Introduction: Tibialis anterior tendon transfer (TATT) is a common procedure for recurrence in clubfeet treated with the Ponseti method. Fixation usually includes passing the tendon through a drill hole in the lateral cuneiform using sutures brought out through the plantar aspect of the foot. Drilling of the tunnel and passing the sutures holds potential for neurovascular damage. We performed a cadaver study to evaluate plantar nerve structures at risk during TATT.

Method: TATT was performed to the lateral cuneiform in fresh frozen adult cadaver limbs. In 3 feet, the drill hole was made perpendicular to the surface of the lateral cuneiform (group A), in 3 feet, the drill hole was perpendicular to the weight bearing surface of the foot (group B), in 3 feet, the drill was directed at 15 degrees in the frontal and sagital planes (group C) and in another 3 feet the drill was aimed at the middle of the foot (group D). The tendon sutures were pulled through the plantar aspect using two Keith needles aimed in the same direction as the drill hole. A layered dissection was performed. The distance from the drill hole to the nearest nerve or nerve branch was measured. Keith needles were passed 20 times per foot. With each pass, damage to nerve structures was noted.

Results: In group A, the drill was in proximity to the medial plantar nerve at a mean distance of 1.7mm (1–3mm). The bifurcation of the nerve trunk was found more proximally at a mean distance of 5mm (2–9mm). In group B, the drill was found to be close to the lateral plantar nerve branches at a mean distance of 0.3mm (0–1mm) with a mean distance to the bifurcation of 25.3mm (16–37mm). The drill hole in group C was at a mean distance of 1.7mm (0–3mm) to the lateral plantar nerve bifurcation and at a distance of 1mm to the lateral nerve branch in one case. In group D, the drill exited in the middle of the plantar aspect at a mean distance of 7.7mm (5–11mm) from the medial nerve branch and 13mm (10–18mm) from the bifurcation of the medial nerve and at a mean distance of 4.3mm (3–6mm) from the lateral nerve branch and 14.7mm (11–19mm) from the lateral nerve bifurcation.

Passing the Keith needles resulted in hitting a nerve structure 12 times in group A, 20 times in group B, 6 times in group C and once in group D.

Conclusion: In TATT, the drill hole should be aimed at the middle of the foot in the transverse and longitudinal planes. This results in a maximum distance to both the lateral and medial nerve. A blunt Keith needle might allow a safer passing of the sutures to avoid damage to nerves and vessels.

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: Congenital clubfoot is a very common deformity in developing countries which leads to secondary socioeconomic problems. Clubfoot programs using the Ponseti method have been initiated in many third world countries in the last years. However, many treatment related, logistic, and structural problems are encountered during these efforts. We report our two-year experience with a clubfoot program in Mali.

Methods: In April 2006 a clubfoot program was initiated in Bamako, Mali by Doctors for Disabled, an Austrian society for medical development cooperation. Teaching material and documentation forms were created and a first Ponseti course was held in Bamako in October 2006. Further visits for advanced teaching, documentation, follow-up and implementation of a clinical structure were scheduled approximately every three months. Parallel to the Ponseti program a program to operate neglected or resistant clubfeet was initiated. Regular meetings with the government at different levels were attained and efforts were made to include the clubfoot program into the national RBC program.

Results: During workshops in October 2006 and January and March 2007 seven health care workers have been intensively trained in the Ponseti method. A review of our documentation showed that up to now 235 patients had been seen and treated. Out of 105 children with idiopatic clubfoot who presented younger than one year of age 52 were available for follow-up after the end of Ponseti treatment. The outcome was “good” or “medium” in 40 patients (77%) and “poor” in 12 children (23 %). The late age at presentation, the low compliance and the rare use of the abduction orthosis are ongoing problems which could not have been solved yet. Additionally, the structural improvements in our treatment center as well as the direct government support are still insufficient.

Conclusion: Due to the low-tech and low-cost approach the Ponseti method is suitable for the developing world. Nevertheless, many obstacles have to be overcome to implement a sustainable project, most of which are not so much treatment associated but of structural, organizational and political nature.

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: In many developing countries clubfeet are not recognized at birth and usually remain untreated due to limited medical and financial recourses. With high births rates of up to 50 births per 1000 population in the poorest countries like Mali, Uganda or Niger the clubfoot deformity has become a socioeconomic problem.

Methods: In April 2006 a clubfoot program was initiated in Bamako, Mali by Doctors for Disabled, an Austrian society for medical development cooperation. During the project design and planning members from an already established Ponseti program, the Uganda Sustainable Clubfoot Care Project, gave valuable advice and guidance for the planning of the Mali program. Teaching material and documentation forms were created and a first Ponseti course was held in Bamako in October 2006.

Results: During workshops in October 06 and January and March 07 a total of 31 health care workers have been trained using the Ponseti method. Documentation as of March 07 shows that 124 clubfeet in 80 Patients have been treated. There were 54 male and 26 female patients which resembles the male to female ratio described in literature. The mean age at presentation was 12.1 months (range: 9 days to 37 months). The Pirani score was evaluated at presentation in 93 of 124 feet and was 4.23 at the average. In March 07 follow-up for patients in whom treatment was initiated from October to January was available for 25 patients with 38 clubfeet. A medium result (plantigrade foot, DF at least neutral) was seen in 11 feet, a good result (plantigrade foot, DF possible) in 23 feet, an early recurrence with need for re-casting in 4 feet. A release operation was performed in 2 feet (2 patients), and 11 feet (7 patients) are awaiting operation. These patients presented at a mean age of 22 months (12–36 months) and included 3 patients with secondary clubfeet.

Conclusion: Due to the low-tech and low-cost approach the Ponseti method is suitable for the developing world and gives these infants in the poorest countries the rare opportunity to receive the same state-of-the-art treatment as infants in the richest countries around the world. Nevertheless, many obstacles have to be overcome to implement a sustainable project. The lack of doctors and especially orthopaedic surgeons can only partly be compensated by highly motivated health care workers. The lack of documentation and follow-up impedes quality control and evaluation needed for funding. Awareness programs to ensure treatment within the first months of live are most important to increase the success-rate but imply fully operable Ponseti clinics which are able to take care of the increasing patient flow.

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: 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.

Congenital unilateral anterolateral tibial bowing in combination with a bifid ipsilateral great toe is a very rare deformity which resembles the anterolateral tibial bowing that occurs in association with congenital pseudarthrosis of the tibia. However, spontaneous resolution of the deformity without operative treatment and with a continuously straight fibula has been described in all previously reported cases. We report three additional cases and discuss the options for treatment. We suggest that this is a specific entity within the field of anterolateral bowing of the tibia and conclude that it has a much better prognosis than congenital pseudarthrosis of the tibia, although conservative treatment alone may not be sufficient.

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.