Publications by authors named "Indranil Kushare"

25 Publications

  • Page 1 of 1

Pediatric and adolescent Lisfranc injuries - Presentation, treatment and outcomes.

Foot (Edinb) 2021 Mar 9;46:101737. Epub 2020 Sep 9.

Texas Children's Hospital, 6701 Fannin St., Houston, TX 77030, USA; Department of Orthopedic Surgery, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX 77030, USA.

Purpose: Lisfranc fracture dislocations are rare injuries and even more so in the pediatric population. The main purpose of our study is to present a descriptive analysis of Lisfranc injuries in pediatric patients to add to the current sparse literature on this topic. In addition, our secondary outcome was to analyze any differences in patients treated conservatively versus operatively, and those with isolated Lisfranc injuries versus those with associated foot injuries.

Methods: Charts of patients with Lisfranc injury treated at a tertiary pediatric hospital from January 2010 to July 2019 were reviewed to analyze their demographics, injury characteristics, management details and rehabilitation protocol. Functional outcome was assessed using the Visual Analogue Scale of Pain (VAS) and the Oxford Ankle Foot Questionnaire for Children (OxAFQ-C).

Results: 30 patients/cases were included with mean age of 13.6 years and mean follow up of 36 weeks. 20% of the cases were missed on initial presentation. 19 cases were managed operatively while 11 were managed conservatively. The average OxAFQ-C and VAS pain scores were 83% and 1.3, respectively at mean follow-up of 36 weeks. The functional outcomes between conservative and operative cases or between those with isolated Lisfranc injuries and those with associated foot injuries were not statistically significant (p > 0.05).

Conclusion: Lisfranc injury in pediatrics can be easily missed. High index of suspicion, a thorough clinical examination and the use of advanced imaging is warranted. Various modalities like K-wires, screws and suture-buttons can be used for fixation. Early to mid-term functional outcomes are satisfactory provided that adequate reduction is obtained.
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http://dx.doi.org/10.1016/j.foot.2020.101737DOI Listing
March 2021

Simultaneous bilateral versus unilateral tibial tubercle fractures.

J Clin Orthop Trauma 2021 Feb 17;13:85-91. Epub 2020 Aug 17.

Department of Orthopedic Surgery, Texas Children's Hospital, Houston, 17580 Interstate 45 South, the Woodlands, Texas, 77384, USA.

Purpose: Tibial tubercle/tuberosity fractures are rare injuries in young patients accounting for less than one percent of physeal fractures. Bilateral simultaneous fractures are even rarer, with only a few case reports in literature. The purpose of our study was to describe the largest case series of bilateral simultaneous tibial tuberosity avulsion fractures and compare it with unilateral fractures. We also wanted to compare our bilateral fractures case series with all the cases reported in the last 65 years.

Methods: IRB approved retrospective study involving patients under age 18 years with tibial tuberosity avulsion fractures. Bilateral simultaneous fractures were compared to a unilateral group including demographic data, mechanism of injury, clinical exam findings, complication rates, and outcomes including return to function. Statistical analysis was performed using Mann-Whitney and Fisher Exact tests to compare the different groups.

Results: 138 patients (131 males, 7 females) from a tertiary children's hospital between 2012 and 2019 with tibial tuberosity avulsion fractures were included. 11 bilateral simultaneous fractures (BL Group) were identified and compared to age matched cohort from the 127 unilateral fracture patients (UL group). There was no significant difference found in BMI, height, weight, age, sex, mechanism of injury, return to functional range of motion, and return to sports between the groups. 7/11 (63%) of the patients in the BL group who sustained simultaneous fractures had to be home bound and could not attend school for an average of 8.3 weeks. There was a higher rate of complications in the BL group (63.3%) compared to the UL group (21.1%), which was statistically significant. The most common complications in the bilateral group were hardware removal and wound dehiscence.

Conclusion: This first case series comparing unilateral versus bilateral simultaneous tibial tuberosity avulsion fractures suggests that the final outcomes of the two groups are similar, however it shows a significantly higher complication rate and hardware removal rate in the BL group. This study is also the first to highlight the significant initial morbidity in the BL fracture group with issues with regards to early mobility and loss of school-days. Keeping in mind the profound initial impact the bilateral injury poses to the patient; surgeons can possibly plan for rigid fixation for early mobilization to better prepare bilateral fracture patients for the early post-operative recovery process.
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http://dx.doi.org/10.1016/j.jcot.2020.08.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7920118PMC
February 2021

Chemoprotection with botulinum toxin following proximal hamstring-Ischial tuberosity avulsion fracture repair: Running title: Chemoprotection for hamstring avulsion fractures.

J Clin Orthop Trauma 2021 Jan 23;12(1):172-176. Epub 2020 Jun 23.

Department of Orthopedic Surgery, Texas Children's Hospital, 17580 Interstate 45 South, The Woodlands, TX, 77384, USA.

Introduction: Surgical treatment for avulsion injuries of the proximal hamstrings has gained increasing popularity over the past decade. Despite good outcomes, early failures have been noted and have been attributed to slipping and falling, postoperative muscle spasm, or early mobilization. In a recent review of hamstring repair rehabilitation protocols, it was shown that there is marked variability in post-operative management. Post-operative bracing with limiting knee extension and hip flexion is the standard of care in most early rehabilitation protocols. Braces with limitation of hip flexion and knee locked in 90 flexion can be awkward, cumbersome and create fall risk.Chemoprotection has more recently been proposed to be an alternative approach to prevent tendon repair failure and controlled mobilization which has been shown to be superior to complete immobilization. We present the first case series of the use of botulinum toxin for chemo-protection of the proximal hamstring ischial avulsion repair, demonstrating its safety and efficacy.

