Early MRI-based quantitative outcomes are associated with a positive functional performance trajectory from 6 to 24 months post-ACL surgery.

PURPOSE: Quantitative magnetic resonance imaging (qMRI) has been used to determine the failure properties of ACL grafts and native ACL repairs and/or restorations. How these properties relate to future clinical, functional, and patient-reported outcomes remain unknown. The study objective was to investigate the relationship between non-contemporaneous qMRI measures and traditional outcome measures following Bridge-Enhanced ACL Restoration (BEAR). It was hypothesized that qMRI parameters at 6 months would be associated with clinical, functional, and/or patient-reported outcomes at 6 months, 24 months, and changes from 6 to 24 months post-surgery. METHODS: Data of BEAR patients (n = 65) from a randomized control trial of BEAR versus ACL reconstruction (BEAR II Trial; NCT02664545) were utilized retrospectively for the present analysis. Images were acquired using the Constructive Interference in Steady State (CISS) sequence at 6 months post-surgery. Single-leg hop test ratios, arthrometric knee laxity values, and International Knee Documentation Committee (IKDC) subjective scores were determined at 6 and 24 months post-surgery. The associations between traditional outcomes and MRI measures of normalized signal intensity, mean cross-sectional area (CSA), volume, and estimated failure load of the healing ACL were evaluated based on bivariate correlations and multivariable regression analyses, which considered the potential effects of age, sex, and body mass index. RESULTS: CSA (r = 0.44, p = 0.01), volume (r = 0.44, p = 0.01), and estimated failure load (r = 0.48, p = 0.01) at 6 months were predictive of the change in single-leg hop ratio from 6 to 24 months in bivariate analysis. CSA (ßstandardized = 0.42, p = 0.01), volume (ßstandardized = 0.42, p = 0.01), and estimated failure load (ßstandardized = 0.48, p = 0.01) remained significant predictors when considering the demographic variables. No significant associations were observed between MRI variables and either knee laxity or IKDC when adjusting for demographic variables. Signal intensity was also not significant at any timepoint. CONCLUSION: The qMRI-based measures of CSA, volume, and estimated failure load were predictive of a positive functional outcome trajectory from 6 to 24 months post-surgery. These variables measured using qMRI at 6 months post-surgery could serve as prospective markers of the functional outcome trajectory from 6 to 24 months post-surgery, aiding in rehabilitation programming and return-to-sport decisions to improve surgical outcomes and reduce the risk of reinjury. LEVEL OF EVIDENCE: Level II.

Magnetic resonance imaging of medial collateral ligament avulsion fractures of the knee in children: a potentially underestimated injury.

BACKGROUND: Literature regarding medial collateral ligament (MCL) injuries is focused on adults with superficial MCL disruptions. However, children follow different injury patterns, with avulsion fractures at ligament attachment sites occurring commonly. Such avulsions have not been characterized for pediatric MCL injuries. OBJECTIVE: To elucidate imaging findings, and review management and outcomes of pediatric MCL avulsion fractures. MATERIALS AND METHODS: We conducted a 10-year retrospective review of knee magnetic resonance (MR) imaging reports for patients younger than 16 years old diagnosed with acute MCL avulsion fracture. MR imaging was reviewed to confirm and characterize the components of the avulsion (perichondrium without or with cartilage, and/or bone) and to identify additional knee injuries. Radiographs, if available, from the time of injury were reviewed. Clinical management and patient outcomes were recorded. RESULTS: Eighteen patients (13 boys, 5 girls) incurred an acute MCL avulsion fracture. All avulsions involved the deep MCL attachment: 17 meniscofemoral and 1 meniscotibial component. Two avulsions also included the superficial MCL attachment. Nine boys had non-osseous avulsions, all radiographically occult. All girls had radiographically apparent avulsions. Three girls and three boys sustained associated knee derangements, most commonly anterior cruciate ligament (ACL) injury (n=4). All MCL avulsions were initially treated conservatively; one child required subsequent surgery for ongoing pain. CONCLUSION: Pediatric MCL avulsion fractures in this study uniformly involve the attachment of the deep MCL and can be entirely non-osseous, particularly in boys who lag in skeletal maturity, making these injuries radiographically occult. MR imaging may be required to recognize these avulsions, which can impact the duration of rest and knee bracing.

