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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. 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. 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. 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.

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

Die Huftdysplasie ist eine der haufigsten Erkrankungen in der Kinderorthopadie. Die Behandlung hat sich mit Einfuhrung der Sonographie wesentlich verandert. Die Diagnose und die Therapie haben sich in das fruhe Sauglingsalter vorverlagert. Damit befinden wir uns seit mehr als 20 Jahren in einer Zeit, in der die Huftdysplasiebehandlung durch die Sonographie bestimmt wird. Eine grose Menge an neuen Publikationen ist hinzugekommen. Bildgebende Verfahren wie die Magnetresonanztomographie zeigen neue Aspekte auf. Mit der Arthroskopie ist ein neues operatives Verfahren hinzugekommen. Dennoch spielen viele – vor allem in der operativen Therapie – bewahrte Techniken weiterhin eine grose Rolle. In dieser Arbeit werden neue und bewahrte diagnostische Verfahren sowie konservative und operative therapeutische Masnahmen dargestellt. Dabei muss berucksichtigt werden, dass bei der Vielzahl der Literatur nicht alle Aspekte im Detail beleuchtet werden konnen. Die Arbeit orientiert sich vor allem an der durch ein Huftscreening im deutschsprachigen Raum etablierten Behandlung. Aber internationale diagnostische und therapeutische Sichtweisen sollen einbezogen werden.

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.

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.The present retrospective study includes data on all paediatric cases from 2002 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.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° and two by 10°-20°. 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° 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).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.Die Fraktur des Condylus ulnaris humeri ist eine sehr seltene Salter-Harris-IV-Verletzung des kindlichen Ellenbogens. Aufgrund stetiger radiologischer Veränderungen am Ellenbogen mit unterschiedlichem Auftreten der Ossifikationskerne sowie einer späten Ossifikation der Trochlea ist die Diagnosestellung eine Herausforderung. Um Langzeitkomplikationen zu vermeiden, sollte dem behandelnden Chirurgen das seltene Krankheitsbild, die Diagnostik und adäquate Therapie bekannt sein.Im Rahmen einer retrospektiven Untersuchung wurden alle Kinder erfasst, die eine Condylus-ulnaris-Fraktur zwischen 2002 und 2019 erlitten haben und an einer einzelnen kindertraumatologischen Schwerpunktklinik primär oder sekundär behandelt wurden. Das Follow-up betrug mindestens 12 Monate. Im Rahmen einer klinischen Nachuntersuchung wurde der Bewegungsumfang, die Gelenkstabilität in Valgus- und Varusstress sowie die Achsenverhältnisse im Seitenvergleich überprüft. Zur Objektivierung der funktionellen Ergebnisse wurde der Mayo-Ellenbogen-Performance-Score verwendet.20 Kinder mit einem Durchschnittsalter von 8,6 Jahren (4 – 13) und einer durchschnittlichen Nachbeobachtungszeit von 25 Monaten konnten eingeschlossen werden. Die radiologische Auswertung anhand der Jakob-Fowles-Klassifikation ergab eine Typ-I-Fraktur in 3 Fällen, eine Typ-II-Fraktur in 1 Fall sowie eine Typ-III-Fraktur in 16 Fällen. Bei 3 Kindern wurde eine konservative Behandlung mit Oberarmgips durchgeführt, bei 17 Kindern eine offene Reposition und osteosynthetische Versorgung. Bei 3 Frakturen erfolgte eine verspätete Diagnosestellung. Es traten keine postoperativen Komplikationen wie Infekte, Nervenschäden oder Pseudarthrosen auf. 15 Kinder zeigten eine freie Funktion des Ellenbogens. Drei Kinder zeigten ein leichtes Streckdefizit von unter 10° und 2 Kinder ein Streckdefizit von 10 – 20°. Alle Kinder hatten eine freie Unterarmumwendbewegung. 18 Kinder zeigten eine physiologische und seitengleiche Armachse. Zwei Kinder zeigten einen leicht verstärkten Cubitus valgus mit 5 – 10° Seitendifferenz. Radiologisch zeigten 2 Kinder mit verspätet versorgten Frakturen eine partielle Nekrose der Trochlea. Der Mayo-Ellenbogen-Score zeigte gute (2) bis exzellente Ergebnisse bei allen Kindern (18).Wird die Diagnose ohne Verzögerung gestellt sowie eine adäquate Therapie durchgeführt, ist mit einem sehr guten klinisch-funktionellen Ergebnis zu rechnen. Das Nichterkennen einer Condylus-ulnaris-Fraktur kann mit der Entwicklung einer Pseudarthrose mit funktionellen Einschränkungen sowie nach operativer Therapie mit einer Trochleanekrose einhergehen. Kinder bis zum 6. Lebensjahr sind hier besonders betroffen aufgrund der Fehleinschätzung der noch knorpeligen Trochlea.

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.

ZusammenfassungDer kindliche Knick-Senk-Fuß ist eine 3-dimensionale Fußfehlstellung mit vermehrter Valgusstellung der Ferse, Abflachung der medialen Längswölbung und Abduktion des Vorfußes. Man unterscheidet die flexible von der kontrakten (rigiden) Form. Die Diagnostik gliedert sich in Anamnese, klinische Untersuchung, apparative Diagnostik wie Pedobarografie und die Ganganalyse sowie bildgebende Verfahren. Wichtig ist die Einbeziehung in ein Therapieschema von eventuell vorliegenden pädiatrischen oder neuropädiatrischen Erkrankungen (z. B. Muskeldystrophien, Ehlers-Danlos- oder Marfan-Syndrom u. Ä.). Es zeigt sich, dass bei Kindern ≤ 6 Jahre der flexible Knick-Senk-Fuß fast ausschließlich physiologisch vorkommt (bei 97% aller 19 Monate alten Kinder). Bis zum Alter von 10 Jahren bildet sich die mediale Fußlängswölbung zunehmend aus. Bei einem kleinen Anteil (10-jährige Kinder 4%) persistiert der Knick-Senk-Fuß oder wird progredient. Oberhalb von 10 Jahren besteht die Gefahr der Dekompensation mit zunehmender Rigidität. Nur die Minderheit der Kinder entwickelt eine Schmerzsymptomatik (

