Surgical treatment of infected bones with vascularised bone grafts is well established as an efficient strategy since several years. Nevertheless orthopaedic and trauma surgeons seem to apply vascularised bone grafts as the last treatment option only.

Two strategies exist for treatment of chronically infected bones with vascularised bone grafts. First: Complete resection of the infected, often non-united part of the bones and reconstruction with large vascularised bone grafts, mostly fibular grafts. Second: Augmentation of the kept and intact parts of the bones with vascularised bone grafts. Two small series of patients are presented to illustrate both techniques and to show the results and outcome.

Resection of big parts of the tibia and reconstruction with mostly ipsilateral fibular grafts – single barrel in children and double barrel in adults – led to uneventful healing in all cases. Augmentation of radius, femur and calcaneus with vascularised grafts from the iliac crest or the scapula was followed by primary healing, too. All patients were disburdened from infection up to now and regained full extremity function.

The presented vascularized bone grafts did not only salvage the extremities but also could maintain their functionality. The procedure is demanding, but reliable and safe at a low rate of complications. Thus vascularised bone grafts should not only be used as ultimative salvage procedures, but as early as possible whenever standard treatments for osteomyelitis fail.

Introduction: Temporary hemiepiphyseodesis allows correction of angular deformities of the lower extremities in children before the end of growth. The eight plate is an alternative to Blount staples with the theoretical advantage of a more minimal approach, less risk of loosening with subsequent need for a re-operation and less compression of the growth plate due to the tension band mechanism. We report our results and experiences with this new implant.

Methods: Between August 2005 and May 2007 we implanted 74 eight plates (Orthofix International NV, Netherlands Antilles) in 32 patients. An idiopathic valgus deformity was the indication in 20 patients, an idiopathic varus in 4 patients, and a malalignment due to other reasons like infection, syndrome-association or trauma was seen in 8 patients. For the first part of this study we evaluated intra–and postoperative complications in patients with a minimum follow-up after the operation of 3 months. For the second part of the study we evaluated the results of correction after removal of the plate and analyzed long-standing radiographs using the malalignment test.

Results: Twenty-three patients treated with a total of 52 eight plates were included into the first part of this study. The mean follow-up after implantation was 9,5 months (range:3,4–22 months). One patient suffered from a significant postoperative haematoma which resolved spontaneously after 2 weeks and two patients showed a limited range of motion of the knee joint postoperatively. In both patients the range of motion was completely restored after 10 sessions of physical therapy. No other complication was seen during follow-up. Up to now 25 eight plates in 12 patients with 18 lower limb segments were removed. The mean age of the patients at the time of surgery was 12,2 years(rang: 6 – 13). The x-rays of these 18 lower extremities were reviewed and the alignment was analyzed. The mean preoperative mechanical axis deviation was 30,6mm (range: 8-50 mm). After hardware removal the mechanical axis showed a mean deviation from the center of the knee joint of 0,2 mm medial (range: 6mm lateral to 5 mm medial). The mean duration of implantation was 8,3 months (range: 4 to 16 months). Overcorrection was found in 2 patients, while a lack of correction at the end of growth was seen in one patient.

Conclusion: The eight plate is a safe and effective implant for temporary hemiepiphyseodesis. Especially loosening or implant failure, both commonly reported with the use of Blount staples, was not seen in our case series. Due to the minimal invasive approach with the need to implant only one eight-plate vs. two to four Blount staples and the sizes of the plates available the indications may be spread to a wider spectrum of deformities and ages.

Introduction: Bone marrow edema syndrome (BMES) of the femoral head in pregnant women is a rarely seen disease associated with disabling pain in the hip, beginning in the second or third trimester and persisting after parturition.

Materials and Methods: We treated 4 postpartum women (6 hips) presenting with femoral head BMES with infusions of the prostacycline analogue iloprost (20 μg for 5 days) followed by 3 weeks of partial weight-bearing.

Results: Symptoms regressed rapidly during and after therapy. After 4 weeks, all patients were asymptomatic with no limitations in ambulation. In the magnetic resonance imaging assessment, complete regression of BMES could be detected in three patients and minor residual BMES in the femoral neck was found in one patient (one hip) after 3 months. Pain did not recur in any patient at a mean follow-up of 31 months (range, 14 to 43 months).

Conclusion: The vasoactive drug iloprost has good analgesic potency in the treatment of postpartum women suffering from BMES and accelerates the natural benign course of the disease.

Introduction: Intra-articular migration of bone marrow edema syndrome (BMES) is a very unusual pattern of disease which has been previously described in only a few cases and may raise the suspicion of an aggressive disease.

Materials and Methods: We reviewed 8 patients (4 women, 4 men) with unilateral BMES located in the knee. The patients were aged 39 to 56 years (mean 50.2). In all the patients, bone marrow edema found in the primary magnetic resonance imaging (MRI) migrated within the same joint, i.e. from the medial to the lateral femoral condyle or to the neighboring bone. Conservative therapy including limited weight-bearing for a period of three weeks was provided for seven patients after initial detection of BMES and one patient underwent surgical core decompression twice.