Methods: Retrospective case series at a tertiary children's hospital which included patients <18 years of age who underwent interventional treatment for proximal hamstring avulsion injuries of the ischium utilizing botulinum toxin as a chemoprotective agent. Data collected included demographic data, injury and treatment details, imaging, post-operative rehabilitation and return to activity. Descriptive statistical analysis was conducted.

Results: Five male patients with mean age 14 years (12-17) were included in the study. All were sports related non-contact injuries. Radiographs showed displaced avulsion fractures in all 5 patients. All patients had failed conservative management initially; mean time to surgery from initial injury was 34.4 weeks. 4 patients underwent open reduction and internal fixation (ORIF), 1 patient with less displacement had bone marrow aspirate (BMA) injection; all had chemoprotection using botulinum toxin injected in the hamstrings. No patient required hip immobilization or knee immobilization locked to 90°. We elected to use a brace locked at 20° knee flexion in 2/5 patients. All patients underwent supervised physical therapy and achieved symmetric knee range of motion (ROM). Post-operative radiographs confirmed healing of the avulsion fracture in all 5 patients and they all returned to previous level of activity at mean 32 weeks (21-43) from surgery. None of the patients had a hamstring re-injury at mean follow up of 27 months (11-42).

Conclusion: Our case series is the first in literature that shows the safety and efficacy of chemoprotection with botulinum toxin for the post-operative management of avulsion injuries of proximal hamstrings, by minimizing the need for cumbersome bracing and allowing controlled motion during physical therapy.
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http://dx.doi.org/10.1016/j.jcot.2020.06.030DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7920335PMC
January 2021

Anterior Cruciate Ligament Tear Following Operative Treatment of Pediatric Tibial Eminence Fractures in a Multicenter Cohort.

J Pediatr Orthop 2021 May-Jun 01;41(5):284-289

Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI.

Background: Postoperative ipsilateral anterior cruciate ligament (ACL) tears after tibial eminence fracture fixation has been previously noted in the literature. This study aims to describe the prevalence of and risk factors for postoperative ACL tears in a cohort of patients operatively treated for tibial eminence fracture.

Methods: A retrospective review of children undergoing treatment of a tibial eminence fracture at 10 tertiary care children's hospitals was performed. The primary outcome of interest was subsequent ACL rupture. Incidence of ACL tear was recorded for the entire cohort. Patients who sustained a postoperative ACL tear were compared with those without ACL tear and analyzed for demographics and risk factors. A subgroup analysis was performed on patients with a minimum of 2-year follow-up data or those who had met the primary outcome (ACL tear) before 2 years.

Results: A total of 385 pediatric patients were reviewed. 2.6% of the cohort experienced a subsequent ACL tear. The median follow-up time was 6.5 months (SD=6.4 mo). Subsequent ACL tears occurred at a median of 10.2 months (SD=19.5 mo) postoperatively. There was a statistically significant association with higher grade tibial spine fractures (Myers and McKeever type III and IV) and subsequent ACL tear (P=0.01). Patients with a subsequent ACL tear were older on average (13.5 vs. 12.2 y old), however, this difference was not statistically significant (P=0.08). Subgroup analysis of 46 patients who had a 2-year follow-up or sustained an ACL tear before 2 years showed a 21.7% incidence of a subsequent ACL tear. There was a statistically significant association with higher grade tibial spine fractures (Myers and McKeever type III and IV) and subsequent ACL rupture (P=0.006) in this subgroup. Postoperative ACL tears occurred in patients who were older at the time that they sustained their original tibial eminence fracture (13.4 vs. 11.3 y old, P=0.035).

Conclusions: Ipsilateral ACL tears following operatively treated pediatric tibial eminence fractures in a large multicenter cohort occurred at a rate of 2.6%. However, in those with at least 2 years of follow-up, the incidence was 21.7%. Subsequent ACL tear was more likely in those with completely displaced (type III or IV) tibial eminence fractures and older patients.

Level Of Evidence: Level III-retrospective cohort study.
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http://dx.doi.org/10.1097/BPO.0000000000001783DOI Listing
March 2021

Arcuate sign-fibular head avulsion fracture and associated injuries in the pediatric and adolescent population.

Emerg Radiol 2021 Feb 10. Epub 2021 Feb 10.

E.B. Singleton Department of Radiology, Texas Children's Hospital, 6701 Fannin Street, Suite 470, Houston, TX, 77030-2399, USA.

Purpose: To describe the first "arcuate sign" case series in the pediatric population, radiologic features of the associated injuries, management, and how they compare with the adult population.

Methods: Retrospective study included patients under 18 years of age with a classic "arcuate sign" on radiographs. Data collected included patient demographics, mechanism of injury, and management. Radiographs and advanced imaging (MRI, CT) were reviewed by two musculoskeletal radiologists in a blinded fashion and findings recorded.

Results: Seven patients (4 males, 3 females) with mean age 15 years (range 14-17 years) were included in the study. All 7 injuries were related to sports, 5/7 (71%) being non-contact injuries. Five patients had MRI done-1 LCL injury, MPFL sprain, and MCL sprain were reported; 3 popliteofibular ligament and popliteus sprains were seen; and 3 bone contusions were present on imaging. None of the patients had meniscus or cruciate ligament tears. One patient had an additional fracture of the lateral tibial plateau at the ilio-tibial band attachment and an associated peroneal nerve injury. Five out of seven (71.4%) were treated non-operatively and were able to return back to activity at a mean of 7.2 weeks from injury. Two out of seven (28.6%) needed operative intervention for the fracture but not arthroscopic repair.

