Aristides I. Cruz

All-epiphyseal Acl Reconstruction in Children: Review of Safety and Early Complications.

Background: All-epiphyseal anterior cruciate ligament (ACL) reconstruction is a well-described technique for skeletally immature patients. The purpose of this study was to elucidate the early complication rate and identify associated risk factors for rerupture after this procedure in children. Methods: We retrospectively reviewed patients who underwent all-epiphyseal ACL reconstructions performed at a large, tertiary care children’s hospital between January 2007 and April 2013. Relevant postoperative data including the development of leg-length discrepancy, angular deformity, rerupture, infection, knee range of motion, arthrofibrosis, and other complications were recorded. Independent variables analyzed for association with rerupture included age, body mass index, graft type, graft size, and associated injuries addressed at surgery. Results: A total of 103 patients (average 12.1 y old; range, 6.3 to 15.7) were analyzed. The mean follow-up was 21 months. The overall complication rate was 16.5% (17/103), including 11 reruptures (10.7%), 1 case (<1.0%) of clinical leg-length discrepancy of <1 cm, and 2 cases (1.9%) of arthrofibrosis requiring manipulation under anesthesia. Two patients (1.9%) sustained contralateral ACL ruptures and 3 (2.9%) sustained subsequent ipsilateral meniscus tears during the study period. There were no associations found between age, sex, graft type, graft thickness, body mass index, or associated injuries addressed during surgery and rerupture rate. Knee flexion continued to improve by 20 degrees on an average between the 6 weeks and 6 months postoperative visits (P<0.001; paired samples Students t test). Conclusions: When taken in the context of known risk of future injury in an ACL-deficient knee, all-epiphyseal ACL reconstruction in children is safe. The rate of growth disturbance in this study is similar to previous reports in this patient demographic. The rerupture rate in this cohort is slightly higher compared with ACL reconstruction in older patients. Level of Evidence: Level IV—retrospective case series.

Distal rectus femoris intramuscular lengthening for the correction of stiff-knee gait in children with cerebral palsy.

Purpose To evaluate the effects of rectus femoris intramuscular lengthening, a novel procedure to treat stiff-knee gait in ambulatory patients with cerebral palsy, using preoperative and postoperative 3-dimensional gait analysis. Methods This study was a retrospective data review of ambulatory patients with a diagnosis of cerebral palsy who had undergone rectus femoris intramuscular lengthening. The indications for rectus femoris intramuscular lengthening were identical to those of rectus femoris transfer. Patients must have had preoperative and postoperative gait analyses at our institution. Three-dimensional kinematic and kinetic data was collected using a VICON 512 motion measurement system (VICON Motion Systems, Inc, Lake Forest, CA) after standard techniques. A representative trial was selected for analysis both preoperatively and postoperatively. Preoperative to postoperative differences were measured using a Student t test (P<0.05). Selected sagittal plane kinematic and kinetic parameters were analyzed. Results A total of 42 patients (69 sides) treated between 1991 and 2008 with preoperative and postoperative gait analyses after rectus femoris intramuscular lengthening were analyzed. The mean age at surgery was 8.5 years (SD ±2.9) and the mean time after surgery at postoperative gait analysis was 17.9 months (range, 7 to 53 mo). There were 26 male and 16 female patients. Compared with preoperative values, postoperative gait analysis revealed patients to have earlier timing of peak knee flexion in swing (82%→80% of gait cycle, P=0.001), less crouch (average knee flexion in stance 26→20 degrees, P=0.002), and maintenance (no statistically significant difference) of peak knee flexion. A cohort of patients also showed maintenance of knee function at intermediate-term follow-up (mean 44.6 mo). Patients who underwent soft-tissue surgery only benefited more from the procedure than those who also underwent bony surgery. Conclusions Rectus femoris intramuscular lengthening may offer an alternative procedure for the treatment of stiff-knee gait in ambulatory patients with cerebral palsy. When comparing preoperative and postoperative gait analysis data, our cohort showed maintenance of peak knee flexion in swing, earlier timing of peak knee flexion in swing, and less crouch. Patients who underwent soft-tissue surgery only showed the most benefit. Level of Evidence Level IV.

