Pediatric ACL Tears: Natural History.

BACKGROUND: Increased participation in youth sports is associated with increased rates of anterior cruciate ligament (ACL) tears in the skeletally immature. Historically, ACL reconstruction was avoided in the skeletally immature, or delayed until skeletal maturity, to avoid physeal injury and growth disturbance. Current practices and meta-analyses support early ACL reconstruction in some groups, to allow for return to activities and to avoid delayed cartilage/meniscus injury. PURPOSE: The purpose of this article was to report on the natural history of ACL injuries in the skeletally immature. METHODS: A review of published literature on pediatric, skeletally immature ACL tears and conservative, nonoperative treatment was conducted via Pubmed articles published from 1970 to 2018. The search criteria included the key terms "anterior cruciate ligament," "pediatric" and/or "adolescent," and "conservative" and/or "nonoperative treatment." A PRISMA workflow was used to narrow down the articles to those relevant to our analysis and available in full text format. RESULTS: Multiple articles on the nonoperative treatment of the ACL showed secondary meniscal and cartilage damage at the time of follow-up. Some articles showed no difference between the rates of secondary injuries between the surgical and nonsurgical treatment groups; however, the nonsurgical treatment groups were often on significant activity modification. Some articles concluded that nonoperative treatment of the ACL tear may be appropriate in low risk, lower level activity patients, and those that will comply with activity restrictions. Even with bracing and PT programs, active athletes treated without surgery appear to have a concerning rate of secondary meniscus injury after the primary ACL injury event. CONCLUSIONS: The natural history of the ACL tear shows nonoperative treatment for the skeletally immature may be a viable treatment pathway for those who are able to comply with the physical activity restrictions. For the general population of young, active adolescents, an ACL injury treated nonoperatively often leads to secondary meniscal and/or cartilage damage, which may lead to knee degeneration and functional instability.

Predicting Ambulatory Function Based on Infantile Lower Extremity Posture Types in Amyoplasia Arthrogryposis.

BACKGROUND: Arthrogryposis multiplex congenita (AMC) is a nonprogressive syndrome with multiple rigid joints, fibrotic periarticular tissue, and muscular fibrosis. The most common subgroup is amyoplasia. Ambulation is one of the most significant functions of the lower extremities as it translates to increased functionality and independence in adulthood. There is no predicative scale to determine ambulation at maturity for the infant with amyoplasia. It is believed lower extremity resting position of infants with amyoplasia potentially correlates with ambulation at maturity. The purpose of this study was to classify the infantile position of lower extremities and muscle strength to predict ambulation potential at maturity. METHODS: Children with amyoplasia were retrospectively reviewed and classified into groups based on infantile position of hip-knee alignment and limb muscle function. Sitting, standing, and walking skills from infancy into adulthood were evaluated. The ambulation function was correlated with the infantile position of the lower extremities. RESULTS: Amyoplasia cases were sorted into 5 types and correlated with ambulatory potential. Type I: mild ambulatory impairment with infantile position of flexed knees and hips but full range of motion. At maturity, all were community ambulators. Type II: moderate ambulatory impairment having infantile position of hip flexion, hip external rotation, and knee flexion contractures. Hip abductors and external rotators had antigravity strength. All stood and walked during the first decade of life with knee ankle foot orthoses. Type III: severe ambulatory impairment having infantile position of hip flexion, abduction, external rotation, and knee flexion contractures but lacked hip muscle recruitment. All used wheelchairs at maturity. Type IV: mild ambulatory impairment with infantile position of extended knees and flexed dislocated hips. At maturity, 90% were community ambulators. Type V: variable ambulatory impairment having asymmetric hip and knee alignment with unilateral hip dysplasia with extended knee and opposite limb flexed. Ambulation skill varied at maturity with 27% full-time wheelchair users. CONCLUSIONS: Amyoplasia can be sorted by infantile position of lower extremities and muscle strength into 5 types to predict ambulatory function. LEVEL OF EVIDENCE: Level III-Prognostic Study.

