Background

Several risk factors for the development of osteonecrosis following treatment of developmental dislocated hip have been reported. The need for further research with a large-enough sample size including statistical adjustment of confounders was demanded. The purpose of the present study was to find reliable predictors of osteonecrosis in patients managed for developmental dislocation of the hip.

Surgical treatment of infected bones with vascularised bone grafts is well established as an efficient strategy since several years. Nevertheless orthopaedic and trauma surgeons seem to apply vascularised bone grafts as the last treatment option only.

Two strategies exist for treatment of chronically infected bones with vascularised bone grafts. First: Complete resection of the infected, often non-united part of the bones and reconstruction with large vascularised bone grafts, mostly fibular grafts. Second: Augmentation of the kept and intact parts of the bones with vascularised bone grafts. Two small series of patients are presented to illustrate both techniques and to show the results and outcome.

Resection of big parts of the tibia and reconstruction with mostly ipsilateral fibular grafts – single barrel in children and double barrel in adults – led to uneventful healing in all cases. Augmentation of radius, femur and calcaneus with vascularised grafts from the iliac crest or the scapula was followed by primary healing, too. All patients were disburdened from infection up to now and regained full extremity function.

The presented vascularized bone grafts did not only salvage the extremities but also could maintain their functionality. The procedure is demanding, but reliable and safe at a low rate of complications. Thus vascularised bone grafts should not only be used as ultimative salvage procedures, but as early as possible whenever standard treatments for osteomyelitis fail.

Introduction: Bone defects in septic cases can be caused by the septic process itself or by resection of bone segments. For the budging of segmental defects, segmental bone transport is an alternative method which has been used at our department since 16 years.

For the surgical reconstruction of bone defects there are several options:

Method: Segmental consists of removing all dead bone, then stabilizing the limb by the use of an external fixator and to perform a corticotomy at the proximal or distal metaphysical area followed by bone segment transport, by gradual distraction.

Gradual distraction stimulates active bone regeneration and due to increased vascularisation also healing of the chronic infectious process. The mechanical lengthening device must insure stability.

As soon as both bone ends get into contact a docking manoever has to be performed to remove soft tissues between the bone ends and to stimulate healing by drilling of the bone ends with a k-wire and eventually adding cancellous bone grafts.

The external fixator is kept in place until full bone consolidation is accomplished.

Segmental bone transport can be performed by using monolateral fixators, by intramedullary nails (e.g. fit-bone) and by circular frame fixators like the conventional Illizarov or the new Taylor Spatial Frame.

Our preferred technique is the Weber cable technique with TSF which allows an ideal guidance of the segment to the docking site without cutting through the skin.

Results: At the paediatric orthopaedic department of the Speising hospital Vienna we have treated 32 cases of septic bone defects using different types of external fixators, segmental transport and also external fixation in combination with vascularised fibula transfer.

In all but 2 cases fusion and healing of chronic infection of bone and soft tissues could be achieved. In the 2 cases which could not be treated successfully an amputation had to be performed.

Conclusion: The treatment of segmental bone defects using external fixation and segmental bone transport has proved to be very effective. Gradual distractions of living tissues creates stresses which increase the blood supply and stimulate not only bone healing but also the healing of infection.

Introduction: Congenital clubfeet have increasingly been detected in routine prenatal ultrasound. However, many clubfeet are still missed and surprise the mothers at birth. The complex deformity and different treatment options available seem to make prenatal counseling desirable. Despite published studies on prenatal clubfoot diagnosis by ultrasound, it is unknown if mothers would indeed prefer to know about their child’s clubfoot before birth or not.

Methods: This survey included patients born between 2000 and 2007 who were treated for congenital clubfoot at one of the two participating institutions (center one: East coast USA; center two: Austria). Exclusion criteria were defined as underlying syndrome, genetic abnormality or pregnancy with multiple fetuses. A brief survey about the opinion of mothers towards ultrasound diagnosis of clubfoot consisting of three questions was sent out. A computer database was created for data collection and a statistic analysis was performed.

Results: Surveys were sent out to 401 mothers of patients meeting inclusion criteria. A total of 220 surveys were received back with 105 surveys from center one and 115 surveys from center two. In 97 cases the clubfoot was unilateral and in 123 cases bilateral. Routine ultrasound showed a clubfoot in 91 cases (41%) and failed to show the deformity in 128 cases (59%). The detection rate in center one was 60% compared to 25% in center two. Bilateral clubfeet had a detection rate of 53% whereas unilateral clubfeet had a detection rate of 29%. Between 2000 and the end of 2003 the overall detection rate was 31% versus 50% between 2004 and the end of 2007.

