Joanna H. Roocroft

Treatment of talocalcaneal coalitions.

Background: The purpose of this study was to review outcomes of patients treated for symptomatic talocalcaneal coalition with resection and interposition of fat graft. Methods: A retrospective review was performed on all patients who underwent surgical treatment for symptomatic talocalcaneal coalition over a 13-year period. Ninety-three feet were treated with excision and fat graft interposition by 6 surgeons. All patients underwent a chart review. Patient’s outcome was assessed at the last follow-up using the American Orthopaedic Foot and Ankle Society Hindfoot scale. Postoperative computed tomography scans were available for 20 feet. Results: Forty-nine feet had follow-up of at least 12 months and had a score obtained through the American Orthopaedic Foot and Ankle Society Hindfoot scale. At an average of 42.6 months of follow-up, the average score obtained was 90/100 (excellent). The postoperative computed tomography scans demonstrated 1 recurrence (3%), which was treated with repeat excision. An additional patient was reoperated for failure to excise the coalition completely. Eleven patients (34%) underwent a subsequent surgery to correct the alignment of the foot. To the best of our knowledge, none of the patients excluded because of short follow-up had repeat surgery or recurrence. Conclusions: A symptomatic talocalcaneal coalition can be treated with excision and fat graft interposition, and achieve good to excellent results in 85% of patients. Patients should be counseled that a subset may require further surgery to correct malalignment. Level of Evidence: Level IV—case series.

Childhood Obesity as a Risk Factor for Lateral Condyle Fractures Over Supracondylar Humerus Fractures

BackgroundObese children reportedly have an increased risk of sustaining musculoskeletal injuries compared with their normal-weight peers. Obese children are at greater risk for sustaining fractures of the forearm, particularly from low-energy mechanisms. Furthermore, obesity is a risk factor for sustaining an extremity fracture requiring surgery. However, it is unclear what role obesity plays in fractures about the distal humerus.Questions/purposesWe therefore asked whether (1) children who sustain lateral condyle (LC) fractures have a higher body mass index (BMI) as compared with those with supracondylar (SC) humerus fractures; and (2) children with a higher BMI sustain more severe fractures regardless of fracture pattern.MethodsWe retrospectively reviewed 992 patients: 230 with LC injuries and 762 with SC fractures. We determined BMI and BMI-for-age percentiles. Fracture types were classified by the systems proposed by Weiss et al. (LC fractures) and Wilkins (SC fractures).ResultsThe LC group had both a higher mean BMI and BMI-for-age percentile than the SC group as well as had more obese patients (37% versus 19%). Within the LC group, children with Type 3 fractures had a higher BMI that those with Type 1 fractures (19 versus 17). There was a higher percentage of obese patients with Type 3 LC fractures compared with Type 1 and 2 fractures (44% versus 27% and 26%). Among patients with SC fractures, there was no difference among the BMI, BMI-for-age percentiles, or percentage of obese children when analyzed by fracture subtype.ConclusionsObesity places a child at greater risk for sustaining a LC fracture and when these fractures occur, they are often more severe injuries compared with those in nonobese children.Level of EvidenceLevel II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Tibial Tubercle Fractures: Complications, Classification, and the Need for Intra-articular Assessment

