Publications by authors named "Philip L Wilson"

38 Publications

Quantifying the Relationship Between the Medial Quadriceps Tendon-Femoral Ligament and Patellar Borders: A Pediatric Cadaveric Study.

Am J Sports Med 2022 07 28;50(9):2433-2438. Epub 2022 Jun 28.

Investigation performed at Stanford University School of Medicine, Stanford, California, USA.

Background: The medial patellofemoral complex (MPFC) is a structure composed of the medial quadriceps tendon-femoral ligament (MQTFL) superiorly and the medial patellofemoral ligament (MPFL) inferiorly. The pediatric MPFL anatomy has been well described, but the precise anatomy of the MQTFL has only recently been described and studied in skeletally immature patients.

Purpose: To describe the anatomic relationship between the MQTFL and its insertion on the quadriceps tendon and patella in pediatric specimens.

Study Design: Descriptive laboratory study.

Methods: A total of 22 pediatric cadaveric knee specimens were dissected to analyze attachment of the MQTFL to the quadriceps tendon and patella. Dissection was facilitated using lateral parapatellar arthrotomy followed by eversion of the extensor mechanism to evaluate MQTFL fibers from its undersurface.

Results: The mean specimen age was 7.4 years. Specimens were divided based on age into a younger cohort (1-2 years), middle cohort (4-8 years), and older cohort (9-12 years). The quadriceps tendon attachment (QTA) of the MQTFL proximal to the patella extended a median of 5.0 mm in the younger cohort, 11.4 mm in the middle cohort, and 12.0 mm in the older cohort, with significant differences found between the younger and middle cohorts ( < .047) and the younger and older cohorts ( < .001). The QTA as a percentage of patellar articular height averaged 44.4% across all specimens. The vertical height of the patella measured a median of 14.0 mm, 22.3 mm, and 27.3 mm in the younger, middle, and older cohorts, respectively.

Conclusion: This study expands on the recently described anatomy of the pediatric MPFC to quantify the anatomic relationship between the MQTFL attachment to the quadriceps tendon and patella in a more clinically relevant cohort of donor specimens.

Clinical Relevance: As access to pediatric cadaveric tissue is extremely limited, a better understanding of MPFC and MQTFL anatomy will support surgeons in preoperative planning and intraoperative considerations for their approach to MQTFL and MPFL reconstruction. This may facilitate improved anatomic surgical stabilization of the patellofemoral joint in pediatric patients.
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http://dx.doi.org/10.1177/03635465221103250DOI Listing
July 2022

Epidemiology of Pediatric Gymnastics Injuries Reported in US Emergency Departments: Sex- and Age-Based Injury Patterns.

Orthop J Sports Med 2022 Jun 13;10(6):23259671221102478. Epub 2022 Jun 13.

University of Texas Southwestern Medical Center, Dallas, Texas, USA.

Background: Despite increasing participation rates in youth gymnastics, the majority of epidemiologic literature focuses on older elite athletes or stratifies athletes by level of competition.

Hypothesis: The authors hypothesized that sex- and age-based patterns in youth gymnastics-related injuries exist, which are otherwise overlooked in an unstratified population.

Study Design: Descriptive epidemiology study.

Methods: Publicly available injury data from the National Electronic Injury Surveillance System were collected on pediatric gymnastics injuries presenting to emergency departments in the United States. Participation data from the National Sporting Goods Association were used to calculate national injury incidence rates in 7- to 11-year-olds (childhood) and 12- to 17-year-olds (adolescence) from January 1, 2012, to December 31, 2018. tests were conducted for the comparison of injury rates between girls and boys within each age group and for overall injury rate across age groups.

Results: Girls participated in gymnastics at a frequency 6.5 times that of boys in childhood and 13.5 times that of boys in adolescence. An estimated 72,542 youth gymnastics-related injuries were reported in US emergency departments each year. A large proportion (61.3%) occurred in childhood, with female predominance in both age groups. Overall, there was no difference in weighted annual injury rate (injuries per 100,000 athlete-days per year) by age group (6.9 [childhood] vs 8.8 [adolescence]; = .19) or sex (7.4 [girls] vs 8.1 [boys]; = .65). In adolescence, boys were more likely than girls to experience injury (16.47 vs 8.2; = .003). Wrist and lower arm fractures were more common in childhood than adolescence (1.07 vs 0.43; = .002) and specifically in girls (childhood vs adolescence, 1.06 vs 0.37; = .001). Ankle injuries and concussions were more common in adolescence vs childhood ( = .01 and .0002).

Conclusion: Upper extremity injuries predominated among childhood gymnasts, particularly girls. In adolescence, girls and boys experienced increases in concussions and foot and ankle injuries. Although representing a lower overall number of training gymnasts as compared with girls, adolescent boys experience a higher rate of injuries overall.
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http://dx.doi.org/10.1177/23259671221102478DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9201328PMC
June 2022

Sport Participation and Psychosocial Factors Which Influence Athletic Identity in Youth Athletes With Anterior Cruciate Ligament Injury.

Front Psychol 2022 31;13:906300. Epub 2022 May 31.

Center for Excellence in Sports Medicine, Scottish Rite for Children Orthopedic and Sports Medicine Center, Frisco, TX, United States.

Athletic identity, or the degree with which individuals identify with the athlete role, is an important rehabilitation factor for sports care providers to consider; however, it lacks extensive study in youth. The purpose of this study was to identify demographic, sport participation, and psychosocial measures which correlate with youth athletic identity after anterior cruciate ligament injury. Participants completed standardized sports medicine intake and patient-reported outcome measures, including the Athletic Identity Measurement Scale (AIMS). A total of 226 participants were included, and two groups were created based on high or low total AIMS score. Results indicated that sex ( = ), years active in sport ( = ), activity level ( = ), and ACSI-Coachability ( = ) differed by AIMS score. While youth athletes appear resilient, these results emphasize that they identify strongly with the athlete role and may suffer psychosocial consequences after injury. Future work should evaluate similar factors over course of recovery in a larger, diversified population.
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http://dx.doi.org/10.3389/fpsyg.2022.906300DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9197472PMC
May 2022

Reliability of a New Arthroscopic Discoid Lateral Meniscus Classification System: A Multicenter Video Analysis.

Am J Sports Med 2022 04 2;50(5):1245-1253. Epub 2022 Mar 2.

Investigation performed at Seattle Children's Hospital, Seattle, Washington, USA.

Background: The discoid lateral meniscus (DLM) is one of the most common congenital anomalies of the knee. The pathomorphology of DLM varies. Current classification systems are inadequate to describe the spectrum of abnormality.

Purpose: A study group of pediatric orthopaedic surgeons from 20 academic North American institutions developed and tested the reliability of a new DLM classification system.

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

Methods: After reviewing existing classifications, we developed a comprehensive DLM classification system. Four DLM features were evaluated: meniscal width, meniscal height, peripheral stability, and meniscal tear. Stepwise arthroscopic examination using anteromedial and anterolateral viewing portals was established for evaluating these features. Three senior authors who were not observers selected 50 of 119 submitted videos with the best clarity and stepwise examination for reading. Five observers performed assessments using the new classification system to assess interobserver reliability, and a second reading was performed by 3 of the 5 observers to assess intraobserver reliability using the Fleiss κ coefficient (fair, 0.21-0.40; moderate, 0.41-0.60; substantial, 0.61-0.80; excellent, 0.81-1.00).

