J Child Orthop (2013) 7:331–362 DOI 10.1007/s11832-013-0524-5

ABSTRACTS

27th Annual Meeting of the Children’s Orthopaedics, Augsburg, March 1–2, 2013

1 Biomechanical evaluation of different abduction splints for the treatment of congenital hip dysplasia P.C. Kreuz1+, S. Fro¨hlich1+, T. Lindner2, D. Olbertz3, R. Bader2 und W. Mittelmeier1

Correspondence to Dr. med. Susanne Fro¨hlich, Orthopa¨dische Klinik und Poliklinik Universita¨tsmedizin Rostock, Doberaner Strasse 142, 18057 Rostock, Tel: +49-381-4949319, Fax: +49-381-4949311, e-mail: [email protected]

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1

Department of Orthopaedic Surgery, University Medical Center of Rostock, Doberaner Str. 142, 18057, Rostock, Germany, 2Center for biomechanics and implant technology, University Medical Center of Rostock, Doberaner Str. 142, 18057, Rostock, Germany, 3Department of Neonatology and Intensive Care, Hospital Su¨dstadt of Rostock, Su¨dring 80-81, 18059, Rostock, Germany. Kreuz P.C. and Fro¨hlich S. contributed equally to the work.

Successful early treatment of unstable developmental dysplasia of the hip with the Tuebinger Abduction splint—early radiological outcome in walking age K. Weimann-Stahlschmidt, F. Martiny, H. Putsu, E. Jelinek, B. Westhoff, R Krauspe Heinrich-Heine-Universita¨t Du¨sseldorf, Dusseldorf, Germany

Background Abduction splints for the treatment of hip dysplasia normally operate on curbing the legs at the hip flexion and abduction. The forces are absorbed in different designs of shoulder straps and thus diverted to the shoulder and the spine. The present study is the first comparing these undesired forces of two spread orthoses and subsequently the transmitted forces to the infant‘s spine. Methods Between 3/2009 and 10/2009 the hips of 290 infants were investigated by ultrasound within the first 3 days after birth. Thereof 20 infants with a hip dysplasia Graf type IIc, D or IIIa met our inclusion criteria and were investigated with a Tu¨binger and a Superior abduction splint. Biomechanical evaluation was performed by using a high-sensitive strain gauge sensor applied to the infant‘s orthoses between pelvic harness and shoulder straps. Findings The transmitted forces to the infant‘s shoulders correlated significantly with their body weight (p \ 0.05). Maximal forces on the shoulder of the infants and subsequently transmitted forces on the spine were significantly higher (p \ 0.05) with the Tu¨binger splint (range 7.59 N–32.32 N; MV: 13.71 N) in comparison to the Superior orthosis (range 0.00 N–3.51 N; MV: 0.68 N). Interpretation The Superior orthosis works with primary load transmission to the pelvic bone. Using the Tu¨binger splint the shoulders of the newborn infants are loaded with a maximum of 93.9 % of their body weight. This could influence the development of the growing infant‘s spine. Keywords Ultrasound screening, hip dysplasia, spread orthoses, biomechanics

Introduction The purpose of this study was to detect the early outcome and AVN prevalence after successful treatment of congenital hip dislocation with the Tuebinger abduction brace. As ultrasound screening permits early detection of congenital dislocation of the hip before abduction contracture occurs, closed reduction with abduction splint under ultrasound monitoring can be performed safely in newborns. So far closed reduction and retention in the Pavlik harness or plaster cast in human position are established treatment options. Development of avascular necrosis (AVN) is a well known risk and complication of both open and closed reduction. Method In this prospective study 82 unstable hips in 60 patients were evaluated. Only children at less than 6 weeks of age without limited abduction of the hip were included. Dislocation of the hip was diagnosed by ultrasound according to Graf. The parents were advised to keep the brace 24 h per day without taking it off until an alphaangle of at least 60° was achieved. Aim of over all treatment was a minimum 65° alpha-angle before treatment was terminated. Minimum follow up was 2 years of age, radiological outcome was assessed by pelvic view. The Acetabular index and signs of AVN were assessed according to Kalamchi/MacEwen and Toennis. Results There were 60 patients included, 44 patients (53 %) had bilateral involvement. Type D was assessed in 41 (50 %) hips, III a in 36 (44 %) and type IV in 5 (6 %) hips according to Graf. In 79 out of 82 (96 %) dislocated hips closed reduction was achieved and confirmed by ultrasound examination. Signs of avascular necrosis as flattening of the femoral head was found only in 1 (0.9 %) out of 82

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treated hips. Three out of the 82 hips that did not improve under splint treatment underwent closed reduction with spica cast retention. A minimum of 2 years follow up with x-ray and clinical examination in all patients revealed good containment in all of the 82 conservatively reduced hips. Of the 79 patients with closed reduction by treatment in the Tuebinger hip abduction brace 60 patients received 1–4 pelvic X-rays between age 12 and 72 month. In 19 patients X-rays did not meet quality standards.

Age

12–18 months

18–24 months

24–48 months

48–72

Average acetabular index

Ø 23° (range 18°–31°)

Ø 21° (range 18°–31°)

Ø 20° (range 20°–30°)

Ø 16° (range 11°–20°)

Number of hip X-rays

50

15

49

12

As shown in the table above, there is evidence of delayed remodeling to normal values in developmental dysplasia of the hip, which might improve without further treatment over time. Discussion The clinical and radiological outcome of unstable hips treated with the Tuebinger hip abduction brace shows good results. This treatment regime is safe and easy to handle and allows for complete outpatient management with all positive side effects for the babies and families. The rate for AVN is not increased compared to the use of the Pavlik harness or retention in the plaster cast in the human position. Although ultrasound shows successful closed reduction, residual dysplasia may persist. Therefore long term follow up until cessation of growth is mandatory after successful closed reduction, which-in early childhood- can be achieved in the Tuebinger hip abduction splint. Dr. Kristina Weimann-Stahlschmidt, Heinrich-Heine-Universita¨t Du¨sseldorf, Orthopa¨die, Moorenstr. 5, 40225 Du¨sseldorf, e-mail: [email protected]

3 Development of acetabular index after ultrasound-monitored treatment of developmental dysplasia of the hips D. Dornacher Orthopa¨dische Universita¨tsklinik Ulm, Ulm, Germany Introduction There is consensus that despite normal values for the hip joint are reached at the end of ultrasound-monitored treatment of developmental dysplasia of the hips (DDH), radiological assessment is necessary until skeletal maturity. Due to endogenous factor a physiological hip joint at the end of harness treatment can result in residual dysplasia requiring further treatment. In order to rule out residual dysplasia the first anteroposterior pelvic radiograph is recommended at the age of 15–18 months. The acetabular index (AI) has proven to be a reliable parameter for acetabular development. The aim of this examination was to evaluate to what extent progressive development of the hips can be expected after a follow up at the age of 3 years. Patients and methods We retrospectively reviewed the findings of the second radiographic follow-up of 72 consecutive infants with residual DDH. (54 females, 18 males, 144 hips). When at least one hip showed mild residual dysplasia at the first radiographic follow-up second radiographic follow-up was recommended. In order to assess the severity of residual dysplasia the values of AI were allocated

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according to the age-related classification of To¨nnis. The findings of the second radiological follow-up were evaluated in regard to a persisting residual dysplasia. Generalized estimating equation (GEE) was used in order to assess the statistical difference of the values of AI from the first to the second radiographic follow-up. For the assessment of a difference in the evolution of AI, regarding gender (boys vs. girls) and laterality (right vs. left hip), dependent t test for paired samples was applied. Prior to this, normal distribution of the differences of AI from the first to the second follow-up was stated with the Kolmogorov–Smirnov test. Significance was expressed by p values. Results After allocation of the radiographic findings of the second follow-up according to the criteria described by To¨nnis, the 144 hips were divided into 62 hips (43.1 %) with normal AI, 56 hips (38.9 %) with mild residual dyplasia and 26 hips (18.1 %) with severe residual dysplasia. Regarding the normal hips with the dysplastic contralateral hip at the first follow-up, the mean AI was 22.9° (range16–26°), in the second follow-up the hips developed to a mean AI of 18.5° (range 12–25°). The mildly dysplastic hips at the first follow-up reduced from a mean AI of 27.2° (range 23–31°) to a mean AI of 22.5° (range 9–29°). The initially severely dysplastic hips developed from a mean AI of 31.1° (range 27–36°) to a mean AI of 25.1° (range 15–32°). p values of GEE indicated for each group above-mentioned significant difference for the values of AI (p \ 0.001 respectively). Regarding laterality, dependent t test for paired samples indicated a highly significant improvement of the right hip, as well as the left hip (p \ 0.001). The mean difference of AI from the first to the second follow-up for the right hips was calculated 5.36° (range -4 to 14°), for the left hips 5.34° (range -3 to 16°). Regarding gender, dependent t-test for paired samples indicated highly significant improvement of the boy’s hips, as well as the girl’s hip’s (p \ 0.001). The mean difference of AI from the first to the second follow-up was calculated for the boys 5.4° (range -4 to 14°) and for the girls 5.1° (range -1 to 14°). Although normal values were reached at the end of ultrasound-monitored treatment, 9 hips in 7 infants presented a substantial residual dysplasia at the second followup. These infants received pelvic osteotomy. Discussion Even after successful ultrasound-monitored treatment of DDH and progressive development to the age of 3 years, there remains a serious risk of residual dysplasia. For this reason, radiographic follow-up of every once treated hip as well as the initially physiological contralateral hip is necessary. We recommend followup regimen with the first radiographic control at the age of 18–24 months and a second radiographic control about the age of 3 years in infants with residual dysplasia in the first follow-up. Since there is a high chance of improvement of residual dysplasia until the age of 3 years, in earlier ages the indication for operative treatment should be carried out with caution. Correspondence Daniel Dornacher, Orthopa¨dische Universita¨tsklinik Ulm am RKU, Oberer Eselsberg 45, 89077, Ulm, Germany, Tel.: +731-1775113, Fax: +731-1771185, e-mail: [email protected]

4 One-stage hip reconstruction in late neglected developmental dislocation of the hip B. Heimkes, S. Werner, J. Frenzel, C. Gu¨nther und S. Utzschneider Orthopa¨dische Klinik und Poliklinik, Ludwig-MaximiliansUniversita¨t, Munich, Germany Background Due to ultrasound screening programmes in Central Europe untreated developmental hip dislocations in ambulatory

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children became uncommon. This however bears the risk that the principles of treatment for elder children fall into oblivion. Patients and methods Between 2004 and 2011 seventeen children underwent 22 combined open reductions + innominate + femoral osteotomies. All were ambulatory, previously untreated and suffering from a hip dislocation grade 2–4 according to Toennis. The clinical and radiological status pre- versus postoperatively and at follow-up was analysed by accepted indices (AC-angle, Ullmann-Sharp-angle, CE-angle, migration percentage, neck-shaft-angle). Results Preoperative findings: Patients0 origin: 10 patients came from Arabia, 4 from Germany, 2 from Far East and one from Eastern Europe. Grading: Four hips were classified as grade 2, one grade 3 and 17 grade 4 according to Toennis. Perioperative findings and complications The mean age at operation was 4 years and 8 months (range, 1 year and 4 months to 13 years and 3 months). Two patients suffered from a redislocation immediately after removing the cast and achieved stable hips after a revision which modified femoral anteversion, 1 patient had got a deep infection which was treated in time by jet-lavage. No avascular necrosis occured. Findings at follow–up The mean age at follow-up was 6 years (range, 2 years and 4 months to 16 years). According to the clinical McKay criteria 16 hips were excellent or good and 6 fair. According to the anatomical McKay criteria 15 hips were excellent or good, 6 fair and 1 decentrated. Discussion The one-stage hip reconstruction in late neglected developmental dislocation of the hip is a demanding procedure with a relatively high perioperative complication rate. In our cohort surprisingly occurred no avascular necrosis. The early results are encouraging, as they for now, show only one redecentration. The patients0 origin shows that we are working under globalised medical conditions. Keywords Developmental dislocation of the hip, neglected DDH, late DDH, one-stage hip reconstruction Correspondence Prof. Dr. med. Bernhard Heimkes, Schwerpunkt Kinderorthopa¨die, Orthopa¨dische Klinik und Poliklinik, Campus Grosshadern, Ludwig-Maximilians-Universita¨t, Marchioninistr. 15, 81377 Mu¨nchen, Tel.: +49-89-70953920, e-mail: [email protected]

5 The effects of femoral external derotational osteotomy on frontal plane alignment M. Nelitz1, T. Wehner2, M. Steiner

2

and S. Lippacher

3

1 Kliniken Kempten-Oberallga¨u, Oberstdorf, Germany, 2Institute of Orthopaedic Research and Biomechanics, University of Ulm, Ulm, Germany 3Department of Orthopaedic Surgery, University of Ulm, Ulm, Germany

Introduction In significant torsional deformity of the femur osteotomies are the preferred treatment. The aim of the present study was to evaluate the effects of external derotational osteotomies on proximal, midshaft and distal levels onto frontal plane alignment. Methods The effect of rotation around the anatomical axis of the femur on frontal plane alignment was determined with a 3D computer model, created from CT data of a right human cadaver femur. Virtual torsional osteotomies of 10°, 20° and 30° were performed at proximal, midshaft and distal levels under five antecurvatum angles of the femur. The change of the frontal plane alignment was expressed by the mechanical lateral femoral angle (mLDFA). Results Proximal derotational osteotomies resulted in an increased mechanical lateral distal femoral angle (mLDFA) between 0.8° and 7.9°, indicating an increased varus angulation. Supracondylar derotational osteotomy resulted in a decreased mLDFA between -0.1°

and 6.9°, an increased valgus angulation. The effect increased with the amount of torsional correction and virtually increased antecurvatum angles. Mid-shaft torsional osteotomies had the smallest effect on frontal plane alignment. Conclusion This 3-dimensional computer model study demonstrates the relationship between femoral torsional osteotomies and frontal plane alignment. Proximal external derotational osteotomies tend to result in an increased varus angulation, whilst distal external derotational osteotomies tend to result in an increased valgus angulation. Therefore torsional osteotomies can induce a clinically relevant change of frontal plane femoral malalignment, especially in patients with an increased antecurvatum angle of the femur. Keywords Derotational osteotomy, femoral anteversion, sagittal curvature femur, mechanical lateral distal femur angle Correspondence Priv.Doz. Dr.med. Manfred Nelitz, MVZ Oberstdorf, Kliniken Kempten-Oberallga¨u, Trettachstrasse 16, 87561 Oberstdorf, Germany, Tel.: +49-8322-703103, Fax: +49-8322-703110, e-mail: [email protected]

6 Functional outcome after containment improving surgery in children with Perthes disease B. Westhoff, N. Palmen, C. Zilkens, D. Rosenthal, R. Krauspe Department of Orthopaedics, Heinrich-Heine-University, Duesseldorf, Germany Introduction Gait deviations were described previously in the floride as well as in the final stage in LCPD [1–3]. This study aimed to analyze whether the gait pattern normalizes after containment improving surgery. Patients and methods 17 children with the diagnosis of LCPD (16 male, 1 female), who were treated by pelvic (Salter or Triple) and femoral osteotomy due to loss of containment, could be included. Inclusion criteria were (1) unilateral hip involvement, (2) follow-up of at least 2 years, (3) preoperative gait analysis, (4) no other disorder leading to gait deviations. All children were investigated clinically and classified according to the modified Harris Hip Score (mHHS) [4]. 3Dgait-analysis was performed with a VICON 512 system. Patients walked at a self-selected speed—barefoot. Spatiotemporal, kinematic and kinetic parameters were evaluated and compared to the preoperative data and to a group of normal children (n = 30, 14 #, 16 $, average age 8.1 years.). In addition a comparison involved vs. uninvolved side was performed. The gait patterns in frontal plane were categorized according to Westhoff et al. [1]. The age at time of surgery was 8 + 1.7 years (5–11), the follow-up time was 4.2 + 2.0 years (2–7.5). Results In comparison to the preoperative status the mHHS improved significantly and ranged within normal values. Analysis of the spatio-temporal parameters showed significantly increased gait velocity (p = 0.017), increased step-length on the involved side (p \ 0.001) and a normalized limp-index (p = 0.020). ROM of the pelvis (p \ 0.001) and the maximum anterior tilt of the pelvis (p = 0.001) decreased to normal values. At the hip ROM (p \ 0.001) in the sagittal plane increased due to increased hip extension (p \ 0.001) to normal values. Comparison of the kinematics uninvolved vs. involved side showed a completely normal symmetric movement pattern in the sagittal and frontal plane on average. Analysis of the frontal plane gait pattern revealed an overall improvement—while preoperative 10 patients showed a Duchenne-like pattern this was the case postoperatively only in 3. Power analysis of the hip joint revealed an increase in power generation to normal values

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(p = 0.01). Analysis of the hip flexor index according to Schwarz normalized in all but one patients. Discussion After containment improving surgery gait analysis demonstrated significant improvement of the gait pattern with regain of gait symmetry. 3D-gait analysis enables the analysis of the functional outcome of different treatment options after LCPD. Further studies are necessary to determine the functional predictors for the development of secondary osteoarthritis which may be influenced by conservative or surgical treatment options. References 1. 2. 3. 4.

Westhoff B et al. (2006) Gait Posture 24:196–202 Westhoff B et al. (2011) Int Orthop 35:1833–37 Westhoff B et al. (2012) Gait Posture 35:541–6 Byrd JW, Jones (2003) Arthroscopy 19:1055–60

Correspondence PD Dr. Bettina Westhoff, Orthopa¨dische Klinik, Universita¨tsklinikum du¨sseldorf, Moorenstr. 5, D 40225 Du¨sseldorf, Germany, e-mail: [email protected]

abduction in most cases. Therefore, arthrodiastasis in Perthes’ disease seems to be a valid preparing treatment option for subsequent hip preserving surgical intervention in case of hinge abduction. Keywords Perthes’ disease, arthrodiastasis, hinge abduction, varisation Correspondence Michael Novak, MD, Department of Paediatric Orthopaedics, Altona Children’s Hospital, Bleickenallee 38, 22763 Hamburg, Germany, Tel.: +49-40-88908382, e-mail: michael. [email protected]

8 Analysis and influence of training volume during conservative therapy on passive range of motion and gait performance in patients with Legg–Calve´–Perthes disease S. Adolf1, F. Stief2, C. Ebert3, M. Brkic2, L. Vogt3 and A. Meurer2 1

7 Arthrodiastasis as preparation for subsequent surgical intervention in Perthes’ disease M. Novak, K. Babin, A. L. Meiss, R. Stu¨cker and S. Breyer Altona Children’s Hospital, Hamburg, Germany Introduction The outcome of Perthes’ disease is hard to predict. There are several surgical treatment options dealing with the preservation of the hip containment, which constitutes the main therapeutic goal. Assumption for these techniques is a good hip movement without hinge abduction. We examined the effect of the arthrodiastasis on the improvement of hip movement and the possibility for further hip preserving operations in the case of initial hinge abduction. Patients and methods 10 patients were treated by arthrodiastasis of the hip as preparation for second stage surgery in Perthes’ disease between 2004 and 2011. Inclusion criteria were severe restriction of hip movement and a hinge abduction proved by arthrography. The age of patients at the time of diagnosis ranged from 4.2 to 10.0 years with a mean age of 8.2 years. The mean age at the point of arthrodiastasis was 8.8 ± 1.7 (mean ± SD) years. 7 boys and 3 girls were treated for 1.4 ± 0.6 months by external fixation. The mean follow up after onset of symptoms was 32 ± 24 months. All patients were treated with second stage hip containing operations if possible. If hinge abduction persisted, a salvage procedure was done. Assessment included the clinical hip abduction, radiographic measurements like the uncoverage percentage, the epiphyseal index before surgery and at last follow up, the epiphyseal quotient, and the Stulberg, Herring, and Caterall classification. Statistical analysis was performed by using two-sided t-tests and Wilcoxon tests. Results The range of abduction was significantly increased in all patients after the removal of the external fixateur. Hinge abduction persisted in 2 patients. In 7 patients a varisation of the proximal femur could be performed, in 6 of them in combination with innominate osteotomies, in which in one case a Shelf operation instead of Salter osteotomy was done, due to a very short acetabular roof. One patient had a single Salter osteotomy. In 2 cases of observable persistent hinge abduction a salvage operation with a single Shelf procedure was done. After second stage surgery the hip abduction was significantly reduced compared to abduction after arthrodiastasis but increased in comparison to preoperative range of motion. The radiological indices showed a significant improvement of the coverage of the femoral head after treatment at the last follow up. Discussion Our results show that arthrodiastasis significantly improves hip abduction and that arthrodiastasis is able to elude hinge

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Orthopedic University Hospital Friedrichsheim gGmbH, Frankfurt, Germany, 2Movement Analysis Lab, Orthopedic University Hospital Friedrichsheim gGmbH, Frankfurt, Germany, 3Department of Sports Medicine, Goethe-University Frankfurt, Frankfurt, Germany Introduction Conservative therapy as part of the treatment concept is used to improve the outcome in patients with Legg-Calve´-Perthes disease (LCPD). For example, Brech et al. [1] have shown an improvement of passive range of motion (ROM) with therapeutic training. Besides a positive effect on gait symmetry, it has been shown that pathologic movement pattern, such as a restricted sagittal plane hip ROM, in patients with LCPD persisted after conservative therapy [2]. The mechanisms influencing the final outcome remain unclear. The purpose of the present study was to evaluate the effect of the training volume during a 3 month conservative therapy on passive ROM and gait parameters. Materials and methods Twenty patients with unilateral Perthes disease and a mean age of 5.9 (±1.8) years were grouped according to their training volume (low, mean, high). The gait analysis as well as the clinical examination were performed immediately before the beginning of the standardized therapeutic treatment concept and repeated after 12.7 (±3.6) weeks on average. The treatment program included physiotherapy, sling table therapy and orthopedic traction and was documented with a daily log by the parents of children. Kinematic data were collected using an eight-camera Vicon system. One force plate (AMTI) was used to calculate mechanical power. The Helen Hayes marker set [3] was applied to determine joint centers. Results The results demonstrated an overall improvement in passive ROM after 3 month conservative therapy. The training volume did not affect gait performance. Even in the high training volume group a limitation of the affected side in hip extension and hip power generation persisted after the intervention period. However, the high training volume group showed a tendency towards a decreased passive ROM before the beginning of the treatment concept compared to the low training volume group. Discussion These first results suggest that the base-level (passive ROM and the amount of femoral head involvement) play a key role for the functional outcome during conservative therapy. A high training volume alone may not influence gait performance. Moreover, a reduced base-level in passive ROM may increase the training volume due to a higher motivation of the parents of LCPD children and vice versa. Continued study on the interrelationships between treatment concepts and gait performance with an enlarged sample size will have to show, if the functional limitations disappear over the years. References 1. Brech BC et al. (2006) Clinics (Sao Paulo) 61:521–528

J Child Orthop (2013) 7:331–362 2. Stief et al. (2012) J Child Orthop 6:530–531 3. Kadaba MP et al. (1990) J Orthop Res 8:383–392 Keywords Perthes disease, gait analysis, conservative therapy, training volume, hip extension Correspondence Dr. Felix Stief, Movement Analysis Lab, Orthopedic University Hospital Friedrichsheim gGmbH, Marienburgstraße 2, 60528 Frankfurt/Main, Tel.: +49-69-6705862, e-mail: f.stief@ friedrichsheim.de

9 Screw fixation or kirschner wire fixation in slipped capital femoral epiphysis? No significant difference of femoral neck growth in matched-pair study J.V. Wo¨lfle1, P. Nichterlein1, H. Reichel1 und R. Taurman1 Orthopa¨dische Universita¨tsklinik Ulm am RKU, Ulm, Germany Background When kirschner wires (k-wires) are used for in situ fixation of slipped capital femoral epiphysis (SCFE) there is a possibility of secondary loss of fixation due to length growth of the physis. In screw fixation secondary loss of fixation is less likely but length growth of the physis might be impaired. The aim of this matched-pair study was the comparison of length growth of the femoral neck in screw fixation vs. k-wire fixation of SCFE. Method All 15 patients (female:male = 4:11) who had undergone screw fixation of SCFE and of the asymptomatic contralateral hip before 2010 were matched according to age and gender to another 15 patients with k-wire fixation. The length of the femoral neck of the contralateral hip was measured in parallel to either screw or k-wire from the apex of the femoral head to the opposite cortical bone. The ratio of the femoral neck length measured directly after surgery and on follow-up was defined as femoral neck growth. Result There was no significant difference between groups with regard to age (13.5 ± 1.5 vs. 13.5 ± 1.6 years) and follow-up (1.8 ± 0.5 vs. 1.7 ± 0.5 years). We found no significant difference of femoral neck growth of patients with screw fixation (5.6 ± 3.5 %) when compared to k-wire fixation (7.8 ± 4.1 %, p [ 0.05 matched Wilcoxon Test, statistical power 1-ß = 0.911). Conclusion In this matched-pair study the assumption that length growth of the femoral neck is impaired by screw fixation was not confirmed. Given high rates of secondary loss of fixation in k-wire fixation with need for revision surgery screw fixation should be preferred in SCFE. Keywords SCFE, slipped capital femoral epiphysis, screw fixation, femoral neck length Correspondence Dr. med. Julia V. Wo¨lfle, Orthopa¨disches Universita¨tsklinikum Ulm am RKU, Oberer Eselsberg 45, 89081 Ulm, Germany

