Manfred Nelitz

Recurrent lateral patellar dislocation is a common knee injury in the skeletally immature adolescent. In adults, anatomical reconstruction of the medial patellofemoral ligament (MPFL) is recommended, but due to the open physis, operative therapy in children is more challenging. We present a minimal invasive technique for anatomical reconstruction of the MPFL in children respecting the distal femoral physis. This technical note considers the important fact that the femoral insertion is distal to the femoral physis. Since the importance of an anatomical reconstruction respecting the femoral insertion of the ligament has been proven an insertion proximal of the physis has to be strictly avoided.

Abnormal loading of the hip in obese children may lead to anatomic alterations and an increased prevalence of slipped capital femoral epiphysis (SCFE). The aims of this study were to examine the hip motion in obese children and adolescents and to estimate the prevalence of SCFE in a subgroup of patients characterized by pathological clinical examination and/or pain in the knee or hip joint. A total of 411 individuals (196 males), mean age 14.5 ± 2.5 years (7.8–20.4), mean BMI of 32.9 ± 5.6 kg/m² (20.3–51.5, z score +2.65) who were consecutively admitted for an inpatient weight loss program were included in the study. Twenty-six percent of the patients had load-dependent and 11.7 % had load-independent pain in the knee joint. A total of 9.3 % had load-dependent and 4.7 % had load-independent pain in the hip joint. Two patients (0.5 %) underwent surgical treatment of SCFE prior to entry. A total of 18.2 % of the patients showed a reduced range of motion for hip flexion (n = 54) revealed an abnormal head–neck ratio as a sign of prior silent slipped capital femoral epiphysis in 11 patients (20.4 % of the 54 patients, 2.7 % of total cohort). In conclusion, these data show a high prevalence of SCFE-like tilt deformities in a selected group of severely obese children. Mild deformation of the epiphysis at young age might be a major predisposing factor for the development of hip osteoarthritis in obese adults.

Purpose: Many surgical procedures have been proposed to treat recurrent patellar dislocation in children. In recent years, a more tailored approach considering the underlying pathology has been advocated. The aim of the study was to analyze a group of patients with recurrent patellofemoral instability after unsuccessful operative stabilization (Roux‐Goldthwait procedure, lateral release, medial reefing or in combination) in childhood and adolescence.Methods: A total of 37 children and adolescents with recurrent patellofemoral instability despite previous surgery were analyzed retrospectively. Radiographic examination included AP and lateral views to assess patella alta and limb alignment. MRI was performed to evaluate trochlear dysplasia and tibial tubercle‐trochlear groove (TTTG) distance. As a control group, 23 age‐ and sex‐matched adolescents that were treated with a favorable outcome after medial reefing alone or combined with a Roux‐Goldthwait procedure were analyzed.Results: Severe trochlear dysplasia (type B–D according to Dejour) as detected on MRI scans was found significantly more often in the study group (89%) than in the control group (21%). No statistical difference of patellar height ratio (Insall‐Salvati index) and TTTG distance between the two groups could be found.Conclusion: Of the measured parameters, only the incidence of trochlear dysplasia was increased. Trochlear dysplasia therefore seems to be a major risk factor for failure of operative stabilization of recurrent patellofemoral instability in children and adolescents. The results in children are in consensus with the literature in adults that a more tailored operative therapy including reconstruction of the MPFL and trochleaplasty has to be considered.Level of evidence: Retrospective study, Level III.

Purpose: The purpose of this study was to analyse true lateral radiographs of children and adolescents to determine the relation of the origin of the MPFL and the distal femoral physis considering the complex anatomy of the physis. The hypothesis was that the femoral insertion of the MPFL is distal to the growth plate.Methods: Antero‐posterior and true lateral radiographs from PACS computer records of 27 patients with a history of patellofemoral instability were assessed. To determine the femoral origin of the MPFL, the method by Schöttle et al. and the method by Redfern et al. were applied independently. On the anteroposterior radiograph, the distance between the medial most part of the physis and the central part of the physis was measured to quantify the concave curvature of the physis. To cross‐reference the femoral insertion of the MPFL onto an ap view, the projected MPFL origin–physis distance was subtracted from the distance between the most medial part of the physis and the central part of the physis.Results: The projected median origin of the MPFL as measured on a lateral radiograph was located 3.2 mm (1.2–5.8 mm) proximal to the physis. The median distance between the most medial part of the physis and the physeal line on the anteroposterior radiograph was 9.9 mm (4.1–12.0 mm). Subtracting the two measured values, the median origin of the MPFL as seen on the ap view was 6.4 mm (2.9–8.5 mm) distal to the femoral physis.Conclusion: Considering the concave curvature of the distal femoral physis, it can be assumed that the femoral insertion of the MPFL is distal to the femoral physis. As a too proximal insertion of the graft can cause unintentional tightening of the MPFL in knee flexion, these results have to be considered when performing reconstruction of the MPFL in children and adolescents with open growth plates.Levels of evidence: Diagnostic study, Level II.