Results: Interobserver reliability was substantial for most rating factors: meniscal width, meniscal height, peripheral stability, tear presence, and tear type. Interobserver reliability was moderate for tear location. Intraobserver reliability was substantial for meniscal width and meniscal height and excellent for peripheral stability. Intraobserver agreement was moderate for tear presence, type, and location.

Conclusion: This new arthroscopic DLM classification system demonstrated moderate to substantial agreement in most diagnostic categories analyzed.
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http://dx.doi.org/10.1177/03635465221076857DOI Listing
April 2022

Osteochondral Allograft for Unsalvageable Osteochondritis Dissecans in the Skeletally Immature Knee.

Orthop J Sports Med 2022 Feb 11;10(2):23259671211072515. Epub 2022 Feb 11.

University of Texas Southwestern Medical Center, Dallas, Texas, USA.

Background: While an excellent option for osteochondral defects in the adult knee, fresh osteochondral allograft (FOCA) in the skeletally immature adolescent knee has been infrequently studied.

Purpose: To compare radiographic and patient-reported outcomes (PROs) in skeletally mature and immature adolescents after FOCA in the knee for treatment of unsalvageable osteochondritis dissecans (OCD).

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

Methods: Included were 34 patients (37 knees) who underwent size-matched FOCA of the knee for unsalvageable OCD lesions. All patients were aged ≤19 years and had a minimum of 12 months of follow-up. Patient characteristics, lesion characteristics, reoperations, and PROs were evaluated and compared between patients with open physes (skeletally immature; n = 20) and those with closed physes (skeletally mature; n = 17). Graft failure was defined as the need for revision osteochondral grafting. Postoperative radiographs were analyzed at 1 year and the final follow-up for graft incorporation and classified as A (complete), B (≥50% healed), or C (<50% healed).

Results: The mean patient age was 15.4 years (range, 9.6-17.6 years), and the mean follow-up was 2.1 years (range, 1-5.3 years). The mean graft size was 5.0 cm and did not differ significantly between the study groups. Patients with open physes were younger (14.7 vs 16.2 years; = .002) and more commonly male (80% vs 35%; = .008). At the 1-year follow-up, 85% of immature patients and 82% of mature patients had radiographic healing grades of A or B. Patients with open physes were more likely to achieve complete radiographic union at 1 year (65% vs 15%; = .007) and demonstrated better Knee injury and Osteoarthritis Outcome Score (KOOS) Daily Living (96.8 vs 88.5; = .04) and KOOS Quality of Life (87.0 vs 56.8; = .01) at the final follow-up. Complications were no different in either group, and graft failure occurred in only 1 skeletally mature patient with a trochlear lesion.

Conclusion: FOCA treatment for unsalvageable OCD in the young knee may be expected to yield excellent early results. Despite the presence of open physes and immature epiphyseal osteochondral anatomy, equivalent or improved healing and PRO scores compared with those of skeletally mature patients may be expected.
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http://dx.doi.org/10.1177/23259671211072515DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8844736PMC
February 2022

Youth athletes sleep more, practice less, and may lose interest in playing sports due to social distancing mandates.

Prev Med Rep 2022 Apr 2;26:101722. Epub 2022 Feb 2.

Scottish Rite for Children, Center for Excellence in Sports Medicine, 2222 Welborn St, Dallas, TX 75219, USA.

In-person sport participation was suspended across the United States in the spring of 2020 to slow the spread of the novel coronavirus (COVID-19). The purpose of this study was to survey the impact of COVID-19 on young athletes during a period of social and organized sports restrictions. An anonymous cross-sectional survey study was conducted of youth athletes in the midst of social distancing mandates and consisted of six components: demographics, sport participation, changes in sport-related goals/aspirations, sleep habits, and measures of anxiety and depression. 711 individuals who accessed the survey link yielded 575 (81%) participants with responses available for analysis. All respondents (aged 13.0 years) played organized sports, 62% were single-sport athletes, and 74% considered high-level. Participants were training ∼3.3 h less per week, spending more time outside, and 86% of participants continued to train while social distancing. Sleep duration increased (∼1.2 h/night) and sleep quality improved in 29% of young athletes. Additionally, 22% and 28% reported PROMIS® anxiety and depression scores characterized as 'mild', 'moderate', or 'severe'. Older single-sport participants reported higher depression scores, while higher anxiety scores were seen in female participants with fewer years played. 10% of young athletes and 20% of teenagers changed their sports-related goals. Training style modifications, decreased training, and increased sleep quantity and quality were positive effects of COVID-19 restrictions, while athletic aspirational changes were undesirable effects. Single-sport athletes may be at greater risk for psychological symptoms when their routine is altered.
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http://dx.doi.org/10.1016/j.pmedr.2022.101722DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8811421PMC
April 2022

Epidemiology of Pediatric Basketball Injuries Presenting to Emergency Departments: Sex- and Age-Based Patterns.

Orthop J Sports Med 2022 Jan 17;10(1):23259671211066503. Epub 2022 Jan 17.

Scottish Rite for Children, Dallas, Texas, USA.

Background: There is limited epidemiologic data on pediatric basketball injuries and the comparison of these injuries before and after adolescence and between male and female athletes.

Purpose: To assess common sex- and age-based injury patterns in pediatric basketball players.

Study Design: Descriptive epidemiology study.

Methods: Injury data from the National Electronic Injury Surveillance System (NEISS) and participation data from the National Sporting Goods Association were used to complete this study. Data on pediatric basketball injuries between January 2012 and December 2018 in patients aged 7 to 11 years (childhood) and 12 to 17 years (adolescence) were extracted and used to calculate national injury incidence rates with 95% CIs. Sex and age group patterns were examined utilizing Pearson chi-square tests. tests were conducted for the comparison of injury rates between female and male athletes in each age group and overall injury rate across age groups.

Results: An average of 9582 basketball injuries were reported annually in the NEISS, which calculated to an annual national estimate of 294,920 injuries. The most common diagnoses were ankle strain/sprain (17.7%), finger strain/sprain/fracture (12.1%), concussion/head injury (9.4%), knee strain/sprain (4.5%), and facial laceration (3.3%). There was a significant increase in injury prevalence in adolescents (12- to 17-year-old category: 238,678 injuries per year) when compared with childhood (7- to 11-year-old category: 56,242 injuries per year) ( < .0001). Concussions/head injuries occurred at a high rate in childhood, second only to finger strain/sprain/fracture, and at a similar rate in females and males (injuries per 100,000 athlete-days: 4.9 [95% CI, 3.1-6.7] vs. 5.9 [4.3-7.5], respectively; = .41). From childhood to adolescence, injury prevalence increased for all areas and across both sexes, except for female finger strain/sprain/fracture; however, the rate of increase for concussion/head injuries and knee injuries was significantly higher in female compared with male athletes ( < .0001 for both). In adolescents, ankle injuries were the most common injury overall.

Conclusion: Ankle injuries continue to be the most predominant pediatric basketball injury. However, disproportionate rates of both knee and concussion/head injuries in female athletes during adolescent basketball are of concern and have implications for injury prevention.
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http://dx.doi.org/10.1177/23259671211066503DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8777358PMC
January 2022

Descriptive Epidemiology From the Research in Osteochondritis Dissecans of the Knee (ROCK) Prospective Cohort.

Am J Sports Med 2022 01 24;50(1):118-127. Epub 2021 Nov 24.

The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.

