[Squatting cast for biomechanical treatment of decentred hip joints]

The so-called "congenital" luxation of the hip joint is endemic in Central Europe and occurs in about 1% of all newborn infants. By the means of ultrasonographic diagnosis according to the Graf method an early detection instantly after birth has become a good clinical routine in the German-speaking countries. Sonography-based conservative treatment has become the gold standard. The cast in squatting ("human") position is a standard procedure in order to retain the originally decentred or unstable hip joints in the reduced position: 100° flexion and 50° abduction are necessary to fix the hip joint in the reduced position without the risk of avascular necrosis. After the fixation in a squatting-cast, a period of functional bracing in flexed position enhances bony maturation. This two-phase functional conservative treatment can avoid later osteotomies or even early total hip replacement.

Painful nonunion after triple pelvic osteotomy. Report of five cases

Tönnis triple pelvic osteotomy is an accepted technique to correct acetabular dysplasia and degenerative labral pathology. A series of 409 consecutive patients who underwent a triple pelvic osteotomy between 1987 and 1999 were followed for a mean of 7.1 years (2 to 15). Five patients (1.2%), all women, developed a double nonunion and required revision, which involved excision of the pseudarthrosis, autologous bone grafting and osteosynthesis with screws or reconstruction plates. Bony healing was achieved in all after a mean of 7.8 months.

[Rotational abnormalities of the hip joint]

Changes or limitations of the rotational range of motion of the hip are a non-specific clinical sign. There is a big variety of underlying morphological pathologies resulting in a symptomatic alteration of hip rotation. They need to be assessed by imaging techniques: based on plain radiographs (including specialized projections), often CT or MRI are necessary to visualize the underlying changes of shape, rotation and offset of the articulating surfaces, which might result in a painful "femoroacetabular impingement" as a trigger of secondary osteoarthritis. Highly sophisticated MR-arthrography-protocols are able to visualize conventionally "obscure" but biomechanically relevant morphological changes, that might be individually normalized by joint-preserving corrective surgery.

[Perthes disease]

The Legg-Calve-Perthes disease is an idiopathic avascular necrosis of the hip during early childhood. It is characterized by different stages with the main risk of persisting hip deformation, dysfunction of the joint movement, and the potential for early osteoarthritis. For the evaluation of prognosis and therapy planning patients age and extent of the necrotic area of the epiphysis are important factors. For an early diagnosis and sufficient therapy all radiological efforts have to be performed. MR imaging is an ideal method for the assessment of osteonecrotic changes of the Morbus Perthes. Compared to plain radiography by MR imaging pathologic alterations can be detected earlier and with higher specificity. However, conventional radiograms have to be still used as basic imaging modality. Nowadays x-rays and MR imaging should be the main methods for the evaluation of children suffering from Perthes disease.

[MR arthrography of the hip joint]

MR arthrography of the hip joint is usually performed after a conventional MRI has been obtained to rule out other pathologies of the hip joint as for instance bone marrow edema or osteonecrosis of the hip. MR arthrography is mainly performed as a very special investigation, and it is executed in most cases if the clinician asks for the diagnosis of a labral lesion. In very rare cases, MR arthrography of the hip is performed to image cartilage disease or osteochondrosis dissecans or free intraarticular bodies. In this paper, the indications, the technique, and the most important pathology of the hip joint--labral lesions--will be described as well as variants of the normal acetabular labrum. After a conventional MRI of the hip joint has been performed, a MR arthrography of the hip will be obtained to search for labral pathology or cartilage disease. MR arthrography is obtained after the intraarticular injection of 10-20 ml of a 0.1 mmol solution of gadopentate-dimeglumine has been performed. The intraarticular injection can either be fluoroscopic-guided or CT-guided or directly MR-guided. After the intraarticular injection, MR arthrography will be performed by the use of paracoronal and parasagittal T1-weighted spin echo or gradient echo sequences. In cases of labral lesions (degeneration, labral tear, labral detachment) or cartilage disease MR arthrography proved to be more sensitive as conventional MRI as shown in the literature. The sensitivity of MRI to detect labral pathology was reported to be about 65%, and that of MR arthrography was reported to be about 92-95% compared to surgical results. According to the current literature, MR arthrography is the most sensitive method to delineate these kind of pathologies. Therefore, the invasive technique of MR arthrography may be justified for the correct diagnosis of these kind of pathologies after other pathologic entities have been ruled out by conventional MRI.

