Paediatric anterior cruciate ligament tears: management and growth disturbances. A survey of EPOS and POSNA membership.

PURPOSE: The therapeutic algorithm of paediatric anterior cruciate ligament (ACL) tears remains controversial. The primary aim of the study was to describe variations in practice patterns among European Paediatric Orthopaedic Society (EPOS) and Pediatric Orthopaedic Society of North America (POSNA) members with respect to management of ACL tears in skeletally immature patients. The secondary objective was to determine the number, type and severity of growth disturbances associated with ACL reconstruction (ACLR). METHODS: An email invitation to complete a 52-question survey was sent to all members of POSNA and EPOS. Data were collected automatically. Descriptive statistics were applied. RESULTS: In all, 305 (25.4%) surgeon members responded. Only 182 (60%) of the participants treated ACL injuries in skeletally immature patients and completed the survey. A total of 17% of EPOS and 70% of POSNA members recommended ACLR within three months for a prepubescent paediatric ACL tear. In total, 61% of POSNA and 83% of EPOS members recommended ACLR within three months for a pubescent paediatric ACL tear. Epiphyseal tunnels were the preferred technique in prepubescent children (43% at the tibia and 49% at the femur), while transphyseal tunnels were recommended preferentially in pubescent children (85% at the tibia and 63% at the femur). In all, 5.5% of participants reported growth disturbances after ACLR. CONCLUSION: Current practice patterns across the Atlantic remain varied and controversial. Consensus remains elusive; as such, research collaboration among societies will be important to develop an evidence-based treatment algorithm. The use of transphyseal tunnels has been reinforced. The number of cases of significant growth disturbance is minimal, yet worrisome. LEVEL OF EVIDENCE: II.

Validity and comprehensibility of the International Knee Documentation Committee Subjective Knee Evaluation form in Children.

The International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form is a knee-specific measure developed for adults. Its usefulness in children is not established. This study describes how children interpret IKDC items, identifies sources of response errors, and provides suggestions for modification. Cognitive interviews were conducted in 30 children with a primary knee injury, purposefully sampled based on age and gender. Most children could not recall their injury date or symptoms 4 weeks after injury. All reported problems interpreting directions; half noted item timeframes were unclear and did not realize all questions pertained to their injured knee. Seventy percent read only the first half of a question, missing subtle differences between items. Children had difficulty comprehending the following concepts: strenuous/moderate activity, pivoting, locking, giving way, significant pain/swelling, and knee catching. Examples to describe activity levels either did not apply (e.g. housework) or were ranked differently by children. Younger children had difficulty using five-point responses. The two most difficult items were assessment of current and prior function. Children found the IKDC Subjective Knee Evaluation Form difficult to comprehend and to answer. Modifications to directions, item formatting, and definitions are needed to ensure comprehensibility and validity.

Collegiate rugby union injury patterns in New England: a prospective cohort study.

OBJECTIVE: To establish injury profile of collegiate rugby union in the USA. DESIGN/ SETTING: 31 men's and 38 women's collegiate rugby union teams prospectively recorded injuries during games and practice during the 2005-06 season. Three teams withdrew before data collection. An injury was defined as one: (1) occurring in an organised intercollegiate game or practice; and (2) requiring medical attention during or after the game or practice, or (3) resulting in any restriction of the athletes' participation for >or=1 day(s) beyond the day of injury, or in a dental injury. MAIN OUTCOME MEASURES: In total, 847 injuries (447 in men; 400 in women) during 48,026 practice (24,280 in men; 23,746 in women) and 25,808 game (13,943 in men; 11,865 in women) exposures were recorded. RESULTS: During games, injury rates of 22.5 (95% CI 20.2 to 25.0) and 22.7 (20.2 to 25.5) per 1000 game athletic exposures or 16.9 (15.1 to 18.9) and 17.1 (15.1 to 19.1) per 1000 player game hours were recorded for men and women, respectively. Over half of all match injuries were of major severity (>7 days' absence) (men 56%; women 51%) and the tackle was the game event most often associated with injury (men 48%; women 53%). CONCLUSIONS: Collegiate game injury rates for rugby were lower than rates recorded previously in men's professional club and international rugby and lower than reported by the National Collegiate Athletic Association Injury Surveillance System for American football, but similar to rates reported for men's and women's soccer in 2005-06.

Titanium elastic nailing of fractures of the femur in children. Predictors of complications and poor outcome.