Collateral Ligament Knee Injuries in Pediatric and Adolescent Athletes.

BACKGROUND: The majority of research on medial (MCL) and lateral (LCL) collateral ligament injuries has focused on adults and combined collateral/cruciate injuries. The purpose of this study was to determine characteristics associated with isolated collateral ligament injuries in adolescents, and assess timing for return to sports. METHODS: Electronic medical records were queried to identify patients aged below 17 years who sustained a magnetic resonance imaging-confirmed isolated MCL or LCL injury over an 8-year period. Retrospective review then documented patient and injury characteristics and clinical course. General linear modeling was used to analyze risk factors for prolonged return to sports, continued pain or reinjury. RESULTS: Fifty-one knees (33 in males, 65%), mean age 13.8 years (range, 5 to 17), were identified, of which 40 (78%) had MCL injuries. Over half (29, 57%) of knees had an open distal femoral physis including all 5 bony avulsion injuries. Eleven (22%) had LCL injuries of which 3 (6%) had concurrent posterolateral corner injuries. Forty-two (82%) knees had injuries that occurred during sports. Eleven knees (28%) with MCL tears had a simultaneous patellar instability episode. Knee injuries that occurred during sports had 37% shorter recovery time (P=0.02). Eight knees (16%) experienced a reinjury and 12 (24%) were followed over an extended period of time for various knee issues. Football injuries were more likely to be grade 3 (P=0.03), and football and soccer accounted for all grade III injuries. The mean return to sports was 2.2 months, with grade III cases returning at 2.4 months, and 95% of cases within 4 months. CONCLUSIONS: Isolated collateral ligament injuries are rare in adolescent athletes. MCL injuries, one-quarter of which occurred in conjunction with patellar instability events, were 4 times more common than LCL injuries, one quarter of which have other posterolateral corner structures involved. Grade III injuries represent 20% to 25% of collateral ligament injuries and occurred most commonly in football and soccer. LEVEL OF EVIDENCE: Level IV-retrospective case series.

Effect of Graft Type on Thigh Circumference, Knee Range of Motion, and Lower-Extremity Strength in Pediatric and Adolescent Males Following Anterior Cruciate Ligament Reconstruction.

CONTEXT: To treat anterior cruciate ligament (ACL) injury, ACL reconstruction (ACLR) surgery is currently a standard of the care. However, effect of graft type including bone-patellar tendon-bone (BTB), hamstring tendon, or iliotibial band (ITB) on thigh size, knee range of motion (ROM), and muscle strength are understudied. OBJECTIVE: To compare postoperative thigh circumference, knee ROM, and hip and thigh muscle strength in adolescent males who underwent ACLR, based on the 3 different autograft types: BTB, hamstring (HS), and ITB. SETTING: Biomechanical laboratory. PARTICIPANTS: Male ACLR patients who are younger than 22 years of age (total N = 164). INTERVENTION: At 6- to 9-month postoperative visits, thigh circumference, knee ROM, and hip and thigh muscle strength were measured. MAIN OUTCOME MEASURES: Deficits of each variable between the uninvolved and ACLR limb were compared for pediatric and adolescent ACLR males in the BTB, HS, and ITB cohorts. Baseline characteristics, including physical demographics and meniscus tear status, were compared, and differences identified were treated as covariates and incorporated in analysis of covariance. RESULTS: Data were from 164 adolescent male ACLR patients [mean age 15.7 (1.2) years]. There were no statistical differences in thigh circumference, knee ROM, hip abductor, and hip-extensor strength among the 3 autografts. However, patients with BTB demonstrated 12.2% deficits in quadriceps strength compared with 0.5% surplus in HS patients (P = .002) and 1.2% deficits in ITB patients (P = .03). Patients with HS showed 31.7% deficits in hamstring strength compared with 5.4% deficits in BTB (P = .001) and 7.7% deficits in ITB (P = .001) groups at 6- to 9-month postoperative visits. CONCLUSION: Adolescent male ACLR patients with BTB and HS autografts demonstrated significant deficits in quadriceps and hamstring strength, respectively, at 6 to 9 months postoperatively. Minimal lower-extremity strength deficits were demonstrated in pediatric male ACLR patients undergoing ITB harvest.

Incarcerated Medial Epicondyle Fractures With Elbow Dislocation: Risk Factors Associated With Morbidity.

