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Koshinski JL, Bram JT, Gross PW, Hine SH, Hayes DS, Fabricant PD, Seeley MA. Exploring Outcomes of Tibial Rigid Intramedullary Nailing in Adolescent Patients. J Orthop Trauma 2025:00005131-990000000-00469. [PMID: 39774635 DOI: 10.1097/bot.0000000000002957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2025]
Abstract
OBJECTIVES To explore outcomes after tibial rigid intramedullary nailing (RIMN) in skeletally immature patients, with a focus on post-operative complications and iatrogenic changes in tibial slope due to anterior physeal arrest. METHODS Design: Retrospective case series. SETTING A large, tertiary care health system in the rural Mid-Atlantic United States, including two Level 1 trauma centers and one Level 2 trauma center. PATIENT SELECTION CRITERIA Included were skeletally immature patients within 2 years of skeletal maturity undergoing tibial RIMN for OTA/AO 42 A to C fractures between March 2009 and January 2024 with post-operative follow-up more than 1-year. OUTCOME MEASURES AND COMPARISONS The primary outcome was change in tibial slope after RIMN. Secondary outcomes included post-operative weight-bearing status and complications. RESULTS Thirty-seven skeletally immature patients were included (mean age 15.2 ± 1.3 years, 76% male). For 22 patients with minimum 6-month post-operative radiographs (mean 18.4 ± 12.7 months), there was no significant change from pre- to post-operative tibial slope (80.0 ± 1.9° vs 80.1 ± 1.6°, p=0.86). Time to achievement of full weightbearing across the series averaged 45.4 ± 35.6 days. Five (14%) of patients necessitated hardware removal, and 89% of patients reported they had returned to "normal" activity at latest follow-up (mean 56.2 ± 42.5 months). CONCLUSIONS This study demonstrated that RIMN for tibial shaft fractures in skeletally immature pediatric patients within 2 years of maturity was not associated with iatrogenic physeal injury and resultant changes in tibial slope. Additional favorable clinical outcomes, the potential for early weight-bearing, and few associated post-operative complications, indicate that RIMN is a safe option for skeletally immature patients with tibial shaft fractures. Caution should be exercised when extrapolating these results to younger pediatric patients with >2 years of skeletal growth remaining. LEVEL OF EVIDENCE IV.
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Milewski MD, Miller PE, Gossman EC, Coene RP, Tompkins MA, Anderson CN, Bauer K, Busch MT, Carey JL, Carsen S, Chambers HG, Coene RP, Edmonds EW, Ellermann J, Ellis HB, Erickson J, Fabricant PD, Ganley TJ, Gossman EC, Green DW, Heyworth BE, Hoi Po Hui J, Kocher MS, Krych AJ, Latz K, Lyon RM, Mayer S, Milewski MD, Miller PE, Nelson BJ, Nepple JJ, Nguyen JC, Nissen CW, Lee Pace J, Paterno MV, Pennock AT, Perkins C, Polousky JD, Saluan P, Shea KG, Tompkins MA, Wall EJ, Weiss JM, Willimon C, Wilson P, Wright RW, Zbojniewicz A, Myer GD. A Simple Clinical Predictive Model for Arthroscopic Mobility of Osteochondritis Dissecans Lesions of the Knee. Am J Sports Med 2024; 52:3543-3550. [PMID: 39584729 DOI: 10.1177/03635465241296133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2024]
Abstract
BACKGROUND Osteochondritis dissecans (OCD) of the knee is a focal idiopathic alteration of subchondral bone and/or its precursor with risk for instability and disruption of adjacent cartilage. Treatment options focused on preventing premature osteoarthritis vary depending on multiple patient and lesion characteristics, including lesion mobility. PURPOSE To differentiate lesion mobility before arthroscopy using a multivariable model that includes patient demographic characteristics and physical examination findings. STUDY DESIGN Cohort study (Diagnosis); Level of evidence, 2. METHODS Demographic, preoperative physical examination, and radiographic data were collected from a multicenter national prospective cohort of patients with OCD of the knee. Inclusion criteria included patients <19 years of age and patients with arthroscopically confirmed mobility status based on the Research on Osteochondritis Dissecans of the Knee arthroscopy classification. Multivariable logistic regression analysis using stepwise model selection was used to determine factors associated with the likelihood of a mobile versus an immobile lesion. A 75% partition of the data was used for model training, and 25% was used as a validation cohort. Quantitative model fit statistics were computed using the holdout data, including sensitivity, specificity, and the area under the receiver operating characteristic curve (AUC), along with the corresponding 95% CI. RESULTS A total of 407 patients in the prospective cohort met inclusion criteria, and 62% were male. The mean ± SD age was 13.7 ± 2.2 years, height 161.8 ± 5.3 cm, and weight 59.2 ± 42.2 kg. Arthroscopic evaluation yielded 235 immobile and 172 mobile lesions. Multivariable analysis determined that the best model to predict lesion mobility included chronologic age ≥14 years (P < .001), effusion on physical examination (P < .001), and any loss of range of motion on physical examination (P = .07), while controlling for male sex (P = .38) and weight >54.4 kg (P = .12). In the 25% holdout validation sample (n = 102), a sensitivity of 83%, a specificity of 82%, and an AUC of 0.89 (95% CI, 0.82-0.95) were achieved with these predictive factors. CONCLUSION Age, effusion, and loss of motion can predict knee OCD lesion mobility at the time of arthroscopy. Education about lesion mobility can help with surgical planning and patient and family counseling.
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Jones RH, Beber SA, Lawrence JTR, Fabricant PD. Length of post-treatment immobilization following medial humeral epicondyle avulsion fracture predicts return of full range of motion. J Shoulder Elbow Surg 2024:S1058-2746(24)00780-8. [PMID: 39522863 DOI: 10.1016/j.jse.2024.08.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 08/12/2024] [Accepted: 08/24/2024] [Indexed: 11/16/2024]
Abstract
BACKGROUND Medial epicondyle fractures of the distal humerus are common pediatric fractures, which are increasing in frequency among pediatric and adolescent athletes. Residual elbow stiffness is a feared complication of both surgical and nonoperative treatment. The purpose of this study is to investigate the association of the relevant variables with the ability of patients to regain full elbow range of motion (ROM). METHODS Patients 8-18 years old enrolled in the Medial Epicondyle Multicenter Outcomes prospective cohort with ≥3 mm of displacement, and >1 year of follow-up data were included. Bilateral elbow range of motion (ROM), complications, length of immobilization following definitive treatment (surgical vs. nonoperative), participation in formal physical or occupational therapy (PT/OT), and weeks from injury to treatment were recorded. RESULTS The study cohort consisted of 202 patients (aged 12.7 ± 2.3 years; 59% male). A greater proportion of surgically managed patients regained full ROM compared to nonoperatively managed patients (71% vs 56%, P = .05). Immobilization time was significantly shorter in surgical than in nonoperative patients (2.0 ± 1.1 weeks vs. 3.0 ± 1.2 weeks, P < .001). In multivariable logistic regression analysis, only immobilization time was an independent predictor of regaining full ROM (β = -0.353, P = .02), which remained statistically significant while controlling for PT/OT (β = 0.079, P = .829) and treatment strategy (β = -0.375, P = .35). While controlling for treatment strategy and whether a patient received PT/OT, each week of prolonged immobilization decreased the chance of regaining full ROM by 35%. CONCLUSIONS This large multicenter cohort study found that of the variables studied, increased immobilization time was the only independent predictor of residual elbow stiffness following medial epicondyle fractures in children, independent of treatment strategy and receiving PT/OT. With surgical treatment often warranting shorter post-treatment immobilization times, surgery may provide an avenue for consistently regaining full ROM when treating these fractures, especially in the setting of concomitant dislocation. In cases of minimally displaced fractures, implementing protected early ROM in nonoperative cases could be considered. However, when nonoperatively-treated patients in this study were analyzed separately, earlier mobilization was not associated with a protective effect against residual stiffness. Further prospective study into the nuances of surgical indications as well as nonoperative and postoperative immobilization and early motion strategies is therefore warranted.
