The Paediatric Knee

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The Paediatric Knee
Manoj Ramachandran Consultant Paediatric and
Young Adult Orthopaedic Surgeon Barts and The
London NHS Trust
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Objectives

• Disorders of infancy
• Hyperextension
• Flexion
• Disorders of childhood
• Anatomic
• Overuse/Apophysitides
• Idiopathic
• Patellofemoral instability
• Tibial bowing

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Disorders of infancyHyperextension
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Congenital dislocation of the knee

• Hyperextended knee at birth
• Less than 1 in 1000
• Ipsilateral DDH 50 / CTEV 50
• Bilateral CDK syndromic e.g. arthrogryposis, EDS
• Pathology Quads fibrosis/hypoplastic
  patella/contracture ITB/hamstrings anteriorly
  displaced/cruciates absent
• Nonoperative serial casting in flexion
• Operative reconstruction at 6 mo 1yr

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Disorders of infancyFlexion
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Congenital patella dislocation

• Diagnosed at birth or within first decade
• Patella fixed to lateral femur
• Due to failure of internal rotation of myotome
  in 1st trimester
• Pathology - extensor mechanism lateralized/contrac
  ture ITB and VL/loose medial structures/hypoplasti
  c trochlea
• Surgery at 6 mo 1yr
• Extensive lateral release and medial reefing
• /- medialize PT (Roux Goldthwaite)

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Disorders of childhoodAnatomicDiscoid menisci
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Discoid menisci

• Uncommon (except Japan)
• Mostly lateral
• Forms from fibrocartilage in mesenchymal
  condensation
• Snapping / flexion contracture
• X-rays / MRI
• 3 types (Watanabe) Wrisberg/complete/incomplete
• Arthroscopic/open meniscoplasty
• Rim stabilization in Wrisberg type

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Disorders of childhoodAnatomicPopliteal cysts
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Popliteal cysts

• Gastrocnemius-semimembranosus bursa
• Malegtfemale
• Asymptomatic mass
• Transilluminates
• USS / MRI
• Leave alone (most disappear in a few months to
  years)
• Rarely surgical excision

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Disorders of childhoodAnatomicOsteochondritis
dissecans
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Osteochondritis dissecans

• Separation of cartilage and subchondral bone
  segment, usually lateral aspect of MFC
• Hereditary, mechanical or ischaemia?
• Pathology
• AVN of subchondral bone
• Ischaemia and fibrosis of articular cartilage
• Revascularization
• Creeping substitution
• Dense fibrous tissue if healing incomplete

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Osteochondritis dissecans

• Guhl arthroscopic classification
• Intact lesion
• Early separated lesion
• Partially detached lesion
• Craters with loose bodies (salvageable/unsalvageab
  le)

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Osteochondritis dissecans

• Diagnosis
• Clinical
• Tunnel view
• MRI Scans
• Restrict activity
• Arthroscopy
• Drilling
• Fixation
• Excision
• Mosaicplasty
• Microfracture
• ACI/MACI

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Disorders of childhoodOveruse/Apophysitides
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Examples

• Osgood-Schlatter

Sinding-Larsen-Johannson
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Disorders of childhoodIdiopathicBlounts disease
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Blounts disease

• Progressive varus and internal rotation due to
  posteromedial growth retardation
• Infantile or adolescent
• Aetiology unknown
• Obese
• Early walker
• Afro-Caribbean
• Present with deformity and abnormal gait

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Blounts disease

• Radiological signs
• Varus angulation
• Widened, irregular physeal line medially
• Medially sloped, irregularly ossified
  epiphysis
• Prominent beaking of the medial metaphysis
  with lucent cartilage islands within the beak
• Lateral subluxation of the proximal end of the
  tibia
• Levine-Drennan MDAgt11 degrees

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Blounts disease

• Surgical options
• KAFO (below age 3)
• Osteotomy (OW/CW/dome/oblique)
• Physeal bridge resection
• Epiphysiodesis
• Hemiplateau elevation
• Frame correction

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Disorders of childhoodPatellofemoral pain and
instability
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Patellofemoral instability

• Bone
• Whole limb
• PFA, external tibial torsion, genu valgum
• Knee
• Patella alta, trochlear dysplasia
• Soft tissue
• General
• Benign hypermobility, syndromic laxity
• Local
• Medial laxity, lateral tightness

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Patellofemoral instability

• History
• Acute or chronic
• Number of episodes
• Symptoms
• Circumstances of injury
• Previous treatment
• Other injuries e.g. ACL, meniscus
• Syndromes

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Patellofemoral instability

• Examination
• Knee
• Patella tracking (J-sign)
• Medial or lateral tenderness
• Lateral tightness
• Fairbanks apprehension test
• Q-angle
• Full knee examination
• Limb
• Torsional profile
• Coronal profile
• General
• Laxity

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Patellofemoral instability

• Plain X Rays
• Lateral view
• 30 deg flexion
• Trochlea
• Merchant View
• 45 deg flexion

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Patellofemoral instability

• CT Scans
• Knee flexion
• Quads contracted
• MRI Scans
• Medial structures
• Cartilaginous/ligamentous lesions
• EUA Arthroscopy
• Acute injuries (MPFL)
• Tracking
• Cartilaginous/ligamentous lesions

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Patellofemoral instability

• Nonoperative
• RICE for acute injuries
• Analgesia
• SLR/ Isometric quadriceps/VMOs/hamstring
  stretches/biofeedback/McConnell taping
• Temporary immobilization e.g. patella stabilizing
  orthosis
• Radiographs - ?osteochondral fragment for
  fixation
• Modification of activities

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Patellofemoral instability

• Soft tissue
• Lateral release (if tilt)
• VMO advancent
• MPFL reconstruction (acute)
• Galeazzi semitenodesis
• Roux Goldthwaite (skeletally immature)
• Green quadricepsplasty

h
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Patellofemoral instability

• Bone
• Derotational osteotomies
• Tubercle transfer (skeletally mature)
• Trochleoplasty
• Microfracture/ACI/MACI

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Tibial bowing
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Causes

• Localised
• Physiological
• Posteromedial (bowing and CV corrects leaving 10
  LLD)
• Blounts disease
• Anteromedial (fibular dysplasia)
• Anterolateral (congenital pseudarthrosis of the
  tibia/NF1)
• Posttraumatic (valgus following proximal tibial
  metaphyseal fracture Cozens fracture)
• Generalised
• Osteogenesis imperfecta
• Rickets
• (Rare - Thanatophoric dwarfism, Campomelic
  dwarfism Metaphyseal chondrodysplasia)

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Exam question fibular dysplasia

• Associations
• Short femur (60)
• Lateral femoral condyle hypoplasia
• Absent cruciates
• Valgus ankle
• Tarsal coalition (ball and socket ankle)
• Absent lateral rays of foot
• Upper limb and visceral anomalies (rare)

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Objectives

• Disorders of infancy
• Hyperextension
• Flexion
• Disorders of childhood
• Anatomic
• Overuse/Apophysitides
• Idiopathic
• Patellofemoral instability
• Tibial bowing

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Thank you!
Manoj Ramachandran Consultant Paediatric and
Young Adult Orthopaedic Surgeon Barts and The
London NHS Trust