The medial condyle fracture of the humerus is-in comparison to the lateral condyle fracture-a very rare Salter-Harrison IV-fracture of the elbow. In this prospective study 14 children were included and reviewed. One child had minimal displacement fracture type I, one child had type II, and 12 children had type III-fractures. One patient was treated conservatively by an upper arm cast; thirteen were surgically treated using open reduction and osteosynthetical treatment. Postoperatively the elbow was immobilized in 90° flexion and neutral position in a long-arm cast for 4-6 weeks. In 11 children the diagnosis was made immediately after trauma, in 3 children the fracture was overlooked initially. Medial condyle fractures may be difficult to diagnose in children younger than 6 years and the lesion may be mistaken for a simple avulsion of the medial epicondyle or even missed. The C-sign is a hint for a medial condyle fracture. The development of nonunion happens in consequence of failure to recognize the fractures. Results after an average follow-up of 36 months showed that children who were diagnosed immediately and received operative stabilization had very good functional and aesthetical results. Three children with delayed diagnosis of the fracture had open surgery with reposition and osteosynthetical fixation. In two of the overlooked cases a slight contracture and angular misalignment persisted. If in this injury the diagnosis is made without delay, an appropriate therapy is implemented and radiographical controls are performed until consolidation, good results can be expected. The main risk in medial condyle fractures of the humerus is to overlook them. This can lead to the development of a nonunion with joint malformations.

The aim of this study is to evaluate the clinical, radiographic short-term results and complications after surgical hip dislocation in young patients (≤18 years). Clinical and radiographic outcomes were assessed in patients who underwent a surgical hip dislocation Ganz-type approach between 2008 and 2012. Diagnosis included Legg–Calve–Perthes disease, slipped capital femoral epiphysis, femoroacetabular impingement, osteonecrosis of the femoral head, multiple hereditary exostoses and pigmented villonodular synovitis. Clinical data, the modified Harris hip score, nonarthritic hip score, 12-item short form health survey, the Stulberg classification, morphometric indexes, signs of osteonecrosis and osteoarthrosis were used for the evaluation. After a mean 3 years follow-up (range 0.5–6 years), 53 hips (51 patients) were evaluated. The most common diagnoses were Legg–Calve–Perthes disease, slipped capital femoral epiphysis, femoroacetabular impingement and multiple hereditary exostoses. Mean age at surgery was 14 years (range 10–18 years). Through this approach femoral head-neck osteoplasty, Dunn-type osteotomy, labrum refixation, synovectomy, femoral head mosaicplasty open reduction and fixation for slipped capital femoral epiphysis were performed, finally in association with pelvic or intertrochanteric osteotomy. At follow-up, better outcome scores were obtained, progression of the osteonecrosis of the femoral head was observed in four cases and three further patients required the implant of a total hip prosthesis. After 3 years follow-up, results are comparable to previous studies and patients have a high rate of satisfaction, however the effectiveness of those procedures have to be proved on the long term. Results and complications seem to be related with preoperative lesion(s) and type of treatment. Level IV, retrospective study, case series.

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 berucksichtigen. Die Darstellung …

