Postoperative Strength Differences at Short-Term Follow-up Vary Based on Autograft Harvest Site After Adolescent Transphyseal Anterior Cruciate Ligament Reconstruction.

PURPOSE: To compare the clinical and patient-reported outcomes of adolescent patients who underwent anterior cruciate ligament reconstruction (ACLR) with quadriceps tendon (QT) versus hamstring tendon (HT) autograft. METHODS: This was a retrospective cohort study of adolescent patients aged 18 years or younger treated at a single tertiary care children's hospital who underwent primary transphyseal ACLR using QT or HT between January 2018 and December 2019. All patients had minimum 6-month follow-up. Outcomes included isokinetic strength testing, postoperative Patient-Reported Outcomes Measurement Information System and International Knee Documentation Committee scores, and complications; these were compared between the QT and HT cohorts. RESULTS: A total of 84 patients (44 HT and 40 QT patients) were included. The QT cohort had a higher proportion of male patients (62.5% vs 34.1%, P = .01). At 3 months, HT patients had a lower hamstring-quadriceps (H/Q) strength ratio (60.7 ± 11.0 vs 79.5 ± 18.6, P < .01) and lower Limb Symmetry Index in flexion (85.6 ± 16.1 vs 95.5 ± 15.7, P = .01) whereas QT patients had a lower Limb Symmetry Index in extension (67.3 ± 9.5 vs 77.4 ± 10.7, P < .01). The H/Q ratio at 6 months was lower in HT patients (59.4 ± 11.5 vs 66.2 ± 7.5, P < .01). Patient-Reported Outcomes Measurement Information System and International Knee Documentation Committee scores were not different at 3 months or latest follow-up. QT patients had more wound issues (20.0% vs 2.3%, P = .01). Patients receiving HT autograft had more ipsilateral knee injuries (18.2% vs 2.5%, P = .03), but there was no difference in graft failure for ACLR using HT versus QT (9.1% vs 2.5%, P = .36). CONCLUSIONS: There were no differences in patient-reported outcome measures between patients receiving QT autografts and those receiving HT autografts. Patients with QT grafts had more postoperative wound issues but a lower rate of ipsilateral knee complications (graft failure or meniscal tear). Differences in quadriceps and hamstring strength postoperatively compared with the contralateral limb were observed for adolescent ACLR patients receiving QT and HT autografts, respectively. This contributed to higher H/Q ratios seen at 3 and 6 months postoperatively for patients receiving QT autografts. LEVEL OF EVIDENCE: Level III, retrospective comparative therapeutic study.

Combined Hip Arthroscopy and Periacetabular Osteotomy (PAO): Technical Focus on Arthroscopically Elevating the Iliocapsularis and Performing the Open PAO.

In this Technical Note, we discuss the combined hip arthroscopy and periacetabular osteotomy (PAO) for the treatment of symptomatic hip dysplasia, with a focus on the technique we use for the PAO. We identify modifications that can be made during the arthroscopic portion of the procedure to assist in the PAO dissection, including arthroscopic capsular closure and arthroscopic elevation of the iliocapsularis muscle off the capsule, which allows for expedited open exposure during the PAO.

A Rare Incident of Intraarticular Fibromatosis of the Knee: A Case Report.

CASE: Our patient is a 34-year-old male aHthlete who presented for consultation after left knee discomfort and pressure for greater than 2 years. Advanced imaging revealed a nonspecific intraarticular suprapatellar lesion with subsequent ultrasound-guided core biopsy demonstrating a spindle cell proliferation consistent with superficial fibromatosis. Thus, the patient underwent an open en bloc surgical resection by a fellowship-trained orthopaedic oncologist. CONCLUSION: As the first reported case of intraarticular fibromatosis of the knee, this case highlights the importance of a thoughtful approach to the management of nonspecific intraarticular lesions through a comprehensive and collaborative strategy to decrease patient morbidity and optimize outcomes.

Administration of TGF-ß Inhibitor Mitigates Radiation-induced Fibrosis in a Mouse Model.

