[Osteochondral injury of the femoral insertion of the deep medial collateral ligament of the knee-is there a successful surgical treatment?] / Osteochondrale Verletzung des femoralen Ansatzes des tiefen medialen Seitenbandes am Knie ­ chirurgisch erfolgsversprechende Therapie?!

Isolated ruptures of the deep portion of the medial collateral ligament (MCL) without clinical instability can mostly be treated conservatively with good clinical results. A 10-year-old girl was initially also treated conservatively. As symptoms of pain and limited range of motion were not resolved after 3 months of conservative treatment and although there were no signs of instability, it was decided to proceed with the surgical intervention. A small osteochondral fragment on the femoral insertion of the deep MCL (medial meniscofemoral ligament) was removed and the soft tissue portion of the ligament was reinserted in the anatomical footprint. The patient showed complete resolution of the pain and a full range of motion of the knee joint. At the last follow-up 18 months after surgery the patient was completely free of symptoms.

Fractures of the Bilateral C2 Neurocentral and Lateral Dental Synchondroses with Kyphotic C1-C2 Subluxation in a 3-Year-Old Girl: A Description of a Rare Fracture Pattern and Its Treatment: A Case Report.

CASE: Spinal fractures are rare in young children. Because spinal anatomy and biomechanics differ in children and adults, knowledge of the deviations of the juvenile spine is necessary for adequate treatment. We present the case of a young girl with an unusual C2 fracture that included rupture of both of the neurocentral and lateral dental synchondroses, with an opening of the synchondroses and a caudal dislocation of both vertebral arches following a head-on motor vehicle collision. The whole body and apex of the dens was displaced anteriorly and cranially with a kyphotic angulation of 34°. We describe the treatment and clinical and radiographic outcome after 1 year. CONCLUSION: Using passive hyperextension and distraction of the head, a closed open-mouth digital reduction was performed under continuous fluoroscopy. At the 1-year follow-up, the patient had full range of motion of the head without pain or neurologic dysfunction.

A balanced approach for stable hips in children with cerebral palsy: a combination of moderate VDRO and pelvic osteotomy.

BACKGROUND: Hip reconstructive surgery in cerebral palsy (CP) patients necessitates either femoral varus derotational osteotomy (VDRO) or pelvic osteotomy, or both. The purpose of this study is to review the results of a moderate varisation [planned neck shaft angle (NSA) of 130°] in combination with pelvic osteotomy for a consecutive series of patients. METHODS: Patients with CP who had been treated at our institution for hip dysplasia, subluxation or dislocation with VDRO in combination with pelvic osteotomy between 2005 and 2010 were reviewed. RESULTS: Forty patients with a mean follow-up of 5.4 years were included. The mean age at the time of operation was 8.9 years. The majority were non-ambulant children [GMFCS I-III: n = 11 (27.5 %); GMFCS IV-V: n = 29 (72.5 %)]. In total, 57 hips were treated with both femoral and pelvic osteotomy. The mean pre-operative NSA angle of 152.3° was reduced to 132.6° post-operatively. Additional adductor tenotomy was performed in nine hips (16 %) at initial operation. Reimers' migration percentage (MP) was improved from 63.6 % pre-operatively to 2.7 % post-operatively and showed a mean of 9.7 % at the final review. The results were good in 96.5 % (n = 55) with centred, stable hips (MP <33 %), fair in one with a subluxated hip (MP 42 %) and poor in one requiring revision pelvic osteotomy for ventral instability. CONCLUSIONS: This approach maintains good hip abduction and reduces soft-tissue surgery. Moderate varisation in VDRO in combination with pelvic osteotomy leads to good mid-term results with stable, pain-free hips, even in patients with severe spastic quadriplegia.

Arthroscopic osteochondroplasty in patients with mild slipped capital femoral epiphysis after in situ fixation.

PURPOSE: Mild slipped capital femoral epiphyses (SCFE) nevertheless show significant femoral head-neck deformities which may put cartilage and acetabular labrum at risk. Whether this deformity can be restored to normal has not yet been described in the literature. METHODS: In a prospective follow-up study, 14 patients with mild SCFE underwent in situ fixation with a single 6.5-mm cancellous, partially threaded screw. In 14 patients arthroscopic osteochondroplasty was performed, and in 13 patients pre- and postoperative measurements of the α-angle were made using antero-superior radial magnetic resonance imaging. RESULTS: After arthroscopic osteochondroplasty, the mean α-angle decreased from 57° (range 50°-74°) to 37° (range 32°-47°; p < 0.001). Six patients showed beginning degenerative intra-articular changes (four antero-superior cartilage and three antero-superior labrum lesions) at the time of hip arthroscopy. No intra-operative complications occurred. In one patient, arthroscopic debridement was necessary due to arthrofibrosis and persistent pain. CONCLUSION: Arthroscopic osteochondroplasty can successfully correct the antero-superior α-angle in patients with mild SCFE to normal values. Clinical randomized controlled studies with long-term follow-up are required to find evidence of improved functional and radiographic mid- and long-term outcome compared to in situ fixation alone.

LCP 140° Pediatric Hip Plate for fixation of proximal femoral valgisation osteotomy.

