The German version of the KOOS-Child questionnaire (Knee injury and Osteoarthritis Outcome Score for children) shows a good to excellent internal consistency and a high test-retest reliability in children with knee problems.

PURPOSE: The Knee Injury Osteoarthritis Outcome Score for children (KOOS-Child) is a self-administered, valid and reliable questionnaire for children and adolescents with knee disorders such as Osgood Schlatter disease, anterior knee pain, and patella dislocation. This study aimed to cross-culturally adapt the German version of the KOOS-Child questionnaire and test the reliability in two groups of children, one treated conservatively and the other surgically. METHODS: A forward-backward translation of the original questionnaire into the German language was conducted. Children and adolescents between 10 and 18 years of age with knee disorders were included. Two groups were compared: sample one consisted of 24 participants with knee pain [20.8% boys; mean age = 13.4 (1.8) years treated conservatively. These participants completed the KOOS-Child questionnaire twice within two weeks to assess test-retest reliability. The second sample included 23 subjects (21.7% boys; mean age = 15.3 (1.9) years] treated surgically due to a knee disorder. They completed the questionnaire before surgery and six months postoperatively. Test-retest reliability and internal consistency were assessed using Spearman's rank correlation and Cronbach's alpha. RESULTS: All subscales showed a good to excellent internal consistency at both measurement points in both groups (conservatively treated group: a = 0.88-0.95; surgery group a = 0.80-0.91), with the exception of the subscale knee problems (conservatively treated: a = 0.60 and 0.52; surgery: α = 0.77 and 0.66). Test-retest reliability was between r = 0.85 and 0.94. CONCLUSION: The predominantly good to excellent internal consistency and the high test-retest reliability justifies the use of the German adaptation of the KOOS-Child questionnaire as a reliable multidimensional instrument for measuring health status and therapeutic effects in adolescents' knee disorders.

Elevated hip adduction angles and abduction moments in the gait of adolescents with recurrent patellar dislocation.

INTRODUCTION: Impaired hip kinematics and kinetics may incite patellar instability. This study tested the hypothesis that hip adduction and internal rotation angles during gait are higher in adolescents with recurrent patellar dislocations compared to healthy controls. MATERIAL AND 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). Peak hip, knee and pelvis kinematics and kinetics were captured using 3D-gait analysis (VICON, 12 cameras, 200 Hz, Plug-in-Gait, two force plates) and compared between the two groups. One cycle (100%) consisted of 51 data points. The mean of six trials was computed. RESULTS: Peak hip adduction angles and abduction moments were significantly higher in patients with recurrent patellar dislocation compared to the control group (p < 0.001 and 0.002, respectively). Peak internal hip rotation did not differ significantly. CONCLUSION: Elevated hip adduction angles and higher hip abduction moments in gait of adolescents with recurrent patellar dislocation may indicate an impaired function of hip abductors that contributes to patellar instability.

Meniscal rim instability has a high prevalence and a variable location.

INTRODUCTION: Most classification systems for lateral discoid meniscus do not evaluate instability of the meniscal peripheral rim. Considerable variability in the prevalence of peripheral rim instability has been published, and it appears that instability is underestimated. The purpose of this study was: first, to evaluate the prevalence of peripheral rim instability and its location in the symptomatic lateral discoid meniscus, and second, to investigate if patient age or type of discoid meniscus are possible risk factors for instability. METHODS: A cohort of 78 knees that underwent operative treatment due to symptomatic discoid lateral meniscus was analyzed retrospectively for the rate and location of peripheral rim instability. RESULTS: Out of the 78 knees, 57.7% (45) had a complete and 42.3% (33) had an incomplete lateral meniscus. The prevalence of peripheral rim instability in symptomatic lateral discoid menisci was 51.3%, and with 32.5%, the anterior attachment was most commonly affected, followed by the posterior (30%) and central (10%) attachment. 27.5% of the tested menisci were unstable anteriorly and posteriorly. There was no significant difference in the prevalence of rim instability between the type of discoid menisci (complete vs. incomplete), nor was there a significant correlation for age as a risk factor for instability. CONCLUSION: The discoid lateral meniscus has a high prevalence and variable location of peripheral rim instability. Meniscal rim stability must be tested and addressed cautiously in all parts and in all types of discoid lateral menisci during operative treatment.

