T. Wirth

The Blood Supply of the Growth Plate and the Epiphysis: A Comparative Scanning Electron Microscopy and Histological Experimental Study in Growing Sheep

The blood supply of the growth plate has been described in the late 50s and early 60s, and there was controversial discussion about the existence of transphyseal vessels. The vascular supply of growth plate and epiphysis of the proximal tibia was reinvestigated using a modern technique, the Mercox-perfusion method, in six sheep aged 6-24 weeks. A comparison was made among pure perfusion specimens, the corrosion casts, and histological sections. The metaphyseal, epiphyseal, and perichondral blood supply systems were confirmed. However, there was evidence of regular transphyseal anastomoses between the metaphyseal and epiphyseal system. Based on the histological arrangement of the blood vessels, the arterial blood flow would appear to be from the metaphysis to the epiphysis. The existence of transphyseal arterial vessels originating metaphyseally and seen both in cast preparations and histological sections was added to the present description of the blood supply of the growth plate. Age-related differences in the vascularization of the growth plate were not found in this study.

Die elastische stabile intramedulläre Nagelung als Therapiealternative in der Versorgung kindlicher Humerusschaftfrakturen

AIM We report about our experiences with the elastic stable intramedullary nailing (ESIN) of traumatic humeral shaft fractures in children and adolescents. METHOD Children with traumatic humerus shaft fractures who were treated by ESIN were included. All patients underwent clinical follow-up examinations. RESULTS 31 children (average age 11.4 years) with traumatic humeral shaft fractures could be included. There were 14 oblique, 12 transverse and 5 wedge fractures. In 5 cases the fracture was located in the proximal third, in 22 cases in the middle third and in 4 cases in the distal third. After an average period of 32 months a follow-up-examination with the Constant-Murley score was performed. All children attained 100 points and all patients could take part in sports activities like before the accident. 30 children and their parents were very satisfied with the treatment success and 1 patient was satisfied. The following complications were seen: 1 postoperative damage of the radial nerve in a patient with secondary fracture dislocation (complete remission), 1 skin irritation, 1 fracture dislocation with axial deviation, 1 secondary dislocation of the nails after a second accident and 1 secondary axial deviation. CONCLUSIONS Elastic stable intramedullary nailing (ESIN) of humerus shaft fractures has a low complication rate if attention is paid to biomechanical principles. The observed complications are based on mistakes concerning the indication or technical errors. The ESIN shows very good functional and cosmetic results. It allows an early functional and cast-free follow-up with a quick pain reduction. The ESIN of humeral shaft fractures is a minimally invasive, simple and well reproducible technique with a steep learning curve. Because of the excellent objective and subjective results, the operative stabilization of humerus shaft fractures with ESIN should be recommended to the patients and their parents.

