Congenital hip dislocation represents the most severe form of developmental dysplasia of the hip (DDH) and, if left untreated, it leads to permanent functional impairment. Since the nationwide implementation of ultrasound screening in Germany in 1996, the condition can be detected and managed early on. The primary goal of treatment is a stable concentric reduction of the femoral head to allow normal acetabular development. In irreducible hips, operative reduction and additional corrective osteotomies may be required. Early diagnosis, standardized treatment protocols, and close follow-up are essential to achieve optimal long-term outcomes.

Die kongenitale Hüftluxation ist die schwerste Form der kongenitalen Hüftdysplasie und führt unbehandelt zu bleibenden Funktionseinschränkungen. Durch das seit 1996 etablierte Hüftscreening mittels Ultraschall kann sie frühzeitig erkannt und behandelt werden. Ziel ist die stabile Rezentrierung des Hüftkopfs und die physiologische Pfannenentwicklung. Bei irreponiblen Hüften sind operative Repositionen, gegebenenfalls in Kombination mit knöchernen Korrekturen erforderlich. Frühdiagnostik, standardisierte Therapie und engmaschige Kontrollen sichern die besten Langzeitergebnisse.

Treating vertical talus using the minimally invasive method according to Dobbs is becoming increasingly more common and appears to reduce the need for extensive surgery. In this paper, we report on the long-term findings for treating these idiopathic and non-idiopathic deformities. Twenty-three vertical talus deformities were treated between 11/2007 and 12/2014. Treatment was primarily carried out using the minimally invasive Dobbs method with reverse Ponseti casting. Patient data, treatment data, surgical methods, relapse rates, functional results and weight-bearing imaging results were documented over the course of the study. The talar axis-first metatarsal base angle (TAMBA) was used to assess the severity of the deformity. Long-term clinical findings and imaging were presented. Nineteen vertical talus deformities were examined over an average follow-up period of 10.4 years. A minimally invasive primary correction was performed on 74

Intraligamentäre Verletzungen des vorderen Kreuzbandes (VKB) sowie Meniskusverletzungen sind im Kindes- und Jugendalter selten und treten häufig als Folge von Sportverletzungen auf. Klinisch präsentieren sie sich meist durch ein Hämarthros. Die Diagnostik der Wahl ist die MRT-Untersuchung. Mittlerweile ist auch im Kindes- und Jugendalter die operative Versorgung von intraligamentären Verletzungen des VKB mittels der transphysären Technik der Goldstandard in der Behandlung, allerdings sind hier bis zum Wachstumsabschluss Beinachs- und -längenkontrollen notwendig. Auch Meniskusverletzungen werden operativ adressiert. Besondere Bedeutung hat die postoperative Nachbehandlung und Rehabilitation, um eine Reruptur zu vermeiden. Der Scheibenmeniskus stellt eine besondere Entität dar und wird bei Symptomatik ebenfalls operativ angegangen. Isolierte Seitenband- und HKB-Rupturen sind Raritäten.

Intraligamentous injuries to the anterior cruciate ligament (ACL) and meniscus injuries are rare in children and adolescents and often occur as a result of sports injuries. Clinically, they usually present as a hemarthrosis. The diagnosis of choice is the MRI examination. Surgical treatment of intraligamentary ACL injuries using the transphyseal technique is now also the gold standard treatment for children and adolescents, leg axis and length checks are necessary after surgery until growth is complete. Meniscus injuries are also addressed surgically. Postoperative follow-up treatment and rehabilitation are particularly important in order to prevent reinjury. The disc meniscus is a special entity and is also treated surgically if it is symptomatic. Isolated collateral ligament and posterior cruciate ligament ruptures are rarities.

