Adolescents with cerebral palsy (CP) often require scoliosis surgery. Low bone mass may counteract benefits of surgical treatment. This study compares volumetric bone mineral density (vBMD) in adolescents with CP to age and sex matched healthy controls and evaluates its effect on scoliosis treatment. Computed tomogramms (CT) of 51 adolescents with CP (15.0 ± 2.6 years) were performed for scoliosis surgery and also used for vBMD calculation. Reference control vBMD values were calculated from 62 CT examinations of patients (15.1 ± 2.3 years) after trauma or conditions not related to bone mass. Z-scores were calculated based on the reference values. Correction of scoliosis in relation to vBMD was evaluated on perioperative spinal radiographs of operated adolescents with CP. Adolescents with CP had lower vBMD (123.3 ± 46.3 mg/cm3) than healthy controls (166.9 ± 31.4 mg/cm3). The lowest vBMD (97.3 ± 49.8 mg/cm3) had patients with CP and pathological fractures (n = 8). Male CP Z-scores (− 2.2 ± 1.6, n = 22) (16.2 ± 2.5 years) were significantly lower than female CP Z-scores (− 1.0 ± 1.3, n = 29) (14.1 ± 2.3 years). Higher vBMD (179.2 ± 45.4 mg/cm3, n = 41) correlated to scoliosis correction > 50% (average 67.0 ± 12%), while lower vBMD (134.9 ± 30.9 mg/cm3, n = 7) related to correction ≤ 50% (average 36.8 ± 14%). Non-ambulant adolescents with CP have lower vBMD values compared to a healthy population, which negatively affects surgical correction of scoliosis. Level of evidence/clinical relevance: Therapeutic Level III.

Die juvenile Osteochondrosis dissecans des Kniegelenkes ist die häufigste osteochondrale Läsion des Wachstumsalters und tritt am häufigsten zwischen dem 10. und 14. Lebensjahr auf. Sie entsteht durch repetitive Mikrotraumata und ist typischerweise im subchondralen Knochen des medialen Femurkondylus lokalisiert. Während die sportliche Aktivität als die Hauptursache betrachtet wird, scheinen genetische und hereditäre Faktoren sowie ein Vitamin‑D3-Mangel ebenfalls eine Rolle zu spielen. Etablierte Klassifikationen dienen der Unterscheidung zwischen stabilen und instabilen osteochondralen Läsionen, die maßgebend für die weitere Behandlung sind. Stabile Läsionen können in der Regel konservativ durch konsequente Schonung vollständig ausheilen. Instabile Läsionen können hingegen zu einem vollständigen Defekt der Gelenkoberfläche mit Entstehung eines freien Gelenkkörpers führen. In diesen Fällen stehen unterschiedliche operative Techniken zur Verfügung, die auf die Wiederherstellung der Kontinuität der Gelenkoberfläche abzielen, um das Risiko einer sekundären Arthrose zu reduzieren.

BACKGROUND:Juvenile osteochondritis dissecans of the knee joint is the most common osteochondral lesion during growth, usually occurring between the 10th and 14th year of age. PATHOGENESIS:Repetitive microtraumata lead to a subchondral osseus lesion, which is commonly located at the medial aspect of the femoral condyle. Sport activities are considered to be the main cause, although genetic and hereditary factors as well as vitamin D3 deficiency also play a role. Current classification systems distinguish between stable and unstable osteochondral lesions, which is decisive for further treatment. TREATMENT:Stable lesions may heal through conservative treatment by avoiding weight bearing and sport. Unstable lesions, on the other hand, can lead to a complete defect of the joint surface with the formation of a free joint body. In such cases, various surgical techniques aim at reconstructing the surface of the joint, in order to reduce the risk of secondary arthritis.