Background: Osteochondritis dissecans (OCD) occurs most commonly in the knees of young individuals. This condition is known to cause pain and discomfort in the knee and can lead to disability and early knee osteoarthritis. The cause is not well understood, and treatment plans are not well delineated. The Research in Osteochondritis Dissecans of the Knee (ROCK) group established a multicenter, prospective cohort to better understand this disease.

Purpose: To provide a baseline report of the ROCK multicenter prospective cohort and present a descriptive analysis of baseline data for patient characteristics, lesion characteristics, and clinical findings of the first 1000 cases enrolled into the prospective cohort.

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

Methods: Patients were recruited from centers throughout the United States. Baseline data were obtained for patient characteristics, sports participation, patient-reported measures of functional capabilities and limitations, physical examination, diagnostic imaging results, and initial treatment plan. Descriptive statistics were completed for all outcomes of interest.

Results: As of November 2020, a total of 27 orthopaedic surgeons from 17 institutions had enrolled 1004 knees with OCD, representing 903 patients (68.9% males; median age, 13.1 years; range, 6.3-25.4 years), into the prospective cohort. Lesions were located on the medial femoral condyle (66.2%), lateral femoral condyle (18.1%), trochlea (9.5%), patella (6.0%), and tibial plateau (0.2%). Most cases involved multisport athletes (68.1%), with the most common primary sport being basketball for males (27.3% of cases) and soccer for females (27.6% of cases). The median Pediatric International Knee Documentation Committee (Pedi-IKCD) score was 59.9 (IQR, 45.6-73.9), and the median Pediatric Functional Activity Brief Scale (Pedi-FABS) score was 21.0 (IQR, 5.0-28.0). Initial treatments were surgical intervention (55.4%) and activity restriction (44.0%). When surgery was performed, surgeons deemed the lesion to be stable at intraoperative assessment in 48.1% of cases.

Conclusion: The multicenter ROCK group has been able to enroll the largest knee OCD cohort to date. This information is being used to further understand the pathology of OCD, including its cause, associated comorbidities, and initial presentation and symptoms. The cohort having been established is now being followed longitudinally to better define and elucidate the best treatment algorithms based on these presenting signs and symptoms.
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http://dx.doi.org/10.1177/03635465211057103DOI Listing
January 2022

Comparison of Weightbearing and Nonweightbearing Juvenile Osteochondritis Dissecans Lesions of the Lateral Femoral Condyle.

Orthop J Sports Med 2021 Aug 11;9(8):23259671211026901. Epub 2021 Aug 11.

Department of Sports Medicine, Scottish Rite for Children, Dallas, Texas, USA.

Background: Repetitive microtrauma may contribute to osteochondritis dissecans (OCD) lesions of the femoral condyle. The effect of differential loading between OCD weightbearing (WB) zones has not been studied.

Purpose: To determine whether clinical and radiographic variables differ by WB zone in lateral femoral condyle OCD lesions.

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

Methods: We retrospectively reviewed a consecutive series of patients aged <18 years with lateral femoral condyle OCD lesions presenting at a single institution between 2004 and 2018. Patients with OCD lesions outside of the lateral femoral condyle were excluded. Lesions were localized on radiographs using the Cahill and Berg classification, referencing the Blumensaat line and an extension of the posterior femoral cortex. Progeny bone characteristics evaluated at baseline and 24-month follow-up included ossification, distinct borders from parent bone, and displacement. Baseline lesion dimensions were measured on magnetic resonance imaging (MRI) scans. We evaluated posttreatment pain level, return-to-activity rate, and patient-reported outcome measures (PROMs) including the Pediatric International Knee Documentation Committee score, Knee injury and Osteoarthritis Outcome Score, and Pediatric Functional Activity Brief Scale.

Results: A total of 62 lateral femoral condyle OCD lesions (mean follow-up, 24.1 months) presented within the study period: 26 WB lesions and 36 nonweightbearing (NWB) lesions. At presentation, no differences between the lesion types were observed in symptom chronicity or symptomatology. NWB lesions were deeper on MRI scans (sagittal depth, 7.11 vs 5.96 mm; = .046; coronal depth ratio, 0.05 vs 0.01 mm; = .003), were more likely to develop progeny bone (69.4% vs 44%; = .047), and demonstrated higher radiographic healing rates (52.8% vs 24%; = .025) compared with WB lesions. PROMs at follow-up were available for 25 of 62 patients (40.3%), with no statistically significant differences between cohorts at any time. Return to full activity was observed in 72% of WB and 82.1% of NWB lesions ( = .378).

Conclusion: Lateral femoral condyle OCD lesions of the knee in WB and NWB zones presented similarly at initial evaluation; however, NWB lesions demonstrated higher rates of progeny bone formation and radiographic healing at mean 2-year follow-up.
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http://dx.doi.org/10.1177/23259671211026901DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8361527PMC
August 2021

Coronal and Transverse Malalignment in Pediatric Patellofemoral Instability.

J Clin Med 2021 Jul 8;10(14). Epub 2021 Jul 8.

Scottish Rite for Children, Dallas, TX 75219, USA.

Patellofemoral instability (PFI) encompasses symptomatic patellar instability, patella subluxations, and frank dislocations. Previous studies have estimated the incidence of acute patellar dislocation at 43 per 100,000 children younger than age 16 years. The medial patellofemoral ligament (MPFL) complex is a static soft tissue constraint that stabilizes the patellofemoral joint serving as a checkrein to prevent lateral displacement. The causes of PFI are multifactorial and not attributed solely to anatomic features within the knee joint proper. Specific anatomic features to consider include patella alta, increased tibial tubercle-trochlear groove distance, genu valgum, external tibial torsion, femoral anteversion, and ligamentous laxity. The purpose of this paper is to provide a review of the evaluation of PFI in the pediatric and adolescent patient with a specific focus on the contributions of coronal and transverse plane deformities. Moreover, a framework will be provided for the incorporation of bony procedures to address these issues.
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http://dx.doi.org/10.3390/jcm10143035DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8307206PMC
July 2021

Elbow Overuse Injuries in Pediatric Female Gymnastic Athletes: Comparative Findings and Outcomes in Radial Head Stress Fractures and Capitellar Osteochondritis Dissecans.

J Bone Joint Surg Am 2021 09;103(18):1675-1684

Texas Scottish Rite Hospital for Children, Dallas, Texas.

Background: Radial head stress fractures (RHSFs) and capitellar osteochondritis dissecans (COCD) are rare but may be seen in gymnasts. The purpose of this study was to compare the clinical and radiographic characteristics and the outcomes of RHSF and COCD in pediatric and adolescent gymnastic athletes.

Methods: Classical gymnasts and competitive tumblers ≤18 years of age presenting with RHSF or COCD over a 5-year period were reviewed. Radiographic characteristics, clinical characteristics, and patient-reported outcomes were compared.

