An operative approach to address severe genu valgum deformity in the Ellis-van Creveld syndrome

BACKGROUND: The genu valgum deformity seen in the Ellis-van Creveld syndrome is one of the most severe angular deformities seen in any orthopaedic condition. It is likely a combination of a primary genetic-based dysplasia of the lateral portion of the tibial plateau combined with severe soft-tissue contractures that tether the tibia into valgus deformations. Progressive weight-bearing induces changes, accumulating with growth, acting on the initially distorted and valgus-angulated proximal tibia, worsening the deformity with skeletal maturation. The purpose of this study is to present a relatively large case series of a very rare condition that describes a surgical technique to correct the severe valgus deformity in the Ellis-van Creveld syndrome by combining extensive soft-tissue release with bony realignment. METHODS: 1. Complete proximal to distal surgical decompression of the peroneal nerve. 2. Radical release and mobilization of the severe quadriceps contracture and iliotibial band contracture. 3. Distal lateral hamstring lengthening/tenotomy and lateral collateral ligament release. 4. Proximal and distal realignment of the subluxed/dislocated patella, medial and lateral retinacular release, vastus medialis advancement, patellar chondroplasty, medial patellofemoral ligament plication, and distal patellar realignment by Roux-Goldthwait technique or patellar tendon transfer with tibial tubercle relocation. 5. Proximal tibial varus osteotomy with partial fibulectomy and anterior compartment release. 6. Occasionally, distal femoral osteotomy. RESULTS: In all cases, the combination of radical soft-tissue release, patellar realignment and bony osteotomy resulted in 10° or less of genu valgum at the time of surgical correction. Complications of surgery included three patients (five limbs) with knee stiffness that was successfully manipulated, one peroneal nerve palsy, one wound slough and hematoma requiring a skin graft, and one pseudoarthrosis requiring removal of hardware and repeat fixation. At last follow-up, radiographic correction of no more than 20° of genu valgum was maintained in all but four patients (four limbs). Two patients (three limbs) had or currently require revision surgery due to recurrence of the deformity. CONCLUSION: The operative approach presented in this study has resulted in correction of the severe genu valgum deformity in Ellis-van Creveld syndrome to 10° or less of genu valgum at the time of surgery. Although not an outcomes study, a correction of no more than 20° genu valgum has been maintained in many of the cases included in the study. Further clinical follow-up is still warranted. LEVEL OF EVIDENCE: IV

Growth Plate Injuries of the Lower Extremity: Case Examples and Lessons Learned.

BackgroundThe presence of growth plates at the ends of long bones makes fracture management in children unique in terms of the potential risk of developing angular deformities and growth arrest.Materials and methodsWe discuss three distinct cases depicting various aspects of physeal injury of the lower extremity in children.ResultsThe case illustrations chosen represent distinct body regions and different physeal injuries: Salter-Harris II fracture of the distal femur, Salter-Harris VI perichondrial injury of the medial aspect of the knee region, and Salter-Harris III fracture of the distal tibia. The clinical presentation, pertinent history and physical findings, imaging studies, management, and subsequent course are presented.ConclusionsGrowth plate injuries of the lower extremity require a high index of suspicion and close monitoring during skeletal growth. Early recognition and proper management of these injuries can minimize long term morbidity. The treatment plan should be individualized after a comprehensive analysis of the injury pattern in each patient. Establishing a long term treatment plan and discussing the prognosis of these injuries with the child's caretakers is imperative

Clinical and radiological outcome of medial patellofemoral ligament reconstruction with a semitendinosus autograft for patella instability

