Treatment of congenital pseudarthrosis of tibia with the circular frame technique

We treated nine patients with congenital pseudarthrosis of the tibia consecutively by a modification of the Ilizarov (circular frame) technique. Seven patients had had several previous operations, and two patients had had none. After resecting of the pseudarthrosis and the surrounding pathologic periosteum, we performed acute shortening and compression at the level of resection, together with simultaneous lengthening of the proximal tibia. Union was achieved in all cases. With this technique, not only the mechanical but also the biologic problems are addressed. As compared with other methods, the circular frame technique also offers the possibility of correcting angulation and limb length discrepancy.

Bilateral nonunited femoral neck fracture in a child with osteopetrosis

We report a case of osteopetrosis with bilateral nonunited femoral neck and coxa vara in a 7-year-old boy. There was a history of traumatic transcervical left femoral neck fracture unsuccessfully treated by internal fixation. We performed a bilateral subtrochanteric valgus osteotomy. K-Wire fixation failed on the right side due to hardness of the bone. Finally, internal fixation with an angular plate after predrilling of the femoral neck offered stability. Bone union was achieved on both sides, resulting in full recovery of normal physical activity.

[Premature maturation of the carpal bones as an early diagnostic sign of juvenile rheumatoid arthritis]

A rare premature maturation of the carpal bones in combination with swelling and flexion contracture of the wrist is demonstrated in two cases of juvenile rheumatoid arthritis. The radiologically verified premature and asymmetrical maturation of the carpal bones was the earliest diagnostic sign in juvenile rheumatoid arthritis.

[Results of treatment of old congenital hip dislocations after the start of walking]

Between 1980 und 1986 32 patients with 42 longstanding congenitally dislocated hips were treated by operation. Age at surgery ranged from 13 months to 18 years (mean 4.5 years) with a follow up of 6.7 years. Surgery was done by open reduction mostly combined with innominate and femoral shortening osteotomy. Not in all cases this was done as a one stage procedure. Results were excellent in 20 hips, good in 11, and poor in 11 hips. Quality of results decreased with age at surgery. The best results could be achieved with the one stage combined operations (open reduction, capsuloraphy, femoral shortening osteotomy, iliac osteotomy). The rate of avascular necrosis of the femoral head was 7.14%. The poor results mostly depended on the operating technique and the indication of surgery in cases with no or with extremly flat acetabulum.

Lengthening for congenital short femur. Results of different methods

We have reviewed the results in 37 patients with unilateral congenital short femur (Pappas classes III to IX), treated by different lengthening procedures. The increase in the length of the femur varied from 15.6% to 142%, excellent or good results being obtained in 32 patients (86%). There was an average of 1.9 complications per case, most being seen earlier in the series when the Wagner technique was used. With the Orthofix and the Ilizarov techniques, we used callus distraction in all cases. We found that the proximal diaphysis of the congenitally abnormal femur healed less well, and we now prefer to perform corticotomy and callus distraction of the distal metaphysis. The Ilizarov method gave the best results, offering the possibilities of the simultaneous use of a Hoffmann fixator across the hip and the treatment of knee dislocation and instability.

[Pelvic tilt and leg length discrepancy]

