Open Physes Research Articles

Intra-articular findings during the modified Brostrom procedure for lateral instability of the pediatric ankle.

Level IV Case Series.

The Outcome of Modified Dunn's Procedure for Moderate and Severe Slipped Capital Femoral Epiphysis

The aim of this study was to evaluate the outcome of 20 children with moderate-severe slipped capital femoral epiphysis (SCFE) with open physes, treated by the modified Dunn's procedure, as regards: intraoperative findings, clinical and radiographic outcomes, and postoperative complication rate. PATIENTS AND METHODS: A prospective study was executed , between 2012 and 2016, for treating moderate-severe SCFE with modified Dunn procedure in 20 hips of 20 patients, with a mean age of 13.6 ± 3.4 years (range: 10 – 16.5 years). Seven cases were unstable SCFE. We excluded mild SCFE, endocrinopathy and renal cases. RESULTS: The mean follow-up was 19 ± 9.2 months (range: 12 - 36 months). Radiologically . all parameters showed significant improvement; with the mean slip angle corrected from 61º± 14.4 preoperatively to 10º±10.1 postoperatively, the mean alpha angle corrected from 90.2±21º preoperatively to 49.1± 8º postoperatively and the mean femoral neck length difference was 8.1 ± 6 mm. Functionally , the mean Harris hip score (HHS) was 86.2 ± 9.6 and the Heyman and Herndon score was excellent-good in 15 cases (75%), fair in two, poor in two and failed in one. Postoperative major complications occurred in only two cases (10%); AVN in one and secondary FAI in another case

Osteochondritis dissecans of the knee.

Osteochondritis dissecans (OCD) of the knee is an idiopathic, focal, subchondral-bone abnormality that can cause instability or detachment of a bone fragment and overlying articular cartilage, with subsequent progression to osteoarthritis. The diagnosis is usually made during adolescence. Mechanical factors play a major role in the pathophysiology of OCD. When the radiographic diagnosis is made early in a patient with open physes, healing can often be obtained simply by restricting sports activities. The degree of lesion instability can be assessed by magnetic resonance imaging. When the lesion remains unstable and the pain persists despite a period of rest, surgery is indicated. Arthroscopic exploration is always the first step. Drilling of the lesion produces excellent outcomes if the lesion is stable. Unstable lesions require fixation and, in some cases, bone grafting. Defects must be filled, depending on their surface area. Although many surgical techniques are available, the therapeutic indications are now standardized.

Complicaciones asociadas a las diferentes técnicas de reconstrucción del ligamento cruzado anterior en menores de 18 años: Revisión sistemática

ObjectiveDetermine the complications related to the different techniques for anterior cruciate ligament reconstruction in patients under 18 years old. MethodologySystematic review using the databases Medline, Cochrane Database of Systematic Reviews and Embase (until July 2016), additional studies were included conducting a search of the references of previous studies. The terms included in the search were: «cruciate», «ligament», «anterior», «immature», «complications», «outcome», «acl reconstruction»,« cruciate ligament anterior reconstruction», «children», «child», «infants», «adolescent», «open physis», «growth plate» and «skeletally immature». ResultsA number of 73 studies were included; 1300 patients in total, average age 13 years, 70% were male, medial and lateral meniscal lesions in 26% and 30% respectively. Eleven cases of length discrepancy (0,8%): 4 cases were presented with physeal-sparing techniques (1,4%), 3 cases with partial physeal-sparing techniques (2.2%) and 4 cases were presented with transphyseal techniques (0.4%). There were 22 cases of axis deviation: 6 cases with physeal-sparing techniques (2%), 3 cases with partial physeal-sparing techniques and 13 cases with transphyseal techniques (1.4%). The use of allograft achilles tendon allograft and fascia lata was associated with increased length discrepancy and axis deviation (25%). There was no difference according to Tanner. ConclusionsThe different anterior cruciate ligament reconstruction techniques in patients under 18 years old had low complications related to lower limb growth, arthrofibrosis and review. There was a higher percentage of cases of length discrepancy and axis deviation with physeal-sparing techniques than with the other surgical techniques. The evidence level studies cannot determine causality.

