Treatment of Tibial Non-Unions - State of the Art and Future Implications.

healing disturbances occur in 5-10% of the cases. The anatomical region of the lower limb predisposes the tibia for bone healing disturbances. Reports about the incidence of non-unions of the tibial shaft are inhomogeneous. Different treatment strategies have been published which depend on the type of non-union as well as the history of the patient. These range from conservative approaches to complex procedures including segmental resection and bone transport. This review aimed to summarize the state of the art treatment of tibial non-unions and report about recent basic research results that may improve bone healing. Key words: tibial non-unions, treatment strategies, bone healing.

[Diagnostics and therapy of luxation after total hip arthroplasty]. / Diagnostik und Therapie der Luxation nach Hüfttotalprothesenimplantation.

BACKGROUND: Luxation following endoprosthetic hip replacement represents a frequent and severe complication and is the reason for a relevant number of hip arthroplasty revision interventions. The probability of occurrence of luxation of a total hip arthroplasty is associated with the indications, patient and operation-specific risk factors. Approximately 50 % of luxations after total hip arthroplasty occur within 3 months of the operation (early luxation). DIAGNOSTICS: The diagnostics of luxation of total hip arthroplasty are carried out by clinical and radiological methods. The causative assignment is made by assessment of joint stability, the bony situation (e.g. loosening, periprosthetic fracture and defects) and the soft tissue (e.g. pelvitrochanterian musculature). In cases of clinical and paraclinical signs of infection and of late luxations, a joint puncture is indicated. THERAPY: Therapy decisions are made depending on the cause (e.g. implant malpositioning, pelvitrochanterian insufficiency, impingement, incongruence between head and inlay and combinations of causes). Therapy of acute total hip prosthesis luxation begins with imaging controlled repositioning carried out with the patient under adequate analgesia and sedation. Conservative therapy is carried out by immobilization with a hip joint orthesis or pelvis-leg cast for 6 weeks. Operative therapy strategies for recurrent luxation are restoration of the correct implant position and sufficient soft tissue tension. Larger hip heads, bipolar heads and tripolar cups are more commonly used due to the geometrically lower probability of dislocation (higher jumping distance). Luxation of total hip prostheses due to infection is treated according to the principles of periprosthetic infection therapy. The rate of recurrence of luxation of 30 % is high so that in cases of unsuccessful therapy treatment should best be carried out in a center for revision arthroplasty. CONCLUSIONS: The search for the exact cause of total hip prosthesis luxation is extremely important. A classification is only possible when the exact cause is known and together with patient and implant-specific details the therapeutic approach can be ascertained. In revision operations the intraoperative functional diagnostics must be exactly documented. The reasons for delayed luxations could be prosthesis infections, abrasion and loosening.

[Diagnostic standards for extradural tumors and metastases of the spinal column]. / Diagnostische Standards bei extraduralen Tumoren und Metastasen der Wirbelsäule.

Because of the heterogeneous clinical and paraclinical symptoms accompanied by the urgent necessity to rapidly find a diagnosis, the differential diagnostic delineation of spinal tumors from back pain related to other reasons is a special challenge in the orthopedic practice. Employing an algorithm based on anamnesis, clinical, radiological and paraclinical examinations, a guideline-related biopsy as well as histological processing of the biopsy material, tumor lesions can usually be classified regarding entity, dignity and extent. Following this a treatment strategy can be defined. Because of the necessity of an interdisciplinary approach the diagnostic algorithm should be planned during a tumor conference and performed in specialized centers.

[Dislocation after total hip arthroplasty]. / Luxationen nach Hüftendoprothetik.

