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.].

Arthroscopic treatment of intercondylar eminence fractures with intraepiphyseal screws in children and adolescents

INTRODUCTION

Tibial intercondylar eminence fracture rarely occurs in childhood. Its treatment requires anatomic reduction to provide knee stability and a rigid fixation to minimize postoperative immobilization time.

HYPOTHESIS

Arthroscopy combined with fluoroscopy with intra-epiphyseal ASNIS screw fixation can meet the requirements of this treatment.

MATERIAL AND METHODS

The series comprised 24 patients (mean age: 11 years) with Meyers and McKeever type II tibial intercondylar eminence fractures (n=15) or type III (n=9), operated on between 2011 and 2013. Fixation with 4-mm ASNIS screws was placed arthroscopically. The demographic data, associated lesions, radiological union, stability, functional result, and the Lysholm score were evaluated.

RESULTS

With a mean follow-up of 2 years, the mean Lysholm score was 99.3 for type II and 98.6 for type III fractures. At the 6th postoperative week, range of motion in the operated knees was identical to the healthy knees. At the 12th postoperative week, there was no sign of anterior laxity. Twelve cases included meniscal entrapment, but no significant difference was observed in the functional results.

DISCUSSION, CONCLUSION

ASNIS screw fixation under arthroscopy can be successfully applied in the treatment of types II and III tibial intercondylar eminence fractures in children. This technique provides excellent stability, allows early weigh-tbearing, and preserves function of the knee and its growth.

LEVEL OF EVIDENCE

IV, retrospective study.

[TREATMENT OF RECURRENT PATELLAR DISLOCATION ASSOCIATED WITH OLD OSTEOCHONDRAL FRACTURE]

OBJECTIVE

To explore the treatment methed of recurrent patellar dislocation associated with old osteochondral fracture and to evaluate its effectiveness.

METHODS

Between August 2010 and August 2014, 12 cases of recurrent patellar dislocation with old osteochondral fracture were treated. There were 4 males and 8 females with an average age of 18.3 years (range, 15-24 years). The left knee was involved in 7 cases and the right knee in 5 cases. All the patients had a history of patellar dislocation, the average interval from injury to first hospitalization was 7.6 months (range, 6-13 months). At preoperation, the range of motion (ROM) of the injured knee was (89.17 ± 13.11)degrees; the Lysholm score was 56.67 ± 18.91; the Q-angle was (17.50 ± 5.28)degrees; and tibial tuberosity-trochlear groove (TT-TG) distance was (18.33 ± 4.03) mm. The Q-angle was more than 20 degrees and TT-TG distance was more than 20 mm in 6 of 12 cases. There were 6 cases of patellar osteochondral fracture, 5 cases of lateral femoral condylar osteochondral fracture, and 1 case of patellar osteochondral fracture combined with lateral femoral condylar osteochondral fracture. After osteochondral fracture fragments were removed under arthroscope, lateral patellar retinaculum releasing and medial patellar retinaculum reefing was performed in 2 cases, medial patellofemoral ligament (MPFL) reconstruction combined with both lateral patellar retinaculum releasing and medial patellar retinaculum reefing in 4 cases, and MPFL reconstruction, lateral patellar retinaculum releasing, medial patellar retinaculum reefing, and tibial tubercle transfer in 6 cases. Results All wounds healed by first intention with no complication of infection, haematoma, skin necrosis, or bone nonunion. All patients were followed up 12-60 months with an average of 24.2 months. At 3 months after operation, all patellar dislocations were corrected; the Q-angle was (13.33 ± 1.37)degrees and the TT-TG distance was (12.17 ± 1.17) mm in 6 patients undergoing tibial tubercle transfer, showing significant differences when compared with preoperative values [(22.50 ± 2.17)degrees and (21.33 ± 2.34 mm (t = 15.25, P = 0.00; t = 8.27, P = 0.00. All patients achieved relief of knee pain and knee locking; the knee ROM and the Lysholm score at last follow-up were (120.42 ± 11.57)degrees and 89.25 ± 9.71, showing significant differences when compared with preoperative ones (t = -11.61, P = 0.00; t = -8.66, P = 0.00).

