Jeremy T. Smith

Transphyseal anterior cruciate ligament reconstruction in skeletally immature pubescent adolescents.

BACKGROUND Management of anterior cruciate ligament injuries in skeletally immature patients is controversial. Conventional surgical reconstruction techniques for adults can cause iatrogenic growth disturbance due to physeal damage in children. The purpose of this study was to evaluate the results of a transphyseal reconstruction technique in pubescent but skeletally immature adolescents. METHODS Between 1996 and 2004, sixty-one knees in fifty-nine skeletally immature pubescent adolescents (Tanner stage 3) with a mean chronological age of 14.7 years (range, 11.6 to 16.9 years) underwent transphyseal reconstruction of the anterior cruciate ligament with use of an autogenous quadrupled hamstrings-tendon graft and metaphyseal fixation. Thirty-one knees had additional meniscal surgery. The functional outcome, graft survival, radiographic outcome, and any growth disturbance were evaluated at a mean of 3.6 years (range, 2.0 to 10.2 years) after the surgery. RESULTS Two patients (3%) underwent revision anterior cruciate ligament reconstruction because of graft failure at fourteen and twenty-one months postoperatively. For the remaining fifty-nine knees, the mean International Knee Documentation Committee subjective knee score (and standard deviation) was 89.5 +/- 10.2 points and the mean Lysholm knee score was 91.2 +/- 10.7 points. The result of the Lachman examination was normal in fifty-one knees and nearly normal in eight; it was not abnormal or severely abnormal in any knee. The result of the pivot-shift examination was normal in fifty-six knees and nearly normal in three knees; it also was not abnormal or severely abnormal in any knee. The mean increase in total height was 8.2 cm (range, 1.2 to 25.4 cm) from the time of surgery to the time of final follow-up. No angular deformities of the lower extremity were measured radiographically, and no lower-extremity length discrepancies were measured clinically. Complications included three cases of arthrofibrosis requiring manipulation with the patient under anesthesia. CONCLUSIONS Transphyseal reconstruction of the anterior cruciate ligament with use of an autogenous quadrupled hamstrings-tendon graft with metaphyseal fixation in skeletally immature pubescent adolescents provides an excellent functional outcome with a low revision rate and a minimal risk of growth disturbance.

Reliability, Validity, and Responsiveness of a Modified International Knee Documentation Committee Subjective Knee Form (Pedi-IKDC) in Children With Knee Disorders

Background: The International Knee Documentation Committee (IKDC) Subjective Knee Form is a knee-specific measure of symptoms, function, and sports activity. A modified IKDC Subjective Knee Form (pedi-IKDC) has been developed for use in children and adolescents. The purpose of this study was to determine the psychometric characteristics of the pedi-IKDC in children and adolescents with knee disorders. Hypothesis: The pedi-IKDC is a reliable, valid, and responsive patient-administered outcome instrument in the pediatric population with knee disorders. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: Test-retest reliability, content validity, criterion validity, construct validity, and responsiveness to change were determined for the pedi-IKDC in patients aged 10 to 18 years with a variety of knee disorders. Test-retest reliability was measured in a group of 72 patients with a stable knee disorder. Validity was measured in a group of 589 patients with the Child Health Questionnaire to determine criterion validity. Responsiveness was measured in a group of 98 patients undergoing a variety of knee surgical procedures. Results: The overall pedi-IKDC had acceptable test-retest reliability (intraclass correlation coefficient, .91) and excellent internal consistency (Cronbach alpha, .91). The form also demonstrated acceptable floor (0%) and ceiling (6%) effects. There was acceptable criterion validity with significant (P < .01) correlation between the overall pedi-IKDC and 9 relevant domains of the Child Health Questionnaire. Construct validity was acceptable, with all 11 hypotheses demonstrating significance (P < .0001). Responsiveness to change was acceptable (effect size, 1.39; standardized response mean, 1.35). Conclusion: The pedi-IKDC demonstrated overall acceptable psychometric performance for outcome assessment of children and adolescents with various disorders of the knee.

Complications of Talus Fractures in Children

Background Pediatric talus fractures are rare with variable rates of posttraumatic complications reported in the literature. The purpose of this retrospective study was to evaluate posttraumatic complications in children after talus fracture and report injury characteristics. Methods This study included 29 children with talus fractures sustained between 1999 and 2008 at an average age of 13.5 years (range, 1.2-17.8). Patient records and radiographs were reviewed to determine the mechanism of injury, fracture type, associated injuries, and treatment. Posttraumatic complications assessed were avascular necrosis, arthrosis, nonunion or delayed union, neurapraxia, infection or wound-healing problems, and the need for further unanticipated surgery. Clinical follow-up averaged 24 months (range, 6 mo-5 y). Results Twenty-nine children sustained a major fracture of the talar body, neck, or head. Avascular necrosis occurred in 2 patients (7%), arthrosis in 5 (17%), delayed union in 1 (3%), neurapraxia in 2 (7%), infection in 0, and the need for further surgery in 3 (10%). Both high-energy mechanism and fracture displacement corresponded to a greater number of posttraumatic complications. The number and severity of talus fractures increased in older children. Conclusions In this case series, posttraumatic complications after pediatric talus fractures occurred more frequently after a high-energy mechanism of injury or a displaced fracture. Talus fractures occurred more commonly and with more severity in older children. Level of Evidence Level IV. Retrospective case series.

