Percutaneous k-wire leverage reduction and retrograde transphyseal k-wire fixation of angulated radial neck fractures in children

PURPOSE

To describe clinical and radiographic outcomes after surgical management of angulated radial neck fracture in children.

METHODS

Twenty children (aged 2-11 years) with angulated radial neck fracture with more than 30° angulations (Judet type III and IV fractures) were retrospectively reviewed. All the enrolled patients were surgically treated with percutaneous k-wire leverage reduction and retrograde transphyseal k-wire fixation. Clinical outcomes were evaluated using Tibone and Stoltz score and the Mayo Elbow Performance Score (MEPS). Radiographic outcomes were evaluated with Métaizeau score. Complications were also evaluated.

RESULTS

At a mean follow-up of 20 months, no patients showed axial deformity of the upper limb or instability of the elbow. The mean value of the MEPS was 99.2, and excellent clinical results were achieved in 14 patients (73.7%) at Tibone and Stoltz score. The final X-rays showed fracture healing in all patients; furthermore, 75% of patients showed excellent reduction at Métaizeau score. No patient developed complication. There were no iatrogenic nerve injuries or pin infections.

CONCLUSIONS

The results demonstrate that percutaneous k-wire leverage reduction and retrograde transphyseal k-wire fixation of angulated radial neck fracture treatment is a simple, effective, rapid and inexpensive procedure.

LEVEL OF EVIDENCE

IV (case series and systematic review of level IV studies).

Management of neglected distal femur epiphyseal fracture-separation

INTRODUCTION

Neglected epiphyseal fracture-separations of the distal femur are rare. Still reported in developing countries, they lead to therapeutic issues. The objective of the study is to describe their characteristics and to propose treatment options.

MATERIALS AND METHODS

Ten years of ongoing study was held in our orthopedics department. All patients with a neglected epiphyseal fracture-separations of the distal femur after a knee trauma were included in the study. Pre-operative and post-operative data were collected and analyzed.

RESULTS

A total of 13 cases of neglected traumatic epiphyseal fracture-separations of the distal femur were found among 8616 in-patients of the department. It was mainly boys (9M/4F) around 16 years that were received 14 weeks after knee trauma. Most of the injuries were an AO-type 33-E/2.1 (Simple Salter-Harris' type II) (n=12) distal femur malunion (n=10). Associated complications were cutaneous opening (n=7), superficial infection (n=4), deep infection (n=4). Fractures were management surgically (n=12) by an open osteoclasis procedure (n=9), debridement (n=7) and a thigh amputation (n=1). The outcome was better if an open osteoclasis procedure was early performed in closed distal femur mal-union with a complementary rehabilitation program.

CONCLUSION

Specialized trauma care facilities must be increased, and trauma education programs must be undertaken to avoid neglected epiphyseal fracture-separations of the distal femur in developing countries.

The effect of stem fit on the radiocapitellar contact mechanics of a metallic axisymmetric radial head hemiarthroplasty: is loose fit better than rigidly fixed?

BACKGROUND

Radial head hemiarthroplasty is commonly used to manage comminuted displaced fractures. Regarding implant fixation, current designs vary, with some prostheses aiming to achieve a tight "fixed" fit and others using a smooth stem with an over-reamed "loose" fit. The purpose of this study was to evaluate the effect of radial head hemiarthroplasty stem fit on radiocapitellar contact using a finite element model that simulated both fixed (size-for-size) and loose (1-, 2-, and 3-mm over-reamed) stem fits. It was hypothesized that a loose stem fit would improve radiocapitellar contact mechanics, with an increased contact area and decreased contact stress, by allowing the implant to find its "optimal" position with respect to the capitellum.

METHODS

Finite element models of the elbow were produced to compare the effects of stem fit on radiocapitellar contact of a metallic axisymmetric radial head implant. Radiocapitellar contact mechanics (contact area and maximum contact stress) were computed for 0°, 45°, 90°, and 135° of elbow flexion with the forearm in neutral rotation, pronation, and supination.

RESULTS

The data suggest that the loose smooth stem radial head implant may be functioning like a bipolar implant in optimizing radiocapitellar contact. Over-reaming of 3 mm produced a larger amount of stress concentration on the capitellum, suggesting there may be a limit to how loose a smooth stem implant should be implanted.

CONCLUSIONS

The loose 1 to 2 mm over-reamed stem provided optimal contact mechanics of the metallic axisymmetric radial head implant compared with the fixed stem.

Distal Tibial Chondroblastoma With Intra-articular Penetration Treated With Gelatin Foam Sponge and Bone Grafting

A 14-year-old boy presented with sharp left ankle pain for 1.5 years. Evaluation showed an irregular lytic lesion with surrounding sclerosis (diameter, 1.3×1.2×1.1 cm) in the central part of the distal tibial epiphysis, extending from the physis to the plafond with articular penetration. Treatment included intralesional curettage and bone grafting through a mid-anterior epiphyseal bone tunnel with fluoroscopic guidance and use of a gelatin foam sponge to help contain the bone graft within the epiphyseal cavity. Microscopic examination of the excised tissue was consistent with chondroblastoma. Ankle arthroscopy 11 months later showed that the tibial plafond articular surface was fully healed. Two years postoperatively, the patient was asymptomatic and had no recurrence. This case shows that intralesional curettage and bone grafting, with a gelatin foam sponge to prevent graft extrusion, may be used successfully in treating distal tibial epiphyseal chondroblastoma that penetrates the ankle joint. [Orthopedics. 2019; 42(4):e391-e394.].

