Manipulation Under Anesthesia is Safe and Effective for Management of Early Postoperative Knee Arthrofibrosis in Adolescent Patients.

BACKGROUND: Management of postoperative knee arthrofibrosis can be challenging and the preferred time for intervention remains controversial. The purpose of this study is to evaluate the safety and efficacy of early (<3 mo postoperatively) manipulation under anesthesia (MUA) for the treatment of knee arthrofibrosis in adolescent patients. We hypothesized that early MUA could restore normal knee motion with a low complication rate and without the need for more invasive intervention. METHODS: In a retrospective review, 57 patients who underwent MUA for postoperative knee arthrofibrosis were identified. The time between the index surgery and MUA as well as changes in range of motion (ROM) before and after MUA were analyzed. Descriptive statistics with median and interquartile range were used to analyze this non-parametric study cohort. Repeated measures ANOVA was performed to assess improvement in ROM over time. A P value <0.05 denoted statistical significance. RESULTS: The median age of the cohort at time of MUA was 14.5 years [interquartile range (IQR) 12.9 to 17.6)]. 54.4% were male. Median time to MUA was 64 days (IQR 52 to 79) after index surgery. ROM before MUA was 90.0 degrees (IQR 75 to 100), which improved to 130 degrees (120 to 135) after MUA. At final median follow-up of 8.9 months (IQR 5.1 to 16.1), mean ROM was 133 degrees (130 to 140). There were no iatrogenic fractures or physeal separations associated with MUA. 12.3% (n=7/57) failed MUA either due to the need for subsequent repeat MUA (n=2), need for lysis of adhesions (n=3) or need for surgery after MUA (n=2). Those who failed early MUA and required subsequent procedures had ROM >120 degrees at final follow-up. CONCLUSIONS: Postoperative knee arthrofibrosis can be safely and effectively treated with early (<3 mo postoperative) MUA. There were no iatrogenic fractures or physeal separations during MUA. Patients who had recurrence of motion deficits after early MUA and required further intervention, regained satisfactory knee motion at final follow-up. Although further research is warranted to better characterize risk factors for knee arthrofibrosis in adolescent patients, early recognition and MUA is a safe and effective treatment for arthrofibrosis to help patients regain full ROM without invasive intervention. LEVEL OF EVIDENCE: Therapeutic Study - Level IV.

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

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

Common Pediatric Fractures for Community Orthopaedic Specialists: Fix Them or Ship Them?

It is important to focus on common pediatric fractures seen in community emergency rooms, including supracondylar humerus, elbow, forearm, distal radius, and femoral shaft fractures, along with periarticular fractures around the knee and ankle in children. The principles of surgical and nonsurgical management of these fractures are based on the fracture type and age of the patient. The orthopaedic surgeon should be aware of important tips and tricks to help manage these injuries and be familiar with common complications that may occur when these injuries are encountered during trauma call.

Patients with bilateral patellar instability have multiple and symmetric risk factors in each knee.

PURPOSE: Bilateral involvement is common in patients with patellar instability. The management of bilateral patellar instability is associated with increased complication rate. The higher complication rate in this cohort may be related to the presence of underlying anatomic risk factors. The purpose of the study was to evaluate the presence and side-to-side differences in risk factors between knees in bilateral patellar instability. METHODS: In a retrospective study (2008-2017), demographic information, characteristics of patellar dislocation and anatomic risk factors on MRI (trochlear dysplasia, patellar height, tibial tubercle lateralization, patellar tilt, sulcus angle, bump height) were evaluated in both knees of all patients (n = 32, 15 males and 17 females) with bilateral patellar instability. The risk factors were analyzed based on established cut off values and were compared between gender, laterality and more symptomatic (index) knee. Knee symmetry and absolute differences between risk factors for both knees were analyzed. RESULTS: The mean age of 32 patients was 14.6 ± 2.3 years. Of the 4 major anatomic risk factors, the most common were trochlear dysplasia in 59/64 (92.1%) knees and patella alta in 51/64 (79.7%) knees. Tibial tubercle lateralization was the least common risk factor being present in 8/64 (12.5%) knees. Of 64 knees, 55 (85.9%) had 2 or more risk factors and 30 (46.8%) had 3 or all 4 risk factors present. There were no significant differences in risk factors based on gender, laterality or index knee. There was symmetry between paired knees for 31/32 (96.8%) patients for trochlear depth, 29/32 (90.6%) for patellar tilt, 27/32 (84.3%) for TT-TG distance and 25/32 (78.1%) for patellar height. There were no significant differences in absolute measurements between knees for any of the risk factors. CONCLUSION: Patients with bilateral instability had multiple risk factors, with trochlear dysplasia being the most common and increased TT-TG distance being the least common. Majority of patients had 2 or more risk factors and about half had 3 or 4 risk factors in each knee. There was symmetry between paired knees for each risk factor without any significant differences between the index knee compared to the contralateral knee. LEVEL OF EVIDENCE: Level III.