PURPOSE: Femoral osteotomy is one of the most widely performed reconstructive operations in pediatric orthopedic surgery. Many implants for fixation have been used, but so far there is no literature about the application and outcome of the LCP 140° Pediatric Hip Plate for proximal femoral valgisation in children. METHODS: Data of patients with a valgisation of the proximal femur using the LCP 140° Pediatric Hip Plate between February 2011 and July 2012 were retrospectively collected and analyzed. RESULTS: We included 10 patients (11 hips) with a mean follow-up of 15.3 ± 6.3 months (range 5.6-23 months). The mean age was 9.6 ± 1.2 years (range 7.3-11.8 years) with a mean hospital stay of 5.2 ± 1.7 days (range 3-9 days). Callus formation was observed in all cases at 6 weeks postoperative control and consolidation was shown after a mean time of 14.1 ± 2.3 weeks (range 12.1-19.1 weeks). There was no delayed union or any case of non-union in our series. The stability of the operative reduction including the corrected neck-shaft angle (mean 19° ± 7.9°; range 10.5°-38.5°) was maintained during the follow-up period. No cases of recurrence (varisation) or complications requiring further treatment or revision were observed. CONCLUSIONS: In our series, the 140° LCP Pediatric Hip Plate was shown to be safe and applicable in the clinical setting with good results. We therefore consider this device to be valuable for the correction of pathologic varus conditions of the proximal femur in children.

Persisting growth after prophylactic single-screw epiphysiodesis in upper femoral epiphysis.

BACKGROUND: Prophylactic fixation of the contralateral hip in cases of slipped upper femoral epiphysis is controversial. Therefore, using a single-cannulated screw has been widely accepted. However, differing reports exist on the occurrence of persisting growth after prophylactic epiphysiodesis. The aim of this retrospective study was to evaluate the presence of persisting growth of the upper femoral epiphysis after prophylactic fixation. METHODS: From 2006 until 2009, 11 children underwent prophylactic pinning using a single-cannulated 6.5-mm cancellous screw. Time to fusion, persisting growth, and overgrowing of the screw were measured on plain radiographs taken postoperatively and at least after the growth plate was fused. RESULTS: All patients except 1 (91%) showed a persisting growth of the epiphysis, and in 2 cases a hardware replacement was necessary. The mean increase of the femoral neck length was 8.2% (SEM 1.46%). Mean follow-up was 37 months (range, 12 to 49 mo). All patients had a Risser sign grade 0 at the time of surgery, and equal or less than grade 3, when the growth plate was fused. CONCLUSIONS: Despite previous reports that a prophylactic fixation using a single-cannulated cancellous screw is unproblematic and safe, we showed that in our series growth persistence was the rule and in some cases the physeal overgrowth necessitates a hardware replacement. Careful follow-up until fusion of the growth plate should be recommended.

Fixation of subtrochanteric extending/derotational femoral osteotomies with the Locking Compression Plate in ambulatory neuro-orthopaedic patients.

PURPOSE: Patients with neuro-orthopaedic disorders often develop hip flexion contractures or rotational hip deformities. Increasing deformities impair the already diminished walking abilities and proximal femoral osteotomies are often performed to maintain/improve walking abilities. Fixation of the osteotomies with condylar plates has been successfully used but does often not allow immediate postoperative full weight bearing. To avoid a substantial postoperative rehabilitation deficit and additional bone loss due to inactivity, a postoperative treatment with full weight bearing is, therefore, wishful. Newer fixed-angled implants with stronger anchoring in osteopenic bone might fit these demands. The objective of this study was to evaluate bone healing and the complication rate after proximal extending and/or derotational femoral osteotomy fixed with 3.5/4.5 Locking Compression Plate (LCP; Synthes(®)) and postoperative full weight bearing in ambulatory neuro-orthopaedic patients. METHODS: Fifteen ambulatory neuro-orthopaedic patients (12 cerebral palsy [CP], 1 trisomy 21, 2 hemiparesis) with a mean age of 13.7 years (range 7-22) with hip flexion contractures and/or rotational deformities underwent subtrochanteric (n = 26) osteotomy between July 2004 and October 2007. All patients were allowed to bear their full weight postoperatively. We investigated the fusion rate, implant failure, and general complication rate until union had occurred. RESULTS: Fourteen patients (mean weight 42.0 kg [range 21.8-59]) uneventfully achieved solid fusion. One patient (19 years of age, 73 kg) needed revision surgery due to implant failure with consecutive varus deformity and achieved solid fusion after the second intervention. Besides one superficial wound infection, no other complications occurred. CONCLUSIONS: Subtrochanteric extending and/or derotational osteotomies fixed with an LCP are a reliable procedure in neuro-orthopaedic patients. Most patients can be treated with early postoperative full weight bearing. However, in heavier patients, possible implant failure must be considered.

Treatment of reduced femoral antetorsion by subtrochanteric rotational osteotomy.

The purpose of this study was to assess bone healing and complication rate following subtrochanteric rotational osteotomy fixed with a 4.5/5.0 Locking Compression Plate (LCP, Synthes) for reduced femoral antetorsion with early full weight bearing. The effects of the osteotomy on the range of internal rotation of the hip and complaints due to reduced antetorsion were also recorded. Between July 2004 and October 2007, 25 children (39 hips) with a mean age of 13 years (range, 9-18 years) were treated for reduced internal rotation of the hip by a subtrochanteric rotational osteotomy. Four patients (six hips) were excluded from this study due to concomitant surgeries prohibiting full weight bearing. Of the 21 patients who were allowed full weight bearing, nine had a unilateral and twelve a single-stage bilateral correction. We investigated time to union, implant failure, and complication rate as well as improvement in the range of internal rotation. All osteotomies healed without secondary displacement or angulation. Internal rotation improved from a mean of 8.6 degrees (-5 degrees to 20 degrees) preoperatively to 37.3 degrees (25 degrees to 60 degrees) postoperatively. We noted no complication related with the femoral osteotomy. Subtrochanteric rotational osteotomy appeared as a reliable procedure to improve internal rotation of the hip. Fixation with 4.5/5.0 LCP allows simultaneous bilateral correction and immediate full weightbearing with crutches, with a minimal risk of implant failure.