Influence of a posteromedial meniscocapsular injury on the knee anterior laxity. A cadaveric study.

PURPOSE: The number of anterior cruciate ligament (ACL) injuries has considerably increased in the recent years, especially in young adults and adolescents. Associated meniscal tears increase anterior and rotary laxity. Posterior peripheral meniscocapsular tear of medial meniscus is also called ramp lesion. Prevalence of 9% to 17% in adults and up to 23% in pediatric population has been reported. The aim of this study was to determine anterior laxity of cadaveric ACL-deficient knees with several size of ramp lesions. METHODS: Fresh cadaveric knees were explored. Major osteoarthritis and/or ACL and meniscal tears on arthroscopy were exclusion criteria. Mean age at death was 86 years old. Dynamic laximetry with GNRB® device was made in several conditions: Knee prior to any procedure, after arthroscopic exploration, after ACL section, and then after increasing sizes of ramp lesions up to 30 mm. Anteroposterior laxity was measured with 2 loading forces successively (134N and 200N). RESULTS: After ACL section only, tibiofemoral joint anterior laxity was significantly increased. Mean increase was 156% regardless of the loading force. No statistical laxity difference was found between knees with ACL section only and knees with ACL and meniscal section for any size of ramp lesions. Increasing size of ramp lesion was not correlated with increasing of laxity. CONCLUSION: We could not find a threshold size of ramp lesion which increases knee anterior laxity. We were not able to determine a threshold recommending a ramp lesion repair.

Prevalence and Detection of Meniscal Ramp Lesions in Pediatric Anterior Cruciate Ligament-Deficient Knees.

BACKGROUND: Anterior cruciate ligament (ACL) tears represent 13% of knee injuries in children. Medial meniscal tears are commonly associated with ACL ruptures. Ramp lesions correspond to posterior meniscocapsular tears of the medial meniscus. Depending on the study, the prevalence of ramp lesions is inconsistent. PURPOSE: To describe the prevalence of ramp lesions in children and adolescents and to investigate the sensitivity of magnetic resonance imaging (MRI) for diagnosing such lesions. STUDY DESIGN: Cohort study (Diagnosis); Level of evidence, 3. METHODS: We analyzed videos from arthroscopic ACL reconstruction (ACLR) in children. During these procedures, we systematically looked for potential ramp lesions. To do so, an arthroscope was passed through the intercondylar notch to visualize the posteromedial compartment. A needle was introduced at the site of a posteromedial portal to unfold the meniscocapsular junction to reveal any hidden meniscal tear. Surgical procedures were performed by 2 senior surgeons. Videos were blindly analyzed by a third surgeon. Preoperative MRIs were screened by 2 blinded, independent senior radiologists to look specifically for ramp lesions. RESULTS: Videos of 50 consecutive arthroscopic ACLRs concerning 32 boys and 18 girls were analyzed. Mean age at surgery was 14.2 years (range, 8.5-17.6 years). A total of 14 ramp lesions (28%) in 8 boys and 6 girls were identified. In addition, there were 22 tears of the meniscal body in 20 patients (40%). Arthroscopic and MRI findings did not correlate. Among 14 arthroscopically diagnosed ramp lesions, only 8 were detected on the MRI. Conversely, 12 patients had a ramp lesion detected on the MRI, which could not be confirmed intraoperatively. The sensitivity of MRI was 57% and the positive predictive value was 40%. CONCLUSION: A meniscal ramp lesion was present in 14 of 50 children (28%) undergoing ACLR. MRI has a low sensitivity for diagnosis of ramp lesions in children. Careful exploration of the posteromedial compartment is strongly recommended. Overlooking such lesions during ACLR may contribute to ongoing instability and higher re-rupture rates in these young patients.

Paediatric musculoskeletal infections with Panton-Valentine leucocidin.

AIMS OF THE STUDY: Paediatric musculoskeletal infections by Panton-Valentine leucocidin (PVL)-producing Staphylococcus aureus constitute a rare, but highly critical event. They are characterised by a rapid course of marked inflammation, worsening under conservative therapy and a high rate of recurrence. This study aimed to illustrate the importance of paediatric PVL-producing S. aureus musculoskeletal infections in western Switzerland. METHODS: Case records, clinical parameters and biological assessments of children with musculoskeletal infections due to PVL-producing S. aureus who attended the University Hospitals of Lausanne and Geneva from 2008 to 2016 were studied retrospectively. RESULTS: Of the nine cases (seven male), four presented with haematogenous acute osteomyelitis, two with septic arthritis, and three with skin and soft tissue infections. Laboratory analysis revealed mean values for white blood cell count of 12,700/mm3, C-reactive protein (CRP) 171mg/l, erythrocyte sedimentation rate (ESR) 62 mm/h and platelet count 241,000/mm3. Notably, fever and laboratory values were higher for osteoarticular infections. PVL was produced by methicillin-sensitive S. aureus (MSSA) in eight cases and by community-acquired methicillin-resistant S. aureus (CA-MRSA) in one case. PVL was identified in blood cultures (six cases), operative samples (seven cases) and an oral swab (one case). Treatment relied on surgical procedures, endorsed by two-agent antimicrobial therapy for up to 9 weeks. Complications included recurrent infections (five cases), pathological fracture (one case) and growth arrest (two cases), as well as an important psychological impact (one case). CONCLUSION: The results of this study highlight the low prevalence of PVL-producing S. aureus musculoskeletal infections in the paediatric population in our region. Nevertheless, given the importance of complications, the recurrence rate and the duration of treatment, clinicians caring for children need to be especially well versed with the peculiarity of this entity. Retrospective case series. LEVEL OF EVIDENCE: IV.

