Francesco Falciglia

Physeal-Sparing Intraarticular Anterior Cruciate Ligament Reconstruction in Preadolescents

Background: In the very young patient in need of anterior cruciate ligament reconstruction, the option of reconstruction with physeal-sparing techniques is valid because it is not known what percentage of physeal transgression causes adverse growth consequences. Purpose: To report our experience with an intraarticular technique for anterior cruciate ligament reconstruction that spares the open femoral and tibial physes yet allows soft tissue graft fixation in the femoral and tibial tunnels. Methods: Eight preadolescents underwent physeal-sparing intraarticular reconstruction for anterior cruciate ligament insufficiency with the use of semitendinosus and gracilis tendon grafts. All eight patients were in Tanner stage 1 with an average chronologic age of 11.15 years and average bone age of 10.9 years. Preoperative prediction of lower limb growth averaged 10.8 cm. Results: Five of the eight patients had reached skeletal maturity at follow-up, which was at an average of 69.2 months postoperatively. For these five, the Orthopadische Arbeitsgruppe Knie (OAK) score averaged 97 and the average KT-2000 arthrometer difference was 1.8 mm. Average growth in total height from surgery to final follow-up was 21.7 cm. No patient had a leg-length discrepancy or angular deformity, as verified by clinical or teleroentgenogram measurements. Conclusions: The technique presented in this study provided graft isometry and stability without adverse physeal consequences. Additional research is needed to determine the threshold percentage of physeal transgression for avoiding growth disturbances in humans.

Preoperative Evaluation and Anterior Cruciate Ligament Reconstruction Technique for Skeletally Immature Patients in Tanner Stages 2 and 3

Background: Transphyseal anterior cruciate ligament reconstruction in skeletally immature patients carries the risk of adverse sequelae. Purpose: 1) To provide clinical and radiographic methods to identify skeletally immature patients with significant remaining lower limb growth. 2) To provide a method for calculating the percent area lesion created by a 6-mm distal femoral physeal tunnel. 3) To present a method of partial transphyseal intraarticular anterior cruciate ligament reconstruction with bipolar graft fixation in these patients. 4) To report on clinical, functional, and radiographic results at skeletal maturity. Methods: Fourteen adolescents with symptomatic anterior cruciate ligament instability who were identified as being in Tanner stages 2 and 3 underwent partial transphyseal intraarticular anterior cruciate ligament reconstruction with the use of hamstring tendon grafts (transphyseal only in the femur and through the epiphysis in the tibia). Results: At skeletal maturity, 10 patients were asymptomatic and fully active in sports. No patient had significant leg-length inequality or angular deformity after use of a 6-mm femoral physeal tunnel, which represented 1) less than 7% of the frontal plane and 2) less than 1% of the transverse plane cross-sectional femoral physeal areas. Conclusions: The choice of the exposed technique and the method used to select patients permitted us to avoid adverse sequelae.

Treatment of thoraco-lumbar curves in adolescent females affected by idiopathic scoliosis with a progressive action short brace (PASB): assessment of results according to the SRS committee on bracing and nonoperative management standardization criteria

BackgroundThe effectiveness of conservative treatment of scoliosis is controversial. Some studies suggest that brace is effective in stopping curve progression, whilst others did not report such an effect.The purpose of the present study was to effectiveness of Progressive Action Short Brace (PASB) in the correction of thoraco-lumbar curves, in agreement with the Scoliosis Research Society (SRS) Committee on Bracing and Nonoperative Management Standardisation Criteria.MethodsFifty adolescent females (mean age 11.8 ± 0.5 years) with thoraco-lumbar curve and a pre-treatment Risser score ranging from 0 to 2 have been enrolled. The minimum duration of follow-up was 24 months (mean: 55.4 ± 44.5 months). Antero-posterior radiographs were used to estimate the curve magnitude (CM) and the torsion of the apical vertebra (TA) at 5 time points: beginning of treatment (t1), one year after the beginning of treatment (t2), intermediate time between t1 and t4 (t3), end of weaning (t4), 2-year minimum follow-up from t4 (t5). Three situations were distinguished: curve correction, curve stabilisation and curve progression.The Kruskal Wallis and Spearman Rank Correlation tests have been used as statistical tests.ResultsCM mean value was 29,30 ± 5,16 SD at t1 and 14,67 ± 7,65 SD at t5. TA was 12.70 ± 6,14 SD at t1 and 8,95 ± 5,82 at t5. The variation between measures of Cobb and Perdriolle degrees at t1,2,3,4,5 and between CM t5-t1 and TA t5-t1 were significantly different.Curve correction was accomplished in 94% of patients, whereas a curve stabilisation was obtained in 6% of patients.ConclusionThe PASB, due to its peculiar biomechanical action on vertebral modelling, is highly effective in correcting thoraco-lumbar curves.