CONCLUSION

It gas satisfactory short-term effectiveness to remove old osteochondral fragments that can not be rest and to correct patellar dislocation for recurrent patellar dislocation with old osteochondral fracture.

Prediction of Clinically Significant Leg-Length Discrepancy in Congenital Disorders

Leg-length discrepancy greater than 2 to 2.5 cm can potentially have an adverse effect on our walking and standing mechanisms and requires proper correction involving surgical treatment. However, for minor leg-length discrepancy in childhood, decision making for the indications for and timing of epiphysiodesis is difficult because of unpredictable final discrepancy. The purpose of this study was to analyze longitudinal changes of minor leg-length discrepancy in congenital disorders and to determine earlier predictive values for the clinically significant discrepancy. Twenty-one patients with congenital disorders who had minor leg-length discrepancy less than 2 cm at the first presentation were retrospectively evaluated. The patients were divided into 2 groups according to leg-length discrepancy at latest follow-up: the significant group (n=11) had 25 mm or more of leg-length discrepancy and the minor group (n=10) had less than 25 mm of leg-length discrepancy. The authors evaluated longitudinal changes of leg-length discrepancy within the first 10 years by mixed-effects regression model. All patients showed monotonically increasing leg-length discrepancy with age, except for 2 (neurofibromatosis type 1 and macrodactyly of the foot) who demonstrated fluctuating leg-length discrepancy. Mean annual rate of leg-length discrepancy change in the significant group was 2.1 mm across the first decade of life and was significantly larger than that in the minor group (difference in slope, 1.3 mm; P<.0001). In minor leg-length discrepancy associated with congenital disorders, the incidence of clinically significant leg-length discrepancy can be predictable by the annual rate of leg-length discrepancy change in the first decade of life.

[ALLOTRANSPLANTATION OF CRYOPRESERVATED VASCULARIZED BONE IN LIMB SALVAGE SURGERY FOR CHILDREN AND ADOLESCENTS WITH OSTEOSARCOMA]

OBJECTIVE

To investigate the effectiveness and technical key points of limb salvage surgery by allotransplantation of cryopreservated vascularized bone in children and adolescents with osteosarcoma.

METHODS

A retrospective analysis was made on the clinical data of 21 children and adolescents with osteosarcoma receiving limb salvage surgery by allotransplantation of cryopreservated vascularized bone from their relatives between February 2004 and April 2012. There were 13 males and 8 females, aged from 7 to 16 years (mean, 12.6 years). According to Enneking stage system, 15 cases were rated as stage IIA and 6 cases as stage IIB. The tumors located at the distal femur in 10 cases, at the proximal femur in 1 case, at the proximal tibia in 8 cases, at the proximal humerus in 1 case, and at the distal radius in 1 case. Imaging examination showed that epiphyseal extension of malignant bone tumors in 7 cases. The iliac bone allograft with deep iliac vessels was obtained from their lineal consanguinity. After preservation by a two-step freezing schedule, the iliac bone allograft with deep iliac vessels was implanted into the bone defect area after tumor resection. The size of iliac bone flap was 8.0 cm x 3.0 cm x 2.0 cm-14.0 cm x 5.0 cm x 2.5 cm. Reserved joint surgery was performed on 16 cases and joint fusion surgery on 5 cases, and external fixation was used in all cases. The chemotherapy was given according to sequential high-dose methotraxate, adriamycin, and cisplatine before and after operation.

RESULTS

All 21 cases were followed up from 5 months to 11 years (mean, 6.4 years). At 2 weeks after operation, the erythrocyte rosette forming cells accounted for 56.7% ± 3.9%, showing no significant difference when compared with that of normal control (58.3% ± 4.3%) (t = 1.56, P = 0.13), which suggested no acute rejection. At 4 weeks after operation, single photon emission computerized tomography bone scan indicated that the blood supply of bone graft was rich, and the metabolism was active. At 12 weeks after operation, the digital subtraction angiography showed the artery of iliac bone flap kept patency. X-ray films showed that malunion and non-union occurred at 5 and 6 months after operation in 1 case, respectively. The bone graft healed in the other patients, and the healing time was 3.2-6.0 months (mean, 4.4 months). At last follow-up, American Musculoskeletal Tumor Society (MSTS) score was significantly improved to 26.80 ± 2.14 from preoperative value (17.15 ± 1.86) (t = -4.15, P = 0.00). The survival rate was 85.7% (18/21) and the recurrence rate was 9.5% (2/21).

