Consensus-Based Guidelines for Management of First-Time Patellar Dislocation in Adolescents.

BACKGROUND: The management of first-time patellar dislocation remains variable, with limited evidence to support or compare different operative and nonoperative modalities. The primary aim was to establish consensus-based guidelines for different components of nonoperative treatment following a first-time patellar dislocation. The secondary aim was to develop guidelines related to management after failed nonoperative treatment. The tertiary aim was to establish consensus-based guidelines for the management of first-time patellar dislocation with a concomitant osteochondral fracture. METHODS: A 29-question, multiple-choice, case-based survey was developed by 20 members of the Patellofemoral Research Interest Group of the Pediatric Research in Sports Medicine Society. The survey consisted of questions related to demographic information, management of first-time patellar dislocation without an osteochondral fracture, and management of first-time patellar dislocation with a 2 cm osteochondral fracture. The survey underwent 2 rounds of iterations by Patellofemoral Research Interest Group members and the final survey was administered to Pediatric Research in Sports Medicine members, using REDCap. Consensus-based guidelines were generated when more than 66% of respondents chose the same answer. RESULTS: Seventy-nine of 157 (50%) eligible members responded. Sixty-one were orthopaedic surgeons and 18 were primary sports medicine physicians. Eleven consensus-based guidelines were generated based on survey responses. Those that met the criteria for consensus included initial knee radiographs (99% consensus), nonoperative treatment for first-time patellar dislocation without an osteochondral fracture (99%), physical therapy starting within the first month postinjury (99%), with return to sport after 2 to 4 months (68%) with a brace (75%) and further follow-up as needed (75%). Surgical treatment was recommended if there were patellar subluxation episodes after 6 months of nonoperative treatment (84%). Patellar stabilization should be considered for a first-time dislocation with an osteochondral fracture (81.5%). CONCLUSION: Consensus-based guidelines offer recommendations for the management of first-time patellar dislocation with or without an osteochondral fracture. Several changing trends and areas of disagreement were noted in clinical practice. CLINICAL RELEVANCE: In the absence of high-level evidence, consensus-based guidelines may aid in clinical decision-making when treating patients following a first-time patellar dislocation. These guidelines highlight the evolving trends in clinical practice for the management of first-time patellar dislocation. Areas not reaching consensus serve as topics for future research.

Reliability of MRI Interpretation of Discoid Lateral Meniscus: A Multicenter Study.

Background: Discoid lateral meniscus (DLM) has a varied and complex morphology that can be challenging to assess and treat. Preoperative magnetic resonance imaging (MRI) is frequently used for diagnosis and surgical planning; however, it is not known whether surgeons are reliable and accurate in their interpretation of MRI findings when defining the pathomorphology of DLM. Hypothesis: Surgeons experienced in treating DLM are able to reliably interpret DLM pathology using MRI. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: Knee MRI scans from 44 patients (45 knees) were selected from a pool of surgically treated patients with DLM. Five reviewers (fellowship-trained pediatric sports medicine surgeons) performed independent review of each MRI scan using the PRiSM Discoid Meniscus Classification. Inter- and intraobserver reliability of the rating factors-primary (width, height, presence of peripheral instability or tear) and secondary (location of instability or tear, tear type)-was assessed using the Fleiss κ coefficient, designed for multiple readers with nominal variables (fair reliability, 0.21-0.40; moderate, 0.41-0.60; substantial, 0.61-0.80; excellent, 0.81-1.00). Reliability is reported as κ (95% CI). Results: Interobserver reliability in assessing most primary and secondary characteristics ranged from substantial (meniscal width) to moderate (peripheral instability, anterior instability, posterior instability, and posterior tear). Intraobserver reliability for most characteristics ranged from substantial (peripheral instability, presence of tear, anterior instability, posterior instability, and posterior tear) to moderate (meniscal width, anterior tear, and tear type). Notable exceptions were presence of tear, anterior tear, and tear type-all with fair interobserver reliability. Height had poor interobserver reliability and fair intraobserver reliability. Conclusion: Orthopaedic surgeons reliably interpret MRI scans using the PRiSM Discoid Meniscus Classification for the majority of DLM characteristics but vary in their assessment of height and presence and type of tear. MRI evaluation may be helpful to diagnose discoid by width and identify the presence of instability: 2 major factors in the decision to proceed with surgery. Arthroscopic evaluation should be used in conjunction with MRI findings for complete DLM diagnosis.

