[Physiotherapeutic and rehabilitative options for neuromuscular scolioses : Areas of physiotherapy techniques in the field of tension between hypertonic and hypotonic forms of neuromuscular scoliosis]

Conservative treatment and physiotherapy (PT) of neuromuscular scoliosis and its underlying systemic causes is dominated by a pragmatic approach. In the choice of treatment, the observance of the underlying muscle tone sets the essential course to select an appropriate PT technique. Hypertonic forms need the reflex-modulation techniques included in Bobath or Vojta programmes. They sometimes necessitate tone-reducing medication and additional orthotics with a likely risk of pressure sores. In hypotonic forms of scoliosis on the other hand, gravity and spine collapse with pulmonal dysfunction are the key issues addressed by conservative treatment. Sustained quality of life and supported partaking in social life through maintenance of pulmonary function and upright sitting ability are of continuing concern. PT programmes with a neurophysiologic background such as those of Bobath and Vojta are of central significance.

Lower Limb Malrotation Is Regularly Present in Long-Leg Radiographs Resulting in Significant Measurement Errors

Weight-bearing long-leg radiographs are commonly used in orthopaedic surgery. Measured parameters, however, change when radiographs are conducted in different rotational positions of the leg. It was hypothesized that rotational errors are regularly present in long-leg radiographs resulting in wrong measurements. In 100 consecutive long-leg radiographs conducted according to the method of Paley, rotation was assessed by fibular overlap. Angular parameters in radiographs (mechanical lateral proximal femoral angle (mLPFA), mechanical lateral distal femoral angle (mLDFA), angle between the anatomical and mechanical femoral axis (AMA), mechanical medial proximal tibia angle (mMPTA), mechanical lateral distal tibial angle (mLDTA), and the mechanical femoral and tibial axis (mFA-mTA) were measured and deviations related to malrotation calculated. An average internal rotation of 8 degrees was found in lower limbs showing a range between 29 degrees of internal and 22 degrees of external rotation. As a result, mean differences before and after rotational correction for measured parameters (mLPFA, mLDFA, AMA, mMPTA, mLDTA, mFA-mTA) ranged between 0.4 and 1.7 degrees (-2.1; 5.6 95% confidence interval [CI]). In conclusion, malrotation of lower limbs is regularly present in long-leg radiographs. As all measured parameters are influenced by malrotation, correct lower limb rotation needs to be verified.

Rotation of intramedullary alignment rods affects distal femoral cutting plane in total knee arthroplasty

PURPOSE

Intramedullary rods are widely used to align the distal femoral cut in total knee arthroplasty. We hypothesised that both coronal (varus/valgus) and sagittal (extension/flexion) cutting plane are affected by rotational changes of intramedullary femoral alignment guides.

METHODS

Distal femoral cuts using intramedullary alignment rods were simulated by means of a computer-aided engineering software in 4°, 6°, 8°, 10°, and 12° of valgus in relation to the femoral anatomical axis and 4° extension, neutral, as well as 4°, 8°, and 12° of flexion in relation to the femoral mechanical axis. This reflects the different angles between anatomical and mechanical axis in coronal and sagittal planes. To assess the influence of rotation of the alignment guide on the effective distal femoral cutting plane, all combinations were simulated with the rod gradually aligned from 40° of external to 40° of internal rotation.

RESULTS

Rotational changes of the distal femoral alignment guides affect both the coronal and sagittal cutting planes. When alignment rods are intruded neutrally with regards to sagittal alignment, external rotation causes flexion, while internal rotation causes extension of the sagittal cutting plane. Simultaneously the coronal effect (valgus) decreases resulting in an increased varus of the cutting plane. However, when alignment rods are intruded in extension or flexion partly contradictory effects are observed. Generally the effect increases with the degree of valgus preset, rotation and flexion.

CONCLUSION

As incorrect rotation of intramedullary alignment guides for distal femoral cuts causes significant cutting errors, exact rotational alignment is crucial. Coronal cutting errors in the distal femoral plane might result in overall leg malalignment, asymmetric extension gaps and subsequent sagittal cutting errors.

Assessment of pelvic tilt in anteroposterior radiographs by means of tilt ratios

INTRODUCTION

In anteposterior (AP) radiographs, cup position in total hip arthroplasty and acetabular anatomy in hip-preserving surgery are highly influenced by pelvic tilt. The sagittal rotation of the anterior pelvic plane is an important measurement of pelvic tilt during hip surgery. Thus, correct evaluation of cup position and acetabular parameters requires the assessment of pelvic tilt in AP radiographs.