Dislocations after total hip arthroplasties are one of the most common complications of the procedure. According to registers, recurrent hip dislocations account for up to 30 % of the indications for a revision operation. The incidence of a dislocation is influenced by indication-associated, patient-dependent and operation-specific risk factors. 50 % of the dislocations occur within the first 3 months which confirms the high relevance of operation-specific influencing factors. The diagnosis is almost always made with the help of computed tomography, as this is the only method to determine the three-dimensional relationship of the components. A dynamic fluoroscopic examination can verify an increased translation (reduced soft-tissue tension) and thus enables a functional examination to determine the mechanism of the dislocation. By means of a classification of dislocations into five types under consideration of the implant position, the sufficiency of the pelvitrochantar musculature, the presence of an impingement, the congruence of head and acetabular liner as well as combinations of these factors it is possible to plan an adequate therapy. From the therapeutic point of view the correct positioning of the stem and head is of decisive importance. In addition therapeutic success can be realized by using larger head diameters through to tripolar sockets, reconstruction of soft tissues and, last but not least, an adequate postoperative immobilization. Even so, this treatment is associated with a high rate of complications and in the literature failure rates of up to one third, i.e., the reoccurrence of a dislocation, are reported.

Infant formulas. Recent developments and new issues.

Infant formulas on the market today should be aimed at providing the best alternative to breast milk for infants of those women who are unable to continue breastfeeding until 6 months of age and substituting ideally for human milk after 6 months of age approaching the structural and functional effects observed in breastfed infants. The aim is to mimic the functional outcome of the breastfed infant (e.g. growth and development), and not to copy the composition of human milk. For this purpose, the following compounds have been added to formulas and are reviewed: long-chain polyunsaturated fatty acids (LCPUFA) for brain composition and neurodevelopment, probiotics and prebiotics for the fecal flora and the local intestinal defense, and nucleotides for promoting the immune response. Changes in protein quantity and quality allow to balance the blood amino acid pattern (possibly relevant to the early stages of brain development for the neurotransmitter function) and reducing the protein intake could be important for the prevention of later overweight. Hydrolysed proteins are important in the prevention of atopic disorders. Many trials have been published so far with short-term assessments, most of them with positive findings. However, we need more data on the long-term follow-up of infants who were fed the new formulas. Such data will allow to look at neural performance, prevention of overweight and obesity, and effects on the immune-allergic pattern.

Prevalence of iron deficiency in 12-mo-old infants from 11 European areas and influence of dietary factors on iron status (Euro-Growth study).

A prospective longitudinal cohort study was performed to assess the prevalence of iron deficiency in European infants at 12 mo of age, and to study the influence of socio-economic status, dietary factors, growth and morbidity on iron status. The cohort consisted of 488 normal term infants from primary healthcare centres in 11 European areas. Assessed were socio-economic variables, dietary intake, anthropometry and morbidity at regular intervals from birth to 12 mo, and haemoglobin, serum ferritin, mean corpuscular volume, transferrin saturation and serum transferrin receptor concentrations at age 12 mo. The prevalence of anaemia was 9.4%, of iron deficiency 7.2%, and of iron deficiency anaemia 2.3%. More than 40% of anaemia was associated with normal iron status and associated with an increased frequency of recent infections. Iron deficiency anaemia was significantly more frequent with low (5.1%) than high socio-economic status (0%). Dietary factors accounted for most of this variation in multiple regression analysis. Early introduction of cows' milk was the strongest negative determinant of iron status. Feeding of iron-fortified formula was the main factor positively influencing iron status. Other dietary factors, including breastfeeding, did not play a significant role as determinants of iron status at age 12 mo. Conclusion. Iron deficiency anaemia is present in 2.3% of 12-mo-old European infants. The prevalence of iron deficiency anaemia varies strongly with socio-economic status. Avoidance of cows' milk feeding during the first year of life is the key measure in the prevention of iron deficiency.

The Euro-Growth Study: why, who, and how.