Conclusion: Pediatric patients with a radiographic arcuate sign tend not to have ACL, PCL, or meniscal injuries, and treatment is predominantly non-operative in contrast to literature reported in adults.
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http://dx.doi.org/10.1007/s10140-021-01910-9DOI Listing
February 2021

A Comparison of Nonoperative and Operative Treatment of Type 2 Tibial Spine Fractures.

Orthop J Sports Med 2021 Jan 22;9(1):2325967120975410. Epub 2021 Jan 22.

Investigation performed at The Johns Hopkins University, Baltimore, Maryland, USA.

Background: 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.

Purpose: 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.

Study Design: Cohort study; Level of evidence, 3.

Methods: 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]; = .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.

Results: At final follow-up, the nonoperative group had more ACL laxity than did the operative group ( < .01). Groups did not differ significantly in overall complication rate, reoperation rate, or total range of motion (all, > .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%; = .01). The operative group had a higher rate of arthrofibrosis (8.9%) than did the nonoperative group (0%; = .047). Reoperation was most common for hardware removal (14%), lysis of adhesions (6.5%), and manipulation under anesthesia (6.5%).

Conclusion: 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.
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http://dx.doi.org/10.1177/2325967120975410DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7841676PMC
January 2021

Missed Fracture Dislocation of the Fifth Toe in a Two-Year-Old Child: A Case Report.

J Foot Ankle Surg 2021 Jan-Feb;60(1):172-175. Epub 2020 Jun 30.

Research Fellow, Texas Children's Hospital, Division of Orthopedic Surgery; Houston, TX; Research Fellow, Baylor College of Medicine, Department of Orthopedic Surgery, Houston, TX. Electronic address:

Fracture dislocation injuries of the toes are rare among pediatric population. These injuries when acute are mostly treated conservatively and a good reduction must be ensured. We present the case of a 2-year-old girl who presented with missed chronic fracture dislocation of the proximal interphalangeal joint of the fifth toe, which was managed by open reduction and internal fixation and had a good outcome at over 1 year of follow up. We believe that this is the first case of this injury to be published in the peer-reviewed literature.
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http://dx.doi.org/10.1053/j.jfas.2020.06.021DOI Listing
June 2020

Tibial Spine Fractures: How Much Are We Missing Without Pretreatment Advanced Imaging? A Multicenter Study.

Am J Sports Med 2020 11 24;48(13):3208-3213. Epub 2020 Sep 24.

Investigation performed at University Hospitals Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA.

Background: There is a high rate of concomitant injuries reported in pediatric patients with tibial spine fractures, ranging from 40% to 68.8%. Many tibial spine fractures are treated without initial magnetic resonance imaging (MRI).

Purpose: To understand rates of concomitant injury and if the reported rates of these injuries differed among patients with and without pretreatment MRI.

Study Design: Cross-sectional study; level of evidence, 3.

Methods: We performed an institutional review board-approved multicenter retrospective cohort study of patients treated for tibial spine fractures between January 1, 2000, and January 31, 2019, at 10 institutions. Patients younger than 25 years of age with tibial spine fractures were included. Data were collected on patient characteristics, injury, orthopaedic history, pretreatment physical examination and imaging, and operative findings. We excluded patients with multiple trauma and individuals with additional lower extremity fractures. Patients were categorized into 2 groups: those with and those without pretreatment MRI. The incidence of reported concomitant injuries was then compared between groups.

Results: There were 395 patients with a tibial spine fracture who met inclusion criteria, 139 (35%) of whom were reported to have a clinically significant concomitant injury. Characteristics and fracture patterns were similar between groups. Of patients with pretreatment MRI, 79 of 176 (45%) had an identified concomitant injury, whereas only 60 of 219 patients (27%) without pretreatment MRI had a reported concomitant injury ( < .001). There was a higher rate of lateral meniscal tears ( < .001) in patients with pretreatment MRI than in those without. However, there was a higher rate of soft tissue entrapment at the fracture bed ( = .030) in patients without pretreatment MRI. Overall, 121 patients (87%) with a concomitant injury required at least 1 treatment.

Conclusion: Patients with pretreatment MRI had a statistically significantly higher rate of concomitant injury identified. Pretreatment MRI should be considered in the evaluation of tibial spine fractures to improve the identification of concomitant injuries, especially in patients who may otherwise be treated nonoperatively or with closed reduction. Further studies are necessary to refine the indications for MRI in patients with tibial spine fractures, determine the characteristics of patients at highest risk of having a concomitant injury, define the sensitivity and specificity of MRI in tibial spine fractures, and investigate patient outcomes based on pretreatment MRI status.
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http://dx.doi.org/10.1177/0363546520957666DOI Listing
November 2020

Four Risk Factors for Arthrofibrosis in Tibial Spine Fractures: A National 10-Site Multicenter Study.

Am J Sports Med 2020 10 8;48(12):2986-2993. Epub 2020 Sep 8.

Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.

Background: Tibial spine fractures (TSFs) are relatively rare pediatric injuries. Postoperative arthrofibrosis remains the most common complication, with few studies having examined factors associated with its development.

Purpose: To identify risk factors for arthrofibrosis and required MUA or lysis of adhesions in the largest known cohort of patients with TSFs.

Study Design: Case-control study; Level of evidence, 3.

Methods: This was a multicenter study of 249 patients ≤18 years old who had a TSF between January 2000 and February 2019. Patients were separated into cohorts based on whether they developed arthrofibrosis, defined as a 10° deficit in extension and/or 25° deficit in flexion at postoperative 3 months or a return to the operating room for manipulation under anesthesia (MUA) and/or lysis of adhesions.