The treatment of complex atypical clubfoot poses many challenges. In this paper, we report on the course of complex clubfoot, primary correction using the modified Ponseti method and midterm outcomes. Special consideration is given to clinical and radiological changes in cases of relapse. Twenty-seven cases of complex, atypical, non-syndromic clubfoot were treated in 16 children between 2004 and 2012. Patient data, treatment data, functional outcomes and, in the relapse cohort, radiological findings were documented during the course of treatment. The radiological findings were correlated with the functional outcomes. All atypical complex clubfeet could be corrected using a modified form of the Ponseti method. Over an average study period of 11.6 years, 66.6% (n = 18) of clubfeet relapsed. Correction after relapse showed an average dorsiflexion of 11.3° during a 5-years’ follow-up period. Radiological results showed residual clubfoot pathologies such as a medialized navicular bone in four clubfeet. There were no instances of subluxation or dislocation of the talonavicular joint. Extensive release surgery was not necessary. Nevertheless, after 2.5 preoperative casts (1–5 casts), bone correction was performed in n = 3 feet in addition to Achilles tendon lengthening and tibialis anterior tendon transfer. Good primary correction of complex clubfoot using the modified Ponseti technique results in a high recurrence rate in the medium term. Relapse treatment without peritalar arthrolysis procedures produces good functional results even though minor residual radiological pathologies did persist in a minor number of cases.

Stressverletzungen des Knochens im Kindes- und Jugendalter stellen die Folge eines Missverhältnisses von körperlicher Belastung auf das wachsende muskuloskeletale System und dessen intrinsischer Belastbarkeit dar. Insbesondere sportlich sehr aktive Kinder sind betroffen. Durch überproportionale Belastung eines gesunden Knochens treten die klassischen Stressverletzungen hauptsächlich im Bereich des Unterschenkels, des Mittelfußes und der unteren LWS auf. Auch im Bereich der Wachstumsfugen können Überlastungssyndrome vorkommen und ggf. zu Wachstumsfugenstörungen führen. Die Anamnese weist meist einen seit Längerem bestehenden Belastungsschmerz ohne Trauma auf. Im Rahmen der Differenzialdiagnose muss zunächst aufgrund der seltenen Entität überhaupt an die Stressverletzungen gedacht werden. Eine Röntgenuntersuchung kann erste Hinweise auf eine Stressreaktion zeigen. Hier muss bei auffälliger Periostreaktion auch ein malignes Geschehen in Betracht gezogen werden. Eine MRT-Untersuchung ist dann wegweisend; selten müssen Biopsien erwogen werden. Die Therapie der Stressverletzungen ist konservativ. Rezidiven sollte über Belastungssteuerung entgegengewirkt werden.

Septic arthritis of the hip can appear isolated or concomitant with pelvic osteomyelitis. Delay in the diagnosis of a concomitant osteomyelitis increases the number of required surgeries and of possible complications. This study aims to establish relevant factors in the diagnosis of concomitant osteomyelitis in cases with septic arthritis of the hip among paediatric patients. The data were collected between 2005 and 2020. 41 pediatric patients with suspicion of septic arthritis of the hip joint, treated arthroscopically, were included. The following diagnostic test parameters were collected: ultrasound, MRI, X-Rays, blood samples, temperature, and incapacity to bear weight. The data were analysed with the sensitive analysis method using descriptive statistic. 41 patients were analyzed, with an average age of 6.04 y (7 months to 14 years), of which ten patients (24.39%) presented concomitant osteomyelitis. 6 out of ten patients needed secondary surgery. Regarding age, concomitant osteomyelitis was most common in the age group 4–14 years old. Average number of days of clinical symptoms before admission was 6.2 days. 36/41 cases showed CRP values higher than 2 mg/dl. 9/10 cases with concomitant osteomyelitis showed a CRP > 2 mg/dl, with an average value of 8.9 mg/dl. 22/41 patients underwent an MRI, of which nine cases presented a concomitant osteomyelitis. The probability of a child to have septic arthritis of the hip with adjacent osteomyelitis was analysed through a score based on four factors: impossibility to bear weight and/or hip pain in children in the non-walking age category, CRP > 2 mg/dl, age older than > 4 y, symptoms longer than 4 days. Children at the age of walking, with incapacity to bear weight, presenting symptoms longer than 4 days and a CRP > 2 mg/dl, should receive an MRI before surgery to exclude adjacent osteomyelitis. IV.