METHODS

Changes in pelvic tilt inversely change the height of the lesser pelvis and the obturator foramen in AP radiographs. Tilt ratios were calculated by means of these two parameters in simulated radiographs for ten male and ten female pelvises in defined tilt positions. A tilt formula obtained by exponential regression analysis was evaluated by two blinded investigators by means of 14 simulated AP radiographs of the pelvis with pelvic tilts ranging from + 15° to - 15°.

RESULTS

No differences were found between male and female tilt ratios for each 5° step of simulated pelvic tilt. Pelvic tilt and tilt ratios correlated exponentially. Using the tilt formula, the two blinded investigators were able to assess pelvic tilt with high conformity, a mean relative error of + 0.4° (SD ± 4.6°), and a mean absolute error of 3.9° (SD ± 2.3°). Neutral pelvic tilt is indicated by a tilt ratio of 0.5 when the height of the lesser pelvis is twice the height of the obturator foramen.

CONCLUSION

The analysis and interpretation of cup position and acetabular parameters may be improved by our method for assessing pelvic tilt in AP radiographs.

[Treatment recommendations for protracted hip immaturity in infants : Conservative approach versus open reduction]

The healthy upright posture is a result of a continuous maturation process of the locomotor system throughout skeletal growth rendering muscle strength and stability: The hip joint in its central position plays a key role for unimpaired and pain-free gait. Nonetheless, it is also regularly affected by delayed maturation, thus being of special interest for the disease screening procedures of every newborn child. Structured screening examinations in the first 3 postnatal months will ideally detect any dysplasia, therefore simple conservative interventions will usually accelerate the maturation process. Effective hip screening programs in Austria and Germany have reduced the necessity for open surgical hip reductions to a worldwide all-time low. Perinatal risk factor awareness in doctors and parents triggers an increased sensitivity to possible immature hip structures. Nevertheless, severe hip dysplasia in toddlers is regularly presented in pediatric orthopedic centers with or without hip dislocation, mostly due to the delay of or inefficiency of treatment options. This review deals with highly effective strategies for quick treatment and provides a balanced view on conservative and surgical methods.

[Disease-specific Knowledge in Conservative Treatment of Adolescent Idiopathic Scoliosis]

BACKGROUND

The typical onset of adolescent idiopathic scoliosis falls in a sensitive stage of life. Nevertheless, conservative brace treatment requires a high degree of compliance. Disease-specific knowledge influences therapy outcome in many diseases and potentially improves patient compliance and quality of life. We analysed disease-specific knowledge and quality of life of patients with adolescent idiopathic scoliosis.

METHODS

Scoliosis patients (n = 67) undergoing conservative brace treatment were asked to answer a questionnaire with items about scoliosis-specific knowledge. This was anonymous and prior to regular interviews and examinations. The scoliosis-research-society-22 r score was determined in order to assess quality of life.

RESULTS

The major sources of information for the patients were the attending physicians and the world wide web. The majority stated that they understood the nature of scoliosis, although their answers to more detailed questions revealed a major lack of knowledge. A significant gap in provision of information was found, especially in the field of therapy regimen and treatment goals. The expected duration of the therapy was unclear to most patients. Nevertheless, higher quality of life correlated with high compliance and patients who regarded alleviation of the disturbing appearance of their trunk as a main treatment aim also experienced a lower quality of life in the section of self image.

CONCLUSIONS

Our study revealed a significant lack of disease-specific knowledge in patients with idiopathic scoliosis. Facilitation of knowledge might improve quality of life and therapy outcome in the future. As the attending physicians are the main source of information, it is up to us to improve this situation.

[Conservative treatment of idiopathic scoliosis : Influence of archetypical Cheneau-Corsets on trunk asymmetry]

BACKGROUND

The vertical posture of the growing child requires minute central nervous control mechanisms to maintain the symmetry of the torso in its various activities. Measuring only static parameters such as the Cobb angle does not describe the dynamic changes of scoliotic deformities in gait. A constant deviation in the frontal, transverse, and sagittal planes from the dynamic symmetry of the trunk is described in motion analysis and the surface changes of the spinopelvic complex.

