The surgical treatment of Rockwood grade III acromioclavicular dislocations.

The conservative or surgical treatment of Rockwood grade III acromioclavicular dislocations continues to be a controversial subject. Thus, the authors report their experience with 52 cases; long-term follow-up was obtained for 40 of these, paying close attention to the preoperative clinical and radiographic evaluation and to the results obtained in order to ascertain whether or not surgical repair is required. The results of surgical treatment, however satisfactory (90% excellent or very good), are nearly the same as those obtained when non surgical treatment is used as reported in the international literature. The authors conclude that the use of surgical treatment must be limited to carefully selected cases, should prolonged conservative treatment fail. Of the three surgical techniques used, temporary stabilization of the acromioclavicular joint using AO wires associated with restoration of the coracoclavicular connections has proven to be more effective than Dall-Miles metal wiring and tangential resection, with a lower incidence of complication.

Intra-articular deformities of the knee in congenital hypoplasias of the lower limb: an arthroscopic study.

A knowledge of the morphology of the cruciate ligaments in congenital hypoplasias of the lower limb, susceptible to treatment to even the length discrepancy, is of practical importance in the prevention of subdislocation and dislocation of the knee during the distraction phase of femoral and/or tibial lengthening. The authors report their experience with 20 arthroscopies diagnosed in 20 children affected with congenital hypoplasia of the lower limb (shoft congenital femur, longitudinal peroneal hemimelia) performed prior to assembling the Ilizarov external fixator for femoral and/or tibial lengthening. None of the patients had congenital dislocation of the knee or knee with recurvation. In the patients in our study, it is possible to demonstrate that the anatomical cause of instability of the knee in congenital hypoplasias of the lower limb may be constituted by aplasia of one or both cruciate ligaments.

The surgical treatment of inveterate hip dislocation in children affected with cerebral palsy: a preliminary report.

The incidence of hip dislocation in patients affected with cerebral palsy is directly correlated with the degree of neurologic deficit. Surgical treatment aimed at stabilization of the coxofemoral joint relieves pain and avoids the occurrence of changes in the static of the pelvis and vertebral column. The authors report their experience with procedures for the recovery of joint congruency (release of the adductors and psoas, surgical reduction of the dislocated epiphysis, femoral shortening associated with varus-derotation at the osteotomy level, acetabuloplasty) performed in one or more surgical stages, and operations with a purely anthalgic purpose (innominate osteotomy according to Chiari), specifying relative indications in relation to age.

Fracture of the patella in children and adolescents.

Fractures of the patella in childhood and adolescence are a rare occurrence, and they are differentiated from those occurring the adult. Between 1975 and 1995, 76 cases of fracture of the patella in patients aged under 15 years were treated at our institute. A mean clinical-radiographic follow-up of 2 years was available for all of the patients; 18 patients were followed-up after a considerable amount of time (mean 18 years). After analyzing the specific features that distinguish there fractures when they affect a subject who is still growing, the authors report the results obtained and the short and long-term complications observed.

Arthroscopic surgery of the discoid meniscus during childhood.

A total of 43 lateral discoid menisci in 38 patients submitted to arthroscopy between 1990 and 1995 is discussed. Age ranged from 2 to 14 years. Morphological changes of the lateral meniscus were classified according to Watanabe criteria. The features of preoperative symptoms were related to the type of meniscal lesion and to the age of the patient, and the results evaluated according to the Ikeuchi scale.

Retrograde intramedullary osteosynthesis in the surgical treatment of fractures of the radial capitellum during childhood.

The authors report 12 cases of fracture of the radial capitellum occurring during childhood, treated by retrograde intramedullary osteosynthesis. Preoperative assessment involved the four-stage "prognostic-therapeutic" radiographic method proposed by Métaizeau. The results were extremely encouraging, 92% excellent and good, particularly when there were no (except in one case) severe complications (necrosis of the head, pseudarthrosis, poor consolidation, synostosis) typical of these traumatic lesions. At the same time clinical data observed, in agreement with what is reported in the literature, confirmed that the principal prognostic factors are represented by the amount of traumatic lesion, and above all by epiphyseal dislocation, the quality of reduction obtained, and the age of the patient.

Mucous cysts of the external popliteal sciatic nerve during childhood: presentation of two cases and a review of the literature.