335 weakness. In particular, weakness of the hip abductors was suggested to cause Duchenne gait in children with Myelomeningocele (MMC) [1]. However, this has not been confirmed in children with Arthrogryposis multiplex congenita (AMC) or cerebral palsy (CP). If abductor strength was the underlying reason, correlation between abductor strength and Duchenne gait is a necessary prerequisite. Therefore the purpose of this study was to show whether Duchenne gait has the same etiology in children and adolescents with CP, AMC and MMC. Materials and methods In a retrospective study 99 children and adolescent (age between 6 and 18 years) were included. 51 had spastic bilateral CP, 28 AMC and 20 MMC. All participants were able to walk barefoot without assistance, and did not have surgeries within at least 2 years; participants with CP were not operated previously. All patients underwent a 3D gait analysis followed by a clinical exam. 20 typically developed children and adolescents (TD) served as controls. Extent of Duchenne gait was quantified by the range of trunk lean in the frontal plane (TRL) at preferred walking speed. To investigate possible reasons for Duchenne gait, bivariate correlations between TRL and abductor strength and between TRL and hip extensor generation energy were performed. Results Duchenne gait with TRL of more than 3 times the standard deviation of the TD group could be observed in 73, 50 and 55 % of the patients with CP, AMC and MMC respectively. Correlations between TRL and abductor strength were significant in AMC and MMC with r = -0.6 and r = -0.8 (p \ 0.001). The CP group showed a weaker and non-significant correlation (r = -0.2, p = 0.06). However, TRL and hip extensor generation energy were significantly positively related in the CP group (r = 0.4, p \ 0.001) but not in both other groups. Discussion The prevalence of Duchenne gait was considerable in all three groups. The assumption that abductor strength determines Duchenne gait could be only confirmed for the AMC and MMC group. Lack of significant correlations for participants with CP, suggested that other factors such as spasticity of the muscles at the hip, not present in the other two groups, maybe more decisive. Biomechanically the Duchenne gait is a mechanism to unload the hip abductors. In CP unloading of abductors might be advantageous since poor selectivity might activate hip abductors and hip flexors together, that would increase crouch and reduce hip extensor power during walking. This explanation can be confirmed since only in the CP group increased TRL correlates with improved hip extensors generation energy. In conclusion treatment of excessive frontal plane trunk lean in CP might be different from AMC or MMC patients. References 1. Bartonek et al. (2002) Gait and Posture 15:120–129 2. (1998) Kendall Muskeln Funktion und Test pp 178 Keywords Cerebral palsy, Myelomeningocele, Arthrogyposis multiplex congenita, Duchenne gait Correspondence Harald Bo¨hm, Orthopaedic Clinic for Children, Bernauerstraße 18, 83229 Aschau i. Chiemgau, Tel.: +8052-1712016, e-mail: [email protected]

10 Duchenne gait in neuro-orthopaedic patients: is it always the same etiology? H. Bo¨hm M. Ho¨sl, L. Do¨derlein Orthopaedic Hospital for Children, Behandlungszentrum Aschau GmbH Introduction Neuro-orthopaedic patients are often concerned about their excessive trunk lean during walking (Duchenne gait), mainly because of their distinct physical appearance among peers. Duchenne gait might assist foot clearance to compensate for contractures and muscle

11 Comparison of gait parameters after conservative, soft tissue and bony procedure to treat crouch gait in cerebral palsy M. Salzmann, N.C. Berger, M. Ho¨sl, H. Bo¨hm, L. Do¨derlein Orthopaedic Hospital for Children, Behandlungszentrum Aschau GmbH Introduction Cerebral palsy is the result of a static lesion of the developing brain. The musculoskeletal deformities in growing

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336 children are often progressive. Crouch gait is a common condition among children with cerebral palsy and decreases walking efficiency. Many conservative and operative interventions are suggested but determing the appropriate corrective treatment is difficult because of the heterogeneity in the patient population. The aim of this study was to compare the outcome of conservative treatment, soft tissue surgery and bony surgery on gait of children with cerebral palsy and crouch gait. Materials and methods In this retrospective study 3D gait analysis was performed in three groups of children with cerebral palsy GMFCS II + III and crouch gait pattern. In the first group 22 children (aged 14.6 ± 2.5 years) with bilateral spastic CP were managed with conservative treatment. In the second group 19 children (aged 16.0 ± 3.4 years) with bilateral spastic CP were managed with soft tissue single event multilevel surgery (SEMLS). In the third group 10 children (aged 13.9 ± 6.3 years) were managed with supracondylar femoral osteotomy in combination with patellar tendon shortening. We extracted parameters of the more affected side. Gait deviations from typically developed children were determined by the Gait profile Score (GPS). Gait parameters concerning crouch gait were compared between the three groups. Results Comparing the results concerning the Gait Profile Score there are no significant differences between the groups. The first group (conservative treatment) show a GPS of 12.2° (range 7.2°–15°), the second group (soft tissue SEMLS) of 11.2° (range 8°–14°) and the third group indicates a GPS of 12.1° (range 9°–14.5°). In particular sagittal plane kinematics show the typical ‘‘double bump’’ pattern at the pelvis in all groups with only a slight better pelvis extension in the first group. The maximum of the hip extension in stance phase was best in the second group. At the knee all groups indicates a late peak knee flexion in swing with a better maximum of knee extension in the second and third groups. Concerning the transversal plane kinematic there is no difference in the hip rotation between the three groups but a better foot progression angle (10°) in the two operative groups. Discussion The results suggest only little differences between the three groups concerning gait parameters. Crouch gait pattern are still present and the two operative groups indicate only a small improvement in sagittal und transversal kinematics. This study was limited by its retrospective nature. No gait analysis was implemented preoperative and a statement about intraindividual improvement is not to be made. Verification of the current results in a larger sample is in progress. Keywords Cerebral palsy, crouch gait, 3D gait analysis, outcome Correspondence Dr. Maya Salzmann, Orthopaedische Kinderklinik Aschau, Bernauerstr. 18, 83229 Aschau im Chiemgau, Tel.: 08052/1710, e-mail: [email protected]

J Child Orthop (2013) 7:331–362 Materials and methods 3D gait analysis was performed in two groups pre- and post-treatment. In the first group 7 children (aged 8.3 ± 1.9 years) with bilateral spastic CP (GMFCS II: n = 4; III: n = 2 and IV: 1) were managed by a single event multilevel surgery (SEMLS) integrating myofasciotenotomies at the hip, knee and ankle. At least three muscles were selected. Children were followed up 6.1 ± 1.5 months later. In the control group 5 children were treated with physical therapy and orthotics (GMFCS II: n = 4, III: n = 1; age: 8.5 ± 1.0 years; follow up: 7.9 ± 0.7 months). All children walked with knee flexion [30° at initial contact. We extracted parameters of the more affected side. Gait deviations from typically developed children were determined by the Gait Profile Score [3] (GPS). Pre- and post data in each group were analyzed with dependent t test. Treatment effects were compared with independent t-test. Results Concerning the surgical group, all children improved, as indicated by smaller deviation from the norm, leading to a significant overall GPS change of 0.8°–6.1° (p = 0.01). In particular, minimum knee flexion in stance significantly decreased from 36 ± 7° to 26 ± 6° (p = 0.03). Children treated conservatively only further deviated from the norm and showed a small but consistent increase on the GPS, ranging from 0.0° to 1.9 (p = 0.06). Contrasting both treatments, surgery showed a highly significant better outcome (p \ 0.01). Discussion These preliminary results indicate that soft tissue SEMLS integrating myofasciotenotomies can have a positive impact on crouch gait in children with severe CP. Only one child in the surgical group gained less than the minimal clinically important change in the GPS of 1.6° [3]. Conservative treatment alone may not be capable of stopping deterioration as motor function of children in GMFCS II or higher, on average is dominated by stagnation and decline from late childhood on [4]. It remains to be determined if results persist over a longer period of time and if Ulzibat’s technique contains its effectiveness. Verification of the current results in a larger sample is in progress. References 1. 2. 3. 4.

Rozumalski, Schwartz (2009 Gait Posture 30(2):155–160 Heinen et al. (2009) Monatsschr Kinderheilkd 157(8):789–794 Baker et al. (2012) Gait Posture 35(4):612–615 Hanna et al. (2009) Dev Med Child Neurol 51(4): 295–302

Keywords Cerebral palsy, myofasciotomy, Ulzibat’s procedure Correspondence Dr. med. Maya Salzmann, Obera¨rztin, Orthopaedische Kinderklinik Aschau, Bernauerstr. 18, 83229 Aschau im Chiemgau, Tel.: 08052/1710, e-mail: [email protected]

13 12 Effects of multilevel myofasciotomy on crouch gait in children with cerebral palsy

A critical consideration on common orthotic treatment concepts for gait problems in cerebral palsy D. Sabbagh, J. Fior, R. Gentz

M. Salzmann, M. Ho¨sl, H. Bo¨hm and L. Do¨derlein Orthopaedic Hospital for Children, Behandlungszentrum Aschau GmbH Introduction Young children with spastic Cerebral Palsy (CP) who already walk with excessive knee flexion are at particular risk of functional decline [1]. Orthopaedic surgery should be considered earlier in case of high GMFCS-levels [2]. Ulzibat’s technique, a minimal invasive procedure of myofasciotomies, is suggested as a treatment for severe muscle contracture. Despite its growing popularity, no objective data on functional outcomes are available.

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FIOR & GENTZ GmbH, Lu¨neburg, Germany Introduction The goal of an orthotic treatment in cerebral palsy (CP) is to come closer at best to a physiological gait. According to the Amsterdam Gait Classification, the pathological gait patterns of CP patients are divided into five gait types. This classification must be considered for an optimal care. During swing phase an ankle foot orthosis (AFO) prepares the foot for initial contact (IC). It also enables a better stability and supports the ankle’s push off during stance phase. Besides, an AFO should have a positive effect on therapy and must not lock residual physiological motion. A detailed

J Child Orthop (2013) 7:331–362 consideration of existing orthosis types should indicate whether the requirements for all gait types can be met. Materials and methods The effect of already existing AFO is evaluated. Considering the criteria of adjustable alignment, pivot point, range of motion and spring force, supramalleolar orthoses, solid AFO (SAFO), dynamic AFO (DAFO), floor reaction AFO (FRAFO), posterior leaf spring AFO (PLS AFO) and hinged AFO (HAFO) are compared with each other. Results The alignment of most of the compared orthoses cannot be subsequently adjusted. In HAFO this is only possible to a limited extent depending on the joint type used. In PLS AFO, FRAFO and DAFO a defined pivot point is missing, while in HAFO it can be placed on the anatomical pivot point. Nevertheless, all orthoses lock the plantar flexion or just allow it through active muscle work. The range of motion is not possible, except for certain joint types (HAFO). In PLS AFO, FRAFO and DAFO the spring force can only be regulated by the material and its thickness used during producing. Elastomer spring or coil spring joints that are mounted in a HAFO have too low spring forces. Discussion Due to an appropriate orthosis, coming closer to a physiological gait and improving the energy consumption of CP patients are possible. Depending on the gait type, different AFO are used for the treatment. Already existing AFO do not fulfil all necessary requirements because basic adjustment possibilities are missing. The spring force needed to be applied to the ankle by an AFO depends on the gait type as well as on the anthropometric data of the patient. The correct alignment of the orthosis using biomechanical principles is essential for a successful orthotic treatment. The remaining function of the muscles involved is used to provide the nervous system with proprioceptive input. This process is known as neuroplasticity and takes place especially during plantar flexion in IC. Therefore, the resulting demand is: Both dynamic and static AFO should be produced with an adjustable ankle joint. The optimal ankle joint for a HAFO should dispose of three adjustments that can be changed separately and do not influence each other: (1) spring force, (2) alignment of the orthosis and (3) range of motion. Keywords Cerebral palsy, ankle foot orthosis, alignment, gait type, neuroplasticity Correspondence Daniel Sabbagh, FIOR & GENTZ GmbH, Dorettevon-Stern-Straße 5, D-21337 Lu¨neburg, Germany, Tel.: +49-41312444546, e-mail: [email protected]

14 A prospective dynamic pedobarographic study of indirect kinematic changes in the roll-over process of valgus foot deformities pre/post surgery in cerebral palsy J. Matussek, F. Wagner Paediatric Orthopaedic Department; University of Regensburg Medical Center; Regensburg/Bad Abbach, Germany Introduction 3-D dynamic kinematic data aquisition in the child0 s foot is difficult as marker positioning is challenging and the process of a full gait analysis time consuming and costly. Especially the evaluation of dynamic foot kinematics when in ankle–foot-orthotics is hardly possible Readily available pedobarographic insoles to measure rapid pressure changes during gait possibly give sufficient indirect kinematic data to characterize relative pressure changes during the foot0 s roll-over process. This enables the clinician to prospectively compare a baseline of dynamic pedobarographic and indirect kinematic data of pre- and postoperative gait in valgus feet with data acquired from healthy subjects.

337 Materials and methods 19 children and adolescents (GMFCS I-III) between 9 and 12 years.(f: 8/m:11) with severe flexible valgus foot deformities due to CP (Tetraplegic n: 2; Diplegic n: 14; Hemiplegic n:3) who underwent bony subtalar fusion and calf tendon lengthening procedures were studied pre and postoperatively with and without orthotics. Of the tetraplegic/diplegic group n: 8 needed bilateral subtalar fusion treatment. 9 children had previous bony and/or other SEML surgery before addressing the foot problem, 10 children qualified for SEML surgery with the subtalar fusion procedure. Outcome measurements were done between 12 and 18 months postsurgery. These children underwent video and pedobarographic gait analysis with a wireless 64-pressure-sensor 60-Hz system (capacitive pressure measurement system MedilogicÒ). All had standardized foot X-ray. A control group of 20 clinically healthy feet rendered so-called normal pressure distribution data. Gait parameters included speed, stride length, effective foot length, CoP line (centre of pressure), width of gait line as well as hind-, mid- and fore-foot pronation indexes as a measure of indirect foot kinematics (inversion/eversion). Results CoP line, effective foot length and foot pronation indexes significantly improved in n: 14 (n: 3 hemiplegic, n: 11 diplegic patients) already without bracing, whereas an additional AFO adjusted measurements close to those of the control group. In n: 5 children, AFO bracing was compulsory to stabilize gait, but was done more comfortably postsurgically than before. Data from the control group surprised with a high degree of variation and although clinically normal, foot pressure patterns from highly inverted to plano-valgus were observed. Discussion Insights into the indirect kinematics of valgus foot deformities are easily available with dynamic pedobarography; functional evaluation with and without AFO bracing is possible giving valuable information into whether longterm postsurgical bracing is necessary. Keywords Cerebral palsy; valgus foot; surgical correction; pedobarography Corresponding Author Dr.med. Jan Matussek, Paediatric Orthopaedic Department, University of Regensburg Medical Center, Kaiser-KarlV.-Allee 3, D-93077 Regensburg/Bad Abbach, Tel.: 09405-18-4826, e-mail: [email protected]

15 Reduction of spasticity improves hip geometry in children with cerebral palsy N. Floeter1, C. Wagner2, H. Haberl3, S. Lebek1 and J.F. Funk1 1 Department for Pediatric Orthopaedic Surgery and Neuroorthopaedics, Center for Musculoskeletal Surgery, Charite´ – University Medicine Berlin, Berlin, Germany, 2Social Pediatric Center, Sana Hospital Lichtenberg, Berlin, Germany, 3Division of Pediatric Neurosurgery, Charite´ – University Medicine Berlin

Introduction Cerebral palsy is worldwide the most common cause of physical disability. Spasticity is not only regarded as the main reason for functional limitations but also leads to osseous deformities such as hip dysplasia and dislocation also known as lever-arm diseases. Selective dorsal rhizotomy (SDR) is one treatment option to reduce spasticity. Many studies show the positive effect of SDR on spasticity but few and controverse investigations exist concerning the progression of spasticity induced hip deformities after SDR. This study hypothesizes that the reduction of the abnormal forces of the pericoxal muscles through the reduction of spasticity via SDR will reduce the progression of hip deformities in children with bilateral spastic cerebral palsy.

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338 Patients and methods The present study included 16 patients with a mean age of 6.5 years (range 4–11 years) and GMFCS levels I-II who underwent SDR via monosegmental laminectomy and did not have any operative orthopaedic treatment before. To analyze hip geometry, femoral anteversion (FAV), migration percentage (MP), and acetabular index (AI) were measured preoperatively and 1–2 years after SDR. Therefore, anteroposterior and Rippstein II radiographs of the hip were taken. The reduction of spasticity was measured with the modified Ashworth scale (MAS). Results Spasticity of adductor and medial ischiocrural muscles was reduced from 3.5 on average preoperatively to 1.4 12 months after SDR. Reduction of spasticity was found in all patients. Concerning the geometry of the proximal femur a significant reduction of 4° ± 4.6 (FAV preOP 41.9° ± 6.7; FAV postOP 38.4° ± 6.4) of femoral anteversion was observed on average 17 months after SDR (Fig. 1). The migration percentage (MP preOP 20.6 % ± 7.8; MP postOP 18.5 % ± 7.1) and the acetabular index (AI preOP 15.8° ± 4.3; AI postOP 14.4° ± 5.0) were slightly reduced or remained unchanged in most of the patients at this point in time (reduction of MP 2 % ± 4.2; reduction of AI 1.2° ± 2.2). Discussion This study shows that not only spasticity but also the deformity of the proximal femur can be reduced after SDR in CP children through the reduction of lever-arm imbalance. Although the femoral anteversion is still elevated postoperatively compared to values of typically developing children, the reduction of FAV is significant and might be clinically important for a better walking pattern of the child in the long term. It is well known that increased femoral anteversion is common in children with cerebral palsy and that it is one of the main reasons for secondary hip dysplasia. Without corrective therapy, an increase of FAV of about 2° per year can be expected in CP children. In typically developing children FAV decreases about 4° per year. As MP and AI showed no progression in our patients after SDR a rather stable hip situation may be assumed concerning subluxation. Further studies including gait analysis to evaluate the correlation between spasticity, deformity, and walking pattern are necessary to show a functional benefit for the children through improved hip geometry. By improving hip geometry and possibly the walking pattern, SDR might be beneficial to reduce secondary diseases such as lever-arm deformities and osteoarthritis. Keywords Cerebral palsy, selective dorsal rhizotomy, femoral anteversion, hip subluxation Correspondence Dr. med. Julia F. Funk, Department for Pediatric Orthopaedic Surgery and Neuroorthopaedics, Center for Musculoskeletal Surgery, Charite´ – University Medicine Berlin, Charite´platz 1, 10117 Berlin, Germany, Tel.: +49-30-450652257, e-mail: [email protected]

16 Outcome of single event multilevel surgery of upper limb (SEMLS) in cerebral palsy—patients perspective C.U. Dussa, L. Doederlein Orthopaedische Kinderklinik, Aschau i. Chiemgau Introduction Hand is often involved in cerebral palsy. Apart from Spasticity, the cardinal feature is loss of selective control of the involved hand. This produces not only a significant disability, but also a cosmetic disturbance. Surgical correction of the hand is indicated to improve function of the hand. The aim of the study is to assess patients/caretakers perception of functional improvement of the hand following surgery. Material, methods A prospective study was conducted in 25 patients (27 limbs) with cerebral palsy who were operated on their hands. All

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J Child Orthop (2013) 7:331–362 patients underwent SEMLS of upper limb. Apart from demographics, the types and levels of surgery and complications were documented. Minimum follow up time was 3 years. The function of the upper limb was classified using MACS both pre and postoperatively. A patient/caretaker questionnaire was designed to the document the current hand function and satisfaction. Caretakers perception of improvement was documented in 5 activities of daily living were also documented. In addition perception of improvement of thumb position was also documented. Results 93 % reported improvement in Thumb position following surgery. However 40 % patients perceived that Thumb is still adducted. 44 %—perceived that the Thumb prevented gripping an object. 50 % of the patients felt thumb still needed orthotic support to help improve abduction. MACS did not improve in 40 % of our patients following SEMLS. 33 % of patients \15 years and 38 % [15 years did not improve in MACS following SEMLS. Relation to dominant side could not be measured. [80 % of the patients with no improvement in MACS would like to undergo the surgery again. Complications include: temporary Neuropraxia in 2, Supination deformity in 1, recurrent elbow contracture 1, thumb rearthrodesis 1. Discussion SEMLS in upper limb corrects the deformities at all levels. This positions the limb in an optimal position to improve the function. However, the selective control of the muscles is not improved following surgery. Therefore only those patients who use the arm before the surgery show an improvement in function after the surgery. This is evident in the preoperative MACS scores. The correction of the thumb poses a challenging problem. In spite of lack of improvement of function following surgery, most of the patients/ caretakers were happy to have the surgery. This reflects the cosmetic improvement of the hand following surgery. Keywords Cerebral Palsy, upper limb surgery, outcome Correspondence Dussa CU, Orthopaedische Kinderklinik, Bernauer Strasse 18, 83229 Aschau im Chiemgau, Germany, Tel.: 0049 8052 171 0, e-mail: [email protected]

17 Does selective dorsal rhizotomy reduce the variability and enhance the stability of gait in children with bilateral spastic cerebral palsy? J.F. Funk1, S. Bakir2, F. Gruschke2, W.R. Taylor3 and S. Lebek1 1

Department for Pediatric Orthopaedic Surgery and Neuroorthopaedics, Center for Musculoskeletal Surgery, Charite´ – University Medicine Berlin, Berlin, Germany, 2Julius-Wolff-Institute for Biomechanics and Musculoskeletal Regeneration, Charite´ – University Medicine Berlin, Berlin, Germany; 3Department of Health Sciences and Technology, Swiss Federal Institute of Technology, Zurich, Switzerland Introduction Three dimensional gait analysis (3DGA) shows varying results concerning changes after selective dorsal rhizotomy (SDR) in children with cerebral palsy (CP). Subjective impressions of the patients concerning functional improvement are usually depicted less impressively in functional scores or 3DGA. This may be due to only subtle changes in standard parameters which may accumulate to a clinically relevant change concerning variability of gait. We assume that a reduction in variability leads to a more ‘‘normal’’ gait pattern. Thus, the hypothesis of this study is that variability decreases and hence the stability of gait increases after SDR in children with bilateral spastic cerebral palsy. Patients and methods All patients who underwent SDR in our institution via a monosegmental laminectomy approach and were able to