Referencias argentinas de estatura sentada y longitud de miembros inferiores de 0 a 18 años / Argentine reference values for sitting height and lower limb length between 0 and 18 years of age

Para el seguimiento del crecimiento de niños con severa malformación de miembros inferiores o de columna, disponer de referencias de estatura sentada (ES) y de miembros inferiores (MI) según edad es una herramienta de gran utilidad. Objetivos: estimar los centilos de ES y MI para ambos sexos, entre 0 a 18 años de edad y evaluar la utilidad de estas referencias en niños con malformaciones localizadas en MI o columna. Material y Métodos: los centilos 3°,10°, 25°, 50°, 75°, 90° y 97° de ES y MI según Edad (SE/E y MI/E) fueron estimados en una población sana de 4803 y 4818 varones y mujeres respectivamente, por el método LMS que utiliza la transformación BOX-COX para normalizar la distribución de los datos a cada edad. Resultados: en los primeros años de edad, la mediana de ES en ambos sexos fue similar. Entre los 11 y 13 años, las niñas tuvieron una ES mayor a la de los varones, pero luego se invirtió y se mantuvo así hasta la adultez. En MI la mediana también fue similar en ambos sexos durante los primeros años, pero a partir de los 12 el incremento fue mayor en los varones. A los 12 años la diferencia fue 0,71 cm, finalizando con 9 cm a los 18 años. El uso de estas referencias en niños con malformaciones de columna ó MI mostró un crecimiento patológico de estatura total y del segmento corporal comprometido, con un tamaño y crecimiento normal del segmento no afectado. Conclusión: los centilos de segmentos corporales según la edad constituyen una herramienta útil para la supervisión del crecimiento de niños con severa malformación de columna o miembros inferiores (AU)

For the follow-up of growth of children with severe lower-limb or spinal deformities, reference values for sitting height (SH) and lower-limb (LL) length according to age are extremely useful. Aims: To define percentiles of SH and LL for both sexes between 0 and 18 years of age and evaluate the usefulness of these references in children with LL or spinal deformities. Material and Methods: 3rd,10th, 25th, 50th, 75th, 90th, and 97th percentiles for SH and LL according to age (SE/age and LL/age) were estimated for a healthy population of 4803 and 4818 boys and girls, respectively, with the LMS method that uses the Box-Cox power exponential (BCPE) to normalize data distribution for age. Results: In the first years of life, mean SH was similar for both sexes. Between 11 and 13 years of age, girls had a greater SH than boys, but this relationship subsequently inverted and remained so until adulthood. The median length of LL was also similar in the first years of life, but after 12 years of age growth was increased in boys. At 12 years of age the difference was 0.71 cm, with a final difference of 9 cm at 18 years of age. The use of these reference values in children with spinal or LL deformities showed pathological growth of the whole body and the body segment involved with normal growth of the nonaffected segment. Conclusion: percentiles of the body segments according to age are a useful tool for the monitoring of growth of children with severe deformities of the spine or lower limbs (AU)

Limits of Growth Modulation Using Tension Band Plates in the Lower Extremities.

Growth modulation using tension band plates (TBP) has been shown to be a safe, effective, and popular method for correcting pediatric frontal plane angular deformity around the knee. Recently, TBPs have been used to achieve reversible epiphysiodesis to treat limb-length discrepancy. Many surgeons have expanded the indications to include diagnoses other than frontal plane angular deformities, anatomic sites other than the knee, and correction of sagittal and oblique plane deformities. Despite the rapid acceptance of TBPs, the limits of this option have not been explored. We undertook a systematic literature review and found that the success rate for idiopathic cases approaches 100% with a low complication rate. Pathologic cases have a slightly lower success rate and a higher complication rate. The potential to avoid osteotomy with growth modulation makes TBPs a reasonable option for all but the most extreme pediatric frontal and sagittal plane lower extremity deformities. Applications to hip deformities remain unproven.