Pelvic obliquity caused by leg length discrepancy is a problem facing patients with a wide variety of conditions. It is the degree of discrepancy and the growth pattern of the legs that usually govern treatment decisions, with the cause of the discrepancy having little influence. We analyzed the results recorded in 345 patients with pelvic obliquity caused by leg length inequality operated on between 1969 and 1989. In 146 patients a shortening procedure was done and in 199 patients a lengthening procedure. Biological bone growth stimulation did not prove to be predictable and effective in 65 cases. In 134 patients and 138 segments a distraction procedure was performed. In 26 segments the technique was according to Wagner; in 37 cases the Ilizarov fixator was used and in 75 the Orthofix device. Excellent results were obtained in 65% and good results in 23%; the condition became worse in 12%. Analysis of the results justifies the use of epiphysiodesis, shortening osteotomies and bone lengthening according to the biological principles investigated by Ilizarov in the presence of well-defined indications outlined in this report. Patients with a discrepancy of up to 2-3 cm are treated conservatively by shoe lift. For patients with a leg length inequality of 3-5 cm, epiphysiodesis or shortening osteotomy is still a good indication although lengthening procedures can also be performed. Discrepancies between 5 and 15 cm are treated mainly by lengthening operations. New lengthening techniques such as corticotomy and callus distraction, as well as new external fixation systems like Orthofix and Ilizarov, have made bone lengthening a less risky, easier, and more effective procedure. In a growing child, careful clinical and radiological assessment and repeated analysis of past growth in order to predict future growth can provide an exact plan for effective treatment, which often consists of bone lengthening, combined with shortening procedures on the contralateral side to establish leg length equality even in cases when there is 20 cm difference. Surgical treatment can be especially gratifying when anatomical, cosmetic and functional symmetry is restored and a lifetime of shoe lifts, braces or prostheses can be avoided.

[The hip joint in arthrogryposis]

In a retrospective review of 70 hips in 35 patients with arthrogryposis 56 of all hips studied were affected by the disorder. Clinically 4 types of arthrogrypotic hip deformity could be distinguished. In 19 hip joints not only a deformity and a restriction of movement but also a dislocation was found. Based on the results of this study a one-stage open reduction combined with a varus shortening, femoral derotation osteotomy for unilateral hip dislocations is recommended. In cases of bilateral dislocations the above mentioned surgical procedure is indicated only if there is a less severe generalized involvement of AMC. For correction of hip deformities type II during neonatal period conservative treatment by traction or by plaster cast redression has proved be successful. The authors experience is compared with reports of other authors and guidelines for clinical classification and treatment are presented.

Correction of clubfoot relapse using Ilizarov's apparatus in children 8-15 years old

Treatment of relapsed or neglected clubfeet between the age of 8-15 years is at present unsatisfactory. Correction by triple arthrodesis with wedge osteotomies is not possible before the end of skeletal maturation. This caused us to use Ilizarov's external fixator, which made it possible to correct all components of clubfoot simultaneously by continuous guided distraction. Thirteen feet in 12 children were treated. A plantigrade foot was achieved in all cases. All patients were able to wear ready-made shoes. Complications were some slight and two severe pin track infections, temporary edema, and two relapses successfully treated by means of second procedures.

Correction of complicated extremity deformities by external fixation

Thirty-three limb segments with various deformities in 28 children were treated by external fixation. Sole bone lengthenings and trauma cases were excluded from this study. The Wagner device was used in six cases, the Ilizarov ring fixator in seven, and the Orthofix in 20. Indications, techniques, results, and complications are discussed. The results indicate that modern external fixation is an effective alternative method in the treatment of problem cases such as congenital pseudarthroses, severe relapsed or neglected clubfoot, high dislocated hips, and limb deformities with length discrepancies.

The osteoporosis pseudoglioma syndrome. Update and report on two affected siblings

Two siblings (male, 29 years, and female, 13 years) with the rate autosomal recessive osteoporosis pseudoglioma syndrome are reported in detail. All essential signs and symptoms of the full clinical picture were present and are documented by impressive X-ray pictures. Some aspects of our patients are compared with relevant findings of previous reports. Collagen studies (skin biopsies) failed to reveal any significant disorder of the main collagen types composition. Striking similarities with established genetic disorders of collagen (like the osteogenesis imperfecta group and the Ehlers-Danlos syndrome) suggest, however, that the OPS could be a primary collagen disorder. Genetic counselling and devoted socio-medical care for these handicapped children is presently the only help which can be offered.

