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Background: Positional plagiocephaly (PP) is a common cranial asymmetry of infancy. Its treatment options include conservative management and helmet therapy. However, the efficacy of each, particularly at achieving a normal cranial shape, remains uncertain.Purpose: This study aimed to compare the efficacy of conservative management and helmet therapy for PP.Methods: We retrospectively analyzed 199 infants with PP treated in 2015–2024. A total of 72 patients with a minimum treatment duration of 90 days and minimum plagiocephaly severity level of 2 (Children's Healthcare Atlanta Plagiocephaly Severity Scale) were included. Of them, 36 received conservative management and 36 received helmet therapy. Each infant underwent three-dimensional surface scanning of the cranium (StarScanner).Results: The mean±standard deviation age at treatment initiation was 31.9±6.6 weeks in the helmet group versus 21.0±5.7 weeks in the conservative management group (P<0.001). The average treatment duration was 21.9 (interquartile range [IQR], 15.3–31.4) weeks vs. 20.6 (IQR, 14.1–26.6) weeks (P=0.171), respectively. The monthly correction speed of the cranial vault asymmetry index (CVAI) was comparable between groups (0.66±2.09 vs. 0.64±0.55, P=0.964). Plagiocephaly degree was reduced to level 1 in 9 of 36 patients (25%) who received helmet therapy versus 4 of 36 patients (11%) in the conservative management group (P=0.220), whereas a reduction in severity level was observed in 24 of 36 (67%) versus 15 of 36 (42%), respectively (P=0.058). In the helmet group, an earlier treatment initiation was significantly associated with a greater severity level reduction (r=-0.480, P=0.003). A longer treatment duration showed a trend toward a greater reduction in CVAI (r=0.331, P=0.052). In the conservative management group, both earlier treatment initiation (r=-0.537, P<0.001) and longer treatment duration (r=0.381, P=0.022) correlated significantly with improved outcomes.Conclusion: Conservative management and helmet therapy reduced cranial asymmetry with no significant difference in correction speed. An early treatment initiation was the strongest predictor of improvement, while a longer treatment duration was associated with better outcomes. A trend toward a greater reduction in severity level was observed with helmet therapy, suggesting its potential benefits in more severe cases.

Developmental dysplasia of the hip (DDH) is a common neonatal musculoskeletal disorder. In Germany, sonographic screening is recommended at 1–10 days of life for neonates with specific risk factors. This study aims to determine reference values for early sonographic screening and to evaluate associated risk factors. Between 2007 and 2022, 3383 neonates (6766 hips) underwent hip ultrasound according to Graf. Of these, 967 neonates were screened universally (2007–2015) and 1900 based on predefined risk factors (2015–2022). DDH was defined as ≥type IIc, according to Graf. A subgroup of 20 neonates with borderline alpha angles (51–52°) was followed up after 3–6 weeks. The mean alpha angle was 61.2° ± 5.3° (range 50.5–71.9°), and beta angle 70.8° ± 8.6° (range 53.6–88.0°). DDH prevalence was 2.5% in the universal and 3.2% in the risk-based cohort (p = 0.350). Logistic regression revealed associations with abnormal birth presentation (OR = 3.09, p < 0.001) and female sex (OR = 3.77, p < 0.001), not with Cesarean section or familial predisposition. In the follow-up subgroup, all hips showed a sufficient maturation to an alpha angle of 61.0° (range 57–66°). This study provides reference values for early DDH screening and confirms abnormal birth presentation and female sex as relevant risk factors.

Background Permanent epiphysiodesis (pED) according to Phemister is an established treatment for leg length discrepancies (LLD) but has largely been replaced by less invasive techniques. Nevertheless, modern pED procedures based on the Phemister principle are still widely used in paediatric orthopaedics for LLD correction and treatment of tall stature. However, the long-term effects of pED on the knee joint remain unclear. This study aimed to evaluate the long-term outcomes of Phemister pED, specifically assessing secondary alterations in knee joint morphology and the incidence of pre-mature osteoarthritis. A clearer understanding of these sequelae may help guide treatment decisions in paediatric orthopaedic care. Materials and methods A retrospective review of our institution’s longitudinal database identified 75 patients who underwent Phemister pED for LLD between 1980 and 2006. Of these, 20 patients met inclusion criteria and were available for long-term evaluation. Their clinical and radiographic outcomes were compared with those of an age- and sex-matched control cohort of ten untreated individuals. Clinical and radiographic assessments included LLD, mechanical axis deviation, joint orientation angles, central knee anatomy and osteoarthritis grading. Patient-reported outcomes were evaluated using the Oxford Knee Score (OKS), EQ-5D-3L and Knee Injury and Osteoarthritis Outcome Score (KOOS). Results The median follow-up was 37 years (interquartile range 33–39). The mean pre-operative LLD of 2.8 cm (standard deviation (SD) 0.7) was reduced to 1.1 cm (SD 0.6) at last follow-up, although 55% of patients had residual LLD > 1 cm. No relevant differences in joint alignment or central knee anatomy were found between patients and controls. Mild knee osteoarthritis (Kellgren–Lawrence grade 1) was observed in two patients and none in controls. Patient-reported outcomes showed lower OKS and EQ-5D-3L scores in the pED group, although KOOS scores were similar. Conclusions Phemister pED showed satisfactory long-term results for LLD correction, without secondary angular or intra-articular deformities or relevant knee osteoarthritis. Despite slightly lower function and more discomfort, findings support the use of modern pED techniques based on the Phemister principle. This is especially relevant for elective indications such as tall stature. Further comparative studies with percutaneous methods remain necessary to confirm these observations. Level of evidence Level IV, therapeutic study.

