Recurrent patellar dislocations in adolescents result in decreased knee flexion during the entire gait cycle.

PURPOSE: To evaluate the kinematics/kinetics of the ankle, knee, hip in the sagittal plane in adolescents with recurrent patellar dislocation in comparison to a healthy control. METHODS: Case-control study. Eighty-eight knees (67 patients) with recurrent patellar dislocation (mean age 14.8 years ± 2.8 SD) were compared to 54 healthy knees (27 individuals, 14.9 years ± 2.4 SD). Kinematics/kinetics of ankle, knee, hip, and pelvis were captured using 3D-gait analysis (VICON, 12 cameras, 200 Hz, Plug-in-Gait, two force plates). One cycle (100%) consisted of 51 data-points. The mean of six trials was computed. RESULTS: The loading-response increased by 0.02 s ± 0.01SE (10.8%) with dislocations (0.98% of total gait, P < 0.01). The mid-stance-phase decreased equally (P < 0.01). Dislocation decreased knee flexion during the entire gait cycle (P < 0.01), with the largest difference during mid-stance (9.0° ± 7.2 SD vs. 18.5° ± 6.7 SD). Dislocation increased plantar-flexion during loading response 4.1° ± 0.4 SE with (P < 0.01), afterward, the dorsal-extension decreased 3.2° ± 0.3 SE, (P < 0.01). Dislocation decreased hip flexion during all phases (P < 0.01). Maximal difference: 7.5° ± 0.5 SE during mid-stance. 80% of all patients developed this gait pattern. Internal moments of the ankle increased, of the knee and hip decreased during the first part of stance. CONCLUSION: Recurrent patellar dislocation decreases knee flexion during the loading-response and mid-stance phase. A decreased hip flexion and increased plantar-flexion, while adjusting internal moments, indicate a compensation mechanism. LEVEL OF EVIDENCE: III.

Trochleoplasty improves knee flexion angles and quadriceps function during gait only if performed bilaterally.

PURPOSE: To investigate if a trochleoplasty increases knee flexion angles and extensor moments in the gait of patients with patellar instability and to compare postoperative gait to a healthy control group. METHODS: A bilateral dislocation group (6 patients) and a unilateral dislocation group (14 patients) were treated with bilateral and unilateral trochleoplasty, respectively. Kinematics and kinetics of the lower extremity were captured using 3D-gait analysis (VICON, 12 cameras, 200 Hz, plug-in-gait, two force plates). The mean of six trials was computed. The gait cycles were compared pre to postoperatively for each group. The gait of the two groups was compared to each other and the gait of a healthy population (54 knees). RESULTS: After trochleoplasty, the knee flexion angles and knee extensor moments only increased in the bilateral dislocation group, whereas the gait pattern of the unilateral dislocation group remained unchanged. Compared to the healthy population, the postoperative gait pattern of the bilateral dislocation group did not differ. In contrast, knee flexion angles and extensor moments of the unilateral dislocation group were still lower. CONCLUSION: In adolescents with bilateral recurrent patellar dislocations, trochleoplasty of both knees increases knee flexion angles and knee extensor moments comparable to normal gait. Unilateral symptomatic patients undergoing a unilateral trochleoplasty did not achieve normal walking. These findings point out that patellar instability should be considered as a bilateral problem, even in patients with unilateral dislocations. LEVEL OF EVIDENCE: III.

Solitary Trochleoplasty for Treatment of Recurrent Patellar Dislocation.