Growth modulation by hemi epiphysiodesis using eight-plate in Genu valgum in Paediatric population

IntroductionGenu valgum is an angular deformity of the knee, often treated surgically by osteotomy or by growth modulation (using tension band, staples, transphyseal screws and eight-plate which require removal after correction). With this study, we attempt to evaluate the efficacy, rate of correction and complications with the use of 8-plate in the correction of genu valgum deformity in children. Material and methodIn a retrospective study of 24 patients with 11 bilateral and 13 unilateral (35 knees) genu valgum deformity which required surgical corrections were included. There were 11 males, and 13 females and all of them were treated with Steven’s technique (Stevens, 2006) using eight-plate and monitored closely. ResultTwenty-four patients with an average age of 10 years and 8 months (range: 5 yrs, 7 months–14 yrs, 2 months), with the mean preoperative & post-implant removal (Post-IR) tibiofemoral angle of 22.02°±5.15° (range 14°–31°) & 6.14°±1.92° (range 2°–10°) respectively, required an average time period of 1yr & 5m±5m (range 10 months–28 months) for correction after which implants were removed. Of the 35 limbs, we achieved excellent results in 91.6%. One case (4.16%) had a partial correction of the deformity, and one case (4.16%) had reported with a superficial infection which was taken care. There were 2 cases (8.33%) of over-correction, which was gradually self-corrected during follow-up. ConclusionOur results reflect the efficacy of flexible titanium eight plate which corrects angular deformity by acting as a tension band on one side of the growth plate and offers the advantage of reversible Hemi epiphyseal growth modulation. Guided growth modulation is a best available alternative for the treatment of an angular deformity in the patients with open physis.

Any Cortical Bridging Predicts Healing of Supracondylar Femur Fractures After Treatment With Locked Plating.

To determine the accuracy and reliability of radiographic cortical bridging criteria in predicting the final healing of supracondylar femur fractures after treatment with locked plating. Retrospective review. Two Level 1 trauma centers. Patients who presented with supracondylar femur fractures (OTA/AO 33A, C) and were treated with locking plate fixation between January 1, 2004, and January 1, 2011. The final study population included 82 fractures after excluding patients with open physes (n = 4), nondisplaced fractures (n = 4), early revision for technical failure (n = 4), or inadequate follow-up (n = 42). Distal femur locking plate fixation. Postoperative radiographs until final follow-up were assessed for cortical bridging at each cortex on anterior-posterior and lateral views. Images were analyzed independently by 3 orthopaedic traumatologists to allow for assessment of reliability. Final determination of union required both radiographic and clinical confirmation. Assessment for any cortical bridging was the earliest accurate predictor of final union (95.1% accuracy at 4 months postoperatively), compared with criteria requiring bicortical bridging (93.9% accuracy at 6 months) and tricortical bridging (78% accuracy at 21 months). Any cortical bridging demonstrated a higher interobserver reliability (kappa = 0.73) relative to bicortical (kappa = 0.27) or tricortical bridging (kappa = 0.5). Our results for plate fixation of supracondylar distal femur fractures mirror those previously described for intramedullary nailing of tibia shaft fractures. Any radiographic cortical bridging by 4 months postoperatively is an accurate and reliable predictor of final healing outcome after locking plate fixation of supracondylar femur fractures. Assessment for bicortical or tricortical bridging is less reliable and inaccurate during the first postoperative year. Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Treatment of osteosarcoma around the knee in skeletally immature patients.

Limb sparing surgery in growing young patients with malignant tumors is difficult as invasion of the physis by the tumor or surgical resection through the metaphysis may cause significant limb discrepancy following surgery. At present, hinged tumor prosthesis or biological reconstructions are the main methods following tumor resection in these patients. The aim of the present study was to assess different procedures for the treatment of osteosarcoma around knee joints in immature patients. A retrospective study of 56 patients (<15 years old, open physis) who had been treated for osteosarcoma around the knee joint between January 2007 and December 2015 was performed. Clinical data collected included patient demographics (age at diagnosis, sex and date of diagnosis), tumor characteristics [location, Enneking stage and subtype on magnetic resonance imaging (MRI)], treatment (response to neoadjuvant chemotherapy and type of primary surgery) and clinical outcomes (limb function, discrepancy and overall survival). The median age at the time of diagnosis was 12.14 years (range, 3–15 years). There were 32 male patients (57.1%). A total of 41 (82%) tumors were located at the distal femur, and 15 (18%) at the proximal tibia. A total of 49 (87.5%) patients were diagnosed with stage IIB tumors, and 7 (12.5%) had stage III, according to the Enneking stage classification. Different surgical methods, including amputation, rotation-plasty, endoprosthesis and biological instructions (e.g., allograft) were performed according to MRI type classification. During follow-up, 21 patients (37.5%) succumbed to disease. The Musculoskeletal Tumor Society score ranged from excellent to fair functional result. Recurrence (2 cases, 16.67%) and infection (2, cases, 16.67%) were the main complications following endoprosthesis replacement, while delayed union (12 cases, 57.14%) and fracture (3 cases, 14.29%) were the main causes for biological reconstructions. Limb-length discrepancy ranged from 0–10 cm in limb-saving surgery. The overall survival rate was 57.66% with different cohorts in Enneking stages IIB and III, with or without involvement of the physis and different cycles of chemotherapy. Results of the present study indicated that different limb saving surgeries, including epiphysis/physis preservation with biological construction in patients with MRI types I to III and endoprosthetic/osteoarticular reconstruction in patients with MRI types IV and V, are useful in the management of osteosarcoma in growing young patients with proper surgery indications, and knee joint function was maintained with acceptable complications including limb discrepancy, delayed union, infection, recurrence and fracture.

