We present the results of a prospective study about twenty-nine patients (thirty-two hips) with unstable slipped capital femoral epiphysis (SCFE), which were treated by indirect reduction and internal fixation of the epi- and metaphysis with 3–4 Kirschner-wires between 1990 – 1999.

Methods: The 29 patients with a mean age of 12,9 years were clinically and radiologically evaluated after a mean follow-up of 3 years applying the score of Heymann and Herndon and by different roentgenological parameters (CCD-angle, femoral head diameter, length of the femoral neck and sphericity of the femoral head). Compared to the uninvolved side in unilateral case, which all had prophylactic pinning, all patients showed overall a good subjective and objective outcome. The average slip angle of all 29 unstable SCFE patients (32 hips) was 31° with 19 (59,4%) mild SCFE (< 30°), 7 (21,9%) moderate forms (30–50°) and 6 (18,8%) severe slips (> 50°).

Results: According to the classification of Heyman and Herndon we had 18 excellent (62,1%), 9 good (31,1%), 1 fair (3,4%) and 1 poor (3,4%) results. None of the patients developed chondrolysis, but AVN occurred in one patient with complete and in one patient with partial involvement of the femoral head. The mean CCD-angle at the follow-up after skeletal maturity of the affected side was 133,3° in comparison to 135,9° of the non affected hips, indicating only a slight increase of varus position of the femoral neck of at average 2,6°. The mean length of the femoral neck of the affected hips was 64,5 mm in comparison to 70,8 mm of the not affected hips, thus a average difference of 6,3 mm. The neck/shaft-ratio between the affected and the not affected side was 0,88 (0,78 – 1,0). The mean femoral head diameter of the affected hips was 57,1 mm in comparison to 55,4 mm of the non affected hips. The radius quotient (RQ), measuring the relation of the femoral heads between the affected and the not affected hip was at average 103% (min 100 %, max. 114%). The sphericity according to Mose of the 58 hips (29 patients) treated by pinning with K-wires was normal (< 2mm) in 89,7% (52 hips), mild I°-aspheric (2–3mm) in 3,4% (2 hips), moderate II°-aspheric (3–4mm) in 3,4% (2 hips) and severe III°-aspheric (> 4mm) in 3,4% (2 hips).

Conclusion: As a standard in our institution we recommend the simultaneous transfixation of the epi- and metaphysis with Kirschner-wires in patients with unstable SCFE as therapeutic method for the involved as well as prophylactic for the uninvolved femoral epiphysis. Implants should not be placed in the anterosuperior quadrant of the femoral head and correct implant position has to be documented by the withdrawl maneouver using image intensifier during surgery. With this technique the slip could efficiently be stabilized, further slippage or any progression could be prevented and remodeling of the joint led to an optimal sphericity and improved femoral neck length at the end of growth, thus improving hip function. The rate of severe complications like AVN and chondrolysis was low in our prospective series (6,8% respectively 0%) compared to other series with different implants (screws, nails). There were no complications like implant failure or problems with hardware removal.

The goal of clubfoot management, regardless of the method applied, is still to improve function and form as close as possible to normal values. Since the final outcome of any therapy will only become evident at the end of growth, long-term follow-up studies are necessary to evaluate the results and methods. The aim of this study was to evaluate long-term results of corrective surgery for clubfoot deformity in a selected group of patients. Other congenital or acquired abnormalities like neuromuscular disease, arthrogryposis or others were excluded in order to identify the factors associated with the success or failure of the treatment.

A retrospective clinical and radiological study of 64 patients with 104 treated feet with a follow-up of 8 to 35 years (mean: 19.2 years) is presented. All of the patients were operated on by Scheel′s technique. In this technique the Achilles tendon was lengthened and combined with a dorsal arthrolysis. In some cases medial structures such as the tibialis posterior, long-toe flexors tendon sheaths and the medial ligaments of the talonavicular joint were released. A calcaneal traction was applied for four weeks and a plaster cast for six weeks.

The patients were grouped according to the duration of follow-up (< 10, 10–20 and > 20 years) and the results were compared. Clinical evaluation followed the criteria according to the McKay Score, a score of 180 from which points for sequela (either morphologic or functional) are subtracted.

There was an inverse relationship between the functional rating score and the length of follow-up. Acceptable results decrease over time as the patient approaches skeletal maturity. In the group with a follow-up of > 20 years, only 5% were rated as good, 34% as satisfactory, 28% as poor and 33 % as failure.

Radiographic evaluation of the last group showed marked deformities of the talus and navicular bones, as well as advanced osteoarthritis. The degree of bone deformity of the talus (flat-top-talus) and navicular seems to depend on the degree of persistent residual joint subluxation after surgery and contribute to the development of secondary osteoarthritis of the ankle and subtalar joint over time. Considering the goal of treatment is to restore form and function, assessment and approach of all the components of the individual deformity is required.

A complete subtalar release to realign the calcaneus to an externally rotated position is followed by a reduction of the talonavicular joint. To achieve full reduction, release of the calcaneocuboid joint is necessary because it is linked with the talonavicular joint.

Preliminary results of 89 congenital clubfeet treated with a complete subtalar release with an average follow- up of five years show 12.4% excellent, 41.6% good and 39.3% satisfactory according to the McKay-Score. The results of this series underlines the importance of careful and complete derotation and anatomic realignment of the talocalcaneonavicular joint complex in order to have a lifelong functional foot with the least amount of deformity and disability. The results of any treatment for clubfoot deformity should be judged after skeletal maturity, making a follow-up of at least 20 years necessary.

The objective of our research is to elucidate the pathogenesis of soft-tissue contracture. Here we present a comparison of collagens isolated from deltoid ligament of 23 clubfeet classified according to the Dimeglio-classification and of 14 matched controls of normal feet.

Collagens were isolated by acetic acid extraction and by limited pepsin-solubilisation and analysed by SDS-PAGE. Ligaments and solubilised collagens were analysed for their extent of hydroxylation of prolyl- and lysyl-residues, their content of galactosyl-hydroxylysine and glucosyl-galacto-syl-hydroxylysine and their content of lysyl-oxidase dependent cross-links histidinohydroxylysino-norleucine (HHL), hydroxylysylpyridinoline (HP) and lysylpyridinoline (LP). Analysis were carried out using an amino acid analyser (Bio-chrom 20, Amersham Pharmacia Biotech) and a reverse-phase HPLC system (Gynkothek).

Percentage of collagen of total protein decreases in club-foot as compared to controls. SDS-PAGE of solubilised collagens shows a high content of type I, less of type III and small amounts of type V collagen in both groups. The extent of hydroxylation of proline appears to be very similar, whereas the degree of hydroxylation of lysine follows the Dimeglio-classification. In addition, glycosylation of hydroxylysine increases parallelly to the classification. However, the increase is found solely in the amount of disac-charides. Total content of HHL, the most important collagen cross-link in soft tissues, was increased significantly in club-feet as compared to controls. HP, the hard tissue specific collagen cross-link was increased slightly in clubfeet. Levels of LP were too low to detect differences precisely.

The data presented show distinct differences in the post-translational modifications of collagen (hydroxylation of lysyl-residues, glycosylation and lysyl-oxidase dependent cross-links) isolated from congenital idiopathic clubfeet and from controls.