Background: Recurrent patellar instability is a common problem after dislocation. The medial patellofemoral ligament (MPFL) contributes 40-80% of the total medial restraining forces. This study assessed the clinical and radiological outcome after a follow-up of 4years after linear MPFL reconstruction using an ipsilateral Semitendinosus tendon autograft. Study design and methods: 15 knees in 12 patients were examined with a mean of 47months after linear reconstruction of the MPFL at a mean age of 30years. 3 knees underwent previous surgery. 3 patients had mild trochlear dysplasia grade I or II, according to the classification of Dejour. If preoperative tibial tuberosity-trochlear groove distance (TTTG) was more than 15mm, patients underwent additional medialisation of the tibial tuberosity (n=8) creating a similar postoperative situation for all patients. All patients were available for a postoperative evaluation, which consisted of a subjective questionnaire, the Kujala score, and the recording of potential patellar redislocation and apprehension. Patellar height and tilt was measured on plain radiographs. Postoperative CT scans were performed in patients with an additional tibial tuberosity-transfer. Results: Postoperatively, one patient reported on recurrent bilateral redislocation. Physical examination however revealed no findings. Three knees presented with persistent patellar apprehension. Thirteen knees had improved subjectively after surgery. The mean Kujala score improved significantly from 55.0 to 85.7 points. The patellar tilt decreased significantly from 11.3° to 9.2°. Four knees had patella alta preoperatively, but only two at the latest follow-up visit. Previous surgery or additional trochlear dysplasia had no influence on the clinical outcome. Conclusion: MPFL reconstruction improves clinical symptoms, reduces the patellar tilt substantially, and may correct patella alta. Additional mild trochlear dysplasia did not compromise the outcome; however, this fact needs further attention in a larger study grou

Traumatic patellar dislocation in childhood : late effects on knee function and cartilage quality

Background and aim: Acute patellar dislocation affects approximately 1:1000 healthy children 9- 15 years of age, and up to 50% are at risk for recurrent dislocations. In adults the condition is associated with long-term complications, such as osteoarthritis and impairment of knee function. However, literature describing the outcome in a pediatric population is sparse. The aim of this thesis was to evaluate the long-term effects on knee function and cartilage quality after traumatic patellar dislocation in childhood, and also to evaluate the reliability of two clinical tests of medio-lateral knee position, in healthy children. Patients and methods: In Study I, 246 healthy children were included to evaluate the Q-angle and the Single-limb mini squat test, reflecting static and dynamic medio-lateral knee position, respectively. In Study II, III and IV patients with a history of acute, unilateral, first-time traumatic patellar dislocation, 9-15 years of age at index injury, and with a follow-up time of ≥5 years were included. Recurrence rate and patient reported outcome were assessed. In Study II, n=52, the objective- and subjective knee function were evaluated in relation to type of obtained treatment. In Study III and IV the quality of the patellar cartilage was evaluated with quantitative MRI metrics, T2 mapping and delayed Gadolinium Enhanced Magnetic Resonance Imaging of Cartilage (dGEMRIC). In Study III 16 non-operatively treated patients with recurrent patellar dislocation, and in Study IV 17 patients surgically treated in childhood due to unilateral recurrent patellar dislocation, were evaluated. Results: In Study I the reliability for the Single-limb mini squat test was determined moderate, the Q-angle measurement was found to have fair to moderate reliability. The Q-angle varied with age and sex; however, this finding may not be clinically relevant. Study II, III and IV reveal that the patients were affected KOOS quality of life and sports and recreation, with lower scores than normal for the age. 67% reported recurrence among the non-operatively treated patients. Despite regained stability in patients operated on due to recurrences, the subjective knee function was not restored. In both the non-operatively treated patients with recurrent patellar dislocations (Study III), and the surgically stabilized patients (Study IV), very early cartilage changes were detected in the patellar cartilage of the affected knee with dGEMRIC and T2 mapping. The shortening of T1(Gd) indicate loss of glycosaminoglycans. The localization of the findings were similar in Study III and IV, although, at different tissue depths; with changes in the superficial half of the cartilage in patients with recurrent dislocations (study III), and changes in the deep half in the operated patients (study IV). In Study III shorter T2 values were detected in superficial half of the cartilage in the peripheral parts of affected patella, whereas longer T2 was observed most medially in the deep cartilage of the operated group (Study IV). Conclusion: The Single-limb mini squat test can be used to evaluate the medio-lateral knee position in a pediatric population, whereas the Q-angle only showed fair reliability. Acute traumatic patellar dislocation in childhood has a negative long-term impact on quality of life and ability to participate in physical activities. Traditional surgical methods reduced the recurrence rate, but the knee function was not restored. Recurrent patellar dislocation, and patellar stabilizing surgery, seem to have a negative effect on cartilage quality; most likely through different biological mechanisms and at different depths of the cartilage. The results from quantitative MRI of the patellar cartilage indicate changes in both GAG content and collagen structure. These new findings show that dGEMRIC, in combination with T2 mapping, are feasible methods to detect early degenerative changes in vivo in this condition