BACKGROUND:Symptomatic adult flatfeet are a common problem that is treated with various therapeutic approaches. In this study, three different surgical approaches, subtalar arthroereisis (SA), medializing calcaneal osteotomy (MDCO) and a combination of both techniques (SA+MDCO) were analyzed. METHODS:32 patients (36 feet) with pes planovalgus (mean age 49 +/- 16 years) were surgically treated with either SA (n = 8 feet), MDCO (n = 9 feet) or SA+MDCO (n = 19 feet). The American Orthopaedic Foot and Ankle Society (AOFAS) and the European Foot and Ankle Society (EFAS) questionnaires, as well as radiological parameters were compared before and after surgery within and between groups. At follow up (6 +/- 2 years) patients were additionally invited for dynamic pedobarography and static hindfoot axis examination. RESULTS:Within all three groups AOFAS and EFAS questionnaire values and radiological parameters improved significantly after surgery. Questionnaires did not differ between all groups. Before surgery the SA+MDCO group displayed the most severe radiological flatfeet parameter in comparison to the other cohorts. After surgery, the SA and SA+MDCO groups were greatly improved, while the MDCO group displayed less correction, indicating poorer surgical results with MDCO only. Pedobarography of surgically treated feet revealed similar results in comparison to the contralateral side within all three groups and all feet displayed a normal gait line after surgery. CONCLUSIONS:Analyzing questionnaires and radiographs, all three surgical techniques (SA, MDCO and SA+MDCO) significantly improved the severity of flatfoot deformity. Pedobarography revealed similar dynamic properties of treated feet in comparison to the contralateral side. While treatment with SA showed better results than treatment with MDCO alone, the combination of SA+MDCO was most effective. In this study, severe adult flatfeet benefited most from a surgical combination of SA+MDCO with respect to normalization of radiological parameter. LEVEL OF EVIDENCE/CLINICAL RELEVANCE:Therapeutic Level III.

Non-ambulant adolescents with cerebral palsy (CP) may develop secondary scoliosis requiring surgical correction. However, low bone mineral density may counteract benefits of surgical treatment. This study aims to examine volumetric bone mineral density in adolescents with CP and scoliosis and its effect on scoliosis treatment. Spinal vBMD was evaluated on computed tomography (CT) of 51 adolescents with CP and scoliosis (15.0 ± 2.6 years). 62 CTs of patients (15.1 ± 2.3 years) with trauma or other acute and not bone related conditions provided vBMD reference values for Z-scores extrapolation. Other present factors such as epilepsy, medication or pathological fractures were examined in relation to vBMD. Pre- and postoperative spinal radiographs were compared for achieved correction of deformity. Adolescents with CP had significantly lower vBMD (123.3 ± 46.3 mg/cm3) compared to healthy controls (166.9 ± 31.4 mg/cm3). Patients with pathological fractures (n = 8) showed the lowest measurements (97.3 ± 49.8 mg/cm3). Male patients had significantly lower Z-scores (-2.2 ± 1.6, n = 22) compared to their female counterparts (-1.0 ± 1.3, n = 29). Higher vBMD values (179.2 ± 45.4 mg/cm3, n = 41) correlated significantly to scoliosis angle reduction > 50% (average 67.0 ± 12%), while lower vBMD (134.9 ± 30.9 mg/cm3, n = 7) related to reduction ≤ 50% (average 36.8 ± 14%). Non-ambulant adolescents with CP have lower vBMD values compared to healthy population, which negatively affects surgical correction of scoliosis. Level of Evidence/Clinical relevance: Therapeutic Level III

