The Locking Compression Paediatric Hip Plate: technical guide and critical analysis

PURPOSE

Osteotomies of the proximal femur and stable fixation of displaced femoral neck fractures are demanding operations. An LCP Paediatric Hip Plate was developed to make these operations safer and less demanding. The article focuses on the surgical technique and critically analyses the device.

METHODS

Between 2006 and 2008, 30 hips in 22 patients underwent surgery. Patients' demographics, perioperative details, postoperative outcome and complications were retrospectively collected and analysed.

RESULTS

Patients' diagnoses included persistent congenital hip dysplasia (n = 4), neuropathic hip dysplasia (n = 9), idiopathic ante/retroversion (n = 8), femoral neck fracture (n = 3), Perthes' disease (n = 2), deformity after slipped capital femoral epiphysis (SCFE), congenital femoral neck pseudarthrosis, deformity after pelvic tumour resection and malunion following proximal femoral fracture (one each). In 21 of 22 patients, the postoperative radiographs showed corrections as planned. Two cases had to be revised for screw loosening. Intraoperative handling using the plate was excellent in all cases.

CONCLUSIONS

In our case series of 30 hip operations, the LCP Paediatric Hip Plate was shown to be safe and applicable in the clinical setting with excellent results and a low complication rate. We consider that the LCP Paediatric Hip Plate is a valuable device for correction of pathological conditions of the proximal femur and for fixation of displaced femoral neck fractures in children. Larger studies should be carried out to better quantify the risk of clinically relevant complications.

Complications of anterior subcutaneous internal fixation for unstable pelvis fractures: a multicenter study

BACKGROUND

Stabilization after a pelvic fracture can be accomplished with an anterior external fixator. These devices are uncomfortable for patients and are at risk for infection and loosening, especially in obese patients. As an alternative, we recently developed an anterior subcutaneous pelvic internal fixation technique (ASPIF).

QUESTIONS/PURPOSES

We asked if the ASPIF (1) allows for definitive anterior pelvic stabilization of unstable pelvic injuries; (2) is well tolerated by patients for mobility and comfort; and (3) has an acceptable complication rate.

METHODS

We retrospectively reviewed 91 patients who incurred an unstable pelvic injury treated with an anterior internal fixator and posterior fixation at four Level I trauma centers. We assessed (1) healing by callous formation on radiographs and the ability to weightbear comfortably; (2) patient function by their ability to sit, stand, lie on their sides, and how well they tolerated the implants; and (3) complications during the observation period. The minimum followup was 6 months (mean, 15 months; range, 6-40 months).

RESULTS

All 91 patients were able to sit, stand, and lie on their sides. Injuries healed without loss of reduction in 89 of 91 patients. Complications included six early revisions resulting from technical error and three infections. Irritation of the lateral femoral cutaneous nerve was reported in 27 of 91 patients and resolved in all but one. Heterotopic ossification around the implants, which was asymptomatic in all cases, occurred in 32 of 91 patients.

CONCLUSIONS

The anterior internal fixator provided high rates of union for the anterior injury in unstable pelvic fractures. Patients were able to sit, stand and ambulate without difficulty. Infections and aseptic loosening were reduced but heterotopic ossification and irritation of the LFCN are common.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Effects of sex and lower extremity alignment on orientation of the knee joint line in knee surgery

BACKGROUND

Determination of the proper orientation of the knee articular surface is required both for correction of knee malalignment by osteotomy and for correct component alignment in knee arthroplasty. We sought to determine whether the patients' sex and lower extremity alignment (hip-knee-ankle angle) affects proper knee realignment in osteotomy or component alignment in total knee arthroplasty.

METHODS

We examined 199 healthy adult knees with malalignment of < 5° to determine the mechanical medial distal femoral angle, mechanical medial proximal tibial angle, surgical transepicondylar axis angle, and discrepancies between bone-cut orientations of osteotomy or total knee arthroplasty and the joint line of the distal femoral condyles, posterior femoral condyles and proximal tibial plateaus, using a three-dimensional computed tomography model.

RESULTS

The mean mechanical medial distal femoral angle and mean mechanical medial proximal tibial angle were (94.4 ± 1.9)° and (87.6 ± 1.8)° respectively for women and (93.8 ± 2.0)° and (87.1 ± 1.4)° respectively for men. The surgical transepicondylar axis angle was (2.9 ± 1.6)° for women and (3.2 ± 1.7)° for men. Independent of sex, the hip-knee-ankle angle was closely related to the mechanical medial distal femoral angle and mechanical medial proximal tibial angle, but not to the surgical transepicondylar axis angle. A slightly more valgus alignment of the knee and a more valgus angulation of the distal femoral joint line were found in women, whereas a more varus angulation of the proximal tibial joint line was found in men. Sex had the greatest effect on knee joint line orientation when the lower extremity was valgus in alignment.