Multiligament Knee Injuries in Older Adolescents: A 2-Year Minimum Follow-up Study.

Background:Multiligament knee injuries cause significant functional impairment. Adults undergoing anatomic reconstruction of multiligament knee injuries have excellent outcomes postoperatively. However, less is known about the outcomes in adolescent patients following multiligament reconstruction.Purpose/Hypothesis:We aimed to assess patient outcomes and failure rates following unstaged multiligament reconstruction in an adolescent population at a minimum 2-year follow-up. We hypothesized that outcomes of multiligament reconstruction in these patients would be comparable to previously reported outcomes in the adult population.Study Design:Case series; Level of evidence, 4.Methods:The study included patients who had undergone multiligament knee reconstruction at 19 years of age or younger and had at least 2 years of follow-up. All procedures were performed by the same surgeon. Exclusion criteria included patient age 14 years or younger at the time of surgery, open physes, prior ipsilateral meniscal or knee ligament surgery, or a tibial plateau fracture at the time of injury. Multiligament reconstruction was defined as a reconstruction of at least 1 cruciate ligament and at least 1 component of the posterolateral corner or the medial knee. Patients were evaluated according to Lysholm score, Tegner score, Short Form–12 physical component summary (SF-12 PCS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, and postoperative patient satisfaction.Results:Twenty patients (mean age, 17.7 years; mean follow-up, 37.1 months) were included in this study. No patient required additional ligament surgery after the index surgery because of graft failure. The median preoperative Lysholm score was 49.5 (range, 18-90), and the median postoperative Lysholm score was 86 (range, 44-100) (P < .001). The median preoperative Tegner activity score was 2 (range, 0-9), and the median postoperative Tegner activity score was 6 (range, 2-10) (P = .012). The median SF-12 PCS improved from 40.5 preoperatively to a median of 56.1 postoperatively (P < .001). WOMAC total score improved from a median of 26.5 preoperatively to a median of 2 postoperatively (P < .001). Median postoperative patient satisfaction was 10 (range, 5-10).Conclusion:Single-stage multiligament knee reconstruction is a reliable procedure that improves knee function at 2-year follow-up in adolescent patients. Patient satisfaction was excellent, but longer follow-up in a larger series of patients is required to determine the long-term benefits of multiligament reconstruction in this patient population.

