Elbow arthroscopy in the pediatric and adolescent population.

PURPOSE: The purpose of this study was to show the diagnostic and therapeutic benefits of elbow arthroscopy in athletically active pediatric patients. We describe our techniques for elbow arthroscopy in young patients. TYPE OF STUDY: Case series of 47 patients. METHODS: We reviewed 49 cases of elbow arthroscopies performed in 47 pediatric and adolescent patients retrospectively over a 16-year period. Charts were reviewed to identify the age of patients at the time of surgery, side involved, hand dominance, diagnosis, complications, the primary sport involved, and the average volume of loose bodies if surgical removal was performed. Each patient was contacted after a minimum of 2 years after surgery and a modified Andrews elbow scoring system was used to rate elbow function. RESULTS: The average age of this group was 14.0 years (range, 3.5 to 17.0 years) with an average follow-up of 4.7 years. Elbow arthroscopy was performed for osteochondritis dissecans (58%), arthrofibrosis and joint contracture (20%), synovitis (10%), acute trauma (10%), and posterior olecranon impingement syndrome (5%). Based on a modified Andrews elbow scoring system, 85% of patients had good or excellent result with 90% of the children returning to sports without limitation. No patient experienced nerve injury, infection, or loss of elbow motion as a postoperative complication. CONCLUSIONS: This series shows that elbow arthroscopy has a safe and effective role in the treatment of selective elbow pathologies in the pediatric and adolescent population when performed by experienced small joint arthroscopists.

Surgical treatment of pediatric scaphoid fracture nonunions.

Scaphoid fractures in the pediatric population are uncommon but can usually be successfully managed with standard immobilization techniques. However, nonunions of pediatric scaphoid wrist fractures have been reported. We present the treatment and outcome of 13 pediatric scaphoid fracture nonunions in 12 children treated over an 18-year period. The average time elapsed between time of fracture and time of surgery was 16.7 months. Four of the nonunions were treated by using the Matti-Russe procedure, and nine were treated with Herbert screw fixation and iliac crest bone grafting. The average time of follow-up was 6.9 years (range, 2-19 years). All cases went on to clinical and radiographic union. There was no statistically significant difference in range of motion or strength between the operative and nonoperative wrist. Eleven of 12 patients demonstrated an excellent rating based on the Mayo Modified Wrist score. The length of time for postoperative immobilization in the Herbert screw group was significantly less than that in the Matti-Russe group. Currently our standard approach to the treatment of scaphoid fracture nonunions in the skeletally immature patient is the use of the Herbert screw and iliac crest bone graft.

Meniscal repair in the young athlete.

Twenty-nine meniscal repairs in 26 patients 17 years of age or younger were performed using arthroscopic techniques. Clinical follow-up examinations were performed and the SF-36 Health Status Survey and International Knee Documentation Committee evaluation form were administered. A Lysholm score was determined for each patient. All 26 patients were seen for follow-up at an average of 5.0 years (range, 2.0 to 13.5). All patients had a full range of motion with no effusion, joint line tenderness, or McMurray sign present at the time of examination. No patient experienced symptoms of locking. No patient underwent repeat surgery for a nonhealed meniscal repair. The clinical healing rate in this group was 100%. The SF-36 data demonstrated an average physical functioning score of 91 and an average role physical score of 91. The average Lysholm score was 90. Twenty-two patients (85%) were performing level I activities based on the International Knee Documentation Committee rating. Excellent rates of healing, even higher than those obtained in the adult population, can be obtained with meniscal repairs performed in this young age group.

Noninvasive measurement of distal radius instability.

Except for subjective clinical criteria, there is no formal definition of distal radius fracture instability in the literature. The purposes of this ex vivo biomechanical study were (1) to provide an objective mechanical definition of fracture instability and (2) to demonstrate a noninvasive method that allows for direct measurement of instability. The following 3 questions are addressed: (1) Can the stability of distal radius fractures be measured using computed tomography (CT)? (2) Are the stability measurements reproducible? (3) How does external fixation change stability? A CT technique is described that was used to measure displacement of fracture fragments and measure the compliance of ex vivo distal radius fractures before and after external fixation. Validation studies of the CT technique revealed a mean coefficient of variation of 0.38. There was a linear relationship between measured and known displacements for all 3 orthogonal planes (coefficient of determination 0.99; p < .01). There was significant fracture displacement with loads as small as 20 N. The slope of the load-displacement curve (structural compliance) provided a quantitative measure of fracture instability. Fracture compliance decreased up to 69% after application of an external fixator.