IntroductionArthrogryposis multiplex congenita (AMC) is a rare congenital condition that leads to severe joint contractures and deformities. As painful joint dysplasia and degeneration might develop over time, total joint replacement (TJR) can be a potential treatment option for these patients. The aim of this study is to investigate functional results, implant survivorship and potential complications in patients with AMC who undergo hip or knee arthroplasty.Materials and methodsWe retrospectively identified six TJR in three patients at a single centre performed between 2006 and 2019. The median patient age at surgery was 23 years and the median follow-up period was 69 (IQR 55–99) months. We analysed surgical technique, implant survivorship and complications as well as functional outcome determined by pain reported on the Numerical Rating Scale (NRS), patient-reported outcome scores [Oxford Hip Score (OHS), Harris Hip score (HHS), Oxford Knee Score (OKS)], range of motion and ambulatory status. Depending on data distribution means with ranges and median with interquartile range were compared with the Wilcoxon signed rank test or Student’s t test. The level of significance was defined at < 0.05.ResultsIn hips, the mean range of motion in flexion/extension (52° vs. 85°, p = 0.014) and in rotation (28° vs. 68°, p = 0.02) as well as mean pain score on the NRS (8.5 vs. 0, p = 0.001), OHS (9 vs. 26, p = 0.031) and HHS (17 vs. 52, p = 0.007) significantly improved. In knees, mean range of motion (55° vs. 93°, p = 0.403), mean pain score on the NRS (0 vs. 7) and the OKS (2 vs. 21) also improved. While the ambulatory status did not change, the patients who were wheelchair dependent reported less problems with transfers to a bed or chair and the patient who ambulated reported an improved walking distance. One total knee arthroplasty (TKA) underwent revision for an acute, late infection 155 months following the initial surgery.ConclusionsTJR is a safe procedure in patients with AMC that effectively improves function and reduces pain irrespective of preoperative ambulatory status.

Background Temporary epiphysiodesis (tED) around the knee is a well-established treatment approach for leg length discrepancies (LLD) in skeletally immature patients. Moreover, it may be conducted bilaterally to reduce height in tall stature. However, secondary changes in the bony morphology of the tibial plateau after tED have been reported. This study thus aimed to evaluate secondary alterations in knee joint morphology following tED around the knee. Methods Radiographs of 81 skeletally immature patients aged 7-15 years were retrospectively analysed. 10/81 patients underwent bilateral tED with RigidTacks TM (RT) to reduce growth in tall stature, whereas 71/81 patients (35 with eight-Plates TM (EP), 36 with RT) received unilateral treatment for LLD. To assess changes in knee joint morphology, following radiographic parameters were evaluated: femoral floor angle (FFA), tibial roof angle (TRA), width at femoral physis (WFP), and femoral notch-intercondylar distance (FNID). Furthermore, mechanical axis deviation (MAD), mechanical lateral distal femoral angle, medial proximal tibial angle, and joint line convergence angle were measured to analyse coronal alignment. All parameters were assessed prior to implantation, prior to device removal, and at last follow-up. Results Mean treatment duration was 2.7 years (standard deviation (SD) 1.1). Statistically relevant changes were observed in WFP (p=0.025), FNID (p=0.008), and MAD (p=0.002) after tED using EP, and in FNID (p=0.043) using RT. Compared with reference values for untreated healthy children, these relevant changes remained within one SD. Mean absolute MAD change using EP was 3.9 mm (SD 7.1) compared to 1.9 mm (SD 8.8) using RT. Secondary coronal malalignment with need for revision surgery was found in 11/81 patients (4/35 with EP, 7/46 with RT). Conclusions Statistically relevant changes in bony morphology after tED were only observed in the distal femur. However, there was no evidence of intra-articular knee deformities as all measured femoral and tibial parameters remained within physiological margins and were considered clinically inconsequential. Nevertheless, there was a considerable number of patients with secondary coronal malalignment among both implant groups, necessitating further elucidation.

