Popliteal Artery Occlusion with Collateral Blood Flow in a Reducible Knee Dislocation During Pregnancy: A Case Report.

CASE: A 29-year-old healthy woman, 19 weeks pregnant, sustained a right posterolateral knee dislocation with multiligamentous injury and a complete occlusive injury to the right popliteal artery yet had adequate distal perfusion. She declined operative management for both the knee dislocation and the arterial injury, and successful collaboration between obstetrical, vascular, and orthopaedic surgical services resulted in limb preservation and restoration of function. CONCLUSION: This is a unique case of traumatic complete popliteal artery occlusion with adequate collateral arterial perfusion after a reducible posterolateral knee dislocation in a pregnant patient that resulted in limb preservation with nonoperative management.

Persistent Streptococcus pyogenes infection of the forearm following blunt trauma.

Necrotizing soft tissue infections are aggressive manifestations of Streptococcus pyogenes, often described after minor skin trauma. However, a subset of infections may present without cutaneous findings. We report a case of toxic shock syndrome and recalcitrant streptococcal infection of the forearm in a healthy teenager following blunt trauma.

Outcomes of Surgically Treated Chronic Exertional Compartment Syndrome in Runners.

BACKGROUND: Chronic exertional compartment syndrome (CECS) is primarily seen in running athletes. Previous outcomes of surgical treatment with fasciotomy have suggested moderate pain relief, but evidence is lacking regarding postoperative return to running. HYPOTHESIS: Running athletes with limiting symptoms of CECS will show high rates of return to running after fasciotomy. STUDY DESIGN: Case series. LEVEL OF EVIDENCE: Level 4. METHODS: Running athletes treated with fasciotomy for CECS at a single institution were identified using a surgical database and asked to complete a questionnaire designed to assess postoperative pain, activity level, return to running, running distances, overall satisfaction, and rate of revision fasciotomy. RESULTS: A total of 43 runners met the inclusion criteria, and 32 runners completed outcomes questionnaires at a mean postoperative follow-up of 66 months. In total, 27 of these 32 patients (84%) returned to sport(s) after fasciotomy. However, 9 (28%) of these patients pursued nonrunning sports, 5 (16%) due to recurrent pain with running. Of the 18 patients who returned to running sports (56%), the mean weekly running distance decreased postoperatively. Recurrence of symptoms was reported in 6 patients (19%), 4 of whom had returned to running and 2 of whom had been unable to return to sports. All of these 6 patients elected to undergo revision fasciotomy surgery. Twenty-five (78.1%) patients reported being satisfied with their procedure. In the overall cohort, the mean visual analog scale scores for pain during activities/sports decreased from 7.9 preoperatively to 1.7 postoperatively. CONCLUSION: Fasciotomy for CECS in runners may provide significant improvement in pain and satisfaction in over three-quarters of patients and return to sports in 84% of patients. However, only 56% returned to competitive running activity, with a subset (19%) developing recurrent symptoms resulting in revision surgery. CLINICAL RELEVANCE: Fasciotomy has been shown to decrease pain in most patients with CECS. This study provides outcomes in running athletes after fasciotomy for CECS with regard to return to sports, maintenance of sports performance, and rates of revision surgery.

Applying to Orthopaedic Residency and Matching Rates: Analysis and Review of the Past 25 Years.

BACKGROUND: The competitiveness of orthopaedics and recent changes in the residency application process have resulted in increased costs to both applicants and programs. Our purpose was to investigate changes in the orthopaedic residency application process between 1992 and 2017. Also, we aimed to determine an ideal number of applications that each student can submit without jeopardizing his or her probability of matching into an orthopaedic residency slot while concurrently reducing the excessive number of applications that are received by program selection committees. METHODS: Retrospective data from both the Electronic Residency Application Service (ERAS) and the National Resident Matching Program (NRMP) were collected and analyzed for changes in the characteristics of applications, applicants, and programs over the study period. Using these data, the probability of matching into orthopaedics through the years was calculated and compared in order to propose an ideal number of applications for a medical student to submit to match into an orthopaedic residency. RESULTS: Over the study period of 25 years, there has been an increase in the number of residency positions offered and a decrease in the number of applicants per offered position among U.S. senior medical students. Nonetheless, the average number of submitted applications per applicant significantly increased from 1992 to 2017, from 28 to 80 applications (p < 0.001). As a result, the overall costs to apply and review applications also have increased. There was no association between the increased number of submitted applications and the match rate. Our analysis showed that 50 applications per student offer is the most effective option without compromising the overall applicant match rate. CONCLUSIONS: Based on these data, we suggest encouraging students to limit the number of applications that they submit. This limit could reduce the cost for both applicants and programs while likely maintaining the current match rate and competitiveness of the specialty.

