First, we describe the physiological development of the torsion of the femoral neck, starting from about an angle of 35 degrees at the time of birth up to an angle of a mean value of about 15 degrees at the end of bone growth. Furthermore, we explain diagnostic procedures (clinical examination, X-ray, tomography) according to their clinical relevance. The differences from the normal range are discussed in their pathogenetic context with the clinical symptoms characteristic for the hip and knee joint. The most relevant aspect of the pathological torsion of the femoral neck is a decreased antetorsion angle, while an increased antetorsion angle was overestimated in the past.
The regulations in the recent German Tissue Act have completely changed the working situation for musculoskeletal tissue establishments. According to the requirements of section 20b, section 20c and section 21a AMG it should be possible to maintain local bone banks but centralised regional tissue banks will dominate in the future. The transmission of viral and non-viral infectious pathogens continues to be the most serious of the potential adverse effects of allogenic tissue transplants. Accordingly, tissue banks must focus on comprehensive and robust quality assurance in the areas of donation, testing, processing and preservation. Whenever possible, a validated inactivation procedure should be included in the manufacturing process of musculoskeletal tissue transplants.
Two cases of posttraumatic "psychogenic clubfoot" deformity are reported. Case I. A woman, aged 44, with foot deformity after infantile paralysis on the right side sustained an inversion injury to the left ankle in April 1979. Two weeks later she was admitted to our hospital. She was unable to walk and examination showed a drop foot with supination contracture of the left foot. Neurological examination was normal inclusive electromyogram. Ligaments of the ankle and peroneal tendons were reviewed by operative procedure under suspicion of rupture. There were no pathological findings, no hematomas or other traumatic signs. The neurological control examination was normal and psychogenic contracture was diagnosed. The personal history showed a corresponding problematical psychic background. Case II. A man, aged 24, was admitted to our hospital 3 months after an inversion injury to the right ankle. Examination showed a drop foot with supination contracture (Fig. 1 a, b). He walked with two crutches. Roentgenograms were normal, the ankle had normal stability, and neurological examination showed no pathological findings. There were no signs of an organic lesion. Psychogenic club-foot was diagnosed. Both patients were treated functionally with active exercises and psychological care. The follow-up control 1 resp. 1/2 year after injury showed normal muscles and free active mobility in both cases (Fig. 1 c, d).
121 children with cdh, which haven been treated between June 84 and December 85 in our out-patient-ward with Aktivspreizhose (abduction-pants), have been followed by ultrasound examination. Reliability of hip ultrasonography, duration of treatment and results have been evaluated. At the beginning of treatment the diagnosis were: 24.8% type IIa, 29.6% type IIb, 13.2% type IIG or IID and 5.8% type IIIa according to Graf; in 6.6% of the cases cdh was diagnosed only by x-rays. Hip ultrasonography was highly reliable according to quality controls in comparison to x-rays and short-ended the duration of treatment. With the exception of 3 children (1 Myelodysplasia, 2 start of treatment after the 6 months of life) all children with "Aktivspreizhose" treatment showed anatomic healing. Duration of treatment was 4.2 months on the average, 3.5 months when treatment started in the first 3 months of life, and 4.7 months, when started after the first 3 months of life. X-ray-controls at the end of treatment showed mild forms of femoral head necrosis (type I and II) in two cases, which healed completely according to follow up controls. For the treatment of cdh in babies the Aktivspreizhose is the optimal therapy, especially when started in the first 3 months of life. A general legal orthopaedic clinical and ultrasound screening of babies hip in the first week of life should be introduced.
Allogenic bone grafting is an established method in revision surgery of artificial joint replacement and spinal surgery in case of bone defects. In Germany, femoral heads from living donors undergoing total hip replacement are frequently used. These grafts are processed according to the "Guidelines for the management of bone banking" issued by the Federal Medical Board. Bone grafts are drugs according to German law. Local bone banks are excluded from the regulations of the federal law on drugs [Arzneimittelgesetz (AMG) section sign 4a (4)] if certain requirements are fulfilled. The Directive 2004/23/EC of the European Parliament and of The Council on Setting Standards of Quality and Safety for the Donation, Procurement, Testing, Processing, Preservation, Storage and Distribution of Human Tissues and Cells has to be implemented into national law within 2 years. The exception of section sign 4a (4) will no longer be possible. Thus a legal construction has to be found which allows running local bone banks in compliance with the new legal settings. Three conditions will be possible: (1) a single physician procures a graft for another patient of his, (2) grafts are procured in one hospital and are used exclusively in this hospital: a license from the local authorities and a strict quality assessment according to GMP-rules is required, (3) if the grafts are distributed to other hospitals, a license from the local authorities and registration as a drug by the federal authorities are necessary.
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