[Assessment of patellar dislocations in childhood and adolescence : Accident-related or predisposition-related?] / Begutachtung von Patellaluxationen im Kindes- und Jugendalter : Unfall- oder anlagebedingt?

BACKGROUND: Numerous predisposing factors are known for patellar dislocations but the extent to which these or the trauma cause the dislocation is often unclear. AIM: This study investigated whether the analysis of the accident mechanism and anatomical predisposition in juvenile patellar dislocations enables a conclusion as to the causality. MATERIAL AND METHODS: Retrospective cohort study, evidence level III. In-house employers' liability insurance association (BG) cases with the diagnosis of patella dislocation in patients under 18 years were descriptively evaluated with respect to demographic and predisposing aspects as well as regarding accident information. The accident mechanisms were sorted into subgroups: direct impact, trivial trauma, fall, torsional trauma. RESULTS: A total of 54 patellar dislocations were identified with a patient age of 14 years (range 9-18 years). A mild valgus configuration was found in 39% of the cases, on average normal torsion, a tibial tuberosity-trochlea groove (TTTG) distance of 17 mm (range 8-24mm), with 41% a high proportion of patella alta and a trochlear deformity in 57%. Only 20% of the children had no relevant predispositions. The trivial traumas showed the highest proportion of recurrent dislocations with 50% and in the other accident categories the proportion of first dislocations was >75%. In the fall cohort the rate of children without relevant predisposition was highest. CONCLUSION: The predisposition rate in infantile patellar dislocations is high; however, falls are always significant accident events as well as medial direct impact. Torsional trauma is also a significant causative factor, unless high-grade trochlear dysplasia is present, whereas trivial traumas are not.

Corrective osteotomies of femur and tibia: which factors influence bone healing?

INTRODUCTION: Corrective osteotomies of the lower limb are standard procedures in orthopedic surgery. Still, there is only limited research on factors affecting bone healing after osteotomies. We hypothesize that especially the location of the osteotomy, smoking status and BMI affect bone healing. MATERIAL AND METHODS: The healing process of 547 patients who underwent osteotomies of the lower limb (259 female, 288 male; average 40.6 years, range 14-77) was evaluated. To assess bone healing, participants were divided into three groups by bone healing duration ( < 5/5-8/ > 8 months). Differences in healing duration related to the anatomic level of the osteotomy (diaphysis vs. metaphysis), age, gender, smoking status, BMI, and modus of the osteotomy (open vs. closed wedge) were tested for significance using an ordinal regression analysis. RESULTS: A significant correlation between bone healing and the anatomical level of the osteotomy on femur and tibia and the patients' smoking status was found. The odds of the diaphysis considering bone healing was 0.187 (95% CI, 0.08-0.44) times that of the metaphysis (Wald χ2(1) = 14.597, p < 0.000). The odds ratio of smokers considering bone healing was 0.192 (95% CI, 0.11-0.33) times that of non-smokers (Wald χ2(1) = 35.420, p < 0.000). All other analyzed factors did not show a significant correlation with bone healing. CONCLUSIONS: Smoking status and the localization of the osteotomy on femur and tibia (diaphysis vs. metaphysis) are significantly correlated with bone healing duration. In line with current literature emphasizing the detrimental effect of smoking on bone healing, our findings should encourage surgeons to think twice about the indication to perform osteotomies on smokers. Furthermore, if applicable, osteotomies should be performed in the metaphyseal areas of femur and tibia.

[Percutaneous sclerotherapy with polidocanol : Successful relapse therapy of infantile aneurysmal bone cyst]. / Perkutane Sklerotherapie mit Polidocanol : Erfolgreiche Rezidivtherapie einer kindlichen aneurysmatischen Knochenzyste.

The aneurysmal bone cyst (ABC) is well-known for its local expansile growth form and for the high risk of recurrence after treatment. We present the case of a 6­year-old patient with a large ABC in the metaphysis of the proximal tibia, which showed recurrence only five months after treatment with curettage and autologous bone graft. By using six percutaneous intralesional injections of polidocanol the patient was successfully treated with no recurrence. After 18 months, a mild genu valgum was clinically noted.