Die offene Reposition von kongenitalen Hüftgelenkluxationen ist aktuell weiterhin die Standardoperation zur Therapie von geschlossen, nicht zu reponierenden luxierten Hüftgelenken. Daher stellt die offene Reposition des luxierten Hüftgelenkes eine relativ invasive Operationsmethode dar. Ziel war es, ein minimal-invasives, sicheres und komplikationsarmes Verfahren als Alternative zur offenen Reposition zu entwickeln. In dieser Arbeit wird die 2009 erstmals beschriebene arthroskopische Reposition luxierter Hüftgelenke als standardisierte Operationstechnik dargestellt. Konservativ irreponible kongenitale Hüftgelenkluxationen. Arthroskopische Reposition des luxierten Hüftkopfs in einer arthroskopischen 2‑Portal-Technik. Als Zugang für das Arthroskop dient der Subadduktorzugang und als Arbeitsportal ein hohes anterolaterales Portal. Schrittweise Identifizierung von Repositionshindernissen wie Lig. capitis femoris, Pulvinar in der Gelenkpfanne, Kapselkonstriktion oder Psoassehne. Reposition des Hüftkopfs unter arthroskopischer Kontrolle. Retention des Hüftgelenks erfolgt im Becken-Bein-Gips in Fettweis-Position. Arthroskopische Hüftgelenkreposition von 20 kongenitalen Hüftluxationen; 13 Mädchen und 3 Jungen mit einem Durchschnittsalter bei der Operation von ø 5,8 Monaten (3 bis 9 Monate). Alle Kinder hatten präoperativ mehrfache frustrane Versuche mit einer geschlossenen Reposition mit Overheadextensionen, Pavlik-Bandagen- oder Gipsanlage. Nach der Graf-Klassifikation lag 20-mal ein Typ IV vor, nach der radiologischen Einteilung von Tönnis 9‑mal Typ 4, 7‑mal Typ 3 und 4‑mal Typ II. An Repositionshindernissen waren Kapselkonstriktion, hypertrophes Lig. capitis femoris und eine ausgefüllte Hüftgelenkpfanne vorhanden. Ein invertiertes Labrum war in keinem Fall zu sehen. Dagegen zeigte sich in zwei Drittel der Fälle eine erhebliche Einziehung am dorsalen Pfannenrand durch das sich darüber spannende Lig. capitis femoris. In allen Fällen wurde intraoperativ im Gips ein transinguinaler Ultraschall und postoperativ ein MRT durchgeführt. In allen Fällen zeigte sich eine tiefe Zentrierung des Hüftkopfs im Azetabulum. Intra- oder postoperative Komplikationen wie Blutungen, Infekte oder Nervenläsionen traten nicht auf. In keinem Fall kam es zu einer Reluxation des Hüftkopfs. In einem Follow-up von 15 Monaten fand sich keine Reluxation oder Dezentrierung der Hüften. Der AC-Winkel betrug 24,5°. Eine Coxa magna trat in 1 Fall auf. Nach der Salter-Klassifikation fand sich eine avaskuläre Nekrose mit fragmentiertem Hüftkopfkern.

Introduction: It is often difficult to clinically and radiologically diagnose intra-articular osteoid osteomas and osteoid osteomas of the hip joint. Treatment can also be difficult due to complex locational relationships. CT-guided radiofrequency ablation is currently the standard form of treatment. In this paper we report on a minimally-invasive concept for treating osteoid osteomas near the hip joint in children and adolescents which does not involve using computed tomography. Material and method: 10 patients with an average age of 12.1 years underwent treatment for osteoid osteomas in the hip joint region. The diagnosis was made using a contrast-enhanced MRI. The osteoid osteomas were marked percutaneously using x-ray and MRI guidance. MRI-guided drilling/curettage was performed in 4 cases and arthroscopic resection in 6 cases. Results: All lesions were successfully treated using the MRI-guided method. All patients were free of pain after the treatment. There was no instance of recurrence during the follow-up period, which averaged 10 months. The effective dose for marking the lesion was between 0.0186 mSv and 0.342 mSV (mean 0.084 mSV). Conclusions: Our MRI diagnostics protocol, the MRI-guided drilling and the minimally invasive hip arthroscopy represent an alternative to CT-guided radiofrequency ablation in the treatment of osteoid osteomas. Radiation exposure can thereby be significantly reduced. Hip arthroscopy can also be used to treat secondary pathologies such as femoroacetabular impingement.