4-in-1 Quadricepsplasty for Habitual and Fixed Lateral Patellar Dislocation in Children.

BACKGROUND: Habitual and fixed patellar dislocations represent extreme forms of patellar instability and can lead to significant functional loss. The underlying complex pathoanatomy of a laterally positioned and shortened extensor mechanism poses challenges in its management. The purpose of our study was to evaluate the anatomic risk factors and outcomes of a 4-in-1 quadricepsplasty (wide lateral releases, Insall proximal tube realignment, Roux-Goldthwait patellar tendon hemi-transfer, and step-wise quadriceps lengthening) for stabilization of habitual and fixed patellar dislocation. METHODS: In a retrospective study, all patients with habitual and fixed patellar dislocation who underwent 4-in-1 quadricepsplasty and had a minimum 2-year follow-up were identified. Preoperative magnetic resonance imagings were evaluated for the presence of anatomic risk factors. As a prospective part of the study, patient-reported outcomes were collected using validated instruments including Pedi-IKDC, HSS-Pedi FABS activity score, BPII 2.0 score, Kujala score, and KOOS score. RESULTS: Seventeen knees (12 patients) formed the study cohort. Twelve knees had habitual dislocation (9 in extension and 4 in flexion) and 5 had fixed dislocation. Mean age was 9 years. 6/17 (35.3%) knees were associated with syndromes. On magnetic resonance imaging, trochlear dysplasia was the most common anatomic risk factor present in 15/17 (88.2%) knees. 13/17 (76%) knees had presence of 2 or more risk factors. At the mean follow-up of 43.3 months, the mean Pedi-IKDC score was 88.1, the HSS-Pedi FABS activity score was 15.6, the BPII 2.0 score was 78.2, the Kujala score was 90, KOOS score was 93.9, and overall patient satisfaction score was 83.3. For complications, 3/17 knees (17.6%) had recurrent patellar instability, 1 knee had postoperative stiffness that required manipulation under anesthesia and 1 knee had a superficial wound infection. CONCLUSIONS: Most patients with habitual and fixed patellar dislocation present during the first decade of life. There are several underlying anatomic risk factors, the most common being trochlear dysplasia and patellar tilt. The 4-in-1 quadricepsplasty technique provides reliable patellar stabilization, satisfactory clinical results, and acceptable patient-reported outcomes at a minimum 2-year follow-up, with a 17.6% redislocation rate. LEVEL OF EVIDENCE: Level IV.

Intrarater and Interrater Reliability of Radiographic Characteristics in Skeletally Immature Patients With Anterior Cruciate Ligament Tears: A PLUTO Study Group Reliability Study.

