Lateral Humeral Condyle Fracture in Childhood: Results of a New Surgical Technique.

Fractures of the lateral condyle of the humerus are one of the most common fractures in children, accounting for between 10% and 20% of fractures involving the elbow, with a peak incidence at 6 years of age. Treatment is often surgical for displaced fractures > 2 mm, according to Milch and Jakob classification. There is no consensus in the literature about the appropriate surgical management of these fractures. Objectives: The aim of this study is to describe, propose, and evaluate outcomes and complications of the surgical technique of reduction and osteosynthesis using trans-bone suture with resorbable threads. Methods: Patients with lateral condyle fractures treated with this surgical technique from 2015 to 2019 were included in this retrospective study, with a minimum follow-up of 24 months. For clinical and functional assessment of the elbow, Mayo Elbow Scores were recorded; we assessed the time of fracture healing, carrying angles, and Baumann angle of the affected limb compared to the healthy contralateral elbow for radiographic data. Complications have also been described. Results: We achieved satisfactory results; 36 patients with lateral condyle fractures were included in this study. Radiological healing was achieved in all cases. There was only one complication. No cases required additional surgical procedures. Almost all patients achieved a complete flexion of 110 degrees or more and complete extension. Conclusions: This surgical technique has good functional outcomes and fracture healing, a lower incidence of complications when compared to other surgical techniques, and no mechanical failure with good clinical and radiological results.

Management of Open Pediatric Fractures: Proposal of a New Multidisciplinary Algorithm.

BACKGROUND: An algorithm for managing open fractures in children is still being debated; the present study suggests an evidence-based way to manage these patients in the emergency department. METHODS: The literature on "Open fractures in children" was carefully analyzed using keywords. The primary sources were The Cochrane Library, PubMed, and Researchgate. CONCLUSION: We proposed an evidence-based algorithm for managing open fractures in children to standardize clinical practice and improve the care of these patients.

Bone wax in the treatment of partial epiphysiodesis of distal femoral growth plate: Case report at 10-year follow-up.

The growth plate is the weakest structure in the skeleton of a child and a frequent site of injury or fracture; physeal injuries represent 15%-30% of all fractures in children. Of all growth plate fractures, the incidence of growth arrest and disorders is around 15%. Here, we discuss a female patient who, at the age of 5 years, was treated for a polytrauma that involved a complex lesion of the growth plates of the knee. Four days after trauma, she underwent closed reduction surgery and internal fixation with cannulated screws for femoral and tibial fractures of the growth plate. A 20° valgus deviation of the left knee was found at 3-month postoperative clinical check-up likely as a result of a growth disorder of the femur. She was diagnosed with valgus knee secondary to epiphysiodesis of the lateral portion of the femoral physis and she was readmitted to the hospital. In the operating theater, an open femoral de-epiphysiodesis was performed with a burr; the drilled hole was then filled with bone wax. At 20-month post-trauma follow-up, the left knee was still valgus about 20° relative to the other side. During follow-up, a slow but progressive improvement in the axis of the lower limbs was noted. Clinical and radiographic control 10 years after the trauma showed a complete recovery of the axis of the lower limbs. In the initial stages, the presence of bone wax in the area of de-epiphysiodesis allowed for stabilization of the deformity on the 20° of preoperative valgus. The interpretation of the growth cartilage activity occurred in an asymmetrical way such as to realign the femoral load axis, it can be based on the different mechanical stimulus on the two knee areas due to the preexisting deformity. There is no unanimous evidence in the literature in terms of management of growth disorders resulting from this type of injury. Bone wax resulted in effectively filling the hole of de-epiphysiodesis in the distal femoral growth plate and allowed us to obtain the response of the growth plate and to improve the recovery time in young children.

Non-traumatic scapholunate dissociation in a 10-year-old female: A case report.

Introduction: Severe or minor repetitive trauma, inflammation, infection, tumors, and congenital ligamentous laxity have been etiologically implicated in scapholunate dissociation (SLD). While a few cases of patients with asymptomatic SLD have been reported in the literature, despite radiographically demonstrated widened scapholunate angles and rotatory subluxation of the scaphoid bone, these patients experienced only mild or no pain and no dorsal intercalated segment instability deformity. Here, we report the case of a monolateral non-traumatic SLD in a young 10-year-old girl that led to an important range of motion impairment with no wrist pain. The case represents a rarity for no previous history of trauma, young age, and no pain. Main symptoms and important clinical findings: In our patient, an examination revealed a reduced range of motion in the left wrist and no pain during passive or active mobilization. The X-ray showed a 16 mm scapholunate gap in the anteroposterior roentgenogram. In this case, we suggested that congenital or developmental ligamentous laxity may be the cause of SLD. The diagnostic assessment was completed with a wrist MRI and CT. Therapeutic interventions and outcomes: The patient underwent an open dorsal surgery: we directly reduced the dislocated bones and fixed them with five percutaneous 1 mm k-wires. Finally, the scapholunate ligaments were repaired using bone-absorbable anchor sutures. The wrist was immobilized in a volar cast for 8 weeks. The patient was able to resume her daily life activities (included sport) within 12 months. Conclusion: Carpus injuries are rare in children, and treatment, especially for young-age patients, is fraught with risks and remains controversial. Our case demonstrates that the patient has had a good clinical outcome. The physio-rehabilitation program for this patient has been of long duration. Most previous studies have shown excellent clinical results after an average of 2.4 years.