Partial Transphyseal Anterior Cruciate Ligament Reconstruction: Clinical, Functional, and Radiographic Outcomes

BACKGROUND

With a steadily increasing rate of anterior cruciate ligament (ACL) injury and reconstruction in the pediatric population, disagreement remains regarding the optimal reconstruction technique for patients with ACL injury and ≥2 years of growth remaining.

PURPOSE

This study aims to quantify the incidence of linear and angular growth disturbance of adolescents undergoing partial transphyseal ACL reconstruction (ACLR) while assessing graft failure rates, reoperation rates, and functional outcomes in the population.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Consecutive patients undergoing partial transphyseal ACLR by 2 surgeons were retrospectively reviewed. Radiographic outcomes, including bilateral limb length, mechanical axis deviation (MAD), mechanical lateral distal femoral angle (MLDFA), and medial proximal tibial angle (MPTA), were measured on long standing anterior-posterior view radiographs postoperatively. Growth disturbance was defined as ≥1-cm leg length discrepancy, ≥1-cm difference in MAD, or 5° difference in MLDFA or MPTA as compared with the nonoperative side and as MAD, MLDFA, or MPTA outside the established range of reference values. Clinical outcomes, including graft failure and reoperation, were recorded at each follow-up visit. Pediatric International Knee Documentation Committee (Pedi-IKDC) scores were collected electronically after last follow-up.

RESULTS

Twenty-four patients (mean ± SD age, 12.3 ± 0.9 years; 79.2% male) with a mean follow-up of 31.5 ± 17.1 months met inclusion criteria for the study. Overall postoperative growth disturbance incidence was 16.7% (4 of 24), but the incidence of growth disturbance was 66.7% (2 of 3) for those patients with >5 years of growth remaining. Seven patients (29.2%) required reoperation, most frequently for hardware removal. Two patients (8.3%) had graft failure with subsequent revision ACL reconstruction. One patient underwent bilateral medial distal femur hemiepiphysiodesis for genu valgum that was present before ACLR, but no other patients required guided growth procedures. In the subset of patients who completed a Pedi-IKDC questionnaire, the mean score was 94.8 ± 5.3.

CONCLUSION

Overall, partial transphyseal ACLR has good functional outcomes and graft failure and reoperation rates, comparable with those seen with transphyseal and all-epiphyseal techniques. While postoperative growth disturbance occurred in 16.7% of the cohort, the severity was mild and well tolerated without necessitating secondary procedures. There is a high rate of growth disturbance of patients with >5 years of growth remaining (66.7%). Partial transphyseal ACLR represents a valid recommendation for adolescent patients with ACL injury and ≤5 years of growth remaining.

The shape match of the olecranon tip for reconstruction of the coronoid process: influence of side and osteotomy angle

BACKGROUND

The integrity of the coronoid process is critical to maintaining elbow stability. Unreconstructible fractures and chronic coronoid deficiency are challenging clinical problems with no clear solution. The purposes of this study were to investigate the shape match of the ipsilateral and contralateral olecranon tips as graft options and to determine the influence of the osteotomy angle on fitment.

METHODS

Nineteen paired cadaveric elbow joints were investigated by 3-dimensional digital analysis of computed tomography DICOM (Digital Imaging and Communications in Medicine) data. After construction of an ulnar coordinate system, the ipsilateral and contralateral olecranon tips were digitally harvested at 10°, 20°, 30°, 40°, 50°, and 60° osteotomy angles. In an overlay analysis, we compared the shape match of the ipsilateral and contralateral grafts and the different angles.

RESULTS

The ipsilateral grafts showed an average mismatch of 1.8 mm (standard deviation, 1.38 mm), whereas the contralateral grafts had a significantly lower (P < .001) mean mismatch of 1.3 mm (standard deviation, 0.95 mm). The 50° osteotomy plane showed the best shape match in comparison with the native coronoid-in both the ipsilateral and contralateral grafts. Evaluation of the intraclass correlation coefficient was calculated at r = 0.944, showing high repeatability of the measurements.

CONCLUSIONS

The contralateral olecranon tip graft showed significantly better shape matching to the native coronoid than the ipsilateral olecranon graft. Specifically, the contralateral graft more closely matched the biomechanically critical anteromedial coronoid facet. Finally, both the contralateral and ipsilateral olecranon grafts had better shape matching with the native coronoid when osteotomy was performed at higher angles, specifically 50°.

Hemiepiphysiodesis is a potentially effective surgical management for skeletally immature patients with patellofemoral instability associated with isolated genu valgum

PURPOSE

Genu valgum is one of the well-known predisposing factors for patellofemoral instability. The study aims to investigate the outcomes of isolated hemiepiphysiodesis in the correction of genu valgum and in the management of recurrent patellofemoral instability. The hypothesis was that hemiepiphysiodesis alone would result in significant correction of genu valgum, thereby preventing recurrent patellofemoral instability.