BACKGROUND: Radiographic measurements of limb alignment in skeletally immature patients with anterior cruciate ligament (ACL) tears are frequently used for surgical decision-making, preoperative planning, and postoperative monitoring of skeletal growth. However, the interrater and intrarater reliability of these radiographic characteristics in this patient population is not well documented. HYPOTHESIS: Excellent reliability across 4 raters will be demonstrated for all digital measures of length, coronal plane joint orientation angles, mechanical axis, and tibial slope in skeletally immature patients with ACL tears. STUDY DESIGN: Cohort study (diagnosis). METHODS: Three fellowship-trained orthopaedic surgeons and 1 medical student performed 2 rounds of radiographic measurements on digital imaging (lateral knee radiographs and long-leg radiographs) of skeletally immature patients with ACL tears. Intrarater and interrater reliability for continuous radiographic measurements was assessed with intraclass correlation coefficients (ICCs) across 4 raters with 95% CIs for affected and unaffected side measurements. Interrater reliability analysis used an ICC (2, 4) structure and intrarater reliability analysis used an ICC (2, 1) structure. A weighted kappa coefficient was calculated for ordinal variables along with 95% CIs for both interrater and intrarater reliability. Agreement statistic interpretations are based on scales described by Fleiss, and Cicchetti and Sparrow: <0.40, poor; 0.40 to 0.59, fair; 0.60 to 0.74, good; and >0.74, excellent. RESULTS: Radiographs from a convenience sample of 43 patients were included. Intrarater reliability was excellent for nearly all measurements and raters. Interrater reliability was also excellent for nearly all reads for all measurements. CONCLUSION: Radiographic reliability of long-leg radiographs and lateral knee x-rays in skeletally immature children with ACL tears is excellent across nearly all measures and raters and can be obtained and interpreted as reliable and reproducible means to measure limb length and alignment. LEVEL OF EVIDENCE: Level III.

Many Radiographic and Magnetic Resonance Imaging Assessments for Surgical Decision Making in Pediatric Patellofemoral Instability Patients Demonstrate Poor Interrater Reliability.

PURPOSE: To evaluate the interrater reliability of several common radiologic parameters used for patellofemoral instability and to attempt to improve reliability for measurements demonstrating unacceptable interrater reliability through consensus training. METHODS: Fifty patients with patellar instability between the ages of 10 and 19 years were selected from a prospectively enrolled cohort. For measurements demonstrating unacceptable interrater reliability (intraclass correlation coefficient [ICC]: <0.6), raters discussed consensus methods to improve reliability and re-examined a subset of 20 images from the previous set of images. If reliability was still low after the second round of assessment, the measure was considered unreliable. RESULTS: Of the 50 included subjects, 22 (44%) were male and the mean age at the time of imaging was 14 ± 2 years. With 1 or fewer consensus training sessions, the interrater reliability of the following radiograph indices were found to be reliable: trochlea crossing sign (ICC: 0.625), congruence angle (ICC: 0.768), Caton-Deshamps index (ICC: 0.644), lateral patellofemoral angle (ICC: 0.768), and mechanical axis deviation on hip-to-ankle alignment radiographs (ICC: 0.665-0.777). Reliable magnetic resonance imaging (MRI) indices were trochlear depth (ICC: 0.743), trochlear bump (ICC: 0.861), sulcus angle (ICC: 0.684), patellar tilt (ICC: 0.841), tibial tubercle to trochlear groove distance (ICC: 0.706), effusion (ICC: 0.866), and bone marrow edema (ICC: 0.961). CONCLUSIONS: With 1 or fewer consensus training sessions, the interrater reliability of the following patellofemoral indices were found to be reliable for trochlear morphology: trochlea crossing sign and congruence angle on radiograph and trochlear depth, trochlear bump, and sulcus angle on MRI. Reliable patellar position measurements included: Caton-Deshamps index and lateral patellofemoral angle on radiograph and patellar tilt and tibial tubercle to trochlear groove distance on MRI. Additional global measurements (e.g., mechanical axis deviation on standing radiographs) and MRI assessments demonstrated acceptable reliability. LEVEL OF EVIDENCE: II, prospective diagnostic study.

What's New in the Management of Pediatric Anterior Cruciate Ligament Tears and Tibial Spine Fractures.

As the number of pediatric and adolescent patients participating in sports continues to increase, so too does the incidence of anterior cruciate ligament (ACL) tears in this population. There is increasing research on pediatric and adolescent ACL tears; hundreds of articles on the topic have been published in the past few years alone. It is important to highlight the most pertinent information in the past decade. In discussing pediatric ACL tears, it is also important to review tibial spine fractures. These injuries are rightfully grouped together because tibial spine fractures often occur with a mechanism of injury similar to that of ACL tears, but typically in a younger age group. Because management is different, understanding the similarities and differences between the two pathologies is important. Recent updates on the epidemiology, diagnosis, management, and outcomes of both pediatric ACL tears and tibial spine fractures need to be reviewed.