Reconstruction of Symptomatic Congenital Anterior Cruciate Ligament Insufficiency.

BACKGROUND: Hypoplasia or congenital absence of the anterior cruciate ligament (ACL) is a rare disorder occurring in ∼1 in every 6000 births. Although some patients with hypoplasia or agenesis of the ACL may not complain of instability, others desire to participate in more demanding activities that require the stability of a competent ACL. There are limited reports of surgical treatment of this patient population. The purpose of this study was to report ACL reconstruction in a case series of patients with symptomatic congenital ACL deficiency. METHODS: A retrospective medical record review of the surgical treatment of 14 knees (13 patients) with congenital absence of the ACL at a tertiary care institution from 1995 to 2012 was performed. Patients with a minimum of 1 year of clinical follow-up were eligible for inclusion. RESULTS: The mean age at time of surgery was 12.6 (range, 3 to 22), including 6 patients <12 years of age. Mean follow-up was 2.9 years (range, 1 to 6.6). Nine of 13 patients (69%) had underlying congenital abnormalities/associated syndromes. Preoperative Lachman and pivot shift examination was International Knee Documentation Committee grade C or D in all but 1 knee. ACL reconstruction was performed with combined intra-articular/extra-articular physeal sparing reconstruction with iliotibial band (n=5), autograft hamstring (n=2) or bone-patellar tendon-bone (n=3), or allograft (n=4). Multiligament reconstruction of associated ligamentous deficiency was performed in 7 knees (50%). Postoperative Lachman and pivot shift testing was International Knee Documentation Committee (IKDC) grade A or B in all but 1 knee. One patient with congenital absence of multiple knee ligaments required revision ACL reconstruction surgery, with concurrent first-time posterior cruciate ligament reconstruction, due to persistent instability. None required revision surgery due to graft tear at a minimum of 1-year follow-up. CONCLUSIONS: Surgical stabilization of symptomatic congenital ACL insufficiency, with associated ligamentous reconstruction as required on a case-by-case basis, results in improved stability at early clinical follow-up, with low complication rates. LEVEL OF EVIDENCE: Level IV-retrospective case series.

Catcher's Knee: Posterior Femoral Condyle Juvenile Osteochondritis Dissecans in Children and Adolescents.

BACKGROUND: Juvenile osteochondritis dissecans is an idiopathic condition involving subchondral bone and articular cartilage in skeletally immature patients in whom the growth plates are open, potentially leading to lesion instability. Because of the differing forces experienced by baseball/softball catchers versus position players, the age at which lesions develop and the characteristics of the lesions themselves may differ between these 2 populations. The purpose of the study was to examine relative age and characteristics of osteochondritis dissecans (OCD) knee lesions in catchers compared with position players. METHODS: Using a text-based search tool that queries clinic notes and operative reports, computerized medical records from 1990 to 2014 from the Sports Medicine Program of a tertiary care Children's Hospital were searched to find children and adolescents who had OCD of the knee, played baseball/softball, had a specified field position, and had magnetic resonance imaging of the knee. Ultimately, 98 knees (78 patients) were identified: 33 knees (29 patients) in catchers and 65 knees (49 patients) in noncatchers. Data collected included position played (catcher/noncatcher), demographics (age, unilateral/bilateral, and sex), lesion severity, and sagittal and coronal lesion location. RESULTS: When compared with noncatchers, catchers presented at a younger age (P=0.035) but were similar with respect to bilateral involvement (P=0.115), sex (P=0.457), and lesion severity (P=0.484). Lesions in catchers were more posterior on the femoral condyle in the sagittal plane (P=0.004) but similar in location in the coronal plane (P=0.210). CONCLUSIONS: Catchers developed OCD at a younger age and in a more posterior location on the medial and lateral femoral condyles than noncatchers. These results may represent the effects of repetitive and persistent loading of the knees in the hyperflexed position required of catchers. Increased awareness of this risk may lead to surveillance and prevention programs. LEVEL OF EVIDENCE: Level III-case-control study.

Dynamic Splinting in Children and Adolescents With Stiffness After Knee Surgery.

