Failure of tension band plating: a case series.

Growth modulation with tension band plates (TBP) has been shown to be a very useful method for the treatment of angular deformities in growing children. Recently, we have observed cases of failure where the epiphyseal screw was drawn through the physis into the metaphysis. This study describes a series of children who developed this complication. Patients who developed TBP failure after operative treatment of lower limb angular deformities were identified from the databases at four institutions over a 5-year period. The medical records were reviewed to record demographics, primary diagnoses, details of the operative procedure, development of physeal arrest, and recurrence of the original deformity. Six patients (five girls) with nine implant failures were identified. The mean age of the children at the time of implant insertion was 7.2 years (range, 4-10 years). The primary diagnoses included hypophosphatemic rickets (n=7), congenital pseudoarthrosis of the tibia associated with neurofibromatosis 1 (n=1), and post-traumatic malunion after distal tibial fracture (n=1). Of the nine TBP that presented with the complication, four were inserted into the medial distal femur (one bilateral case), two into the medial proximal tibia (one bilateral case), two into the lateral distal tibia, and one into the medial distal tibia. None of these patients developed physeal growth arrest at the last follow-up as assessed on the latest radiographs. The use of TBP for guided growth in patients younger than 10 years old with rickets, neurofibromatosis, or other conditions that produce osteopenia leads to an increased risk for implant failure. In these cases, it is important to confirm that the epiphyseal screw has good purchase. Patients with these features should be monitored closely for early detection of this complication.

Arthroscopic Retrograde Drilling in Juvenile Osteochondritis Dissecans of the Talus.

BACKGROUND: Juvenile osteochondritis dissecans of the talus is rare, and the literature provides little data to guide treatment. The purpose of the present study was to evaluate our clinical and radiographic results with arthroscopic retrograde drilling in patients who were refractory to conservative care. METHODS: We retrospectively evaluated all patients with juvenile osteochondritis dissecans of the talus who underwent surgery for the treatment of stable lesions that failed conservative treatment. Medical records were reviewed for symptoms and demographic information. Preoperative and latest postoperative radiographs were used to determine degree of healing. AOFAS Ankle/Hindfoot scale and visual analog scale for pain were used to evaluate clinical outcomes. RESULTS: We identified 6 patients (6 ankles). The mean age was 13 years, and the mean duration of follow-up was 37 months (range, 16 to 69 mo). All of them had progressed toward healing and were asymptomatic, but only 3 out of 6 had a complete radiographic healing at last follow-up. The average AOFAS Ankle/Hindfoot score improved from 69 points (55 to 75, IQR=10) preoperatively to 98 points (90 to 100, IQR=7) (P<0.0027). Visual analog scale improved from 6.2 (4 to 8, IQR=3) to 0.3 (0 to 2, IQR=1) (P<0.002). All patients expressed satisfaction with operative results. CONCLUSIONS: Arthroscopic retrograde drilling seems to be effective for symptoms relief, although 50% of the cases have had persistent lesions on radiographs. A longer follow-up is necessary to assess joint function in those cases with partial radiographic healing. LEVEL OF EVIDENCE: Level IV-therapeutic.

Guided growth with the tension band plate construct: a prospective comparison of 2 methods of implant placement.

INTRODUCTION: Since its introduction in 2007, the use of 8-plates has gained great popularity for the correction of diverse deformities in skeletally immature patients. In this study, we evaluate 2 different techniques of implant placement. METHODS: A consecutive series of patients with indication of guided growth around the knee (femur or tibia) were included in the study. Patients were randomly divided in 2 groups, with 8-plate inserted using technique as described by Stevens (group A) versus technique modified from Paley (group B). We analyzed operative time, radiation exposure, incision size, and intraoperative complications. Comparisons between groups were performed with a Mann-Whitney test. A 2-tailed P-value <0.05 was considered significant. RESULTS: We evaluated a total of 31 procedures in 18 patients (16 in group A and 15 in group B). Age and sex was similar in both groups (P=0.470 and 0.720). Operative time and radiation exposure was significantly lower in group B: 20 minutes (range, 11.37 to 29.30 min) versus 13.09 minutes (range, 9.31 to 25 min) (P 0.009), and 0.30 µGy (range, 0.10 to 1.30 µGy) versus 0.10 µGy (range, 0.00 to 0.70 µGy) (P=0.013), respectively. The incision size was also smaller in group B: 27 mm (range, 23 to 29 mm) versus 23 mm (range, 18 to 24 mm) (P=0.05). There were no intraoperative complications in any of the 2 groups. CONCLUSIONS: Modified technique for 8-plate placement seems to reduce operative time, radiation exposure, and incision size for guided growth around the knee. STUDY DESIGN: Level of evidence II-prospective randomized study.

Percutaneous plating of distal tibial fractures in children and adolescents.

UNLABELLED: Fractures of the tibia and fibula are among the most common injuries involving the lower extremities in children and adolescents. Although most can be treated nonoperatively, with satisfactory long-term results, some fractures require surgical stabilization. The increasing experience in adults with minimally invasive plate osteosynthesis for the treatment of complex fractures of the lower extremity has supported the treatment of selected distal tibia fractures in older children and adolescents. This article details the surgical technique for plating of the distal tibia using the percutaneous approach and assesses the results and complications in a pediatric series. We retrospectively reviewed 11 consecutive patients with open physes who had undergone percutaneous plating of a distal tibial fracture between January 2008 and January 2012. All patients were monitored clinically and radiographically until fracture union. Complications related to treatment, such as malunion, delayed union, nonunion, infection, and the need for subsequent surgical treatment, were recorded. Eleven patients (11 tibial fractures) were treated with minimally invasive plate osteosynthesis. The average follow-up period was 22 months (range, 12-48 months). Fractures healed with an average time to union of 9.4 weeks (range, 8-16 weeks). There were no cases of delayed union or nonunion. No clinically evident neurovascular complications were observed. One patient had a superficial infection, treated successfully by oral antibiotics. There were no cases of rotational deformity or leg-length discrepancy at the final follow-up. Because of its biologic advantages and stable fixation that allows early mobilization, percutaneous plating seems a reasonable treatment option for selected distal tibial fractures in children and adolescents. LEVEL OF EVIDENCE: Level IV therapeutic study - Case series.

