Skeletal Maturity Is Associated With Increased Meniscal and Chondral Pathology in Patients Under 21 Years of Age Undergoing Primary Anterior Cruciate Ligament Reconstruction Within 6 Months of Injury.

PURPOSE: To compare injury profiles of meniscal and/or chondral injury in skeletally mature (SM) with immature (SI) patients undergoing primary anterior cruciate ligament reconstruction (ACLR). METHODS: Current Procedural Terminology code 29888 was queried from January 2012 to April 2020. Patients younger than 22 years who underwent primary ACLR within 6 months of injury were included. Exclusion criteria included age older than 22 years, treatment after 6 months, revision ACLR, concurrent osteotomy, or multiligamentous injury. All patients required a minimum 1-year follow-up. Demographics and intraoperative pathology were recorded. Data were analyzed for factors affecting intra-articular injury and stratified by sport. RESULTS: Of 927 patients (739 SM, 188 SI), the mean age was 16.63 and 14.00 years for the SM and SI cohorts, respectively (P < .001). There were more SM males (51.4%) compared to SI males (81.9%) (P < .001); however, in univariate analysis, sex did not significantly affect the rates of meniscal (P = .519) or chondral injury (P = .961). In total, 887 meniscal injuries were recorded (344 medial, 543 lateral) in 659 patients. SM sustained greater rates of medial meniscal tear (MMT) (P < .001) and underwent higher rates of partial meniscectomy (P = .022). Male sex conferred meniscal injury (95% confidence interval [CI], 0.43-0.81; P = .001). Body mass index prognosticated medial meniscal (95% CI, 1.01-1.06; P = .002) and medial chondral injuries (95% CI, 1.02-1.09; P < .001). Skeletal maturity was a superior predictor of intra-articular pathology than age for all outcomes: MMT (95% CI, 0.00-0.06; P = .002), lateral meniscal tear (95% CI, 0.00-0.75; P = .034), and chondral injury (95% CI, 0.00-0.49; P = .049). In sport subanalysis, soccer anterior cruciate ligament (ACL) injuries were most common (32.6%). Soccer and basketball athletes were more likely SM (P = .016, P = .003 respectively) with increased medial compartment pathology. Football ACL injuries occurred significantly in SI athletes (P = .001) via contact mechanisms (P = .025). CONCLUSIONS: Skeletal maturity affects the meniscal and chondral injury profile in ACL-injured patients. SM patients have greater risk of sustaining concomitant meniscal injury, while chondral injury profile depends more on the mechanism of injury. Mechanism of injury and skeletal maturity status affect risk of sports-related ACL rupture and ACL-concurrent pathology in young patients. Patient-specific variables influence injury profiles within each sport. Skeletal maturity rather than age predicts concomitant intra-articular injury risk. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

MRI findings of peroneal tendon tears do not necessarily correlate to clinical findings in paediatric and adolescent patients.

PURPOSE: Pathologic abnormality of the peroneal tendons are thought to be an under-appreciated source of vague ankle and hindfoot pain in paediatric patients, partly because they can be difficult to diagnose and differentiate from lateral ankle ligament injuries. While magnetic resonance imaging (MRI) is the primary imaging modality used to detect peroneal tendon pathology, previous studies in adults have found that positive MRIs demonstrate a positive predictive value (PPV) of associated clinical findings around 48%. There are no similar known published studies in the paediatric population. Our objective was to determine the positive predictive value of peroneal tendon pathology as diagnosed by MRI as related to positive clinical exam findings in the paediatric and adolescent population. METHODS: This IRB approved retrospective study was conducted at a tertiary children's hospital. Inclusion criteria included patients under 18 years from our tertiary care institution with (a) ankle MRI findings indicating pathology of the peroneus brevis/longus tendons confirmed by a board certified paediatric musculoskeletal radiologist and (b) formal review of the clinical examination by a fellowship trained paediatric orthopaedic surgeon. Patients with congenital deformities or previous surgical intervention of the lateral ankle were excluded. RESULTS: Forty-seven patients (with 48 MRIs) met inclusion criteria over a ten year period. The majority of the positive MRI scans (70%) demonstrated a peroneus brevis split tear. Of the patients with positive findings on MRI, 17 patients had an associated positive clinical exam. The positive predictive value of MRI for peroneal tendon tears with positive clinical findings was 35.41% (95% confidence interval = 31.1% to 41.6%). There were 31 patients with MRI positive findings with a negative clinical exam. CONCLUSION: Despite having a negative clinical exam, a high percentage of patients had positive MRI findings suggestive of peroneal tendon pathology which confirms findings of adult populations demonstrating a high rate of incidental finding of peroneal tendon pathology on MRI in paediatric patients.