Anterior Cruciate Ligament Injury—and Repeat Injury

Research Article| September 01 2017 Anterior Cruciate Ligament Injury—and Repeat Injury AAP Grand Rounds (2017) 38 (3): 31. https://doi.org/10.1542/gr.38-3-31 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Anterior Cruciate Ligament Injury—and Repeat Injury. AAP Grand Rounds September 2017; 38 (3): 31. https://doi.org/10.1542/gr.38-3-31 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search toolbar search search input Search input auto suggest filter your search All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: anterior cruciate ligament injuries, reinjuries, anterior cruciate ligament reconstruction Source: Dekker TJ, Godin JA, Dale KM, et al. Return to sport after pediatric anterior cruciate ligament reconstruction and its effect on subs equent anterior cruciate ligament injury. J Bone Joint Surg Am. 2017; 99(11): 897– 904; doi: https://doi.org/10.2106/JBJS.16.00758Google Scholar Investigators from Duke University conducted a retrospective study to assess the risk of subsequent ACL injury after primary ACL reconstruction surgery in children and adolescents. Eligible study participants were youth <18 years old undergoing primary ACL reconstruction at the authors’ institution between 2006 and 2013 and were identified by using CPT® codes for ACL reconstruction. The medical records of identified patients were reviewed, and demographic data and clinical information were abstracted. Preoperative radiographs of study participants were reviewed, and physeal status (open or closed) was determined. Standardized phone interviews conducted ≥2 years after the index ACL reconstruction were conducted. Data collected during the interview included pre-and postoperative sports participation, time to return to sports, whether a subsequent ACL injury occurred, and time from initial surgery to subsequent injury. Cox regression was used to identify potential risk factors for subsequent ACL injury; risk factors assessed included time to return to sports, return to a high-risk sport (defined as football, basketball, lacrosse, and soccer), physeal status, and type of graft used for index ACL reconstruction. Among 112 eligible patients, complete follow-up data were available for 85 (76%). The mean age of study patients was 13.9 years (range, 6–17 years), and 60% were female. Prior to their initial ACL injury, all study patients participated in sports, with 35% competing in basketball and 28% playing soccer. At the time of surgery, 77% had open physes. After ACL reconstruction, 77 youth (90%) returned to sports. After their primary ACL reconstruction, 27 study participants (32%) sustained a second ACL injury, including 16 patients who injured the ipsilateral ACL and 11 who injured the contralateral side; 1 youth had a tear on both sides. Among the risk factors for subsequent ACL injury assessed in multivariate analyses, only an increased time to return to sports was associated with a decreased risk of a second ACL injury after the initial ACL reconstruction (hazard ratio per month of additional delay in returning to sports = 0.87, P = .04). For youth who had a second ACL tear, mean time from index surgery until return to sports was 8.9 months ± 2.5, compared to 9.9 months ± 3.4 for those who had not experienced a second injury at the time of follow-up. The authors conclude that among youth undergoing ACL reconstruction, there is a substantial risk of a second ACL injury. Dr Hennrikus has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device. ACL reconstruction is increasingly common in children. The increasing prevalence of ACL injuries is thought to be due to year-round youth sports participation and early sport specialization.1 Nonsurgical treatment of... You do not currently have access to this content.

Modified adductor sling technique: A surgical therapy for patellar instability in skeletally immature patients

BackgroundDue to open femoral physis the therapy of patellar instability in skeletally immature patients is challenging. We developed a modified surgical technique of the ‘Adductor-Sling-Approach’ by Sillanpää. The purpose of this study was to evaluate the clinical outcome of the operative technique and to analyse the reasons for failure. MethodsThirty ‘modified adductor sling’ reconstructions in 28 patients were included in the study. From 2010 to 2016 modified adductor sling reconstruction was performed by looping the gracilis or semitendinosus tendon around the adductor magnus tendon and attaching it at the medial facet of the patella. Clinical outcome was retrospectively evaluated at a mean follow up of 25.6months (range 12–43). The evaluation also included subjective International Knee Documentation Committee (IKDC), Lysholm Score, Kujala Score and Tegner Activity Score. ResultsThe average age at the time of operation was 15.10years (range 11–17). Eighty-seven percent of the patients, who underwent the modified adductor sling technique, gained a stable patella and excellent results in postoperative scores. Recurrent dislocation occurred in four of 30 cases (13%). Analysis showed that possible reasons for failure of the tendon graft could be maltracking of the patella due to patella alta, trochlear dysplasia or an elevated tibial tuberosity to trochlear groove distance. ConclusionThe modified adductor sling technique for MPFL reconstruction in children and adolescents showed elevated redislocation rates. Only in absence of additional patellofemoral maltracking, caused by elevated tibial tubercle to trochlear groove distance (>15mm), patella alta or especially severe trochlear dysplasia, the modified adductor sling technique could be recommended.