Patellar dislocation in skeletally immature patients: semitendinosous and gracilis augmentation for combined medial patellofemoral and medial patellotibial ligament reconstruction.

PurposePatellar instability is a frequent condition in children and adolescents. The problem can be associated with malalignment resulting from different anatomical abnormalities. Several surgical procedures have been suggested for recurrent patellar dislocation consequent to failed conservative treatment.MethodsWe present an original surgical procedure for reconstructing both the medial patellofemoral (MPFL) and medial patellotibial ligaments (MPTL) by semitendinosus (ST) tendon with gracilis (G) autograft augmentation in skeletally immature patients with recurrent patellar dislocation.ResultsThis technique is effective and permits satisfactory patellar congruency documented by static and dynamic CT.ConclusionsThe operation is associated with optimal functional results and is minimally invasive, causing no growth disturbance.Level of evidence Expert opinion, Level V.

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.

Radial Neck Fractures in Children: Results When Open Reduction Is Indicated

Background: Radial neck fractures in children are rare, representing 5% of all elbow pediatric fractures. Most are minimally displaced or nondisplaced. Severely displaced or angulated radial neck fractures often have poor outcomes, even after open reduction, and case series reported in literature are limited. The aim of the study is to analyze the outcomes of patients with a completely displaced and angulated fracture who underwent open reduction when closed reduction failed. Methods: Between 2000 and 2009, 195 patients with radial neck fractures were treated in our institute. Twenty-four cases satisfied all the inclusion criteria and were evaluated clinically and radiologically at a mean follow-up of 7 years. At follow-up, the carrying angle in full elbow extension and the range of motion of the elbow and forearm were measured bilaterally. We recorded clinical results as good, fair, or poor according to the range of movement and the presence of pain. Radiographic evaluation documented the size of the radial head, the presence of avascular necrosis, premature physeal closure, and cubitus valgus. Results: Statistical analysis showed that fair and poor results are directly correlated with loss of pronation-supination (P=0.001), reduction of elbow flexion-extension (P=0.001), increase of elbow valgus angle (P=0.002), necrosis of the radial head (P=0.001), premature physeal closure (P=0.01), and associated lesions (olecranon fracture with or without dislocation of the elbow) (P=0.002). Discussion: In our cases, residual radial head deformity due to premature closure of the growth plate and avascular necrosis were correlated with a functional deficit. Associated elbow injury was coupled with a negative prognosis. In our series, about 25% of patients had fair and 20% had poor results. Outcomes were good in 55% and felt to represent a better outcome than if the fracture remained nonanatomically reduced with residual angulation and/or displacement of the radial head. This study reports the largest series of these fractures with a combination of significant angulation and displacement of the fracture requiring open reduction. We feel that open reduction is indicated when the head of the radius is completely displaced and without contact with the rim of the metaphysis.

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.

Treatment of lumbar curves in scoliotic adolescent females with progressive action short brace: a case series based on the Scoliosis Research Society Committee Criteria.

Study Design. A prospective interventional study. Objective. To determine the outcomes of adolescents affected by idiopathic lumbar scoliosis treated with a progressive action short brace (PASB). Summary of Background Data. The efficacy of conservative treatment of scoliosis is still debated. In a recent study, we showed that the PASB was effective in correcting deformities in adolescents with idiopathic thoracolumbar scoliosis. The purpose of the present study was to extend our preliminary findings by determining the results of PASB treatment in scoliotic adolescents with lumbar curves. Methods. Patients were 40 adolescent girls (age [mean ± SD] = 11.6 ± 0.7 yr]) with lumbar curves and a pretreatment Risser score between 0 and 2. All patients were prescribed with a full-time PASB. The minimum duration of follow-up was 24 months (mean ± SD = 41.6 ± 34.5 mo). Anteroposterior radiographs were used to estimate the curve magnitude (CM) and the torsion of the apical vertebra (TA) at 5 time points: beginning of treatment (t1), 1 year after the beginning of treatment (t2), intermediate time between t1 and t4 (t3), end of weaning (t4), and 2-year minimum follow-up from t4 (t5). Three outcomes were distinguished: curve correction, curve stabilization, and curve progression. Results. A significant reduction in CM was achieved from t1 (Cobb angle [mean ± SD] = 26.4° ± 2.8) to t5 (Cobb angle [mean ± SD] = 13.8° ± 7.9; P < 0.001). Likewise, the PASB reduced TA from Perdriolle rotation angles of 10.8° (SD = 3.7) at t1 to 7.9° (SD = 4.2) at t5 (P < 0.05). Curve correction was accomplished in 82.5% of patients, whereas curve stabilization was obtained in 17.5% of patients. None of the patients experienced curve progression. Conclusion. The PASB allows a complete curve correction in most cases. No patients exhibited curve progression.