Tibial tubercle avulsion fractures are rare, they represent less than 1% of all physeal fractures. Compared to monolateral tibial tubercle avulsion fractures, bilateral occurrence is even rarer. The purpose of this study is to report about the so far largest group of bilateral avulsion fractures and to compare them to unilateral fractures as well as to current literature.All patients who suffered from bilateral tibial tubercle fractures between January 2009 and March 2019 were included. All medical records and radiographs were reviewed and a clinical follow-up was performed. The examined criteria were age, gender, mechanism of injury, classification, risk factors, complications, management and outcomes. Clinical outcome was measured using the well established Tegner activity scale and Lysholm-Gillquist score. The same criteria were analyzed in a literature review of bilateral tibial tubercle fractures to compare our results to available literature.We found four children with bilateral tibial tubercle avulsion fractures. All patients were male with a mean age of 14.5 ± 0.7 years (13 - 15). Mean follow-up examination was 13.6 ± 6.5 months (8 - 29) after surgery. The avulsions occurred during jumping activities in all cases. All children could no longer stand or move because of sudden pain in the knee. We found type IV fractures in three cases, type III fractures in four cases and one type V fracture according to the Ogden classification. All children were treated by open or closed reduction and stabilization with screws or K-wires. Follow-up showed complete fracture healing without complications in all patients. There were no changes in Tegner activity scale and Lysholm-Gillquist Score and knee function comparable to prior to the accident was achieved in all cases.Good clinical results without restrictions regarding function of the knee joint can be achieved by direct operative treatment of bilateral tibial avulsion fractures. A reduction in sporting activity has not to be expected. There were no differences between bilateral or unilateral tibial tubercle avulsion fractures.Bei der Avulsionsfraktur der Tuberositas tibiae handelt es sich um eine seltene Verletzung im Wachstumsalter. Das simultane Auftreten der beidseitigen Verletzung ist eine Rarität. Langzeitkomplikationen im Sinne von Achsdeformitäten und Beinlängendifferenzen sind zu vermeiden. Im Rahmen der vorliegenden Arbeit sollen klinische Ergebnisse der beidseitigen Verletzung anhand der bislang größten publizierten Fallserie dargestellt und mit klinischen Ergebnissen der einseitigen Verletzung verglichen werden.Alle Jugendlichen, die zwischen Januar 2009 und März 2019 monozentrisch an einer kindertraumatologischen Schwerpunktklinik aufgrund einer beidseitigen Avulsionsverletzung der Tuberositas tibiae behandelt wurden, konnten bis zum Schluss der Wachstumsfugen klinisch sowie radiologisch nachuntersucht werden. Das klinische Ergebnis wurde mittels Tegner-Aktivitätsscore sowie Lysholm-Gillquist-Score retrospektiv zum Zeitpunkt vor dem Unfall sowie zum Zeitpunkt der letzten Follow-up-Untersuchung bestimmt. Alle Frakturen wurden anhand der modifizierten Ogden-Klassifikation eingeteilt. Patientenspezifische Parameter wurden aus dem Krankenhausinformationssystem entnommen. Anhand einer Literaturrecherche wurden die Ergebnisse mit den bislang publizierten Fällen zur beidseitigen/einseitigen Verletzung verglichen.Vier Patienten (8 Fälle) konnten zur weiteren deskriptiven statistischen Auswertung eingeschlossen werden. Das Alter zum Unfallzeitpunkt betrug 14,5 ± 0,7 Jahre (13 – 15). Das letzte Follow-up erfolgte 13,6 ± 6,5 Monate (8 – 29) nach dem Unfallereignis bei Verschluss der Wachstumsfugen. Nach modifizierter Ogden-Klassifikation zeigte sich in 3 Fällen eine Typ-IV-Verletzung, in 4 Fällen eine Typ-III-Verletzung und in 1 Fall eine Typ-V-Verletzung. In allen Fällen erfolgte die unmittelbare operative Versorgung mittels Schrauben bzw. K-Draht-Osteosynthese. Es konnte in allen Fällen das Aktivitätslevel vor dem Unfallereignis wieder erreicht werden. Tegner-Aktivitätsscore sowie Lysholm-Gillquist-Score zeigten keine Veränderungen zum Ergebnis vor dem Unfallereignis.Mittels direkter operativer Versorgung im Sinne einer offenen oder geschlossenen Reposition und Stabilisierung mittels Schrauben- und/oder K-Draht-Osteosynthese können sehr gute klinische Ergebnisse mit voller Kniegelenkfunktion und geringen Komplikationsraten nach Schluss der Wachstumsfugen erzielt werden. Eine Rückkehr in die vorherige sportliche sowie Alltagaktivität ist zu erwarten. Im Hinblick auf Alter, Geschlecht, Unfallursache sowie das klinische Ergebnis ergibt sich kein Unterschied zum in der Literatur beschriebenen unilateralen Verletzungsmuster.

Purpose Children with sonographic grade IV hip dysplasia according to Graf and with failed conservative treatment usually need surgical reduction afterwards. Surgical reduction of the hip can lead to severe complications, the occurrence of residual acetabular dysplasia, osteonecrosis, redislocation and other postoperative complications. This paper investigates whether arthroscopic reduction is a promising alternative to open reduction. Methods We retrospectively examined 66 patients (78 hips) who were not older than two years at the first time of surgery. Arthroscopic reduction was performed on 17 children (19 hips) and open reduction on 49 children (59 hips). Patient records were used to determine redislocation, postoperative complication and residual dysplasia. Radiographs were used to determine Tönnis classification for osteonecrosis and pathological acetabular (AC) angle for residual dysplasia. We considered data up to a two-year follow-up. Statistical evaluation was performed with binary logistic regression. Results After arthroscopic reduction, 6% showed osteonecrosis, compared with 20% with open reduction (p = 0.334). Redislocation was not observed after arthroscopic reduction but for 29% after open reduction (p = 0.005). An improvement of femoral head coverage was achieved with residual dysplasia of 23.5% after arthroscopic reduction, compared with 62% after open reduction (p = 0.002). Conclusion The arthroscopic procedure represents a meaningful alternative to the open procedure due to a lower complication rate, a safe setting, a lower rate of residual dysplasia, no observed redislocation and occurrence of osteonecrosis only once in the arthroscopic group of developmental dysplasia of the hip. The arthroscopic procedure should be tested in further studies and in other clinics in order to broaden the empirical base. Level of Evidence Level III (retrospective cohort study)

Purpose The purpose of this study was to describe the anatomy as seen arthroscopically, the role of the labrum and its relevance in luxation and reduction procedures, and secondary changes to the cartilaginous acetabular roof and to determine the main obstacles preventing reduction of dislocated hips in infants and young children. Methods A specialized pediatric medial approach to hip arthroscopy was performed on 25 hip joints in 21 patients younger than 4 years of age. The arthroscopic procedure was conducted using a 2.7-mm cannulated instrument. A subadductor portal was used for the 70° arthroscope, and a high anterolateral portal served as a working portal. The anatomic findings of the individual hip joints were recorded. We examined the femoral head, the teres ligament, the transverse ligament, the acetabulum, and the acetabular labrum. The obstacles preventing reduction were successively resected. Results An arthroscopic investigation of all major structures and arthroscopic reduction was possible in 25 hip joints. A hypertrophic teres ligament was present in 23 of the 25 hips. Capsular constriction prevented reduction in 22 of the 25 hips. The acetabular labrum was not inverted in any of the examined hip joints and was also never an obstacle to reduction. Secondary changes to the cartilaginous preformed acetabular roof were present in 10 hips. Conclusions We have shown that arthroscopy of a developmentally dislocated hip can be safely performed using the subadductor portal. Through this arthroscopic approach, we were able to identify the previously described pathologic structures—the limbus, neolimbus, pulvinar, hypertrophic teres ligament, and capsular constriction. The capsule was the most common block to reduction, followed by the teres ligament. Successful reduction can be achieved by removal of intra-articular tissues, the pulvinar, and the teres ligament, and nearly always a capsular release. The limbus and neolimbus were not factors in achieving reduction in our series. Level of Evidence Level IV, case series.