BACKGROUND: Incarcerated medial epicondyle fractures in association with elbow trauma are rare and an absolute indication for intervention. Because of the infrequent nature, outcomes following this injury are not well documented. We studied a large cohort of these injuries to determine factors associated with functional outcomes. It was hypothesized that a greater duration between initial presentation and time of surgery would lead to poorer outcomes. METHODS: A total of 32 patients aged 18 and under who underwent surgical treatment for an incarcerated medical epicondyle fracture at a level-1 pediatric trauma center from 2003 to 2015 were identified. All patients had a confirmed diagnosis of an incarcerated medial epicondyle at surgery. Medical records and radiographs were reviewed to determine the patient demographics, mechanism of injury, preoperative neurological symptoms, time of primary presentation, time of elbow reduction, and time to surgical intervention. Postoperative outcomes, including pain, range of motion, and ulnar nerve symptoms, were also collected. The Roberts outcome score was determined for each subject. RESULTS: A radiographically confirmed elbow dislocation was identified in 25 subjects. The mean age at injury was 13.2 years (range, 7.3 to 17.8 y). Initial presentation was at a referring institution in 30 patients (94%). First closed reduction attempt of the ulnohumeral joint occurred in the emergency room in 24 subjects (75%); of these 7 subjects (22%) had a first reduction attempted in the emergency room at our institution, 2 patients experienced first elbow reduction during surgical intervention. The median time from first presentation to surgery was 21.9 hours (interquartile range, 15 to 40). Fourteen subjects displayed preoperative ulnar nerve symptoms. Of these, 9 subsequently reported postoperative ulnar nerve symptoms. There was no effect of time to surgical intervention on the Roberts outcome scores at follow-up, nerve symptoms, symptomatic hardware, or need for second surgery to remove hardware. There were 16 subjects with excellent outcomes, 13 with good outcomes, 3 with fair outcomes, and 0 with poor outcomes (based on the Roberts criteria). CONCLUSIONS: Incarcerated medial epicondyle fractures are commonly associated with ulnar nerve symptoms; however, they are not associated with a significant rate of other complications. There was no increased risk of complications in subjects who had a longer duration between initial presentation and surgery. This suggests that, while the presence of an incarcerated medial epicondyle fracture is certainly an indication for timely operative intervention; the injury in isolation does not need to be considered emergent. Other factors including neurovascular status and ability to achieve joint reduction may still necessitate emergency operative care. LEVEL OF EVIDENCE: Level IV-therapeutic study, case series.

Effect of Graft Type on Balance and Hop Tests in Adolescent Males Following Anterior Cruciate Ligament Reconstruction.

Context: Recent epidemiology studies indicated a steady increase of anterior cruciate ligament (ACL) injury in young athletes. ACL reconstruction (ACLR) is currently a standard of care, but the effect of ACLR graft including bone patellar tendon bone (BTB), hamstring tendon (HT), or iliotibial band (ITB) on balance and hop performance is understudied. Objective: To compare balance and hop deficits between uninvolved and reconstructed limbs in each autograft type (aim 1) and among the 3 autograft groups (aim 2). Setting: Biomechanical laboratory. Participants: Male ACLR patients who are younger than 22 years (total N = 160; BTB: N = 19, HT: N = 108, ITB: N = 33). Intervention: Approximately 6 to 9 months following ACLR, Y-balance and 4 types of hop tests were measured bilaterally. Main Outcome Measures: Limb symmetry index of balance and hop tests within each graft type and between the 3 graft types. Results: In the BTB group, significant anterior reach, single hop, triple hops, and cross-over hops deficits were observed on the ACLR limb compared with the uninvolved limb. The HT group showed significant deficits in single hop, triple hops, and cross-over hops on the ACLR limb relative to the uninvolved limb. Compared with the uninvolved limb, significantly decreased triple hops and 6-m timed hop deficits in the ACLR limb were recorded in the ITB group. When controlling for confounders and comparing among the 3 autograft types, the only significant difference was anterior reach, in which the BTB group showed significant deficits. Conclusion: Compared with the uninvolved limb, significant hop deficits in ACLR limb were prevalent among adolescent ACLR at ∼6 to 9 months postoperatively. After controlling covariates, significantly reduced anterior reach balance was found in the BTB group compared with the HT and ITB groups.

