Senthil T. Nathan

Complications of Medial Patellofemoral Ligament Reconstruction in Young Patients

Background: The medial patellofemoral ligament (MPFL) has been recognized as the primary restraint to lateral subluxation of the patella. Reconstruction of the MPFL for patellar instability has demonstrated early clinical success, but postoperative complications have rarely been reported, especially in young patients. Purpose: To assess early complications (<3 years) of MPFL reconstruction in young patients. Study Design: Case series; Level of evidence, 4. Methods: The charts and radiographs of all patients who underwent MPFL reconstruction between 2005 and 2011 were retrospectively reviewed to identify postoperative complications. A complication was considered major if the patient required hospitalization or further surgery. Each complication was analyzed to identify the technical factors related to it. Results: A total of 179 knees underwent MPFL reconstruction during the study period. There were 38 complications in 29 knees (16.2%), with 34 major and 4 minor. Major complications included recurrent lateral patellar instability (8 patients), knee motion stiffness with flexion deficits (8 patients), patellar fractures (6 patients), and patellofemoral arthrosis/pain (5 patients). Eighteen of 38 (47%) complications were secondary to technical factors and were considered preventable. Female sex and bilateral MPFL reconstructions were risk factors associated with postoperative complications. Conclusion: Complications occurred in 16.2% of MPFL reconstruction surgeries for patellar instability in young patients, with almost half resulting from technical problems. Patients should be counseled preoperatively on the risk of potential complications.

Mid- to long-term outcomes in adolescent idiopathic scoliosis after instrumented posterior spinal fusion: a meta-analysis.

Study Design. Meta-analysis on mid- to long-term outcomes in adolescent idiopathic scoliosis after instrumented posterior spinal fusion. Objective. To compare mid- to long-term outcomes and complications of the most commonly used instrumentation systems in adolescent idiopathic scoliosis. Summary of Background Data. A meta-analysis of mid- to long-term results of different methods of instrumentation, including the most currently used all-pedicle screw construct, is lacking. Methods. A structured literature review was conducted for studies concerning management of patients with adolescent idiopathic scoliosis with instrumented posterior fusion. Pooled means, standard deviations, and sample sizes were either identified or calculated on the basis of the results of each study. Results. Meta-analyses were performed on outcomes from 27 studies. Overall, 1613 patients who had been treated with Harrington rods, 361 patients who had undergone Cotrel-Dubousset instrumentation, and 298 patients who managed with all-pedicle screw constructs were reviewed. The mean follow-up was 14.9 years. Cotrel-Dubousset and pedicle screw instrumentations achieved a significantly greater degree of correction of the thoracic curve than Harrington rods (40.3° vs. 14.7°; P < 0.001 and 21.9° vs. 14.7°; P = 0.005, respectively). Cotrel-Dubousset technique achieved a significantly higher degree of correction than all-pedicle screw construct in both the thoracic (40.3° vs. 21.9°, respectively; P < 0.001) and lumbar curves (37.2° vs. 16°, respectively; P < 0.001). Similarly, Cotrel-Dubousset construct achieved a greater correction of both thoracic kyphosis (33.5° vs. 23°, respectively; P < 0.001) and lumbar lordosis (46° vs. 50.7°, respectively; P = 0.002) than pedicle screws. All-pedicle screw fixation was associated with the lower risk of pseudarthrosis, infection, neurological deficit, and reoperation. Conclusion. This study confirms the negative effect of Harrington rods on sagittal alignment. We further found that the degree of correction in the coronal and sagittal planes was higher after Cotrel-Dubousset instrumentation than all-pedicle screw fixation. All-pedicle screw constructs offered the lower risk of mid- to long-term complications and revision surgery.

All-Epiphyseal Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients: A Surgical Technique Using a Split Tibial Tunnel

Many techniques have been described for anterior cruciate ligament (ACL) reconstruction in skeletally immature patients, including extra-articular, complete or partial transphyseal, and physeal-sparing techniques. An all-epiphyseal technique places the tendon and its tunnels and fixation all within the childs epiphysis, leaving the growth plates untouched. We describe an all-epiphyseal quadruple-hamstring ACL reconstruction using a split tibial tunnel. The split tibial tunnels drop the tunnel size down to 4.5 to 5.5 mm from 7 to 8 mm because only half the total graft diameter passes through each of the split tunnels. This increases the safety margin for keeping the tunnel within the tibial epiphysis, in addition to avoiding damage into the growth plate. The bone bridge between the 2 tunnels serves as a solid low-profile fixation post. Femoral graft fixation is achieved with an interference screw, which allows precise tensioning and low-profile fixation entirely within the femoral tunnel. By placing the graft at the native ACLs anatomic attachment points without spanning or violating the growth plates at any step of the procedure, an all-epiphyseal ACL reconstruction with a split tibial tunnel theoretically minimizes the risk of growth disturbance in an ACL-deficient child.