Single-Event Multi-Level Surgery in Cerebral Palsy: A Bibliometric Analysis.

Background and Objectives: Single-Event Multi-Level Surgery (SEMLS) is a complex surgical programme in which soft tissue contractures and bony torsional deformities at the ankle, knee and hip, in both lower limbs are surgically corrected during a single operative session, requiring one hospital admission and one period of rehabilitation. The aim of SEMLS is to improve gait and function in ambulant children with cerebral palsy. Utilisation of the SEMLS concept can reduce the number of surgical events, hospital inpatient stays and reduce rehabilitation requirements to a single intensive episode. Three-dimensional gait analysis is a pre-requisite to plan intervention at multiple anatomic levels to correct fixed deformities and to improve gait and function. Materials and Methods: This study was a bibliometric analysis of SEMLS in cerebral palsy using the Clarivate Web of Science Core Collection database from 1900 to 29 May 2023. Results: A total of 84 studies met the inclusion criteria. The most highly cited article was "Correction of severe crouch gait in patients with spastic diplegia with use of multilevel orthopaedic surgery" by Rodda et al. (2006) with 141 citations. The most productive institutions by number of articles were the Royal Children's Hospital Melbourne (Australia), Murdoch Children's Research Institute (Australia) and University of Melbourne (Australia). The most productive author by number of citations was HK Graham (Australia). Conclusions: The literature base for SEMLS consists largely of retrospective cohort studies. The aforementioned three institutes in Melbourne, Australia, which frequently collaborate together, have contributed the greatest number of studies in this field.

Hip reconstruction in closed triradiate cartilage: long-term outcomes in patients with cerebral palsy.

INTRODUCTION: Hip reconstruction is an established procedure in pediatric patients with neurogenic hip dislocation. An open triradiate cartilage provides the advantage of a high plasticity of the bone which prevents an intraarticular fracture and postoperative adaptation of shape. Some patients with dislocated hips, however, arrive late. A hip reconstruction is still feasible as shown earlier but the long-term risk for osteoarthritis, and recurrence of dislocation, and functional outcome is unknown. It is the aim of our investigation to evaluate long-term clinical and radiological outcomes of hip reconstruction by Dega type pelvic osteotomy performed after fusion of the triradiate epiphyseal cartilage in patients suffering from cerebral palsy. MATERIAL AND METHODS: We retrospectively analyzed 43 hips in 37 patients with a hip reconstruction for correction of hip dislocation or subluxation. In all patients, the triradiate cartilage was fused before surgery. Age at surgery was 15 years and 2 months on average and follow-up time was mean 13 years 5 months. RESULTS: Mean Kellgren Lawrence score at final follow-up was significantly higher than at preoperative investigation (P < 0.00001). At long-term follow-up 3 of 43 hips had developed pain, and 1 of them required arthroplasty. Reimers´ migration index was stable over the years and was not higher at last follow-up compared to the index observed shortly after surgery (P = 0.857), so was the Sharp angle (P = 0.962). We found no significant reduction in the range of motion of the hip in the sagittal plane. CONCLUSION: We noted mild radiological signs of osteoarthritis which possibly occur due to an intraarticular acetabulum fracture during bending down the acetabulum. Nevertheless, hip reconstruction in patients with cerebral palsy and closed triradiate cartilage remains a valuable option as it results in a stable, painless hip for more than a decade.

Short-term outcome of double-shelled braces in neuromuscular scoliosis.

INTRODUCTION: Scoliosis in patients with neuromuscular disease is a common issue and leads to secondary impairment. It is thus important to help such patients to regain and retain best possible stability to improve their quality of life. One option is the double-shelled brace (DSB). The aim of this study was to provide information on the degree of correction when using a DSB on patients with neuromuscular scoliosis. METHODS: We included patients with neuromuscular scoliosis treated with double-shelled braces in this retrospective study. Radiographs of the full spine were taken with and without the DSB, the Cobb angles were measured and compared. The correction was expressed in percent of the lumbar and thoracic Cobb angles. In addition, compounding factors such as age, sex, type of the curves, and movement disorder were included. RESULTS: We analyzed data from 84 patients with scoliosis with different neuromuscular disorders. The mean age was 12.3 years (± 5.9). In the lumbar spine we detected an improvement of 27.5% (SD ± 32.9), in the thoracic spine 25.3% (SD ± 38.0). INTERPRETATION: Short-term corrections with a double-shelled brace in neuromuscular scoliosis present an average improvement of one fourth of the lumbar and thoracic Cobb angles and, independent of age, sex, movement disorder, shape or type of the curve. Only spasticity has an influence on the lumbar scoliosis outcome.

