A modified Delphi consensus statement on patellar instability: part I.

Aims: The aim of this study was to establish consensus statements on the diagnosis, nonoperative management, and indications, if any, for medial patellofemoral complex (MPFC) repair in patients with patellar instability, using the modified Delphi approach. Methods: A total of 60 surgeons from 11 countries were invited to develop consensus statements based on their expertise in this area. They were assigned to one of seven working groups defined by subtopics of interest within patellar instability. Consensus was defined as achieving between 80% and 89% agreement, strong consensus was defined as between 90% and 99% agreement, and 100% agreement was considered to be unanimous. Results: Of 27 questions and statements on patellar instability, three achieved unanimous consensus, 14 achieved strong consensus, five achieved consensus, and five did not achieve consensus. Conclusion: The statements that reached unanimous consensus were that an assessment of physeal status is critical for paediatric patients with patellar instability. There was also unanimous consensus on early mobilization and resistance training following nonoperative management once there is no apprehension. The statements that did not achieve consensus were on the importance of immobilization of the knee, the use of orthobiologics in nonoperative management, the indications for MPFC repair, and whether a vastus medialis oblique advancement should be performed.

A modified Delphi consensus statement on patellar instability: part II.

Aims: The aim of this study was to establish consensus statements on medial patellofemoral ligament (MPFL) reconstruction, anteromedialization tibial tubercle osteotomy, trochleoplasty, and rehabilitation and return to sporting activity in patients with patellar instability, using the modified Delphi process. Methods: This was the second part of a study dealing with these aspects of management in these patients. As in part I, a total of 60 surgeons from 11 countries contributed to the development of consensus statements based on their expertise in this area. They were assigned to one of seven working groups defined by subtopics of interest. Consensus was defined as achieving between 80% and 89% agreement, strong consensus was defined as between 90% and 99% agreement, and 100% agreement was considered unanimous. Results: Of 41 questions and statements on patellar instability, none achieved unanimous consensus, 19 achieved strong consensus, 15 achieved consensus, and seven did not achieve consensus. Conclusion: Most statements reached some degree of consensus, without any achieving unanimous consensus. There was no consensus on the use of anchors in MPFL reconstruction, and the order of fixation of the graft (patella first versus femur first). There was also no consensus on the indications for trochleoplasty or its effect on the viability of the cartilage after elevation of the osteochondral flap. There was also no consensus on postoperative immobilization or weightbearing, or whether paediatric patients should avoid an early return to sport.

Radiographic evaluation of the hook of the hamate: a new technique.

Radiographic confirmation in cases of suspected hook of hamate fractures can be very difficult. Films, including the carpal tunnel view, may be difficult to interpret. We describe a new semisupine oblique radiographic view of the carpus that permits excellent visualization of the hamate hook, is cost efficient, and allows for patient comfort during the study.

Clinical manifestations of congenital insensitivity of the hand and classification of syndromes.

Lesions of the upper extremity, particularly of the hand, are common in congenital insensitivity syndromes. Five cases are described with findings including fractures, infections, stiffness of fingers, self-mutilation, and traumatic amputations. The best form of treatment is preventative, since reconstructive surgery has little to offer. If conservative efforts are of no avail, amputation of the part is, unfortunately, the best way to obtain satisfactory results.

Osteochondromas of the hand in hereditary multiple exostosis: report of a case presenting as a blocked proximal interphalangeal joint.

Blocking of motion of an interphalangeal joint in the hand by an osteochondroma has not been reported previously. Osteochondromas, which are uncommon in the hand, are encountered most frequently in patients with hereditary multiple exostosis. They can occur away from the epiphyseal plate region at the distal end of the proximal and middle phalanges. Osteochondromas that occur in these locations characteristically cause angular and rotational deformities. Early recognition and prompt surgical treatment in this child resulted in full motion with minimal angular deformity.

A dynamic approach to the thumb-in palm deformity in cerebral palsy.

One hundred and sixty-five different surgical procedures were performed for the correction of thumb deformities in fifty-six patients with spastic cerebral palsy at Gillette Children's Hospital, St. Paul, Minnesota, between 1967 and 1975. The quality of voluntary muscle control and sensibility were the most important factors in predicting the success of operation. In the past, thumb deformities were classified on the basis of the static position of the thumb, but rational treatment decisions can be made only by a careful assessment of the patient's hand and thumb function. Using various combinations of releases, tendon transfers, and joint stabilizations, measurable and predictable improvement in function was achieved in all fifty-six patients whose records were analyzed.

Spinal fusion for chronic low back pain.

Results of spinal fusion for chronic low back pain in 46 patients are analyzed, and the authors set forth the clinical circumstances in which the procedure may relieve this common complaint.

Undiagnosed bleeding states and medical treatment.

Relatively little attention has been placed in mild hemophilia in the orthopedic literature even though there are probably an equal number of patients with mild as compared to classic manifestations. Mild hemophilia and similar related conditions frequently are undiagnosed and may represent major problems and if associated with surgery, catastrophic results. Patients with milder bleeding diatheses may not have a diagnosis made until late in life. Mild hemophilia and hemophiloid conditions are defined and typical findings are given. Other causes of intra or postoperative hemorrhagic states are mentioned. Three case reports of mild Factor VIII and Factor XI deficiency, undiagnosed prior to the author's medical treatment, are presented. Knowledge of the typical historical findings, diagnostic methods, and proper treatment of patients seeking medical treatment with mild hemophilia, hemophiloid and similar conditions explaining hemorrhage following trauma and intra and postoperatively will help to prevent undesirable results as well as severe complications.

Restoration of strong grasp and lateral pinch in tetraplegia due to cervical spinal cord injury.

Patients with tetraplegia who have "strong" sixth cervical neurologic (C-6) function often can be given active grasp and strong lateral pinch by tendon transfers and tenodeses. Wrist control can be retained by the extensor carpi radialis brevis and flexor carpi radialis and can permit transfer of the extensor carpi radialis longus to provide finger flexion. Either the brachioradialis or pronator teres then is available for transfer to restore adduction-opposition of the thumb with an in situ tendon graft of a paralyzed flexor superficialis rerouted to the thumb through a palmar fascial pulley. The other motor can provide thumb flexion for strong lateral pinch. Extrinsic extension can be provided by tendoeses. With seventh cervical neurologic (C-7) function retained, active digital extension is present and functional expectations are better. Ten hands in seven patients with traumatic tetraplegia from injuries at C-6 or C-7 level have been reconstructed. The average grasp and pinch force after operation was 5.5 and 3.0 Kg., respectively. All patients but one were pleased with the increased function a