BACKGROUND: Solitary trochleoplasty for recurrent patellar dislocation offers a unique benefit in that it addresses the most important factor in patellar instability: the trochlear dysplasia. DESCRIPTION: The trochlea is visualized through a lateral arthrotomy of the knee joint. An osteochondral layer is peeled off with curved chisels and extended into the intercondylar notch. A triangular bone block is removed from the subchondral bone to form the new groove. A new groove is begun with a chisel and smoothed with a high-speed burr. Also, the osteochondral layer is thinned out and fixed back transosseously in the new groove with 2 Vicryl (polyglactin) bands. The bone block is used to lengthen the lateral condyle by placing it under the osteochondral layer at the proximal extension of the lateral femoral condyle with an overlap of 1 cm. ALTERNATIVES: Nonsurgical alternatives include a knee or patellar brace, taping of the patella, and physiotherapy for strengthening of the vastus medialis obliquus of the quadriceps muscle. Surgical alternatives include reconstruction of the medial patellofemoral ligament; several femoral and tibial osteotomies, such as rotational osteotomies of the femur and tibia or medialization of the tibial tuberosity; and several soft-tissue interventions, such as medial reefing, relocation of the patellar tendon as described by Goldthwait1, and proximal realignments according to the method described by Insall et al.2 or Green et al.3. RATIONALE: Most patients with recurrent patellar dislocation have a dysplastic trochlea4, which is considered to be the primary reason for a recurrence. While interventions such as reconstruction of the medial patellofemoral ligament or femoral and tibial osteotomies also provide stability of the patella, they do not change the most essential factor of the instability-the trochlear dysplasia. The trochleoplasty addresses this underlying condition and reshapes the trochlea.

Concurrent Meniscal and Chondral Injuries in Pediatric and Adolescent Patients Undergoing ACL Reconstruction.

BACKGROUND/PURPOSE: The aim of this study is to assess the prevalence of and risk factors for concurrent meniscal and articular cartilage injury in children and adolescents undergoing anterior cruciate ligament (ACL) reconstruction. METHODS: Medical records of pediatric patients (below 18 y old) undergoing ACL surgery during the 2013 to 2014 academic year at a tertiary care children's hospital were reviewed for clinical or radiographic documentation of meniscal or chondral injury. Prevalence of concurrent injury was regressed on the basis of age, sex, body mass index (BMI), and time between injury and surgery. Skeletally immature patients were analyzed as a separate subgroup. RESULTS: Medical records of 208 patients with a mean age of 15±2 years were reviewed. Overall, 117 patients (56%) were found to have had at least 1 concurrent injury; 66 patients (32%) had a medial meniscus tear, 72 patients (35%) had a lateral meniscus tear, and 10 patients (5%) had a chondral lesion. Both BMI and time duration between injury and ACL reconstruction surgery were significant predictors for meniscal or chondral injury, with increase in injury prevalence of approximately 10% per point BMI and 6% per month delay to surgery. CONCLUSIONS: More than half of the children and the adolescents treated for ACL tear have concurrent meniscal or chondral injury. Risk factors for concurrent injury are BMI and time duration between injury and surgery. The prevalence of concurrent injury and associated risk factors should be considered when counseling a pediatric patient and family regarding operative versus nonoperative management in the setting of an ACL tear. LEVEL OF EVIDENCE: Level IV-case series.

Trochleoplasty as a Solitary Treatment for Recurrent Patellar Dislocation Results in Good Clinical Outcome in Adolescents.

BACKGROUND: The essential static patellar stabilizer is a normal-shaped trochlear groove. A dysplastic groove destabilizes the patella. Trochleoplasty approaches this underlying condition and reshapes the trochlea. However, studies have reported on trochleoplasty for revision cases or as accompanied by other interventions. The effect of trochleoplasty alone remains unexplained. PURPOSE: To introduce trochleoplasty as a stand-alone treatment for recurrent patellar dislocation and to compare its pre- to postoperative functional and clinical variables. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A trochleoplasty was performed in 50 knees (27 right) in 44 patients (30 females; mean ± SD age, 15.6 ± 2.0 years). The indication for surgery was recurrent patellar dislocation not responding to nonoperative treatment (>6 months), with types B through D dysplasia and closed or closing physes in adolescents aged 10 to 20 years. Assessment included J-sign and apprehension test, Kujala and Lysholm scores, patients' subjective assessment and activity level according to the International Knee Documentation Committee questionnaire, and patients' overall satisfaction. The Caton-Deschamps ratio and the lateral condyle index were measured. Pre- versus postoperative values were compared with a paired Wilcoxon signed-rank test. The minimum follow-up was 24 months (33 ± 10.6 months). RESULTS: The Kujala score improved from 71 preoperatively to 92 postoperatively (P < .001) and the Lysholm score from 71 to 95 (P < .001). Patients' subjective assessment improved at the final follow-up as compared with that preoperatively (P < .001). Most patients enhanced their activity (P < .001), and their overall satisfaction increased postoperatively (P < .001). Preoperatively, there was a positive J-sign in 45 knees and a positive apprehension test in 41 knees. Both markers disappeared postoperatively in 39 and 33 knees, respectively, leaving 6 knees with a positive J-sign and 8 knees with a positive apprehension test (P < .001). One patella redislocated postoperatively after 38 months. Four patients required a single arthroscopic debridement. CONCLUSION: In this study, trochleoplasty as a solitary treatment for recurrent patellofemoral dislocations in patients with trochlear dysplasia resulted in good clinical outcomes if severe torsional and axial malalignment was excluded. Kujala and Lysholm scores increased postoperatively, as well as subjective International Knee Documentation Committee assessment of outcomes, activity level, and overall satisfaction.