CONCLUSIONS

A more valgus femoral joint line can be expected in women and in persons with valgus lower extremity alignment; a more varus tibial joint line can be found in men and in persons with varus lower extremity alignment.

Fracture at the stem-condylar junction of a modular femoral prosthesis in a varus-valgus constrained total knee arthroplasty

We present a rare case of fracture of the modular femoral component in a varus-valgus constrained total knee arthroplasty (TKA) prosthesis which occurred 2 years after implantation. Both femoral and tibial components underwent a second revision using a constrained hinged TKA. Laboratory analysis revealed insufficient metaphyseal bone stock in association with inadequate cement mantle incorporation which made implant fixation solely reliant on the intramedullary stem construct. It was therefore hypothesized that high repetitive stresses over the junction of the modular component led to the fracture.

LEVEL OF EVIDENCE

Case report, Level IV.

Vascularized bone grafts for scaphoid nonunions

Scaphoid fractures that fail to unite are at risk of developing avascular necrosis and progressive structural collapse, thereby complicating attempts at revision surgical treatment. Vascularized bone grafts have demonstrated utility in promoting consolidation in the treatment of scaphoid nonunions complicated by avascular necrosis. Numerous pedicled and free vascularized grafts have been described with variable, but generally favorable, outcomes. Understanding the indications for different grafts is critical to the successful application of these techniques and grafts in the treatment of challenging scaphoid nonunions.

Coronal plane knee moments improve after correcting external tibial torsion in patients with cerebral palsy

BACKGROUND

External tibial torsion causes an abnormal axis of joint motion relative to the line of progression with resultant abnormal coronal plane knee moments and affects lever arm function of the foot in power generation at the ankle. However, it is unclear whether surgical correction of the tibial torsion corrects the moments and power.

QUESTIONS/PURPOSES

We evaluated whether surgical correction of external tibial torsion in patients with cerebral palsy would correct the abnormal coronal plane knee moments and improve ankle power generation.

METHODS

We studied 22 patients (26 limbs) with cerebral palsy (Gross Motor Function Classification System Level I or II) who underwent distal internal rotation osteotomies for correction of external tibial torsion as part of a multilevel surgical intervention. There were 10 males and 12 females with a mean age at surgery of 14 years (range, 6.8-20.9 years). All patients had pre- and postoperative standardized clinical evaluation and computerized three-dimensional gait analysis. Minimum followup was 9 months (average, 13 months; range, 9-19 months).

RESULTS

On physical examination, the mean (± SD) transmalleolar axis improved from 43° ± 10° preoperatively to 20° ± 7° postoperatively. Mean knee rotation improved kinematically from 40° ± 9° preoperatively to 21° ± 9° postoperatively. Twenty-two of 26 limbs (88%) improved in one or both peaks of the abnormal coronal plane knee moments. Ankle power generation did not change from preoperative (1.6 ± 0.7 W/kg) to postoperative (1.6 W/kg).

CONCLUSIONS

Correction of external tibial torsion in ambulatory patients with cerebral palsy improves the kinematic and kinetic deviations identified by gait analysis.

LEVELS OF EVIDENCE

Level IV, therapeutic series. See Guidelines for Authors for a complete description of levels of evidence.

Plate fixation versus intramedullary fixation for displaced mid-shaft clavicle fractures: a systematic review

Purpose

The optimal surgical approach for displaced midshaft clavicle fracture remains controversial. The objective of this systematic review is to compare functional outcome and complications after plate fixation and intramedullary fixation for displaced midshaft clavicle fractures.

Methods

A computer aided search of PUBMED and Embase was carried out on January 11th 2011. Every study that was published in the English, German, French or Dutch language was considered for inclusion. A total of four studies could be included of which two compared intramedullary fixation versus plate fixation, and two compared intramedullary fixation and plate fixation versus conservative treatment for displaced midshaft clavicle fractures. Studies that compared plate fixation with intramedullary fixation in patients with fresh unilateral displaced midshaft clavicle fractures were included. Dislocation or displacement had to be mentioned in the inclusion criteria of the study for inclusion in this review. The modified version of the Cochrane Bone, Joint and Muscle Trauma Group’s former quality assessment tool was used. Furthermore, the studies included were scored according to the GRADE approach to assess the quality. The chosen studies were summarised in a data-extraction form. Because of the different study designs and characteristics data were summarised separately for each study.

