the remaining defect. METHODS: From 1988 to 2008, we treated 56 consecutive patients (mean age 52.5 years, 41.1 % women). Patients were followed up either until death or February 2011 (mean follow up 5.5 years, range 0.1-22.5, standard deviation ± 5.3). Kaplan-Meier analysis was used to estimate survival rates. RESULTS: Disease-specific survival was 59.9 % at five years and 49.7 % at ten and 20 years, respectively. Wide resection margins were achieved in 38 patients, whereas 11 patients underwent marginal and seven intralesional resection. Survival was significantly better in patients with wide or marginal resection than in patients with intralesional resection (p = 0.022). Survival for patients with secondary tumours was significantly worse than for patients with primary tumours (p = 0.003). In 29 patients (51.8 %), at least one reoperation was necessary, resulting in a revision-free survival of 50.5 % at five years, 41.1 % at ten years and 30.6 % at 20 years. Implant survival was 77.0 % at five years, 68.6 % at ten years and 51.8 % at 20 years. A total of 35 patients (62.5 %) experienced one or more complications after surgery. Ten of 56 patients (17.9 %) experienced local recurrence after a mean of 8.9 months. The mean postoperative Musculoskeletal Tumor Society (MSTS) score was 18.1 (60.1 %). CONCLUSION: The surgical approach assessed in this study simplifies the process of tumour resection and prosthesis implantation and leads to acceptable clinical and oncological outcomes.

Acute osteomyelitis of the humerus mimicking malignancy: Streptococcus pneumoniae as exceptional pathogen in an immunocompetent adult.

BACKGROUND: Chronic osteomyelitis due to direct bone trauma or vascular insufficiency is a frequent problem in orthopaedic surgery. In contrast, acute haematogenous osteomyelitis represents a rare entity that almost exclusively affects prepubescent children or immunodeficient adults. CASE PRESENTATION: In this article, we report the case of acute pneumococcal osteomyelitis of the humerus in an immunocompetent and otherwise healthy 44-year-old male patient presenting with minor inflammation signs and misleading clinical features. CONCLUSIONS: The diagnosis had to be confirmed by open biopsy which allowed the initiation of a targeted therapy. A case of pneumococcal osteomyelitis of a long bone, lacking predisposing factors or trauma, is unique in adults and has not been reported previously.

A novel technique to treat Grisel's syndrome: results of a simplified, therapeutical algorithm.

PURPOSE: Grisel's syndrome is a rare entity and usually develops in paediatric patients after otolaryngologic surgery or infection. It is defined as a fixed torticollis combined with a rotatory atlanto-axial subluxation. The success rate of physiotherapy is low. Conventional therapy concepts imply stage-related recommendations based on the Fielding classification (type I-IV). This classification was introduced in 1977 to assess the degree of subluxation between atlas (C1) and axis (C2). Thus, instability increases from type I to IV. Higher stages may require surgical intervention. The purpose of this study was to evaluate the value of an alternative, less invasive treatment protocol in Grisel's syndrome. METHODS: Irrespective of the underlying Fielding type we treated five children (Fielding type I-III) by manual repositioning under general anaesthesia. Consecutively, the cervical spine was immobilized with a Minerva cast for four to eight weeks. Additional surgical treatment or immobilization in a Halo-Fixateur was not necessary. RESULTS: Overall period of treatment was reduced, even in patients with delayed diagnosis. No case of recurrence was observed within a follow-up of six months. CONCLUSIONS: Current conventional recommendations suggest invasive treatment with Halo-Fixateur in patients with higher degrees of subluxation (e.g., Fielding type III) or after delayed diagnosis. Even in those patients, this novel therapy concept enables us to achieve excellent clinical results without surgical intervention.

Surgical resection and radiation therapy of desmoid tumours of the extremities: results of a supra-regional tumour centre.

PURPOSE: Desmoid tumours of the extremity have a high recurrence rate. The purpose of this study was to analyse the outcome after resection of these tumours with special emphasis on recurrent disease and adjuvant therapeutic strategies. METHODS: In this retrospective study we evaluated prognostic factors for recurrence-free survival after surgical treatment of desmoid tumours of the extremity in 27 patients with an average age of 41 years treated from 1997 to 2009. Adjuvant radiotherapy (50-60 Gy) was given in five cases with primary and in nine patients with recurrent disease. The average follow-up was 64 months. RESULTS: The five-year recurrence-free survival in patients with primary disease was 33%. Patients with negative resection margins tended to have a better outcome than patients with positive resection margins, but the difference between both groups was not significant (56 vs 14%, p = 0.145). In patients with positive margins, adjuvant radiotherapy did not significantly improve recurrence-free survival (40 vs 14%, p = 0.523). Patients with local recurrence had a five-year further recurrence-free survival of 47%. In those patients further recurrence-free survival was significantly better after adjuvant radiation (89 vs 25%, p = 0.015). Two thirds of all patients suffered moderate or severe complications due to the treatment regimen. CONCLUSIONS: Compared to desmoids of the trunk or the head and neck region, desmoids affecting the limbs show by far the worst outcome in terms of relapse or treatment-related morbidity. The importance of negative resection margins is still not clear. Particularly in recurrent desmoids adjuvant radiotherapy appears to reduce the further recurrence rate. Therefore, a general use of radiation should be considered for this high-risk group.