BACKGROUND: Radiation-induced fibrosis is a long-term adverse effect of external beam radiation therapy for cancer treatment that can cause pain, loss of function, and decreased quality of life. Transforming growth factor beta (TGF-ß) is believed to be critical to the development of radiation-induced fibrosis, and TGF-ß inhibition decreases the development of fibrosis. However, no treatment exists to prevent radiation-induced fibrosis. Therefore, we aimed to mitigate the development of radiation-induced fibrosis in a mouse model by inhibiting TGF-ß. QUESTION/PURPOSES: Does TGF-ß inhibition decrease the development of muscle fibrosis induced by external beam radiation in a mouse model? METHODS: Twenty-eight 12-week-old male C57BL/6 mice were assigned randomly to three groups: irradiated mice treated with TGF-ßi, irradiated mice treated with placebo, and control mice that received neither irradiation nor treatment. The irradiated mice received one 50-Gy fraction of radiation to the right hindlimb before treatment initiation. Mice treated with TGF-c (n = 10) received daily intraperitoneal injections of a small-molecule inhibitor of TGF-ß (1 mg/kg) in a dimethyl sulfoxide vehicle for 8 weeks (seven survived to histologic analysis). Mice treated with placebo (n = 10) received daily intraperitoneal injections of only a dimethyl sulfoxide vehicle for 8 weeks (10 survived to histologic analysis). Control mice (n = 8) received neither radiation nor TGF-ß treatment. Control mice were euthanized at 3 months because they were not expected to exhibit any changes related to treatment. Mice in the two treatment groups were euthanized 9 months after radiation, and the quadriceps of each thigh was sampled. Masson's trichome stain was used to assess muscle fibrosis. Slides were viewed at 10 × magnification using bright-field microscopy, and in a blinded fashion, five representative images per mouse were used to quantify fibrosis. The mean ± SD fibrosis pixel densities in the TGF-ßi and radiation-only groups were compared using Mann-Whitney U tests. The ratio of fibrosis to muscle was calculated using the mean fibrosis per slide in the TGF-ßi group to standardize measurements. Alpha was set at 0.05. RESULTS: The mean (± SD) percentage of fibrosis per slide was greater in the radiation-only group (1.2% ± 0.42%) than in the TGF-ßi group (0.14% ± 0.09%) (odds ratio 0.12 [95% CI 0.07 to 0.20]; p < 0.001). Among control mice, mean fibrosis was 0.05% ± 0.02% per slide. Mice in the radiation-only group had 9.1 times the density of fibrosis as did mice in the TGF-ßi group. CONCLUSION: Our study provides preliminary evidence that the fibrosis associated with radiation therapy to a quadriceps muscle can be reduced by treatment with a TGF-ß inhibitor in a mouse model. CLINICAL RELEVANCE: If these observations are substantiated by further investigation into the role of TGF-ß inhibition on the development of radiation-induced fibrosis in larger animal models and humans, our results may aid in the development of novel therapies to mitigate this complication of radiation treatment.

Who should you be following? The top 100 social media influencers in orthopaedic surgery.

BACKGROUND: Social media has been credited with the potential to transform medicine, and Twitter was recently named "an essential tool" for the academic surgeon. Despite this, peer-to-peer and educational influence on social media has not been studied within orthopaedic surgery. This knowledge is important to identify who is controlling the conversation about orthopaedics to the public. We hypothesized that the plurality of top influencers would be sports medicine surgeons, that social media influence would not be disconnected from academic productivity, and that some of the top social media influencers in orthopaedic surgery would not be orthopaedic surgeons. AIM: To identify the top 100 social media influencers within orthopaedics, characterize who they are, and relate their social media influence to academic influence. METHODS: Twitter influence scores for the topic "orthopaedics" were collected in July 2018 using Right Relevance software. The accounts with the top influence scores were linked to individual names, and the account owners were characterized with respect to specialty, subspecialty, practice setting, location, board certification, and academic Hirsch index (h-index). RESULTS: Seventy-eight percent of top influencers were orthopaedic surgeons. The most common locations included California (13%), Florida (8%), New York (7%), United Kingdom (7%), Colorado (6%), and Minnesota (6%). The mean academic h-index of the top influencers (n = 79) was 13.67 ± 4.12 (mean ± 95%CI) and median 7 (range 1-89) (median reported h-index of academic orthopaedic faculty is 5 and orthopaedic chairpersons is 13). Of the 78 orthopaedic surgeons, the most common subspecialties were sports medicine (54%), hand and upper extremity (18%), and spine (8%). Most influencers worked in private practice (53%), followed by academics (17%), privademics (14%), and hospital-based (9%). All eligible orthopaedic surgeons with publicly-verifiable board certification statuses were board-certified (n = 74). CONCLUSION: The top orthopaedic social media influencers on Twitter were predominantly board-certified, sports-medicine subspecialists working in private practice in the United States. Social media influence was highly concordant with academic productivity as measured by the academic h-index. Though the majority of influencers are orthopaedic surgeons, 22% of top influencers on Twitter are not, which is important to identify given the potential for these individuals to influence patients' perceptions and expectations. This study also provides the top influencer network for other orthopaedic surgeons to engage with on social media to improve their own social media influence.