INTRODUCTION:Children with spinal muscular atrophy (SMA) and progressive neuromuscular scoliosis often require early growth-friendly spinal implant (GFSI) treatment for deformity correction with implant fixation either through pedicle screws or bilateral to the spine using ribto pelvis fixation. It has been proposed that the latter fixation may change the collapsing parasol deformity via changes in the rib-vertebral angle (RVA) with a positive effect on thoracic and lung volume. The purpose of this study was to analyze the effect of paraspinal GFSI with bilateral rib-to-pelvis fixation on the parasol deformity, RVA, thoracic, and lung volumes.METHODS:SMA children with (n = 19) and without (n = 18) GFSI treatment were included. Last follow-up was before definite spinal fusion at puberty. Scoliosis and kyphosis angles, parasol deformity, and index, as well as convex and concave RVA, were measured on radiographs, whereas computed tomography images were used to reconstruct thoracic and lung volumes.RESULTS:In all SMA children (n = 37; with or without GFSI), convex RVA was smaller than concave values at all times. GFSI did not crucially influence the RVA over the 4.6-year follow-up period. Comparing age- and disease-matched adolescents with and without prior GFSI, no effect of GFSI treatment could be detected on either RVA, thoracic, or lung volumes. Parasol deformity progressed over time despite GFSI.CONCLUSION:Despite different expectations, implantation of GFSI with bilateral rib-to-pelvis fixation did not positively influence parasol deformity, RVA and/or thoracic, and lung volumes in SMA children with spinal deformity directly and over time.

BackgroundIn pediatric orthopedics, long bone lengthening procedures are routinely performed using manual, motorized or magnetically controlled implants. This study aims to prove expansion of a newly designed osmotic pump prior to long bone lengthening in living organisms and to rule out any complications related to in vivo conditions, such as congestion of the semipermeable membrane, local infection, or lack of water to drive the osmotic pump, as well as to compare in vivo and in vitro expansion data.MethodsOsmotic pumps, which were designed to distract a plate osteosynthesis, were inserted in the dorsal paraspinal musculature of four piglets. To compare the performance of the pumps in in vivo and in vitro conditions, another set of pumps was submerged in physiologic saline solution at different temperatures. The lengthening progress was measured radiographically and sonographically in the study animals.ResultsBoth, in vitro and in vivo tested osmotic pumps started distraction after an intended rest phase of four days and distracted evenly over the following twelve days. No complications, clogging or damages occurred. However, we observed a temperature dependency of the distraction rate ranging from 0.98 mm/day at 39°C to 1.10 mm/day at 42°C. With a second setup, we confirmed that the distraction rate differed by 72% within a measured temperature interval of 14° C.ConclusionsThe data presented here confirm that the novel osmotic pump showed comparable lengthening characteristics in vivo and in vitro. No complications, such as congestion of the semipermeable membrane, local infection, or lack of water to drive the osmotic pump were observed. Thus, osmotic pumps may have great potential in future applications such as long bone lengthening procedures, where continuous distraction probably provides a better bone quality than intermittent lengthening procedures. The fact that one pump failed to elongate in each condition, highlights the importance of technical improvement, but also demonstrates that this was not due to different circumstances within the in vivo or in vitro condition.

Spinal muscular atrophy (SMA) is a rare genetic disorder, with the most common form being 5q SMA. Survival of children with severe SMA is poor, yet major advances have been made in recent years in pharmaceutical treatment, such as gene-therapy, which has improved patient survival. Therefore, clinical problems, such as the development of spinal deformities in these genetically treated SMA children represent an unknown challenge in clinical work. In a retrospective case series, the development of spinal deformities was analyzed in 16 SMA children (9 male, 7 female) treated with onasemnogene abeparvovec in two institutions during the years 2020 to 2022. Ten out of sixteen patients had a significant kyphosis, and nine out of sixteen patients had significant scoliosis, with the mean curvature angles of 24 ± 27° for scoliosis, and 69 ± 15° for kyphosis. Based on these preliminary data, it can be assumed that early-onset kyphosis presents a clinical challenge in gene-therapy-treated SMA children. Larger datasets with longer follow-up times need to be collected in order to verify these preliminary observations.