Total hip replacement in developmental dysplasia using an oval-shaped cementless press-fit cup.

PURPOSE: Acetabular roof deficiency due to subluxation of the femoral head (Hartofilakidis type II) increases the complexity of total hip arthroplasty. In these cases some form of support is usually required, to reach stable fixation of the acetabular component. Pursuing this aim, the oval-shaped cementless cranial socket could be an alternative to conventional treatment options. METHODS: Between 1998 and 2008, 37 patients (40 hips) underwent primary total hip arthroplasty using the cranial socket (mean follow-up 5.6 years, range 26 to 133 months). In a retrospective study we compared these clinical and radiological results with the results of a matched control group consisting of 35 patients (40 hips) treated with a standard cementless hemispherical cup in combination with bulk femoral autografting (mean follow-up 6.9 years, range 30 to 151 months). RESULTS: There were no statistically significant differences in the HHS (p=0.205) or the SF-36 (p=0.26) between both groups. There was no prosthesis failure due to septic or aseptic loosening. Time of surgery was significantly shorter in the cranial socket group (p<0.001). The acetabular component could be placed in the ideal rotational hip centre in 24 (60%) hips in the cranial socket group and 32 (80%) hips in the control group, respectively. CONCLUSIONS: Our study indicates, that the cranial socket can be an alternative treatment option for the reconstruction of acetabular deficiency in osteoarthritis secondary to developmental dysplasia.

Alloplastic reconstruction of the extensor mechanism after resection of tibial sarcoma.

Reconstruction of the extensor mechanism is essential for good extremity function after endoprosthetic knee replacement following tumor resection. Only a few biological methods have been able to reliably restore a functional extensor mechanism, but they are often associated with significant complication rates. Reattachment of the patellar tendon to the prosthesis using an alloplastic patellar ligament (Trevira cord) can be an appropriate alternative. In vivo and in vitro studies have already shown that complete fibrous ingrowth in polyethylene chords can be seen after a period of six months. However, until now, no biomechanical study has shown the efficacy of an alloplastic cord and its fixation device in providing sufficient stability and endurance in daily life-activity until newly formed scar tissue can take over this function. In a special test bench developed for this study, different loading regimes were applied to simulate loads during everyday life. Failure loads and failure modes were evaluated. The properties of the cord were compared before and after physiological conditioning. It was shown that rubbing was the mode of failure under dynamic loading. Tensile forces up to 2558 N did not result in material failure. Thus, using an artificial cord together with this fixation device, temporary sufficient stable fixation can be expected.

Rifampicin has - Compared to clindamycin - A dose and time dependent effect on hMSCs during osteogenic differentiation in vitro.

BACKGROUND: The effects of rifampicin and clindamycin on human mesenchymal stromal cell (hMSC) were examined. METHODS: hMSC were cultured with rifampicin and clindamycin (0.5 µg/ml, 5 µg/ml, 50 µg/ml) and examinations of proliferation (Bromodeoxyuridine), calcification (Alizarin red) and mineralization (alkaline phosphatase) were performed after 7th, 14th and 21st days. RESULTS: With rifampicin (50 µg/ml) cultured hMSC showed a significant negative effect during proliferation, mineralization (7, 14 and 21 days) and calcification (21 days). Clindamycin seems to have no effect. CONCLUSIONS: Rifampicin in a dosage of 50 µg/ml showed a negative impact on proliferation, mineralization and calcification of hMSC after 21 days.

Histologic examination of the shoulder capsule shows new layer of elastic fibres between synovial and fibrous membrane.

PURPOSE: In the present study, a systematic histological analysis of the glenohumeral joint capsule was conducted. MATERIALS AND METHODS: 12 cadaveric shoulders were examined. Inclusion criteria were: 1) intact joint capsule and 2) fixation in neutral position. The tissue samples were Elastica Hematoxylin-van-Gieson-(ElHvG) stained and diameter, quantity, and distribution patterns were analyzed. RESULTS: We detected a new layer (elastic boundary layer, EBL) between the synovial and fibrous membrane. The elastic fibres of the EBL differ considerably in diameter, quantity, and distribution pattern. CONCLUSIONS: A previously undescribed layer was noticed, which we named elastic boundary layer for now.

Treatment of unstable hips with the Tübingen splint in early postnatal period: radiological mid-term results of 75 hips with mean follow-up of 5.5 years.