PURPOSE: The purpose of this study was to investigate the indications and outcomes of dynamic splinting (DS) of the arthrofibrotic knee in the pediatric population. METHODS: Seventy-four patients (41 males, 33 females) with postoperative arthrofibrosis treated with DS after an index knee surgery were reviewed. Median age was 13 years (range, 4 to 18 y), and median follow-up was 17 months (interquartile range, 10 to 28 mo). Demographics, index surgery procedure, preoperative and postoperative knee range of motion (ROM) measurements, treatment length and subsequent need for manipulation under anesthesia (MUA), and surgical lysis of adhesions (LOA) were evaluated. A ROM deficit was defined as lack of extension ≥10 degrees or lack of flexion <130 degrees. Successful improvement of ROM was defined as an increase of ≥10 degrees in flexion, extension, or both. There were 23 patients with flexion deficit only, 17 with extension deficit only, and 34 with combined flexion and extension deficits. Wilcoxon signed-rank test was used to assess median improvement in ROM. Patients were classified into 4 surgical groups: anterior cruciate ligament (ACL) reconstruction without meniscal repair (n=19), ACL reconstruction with meniscal repair (n=12), tibial spine fracture repair (n=21), and other (n=22). Multivariable logistic regression was used to identify independent predictors of failure of DS requiring MUA and LOA. RESULTS: A total of 57 patients with flexion deficits showed median improvement of 30 degrees in flexion (95% confidence interval, 0-90 degrees; P<0.001), and 51 patients with extension deficits showed median improvement of 7 degrees in extension (95% confidence interval, 0-60 degrees; P<0.001). DS was associated with ROM improvement in 84% and avoided the need for surgery in 58% of all 74 patients included in the study. Multivariate analysis of the ACL with meniscus repair subgroup revealed that each 1-month delay in DS treatment was associated with a 5-fold increased risk of undergoing a LOA (P=0.007). Thirty-six (63%) patients with flexion deficit avoided need for surgery, whereas 26 (51%) patients with extension deficits avoided surgery. CONCLUSIONS: Our data suggest that DS is an effective method to increase knee ROM and reduce the need for subsequent MUA/LOA in the pediatric and adolescent patient with arthrofibrosis after an index knee surgery. LEVEL OF EVIDENCE: Level IV-retrospective case series.

An Evaluation of Seasonal Variation of Nonaccidental Fractures in Children Less Than 1 Year of Age.

The aim of this study was to identify seasonal variation in nonaccidental injury (NAI) in children <1 year of age. Fifty consecutive patients age ≤12 months with a fracture were identified between January 2010 and June 2012. Patients' records were reviewed for demographic, clinical, and radiographic data. Zip code was used to collect socioeconomic data. Out of 50 patients included in the study, fractures in 16 (32%) patients were reported for abuse. NAI was reported in 2/13 (15%) fracture cases presenting in the spring, 5/6 (83%) in summer, 6/15 (40%) in autumn, and 3/14 (21%) in winter. The ratio of NAI to accidental injury was highest in the summer. Presentation in summer was associated with NAI ( P < .001). In addition, NAI was associated with parental unemployment, single parents, and lower socioeconomic status ( P < .001). Seasonal variation occurred, and the most common season for NAI was the summer; also, NAI in children <1 year of age was associated with parental unemployment, single parent, and poverty.

Efficacy of the Modified Broström Procedure for Adolescent Patients With Chronic Lateral Ankle Instability.

BACKGROUND AND PURPOSE: Lateral ankle sprains are very common, representing up to 30% of sports-related injuries. The anterior talofibular ligament (ATFL) and less commonly the calcaneofibular ligament (CFL) are injured. Surgical treatment is reserved for injuries that fail nonoperative treatment with recurrent instability. Anatomic repair using the modified Broström technique has been shown to have good clinical outcomes in the adult population. The purpose of this study was to report on the outcomes of the modified Broström technique in the pediatric and adolescent population (under 18 y old) for chronic lateral ankle instability. METHODS: Thirty-one patients over an 8-year period were included in the current study after excluding for congenital malformation or underlying connective tissue disease. All patients were treated with a modified Broström technique in which the ATFL was repaired anatomically. Twenty-four patients (77%) underwent concomitant arthroscopy for intra-articular pathology. Demographic, surgical, and clinical data were collected and outcome scores were obtained, including the Marx activity scale, University of California, Los Angeles (UCLA) activity score, and modified American Orthopedic Foot and Ankle Society (AOFAS) score. RESULTS: Mean time from initial injury to surgery averaged 27 months with an overall mean clinical postoperative follow-up of 36 months. Of the 24 patients who underwent concomitant arthroscopy, all had thickening of Bassett ligament and 3 (12.5%) had cartilage lesions. Postoperatively, the mean Marx activity score was 9.9±4.7, mean UCLA score was 9.3±1.3, and mean modified AOFAS score was 83.8±11.7. 71% (22 of 31) of patients achieved good-to-excellent results (as defined by a modified AOFAS score of 80 or greater). Two patients had superficial wound infections; no other complications were experienced in this cohort. CONCLUSIONS: Lateral ankle sprains are common injuries that can frequently be treated nonoperatively; chronic instability may result despite appropriate therapy. Surgical treatment with anatomic repair of the ATFL and CFL using the modified Broström technique in pediatric and adolescent patients results in improved stability, low complication rate, and good clinical outcome scores. LEVEL OF EVIDENCE: Level IV-prognostic retrospective case series.