Eine typische Coxitis fugax und ein Morbus Perthes werden hauptsächlich im Kleinkind- und Grundschulalter diagnostiziert. © New Africa / stock.adobe.com (Symbolbild mit Fotomodellen)

Background: Children with spinal muscular atrophy (SMA) frequently develop neuromuscular scoliosis at an early age, requiring surgical treatment with growth-friendly spinal implants (GFSI), such as magnetically controlled growing rods. This study investigated the effect of GFSI on the volumetric bone mineral density (vBMD) of the spine in SMA children. Methods: Seventeen children (age 13.2±1.2 y) with SMA and GFSI-treated spinal deformity were compared with 25 scoliotic SMA children (age 12.9±1.7 y) without prior surgical treatment as well as age-matched healthy controls (n=29; age 13.3±2.0). Clinical, radiologic, and demographic data were analyzed. For the calculation of the vBMD Z-scores of the thoracic and lumbar vertebrae, phantom precalibrated spinal computed tomography scans were analyzed using quantitative computed tomography (QCT). Results: Average vBMD was lower in SMA patients with GFSI (82.1±8.4 mg/cm 3) compared with those without prior treatment (108.0±6.8 mg/cm 3 ). The difference was more prominent in and around the thoracolumbar region. The vBMD of all SMA patients was significantly lower in comparison with healthy controls, especially in SMA patients with previous fragility fractures. Conclusions: The results of this study support the hypothesis of reduced vertebral bone mineral mass in SMA children with scoliosis at the end of GFSI treatment in comparison with SMA patients undergoing primary spinal fusion. Improving vBMD through pharmaceutical therapy in SMA patients could have a beneficial effect on the surgical outcome of scoliosis correction while reducing complications. Level of Evidence: Therapeutic Level III.

Duchenne muscular dystrophy is a progressive disease usually associated with loss of ambulation and progressive scoliosis. Immobilisation and glucocorticoid treatment are predisposing factors for reduced bone mineral density (BMD). Analysis of quantitative computed tomography revealed low BMD in thoracic and lumbar vertebrae in comparison to age- and sex-matched healthy controls. Evaluation of vertebral bone mineral density (BMD) in Duchenne Muscular Dystrophy (DMD) adolescents with untreated advanced scoliosis and comparison with the BMD values of healthy age-matched controls, based on quantitative computer tomography. Thirty-seven DMD adolescents (age 15.6 ± 2.5 years) with spinal deformity were evaluated clinically and radiologically prior to definite spinal fusion and compared to 31 male and age-matched healthy individuals (age 15.7 ± 2.3 years). Data related to previous medical treatment, physiotherapy and ambulatory status was also analysed. Scoliotic curves were measured on plain sitting radiographs of the spine. The BMD Z-scores of the thoracic and lumbar vertebrae were calculated with QCTpro® (Mindways Software Inc., USA), based on data sets of preoperative, phantom pre-calibrated spinal computed tomography scans. A statistically significant lower BMD could be found in DMD adolescents, when compared to healthy controls, showing an average value for the lumbar spine of 80.5 ± 30.5 mg/cm3. Z-scores deteriorated from the upper thoracic towards the lower lumbar vertebrae. All but the uppermost thoracic vertebrae had reduced BMD values, with the thoracolumbar and lumbar region demonstrating the lowest BMD. No significant correlation was observed between BMD and the severity of the scoliotic curve, previous glucocorticoid treatment, cardiovascular impairment, vitamin D supplementation, non-invasive ventilation or physiotherapy. DMD adolescents with scoliosis have strongly reduced BMD Z-scores, especially in the lumbar spine in comparison to healthy controls. These findings support the implementation of a standardised screening and treatment protocol. Level of evidence/clinical relevance: therapeutic level III