METHODS

Early intervention with effective bracing, physiotherapy and sport can reverse curve progression in growth spurts, once these are identified by screening. Modern braces have a derotating and reducing effect ("mirror effect") on asymmetric body volumes, thus influencing the growing torso and restoring lasting symmetry. These braces can be reduced for archetypical designs. Latest data support the use of braces to reverse progressing scoliosis.

[Surgical treatment of scoliosis in childhood and adolescence: Age group and etiology-related indications and choice of instrumentation]

The indications for a corrective surgical procedure for the complex 3-dimensional deformations of the spine collectively known under the term scoliosis, essentially depend on knowledge of the underlying etiology, the time of initial diagnosis in relation to the growth curve of the child and on considerations about the general operability of the patient. An early onset of scoliosis in childhood under defined diagnostic criteria is usually associated with a fast progression of spinal curvature and requires early surgical intervention during the growth period, while scoliosis in adolescence often allows a delayed surgical intervention until all conservative means have been taken into consideration. Corrective measures in the growing spine require procedures and adjustable hardware which can be adapted to vertebral and thoracic growth and thus anticipate the threat of pulmonary insufficiency due to postural and spinal collapse. Towards the end of puberty when spinal growth slowly comes to an end, corrective spinal fusion procedures are considered in those cases of early and late onset scoliosis, where curvature progression is likely to occur.

Current therapeutic strategies of heterotopic ossification--a survey amongst orthopaedic and trauma departments in Germany

Background

Heterotopic ossification (HO) is a complication after tissue trauma, fracture and surgery (i.e. total hip arthroplasty). Prophylaxis is the most effective therapy. If HO formations become symptomatic and limit patients’ quality of life, revision surgery is indicated and is usually combined with a perioperative oral prophylaxis (NSAIDs) and/or irradiation. However, a long-term use of NSAIDs can induce gastro-intestinal or cardiac side-effects and possible bony non-unions during fracture healing. Subject of this study was to assess the current status of HO prophylaxis after injuries or fractures and to evaluate current indications and strategies for excision of symptomatic HO.

Methods

Between 2013 and 2014, a questionnaire was sent to 119 orthopaedic and trauma surgery departments in Germany. Participation was voluntary and all acquired data was given anonymously.

Results

The cumulative feedback rate was 71 %. Trauma and orthopaedic surgery departments in Germany recommend oral HO prophylaxis after acetabulum and femoral neck fractures, elbow dislocation, and fracture or dislocation of the radial head. Pain upon movement and an increasing loss of range of motion in the affected joint are considered to be clear indications for HO surgery. A partial removal of ROM-limiting HO formations was also considered important. The vast majority of all departments include perioperative oral HO prophylaxis and/or irradiation if surgical HO removal is planned. The choice and duration of NSAIDs is highly variable.

Conclusion

HO is of clinical significance in current traumatology and orthopaedics. Certain fractures and injuries are prone to HO, and prophylactic measures should be taken. The respondents in this survey assessed current therapeutic strategies for HO formations similarly. These concepts are in line with the literature. However, the duration of perioperative oral HO prophylaxis varied greatly among the specialist centres. This is significant as a long-term use of NSAIDs fosters a potential risk for the patients’ safety and could influence the clinical outcome. National and international guidelines need to be developed to further reduce HO rates and improve patients’ safety in trauma and orthopaedic surgery.

[Conservative treatment of idiopathic scoliosis with effective braces: early response to trunk asymmetry may avoid curvature progress]

Vertical posture of the growing child requires minute central nervous control mechanisms in order to maintain symmetry of the torso in its various activities. Scoliosis describes a constant deviation in the frontal, transverse and sagittal planes from the dynamic symmetry of the trunk. Early intervention with effective bracing, physiotherapy and sports can reverse curve progression during growth spurts, once these are identified in screening. Modern braces have a derotating and reducing effect (mirror effect) on asymmetric body volumes, thus influencing the growing torso and restoring lasting symmetry. Recent data support the use of braces to reverse progressing scoliosis.

[Flexible flatfoot in children: variation within normal range or need for treatment?]

