Relevant factors in the diagnosis of concomitant osteomyelitis in pediatric hip septic arthritis. A series of 41 cases treated by hip arthroscopy.

INTRODUCTION: Septic arthritis of the hip can appear isolated or concomitant with pelvic osteomyelitis. Delay in the diagnosis of a concomitant osteomyelitis increases the number of required surgeries and of possible complications. PURPOSE: This study aims to establish relevant factors in the diagnosis of concomitant osteomyelitis in cases with septic arthritis of the hip among paediatric patients. METHODS: The data were collected between 2005 and 2020. 41 pediatric patients with suspicion of septic arthritis of the hip joint, treated arthroscopically, were included. The following diagnostic test parameters were collected: ultrasound, MRI, X-Rays, blood samples, temperature, and incapacity to bear weight. The data were analysed with the sensitive analysis method using descriptive statistic. RESULTS: 41 patients were analyzed, with an average age of 6.04 y (7 months to 14 years), of which ten patients (24.39%) presented concomitant osteomyelitis. 6 out of ten patients needed secondary surgery. Regarding age, concomitant osteomyelitis was most common in the age group 4-14 years old. Average number of days of clinical symptoms before admission was 6.2 days. 36/41 cases showed CRP values higher than 2 mg/dl. 9/10 cases with concomitant osteomyelitis showed a CRP > 2 mg/dl, with an average value of 8.9 mg/dl. 22/41 patients underwent an MRI, of which nine cases presented a concomitant osteomyelitis. The probability of a child to have septic arthritis of the hip with adjacent osteomyelitis was analysed through a score based on four factors: impossibility to bear weight and/or hip pain in children in the non-walking age category, CRP > 2 mg/dl, age older than > 4 y, symptoms longer than 4 days. CONCLUSIONS: Children at the age of walking, with incapacity to bear weight, presenting symptoms longer than 4 days and a CRP > 2 mg/dl, should receive an MRI before surgery to exclude adjacent osteomyelitis. LEVEL OF EVIDENCE: IV.

Radial head distalisation with an external ring fixator as a therapy option in children with chronic posttraumatic radiocapitellar dislocations.

PURPOSE: Missed monteggia-type injuries in children can result in chronic radial head dislocation with anatomic changes and osteoarticular remodeling of the radial head. In later stages, joint reconstruction is impossible and a functional radial head distalization can be a therapy option in symptomatic patients. METHODS: From 2010 to 2018, 46 patients (18 female and 28 male, mean age 11.8 (4-20)) with chronic radius head dislocation treated in our institution were retrospectively analyzed. A radial head distalization was performed in symptomatic patients at the time of ulna lengthening and angulation by use of an external ring fixator. We analyzed the surgical and radiographic data as well as the clinical outcome of the patients measured by DASH and Mayo Elbow score. RESULTS: 16 patients (6 female, 10 male) fulfilled the criteria for functional radial head distalization. Main reason was Monteggia injury in 11 cases, and radial head fracture in 5 cases. Average follow-up was 5.1 years (range 1-9, SD 2.1). Mean time from injury was 4.14 years (range: 4 months to 12 years, SD 3.5 years). Mean duration of external fixation was 106 days (range 56-182, SD 31.2), lengthening was 21.3 mm (range 12-42, SD 8.8). Average degree of sagittal angulation 14.8° (0-32°, SD 10.7°), coronal angulation 4.4° (0-25°, SD 7.3°). DASH score showed a good result with 2.4, and the MAYO Elbow Score was excellent (95/100). No secondary luxation of the radius head was detected. CONCLUSION: Radial head distalization with external ring fixator can be a therapy option for chronic radius head dislocations in symptomatic patients without losing stability of the elbow joint in contrast to radial head resection.

[Arthroscopic reduction of congenital hip dislocations in infants]. / Arthroskopische Reposition der kongenitalen Hüftgelenkluxation im Säuglingsalter.