Results: A total of 58 (23.3%) patients developed postoperative arthrofibrosis, with 19 (7.6%) requiring a return to the operating room for MUA. Patients with arthrofibrosis were younger (mean ± SD, 11.3 ± 2.7 vs 12.3 ± 2.8 years; = .029). They were more likely to have a nonsport, trauma-related injury (65.4% vs 32.1%; < .001) and a concomitant ACL injury (10.3% vs 1.1%; = .003). Those with arthrofibrosis had longer operative times (135.0 vs 114.8 minutes; = .006) and were more likely to have been immobilized in a cast postoperatively (30.4% vs 16.6%; = .043). In multivariate regression, concomitant anterior cruciate ligament (ACL) injury (odds ratio [OR], 20.0; = .001), traumatic injury (OR, 3.8; < .001), age <10 years (OR, 2.2; = .049), and cast immobilization (OR, 2.4; = .047) remained significant predictors of arthrofibrosis. Concomitant ACL injury (OR, 7.5; = .030) was additionally predictive of a required return to the operating room for MUA.

Conclusion: Surgeons should be cognizant of arthrofibrosis risk in younger patients with concomitant ACL tears and traumatic injuries not resulting from athletics. Furthermore, postoperative immobilization in a cast should be avoided given the high risk of arthrofibrosis. Concomitant ACL injury is associated with a higher return to the operating room for MUA.
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http://dx.doi.org/10.1177/0363546520951192DOI Listing
October 2020

Morel-Lavallée lesions (internal degloving injuries) of the lower extremity in the pediatric and adolescent population.

Phys Sportsmed 2021 May 22;49(2):182-186. Epub 2020 Oct 22.

Department of Orthopedic Surgery, Texas Children's Hospital, Houston, TX, USA.

Purpose: To describe the largest case series of lower extremity traumatic internal degloving injury, i.e. Morel-Lavallée lesion (MLL) in the pediatric and adolescent population, its treatment and outcomes.

Methods: Retrospective review of patients under 18 years who presented with MLL to a tertiary children's hospital. Demographic, clinical, radiographic, treatment and outcomes data were collected. Descriptive statistical analysis was conducted.

Results: 38 patients having MLL with mean age 14.6 years were classified into two groups: hip/thigh MLL (nine patients) and lower leg MLL (29). Most common cause of lower leg and hip/thigh MLL was sports injury (79.3%) and motor vehicle accident (MVA) (33%) respectively. Most implicated sports were football and baseball. Primary care physicians/pediatricians were the initial treating providers for 63% of patients. Imaging modality of choice was magnetic resonance imaging (MRI) for lower leg MLLs (72.4%) and ultrasonography (US) for hip/thigh MLL (66.7%). Twenty-five (65.8%) patients were treated with conservative management, 12 (31.6%) with minimally invasive methods and 1 (2.6%) needed surgical management. Average return to normal activities took 14.3 and 9.1 weeks for hip/thigh and lower leg MLL, respectively. Twenty-four patients with adequate documentation demonstrated lower extremity functional score (LEFS) and pain level of 74/80 (92.5%) and 0.7/10, respectively, at mean 12.5 months follow-up.

Conclusion: In contrast to adult injury literature, pediatric MLLs are more common in the leg/knee than hip/thigh region and caused mostly by sports injuries. Primary care physicians are the initial treating providers for the majority of the patients. Intervention is more often needed in the hip/thigh MLLs as opposed to non-operative management for lower leg injuries. This large case series on MLL in the pediatric population demonstrates differences in the management of hip and thigh lesions when compared to the management of the knee and leg lesions in the majority of these patients. Non-operative management in the majority of these lesions provided overall satisfactory outcomes.
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http://dx.doi.org/10.1080/00913847.2020.1803712DOI Listing
May 2021

Posterior ankle impingement disguised as peroneal tendon subluxation in young athletes - a case report.

J Clin Orthop Trauma 2020 May-Jun;11(3):479-481. Epub 2020 Mar 18.

Texas Children's Hospital, Department of Orthopedic Surgery, Houston, TX, USA.

Posterior ankle impingement is a cause of posterior ankle pain common in those who perform frequent plantarflexion activities. Three young patients presented with posterior ankle pain which was initially attributed to peroneal tendon subluxation. However, detailed physical exam and imaging confirmed the diagnosis of posterior ankle impingement as the actual cause of pain. The peroneal tendon subluxation was not causal but an unrelated co-incidental finding. After failed prolonged conservative management (rest, immobilization and physical therapy), the patients underwent posterior ankle arthroscopic debridement for the impingement resulting in return to prior sporting activity without limitation and no recurrence of pain at 19 months follow-up. Posterior ankle impingement diagnosis could be masked by co-incidental asymptomatic peroneal tendon subluxation in pediatric patients.
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http://dx.doi.org/10.1016/j.jcot.2020.03.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7211818PMC
March 2020

Posterior ankle impingement-an underdiagnosed cause of ankle pain in pediatric patients.

World J Orthop 2019 Oct 18;10(10):364-370. Epub 2019 Oct 18.

Department of Orthopaedics, University of California, San Francisco, CA 94143, United States.

Background: Posterior ankle impingement syndrome (PAIS) is a cause of ankle pain due to pinching of bony or soft tissue structures in the hindfoot. The diagnosis is primarily made based on detailed history and accurate clinical examination. The delay in its diagnosis has not yet been described in the pediatric and adolescent population.

Aim: To identify and characterize misdiagnosed cases of PAIS in pediatric and adolescent patients.

