Anterior cruciate ligament reconstruction in adolescents with open physes.

The purpose of this study was to evaluate anterior cruciate ligament reconstructions performed in adolescents with open physes and a skeletal age of at least 14 years. At one center, from 1992 to 1996, 19 adolescents (ages, 11 to 15 years) with open physes and a skeletal age of at least 14 years underwent arthroscopic anterior cruciate ligament reconstruction using an Achilles tendon allograft placed through drill holes across the open physes in both the distal femur and proximal tibia. Fifteen patients returned for reevaluation at an average of 25 months postoperatively (range, 12 to 60 months); the remaining four patients were interviewed by telephone. There were no significant leg-length discrepancies or angular deformities as determined by scanograms and anteroposterior and lateral radiographs of the femur and tibia. The mean Lysholm knee score was 97 (range, 94 to 100) and the mean KT-1000 arthrometer side-to-side difference at 20 pounds of anterior force was 1.7 mm (range, 0.0 to 3.0). All patients were satisfied with the results of surgery, and 16 of 19 patients returned to the same sport they were participating in before the injury. This study demonstrates that anterior cruciate ligament reconstruction using an Achilles tendon allograft is a viable treatment option for skeletally immature patients with a skeletal age of 14 years who have sustained midsubstance tears of the anterior cruciate ligament.

Growth disturbances after distal tibial physeal fractures.

Twenty-four patients with distal tibial growth disturbance were reviewed. Disturbances were classified as physeal bar (prior to deformity), angular, linear or combined deformities. Treatment consisted of osteotomy in fourteen, epiphyseodesis in seven, excision of bony bar in two, and observation in one patient. Follow up was an average 36.6 months (range 4-129 months) after treatment of growth disturbance. The age at time of injury was 10.4 years of age average (range 3-15 years). There were 12 SH2, 2 SH3, 7 SH4, and 3 SH5 distal tibial physeal fractures. Thirteen of 15 fractures considered high energy and only 1 of 9 fractures considered low energy resulted in angular deformity. Angular and linear deformities presented an average 46 months (range 12-120 months) and physeal bars at an average 14 months (range 6-25 months) after injury. Patients with a delay in presentation of growth disturbance greater than 24 months had angular deformities in 92% compared with 33% in children presenting less than or at 24 months. Treatment based on type of deformity, age at time of injury, and growth remaining was considered successful in 83%. Patients with angular or linear deformities were more likely to present late, have high energy injuries, be male patients and have Salter-Harris types IV and V. Early diagnosis and treatment of growth disturbance can prevent severe deformity.

Pediatric fracture without radiographic abnormality. Description and significance.

With an expanding application of magnetic resonance imaging in acute musculoskeletal injury, an increasing number of occult traumatic lesions of bone are being identified. The authors describe the entity of fracture without radiographic abnormality, which as the name suggests is a bony injury not apparent on plain radiographs. The clinical significance and potential sequelae have not been defined in the pediatric patient. Accordingly, the purpose of this study is to describe and classify the entity of the pediatric fracture without radiographic abnormality and delineate its importance and appropriate management. Twenty-five children were seen primarily or referred to The Children's Hospital of Philadelphia after having sustained an acute traumatic injury; all refused to bear weight or use their extremity, and all had initial plain radiographs that were interpreted as normal. Subsequent magnetic resonance images of all 25 children showed an occult fracture. These included Salter-Harris fracture Types II (two patients), III (one patient), and IV (three patients), intraosseous epiphyseal fractures (18 patients), and a metaphyseal diaphyseal fracture (one patient). Four patients with intraosseous epiphyseal fractures ultimately sloughed a portion of their articular cartilage, as observed at arthroscopy. The decision to proceed with magnetic resonance imaging in the evaluation of a child who refuses to use an extremity depends on many variables. However, magnetic resonance imaging has proven useful in revealing fractures without radiographic abnormality and in ruling out other pathosis.

Accessory soleus muscle. A report of 4 cases and review of literature.