Prognose des Erfolges von Operationen an der Bandscheibe

The outcome of disk surgery in 40 consecutive patients was predicted by pre-treatment assessments of sociodemographic and psychological variables and findings in a standardised orthopaedic and neurological examination. The pre-surgery variables that proved to be associated with outcome criteria six months post surgery by means of a multiple stepwise regression procedure were selected for discriminant analyses, using three outcome criteria: functional status, patient evaluation of the outcome, and vocational rehabilitation. The correct classification rate was 85%, 77.5%, and 90%, respectively. No prediction was possible for postoperative pain behaviour and postoperative orthopaedic and neurological status. Significant predictors were time off work before surgery, active search for information about disease and surgery, presence of conditions that reinforce pain behaviour, and cognitive variables indicating helplessness.The outcome of disk surgery in 40 consecutive patients was predicted by pre-treatment assessments of sociodemographic and psychological variables and findings in a standardised orthopaedic and neurological examination. The pre-surgery variables that proved to be associated with outcome criteria six months post surgery by means of a multiple stepwise regression procedure were selected for discriminant analyses, using three outcome criteria: functional status, patient evaluation of the outcome, and vocational rehabilitation. The correct classification rate was 85%, 77.5%, and 90%, respectively. No prediction was possible for postoperative pain behaviour and postoperative orthopaedic and neurological status. Significant predictors were time off work before surgery, active search for information about disease and surgery, presence of conditions that reinforce pain behaviour, and cognitive variables indicating helplessness.ZusammenfassungVierzig konsekutive für eine Nukleotomie vorgesehene Patienten wurden daraufhin untersucht, ob der Operationserfolg neben orthopädisch-neurologischen Indikatoren auch durch psychologische Indikatoren vorhergesagt werden kann. Die psychologischen Indikatoren werden begründet durch verhaltensmedizinische Konzepte, die zur Chronifizierung von Schmerzen vorgelegt wurden. Der Operationserfolg wurde 1/2 Jahr postoperativ gemessen über die Schmerzintensität, den Funktionsstatus, die berufliche Rehabilitation, das Patientenrating des Erfolges und das Ergebnis der orthopädisch-neurologischen Untersuchung. Für die durch schrittweise multiple Regression aufgefundenen Prädiktorvariablen wurden Diskriminanzanalysen berechnet. Die Trefferquoten betrugen für den funktionellen Status 85%, für das Patientenrating des Operationserfolges 77,5% und für die berufliche Rehabilitation 90%. Postoperatives Schmerzverhalten und postoperativer orthopädisch-neurologischer Befund konnten nicht vorhergesagt werden. Bedeutsame Prädiktorvariablen sind die Dauer der Arbeitsunfähigkeit vor der Operation, die aktive Suche nach Information über die Erkrankung und die Operation, die Verstärkungsbedingungen des Schmerzverhaltens sowie Gedanken der Hilflosigkeit.

Arthroskopische Behandlung von septischen Hüftgelenksinfekten im Kindes- und Jugendalter

GOAL Irrigation of the hip joint by hip arthrotomy represents the standard treatment for septic arthritis of the hip in childhood and adolescence. Arthroscopic lavages for treating a septic knee, elbow, ankle and glenohumeral joints are well established, but have only reached little acceptance in the therapy of septic hip arthritis in children. The goal of this study is to evaluate the advantages of the minimally invasive arthroscopic high-volume lavage for septic hip arthritis with regards to treatment safety and complication frequency. PATIENTS AND METHODS 20 children aged 6.4 years on average (2-14 years) with obvious signs of septic arthritis of the hip proven clinically and by blood tests were arthroscopically treated in a 2-portal technique. In a prone position on a standard table the patient had the arthroscopic lavage procedure followed by insertion of a Redon tube. In all cases a histological sample and a bacterial swab were taken. A traction table was not used. In three children there was a stage I according to Stutz and Gächter, in thirteen a stage II and in four patients a stage III. Because of a concomitant femoral neck osteomyelitis in three cases and an osteomyelitis of the os pubis in a single patient, PMMA mini chains were locally administered. The histological samples were reported as purulent in 16 and as non-specific synovitis in four patients. In ten children a positive bacterial result was given, with Staphylococcus aureus found in 7 cases and single cases with Meningococci, Salmonella and Staphylococcus warneri. All patients received an intravenous antibiotic treatment for 14 days followed by four weeks of oral antibiotics. RESULTS 16 out of 20 children were sufficiently treated by one single arthroscopic lavage. In three cases with additional osteomyelitis a secondary procedure was needed for removal of the antibiotic chain. During follow-up after an average of 2.9 years 19 of 20 children demonstrated a free range of hip joint motion and a full sporting activity without any restrictions. One girl with stage III arthritis and a preoperative duration of symptoms of seven days developed a femoral head necrosis and chondrolysis with hip joint subluxation. The other 19 patients regained an excellent Harris hip score at follow-up, whereas the girl only produced moderate score values. So, 19 children had an unrestricted function of their hips on the same activity level as before. CONCLUSION The 2-portal hip arthroscopy with high-volume lavage represents a safe and minimally invasive method in order to successfully treat septic arthritis of the hip and concomitant femoral neck osteomyelitis in children and adolescents. This technique leads to a very low morbidity offering all advantages of arthroscopic procedures. The use of cannulated instruments through well established safe portals makes this arthroscopic lavage procedure a simple and easily adoptable technique.