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.

Discoid Meniscus.

Discoid meniscus is the most common congenital variant of the meniscus. Its variability in pathology leads to a spectrum of clinical presentations in patients. Treatment must be tailored to the specific pathology of the discoid meniscus. Imaging studies such as radiographs and magnetic resonance imaging can be useful in confirming the diagnosis, but may be the most accurate in determining specific pathology. Thorough intraoperative evaluation of the discoid is critical to appropriate surgical management. Rim preservation and repair is preferred to prevent degenerative changes in the knee.

Reliability of a New Arthroscopic Discoid Lateral Meniscus Classification System: A Multicenter Video Analysis.

BACKGROUND: The discoid lateral meniscus (DLM) is one of the most common congenital anomalies of the knee. The pathomorphology of DLM varies. Current classification systems are inadequate to describe the spectrum of abnormality. PURPOSE: A study group of pediatric orthopaedic surgeons from 20 academic North American institutions developed and tested the reliability of a new DLM classification system. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: After reviewing existing classifications, we developed a comprehensive DLM classification system. Four DLM features were evaluated: meniscal width, meniscal height, peripheral stability, and meniscal tear. Stepwise arthroscopic examination using anteromedial and anterolateral viewing portals was established for evaluating these features. Three senior authors who were not observers selected 50 of 119 submitted videos with the best clarity and stepwise examination for reading. Five observers performed assessments using the new classification system to assess interobserver reliability, and a second reading was performed by 3 of the 5 observers to assess intraobserver reliability using the Fleiss κ coefficient (fair, 0.21-0.40; moderate, 0.41-0.60; substantial, 0.61-0.80; excellent, 0.81-1.00). RESULTS: Interobserver reliability was substantial for most rating factors: meniscal width, meniscal height, peripheral stability, tear presence, and tear type. Interobserver reliability was moderate for tear location. Intraobserver reliability was substantial for meniscal width and meniscal height and excellent for peripheral stability. Intraobserver agreement was moderate for tear presence, type, and location. CONCLUSION: This new arthroscopic DLM classification system demonstrated moderate to substantial agreement in most diagnostic categories analyzed.

Pediatric discoid meniscus: can magnetic resonance imaging features coupled with clinical symptoms predict the need for surgery?

BACKGROUND: Magnetic resonance imaging (MRI) criteria for evaluating discoid meniscus is limited in the pediatric population. OBJECTIVE: To assess MRI features of intact discoid meniscus and correlate with clinical outcomes. MATERIALS AND METHODS: In this institutional review board (IRB)-approved retrospective cohort study, knee MRIs at our institution from 2008 to 2019 were reviewed. The inclusion criterion was diagnosis of discoid meniscus on MRI. Exclusion criteria were torn discoid meniscus at presentation, previous meniscal surgery and confounding knee conditions. MRI features of discoid meniscus collected were craniocaudal dimension, transverse dimension, transverse dimension to tibial plateau (TV:TP) ratio and increased intrameniscal signal. The clinical course was reviewed for knee pain, mechanical symptoms and treatment type. RESULTS: Two hundred and nineteen of 3,277 (6.7%) patients had discoid meniscus. Of the 219 patients, 71 (32.4%) satisfied inclusion criteria. Seven patients had discoid meniscus of both knees resulting in 78 discoid menisci. The average patient age was 11.1 years (min: 2.0, max: 17.0). The average follow-up was 30.6 months. Of the 78 discoid menisci, 14 (17.9%) required surgery. Increased intrameniscal signal was found more in discoid meniscus requiring surgery (surgical: 10/14, nonsurgical: 19/64, P=0.009). Surgically treated discoid meniscus had a statistically significant increase in transverse dimension (surgical: 18.3±5.0 mm, nonsurgical: 15.7±4.3 mm, P=0.045) and TV:TP ratio (surgical: 0.55±0.15, nonsurgical: 0.47±0.12, P=0.036). Mechanical symptoms (surgical: 9/11, nonsurgical: 21/60, P=8.4×10-6) and pain ≥1 month (surgical: 11/11, nonsurgical: 17/60, P=0.006) were found more often in surgical patients. Clinical and imaging criteria of mechanical symptoms and knee pain ≥1 month and at least one of (1) increased intrameniscal signal or (2) TV:TP ratio greater than 0.47 identified discoid menisci that developed a tear and/or required surgery with a sensitivity of 0.86 and specificity of 0.88. CONCLUSION: Mechanical symptoms and knee pain ≥1 month, and at least one of (1) increased intrameniscal signal or (2) TV:TP ratio greater than or equal to 0.47, identified discoid menisci that would go on to tear and/or require surgery with a sensitivity and specificity of 0.86 and 0.88, respectively.