Percutaneous trigger thumb release in children: neither effective nor safe.

BACKGROUND: Although percutaneous trigger thumb release has been extensively used in adults, the technique is not widespread in children. The purpose of this study was to evaluate the efficacy and safety of percutaneous trigger thumb release in the pediatric age group. METHODS: Twenty consecutive thumbs of 15 patients scheduled for surgical release of the A1 pulley were included in this cohort. Each patient received first the percutaneous release (PR) followed by an open release (OR) and served as self-controls. Thumb extension was assessed immediately before PR, after PR, and finally after OR, using a goniometer. Extent of the A1 pulley release, iatrogenic injury to the digital nerve and vessels, and flexor tendon laceration was assessed after PR. The distance between the PR and the digital nerve was measured in millimeters. Comparison between thumb extension after PR and OR was made using a paired t test. RESULTS: Preoperative range of motion averaged -45.2 ± 21.7 degrees loss of extension (range, -80 to -10 degrees), decreased to -4 ± 8 degrees loss of extension (range, -25 to 0 degrees) after PR, and to 0 degrees after OR. Clinically, release was complete in 14 cases (70%) and partial in 6 cases (30%). Once the thumb was approached, we confirmed that A1 pulley was completely cut in 4 cases (20%), to >75% in 2 cases (10%), and between 50% and 75% in the remaining 14 cases (70%). There were no neurovascular iatrogenic injuries. Mean distance between the needle and the digital nerve was 2.45 ± 0.9 mm (range, 1 to 4 mm). Lacerations to the flexor tendons were observed in 80% of the cases. CONCLUSIONS: We do not recommend PR in the pediatric thumb given the risk of neurovascular iatrogenic injury or incomplete A1 pulley release. LEVEL OF EVIDENCE: Level II therapeutic study-prospective comparative study.

[Dysplasia epiphysealis hemimelica (Trevor's disease)]. / Displasia epifisaria hemimélica (enfermedad de Trevor).

Dysplasia epiphysealis hemimelica is a rare skeletal developmental disorder characterized by asymmetric overgrowth of cartilage in the epiphyses. Due to the unusual and variable clinical picture, there is no standardized treatment and evolution is variable. We report the case of an 8 year-old boy, who was referred for the gradual appearance of a mass in the anterior region of the right knee. Plain films matched with dysplasia epiphysealis hemimelica. The histological findings confirmed the diagnosis. Treatment of dysplasia epiphysealis hemimelica is not clearly defined in the literature. However, only surgically symptomatic lesions or those that interfere with the function should be treated. Prognosis is variable and depends on the location and size of the lesion. Due to the risk of recurrence, patients with this unusual dysplasia should be monitored on a regular basis.

Displasia epifisaria hemimélica (enfermedad de Trevor) / Dysplasia epiphysealis hemimelica (Trevor’s disease)

La displasia epifisaria hemimélica es un trastorno esquelético raro caracterizado por el crecimiento asimétrico del cartílago en una o más epífisis. Debido a la infrecuente presentación y a la variabilidad del cuadro, no existe un tratamiento estandarizado y la evolución es muy diversa. Comunicamos el caso de un paciente de 8 años de edad, que consultó por la aparición progresiva de una tumoración en la región anterior de la rodilla derecha. Las imágenes fueron compatibles con displasia epifisaria hemimélica. Los hallazgos histológicos confirmaron el diagnóstico. El tratamiento de la displasia epifisaria hemimélica no está claramente definido en la bibliografía. Sin embargo, sólo deben ser tratadas quirúrgicamente las lesiones sintomáticas o que interfieran con la función. El pronóstico es variable y depende, básicamente, de su localización y tamaño. Los portadores de esta inusual displasia deben ser controlados periódicamente por el riesgo de recidiva.

Displasia epifisaria hemimélica (enfermedad de Trevor) / Dysplasia epiphysealis hemimelica (Trevors disease)

La displasia epifisaria hemimélica es un trastorno esquelético raro caracterizado por el crecimiento asimétrico del cartílago en una o más epífisis. Debido a la infrecuente presentación y a la variabilidad del cuadro, no existe un tratamiento estandarizado y la evolución es muy diversa. Comunicamos el caso de un paciente de 8 años de edad, que consultó por la aparición progresiva de una tumoración en la región anterior de la rodilla derecha. Las imágenes fueron compatibles con displasia epifisaria hemimélica. Los hallazgos histológicos confirmaron el diagnóstico. El tratamiento de la displasia epifisaria hemimélica no está claramente definido en la bibliografía. Sin embargo, sólo deben ser tratadas quirúrgicamente las lesiones sintomáticas o que interfieran con la función. El pronóstico es variable y depende, básicamente, de su localización y tamaño. Los portadores de esta inusual displasia deben ser controlados periódicamente por el riesgo de recidiva.(AU)