Arthroscopic Treatment of Pediatric Fractures.

Management of pediatric articular fractures has evolved over the years with a growing interest in arthroscopic handling. Several factors account for this recent appeal among which are progress in technology with increased availability of diagnostic methods, rise in athletic activities responsible for these fractures, and pediatric orthopaedic surgeons getting familiar with arthroscopic techniques. In our institution, 9 of 100 arthroscopic procedures are performed as a consequence of an articular fracture. In total, 80% of the fractures concern the knee (56% of tibial eminence fracture, 24% osteochondral fracture). Most of the remaining 20% are located at the ankle joint. Given the thorough articular exploration that arthroscopy provides, any associated cartilaginous or meniscal lesions is identified and addressed in the same procedure as the fracture fixation. Being a less invasive surgery with low complication rate, arthroscopic management of pediatric articular fractures provides very satisfactory results with earlier recovery. Of note, it is technically demanding and requires constant training. The operative time should be monitored and alternative options considered for each surgery. In this regard, arthroscopy has to be viewed as a means not an end.

Isolated heptadactylia: A case report of central polydactyly of the foot.

RATIONALE: Heptadactylia is a rare congenital disorder from the polydactyly family. Polydactyly is generally classified into 3 major groups: preaxial (medial ray), postaxial (lateral ray), and central polydactyly. Most common cases are related to preaxial or postaxial polydactyly. The rarity of central polydactyly can be explained in 3 ways. First, central polydactyly with duplication appearing on metatarsal is pretty uncommon. Second, the duplication appears isolated on the foot. Polydactyly is mostly associated with other physical defects or others duplications. Last, the duplication of the digital rays does not appear once but twice concerning all the digital rays and makes 7 functional toes appear. We describe this malformation with supporting iconography and radiography as well as its surgical management and functional results. PATIENT CONCERNS: We analyzed an original case of isolated heptadactylia on the foot of a 14-month-old girl. The supernumerary toes made it impossible for the child to wear standard shoes and her parents were worried about this problem. DIAGNOSES: Clinical foot examination and radiographs revealed the presence of 7 complete rays. Every toe was composed of phalanx and metatarsal ray. There was no other congenital deformity. INTERVENTIONS: Decision was made to resect the second and third rays (the two most misaligned toes in our consideration). The first stage of surgery was the ray resection and the second stage was the reconstruction of the intermetatarsal ligament to achieve a good functional and cosmetic results. OUTCOMES: After wound healing, the child was able to walk alone while wearing normal shoes. LESSONS: We demonstrated that treatment of foot polydactyly requires careful preoperative assessment, including radiographs and photography. A good clinical evaluation of the medial polydactyly improves type-specific recognition which may enhance the accuracy of surgical treatment. Polydactyly is frequently associated with other malformations. We recommend performing a general clinical examination to exclude concomitant malformations. We recommend surgical treatment around the onset of walking.

Stress radiography and posterior pathological laxity of knee: comparison between two different techniques.

Stress radiographs have been recommended in order to obtain a better objective quantification of abnormal compartment knee motion. This tool has showed to be superior in quantifying a posterior cruciate ligament (PCL) lesion compared to clinical or arthrometer evaluation. Different radiographic techniques have been described in literature to quantify posterior pathological laxity. In this study we evaluated the total amount of posterior displacement (PTD) and side to side difference (SSD), before and after surgical reconstruction of PCL or PCL and posterolateral complex (PLC), using two different stress radiography techniques (Telos stress and kneeling view). Twenty patients were included in this study. We found a statistical significant difference about both total PTD and SSD among the two techniques preoperatively and at follow-up, with greatest values occurring using the kneeling view. Although stress radiographies has been introduced to allow an objective quantification of laxity in ligamentous injured knee, we believe that further studies on a large numbers of subjects are required to define the relationship between PTD values, measured with stress knee radiography, particularly using kneeling view, and ligamentous knee injury, in order to obtain a real useful tool in the decision making process, as well as to evaluate the outcome after ligamentous surgery.