Introduction: Previous investigation showed that joint distraction (arthrodiastasis) is able to reduce intraarticular pressure and to have a positive effect on the regeneration of bone and cartilage on both sides of the joint. Many reports have been published about the results of arthrodiastasis in the treatment of femoral head necrosis in young children, pointing out good reconfiguration of the femoral head and improved range of motion. In contrast to that, -to our knowledge- there is so far no study showing the effect of hip joint distraction in older children with femoral head avascular necrosis.

Question: In the present study the outcome of the treatment of femoral head avascular necrosis in older children by hip joint distraction was investigated.

Methods: The hip joint distraction method was performed in three patients with necrosis of the femoral head. The causes of avascular necrosis were: Late onset Perthes’ disease in two patients and slipped capital femoral epiphysis (ECF) in one patient. The average age of the patients was 13.4 years. They all suffered from persistent severe pain and mostly limited range of motion of the hip joint. The plain radiographs revealed a Catterall IV, Herring C stade in both patients with late onset Perthes’disease. In the radiograph of the ECF patient a severe deformity of the femoral head was visible. After intraoperative soft tissue release, joint distraction was performed with an Ilizarov-ring fixation and immediately distracted 4–5 mm under image control. Distraction was continued 1 mm per day until the Shenton line was overcorrected. At this time the fixator was changed so that flexion-extension exercises were encouraged with the fixator in place. The patients were kept non-weight bearing. After 4 weeks the fixator was changed, so that in addition abduction up to 30° was possible. In total fixator duration time was 3.5 months. (In one case due to a fracture, the fixator was left for further 3 months) During distraction period with the fixator two patients suffered a femoral fracture without a causal adequate trauma.

Due to these major complications further investigations on additional patients have been stopped.

Results: The outcomes after 2.5 years showed in two patients an ankylosis of the hip joint with adductionflexion contracture and radiographical no reshaping of the femoral head. The third patient had a poor range of motion while radiographic findings showed a good reconfiguration of the femoral head. Nevertheless even in this patient advanced arthrosis was evident.

Conclusion: In conclusion, due to the major complications and the unsatisfactory “middle-term”-results, arthrodiastasis as a therapy of avascular necrosis of the femoral head in older children has failed in our study. In our opinion fracture was as a result of immobilisation osteopenie.

A slipped capital femoral epiphysis (SCFE) can be fixed in-situ with K-wires or screws. For the latter is said that one disadvantage is the lack of femoral neck growth. Assumed reasons for this is despite an injury of the physis by the often too long thread the missing lubrication of the screw in the bone.

The following study evaluates the amount of remaining bony growth and method-depending complications in screw fixation of SCFE.

Method: All children with titanium screw fixed SCFE and completed growth were evaluated retrospectively. For percutaneously fixation a cannulated titanium screw (Fa. Firma Königsee) was used. With help of the postoperative X-ray follow-up in two dimensions the remaining bony growth was assessed. Further parameters were possible complications like AVN, misplaced screws, problems in removal of the screws and duration of surgery.

Result: 40 patients with 49 SCFEs were treated bilaterally with cannulated screws in the time period 1999 to 2005, 4 got an additional closed reduction. In 6 cases a correction osteotomy was performed. The contralateral hips off these patients were enclosed in the study. The average growth of the femoral neck was 6 mm both at the healthy and SCFE-hip (Range 0–19mm) and depended not on the degree of dislocation. None had a premature closure of physis. In 2 cases screws were changed due to excessive growth despite a growth reserve in screw length of 1 cm. 1 acute and 4 of 7 acute-on-chronic slips developed a clinically relevant AVN.

In 20 patients we tried to remove the screws after completed growth. This was possible in 30% minimal invasively and in 30% with open surgery. In 40% parts of the screws or even the whole screw remained in situ. Time of surgery for bilateral screw pinning was 51 minutes, for removal 91 minutes in average (34–278).

Discussion: The percutaneously fixation of SCFE with cannulated screws is a save and easy procedure that allows further bony growth of the femoral neck and remodelling but is more than difficult to remove the titanium screws due to bony integration. One screw is sufficient for fixation, secondary dislocation does not happen. We recommend the use of cannulated steal-screws with a backward incisive thread. Titanium screws should be used only in cases of a high risk of AVN to allow the early control of femoral head blood flow with MRI.

Aim: During periods of rapid growth hip diseases can deteriorate unexpectedly. This retrospective evaluation should determine standard values that might allow earlier determination of such growth disturbances and a better classification of almost normal findings.

Methods: 520 standardized made and normal pelvis x-rays of children aged 4–16 years were examined under respect to the development of the hip and pelvis itself (20 x-ray pictures per age-group and gender). Among others these parameters were assessed: acetabular index (AC) and ACM-angle, acetabular width, depth and length, width and altitude of the epiphysis, transverse pelvic diameter and pelvic altitude.

Results: At the age 6–14 years boys have a higher ace-tabular index and ACM-angle than girls. The acetabular index decreases up to the age of 15 to 10 in average, the ACM-angle up to the age of 9 years to 47 in boys and 45 in girls to be subsequently constant. The bony acetabulum grows concentrically and spherically in form and slower than the femoral head. The acetabulum of girls is deeper, smaller and stops growing at the age of 14. The pelvic growth proceeds with the exception of iliac width in girls up to the age of 16.

Conclusion: Due to an age depending mechanical load of the femoral head on the acetabulum a mild DDH can develop to severe pathology in times of rapid growth. With the found normal values and its variations it is easier to assess the development of hip joints especially in such cases.