Flexible flatfoot in childhood is a common cause for repetitive consultations and the diagnosis is verified by the clinical examination. In most cases the findings are age-dependent variants of the norm and if asymptomatic there is no need for treatment. In the first decade of life symptomatic flexible flatfoot should initially be treated with shoe inserts. Further diagnostic steps are required once conservative treatment is unsuccessful or a rigid structural deformity is found in the clinical examination. The underlying reasons may be neuropathic or structural anatomical in origin. Lateral column lengthening as described by Evans or minimally invasive arthroereisis are well established surgical options but for arthroereisis the number of long-term studies is low. In general the indications for surgical and conservative therapy have to be judged with caution although parents often see an urgent need for treatment.

[Treatment of patellar instability in children and adolescents]

To address recurrent patellar instability in children and young adolescents a variety of therapeutic options exist either as non-operative or operative treatment. Recent options, such as reconstruction of the medial patellofemoral ligament have evoked a new focus of attention on this topic. The intention of this article is to present diverse therapeutic options and to evaluate them by reference to the current literature.

[Clinical pathway - conservative back pain treatment]

Back pain is a very common clinical picture. The causes are often not only somatic, which generally has led to a biopsychosocial understanding of this disease. Therefore, it is necessary to employ a multimodal treatment approach to achieve effective and longer-lasting relief. Such a concept requires the cooperation of multiple disciplines in a sophisticated and strongly organized manner. In our clinic we have developed a clinical pathway for conservative back pain treatment that avoids the use of too much time by careful coordination of the therapy elements. It has proven to be a successful tool for the efficient treatment of patients with primarily somatically caused back pain. The following article describes this clinical pathway.

[Minimally invasive injection therapy in lumbar syndromes]

Minimally invasive injection therapy is an effective approach for the treatment of sciatica with less complications. This therapy is a sufficient option in cases without absolute indications for operation.The paper describes in detail the different injection techniques like spinal nerve analgesia, epidural dorsal/perineural injections, vertebral joint infiltrations, and radiculographies.

[Minimally invasive injection therapy for patients with radicular lumbar spine syndrome. First results of an minimally invasive treatment for patients with lumbar radiculopathy]

BACKGROUND

There are few studies on minimally invasive injection therapy (MIT) combined with multimodal conservative therapeutic options. Here, we evaluate the results of MIT in a clinical study.

METHODS

A total of 61 patients with radicular lumbar symptoms treated with MIT were examined before and 14.5 months after treatment. Subjective, objective, clinical and anamnestic parameters were considered.

RESULTS

In most cases, protrusions and prolapses were seen. Radicular pain, sensible and motoric deficits and also functionality of the spine could be rectified after MIT. No major complications were seen during treatment.

CONCLUSION

MIT is an effective approach with few complications for the treatment of patients with radicular syndromes.

[Minimal-invasive injection therapy for cervical syndromes]

The specific minimal-invasive injection therapy is a key-procedure for cervical spine syndromes when performing a multimodal pain-therapy. Due to the exactly placed injections pain can be overcome. Indication is given in cases of continuing spine pain and is an alternative to operative procedure, as for as no absolute indication for operation is given. The complex injection technique affords knowledge and expertise. The exact application and the specific complications are presented in detail.

Ausrissfestigkeit implantierter Pedikelschrauben in konventioneller und fluoroskopisch-navigierter Technik

AIM

Aim of the study was to compare pullout resistance of pedicle screws after conventional and fluoroscopic computer-assisted implantation in the cadaveric thoracic and lumbar spine.

METHODS

Pedicle screws were inserted in a total of 10 vertebrae of different human specimens: 10 screws were placed using conventional technique (group 1) and 10 screws were inserted with fluoroscopic computer-assisted system contralaterally (group 2). Then pedicle screws were evaluated for biomechanical axial pullout resistance.

RESULTS

Mean pullout force was 232 N (range 60-600 N) in group 1 and 353 N (range 112-625 N) in group 2. The difference was significant (p=0,0425).

CONCLUSION

Fluoroscopic navigated implantation of pedicle screws increases the pullout strength in thoracic and lumbar cadaveric spines as compared with conventional methods.

[Stability of pedicle screws in comparison to anterior vertebral body screws after kyphoplasty augmentation]

AIM

Aim of the study was to compare stability of pedicle screws and ventral implanted screws after insertion in soft or cured kyphoplasty cement.

METHODS

Pedicle screws were inserted in a total of 40 thoracolumbar vertebrae of 10 different formalin-fixed human specimens: each 10 pedicle screws were implanted in soft (group 1) and cured cement (group 2), each 10 ventral screws were placed in soft (group 3) and cured (group 4) cement. Pedicle screws were then evaluated for biomechanical axial pullout resistance.