Background: Adolescent tibial tubercle fractures are uncommon, complex, high-energy injuries. The use of lateral radiographs in isolation to diagnose and treat these injuries is the standard of practice. However, with a single 2-dimensional (2D) view, there may be a risk that the degree of injury can be underestimated. This study was performed to report on the outcomes of tibial tubercle fractures operatively treated, determine the utility of a single lateral x-ray to accurately document injury severity and pattern, delineate the role of advanced imaging and intraoperative arthroscopy/arthrotomy in injury treatment, and propose a new classification system of tibial tubercle fractures that accounts for the complex 3D nature of proximal tibial physeal closure, and recognizes the importance of intra-articular extension, providing guidance for intervention. Methods: A retrospective review of operatively treated tibial tubercle fractures at our institution from 2003 to 2010 was performed. Child age, weight, mechanism of injury, Ogden classification (x-ray), advanced imaging results [computed tomography (CT)/magnetic resonance imaging (MRI)] including intra-articular fracture patterns, surgical techniques, intraoperative articular findings, and postoperative complications were collected. In addition, we classified all of our patients into a new classification system (type A—tubercle youth, type B—physeal, type C—intra-articular, type D—tubercle teen) based on a combination of plain radiograph (anteroposterior and lateral), advanced imaging (CT/MRI), and intraoperative arthrotomy/arthroscopy findings. Results: We found 41 tibial tubercle fractures in 40 children (all of whom were male) with a mean age of 15.0±1.1 years, and mean weight of 80.3±23.4 kg. Injuries mostly occurred during jumping activities. At initial presentation, compartment syndrome or vascular compromise was seen in nearly 10% of patients, all of whom had type B—physeal injuries under our new classification system. Fifty percent of injuries were underestimated and/or not appreciated by lateral x-ray alone. In patients with intra-articular involvement, consistent 3D fracture patterns were seen on CT including anterior fragments (sagittal plane), lateral fragments (coronal plane), and anterolateral fragments (axial plane). Our new 4 part classification system was able to classify all fractures: type A (2 patients, mean age, 12.7±0.2 y), type B (13 patients, mean age, 14.8±0.7 y), type C (22 patients, mean age, 15.3±1.1 y), and type D (2 patients, mean age, 15.5±0.1 y). All fractures achieved radiographic union with 2 patients (type A—tubercle youth and type B—physeal) requiring additional procedures due to premature physeal closure. Conclusions: Tibial tubercle fractures represent high-energy injuries with potentially devastating complications such as compartment syndrome and/or vascular compromise. Intra-articular involvement is often missed with the use of plain x-ray and drastically underestimates injury severity. The use of preoperative CT scan or MRI should be utilized as adjunct to plain lateral radiograph. If intra-articular involvement is recognized preoperatively, arthroscopy or open arthrotomy should be utilized at the time of surgery. Our new classification system is rooted in the development of the proximal tibia, accounts for intra-articular involvement, and provides guidance for treatment. Level of Evidence: Level III—diagnostic study.

Traumatic anterior instability of the pediatric shoulder: a comparison of arthroscopic and open bankart repairs.

Background: Arthroscopic and open Bankart repairs have proven efficacy in adults with recurrent anterior shoulder instability. Although studies have included children in their analysis, none have previously compared functional outcomes or redislocation rates between these 2 methodologies for anteroinferior glenoid labrum repair in this young population. We hypothesize that open and arthroscopic Bankart repair in children will have similar functional outcomes and redislocation rates, but differing results from adults treated in a similar manner. Methods: A retrospective chart review was performed on all Bankart repairs performed between 2006 and 2010 at a tertiary care children’s hospital. A shift in treatment modalities occurred in 2008 creating 2 cohorts, open and arthroscopic. Brachial plexus injury, congenital soft-tissue disorder, or incomplete charts were excluded. Demographics, age at surgery, follow-up length, and sport were recorded. Telephone interviews were then performed obtaining the most current QuickDASH (Disability Arm, Shoulder, or Hand), WOSI (Western Ontario Shoulder Instability Index), SF-12 (Short Form 12), SANE (Single Assessment Numeric Evaluation), and verbal pain scores; as well as, inquiring about recurrent dislocation and further surgery. Results: Ninety-nine children (16.9±1.5 y) were included (28 open, 71 arthroscopic). There were no differences in preoperative demographics. Fifty-one patients completed the questionnaires (11 open, 40 arthroscopic). No significant differences in the outcomes scores were seen between the 2 groups. Of the 99 patients, 21 (21%) had redislocation or secondary surgery; there was no significant difference in failure rate between groups (4 open, 17 arthroscopic). A plotted survival curve demonstrated that the adolescent shoulder undergoing Bankart repair for recurrent traumatic anterior instability has a 2-year survival of 86% and a 5-year survival of only 49%, regardless of technique. Conclusions: In adolescents, there is no significant difference in functional outcomes or redislocation rates between open and arthroscopic Bankart repair, yet both demonstrate a very high risk of failure in this young, athletic population which contrasts the results in the historic adult population. Level of Evidence: Level III—retrospective comparative study.

