Stenotic Intercondylar Notch as a Risk Factor for Physeal-Sparing ACL Reconstruction Failure: A Case-Control Study.

INTRODUCTION: Identifying risk factors is crucial for developing strategies that minimize reinjury after anterior cruciate ligament reconstruction (ACLR). This study aims to determine whether certain features of intercondylar notch geometry are associated with failure of physeal-sparing ACLRs in skeletally immature athletes. METHODS: Nine failed physeal-sparing ACLRs were compared with a control subject group of 15 age- and sex-matched intact physeal-sparing ACLRs. Notch width index (NWI), notch angle (NA), and intercondylar notch roof inclination angle (RA) were measured on preoperative MRIs. RESULTS: Median NWI was smaller in the failed ACLR versus control subject group in coronal (0.23 versus 0.27; P < 0.05) and axial planes (0.25 versus 0.27; P = 0.055). Median NA was smaller in the failed ACLR versus control subject group in coronal (49.6 versus 61.0°; P < 0.05) and axial planes (48.6° versus 54.9°; P < 0.05). Median RA was steeper in the failed ACLR versus control subject group (132.0° versus 125.7°; P < 0.05). CONCLUSION: NWI, NA, and RA were associated with ACLR failure in skeletally immature patients undergoing physeal-sparing reconstruction. A smaller, narrower, and steeper notch may predispose these patients to reinjury.

Juvenile Osteochondritis Dissecans of the Trochlea: A Cohort Study of 34 Trochlear Lesions Associated With Sporting Activities That Load the Patellofemoral Joint.

BACKGROUND: Juvenile osteochondritis dissecans (JOCD) lesions are rarely located in the trochlea and few studies have focused on the causes and outcomes of JOCD lesions in this part of the knee. The purpose of this study is to (1) evaluate the clinical characteristics and outcomes of patients who undergo surgery for JOCD in this unusual location as well as (2) assess the association between trochlear JOCD and participation in sporting activities that load the patellofemoral joint. METHODS: We conducted a retrospective cohort study of 34 trochlear JOCD lesions in 30 patients. Cases that involved traumatic cartilage shear or patella instability were excluded. Preoperative and postoperative magnetic resonance images and x-rays were evaluated and demographic data, sports played, comorbidities, surgical procedures, and clinical data were extracted from medical records. A case-control cohort of 102 femoral condyle lesions was used to assess the correlation between sports played and lesion location. RESULTS: The cohort comprised 34 consecutive trochlear JOCD lesions in 30 patients (26 males, 4 females). Average age at surgery was 13.8 years (9.3 to 18.0 y). In total, 27 (90%) patients were active, and of these active patients, soccer and basketball were the most common sports played. In the case-control comparison, the correlation between playing either basketball or soccer and the presence of a trochlear JOCD lesion was statistically significant (P=0.017). In total, 21 knees (62%) received operative treatment. Sixteen of the surgical patients underwent repair and fixation with bioabsorbable nails. The average length of clinical and radiographic follow-up was 21.1 months. All patients who underwent fixation showed radiographic and/or clinical indications of healing at most recent follow-up. Thirteen of the patients who underwent fixation were active, and all of these patients reported successful return to sports. Thirteen knees underwent nonoperative treatment, and the majority of these patients had limited follow-up. CONCLUSIONS: We report a significant association between pediatric athletes who play basketball and soccer and the development of trochlear JOCD, suggesting that repetitive loading of the patellofemoral joint may play a role in the development of JOCD lesions. Patients with trochlear JOCD lesions were likely to undergo surgery, and repair and fixation of the lesions produced good outcomes at short-term follow-up. LEVEL OF EVIDENCE: Level III-case-control study.

Tibial tubercle avulsion fractures in children.