Results: Fifty-eight elbows (39 with COCD and 19 with RHSF) were studied; the mean patient age was 11.6 years. Gymnastic athletes with RHSF competed at a higher level; of the athletes who competed at level ≥7, the rate was 95% of elbows in the RHSF group and 67% of elbows in the COCD group. The RHSF group presented more acutely with more valgus stress pain than those with COCD (p < 0.01) and demonstrated increased mean valgus angulation (and standard deviation) of the radial neck-shaft angle (13° ± 3.8° for the RHSF group and 9.3° ± 2.8° for the COCD group; p < 0.01) and decreased mean proximal radial epiphyseal height (3.7 ± 0.6 mm for the RHSF group and 4.2 ± 1.5 mm for the COCD group; p < 0.01). At a minimum of 2 years (range, 2.0 to 6.3 years), the RHSF group reported fewer symptoms; the QuickDASH (abbreviated version of the Disabilities of the Arm, Shoulder and Hand questionnaire) score was 1.75 ± 3.84 points for the RHSF group and 7.45 ± 7.54 points for the COCD group (p < 0.01). Those at a high level (≥7) were more likely to return to gymnastics independent of pathology, with the RHSF group reporting higher final activity levels with the mean Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS) score at 26.0 ± 7.5 points compared with the COCD group at 23.6 ± 5.7 points (p < 0.05). Of the 9 patients with bilateral COCD, only 3 (33%) returned to gymnastics.

Conclusions: RHSF with features similar to the more familiar COCD lesion may present in gymnastic athletes. Those with RHSF may present more acutely with a high competitive level and may have a better prognosis for return to competitive gymnastics than those with COCD.

Level Of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.2106/JBJS.20.01863DOI Listing
September 2021

Changes in superior displacement, angulation, and shortening in the early phase of healing for completely displaced midshaft clavicle fractures in adolescents: results from a prospective, multicenter study.

J Shoulder Elbow Surg 2021 Dec 2;30(12):2729-2737. Epub 2021 Jun 2.

Washington University Orthopedics, St. Louis, MO, USA.

Background: Progressive displacement of diaphyseal clavicle fractures has been observed in adult patients, at times necessitating a change from nonoperative to operative treatment. Whether this occurs in adolescent patients has not been well investigated. The purpose of this study was to assess the rate and extent of progressive clavicle fracture displacement in adolescent patients following injury and during the early stages of healing.

Methods: This was a multicenter study evaluating prospective data that had previously been collected as part of a larger study evaluating the functional outcomes of adolescent clavicle fractures. A consecutive series of completely displaced diaphyseal clavicle fractures in patients aged 10-18 years treated at 1 of 3 tertiary-care pediatric trauma centers was included; all fractures underwent standardized imaging within 2 weeks of the date of injury and during the course of healing (5-20 weeks after injury). Measurements of clavicle shortening, superior displacement, and angulation were performed using validated techniques. Progressive displacement and/or interval improvement in fracture alignment, as well as the subsequent need for surgical intervention, was noted. Patient demographic and radiographic parameters were assessed as possible risk factors for interval displacement.

Results: One hundred patients met the inclusion criteria. Mean end-to-end shortening, cortex-to-cortex shortening, superior displacement, and angulation at the time of injury were 24 mm, 15 mm, 15 mm, and 7°, respectively. At a mean of 10 weeks after injury, the fracture alignment improved across all 4 measurements for the overall cohort, with mean improvements of 3.5 mm in end-to-end shortening, 3.3 mm in cortex-to-cortex shortening, 2.1 mm in superior displacement, and 2° in angulation. By use of a clinical threshold of a change in shortening or displacement of 10 mm or change in angulation of 10°, 26% of fractures improved, 4% worsened, and 70% remain unchanged. Patients with more severe fractures were more likely to have improved alignment than were patients with less displaced fractures (P < .001). No patient underwent surgical intervention for progressive displacement.

Conclusion: Significant early improvements in fracture alignment were observed in a substantial percentage of adolescent patients with completely displaced clavicle fractures. Among the most severely displaced fractures, shortening improved approximately 6 mm and angulation improved approximately 9°. In 4% of cases, increased displacement was observed, but this tended to be mild, and in no cases did it prompt surgical intervention. This finding indicates that the true final deformity after an adolescent clavicle fracture is commonly less than that present at the time of injury.
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http://dx.doi.org/10.1016/j.jse.2021.05.006DOI Listing
December 2021

Reliability of Radiologic Assessments of Clinically Relevant Growth Remaining in Knee MRI of Children and Adolescents With Patellofemoral Instability: Data From the JUPITER Cohort.

Orthop J Sports Med 2021 Apr 13;9(4):2325967121991110. Epub 2021 Apr 13.

Investigation performed at Hospital for Special Surgery, New York, New York, USA and Cincinnati Children's Hospital, Cincinnati, Ohio, USA.

Background: Surgical decision making and preoperative planning for children and adolescents with patellofemoral instability rely heavily on a patient's skeletal maturity. To be clinically useful, radiologic assessments of skeletal maturity must demonstrate acceptable interrater reliability and accuracy.

Purpose: The purpose of this study was to examine the interrater reliability among surgeons of varying experience levels and specialty training backgrounds when evaluating the skeletal maturity of the distal femur and proximal tibia of children and adolescents with patellofemoral instability.

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

Methods: Six fellowship-trained orthopaedic surgeons (3 pediatric orthopaedic, 2 sports medicine, and 1 with both) who perform a high volume of patellofemoral instability surgery examined 20 blinded knee radiographs and magnetic resonance images in random order. They assessed these images for clinically relevant growth (open physis) or clinically insignificant growth (closing/closed physis) remaining in the distal femoral and proximal tibial physes. Fleiss' kappa was calculated for each measurement. After initial ratings, raters discussed consensus methods to improve reliability and assessed the images again to determine if training and new criteria improved interrater reliability.

Results: Reliability for initial assessments of distal femoral and proximal tibial physeal patency was poor (kappa range, 0.01-0.58). After consensus building, all assessments demonstrated almost-perfect interrater reliability (kappa, 0.99 for all measurements).

Conclusion: Surgical decision making and preoperative planning for children and adolescents with patellofemoral instability rely heavily on radiologic assessment of skeletal maturity. This study found that initial interrater reliability of physeal patency and clinical decision making was unacceptably low. However, with the addition of new criteria, a consensus-building process, and training, these variables became highly reliable.
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http://dx.doi.org/10.1177/2325967121991110DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8047867PMC
April 2021

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

Instr Course Lect 2021 ;70:433-452

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.
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January 2021

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

Instr Course Lect 2021 ;70:399-414

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.
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January 2021

Osteochondritis Dissecans of the Knee: An Interrater Reliability Study of Magnetic Resonance Imaging Characteristics.

Am J Sports Med 2020 07 25;48(9):2221-2229. Epub 2020 Jun 25.

Investigation performed at the Hospital for Special Surgery, New York, New York, USA, and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.

Background: Imaging characteristics of osteochondritis dissecans (OCD) lesions quantified by magnetic resonance imaging (MRI) are often used to inform treatment and prognosis. However, the interrater reliability of clinician-driven MRI-based assessment of OCD lesions is not well documented.

Purpose: To determine the interrater reliability of several historical and novel MRI-derived characteristics of OCD of the knee in children.

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

Methods: A total of 42 OCD lesions were evaluated by 10 fellowship-trained orthopaedic surgeons using 31 different MRI characteristics, characterizing lesion size and location, condylar size, cartilage status, the interface between parent and progeny bone, and features of both the parent and the progeny bone. Interrater reliability was determined via intraclass correlation coefficients (ICCs) with 2-way random modeling, Fleiss kappa, or Krippendorff alpha as appropriate for each variable.