Meniscus Tear Patterns in Relation to Skeletal Immaturity Children Versus Adolescents

Background: Meniscus tear patterns in the pediatric population have not been well described. Purpose: To delineate the pattern of meniscus tears and the likelihood of repair at the time of surgery in both children and adolescents. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A retrospective review was performed on all patients between the ages of 10 and 19 years who underwent arthroscopic surgery for a meniscus injury at a single institution. Patients with open growth plates were classified as children, while those with closed growth plates were classified as adolescents. Demographic data were documented, including age, sex, body mass index (BMI), mechanism of injury, and time from injury to surgery. Operative reports and intraoperative photographs were used to assess the tear pattern (type, location, zone) as well as all concomitant procedures and injuries. Tears were classified as discoid, vertical, bucket-handle, radial, oblique, horizontal, fray, root detachment, or complex. Results: Of the 293 patients reviewed, 197 (67%) had lateral meniscus tears, 65 (22%) had medial meniscus tears, and 31 (11%) had tears to both menisci. The cohort was separated into 119 (41%) children (mean age, 13.5 years) and 174 (59%) adolescents (mean age, 16.4 years). Children were more likely to have discoid meniscus tears, lower BMI, and meniscus injuries not associated with ligamentous injuries (P < .05). The rate of associated ligament injuries in children was 28% compared with 51% in adolescents. Overall, the most frequent tear pattern was complex (28%), followed by vertical (16%), discoid (14%), bucket-handle (14%), radial (10%), horizontal (8%), oblique (5%), fray (3%), and root detachment (2%). Complex tears were associated with boys (32% vs 20% in girls; P < .03) and greater mean BMI (27.4 vs 25.1 kg/m2 in those with noncomplex tears; P < .002), even when taking sex into account. Surgical repair was performed in 47% of all cases (56% in those treated within 3 months of injury vs 42% in those treated after 6 months; P < .03), and there was no difference in the repair rate between the two age groups (49% in children vs 46% in adolescents; P > .05). Conclusion: Adolescents and children sustain more complex meniscus injuries that are often less repairable than previously reported in the literature. Factors that are associated with greater tear complexity include male sex and obesity. Our findings also suggest that the earlier treatment of meniscus tears may increase the likelihood of repair in younger patients.

Results of Displaced Pediatric Tibial Spine Fractures: A Comparison Between Open, Arthroscopic, and Closed Management.

Background: Displaced tibial spine fractures are frequently treated with surgical reduction and fixation, but no comparison studies have been performed. This study was undertaken to compare fragment reduction and adverse outcomes between open arthrotomy [open reduction and internal fixation (ORIF)], arthroscopy [arthroscopic-assisted internal fixation (AAIF)], and closed management [closed management and casting (CMC)] of pediatric tibial spine fractures. Methods: A retrospective review of children treated for displaced tibial spine fractures from 2003 to 2011 was performed after categorizing into the 3 treatment groups. Demographics, mechanism of injury, radiographic measures (plain film and computed tomography), treatment, duration of immobilization and follow-up, final range of motion, and complications were recorded. Families were contacted to obtain long-term Lysholm scores, return to activity, pain, and satisfaction with treatment. Results: Seventy-six children (mean age, 12.4 y) met criteria with 29 ORIF, 28 AAIF, and 19 CMC. Radiographic measurements between x-ray and computed tomography scans found a mean error of 1 mm (SD=1.33 mm; inter-class coefficient=0.977, P<0.001). Initial fracture displacement was similar between AAIF and ORIF, 10.3±4.4 mm and 10.8±3.9 mm; but, less in CMC group (5.3±2.6 mm). The mean reduction amount was 8.6±4.7, 9.1±4.0, and 2.3±2.6 mm, respectively. A Bonferroni post hoc analysis revealed a difference between surgical and nonoperative reduction (P<0.001), but not between AAIF and ORIF (P=0.9). Arthrofibrosis occurred with equal frequency in surgical cohorts (AAIF 12.5%, ORIF 11.1%), compared with none in the CMC group. Yet, the CMC group had a 16.7% risk for reoperation secondary to instability, loose bodies, or impingement. Twenty-four percent of each cohort was available (at mean 6.0 y) for interview with mean (median) Lysholm score: ORIF 97.4 (99), AAIF 95 (100), and CMC 86 (97.5), P=0.35. Conclusions: Open or arthroscopic treatment of displaced tibial spine fractures affords a better reduction than closed management, but with higher risk for arthrofibrosis. Closed management may be successful when displacement is <5 mm, and advanced imaging may not be necessary to delineate the amount of displacement. Level of Evidence: Level III—therapeutic study.

