Bettina Westhoff

Ultrasound-guided botulinum toxin injection technique for the iliopsoas muscle

Intramuscular botulinum toxin A injections are beneficial for the treatment of functional shortening of the iliopsoas muscle, but it is difficult to achieve precise needle positioning and injection. As a solution to this we present an ultrasound‐guided injection technique for the iliopsoas muscle using an anterior approach from the groin. The procedure was performed 26 times in 13 patients (seven males, six females; mean age 11 years, SD 9 years 8 months; age range 4 to 31 years), 10 times bilaterally. Indications were functional iliopsoas shortening due to cerebral palsy (17 hips), hereditary spastic paraplegia (four hips), and Perthes disease (five hips). In all cases the iliopsoas muscle was identified easily by ultrasound; the placement of the injection needle and injection into the site of interest were observed during real time. No complications were encountered.

Computerized gait analysis in Legg Calvé Perthes disease—Analysis of the frontal plane

UNLABELLED Current follow-up- and outcome-evaluations of Legg-Calvé-Perthes disease (LCPD) are based on subjective measures of function, clinical and radiological parameters. The objective of this study was to evaluate the sagittal plane kinematics and the effect on hip joint loading on the affected hip in children with LCPD. MATERIALS AND METHODS Computerized gait analysis was performed in 49 LCPD patients aged ≥ 5 years with unilateral hip involvement. Sagittal plane kinematics and kinetics were compared to a group of healthy children (n=30). RESULTS Kinematics: a significantly increased anterior tilt and range of motion (ROM) of the pelvis combined with a marked reduction of the extension of the involved hip joint compared to the control group was observed. The increased ROM of the contralateral hip results from increased maximum flexion. Power generation: overall significantly decreased on the involved side during florid stage. Global hip function: significantly reduced hip flexor index of the involved hip; 46.2% of the patients in advanced stage, although having no significant changes in kinematics - except increased anterior pelvic tilt - had a pathologic HFI. CONCLUSION Sagittal plane hip function is significantly impaired in florid and advanced LCPD. The results of this study will lead to further investigations into whether this development can be prevented by conservative or operative treatment thus improving function and long-term prognosis.

Radiological evaluation of unstable (acute) slipped capital femoral epiphysis treated by pinning with Kirschner wires.

Treatment of slipped capital femoral epiphysis is still controversial with regard to the implants used for stabilization and the need for prophylactic treatment of the contralateral, unaffected, side. The objective of this study was to ascertain whether prophylactic transfixation of the epiphysis with Kirschner wires in patients with unstable slipped capital femoral epiphysis resulted in significant disturbance of the growth plate and impairment of further growth of the femoral neck and head. Between 1990 and 1999, 29 patients with unstable slipped capital femoral epiphysis were simultaneously treated with internal fixation of the epiphysis and metaphysis with 3–4 Kirschner wires on the affected and the not (yet) affected side. After a mean follow-up of 3.5 years, we evaluated the hip joints radiologically, analysing different roentgenological parameters (CCD angle, femoral head diameter, length of the femoral neck and sphericity of the femoral head). CCD angle, femoral head diameter and length of the femoral neck showed statistically significant (P<0.001, Students t-test) differences between the affected and unaffected, but prophylactically pinned, sides. Asphericity of the femoral head was found in six cases only on the affected side, whereas all hips, which were operated prophylactically, showed spherical femoral heads at follow-up (P<0.02, Pearsons χ2 test). These results indicate that the slip itself may cause impairment of the femoral growth plate in patients with unstable slipped capital femoral epiphysis and not stabilization with Kirschner wires. Compared with other series from the literature using different implants (screws, nails), prophylactic transfixation of the epiphysis and metaphysis with Kirschner wires is less compromising to the growth plate on the not (yet) affected side.

