Lawrence Wells

Predicting the outcome of physeal fractures of the distal femur.

Background: Distal femoral epiphyseal fractures are uncommon but have a high incidence rate of complications. It is not clear whether there are any reliable predictor factors and whether the type of fracture, displacement (degree and direction), and treatment method alter the outcome. Methods: We retrospectively reviewed the medical charts and images of all patients who sustained a distal femoral epiphyseal fracture and were treated at 2 large level I pediatric centers during the past 10 years. Results: The selected group included 73 patients (boys, 59; mean age, 10 years). On the basis of the Salter-Harris classification (SH), 43 fractures (59%) were of type II. Fifty-nine percent of the fractures were displaced; 36 fractures were managed conservatively with long leg cast (with or without pelvic band) in 33 patients, cylinder cast in 2, and posterior splint in 1. Thirty-seven patients underwent surgery, and 34 underwent closed reduction followed by percutaneous fixation (crossed Steinman pins, 20; cannulated screws, 13; open reduction, 3; external fixation, 1). The overall complication rate was 40% (29/73), and growth arrest was the most frequent. The SH classification significantly correlated with the incidence of complications (P = 0.031). There was also a significantly higher (P < 0.0001) incidence rate of complications among displaced fractures (48.8% vs 26.6%); the amount and direction of displacement did not correlate with the outcome (P > 0.05). The group treated conservatively had a lower incidence rate of complications (25%) than did the surgical group (54%) (P < 0.05). Among the surgical group, a higher incidence rate of complications occurred when the physis was violated by hardware (65% vs 30%; P = 0.06). Conclusions: Both SH classification and displacement of the fracture are significant predictors of the final outcome. The degree and the direction of displacement do not statistically correlate with outcome. The treatment method may influence the final outcome.

Functional outcomes of early arthroscopic bankart repair in adolescents aged 11 to 18 years.

Recurrent shoulder instability can significantly affect a patients quality of life and place them at risk for extensive soft tissue and bony injury with repeated dislocations. Literature on the operative management of recurrent instability in pediatric patients is limited, as most studies include pediatric patients within a larger sample group comprised primarily of adults. The purpose of this paper was to investigate the role of early arthroscopic Bankart repair (ABR) after anterior shoulder dislocation or subluxation in a pure pediatric population. We retrospectively reviewed 32 consecutive ABRs in 30 pediatric patients. Sixteen shoulders failed initial nonoperative therapy before ABR, whereas surgical stabilization was the primary treatment in 16 shoulders after initial evaluation at our institution. There were 17 males and 13 females with an average age of 15.4 years (age range, 11-18 years). The average follow-up was 25.2 months. Functional outcomes were measured using the single assessment numerical evaluation (SANE) score. In the initial nonoperative group, the average SANE score was 92.2. There were 3 shoulder redislocations in 2 patients (18.75%). In the 16 shoulders treated with ABR as initial therapy, the average SANE score was 91.8, and there were 2 shoulder redislocations in 2 patients (12.5%). We conclude that primary ABR is an effective treatment of traumatically induced shoulder instability in pediatric patients. Primary ABR limits multiple recurring shoulder dislocations that hinder a patients quality of life and places them at risk for future negative sequelae.

Combined Anterior Cruciate Ligament and Medial Collateral Ligament Injuries in Adolescents

Abstract: Although literature supports bracing of most medial collateral ligament (MCL) injuries followed by arthroscopic repair of anterior cruciate ligament (ACL) tears in adults with combined ACL-MCL injuries, little is published regarding the treatment of these injuries in the pediatric population. The purpose of this study was to present our outcomes after treatment of combined ACL-MCL injuries in a series of adolescents. All 180 patients who underwent ACL reconstruction at our childrens hospital from January 1997 to January 2003 were reviewed to identify those patients with concomitant grade II or III MCL injuries. Clinical data were obtained from chart review. All patients were treated with a hinged brace for their MCL injury followed by delayed arthroscopic reconstruction of their ACL using a transphyseal technique with Achilles tendon soft tissue allograft. Patients were contacted by phone to complete Lysholm knee questionnaires and assess return to athletic competition. Data were compared with a control cohort of patients who underwent isolated ACL reconstruction using the same technique. Twelve (6.7%) of 180 patients had combined ACL-MCL injuries. There were 6 boys and 6 girls; the mean age was 15.6 years (range, 14-17 years). Follow-up averaged 5.3 years (range, 2.6-8.2 years), and no patients were lost to follow-up. At last examination, all patients had a stable knee on both Lachman and valgus stress tests; the mean Lysholm knee score was 96 (range, 94-100). All patients were able to return to their preinjury level of athletics. One patient required manipulation for arthrofibrosis. When compared with the control group of 19 isolated ACL reconstructions, there was no significant difference with regards to Lysholm scores or return to athletics. Bracing of grade 2 or 3 MCL injuries followed by ACL reconstruction was an effective means of treating combined ACL-MCL injuries in this small series of adolescent patients.