OBJECTIVE: Open reduction of congenital hip dislocations currently remains the standard treatment for those hip joints which are irreducible by closed means. The open reduction of the dislocated hip joint represents a relatively invasive surgical method. Thus, the goal was to develop a minimally invasive and safe procedure with a lower complication rate as an alternative to open reduction. This work presents the arthroscopically guided reduction of dislocated hip joints, first described in 2009, as a standardized surgical technique. INDICATIONS: Failed closed reduction for congenital hip dislocation. SURGICAL TECHNIQUE: Arthroscopic reduction of the dislocated femoral head using an arthroscopic two-portal technique, a high anterolateral and a medial subadductor portal. The arthroscope is inserted through the subadductor portal. The high anterolateral portal serves as working portal. Step-by-step identification and removal of obstacles to reduction such as the ligament of the femoral head, fat tissue, capsular constriction and psoas tendon. Reduction of the femoral head under arthroscopic control. POSTOPERATIVE TREATMENT: The hip joint is retained in a hip spica cast with the legs in human position. RESULTS: Arthroscopic hip reduction of 20 congenital hip dislocations: 13 girls and 3 boys with an average age at the time of operation of 5.8 months (3-9 months). All children had multiple, unsuccessful attempts of closed reduction by use of overhead traction, Pavlik harness or closed reduction and hip spica application. According to the Graf classification, there were 20 type IV hips. According to the radiological classification of Tönnis, there were 9 type 4, 7 type 3, and 4 type II grades. The obstacles to reduction were capsular constriction, hypertrophic ligament of the femoral head, and an extensively large pulvinar in the acetabulum. An inverted labrum was not seen in any of the cases. In contrast, in 2/3 of the cases, there was considerable retraction of the dorsal edge of the socket due to the ligament of the femoral head expanding right over it. In all cases, postreduction transinguinal ultrasound and MRI were used to check the femoral head position in the cast postoperatively. In all cases there was a deep reduction of the femoral head in the acetabulum. There were no intra- or postoperative complications such as bleeding, infections or nerve lesions. There were no cases of redislocation or decentering of the femoral head, which was also confirmed after an average follow-up of 15 months. The mean AC angle at follow-up was 24.5°. There was one coxa magna in the series and one avascular necrosis with a fragmented femoral head according to the Salter classification.

Comparison of arthroscopic and open reduction of conservatively irreducible dislocated hips of children.

PURPOSE: Children with sonographic grade IV hip dysplasia according to Graf and with failed conservative treatment usually need surgical reduction afterwards. Surgical reduction of the hip can lead to severe complications, the occurrence of residual acetabular dysplasia, osteonecrosis, redislocation and other postoperative complications. This paper investigates whether arthroscopic reduction is a promising alternative to open reduction. METHODS: We retrospectively examined 66 patients (78 hips) who were not older than two years at the first time of surgery. Arthroscopic reduction was performed on 17 children (19 hips) and open reduction on 49 children (59 hips). Patient records were used to determine redislocation, postoperative complication and residual dysplasia. Radiographs were used to determine Tönnis classification for osteonecrosis and pathological acetabular (AC) angle for residual dysplasia. We considered data up to a two-year follow-up. Statistical evaluation was performed with binary logistic regression. RESULTS: After arthroscopic reduction, 6% showed osteonecrosis, compared with 20% with open reduction (p = 0.334). Redislocation was not observed after arthroscopic reduction but for 29% after open reduction (p = 0.005). An improvement of femoral head coverage was achieved with residual dysplasia of 23.5% after arthroscopic reduction, compared with 62% after open reduction (p = 0.002). CONCLUSION: The arthroscopic procedure represents a meaningful alternative to the open procedure due to a lower complication rate, a safe setting, a lower rate of residual dysplasia, no observed redislocation and occurrence of osteonecrosis only once in the arthroscopic group of developmental dysplasia of the hip. The arthroscopic procedure should be tested in further studies and in other clinics in order to broaden the empirical base. LEVEL OF EVIDENCE: Level III (retrospective cohort study).

[Early and late complications and their management in slipped capital femoral epiphysis]. / Früh- und Spätkomplikationen sowie deren Management bei der ECF.

