J. Knörr

Arthroscopic treatment of discoid meniscus in children: Clinical and MRI results

INTRODUCTION Treatment of symptomatic discoid meniscus in children is saucerization performed under arthroscopy. The strategy to adopt for associated meniscus lesions is discussed, from partial meniscectomy to meniscal repair. The latter was applied in the series studied herein. The objective was to assess this surgical strategy. PATIENTS This was a retrospective study of 20 discoid menisci (18 patients) operated between 2004 and 2007. METHOD The patients first underwent arthroscopic saucerization and then, a procedure that depended on the residual meniscus: no additional procedure if there was no lesion, suturing or reinsertion in cases with a repairable lesion, and partial meniscectomy in cases of a non repairable lesion. All patients were assessed clinically and with postoperative MRI. RESULTS The mean follow-up was 37 months. Five discoid menisci presented no lesion and were treated with isolated saucerization. Fifteen discoid menisci presented a lesion. In four cases, saucerization removed this lesion. In eight cases, we performed meniscal repair after saucerization. In three cases, partial meniscectomy was necessary. The Lysholm score ranged from 67 to 88. Sixteen patients were satisfied or very satisfied in 16 cases. The mean Tegner score was 5.9. Postoperative MRI showed no signs of chondral degeneration. The mean measurements of the residual meniscus corresponded to the guidelines. Patients having undergone saucerization associated with meniscal repair had better results than those who had partial meniscectomy or meniscus repair alone (P=0.007, Fisher test). DISCUSSION No other study having evaluated discoid meniscus surgery with postoperative MRI has been reported and few studies have been published on saucerization associated with repair. This approach spares the meniscus, as confirmed by MRI, with the size of the residual meniscus within the guidelines. We obtained good clinical and anatomic results, with good healing of the meniscus and satisfactory measurements.

All inside transtibial arthroscopic posterior cruciate ligament reconstruction in skeletally immature: Surgical technique and a case report

UNLABELLED Posterior cruciate ligament (PCL) tears are rare in children and may cause posterior instability of the knee. We present an original reconstruction technique. An 11-year-old boy sustained a PCL rupture. Despite initial immobilization followed by physiotherapy, he could not resume his previous sporting activities at the pre-injury level and complained of anterior knee pain. We performed an arthroscopic PCL reconstruction using a single bundle four-strand hamstring autograft. The femoral tunnel was drilled through the epiphysis and the tibial tunnel went through the physis under both arthroscopic and fluoroscopic control. The graft was secured using absorbable interference screws. At 2 years follow-up, the patient was asymptomatic and resumed sports at the same level as before the injury. Clinical examination was normal. There was no sign of growth disturbance. PCL injury is extremely rare in children. This original technique seemed appropriate in a symptomatic patient. LEVEL OF EVIDENCE IV.

Isolated meniscal injuries in paediatric patients: Outcomes after arthroscopic repair

BACKGROUND The management of isolated meniscal tears in paediatric patients is poorly standardised, and few published data are available. Nevertheless, there is widespread agreement that meniscectomy, even when partial, produces poor outcomes including the premature development of osteoarthritis. HYPOTHESIS Arthroscopic repair of isolated meniscal tears in paediatric patients yields good outcomes and should be attempted routinely. MATERIALS AND METHODS We retrospectively assessed 19 arthroscopic repair procedures performed between 2006 and 2010 by a single surgeon in 17 patients with a mean age of 14 years. In every case, the knee was stable and the meniscus normal before the meniscal tear, which was the only injury. Mean follow-up was 22 months. In all 19 cases, the evaluation included a physical examination, pre-operative magnetic resonance imaging (MRI), and determination of the Tegner and Lysholm scores. Post-operative MRI was performed in 10 cases. RESULTS The outcome was good in 12/17 (70%) patients with significant improvements in the mean Tegner score, from 3.9 to 7.1, and mean Lysholm score, from 55.9 to 85.4, between the pre-operative and post-operative assessments. The clinical outcomes were not significantly associated with time to arthroscopic repair, gender, lesion site, or lesion type. Neither was any correlation demonstrated between clinical outcomes and meniscal healing as assessed by MRI. DISCUSSION The known poor outcomes after meniscectomy in paediatric patients, the results of our study, and previously published data support routine arthroscopic repair of isolated meniscal tears in this age group, regardless of the site and type of injury. In addition, in asymptomatic patients, clinical follow-up is sufficient and post-operative MRI unnecessary. LEVEL OF EVIDENCE Level IV. Retrospective study.

Comportamiento de la primera cuña en la corrección quirúrgica del metatarso adducto

Objetivo El metatarso adducto (MTA) es una deformacion en adduccion del antepie. Nuestro objetivo es apoyar la hipotesis por la cual la principal anomalia se encuentra en el lado cuneiforme de la articulacion cuneo-metatarsiana, y que el crecimiento de la primera cuna es fundamental en la correccion tras la capsulotomia. Material y metodo Se trata de un estudio radiologico realizado con 23 ninos con MTA idiopatico o secundario a pie zambo, operados entre los anos 1982 y 2000, con liberacion de la articulacion cuneo-metatarsiana. Se realizaron radiografias de los 30 pies operados, y de 12 pies contralaterales utilizados como controles, con las siguientes mediciones: angulo cuneo-metatarsiano (FMCA), angulo de inclinacion distal de la primera cuna (DCAA), angulo entre esta superficie y la del primer metatarsiano (PENTE) y angulo proximal articular del primer metatarsiano (PMAA). Se compararon las medias de estos angulos tomadas en pre, post-operatorio inmediato y final del seguimiento, mediante los pertinentes tests estadisticos. Resultados Respecto al MTA idiopatico, el FMCA aumento de 150,4° en el preoperatorio a 170,2° al final, el DCAA paso de 62° a 81,1°, y el PMAA de 88,4° a 89,1°. Respecto al MTA secundario a pie zambo, el FMCA aumento de 155,3° a 169,7°, el DCAA paso de 61,9° a 79,7°, y el PMAA de 88,3° a 90°. En el lado sano los angulos apenas se modificaron. Conclusiones La oblicuidad de la articulacion cuneo-metatarsiana medial esta estrechamente relacionada con el metatarso adducto. La correccion post-quirurgica se hace tambien a expensas de este hueso, que tiende a rellenar el espacio creado por la capsulotomia.