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Tracey OC, Lijesen E, Bram JT, Oji NM, Chipman DE, Fabricant PD, Green DW. Comparison of Imaging Characteristics in Pediatric Patients With Trochlear Versus Medial Femoral Condyle Osteochondritis Dissecans. Orthop J Sports Med 2024; 12:23259671241291919. [PMID: 39600417 PMCID: PMC11590130 DOI: 10.1177/23259671241291919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Accepted: 04/30/2024] [Indexed: 11/29/2024] Open
Abstract
Background Although osteochondritis dissecans (OCD) lesions are well-described in the femoral condyles and have been associated with varus limb alignment, there is limited data on OCD lesions in the trochlea. Purpose To compare the baseline imaging characteristics in pediatric patients with trochlear OCD with those with medial femoral condyle (MFC) OCD to understand whether measures of coronal plane alignment predispose to OCD development by anatomic location. Study Design Cross-sectional study; Level of evidence, 3. Methods This study retrospectively reviewed all pediatric patients (age ≤18 years) diagnosed with isolated trochlear OCD at a tertiary-care medical center from January 2016 to May 2023; all included patients had weight-bearing hip-to-ankle alignment radiographs. Hip-knee-ankle angle (HKA), mechanical lateral distal femoral angle (mLDFA), medial proximal tibial angle (MPTA), mechanical axis deviation (MAD), Caton-Deschamps Index (CDI), patellar tilt, and sulcus angle were measured on initial/preoperative anteroposterior and lateral knee radiographs. Tibial tubercle-trochlear groove (TT-TG) distance and OCD lesion size were measured on initial/preoperative magnetic resonance imaging sequences. Patients were 1 to 2 matched based on age (±2 years) and sex to a cohort with isolated MFC OCD. Results A total of 18 extremities in 16 patients were included in the trochlear OCD cohort and matched to 36 extremities in the MFC OCD cohort. The mean age at the first clinical visit for all patients was 14.8 ± 1.5 years and did not differ significantly between the two groups (P = .40). The extremities with trochlear OCD had significantly less varus HKA (1°± 2° vs -1°± 2°; P = .004) and MAD (4 ± 8 vs -3 ± 8 mm; P = .004) compared with the MFC cohort as well as lower mLDFA (86°± 2° vs 88°± 2°; P = .004). There were no differences in MPTA, CDI, patellar tilt, sulcus angle, TT-TG distance, or OCD lesion size between groups. Conclusion Pediatric patients with trochlear OCD had statistically less varus coronal plane alignment compared with age- and sex-matched patients with MFC OCD, with the latter exhibiting more significant varus based on the HKA and MAD.
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Hamilton AA, Wongcharoenwatana J, Hoellwarth JS, Geffner A, Mehta R, Epstein BS, Fabricant PD, Fragomen AT, Rozbruch SR. Core psychosocial insights, challenges, and opportunities in the orthopedic surgery care of children and adolescents. J Child Orthop 2024:18632521241278159. [PMID: 39539478 PMCID: PMC11556609 DOI: 10.1177/18632521241278159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Accepted: 08/07/2024] [Indexed: 11/16/2024] Open
Abstract
Purpose This is the second phase in an investigation of the psychosocial impact of orthopedic surgery on adolescents. What are the core psychosocial factors that shape the experience of adolescent patients aged 11-18 who are undergoing orthopedic surgery? Methods Two 43-question surveys (preoperative and postoperative) were developed as modified versions of the survey used in phase 1. The preoperative survey was administered 2 weeks before surgery. The postoperative survey was administered 6 weeks later. Responses were collected from free-response and Likert-scale questions exploring patient-physician relationships, office visits/hospital stays, family, peers, academics, sports, and surgical expectations. The survey was administered prospectively to patients aged 11-18 undergoing limb lengthening/reconstruction, pediatric, spine, sports, or hand/upper extremity orthopedic surgery. In all, 135 patients were identified; 105 were enrolled and completed both surveys. Results There were some statistically significant changes in responses to questions regarding office visits/hospital stays, patient-physician relationships, friends/community, academic performance, and expectations for surgical experience throughout the perioperative period. There were no statistically significant changes in responses to questions regarding the role of parent/family and sports. There was no statistically significant difference between the female and male genders or between age groups in any of the domains. Overall statistical significance in this study did not consistently correlate to clinical significance. Conclusion Adolescents require psychosocial support from their surgeons, caregivers, and peers in addition to respect for their independence and personal needs. Level of evidence Level II.
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Fabricant PD. CORR Insights®: Does Early Conversion to Below-elbow Casting for Pediatric Diaphyseal Both-bone Forearm Fractures Adversely Affect Patient-reported Outcomes and ROM? Clin Orthop Relat Res 2024; 482:1882-1884. [PMID: 38843506 PMCID: PMC11419505 DOI: 10.1097/corr.0000000000003148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Accepted: 05/15/2024] [Indexed: 09/25/2024]
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Adhiyaman A, Tracey OC, Nagra K, Zucker CP, Wisch JL, Jones RH, Fabricant PD, Heyer JH, Widmann RF, Doyle SM. Focal Fibrocartilaginous Dysplasia and Growth Arrest: Case Report. JBJS Case Connect 2024; 14:01709767-202412000-00008. [PMID: 39729616 DOI: 10.2106/jbjs.cc.24.00174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2024]
Abstract
CASE A pediatric patient with focal fibrocartilaginous dysplasia (FFCD) developed angular deformity and growth arrest despite standard guided growth management. The patient underwent implant-mediated guided growth for proximal tibia varus deformity which recurred; subsequently, a physeal bar of the medial proximal tibia was diagnosed, which progressed to physeal arrest. CONCLUSION Treatment options for FFCD-associated angular deformity include observation and guided growth. This case highlights the risk of complete physeal arrest in FFCD.