Conclusions

High quality evidence from one study and low quality evidence from three studies showed no difference in functional outcome or complications after plate fixation or intramedullary fixation for displaced midshaft clavicle fractures.

Recurrent dislocation of the patella accompanying hypotrochlea of the femur and malalignment of the patella

This case report describes a rare case of recurrent dislocation of the patella which was accompanied with trochlear dysplasia and malalignment of the patella in a 15-year-old girl. She complained of hemoarthrosis and recurrent patellar dislocation in the early knee flexion phase. Plain radiography and computed tomography (CT) showed patellar malalignment (quadriceps angle 20°) and severe dysplasia of the trochlea of the femur (sulcus angle 170°). Surgery was performed, consisting of trochleoplasty in addition to proximal and distal realignment. Trochleoplasty was undertaken using a modified Dejour technique. After surgery, the patient complained of joint contracture. Arthroscopic release of fibrous tissue relieved symptoms and obtained normal range of motion without patellar dislocation. Postoperative radiography and CT demonstrated improvement of the quadriceps angle (10°) and sulcus angle (140°).

Sacral dome resection and single-stage posterior reduction in the treatment of high-grade high dysplastic spondylolisthesis in adolescents and young adults

OBJECTIVE

The description of the operation technique and retrospective review of 15 consecutive patients who were treated by posterior sacral dome resection and single-stage reduction with pedicle screw fixation for high-grade, high-dysplastic spondylolisthesis.

MATERIALS AND METHODS

All the patients had high-grade, high-dysplastic spondylolisthesis L5 and were treated by posterior sacral dome resection and posterior single-stage reduction from L4-S1. The average age at the time of surgery was 17.3 (11-28) years. The average follow-up time is 5.5 (2-11.6) years. Clinical and radiological data were retrospectively reviewed.

RESULTS

Spondylolisthesis was reduced from average 99% preoperative to 29% at the last follow-up. L5 incidence improved from 74° to 56°, the lumbosacral angle improved from 15° kyphosis to 6° lordosis, lumbar lordosis decreased from 69° to 53° from preoperative to the last follow-up. While pelvic incidence of 77° remained unchanged, sacral slope decreased from 51° to 46° and pelvic tilt increased from 25° to 30°. Clinical outcome was subjectively rated to be much better than before surgery by 14 out of 15 patients. Four out of 15 patients had temporary sensory impairment of the L5 nerve root which resolved completely within 12 weeks. There were no permanent neurological complications or no pseudarthrosis.

CONCLUSION

The sacral dome resection is a shortening osteotomy of the lumbosacral spine which allows a single-stage reduction of L5 without lengthening of lumbosacral region in high-grade spondylolisthesis, which helps to avoid neurological complications. This is a safe surgical technique resulting in a good multidimensional deformity correction and restoration of spino-pelvic alignment towards normal values with a satisfactory clinical outcome.

Outcome of intramedullary fixation of clavicular fractures

We conducted a retrospective, single-center (tertiary referral center with associated level I trauma center) review to evaluate the outcome of open reduction and internal fixation (ORIF) with intramedullary (IM) clavicle pin of displaced clavicular fractures. Sixty-eight displaced midshaft clavicle fractures in 68 patients underwent ORIF with IM clavicle pins. Patients were identified through a perioperative database by searching for Current Procedural Terminology (CPT) codes. Union was the primary outcome. Secondary outcomes included time to union, pain, incidence of nonunion and delayed union, postoperative range of motion, and incidence of complications. Sixty-six fractures (97%) went on to union. Complications included painful hardware (44%), deep and superficial wound infections (10%), and hardware failure (4%), including pin breakage and extrusion. Postoperative shoulder pain was present in 10% of patients and limited shoulder range of motion in 12%. IM pin fixation can provide good outcomes, even for fractures with a significant amount of shortening and comminution.