Tumor de células gigantes óseo en niños y adolescentes: reporte de 11 casos

BackgroundGiant cell tumours (GCT) of the bone are benign and consist of aggressive local growth with rare metastatic disease. Its reported incidence in the immature skeleton is less than 10%, ranging from 1.8% to 10.6%. Few GCT series have been reported in the immature skeleton. In our ¿country?, the overall incidence and impact of GCT in these patients is unknown. A series of 11 cases is presented, demonstrating their demographic characteristics, treatment, and follow-up. MethodsBetween the year 2000 and 2014, out of a total of77 patients with GCT, 11 of them presented with skeletal immaturity at the time of diagnosis. These patients were treated and followed-up in our institution. A retrospective analysis was performed. All patients had histologically confirmed GCT, and in all cases a review was made of the X-rays, chest CT and, bone scans, and MRI scans of the compromised region. Skeletal maturity was determined if there was open physes at the time of diagnosis. The mean follow-up was 6.6 years (range 2 to 10 years) ResultsA total of 8 females and 3 males, with a mean age of 14.8 years at the time of diagnosis, presented with a GCT. The incidence of GCT in the skeletally immature patient was 7%. The compromised site was: around the knee in 8 cases, of which 4 were in the distal femur and 4 in the proximal tibia, with two in the proximal humerus and one in a metatarsal. All patients were treated with allografts. Nine received structural allografts and two osteochondral allografts. One patient received denosumab. Seven out of the 11 patients had no complications. Three did have complications. One had a local recurrence, one required removal of hardware material, and a third presented with a fracture. The patient treated with osteochondral allograft presented with a traumatic fracture, which consolidated without surgical management. DiscussionGCT in the skeletally immature patient is rare, and poses a challenge for the surgeon. The impact on our practice is similar to that reported in the literature. In our series, successful reconstruction was achieved in the majority of patients, with one local recurrence. Allograft reconstruction is a good method of treatment, with successful results. The modality of our study limits our ability to assess effectiveness, and the low incidence in this age group limits the number of cases presented. A prospective study could further consider other aspects, such as length discrepancy and local recurrence, and functional scales could improve our knowledge about the impact of treatment in this population. Evidence levelIV.

Anterior cruciate ligament reconstruction in skeletally immature patients : a systematic review.

Different methods of anterior cruciate ligament (ACL) reconstruction have been described for skeletally immature patients before closure of the growth plates. However, the outcome and complications following this treatment remain unclear. The aim of this systematic review was to analyse the outcome and complications of different techniques which may be used for reconstruction of the ACL in these patients. We performed a systematic review of the literature according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. This involved a comprehensive search of PubMed, Medline, CINAHL, Cochrane, Embase and Google Scholar databases using the following combinations of keywords, "knee", "anterior cruciate ligament", "reconstruction", "injury", "children", "adolescent", "skeletally immature", "open physis" and "surgery". A total of 53 studies met the inclusion criteria and were included for analysis. The overall rate of disturbance of growth after ACL reconstruction was 2.6%, with no statistical difference between transphyseal and physeal-sparing techniques. Physeal-sparing techniques had a lower rate of post-operative complications compared with transphyseal techniques (p = 0.0045). Outcomes assessed were Lysholm score, International Knee Documentation Committee (IKDC) score, the IKDC grade, the Tegner score and the KT-1000. Both techniques had similar clinical outcomes. This review reveals low rates of disturbance of growth after ACL reconstruction in skeletally immature patients. Although limited, the available evidence did not support any particular surgical technique when considering disturbance of growth or clinical outcome. Further randomised controlled trials are needed to investigate the efficacy of differing surgical techniques on outcomes in skeletally immature patients. Cite this article: Bone Joint J 2017;99-B:1053-60.

Posterior plating of tibial shaft fractures: A functional outcome analysis

Tibial shaft fractures are the most common of long bone fractures. Tibial fractures are usually the result of trauma, both high energy and low energy. Increasing energy of injury leads on to both bone and soft tissue complications. Approximately 25 % of both bone fractures of leg are open fractures requiring external fixation or wound debridement with resultant problems in wound healing by secondary intention. A few often require secondary procedures for internal fixation which might get infected leading on to a vicious cycle implant exit, external fixation, wound debridement. Posterior tibial plating aims at avoiding the vicious cycle by providing primary internal fixation. We have reported a case series of patients who got operated for fracture tibia with posterior tibial plating, patients were followed up and functional outcome is reported in this study. Materials & Methods: Patients who had sustained lower limb fractures were examined and those patients with fracture at distal diametaphyseal region of tibia along with minor soft tissue injuries (Gustilo Anderson Type I and Type II) were chosen. Patients with fracture both bone leg with open physes were also included. We treated three patients with posterior plating of tibia. Results: Bone Union was achieved in all three patients with all of them bearing full weight at the end of four months. Conclusion: Posterior tibial plating adds another viable alternative in treating distal diametaphyseal fractures with soft tissue compromise or open physes.