PURPOSE OF REVIEW: To summarize and discuss the fundamentals of pediatric tibial tubercle avulsion fractures (TTAFs) including preferred imaging modalities, systems for fracture classification, frequently associated injuries, treatment options, outcomes, and common complications. RECENT FINDINGS: Although TTAFs amount to fewer than 1% of all physeal injuries in children, the incidence is increasing, likely because of greater participation in high-level athletics. SUMMARY: TTAFs tend to occur in adolescents nearing skeletal maturity who engage in sports with repetitive jumping. The most popular classification system was proposed by Ogden, which defines five fracture types based on the fracture pattern and extent of fragment displacement. Treatment can be nonsurgical or surgical, and indications depend on fracture type. Most fractures are surgical candidates and can be repaired with open reduction and internal fixation (ORIF) or arthroscopy. Arthroscopic approaches can reveal associated soft tissue injuries, such as meniscal tears, and confirm articular reduction. The most common postoperative complication is irritation because of hardware. With proper treatment, both nonsurgical and surgical outcomes are excellent. TTAFs have high rates of union and patients typically return to sports.

A new, MRI-based classification system for tibial spine fractures changes clinical treatment recommendations when compared to Myers and Mckeever.

PURPOSE: Tibial spine fractures (TSFs) are graded according to the Meyers and McKever (MM) classification system, which is based on a qualitative evaluation of plain radiographs. However, although MRI images can provide important information about these fractures, there is no MRI-based classification system. This study aims to (1) establish the intra- and inter-rater reliability of the MM system for use with radiographs, (2) propose a quantitative, MRI-based system and compare its reliability to the MM system, and (3) assess how often using the MRI-based system changes the classification and potential treatment plan as previously determined using MM. METHODS: The MRI-based system was designed with three grades based on quantitative displacement patterns of the fractured fragment and tissue entrapment. Four raters from a tertiary care center evaluated 20 fractures according to the MM and MRI-based systems. Observers graded images at two time points at least 2 weeks apart, after which we compared the intra- and inter-rater reliability of each system (using Fleiss' kappa and weighted kappa, respectively) and assessed how often using the MRI-based system changed the fracture grade. RESULTS: Both the MM and MRI-based systems exhibit fair to moderate intra- and inter-rater reliability (average kappa values ranged from 0.38 to 0.66). Use of the MRI-based system changed the fracture grade and as a result modified the treatment recommendations in 32.5% of cases: 6.9% were previously unnoticed fractures, 13.1% underwent a raise in grade, and 12.5% were graded as lower than before. CONCLUSION: The MRI-based system is as reliable as the MM system and provides specific, quantitative criteria for classifying fractures according to fragment displacement and tissue entrapment. The new MRI-based system potentially clarifies treatment indications for TSFs. LEVEL OF EVIDENCE: Diagnostic Study, Level II.

Tibial spine avulsion fractures: treatment update.

PURPOSE OF REVIEW: The purpose of this review is to summarize and clarify the current framework for treating tibial spine avulsion fractures (TSAFs). We will discuss how these fractures are classified both on plain radiographs and MRI as well as report the incidence of concomitant soft tissue injury, an important consideration that guides treatment. We will also compare guidelines for nonsurgical versus surgical treatment and summarize frequently used surgical techniques. Finally, we will review outcomes following treatment, including common complications. RECENT FINDINGS: Although TSAFs only constitute 2-5% of all pediatric knee injuries, the incidence is increasing. A recently developed MRI-based system for evaluating TSAFs is another tool that aids in the treatment of these injuries. SUMMARY: TSAFs can be classified using plain radiographs as well as MRI. Type I fractures are usually treated with immobilization whereas type II fractures typically undergo an initial attempt at closed reduction followed by arthroscopic or open reduction and fixation if needed. Type III fractures are indicated directly for arthroscopic surgery and both suture and screw fixation produce good clinical outcomes. All-epiphyseal or transphyseal approaches can minimize the risk of physeal injury in skeletally immature patients. Common complications following TSAF injury and treatment are residual laxity, knee stiffness, and nonunion or malunion.

Surgical excision of a large, verrucous, scrotal mass in a patient with HSV-2 and HIV-1 co-infection.

Genital herpes simplex virus (HSV) infection in HIV-positive individuals can result in a unique presentation of symptoms. Instead of small papules or vesicles that recur and heal periodically, certain individuals present with large, chronic, verrucous lesions. We report a case in which a 45 year old male with acyclovir-resistant HSV-2 and positive HIV-1 serology underwent surgical excision of a verrucous mass on his left hemiscrotum.