Flatfoot is a severe complication of extensive clubfoot surgery. In this retrospective study, we evaluated our results following flatfoot surgery in overcorrected clubfeet. The aim was to analyze the success of different surgical techniques, including tarsal osteotomies and arthrodesis, in correcting different types of flatfeet. Between January 1, 2011 and December 31, 2015 we treated 25 severe cases of flatfeet after extensive clubfoot surgery. We classified the hindfoot deformities into rotational valgus, hinge valgus or translatory valgus based on AP standing X-rays. Tarsal osteotomies (Mitchell, Evans, Cotton) and arthrodesis were adapted based on age and severity. Age, gender, pain, hindfoot valgus and function were documented. Function and X-rays were compared pre- and postoperatively. There were 17 male and 4 female patients. Age at operation ranged from 11 to 26 years with an average age of 14.3 years. The mean follow-up was 27.6 months (7–60 months). Primary surgical treatment was a tarsal osteotomy in 19 cases and in six cases it was arthrodesis. Hindfoot valgus (O 18.6°–3.2°), calcaneal pitch (O 6.2°–14.6°), Costa Bartani angle (O155°–142°) and Meary angle (O 2.0°–8.8°) improved pre- to postoperatively. Range of motion did not improve after surgical correction. 81% were satisfied with the postoperative results. All flatfeet with translatory valgus, initially treated with a tarsal osteotomy, needed further arthrodesis due to primary undercorrection. Tarsal osteotomies are successful methods for correcting flatfeet following extensive clubfoot surgery with rotational valgus and mild hinge valgus. Tarsal osteotomies are unable to successfully correct flatfeet that have a translatory valgus. In such cases, we recommend double or triple arthrodesis. The functional outcome is limited by the preop range of motion and the appearance of talus deformities.

Wahrend die adaquat versorgte akute Monteggia-Lasion eine sehr gute Prognose hat, sind die Behandlungsergebnisse bei veralteten Monteggia-Frakturen sehr unterschiedlich. Durch ein groseres Verstandnis 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.

Hintergrund: Die Behandlung der Huftgelenksinstabilitat bei Kindern mit dem Down-Syndrom ist eine grose Herausforderung. An unserem Klinikum wurden im zeitlichen Verlauf zur operativen Behandlung verschiedene Beckenosteotomien und Korrektureingriffe am proximalen Femur durchgefuhrt. Ziel dieser retrospektiven Studie ist es, diese durchgefuhrten Operationsverfahren auf das postoperative klinische und radiologische Ergebnis zu untersuchen. Material und Methoden: Die Patienten rekrutierten sich aus einem Gesamtkollektiv von 166 Patienten mit dem Down-Syndrom. Von diesen waren 63 Patienten wegen Huftgelenksproblemen in Behandlung. Ausschlieslich die operativ versorgten Patienten wurden in diese Studie eingeschlossen. Die vollstandig vorhandenen Patientenakten und Rontgenbilder dieser 31 Patienten wurden hinsichtlich folgender Parameter ausgewertet: Auftreten der Huftgelenksbeschwerden, Begleiterkrankungen, zeitliche Progredienz der Erkrankung, ausgewahltes OP-Verfahren und dessen Zeitpunkt, Lange des stationaren Aufenthalts, Nachbehandlung und etwaige Reoperationen aufgrund von Komplikationen, AC-Winkel, CE-Winkel, ACM-Winkel, CCD-Winkel, Migrationsindex nach Reimers, Kongruenzstufen nach Bauer und Kerschbaumer sowie allgemeine Morphologie des Femurkopfs. Um einen Vergleich der Krankheitsverlaufe mit Kindern ohne Trisomie 21 stellen zu konnen, wurden – im Sinne einer Matched-Pair-Analyse – 18 Patienten mit kongenitaler Huftdysplasie aus der Kartei unseres Klinikums herausgesucht, die sich im selben Jahr einer gleichen Operation unterzogen. Ergebnisse: Insgesamt wurden bei den 31 beobachteten Patienten mit dem Down-Syndrom 49 huftgelenkserhaltende Operationen durchgefuhrt. Diese umfassten 13 Osteotomien nach Chiari, 11 Triple-Osteotomien nach Tonnis, 10 reine intertrochantare derotierende Varisationsosteotomien (IDVO), 8 Azetabuloplastiken nach Pemberton, 5 Beckenosteotomien nach Salter und 2 offene Huftgelenksrepositionen. Drei Altersgipfel hinsichtlich Zeitpunkt des operativen Eingriffs liesen sich bei der Morbus-Down-Gruppe feststellen. Bezuglich der Krankheitsverlaufe und der Anzahl aufgetretener Komplikationen unterschieden sich die beiden Gruppen nicht wesentlich. Klinisch und radiologisch uberzeugende Ergebnisse wurden uberwiegend mit reorientierenden Beckenosteotomien erzielt. Bei ausschlieslicher Behandlung mittels IDVO kam es in 50 % der Falle zu Nachoperationen in Form von Beckenosteotomien. Die Hypermobilitat des Muskel- und Bandapparats bei Kindern mit dem Down-Syndrom lies sich im Gegensatz zur Kontrollgruppe anhand des Vergleichs des pra- und postoperativen Bewegungsausmases am Huftgelenk feststellen. Der Vergleich der Rontgen-Beckenubersichtsaufnahmen zeigte bei beiden Gruppen eine signifikante Verbesserung der gemessenen Winkel. Die praoperativ gemessenen Werte fur den AC- und CE-Winkel waren bei der Huftdysplasie-Kontrollgruppe signifikant schlechter als bei den Kinder der Morbus-Down-Gruppe (p