Surgery for Femoroacetabular Impingement in Skeletally Immature Patients: Radiographic and Clinical Analysis

Objectives:The improved recognition of symptomatic femoroacetabular impingement (FAI) has lead to an emphasis of early diagnosis and treatment in the adolescent population. The purpose of this study was to evaluate the radiographic and clinical outcomes in patients with open physes that underwent hip arthroscopy for the treatment of symptomatic FAI. Additionally, we describe the three-dimensional (3D) pathomorphology in this unique population.Methods:We retrospectively reviewed 39 hips (28 patients; 75% male) with a mean age 15.8 years (range, 12.8-19.3 years) with FAI, who additionally demonstrated open physes on pre-operative radiographs. Radiographic parameters included the lateral center edge (LCE), Tonnis angle, AP and lateral alpha angle and head-neck offset ratio (HNOr). Each patient also underwent a pre-operative CT scan, which was utilized for the evaluation for femoral and acetabular measurements and simulated range of motion (ROM) to impingement. Preoperative and post-operative functions were evaluated prospectively using the modified Harris Hip Score (mHHS) and pain on a visual analogue scale (VAS). All patients participated in organized athletics and 50% were in multiple sports year round.Results:All patients (100%) within this cohort had open femoral neck and iliac crest physis. The ischial tuberosity and greater trochanteric physes were open in 95% and 54% of the hips respectively. Although there was no significant difference between pre-operative and post-operative LCE and Tonnis angles, the alpha angle and HNOr were significantly improved (39.7° vs. 61.7°; p<0.001 and 0.19 vs. 0.17; p<0.001). Mean femoral version was 17.6°±7.4°, while the acetabular version at the 1:30 and 3:00 positions were 1.0°±6.7° and 14.0°±4.1°. The mean maximum alpha angle was 72.0°±12.1° and was located on average at the 1:15 position. Simulated ROM to bony impingement was 121.6°±12.1° for flexion, 33.8°±13.3° for internal rotation in 90 degrees of flexion. Mean follow-up was 18.6 months (range, 6.3 - 55.8 months). There was a mean 23.0-point improvement in the mHHS (pre-operative 69.4, post-operative 92.4; p<0.001) and a mean decrease of 3.5 points in the VAS for pain (pre-operative 5.2, post-operative 1.7; p<0.001). 93% percent of patients returned to their preinjury level of sports participation and did not feel limited by their hip. Multivariate analysis demonstrated that a greater pre-operative LCEA correlated with a greater change in the mHHS score (r=0.374, p=0.038). Similarly, a greater pre-operative AP alpha angle and change in the AP alpha angle also correlated with a greater change in the VAS pain score (r=0.411, p=0.038 and r=0.426,p=0.019, respectively). No major complications were noted, but 3 hips (2 patients) underwent revision hip arthroscopy during the follow-up period secondary to further development of cam-type FAI. There were no cases physeal growth arrest, growth disturbance, avascular necrosis.Conclusion:The arthroscopic approach for the treatment of FAI in adolescents with open physes is a safe and effective and has a high return to sports rate. Risk for recurrent FAI in the presence of open growth plates was noted. Young, highly athletic adolescent patients with a larger FAI pathomorphology demonstrate the most predictable improvement in clinical outcomes after arthroscopicy.

Functional outcome of treatment of paediatric diaphysial femur fractures operated using titanium elastic nailing

Objectives: to review the experience of clinical recovery in treatment of pediatric shaft femur fracture with titanium elastic nailing. Observation: common type of fracture were transverse (41.5%) and spiral (39%) fracture. And at 12 weeks only 2 (4.9%) patients had the significant tenderness, 4 (9.8%) of patients had limb length discrepancy of 1 to 2 cms, and 41 (100%) radiological union was seen in (100%) patients. The final outcome according to Flynn’s criteria shows that excellent outcome seen in 35 (85.3%) of patients, while 4 (9.8%) patients showed satisfactory outcome. Conclusion: Titanium elastic nail seems advantageous over other surgical methods particularly in this age group because it is simple, is a load shearing device, internal splint that doesn’t violate open physis, allows early mobilization and maintains alignment. Micromotion conferred by the elasticity of the fixation promotes faster external bridging callus formation. The periostium is not disturbed and being a closed procedure there is no disturbance of fracture hematoma, thereby less risk of infection.

Osteochondritis Dissecans: Etiology, Pathology, and Imaging with a Special Focus on the Knee Joint.