Glenoid version in children.

Computed tomographic scans and magnetic resonance images of 111 normal shoulders of children were reviewed to determine the normal glenoid version in the pediatric age population. Glenoid version varies with age in this population. The glenoid is most retroverted during the first 2 years of life (-6.3 +/- 6.5 degrees) and by the end of the first decade of life reaches adult glenoid version (-1.7 +/- 6.4 degrees). The difference between mean glenoid version in early life and mean glenoid version at the end of the first decade of life was statistically significant (p = 0.0013). Our value determined for adult glenoid version agrees with previous published data in the orthopedic and anthropologic literature. This study provides the normal baseline data for glenoid version in the pediatric age group.

Nonunion of the scaphoid in children treated by Herbert screw fixation and bone grafting. A report of five cases.

In children, nonunion of fractures of the waist of the scaphoid is uncommon. Treatment has included bone grafting without internal fixation, bone grafting with Kirschner-wire fixation, and screw fixation without bone grafting. We report the successful use of Herbert screw fixation and iliac-crest bone grafting in five cases, all of which healed without further surgery. At an average follow-up of 3.3 years, the range of motion, grip strength, carpal stability, and radiological appearances were all excellent.

Remodelling of a displaced phalangeal neck fracture.

Phalangeal neck fractures are uncommon in children. When these injuries to the proximal and middle phalanges are displaced and not treated operatively the fracture may heal in a malunited position with loss of motion at the IP joint. Remodelling in the area of the phalangeal neck is thought to be reduced because of its distance from the physis. In cases of malunion osteotomy of the phalangeal neck may be required to restore anatomy and motion. A case is described which demonstrates complete remodelling of a displaced middle phalangeal neck fracture in a child and recovery of a normal range of motion without operative intervention.

Osteochondroma formation after a Salter II fracture.

Osteochondromas are one of the most commonly observed benign bone tumors. Although there have been a number of experimental studies carried out to determine the origin of osteochondromas, their etiology remains a controversial issue. A well-documented case is presented in which a displaced Salter-Harris type II physeal fracture preceded the development of an osteochondroma.

Percutaneous pinning in the treatment of displaced lateral condyle fractures.

This is a review of a unique group of 12 children with lateral condyle fractures of the distal humerus with displacement of > 2 mm. Intraoperative arthrograms of each elbow demonstrated no articular incongruity associated with minimal rotation of the distal fracture fragment. After closed reduction the lateral condyle fractures were percutaneously pinned, obviating the need for open reduction and internal fixation. The results in this study group were uniformly excellent as based on the rating system of Hardcare. Each child had a normal range of elbow motion and all cases healed clinically and radiographically without complication. Previous literature has recommended that all lateral condyle fractures displaced > 2 mm be treated with open reduction and internal fixation. The authors feel that in selected cases of lateral condyle fractures with > 2 mm displacement and an arthrographically demonstrated congruent joint surface, percutaneous pinning may safely and effectively be performed.

Distal loss of femoral bone following total knee arthroplasty. Measurement with visual and computer-processing of roentgenograms and dual-energy x-ray absorptiometry.