J Child Orthop (2013) 7:331–362 perform instrumented gait analysis applying a functional model with the correspondent marker set pre- and 12 months postoperatively were included in this study. Data was evaluated applying previously published algorithms. Mean values as well as coefficients of variability were analyzed for the following parameters: cadence (CAD), velocity (VEL), percentage of stance phase of the gait cycle (STP), double limb support (DLS), and foot progression angle at midstance (FPA). Parameters were normalized for leg length where applicable. Due to the small number of patients the Wilcoxon signed rank test was applied for statistical analysis. Results The required data existed from 13 patients with a mean age of 5.9 ± 1.5 years at SDR. The mean FPA changed significantly from -5° preoperatively to +4° postoperatively (p = 0.034) whereas the variability of the FPA did not change significantly (p = 0.695). The mean CAD changed significantly from 2.4 steps/s preoperatively to 2.2 steps/s postoperatively (p = 0.046). The variability of CAD also decreased significantly from 11.0 to 8.5 (p = 0.009). Neither mean nor variability of VEL changed significantly after SDR (p = 0.279, p = 0.173). Although the mean STP did not show significant changes after SDR (p = 0.279) and was 62 % preoperatively and 60 % postoperatively, the variability of the STP was significantly reduced (p = 0.002) from 9.3 preoperatively to 6.4 postoperatively. The same was found for the double limb support (mean p = 0.133, variability p = 0.033). Discussion This study shows that a more stable walking pattern with less variability may be achieved through the reduction of spasticity via SDR although not much change is found in the absolute or normalized values. While different changes of temporospatial, kinematic, and kinetic parameters of gait after SDR have been found those did not depict the subjectively experienced improvement of the patients well and led to controversial scientific discussions about the benefit of this procedure. Therefore, additional parameters such as variability of gait may be helpful in analyzing higher motor functions. In already very well ambulating patients those parameters may yield essential information to comprehend stability of gait which is important to achieve a more ‘‘normal’’ walking pattern as well as the ability to perform even more difficult tasks. Keywords Cerebral palsy, selective dorsal rhizotomy, motion analysis, variability of gait Correspondence Dr. med. Julia F. Funk, Department for Pediatric Orthopaedic Surgery and Neuroorthopaedics, Center for Musculoskeletal Surgery, Charite´ – University Medicine Berlin, Charite´platz 1, 10117 Berlin, Tel.: +49-30-450652257, e-mail: [email protected]

18 Spastic gait pattern in full knee extension and talipes calcanei after achilles tendon lengthening in a patient with Leigh syndrome

339 After rehabilitation time a spastic gait pattern with Pes equinus developed, which was treated outwards with open achilles tendon lengthening. Methods We present the clinical examination, X-ray of the knee joints and the 3D instrumental gait analysis. Results The patient presented with an impaired gait pattern with markedly impaired balance and coordination capabilities. A disturbing circumduction gait in knee extension and painful toe flexion was observed on both sides. Clinical examination observed inconspiciuos passive ROM of hip and knee joints, but inducible spastic acitivity of the M. quadriceps at knee flexion. Dorsiflexion of the ankle joint was 35° on both sides in terms of talipes calcanei. Claw toes on both sides were passively reducible. The Patella and Achilles tendons reflexes were hypertonic. Babinski reflex was positive. The 3D instrumental gait analysis showed the typical pattern of a spastic pelvic tilt with a double curve and increased knee flexion during the complete gait cycle, with knee excursion markedly reduced. Dorsiflexion of the ankle joint was markedly increased representing talipes verticales. Distinctive pelvic rotation represented circumduction of both legs. Kinetic analysis showed a pathological internal knee extension moment during whole standing phase and an initial internal extension moment of the hip joint. Electromyographic examination impressed with a permanent activity of the M.rectus femoris, pronounced at the end of the stance phase. Therefore we treated the patient with a ventrally stabilizing stapeorthesis of the lower leg combined with botulinum toxin injection of the M. rectus femoris on both sides. Gait analysis 8 weeks after treatment begin showed an improved gait pattern with reduced circumduction gait, improved knee movement excursion during whole gait cycle and reduced activity of the M. rectus femoris at the end of the stance phase. Discussion The patient presented with spastic gait pattern in moderate crouch gait and circumduction. She was diagnosed with the neurological setup of Leigh syndrome, a cytomchrome c oxidase deficiency. Untypical for this metabolic disease with normally hypotone muscle status, she presented with a spastic gait pattern. The treatment of the talipes calcanei with ventral bracing ortheses as well as the botulinumtoxin injection in order to reduce the pathological activity of the M. rectus femoris could improve the gait cycle. Care should be taken regarding the Achilles tendon lengthening in patients with spastic pes equinus because of risk for overcorrection leading to weakness and crouch gait. Keyword Spastic gait patern, knee extension contracture, Leigh-syndrome, Botulinumtoxin Korrespondenzadresse Dr.med. Harald Lengnick, Kinderorthopa¨die, Orthopa¨dische Kinderklinik Aschau, Bernauer Strasse 18, 83229 Aschau im Chiemgau, Tel.: 08052/171 – 0, e-mail: [email protected]

H. Lengnick, C. Dussa und L. Do¨derlein Orthopa¨dische Kinderklinik, Behandlungszentrum Aschau im Chiemgau Anamnesis We present the case of a 17 year old girl with moderate crouch gate and talipes calcanei combined with extension spastic of the M. quadriceps femoris with consecutive circumduction gait pattern on both legs. The past medical history offered that the girl suffered two times spontaneously the situation of non-movement of both legs during normal walking 3 years ago. A cortisone booster therapy adjuvantibus on spec to inflammatoric neurologic disease led to complete paralytic malfunction of the lower extremity.

19 Brace treatment of scoliosis in patients with neuromuscular diseases M. Salzmann, N.C. Berger and L. Do¨derlein Orthopaedic Hospital for Children, Behandlungszentrum Aschau GmbH Introduction Neuromuscular scoliosis occurs in various diseases and is due to deficient function of postural control and motor control of

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340 trunk muscles. Its natural history shows an early onset followed by relatively fast progression, finally resulting in a rigid, structural curve. Contrary to idiopathic scoliosis there still remains doubt about the efficacy of brace treatment in neuromuscular spine deformities. The objective of this retrospective study was to determine the impact of spinal bracing on curve pattern and rate of progression of neuromuscular scoliosis in children and adolescents. Materials and methods 98 patients diagnosed with a neuromuscular disease (cerebral palsy: 58, arthrogryposis: 8, myelomeningocele: 10, other syndromes: 22) started bracing treatment for spinal deformity in 2005. All patients were wheelchair-bound. Daily bracing time and radiographic findings (Cobb angle) in sitting position without brace were recorded on a regular basis. At the end of follow-up a curve progression of less than 20° and/or a Cobb angle no greater than 50° was considered to be a satisfactory result. Results Mean age at beginning of treatment was 10.3 years (range 6–14 years), mean follow-up was 5–7 years. The average daily time of brace wear was 11 h (range 4–23 h). In some patients brace wear time had to be reduced due to pressure sores and feeding problems. No patient discontinued the brace treatment completely. The mean initial Cobb angle of 31.6° (5°–68°) deteriorated from 2005 onwards to a mean of 60.1° (20°–116°) in 2012. At last follow-up the brace treatment was satisfactory in 28 %. The best outcome was observed in thoracolumbar scoliosis (39 % satisfactory results), followed by thoracic curves (26 %) and lumbar curves (19 %). If a child displayed a curve of more than 40° before the age of 15 years this would lead to a severe scoliosis ([60° Cobb angle) in almost all cases at the end of follow-up. The underlying disease or daily time of brace wear did not play a significant role regarding curve progression and deterioration of Cobb angle. Discussion The treatment of neuromuscular scoliosis in children and young adults is a challenge due to its resistance and tendency to progress. Although these patients benefit from conservative treatment like bracing regarding sitting stability and lung function, severe progression of scoliosis can only be prevented in 28 %. Particularly the lumbar spine seems to be very difficult to control with a brace. If a curve exceeds a Cobb angle of 40° before the age of 15 years brace treatment will no longer be successful and surgery should be considered to prevent the spine from collapsing. Keywords Neuromuscular scoliosis, brace treatment, curve progression. Correspondence Dr. Maya Salzmann, Orthopaedische Kinderklinik Aschau, Bernauerstr. 18, 83229 Aschau im Chiemgau, Tel.: 08052/171-0, e-mail: [email protected]

20 Results of ellipse magec rod implantation in children with neuromuscular scoliosis A. Hell, H. Lorenz, E. Freifrau von Richthofen, C. Tsaknakis, K. Horst Schwerpunkt Kinderorthopa¨die, Operatives Kinderzentrum, Universita¨tsmedizin Go¨ttingen, Go¨ttingen, Germany Introduction Within the last decades scoliosis in children has been mainly treated with expandable methods such as VEPTR or growing rod systems. However, repetitive surgeries for lengthening of the implants have put stress on both the children and their parents. The complication rate rises with an increased number of surgeries (e.g. infection). Additionally, for children with spinal muscular atrophy (SMA) severe pulmonary problems are common after surgical procedures any may lead to long-term intensive care unit visits. Methods Within the last 12 months 11 children (5 female, 6 male) with neuromuscular scoliosis were treated with the Ellipse Magec rod

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J Child Orthop (2013) 7:331–362 in combination with a bilateral VEPTR fixation. The average age was 9 years. The diagnoses of the treated children were SMA (7), Rett syndrome (1), congenital myopathy (1), Marfan syndrome (1), paraplegia (1) due to an intrauterine neuroblastoma. 10 children were wheelchair bound. Results Out of the 11 patients 4 children had had prior VEPTR implantation with an average of 5.25 lengthenings (2–9). The reasons to change to the Magec system were severe respiratory problems after the lengthening surgeries with long-term ICU visits. One patient had an infected implant due to a low BMI (8) which had to be removed and a new treatment concept had to be applied after healing of infection. In 7 children Magec implantation was the first spinal surgery. Until now 12 outpatient Magec lengthening were performed in 5 patients. At the initial Magec surgery Cobb angle of the scoliosis was corrected an average of 54 % (67° to 31°). Thoracic kyphosis changed from 45° to 35° and lumbar lordosis from -29° to -26°. At the lengthening procedures scoliosis was reduced from 27° to 22° (20 %) while thoracic kyphosis and lumbar lordosis stayed the same. There were two complications during the course, one related to technical problems with the fixation of the new device. Conclusion Ellipse Magec rod implantation in combination with a VEPTR fixation is a sufficient method to treat flexible scoliosis in children without instrumentation of the spine. The lack of repeated surgeries is especially beneficial in children with impaired pulmonary function such as SMA patients. Keywords scoliosis, magnetic lengthening device, children Correspondence Prof. Anna K. Hell, Leiterin des Schwerpunktes Kinderorthopa¨die, Operatives Kinderzentrum, Universita¨tsmedizin Go¨ttingen, Robert-Koch-Str. 40, 37075 Go¨ttingen

21 Subtalar arthroereisis for correction of idiopathic and paralytic flatfeet in children – Comparison between absorbable and not absorbable sinus tarsi implants and calcaneus stop screws B. Vogt1, H. Tretow1, M. Horter1, F. Schiedel1, D. Rosenbaum2 and R. Roedl1 1

Department of Children’s Orthopaedics, Deformity Reconstruction and Foot Surgery, University Hospital Muenster, Muenster, Germany, 2 Institute of Experimental Musculoskeletal Medicine, Movement Analysis Laboratory, University Hospital Muenster, Muenster, Germany

Introduction Symptomatic flatfeet in children develop idiopathic or due to primary diseases like cerebral palsy. If conservative treatment fails, surgical intervention must be considered. Subtalar arthroereisis is a less invasive and reversible operative procedure for flexible flatfeet. Different techniques have been described either placing an expanding implant in the sinus tarsi like the not absorbable KalixÒand the absorbable Giannini-endorthesis or implanting a lateral calcaneus stop screw as described by de Pellegrin. This retrospective cohort study compares the postoperative outcome and complication rates of the three different methods on the basis of clinical, pedobarographic and radiographic parameters in a mid-term follow up. Methods 65 children with 102 operated flatfeet were investigated preoperatively and after surgery with a mean follow up of 12.3 ± 6.8 [2–31] months. 11 patients were treated by KalixÒ- (2002-2004; 5x$, 6x#, 8x paralytic; 10x bilateral, 1x left; mean age 9.7 ± 2.2 [6–14] years), 35 by Giannini-implants (2004–2009; 12x$, 23x#, 10x paralytic; 21x bilateral, 6x right, 8x left; mean age 10.0 ± 3.6 [5–16] years) and 19 by de Pellegrin-screw (2009–2012; 11x$, 8x#, 6xparalytic; 6xbilateral, 4xright, 9xleft; mean age 11.7 ± 2.4

J Child Orthop (2013) 7:331–362 [8–16] years). Standardized clinical examination was done in all patients, while pedobarographic evaluation could be accomplished in 76 feet (74.5 %). Assessment of pre- and postoperative weightbearing radiographs could be performed in 93 feet (91.2 %) including measurement of the calcaneal pitch angle (CPA, normal range 15–25°) and the lateral talocalcaneal angle (LTCA, normal range 25–50°). Student’s t- and Fisher–Halton–Freeman-test were used for statistical analysis. Results Subjective satisfaction rate was comparable between the KalixÒ- (8x, 72.7 %), Giannini- (25x, 73.5 %) and de Pellegrin-group (14x, 73.7 %), although persistent pain was relatively more frequent in the KalixÒ- (4x, 36.4 %) compared to Giannini- (4x, 11.8 %) or de Pellegrin-group (3x, 15.8 %). Clinically and pedobarographically a significant and comparable average correction of the hindfoot valgus and reduction of the medial plantar pressure were determined (P \ 0.05). Radiologically the preoperative CPA increased in the KalixÒ-, Giannini- and de Pellegrin-group, respectively from 5.7 ± 6.1 [0–20]°, 12.8 ± 5.1 [1–22]° and 11.2 ± 6.1 [1–23]°, respectively to 9.6 ± 6.2 [6–20]°, 16.3 ± 5.7 [4–26]° and 16.2 ± 4.8 [11–25]°, respectively at follow up (P = 0.070, P = 0.011 and P = 0.033, respectively). The preoperative LTCA reduced from 44.3 ± 9.9 [21–62]°, 42.6 ± 10.4 [22–60]° and 43.4 ± 7.2 [32–58]°, respectively to 35.9 ± 8.0 [22–56]°, 38.4 ± 7.2 [15–50]° and 34.4 ± 8.3 [20–54]°, respectively at follow up (P = 0.008, P = 0.048 and P \ 0.001, respectively). Radiographic correction rates showed no significant difference between the methods (P [ 0.05). Primary malposition and secondary dislocation or breakage of the implant was relatively more frequent in the KalixÒ(6x, 28.6 %) and Giannini- (8x, 14.3 %) compared to de Pellegringroup (1x, 5.0 %). Premature implant removal was more often necessary in the KalixÒ- (6x, 28.6 %) compared to Giannini- (4x, 7.1 %) and de Pellegrin-group (4x, 16.0 %). Discussion All three procedures obtained comparable improvements of the objective clinical, pedobarographic and radiographic parameters. However, we abandoned the sinus tarsi implants in favour of the calcaneus stop screw as the last mentioned method showed comparatively lower rates of implant associated complications. Keywords Children, flexible flatfoot, subtalar arthroereisis, sinus tarsi implant, calcaneus stop screw Corresdondence Bjoern Vogt, MD, Department of Children’s Orthopaedics, Deformity Reconstruction and Foot Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germnay, Tel.: +49-251-83-44245, e-mail: [email protected]

341 transection of tendons, elongation of tendons or tendon-transfers, in case of fixated deformities additional osteotomies. Aim of our treatment strategy is abatement of discomfort, optimisation of walk-gait, and improvement of the pedobarographical pressure distribution pattern to prevent long-term-consequences. In-between 2000 and 2012 we made surgical corrections of cavovarus foot deformity in 36 adolescent patients with HSMN (16 f, 20 m; mean age 14.5 years) with 78 operations and 304 procedures on 42 right and 36 left feet. Standardized a pedobarographic examination was performed before and after surgery and in the clinical course. Results We performed 272 soft tissue surgeries: 72 tendon-elongations (thereunder 39 achilles tendons), 91 transections of tendons (thereunder 45 Steindler release of the plantar fascia), 94 tendon transfers (thereunder 17 Hibbs procedures, 17 Jones procedures, 20 Gocht procedures and 27 tibial anticus transfers) and 15 other procedures. In 32 cases we performed osteotomies, thereunder 14 on the hind foot and 18 on the forefoot. That implies, that merely in 10.5 % cases osseous interventions were necessary. Excluding the less invasive treatments on the forefoot, results in only 4.6 %. With 15.8 years the mean age of this group exceeds that of the entire collective. Discussion/conclusion Deformities merely are no indication for operation. Determining is the therewith associated increase of function. If surgical intervention is necessary, we perform muscular rebalancing on flexible deformities. In our clinic osseous interventions are—especially on adolescents—only performed if aggravating deformities of bones are present. The staged concept of operations leads towards a reduction of symptoms, improvement of gait pattern and to improving pedobarographical pressure distribution pattern preventing long-term-consequences. Because of the progressive course of the ailment, the definitive correction is anyhow difficult in the long run. Osseous interventions are getting evermore necessary. Keywords Hereditary motor and sensory neuropathy (HMSN), operation, pes cavus deformity Correspondence Dr. Melanie Horter, Kinderorthopa¨die, Deformita¨tenrekonstruktion und Fußchirurgie, Universita¨tsklinikum Mu¨nster, Albert-Schweitzer-Campus 1, 48149 Mu¨nster, Durchwahl: +49 (0)2 51/83-4 79 09, Fax: +49 (0)2 51/83 - 4 79 89, e-mail: horter@ ukmuenster.de

23 Abnormal muscle activation during walking in patients with excessive internal and external tibial torsion

22 Actual surgical management of pes cavus deformity in HMSN M.J. Horter, B. Vogt, D. Rosenbaum, F. Schiedel und R. Roedl. Kinderorthopa¨die, Deformita¨tenrekonstruktion und Fußchirurgie Universita¨tsklinikum Mu¨nster, Mu¨nster, Germany Introduction The Hereditary motor and sensory neuropathy (HMSN) is a heterogeneous group of genetical diseases, mostly transmitted autosomal dominant (prevalence 1:2500), appearing with different distinctive motoric and sensorial peripheral neuropathy. In case of HMSN type I (Dyck0 s classification), the Charcot-MarieTooth-disease (CMT), frequently causes a pes cavus deformity on both sides, leading to a limitation of mobility and therefore to a strong reduction of quality of life for the often young patients. Materials and methods After exhaustion of conservative measures (shoe supply, orthotics) we accomplish a staged, individually adapted surgical treatment. Initially we perform soft tissue surgery like

R. Wegener1,2, K. Zdenek3, H. Klima3, M. Huybrechts1, E. Payne3 and V. Fenner1,2 1 Laboratory of Motion Analysis, Paediatric orthopaedics, Children’s Hospital of Eastern Switzerland, St.Gallen, Switzerland, 2Department of Orthopedics and Traumatology, Kantonsspital, St.Gallen, Switzerland, 3Paediatric orthopaedics, Children’s Hospital of Eastern Switzerland, St.Gallen, Switzerland

Introduction Excessive external and internal tibial torsion (TT) leading to a disuse of the plantarflexors due to a lever arm dysfunction can limit the effectiveness of the muscles that stabilize the knee. It is known that TT changes the line of action of the soleus (internal lever) and affects the location and magnitude of the ground reaction force (external lever) [1]. To date muscle activity as a result of the lever arm dysfunction of the soleus has not been investigated by SEMG. Material and methods Gait analysis data of 16 patients (12.3 years) and 23 legs resp. 8 patients (13.2 years) and 11 legs with CT-diagnosed internal (17°) and external (49°) TT were studied

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retrospectively. Bilateral SEMG (12-canal-wireless, Noraxon) was examined from vastus medialis (VM), medial hamstrings (MH), and gastrocnemius medialis (GM). Exclusion criteria were age \10 and [18 years, leg length discrepancy [1 cm, foot deformities, neurological diseases, scoliosis[10° and obesity ([P90). For each patient 3 gait cycles were analysed by means of on/off analysis. Principal Component Analysis (PCA) was used to compare transversal hip and ankle kinematics (8 cameras, VICON) between each patient group and 17 healthy subjects in order to analyse possible influence on the EMG-activity. PCA is a multivariate statistical technique that has been shown to be an effective tool in the reduction and interpretation of gait waveform data. The first PC explains the largest possible variance. Results An additional activity was found in VM and MH during the last 20 % of the stance phase in 6 resp. 7 of 16 patients with decreased TT and in 5 resp. 2 patients of 8 patients with increased TT. The GM also showed abnormal SEMG in terms of premature activity at the beginning of the gait cycle in 13 patients. Ankle and hip transversal angles were not different between patients with decreased TT and healthy controls (ankle PC1: 85.1 %, p = 0.195, hip PC1: 74.4 %, p = 0.272). However, patients with increased TT rotated the ankle significantly more external during the gait cycle (PC1: 88.2 %, p \ 0.001). The hip was significant more internally rotated during the overall gait cycle in patients with increased TT compared to a healthy control group (PC1: 72.5 %, p \ 0.001). Discussion The lever arm dysfunction leads to disuse of the soleus. We assume that activity of the VM leads to extension and stabilization of the knee. Activity of MH may also compensate the insufficiency of the triceps. We interpret premature activity of the GM as a secondary effect [2]. In order to compensate the external foot progression angle, patients with increased TT may activate the MH to rotate the hip internally. In patients without significant differences in ankle and hip rotation the observed activity in MH, VM and GM can be assumed as inefficient, because they generate unbalanced joint moments which require compensatory activation in other muscles [3]. References

Patients and methods About fifty patients with osteogenesis imperfecta are currently being treated in our institution. Of these two patients with a severe form of OI have demonstrated a complete unilateral hip dislocation in addition to severely deformed long bones of the lower extremities. At the time of treatment in the second year of life they were mobilized in a stroller and unable to stand. Both patients receive bisphosphonate treatment regularly. Results In a combined approach both patients were treated surgically from the beginning without an attempt of closed reduction beforehand. They underwent formal open reduction in combination with a realignment procedure of the equilateral femur and implantation of a Fassier-Duval telescopic rod using multiple multiplanar and shortening osteotomies as required. After a follow-up of 9 and 15 months no redislocation has occurred and verticalisation has started. Conclusion In these rare cases a combined approach to both reduction of the dislocated hip and realignment of the deformed femur is recommended. Keywords Hip dislocation, osteogenesis imperfecta, Fassier-Duval nail Korrespondenzadresse Prof. Dr. med. Thomas Wirth, Klinik fu¨r Orthopa¨die Olgahospital, Klinikum Stuttgart, Bismarckstraße 8, 70176 Stuttgart, Tel.: 0711-27873001, e-mail: [email protected]

1. Schwartz et al. (2003) Gait Posture 17:113–118 2. Brunner, Romkes (2008) Gait Posture 27:399–407 3. van der Krogt et al. (2012) Gait Posture 36:113–119

Introduction The out-come of conservative scoliosis treatment depends on precise patient selection and good brace compliance. The purpose of this study is to correlate the knowledge of scoliosis patients about their deformity with the out-come of brace therapy and qualitiy of life. What questions concern the patients most? Materials and methods So far 51 patients with idiopathic scoliosis have been asked to fill out a form with 16 questions about ethiology, general treatment and their patient specific therapy. Data was correlated with the results of the SRS-30 (out-come and qualitiy of life score) and with the results of X-ray and rasterstereographic analysis (Diers formetric 4D). All patients are under conservative brace therapy with a modified active derotational Cheneau brace. Results The mean SRS-30 Score was 87.2 points (±12.2 stdev). 67.8 % stated to know, what scoliosis is exactly. The fast majority ([85 %) knew, that scoliosis is a rotational deformity of the spine and treatment consists of physiotherapy, sports and brace therapy. Only 33 % knew of surgery as a therapeutical option. Among these there was no correlation between good and poor results in the SRS quality of life score, esp. in the category regarding pain. Surprisingly the patients who definitely fear surgery showed a better quality of life than the ones who do not know if surgery is a possible option (mean thoracic Cobb angle 41° vs. 33°). The ones who do not fear surgery had a mean thoracic Cobb angle of 32°. The opinion of a treatment failure if the spine is not getting straight during therapy correlated with a poorer result in the SRS score especially in the category of self image (mean thoracic Cobb angle 46° in the ‘‘failure’’ group vs. 29°). Over 50 % stated that the origin of scoliosis is unclear, whereas 22.6 % where not sure. 12.9 % did not know if they had scoliosis because of there own fault, 9.7 % did not know if scoliosis is a

Keywords Gait analysis, tibial torsion, EMG, principal component analysis Korrespondenzadresse Dr. phil. Regina Wegener, Stiftung Ostschweizer Kinderspital, Labor fu¨r Bewegungsanalyse, Claudiusstr. 6, 9006 St.Gallen, Tel.: +41(0)799468099, e-mail: regina.wegener@ kispisg.ch

24 The treatment of congenital hip dislocation in children with osteogenesis imperfecta T. Wirth Klinik fu¨r Orthopa¨die, Olgahospital., Klinikum Stuttgart, Stuttgart, Germany Introduction The presence of congenital hip dislocation in children with osteogenesis imperfecta (OI) is not alluded to in the literature since it obviously does only exist in very single cases. With improved treatment modalities the management of these patients has changed with verticalising even the most severely affected children. The treatment of congenital hip dislocation in two children with OI is reported and general recommendations are outlined.