Between 1996 and 2003 six institutions in the United States and France contributed a consecutive series of 234 fractures of the femur in 229 children which were treated by titanium elastic nailing. Minor or major complications occurred in 80 fractures. Full information was available concerning 230 fractures, of which the outcome was excellent in 150 (65%), satisfactory in 57 (25%), and poor in 23 (10%). Poor outcomes were due to leg-length discrepancy in five fractures, unacceptable angulation in 17, and failure of fixation in one. There was a statistically significant relationship (p = 0.003) between age and outcome, and the odds ratio for poor outcome was 3.86 for children aged 11 years and older compared with those below this age. The difference between the weight of children with a poor outcome and those with an excellent or satisfactory outcome was statistically significant (54 kg vs 39 kg; p = 0.003). A poor outcome was five times more likely in children who weighed more than 49 kg.

Functional and radiographic outcome of juvenile osteochondritis dissecans of the knee treated with transarticular arthroscopic drilling.

Management of juvenile osteochondritis dissecans is controversial. The purpose of this study was to evaluate the functional and radiographic outcomes of transarticular arthroscopic drilling for isolated stable, juvenile osteochondritis dissecans lesions of the medial femoral condyle with an intact articular surface after 6 months of nonoperative management had failed. We reviewed 30 affected knees in 23 skeletally immature patients (mean age, 12.3 years; range, 8.5 to 16.1) at an average follow-up of 3.9 years (range, 2.0 to 7.2). Functional outcome was determined using the Lysholm score and radiographic outcome was determined using lesion size, and the radiographic score of Rodegerdts and Gleissner. There was significant improvement in the mean Lysholm score (from 58 to 93). There was significant improvement in the mean lesion size on anteroposterior (4.5 +/- 5.8 mm decrease) and lateral (8.4 +/- 8.1 mm decrease) radiographs. There was also significant improvement in the mean radiographic score (from 3.0 to 1.9). Radiographic healing was achieved in all patients at an average of 4.4 months after drilling (range, 1 to 11 months). Linear regression analysis revealed that younger age was an independent, multivariate predictor of Lysholm score improvement. There were no apparent surgical complications.

Diagnostic performance of clinical examination and selective magnetic resonance imaging in the evaluation of intraarticular knee disorders in children and adolescents.

To determine the diagnostic performances of clinical examination and selective magnetic resonance imaging in the evaluation of intraarticular knee disorders in children and adolescents we compared them with arthroscopic findings in a consecutive series of pediatric patients (< or = 16 years old). Stratification effects by patient age and magnetic resonance imaging center were examined. There were 139 lesions diagnosed clinically, 128 diagnosed by magnetic resonance imaging, and 135 diagnosed arthroscopically. There was no significant difference between clinical examination and magnetic resonance imaging with respect to agreement with arthroscopic findings (clinical examination, 70.3%; magnetic resonance imaging, 73.7%), overall sensitivity (clinical examination, 71.2%; magnetic resonance imaging, 72.0%), and overall specificity (clinical examination, 91.5%; magnetic resonance imaging, 93.5%). Stratified analysis by diagnosis revealed significant differences only for sensitivity of lateral discoid meniscus (clinical examination, 88.9%; magnetic resonance imaging, 38.9%) and specificity of medial meniscal tears (clinical examination, 80.7%; magnetic resonance imaging, 92.0%). For magnetic resonance imaging, children younger than 12 years old had significantly lower overall sensitivity (61.7% versus 78.2%) and lower specificity (90.2% versus 95.5%) compared with children 12 to 16 years old. There was no significant effect of magnetic resonance imaging center. In conclusion, selective magnetic resonance imaging does not provide enhanced diagnostic utility over clinical examination, particularly in children, and should be used judiciously in cases where the clinical diagnosis is uncertain and magnetic resonance imaging input will alter the treatment plan.

Cost and effectiveness of routine pathological examination of operative specimens obtained during primary total hip and knee replacement in patients with osteoarthritis.