Overall 74% of mothers wanted to know about their baby’s clubfoot before birth and 24% after birth. Of the 91 mothers who had a positive ultrasound 96% wanted to know before birth. Of the 128 patients who had a negative ultrasound 59% would have wanted to know while 38% did not want to know about the clubfoot prenatally. In center one 89% of mothers wanted to know before birth versus only 60 % in center two. Comments on the survey form showed that mothers who had or wanted to have the prenatal diagnosis appreciated the time to prepare and to find out more about the condition and different treatment options. Many wished for more information at the time of prenatal diagnosis. Mothers that would prefer to find out about the clubfoot postnatally feared that the diagnosis would have affected the experience of the pregnancy.

Discussion: Although the detection rate increased over time there are still cases of clubfeet missed in the routine ultrasound, especially in center two where the rate of detection was low. Mothers in the US are more reluctant to know before birth than mothers in Austria which is most likely related to the differences in the two health care systems. Detailed information about the nature and treatment of clubfeet should be given at prenatal diagnosis.

Introduction: It has been proposed that rotational gait abnormalities in the normal child are usually reflections of the anatomic deformity. A decreased acetabular and femoral anteversion have been recognized as a predisposing factor for osteoarthritis of the hip and the McKibbin instability index was introduced to quantify this relationship. Additionally, an increased femoral anteversion has been associated with osteoarthritis of the knee. However, it is well known that compensatory factors influence the dynamic rotational profile during gait. We compared rotational computed tomography data with gait analysis to evaluate their correlation and to elucidate the influence of compensatory mechanisms.

Materials and Methods: In a prospective study conducted between 2001 and 2005 patients presenting with rotational malalignment were sent for 3D gait analysis. Main exclusion criterion was any kind of neurological affection. Patients in whom surgery was considered were referred to rotational computed tomography. The rotational alignment of the pelvis, hip and knee at different times during the gait cycle as evaluated in the 3D gait analysis was compared to the angular values derived from the rotational computed tomography for the femur and tibia and statistically analyzed and correlated.

Results: There were 12 female and 16 male patients with a mean age of 16 (± 9.7) years at the time of gait analysis. After a first evaluation of data 8 limb segments were excluded to increase the quality of data. The mean anteversion of the femur was 29 degrees (2 degrees of retrotorsion to 56 degrees of anteversion) and the mean tibial torsion was 31 degrees (1 to 66 degrees of external torsion). The calculation of the Pearson correlation showed that an increase of femoral anteversion resulted in an increase of pelvic range of motion. An increase of femoral anteversion resulted in an increase of the internal rotation of the hip. Highly significant correlations were found between the rotational–CT values for the tibia and the all parameters describing rotation of the knee. The determination coefficient was high for tibial torsion versus knee rotation (R2 = 0.64), but showed a low value for femoral anteversion versus hip rotation (R2 = 0.2).

Conclusion: The rotation of the hip as found in the gait analysis showed only weak correlation with rotational CT data. This is not surprising as the hips segment offers many possibilities for compensation. The torsion of the tibia was found to correlate very strongly with the gait analysis. The McKibbin index seems questionable as a prognostic factor for the individual patient in the light of a multitude of dynamic compensatory influences. Effort should be made to integrate the static instability index with dynamic gait analysis data.

Introduction: Temporary hemiepiphyseodesis allows correction of angular deformities of the lower extremities in children before the end of growth. The eight plate is an alternative to Blount staples with the theoretical advantage of a more minimal approach, less risk of loosening with subsequent need for a re-operation and less compression of the growth plate due to the tension band mechanism. We report our results and experiences with this new implant.

Methods: Between August 2005 and May 2007 we implanted 74 eight plates (Orthofix International NV, Netherlands Antilles) in 32 patients. An idiopathic valgus deformity was the indication in 20 patients, an idiopathic varus in 4 patients, and a malalignment due to other reasons like infection, syndrome-association or trauma was seen in 8 patients. For the first part of this study we evaluated intra–and postoperative complications in patients with a minimum follow-up after the operation of 3 months. For the second part of the study we evaluated the results of correction after removal of the plate and analyzed long-standing radiographs using the malalignment test.

Results: Twenty-three patients treated with a total of 52 eight plates were included into the first part of this study. The mean follow-up after implantation was 9,5 months (range:3,4–22 months). One patient suffered from a significant postoperative haematoma which resolved spontaneously after 2 weeks and two patients showed a limited range of motion of the knee joint postoperatively. In both patients the range of motion was completely restored after 10 sessions of physical therapy. No other complication was seen during follow-up. Up to now 25 eight plates in 12 patients with 18 lower limb segments were removed. The mean age of the patients at the time of surgery was 12,2 years(rang: 6 – 13). The x-rays of these 18 lower extremities were reviewed and the alignment was analyzed. The mean preoperative mechanical axis deviation was 30,6mm (range: 8-50 mm). After hardware removal the mechanical axis showed a mean deviation from the center of the knee joint of 0,2 mm medial (range: 6mm lateral to 5 mm medial). The mean duration of implantation was 8,3 months (range: 4 to 16 months). Overcorrection was found in 2 patients, while a lack of correction at the end of growth was seen in one patient.