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25 Preliminary results of a clinical scoliosis study correlating knowledge, out-come and quality of life of patients with brace therapy F. Wagner, J. Brendel, E. Dingeldey, J. Wolfsteiner, V. Bayraktar, J. Grifka und J. Matussek Department of Orthopaedic Surgery, University of Regensburg, Asklepios-Klinikum Bad Abbach

J Child Orthop (2013) 7:331–362 contagious disease. 22.6 % were not sure if scoliosis is due to sitting on wrong chairs at school. Discussion This study is a step towards a better understanding, what questions concern the young adolescent patients with idiopathic scoliosis. It uncovers lack of information, possibly due to a deficit in communication with or through the treating physicians. Further investigation will go on to a detailled description of what patients need to know. Keywords Scoliosis, Quality of Life, patent knowledge, brace therapy Correspondence Dr. med. Ferdinand Wagner, Orthopa¨dische Klinik der Universita¨t Regensburg am Asklepiosklinikum Bad Abbach, Kaiser-Karl-V.-Alle 3, 93077 Bad Abbach, Tel.: +49/9405/18-0, e-mail: [email protected]

26 VEPTR (vertical expandable prosthetic titantium ribs) promotes spinal growth in instrumented segments—a 3D radiographic analysis C. Hasler1, E. De Oliveira2, P. Bu¨chler2 and A. Burckhardt1 1 Orthopaedic Department, University Children’s Hospital, Basel, Switzerland, 2Institute for Surgical Technology and Biomechanics, University of Bern, Bern, Switzerland

Introduction The growth promoting effect of repeat expansions of VEPTR implants in children with early onset scoliosis has so far only been examined by simple measurement of the global T1-S1 distance and by a single CT study investigating the elongation of osseous spinal bars in patients with congenital deformities. The latter was performed at the institute of the VEPTR inventor. We therefore tested the hypothesis that VEPTR promotes spinal growth. Method A new software was developed which allows to compute the length of the spine in space based on a digitized measurements on an ap and lateral standard radiograph. Since magnification factors are not consistent and the computation of absolute lengths may lead to errors, we compared the relation R (I/NI) between the lengths of the instrumented (I) and non instrumented (NI) parts of the spine. Untreated, the sick segments of the spine would grow less than the normal vertebrae. We therefore hpyothetized that VEPTR promotes growth if the relation R would not change significantly over time. We included 26 early onset scoliosis patients (14 congenital, 10 neuromuscular, 1 idiopathic, 1 secondary) treated at our institution with an observation period of 4 years. The relative lengths after the index procedure R1 and after 4 years R2 were statistically evaluated by paired-sample-t-tests (SPSS Vers.12, significance level p \ 0.05) by an independent statistician. Results Repetitive measurements of the same radiographs at different time points showed a high reliability (coefficient of variation of \0.03 %) There was no significant change in the relation of lengths between the instrumented and non instrumented parts of the spine over time. Discussion A new software and methodology provides reliable assessment of the growth stimulating effects of spinal implants in children with early onset deformities. VEPTR instrumentation and repeat halfyearly expansions of the telescopic mechanism promotes growth of the affected, instrumented spine segments. Subsequently the resulting, stimulated growth does not significantly differ from the growth in the normal, unaffected segments as it would naturally without treatment. Keywords VEPTR, growth, spinal software Corresponding author Carol C. Hasler, University Children’s Hospital, Orthopaedic Department, PO Box, 4031 Basel, Switzerland, Tel.: +41 61 704 28 03, Fax: +41 61 704 12 13, e-mail: [email protected]

343 27 Preliminary results of Magnetically Controlled Growing Rod (MCGR) in 11 patients with early onset scoliosis K. Ridderbusch, M. Rupprecht, R. Stu¨cker Department of Pediatric Orthopedics, Children’s Hospital Altona, Hamburg, Germany Introduction Growth-sparing technique for treatment of progressive early-onset scoliosis has developed significantly over the last years. Traditional growing rod is used for the treatment of early onset scoliosis. This treatment requires repeated lengthenings with the patient anaesthetised and surgery. Since June 2011 we use a technique of magnetically controlled Growing rod and present the first results from our clinic. Methods There were 11 patients underwent treatment with early onset scoliosis different origin. 6 patients with neuromuscular scoliosis, 2 patient with neurofibromatosis and 3 with syndromes. The average age of the 8 female and 3 male patient was 7.8 years (4.7–12.4). Correction of the primary curve and after lengthening was measured as the difference in Cobb angle between pre- and postop X-rays, spinal length T1-T12, T1-S1. Intra-and postoperative complications were recorded. Patient- and parents satisfaction were analyzed. Results The average primary curve measured 69° (47°–96°) and improved to 34° (22°–46°) after the index procedure. The average Cobb angle at final magnetically lengthening review was 30° (20–49°). The average pre-operative T1–T12 length measured 169 mm (128–217) and increased to 194 mm (161–232) immediately postoperatively. The average pre-operative T1–S1 length measured 279 mm (230–325) and increased to 313 mm (272–358) postoperatively. In one patient loss of distraction occurred. This necessitated a complete rod changing. All patients and parents were pleased with the results and would have the procedure performed again. Discussion The first results after MCGR implantations in 11 patients with early onset scoliosis are very encouraging. The early results have demonstrated that the Magnetic Rod is a safe and effective non fusion technique in the treatment of progressive early onset scoliosis avoiding repeated surgical lengthening procedures. MCGR provided adequate distraction similar to standard Growing Rod. The magnetically transcutane lengthening allows non-invasive distraction achieving comparable spinal growth to conventional growing rod. Remarkable is the high patient satisfaction. A larger cohort study with longer followup is required to confirm the long term outcomes of this technique. Keywords Early onset scoliosis, non fusion technique, magnetic rod, growing rod, MCGR Correspondence Dr. med. K. Ridderbusch, Department of Pediatric Orthopedics, Children’s Hospital Altona, Bleickenallee 38, 22763 Hamburg, e-mail: [email protected]

28 Bacterial colonization of spine implants in children with severe spinal and thoracic deformities treated with growth retaining implants C. Hasler1, D. Studer1, A. Trampuz2 and C. Plaass3 1 Orthopaedic Department, University Children’s Hospital, Basel, Switzerland; 2Division of Infectious Diseases, University Hospital Lausanne (CHUV), Lausanne, Switzerland; 3 Orthopedic Department, Hannover Medical School, Hannover, Germany

Introduction Due to repeat interventions children with growth retaining implants for severe spinal and thoracic deformities have

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344 bacterial colonizations rates up to 6 times higher than clinical apparent infections Vertical expandable prosthetic titanium ribs (VEPTRÓ) are the current gold standard operative approach to maintain thoracic and spinal growth. The implants need to be expanded halfyearly to compensate for the ongoing growth. With each operation there is an infection risk. Implant associated infections do not have to be clinical apparent in the beginning, but may become symptomatic over time and complicate further treatment. To objectify the colonization rate of the implants, identify potential precursors of infections and the relevance of asymptomatic infections in these children, removed implant parts are analyzed by sonication and microbiologically based on a prospective protocol. Material and methods Between January 2009 and April 2012 162 VEPTR-expansion procedures in 39 children were performed at our institution. Preoperative a patient and a surgeon-based questionnaire were filled in regarding clinical signs of infection. Blood samples were analyzed for C-reactive protein and white blood cell count. All retrieved implants (mainly locks) were sonicated and the fluid used for microbiological work up. Results 146 implant parts were eligible for analysis. In four children an infection was suspected preoperatively and confirmed microbiologically. 23/146 (16 %) of the probes showed bacteria growth, in 10 after enrichment. Propionibacterium acnes and coagulase negative staphylococci were the dominant germs with 10 and 11 detections, respectively. Staphylococcus epidermidis, Streptococcus, Bacillus species and Corynebacterium were found once each. In 5 patients repeated sonication showed a colonization, without becoming symtomatic. Discussion There are asymptomatic bacterial colonization of implants in children with VEPTR-Implants. Clinical and intraoperative findings do not always arise suspicion for infection. Colonization remain for longer periods. There is a potential danger that these infections may become symptomatic with the time or after reoperations. To further understand the relevance and natural history of these infections a longer follow-up period is necessary. The VEPTR-concept gives the unique possibility to analyze the frequency and development of asymptomatic implant related infections. Keywords VEPTR, colonization, infection Corresponding author Carol C. Hasler, University Children’s Hospital, Orthopaedic Department, PO Box, 4031 Basel, Switzerland, Tel.: +41 61 704 28 03, Fax: +41 61 704 12 13, e-mail: [email protected]

29 Treatment of chest wall deformities—an update B. Reingruber Department of Pediatric Surgery, Regensburg, Germany Introduction Cautious counseling and minimal invasiveness are the key principles in any pediatric surgical treatment. This especially applies to the correction of chest wall deformities, pectus excavatum, pectus carinatum and its more complex combinations or other rare variants of congenital thoracic abnormalities. Therapeutic decision making should take account of the patient’s age, type and severity of the deformity, concomitant organ or orthopedic complaints and the patient’s aspirations within his social environment. Treatment Conservative treatment options have been evaluated in their primary as well as adjuvant applications with valid long term results now becoming available supporting our aims of a rational decision making. Surgical treatment can now be limited to the adolescent and adult age with little exception, tailored concepts for each

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J Child Orthop (2013) 7:331–362 individual are based on the principles of the minimally invasive or the minimalised open approaches performed and evaluated for the past two decades. An overview will be given on history, recent developments and results of the methods and principles of the contemporary repair of chest wall deformities. Prof. Bertram Reingruber, Klinik fu¨r Kinderchirurgie, Klinik St. Hedwig, Steinmetzstr. 1-3, 93049 Regensburg, e-mail: [email protected]

30 Foot type characteristics in the child’s development—longitudinal assessment over nine years of observation D. Rosenbaum1, K. Bosch2 1

Funktionsbereich Bewegungsanalytik, IEMM, Universita¨tsklinikum Mu¨nster, 2Sozialpa¨diatrisches Zentrum Westmu¨nsterland, St. VincenzHospital Coesfeld Introduction The child’s foot has been shown to develop rapidly as soon as weight-bearing begins [1–3] and will present distinct individual characteristics already at an age of about 5–6 years, ranging from flat feet, to normal and high-arched feet. However, it is not clear how early the development of a persisting high-arch or flat foot emerges, i.e. at what stage the first changes between foot types might be detected. Therefore, the aim of this study was to retrospectively analyze the development of children’s foot loading patterns with respect to certain foot types. Potential findings might help to predict the individual foot shape in upcoming years. Material and methods The data of the longitudinal ‘Kidfoot Mu¨nster’ study were re-evaluated for 65 children who had completed 8 years of observation. For each child, a total of 16 appointments were used for the assessment of plantar pressures (Emed X, free barefoot walking, 5 trials per foot). The arch index was determined with the Novel software and all 130 feet were sorted according to their last arch index at the 8-year visit. These feet were subdivided into 3 groups, with a low (\0.1, n = 36), intermediate (0.1–0.2, n = 56) or high arch index ([0.2, n = 38) corresponding to relatively high-arched, normal or flat feet. These subject groups were then compared with respect to their previous arch indices at all 16 appointments. Results The three groups showed an average arch index of 0.05 ± 0.03 for high-arch, 0.16 ± 0.03 for normal and 0.24 ± 0.02 for flat feet. The differences between the groups are significant for all 16 visits (p \ 0.0001). The rate of changes appears similar in the three groups (Fig. 1) so that the overall development is comparable for the foot types. Discussion Even though the groups overlap to a certain degree when the range of arch index values is considered, the groups that were retrospectively identified at age 9 seem to separate early in their individual development. Therefore, predictions about the later development of distinct foot shapes might be possible already at an early stage of the growing foot. Acknowledgment Supported by the DFG (Ro 2146/3) Keywords Foot loading, Pedobarography, Children, Gait speed Correspondence Prof. Dr. Dieter Rosenbaum, Funktionsbereich Bewegungsanalytik, Institut fu¨r Experimentelle Muskuloskelettale Medizin, Universita¨tsklinikum Mu¨nster, Domagkstr. 3, 48149 Mu¨nster, Germany, Tel.: +49 251 835 2970, e-mail: [email protected] References 1. Bertsch C et al. (2004) Gait & Posture 19(3):235–242 2. Unger H, Rosenbaum D (2004) Foot Ankle Int 25(8):582–587 3. Bosch K et al. (2007) Gait & Posture 26(2):238–247

J Child Orthop (2013) 7:331–362 31 Load distribution after ‘‘reverse Jones’’ procedure for dorsal bunion in overcorrected clubfeet J. Hamel1, A. Kalpen2 1

Zentrum fu¨r Orthopa¨dische Fußchirurgie Mu¨nchen, 2Novel GmbH

Introduction One important component of clubfoot-overcorrection after extensive surgical release is dorsal bunion with deloading of the first metatarsal and overactivity of flexor hallucis longus resulting in severe malfunction of the forefoot and first metatarsophalangeal joint. Transfer of flexor hallucis longus to the first metatarsal (‘‘reverse Jones’’ procedure) is recommended as part of the corrective procedure for dorsal bunion. However, a detailed analysis of the changes in load distribution during stance phase of gait is lacking. Material and method From 2005 to 2012 eleven children and adolescents (8–15 years of age) were treated (13 cases) with transfer of flexor hallucis longus in combination with plantarflexing osteotomies at the first ray. For the pedographic study one case with additional fusion of the first metatarso-phalangeal joint and two others with incomplete pedographic data were excluded, leaving 10 cases for detailed analysis preoperative and at least 12 months postoperative. In all these cases additional transfer of the anterior tibial tendon to the second ray and bony realignment of severe hindfoot valgus were also necessary. Results Maximum force at the first metatarsal was 24.6 N preoperative and 86.7 N postoperative in the mean. The relation of maximum force at the first metatarsal to the whole forefoot changed from 7.9 to 23.1 % in the average, whereas maximum force at the big toe in relation to the whole forefoot decreased from 31.2 to 15.4 %. 82.6 % of the preoperative maximum force at the big toe was preserved at the pedographic control in the average. The relation of maximum force at the first metatarsal to the second metatarsal was 28.3 % preoperative and 106.9 % postoperative. Discussion Transfer of flexor hallucis longus tendon in combination with bony realignment procedures at the first ray is very effective to increase loading of the first metatarsal in late stance phase and thereby to improve load distribution of the forefoot. Maximum force at the big toe is reduced markedly, leaving an acceptable amount of loading at the big toe. The influence of anterior tibial tendon transfer and hindfoot correction, which were carried out simultaneously, have to be taken into account. Keywords Dorsal bunion; flexor-hallucis-longus-transfer; overcorrected clubfoot; reverse Jones procedure Correspondence Prof. Dr. med. Johannes Hamel, Zentrum fu¨r Orthopa¨dische Fußchirurgie, Schu¨tzenstraße 5, 80335 Mu¨nchen, Tel.: 0170/8516396, e-mail: [email protected]

32 Borderline cases of surgical treated clubfoot relapses treated using the Ponseti-method A. C. Helmers Department for paediatric orthopedic surgery, Ev. Waldkrankenhaus Spandau, Berlin, Germany Introduction The Ponseti-Method is the most common and effective method to treat clubfoot deformities around the world. In our clinic we encounter a large number of relapse cases of surgical treated clubfeet, often referred to us by other clinics.

345 Actually the corrective treatment is a new surgical therapy, a second or third peritalar release. With the new surgical treatment, the ligaments and joints will become more stiff and there is less movement in the talar joints. Hence, it is very important to find alternative treatment methods for clubfeet relapses following surgical treatment. Method In our department, we begin our treatment of relapsed clubfeet after surgery with the traditional Ponseti-Method which is used for the congenital clubfeet. We always start with the first position and try to accomplish more abduction in the forefoot. Firstly we apply a white plastercast in the overknee position. In order to to allow the patient to walk, we tape a scotch-cast over the regular plaster. So far we have successfully treated children in the range of 2–11 years of age. In every case we did require four to ten casts throughout the treatment. Before the treatment, the Pirani-Score ranged form 2.5 to 5. Twenty-four feet from 15 children were treated and photo documented during every follow up. Summary/results All together 21 feet were corrected resulting in more abduction in the forefoot. The feet showed full correction in adduction and excavatus, but not full correction in the equinus. After our treatment with the Ponseti-Method, all patients gained increased movement in the talar joints and decreased stiffness and pain. Dicussion The Ponseti-Method can be successfully applied in cases with relapsed clubfeet, that before have been treated with surgical methods as commonly recommended (peritalar release). 21 relapses of the 24 feet were completely corrected in adduction and excavatus but less in the equinus position. All patients experienced less pain and felt more comfortably wearing shoes. As a result we were able to spare 20 patients the otherwise required second and third surgical therapy to treat them with the traditional Ponseti-Method. Due to the combination of plasterand scotchcast, all children were able to walk and could participate in their everyday life. To prevent a new relapse we put on a special developed nightcast in the abducted position on for 12–24 month. This cast is very comfortable to wear with a good patient compliance. Corresponding adress Anja Cornelia Helmers MD, Secretary Mrs. Hamar: Stadtrandstr. 555, 13589 Berlin, Germany, Tel.: 00493037021200, Fax: 00493037022211, e-mail: a.helmers@ waldkrankenhaus.com

33 Preliminary results: Ponseti treatment in arthrogrypotic clubfeet N.C. Berger, C. Multerer, C. Pohlig-Wetzelsperger, M. Baise, M. Salzmann, L. Do¨derlein Kinderorthopa¨dische Klinik Aschau im Chiemgau Introduction The aim in our clubfoot treatment in arthrogrypotic children (distal and classic arthrogryposis) is to create a (1) plantigrade (2) braceable (3) painfree foot with (4) as less surgery as possible. With this retrospective study we wanted to evaluate if—by using the Ponseti method—we meet those criteria. We modified the classic bracing regimen by using unilateral lower or upper leg orthoses. The minimum follow-up period was 2 years. Materials and methods Only children presenting with distal or classic arthrogryposis (amyoplasia) were included in the study (19 patients/ 35 feet). After completing the standard Ponseti procedure (serial casting and achillotenotomy) we braced the children with unilateral lower or upper leg orthoses. Pirani scores, number of casts, initial correction results, walking age, recurrences and secondary procedures such as repeated tenotomies, second series of casting, or more invasive surgery, were noted. Results Initial correction was obtained in 24 feet (69 %). 5 patients (7 feet; 20 %) received a second series of casts, 5 of them a repeated achillotenotomy. 18 feet had to be operated on (other than

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346 retenotomy) in their second year of life. 3 feet have been operated on at late age (4–6 years) or aren’t operated at all so far [14 feet; 40 %; mean age 4.6 (range 2.8–7.2)]. The average follow-up period was 4.7 (2.1–7.6) years. Discussion By using the Ponseti method and unilateral lower or upper leg orthoses we had a significant reduction of more invasive operations due to clubfoot recurrence in our cohort of children with distal or classic arthrogryposis (amyoplasia) compared to the literature. To our knowledge this is the study with the largest cohort of arthrogrypotic children treated with the Ponseti method so far. Keywords Arthrogryposis, amyoplasia, Ponseti treatment, clubfoot, unilateral bracing Correspondence Dr. med. Nina Ch. Berger, Kinderorthopa¨dische Klinik Aschau im Chiemgau, Bernauer Str. 18, 83229 Aschau im Chiemgau, Tel.: 08052-171-0, e-mail: [email protected]

34 Treatment of relapsed clubfoot with Ponseti-therapy in older children in Tanzania U. Bru¨ckner, A. Reeg Diakoniekrankenhaus Rotenburg/Wu¨mme, Kinderorthopa¨die Introduction In April 2012 we introduced the modified treatment of older clubfoot in Usa River/Arusha (Tanzania). There are a lot of older children, beginning the clubfoot therapy. The children with relapses are older too. The newborn babies with clubfeet sometimes stashed away! The children benefit from the Ponseti-therapy, because they become able to walk the long way to school and so they become social well-integrated. That’s very important for the life in Tanzania! It0 s very difficult with clubfeet. The outpatient department in Usa River/Arusha is leaded by a midwife, who learnt the Ponseti-therapy by German doctors (‘‘Feuerkinder-Team’’) a few years ago. She is dedicated to organize the treatment also with financial help for the families. Method after the age of 2 years We choise the Ponseti-method everytime. For the older children we take hardcast, because it0 s more resilient and more resistant to water and dirt. The first cast is usually for the correction of the cavus, we make it short below knee, next casts only 6 to maximal 10 cm over knee, well molded condylar, the knee is only in 30° flexion. That’s important to enable walking. The children get removable walking soles, made from tire-parts, leather or sponsored. So the children don0 t need a wheelchair and can overcome all obstacles on their way. We change the casts every 2 weeks to avoid long ways with a short break. Then we have to decide wether there is an indication for tenotomy of the achilles tendon. When the abduction of the forefoot reached 30° we build a cast brace for the nights in maximal foot correction and 60° knee flexion. We change the cast-brace in increased foot correction after 3–6 months, determined by the age of the child and the foot correction. The try to fix the corrected foot in the Steenbeek brace is not practicable, because the production of the braces stops with 15 cm length of the foot and especially; if only one foot is affected, the compliance is bad. All siblings sleep with their mother in one bed, so they could be bumped by the brace. We finish the treatment at the age of 5 or later, it depends on the age by the beginning the (relapse) therapy. Conclusion It0 s possible to treat older clubfeet with shortened Ponseticasts with knee flexion of only 30° and cast braces for wearing at night. That0 s a well-accepted method, easy to learn and now successful in Tanzania.

