Recent Injuries of the Ligaments of the Knee Joint in Children

The author's series comprises 17 cases of fresh ligamental injuries to the knee joint in growing individuals, i.e., patients with residual epiphyseal cartilage.

A clear difference seems to exist between the ligamental injuries to the knee joint of the adult and those of the child in such a way that children exhibit isolated ruptures to a greater degree. Combined injuries in the strict sense did not occur in the author's series. The general picture is dominated by injuries to the anterior cruciate ligament (11 cases) and these are all located to the tibial attachment and possess bony fragments.

Although in adults the tendency is towards a reconstruction and suturing of the ligamental injury in the acute stage we were more conservatively minded with child patients.

Only 4 of the 17 cases were given operative treatment, and in all cases an anterior cruciate injury was involved.

The collateral ligamental injuries in this series were all of the partial type, localised to the femoral attachments. We did not see in a fresh condition any total injury of the type relatively common in adults. However, we encountered the residual condition of a non-treated injury to the medial collateral ligament with considerable consequences. This case is reported, hut does not belong to the series.

Sixteen of the seventeen cases were followed-up and it was found that on isolated occasions one individual had very slight subjective discomfort from the injured knee when playing football, while the others declared themselves to be completely free from subjective trouble. In two cases a slight quadriceps atrophy was ascertained, and one of these two exhibited slightly increased “forward drawer” by comparison with the healthy side.

We interpreted the result to mean that it was correct to treat these injuries more conservatively in children than in adults.     

Partial arthrodesis of the wrist: An investigation in cadavers

Partial arthrodesis of the wrist was performed on six cadavers in order to study the residual excursion of the wrist. Arthrodesis between the radius and scaphoid left 40 per cent extension/flexion and 61 per cent radial/ulnar deviation. Arthrodesis between the radius, scaphoid and lunate left 36 per cent extension/flexion and 59 per cent radial/ulnar deviation. Arthrodesis between the capitate, scaphoid and lunate left 59 per cent extension/flexion and 91 per cent radial/ulnar deviation.     

Complications and outcome of four-corner arthrodesis: circular plate fixation versus traditional techniques

PURPOSE: To review the clinical and radiographic results of scaphoid excision and four-corner arthrodesis using a circular plate and screws compared with traditional fusion techniques (wires, staples, screws). METHODS: Fifty-eight patients with four-corner arthrodesis (plate fixation, n = 27; traditional fixation, n = 31) were evaluated for radiographic and clinical success using wrist radiographs and functional assays. Patients were subjectively surveyed using the standardized Disabilities of the Arm, Shoulder, and Hand questionnaire and classification scales for pain and satisfaction. Objective measurements included grip-strength and range-of-motion measurements. RESULTS: Radiographic analysis showed 26% nonunion with loose hardware in the plate group compared with 3% in the traditional group and 22% hardware impingement in the plate group compared with 3% in the traditional group. Clinical evaluation yielded a mean grip strength of 31 kg (70% of opposite side) for plate fixation and 33 kg (79% of opposite side) for traditional fixation. The mean flexion-extension arc was 48% and 50% of the opposite wrist for plate and traditional patients, respectively. The mean adjusted Disabilities of the Arm, Shoulder, and Hand questionnaire scores were 27 out of 100 for plate patients and 8 out of 100 for traditional patients. Pain classification scores showed that only 2 patients in the plate group were pain free whereas there were 8 patients in the traditional group who were pain free. Overall patient satisfaction was 60% for the plate group whereas the traditional patient group reported 100% satisfaction. CONCLUSIONS: The rate of major complications (nonunion or impingement) was much greater with circular plate fixation (48%) versus traditional fixation techniques (6%). With the plate procedure the grip strength and arc of motion decreased approximately 30% and 52%, respectively, compared with decreases of 21% and 50%, respectively, for traditional fusion methods. Additionally, subjective patient dissatisfaction was 40% in the plate group compared with 0% in the traditional group. We postulate that the increased complication and dissatisfaction rates associated with plate fixation may be attributable to possible biomechanical imperfections or increased technical demands with this fusion system.     

Technique for percutaneous fixation of displaced and nondisplaced acute scaphoid fractures and select nonunions

Percutaneous surgical intervention for scaphoid fractures and some nonunions is increasingly common. There is a considerable learning curve for these procedures. Here we review basic and advanced techniques for volar and dorsal fixation of acute nondisplaced and displaced fractures as well as nonunions with minimal resorption and no humpback deformity.     

The total scaphoid titanium arthroplasty: A 15-year experience

Scaphoid nonunion followed by necrosis of bone segments is a common pathologic condition for the hand surgeon, and the difficulty of its management is well known. The total titanium scaphoid replacement, although not well-described in the literature, in our experience represents a reasonable choice in the treatment of this condition. Strict patient selection is necessary to achieve good clinical results. The titanium avoids the silicone synovitis, a well-described complication of silastic implants. Furthermore, this technique permits other surgical steps in case of failure.