Calcaneofibular Ligament Transfer for Recurrent Peroneal Tendon Subluxation in Pediatric and Young Adult Patients.

BACKGROUND: Peroneal tendon subluxation is an uncommon cause of lateral ankle pain and instability but can be disabling for some young patients. Surgical management may be required to restore function for patients who fail nonoperative management. The purpose of this study was to determine the functional outcomes after surgical management of peroneal tendon subluxation in pediatric and adolescent patients. METHODS: A retrospective review of patients presenting to our institution over a 10-year period yielded 18 cases of recurrent subluxation refractory to nonoperative management in 14 children or young adults (mean age 15.0 y). All patients failed nonoperative management and were treated operatively with isolated calcaneofibular ligament transfer to construct a new soft tissue restraint for the peroneal tendons. Patients were evaluated clinically and sent validated questionnaires, including the Foot and Ankle Ability Measure (FAAM) and the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale. RESULTS: All 18 ankles of 14 patients had minimum 2-year follow-up. Ten of 18 ankles (55.6%) returned the outcome surveys at an average of 5.7 years after the index procedure (range, 2. 0 to 9.7 y). The average FAAM activities of daily living score was 93.5 (±2.9) and the sports subscale was 77.8 (±6.1). The mean AOFAS subjective scaled score was 84.3 (±4.5). All patients returned to sports and recreational activity. Complications included 1 case of recurrent subluxation (1/18, 5.5%) treated with revision to a Chrisman-Snook procedure and 4 ankles (4/18, 22.2%) with stiffness or arthrofibrosis treated with a secondary procedure of peroneal tendon release or lysis of adhesions. CONCLUSIONS: Surgical management with rerouting of the peroneal tendons under the calcaneofibular ligament appears to be safe and effective for young patients with chronic peroneal tendon subluxation. It provides a low rate of recurrent subluxation, excellent stability, and good long-term functional outcomes. However, the potential for postoperative stiffness appears to be a limitation to the procedure and necessitates aggressive physical therapy to maintain ankle motion. LEVEL OF EVIDENCE: Level IV- retrospective case series.

Musculoskeletal Conditions in a Pediatric Population with Ehlers-Danlos Syndrome.

OBJECTIVE: To describe musculoskeletal conditions in children with Ehlers-Danlos syndrome (EDS). STUDY DESIGN: A retrospective medical record review was performed, which evaluated 205 patients with EDS (ages 6-19 years) seen in sports medicine or orthopedic clinic at a large pediatric hospital over a 5-year period. RESULTS: Female (n = 147) and male (n = 57) patients were identified (mean age 12.7 years). The most common EDS subtype (55.6%) was hypermobility type. Patients had between 1 and 69 visits (median 4), and 764 diagnoses were recorded, most commonly laxity/instability, pain, subluxation, and scoliosis/spinal asymmetry. Nearly one-half of patients (46.8%) received a general diagnosis of pain because no more specific cause was identified, in addition to 8.3% who were diagnosed with chronic pain syndrome. The most common sites of presenting issue were knee (43.4%), back (32.2%), and shoulder (31.2%). Over three-fourths (77.1%) of patients had imaging. Most (88.1%) were prescribed physical therapy and/or other conservative measures, such as rest (40.5%), orthotics (35.6%), and medication (32.2%). Surgery was recommended to 28.8% of the study population. CONCLUSIONS: Many pediatric and adolescent patients with EDS experience joint pain, instability, and scoliosis, along with other musculoskeletal issues. Despite extensive workup, the etiology of pain may not be identified. Large numbers of office visits, imaging studies, treatment prescriptions, and specialist referrals indicate considerable use of medical resources and highlight a great need for injury prevention and additional study.

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.

Treating Subscapularis and Lesser Tuberosity Avulsion Injuries in Skeletally Immature Patients: A Systematic Review.