What's New in Osteochondritis Dissecans of the Knee, Elbow, and Ankle.

Osteochondritis dissecans is a condition of the subchondral bone, with secondary effects on the articular cartilage. It most commonly affects the knee, elbow, and ankle and is typically seen in young, active populations. Many osteochondritis dissecans lesions are asymptomatic, but more advanced lesions can cause pain, swelling, and mechanical symptoms. Multiple treatment options have been proposed, including nonsurgical and surgical approaches. It is important to be aware of the epidemiology, presenting symptoms, and indications for nonsurgical and surgical treatment options for osteochondritis dissecans of the knee, elbow, and ankle.

Missed Diagnosis and Acute Management of Radial Head Dislocation With Plastic Deformation of Ulna in Children.

BACKGROUND: Radial head dislocation with ulnar bowing (Monteggia type I equivalent injury) is a frequently missed injury. If not recognized acutely, these missed injuries can lead to serious long-term complications. The purpose of this study was to evaluate the rate of missed diagnosis and to report on the characteristics and early management of this specific injury pattern. METHODS: A total of 112 patients with Monteggia fracture-dislocation were identified, of which 18 patients had sustained a Monteggia type I equivalent injury. The total duration between injury, diagnosis, and treatment was noted. Medical records were reviewed to identify cases with the initially missed diagnosis. The radiographic assessment included the direction of radial head dislocation and location/displacement of the apex of the ulnar bow. Clinical outcomes were evaluated using Kim elbow performance score. RESULTS: Thirteen of 18 cases with Monteggia equivalent injury were missed at the initial presentation. The diagnosis was established when the patients followed up in the orthopaedic clinic. Of these 18 patients, 11 were treated by closed reduction/cast and 7 patients required surgery. Significant differences were found between the closed reduction/cast and operative group for the mean time from injury to treatment (3.2±2.6 vs. 12.7±13.6 d). For each day of delay in treatment, the odds for surgical intervention increased by a factor of 1.126 (12.6%). There were no significant differences between the location and magnitude of the apex of the ulnar deformity between the 2 groups. Kim elbow score was excellent in all cases at the latest follow-up. CONCLUSIONS: Clinical suspicion and careful radiographic assessment are of utmost importance for every child with forearm and elbow injury without an apparent fracture, as there is a high rate of missed diagnosis for this specific Monteggia injury pattern. Prompt treatment would allow for successful closed reduction while even minor delays would increase the need for surgical intervention. LEVEL OF EVIDENCE: Therapeutic, level III.

Validity and Reliability of the Banff Patellofemoral Instability Instrument 2.0 in an Adolescent Population.

BACKGROUND: Lateral patellofemoral instability is a relatively common problem in the adolescent population. Subjective and objective patient outcomes are commonly used to evaluate treatment success or failure. The Banff Patellofemoral Instability Instrument (BPII) and Paediatric International Knee Documentation Committee (Pedi-IKDC) Subjective Knee Form are patient-reported outcome measures that have been used with an adolescent population previously. The BPII 2.0 is a shortened version of the BPII and has not been validated in an adolescent population. The purpose of the current study was to validate the BPII 2.0 with an adolescent population. METHODS: This was a multicenter study where patients were recruited from 3 tertiary orthopaedic surgery clinics. A convenience sample (n=140 adolescent patients) with a confirmed diagnosis of lateral patellofemoral instability and who had failed conservative treatment was referred to one of the 3 orthopaedic surgeons. All patients completed the BPII 2.0 and Pedi-IKDC before their clinic appointment. Cronbach's alpha and floor/ceiling effects were used to determine the content validity of both instruments. Patients were also interviewed to ask questions about the BPII 2.0 comprehension and importance of items. One clinic site sent out the BPII 2.0 to 30 additional patients twice in 2 weeks to measure the test-retest reliability (intraclass correlation coefficient 2,k). A Pearson r correlation coefficient was used to determine the relationship between the BPII 2.0 and the Pedi-IKDC and criterion validity. RESULTS: Cronbach's alpha values were 0.95 and 0.76 for the BPII 2.0 and Pedi-IKDC, respectively. There was no evidence of floor or ceiling effects for either the BPII 2.0 or the Pedi-IKDC. The Pearson r correlation coefficient between the BPII 2.0 and IKDC baseline scores taken at the initial consultation was 0.65 (P<0.001; 95% confidence interval, 0.94-0.97). The intraclass correlation coefficient (2,k) for the test-retest subsample (n=30) was 0.94. Patient interviews revealed that they thought the BPII 2.0 questions were both important and comprehensible. CONCLUSIONS: The BPII 2.0 is a valid, reliable, and disease-specific patient-reported outcome measure that can be used with an adolescent population with lateral patellofemoral instability. The BPII 2.0 has demonstrated criterion validity through its moderately strong correlation to the Pedi-IKDC for adolescents.