Union Rate and Complications in Spine Fusion with Recombinant Human Bone Morphogenetic Protein-7: Systematic Review and Meta-Analysis.

Study Design Systematic review and meta-analysis. Objective The objective of this meta-analysis was to evaluate the current best evidence to assess effectiveness and safety of recombinant human bone morphogenetic protein-7 (rhBMP-7) as a biological stimulant in spine fusion. Methods Studies were included if they reported on outcomes after spine fusion with rhBMP-7. The data was synthesized using Mantel-Haenszel pooled risk ratios (RRs) with 95% confidence intervals (CIs). Main end points were union rate, overall complications, postoperative back and leg pain, revision rates, and new-onset cancer. Results Our search produced 796 studies, 6 of which were eligible for inclusion. These studies report on a total of 442 patients (328 experimental, 114 controls) with a mean age of 59 ± 11 years. Our analysis showed no statistically significant differences in union rates (RR 0.97, 95% CI 0.84 to 1.11, p = 0.247), overall complications (RR 0.92, 95% CI 0.71 to 1.20, p = 0.545), postoperative back and leg pain (RR 1.03, 95% CI 0.48 to 2.19, p = 0.941), or revision rate (RR 0.81, 95% CI 0.47 to 1.40, p = 0.449). There was a mathematical indicator of increased tumor rates, but with only one case, the clinical meaningfulness of this finding is questionable. Conclusion We were not able to find data in support of the use of rhBMP-7 for spine fusion. We found no evidence for increased complication or revision rates with rhBMP-7. On the other hand, we also found no evidence in support of improved union rates.

Outcome Predictors in Prosthetic Joint Infections--Validation of a risk stratification score for Prosthetic Joint Infections in 120 cases.

Prosthetic joint infections are a major challenge in total joint arthroplasty, especially in times of accumulating drug resistancies. Even though predictive risk classifications are a widely accepted tool to define a suitable treatment protocol a classification is still missing considering the difficulty in treating the -causative pathogen antibiotically. In this study, we present and evaluate a new predictive risk stratification for prosthetic joint infections in 120 cases, treated with a two-stage exchange. Treatment outcomes in 120 patients with proven prosthetic joint infections in hip and knee prostheses were regressed on time of infection, systemic risk factors, local risk factors and the difficulty in treating the causing pathogen. The main outcome variable was "definitely free of infection" after two years as published. Age, gender, and BMI were included as covariables and analyzed in a logistic regression model. 66 male and 54 female patients, with a mean age at surgery of 68.3 years±12.0 and a mean BMI of 26.05±6.21 were included in our survey and followed for 29.0±11.3 months. We found a significant association (p<0.001) between our score and the outcome parameters evaluated. Age, gender and BMI did not show a significant association with the outcome. These results show that our score is an independent and reliable predictor for the cure rate in prosthetic joint infections in hip and knee prostheses treated within a two-stage exchange protocol. Our score illustrates, that there is a statistically significant, sizable decrease in cure rate with an increase in score. In patients with prosthetic joint infections the validation of a risk score may help to identify patients with local and systemic risk factors or with infectious organisms identified as "difficult to treat" prior to the treatment or the decision about the treatment concept. Thus, appropriate extra care should be considered and provided.