Conclusion: The eight plate is a safe and effective implant for temporary hemiepiphyseodesis. Especially loosening or implant failure, both commonly reported with the use of Blount staples, was not seen in our case series. Due to the minimal invasive approach with the need to implant only one eight-plate vs. two to four Blount staples and the sizes of the plates available the indications may be spread to a wider spectrum of deformities and ages.

Introduction: Congenital tarsal coalition is one of the most prevalent (1–6%) anomalies of the hindfoot and midfoot. Its etiology is unknown. By definition there are boney, cartilaginous or fibrous brigdes between 2 bones of the hindfoot and midfoot, which are classified by their localization; the most common coalitions are calcaneonavicular (53%) and talocalcaneal (37%).

Patients and Methods: From 2001 to 2007 28 patients with 37 coalitions had surgery at the Orthopedic Hospital Vienna-Speising.

32 calcaneonavicular coalitions were surgically excised and an autogenous free fat graft was interponed to prevent a relapse. 1 calcaneonavicluar coalition also had an interposition of the extensor digitorum brevis after resection, while 1 calcaneonavicular coalition had lengthening of the short peroneal tendon in addition to excision and autogenous free fat graft. 1 calcaneonavicular coalition had to have an arthrodesis of the talocalcaneal joint.

From 2 talocalcaneal coalitions 1 had excision the other 1 talocalcaneal arthrodesis.

Both of the coalitions that had arthrodesis had short-leg plastercasts for 12 to 13 weeks.

For patients with bilateral coalition pedobarography was performed and the foot that had been treated compared to the untreated contralateral side. For these patients the AOFAS ankle and hind foot score and pain according to the VAS were evaluated.

Results: 22 coalitions that had had surgery were uncomplaining after intervention, including 1 patient who had had arthrodesis. 3 calcaneonavicular coalitions that had had excision and autogenous free fat graft had a relapse within 2 to 3 years. 2 of them had a revision and second-look excision of the bridge.

1 patient showed a suspicious relapse in MRI after excision of a calcaneonavicular coalition. 1 talocalcaneal coaltion that had had excision continued to have pain after surgery. Both patients did not want a revision.

1 patient who was treated by an arthrodesis of the subtalar joint had a fracture of the tibial head, where autogenous bone graft had been taken. Osteosynthesis of the tibia was performed.

4 patients had pain after excision of a calcaneonavicular coalition but could be relieved by conservative treatment.

For 5 patients adequate follow up is still pending due to short interval to surgery.

Pedobarography showed tendecies of improved pressure distribution of the treated feet that were not significant.

Conclusion: Excision and autogenous free fat graft should be first approach to surgery of symptomatical congenital tarsal coalitions for whom conservative treatment was not satisfying. When resected sufficiently the rate of relapse of the boney, cartilaginous or fibrous bridge is 7%. Depending on the patients age, the size of the affected area of the joint (50%) and secondary arthrotic changes of the joint an arthrodesis of the talo-calcaneal joint should be performed.

Background: Screening modalities in early detection of DDH remain controversial worldwide despite of universal accessibility to ultrasound and despite of encouraging preliminary results reported about the Austrian and German general ultrasound screening programs. The goal of our investigations was to provide a long time survey on effects following the introduction of the ultrasound exam in prevention of DDH and to proof its beneficial medical and economic effects as well as to analyze possible adverse effects, when utilized by a general screening.

Method: Nationwide data about ultrasound screening exams, sonographic follow up exams, frequencies of functional abductive treatment measures as well as hospitalizations due to DDH were requested by different Austrian health care providers. Through a representative recall over a time frame ranging partially back to 1980 a surveillance analysis is provided. The medical effectiveness of the screening was mainly assessed by the annual appearance of early late cases, representing open reductions (O.R.) upon the first two years of life. Other variables as the disease related incidence of age matched annual hospitalizations and the disease prevalence measured by non age matched hospitalizations in relation to the year specific population were analyzed. A cost benefit analysis was performed by comparing the treatment and diagnostic costs in the year before program start (1991) to the last year of surveillance (2004).

Results: Since 1980 the functional treatment rate has continuously been reduced from approximately 12 percent to 3.23 percent in 2004. Early late cases (O.R.) due to DDH have been also diminished to an international competitive rate of 0.13 per 1000 newborns, while other age specific early surgical interventions could be almost eradicated. Current additional investments of the program figure only 16.94 € per newborn and embody approximately 1370 € per detection of one affected newborn. Control exams are contributing to roughly 25% of the calculated costs.