Superficial peroneal nerve entrapment in ankle sprain in childhood and adolescence.

Traumatic injuries of the ankle are the most common injuries in sports. Up to 40% of patients who have undergone inversion ankle sprain report residual symptoms. The primary purpose of the study is to evaluate the incidence of SPN entrapment as consequence of acute severe inversion ankle sprain in children and adolescents; the secondary is to report the diagnostic pathway and the results after surgical treatment. From 2000 to 2015 were reviewed to summarize patients under the age of 15 years treated for a first episode of severe inversion ankle sprain. Cases with persistent symptoms (more than 3 months) indicative for SPN neuropathy were then identified. Instrumental investigations were recovered and a pre-operative assessment of pain (VAS) was recorded. Patients were evaluated at minimum of 1-year post-operative follow-up. 981 acute ankle sprains have been evaluated. 122 were considered severe according to van Dijk criteria. 5 patients were considered affected by neuropathy of the SPN. All patients underwent surgery consisting in neurolysis and capsular retention and ligament reconstruction. At 25 months of follow-up AOFAS moved from 57.6 to 98.6. The study highlights a previously unreported condition of perineural fibrosis of the superficial peroneal nerve at the level of the ankle following first acute severe inversion ankle sprain in children.

Long-Term Results of Anterior Cruciate Ligament Reconstruction Using Hamstring Grafts and the Outside-In Technique: A Comparison Between 5- and 15-Year Follow-up.

BACKGROUND: Increased femoral tunnel widening and weakness of the hamstring muscles postoperatively have been described as potential adverse events after anterior cruciate ligament (ACL) reconstruction (ACLR) with a hamstring graft. Meniscectomy and cartilage lesions are important factors for the development of degenerative osteoarthritis. PURPOSE: To compare 15-year follow-up data with 5-year follow-up data from the same cohort of patients after ACLR with a hamstring autograft using an outside-in technique. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A total of 72 patients who underwent anatomic ACLR with a quadruple hamstring graft and an outside-in technique were selected for this prospective study. Patients were reviewed at a minimum follow-up of 15 years. Results were compared with the same series of patients previously reviewed at 5 years after surgery. Lysholm, International Knee Documentation Committee (IKDC), and Tegner scores as well as KT-1000 arthrometer measurements were obtained at final follow-up. Comparative weightbearing radiographs were obtained and analyzed according to the Fairbank, Kellgren-Lawrence, and IKDC classifications and used for the tunnel evaluation. RESULTS: No significant difference was detected on the subjective evaluation. Objectively, patients categorized as A or B according to the IKDC score were not significantly different at 5 and 15 years (P < .01). A KT-1000 arthrometer side-to-side manual maximum difference >5 mm, a pivot shift >2+, any giving-way episode, and ACL revision surgery were considered as failures, and these were noted in 6 patients at 5 years and 6 patients at 15 years. The radiological evaluation at 15 years showed a higher rate of osteoarthritis in 2 of 3 radiological scales used in the study compared with results at 5-year follow-up (P < .01). At 15-year follow-up, there was a statistically significant reduction in the mean tibial tunnel diameter (P < .01). CONCLUSION: Endoscopic single-bundle ACLR using hamstring grafts and an outside-in technique demonstrated good results at 15-year follow-up in terms of subjective, objective, and radiographic evaluations. As compared with 5-year follow-up, clinical results remained stable both subjectively and objectively. However, a progression of osteoarthritis changes was observed, especially in patients in whom meniscectomy had been performed.

Combined Intra-articular and Extra-articular Reconstruction in Anterior Cruciate Ligament-Deficient Knee: 25 Years Later.

PURPOSE: To determine whether an anterior cruciate ligament (ACL)-reconstructed knee with hamstring autograft has a greater incidence of degenerative changes when an extra-articular reconstruction is added and to determine the effect of the combined reconstruction on knee stability and function at long-term follow-up. METHODS: For this retrospective study, patients who underwent ACL reconstruction between January 2002 and December 2003 were selected and classified into 2 groups, I and II. Group I consisted of patients operated by a standard ACL reconstruction, and group II consisted of patients in whom, owing to the presence of risk factors (severe pivot shift graded +++ or high-risk sports), an extra-articular reconstruction performed with ileo-tibial tract according to McIntosh as modified by Cocker Arnold technique, was used in conjunction with intra-articular ACL reconstruction. At final follow-up, Lysholm, International Knee Documentation Committee (IKDC), and Tegner scores were used. An arthrometric KT-1000 evaluation was done. Comparative weight-bearing radiographs were taken, including a skyline view for the patellofemoral joint and analyzed according to Fairbank, Kellgren, and IKDC classification. RESULTS: Seventy-two of the 75 (96%) patients in group I and 68 of the 75 patients in group II were available at the final follow-up (minimum 10 years). Subjective scores improved significantly in both groups, with no significant difference. Objectively, the number of patients receiving C and D IKDC objective activity scores in group I (7/56; 12.5%) was significantly higher than in group II (0/60) (P = .01). Considering as a failure a side-to-side arthrometric difference more than 5 mm or a pivot shift test graded as ++ or +++, or any giving way episode occurring postoperatively, we found 8 cases in group I and no cases in group II (P = .01) despite the presence of risk factors that group I did not include. Radiologic evaluation showed less arthritic changes in group II in both tibiofemoral and patellofemoral joints. CONCLUSIONS: On the basis of the results of this study, adding an extra-articular reconstruction to an anatomically placed intra-articular ACL reconstruction, followed by a modern rehabilitation protocol, does not increase the risk of osteoarthritis and may be able to reduce the rate of failure. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Mediolateral oversizing influences pain, function, and flexion after TKA.

