Arthroscopy of the hip in children and adolescents

Intra-articular abnormalities of the hip, such as labral tears, loose bodies, chondral lesions, ligamentum teres tears and femoral acetabular impingement are increasingly being recognized in the pediatric age group. Evaluation for these abnormalities starts with a good history and physical exam. Radiographic imaging with plain films and magnetic resonance imaging help confirm the clinical impression. Arthroscopy of the hip can be utilized to diagnose and treat these abnormalities. Arthroscopy of the hip is a challenging procedure with a learning curve that requires a thorough knowledge of the anatomy of the hip. The hip is a deeply recessed joint that has a large muscular envelope, thick joint capsule and convex and concave surfaces of the femoral head and acetabulum, respectively. The normal anatomy may be distorted due to childhood developmental disorders such as hip dysplasia, Legg–Calve–Perthes Disease and Slipped Capital Femoral Epiphysis that adds additional challenges to the arthroscopist. Isolated intra-articular abnormalities occur rarely and an underlying morphologic abnormality should be identified which also requires management. Complications can be minimized with attention to detail.     

Arthroscopy of the knee in children

Diagnostic arthroscopy was performed in 174 consecutive patients under the age of 18 years. Eight arthroscopies were bilateral. The clinical diagnosis was confirmed in only three of 17 knees in children under aged 14 years and in 44 per cent of the knees in older children. The most commonly disproved diagnoses were torn meniscus and chondromalacia patella. Arthroscopy seldom changed the diagnosis in cases of osteochondritis dissecans. In 38 per cent of the knees, arthroscopy revealed no surgical treatable abnormality, and unnecessary arthrotomy was avoided.

Arthroscopy in acute hemarthrosis revealed that ligamentous tears are rather common in children; in nine of 25 knees a partial or complete tear of the anterior cruciate ligament was demonstrated at arthrosocopy. The clinical diagnosis was confirmed in eight knees in cases of hemarthrosis. There was no significant difference between the hemarthrosis group and the remaining group as regards a disproved clinical diagnosis. We conclude that arthrotomy should always be preceded by diagnostic arthroscopy in children and adolescents if the clinical diagnosis leaves any doubt.     

Arthroscopy of the knee in children

A review was carried out of arthroscopy of the knee in children. During a 34-month period, 2,378 arthroscopies were performed, 80 of these on children less than 16 years of age. Seventy-one cases were reviewed, which is approximately 2% of all children seen at the clinic. Thirty procedures were carried out in patients with hemarthrosis. Eleven patients required operative repair or reconstruction. There were 13 ruptures of the anterior cruciate ligament (43%), 4 ruptures of the posterior cruciate ligament, 14 ruptures of the medial collateral or posterior oblique ligament, and 5 ruptures of the lateral meniscus. Forty-one arthroscopies were done in patients without hemarthrosis or history of acute trauma. A clinical diagnosis of meniscus tear was correct in only 20%. Only one meniscectomy was performed and another meniscus tear was repaired. The most common diagnostic finding was abnormality of the patellofemoral articulation, which was diagnosed in 31 patients. Arthroscopic shaving of the patella was rarely indicated. As in adults, hemarthrosis indicates significant injury to the knee. Meniscus lesions are rare.     

Arthroscopy of the knee in children

Diagnostic arthroscopy was performed in 174 consecutive patients under the age of 18 years. Eight arthroscopies were bilateral. The clinical diagnosis was confirmed in only three of 17 knees in children under aged 14 years and in 44 per cent of the knees in older children. The most commonly disproved diagnoses were torn meniscus and chondromalacia patella. Arthroscopy seldom changed the diagnosis in cases of osteochondritis dissecans. In 38 per cent of the knees, arthroscopy revealed no surgical treatable abnormality, and unnecessary arthrotomy was avoided. Arthroscopy in acute hemarthrosis revealed that ligamentous tears are rather common in children; in nine of 25 knees a partial or complete tear of the anterior cruciate ligament was demonstrated at arthroscopy. The clinical diagnosis was confirmed in eight knees in cases of hemarthrosis. There was no significant difference between the hemarthrosis group and the remaining group as regards a disproved clinical diagnosis. We conclude that arthrotomy should always be preceded by diagnostic arthroscopy in children and adolescents if the clinical diagnosis leaves any doubt.     