Results: Raters were reliable when the lesion was measured in the coronal plane (ICC, 0.77). Almost perfect agreement was achieved for condylar size (ICC, 0.93), substantial agreement for physeal patency (ICC, 0.79), and moderate agreement for joint effusion (ICC, 0.56) and cartilage status (ICC, 0.50). Overall, raters showed significant variability regarding interface characteristics (ICC, 0.25), progeny (ICC range, 0.03 to 0.62), and parent bone measurements and qualities (ICC range, -0.02 to 0.65), with reliability being moderate at best for these measurements.

Conclusion: This multicenter study determined the interrater reliability of MRI characteristics of OCD lesions in children. Although several measurements provided acceptable reliability, many MRI features of OCD that inform treatment decisions were unreliable. Further work will be needed to refine the unreliable characteristics and to assess the ability of those reliable characteristics to predict clinical lesion instability and prognosis.
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http://dx.doi.org/10.1177/0363546520930427DOI Listing
July 2020

Descriptive Epidemiology of Adolescent Clavicle Fractures: Results From the FACTS (Function after Adolescent Clavicle Trauma and Surgery) Prospective, Multicenter Cohort Study.

Orthop J Sports Med 2020 May 29;8(5):2325967120921344. Epub 2020 May 29.

Investigation performed at the Division of Sports Medicine, Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA.

Background: The majority of previous investigations on operative fixation of clavicle fractures have been related to the adult population, with occasional assessments of the younger, more commonly affected adolescent population. Despite limited prospective data for adolescents, the incidence of operative fixation of adolescent diaphyseal clavicle fractures has increased.

Purpose: To detail the demographic features and descriptive epidemiology of a large pooled cohort of adolescent patients with diaphyseal clavicle fractures presenting to pediatric tertiary care centers in the United States through an observational, prospective, multicenter cohort study (Function after Adolescent Clavicle Trauma and Surgery [FACTS]).

Study Design: Cross-sectional study; Level of evidence, 4.

Methods: Patients aged 10 to 18 years who were treated for a diaphyseal clavicle fracture between August 2013 and February 2016 at 1 of 8 geographically diverse, high-volume, tertiary care pediatric centers were screened. Treatment was rendered by any of the pediatric orthopaedic providers at each of the 8 institutions, which totaled more than 50 different providers. Age, sex, race, ethnicity, fracture laterality, hand dominance, mechanism of injury, injury activity, athletic participation, fracture characteristics, and treatment decisions were prospectively recorded in those who were eligible and consented to enroll.

Results: A total of 545 patients were included in the cohort. The mean age of the study population was 14.1 ± 2.1 years, and 79% were male. Fractures occurred on the nondominant side (56%) more frequently than the dominant side (44%). Sport was the predominant activity during which the injury occurred (66%), followed by horseplay (12%) and biking (6%). The primary mechanism of injury was a direct blow/hit to the shoulder (60%). Overall, 54% were completely displaced fractures, defined as fractures with no anatomic cortical contact between fragments. Mean shortening within the completely displaced group was 21.9 mm when measuring the distance between fragment ends (end to end) and 12.4 mm when measuring the distance between the fragment end to the corresponding cortical defect (cortex to corresponding cortex) on the other fragment (ie, true shortening). Comminution was present in 18% of all fractures. While 83% of all clavicle fractures were treated nonoperatively, 32% of completely displaced fractures underwent open reduction and internal fixation.

Conclusion: Adolescent clavicle fractures occurred more commonly in male patients during sports, secondary to a direct blow to the shoulder, and on the nondominant side. Slightly more than half of these fractures were completely displaced, and approximately one-fifth were comminuted. Within this large cohort, approximately one-third of patients with completely displaced fractures underwent surgery, allowing for future prospective comparative analyses of radiographic, clinical, and functional outcomes.
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http://dx.doi.org/10.1177/2325967120921344DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7263158PMC
May 2020

Activity Measures in Pediatric Athletes: A Comparison of the Hospital for Special Surgery Pediatric Functional Activity Brief Scale and Tegner Activity Level Scale.

Am J Sports Med 2020 03;48(4):985-990

Texas Scottish Rite Hospital for Children, Dallas, Texas, USA.

Background: In young athletes, patient-reported activity level is frequently used to determine return to the same level of sport after treatment.

Purpose: To evaluate the validity and score distributions of the Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS) compared with the Tegner Activity Level Scale (Tegner) in pediatric athletes.

Study Design: Cohort study (Diagnosis); Level of evidence, 2.

Methods: A retrospective review of 517 consecutive youth athletes who came to a sports medicine specialty clinic for a knee evaluation was performed. Patients completed the HSS Pedi-FABS, Tegner, and a sports participation survey before evaluation. Scores were compared with reported hours, days, and weeks of participation in sports as well as level of competition. Floor or ceiling effects were identified, and finally, the means and distributions of scores in the 8 most common primary sports were analyzed.

Results: A total of 398 participants (54.0% female) with an average age of 14.5 years (range, 10.0-18.8 years) were included in the study. The HSS Pedi-FABS demonstrated correlations with hours per week ( = 0.302; < .001), days per week ( = 0.278; < .001), and weeks per year ( = 0.136; = .014) playing a primary sport. The Tegner only demonstrated a correlation with days per week ( = 0.211; = .001). Additionally, club/select-level athletes scored higher than junior high/high school-level athletes on the HSS Pedi-FABS (23.8 vs 21.0; = .004), but no difference was observed with the Tegner. No floor or ceiling effect was observed for the HSS Pedi-FABS, but a ceiling effect was present for the Tegner (32.8%). The HSS Pedi-FABS demonstrated a varied score distribution between the 8 most common primary sports ( < .001), with soccer players scoring the highest, on average (23.5).

Conclusion: The HSS Pedi-FABS, compared with the Tegner, demonstrated more correlations with an athlete's participation in sport with no floor or ceiling effect and had a wide distribution of scores even among same-sport athletes. The HSS Pedi-FABS may be a more valuable activity measure than the Tegner in pediatric athletes.
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March 2020

Combined Transphyseal and Lateral Extra-articular Pediatric Anterior Cruciate Ligament Reconstruction: A Novel Technique to Reduce ACL Reinjury While Allowing for Growth.

Am J Sports Med 2019 12 6;47(14):3356-3364. Epub 2019 Nov 6.

Texas Scottish Rite Hospital for Children, Dallas, Texas, USA.

Background: Treatment of anterior cruciate ligament (ACL) injuries in the adolescent population continues to be complicated by an unacceptably high rate of secondary ACL injury.

Purpose: To describe the failure rate and outcomes after a hybrid pediatric ACL reconstruction (ACLR) employing transphyseal hamstring (TPH) autograft combined with an extra-articular technique using an iliotibial band (ITB) autograft.

Study Design: Case series; Level of evidence, 4.

Methods: Consecutive patients undergoing combined TPH-ITB ACLR between January 2012 and April 2017 with a minimum 2-year follow-up were reviewed. With the goal of decreasing ACL graft injury in this high-risk group, this technique employed anteromedial portal drilling for TPH with an extraosseous femoral ITB technique and intra-articular TPH-ITB grafts fixed within the tibial bone tunnel. Demographics, bone age, standing alignment radiograph for growth and mechanical axis grade, return to sport, graft failure, and patient-reported outcome measures were analyzed.