BACKGROUND: Slipped capital femoral epiphysis (SCFE) remains a challenge for the treating surgeon. First of all, SCFE should be diagnosed as early as possible. The earlier the diagnosis is made in adolescents, the lower the slip angle will be. Mild slips show more favourable long-term courses than moderate and severe SCFE. COMPLICATIONS: With increasing slip angle, the risk of complications increases. The complications of SCFE are diverse, the most severe of which are avascular necrosis (AVN) and chondrolysis. AVN is more common in surgically treated than in non-operatively managed patients and unstable SCFE bears the highest risk of AVN. THERAPY: Adequate treatment of AVN is still controversial. For surgical treatments, variable rates of AVN have been reported. There is a wide spectrum of surgeries for treating AVN, from hip joint-preserving techniques to total hip replacement. In central Europe there is wide consensus in favour of treating the contralateral side, but this is not without complications. Surgical treatment with in-situ pinning must be carried out with great care to take into consideration the morphology of the femoral head and not to perforate it. It should always be ensured that no osteosynthesis material penetrates the hip joint.

[Specific cases of slipped capital femoral epiphysis : Endocrinopathies, hormone therapy and other rare causes]. / Besondere Fälle der Epiphyseolysis capitis femoris : Endokrinopathien, Hormontherapie und andere seltene Ursachen.

In slipped capital femoral epiphysis (SCFE) atypical causes can be found in about 5% of cases. The patients' age differs from the typical age of SCFE patients of between age 10 and 16. There are numerous causes of atypical SCFE: different endocrine disorders, sequelae of chronic renal failure and effects of radiation and chemotherapy on the proximal femoral physis. The diagnostic and therapeutic procedures must be expanded to the search for and treatment of endocrinological disorders. Orthopaedic treatment follows the principles applied to patients with idiopathic SCFE. However, the specific treatment modalities which arise from different patient ages and bone qualities are taken into account.

Medial humeral condyle fracture in childhood: a rare but often overlooked injury.

The medial condyle fracture of the humerus is-in comparison to the lateral condyle fracture-a very rare Salter-Harrison IV-fracture of the elbow. In this prospective study 14 children were included and reviewed. One child had minimal displacement fracture type I, one child had type II, and 12 children had type III-fractures. One patient was treated conservatively by an upper arm cast; thirteen were surgically treated using open reduction and osteosynthetical treatment. Postoperatively the elbow was immobilized in 90° flexion and neutral position in a long-arm cast for 4-6 weeks. In 11 children the diagnosis was made immediately after trauma, in 3 children the fracture was overlooked initially. Medial condyle fractures may be difficult to diagnose in children younger than 6 years and the lesion may be mistaken for a simple avulsion of the medial epicondyle or even missed. The C-sign is a hint for a medial condyle fracture. The development of nonunion happens in consequence of failure to recognize the fractures. Results after an average follow-up of 36 months showed that children who were diagnosed immediately and received operative stabilization had very good functional and aesthetical results. Three children with delayed diagnosis of the fracture had open surgery with reposition and osteosynthetical fixation. In two of the overlooked cases a slight contracture and angular misalignment persisted. If in this injury the diagnosis is made without delay, an appropriate therapy is implemented and radiographical controls are performed until consolidation, good results can be expected. The main risk in medial condyle fractures of the humerus is to overlook them. This can lead to the development of a nonunion with joint malformations.

[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.

[Long-term effects of deep brain stimulation for movement disorders: a literature-based analysis]. / Langzeiteffekte der tiefen Hirnstimulation bei Bewegungsstörungen : Eine literaturbasierte Analyse.

