Carl L. Stanitski

Acute tibial tubercle avulsion fractures

Acute tibial tubercle avulsion fractures are uncommon, and these injuries typically occur in mature-appearing adolescent boys involved in jumping sports, particularly basketball. The developmental anatomy of the tibial tuberosity and the changes surrounding normal physiologic epiphysiodesis render this structure susceptible to acute avulsion fractures. Possible associated injuries include patellar and quadriceps avulsions, collateral and cruciate ligament tears, and meniscal damage. The treatment of this injury is based on the amount of displacement and associated injuries. Nondisplaced fractures are treated nonoperatively with cast immobilization. Displaced fractures require open reduction and internal fixation. Even in Type III injuries, the outcome is usually excellent.

Osteochondritis Dissecans: Wilson’s Sign Revisited

Background In 1967, Wilson described a clinical sign that he thought was diagnostic of medial femoral osteochondritis dissecans. He postulated that impingement of the tibial eminence on the osteochondritic lesion caused pain and a resultant compensatory lateral rotation during gait. He described reproducing the pain by internally rotating the patients tibia during knee extension between 90° and 30° of flexion and then relieving that pain by externally rotating the tibia. He correlated healing of the lesion with conversion of the sign from positive to negative. Purpose To assess the validity of Wilsons assertions. Study Design Retrospective clinical and radiographic case analysis. Methods Case records from 17 juvenile patients (ages 9 to 12) and 15 adolescent patients (ages 13 to 17) with medial femoral osteochondritis dissecans were reviewed for the presence or absence of Wilsons sign at initial and subsequent visits. Results: Of the 32 patients, 24 (75%) with radiographically evident osteochondritis dissecans at the initial visit had negative signs. The remaining eight patients with positive signs had conversion of the sign to negative with lesion resolution. Conclusions In this series, Wilsons sign was of minimal clinical diagnostic value. When positive, the sign is useful as a clinical monitor during treatment.

Slipped capital femoral epiphysis in skeletally immature patients

Fixation by a single screw is considered the current treatment of choice for a slipped capital femoral epiphysis. This approach promotes premature physeal closure. The use of a modified, standard, single, cannulated screw designed to maintain epiphyseal fixation without causing premature closure of the physis was reviewed in ten patients. The nine boys and one girl aged between 10.6 and 12.6 years with unilateral slipped capital femoral epiphysis (SCFE), were markedly skeletally immature (Tanner stage I, bone age 10 to 12.6 years). Clinical and radiological review at a mean follow-up of 44.3 months (36 to 76) showed no difference in the time to physeal closure between the involved and uninvolved side. Measurement of epiphyseal and physeal development showed continued growth and remodelling in all patients. Use of this device provided epiphyseal stability and maintained the capacity for physeal recovery and growth following treatment for both unstable and stable slipped capital femoral epiphysis.

Juvenile Osteochondritis Dissecans of the Lateral Femoral Condyle After Lateral Discoid Meniscal Surgery

Juvenile osteochondritis dissecans (JOCD) is a potentially reversible idiopathic lesion of subchondral epiphyseal bone that may involve the articular mantle. Since its description a century ago, JOCD’s etiology remains enigmatic. Etiologic theories of traumatic, ischemic, accessory ossification center persistence and various genetic factors have been proposed. The initial suggestion (later retracted) by Koenig that the lesion was a sequela of inflammatory dissection has been shown to be false because no inflammatory component of the condition has been documented. Repetitive microtrauma has been suggested as the inciting factor that produces delamination of an avascular subchondral centrum with necrosis, architectural structural compromise, surface modulus mismatch, continued articular surface growth, and possible articular loss of continuity with subchondral and articular fragmentation and loose body formation due to lack of fragment stability, revascularization, and union. Discoid menisci are abnormal in macroscopic and microscopic architecture. Their ability to provide normal articular surface and subchondral region load sharing and stress shielding has not been documented. Alterations of joint mechanics produced by a tear of the discoid meniscus with fragment instability and compromised joint function may produce increases in peak loading forces such as those documented following compromise of menisci of normal morphology. This modification may allow repetitive microtrauma to summate in forces that produce a subchondral lesion. Three studies report coexistence of discoid lateral menisci and lateral compartment JOCD. Only 1 report documents development of JOCD following surgery for a symptomatic lateral discoid meniscus. We present 2 cases of sequential development of lateral femoral JOCD 20 and 28 months following partial meniscectomy and meniscoplasty for symptomatic Watanabe type II torn lateral discoid menisci.