The Pavlik harness in the treatment of congenital dislocating hip: report on a multicenter study of the European Paediatric Orthopaedic Society

The results of functional treatment using the Pavlik harness in congenital dislocation and congenital dysplasia of the hip in children aged less than 11 months were examined by an EPOS study group. This study was conducted on 3,611 hips in 2,636 patients for a period of 1-9 years after treatment. The reduction rate was 92% in grade Tonnis 2 and 3; the healing rate was 80%. In children with dysplastic hips, the healing rate was 95.35%. Avascular necrosis of the femoral head was observed in 2.38%. The Pavlik harness is designed for outpatient treatment if the parents are compliant.

The Ilizarov distractor for the correction of relapsed or neglected clubfoot

The correction of a relapsed or neglected clubfoot by an external distractor is an alternative to a major operation which may involve triple arthrodesis and is often associated with skin problems. We report the use of the Ilizarov method to treat nine severely deformed feet, with satisfactory results in terms of function and appearance. The distractor enables treatment to be applied before maturity and avoids the shortening of the foot that results from wedge osteotomies. We discuss the indications, technique, complications and results of the method.

Experiences with the chevron (V-)osteotomy on adolescent hallux valgus

The results of a distal chevron (V-)osteotomy in 31 adolescent patients are reported. The distal V-osteotomy of the first metatarsal appeared to provide excellent correction of hallux valgus deformities. The surgical technique and the advantages over other forms of distal osteotomy are described. The authors recommend that distal V-osteotomy be considered as an alternative to other forms of distal osteotomy when treating hallux valgus in adolescents and growing children.

[Operative treatment of hallux varus duplex]

The double great toe is a very rare deformity of the foot. This paper describes two cases with such a bilateral anomaly. In both cases the accessory toe was found lateral and not as described in literature medial. Surgery was done by excision of the rudimentary lateral great toe and correction of the varus position of the hallux by the use of a rotational skin flap.

Clubfoot therapy according to Bösch: conservative and operative aspects

To Bösch goes the honor of having revealed the contradictions of the classical redressment treatment as early as 1950. Bösch's method was new insofar as he exerted pressure on the calcaneus from laterally and thus intuitively corrected the most important deformity, the subtalar horizontal internal rotation. Theoretical confirmation of this subtalar rotation was only made possible by computer tomography investigations, as described herein. On the grounds of these findings, the current operative concept has to be questioned and adapted to the latest scientific findings on the pathomorphology of the clubfoot. Also reported is an operation technique which permits correction of subtalar internal rotation and simultaneous complete reduction of the navicular on the talus, including the calcaneocuboid joint.

Distraction of the epiphyseal cartilage as a method of limb lengthening

This case report presents a girl with congenital short femur and a limb length discrepancy of 12 cm. After a series of complicated operations failed to lengthen the limb, we applied distraction epiphysiolysis and succeeded in correcting the length discrepancy. This method, rarely mentioned in medical literature, is described and discussed.

Treatment of hip dislocation after walking age

Between 1979 and 1981, 35 patients were treated at our institution. All patients were more than 18 months of age and 50 congenitally dislocated hips were treated. The average age at operation was 7 years and 3 months. Whereas children under the age of 6 were typically operated upon by open reduction and Salter, Pemberton, or Dega osteotomy partly combined with femoral osteotomy, in the group of the patients older than 6 years with high iliac hip dislocations, a method was used to avoid femoral shortening. By means of the Wagner distractor the dislocated hips were brought opposite to the acetabulum. This procedure was followed by femoral osteotomy and in most cases Chiari pelvic osteotomy. Despite a number of complications the results turned out better than expected. Compared with the preoperative X-ray classifications (Severin) the postoperative result was excellent in 10 cases, good in 20, fair in 15, and poor in 1 case.

[Contrast medium visualization of the cavum epidurale via Dimer X (peridurography) (author's transl)]

The term "peridurography" stands for visualization of the cavum epidurale via a water-soluble contrast medium. The article reports on the technique and indication. The experience collected on the basis of 93 peridurographies effected by the authors justify the assumption that this method can be considered as reliable in the diagnosis of prolapsed vertebral disk.