Opioids and Youth Athletes.

CONTEXT: The ongoing opioid epidemic and associated adverse effects impart a large burden on our current healthcare system. The annual economic and noneconomic cost of opioid use disorder and fatal opioid overdose is currently estimated at $1 trillion. OBJECTIVE: This review presents the prevalence, frequency of use, need, and effectiveness of opioid analgesia in the youth and adolescent athlete population. It identifies current indications for opioid versus nonopioid analgesic use in the setting of acute orthopaedic injuries, postoperative management, concussion, and chronic pain. Current knowledge of youth athlete opioid use, risks related to use, misuse, diversion, and addiction are reviewed. DATA SOURCES: A PubMed, Medline, and Cochrane Library search was conducted in February 2023 to review opioid pain management strategies in the pediatric athlete population from 2000 to present. STUDY SELECTION: Searches were restricted to English language articles and human subjects. Initial reviews of titles and abstracts were performed by all authors and relevant full-text articles were selected. Priority was given to systematic and narrative reviews, meta-analyses, and prospective studies. STUDY DESIGN: Narrative review. LEVEL OF EVIDENCE: Level 3. DATA EXTRACTION: First author name, publication year, study design, study country, subject demographics, and data on the frequency, type, and duration of analgesic treatments for musculoskeletal injuries, postsurgical care, chronic pain disorders, and concussion were extracted. RESULTS: Pediatric athletes comprise a high-risk population seeking analgesic relief for injury-related pain. Participation in high school sports is associated with increased risk of opioid use. An average of 28% to 46% of high school athletes have used opioids in their lifetime. Participation in ≥1 high school sport puts adolescents at 30% greater odds of future opioid misuse. CONCLUSION: The use of opioids in the pediatric athlete population is common and associated with both short- and long-term risks of misuse and addiction.

Pediatric Elbow Dislocations and Associated Fractures.

The objective was to evaluate pediatric patients with acute elbow dislocation and/or associated fracture to determine which were indicated for surgical intervention, using a single institution, Institutional Review Board (IRB) approved retrospective review of patients who presented to the Emergency Department (ED) with an acute elbow dislocation. Inclusion criteria were age ≤ 18 years, acute elbow dislocation injury, and appropriate imaging. A total of 117 patients were included 37 had a simple elbow dislocation, 80 had an associated fracture (medial epicondyle 59, lateral condyle 9, radial head/neck 7, other 5). A total of 62% (73/117) were male. The average age was 10.3 years (range 4-17). Mechanisms of injury included: falls from height/playground equipment (46), trampoline (14), and sports (57). All 37 patients with a simple elbow dislocation were successfully treated with closed reduction. Of the 80 patients with an associated fracture, 30 (38%) went on to open reduction internal fixation (ORIF). A total of 59 patients had an associated medial epicondyle fracture; 24 (41%) of whom went on to ORIF. Nine patients had an associated lateral condyle fracture, five (56%) of whom went on to ORIF. Patients with a simple elbow dislocation can be successfully treated with a closed reduction in the ED. However, 30/80 patients with an associated fracture (medial epicondyle, lateral condyle, or radial neck) required operative management.

Functional and Radiographic Disease Progression in Nonoperatively Managed Kienböck Disease.

BACKGROUND: The purpose of this study was to describe the natural history of Kienböck disease among patients who elected to proceed with nonoperative treatment. METHODS: The authors performed a retrospective study of all patients treated nonoperatively for Kienböck disease within their institution from January 1, 1999, to December 31, 2014. Inclusion criteria included follow-up greater than 1 year, serial posteroanterior and lateral wrist radiographs, and clinical examination. Posteroanterior/lateral radiographs were independently reviewed at initial presentation and at final follow-up, including Lichtman stage, carpal index, Stahl index, ulnar variance, and intercarpal angles. RESULTS: Twenty-five patients with 25 wrists were included (mean age, 50.2 years), with an average length of clinical follow-up of 3.9 years and a mean length of radiographic follow-up of 5.2 years. There was no significant difference in range of motion; however, patient-reported pain was significantly decreased, and modified Mayo wrist scores and grip strength were increased. Lichtman stage, scapholunate angle, and radioscaphoid angle were increased; and carpal index, posteroanterior lunate ratio, and Stahl index were decreased across the study period. The mean progression in Lichtman stage was 0.5 stage/year with a range of 0 to 1.6 stages/year throughout the study period. There was no significant difference in Lichtman stage progression based on stage at presentation. A history of smoking was associated with increased radiographic disease progression. CONCLUSION: The present study demonstrates that among patients with Kienböck disease managed nonoperatively, the majority of patients significantly improve over time with respect to pain, grip strength, and Mayo wrist score, despite radiographic progression of disease. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, IV.