Conservative Trio-Therapy for Varus Knee Osteoarthritis: A Prospective Case-Study.

Background and Objectives: Knee osteoarthritis (OA) is a frequent cause of pain, functional limitations, and a common reason for surgical treatment, such as joint replacement. Conservative therapies can reduce pain and improve function; thus, delaying or even preventing surgical intervention. Various individual conservative therapies show benefits, but combination therapies remain underexplored. The aim of this prospective case-study was to assess the effect of a conservative combination therapy in patients with painful varus knee OA. Materials and Methods: With strong inclusion and exclusion criteria, nine patients with painful varus knee OA (mean age 56 years (range 51−63 years) were selected and monitored over six months, using the following clinical outcome scores: pain visual analog scale (VAS), Western Ontario and McMaster Universities osteoarthritis index (WOMAC score), short-form−36 items (SF-36) quality of life score, and the sports frequency score. All patients received a standardized conservative trio-therapy with varus-reducing hindfoot shoe-insoles with a lateral hindfoot wedge, oral viscosupplementation, and physiotherapy for six months. Results: The pain was reduced significantly from initial VAS values of 5.4 points (range, 3−10) to values of 0.6 points (range, 0−3; p < 0.01), at the end of treatment. After six months, seven out of nine patients reported no pain at all (VAS 0). The WOMAC score improved significantly, from initial values of 35 (range, 10−56) to values of 2 (range, 0−9; p < 0.01). The SF-36 score showed significant improvement after six months in all four domains of physical health (p < 0.01) and in two of the four domains of mental health (p < 0.05). The sports frequency score increased by at least one level in six out of nine patients after six months. Conclusions: The conservative trio-therapy in patients with varus knee OA showed positive initial clinical results: less pain, higher function, better quality of life, and higher sport activity. Further studies are required to evaluate the long-term effect.

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.

High failure rate 10.8 years after vastus medialis transfer and lateral release (Green's quadricepsplasty) for recurrent dislocation of the patella.

PURPOSE: In adolescent patients with recurrent patellar dislocation, the Green's quadricepsplasty stabilizes the patella in a combination of a lateral release, a transfer of the medial head of the quadriceps onto the lateral part of the patella and an imbrication of the medial patellar retinaculum and joint capsule. This study aimed to evaluate the long-term performance, considering re-dislocations and functional outcomes. We hypothesized a high failure rate in the long term. METHODS: In this single surgeon and single center study 26 knees in 23 patients (mean age 14.2 years; 4-22 years, 18 females) with recurrent patellofemoral dislocation underwent a vastus medialis transfer, medial reefing and lateral release as it was described by Green in 1965 with a mean follow-up 10.8 years (6-24 years). Clinical assessment was carried out with an IKDC-score (international knee documentation committee) and a self-assessment for each knee separately. The radiologic evaluation included measurement of the patella height, the grade of trochlear dysplasia and the sulcus angle. RESULTS: In 12 of 26 cases (46.2%) the patella did not re-dislocate after vastus medialis transfer and lateral release. In 11 of 26 cases (42.3%), the patients described the function of their knees as normal or nearly normal according to IKDC after the surgical treatment without any re-dislocation. In 14 of 26 cases (53.8%), the patella re-dislocated. 7 of these 14 cases underwent a revision operation. Re-dislocations occurred after a mean interval of 21 months after the index procedure. In only 2 of 26 cases (7.7%) the patients returned to sports. CONCLUSION: Green's procedure to stabilize patellofemoral instabilities results in a high failure rate on the long-term and low subjective assessments. We do not recommend performing vastus medialis transfer, medial imbrication and lateral release as a standalone technique. LEVEL OF EVIDENCE: IV.

Surgical treatment of patellofemoral instability using trochleoplasty or MPFL reconstruction: a systematic review.