[Torsional osteotomy : Operative treatment of patellofemoral maltracking]. / Die Torsionsosteotomie : Behandlung des patellofemoralen Maltracking.

BACKGROUND: Patellofemoral maltracking may congenitally be caused by excessive internal maltorsion of the femur and/or excessive external maltorsion of the tibia. OBJECTIVE: Pain relief, femoropatellar stability, well-balanced charge of femoral and patellar cartilage. INDICATIONS: Anterior knee pain, patellar instability, associated with "inwardly pointing knee" syndrome. CONTRAINDICATIONS: Open physes, > 50 years, chronic/fixed patella luxation, congenital connective tissue and bone healing disorders. SURGICAL TECHNIQUE: Analysis of leg geometry and patellofemoral anatomy. Knee arthroscopy. Supracondylar external torsional osteotomy of the femur: medial approach, ventral shift of vastus medialis muscle. Definition of osteotomy plane. Torsion control. Complete transversal osteotomy. Acute external torsional correction. Fixation with internal plate. Supratuberositary internal torsional osteotomy of the tibia: exposure of lateral tibial head, detachment of the tibialis anterior muscle. Partial chisel osteotomy of the proximal tibial tuberosity. Definition of supratuberositary osteotomy plane. Torsion control with Schanz screws. Bending of a DC plate (DCP). Complete transversal osteotomy. Acute internal torsional correction and fixation with prebent DCP. With internal torsional correction > 10°, decompression of the peroneal nerve and proximal tibialis anterior fasciotomy. POSTOPERATIVE MANAGEMENT: Neurovascular and muscle function follow-up. On postsurgery day 1, drainage removal, x-ray control, mobilization. Partial weight bearing (20 kg) for 4 weeks with stepwise load increments. Active/passive exercises. Thromboprophylaxis. RESULTS: In 25 patients, 30 external torsional osteotomies of the supracondylar femur with 13.8° (5-26°); in 45 patients, 53 internal torsional osteotomies of the supratuberositary tibial head with an average 10.8° (5-18°). No persisting compartment syndrome or infection. One non-union healed after revision. One dysfunction of the peroneal nerve resolved with time. No subluxation or redislocation of the patella. Anterior knee pain decreased significantly in both groups.

[Deformities around the knee after growth plate injuries: Analysis and correction]. / Kniegelenknahe Deformitäten nach Epiphysenverletzungen: Analyse und Korrektur.

INTRODUCTION: Growth plate injuries of the distal femur and the proximal tibia are rare, but may induce deformities around the knee. The type of primary injury and the patient's age at the time of injury influence the extent and complexity of the deformity. PATIENTS AND METHODS: Twelve patients (median age = 12 years; range = 7-16 years) experienced growth plate injuries of the knee, followed by post-traumatic deformities. In fully developed growth plates, the deformities were subjected to a comprehensive and standardized analysis. Eleven patients had deviations in the frontal plane and 9 patients in the sagittal plane. Ten patients had relevant length differences and 7 patients had torsional deviations. One of the deformities was unidimensional, one was two-dimensional, six were three-dimensional, and four were four-dimensional. Ten corrective osteotomies were performed in the femoral aspect and 5 in the tibial aspect. Three patients needed bifocal osteotomies. Eight osteotomies were performed with an oscillating saw and 7 osteotomies with a drill hole and chisel. Acute correction could be achieved in 4 cases and continuous correction by means of callus distraction in 5 cases, whereas 3 patients needed combined procedures. RESULTS: One arterial injury had to be treated immediately by performing acute vascular surgery. A pin tract infection healed after early removal of the external fixator for distraction. Delayed bone healing necessitated a local revision with cancellous bone grafting. The goals of correction and acceptable knee function were achieved in all patients. CONCLUSION: Growth plate injuries frequently cause very complex deformities. A comprehensive and structured analysis of the deformity and customized acute/continued corrective procedures are essential for a satisfactory anatomic and functional outcome.