Pediatric Radial Neck Fractures: Which Ones Can Be Successfully Closed Reduced in the Emergency Department?

BACKGROUND: The purpose of this study is to examine pediatric patients with a radial neck fracture and determine the factors associated with a failed closed reduction (CR) in the emergency department (ED). METHODS: A total of 70 patients with acute radial neck fractures were retrospectively reviewed. Inclusion criteria were: age 18 years or younger at time of injury, diagnosis of radial neck fracture without other associated elbow fractures, an attempt at CR with manipulation in the ED or immediate surgery, open proximal radial physis, and appropriate imaging to categorize the injury. Charts were reviewed and demographic data was obtained. Initial injury films were reviewed and the Judet classification was used to define fracture types/categories. RESULTS: CR was attempted on 41 patients. Twenty-nine patients went straight to surgery without a CR attempt. Compared with patients that had an attempted CR in the ED, patients that went straight to surgery had longer mean time from injury to ED presentation (5.6 d; P=0.0001), greater mean fracture angulation (55.0 degrees; P=0.001), and greater fracture translation (46.2%; P=0.001). When analyzing the patients that had a CR attempted in the ED, univariate statistical analysis demonstrated that ≥Judet 4 classification (P=0.03), greater amounts of fracture angulation (P=0.003), and a treatment delayed >24 hours from injury (P=0.007) were significant risk factors for failure of CR in the ED. Zero (0/10) patients with fracture angulation ≥60 degrees had a successful CR. Only 1/14 patients presenting >24 hours after injury had a successful CR in the ED. CONCLUSIONS: Circumventing sedation in the ED, and instead splinting for a planned surgical intervention may be a more efficient treatment method for pediatric radial neck fractures that present to the ED>24 hours after injury and/or have angulations ≥60 degrees. Adopting this new strategy may save time, reduce costs, and avoid possible harm/complications associated with sedation in the ED. LEVEL OF EVIDENCE: Level III-prognostic.

Scapholunate Ligament: Comparing the Native Strength of the Ligament to an All-suture Anchor Construct.

Our aim was to compare the tensile strength of the native scapholunate ligament (SLL) with that of an all-suture anchor construct in a cadaveric model. The scaphoid and lunate were isolated, preserving all segments of the SLL. Using a servohydraulic testing machine, we increased the load until peak load-to-failure of the native SLL was reached in nine specimens (mean ± standard deviation, 273 ± 132 N). Using the same specimens, two JuggerKnot 1.4-mm suture anchors (Zimmer Biomet) were placed into the lunate and tensioned through transosseous tunnels in the scaphoid. Sutures were tied over the radial nonarticular aspect of the scaphoid. Load-to-failure testing was repeated. The mean peak load-to-failure for the all-suture anchor constructs was 172 ± 59 N versus 231 ± 117 N for the native group (p = 0.157). This represents approximately 75% of the native ligament strength. (Journal of Surgical Orthopaedic Advances 29(3):169-172, 2020).

Dreaded Ulnar Wrist Pain: Long-Term Results of Pisiformectomy for Painful Pisotriquetral Arthrosis.