MRI of HAGL lesions: four arthroscopically confirmed cases of false-positive diagnosis.

OBJECTIVE The purpose of this article is to present the cases of four consecutive patients with preoperative MR diagnosis of humeral avulsion of the glenohumeral ligament (HAGL) who had no evidence of HAGL at arthroscopy. CONCLUSION These four cases suggest that the diagnosis of HAGL should be reserved for arthroscopy and illustrate the difficulty in distinguishing HAGL from other abnormalities of the inferior glenohumeral ligament complex with MRI. Thus, MRI findings classically associated with HAGL should be more broadly described as defects of the inferior glenohumeral ligament complex. This terminology more accurately describes the abnormalities of the inferior glenohumeral ligament complex that may be depicted by MRI.

Adolescent anterior cruciate ligament reconstruction: a retrospective analysis of quadriceps strength recovery and return to full activity after surgery.

Background This study was intended to provide quantitative assessment of quadriceps muscle recovery in adolescent athletes after anterior cruciate ligament (ACL) reconstruction. Methods Quadriceps peak torque values from 55 athletes who underwent ACL reconstruction were analyzed. The mean age of the patients was 15.93±1.65 years (40 girls, 15 boys). Isokinetic data were obtained using the Biodex System 3. Quadriceps muscle recovery was defined as achieving ≥85% peak torque for side-to-side comparison. Results Time-to-quadriceps muscle recovery was as follows: 15% by the end of 3 months, 11% by 4 months, 13% by 5 months, and 20% by 6 months. Overall, 32 patients (59%) achieved ≥85% quadriceps strength within 6 months of their surgery date. Of those patients, 16 (50%) patients returned to full activity within 6 months of the date of surgery. Sex was not found to be a significant difference in regard to strength outcomes. Conclusions Quadriceps muscle recovery is one criterion considered when allowing return to unrestricted activities after ACL reconstruction. On the basis of results of this study, middle and high school age athletes have the ability to regain the necessary quadriceps muscle strength required to return to sport within 6 months. Significance Using objective measures of quadriceps muscle return after ACL reconstruction can pinpoint timing of recovery, aid in specific training of deficient muscle groups, and guide return-to-play recommendations for those treating athletes with ACL reconstruction. Level of Evidence Level IV—This is a retrospective cohort study of all patients who underwent ACL reconstruction.

Fixation of Displaced Midshaft Clavicle Fractures in Skeletally Immature Patients

Background There is ongoing debate in the adult literature regarding fixation of displaced, closed midshaft clavicle fractures. Functional outcomes of treatment of these fractures in skeletally immature patients have not been previously investigated. Methods We retrospectively reviewed 14 skeletally immature patients with closed, displaced, midshaft clavicle fractures treated with open reduction internal fixation. Baseline data acquisition included demographic and radiographic indices. Follow-up data included radiographic and functional outcomes assessment using the Quick Disability of Arm, Shoulder, and Hand Questionnaire (QuickDASH), the simple shoulder test, and additional binary questions. Results Mean age for operative patients was 12.9 years. There were 12 male and 2 female cases. Twelve patients had injuries to the dominant extremity. Twelve patients had initially been treated nonoperatively, but underwent surgery due to increased displacement at 3 weeks. Minimum follow-up was 24 months. Mean postoperative total QuickDASH score was 7.0. Patients had a mean of 11 questions answered “yes” for the simple shoulder test. Four patients from the operative group underwent a second surgical procedure to remove hardware. Eight (57%) patients complained of numbness at the site of injury/surgery. Preoperative mean fracture shortening and vertical displacement were 14.4 and 19.7 mm, respectively. Follow-up radiographs at mean 3 months demonstrated healed fractures in all cases. Multiple linear regression showed no difference in QuickDASH score after adjusting for age, sex, injury to dominant extremity, shortening, and percent displacement (P=0.220). Conclusions In conclusion, operative treatment of displaced midshaft clavicle fractures in skeletally immature patients resulted in high scores on commonly used instruments of outcomes assessment. Operative patients may require additional surgery to remove prominent or painful hardware and may be prone to numbness at the incision site. Level IV.

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.