Interobserver and Intraobserver Agreement are Unsatisfactory When Determining Abstract Study Design and Level of Evidence.

BACKGROUND: Understanding differences between types of study design (SD) and level of evidence (LOE) are important when selecting research for presentation or publication and determining its potential clinical impact. The purpose of this study was to evaluate interobserver and intraobserver reliability when assigning LOE and SD as well as quantify the impact of a commonly used reference aid on these assessments. METHODS: Thirty-six accepted abstracts from the Pediatric Orthopaedic Society of North America (POSNA) 2021 annual meeting were selected for this study. Thirteen reviewers from the POSNA Evidence-Based Practice Committee were asked to determine LOE and SD for each abstract, first without any assistance or resources. Four weeks later, abstracts were reviewed again with the guidance of the Journal of Bone and Joint Surgery (JBJS) LOE chart, which is adapted from the Oxford Centre for Evidence-Based Medicine. Interobserver and intraobserver reliability were calculated using Fleiss' kappa statistic (k). χ2 analysis was used to compare the rate of SD-LOE mismatch between the first and second round of reviews. RESULTS: Interobserver reliability for LOE improved slightly from fair (k=0.28) to moderate (k=0.43) with use of the JBJS chart. There was better agreement with increasing LOE, with the most frequent disagreement between levels 3 and 4. Interobserver reliability for SD was fair for both rounds 1 (k=0.29) and 2 (k=0.37). Similar to LOE, there was better agreement with stronger SD. Intraobserver reliability was widely variable for both LOE and SD (k=0.10 to 0.92 for both). When matching a selected SD to its associated LOE, the overall rate of correct concordance was 82% in round 1 and 92% in round 2 (P<0.001). CONCLUSION: Interobserver reliability for LOE and SD was fair to moderate at best, even among experienced reviewers. Use of the JBJS/Oxford chart mildly improved agreement on LOE and resulted in less SD-LOE mismatch, but did not affect agreement on SD. LEVEL OF EVIDENCE: Level II.

High Incidence of Intra-articular Injuries With Segond Fractures of the Tibia in the Pediatric and Adolescent Population.

BACKGROUND: Segond fractures (avulsion fractures of the proximal lateral tibia) are highly associated with anterior cruciate ligament (ACL) tears in adult patients. This large case series of pediatric Segond fractures describes the associated intra-articular knee injuries to determine if these fractures have a high incidence of ACL tears or its equivalent injury in young patients. METHODS: Institutional review board approved retrospective study at a tertiary children's hospital of patients under 19 years who were diagnosed with a Segond fracture between 2009 and 2019 was conducted. Demographics, clinical data, imaging features, associated injuries, and treatment information were collected. RESULTS: Fifty-three patients (44 males and 9 females) with median age 15.4 (11.8 to 19) years with Segond fractures of the proximal tibia on radiographic imaging were included. Diagnosis of associated injuries was established based on clinical examination, radiology report, and arthroscopic findings. Median Segond fracture size was 2.0×9.0 mm measured on standard anteroposterior knee radiographs. Magnetic resonance imaging (MRI) was obtained in 49/53 (92.5%) patients. Associated injuries included ACL tears (39 patients, 73.6%), tibial spine fractures (9, 17.0%), and other injuries (5, 9.4%). 37/53 (69.8%) patients had meniscal injury. Three (5.7%) patients sustained multiligament injuries. All associated injuries were confirmed by either MRI/computerized tomography or direct operative examination. Among Segond fractures found with ACL tears, 12 (30.8%) were contact injuries, 30 (76.9%) were sports injuries. In associated tibial spine fractures, 7 (78%) injuries were contact in nature and were sports related. There was a statistically significant difference (P=0.013) in age, patients with tibial spine fractures (median 13.6 y) being younger than those with ACL tears (median 15.4 y). 12/53 (22.6%) had associated articular cartilaginous injuries, 3 of which were treated surgically. Overall, 81.1% of patients were treated operatively for associated intra-articular injuries. CONCLUSIONS: This large case series of Pediatric Segond fractures suggests a high association with intra-articular injuries, specifically, ACL tears and its equivalent injury, that is, tibial spine fractures, the later more common in the younger patient population. An MRI is recommended in patients with a Segond fracture for characterizing the exact intra-articular injury to help plan the appropriate management. LEVEL OF EVIDENCE: Level IV-prognostic.