The Pediatric International Knee Documentation Committee (Pedi-IKDC) Subjective Knee Evaluation Form: Normative Data.

BACKGROUND: Children are participating in sports at an increasingly younger age, which has contributed to an increased incidence of knee injuries among this population. Because of increased interest in the application of patient-reported outcome measures in orthopaedic surgery to evaluate treatment results, numerous knee outcome scores, including the International Knee Documentation Committee Subjective Form (IKDC), have been used to evaluate the knee. Although the IKDC has been validated only in adults, it is also being used for children because of a lack of appropriate outcome scores in the pediatric population. To address this concern, a pediatric version of the IKDC (Pedi-IKDC) was developed and evaluated for reliability, validity, and responsiveness. However, normative data for the Pedi-IKDC have not been established. PURPOSE: We aimed to aid the interpretation of Pedi-IKDC scores by characterizing normative data in children and adolescents and to validate the Pedi-IKDC by examining differences in scores among children who had a history of knee surgery or limited activity compared with those who did not. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: We conducted a cross-sectional survey of 2000 children and adolescents aged 10 to 18 years living in the United States, who were recruited by ORC International to obtain equal numbers of participants by sex and by integer age group. Participants were asked to complete the Pedi-IKDC for 1 study-designated "index" knee (right or left) and to provide demographic data and information on their knee surgery history and recent (4-week) activity limitations. Raw Pedi-IKDC total scores were rescaled to a 0 to 100 scale. We used nonparametric Wilcoxon or Kruskal-Wallis tests to compare subgroup scores, and we used the van Elteren test to adjust for age. Unadjusted and adjusted P values were similar, and only unadjusted values are reported. RESULTS: The number of respondents (N = 2000) was uniform with respect to age and sex, with 11% in each age represented (10-18 years). Fifty percent of respondents were female. Forty-nine states plus Washington, DC, were represented. In addition, 68% and 86% of respondents identified themselves as white and non-Hispanic, respectively. Seven percent of respondents (n = 136) respondents reported having prior surgery in 1 or both knees; 4% of these surgeries (n = 79) were in the index knee. The Pedi-IKDC score distribution was skewed left (mean ± SD score, 86.7 ± 16.8; median, 94.6) and 34% of scores reached the ceiling value of 100. Participants who reported prior surgery or limited activity in the index knee had median Pedi-IKDC scores that were approximately 25 points lower than participants without these histories ( P < .0001 for both comparisons). In contrast, although it was statistically significant, the variation by age ( P = .02), race ( P = .02), ethnicity ( P = .01), and level of sports/exercise participation ( P = .04) was much smaller (all ranges of median scores <4.5). There were no significant differences in scores in terms of respondent sex or geographic region. CONCLUSION: Normative Pedi-IKDC scores were determined in this study. The strong association between Pedi-IKDC scores and prior knee surgery as well as recent activity limitations in the index knee can be used to evaluate clinical outcomes and supports the construct validity of the Pedi-IKDC. There was a large ceiling effect, with 34% of scores at the maximum value of 100. The lack of a sex-based effect and the minor variation with age both simplify the interpretation and use of the Pedi-IKDC. Therefore, Pedi-IKDC score distributions can provide assumptions for use in sample size or power calculations for research.

Treatment of Snapping Scapula Syndrome in Children and Adolescents.

PURPOSE: The purpose of this study was to review 2 separate cohorts of young patients treated for snapping scapula: those treated surgically and those managed nonoperatively. METHODS: A retrospective IRB-approved review was conducted on 18 pediatric aged patients (19 shoulders): 12 patients (average age 13.3) were treated nonoperatively, 6 patients (average age 15.4) (7 shoulders) were treated operatively. Demographic and clinical data were collected from medical records and 2 questionnaires for level of activity, return to sport, subjective satisfaction from treatment, and preoperative/postoperative levels of pain. The American Shoulder and Elbow Society (ASES) score was measured for both groups. RESULTS: Mean follow-up for nonoperative patients was 43.7 months (range, 20 to 116 mo). Pretreatment subjective pain levels were 5.2 (scale 1 to 10), posttreatment were 1.5. There was a 75% return to play rate, and an overall 75% satisfaction rate. Posttreatment ASES scores were 90.0. Mean follow-up for surgical patients was 129.5 months (range, 68 to 177 mo). Pretreatment subjective pain level was 8.6, posttreatment was 0.75. There was an 83% return to play rate, and an overall 100% satisfaction rate. There were no complications. Posttreatment ASES scores were 92.6. CONCLUSIONS: Outcomes for nonoperative treatment of snapping scapula are good for young patients. Surgical management of snapping scapula is a safe and viable treatment option for patients who fail nonoperative treatment. LEVEL OF EVIDENCE: Level IV.