Der Klumpfuß bei tibialer und fibularer Hemimelie

AIM Clubfoot is rarely associated with tibial or fibular hemimelia. Treatment is complex and in most of the cases extensive surgery is required. At present experience with Ponseti casting is limited. We describe casting and surgical treatment of 10 clubfeet associated with tibial and fibular hemimelia. MATERIAL AND METHOD Between 1.1.2004 and 31.12.2009 398 clubfeet were treated with casting in our institution. In the same period 10 clubfeet were associated with fibular or tibial hemimelia. Treatment started in 9 clubfeet with Ponseti manipulation and casting. We used the classification of Weber for tibial hemimelia and the Kalamchi-Achterman classification and Paley classification for fibular hemimelia. Data of all patients were prospectively documented and the result of the foot deformity was evaluated before a first lengthening procedure. Documentation included patient data, associated foot pathologies, surgical procedures, functional results. Functional results were evaluated before the first lengthening procedure started. RESULTS Three patients had tibial hemimelia, two Weber type 1, one Weber type 2, one Weber type 3. five patients had fibular hemimelia, Paley type IV or Kalamchi-Achterman Type IA. One child had bilateral fibular hemimelia. The prospective leg length discrepancy ranged from 3.2 cm to 14 cm. Four feet had initially a successful treatment with casting. In a type 2 according to Weber we performed an ankle reconstruction procedure to correct tibiofibular diastases. Four feet underwent PMR. We had four relapses. Two equinus relapses were treated with a posterior release. Two severe relapses were finally corrected with resection of the coalition and midfoot osteotomies. In a Weber type 3 case a complex reconstruction was performed using an Ilisarov and a TSF frame. Functional results showed in a mean follow-up of 42.2 months (24-72 months) a dorsiflexion between 5 and 20° (Ø 7.7°) and a plantarflexion between 10 and 40° (Ø 26.1°). CONCLUSION Treatment of clubfoot associated with tibial or fibular hemimelia with the Ponseti technique is limited because of complex hindfoot deformities including tarsal coalitions. Nevertheless treatment after birth starts with casting. Only mild cases of hemimelia without coalition can be corrected with the Ponseti technique. In a case of tibiofibular diastasis successful casting is possible, but extensive surgery is often necessary. In more severe cases we do not recommend casting. In these cases surgical treatment, including posteromedial release, osteotomies for the hindfoot, resection of coalitions or complex osteotomies with Ilisarov or TSF frame is the treatment of choice.

Korrektur von veralteten Monteggia-Verletzungen im Kindes- und Jugendalter

ZusammenfassungWährend die adäquat versorgte akute Monteggia-Läsion eine sehr gute Prognose hat, sind die Behandlungsergebnisse bei veralteten Monteggia-Frakturen sehr unterschiedlich. Durch ein größeres Verständnis der gesamten Verletzungen am Ellenbogen haben sich die Resultate deutlich gebessert. Verbleibt der Radiuskopf in einer Luxationsstellung, kommt es zu einer Fehlentwicklung am Radioulnar- und Radiohumeralgelenk.Wesentlichen Einfluss auf die Prognose der veralteten Monteggia-Fraktur haben: morphologische Veränderungen am Ellenbogengelenk, Luxationsdauer und das Patientenalter. Es bedarf eines individuellen Behandlungskonzeptes, um die unterschiedlichen komplexen Fehlstellungen zu korrigieren.Bei der Indikation zur Korrektur gilt es, abzuschätzen, inwieweit diese sinnvoll ist. Nicht jede Radiuskopfluxation muss zwingend reponiert werden; gelegentlich kann der sich einstellende Spontanzustand funktionell und vonseiten der Beschwerden besser sein als ein frustraner Korrekturversuch. Die vorliegende Arbeit führt Aspekte auf, die es bei der Versorgung von veralteten Monteggia-Läsionen zu beachten gilt. Der zentrale Korrekturpfeiler ist die Ulnaosteotomie, die von der einfachen angulierenden bis hin zur komplexen mehrdimensionalen Korrektur reicht. Das Resultat der Therapie ist bei der veralteten Monteggia-Läsion stark von der Erfahrung des Operateurs und der gewählten Operationstechnik abhängig.AbstractWhile adequately treated acute Monteggia lesions have a good prognosis, results in neglected Monteggia fractures are varied. Outcomes improved as a consequence of a better understanding of the pathology of the elbow joint. Persistent malposition of the radial head leads to maldevelopment of the radioulnar and radiohumeral joints. The following parameters have a crucial influence on prognosis of neglected Monteggia fractures: morphological changes of the elbow joint, duration of dislocation and the age of the patient. An individual treatment concept is necessary for an adequate correction of the complex malformations. Concerning the indications for corrective surgical procedures it is important to estimate whether they are advantageous. Not every dislocation of the radial head has to be treated and sometimes the spontaneous development can be functionally and symptomatically better than an unsuccessful attempt at correction. This publication presents the criteria which are necessary for a correct treatment of neglected Monteggia lesions. The key procedure of correction is osteotomy of the ulna which can range from simple angulation up to complex multidimensional corrections. The results of treatment of neglected Monteggia lesions depend strongly on the surgeon’s experience and the technique chosen.