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Cirrincione PM, Bram JT, Nichols ET, Beber SA, Matsuzaki Y, Fabricant PD, Scher DM. Health State Utilities and Cost-Effectiveness Economic Evaluation for Treatment of a Symptomatic Accessory Navicular. Foot Ankle Int 2024; 45:1156-1167. [PMID: 39075769 DOI: 10.1177/10711007241262794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/31/2024]
Abstract
BACKGROUND Treatment strategies for a symptomatic accessory navicular include both operative and nonoperative approaches. The primary aim of this study is to define health utility values for 7 health states experienced by those with a symptomatic accessory navicular who undergo operative and/or nonoperative treatment. Secondarily, the study incorporates the health utility values with treatment costs, probabilities of various outcomes, and duration of health states into a cost-effectiveness model comparing the nonoperative treatment protocol at our institution vs surgical excision. METHODS Institutional review board approval was obtained to call parents of patients 10-20 years old at the time of interview who were evaluated for a symptomatic accessory navicular from February 1, 2016, to March 2, 2023, at a single institution by one of 4 pediatric orthopaedic surgeons. Participants were asked to rate 7 health states from 0 to 100, with 0 representing death (if 18 years or older) or the worst health imaginable (if under 18 years) and 100 representing perfect health. Using published values for the probabilities of various treatment outcomes, time spent in various health states, and Medicare costs from the perspective of the payor and society, a decision analysis was constructed. RESULTS Health utility values for 7 health states were obtained. Operative treatment was preferred to nonoperative treatment in the base case model. Surgery was more expensive ($16 825) than nonoperative treatment ($7486). Using a willingness-to-pay threshold of <$50 000 per quality-adjusted life year (QALY), surgery was cost-effective compared to nonoperative treatment with an incremental cost-effectiveness ratio of $20 303/QALY. Sensitivity analysis revealed that the only variable that indicated a preference for nonoperative treatment is a 71% likelihood of nonoperative treatment resolving the condition. CONCLUSION Unless a physician suspects at least a 71% chance of a symptomatic accessory navicular resolving without operative treatment, surgical excision is recommended from a cost-effectiveness perspective.
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Jones RH, Beber SA, Adhiyaman A, Tracey OC, Lijesen E, Green DW, Fabricant PD. No Association Between Growth Hormone Therapy and Upper Extremity Physeal Tension Injuries: A Matched Case-control Study. Clin Orthop Relat Res 2024:00003086-990000000-01736. [PMID: 39255469 DOI: 10.1097/corr.0000000000003248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 08/20/2024] [Indexed: 09/12/2024]
Abstract
BACKGROUND Recent evidence has identified a strong association between growth hormone therapy and physeal injuries in the lower extremity; however, few studies have investigated this association in the upper extremity. QUESTIONS/PURPOSES (1) Do pediatric patients with physeal tension injuries of the shoulder and elbow have higher odds of having exposure to recombinant growth hormone therapy than matched controls? (2) Are the odds of having exposure to recombinant growth hormone therapy in physeal tension injuries different when stratified by shoulder and elbow injuries? METHODS Using a matched case-control study design, patients between 4 and 18 years of age treated at a large, urban, academic center from February 1, 2016, to November 6, 2023, were identified by ICD-10 codes using EPIC SlicerDicer, an electronic medical record-based data mining tool. Patients diagnosed with physeal tension injuries in the shoulder or elbow were included in the case group, and those with midshaft radius, metaphyseal radius, or both-bone forearm fractures were included in the control group. A total of 618 patients with physeal injuries and 1244 with non-physeal fractures were identified and screened for inclusion. After further chart review to confirm diagnoses, 46% (283) of patients with physeal injuries and 54% (670) of patients with non-physeal fractures were included. A further 6% (16) of patients with physeal injuries and 2% (15) of patients with non-physeal injuries were excluded due concomitant dislocations or missing data, resulting in 267 eligible patients with physeal injuries and 655 eligible patients with non-physeal fractures. Two patients with concurrent elbow and shoulder physeal injuries were additionally excluded from stratified analyses. Patients with physeal injuries and non-physeal fractures were 1:1 matched by age ± 0.5 years, sex, and BMI ± 2 kg/m2. In all, 522 patients were included in the analysis, including 261 patients with physeal injuries and 261 with non-physeal fractures. The mean ± SD ages for both patient groups was 13 ± 2 years (p = 0.44), 88% (229 of 261) of all participants were male, and the mean BMIs were 19.9 ± 3.0 kg/m2 and 19.4 ± 3.0 kg/m2 (p = 0.11), respectively. Growth hormone exposure was compared between patients with physeal injuries and non-physeal fractures using a conditional logistic regression model. RESULTS Overall, 4% (10 of 261) of patients with physeal injuries had exposure to growth hormone therapy as compared with 2% (4 of 261) of patients with non-physeal fractures (OR 2.5 [95% confidence interval 0.8 to 8.0]). Subgroup analyses of shoulder and elbow injuries demonstrated no difference in growth hormone exposure between patients with physeal injuries and non-physeal fractures (OR 2 [95% CI 0.4 to 10.2] and OR 3 [95% CI 0.6 to 14.9], respectively). CONCLUSION In light of these results, clinicians may not need to advise precaution against sports or other activities that put the upper extremity physes under stress when treating patients with growth hormone supplementation therapy. Future multicenter studies, however, are indicated to further investigate for the existence of any subtle association between growth hormone therapy and upper extremity physeal injuries relative to the large association previously noted in the lower extremity in pediatric and adolescent patients. LEVEL OF EVIDENCE Level III, therapeutic study.
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Farid AR, Pradhan P, Stearns SA, Kocher MS, Fabricant PD. Association Between Posterior Tibial Slope and ACL Injury in Pediatric Patients: A Systematic Review and Meta-analysis. Am J Sports Med 2024; 52:2911-2918. [PMID: 38275009 DOI: 10.1177/03635465231199649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
BACKGROUND The posterior tibial slope (PTS) has been proposed to be a radiographic risk factor for anterior cruciate ligament (ACL) injury in adults. However, this has not been well established in pediatric patients. PURPOSE This systematic review and meta-analysis was performed to investigate any association between PTS and ACL tears in the pediatric population. STUDY DESIGN Systematic review and meta-analysis; Level of evidence, 4. METHODS A systematic review was performed to identify studies that examined the relationship between PTS, medial tibial slope (MTS), and lateral tibial slope (LTS) and ACL tears in children and adolescents aged ≤18 years. Full-text observational studies comparing PTS, MTS, and/or LTS values between pediatric (≤18 years of age) patients with and without ACL injury were included in this analysis. Review articles and case series were excluded. The authors calculated the mean difference (MD) via a restricted maximum-likelihood estimator for tau square and a Hartung-Knapp adjustment for random-effects model. RESULTS A total of 348 articles were identified in the initial database search, yielding 10 for final inclusion and analysis. There was no statistically significant association between PTS (MD, 1.13°; 95% CI, -0.55° to 2.80°; P = .10), MTS (MD, 0.36°; 95% CI, -0.37° to 1.10°; P = .27), or LTS (MD, 1.41°; 95% CI, -0.20° to 3.02°; P = .075) and risk for ACL injury in this population. CONCLUSION The current study found that unlike what has been shown in adult populations, increased PTS may not be a significant risk factor for ACL tears in pediatric and adolescent patents. LTS was the only measured parameter that neared statistical significance, perhaps suggesting a potential role for this measurement in determining ACL risk if further research is done in this population.