METHODS

In the cohort study, all skeletally immature patients who underwent isolated hemiepiphysiodesis for recurrent patellofemoral instability were included. All patients included in the study had a minimum of 1-year follow-up duration prior to the conclusion of the study.

RESULTS

Sixteen of twenty knees had no further patellofemoral instability post-operatively. The change in the status of patellofemoral instability was statistically significant (p = 0.001), similar to the change in the tibiofemoral angle (p = 0.015) and patellar tilt angle (p = 0.002). Comparison between patients with and without patellofemoral instability post-operatively revealed that the pre-operative patellar tilt angle (p = 0.005) and tibiofemoral angle (p = 0.001), post-operative patellar tilt angle (p = 0.004) and tibiofemoral angle (p = 0.027) as well as the change in patellar tilt angle (p = 0.001) and tibiofemoral angle (p = 0.001) were all significant predictors of the outcomes of genu valgum.

CONCLUSION

Hemiepiphysiodesis is a potentially effective surgical management for skeletally immature patients with patellofemoral instability associated with isolated genu valgum. This is especially for patients who are skeletally immature and have sufficient remaining years for their genu valgum to be corrected using hemiepiphysiodesis. These patients also tended to have less severe genu valgum and patellar tilt angle, which could be corrected using hemiepiphysiodesis with the remaining years of growth.

LEVEL OF EVIDENCE

II.

Treatment of tumor-like lesions in the femoral neck using free nonvascularized fibular autografts in pediatric patients before epiphyseal closure

Objectives

Surgical resection of benign bone tumors and tumor-like lesions at the femoral neck presents a difficult reconstructive challenge. However, the safety and efficacy of free nonvascularized fibular autografts (FNFAs) in the treatment of femoral neck tumor-like lesions before epiphyseal closure in young patients remain unknown.

Methods

Sixteen pediatric patients who had not yet undergone epiphyseal closure were treated with FNFAs after resection of tumor-like lesions in the femoral neck from August 2012 to September 2016. All patients underwent supplementary skeletal traction through the supracondylar femur for 4 to 6 weeks after resection. Demographic data were recorded and clinical and radiological outcomes were evaluated during the follow-up.

Results

All patients could walk with partial weight bearing 4 weeks postoperative, and full weight bearing was permitted after a mean of 8 weeks. Graft union was attained in all 16 patients at a mean of 2 months. The donor site of the fibular cortical strut showed good regeneration in all patients. The Harris hip score significantly improved from 65% to 95%.

Conclusions

Application of an FNFA is a feasible method in the treatment of tumor-like lesions in the femoral neck before epiphyseal closure in pediatric patients.

Level of Evidence

Level IV.

Capitellar erosion after radial head arthroplasty: A comparative biomechanical study of operated radial head fractures on cadaveric specimens

BACKGROUND

We asked whether open reduction and internal fixation (ORIF) or radial head arthroplasty (RHA), common techniques used for the confrontation of displaced or comminuted radial head fractures, are correlated with cartilage wear of the capitulum.

HYPOTHESIS

We hypothesized that neither ORIF nor RHA are correlated with capitellar cartilage wear.

MATERIAL AND METHODS

On 5 cadaveric elbow specimens, osteotomies were employed to simulate radial head comminuted fractures followed with ORIF by Herbert screws. Radial heads were also excised from other 5 cadaveric elbow specimens and were replaced by metallic monopolar implants. Finally, 2 elbows were not operated and used as a control group. Custom-made rotary machines, working unstoppably, generated 700,000 pronation and supination forearm movements at a 110° arc of motion. The elbow joints were examined with pre- and postoperative magnetic resonance imaging (MRI) scans and the articular surfaces of the capitula were resected and sent for histopathology study.

RESULTS

In the 2 cadaveric elbows of the control group and the 4 elbows treated with ORIF, no cartilage damage was found. The fifth one displayed cartilage fissures, which were, classified according to International Cartilage Repair Society (ICRS) grading system as grade I cartilage damage. On the contrary, all 5 elbows treated with RHA sustained complete cartilage loss, exposure of the subchondral bone and were classified as ICRS grade IV cartilage damage.

DISCUSSION

Our study suggests that metallic monopolar RHA after a displaced or comminuted radial head fracture carries a high risk of rapidly evolving cartilage loss of the capitulum.

An In Vivo Prediction of Anisometry and Strain in Anterior Cruciate Ligament Reconstruction - A Combined Magnetic Resonance and Dual Fluoroscopic Imaging Analysis

PURPOSE

To evaluate the in vivo anisometry and strain of theoretical anterior cruciate ligament (ACL) grafts in the healthy knee using various socket locations on both the femur and tibia.

METHODS

Eighteen healthy knees were imaged using magnetic resonance imaging and dual fluoroscopic imaging techniques during a step-up and sit-to-stand motion. The anisometry of the medial aspect of the lateral femoral condyle was mapped using 144 theoretical socket positions connected to an anteromedial, central, and posterolateral attachment site on the tibia. The 3-dimensional wrapping paths of each theoretical graft were measured. Comparisons were made between the anatomic, over the top (OTT), and most-isometric (isometric) femoral socket locations, as well as between tibial insertions.

