Does Surgical Repair Benefit Pipkin Type I Femoral Head Fractures?: A Systematic Review and Meta-Analysis

Background: Femoral head fractures are rare injuries with or without traumatic dislocations. The management of these fractures is crucial to prevent the development of severe complications and to achieve optimal functional outcomes. Wide treatment options for Pipkin 1 femoral head fractures range from fragment excision, fixation following open reduction with internal fixation, or conservative treatment such as close reduction alone after fracture dislocation. However, the best decision making remains controversial not only due to lack of large trials, but also inconsistent results reported. Therefore, we aim to compare the operative with nonoperative outcomes of Pipkin type 1 patients. Patients and Methods: We systemically searched MEDLINE, EMBASE, Cochrane library, In-Process & Other Non-Indexed Citations to identify studies assessing outcomes of Pipkin type 1 patients after conservative treatment, and open reduction with excision or fixation. Data on comparison of clinical outcomes of each management were extracted including arthritis, heterotopic ossification (HO), avascular necrosis (AVN), and functional scores (Thompson Epstein, Merle’ d Augine and Postel Score). We performed a meta-analysis with the available data. Results: Eight studies (7 case series and 1 RCT) were included in this study. In a pooled analysis, the overall rate of arthritis was 37% (95% CI, 2–79%), HO was 20% (95% CI, 2–45%), and AVN was 3% (95% CI, 0–16%). In comparison of management types, the excision group reached the best functional outcomes including Thompson Epstein Score (poor to worse, 9%; 95% CI, 0–27%) and Merle d’ Aubigne and Postel Score (poor to worse, 18%; 95% CI, 3–38%); ORIF group had the highest AVN rate (11%; 95% CI, 0–92%); conservative treatment had the highest arthritis rate (67%; 95% CI: 0–100%) and lowest HO rate (2%; 95% CI, 0–28%). Discussion: This meta-analysis demonstrates that different procedures lead to various clinical outcomes: fragment excision may achieve better function, conservative treatment may result in a higher arthritis rate, while ORIFs may have a higher AVN rate. These findings may assist surgeons in tailoring their decision-making to specific patient profiles. Future RCTs with multicenter efforts are needed to validate associations found in this study. Level of Evidence: II, systematic review and meta-analysis.

Operative Treatment of Bipartite Patella in Pediatric and Adolescent Athletes: A Retrospective Comparison With a Nonoperatively Treated Cohort

Background: Bipartite patella (BPP) is a developmental anomaly that forms when incomplete patellar ossification leaves a residual fibrocartilaginous synchondrosis between ossification centers. Repetitive traction forces across the synchondrosis can cause knee pain, most commonly presenting in adolescence. Symptoms frequently resolve with nonoperative management. Few surgical case series exist to guide treatment approaches for refractory pain. Purpose: To investigate the clinical features, surgical techniques, and outcomes associated with operative treatment of symptomatic BPP in pediatric and adolescent athletes and to compare features of the series with a large control group managed nonoperatively. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective medical record review was conducted of all patients aged ≤20 years who were diagnosed with symptomatic, radiologically confirmed BPP between 2003 and 2018 at a single tertiary-care pediatric hospital (N = 266). Demographic and clinical variables were analyzed, and additional radiologic and perioperative variables were collected for the surgical subcohort. Results: Of the 266 patients included, 27 were treated operatively (10.2%). When compared with those treated nonoperatively (with rest, physical therapy, cryotherapy, and anti-inflammatory medications), the operatively managed group experienced a longer duration of symptoms before first presentation (21.5 vs 7.6 months; P < .001) and were more likely to be older (mean age, 15.4 vs 12.4 years; P < .001), female (59.3% vs 35.6%; P = .03), and competitive athletes (100% vs 84.5%; P = .02). In the 27 patients treated operatively, procedures were categorized as isolated fragment excision (n = 9), fragment excision with lateral release (n = 8), isolated lateral release (n = 5), fragment screw fixation (n = 4), and synchondrosis drilling (n = 1). The mean time between surgery and return to sports was 2.2 months. Four patients (14.8%) reported residual symptoms requiring secondary surgery, including lateral release (n = 1), excision of residual fragment (n = 1), and fixation screw removal (n = 2). Conclusion: BPP can cause knee pain in adolescent athletes and is generally responsive to nonoperative treatment. Patients undergoing surgical treatment—most commonly female competitive athletes with prolonged symptoms—represented 10% of cases. A variety of surgical techniques may be effective, with a 15% risk of persistent or recurrent symptoms warranting reoperation. Prospective multicenter investigations are needed to identify optimal candidates for earlier interventions and the optimal operative treatment technique.