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Fabricant PD, Bram JT. Methods of Assessing Skeletal Maturity When Planning Surgeries About the Knee. J Am Acad Orthop Surg 2024:00124635-990000000-01085. [PMID: 39231293 DOI: 10.5435/jaaos-d-24-00133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 07/23/2024] [Indexed: 09/06/2024] Open
Abstract
Increased participation in youth sports has led to more knee injuries necessitating surgical intervention. Among the youngest athletes, such procedures typically involve physeal-respecting techniques for anterior cruciate ligament reconstruction, medial patellofemoral ligament reconstruction for patellar instability, osteochondritis dissecans fixation, and implant-mediated guided growth procedures. In each case, the choice of appropriate intervention is critically dependent on a patient's skeletal maturity. Compared with chronologic age, skeletal age accounts for individual maturation and is the benchmark for determination of development in orthopaedics. This is historically assessed using the Greulich and Pyle method, in which bone age is determined through comparison of a patient's hand radiograph with the closest standard radiograph from an atlas of American children from the early 1900s. In the setting of knee pathology, obtaining additional imaging requires further radiation and time. Several bone age determination methods exist incorporating radiographic characteristics of the distal femur, proximal tibia, and/or proximal fibula. This study therefore sought to review available methods for determination of skeletal age when planning surgeries about the knee using readily available, routine knee imaging. The review focuses on both radiograph and MRI-based skeletal maturity staging systems that surgeons may use to guide appropriate treatment while describing the strengths and weaknesses of each method.
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Blumenschein LA, Kolin DA, Fabricant PD, Park J, Gilmore A, Seeley M, Mistovich RJ. Prevalence of Concomitant Injuries by Sport in Pediatric Patients With ACL Rupture. Orthop J Sports Med 2024; 12:23259671241260051. [PMID: 39157019 PMCID: PMC11328314 DOI: 10.1177/23259671241260051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 01/01/2024] [Indexed: 08/20/2024] Open
Abstract
Background Although the risk of concomitant injury with anterior cruciate ligament (ACL) tears as a function of specific sports participation has been studied in adults, the topic has not been examined in pediatric and adolescent patients. Purpose/Hypothesis The purpose of the study was to determine if certain sports were associated with a higher risk of concomitant injuries in the setting of an ACL tear. It was hypothesized that the risk of concomitant injuries with ACL tears will differ by type of sport participation in the pediatric population. Study Design Cross-sectional study; Level of evidence, 3. Methods Patients ≤18 years old from 2 tertiary children's hospitals who had undergone primary ACL reconstruction between 2006 and 2018 were included. Sport at the time of injury, demographic factors, and injury pattern (medial meniscal [MM] tears, lateral meniscal [LM] tears, posterior cruciate ligament [PCL] tears, medial collateral ligament [MCL] tears, lateral collateral ligament [LCL] tears, and any concomitant injury) were identified. Results A total of 855 patients with a mean age of 15.5 ± 1.7 years (range, 7-22 years) met the inclusion criteria. Of the included patients, 353 (41.3%) had an isolated ACL tear. A concomitant MM tear was identified in 27.6% of patients, LM tear in 42.9%, PCL injury in 0.4%, MCL injury in 3.0%, and LCL injury in 0.5%. There was no difference in the likelihood of concomitant MM injuries by sex (29.3% for male patients vs 26% for female patients; P = .31) or by sex within basketball (29.3% for male patients vs 25.6% for female patients; P = .96) or soccer (32.3% vs 26.3%; P = .06). Boys had higher proportions of LM injuries overall (51.7% for male patients vs 34.6% for female patients; P < .001) but not within the basketball subgroup (50.5% vs 40.0%; P = .86) or the soccer subgroup (59.7% vs 40.0%; P = .19). No statistically significant associations were found between patient age and specific ACL concomitant injury patterns. When stratifying by body mass index, it was found overweight and obese individuals constituted a greater proportion of LM (49.6% vs 39.1%; P = .01) but not MM (29.4% vs 25.5%; P = .28) injuries when compared to normal-weight patients. Using basketball as the comparison group, soccer and football injuries were 18% more likely to result in any concomitant injury, including concomitant MM, LM, PCL, MCL, and LCL injuries. Conclusion In the pediatric population, soccer and football players were more likely to present with a concomitant injury in addition to ACL injury relative to basketball players. This study aids in understanding sport-associated ACL injury patterns and can help physicians with patient counseling and injury prevention.
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Beber SA, Jones RH, Cirrincione P, Gross PW, Green DW, Greditzer HG, Heyworth BE, Fabricant PD. The Intra-articular Tendinous Graft Diameter of 10-mm Bone-Patellar Tendon-Bone Autografts in Adolescent Patients: An MRI Analysis of 100 Patients. Orthop J Sports Med 2024; 12:23259671241264503. [PMID: 39165331 PMCID: PMC11334251 DOI: 10.1177/23259671241264503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 02/26/2024] [Indexed: 08/22/2024] Open
Abstract
Background Bone-patellar tendon-bone (BPTB) autograft size may be one modifiable predictor of anterior cruciate ligament (ACL) reconstruction postoperative success, as smaller graft diameter has been associated with higher rates of rupture requiring revision. However, measuring the true intra-articular tendinous graft diameter of the soft tissue portion of a BPTB graft with standard intraoperative methods is difficult while keeping the graft intact. Purpose/Hypothesis The purpose of the study was to use 3-dimensional magnetic resonance imaging (MRI) measurements to determine the cross-sectional area of the soft tissue, tendinous portion of a standard BPTB autograft with 10-mm diameter bone plugs, and, by calculation, the collagen graft size (ie, graft diameter), as would typically be reported in ACL reconstruction studies that consider soft tissue graft size. It was hypothesized that the calculated collagen graft diameter of 10-mm BPTB autografts would be significantly smaller than 10 mm. Study Design Cross-sectional study; Level of evidence, 3. Methods A total of 100 patients (10 girls and 10 boys at each age from 13 to 17 years) who underwent a knee MRI at a single academic orthopaedic center without documented extensor mechanism pathology were identified. The central 10-mm width of the patellar tendon that would be harvested for BPTB autograft was measured. The region of interest area tool was then used to measure the cross-sectional area of a 10-mm BPTB graft with subsequent soft tissue autograft diameter calculation. Results The mean calculated tendinous graft diameter of a 10 mm-wide BPTB graft was 6.3 ± 0.5 mm and was significantly smaller than a 10-mm reference (P≤ .001). There was no significant association between age and cross-sectional area or graft diameter. Conclusion Modern 3-dimensional imaging-based measurement techniques demonstrated that the true intra-articular tendinous soft tissue portion of 10-mm BPTB autografts shows substantial variation and is significantly smaller in diameter than the tunnels typically reamed to accommodate the bone plug portions of these grafts. Moreover, as graft size is a predictor of rupture rate, preoperative MRI-based evaluation may be an important tool when considering BPTB autograft for ACL reconstruction. Future comparative clinical research utilizing graft size as a study variable should consider quantifying and utilizing the diameter of the soft tissue component of BPTB autografts.
