[Treatment of congenital dislocation of the hip in older children (author's transl)]. / Zur Therapie der veralteten Hüftluxation.

In children who are older than three years the obstacles of reduction can be overcome without danger for the blood supply of the femoral head only by operative measures. It stands the test to combine open reduction with the nearly always necessary correction of the dysplastic acetabulum, the shortening of the femur and derotating osteotomy. The results definitely depend on the individual indication and the operating technique. In cases of severe dysplasia of the acetabulum the acetabuloplasty shows better results in correction and reduction of the hip joint than Salter's osteotomy. Chiari's osteotomy of the pelvis should be taken into consideration only in such special cases with residual subluxation or with an extreme flat acetabulum. The follow up of 67 congenital dislocations of the hip in children aged between three and thirteen years shows, that operative treatment of bilateral luxation is indicated in patients between three and six years of age and unilateral luxation up to the age of adolescence.

[Radiology and measurement in adolescent slipped capital femoral epiphysis]. / Radiologie und Radiometrie der Epiphyseolysis capitis femoris adolescentium.

Two X-rays taken in two planes perpendicular to each other secure the early diagnosis of adolescent slipped capital femoral epiphysis (SCFE). In imminent SCFE, two radiographic features are considered the most important signs: the broadening and the irregular demarcation of the upper femoral epiphyseal plate. In the beginning of SCFE, the process of dislocation is much better visible in the second radiographic plane (the lateral tangent of the femoral neck builds a smaller secant of the lateral femoral head). In chronic SCFE, the aforementioned radiographic signs including the epiphyseal dislocation are more marked. An additional feature can be various deformities of the femoral neck and duplicate contours of the medial demarcation of the femoral neck. In acute SCFE, there is a complete disruption of continuity between the metaphysis and epiphysis. Beside the marked gap in the epiphyseal plate, there is a severe dislocation between the femoral neck and the epiphysis. There are also partly patchy, partly cystic changes in the metaphyseal part of the femoral neck. The so-called acute on chronic slip, a sudden slip of the upper epiphysis after prolonged chronic slipping, is considered a specific case of SCFE. The long-term result of treated as well as untreated SCFE can be the gradual increase of coxarthrosis, which is typically more marked in the medial direction of the joint. The direction and the degree of the epiphyseal slip play an important role in the development of "epiphyseal" coxarthrosis. The planning of corrective operations as well as the quantitative evaluation of the prearthrotic deformity require the conversion of angles of dislocation that are projected on X-rays into anatomically correct angles. This conversion is done with tables that were created with the aid of computers and requires that the positioning of the femur for taking the X-rays is always done under standardized conditions.Mostly, in minor dislocations in the usual direction (medially and dorsally), the difference between the projected and the real angles is relatively small. Therefore, in these cases of SCFE it might not be necessary for practical and operative needs to convert these angles into real angles. However, this simplification is only then acceptable if the prescribed positioning of the femur for taking the X-rays is strictly adhered to so that additional errors of projection are excluded.

[Corrective intra-articular surgery in juvenile femur head epiphysiolysis]. / Intraartikuläre Korrektureingriffe bei jugendlicher Hüftkopfepiphysenlösung.

Treatment of severely slipped capital femoral epiphysis depends on the individual pathoanatomic and pathophysiologic conditions. Since the femoral neck vessels remain intact in chronic slip, they should be preserved whenever possible. Bilateral chondrolysis developed in 1 of our 9 cervical osteotomy patients. Long-term radiologic and clinical findings after a cervical osteotomy do not differ appreciably from those after an Imhäuser osteotomy, in some cases, with incomplete realignment of the femoral head-acetabulum relation. Apparently, not only the "quantitative" factor but also the "qualitative" factor plays an important role in epiphyseal separation. By contrast, severe acute slip is a severe irritation of the joint accompanied by intra-articular bleeding and rupture of the femoral neck vessels. Good results are achieved after immediate operative decompression, controlled reduction, and stable fixation of the epiphysis, providing anatomic realignment of the femoral head-acetabulum relation is not forced, but rather carried out only to the limit of tolerance without leverage maneuver and under moderate traction and vision. Epiphyseal necrosis developed after conventional open reduction in 2 of our 16 patients with acute slip. No cases of epiphyseal necrosis have been observed to date in any of our patients (N = 5) treated with this new technique of controlled reduction (i.e., partial reduction in "acute chronic slip").

Aseptic loosening of cement-anchored total hip replacements.