The Influence of Local Vascular Regeneration on Growth Plate Activity after Defined Growth Plate Lesions

Background: The vascular anatomy of the growth plate is not yet fully understood with some reports on transphyseal vessels the role of which remains unclear. Further, the development of bone bridges and axial and longitudinal deformities cannot be completely explained with present knowledge. Material and Methods: Under general anesthesia, a Salter-Harris-II-fracture was created at the medial aspect of the proximal tibia in 16 immature sheep and stabilized by an external fixateur. The perfusion study in ten sheep used Mercox® and corrosion casts were obtained. The histological analysis of the remaining six sheep was made by conventional stains and immunohistochemistry against bromodeoxyuridine (BrdU) to evaluate the cell proliferation rate. The observation time was 0, 1, 2, 4, 6, and 12 weeks. Results: The healing process of growth plate fractures followed a regular pattern. After posttraumatic depression of any proliferation up to 1 week, a rich neovascularization took place seen in the vascular casts and the histological sections. This phenomenon was dominant until the 6th week after injury. Then, the hypervascularity and the proliferation rate returned to normal. The temporary hypervascularity was closely associated with the increased proliferation rate demonstrated by immunohistochemistry. Conclusions: Healing growth plate fractures is dominated by the vascular response to the injury. The temporary hypervascularity 1–6 weeks after the fracture leads to a higher proliferation rate of the chondrocytes in the proliferative zone. These results may be one explanation for the development of posttraumatic longitudinal and angular deformities as a result of temporary hypervascularity.

Der transinguinale Ultraschall zur Bestimmung der Hüftkopfzentrierung in der Behandlung der Hüftdysplasie und Hüftluxation

AIM Determination of the femoral head position after closed or open reduction and application of a spica cast is possible by X-ray, MRI, CT or transinguinal ultrasound. In this study we compared the efficacy of transinguinal ultrasound and radiography. Further options with transinguinal ultrasound such as the determination of soft tissue and intraoperative possibilities are also described. MATERIAL AND METHODS In a first cohort of 25 patients with 33 affected hips ultrasound and radiography were compared. In a second cohort of 8 patients with 11 affected hips ultrasound and arthrography were compared. RESULTS 32 radiographs proved to be not useful for the precise determination of the femoral head position. In all ultrasound images the criteria described by van Douveren et al. could be identified. All ultrasound images in the study were useful and gave reliable information with regard to the femoral head position. CONCLUSION Consequently, standard radiographic documentation is no longer used as a standard in our clinic. MRI and CT are reserved for special cases. We recommend transinguinal ultrasound as a standard diagnostic method for determination of the femoral head position in hip spica casts. With a portable ultasound system, determination of the hip position using transinguinal ultrasound is immediately possible in the operating theatre.