Prevalence of Vitamin D Deficiency in Patients With Foot and Ankle Injuries

Background: Vitamin D deficiency has been identified as one of the most common causes of fragility fractures and poor fracture healing. Although rates of vitamin D deficiency have been delineated in various orthopaedic populations, little is known about the prevalence of vitamin D deficiency in patients with foot and ankle disorders. The goal of this study was to identify the prevalence of vitamin D deficiency in patients with a low energy fracture of the foot or ankle. Methods: Over a 6-month period, a serum 25-OH vitamin D level was obtained from consecutive patients with a low energy ankle fracture, fifth metatarsal base fracture, or stress fracture of the foot or ankle. For comparative purposes, vitamin D levels in patients with an ankle sprain and no fracture were also examined. Results: The study cohort included 75 patients, of which 21 had an ankle fracture, 23 had a fifth metatarsal base fracture, and 31 had a stress fracture. The mean age was 52 (range, 16–80) years. Thirty-five of the fracture patients (47%) had an insufficient vitamin D level (below the recommended level of 30 ng/mL), and 10 of the patients (13%) had a level that was deficient (< 20 ng/mL). Vitamin D levels were significantly lower in those with a fracture than in those with an ankle sprain (P = .02). In the fracture cohort, the factors significantly associated with vitamin D insufficiency in the multivariate analysis were smoking (P = .03), obesity (P = .003), and other medical risk factors for vitamin D deficiency (P = .03). Conclusion: Hypovitaminosis D was common among patients with a foot or ankle injury seen at our institution. Patients with a low energy fracture of the foot or ankle were at particular risk for low vitamin D, especially if they smoked, were obese, or had other medical risk factors. Given that supplementation with vitamin D (± calcium) has been shown to reduce the risk of fragility fractures and improve fracture healing, monitoring of 25-OH vitamin D and supplementation should be considered in patients with fractures. Level of Evidence: Level III, prospective case control.

Operative fixation of medial humeral epicondyle fracture nonunion in children.

Background There is little information regarding the clinical presentation and/or surgical treatment of symptomatic medial humeral epicondyle nonunions. The purpose of this investigation was to describe the presenting symptoms and evaluate the results of surgical fixation of medial epicondyle nonunions. Methods Eight patients with symptomatic medial humeral epicondyle nonunions were evaluated after open reduction and internal fixation of the medial epicondyle. Average age at the time of initial injury was 11.3 years (range: 9.2 to 13.9 y). Outcome was assessed with radiographs and a questionnaire that included 3 self-reported functional outcome tools at a mean of 4.7 years (range: 1.5 to 7.5 y) after the surgery. Results Common presenting symptoms and signs included medial elbow pain and prominence, pain with lifting weights or throwing, limited range of motion, valgus instability, and ulnar nerve compression. After open reduction and internal fixation, patients reported improved pain score from a mean of 6.2 to 0.5. All patients returned to athletics. Mean postoperative QuickDASH (Disability of Arm, Shoulder, and Hand) score (and SD) was 6.8±11.7; mean Mayo Elbow Performance Score was 85.8±14.6; and mean Timmerman-Andrews Elbow Score was 87.5±10.4. Radiographic union was achieved in all but one patient postoperatively and there were no operative complications. Conclusions Open reduction and internal fixation of symptomatic medial humeral epicondyle nonunion results in improved pain and good elbow function. Level of Evidence Retrospective Case Series. Therapeutic Level IV.

Update on stage IV acquired adult flatfoot disorder: when the deltoid ligament becomes dysfunctional.

Deltoid ligament complex insufficiency is a fundamental pathologic component of stage IV AAFD. Failure of the deltoid ligament allows the talus to tilt into valgus within the ankle mortise. If left untreated, ankle joint biomechanics are altered and may lead to debilitating tibiotalar arthritis. All surgical treatments that address the valgus talar tilt seen with stage IV AAFD require accompanying procedures to properly realign the hindfoot. Stage IV AAFD can be subdivided into two groups. Patients with a flexible ankle deformity without advanced tibiotalar arthritis (stage IV-A) can be considered for a joint-sparing procedure. A variety of procedures have been described, but longterm follow-up studies have yet to determine which of these techniques is optimal. Patients with a rigid valgus ankle deformity or a flexible deformity accompanied by advanced tibiotalar arthritis (stage IV-B) should be considered for a joint-sacrificing procedure. To date, the most reliable results for stage IV-B AAFD have been reported with either tibiotalocalcaneal or pan-talar arthrodesis.