Anterior Cruciate Ligament Tear Following Operative Treatment of Pediatric Tibial Eminence Fractures in a Multicenter Cohort.

BACKGROUND: Postoperative ipsilateral anterior cruciate ligament (ACL) tears after tibial eminence fracture fixation has been previously noted in the literature. This study aims to describe the prevalence of and risk factors for postoperative ACL tears in a cohort of patients operatively treated for tibial eminence fracture. METHODS: A retrospective review of children undergoing treatment of a tibial eminence fracture at 10 tertiary care children's hospitals was performed. The primary outcome of interest was subsequent ACL rupture. Incidence of ACL tear was recorded for the entire cohort. Patients who sustained a postoperative ACL tear were compared with those without ACL tear and analyzed for demographics and risk factors. A subgroup analysis was performed on patients with a minimum of 2-year follow-up data or those who had met the primary outcome (ACL tear) before 2 years. RESULTS: A total of 385 pediatric patients were reviewed. 2.6% of the cohort experienced a subsequent ACL tear. The median follow-up time was 6.5 months (SD=6.4 mo). Subsequent ACL tears occurred at a median of 10.2 months (SD=19.5 mo) postoperatively. There was a statistically significant association with higher grade tibial spine fractures (Myers and McKeever type III and IV) and subsequent ACL tear (P=0.01). Patients with a subsequent ACL tear were older on average (13.5 vs. 12.2 y old), however, this difference was not statistically significant (P=0.08). Subgroup analysis of 46 patients who had a 2-year follow-up or sustained an ACL tear before 2 years showed a 21.7% incidence of a subsequent ACL tear. There was a statistically significant association with higher grade tibial spine fractures (Myers and McKeever type III and IV) and subsequent ACL rupture (P=0.006) in this subgroup. Postoperative ACL tears occurred in patients who were older at the time that they sustained their original tibial eminence fracture (13.4 vs. 11.3 y old, P=0.035). CONCLUSIONS: Ipsilateral ACL tears following operatively treated pediatric tibial eminence fractures in a large multicenter cohort occurred at a rate of 2.6%. However, in those with at least 2 years of follow-up, the incidence was 21.7%. Subsequent ACL tear was more likely in those with completely displaced (type III or IV) tibial eminence fractures and older patients. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

Arcuate sign-fibular head avulsion fracture and associated injuries in the pediatric and adolescent population.

PURPOSE: To describe the first "arcuate sign" case series in the pediatric population, radiologic features of the associated injuries, management, and how they compare with the adult population. METHODS: Retrospective study included patients under 18 years of age with a classic "arcuate sign" on radiographs. Data collected included patient demographics, mechanism of injury, and management. Radiographs and advanced imaging (MRI, CT) were reviewed by two musculoskeletal radiologists in a blinded fashion and findings recorded. RESULTS: Seven patients (4 males, 3 females) with mean age 15 years (range 14-17 years) were included in the study. All 7 injuries were related to sports, 5/7 (71%) being non-contact injuries. Five patients had MRI done-1 LCL injury, MPFL sprain, and MCL sprain were reported; 3 popliteofibular ligament and popliteus sprains were seen; and 3 bone contusions were present on imaging. None of the patients had meniscus or cruciate ligament tears. One patient had an additional fracture of the lateral tibial plateau at the ilio-tibial band attachment and an associated peroneal nerve injury. Five out of seven (71.4%) were treated non-operatively and were able to return back to activity at a mean of 7.2 weeks from injury. Two out of seven (28.6%) needed operative intervention for the fracture but not arthroscopic repair. CONCLUSION: Pediatric patients with a radiographic arcuate sign tend not to have ACL, PCL, or meniscal injuries, and treatment is predominantly non-operative in contrast to literature reported in adults.

Missed Fracture Dislocation of the Fifth Toe in a Two-Year-Old Child: A Case Report.

Fracture dislocation injuries of the toes are rare among pediatric population. These injuries when acute are mostly treated conservatively and a good reduction must be ensured. We present the case of a 2-year-old girl who presented with missed chronic fracture dislocation of the proximal interphalangeal joint of the fifth toe, which was managed by open reduction and internal fixation and had a good outcome at over 1 year of follow up. We believe that this is the first case of this injury to be published in the peer-reviewed literature.

Delayed diagnosis of posterior ankle impingement in pediatric and adolescent patients: does radiology play a role?