CONCLUSION

Allotransplantation of cryopreservated vascularized bone from the relatives provides a new method for the treatment of osteosarcoma in children and adolescents. A combination of allotransplantation and chemotherapy can achieve the ideal treatment effect. The correct cutting, preservation, and transplantation of the donor bone, and indication are the key to improve the effectiveness.

Fracture-dislocation of the humeral condyles in adults: results of surgical treatment

Fracture-dislocation of the humeral condyle is exceptional in adults. The purpose was to analyze the results of surgical treatment by open reduction and internal fixation without ligamentous repair. There were six men with an average age of 31 years. According to the AO classification, five fractures were classified as AO type B1 and one as B2. Dislocation was reduced in emergency before osteosynthesis. Postoperatively, the joint was held immobile with a brace for 25.40 days. Five patients were reviewed after a mean follow-up of 52.96 months. The median arc of flexion/extension was 104.80° and 157.8° for pronation-supination. All elbows were stable and all fractures were consolidated. Two elbows were painful. The results were satisfactory in five patients. The elbow stability can be ensured only by the synthesis of bone structures. Surgical treatment should restore exact anatomy between the condyle and trochlea. This protocol may provide a joint stability and satisfactory results.

Anterior Longitudinal Osteotomy of the Greater Trochanter in Total Hip Arthroplasty

The extra-articular impingement of the greater trochanter against the ileum is an underrated cause of early dislocation in total hip arthroplasty. In this preliminary study, the authors assess the effectiveness of an anterior longitudinal osteotomy of the greater trochanter for preventing dislocation. A total of 115 patients underwent a total hip arthroplasty through a posterolateral approach. All patients underwent clinical and radiological follow-up at 1, 3, and 6 months. No dislocation was reported. All patients demonstrated fast recovery of range of motion and walking. No trochanter fractures were observed. The osteotomy of the greater trochanter is an effective surgical technique that decreases anterior impingement and consequently lowers the dislocation rate in primary total hip arthroplasty. [Orthopedics. 2015; 38(8):490-493.].

Use of auxiliary locking plates for the treatment of unstable pertrochanteric femur fractures

Pertrochanteric femur fractures are successfully treated by orthopedic surgeons worldwide, but maintaining the reduction status or fixation of the greater trochanter is sometimes difficult in unstable cases in elderly patients. Several biomechanical advantages have been reported in locking plates when compared with conventional plates; locking plates provide angular and axial stability, better rigidity, and no toggling, and they preserve periosteal blood supply. The authors describe the use of auxiliary locking plates in unstable pertrochanteric femur fractures in elderly patients. Mini locking plates are simple, straightforward, and versatile enough to be used in elderly patients.

First metatarsal proximal opening wedge osteotomy for correction of hallux valgus deformity: comparison of straight versus oblique osteotomy

PURPOSE

The aim of this study was to compare clinical and radiographic outcomes of proximal opening wedge osteotomy using a straight versus oblique osteotomy.

MATERIALS AND METHODS

We retrospectively reviewed 104 consecutive first metatarsal proximal opening wedge osteotomies performed in 95 patients with hallux valgus deformity. Twenty-six feet were treated using straight metatarsal osteotomy (group A), whereas 78 feet were treated using oblique metatarsal osteotomy (group B). The hallux valgus angle (HVA), intermetatarsal angle (IMA), distal metatarsal articular angle, and distance from the first to the second metatarsal (distance) were measured for radiographic evaluation, whereas the American Orthopaedic Foot and Ankle Society (AOFAS) forefoot score was used for clinical evaluation.

RESULTS

Significant corrections in the HVA, IMA, and distance from the first to the second metatarsal were obtained in both groups at the last follow-up (p<0.001). There was no difference in the mean IMA correction between the 2 groups (6.1±2.7° in group A and 6.0±2.1° in group B). However, a greater correction in the HVA and distance from the first to the second metatarsal were found in group B (HVA, 13.2±8.2°; distance, 25.1±0.2 mm) compared to group A (HVA, 20.9±7.7°; distance, 28.1±0.3 mm; p<0.001). AOFAS scores were improved in both groups. However, group B demonstrated a greater improvement relative to group A (p=0.005).