Trochlear Dysplasia and Its Relationship to the Anterior Distal Femoral Physis.

BACKGROUND: Trochlear dysplasia is a known risk factor for patellar instability in adolescent patients. A spatial relationship between dysplastic trochlea and anterior distal femoral physis has not been established. The purpose of this study was to investigate this relationship. Our hypothesis was that the position of the dysplastic trochlea and trochlear bump would coincide with the anterior distal femoral physis and that the distance between them would increase with age. METHODS: In a retrospective study, magnetic resonance images of adolescents with trochlear dysplasia were evaluated. Measurements performed included trochlear depth, trochlear bump size, proximal trochlea-physis distance, and trochlear bump-physis distance. Linear regression analyses were performed to correlate the variables with increasing age. RESULTS: In total, 175 knees (160 patients) with trochlear dysplasia were included. The mean trochlea-physis distance was 4.50 mm (SD=1.93) and it increased with age (slope=0.26; P<0.01). The lateral aspect of trochlea was proximal to the physis in 24 (13.7%) knees and was at the level of the physis in 31 (17.7%) knees. The size of trochlear bump increased with age (slope=0.15; P=0.01). The bump-physis distance increased with age (slope=0.41; P<0.01). CONCLUSIONS: The dysplastic trochlea is closely related to the anterior distal femoral physis. The distance between the dysplastic trochlea and femoral physis increases with age. The close relationship between proximal aspect of trochlea and anterior distal femoral physis should be considered when trochlear surgery is planned in skeletally immature patients. LEVEL OF EVIDENCE: Level II.

Extensor Tendon Injury Associated With Dorsal Entry Flexible Nailing of Radial Shaft Fractures in Children: A Report of 5 New Cases and Review of the Literature.

BACKGROUND: Extensor pollicis longus (EPL) tendon injury following the dorsal approach to elastic stable intramedullary nailing (ESIN) of the radius has been reported in a growing number of cases in the literature. This study includes 5 new cases from our institution as well as a comprehensive review of previously reported cases from the literature. METHODS: We conducted a retrospective chart review of all patients undergoing ESIN between January 1, 2004 and December 31, 2013 at our institution. Those patients with an EPL injury or rupture were identified and clinical data collected included operative technique, diagnosis, treatment, and outcomes data. In addition, we performed a systematic review of the literature using Pubmed MEDLINE database, the Chochrane database, Scopus, Web of Science, and Embase. A total of 28 cases of EPL injury following ESIN of the radius were identified in the literature and the relevant data were extracted from those studies. RESULTS: All 33 pediatric cases of EPL tendon injury occurred after entry to the radial canal was obtained by the dorsal approach to ESIN. EPL injury was diagnosed an average of 10 weeks following the index procedure. Extensor indicis pollicis to EPL transfer was performed in 13 patients, tendon release/lysis of adhesions in 5, EPL repair in 2, EPL graft reconstruction from palmaris longus tendon in 1, 3 patients refused further intervention, and treatment was unreported in 7 cases. By 12-month follow-up, all operatively treated patients had a good functional outcome with near anatomic extension at the thumb interphalangeal joint, no pain, and no further complication. CONCLUSIONS: EPL tendon injury was found to be a complication unique to the dorsal entry approach for ESIN of the radius. The lateral approach appears to offer a safer alternative with regard to the EPL tendon. We suggest that physicians consider the risk of EPL tendon injury when planning for ESIN of the radius, and make an effort to avoid direct injury when using a dorsal approach. LEVEL OF EVIDENCE: Level III-therapeutic.