Transkondyläre Humerusfrakturen (Frakturen des Kondylus radialis, Kondylus ulnaris und bikondyläre Y- oder T-förmige Frakturen) sind Gelenkfrakturen und machen 1,8 % aller Frakturen im Wachstumsalter aus. Ziel der Therapie ist der Erhalt einer intakten Gelenkfläche, sodass nicht dislozierte Frakturen konservativ und dislozierte Frakturen operativ behandelt werden. Schwierig zu unterscheiden sind primär und islozierte hängende inkomplette und komplett-artikuläre Frakturen des Kondylus radialis. Letztere haben ein nennenswertes Risiko für eine sekundäre Dislokation, die eine Konsolidationsverzögerung und Pseudarthrosebildung zur Folge haben kann mit konsekutiver Varisierung der Armachse. Dies sollte durch eine adäquate Diagnostik (d. h. Erkennen der Sekundärdislokation) und eine adäquate Therapie (Kompressionsosteosynthese) verhindert werden, wobei die Zugschraubenosteosynthese bei einem großen metaphysären Fragmentanteil die Methode der Wahl darstellt und gleichzeitig die Konsolidierungszeit gering hält. Bei kleinen Kindern oder kleinen Fragmenten erfolgt eine möglichst divergierende Kirschner-Draht-Osteosynthese. Bei adoleszenten Patienten mit Y- oder T-förmigen bikondylären Frakturen ist unter Umständen eine (auch doppelseitige) Plattenosteosynthese aus Gründen der Stabilität erforderlich und richtet sich nach den Prinzipien der Erwachsenen.

Background: Equinus foot deformity is secondary to either spasticity or contracture of the gastrocnemius–soleus complex. The plantar flexion is basically treated conservatively; several different surgical methods have been discussed. This paper focuses on the improvement of passive ankle dorsiflexion after a transverse Vulpius procedure in equinus foot deformity. Additionally, the influence of consequent postoperative wear of orthosis on the improvement of ankle range of motion was investigated. Methods: In total, 41 patients with neuromuscular impairment and 59 equinus feet deformities were surgically treated by using a transverse Vulpius procedure. A total of 19 female patients and 22 male patients with a mean age at surgery of 10.18 years (2 to 31) were included. Mean follow-up took place 12.26 ± 7.95 months after surgery. Passive ankle dorsiflexion was measured and subjective patients’ satisfaction was assessed. Results: Range of motion, measured as the maximum of passive ankle joint dorsiflexion, improved significantly from −8° ± 5.9° to 11.1° ± 6.7° directly after surgery to 16.2° ± 10.7° at follow-up. The improvement of passive ankle dorsiflexion was significantly associated with the continuous wearing of night and day orthosis (p = 0.0045). Patient subjective satisfaction was very high. Conclusion: A transverse Vulpius procedure for aponeurotic gastrocnemius and soleus muscle lengthening of equinus foot deformity resulted in a significant improvement of passive ankle dorsiflexion. Positive surgical results correlated to a continuous use of orthotic devices.

In advanced Rett syndrome (RTT), limited or complete loss of ambulation, nutritional problems and scoliosis are unfavorable factors for bone mineral density (BMD). Still, there are few data available in this research area. Spinal quantitative computed tomography (QCT) allows an exact measurement of the volumetric BMD (vBMD) in this patient group. Two examiners measured vBMD of thoracic and lumbar vertebrae on asynchronous calibrated CTs that were acquired prior to surgical scoliosis correction (n = 21, age 13.6 ± 2.5 years). The values were compared to age- and sex-matched healthy controls to additionally derive Z-scores (n = 22, age 13.8 ± 2.0 years). The results showed the most significant reduction of vBMD values in non-ambulatory RTT patients, with p < 0.001 and average BMD-Z-score −1.5 ± 0.2. In the subgroup comparison, non-ambulatory patients with valproate treatment had significant lower values (p < 0.001) than ambulatory patients without valproate therapy, with an average BMD-Z-score of −2.3 ± 0.2. Comparison of the Z-scores to critical BMD thresholds of 120 and 80 mg/cm3 showed normal Z-scores in case of the ambulatory RTT subgroup, as opposed to BMD-Z-scores of the non-ambulatory RTT subgroups, which were partially below osteopenia-equivalent values. Furthermore, valproate treatment seems to have a direct effect on vBMD in RTT patients and when combined with loss of ambulation, BMD-Z-scores are reduced to osteoporosis-equivalent levels or even further.