CT changes after trochleoplasty for symptomatic trochlear dysplasia

Trochlear dysplasia is an important risk factor for patellar instability. Because of a decreased trochlear depth in combination with a low lateral femoral condyle, the patella cannot engage properly in the trochlea. Trochleoplasty is a surgical procedure, which strives to correct such bony abnormalities. The aim of this study was to describe morphological features of trochlear dysplasia and the corrective changes after trochleoplasty on CT scan. The study group consists of 17 knees with trochlear dysplasia having undergone trochleoplasty for recurrent patellofemoral dislocation at a mean age of 22.4years. The evaluation consisted in pre- and postoperative measurements on the proximal and distal trochlea on transverse CT scans in order to determine the morphological features. We measured the transverse position and depth of the trochlear groove, the transverse position of the patella, the ratio between the posterior patellar edge and the trochlear groove, the lateral patellar inclination angle, the sulcus angle, and the lateral trochlear slope. The trochlear groove lateralised a mean of 6.1mm in the proximal aspect and 2.5mm in the distal aspect of the trochlea, while the patella medialised a mean of 5mm. Preoperatively the patella was lateral in relation to the trochlear groove in 13 cases, neutral in two cases, and medial in two cases. Postoperatively it was lateral in four cases, in neutral position in seven cases, and medialised in six cases, referenced to the trochlear groove. The trochlear depth increased from 0 to 5.9mm postoperatively in the proximal aspect of the trochlea, and from 5.5 to 8.3mm postoperatively in the distal trochlea. The lateral patellar inclination angle decreased from a mean of 21.9° to a mean of 7.8°. The sulcus angle decreased from a mean of 172.1° to a mean of 133° in the proximal trochlea and from a mean of 141.9° to a mean of 121.7° in the distal trochlea. The lateral trochlear slope changed from 2.8° to 22.7° in the proximal and from 14.9° to 26.9° in the distal part of the trochlea. In the CT scan patients with trochlear dysplasia demonstrated a poor depth, or even a flat or convex trochlea with a greater sulcus and lateral trochlear slope angle, a lateralised patella to the trochlear groove with poor congruency, and a greater lateral patellar inclination angle. Trochleoplasty can correct the pathological features of trochlear dysplasia by surgically creating more normal anatomy. The goal of this surgical procedure is to steepen and lateralise the trochlear groove for a better engagement of the patell

Traumatic patellar dislocation in children : epidemiology, risk factors, the MPFL and treatment outcome