RESULTS

Mean pull-out force was 452 N (range 60-1 125 N) in group 1, 367 N (range 112-840 N) in group 2, 364 N (range 65-875 N) in group 3 and 271 N (range 35-625 N) in group 4.

CONCLUSION

Implantation of pedicle screws and ventral implanted screws in soft and cured kyphoplasty cement is a sufficient method. We achieved more stability with pedicle screws compared with ventral implanted screws in soft and cured cement. No significant difference was seen.

Long-term results of ventro-dorsal versus ventral instrumentation fusion in the treatment of spondylitis

This study examines prospectively the randomised, long-term, clinical and radiological results of the treatment of spondylitis patients by ventro-dorsal or ventral spine fusion. Group 1 consisted of 12 patients who (after ventral removal of the focus of infection and autologous bone grafting) were treated by dorsal instrumentation. Group 2 consisted of ten patients who, after similar ventral removal and bone interposition, were stabilised by ventral instrumentation. The patients prospectively underwent clinical and radiological studies. In addition, they were asked to fill in self-assessment questionnaires such as the short-form (SF)-36 health survey, the Oswestry questionnaire, and the visual analog scales (VAS). The postoperative follow-ups were at 6 months, 2 years and 5.4 years. It proved possible to demonstrate clinically that patients with an isolated ventral spondylodesis feel significantly better and experience significantly less pain in the area of spinal fusion than patients with ventro-dorsal fusion 2 and 5.4 years after the operation. Over a number of years a stable fusion can be achieved through either operation. Ventral stabilisation yields more advantages than dorsal instrumentation in the long term. These advantages result in a clinically smoother course after the operation. If, in the individual case, ventral instrumentation is feasible, this method should be used.

Stability of anterior vertebral body screws after kyphoplasty augmentation. An experimental study to compare anterior vertebral body screw fixation in soft and cured kyphoplasty cement

The goal of this cadaver study was to compare the stability of anterior vertebral body screws after implantation in soft or cured kyphoplasty cement. Anterior vertebral body screws were inserted in a total of 30 thoracolumbar vertebrae of ten different human specimens: ten screws were implanted in non-augmented vertebrae (group 1), ten screws were placed in soft cement (group 2), and ten screws were placed in cured cement (group 3). The screws were then tested for biomechanical axial pullout resistance. Mean axial pullout strength was 192 N (range: 10-430 N) in group 1, 364 N (range: 65-875 N) in group 2, and 271 N (range: 35-625 N) in group 3. The paired Student's t-test demonstrated a significant difference between pullout strength of groups 1 and 2 (p= 0.0475). No significant difference was seen between pullout strength of groups 1 and 3 (p= 0.2646) and between groups 2 and 3 (p= 0.3863). We achieved a 1.9 times higher pullout strength with kyphoplasty augmentation of osteoporotic vertebrae compared with the pullout strength of non-augmented vertebrae. Implantation of anterior vertebral body screws in cured cement is a satisfactory method. With this method we found a 1.4 times higher pullout strength than non-augmented vertebrae.

Stability of Pedicle Screws After Kyphoplasty Augmentation

OBJECTIVE

The goal of this cadaver study was to compare the stability of pedicle screws after implantation in soft or cured kyphoplasty cement.

METHODS

Pedicle screws were inserted in a total of 30 thoracolumbar vertebrae of 10 different human specimens: 10 screws were implanted in nonaugmented vertebrae (group 1), each 10 screws were placed in soft (group 2) and cured (group 3) cement. Pedicle screws were than evaluated for biomechanical axial pullout resistance.

RESULTS

Mean axial pullout strength was 232 N (range 60-600 N) in group 1, 452 N (range 60-1125 N) in group 2 and 367 N (range 112-840 N) in group 3. The paired Student t-test demonstrated a significant difference between pullout strength of groups 1 and 2 (P = 0.0300). Between pullout strength of groups 1 and 3 and between groups 2 and 3 no significant difference was seen.

CONCLUSION

We achieved a 1.9 times higher pullout strength with kyphoplasty augmentation of osteoporotic vertebrae compared with the pullout strength of nonaugmented vertebrae. Implantation of pedicle screws in cured cement is a sufficient method. With this method we found a 1.6 times higher pullout strength then in nonaugmented vertebrae.