Histoenzymatic and morphometric analysis of muscle fiber type transformation during the postnatal development of the chronically food-deprived rat.

We analyze the effect of chronic undernourishment on extensor digitorum longus (EDL) muscle maturation in the rat. Cytochrome c oxidase (COX) and alkaline ATPase histoenzymatic techniques were used to determine the relative proportion of different fiber types (oxidative/glycolytic and type I, IIa/IId, or IIb, respectively) and their cross-sectional area in control and undernourished EDL muscles at several postnatal (PN) ages. From PN days 15 to 45, undernourished EDL muscles showed predominance of oxidative and type IIa/IId fibers, but from PN days 60 to 90, there were a larger proportion of oxidative fibers and an equal proportion of type IIa/IId and IIb fibers. Meanwhile, in adult stages (from PN days 130-365), the relative proportion of fiber types in control and undernourished EDL muscles showed no significant differences. In addition, from PN days 15 to 90, there was a significant reduction in the cross-sectional area of all fibers (slow: 13-53%; intermediate: 24-74%; fast: 9-80%) but no differences from PN days 130 to 365. It is suggested that chronic undernourishment affects the maturation of fast-type muscle fibers only at juvenile stages (from PN days 15-45) and the probable occurrence of adaptive mechanisms in muscle fibers, allowing adult rats to counterbalance the alterations provoked by chronic food deprivation.

Growth disturbance after lengthening of the lower limb and quantitative assessment of physeal closure in skeletally immature patients with achondroplasia.

This study evaluated the effect of limb lengthening on longitudinal growth in patients with achondroplasia. Growth of the lower extremity was assessed retrospectively by serial radiographs in 35 skeletally immature patients with achondroplasia who underwent bilateral limb lengthening (Group 1), and in 12 skeletally immature patients with achondroplasia who did not (Group 2). In Group 1, 23 patients underwent only tibial lengthening (Group 1a) and 12 patients underwent tibial and femoral lengthening sequentially (Group 1b). The mean lengthening in the tibia was 9.2 cm (59.5%) in Group 1a, and 9.0 cm (58.2%) in the tibia and 10.2 cm (54.3%) in the femur in Group 1b. The mean follow-up was 9.3 years (8.6 to 10.3). The final mean total length of lower extremity in Group 1a was 526.6 mm (501.3 to 552.9) at the time of skeletal maturity and 610.1 mm (577.6 to 638.6) in Group 1b, compared with 457.0 mm (411.7 to 502.3) in Group 2. However, the mean actual length, representing the length solely grown from the physis without the length of distraction, showed that there was a significant disturbance of growth after limb lengthening. In Group 1a, a mean decrease of 22.4 mm (21.3 to 23.1) (4.9%) was observed in the actual limb length when compared with Group 2, and a greater mean decrease of 38.9 mm (37.2 to 40.8) (8.5%) was observed in Group 1b when compared with Group 2 at skeletal maturity. In Group 1, the mean actual limb length was 16.5 mm (15.8 to 17.2) (3.6%) shorter in Group 1b when compared with Group 1a at the time of skeletal maturity. Premature physeal closure was seen mostly in the proximal tibia and the distal femur with relative preservation of proximal femur and distal tibia. We suggest that significant disturbance of growth can occur after extensive limb lengthening in patients with achondroplasia, and therefore, this should be included in pre-operative counselling of these patients and their parents.

Relação entre o uso do calçado de salto alto e o encurtamento da musculatura posterior de membro inferior e tronco / Relationship between high heeled footwear use and muscle shortening of trunk and lower limb

Objetivo: Identificar a relação entre o uso do salto alto e o encurtamento da musculatura posterior de membros inferiores e tronco. Métodos: Foi realizado um estudo transversal com uma amostra por conveniência que incluiu 50 mulheres divididas em 2grupos. Grupo 1: mulheres que usavam apenas calçado sem salto ou de até 3 cm e no grupo 2 mulheres que usam salto alto ≥ 10cm. Resultados: A análise estatística mostrou maior encurtamento muscular no grupo das mulheres que usavam calçados de salto alto com diferença estatisticamente significativa [t(48) = 2,92; p =0,005] e correlação negativa fraca e sem significância estatística (r =-0,340; p = 0,096) com o tempo de uso do mesmo. Conclusão: As mulheres que utilizavam calçados de salto alto apresentaram maior tendência ao encurtamento da musculatura posterior de membros inferiores e tronco quando comparadas às mulheres que utilizavam preferencialmente calçados sem saltos.