Methods: This descriptive prospective study at a tertiary children's hospital included patients ≤ 18 years who underwent posterior ankle arthroscopy after presenting with chronic posterior ankle pain after being diagnosed with PAIS. Collected data included: Demographics, prior diagnoses and treatments, providers seen, time to diagnosis from presentation, and prior imaging obtained. Visual Analogue Scale (VAS) for pain and American Orthopedic Foot Ankle Society (AOFAS) ankle-hindfoot scores were noted at initial presentation and follow-up.

Results: 35 patients (46 ankles) with average age of 13 years had an average 19 mo (range 0-60 mo) delay in diagnosis from initial presentation. 25 (71%) patients had previously seen multiple medical providers and were given multiple other diagnoses. All 46 (100%) ankles had tenderness to palpation over the posterior ankle joint. Radiographs were reported normal in 31/42 (72%) exams. In 32 ankles who underwent MRI, the most common findings included os trigonum (47%)/Stieda process (47%). Conservative treatment had already been attempted in all patients. Ankle impingement pathology was confirmed during arthroscopy in 46 (100%) ankles. At an average follow-up of 13.1 mo, there was an improvement of VAS (pre-op 7.0 to post-op 1.2) and AOFAS scores (pre-op 65.1 to post-op 94).

Conclusion: This is the first study which shows that PAIS is a clinically misdiagnosed cause of posterior ankle pain in pediatric and adolescent population; an increased awareness about this diagnosis is needed amongst providers treating young patients.
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http://dx.doi.org/10.5312/wjo.v10.i10.364DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6854055PMC
October 2019

Delayed diagnosis of posterior ankle impingement in pediatric and adolescent patients: does radiology play a role?

Pediatr Radiol 2020 02 9;50(2):216-223. Epub 2019 Nov 9.

E. B. Singleton Department of Pediatric Radiology, Texas Children's Hospital, 6701 Fannin St., Suite 470, Houston, TX, 77030, USA.

Background: Posterior ankle impingement syndrome (PAIS) results from the pinching of anatomical structures in the posterior part of the ankle.

Objective: To identify the possible role of imaging in the delayed diagnosis of PAIS and identify key findings on imaging to suggest PAIS in pediatric and adolescent patients.

Materials And Methods: Data were collected prospectively in patients younger than 18 years of age who underwent arthroscopy after being diagnosed with PAIS. Imaging was reviewed retrospectively by two radiologists, compared with findings in literature and an age-matched control group, and correlated with arthroscopic findings. Pre- and postsurgical Visual Analogue Scale (VAS) pain and American Orthopedic Foot Ankle Society (AOFAS) ankle-hindfoot scores were noted.

Results: Thirty-eight patients (20 females, 18 males), 51 ankles, with an average age of 12.9 years had an average 18-month delay in diagnosis. Twenty-seven of the 38 (73%) patients had previously seen multiple medical providers and were given multiple misdiagnoses. Radiographs were reported normal in 34/47 (72%) ankles. Thirty patients had magnetic resonance imaging (MRI) and findings included the presence of an os trigonum/Stieda process (94%) with associated osseous edema (69%), flexor hallucis longus (FHL) tenosynovitis (16%), and edema in Kager's fat pad (63%). Although individual findings were noted, the impression in the MRI reports in 16/32 (50%) did not mention PAIS as the likely diagnosis. There was a significant difference in the MRI findings of ankle impingement in the patient population when compared to the control group. Surgery was indicated after conservative treatment failed. All 51 ankles had a PAIS diagnosis confirmed during arthroscopy. At an average follow-up of 10.2 months, there was improvement of VAS pain (7.0 to 1.1) and AOFAS ankle-hindfoot scores (65.1 to 93.5).

Conclusion: PAIS as a diagnosis is commonly delayed clinically in young patients with radiologic misinterpretation being a contributing factor. Increased awareness about this condition is needed among radiologists and physicians treating young athletes.
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http://dx.doi.org/10.1007/s00247-019-04547-6DOI Listing
February 2020

Spontaneous Hemarthrosis of the Knee - Late Complication of Flexible Femur Nailing: A Case Report.

Trauma Mon 2016 Sep 27;21(4):e23063. Epub 2016 Mar 27.

Division of Orthopaedic Surgery and Sports Medicine, Children's National Medical Center, Washington DC, USA.

We present a case report of acute spontaneous knee hemarthosis due to erosion of the nail through the knee joint capsule in a boy, seven months following retrograde flexible nailing for fractured femur. Careful positioning of the location of the insertion site of flexible nails and proper nail tip management are important to avoid this rare late complication.
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http://dx.doi.org/10.5812/traumamon.23063DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5282937PMC
September 2016

Discoid Meniscus: Diagnosis and Management.

Orthop Clin North Am 2015 Oct 6;46(4):533-40. Epub 2015 Aug 6.

Department of Orthopedics, Nationwide Children's Hospital, 700 Childrens Drive, Columbus, OH 43205, USA. Electronic address:

Discoid lateral meniscus is a common abnormal meniscal variant in children. Detailed history and physical examination combined with an MRI of the knee predictably diagnose a discoid meniscus. The clinical presentation varies from being asymptomatic to snapping, locking, and causing severe pain and swelling of the knee. Because of the pathologic anatomy and instability, discoid menisci are more prone to tearing. Treatment options for symptomatic patients vary based on the type of anomaly, the age of the patient, stability, and the presence or absence of a tear. Improvements in arthroscopic equipment and technique have resulted in good to excellent short-term outcomes for saucerization and repair.
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http://dx.doi.org/10.1016/j.ocl.2015.06.007DOI Listing
October 2015

Acute, unstable slipped capital femoral epiphysis with associated congenital coxa vara.