[Postoperative autologous retransfusion of collected shed blood after total knee arthroplasty with the cell saver]

AIM

The purpose of this study was to examine if it is possible to reduce transfusion of blood units by collecting shed blood with the Cell Saver for autologous retransfusion in total knee arthroplasty (TKA).

METHOD

In 186 patients drainage blood was collected over a 6-h period after total knee arthroplasty with a Cell Saver system in order to make retransfusions if necessary. A tourniquet was used routinely throughout the operation. No preoperative blood donation was performed. In 19 patients preoperative haemoglobin levels were below 12 g/dL (group A, anaemic patients). In the other 167 patients (group B) the preoperative haemoglobin levels were higher.

RESULTS

4 patients (21 %) in group A received a homologous blood transfusion. Only 1 patient (0.6 %) in group B received one unit of erythrocyte concentrate (difference statistically significant, P < 0.001). In group A 8 patients (42 %) received 284 ml (145-621 ml) Cell-Saver concentrate on average, 38 patients (23 %) in group B received 358 mL (147-776 ml) Cell-Saver concentrate on average.

CONCLUSION

With a risk lower than 1 % for patients without anaemia to get a homologous blood transfusion one can do without the more expensive preoperative blood donation in total knee arthroplasty if a tourniquet is used for the operation and a Cell Saver is used for facultative retransfusion of drainage blood.

[The artificial hand. An overview of hand prostheses]

In spite of constant demands made by patients for optimal reconstruction of the hand in cases of injury or amputation, prosthetic devices allow only basic functions of the hand. The most important function, i.e., to connect sensitive-tactile abilities of the hand with the eye and central nervous system, has not yet been achieved and will not be feasible in the near future. There have been numerous attempts to reconstruct single hand functions such as subtle finger control in all known directions etc. Until now none of these attempts have led to any serial production of a functional "tool" because the interface between prosthesis and CNS has not been sufficiently resolved. Minute finger control requires considerable mechanical engineering that includes an efficient motor drive and an adequate power supply,which renders possible prototypes for hand prostheses heavy and complicated in everyday performance. This survey offers a short and comprehensive introduction to high-performance but simple "down-to-earth" orthotic and prosthetic devices for the replacement of lost forearm,hand, and finger function.

Recurrent crepitant cellulitis caused by Clostridium perfringens

A previously healthy 13-year-old boy developed extensive subcutaneous emphysema of the lower limb after a penetrating injury to the knee. Clostridium perfringens was isolated from the wound. Despite surgical debridement and appropriate antibiotics, the emphysema recurred, and prolonged antibiotic treatment was required. This case highlights the distinction between gas gangrene and the lesser known entity of clostridial crepitant cellulitis.

Duration of antibiotics in children with osteomyelitis and septic arthritis

OBJECTIVE

To evaluate the outcomes of children with acute osteomyelitis and septic arthritis at a hospital where short-duration antibiotic treatment (< or = 3.5 weeks) was considered routine.

METHODOLOGY

We carried out a retrospective chart review, with telephone interviews to follow up and determine long-term outcomes. Patients were selected to be at low risk for complications (illness < or = 14 days, no underlying disease, uncomplicated presentation).

RESULTS

Thirty-two children with osteomyelitis (OM), 34 with septic arthritis (SA) and five with OM and SA (OMSA) were included. Blood cultures were positive (mainly Staphylococcus aureus) in 15% of patients who had not had prior antibiotic treatment, and microbiological confirmation (positive blood culture, Gram stain or culture of surgical specimen) was obtained in 36%. The median duration of antibiotic treatment was 5.4, 4.4 and 5.0 weeks for OM, SA and OMSA, respectively. Only 22% of patients received antibiotics for 3.5 weeks or less. Overall, the recurrence rate was 1.4%. At follow-up, only two patients had mild occasional pain at the site of the original infection; all patients had normal function.

CONCLUSIONS

Contrary to expectations and local protocols, most patients were treated with conventional long-duration therapy. Patients treated for short courses had good outcomes. The low rate of complications may make randomized controlled equivalence trials unfeasible. Increasing evidence of the efficacy and safety of short-duration treatment (3-3.5 weeks) for acute, uncomplicated OM or SA in children suggests that this could be accepted as the standard treatment. However, this should be evaluated prospectively using a register, with at least 12 months' of follow-up.