The Growth of Trochlear Dysplasia During Adolescence.

BACKGROUND: Femoral trochlear dysplasia is a known risk factor for patellar instability. The growth pattern of the normal trochlea is known, but there have been no studies investigating the growth and development of the dysplastic trochlea. The purpose of this study was to assess the growth pattern of trochlear dysplasia in adolescents. METHODS: In a retrospective analysis, magnetic resonance images of adolescents with patellar instability and trochlear dysplasia were evaluated. These images were measured for lateral and medial condylar height, trochlear height, cartilaginous and bony trochlear bump, and cartilaginous and bony sulcus angle. The type of trochlear dysplasia was classified as per Dejour classification. These measurements were plotted against age, and their growth patterns were evaluated using statistical methods. RESULTS: Of 235 knees with patellar instability, trochlear dysplasia was present in 175 knees (74% knees) and these were further analyzed. With increasing age, the mean lateral and medial condylar heights and mean trochlear height showed statistically significant increase (P<0.01). Cartilaginous trochlear bump (slope=0.15, P=0.013) and bony trochlear bump (slope=0.22, P<0.01) increased with age, with some reaching the pathologic value by age of 15.1 years. After age 11 years, there were no significant changes for cartilaginous and bony sulcus angles (cartilage: slope=0.03, P=0.96; bony: slope=-0.90, P=0.11). The mean cartilaginous sulcus angle was significantly greater than the mean bony sulcus angle (P<0.01). All Dejour types of trochlear dysplasia were present across all age groups. CONCLUSIONS: All linear measurements of trochlear dysplasia (condylar height, trochlear height, trochlear bump) increased with age. However, the shape of trochlear dysplasia, as reflected by sulcus angle and Dejour classification, did not change with increasing age. The shape of trochlear dysplasia is most likely a genetic predisposition and does not necessarily change during skeletal growth. LEVEL OF EVIDENCE: Level II-diagnostic, cross-sectional.

Skeletally Immature Anterior Cruciate Ligament Injuries: Controversies and Management.

At one time, anterior cruciate ligament (ACL) tears in skeletally immature patients were considered rare. The recommended treatment option for skeletally immature patients with ACL tears was to modify activities until skeletal maturity, at which point definitive ACL reconstruction could be safely performed. The management of ACL tears in skeletally immature patients has evolved as a result of the increased frequency of ACL tears in younger patients and an increased awareness for the potential development or worsening of meniscal tears, chondral lesions, and degenerative changes that occur with the "wait-and-fix-later" approach. The surgical options for ACL reconstruction in skeletally immature patients include physeal-sparing, partial transphyseal, and complete transphyseal techniques. The timing and ideal technique for ACL reconstruction in skeletally immature patients are controversial. Accurate assessment of skeletal growth remaining and concerns for iatrogenic growth disturbances continually challenge treating physicians. Similar controversies with regard to the treatment of skeletally immature patients who have partial ACL tears or congenital absence of the ACL also exist.

Predictors of Recurrent Patellar Instability in Children and Adolescents After First-time Dislocation.