PURPOSE: To develop evidence-based recommendations for the diagnosis and treatment of skeletally immature patients with subscapularis and lesser tuberosity avulsion injuries. METHODS: We searched the online databases PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and Cochrane Database of Systematic Reviews (CDSR) for relevant publications on subscapularis and lesser tuberosity injuries in skeletally immature patients. All publication dates and languages were included. From studies identified, data were extracted to identify patient characteristics, history and physical examination findings, time to diagnosis, results from imaging studies, and treatment outcomes. These findings were combined and descriptively analyzed. RESULTS: We identified 32 publications on 60 patients with a mean age of 13.5 ± 1.7 years. The most common physical examination finding at the time of diagnosis was anterior shoulder pain, followed by subscapularis muscle weakness. The sensitivity of imaging was 16% for radiographs and 95% for magnetic resonance imaging. The median time to diagnosis was 2 months (interquartile range, 1 to 7 months). Of 60 patients, 10 (17%) underwent successful nonoperative treatment. Fifty patients (83%) underwent surgical repair, without differences in clinical outcomes after open versus arthroscopic repair. Five cases (8%) were identified where delayed treatment was associated with suboptimal outcomes and ongoing shoulder pain. CONCLUSIONS: Subscapularis and lesser tuberosity avulsion injuries in skeletally immature patients are most commonly seen in male patients during early adolescence. A high index of suspicion should be maintained in patients with anterior shoulder pain and subscapularis muscle weakness, especially after a fall on an outstretched arm or an eccentric external rotation injury. Magnetic resonance imaging should be considered early, even if radiographic findings are negative. Both open and arthroscopic repairs are effective in restoring function, if fixation respects the soft bone of the lesser tuberosity. LEVEL OF EVIDENCE: Level IV, systematic review of low-quality studies.

Management of Syndesmotic Ankle Injuries in Children and Adolescents.

Pediatric ankle injuries are common, especially in athletes; however, the incidence of syndesmosis injuries in children has been scarcely reported. Injuries to the ankle syndesmosis, termed "high ankle sprains," can affect high-level and recreational athletes and have been related to delayed return to play, persistent pain, and adult injuries have been associated with long-term disability. Syndesmotic injuries do occur in children, especially those who participate in sports that involve cutting and pivoting (football, soccer) or sports with rigid immobilization of the ankle (skiing, hockey). Unstable pediatric syndesmosis injuries requiring surgical fixation are often associated with concomitant fibular fracture in skeletally mature children. Physician vigilance and careful clinical examination coupled with appropriate radiographs can determine the extent of the injury in the majority of circumstances.

Variation of Syndesmosis Anatomy With Growth.

BACKGROUND: Syndesmosis injury is common in trauma and in the sport medicine population. Diagnosis and treatment of this pathology is controversial in adult population and almost unknown in a growing and immature ankle. The objective of this study was to describe the relationship between the distal tibia and fibula in immature, growing, and mature children. METHODS: A retrospective imaging study was performed on ankle magnetic resonance images (MRI), which were divided into 3 groups according to age: immature, growing, or mature. The syndesmosis anatomy was described in 3 planes following an established measurement system. The measurement system was also validated (intraobserver and interobserver reproducibility) on a subgroup of 30 MRIs with 4 surgeons. RESULTS: The measurement system, previously described on CT scans, is valid when used on MRIs. The mediolateral translation significantly increases with growth and external rotation of fibula decreases. The anteroposterior position is also significantly different between groups but the ratios are similar. CONCLUSIONS: This study reported differences in distal tibiofibular relationship in a growing population. This information will be crucial in future development of diagnostic and follow-up criteria of syndesmosis injury. It also presented a valid and precise measurement system to describe syndesmotic anatomy in 3 planes. LEVEL OF EVIDENCE: Level IV.

The Effectiveness of a Functional Knee Brace on Joint-Position Sense in Anterior Cruciate Ligament-Reconstructed Individuals.

It is estimated that approximately 350,000 individuals undergo anterior cruciate ligament (ACL) reconstruction surgery in each year in the US. Although ACL-reconstruction surgery and postoperative rehabilitation are successfully completed, deficits in postural control remain prevalent in ACL-reconstructed individuals. In order to assist the lack of balance ability and reduce the risk of retear of the reconstructed ACL, physicians often provide a functional knee brace on the patients' return to physical activity. However, it is not known whether use of the functional knee brace enhances knee-joint position sense in individuals with ACL reconstruction. Thus, the effect of a functional knee brace on knee-joint position sense in an ACL-reconstructed population needs be critically appraised. After systematically review of previously published literature, 3 studies that investigated the effect of a functional knee brace in ACL-reconstructed individuals using joint-position-sense measures were found. They were rated as level 2b evidence in the Centre of Evidence Based Medicine Level of Evidence chart. Synthesis of the reviewed studies indicated inconsistent evidence of a functional knee brace on joint-position improvement after ACL reconstruction. More research is needed to provide sufficient evidence on the effect of a functional knee brace on joint-position sense after ACL reconstruction. Future studies need to measure joint-position sense in closed-kinetic-chain fashion since ACL injury usually occurs under weight-bearing conditions.