Results: A total of 61 knees in 60 adolescents underwent the combined TPH-ITB ACLR, with 57 knees (93.4%) meeting inclusion criteria with a mean follow-up of 38.5 months (range, 24-78 months). Only 3 of 57 knees (5.3%) sustained ACL reinjury. The mean age was 13.0 years (range, 11-16 years) with 36 male patients (mean bone age, 14.2 years) and 21 female patients (mean bone age, 13.3 years), and 91% of patients (52 of 57) returned to sport. Participants demonstrated a high functional level at final follow-up, with a mean score of 91.2 (range, 46.7-100) on the Pediatric International Knee Documentation Committee (Pedi-IKDC) Subjective Knee Evaluation Form and mean score of 22.4 (range, 4-30) on the Pediatric Functional Activity Brief Scale (Pedi-FABS). To critically assess growth, a cohort with ≥18 months of growth remaining at surgery was evaluated at maturity. No difference was seen in mean operative and nonoperative leg growth (49.7 mm and 49.8 mm). Although no family reported cosmetic or functional alignment or length concerns, 1 of 18 (5.5%) had a final limb length discrepancy >10 mm (12 mm) and a perioperative alignment difference (0-Grade II valgus).

Conclusion: Combined TPH-ITB ACLR in adolescents resulted in high activity levels (Pedi-FABS, 22.4; median, 25) and a low (5.3%) graft failure rate at a mean 38.5 months.
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December 2019

Quadriceps Tendon Graft Anatomy in the Skeletally Immature Patient.

Orthop J Sports Med 2019 Jul 11;7(7):2325967119856578. Epub 2019 Jul 11.

Division of Orthopaedics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.

Background: The quadriceps tendon (QT) is increasingly considered for primary and revision anterior cruciate ligament reconstruction in skeletally immature patients, as it may be harvested as a purely soft tissue graft with considerable tissue volume. Because of distinct rectus tendon (RT) separation from the QT complex, the potential for RT retraction exists and could lead to QT weakness after QT graft harvest.

Purpose: To describe the anatomy of the pediatric QT and clarify decussation of the RT and QT to avoid the risk of delayed RT retraction and QT weakness after QT graft harvest.

Study Design: Descriptive epidemiology study.

Methods: Nine cadaveric knee specimens (aged 4-11 years) underwent gross dissection. Coronal-plane width and depth of the QT were measured at intervals proximal to the superior pole of the patella at distances of 0.0, 0.5, 1.0, and 1.5 times the length of the patella. The distance was measured from the superior patellar pole to the point of RT separation from the remainder of the deeper/posterior QT.

Results: The median patellar length was 28 mm (interquartile range, 26-37 mm). The coronal-plane width of the QT was larger superficially/anteriorly when closest to the patella but wider when measured deeper/posteriorly as the tendon extended proximally. The median distance between the superior pole of the patella and RT separation from the QT was 0.95 times the patellar length. The distance to widening of the deeper/posterior aspect of the QT was 1.14 times the patellar length proximal to the patella.

Conclusion: The RT begins a distinct separation from the QT above the superior pole of the patella at a median of 0.95 times the patellar length in skeletally immature specimens. The deeper/posterior aspect of the QT begins to increase in coronal-plane width proximally after a distance of 1.14 times the patellar length above the knee, while the superficial/anterior aspect of the tendon continues to narrow. Awareness of the separation of the RT from the QT, and the coronal-plane width variation aspects of the QT proximally, is important for surgeons utilizing the QT as a graft to avoid inadvertent release of the RT from the rest of the QT complex.
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http://dx.doi.org/10.1177/2325967119856578DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6624918PMC
July 2019

Patellar-Trochlear Morphology in Pediatric Patients From 2 to 11 Years of Age: A Descriptive Analysis Based on Computed Tomography Scanning.

J Pediatr Orthop 2020 Feb;40(2):e96-e102

Department of Orthopaedic Surgery, University of Minnesota, Minneapolis.

Background: Despite the critical role the trochlea plays in patellofemoral (PF) pathology, the development of the trochlea is poorly understood. The purpose of this study was 2-fold: (1) Describe quantitative osseous and soft tissue anatomy of the patella and trochlea in skeletally immature cadaveric specimens utilizing known measurements used in PF instability, and (2) evaluate additional measurement techniques in the sagittal plane as they relate to PF morphologic development.

Methods: Thirty-one skeletally immature fresh frozen cadaveric knees between the ages of 2 and 11 years old were evaluated using 0.625 mm computed tomography scans. In the axial plane, measurements included condylar height asymmetry, trochlear facet asymmetry, trochlear depth, osseous sulcus angle, cartilaginous sulcus angle, patella sulcus angle, and tibial tubercle-trochlear groove distance. In the sagittal plane, measurements included previously undescribed measurements of trochlear length and condylar height asymmetry which are based on the anterior femoral cortex.

Results: Analysis of trochlear morphology using condylar height asymmetry (both axial and sagittal), trochlear facet asymmetry, and trochlear depth and length demonstrated an increase in the size of the medial and lateral trochlea as age increased. There was more variability in the change of size of the medial trochlea (height, length, and facet length) than the lateral trochlea. The osseous sulcus angle, cartilaginous sulcus angle, and patella sulcus angle decreased (became deeper) with age until after 8 years and then plateaued.

Conclusions: This cadaveric analysis demonstrated that there is an increase in the medial and lateral trochlear height as age increased by all measurements analyzed. The findings also demonstrate that the shape of the patella and trochlea change concurrently, which suggests that there may be interplay between the 2 during development. These new sagittal measurement techniques evaluating the medial, central, and lateral trochlear height and length with respect to age may help guide clinicians when investigating patellar instability in skeletally immature patients.

Levels Of Evidence: Level IV.
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http://dx.doi.org/10.1097/BPO.0000000000001405DOI Listing
February 2020

Is Anteromedial Drilling Safe in Transphyseal Anterior Cruciate Ligament Reconstruction in Adolescents with Growth Remaining?

J Pediatr Orthop 2019 Apr;39(4):e278-e283

Texas Scottish Rite Hospital for Children.

Background: Previous reports of transphyseal drilling in anterior cruciate ligament (ACL) reconstruction have demonstrated good clinical outcomes without subjective changes in further skeletal development. The purpose of this study is to evaluate radiographic changes during continued growth following a transphyseal ACL reconstruction using an anteromedial femoral (AM) drilling technique in patients with >18 months of growth remaining.

Methods: A review of consecutive adolescents who underwent a soft tissue transphyseal ACL reconstruction using an AM drilling technique was performed. Inclusion criteria was 18 months of growth remaining based on radiographic bone age and standing radiographs at least one year from the index procedure. Demographic, preoperative, and postoperative data, and follow-up three-foot standing lower extremity radiographs were reviewed. Radiographic data included femoral length, tibial length, total lower extremity length, mechanical axis deviation (MAD), lateral distal femoral angle (LDFA), and medial proximal tibial angle (MPTA).

Results: In total 12 adolescent patients with a mean age of 13.4 years (range, 12.3 to 14.4) and bone age of 13.4 years (11.5 to 14) at the time of surgery were included. At an average of 2.27-year follow-up (412 to 1058 d), there was no difference in the total growth of the operative and nonoperative limb (48.5 mm vs. 47 mm; P=0.36). In addition, the average increases in femoral length (23.4 mm) and tibial length (25.8 mm) were not statistically different between the operative and the nonoperative limb (P=0.12; P=0.75). There was no statistical difference in mechanical axis deviation, LDFA, or MPTA between preoperative and postoperative radiographs. Mean differences in operative and nonoperative coronal angular changes were all <1.5 degrees.