Change in Size of Hamstring Grafts During Preparation for ACL Reconstruction: Effect of Tension and Circumferential Compression on Graft Diameter.

BACKGROUND There is good consensus that anterior cruciate ligament (ACL) grafts should be pretensioned to remove creep prior to implantation, but the literature contains little information on the influence of graft preparation or circumferential compression on graft size. The purpose of this study was to investigate how the size of hamstring allografts changes as they are prepared for ACL reconstruction. We hypothesized that grafts decrease in diameter as they are prepared with both tension and circumferential compression. We also investigated the interrater reliability of graft diameter measurements during each step of graft preparation. METHODS Twenty pairs of fresh-frozen human hamstring tendons obtained from an allograft supplier were prepared in a standardized fashion for ACL reconstruction (suturing followed by longitudinal tensioning followed by circumferential compression followed by relaxation). Four blinded raters measured each graft in a sequential manner after each graft preparation step. Interrater reliability was assessed using the intraclass correlation coefficient ICC(2,1). The mean allograft diameter at each time point was calculated and compared across all time points using repeated-measures analysis of variance (ANOVA). RESULTS Subjecting the grafts to both tension and circumferential compression significantly decreased their mean diameter (to 7.38 mm compared with 8.28 mm at baseline; p = 0.044). Interrater reliability revealed almost perfect agreement at each measurement interval, with the ICC ranging from 0.933 to 0.961. CONCLUSIONS The average diameter of hamstring ACL grafts decreases by almost 1 mm after they are subjected to both tension and circumferential compression within a standard cylindrical sizing block. CLINICAL RELEVANCE Because ACL bone tunnels are drilled in 0.5-mm increments, preparing soft-tissue grafts with circumferential compression in addition to tension may allow creation of tunnels that are one to two incremental sizes smaller. This could permit less bone removal, which may be particularly applicable for certain reconstruction techniques such as pediatric, double-bundle, or revision ACL reconstruction, in which limited space is available for tunnel drilling.

ACL reconstruction in youth athletes results in an improved rate of return to athletic activity when compared with non-operative treatment: a systematic review of the literature

Background Anterior cruciate ligament (ACL) tears are being seen and treated with increasing frequency in youth athletes, with the goal of returning patients to sports activity. This is particularly important for youth athletes, for whom sports provide physical, social and psychological development. Objectives To perform a systematic review of the orthopaedic surgery literature to investigate for any associations between treatment strategy and return to athletic activity after ACL tear in youth athletes under age 18 years. Data sources PubMed, EMBASE and Cochrane computerised databases. Study eligibility criteria Inclusion criteria: (1) <18 years of age, (2) investigation of a relationship between time to treatment and consequent rates of returning to preinjury levels of athletic activity, (3) original research article (eg, not a review, case report or meta-analysis). Exclusion criteria: (1) revision ACL surgery, (2) language other than English, and (3) not a clinically based study. Participants Youth <18 years old with ACL tears. Interventions Acute ACL reconstruction, delayed ACL reconstruction, non-operative management. Synthesis methods Qualitative synthesis. Results Twenty studies met inclusion and exclusion criteria, of which four evaluated return to play after acute ACL reconstruction (ACLR), five studies evaluated return to play after delayed ACLR, and nine evaluated return to play after ACLR with an unspecified injury-to-surgery time interval. Two studies investigated return to play in a non-operative cohort. Of the 18 surgical studies, 14 employed a soft tissue transphyseal reconstruction. Rates of return to play were 78–100% after acute ACLR, 84–100% after delayed ACLR, 41–100% after ACLR with an indeterminate injury-to-surgery time interval and 6–52% after non-operative treatment of ACL tear. Limitations Several studies did not provide details about the timing of injury-to-surgery, and study heterogeneity precluded combining results in quantitative meta-analysis. Furthermore, the amount of time to full postinjury recovery remains largely unstudied. Conclusions and implications of key findings Based on available literature, there appears to be an improved rate of return to athletic activity after ACLR when compared with non-operative treatment. Future research should directly focus on time to return to sports activity, while taking into account the unique aspects of ACL reconstruction and non-operative management in youth athletes. This is of particular importance in children and adolescents given the physical, social and psychological development that occurs with sports participation. Trial registration number CRD42015027536.