BACKGROUND: Assessment of growth is important in health management of infants and children. Evaluation of growth performance requires anthropometric measurements, with proper interpretation depending on the use of appropriate references. Europe-specific growth references have not been available. The purpose of the present study was to generate such references for infants and children from birth to 3 years of age. The study was further intended to assess the influence of nutrition and lifestyle factors on growth. METHODS: The Euro-Growth Study was designed as a multicenter longitudinal cohort study. This report describes the study design, the sample (cohort), and the methods used. Quality control measures included standardized measurement techniques with ongoing cross-sectional and longitudinal consistency checks. Selectivity in participation and discontinuation and reproducibility of data over time were evaluated. RESULTS: Of 2,245 infants who were enrolled in the study at 22 study sites in 11 countries, 1,746 (78%) provided longitudinal data until 12 months of age, 1,205 (57%) until 24 months of age, and 1071 (48%) until 36 months of age. Anthropometric measurements were performed on 21,773 occasions. As a result of cross-sectional and longitudinal data checks, 209 data points (0.09% of all data points) were rejected. Comparison of participants's demographic data with those of nonparticipating local subjects indicated that the cohort was selective in maternal age (higher), maternal education level (higher), household location, and family structure. The withdrawal rate during the study was low (24%), and withdrawals occurred at random. Analysis of reproducibility over time resulted in the elimination of the data from one study site. CONCLUSION: The Euro-Growth Study provided longitudinal growth data from a large cohort of normal European children. Because of the chosen sampling method, the study cohort ws somewhat selective relative to the local background population. Internal validity was satisfactory in that the reproducibility of anthropometric measurements was high in 21 sites and the withdrawal rate was low and random.

Euro-Growth references for length, weight, and body circumferences. Euro-Growth Study Group.

BACKGROUND: Several concerns have been raised by World Health Organization (WHO) expert groups regarding the adequacy of currently existing growth references, including those currently supported by WHO. As part of a concerted action of the European Union, new references were developed that were based on a well-defined sample of the European population and were compared with existing references. METHODS: During the longitudinal, observational multicenter study, anthropometric measurements using standardized methodology were performed in 2,245 children between 1 and 36 months of age, and sex- and age-specific growth references for recumbent length, weight, mid-upper arm, thigh, and calf circumferences were developed. RESULTS: The validity of the curve-fitting programs was demonstrated by comparing the selected sex-specific percentile distributions for all indices with the smoothed references. Comparison with the National Center for Health Statistics (NCHS)-WHO references for length and weight for age indicated that the -2 z-score value of the WHO reference as cutoff value shows that a substantial part of the children with suspected failure to thrive should be classified as normal. The references also indicate that the mid-upper arm circumference is age and sex dependent and that a single cutoff value for children less than 5 years of age should no longer be used. Mid-parental height was the best single predictor of recumbent length until 36 months of age. CONCLUSIONS: The Euro-Growth references that were developed reflect growth of a well-defined, large cohort of healthy infants and can be used for international comparisons.

Euro-Growth references on increments in length, weight, and head and arm circumferences during the first 3 years of life. Euro-Growth Study Group.

BACKGROUND: Reliable assessment of growth performance of infants and young children requires reference data increments. Available increment references are based on data fitted to mathematical models, a process that diminishes variation in increment values. METHODS: Fully longitudinal data from the multicenter Euro-Growth Study (21 study sites: n = 2145 children) were used to develop sex-specific percentiles for increments in length, weight, and head and mid-upper arm circumferences for selected intervals during the first 36 months of life. Increments (per unit of time) were calculated for 2-, 3- and 6-month intervals from birth to 12 months of age and for 6-month intervals from 12 to 36 months of age. Weight increments were also calculated for 1-month intervals from birth to 6 months of age. The influence of sex, mid-parental height, and study site was determined using analysis of covariance. Comparison with other references was accomplished using percentile values. RESULTS: Mean and standard deviation values as well as selected percentiles (P; P3, P5, P10, P25, P50, P75, P90, P95, and P97) of increments are presented. Length increments of boys were higher than those of girls until 5 months of age but tended to be lower thereafter. Weight increments of boys were higher until 9 months of age. Sex, mid-parental height, and study site explained only between 2% and 13% of the variances of increments. Mean increments were comparable but P10 and P90 substantially differed from published data. CONCLUSIONS: The new Euro-Growth references for increments in length, weight, and head and mid-upper arm circumferences provide tools for health workers that should be useful in screening for adequacy of growth during the first 3 years of life.