Objective: To assess the relationship between using high heels and shortening of the posterior muscles of the lower limbs and trunk through the test bank Wells. Methods: Was conducted across-sectional study with a convenience sample that included 50 women divided into 2 groups. Group 1: women wearing only shoes without heels or ≤ 3 cm and in group 2 women using high heel ≥10 cm. Results: Statistical analysis showed greater muscle shorteningin the group of women who wore high-heeled shoes with a statistically significant difference [t (48) = 2.92, p = 0.005] and a weak negative correlation and no statistical significance (r = - 0.340, p= 0.096) with duration of use of it. Conclusion: Women who used high-heeled shoes were more likely to shortening of the posterior muscles of the legs and torso when compared to women who used preferably shoes without heels.

Comparative osteometric study of long bones in Yankasa sheep and red Sokoto goats / Estudio osteométrico comparativo de los huesos largos entre oveja Yankasa y las cabras rojas Sokoto

A morphometric study was undertaken on the long bones in the two predominant breeds of small ruminant in Northern Guinea Savanna zone of Nigeria, to determine their anatomical differences and thus, provide a means of differentiating the remains of these two species during zooarchaeological studies and gross anatomy practical session. The pelvic and pectoral limbs from thirty animals (15 Yankasa sheep and 15 Red Sokoto goats) of both sexes were used for this study. The long bones of the pectoral limbs considered were the humerus, radius, ulna and metacarpal III while those of the pelvic limbs were the femur, tibia and metatarsal III. The parameters considered were the mean weights, lengths and diameters of the proximal extremity, mid-shaft and distal extremities of these bones. The result of this study showed that there is a very high statistically significant difference (p < 0.001) in the length of long bones between the two species, with that of the Yankasa sheep being significantly longer than the Red Sokoto goat. Also, the differences in weights as well as diameters of the proximal, middle and distal shafts of the tibia between the two species are of a very high statistical importance (p < 0.001). Conversely, the differences in the proximal and distal diameters of the femur between the two species are not statistically significant (p > 0.05). Factors that may be responsible for these differences were discussed. It is concluded that the bones of the Yankasa sheep and Red Sokoto goat can be differentiated by the disparity in the length of these long bones or the disparity in the entire morphometry of the tibia bone.

Se realizó un estudio morfométrico en los huesos largos en las dos razas predominantes de pequeños rumiantes del norte de Guinea, zona de Sabana de Nigeria, para determinar sus diferencias anatómicas y proporcionar un medio de que permita diferenciar los restos, de estas dos especies, durante los estudios zooarqueológico y en además en práctica de anatómica. Se utilizaron los miembros pélvicos y pectorales de treinta animales (15 ovejas Yankasa y 15 cabras rojas de Sokoto) de ambos sexos. Los huesos largos de los miembros pectorales considerados fueron: húmero, radio, ulna y III metacarpiano, mientras que en los miembros pélvicos fueron: fémur, fíbula y el III metatarso. Los parámetros considerados fueron los pesos medios, longitudes y diámetros de la extremidad proximal y tercios medio y distal de estos huesos. Los resultados mostraron que existe una diferencia altamente significativa (p <0,001) en la longitud de los huesos largos entre las dos especies. Los huesos en las ovejas Yankasa son significativamente más largos que los de la cabra roja de Sokoto. Además, de las diferencias en el peso, así como los diámetros de los ejes proximal, media y distal de la fíbula entre las dos especies son estadísticamente significativos (p <0,001). Por el contrario, las diferencias en los diámetros proximal y distal del fémur entre las dos especies no son estadísticamente significativas (p> 0,05). Fueron discutidos los factores que pueden ser responsables de estas diferencias. Se concluye que los huesos de las ovejas y cabras Yankasa Red Sokoto, se pueden diferenciar por la disparidad en la longitud de los huesos largos o en la morfometría de la tibia.