RESULTS

The area of least anisometry was found in the proximal-distal direction just posterior to the intercondylar notch. The most isometric attachment site was found midway on the Blumensaat line with approximately 2% and 6% strain during the step-up and sit-to-stand motion, respectively. Posterior femoral attachments resulted in decreased graft lengths with increasing flexion angles, whereas anterodistal attachments yielded increased lengths with increasing flexion angles. The anisometry of the anatomic, OTT and isometric grafts varied between tibial insertions (P < .001). The anatomic graft was significantly more anisometric than the OTT and isometric graft at deeper flexion angles (P < .001).

CONCLUSIONS

An area of least anisometry was found in the proximal-distal direction just posterior to the intercondylar notch. ACL reconstruction at the isometric and OTT location resulted in nonanatomic graft behavior, which could overconstrain the knee at deeper flexion angles. Tibial location significantly affected graft strains for the anatomic, OTT, and isometric socket location. CLINICAL RELEVANCE: This study improves the knowledge on ACL anisometry and strain and helps surgeons to better understand the consequences of socket positioning during intra-articular ACL reconstruction.

Mechanical Testing of Epiphysiodesis Screws

Epiphysiodesis is performed to treat leg-length discrepancies and angular deformities in children. However, when placed across a physis to modulate growth, screws can bend or break postoperatively. This study evaluated the mechanical properties of 3 different screw designs commonly used when performing an epiphysiodesis. Six 4.0-mm cannulated, fully threaded; six 4.0-mm cannulated, partially threaded; and six 4.0-mm noncannulated, partially threaded cancellous screws underwent cantilever bending and tension testing in a simulated physis. All screws were tested in simulated cancellous bone foam blocks. All testing was performed using a servo-hydraulic testing machine to determine stiffness and ultimate load. For statistical analysis, one-way analysis of variance with Tukey's honestly significant difference test in post hoc analysis was used to assess significant differences among groups (P<.05). The noncannulated, partially threaded screws had a significantly lower stiffness than the 2 cannulated screw types in the tension test (P<.001) and bending test (P<.001). Additionally, the noncannulated, partially threaded screws had significantly higher ultimate load to failure than the 2 cannulated screw types in the tension test (P<.001) and the cannulated, partially threaded screws in the bending test (P=.045). The results indicate that noncannulated, partially threaded screws have a higher ultimate load capacity and are less stiff than both cannulated, partially threaded screws and cannulated, fully threaded screws. Surgeons should take into consideration that noncannulated, partially threaded screws are less likely to fail following epiphysiodesis. [Orthopedics. 2018; 41(2):e240-e244.].

Surgical reduction of congenital hip dislocation

Surgical reduction of congenital hip dislocation is technically challenging. In our practice, surgical reduction is usually reserved for patients who have failed non-operative treatment, which is the first-line strategy. However, primary surgery may be indicated if the dislocation is diagnosed late and can be performed until 8 years of age. The reduction step is crucial. It starts with painstaking exposure of the capsule. Identifying the lower part of the acetabulum is the key to accurate repositioning of the epiphysis. The main intra-articular procedures are resection of the ligament teres, adipose tissue within the acetabular cavity, and transverse acetabular ligament; and eversion of the radially incised limbus. In patients younger than 1 year of age, surgical reduction can be performed via the anterior approach or, in some cases, the obturator approach. No complementary steps are needed. If the diagnosis is made late, in contrast, reduction of the hip must be combined with corrective procedures on the femur and acetabulum designed to stabilise the reduction before the capsulorrhaphy, with the goal of optimising hip stability and minimising the risk of residual dysplasia. Femoral shortening and derotation osteotomy was classically reserved for children older than 3 years but has now been shown to be a useful and prudent procedure in younger patients. This osteotomy decreases pressure on the epiphysis, facilitates the reduction, and diminishes the risk of recurrence and avascular necrosis of the femoral head, which are the two dreaded complications. The outcome depends on the care directed to the procedure and on the quality of postoperative management.

Increasing Use of Reverse Total Shoulder Arthroplasty for Proximal Humerus Fractures in Elderly Patients

This study described surgical treatment patterns for proximal humerus fractures among elderly patients, focusing on reverse total shoulder arthroplasty (TSA), and evaluated how the type of fixation affects inpatient factors (cost, length of stay), transfusion rates, and patient disposition (home vs skilled nursing facility). With Nationwide Inpatient Sample data from 2011 to 2013, the authors identified patients 65 years and older who had proximal humerus fractures and divided them into 3 groups: (1) open reduction and internal fixation (ORIF); (2) hemiarthroplasty; and (3) reverse TSA. From 2011 to 2013, 38,729 surgically treated proximal humerus fractures were identified. The rate of reverse TSA increased 1.8-fold during this time, from 13% of operative cases in 2011 to 24% of operative cases in 2013 (P<.001). At the same time, the rates of hemiarthroplasty and ORIF decreased (hemiarthroplasty, from 28% to 21%; ORIF, from 59% to 55%). Although reverse TSA accounted for 32.2% of arthroplasty procedures for proximal humerus fractures in 2011, this value was 53.3% in 2013 (P<.001). In 2013, mean total hospital cost for reverse TSA was $24,154, which was significantly higher than that for ORIF ($16,269) or hemiarthroplasty ($19,175) (P<.001). In a multivariable model, patients undergoing reverse TSA were less likely than those undergoing hemiarthroplasty to be discharged to a skilled nursing facility (odds ratio, 0.75; P=.027). The national rate of reverse TSA nearly doubled from 2011 to 2013. As of 2013, reverse TSA replaced hemiarthroplasty as the most commonly performed arthroplasty procedure for proximal humerus fractures for patients 65 years and older. Patients undergoing reverse TSA were more likely than those undergoing hemiarthroplasty to be discharged home. [Orthopedics. 2017; 40(6):e982-e989.].