Interpretation: By founding a nationwide program Austria has introduced a medically efficient screening modality to reduce early late cases and to limit treatment of DDH exposed children to less invasive measures by early diagnosis. In contrary to suspicions of possible adverse effects of such screening, overtreatment has been abandoned while the functional treatment rate has sunken to an acceptable level. Costs saving effects have been already realized on the treatment side. Further savings shall be realized by limiting an unacceptable rate of control exams.

Introduction: The Ponseti method has been adopted by many pediatric orthopaedic centers throughout Europe in the last years. The minimal invasive approach and the short duration of the active treatment phase have been the main reasons to change to the Ponseti method at our institution. We report the short term results of patients treated with the Ponseti method for idiopathic clubfeet and discuss experiences and pitfalls.

Material and Methods: From the end of 2002 on we have applied the treatment regime strictly as described by Ponseti himself. For this study we analyzed a group of patients comprising all patients treated for congenital idiopathic clubfoot according to the Ponseti protocol within the first three weeks after births. The need for open release surgery was the main outcome measurement in this group.

Results: Between December 2002 and July 2004 we treated a total of 59 clubfeet in 37 patients with the Ponseti method. Our patient population consisted of 14 female and 23 male patients. The mean Dimeglio score was 9.2 points (5–15 points). Using the Pirani score the mean midfoot score was 1.7 points (1–3 points), the mean hindfoot score was 2 points (0.5–3 points) and the mean total score was 3.8 points (2–6 points). Three feet in two patients were treated with Ponseti casting only (5 %) and did not need a percutaneous achilles tenotomy (pAT) or open release surgery. Fifty-two feet in 33 patients (88 %) were successfully treated with Ponseti casting and pAT. Four cases in two patients had to undergo a McKay Simons procedure (7 %). Thereby 93% of all cases were treated without open release surgery. Mean follow-up after the last cast was 7.4 months (3–16 months). A recurrence was seen in one patient representing two cases after about 8 months after pAT. The parents were non compliant with the abduction bar protocol and could not be convinced of the importance of the orthosis; a McKay Simons procedure was performed. No other cases of recurrence were observed during the follow up period.

Discussion: The Ponseti method should be applied as originally described, and especially, if more people are involved in the treatment, a standard treatment regime is desirable. As the compliance of the parents is a crucial factor, everything should be done to ensure that the treatment is made as easy for them as possible. Only if a full support for questions or problems with the casts and especially with the braces is available, a good compliance can be ensured. The minimal invasive approach utilized by the percutaneous tenotomy is the lead argument in favor of the Ponseti method. In cases of recurrence or residual deformity when open surgery is necessary, this secondary procedure is in fact primary surgery. Thereby the danger of massive scaring associated with limited range of motion, pain and disability after a second procedures is prevented.

Background: Congenital absence of the cruciate ligaments is a commonly associated pathology of the knee joint in congenital longitudinal deformities. We performed a radiological analysis and investigated gait patterns in patients with congenital absence of one or both cruciate ligaments.

Patients and Methods: Thirty-four knee joints in thirty-one patients with congenital longitudinal deficiency of the lower limb were evaluated. The cruciate ligaments and associated abnormalities of the bony configuration were evaluated on magnetic resonance imaging and tunnel view radiographs. A radiological classification is proposed. Gait analysis was employed to determine kinematic, kinetic and electromyographic data in 24 of these patients and the results were compared to an age-matched control group.

Results: We differentiated 3 main types of absence of the cruciate ligaments with typical associated changes in the femoral intercondylar notch (FIN) and the tibial eminence (TE). In type I (n=19) partial closure of the FIN and hypoplasia of the TE was observed in hypoplasia or absence of the ACL, in type II (n=7) these findings were aggravated by additional underlying hypoplasia of the PCL and in type III (n=8) absence of the FIN and a flat TE was observed in aplasia of both cruciate ligaments. The main findings in gait analysis were significantly increased flexion moment of the hip, increased flexion of the knee in midstance phase and reduced ankle power in comparison to the control group.

Conclusion: The knee joint with aplastic cruciate ligaments shows typical radiological changes, thus, one will be able to distinguish between aplasia of the ACL only or both cruciate ligaments by observing plain tunnel view radiographs. Our obtained data of the gait analysis revealed specific gait patterns as adaption to underlying aplasia of the cruciate ligaments.

Introduction: Cases of developmental dislocation of the hip occur after walking age because of late or missed diagnosis and failed conservative or operative treatment. Up to now there is no consensus on the treatment of DDH after walking age. The purpose of this retrospective study was to evaluate the results of operative treatment in DDH after walking age in our patient population and to describe the treatment strategies and operative techniques used.