Background/Objectives: Legg–Calvé–Perthes disease (LCPD) presents challenges in treatment due to its varied course and unclear etiology. This study aimed to evaluate the efficacy of combining proximal femoral varus osteotomy (PFVO) with a modified trochanteric flip osteotomy to address biomechanical consequences and improve hip abductor muscle strength. Methods: We present a modified approach combining PFVO with a trochanteric flip osteotomy. In this technique, the greater trochanter in compound with its muscular insertions is separated from the femur and attached distally using a varization blade plate. Nine patients (ten hips, mean age 8 years) with LCPD were treated using this technique. Clinical examination findings and radiographic evaluations were retrospectively analyzed. The median follow-up was 33 months. Results: At the last follow-up, two patients exhibited Trendelenburg gait, but hip abduction was improved in all patients. Radiographically, consolidation at the osteotomy site was observed in all cases with no delayed union or non-union. The median CE angle improved by 7°, while the median CCD decreased by 18°. The median MPFA decreased by 13°, resulting in a median of 82°. Conclusions: Combining PFVO with a modified trochanteric flip osteotomy addresses biomechanical issues associated with PFVO, potentially improving hip containment and abductor muscle strength. This approach may offer advantages over traditional osteotomy techniques in treating LCPD, and it appears to produce a superior functional outcome in particular in regard to limping when compared to conventional PFVO. Despite satisfactory radiological outcomes in most cases, further research is needed to assess long-term effectiveness and address challenges such as femoral head enlargement and persistent gait abnormalities.

Subtalar arthroereises (STA) is a minimally invasive and reversible surgery to correct symptomatic flexible flatfoot (FFF) in children. Various techniques were described either applying expandable sinus tarsi implants or lateral calcaneus stop screws. Studies comparing the outcome of STA with different devices are rare. This retrospective single-center cohort study analyzes the results of STA using three different implants. 113 STA were performed in 73 consecutive patients (28 females). Mean age at surgery was 10.8 years (range 5–16). Mean follow-up was 29.0 months (range 1–111). In 21 feet the non-absorbable Kalix® endorthesis and in 56 feet the absorbable Giannini endorthesis were applied. Subtalar extraarticular screw arthroereises (SESA) was conducted in 36 feet. Clinical, radiographic and pedobarographic parameters were analyzed. No intraoperative complications were observed. All three procedures achieved comparable improvements of the clinical, radiographic and pedobarographic parameters. The mean foot function index (FFI) improved from 36.4 (range 12–63) to 22.8 (range 2–55). The mean preoperative calcaneal inclination angle and the lateral talocalcaneal angle improved from 9.5° (range 0–22) and 42.3° (range 21–62) to 12.8° (range 0–26) and 37.6° (range 15–56), respectively. Pedobarographically determined values of the arch index, the medial midfoot contact area and the medial forefoot peak pressure decreased. In contrast to SESA (1/36, 3%), a higher incidence of implant-related complications was observed using Kalix® (6/21, 29%) and Giannini (10/56, 8%) sinus tarsi implants. Peroneal muscle contractures only occurred in the SESA group (4/36, 11%). Premature removal due to treatment-related complications was necessary in 6/21 Kalix® implants (29%), 4/56 Giannini implants (7%) and 4/36 SESA implants (11%). Implant choice for treatment of painful FFF in children with STA seems to play a subordinate role. Clinical, radiographic and pedobarographic outcomes are comparable between the applied implants. Surgeons and patients should be aware of the different spectrum of implant-related complications. Treatment can be reliably monitored by radiation-free pedobarography providing dynamic information about the deformity.