BACKGROUND: Posterior ankle impingement syndrome (PAIS) results from the pinching of anatomical structures in the posterior part of the ankle. OBJECTIVE: To identify the possible role of imaging in the delayed diagnosis of PAIS and identify key findings on imaging to suggest PAIS in pediatric and adolescent patients. MATERIALS AND METHODS: Data were collected prospectively in patients younger than 18 years of age who underwent arthroscopy after being diagnosed with PAIS. Imaging was reviewed retrospectively by two radiologists, compared with findings in literature and an age-matched control group, and correlated with arthroscopic findings. Pre- and postsurgical Visual Analogue Scale (VAS) pain and American Orthopedic Foot Ankle Society (AOFAS) ankle-hindfoot scores were noted. RESULTS: Thirty-eight patients (20 females, 18 males), 51 ankles, with an average age of 12.9 years had an average 18-month delay in diagnosis. Twenty-seven of the 38 (73%) patients had previously seen multiple medical providers and were given multiple misdiagnoses. Radiographs were reported normal in 34/47 (72%) ankles. Thirty patients had magnetic resonance imaging (MRI) and findings included the presence of an os trigonum/Stieda process (94%) with associated osseous edema (69%), flexor hallucis longus (FHL) tenosynovitis (16%), and edema in Kager's fat pad (63%). Although individual findings were noted, the impression in the MRI reports in 16/32 (50%) did not mention PAIS as the likely diagnosis. There was a significant difference in the MRI findings of ankle impingement in the patient population when compared to the control group. Surgery was indicated after conservative treatment failed. All 51 ankles had a PAIS diagnosis confirmed during arthroscopy. At an average follow-up of 10.2 months, there was improvement of VAS pain (7.0 to 1.1) and AOFAS ankle-hindfoot scores (65.1 to 93.5). CONCLUSION: PAIS as a diagnosis is commonly delayed clinically in young patients with radiologic misinterpretation being a contributing factor. Increased awareness about this condition is needed among radiologists and physicians treating young athletes.

Incidence of Hip Dysplasia Associated With Bladder Exstrophy.

BACKGROUND: Exstrophy of the bladder is a rare congenital defect seen in 2.15 children out of every 100,000 live births, with the most severe variant, cloacal exstrophy (CE), only occurring in 1 in 200,000. Developmental dysplasia of the hip (DDH) describes a spectrum of disease ranging from mild hip instability to frank dislocation. Underlying malformations, such as myelomeningocele and arthrogryposis, are often associated with the most severe variant of hip dysplasia, teratologic hip dislocation. The varying degrees of severity in DDH have been encountered in classic bladder exstrophy (CBE) patients, but the exact incidence is unknown. We sought to determine the incidence of DDH in CBE and CE patients. METHODS: We performed a retrospective review of all children with CBE or CE presenting to a single pediatric center between 1994 and 2014. Each chart was reviewed for correct diagnosis of CBE or CE, patient age and demographics, associated medical conditions, pertinent surgeries performed, and the age at operation. Patient imaging was reviewed to determine whether bilateral hip imaging was available. RESULTS: In a 20-year retrospective review, we identified 66 patients who were diagnosed with either CBE or CE and had available hip imaging (38 males and 28 females). Of these, 11 patients were found to have radiographic evidence of DDH, for an incidence of 16.7% (11/66). Five of these patients had CE, whereas 6 presented with CBE. The first radiographic evidence of DDH was noted at a mean age of 5.75 years (range, birth to 22 y). CONCLUSIONS: We advocate the use of routine hip screening ultrasound in all infants born with either CBE or CE. Early identification of DDH in these patients may allow additional treatment options to coincide with frequently used osteotomy and orthopaedic interventions. LEVEL OF EVIDENCE: Level III-retrospective study.

Radial Neck Fractures in Children and Adolescents: An Examination of Operative and Nonoperative Treatment and Outcomes.