Material and Methods: Forty-two patients presenting 54 cases of DDH after walking age were operated on in our clinic between 1985 and 1997. There were 34 female and 8 male patients, with an average age at the time of operation of 47 months (range: 14 – 151 months). The parameters studied were the type of DDH according to Ts, the preoperative AC- angle, the postoperative AC- and CE- angles as well as the radiological outcome using the Severin classification.

Results: Based on the Ts classification we found 18 cases of type II, 22 cases of type III and 14 cases of type IV dislocations. Each hip had an average of 1.4 operations. The average preoperative AC- angle was 38.2 degrees (range: 22–50) whereas the average AC- angle in the last radiographic follow up was 22.2 degrees (range:5–10). The statistical analysis showed that the AC angle at the last follow up was significantly (p< 0,001) smaller than in the preoperative radiographs. The classification according to Severin showed class I in 28 cases, class II in 15 cases, class III in 8 cases and class V in 3 cases.

Conclusion: Although our study presents the results after a mid-term follow up the radiological results favor our clinical experience that a single stage combined procedure consisting of open reduction, pelvic osteotomy as well as a corrective osteotomy within the proximal femur with subsequent shortening should be recommended.

Introduction: A growing number of pediatric orthopaedic surgeons have adopted the Ponseti method for the treatment of idiopathic congenital clubfeet. Ponseti himself does not recommend the standard use of radiographs but suggests that palpation alone should be used to assess the correction in infant clubfeet. Although ultrasound diagnostic techniques for evaluating the infant foot are on the rise, most orthpaedic surgeon still rely on native radiographs to objectify the course of treatment. The aim of our study was to elucidate the role of radiographs in Ponseti clubfoot treatment.

Material and Methods: From the end of 2002 on we have used the treatment regime as originally described by Ponseti. Only infants with idiopathic clubfeet treated within the first three weeks of life were included. Radiographs of infant clubfeet are taken in ap.- view and lateral view in maximum dorsiflexion. Radiographs were taken at presentation mostly for legal documentation, before tenotomy at about 6 to 15 weeks of age, and 1 week after the percutaneous Achilles tenotomy (pAT). The tibiocalcaneal angle (Tib.C.-angle), the ap.- talo-calcaneal angle (TC-angle) and the lateral talo-calcaneal angle (lat. TC- angle) were evaluated. The maximum dorsiflexion was evaluated clinically.

Results: Forty-seven feet met the inclusion criteria. The mean gain of the tibiocalcaneal angle after tenotomy was 15,08 degrees. The ap.- talo-calcaneal angle only showed a mean change of 2,57 degrees and the lateral talo-calcaneal angle changed 0,44 degrees. The dorsi-flexion was found to have gained 13,85 degrees after tenotomy. The values of the tibiocalcaneal angle (Tib. C.-angle) and the values for dorsiflexion (DF) before and after pAT showed a significant difference (p< 0.05). No significant difference was found for the ap.- talo-calcaneal angle (TC-angle) and the lateral talo-calcaneal angle (lat. TC- angle) before and after tenotomy.

Discussion: The results of our series indicate that the tib-iocalcaneal angle changes about the same amount as the clinical dorsiflexion does. The ap.- talo-calcaneal angle (TC-angle) and the lateral talo-calcaneal angle (lat. TC- angle) were not influenced much by the Achilles tenotomy in our series. This seems reasonable as cutting of the Achilles tendon mostly influences the calcaneous which is the endpoint of the tendon. The dorsal opening of the talocalcaneal joint is coupled with derotation of the talus and calcaneous in the ap.-view and is hardly influenced by pAT. Although the position of the calcaneous in the heel can be palpated and even quantified by the empty heel sign according to Pirani, radiographs are the only way to objectify the true anatomy.

Background: The aim of this study was to evaluate Ponseti’s method of clubfoot management objectively and quantitatively by using ultrasound.

Methods: 22 newborns with 39 club feet were studied sonographically. Ultrasound examinations of all club feet were performed three times during the treatment according to Ponseti: at birth (1st measurement), one day before performing the percutaneous tenotomy of the Achilles tendon (2nd measurement) and 3 weeks after the operation (3rd measurement). In order to prove sonographic changes during the treatment precisely and quantitatively four angles (TnCe, TnMT1e, CaCue, TTd) were measured.