Current practice of antibiotic prophylaxis for surgical fixation of closed long bone fractures: a survey of 297 members of the Orthopaedic Trauma Association.

BACKGROUND: The risk of postoperative surgical site infection after long bone fracture fixation can be decreased with appropriate antibiotic use. However, there is no agreement on the superiority of a single- or multiple-dose perioperative regimen of antibiotic prophylaxis. The purpose of this study is to determine the following: 1) What are the current practice patterns of orthopaedic trauma surgeons in using perioperative antibiotics for closed long bone fractures? 2) What is the current knowledge of published antibiotic prophylaxis guidelines among orthopaedic trauma surgeons? 3) Are orthopaedic surgeons willing to change their current practices? METHODS: A questionnaire was distributed via email between September and December 2015 to 955 Orthopaedic Trauma Association members, of whom 297 (31%) responded. RESULTS: Most surgeons (96%) use cefazolin as first-line infection prophylaxis. Fifty-nine percent used a multiple-dose antibiotic regimen, 39% used a single-dose regimen, and 2% varied this decision according to patient factors. Thirty-six percent said they were unfamiliar with Centers for Disease Control and Prevention (CDC) antibiotic prophylaxis guidelines; only 30% were able to select the correct CDC recommendation from a multiple-choice list. However, 44% of surgeons said they followed CDC recommendations. Fifty-six percent answered that a single-dose antibiotic prophylaxis regimen was not inferior to a multiple-dose regimen. If a level-I study comparing a single preoperative dose versus multiple perioperative antibiotic dosing regimen for treatment of closed long bone fractures were published, most respondents (64%) said they would fully follow these guidelines, and 22% said they would partially change their practice to follow these guidelines. CONCLUSION: There is heterogeneity in the use of single- versus multiple-dose antibiotic prophylaxis for surgical repair of closed long bone fractures. Many surgeons were unsure of current evidence-based recommendations regarding perioperative antibiotic use. Most respondents indicated they would be receptive to high-level evidence regarding the single- versus multiple-dose perioperative prophylactic antibiotics for the treatment of closed long bone fractures.

The Surgical Management of Osteochondritis Dissecans of the Knee in the Skeletally Immature: A Survey of the Pediatric Orthopaedic Society of North America (POSNA) Membership.