Molecular profiling of chordoma

The molecular basis of chordoma is still poorly understood, particularly with respect to differentially expressed genes involved in the primary origin of chordoma. In this study, therefore, we compared the transcriptional expression profile of one sacral chordoma recurrence, two chordoma cell lines (U-CH1 and U-CH2) and one chondrosarcoma cell line (U-CS2) with vertebral disc using a high-density oligonucleotide array. The expression of 65 genes whose mRNA levels differed significantly (p<0.001; ≥6-fold change) between chordoma and control (vertebral disc) was identified. Genes with increased expression in chordoma compared to control and chondrosarcoma were most frequently located on chromosomes 2 (11%), 5 (8%), 1 and 7 (each 6%), whereas interphase cytogenetics of 33 chordomas demonstrated gains of chromosomal material most prevalent on 7q (42%), 12q (21%), 17q (21%), 20q (27%) and 22q (21%). The microarray data were confirmed for selected genes by quantitative polymerase chain reaction analysis. As in other studies, we showed the expression of brachyury. We demonstrate the expression of new potential candidates for chordoma tumorigenesis, such as CD24, ECRG4, RARRES2, IGFBP2, RAP1, HAI2, RAB38, osteopontin, GalNAc-T3, VAMP8 and others. Thus, we identified and validated a set of interesting candidate genes whose differential expression likely plays a role in chordoma.

Association between botulinum toxin injection into the arm and changes in gait in adults after stroke.

Botulinum toxin (BTX) is often used to improve arm function in persons with hemiparesis after stroke. Persons injected into the arm sometimes report changes in their gait. The purpose of this open‐labeled pilot study was to investigate the association between injecting BTX into the upper limb and ankle and knee range of motion (ROM) and paretic‐leg stride‐time, defined as the time in seconds required to move the hemiparetic leg from initial contact of the foot to initial contact of the same foot. Gait parameters were recorded before and 4 to 6 weeks after the hemiparetic arm was injected with BTX in 13 adults with hemiparesis secondary to stroke, using a three‐dimensional computerized motion analysis system. BTX injection into the paretic arm was associated with a decrease in stride‐time of the paretic leg in all participants. Slower striding participants improved knee and ankle ROM in the paretic leg. There was no change in ankle and knee ROM in faster striding participants. Injection of BTX into the upper extremity is associated with a change in hemiparetic leg stride‐time and ankle and knee ROM. There is a variability of response, with slow striders improving to a greater extent than fast striders.