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Moran J, Amaral JZ, Lee M, Jones RH, Gross P, Katz LD, Wang A, Carrino JA, Jimenez AE, Chhabra BN, Kan JH, Smith BG, Gladstein AZ, McKay SD, LaPrade RF, Fabricant PD, Medvecky MJ. Investigating the Bone Bruise Patterns in Pediatric Patients With Contact and Noncontact Acute Anterior Cruciate Ligament Tears: A Multicenter Study. Am J Sports Med 2024; 52:2456-2463. [PMID: 39101652 DOI: 10.1177/03635465241264282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/06/2024]
Abstract
BACKGROUND In adults with anterior cruciate ligament (ACL) tears, bone bruises on magnetic resonance imaging (MRI) scans provide insight into the underlying mechanism of injury. There is a paucity of literature that has investigated these relationships in children with ACL tears. PURPOSE To examine and compare the number and location of bone bruises between contact and noncontact ACL tears in pediatric patients. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Boys ≤14 years and girls ≤12 years of age who underwent primary ACL reconstruction surgery between 2018 and 2022 were identified at 3 separate institutions. Eligibility criteria required detailed documentation of the mechanism of injury and MRI performed within 30 days of the initial ACL tear. Patients with congenital lower extremity abnormalities, concomitant fractures, injuries to the posterolateral corner and/or posterior cruciate ligament, previous ipsilateral knee injuries or surgeries, or closed physes evident on MRI scans were excluded. Patients were stratified into 2 groups based on a contact or noncontact mechanism of injury. Preoperative MRI scans were retrospectively reviewed for the presence of bone bruises in the coronal and sagittal planes using fat-suppressed T2-weighted images and a grid-based mapping technique of the tibiofemoral joint. RESULTS A total of 109 patients were included, with 76 (69.7%) patients sustaining noncontact injuries and 33 (30.3%) patients sustaining contact injuries. There were no significant differences between the contact and noncontact groups in terms of age (11.8 ± 2.0 vs 12.4 ± 1.3 years; P = .12), male sex (90.9% vs 88.2%; P > .99), time from initial injury to MRI (10.3 ± 8.1 vs 10.4 ± 8.9 days; P = .84), the presence of a concomitant medial meniscus tear (18.2% vs 14.5%; P = .62) or lateral meniscus tear (69.7% vs 52.6%; P = .097), and sport-related injuries (82.9% vs 81.8%; P = .89). No significant differences were observed in the frequency of combined lateral tibiofemoral (lateral femoral condyle + lateral tibial plateau) bone bruises (87.9% contact vs 78.9% noncontact; P = .41) or combined medial tibiofemoral (medial femoral condyle [MFC] + medial tibial plateau) bone bruises (54.5% contact vs 35.5% noncontact; P = .064). Patients with contact ACL tears were significantly more likely to have centrally located MFC bruising (odds ratio, 4.3; 95% CI, 1.6-11; P = .0038) and less likely to have bruising on the anterior aspect of the lateral tibial plateau (odds ratio, 0.27; 95% CI, 0.097-0.76; P = .013). CONCLUSION Children with contact ACL tears were 4 times more likely to present with centrally located MFC bone bruises on preoperative MRI scans compared with children who sustained noncontact ACL tears. Future studies should investigate the relationship between these bone bruise patterns and the potential risk of articular cartilage damage in pediatric patients with contact ACL tears.
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White AE, James EW, Jahandar A, Jones RH, Fabricant PD. Effect of Medial Patellofemoral Complex Reconstruction Technique on Patellofemoral Contact Pressure, Contact Area, and Kinematics. Am J Sports Med 2024; 52:2215-2221. [PMID: 38872411 DOI: 10.1177/03635465241252818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/15/2024]
Abstract
BACKGROUND Medial patellofemoral ligament (MPFL) reconstruction is considered by many to be the gold standard to treat lateral patellar instability; however, some investigators have reported good clinical results after isolated medial quadriceps tendon-femoral ligament (MQTFL) reconstruction or a combined MPFL/MQTFL reconstruction. A handful of studies have preliminarily investigated the biomechanical consequences of these various medial patellar stabilizing procedures. Despite this, no existing study has included multiple medial patellofemoral complex (MPFC) reconstructions and assessment of lateral patellar translation at distinct flexion angles. HYPOTHESIS Combined MPFL/MQTFL reconstruction would restore patellofemoral contact areas, forces, and kinematics closest to the native state compared with isolated reconstruction of the MPFL or MQTFL alone. STUDY DESIGN Controlled laboratory study. METHODS Ten adult cadaveric knee specimens were prepared and analyzed under 5 different conditions: (1) intact state, (2) transected MPFC, (3) isolated MPFL reconstruction, (4) isolated MQTFL reconstruction, and (5) combined MPFL/MQTFL reconstruction. Patellar tilt, lateral patellar translation, patellofemoral contact forces, and patellofemoral contact areas were measured in each condition from 0° to 80° through simulated knee flexion using a custom servohydraulic load frame with pressure sensor technology and a motion capture system for kinematic data acquisition. RESULTS The isolated MPFL, isolated MQTFL, and combined MPFL/MQTFL reconstruction conditions produced significantly less lateral patellar tilt compared with the transected MPFC state (P < .05). No statistically significant differences were found when each reconstruction technique was compared with the intact state in patellar tilt, lateral patellar translation, contact forces, and contact areas. CONCLUSION All 3 reconstruction techniques (isolated MPFL reconstruction, isolated MQTFL reconstruction, and combined MPFL/MQTFL reconstruction) restored native knee kinematics, contact forces, and contact areas without overconstraint. CLINICAL RELEVANCE Isolated MPFL reconstruction, isolated MQTFL reconstruction, and combined MPFL/MQTFL reconstruction all restore patellofemoral stability comparable with the intact MPFC state without the overconstraint that could be concerning for increasing risk of patellofemoral arthritis.
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Gross PW, Meza BC, Nimura CA, Sneag DB, Trehan SK, Fabricant PD. Visualization of Median Nerve Entrapment After Reduction of an Elbow Fracture Dislocation Using 3-Dimensional Magnetic Resonance Imaging: A Case Report. JBJS Case Connect 2024; 14:01709767-202409000-00035. [PMID: 39172881 DOI: 10.2106/jbjs.cc.24.00169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2024]
Abstract
CASE A 10-year-old girl presented after closed reduction of an elbow fracture dislocation. She demonstrated intact vascularity but a dense median nerve palsy. Preoperative magnetic resonance neurography (MRN) precisely mapped the median nerve entrapped within the medial epicondylar fracture. Intraoperatively, the median nerve was freed preceding reduction and fracture fixation. Postoperatively, neurological symptoms completely resolved, and she regained full elbow function. CONCLUSION Median nerve injury can present without associated vascular injury. In this case, MRN was helpful in preoperatively illustrating the spatial relationship between the median nerve and the medial epicondyle.