BACKGROUND: While the characteristics of osteochondritis dissecans (OCD) of the knee that require surgery to heal have been described, several surgical techniques/procedures exist with no consensus established regarding timing of treatment and specific surgical intervention. In this study, we aim to determine current trends in surgical treatment for OCD lesions in the skeletally immature who have failed 6 months of nonoperative management by surveying a large cohort of orthopaedic surgeons. METHODS: An electronic survey designed using REDCap to capture surgeon treatment preferences for OCD lesions was distributed to members of the Pediatric Orthopaedic Society of North America (POSNA). The survey inquired about treating physicians' training and demographics. It then offered a series of clinical vignettes alongside imaging describing patients with varying degrees of severity of OCD following nonoperative treatment. Surgeons were prompted to select from a variety of multiple-choice-based options for further patient management. Standard descriptive statistics were used to summarize and compare the responses. RESULTS: Of the 129 POSNA members completing the pediatric survey, 97.7% were attending level orthopaedic surgeons, the majority identifying with an academic institution and treating mostly skeletally immature patients. In the skeletally immature population, the majority would treat intact, stable OCD lesions with drilling in a retroarticular or transarticular manner. Preferred treatment for unstable, salvageable lesions was screw fixation using bioabsorble materials or metal with variable pitch with no bone graft. The majority of respondents would treat unstable, unsalvageable OCD lesions with chondroplasty and osteochondral transplant/transfer or microfracture/drilling. CONCLUSIONS: The POSNA membership appears to agree on principle in terms of treatment modalities for various stages of OCD lesions in the skeletally immature, whereas individual techniques of achieving these principles may vary. Members endorse drilling for stable intact lesions; fixation for unstable, salvageable lesions; and "defect fill" for unsalvageable lesions. CLINICAL SIGNIFICANCE: OCD surgical treatment patterns can be used in future studies to determine which techniques are most effective for given indications, with the goal of designing a research-proven optimal treatment regimen for skeletally immature patients.

Do Surgical Times and Efficiency Differ Between Inpatient and Ambulatory Surgery Centers That are Both Hospital Owned?

PURPOSE: The aim of this study was to examine the differences in primary anterior cruciate ligament reconstruction (ACLR) surgical time and operation room (OR) work efficiency between inpatient and ambulatory facilities within the same institution. METHODS: Patients studied included those who underwent primary ACLR at either the inpatient hospital or the ambulatory facility by a single orthopaedic surgeon on elective surgery days. Time variables were calculated for ACLR to compare the 2 facilities. The OR work efficiency was calculated as the percentage of work that was completed before mid-day that was determined by the midpoint of the surgical day at each facility. RESULTS: Two hundred twenty-seven ACLR surgeries were performed on 187 elective surgery days, 153 surgeries at the inpatient facility and 74 at the outpatient facility. The mean age at the time of surgery was 14.9±2.2 years. The ACLR surgeries at the ambulatory facility were of shorter duration than those at the inpatient facility (P<0.0001). One OR was most commonly utilized and 2 to 3 surgeries were performed on most surgery days at both facilities. Seven nurses served as alternating circulators at the ambulatory facility compared with 41 nurses serving in the same capacity at the inpatient facility. The median turnover time was longer at the inpatient facility compared with the ambulatory facility. OR work efficiency (work done before mid-day) was 72.5% at the ambulatory facility and 49.5% at the inpatient facility, P<0.0001. If 2 ACLR surgeries were performed consecutively, the surgery day lasted for 6 hours at the hospital-owned ambulatory surgery center compared with 9 hours at the inpatient hospital. CONCLUSIONS: Despite the common variables of the same surgeon performing the same surgery at facilities owned by the same institution primarily working in a single OR, differences exist in OR procedure time and work efficiency. LEVEL OF EVIDENCE: Level III.

Diagnostic performance of magnetic resonance imaging and pre-surgical evaluation in the assessment of traumatic intra-articular knee disorders in children and adolescents: what conditions still pose diagnostic challenges?