[Magnetic resonance imaging and magnetic resonance arthrography of the acetabular labrum: comparison with surgical findings]

AIM OF THE STUDY

To evaluate the accuracy of magnetic resonance imaging (MRI) and magnetic resonance (MR) arthrography in detecting acetabular labral lesions in correlation to surgical findings.

PATIENTS AND METHODS

Forty patients (40 hips) with chronic hip pain and a strong clinical suspicion of labral lesions were examined with MRI in the coronal and axial plane by obtaining T1 weighted and proton density-weighted spin echo sequences. Additionally, MR arthrography of the hip joint in the coronal oblique and sagittal oblique plane was performed by obtaining T1-weighted three-dimensional gradientecho sequences after the intraarticular injection of gadopentate dimeglumine. The labra were prospectively evaluated on the basis of morphology, signal intensity, the presence or absence of a tear, and their attachment to the acetabulum. All patients underwent surgery, and the MRI findings and MR arthrography findings were compared with the surgical results.

RESULTS

Surgically, 34 labral lesions, and 6 normal labra were detected. MRI correctly depicted labral lesions in 24 patients and two normal labra, and MR arthrography correctly depicted labral lesions in 30 patients and 5 normal labra compared with the surgical results. The sensitivity of MRI was 80%, the accuracy of MRI was 65%, the sensitivity of MR arthrography was 95%, and the accuracy of MR arthrography was 88%.

CONCLUSIONS

MR arthrography enables considerably more accurate detection of acetabular labral lesions than MRI. MR arthrography should be the method of choice for the diagnosis of the presence or absence of acetabular labral lesions in patients with chronic hip pain and a strong clinical suspicion of labral lesions.

Osteochondritis dissecans: a multicenter study of the European Pediatric Orthopedic Society

To assess of the value of conservative and operative treatment of osteochondritis dissecans of the knee, a multicenter study was performed. In 12 European countries, 798 cases of osteochondritis of the knee have been collected from 44 hospitals. Results were based on 452 patients with 509 affected knees with minimum follow-up was 1 year (mean follow-up, 3 years and 11 months) and sufficient data for evaluation: 61% were male patients; 39% female patients; 318 affected knees were found in juvenile patients; 191 affected knees were in adult or premature patients. The localization was the medial femoral condyle on the lateral side in 51% (typical site) of patients. Various other sites were involved. Of the 509 affected knees, 154 were treated conservatively, 355 were treated surgically (many with multiple operations). For evaluation, the initial situation (at the time of the diagnosis) was favorable in 198 patients (no effusion, diameter of the lesion < 20 mm and no gross dissection on imaging) and unfavorable (one of the parameters did not meet these prerequisites) in 311 patients. The results were better in young patients than in adult patients. However, in the adolescent group, 22% of patients had abnormal knee at follow-up. The classical localization has a better prognosis than an unusual one. Patients with a favorable situation at diagnosis have significantly better results after conservative treatment than those who have undergone operation. When there are signs of dissection, the results are better after operative than after conservative treatment.

MR arthrography of the adult acetabular capsular-labral complex: correlation with surgery and anatomy

OBJECTIVE

Our purpose was to describe the appearance of the acetabular capsular-labral complex on MR arthrography and to correlate this appearance with surgical findings in adult patients and with gross anatomic findings in cadavers.

SUBJECTS AND METHODS

MR arthrography of the hip joint was performed in 40 patients and six cadavers. All patients underwent subsequent arthrotomy of the hip. MR arthrography consisted of a T1-weighted three-dimensional gradient-echo sequence in both the coronal oblique and sagittal oblique planes after intraarticular injection of a 2 mmol/l solution of gadopentetate dimeglumine. The normal and pathologic appearance of the capsular-labral complex was assessed, and the labra were evaluated on the basis of morphology, signal intensity, presence of a tear, and attachment to the acetabulum. MR arthrography findings were correlated with the surgical results in all patients and with the anatomic sections of the cadaveric hip joint specimens.

RESULTS

MR arthrography images of the T-weighted three-dimensional gradient-echo sequences allowed visualization of the anatomic structures. The normal labrum was triangular, without any sublabral sulcus, and of homogeneous low signal intensity. A recess between the labrum and the joint capsule could be identified in instances in which no thickened labrum was present. Labral lesions included labral degeneration, a tear, or a detached labrum either with or without thickening of the labrum. The sensitivity for detection and correct staging of labral lesions with MR arthrography in the patient study was 91%; the specificity, 71%; and the accuracy, 88%.

