Management of ankle valgus in a skeletally immature patient by tension band plate hemiepiphysiodesis: A case report

Temporary hemiepiphysiodesis is the procedure of choice to correct ankle valgus deformity in a skeletally immature patient. However, the literature is inconclusive regarding the ideal choice of implant and the timing of the surgery. In the current case report, a 9-year-old girl with multiple hereditary exostoses and unilateral ankle valgus deformity underwent tension band plate (TBP) hemiepiphysiodesis, and gained a modest correction at a rate of 0.61°/month. After 18 months of follow-up, there were no implant-related complications, and the functional outcome was also good. This case report shows a promising result of medial malleolar temporary hemiepiphysiodesis using a TBP for ankle valgus deformity in the pediatric population.

All Inside Intraepiphyseal ACL Reconstruction Using Flexible Curved Instrumentation and Intraoperative Fluoroscopy in a Skeletally Immature Patient

Case. A 13-year-old skeletally immature female presenting with an anterior cruciate ligament (ACL) rupture after a noncontact injury was treated with an intraepiphyseal ACL reconstruction. Flexible instrumentation was utilized to drill a femoral tunnel with an anatomic starting point, with a trajectory that curved inferolaterally away from the physis. At three years postoperatively, she had returned to her preinjury functioning and did not display any lower limb length growth abnormalities. Conclusions. The novel application of curved guides and flexible instruments, with intraoperative fluoroscopy, facilitated growth plate avoidance and a successful outcome of ACL reconstruction in a skeletally immature patient.

Management of bilateral osteochondritis dissecans of the trochlea in a skeletally immature patient

Osteochondritis dissecans (OCD) lesions are injuries that occur more commonly in the skeletally immature population. In most cases, the aetiology is not well understood, but fortunately, many OCD lesions may heal on their own over time, particularly in skeletally immature patients with open physes. Conversely, if the lesion is considered unstable, surgical intervention may be required. This case demonstrates an especially rare presentation of bilateral OCD lesions within the lateral femoral trochlear facet. The lesions became symptomatic approximately 1 year apart without a specific injury. Non-operative treatment was not recommended in either case due to the size and instability of each lesion. The surgical treatment used an augmented microfracture technique. At 12 and 23 months after surgery, both knees remain asymptomatic and the patient has returned to their desired activities.

Metachronous multicentric giant cell tumour of bone in a 12-year-old girl: A case report and review of literature

While giant cell tumour of bone is a relatively common tumour in adults, it is exceedingly rare in children. Multicentric metachronous giant cell tumour is an even rarer presentation of this tumour in skeletally immature patients. We present here the challenges in management of this rare tumour. A 12-year-old girl presented with a giant cell tumour affecting four different bones sequentially, three times within a 3-year period. The disease first appeared in the right distal fibula, then a year later in ipsilateral talus and calcaneus and finally a year later, in the T5 vertebral body, all requiring surgical treatment. Our strategy was to manage this lesion aggressively based on the limited literature available and present our own long-term surveillance strategy. Our patient responded well to treatment each time and has remained disease-free for 24 months from her last surgery. This is a rare case of metachronous multicentric giant cell tumour of bone in a skeletally immature patient requiring aggressive treatment and surveillance.

Comparison of Ligament Isometry and Patellofemoral Contact Pressures for Medial Patellofemoral Ligament Reconstruction Techniques in Skeletally Immature Patients

Background: Adult medial patellofemoral ligament (MPFL) reconstruction techniques are not appropriate for the skeletally immature patient given the proximity of the distal femoral physis. Biomechanical consequences of reconstructions aimed at avoiding the physis have not been adequately studied. Purpose: To quantify the biomechanical effects of MPFL reconstruction techniques intended for skeletally immature patients. Study Design: Controlled laboratory study Methods: Four MPFL reconstruction techniques were evaluated using a computationally augmented cadaveric model: (1) Schoettle point: adult-type reconstruction; (2) epiphyseal: socket distal to the femoral physis; (3) adductor sling: graft wrapped around the adductor tendon; (4) adductor transfer: adductor tendon transferred to patella. A custom testing frame was used to cycle 8 knees for each technique from 10° to 110° of flexion. Patellofemoral kinematics were recorded using a motion camera system, contact stresses were recorded using Tekscan pressure sensors, and MPFL length was computed using an inverse kinematics computational model. Change in MPFL length, patellar facet forces, and patellar kinematics were compared using generalized estimating equation modeling. Results: Schoettle point reconstruction was the most isometric, demonstrating isometry from 10° to 100°. The epiphyseal technique was isometric until 60°, after which the graft loosened with increasing flexion. The adductor sling and adductor transfer techniques were significantly more anisometric from 40° to 110°. Both grafts tightened with knee flexion and resulted in significantly more lateral patellar tilt versus the intact state in early flexion and significantly higher contact forces on the medial facet versus the epiphyseal technique in late flexion. Conclusion: In this cadaveric simulation, the epiphyseal technique allowed for a more isometric ligament until midflexion, when the patella engaged within the trochlear groove. The adductor sling and adductor transfer grafts became tighter in flexion, resulting in potential loss of motion, pain, graft stretching, and failure. Marginal between-condition differences in patellofemoral contact mechanics and patellar kinematics were observed in late flexion. Clinical Relevance: In the skeletally immature patient, using an epiphyseal type MPFL reconstruction with the femoral attachment site distal to the physis results in a more isometric graft compared with techniques with attachment sites proximal to the physis.