Pisiform pathology may be a source of ulnar-sided wrist pain. This study reviews the long-term outcomes of patients treated with pisiformectomy. A retrospective study approved by the institutional review board was performed over a 27-year period of patients undergoing pisiformectomy. Range of motion, grip strength, complications, and need for revision surgery were recorded. The series includes 61 wrists (60 patients) with an average age at surgery of 46 years. Two complications were noted (3%): a postoperative ulnar nerve palsy and symptomatic retained suture. At final follow-up, average flexion-extension arc was 81% (expressed as percent of contralateral), radioulnar deviation arc was 88%, and average grip strength was 89%. Pisiformectomy is a reliable, motion-preserving procedure with low complication rates for patients with chronic ulnar-sided wrist pain. In this series, 93% of patients did not require further procedures at an average of 8.2 years follow-up. (Journal of Surgical Orthopaedic Advances 28(3):196-200, 2019).

Partial Tibial Nonunion due to Entrapment of Anterior Tibial Artery: A Case Report.

INTRODUCTION: Arterial injury/entrapment is an uncommon sequelae of long bone fractures, particularly in closed injuries. The proximity of the anterior tibial artery to the distal tibia poses a risk of entrapment with a fracture at this level. To the best of our knowledge, this is the first case report of a partial nonunion due to entrapment of the anterior tibial artery in a healed tibia fracture in a pediatric patient. CASE REPORT: We describe a case of a 16-year-old male who presented with leg pain 2 years after a left distal third oblique tibia fracture. The fracture was initially treated non-operatively with excellent alignment. He did well for many months and returned to playing football with some vague persistent discomfort in his leg. Two years after the original injury, he was hit while playing football and started experiencing increasing left leg pain. The subsequent evaluation and findings are outlined here. CONCLUSION: This is an original case report of an adolescent patient with a partial tibial nonunion requiring surgical intervention. Possible entrapment of neurovascular structures should be considered when managing these patients following injury.

Adventitial cysts of the radial artery are joint connected.

Volar radial wrist masses are common. Adventitial cysts of the radial artery are rarely reported and poorly understood. We describe a case series of adventitial cysts in association with the radial artery and detail their pathophysiology and treatment. We conducted an Institutional Review Board-approved retrospective review of patients treated at our institution from 1997 to 2018. Twelve patients were identified. Presenting symptoms typically included pain and swelling over the volar radial wrist. High-resolution magnetic resonance imaging (MRI) demonstrated tubular, cystic lesions within the adventitia of the radial artery with connections to the wrist joint confirmed on multiplanar imaging: (radiocarpal joint = 10; scaphotrapeziotrapezoidal joint = 1; and intercarpal joint = 1). Seven patients underwent operation, at which time the cyst was resected and the articular branch disconnected. These patients reported resolution of their symptoms without clinical recurrence. The consistent finding of a joint connection in these cases of adventitial cysts associated with the radial artery has important clinical implications. The joint connection needs to be disconnected. Level of evidence: Level IV, case series. Clin. Anat. 32:201-205, 2019. © 2018 Wiley Periodicals, Inc.

Pediatric Pelvic Ring Injuries.

The purpose of this study was to determine whether pelvic fracture pattern is associated with transfusion requirements or concomitant injuries in pediatric patients. This was a single-institution, retrospective review from 1970 to 2000. Pelvic ring injuries were classified using the Orthopaedic Trauma Association system. Injury Severity Scores were assigned. Ninety patients were included in this study. There were 27 A-type (30.0%), 51 B-type (56.7%), and 12 C-type (13.3%) injuries. Mean Injury Severity Scores were 8.1 for 61 A-type, 12.7 for 61 B-type, and 23.6 for 61 C-type fractures (P<.0001). Transfusion was required for 14.8% of A-type, 18.4% of B-type, and 66.7% of C-type injuries (P=.0009). There was no significant association with the number of units transfused (P=.9614). Decreased pelvic ring fracture stability was associated with an increased need for blood transfusion, although not with the number of units. Pelvic ring fracture stability may be a marker of associated injuries. [Orthopedics. 2018; 41(5):e701-e704.].

Phalangeal Fracture During Attempted Dupuytrens Release Following Clostridial Collagenase Injection: Case Report.