BACKGROUND: Deep brain stimulation has become an established therapy for various movement disorders but questions regarding its long-term effectiveness remain. OBJECTIVES: This study was designed to evaluate the long-term effectiveness of deep brain stimulation for movement disorders refractory to current medical therapy based on published long-term studies. METHODS: A review was carried out of all available studies with a minimum follow-up of 5 years of patients with deep brain stimulation for Parkinson's disease, essential tremor and dystonia. RESULTS: A total of 23 studies of deep brain stimulation for Parkinson's disease, 7 studies for essential tremor and 14 studies for dystonia were included. After a follow-up of at least 5 years, improvement of current motor scores could be observed in Parkinson's disease (subthalamic stimulation) by approximately 40%, by approximately 50% for essential tremor and by 60% for dystonia (mostly generalized forms). In Parkinson's disease, motor improvements tend to diminish over time due to progression of dysarthria, axial symptoms and other motor features less responsive to deep brain stimulation. Non-dopaminergic symptoms tend to progress and lessen the positive effects on the quality of life. There appears to be a subgroup of patients with essential tremor who show decreasing effectiveness of deep brain stimulation, probably related to disease progression. Currently, no single prognostic marker has been established to identify this subgroup. Most forms of secondary dystonia seem to respond more variably than primary generalized dystonia. CONCLUSION: Deep brain stimulation remains a relatively safe and effective therapy in carefully selected patients after long-term follow-up according to published data, although disease progression and other disease-specific factors seem to modify its effectiveness over time.

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

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

[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.

[Minimally invasive treatment of congenital foot deformities in infants: new findings and midterm-results]. / Minimal-invasive Therapieverfahren angeborener Fußdeformitäten im Säuglingsalter : Berücksichtigung neuer Erkenntnisse und mittelfristiger Ergebnisse.

In the last decade treatment of foot deformities has changed from extensive surgery to casting and minimally invasive surgery. The Ponseti method has become the most preferred treatment for clubfoot deformities and early evaluations showed promising results. Mid-term results for idiopathic clubfoot revealed the need for additional surgery by anterior tibial tendon transfer in 11-32% of cases depending on the duration of bracing. Anterior tibial tendon transfer is the most important surgical procedure for relapses in the Ponseti concept. Casting, recasting in cases of relapses, bracing and anterior tibial tendon transfer altogether represent the Ponseti method and cannot be considered as single entities.The Dobbs method is a new concept for the treatment of vertical talus. Treatment of vertical talus should start with the Dobbs method but in comparison to clubfoot treatment there has not been a complete change to minimally invasive treatment. Especially in non-idiopathic vertical talus cases open reduction of the talonavicular and calcaneocuboid joint are often necessary.

[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.

Arthroscopic reduction of the dislocated hip in infants.

We present our early experience of arthroscopic reduction of the dislocated hip in very young infants with developmental dysplasia of the hip (DDH). Eight dislocated hips, which had failed attempts at closed reduction, were treated by arthroscopy of the hip in five children with a mean age of 5.8 months (4 to 7). A two-portal technique was used, with a medial sub-adductor portal for a 2.7 mm cannulated system with a 70° arthroscope and an anterolateral portal for the instruments. Following evaluation of the key intra-articular structures, the hypertrophic ligamentum teres and acetabular pulvinar were resected, and a limited release of the capsule was performed prior to reduction of the hip. All hips were reduced by a single arthroscopic procedure, the reduction being confirmed on MRI scan. None of the hips had an inverted labrum. The greatest obstacle to reduction was a constriction of the capsule. At a mean follow-up of 13.2 months (9 to 24), all eight hips remained stable. Three developed avascular necrosis. The mean acetabular index decreased from 35.5° (30° to 40°) pre-operatively to 23.3° (17° to 28°). This study demonstrates that arthroscopic reduction is feasible using two standardised portals. Longer follow-up studies are necessary to evaluate the functional results.

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

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

[Acute traumatic and especially neglected traumatic hip dislocations are very rare in children]. / Hüftarthroskopische Therapie bei veralteten extrakapsulären traumatischen Hüftluxationen bei Kindern.

We report about the first hip arthroscopies of extracapsular neglected hip dislocations with concomitant injuries in two children (2 and 4 years old). The major problem of traumatic hip dislocation is avascular necrosis. Further problems are possible concomitant injuries. It is important not to cause further damage by therapeutic procedures. In a 4-year-old child the hip could be reduced under visualization and in a 2-year-old child with epiphyseal fracture the extent of the operation could be reduced. In both children large avulsion injuries of the ligamentum capitis femoris could be resected via hip arthroscopy. Hip arthroscopy can reduce surgical morbidity considerably and can possibly contribute to prevention of the feared avascular necrosis of the femoral head.

[Treatment of vertical talus with the Dobbs method]. / Die Behandlung des Talus verticalis mit der Methode nach Dobbs.