BACKGROUND: The challenge of cost-efficiency is maintaining the quality of medical care while reducing costs and eliminating unnecessary practices. The purpose of this investigation was to evaluate the cost and effectiveness of routine pathological examination of surgical specimens from patients undergoing primary total hip or knee replacement for the treatment of osteoarthritis. METHODS: Effectiveness was assessed by comparing clinical and pathological diagnoses associated with 1,234 consecutive primary total joint replacements (471 hip and 763 knee replacements) performed between 1992 and 1995 in one hospital in patients with the clinical diagnosis of osteoarthritis. Clinical and pathological diagnoses were considered concordant if they agreed, discrepant if they differed without a resultant change in patient management, and discordant if they differed with a resultant change in patient management. Cost identification was performed by determining charges, reimbursement, and costs in 1998-adjusted American dollars for both total hip and total knee replacement. The cost per health-effect was determined by calculating the cost per discrepant and discordant diagnosis. RESULTS: The prevalence of concordant diagnoses was 97.6 percent (1,205 of 1,234) (95 percent confidence interval, 96.6 to 98.4 percent), the prevalence of discrepant diagnoses was 2.3 percent (twenty-eight of 1,234) (95 percent confidence interval, 1.4 to 3.1 percent), and the prevalence of discordant diagnoses was 0.1 percent (one of 1,234) (95 percent confidence interval, 0.1 to 0.3 percent). The cost per discrepant diagnosis was $4,383, and the cost per discordant diagnosis was $122,728. CONCLUSIONS: Routine pathological examination of surgical specimens from patients undergoing primary total hip or knee replacement because of the clinical diagnosis of osteoarthritis had limited cost-effectiveness at our hospital due to the low prevalence of findings that altered patient management.

Upper extremity injuries in the paediatric athlete.

Injuries to the upper extremity in paediatric and adolescent athletes are increasingly being seen with expanded participation and higher competitive levels of youth sports. Injury patterns are unique to the growing musculoskeletal system and specific to the demands of the involved sport. Shoulder injuries include sternoclavicular joint injury, clavicle fracture, acromioclavicular joint injury, osteolysis of the distal clavicle, little league shoulder, proximal humerus fracture, glenohumeral instability and rotator cuff injury. Elbow injuries include supracondylar fracture, lateral condyle fracture, radial head/neck fracture, medial epicondyle avulsion, elbow dislocation and little league elbow. Wrist and hand injuries include distal radius fracture, distal radial physeal injury, triangular fibrocartilage tear, scaphoid fracture, wrist ligamentous injury thumb metacarpalphalangeal ulnar collateral ligament injury, proximal and distal interphalangeal joint injuries and finger fractures. Recognition of injury patterns with early activity modification and the initiation of efficacious treatment can prevent deformity/disability and return the youth athlete to sport.

Surgical management of spinal involvement in children and adolescents with Gaucher's disease.

Gaucher's disease is an uncommon hereditary glycolipid storage disorder characterized by the accumulation of glucocerebroside in the lysosomes of macrophages of the reticuloendothelial system. Skeletal manifestations are variable in severity and typically involve the long bones. Vertebral involvement is less well characterized, particularly in children and adolescents. We report on the surgical management of spinal involvement in four children and adolescents with Gaucher's disease; two for kyphotic deformity and two for kyphotic deformity associated with neurologic compromise. We recommend anterior spinal release with fusion and posterior spinal fusion with segmental instrumentation in cases of kyphotic deformity. In cases of spinal cord compromise at the apex of the kyphotic deformity with retropulsion of involved bone, anterior decompression also should be performed. Routine surveillance for spinal deformity in patients with Gaucher's disease is necessary to allow early intervention before the development of severe deformity and neurologic compromise.

Orthopaedic aspects of child abuse.

Increased awareness of child abuse has led to better understanding of this complex problem. However, the annual incidence of abuse is estimated at 15 to 42 cases per 1,000 children and appears to be increasing. More than 1 million children each year are the victims of substantiated abuse or neglect, and more than 1,200 children die each year as a result of abuse. The diagnosis of child abuse is seldom easy to make and requires a careful consideration of sociobehavioral factors and clinical findings. Because manifestations of physical abuse involve the entire child, a thorough history and a complete examination are essential. Fractures are the second most common presentation of physical abuse after skin lesions, and approximately one third of abused children will eventually be seen by an orthopaedic surgeon. Thus, it is essential that the orthopaedist have an understanding of the manifestations of physical abuse, to increase the likelihood of recognition and appropriate management. There is no pathognomonic fracture pattern in abuse. Rather, the age of the child, the overall injury pattern, the stated mechanism of injury, and pertinent psychosocial factors must all be considered in each case. Musculoskeletal injury patterns suggestive of nonaccidental injury include certain metaphyseal lesions in young children, multiple fractures in various stages of healing, posterior rib fractures, and long-bone fractures in children less than 2 years old. Skeletal surveys and bone scintigraphy with follow-up radiography may be of benefit in cases of suspected abuse of younger children. The differential diagnosis of abuse includes other conditions that may cause fractures, such as true accidental injury, osteogenesis imperfecta, and metabolic bone disease. Management should be multidisciplinary, with the key being recognition, because abused children have a substantial risk of repeated abuse and death.

Ultrasonographic screening for developmental dysplasia of the hip: an epidemiologic analysis (Part I).

