Darin Davidson

Semitendinosus tenodesis for repair of recurrent dislocation of the patella in children.

Recurrent dislocation of the patella is more common in girls than in boys. Although several predisposing factors may exist, patellar dislocation is most commonly associated with familial ligamentous laxity. Many surgical repairs have been described to stabilize the patella. We have found the semitendinosus transfer to the patella to result in a predictable, stable patellofemoral joint without risk of injury to the proximal tibial physis. Between January 1990 and December 1997, 29 children have been treated at the Childrens Hospital of Eastern Ontario with a semitendinosus transfer for recurrent dislocation of the patella. Seven children were excluded from the study because of insufficient follow-up; consequently this series consisted of 22 children. Four children underwent bilateral repairs, hence 26 knees that have been operated on with this procedure were included in this study. There were three boys and 19 girls, with an average age at surgery of 14 years and 4 months, ranging from 8 years and 11 months to 17 years and 10 months. The average length of follow-up was 3 years and 2 months, ranging between 2 years and 7 years and 4 months. All children had experienced greater than three episodes of recurrent dislocation of the patella. Pain consistent with patellofemoral syndrome or chondromalacia was present in 17 of 26 knees. On clinical examination, 10 knees exhibited marked ligamentous laxity. There were nine positive patellar apprehension tests, and eight patellae were hypermobile. All children were treated with a semitendinosus transfer to the patella with concomitant tightening of the medial retinaculum and a lateral retinacular release. On long-term follow-up, 23 of the 26 knees (88%) were asymptomatic, and the child had returned to regular activities. Each child completed the Lysholm and the subjective component of the Zarins-Rowe questionnaire to determine the subjective results of the repair procedure. Three children complained of patellofemoral symptoms. One child experienced recurrence of the patellar dislocation, and one child developed medical patellar subluxation.

Complications of rigid intramedullary rodding of femoral shaft fractures in children

BACKGROUND Intramedullary rodding of femoral shaft fractures has been frequently performed in adults, but until recently rarely in children. It was the purpose of this study to investigate the experience with this treatment method at a pediatric trauma center. METHODS From 1987 to 1998, 54 children were treated for traumatic femoral fractures with intramedullary rods at a major pediatric trauma center. The average age was 15 years 3 months, ranging between 11 years 4 months and 17 years 11 months. The average follow-up was 5 years 3 months, ranging from 20 months to 10 years 1 month. RESULTS All of the fractures occurred secondary to trauma and the most common anatomic fracture site was the femoral midshaft. Complications encountered included 8 instances of minor limb length discrepancy, 11 instances of discomfort because of rod prominence, 1 case of avascular necrosis of the femoral head, 2 instances of heterotopic ossification over the rod tip, 1 broken rod, and 3 cases that demonstrated decreased external rotation of the affected limb. One child developed osteomyelitis after intramedullary rodding for a fracture previously treated with external fixation. There were no cases of surgically induced nonunion or malunion and only one delayed union secondary to infection. CONCLUSION Results of this series demonstrate intramedullary rodding to be an effective treatment modality for femoral fractures in skeletally mature children. In children with open femoral physes, rigid rodding should be avoided because of the small but serious occurrence of avascular necrosis of the femoral head. Intramedullary rodding is not recommended in children initially treated with external fixation because of the increased risk of infection.

Subungual Exostosis: Diagnosis and Treatment in Children

Subungual exostosis is a benign bone tumor of the distal phalanx occurring beneath or adjacent to the nail. The exostosis occurs most commonly in the toes, most frequently involving the distal phalanx of the hallux. The majority of the lesions occur in the second or third decade of life. From 1975 to 1995, 21 children were treated for subungual exostosis at the Childrens Hospital of Eastern Ontario, 20 of whom underwent local excision. One patient required an amputation of the affected distal phalanx due to recurrence of the lesion. The subungual exostosis occurred on the hallux in 14 children, the second toe in three children, the third toe in two children, and the fourth toe in two children. No lesion was encountered in the little toe. The exostosis is very rare in patients under 7 years of age; the average age in this review being 12 years and 6 months. The lesion recurred in three children. Removal of the nail over the exostosis facilitates the mandatory entire removal of the lesion.

The spinal manifestations of Stickler's syndrome.