INTRODUCTION: Dupuytren's disease can be a challenging condition for both patients and surgeons. Injectable collagen clostridium histolyticum was approved for clinical use by the Food and Drug Administration in 2010. A number of side effects have been described. In this case report, we present a complication of a proximal phalanx fracture which occurred during attempted release post injection. To the best of our knowledge, this is the first reported case of this particular complication. CASE REPORT: The patient is an 80-year-old right-hand dominant retired male with bilateral hand contractures and palmar fibromatosis. His medical history is notable for Type II diabetes mellitus and metastatic thyroid cancer. The patient underwent Xiaflex injection of the left small finger and returned 4 days later for planned release. An appreciable release of the contracture was noted; however, there was a concern for plastic deformation of the proximal phalanx as a result of the manipulation. X-rays confirmed the fracture and apex volar angulation at the base of the proximal phalanx. The fracture appeared amenable to non-operative treatment. The patient has been followed closely and has had no pain or tenderness at the fracture site and minimal swelling. X-rays at 1 week and 1 month showed maintained alignment and signs of consolidation at the fracture site. The patient is currently 4-month post-fracture, and no further intervention has been pursued. CONCLUSIONS: This report represents an additional potential complication associated with the use of Xiaflex. We recommend judicious use in elderly patients with severe contractures and/or multiple comorbidities. It is important to appreciate the possibility of this complication at the time of release.

Giant Cell Tumor of the Metacarpal: Case Report.

BACKGROUND: Giant cell tumor (GCT) of bone is a benign, though locally aggressive tumor, classically described as an eccentric lytic lesion, often with cortical expansion and destruction. It typically involves the metaphysis or epiphysis of long bones in skeletally mature patients, with a slight female predominance. The incidence in the small bones of the hand has been reported to be 2% to 5%. METHODS: Treatment options have evolved in recent years, and currently include intralesional curettage with or without adjuvant therapy, wide resection, and occasionally amputation. RESULTS: In this report, we present a long-term follow-up (10 years) of a patient with GCT involving a metacarpal, who was initially reconstructed with a metacarpal head allograft, which was eventually revised to a metacarpophalangeal (MCP) total joint arthroplasty. CONCLUSIONS: To our knowledge, this is the only report of pyrocarbon being used for tumor reconstruction and the only report of late MCP allograft salvage.

The Utility of Routine Postoperative Radiographs After Pinning of Pediatric Supracondylar Humerus Fractures.

BACKGROUND: The purpose of this study was to determine the frequency with which postoperative radiographs resulted in a change in management following closed reduction and percutaneous pinning of displaced pediatric supracondylar humerus fractures. We hypothesize that only the initial postoperative radiograph will lead to changes in management of operative supracondylar humerus fractures. METHODS: A retrospective review was performed at 2 level I pediatric trauma centers. Inclusion criteria were patients below 18 years of age who sustained supracondylar humerus fractures (Gartland type II, III, IV) who were operatively treated from 2008 to 2013 with adequate radiographic follow-up. Patients with flexion type, intra-articular, transphyseal, and open fractures were excluded from the study. Routine radiographs were taken at initial follow-up (1 wk postoperatively) and at pin removal (3 to 4 wk postoperatively). RESULTS: The final analysis included 572 patients. Initial postoperative radiographs changed treatment in 9 patients (1.6%), including revision surgeries, 2 pin adjustments, and 2 early pin removals. At the time of pin removal, 20 (3.5%) patients required further immobilization. There were no changes to the initial plan for continued nonoperative treatment at final follow-up (6 to 8 wk postoperatively). CONCLUSIONS: In this large retrospective series of patients treated with closed reduction and percutaneous pinning of displaced supracondylar humerus fractures, radiographs at 3 weeks do not reveal a need to return to the operating room or other significant pathology. These findings suggest that radiographs should be obtained within 7 to 10 days postoperatively for type III fractures and may only need to be repeated if the clinical situation warrants it, such as severe fracture pattern, persistent pain, or clinical deformity. LEVEL OF EVIDENCE: Level IV-case series.

First-Time Patellofemoral Dislocation: Risk Factors for Recurrent Instability.