Slipped capital femoral epiphysis: physeal histologic features before and after fixation.

Physeal histopathologic changes following slipped capital femoral epiphysis (SCFE) are usually considered permanent. This assumption may not be correct, since radiographic signs of proximal femoral neck growth and remodeling are commonly seen after fixation. This work analyzed the physeal histologic features of chondroepiphyseal biopsies before and after SCFE surgical fixation but before complete physiologic epiphysiodesis. Eighteen patients, nine with unstable and nine with stable SCFE of varying severity, had pretreatment biopsies. Three patients had postfixation biopsies prior to total physiologic proximal femoral epiphysiodesis. Pretreatment biopsies showed varied degrees of histoarchitectural changes ranging from almost normal arrangement to markedly deranged physeal morphology. Postfixation biopsies showed improved physeal organization in a case of moderate unstable SCFE. In one severe unstable case and one severe stable case, nearly normal physeal architecture was seen. Physeal histopathologic changes appear to improve after fixation. Progressive modulation of the recovering physis after fixation helps explain the remodeling and growth changes seen radiographically after chondroepiphyseal fixation.

Intra-observer and inter-observer errors in CT measurement of torsional profiles of lower limbs: a retrospective comparative study

BackgroundThe purpose of this study was to determine errors in measurement of torsional profiles (TP) (torsional femoral angle, torsional tibial angle, and femoral ankle angle) among four orthopedic surgeons, experts, and non-experts in measurement, and the learning curve.MethodsTwenty-six lower extremities of 13 patients with spastic diplegia candidates for femoral/tibial derotational osteotomy had preoperative bilateral computer tomography (CT) scan grams to establish the TP. Each measurement was done by four orthopedic surgeons, two experienced clinicians and interpreters of CT imaging and two with limited clinical and imaging assessment experiences. Images were blinded and the surgeons made three determinations at least 5 days apart; the three angles were measured each time for each limb. Intra-observer and inter-observer variability were determined using bias, standard deviation, and interclass correlation coefficient.ResultsSignificant inter-observer variability and bias were noted between experts and non-experts (average variability: ICC experts: 0.88 ± 0.15; ICC non-experts: 0.91 ± 0.09). For non-experts, excessive bias (25° and 14°) was observed. An associated improvement in bias with additional measurement experience indicated a potential significant learning curve for interpreting these studies. Less inter-observer variability was observed between experts.ConclusionsMeasurement of TP is a reliable tool when used by experienced personnel, and their use as a preoperative tool should be reserved to ones with experience with such image assessments. Non-experts’ measurements produced a weak agreement when compared to experts’.

Pediatric and Adolescent ACL Injury and Sports Medicine: The Early Years

Since the 1970s, sports medicine has grown rapidly into a multispecialty discipline with development of societies, courses, journals, and fellowships. With a major focus on understanding knee injuries, the normal function of the ACL was first defined and an appreciation of the functional instability that results from its compromise with onset of premature degenerative joint disease. Arthroscopy created a revolution in diagnosis and management of ACL injuries.

Sports injuries in School-age Athletes

Despite the fact that a major segment of our This issue of the Orthopedic Clinics of North nation’s youth choose obesity and a sedentary lifestyle, a significant number of children and adolescents participate in a myriad of individual and team athletic endeavors, often with intense, prolonged training and competition. These athletes present a broad, changing spectrum of sizes, ages, as well as athletic interests, abilities, and potentials. School-age athlete injury rates and severity reflect the type of sport (noncontact versus collision) and the individual participant’s age. The majority of injuries these young athletes receive are minor and self-limiting, whether they are due to repetitive microtrauma or acute macrotrauma. However, some of the injuries are significant, with potential sequelae later in life if not properly diagnosed and treated. Growth must be considered orthopedic surgery’s fourth dimension, and the effects of growth and maturation should be kept in mind when managing youths’ athletic injuries. This is especially true during that physiologic ‘‘never never land’’ of adolescence. Physiologic, not chronologic, age must be reviewed because of the broad magnitude, rate, and duration of pubertal effects and their impact on strength, flexibility, coordination, and endurance.