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.

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.

Radiographic outcome after greater trochanteric epiphysiodesis in patients with Perthes disease.

Purpose: Legg-Calvé-Perthes disease often leads to greater trochanteric overgrowth, which negatively affects the biomechanics of the hip joint. This study aimed to evaluate the physiologic growth of the greater trochanter and the effectiveness of greater trochanteric epiphysiodesis radiographically. Methods: Retrospectively, 46 children (33 male, average age at greater trochanteric epiphysiodesis 8 ± 1.3 years) with unilateral Legg-Calvé-Perthes disease undergoing greater trochanteric epiphysiodesis with screws and curettage of the epiphysis were included. On radiographs of the pelvis pre- and postoperatively (mean follow-up 3.5 years), trochanteric height, articulotrochanteric distance, and center-trochanter distance were determined and compared to the unaffected side. Reference values for the physiological development of trochanteric height, articulotrochanteric distance, and center-trochanter distance over time were established. Results: Greater trochanteric epiphysiodesis reduced trochanteric growth by 29% measured by trochanteric height, but only statistically significant in the group "<8 years" (p = 0.02). Regression analysis revealed inhibition of trochanteric growth of 0.92 mm/year. Both articulotrochanteric distance and center-trochanter distance of the affected and unaffected side converged during the follow-up period: articulotrochanteric distance of the affected hip increased (preop: 11.2 ± 7 mm, maturity: 18.5 ± 10 mm; p < 0.01) compared to no change on the unaffected side (preop: 19.3 ± 5 mm, maturity: 18 ± 6 mm; p = 0.69). Center-trochanter distance of the affected hip stayed unchanged (preop: (-7.9) ± 7 mm, maturity: (-7.8) ± 9 mm; p = 0.13). On the unaffected side, center-trochanter distance became negative (preop: 0.9 ± 6 mm, maturity: (-6.5) ± 5 mm; p < 0.001). Measured by articulotrochanteric distance and center-trochanter distance, 31.8% achieved an optimal result. Conclusion: Greater trochanteric epiphysiodesis has a positive effect on greater trochanter growth and therefore on hip anatomy. Further studies must show whether these positive effects also result in biomechanical and functional benefits. Level of evidence: level III.

Approach to the management of slipped capital femoral epiphysis and primary hyperparathyroidism.

CONTEXT: Worldwide, only nine cases of revealing slipped capital femoral epiphysis (SCFE) associated with primary hyperparathyroidism (PHP) have been reported. CASE ILLUSTRATION: This study included adolescent subjects with the described association, the clinical course, and exhibiting the leading pathogeneses. METHODS: Here, we reviewed all known cases and developed an effective approach to the management of SCFE and PHP. RESULTS: In cases of emergency, SCFE fixation is primarily done regardless of any preexistent hypercalcemia due to PHP and followed by parathyroidectomy as soon as possible. In cases of mild and moderate hypercalcemia, whether SCFE fixation is followed by parathyroidectomy and vice versa or resolved during a single operating session depends on manifest side effects due to hyercalcemia. Patients with severe hypercalcema should undergo urgent parathyroidectomy, followed by immediate orthopedic surgery, even as a simultaneous procedure. This is to avoid onset of hypercalcemic side effects or worsening of preexisting side manifestations resulting from hypercalcemia. CONCLUSION: Our report demonstrates that SCFE presenting with hypercalcemia, with signs of low bone density, or in atypical age deserves further workup for secondary causes. In addition, the newly developed systematic approach toward achieving an effective, efficient management should help to improve the patients' long-term outcome.

Approach to the management of slipped capital femoral epiphysis and primary hyperparathyroidism.

CONTEXT: Worldwide, only nine cases of slipped capital femoral epiphysis (SCFE) associated with primary hyperparathyroidism (PHP) have been reported. CASE ILLUSTRATION: This is a report on adolescent subjects with SCFE associated with PHP exhibiting the leading pathogenesis and clinical course. METHODS: Here, we reviewed all known cases and developed an effective approach to the management of SCFE and PHP. RESULTS: In cases of emergency, SCFE fixation is primarily done regardless of any preexistent hypercalcemia due to PHP and is followed by parathyroidectomy as soon as possible. In cases of mild and moderate hypercalcemia, whether SCFE fixation is followed by parathyroidectomy and vice versa or resolved during a single operating session depends on the side effects of hypercalcemia. Severely hypercalcemic patients should undergo urgent parathyroidectomy followed by immediate orthopedic surgery or even as a simultaneous procedure. This is to avoid onset of hypercalcemic side effects or worsening of preexisting side manifestations resulting from hypercalcemia. CONCLUSION: Our report demonstrates that SCFE patients presenting with hypercalcemia, signs of low bone density, or with non-typical age of onset deserve further workup for secondary causes. In addition, the newly developed systematic approach toward achieving an effective, efficient management should help in improving the patients' long-term outcome.