PURPOSE: Trochleoplasty and reconstruction of the medial patellofemoral ligament (MPFL) are among the most commonly performed surgical treatments in patients with patellofemoral instability. The primary purpose of the study was to perform a systematic literature review on trochleoplasty in the treatment of patients with patellofemoral instability. The secondary purpose was to compare the outcomes with those seen in patients treated after reconstruction of the MPFL. METHODS: A standardised search on search engines was performed. All observational and experimental studies dealing with trochleoplasty were then obtained and reviewed in a consensus meeting. Fifteen articles out of 1543 were included and analysed using the CASP appraisal scoring system. Twenty-five studies on MPFL reconstruction were obtained for comparison. The clinical and radiological outcomes were statistically analysed. RESULTS: Both treatment groups showed significant improvement in outcomes from pre- to post-operatively. The mean post-operative Kujala and the Lysholm scores significantly increased in both groups when compared to preoperatively (trochleoplasty group: Kujala 61.4-80.8 and Lysholm 55.5-78.5; MPFL group: Kujala 46.9-88.8 and Lysholm 59.9-91.1). Post-operatively a positive apprehension test was found in 20 and 8 % of the trochleoplasty and MPFL groups, respectively. No significant differences in redislocation (2 %) and subluxation (5-6 %) rates were found. CONCLUSIONS: This systematic review showed that both trochleoplasty and MPFL reconstruction are able to deliver good clinical outcomes with stable patellofemoral joints. LEVEL OF EVIDENCE: III.

Meniscal injuries in children and adolescents undergoing surgical treatment for tibial eminence fractures.

PURPOSE: To prospectively evaluate the prevalence and characteristics of meniscal injuries in children and adolescents undergoing surgical treatment for tibial eminence fractures and to test for possible relationships between associated meniscal lesions and patient demographics or injury characteristics. METHODS: A prospective multicenter study was conducted to arthroscopically assess the prevalence and characteristics of meniscal injuries in children and adolescents undergoing surgical treatment for tibial eminence fractures between 04/2014 and 10/2015. Patient demographics and injury characteristics were assessed preoperatively. The presence of a meniscal injury was evaluated arthroscopically and characterized according to tear type and location (Cooper classification). Patients with and without meniscal injuries were compared with regard to sex, age, height, weight, BMI, type of injury, mechanism of injury, time to surgery, Tanner stage, sexual maturity (prepubescent vs. pubescent), and modified Meyers and McKeever classification. RESULTS: A total of 54 consecutive patients (65 % males, mean age: 12.5 ± 3.2 years) were enrolled. Meniscal injury were found in 20 patients (37 %). The lateral meniscus was involved in 18 patients (90 % of all meniscus injuries) and the medial meniscus in 2 patients (10 % of all meniscus injuries). The most common tear pattern was a longitudinal tear of the posterior horn of the lateral meniscus (30 % of all meniscus injuries) and the second most common tear was a root detachment of the anterior horn of the lateral meniscus (20 % of all meniscus injuries). Higher age, advanced Tanner stage, and pubescence were significantly associated with an accompanying meniscal injury. CONCLUSION: Meniscal injuries in children and adolescents undergoing surgical treatment for tibial eminence fractures must be expected in almost 40 %, with a higher prevalence with increasing age and sexual maturity. With regard to the clinical relevance, the results of the present study argue in favor for magnetic resonance imaging prior to surgery in every patient with a suspected tibial eminence fracture and for an arthroscopic approach to adequately diagnose and treat meniscal injuries. LEVEL OF EVIDENCE: II.

Platelet concentrates in spine fusion: meta-analysis of union rates and complications in controlled trials.

