Effects of tension band plating on coronal plane alignment of lower extremities in children treated for idiopathic limb length discrepancy.

Purpose: One of the most common treatment methods for moderate limb length discrepancy in children is growth modulation using tension band plating. Coronal plane deformities after tension band plating for limb length discrepancy have been documented as an important complication in articles involving heterogeneous groups consisted of both idiopathic cases and patients with pathological physes. The aim of the study was to determine the rate of coronal plane deformities after treatment of a homogeneous group of idiopathic limb length discrepancy cases with tension band plating and to compare screw constructs of medial and lateral plates. Methods: Patient files were retrospectively reviewed for amount of limb length discrepancy, anatomical femorotibial angle, mechanical lateral distal femoral angle, mechanical medial proximal tibial angle, and inter-screw angles of each plate on both sides of the tibiae and femora. Measurements at each follow-up period were compared to each other. Results: A total of 26 patient files (37 bones) were included to the study. The mean age was 10.5 years. The mean limb length discrepancy was 27.5 mm. Implants were removed after mean 34.5 months. The mean follow-up period was 58.5 months. There was no significant difference in inter-screw angle on each side of the bones at the time of implantation and in lower limb alignments during follow-up. Conclusion: Treatment of mild-to-moderate idiopathic limb length discrepancy with tension band plating in children was found to be safe against any coronal plane deformity during follow-up until skeletal maturity. Level of evidence: Level IV.

Relation of the Sural Nerve and Medial Neurovascular Bundle With the Achilles Tendon in Children With Cerebral Palsy Treated by Percutaneous Achilles Tendon Lengthening.

BACKGROUND: One of the most common treatment options for a short Achilles tendon (AT) in cerebral palsy is percutaneous AT lengthening using 3 hemisections. Because of proximity of neurovascular structures around the tendon, iatrogenic injury to them have been a concern about this technique. The sural nerve (SN) is under risk of injury at the site of the lateral incomplete cut, especially if it is done proximally. The medial neurovascular bundle is under injury risk at medial cuts. The aim of the article was to study the anatomical relations of the SN and medial neurovascular bundle to the AT, and define dangerous levels for injury with the help of magnetic resonance imaging (MRI). METHODS: Patients operated for percutaneous Achilles lengthening were called for MRI investigation of the SN and medial neruvascular bundle integrity and their anatomical relation with the AT. The distance of 5 mm was taken as the threshold for increased risk of injury. Measurements were done on MRI at each cm from the insertion of the tendon on both medial and lateral sides, and at the level of the middle cut. RESULTS: Thirty ankles operated and followed at least 1 year were included to the study. On the medial side, the tibial nerve, and the posterior tibial artery lied more than 5 mm away from the tendon at all levels in all patient. On the lateral side, the first 4 cm were relatively safe for the middle lateral cut, while increased risk of SN damage was detected in more proximal levels. Overall, 6 of 30 ankles had radiographically detectable SN injury. CONCLUSIONS: The first 4 cm of the AT on the lateral side was detected to be safe for the middle lateral directed cut, while whole tendon length were found to be safe for the first and the third cuts of the percutaneous Achilles lengthening surgery using 3 hemisections in children with cerebral palsy. LEVEL OF EVIDENCE: Level III.

Intraoperative neuromonitoring during distal femoral extension osteotomy in children with cerebral palsy.

The most common treatment method for a fixed knee flexion contracture more than 10 degrees in cerebral palsy (CP) is distal femoral extension osteotomy (DFEO). However, a serious complication after a DFEO is neurological impairment. Its rates were reported as 5- 40%. Intraoperative neuromonitoring (IONM), widely used in spinal surgery and in other fields, is a valuable tool to define any neurological injury during operation. The aim of our study was to determine surgical steps with risk of neurological injury and to report if precautions would be effective in recovering signal loss. We performed IONM during DFEO of 23 knees of 12 children with CP. IONM was performed by recording somatosensory evoked potentials, transcranial motor evoked potentials and free-run electromyography during defined steps throughout the surgery. Preoperative and postoperative popliteal angles, flexion contractures and physeal posterior distal femoral angles were evaluated. We detected alert signals at osteotomy or manipulation steps of surgeries of all patients. We observed persistent alert signals in two cases (2 out of 23 knees; Group 2). In this group, the action potentials recovered only after 5 and 10 degrees of undercorrection at the osteotomy sites. Alert signals disappeared after a brief period of waiting in other cases. Throughout mean 37 months of follow-up, none of our patients experienced any neurological complication. The study concludes that the surgical steps in DFEO with a higher risk for a neurological complication were the osteotomy and manipulation steps. Alert signals were detected with the help of IONM, and preventive measures were effective in recovering neuromonitoring recordings.

Retro-patellar approach in telescopic nailing of the tibia in children with osteogenesis imperfecta.

