Shital N. Parikh

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.

Displaced type II extension supracondylar humerus fractures: do they all need pinning?

The treatment of a displaced type II extension supracondylar humerus fracture is controversial. Many authors recommend that all displaced type II fractures be surgically pinned. The purpose of this study was to determine the success of reduction and casting (without pinning) in maintaining the alignment of type II fractures. Of the 25 elbows that underwent an initial reduction in the emergency room, 18 (72%) maintained alignment. Seven fractures lost position, and five of the seven patients underwent secondary reduction and pinning. Twenty-three of the 25 (92%) elbows had a satisfactory outcome and 2 of the 25 (8%) had an unsatisfactory outcome according to the Flynn criteria. All 24 patients were satisfied with the treatment on a satisfaction survey. An attempt at closed reduction and casting, with selective pinning of the fractures that lose position, appears justified if close follow-up can be maintained.

Patellar Fracture After Medial Patellofemoral Ligament Surgery

The medial patellofemoral ligament (MPFL) has been identified as the primary medial restraint to prevent lateral patellar displacement; it contributes up to 80% of the medial restraining forces on the patella1,2. Anatomically, the MPFL originates from the superior two-thirds of the medial patellar border and runs posteriorly toward the medial femoral epicondyle to insert in close relation to the origin of the superficial medial collateral ligament and slightly distal to the adductor tubercle3-5. Several techniques of MPFL repair and reconstruction have been described, with various graft options, tunnel placements, and fixation options, with or without concomitant procedures such as lateral retinacular release or tibial tuberosity osteotomy. Most techniques for patellar attachment of a reconstructed MPFL use patellar tunnels6-8, while some use suture anchors or soft-tissue fixation7,9,10. The potential complications of MPFL surgery include iatrogenic medial instability, persistent or recurrent lateral instability, patellofemoral arthrosis, loss of knee motion, and patellar fracture. In 1992, in a series of thirty patients, Ellera Gomes11 reported the first patellar fracture after MPFL reconstruction with use of a transverse patellar tunnel that traversed the entire width of the patella. Since then, eight patellar fractures have been reported after MPFL reconstruction with use of patellar bone tunnels. Four fractures in three series7,12,13 were attributed to technical errors associated with patellar tunnel placement. The other four fractures14,15 were medial rim avulsion fractures of the patella after MPFL reconstruction as the treatment for recurrent patellar dislocation. Fractures of the superior pole of the patella (superior pole sleeve avulsions) have been reported after medial soft-tissue imbrication and lateral retinacular release16-18; to our knowledge, similar proximal patellar fractures have not …

Experience with combined video-assisted thoracoscopic surgery (VATS) anterior spinal release and posterior spinal fusion in Scheuermann's kyphosis

Study Design. Retrospective. Objectives. To determine whether anterior endoscopic release and posterior spinal fusion could achieve stable correction in Scheuermann’s kyphosis. Summary of Background Data. The initial treatment of choice of Scheuermann’s kyphosis is thoracic hyperextension and postural exercises and/or Milwaukee brace. Milwaukee bracing is most efficacious in the early stages when the curvature is flexible and in the skeletally immature. However, it is known that larger curves, vertebral wedging greater than 10°, and skeletally mature patients will not usually respond to this treatment. Surgery is indicated in the skeletally immature with severe deformity where brace treatment has failed to prevent progression. Posterior spinal instrumentation can achieve adequate correction in the less rigid curves. However, the more rigid curves have been shown to be resistant to posterior spinal fusion alone, therefore needing anterior spinal release. Methods. Between 1995 and 2001, 19 patients underwent video-assisted thoracoscopic surgery and posterior spinal fusion for the treatment of Scheuermann’s kyphosis. The average age was 17.4 years with closed triradiate cartilage in all. Average follow-up was 2.7 years. An average of 8.3 discs were released anteriorly; an average of 13 levels were fused posteriorly. Results. Average preoperative kyphosis was 84.8°. Average postoperative kyphosis was 43.7°. Average kyphosis at follow-up was 45.3°. Only 1.6° of correction loss was noted. No junctional kyphosis was present. Two patients developed pleural effusion; one required thoracocentesis. Two patients developed pneumothorax. One patient underwent revision surgery for inferior hook pullout. One required mechanical ventilation. Conclusions. Combined video-assisted thoracoscopic surgery release and posterior spinal fusion for the treatment of Scheuermann’s kyphosis is a viable option for the treatment of the more severe and rigid curves.

Operating Room Traffic: Is There Any Role of Monitoring It?