Permanent brachial plexus birth palsy does not impair the development and function of the spine and lower limbs.

Permanent brachial plexus birth palsy (BPBP) impairs the function of the affected upper limb. Avulsion type root injuries may damage the cervical spinal cord. Whether abnormal function of an upper limb affected by BPBP has any observable effects on the development of the locomotion system and overall motor function has not been clarified in depth. A total of 111 patients who had undergone brachial plexus surgery for BPBP in infancy were examined after a mean follow-up time of 13 (5-32) years. Patients' physical activities were recorded by a questionnaire. No significant inequalities in leg length were found and the incidence of structural scoliosis (1.7%) did not differ from that of the reference population. Nearly half of the patients (43%) had asynchronous motion of the upper limbs during gait, which was associated with impaired upper limb function. Data obtained from the completed questionnaires indicated that only few patients were unable to participate in normal activities such as: bicycling, cross-country skiing or swimming. Not surprisingly, 71% of the patients reported problems related to the affected upper limb, such as muscle weakness and/or joint stiffness during the aforementioned activities.

The suspensory apparatus and digital flexor muscles of the llama (Lama glama) 2: The pelvic limb / El aparato suspensorio y los músculos flexores digitales de la llama (Lama glama) 2: El miembro pélvico

This paper provides data (text and illustrations) about the digital flexor muscles of the pelvic limb and the / metatarsophalangeal joint, evaluating the suspensory (support) apparatus and weight bearing structures. Similar to the above mentioned paper, a literature search provided incomplete information about these anatomical structures. As in the thoracic limb, unique anatomically variations exist in the pelvic limb of the llama. The caudal tibial muscle is fused with the lateral head of the deep digital flexor muscle (DDF), and the soleus muscle is missing. A symmetrical unexpected lumbricalis pedis muscle was found; the tendons are fusing with the axial branches of the lateral tendon of the long digital extensor muscle. A quadratus plantae muscle, also unexpected is present on the medial aspect of the tarsal region. The superficial digital flexor muscle (SDF) resembles that of the domestic ruminants. The metacarpo/ metatarsophalangeal joints, referred to as the fetlock joints (FJ) are very different from those of the domestic ruminants. Particular structures were found and they will be described and illustrated in the text. The anatomy of the suspensory (support) apparatus in the pelvic limb is evaluated in this paper.

El presente artículo ofrece datos (texto e ilustraciones) sobre el músculo flexor digital del miembro pélvico y la articulación metatarsofalángica, evaluando el aparato suspensorio (de apoyo) y el peso que soportan estas estructuras. La literatura proporciona información incompleta acerca de estas estructuras anatómicas. Al igual que en el miembro torácico, existen variaciones anatómicamente únicas en el miembro pélvico de la llama. El músculo tibial caudal se fusiona con la cabeza lateral del músculo flexor digital profundo (FDP), y el músculo soleo no existía. Fue encontrada una simetría inesperada del músculo lumbrical del pie; los tendones se encontraban fusionados con las ramas axiales del tendón lateral del músculo extensor digital largo. Un músculo cuadrado plantar, se encontraba presente en la cara medial de la región tarsal. El músculo flexor digital superficial (FDS) se asemeja al de rumiantes domésticos. Las articulaciones metacarpo/metatarsofalángicas, denominadas articulaciones del nudillo (AN) son muy diferentes de las de rumiantes domésticos. Fueron encontradas estructuras particulares que se describen e ilustran en el texto. Se evalúa la anatomía del aparato suspensorio (de apoyo) en el miembro pélvico.

