Operative Techniques in Orthopaedics最新文献

Chronic patellar instability in the pediatric population presents early in life and can present as a permanent irreducible dislocation or a habitual dislocation with knee flexion. Congenital patellar dislocation tends to present at birth, with a knee flexion contracture, valgus malalignment of the lower limb and external tibial torsion. Habitual dislocation may present later. The pathoanatomy of congenital and habitual dislocation differentiate. Accurate diagnosis of the underlying pathology is important as the operative management of these conditions is based on addressing these underlying pathologies and so a thorough history and clinical exam is vital. Plain radiographs generally provide the information required to make a diagnosis and plan operatively. Nonoperative management tends to lead to poor long-term outcomes but there is poor consensus in the literature regarding the operative treatment of these conditions. The evaluation and operative treatment of these conditions is described in detail here, addressing the extensor mechanism rotation or attachment abnormalities, the lateral position of the patellar tendon insertion and the laxity of the medial soft tissues.

Prepubescent anterior cruciate ligament reconstruction presents a technical challenge to the surgeon due to the presence of the growth plates. Regaining knee stability and functionality are the main goals of treatment, while avoiding growth disturbances in this young population. Transphyseal reconstructions allows for an anatomic graft placement and is a safe option, even in the youngest patients, as long as specific technical points are taken into consideration. This present article describes in detail the operative technique of a transphyseal anterior cruciate ligament reconstruction with special attention to the pearls and pitfalls. The senior author has used this technique in 123 Tanner stage I, II, and III patients and his experience will also be presented.

Tibial spine fractures (TSF) are an avulsion injury of the anterior cruciate ligament (ACL) at the insertion on the tibial plateau. These injuries predominantly affect the pediatric population and are important to treat appropriately as they act similarly to complete ACL injuries. The decision to pursue surgical management is dictated mostly by fracture displacement, but also by various factors such as concomitant injuries, age and level of activity. Multiple fixation strategies are available, ranging from transosseous suture and suture anchors to the use of screws, staples, or absorbable nails.

This technique paper describes the author's preferred technique involving an arthroscopic assisted reduction of the tibial spine fracture and transosseous suture fixation. High tensile nonabsorbable sutures are passed through the base of the ACL which are then passed through two 2.4 mm transosseous tunnels tied over a bone bridge on the anterior medial tibia.

An arthroscopic approach has been reported to have similar positive outcomes when compared to open reductions. Furthermore, the transosseous suture construct has been described to be advantageous biomechanically and to yield satisfactory results when compared to alternative fixation options.

The discoid meniscus (DM) is a congenital variant of the normal crescent-shaped meniscus, resulting in hypertrophic meniscal tissue, altered collagen structure, decreased peripheral vascularity, and an atypical shape. Although significant advances have been made in the operative treatment of DM, there still needs to be more clarity regarding best practices. The following review aims to summarize current knowledge to help practitioners improve their approach when dealing with patients with DM.

Osteochondritis dissecans (OCD) of the knee is a relatively rare condition with multifactorial etiology. OCD of the knee most commonly presents in children and adolescents; therefore, timely and appropriate treatment is necessary to prevent long-term cartilage damage and osteoarthritis. The clinical presentation of OCD may vary depending on the location and stability of the lesion. Radiographic and magnetic resonance imaging (MRI) is essential to further classify the lesion and guide treatment. Depending on the lesion's characteristics, nonoperative or operative treatment may be recommended. Nonoperative treatment is recommended for stable lesions in patients with open physes. A period of activity restriction, decreased weight-bearing and immobilization may be recommended. Operative treatment is recommended for stable lesions in patients with closed physes, unstable lesions or failure of nonoperative treatment. A variety of operative techniques are utilized based on stability of the lesion and articular surface integrity. Given the varied presentation of knee OCD lesions, it is critical for clinicians to maintain a high index of suspicion in the at-risk age group. It is also necessary to maintain an in depth understanding of recommended evaluation and treatment techniques to optimize prognosis for healing and minimize long-term sequelae.

Pediatric anterior cruciate ligament (ACL) tears are rising due to increased youth sport participation, often prompting early surgical interventions. Over-the-top ACL reconstruction with iliotibial band (ITB) autograft, aimed at minimizing growth disturbances, is a preferred technique for prepubescent patients (Tanner Stage I or II). Surgical technique involves harvest of the ITB with passage in the over-the-top position into the knee, extra-articular tenodesis at the femoral condyle, and tibial fixation distal to the physis and medial to the tubercle. Outcomes include excellent function, high return-to-sport rates, and low graft rupture rates, comparable to alternatives. Systematic reviews support ITB reconstruction, showing high return-to-activity rates and low growth disturbance incidences. Biomechanical studies affirm satisfactory kinematic restoration postsurgery and superior rotatory control. ITB reconstruction offers a promising technique for pediatric ACL tears, warranting further research on long-term efficacy and refined patient selection.

Patellofemoral instability (PFI) is a prevalent orthopedic issue that leads to significant morbidity and functional limitation. It has a notable incidence, specifically higher amongst adolescent females, and a recurrence rate ranging from 17% to 33%. Recurrent PFI significantly increases the risk of degenerative changes and early-onset osteoarthritis. Patients with multiple risk factors have a remarkably increased rate of recurrence, and thus identifying and managing anatomical risk factors is an effective strategy for patients. These include: trochlear dysplasia, patella alta, increased tibial tubercle-to-trochlear groove (TT-TG) distance, increased femoral anteversion, external tibial torsion, and valgus limb alignment. This study outlines a comprehensive evaluation and surgical approach focusing on PFI associated with torsional or coronal malalignments. The evaluation includes a detailed patient history, clinical examination, and diagnostic imaging. Surgical interventions are selected based on an algorithmic approach tailored to the specific pathoanatomy of the instability, focusing on both bony and soft-tissue procedures. Surgical techniques for addressing PFI in the presence of malalignment include proximal and distal bony procedures. Specific techniques detailed in this study include femoral torsional osteotomy over an intramedullary nail, distal femur opening and closing wedge osteotomies, and torsional tibial osteotomies fixated with an intramedullary nail or plate.