Transient cortical blindness as a complication of posterior spinal surgery in a pediatric patient.

Postoperative vision loss after spinal surgery is a well-known but devastating complication that may result from direct ocular ischemia, embolism to the central retinal artery, ischemic optic neuropathy, or occipital cortical ischemia. The occipital cortex is situated in the posterior border zone of the middle and posterior cerebral arteries and is susceptible to ischemic damage. Transient cortical blindness as a cause of postoperative vision loss has never been reported after spine surgery in a child. We report an 11-year-old female patient with muscular dystrophy who underwent posterior spinal fusion and instrumentation under hypotensive anesthesia for scoliosis who developed transient cortical blindness.

Genu Recurvatum after Tibial Tuberosity Fracture

Fractures of the tibial tuberosity are infrequent injuries that occur during adolescence. Displaced tibial tuberosity fractures are typically treated with open reduction and internal fixation. Since these fractures occur at or near skeletal maturity, growth disturbances are not seen. This paper presents a case, the first report to our knowledge, of genu recurvatum deformity after open reduction and internal fixation of a tibial tuberosity fracture. A successful treatment plan of tibial tuberosity osteotomy with proximal tibial opening wedge osteotomy was used for the correction of genu recurvatum deformity and to maintain appropriate patellar height. At eighteen-month followup, the deformity remains corrected with satisfactory functional results. This case highlights the importance of recognition of potential complications of fracture management in adolescence.

Osteoarticular Allograft Reconstruction for Hill-Sachs Lesion in an Adolescent

Glenoid and humeral head bone loss is the most common cause of failure after surgical shoulder instability stabilization. Large Hill-Sachs lesions involving >30% of the articular surface of the humeral head typically occur after neglected or locked shoulder dislocations. Such large lesions may require osteochondral allograft reconstruction or prosthetic replacement to regain shoulder stability and function.Previous reports of osteochondral allograft reconstruction have focused on adults. This article describes a case of a 16-year-old autistic boy who sustained an anterior dislocation of the right shoulder following a seizure episode. The dislocation was diagnosed 12 days later as a progressive deformity, and his parents noticed his inability to use his upper extremity. The patient had a large (30%) humeral head Hill-Sachs lesion and persistent anterior shoulder instability after initial closed reduction. He underwent an open osteochondral allograft reconstruction for the restoration of the humeral head articular surface. The sizing of the defect, matching harvest of the allograft, and perfect fit of the allograft to the defect are critical steps to ensure congruent restoration of the humeral head. The allograft was stabilized in the defect of the humeral head using cancellous screws placed from below the articular surface. Radiographs 20 months postoperatively showed complete incorporation of the osteochondral allograft. At 30 months postoperatively, his shoulder was stable and functional.

Growth Stimulation Following an All-Epiphyseal Anterior Cruciate Ligament Reconstruction in a Child

Over the past decade, there has been a substantial increase in the number of reported intrasubstance tears of the anterior cruciate ligament (ACL) in children younger than twelve years of age or in prepubescent children1-6. Multiple studies have emphasized the need for early ACL reconstruction in skeletally immature patients to prevent the development of meniscal tears and early knee arthrosis7-10. The native ACL in children always courses from the distal femoral epiphysis to the proximal tibial epiphysis. If the usual ACL reconstruction used in adults is performed on a child or adolescent, this anatomy becomes problematic because tunnels are drilled through the growth plates into the distal part of the femur and the proximal tibial metaphyses. In children with wide-open growth plates, a solidly fixed and tensioned graft, placed as in adults, may potentially cause a “tether effect” that can retard growth at these growth plates11,12. In order to avoid tether or bone-bar formation, multiple partial or complete physeal-sparing techniques to reconstruct the ACL in this age group have been proposed1,6,13-16. Growth disturbance, especially growth arrest, has been a major concern with the surgical management of intrasubstance ACL tears in growing children and adolescents12,15,17-20. In contrast, limb overgrowth is a theoretical possibility following any long-bone surgery in a child. To our knowledge, there are no reported cases of clinically significant limb overgrowth that required surgical epiphysiodesis as a consequence of a physeal-sparing or an all-epiphyseal ACL reconstruction in a child. This case is reported to alert physicians, patients, and their parents that overgrowth requiring surgical correction can occur after ACL reconstruction in a skeletally immature child. The patient and his parents were …