Ultrasonography offers distinct advantages in the imaging of the neonatal hip and has proved useful in the diagnosis and management of developmental dysplasia of the hip (DDH). However, its role as a screening tool for DDH remains controversial. The purpose of this article is to critically assess ultrasonographic screening of DDH from an epidemiologic viewpoint, considering aspects of the disease to be screened and characteristics of the screening tool, while evaluating screening efficacy and feasibility.

Differentiating between septic arthritis and transient synovitis of the hip in children: an evidence-based clinical prediction algorithm.

BACKGROUND: A child who has an acutely irritable hip can pose a diagnostic challenge. The purposes of this study were to determine the diagnostic value of presenting variables for differentiating between septic arthritis and transient synovitis of the hip in children and to develop an evidence-based clinical prediction algorithm for this differentiation. METHODS: We retrospectively reviewed the cases of children who were evaluated at a major tertiary-care children's hospital between 1979 and 1996 because of an acutely irritable hip. Diagnoses of true septic arthritis, presumed septic arthritis, and transient synovitis were explicitly defined on the basis of the white blood-cell count in the joint fluid, the results of cultures of joint fluid and blood, and the clinical course. Univariate analysis and multiple logistic regression analysis were used to compare groups. A probability algorithm for differentiation between septic arthritis and transient synovitis on the basis of independent multivariate predictors was constructed and tested. RESULTS: Patients who had septic arthritis differed significantly (p < 0.05) from those who had transient synovitis with regard to the erythrocyte sedimentation rate, serum white blood-cell count and differential, weight-bearing status, history of fever, temperature, evidence of effusion on radiographs, history of chills, history of recent antibiotic use, hematocrit, and gender. Patients who had true septic arthritis differed significantly (p < 0.05) from those who had presumed septic arthritis with regard to history of recent antibiotic use, history of chills, temperature, erythrocyte sedimentation rate, history of fever, gender, and serum white blood-cell differential. Four independent multivariate clinical predictors were identified to differentiate between septic arthritis and transient synovitis: history of fever, non-weight-bearing, erythrocyte sedimentation rate of at least forty millimeters per hour, and serum white blood-cell count of more than 12,000 cells per cubic millimeter (12.0 x 10(9) cells per liter). The predicted probability of septic arthritis was determined for all sixteen combinations of these four predictors and is summarized as less than 0.2 percent for zero predictors, 3.0 percent for one predictor, 40.0 percent for two predictors, 93.1 percent for three predictors, and 99.6 percent for four predictors. The chi-square test for trend and the area under the receiver operating characteristic curve indicated excellent diagnostic performance of this group of multivariate predictors in identifying septic arthritis. CONCLUSIONS: Although several variables differed significantly between the group that had septic arthritis and the group that had transient synovitis, substantial overlap in the intermediate ranges made differentiation difficult on the basis of individual variables alone. However, by combining variables, we were able to construct a set of independent multivariate predictors that, together, had excellent diagnostic performance in differentiating between septic arthritis and transient synovitis of the hip in children.

Osteogenesis imperfecta.

Osteogenesis imperfecta (OI) is a genetically determined disorder of connective tissue characterized by bone fragility. The disease state encompasses a phenotypically and genotypically heterogeneous group of inherited disorders that result from mutations in the genes that code for type I collagen. The disorder is manifest in tissues in which the principal matrix protein is type I collagen (mainly bone, dentin, sclerae, and ligaments). Musculoskeletal manifestations are variable in severity along a continuum ranging from perinatal lethal forms with crumpled bones to moderate forms with deformity and propensity to fracture to clinically silent forms with subtle osteopenia and no deformity. The differential diagnosis includes other entities with multiple fractures, deformities, and osteopenia. Classification is based on the timing of fractures or on multiple clinical, genetic, and radiologic features. Molecular genetic studies have identified more than 150 mutations of the COL1A1 and COL1A2 genes, which encode for type I procollagen. Various systemic treatments have been attempted; however, these interventions have been ineffective or inconclusive or are still experimental. Gene therapy has the potential to increase the synthesis of type I collagen in mild variants and to correct mutations in severe variants, but there are a great number of technical difficulties to overcome. The goals of treatment of OI are to maximize function, minimize deformity and disability, maintain comfort, achieve relative independence in activities of daily living, and enhance social integration. Attainment of these goals requires a team approach to tailor treatment needs to the severity of the disease and the age of the patient. Nonoperative management is the mainstay of orthopaedic treatment, with the goals of preventing and treating fractures and enhancing locomotion. Operative intervention is indicated for recurrent fractures or deformity that impairs function.