CONCLUSION

MR arthrography with T1-weighted three-dimensional gradient-echo sequences allows excellent assessment of the normal and pathologic acetabular capsular-labral complex.

[Labrum lesions and residual dysplasia of the hip joint. Definition and prospectives]

Labral lesions are a sign of biomechanical decompensation of the hip joint and often represent the first clinical symptom of residual hip dysplasia (RHD) in the adult. Provocation tests (impingement, apprehension) are typical but not specific. Labral lesions and concomitant findings (intra- and extraosseous ganglia, stress bone marrow oedema) can be detected by magnetic resonance arthrography (MRA) with an accuracy of 91%. Primary therapeutic goal is the normalization of the underlying pathomorphology and instability by a redirectional acetabular osteotomy. There are several concepts concerning simultaneous arthrotomy at the time of osteotomy: no arthrotomy at all, selective arthrotomy, routine arthrotomy in every case. There are more clinical studies necessary before one of these concepts can be widely accepted and recommended. Based on preliminary results, palliative arthrotomy with partial labral resection but without corrective osteotomy in osteoarthritis secondary to residual hip dysplasia gives poor results; we therefore urgently dissuade from palliative labral surgery via arthrotomy. Whether labral surgery via arthroscopy might be a useful concept in symptomatic residual hip dysplasia, is still an open question. In this review article, the "state of the art" presented at the "Vienna Labral Symposium 1997" is reflected and summarized. At the end of this article, a "common statement" of the experts is published in English and German language.

Clinical and imaging diagnosis of lesions of the labrum acetabulare

Labral lesions are common findings in residual hip dysplasia, indicating biomechanical decompensation of the hip joint. MR-Arthrography has shown an excellent accuracy of over 90 % to detect these lesions. Nevertheless, so far clinical sings, radiological diagnosis and therapeutical consequences are not well known. In a prospective study, patients suspicious for labral lesions were evaluated using a standard clinical protocol, including history, clinical signs, radiography and MR-Arthrography. Clinical signs were tested by six criteria and two provocation tests. In 11 % patients clinical suspicious was wrong. Best agreement with MR-Arthrography was found for "knife sharp" groin pain (100 %), impingement test (100 %) and painful giving way (83 %). 35 % of patients showed minor (grade 2) and 52 % severe (grade 3 and 4) dysplasia. Independent from grade of dysplasia, no or only slight arthrosis (grade 0 and 1) was found in 64 % of patients. In 16 % a single acetabular cyst could be detected on radiographs, which all could be identified as intraosseous ganglia on MR-Arthrography. Labral lesions type A (post traumatic) were found in 23 % of the patients with only no or minor dysplasia (grade 1 and 2), whereas labral lesions type B (dysplastic) were found in 67 % of the patients with severe dysplasia (grade 3 and 4). Clinical signs for labral lesions are typical but can also be observed in other pathologies of the hip joint. Based on the findings of this study, we recommend radiographic evaluation for dysplasia and MR-Arthrography in patients with clinical suspicion for labral lesions of the hip joint.

[Labrum lesions in residual dysplasia of the hip joint. Biomechanical considerations on pathogenesis and treatment]

The capsular-labrum-complex consists of the triangular fibrocartilaginous labrum, which is fixed at the bony acetabular ring and supported by the ligamentum transversum actetabuli in the caudal part. In a normally developed and correctly orientated acetabulum, the femoral head is symmetrically covered by the contact area of the lunate surface. The vertical component of the resultant hip joint force concentrically meets the horizontal weight bearing surface: Evenly distributed compressive forces are transmitted; the capsular-labrum-complex does not have to compensate excessive shear or tension. In contrast, in a "dysplastic" acetabulum the femoral head is poorly covered by the pathologically orientated lunate surface: The lunate surface is sloping in an anterolateral direction, leading to tension and shear on the superolateral capsular-labrum-complex, which becomes a secondary stabilizer ("guide rail") against the decentering femoral head. The vertical component of the resultant hip force eccentrically meets the oblique weight bearing surface, causing extra stress in the labrum: The capsular-labrum-complex is trying to compensate this biomechanical stress with hypertrophy (Type IB). Progressive mechanical decompensation of the capsular-labral-complex might lead to tears (Type IIB) or complete avulsions (Type IIIB) of the labrum. In conclusion labral lesions result from pathobiomechanics caused by residual hip dysplasia (RHD). Logically, the basic therapeutic principle can only be corrective osteotomy.