J Pediatr Orthop B 2015 Nov;24(6):511-4

aDepartment of Orthopedic Surgery, Nationwide Children's Hospital bDepartment of Orthopaedics, The Ohio State University, Columbus, Ohio, USA.

Slipped capital femoral epiphysis in patients younger than 10 years is rare and is often associated with some identifiable metabolic or endocrinologic abnormality. We present a case of a 5-year-old girl with an acute, unstable, severe slipped capital femoral epiphysis associated with congenital coxa vara and its surgical management. This association has not been described in previous literature. Surgical treatment is proposed and described.
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http://dx.doi.org/10.1097/BPB.0000000000000209DOI Listing
November 2015

Incidence of Hip Dysplasia Associated With Bladder Exstrophy.

J Pediatr Orthop 2016 Dec;36(8):860-864

Departments of *Orthopedic Surgery †Urology, Nationwide Children's Hospital, Columbus, OH.

Background: Exstrophy of the bladder is a rare congenital defect seen in 2.15 children out of every 100,000 live births, with the most severe variant, cloacal exstrophy (CE), only occurring in 1 in 200,000. Developmental dysplasia of the hip (DDH) describes a spectrum of disease ranging from mild hip instability to frank dislocation. Underlying malformations, such as myelomeningocele and arthrogryposis, are often associated with the most severe variant of hip dysplasia, teratologic hip dislocation. The varying degrees of severity in DDH have been encountered in classic bladder exstrophy (CBE) patients, but the exact incidence is unknown. We sought to determine the incidence of DDH in CBE and CE patients.

Methods: We performed a retrospective review of all children with CBE or CE presenting to a single pediatric center between 1994 and 2014. Each chart was reviewed for correct diagnosis of CBE or CE, patient age and demographics, associated medical conditions, pertinent surgeries performed, and the age at operation. Patient imaging was reviewed to determine whether bilateral hip imaging was available.

Results: In a 20-year retrospective review, we identified 66 patients who were diagnosed with either CBE or CE and had available hip imaging (38 males and 28 females). Of these, 11 patients were found to have radiographic evidence of DDH, for an incidence of 16.7% (11/66). Five of these patients had CE, whereas 6 presented with CBE. The first radiographic evidence of DDH was noted at a mean age of 5.75 years (range, birth to 22 y).

Conclusions: We advocate the use of routine hip screening ultrasound in all infants born with either CBE or CE. Early identification of DDH in these patients may allow additional treatment options to coincide with frequently used osteotomy and orthopaedic interventions.

Level Of Evidence: Level III-retrospective study.
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http://dx.doi.org/10.1097/BPO.0000000000000571DOI Listing
December 2016

Traumatic, Posterior Pediatric Hip Dislocations With Associated Posterior Labrum Osteochondral Avulsion: Recognizing the Acetabular "Fleck" Sign.

J Pediatr Orthop 2016 Sep;36(6):602-7

*Department of Orthopaedic Surgery, Nationwide Children's Hospital †Department of Orthopaedics, The Ohio State University, Columbus, OH.

Background: Traumatic dislocation of the hip is uncommon in the pediatric population. Concentric reduction is usually achieved by closed means. Open reduction may be needed if there is femoral head fracture, incarcerated fragment, or incomplete reduction due to soft tissue entrapment. We present a series of 10 patients who sustained a posterior hip dislocation or subluxation with associated osteochondral avulsion of the posterior labrum. During surgery they were noted to have a labral injury pattern not previously recognized. Such treatment was dictated by postreduction advanced imaging, which revealed a consistent acetabular "fleck" sign indicative of this labral injury, which has not been previously described in literature.

Methods: We performed a retrospective case review of patients with traumatic posterior hip dislocation/subluxation, treated operatively for a suspected associated labral tear and fractures.

Results: Ten patients (2 girls and 8 boys) were identified. Average age was 12.7 years. Eight patients had postreduction computed tomography scans, which revealed a posterior acetabular wall "fleck" sign, suggestive of osteochondral injury. The small bony fragment was consistently displaced at least 2 to 3 mm in all patients with majority of the posterior wall remaining intact. Closed reduction was felt to be congruent in 7 of the 10 patients. All patients were treated operatively for exploration and stabilization of the suspected posterior labrum pathology and associated injuries using a surgical hip dislocation. A consistent pattern of labral pathology was seen in all patients, with disruption of the posterior labrum from the superior 12 o'clock attachment to detachment at the inferior 6 o'clock location. Reattachment of the osteochondral labral avulsion was performed with suture anchors along the posterior rim, and the associated femoral head fractures were also addressed with internal fixation. Two patients had inadequate follow-up and were excluded, the average follow-up for the remaining 8 patients was 9.8 months (range, 6 to 26 mo). There were no findings of avascular necrosis in any of the 8 patients.

Conclusions: Posterior hip dislocation in children may produce an acetabular "fleck" sign on advanced imaging, which in a stable, concentrically reduced hip has been treated without surgery in the past. Acetabular fleck sign may represent a near-complete avulsion of the posterior labrum as seen in our series. We recommend a high suspicion for this type of labral pathology and surgical repair when acetabular "fleck" sign is identified with hip subluxation or dislocation. Traumatic, posterior hip dislocations in young patients may be associated with significant labral pathology. Acetabular "fleck" sign on advanced imaging may predict such pathology.

Level Of Evidence: IV, retrospective study.
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http://dx.doi.org/10.1097/BPO.0000000000000507DOI Listing
September 2016

Radial Neck Fractures in Children and Adolescents: An Examination of Operative and Nonoperative Treatment and Outcomes.

