R. Krauspe

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.

Epiphysenlösung@@@Slipped capital femoral epiphysis

Slipped capital femoral epiphysis (SCFE) is a common hip disorder in adolescence and should be diagnosed and treated surgically as soon as possible. The etiology, biomechanical, biochemical and hereditary factors are still under investigation. The classification of SCFE is based on the acuteness, clinical and radiomorphological findings. Avascular necrosis of the epiphysis (AVN) and chondrolysis occur more often in operated than in non-operated patients. Medium and long-term sequelae of SCFE are loss of function and degenerative joint disease due to femoroacetabular impingement (FAI) or consequences from complications such as AVN and chondrolysis. For mild slips the long-term prognosis is better than for moderate or severe slips. Higher grade unstable SCFE may benefit from reduction while in chronic slips corrective osteotomy may be indicated. Traditional osteotomy procedures, such as Imhäuser or Southwick intertrochanteric osteotomy are safe procedures but correct the deformity distant from the site of the deformity. The surgical dislocation with modified Dunn osteotomy according to Ganz allows the preparation of an extended retinacular soft tissue flap and offers an extensive subperiosteal exposure of the circumference of the femoral neck before reducing the slipped epiphysis anatomically. In cases of FAI due to mild deformities restoration of the head-neck offset via hip arthroscopy or surgical dislocation should be considered before higher grade cartilage damage occurs.

Zelltherapie bei Knochenheilungsstörungen

In addition to stabilizing osteosynthesis and autologous bone transplantation, so-called orthobiologics are playing an increasing role in the treatment of bone-healing disorders. Besides the application of different growth factors, new data in the literature suggest that cell therapeutic agents promote local bone regeneration. Due to ethical and biological considerations, clinical application of progenitor cells for the musculoskeletal system is limited to autologous postpartum stem cells. Here in particular, cell therapy with autologous progenitor cells in one surgical session has delivered first promising results. Based on a review of the literature and on our own experience with 75 patients, this article reviews the rationale and characteristics of the clinical application of cell therapy for the treatment of bony substance defects. Most clinical trials report successful bone regeneration after the application of mixed cell populations from bone marrow.

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.

Surgical hip dislocation in symptomatic cam femoroacetabular impingement: what matters in early good results?

In order to assess outcome and possible predictors of early good results, a prospective study on 22 patients who were treated with save surgical hip dislocation for symptomatic isolated cam-type femoroacetabular impingement (FAI) was performed. After a follow-up of 6 and 12 months, standard clinical and radiographic parameters were recorded. A statistically significant improvement of the clinical status according to the Harris hip score could be assessed at six months (p-value = 0.003) and 12 months (p-value = 0.001) post-surgery. By comparing standard clinical and radiographic preoperative parameters with various follow-up outcomes, we revealed no specific parameter with predictive value. These findings are important for centers that have just started to use this surgical technique and are still identifying their learning curve.

[Cell therapy in bone-healing disorders].

In addition to stabilizing osteosynthesis and autologous bone transplantation, so-called orthobiologics are playing an increasing role in the treatment of bone-healing disorders. Besides the application of different growth factors, new data in the literature suggest that cell therapeutic agents promote local bone regeneration. Due to ethical and biological considerations, clinical application of progenitor cells for the musculoskeletal system is limited to autologous postpartum stem cells. Here in particular, cell therapy with autologous progenitor cells in one surgical session has delivered first promising results. Based on a review of the literature and on our own experience with 75 patients, this article reviews the rationale and characteristics of the clinical application of cell therapy for the treatment of bony substance defects. Most clinical trials report successful bone regeneration after the application of mixed cell populations from bone marrow.

Osteonecrosis after chemotherapy in children

The application of modern chemotherapy protocols has improved healing and survival rates significantly in pediatric malignancies. As a result, the long-term drug-related side effects are becoming increasingly apparent. Avascular osteonecrosis (AVN) occurs in up to 40% of all patients who have undergone chemotherapy, the average time of onset being 12-18 months after chemotherapy. Compared to other bones, the weight-bearing regions of hip and knee joints are most commonly affected. Incidentally and in early stages, AVN may show only mild symptoms or may not be clinical apparent. Typical risk factors for AVN after chemotherapy are the application of glucocorticoids and an age of 10 ys. and older. The etiology remains unclear. In early stages, AVN can be detected by magnetic resonance imaging (MRI). Evidence-based, standardized therapeutic concepts or orthopedic guidelines are not available for these patients to date. The range of treatment options includes several operative and non-operative treatment alternatives.

Spinning around or stagnation - what do osteoblasts and chondroblasts really like?

ObjectiveThe influcence of cytomechanical forces in cellular migration, proliferation and differentation of mesenchymal stem cells (MSCs) is still poorly understood in detail.MethodsHuman MSCs were isolated and cultivated onto the surface of a 3 × 3 mm porcine collagen I/III carrier. After incubation, cell cultures were transfered to the different cutures systems: regular static tissue flasks (group I), spinner flasks (group II) and rotating wall vessels (group III). Following standard protocols cells were stimulated lineage specific towards the osteogenic and chondrogenic lines. To evaluate the effects of applied cytomechanical forces towards cellular differentiation distinct parameters were measured (morphology, antigen and antigen expression) after a total cultivation period of 21 days in vitro.ResultsDepending on the cultivation technique we found significant differences in both gen and protein expression.ConclusionCytomechanical forces with rotational components strongly influence the osteogenic and chondrogenic differentiation.