Intraarticular bupivacaine-clonidine-morphine versus femoral-sciatic nerve block in pediatric patients undergoing anterior cruciate ligament reconstruction

We hypothesized that combined femoral-sciatic nerve block (FSNB) offers better analgesia with fewer side effects than intraarticular infiltration (IA) in children undergoing anterior cruciate ligament (ACL) reconstruction. Thirty-six children undergoing ACL reconstruction were randomized to FSNB or IA. FSNB patients had FSNB with bupivacaine (0.125%)-clonidine (2 &mgr;g/kg), whereas IA patients received bupivacaine (0.25%)-clonidine (1 &mgr;g/kg)-morphine (5 mg). Postoperatively, analgesia was provided with patient-controlled analgesia and rescue morphine. Patient demographics were similar. FSNB patients required less intraoperative fentanyl (50 ± 40 &mgr;g versus 80 ± 50 &mgr;g; P = 0.04). Visual analog scale score for FSNB was smaller than IA in the recovery room (1.8 ± 3 versus 5.4 ± 3; P = 0.0002) and during the first 24 h (1.6 ± 1 versus 2.9 ± 2; P = 0.01)). FSNB morphine use in the first 18 h was less (7 ± 13 mg versus 21 ± 21 mg; P = 0.03). Fewer FSNB patients vomited (11% versus 50%; P = 0.03). IA patients required morphine patient-controlled analgesia sooner. After ACL reconstruction in children, FSNB with bupivacaine-clonidine provides better analgesia with fewer side effects than IA with bupivacaine-clonidine-morphine.

The Treatment of Low-Energy Femoral Shaft Fractures: A Prospective Study Comparing the “Walking Spica” with the Traditional Spica Cast

BACKGROUND A single-leg, walking hip spica cast has been shown to be a safe and effective treatment for a low-energy femoral shaft fracture in young children. We designed a prospective cohort trial comparing walking and traditional hip spica casting to determine whether a walking hip spica cast was superior to a traditional hip spica cast following a low-energy femoral shaft fracture in children one to six years old. METHODS We studied forty-five consecutive low-energy femoral shaft fractures during a three-year period in children one to six years old. Three surgeons treated their patients with a walking hip spica cast, and three other surgeons treated their patients with a traditional spica cast. Complications and subsequent interventions were recorded prospectively. Caregivers were asked to complete the validated Impact on Family Scale as well as a ten-item questionnaire developed by the authors at the time of cast removal. RESULTS Forty-five patients with a low-energy fracture were enrolled in the study. Nineteen patients were treated with a walking hip spica cast and twenty-six, with a traditional hip spica cast. The two cohorts were similar with respect to age, length of hospital stay, time to initial callus formation, and time to fracture union. Two children treated with a traditional hip spica cast and no children in the walking hip spica group returned to the operating room for the treatment of spontaneous loss of fracture reduction. Five of the nineteen children treated with a walking hip spica cast and one of the twenty-six treated with a traditional hip spica cast required wedge adjustment of the cast in the clinic to treat fracture malalignment (p = 0.04). One patient treated with a walking hip spica cast required repeat reduction in the operating room because of overcorrection during wedge adjustment. The malunion rate did not differ significantly between the groups (three of twenty-six in the traditional hip spica group compared with none of nineteen in the walking hip spica group). All patients treated with a walking hip spica cast were able to crawl in the cast, and 71% (twelve of seventeen) were able to walk. Use of the traditional hip spica cast resulted in a significantly greater care burden for the family as measured with use of the Impact on Family Scale (43.3 for the traditional hip spica group compared with 35.6 for the walking hip spica group, p = 0.04). Insurance-funded ambulance transportation was needed for eleven of the twenty-six patients treated with a traditional hip spica cast compared with none of the nineteen patients treated with a walking hip spica cast (p = 0.001). CONCLUSIONS The walking hip spica cast and the traditional hip spica cast resulted in similar orthopaedic outcomes, and the walking hip spica cast resulted in a lower care burden for the family. Surgeons and families should be aware that use of a walking hip spica cast rather than a traditional hip spica cast may be associated with a greater likelihood that wedge adjustment of the cast will be necessary to treat fracture malalignment.

Rotator cuff injuries in adolescent athletes.

The cause of rotator cuff injuries in the young athlete has been described as an overuse injury related to internal impingement. Abduction coupled with external rotation is believed to impinge on the rotator cuff, specifically the supraspinatus, and lead to undersurface tears that can progress to full-thickness tears. This impingement is believed to be worsened with increased range of motion and instability in overhead athletes. A retrospective review of seven patients diagnosed with rotator cuff injuries was performed to better understand this shoulder injury pattern. The type of sport played, a history of trauma, diagnosis, treatment method, and outcome were noted. Six patients were male and one was a female. Baseball was the primary sport for four patients, basketball for one, gymnastics for one, and wrestling for one. The following injury patterns were observed: two patients tore their subscapularis tendon, two sustained avulsion fractures of their lesser tuberosity, one tore his rotator interval, one tore his supraspinatus, and one avulsed his greater tuberosity. Only four patients recalled a specific traumatic event. Three patients were treated with arthroscopic rotator cuff repair, three with miniopen repair, and one was treated with rehabilitation. Six of the seven patients returned to their preinjury level of sport after treatment. Rotator cuff tears are rare in the adolescent age group. The injury patterns suggest that acute trauma likely accounts for many rotator cuff tears and their equivalents in the young patient. Adolescents with rotator cuff tears reliably return to sports after treatment. The possibility of rotator cuff tears in skeletally immature athletes should be considered. The prognosis is very good once this injury is identified and treated.