Likelihood of surgery in isolated pediatric fifth metatarsal fractures.

BACKGROUND: Fractures of the fifth metatarsal bone are common and surgery is uncommon. The "Jones" fracture is known to be in a watershed region that often leads to compromised healing, however, a "true Jones" fracture can be difficult to determine, and its impact on healing in pediatric patients is not well described. The purpose of this study was to retrospectively assess patterns of fifth metatarsal fracture that led to surgical fixation in an attempt to predict the likelihood for surgery in these injuries. METHODS: A retrospective review was performed on patients aged 18 and under who were treated for an isolated fifth metatarsal fracture from 2003 through 2010 at our pediatric hospital. Patient demographics, treatment, and complications were noted. Radiographs were reviewed for location of fracture and fracture displacement. Patients and fracture characteristics were then compared. RESULTS: A total of 238 fractures were included and 15 were treated surgically. Most surgical indications were failure to heal in a timely manner or refracture and all patients underwent a trial of nonoperative treatment. Jones criteria for fracture location were predictive of needing surgery (P<0.01) but confusing in the clinic setting. Fractures that occurred between 20 and 40 mm (or 25% to 50% of overall metatarsal length) from the proximal tip went on to surgery in 18.8% (6/32) of the time, whereas those that occurred between <20 mm had surgery in 4.9% (9/184). This was a statistically significant correlation (P=0.0157). CONCLUSIONS: Although fractures of the fifth metatarsal are common, need for surgery in these fractures is not. However, a region of this bone is known to have trouble healing, and it can be difficult to identify these "at-risk" fractures in the clinical setting. We found simple ruler measurement from the proximal tip of the fifth metatarsal to the fracture to help determine this "at-risk" group and found a significant difference in those patients with a fracture of <20 mm compared with those 20 to 40 mm from the tip; this can help guide treatment and counsel patients. LEVEL OF EVIDENCE: Level 3.

Results of Surgical Management of Osteochondritis Dissecans of the Ankle in the Pediatric and Adolescent Population.

BACKGROUND: There is a paucity of published literature on operative management of osteochondritis dissecans (OCD) in the ankle in adolescents. This study seeks to elucidate patient and lesion characteristics associated with surgical success and failure as well as reporting functional outcomes. METHODS: Retrospective chart review identified all patients aged 18 years old or younger surgically treated for OCD of the ankle at our institution from 2001 to 2010. This included 109 ankles in 100 patients (75 female, 25 male), mean age 14.3 ± 2.3 years (range, 7 to 18 y), with a median follow-up of 3.3 years (range, 1 to 10.8 y). Patient and lesion data, surgical procedure, clinical results, and complications were recorded. Postoperative radiographs were reviewed in 80 ankles. A return to sport survey and a Foot and Ankle Outcome Score (FAOS) was sent to all patients. Multivariate statistical analysis evaluated predictors of reoperation rate, Berndt and Harty clinical grade, and FAOS scores. Kaplan-Meier analysis was applied to determine freedom from reoperation. RESULTS: The OCD lesion was most commonly found on the medial talus (80, 73%). The most common procedures performed included transarticular drilling (59, 54%), fixation (22, 20%), and excision microfracture (27, 26%). The overall rate of reoperation was 27% (29/109). Berndt and Harty clinical grade was poor (33, 30%), fair (23, 21%), and good (53, 49%). Reoperation rates were significantly higher for OCD lesions in which postoperative radiographs had no change or looked worse (10/16, 63%) (P = 0.002). Thirty-six of 44 survey respondents (82%) were satisfied and 37 (84%) returned to sports at a median time of 6 months. Average FAOS score was 77 ± 18. Multiple linear regression confirmed that female sex and elevated body mass index were significant negative predictors for FAOS score. CONCLUSIONS: The reoperation rate following surgical intervention for OCD of the ankle is high. Females and those with a higher body mass index may have worse subjective functional ankle outcomes.

Displaced intra-articular fractures of the great toe in children: intervene with caution!