Cadaveric studies have demonstrated the incidence of an accessory soleus muscle ranges from 0.7% to 5.5%. The differential diagnosis of a painful soft tissue mass in the posteromedial region of the ankle includes ganglion, lipoma, hemangioma, synovioma, and sarcomas. In light of these possibilities, most of the early reports of accessory soleus included evaluation and treatment with biopsy, fasciotomy, or excision. Four patients, ranging in age from 14 to 66 years of age at the time of presentation, are discussed. Reports in the literature indicate that accessory soleus is a benign condition, and in most patients, a conservative approach is indicated. In addition, magnetic resonance imaging is the preferred study for the evaluation of this condition. If a diagnosis of accessory soleus is made, and the patient has no symptoms, observation is recommended. However, if the patient has symptoms, fasciotomy generally is a successful form of treatment. For symptoms that persist after fasciotomy, excision of the accessory soleus can be curative.

Screw fixation of Grade III slipped capital femoral epiphysis.

From 1987 to 1992, 161 children were treated at The Children's Hospital of Philadelphia for slipped capital femoral epiphysis. Of these, 23 patients (23 hips) had Grade III slips (> 50%). Fixation was achieved by 1 or 2 screws in all patients. Twenty-one of 23 patients were available for followup (average followup, 2.8 years). Four slips were acute, 11 were acute-on-chronic, and 6 were chronic. At the most recent followup, radiographs were taken and a Harris Hip Score was assigned for each patient. Stabilization without progression of slip at followup was achieved in all patients. Screw placement was satisfactory per the criteria of Stambough in all patients. Four children (19%) had major complications: Three (1 acute slip and 2 acute-on-chronic slips) had avascular necrosis of the femoral head; One (chronic slip) had chondrolysis. There were no immediate postoperative complications. The mean Harris Hip Score for these 4 patients was 85 points, versus a mean score of 94 points for all 21 patients. Chronic Grade III slipped capital femoral epiphysis can be treated safely and effectively by screw fixation. Five of 6 patients had satisfactory results; the only exception had evidence of chondrolysis preoperatively. Acute and acute-on-chronic Grade III slipped capital femoral epiphyses treated with screw fixation are less predictable. In 15 patients, reduction occurred in 9 hips despite deliberate avoidance of forceful manipulative maneuvers. Avascular necrosis developed in 3 (33%) of these 9 hips. Reduction of the acute component of the slip during screw fixation, whether deliberate or not, indicates gross instability. It is hypothesized that avascular necrosis may be associated with injury to the epiphyseal vasculature occurring at the time of the acute slip.

Arthroscopically assisted proximal quadricepsplasty for patellar instability.

Arthroscopy has come to play a major role in the evaluation and treatment of patellofemoral instability. In fact, most patients sustaining a traumatic dislocation or recurrent subluxations are subjected to, at a minimum, an arthroscopic evaluation to assess intraarticular damage and patellar tracking.

Arthroplasty of the hip and knee in juvenile rheumatoid arthritis.

The primary reason for total hip and total knee replacement in patients with juvenile rheumatoid arthritis is marked functional impairment. Secondary reasons are severe disabling pain and deformity. By the time a patient is ready for arthroplasty, alternatives to surgery have already been considered; synovectomies, soft-tissue releases, and osteotomies have already been performed, or the destructive process is too advanced for any form of therapy to have a considerable effect.

Keeping fit when injured.

Staying physically fit while injured can improve the patient's outlook, both physiologically and psychologically, and help him or her return to regular activities completely, safely, and with decreased risk of re-injury. Although treating and protecting the injured area is of primary concern, it is important to then look beyond the injury, toward keeping the rest of the body as fit as possible. Whether through alternative sports, cross training, or water exercise, the patient can preserve the integrity of the injured joint, keep the noninjured muscles active, and maintain ever-important cardiovascular fitness. The exercise prescription for the injured athlete should emphasize our most vital muscle, the heart.

The use of single photon emission computed tomography (SPECT) in the diagnosis of low-back pain in young patients.