Meniscus transplantation in skeletally immature patients.

UNLABELLED: Meniscal pathology in skeletally immature patients includes meniscal tears and discoid lateral meniscus. Total or subtotal meniscectomy may occur in patients with discoid lateral meniscus or severe meniscal tears. Meniscal transplantation may be an option in skeletally immature patients status after total or subtotal meniscectomy with knee symptoms or dysfunction. This study focuses on the surgical technique and short-term outcomes of meniscus transplantation in skeletally immature patients. We reviewed our clinical database for skeletally immature patients who had undergone meniscus transplantation with a minimum of 2 years of follow-up. Patients were contacted, invited for a physical exam, and asked to complete a Pedi-IKDC, Lysholm, and Tegner outcomes questionnaire. The study protocol was approved by the responsible institutional review board. Three patients (two females/one male) were eligible for the study, each of whom responded to our invitation indicating availability for physical exam and questionnaire. Two patients had undergone subtotal discoid meniscus resection, leading to early lateral compartment degeneration. One patient developed advanced degeneration after a delay in treatment for a medial bucket-handle tear associated with anterior cruciate ligament rupture. The mean age of the patients at the time of surgery was 12.6±2.3 years. At a mean follow-up of 31±20 months, the mean Pedi-IKDC score was 68.3±4, the mean Lysholm was 55.7±22.3, and the median Tegner was 7 points. There were no indications of growth deformity during the regular postoperative radiological assessments. One patient required subsequent lysis of adhesions along the lateral mini arthrotomy and mobilization under anesthesia. The other two patients were able to return to sports at the same level as before meniscus transplantation and were able to do so within 9 months postoperatively. Over-resection of discoid menisci as well as untreated meniscus injury, the latter typically in conjunction with ligamentous instability, can lead to advanced cartilage degeneration and recalcitrant complaints necessitating surgical treatment before skeletal maturity. We were able to show that meniscus transplantation in skeletally immature patients leads to acceptable clinical outcomes without growth deviation. LEVEL OF EVIDENCE: IV.

Treating Subscapularis and Lesser Tuberosity Avulsion Injuries in Skeletally Immature Patients: A Systematic Review.

PURPOSE: To develop evidence-based recommendations for the diagnosis and treatment of skeletally immature patients with subscapularis and lesser tuberosity avulsion injuries. METHODS: We searched the online databases PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and Cochrane Database of Systematic Reviews (CDSR) for relevant publications on subscapularis and lesser tuberosity injuries in skeletally immature patients. All publication dates and languages were included. From studies identified, data were extracted to identify patient characteristics, history and physical examination findings, time to diagnosis, results from imaging studies, and treatment outcomes. These findings were combined and descriptively analyzed. RESULTS: We identified 32 publications on 60 patients with a mean age of 13.5 ± 1.7 years. The most common physical examination finding at the time of diagnosis was anterior shoulder pain, followed by subscapularis muscle weakness. The sensitivity of imaging was 16% for radiographs and 95% for magnetic resonance imaging. The median time to diagnosis was 2 months (interquartile range, 1 to 7 months). Of 60 patients, 10 (17%) underwent successful nonoperative treatment. Fifty patients (83%) underwent surgical repair, without differences in clinical outcomes after open versus arthroscopic repair. Five cases (8%) were identified where delayed treatment was associated with suboptimal outcomes and ongoing shoulder pain. CONCLUSIONS: Subscapularis and lesser tuberosity avulsion injuries in skeletally immature patients are most commonly seen in male patients during early adolescence. A high index of suspicion should be maintained in patients with anterior shoulder pain and subscapularis muscle weakness, especially after a fall on an outstretched arm or an eccentric external rotation injury. Magnetic resonance imaging should be considered early, even if radiographic findings are negative. Both open and arthroscopic repairs are effective in restoring function, if fixation respects the soft bone of the lesser tuberosity. LEVEL OF EVIDENCE: Level IV, systematic review of low-quality studies.