Patellofemoral instability is a complex problem, which can be difficult to manage. The purpose of this study was to describe the demographics of patients with a first-time patellofemoral dislocation, and identify risk factors for recurrent instability. This was a single institution, institutional review board-approved, retrospective review of >2,000 patients with a patellar dislocation between 1998 and 2010. Inclusion criteria are as follows: (1) no prior history of patellofemoral subluxation or dislocation of the affected knee; (2) X-rays within 4 weeks of the initial instability episode; and (3) a dislocated patella requiring reduction, or history/findings suggestive of acute patellar dislocation (effusion/hemarthrosis, tenderness along the medial parapatellar structures, and apprehension with lateral patellar translation). Clinical records and radiographs were reviewed. The Caton-Deschamps and Insall-Salvati indices were used to evaluate patella alta. Trochlear dysplasia was assessed using the Dejour classification system. Skeletal maturity was graded based on the distal femoral and proximal tibial physes, using one of the following categories: open, closing, or closed. Three hundred twenty-six knees (312 patients) met the aforementioned criteria. There were 145 females (46.5%) and 167 males (53.5%), with an average age of 19.6 years (range, 9-62 years). Thirty-five patients (10.7%) were treated with surgery after the initial dislocation. All others were initially managed nonoperatively. Of the 291 patients managed nonoperatively, 89 (30.6%) had recurrent instability, 44 (49.4%) of which eventually required surgery. Several risk factors for recurrent instability were identified, including younger age (p < 0.01), immature physes (p < 0.01), sports-related injuries (p < 0.01), patella alta (p = 0.02), and trochlear dysplasia (p < 0.01). Sixty-nine percent of patients with a first-time patellofemoral dislocation will stabilize with conservative treatment. However, patients younger than 25 years with trochlear dysplasia have a 60 to 70% risk of recurrence by 5 years. This information is helpful when counseling patients on their risk for recurrent instability and determining the most appropriate treatment plan. The clinical tool shown in Fig. 4 may be especially useful.

Diabetes mellitus, hyperglycemia, hemoglobin A1C and the risk of prosthetic joint infections in total hip and knee arthroplasty.

Diabetes mellitus is an established risk factor for infections but evidence is conflicting to what extent perioperative hyperglycemia, glycemic control and treatment around the time of surgery modify the risk of prosthetic joint infections (PJIs). In a cohort of 20,171 total hip and knee arthroplasty procedures, we observed a significantly higher risk of PJIs among patients with a diagnosis of diabetes mellitus (hazard ratio [HR] 1.55, 95% CI 1.11, 2.16), patients using diabetes medications (HR 1.56, 95% CI 1.08, 2.25) and patients with perioperative hyperglycemia (HR 1.59, 95% CI 1.07, 2.35), but the effects were attenuated after adjusting for body mass index, type of surgery, ASA score and operative time. Although data were limited, there was no association between hemoglobin A1c values and PJIs.

Do claims-based comorbidities adequately capture case mix for surgical site infections?

BACKGROUND: There is increasing interest in using administrative claims data for surveillance of surgical site infections in THAs and TKAs, but the performance of claims-based models for case-mix adjustment has not been well studied. Performance of claims-based models can be improved with the addition of clinical risk factors for surgical site infections. QUESTIONS/PURPOSES: We assessed (1) discrimination and calibration of claims-based risk-adjustment models for surgical site infections; and (2) the incremental value of adding clinical risk factors to claims-based risk-adjustment models for surgical site infections. PATIENTS AND METHODS: Our study included all THAs and TKAs performed at a large tertiary care hospital from January 1, 2002 to December 31, 2009 (total n = 20,171 procedures). Revision procedures for infections were excluded. Comorbidity data were ascertained through administrative records and classified by the Charlson comorbidity index. Clinical details were obtained from the institutional joint registry and patients' electronic health records. Cox proportional hazards regression models were used to estimate the 1-year risk of surgical site infections with a robust sandwich covariance estimator to account for within-subject correlation of individuals with multiple surgeries. The performance of claims-based risk models with and without the inclusion of four clinical risk factors (morbid obesity, prior nonarthroplasties on the same joint, American Society of Anesthesiologists score, operative time) was assessed using measures of discrimination (C statistic, Somers' D xy rank correlation, and the Nagelkerke R(2) index). Furthermore, calibrations of claims-based risk models with and without clinical factors were assessed graphically by plotting the smoothed trends between model predictions and empirical rates from Kaplan-Meier. RESULTS: Discrimination of the claims-based risk models was moderate for the THA (C statistic = 0.662, D xy = 0.325, R(2) = 0.028) and TKA (C statistic = 0.621, D xy = 0.241, R(2) = 0.017) cohorts. Inclusion of four clinical risk factors improved discrimination in both cohorts with significant improvement in the C statistic in the THA cohort (C statistic = 0.043; 95% CI, 0.012-0.074) and in the TKA cohort (C statistic = 0.027; 95% CI, 0.007-0.047). Visual inspection suggested that calibration of the claims-based risk models was adequate and comparable to that of models which included the four additional clinical factors. CONCLUSIONS: Claims-based risk-adjustment models for surgical site infections in THA and TKA appear to be adequately calibrated but lack predictive discrimination, particularly with TKAs. The addition of clinical risk factors improves the discriminative ability of the models to a moderate degree; however, addition of clinical factors did not change calibrations, as the models showed reasonable degrees of calibration. When used in the clinical setting, the predictive performance of claims-based risk-adjustment models may be improved further with inclusion of additional clinical data elements.

