Treatment of recurrent patellar instability with a modification of the Roux-Goldthwait technique.

Recurrent instability of the patella may be a significant disability in the childhood and adolescent population. Numerous surgical procedures to address this instability have been described, with variable outcome. This has led to considerable confusion in the literature as to how to treat patellofemoral problems in children. This study retrospectively reviews 30 knees in 20 patients with chronic recurrent patellar instability who were treated with a modified Roux-Goldthwait technique including the release of contracted lateral structures by a single surgeon over a 13-year period, with an average of 6.2 years follow-up. By Insall's criteria, 26 knees had an excellent result, 3 good result, and 1 fair result. Ten patients evaluated using a dynamometer showed that strength achieved in the operated leg was greater than 90% in 8 patients and greater than 80% in 2 patients. Here, we report upon a single operation to treat patellar instability performed in the pediatric population with consistently excellent results.

Arthroscopically assisted central physeal bar resection.

Thirty-seven central physeal bars were removed with an arthroscopically assisted technique. Thirty children (32 cases) have been followed to maturity or physeal closure. There were 19 boys and 11 girls, aged 4-14 years (mean, 9.5 years). Site of arrest was distal femur (15), proximal tibia (9), distal tibia (6), and distal radius (2). Mean follow-up was 6.5 years (range, 2-12 years). Adequate longitudinal growth was realized in 21 patients (70%) just after bar resection. Five patients (17%) required osteotomy, lengthening, or epiphysiodesis in addition to bar resection. In 4 patients (13%), bar resection failed. Failures occurred in those patients whose source of growth arrest was infection (3) or degree of physeal trauma approached 50% (1 case). This is the first series that studies and documents the efficacy of the arthroscope in central physeal bar resection. It provides the best visualization with minimal morbidity. The technique is described, including a discussion of technical tips and pitfalls.

Treatment of ankle instability in children and adolescents with a modified Chrisman-Snook repair: a clinical and patient-based outcome study.

Ligamentous injuries to the lateral ankle complex, although rare in the child with open physes, increase with age and are seen with considerable frequency in late childhood and adolescence. In athletic, ligamentously lax individuals, recurrent sprains may lead to ligament attenuation and instability. When instability becomes chronic and interferes with everyday activity, reconstruction is indicated. The literature on reconstruction addresses primarily the adult population, with minimal guidance in treating the child and adolescent. The authors report their experience with 48 reconstructions performed in patients aged 8 to 17 years (mean 14.5 years) over a 12-year period. Mean follow-up was 6.5 years. All patients failed to respond to conservative treatment, including casting or bracing and physical therapy. All had disabling instability. All had a positive drawer sign clinically, and all but one had significant talar tilt on preoperative stress radiographs. A modification of the Chrisman-Snook procedure was used. Forty-four ankles in 38 patients were available for clinical and radiographic re-evaluation. One patient with generalized systemic ligamentous laxity required bilateral repair for failure of previous Evans procedures 8 years earlier; the remaining patients had primary repairs and remain asymptomatic. Each has a negative drawer sign and a reduction of talar tilt from a preoperative average of 14.5 degrees to a postoperative average of 4 degrees, based on stress radiographs. An outcomes questionnaire was administered to all patients, who subjectively rated their pain and instability at extremely low levels (1/10) and their function at a high level (8/10). All patients had their expectations met regarding the results of surgery. There was no radiographic evidence of degenerative arthritis at follow-up. The authors recommend this as an excellent means of treating children with chronic ankle instability who have failed to respond to conservative treatment. The authors have modified Chrisman's procedure by using a much smaller incision and improved graft isometry.