BACKGROUND: Although most pediatric radial neck fractures can be treated with either immobilization alone or closed reduction and immobilization, a small subset result in permanent loss of motion despite surgical management. We sought to characterize the most problematic fractures and correlate final outcomes with both presenting fracture characteristics and the reduction achieved through surgical intervention. METHODS: One hundred ninety-three consecutive children with a radial neck fracture, satisfactory initial treatment data, and follow-up range-of-motion (ROM) data presenting between 1999 and 2012 to our level 1 trauma center were evaluated. The O'Brien classification was used to evaluate angulation on radiographs. Final ROM outcomes were categorized into excellent, good, fair, and poor. ROM data were not used in the operative group if follow-up was <12 weeks (<6 wk in the nonoperative group) or if there was no follow-up after cast removal. RESULTS: Thirteen percent of all patients presenting with radial neck fractures required operative treatment (average age 9.1 y). Of patients treated operatively with adequate ROM data, 26.4% healed with fair or poor outcomes. Patients requiring open management were of older average age (average 10 y old, P=0.02) and had a significantly greater risk of a fair or poor ROM outcome than those treated with closed operative techniques (P=0.02). Patients treated nonoperatively were of a younger average age than those in the operative cohort (8.2 vs. 9.1 y, P=0.03). Patients treated operatively were more likely to develop complications (P=0.004); however, presence of a complication was not predictive of fair or poor outcomes in either the operative (P=0.117) or nonoperative (P=0.264) groups. CONCLUSIONS: Older children are more likely to have more severely displaced radial neck fractures requiring open surgical management, thus resulting in a greater risk of fair or poor outcomes. In the series as a whole, more complications were seen when operative management was required. Final outcomes were not shown to be significantly related to preoperative displacement, postoperative reduction, presence of associated injuries, energy of injury, or treatment complications. LEVELS OF EVIDENCE: Level III­therapeutic.

Traumatic, Posterior Pediatric Hip Dislocations With Associated Posterior Labrum Osteochondral Avulsion: Recognizing the Acetabular "Fleck" Sign.

BACKGROUND: Traumatic dislocation of the hip is uncommon in the pediatric population. Concentric reduction is usually achieved by closed means. Open reduction may be needed if there is femoral head fracture, incarcerated fragment, or incomplete reduction due to soft tissue entrapment. We present a series of 10 patients who sustained a posterior hip dislocation or subluxation with associated osteochondral avulsion of the posterior labrum. During surgery they were noted to have a labral injury pattern not previously recognized. Such treatment was dictated by postreduction advanced imaging, which revealed a consistent acetabular "fleck" sign indicative of this labral injury, which has not been previously described in literature. METHODS: We performed a retrospective case review of patients with traumatic posterior hip dislocation/subluxation, treated operatively for a suspected associated labral tear and fractures. RESULTS: Ten patients (2 girls and 8 boys) were identified. Average age was 12.7 years. Eight patients had postreduction computed tomography scans, which revealed a posterior acetabular wall "fleck" sign, suggestive of osteochondral injury. The small bony fragment was consistently displaced at least 2 to 3 mm in all patients with majority of the posterior wall remaining intact. Closed reduction was felt to be congruent in 7 of the 10 patients. All patients were treated operatively for exploration and stabilization of the suspected posterior labrum pathology and associated injuries using a surgical hip dislocation. A consistent pattern of labral pathology was seen in all patients, with disruption of the posterior labrum from the superior 12 o'clock attachment to detachment at the inferior 6 o'clock location. Reattachment of the osteochondral labral avulsion was performed with suture anchors along the posterior rim, and the associated femoral head fractures were also addressed with internal fixation. Two patients had inadequate follow-up and were excluded, the average follow-up for the remaining 8 patients was 9.8 months (range, 6 to 26 mo). There were no findings of avascular necrosis in any of the 8 patients. CONCLUSIONS: Posterior hip dislocation in children may produce an acetabular "fleck" sign on advanced imaging, which in a stable, concentrically reduced hip has been treated without surgery in the past. Acetabular fleck sign may represent a near-complete avulsion of the posterior labrum as seen in our series. We recommend a high suspicion for this type of labral pathology and surgical repair when acetabular "fleck" sign is identified with hip subluxation or dislocation. Traumatic, posterior hip dislocations in young patients may be associated with significant labral pathology. Acetabular "fleck" sign on advanced imaging may predict such pathology. LEVEL OF EVIDENCE: IV, retrospective study.

Pinless halo in the pediatric population: indications and complications.