The 8-plate versus physeal stapling for temporary hemiepiphyseodesis correcting genu valgum and genu varum: a retrospective analysis of thirty five patients.

PURPOSE: In skeletally immature patients, treatment of malalignment about the knee is possible by performing temporary hemi-epiphyseodesis. Following the well-established procedure of physeal stapling, the 8-plate was introduced as a new device. The purpose of this study was to compare physeal stapling with 8-plate hemi-epiphyseodesis. We focused on evaluating deformity correction, complication rate and duration of the procedures. METHODS: We retrospectively analysed 35 patients (61 extremities, age 2.9-16.0 years) who were treated by temporary hemi-epiphyseodesis about the knee for correction of genu varum or genu valgum by using Blount staples (32 extremities) or the 8-plate (29 extremities). Plain radiographs were analysed at the time of operation and at hardware removal that included measurement of mechanical axis deviation, mechanical lateral distal femoral angle and mechanical medial proximal tibial angle. Time until hardware removal, operation time and complications were recorded. RESULTS: A statistically significant improvement of all radiographic measurements could be achieved with comparable results in both groups. Complications were similar in both groups with no relevant differences in amount and severity. In the 8-plate group, however, the surgical time was significantly shorter by an average of ten minutes for implantation and 12 minutes for explantation. CONCLUSIONS: Both Blount stapling and the 8-plate technique are methods for correction of genu varum and valgum deformity in skeletally immature patients; however, a shorter operating time for implantation and explantation was noted for the 8-plate technique.

The gait function of slipped capital femoral epiphysis in patients after growth arrest and its correlation with the clinical outcome.

PURPOSE: Slipped capital femoral epiphysis (SCFE) represents the preliminary stage of osteoarthritis. Reliable tools for outcome evaluation should be developed to prevent persisting defects. The functional outcome of SCFE-patients after growth arrest is analysed by instrumented 3D-gait analysis (GA). The results are matched to the clinical examination findings. METHODS: A total of 39 SCFE patients after growth arrest (18.8 years; BMI 26.5 kg/m²) with unilateral affection were included. The clinical results were classified according to Harris hip and clinical Heyman Herndon scores. 3D-GA-parameters were evaluated and compared to the sound side and a group of 40 healthy adults (28.0 years; 21.9 kg/m²). The subgroup analysis was performed according to clinical results. RESULTS: The clinical examination revealed very good results. GA could detect even small alterations. Some parameters indicated sustained functional impairments: Compared to the control group patients' walking speed (p = 0.022), step frequency (p < 0.001) and single support of the slip side (p < 0.001) decreased, while step width (p = 0.014), double support (p = 0.004) and stance time of sound side increased (p = 0.001). For kinematics patients, the sagittal range of motion (ROM) of pelvis (p < 0.001) and the external rotation of the ankle on both sides increased (p = 0.011) and sagittal ROM of hip (p = 0.002) and knee flexion of slip side (p < 0.001) decreased. The sagittal ROM of the ankle on the slip side decreased compared to the sound side (p = 0.003). Subgroup analysis revealed a positive correlation between clinically unsatisfying results and GA parameters. CONCLUSIONS: Functional impairments in SCFE-patients can be found even after growth arrest. Alterations are explained partly by the disease and partly by patients' constitution. BMI-matched controls and long-term follow-up are needed.

Evaluation of overall gait quality in Perthes disease. Are global gait indices of value for a local musculoskeletal disorder?

BACKGROUND: Until now follow-up- and outcome evaluations in Perthes disease are analysing predominantly subjective results and clinical/radiological parameters. To enlarge the assessment by quantitative, functional aspects a summary measure for overall gait quality would be helpful. Therefore, the objective of this study is to evaluate whether commonly used global gait indices are sensitive to detect gait deviations during the early stages of the Perthes disease. METHODS: 3D gait data of 70 patients scheduled for containment improving surgery with the diagnosis of Perthes were included. A group of 31 healthy children served as a control group. Based on 4 gait cycles of each subject the Gait Deviation Index, the Gillette Gait Index, the Hip Flexor Index and the Gait Deviation Index-Kinetic were calculated for the involved and non-involved side. The gait indices were compared (1) between patients and controls, (2) among patients sub-grouped by ROM/radiological classifications and (3) between the two limbs. FINDINGS: All applied gait indices besides the Gait Deviation Index-Kinetic of the patient-group are significantly different from the controls. The subgroup-analysis resulted only in significant differences between the radiological groups Herring B and C for the Gillette Gait Index. Comparing involved and non-involved side showed no significant differences. INTERPRETATION: The evaluated gait indices are sensitive to identify a pathologic gait pattern in Perthes disease, so they can be used as a functional outcome parameter evaluating treatment concepts. Nevertheless, these are not applicable to identify the pathologic side indicating that a local hip problem leads to global gait deviations.