The UniSpacer™: correcting varus malalignment in medial gonarthrosis

While options for operative treatment of leg axis varus malalignment in patients with medial gonarthrosis include several established procedures, such as unicompartmental knee arthroplasty (UKA), total knee arthroplasty (TKA) or high tibial osteotomy (HTO), there has been little focus on a less invasive option introduced more recently: the UniSpacer™ implant, a self-centering, metallic interpositional device for the knee. This study evaluates clinical and radiological results of the UniSpacer™, whether alignment correction can be achieved by UniSpacer™ arthroplasty and alignment change in the first five postoperative years. Anteroposterior long leg stance radiographs of 20 legs were digitally analysed to assess alignment change: two relevant angles and the deviation of the mechanical axis of the leg were analysed before and after surgery. Additionally, the change of the postoperative alignment was determined one and five years postoperatively. Analysing the mechanical tibiofemoral angle, a significant leg axis correction was achieved, with a mean valgus change of 4.7 ± 1.9°; a varus change occurred in the first postoperative year, while there was no significant further change of alignment seen five years after surgery. The UniSpacer™ corrects malalignment in patients with medial gonarthrosis; however, a likely postoperative change in alignment due to implant adaptation to the joint must be considered before implantation. Our results show that good clinical and functional results can be achieved after UniSpacer™ arthroplasty. However, four of 19 knees had to be revised to a TKA or UKA due to persistent pain, which is an unacceptably high revision rate when looking at the alternative treatment options of medial osteoarthritis of the knee.

Operative treatment of distal radial fractures with locking plate system-a prospective study

The aim of this study was to determine the results of operative treatment of distal radial fractures with a 2.4-mm locking plate system in a single tertiary teaching hospital. Seventy-five patients were recruited into the study between May 2004 and November 2006. There were 41 males and 34 females, with a mean age of 51. Seventy-five percent of patients had AO type C fractures. All patients were allowed free active mobilisation of the wrist joint immediately after surgery. They were followed up at two weeks, three months, six months, one year and two years. Assessments of pain, motion, grip strength, and standard radiographs were performed. The Gartland and Werley functional scores, the modified Green and O'Brien score, and the disabilities of the arm, shoulder and hand (DASH) scores were recorded. The radiographic results at the final follow-up showed a mean of 18° of radial inclination, 5° of volar tilt, 1.3-mm radial shortening, and no articular incongruity. Twenty-nine percent of patients showed grade 1 osteoarthritic changes and 6% had grade 2 changes in their final follow-up radiographs. An excellent or good result was obtained in 98% and 96% of patients according to the Gartland and Werley, and modified Green and O'Brien scores, respectively. The mean DASH score was 11.6, indicating a high level of patient satisfaction. Internal fixation of distal radial fractures with a 2.4-mm locking plate system provided a stable fixation with good clinical outcomes and patient satisfaction.

Complications associated with realignment osteotomy of the knee performed simultaneously with additional reconstructive procedures

Debate remains regarding whether knee realignment osteotomy should be performed concomitantly with additional major knee reconstruction procedures or if it should be performed in a staged fashion. The purpose of this study is to analyze complications that occur when distal femoral osteotomy or high tibial osteotomy is performed concomitantly with other significant reconstructive procedures. Thirty-five patients with a minimum of one year follow up were identified. These patients underwent either high tibial or distal femoral osteotomy with concomitant significant additional knee reconstruction which included cartilage resurfacing requiring an arthrotomy, ligament reconstruction, meniscal transplantation, or extensor mechanism realignment requiring tibial tubercle osteotomy. Overall, 13/35 (37%) of these patients suffered at least one major or minor complication. Major complications occurred in 20.0% (7/35) and minor complications occurred in 25.7% (9/35). In conclusion, the rate of complication for combined osteotomy and reconstructive knee surgery is similar to that seen in cases of osteotomy done alone and combined surgery is advocated.

Leg axis correction with ConforMIS iForma (interpositional device) in unicompartmental arthritis of the knee

Degeneration of the meniscus and the articular cartilage in unicompartmental osteoarthritis of the knee results in progressive deformity of the leg axis. It is the aim of this study to evaluate if a leg axis correction can be achieved by implanting a customised metallic interpositional device for the knee (ConforMIS iForma). Before and after implanting a ConforMIS iForma knee implant, a radiological analysis of the leg axis deviation in the frontal plane was performed prospectively in 27 patients by evaluating anteroposterior single-leg stance radiographs. We achieved a sufficient leg axis correction with an average correction of 3.8 degrees and an averaged small under-adjustment of 0.9 degrees by inserting the ConforMIS iForma interpositional knee implant. Apart from the primary treatment objective of articular surface restitution the ConforMIS iForma knee implant can be reliably used to correct axis deformity occurring with unicompartmental osteoarthritis of the knee.

