Tibial spine fractures (TSFs) are typically treated nonoperatively when nondisplaced and operatively when completely displaced. However, it is unclear whether displaced but hinged (type 2) TSFs should be treated operatively or nonoperatively.To compare operative versus nonoperative treatment of type 2 TSFs in terms of overall complication rate, ligamentous laxity, knee range of motion, and rate of subsequent operation.Cohort study; Level of evidence, 3.We reviewed 164 type 2 TSFs in patients aged 6 to 16 years treated between January 1, 2000, and January 31, 2019. Excluded were patients with previous TSFs, anterior cruciate ligament (ACL) injury, femoral or tibial fractures, or grade 2 or 3 injury of the collateral ligaments or posterior cruciate ligament. Patients were placed according to treatment into the operative group (n = 123) or nonoperative group (n = 41). The only patient characteristic that differed between groups was body mass index (22 [nonoperative] vs 20 [operative]; P = .02). Duration of follow-up was longer in the operative versus the nonoperative group (11 vs 6.9 months). At final follow-up, 74% of all patients had recorded laxity examinations.At final follow-up, the nonoperative group had more ACL laxity than did the operative group (P < .01). Groups did not differ significantly in overall complication rate, reoperation rate, or total range of motion (all, P > .05). The nonoperative group had a higher rate of subsequent new TSFs and ACL injuries requiring surgery (4.9%) when compared with the operative group (0%; P = .01). The operative group had a higher rate of arthrofibrosis (8.9%) than did the nonoperative group (0%; P = .047). Reoperation was most common for hardware removal (14%), lysis of adhesions (6.5%), and manipulation under anesthesia (6.5%).Although complication rates were similar between nonoperatively and operatively treated type 2 TSFs, patients treated nonoperatively had higher rates of residual laxity and subsequent tibial spine and ACL surgery, whereas patients treated operatively had a higher rate of arthrofibrosis. These findings should be considered when treating patients with type 2 TSF.
Objectives: In the adult population, anterior glenohumeral instability has been associated with a tall and narrow glenoid morphology, assessed using glenoid index (GI). This morphological association has not been assessed in children and adolescents. This study was designed to examine the association of GI with anterior glenohumeral dislocation in patients 19 years old and younger using a case-control study design. Methods: An institutional radiology database was queried over a 10-year period to identify patients 19 years old and younger who underwent glenohumeral MRI arthrography and were diagnosed with anterior shoulder dislocation (cases) and those without dislocation and normal shoulder arthrogram studies (controls). Those with bony Bankart lesions were excluded. Glenoid index (glenoid height-to-width ratio) was measured by an attending pediatric musculoskeletal radiologist and a fellowship-trained attending orthopedic surgeon. Comparative analysis between the two groups was performed using Student’s t-test for each variable, followed by receiver-operating-characteristic (ROC) analysis to determine discriminative ability when statistically significant. Results: Thirty-three males and 22 females (mean age: 15.4±2.1 years old) meeting inclusion and exclusion criteria were identified. Mean glenoid index in the dislocator group was significantly greater than the control group (1.55±0.14 vs. 1.38±0.08, P<0.001). ROC analysis revealed adequate discrimination of glenoid index in predicting glenohumeral dislocation (area under the curve [AUC] = 0.88). A glenoid index ≥1.45 was 83% sensitive and 79% specific for predicting dislocation in the study cohort. Conclusion: Patients with anterior glenohumeral dislocation were noted to have increased glenoid index (taller and narrower glenoid morphology) than controls. Glenoid index may help identify patients at risk for primary or recurrent anterior glenohumeral instability events, and can help guide treatment and anticipatory guidance.