Results: MRI showed complete restitution in 6 cases and small residual edema in one case. A final MRI control was not obtained in one painless patient. In one patient, avascular necrosis of the contralateral hip was evident after 16 months. Improvement of the MRI pattern was correlated with the clinical outcome in all patients. All patients became asymptomatic after a mean of 9 months (range, 6–11).

Conclusion: Intra-articular migrating BMES is a condition seen very rarely. The disease is self-limited so that conservative therapy can be recommended.

Bone marrow edema is a common cause of pain of the locomotor apparatus. We reviewed 50 patients (28 male, 22 female) with bone marrow edema of the knee. The patients mean age was 56.2 12.8 years. 8 cases were estimated to have an idiopathic BME, 10 posttraumatic and the other 32 ones to be secondary to an activated osteoarthritis or to mechanic stress. Iloprost is a vasoactive prostacyclin analogue. Therapy consisted of a series of five infusions with either 20 or 50g of iloprost given over 6 hours on 5 consecutive days each. Pain at rest as well as under stress were assessed with a semi quantitative scale from before and 4 months after therapy. MRI investigations were done before and repeated 4 months after therapy.

At the clinical follow-up 4 months after therapy, pain level at rest had diminished 84% (p < 0.0001). 70% of patients referred about a reduction, 30% about no change. Pain under stress decreased 57%, (p < 0.0001). 76% of patients showed lower pain under activity, 24% no change from baseline. There was no increase of pain level in any patient. In MRI in 85% a significant reduction of the BME size or complete restitution could be observed, 15% showed no change. Response rate to iloprost infusions came to 100% in idiopathic, 100% in posttraumatic and 66% in secondary BME. A significant reduction of side effects could be reached by lowering the daily dosage from 50 to 20g.

The authors conclude that parenteral application of iloprost might be a viable method in the treatment of BME of different origins.

Introduction: Cases of developmental dislocation of the hip occur after walking age because of late or missed diagnosis and failed conservative or operative treatment. Up to now there is no consensus on the treatment of DDH after walking age. The purpose of this retrospective study was to evaluate the results of operative treatment in DDH after walking age in our patient population and to describe the treatment strategies and operative techniques used.

Material and Methods: Forty-two patients presenting 54 cases of DDH after walking age were operated on in our clinic between 1985 and 1997. There were 34 female and 8 male patients, with an average age at the time of operation of 47 months (range: 14 – 151 months). The parameters studied were the type of DDH according to Ts, the preoperative AC- angle, the postoperative AC- and CE- angles as well as the radiological outcome using the Severin classification.

Results: Based on the Ts classification we found 18 cases of type II, 22 cases of type III and 14 cases of type IV dislocations. Each hip had an average of 1.4 operations. The average preoperative AC- angle was 38.2 degrees (range: 22–50) whereas the average AC- angle in the last radiographic follow up was 22.2 degrees (range:5–10). The statistical analysis showed that the AC angle at the last follow up was significantly (p< 0,001) smaller than in the preoperative radiographs. The classification according to Severin showed class I in 28 cases, class II in 15 cases, class III in 8 cases and class V in 3 cases.

Conclusion: Although our study presents the results after a mid-term follow up the radiological results favor our clinical experience that a single stage combined procedure consisting of open reduction, pelvic osteotomy as well as a corrective osteotomy within the proximal femur with subsequent shortening should be recommended.

Congenital unilateral anterolateral tibial bowing in combination with a bifid ipsilateral great toe is a very rare deformity which resembles the anterolateral tibial bowing that occurs in association with congenital pseudarthrosis of the tibia. However, spontaneous resolution of the deformity without operative treatment and with a continuously straight fibula has been described in all previously reported cases. We report three additional cases and discuss the options for treatment. We suggest that this is a specific entity within the field of anterolateral bowing of the tibia and conclude that it has a much better prognosis than congenital pseudarthrosis of the tibia, although conservative treatment alone may not be sufficient.

Introduction: Although well-recognized in adults, RSD is rarely diagnosed in children. Management is still controversial and includes, mobilization and physical therapy, spinal cord stimulation, transcutaneous electrical nerve stimulation, steroids, tricyclic antidepressants, anticonvulsants, non-steroidal anti-inflammatory drugs, injections of calcitonin, vasodilators and calcium channel blocker or alpha-sympathetic blocker. In this study, we describe the treatment of RSD in children using Iloprost, a pros-tacyclin analog that mimics sympathicolysis. We report our treatment regime, the clinical course, complications and the outcome in our first seven patients.

Patients and Methods: Seven female patients with a mean age of 9 years (6 to 11 years) suffering from reflex sympathetic dystrophy (RSD) stage II were included in this prospective study. Inclusion criteria were RSD stage II – III, an age between 4 to 12 years, no previous operative procedures and duration of symptoms for a minimum of 6 months. Diagnosis of RSD was based on the presence of neuropathic pain, such as burning, dysaesthesia, paresthesia, and hypalgesia to cold, and physical signs of autonomic dysfunction such as skin cyanosis, mottling, hyperhidrosis, edema and coldness of the extremity. Treatment regime consisted of two infusions of Iloprost (IlomedinÒ, Schering AG, Germany) administered over 6 hours on two consecutive days. Additionally, all patients underwent physiotherapy as part of their inpatient treatment and were offered psychological counselling.

