Introduction

Patient-specific instruments (PSI) and surgical-guiding templates are gaining popularity as a tool for enhancing surgical accuracy in the correction of oblique bone deformities Three-dimensional virtual surgical planning technology has advanced applications in the correction of deformities of long bones and enables the production of 3D stereolithographic models and PSI based upon a patient's specific deformity. We describe the implementation of this technology in young patients who required a corrective osteotomy for a complex three-plane (oblique plane) lower-limb deformity.

Background: Congenital dislocation of the patella can cause significant functional disability and is often associated with limb deformity in childhood. Two types or clinical manifestations of this condition have been previously described, namely the fixed lateral dislocation and the habitual or obligatory dislocation of the patella. Few surgical procedures have been suggested for the treatment of the complex condition.

Objective: We reviewed our surgical approach in ten knees (seven children) with both types of patellar dislocation, and evaluated the clinical and functional outcomes.

Methods: All our patients underwent an extensive sub-periosteal mobilization of the extensor mechanism from the lateral side of the thigh combined anteriorly with plication of the medial patellar retinaculum. This procedure was supplemented by medialization of half of patellar tendon in the skeletally immature patients, and by tibial tuberosity transfer that was performed in one skeletally mature patient.

Results: In six children, patellar dislocation was a part of a diagnosed syndrome, namely Down (3 patients), Larsen (1 patient), Rubinstein-Taybi (1 patient) and fibular hemimelia (1 patient). Six knees had fixed type and four (all Down syndrome) had obligatory type of patellar dislocation. Average age at surgery was 9.5 years (range 3.5–14) and the mean follow-up period was 19 months (range 7–33). There was no recurrence during the follow-up period. Two children with Down syndrome, who had flexion contraction and were non-ambulatory, began to walk three months and five months after the surgery. A significant resolution of the valgus deformities was obtained in the operated knees. Two complications were recorded, an undisplaced supracondylar fracture following removal of plastic cast and transitory peroneal nerve palsy.

Conclusions: Abnormal anatomical muscular and bony changes, soft tissue structural changes and limb alignment contribute to patellar dislocation and to subsequent clinical deterioration and deformity progression. Our surgical intervention aimed to realign the extensor mechanism and was effective in treating both types of congenital dislocation of the patella. Based on our experience, the long-standing habitual dislocation is accompanied by changes in the extensor mechanism of the knee that are similar to those occurring in the fixed patellar dislocation and therefore should be addressed surgically in a similar manner.

Despite the impressive advancements in prenatal planning and assessment, obstetrical brachial plexus palsy remains an unfortunate consequence of difficult childbirth.

Although the majority of infants with plexopathy recover with minor or no residual functional deficits, a number of children do not regain sufficient limb function and develop significant functional limitations, bony deformities and joint contractures.

Recent developments in the technique of microsurgical reconstruction of peripheral nerve injuries proved to be effective in selected cases of children with obstetrical brachial plexus injury.

Many of these children and those who were defined as having minor injury will remain with considerable functional limitation and deserve late orthopaedic reconstruction.

Based on that, we developed a multidisciplinary Brachial Plexus clinic gathering a microsurgeon, a pediatric orthopaedic surgeon, an electrophysiologist clinician, physiotherapists and occupational therapist in order to assess and evaluate these children.

A total of 105 children were seen and followed up in our clinic during the last 2 years.

Most of these children were referred to our clinic from other centers and from physiotherapists treating these children on an out-patient basis.

We report the orthopaedic reconstruction operations performed in 9 cases of residual functional disabilities in children born with obstetric palsy.

4 patients had latissimmus dorsi and teres major transfer.

2 patients had derotation osteotomy of the humerus.

1 patient had Steindler flexorplasty of the elbow.

2 patients had open reduction and capsulorrhapy for a dislocated shoulder.

Video assessment of these children was performed before and after the operation. Function was also analyzed before and after operation by a physiotherapist and an occupational therapist.

Significant functional improvement was achieved, to the satisfaction of patients and parents.