Post Traumatic Neuroma in Continuity of the Median Nerve in a Child: A Case Report.

An 8-year-old girl suffered a wrist laceration from a sharp glass, severing the median nerve. The nerve was end-to-end repaired at the time by a pediatric orthopedic surgeon. Six months later, the girl suffered wrist pain and hyperesthesia over the previous surgical incision, significantly affecting her daily activities. Physical examination revealed a palpable mass over the median nerve with a positive Tinel sign, and the diagnosis of a painful neuroma in continuity was set. She underwent another surgery where the defective neuroma in-continuity was excised, and the median nerve was reconstructed using sural nerve cable autografts. At 18 months follow-up after the second surgery, the girl appeared with a full passive and active painless range of motion and a negative Tinel sign. This is the first case of neuroma in continuity presenting in a child in the literature, successfully managed surgically.

"Greek KOOS-Child: a valid, disease specific, diagnostically accurate and responsive PROM in children with knee-related pathology".

PURPOSE: The Knee Injury Osteoarthritis Outcome Score (KOOS)-Child questionnaire is one of the frequently child-friendly measures used in pediatric studies. The aim of this study was to transculturally adapt the Greek version of KOOS-Child and evaluate its clinimetric properties in children with knee disorders. METHODS: Children visiting the Outpatients Orthopaedic Clinic of a Greek Paediatric General Hospital were considered eligible if they were aged 8-14 years, had a knee soft tissue injury and associated physical limitations. The transcultural adaptation was based on a multistage backward translation approach. Participants completed the KOOS-Child at their first visit to the orthopedic specialist (baseline), 2 weeks and 3 months after baseline. Content validity of the KOOS-Child was evaluated using general QoL measures (KIDSCREEN and Kid-KINDL) and construct validity was explored by correlating relevant items. Responsiveness was evaluated according to the children's response on the given orthopeadic treatment. RESULTS: Sample consisted of 59 children (30 males), aged: 11 ± 1.8 years. The KOOS-Child showed high internal consistency (Cronbach's a: 0.80-0.96). Adequate convergent validity with > 75% relevant a priori hypotheses was confirmed. Construct validity was moderate to strong (Pearson's r correlations between related KOOS and Kid-KINDL subdimensions: 0.54-0.62). KOOS and KIDSCREEN subdimensions correlations were fair (Pearson's r correlations: 0.32-0.65). KOOS-Child's diagnostic accuracy was high. Factor analysis extracted height factors accounting for 76.15% of the total variance, confirmed by the scree plot. Responsiveness was moderate to high with Cohen's d from 0.6 to 1.4. CONCLUSION: The Greek version of the KOOS-Child demonstrated excellent internal consistency, good construct validity, diagnostic accuracy and interpretability as well as good responsiveness. The measure could be used across Greek children with orthopaedic knee problems. Generalisability of findings is limited due to the relatively limited cohort. LEVEL OF EVIDENCE: II.

Does Cozen's phenomenon warrant surgical intervention?

PURPOSE: Proximal tibial metaphyseal fractures can be complicated by a late valgus deformity, referred to as Cozen's phenomenon. We studied children with such fractures to determine whether the child's age at the time of injury influenced the development of Cozen's as well as the occurrence of elongation. In addition, we explored whether the deformity resolved at long-term follow-up. METHODS: We conducted a retrospective study of 33 patients (six months to 14 years old). Mean follow-up was 8.8 years (3 to 25). We measured angulation of the fractured limb post-treatment, at maximum deformity and final follow-up, as well as elongation and compared them with the uninjured limb. RESULTS: Three of the fractures were treated surgically whereas the rest, nonoperatively. In all, 15 out of 33 fractures developed late valgus deformity between eight and 19 months (mean time 12.5 months). A total of 24 fractures developed elongation. We found no association of either of these with age. Angulation increased to a statistically significant level, from post-treatment to maximum deformity, and then decreased at final follow-up, leaving no statistically significant difference from the initial measurement. The difference in valgus between fractured and uninjured limb increased to a statistically significant level from post-treatment to maximum deformity and then decreased, leaving an excess from the initial measurement. CONCLUSION: In almost half the patients, late valgus deformity developed within two years post-fracture and corrected to the initial post-treatment angles. Patients should be warned of this possibility and reassured of its natural resolution. LEVEL OF EVIDENCE: IV.

Type IV capitellum fractures in children.

Capitellum fractures represent 1% of elbow fractures. A coronal shear fracture which involves the trochlea is classified as a type IV McKee fracture. The combination of its rarity in the paediatric population as well as its unique appearance on X-ray make diagnosis of this fracture a challenge. We present the case of a 14-year-old boy who sustained this fracture falling from his bike. It was diagnosed from the double arc sign on X-ray. In addition, a CT scan was obtained to aid preoperative planning. It was treated by open reduction and fixation with two headless compression screws. Follow-up at 6 months showed no avascular necrosis. The patient could achieve full extension, while flexion was reduced only by 5°. Final follow-up was conducted at 15 months. Anatomic reduction and stable internal fixation are essential for a good outcome in these uncommon paediatric fractures.