[The Donauspital-Stolzalpe concept (Danube Hospital, Vienna, Austria). Corrective osteotomy with selective labrum surgery following preoperative MRI arthrography]

Concomitant pathologies (labral lesions, intra-/extra-osseous ganglia and stress bone marrow edema) in adult residual hip dysplasia (RHD) might influence the outcome of conservative hip surgery. The aim of our prospective clinical study was to assess the value of preoperative MR arthrography in diagnosing concomitant lesions and in making surgical decisions in RHD. The first 37 consecutive patients with a minimum follow-up of 18 months have been analysed. All 37 patients presented RHD with the clinical symptomatology of labral lesions and underwent routine preoperative MRA. According to clinical, radiological and MR arthrographical criteria, these 37 patients were subdivided into four therapeutic subgroups: (1) reorientation of the acetabulum using the Tönnis triple pelvic osteotomy (TPO); (2) intertrochanteric varisation osteotomy (IVO); (3) palliative decompression with only symptomatic partial resection of the torn labrum (PALL); (4) primary total hip replacement (TEP). Based on the preliminary clinical and radiological outcomes of these four subgroups, the following conclusions can be drawn: labral lesions are considered to be a sign of chronic joint instability. Therefore, acetabular malorientation should be corrected by redirectional osteotomy of the acetabulum (TPO-subgroup) even in low grades of RHD if labral lesions are present. "Palliative" labral resections without corrective osteotomy (PALL subgroup) in secondary osteoarthritis due to RHD are definitively obsolete, because they rapidly progress to severe osteoarthritis due to surgically accelerated joint instability. In RHD with highly osteoarthritic hip joints and concomitant lesions, one should not hesitate to perform primary THR even in young patients.

[MRI arthrography in labrum lesions of the hip joint. Method and diagnostic value]

Magnetic Resonance imaging with its excellent soft tissue contrast represents the method of choice for examination of intraarticular and periarticular structures of joints. However, conventional MR-imaging without intraarticular contrast application is not suitable for the diagnosis of labral lesions. MR-arthrography (MRA) of the hip clearly demonstrates labral pathology by distension of the joint space and entrance of the contrast medium into the lesion. Multiplanar 3-D-gradient echo sequences enable visualisation of the most important cranio-ventral portion of the labrum. With the MRA labral lesions can be subdivided into different, clinically relevant stages. Furthermore accompanying lesions (intra- and extraosseous ganglia, stress-bone marrow-edema) can be demonstrated. In our study including operatively verified cases, MRA showed excellent sensitivity (90%) and accuracy (91%) in detecting labral lesions. So far no complication occurred with more than 100 MRA's. Therefore this technique represents the method of choice for the radiological evaluation of labral lesions of the hip joint. In this review the technical details and results of our MRA method will be presented.

[Clinical and diagnostic imaging of labrum lesions in the hip joint]

Labral lesions are common findings in residual hip dysplasia, indicating biomechanical decompensation of the hip joint. MR-Arthrography has shown an excellent accuracy of over 90% to detect these lesions. Nevertheless, so far clinical sings, radiological diagnosis and therapeutical consequences are not well known. In a prospective study, patients suspicious for labral lesions were evaluated using a standard clinical protocol, including history, clinical signs, radiography and MR-Arthrography. Clinical signs were tested by six criteria and two provocation tests. In 11% patients clinical suspicious was wrong. Best agreement with MR-Arthrography was found for "knife sharp" groin pain (100%), impingement test (100%) and painful giving way (83%). 35% of patients showed minor (grade 2) and 52% severe (grade 3 and 4) dysplasia. Independent from grade of dysplasia, no or only slight arthrosis (grade 0 and 1) was found in 64% of patients. In 16% a single acetabular cyst could be detected on radiographs, which all could be identified as intraosseous ganglia on MR-Arthrography. Labral lesions type A (post traumatic) were found in 23% of the patients with only no or minor dysplasis (grade 1 and 2), whereas labral lesions type B (dysplastic) were found in 67% of the patients with severe dysplasia (grade 3 and 4). Clinical signs for labral lesions are typical but can also be observed in other pathologies of the hip joint. Based on the findings of this study, we recommend radiographic evaluation for dysplasia and MR-Arthrography in patients with clinical suspicion for labral lesions of the hip joint.