Background Ulnar humeral condyle fractures are rare paediatric elbow fractures, classified as Salter-Harris IV paediatric elbow injuries. Due to constant radiological changes in the elbow with varying manifestation of ossification centres as well as late ossification of the trochlea, diagnosis of these injuries is challenging. To avoid long-term complications, the treating surgeon should be familiar with the rare injury picture, diagnostics and adequate therapeutic measures. Material and Methods The present retrospective study includes data on all paediatric cases from2002 to 2019 with primary or secondary treatment at a paediatric traumatology centre for ulnar condyle fracture with a minimum follow-up of 12 months. Range of motion, joint stability under valgus and varus stress as well as axial ratios of the injured and uninjured side were evaluated in a clinical follow-up examination. The Mayo Elbow Performance Score was used to objectify functional results. Results 20 children, average age 8.6 years (4-13) and average follow- up time 25 months, were included. Radiological evaluation based on Jakob and Fowles classification revealed a type I fracture in three cases, a type II fracture in one case and a type III fracture in 16 cases. Three cases were treated nonoperatively with an upper arm cast. 17 children were treated with open reduction and internal fixation. Diagnosis of three fractures was delayed. No postoperative complications such as infections, nerve damage or nonunions. 15 children showed free elbow function. Three children showed slightly restricted elbow extension by less than 10 degrees and two by 10 degrees-20 degrees. All children showed free pro/supination. 18 children showed a physiological and bilaterally identical arm axis compared to the uninjured side. Two children showed a slightly increased cubitus valgus with a 5-10 degrees difference between sides. Radiologically, two children with delayed fracture treatment showed partial necrosis of the trochlea. The Mayo Elbow Score showed good (2) to excellent results in all children (18). Conclusion Very good clinical and functional results can be expected if the injury is diagnosed without delay followed by adequate therapy. Misdiagnosis of ulnar condyle fractures can be associated with the development of nonunions and functional restrictions as well as, after operative therapy, trochlear necrosis. Children up to the age of 6 in particular are at risk of misdiagnosis due to faulty assessment of the cartilaginous trochlea.

Der Beitrag widmet sich der Hüftdysplasie, einer der klassischen Diagnosen in der Orthopädie. Vor der Darstellung der diagnostischen und therapeutischen Maßnahmen werden zu Beginn Epidemiologie und Ätiologie in das Krankheitsbild einführen. Bei der Diagnostik steht die Ultraschallmethode nach Graf an vorderster Front. Andere Ultraschalltechniken und die Rolle der MRT-Untersuchung werden dargestellt, um auch bei besonderen Fällen die Diagnostik in der Praxis zu erleichtern. Die im mitteleuropäischen Sprachraum etablierte, konservative, ultraschallgesteuerte Therapie im Säuglingsalter mit dem 1996 eingeführten Hüftscreening steht im Zentrum des Beitrags. Bei Versagen der konservativen Therapie müssen operative Maßnahmen ergriffen werden. Hier werden die etablierten operativen Maßnahmen wie die offene Reposition, Azetabuloplastiken, Beckenosteotomien und Femurosteotomien mit deren Operationszugängen, Risiken und Komplikationen im Detail beschrieben.