Open inferior capsular shift for multidirectional shoulder instability in adolescents with generalized ligamentous hyperlaxity or Ehlers-Danlos syndrome.

BACKGROUND: The objective of this study was to assess the outcome of open inferior capsular shift for multidirectional shoulder instability in patients with generalized ligamentous hyperlaxity or Ehlers-Danlos syndrome. METHODS: Data were obtained for 18 open inferior capsular shift surgeries in 15 adolescent patients with generalized ligamentous hyperlaxity or Ehlers-Danlos syndrome with a mean follow-up of 7.5 years. End points were subjective clinical outcome (pain, stability, satisfaction, return to sport), objective clinical outcome (recurrence, complications), and functional outcome scores (American Shoulder and Elbow Surgeons, 11-item version of the Disabilities of Arm, Shoulder and Hand). RESULTS: Thirteen patients (87%) reported improved pain and stability and were satisfied with the procedure. Nine patients (64%) were able to return to sports. One patient (7%) was dissatisfied with continuous pain and recurrent instability and considered a surgical failure. Seven patients (47%) reported no further episodes of instability. The mean American Shoulder and Elbow Surgeons score at a mean of 7.5 years of follow-up was 88 ± 10 points, and the mean score for the 11-item version of the Disabilities of Arm, Shoulder and Hand was 14 ± 14 points. DISCUSSION: The management of multidirectional shoulder instability in adolescent patients with generalized ligamentous hyperlaxity or Ehlers-Danlos syndrome is challenging. Open inferior capsular shift results in improvement in subjective and objective shoulder function and stability in adolescent patients with ligamentous hyperlaxity or Ehlers-Danlos who have failed nonoperative treatment. We found no effect of the recalled number of prior dislocations, laterality, and type of hyperlaxity on subjective and objective clinical outcomes. LEVEL OF EVIDENCE: Level IV; Case Series; Treatment Study.

Polymicrobial infections reduce the cure rate in prosthetic joint infections: outcome analysis with two-stage exchange and follow-up ≥two years.

PURPOSE: Prosthetic joint infections (PJI) are a serious and challenging complication after total joint arthroplasty. According to the literature, most PJI are monomicrobial infections caused by gram-positive cocci. The number of polymicrobial PJI might be underrepresented in the literature and only limited data are available regarding the outcome of polymicrobial PJI. Our hypothesis was that polymicrobial PJI are associated with a reduced cure rate compared with monomicrobial PJI. METHODS: Routine clinical data were collected and analysed retrospectively as anonymised, aggregated data. A total of 77 consecutive patients with 77 confirmed PJI and proven infectious organism of the hip and knee joint treated within a two-stage exchange concept and a follow-up ≥ two years were investigated. Detection of the infectious organism was based on multiple microbiological cultures taken intra-operatively. Superficial wound swabs or swabs from sinus tracts were not taken into account. Data were grouped into polymicrobial and monomicrobial PJI. The main outcome variable was "definitively free of infection after two years" as published. Second, we considered several variables as potential confounders or as risk factors. RESULTS: A total of 42 men and 35 women with 46 infected total hip arthroplasties and 31 infected total knee arthroplasties were evaluated. In 37 (46.6 %) of our 77 patients a polymicrobial PJI could be detected. We found a significant association between polymicrobial PJI and the outcome parameter definitively free of infection after two years with an odds ratio (OR) of 0.3 [95 % confidence interval (CI) 0.1-1.0]. The rate of patients graded as definitively free of infection after two years was 67.6 % for polymicrobial infections vs. 87.5 % for monomicrobial infections. The American Society of Anesthesiologists (ASA) score (OR 0.4, 95 % CI 0.2-1.0, p = 0.062) was identified as a borderline significant covariable. CONCLUSIONS: Our data suggest that polymicrobial PJI might be underrepresented in the current literature. Additionally, the presence of multiple infectious organisms is associated with a reduced rate after two years with 67.6 vs 87.5 % for monomicrobial infections. Special attention and extra care should be considered for these patients.

First 50 Pediatric and Adolescent Elbow Arthroscopies: Analysis of Indications and Complications.