Biomechanical Evaluation of Unicortical Stress Risers of the Proximal Humerus Associated With Pectoralis Major Repair

Proximal humerus fracture after pectoralis major tendon repair has been recently reported. Although this complication is rare, it may be possible to decrease such risk using newer techniques for myotenodesis. This study was designed to evaluate various unicortical stress risers created at the proximal humeral metadiaphysis during myotenodesis for repair of pectoralis major ruptures. A simulated pectoralis major myotenodesis was performed using fourth-generation Sawbones (N=30). Using previously described anatomic landmarks for the tendinous insertion, 3 repair techniques were compared: bone trough, tenodesis screws, and suture anchors (N=10 each). Combined compression and torsional load was sequentially increased until failure. Linear and rotational displacement data were collected. The average number of cycles before reaching terminal failure was 383 for the bone trough group, 658 for the tenodesis group, and 832 for the suture anchor group. Both the tenodesis and the suture anchor groups were significantly more resistant to fracture than the bone trough group (P<.001). The suture anchor group was significantly more resistant to fracture than the tenodesis group (P<.001). All test constructs failed in rotational stability, producing spiral fractures, which incorporated the unicortical defects in all cases. When tested under physiologic parameters of axial compression and torsion, failure occurred from rotational force, producing spiral fractures, which incorporated the unicortical stress risers in all cases. The intramedullary suture anchor configuration proved to be the most stable construct under combined axial and torsional loading. Using a bone trough technique for proximal humerus myotenodesis may increase postoperative fracture risk. [Orthopedics. 2017; 40(5):e801-e805.].

What Injury Mechanism and Patterns of Ligament Status Are Associated With Isolated Coronoid, Isolated Radial Head, and Combined Fractures?

BACKGROUND

Isolated coronoid, isolated radial head, and combined coronoid and radial head fractures are common elbow fractures, and specific ligamentous injury of each fracture configuration has been reported. However, the osseous injury mechanism related to ligament status remains unclear.

QUESTIONS/PURPOSES

The objectives of this study were: (1) to determine what ligamentous injury patterns (medial or lateral collateral) and bone contusion patterns (medial or lateral) are associated with isolated coronoid, isolated radial head, and combined coronoid and radial head fractures; (2) to correlate the osseous injury mechanism based on these findings with isolated coronoid, isolated radial head, and combined coronoid and radial head fractures; and (3) to determine whether isolated and combined coronoid fractures have different fracture lines through the coronoid (tip or anteromedial facet), speculated to be caused by different injury mechanisms.

METHODS

Between June 2007 and June 2012, 100 patients with elbow fractures were included in the cohort, with 46 of these patients being excluded owing to incongruity for our surgical indication. Finally, 54 patients with surgically treated elbow fractures who had MRI preoperatively were assessed retrospectively. There were 17 elbows with isolated coronoid fractures, 22 with isolated radial head fractures, and 15 with combined coronoid and radial head fractures. Collateral ligament injury pattern and existence of distal humerus bone contusion were reviewed on MR images.

RESULTS

Patients with isolated radial head fractures were at greater risk of medial collateral ligament rupture compared with patients with isolated coronoid fractures (radial head only: 15 of 22 [68%]; coronoid only: three of 17 [18%]; odds ratio [OR], 10.0; 95% CI, 2.2-46.5; p = 0.002). Patients with isolated coronoid fractures had greater risk of lateral ulnar collateral ligament ruptures (coronoid: 16 of 17 [94%]; radial head: seven of 22 [32%]; OR, 3.5; 95% CI, 3.8-333.3; p < 0.001). The presence of radial head fractures was associated with the risk of lateral bone bruising (isolated radial head fracture: 32 of 37 [86%], isolated coronoid fracture: four of 17 [24%]; OR, 29.6; 95% CI, 5.2-168.9; p < 0.001). Medial bone bruising was only detected in isolated coronoid fractures (isolated coronoid fracture: 12 of 17 [71%], others: zero of 37 [0%]). All isolated coronoid fractures involved the anteromedial facet of the coronoid (17 of 17; 100%). However, combined coronoid and radial head fractures often involved the tip (13 of 15; 87%).