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Shin CH, Syed AN, Swanson ME, Kushare IV, Shea KG, Ganley TJ, Baghdadi S, Cruz AI, Ellis HB, Fabricant PD, Ganley TJ, Green DW, Kerrigan A, Kirby J, Kocher M, Kushare IV, Jay Lee R, MacDonald JP, McKay SD, Parikh SN, Patel NM, Yen YM, Schmale GA, Shea KG, Justin Mistovich R. Evaluation of Tibial Slope on Radiographs in Pediatric Patients With Tibial Spine Fractures: An Age- and Sex-Matched Study. Orthop J Sports Med 2024; 12:23259671241256445. [PMID: 39100212 PMCID: PMC11295229 DOI: 10.1177/23259671241256445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 04/02/2024] [Indexed: 08/06/2024] Open
Abstract
Background A recent study has reported that the radiographic measurement of posterior tibial slope (PTS) is larger in male pediatric patients with tibial spine fractures (TSF) than in controls. However, they found no difference in PTS between female patients and controls. Purpose (1) To identify whether PTS is larger in female pediatric patients with TSF than in female controls and (2) to validate the relationship between PTS and pediatric TSF in male patients. Study Design Cross-sectional study; Level of evidence, 3. Methods After an a priori power analysis, 84 pediatric patients with TSF (50 female patients and 34 male patients) and 84 age- and sex-matched controls were enrolled in this study. Demographic information, including sex, age, and race, was recorded. Skeletal maturity was determined based on the stage of epiphyseal union on knee radiographs. PTS was defined as the angle between a line perpendicular to the longitudinal axis of the tibia and the posterior inclination of the medial tibial plateau on standard knee lateral radiographs. Results The mean age when the TSF occurred was 11.2 ± 2.7 years for female patients and 12.9 ± 2.5 years for male patients. There was no significant difference in skeletal maturity between female patients and female controls or between male patients and male controls. The mean PTS was not significantly different between female patients (8.8°± 2.8°) and female controls (8.3°± 3.1°) (P = .366) or between male patients (9.0°± 2.8°) and male controls (9.3°± 2.6°) (P = .675). Those with a PTS >1 SD (2.9°) above the mean (8.8°) had no greater odds (1.0 [95% CI, 0.4-2.5]; P≥ .999) of having a TSF than others. Conclusion PTS was not found to be a risk factor for pediatric TSF in female or male patients in this study.
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Kolin DA, Jones RH, Heyworth BE, Jivanelli B, Fabricant PD. No difference in stability among various knee flexion angles during fixation of anterolateral ligament reconstruction or lateral extra-articular tenodesis: A systematic review and meta-analysis of biomechanical studies. J Exp Orthop 2024; 11:e12079. [PMID: 39015341 PMCID: PMC11250156 DOI: 10.1002/jeo2.12079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Revised: 06/18/2024] [Accepted: 06/21/2024] [Indexed: 07/18/2024] Open
Abstract
Purpose The purpose of this study was to investigate the effect of anterolateral ligament reconstruction (ALLR) or lateral extra-articular tenodesis (LET) fixation at low versus high flexion angles during anterior cruciate ligament reconstruction (ACLR) on rotation or translational knee stability. Methods The inclusion criteria for this study were (1) cadaveric study, (2) cadaveric specimens underwent ACLR, (3) cadaveric specimen underwent ALLR or LET and (4) specimen preparation technique described the knee flexion angle at the time of ALLR or LET tensioning and fixation. A priori, 'low flexion' was defined as 0-30° and 'high flexion' was defined as 60-90° at graft fixation. Main outcomes of interest included internal rotation and anterior translation. Results Data from 92 cadaveric knees (from 9 studies) were extracted and included in the meta-analysis. The mean pooled value for internal rotation was 10.1° (95% confidence interval [CI], 5.7-14.5°) for the low flexion group and 11.5° (95% CI, 7.4-15.7°) for the high flexion group (n.s.). The mean pooled value for anterior translation was 4.3 mm (95% CI, 0.5-8.1 mm) for the low flexion group and 3.0 mm (95% CI, 1.1-5.0 mm) for the high flexion group (n.s.). Conclusion This meta-analysis of existing biomechanical research found that the rotational and translational stability of the knee were not significantly different between scenarios in which ALLR or LET fixation was performed at low knee flexion angles (0-30°) versus high knee flexion angles (60-90°). Level of Evidence Level IV.
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Dingel AB, Tompkins M, Yen YM, Karius AK, Cinque M, Vuong BB, Taylor V, Pham NS, Ganley TJ, Wilson P, Ellis HB, Green D, Fabricant PD, Boucher L, Shea KG. A Recess Is Observed Between the Posterior Knee Capsule and the Meniscotibial Ligament Complex in Pediatric Specimens. Arthrosc Sports Med Rehabil 2024; 6:100852. [PMID: 39006787 PMCID: PMC11240032 DOI: 10.1016/j.asmr.2023.100852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 11/19/2023] [Indexed: 07/16/2024] Open
Abstract
Purpose To define the surgical anatomy of the meniscotibial ligament complex of the pediatric medial and lateral menisci and their relation to the proximal tibial physis and posterior joint capsule. Methods Fourteen pediatric cadaveric knee specimens (aged 3 months to 11 years) were dissected to clarify the relation of the posterior knee capsule, the meniscus, and the meniscotibial ligament complex. Metallic markers were placed marking the meniscotibial ligament capsular attachment on the proximal tibia. Specimens underwent computed tomography scanning to evaluate pin placement and relation to the physis. A digital measurement tool was used to measure the distances between the proximal tibial physis and the pins (placed at 5 points on both the lateral and medial menisci). Results In each specimen, clear separation was noted between the posterior joint capsule from the meniscus and meniscotibial ligament complex in the medial and lateral compartments. There was an increase in the distance between the proximal tibial physis and the insertion points of the meniscotibial ligament complex with increasing specimen age. For both the medical and lateral menisci in group 1, the median meniscotibial ligament insertion points were often less than 7 mm (interquartile range, 0.00-7.8 mm) away from the physis. The median meniscotibial ligament insertion points in group 2 tended to be farther from the physis but always less than 20 mm (interquartile range, 2.5-17.5 mm)-and as close as less than 5 mm (lateral posterior root). Conclusions In this anatomic study of pediatric knees, we observed a distinct recess/cul-de-sac space between the posterior knee capsule and meniscal attachments in all specimens. This defines a distinct plane between the posterior knee capsule and the meniscotibial ligament complex, with a distance between the physis and meniscotibial ligament capsular attachments that increases with age. Clinical Relevance The anatomic parameters evaluated in our study should be considered as future meniscal repair and transplantation techniques aim to restore the meniscal anatomy, stability, and mobility provided by the meniscotibial ligament complex and capsule structures.
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Nagra KK, Jones RH, Gross PW, Cirrincione P, Chipman DE, Farrell AM, Greditzer HG, Green DW, Fabricant PD. Transosseous Repair of Isolated Posterior Medial Meniscal Root Injuries in Children and Adolescents. Arthrosc Tech 2024; 13:102951. [PMID: 38835467 PMCID: PMC11144944 DOI: 10.1016/j.eats.2024.102951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 01/14/2024] [Indexed: 06/06/2024] Open
Abstract
The meniscal roots are critically important for maintaining knee stability, functional load distribution, and proper knee kinematics. Although adult meniscal root injuries have been a topic of increasing research, medial meniscus injuries also occur in pediatric and adolescent patients, with up to 2% of meniscal injuries involving root attachments. The purpose of this Technical Note is to demonstrate the transosseous repair of isolated posterior medial meniscal root injuries in children and adolescents, including tear visualization on magnetic resonance imaging and during arthroscopy, operative technique, and postoperative management.