PRESENTING FEATURES, CLINICAL COURSE, SURGICAL TECHNIQUES, AND OUTCOMES ASSOCIATED WITH OPERATIVE TREATMENT OF BIPARTITE PATELLA IN PEDIATRIC AND ADOLESCENT ATHLETES: A RETROSPECTIVE COMPARISON TO A NON-OPERATIVELY TREATED COHORT

Background: The bipartite patella is a developmental variant in which incomplete ossification leads to a fibrocartilaginous synchondrosis between ossification centers; repetitive traction on the synchondrosis in young athletes may lead to pain. Few series of surgical cases exist to guide treatment approaches to refractory pain. Hypothesis/Purpose: To investigate the presenting features, clinical course, surgical techniques, and outcomes associated with operative treatment of symptomatic bipartite patella in pediatric and adolescent athletes, with comparison to a control group of symptomatic, non-operative patients. Methods: A retrospective medical record review of patients ≤20 years-old diagnosed with symptomatic, radiographically-confirmed bipartite patellae between 2003 and 2018 at a single tertiary-care pediatric hospital was conducted. Patients for whom knee pain could not be attributed to bipartite patella were excluded. Additional clinical and operative variables were collected for the subset that underwent surgical treatment. Outcomes analyzed included time to return to sport (RTS) and re-operation. Results: 278 patients (37.8% females; mean age: 12.7 years, range 7-20 years) were included, 27 (mean age: 15.3 years, range 10-20 years) of whom were treated operatively (9.7%). Compared to the 251 patients who underwent non-operative treatment (consisting of physical therapy, activity modification, non-steroidal anti-inflammatory medicines, and cryotherapy), the operatively treated patients were more likely to be older (mean age 12.4 years vs. 15.3 years, p<0.001), female (35.5% vs. 59.3%, p=0.02) and competitive athletes (83.6% vs. 100%, p=0.10). Of the operative patients, 16 (59%) had Saupe III (superolateral) ossicles, 8 (30%) had Saupe II (lateral) ossicles, and 3 (11%) had Saupe I (inferior) ossicles. Most operative patients (79%) reported insidious onset of pain, with minor trauma precipitating symptom onset in the remainder (21%). Symptom duration prior to surgery was 2.2 years (range 1.7 mo-10.1yrs). Procedures were categorized as isolated fragment excision (n=10), fragment excision with lateral release (n=9), isolated lateral release (n=4), ORIF (n=3), and arthroscopic drilling (n=1). Operative outcomes are found in Table 1. Conclusions: Bipartite patella may be an underappreciated cause of knee pain in adolescent athletes. Patients who underwent surgery displayed symptoms lasting >2 years, representing ˜10% of cases, and were most likely to have superolateral bipartite fragments with a mean size of ˜1cm2. Surgery was more common amongst females, competitive athletes, and older adolescents. There was an overall 11% risk of persistent or recurrent symptoms warranting re-operation. Prospective multi-center investigations may be warranted to identify optimal candidates for earlier interventions, as well as optimal non-operative and operative treatment techniques. [Table: see text]

Coronal Shear Fractures of the Distal Humerus: A Review of Diagnosis, Treatment, and Outcomes

Fractures of the capitellum and trochlea are uncommon fractures of the elbow and can be challenging to treat due to their size, location, and articular nature. Because of their intra-articular nature and predilection toward displacement, these fractures are typically treated operatively. Furthermore, capitellum fractures have high rates of associated injuries, including radial head fractures or lateral collateral ligament injury in ~30% to 60% of patients. In addition to open reduction internal fixation, operative options include fragment excision, arthroscopic assisted reduction and fixation, and elbow arthroplasty. In this article, we undertake a comprehensive literature review of capitellum fractures of the distal humerus, in an attempt to summarize the existing body of evidence and propose areas of future study.