CONCLUSIONS

Isolated coronoid fractures mostly involved the anteromedial facet of the coronoid process associated with lateral ulnar collateral ligament rupture and medial bone bruising. However, isolated radial head fractures were associated with medial collateral ligament rupture and lateral bone bruising. Combined coronoid and radial head fractures mostly involved a tip fracture of the coronoid with lateral ulnar collateral ligament rupture and lateral bone bruising. Thus surgeons may predict which ligament they should be aware of in the surgical field.

LEVEL OF EVIDENCE

Level III, prognostic study.

Epiphysiodesis Screw Bending

Percutaneous epiphysiodesis using transphyseal screws is a common method for treatment of limb length discrepancy and angular deformity. The authors report 3 cases of a previously unreported complication following treatment with percutaneous epiphysiodesis using transphyseal screws: bending of the transphyseal screw. In each case, this rare complication was associated with difficult removal of the screw. This retrospective case report accessed the medical records of 3 children, 2 boys and 1 girl, 9 to 14 years old. All of the children had 4.0-mm cannulated stainless steel screws ranging from 40 to 50 mm in length. Two of the patients had partially threaded and 1 had fully threaded screws with bending noted a minimum of 6 months following implantation. Additionally, each of the screws bent near the physis of the bone, which was not located at the center of the screw in every case or at the transition from threaded to nonthreaded portions in each partially threaded screw. To the authors' knowledge, these are the first reported cases of cannulated screw bending following transphyseal tibial or femoral placement for the correction of leg length or angular deformity in a pediatric population. Although the true incidence rate is unknown, screw bending following percutaneous epiphysiodesis presents complications in the hardware removal process. Further biomechanical tests should be conducted to determine the best screw design to minimize bending of transphyseal screws from physiologic growth. [Orthopedics. 2017; 40(4):e717-e720.].

Recent advances in liver transplantation for metabolic disease

The indications and outcomes of liver transplantation for metabolic disease have been reviewed recently and this short review concentrates on recent developments and advances. Recently recognized metabolic causes of acute liver failure are reviewed and their implications for transplantation discussed. Newly described indications for liver transplantation in systemic metabolic diseases are described and an update is given on the role of auxiliary and domino liver transplantation.

What Happens to the Articular Surface After Curettage for Epiphyseal Chondroblastoma? A Report on Functional Results, Arthritis, and Arthroplasty

BACKGROUND

Chondroblastoma is an uncommon, benign, but locally aggressive bone tumor that occurs in the apophyses or epiphyses of long bones, primarily in young patients. Although some are treated with large resections, aggressive curettage and bone grafting are more commonly performed to preserve the involved joint. Such intralesional resection may result in damage to the growth plate and articular cartilage, which can result in painful arthritis. Prior studies have focused primarily on oncologic outcomes rather than long-term joint status and functional outcomes.

QUESTIONS/PURPOSES

(1) What local complications can be expected after aggressive intralesional curettage of epiphyseal chondroblastoma? (2) What is the joint survival of a joint treated in this way for chondroblastoma? (3) What additional procedures are used in treating symptomatic joint osteoarthritis after treatment of the chondroblastoma? (4) What are the functional outcomes in this group of patients?

METHODS

A retrospective study of our prospectively collected database between 1975 and 2013 was done. We found 64 patients with a diagnosis of chondroblastoma of bone. After applying our selection criteria, 53 patients were involved in this study. We excluded seven patients with tumors initially treated with en bloc resection (five located in the extremities and two in the axial skeleton) and two patients with apophyseal tumors. One patient who underwent nonsurgical treatment and one patient lost to followup were also excluded. The mean age was 18 years (range, 11-39 years); the minimum followup was 2 years with a mean followup 77 months (range, 24-213 months). We analyzed all patients with a diagnosis of epiphyseal chondroblastoma of the limb treated with aggressive curettage and joint preservation surgery. During the period in question, our general indications for curettage were patients with active, painful tumors and those with more aggressive ones that remained intracompartmental, whereas initial wide en bloc resection was indicated in patients who had tumors with an extracompartmental extension breaching the adjacent joint cartilage and massive articular destruction. The tumor location was the distal femur in 14 patients, proximal tibia in 11, proximal humerus in 10, proximal femur in eight, the talus in seven, and elsewhere in the lower extremity in three. Local complications including joint degeneration and tumor recurrence were evaluated. Based on radiographic analysis, secondary osteoarthritis was classified by using the Kellgren-Lawrence grading system from Grade 0 to Grade IV. Patients who underwent joint replacement resulting from advanced symptomatic osteoarthritis were considered to have had joint failure for purposes of survivorship analysis, which was estimated using the Kaplan-Meier method. Functional results were evaluated with the Musculoskeletal Tumor Society functional score by the treating surgeon, who transcribed the results on the digital records every 6 months of followup.

RESULTS

Twenty-two patients (42%) developed 26 local complications. The most common local complication was osteoarthritis in 20 patients (77% [20 of 26 complications]); tumor recurrence was observed in four patients; an intraarticular fracture and superficial infection treated with surgical débridement and antibiotics developed in one patient each. Joint survival was 90% at 5 years (95% confidence interval [CI], 76%-100%) and 74% at 10 years (95% CI, 48%-100%). Proximal femoral tumor location was associated with lower survivorship of the joint than other locations showing a 5-year survival rate of 44% (95% CI, 0%-88%; p = 0.000). Of the 20 patients with osteoarthritis, four were symptomatic enough to undergo joint replacement, all of which were for tumors in the proximal femur. The mean Musculoskeletal Tumor Society functional score was 28 of 30 points (93%).