[2- and 3-dimensional correction of scoliosis by corset treatment. Optimized conservative therapy of idiopathic scoliosis with the improved Cheneau corset]

It is generally accepted that the progression of an idiopathic scoliotic deformity with a Cobb angle of between 25 degrees and 40 degrees can be stopped by brace treatment alone provided that the generally acknowledged criteria for the treatment concerning skeletal growth of the individual are respected. In Europe, the Cheneau brace, which was originally designed as an active derotation orthosis, is widely in use and is constantly being improved. The biomechanical principle of this orthosis consists of a pressure vector that is applied laterally (with regard to the 3-point principle) to exert pressure on the peak of the curvature in the frontal and transversal planes. Thus, the thoracic, lumbar and pelvic body mass that was rotated out of normal body symmetry is transferred back to its original position via pressure and derotation. Therefore, an active back like the Cheneau orthosis must provide pressure surfaces and sufficient expansion spaces. Subtle insights into the actual effect of braces have furthered ongoing development to take into consideration the changes to the trunk in the sagittal plain and have respected the different states of expansion of the two halves of the trunk in the craniocaudal direction. The thoracic flat back and cyphosis of the lumbal spine, which were formerly ignored, actually provide a real challenge for the technical realization of the brace. The new generation of Cheneau braces potentially provides an effective means for the active correction of scoliotic spinal deformity in all three dimensions and thus fulfills the requirements of modern conservative scoliosis treatment.

[Ventrodorsal correction and instrumentation in idiopathic scoliosis]

A number of different procedures are used for the surgical treatment of King II scoliosis. One reason for the controversial discussion in this context is that the term King II scoliosis is usually inadequate, because there are partly marked clinical and radiological differences in this type of curvature. From January 1996 to December 1997, a total of 26 patients with rigid King II scoliosis were submitted to a ventrodorsal procedure. Twenty-three patients were included in the study. The indication for this procedure was established in cases with a secondary lumbar curvature of at least 50 degrees as well as unsatisfactory straightening of the primary and secondary curvature in the bendings and inadequate horizontal positioning of the caudal end vertebra of not less than 10 degrees. Ventral Derotation-Spondylodesis (VDS) and Dorsal correction-Spondylodesis (DKS) led to a thoracic and lumbar straightening from 68.4 degrees to 13.2 degrees and from 61.4 degrees to 17.8 degrees, respectively. The tilt of the vertebra instrumented farthest caudally was corrected from 21.2 degrees to 4.9 degrees. The thoracic hypokyphosis was improved from 16.6 degrees to 25.1 degrees. In 11 patients, the dorsal instrumentation was extended to the caudal end vertebra, in another 11 patients, instrumentation was achieved up to a vertebra cranial from the end vertebra. The correction loss and complication rate was extremely low. Based on the surgical goals discussed further down, combined application of VDS and DKS is efficient and suitable in conjunction with the indication described. The complication rate is quite low. The different types of King II scoliosis have to be differentiated preoperatively.

Long-term results of Salter and Chiari hip osteotomies in developmental hip dysplasia. A survey of over 10 years follow-up with a new hip evaluation score

When conservative treatment of developmental hip dysplasia (DDH) does not render satisfactory results, surgical methods are indicated to gain a maximum of joint posture and stability. To assess the efficiency of these surgical procedures, the long-term results of the most often used pelvic osteotomies were examined. As common evaluation scores do not apply for DDH, we developed a specific score system of 100 points to integrate subjective factors such as patient's complaints with objective functional and radiological findings after surgical intervention. Our survey with an average postoperative follow-up examination of 10 years indicated that Salter's innominate osteotomy can render long-term pain relief and enable normal hip development, whereas Chiari's capsular arthroplasty does not. Here, subjective patient complaints do not correlate with clinical and radiological findings, which leads to unsatisfactory results. Ideally, patients aged 2-3 years can undergo Salter's innominate osteotomy whereas the Chiari osteotomy should be considered for patients older than 15 years. Even under optimal surgical conditions, Chiari's osteotomy cannot significantly prevent the development of joint arthritis. Undoubtedly, late results of both surgical procedures are dependent upon the initial stage of DDH. Additional upper femoral correction osteotomies have no further influence on hip development.