Complex knee injuries treated in acute phase: Long-term results using Ligament Augmentation and Reconstruction System artificial ligament.

AIM: To present the long-term results of complex knee injuries, treated early using the Ligament Augmentation and Reconstruction System (LARS) artificial ligament to reconstruct posterior cruciate ligament (PCL). METHODS: From September 1997 to June 2010, thirty-eight complex knee injuries were treated, where early arthroscopic PCL reconstructions were undergone, using the LARS (Surgical Implants and Devices, Arc-sur-Tille, France) artificial ligament. Exclusion criteria were: Late (> 4 wk) reconstruction, open technique, isolated PCL reconstruction, knee degenerative disease, combined fracture or vascular injury and use of allograft or autograft for PCL reconstruction. Clinical and functional outcomes were assessed with IKDC Subjective Knee Form, KOS-ADLS questionnaire, Lysholm scale and SF-12 Health Survey. Posterior displacement (PD) was measured with the Telos Stress Device. RESULTS: Seven patients were excluded; two because of co-existing knee osteoarthritis and the remaining five because of failure to attend the final follow-up. The sample consisted of 31 patients with mean age at the time of reconstruction 33.2 ± 12.5 years (range 17-61). The postoperative follow-up was on average 9.27 ± 4.27 years (range 5-18). The mean average IKDC and KOS scores were 79.32 ± 17.1 and 88.1 ± 12.47% respectively. Average PD was 3.61 ± 2.15 mm compared to 0.91 ± 1.17 mm in the uninjured knees (one with grade 1 + and two with grade 2 +). Dial test was found positive in one patient, whereas the quadriceps active drawer test was positive in three patients. None was tested positive on the reverse-pivot shift test. The range of motion (ROM) was normal in thirty knees, in comparison with the contralateral one. There was no extension deficit. Osteoarthritic changes were found in three knees (9.6%). CONCLUSION: Early treatment of complex knee injuries, using LARS artificial ligament for PCL reconstruction sufficiently reduces posterior tibia displacement and provides satisfactory long-term functional outcomes.

Translation, cultural adaptation, validity and reliability of the Greek version of the modified Constant Score.

AIM: The purpose of this study was to produce a modified Greek translation of the CS and to test this version in terms of reliability and validity. MATERIALS AND METHODS: Translation of the modified Constant score testing protocol was done according to established international guidelines. Sixty-three patients with shoulder pain caused by degenerative or inflammatory disorders completed the Greek version of CS along with the Greek versions of SF-12 and Quick Dash Scores and the ASES Rating Scale and were included into the validation process. To assess test-retest reliability, 58 individuals completed the subjective part of the test again after 24-36 hours, while abstaining from all forms of treatment; internal consistency was measured using Cronbach's alpha (α); reliability was assessed with test-retest procedure and the use of Interclass Correlation Coefficient (ICC), whereas the validity of the reference questionnaire was evaluated using Pearson's correlation coefficient in relation to control questionnaires. RESULTS: There were no major problems during the forward-backward translation of the CS into Greek. The internal consistency was high (Cronbach's alpha 0.92) while the test-retest reliability for the overall questionnaire was also high (intra-class coefficient 0.95). Construct validity was confirmed with high values of Pearson's correlation between CS and Q-DASH (0.84), SF-12 (0.80) and ASES score (0.86) in respect. CONCLUSION: A translation and cultural adaptation of CS into Greek was successfully contacted. The Greek version of the modified Constant Score can be a useful modality in the evaluation of shoulder disorders among Greek patients and doctors.

Clinical Outcomes and Complications of Cortical Button Distal Biceps Repair: A Systematic Review of the Literature.

Objectives. The purpose of the present study was to investigate the clinical outcomes and complications of the cortical button distal biceps fixation method. Material and Methods. All methods followed the PRISMA guidelines. Included studies had to describe clinical outcomes and complications after acute distal biceps repair with cortical button fixation. Eligibility criteria also included English language, more than 5 cases with minimum follow-up of 6 months, and preferably usage of at least one relevant clinical score (MEPS, ASES, and/or DASH) for final outcome. A loss of at least 30° in motion-flexion, extension, pronation, or supination-and a loss of at least 30% of strength were considered an unsatisfactory result. Results. The review identified 7 articles including 105 patients (mean age 43.6 years) with 106 acute distal biceps ruptures. Mean follow-up was 26.3 months. Functional outcome of ROM regarding flexion/extension and pronation/supination was satisfactory in 94 (89.5%) and 86 (82%) patients in respect. Averaged flexion and supination strength had been reported in 6/7 studies (97 patients) and were satisfactory in 82.4% of them. The most common complication was transient nerve palsy (14.2%). The overall reoperation rate was 4.8% (5/105 cases). Conclusion. Cortical button fixation for acute distal biceps repair is a reproducible operation with good clinical results. Most of the complications can be avoided with appropriate surgical technique.