This article is a review of the current understanding of the etiology, pathogenesis, and how to diagnose and treat knee osteochondritis dissecans (OCD) followed by an analysis of and outcomes of the treatments available. OCD is seen in children and adolescents with open growth plates (juvenile OCD) and adults with closed growth plates (adult OCD). The etiology of OCD lesions remains unclear and is characterized by an aseptic necrosis in the subchondral bone area. Mechanical factors seem to play an important role. Clinical symptoms are unspecific. Thus, imaging techniques are most important. Regarding treatment, a tremendous number of publications exist. Spontaneous healing is expected unless there is an unstable fragment, and treatment involves rest and different degrees of immobilization until healing. Patients with open physes and low-grade lesions have good results with conservative therapy. When surgery is necessary, the procedure depends on the stage and on the state of the cartilage. With intact cartilage, retrograde procedures are favorable. When the cartilage is damaged, several techniques can be used. While techniques such as drilling and microfracturing produce reparative cartilage, other techniques reconstruct the defect with additional osteochondral grafts or cell-based procedures such as chondrocyte transplantation. There is a tendency toward better results when using procedures that reconstruct the bone and the cartilage and there is also a trend toward better long-term results when comorbidities are treated. Severe grades of osteoarthrosis are rare.

Return to Sport After Pediatric Anterior Cruciate Ligament Reconstruction and Its Effect on Subsequent Anterior Cruciate Ligament Injury.

Anterior cruciate ligament (ACL) graft failure and contralateral ACL tears are more frequent in children and adolescents than adults. The reasons for higher subsequent injury rates in this population are incompletely understood. We analyzed a continuous cohort of patients who were <18 years of age. Subjects underwent isolated, primary ACL reconstruction with autograft between 2006 and January 1, 2014, and had a minimum 2-year follow-up. Return-to-sport characteristics were described, and multivariable Cox regression modeling was used to identify predictors of a second ACL injury. Candidate variables included patient factors (age, sex, physeal status, tibial slope, notch width index), surgical characteristics (graft type, surgical technique), measures of recovery (time to return to sport, duration of physical therapy), and patients' preoperative and postoperative sports involvement (primary and secondary sports, number of sports). A total of 112 subjects met inclusion criteria; of these patients, 85 (76%) had complete follow-up data and were analyzed. The mean age (and standard deviation) was 13.9 ± 2.1 years (range, 6 to 17 years); 77% had open physes. The mean follow-up was 48.3 ± 15.3 months. Seventy-seven patients (91%) returned to sports, and 84% returned to the same sport. The mean Marx activity score at the time of the latest follow-up was 13.7 ± 3.5 points. Patients were involved in fewer sports after ACL reconstruction, 1.48 ± 0.92 compared with 1.83 ± 1.01 sports before reconstruction (p = 0.002). Sixteen patients (19%) sustained an ACL graft rupture, 11 patients (13%) sustained a contralateral ACL tear, and 1 of these patients (1%) sustained both. The overall prevalence of a second ACL injury was 32%. Time to return to sport was the only significant predictor of a second ACL injury, with a slower return being protective (hazard ratio per month, 0.87 [95% confidence interval, 0.73 to 0.99]; p = 0.04). Pediatric athletes return to sports at a high rate (91%) after ACL reconstruction. Unfortunately, the prevalence of a second ACL injury is high at 32%. Within this population, an earlier return to sport is predictive of a second ACL injury. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Medial patellofemoral ligament and medial patellotibial ligament reconstruction in children: preliminary results

ObjectiveThe aim of this study was to evaluate the reconstruction of the medial patellofemoral ligament associated with the medial patellotibial ligament in skeletally immature patients. MethodThis is a case series study in patients with patellar instability with open physis. In total, seven patients were evaluated: four males and three females were operated using the proposed technique. Patients with open physis who had more than two episodes of recurring patellar dislocation were included. No patients underwent additional procedures. The distance from the anterior tibial tuberosity to the trochlea grove (TT-TG) was measured in all patients. On physical examination, the inverted J-sign, the apprehension sign, and the knee range of motion parameters were used in the pre- and post-operative period. In addition, the Kujala and Lysholm scores were applied before and 12 months after surgery. The results were analyzed with the Wilcoxon test. ResultsThe mean age of the patients was 11.28 in both genders. Comparing the data of the pre- and post-operative period, the inverted J-sign was present in six patients (85.7%) vs. absent in one (14.3%). The apprehension sign was absent in cases in the postoperative period; the range of motion was 117.85±8.09 vs. 148.57±3.77. The Kujala score was 42.57±8.9 vs. 88.57±5.09 and the Lysholm scores were classified as excellent or good in 28.6% and 71.4%, respectively. ConclusionThe combined reconstruction of the medial patellofemoral ligament combined with the medial patellotibial ligament in skeletally immature patients with predisposing factors, presents satisfactory results without episodes of recurrence or residual subluxation; according to these preliminary results, it should be considered as a treatment option.