J Pediatr Orthop 2016 Jan;36(1):6-12

Department of Orthopaedic Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA.

Background: Although most pediatric radial neck fractures can be treated with either immobilization alone or closed reduction and immobilization, a small subset result in permanent loss of motion despite surgical management. We sought to characterize the most problematic fractures and correlate final outcomes with both presenting fracture characteristics and the reduction achieved through surgical intervention.

Methods: One hundred ninety-three consecutive children with a radial neck fracture, satisfactory initial treatment data, and follow-up range-of-motion (ROM) data presenting between 1999 and 2012 to our level 1 trauma center were evaluated. The O'Brien classification was used to evaluate angulation on radiographs. Final ROM outcomes were categorized into excellent, good, fair, and poor. ROM data were not used in the operative group if follow-up was <12 weeks (<6 wk in the nonoperative group) or if there was no follow-up after cast removal.

Results: Thirteen percent of all patients presenting with radial neck fractures required operative treatment (average age 9.1 y). Of patients treated operatively with adequate ROM data, 26.4% healed with fair or poor outcomes. Patients requiring open management were of older average age (average 10 y old, P=0.02) and had a significantly greater risk of a fair or poor ROM outcome than those treated with closed operative techniques (P=0.02). Patients treated nonoperatively were of a younger average age than those in the operative cohort (8.2 vs. 9.1 y, P=0.03). Patients treated operatively were more likely to develop complications (P=0.004); however, presence of a complication was not predictive of fair or poor outcomes in either the operative (P=0.117) or nonoperative (P=0.264) groups.

Conclusions: Older children are more likely to have more severely displaced radial neck fractures requiring open surgical management, thus resulting in a greater risk of fair or poor outcomes. In the series as a whole, more complications were seen when operative management was required. Final outcomes were not shown to be significantly related to preoperative displacement, postoperative reduction, presence of associated injuries, energy of injury, or treatment complications.

Levels Of Evidence: Level III—therapeutic.
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http://dx.doi.org/10.1097/BPO.0000000000000387DOI Listing
January 2016

Comparative results of percutaneous Achilles tenotomy to combined open Achilles tenotomy with posterior capsulotomy in the correction of equinus deformity in congenital talipes equinovarus.

Int Orthop 2015 Apr 18;39(4):721-5. Epub 2015 Feb 18.

Division of Orthopedic Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.

Purpose: The purpose of this study is to compare the efficacy of percutaneous Achilles tenotomy (AT) to combined open Achilles tenotomy and posterior capsulotomy (PC+AT) in the correction of residual equinus deformity in congenital talipes equinovarus after Ponseti serial casting in both idiopathic and non-idiopathic clubfeet.

Methods: The authors retrospectively reviewed 591 patients treated for congenital talipes equinovarus between January 1, 2001 and January 1, 2011. Available medical and operative records were reviewed for basic demographic data as well as ankle dorsiflexion pre-operatively, postoperatively and at latest follow up.

Results: A total of 167 children with 260 discrete clubfeet that met our inclusion criteria were identified. Of them, 189/260 clubfeet (72.7 %) were idiopathic and 71/260 clubfeet (27.3 %) were non-idiopathic with a mean total follow up of 4.8 ± 2.4 years (minimum follow-up of two years). At latest follow up, there was no statistically significant difference in the mean ankle dorsiflexion (p = 0.333) or recurrence rate (p = 0.545) between PC+AT and AT groups in both idiopathic and non-idiopathic clubfeet.

Conclusion: In our series, the addition of posterior capsulotomy to Achilles tenotomy did not improve the mean dorsiflexion at latest follow up or decrease the rate of recurrence of equinus deformity in both idiopathic and non-idiopathic clubfeet. It is therefore advisable that percutaneous Achilles tenotomy alone be used in the correction of equinus deformity in both idiopathic and non-idiopathic congenital talipes equinovarus after successful Ponseti serial casting.
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http://dx.doi.org/10.1007/s00264-014-2631-4DOI Listing
April 2015

Fibrous dysplasia of the proximal femur: surgical management options and outcomes.

J Child Orthop 2014 Dec 20;8(6):505-11. Epub 2014 Nov 20.

Division of Orthopaedic Surgery, The Children's Hospital of Philadelphia, 3400 Civic Center Boulevard, Philadelphia, PA, 19104, USA.

Purpose: The management of proximal femoral deformity in fibrous dysplasia (FD) is a challenge to the orthopaedic surgeon. The purpose of this study was to analyze the various presentations of FD of proximal femur and the results of the various treatment modalities for the same.

Methods: This is a retrospective cohort study of 23 patients (24 femora) with FD who underwent surgery for the proximal femur. The study sample included 14 males, nine females. Ten patients had a monostotic disease, eight patients had polyostotic disease, and five patients had McCune-Albright syndrome.

Results: Group 1: shepherd crook deformity-included five patients who underwent femoral neck osteotomy. Four patients had intramedullary (IM) nailing with neck cross-pinning and all patients showed union. One patient was stabilized with external fixation, which failed. Group 2: nine patients (ten femora) presented with frank pathological fracture. Nine underwent fixation with IM nailing, one with locking plate and screws. Three patients had to undergo more than one procedure and all fractures showed good union. Group 3: nine patients who presented with bone cyst and pain. All patients underwent biopsy; four of them had curettage with bone graft.

