Paediatric patellar instability encompasses many anatomic entities located along a continuum of knee extensor mechanism abnormalities. Major or minor clinical manifestations may occur at a variable age. In major forms with irreducible patellar dislocation or habitual patellar dislocation during knee flexion, shortness of the quadriceps is a consistent feature. A comprehensive aetiological work-up is in order, as syndromic conditions are common. Early surgical treatment is mandatory and should be performed by an experienced paediatric orthopaedic surgeon, as the procedure is technically challenging. Minor forms are more common; they are characterised by patellar dislocation or subluxation near terminal knee extension. The diagnosis may be difficult, particularly at the acute phase. Surgery is needed in patients with recurrent dislocation or functional impairments. The semiology of patellar instability has undergone considerable development in recent years, and a three-dimensional evaluation of patellar position can now be obtained using magnetic resonance imaging. Individually tailored surgical treatment "à la carte" remains a valid approach in 2013. However, new techniques for medial patello-femoral ligament reconstruction have modified the management strategies for adults and superseded many stabilisation procedures. Adapting these new techniques to paediatric patients and developing new procedures constitute major challenges.
Femoral tunnel enlargement after MPFL reconstruction is common, with patients with patella alta at an increased risk. The influence of tunnel malposition and trochlear dysplasia on this condition requires further research. Recurrent instability and patient-reported outcome scores are not affected by tunnel enlargement.
Isolated congenital elbow contracture is a rare upper-extremity disorder and there are few data about management of this condition. Authors report their experience after aggressive management of children with isolated congenital elbow contracture in flexion. Because of total absence of range of motion (ROM) improvement despites physical therapy (ROM 90-120°) and bone deformity, an anterior surgical release of the elbow was performed through an extensive lateral approach, at sixteen months of age. After surgery, this child was treated by three casts at maximal gained extension followed by sequential Turnbuckles splints. After five years of follow-up, the result was excellent with ROM 5-135°, normal function and absence of growth disturbance. The limiting factor of this protocol was excessive traction in elbow extension on the neurovascular structures, especially the radial nerve. This treatment represents an aggressive management with multiple general anaesthesia, but was found to be a valid option.
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