Missed monteggia-type injuries in children can result in chronic radial head dislocation with anatomic changes and osteoarticular remodeling of the radial head. In later stages, joint reconstruction is impossible and a functional radial head distalization can be a therapy option in symptomatic patients. From 2010 to 2018, 46 patients (18 female and 28 male, mean age 11.8 (4–20)) with chronic radius head dislocation treated in our institution were retrospectively analyzed. A radial head distalization was performed in symptomatic patients at the time of ulna lengthening and angulation by use of an external ring fixator. We analyzed the surgical and radiographic data as well as the clinical outcome of the patients measured by DASH and Mayo Elbow score. 16 patients (6 female, 10 male) fulfilled the criteria for functional radial head distalization. Main reason was Monteggia injury in 11 cases, and radial head fracture in 5 cases. Average follow-up was 5.1 years (range 1–9, SD 2.1). Mean time from injury was 4.14 years (range: 4 months to 12 years, SD 3.5 years). Mean duration of external fixation was 106 days (range 56–182, SD 31.2), lengthening was 21.3 mm (range 12–42, SD 8.8). Average degree of sagittal angulation 14.8° (0–32°, SD 10.7°), coronal angulation 4.4° (0–25°, SD 7.3°). DASH score showed a good result with 2.4, and the MAYO Elbow Score was excellent (95/100). No secondary luxation of the radius head was detected. Radial head distalization with external ring fixator can be a therapy option for chronic radius head dislocations in symptomatic patients without losing stability of the elbow joint in contrast to radial head resection.

Eine Frakturklassifikation ist Grundlage der Erfassung epidemiologischer und klinischer Frakturdaten in einer systematischen einheitlichen Dokumentation und damit auch Grundvoraussetzung zur Evaluierung diagnostischer und therapeutischer Maßnahmen im Sinne einer Effizienz- und Effektivitätskontrolle. Mit der AO-Fraktur-Klassifikation des Erwachsenen konnten zwar auch bezüglich kindlicher Frakturen Erkenntnisse gewonnen werden, dennoch ist diese Einteilung nicht unverändert auf Brüche des wachsenden Skelettes übertragbar, da sowohl das Verletzungsmuster als auch Therapie und Outcome vom Alter und Reifestadium der Wachstumsfugen abhängen. Jüngst wurden 2 systematische kinderspezifische Klassifikationen erarbeitet und validiert, die Klassifikation der AO Paediatric Expert Group (PAEG) wird im vorliegenden Beitrag vorgestellt. Der vollständige Frakturkode wird aus 5 (Knochen-, Segment-, Typ-, Kinder- und Frakturschwerekode) bzw. 6 Kodes gebildet, in Abhängigkeit davon, ob ein Ausnahme- bzw. Zusatzkode angewendet wird.

Purpose Nonunion of the radial neck poses an enormous challenge for treating surgeons. It is a very rare complication of the radial neck with limited experiences. In this current major study, the authors report of their own experiences concerning this problem. Methods 11 patients with severe displaced radial neck fracture Metaizeau type IV with elbow dislocation and 2 ongoing fractures. 9 fractures had to be treated with open reduction, six with intramedullary nailing, two with K-wires and one with periosteal suture fixation. In two children, aged 4 and 5, the fracture was not diagnosed initially. The patients showed a successful reduction intraoperatively. Results All patients developed nonunion of the radial neck. 9 out of 11 children presented with pain and 5 out of 11 with valgus deformity. All children underwent surgical management of the complications. 3 children received a debridement of the elbow joint with resection of the fragmented radial head. 7 cases needed a following reduction, spongiosa-plasty and periosteal flap reconstruction and plate osteosynthesis. One patient received radial intramedullary pinning. All nonunions showed reunion. All patients with obtained radial head showed significant improvement concerning complaints and range of motion. Only one child showed a slight deterioration in range of motion. Children with resected radial head showed good range of motion but complaints and instability in loaded joint needing further surgical treatment. Conclusion Treatment of radial neck nonunion in children should not be delayed until pain, deformity and limited function occurs because this goes along with severe transition of the radial head right up to bone atrophy.