BACKGROUND: Elbow arthroscopy is a challenging, yet extremely productive procedure in orthopaedic sports medicine. The severely confined anatomy of the pediatric and adolescent elbow is particularly prone for perioperative complications. This study focuses on the indications and complications of the first 50 elbow arthroscopies in skeletally immature patients done in a specialized pediatric orthopaedic department. PURPOSE: To review analysis of indications and complications in pediatric and adolescent elbow arthroscopy. We hypothesized that the complication rate in these patients is similar to adults. METHODS: Data on 50 consecutive elbow arthroscopies were prospectively gathered in a dedicated database and retrospectively analyzed for indications and perioperative complications. All procedures were performed by a surgeon trained in orthopaedic sports medicine. RESULTS: A total of 26 boys and 24 girls with a mean age of 13.6±3.3 years at the time of surgery and a minimum follow-up of 1 year were included.Fifty-eight percent were treated for osteochondritis dissecans, 24% for arthrofibrosis, 14% for a congenital disorder, and 4% for a posttraumatic problem other than arthrofibrosis. The complication rate was 8%, including 3 cases of transient neuropraxia and 1 superficial wound infection. There were no major complications such as septic arthritis, vascular injury, or permanent nerve damage. All complications resolved fully with conservative treatment, no revision were required. DISCUSSION: Although osteochondritis dissecans is still the leading reason for such surgery, fractures and posttraumatic conditions are becoming more important. With a rate of 5% to 8% of minor, fully resolving complications such an increase is not a reason for concerns. LEVEL OF EVIDENCE: Level IV-case series.

Complications and cancer rates in spine fusion with recombinant human bone morphogenetic protein-2 (rhBMP-2).

PURPOSE: To quantitatively synthesize the available best evidence for general complications, heterotopic ossification (HO), retrograde ejaculation, cervical swelling, and cancer rates with the use of rhBMP-2 in lumbar and cervical spine fusion. METHODS: We conducted an online search for relevant controlled trials and extracted data on the abovementioned endpoints. Studies were eligible for inclusion if they reported on spinal fusion with rhBMP-2 in humans. Publication bias and heterogeneity were assessed mathematically. These data were synthesized in a meta-analysis using DerSimonian-Laird random effects modeling to calculate pooled odds ratios. RESULTS: We identified 26 studies reporting on a total of 184,324 patients (28,815 experimental, 155,509 controls) with a mean age of 51.1 ± 1.8 years. There was a significantly higher risk of general complications with rhBMP-2 compared to iliac crest bone graft (ICBG) with an odds ratio (OR) of 1.78 (95 %CI 1.20-2.63), (p = 0.004). The odds ratio for HO was 5.57 (95 %CI 1.90-16.36), (p = 0.002), for retrograde ejaculation 3.31 (95 %CI 1.20-9.09), (p = 0.020), and for cervical swelling 4.72 (95 %CI 1.42-15.67), (p = 0.011), all significantly higher in the rhBMP-2 group. The pooled odds ratio for new onset of tumor was 1.35 (95 %CI 0.93-1.96), which represents no statistically significant difference between the groups (p = 0.111). CONCLUSION: rhBMP-2 is associated with a higher rate of general complications as well as retrograde ejaculation, HO, and cervical tissue swelling in spine fusion. There is a slightly increased risk of new onset of tumors, however, without statistical significance.

Absorbable and non-absorbable suture fixation results in similar outcomes for tibial eminence fractures in children and adolescents.