Ziel: Durch die Anderung der Therapie der Unterarmschaftfrakturen von einer eher konservativen zur einer zunehmenden operativen Stabilisierung, insbesondere durch die elastische stabile intramedullare Nagelung (ESIN), treten nun Komplikationen auf, die bisher als solche im Kindesalter kaum beschrieben sind. Uber Pseudarthrosen nach operativ versorgten Unterarmschaftfrakturen des Kindes und der Jugendlichen wird nur vereinzelt, im deutschsprachigen Raum noch gar nicht berichtet. Das Ziel dieser Studie ist es, pradisponierende Faktoren herauszuarbeiten, die nach Operation von Unterarmschaftfrakturen Pseudarthrosen begunstigen. Methode: Im Zeitraum von 1990 bis 2011 wurden alle Kinder mit einer Pseudarthrose nach Unterarmschaftfraktur, die in unserer Klinik behandelt wurden, eingeschlossen. Berucksichtigt wurden alle Kinder, bei denen 6 Monate nach einer Unterarmfraktur noch keine knocherne Konsolidierung ihrer Unterarmschaftfraktur erfolgt war. Ausgeschlossen wurden alle Pseudarthrosen, die eine Grunderkrankung als Ursache hatten. Ergebnisse: Wahrend eines Zeitraums von 21 Jahren wurden 14 Kinder behandelt, welche die Kriterien einer Pseudarthrose erfullten. Von den 14 Kindern waren 9 Kinder auswartig primar behandelt worden und 5 Kinder primar in unserer Klinik. Der Altersdurchschnitt lag bei 10,8 Jahren (7–15 Jahre). Es handelte sich um 13 Ulnaschaft- und um 1 Radiusschaft-Pseudarthrose. Bei 11 Kindern trat die Pseudarthrose im mittleren Drittel auf und bei je 1 Kind im proximalen bzw. distalen Ulnadrittel. 13-mal handelte es sich um Unterarmschaftfrakturen und in 1 Fall um eine Monteggia-Lasion. In 12 Fallen waren die Frakturen geschlossen und in 2 Fallen erstgradig offen. In 9 Fallen war eine offene Ulnareposition durchgefuhrt worden, der Radius war in 4 Fallen offen reponiert worden. Bei 5 Kindern trugen technische Fehler bei der osteosynthetischen Versorgung wesentlich zur Pseudarthrosebildung bei. Funf der 14 Kinder hatten eine Refraktur. Bei 9 Kindern musste ein Revisionseingriff erfolgen. Diese Kinder wurden mit einer Plattenosteosynthese oder ESIN versorgt. Bei 5 Patienten kam es zu einer spontanen Pseudarthroseheilung. In 13 Fallen handelte es sich um hypertrophe und in 1 Fall um eine hypotrophe Pseudarthrose. Schlussfolgerung: Pseudarthrosen am Unterarm nach operativer Versorgung von Unterarmschaftfrakturen treten sowohl bei Kindern als auch bei Jugendlichen im Wesentlichem im mittleren Drittel der Ulna auf. Wird eine offene Reposition notwendig oder handelt es sich um offene Frakturen, so steigt das Risiko einer Pseudarthrose. Auch bei Kindern kann es bei nicht adaquater osteosynthetischer Versorgung zu Problemen bei der Knochenbruchheilung kommen. Trotz des Auftretens von Pseudarthrosen ist die Indikation zur ESIN unzweifelhaft. Das operative Trauma muss bei der offenen Reposition minimal gehalten werden und die Durchblutung des Knochens auch beim Kind respektiert werden.