Lesions of the acetabular labrum: accuracy of MR imaging and MR arthrography in detection and staging

PURPOSE

To determine the accuracy of magnetic resonance (MR) imaging and MR arthrography in the detection and staging of lesions of the acetabular labrum.

MATERIALS AND METHODS

Fifty-seven hips of 56 patients with chronic hip pain and a strong clinical suspicion of labral lesions were examined with a three-dimensional gradient-echo sequence in the coronal oblique and sagittal oblique projections before and after the intraarticular injection of gadopentetate dimeglumine. The labra were evaluated on the basis of morphology, signal intensity, the presence or absence of a tear, and their attachment to the acetabulum. Twenty-two of the hips underwent surgical intervention, and 35 hips were treated conservatively.

RESULTS

Twenty of the 22 labra with surgical proof were staged accurately with MR arthrography. On the conventional MR images, only eight of the 22 labra were staged correctly. Whereas the sensitivity of MR arthrography was 90% and its accuracy was 91%, the sensitivity of MR imaging was 30% and its accuracy was 36%, compared with surgical findings.

CONCLUSION

MR arthrography enables accurate detection and staging of lesions of the acetabular labrum and appears to be indicated in the assessment of chronic hip pain in patients with a strong suspicion of labral lesions.

[Use of a dynamic balance for standardized imaging technique in entire roentgen images of the spine of children in the upright position]

INTRODUCTION

Malposture can simulate deformities of the spine in non-standardized X-rays of the spine.

MATERIALS AND METHODS

A balancelike positioning device was developed in order to avoid "pseudodeformities" because of the patient's malposture while an X-ray of the spine was being taken. A comparative pilot study (100 patients) was performed and about 3,000 X-rays of the spine were taken routinely using the positioning device.

RESULTS

The clinical examination and radiological findings did not agree, a second X-ray was taken using the balancelike positioning device. One-third of those patients had much better findings with the balance, one-third slightly better results, and one-third revealed no significant improvement of the malposture in the X-ray film compared with the initial X-ray without the balance device.

DISCUSSION

Comparable X-rays of the spine can only be taken if posture during the procedure is defined and reproducible. "Casual" posture and "standardized" posture differed in more than two-thirds of our comparative pilot study (n = 100). The findings with a balance device were never inferior compared to the X-rays taken without it.

CONCLUSION

A simple balancelike positioning device can help to standardize X-rays of the spine when the patient is standing, providing better reproducibility, more accurate prognostic aspects and fewer ionizing hazards.

[Maturation curve of the ultrasonographic alpha angle according to Graf's untreated hip joint in the first year of life]

In addition to Graf's classification into different hip-types a maturation-curve of the sonographic alpha-angle was established in order to optimize the differentiation between mature hip joints and those ones which need follow-up and those ones which need treatment at any time within the first year of life. The results obtained are confirming our present knowledge about the spontaneous maturation of physiologically immature hip joints: The mean-value of the alpha-angle crosses the 60 degrees-borderline at about the age of two months, then reaches an about 64 degrees-level at about four months. This 64-degrees-level is more or less unchanged up to the end of the first year of life.

[Sonography of the infant hip. Sources of error, progress and current clinical relevance]

Effective prevention of late dysplastic dislocation of the hip (DDH) has become a reality since reliable diagnosis has been possible at an early stage by means of the original sonographic method according to Graf. A correct sonographic diagnosis must be instantly followed by adequate, biomechanically rational, and consistent therapeutic management and long-term follow-up. The results of a strictly comparative follow-up study emphasize the enormous progress in the quality of therapeutic results gained when routine sonographic newborn hip "screening" is performed directly in the maternity wards: successful anatomical healing with conservative treatment is regularly obtained without femoral head necrosis, without surgery and without late DDH, and costs less when sonographic assessment is done within the first days of life. For this reason, the Austrian government has included sonographic neonatal hip screening in its general health prevention program-and also reimbursed the cost of this preventive procedure-since 1992.