The special conditions contributing to the loosening of 61 hip prostheses were studied and compared with 325 clinical and roentgenologically intact total hip replacements. The loosening rate rose sharply after the 6th postoperative year. One third of the artificial joints examined showed signs of loosening after the 9th year. The average loosening rate was 15.8% after 5.8 years. The condition of the bony bed apparently plays an important role, both qualitatively and quantitatively, in the success of the implant. The operative procedure is of equal importance. Deep fraising of the acetabulum, removal of insufficient amounts of cancellous bone from the proximal femur and inadequate embedding of the prosthesis stem, implantation of the stem in varus, and the use of long-neck femoral head prostheses are all factors which increase the risk of loosening. Ultimately, it is the sum of these loosening factors including the biological reaction of the tissue to the biomechanical and biochemically active foreign body which, depending on the period of influence, leads to prosthesis loosening. It is imperative that the patient's lifestyle be adjusted accordingly since external weight-bearing stress also affects durability of the prosthesis.

[Experiences with the total endoprosthesis of the knee joint to Blauth (author's transl)]. / Erfahrungen mit der Knie-Totalendoprothese nach Blauth.

Following a brief review of the differential indication for total prosthesis of the knee joint, the article reports on 136 implantations of the hinged prosthesis according to Blauth. In 94% of the cases the results were good and very good (n = 66) within an average follow-up examination period of 2 years. One of the main features of the success of the treatment is the relief from pain achieved with this prosthesis provided it functions well. Differentation of the treatment results according to the basic underlying disease (rheumatoid arthritis; pangonarthrosis) shows that good results were achieved particularly in relatively young rheumatic patients thanks to their co-operative capacity during the follow-up treatment period. The following relevant complications were seen among the 136 implantations: one early infection, three late infections, two deaths due to cardiovascular general complications, and one fatal case of sepsis as a result of a late infection. The rate of the aseptic loosenings was 1.5% only, and hence favourably low, as was evident from the follow-up examinations of the implanted knee joints. Lateralisation of the patella, which occurred in one-half of the cases, is attributed by us to an intraoperative weakening of the medial patella ligament (which acts as an auxiliary extension apparatus). We intend to counteract this in future via an additional lateral capsular discision. The follow-up study presented here confirms the efficiency of the Blauth model, as well as the generally valid indication criteria for total implantation of the knee joint.

[Results of the follow-up of Ludloff open hip repositions and closed repositions in congenital hip dislocations]. / Nachuntersuchungsergebnisse der offenen Hüftrepositionen nach Ludloff und der geschlossenen Repositionen bei angeborenen Hüftluxationen.

Three combinations of therapy of CDH (closed and open reduction, with and without foregoing so called "functional" conservative treatment, and with and without retention in the frog position) have been evaluated among 82 children with 100 dislocated hips. They had been operated on 71 times by Ludloffs open reduction and 29 times by gentle closed reduction in anaesthesia. If following a test-x-ray in 130 degrees flexion of the hips and 50 degrees of abduction no spontaneous reduction occurs, an attempt at careful closed reduction under anaesthesia seems to be justified. If it is not successful with lack of a deep position of the head, an immediate open reduction after Ludloff with retention in hip flexion of about 130 degrees and slight abduction was in our hands less frequently followed by an avascular necrosis of the femoral head than following conservative treatment. The latter and the inhuman frog position are according to our statistics probably more responsible for the avascular necroses than the open reduction as such. Every treatment of CDH has to be evaluated in regard to the frequency of irreversible avascular necrosis of the femoral head.

[Prognosis of leg length difference in congenital fibula defect]. / Die Prognose der Beinlängendifferenz beim angeborenen Fibuladefekt.

Predetermination of leg length discrepancy, which has to be expected in patients with congenital defects of the fibula, is very useful for the treatment program. Taking morphologic aspects and the principles of growth into consideration it is possible to predict quite accurately the final leg length in unilateral fibula defect. The prognosis is based on the finding, that the percentage longitudinal deficiency is constant during the growth of the lower limb. The calculation of the absolute leg length is done by assistance of the diagrams by Anderson and coworkers. The overall length discrepancy of unilateral hypoplasia of the fibula exceeds 8.5 cm. In cases of fibula aplasia a discrepancy of more than 10 cm. has to be expected. We saw this severe deformity on more than 50% of our cases. Experience supports the conclusion that preservation of the foot even by a number of reconstructive operations gives mostly better results than early amputation and provision of a prosthesis. There is a good chance to achieve limb-length equality by operations in cases of fibula hypoplasia type IA and IB. This chance is limited in hypoplasia type II and absence of the fibula.