Single photon emission computed tomography (SPECT) is a method of scintigraphy that provides sectional and multi-planar imaging that should improve the sensitivity for diagnosis in remote areas of the spine. To test this hypothesis, the authors reviewed 15 patients with low-back pain and compared the results of the radiographs, planar bone scans (PBS), and SPECT. Four of 15 had normal examinations with all three methods of imaging. The rest had a positive test in at least one of the three methods. Single photon emission computed tomography was positive in eleven, PBS in six, and the radiograph in three of the 11 patients. It appears that the SPECT was the most sensitive method of imaging and greatly enhanced our diagnostic acumen for stress fractures or stress reactions of the spine.

Upper extremity injuries in adolescent tennis players.

The majority of adolescent tennis players will have their playing temporarily interrupted by an injury, with lower extremity problems predominating. Although upper extremity injuries occur less frequently, they tend to be more troublesome. Injuries discussed in this article include "King Kong arm," slipped capital humeral epiphysis, "Osgood-Schlatter disease" of the shoulder, tennis elbow, stress synovitis and elbow flexion contracture, and friction burns and collagen stress fractures of the rotator cuff.

A modified Bristow-Helfet-May procedure for recurrent dislocation and subluxation of the shoulder. Report of two hundred and twelve cases.

A modified Bristow-Helfet-May procedure was performed for recurrent dislocation or subluxation of the glenohumeral joint in 207 patients (212 shoulders), whose average age at the time of surgery was 20.3 years (range, fourteen to forty-seven years). The procedure was modified by directing the coracoid segment and conjoined tendon over the superior border rather than through the substance of the subscapularis tendon and muscle. The indications were either documented recurrent anterior dislocation of the glenohumeral joint or subluxation with instability as demonstrated on examination with the patient under anesthesia. The procedure was evaluated on the basis of the rate of recurrence of dislocation and subluxation, postoperative complications, the patients' subjective evaluation, and the effect of the procedure on the motion of the glenohumeral joint and the strength of the muscles of the shoulder as related to overhead throwing. Eight (3.8 per cent) of the shoulders redislocated and ten (4.7 per cent) had one or more subjective episodes of subluxation after the procedure. Complications included postoperative infection in two patients and problems with the screw that required its removal in ten. One hundred and thirty-one (62 per cent) of the patients responded to a questionnaire regarding their subjective evaluation of the results of surgery. Eleven (8 per cent) were unable to perform daily activities that involved overhead work, and forty-five (34 per cent) stated that they still had some degree of discomfort or pain in the shoulder. One hundred and twenty-six patients (96.2 per cent) stated that they were happy with the results of the surgery and would have the procedure again. Thirty patients had Cybex testing of the muscles of the shoulder. Only three (16 per cent) of the nineteen athletes whose dominant arm had been operated on returned to their pre-injury level of throwing. Data obtained with regard to changes in the range of motion and strength of the glenohumeral joint indicate that this loss of throwing ability was not due solely to a loss of glenohumeral motion. It appeared to be also related to a concomitant loss of strength at the extreme of external rotation of the humerus and the initiation of internal rotation of the humerus.

Osteochondritis dissecans of the midfoot.

Osteochondritis dissecans of the midfoot is described with discussion focusing on its etiology, classification, and treatment. Two cases are presented in which workup, treatment, and follow-up are described. Difficulty in making the diagnosis is caused by a lack of awareness of this entity and the specific studies needed to identify the lesion.

Knee, ankle, and foot problems in the preadolescent and adolescent athlete.

Children are the nearest thing in the human race to tadpoles in that they have tremendous powers of healing and regeneration. It should be remembered that they are subject to overstress injuries, more so than middle-aged adults. Precautions should be taken and the proper radiographs made when any swelling or tenderness occurs about a joint because of the tendency of children to develop injuries involving the growing centers of bone.

Slipped capital femoral epiphysis: an analysis of 80 patients as to pin placement and number.