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Bram JT, Tracey OC, Lijesen E, Li DT, Chipman DE, Retzky JS, Fabricant PD, Green DW. Simultaneous MPFL reconstruction and guided growth result in low rates of recurrent patellofemoral instability. Knee Surg Sports Traumatol Arthrosc 2024; 32:1105-1112. [PMID: 38469940 DOI: 10.1002/ksa.12134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 02/20/2024] [Accepted: 02/22/2024] [Indexed: 03/13/2024]
Abstract
PURPOSE Implant-mediated guided growth (IMGG) is used to address coronal plane deformity in skeletally immature patients. Few studies have reported on IMGG and simultaneous medial patellofemoral ligament (MPFL) reconstruction for paediatric patients with concurrent genu valgum and patellofemoral instability (PFI). This study aimed to report on the outcomes of these simultaneous procedures. MATERIALS AND METHODS This was a retrospective review of paediatric patients undergoing simultaneous MPFL reconstruction and IMGG between 2016 and 2023. Mechanical lateral distal femoral angle (mLDFA), hip-knee-ankle angle (HKA) and mechanical axis deviation (MAD) were measured on full-length hip-to-ankle plain radiographs. Measurements were taken preoperatively, prior to implant removal and/or at final follow-up with minimum 1-year clinical follow-up. RESULTS A total of 25 extremities in 22 patients (10 female) underwent simultaneous IMGG and MPFL reconstruction. The mean age at surgery was 12.6 ± 1.7 years. The mean duration of implant retention was 18.6 ± 11.3 months. Nineteen extremities (76%) underwent implant removal by final follow-up. Preoperative HKA corrected from a mean of 5.8 ± 2.3° to -0.8 ± 4.5° at implant removal or final follow-up (p < 0.001), with mLDFA and MAD similarly improving (both p < 0.001). HKA corrected a mean of 0.7 ± 0.9° per month, while mLDFA and MAD corrected a mean of 0.5 ± 0.6°/month and 2 ± 3 mm/month, respectively. At the time of implant removal or final follow-up, 88% of patients demonstrated alignment within 5° of neutral. Only one extremity experienced subsequent PFI (4%). For 14 patients who underwent implant removal with further imaging at a mean of 7.8 ± 4.9 months, only one patient (7%) had a valgus rebound to an HKA > 5°. CONCLUSION Simultaneous MPFL reconstruction and IMGG provided successful correction of lower extremity malalignment with only one recurrence of PFI. This approach is a reliable surgical option for skeletally immature patients with genu valgum and PFI. LEVEL OF EVIDENCE Level 4 case series.
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Fabricant PD, Gross PW, Mackie AT, Heath MR, Pascual-Leone N, Denneen JP, Gelley PE, Scher DM, Ipp LS. Virtual Reality Distraction Is No Better Than Simple Distraction Techniques for Reducing Pain and Anxiety During Pediatric Orthopaedic Outpatient Procedures: A Randomized Controlled Trial. Clin Orthop Relat Res 2024; 482:854-863. [PMID: 37939199 PMCID: PMC11008647 DOI: 10.1097/corr.0000000000002889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 09/14/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND In-office procedures can be painful and anxiety-provoking for pediatric patients. Minimizing such pain and anxiety in children improves the patient experience and promotes a rewarding and productive patient-caregiver-provider relationship, which may for some young patients be their first memorable encounter with the healthcare system. Although virtual reality (VR) techniques have proven to be helpful in minimizing pain and anxiety during procedures in pediatric intensive care settings, it remains unclear how VR affects objective and subjective measures of pain and anxiety in children undergoing in-office orthopaedic procedures such as cast removal or percutaneous pin removal after fracture healing. QUESTIONS/PURPOSES Is a VR gaming simulation more effective than either of two forms of noninteractive visual distraction (VR goggles or tablet computer displaying a noninteractive video) for reducing (1) objective measures of pain and anxiety and (2) subjective measures of pain and anxiety in children undergoing in-office cast removal or percutaneous pin removal? METHODS This study was a randomized controlled trial with two parallel, separately analyzed cohorts: children undergoing in-office cast removal or in-office percutaneous pin removal at a single urban tertiary institution. We approached eligible patients who were scheduled to undergo outpatient cast or percutaneous pin removal and who met prespecified inclusion criteria. We enrolled until 105 patients were available for analysis in each of the cast removal and pin removal cohorts. Of note, the study institution was in an urban epicenter of the coronavirus-19 pandemic, and clinical research was paused sporadically, which resulted in a longer-than-expected enrollment period. In the cast removal cohort, all patients were eligible for inclusion and were enrolled and randomized into one of three groups: VR gaming simulation (n = 37), VR goggles with a noninteractive video (n = 36), or a tablet computer with the same noninteractive video (n = 40). Eleven percent (4), 8% (3), and 3% (1) withdrew from each of the three intervention groups, respectively. In the pin removal cohort, all patients were eligible for inclusion and were enrolled and randomized into the same three groups (37, 44, and 41 patients, respectively). In the pin removal group, 14% (5), 18% (8), and 10% (4) withdrew from each of the three intervention groups, respectively. In all, 235 patients were enrolled in the study and 210 patients (mean ± SD age 9 ± 3 years; 48% [100] girls) were included in the final analyses. There were no clinically important differences in age, gender, preprocedure pain, or anxiety among the intervention groups. Primary outcomes included preprocedure-to-maximum heart rate increase (objective measure) and preprocedure and postprocedure pain and anxiety using a VAS (subjective measures). One-way ANOVA and Bonferroni-adjusted pairwise comparisons were used to calculate between-group differences for the primary outcomes. RESULTS There were no intervention-level groupwise differences between VR goggles with an interactive game, VR goggles with a noninteractive video, or the tablet computer with the same video in preprocedure-to-maximum heart rate increase in the cast removal cohort (18 ± 21 bpm versus 14 ± 11 bpm versus 20 ± 16 bpm, respectively; largest mean difference -6 bpm [95% CI -16 to 3]; p = 0.36) or pin removal cohort (27 ± 20 bpm versus 23 ± 12 bpm versus 24 ± 19 bpm, respectively; largest mean difference 4 bpm [95% CI -7 to 14]; p = 0.99). Similarly, there were no intervention-level groupwise differences in preprocedure to postprocedure VAS pain in the cast removal cohort (1 ± 1 versus 1 ± 2 versus 0 ± 2, respectively; largest mean difference 0 points [95% CI 0 to 1]; p = 0.89) or pin removal cohort (0 ± 3 versus 2 ± 3 versus 0 ± 3 points, respectively; largest mean difference 1 point [95% CI 0 to 3]; p = 0.13). Finally, there were no intervention-level groupwise differences between the same intervention groups in preprocedure to postprocedure VAS anxiety in the cast removal cohort (-2 ± 2 versus -1 ± 2 versus -1 ± 2 points, respectively; largest mean difference -1 point [95% CI -2 to 1]; p = 0.63) or pin removal cohort (-3 ± 3 versus -4 ± 4 versus -3 ± 3 points, respectively; largest mean difference -1 point [95% CI -2 to 1]; p = 0.99). CONCLUSION During in-office cast and pin removal in pediatric patients, simple distraction techniques such as tablet video viewing are as effective as higher-fidelity VR headset video and interactive games in minimizing objective measures of procedural pain and subjective measures of pain and anxiety. Because of these findings and because of the associated costs, implementation logistics, and variable tolerance by young patients, widespread use of VR distraction techniques in the pediatric orthopaedic outpatient setting is unnecessary. LEVEL OF EVIDENCE Level I, therapeutic study.