BACKGROUND: Intra-articular fractures of the proximal phalanx of the great toe in children are extremely rare and sparsely reported in the literature. We have noted a series of these fractures at our institution. The purpose of this report is to present a retrospective case series of children with intra-articular fractures managed operatively in order to highlight the inherent difficulties in managing these fractures. METHODS: Operative notes and billing records were searched from 2001 to 2011 to identify all children aged 18 years or younger who underwent surgical intervention for an intra-articular fracture of the proximal phalanx of the great toe. Charts and imaging studies were retrospectively reviewed to identify the mechanism of injury, fracture classification, operative details, clinical results, and complications. RESULTS: Seven boys and 3 girls with a mean age of 12.6 years (range, 8.7 to 15.7 y) were identified. The mechanism of injury was a direct blow from a stubbed toe (8 cases) or a dropped object onto the foot (2 cases). There were 7 intra-articular fractures of the proximal phalanx base, 4 of which occurred in the setting of an open physis. Mean fracture displacement was 4.4 mm. Open reduction was necessary in 9 cases, with K-wire fixation used in 9 cases. Median follow-up was 50.5 months (range, 11 to 123 mo). Seven fractures healed at a mean of 7.9 weeks. Nine patients returned to full activity without limitation at latest follow-up. Six patients had significant complications: 2 underwent revision open reduction internal fixation (one for postoperative redisplacement and the other for painful nonunion), 1 suffered a refracture, 1 developed posttraumatic arthritis requiring interphalangeal joint fusion, 1 developed an asymptomatic fibrous nonunion with avascular necrosis of the fragment, and 1 had K-wire migration necessitating early surgical removal. CONCLUSIONS: Intra-articular fractures of the great toe primarily occur in adolescents after direct impact injuries. The most common location was the proximal phalangeal base. There is a high complication rate after surgical intervention, although most patients were asymptomatic at latest follow-up. LEVEL OF EVIDENCE: IV (retrospective case series).

Outcomes of treatment of patella fractures in children and adolescents.

Purpose: The purpose of this study is to assess clinical and functional outcomes in separate cohorts of operatively and nonoperatively managed pediatric patella fractures. Methods: A retrospective review was completed for patients aged 5-19 years treated for a unilateral patella fracture at a single pediatric level-1 trauma center. Patients were excluded for osteochondral fracture associated with patellar dislocation, polytrauma presentation with additional fractures, or <3 months of clinical follow-up. Functional outcomes were assessed via the Pediatric International Knee Documentation Committee form and the Marx Knee Activity Scale. Results: A total of 53 patients met inclusion criteria; 30 patients were treated operatively and 23 patients were treated nonoperatively. Patients with patellar sleeve/pole fractures were significantly younger by 5.2 years (p < 0.01) and presented with greater variability in mechanism of injury (p < 0.01). The nonoperative cohort achieved bony healing and returned to sports at a median (interquartile range) of 1.7 (1.2-2.3) months and 2.8 (2.3-3.3) months, respectively, post-injury. The operative group achieved bony healing and returned to sports at 2.8 (2.1-3.5) months and 5.9 (4.0-7.1) months, respectively, following surgery. Median (interquartile range) Pediatric International Knee Documentation Committee and Marx scores were 98 (89-100) and 14 (10-16), respectively, for the nonoperative group, and 92 (84-99) and 13 (12-16), respectively, for the operative group. No significant differences in patient-reported outcomes were observed between fracture patterns or treatment cohorts. Conclusion: Pediatric and adolescent patients sustaining patella fractures reported long-term functional outcomes comparable to normative values, across multiple fracture patterns and with appropriate operative and nonoperative treatment. Fractures requiring surgery were expectedly associated with slower healing and return to sport timelines. Level of evidence: Therapeutic Level III.

Prevalence and Predictors of Concomitant Meniscal and Ligamentous Injuries Associated With ACL Surgery: An Analysis of 20 Years of ACL Reconstruction at a Tertiary Care Children's Hospital.