BackgroundIn the treatment of tall stature, the reduction of excessive predicted final height can either be achieved by hormonal treatment or surgically by temporary (tED) or permanent (pED) epiphysiodesis. The present study evaluates the preliminary results of two novel devices for tED and pED around the knee to reduce the predicted final height.Materials and methodsA retrospective analysis was performed to evaluate the clinical and radiographic outcome after bilateral epiphysiodesis for the treatment of tall stature. A cohort of 34 patients (16 girls, 18 boys) who underwent either tED or pED between 2015 and 2020 were eligible for analysis based on the electronic patient records and picture archiving and communication system of our orthopaedic teaching hospital. tED was conducted in 11 patients (32%) through bilateral implantation of four RigidTacks™ (Merete, Berlin, Germany) around the knee. Twenty-three patients (68%) received pED, performed with an EpiStop™ trephine (Eberle, Wurmberg, Germany). The mean overall follow-up time was 2.9 years.ResultsThe mean age at surgery was 12.3 years in girls and 13.2 years in boys. Patients had a mean body height of 175.2 cm in girls and 184.7 cm in boys at surgery. The mean predicted final height was 191.4 cm in girls and 210.4 cm in boys. At the last follow-up, 26 patients (76.5%) had achieved skeletal maturity. The mean height of skeletally mature patients was 187.2 cm in girls and 198.5 cm in boys. A mean reduction of the predicted final height of 5.9 cm in girls and 8.7 cm in boys was achieved, corresponding to a reduction in remaining growth of 46% in girls and 38% in boys. Secondary frontal plane deformities of the knee were detected in 5/11 patients (45.5%) in the tED group and 1/23 treatments (4.3%) in the pED group.ConclusionstED and pED have both proven to be efficient at achieving growth inhibition to reduce excessive predicted height. However, tED has been associated with an increased risk of secondary angular deformities of the knee. Furthermore, the risk of implant-related complications and the necessity of a subsequent surgical intervention for implant removal have led our study group to abandon tED when treating tall stature. Long-term results of both procedures are pending.Level of evidence4.

Background LIMB-Q Kids is a new patient-reported outcome measure (PROM) for children and adolescents with Lower limb differences (LLDs). This international field test study aimed to evaluate the psychometric properties of LIMB-Q Kids. Methodology Patients from pediatric orthopaedic clinics with a diagnosis of LLDs were recruited. Participants completed LIMB-Q Kids and 2 generic quality of life questionnaires, i.e., PROMIS Pediatric Short Form v2.0 – Mobility 8a, and PedsQL. Demographic and clinical data were collected including the LLRS AIM Index, a measure of clinical severity for LLDs. Rasch measurement theory (RMT) analysis was used to examine the psychometric properties of LIMB-Q Kids. Test-retest (TRT) reliability was examined and tests of construct validity were performed. Results Participants (N = 800) were recruited from 16 sites in 7 countries. Participants were aged 8 years and older (mean = 13, standard deviation = 3.2, range 8–25 years) and had a broad range of LLDs (e.g., Leg Length Discrepancy, Fibular Hemimelia, Skeletal Dysplasia, Blount’s disease, Posteromedial Tibial Bowing, Osteogenesis Imperfecta, Congenital Pseudarthrosis of Tibia, Tibial Hemimelia and Amputations). RMT analysis provided evidence of the reliability and validity of 9 independently functioning scales that measure leg appearance, physical function, symptoms (hip, leg, knee, ankle, and foot), leg-related distress, and social, and psychological function. In addition, TRT reliability based on a sample of 46 participants was high for all 9 scales (Intraclass correlation coefficient ranges from 0.76–0.95). LIMB-Q Kids Physical Function scale correlated strongly with the PROMIS Pediatric Short Form v2.0 – Mobility 8a (Pearson correlation 0.82) and the PedsQL Physical Function total score (Pearson correlation 0.77). As hypothesized, participants with more severe LLDs based on the LLRS AIM index scores reported lower scores on all LIMB-Q Kids scales, indicating more impact on the patients. Conclusions This study provided evidence for the validity and reliability of LIMB-Q Kids. This new PROM can be used to inform research, quality improvement efforts, and clinical care. By measuring outcomes that matter most to children and adolescents with LLDs, LIMB-Q Kids can provide information to support evidence-based decisions. Level of evidence Level III

(1) Purpose: Lower limb deformities can have a severe impact on health-related quality of life (HRQL). LIMB-Q Kids is a new patient-reported outcome measure (PROM) aiming to elucidate the experience of 8–18-year-old patients before, during and after treatment, and to measure the different aspects of HRQL. The aim of this study was to translate and culturally adapt LIMB-Q Kids to German. (2) Methods: The International Society for Pharmacoeconomics and Outcomes Research (ISPOR) guidelines were followed. Three forward translations, a backward translation, an expert panel meeting with eight participants, and twenty cognitive debriefing interviews led to the final German version of LIMB-Q Kids. (3) Results: In the forward translations, 4/159 items were difficult to translate, and 2/159 items in the backward translation differed from the original English version. Cognitive debriefing interviews with 20 patients identified 7/159 items that were difficult to comprehend/answer, and 2 of these items were changed. (4) Conclusions: Lower limb deformities can have a great impact on children, and it is important to measure and consider the impact on HRQL. In order to be able to use PROMs in different countries, conceptually equivalent translations and cultural adaptations should be performed in order to ensure comprehensibility. The final German version of LIMB-Q Kids is ready for use in an international field test.