BACKGROUND: Diagnosis of intra-articular lesions in children based on clinical examination and MRI is particularly challenging. OBJECTIVE: To evaluate the diagnostic performance of MRI and pre-surgical evaluation of the knee in pediatric patients relative to arthroscopic evaluation as the gold standard. We report diagnoses frequently missed or inaccurately diagnosed pre-operatively. MATERIALS AND METHODS: We conducted a retrospective review of MRI and pre-surgical evaluation in children and adolescents ages 1-17 years who were treated by knee arthroscopy during a 2½-year period. All MRIs were reviewed by a pediatric radiologist blinded to clinical findings. Pediatric orthopedic clinic notes were reviewed for pre-surgical evaluation (based on physical exam, radiograph, MR images and radiologist's MRI report). Arthroscopic findings were used as the gold standard. We calculated the percentages of diagnoses at arthroscopy missed on both MRI and pre-surgical evaluation. Diagnostic accuracy between children and adolescents and in patients with one pathological lesion vs. those with >1 lesion was analyzed. We performed a second review of MR images of the missed or over-called MRI diagnoses with knowledge of arthroscopic findings. RESULTS: We included 178 children and adolescents. The most common diagnoses missed on MRI or pre-surgical evaluation but found at arthroscopy were: discoid meniscus (8/30, or 26.7% of cases); lateral meniscal tears (15/80, or 18.8% of cases); intra-articular loose bodies (5/36, or 13.9% of cases), and osteochondral injuries (9/73, or 12.3% of cases). Overall diagnostic accuracy of MRI and pre-surgical evaluation was 92.7% and 95.3%, respectively. No significant difference in diagnostic accuracy between children and adolescents was observed. When multiple intra-articular lesions were present, lateral meniscal tears were more likely to be inaccurately diagnosed (missed or over-called) on both MRI (P = 0.009) and pre-surgical evaluation (P < 0.001). CONCLUSION: Overall diagnostic accuracy of MRI and pre-surgical evaluation was quite high. The traumatic intra-articular knee lesions that still pose a diagnostic challenge for MRI and pre-surgical evaluation are lateral discoid meniscus, lateral meniscal tears, intra-articular loose bodies and osteochondral injuries. Special attention should be given to those diagnoses when evaluating a pediatric knee MRI. In children with multiple intra-articular injuries, there is significantly more inaccuracy in pre-arthroscopic diagnosis of lateral meniscal tears on both MRI and pre-surgical evaluation.

Timing of forearm arterial repair in the well-perfused limb.

The purpose of this study was to evaluate the difference in the outcomes of patients with a well-perfused hand who were taken to the operating room (OR) within 6 hours of forearm arterial injury vs patients who were treated in a semiurgent fashion. A review of 201 consecutive patients who were taken to the OR with forearm-level radial or ulnar arterial injury identified 26 patients who had a well-perfused hand at presentation in whom hemostasis was achieved within 15 minutes with manual pressure and no signs of hemodynamic instability. Outcomes of interest included short-version Disabilities of the Arm, Shoulder and Hand (quickDASH) scores and patient-reported cold intolerance. Of the 26 patients, group 1 included 17 patients who were taken to the OR within 6 hours and group 2 included 9 patients who were taken to the OR in a delayed fashion. Minimum follow-up in both groups was 13 months. Average quickDASH score was 24.5 and 14.1 for groups 1 and 2, respectively. Average time spent in the OR was significantly less in group 2 compared with group 1 (1.7 vs 2.8 hours). In the setting of forearm arterial injury with a well-perfused distal limb, there was no difference in functional outcome in patients taken to the OR emergently compared with those who underwent surgery in a delayed manner. With careful evaluation and monitoring, semiurgent operative repair is feasible and may improve certain aspects of patient care and hospital resource use. Outcome measures in this study support semiurgent treatment of these injuries.

The medial dye pool revisited: correlation between arthrography and MRI In closed reductions for DDH.

BACKGROUND: Closed reduction (CR) and spica casting is performed using arthrography to assess the adequacy of reduction based in part on the width of medial dye pool (MDP); however, the amount of MDP that is acceptable and its correlation to the actual anatomic position of the femoral head within the acetabulum has been poorly delineated. The purpose of this study was to determine this correlation and to explore the potential limits of acceptable MDP measurements. METHODS: We retrospectively reviewed a consecutive series of patients with DDH treated at our institution by CR and immediate postoperative magnetic resonance imaging (MRI) and found 20 patients (23 hips) meeting inclusion criteria. We measured the MDP and femoral head area on the best reduced arthrographic image, the immediate postoperative mid-coronal MRI, and on 3 planes (neutral, 30-degree anterior, and 30-degree posterior) of the mid-axial MRI and compared MDP values from both imaging modalities using the Pearson correlation coefficient (R). To provide useful data for establishing intraoperative thresholds, MDP was also expressed as a percentage of femoral head width to control for fluoroscopic magnification. RESULTS: Twenty-two of the 23 hips were reduced on postoperative MRI; the one persistently dislocated hip was excluded from our analysis. The Pearson correlation coefficient was R = 0.73 comparing arthrography and coronal MRI, indicating excellent correlation. Correlation was even stronger between arthrography and axial MRI (neutral R = 0.73; 30-degree anterior, R = 0.81; 30-degree posterior, R = 0.81). The mean fluoroscopic MDP in the successful, fully concentric, CRs was 4.2% of the femoral head width (range, 0.6% to 15.8%). CONCLUSIONS: There is very strong correlation between MDP measurements on arthrography and immediate postoperative MRI in both the axial and coronal planes. On the basis of our data, an arthrographic MDP between 0.6% and 15.8% of the femoral head width always resulted in an excellent reduction, suggesting that an MDP of ≤ 16% of femoral head width may be a useful intraoperative criterion for determining the adequacy of CR. LEVEL OF EVIDENCE: Level I Diagnostic Study.