Treatment of Symptomatic Bipartite Patella by Fragment Excision, Capsular Repair and Novel ITB Release

Objectives: The aim of this paper is to present the mid-term results of a novel technique used to treat symptomatic bipartite patella. Methods: Diagnosis of symptomatic bipartite patella was made by history, examination, Xray, MRI and/or bone scan. Patients with typical localised pain, pain on manually stressing the fragment, a positive ITB tightness test, a typical Xray and either, a hot bone scan or bone oedema on MRI were considered for treatment. All patients had a pre-op Kujala and Lysholm score recorded. Surgical Technique: Under GA and tourniquet a 4 part procedure was performed: Routine arthroscopy to assess patella tracking and fragment stability A 2 cm incision was made on the distal thigh 10-12 cm above the joint line over the ITB. A zig-zag incision was made across the ITB/IPB from anteriorly to the corner of the intermuscular septum. A 4 cm incision was made over the edge of the lateral patella. A longitudinal capsular incision was made at the edge of the patella. The capsule was reflected off the dorsal patella by sharp dissection and the bipartite fragment was excised through the synchondrosis. A watertight repair of the lateral capsule was performed with absorbable suture. Routine closures were performed. Comment: The author considers the ITB/IPB to be an important factor in the development and progression of the disorder. The addition of the novel release allows a tension-free capsular repair, reducing lateral facet loads, improving patella tracking without affecting patella stability Results: Over an 11 year period twenty patients underwent the procedure. 15 were available with a minimum 2 year and mean 6.35 year follow-up. Pre-op and post-op Kujala and Lysholm scores were compared. Patients were predominantly male (14:1) between ages 10-54 years. A clear history of trauma was present in 6 patients while in 9 symptoms were related to overuse. The pre-op Kujala score ranged from 28-90 with an average of 59. Post-op scores improved markedly with range 70-100 with 12 patients (80%) scoring >90 and an average improvement of 32 pts. Lysholm scores similarly improved significantly, with an average 32 pts improvement (range 1-66). Complications were minimal. Conclusion: Fragment excision, capsular repair and novel ITB release resulted in significant reproducible improvements in both objective and subjective outcome measures. Resolution of symptoms occurred in all patients suggesting the technique is a useful option in the treatment of symptomatic bipartite patella.

Valgus Instability of the Elbow Due to Medial Epicondyle Nonunion: Treatment by Fragment Excision and Medial Collateral Ligament Reconstruction

Background: The medial epicondyle nonunion becomes symptomatic valgus instability with medial elbow pain and joint instability due to dysfunction of the medial collateral ligament (MCL), thus requiring surgical treatment. The purpose of the present study is to report the clinical result of the fragment excision and ligament reconstruction by free tendon graft in the treatment of symptomatic medial epicondyle nonunion. Methods: A retrospective study of five consecutive patients was performed. All five patients had signs and symptoms of valgus instability of the elbow. The mean period of nonunion was 25 years, and their injuries progressed asymptomatically until symptoms developed in adulthood after a second injury. Results: All patients were treated by fragment excision and MCL reconstruction. At the final follow-up, no patients exhibited pain or instability. The mean joint range of motion was 0o of extension and 138o of flexion, with an MEPS of 100 points in all patients. Conclusions: By ligament reconstruction for MCL insufficiency and removing the bone fragments avoided irritation by the bone fragments, pain and instability disappeared, good range of motion was restored, and excellent outcomes were achieved in all patients. We believe that fragment excision and MCL reconstruction should be considered as the treatment option for symptomatic medial epicondyle nonunion of the humerus.