Wir berichten über eine Patientin mit Patellaquerfraktur nach adäquatem Trauma (Sturz auf Glatteis) 2 Monate nach Rekonstruktion des medialen patellofemoralen Ligaments (MPFL) bei patellofemoraler Instabilität (PFI). Die Rekonstruktion des Lig. patellofemorale mediale erfolgte mit autologem Grazilistransplantat, die patellare Fixierung mit resorbierbarem Knochenanker und Biointerferenzschraube femoral. Bei der operativen Versorgung der dislozierten Patellafraktur zeigte sich, dass die Fraktur direkt durch den distalen Bohrkanal verlief. Die Fraktur wurde mit einer Drahtcerclage versorgt. Der weitere postoperative Verlauf gestaltete sich komplikationsfrei. Bisher gibt es in der Literatur nur wenige Beispiele der Patellafraktur als postoperative Komplikation nach MPFL-Rekonstruktion ohne adäquates Trauma. Hierbei werden eine Unterbrechung der Blutversorgung und eine daraus resultierende avaskuläre Nekrose als Mitursache vermutet. We report on a 20-year-old female patient with a fracture of the patella after she fell on“black ice” 2 months after medial patellofemoral ligament (MPFL) reconstruction for patellar instability. For reconstruction of the MPFL, a single hamstring tendon graft was passed through the medial intermuscular septum and was fixed to the superomedial pole of the patella. The fracture was reduced by wire cerclage. Intraoperatively it was shown that the fracture line went through the patellar drill hole. No complications occurred during the further postoperative period. The literature contains only a few case reports describing fractures of the patella after MPFL reconstruction without any specific trauma. In this case, an interruption in blood supply with resulting avascular necrosis was suspected as a causal factor.

An important cornerstone of conservative treatment of Perthes disease is to reduce the weight placed on the affected hip joint. Strict mechanical unloading of the affected hip joint is not necessary. What is important, however, is that extreme...

Zur Behandlung des angeborenen Klumpfußes hat sich die Behandlung nach Ponseti mit redressierender Gipsanlage und anschließender perkutaner Tenotomie der Achillessehne durchgesetzt. Insbesondere bei Versagen der Gipstechnik nach Ponseti sollten Koalitionen des Rückfußes als seltene sekundäre Klumpfußursache ausgeschlossen werden, da in diesen Fällen nur durch eine operative Maßnahme mit Lösung der Coalitio und zusätzlichem Weichteilrelease eine Korrektur der Klumpfußdeformität erzielt werden kann. The Ponseti method has proven to be successful in the treatment of idiopathic congenital talipes equinovarus (clubfoot). In particular, if plaster cast treatment as recommended by Ponseti does not show the desired correction of the foot, tarsal coalitions as a rare cause for a secondary clubfoot deformity have to be ruled out. In these cases a surgical release of the coalition in addition to the tenotomy has to be performed to achieve a satisfactory correction.

Because the course of Legg-Calvé-Perthes disease (LCPD) is highly variable, its appropriate diagnostic evaluation and treatment are still debated. The authors selectively review the literature, present their own study findings, and discuss the guidelines of the German Society for Orthopedics and Orthopedic Surgery. The main prognostic factors are the patient's age at the onset of the disease, the degree of limitation of range of motion, the extent of involvement of the femoral epiphysis, and any additional radiographic "head-at-risk" signs. Depending on the severity of the disease, the treatment options range from observation and frequent follow-up to reconstructive hip surgery. The goal of all treatments is to prevent a prearthrotic deformity and the ensuing premature coxarthrosis. This goal is best met by adherence to the principle of containment, i.e., the maintenance or restoration of joint congruence while biological plasticity is still present. In view of the variable course of LCPD, the proper course of treatment must be determined individually in each case. Every child with LCPD must receive individually adapted treatment and continued follow-up into adulthood.