STUDY DESIGN A review of current knowledge, clinical publications, and recent concepts of the causes of Sticklers syndrome was correlated with a clinical review of the condition at the Childrens Hospital of Eastern Ontario, Canada. OBJECTIVES To acquaint orthopedic spine surgeons with the natural history, associated anomalies, and high incidence of spinal deformity and scoliosis in children with Sticklers syndrome. SUMMARY OF BACKGROUND DATA Sticklers syndrome is a hereditary, progressive arthro-ophthalmopathy with an autosomal dominant inheritance pattern. The estimated incidence is 1 in 10,000 people, which is slightly more common than Marfan syndrome. METHODS The experience with Sticklers syndrome was reviewed in seven children, 2-15 years of age, with particular attention to the spinal abnormalities secondary to the connective tissue dysplasia. RESULTS Six of the children had kyphosis or scoliosis, and four had wedging or flattening of the vertebrae or platyspondylia. In general, the spinal changes became more prominent in the older children with Sticklers syndrome, with the spinal vertebrae affected by the generalized epiphyseal dysplasia. The treatment of scoliosis and kyphosis is no different in children with Sticklers syndrome. The most difficult aspect is in diagnosing the condition. CONCLUSIONS The importance of recognizing the syndrome is to allow for the investigation and treatment of the many other associated connective tissue disorders associated with Sticklers syndrome, such as the high incidence of retinal detachment, mitral valve prolapse, and mandibular hypoplasia that may result in problems with anesthesia should the spine require surgical stabilization.

Atrial and venous thrombosis secondary to Septic arthritis of the sacroiliac joint in a child with hereditary protein C deficiency

Septic arthritis and osteomyelitis in children is seldom accompanied by calf vein thrombosis and rarely by atrial thrombosis. We report the case of an 11-year, 5-month-old boy with septic arthritis and osteomyelitis of the sacroiliac region who developed deep venous thrombosis, in addition to life-threatening right atrial thrombosis. After an intensive hematologic investigation, a hereditary protein C deficiency was revealed. The association of venous thrombosis with septic arthritis or osteomyelitis should raise the possibility of the presence of protein C deficiency.

Symphalangism in children. Case report and review of the literature.

Symphalangism is an uncommon syndrome characterized by fusion of the interphalangeal joints of the hands and feet. The fusion can involve the proximal or the distal joints; however, involvement of the proximal interphalangeal joints is more common. Symphalangism often is associated with several other skeletal and nonskeletal abnormalities. Analysis of the pedigrees of affected families reveals this trait to be autosomal dominant. The authors present the case of a 9-year-old boy with bilateral symphalangism of the proximal interphalangeal joints in the fingers and toes. His father is affected similarly. A comparison of these cases with those published in the literature indicates that although the radiologic appearance of symphalangism appears disabling, the fused phalanges seldom cause disability or loss of function of the hand. Surgical intervention is not required in most patients. The father and son reported also had capitellar hypoplasia and subluxation of the radial head associated with limitation of elbow flexion and extension.

The SAPHO syndrome in children: a rare cause of hyperostosis and osteitis.

The SAPHO syndrome is a rare constellation of signs and symptoms characterized by synovitis, acne, pustulosis, hyperostosis, and osteitis. The most common musculoskeletal complaints are hyperostosis, causing pain, tenderness, and swelling of the anterior chest wall, although any part of the axial and appendicular skeleton may be affected. There is a great degree of variability in the dermatologic involvement of this syndrome. A combination of clinical, radiographic, and pathological investigation is required to establish the correct diagnosis. No single treatment has been found to be effective, although nonsteroidal antiinflammatory drugs have been the most frequently used. Because there is no mention of SAPHO syndrome in the English orthopaedic literature, and pediatric orthopaedic surgeons may be the first caregivers to treat these children, we thought it appropriate to share our experience with a 5-year-old boy with SAPHO syndrome recently under our care.

The adolescent pilon fracture: management and outcome.

Pilon fractures in the adolescent are complicated by the presence of the adjacent physis. These fractures usually result from high-energy trauma, frequently associated with soft-tissue trauma, further potentiating treatment difficulties. Although rare, such fractures are associated with a high complication rate, including physeal arrest. It was the objective of this review to increase awareness of this fracture pattern in the adolescent, to determine the types of complications in this difficult group, and to develop a treatment plan to improve the outcome of treatment. Seven children, with a total of eight pilon fractures were treated at a major pediatric tertiary referral center over the past 10 years. The average age of the children was 15 years 10 months (range, 13 years 6 months to 17 years 7 months). The average length of follow-up was 16 months (range, 3 months and 3 years 10 months). There were three Reudi type II equivalent fractures and two Reudi type III equivalent injuries. Three fractures did not fit the Reudi classification system as there was an associated ankle dislocation. All fractures were treated with open reduction and internal fixation. There were two cases of posttraumatic osteoarthritis and one physeal arrest. Results were good to excellent in 63% of cases. A new classification system for pediatric pilon fractures has been proposed.