CONCLUSIONS

Osteoarthritis was a frequent complication of aggressive curettage of epiphyseal chondroblastoma, and tumors located in the proximal femur appeared to be at particular risk of secondary osteoarthritis and prosthetic replacement. Because chondroblastoma is a tumor that disproportionately affects younger patients, the patient and surgeon should be aware that arthroplasty at a young age is a potential outcome for treatment of proximal femoral chondroblastomas.

LEVEL OF EVIDENCE

Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Lateral tibial plateau autograft in revision surgery for failed medial unicompartmental knee arthroplasty

PURPOSE

Revision surgery for failed unicompartmental knee arthroplasty (UKA) with bone loss is challenging. Several options are available including cement augmentation, metal augmentation, and bone grafting. The aim of the present study was to describe a surgical technique for lateral tibial plateau autografting and report mid-term outcomes.

METHODS

Eleven consecutive patients (median age 69.5 years) affected by posteromedial tibial plateau collapse after medial UKA were enrolled in the present study. The delay between UKA and revision surgery was 21 months (range 15-36 months). All patients were revised with a cemented posterior-stabilized implant, with a tibial stem. Medial tibial plateau bone loss was treated with an autologous lateral tibial plateau bone graft secured with two absorbable screws. All patients were evaluated with the Oxford Knee Score (OKS), visual analogue scale for pain (VAS), and complete radiographic evaluation.

RESULTS

At a median follow-up of 60 months (range 36-84 months), the OKS improved from 21.5 (range 16-26) to 34.5 (range 30-40) (p < 0.01) and the median VAS score improved from 8.0 (range 5-9) to 5.5 (range 3-7) (p < 0.01). No intraoperative complications were recorded. Partial reabsorption of the graft was observed in two cases at final follow-up.

CONCLUSION

Lateral tibial plateau bone autograft is an alternative to metal wedge or cement augments in the treatment of medial plateau collapse after UKA. Primary fixation of the tibial plateau autograft can be achieved with absorbable screws and a tibial-stemmed implant. Further comparative studies with a larger series may be helpful to draw definitive conclusions.

LEVEL OF EVIDENCE

Case series, Level IV.

Distal Humeral Hemiarthroplasty Versus Total Elbow Arthroplasty for Acute Distal Humeral Fractures

For acute distal humeral fractures not amenable to open reduction and internal fixation, total elbow arthroplasty has become an established alternative. However, lifelong activity restrictions designed to prevent early mechanical failure make this a poor option for some patients. This has led to a renewed interest in distal humeral hemiarthroplasty. Using modern implants and techniques, distal humeral hemiarthroplasty has shown outcomes comparable to those of total elbow arthroplasty at short- to mid-term follow-up, with an overall higher but different complication rate. Long-term data are needed, but the available literature suggests that distal humeral hemiarthroplasty be considered as another option on the treatment spectrum in select patient populations. [Orthopedics. 2017; 40(1):13-23.].

Primary epiphyseal and metaepiphyseal tubercular osteomyelitis in children A series of 8 case

Clinical series of primary epiphyseal and metaepiphyseal tubercular osteomyelitis are few. The purpose of our study was to retrospectively review the presentation, healing response and functional results of 8 such cases in children.

MATERIAL AND METHODS

The patients were evaluated for pain, deformity, range of motion, limb length discrepancy (if any) and recurrence. Serial radiographs of the region were studied to see remineralization, obliteration of radiological lesions, status of physis and remodeling of the growth plate.

RESULTS

The mean patient age was 7.1 years. Average follow up was 3.7 years. The mean duration of symptom before presentation was 2.9 months (range, 0.5-8 months). Knee region was involved in 4, distal radius in 2, shoulder and distal fibula in 1 patient each. The lesions were either localized or diffuse depending upon physeal involvement and osseous destruction. At the last follow up, the involved joints were painfree and had useful range of motion. Limb length lengthening was seen in all knee patients. The diffuse variety resulted in premature physeal closure. The residual lucencies persisted for several years without any clinical manifestations.

CONCLUSIONS

Primary epiphyseal and metaepiphyseal tuberculosis was relatively uncommon. The clinical outcome was good following curettage and multidrug antitubercular therapy. The epiphyseal and metaphyseal lucencies persisted for several months even after successful treatment. The diffuse variety lead to premature physeal closure. Limb length lengthening was common sequelae of tuberculosis of knee region.

Lower limb equalization with percutaneus epiphysiodesis of the knee joint area

INTRODUCTION

Epiphysiodesis has become one of the most popular methods in the treatment of leg length discrepancy (LLD) due to its surgical simplicity, short hospitalization time, and a low risk of complications.

PATIENTS AND METHODS

A retrospective analysis was performed on 34 patients treated for LDD with percutaneus epiphisiodesis of the distal femur and/or the proximal tibia. The mean discrepancy was 2.8 cm. The outcome evaluation method was based on Kemnitz et al.