Anterior cruciate ligament (ACL) injury rates are affected by frequency and level of competition, gender, and sport. Specifically, adolescent and high school athletes have a number of unique risk factors that differentially affect their ACL injury risk profile as compared to collegiate, adult or elite-level athletes. To date, no study has sought to quantify sport-specific yearly risk for ACL tears in the high school athlete by gender and sport played. Therefore, the purpose of this study was to establish evidence-based incidence and …
Meniscal injuries in children continue to increase, which may be attributable to increasing levels of athletic participation and may be associated with additional injuries or need for additional surgeries.To better understand the patterns of pediatric meniscal injuries by analyzing tear location, morphologic features, and associated injury patterns over a 16-year period.Case series; Level of evidence, 4.Pediatric patients were identified and were included in the study if age at the time of initial surgery for meniscal tear was between 5 and 14 years for female patients and 5 and 16 years for male patients. Patients were observed until age 18, and any subsequent surgeries were noted. Demographic factors, tear type and location, associated injuries, and treatment type were analyzed.Mean patient age at surgery was 13.3 years, and 37% of patients were female. A total of 1040 arthroscopic meniscal surgeries in 880 pediatric patients were evaluated. There were 160 reoperations in 138 patients, representing a reoperation rate of 15%. These included 98 reoperations on the ipsilateral knee in 88 patients and 62 operations for injuries to the contralateral knee in 50 patients; 53% of surgeries were meniscal repair, as opposed to partial meniscectomy, and the most common technique was an all-inside repair (91%). Significant differences were identified between male and female patients. Male patients were more likely to have lateral meniscus (74% vs 65%), posterior horn (71% vs 60%), peripheral (45% vs 30%), and vertical tears (31% vs 21%); concomitant ACL injury (50% vs 40%); and an associated osteochondritis dissecans lesion (7% vs 4%). Female patients were more likely to have medial meniscus (24% vs 17%), anterior horn (25% vs 15%), and degenerative tears (34% vs 26%); discoid meniscus (33% vs 24%); and isolated meniscal tears (47% vs 33%).This evaluation of a large series of patients has helped characterize injury patterns associated with pediatric meniscal surgeries. Most meniscal tears were repaired (53%) and were associated with additional injuries (62%), especially anterior cruciate ligament injuries (48%). More than 25% of patients had a discoid meniscus. Injury patterns differed significantly between male and female patients.
Background: Tibial spine fractures (TSFs) are intra-articular avulsion fractures of the intercondylar eminence which tend to afflict younger, skeletally immature patients. Given the relatively rare nature of these injuries, the epidemiology is not well-understood. There have been several estimates reported from single centers, though the potential for historical and regional variability in activities and risk factors limits the generalizability of their findings. Thus, the aim of the present investigation was to characterize the epidemiology of TSFs using pooled multicenter data. Hypothesis/Purpose: Report on the epidemiology of tibial spine fractures. Methods: This study was a retrospective analysis of patients with TSFs who were evaluated and treated at one of ten different sites across the United States. Information regarding patient demographics, injury mechanism, and imaging reports were collected. Fractures were classified according to the modified Meyers and McKeever method which groups the injuries as non-displaced (Type I), minimally displaced with an intact hinge (Type II), completely displaced (Type III), or completely displaced and comminuted (Type IV). Descriptive analyses were performed to evaluate the epidemiology of these fractures across the country. Results: We identified 469 patients (69% male; mean age 12.1 + 2.9 years) with TSFs over an eight-year period. 73% of patients were 14 years or younger. With respect to fracture severity, 5% of patients were Meyers and McKeever Type I, 35% Type II, and 50% Type III, and 10% Type IV. Overall, 60% of the fractures were completely displaced (Types III and IV). The most common mechanism of injury was a contact injury (48%), while 46% reported a non-contact twisting injury. With regard to activity at the time of injury, over half (53%) of patients were involved in sports and 14% of patients were biking recreationally. Less common causes included a fall from height (9%), motor vehicle accident (4%) recreational running (3%), and horseplay (3%). Of those injured playing sports, football (35%), skiing (21%), basketball (10%), and soccer (10%) accounted for almost 80% of the injuries in this cohort. Conclusion: Ultimately, our study represents the first multicenter analysis of the epidemiology of tibial spine fractures. The patient demographics and mechanism of injury for these injuries appears relatively consistent across geographic distributions. However, the recent rise in youth sports participation, single sport specialization, and year-round play in pediatric athletes appears to have generated a new principal risk factor for this injury in sports participation as opposed to the historically-described biking accidents. [Table: see text][Figure: see text]