External validation of the national healthcare safety network risk models for surgical site infections in total hip and knee replacements.

BACKGROUND: The National Healthcare Safety Network surgical site infections risk models for hip (HPRO) and knee (KPRO) replacement are intended for case-mix adjustment when reporting surgical site infection rates across institutions, but they are not validated in external data sets. OBJECTIVE: To evaluate the validity of HPRO and KPRO risk models and improvement in risk prediction with inclusion of information on morbid obesity and diabetes mellitus. DESIGN: Retrospective cohort study. PATIENTS: A single-center cohort of 21,941 hip and knee replacement procedures performed between 2002 and 2009. METHODS: Discriminative ability was assessed using the concordance statistic (C statistic). Calibration was assessed using the Hosmer-Lemeshow goodness-of-fit tests. RESULTS: The discrimination of HPRO was good, with a C statistic of 0.695 for surgical site infections and 0.749 for prosthetic joint infections. The discrimination of KPRO was worse than that of HPRO, with a C statistic of 0.592 for surgical site infections and 0.675 for prosthetic joint infections. Adding morbid obesity and diabetes mellitus to the HPRO and KPRO risk models modestly improved discrimination. There was no significant evidence of miscalibration based on the Hosmer-Lemeshow tests, but calibration of HPRO models appeared to be better than that of the KPRO models. CONCLUSION: HPRO performed better than the KPRO in predicting surgical site infections after hip and knee replacements. Both fared well in predicting prosthetic joint infections.

Peri-operative complications in pediatric and adolescent shoulder arthroscopy.

BACKGROUND: Shoulder arthroscopy is not common in the pediatric and adolescent population, but the frequency may be on the rise. The purpose of the study was to determine the incidence of acute complications of arthroscopic shoulder surgery in children and adolescents. METHODS: A retrospective, cross-sectional review was performed identifying patients aged 18 years or less who underwent an arthroscopic shoulder procedure from 1997 to 2009 at Institution 1 and 2007 to 2010 at Institution 2. Exclusion criteria included open procedures and missing records. Demographic and surgical data were collected, including intra-operative and post-operative complications during the first 6 months. The complications were divided into minor (no secondary treatment) and major (secondary treatment rendered). RESULTS: Two hundred children, mean age 15.9 years, met criteria and 73 % were boys. All procedures were performed under general anesthesia, but 51 % included inter-scalene regional anesthesia. There were 16 (8.0 %) total complications recorded. Major complications occurred in five (2.5 %) patients, including two tendinitis/bursitis requiring injections, one broken pain pump catheter requiring an accessory incision to retrieve, one pain control readmission, and one laceration of the cephalic vein requiring ligation. Minor complications occurred in 11 (5.5 %) patients, including allergic reactions, transient dysesthesias, headaches, bronchitis, syncope, transient hypotension, and uvula swelling. CONCLUSION: Although we found no seriously deleterious outcomes, it is important to recognize that an additional service was rendered for 2.5 % of children undergoing shoulder arthroscopy. The events that did occur may be preventable and this study should serve as a baseline to improve quality and safety of shoulder arthroscopy in the pediatric population.