[Juvenile osteochondrosis and osteonecrosis]. / Juvenile Osteochondrosen und Osteonekrosen.

BACKGROUND: Juvenile osteonecrosis is an important topic in orthopedics. A wide variety of body regions of the growing patient are affected, predominantly during adolescence. All are characterized by a usually unknown aetiology as well as a stadium-like course. The main problem is a local osseous circulatory disorder, which causes osteonecrosis. RISK FACTORS: Mechanical overloading due to increased body weight, axial misalignment, and sports activity is discussed as a risk factor. Healing depends on the localization and extent of the osseous necrosis. DIAGNOSTICS: Diagnostically, radiologic imaging is used, in which the typical bony remodeling can be followed. THERAPY: The therapeutic procedure depends on the affected region but is usually accompanied by a reduction of mechanical loading. If the clinical and radiological findings worsen, surgical treatment must be considered. The recognition and treatment of juvenile osteonecrosis is important and significantly influences the further development of the patient.

Correlation of functional outcome and X-ray findings after Perthes disease.

PURPOSE: The purpose of this study was to evaluate the functional impairments during gait after Legg-Calvé-Perthes Disease (LCPD) and to correlate these data with the clinical and radiographic outcome. METHODS: In 13 individuals with LCPD in recovery or final stage (mean age 9.5 ± 3.5 years) with unilateral hip involvement the clinical result was graded according to Tönnis and the radiographic outcome according to Heyman and Herndon; the functional impairment during gait was compared to a group of healthy children (n = 30, mean age 8.1 ± 1.2 years). All children underwent computerised three-dimensional gait analysis. RESULTS: The standard physical examination resulted in 69.2% normal range of movement according to Tönnis, but overall analysis of gait revealed that only 30.7% had a normal gait pattern. All children with an excellent or good radiographic (n = 6) outcome walked normally or showed minor deviations. CONCLUSIONS: The results of the standard clinical examination do not reflect the function of the hip joint during gait. Additional information is revealed from gait analysis and should be part of outcome studies in LCPD.

Significance of clinical and radiographic findings in young adults after slipped capital femoral epiphysis.

The purpose of this study was to assess the clinical and radiographic presentation of young adults in the mid-term follow-up after pinning in situ for mild to moderate slipped capital femoral epiphysis (SCFE). We postulated that there was a correlation between the degree of head-neck-offset decrease and clinical and radiographic signs of hip joint degeneration. Thirty-eight young adults (average age 23.4 ± 3.6 years old) with various grades of femoral head-neck-offset pathologies were assessed clinically via Harris hip score (HHS), Tegner-Lysholm score (TLS) and Short Form 36 (SF-36), and radiographic signs of OA were measured on plain X-ray films after a follow-up of 11.1 ± 3.8 years. We conclude that clinical and radiographic signs of joint degeneration appear early in the follow-up after SCFE, but there is no linear correlation between offset-pathology and joint degeneration.

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.

Clinical presentation of young adults after Legg-Calvé-Perthes disease.

The purpose of the present study was to review the clinical and radiological outcome of young adult individuals who had Legg-Calvé-Perthes disease (LCPD) during child age. After a mean follow-up of 18.7 +/- 6.2 years, 25 young adults with various morphological deformity grades were assessed clinically and radiologically. Deterioration of hip joint function and onset of pain were found to manifest early in the intermediate follow-up of LCPD and to correlate with the residual hip deformity.

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.

Ulna/height ratio as clinical parameter separating EXT1 from EXT2 families?

Multiple osteochondromas (MO) is an autosomal-dominant inherited disorder. The two genes responsible (EXT1 and EXT2) have been identified. We investigated 12 MO families for phenotype details and the genetic basis by cosegregation and mutation analysis (seven novel pathogenic mutations [five frameshift, one splice site, and one gross deletion] and one novel missense polymorphism). We found EXT1 to be responsible in seven families (19 affected members) and EXT2 in four families (17 affected members). One family remains undetermined. We found a tendency to a more severe phenotype in EXT1 families. As a novel finding, we could identify a single parameter (ulna/height ratio) that separates EXT1 family from EXT2 family in our series.

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.