BACKGROUND: The use of the conventional halo is accompanied by the possibility of serious complications, especially in the pediatric population. Complications could include penetration of pin into the skull, pin loosening, pin tract infection, cranial nerve palsies, and vest-related pressure sores. The noninvasive "pinless" halo was introduced in an attempt to mitigate these problems while retaining the effectiveness of the conventional halo. The purpose of this study is to determine the indications and complications related to pinless halo application. METHODS: We retrospectively reviewed 61 patients, whose treatment included the use of a pinless halo device, presenting to our institution between 2004 and 2012. RESULTS: There were 35 male and 26 female patients with an average age of 6.04 years. Indications of pinless halo application included postoperative immobilization for congenital muscular torticollis in 38 cases, conservative management of atlantoaxial rotatory subluxation in 11 cases, postoperative immobilization following cervical fusion in 10 cases, and immobilization for occipital condyle fracture in 2 cases. The average duration of the pinless halo application was 32.68 days. Thirteen patients had complications, among which major complications were seen in 2 patients, each of whom developed a pressure sore; one on the scalp and the other on the chest. Both the pressure sores responded to local treatment; however, 1 resulted in permanent alopecia. CONCLUSIONS: The use of the noninvasive pinless halo was found to be safe with few complications in our study. The complications were infrequent and patients were compliant to treatment, indicating that this modality is patient-friendly. Effectiveness of this treatment in comparison with invasive halos and other cervical orthoses was not determined and is a limitation of this study. LEVEL OF EVIDENCE: Level IV-Case series.

Comparative results of percutaneous Achilles tenotomy to combined open Achilles tenotomy with posterior capsulotomy in the correction of equinus deformity in congenital talipes equinovarus.

PURPOSE: The purpose of this study is to compare the efficacy of percutaneous Achilles tenotomy (AT) to combined open Achilles tenotomy and posterior capsulotomy (PC+AT) in the correction of residual equinus deformity in congenital talipes equinovarus after Ponseti serial casting in both idiopathic and non-idiopathic clubfeet. METHODS: The authors retrospectively reviewed 591 patients treated for congenital talipes equinovarus between January 1, 2001 and January 1, 2011. Available medical and operative records were reviewed for basic demographic data as well as ankle dorsiflexion pre-operatively, postoperatively and at latest follow up. RESULTS: A total of 167 children with 260 discrete clubfeet that met our inclusion criteria were identified. Of them, 189/260 clubfeet (72.7 %) were idiopathic and 71/260 clubfeet (27.3 %) were non-idiopathic with a mean total follow up of 4.8 ± 2.4 years (minimum follow-up of two years). At latest follow up, there was no statistically significant difference in the mean ankle dorsiflexion (p = 0.333) or recurrence rate (p = 0.545) between PC+AT and AT groups in both idiopathic and non-idiopathic clubfeet. CONCLUSION: In our series, the addition of posterior capsulotomy to Achilles tenotomy did not improve the mean dorsiflexion at latest follow up or decrease the rate of recurrence of equinus deformity in both idiopathic and non-idiopathic clubfeet. It is therefore advisable that percutaneous Achilles tenotomy alone be used in the correction of equinus deformity in both idiopathic and non-idiopathic congenital talipes equinovarus after successful Ponseti serial casting.

Unicameral bone cysts: general characteristics and management controversies.

Unicameral bone cysts are benign bone lesions that are often asymptomatic and commonly develop in the proximal humerus and femur of skeletally immature patients. The etiology of these lesions remains unknown. Most patients present with a pathologic fracture, but these cysts can be discovered incidentally, as well. Radiographically, a unicameral bone cyst appears as a radiolucent lesion with cortical thinning and is centrally located within the metaphysis. Although diagnosis is frequently straightforward, management remains controversial. Because the results of various management methods are heterogeneous, no single method has emerged as the standard of care. New minimally invasive techniques involve cyst decompression with bone grafting and instrumentation. These techniques have yielded promising results, with low rates of complications and recurrence reported; however, prospective clinical trials are needed to compare these techniques with current evidence-based treatments.

Bilateral C6 spondylolysis with spondylolisthesis in 3 adolescent siblings.

BACKGROUND: Cervical spondylolysis with spondylolisthesis is a rare condition in the pediatric population. The nature of this condition and clinical presentation are important to provide appropriate management. METHODS: This is a case report of 3 adolescent siblings who had C6 cervical spondylolysis with spondylolisthesis. RESULTS: Two cases were diagnosed insidiously with absence of neurological deficits and no instability on imaging and were treated conservatively. One case had a traumatic presentation associated with instability on imaging and was managed with cervical fusion and instrumentation. All 3 patients were doing well on a follow-up of >2 years. CONCLUSIONS: These cases suggest that cervical spondylolysis could be familial. The treatment was offered based on clinical presentation and presence of instability on radiographic studies. LEVEL OF EVIDENCE: Level IV.

Chest wall osteochondroma in children: a case series of surgical management.