Intra-articular nodular fasciitis of the knee in a pediatric patient.

The differential diagnosis for an intra-articular lesion in the knee of a pediatric patient is broad. Diagnostic considerations include pigmented villonodular synovitis (PVNS)-the most common intra-articular tumor-and a variety of both benign and malignant tumors, including lipomas, hemangiopericytomas, nodular fasciitis, parosteal osteosarcomas, and fibromyxoid sarcomas. If there is concern over possible malignant lesions, a tumor surgeon should be consulted. Precise pathologic diagnosis is ideal for identifying these enigmatic lesions and for determining the appropriate treatment plan. This article presents the case of a 13-year-old boy who presented with 1-month duration of knee pain and no history of trauma to the extremity. Physical examination revealed pain along the medial and lateral joint lines, pain with range of motion, and limited range of motion of the affected knee. Magnetic resonance imaging revealed a 3×1×3-cm lesion in the posterolateral corner that was believed to be localized PVNS. Arthroscopically, there was no evidence of PVNS, but a posterolateral soft tissue mass was found and removed, which was pathologically diagnosed as a rare, benign, intra-articular nodular fasciitis. When working with intra-articular masses, it is important to assess the likelihood of malignancy and to both consult a tumor surgeon and use the appropriate surgical tumor principles when malignancy is a concern. Additionally, the pathology team should be consulted prior to surgery and be on standby during arthroscopic evaluation of the knee to help with precise diagnosis of the intra-articular mass. Discussing the case with the pathologist with imaging studies present is helpful and often aids in the diagnosis of the lesion.

The association of metabolic syndrome markers with adhesive capsulitis.

BACKGROUND: Research has associated adhesive capsulitis with diabetes mellitus but suggests that glucose-mediated injury may begin before diabetes is diagnosed. The period preceding diabetes is often marked by metabolic syndrome. METHODS: We investigated the relationship between metabolic syndrome components (insulin resistance, hypertension, dyslipidemia, and obesity) and the development of adhesive capsulitis using a case-control study. We retrospectively reviewed 150 consecutive adhesive capsulitis patient charts to determine the prevalence of obesity and of medications used for treating metabolic syndrome elements and compared these with previously reported nationwide values. RESULTS: The prevalence of anti-hyperglycemia medications in the adhesive capsulitis cohort was 18.4% (95% confidence interval [CI], 12.9%-25.7%), twice the national rate of diagnosed diabetes of 7.6% (95% CI, 6.7%-8.5%). In the 20- to 39-year-old group, the prevalence of anti-hyperglycemic medications, 26.3% (95% CI, 11.8%-48.8%), was over 10 times the nationwide rate. The overall prevalence of hypertensive medication use in the adhesive capsulitis group, 33.1% (95% CI, 25.9%-41.2%), was notably higher than the nationwide rate, 21.6% (95% CI, 19.8%-23.4%). In the 40- to 64-year-old group, the prevalence of hypertensive medication use, 36.8% (95% CI, 28.6%-46.0%), was notably higher than the nationwide rate of 24.5% (95% CI, 22.2%-27.0%). The prevalence of anti-lipid medications and obesity was similar between the groups. CONCLUSIONS: The relationship between adhesive capsulitis and metabolic syndrome remains unclear. Our results confirm previous work associating hyperglycemia with adhesive capsulitis. We have also shown a possible association of hypertension, part of metabolic syndrome and a proinflammatory condition, with adhesive capsulitis, which has not been previously described.