Component version in modular total hip revision

Morphologic changes of the proximal femur make revision total hip arthroplasty challenging. Metaphyseal retroversion and diaphyseal varus are common in this scenario. Twenty-one total hip revisions using a modular femoral prosthesis were examined by obtaining three radiographs (A/P, surgical lateral, and true lateral of the femur) to assemble CAD models for determining the range of modular component positioning. An average of femoral neck anteversion was observed. Seventeen of 21 cases (81%) had retroverted metaphyseal segments (-23.2 degrees +/-17.4 degrees ) and/or varus stems (-32.1 degrees +/-13.0 degrees ). Neck anteversion averaged 21.4 degrees (+/-10.0 degrees ). One of 21 cases (5%) resulted in component orientation similar to a non-modular prosthesis. Modular components provide options to accommodate proximal femoral remodeling not afforded by monobloc stems in total hip revision surgery.

Recurrent patellar dislocation: reappraising our approach to surgery

INTRODUCTION

The management of recurrent traumatic patellar dislocation includes surgical realignment. There is no clear distinction whether proximal soft tissue or distal procedures produce superior results. However, distal realignment procedures are commonly associated with greater morbidity. We advocate a distal procedure only for cases which are more severe, such as the presence of patellar maltracking.

MATERIALS AND METHODS

Between January 2002 and June 2007, all patients who had a history of traumatic patellar dislocation with recurrent symptoms and failed conservative management underwent surgical realignment. Patients who had evidence of lateral patellar subluxation on computed tomography (CT) scan were offered a distal realignment procedure using the Elmslie-Trillat or Roux Goldthwaite procedure. All other patients underwent proximal soft tissue medial patellofemoral ligament (MPFL) reconstruction. Pre and postoperative functional International Knee Documentation Committee (IKDC), Lysholm and Tegner score assessments were performed for a minimum follow-up period of 6 months. The mean scores for each group were analysed using the Wilcoxon Matched-Pairs Signed-Ranks test and the Mann-Whitney U test was used to evaluate the difference between the groups.

RESULTS

A total of 23 patients underwent surgery for patellar realignment. Of whom, 14 patients had a distal realignment procedure while 9 patients had a proximal procedure of MPFL reconstruction. There was greater morbidity reported with distal realignment procedures. Pre and postoperative IKDC, Lysholm and Tegner scores showed significant improvement for both treatment arms. However, there was no significant difference between the improvement scores for both groups.

CONCLUSION

Patients with significant patellar maltracking following traumatic patellar dislocation would benefit from distal realignment using the Elmslie-Trillat or Roux Goldthwaite procedure. Otherwise, a proximal soft tissue procedure involving MPFL reconstruction would be adequate. A management algorithm is proposed for clinical use.

[Humeral diaphyseal fractures: functional bracing]

Functional bracing of humeral diaphyseal fractures was conceived after initial experiences with a similar method was used in the management of diaphyseal tibial fractures. Over the years, tibial functional bracing underwent major evolutionary changes, and found its indications basically limited to a smaller group of fractures, consisting of closed, axially unstable fractures that experience at the time of the injury an acceptable degree of shortening, and to transverse fracture that are appropriately reduced and rendered stable. On the other hand, functional bracing of diaphyseal humeral fractures has, maintained the initial indications, contraindications and methodology. This article describes the concept, indications and contraindications of functional bracing of humeral diaphyseal fractures and provides results of 620 fractures with complete follow-up. In 97.5% of the patients, the average healing time was 11.5 weeks. 16 patients (2.5%) required operative intervention because of a nonunion and 4 patients (<1 degrees) of the patient had a refracture after brace removal. Nerve function did not return in only one of the 67 patient who had radial nerve palsy.

Free medial femoral condyle bone grafting for scaphoid nonunions with humpback deformity and proximal pole avascular necrosis

Treatment of scaphoid nonunions remains a challenging problem, especially in the setting of proximal pole avascular necrosis or humpback deformity. Conventional bone grafting techniques have demonstrated unpredictable results in the setting of collapse deformities, whereas pedicled dorsal distal radius vascularized bone grafts have recently been reported to have nearly a 50% failure rate when used in scaphoid nonunions with proximal pole nonunion. Free vascularized medial femoral condyle bone grafting is one option for the treatment of scaphoid nonunions with proximal pole avascular necrosis associated with a humpback deformity. The indications, contraindications, and technique of free vascularized medial femoral condyle bone grafting are presented for the treatment of scaphoid nonunions associated with proximal pole avascular necrosis and humpback deformities.