Rekonstruktion des vorderen Kreuzbandes bei Kindern

ZusammenfassungOperationsziel Rekonstruktion des vorderen Kreuzbandes bei Kindern ohne dauerhafte Schädigung der Wachstumsfugen an Tibia und Femur. Die distal gestielte Semitendinosussehne wird durch einen Bohrkanal in der medialen tibialen Epiphyse eingezogen, dann durch das Gelenk hinter den lateralen Femurkondylus geführt und an seiner Außenseite mit einer Krampe fixiert. Indikationen Symptomatische oder chronische Knieinstabilität als Folge einer vorderen Kreuzbandruptur.Eingeschränkte Kniegelenkfunktion.Erfolglose konservative Therapie. Kontraindikationen Fehlende Motivation zur Rehabilitation.Jugendliche mit abgeschlossenem Knochenwachstum. Operationstechnik Nach Absetzten der Sehne des Musculus semitendinosus an seinem muskulotendinösen Übergang etwa in der Mitte des dorsalen Oberschenkels wird diese mit Hilfe einer zweiten anteromedialen Inzision zunächst vor den Pes anserinus mobilisiert. Anschließend wird die Sehne unter dem Pes anserinus hindurch an die anteromediale Flä,che der proximalen Tibia gezogen. Von hier wird ein Bohrkanal durch die tibiale Epiphyse zum Ansatz des vorderen Kreuzbandes geschaffen. Die Sehne wird durch das Gelenk in “Over-the-top”-Technik hinter den lateralen Femurkondylus gebracht und dort an seiner Außenseite mit einer Krampe fixiert. Ergebnisse Zwischen 1990 und 1998 wurden drei Kinder (zwei Mädchen, ein Junge) operiert. Die Nachbeobachtungszeit betrug durchschnittlich 19 (14 bis 42) Monate. Während vor der Operation alle Kinder einen positiven Lachman-Test aufwiesen, war er postoperativ bei zwei Kindern negativ und bei einem Kind erstgradig positiv. Alle Kinder nahmen ihre ursprünglichen sportlichen Aktivitäten wieder auf und beklagten keine Instabilität oder Schmerzen. Bewegungsumfang und Kraftentwicklung der operierten Kniegelenke waren seitengleich.SummaryObjectives Reconstruction of the anterior cruciate ligament in children without creating permanent damage to the tibial or femoral physes. The semitendinosus tendon, left attached distally, is passed through a tunnel in the tibial epiphysis, led through the joint, passed behind the lateral femoral condyle and fixed to the outer aspect of the femur with a staple. Indications Symptomatic or recurrent knee instability.Impaired function of the knee.Failure of conservative treatment.Skeletally immature child with bone age less than 12 years. Contraindications Lack of motivation for rehabilitation.Skeletally mature child. Surgical Technique After division of the semitendinosus tendon at ist musculotendinous junction, the tendon is pulled into a second incision over the pes anserinus. It is then passed under the pes anserinus to the anteromedial flare of the tibia where a tunnel is drilled through the tibial epiphysis into the joint, the tendon is passed through this tunnel, led around the posterior aspect of the lateral femoral condyle and fixed with a staple over the outer aspect of the lateral femoral condyle. Results Between 1990 and 1998, 3 children (2 girls, 1 boy, average age: 15 years, 4 months) underwent this reconstruction with the semitendinosus transfer. The follow-up period ranged from 14 to 42 months with an average 19 months. Whereas all children had a positive Lachman sign preoperatively, 2 had a negative Lachman sign and 1 a Grade-I Lachman at follow-up. All children returned to their former sport activities with no complaints of instability or pain. The range of motion and the strength of the operated knee were full.

Die Tenodese des Musculus semitendinosus bei habitueller Patellaluxation des Jugendlichen