Background Operating room (OR) human traffic has been implicated as a cause of surgical site infection. We first observed the normal human traffic pattern in our Pediatric Orthopedic ORs, and then examined the effect of surveillance on that traffic pattern. Methods This study consisted of 2 phases: phase I sought to observe the OR traffic pattern (number of door swings, maximum and minimum number of OR personnel, number of OR personnel at 30-minute intervals, or changes in nursing, anesthesia, or surgeon staff) during surgical cases without OR personnel being notified, and for phase II, the same traffic pattern was monitored with their knowledge. Results Two thousand four hundred forty-two minutes of surgical time were observed in phase I, and 1908 minutes were observed in phase II. There was no difference (P=0.06) in the time between door swings between phase I (1.39 min) and phase II (1.70 min), no difference (P=1.000) in the maximum number of people in the OR between phase I (11.5 people, range: 7-15 people) and phase II (11.5 people, range: 8-20 people), and no difference (P=1.000) in the minimum number of people in the OR between phase I (4.67 people, range: 4-6 people) and phase II (4.71 people, range: 3-6 people). There was a difference in the time between door swings (P=0.03) and maximum number of people in the OR (P=0.005) based on the length of the surgery (less or more than 120 min). There was no difference in the time between door swings (P=0.11), but there was a difference in the maximum number of people in the OR (P=0.002) based on type of surgery (spine vs. others). Conclusions There was no role of surveillance of human traffic in the OR. To achieve any change in the OR traffic pattern, monitoring alone may not be sufficient; other novel techniques or incentives may need to be considered.

The Immature Spine in Type-1 Neurofibromatosis

Neurofibromatosis is a multisystem disease that primarily affects cell growth of neural tissue. The intent of this article is to identify the spinal complications in skeletally immature patients that are most commonly associated with neurofibromatosis and to present strategies for management. The neurofibromatoses are a spectrum of multifaceted diseases involving not only neuroectoderm and mesoderm but also endoderm. These disorders present with a wide range of clinical manifestations that have in common the presence of schwannomas, neurofibromas, and/or cafe au lait spots. Clinically, this multisystemic, hereditary disease may manifest as abnormalities of the skin, nervous tissue, bones, and soft tissues. The primary pathology is believed to be a tumor-suppressor disorder. Previous reports have dealt primarily with specific entities, such as spinal deformity, paraplegia, hemihypertrophy with overgrowth phenomena of the extremities, soft-tissue tumors, neoplasia, and congenital tibial dysplasia and pseudarthrosis following extremity fractures. Scoliosis is the most common musculoskeletal complication of peripheral neurofibromatosis1,2. Most investigators now accept three clinical forms of neurofibromatosis: peripheral or type-1 neurofibromatosis (NF1), central or type-2 neurofibromatosis (NF2), and segmental neurofibromatosis (a mosaic form of NF1)1. A recently described fourth form, schwannomatosis, consists of multiple deep, painful schwannomas and is thought to represent a mosaic form of NF23. A variety of eponyms have been used in the past to describe all forms, although subsequent information has made these names technically inaccurate or incomplete. The most common type (NF1) was previously known as von Recklinghausen disease and is an autosomal dominant disorder that affects approximately one in 4000 persons; multiple hyperpigmented areas ( cafe au lait macules) and neurofibromas are characteristic. In their statement on neur ofibromatosis, the 1987 Consensus Development Conference of the National Institutes of Health concluded that the diagnosis of von Recklinghausen disease or NF1 can be considered …

Outcomes After Isolated Medial Patellofemoral Ligament Reconstruction for the Treatment of Recurrent Lateral Patellar Dislocations A Systematic Review and Meta-analysis

Background: A patellar dislocation is a common knee injury in the young, athletic patient population. Recent trends indicate that the use of long-term nonoperative treatment is decreasing, and surgical intervention is more commonly recommended for those patients who fail initial nonoperative management with recurrent patellar dislocations. Medial patellofemoral ligament (MPFL) reconstruction has become increasingly utilized in this regard. Purpose: To evaluate outcomes, particularly return to sports and its relationship to postoperative instability, of isolated MPFL reconstruction for the treatment of recurrent patellar dislocations. Study Design: Systematic review and meta-analysis. Methods: A review of the current literature was performed using the terms “medial patellofemoral ligament reconstruction” and “MPFL reconstruction” in the electronic search engines PubMed and EBSCOhost (CINAHL, MEDLINE, SPORTDiscus) on July 29, 2015, yielding 1113 abstracts for review. At the conclusion of the search, 14 articles met the inclusion criteria and were included in this review of the literature. Means were calculated for population size, age, follow-up time, and postoperative Tegner scores. Pooled estimates were calculated for postoperative Kujala scores, return to play, total risk of postoperative instability, risk of positive apprehension sign, and risk of reoperation. Results: The mean patient age associated with MPFL reconstruction was 24.4 years, with a mean postoperative Tegner score of 5.7. The pooled estimated mean postoperative Kujala score was 85.8 (95% CI, 81.6-90.0), with 84.1% (95% CI, 71.1%-97.1%) of patients returning to sports after surgery. The pooled total risk of recurrent instability after surgery was 1.2% (95% CI, 0.3%-2.1%), with a positive apprehension sign risk of 3.6% (95% CI, 0%-7.2%) and a reoperation risk of 3.1% (95% CI, 1.1%-5.0%). Conclusion: A high percentage of young patients return to sports after isolated MPFL reconstruction for chronic patellar instability, with short-term results demonstrating a low incidence of recurrent instability, postoperative apprehension, and reoperations.