Ziel: Der kongenitale Klumpfus ist selten mit einer fibularen oder tibialen Hemimelie assoziiert. Die Behandlung des Klumpfuses ist dabei komplex und umfangreiche operative Masnahmen sind oft notwendig. Wir berichten uber die Ergebnisse nach einer Gipsredression und uber die operativen Masnahmen bei 10 Patienten mit Klumpfusen im Rahmen einer fibularen oder einer tibialen Hemimelie. Material und Methode: Zwischen 1. 1. 2004 und 31. 12. 2009 wurden 398 Klumpfuse an unserem Klinikum primar mit der Gipsredression nach Ponseti behandelt. Insgesamt waren 10 Klumpfuse bei 9 Patienten mit einer fibularen oder tibialen Hemimelie assoziert. Bei 8 Patienten (9 Klumpfuse) wurde primar eine Ponseti-Redression angewandt. Zur Klassifikation der tibialen Hemimelie verwendeten wir die Klassifikation nach Weber und fur die fibulare Hemimelie die Klassifikation nach Achterman und Kalamchi und die Klassifikation nach Paley. Alle Patienten wurden prospektiv erfasst. Dokumentiert wurden die Patientendaten, prospektive Beinlangendifferenz, die zusatzlichen knochernen Fehlbildungen am Klumpfus, operative Masnahmen zur vollstandigen Korrektur und die funktionellen Ergebnisse. Die Ergebnisse wurden vor einem 1. Verlangerungsverfahren beurteilt. Resultate: Vier Patienten hatten eine tibiale Hemimelie, 2 Weber Typ I, 1 Typ 2, 1 Typ 3. Funf Patienten hatten eine fibulare Hemimelie Achterman Kalamchi IA, Paley Typ V. In 1 Fall handelte es sich um eine beidseitige fibulare Hemimelie. Die prospektive Beinlangendifferenz lag zwischen 3,2 und 14 cm. Vier Fuse konnten primar mit einer Gipsredression korrigiert werden. Bei einer fibulotalaren Diastase erfolgte eine knocherne Rekonstruktion einer Malleolengabel mittels Osteotomien. Vier Fuse wurden mit einem posteromedialen Release korrigiert. Bei 4 Rezidiven erfolgten 2-mal ein posteriores Release und 2-mal eine Korrektur mit Losung der Coalitiones und mit Mittelfusosteotomien. Bei einer tibialen Hemimelie Weber 3 erfolgte eine komplexe Rekonstruktion mit Ilisarov-Fixateur und Hexapodenfixateur (Taylor Spatial Frame). Die funktionellen Ergebnisse zeigten in einer Nachuntersuchungszeit zwischen 24–72 Mo. (∅ 42,2 Mo.) eine Dorsalextension zwischen 5 und 20° (∅ 7,7°) und eine Plantarflexion zwischen 10 und 40° (∅ 26,1°). Schlussfolgerung: Die Behandlung kongenitaler Klumpfuse bei tibialer und fibularer Hemimelie mit der Ponseti-Methode ist aufgrund der komplexen Ruckfuspathologie mit Coalitiones limitiert. Nur Klumpfuse bei gering ausgepragten Hemimelien ohne Coalitio konnen mit einer Gipsredression in der Ponseti-Technik primar korrigiert werden. Bei tibialen Hemimelien Weber 2 (tibiofibulare Diastase) kann eine Gipsredression versucht werden. Komplexe operative Korrekturen sind jedoch nicht selten notwendig. Bei hohergradigen Hemimelien empfehlen wir keine Gipsredression. Hier kommen umfangreiche rekonstruktive Masnahmen mit komplexen Osteotomien und Fixateurbehandlungen zur Anwendung.

AIM The Ponseti method is accepted worldwide for the treatment of congenital clubfoot. We report about our experience in a 7-year period. The purpose of the study was to evaluate the history of well treated feet between primary correction and the age of 5-6 years with relapse rate and functional results. MATERIAL AND METHOD Between 1.1.2004 and 31.12.2005 we treated 71 patients with 102 idiopathic clubfeet with the Ponseti method. All patients were prospectively evaluated. We used the Pirani score. The patients' results were documented when the children started to walk and before primary school. The results were compared and statistically evaluated. We used the McKay score and measured the talocalcaneal angle on lateral and a. p. radiographs. RESULTS 89 % clubfeet were successful treated with the Ponseti method. At walking age plantar flexion was between 30° und 50° (∅ 42°) and dorsiflexion between 5° and 30° (∅ 25°). Before primary school plantar flexion was between 30° and 50° (∅ 37,8°) and dorsiflexion between 0° and 25° (∅ 13,9°). Using the McKay score we had 91 % excellent or good results. 31 % cases had surgical treatment of a relapse. In the relapse group 82 % had an excellent or good result according to the McKay score. CONCLUSION The Ponseti method is a very effective technique to treat idiopathic clubfeet. In the first 5 to 6 years of age there is a significant loss of range of motion. The relapse rate is comparable to those of other clubfoot treatment concepts. The relapse treatment of the Ponseti technique, with recasting, tibialis anterior tendon transfer and Achilles tendon lengthening leads to good functional results.

Aim The widely accepted treatment of vertical talus after casting is correction by extensive surgery. Dobbs described a new method for the treatment of vertical talus by casting and minimally invasive surgery. The purpose of the present study was to evaluate the efficacy of this new method. Material and method Between 11/06 and 11/09 we treated 7 patients with 12 vertical tali. Treatment followed the protocol of Dobbs. The initiation of treatment, number of casts, surgery, as well as clinical and radiological results were documented. To evaluate the radiological result we used the Hamanishi score. Results From the beginning all feet could be treated successfully with the Dobbs method. According to the Hamanishi classification we have four excellent and five good results. Two feet had a relapse with subluxation or dislocation of the talonavicular joint. Conclusion Treatment of vertical talus with the Dobbs method is successful. Extensive surgery could be reduced. We recommend the method as primary treatment for vertical talus.

Aim The evaluation of paediatric thoracic or lumbar compression fractures can be challenging. The anatomy of the growing spine often makes a correct diagnosis by plain radiography difficult. The aim of our study was to compare the diagnostic reliability of X-Ray and that of magnetic resonance imaging in the evaluation of acute compression fractures of the paediatric spine. Method From January to December 2008 20 patients (12 boys, 8 girls) who were treated because of clinically suspected compression fractures of the vertebra were included in our study. The average age was 8.3 years. In all cases a radiograph in two planes and an MRI of the lumbar and thoracic spine were obtained. Two orthopaedic surgeons and one radiologist retrospectively assessed the radiographs. The results were compared with the MRI findings. Results In six cases the MRI was normal, in one case there was only a bone bruise without compression of the vertebra. 13 children had two or more than two minor compression fractures (29 fractures altogether). The 5th and 6th thoracic vertebra predominated. In only two cases there was a corresponding result of all three physicians and the MRI. In 4 cases the observers agreed on the localisation of the fracture. There was no agreement about the number of fractured vertebrae. Conclusion An exact evaluation of minor compression fractures of the pediatric spine with plain X-ray was not satisfactory.

Treatment of displaced radial neck fractures is challenging. Between 1993 and 2006, we treated 63 children using the closed intramedullary pin reduction technique according to Metaizeau in our department. In a retrospective study, associated injuries and complications were evaluated. Eighty-six percent of the patients could be contacted for follow-up questioning. Thirty-nine percent had associated injuries. All Judet II, III and most of type IV fractures could be treated with the closed method. Ninety-eight percent showed an excellent or good result according to Morrey, 90% to Metaizeau score. The closed intramedullary pin reduction technique proved to be an innovative minimal invasive technique for displaced radial neck fractures by allowing anatomical reconstruction and stable treatment.