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J Child Orthop (2013) 7:331–362 Dr. Ute Bru¨ckner,Diakoniekrankenhaus Rotenburg/Wu¨mme, Kinderorthopa¨die, Elise-Averdieck-Str. 17, 27356 Rotenburg/Wu¨mme, Tel.: 04261 772190, e-mail: [email protected]

35 Joint load during gait in adolescents with tibial malalignment V. Fenner1,2, T. Urech1, K. Zdenek3, H. Klima3, R. Wegener1,2 1 Laboratory for Motion Analysis, Children’s Hospital of Eastern Switzerland, St. Gallen, Switzerland, 2Department of Orthopedics and Traumatology, Kantonsspital St. Gallen, St. Gallen, Switzerland; 3 Department of Orthopaedics, Children’s Hospital of Eastern Switzerland, St. Gallen, Switzerland

Introduction Gait analysis is a diagnostic tool that can be used to gain a better understanding of the relationship between malalignments and (pathological) joint load. Studies exist which deal with the effect of tibial malalignment on the gait [1, 2, 3]; however there is still a lack of knowledge on joint load (especially of the ankle and hip) of the lower extremity with a sufficient number of adolescents with idiopathic tibial malalignment. Therefore the aim of this study was to analyze the joint kinetics of the lower leg in adolescents with isolated tibial- as well as with femoral and tibial malalignment. Materials and methods Twenty five adolescents (32 legs) with reduced tibial torsion (rTT, CT = 17.5° ± 3.9), 12 adolescents (18 legs) with increased tibial torsion (iTT, CT = 50.5° ± 4.6), 12 adolescents (16 legs) with rTT (CT = 20.02° ± 3.5) and increased femoral torsion (iFT, CT = 37.5° ± 5.0) and 9 adolescents (10 legs) with iTT (CT = 51.6° ± 5.1) and iFT (CT = 38.6° ± 4.6) all of them without other pathology and a control group (CG) of 17 healthy age-matched subjects (32 legs) were included in the study. Gait data was analyzed using an 8-camera Vicon-system (200 Hz) and 2-AMTI (1000 Hz) force plates. Joint kinetics were calculated using the PiGModel and normalized with respect to body mass. Parameters with high clinical relevance were compared using statistics of linear mixed models. The Bonferroni procedure was used to guarantee the overall significance level. Results All groups show a significant lower hip extension moment in terminal stance (tst) in comparison to the CG. The iTT-patients showed a significant higher knee adduction moment (KAM) in loading response. iTT and iTTiFT-patients showed significant lower KAM in tst. In the rTT-group the KAM was significantly higher in tst. The rTT and iTT-patients showed a significant lower mechanical ankle power, the patients with rTTiFT had a reduced knee extension moment in tst in comparison to the CG. Discussion The lower mechanical ankle power in the iTT and rTT groups is probably due to the changed lever arm of the patients. The rTTiFT-group shows the effect of lever arm dysfunction in the reduced knee extension moment during tst. These 3 groups also show reduced muscle force in the M. triceps surae. The iTTiFT-group did not show any differences in muscle force and in conclusion no differences in ankle and knee kinetics in the sagittal plane were found. The higher KAM in tst of rTT-patients and the lower KAM in tst from the iTT-patients were consistent with the literature [1, 3]. In addition our iTT-patients also showed a higher KAM in loading response. The KAM had high standard deviation in all groups and there were no significant statistical correlations between KAMs and the CT-values. This allows the assumption that besides their malalignment their joint load is influenced by the individual gait pattern. Studies with adult gonarthrosis patients [4, 5] show reduced hip extension moments during gait in comparison to healthy controls. Therefore the reduced hip extension moment found in all groups seems to be a problematic

J Child Orthop (2013) 7:331–362 deficit of patients with tibial malalignment which should be considered during analysis and therapy. References 1. Dunteman et al. (2000) J.Pediatr.Orthop 20(5);623–628 2. Radler et al. (2010) GaitPosture 32(3):405–410 3. MacWilliams et al. (2010) J Bone Joint Surg Am 92(17): 2835–2842 4. Al-Zahrani, Bakheit (2002) Disabil Rehabil 24(5):275–280 5. Mu¨ndermann et al. (2005) Arthritis Rheum 52(9):2835–2844

347 need more extensive surgery. These feet are associated in most cases with a TAMBA greater than 120° in neutral position and particularly a TAMBA difference (neutralposition minus plantarflexion) smaller than 25°. Keywords Vertical talus, flatfoot, rocker bottom deformity, TAMBA Correspondence Dr. med. Oliver Eberhardt, Orthopa¨dische Klinik, Olgahospital Stuttgart, Bismarckstrasse 8, 70176 Stuttgart, Tel.: 0711 27873210, e-mail: [email protected]

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Symphyseal approximation in congenital bladder extrophy repair. Long-term hip function

The Talus-Axis Metatarsal One Base Angle (TAMBA) in the diagnosis and treatment of idiopathic and non-idiopathic vertical talus

M. Kertai1, H. Hirschfelder2, R. Brandl3, W.H. Roesch4 and A.K. Ebert4 1

O. Eberhardt, F.F. Fernandez und T. Wirth Orthopa¨dische Klinik, Olgahospital Stuttgart, St Gallen, Switzerland Introduction Congenital vertical talus (CVT) appears as an idiopathic or non-idiopathic deformity. There is no clinical classification which assesses the severity of the deformity. The Talus-axis metatarsal one base angle is a radiological measurement to differentiate oblique talus and vertical talus and assesses the severity of the dislocation in the talonavicular joint. In this study we compared TAMBA values of idiopathic and non-idiopathic CVT cases with successful and unsuccessful treatment with the Dobbs method. The goal was to determine whether TAMBA values are predictive for the treatment of CVT. Materials and methods Between January 2007 and July 2012, 20 cases of congenital vertical talus were treated, starting with a minimally invasive approach. We analysed retrospectively the talar-axis metatarsal one base angle (TAMBA) values in idiopathic and non-idiopathic CVT. As new indicator for the mobility in the talonavicular complex, we introduced the difference of TAMBA in neutral position and the TAMBA in plantarflexion (TAMBA difference). TAMBA measurements of CVT successfully treated using a minimally invasive approach were compared to TAMBA values of CVT unsuccessfully treated using a minimally invasive approach. Results Out of 20 CVT, 14 were successfully treated with a minimally invasive approach. Of these 14, 5 feet were non-idiopathic and 9 feet idiopathic. 6 feet had no complete correction following the minimally invasive approach, and were associated with arthrogryposis or caudal regression syndrome. Initial TAMBA in idiopathic feet ranged from 70 to 110° (Ø88°). TAMBA in non-idiopathic feet ranged from 75 to 128° (Ø105). Feet successfully treated using a minimally invasive approach had initial TAMBA between 74 and 110° (Ø87°). Feet unsuccessfully treated using a minimally invasive approach had initial TAMBA between 95 and 128° (Ø118°). The measurement difference between TAMBA in neutral and plantarflexion positions in cases unsuccessfully treated with the minimally invasive approach were smaller compared to values of feet successfully treated with the minimal invasive approach. These differences were statistically significant (p \ 0.0001). Discussion In our series, the success of a minimally invasive treatment in CVT depended on the flexibility in the talonavicular complex. The TAMBA value, TAMBA difference (TAMBA in neutral position minus TAMBA in plantarflexion) express the flexibility in the talonavicular joint. These values could be predictive for the treatment of CVT. A minimally invasive approach is successful in treating most cases of idiopathic and non-idiopathic CVT. Some CVT deformities

Department of Paediatric Surgery, Klinik St.Hedwig, University Medical Center, Regensburg, Germany; 2Department of Rehabilitation Medicine and Orthopaedics, Klinikum Nu¨rnberg, Germany; 3Department of Radiology, Krankenhaus der Barmherzigen Bru¨der, Regensburg, Germany; 4Department of Paediatric Urology, Klinik St. Hedwig, University Medical Center, Regensburg, Germany Introduction Abnormalities of the bony pelvis in EEC and their possible relation to hip disease are well described in the ExstrophyEpispadias Complex (EEC). However, there is a lack of information about long-term orthopaedic consequences and hip function in patients with EEC. Therefore, we investigated clinical and radiological results in a EEC patient cohort after long-term follow-up. Materials and methods We conducted a cross-sectional study using standardized radiography, clinical investigation and a hip score. 17 post-puberty unselected EEC patients (3 female, 14 male; mean age 18.2 years) that presented to our clinic due to urological procedures or check-up from 2010 to 2011 were included. All had undergone symphysis approximation with a traction bandage without osteotomy in early childhood. Radiological analysis was conducted offline by two independent investigators. Results Radiological analysis showed a mean pubic diastasis of 5.34 cm (range 2.6–8.5 cm). Mild hip dysplasia was present in four patients, one of them having had co-occurring developmental hip dysplasia in previous history. No severe dysplasia, subluxation or luxation of the hip was found, however one patient showed early coxarthrosis. Clinical examination revealed no relevant restriction of range of motion (ROM), although 2 patients had slightly decreased internal rotation. None of the EEC patients complained themselves about pain or restriction in sports or daily activities. Harris hip score was perfect for all study participants. Discussion Despite EEC specific hip morphology long-term hip function is not impaired in patients after symphyseal approximation without osteotomy in the newborn period. The symphysis diastasis after this procedure is comparable to available post-osteotomy data. The large majority of EEC patients did not show dysplastic or degenerative hip disease. Functional hip score results confirmed reasonable age-related hip function in nearly all examined patients. However, postnatal ultrasound hip screening is recommended to prevent and adequately treat potential co-occurring developmental hip dysplasia. Keywords Hip, bladder extrophy, symphysis diastasis, osteotomy Korrespondenzadresse Dr. med. Michael Kertai, Kinderchirurgische Klinik, Klinik St. Hedwig, Krankenhaus Barmherzige Bru¨der, Steinmetzstr. 1-3, 93049 Regensburg, Tel.: 0941/36995906, e-mail: [email protected]

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(Promising) preliminary results: a new unilateral lower leg orthosis after Ponseti treatment in idiopathic clubfeet

Postoperative management with individualized foam support in cerebral palsy—new perspectives in hip surgery

N.C. Berger, C. Multerer, C. Pohlig-Wetzelsperger, M. Baise, L. Do¨derlein and M. Salzmann

N.C. Berger, C. Multerer, L. Do¨derlein and M. Salzmann Kinderorthopa¨dische Klinik Aschau im Chiemgau

Kinderorthopa¨dische Klinik Aschau im Chiemgau Introduction The Ponseti treatment for clubfeet consists of a series of plaster casts, an achillotentomie if necessary, and bracing treatment for up to 4 years after the initial correction. The most widely used foot abduction braces follow the principle of Denis Browne with sandals attached to a rigid or flexible middle bar. Literature reports serious compliance issues with those braces of up to 61 %. To improve compliance by minimizing pressure sores and sleeping problems we developed a unilateral lower leg orthosis. The purpose of this retrospective study was to evaluate the efficacy of our lower leg orthosis to prevent clubfoot recurrence and to improve compliance with the bracing protocol. The minimum follow-up was 2 years. Material, methods We developed a lower leg orthosis that guaranteed the same functions as a Ponseti cast by creating and maintaining subtalar outward rotation and foot abduction as well as ankle dorsiflexion. If unsolvable problems with the foot abduction brace (Alfa-FlexÒ Brace Semeda/Hamburg Germany) occurred we switched to the individualized lower leg orthosis until the end of treatment. Initial Pirani score, number of casts applied, compliance issues with the brace or orthosis, recurrence of clubfoot deformity and secondary interventions during treatment were recorded. Results Of 48 patients (79 feet) initially treated with the Alfa-FlexBrace 35 feet (44 %) developed problems leading to intermediate or total non-compliance with the bracing protocol. 30 feet (38 %) had to change to lower leg orthosis due to persistent non-tolerance [mean age at change 10.9 (range 1–23) months]. In the group of patients that tolerated the Alfa-Flex Brace (AFB) well, four feet (8 %) had serious clubfoot recurrence requiring second series of casting (1x), second tenotomy (1x) or peritalar release (2x). In the group treated with the lower leg orthosis (LLO), 4 feet (13 %) developed problems leading to intermediate or total non-compliance with the bracing protocol. 1 foot (3 %) had to receive a peritalar release. Total treatment time in the AFB-group was 2131 months and 1046 months in the LLOgroup. Mean treatment time per foot in the AFB-group was 29 months and 31 months in the LLO-group. Follow-up period in the AFB-group was 5.1 (2.0–7.7) years and 4.5 (2.7–8.1) years in the LLO-group. Discussion The compliance rate with our lower leg orthosis is considerably higher than with the Alfa-Flex-Brace (87 vs. 56 %). Though in the LLO-group were the ‘‘more difficult’’ feet that already had compliance issues during treatment with the AFB, we observed less clubfoot recurrence requiring second interventions than in the AFB group (3 vs. 8 %). We conclude that treatment after initial Ponseti correction using our lower leg orthosis is at least as safe as using a standard foot abduction brace as the Alfa-Flex Brace and better tolerated. A prospective study with longer follow-up will be necessary. Keywords Alfa-Flex Brace, clubfoot, Ponseti treatment, unilateral lower leg orthoses, ankle foot orthoses. Correspondence Dr. med. Nina Ch. Berger, Kinderorthopa¨dische Klinik Aschau im Chiemgau, Bernauer Str. 18, 83229 Aschau im Chiemgau, Tel.: 08052-171-0, e-mail: [email protected]

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Introduction To allow for early mobilization, reduction of comorbidity, reduction of loss of muscle power, facilitated mobility (wheel chair) and hygienic aspects, we changed our post-operative management protocol after hip reconstruction surgery in patients with cerebral palsy. Formerly using hip spica-casts, we introduced individualized foam supports in supine, prone and sitting position. Weight-bearing was allowed after 6 weeks if sufficient consolidation was documented by X-ray. Materials and methods 1 day prior to the operative procedure we used a readymade foam block to cut out the contours of the patient extending from the iliac crests to the toes. Velcro straps restrained the child from lifting the legs in supine and/or prone position. Wedges for femoral abduction and hip extension in arthrodesis position were adjusted to a wheel chair. Physiotherapy was introduced as early as on the first day post-operatively. As soon as hip flexion of 80° degrees was tolerated, sitting in a wheel chair was advised. We are using the postoperative foam support systems since 2009. Results In 2009 43 children and young adults [mean age 11.0 (range 4–25) years] with cerebral palsy were managed with foam support systems after hip reconstruction surgery. In 41 patients pelvic osteotomies in combination with osteotomy of the proximal femur and in 2 patients only osteotomy of the proximal femur were performed. In one patient, deep vein thrombosis after a triple osteotomy occurred. There were no other complications and consolidation without any sign of dislocation of material was observed after 6 weeks in all cases. Early mobilization into a wheel chair was obtained in all patients. Discussion The use of individualized foam support after reconstructive hip surgery in children with cerebral palsy allows for increased benefits like early mobilization in a wheel chair and therefore reduced comorbidity without significant unwanted side effects. We recommend the routine use of this post-operative management tool. Keywords Foam support, hip reconstructive surgery, post-operative management, early mobilization. Correspondence Dr. med. Nina Ch. Berger, Kinderorthopa¨dische Klinik Aschau im Chiemgau, Bernauer Str. 18, 83229 Aschau im Chiemgau, Tel.: 08052-171-0, e-mail: [email protected]

40 Residual hip dysplasia after treatment of congenital unstable hips with the Tu¨binger abduction Brace V. Parrisius, C. Multerer, M. Salzmann, L. Do¨derlein, N.C. Berger Kinderorthopa¨dische Klinik Aschau im Chiemgau Introduction Today, newborns with congenital unstable hips (Graf type IIc unstable and more severe) are managed with a cast in human position or the Pavlik harness. In this prospective study we evaluate the Tu¨binger brace, as another option for treating congenital unstable hips, regarding its efficacy and its long-term residual hip dysplasia outcome.

J Child Orthop (2013) 7:331–362 Material, methods The inclusion criteria of our study were idiopathic congenital hip dysplasia Graf type IIc unstable or more severe, age of less than or equal to 6 weeks at beginning of treatment, and regular follow-up intervals of at most 3 weeks until the end of treatment. If no amelioration of the acetabulum angles was noticed in subsequent visits, a cast in human position was applied. An X-ray of both hips was obtained after the beginning of walking and at the age of 3 years. Results Our study includes 112 patients. Their 152 dysplastic hips encompass 12 IIc instable, 75 IIIa, 63 D, and 2 IV hips according to Graf. One hip was affected in 68 patients while dysplasia occurred bilaterally in 44 patients. 17 patients’ hips did not improve when treated with the Tu¨binger brace; in consequence a cast in human position was applied. The remaining 95 patients (85 %) treated with the Tu¨binger brace showed physiological a- and b-angles at their last ultrasonic testing. Of the initial 112 patients we have obtained follow-up X-rays of 68 patients with an average age of 40 months. Of those patients, 50 % showed residual dysplasia (no child has been operated so far). The side of dysplasia in the X-ray examination didn’t correspond to the initial affected side in 44 %. Out of the patients with initially unilateral dysplasia, 35 % showed bilateral dysplasia at the follow-up. No child showed evidence of avascular necrosis of the ossific nucleus of the femur. Discussion The primary outcome of congenital unstable hips after treatment with the Tu¨binger abduction brace is satisfying and safe, regarding the potential for acetabular improvement and the absence of avascular necrosis of the femoral head epiphysis in our study. Though, it remains unclear if the high percentage of secondary dysplasia is due to the treatment or lies within the nature of this pathology. Keywords Tu¨binger abduction brace, congenital unstable hip, residual hip dysplasia, Graf ultrasound. Correspondence Dr. med. Nina Ch. Berger, Kinderorthopa¨dische Klinik Aschau im Chiemgau, Bernauer Str. 18, 83229 Aschau im Chiemgau, Tel.: 08052-171-0, e-mail: [email protected]

349 (CRP) of 9.3 mg/dl (0.0–1.1 mg/dl). The CT scan showed an osteolytic lesion of the patella. The girl was referred from the paediatrician to our department. Method We took a biopsy and a swap by a ventral approach. Histological findings showed acute osteomyelitis and staphylococcus aureus was grown from the culture out of the bone. Debridement and curettage was performed and a gentamycin chain (Septopal Minikette) was placed into the defect. In a second operation after 7 days, the gentamycin chain was removed. The patient was subsequently treated by intravenous antibiotics for 12 days followed by 16 days of oral antibiotics. The limb was immobilized in a long leg cast for 2 weeks after discharge. Result At discharge the girl had no pain. Laboratory parameters at the follow up 3 weeks later showed a normal white blood cell count and CRP. The follow-up examinations after 17 months showed no fragmentation and a nearly full osseous recovery of the patella. Discussion The diagnosis of patellar osteomyelitis can be difficult; it includes an exact clinical examination, laboratory tests, and imaging procedures. In the laboratory tests leukocytosis may be absent. Early in the course of the disease plane radiographies can be negative, therefore gadolinium-enhanced sequences of MRI are Gold standard in diagnosis of osteomyelitis. There is no consensus for the use of antibiotic chains. Advantages is the high local concentration, the disadvantage is the need of a second operation for chain removal. Antibiotic treatment and curettage is the recommended treatment for patients with osteomyelitis of the patella, particularly in cases with delayed diagnosis. Conclusion The diagnosis of patellar osteomyelitis can be difficult and this may cause a delay in diagnosis. For early diagnosis an exact clinical examination, laboratory tests, plain radiographs, and MRI are indispensable. Keywords Osteomyelitis patella pediatric Correspondence Dr. Matthias Sperl, Klinische Abteilung fu¨r Kinderorthopa¨die,Medizinische Universita¨t Graz, Auenbruggerplatz 34, ¨ sterreich, Tel.: 0043/316/385 13773, e-mail: matth8010 Graz, O [email protected]

41 Delayed diagnosis of patella osteomyelitis in a 10 year old girl M. Sperl, T. Kraus, M. Svehlik, E. Wolf und W. Linhart Klinische Abteilung fu¨r Kinderorthopa¨die, Medizinische Universita¨t Graz, Auenbruggerplatz 34, 8010, Graz, Austria Introduction Although acute osteomyelitis is a well known disease in children, its localization in the patella is uncommon. We present a case of a 10 year old girl with delayed diagnosis and following operative treatment. Material The girl described pain after an initial trauma 7 weeks before. Pain occurred mainly during the night, no swelling or redness was seen. The family consulted a medical practitioner, a paediatrician and an orthopaedic specialist, radiographs were taken and no alteration of the patella was detected. The diagnosis was growing pain. However, as pain did not disappear the local paediatric department was consulted. Laboratory data demonstrated an erythrocyte sedimentation rate of 19 mm/h. A MRI of the left knee showed a 1.5 cm diameter osteolytic lesion in the patella with central necrosis. Radiologists and an orthopaedic surgeon interpreted the lesion as a chondroblastoma and a follow-up MRI was planed. 5 days after hospital discharge the girl appeared again with pain of her left knee. Clinical examination showed swelling and hyperthermia of the left knee for the first time but no fever. The laboratory showed a white blood cell count of 8.750/ll (5.50–13.50/lL), an erythrocyte sedimentation rate of 61 mm/h (1–10 mm/h) and a C-reactive protein

42 How to treat still ongoing knee flexion contracture after supracondylar extension osteotomy of the distal femur in a patient with proteus syndrome H.Lengnick, C.Dussa, A.Pavlova und L. Do¨derlein Orthopa¨dische Kinderklinik, Behandlungszentrum Aschau im Chiemgau Anamnesis We show the case of a 4 year old boy with Proteus Syndrome, who presented in our out-patient department with massive knee and hip flexion contracture of the lower extremity and a difference in leg length of -6 cm on the right side. The past medical history shows a fracture of the femur 1 year earlier, which was treated with open reduction and intramedullare nailing. The boy’s development was normal with verticalization at the age of 6 months and free walking ability at the age of 1 year. The diagnosis was made by human genetic examination. Methods We used clinical examination of lower extremity joints as well as standard X-ray diagnostic tools. Results The boy presented with hip flexion contracture of EXT/FLEX 0/70/130° and ABD/ADD 20/0/20° on the right side. Knee EXT/ FLEX showed readings of 0/70/120°. Right foot DE initially showed readings of 20° with gigantism of the whole foot and most particularly of second through fifth toe on the right foot.

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The skin showed typical gyrus-like changes. X-ray examination showed centred hip joints with Coxa vara particularly on the right side. The epiphysis presented in neck position. The neck of the femur was deformed into a hypertrophic shape. The massive contracture of the knee joint was confirmed by an X-ray examination done in full extension, which showed an extension deficit of 70°. Concerning the hip flexion contracture of 70° with internal rotation contracture and adduction contracture we performed an open capsulolysis of the right hip joint with inter-trochanteric valgisation, derotation and extension osteotomy using a Surfix Plate. Intra-surgical range of motion of the hip showed FLEX 90° with full extension capability, ABD 20°, ADD 30°, external/internal rotation 40/0/30°. Due to the knee flexion contracture we performed a supra-condylar extension and derotation ostetomy of the right leg. An open arthrolysis of the knee joint with set lengthening of the Lig. patellae and the Tractus iliotibialis was done. Intraoperative range of motion of the knee joint showed readings of FLEX 80°, EXT 10°. Post-surgical treatment was performed by a thigh cast for 6 weeks which was removable for early functional post-treatment by the physiotherapist. A thigh orthesis with an adaptable pelvic part was constructed for the follow-up mobilization. 3 months post-surgery the patient presented himself again at out clinic with a remarkable reduced ROM of the knee of EXT/FLEX 0/20/40°, while hip mobility was unchanged. To improve knee mobility, we performed a partial tenotomy of the M. rectus femoris on the right side as well as an unsuccessful try for a ventral epiphyseodesis by Eight Plates at the distal right Femur. Discussion We ask how to treat the persisting knee flexion contracture after the already performed supra-condylar extension and derotation osteotomy and open arthrolysis of the knee joint. Keywords Knee flexion contracture, Proteus syndrome, relapse, treatment option Korrespondenzadresse Dr.med. Harald Lengnick, Kinderorthopa¨die, Orthopa¨dische Kinderklinik Aschau, Bernauer Strasse 18, 83229 Aschau im Chiemgau, Tel.: 08052/171 – 0, e-mail: [email protected]

Methods In 11 patients femoral lengthening was performed with a monolateral lengthening system (LRS Orthofix pediatric), in 7 cases a special Ilizarov construction was used. All patients were evaluated through clinical and radiological examination. If necessary, we stabilized the bone with ESIN, or plate osteosynthesis after removal of the external fixation. Results Most of the patients operated on with LRS develop severe varus or procurvatum deformity of the femur during, or after lengthening, and second surgery was necessary to correct the deformity. In two cases we changed from LRS to an Ilizarov construction, one because of a femur fracture 1 week after removal of the fixateur. In one patient lengthening had to be stopped because of pencil-like autoregenrate. In patients, which were initially treated with the Ilizarov method, such deviations also occurred, but could be corrected during lengthening. A deformity after lengthening was not seen in these patients. The main complication in these patients was pin loosening because of infection. Discussion In many other diseases monolateral and circular systems are both sufficient methods for limb lengthening. In PFFD lengthening the monolateral fixation bears the high risk of an increasing varus and procurvatum deformity during the lengthening. The monolateral lengthening system does not allow for a sufficient correction of the deformity. Often it is not possible to fixate the bone with three screws in a row, because of the pathological consistence. The Ilizarov method offers a possibility to correct gradually any deformity which occurs during lengthening. Also it is technically easier to affix, when the femur is very small and friable. Therefore we recommend a circular external fixation system in lengthening in PFFD. Keywords PFFD, limb lengthening, Ilizarov method, monolateral fixation Correspondence Johanna Katharina Correll, Behandlungszentrum Vogtareuth, Klinik fu¨r Kinderorthopa¨die, Krankenhausstr. 20, 83569 Vogtareuth, Tel.: +49 (0)8038-904610, e-mail: [email protected]

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H. Lengnick, C. Dussa, M. Ho¨sl und L. Do¨derlein

Comparison of femoral lengthening in proximal femoral focal deficiency with monolateral und circular fixation

Orthopa¨dische Kinderklinik, Behandlungszentrum Aschau im Chiemgau

J.-K. Correll, und S. Nader

Anamnesis Skewfoot is a rare foot deformity with generally recommended surgical treatment in contrast to the spontaneous resolving nature of single Pes adductus (1). Surgical techniques distinguish hindfoot correction by calcaneus lengthening procedure (Evans), Chopart arthrodesis and triple arthrodesis. Forefoot adductus correction is done by open wedge cuneiforme I- and/or closing wedge cuboid-ostetomy (McHale). Less is known about the benefit of surgical intervention for the individual patient’s state of health and foot function. This study examined the different operative techniques and the potential benefit of operative treatment of skewfoot using patient outcome questionnaire. Methods We present the data of six patients with ten surgical interventions in skewfoot. Patients were interviewed before and 6–24 months after operation regarding their function of the affected foot. ‘‘Foot and Ankle Outcome Questionnaire’’ provided by the American Academy of Orthopaedic Surgeons includes ‘‘Foot and Ankle Core Scale’’ (judging subjective patients foot function) and ‘‘Shoe Comfort Scale’’ asking for shoe wearing habits. In order to reveal the dimensions of operative adjustment we compared pre- and post-surgical bone angles (Calcaneus pitch and

Behandlungszentrum Vogtareuth, Klinik fu¨r Kinderorthopa¨die Introduction Proximal femoral focal deficiency (PFFD) is a rare skeletal anomaly characterized by failure of normal development of the proximal femur and in most patients also of the hip joint, with several degrees of severity. If the patient has stability of the knee and hip joint, femoral lengthening, dependent on the amount of femoral shortening, can be done. The purpose of this study was to compare the outcome of callus distraction with monolateral fixation and with circular fixation in the treatment of leg length discrepancy in children with proximal focal femoral deficiency. We compared our results with those from other reports with a focus on lengthening time, final leg length achieved, rate of complications and consistence of the new formed bone. Material We review our experience of femur lengthening in 16 patients [2 of these in combination with fibular and ulnar deficiency (FFU syndrome), 2 in combination with unusual facies syndrome (FHUFS)]. All of these patients were followed at least 6 month, in 2 cases more than 12 month.