Conclusion: Shepherd crook deformity can be treated by a well-planned osteotomy and fixation with intramedullary implants with neck cross-pinning. Frank pathological fractures fixation with an intramedullary nail has excellent results even if not accompanied by resolution of the fibrodysplastic lesion. More than one procedure may be required. External fixation is not an optimal choice for fixation of femoral osteotomies in FD.
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http://dx.doi.org/10.1007/s11832-014-0625-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4252268PMC
December 2014

Chest wall osteochondroma in children: a case series of surgical management.

J Pediatr Orthop 2014 Oct-Nov;34(7):733-7

Divisions of *Orthopaedic Surgery †Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA.

Background: Chest wall osteochondroma is a rare tumor in children. Even though the potential for malignant transformation or serious intrathoracic complications is low, it has led some centers to advocate surgical management of these bony tumors. We present our experience of the surgical management of costal osteochondromata.

Methods: Between January 1, 2006 and November 1, 2012 we saw 854 patients with solitary or multiple exostoses in our clinics. By reviewing our billing lists we found 7 children who had surgical management of chest wall osteochondromata. The indications for surgery were pain (3 patients), excision for confirmation of diagnosis (2 patients), recurrent pneumothorax (1 patient), and malignancy (1 patient).

Results: All patients made a good postoperative recovery with a median hospital stay of 1.8 days (range, 0 to 4 d). There was no recurrence of exostosis on follow-up (range, 8 mo to 2.6 y). One patient required surgery for excision of another chest wall osteochondroma at an adjacent location. No patient reported scar-related pain symptoms. No malignant transformation or intrathoracic complications occurred. We found ribs as the first site of presentation of multiple hereditary exostoses in 2 young patients.

Conclusions: Surgical management of thoracic osteochondroma, with excision for painful, symptomatic, malignant lesions or lesions adjudged to be at risk of intrathoracic complications, yields good outcomes in terms of symptom control, establishing histologic diagnosis, and prevention of thoracic complications.

Level Of Evidence: Level IV-case series.
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http://dx.doi.org/10.1097/BPO.0000000000000153DOI Listing
June 2015

Pinless halo in the pediatric population: indications and complications.

J Pediatr Orthop 2015 Jun;35(4):374-8

Division of Orthopedic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA.

Background: The use of the conventional halo is accompanied by the possibility of serious complications, especially in the pediatric population. Complications could include penetration of pin into the skull, pin loosening, pin tract infection, cranial nerve palsies, and vest-related pressure sores. The noninvasive "pinless" halo was introduced in an attempt to mitigate these problems while retaining the effectiveness of the conventional halo. The purpose of this study is to determine the indications and complications related to pinless halo application.

Methods: We retrospectively reviewed 61 patients, whose treatment included the use of a pinless halo device, presenting to our institution between 2004 and 2012.

Results: There were 35 male and 26 female patients with an average age of 6.04 years. Indications of pinless halo application included postoperative immobilization for congenital muscular torticollis in 38 cases, conservative management of atlantoaxial rotatory subluxation in 11 cases, postoperative immobilization following cervical fusion in 10 cases, and immobilization for occipital condyle fracture in 2 cases. The average duration of the pinless halo application was 32.68 days. Thirteen patients had complications, among which major complications were seen in 2 patients, each of whom developed a pressure sore; one on the scalp and the other on the chest. Both the pressure sores responded to local treatment; however, 1 resulted in permanent alopecia.

Conclusions: The use of the noninvasive pinless halo was found to be safe with few complications in our study. The complications were infrequent and patients were compliant to treatment, indicating that this modality is patient-friendly. Effectiveness of this treatment in comparison with invasive halos and other cervical orthoses was not determined and is a limitation of this study.

Level Of Evidence: Level IV-Case series.
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http://dx.doi.org/10.1097/BPO.0000000000000267DOI Listing
June 2015

Unicameral bone cysts: general characteristics and management controversies.

J Am Acad Orthop Surg 2014 May;22(5):295-303

Unicameral bone cysts are benign bone lesions that are often asymptomatic and commonly develop in the proximal humerus and femur of skeletally immature patients. The etiology of these lesions remains unknown. Most patients present with a pathologic fracture, but these cysts can be discovered incidentally, as well. Radiographically, a unicameral bone cyst appears as a radiolucent lesion with cortical thinning and is centrally located within the metaphysis. Although diagnosis is frequently straightforward, management remains controversial. Because the results of various management methods are heterogeneous, no single method has emerged as the standard of care. New minimally invasive techniques involve cyst decompression with bone grafting and instrumentation. These techniques have yielded promising results, with low rates of complications and recurrence reported; however, prospective clinical trials are needed to compare these techniques with current evidence-based treatments.
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http://dx.doi.org/10.5435/JAAOS-22-05-295DOI Listing
May 2014

Bilateral C6 spondylolysis with spondylolisthesis in 3 adolescent siblings.

J Pediatr Orthop 2014 Oct-Nov;34(7):e40-3

Division of Orthopaedic Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA.

Background: Cervical spondylolysis with spondylolisthesis is a rare condition in the pediatric population. The nature of this condition and clinical presentation are important to provide appropriate management.

Methods: This is a case report of 3 adolescent siblings who had C6 cervical spondylolysis with spondylolisthesis.

Results: Two cases were diagnosed insidiously with absence of neurological deficits and no instability on imaging and were treated conservatively. One case had a traumatic presentation associated with instability on imaging and was managed with cervical fusion and instrumentation. All 3 patients were doing well on a follow-up of >2 years.

Conclusions: These cases suggest that cervical spondylolysis could be familial. The treatment was offered based on clinical presentation and presence of instability on radiographic studies.

Level Of Evidence: Level IV.
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http://dx.doi.org/10.1097/BPO.0000000000000175DOI Listing
June 2015