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.

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.

Purpose In this retrospective study we compared the efficacy of ultrasound and radiography for determining the position of the femoral head after closed or open reduction in DDH. Materials and methods The ultrasound was performed using the van Douveren technique by a transinguinal approach through a perineal window of the spica cast. Sixty-eight a.p. radiographs of the pelvis were correlated to 68 ultrasound images. Results Thirty-two radiographs were not useful for precisely determining the femoral head position, whereas the criteria described by van Douveren et al. could be identified in all ultrasound images. All ultrasound images in the study were useful and gave reliable information about the position of the femoral head. 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 to determine the position of the femoral head in hip spica casts safely and reliably.

Fragestellung Evaluiert werden sollen Ergebnisse der operativen Versorgung von dislozierten Frakturen des Condylus radialis im Kindes- und Jugendalter.

AIM The results of 16 patients in growth age (mean age at surgery 13.7 years) with an ACL rupture that was treated with an ACL reconstruction using an periost-patella tendon-periost graft were reviewed. RESULTS The follow-up was done 12 months postoperatively. All patients were satisfied with the result of the surgery. No leg length differences or abnormalities of the axis were found. 14 patients had already regained their original sports level. In the Tegner score, an average level of 8 was reached and a mean of 97 points in the Lysholm score. In the IKDC score we found a level of A (normal) 9 times and of B (nearly normal) 7 times. CONCLUSION These follow-up examinations show that the treatment of an ACL rupture in growth age with a periost-patella tendon-periost graft leads to good results. It is a good alternative to the other methods (e.g., semitendinosus). Today, it can be regarded as a standard that an ACL rupture with open growth plates should be treated operatively.

Purpose Various pin configurations are possible to stabilize a supracondylar fracture. While cross pinning gives the best stabilty the disadvantage is the risk of iatrogenic ulnar nerve injury. We combine a cross pin fixation with a lateral approach. The aim of the study was to prove our method retrospectively to show the advantage of lateral cross-pinning achieving stabilty and avoiding ulnar nerve injury. Method Between 1 January 2001 and 31 December 2002, 84 supracondylar fractures were treated with invasive surgical procedure. The intention was a primary closed reduction. Following closed reduction under general anaesthesia, two K-wires were introduced from the lateral side, one ascending and the other descending. If it was not possible to perform a closed reduction, an open reduction was performed by medial–lateral crossed K-wire fixation. After either an open or closed reduction, the pins were buried under the skin. The results were evaluated using Flynn's score. The mean time of follow-up was 18.9 months. Results Seventy-seven percent of the patients were treated with a closed reduction, while 23% needed an open reduction. A clinical follow-up examination was done at an average of 18.9 months following the trauma. Of those treated with a closed reduction alone, 93% had an excellent or good functional result. Of those requiring an open reduction, 88% had excellent or good result. None of our patients exhibited secondary dislocation or iatrogenic ulnar palsies. Conclusion Closed reduction and lateral crossed pin fixation with ascending and descending K-wires buried under the skin is an effective method to treat type II and III supracondylar fractures in children. The method gives stability and avoids iatrogenic ulnar nerve injuries.

We report on three children with bilateral, congenital clubfoot. Four of the six clubfeet were associated with preaxial polydactyly. Five of the six clubfeet were treated without extensive surgery. A plantigrade foot was achieved, even in the three clubfeet with polydactyly, using serial casting and percutaneous Achilles tenotomy. Casting was adapted according to the existing polydactyly. One case with tibial hemimelia and a complex clubfoot deformity with preaxial tarsal polydactyly required more comprehensive surgery. A foot with good weight-bearing function was also achieved in this case following resection of the accessory medial ray, including resection of the accessory tarsal bones and posterior release. Remaining limitations in mobility were ascribed to hindfoot pathologies.

This paper presents our initial findings on the use of arthroscopic hip reduction in conjunction with acetabuloplasty to treat patients of walking age who had congenital dislocation of the hip.Arthroscopic reduction with acetabuloplasty was performed on nine children of walking age with nine dislocated hips. The average age of the patients was 21.4 months (14-41 months). Arthroscopic reduction was performed using a two-portal method with a 2.7-mm mini cannulated arthroscopic instrument. We used a subadductor portal and a high anterolateral portal. The obstacles preventing reduction-hypertrophic teres ligament, pulvinar, capsular constriction, hypertrophic transverse ligament-were eliminated.We treated one grade 4 hip, four grade 3 hips and four grade 2 hips, as classified by Tönnis. We were able to perform arthroscopic reduction on all of the hips. The main obstacles preventing reduction were a capsular constriction and a hypertrophic teres ligament. During the investigation period, which averaged 15.4 months (6-29 months), no repeat dislocation occurred. According to the Tönnis classification system for avascular necrosis, there were two cases of a grade 2 necrosis of the femoral head. The average preoperative AC angle was 40° (34°-47°). The average AC angle at the follow-up examination was 18.7° (11°-27°).We can conclude that the standardized arthroscopic surgical technique presented here can also be used to safely perform arthroscopic reduction in toddlers. The new arthroscopic method is an alternative to open reduction for selective hip dislocations. We believe this approach can be used to treat dislocated hips that are classified as grades 2 and 3 dislocations according Tönnis. Early results are promising. Medium-term results are needed to make a definitive statement on the rates of necrosis of the femoral head.