The changes in bone-mineral content in the distal aspect of a cadaveric femur that had been prepared for insertion of the femoral component of a total condylar knee prosthesis were evaluated with visual inspection and computer-processing of roentgenograms and with dual-energy x-ray absorptiometry. Seventeen small slices of bone, each three millimeters wide, were removed so that, finally, 89 per cent of the bone was lost from the distal femoral metaphysis. Standardized lateral roentgenograms of the specimen were made with use of a reference step-wedge of hydroxyapatite, and dual-energy x-ray absorptiometry studies were performed with the x-ray beam tangential to the interface. The roentgenograms were digitized and the bone mineral was measured with use of computer analysis. Dual-energy x-ray absorptiometry was performed with and without the femoral prosthesis in place, in order to determine the effect of the metallic prosthesis on the accuracy of the measurement. A bone loss of 25 per cent or more was identified visually by all five of the readers 100 per cent of the time; losses of 20 to 24 per cent, 15 to 19 per cent, 10 to 14 per cent, and 3 to 9 per cent were correctly identified 92, 75, 66, and 59 per cent of the time, respectively. The measurements of bone-mineral content that were obtained from the digitized roentgenograms were linearly correlated with the actual bone-mineral content (the ash content) (r = 0.97, p < 0.001) and were three times more accurate than the visual readings. The determinations of bone-mineral content with dual-energy x-ray absorptiometry correlated highly with the ash content (r = 1.00, p < 0.001) and were seven times more accurate than the visual readings. There was only a 4 per cent difference between the measurements with dual-energy x-ray absorptiometry made with the prosthesis in place and those made without it in place (p < 0.01). Dual-energy x-ray absorptiometry was the most accurate of the three methods and could detect the smallest experimentally created loss; computer-processing and visual-processing of roentgenograms detected losses of 8 per cent or more and 25 per cent or more, respectively. Dual-energy x-ray absorptiometry and computer-processing of the roentgenograms quantified the bone loss, while visual-processing could detect only the presence or absence of bone loss.(ABSTRACT TRUNCATED AT 400 WORDS)

Uncemented press-fit total knee arthroplasty.

Nineteen total knee arthroplasties in 16 patients were performed using a new prosthesis designed specifically for uncemented, press-fit fixation without any provision for tissue ingrowth. This design may be suited for use in patients with juvenile rheumatoid arthritis, postseptic knees, failed total knee arthroplasties with large bone stock deficiencies, and young, active, overweight individuals. Preservation of bone stock is possible because the fixation stems are nails rather than larger cement pegs, removal for revision is easier without cement, sequestration of microbes within cement cannot occur, and bone graft may be continually loaded with this type of prosthesis. Pain relief, discarding crutch support, operative blood loss, and corrective alignment were equivalent to results obtained with cemented arthroplasty. Seventeen of the 18 knees available for review (average follow-up period, 3 years, 7 months; range of follow-up period, 2 years, 10 months to 4 years, 11 months) were pain-free. Range of motion averaged -2 degrees of extension to 101 degrees of flexion. Ambulation was unrestricted and unsupported in the majority of patients. Radiographic evaluation showed the development of increased bone density under the tibial plateau as well as a sclerotic line at the ends of the femoral and tibial stems. This observation gives support to the theory that multiple microtrabecular fractures with healing form a new supportive "subchondral bone plate." There was one incidence of tibial subsidence. Prosthesis migration and loosening were not observed.

Bone loss in the distal anterior femur after total knee arthroplasty.

Bone loss in the distal anterior femur in asymptomatic total knee arthroplasty (TKA) patients has been noted roentgenographically and during revision surgery. A retrospective roentgenographic review of 147 TKA cases was carried out to document bone loss. The influence that the mode of fixation (porous coated and cemented) and the implant design have on bone loss was examined. The time of onset and the progression of bone loss were studied. Bone loss occurred in the distal anterior femur in the majority of cases reviewed (68%). The prevalence of bone loss was independent of the mode of fixation and the implant design. By qualitative observation, roentgenographically detectable bone loss occurred within the first postoperative year and did not progress further. Previously three-dimensional finite element analysis demonstrated that the replacement of the bearing surface of the femur with a stiff metallic implant reduces the stress in the distal anterior femur by at least one order of magnitude. It is therefore speculated that the observed bone loss results from stress shielding. The apparent lack of progression may reflect the development of a new remodeling equilibrium under the altered stress conditions. The bone loss in the distal anterior femur described has not been implicated as a source of failure. However, since the bone strength in the femoral region is compromised as it becomes osteopenic, bone failure may occur with longer periods of cyclic loading. Furthermore, as a result of bone loss, revision arthroplasty may be more difficult.

The application of advanced CT imaging and computer graphics methods to reconstructive surgery of the hip.

Advanced computed tomographic and computer graphic techniques enhance diagnostic accuracy and offer the means by which three-dimensional operative planning can be achieved. These techniques have been used to diagnose hip pathology, rehearse and evaluate surgical plans, assess postoperative results, and design individualized prostheses.