Raymond A. Klug

Arthroscopically-assisted treatment of pediatric lateral humeral condyle fractures.

Background: Pediatric lateral humeral condyle fractures are common injuries. Current treatment recommendations include nonoperative treatment for nondisplaced Milch type 1 fractures; however, truly nondisplaced fractures may be rare. Although closed reduction and percutaneous pinning under arthrographic visualization are most commonly used, anatomical reconstitution of the articular surface may require a lateral Kocher approach. This approach may compromise the vascularity of the distal fragment. To avoid this catastrophic complication while still obtaining anatomical articular surface reduction, we have investigated a new technique in which the lateral condyle fracture is reduced arthroscopically, allowing visualization of the articular surface without the soft tissue dissection required with open approaches. The fracture is then percutaneously pinned and immobilized as previously recommended. Methods: Six skeletally immature patients with lateral humeral condyle fractures underwent arthroscopic reduction and percutaneous pinning. The mean age of the patients was 48 months (range, 21-69 months). There were 2 girls and 4 boys. Surgery was performed on 4 left and 2 right elbows. The mean follow-up was 32 weeks (range, 21-44 weeks). Postoperatively, all patients were placed in a long arm cast for 4 weeks. Pins and casts were removed at 4 weeks, and motion was begun. Elbow radiographs were evaluated for fracture healing, articular congruity, malunion, growth disturbance, and presence of avascular necrosis. Range of motion, function, pain, and cosmetic deformity were recorded. Results: All patients had full active and passive range of motion. There was no difference in range of motion compared with the contralateral side (P < 0.05). All fractures healed radiographically by 4 weeks. There were no cases of nonunion or malunion. No patients developed cubitus varus. One patient developed radiolucency of the capitellum. There were no other complications. Conclusions: Arthroscopic reduction and percutaneous fixation of pediatric lateral humeral condyle fractures may offer a safe and effective alternative to open treatment with decreased soft tissue stripping and a possibly decreased risk of malunion or avascular necrosis. Level of Evidence: Level IV.

Cycle-dependent matrix remodeling gene expression response in fatigue-loaded rat patellar tendons

Expression profiling of selected matrix remodeling genes was conducted to evaluate differences in molecular response to low‐cycle (100) and high‐cycle (7,200) sub‐failure‐fatigue loading of patellar tendons. Using our previously developed in vivo patellar tendon model, tendons were loaded for 100 or 7,200 cycles and expression of selected metalloproteinases (MMPs), tissue inhibitors of metalloproteinases (TIMPs), and collagens were quantified by real‐time RT‐PCR at 1‐ and 7‐day post‐loading. Expression profiles were also obtained from lacerated tendons as an acute injury model. The high‐cycle group showed upregulation of TIMP‐1, ‐2, Col3a1, and Col5a1, and downregulation TIMP‐4 at both time points, upregulation of MMP‐2 at 7‐day post‐loading and downregulation of MMP‐13 and ‐14 at 1‐day post‐loading, suggesting overall repair/remodeling. In contrast, the low‐cycle loaded group showed upregulation of MMP‐2, ‐3, ‐13, and Col12a1 at both time points, upregulation of TIMP‐1, ‐2, ‐3, Col3a1, and integrin β1 and downregulation of integrin α11 at 1‐day post‐loading and upregulation of Col1a1 at 7‐day post‐loading, consistent with a hypertrophic (adaptive) pattern. Lacerated tendons showed a typical acute wound response with upregulation of all examined remodeling genes. Differences found in tendon response to high‐ and low‐cycle loading are suggestive of the underlying mechanisms associated with a healthy or damaging response. Published by Wiley Periodicals, Inc. J Orthop Res 28:1380–1386, 2010

Minimally Invasive Approaches for Complex Elbow Trauma

The use of arthroscopic approaches in complex elbow trauma has several advantages over more traditional open approaches. Arthroscopy results in less soft tissue dissection and may reduce postoperative pain and ease rehabilitation. Additionally, arthroscopy allows for improved visualization of intraarticular fractures and may improve anatomic reduction of the articular surface. Aside from standard diagnostic or therapeutic arthroscopy, there are several indications for arthroscopy in addressing fractures about the elbow.

Overview of Shoulder Approaches: Choosing Between Mini-incision and Arthroscopic Techniques

In recent years, there has been great interest in minimally invasive orthopedic surgery. Several branches of orthopedics have embraced the principles of minimally invasive surgery, including traumatology,1–3 spinal surgery,4 and adult reconstruction.5–7 By far the greatest influence has been felt in the field of sports medicine with the introduction, routine, and later obligate use of the arthroscope. Indeed, the days of the open menisectomy or extraarticular anterior cruciate ligament (ACL) reconstruction are almost beyond us, as in these and many other cases, arthroscopic and arthroscopically assisted techniques have become the standard of care. More recently, the field of shoulder and elbow surgery has begun a similar transition; however, a single, distinct difference exists. Previously in sports medicine, the arthroscope was a new tool and standard open procedures were subsequently approached arthroscopically; however, we are currently witnessing a surge of interest in minimally invasive approaches to techniques that are not amenable to arthroscopic treatment, such as arthroplasty5–7 or plate osteosynthesis for fractures.1–3 This creates an interesting dilemma: when to choose arthroscopy versus minimally invasive open surgery or even more traditional open approaches.