Early ACL reconstruction in children leads to less meniscal and articular cartilage damage when compared with conservative or delayed treatment

Background Anterior cruciate ligament (ACL) tears are being seen and treated with increasing frequency in children and adolescent athletes. The superiority of treating ACL tears in children and adolescents with acute reconstruction, delayed reconstruction or non-operative treatment remains controversial. Objectives To perform a systematic literature review to investigate for any associations between progressive intra-articular joint damage (increasing rates of meniscal and cartilage injury) with delayed or non-operative treatment of ACL tears in children and adolescents under age 18 when compared with acute ACL reconstruction (ACLR). Data sources PubMed, EMBASE and Cochrane computerised databases. Study eligibility criteria Inclusion criteria: (1) paediatric patient population (defined as <18 years of age), (2) investigated association between operative or non-operative treatment and consequent meniscal/chondral injury rates, (3) original research article, rather than a review, case report or meta-analysis. Exclusion criteria: (1) revision ACL cohort, (2) full-text article in a language other than English and (3) not a human clinical study. Participants Youth aged <18 years with ACL tears. Interventions Acute ACLR, delayed ACLR, non-operative management. Synthesis methods Qualitative synthesis. Results 17 studies were included in the final analysis, all of which reported on medial meniscal injuries, of which 8 (47%) favoured acute reconstruction. 10 of 17 reported on cartilage injuries, of which 4 (40%) favoured acute ACLR. No study concluded that delayed reconstruction or non-operative management was associated with fewer cartilage or meniscus injuries. Limitations While the included studies provided patient age data, not all provided details about distribution of skeletal maturity. Furthermore, the majority of studies were retrospective and subject to selection bias, measurement bias and design bias (eg, surgical decision-making may have accounted for intra-articular pathology sustained at the time of injury). Constituent study heterogeneity with regard to ACLR techniques, definitions of surgical delay and variable length of follow-up precluded combining results in quantitative meta-analysis. Conclusions and implications of key findings On the basis of the available published literature which is largely retrospective, acute reconstruction for ACL tears appears to be associated with fewer medial meniscal injuries and articular cartilage lesions when compared with delayed or non-operative management. Several studies that were equivocal showed clinically relevant effect sizes but were underpowered to detect statistical differences between groups. Future prospective research in a large uniform cohort of skeletally immature patients with ACL tears may provide more answers to this important clinical question. Trial registration number CRD42015027614.

Pediatric Knee Osteochondritis Dissecans Lesions

Osteochondritis dissecans (OCD) can cause knee pain and dysfunction in children. The etiology of OCD remains unclear; theories on causes include inflammation, ischemia, ossification abnormalities, genetic factors, and repetitive microtrauma. Most OCD lesions in skeletally immature patients will heal with nonoperative treatment. The success of nonoperative treatment decreases once patients reach skeletal maturity. The goals of surgical treatment include maintenance of articular cartilage congruity, rigid fixation of unstable fragments, and repair of osteochondral defects with cells or tissues that can adequately replace lost or deficient cartilage. Unsalvageable OCD lesions can be treated with various surgical techniques.

Challenges of Fracture Management for Adults With Osteogenesis Imperfecta

Osteogenesis imperfecta is caused by qualitative or quantitative defects in type I collagen. Although often considered a disease with primarily pediatric manifestations, more than 25% of lifetime fractures are reported to occur in adulthood. General care of adults with osteogenesis imperfecta involves measures to preserve bone density, regular monitoring of hearing and dentition, and maintenance of muscle strength through physical therapy. Surgical stabilization of fractures in these patients can be challenging because of low bone mineral density, preexisting skeletal deformities, or obstruction by instrumentation from previous surgeries. Additionally, unique perioperative considerations exist when operatively managing fractures in patients with osteogenesis imperfecta. To date, there is little high-quality literature to help guide the optimal treatment of fractures in adult patients with osteogenesis imperfecta. [Orthopedics. 2017; 40(1):e17-e22.].