Brace technology thematic series: the progressive action short brace (PASB)

BackgroundThe Progressive Action Short Brace (PASB) is a custom-made thoraco-lumbar-sacral orthosis (TLSO), devised in 1976 by Dr. Lorenzo Aulisa (Institute of Orthopedics at the Catholic University of the Sacred Heart, Rome, Italy). The PASB was designed to overcome the limits imposed by the trunk anatomy. Indeed, the particular geometry of the brace is able to generate internal forces that modify the elastic reaction of the spine. The PASB is indicated for the conservative treatment of lumbar and thoraco-lumbar scoliosis. The aim of this article is to explain the biomechanic principles of the PASB and the rationale underlying its design. Recently published studies reporting the results of PASB-based treatment of adolescent scoliotic patients are also discussed.Description and principlesOn the coronal plane, the upper margin of the PASB, at the side of the curve concavity, prevents the homolateral bending of the scoliotic curve. The opposite upper margin ends just beneath the apical vertebra. The principle underlying such configuration is that the deflection of the inferior tract of a curved elastic structure, fixed at the bottom end, causes straightening of its upper tract. Therefore, whenever the patient bends towards the convexity of the scoliotic curve, the spine is deflected. On the sagittal plane, the inferior margins of the PASB reach the pelvitrochanteric region, in order to stabilize the brace on the pelvis. The transverse section of the brace above the pelvic grip consists of asymmetrical ellipses. This allows the spine to rotate towards the concave side only, leading to the continuous generation of derotating moments. On the sagittal plane, the brace is contoured so as to reduce the lumbar lordosis. The PASB, by allowing only those movements counteracting the progression of the curve, is able to produce corrective forces that are not dissipated. Therefore, the brace is based on the principle that a constrained spine dynamics can achieve the correction of a curve by inverting the abnormal load distribution during skeletal growth.ResultsSince its introduction in 1976, several studies have been published supporting the validity of the biomechanical principles to which the brace is inspired. In this article, we present the outcome of a case series comprising 110 patients with lumbar and thoraco-lumbar curves treated with PASB brace. Antero-posterior radiographs were used to estimate the curve magnitude (CM) and the torsion of the apical vertebra (TA) at 5 time points: beginning of treatment (t1), one year after the beginning of treatment (t2), intermediate time between t1 and t4 (t3), end of weaning (t4), 2-year minimum follow-up from t4 (t5). The average CM value was 29.3°Cobb at t1 and 13.0°Cobb at t5. TA was 15.8° Perdroille at t1 and 5.0° Perdriolle at t5. These results support the efficacy of the PASB in the management of scoliotic patients with lumbar and thoraco-lumbar curves.ConclusionThe results obtained in patients treated with the PASB confirm the validity of our original biomechanical approach. The efficacy of the PASB derives not only from its unique biomechanical features but also from the simplicity of its design, construction and management.

Slipped capital femoral epiphysis: An ultrastructural study before and after osteosynthesis

Background and purpose Several different theories have been proposed to explain the pathogenesis of slipped capital femoral epiphysis (SCFE). Using transmission electron microscopy (TEM), we carried out an ultrastructural study of core biopsy specimens of the physis at various stages of the disease. Methods Core biopsies were performed in 6 patients with different forms of SCFE during the first operation, and in 3 of them when removing the osteosynthesis material before physeal closure. The specimens were prepared for TEM examination. Results In 6 specimens obtained at first surgery, a marked distortion of the physeal architecture was observed. In 2 of the 3 specimens obtained at removal of the osteosynthesis material, the physis showed a more normal organization. Interpretation The improvement of the pathological alterations observed in the 2 cases after surgical intervention leads us to consider the possibility that when the growth plate is stabilized directly by pinning or indirectly by creating more optimal loading conditions with an intertrochanteric osteotomy, the morpho-functional characteristics of the physis can be restored and its growth process may resume.