Vascularized fibular grafts extended with vascularized periosteum in children

The purpose of this report is to evaluate the results of extending vascularized fibular grafts (VFG) with vascularized periosteum (VPG) in bone defect reconstruction in children.

Agénésie isolée du ligament croisé antérieur traitée par ligamentoplastie à l'âge de 5 ans

Resume L’agenesie isolee du ligament croise anterieur est une entite rare. Elle est exceptionnellement symptomatique. Nous rapportons le cas d’un garcon de 5 ans dont l’instabilite du genou a ete traitee par ligamentoplastie selon la technique de Clocheville. A 5 ans de recul, le resultat fonctionnel est satisfaisant, le patient est asymptomatique et pratique le sport. Il n’a presente aucune complication hormis une limitation de la flexion a 130. Une IRM a permis de montrer la bonne integration du greffon. L’instabilite anterieure du genou chez l’enfant entraine une limitation des activites physiques. Elle est a l’origine de lesions meniscales et d’une arthrose precoce. La technique de Clocheville est adaptee au jeune enfant qui presente une instabilite du genou, qu’elle soit d’origine traumatique ou congenitale.

Percutaneous correction of congenital overlapping fifth toe in paediatric patients

The various available surgical methods for correcting congenital overlapping fifth toe deformity consistently require a skin plasty step, which can result in complications (necrosis, tight scar, unbecoming appearance). Here, we describe a percutaneous technique involving extensor tenotomy combined with release of the dorso-medial capsule and ligaments. No skin plasty is required. Percutaneous osteotomy of the first phalanx can be performed if needed. From 2006 to 2010, we used this technique in 16 patients (27 toes) with a mean age of 12.6years (range, 6-17years). Mean follow-up at last evaluation was 2.1 years. Osteotomy of the first phalanx was performed for 13 toes. The outcome was very good for 21 toes and good for six toes. No relapses or complications were recorded. This simple and safe technique deserves consideration in children with congenital overlapping fifth toe.

Clinical measurements for inferior, posterior, and superior glenohumeral joint contracture evaluation in children with brachial plexus birth palsy: intraobserver and interobserver reliability

BACKGROUND Glenohumeral (GH) contractures appear in most patients with incomplete motor recovery as a result of progressive development of periarticular muscle contractures. The objectives of this study were to describe a method to measure the passive range of motion of the glenohumeral joint (GHJ) in patients with brachial plexus birth palsy (BPBP) and to evaluate its intraobserver and interobserver reproducibility. METHODS Three orthopedic surgeons measured the passive GHJ mobility of 25 patients older than 4 years with unilateral BPBP. Measurements were performed twice on both shoulders. They comprised the spinohumeral abduction angle (SHABD), spinohumeral adduction angle (SHADD), GH cross-body adduction (CBADD), and GH internal rotation in abduction (IRABD). Anterior GH contracture was not evaluated. RESULTS Passive shoulder measurements obtained from the uninvolved and involved shoulders were as follows: SHABD, 42° and 18°, respectively; SHADD, 14° and -1°, respectively; CBADD, 71° and 41°, respectively; and IRABD, 54° and 37°, respectively. Contracture of the lower portion of the involved GHJ was observed in 18 of 25 patients (72%); the upper portion, in 16 of 25 (64%); and the posterior portion, in 22 of 25 (88%). Interobserver variation (intraclass correlation coefficient) was 0.91 (excellent) for SHABD, 0.63 (good) for SHADD, 0.86 (excellent) for CBADD, and 0.67 (good) for IRABD. Intraobserver variation (intraclass correlation coefficient) was 0.94 (excellent) for SHABD, 0.87 (excellent) for SHADD, 0.92 (excellent) for CBADD, and 0.89 (excellent) for IRABD. CONCLUSIONS Clinical measurements of passive GHJ range-of-motion analyzed in this study showed excellent or good intraobserver and interobserver variability. Our study showed that BPBP resulted in a multidirectional GH contracture in most patients. We have described a simple and reliable way to evaluate passive GH motion, providing reliable anatomic landmarks.

On-Top-Plasty for Atypical Thumb Duplication: A Case Report With 10 Year Follow-up

Background: A very uncommon pattern of thumb duplication consists of an ulnar-side floating thumb and a radial-side distally hypoplastic thumb. Methods: We report the case of a 15-month-old child with this type of thumb duplication on his right hand treated with an on-top-plasty technique. The ulnar-side segment was pedicled and transferred to the lateral thumb, which was distally resected. Results: A well-aligned and widely mobile thumb with a wide first web and an excellent cosmetic appearance was exhibited 10 years after surgery. Conclusions: On-top-plasty technique might be amenable to reconstruct certain atypical thumb duplications.

Vascularized thumb metacarpal periosteal pedicled flap for scaphoid nonunion: An anatomical study and pediatric case report

Through an anatomical review, the primary aim of this study was to delineate the dorsal thumb metacarpal (TM) periosteal branches of the radial artery (RA). In addition, we report here the clinical utility of a vascularized TM periosteal pedicled flap (VTMPF), supplied by the first dorsal metacarpal artery (FDMA), in a complex case of scaphoid nonunion.