OBJECTIVES Correction of recurrent dislocation of the patella in children using a semitendinosus tenodesis and a double breasting of the medial retinaculum. INDICATIONS Recurrent lateral patellar sub- or dislocation in skeletally immature patient. Patella alta with recurrent subluxation of the patella. Patella dislocation in the presence of generalized ligmentous laxity. CONTRAINDICATIONS Degenerative changes of the patellofemoral joint. Congenital dislocation of the patella. SURGICAL TECHNIQUE First incision at the posterior aspect of the thigh: division of the semitendinosus at its musculotendinous junction. Its muscle belly is sutured to the semimembranosus. Second incision over the pes anserinus: the tendon is delivered through this wound. Third incision over the inferior pole of the patella: division of the lateral patellar retinaculum. Passing of the semitendinosus tendon through a drill hole in the patella from mediodistal to proximolateral and fixation at the proximal pole of the patella. Double breasting of the medial patellar retinaculum. RESULTS Between 1990 and 1997, 29 children (5 boys, 24 girls) were operated for a recurrent patellar dislocation. Average age at surgery: 14 years and 3 months (7 years and 8 months to 17 years and 10 months). Preoperatively, pain was present in 19 out of 34 knees, ligamentous laxity in 13, a positive apprehension sign in 12, and a patellar hypermobility in 11. Average length of follow-up: 3 years and 2 months (1 year to 7 years and 2 months). Twenty-seven out of 34 knees were asymptomatic and the children returned to normal activities. Patellofemoral pain persisted in 7 children. A medial patellar subluxation occurred in 1 child. A medial release led to a good result.ZusammenfassungOperationszielZügelungsoperation der Patella zur Behandlung der habituellen Patellaluxation bei Kindern mittels Tenodese der Semitendinosussehne und Raffung des medialen Retinakulums.IndikationenHabituelle Subluxation oder Luxation der Patella nach lateral bei noch offenen Wachstumsfugen. Patella alta mit habitueller Subluxation.Allgemeine Laxizität des Kapsel-Band-Apparates mit rezidivierender Patellaluxation.KontraindikationenDegenerative Veränderungen des femoropatellaren Gelenkes.Kongenitale PatellaluxationOperationstechnikErster Hautschnitt an der Oberschenkelrückseite, Ablösung der Sehne des Musculus semitendinosus am Übergang zum Muskelparenchym. Der verbleibende Muskelbauch wird mit dem Musculus semimembranosus vernäht. Zweiter Hautschnitt über dem Pes anserinus und Präparation der Semitendinosussehne. Dritter Hautschnitt über der Spitze, der Patella, Spaltung des lateralen Retinakulums. Durchzug der Semitendinosussehne durch ein schräges Bohrloch in der Patella von medial-distal nach proximal-lateral verlaufend. Türflügelartige Raffung des medialen Retinakulums.ErgebnisseZwischen 1990 und 1997 wurde bei 29 Kindern (fünf Buben, 24 Mädchen) eine Semitendinosustenodese bei habitueller Patellaluxation durchgeführt. Das durchschnittliche Alter zum Zeitpunkt der Operation betrug 14 Jahre drei Monate (minimal sieben Jahre acht Monate, maximal 17 Jahre zehn Monate). Präoperativ waren 19 von 34 Kniegelenken schmerzhaft, 13mal bestand eine allgemeine Bandschwäche, zwölfmal bestand ein Anpreßschmerz der Patella, und elfmal war die Patella hypermobil. Der Nachuntersuchungszeitraum betrug durchschnittlich drei Jahre zwei Monate (ein Jahr bis sieben Jahre zwei Monate). 27 von 34 Kniegelenken waren beschwerdefrei und die Kinder in ihrer Aktivität nicht eingeschränkt. Sieben Kinder klagten über retropatellare Beschwerden, in einem Fall war eine erneute Luxation zu verzeichnen. Bei einem Patienten war zur Behandlung einer medialen Subluxation der Patella die Verlängerung der Semitendinosussehne erforderlich.SummaryObjectivesCorrection of recurrent dislocation of the patella in children using a semitendinosus tenodesis and a double breasting of the medial retinaculum.IndicationsRecurrent lateral patellar sub- or dislocation in skeletally immature patient.Patella alta with recurrent subluxation of the patella.Patella dislocation in the presence of generalized ligmentous laxity.ContraindicationsDegenerative changes of the patellofemoral joint.Congenital dislocation of the patella.Surgical TechniqueFirst incision at the posterior aspect of the thigh: division of the semitendinosus at its musculotendinous junction. Its muscle belly is sutured to the semimembranosus. Second incision over the pes anserinus: the tendon is delivered through this wound. Third incision over the inferior pole of the patella: division of the lateral patellar retinaculum. Passing of the semitendinosus tendon through a drill hole in the patella from mediodistal to proximolateral and fixation at the proximal pole of the patella. Double breasting of the medial patellar retinaculum.ResultsBetween 1990 and 1997, 29 children (5 boys, 24 girls) were operated for a recurrent patellar dislocation. Average age at surgery: 14 years and 3 months (7 years and 8 months to 17 years and 10 months). Preoperatively, pain was present in 19 out of 34 knees, ligamentous laxity in 13, a positive apprehension sign in 12, and a patellar hypermobility in 11. Average length of follow-up: 3 years and 2 months (1 year to 7 years and 2 months). Twenty-seven out of 34 knees were asymptomatic and the children returned to normal activities. Patellofemoral pain persisted in 7 children. A medial patellar subluxation occurred in 1 child. A medial release led to a good result.