Multiplier method for prediction of adult height in patients with achondroplasia.

To date, the only way to predict adult height in achondroplastic dwarves has been to consult a growth chart. The purpose of this study was to ascertain whether the multiplier method of predicting adult height at skeletal maturity in healthy persons can be applied to persons with achondroplasia. Previous studies have shown that the multiplier method can be applied to lower limb length, upper limb length, total height, foot length, and foot height. It is therefore reasonable to suggest that the growth pattern for total height in achondroplastic dwarves might also be characterized by a multiplier. Total height multipliers for achondroplastic dwarves ("achondroplasia height multipliers") were calculated from two separate databases by dividing height at maturity by height at each respective age for both genders. Little variability was found among multipliers for each age and among multipliers calculated from different databases. Upper torso (sitting height) multipliers and lower limb multipliers were also derived for achondroplastic dwarves. Lower limb and total height growth rates were slower in achondroplastic dwarves compared with healthy persons. However, sitting height multipliers for achondroplastic dwarves were closely related to sitting height multipliers for healthy persons. Because these findings showed that the multiplier values were independent of population and percentile, the multiplier method may be a valid method for quickly predicting height at any age for achondroplastic dwarves.

Development of the adult leg epidermis in Manduca sexta: contribution of different larval cell populations.

During metamorphosis of the tobacco hornworm Manduca sexta, the simple thoracic legs of the larva are remodeled into the more complex adult legs. Most of the adult leg epidermis derives from the adult primordia, small sets of epidermal cells located in specific regions of the larval leg, which proliferate rapidly in the final larval instar. In contrast, the contribution of the epidermal cells outside the primordia is unknown. In this study we have determined their contribution to the adult leg by labeling them with 5-bromodeoxyuridine (BUdR) and following their fate. Although the labeled cells diminished drastically in number, small groups of these cells persisted into the midpupal stage suggesting that they do contribute to the adult leg epidermis. We also found that during the wandering stage the adult primordia went through active proliferation and very little cell death, while the cells outside the primordia went through extensive cell death accounting for the decrease in their number. Our results indicate that two distinct cell populations exist outside the adult primordia. Most cells belong to the first population, which is larval-specific and disappears through apoptosis early in metamorphosis. The second population consists of polymorphic cells that contribute to the larval, pupal and adult leg epidermis.

Alterações posturais decorrentes da discrepancia dos membros inferiores / Posture disorders in consequense of lower limb discrepancy

Os menbros inferiores tem seu crascimento individualizado.a populaçao apresenta 50 por cento de discrepancia entre os mesmos. Essa afecçao leva a alteraçao da biomecanica esqueletica exigindo adaptaçao postural mum processo ascendente, na qual encontramos obliquidade pelvica e escoliose. O presente estudo foi realizado com po proposito de diagnosticar de modo precoce e preciso a discrepancia de membros inferiores. Quatro pacientes(2 homens e2 mulheres)com discrepancia de membros inferiores foram avaliados atraves da fita metrica e exame de escanometria, e todos apresentaram o membro inferior esquerdo menor. As fotografias foram realizadas com os individuos alinhados em frente ao simetografo, nas vistas anterior, posterior, laterais esquerda edireita e flexao anterior da coluna. As medidas obtidas variaram de 1cm e2,5cm. Nas analise das fotografias, todod os sujeitos apresentaram praticamente as mesmas alteraçoes posturais como: rotaçao de tronco á direita, pelve assim como as espinhas iliacas anterior e posterior superior, prega glutea e linha poplitea mais elevada a direita, alem de outras alteraçoes menos significativas. Os metodos utilizados mostraram cinfiabilidade no diagnostico das discrepancias, no qual a mensuraçao por fita metrica foi confirmada pelos exames de escanometria. Os recursos fotograficos permitiram minuciosa avaliacao das alteraçoes posturais sem submeter o paciente ao desconforto da manutençao estatica por longo tempo.