The knee joint is one of the most common injury sites in children, with the spectrum of injuries differing from those in adults. Traumatic lateral patellar dislocation (LPD) is the most common serious injury; the incidence is approximately 1/1000 in children 9-15 years of age. The risk for recurrent dislocation is high in this age group. The most important static stabilizer for lateral patellar dislocation is the medial patellofemoral ligament (MPFL). The injury to the MPFL and the anatomic patellar instability risk factors for lateral patellar dislocation are best described in the adult population. There is no consensus about the best treatment for the first-time traumatic lateral patellar dislocation in children. The aim of this thesis was firstly to describe the current spectrum of acute knee injuries presenting with knee hemarthrosis, with a detailed description of the most common injury, the traumatic lateral patellar dislocation. Secondly, the aim was to describe the patellofemoral joint morphology, the anatomic patellar instability risk factors and the medial patellofemoral ligament injury in the skeletally immature child. Thirdly, the aim was to evaluate if an acute refixation of the medial patellofemoral ligament injury vs. non-operative treatment for firsttime traumatic lateral patellar dislocation could reduce the high recurrence rate. All studies were prospective in design. Patients were skeletally immature, 9-14 years old, and previously had healthy knees before an acute knee trauma that caused hemarthrosis. They were following an algorithm to investigate the injury with standardized radiographs and MRI within two weeks from the index injury. In Study I, 117 patients with acute knee trauma were examined. Seventy percent had a serious knee injury that needed specific medical care. Fifty-six percent of these patients had no visible injury on their radiographs. Lateral patellar dislocation (41%), ACL injury (12%) and anterior tibial spine injury (7%) were the most common injuries and the majority were sports-related. Study II included 74 patients with first-time traumatic LPD. The medial patellofemoral injury was evaluated by MRI and arthroscopy. An injury to the MPFL at the patellar attachment site was diagnosed in 99% of patients, either as an isolated injury at the patellar site or as part of a multi-focal injury. Study III consisted of 103 patients with firsttime traumatic LPD and a control group of 69 patients with acute knee trauma without LPD. The morphology of the patellofemoral joint and anatomic patellar instability risk factors were analyzed and the two groups were compared. Central condylar height was higher in the group with lateral patellar dislocation, resulting in lower trochlear depth and higher sulcus angles. There was a significant difference in mean values of all established anatomic patellar instability risk factors between children with first-time traumatic LPD and the control group. The main divergent anatomic patellar instability risk factor was trochlear dysplasia (defined as trochlear depth < 3mm), which was seen in 74% in the LPD group compared to 4% in the control group. Trochlear dysplasia, together with lateral patellar tilt ( ³ 20°), had the strongest association with LPD. The 74 patients from Study II were in Study IV randomized in a RCT to either non-operative treatment (soft knee brace and physiotherapy) or operative treatment (arthroscopic assisted medial patellofemoral ligament refixation, soft cast splint and physiotherapy). The follow-up time was two years; the main outcome was redislocation and evaluation of subjective and objective knee function. A refixation of the MPFL injury in the acute phase in skeletally immature children with first-time traumatic lateral patellar dislocation significantly reduced the redislocation rate but did not improve the subjective and objective knee function compared with non-operative treated patients. The majority of the patients were satisfied with their knee function

A Review of Treatment Methods for Patients with Patellofemoral Pain

There have been many therapeutic methods proposed for the treatment of patellofemoral pain, but there still remains some question as to which of these options is most beneficial to the patient. There are many steps to follow in order to find the most effective treatment method for an individual suffering from patellofemoral pain syndrome. This paper is a review of the literature regarding patellofemoral pain syndrome. The paper begins with a discussion of the anatomy of the patellofemoral joint. Etiological factors of this common syndrome are also presented as well as the clinical presentation of this patient population. The focus of the paper involves treatment techniques for patients with patellofemoral pain. Several months of conservative treatment measures are encouraged preceding more invasive surgical techniques. The surgical techniques discussed here include the lateral retinacular release, proximal patellar realignment, distal patellar realignment, and the patellectomy