Arthroscopy of the knee in pre-adolescent children

Introduction: Arthroscopic operations performed in the pediatric age group constitute less than 5% of all arthroscopies. Diagnostic accuracy is reported to be lower than the procedures in adult patients. The incidence of pathologies also varies in the literature. We aimed at assessing the diagnostic accuracy of arthroscopy and review the incidence of pathologies in pre-adolescent patients. Materials and methods: In the period April 1990–January 2002, 50 pre-adolescent patients underwent knee arthroscopy after clinical and radiological assessment. Average age was 10.24 (1–13) with a male-to-female ratio of 34:16. Results: Discoid lateral meniscus was found to be the most common pathology encountered in 17 cases followed by infection and synovitis in 8 cases each. Diagnostic accuracy of arthroscopy correlated with preoperative clinical and radiologic evaluation was 90%. Arthroscopy findings were negative in two cases. Two cases of plica syndrome and one case of chondral injury were mistaken for medial meniscal tear. Final diagnosis was familial Mediterranean fever in one case of synovitis and knee fusion was performed at follow-up due to progressive degenerative changes. No other patient required reoperation. Conclusion: Arthroscopy is a safe procedure with minor morbidity allowing treatment of various intraarticular knee disorders. Diagnostic accuracy of the procedure may increase with careful preoperative work-up.     

Arthroscopy in injuries of the knee joint in children

The author analyses his experience in performing arthroscopy in 51 children with injuries of the knee joint. 21 patients had haemarthroses of the knee joint. Arthroscopy revealed avulsion of radiopaque osteochondrous fragments in 8 of them. Arthroscopy was performed in 15 children with knee joint blocks. Meniscus injuries were revealed in 5 children and avulsions of the osteochondrous fragments were determined in 5 patients. 9 cases of posttraumatic synovitis of the knee joint were investigated; in 3 cases there were avulsions of the osteochondrous fragment and in 3 cases there was systemic pathology. Arthroscopy as a therapeutic measure was performed in 26 children. The indications for using this method are discussed.     

Osteoporosis in children and adolescents

There is currently no consensus definition of osteopenia and osteoporosis in children according to bone mineral density (BMD) values measured by dual energy x-ray absorptiometry (DXA); interpretation of BMD measures must take into account the child's weight and pubertal status. In children, primary forms of osteoporosis--juvenile idiopathic osteoporosis and osteogenesis imperfecta--are rare; on the other hand, the frequency of secondary osteoporosis is increasing. Fractures, especially of the forearm, are frequent in children. During the peak growth period, bone growth and mineralization are dissociated; in consequence temporary bone fragility promotes fractures. Several recent studies show that children with fractures have reduced BMD and that the occurrence of fractures in children may constitute a risk factor for osteoporosis and fracture during adulthood. In cases of secondary osteoporosis, close monitoring of the causal disease is the key element of treatment; there are very few controlled studies of the prevention or treatment of osteoporosis in children.     

Osteoporosis in children and adolescents

In recent years, the issue of low bone density in children and adolescents has attracted much attention. The classical definition of osteoporosis should be valid at any age, yet its practical applicability to children and adolescents remains a matter of debate and there is no consensus on a diagnosis based solely on the BMD value. The clinical relevance of uncomplicated low bone density in the young and its long-term consequences remain difficult to evaluate and there is only preliminary evidence that the BMD value is a predictor of fracture risk in growing subjects. Moreover, the interpretation of densitometric data in the young is difficult because the "normal" BMD values to be used for comparison are continuously changing with age, and in addition, depend on several variables, such as gender, body size, pubertal stage, skeletal maturation and ethnicity. Although Z-score values below -2 are generally considered a serious warning, most bone specialists make a diagnosis of osteoporosis in children and adolescents only in the presence of low BMD and at least one fragility fracture. The scope of this review is limited to presenting a picture of the available knowledge. The literature on fractures will be presented in detail, since fractures are one of the key elements in the debate. There are countless papers on fractures in childhood and adolescence, but very few of them attempt to identify fragility fractures, and still fewer develop the concept of osteoporosis in the young in relation to fractures. The different forms of primary and secondary osteoporosis, the more technical aspects of bone densitometry in pediatrics, and the delicate issue of treatment will be discussed only briefly.     

Varicocele in children and adolescents

Idiopathic varicocele is quite common even among children and adolescents. Irreversible testicular damage may occur before adult age. Diagnosis and therapy for the purpose of preventing infertility constitute a challenge to youth health organisations and paediatric surgeons. Surgery according to Bernardt or Ivanissevich is considered the optimal therapeutic approach.     

Diabetic nephropathy in children and adolescents

Type 1 diabetes mellitus (T1DM) commonly occurs in childhood or adolescence, although the rising prevalence of type 2 diabetes mellitus (T2DM) in these age groups is now being seen worldwide. Diabetic nephropathy (DN) develops in 15–20% of subjects with T1DM and in similar or higher percentage of T2DM patients, causing increased morbidity and premature mortality. Although overt DN or kidney failure caused by either type of diabetes are very uncommon during childhood or adolescence, diabetic kidney disease in susceptible patients almost certainly begins soon after disease onset and may accelerate during adolescence, leading to microalbuminuria or incipient DN. Therefore, all diabetics warrant ongoing assessment of kidney function and screening for the earliest manifestations of renal injury. Pediatric health care professionals ought to understand about risk factors, strategy for prevention, method for screening, and treatment of early DN. This review considers each form of diabetes separately, including natural history, risk factors for development, screening for early manifestations, and strategy recommended for prevention and treatment of DN in children and adolescents.     