BACKGROUND: Chest wall osteochondroma is a rare tumor in children. Even though the potential for malignant transformation or serious intrathoracic complications is low, it has led some centers to advocate surgical management of these bony tumors. We present our experience of the surgical management of costal osteochondromata. METHODS: Between January 1, 2006 and November 1, 2012 we saw 854 patients with solitary or multiple exostoses in our clinics. By reviewing our billing lists we found 7 children who had surgical management of chest wall osteochondromata. The indications for surgery were pain (3 patients), excision for confirmation of diagnosis (2 patients), recurrent pneumothorax (1 patient), and malignancy (1 patient). RESULTS: All patients made a good postoperative recovery with a median hospital stay of 1.8 days (range, 0 to 4 d). There was no recurrence of exostosis on follow-up (range, 8 mo to 2.6 y). One patient required surgery for excision of another chest wall osteochondroma at an adjacent location. No patient reported scar-related pain symptoms. No malignant transformation or intrathoracic complications occurred. We found ribs as the first site of presentation of multiple hereditary exostoses in 2 young patients. CONCLUSIONS: Surgical management of thoracic osteochondroma, with excision for painful, symptomatic, malignant lesions or lesions adjudged to be at risk of intrathoracic complications, yields good outcomes in terms of symptom control, establishing histologic diagnosis, and prevention of thoracic complications. LEVEL OF EVIDENCE: Level IV-case series.

Tibial Spine Fractures in the Child and Adolescent Athlete: A Systematic Review and Meta-analysis.

BACKGROUND: Tibial spine fractures (TSFs) are uncommon injuries that may result in substantial morbidity in children. A variety of open and arthroscopic techniques are used to treat these fractures, but no single standardized operative method has been identified. PURPOSE: To systematically review the literature on pediatric TSFs to determine the current treatment approaches, outcomes, and complications. STUDY DESIGN: Meta-analysis; Level of evidence, 4. METHODS: A systematic review of the literature was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) guidelines using PubMed, Embase, and Cochrane databases. Studies evaluating treatment and outcomes of patients <18 years old were included. Patient demographic characteristics, fracture characteristics, treatments, and outcomes were abstracted. Descriptive statistics were used to summarize categorical and quantitative variables, and a meta-analytic technique was used to compare observational studies with sufficient data. RESULTS: A total of 47 studies were included, totaling 1922 TSFs in patients (66.4% male) with a mean age of 12 years (range, 3-18 years). The operative approach was open reduction and internal fixation in 291 cases and arthroscopic reduction and internal fixation in 1236 cases; screw fixation was used in 411 cases and suture fixation, in 586 cases. A total of 13 nonunions were reported, occurring most frequently in Meyers and McKeever type III fractures (n = 6) and in fractures that were treated nonoperatively (n = 10). Arthrofibrosis rates were reported in 33 studies (n = 1700), and arthrofibrosis was present in 190 patients (11.2%). Range of motion loss occurred significantly more frequently in patients with type III and IV fractures (P < .001), and secondary anterior cruciate ligament (ACL) injury occurred most frequently in patients with type I and II fractures (P = .008). No statistically significant differences were found with regard to rates of nonunion, arthrofibrosis, range of motion loss, laxity, or secondary ACL injury between fixation methods (screw vs suture). CONCLUSION: Despite variation in TSF treatment, good overall outcomes have been reported with low complication rates in both open and arthroscopic treatment and with both screw and suture fixation. Arthrofibrosis remains a concern after surgical treatment for TSF, but no significant difference in incidence was found between the analysis groups. Larger studies are necessary to compare outcomes and form a consensus on how to treat and manage patients with TSFs.

An assessment of the diagnosis, treatment, and outcomes of lower extremity stress fractures in pediatric and adolescent populations.

OBJECTIVES: To present one of the first descriptive case series of pediatric and adolescent lower extremity stress injuries, their management, and outcomes in athletes and non-athletes. METHODS: The IRB-approved retrospective study included patients under 18 years at a tertiary children's hospital who were diagnosed with a lower extremity stress fracture/reaction. Demographic data, mechanism of injury, physical exam, radiographic findings, treatment, & outcomes were collected. Descriptive statistical analysis was conducted. RESULTS: Ninety-seven patients with stress injuries on clinical exams and on radiographs or MRI were included. The average age when diagnosed was 11.7 years (range 1.1-18 years) and the most common injuries were to the tibia (n = 33, 28.4%) and the least common involved were the cuneiforms (n = 4, 3.4%). Patients under the age of 14 were more likely to experience cuboid and calcaneal stress injuries (mean age 5.5 and 8.3 years respectively). Nineteen patients (19.6%) had high-risk stress fractures, with the average age of 14.9 years versus 11.6 for those with low risk (p-value = 0.01) and return to activity time being 15 weeks compared to 10.5 (p-value = 0.027). The most common forms of treatment were controlled ankle motion (CAM), walker boots (58.6%), and physical therapy (PT) (38.1%). The mean Lower Extremity Function Score of the patient population was 73.8, indicating no clinically important difference from full functionality. CONCLUSION: Lower extremity stress injuries in this cohort were most seen in the tibia, although patients younger than 14 had a high number of cuboid and calcaneal stress injuries. Those with high-risk stress fractures were older and took longer to recover from when compared to low-risk injuries. Treatment is commonly conservative, with CAM boots and PT being the most frequently utilized interventions and serving as a successful approach to treatment, with patients returning to activity at an average of 11.4 weeks, which is comparable to similar studies.

