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Developmental dysplasia of the hip (DDH) is a significant health problem that can lead to lifelong treated or disabled individuals if the diagnosis is missed in the first weeks of life. In Mongolia, an ultrasonic method (Graf) of DDH screening was introduced, piloted, and expanded as a nationwide newborn screening program in 2010. Trained neonatologists or pediatricians perform the hip ultrasound screening following standardized procedures and are responsible for the flexion-abduction treatment, if necessary. Complete documentation of all cases is mandatory. Screening, follow-up monitoring, and flexionabduction treatment are offered free of charge. The program aims to screen every newborn baby using hip ultrasound and provide early preventive treatment to eliminate disability due to DDH. As Mongolia is the first Asian country to launch a program of universal ultrasound screening for DDH, we needed to determine its coverage and treatment rate. During the implementation of the screening, we documented that physiological immaturity (Graf’s Type 2a) hips degrade and develop DDH. In these cases, unfavorable mechanical conditions may exist after birth since traditional Mongolian swaddling requires a tight wrapping with stretched legs, and the hips are held in an adducted position. Therefore, traditional swaddling possibly increases the risk for DDH. This hypothesis was tested with a randomized controlled trial. Another challenge of the nationwide screening program was a human resources issue. Because resources are limited, adequately trained physicians are not always available, especially in remote rural areas. Thus we compared the quality and interpretation of hip ultrasound between trained nurses and junior physicians with no previous ultrasound experiences. This thesis demonstrated that a simplified diagnostic and therapeutic framework for hip ultrasound DDH screening for newborns was successfully deployed in Mongolia, providing high,  + UNILU Diss 2024 F5 EL

In diesem Kapitel werden die wichtigsten orthopädischen Erkrankungen im Kindesalter dargestellt. Von den Krankheitsbildern rund um die Hüfte, über den Fuß bis hin zu Fehlstellungen und gestörter Entwicklung finden sich hier die „must-knows“ der Kinderorthopädie.

Conservative and operative treatments with gradual or acute correction of severe varus deformities of the leg have been described. We evaluated whether the corrective osteotomy used within the NGO Mercy Ships is an effective treatment for genu varum deformity of different etiologies in children and which patient specific factors have an influence on the radiographic outcome. In total, 208 tibial valgisation osteotomies were performed in 124 patients between 2013 and 2017. The patients' mean age at the time of surgery was 8.4 (2.9 to 16.9 (min/max)) years. Seven radiographically measured angles were used to assess the deformity. Clinical photographs taken pre- and postoperatively were assessed. The mean time between the surgery and the end of physiotherapeutic treatment was 13.5 (7.3 to 28) weeks. Complications were monitored and classified according to the modified Clavien-Dindo-classification system. The mean preoperative mechanical tibiofemoral angle was 42.1° varus (range: 85°-12° varus). The mean postoperative mechanical tibiofemoral angle was 4.3° varus (range: 30° varus-13° valgus). The factors predicting a residual varus deformity were higher age, greater preoperative varus deformity and the diagnosis of Blount disease. The tibiofemoral angle measured on routine clinical photographs correlated well with the radiographic measurements. The single-stage tibial osteotomy described is a simple, safe and cost-effective technique to correct three-dimensional deformities of the tibia. Our study shows very good mean postoperative results, but with a higher variability than in other studies published. Nevertheless, considering the severity of preoperative deformities and the limited opportunities for aftercare, this method is excellent for the correction of varus deformities.

BACKGROUND Equinus deformity with or without concomitant drop foot is a common finding in children with unilateral spastic cerebral palsy and spastic hemiplegia of other causes. Hypothetically, these deformities may lead to pelvic retraction and hip internal rotation during gait. Orthoses are used to reduce pes equinus during gait and to restore hindfoot first contact. OBJECTIVE We aimed to investigate whether the use of orthotic equinus correction reduces rotational hip and pelvic asymmetries. METHODS In a retrospective study, 34 children with unilateral spastic cerebral palsy or spastic hemiplegia of other causes underwent standardized instrumented 3D gait analysis with and without orthotic equinus management. We analyzed the differences in the torsional profile during barefoot walking and while wearing orthoses, as well as investigated the influence of ankle dorsiflexion and femoral anteversion on pelvic and hip kinematics and hip kinetics. RESULTS Wearing orthoses corrected pes equinus and pelvic internal rotation at the end of the stance phase and in the swing phase compared to barefoot walking. Hip rotation and the rotational moment did not significantly change with orthoses. Orthotic management or femoral anteversion did not correlate to pelvic and hip asymmetry. CONCLUSION The findings indicate that the correction of the equinus by using orthoses had a variable effect on the asymmetry of the hip and pelvis and internal rotation; both appear to have a multifactorial cause that is not primarily driven by the equinus component.