Giant Cell Tumor of the Patella Tendon Sheath Presenting as a Painful Locked Knee.

BACKGROUND: The giant cell tumor of the tendon sheath (GCT-TS) is a benign proliferative synovial tumor manifesting as an intra-articular solitary nodule. When it involves the infrapatellar fat pad it can present acutely as a painful locked knee. CASE REPORT: A 26-year-old white male presented with a 2-week history of painful locking in his right knee. Clinical examination revealed lack of extension by approximately 20°. To help establish the diagnosis, an MRI scan of the right knee was performed, showing a large (5×4×2 cm), oval, well-circumscribed mass with a low-intensity homogenous signal. The size of the mass prohibited the removal by arthroscopy and we therefore proceeded with an open arthrotomy. Histological examination showed a tendosynovial giant cell tumor of the patella tendon sheath. At the latest follow-up, 2 years postoperatively, there was no local tumor recurrence. CONCLUSIONS: These rare tumorous lesions should be included in the differential diagnosis of painful locking knee, especially in the absence of definite traumatic history.

Cross-cultural translation and validation of the Greek version of the Knee Injury and Osteoarthritis Outcome Score (KOOS) in patients with total knee replacement.

PURPOSE: Aim of this study is to assess the psychometric properties of the developed Greek version of the Knee Injury and Osteoarthritis Outcome Score (KOOS) in total knee replacement (TKR) patients. METHODS: Psychometric properties of the Greek version of KOOS were evaluated according to the Consensus-based Standards Measurements Instruments (COSMIN) checklist. Patients' pre-operative clinical status and post-operative outcomes at two occasions (at discharge and 10-12 days post-operatively) were evaluated using the KOOS, KOS-ADL and SF-12 Health Survey. RESULTS: A comprehensive Greek KOOS was piloted and well accepted by patients and therefore administered to 60 consecutive TKR patients (mean age 72.2 ± 7.2 years, 39 women). Excellent Internal consistency, good test-retest reliability of KOOS and KOOS 5 subdomains, respectively [ICC(2-1) 0.76, 95% CI = 0.235-0.902 and 0.89, 95% CI = 0.843-0.927] was yielded. A priori hypotheses for construct validity were confirmed with KOOS score and subdomains for pain, symptoms and Everyday Living function (ADL) correlating moderately with KOS-ADL. Responsiveness for KOOS subdomains of Pain and Symptoms yielded moderate effect size (ES = 0.4). CONCLUSION: The Greek KOOS was found to be a practical and comprehensible self-reported measure for TKR patients with acceptable psychometric properties. It is therefore, recommendable for usage in future clinical trials and clinical practice. Implications for Rehabilitation The Greek version of KOOS is an essential assessment scale to evaluate not only acute injuries but also chronic knee associated conditions in a holistic perspective. The Greek KOOS has been found to be a practical and comprehensible self-reported measure for TKR patients with acceptable psychometric properties, recommendable for usage in future clinical trials and clinical practice. KOOS Greek version (downloadable at the official site http://www.koos.nu/koosgreek.pdf ) was used in the validity study.

Intramedullary nailing of humeral diaphyseal fractures. Is distal locking really necessary?

PURPOSE: Distal interlocking is regarded as an inherent part of the antegrade humeral nailing technique, but it exposes both the patient and surgeon to radiation, is time consuming, and has a potential risk of damaging neurovascular structures. We have presented our technique of diaphyseal humeral nailing without any distal interlocking in this paper. MATERIALS AND METHODS: We have presented a series of 64 consecutive patients (33 male and 31 female, mean age: 41.5 years) with humeral shaft fractures treated with antegrade rigid intramedullary nailing without distal interlocking following a strict intra and postoperative protocol. According to the AO classification, there were 36 type A fractures, 22 type B, and 6 type C. Nails were inserted unreamed or by using limited proximal reaming and they were fitted as snuggly as possible into the medullary canal. After impaction of the nail into the fossa, we carefully tested rotational stability of fixation by checking any potential external rotation when the arm was slightly turned externally and left to the gravity forces. We were ready to add distal screws, but that was not required in these cases. Follow-up assessment included fracture union, complications and failures, and the final clinical outcome at minimum 2-year follow-up using the parameters of the constant score. RESULTS: All fractures, except two, united between the 4(th) and 5(th) postoperative month. In one case, nail was exchanged with plate, and, in another, a larger nail was used at a second surgery. Shoulder function according to constant score, at a minimum of 2-year follow-up, was excellent or very good in 93.7% of the patients. CONCLUSIONS: Provided that some technical issues are followed, the method reduces intraoperative time and radiation exposure and avoids potential damage to neurovascular structures.