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44 Skewfoot—a rare foot deformity: do surgical techniques improve patient outcome?

J Child Orthop (2013) 7:331–362 Metatarsale 1 angle in lateral plane, Kite‘s Talo-Calcanear angle, Talo-Navicular (TN) angle, Talo-Metatarsale 2 (TM2) angle and Cuneiforme-Metatarsale 2 (CM2) angle in dorsoplantar plane). The data were reviewed by two independent observers, who were not involved in the surgical procedures. Results ‘‘Foot and Ankle Outcome Questionnaire’’ scored an improvement of the ‘‘Foot and Ankle Core Scale’’ from pre-surgical 76 to post-surgical 93 points. The ‘‘Shoe Comfort Scale’’ improved from pre-surgical 18 to post-surgical 83 points. 55 % of patients were able to wear orthopaedic insoles only or no support at all on average 1 year after operation. Chopart arthrodesis and Evans osteotomy showed a significant improvement of the Calcaneus pitch (p = 0.02), TN angle (p \ 0.005), Kite‘s angle however showed only a tendency of correction. Cuneiforme I- and/or closing wedge cuboid-ostetomy were done in 6 feet improving the CM2 angle significantly (p \ 0.005). There was no significant difference between surgical techniques of peritalare release (n = 4) and calcaneus lengthening procedure (Evans) with cuneiforme 1 osteotomy concerning functional outcome and bony correction potential. Conclusion Post-surgical results showed a positive patient evaluation regarding their foot function as well as their participation in daily life underlining literatures recommendation of surgical treatment in skewfoot (1, 2). Operative correction should distinguish between foreand hindfoot deformity considering the special role of structural adduction. The surgical goal of forefoot adductus correction should be a re-established horizontal orientation of MT1-cuneiforme joint line. Keywords Skew foot, forefoot and hindfoot deformity, operative technique, patient outcome References 1. Peterson H., Skewfoot (1986) J Ped Orthop 6:24–30 2. Hagman S. et al. (2009) Skewfoot, foot and ankle. Clin N Am 14:409–434. Correspondence Dr.med. Harald Lengnick, Kinderorthopa¨die, Orthopa¨dische Kinderklinik Aschau, Bernauer Strasse 18, 83229 Aschau im Chiemgau, Tel.: 08052/171 – 0, e-mail: [email protected]

351 [5] during barefoot walking at self-selected speed. We extracted peak and ROM values from kinematic traces concerning rearfoot to tibia and foreto rearfoot motion in stance. Differences between ASFF, SFF and TD were analyzed with ANOVA and post hoc tests. Results No significant differences between ASFF and SFF could be noticed. Yet, both flatfoot groups significantly deviated from TD: Peak eversion during stance was significantly (p \ 0.04) increased in flatfeet (ASFF: 12.0 ± 5.4°; SFF: 11.2 ± 3.9° vs. TD: 8.2 ± 5.3°), while eversion ROM was significantly reduced (p \ 0.04). Dorsiflexion ROM at the ankle was on average limited by *50 % (p \ 0.01). On the other hand, dorsiflexion at the midfoot significantly increased (p \ 0.02). Moreover, the forefoot of flatfeet remained significantly more supinated and also more abducted throughout stance (all p \ 0.01). Discussion Foot kinematics could not discriminate between ASFF and SFF. We could not confirm that symptoms are linked to overall restraint in foot motion [4]. Yet, our clinical sample showed pronounced deviations from TD affecting both fore- and rearfoot. We found larger peak rearfoot eversion than previously reported [6]. Besides, dorsiflexion ROM at the ankle was reduced, which was compensated by excessive sagittal midfoot mobility. Interestingly, eversion ROM of the rearfoot was reduced, which could be critical for shock absorption. In conclusion, preventive indication for surgery in pediatric flatfeet needs careful consideration. When planning treatment options, next to the static malalignment, both the restraint and the excess of dynamic foot motion needs to be taken into account. References 1. 2. 3. 4. 5. 6.

Kelikian et al. (2011) Foot Ankle Spec 4(2):112–119 Kosashvili et al. (2008) Foot Ankle Int 29(9):910–913 Moen et al. (2012) Scand J Med Sci Sports 22(1):34–39 Hunt & Smith (2004) Clinical Biomechanics 19(4):391–397 Stebbins et al. (2006) Gait & Posture 23(4):401–410 Levinger et al. (2010) Gait & Posture 32(4):519–532

Keywords Pediatric flatfoot, Pes planovalgus, foot kinematics, Oxford Foot Model Correspondence Matthias Ho¨sl (MSc), Orthopaedische Kinderklinik Aschau, Bernauerstr. 18, 83229 Aschau im Chiemgau, Tel.: 08052/171 – 2016, e-mail: [email protected]

46 45 Foot kinematics in symptomatic and asymptomatic pediatric flatfeet

From the infant to the adult foot—a question of balance? Analysis of the functional causes of developing foot and toe deformities in regard to prevention and therapy N. M. Hien

M. Ho¨sl, H. Bo¨hm, C.Multerer and L. Do¨derlein Orthopaedic Hospital for Children, Behandlungszentrum Aschau GmbH Introduction Preventive surgery on severely deformed but painless flatfeet is highly controversial [1]. While pediatric and juvenile flatfeet are rarely symptomatic, they may lead to knee pain [2] and tibial stress syndrome [3]. Up to now, it is unclear why flatfeet become symptomatic. In adult flatfeet, symptoms may be linked to restraint of motion [4]. To better understand pathology, we aimed to discriminate foot motion of asymptomatic and symptomatic pediatric flatfeet. Materials and methods 28 children with severe idiopathic flatfeet were included from our outpatient department. All depicted bilateral valgus heel and a lowered arch at age 7 or older. They were referred to the gait laboratory for clinical decision making. 17 children (age 11.0 ± 2.6 years) were asymptomatic (ASFF) and 11 children (age 11.2 ± 1.8 years) reported pain (SFF). Tarsal coalitions were excluded. 11 age-matched children with typically developed feet (TD) served as controls. 3D foot kinematics were analyzed with the Oxford Foot Model

Praxis fu¨r Orthopa¨die und Unfallchirurgie Mu¨nchen, Munchen, Germany Introduction The human foot develops from an organ meant to hold and grab to an organ meant to stand and walk as well. It undergoes natural alterations by bio-functional strain and adaption due to the interrelation of in- and extrinsic factors. In addition to natural influences socialisation and civilisation modify the bio-functional strain. 1. Which cornerstones and main reasons for developing foot and toe deformities can be discovered? 2. Which requirements are indispensable for prevention and treatment? Materials and methods In 25 years of orthopaedic practice more than 12,000 newborns underwent clinical and sonographic examination when screening for DDH was performed. Findings were documented including diagnosed deformities of legs and feet. A clinical and sonographic re-examination was recommended 3 months after the child had begun to walk freely or if the child had

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not started walking at the age of 15 months, and again findings were documented including leg and foot deformities. Further re-examinations were recommended before or after the start of schooling at the age of 5–7 and at the beginning of the last growth phase and pre-puberty. The findings of these different examinations are compared and analysed and the questions mentioned above are discussed and answered. Results In the unselected group of the screened newborns 2 % showed remarkable structural deformities of their feet; the majority of these did not require any long-term therapy. At the time of the first re-evaluation after 3 months of free walking up to the age of 5, the variety of leg and foot axes and forms was especially high depending on spontaneous neuro-motoric behaviour, body weight, psycho-motoric setting, shoes worn and play and sports activities. Deformities that required external therapy were found in less than 1 %. From the start of school up to the beginning of puberty an increase of strain to forefoot and toes in inadequate shoes was noted together with a neglect and decrease of the grab and extension function of the toes, unbalanced strain by competitive and cultural sports and a decrease in spontaneous movements at school and during the use of media, leading to up to 30 % remarkable alterations of feet and toes. From puberty to the end of the growth period an increase in imbalance and unhealthy stress was found under the influence of commercial advertising and marketing for fashionable shoes and clothes, one-sided competitive sports and collective behaviour resulting in up to 50 % foot and toe deformities. Gait analysis and biomechanical aspects are considered when basic requirements of a natural and healthy development of the feet are defined. Discussion Most of the foot and toe deformities seen in daily practice today are not congenital or hereditary but develop due to an imbalance of the interrelation of individual behaviour and cultural and civilizing influences on a long-term base of habits. Indispensable requirements for the prevention and therapy of foot and toe deformities are: Weight bearing upon the heel instead of forefoot and toes, rolling on the heel, grabbing and pushing off by toe activity. Development and promotion of toe extension and grabbing during sitting, standing, walking and running as well. Anatomically and bio-functionally correct shoes, straight outer and inner edge of shoe, anatomic shape of the toe profile with free pushing space, tight hold on the ankle, flat sole without any heel. Physiological foot movement even at school, at the office and during the use of media. Change in attitude within the population away from following commercial influence of unhealthy fashion marketing towards responsibility for prevention. Commercial marketing makes money by selling attractive but unhealthy products. The engagement of the orthopaedic physician for prevention requires idealism and is not really honoured. Keywords Foot and toe deformities, development, prevention, therapy, shoes. Correspondence Dr. med. Norbert M. Hien, Praxis fu¨r Orthopa¨die u. Unfallchirurgie, Kinderorthopa¨die, Friedrichshafenerstr. 11, 81243 Mu¨nchen, Tel.: 089 83 44 025, e-mail: [email protected]

immobilisation due to early surgery or a combination of the above. Plagiocephaly is often a symptom of permanent or temporary cervical immobility, which can be a result of blockages or torticollis. However, in multiple cases there is no proper explanation for the deformation. This can be very frustrating for the parents and results in great need for relief. Also an ear-shift can be found in many patients, which indicates a subcranial asymmetry. It is of great importance to treat this symptom as well, as it may lead to cranio-mandibular dysfunction. Method In order to prevent a helmet therapy and its effort and cost it is essential to explain the non-orthotic treatments to the parents. These are especially important for children up to 6 months and include the removal of possible blockages, physical therapy and the use of special pillows. Most important however is the prone position. Lying prone the occiput is relieved from the head’s weight. In young infants these strategies can lead to spontaneous improvement in shape and asymmetry, assumed that the bone is still soft enough for the brain to form the skull (like a balloon that is inflated). If the above-mentioned strategies fail, initiating early helmet therapy is often the only solution in severe cases. In a short interval from six to 12 months we start therapy and guide the growth of the head with an orthosis. This brace prevents further growth of the dominant areas and offers space for the skull to expand towards the deficient areas. Since the growth of the skull decreases at the end of the first year of life, the duration of treatment depends on the severity of the deformity and the age at the onset of therapy. The circumference of the head increases by 12,5 cm in the first, but only by 2.5 cm in the entire second year of life. The helmet must be worn 23 h a day, the free hour is necessary to clean the orthosis and the head. Results Within the last 5 years we provided helmets to over 1000 patients. This large number of patients offers us a vast amount of data that is collected during each therapy. In average a helmet is worn 6 months (23.33 weeks), while therapy starts at a median age of 8 months (8.04). The evaluation also supplies information about important questions such as when to start helmet therapy or the possible improvements. Further the change in ear-shift is part of our analysis. In our specialised ambulance head deformities are treated by a children’s orthopaedic. This is unique to helmet therapy in Germany. Hereby we lay focus on the skull but also include further diagnostic and treatment if necessary (manual therapy, X-ray, sonography). If needed, patients are referred to the responsible disciplines. Discussion The last 5 years made it obvious to us that all disciplines that are involved in the treatment of infants with head deformities should be aware of the possibilities of this method as well as its limitations. This way the right treatment is offered at the right time and unfortunate courses can be prevented. Keywords Plagiocephaly, brachycephaly, helmet therapy, torticollis, ear-shift Hannelore Willenborg, Facha¨rztin fu¨r Orthopa¨die/Kinderorthopa¨die, Department Kinder- und Neuroorthopa¨die, Orthopa¨die der MHH im Annastift, Anna-von-Borries-Str. 1 – 7, 30625 Hannover, Tel.: 0511 5354 303, Fax: 0511 5354 675, [email protected]

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Helmet therapy: five years and 1000 cases

Beidseitige septische Arthritis des Hu¨ftgelenkes bei einem fu¨nfja¨hrigen Ma¨dchen nach verschlepptem Infekt der oberen Atemwege

H. Willenborg und L. Hinken Orthopa¨dische Klinik der Medizinischen Hochschule Hannover im Annastift

N. Schikora, C. Weber und A. Forth Klinik fu¨r Kinder – und Neuroorthopa¨die, Hessing Stiftung Augsburg

Introduction There are various causes for head deformities in infants. Due to the campaign ‘‘back to sleep’’ (in order to prevent the SIDS) an increasing share of brachycephaly can be found in infants. Other reasons for brachycephaly are muscular hypotonia, craniotabes,

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Abstract Septic arthritis of the hip in young children still remains an important and serious condition, because of its high potential to cause permanent sequelae to the hip. In 95 % only one hip is affected by an

J Child Orthop (2013) 7:331–362 infection which is caused by bacteria like Staphylococcus or Streptococcus via haematogenous infection some weeks after an infection of the bronchopharyngeal system. Arthritis of the hip is a rapidly destructive disease of the joint and that for it is an pediatric orthopaedic emergency, which has to be operated on immediately. We report a rare case of septic arthritis reaching both hips in a time period of 10 days after the first operation on the left side and review the common literature. Einleitung Die septische Arthritis des Hu¨ftgelenkes ist mit 2–3 % der entzu¨ndlichen Hu¨fterkrankungen insgesamt sehr selten, allerdings ist es trotzdem die ha¨ufigste septische Affektion eines Gelenkes im Kindesalter. Sie kann in jedem Alter auftreten, geha¨uft in der ersten Lebensdekade. Ha¨ufigster Erreger ist Staphylococcus aureus. Zu spa¨t behandelt fu¨hrt die septische Arthritis zu einer schnellen Zersto¨rung des Gelenkes mit schwerwiegenden Folgen. Die Diagnose und Indikationsstellung basiert auf der klinischen Untersuchung, sowie den laborchemischen und radiologischen Daten. Die Therapie reicht von der offenen Spu¨lung bis zur arthroskopischen Revision des Gelenkes. Im folgenden Beispiel wird der Fall einer beidseitigen septischen Arthritis des Hu¨ftgelenkes bei einem fu¨nfja¨hrigen Ma¨dchen mit einer Peri-/Myokarditis nach verschlepptem Infekt der oberen Atemwege dargestellt und die Besonderheiten unter Beru¨cksichtigung der aktuellen Literatur herausgearbeitet. Material und Methodik Berichtet wird u¨ber eine 5 ja¨hrige Patientin, welche sich mit Hu¨ftschmerzen rechtsseitig in der Notaufnahme vorstellte. Die klinische Untersuchung zeigte eine schmerzbedingt eingeschra¨nkte Beweglichkeit der rechten Hu¨fte, eine Erho¨hung der Ko¨rpertemperatur auf 38,8° und ein allgemeines Krankheitsgefu¨hl. Fremdanamnestisch wurde u¨ber eine verschleppte Erka¨ltung ca. 3 Wochen zuvor berichtet. Sonographisch fand sich ein ausgepra¨gter Gelenkerguss bei einem unauffa¨lligen Ro¨ntgen-befund. CRP von 2.05 mg/dl ohne Leukozytose. Die Gelenkpunktion zeigte ein tru¨bes, putrides Sekret. Die Cytologie wies 116000 Zellen auf, worauf die offene Spu¨lung des rechten Hu¨ftgelenkes u¨ber einen anterioren minimalinvasiven Zugang durchgefu¨hrt wurde. Intraoperativ fand sich eine ausgepra¨gte Synovialitis und ein putrides Sekret. Postoperativ wurde eine kalkulierte i.v. Antibiose mit Cephazolin gewichtsadaptiert verabreicht, worauf sich die Laborparameter normalisierten und die Patientin nach 6 ta¨gigem stationa¨ren Aufenthalt oralisiert mit Cefuroxim bei guter Beweglichkeit und beschwerdefrei entlassen wurde. Die mikrobiologischen Untersuchungen des Punktates und der Synovia – PE blieben unauffa¨llig, dafu¨r fand sich ein positiver Befund fu¨r M. pneumoniae im Coxitis Labor. Drei Tage nach der Entlassung stellte sich die Patientin mit subfebrilen Temperaturen und Schmerzen im linken Hu¨ftgelenk erneut in unserer Notaufnahme vor. Die Sonographie zeigte einen massiven Gelenkerguss bei einem CRP von 2,2 mg/dl und einer Leukozytose von 13900. In der Punktion fanden sich 100000 Zellen bei einem putriden Sekret. Es wurde wiederum die Indikation zur offenen Spu¨lung diesmal des linken Hu¨ftgelenkes u¨ber einen anterioren minimalinvasiven Zugang gestellt. Intraoperativ fand sich ein putrides Sekret und eine ausgepra¨gte Synovialitis. Postoperativ wurde eine kalkulierte i.v. Antibiose mit Cephazolin verabreicht, worauf sich die Laborparameter normalisierten und die kleine Patientin nach 5 ta¨gigem stationa¨ren Aufenthalt oralisiert mit Cefuroxim bei guter Beweglichkeit und Beschwerdefrei entlassen wurde. Auch hier blieben die intraoperativen PE‘s und das Punktat steril. Blutkulturen wurden zu beiden Zeitpunkten nicht abgenommen. Die anschließende ausfu¨hrliche Focussuche zeigte in der Kinderkardiologie eine milde Peri-/Myokarditis mit EKG Vera¨nderungen. Es wurde nun eine zu¨gige Aufbelastung an beiden Hu¨ften gestattet unter krankengymnastischer Anleitung und Sportverbot. Die orale Antibiose wurde fu¨r insgesamt 6 Wochen eingenommen. Die letzte Verlaufskontrolle 6 Wochen postoperativ zeigte unauffa¨llige Laborparameter, ein unauffa¨lliges Sonogramm und eine sehr gute Mobilita¨t der kleinen Patientin ohne weitere Krankheitszeichen. Zusammenfassung Die septische Arthritis des Hu¨fgelenkes ist mit einer Inzidenz von 5.5 – 12/100000 sehr selten und zeigt sich in 95 %

353 der Fa¨lle einseitig. Ursa¨chlich ist meistens eine ha¨matogene Infektion mit Staphylo- oder Streptokokken im Rahmen eines Infektes der oberen Atemwege Wochen zuvor. Sie fu¨hrt unbehandelt zur raschen Destruktion des Gelenkes mit schweren Langzeitfolgen. Beidseitige septische Coxitiden werden in der Literatur kaum beschrieben. In unserem Fall ist die Ursache fu¨r das beidseitige Auftreten wohl eine Peri-/Myokarditis im Rahmen eines verschleppten Infektes der oberen Atemwege. Der positive Coxitisbefund bei Befall des ersten Hu¨fgelenkes und die Diagnose einer Peri-/Myokarditis nach Befall des zweiten Hu¨ftgelenkes sollte generell Anlass dazu geben eine genaue und ausgiebige Abkla¨rung (Kardiologie, Rheumatologie und HNO) durchzufu¨hren, um mo¨glicherweise den beidseitigen Befall durch schwerwiegende Cofaktoren zu verhindern. Keywords Septic coxitis, hip, bilateral, peri-/myocarditis Correspondence Dr. med. Nils Schikora, Hessingstraße 17, Klinik fu¨r Kinder - und Neuroorthopa¨die, 86199 Augsburg

49 150 degrees kyphoscoliosis in a patient with Proteus syndrome—a case report P. Nichterlein, R. Taurman und F. Lattig Orthopa¨dische Universita¨tsklinik an den RKU - Universita¨ts- und Rehabilitationskliniken Ulm, Ulm, Germany Introduction Proteus syndrome is a rare congenital condition caused by a mosaic activating mutation in AKT1 manifesting with disproportionate, asymmetric overgrowth, cerebriform connective tissue nevi, epidermal nevi and vascular malformations. We present a case of Proteus syndrome in a 20 year old male with severely rapid progressive kyphoscoliosis. Material/methods The patient was followed from the age of 8 weeks to the age of 20 years. A scoliosis Lenke type 1AN of 30° Cobb at the main curve Th4-Th9 was treated with a brace between the age of 11 and 16 years and kept stationary. With accompanying delayed puberty the patient developed a kyphoscoliosis of 150° Cobb scoliosis from Th5 to Th11 and 110° kyphosis with compensatory fixated C1/2 subluxation and consecutive restrictive ventilation disorder within 2 years. Therefore, we decided to perform corrective spinal surgery after prior Halo gravity traction for 10 weeks. Results After successfully treating with Halo traction without any complications, corrective spinal surgery with dorsal instrumentation C6-Th12, decompression, Ponte osteotomies and rib release under intraoperative neuromonitoring was performed. The extent of correction was limited intraoperatively by spinal cord function. Clinical and radiological follow-ups three, 6 and 12 months postoperative did neither show any complications nor a rebound. Conclusion The few published cases of patients with Proteus syndrome associated scoliosis treated surgically show a greater risk for rebound or adjacent kyphosis. Simultaneously, the risk of rapid deterioration due to disproportionate, asymmetric overgrowth seems to increase. Close intervals of clinical and radiographic follow-up are therefore recommended. If the deterioration worsens, surgical intervention after risk assessment is indicated. The frequently seen vascular malformations imply the risk of extensive bleeding and neurological complications. Therefore, these potential complications must be taken into consideration and the appropriate steps taken. Keywords Proteus syndrome, scoliosis, kyphoscoliosis, surgical treatment Korrespondenzadresse Dr. med. Peter Nichterlein, Orthopa¨dische Universita¨tsklinik, RKU - Universita¨ts- und Rehabilitationskliniken Ulm, Oberer Eselsberg 45, 89081 Ulm, Germany, Tel.: 0731/177 – 1101, e-mail: [email protected]

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Hypercorrection braces (‘‘mirror-braces’’) yield more radiologic in-brace correction and better active posture control in left lumbar scoliosis (AIS)

Atlantoaxial nontraumatic subluxation—presentation of two cases and review of literature M.P. Tedeus, C. Gross, J.F. Funk, R. Placzek

J. Matussek, F. Wagner, E. Dingeldey, G. Rezai Paediatric Orthopaedic Department, University of Regensburg Medical Center, Regensburg/Bad Abbach, Germany

Department for Pediatric Orthopaedic Surgery and Neuroorthopaedics, Center for Musculoskeletal Surgery, Charite´ – University Medicine, Berlin, Germany