CONCLUSION

Compared with a straight first metatarsal osteotomy, an oblique first metatarsal osteotomy yielded better clinical and radiological outcomes.

Surgical interventions for treating distal tibial metaphyseal fractures in adults

BACKGROUND

The distal tibial metaphysis is located in the lower (distal) part of the tibia (shin bone). Fractures of this part of the tibia are most commonly due to a high energy injury in young men and to osteoporosis in older women. The optimal methods of surgical intervention for a distal tibial metaphyseal fracture remain uncertain.

OBJECTIVES

To assess the effects (benefits and harms) of surgical interventions for distal tibial metaphyseal fractures in adults. We planned to compare surgical versus non-surgical (conservative) treatment, and different methods of surgical intervention.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (9 December 2014), the Cochrane Central Register of Controlled Trials (2014, Issue 12), MEDLINE (1946 to November Week 3 2014), EMBASE (1980 to 2014 Week 48), the Airiti Library (1967 to 2014 Week 8), China Knowledge Resource Integrated Database (1915 to 2014 Week 8), ClinicalTrials.gov (February 2014) and reference lists of included studies.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled clinical studies comparing surgical versus non-surgical (conservative) treatment or different surgical interventions for treating distal tibial metaphyseal fractures in adults. Our primary outcomes were patient-reported function and the need for secondary or revision surgery or substantive physiotherapy because of adverse outcomes.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies, assessed the risk of bias in each study and extracted data. We resolved disagreement by discussion and, where necessary, in consultation with a third author. Where appropriate we pooled data using the fixed-effect model.

MAIN RESULTS

We included three randomised trials that evaluated intramedullary nailing versus plating in 213 participants, with useable data from 173 participants of whom 112 were male. The mean age of participants in individual studies ranged from 41 to 44 years. There were no trials comparing surgery with non-surgical treatment. The three included trials were at high risk of performance bias, with one trial also being at high risk of selection, detection and attrition bias. Overall, the quality of available evidence was rated as very low for all outcomes, meaning that we are very unsure about the estimates for all outcomes.The results of two large ongoing trials of nailing versus plating are likely to provide sufficient evidence to address this issue in a future update.

AUTHORS' CONCLUSIONS

Overall, there is either no or insufficient evidence to draw definitive conclusions on the use of surgery or the best surgical intervention for distal tibial metaphyseal fractures in adults. The available evidence, which is of very low quality, found no clinically important differences in function or pain, and did not confirm a difference in the need for re-operation or risk of complications between nailing and plating.The addition of evidence from two ongoing trials of nailing versus plating should inform this question in future updates. Further randomised trials are warranted on other issues, but should be preceded by research to identify priority questions.

Surgical indications for distal tibial epiphyseal fractures in children

The goal of this study was to investigate the treatment methods and surgical indications of distal tibial epiphyseal fractures in children. Two hundred eighty-six children with distal tibial epiphyseal fractures were included in the study. Among these patients, 202 were male and 84 were female. Mean age was 11.7 years. A retrospective study on the postoperative long-term complications and related risk factors was performed. Treatment methods were determined according to the distance of fracture displacement. A long-leg cast was applied after closed reduction for patients with primary fracture displacement less than 2 mm. For cases with more than 2 mm of fracture displacement, K-wire or screw fixation was performed. For patients with less than 2 mm of fracture displacement, closed reduction and internal fixation was performed. Open reduction was performed in patients with more than 2 mm of fracture displacement, even after closed reduction. Mean follow-up was 6.4 years. Premature physeal closure occurred in 42 patients, and, among them, varus and valgus ankle deformities occurred in 16 patients. Associated fibular fractures and cast immobilization after closed reduction for Salter-Harris type III and IV fractures were risk factors for premature physeal closure. It is not effective to determine the surgical procedure according to the distance of preoperative fracture displacement for improving the prognosis of distal tibial epiphyseal fractures in children. Conservative treatment should be performed for patients with Salter-Harris type I and II distal tibial epiphyseal fractures, and surgery should be performed in patients with Salter-Harris type III and IV distal tibial epiphyseal fractures to reduce the incidence of premature physeal closure.