Treatment and Management Outcomes of Tibial Eminence Fractures in Pediatric Patients: A Systematic Review.

BACKGROUND: Tibial eminence fractures are rare but occur more frequently in children and adolescents. There are a variety of methods to surgically treat these fractures, but surgeons disagree about the optimal method of reduction and fixation. HYPOTHESES: Regarding clinical results and complications after treatment in children and adolescent patients with tibial eminence fractures, the authors hypothesize that (1) there is no difference between reduction and fixation with screws versus sutures, (2) there is no difference in arthroscopic versus open reduction and fixation, and (3) outcomes are better in patients with minimally displaced (types I and II) versus completely displaced (types III and IV) fractures. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A systematic review of the literature was performed studying the treatment of tibial eminence fractures in children and adolescents to determine clinical results, functional outcomes, and complications. A meta-analytic technique on observational studies was used to compare outcomes when sufficient data were available. RESULTS: The review identified 26 articles with extractable clinical results and data on complications: 1 level 3 article and 25 level 4 articles. Ten of 580 tibial eminence fractures identified in the literature had nonunion, with 60% of nonunions occurring in type III fractures treated by nonoperative modalities. Appreciable healing was noted for both open and arthroscopic fixation techniques as well as patients treated by screw or suture fixation. Laxity (P < .001) and loss of range of motion (P = .009) occurred significantly less after the treatment of minimally displaced fractures (types I and II). CONCLUSION: The level of evidence supporting various treatments of tibial eminence fractures in children and adolescents is low. There is insufficient evidence to conclude the superiority of open versus arthroscopic fixation or screw versus suture fixation techniques. Nonoperative treatment of completely displaced tibial eminence fractures results in higher rates of nonunion. Type III and IV fractures heal with greater laxity and greater loss of range of motion after treatment. Higher level studies are necessary to determine the optimal method of fixation for tibial eminence fractures.

Hybrid fixation of tibial eminence fractures in skeletally immature patients.

Tibial eminence fractures most commonly occur in children and adolescents. When treating displaced fractures of the tibial eminence, some surgeons prefer screw fixation whereas others prefer suture fixation. The ultimate goal is to limit morbidity through early return to range of motion and activity. In this technical note, we describe 2 hybrid fixation techniques for fixing tibial eminence fractures, one for type III and the other for type IV fractures. The first technique (variation A) is used to treat type III fractures and combines use of both a bioabsorbable compression screw and suture for fixation. The second technique (variation B) is used to treat type IV fractures and combines use of both a bioabsorbable compression screw and shoulder anchor fixation. We have found that these methods provide efficient, secure, and reliable fixation using standard techniques common to arthroscopic surgery. In addition, the growth plates are spared in children and adolescents, and the need for reoperation to remove hardware is eliminated.

Abduction bracing for residual acetabular dysplasia in infantile DDH.

BACKGROUND: Abduction bracing is often used to treat residual acetabular dysplasia in infants whose acetabular indices (AI) exceed 30 degrees after 6 months of age. However, little data exist to support this practice. The purpose of this study was to determine the efficacy of part-time abduction bracing in treating residual acetabular dysplasia by comparing a cohort of braced infants with a cohort of unbraced infants. METHODS: We performed a retrospective review of a consecutive series of patients with developmental dysplasia of the hip (DDH) treated at our institution over 4 years. Children with stable, treated DDH but residual acetabular dysplasia at 6 months of age were identified; those with available anteroposterior pelvic radiographs at 6 months and 1 year of age were included. Patients who required open surgical reduction and those with syndromic or neuromuscular diagnoses were excluded. On the basis of practice variations at our institution, some orthopaedists start bracing when the 6-month radiograph demonstrates an AI≥30 degrees, whereas others do not; we compared these 2 cohorts. Braced patients were instructed to wear an abduction orthosis during nights and naps until follow-up at 1 year of age. The AI at 6 months and 1 year of age for both cohorts were then measured by a single observer and the differences compared. RESULTS: Seventy-six hips in 52 patients were identified with residual dysplasia on the 6-month radiograph. Thirty-nine hips (27 patients) were unbraced, 31 hips (21 patients) were braced, and 6 hips (4 patients) were excluded for cross-over. Over a 6-month period, the braced cohort had significantly better improvement in the AI of 5.3 degrees (95% confidence interval, 4.3 to 6.3 degrees) compared to the unbraced cohort which had an improvement in the AI of only 1.1 degrees (95% confidence interval 0.6 to 1.6 degrees) (P<0.001). CONCLUSIONS: In this comparative analysis of infants with residual acetabular dysplasia treated with abduction bracing or observation, part-time bracing significantly improved the acetabular index between 6 and 12 months of age. Part-time use of an abduction orthosis is effective for improving residual acetabular dysplasia in infants with DDH. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Adjunctive vancomycin powder in pediatric spine surgery is safe.