Purpose Congenital vertical talus (CVT) appears as an idiopathic or non-idiopathic deformity. In this study, we analysed the talar axis–first metatarsal base angle (TAMBA) values of idiopathic and non-idiopathic CVT cases treated with the Dobbs method. Materials and methods Between January 2007 and July 2012, 20 cases of CVT were treated, starting with a manipulation, casting and a minimally invasive surgical approach. We analysed retrospectively the TAMBA values in idiopathic and non-idiopathic CVT. As a new indicator for the mobility in the talonavicular complex, we used the difference of the TAMBA in neutral position and the TAMBA in plantarflexion. TAMBA measurements of CVT successfully treated with the Dobbs method were compared to TAMBA values of CVT unsuccessfully treated using a minimally invasive approach. Results Out of 20 CVT, 14 were successfully treated with the Dobbs method. Of these 14, five feet were non-idiopathic and nine feet were idiopathic. Six feet did not have complete correction following the Dobbs protocol, and were associated with arthrogryposis or caudal regression syndrome. The initial TAMBA in idiopathic feet ranged from 70 to 110° (mean 88°). The TAMBA in non-idiopathic feet ranged from 75 to 128° (mean 105). Feet successfully treated with the Dobbs method had an initial TAMBA between 74 and 110° (mean 87°). Feet unsuccessfully treated with the Dobbs method had an initial TAMBA between 95 and 128° (mean 118°).The measurement difference between the TAMBA in neutral and plantarflexion positions in cases unsuccessfully treated with the Dobbs method were smaller compared to values of feet successfully treated with the Dobbs method. These differences were statistically significant ( p < 0.0001). Conclusion In our series, the success of the Dobbs method in CVT treatment depended on the flexibility in the talonavicular complex. The TAMBA value and TAMBA difference (TAMBA neutral minus TAMBA plantarflexion) express the flexibility in the talonavicular joint and could be predictive for the success of a minimally invasive treatment. Only in a few cases is the success of the Dobbs method limited. These feet are associated with a TAMBA greater than 120° in neutral position and, particularly, a TAMBA difference smaller than 25°.

The elastic stable intramedullary nailing (ESIN) is the current treatment of choice for unstable forearm shaft fractures in children. There is no large study on paediatric nonunion of forearm shaft fractures in children after intramedullary nailing. There are only sporadic reports on nonunions after ESIN in children. The aim of this study was to define predisposing factors of nonunions in paediatric forearm fractures. All children who had been treated for forearm fractures by ESIN in our hospital from 1990 to 2006, and all children treated elsewhere surgically and being followed up at our institution were included in the study. In these children, we identified all patients who did not show bony consolidation of the fracture after 6 months from ESIN. Over a period of 16 years, 537 patients were primarily treated in our hospital and 55 children had been initially treated in a different institution. Six children were identified to fulfill the criteria of having developed a pseudarthrosis. Of these six children, three patients had been primarily treated in another hospital and three were our original patients. The average age was 11.1 years (9-14 years). There were only pseudarthroses of the ulna to be observed. In five children, the pseudarthrosis was in the middle third and in one patient in the distal third of the ulna. There were five closed fractures and one first-degree open fracture. Five times an open reduction of the ulna had been performed because closed reduction and insertion of the ESIN was impossible, whereas the radius had been treated closed in five cases and open in one case for intramedullary stabilization. Three cases were refractures, in one child it was a second refracture. In one case, we identified a technical error as cause of the development of the pseudarthrosis. Four children needed a revision surgery. In these children, the ulna was plated. Two patients showed spontaneous healing of the pseudarthrosis. In five patients, there was a hypertrophic pseudarthrosis present and in one case was hypotrophic pseudarthrosis. The reintervention was necessary because of increasing deformity in four patients and implant failure in one case. In conclusion, Non-unions after forearm fractures are observed in children and adolescents mainly in the middle third of the ulna. With the need of initial open reduction or the presence of an open fracture in the first instance, the risk of developing a pseudarthrosis. It may also be higher in such cases, which represent a refracture. Despite the small risk of developing a pseudarthrosis after forearm fracture, the indication for ESIN is clear. The surgical trauma needs to be as minimal as possible in cases with open reduction with as little as possible compromise of the blood circulation of the affected bone.

Purpose There are published studies of outcomes in the use of ESIN that raise concerns about serious complications: the aim of this study is to report our experiences over 17 years of use of this technique, which shows that complications and failures are insignificant when the method is applied correctly. Method We present a retrospective analysis of 553 children with forearm shaft fractures treated with elastic stable intramedullary nailing over a period of 17 years. The 354 boys (64%) and 199 girls (36%) had an average age of 9.1 years. A total of 61% of the fractures were located in the midshaft, 21% in the distal diaphyseal and 18% in the proximal third. Continuous documentation of treatment, postoperative course and follow-up after an average time of 37 months formed the basis of this study. The analysis included all kinds of failures and complications. Results The following complications and problems were encountered: 5 children with wound infections and disturbed wound healing, 1 case of osteomyelitis, 7 children with ulnar non-unions, 14 children with delayed unions, 6 cases of loss of correction, 15 children with lesions of the superficial radial nerve, one case of malplacement of a nail, 5 children with skin perforations caused by the ends of implants and 27 children with refractures. Conclusion The analysis of the failures and complications shows that a differentiated approach to the data has to be taken. Most complications occur because of incorrect use of the method with neglect of biomechanical principles. The usage of the ESIN method is extended to more problematic regions, such as the distal diaphyseal portion of the forearm, and therefore, an increase in complications is likely. Despite this risk, ESIN should still be the standard treatment for forearm shaft fractures in children, and no change in therapeutical strategy is necessary. However, it is of special importance to follow the right indication and to pay attention to biomechanical principles and to correct technical procedure.