Partial rotator cuff tears in adolescents: factors affecting outcomes.

Introduction: In the adult population, rotator cuff tears are common and established treatment methods yield satisfactory results. In adolescents, however, these injuries are uncommon and few treatment methods and outcome reports exist. The purpose of this study was to examine a series of adolescent rotator cuff tears, identify associated pathology, and report treatment outcomes. Methods: A retrospective comparative analysis of adolescent patients treated for rotator cuff tears diagnosed by magnetic resonance imaging (MRI) or arthroscopy between 2008 and 2010 was performed. Patients were divided by treatment rendered: nonoperative or operative. Demographic and diagnostic variables were compared between the 2 groups. After release to full activity, 3 patient outcome measures were obtained: QuickDASH (Disability of the Arm, Shoulder, and Hand), QuickDASH Sports module, and the Single Assessment Numerical Evaluation (SANE). Results: Fifty-three adolescents (38 boys and 15 girls) with a mean age of 15.8 years (8.8 to 18.8 y) met the inclusion criteria. All rotator cuff tears were partial articular-sided tendon avulsions, and surgical treatment (when required) consisted of debridement to stable edges. All patients underwent a trial of at least 6 weeks of physical therapy, with 57% failing to improve and requiring subsequent surgery. In the patients that were treated nonoperatively, 39% were diagnosed with associated pathology based on MRI findings, whereas operative patients exhibited an associated pathology rate of 70%. Patients with MRI-diagnosed associated pathology were 1.8 times more likely (95% confidence interval, 1.02-3.13, P=0.025) to require surgery compared with those without MRI-identified associated pathology. Nineteen patients (13 operative, 6 nonoperative) completed the outcome questionnaires at a mean 16.9 months after treatment. QuickDASH, SANE, and QuickDASH Sports module scores were not statistically different between nonoperative and operative treatment groups (7.5 vs. 8.1, P=0.90; 85.3 vs. 80.6, P=0.47; and 5.2 vs. 19.5, P=0.39, respectively). All outcome measures exhibited significant correlations with one another, with the strongest correlation being a negative association between SANE and Sports module scores (r=−0.76, P=0.001). Discussion: Isolated partial articular-sided tendon avulsion injuries may be successfully treated with physical therapy, with return to sports expected; however, if associated pathology was present then nonoperative treatment was less successful. Improvement in pain and activities of daily living can be achieved with surgery after failed conservative management for rotator cuff injuries; however, the adolescent athlete will often have residual shoulder complaints during sports participation. Level of Evidence: Level III—retrospective cohort study.

Surgeon learning curve for pediatric supracondylar humerus fractures.

Background: There has been an increasing trend toward referral of supracondylar humerus fractures in children to pediatric orthopaedic centers. The learning curve for treating this fracture is not well described. Methods: We retrospectively reviewed all supracondylar fractures treated by 21 pediatric orthopaedic fellows over the 2003 to 2009 academic years, with attending cases from 2005 to 2007 to serve as a control. Type IIa, IIb, and III fractures were used in the case count of for each fellows, whereas only type III fractures were used to record fluoroscopy time, operative time, and for radiographic review. Nonideal reduction was defined as a Baumann angle outside the range of 64 to 81 degrees, or an anterior humeral line that does not intersect the capitellum. Results: Of the 654 total operatively treated fractures, fellows treated 479 total and 213 type III fractures. Backup attendings were present in the operating room for 39% of type III fractures in the first academic quarter before falling to a baseline of 10% to 20% during the remaining quarters. Fluoroscopy time and operative time were consistent for fellows throughout the year. Nonideal reductions increased notably at case 7, correlating with increased fellow independence in the operating room, with reversal of the trend at case 15. There were no differences in complication rates and no malunions requiring osteotomy. Conclusions: In order to balance training and patient care, we recommend the availability of an attending backup surgeon for the first 15 cases of supracondylar humerus fractures treated by pediatric orthopaedic fellows. Level of Evidence: Level III, retrospective comparative study.