PURPOSE: For treatment of unstable hips, the Tübingen splint is a treatment option. After the initial treatment, regular radiological follow-up examinations are recommended but there is a lack of long-term outcome studies. Therefore, the further development of unstable hips treated with the Tübingen splint were evaluated. METHODS: From 2004 to 2015 116 patients with 161 unstable hips treated with the Tübingen splint were evaluated. Inclusion criteria were: 1) successfully treated unstable hip (type D, III and IV); 2) pelvic radiographs at the age of one to ≤ two, two to ≤ four and four to ≤ eight years. The acetabular index (ACI) of all and the centre-edge angle (CEA) of the third radiograph were measured and classified according to the Tönnis classification. RESULTS: A total of 53 patients with 75 unstable hips (type D 34 (45.3%), III 33 (44.0%), IV 8 (10.7%)) were included. In comparison of the first, second and third radiograph, an increase of normal findings was seen in 31 (41.3%) to 53 (70.7%) and 60 (80.0%) hips, respectively. However, a decrease of slightly dysplastic hips from 31 (41.3%) to 19 (25.3%) and 14 (18.7%) respectively and severely dysplastic hips from 13 (17.3%) to three (4.0%) and one (1.3%) hip respectively was detected. In comparison of first to second radiograph, 32 hips improved and five hips deteriorated and of second to third radiograph 16 hips improved and six hips deteriorated. The Tönnis classification of ACI compared with CEA showed no significant differences (p = 0.442). CONCLUSION: This study shows a good development of unstable hips treated with the Tübingen splint with mean follow-up 5.5 years. Nevertheless, unexpected deteriorations could be identified. The CEA is an alternative to the ACI. LEVEL OF EVIDENCE: IV.

MRI reveals unrecognized treatment failures after application of Fettweis plaster in children with unstable hip joints.

We evaluated the success of treatment of unstable hip joints with the Fettweis plaster followed by MRI to detect potential treatment failures. A total of 132 ultrasound-detected unstable hips of type D, III, or IV according to Graf were treated with closed reduction and Fettweis plaster, followed by MRI. We examined 19 type D, 55 type III, and 58 type IV. Mean age at diagnosis was 84.5 days (SD: ± 55.4). Treatment period was 63.2 days (SD: ± 22.2). In 13 cases, the MRI showed a poor reduction. After repetition of this treatment, all 13 showed a concentric reduction. The use of MRI detects 9.8% of treatment failures. We recommend an MRI examination after each closed reduction to ensure the success of the therapy.

Blood supply in the bicipital groove: A histological analysis.

The vascular anatomy in the closed bicipital groove with the long head of the biceps brachii muscle tendon (LHBT), its mesotenon and the transverse ligament intact has not been analyzed on a histological level yet. An anatomic dissection and histologic study was conducted by using 24 cadaveric formaldehyde fixated shoulders. The bicipital groove including the LHBT and its intact sheath was cut en-bloc, fixated, sliced in 7 µm sections, Azan stained and the vascular anatomy analyzed under light microscopy. Each sideward branch deriving from the main ascending branches of the anterior humeral circumflex artery (ACHA) in the mesotenon of the LHBT was identified and followed through multiple sections to identify its direction and area of supply. Per specimen, a mean of 2.71±1.85 branches could be identified running through the soft tissue of the mesotenon towards the osseous walls of the groove. Of the total 65 arterial branches in all specimens, 22 (33.8%) were running into the medial wall of the groove and 40 (61.5%) into the lateral wall (P<0.01). The results indicate that branches of the ACHA in the mesotenon of the LHBT provide blood supply not only to the tendon but to the osseous bicipital groove as well and here significantly more to the lateral than to the medial osseous wall. In addition, Pacini-like mechanoreceptors could be identified in the mesotenon in 9 (37.5%) of the specimens which has not been described up to now.

Lengthening of newly formed humerus after autologous fibula graft transplantation following intercalary tumor resection.

Secondary limb lengthening after intercalary bone resection in pediatric patients is still challenging. After the resection, a free fibula autograft can be used to reconstruct the osseous gap. However, in particular in young pediatric patients, insufficient growth of the epiphyseal plate after transplantation may lead to a significant limb-length discrepancy (LLD). In this case, the autograft was used for limb lengthening. We report on the lengthening of a humerus regenerate after fibula autograft transplantation into a humeral defect in a pediatric/young adolescent patient. Because of LLD, she underwent callus distraction of the humerus regenerate after transplantation of a fibula autograft using a unilateral external fixator device. An 18-year-old female patient with status postintercalary proliferating chondroma resection (at the age of 7 years) required treatment for correction of a 13 cm humerus shortening. She reported no pain, had no functional limitations, and had a full range of motion of the shoulder and elbow joint. She complained about her short humerus and overall body scheme. A unilateral external fixator device for callus distraction was applied to the transplanted humerus regenerate after free fibula autograft transplantation. Bone lengthening was performed by distraction (2×0.5 mm/day). After 62 days and a lengthening of 6 cm in total, bone distraction was stopped mainly to avoid any complication. At this time, there was no limitation in the range of motion. No nerve palsy or other problems occurred at any time of the distraction. In pediatric patients, the transplantation of a fibula autograft is a well-established option to bridge an osseous gap after intercalary bone resection. This case report shows that even the humerus regenerate after fibula autograft transplantation has excellent potential for callotasis and bone remodeling and therefore bone lengthening in patients with LLD is an option even after transplantation of an autograft. This method provides a new therapeutic option for patients with LLD after fibula transplantation.