[Cortisone-induced humerus head necrosis in acute myeloid leukemia: cartilage-preserving arthroscopic spongioplasty]. / Cortison-induzierte Humeruskopfnekrose bei akuter myeloischer Leukämie : Knorpelerhaltende arthroskopisch unterstützte Spongiosaplastik.

Osteonecrosis is a long known side effect in patients receiving cortisone or chemotherapy. A young patient was diagnosed with acute myeloid leukemia (AML) in 2005. After receiving combined cortisone and chemotherapy the patient was in complete remission. In 2007 a total hip replacement was necessary due to femoral head necrosis. Years after the joint replacement the patient reported acute shoulder pain without trauma. In this article an alternative procedure to an endoprothesis in a young patient with a humeral head osteonecrosis is presented.

[Sports ability after patella dislocation]. / Sportfähigkeit nach Patellaluxation.

A dislocation of the patella is a serious injury which can far affect the career of every athlete or even finish it. In a retrospective study we examined 24 athletes (mean age 19.3 years, post surgical observation period 39 (13 to 79) months) which suffered from a patellar dislocation and received arthroscopic surgical treatment. The diagnostics contained clinical investigation and X-rays of the knee joint in 2 plains as well as patella tangential, in pathological axial deformations of the leg completed with whole-leg-images and optional a torsion computed tomography. All 24 patients received an arthroscopical assisted suturing of the medial retinaculum, in 12 patients additional a lateral release was carried out. The postoperative course followed a standard pattern. In 24 operated patients the reoccurrence rate was 12.5 % (3 patients), which is within the range of the latest published figures (average 12.0 %). The Lysholm score was in 15 (62.4 %) of all patients higher than 80 demonstrating the good to very good results, the average Lysholm score was 83.4. Out of 24 patients with patellar dislocation 11 patients (45.8 %) were able to continue their sport career after surgical therapy at the pre-trauma level, 4 patients (16.6 %) had to continue at lower level, 9 patients (37.5 %) had to finish their sport career. The Tegner activity score decreased from 7.2 to 6.0 at about 1.2 points what means a clear decrease of the activity level. On average a full sportive level was reached 9.7 months after surgery. Especially sport athletes needs to be informed about the seriousness of the injury and the long process of rehabilitation.

[Arthroscopy prior to osteotomy in cases of unicondylar osteoarthritis]. / Die Arthroskopie vor kniegelenknahen Korrekturosteotomien bei unikompartimenteller Gonarthrose.

BACKGROUND: Osteotomy around the knee is an established procedure in orthopaedic surgery. However, there is no consensus regarding whether the patient should have arthroscopy prior to osteotomy in the same operative session. PATIENTS AND METHODS: This prospective study included 300 cases of osteotomy around the knee with routine arthroscopy. During arthroscopy, the indication for osteotomy was checked first. Then the cartilage status was determined to modify the type and degree of osteotomy correction accordingly. Finally, therapeutic procedures were performed in cases of intraarticular pathology. RESULTS: The indication for osteotomy was rejected in 51 cases because of worse cartilage status than expected. Twelve patients received immediate or early endoprosthetic treatment. In 208 cases, the degree of correction was modified, in five cases at the level of the osteotomy. For the 288 nonendoprosthetic sessions, there were 268 arthroscopies with therapeutic treatments. CONCLUSION: This study demonstrated that arthroscopy is indispensable for checking the indications for osteotomy, modifying the type and degree of correction, and performing therapeutic procedures.

[Carotid dissection with cerebri media thrombosis due to a tonsillar lesion]. / Karotisdissektion mit Cerebri-media-Thrombose nach Tonsillenverletzung.

A 7-year-old boy suffered a tonsillar lesion due to trauma and presented to hospital with a GCS of 15. Some hours later he developed hemiparesis with loss of consciousness. Angiography displayed a left-sided carotid dissection associated with thrombosis of the arteria cerebri media. After initial treatment by heparinization, the increase of intracranial pressure was treated by craniectomy. The neurological deficits diminished partially after days and reimplantation of the skull cap was possible. The initial hemiparesis decreased slightly during rehabilitation after 5 weeks.