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Ayala SG, Thomas N, Rohde M, Gupta A, Sanchez M, Tompkins M, Parikh SN, Ellis HB, Green DW, Yen YM, Fabricant PD, Wilson P, Shea KG. Osseous and Cartilaginous Trochlear Development in the Pediatric Knee: A Cadaveric Computed Tomography Study. Orthop J Sports Med 2024; 12:23259671241249132. [PMID: 38751851 PMCID: PMC11095196 DOI: 10.1177/23259671241249132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 11/13/2023] [Indexed: 05/18/2024] Open
Abstract
Background The anatomy of the trochlea plays a significant role in patellar stability. The developmental anatomy of the trochlea and its relationship to patellar stability remains poorly understood. Purpose To describe the developmental changes of the osseous and cartilaginous trochlear morphology in skeletally immature specimens. Study Design Descriptive laboratory study. Methods A total of 65 skeletally immature cadaveric knees between the ages of 2 months and 11 years were evaluated using computed tomography scans. The measurements in the axial plane of both cartilage and bone include medial, central, and lateral trochlear height; sulcus height; medial and later trochlear facet length; trochlear sulcus angle; patellar sulcus angle; condylar height asymmetry; and trochlear facet asymmetry. Additional measurements included trochlear depth and lateral trochlear inclination angle. In the sagittal plane, measurements included curvilinear trochlear length, direct trochlear length, condylar height, and patellar sulcus angle. Results Analysis of trochlear morphology using condylar height, condylar height asymmetry, and trochlear depth all increased with increasing age. The osseous and cartilaginous sulcus angles became deeper with age until age 8 and then plateaued. This corresponded with an increase in trochlear depth that also plateaued around age 8. Osseous condylar asymmetry increased with age but flipped from a larger medial condyle to a larger lateral condyle around age 8. The continued growth of the trochlea with age was further demonstrated in all measures in the sagittal view. Conclusion This cadaveric analysis demonstrated that there is an increase in condylar height as age increased by all measurements analyzed. These changes in condylar height continued to be seen through age 11, suggesting a still-developing trochlea past this age. By age 8, a plateau in sulcus angle, and sulcus depth suggests more proportionate growth after this point. Similar changes in trochlear and patellar shape with age suggests that the 2 structures may affect each other during development. Clinical Relevance This information can help design, develop, and determine timing of procedures that may alter the anatomy and stabilize the trochlear and patellofemoral joint.
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Maheu AR, Shih YC, LeBrun DG, Fabricant PD, Atanda AW. A Telemedicine Solution to Minimize Unnecessary Emergency Department Transfers for Low-acuity Pediatric Orthopaedic Patients: A Model for Cost Minimization. J Am Acad Orthop Surg 2024; 32:e443-e451. [PMID: 37793173 DOI: 10.5435/jaaos-d-21-01201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 08/24/2023] [Indexed: 10/06/2023] Open
Abstract
INTRODUCTION Unnecessary emergency department (ED) transfers represent a notable source of excess costs and misutilization of healthcare resources, particularly with management of acute pediatric musculoskeletal injuries. This study used institutional data to create a model investigating the expected costs of a formal peer-to-peer telemedicine intervention designed to triage pediatric orthopaedic transfers, which we hypothesized would decrease healthcare costs by minimizing unwarranted ED-to-ED transfers. METHODS In this retrospective modeling analysis, 350 pediatric orthopaedic trauma patients transferred to two in-network referral hospitals from outside facilities were identified and stratified into three groups representing how patients theoretically optimally could have been treated. Group 1 patients required ambulance transfer, group 2 patients required ED-level care but no ambulance transfer, and group 3 patients did not require ED-level care. Base case estimates for the proportions of patients in each group, probability of ambulance transport, and direct costs of care for each patient were derived from the database. A decision tree was developed to evaluate the expected costs of two triaging strategies: (1) transfer everyone or (2) triage first using e-consultation. Probabilistic sensitivity analyses were used to determine how the results of the decision analysis varied across ranges of cost and probability estimates. RESULTS In the base case analysis, the telemedicine triage strategy was cheaper than the transfer-all strategy ($4,858 versus $6,610). In a 2-way sensitivity analysis comparing cost of a telemedicine visit and proportion of telemedicine triaged patients requiring ambulance transport, the telemedicine triage strategy remained cheaper than the transfer-all strategy across almost all possibilities for both variables. Additional potential benefits of triage before transfer, such as decreased length of time to completion of ED visit, cost to the family, and patient comfort and satisfaction, were not incorporated into this analysis. The potential for misdiagnosis related to telehealth and its potential costs were not included. DISCUSSION We revealed substantial cost savings for the healthcare system from implementing a telehealth platform for peer-to-peer consultation when considering patient transfer for musculoskeletal trauma. Initial peer-to-peer e-consultations cost less than reflexive ambulance transfer in most situations. LEVEL OF EVIDENCE Economic Level II.
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Burkhart RJ, Kolin DA, Fabricant PD, Liu RW, Mistovich RJ. Less common than expected: late displacement after minimally displaced pediatric lateral condyle fractures of the elbow. J Pediatr Orthop B 2024; 33:130-135. [PMID: 37040657 DOI: 10.1097/bpb.0000000000001085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/13/2023]
Abstract
The incidence of late displacement among pediatric lateral condyle fractures has been described as 1.3-26%. However, prior studies are limited by small cohort sizes. The aim of this study was to determine the rate of late displacement and delayed union among lateral condyle fractures following immobilization in a large cohort and to establish additional radiographic criteria to help surgeons choose between immobilization and operative fixation for minimally displaced fractures. We performed a dual-center retrospective study of patients with lateral condyle fractures between 1999 and 2020. Patient demographics, injury mechanism, time to orthopedic presentation, duration of cast immobilization, and complications following casting were recorded. There were 290 patients with lateral condyle fractures included. The initial management in 61% of patients (178/290) was nonoperative, of which four had delayed displacement at follow-up and two developed delayed union requiring surgery (failure in 6/178, 3.4%). The mean displacement on the anteroposterior view was 1.3 ± 1.1 mm and the lateral view was 0.50 ± 1.0 mm in the nonoperative cohort. In the operative cohort, the mean displacement on AP was 6.6 ± 5.4 mm and the lateral view was 5.3 ± 4.1 mm. Our analysis found the rate of late displacement in patients treated with immobilization was lower than previously reported (2.5%; 4/178). The mean displacement on the lateral film in the cast immobilization cohort was 0.5 mm, suggesting that necessitating near anatomic alignment on the lateral film to consider nonoperative management may lead to a lower incidence of late displacement than previously reported. Level of evidence: Level III, retrospective comparative study.
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