A Modification of the Dunn Osteotomy With Preservation of the Ligamentum Teres.

We aimed to determine if a modified Dunn osteotomy could be safely performed without surgical dislocation and consequent preservation of the ligamentum teres. All patients undergoing a modified Dunn osteotomy for a slipped capital femoral epiphysis over an 8-year period were included in this study, and all had a severe slip with an open physis. The modified Dunn procedure was performed on 34 hips in 34 patients. The mean age was 13.1 years (range, 11 to 16 y) with a mean follow-up time of 54 months (range, 15 to 102 mo). All slips were severe (grade 3) with a mean slip angle of 73.2 degrees (range, 60 to 90 degrees). Nineteen slips were stable and 15 were unstable. Of the unstable slips, the average time from initial presentation to the emergency department until surgery was 9.4 days (range, 2 to 42 d). Excluding 1 patient who developed complete collapse of the femoral head (NAHS 56), the average Nonarthritic Hip score was 98 (range, 93.7 to 100). Four (11.8%) patients developed avascular necrosis of the femoral head, of which 3 were unstable slips. A modified Dunn osteotomy with preservation of the ligamentum teres allows an excellent restoration of the anatomic alignment of the femoral head and neck. Rates of AVN are not increased compared with other techniques of subcapital osteotomy but this complication cannot be eliminated particularly in patients with unstable slips. Level III.

Clinical Outcome After Arthroscopic Debridement and Microfracture for Osteochondritis Dissecans of the Capitellum

Background: Various surgical treatment techniques have been developed to treat capitellar osteochondritis dissecans; however, the optimal technique remains the subject of ongoing debate. Purpose: To evaluate clinical outcomes after arthroscopic debridement and microfracture for advanced capitellar osteochondritis dissecans. Study Design: Case series; Level of evidence, 4. Methods: Between 2008 and 2015, the authors followed 77 consecutive patients (81 elbows) who underwent arthroscopic debridement and microfracture, and loose body removal if needed, for advanced capitellar osteochondritis dissecans. Seventy-one patients (75 elbows) with a minimum follow-up of 1 year were included. The mean age was 16 years (SD, ±3.3 years; range, 11-26 years) and the mean follow-up length was 3.5 years (SD, ±1.9 years; range, 1-8.2 years). Based on CT and/or MRI results, 71 lesions were classified as unstable and 4 as stable. Clinical elbow outcome (pain, function, and social-psychological effect) was assessed using the Oxford Elbow Score (OES) at final follow-up (OES range, 0-48). Range of motion and return to sports were recorded. Multivariable linear regression analysis was performed to determine predictors of postoperative OES. Results: Intraoperatively, there were 3 grade 1 lesions, 2 grade 2 lesions, 10 grade 3 lesions, 1 grade 4 lesion, and 59 grade 5 lesions. The mean postoperative OES was 40.8 (SD, ±8.0). An open capitellar physis was a predictor of better elbow outcome (5.8-point increase; P = .025), as well as loose body removal/grade 4-5 lesions (6.9-point increase; P = .0020) and shorter duration of preoperative symptoms (1.4-point increase per year; P = .029). Flexion slightly improved from 134° to 139° (P < .001); extension deficit slightly improved from 8° to 3° (P < .001). Pronation (P = .47) and supination did not improve (P = .065). Thirty-seven patients (55%) returned to their primary sport at the same level, and 5 patients (7%) returned to a lower level. Seventeen patients (25%) did not return to sport due to elbow-related symptoms, and 10 patients (13%) did not return due to non–elbow-related reasons. No complications were recorded. Conclusion: Arthroscopic debridement and microfracture for advanced capitellar osteochondritis dissecans provide good clinical results, especially in patients with open growth plate, loose body removal, and shorter duration of symptoms. However, only 62% of patients in this study returned to sports.