Mucous cysts of the peroneal head constitute the most frequent cause of compression of the external popliteal sciatic nerve (EPS). Depending on the site in which it occurs, we distinguish between intranervous cysts, which are very rare, and extranervous ones, which are more frequent. The two varieties, which constitute anatomical variants of the same lesion and, probably, of a metaplasia of the connective tissue, are, from an anatomical point of view, true cysts, with their own connective walls, endothelial covering, and mucoid contents. Clinically, there is pain, paresthesia, a palpable mass, and motor deficit, all occurring at an early stage of the disease, depending on its site and size. At times, when there is no palpable mass, there may be problems with differential diagnosis with regard to disc compression. Ultrasound examination, electromyography, and, above all, MRI, have all proven to be useful in the study of the features of the neoformation; nonetheless, in our experience, they were not able to reveal either intra- or extranervous localization.

Agenesia of the pectoral muscle.

Two cases of agenesia of the pectoral muscle are presented. Clinical examination is sufficient for diagnosis. Nonetheless, dosage of LDH and CPK is needed in order to exclude primary myopathy. Surgery is rarely indicated in selected cases of female sex, for cosmetic purposes.

The external fixator in the treatment of closed diaphyseal fractures of the lower limb during childhood. Indications and limits.

The authors successfully used an external fixator in 10 children affected by one of the following pathologies: fracture of the femur with poor consolidation and marked shortening of the limb; fracture in a hypoplastic segment; severe multiple trauma; delay in consolidation of pathologic bone; fracture in bone regeneration. On the basis of the results obtained, it is affirmed that the external fixator is the ideal means of osteosynthesis for use in any of the above-described situations.

Arthroscopic medial meniscectomy. Technique, results, complications and medium-term follow-up in adult patients with no ligamentous lesion.

The authors report the medium-term results of arthroscopic medial meniscectomy performed on 102 adult patients. Some notes on the surgical technique and the objective and subjective results obtained in each type of meniscal lesion are also reported.

Epiphyseodesis of the great trochanter.

The authors report 9 cases of congenital or acquired coxa vara due to abnormalities of the epiphyseal growth cartilage, treated by epiphyseodesis of the great trochanter. The operations were performed on children between the ages of 4 and 8 years. The follow-up was a minimum of 6 months and a maximum of 2 1/2 years. A constant correlation was established between a negative preoperative A.T.D. index (height between tip of trochanter and roof of acetabulum) and a Trendelenburg gait. Both these parameters were markedly improved after operation. The conditions treated comprised congenital coxa vara, osteochondrosis following reduction in C.D.H., septic arthritis and Perthes disease type 3.

Long term results of triradiate osteotomy of the pelvis. A follow-up study of 26 hips.

The authors reviewed 26 hips in 21 patients treated by triple osteotomy of the pelvis for the sequelae of congenital dysplasia or congenital dislocation of the hip. The minimum follow-up was 3 years, maximum 6 years. The clinical condition remained constant over this period. Pain, if present before operation, was either improved or disappeared. The Trendelenburg limp was either unchanged or improved. Reduction of range of hip movement was very rare. There was 0.5 cms lengthening of the leg compared with the pre-operative state. The post-operative radiographic parameters were unchanged over the follow-up period. These included the acetabular roof angle (C.E. angle), Hilgenreiner's roof angle, the neck/shaft angle, and anterior coverage of the femoral head. In about one third of the cases, however, there was deterioration in centralization.

Küntscher nailing in the treatment of femoral fractures in children. Is it completely contraindicated?

Seventeen children between the ages of 6 and 12 years with fractured femoral shafts were treated by Küntscher nailing. They were followed up clinically and radiographically to ascertain if nailing had any long term adverse effects. The following radiographic parameters were considered: --valgus, varus angle; --distance between lesser trochanter and acetabulum; --width of the neck of the femur; --distance between greater trochanter and acetabulum; --intertrochanteric distance. On analysing the results it was found that Küntscher nailing did not give rise to any adverse effects provided it is carried out after 8-9 years of age.

Lumbar spinal artery syndrome. Report of an unusual case.

The literature on the lumbar spinal artery syndrome and the anatomy of the vascular supply to the spinal cord is discussed. The authors report a case which is exceptional in that it occurred in a child aged 4 years after apparently trivial trauma.

Tenomyoplasty of the flexor muscles in the surgical treatment of congenital recurvatum, subluxation and dislocation of the knee.

The writers present eight cases of congenital recurvatum or dislocation of the knee in which tenomyoplasty of the flexor muscles of the knee was performed. The operation was the only one used in cases with flexion greater than 60 degrees, while in cases of more severe loss of flexion, it was supplementary to mobilisation of the quadriceps according to Judet's technique. The technique of tenomyoplasty is described and the results are reported. These are considered to be favourable.