STUDY DESIGN: Therapeutic level II cohort study. OBJECTIVE: To evaluate the safety of adjunctive local application of vancomycin powder (VP) for infection prophylaxis in posterior instrumented thoracic and lumbar spine wounds in pediatric patients weighing more than 25 kg. SUMMARY OF BACKGROUND DATA: Spine surgeons have largely turned to vancomycin prophylaxis in an attempt to decrease the incidence of late surgical site infection and acute surgical site infection from methicillin-resistant Staphylococcus aureus. In adult patients, the adjunctive local application of VP with an intravenous cephalosporin has been shown to decrease postsurgical wound infection rates significantly; however, the safety of VP as an adjunct in pediatric spine surgery has not been reported. METHODS: We reviewed data collected under a systematic protocol specifically designed to monitor the safety profile of VP. We measured changes in creatinine and systemic vancomycin levels after intrawound application of 500 mg of unreconstituted VP during spine deformity correction surgery in patients weighing more than 25 kg (patients also received routine intravenous cephalosporin prophylaxis). Laboratory values were measured preoperatively and on postoperative days 1 and 4. Any adverse reactions and infections through available follow-up (2-8 mo) were recorded. RESULTS: Eighty-seven consecutive pediatric patients with spinal deformity weighing more than 25 kg who received intraoperative VP during a 9-month period were identified. Sixty-three percent of the patients in this series had adolescent idiopathic scoliosis, 15% congenital scoliosis, 15% neuromuscular scoliosis, and 5% spondylolisthesis. The average change in creatinine levels between the preoperative and postoperative day 1 draw was -0.03 and between the preoperative and postoperative day 4 draw was -0.075. The postoperative systemic vancomycin levels remained undetectable. None of the patients experienced nephrotoxicity or red man syndrome. Three of the 87 patients developed a surgical site infection. CONCLUSION: In this cohort there were no clinically significant changes in creatinine level or systemic vancomycin level caused by use of intraoperative VP. LEVEL OF EVIDENCE: 2.

Identical osteochondritis dissecans lesions of the knee in sets of monozygotic twins.

Osteochondritis dissecans (OCD) is a focal, idiopathic alteration of subchondral bone structure with the risk for secondary damage to adjacent articular cartilage and the development of premature osteoarthritis. The exact etiology of OCD is unknown, although repetitive microtrauma and vascular insufficiency have been previously described. A genetic predisposition has been suggested, but the existing evidence is sparse. There are multiple case reports of twins and siblings with OCD and a few large family series in the literature, promoting the theory that OCD may have a genetic component to its etiology. This article describes 2 sets of monozygotic twins presenting concurrently with OCD of their dominant knees, offering further support for a genetic component to the etiology of OCD. Interestingly, in both sets of twins, 1 was left-handed and 1 was right-handed. Both sets of twins had simultaneous presentations and clinical courses, lending support to a genetic element to OCD. The development of the OCD lesion in the dominant knee of each patient suggests an environmental influence, perhaps due to repetitive microtrauma and overuse. Recently, a genome-wide linkage study identified a prime candidate locus for OCD. However, despite the suggested association, genetic and developmental factors in the development of OCD remain relatively unstudied. The authors believe monozygotic twins provide an excellent clinical opportunity for future examination of the role of familial inheritance in the etiology of OCD.