Conclusions: With at least 2 years of growth remaining, transphyseal ACL reconstruction with anteromedial drilling did not significantly affect the physis or residual growth compared with the contralateral extremity. Although this technique may create a larger defect in the physis, standing radiographs demonstrate there is no change in limb length or angulation in growing adolescents approximately 2 years after surgery.

Level Of Evidence: This is a case series; Level IV evidence.
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http://dx.doi.org/10.1097/BPO.0000000000001289DOI Listing
April 2019

Patellofemoral Instability in the Skeletally Immature Patient: A Review and Technical Description of Medial Patellofemoral Ligament Reconstruction in Patients with Open Physes.

Am J Orthop (Belle Mead NJ) 2018 Dec;47(12)

University of Texas Southwestern, 5323 Harry Hines Blvd, Dallas, Texas, USA. Email:

Patellofemoral instability commonly occurs in the young patient, and, often, skeletal immaturity may be a risk factor for possible recurrence. Treatment considerations, including operative and nonoperative management, are based on anatomic factors. A medial patellofemoral ligament (MPFL) reconstruction is a treatment option for a skeletally immature patient with recurrent instability or for patients with a high risk of patellofemoral instability recurrence. A physeal-sparing MPFL reconstruction technique that considers the origin of the MPFL to be distal to the distal femoral physis may be employed.
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http://dx.doi.org/10.12788/ajo.2018.0110DOI Listing
December 2018

The Importance of a Standardized Screening Tool to Identify Thromboembolic Risk Factors in Pediatric Lower Extremity Arthroscopy Patients.

J Am Acad Orthop Surg 2019 May;27(9):335-343

From the Department of Orthopaedics (Dr. Ellis, Ms. Sabatino, Mr. Clarke, Mr. Dennis, Ms. Fletcher, Mr. Wyatt, and Dr. Wilson), Texas Scottish Rite Hospital for Children, and the Department of Orthopaedic Surgery (Dr. Ellis, and Dr. Wilson), and Department of Pediatrics-Hematology-Oncology (Dr. Zia), University of Texas Southwestern, Dallas, TX.

Introduction: Deep vein thrombosis and pulmonary embolism are major complications that can occur in common orthopaedic procedures such as knee arthroscopy. The purpose of this study is to determine the incidence of venous thromboembolism (VTE) risk factors in adolescent patients undergoing elective lower extremity arthroscopy. A second objective is to determine whether a targeted, standardized screening tool is both cost- and clinically effective in the identification of VTE risk factors in adolescents.

Methods: A standardized VTE screening tool was prospectively administered to all elective arthroscopic procedures in a pediatric sports medicine practice. A comparison cohort that did not complete the screening tool was isolated through a retrospective chart review identifying VTE risk factors. The incidence and cost between the two cohorts were compared.

Results: Of 332 subjects who did not receive a targeted screening (TS) tool, 103 risk factors were noted. One pulmonary embolism case was identified with a total incidence of 0.15% over 3 years. With TS, we identified 325 subjects with 134 identifiable risk factors. Six patients (1.8%) were noted to be very high risk, requiring consultation with hematology. No VTEs were reported. When compared with the retrospective review, TS identified 30% more risk factors. A significant increase in the identification of family history of blood clots (P < 0.001), history of previous blood clot (P = 0.059), recurrent miscarriages in the family (P = 0.010), and smoking exposure (P = 0.062) was found. Additionally, the total cost of screening was less than the cost of prophylaxis treatment with no screening ($20.98 versus $23.51 per person, respectively).

Discussion: Risk factors for VTE may be present in 32.5% of elective adolescent arthroscopic patients. A TS model for VTE identified 30% more risk factors, especially a significant family history, and was shown to be a cost-effective way to safely implement a VTE prevention program.

Level Of Evidence: Level II.
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http://dx.doi.org/10.5435/JAAOS-D-18-00390DOI Listing
May 2019

Proximity of the neurovascular structures during all-inside lateral meniscal repair in children: a cadaveric study.

J Exp Orthop 2018 Dec 18;5(1):50. Epub 2018 Dec 18.

Department of Orthopedic Surgery, Stanford University, Stanford, CA, USA.

Purpose: Meniscal repair has become increasingly common in a pediatric and adolescent population. All-inside repair techniques are utilized more often given their ease of insertion and decreased operative time required. However, there are possible risks including damage to adjacent neurovascular structures. The purpose of this study to was examine the proximity of the neurovascular structures during lateral meniscus repairs in pediatric specimens simulating a worst-case scenario.

Methods: Ten pediatric cadaveric knees (age 4-11) were utilized and simulated lateral meniscal repair through the posterior horn of the lateral meniscus and both medial and lateral to the popliteal hiatus through the body of the lateral meniscus was performed with an all-inside meniscal repair device. The distance to the popliteal artery or peroneal nerve was measured.

Results: During posterior horn repair, the average distance from the all-inside device to the popliteal artery was 1.9 mm ± 1.1 mm. There was penetration of the artery in one specimen. During repair on the medial side of popliteal hiatus, the average distance from the all-inside device to the peroneal nerve was 3.2 mm ± 2.0 mm. During repair on the lateral side of popliteal hiatus, the average distance from the all-inside device to the peroneal nerve was 12.4 mm ± 3.7 mm.

Conclusions: This study demonstrates that the proximity of the neurovascular structures to the lateral meniscus in children is extremely close and at high risk during meniscal repair with all-inside devices. This study gives important data for the proximity of these structures during these repair techniques.

Level Of Evidence: Level 5 Cadaveric Study.
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http://dx.doi.org/10.1186/s40634-018-0166-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6298911PMC
December 2018

Incidence, Presentation, and Treatment of Pediatric and Adolescent Meniscal Root Injuries.

Orthop J Sports Med 2018 Nov 8;6(11):2325967118803888. Epub 2018 Nov 8.

Department of Orthopaedic Surgery, University of Texas Southwestern, Dallas, Texas, USA.

Background: Despite the increasing incidence of sports-related knee injuries in youth athletes, few studies have reported on the diagnosis and treatment of pediatric and adolescent meniscal root injuries.

Purpose: To describe traumatic posterior meniscal root injuries in a pediatric and adolescent population and compare the presentation of meniscal root injuries versus that of nonroot injuries.

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

Methods: A study was conducted of all knee arthroscopies performed on consecutive patients treated in a pediatric sports practice from March 2012 through February 2015. All patients who were younger than 20 years at the time of their injury and who underwent an arthroscopy with meniscal injury were included. Patients with discoid lateral meniscus, atraumatic meniscal cysts, partial-thickness meniscal root injuries (LaPrade type 1), and recurrent root tears were excluded. A comparative analysis of root and nonroot injuries was performed.

Results: A total of 314 patients had surgery for meniscal injury (mean patient age, 16.0 years; range, 10.5-19.6 years). Of these patients, 58 (18.5%) posterior meniscal root injuries were identified. The root injuries were more likely to have joint line tenderness on preliminary physical examination compared with nonroot injuries (96.5% vs 58.6%, respectively; < .001). Root injuries rarely occurred in isolation compared with nonroot meniscal tears (6.9% vs 17.6%; = .021) and were frequently treated in combination with anterior cruciate ligament (ACL) injuries (86.2%). Lateral root injuries occurred more often in conjunction with ACL injuries compared with medial root injuries (84.8% vs 22.2%; < .001). On review of preoperative imaging, meniscal extrusion occurred more often in root injuries than in nonroot injuries (32.8% vs 3.5%; < .0001) and was uncommonly seen in the skeletally immature patient. Extrusion was seen more often in medial than lateral root tears (66.7% vs 21.7%; = .008). A majority of patients (57/58) underwent transosseous suture repair of the meniscal root.