PURPOSE: To evaluate efficacy and safety of extraphyseal tibial eminence avulsion fracture repair with absorbable sutures and a distal bone bridge fixation in comparison to previously described technique with non-absorbable sutures and distal screw fixation. METHODS: In a physeal-sparing technique, tibial eminence fractures (n = 25; McKeever type II/III n = 11/14) were either treated in group A (n = 15, follow-up 28.1 months) using an absorbable suture fixed over a bone bridge or in group B (n = 10, follow-up 47.4 months) with a non-absorbable suture wrapped around an extraarticular tibial screw. IKDC and Lysholm scores were assessed, and the difference between the surgical and contralateral knee in anteroposterior (AP) translation, measured with a Rolimeter. RESULTS: There was no significant difference between group A and group B in IKDC and Lysholm scores with 90.1 points ± 10.2 and 94.1 points ± 8.1, respectively (n.s.). AP translation did not differ between groups (n.s.). Eight of ten screws in group B had to be removed in a second intervention. A total of four arthrofibroses were counted (three in group A). CONCLUSION: Extraphyseal tibial eminence repair with absorbable sutures and a distal bone bridge fixation results in similar rates of radiographic and clinical healing at 3 months after surgery as non-absorbable sutures tied around a screw, while avoiding the need for hardware removal. The minimal invasive technique to fix an eminence fracture without any permanent sutures or hardware is advantageous for children. To our knowledge, this is the first study that compares non-absorbable with absorbable sutures for a physeal-sparing technique. LEVEL OF EVIDENCE: III.

Long-term results and outcome predictors in one-stage hip reconstruction in children with cerebral palsy.

BACKGROUND: One-stage hip reconstruction is the gold standard for treatment of hip displacement in children with cerebral palsy. The aims of this study were (1) to report the subjective clinical, objective clinical, and radiographic outcomes; and (2) to investigate outcome predictors, including the influence of the following risk factors: femoral head shape, migration percentage, direction of migration, and age at surgery. METHODS: We reviewed 168 hip reconstructions (eighty-two right, eighty-six left) in 121 patients (101 male, twenty female) at a mean follow-up of 7.3 ± 4.6 years (range, four to eighteen years). Surgical outcomes were assessed on the basis of the pain intensity and frequency (measured on 10-point visual analog scales) as well as GMFCS (Gross Motor Function Classification System) and MCPHCS (Melbourne Cerebral Palsy Hip Classification System) scores and postoperative migration percentage. The effects of femoral head shape, preoperative migration percentage, direction of migration, and age at surgery on surgical outcome were assessed by multivariate regression adjusting for potential confounders including sex, triradiate cartilage status, type of cerebral palsy, and surgical technique. RESULTS: Pain intensity and frequency were reduced significantly. Preoperative femoral head shape had no significant effect on the changes in pain, MCPHCS grade, and GMFCS level. The preoperative migration percentage was the most influential risk factor with respect to postoperative outcome. Age at surgery had no effect on the changes in pain score and GMFCS level. The overall surgical complication rate was 10.5%. CONCLUSIONS: Our data on 168 hip reconstructions at a mean follow-up of seven years showed significant and clinically meaningful improvements in pain intensity and frequency as well as in clinical scores and hip coverage. Analysis of potential risk factors showed only the preoperative migration percentage to have a relevant influence on outcomes.

Platelet-Rich Plasma Reduces Retear Rates After Arthroscopic Repair of Small- and Medium-Sized Rotator Cuff Tears but Is Not Cost-Effective.

BACKGROUND: It has been suggested that platelet-rich plasma (PRP) improves healing after arthroscopic rotator cuff repair. The current literature provides ample but inconsistent data on this topic. PURPOSE: To systematically review the current in vivo evidence for the use of platelet concentrates (PRP) in the arthroscopic treatment of rotator cuff tears to assess effectiveness, safety, and cost-effectiveness. STUDY DESIGN: Meta-analysis and cost-effectiveness analysis. METHODS: Published evidence from controlled, human trials of rotator cuff repair augmented with platelet concentrates was systematically gathered, and data on retear rates were extracted. Mathematical and clinical heterogeneity was evaluated, and fixed-effect meta-analysis was performed to calculate the risk ratio (RR) of retears and the number needed to treat (NNT). Subgroup analyses were made for small/medium tears (n = 404) and large/massive tears (n = 374). Cost-effectiveness was assessed using data from this meta-analysis and using cost data from the literature, including extensive sensitivity analyses, to calculate the incremental cost-effectiveness ratio (ICER). RESULTS: Thirteen studies published between 2010 and 2014 were identified for analysis. The RR for retear for all patients was 0.87 (95% CI, 0.67-1.12; P = .286). For small- and medium-sized tears (<3 cm), the RR for retear was 0.60 (95% CI, 0.37-0.97), consistent with a significant difference in favor of PRP use (P = .038). This translated into an NNT of 14 (95% CI, 7-125). However, at an ICER of US$127,893 per quality-adjusted life year gained, assuming a 5% revision rate, the use of PRP was not cost-effective for small- and medium-sized tears. CONCLUSION: In large tears, even with double-row repair, the beneficial effects of PRP alone are insufficient to compensate the progressed tissue damage. The study data suggest that PRP may promote healing of small- and medium-sized tears to reduce retear rates. However, despite the substantial biological effect, at current cost, the use of PRP is not cost-effective in arthroscopic repair of small- and medium-sized tears.