Studienziel: Ziel dieser Studie war es, die Frage zu klären, ob und in welchem Ausmaß ein femoroazetabuläres Impingement (FAI) 10 bis 20 Jahre nach transphysärer Epiphysenfixation bei milder Epiphyseolysis capitis femoris (ECF) vorliegt. Methode: Klinische und radiologische Nachuntersuchung von 20 Patienten, die von Oktober 1984 bis Dezember 1995 mit einer beidseitigen transphysären Epiphysenfixation mittels Schrauben oder Kirschner-Drähten bei einseitiger ECF behandelt worden waren. Die klinische Nachuntersuchung bestand in der Erfassung des Harris-Hip-Scores, des Aktivitätsgrads nach Tegner und Lysholm, der Hüftgelenksbeweglichkeit und der Durchführung eines Impingementtests. Die radiologische Nachuntersuchung umfasste die qualitative Beurteilung des Femurkopf-/Schenkelhals-Übergangs in anteroposterioren Beckenübersichts- und lateralen „cross table“-Aufnahmen beider Hüftgelenke. Zur quantitativen Beurteilung wurde der α-Winkel nach Nötzli et al. in diesen Aufnahmen bestimmt. Ergebnisse: Mithilfe des Harris-Hip-Scores wurden hervorragende Ergebnisse belegt, der Aktivitätsgrad der Patienten lag dagegen mehrheitlich nur im unteren Mittelfeld. Für die Beweglichkeit des betroffenen Hüftgelenks zeigte sich im Vergleich zur nicht betroffenen Gegenseite keine statistisch signifikante Einschränkung der Flexion, dagegen der Innenrotation und Abduktion (p = 0,135, p = 0,002 bzw. p = 0,007). Der Impingementtest war in acht Fällen auf der betroffenen Seite und in fünf Fällen auf der nicht betroffenen Seite positiv (p = 0,004). Die radiologische Nachuntersuchung zeigte einen statistisch signfikanten Unterschied zwischen betroffener und nicht betroffener Seite für den α-Winkel im Beckenübersichtsbild (86 vs. 61°; p < 0,001), dagegen nicht in den lateralen Hüftgelenksaufnahmen (52 vs. 46°; p = 0,145). Schlussfolgerung: Die klinischen Nachuntersuchungsergebnisse zeigen Hinweise für die Entwicklung eines FAI nach abgelaufener milder Hüftkopfepiphysenlösung, die mittels transphysärer Epiphysenfixation behandelt wurde. Die radiologischen Nachuntersuchungsergebnisse lassen auf eine laterale und weniger anteriore Lokalisation des FAI schließen. Aim: It was the aim of this study to reveal whether and to what extent femoro-acetabular impingement (FAI) was present 10 to 20 years after transfixation of the gliding epiphysis in patients treated for unilateral slipped capital femoral epiphysis (SCFE). Method: Clinical and radiological evaluations were undertaken of 20 patients who were treated with a bilateral transfixation of the epiphysis with screws or Kirschner wires because of mild unilateral SCFE. The Harris hip score, the activity level according to Tegner and Lysholm and the range of motion of both hip joints were noted. An impingement provocation test was performed on both sides. The femoral head-neck junction was qualitatively and quantitatively assessed in anteroposterior radiographs of the pelvis and “cross table” lateral radiographs of both hip joints. Quantitative assessment was achieved by measuring the α angle according to Nötzli et al. Results: All except one patient showed excellent results in the Harris hip score. The activity levels of the majority of patients, however, were mediocre. There was no difference for flexion, whereas internal rotation and abduction significantly differed between affected and non-affected hips (p = 0.135, p = 0.002 and p = 0.007, respectively). The impingement provocation test was found positive in eight affected and five non-affected hips (p = 0.004). The α angle was significantly different between affected and non-affected hips in the anteroposterior radiographs of the pelvis (86 vs. 61°; p < 0.001), but not so, however, in the “cross table” lateral radiographs (52 vs. 46°; p = 0.145). Conclusion: Clinical evaluation of 20 patients at a mean of 14.9 years after transfixation of the epiphysis revealed some evidence for the presence of FAI in affected hip joints. Radiological evaluation suggests that its localisation is more lateral and less anterior.

Zusammenfassung Die Einführung der Sonographie der Säuglingshüfte und anschließende Einführung des Neugeborenenscreenings im Rahmen der U3 ermöglicht eine frühzeitige Diagnosestellung und Therapie der Hüftreifungsstörung. Durch einen frühen Behandlungsbeginn kann das hohe Reifungspotential des Pfannendaches in den ersten Lebenswochen genutzt und die Behandlungszeit abgekürzt werden. Die frühzeitige, an die Graf-Klassifikation angelehnte Stufentherapie mit Reposition, Retention und Nachreifung führt zu nachweisbar guten Therapieergebnissen. Auch nach sonographischer Ausreifung sind zum Ausschluss einer Restdysplasie radiologische Verlaufskontrollen primär behandelter Hüftreifungsstörungen bis zur Skelettreife zu empfehlen. Die Kosteneffektivität der Behandlung und eine mögliche Übertherapie sind Gegenstand anhaltender Diskussion.