A retrospective study of 80 patients with chronic slipped capital femoral epiphysis was performed, analyzing the clinical results with regard to pin placement and pin number. Follow-up averaged greater than 2 years, with 86% of the 80 patients obtaining a satisfactory clinical outcome. Serious complications occurred in 10 patients. The severity of complications increased as the number of pins used increased (p less than 0.07). A varus pin position resulting in a more inferior pin placement in the proximal femoral epiphysis was found to be associated with the fewest complications. When the pin tip avoided the superior and anterior quadrants in the proximal femoral epiphysis and was greater than 2.5 mm away from subchondral bone, the complication rate was decreased (p less than 0.003).

Predictive leg strength values in immediately prepubescent and postpubescent athletes.

Sixty healthy, athletic children were treated on a Cybex II Dynamometer to obtain values for the relative strengths of the major muscle groups of the lower extremity. Prepubescent and postpubescent boys and girls were tested. Of the anthropometric parameters measured, lean body weight correlated best with maximal torque force development. In prepubescent children, the mean maximal quadriceps torque force, measured in foot-pounds at 60 deg/sec, is equal to 70% of the lean body weight. In postpubescent subjects, the mean peak quadriceps torque equalled 80% of the lean body weight in girls and 90% of the lean body weight in boys. Correlations can be established between the maximal torque force generated by the quadriceps and the strength of the hamstrings, ankle dorsiflexors, and plantar flexors. The values obtained are useful in planning training and rehabilitation programs and in determining when an injured young athlete can safely return to his or her sport.

Lipid composition of the tissues of human knee joints. II. Synovial fluid in trauma.

Synovial fluid was aspirated from the knees of 125 patients and lipid profiles were determined. The patients had knee injuries with or without fracture of bone; these lipid profiles were compared with "controls" (synovial fluid obtained at surgery from patients that did not have a knee injury). Floating lipid droplets were observed in some of the synovial fluid from patients with fractures. These lipid droplets could be separated as a well-defined supernatant layer after a few minutes of centrifugation (100 X g). This layer was found to consist mostly of triglycerides. The synovial fluid from patients with fracture and those with only soft-tissue trauma showed increases in total lipids and triglyceride content but had lower phospholipids when compared with nontraumatized knees. Phosphatidylcholine, phosphatidylethanolamine, phosphatidylinositol, sphingomyelin, cholesterol, monoglycerides, diglycerides, triglycerides, and free fatty acids were present in all synovial fluids assayed. The large amount of triglycerides in the synovial fluid in many cases may be a good indicator of marrow leakage. Because the soft tissue surrounding the knee is also rich in triglycerides, a low phospholipid level in some cases may be an even better indicator of marrow leakage.

The cervical spine in juvenile rheumatoid arthritis.

Clinical and roentgenographic follow-up examinations of patients with juvenile rheumatoid arthritis (JRA) suggest that neurologic complications are less likely to develop in these patients than in patients with adult rheumatoid arthritis (RA). A review of the charts of 92 patients treated for JRA during the period from 1970 to 1976 revealed that 29 (31%) had clinical evidence of cervical spine involvement. Follow-up examinations in 15 of these 29 patients revealed that all had limited cervical spine motion, 14 had neck pain and stiffness, and two had torticollis. Roentgenographic evidence of atlantoaxial subluxation was present in five patients and ankylosis of the facet joints in four. Two patients with atlantoaxial subluxation had hypereflexia and clonus, but both long tract signs and subluxation spontaneously resolved in one of these patients. None of these patients had basilar invagination or subaxial instability, which can occur in adult RA.

Reflex sympathetic dystrophy in children.

Six patients with reflex sympathetic dystrophy were investigated during the period between 1973 and 1978. Children do not develop the severe, disabling pain nor the patchy osteoporosis (Sudeck's atrophy) which are considered essential features of reflex sympathetic dystrophy in adults. In contrast to the adult variety, reflex sympathetic dystrophy in children is a self-limiting condition which usually responds well to mild analgesics and physical therapy. Frequently it may be necessary to administer the physical therapy in an intensive, inpatient program, both to break the pain-disability cycle and to remove the patient from a stressful family environment that may have initiated or prolonged the syndrome. The use of steroids (dexamethasone) had no appreciable effect on the clinical course in these children.