BACKGROUND: There is an increasing rate of procedures being performed for concomitant injuries during anterior cruciate ligament (ACL) surgery. Few studies have examined risk factors for these associated injuries in young patients. HYPOTHESIS: There are patient-related factors predictive of concomitant knee pathology that differ between age-based cohorts. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Natural language processing was used to extract clinical variables from available notes of patients undergoing ACL surgery between 2000 and 2020 at a single institution (5174 ACL surgeries; mean age, 17 ± 4 years; 53.1% female; accuracy, >98%). Patients were stratified to pediatric (5-13 years), adolescent (14-19 years), and young adult (20-35 years) cohorts. Logistic regression was used to determine predictors of concomitant injury to the menisci, medial collateral ligament (MCL), posterolateral corner (PLC), and posterior cruciate ligament (PCL). RESULTS: Between 2000 and 2020, 54% of pediatric, 71% of adolescent, and 70% of adult patients had ≥1 concomitant soft tissue injury. In children and adolescents, increased age was consistently predictive of sustaining a concomitant injury (P < .02). Female children had increased odds of concomitant medial meniscal injury, while female adults had decreased odds (P≤ .046). Adolescent and adult female patients had decreased odds of concomitant lateral meniscal injury (P≤ .027). Female children had increased odds of injury to the MCL (P = .015), whereas female children and adolescents had decreased odds of PCL injury (P≤ .044). Adolescents undergoing revision ACL surgery had increased odds of meniscal injury (P≤ .001) and decreased odds of concomitant MCL injury (P = .028). Increased body mass index (BMI) was associated with increased odds of concomitant medial meniscal injury in all cohorts (P≤ .041), lateral meniscal injury in adults (P = .045), and PLC injury in children (P = .016). Contact injuries were associated with increased odds of MCL injury in adolescents (P = .017) and PLC injury in adolescents and adults (P < .014). CONCLUSION: These findings support the hypothesis, as there were multiple factors that significantly affected the risk of concomitant injuries that differed between cohorts. Increased age, BMI, and contact injury history were generally associated with increased odds of sustaining a concomitant injury, whereas female sex and revision ACL surgery had mixed effects. Further studies are essential to investigate the sex-based differences in risk for concomitant injuries and to develop tailored treatment plans that minimize the risk of secondary ACL injury.

Prevalence and Predictors of Concomitant Meniscal Surgery During Pediatric and Adolescent ACL Reconstruction: Analysis of 4729 Patients Over 20 Years at a Tertiary-Care Regional Children's Hospital.

Background: The rate of concomitant meniscal procedures performed in conjunction with anterior cruciate ligament (ACL) reconstruction is increasing. Few studies have examined these procedures in high-risk pediatric cohorts. Hypotheses: That (1) the rates of meniscal repair compared with meniscectomy would increase throughout the study period and (2) patient-related factors would be able to predict the type of meniscal operation, which would differ according to age. Study Design: Cohort study (prevalence); Level of evidence, 2. Methods: Natural language processing was used to extract clinical variables from notes of patients who underwent ACL reconstruction between 2000 and 2020 at a single institution. Patients were stratified to pediatric (5-13 years) and adolescent (14-19 years) cohorts. Linear regression was used to evaluate changes in the prevalence of concomitant meniscal surgery during the study period. Logistic regression was used to determine predictors of the need for and type of meniscal procedure. Results: Of 4729 patients (mean age, 16 ± 2 years; 54.7% female) identified, 2458 patients (52%) underwent concomitant meniscal procedures (55% repair rate). The prevalence of lateral meniscal (LM) procedures increased in both pediatric and adolescent cohorts, whereas the prevalence of medial meniscal (MM) repair increased in the adolescent cohort (P = .02). In the adolescent cohort, older age was predictive of concomitant medial meniscectomy (P = .031). In the pediatric cohort, female sex was predictive of concomitant MM surgery and of undergoing lateral meniscectomy versus repair (P≤ .029). Female sex was associated with decreased odds of concomitant LM surgery in both cohorts (P≤ .018). Revision ACLR was predictive of concomitant MM surgery and of meniscectomy (medial and lateral) in the adolescent cohort (P < .001). Higher body mass index was associated with increased odds of undergoing medial meniscectomy versus repair in the pediatric cohort (P = .03). Conclusion: More than half of the young patients who underwent ACLR had meniscal pathology warranting surgical intervention. The prevalence of MM repair compared with meniscectomy in adolescents increased throughout the study period. Patients who underwent revision ACLR were more likely to undergo concomitant meniscal surgeries, which were more often meniscectomy. Female sex had mixed effects in both the pediatric and adolescent cohorts.