Surgical versus non-surgical interventions for treating patellar dislocation

Background: Patellar dislocation occurs when the patella disengages completely from the trochlear (femoral) groove. Following reduction of the dislocation, conservative (non-surgical) rehabilitation with physiotherapy may be used. Since recurrence of dislocation is common, some surgeons have advocated surgical intervention rather than non-surgical interventions. This is an update of a Cochrane review first published in 2011. Objectives: To assess the effects (benefits and harms) of surgical versus non-surgical interventions for treating people with primary or recurrent patellar dislocation. Search methods: We searched the Cochrane Bone, Joint and Muscle Trauma Group's Specialised Register, the Cochrane Central Register of Controlled Trials (The Cochrane Library), MEDLINE, EMBASE, AMED, CINAHL, ZETOC, Physiotherapy Evidence Database (PEDro) and a variety of other literature databases and trial registries. Corresponding authors were contacted to identify additional studies. The last search was carried out in October 2014. Selection criteria: We included randomised and quasi-randomised controlled clinical trials evaluating surgical versus non-surgical interventions for treating lateral patellar dislocation. Data collection and analysis: Two review authors independently examined titles and abstracts of each identified study to assess study eligibility, extract data and assess risk of bias. The primary outcomes we assessed were the frequency of recurrent dislocation, and validated patient-rated knee or physical function scores. We calculated risk ratios (RR) for dichotomous outcomes and mean differences MD) for continuous outcomes. When appropriate, we pooled data. Main results: We included five randomised studies and one quasi-randomised study. These recruited a total of 344 people with primary (first-time) patellar dislocation. The mean ages in the individual studies ranged from 19.3 to 25.7 years, with four studies including children, mainly adolescents, as well as adults. Follow-up for the full study populations ranged from two to nine years across the six studies. The quality of the evidence is very low as assessed by GRADE (Grading of Recommendations Assessment, Development and Evaluation Working Group) criteria, with all studies being at high risk of performance and detection biases, relating to the lack of blinding. There was very low quality but consistent evidence that participants managed surgically had a significantly lower risk of recurrent dislocation following primary patellar dislocation at two to five years follow-up (21/162 versus 32/136; RR 0.53 favouring surgery, 95% confidence interval (CI) 0.33 to 0.87; five studies, 294 participants). Based on an illustrative risk of recurrent dislocation in 222 people per 1000 in the non-surgical group, these data equate to 104 fewer (95% CI 149 fewer to 28 fewer) people per 1000 having recurrent dislocation after surgery. Similarly, there is evidence of a lower risk of recurrent dislocation after surgery at six to nine years (RR 0.67 favouring surgery, 95% CI 0.42 to 1.08; two studies, 165 participants), but a small increase cannot be ruled out. Based on an illustrative risk of recurrent dislocation in 336 people per 1000 in the non-surgical group, these data equate to 110 fewer (95% CI 195 fewer to 27 more) people per 1000 having recurrent dislocation after surgery. The very low quality evidence available from single trials only for four validated patient-rated knee and physical function scores (the Tegner activity scale, KOOS, Lysholm and Hughston VAS (visual analogue scale) score) did not show significant differences between the two treatment groups. The results for the Kujala patellofemoral disorders score (0 to 100: best outcome) differed in direction of effect at two to five years follow-up, which favoured the surgery group (MD 13.93 points higher, 95% CI 5.33 points higher to 22.53 points higher; four studies, 171 participants) and the six to nine years follow-up, which favoured the non-surgical treatment group (MD 3.25 points lower, 95% CI 10.61 points lower to 4.11 points higher; two studies, 167 participants). However, only the two to five years follow-up included the clear possibility of a clinically important effect (putative minimal clinically important difference for this outcome is 10 points). Adverse effects of treatment were reported in one trial only; all four major complications were attributed to the surgical treatment group. Slightly more people in the surgery group had subsequent surgery six to nine years after their primary dislocation (20/87 versus 16/78; RR 1.06, 95% CI 0.59 to 1.89, two studies, 165 participants). Based on an illustrative risk of subsequent surgery in 186 people per 1000 in the non-surgical group, these data equate to 11 more (95% CI 76 fewer to 171 more) people per 1000 having subsequent surgery after primary surgery. Authors' conclusions: Although there is some evidence to support surgical over non-surgical management of primary patellar dislocation in the short term, the quality of this evidence is very low because of the high risk of bias and the imprecision in the effect estimates. We are therefore very uncertain about the estimate of effect. No trials examined people with recurrent patellar dislocation. Adequately powered, multi-centre, randomised controlled trials, conducted and reported to contemporary standards, are needed. To inform the design and conduct of these trials, expert consensus should be achieved on the minimal description of both surgical and non-surgical interventions, and the anatomical or pathological variations that may be relevant to both choice of these interventions and the natural history of patellar instability. Furthermore, well-designed studies recording adverse events and long-term outcomes are needed