PURPOSE: Platelet concentrates in spine fusion gained increasing popularity among spine surgeons. They avoid morbidity of bone harvest and promise good union rates without additional device-related adverse events. Therefore, they seem to be a safe and effective alternative to common bone substitutes. This meta-analysis assesses the available evidence for union rate and overall complications with the use of platelet concentrates in spine fusion. METHODS: We conducted an online search for relevant controlled trials and extracted data on union rates, complications, and revision rates. These data were synthesized in a meta-analysis using fixed-effects odds ratios (OR). To assess covariates, meta-regression was performed as well. RESULTS: Our search produced 166 results, ten of which were eligible for inclusion. These studies report on a total of 763 patients (328 experimental, 435 controls) with a mean age of 50.3 ± 7.5 years. Mean follow-up was 1.9 ± 0.0.4 years. With the use of platelet concentrates, union rate decreased significantly, OR 0.53 (95 % CI 0.35-0.79, p = 0.002), compared with the control group. There was no statistically significant difference in complication rates OR 1.34 (95 % CI 0.62-2.90, p = 0.46) or in revision rates OR 3.0 (95 % CI 0.90-10.00, p = 0.74). Meta-regression showed no statistically significant influence of randomization, Jadad score, or assessment of fusion. CONCLUSION: The use of platelet concentrates in spine fusion shows significantly decreased union rates compared with the control group. However, complication and revision rates were not significantly increased. The current data do not recommend the use of platelet concentrate in spine fusion.

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.

The effect of knee flexion and rotation on the tibial tuberosity-trochlear groove distance.

PURPOSE: The purpose was to measure the effect of flexion and additional rotation of the femur relative to the tibia on the tuberosity-trochlear groove distance (TT-TG) in the same subject in 20 cadaveric knees joint. METHODS: In 20 human adult cadavers, formal fixed knees (age: 81.9 years, SD 12.3; 10 female) CT scans were performed in extension and 30° of flexion as well as in neutral, maximal possible internal (IR), and external rotation (ER). On superimposed CT scan images, TT-TG was measured in each position. TT-TG measurements were correlated in all knee positions. RESULTS: TT-TG in full extension/neutral rotation was 7.8 mm (SD 3.4, range, 2.4-15.3). TT-TG in full extension and IR was significantly lower, and TT-TG in full extension and ER was significantly higher than in neutral rotation (5.4 ± 2.3 vs. 10.9 ± 4.8 mm; P < 0.001). IR and ER varied between 1.0°-7.6° and 0.2°-9.2°, respectively. TT-TG in 30° flexion/neutral rotation was 3.9 mm (SD 1.8, range, 1.3-7.8), which was significantly lower than in full extension and neutral rotation (P < 0.001). TT-TG in 30° flexion and IR was significantly lower, and TT-TG in 30° flexion and ER was significantly higher than values obtained in neutral rotation (2.7 ± 1.2 vs. 6.5 ± 3.4 mm; P < 0.001). IR and ER in 30° flexion varied between 0.6°-10.7° and 1.9°-13.0°, respectively. CONCLUSION: Flexion as well as rotation of the knee joint significantly alters the TT-TG. These results may have wider clinical relevance in assessing TT-TG and further decisions based on it.

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.

Implant failure after biodegradable screw fixation in osteochondritis dissecans of the knee in skeletally immature patients.

PURPOSE: The primary purpose of this study was to retrospectively assess the incidence of bioabsorbable screw failure in skeletally immature patients treated for osteochondritis dissecans (OCD) of the knee. The second purpose was to assess implant degradation, focusing on differential breakdown of the intraosseous and extraosseous parts of the screw on magnetic resonance imaging (MRI). METHODS: In this retrospective study, 24 patients (30 knees) with MRI-confirmed OCD were treated with a total of 61 biodegradable screws and followed up for a minimum of 2 years or until the onset of new symptoms. MRI scans were performed every 6 months to assess differences in signal intensity between the head and body of the screw. The angle between the surface of the head and the body of the screw was measured, with an angle greater than 90° interpreted as indicating a broken screw (i.e., failed implant). RESULTS: Seven screws (all 2.7 mm, 11.5% of all screws) in 5 patients were considered broken screws. The implant failed completely in an additional 4 patients with breakage of 7 of 9 screws; 3 patients were considered late failures, occurring after more than 6 months. Altogether, 14 of a total of 61 screws (23%) were broken. CONCLUSIONS: Screw breakage is a surprisingly frequent cause of failure in resorbable OCD fixation in skeletally immature patients. MRI data showed differential decomposition of the screw within and outside of bone as a possible cause. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Meniscal suturing versus screw fixation for treatment of osteochondritis dissecans: clinical and magnetic resonance imaging results.