PURPOSE: Manufacturers of total knee arthroplasty (TKA) have introduced narrower femurs to improve bone-implant fit. However, few studies have reported the clinical consequences of mediolateral oversizing. Our hypothesis was that component oversizing negatively influences the results after TKA. METHODS: One hundred and twelve prospectively followed patients with 114 consecutive TKA (64 females and 50 males) were retrospectively assessed. The mean age of the patients was 72 years (range, 56 to 85 years). The dimensions of the femur and tibia were measured on a preoperative CT-scan and were compared with those of the implanted TKA. The influence of size variation on the clinical outcomes 1 year after surgery was assessed. RESULTS: Mediolateral overhang was observed in at least one area in 66 % of the femurs (84 % in females and 54 % in males) and 61 % of the tibia (81 % in females and 40 % in males). Twenty-two patients presented no overhang in any area and 16 had overhang in all studied zones. The increase in the Pain and KOOS scores were 43 ± 21 and 36 ± 18 in the patients without overhang and 31 ± 19 and 25 ± 13 in patients with overhang (p = 0.033; p = 0.032). Knee flexion was 127° ± 7 and 121° ± 11, respectively. Regression and latent class analysis showed a significant negative correlation between overall oversizing and overall outcome. CONCLUSIONS: This study confirms that oversizing may lead to worse clinical results in TKA. The clinical consequences are that surgeons should pay attention not to oversize implants during implantation nd that oversizing should be ruled out in case of so called unexplained pain. LEVEL OF EVIDENCE: IV.

Should the acetabular cup be medialised in total hip arthroplasty.

BACKGROUND: During total hip arthroplasty (THA), medialisation of the cup decreases the lever arm of body weight and is considered to be beneficial. Theoretically it should be compensated by an equivalent increase of the femoral offset in order to maintain global offset. GOAL OF THE STUDY: We investigated via a numerical model the forces on each bundle of the abductor muscles and the loading forces at the head-cup interface. We compared THA with and without medialisation of the cup and with and without restoration of the global offset. METHOD: A digital finite element model of the hip joint with THA was constructed. Monopodal weightbearing was simulated with the cup positioned so that the hip centre of rotation was left unchanged. Forces in the abductors and pressure on the prosthetic head were measured and then compared with three other configurations: 1. Medialisation of the cup by 5 to 15 mm with reproduction of the native femoral offset or; 2. with an increased femoral offset compensating for the cup medialisation and; 3. no medialisation of the cup with a femoral offset increased. RESULTS: Medialisation of the cup decreased stresses on the head-cup interface and on the abductor muscles, even when the global offset was not restored. Anatomical placement of the cup did not give the best results. The optimal outcome in terms of stress was observed when the cup was medialised but global offset restored. Any increase of global offset significantly increases the length and the tension in the anterior bundles of the abductor muscles.

What are the factors of residual pain after uncomplicated TKA?

PURPOSE: Residual pain during activities of daily living and/or at rest is a major cause of a patient's dissatisfaction after total knee arthroplasty (TKA). The management of a painful TKA, which has no obvious clinical or radiological explanation, requires further investigation with more sensitive imaging modalities (CT scan and bone scan) and hematological tests. It is often challenging for the physician to determine what level of pain warrants these more complex and expensive medical examinations. A precise knowledge of the natural history of postoperative pain following TKA is therefore of fundamental importance. METHODS: We reviewed the literature and highlighted the studies that investigated the evolution of pain after uncomplicated TKAs and the impact of demographic and psychosocial variables on a postoperative painful TKA. RESULTS: Factors that are associated with a more painful knee include female sex, a younger age at the time of surgery, and a higher than normal depressive or anxiety state. In particular, the Pain Catastrophizing Scale (PCS), a scale that quantifies a patient's negative or exaggerated orientation to pain, appears to significantly influence a patient's outcome after TKA. CONCLUSION: The identification of these high-risk patients is critical so that a surgeon can provide detailed preoperative education in order to give these patients a realistic expectation of their possible satisfaction following TKA.