A Modification of the Dunn Osteotomy With Preservation of the Ligamentum Teres.

BACKGROUND: We aimed to determine if a modified Dunn osteotomy could be safely performed without surgical dislocation and consequent preservation of the ligamentum teres. METHODS: All patients undergoing a modified Dunn osteotomy for a slipped capital femoral epiphysis over an 8-year period were included in this study, and all had a severe slip with an open physis. RESULTS: The modified Dunn procedure was performed on 34 hips in 34 patients. The mean age was 13.1 years (range, 11 to 16 y) with a mean follow-up time of 54 months (range, 15 to 102 mo). All slips were severe (grade 3) with a mean slip angle of 73.2 degrees (range, 60 to 90 degrees). Nineteen slips were stable and 15 were unstable. Of the unstable slips, the average time from initial presentation to the emergency department until surgery was 9.4 days (range, 2 to 42 d). Excluding 1 patient who developed complete collapse of the femoral head (NAHS 56), the average Nonarthritic Hip score was 98 (range, 93.7 to 100). Four (11.8%) patients developed avascular necrosis of the femoral head, of which 3 were unstable slips. CONCLUSIONS: A modified Dunn osteotomy with preservation of the ligamentum teres allows an excellent restoration of the anatomic alignment of the femoral head and neck. Rates of AVN are not increased compared with other techniques of subcapital osteotomy but this complication cannot be eliminated particularly in patients with unstable slips. LEVEL OF EVIDENCE: Level III.

Efficacy of distal pedicle screw fixation as a caudal foundation in VEPTR growing rod constructs for early onset scoliosis.

PURPOSE: Surgical treatment of Early Onset Scoliosis (EOS) is challenging. Stable and robust foundations are vital. We have assessed a small cohort of patients with a rib-based proximal fixation and a pedicle screw-based distal foundation for a distraction based growing rod system. METHOD: This is a single center study in a tertiary spinal deformity unit with a catchment population of over 6 million. We performed a retrospective radiographic evaluation of 15 patients with EOS treated with Vertical Expandable Titanium Prosthetic Rib (VEPTR) implant between 2007 and 2017. The review of medical records and imaging data was performed to identify growth of the spine and complications with pedicle screws. RESULTS: There were ten male and five female patients with an average age at index surgery of 4yrs 11 months. Mean length of follow-up was 6 yrs 9 months. Serial radiographs revealed improvements in mean Cobb angle of 12 degrees, T1-T12 height of 29 mm and T1-S1 height of 48 mm with no deterioration in distal LIV tilt angle. We report that none of these patients had any complications related to their pedicle screws including cut-out. CONCLUSION: We report a technique which is efficacious and provides a mechanically robust distal fixation for VEPTR lengthening in early onset scoliosis.

Megaprostheses in the management of trauma of the knee.

OBJECTIVE: Review the outcome of patients with complex fractures around the knee treated with megaprosthesis. METHOD: Retrospective observational study of 10 patients was undertaken. RESULTS: Six patients were treated with a distal femoral endoprosthesis (DEFPR) and four with an augmented rotating hinge knee replacement (RHK). The mean post-operative Toronto Extremity Salvage Score (TESS) was 62.5 for the whole cohort (RHK group 79.3, compared with 49.2 in the DFEPR group (p = 0.038), peri-prosthetic fracture group was 46.3, compared with 75.6 in native knee fracture group (p = 0.04)). CONCLUSION: A megaprosthesis is a viable option in complex fractures around the knee.

Variability of Measurement of Patellofemoral Indices with Knee Flexion and Quadriceps Contraction: An MRI-Based Anatomical Study.

PURPOSE: The purpose of this study was to investigate the impact of varying knee flexion and quadriceps activity on patellofemoral indices measured on magnetic resonance imaging (MRI). MATERIALS AND METHODS: MRI of the knee was performed in 20 patients for indications other than patellar or patellofemoral pathology. Axial and sagittal sequences were performed in full extension of the knee with the quadriceps relaxed, full extension of the knee with the quadriceps contracted, 30° flexion of the knee with the quadriceps relaxed, and 30° flexion with the quadriceps contracted. Bisect offset, patella tilt angle, Insall-Salvati ratio and Caton-Deschamps index were measured. RESULTS: With the knee flexed to 30° and quadriceps relaxed, the mean values of patellar tilt angle, bisect offset, Insall-Salvati ratio and Caton-Deschamps index were all within normal limits. With the knee extended and quadriceps contracted, the mean patellar tilt angle (normal value, <15°) was 14.6° and the bisect offset (normal value, <65%) was 65%, while the Caton-Deschamps index was 1.34 (normal range, 0.6 to 1.3). With the knee extended and quadriceps relaxed, the mean Caton-Deschamps index was 1.31. CONCLUSIONS: MRI scanning of the knee in extension with the quadriceps contracted leads to elevated patellofemoral indices. MRI taken with the knee in 30° of flexion allows more reliable assessment of the patellofemoral joint and minimises the confounding effect of quadriceps contraction.

Surgical exposure of the Distal Radius in a patient with a flexor carpi radialis brevis muscle anomaly.

There are numerous reports of anatomical variants of the muscles of the forearm, particularly the extensors of the wrist and hand. The abnormal deep and short radial wrist flexor (flexor carpi radialis) is rare. There are only two previously reported cases. We present the case of an anomalous 'flexor carpi radialis brevis', muscle found intra-operatively during a volar approach to the distal radius and discuss the strategies needed for further exposure in order to complete the procedure.