Background: Pre- and post-operative standing hip to ankle radiography is critical for monitoring potential post-operative growth arrest and resultant length and angular deformities after pediatric anterior cruciate ligament (ACL) reconstruction. During acquisition of pre-operative standing alignment radiographs, it is possible that patients are lacking full extension, not weight bearing comfortably, or leaning resulting in inaccurate measurements. Purpose: This study aims to assess both pre- and post-operative radiographic measurements to assess if the standing pre-operative x-ray is a accurate and reliable source for baseline measurements. Methods: We retrospectively reviewed prospectively collected pre-operative and first post-operative full-length hip-to-ankle radiographs in a cohort of skeletally immature athletes who presented with an acute ACL injury and underwent subsequent surgical reconstruction. Initially, leg length discrepancy for 25 patients was measured by 3 orthopedic surgeons (top of femoral head to center of tibial plafond). The intraclass correlation was almost perfect (ICC (2,1) = .996) therefore, 1 surgeon measured the remaining 94 radiographs. Measurements for both the injured and uninjured legs were obtained for comparison and surgeons were blinded to the injured side. Results: A total of 119 pediatric patients (mean age 13.4, range 7-14 years) were included (83 males and 36 females). Patient were categorized as either having ≥5mm, ≥10mm, or ≥15mm LLD on pre-operative standing x-ray. Sixty-two patients (52%) were found to have a pre-operative LLD ≥ 5mm. Forty-one (66%) of these patients tore their ACL on the limb measuring shorter. At 6 month post-operative standing x-ray, 35 patients (56%) resolved to ≤5mm LLD. Eighteen patients had a pre-operative LLD of ≥ 10mm. At 6 month post-operative standing x-ray, 13 (72%) patients resolved to ≤5mm LLD. Five patients had a pre-operative LLD of ≥ 15mm. At 6 month post-operative standing x-ray, 4 (80%) resolved ≤5mm. All patients with a pre-operative LLD of ≥ 13mm had sustained an ACL injury on the limb measuring shorter Conclusion: Of the pediatric ACL patients initially presenting with a pre-operative LLD of ≥ 10mm, 72% demonstrated apparent correction of their LLD on their 6 month standing x-ray. This high rate of LLD pre-operatively but not post operatively calls into question the accuracy of pre-operative standing alignment radiographs for patients after an ACL tear. Surgeons and radiology technicians should be aware of injured patients potentially lacking full extension, leaning, or not weight bearing comfortably, and should consider delaying preoperative radiographic length and alignment analysis until after the patient is able to fully straighten the injured knee and weight bear comfortably.
Previous research has demonstrated both greater difficulty in obtaining follow-up appointments and increased likelihood of return visits to the emergency department (ED) for patients with government-funded insurance plans. The purpose of the current study is to determine whether socioeconomic factors, such as race and insurance type, are associated with the frequency of repeat ED visits in pediatric patients with closed fractures.A review of ED visit data over a 2-year period from a statewide hospital discharge database in New York was conducted. Discharges for patients with a unique person identifier in the database age 17 years and younger were examined for an ICD-9 diagnosis of closed upper or lower extremity fracture. Age, sex, race, and insurance type for patients with a return ED visit within 8 weeks for the same fracture diagnosis were compared with those without a return visit using standard univariate statistical tests and logistic regression analyses.Of the 68,236 visits reviewed, the revisit rate was 0.85%. Patients of nonwhite or unidentified race were significantly more likely to have a revisit than white patients (OR, 1.27; P=0.006). Patients with government-funded insurance were significantly more likely to have a revisit than those without government-funded insurance (OR, 1.55; P<0.001). Patients with private insurance were significantly less likely to have a revisit than those without private insurance (OR, 0.72; P=0.001).Our analysis revealed that nonwhite patients are more likely to return to the ED within 8 weeks for the same fracture diagnosis. Patients with government insurance are 55% more likely to have a revisit, whereas patients with private insurance are 28% less likely to have a revisit. Our results suggest that socioeconomic disparities exist in access to orthopaedic care for closed fractures in a pediatric population. Physicians and policy makers should be mindful of these health care disparities when striving to improve access to care among patients and resource utilization in the ED.Prognostic level II.