Conclusion: When treating a pediatric or adolescent patient for a traumatic meniscal tear, a surgeon may expect to see a posterior meniscal root injury in as many as 1 in 6 patients. When treated for an ACL, contact, or multiligament injury or meniscal extrusion, a pediatric or adolescent patient may demonstrate a meniscal root avulsion or complex meniscal tear. These data provide practitioners with an improved ability to identify and treat meniscal root injuries that otherwise lead to rapid cartilage degeneration.
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http://dx.doi.org/10.1177/2325967118803888DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6240976PMC
November 2018

Distal Femoral Valgus and Recurrent Traumatic Patellar Instability: Is an Isolated Varus Producing Distal Femoral Osteotomy a Treatment Option?

J Pediatr Orthop 2018 Mar;38(3):e162-e167

Texas Scottish Rite Hospital for Children, University of Texas Southwestern Medical Center, Dallas, TX.

Background: Genu valgum, a risk factor for recurrent patellofemoral instability, can be addressed with a varus producing distal femoral osteotomy (DFO). The purpose of this study is to report 3-year clinical and radiographic outcomes on a series of skeletally mature adolescents with traumatic patellofemoral instability and genu valgum who underwent a varus producing DFO.

Methods: Consecutive patients (n=11) who underwent an isolated DFO for recurrent traumatic patellar instability over a 4-year study period (2009 to 2012) were reviewed. All patients were below 19 years of age, skeletally mature, had ≥2 patellar dislocations, genu valgum (≥ zone II mechanical axis) and failed nonoperative treatment. Exclusion criteria included less than three-year follow-up, congenital or habitual patellar instability, osteotomy indicated for pathology other than patellar instability, or biplanar osteotomies. Demographic, clinical, and radiographic data were retrospectively analyzed. Recurrence of instability and outcome measures (Kujala and Tegner Activity Scale) were collected at final followed-up prospectively.

Results: Ten of 11 patients (average age, 16 y; range, 14 to 18 y; 4 male individuals: 7 female individuals) with an average follow-up of 4.25 years (range, 3.2 to 6.0 y) met inclusion criteria. The average body mass index (BMI) of all patients was 31.3 (range, 19.7 to 46.8) with 91% considered overweight (BMI>25) and 55% obese (BMI>30). The average preoperative lateral distal femoral angle was 75.4 degrees with an average correction of 10.4 degrees (range, 7 to 12 degrees) (P<0.001). Mean patellar height ratios were reduced; with Caton-Deschamps Index significantly reduced to 1.08 (range, 0.86 to 1.30) (P<0.005). The average postoperative Kujala score was 83.6 (range, 49 to 99) with 7 subjects (70%) reporting good to excellent function (Kujala > 80) and 8 (80%) having no further episodes of instability. The mean postoperative Tegner activity score was 5.5 (range, 3 to 7).

Conclusions: A distal femoral varus producing osteotomy may change radiographic parameters associated with patellar instability and improve clinical outcomes by reducing symptomatic patellofemoral instability in this patient population.

Level Of Evidence: Level IV.
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March 2018

Adolescent clavicle nonunions: potential risk factors and surgical management.

J Shoulder Elbow Surg 2018 Jan 24;27(1):29-35. Epub 2017 Aug 24.

Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA, USA.

Background: Clavicle nonunions in adolescent patients are exceedingly rare. The purpose of this study was to evaluate a series of clavicle nonunions from a pediatric multicenter study group to assess potential risk factors and treatment outcomes.

Methods: A retrospective review of all clavicle nonunions in patients younger than 19 years was performed at 9 pediatric hospitals between 2006 and 2016. Demographic and surgical data were documented. Radiographs were evaluated for initial fracture classification, displacement, shortening, angulation, and nonunion type. Clinical outcomes were evaluated, including rate of healing, time to union, return to sports, and complications. Risk factors for nonunion were assessed by comparing the study cohort with a separate cohort of age-matched patients with a diaphyseal clavicle fracture.

Results: There were 25 nonunions (mean age, 14.5 years; range, 10.0-18.9 years) identified, all of which underwent surgical fixation. Most fractures were completely displaced (68%) initially, but 21% were partially displaced and 11% were nondisplaced. Bone grafting was performed in 24 of 25 cases, typically using the hypertrophic callus. Radiographic healing was achieved in 96% of cases. One patient (4%) required 2 additional procedures to achieve union. The primary risk factor for development of a nonunion was a previous history of an ipsilateral clavicle fracture.

Conclusions: Clavicle nonunions can occur in the adolescent population but are an uncommon clinical entity. The majority occur in male patients with displaced fractures, many of whom have sustained previous fractures of the same clavicle. High rates of union were achieved with plate fixation and the use of bone graft.
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http://dx.doi.org/10.1016/j.jse.2017.06.040DOI Listing
January 2018

A comparison of distal femoral physeal defect and fixation position between two different drilling techniques for transphyseal anterior cruciate ligament reconstruction.

J Pediatr Orthop B 2015 Mar;24(2):106-13

aNaval Medical Center San Diego, San Diego, California bDepartment of Orthopedics cDepartment of Radiology dTexas Scottish Rite Hospital for Children, University of Texas Southwestern Medical Center, Dallas, Texas, USA.

The defect of the femoral tunnel at the level of the physeal scar during transtibial and anteromedial portal (AMP) drilling for transphyseal anterior cruciate ligament reconstruction was compared. Five matched pairs of knees (n=10) were drilled, and computed tomography was used to evaluate tunnel position and size at the level of the physeal scar. Significant radiographic changes were observed, including tunnel defect area at the physeal scar: 0.44 cm (1.2%) in the transtibial group versus 0.99 cm (2.7%) in the AMP group (P=0.008). AMP drilling creates a larger and more lateral tunnel defect at the level of the physeal scar.
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http://dx.doi.org/10.1097/BPB.0000000000000143DOI Listing
March 2015

Segmental metadiaphyseal humeral bone loss in pediatric trauma patients: a case series.

J Pediatr Orthop 2014 Jun;34(4):400-4

*Texas Scottish Rite Hospital for Children †Children's Medical Center Dallas, Dallas, TX ‡Children's National Medical Center, Washington, DC.

Background: The management of posttraumatic bone loss is complicated and often requires complex reconstructive procedures. No options exist that are specific to the treatment of the growing skeleton that has intercalary bone loss. We have observed reconstitution of the humerus in 2 cases that have precluded extensive management.

Methods: Two pediatric patients sustained traumatic injuries to the upper extremities, including humeral bone loss, and are presented after spontaneous reconstitution of the segmental bone loss.

Results: With treatment restricted to soft-tissue injury and bone stabilization with external fixation, both patients demonstrated radiographic healing of humeral segmental bone loss. Both patients were thought to have a partially intact periosteal sleeve. They have returned to sporting activities with mild loss of function.

Conclusions: In certain pediatric injuries, spontaneous healing of segmental bone defects can occur. This response may obviate the need for complex, interventional procedures.

Levels Of Evidence: Level IV-case series.
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http://dx.doi.org/10.1097/BPO.0000000000000131DOI Listing
June 2014
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