Treatment of displaced pediatric supracondylar humerus fracture patterns requiring medial fixation: a reliable and safer cross-pinning technique.

Introduction: Treatment of displaced Gartland type 3 supracondylar humerus fractures in children may include closed reduction and percutaneous pinning. The pin configuration may be all-lateral entry or cross-pin. Despite the improved stability possible with cross-pinning, there is an inherent iatrogenic risk to the ulnar nerve of about 6%. As medial fixation may be necessary for certain fracture patterns, this study was conducted to evaluate the risk of ulnar neuropathy using a technique here described and developed to minimize injury to this structure. Methods: A retrospective review was performed on all children treated for a supracondylar humerus fracture at our institution between 2003 and 2010. All the type 3 displaced fractures were placed into 2 groups: lateral-entry pinning and cross-pinning. The 2 groups were then compared for risk of ulnar nerve injury, and a post hoc power analysis was performed. Results: A total of 381 supracondylar humerus fractures met the inclusion criteria. Our cross-pinning technique was used in 187 (49%) of the children with a mean age of 5.8 years (range, 0.92 to 13.92 y). There were 4 ulnar nerve injuries in the entire cohort and 2 sustained as iatrogenic injuries in the cross-pinning group (1.1%). There was no significant difference between our 2 groups in regard to risk of ulnar nerve injury (P=0.24). There is a statistically significant lower risk of ulnar nerve injury in our cross-pinning technique than previously described techniques (P=0.0028), with a post hoc power analysis of 93%. Conclusions: Despite the inherent risk for iatrogenic nerve injury with cross-pinning completely displaced supracondylar humerus fractures, there is often a need to use this technique to improve fixation and stability of the fracture. Our method of cross-pinning is safe and reproducible for providing fracture stability with a significant decrease in the risk of iatrogenic ulnar nerve injury (1 in 94) when a medial pin is required. Level of Evidence: Level III—therapeutic studies.

Underestimation of labral pathology in adolescents with anterior shoulder instability.

Background: Shoulder instability is not uncommon in the adolescent athlete, and yet the ability for either clinical examination or magnetic resonance imaging (MRI) with arthrogram to accurately detect pathology in this younger population has not been elucidated yet. This study was performed to characterize the ability of physical examination and MRI to identify intra-articular pathology in those adolescents suspected of having anterior shoulder instability. Methods: A retrospective review of patients treated over a year between 2008 and 2009 was undertaken. Included were patients with detailed physical examinations, preoperative MRI, and shoulder arthroscopy. Patients with previous shoulder surgery for instability, those who underwent surgery for brachial plexopathy, and those without an MR arthrogram were excluded. Demographics, age, sex, sports participation, and physical examination findings were recorded. Diagnostic arthroscopy findings were then compared with the clinical suspicion (based on history and physical examination) and the MRI findings. Imaging and arthroscopic results were categorized as anterior tear, anterior + tear (anterior tear with extension superior or posterior), other intra-articular pathology, or normal examination. An anterior instability cohort was then created by applying an exclusion criterion against patients without a clinical suspicion of anterior instability. Results: Forty-three patients were included after application of all inclusion and exclusion criteria. The clinical suspicion of anterior labral tear was 59% accurate (positive predictive value of 79%) and the MRI was 86% accurate (positive predictive value of 95%). Among all included patients, 23 adolescents (24 shoulders) were identified with a preoperative clinical suspicion of anterior labral tear based on history, physical examination, and plain radiographs (8 girls/15 boys). Mean age at surgery was 15.9 years (13.3 to 18.8). In this suspected anterior labral tear cohort, 79% had arthroscopic confirmation of the clinical suspicion, but 58% had extension of the labral tear either superior or posterior. MRI was 100% sensitive, 55% specific for an isolated anterior tear; yet, the MRI was 46% sensitive, 100% specific at identifying the larger anterior + labral tears. A statistically significant difference existed between the extent of the labral tear found on MRI and that found at the time of surgery (P=0.006), with tears of the glenoid labrum often extending beyond what was predicted by MRI. Conclusion: Clinical suspicion and preoperative MR arthrogram of anterior instability in adolescents seem to detect evidence of labral pathology but have limited success in identifying the true extent of the labral pathology as proven by arthroscopy. Level of Evidence: Level III Diagnostic Studies