PURPOSE: The purpose of this study was to compare meniscal stabilization alone with screw fixation in restoring subjective and objective knee function and structural cartilage integrity in skeletally immature patients with osteochondritis dissecans (OCD) of the knee. METHODS: This study comprised 28 patients (32 knees) with magnetic resonance imaging (MRI)-confirmed OCD. Unstable menisci were treated with either stabilization (15 patients, 16 knees) or screw fixation (13 patients, 16 knees; control group). Patients were assessed by functional scoring (Hughston, International Knee Documentation Committee [IKDC]) and MRI for a minimum follow-up period of 2.5 years. RESULTS: In the meniscus stabilization group, the Hughston score improved from 1.4 to 3.8 (P < .01). There was improvement in the IKDC grade, from grade C preoperatively to grade A in 14 knees and grade B in 2 (P < .01). Of 16 knees, 15 had complete defect resolution on MRI by 1 year. There were 3 complications: 1 wound infection, 1 case of trauma requiring reoperation, and 1 revision because of treatment failure at 6 months. In the screw fixation group, the Hughston score improved from 1.4 to 3.6 (P < .01). There was a significant improvement in IKDC grade, from grade C preoperatively to grade A in 11 knees and grade B in 5 (P < .01). At 2 years postoperatively, no differences in these variables were found between the groups. CONCLUSIONS: Meniscal suturing alone for the treatment of an OCD of the knee shows good or excellent results in terms of clinical scoring and MRI assessment at almost 3 years' follow-up. The results are comparable with those of screw fixation but with a faster recovery in the postoperative course. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Poor outcome at 7.5 years after Stanisavljevic quadriceps transposition for patello-femoral instability.

INTRODUCTION: Congenital dislocation of the patella and recurrent symptomatic dislocation in adolescents are difficult pathologies to treat. Stanisavljevic described an extensive release procedure essentially involving medializing the entire lateral quadriceps and medial soft tissue stabilization. There are no significant series reporting the success of this method. This procedure has been performed in our institution over several years and we report our results. METHOD: Retrospective case series. Between 1990 and 2007, 20 knees in 13 children and adolescents (mean age 12.8 years; 4-17, 7 female) with recurrent or congenital dislocation of the patella (8 knees) underwent this procedure after failed conservative treatment (mean follow-up 7.5 years; 4-16). All were immobilized in a long leg cast for 6 weeks. RESULTS: Five knees in five patients (20 %, 1 congenital dislocation) reported their knees as improved without further dislocations. Out of the 15 knees with failures (80 %) 12 in six patients (60 %) were revised due to redislocation. Three knees in two patients (15 %) still had dislocations or subluxations, but any revision was refused. Three knees in three patients caused pain and discomfort during daily activity. Redislocation first developed after a mean of 21.3 months (4-72) postoperatively. Only one patient had returned to sport at the 12-month follow-up. DISCUSSION: The Stanisavljevic procedure produces a mediocre success rate with our long-term follow-up series showing a failure rate up to 80 %. We therefore recommend more specific procedures dealing with the anatomical deformity such as trochleaplasty to produce superior success rates.

Treating patella instability in skeletally immature patients.

PURPOSE: The purpose of this study was to comprehensively and systematically review the current evidence for orthopaedic treatment of immature and adolescent patients with acute and chronic patellar instability. METHODS: We searched the online databases PubMed, CINAHL, EMBASE, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews for relevant publications on patellar instability. All dates and languages were included. RESULTS: Twenty articles reporting on a total of 456 knees in 425 patients (131 male patients, 294 female patients) followed-up for 56.7 ± 42.2 months on average were included in the analysis. Two studies focused specifically on conservative versus surgical treatment in acute dislocations and reported no difference in outcomes after 7 and 14 years, even in the face of slight trochlear dysplasia. For recurrent instability, we found consistent beneficial effects from surgical stabilization on clinical scores, postoperative stability, and radiographic assessment. There is no evidence for growth disturbance with surgical patellar stabilization in immature patients. CONCLUSIONS: The current best evidence does not support the superiority of surgical intervention over conservative treatment in an acute patellar dislocation. However, anatomic variations and their effect on healing should be considered and included in decision making. In recurrent patellar instability in pediatric and adolescent patients with normal or restored knee anatomy, reconstruction of the medial patellofemoral ligament (MPFL) is the most effective treatment option and can be done safely, together with extensor realignment as needed. LEVEL OF EVIDENCE: Level IV, systematic review of mixed-level studies.