Quadricepsplasty for congenital dislocation of the knee and congenital quadriceps contracture

Stepwise Lengthening of the Quadriceps Extensor Mechanism for Severe Obligatory and Fixed Patella Dislocators

We introduce an algorithm of independently performing vastus lateralis lengthening followed by Z lengthening of the rectus and intermedius portion of the quadriceps tendon to treat fixed and obligatory patellar instability in the pediatric population. Performing this procedure in conjunction with medial patellofemoral ligament reconstruction minimizes subsequent episodes of instability without creating extensor mechanism weakness or contracture.

Congenital knee dislocation. Therapeutic protocol and long-term functional results

BACKGROUND AND OBJECTIVE

Congenital knee dislocation is a very rare entity, characterised by deformity in knee recurvatum present at birth, and there is currently no consensus on the optimal treatment. The aim of the present study is to analyse the functional results and long-term complications after the application of a protocol of therapeutic action for the management of congenital knee dislocation (CKD) created in a reference centre for child orthopaedics.

MATERIALS AND METHODS

Retrospective descriptive study of patients with congenital dislocation of the knee who followed CRPL between January 1997 and December 2010. Demographic variables, type of treatment, functional outcomes at the end of the follow-up, complications and relapses were studied. The conservative treatment consisted of serial casts, leaving the surgical treatment for cases in which passive flexion was not achieved above 30° or the conservative treatment failed.

RESULTS

9 patients (11 knees) met the inclusion criteria. The 66.7% were girls and the average follow-up was 15 years (9-22). In all cases, conservative treatment was initiated. Of the 11 knees treated, less than half (36%) required surgery. The average Lysholm questionnaire was 90.3 points, the WOMAC pain 0.4 (0-1), WOMAC stiffness 1.8 (0-6) and WOMAC function 3.8 (1-12).

CONCLUSIONS

The existence and application of the PLCR protocol in a pathology as rare as congenital knee dislocation suggests good long-term functional results with few complications and no recurrences.

Hind limb ossification centre hypoplasia and deformities induced by quadriceps contracture: Radiographic and Computed Tomographic study in 13 Doberman Pinscher littermates

Quadriceps contracture (QC) is reported in dogs mainly as a complication of trauma or parasitic infection. QC causes progressive hind limb deviation, muscular hypotrophy and degenerative joint disease and, in puppies, bone hypoplasia. The aim of this clinical case series is to describe the radiographic and computed tomographic (CT) changes in hind limb ossification centres in thirteen 55 to 57-days-old Doberman Pinscher related littermates induced by QC after repeated intramuscular injections. The presence, size, and shape of ossification centres of affected and unaffected hind limbs were compared. Affected limbs were hyperextended and externally rotated, with genu recurvatum and proximo-medial patellar luxation. QC had no influence on the time of appearance of ossification centres however, it was associated with femoral head flattening, hip subluxation, flattening of the femoral distal epiphysis. The tibial plateau was tilted caudoproximally-craniodistally and wedged into the growth plate. Thirty-two out of fifty-five ossification centres (including diaphyseal and epiphyseal centres, such as femoral head and tibial plateau) were significantly smaller in affected limbs (p < 0.05). Lack of weight-bearing could account for the smaller size of ossification centres in affected tarsi and metatarsi. Progressive limb hyperextension and external rotation might have induced gradual loading withdrawal on the medial aspect of the foot justifying the reduced size observed only for the medial ossification centres of the digits of affected limbs. To the best of our knowledge, this is the first study describing CT findings of hind limb ossification centre changes in puppies with QC contracture.

Surgical management of the congenital dislocation of the knee and hip in children presented after six months of age

PURPOSE

Congenital dislocation of the knee and hip is a rare congenital disorder. The specific aim of the study was to evaluate the clinical and radiological outcomes of the children with congenital dislocation of the knee and hip who presented after six months of age.

METHODS

All the consecutive children with congenital dislocation of the knee and hip joints were retrospectively reviewed. We included cases that were treated after six months of age and followed up for a minimum of two years. Twenty-four children with congenital dislocation of the knee and hip (thirteen with ligamentous laxity, eleven children with stiff joints) were included. The knee was dislocated in 45 limbs; the hip was dislocated in 40 instances. The knee joint dislocation was treated with quadricepsplasty in all twenty-four children (45 knees). The hip dislocation (n = 32) was addressed with either closed reduction (n = 8) or open reduction of the hip (n = 24). Eight hip dislocations were not addressed. The outcome of the hip and knee was evaluated.

RESULTS

The clinical and radiological outcomes were better in children with ligamentous laxity than without laxity. Twenty-two children were community walkers. An orthosis was needed in eight children. The frequency of spontaneous reduction of unreduced dislocation of the hip was noted in three children (5/8 hips).

CONCLUSION

Outcome in combined dislocation of knee and hip is good in most cases with surgical interventions. The outcome is better in children with ligamentous laxity. Spontaneous reduction of the dislocated hips might be achieved after gaining knee flexion following knee surgery for congenital the knee in a few cases.

Congenital dislocation of the knee in a three-year-old-child with Larsen syndrome: Treatment with a hexapod-type external fixator

Congenital knee dislocation (CDK) is a rare condition, and its treatment is subject to debate. Here, we report on a new treatment for CDK (using a hexapod-type external fixator, HEF) in a three-year-old child with Larsen syndrome and grade III anterior dislocations of both knees. The left knee was treated with serial splints, whereas an HEF was used to treat an irreducible dislocation of the right knee. Two HEF aluminium rings were applied surgically. The procedure involved a distraction of the knee, then tibial posterior translation, and lastly progressive flexion. The clinical and radiological outcomes were good; after four years of follow-up, the right knee had stabilized and had a range of motion of 110°. We conclude that as an innovative, effective option for the management of CDK, the use of an HEF may constitute a relatively advantageous alternative to quadriceps tenotomy.

Congenital dislocation of the knee at birth - Part 2: Impact of a new classification on treatment strategies, results and prognostic factors

INTRODUCTION

An original classification of congenital dislocation of the knee (CDK) was drawn up, based on neonatal semiology. The objective of the present study was to assess impact on treatment decision-making and prognosis.

MATERIAL AND METHODS

Fifty-one CDKs in 40 patients were classified neonatally into 3 types: I, reducible (n=28); II, recalcitrant (n=16); and III, irreducible (n=7). Number of anterior skin grooves, range of motion (RoM), flexion deficit and reduction stability were recorded. Depending on reducibility, treatment comprised: physiotherapy with splints, traction with cast immobilization, or surgery. At follow-up, knees were assessed in terms of RoM and stability.

RESULTS

Mean age at first consultation was 5.6 days (range: 0-30). Mean age at follow-up was 9 years (range: 1-26). Physiotherapy with splinting achieved stable reduction in all type-I knees. Five type-II knees (31%) required traction, none of which needed surgery. Four type-III knees (57%) required surgery. Outcome was good or excellent in 82% of type-I knees, good in 68% of type II and poor in all type-III knees.

CONCLUSION

The study confirmed the relevance of the present neonatal classification to treatment, with increasing rates of surgical indication and decreasing rates of satisfactory outcome from types I to III. Therapeutic attitude can be graded according to severity of CDK.

LEVEL OF EVIDENCE

IV, single-center retrospective series.