Indikation und Ergebnisse hüftnaher Osteotomien bei Dysplasie

ZusammenfassungHintergrundRekonstruierende Eingriffe am wachsenden Skelett stellen sowohl in der Indikationsstellung als auch aus operationstechnischer Sicht eine große Herausforderung für den behandelnden Orthopäden dar. Neben der Skelettreife und Gewebequalität zum Operationszeitpunkt müssen die Art und das Ausmaß einer Fehlstellung, die zugrunde liegende Erkrankung sowie die Gesamtprognose in die Entscheidungsfindung für oder gegen ein Operationsverfahren eingeschlossen werden. Die Hüftgelenkdysplasie ist die häufigste Deformität, welche reorientierende Operationen am Hüftgelenk im Kindes- und Jugendalter indiziert. Dabei werden prophylaktische Operationen durchgeführt, um einer frühzeitigen sekundären Hüftarthrose vorzubeugen. Für Patienten und Familien aber auch für den Orthopäden ist die Nutzen-Risiko-Abwägung von großer Bedeutung.MethodenEs werden Techniken und Besonderheiten der einzelnen rekonstruktiven Operationstechniken am Hüfgelenk beschrieben, deren Ergebnisse anhand einer Literaturübersicht dargestellt und kritisch mit den eigenen Erfahrungen verglichen und diskutiert.ErgebnisseEs liegen nur wenige Langzeitstudien zum klinischen Ergebnis nach definierten, rekonstruierenden Operationen am Hüftgelenk im Kindes- und Jugendalter vor. Das Ausmaß der Deformität, die Grunderkrankung, das Patientenalter und die operative Erfahrung des orthopädischen Chirurgen sind wichtige Entscheidungshilfen bei der Wahl eines Operationsverfahrens. Im frühen Kindesalter hat sich bei der operativen Therapie der Hüftgelenkdysplasie insbesondere die Azetabuloplastik und die Salter-Osteotomie durchgesetzt, während im fortgeschrittenen Jugendalter die Dreifachbeckenosteotomie gute Ergebnisse zeigt. Bei geschlossenen Wachstumsfugen kann mit der periazatabulären Osteotomie nach Ganz ebenfalls ein gutes Korrekturergebnis erzielt werden. Intertrochantäre varisierende und derotierende Osteotomien am Femur dienen insbesondere als additive Verfahren zur Beckenosteotomie und werden heute kaum mehr als Einzelverfahren zur Gelenkreorientierung bei Hüftgelenkdysplasie durchgeführt.SchlussfolgerungRekonstruierende Eingriffe am Hüfgelenk führen bei sachgemäßer Indikationsstellung und technisch korrekter Durchführung in den meisten Fällen zur Funktionsverbesserung am Hüftgelenk und können die Entstehung einer frühzeitigen Koxarthrose verzögern oder verhindern.AbstractBackgroundJoint-preserving reconstructive surgeries in children and adolescents remain challenging for orthopaedists with regard to indication and surgical technique. Besides skeletal maturity and tissue quality at the time of surgery, the kind and degree of deformity, the causative pathologies in secondary dysplasias, and the prognosis have to be considered when deciding for or against a surgical procedure. Developmental dysplasia of the hip (DDH) is the most frequent deformity that indicates reorienting surgery on the hip joint in children and adolescents. The aim of these procedures is to prevent early secondary osteoarthritis. For patients and families as well as for the orthopaedist, risk–benefit analysis is of major interest.MethodsIn this study, the surgical techniques and specialities of different reconstructive operations are presented. Based on a review of the literature, the results of defined surgical methods are discussed and compared with own experiences.ResultsOnly limited information is available about the clinical long-term outcome after defined reconstructing surgery on the hip joint in children and adolescents. The degree of the deformity, the age of onset, and the surgical experience of the orthopaedist are crucial factors in decision making for or against a surgical treatment. In early childhood, acetabuloplasty and Salter osteotomy are widely accepted to correct DDH. Triple and periacetabular osteotomies are preferred and have shown promising results in late adolescence and young adults. When the triradiate cartilage (growth plate) is closed, good outcomes can be achieved by the Ganz osteotomy. Intertrochanteric varus and derotation osteotomies of the femur may serve as additional procedures for pelvic osteotomies and are rarely indicated as a single procedure today.ConclusionReconstructive surgery on the hip joint improves function and may prevent early osteoarthritis and delay progression of cartilage degeneration in most patients when the indication and surgical technique are appropriate.BACKGROUND Joint-preserving reconstructive surgeries in children and adolescents remain challenging for orthopaedists with regard to indication and surgical technique. Besides skeletal maturity and tissue quality at the time of surgery, the kind and degree of deformity, the causative pathologies in secondary dysplasias, and the prognosis have to be considered when deciding for or against a surgical procedure. Developmental dysplasia of the hip (DDH) is the most frequent deformity that indicates reorienting surgery on the hip joint in children and adolescents. The aim of these procedures is to prevent early secondary osteoarthritis. For patients and families as well as for the orthopaedist, risk-benefit analysis is of major interest. METHODS In this study, the surgical techniques and specialties of different reconstructive operations are presented. Based on a review of the literature, the results of defined surgical methods are discussed and compared with own experiences. RESULTS Only limited information is available about the clinical long-term outcome after defined reconstructing surgery on the hip joint in children and adolescents. The degree of the deformity, the age of onset, and the surgical experience of the orthopaedist are crucial factors in decision making for or against a surgical treatment. In early childhood, acetabuloplasty and Salter osteotomy are widely accepted to correct DDH. Triple and periacetabular osteotomies are preferred and have shown promising results in late adolescence and young adults. When the triradiate cartilage (growth plate) is closed, good outcomes can be achieved by the Ganz osteotomy. Intertrochanteric varus and derotation osteotomies of the femur may serve as additional procedures for pelvic osteotomies and are rarely indicated as a single procedure today. CONCLUSION Reconstructive surgery on the hip joint improves function and may prevent early osteoarthritis and delay progression of cartilage degeneration in most patients when the indication and surgical technique are appropriate.

Indications and results of corrective pelvic osteotomies in developmental dysplasia of the hip