Results: One day after the last infusion, all seven patients were free of pain and full weight-bearing was possible. The side-effects of Iloprost were a headache in all patients and vomiting in two patients. Two patients relapsed, one 3 months and one 5 months after primary treatment. These two patients received a second series of infusions and were again free of pain within two days. During a mean follow-up period of 30 months all patients remained asymptomatic.

Conclusion: These preliminary results indicate that the treatment of RSD with Iloprost in combination with psychological counselling is a safe and effective treatment regime. Infusion therapy is a non-frightening procedure which may be an important factor considering the possible psychogenic etiology of RSD in children. Additional psychological counselling helps patients and their parents to develop coping strategies which may help to avoid relapses.

Introduction: The Taylor Spatial Frame (TSF) is a circular external fixator based on a hexapod system consisting of two carbon fiber rings connected with six telescopic struts. In conjunction with a software program the TSF allows for correction of deformities in 6 axis. After completion of the computer generated distraction plan a residual program can be used to correct any residual malalignment. Although the TSF received marketing clearance in 1997 and is used in specialized centers around the world, there is, up to date, only one MEDLINE report of two cases treated with the TSF. We present the results of 48 cases of limb lengthening and/or deformity correction using the TSF frame.

Patients and Methods: Between June 1999 and Septem-ber 2002 we implanted a total of 102 Taylor Spatial Frames (TSF). Only cases with a minimum follow up of 6 months after removal of the frame were included in our retrospective study. Thirty-six patients with a total of 48 TSF fixators met the inclusion criteria. The 23 female and 13 male patients had a mean age of 16 years (range:4-49). Eleven cases showed a post-traumatic deformity,13 cases a metabolic, 9 a congenital, 8 a osteodysplastic deformity and 7 showed various underlying pathologies. Seven TSF frames were implanted on the femur, whereas the remaining 41 frames were applied to the tibia.

Results: In 25 cases lengthening was the main treatment goal and in 23 cases the TSF was applied for angular or rotational deformity correction. The mean lengthening achieved in the group of patients treated was 40 mm (range: 20-70) and a mean healing index of 52.73 days/cm (28-105). In the patients who were treated to correct a deformity, the mean healing index was 159.69 days/cm (88-276). The highest mean healing index (178.91 days/cm) was found in patients where a metabolic disease was the underlying pathology, whereas patients treated for congenital lateral longitudinal defects showed the lowest mean healing index (53.25 days/cm). Complications included a superficial pin infection occurred in 66.6 % of the cases. There was no case of deep infection . Further complications were temporary postoperative sensory disturbance in 2 cases, premature consolidation of the fibula requiring re-oste-otomy in 2 cases, femoral fracture after removal of the frame in one case and dislocation of the frame with the need to change the position of a pin in another case. There were no hardware associated complications. A residual program was generated in 15 cases, 3 cases needed 2 and one case 4 residual programs to achieve the desired correction.

Conclusion: The healing index varied widely within our patient population. We assume that the healing index is not applicable to the correction of angular or rotational deformities with a lengthening less than 2 cm. The possibility of performing residual correction in all axis without the need to change the frame setup is a main advantage of the TSF and is very time saving during follow up examinations. Preoperative frame assembly is easy and fast compared to the standard Ilizarov system. A computer printed day-by-day prescription of strut adjustments makes it easy for the patient to perform the distraction and augments patient compliance.

The bone-marrow oedema syndrome is associated with local vascular disturbances and may be treated either conservatively or by core decompression after which recovery may take several weeks. We describe a 15-year-old girl with bone-marrow oedema of the left acetabulum which was confirmed by MRI. She presented with a four-week history of severe constant pain. Routine blood tests and plain radiographs were normal. She was treated with intravenous infusions of iloprost on five consecutive days (20 μg administered in 500 ml of sodium chloride). Iloprost causes vasodilatation with reduction of capillary permeability and it inhibits platelet aggregation. She had relief from pain at rest after three days of treatment and was completely free from symptoms after two weeks. MRI after six weeks showed almost complete resolution of the marrow oedema and was normal after four months. This is the first report of the pharmacological treatment of the bone-marrow oedema syndrome in children.

Bone marrow oedema syndrome of the talus is a rare cause of pain in the foot, with limited options for treatment. We reviewed six patients who had been treated with five infusions of 50 μg of iloprost given over six hours on five consecutive days. Full weight-bearing was allowed as tolerated. The foot score as described by Mazur et al was used to assess function before and at one, three and six months after treatment. The mean score improved from 58 to 93 points. Plain radiographs were graded according to the Mont score and showed grade-I lesions before and after treatment, indicating that no subchondral fracture or collapse had occurred. MRI showed complete resolution of the oedema within three months.

We conclude that the parenteral administration of iloprost may be used in the treatment of this syndrome.