Patellar tendon shortening for flexed knee gait in spastic diplegia.

UNLABELLED: We evaluated the outcome of three different approaches to the management of flexed knee gait patients with spastic diplegia. The three surgical procedures were patellar tendon shortening (PTS), PTS combined with rotational osteotomies of the femur and/or tibia, and PTS combined with supracondylar extension osteotomy (SEO) of the distal femur. The primary outcome measure was gait kinematics. The knee gait variable score (GVS) and the gait profile score (GPS) were derived from gait kinematics. 24 patients (16 male and 8 female), mean age 16.1 years (SD 5.8 years), who had surgery between 2002 and 2008, were followed for a mean of 22 months. Knee extension during gait improved by a mean of 20° throughout the gait cycle, with an improvement in the knee GVS of 14° (p<0.001). The overall gait pattern improved with a mean decrease in GPS of 4.6°. Correction of patella alta was demonstrated by an improvement in the Koshino index from 1.34 pre-operatively to 1.10 post-operatively (p<0.001). Knee and gait kinematics, physical examination measures and Koshino Index improved in all three surgical groups, suggesting that a tailored approach to the correction of flexed knee gait in spastic diplegia is both feasible and appropriate. LEVEL OF EVIDENCE: Level III.

Addition of autologous mesenchymal stem cells to whole blood for bioenhanced ACL repair has no benefit in the porcine model.

BACKGROUND: Coculture of mesenchymal stem cells (MSCs) from the retropatellar fat pad and peripheral blood has been shown to stimulate anterior cruciate ligament (ACL) fibroblast proliferation and collagen production in vitro. Current techniques of bioenhanced ACL repair in animal studies involve adding a biologic scaffold, in this case an extracellular matrix-based scaffold saturated with autologous whole blood, to a simple suture repair of the ligament. Whether the enrichment of whole blood with MSCs would further improve the in vivo results of bioenhanced ACL repair was investigated. HYPOTHESIS: The addition of MSCs derived from adipose tissue or peripheral blood to the blood-extracellular matrix composite, which is used in bioenhanced ACL repair to stimulate healing, would improve the biomechanical properties of a bioenhanced ACL repair after 15 weeks of healing. STUDY DESIGN: Controlled laboratory study. METHODS: Twenty-four adolescent Yucatan mini-pigs underwent ACL transection followed by (1) bioenhanced ACL repair, (2) bioenhanced ACL repair with the addition of autologous adipose-derived MSCs, and (3) bioenhanced ACL repair with the addition of autologous peripheral blood derived MSCs. After 15 weeks of healing, the structural properties of the ACL (yield load, failure load, and linear stiffness) were measured. Cell and vascular density were measured in the repaired ACL via histology, and its tissue structure was qualitatively evaluated using the advanced Ligament Maturity Index. RESULTS: After 15 weeks of healing, there were no significant improvements in the biomechanical or histological properties with the addition of adipose-derived MSCs. The only significant change with the addition of peripheral blood MSCs was an increase in knee anteroposterior laxity when measured at 30° of flexion. CONCLUSION: These findings suggest that the addition of adipose or peripheral blood MSCs to whole blood before saturation of an extracellular matrix carrier with the blood did not improve the functional results of bioenhanced ACL repair after 15 weeks of healing in the pig model. CLINICAL RELEVANCE: Whole blood represents a practical biologic additive to ligament repair, and any other additive (including stem cells) should be demonstrated to be superior to this baseline before clinical use is considered.