Results: Statistical analyses by using student’s t-test were conducted. The results are expressed as the means SD. At the first measurement means for TnCe were 19,41 (SD 11,71), for TnMT1e 15,21 (SD 10,32), for CaCue -6,49 (SD 7,14) and for TTd 33,38 (SD 10,60). At the second measurement means for TnCe were -6,93 (SD 3,96), for TnMT1e -12,24 (SD 4,76), for CaCue -4,00 (SD 5,24) and for TTd 28,66 (SD 6,38). At the third measurement means for TnCe were -7,86 (SD 5,47), for TnMT1e -12,97 (SD 5,69), for CaCue -1,45 (SD 2,05) and for TTd 18,08 (SD 2,75). At the 3rd measurement all angles showed values within the 95% confidence intervals of normal feet. All differences approached high significance (p< 0,0001).

Conclusion: During the treatment of idiopathic club-foot according to Ponseti the sonographically obtained measurements showed a significant improvement of all angles. Therefore this ultrasound technique can be used to evaluate the Ponseti method objectively and to compare one treatment to another.

Classically Radioulnar Synostosis is corrected by rotation-osteotomy. Kanaya first presented a technique for “dynamic” treatment of the deformity. In our institution two cases were treated with a procedure according to Kanayas technique. A four and half year old girl suffered from bilateral radioulnar synostosis, thus presenting the classic indication for surgical correction at least of one side – in our right handed case the left side. A forteen year old boy suffered from radioulnar synostosis of his right upper limb. An increasing luxation of the radial head, causing pain and deformity and decreasing function of the elbow necessitated a surgical intervention. The procedure used was performed identically in both cases: Division of the synostosis and shortening-wedge osteotomy of the proximal radius as described by Kanaya. A deepithelialized fasciocutaneous flap was raised from the dorsum of the proximal forearm and rotated in a position between the separated bones. A cast was applied for six weeks.

Wound healing and consolidation of bones was achieved without problems in both cases. At a 12 months follow up the space between radius and ulna remained open, with no evidence of reoccurence of the deformity. Opening of the synostosis did not affect ellbow flexion and extension and produced an active ROM of about 30 to 40 degrees in pronation; both patients reached neutral position but did neither achieve passive nor active supination.

In our hands Kanayas technique was sufficient for bone separation and produced some active movement, but could not produce active supination. Investigation of the wrists did not reveal deformities of these joints. At the moment the reason for the lack of real supination is not clear. Actually this problem has to be solved to improve the technique to a real dynamic treatment of radioulnar synostosis.

Introduction: The knee joint in congenital longitudinal deformities of the lower extremity shows a large variety of pathological findings. Valgus deformity is found in most cases and is described as being juxta- articular. To describe the true anatomic pathology we performed a radiographic analysis of the knee joint in congenital longitudinal deformities.

Patients and Method: Between 1985 and 2001 we treated 102 patients presenting with congenital longitudinal deformities. Inclusion criteria for this study were diagnoses of fibular hemimelia (FBH) and/or congenital femoral deficiency (CFD), an age between 5 and 16 years, unilateral affection and availability of long standing X-rays, whereas bilateral affection or previous operations on the lower extremities were defined as exclusion criteria. Twenty-four parameters were defined on the femur and tibia respectively and a nomenclature was created. The mean values including standard deviation were calculated and we statistically compared the parameters of the affected to those of the non-affected knee. Furthermore, MRI scans of the knee joint of 20 of these patients were evaluated.

Results: Thirty- nine patients (19 female, 20 male) met the inclusion criteria. The average age at the time of evaluation was 8.87 years (3.1 SD). A combined deficiency of femur and tibia was found in 35 patients. The predominant diagnosis was CFD in 13, fibular hemime-lia in 13 and fibular aplasia in 9 cases. The anatomic lateral distal femoral angle (ALDFA) measured 75.4° (2.5 SD) on the affected, and 81.6° (1.6 SD) on the non-affected knee. The lateral distal femoral metaphyseal angle of the affected side and of the non-affected side showed no significant difference. The distal lateral femoral epiphyseal width (DLFEW) was decreased in the affected limb compared to the non affected limb, whereas the distal medial femoral epiphyseal width (DMFEW) of the affected and non-affected side showed only a minor difference. In the tibia we found no significant difference between the variables for the medial proximal tibial angle (MPTA) and for the medial proximal tibial metaphyseal angle (MPTMA) of the affected and the non-affected limb. A significant difference was found between the proximal lateral tibial epiphyseal width of the affected and the non-affected side. Analysis of the MRI scans revealed aplasia of the anterior cruciate ligament in 18 cases and aplasia of the posterior cruciate ligament in 8 of the 20 cases. The defect of ossification of the lateral tibial epiphysis as seen in plain X-rays is visible in the MRI scans as cartilage anlage. (Only the most important findings are summarized)

Conclusions: In our patient population only four patients had FBH or CFD but 35 cases presented combined defects; we assume that the femur is affected to some extent in almost all cases of FBH. The hypoplasia was only found in the lateral aspects of femur and tibia and was primarily located within the femoral epiphysis. The metaphysis was not or only minimally affected in the evaluated longitudinal deficiencies. Awareness of sagittal instability, due to ACL and/or PCL aplasia, is necessary to avoid subluxation or dislocation when lengthening procedures are performed.