Introduction The conservative AIS treatment as a highly interdisciplinary concept still suffers of many poorly controllable factors that have immense impact on the outcome; thus, conservative AIS treatment quality may vary considerably. Indication of AIS treatment, the patient‘s compliance, sophisticated TLSO design and the right physiotherapy are still far from being common sense. To avoid overblown expectations of patients and their families in the conservative AIS treatment and to protect adolescents of frustrating treatment periods, a realistic prognosis of the proposed treatment path has to be defined after about 4 months. On the other hand, active correction of the postural asymmetry of the spine is a great challenge for the mostly female adolescent. Cosmetic improvement of the deformity seems the most important goal that is worthwhile to pursue. Methods 30 female AIS patients with defined lumbar curvatures (King I(II)) were treated with 2 braces of different designs: A new hypercorrective Cheneau-brace (n: 16) and a generation-2001 Cheneaubrace (n: 14); expected further sceletal growth of \4 - [2 years; bracing for an average of 16–21 h a day; surface stereometric measurements with the 4D-Formetric System were performed initially and at every clinical control date; X-ray control at 4(6)/12/(24) months in the brace in two planes; initial Cobb angles ranged between 20° and 45° lumbally; typical physiotherapy programme (Schroth) (2x/week); no controlled evaluation of compliance to wear the brace. Results Once the primary 3 D-correction after 4 months of brace treatment and physiotherapy programme valued more than 40 % ([1/ 3) (n:30) King I/II curvatures), these improvements could be maintained or even improved during the next 20 months. Hypercorrective braces yielded a significantly better primary Cobb angle improvement and a better surface scan symmetry. The active correction without the brace, documented with the 4D-Formetric-System, did not immediately correspond with changes of the Cobb angle, though usually after a delay of 6 months of repeated training, active improvements could be documented in 30 patients. Discussion In well defined AIS curvatures, the primary 4 D-correction in a modern TLSO after 4 months is believed to be a reliable prognostic parameter for the conservative treatment potential. The interdisciplinary orthoteam together with the patient‘s family have thus a reliable tool at hand to decide whether to continue a succesful and optimistic treatment start or to quit a less favourable course of progress. The adolescent‘s active control of truncal deformity and asymmetry measured with clinical tools and computerized surface stereometry plays an at least similarily important role for the developing self-esteem of the patient as the Cobb angle does for the surgeon. Keywords Scoliosis; Hypercorrective bracing; lumbar curve; surface scan; cobb angle Correspondence Dr.med.Jan Matussek, Orthopa¨dische Klinik der Universita¨t Regensburg im Asklepios Klinikum Bad, Abbach, KaiserKarl V Allee 3, 93077 Regensburg Bad Abbach, Tel.: 09405-18-4826, e-mail: [email protected]

Introduction Atlantoaxial nontraumatic subluxation in children is a rare condition presenting as persisting torticollis. Most of the cases occur after infections of the respiratory tract as well as following otolaryngologic surgery. To date, the pathogenesis is still not completely understood. One common theory postulates septic embolism via pharyngovertebral veins into the perodontoid plexus causing inflammation of paravertebral soft tissue and thus leading to loosening of the transverse ligament resulting in the subluxation. Another theory describes a common torticollis due to spasm of paravertebral muscles as the trigger for atlantoaxial subluxation on the basis of constitutional lax paravertebral ligaments. Therapy is commonly nonoperative consisting of NSAIDs, antibiotics and immobilisation of the cervical spine. Some cases need surgical treatment. A frequent problem in clinical practice is delayed diagnosis caused by an asymptomatic period between airway infection or operation and the onset of symptoms. In some cases, no preliminary infection or operation is reported. Furthermore, atlantoaxial subluxation is often overseen in MRI imaging, and X-ray or computertomography are not commonly used in the diagnosis of children. Delayed diagnosis and therapy leads to higher incidence of therapy resistance or relapse. Material, methods On the basis of two cases of persistent atlantoaxial subluxation a systematic literature review was performed and the state of the art treatment algorithm described. Two patients (5 year old boy, 13 year old girl) treated unsuccessfully elsewhere for torticollis were eventually referred to our department. Their history and previous treatment were analysed, and the resulting diagnostic and therapeutic concepts are shown emphasising the importance of adequate imaging. Our findings are related to the current literature on theories of etiology, diagnosis and therapeutic pathways. Results Closed reduction under anaesthesia was necessary in both cases with Halo fixation due to persistent instability after prolonged subluxation. For confirmation of subluxation as well as correct reduction adequate imaging is essential. In some cases, CT imaging including 3D reconstruction is helpful and needs to be enforced whenever MRI cannot rule out the presumption completely. Discussion Atlantoaxial nontraumatic subluxation is a rare condition that is often diagnosed belatedly or misdiagnosed. We present the latest knowledge on the disorder with regard to a systematic literature review and stress the diagnostic and therapeutic procedures needed based on our two cases. Keywords Atlantoaxial nontraumatic subluxation, torticollis, Grisel0 s syndrome, closed reduction, Halo fixation Correspondence Dr. med. Matthias Tedeus, Department for Pediatric Orthopaedic Surgery and Neuroorthopaedics, Center for Musculoskeletal Surgery, Charite´ – University Medicine Berlin, Charite´platz 1, 10117 Berlin, Tel.: +49-30-450-652263, e-mail: matthias-peter. [email protected]

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Hallux varus caused by a longitudinal epiphyseal bracket-surgical treatment

Treatment of child war victims from Afghanistan—a challenge for an interdisciplinary approach

D. Depeweg und S. Mu¨ller

M. Rogalski1, M. Deja1, F. Schlesinger2 und M. Lempe2

Clinic for Orthopaedics, Trauma Surgery an Paraplegiology, University of Heidelberg, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany Introduction The longitudinal epiphyseal bracket (LEB) is a rare ossification defect located in the tubular bones, especially in hands and feet. The LEB is often associated with different syndromes like oligosyndactyly, Rubinstein-Taybi-Syndrome and Cenani-Lenz syndactyly. The deformity is detectable in up to 14 % of congenital hand and foot deformities. The first metatarsal bone including the great toe is in 11 % of all cases involved. We report about a 5 year old girl with a progressive hallux varus deformity after resection of hexadactyly and valgusosteotomy at the age of 18 months. Materials and methods and results The parents report about hexadactyly with a supplementar first toe on the left foot. At the age of 18 months the toe was resected and additionally a valgisation osteotomy of the first metatarsal bone was performed. The varus deformity of the first ray increased and caused problems during walking and wearing shoes. The width of the forefoot was also increasing. The x-rays of the foot showed a c-shaped secondary ossification center that bridged the diaphysis and metaphysic of the first metatarsal bone resulting in a short, broad deformity with a medial deviation of the metatarso-phalangeal joint. The intermetetarsal angle increased from 6.6° to 11.9° during 1 year. As a result of the progressive discomfort we suggested revision surgery with resection of the medial epiphyseal bracket and open wedge osteotomy correction of the first metatarsal bone with K-wires and autologeous bone graft. The postoperative X-rays showed a complete resection of the medial epiphyseal bracket and a correction of the varus deformity. After postoperative casting for 4 weeks the K-wires were removed after radiological consolidation of the osteotomy, then full weight bearing was allowed in a walking cast for 2 weeks. Discussion The cause of the LEB is an incomplete development in the primary ossification center of metacarpal or metatarsal bones during pregnancy. This could be a reason for associated congenital anomalies like syndacytly, polydactyly a.o. The few described cases in the literature concerning the foot report about a predominance of duplication of the greater toe. The abnormal epiphysis causes growth in a c-shaped bone and not longitudinal. It was first described in 1964 by Jones in the metacarpal bones as a ‘‘delta phalanx’’. Conservative treatment is ineffective to correct the deformities. Jones was also the first to describe the open wedge osteotomy with bone grafting. Additionally, the resection of the tethering bracket should be performed to restore longitudinal growth and correction of the trapezoidal deformity. Keywords Longitudinal epiphyseal bracket, hallux varus, delta phalanx, correction ostoeotmy Correspondant author Dr. Daniela Depeweg, Clinic for Orthopaedics, Trauma Surgery and Paraplegiology, Department of children orthopaedics, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany, Tel.: 0049/6221/5626338, e-mail: [email protected]

1

FB Kinderorthopa¨die, Zentrum fu¨r Orthopa¨die und Unfallchirurgie, Klinik fu¨r Kinderchirurgie; HELIOS-Klinikum Berlin-Buch, Berlin, Germany

2

Introduction Due to long lasting violent conflicts in Afghanistan the number of civil victims is around 90 % of all treated patients, only 10 % are soldiers. Especially among children complex injured victims are reported. One chronic legacy of warfare is blast injury to children from landmines as well as gun shot injury, which affect different organ systems. Paediatric patients were at first admitted at military medical facilities. After primary care physical and psychical problems remain, which can not be solved by the host national medical infrastructure. Patients and methods We present case reports of 3 severely injured child victims (2 girls, 1 boy), who were transferred via help organization camp Friedensdorf International to our hospital during 2008–11. Case 1: 11 years old boy, accident gun shot injury while playing with a friend. Complex pelvic and hip involvement with paresis of ischial nerve and bowel lesions. Case 2: girl, age 8 years with complex infection and septicaemia, fistulae between rectum, bladder and the destroyed hip joint. It was a case of familary violence, she was shot down by an uncle. Case 3: girl, age 6. She suffered from blast injury caused by landmine with traumatic amputation of right lower limb, chronic infection of bladder and urogenital tract combined with pelvic fracture. We report patterns of injury, diagnostic procedure and operative treatment options as well as long lasting postoperative care and rehabilitation process. Results The hospital stay (6, 8 and 2 month) and number of necessary diagnostic and therapeutic interventions is not comparable with mean stay of classic paediatric orthopaedic patients. All children showed significant psychopathological posttraumatic stress symptoms caused by primary trauma and long lasting disjunction from familiar environment and parents. All 3 children were able to stand and walk at final examination in Germany. We have got follow up information after transfer back to Afghanistan, which documents well being of two of them. Discussion Treatment of child victims abroad from their home country is a great challenge. It consists not only of expensive and complex medical diagnostic and therapeutic procedures, but also of long lasting and difficult processes of care giving and efforts to compensate the psychopathological comorbidity in these severely affected patients. Only an interdisciplinary setting with continuous cooperation and communication of all care givers can result in a better outcome of these severely affected children. Keywords War, child victims, complex injury, landmines Correspondence Dr. med. Matthias Rogalski, FB Kinderorthopa¨die, Zentrum fu¨r Orthopa¨die und Traumatologie, HELIOSKlinikum Berlin-Buch, 13125 Berlin, Schwanebecker Chausee 50, Tel.: +49(0)30 9401-12304, e-mail: [email protected]

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Introduction Fibular hemimelia is a common congenital anomaly of lower limb. Commonest Presentation is a longitudinal deficiency of varying severities and Coalition of tarsal bones. Literature search shows several articles regarding the management of limb length discrepancy but is scare on the topic of foot correction. In limbs which cannot be lengthened, a Syme’s amputation is advised. When lengthening is considered, a stable weight-bearing foot is important. Also in cases where lengthening is not possible, the foot should be centralized for pressure free and cosmetically appealing prosthetic fitting. We present our experience with correction of foot deformities in patients with fibular hemimelia. Material, methods A retrospective study was conducted at our centre. Deformity corrections performed after 2007 were included in the study. All patients with diagnosis of fibular hemimelia who had foot deformities were reviewed. Minimum follow-up was 1 year following surgery. Apart from patient demographics, limb length discrepancy, foot deformity, type of surgery and complications were documented. At follow-up the hind foot and forefoot in 3 dimensions were documented. Results Our database revealed 87 Patients with diagnosis Fibular hemimelia. 25 patients underwent corrective foot surgery between 2007 and 2010. M:F = 17:7. The mean age is 10 years. Mean followup period is 2.3 years. The foot deformities were classified into Clubfoot (4), rockerfoot (6), Pes valgus (7) and equinovalgus (8). The surgical corrections involved supramalleolar osteotomies (12), ankle arthrodesis (3), Osteotomy through Talo-Calcaneal Synostosis (15), calcaneus medial shift Osteotomy (6), midfoot osteotomy (17), naviculocuneaform arthrodesis (3) and soft tissue surgeries (15). The surgical wound could not be closed in 2 cases and needed secondary closure and splitthickness skin graft in 1 case respectively. No complications were seen. At follow-up the under correction of the hind foot was seen in 4 cases and of the forefoot in 4 cases. Discussion The foot deformities in fibular hemimelia are complex and complex. Due to this, often combined osteotomies of forefoot and hindfoot are necessary for correction. Since a valgus deformity with or without a rotational deformity of distal tibia a very common associated finding, this should be corrected in the same sitting. Skin closure can occasionally be a problem which can be addressed by grafting or delayed closure. Keywords Fibular Hemimelia, foot, correction Correspondence Dussa CU, Orthopaedische Kinderklinik, Bernauer Strasse 18, 83229 Aschau im Chiemgau, Germany, Tel.: 0049 8052 171 0, e-mail: [email protected]

an abnormal weight distribution of the foot. This may lead to severe pain and instability. Pisani‘s arthroereisis procedure tries to reduce the deformity and stop progression by minimal invasive implantation of a screw into the sinus tarsi. Materials and methods In this retrospective analysis we included all patients which underwent Pisani‘s arthroereisis procedure in our department between 2008 and 2012. The following angles were measured in the preoperative and postoperative radiographs (DP/lateral view of the foot, standing): Costa Bartani0 s angle, talar calcaneal angle, talar-first metatarsal angle, talar- and calcaneal inclination angle, Kite0 s talocalcaneal angle. We compared the collected angular dimensions with values of a healthy reference population. Clinical outcome and complications were evaluated. T-test was performed. The level of significance was set at a = 5 %. Results Thirty-eight Patients and 65 feet were included into the study. In 28 patients surgery was performed on both sides. The mean age at the time of surgery was 11.2 ± 3.0 years. The screws were removed after 2.9 ± 0.9 years. One Patient was excluded, because the screws had to be removed after 3 months due to pain. Additionally 20 radiographs of patients, aged 11.3 ± 2.2 without foot deformity were analyzed and regarded as reference group. In the pre-to post-operative comparison, all collected angular dimensions aligned to the healthy population or the standard values known from literature: Costa Bartani angle (reference group 125.3°) 141.9° preoperatively to 131.1° postoperatively. On average, the erection was 10.8°. The talar calcaneal angle (normal 25–35°) in the lateral view reduced from 41.7° preoperatively to 37.2° postoperatively. The talar inclination angle (reference group 24.3°) was measured 28.9° preoperatively and 22.5° postoperatively. The calcaneal inclination angle (reference group 21.4°) slightly changed from 13.3° preoperatively to 14.2° postoperatively. The talar-first metatarsal angle (reference group 6.3°) was reduced from 11.8° preoperatively to 3.6° postoperatively. In D.P. X-ray view Kite0 s talocalcaneal angle (reference group 25.0°) changed from 25.6° preoperatively, to 20.6° postoperatively. The talo-first metatarsal angle (normal \10°) decreased from 16.7° preoperatively to 8.2° postoperatively. The t-test for paired samples showed significant improvements for all measured angles in the preoperative to postoperative comparison (p = 0.027 for the calcaneal inclination angle, p \ 0.001 for all remaining angles). After surgery the children reported a significant relieve of pain. Apart from one excluded patient, no complications were reported. Discussion Subtalar joint arthroereisis is an effective method for the treatment of symptomatic planovalgus foot deformity in children \15 years. This minimal invasive procedure leads, by using a cannulated calcaneal-stop screw, to immediate stabilisation of the subtalar joint and a relief of pain with less morbidity. Postoperative evaluation shows a significant improvement of tarsal alignment. Keywords Planovalgus foot, subtalar arthroeresis, childhood Correspondence Markus Sensenschmidt, Klinik und Poliklinik fu¨r Orthopa¨die, Universita¨tsklinikum Dresden, Fetscherstraße 74, 01307 Dresden, Tel.: 0351/458-13657, e-mail: markus.sensenschmidt@ uniklinikum-dresden.de

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Subtalar joint arthroereisis procedure for treatment of symptomatic planovalgus foot deformity in childhood

Radiological validation of the center of rotation in new orthoses

Management of foot deformities in fibular hemimelia C.U. Dussa, L. Doederlein Orthopaedische Kinderklinik, Aschau i. Chiemgau

M. Keim1, C. Wetzelsberger-Pohlig2 und L. Do¨derlein1 M. Sensenschmidt, F. Thielemann Department of Orthopaedics, University Hospital, Dresden, Germany Introduction The pediatric planovalgus foot is, with an incidence of 1/1000, a common foot deformity in childhood. A progressive hindfoot valgus and the adduction and lowering of the talar head result in

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1 Behandlungszentrum Aschau im Chiemgau, Orthopa¨dische Kinderklinik, Aschau i. Ch, 2Behandlungszentrum Aschau im Chiemgau, Fa. Pohlig, Aschau i. Ch.

Introduction The use of orthoses after completion of cast treatment or the primary use of orthoses after complex reconstruction of lower limb

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deformities is getting increasingly popular. Standard orthoses are not used routinely in pediatric orthopedics due to the individual functional requirements of the patient population with neuromuscular or congenital diseases and due to functional demands of the orthosis itself. Here custom-made orthoses are the treatment of choice. However, matching the anatomical and orthotic center of rotation is one of the central aspects to ensure a good functional result and good fit. Materials and methods We investigated in our department patients with new hip, knee and ankle orthoses from January to December 2012. Initially the anatomical center of rotation is evaluated by clinical examination and ultrasound by an orthopedic technician. After preliminary completion of the orthosis, we evaluated for correct matching of the anatomical and orthotic center of rotation in a-p X-rays. Results We have seen very few correct matches between the orthotic and anatomical center of rotation. In approximately 80 % a correction of the center of rotation was necessary, despite of an initial ultrasound of the joint and a competent orthopedic technician specializing in custom made orthoses. Discussion In conclusion we recommend the standard use of knee, hip or ankle x-ray control prior to manufacturing a custom-made orthosis. Clinical evaluation and ultrasound-guided placement is not sufficient for correct placement of the center of rotation. This is critical to avoid any pressure sores, secondary loss of correction, lever forces or unphysiological stress on joint surfaces. Keywords Custom-made orthosis, center of rotation, x-ray control Correspondence Dr. med. M. Keim, Behandlungszentrum Aschau GmbH, Orthopa¨dische Kinderklinik, Bernauer Strasse 18, 83229 Aschau i. Chiemgau, Tel.: 0049-8052-171-0, e-mail: [email protected]

effective technique for the treatment of patellofemoral instability and allows patients to return to sports without redislocation of the patella. Keywords Medial patellofemoral ligament; open growth plate; patellofemoral instability; children and adolescents Correspondence Dr. med. Sabine Lippacher, Orthopa¨dische Universita¨tsklinik Ulm am RKU, Oberer Eselsberg 45, 89081 Ulm, Germany, Tel: 0049-731-177-5120, Fax: 0049-731-177-1103, e-mail: [email protected]

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– the cephalic ratio (ratio of head length and width as (head length x100)/head width diagnosing brachiocephaly) and – the oblique diagonal difference (difference of the cranial diagonals diagnosing plagiocephalus).

Anatomic reconstruction of the medial patellofemoral ligament in children and adolescents with open growth plates S. Lippacher1, H. Reichel1, J. Woelfle1 and M. Nelitz2 1

2

Department of Orthopedic Surgery University of Ulm; MVZ Oberstdorf Introduction Recurrent lateral patellar dislocation is a common knee injury in the skeletally immature adolescent. Because of the open physis, operative therapy in children is challenging. Methods Twenty-one consecutive patients with patellofemoral instability and open growth plates underwent anatomic reconstruction of the MPFL that maintained the distal femoral growth plate. Preoperative radiographic examination included AP and lateral views to assess patella alta and limb alignment. Magnetic resonance imaging was performed to evaluate trochlear dysplasia and tibial tubercle–trochlear groove (TT-TG) distance. Evaluation included preoperative and postoperative physical examination, Kujala score, and Tegner activity score. Results The average age at the time of operation was 12.2 years (range 10.3–13.9). The average follow-up after operation was 2.8 years after surgery (range 2.0–3.6). No recurrent dislocation occurred, but 2 patients with high-grade trochlear dysplasia still had a positive apprehension sign. The Kujala score significantly improved from 72.9 (range 37–87) preoperatively to 92.8 (range 74–100) postoperatively (p = 0.01). The Tegner activity score decreased, but not significantly, from 6.0 (range 3–9) preoperatively to 5.8 (range 3–9) postoperatively (p = 0.48). Discussion Anatomic reconstruction of the MPFL that respects the distal femoral physis in skeletally immature patients is a safe and

58 Reliability of the three- dimensional laser scanner ‘‘Starscanner’’ diagnosing infant head deformities B. Schuhknecht, N. Deventer, F. Schiedel, R. Ro¨dl Abteilung fu¨r Kinderorthopa¨die, Deformita¨tenrekonstruktion und Fußchirurgie, Universita¨tsklinikum Mu¨nster, Munster, Germany Introduction Since the ‘‘back to sleep’’- campaign in 1996, which reduced the sudden infant death by 40 % in the USA, the prevalence of positional head deformities increased from 1:300 in 1976 to about 1:60 today. Therefore, the numbers of parents with children consulting in the orthopaedic departments with deformational plagiocephalus increased. The main method diagnosing head deformities today is the laserscan method using a ‘‘STARscanner’’ by Orthomerica (Orlando, USA) which constructs a three- dimensional head shape and calculates the measures needed for diagnosis automatically. Measures important for diagnosis of head shapes deformities are

In the last 4 years, therapy using a dynamic head orthesis is used more and more often to treat asymmetric head deformities. Nevertheless, studies analyzing the methods used for diagnosis of head shapes or to determine norm ranges are still pending. Therefore we examined the internal consistency and reliability of the measurements mentioned above using the three-dimensional laser scanner ‘‘STARscanner’’ by Orthomerica, to test, if this method provides reproducible measures, with which reliable diagnostics can be given. Materials and methods Raw data was used from patients who were scanned in the course of our consultations. As a measure of internal consistency and reliability, we assessed intra- and interobserver variability for the parameters applied in the diagnosis of deformational plagiocephalus. This was done by blinded comparison of these measures for the same trained observer working on the same scan twice (established in 10 patients) and comparison between the measures of two observers (30 patients). The relative intertrial variability (RIV) of these measurements for each patient scan by two different observers (interobserver variability) as well as for two measurements on one scan by a single observer (intraobserver variability) was determined. RIV = [(item1 - item2)/05 (item1 + item2)] 9 100 %, and values of \10 % indicate a high degree of reproducibility. Results For the cephalic ratio, mean ± SD interobserver RIV was 0.71 ± 0.67 %, mean ± SD intraobserver RIV for observer I was 0.43 ± 0.37 % and for observer II 0.47 ± 0.35 %, which indicates a level of reproducibility for the cephalic ratio.