Euro-Growth references for body mass index and weight for length. Euro-Growth Study Group.

BACKGROUND: Fully longitudinal data from the multicenter Euro-Growth study (21 study sites; n = 2145 children) were used to develop sex-specific percentiles and Z-scores for body mass index (BMI) and weight for length (WfL) during the first 36 months of life. METHODS: Smoothed percentile curves for BMI against age were constructed and checked against raw percentiles. Smoothed percentile curves for WfL were constructed according to established procedures and were checked against raw percentiles. The relation of BMI with length and of WfL with age was examined. The relation between BMI and WfL was tested using z-scores of each. The influence of gender, geographic location (study site), and genetic factors on BMI and WfL was examined. Finally, the new references for BMI and WfL were compared with other published references. RESULTS: Selected percentiles (P; P3, P5, P10, P25, P50, P75, P90, P95, and P97) for BMI showed a sharp increase from 1 to 6 months of age and a gradual decline between 12 and 36 months. Smoothed percentiles for WfL showed only small deviations from raw percentiles. BMI was found to be essentially independent of length, whereas WfL showed some degree of dependence on age. Values for BMI and WfL showed very good agreement, except at the extremes of the age range. A modest degree of influence of geographic location on BMI and WfL was found. Correlations with parental BMI and WfL were very weak, however. Comparison with the National Center for Health Statistics (NCHS) references showed the latter to have a narrower range of values. CONCLUSIONS: The new Euro-Growth references for BMI and WfL provide improved tools for health workers and researchers dealing with childhood obesity.

Euro-Growth references for breast-fed boys and girls: influence of breast-feeding and solids on growth until 36 months of age. Euro-Growth Study Group.

BACKGROUND: The World Health Organization (WHO) recommends exclusive breast-feeding during the first 4 to 6 months of life, but limited information is available regarding the growth performance of infants fed according to the recommendation. The present study used data from the Euro-Growth study to determine the growth of breast-fed European infants who did or did not receive solids from an early age, in comparison with growth of infants who were fed by other modes. METHODS: There were 319 infants who were exclusively breast-fed according to the WHO recommendations for at least 4 to 5 months, and 185 infants who were breast fed but received solids (but no formula) from an early age. There were 1,509 infants who were fed in a variety of ways, which included breast-feeding during the early months of life in the majority (65%) of infants. Anthropometric data were available from birth to 36 months of age. Growth of the two groups of breast-fed infants was assessed by comparing z-scores of length, weight, and body mass index with those of the group fed by other means. Furthermore, multiple regression analysis was used to assess the influence on increment in length and weight of the duration of breast-feeding and the age at which solids were introduced. Euro-Growth references for breast-fed boys and girls were developed and compared with the National Center for Health Statistics (NCHS)-WHO and Euro-Growth references. RESULTS: The pattern of growth of children who were fed according to the WHO recommendations showed higher weight during the first 2 to 3 months of life and lower weight and length from 6 to 12 months. Between 12 and 36 months of age, differences between groups were small and clinically nonrelevant. Duration of breast-feeding was negatively correlated with increment in length and weight until 12 and 24 months but not until 36 months of age. The influence of duration of breast-feeding was much weaker than that of mid-parental height. The mean and standard deviation z-scores of the Euro-Growth references for weight of breast-fed infants deviate substantially from the NCHS-WHO references during the first 6 months of life in particular. The mean and standard deviation z-scores for length and weight of breast-fed children were close to the Euro-Growth references. CONCLUSION: The Euro-Growth references may be used to monitor length, weight, body mass index, and body circumferences of children who are fed according to WHO recommendations. The additional references, which were developed for breast-fed boys and girls, will be useful in view of the commitment of WHO to the collection of data for the development of a new international growth reference.