Nonunions are a very rare complication after surgical treatment of displaced forearm fractures in children, but can occur in both the radius or ulna. The aim of this study is to evaluate predisposing factors for non-unions and to discuss treatment options. We conducted a retrospective analysis of all patients who were treated primarily or secondary at our institution for nonunion after forearm fractures and operative treatment. Therefore, we retrospectively reviewed the medical charts and radiographs of affected patients from 1990 to 2020. We analysed demographic and fracture-related data as well as treatment options. Twenty-seven cases were identified. Median age was 12 years (7–16 years). The ulna was affected in 20 cases and the radius in 7. The most common location for ulna nonunion was the middle third of the shaft, and for the radius the mid and distal shaft. In 21 cases an open reduction was required. In 9 cases technical problems were identified. In most cases (26/27) a hypertrophic nonunion occurred. 10 of 27 (37%) nonunions healed without any surgical management after 9 (7–15) months. The median age of the conservatively managed group was 10 (6–13) years, younger than in the group with managed with reoperation [median 13 (7–16) years]. Indications for surgical intervention were increasing deformity, pain and limitation of movement. Open reduction and technical problems seem to be influencing factors. A conservative approach can be adopted in asymptomatic patients, otherwise an operative management, constituting plate osteosynthesis with or without bone grafting, should be performed.

Sehr geehrte Leserin, sehr geehrter Leser, in Abb. 1b wurde die Ausstelllinie nach Graf versehentlich zu steil eingezeichnet und damit auch der Betawinkel nach Graf falsch dargestellt. Wir bitte, die korrigierte Darstellung des Betawinkels nach Graf in Abb. 1b zu berücksichtigen. Die Darstellung …

Purpose The aim of the study was to evaluate predictable parameters with the highest sensitivity used in the diagnosis of children septic shoulder arthritis. Methods All children treated in our paediatric orthopaedic hospital between 2000 and 2017 with intraoperative verified septic arthritis of the shoulder were included in this retrospective study. Diagnostic procedures e.g. ultrasound, MRI, radiograph or blood samples as well as typical clinical symptoms were evaluated as predictable parameters for septic shoulder arthritis in paediatric patients. Descriptive statistics as well as sensitivity analysis were performed. Results In all, 25 children, 20 boys and five girls, aged from eight days to 15 years, were included for further statistical analysis. All parameters included were tested for sensitivity with binomial confidence intervals (Cis) of 95%. Predictive parameters with highest sensitivity were pseudo paralysis (100%, CI 0.86 to 1.00) and C-reactive protein (CRP) (96%, CI 0.79 to 0.99) superior to temperature (52%, CI 0.3 to 0.73), white blood count (11%, CI 0.01 to 0.34), radiograph (21%, CI 0.04 to 0.50), ultrasound (71%, CI 0.47 to 0.88) or MRI (100%, CI 0.78 to 1.00). Conclusion The diagnosis of a septic arthritis of the shoulder in children can be challenging for the clinician and especially for the resident doctor. Clinical symptoms such as pseudo paralysis and increased CRP level must be considered as predictive markers not to delay further diagnostics and treatment. Level of Evidence IV

The objective of the paper is to analyse the role of the labrum with particular attention to its morphological changes in unstable dysplastic hips during treatment. Between January 2013 and December 2015, data were collected on 86 unstable, dysplastic hips, which were divided into type D (n = 13), type III (n = 49) and type IV (n = 24). The labrum was evaluated with ultrasound examination (US) for echogenicity and dimensions with inter-/intra-observer tests comparing the US images at diagnosis and at the end of treatment. Statistical analysis was performed. At the end of treatment of unstable, dysplastic hips, the labrum was more echogenic with a frequency of 97% and was larger with a frequency of 96%. The labrum has an active stabilizing role in unstable dysplastic hips and it undergoes a statistically significant increase of echogenicity and dimensions after treatment. Cite this article: EFORT Open Rev 2019;4 DOI: 10.1302/2058-5241.4.180053