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358 Mean ± SD interobserver RIV for the diagonal difference was 11.6 ± 15.13 %, mean ± SD intraobserver RIV in diagonal difference for observer I was 13.3 ± 14.5 % and for oberver II 11.74 ± 5.7 %. This demonstrates a borderline reproducibility for the diagonal difference. As we dealt with mostly low numbers in the diagonal difference (mean ± SD 8.9 ± 5.48 mm), we additionally calculated the intraclass correlation coefficient, which is a more appropriate way to calculate the reliabilities in small numbers, as small absolute differences at low numers are presented as high percentage while equivalent absolute differences at high numbers are presented as lower percentage values. The correlation coefficient in diagonal difference for the interobserver reliability was 0.993, for separate measures of observer I was 0.991 and for separate measures of observer II was 0.993. This again demonstrates a high level of reproducibility also in the measures of the diagonal difference. Discussion Therapy using the dynamic head orthesis to treat head deformitits in children between the age of 6 months and 12 months has become very popular in the last few years. There have been several studies testing different methods of cranial measurements from manual measurements using specific tools to a threedimensional method using a set of 12 cameras to obtain a threedimensional picture. However, current studies examining the three- dimenasional laser scan method (‘‘Starscanner’’) as a diagnostic tool used for diagnosing a head deformity, or the natural course of the head shape development, which form the basis of a high quality treatment are still missing. With this study we started at the very basis to evaluate the up- todate tools used for diagnosing of head shape deformitis in young children. As data shows, the method using a 3-D- laserscan (‘‘Starscanner’’) has got high standards of reproducibility. Therefore it can be seen as a good basis to perform further surveys on head shape deformities in young children. Nevertheless there are still many aspects to be examined, such as studies examining the natural course of the development of infant head shapes including normative ranges of head shape measures, until a high quality diagnosis of infant head shape deformities can be provided. Keywords Positional head deformity, three- dimensional laserscan, STARscanner Correspondence Universita¨tsklinikum Mu¨nster, Abteilung fu¨r Kinderorthopa¨die, Deformita¨tenrekonstruktion und Fußchirurgie, z. H. Dr. med Britta Schuhknecht, Albert- Schweitzer- Campus 1, Geba¨ude A1, 48149 Mu¨nster, Germany

59 Pathomorphologic findings of wrist arthroscopy in children and adolescents with chronic wrist pain S. Farr, W. Girsch und F. Grill Orthopa¨disches Spital Wien – Speising, Abteilung fu¨r Kinder- und Jugendorthopa¨die Introduction The purposes of this diagnostic study were to show pathomorphologic findings of children and adolescents with persistent wrist pain and to compare these arthroscopic findings with preoperative magnetic resonance imaging (MRI). Materials and methods A total of 41 arthroscopies in 39 patients were retrospectively reviewed. The patients underwent diagnostic wrist arthroscopy because of persistent wrist pain after at least 3 months of

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J Child Orthop (2013) 7:331–362 unsuccessful conservative treatment. Of the patients, 22 (56.4 %) reported an injury before the onset of pain. The mean age at arthroscopy was 15.3 years (range 9.8–19.4 years), and the mean duration between the onset of symptoms and arthroscopic exploration was 19.9 months (range 3.0–121.0 months). Results Among all affected wrists, 33 (80.5 %) showed a triangular fibrocartilage complex (TFCC) tear on arthroscopy, with 75.6 % also showing other pathomorphologic findings. Retrospectively, the condition of the TFCC was correctly identified by MRI in only 17 wrists (41.5 %). In contrast, 23 wrists were incorrectly classified as having ‘‘no tear’’ whereas arthroscopy later indeed showed a TFCC tear. Concerning the TFCC, MRI and arthroscopy showed a significant difference of outcome (P \ 0.01), indicating low agreement (k = 0.09) for the outcome of the two methods. A larger proportion of TFCC tears was found for patients with injuries (91.3 %) as compared with the other patients (66.7 %), although this was not significant on statistical analysis (P = 0.11). No significant difference in the time to surgery was found between patients with TFCC tears and those without TFCC tears classified by MRI (P = 0.76) and by arthroscopy (P = 0.99). Discussion Wrist arthroscopy in children and adolescents with chronic wrist pain shows TFCC lesions in a high percentage. However, most of these lesions have not been correctly identified by MRI before arthroscopy. Thus diagnostic wrist arthroscopy may be recommended to rule out underlying pathologies and initiate further therapeutic steps. Reprinted with permission of the Arthroscopy Association of North America (Arthroscopy 2012;28:1634–1643). Keywords Wrist arthroscopy, children and adolescents, TFCC lesion, chronic wrist pain Korrespondence Dr. Sebastian Farr, Abteilung fu¨r Kinder- und Jugendorthopa¨die, Orthopa¨disches Spital Speising, A - 1130 Wien, Speisinger Str. 109, Tel: +43 1 80 182-1610, E-Mail: [email protected], Web: www.oss.at Ein Unternehmen der Vinzenz Gruppe Wien, FN 177923 b, Handelsgericht Wien, Firmensitz Wien

60 Juvenile Hallux Valgus Deformity—first results after temporary screw epiphyseodesis of the first metatarsal C. Schlickewei, M. Rupprecht, K. Babin, K. Ridderbusch, R. Stu¨cker Department of Pediatric Orthopaedics, Altona Childrens’s Hospital, Hamburg Introduction The juvenile hallux valgus (JHV) is rare, but can be associated with symptoms that make surgical treatment necessary. In addition to soft tissue corrections various techniques to surgically correct the deformity have been described. Recurrent deformities after appropriate surgical interventions are not uncommon. The objective of this study is to report on the technique and to present the preliminary results of this new technique to correct the deformity by screw epiphyseodesis of the lateral part oft the growth plate of the first metatarsal. Materials and methods From June 2011 to October 2012 one boy and three girls with a JHV-deformity and corresponding complaints were treated with a temporary screw epiphyseodesis of the first metatarsal. Six feet were affected. Mean age at time of operation was 9.9 ± 1.3 years (8.1–11.3). All patients were followed clinically and radiologically. For analysis the deformity and the correction rate, the hallux valgus angle (HVA) and the intermetatarsal angle (IMA) were measured. After surgery all patients were asked to use a hallux valgus night splint.

J Child Orthop (2013) 7:331–362 Results The patients had a mean follow up of 8.0 ± 1.0 months. The initial HVA was 25.3 ± 8.4° (19–40), the average IMA 18.3 ± 2.3° (16–22). Up to now, in one patient the screws were removed after successful correction. The average correction of the HVA by the month is 0.9 ± 0.5° (0.4–1.6), and of the IMA 0.7 ± 0.2° (0.4–0.9). Perioperative complications did not occur. Discussion This ist the first report on a minimal invasive screw epiphyseodesis to treat juvenile hallux valgus deformity—to our knowledge. It achieves reliable correction with little morbidity. Correction rate is probably depending on growth and was highly variably in this patient group. Longer follow up and more experience with this technique is required to confirm the final safety, evaluate the risk of rebound and to define best age of treatment. Keywords Juvenile Hallux Valgus, Hemiepiphyseodesis, screw epiphyseodesis Corresponding author Martin Rupprecht, MD,Bleickenalle 38, 22763 Hamburg, e-mail: [email protected], Tel.: 040-88908-797

61 Long-term clinical results in solitary bone cyst—a retrospective study F. Traub1,2 und T. Wirth1 1 Klinikum Stuttgart, Orthopa¨dische Klinik des OLGAHOSPITAL, Stuttgart, Germany, 2HELIOS-Klinikum Berlin-Buch, Sarkomzentrum Berlin – Brandenburg, Department Tumororthopa¨die, Berlin, Germany

Introduction Although of solitary bone cysts (SBC) are not true neoplasms, they may create major structural defects to the bone. Several methods for the management of SBC are employed with variable success rates. There is no consensus or official guideline for when and how to treat a SBC. The aim of our investigation was to share our therapy experience and help to identify reliable methods in the treatment of SBC based on retrospective analysis. Methods We performed a retrospective analysis of patients treated for SBC in our institution between 2000 and 2010. In this time 164 patients (112 boy and 52 girls) diagnosed with a SBC were treated at our institution. The inclusion criterion for this study was a solitary bone cyst diagnosed by radiological or histological features. Followup for at least 3 years or Neer classification I and skeletal maturity. Surgical procedures were the following: aspiration and injection with methylprednisolone, elastic stable intramedullary nailing, curettage followed by bone grafting with an autograft or allograft or a combination of the above. Results 135 patients (48 female, 87 male) with a mean age of 9.6 years were included in the study. The median follow-up time period for all patients was 57.2 month. The cysts were mainly located in long bones (n = 121), predominantly in the humerus (n = 59) and the femur (n = 49). At presentation, 93 patients had a pre-existing pathological fracture. Of the 135 patients, 74 had an active bone cyst at an age of 8.3 years and the other 61 had latent bone cysts at an age of 11.8 years. 16 patients had been managed completely conservatively all the other patients (n = 119) had at least one surgical treatment. The failure rate in the conservative group was 27.3 % (6 of 22). Overall recurrence rate after primary surgical therapy was 26.1 % (31/119) for all surgical procedures—recurrence being defined as requiring further surgical treatment. All of the 37 patients where the first treatment failed received a second treatment and two patients needed a third surgical intervention.

359 Discussion Our results suggest satisfactory overall long-term outcome for the surgical treatment of SBC, although short-and mid-term observation show a considerable rate of recurrence independent of the surgical technique. Keyword Solitary bone cyst, tumor-like lesion, long-term follow-up, treatment options Correspondence Dr. Dr. Frank Traub, HELIOS Klinikum BerlinBuch, Sarkomzentrum Berlin – Brandenburg, Department Tumororthopa¨die, Zentrum fu¨r Orthopa¨die und Unfallchirurgie, Schwanebecker Chaussee 50 - 13125 Berlin, Tel.: +49-30-9401 52300, e-mail: [email protected]

62 Ankle valgus in patients with hereditary multiple exostosis disease—pros and cons of temporary screw epiphyseodesis of the distal tibia M. Rupprecht, C. Schlickewei, K. Babin, K. Ridderbusch, R. Stu¨cker Department of Pediatric Orthopaedics, Altona Childrens’s Hospital, Hamburg, Germany Introduction Exostoses in the distal lower leg can cause a shortening of the fibula, a deformation of the distal tibial epiphysis as well as a tibiofibular synostosis. The associated ankle valgus usually manifests itself in a painful planovalgus foot. Such malformations occure in children with hereditary multiple exostosis disease (HME) in up to 55 %. A first study documented, that the temporary screw epiphyseodesis of the distal tibia leads to a reliable correction of the valgus deformity (1). The aim of this adjacent study was to evaluate the incidence of the rebound phenomenon after screw removal. Materials and methods From January 2002 to August 2012 14 boys and 2 girls with HME and an associated ankle valgus (27 ankles) were treated with a temporary screw epiphyseodesis of the distal tibia. Mean age at time of operation was 11.8 ± 1.4 years (9.8–14.8). After screw removal further checks were carried up till epiphyseal fusion. To objectify a recurrency of the ankle valgus, the tibiotalar tilt was analyzed. Results The mean preoperative tibiotalar tilt was 13.3 ± 5.2° (5–22). Due to a succesful correction of the valgus deformity, in 13 patients (23 ankles) the screw was removed 23.1 ± 12.1 months (10–46 months) after the index procedure. At time of screw removal the tibiotalar tilt was normalized to 0.8 ± 4.9°, according to a mean rate of correction of 0.7 ± 0.3° by month. In two children the distal tibial growth plate was already closed at time of screw removal, so that no rebound could appear. The remaining 11 children were reexamined 23.7 ± 12.3 months (6–37) after screw removal. 5 children displayed a valgus recurrence, necessitating a reoperation in 4 cases. Discussion The temporary screw epiphyseodesis of the distal tibia is an easy, minimally invasive, low-risk treatment option of ankle valgus deformities in children with HME. Principally the same rules have to be followed as by any other temporary epiphyseodesis, whereby the rebound rate seems to be significantly higher in this patient group. Regular examinations and X-rays should be carried out after correction and hardware removal until physeal closure. (1)

Rupprecht et al. (2011) Temporary screw epiphyseodesis of the distal tibia: a therapeutic option for ankle valgus in patients with hereditary multiple exostosis. J Pediatr Orthop 31(1):89–94

Keywords Ankle valgus, Hereditary multiple exostosis disease, temporary epiphyseodesis Corresponding author Martin Rupprecht, MD, Bleickenalle 38, 22763 Hamburg, e-mail; [email protected], Tel: 040-88908-797

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360 63 Initial experience with pelvic support osteotomy in developmental dysplasia of the hip with hip dislocation K. Kuminack, M. Vohrer, A. El Tayeh, S. Ludwig Department Orthopa¨die und Traumatologie, Universita¨tsklinikum Freiburg, Freiburg, Germany Untreated severe DDH may lead to hip dislocation within the first months of life. The consequence is a leg shortening with insufficiency of the hip abductors and extensors and flexion contracture with abnormal pelvic tilt, which is compensated by lumbar hyperlordosis. The high joint dislocation and the muscle insufficiency cause unstable one-legged stance and gait limping. Later in this will cause a painful gait and limit the walking ability. Therapeutic options in this situation are particularly limited in adolescence or young adulthood. The pelvic support osteotomy (PSO), as a 2-level osteotomy improves the bias of pelvitrochanteric muscles. The distal osteotomy allows correction of leg length difference and mechanical axis. We treated two female patients, aged 14 and 15 years, with high hip dislocation. The first patient had a left dislocated hip and in the second case both hips were highly dislocated. Both patients are from Iraq. We performed the PSO using the LRS Limb Reconstruction System (Orthofix). In the first case we could adjust the leg length by lengthening of 5 cm. In the case of bilateral dislocation, we had to stop the lengthening because of apparent pain symptoms among the beginning of distraction in consideration of the symmetric leg length. After completing the distraction and bone healing we removed the fixator system after 29 weeks in the unilateral hip dislocation. A partial removal was performed to the bilateral case after 20 weeks to dynamize the system. Both patients showed a limitation of knee flexion at 20–30°. The first patient could reach a 90 degree knee flexion and almost 70° flexion and 20° abduction of the hip through physical therapy within 6 weeks after complete system removal. The gait shows only minimal limping because of the still remaining muscle weakness. The patient with bilateral dislocation is still in treatment. The further course will be reported. Corresponding to our initial experience, the pelvic support osteotomy seems to be a successful treatment strategy for congenital high dislocation of the hip in adolescence according to the rare literature. Dr. med. Kerstin Kuminack, Universita¨tsklinikum Freiburg, Department Orthopa¨die und Traumatologie, Hugstetter Str. 55, 79106 Freiburg, e-mail: [email protected], Tel.: 004976127026100, Fax: 004976127026130

64 Curettage and bone grafting for aneurysmal bone cysts: an adequate treatment option? H. Gru¨tter, U. Bru¨ckner, B. Schnuck Diakoniekrankenhaus Rotenburg, Kinderorthopa¨die Aneurysmal bone cysts are rare skeletal tumors that most commonly occur in the first two decades of life. Treatment of these lesions remains controversial, management options include curettage and bone grafting or cementation, alcohol sclerotherapy en-bloc resection, embolization and radionuclide ablation.

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J Child Orthop (2013) 7:331–362 We retrospectivelly reviewed 14 patients with histologically proven aneurysmal bone cysts treated by sclerotherapy with absolute alcohol and either curettage and bone graft or PMMA with at least 6 months follow-up (6 months to 9 years). Complications and recurrence were noted. 14 patients with a mean age of 15.3 years (range 6–37) were evaluated. 11 patients underwent curettage and bone grafting, 2 patients were treated with curettage and PMMA, 1 patient received a vascularized fibular autograft. Recurrence was noted in 4 patients, necessitating repeat procedures. Two of these patients were treated with allogenic bone graft, 1 with PMMA and 1 with fibular autograft. The mean time interval before recurrence was 8 months (4–11 months). Curettage and bone grafting is a safe treatment option for aneurysmal bone cysts. More than one surgical procedure may be necessary to completely eradicate the tumor. Recurrence usually occurs within the first year after initial surgical treatment. Beate Schnuck, Diakoniekrankenhaus Rotenburg, Elise-Averdieck-Str. 17, 27356 Rotenburg (Wu¨mme), e-mauil: [email protected], Tel.: 0171-5453649

65 Long-term outcome after modified Austin procedure in Juvenile Hallux valgus patients T. Kraus1, G. Singer3, M. Sˇvehlı´k1,2, J. Kaltenbach1, R. Eberl3 and W. Linhart1 1

Department of Paediatric Orthopaedics, Medical University of Graz, Auenbruggerplatz 34, 8036 Graz, Austria, 2 Department of Orthopaedics and Traumatology for Children and Adults, 2nd Faculty ´ valu 84, Prague 5, 150 of Medicine, Charles; University Prague; V U 06, Czech Republic, 3 Department of Paediatric Surgery, Medical University of Graz, Auenbruggerplatz 34, 8036 Graz, Austria

Background and aim Hallux valgus in children and adolescents is challenging as high rates of recurrences are reported after surgery. This study investigates the longterm outcome of operated juvenile hallux valgus by a modified Austin procedure. Materials and methods We investigated the clinical and radiological outcome of 17 patients (20 feet) aged 14.4 years (SD ± 2.09; range 11–17.2 years) who underwent surgery for hallux valgus by a modified Austin procedure. Radiological measures included Hallux valgus angles (HV), intermetatarsal angles (IMT), the postition of the sesamoids (POS) and the Metatarsalindex (MIT) pre and postoperatively and after 6,3 years (SD ± 3.8; range 2–12.2 years). AOFAS scores were completed and subjective satisfaction was reported. To compare the radiological angles one-way ANOVA with Bonferoni post hoc test was used. A p value of \0.5 was set as statistically significant. Results The HV and IMT improved significantly from pre to postoperative (p \ 0.001) and remained even until follow up (HV p = 0.83; IMA p = 0.48). In 7 patients the position of the sesamoids deteriorated after operation to follow up. AOFAS HMIS showed a mean of 94.46 points (SD ± 7.72; range 73–95) and AOFA-MS was 85.3 points (SD ± 9.19; range 73–95) in mean. Conclusion The modified Austin osteotomy is an effective, and versatile procedure for the correction of a mild to moderate juvenile and adolescent hallux valgus deformity with long lasting improvement and good functional outcome.

J Child Orthop (2013) 7:331–362 Corresponding author Tanja Kraus, MD, Department of Paediatric Orthopaedics, Medical University of Graz, Auenbruggerplatz 34, 8036 Graz ,Tel: +43/316-385-13773, Fax: +43/316-385-13775, e-mail: [email protected]

361 Fußchirurgie, Albert-Schweitzer-Straße 33, 48149 Mu¨nster, Tel.: +49 (0)251 83-48002, e-mail: [email protected]

67 66 Standard therapeutic approach with closed reduction, Fettweis cast and MRI controlled position in cases of congenital dislocation of the hip in children with DDH F. Schiedel, B. Vogt, M. Horter, H. Tretow, V. Wegs und R. Ro¨dl UKM, Abteilung Kinderorthopa¨die, Deformita¨tenrekonstruktion und Fußchirurgie, Munster, Germany Introduction Failure or delay in treatment of congenital hip dislocation leads to severe damage of the hip joint with consecutive pain and alterations of the function, i.e. the walking process. The incidence of congenital dislocation of the hip (CDH) in central Europe according to historical literature is 0.5–1 %. Diagnostic and therapeutic steps still are subject to personal and local preferences and controversial. Still there is a widespread opinion to reduce the hips as soon as possible (same day?). Objectives A standardized procedure for the evaluation and treatment of CDH is essential to achieve the best possible therapy. This work points out the characteristic elements of the workflow as performed in a hospital with clinic. Methods From 01.2007 to 06.2011 18 children with CDH (6 m, 12 f) with a total of 23 dislocations (13 unilateral, 5 bilateral) were treated. Average age at time of diagnosis was 3 weeks (1–8). Average age at closed reduction was 6 weeks (3–12). Diagnostic and therapeutic steps: Physical examination, testing of pathognomonical signs, sonography according to Graf, if suspect of a CDH and patient is at least 3 months of age, a plain a. p. - radiograph Therapy: In all cases of Graf type D, IIIa, IIIb and IV closed reduction under general anaesthesia and appliance of a modified Fettweis cast in hip flexion (110–120°) and abduction (50–60°). Still under general anaesthesia, we then perform MRI in standard layers (corSTIR, corT1, axT2) for verification of successful reduction. Results The plaster cast stays on for average 3.8 weeks, followed by removal and a (second) radiograph to ensure the desired result. The child then receives an orthotic harness for guided development of the hip joint. MRI produces in all cases reliable information for further decisions. All joints were reductet to anatomic positions in first anesthesia. Complications: In one child with a MMC and a shunt, closed reduction was successful at first. Plaster cast therapy has to be canceled because of soft tissue problems in the area of the plasty reconstruction. In another case because of an increasing swelling at one foot the cast has to be doffed after 2 weeks. Both patients had redislocation with need for open reduction. 3 patients had serious dysplasia after initial treatment, and need for surgical intervention acetabuloplasty. Follow up time was at least 1 year. At time of last follow up 18/23 hips had physiological AC angles and had no or grade 1 luxation according to To¨nnis. Conclusion By adhering to the described protocol, decision-making on the correct treatment is safe and easy. We recommend a closed reduction under general anaesthesia with consecutive MRI as powerful means to obtain reliable confirmation of the femoral head position and the acetabulum. Dr. med. Frank Schiedel, Universita¨tsklinikum Mu¨nster (UKM), Abteilung fu¨r Kinderorthopa¨die, Deformita¨tenrekonstruktion und

Long term treatment in congenital hip luxation after surgical reconstruction further treatment due to aggravation of gait pattern? S. Kappl und L. Do¨derlein Behandlungszentrum Aschau im Chiemgau Introduction Female patient, age 12 years, physically and mentally normally developped, no further illnesses. Attending grade 6th at school, hobby swimming, walking distance is not restricted. Underlying disease is a congenital dislocation of the left hip, post open reposition, followed by necrosis of the femoral head. Coxa vara with a considerable difference in length of legs. Deficit in flexion and extension of the left knee, mild ventral instability as consequence of open release and extension of the knee quadriceps muscle. Congenital club foot on the left after surgical adjustment. Material/method Surgical treatment was started at the University hospital Essen. The hip was treated by open reposition, DVO and remodelling of the acetabular roof, age 18 m. Surgical adjustment of congenital club foot, age 5 m.Trochanterapophysiodesis on the left, age 6y in our hospital. Because of decreased ROM in the left knee joint (E/F 0/5/50°), arthrolysis and extension of the quadriceps muscle, age 5 years, resultig in ventral instability. Right distal femurepiphysiodesis due to leg shortening on the left (-3.5 cm), age 11 years. Treated with different ortheses to stabilize the left lower limb. Reducing their wearing with the beginning of age 8, finally resulting in free mobilization. Current shoe enhancement on the left +2 cm, orthopaedic arch support on both sides. Initally intensive physiotherapy, currently once a week only. Current ROM left hip: E/F 0/20/80°; IRO/ARO 15/0/15°; Abd/Add 10/0/20° spontaneous position in neutral; muscle power 4° (MRC). ROM of the left knee joint: passive E/F 0/0/80°, active E/F 0/5/80°, muscle power of extensors 4+°. Current MRI of the pelvis shows a flattened femoral head with laterization and cranialization and a clear coxa vara. No bony impingement to be found.The girl is able to walk smoothly, though showing a limping on the left. No pain in hip or knee wether while walking nor during exam. Results After mobilization under anaesthetic in 10/11 (age 11) due to acute subluxation with locking of the left hip an aggravation of the gait pattern is to be observed followed by an internal rotation and contracture of the flexor muscles of the left hip. This results in a compensatory inclination and retro torsion of the pelvis, lumbar hyperlordosis and an aggravation in stretching the left knee followed by an increase of a functional leg shortening on the left and development of a genu recurvatum on the right.These diagnostic findings are provable by three comparative 3D gait analyses. Discussion How to continue treatment? Any further Diagnostics needed? Another surgical treatment to adjust the left hip? Physiotherapy to strengthen hip extensors and muscles for external rotation? Resume orthotic care? Keywords Congenital hip dysplasia, necrosis of the femoral head, congenital luxation of the hip Correspondence S. Kappl, Behandlungszentrum Aschau, Bernauer Straße 18, D-83229 Aschau i. Chiemgau, Tel.: +49 8052 1 71 – 0, e-mail: [email protected]

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362 68 Mid-term results of type D, 3 and 4 congenital dislocation of the hip R. Taurman, J.V. Wo¨lfle und H. Reichel Department of Orthopedic Surgery, University of Ulm, Ulm, Germany Background Even though the conservative treatment of congenital dislocated hips (CDH) has been improved a lot by ultrasound screening, Types D, 3 and 4 hips still remain a challenge. Method Our study examines the mid-term results of our therapeutic strategy of dislocated hips Type D, 3 and 4. Between 2005 and 2007, 90 dislocated hips were treated according to age and degree of instability with a Pavlik harness in combination with Vojta therapy, Tu¨binger flexion/abduction splint or Fettweis cast. All except one hip achieved an ultrasound Type 1B. After verticalization, x-ray controls were performed, followed by further x-ray controls in regular intervals, in which the Acetabular Index (AI) was measured and compared to physiological values of Toennis and Brunken. Results 66 hips were treated with Pavlik-harness and Vojta therapy, Tu¨binger flexion/abduction splints were used in 21 patients and Fettweis casts on 3 patients. The mean follow-up was 43.0 months. The children underwent an average of 2.5 x-rays. After X-ray

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J Child Orthop (2013) 7:331–362 follow-up 78.9 % of all the hips were within 1 standard deviation (SD). Type 4 showed physiological AI in 88.9 % of the hips, 76.3 % in Type 3 hips and 76.5 % in Type D hips. The Chi square test showed no significant difference (p = 0.509). After comparing the results of the first X-ray control to the second radiological follow-up we observed that 5 of 34 initially physiological hips deteriorated from 1 SD into 2 SD. 12 of 19 hips initially showed 2 SD and meliorated to 1 SD. 5 of 15 hips initially with SD [2 showed melioration into 1 SD. 6 hips showed no tendency to meliorate and stayed [2 SD. The indication for operative treatment was suggested. 3 patients followed the suggestion and showed a physiological AI postoperatively. Conclusion Our strategy for treating dislocated hips has proven to be quite successful. Type 4 hips are no worse off when compared to Type D and 3 hips. After ultrasound-treated dislocated hips, X-ray controls are mandatory even though the majority shows physiological development. Follow-up X-ray controls should be performed to decide whether operative treatment is necessary and to ascertain that initially physiological hips stay within 1 SD on radiological follow-up. Keywords CDH, Pavlik harness, Hip Dysplasia, Acetabular Index Dr. med. Rita Taurman, Orthopa¨dische Universita¨tsklinik Ulm am RKU, Oberer Eselsberg 45, 89081, Ulm, Tel.: 0731/177 5103, e-mail: [email protected]