ZusammenfassungHintergrundRekonstruierende Eingriffe am wachsenden Skelett stellen sowohl in der Indikationsstellung als auch aus operationstechnischer Sicht eine große Herausforderung für den behandelnden Orthopäden dar. Neben der Skelettreife und Gewebequalität zum Operationszeitpunkt müssen die Art und das Ausmaß einer Fehlstellung, die zugrunde liegende Erkrankung sowie die Gesamtprognose in die Entscheidungsfindung für oder gegen ein Operationsverfahren eingeschlossen werden. Die Hüftgelenkdysplasie ist die häufigste Deformität, welche reorientierende Operationen am Hüftgelenk im Kindes- und Jugendalter indiziert. Dabei werden prophylaktische Operationen durchgeführt, um einer frühzeitigen sekundären Hüftarthrose vorzubeugen. Für Patienten und Familien aber auch für den Orthopäden ist die Nutzen-Risiko-Abwägung von großer Bedeutung.MethodenEs werden Techniken und Besonderheiten der einzelnen rekonstruktiven Operationstechniken am Hüfgelenk beschrieben, deren Ergebnisse anhand einer Literaturübersicht dargestellt und kritisch mit den eigenen Erfahrungen verglichen und diskutiert.ErgebnisseEs liegen nur wenige Langzeitstudien zum klinischen Ergebnis nach definierten, rekonstruierenden Operationen am Hüftgelenk im Kindes- und Jugendalter vor. Das Ausmaß der Deformität, die Grunderkrankung, das Patientenalter und die operative Erfahrung des orthopädischen Chirurgen sind wichtige Entscheidungshilfen bei der Wahl eines Operationsverfahrens. Im frühen Kindesalter hat sich bei der operativen Therapie der Hüftgelenkdysplasie insbesondere die Azetabuloplastik und die Salter-Osteotomie durchgesetzt, während im fortgeschrittenen Jugendalter die Dreifachbeckenosteotomie gute Ergebnisse zeigt. Bei geschlossenen Wachstumsfugen kann mit der periazatabulären Osteotomie nach Ganz ebenfalls ein gutes Korrekturergebnis erzielt werden. Intertrochantäre varisierende und derotierende Osteotomien am Femur dienen insbesondere als additive Verfahren zur Beckenosteotomie und werden heute kaum mehr als Einzelverfahren zur Gelenkreorientierung bei Hüftgelenkdysplasie durchgeführt.SchlussfolgerungRekonstruierende Eingriffe am Hüfgelenk führen bei sachgemäßer Indikationsstellung und technisch korrekter Durchführung in den meisten Fällen zur Funktionsverbesserung am Hüftgelenk und können die Entstehung einer frühzeitigen Koxarthrose verzögern oder verhindern.AbstractBackgroundJoint-preserving reconstructive surgeries in children and adolescents remain challenging for orthopaedists with regard to indication and surgical technique. Besides skeletal maturity and tissue quality at the time of surgery, the kind and degree of deformity, the causative pathologies in secondary dysplasias, and the prognosis have to be considered when deciding for or against a surgical procedure. Developmental dysplasia of the hip (DDH) is the most frequent deformity that indicates reorienting surgery on the hip joint in children and adolescents. The aim of these procedures is to prevent early secondary osteoarthritis. For patients and families as well as for the orthopaedist, risk–benefit analysis is of major interest.MethodsIn this study, the surgical techniques and specialities of different reconstructive operations are presented. Based on a review of the literature, the results of defined surgical methods are discussed and compared with own experiences.ResultsOnly limited information is available about the clinical long-term outcome after defined reconstructing surgery on the hip joint in children and adolescents. The degree of the deformity, the age of onset, and the surgical experience of the orthopaedist are crucial factors in decision making for or against a surgical treatment. In early childhood, acetabuloplasty and Salter osteotomy are widely accepted to correct DDH. Triple and periacetabular osteotomies are preferred and have shown promising results in late adolescence and young adults. When the triradiate cartilage (growth plate) is closed, good outcomes can be achieved by the Ganz osteotomy. Intertrochanteric varus and derotation osteotomies of the femur may serve as additional procedures for pelvic osteotomies and are rarely indicated as a single procedure today.ConclusionReconstructive surgery on the hip joint improves function and may prevent early osteoarthritis and delay progression of cartilage degeneration in most patients when the indication and surgical technique are appropriate.BACKGROUND Joint-preserving reconstructive surgeries in children and adolescents remain challenging for orthopaedists with regard to indication and surgical technique. Besides skeletal maturity and tissue quality at the time of surgery, the kind and degree of deformity, the causative pathologies in secondary dysplasias, and the prognosis have to be considered when deciding for or against a surgical procedure. Developmental dysplasia of the hip (DDH) is the most frequent deformity that indicates reorienting surgery on the hip joint in children and adolescents. The aim of these procedures is to prevent early secondary osteoarthritis. For patients and families as well as for the orthopaedist, risk-benefit analysis is of major interest. METHODS In this study, the surgical techniques and specialties of different reconstructive operations are presented. Based on a review of the literature, the results of defined surgical methods are discussed and compared with own experiences. RESULTS Only limited information is available about the clinical long-term outcome after defined reconstructing surgery on the hip joint in children and adolescents. The degree of the deformity, the age of onset, and the surgical experience of the orthopaedist are crucial factors in decision making for or against a surgical treatment. In early childhood, acetabuloplasty and Salter osteotomy are widely accepted to correct DDH. Triple and periacetabular osteotomies are preferred and have shown promising results in late adolescence and young adults. When the triradiate cartilage (growth plate) is closed, good outcomes can be achieved by the Ganz osteotomy. Intertrochanteric varus and derotation osteotomies of the femur may serve as additional procedures for pelvic osteotomies and are rarely indicated as a single procedure today. CONCLUSION Reconstructive surgery on the hip joint improves function and may prevent early osteoarthritis and delay progression of cartilage degeneration in most patients when the indication and surgical technique are appropriate.