Purpose: To evaluate the vascularisation of the femoral head in children with slipped capital femoral epiphysis (SCFE) before and after surgery with use of contrast-enhanced MRI

Methods and Materials: 20 consecutive children, 13 boys and 7 girls, aged 9–15 years, with slipped capital femoral epiphysis, were included into the study. The classification of SCFE was performed traditionally due to the patient’s history, physical examination and findings of the radiographs. There were no pre-slips, 9 children had acute, 5 children had acute-on-chronic and 6 children had chronic SCFE. The MRI-examinations were performed in a 1.5 Tesla MR-scanner with use of the body coil and all postoperative MR-examinations were carried out within 4 weeks after surgery. The examination protocol included a coronal fat-suppressed STIR-sequence, a coronal contrast-enhanced T1-weighted spin-echo sequence and a sagittal 3D-gradient-echo (FFE) sequence. Morphology, signal intensities and contrast-enhancement of the femoral head were assessed retrospectively by two experienced radiologists in consensus.

Results: Morphologic distortion of the physis, bone marrow edema in the metaphysis and epiphysis and joint effusion were the preoperative MRI-findings of slipped capital femoral epiphysis in each child. In 17 children, who underwent in situ-fixation with a single screw, and in one child, who underwent open reduction of the epiphysis, the vascularisation of the femoral head before and after surgery was normal. An avascular zone in the posterior-lateral aspect of the epiphysis was visible preoperatively in one child, which completely revascularized after open reduction and internal fixation of the epiphysis with two screws. One child with severe SCFE developed avascular necrosis of the femoral head after open reduction and corrective osteotomy through the physis.

Conclusion: MRI allows for accurate evaluation of the femoral head vascularisation before and after surgery in children with slipped capital femoral epiphysis.

Aim: Since the thalidomide-catastrophe in the 50th and 60th the sensibility for children with limb defects has become important in the population. Besides the incidence of limb defects, the aetiology of limb defects is a very important question.

Method: Like the ESPED-Model (Documentation of rare paediatric diseases in Germany) we send every three months a letter to 1073 gynaecological clinics to ask the number of live and still births and the number of limb defects. If there are limb defects announced, a second letter is send to ask details about pregnancy, birth and family. The limb defects are registered after the ICD-10-classification.

Results: Time of registration: 48 months (April 2000 – April 2004). Number of all registered births: 1070541, number of live births with limb defects: 1534 (0,14%), number of still births with limb defects: 55 (1,7%), minor limb defects like polydactyly (22,4%) are more often than major defects of the tibia (1,0%) or of the fibula (1,6%), hereditary in 9,7%, no correlation to the profession of parents or their age, no correlation to nicotine abuses, nothing special concerned pregnancy (amniocentesis in 3,3%, oligohydramnie in 0,5%, etc.) and birth (caesarean section in 29%, etc.).

Conclusion: It is very important to continue the registration of limb defects in Germany to terminate the number of incidence of the different types of limb defects and to define there aetiology.

Aim: In Germany an ultrasound screening for CDH is recommended for all children in the þrst 6 weeks of life. We evaluated this program together with the German Association of health insurance carriers over þve years to show if an early ultrasound of the hip can reduce the number and the required operative procedures of children with CDH. Methods: From 1997 to 2002, we documented monthly all otherwise healthy children with CDH aged ten weeks up to þve years in all German orthopaedic paediatric departments with a registration card and questionnaire. Results: Overall we registered 645 children, 534 with single operative procedure. 68% received a closed reduction of the hip, 11% open, while 21% required an osteotomy of the acetabulum and/or femur. The percentage of the single operative procedures did not change over the years. The number of children, who underwent no ultrasound of the hip before diagnosis decreased from 20% in the þrst year to 10% in the last. The þrst ultrasound examination revealed no pathological þndings in 20% of the cases. Children received the þrst screening more and more at the age four to six weeks than during the þrst days of life. Nevertheless, the yearly number of cases declined by 50%. Conclusion: Despite the ultrasound-screening-program late or undiagnosed CDH still exists in our country. A possible reason can be the quality of ultrasound examination, the form of treatment as well as a later worsening of CDH and the so-called endogenous dysplasia.

Aim: In Germany an ultrasound screening examination to determine CDH is recommended for all children in the first 6 weeks of life. We evaluated this ultrasound-screening-program together with the German Association of health insurance carriers over five years to show if an early ultrasound of the hip can reduce the number and the required operative procedures of children with CDH.

Methods: From 1997 to 2002, we documented monthly all children with CDH aged ten weeks up to five years from all German paediatric orthopaedic departments with a registration card and questionnaire. Children with neuromuscular diseases or teratologic dislocation of the hip, enrolled in out-patient treatment programs, as well as children born abroad were excluded.

Results: Overall we registered 645 children, 534 with single operative procedure. 68% received a closed reduction of the hip, 11% open, while 21% required an oste-otomy of the acetabulum and/or femur. The percentage of the single operative procedures did not change over the years. The number of children, who underwent no ultrasound of the hip before diagnosis decreased from 20% in the first year to 10% in the last. The first ultrasound examination revealed no pathological findings in 20% of the cases. During the five years children received the first screening more and more at the age four to six weeks than during the first days of life. Nevertheless, the yearly number of cases declined by 50%.

Conclusion: Despite the German ultrasound-screening-program late or undiagnosed CDH still exists in our country. A possible reason can be the quality of ultrasound examination, the form of treatment as well as a later worsening of CDH and the so-called endogenous dysplasia. The aim must be the improvement of diagnosis and treatment.