Percutaneous Epiphysiodesis Using Transphyseal Screws: a Case Series Demonstrating High Efficacy.

BACKGROUND: Percutaneous epiphysiodesis using transphyseal screws (PETS) has been associated with implant failure, implant prominence, angular deformities, and delayed growth inhibition. QUESTIONS/PURPOSES: The aim of this study was to assess the complication rate and efficacy (defined as actual growth inhibition divided by expected growth inhibition) of PETS and to identify factors associated with improved efficacy. METHODS: Patients who underwent distal femoral and/or proximal tibial PETS between January 2007 and June 2014 were identified. Complications, efficacy, and final limb-length discrepancy (LLD) were calculated using multipliers and inhibition rates based on previous growth. Associations between efficacy and screw insertion angle (SIA), body mass index, and number of threads crossing the physis were calculated. RESULTS: Eight-two patients (126 treated physes) were included. The mean pre-operative LLD was 27.7 mm (SD = 7.5). Following epiphysiodesis, 15 had temporary pain (18%), five had temporary effusion (6.1%), four had broken implants (4.9%), four developed mild angulation (4.9%), and three had failed epiphysiodesis requiring revision (3.7%). Thirty-one underwent screw removal (n = 31, 38%). Mean LLD at maturity was 17.3 mm (SD = 5.8 mm). Mean efficacy at the distal femur was 97% (SD = 46%), at the proximal tibia was 108% (SD = 66%) and was 103% (SD = 57%) overall. Increased screw threads across the lateral proximal tibial physis (Spearman's correlation coefficient = 0.67; 95% CI = 0.40-0.94) and higher BMI (Spearman's correlation coefficient = 0.55; 95% CI = 0.34-0.77) were positively associated with increased efficacy. CONCLUSIONS: The efficacy of PETS may be more favorable than previously reported. Only 3.7% had serious complications requiring revision epiphysiodesis, lower than previous reports. Attention to sufficient screw threads across the physis may be important in optimizing PETS results.

Meniscal transplant in children.

PURPOSE OF REVIEW: The purpose is to review and discuss the fundamentals, indications, surgical technique, controversies, and outcomes regarding meniscal transplantation, focusing on available evidence in pediatric populations. RECENT FINDINGS: Recent studies have confirmed meniscal allograft transplantation as an effective procedure to improve symptoms, knee function, and quality of life following meniscectomy, particularly in symptomatic young patients. Associated procedures, such as osteotomies and cartilage-related surgeries, have expanded the indications for transplantation. Most patients return to sports following meniscal transplantation, and the procedure does not preclude the potential return to high-level athletic competition. The chondroprotective effect of transplantation has not been proven and as a result the role of prophylactic transplantation remains unclear. SUMMARY: Meniscal allograft transplantation is indicated following symptomatic meniscal loss in young, active patients to relieve pain and improve knee function. The quality of the available evidence regarding meniscal transplantation is limited, and no published series to date has focused exclusively on a pediatric population. Further high-quality studies are needed to establish improved indications, timing, and outcomes in a pediatric population.

Comparative phosphoproteomic analysis of neonatal and adult murine brain.

Developmental processes are governed by diverse regulatory mechanisms including a suite of signaling pathways employing reversible phosphorylation. With the advent of large-scale phosphoproteomics, it is now possible to identify thousands of phosphorylation sites from tissues at distinct developmental stages. We describe here the identification of over 6000 nonredundant phosphorylation sites from neonatal murine brain. When compared to nearly three times the number of phosphorylation sites identified from 3-week-old murine brain, remarkably one-third of the neonatal sites were unique. This fraction only dropped to one-quarter when allowing the site to stray plus or minus 15 residues. This provides evidence for considerable change in the profiles of developmentally regulated phosphoproteomes. Using quantitative MS we characterized a novel phosphorylation site (Ser265) identified uniquely in the neonatal brain on doublecortin (Dcx), a protein essential for proper mammalian brain development. While the relative levels of Dcx and phospho-Ser265 Dcx between embryonic and neonatal brain were similar, their levels fell precipitously by postnatal day 21, as did phospho-Ser297, a site required for proper neuronal migration. Both sites lie near the microtubule-binding domain and may provide functionally similar regulation via different kinases.