RESULTS

Based on the Kemnitz criteria, 23 (67.6%) patients experienced good results, while 2 (5.9%) satisfactory and 9 (26.5%) poor results. In 47% of patients, swellings of the knee joint were observed in the postoperative period. One serious complication - varus deformity of 10 degrees in femur occurred in the follow-up period.

CONCLUSIONS

Percutaneous epiphysiodesis is a simple method of the LLD correction, with a low rate of complications and applicable in cases of late LDD diagnosis.

Comparing Entry Points for Antegrade Nailing of Femoral Shaft Fractures

The optimal entry point for antegrade intramedullary nailing of femoral shaft fractures remains controversial. The purpose of this systematic review was to determine whether there is a difference in operative parameters, healing, and functional outcome when comparing the greater trochanter (GT) and piriformis fossa (PF) entry points. A systematic search of multiple databases and 3 major orthopedic meetings (American Academy of Orthopaedic Surgeons, Canadian Orthopaedic Association, and Orthopaedic Trauma Association) was conducted. Four studies (570 patients) met the inclusion criteria. Mean patient age was 34.5 years, and 60.4% were male. The GT entry point was associated with significantly shorter operative (mean difference [MD], -20.05 minutes [95% confidence interval (CI), -23.09 to -17.02]; P<.00001) and fluoroscopy times (MD, -24.55 seconds [95% CI, -43.23 to -5.86]; P=.01). There was no significant difference in nonunion (risk ratio [RR], 0.74 [95% CI, 0.35 to 1.58]; P=.44) and delayed union rates (RR, 0.94 [95% CI, 0.41 to 2.14]; P=.88) between the 2 entry points. Heterogeneity in outcome measures reported prevented pooled analysis of functional outcomes. This review supports the use of the GT entry point during antegrade nailing of femoral shaft fractures over the PF entry point, with regard to shorter operative and fluoroscopy times. Healing and complication rates were not related to the entry point. Further study is required to determine the effect of each entry point on the surrounding soft tissue structures and ultimately its impact on postoperative function.

Complications after epiphyseal reconstruction of the anterior cruciate ligament in prepubescent children

PURPOSE

Reconstruction of the anterior cruciate ligament (ACL) remains a major concern in the prepubescent, skeletally immature patient with wide open growth plates. Different surgical techniques have been proposed. This study reports the results and complications of ACL reconstruction in young children using an all epiphyseal technique.

METHODS

Between 2006 and 2010, 12 patients (10-13 years, median 12.1 years) underwent epiphyseal primary ACL reconstruction, with a total of 13 knee procedures. Patients were assessed retrospectively with a median follow-up of 54 months (range 39-80 months) consisting of a clinical examination, instrumented arthrometer testing and radiological analysis. Functional status was assessed using the Lysholm knee score, Tegner activity scale and IKDC-2000 form.

RESULTS

According to the IKDC examination form, five knees were rated as normal, six near normal and two abnormal. The median IKDC score at follow-up was 88.5 points (range 75-99 points). The mean side-to-side difference in KT-1000 ligament laxity testing was 1.5 mm (±2.5 mm). In two patients, reoperation was necessary due to graft failure. Two patients developed significant leg length inequality; one with 20 mm overgrowth and varus malalignment after re-reconstruction and the second developed arthrofibrosis and overgrowth of 16 mm. Four patients had minor limb length discrepancy ranging between +5 and +10 mm; no growth arrest was noted. One patient with an intact but slightly elongated graft required a meniscal suture 34 months after ACL reconstruction following a traumatic medial meniscal lesion.

CONCLUSION

Despite using the epiphyseal technique in ACL reconstruction, relevant growth discrepancy can occur. Thereby, overgrowth rates appear to potentially pose a major clinical problem, which has remained unreported so far. Overall, there is a considerable high risk of complications in this patient group.

LEVEL OF EVIDENCE

IV.

Distal Humeral Epiphyseal Separation in a Newborn

Distal humeral epiphyseal separations are rare and treatment strategies are not well defined. The case of a full-term male newborn with a distal humeral epiphyseal separation as the result of a birth trauma was reviewed. A literature review of this topic was undertaken to better understand its occurrence, diagnosis, and treatment options. The patient sustained a distal humeral epiphyseal separation during a vaginal delivery. Deformity and decreased movement in the elbow were observed. Radiographs and subsequent ultrasound were used to make the diagnosis of distal humeral epiphyseal separation. Given the displaced and acute nature of the fracture, a closed reduction and percutaneous pinning was performed. Intraoperatively, this was greatly facilitated by an elbow arthrogram. Immobilization consisted of a posterior plaster splint and swathe. Postoperative follow-up with clinical and radiographic examination showed abundant bony healing and early restoration of function. Ultrasound is useful to confirm the diagnosis of a distal humeral epiphyseal separation for elbow injuries in very young patients. However, once the diagnosis is confirmed, an intraoperative elbow arthrogram helps highlight the fracture fragments and ensures proper reduction and fixation of the fracture. [Orthopedics. 2016; 39(4):e764-e767.].