Bilateral pes valgus in an Anatolian Sheepdog

A 15-month-old, male, Anatolian Sheepdog weighing 45 kg, was admitted with uneven stance in both hindlegs, a condition it had had since the age of six months. Radiographs of both hindlimbs revealed lateral deviation of 26 degrees in the distal metaphysis of the left tibia and 32 degrees in the distal metaphysis of the right tibia. Corrective osteotomy was used to treat the deformity. Both tibias were aligned with the closed wedge osteotomy and a suitably curved plate was placed on both bones. In the assessment prior to the removal of both plates, it was determined that a valgus deformation of 6 degrees was still present. However, this did not affect the gait, nor did it have an abnormal effect on the cosmetic appearance. It was concluded that if corrective osteotomy is performed before any degenerative changes have taken place, the outcome will be successful.

[Effect of resection of the lateral retinaculum of the knee in surgical treatment of symptomatic patello-femoral incongruency]

Biomechanical malfunction of the knee extensor mechanism in the patello femoral joint is regarded as patella malalignment but major patients complaints are anterior knee pain and patellar slipping. Lateral retinacular release is one of the basic surgical procedures in the treatment of patellar malalignment. The aim of the study was to estimate the achievements of the lateral retinacular release in solving particular biomechanical disorders of the patello femoral joint, as well as individual patients complaints. Evaluation of objective parameters x-ray and clinical findings before and after the operation, shows statistically highly significant difference, thus confirming implementation of the fore mentioned surgical procedure. Despite the fact that anterior knee pain subsided postoperatively in the number of patients, statistically significant values, comparing to the preoperative findings, could not be obtained. Incidence of the patellar slipping has shown statistically significant reduction two years following the surgery. Achieving proper biomechanical alignment of the patello femoral joint is obviously not sufficient to provide relief of subjective complaints, especially concerning anterior knee pain, although considerable improvements were registered in the number of patients.

Tailored tibial tubercle transfer for patellofemoral malalignment: analysis of clinical outcomes

The purpose of this study was to describe the surgical technique, and evaluate and analyze the clinical outcomes of patients who underwent tibial tubercle realignment in our institution. Reported results of tibial tubercle transfer for patellofemoral malalignment vary considerably. Most authors rely mainly on the passive intraoperative patellar tracking test in determining the new location of the tibial tubercle. Conversely, the senior author relocates the tibial tubercle based on the intraoperative active and passive patellar tracking tests and the condition of the patellar articular surface. The medical records of 66 consecutive patients who underwent 80 tibial tubercle relocation procedures due to patellar instability or patellofemoral pain and maltracking were reviewed. Fifty-five patients with 69 operated knees participated in designated follow-ups which were conducted according to a predesigned protocol. The median follow-up was 6.2 years (range 2-13 years). Clinical outcomes significantly improved compared to the preoperative state; 72.5% of operated knees demonstrated good-to-excellent results according to the Lysholm and Karlsson scores, and physical findings supported the positive effect of the procedure. A statistically significant positive correlation was found between clinical outcomes and male gender, the absence of moderate to severe patellar chondral damage, and instability as the dominant preoperative symptom. Postoperative complication rate was low and patients with longer postoperative follow-ups demonstrated better clinical outcomes. The presented method of tibial tubercle transfer provided a good long-lasting surgical solution for patients with patellar instability and patients with patellar maltracking and anterior knee pain. Good prognostic factors included male gender, clinical patellar instability as the dominant preoperative symptom and intact patellar articular cartilage.

"Shimming" a locking plate with washers to correct axial alignment

The use of fixed-angle locking metaphyseal plate and screw constructs for articular and periarticular injuries has become commonplace. Given the restraints of bone stock in the epiphyseal region or possibly with misplacement of the plate, the use of these fixed-angle devices may produce varus or valgus malalignment. The described surgical technique entails the use of washers to elevate the plate from one end of the diaphyseal bone segment, thereby correcting potential varus or valgus.

[Surgical treatment of knee osteoarthritis]

Surgery for knee osteoarthritis is indicated if the clinical subjective symptoms in conjunction with radiological findings can no longer be adequately treated by conservative measures. Fundamentally, the treatment procedures are differentiated between joint preserving interventions (arthroscopy, knee revision, if necessary with meniscal debridement, partial synovectomy, osteophyte removal, cartilage surgery with microfracturing, autologous chrondrocyte transplantation, mosaic plasty or spacer implantation), corrective osteotomies near the knee joint and joint replacing procedures (knee endoprostheses or knee fusion [arthrodesis]).