The relationship between cam lesion and physis in skeletally immature patients.

BACKGROUND: Although it has been postulated that injury to the proximal femoral physis results in the formation of a cam lesion, a clear causal association has not been established. PURPOSE: The purpose of this study was to investigate the relationship between the physis and the cam lesion. Our hypotheses were that (1) the location of the cam lesion would coincide with the growth plate and (2) the distance between the cam lesion and the physis would vary as a function of skeletal maturity. METHODS: A retrospective review of the charts and magnetic resonance images of adolescent patients with femoroacetabular impingement (FAI) was performed. Data collected included the alpha angle, the distance between the cam lesion and physis, and physeal status. Linear mixed models were used to describe the association between the distance to the cam lesion and physeal status. RESULTS: Twenty-four hips in 17 patients were included. The average alpha angles were 50.7, 63.2, 64.4, and 63.9 degrees for the anterior, anterosuperior, superoanterior, and superior radial magnetic resonance imaging sections. The average distance from the cam lesion to the physis was 0.07 cm. There was a significant association between physeal status and the distance of the cam lesion to the physis. CONCLUSIONS: The location of the cam lesion occurs at the level of the physis. In skeletally mature adolescents, the cam lesion is located further from the physis than it is in patients whose growth plates remain widely open. This suggests a possible causal relationship between physeal injury and the development of the cam deformity in patients with femoroacetabular impingement. LEVEL OF EVIDENCE: Level IV-retrospective case series.

Posterior sternoclavicular joint injuries in skeletally immature patients.

BACKGROUND: Posterior injuries to the sternoclavicular (SC) joint are uncommon. In the skeletally immature (SI) population, these injuries have been described as either dislocations of the SC joint or fractures of the medial clavicular physis. The current literature and standardized test questions state that a posterior SC injury, in a SI patient, is more likely a physeal fracture than a SC joint dislocation. However, this injury characterization is based on case reports or small case series. The purpose of this study is to characterize posterior SC injuries in SI patients in terms of the prevalence of dislocation versus medial clavicle physeal fracture. METHODS: A retrospective review was performed of 48 SI patients treated for posterior SC joint injuries over a 20-year period with a mean age of 15.4 years (range, 13 to 18 y). Forty patients underwent open reduction and internal fixation as their definitive treatment and 8 patients were treated exclusively with closed reduction. Patients treated operatively were utilized in determining the prevalence of SC joint dislocation versus physeal fracture. RESULTS: All patients treated operatively underwent primary repair without reconstruction. Twenty (50%), of the 40 patients treated operatively had a true SC joint dislocation and 20 patients (50%) had a medial clavicle physeal fracture. Twenty-two (46%) of the 48 total patients had an attempted closed reduction of which only 8 (36%) were successful. Among the 14 unsuccessful closed reductions, 12 (86%) were true dislocations (P<0.001). All successful closed reductions occurred in patients within 24 hours from injury. Eleven of the 48 (23%) patients' injuries were missed on initial presentation. CONCLUSIONS: Posterior SC joint dislocation and medial clavicular physeal fracture both occur with roughly equivalent prevalence in patients with an open medial physis. An attempted closed reduction may be more successful if performed within 24 hours after injury. Patients who fail attempts at closed reduction are more likely to have a posterior SC joint dislocation than a physeal fracture. Posterior SC joint injury may be missed in nearly 25% of patients on initial presentation. LEVEL OF EVIDENCE: Level IV-retrospective case series.

Operatively treated type IV tibial tubercle apophyseal fractures.