[The effect of ultrasonography screening of hips in newborn infants on femur head necrosis and the rate of surgical interventions]

We compared two similarly sized groups of sonographically unstable or decentered hips with comparable initial findings, both treated by standardized conservative primary treatment. The results show that an early definite diagnosis improves the prognosis. If built on a secure initial diagnosis rationally grounded and efficient conservative therapy can be initiated and followed through on. Since the treatment is started extremely early, the hip can benefit from the considerably greater potential for spontaneous development present in the first three months of life. In this way we can shorten the treatment time considerably and also complete it at a younger age. Finally, early treatment also reduces the risk of the complication of necrosis of the femoral head and significantly decreases the rate of surgical procedures. Only a sufficiently well executed and comprehensively organized sonographic neonatal screening program can produce a definite very early diagnosis and with it almost 100% successful early treatment of all grades of disturbances of hip maturity. Sonographic screening of the newborn is a very important piece in the jigsaw of prophylaxis and primary prevention in our public health care program.

[Ultrasonographic anatomy and ultrasonographic assessment of the transverse arch of the foot]

A new and original sonographic technique to document the morphology of normal feet and splay feet is presented: a standard sectional plane cuts the transverse arch from the plantar side using the sesamoids of the first metatarsal bone and the head of the fifth metatarsal bone as reference points. A 5-MHz linear transducer and a rather simple custom-made platform with an integrated gel-pad are required in order to get reproducible results. The morphology of the transverse arch can be characterized by the "transverse arch index Q" as the parameter of the relative height of the transverse arch. Based on this transverse arch index Q, splay feet can be distinguished from normal feet in a statistically significant way (p < 0.01). Furthermore, grading of splay feet is possible and a documentation of rigidity/flexibility of the forefoot in splay feet; thus, the decision on whether to use conservative or operative treatment can additionally be based on sonographic documentation, and the results of surgical reconstruction of the transverse arch can be checked and documented sonographically.

[Sonographic screening of neonates' hips. Analysis of the years 1986-1988 and comparison with 1977-1979]

Establishing a sonographical neonate hip screening program in three nearby counties has made us able to simplify our management in socalled "congenital dysplasia of the hip". Earliest diagnosis has led to a percentage of conservative treatment of 95% and therefore to a reduction of surgical interventions and less inpatient treatment. Our results force us to urge a state covering sonographical neonate hip screening done by educated specialists (Orthopaedic surgeons, Paediatricians, Radiologists).

[Sonographic neonatal screening of the hip joint--luxury or necessity?]

Based on the ultrasound investigation of 19,666 babies (1981-1988), 6341 of them directly at the maternity ward, we picked out the group of sonographically unstable or decentered hip joints, which must be treated instantly. Almost 50% of these hips did not show any clinical signs of instability! At follow-up the subgroup of sonographically screened hip joints showed optimal results after consequent earliest treatment: 100% physiological results of CE-angle (Wiberg and Engelhardt), no femoral head necrosis. Ultrasound screening is the only tool to detect definitely all newborn hips requiring therapy. Earliest treatment is the pre-condition of anatomical healing up. Thus--a general sonographic newborn screening is indispensable.

[Does the IIa hip need treatment? Results of a longitudinal study of sonographically controlled hips of infants less than 3 months of age]

In a randomized retrospective study we followed hips classified as Type II a by ultrasound. The classification as "Type IIa" only was found inadequate. It is important to further differentiate the so-called physiologically immature hip, namely to distinguish between joints that, while immature, are appropriate for age [Type IIa(+)], and those hips with a maturation deficit exceeding a tolerable degree [Type IIa(-)]. The follow-up showed that hips classified as Type IIa(-) and treated before the age of 6 weeks had a clearly better healing result than the hips treated only after the sixth week. Thus, to achieve optimal healing and to keep to a minimum the dysplasias requiring treatment after 3 months' age, an ultrasound study of the hip should be done as early as possible. The total percentage of ultrasonically recognized abnormal joints requiring treatment (independently of the patient's age) was 6.6%. This corresponds to the regional average before the advent of ultrasound. However, because of extensive very early screening in our area, we found not a single hip dislocation later then at the age of 10 weeks during the last 2 years.

[A partial weight-bearing lower leg walking prosthesis in the rehabilitation of infected post-traumatic lower leg pseudoarthrosis]

The case reported here is certainly not generally applicable. However, the authors believe that the therapy described, with an orthotic device of this type, represents a possible alternative for appropriately selected, compliant patients.