BACKGROUND: Patellar dislocations are one of the most common knee injuries in children and adolescents and are challenging to treat. Recurrence rates are relatively high and many patients have functional limitations, even in the absence of a recurrent instability episode. The purpose of this study was to examine the risk factors in patients with first-time patellofemoral dislocations to develop a prediction model of recurrence. METHODS: A single institution retrospective review of all patients with a first-time patellofemoral dislocation from 2002 to 2013 was performed. Demographic risk factors (age, sex, laterality, mechanism of injury, and history of contralateral patellar dislocation) and radiographic risk factors (increased patella height, trochlear dysplasia, and skeletal immaturity) were examined. Patella height was measured using Caton-Deschamps index (CDI). Trochlear dysplasia was assessed using the 2-grade Dejour classification and skeletal immaturity was assessed based on the distal femur and proximal tibia physis (open, closing, or closed). RESULTS: In total, 266 knees in 250 patients were included in the study. Of these, 222 (83.5%) were treated nonoperatively and 44 (16.5%) were treated surgically. Of the knees treated nonoperatively, 77 (34.7%) had a recurrence. Significant risk factors for recurrence on univariate analysis were age 14 years and below, history of contralateral patellar dislocation, trochlear dysplasia, skeletal immaturity, and a CDI>1.45. Multivariate analysis was performed and trochlear dysplasia and skeletal immaturity were the most significant factors with odds ratios of 3.56 and 2.23, respectively. The presence of all 4 multivariate risk factors (CDI>1.45, history of contralateral patellar dislocation, trochlear dysplasia, and skeletal immaturity) had a predicted risk of recurrence of 88%. The presence of any 3 risk factors had a predicted risk of about 75% and the presence of any 2 risk factors had a predicted risk of about 55%. CONCLUSIONS: Trochlear dysplasia, skeletal immaturity, CDI>1.45, and a history of contralateral patellar dislocation were all significant risk factors for recurrence in patients with first-time patellar dislocations. A predictive model for calculation of recurrence risk was developed for any combination of the different risk factors. This information is useful when counseling patients and their families after first-time patellar dislocation about prognosis and potential outcomes. LEVEL OF EVIDENCE: Level IV-retrospective case series.

Intercondylar Roof Inclination Angle: Is It a Risk Factor for ACL Tears or Tibial Spine Fractures?

BACKGROUND: The relationship between the angle of inclination of the intercondylar roof [roof inclination angle (RIA)] and likelihood of knee injury has not been previously investigated in children. METHODS: Twenty-five skeletally immature patients with a tibial spine fracture were age matched (±1 y) and sex matched with 25 patients with an anterior cruciate ligament (ACL) tear and with 50 control knees (2 for each patient). Demographic and diagnostic information was collected, and radiographic measurements were performed on notch and lateral radiographs of the knee. RESULTS: Patients with a tibial spine fracture had an increased RIA compared with controls and patients with an ACL tear. Patients with ACL tears had a steeper notch roof, as indicated by a decreased RIA when compared with controls and patients with tibial spine fractures. CONCLUSIONS: Our results demonstrated that a decreased RIA was associated with ACL tear and that an increased RIA was associated with tibial spine fracture. LEVEL OF EVIDENCE: Level III-prognostic.

Rereduction for Redisplacement of Both-Bone Forearm Shaft Fractures in Children.

BACKGROUND: There is a high rate of redisplacement after closed reduction and cast treatment of displaced both-bone forearm shaft fractures in children. Little evidence is available on the efficacy of rereduction of these redisplaced fractures. This study evaluates the impact of rereduction on radiographic outcomes and compares the cost to surgical stabilization. METHODS: This retrospective study included 31 children (mean age, 6.3 y; 18 boys) treated with rereduction for redisplacement of a displaced both-bone forearm shaft fracture between 2008 and 2013. Angulation was measured on anteroposterior and lateral radiographs of the radius and ulna at injury, after reduction, at redisplacement, after rereduction, and at fracture union. Average procedure costs for rereduction and surgical stabilization were calculated. RESULTS: Initial reduction decreased apex volar angulation (initially >20 degrees) of both bones to a median of ≤2 degrees. After an average of 15 days (range, 4 to 35 d), apex volar angulation of the radius worsened to 9 degrees, and apex ulnar angulation worsened to >10 degrees for both bones. For every 5 days after initial reduction, apex ulnar angulation of the radius worsened by 4 degrees. Rereduction reduced apex ulnar and volar angulation of both bones to <5 degrees, which was maintained after cast removal. There were no complications. The average procedure cost for rereduction was $2056 compared with $4589 for surgical stabilization with or without implant removal. CONCLUSION: Rereduction of both-bone forearm shaft fractures after redisplacement following initial closed reduction had satisfactory radiographic outcomes and is a safe, effective, and less expensive option than surgical stabilization. LEVEL OF EVIDENCE: Level IV-therapeutic.