BACKGROUND: Displaced tibial tubercle apophyseal fractures in children and adolescents are typically treated with closed reduction or open reduction with anterior to posterior screw fixation. Since the original classification by Watson-Jones and Ogden, an important variant with a posterior metaphyseal fracture line (type IV) was later described. However, there has been a lack of information regarding type IV tibial tubercle apophyseal fractures and its implications for surgical fixation. METHODS: Twenty-four type IV tibial tubercle fractures in 23 children and adolescents were reviewed. Operative reports and clinic records were used to identify the patient demographics, fracture type, and clinical results. Available imaging was also used to characterize these fractures. Minimum follow-up was 2 years. RESULTS: Type IV fractures accounted for 18.5% (24/130) of all tibial tubercle apophyseal fractures. Three type IV fractures were identified that had an additional epiphyseal split. These were categorized as type IV-B, whereas the rest were considered type IV-A. There were 19 males and 4 females (average age, 14.8 y; range, 11.8 to 16 y). The most common mechanism was an eccentric quadriceps contraction during basketball. Three patients were initially treated with closed reduction and casting and were noted to have loss of reduction. All patients were treated definitively with open reduction and internal fixation or percutaneous screw placement. In addition to AP compression screws, 4 patients required supplemental plate fixation to stabilize the proximal tibia. Major complications included 1 compartment syndrome and 1 large DVT. All fractures healed and there were no growth disturbances. CONCLUSIONS: Type IV tibial tubercle apophyseal fractures are an important variant that requires careful assessment to ensure adequate stabilization of the proximal tibia when surgery is warranted. LEVEL OF EVIDENCE: IV (prognostic case series).

Distal femoral valgus deformity following plate fixation of pediatric femoral shaft fractures.

BACKGROUND: This study investigated the frequency and potential risk factors associated with the development of distal femoral valgus deformity following plate fixation of diaphyseal femoral fractures in children. METHODS: Records of eighty-five skeletally immature patients who underwent plate fixation of a diaphyseal femoral fracture at a tertiary-care pediatric center from January 2003 to December 2010 were reviewed. Demographic data and clinical information were analyzed. Radiographic measurement of the distance from the distal plate edge to the distal femoral physis and of the anatomic lateral distal femoral angle was performed. Development of distal femoral valgus deformity was defined as a change in the anatomic lateral distal femoral angle of ≥5° in the valgus direction. Logistic regression analysis and contingency tables were used to relate the development of distal femoral valgus deformity with retention of hardware, patient age, fracture site, plate-to-physis distance, and the location of a bend in the plate at fixation. RESULTS: Midshaft fractures (45%) were more common than proximal or distal diaphyseal fractures. Intraoperatively, the plate was bent proximally or distally, or both, in 80% of the patients. Distal femoral valgus deformity of ≥5° was seen in ten patients, eight of whom had distal diaphyseal fractures. Three of the ten patients developed symptoms as a result of the distal femoral valgus deformity that required at least one unplanned additional surgical procedure. On the basis of the statistical analysis, patients with a plate-to-physis distance of ≤20 mm (relative risk= 12.77, p = 0.005) and a distal fracture (relative risk = 11.0, p < 0.001) were at a significantly higher risk of developing distal femoral valgus deformity. Although not clearly an independent factor, a distal bend was also found to be associated with distal femoral valgus deformity (p = 0.004) but was not predictive of the pathology. CONCLUSIONS: Distal femoral valgus deformity occurred in 30% of patients with distal diaphyseal fractures and in 12% overall. We advocate long-term monitoring of patients with femoral plate fixation, particularly those in whom the plate is placed ≤20 mm from the distal femoral physis.

A reduction in body mass index lowers risk for bilateral slipped capital femoral epiphysis.

BACKGROUND: Slipped capital femoral epiphysis (SCFE) is occurring in greater numbers, at increasingly younger ages, and more frequently bilaterally (BL-SCFE). Obesity is one risk factor for SCFE. However, it is unclear whether postoperative decreases or increases in body mass index (BMI) alter the risk of subsequent contralateral SCFE. QUESTIONS/PURPOSES: We therefore determined whether (1) BMI percentile was a risk factor for BL-SCFE; and (2) postoperative increases and/or decreases in BMI percentile influenced the risk for BL-SCFE. METHODS: We retrospectively reviewed the records of 502 patients surgically treated for SCFE and identified 138 (27%) with BL-SCFE and 364 (73%) with unilateral SCFE (UL-SCFE); 173 patients, 60 (35%) with BL-SCFE and 113 (65%) with UL-SCFE met our inclusion criteria. Risk factors included sex, age, slip stability, slip chronicity, slip angle, and obesity. Percentile BMI was recorded at the time of first SCFE surgery, at the time of last followup for patients undergoing UL-SCFE, and at the time of second SCFE surgery for patients undergoing BL-SCFE. RESULTS: Sex, age, slip stability, and slip angle were not associated with BL-SCFE. Postoperative obesity (odds ratio [OR], 3.5; 95% confidence interval [CI], 1.2-9.7) and acute slip chronicity (OR, 2.9; 95% CI, 1.3-6.7) had higher risks for sequential BL-SCFE. Obese patients who became nonobese postoperatively had a decreased risk of sequential BL-SCFE compared with those who remained obese (OR, 0.16; 95% CI, 1.2-116.5). CONCLUSIONS: Only postoperative obesity and an acute slip were risk factors for sequential BL-SCFE. BMI reduction to lower than the 95% percentile after SCFE surgery was associated with lower risk for BL-SCFE development. The data suggest early supervised therapeutic weight management programs for patients treated for UL-SCFE are important to reduce risk of subsequent SCFE. LEVEL OF EVIDENCE: Level III, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Correlation between the Child Health Questionnaire and the International Knee Documentation Committee score in pediatric and adolescent patients with an anterior cruciate ligament tear.