Knee injuries in children and adolescents

As more children and adolescents are involved in sporting activities, the number of injuries to immature knees rises. We will focus on three entities: ruptures of the anterior cruciate ligament, patellar dislocation, and meniscal injuries. There is a trend in recent literature toward early reconstruction of the anterior cruciate ligament in children and adolescents. In this article, we will try to highlight the anatomic specialities and the diagnostic steps toward the correct diagnosis, review technical considerations and risks of the different surgical techniques, and present outcomes and offer a treatment recommendation. The treatment of patellar dislocation has changed considerably since we gained a better understanding of the unique anatomy of the patellofemoral joint. We will show diagnostic steps and risk factors for recurrent patellar dislocation, discuss conservative and different operative therapy options, and present a modified technique to achieve a dynamic reconstruction of the medial patellofemoral ligament without damage to the growth plates. Meniscal tears and discoid menisci are rare in comparison to the other injuries. We will herein explain what specialities in the anatomy should be considered in children and adolescents concerning the menisci, and present the diagnostic steps and treatment options available.     

Ankle fractures in children and adolescents

Ankle fractures in children and adolescents usually involve the distal tibial and fibular epiphysis. Unless adequately treated, these fractures may be associated with many complications including limb length discrepancy and angular deformities due to growth arrest, and arthritis due to joint involvement. Fractures of the distal tibial epiphysis are classified according to the type and mechanism of injury. Salter-Harris type 1 and 2 fractures of the ankle have a good prognosis and can be treated by closed reduction. However, type 3 and 4 fractures involving the medial malleolus require surgical treatment because they usually result in compression of the physeal plate and cause angular deformities. External rotation of the foot may result in juvenile Tillaux fractures and triplane fractures of the distal tibia in the transitional period during which asymmetric physiologic closure of the distal tibial physis occurs. These are combinations of Salter-Harris type 2, 3, and 4 fractures, consisting of two or three fragments. Although they are not associated with growth arrest, they may lead to arthritis due to joint involvement. The presence of residual displacement of more than two millimeters necessitates surgical treatment.     

Renovascular disease in children and adolescents

PURPOSE: This retrospective review describes the surgical management of renovascular disease in 25 consecutive children and adolescents with severe hypertension. METHODS: Patients 95 th percentile systolic or diastolic pressure adjusted for gender, age, and height). RA repair comprised 25 bypasses (73%) consisting of 28% saphenous vein, 60% hypogastric artery, and 12% polytetrafluoroethylene; 2 patch angioplasties (6%), and 7 reimplantations (21%). Branch RA exposure was required in 28 kidneys (88%), and branch reconstruction was required in 61%. Warm in situ repair was used in 53%, in situ cold perfusion in 24%, and ex vivo cold perfusion in 23%. Of six bilateral RA repairs, one was staged and two patients are awaiting a staged repair. Combined aortic reconstruction was required in three patients. No unplanned nephrectomy was performed. There were no perioperative deaths. Hypertension was cured in 36%, improved in 56%, and failed in 8% at mean follow-up of 46.4 +/- 7.8 months. The mean calculated glomerular filtration rate increased from 82.0 mL/min/1.73 m 2 preoperatively to 98.2 mL/min/1.73 m 2 postoperatively. The postoperative patency of 30 RA reconstructions was evaluated by angiography, RDS scanning, or both. At mean follow-up of 32.8 months (median, 21.2 months), primary RA patency was 91%. No failures were observed after 2 months follow-up. Estimated survival was 100% at 60 months, with one death 9 years after surgery. CONCLUSIONS: Renovascular hypertension in children and adolescents was caused by a heterogeneous group of lesions. All patients had RA repair, with arterial autografts in most of the RA bypasses. Cold perfusion preservation was used in half of the complex branch RA repairs. These strategies provided 91% primary patency at mean follow-up of 32.8 months, with beneficial blood pressure response in 92%. Surgical repair of clinically significant renovascular disease in children and adolescents is supported by these results.     

Acetabular fractures in children and adolescents

A retrospective study of 23 acetabular fractures in patients up to 17 years of age is presented, with an average follow-up of eight years. Good or excellent functional results were achieved in 21 patients; radiographic results were good or excellent in 16. Conservative treatment gave consistently good results in fractures with minimal initial displacement, stable posterior fracture-dislocations and Salter-Harris type 1 and 2 triradiate cartilage fractures. Less favourable results were seen in type 5 triradiate cartilage fractures and in comminuted fractures, but operation was no better. Unstable posterior fracture-dislocations and irreducible central fracture-dislocations need operative treatment but the results may still be unsatisfactory.