Shoulder injuries from alpine skiing and snowboarding. Aetiology, treatment and prevention.

There has been a decrease in the overall injury rate and the rate of lower extremity injuries for alpine skiing, with a resultant increase in the ratio of upper extremity to lower extremity injuries. Upper extremity injuries account for 20 to 35% of all injuries during alpine skiing and nearly 50% of all injuries during snowboarding. The most common upper extremity injuries during skiing are sprain of the thumb metacarpal-phalangeal joint ulnar collateral ligament, and the most common in snowboarding is wrist fracture. Shoulder injuries from skiing and snowboarding have been less well characterised. With the increased ratio of upper to lower extremity injuries during alpine skiing and the boom in popularity of snowboarding, shoulder injuries will be seen with increasing frequency by those who care for alpine sport injuries. Shoulder injuries account for 4 to 11% of all alpine skiing injuries and 22 to 41% of upper extremity injuries. The rate of shoulder injuries during alpine skiing is 0.2 to 0.5 injuries per thousand skier-days. During snowboarding, shoulder injuries account for 8 to 16% of all injuries and 20 to 34% of upper extremity injuries. Falls are the most common mechanism of shoulder injury, in addition to pole planting during skiing and aerial manoeuvres during snowboarding. Common shoulder injuries during skiing and snowboarding are glenohumeral instability, rotator cuff strains, acromioclavicular separations and clavicle fractures. Less common shoulder injuries include greater tuberosity fractures, trapezius strains, proximal humerus fractures, biceps strains, glenoid fractures, scapula fractures, humeral head fractures, sterno-clavicular separations, acromion fractures and biceps tendon dislocation. Prevention of shoulder injuries during skiing and snowboarding may be possible through interventions in education and technique, conditioning and equipment and environment.

Reconstruction of the distal aspect of the radius with use of an osteoarticular allograft after excision of a skeletal tumor.

Twenty-four patients had reconstruction of the distal aspect of the radius with use of an osteoarticular allograft, between 1974 and 1992, after excision of a giant-cell tumor (twenty patients), a desmoplastic fibroma (two patients), a chondrosarcoma (one patient), or an angiosarcoma (one patient). Nine giant-cell tumors were recurrent lesions, and eleven were extracompartmental primary lesions that had extended through the cortex or subchondral bone. The average age of the patients was 31.5 years (range, fifteen to sixty-one years); thirteen patients were female and eleven were male. Seventeen lesions involved the right wrist and seven involved the left wrist. The reconstruction was performed through a dorsoradial incision with use of a size-matched, preserved, fresh-frozen, distal radial allograft. All procedures included internal fixation and reconstruction of the radiocarpal ligaments. All patients were followed for a minimum of two years (average, 10.9 years; range, 2.1 to 22.3 years). At the time of follow-up, two patients -- one who had a giant-cell tumor and one who had a desmoplastic fibroma -- had a local recurrence. Eight patients needed a revision of the osteoarticular allograft, at an average of 8.1 years (range, 0.8 to 17.8 years) after the initial reconstruction. Seven of these patients had an arthrodesis and one had an amputation. The reason for the revision was a fracture of the allograft in four patients, recurrence of the tumor in one, pain in two, and volar dislocation of the carpus in one. There were fourteen other complications, including ulnocarpal impaction necessitating excision of the distal aspect of the ulna (four), painful hardware necessitating removal (four), rupture of the extensor pollicis longus tendon necessitating transfer of the extensor indicis proprius (two), fracture of the allograft necessitating open reduction and internal fixation (two), volar dislocation of the carpus necessitating closed reduction (one), and a ganglion of the dorsal aspect of the wrist necessitating excision (one). Of the sixteen patients in whom the osteoarticular allograft survived, three did not have pain, nine had pain in association with strenuous activities, and four had pain in association with moderate activities. Three patients reported no functional limitation, nine had limitation in the ability to perform strenuous activities, and four had limitation in the ability to perform moderate activities. The average range of motion of the wrist was 36 degrees of dorsiflexion, 21 degrees of volar flexion, 16 degrees of radial deviation, 15 degrees of ulnar deviation, 58 degrees of supination, and 72 degrees of pronation. Reconstruction of the distal aspect of the radius with use of an osteoarticular allograft was associated with a low rate of recurrence of the tumor, a moderately high rate of revision, little pain in association with common activities, good function, and a moderate range of motion. Osteoarticular allografts are an option for reconstruction of the distal aspect of the radius after excision of a malignant tumor or a recurrent or locally invasive benign lesion.