BACKGROUND: The modified International Knee Documentation Committee (Pedi-IKDC) Subjective Knee Evaluation Form has recently been shown to be valid, reliable, and responsive in a pediatric and adolescent population. The correlations between the Pedi-IKDC and quality-of-life-related health measures have not been studied in depth to determine how a knee injury affects patients in this age group. The purpose of this study was to examine the association between the Pedi-IKDC score and the Child Health Questionnaire (CHQ) in a group of pediatric patients with an anterior cruciate ligament (ACL) injury. METHODS: A prospectively collected registry of patients with ACL injuries was searched to indentify all patients who had completed both the Pedi-IKDC and CHQ (CHQ-CF87) questionnaires. These were analyzed to determine significant correlations between domains of the CHQ and the Pedi-IKDC. RESULTS: A total of 135 patients were included (80 male, 55 female) with a median age of 15.3 years (range, 13.1 to 17.2 y). The cohort included patients treated both operatively (120) and nonoperatively (15). The total Pedi-IKDC score was found to correlate with the majority of the CHQ including expected domains such as physical function (correlation coefficient = 0.64), bodily pain (0.7), and family activities (0.41), in addition to emotional role (0.45), mental health (0.46), self-esteem (0.45), and social limitations--physical (0.38) (P < 0.001 for all correlations). CONCLUSIONS: Seven of the 12 domains on the CHQ are significantly correlated with the IKDC in adolescent patients with an ACL tear. Self-esteem, mental health, emotional role, and social limitations categories are significantly correlated with knee function suggesting that quality-of-life in this population is affected in domains outside of physical function and pain. A greater understanding of the psychosocial impact of injury may be of utility in these patients. STUDY DESIGN: Level III cross-sectional study.

Complications of plate fixation of femoral shaft fractures in children and adolescents.

PURPOSE: This study aims to critically analyze the major and minor complications that may be associated with plate fixation of pediatric diaphyseal femur fractures. METHODS: The medical records of skeletally immature patients (6-15 years of age) who underwent plate fixation of a diaphyseal femur fracture at a tertiary-care level-1 pediatric trauma center between 1/2003 and 12/2010 were reviewed. Demographic and clinical information regarding the mechanism of injury, fracture type, and surgical technique were recorded. Radiographic evaluation of bony healing, hardware position, and deformity was performed throughout the study period. All intraoperative and postoperative complications were recorded. Complication incidence and time from surgery to complication were described. Multivariate logistic regression and multivariate Cox regression models were used to assess the association between different variables and the occurrence of a complication. Kaplan-Meier survivorship curves were used to evaluate the freedom from a complication with longer follow-up. RESULTS: Over an 8-year period, 85 skeletally immature patients (83 % males, mean age 10.2 years) underwent plate fixation for diaphyseal femur fractures. Overall, complications were identified in 11 patients (13 %). Major complications, defined as those resulting in unplanned reoperation (excluding elective removal of asymptomatic plate/screws), occurred in five patients (6 %) and included two patients (2 %) with wound infections requiring irrigation and debridement, two patients (2 %) with distal femoral valgus deformity (DFVD) leading to osteotomy and hardware removal, respectively, and one patient (1 %) with a 3-cm leg length discrepancy (LLD) requiring epiphysiodesis. Minor complications, defined as those not requiring unplanned operative intervention, occurred in six patients (7 %) and included two patients (2 %) with delayed union, two patients (2 %) with symptomatic screw prominence, one patient (1 %) with a superficial wound infection effectively treated with oral antibiotics, and one patient (1 %) with valgus malunion, which was asymptomatic at early follow-up. There were no intraoperative complications and no reports of postoperative knee stiffness, shortening, or reoperations to address fracture stability. Fifty-two patients (61 %) underwent routine elective removal of hardware without related complications following fracture union. Overall, complications occurred postoperatively at a mean time of 20 months (range 0-65 months), though major complications occurred at a later time point (mean 29.1 months, range 0-65 months) than minor complications (mean 12.5 months, range 0-40.1 months). Longer follow-up was associated with higher occurrence of a complication [p = 0.0012, odds ratio = 1.05, 95 % confidence interval (CI): 1.02-1.08]. CONCLUSIONS: The plating of pediatric femur fractures is associated with 6 and 7 % rates of major and minor complications, respectively. There were minimal long-term sequelae associated with the complications noted. This complication rate compares favorably with the published rate of complications (10-62 %) associated with titanium elastic nail fixation of similar fracture types. Most complications occurred >4 months postoperatively, with major complications occurring at a later time point than minor complications. Long-term follow-up of these patients is recommended to ensure that complications do not go undetected. LEVEL OF EVIDENCE: Retrospective case series, Level IV.