MRI findings in adolescent patients with acute traumatic knee hemarthrosis

Background: Physical examination may be inconclusive in adolescents presenting with an acute traumatic knee effusion because of pain and guarding. The purpose of this study was to describe the magnetic resonance imaging (MRI) findings in adolescents with traumatic knee effusions and to compare injuries based on age, sex, and physeal maturity. Methods: All MRIs using a knee trauma protocol performed at our institution over a 2-year period were evaluated. One hundred thirty-one patients between the ages of 10 to 18 years of age with a clinical history of acute knee trauma and an effusion confirmed on MRI met our study inclusion criteria. They were divided into 2 age groups: 10 to 14 and 15 to 18 years old. Pathology was confirmed using clinical history, MRI, and any available surgical reports. Results: Of the 131 patients with an acute knee effusion, there were 59 patients in the younger group (10 to 14 y old) and 72 patients in the older group (15 to 18 y old). In the younger group, patellar dislocations (36%), anterior cruciate ligament (ACL) tears (22%), and isolated meniscus tears (15%) were the most common injuries. In the older group, ACL tears (40%), patellar dislocations (28%), and isolated meniscus tears (13%) were the most common injuries. ACL injuries represented 28% of injuries in males and 38% of injuries in females, whereas patellar dislocations represented 28% of injuries in males and 37% of injuries in females. There was a trend toward adolescents with active growth plates sustaining more patellar dislocations and adolescents with closed growth plates sustaining more ACL injuries. Forty-one percent of patients in this study underwent surgery. Conclusions: Patellar dislocation is a common injury in children who present with a traumatic knee effusion, especially in young adolescents and females. Adolescents presenting with a traumatic knee effusion should undergo MRI because of the high rate of positive findings missed by physical examination and plain radiographs that may warrant surgical repair or reconstruction. Level of Evidence: Level III.

Magnetic Resonance Imaging in the Evaluation of Infantile Torticollis

This retrospective study assessed the use of magnetic resonance imaging (MRI) in 58 infants with infantile torticollis. Eighteen patients had nonmuscular causes of torticollis (group 1); MRI identified lesions in 16 patients. Of 40 patients with a diagnosis of congenital muscular torticollis (group 2), 28 had a normal MRI. Five patients had asymmetry of the sternocleidomastoid without noticeable signal changes. Seven patients showd evidence of fibromatosis colli. Asymmetry of the posterolateral skull consistent with plagiocephaly was common. Magnetic resonance imaging did not alter treatment of group 2. Findings of compartment syndrome of sternocleidomastoid were inconsistent. Magnetic resonance imaging is not recommended for asymptomatic patients with infantile torticollis.

Predictors of recurrent patellar instability in children and adolescents after first-time dislocation

Background: Patellar dislocations are one of the most common knee injuries in children and adolescents and are challenging to treat. Recurrence rates are relatively high and many patients have functional limitations, even in the absence of a recurrent instability episode. The purpose of this study was to examine the risk factors in patients with first-time patellofemoral dislocations to develop a prediction model of recurrence. Methods: A single institution retrospective review of all patients with a first-time patellofemoral dislocation from 2002 to 2013 was performed. Demographic risk factors (age, sex, laterality, mechanism of injury, and history of contralateral patellar dislocation) and radiographic risk factors (increased patella height, trochlear dysplasia, and skeletal immaturity) were examined. Patella height was measured using Caton-Deschamps index (CDI). Trochlear dysplasia was assessed using the 2-grade Dejour classification and skeletal immaturity was assessed based on the distal femur and proximal tibia physis (open, closing, or closed). Results: In total, 266 knees in 250 patients were included in the study. Of these, 222 (83.5%) were treated nonoperatively and 44 (16.5%) were treated surgically. Of the knees treated nonoperatively, 77 (34.7%) had a recurrence. Significant risk factors for recurrence on univariate analysis were age 14 years and below, history of contralateral patellar dislocation, trochlear dysplasia, skeletal immaturity, and a CDI>1.45. Multivariate analysis was performed and trochlear dysplasia and skeletal immaturity were the most significant factors with odds ratios of 3.56 and 2.23, respectively. The presence of all 4 multivariate risk factors (CDI>1.45, history of contralateral patellar dislocation, trochlear dysplasia, and skeletal immaturity) had a predicted risk of recurrence of 88%. The presence of any 3 risk factors had a predicted risk of about 75% and the presence of any 2 risk factors had a predicted risk of about 55%. Conclusions: Trochlear dysplasia, skeletal immaturity, CDI>1.45, and a history of contralateral patellar dislocation were all significant risk factors for recurrence in patients with first-time patellar dislocations. A predictive model for calculation of recurrence risk was developed for any combination of the different risk factors. This information is useful when counseling patients and their families after first-time patellar dislocation about prognosis and potential outcomes. Level of Evidence: Level IV—retrospective case series.