The patellar insertion of the medial patellofemoral ligament in children: a cadaveric study.

BACKGROUND: The purpose of this study was to evaluate the medial patellofemoral ligament (MPFL) patellar insertion in skeletally immature anatomic specimens. METHODS: Nine pediatric cadaveric knee specimens were examined through gross dissection. Metallic markers were placed at the MPFL patellar insertion footprint. Computed tomographic scans for each specimen were analyzed. The MPFL insertion footprint width, patellar height, and patellar width were measured. The distance from the MPFL insertion footprint center to the midline of the patella was assessed. The proportion of the patella that the MPFL footprint inserted upon was calculated. RESULTS: The mean width of the MPFL patellar insertion footprint was 12 mm (range, 8 to 18 mm). The mean patellar height was 31 mm (range, 20 to 48 mm). The mean patellar width was 27 mm (range, 21 to 39 mm). The center of the MPFL insertion footprint was found to be a mean 4.7 mm (range, -2 to 10.5 mm) above the midline of the patella, with insertion centers occurring both above and below the midline. The MPFL insertion footprint spanned a mean 41% (24% to 63%) of the longitudinal width of the patella. CONCLUSIONS: Most adult studies report the MPFL insertion on the upper 1/2 to 2/3 of the patella. This series of skeletally immature subjects demonstrated that the center of the MPFL insertion was above and below the midpoint of the patella. The MPFL insertions of some of the younger specimens did extend into the distal 1/3 of the patella. The insertion of the older specimens was found in the proximal 2/3 of the patella, a similar location to most previous adult anatomic studies. CLINICAL RELEVANCE: This research suggests that the MPFL insertion on the patella may be at slightly different locations in some skeletally immature subjects compared with adults. The specimens dissected in the present study showed more variability than previously published reports, with some insertions extending into the distal 1/3 of the patella in the youngest subjects. These dissections may be useful to surgeons performing MPFL reconstructions in skeletally immature patients.

Elastic nailing for pediatric subtrochanteric and supracondylar femur fractures.

BACKGROUND: Subtrochanteric and supracondylar femur fractures are difficult injuries to treat in children. Although elastic stable intramedullary nails are commonly used for pediatric femur shaft fractures, there is little information on their effectiveness for managing pediatric subtrochanteric and supracondylar femur fractures. QUESTIONS/PURPOSES: We (1) evaluated radiographic union rates and fracture alignment after elastic nailing of pediatric subtrochanteric and supracondylar femur fractures, (2) identified complications, and (3) determined risk factors for complications. METHODS: Between 2005 and 2011, 36 subtrochanteric fractures and eight supracondylar femur fractures were treated with elastic stable intramedullary nails and had complete followup until clinical and radiographic union. Elastic nailing was used for subtrochanteric fractures in children 5 to 12 years of age or after failed spica cast treatment in younger children and for displaced supracondylar fractures in children older than 5 years. Fracture alignment and union were measured on radiographs, and complications were identified from review of patient charts. Patients with and without complications were compared using nonparametric tests to identify risk factors. RESULTS: All fractures healed; 23 of 33 (70%) subtrochanteric femur fractures and five of seven (71%) supracondylar femur fractures healed with anterior angulation of about 5°. For subtrochanteric fractures, complications included repositioning/removal of nails before radiographic union (n = 4), malunion (n = 2), fracture (n = 1), irritation (n = 1) at nail insertion site, and limb length discrepancy (n = 1); despite these complications, there were 22 (61%) excellent, 12 (33%) satisfactory, and only two (6%) poor outcomes. For supracondylar fractures, complications included infection after nail removal (n = 1) and nail site irritation (n = 2); there were three (38%) excellent, five (62%) satisfactory, and no poor outcomes. Complications were more likely after subtrochanteric fracture during motor vehicle accident (p = 0.045). CONCLUSIONS: Although complication rates are high with elastic nailing for pediatric subtrochanteric (22%) and supracondylar (38%) femur fractures, elastic nailing represents an important option for difficult-to-manage femur fractures. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.