Category: Ankle, Arthroscopy, Sports Introduction/Purpose: Historically, microfracture has been the standard surgical treatment for talar osteochondral lesions (OLTs); however, it is associated with unsatisfactory long-term results due to the formation of biomechanically inferior reparative fibrocartilage as opposed to normal hyaline-like cartilage. Thus, the optimal treatment for OLTs remains contested. Application of micronized allogenic cartilage extracellular matrix (ECM) as an adjuvant therapy during the treatment of OLTs offers a promising option that could be administered arthroscopically to improve the quality of reparative tissue. The purpose of this study is to provide a case-control series comparing radiographic and functional outcomes following treatment of OLTs with an adjuvant mixture of micronized allogenic cartilage ECM and bone marrow aspirate concentrate (BMAC) to those achieved following standard microfracture with or without BMAC. Methods: 194 patients (average age 37) with a minimum 1-year follow-up who were treated for an OLT by a fellowship-trained foot and ankle surgeon were screened for inclusion. 107 patients who received mixed micronized cartilage ECM and BMAC (Group I), 40 who were treated by microfracture augmented with BMAC (Group II), and 47 patients who were treated with traditional microfracture alone (Group III) were identified. Preoperative lesion size, lesion location, and concurrent injuries were recorded retrospectively. Foot and Ankle Outcome Scores (FAOS) were completed preoperatively and postoperatively through the prospective Registry database at the authors’ institution. Outcomes were assessed radiographically at a minimum of 6 months postoperatively by a trained radiologist using the MOCART scoring system. Linear regression modeling was used to assess differences in MOCART scores, post-operative FAOS scores, pre-to-postoperative change in FAOS, and the rate of revision surgery between groups I, II, and III. Results: The average MOCART score for Group I was 62.39, (average follow-up 16.13 months; n = 46), 58.8 (26.82 months; n =25) for Group II and, 55.36 (43.12 months; n=14) for Group III patients (p=0.57). The rate of revision surgery for OLTs treated using adjuvant micronized cartilage ECM was 5% and was significantly lower when compared to a 22.7% rate of revision surgery following microfracture with or without BMAC (p<0.001). Finally, when controlling for lesion size, changes in pre-to-postoperative FAOS Pain and Sports Activities were significantly different amongst the 3 treatment groups (p=0.05). Group I had the greatest improvement in Pain. Conclusion: Micronized allogenic cartilage extracellular matrix serves as an adjunctive therapy that may help improve patients’ radiographic and functional outcomes following treatment of OLTs when compared to outcomes following traditional microfracture. Specifically, use of adjunctive ECM appears to have better postop FAOS Pain scores when controlled for lesion size when compared to microfracture. There is a lower rate of revision surgery with the use of allogenic cartilage ECM in the short to intermediate term when compared with microfracture.
Background: Tibial spine fractures are common pediatric injuries with similar mechanism of injury to anterior cruciate ligament tears. Post-operative arthrofibrosis remains the most common complication following treatment of this injury, and many patients require subsequent manipulation under anesthesia. Several prior studies have examined risk factors for the development of arthrofibrosis, but with small patient populations and varying reported predictors. Therefore, our objective was to identify risk factors for arthrofibrosis in the largest known cohort of pediatric tibial spine patients. Hypothesis/Purpose: Identify risk factors for developing arthrofibrosis after TSF treatment. Methods: This was a retrospective, multi-center study across ten institutions of 448 patients <25 years old who presented to care with a tibial spine fracture between 1/2000 and 2/2019. Patient records were reviewed for a multitude of pre-operative, intra-operative, and post-operative characteristics. Patients were then separated into two cohorts based on if they suffered from post-treatment arthrofibrosis. Results: Chart review demonstrated that 43 (9.6%) of the patients suffered from post-treatment arthrofibrosis. There were no demographic differences observed between the two groups. However, based on MRIs at the time of injury, distal femoral and proximal tibial growth plates were more frequently closed in the arthrofibrosis group (17.6% vs 4.4%, p=0.023 for both comparisons). Additionally, there was no difference in Meyers & McKeever (MM) classification (p=0.597). All arthrofibrosis patients received operative treatment (p=0.003), though there was no difference in fixation technique (p=0.734). Intraoperatively, a higher number of screws were used in the arthrofibrosis group (p=0.002) with the placement of hardware more likely to be epiphyseal (p=0.007). Other operative parameters including number of sutures were not different. Post-operatively, arthrofibrosis patients were more likely to have been immobilized in a cast (p<0.001) with no difference observed for weight-bearing status. After multivariate regression, screw number (OR 8.9, CI 1.9-41.7, p=0.005) and immobilization in a cast (OR 7.8, CI 1.0-60.4, p=0.049) remained significant predictors of post-treatment arthrofibrosis. Conclusion: This serves as the largest study of tibial spine fractures to analyze risk factors for the development of post-treatment arthrofibrosis. Our study demonstrates that pre-operative factors were largely similar between groups, but that intra-operative decisions, including the number of screws used for fixation and placement of hardware in relation to the physis, were significant predictors of post-treatment arthrofibrosis. These findings may influence operative decision-making in tibial spine fracture patients. Additionally, post-operative immobilization in a cast should be avoided given the high risk of arthrofibrosis. [Table: see text]