Posterior Root Tears of the Lateral Meniscus Only Affect Tibiofemoral Contact Forces when the Meniscofemoral Ligament Is Involved: A Cadaveric Study.

Purpose: The objective of this study was to examine the impact of progressive radial tears in the lateral meniscal root on the lateral compartment contact forces and joint surface area through a range of motion of knee and evaluate the role of the meniscofemoral ligament (MFL) in preventing adverse tibiofemoral joint forces. Methods: Ten fresh frozen cadaveric knees were tested using 6 experimental conditions (0% lateral meniscal posterior root tear, 25% tear, 50% tear, 75% tear, 100% tear, 100% tear and resection of MFL) at five flexion angles (0°, 30°, 45°, 60°, and 90°) under 100-1,000-N axial load. Contact joint pressure and lateral compartment surface area were measured using Tekscan sensors. Statistical analysis, including descriptive, ANOVA, and post hoc Tukey analysis, was performed. Results: Progressive radial tears of the lateral meniscal root were not associated with an increase in tibiofemoral contact pressure or decrease in lateral compartment surface area. Complete lateral root tear and resection of MFL were associated with increased joint contact pressure (P < .001) at knee flexion angles of 30, 45, 60, and 90° and decreased lateral compartment surface (P < .001) at all knee flexion angles area compared to complete lateral meniscectomy alone. Conclusion: Isolated complete tears of lateral meniscus root and progressive radial tears of the lateral meniscus posterior root were not associated with any change to tibiofemoral contact forces. However, additional resection of the MFL increased contact pressure and decreased lateral compartment surface area.

Medial Discoid Meniscus in Children: A Multicenter Case Series of Clinical Features and Operative Results.

BACKGROUND: The discoid medial meniscus is a rare congenital anomaly of the knee. The literature is limited to small case series. PURPOSE/HYPOTHESIS: Our purpose is to report the clinical manifestations and operative treatments of discoid medial menisci in children from multiple centers in North America. We hypothesized that symptoms and signs, arthroscopic findings, surgical treatments, and outcomes are similar to those for symptomatic discoid lateral menisci. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective review identified patients with a diagnosed discoid medial meniscus confirmed at surgery across 8 children's hospitals between January 2000 and June 2021. The literature on discoid lateral menisci was reviewed and summarized for comparison. RESULTS: A total of 21 patients (9 female, 12 male) with 22 discoid medial menisci were identified. The mean ± SD age at the time of diagnosis was 12.8 ± 3.8 years. The most common symptoms and signs were locking and/or clunking, present in 12 of 22 knees (55%), similar to that reported in patients with discoid lateral menisci. Twelve discoid medial menisci were complete (55%); 8, incomplete (36%); and 2, indeterminate (9%). Tears were present in 13 knees, most commonly horizontal cleavage (54%). Five discoid medial menisci were unstable (23%): 3 for posterior tears and 2 for rim insufficiency. All 22 knees underwent arthroscopic saucerization, and of the 13 torn menisci, 7 (54%) were repaired. The median follow-up was 24 months (range, 2-82 months). Four knees underwent reoperation. All knees that required reoperation had undergone repair for a posteriorly located tear. There was a significant association between operative repair and need for reoperation (P = .0048). High rates of peripheral instability were also noted in case series of patients with discoid lateral menisci. CONCLUSION: Patient presentations and treatments for those with discoid medial menisci were similar to those reported for patients with discoid lateral menisci. Knees with discoid medial menisci also demonstrated instability attributed to peripheral insufficiency and posterior tears. Tears were present in over half of knees with discoid medial menisci, and reoperation was more common in knees that underwent repair of tears than those without repair.