Open Ankle Arthrodesis With a Fibular-Sparing Technique

Background: Many ankle arthrodesis techniques excise the fibula or require a fibular osteotomy. Advantages of fibular preservation include increased surface area for bony union, preservation of the peroneal groove, prevention of valgus drift in cases of delayed union, and facilitation of future ankle arthroplasty. The goal of this study was to evaluate fusion rate and clinical outcomes of a novel open fibular-sparing ankle arthrodesis technique. Methods: A total of 50 consecutive ankle arthrodeses using this technique were included in this study. These consisted of 46 patients with an average age of 52 (range, 30 to 71) years. Outcomes assessed postoperatively included radiographs, complications, patient satisfaction, and functional scoring. Results: At an average of 28 (range, 19 to 56) months postoperatively, 38 patients (42 ankles) were available for review. Of the 42 cases, 39 (93%) achieved union at an average of 12 weeks postoperatively. Of patients, 86% reported being “completely satisfied” with the outcome. Average AOFAS Ankle-Hindfoot Scale was 84 ± 12 and average Foot Function Index pain subscale was 1 ± 0.9. Two ankles (5%) were fused in excessive varus; no patient required revision surgery for malalignment. Conclusion: This method of open ankle arthrodesis preserved the fibula and had a high fusion rate with good patient outcome scores. Level of Evidence: Level IV, retrospective case series.

Internet information quality for ten common foot and ankle diagnoses

BACKGROUND Patients use the Internet regularly to access health-related information. This studys goal was to assess the quality and content of Internet-based information for common foot and ankle diagnoses. METHODS We identified the ten most common foot and ankle diagnoses in our academic foot and ankle practice. Ten websites for each diagnosis were identified using two large Internet search engines. A custom grading form was used to determine website quality, based upon the Health On the Net Foundation (HON) principles, and information content. Four independent reviewers graded each website. RESULTS One hundred thirty-six unique websites were reviewed. Average HON score was 62.4 (range, 52.3-68.8) and content score was 49.7 (range, 33.8-62.1) out of a maximum of 100. Interobserver variability was low. CONCLUSIONS The overall quality of Internet information for common foot and ankle diagnoses is variable, raising concerns about what information is currently available to patients.

Ankle Arthritis: You Can't Always Replace It.

End-stage arthritis of the tibiotalar joint is disabling and causes substantial functional impairment. Most often it is the residual effect of a previous traumatic injury. Nonsurgical treatment of end-stage arthritis of the ankle includes bracing, shoe-wear modifications, and selective joint injections. For patients who fail to respond to nonsurgical modalities, the two primary treatment options are arthroplasty and arthrodesis. Each has its proponents. Although no ideal treatment of ankle arthritis exists, high-quality studies can help guide treatment in patients of varying demographics. Inherent risks are linked with each treatment option, but those of greatest concern are early implant loosening that requires revision following arthroplasty and the acceleration of adjacent joint degeneration associated with arthrodesis.

Patient Compliance with Postoperative Lower-Extremity Non-Weight-Bearing Restrictions

BACKGROUND A period of non-weight-bearing is prescribed following many orthopaedic injuries and procedures. It is believed that a period of non-weight-bearing is important for proper healing and recovery. The degree to which patients are compliant with non-weight-bearing instructions is unknown. The purpose of this study was to measure patient compliance with a period of prescribed non-weight-bearing. METHODS In this single-blinded study, pressure-sensitive film was embedded into short leg casts of 51 consecutive adult orthopaedic patients with unilateral lower-extremity abnormality who had been instructed to be strictly non-weight-bearing. Sensors were retrieved at the time of cast removal (mean, 24.3 days [range, 7 to 48 days]) and then were analyzed for force distribution and magnitude. Noncompliance was defined as maximum detectable pressure exerted on ≥50% of the film. Patient characteristics and the time of year that the casts were worn were also examined to determine if they correlated with weight-bearing. RESULTS Fourteen (27.5%) of 51 patients were noncompliant with the non-weight-bearing restriction. Six (42.9%) of the 14 noncompliant patients compared with 11 (29.7%) of the 37 compliant patients experienced an adverse event (p = 0.51). Sex, age, language spoken, body mass index, time in the cast, and the treating surgeon did not have a significant influence on weight-bearing performance (p > 0.05). Significantly greater weight-bearing was found (p = 0.04) in warmer months (June to October) than in colder months (November to March) in the United States. CONCLUSIONS The noncompliance rate with the postoperative non-weight-bearing restriction was 27.5% (95% confidence interval, 15.2% to 39.8%) in this patient group, despite explicit instructions and education about possible complications associated with weight-bearing. The only factor found to have a significant effect on weight-bearing compliance was the time of year that the cast was worn. No significant difference was found between the complication rate of the compliant patients and that of the noncompliant patients. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.