Introduction: Although well-recognized in adults, RSD is rarely diagnosed in children. Management is still controversial and includes, mobilization and physical therapy, spinal cord stimulation, transcutaneous electrical nerve stimulation, steroids, tricyclic antidepressants, anticonvulsants, non-steroidal anti-inflammatory drugs, injections of calcitonin, vasodilators and calcium channel blocker or alpha-sympathetic blocker. In this study, we describe the treatment of RSD in children using Iloprost, a pros-tacyclin analog that mimics sympathicolysis. We report our treatment regime, the clinical course, complications and the outcome in our first seven patients.

Patients and Methods: Seven female patients with a mean age of 9 years (6 to 11 years) suffering from reflex sympathetic dystrophy (RSD) stage II were included in this prospective study. Inclusion criteria were RSD stage II – III, an age between 4 to 12 years, no previous operative procedures and duration of symptoms for a minimum of 6 months. Diagnosis of RSD was based on the presence of neuropathic pain, such as burning, dysaesthesia, paresthesia, and hypalgesia to cold, and physical signs of autonomic dysfunction such as skin cyanosis, mottling, hyperhidrosis, edema and coldness of the extremity. Treatment regime consisted of two infusions of Iloprost (IlomedinÒ, Schering AG, Germany) administered over 6 hours on two consecutive days. Additionally, all patients underwent physiotherapy as part of their inpatient treatment and were offered psychological counselling.

Results: One day after the last infusion, all seven patients were free of pain and full weight-bearing was possible. The side-effects of Iloprost were a headache in all patients and vomiting in two patients. Two patients relapsed, one 3 months and one 5 months after primary treatment. These two patients received a second series of infusions and were again free of pain within two days. During a mean follow-up period of 30 months all patients remained asymptomatic.

Conclusion: These preliminary results indicate that the treatment of RSD with Iloprost in combination with psychological counselling is a safe and effective treatment regime. Infusion therapy is a non-frightening procedure which may be an important factor considering the possible psychogenic etiology of RSD in children. Additional psychological counselling helps patients and their parents to develop coping strategies which may help to avoid relapses.

Introduction: The Taylor Spatial Frame (TSF) is a circular external fixator based on a hexapod system consisting of two carbon fiber rings connected with six telescopic struts. In conjunction with a software program the TSF allows for correction of deformities in 6 axis. After completion of the computer generated distraction plan a residual program can be used to correct any residual malalignment. Although the TSF received marketing clearance in 1997 and is used in specialized centers around the world, there is, up to date, only one MEDLINE report of two cases treated with the TSF. We present the results of 48 cases of limb lengthening and/or deformity correction using the TSF frame.

Patients and Methods: Between June 1999 and Septem-ber 2002 we implanted a total of 102 Taylor Spatial Frames (TSF). Only cases with a minimum follow up of 6 months after removal of the frame were included in our retrospective study. Thirty-six patients with a total of 48 TSF fixators met the inclusion criteria. The 23 female and 13 male patients had a mean age of 16 years (range:4-49). Eleven cases showed a post-traumatic deformity,13 cases a metabolic, 9 a congenital, 8 a osteodysplastic deformity and 7 showed various underlying pathologies. Seven TSF frames were implanted on the femur, whereas the remaining 41 frames were applied to the tibia.

Results: In 25 cases lengthening was the main treatment goal and in 23 cases the TSF was applied for angular or rotational deformity correction. The mean lengthening achieved in the group of patients treated was 40 mm (range: 20-70) and a mean healing index of 52.73 days/cm (28-105). In the patients who were treated to correct a deformity, the mean healing index was 159.69 days/cm (88-276). The highest mean healing index (178.91 days/cm) was found in patients where a metabolic disease was the underlying pathology, whereas patients treated for congenital lateral longitudinal defects showed the lowest mean healing index (53.25 days/cm). Complications included a superficial pin infection occurred in 66.6 % of the cases. There was no case of deep infection . Further complications were temporary postoperative sensory disturbance in 2 cases, premature consolidation of the fibula requiring re-oste-otomy in 2 cases, femoral fracture after removal of the frame in one case and dislocation of the frame with the need to change the position of a pin in another case. There were no hardware associated complications. A residual program was generated in 15 cases, 3 cases needed 2 and one case 4 residual programs to achieve the desired correction.