Clinical Outcome Reporting in Youth ACL Literature Is Widely Variable

Background: Advances in anterior cruciate ligament (ACL) reconstruction procedures in pediatric and adolescent patients have resulted in an increase in recent clinical studies on this topic. However, the consistency with which outcome measures are reported in this demographic is unknown. Purpose: To document outcome reporting patterns of youth ACL reconstruction studies in high-impact journals. Study Design: Systematic review; Level of evidence, 4. Methods: All articles published in 5 high-impact orthopaedic journals from 2010 to 2016 were reviewed to identify those reporting clinical outcomes of young patients who underwent ACL reconstruction. Studies that were nonclinical, reported on patients older than 18 years, or included fewer than 10 patients were excluded. Outcome measures used in all included studies were recorded. Results: Seventeen studies encompassing 772 subjects (mean age, 14.3 years; range, 6.3-18.0 years) were analyzed. Eight studies (47%) reported on Tanner stage of subjects, while 1 study reported skeletal age. Ten studies (59%) clearly documented the presence or absence of surgical complications. Range of motion was reported in 65% of studies. Leg-length discrepancy and angular deformity were each reported in 76% of studies, with 12% quantifying results through radiographic measurements. Ligament testing was variably defined by inclusion of instrumented testing (65%), Lachman test (53%), and pivot-shift test (53%). Fourteen studies (82%) explicitly reported on the rate of ACL rerupture, while 71% reported on the rate of revision surgery. Rate of return to preinjury activity was reported in 8 studies (47%), of which 2 defined criteria for return to sport and 3 defined the level of competitive sport. Patient-reported outcome measures (PROMs) were used variably. For the 3 most commonly reported PROMs (Lysholm, International Knee Documentation Committee, and Tegner), 24% of studies reported all 3 PROMs, 35% of studies reported 2 PROMs, and 6% of studies reported 1 PROM in isolation. A pediatric-specific PROM was reported in 1 of the 17 studies. Conclusion: Studies on pediatric ACL reconstruction published in high-impact journals unreliably defined subjects’ skeletal maturity, inconsistently reported on objective outcome measures, and used disparate adult-validated PROMs to assess subjective outcomes. These findings highlight the need for standardized, pediatric-specific outcome measures to be applied in future studies evaluating ACL reconstruction in children and adolescents.

Pediatric Orthopedic Hoverboard Injuries: A Prospectively Enrolled Cohort

&NA; Hoverboards pose a significant risk of musculoskeletal injury to pediatric riders. A prospectively enrolled cohort yielded 9 pediatric patients injured while riding hoverboards in 2016. Eight of the injuries involved the upper extremity, and one involved the lower extremity. No riders wore any safety equipment and injury patterns modeled those seen in skateboard riders.

Diagnosis and Management of Traumatic Patellar Instability in the Pediatric Patient

Instability of the patella is a common cause of knee pain and dysfunction in pediatric and adolescent patients and can be due to several factors. Although some patients will recall a specific traumatic event others may not, requiring the diagnosis to be made on the basis of physical examination and imaging. Congenital dislocation and connective tissue disorders should also be considered, even in the setting of trauma. There are radiographic parameters that may identify causes of instability such as trochlear and patellar abnormalities, and magnetic resonance imaging can identify signs of trauma such as bony edema, loose osteochondral fragments, and increased tibial tubercle-trochlear groove distance. The first line of treatment for instability is most commonly nonoperative in nature; however, there are many options for operative management in the event of severe chondral injury or recurrent dislocation. Surgical management to best restore stability of the patellofemoral joint varies depending on the skeletal maturity of the patient and the source of instability (ligamentous, osteocartilaginous, or both). A combination of soft tissue, bony, and anatomic ligamentous repair or reconstruction is used to best augment patellar tracking and optimize patient outcome. [Orthopedics. 2017; 40(5):e749-e757.].