Functional outcomes and quality of life following surgical treatment of aneurysmal bone cysts of the pelvis in children.

BACKGROUND: Aneurysmal bone cysts (ABCs) are a benign aggressive tumor that occurs rarely in the pelvis in the pediatric population. Pelvic ABCs may involve the triradiate cartilage and/or the acetabulum, which increases the technical difficulty of surgical treatment and has potential implications on the growth and development of the hip joint. This study examines the clinical presentation, rate of surgical complications, and recurrence rate, as well as, long-term clinical and functional outcomes of children with pelvic ABCs treated at a single institution by a single treatment modality. METHODS: Between 1988 and 2008, 142 children with histologically confirmed ABCs were treated at our institution. Seventeen (12 %) tumors were located in the pelvis. A total of 13 pelvic ABCs (5 ilium-periacetabular, 4 pubic, 3 ilium-iliac wing, and 1 ischium) were included in this study. There were eight male and five female patients with a mean age of 12.9 years (range 4.1-17.5 years) at the time of surgery. The Toronto Extremity Salvage Score (TESS), the Musculoskeletal Tumor Society 1993 (MSTS'93) score, and the Short Form Health Survey Sf-36 were obtained at a minimum 5-year follow-up in all patients (mean follow-up 11.5 years, range 5.5-19.8 years). The mean age at follow-up was 24.3 years (range 14.6-32.6 years). RESULTS: All patients were treated surgically with intralesional curettage extended with a high-speed burr and bone grafting. Eight patients received adjunctive therapy with phenol. Five patients had preoperative selective arterial embolization. Of the 13 patients, 1 had a local recurrence diagnosed at 6 months after surgery. The only complication in the cohort was a superficial wound infection. At the latest follow-up, all patients were free of disease. The mean TESS score was 95 and the mean MSTS'93 score was 93 %. The mean self-rated general health score, according to the SF-36 was 87 % of total points possible. CONCLUSIONS: Extended curettage and bone grafting of pelvic ABCs in the pediatric population can yield high clinical and functional scores at an average of 11 years follow-up with a low rate of complications and recurrence. LEVEL OF EVIDENCE: IV, case series.

Clinical outcome of internal fixation of unstable juvenile osteochondritis dissecans lesions of the knee.

Juvenile osteochondritis dissecans (OCD) lesions of the knee are a common cause of knee pain in skeletally immature patients.The authors sought to determine lesion healing rates, the risk factors associated with failure to heal, and the clinical outcomes for patients who underwent internal fixation for unstable OCD lesions. A retrospective review was conducted of all patients who underwent internal fixation of OCD lesions from 1999 to 2009. Using validated scoring systems, clinical outcome and functional activity were evaluated at the follow-up. The study group comprised 19 patients (20 knees). Mean patient age was 14.5 years (range, 12-17 years). Mean clinical follow-up was 7 years (range, 2-13 years). Mean radiographic follow-up was 2.5 years (range, 0.5-9 years). Fourteen (70%) lesions were grade 3 and 6 (30%) were grade 4. Eleven knees had lateral condyle lesions and 9 had medial lesions. Bioabsorbable fixation was used in 13 knees, metal fixation was used in 5 knees, and 2 knees were fixed with a combination of methods. Osseous integration was evident in 15 (75%) of 20 knees at final follow-up. The 5 unhealed lesions were lateral condylar lesions. Mean Tegner activity scores improved from 3.3 preoperatively to 5.6 at final follow-up. Mean Lysholm and International Knee Documentation Committee scores were 86.8 and 88.7, respectively, at final follow-up. Further operative intervention was required in 11 knees, with 50% of patients undergoing removal of hardware and 15% requiring subsequent osteochondral allograft transplantation. The authors recommend bioabsorbable fixation for symptomatic stable lesions and metal compression screws with staged removal for unstable lesions.