AIM: The widely accepted treatment of vertical talus after casting is correction by extensive surgery. Dobbs described a new method for the treatment of vertical talus by casting and minimally invasive surgery. The purpose of the present study was to evaluate the efficacy of this new method. MATERIAL AND METHOD: Between 11/06 and 11/09 we treated 7 patients with 12 vertical tali. Treatment followed the protocol of Dobbs. The initiation of treatment, number of casts, surgery, as well as clinical and radiological results were documented. To evaluate the radiological result we used the Hamanishi score. RESULTS: From the beginning all feet could be treated successfully with the Dobbs method. According to the Hamanishi classification we have four excellent and five good results. Two feet had a relapse with subluxation or dislocation of the talonavicular joint. CONCLUSION: Treatment of vertical talus with the Dobbs method is successful. Extensive surgery could be reduced. We recommend the method as primary treatment for vertical talus.

[Comparison of the diagnostic value of X-ray versus MRI in paediatric spine injuries]. / Stellenwert des konventionellen Röntgenbilds versus MRT in der Diagnostik kindlicher Wirbelsäulenverletzungen.

AIM: The evaluation of paediatric thoracic or lumbar compression fractures can be challenging. The anatomy of the growing spine often makes a correct diagnosis by plain radiography difficult. The aim of our study was to compare the diagnostic reliability of X-Ray and that of magnetic resonance imaging in the evaluation of acute compression fractures of the paediatric spine. METHOD: From January to December 2008 20 patients (12 boys, 8 girls) who were treated because of clinically suspected compression fractures of the vertebra were included in our study. The average age was 8.3 years. In all cases a radiograph in two planes and an MRI of the lumbar and thoracic spine were obtained. Two orthopaedic surgeons and one radiologist retrospectively assessed the radiographs. The results were compared with the MRI findings. RESULTS: In six cases the MRI was normal, in one case there was only a bone bruise without compression of the vertebra. 13 children had two or more than two minor compression fractures (29 fractures altogether). The 5th and 6th thoracic vertebra predominated. In only two cases there was a corresponding result of all three physicians and the MRI. In 4 cases the observers agreed on the localisation of the fracture. There was no agreement about the number of fractured vertebrae. CONCLUSION: An exact evaluation of minor compression fractures of the pediatric spine with plain X-ray was not satisfactory.

[Elastic stable intramedullary nailing as alternative therapy for the management of paediatric humeral shaft fractures]. / Die elastische stabile intramedulläre Nagelung als Therapiealternative in der Versorgung kindlicher Humerusschaftfrakturen.

AIM: We report about our experiences with the elastic stable intramedullary nailing (ESIN) of traumatic humeral shaft fractures in children and adolescents. METHOD: Children with traumatic humerus shaft fractures who were treated by ESIN were included. All patients underwent clinical follow-up examinations. RESULTS: 31 children (average age 11.4 years) with traumatic humeral shaft fractures could be included. There were 14 oblique, 12 transverse and 5 wedge fractures. In 5 cases the fracture was located in the proximal third, in 22 cases in the middle third and in 4 cases in the distal third. After an average period of 32 months a follow-up-examination with the Constant-Murley score was performed. All children attained 100 points and all patients could take part in sports activities like before the accident. 30 children and their parents were very satisfied with the treatment success and 1 patient was satisfied. The following complications were seen: 1 postoperative damage of the radial nerve in a patient with secondary fracture dislocation (complete remission), 1 skin irritation, 1 fracture dislocation with axial deviation, 1 secondary dislocation of the nails after a second accident and 1 secondary axial deviation. CONCLUSIONS: Elastic stable intramedullary nailing (ESIN) of humerus shaft fractures has a low complication rate if attention is paid to biomechanical principles. The observed complications are based on mistakes concerning the indication or technical errors. The ESIN shows very good functional and cosmetic results. It allows an early functional and cast-free follow-up with a quick pain reduction. The ESIN of humeral shaft fractures is a minimally invasive, simple and well reproducible technique with a steep learning curve. Because of the excellent objective and subjective results, the operative stabilization of humerus shaft fractures with ESIN should be recommended to the patients and their parents.