Axes of the legs in childhood. What is pathologic

ZusammenfassungBei der Geburt liegen in der Frontalebene des Unterschenkels und Kniegelenks eine varische Achse, in der Transversalebene am Femur eine vermehrte Antetorsion und im Unterschenkel eine Neutral- bis Innentorsion vor. Bis zum Wachstumsende entstehen valgische Beinachsen von 5–9°, die femorale Antetorsion bildet sich auf ca. 15° zurück und die Außentorsion des Unterschenkels nimmt zu (ca. 15°). Die sich mit zunehmender Vertikalisierung verändernden Druck- und Zugkräfte beeinflussen die Beinachsenentwicklung, die Streubreite des Physiologischen ist groß. Pathologische Beinachsenentwicklungen sind selten und oft idiopathisch bedingt. Sekundäre Ursachen sind vielfältig. Sorgfältige klinische Untersuchungen sind für die Differenzierung zwischen physiologischen und pathologischen Abweichungen notwendig. Die apparative Diagnostik kann Hinweise zur Genese geben und ist zur exakten Operationsplanung notwendig. Konservative Maßnahmen allein können die Achsentwicklung nicht wesentlich beeinflussen. Die operativen Optionen sind vielfältig.AbstractAt birth the lower extremity is characterized by a varus axis in the lower leg and the knee joint in the frontal plane (bowleg) and an increased femoral antetorsion and a neutral or increased medial torsion of the lower leg in the tranverse plane. By the time growth is complete a normal valgus axis of 5–9° has developed in the lower limb and the femoral antetorsion has decreased to about 15°. The lower leg will show a normal external rotation of 15° on average. The evolution of the axis values in the lower extremity is influenced by changing compressive and propelling forces acting on the growth plates as the child adopts an upright posture. There is a wide range of normal values, but pathologic development of the leg axes is rare and mostly idiopathic. Secondary deviations of the axis from normal can occur. Careful clinical examinations are necessary to differentiate between pathologic and physiological variations. Further apparative diagnostic procedures help to elucidate the etiology and are essential for surgical planning. Nonoperative treatment alone is rarely sufficient to influence the deformity.

Spastic equinus foot

Pes equinus is the most common deformity in cerebral palsy. A primarily dynamic pes equinus without shortening of the calf muscle in many cases turns into a structural pes equinus. This is due to insufficient linear growth of the calf muscle compared to bone growth. Structural pes equinus has to be distinguished from marked, compensatory and forefoot pes equinus. Conservative as well as operative treatment options are often applied in combination or sequentially. In dynamic pes equinus botulinum toxin A is the therapy of choice. Only slight structural pes equinus may improve under botulinum toxin A injection with and without additional casting. Usually, structural pes equinus requires operative treatment or lengthening of the gastrocnemius and/or soleus muscle (operation according to Baumann). Because of its side effect of inducing loss of power of the calf muscle, lengthening of the Achilles tendon should only be performed with caution. Especially in bilateral spastic cerebral palsy, the increased risk of causing talipes calcaneovalgus and crouch gait has to be considered.

Entwicklung der Beinachse im Kindesalter und Therapieoptionen bei kniegelenknahen Fehlstellungen

Krumme Beine sind ein häufiger Anlass,Kinder beim Kinderarzt oder Orthopäden vorzustellen. Am häufigsten bemerken die Eltern im Kleinkindalter O-Beine sowie einen Innenrotationsgang.Die Beurteilung, ob eine Beinachse noch normal oder pathologisch ist, setzt die genaue Kenntnis der physiologischen Beinachsenentwicklung voraus.Grundsätzlich sind alle 3 Ebenen des Raums zu beurteilen (Frontal-, Sagittal- und Transversalebene), da in jeder Ebene Abweichungen auftreten können.