Predicting Quality of Life After Lumbar Spondylodesis

Quality of life after spondylodesis was predicted by pretreatment psychological variables and findings in a standardized physical examination. Four quality-of-life criteria were used: functional capacity, vocational rehabilitation, satisfaction with the outcome of the operation, and pain intensity recorded in a pain diary. Those of six presurgery variables that proved to be associated with the outcome 9 months postsurgery, by means of a multiple stepwise regression procedure, were selected for discriminant analyses. The sample consisted of 50 consecutive patients who underwent either ventral (n = 10) or posterolateral (n = 40) spondylodesis with or without posterior instrumentation. Their average age was 44.9 years (SD = 12.9) with an average duration of pain of 8.6 years (SD = 8.8). Nearly half of the patients had had previous spine surgery. Follow-up data indicate that about half of the patients show a beneficial outcome in terms of quality-of-life measures. Discriminant analyses suggest that poor presurgical functional capacity and an unclear finding in the physical examination before surgery contribute to our knowledge about patients who are likely to show continuous pain and poor functional capacity after surgery.

Prognose des Erfolges von Operationen an der Bandscheibe@@@Predicting the outcome of diskectomy: Eine Untersuchung an Patienten mit Schmerzen nach einem lumbalen Bandscheibenvorfall

The outcome of disk surgery in 40 consecutive patients was predicted by pre-treatment assessments of sociodemographic and psychological variables and findings in a standardised orthopaedic and neurological examination. The pre-surgery variables that proved to be associated with outcome criteria six months post surgery by means of a multiple stepwise regression procedure were selected for discriminant analyses, using three outcome criteria: functional status, patient evaluation of the outcome, and vocational rehabilitation. The correct classification rate was 85%, 77.5%, and 90%, respectively. No prediction was possible for postoperative pain behaviour and postoperative orthopaedic and neurological status. Significant predictors were time off work before surgery, active search for information about disease and surgery, presence of conditions that reinforce pain behaviour, and cognitive variables indicating helplessness.The outcome of disk surgery in 40 consecutive patients was predicted by pre-treatment assessments of sociodemographic and psychological variables and findings in a standardised orthopaedic and neurological examination. The pre-surgery variables that proved to be associated with outcome criteria six months post surgery by means of a multiple stepwise regression procedure were selected for discriminant analyses, using three outcome criteria: functional status, patient evaluation of the outcome, and vocational rehabilitation. The correct classification rate was 85%, 77.5%, and 90%, respectively. No prediction was possible for postoperative pain behaviour and postoperative orthopaedic and neurological status. Significant predictors were time off work before surgery, active search for information about disease and surgery, presence of conditions that reinforce pain behaviour, and cognitive variables indicating helplessness.ZusammenfassungVierzig konsekutive für eine Nukleotomie vorgesehene Patienten wurden daraufhin untersucht, ob der Operationserfolg neben orthopädisch-neurologischen Indikatoren auch durch psychologische Indikatoren vorhergesagt werden kann. Die psychologischen Indikatoren werden begründet durch verhaltensmedizinische Konzepte, die zur Chronifizierung von Schmerzen vorgelegt wurden. Der Operationserfolg wurde 1/2 Jahr postoperativ gemessen über die Schmerzintensität, den Funktionsstatus, die berufliche Rehabilitation, das Patientenrating des Erfolges und das Ergebnis der orthopädisch-neurologischen Untersuchung. Für die durch schrittweise multiple Regression aufgefundenen Prädiktorvariablen wurden Diskriminanzanalysen berechnet. Die Trefferquoten betrugen für den funktionellen Status 85%, für das Patientenrating des Operationserfolges 77,5% und für die berufliche Rehabilitation 90%. Postoperatives Schmerzverhalten und postoperativer orthopädisch-neurologischer Befund konnten nicht vorhergesagt werden. Bedeutsame Prädiktorvariablen sind die Dauer der Arbeitsunfähigkeit vor der Operation, die aktive Suche nach Information über die Erkrankung und die Operation, die Verstärkungsbedingungen des Schmerzverhaltens sowie Gedanken der Hilflosigkeit.