Patterns of milk and food intake in infants from birth to age 36 months: the Euro-growth study.

BACKGROUND: Little detailed information is available on feeding practices of infants in Europe. The Euro-Growth Study is a longitudinal, observational, multicenter study of milk feeding, the introduction of complementary solid foods, and vitamin and mineral supplementation. Current practice is compared with international feeding recommendations. METHOD: Healthy term infants (n = 2,245) were recruited at birth or during the first month of life. Dietary records were completed at the ages 1, 2, 3, 4, 5, 6, 9, 12, 18, 24, 30, and 36 months by semiquantitative dietary recall. RESULTS: At the age of I month, 52% of the infants were exclusively breast fed and 26% were exclusively formula fed. At the age of 9 months, 18% of infants were fed only cow's milk. At the ages of 3, 4, and 5 months, 50%, 67%, and 95% of infants were fed solid foods, respectively. CONCLUSIONS: Feeding practices vary considerably throughout Europe. High rates of breast-feeding initiation are found in Umea, Sweden, and in Athens, Greece; and low rates in Dublin, Ireland, in Toulouse, France, and in Glasgow, United Kingdom. The use of cow's milk as the main milk drink before the age of 12 months is still common in certain European centers.

Iodine supply in children from different european areas: the Euro-growth study. Committee for the Study of Iodine Supply in European Children.

BACKGROUND: In many areas of Europe iodine deficiency disorders still exist. Urinary iodine excretion is a valuable tool in characterizing the iodine supply of a population. However, there is a continuing discussion on the most appropriate parameter to measure urinary iodine excretion. METHODS: In 247 children (ages 3-5 years) from six European centers, spot urine samples were analyzed for urinary iodine concentration and urinary iodine-creatinine ratio. RESULTS: The median values of urinary iodine concentration from the six centers were very similar (90-106 microg/l) corresponding to a normal or marginal iodine supply according to the criteria of the World Health Organization. However, the median values of the urinary iodine-creatinine ratio from the six centers differed significantly (143-445 microg/g, P < 0.001). The different results of the two urinary parameters to assess urinary iodine supply were due to large significant differences in the urinary creatinine concentration reported by the various centers, which probably reflect marked differences in water intake. CONCLUSIONS: Iodine deficiency is still a significant health problem in many European countries. In comparable and homogeneous population subgroups (even from different countries), the urinary iodine-creatinine ratio appears to be a much better parameter for assessing iodine supply than urinary iodine concentration.

Reduction of rotavirus infection in children receiving bifidobacteria-supplemented formula.

This study was conducted at Pakkred Babies Home, Bangkok, Thailand; with the hypothesis that children receiving probiotic-supplemented milk-based formula may be protected from developing diarrheal diseases. Salivary rotavirus-specific IgA antibody was used as an indicator of rotavirus infection. One hundred and seventy-five children, aged 6-36 months, were enrolled in the study. They were divided into 3 groups according to the type of formula given. There were 81 episodes of diarrhea during an 8-month study period, most of which were caused by bacterial enteropathogens. Ninety-seven pairs of salivary samples were adequate for the analysis of rotavirus antibody. Among 23 children receiving milk-based follow-up formula and serving as control group, 30.4 per cent of them had > or = 4-fold increase in the antibody titre, indicating subclinical rotavirus infection. The majority of children in the other 2 study groups, receiving the same formula supplemented with either Bifidobacterium Bb12 alone or together with Streptococcus thermophilus, had no significant change in the antibody titres between the two time points. The results of this study support our hypothesis that children receiving bifidobacteria-supplemented milk-based formula may be protected against symptomatic rotavirus infection.