PURPOSE The purpose of this study was to establish consensus for the assessment of foot alignment and function in ambulatory children with cerebral palsy, using expert surgeon's opinion through a modified Delphi technique. METHODS The panel used a five-level Likert-type scale to record agreement or disagreement with 33 statements regarding the assessment of foot alignment and function. Consensus was defined as at least 80% of responses being in the highest or lowest of two of the five Likert-type ratings. General agreement was defined as 60%-79% falling into the highest or lowest two ratings. There was no agreement if neither threshold was reached. RESULTS Consensus was achieved for 25 (76%) statements, general agreement for 4 (12%) statements, and lack of consensus for 4 (12%) of the statements. There was consensus that the functional anatomy of the foot is best understood by dividing the foot into three segments and two columns. Consensus was achieved concerning descriptors of foot segmental alignment for both static and dynamic assessment. There was consensus that radiographs of the foot should be weight-bearing. There was general agreement that foot deformity in children with cerebral palsy can be classified into three levels based on soft tissue imbalance and skeletal malalignment. CONCLUSION The practices identified in this study can be used to establish best care guidelines, and the format used will be a template for future Delphi technique studies on clinical decision-making for the management of specific foot segmental malalignment patterns commonly seen in children with cerebral palsy. LEVEL OF EVIDENCE V.

Closed reduction followed by spica casting is a conservative treatment for developmental dysplasia of the hip (DDH). Magnetic resonance imaging (MRI) can verify proper closed reduction of the dysplastic hip. Our aim was to find prognostic factors in the first MRI to predict the possible outcome of the initial treatment success by means of ultrasound monitoring according to Graf and the further development of the hip dysplasia or risk of recurrence in the radiological follow-up examinations. A total of 48 patients (96 hips) with DDH on at least one side, and who were treated with closed reduction and spica cast were included in this retrospective cohort study. Treatment began at a mean age of 9.9 weeks. The children were followed for 47.4 months on average. We performed closed reduction and spica casting under general balanced anaesthesia. This was directly followed by MRI to control the position/reduction of the femoral head without anaesthesia. The following parameters were measured in the MRI: hip abduction angle, coronal, anterior and posterior bony axial acetabular angles and pelvic width. A Graf alpha angle of at least 60° was considered successful. In the radiological follow-up controls, we evaluated for residual dysplasia or recurrence. In our cohort, we only found the abduction angle to be an influencing factor for improvement of the DDH. No other prognostic factors in MRI measurements, such as gender, age at time of the first spica cast, or treatment involving overhead extension were found to be predictive of mid-term outcomes. This may, however, be due to the relatively small number of treatment failures.

PURPOSE There is marked variation in indications and techniques for hamstring surgery in children with cerebral palsy. There is particular uncertainty regarding the indications for hamstring transfer compared to traditional hamstring lengthening. The purpose of this study was for an international panel of experts to use the Delphi method to establish consensus indications for hamstring surgery in ambulatory children with cerebral palsy. METHODS The panel used a five-level Likert-type scale to record agreement or disagreement with statements regarding hamstring surgery, including surgical indications and techniques, post-operative care, and outcome measures. Consensus was defined as at least 80% of responses being in the highest or lowest two of the five Likert-type ratings. General agreement was defined as 60%-79% falling into the highest or lowest two ratings. There was no agreement if neither of these thresholds was reached. RESULTS The panel reached consensus or general agreement for 38 (84%) of 45 statements regarding hamstring surgery. The panel noted the importance of assessing pelvic tilt during gait when considering hamstring surgery, and also that lateral hamstring lengthening is rarely needed, particularly at the index surgery. They noted that repeat hamstring lengthening often has poor outcomes. The panel was divided regarding hamstring transfer surgery, with only half performing such surgery. CONCLUSION The results of this study can help pediatric orthopedic surgeons optimize decision-making in their choice and practice of hamstring surgery for ambulatory children with cerebral palsy. This has the potential to reduce practice variation and significantly improve outcomes for ambulatory children with cerebral palsy. LEVEL OF EVIDENCE level V.

Femoral derotation osteotomy (FDO) is a well-established procedure for the correction of internal rotation gait in children with cerebral palsy. Various studies have demonstrated good results for FDO both in short-term and long-term evaluation with some describing recurrence and over- or under-corrections. The present study evaluates the use of an objective intraoperative derotation measurement through electromagnetic tracking. We report the static and dynamic results of 11 cases with internal rotation gait (8 male, 3 female, mean age 22.2 years), that underwent FDO with intraoperative electromagnetic tracking and conventional goniometric measurement of the correction. The dynamic and static changes were assessed through three-dimensional gait analysis after a mean of 12 months after surgery and rotational imaging preoperative and after a mean of eleven days postoperatively. Mean hip rotation in stance significantly decreased from 20.9° (SD 5.9) to 5.8° (SD 4.7°) after FDO. The mean amount of derotation quantified by electromagnetic tracking was 23.2° (16.5°-28.8°) and 25.1° (20.0°-33.0°) for goniometric measurement. Both measurement modalities showed small differences to rotational imaging (electromagnetic bone tracking [EMT]: 0.72°; goniometer: 1.19°) but a large deviation when compared to three-dimensional gait analysis (EMT: 8.5°, goniometer: 9.1°). In comparison to the static changes and EMT measurement, the dynamic changes measured during 3-D-gait analysis reflected only 66% of the actual derotation performed during surgery. Although electromagnetic tracking allows a precise intraoperative assessment of the derotation during FDO, the amount of intraoperative correction is not reflected in the improvements in three-dimensional gait analysis.