PURPOSE: Telescopic intramedullary nailing (TN) has become the main choice of treatment in children with osteogenesis imperfecta (OI). The classical parapatellar tibial nailing technique poses difficulties in maintaining reduction, insertion of the nail and fluoroscopic imaging. Also, deformities of the proximal tibia in relatively small children with OI can be problematic for tibial nailing. In this report, we present the retro-patellar approach in tibial TN of children with OI as an alternative to the classical approach and report the early radiographic and clinical results of our patients. METHODS: The nail is inserted through a skin incision proximal to the patella, passing inside the patellofemoral joint while the knee is positioned to 15° to 20° of flexion. In total, 30 tibiae of 15 patients had been operated and were reviewed after at least one year of follow-up. Any complications, such as implant failure, joint damage or instability, malunion, nonunion or refracture, were recorded. RESULTS: The mean age of our patients was 8.5 years, and the mean follow-up period was 27 months. There were no complaints involving the knee. All patients showed complete union without any implant failure or refracture. We did not observe any nail protrusion, bending or loss of correction during the procedure. CONCLUSION: The retro-patellar approach for tibial TN appears to be safe and effective in patients with OI. LEVEL OF EVIDENCE: IV.

Femoral derotation osteotomy in children with cerebral palsy using the pediatric proximal femoral nail.

We designed a pediatric proximal femoral nail (PPFN) to overcome fixation method-related complications when performing femoral derotation osteotomy in cerebral palsy patients. Preliminary results of cerebral palsy patients who underwent femoral derotation osteotomy fixed using PPFN to treat in-toeing were evaluated. Sixteen patients with a mean age of 10 years were included. Mean follow-up duration was 36 months. There was no significant difference in the follow-up neck-shaft angle and articulotrochanteric distance values (P = 0.2 and 0.3). PPFN provides stable fixation, early weight-bearing, reduces soft-tissue disruption while limiting the complications due to fixation technique.

Atelosteogenesis type III: orthopedic management.

Atelosteogenesis type III is a rare autosomal dominant skeletal dysplasia caused by mutations in the synthesis of the protein filamin B (FLNB). The mutation in the gene coding for FLNB causes the osteochondrodysplastic features of this disorder. Clinically, osteochondrodysplasia causes unbalanced skeletal maturation and absent or mostly hypoplastic bones, such as the pelvis, vertebrae, ribs, or long bones. In the literature, an orthopedic management for this disorder has not been well described. We report the case and orthopedic management of a 6-year-old female patient with atelosteogenesis type III after 3 years of follow-up.

Matrix-induced autologous mesenchymal stem cell implantation versus matrix-induced autologous chondrocyte implantation in the treatment of chondral defects of the knee: a 2-year randomized study.

BACKGROUND: Cell-based strategies that combine in vitro- expanded autologous chondrocytes with matrix scaffolds are currently preferred for full-thickness cartilage lesions of the knee ≥2 cm(2). Although this approach is reasonable, continuing advances in the field of cartilage repair will further expand the options available to improve outcomes. HYPOTHESIS/PURPOSE: In the present clinical study, we compared the outcomes of matrix-induced autologous mesenchymal stem cell implantation (m-AMI) with matrix-induced autologous chondrocyte implantation (m-ACI) for the treatment of isolated chondral defects of the knee. STUDY DESIGN: Prospective, single-site, randomized, single-blind pilot study. METHODS: Fourteen patients with isolated full-thickness chondral lesions of the knee >2 cm(2) were randomized into two treatment groups: m-AMI and m-ACI. Outcomes were assessed pre-operatively and 3, 6, 12 and 24 months post-operatively. RESULTS: Clinical evaluations revealed that improvement from pre-operation to 24 months post-operation occurred in both groups (p < 0.05). At all follow-up intervals, m-AMI demonstrated significantly better functional outcomes (motion deficit and straight leg raise strength) than did m-ACI (p < 0.05). At all follow-up intervals, m-AMI demonstrated significantly better subjective sub-scale scores for pain, symptoms, activities of daily living and sport and recreation of the knee injury and osteoarthritis outcome score (KOOS) than did m-ACI (p < 0.05). Additionally, m-AMI demonstrated significantly better (p < 0.05) scores than m-ACI for the quality of life sub-scale of the KOOS and visual analog scale (VAS) severity at the 6-month follow-up. The Tegner activity score and VAS frequency were not significantly different between the two groups. Graft failure was not observed on magnetic resonance imaging at the 24-month follow-up. m-AMI and m-ACI demonstrated very good-to-excellent and good-to-very good infill, respectively, with no adverse effects from the implant, regardless of the treatment. CONCLUSION: For the treatment of isolated full-thickness chondral lesion of the knee, m-AMI can be used effectively and may potentially accelerate recovery. A larger patient cohort and follow-up supported by histological analyses are necessary to determine long-term outcomes.