Spondyloptosis of the Cervical Spine in a Patient with Neurofibromatosis Type 1: A Case Report and Review of the Literature

Kyphotic deformities of the cervical spine in patients with neurofibromatosis type 1 (NF-1) have received little attention because of their low incidence and the presence of coexisting thoracic or thoracolumbar spine deformities1-3. To the best of our knowledge, there are few cases (Table I) of severe cervical kyphosis (>90°) in a patient with NF-1 that have been reported in the literature4-7. We present the case of an adolescent who was referred to our NF-1 clinic for a progressive cervical kyphosis (130°) with no neurologic deficits. There was radiographic evidence of a C2-C3 intramedullary spinal cord tumor (IMSCT) with extensive cervical plexiform neurofibromas with intraspinal encroachment. The patient and his parents were informed that data regarding this case would be submitted for publication, and they provided consent. View this table: TABLE I Cases in the Literature of Severe Cervical Kyphosis (>90°) in Patients with Neurofibromatosis Type 1 An eleven-year-old boy with NF-1 was referred to our institution with a history of severe cervical kyphosis. Progressively worsening neck pain was present, although there were no symptoms of weakness, numbness or tingling sensation, or bladder and bowel incontinence. Physical examination revealed multiple cafe-au-lait spots, plexiform neurofibromas in the region of the cervical spine, axillary and inguinal freckles, and substantial cervical kyphosis with no neurological deficit. Radiographs of the cervical spine revealed a kyphosis of 87° (Figs. 1-A and 1-B). Magnetic resonance imaging (MRI) revealed an IMSCT at C2-C3 and large paraspinal plexiform neurofibromas involving the right-sided nerve roots of the cervical spine that extended to T2 with an intraspinal extension from C3-C6, dural ectasia, and focal kyphosis (Figs. 2-A and 2-B). Based on the clinical examination and imaging studies, we recommended intervention. However, the patient was not able to return for the treatment for one year. Fig. 1 Anteroposterior ( Fig. 1-A ) and …

Severe Thoracic Kyphosis with Neuropathy in a Three-Year-Old Child

Childhood spondylodiscitis occurs in 0.4 to 2.4 per 100,000 children each year1. Early diagnosis is important to prevent the development of major complications such as sepsis, spinal cord injury, and severe angular thoracic kyphosis. We report a rare case of a child who first presented as a two-month-old premature infant with an initial diagnosis of congenital cystic adenomatoid malformation (CCAM) of the lung and spondylodiscitis of the seventh and eighth vertebrae of the thoracic spine. The aim of the report is to highlight some challenges in identifying spondylodiscitis in very young children, including difficulty with the detailed neurological evaluation, the need for serial neuromonitoring assessments, progression of spinal deformity following attempted posterior spinal fusion, and technical difficulties involved in corrective surgery. The patient’s family was informed that data concerning the case would be submitted for publication, and they provided consent. This patient, who had been diagnosed in utero with CCAM of the lung, was born two months prematurely and was admitted to the neonatal intensive care unit for respiratory support. Routine computerized tomography (CT) of the chest revealed thoracic angular deformity with destruction of the seventh and eighth thoracic vertebral bodies and a lingular CCAM lesion of the left lung (Figs. 1A through 1-D). Differential diagnosis included congenital abnormality of the spine and vertebral osteomyelitis. Subsequently, she underwent lobectomy of the left upper lobe for the CCAM and debridement of the T7 and T8 vertebral bodies. Anterior strut-grafting was not performed because spondylodiscitis had not yet been diagnosed. During debridement, bone and disc tissue were sent for histopathological examination and cultures. Fig. 1 Fig. 1-A Posteroanterior radiograph of the spine shows the overlap of disc spaces between T5 and T10 caused by kyphosis. Fig. 1-B Lateral radiograph depicts the anomalous nature of the spinal vertebral bodies of T7 and T8 …C hildhood spondylodiscitis occurs in 0.4 to 2.4 per 100,000 children each year. Early diagnosis is important to prevent the development of major complications such as sepsis, spinal cord injury, and severe angular thoracic kyphosis. We report a rare case of a child who first presented as a twomonth-old premature infant with an initial diagnosis of congenital cystic adenomatoid malformation (CCAM) of the lung and spondylodiscitis of the seventh and eighth vertebrae of the thoracic spine. The aim of the report is to highlight some challenges in identifying spondylodiscitis in very young children, including difficulty with the detailed neurological evaluation, the need for serial neuromonitoring assessments, progression