Intra-abdominal fluid extravasation during hip arthroscopy: a survey of the MAHORN group.

PURPOSE: The purpose of this study was to survey experts in the field of hip arthroscopy from the Multicenter Arthroscopy of the Hip Outcomes Research Network (MAHORN) group to determine the frequency of symptomatic intra-abdominal fluid extravasation (IAFE) after arthroscopic hip procedures, identify potential risk factors, and develop preventative measures and treatment strategies in the event of symptomatic IAFE. METHODS: A survey was sent to all members of the MAHORN group. Surveys collected data on general hip arthroscopy settings, including pump pressure and frequency of different hip arthroscopies performed, as well as details on cases of symptomatic IAFE. Responses to the survey were documented and analyzed. RESULTS: Fifteen hip arthroscopists from the MAHORN group were surveyed. A total of 25,648 hip arthroscopies between 1984 and 2010 were reviewed. Arthroscopic procedures included capsulotomies, labral reattachment after acetabuloplasty, peripheral compartment arthroscopy, and osteoplasty of the femoral head-neck junction. Of the arthroscopists, 7 (47%) had 1 or more cases of IAFE (40 cases reported). The prevalence of IAFE in this study was 0.16% (40 of 25,650). Significant risk factors associated with IAFE were higher arthroscopic fluid pump pressure (P = .004) and concomitant iliopsoas tenotomy (P < .001). In all 40 cases, the condition was successfully treated without long-term sequelae. Treatment options included observation, intravenous furosemide, and Foley catheter placement, as well as 1 case of laparotomy. CONCLUSIONS: Symptomatic IAFE after hip arthroscopy is a rare occurrence, with an approximate prevalence of 0.16%. Prevention of IAFE should include close intraoperative and postoperative monitoring of abdominal distention, core body temperature, and hemodynamic stability. Concomitant iliopsoas tenotomy and high pump pressures may be risk factors leading to symptomatic IAFE. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Treatment of posterior cruciate ligament injuries in pediatric and adolescent patients.

BACKGROUND: There is sparse literature regarding the outcomes of treatment for posterior cruciate ligament (PCL) injuries in pediatric and adolescent patients. PCL injuries are rare and are often treated conservatively. The purpose of this study was to review 2 separate cohorts of patients with pediatric and adolescent PCL injuries: those treated surgically with direct repair or ligament reconstruction and those managed nonoperatively. METHODS: Twenty-five patients 18 years or younger underwent treatment of 26 PCL injuries (1 bilateral) at a single institution between 1993 and 2009. Fourteen patients (15 knees) underwent operative treatment, while 11 patients were treated nonoperatively. Demographic and clinical features of each group were reviewed, and validated functional outcome measures [Pediatric International Knee Documentation Committee (Pedi-IKDC), Lysholm, and Tegner scores] were analyzed. RESULTS: Eleven patients (6 females; mean age, 14.4 y) who sustained PCL injuries were treated nonoperatively, At a mean clinical follow-up of 26.7 months, none of the patients who underwent nonoperative treatment had symptomatic instability, with a 100% return-to-play rate. The mean Pedi-IKDC, Lysholm, and Tegner scores were 87.4, 89.0, and 7.5, respectively. In the 15 knees of 14 patients who underwent surgery (4 female; mean age, 15.1 y) mean clinical follow-up was 27.8 months. All of the patients achieved full or near-full range of motion, and none of the patients showed growth arrest or angular deformity. However, 1 patient showed mild joint-space narrowing, and the mean Pedi-IKDC, Lysholm, and Tegner scores were 81.3, 80.1, and 7.2, respectively. Patients who had sustained knee dislocations had lower Pedi-IKDC scores than those who had not dislocated, 70.2 versus 85 (P=0.047). CONCLUSIONS: Outcomes for nonoperative treatment of partial PCL tears or nondisplaced avulsion injuries are good in young patients. PCL repair or reconstruction is a safe and viable treatment option in pediatric and adolescent patients with multiligament injuries or those with isolated PCL injury who have failed conservative treatment, with outcomes related to the severity of the initial injury. LEVEL OF EVIDENCE: Level IV, retrospective case series.