Conclusion: The healing index varied widely within our patient population. We assume that the healing index is not applicable to the correction of angular or rotational deformities with a lengthening less than 2 cm. The possibility of performing residual correction in all axis without the need to change the frame setup is a main advantage of the TSF and is very time saving during follow up examinations. Preoperative frame assembly is easy and fast compared to the standard Ilizarov system. A computer printed day-by-day prescription of strut adjustments makes it easy for the patient to perform the distraction and augments patient compliance.

Clubfoot is medically defined as luxatio pedis sub talo. The process of dislocation mostly caused by muscular imbalance results in bony deformities and soft tissue contractures, which in the majority of cases – even after meticulous conservative treatment – have to be corrected by surgery. In children before school age, surgical corrections should always address the main pathology. To achieve normal alignment of the fore and hindfoot, a complete reduction of the talus within the acetabulum pedis has to be done by soft tissue release.

Analysing the pathomorphology, a clubfoot is characterised by equinus, varus, forefoot adduction, and horizontal subtalar medial rotation. Regarding bony deformation, the medial side of the talus is narrowed by the navicular, the medial malleolus, and the fibrocartilage between. Growth expansion is limited on the medial side and there is more growth expansion on the lateral convex side, leading to external rotation of its body (~ 10-25°) and internal inclination of the neck (~30-50°). The calcaneus is internally rotated 20-30°.

Regarding joint dislocation, there is a displacement of the navicular medially and plantarward towards the medial malleolus. The cuboid bone usually follows the position of the navicular and dislocates gradually to the medial side.

Soft tissue contractures are located medially (Lacinate Lig., M. Add. hallucis, Spring Lig., talo navicular Lig., Master knot of Henry) and posterior (lat. fibulo calc. Lig, post. capsule of the ankle joint). There is also a shortening of muscles e.g. short plantar flexors, M. tib. post., M. flex. hall. longus., M. flex. digit. comm., M. tib. ant.

The method of treatment depends on the severity of a clubfoot, the preoperatively achieved results of conservative treatment, and how extensive a subtalar release has to be performed. If the navicular can be reduced conservatively, a posterolateral surgical approach is indicated.

A transversal incision is performed starting laterally at the calcaneal cuboid joint and ending medially below the medial malleolus. A dorso lateral release of the subtalar joint, Tendo Achilles lengthening, and dorsal release of the ankle joint is performed.

At the age of three to six months, it is possible to correct subtalar malalignment to move the calcaneus away from the fib. Malleolus by external rotation in relation to the talus (Mini Cincinnati technique). If the talonavicular and the calcaneo-cuboid joint are dislocated, a complete subtalar release has to be done in order to reduce the talo-navicular, calcaneo-cuboid and talo-calcaneal joint. To avoid overcorrection, the talo calcaneal interosseous lig. should be kept intact whenever possible (Mc Kay-Simons procedure). This type of surgery should not be performed before the age of six months.

The subtalar release technique described by McKay was introduced in our hospital in 1983. Since then, 362 clubfeet have been treated by the above-mentioned techniques: 249 by the Mini Cincinnati (Group 1) and 113 by the McKay-Simons procedure (Group 2). Age at the time of surgery ranged from 2 to 12 months in Group 1 and 5 to 52 months in Group 2.

In Group 1, the results were excellent in 42%, and good (residual forefoot adduction) in 49%. A second surgical intervention had to be done in only 9%. Regarding shape and appearance of the foot in Group 2, results were excellent in 46%, good in 38% and insufficient in 16% (overcorrection 3%, relapse 13 %). Concerning functional outcome, the feet of Group 2 presented much more stiffness than those of Group 1, which was also found pre-operatively.

The treatment of clubfoot is still a matter of controversy because of different severity of deformity and different treatment philosophies.

According to our experience, the McKay-Simons procedure has proved to be ideal for simultaneous correction of various components of the deformity from one single approach. In particular, correction of subtalar horizontal rotational deformity in the subtalar joint can be easily performed.

Based on the survey, the danger of damaging nerves, blood vessels, tendons and joint cartilages can be kept to a minimum by using the Cincinnati approach. In the majority of cases, the foot appears normal, moves without pain, and is flexible enough to enable the child to walk on his toes or heels and to participate in sportactivities.

Limitation of mobility is nevertheless the main problem of all extensive soft tissue procedures in clubfoot surgery, and it is not known at this time if this will cause subtalar osteoarthritis in early adulthood.

Complete subtalar release develops less osteonecrosis, fewer changes in the navicular, and less cavus and adductus than the use of other surgical techniques.

Overcorrection and poor functional results were seen in patients less than six months old at the time of surgery. We recommend that a complete subtalar release be delayed until the child is aged 6 to 12 months. Treatment should ideally be completed by the time the child is ready to walk.