Predictors of Arthrofibrosis After Pediatric Anterior Cruciate Ligament Reconstruction: What Is the Impact of Quadriceps Autograft?

BACKGROUND: Recent literature on arthrofibrosis after anterior cruciate ligament reconstruction (ACLR) in children and adolescents is limited, especially with regards to quadriceps tendon (QT) autograft. The purpose of this study was to identify predictors of arthrofibrosis after ACLR, with attention to the impact of graft type. METHODS: Patients that underwent primary ACLR at a tertiary children's hospital were reviewed for this retrospective case-control study. Those with multiligament reconstructions, lateral extra-articular tenodesis procedures, allografts, or a modified MacIntosh reconstruction were excluded. Arthrofibrosis was defined as a deficit of 10 degrees of extension and/or 20 degrees of flexion at 3 months after ACLR. Univariate analysis was followed by purposeful entry logistic regression to adjust for confounding factors. RESULTS: A total of 378 patients (mean age 15.9±1.7 y, 49.7% female) were included in the analysis, of which there were 180 patellar tendon (PT), 103 hamstrings tendon (HT), and 95 QT grafts. The rate of arthrofibrosis was 1.9% for HT, 6.3% for QT, and 10.0% for PT (P=0.04). Females developed arthrofibrosis more frequently than males (10.6% vs. 3.2%, P=0.004). Those that ultimately experienced this complication had lower median flexion at 6 weeks after ACLR (88 vs. 110 degrees, P<0.001). In multivariate analysis, PT graft raised the odds of arthrofibrosis 6.2 times compared to HT [95% confidence interval (CI): 1.4-27.6, P=0.02], but there were no significant differences between QT and other grafts. Females were at 4.2 times higher odds than males (95% CI: 1.6-10.8; P=0.003). Patients that were unable to attain 90 degrees of flexion 6 weeks after ACLR had 14.7 times higher odds of eventually developing arthrofibrosis (95% CI: 5.4-39.8; P<0.001). Finally, those with an extension deficit of ≥5 degrees 6 weeks after ACLR had 4.7 times higher odds of experiencing this complication (95% CI: 1.8-12.2, P=0.001). CONCLUSION: The rate of arthrofibrosis with QT autograft is 6.3% after pediatric ACLR. PT autograft, female sex, and motion deficits at 6 weeks after ACLR were predictive of arthrofibrosis in children and adolescents. LEVEL OF EVIDENCE: Level III-prognostic study.

Current Concepts of Diagnosis and Management of ACL Injuries in Skeletally Immature Athletes.

Anterior cruciate ligament (ACL) injuries in skeletally immature athletes are encountered with increasing frequency. The management of such injuries is controversial. Nonsurgical management often results in functional instability and a higher risk of meniscal and chondral injury to the knee. Conventional methods of ACL reconstruction carry the risk of growth disturbance because of iatrogenic damage to the physes around the knee. Multiple cases of growth disturbance have been reported. This article discusses the relevant anatomy, natural history, risk factors, treatment, and prevention of ACL injuries in skeletally immature patients. Surgical treatment is based on physiologic age. For prepubescent patients, we recommend physeal-sparing combined intra-articular/extra-articular reconstruction with autogenous iliotibial band. In adolescent patients with significant growth remaining, we recommend transphyseal ACL reconstruction with hamstrings autograft and fixation away from the physes. In older adolescent patients, we recommend conventional adult ACL reconstruction with autogenous hamstrings or patellar tendon.