Per-Mats Janarv

Anterior cruciate ligament injuries in skeletally immature patients

Twenty-eight consecutive, skeletally immature patients (9.9-15.0 years of age at the time of injury) with total rupture of the anterior cruciate ligament (ACL) were followed up for 3-5 years. The aims of the study were to monitor the natural course of conservative treatment, to identify variables relevant to failure of conservative treatment, and to evaluate an over-the-top procedure for ACL reconstruction by using the semitendinosus tendon and avoiding the physes. The patients were interviewed according to Lysholm knee score and Tegner activity level. Knee laxity and muscle torque were measured. Five patients insisted on immediate reconstruction. Twenty-three patients were sent to a 3-month rehabilitation program. Sixty-eight percent of the patients, who made an attempt with conservative treatment, had been operated on at follow-up. The patients not operated on were younger at injury and had a lower activity level at follow-up. The surgical procedure improved objective and subjective knee function, but there was a correlation between high activity level and a low Lysholm score.

The influence of transphyseal drilling and tendon grafting on bone growth : An experimental study in the rabbit

The undulating area of the distal femoral physis has been measured in New Zealand White rabbits, by using an image analyzer in histologic sections, and correlated to radiographic measurements. The relative size of a physeal drill injury necessary to cause growth disturbance has been found to be 7-9%. A transphyseally placed tendon, even as a free graft, prevented solid bone-bridge formation in the drill hole and growth disturbance. The results are of possible clinical significance.

Long-term follow-up of anterior tibial spine fractures in children

Summary In a long-term follow-up (mean 16 years) of 61 children with anterior tibial spine fractures, subjective knee function (Lysholm score) was excellent or good in 87% of the subjects and fair in 13%. Eleven percent of the children had a lower activity level (Tegner score) than desired. Muscle performance was affected in those subjects with the lowest Lysholm scores. Pathological knee laxity was found in 38% of the subjects, but was not reflected in poor subjective knee function. Age at injury did not influence the outcome. There was no indication that young children can eliminate slackness of the anterior cruciate ligament by further growth. Only in type III fractures was there a correlation between fracture displacement after healing and knee laxity, as well as between knee laxity and Lysholm score. Arthroscopy-guided or open reduction and internal fixation seems to be a worthwhile procedure only in dislocated type III fractures.

The International Olympic Committee Consensus Statement on age determination in high-level young athletes

Most youth sports around the world are classified on the basis of chronological age to guarantee equal chances within each of the different age groups. At the elite level, international sporting federations organise competitions in various age classes ranging from as low as under-13 up to under-21, depending on the sport. In August 2010, the International Olympic Committee (IOC) is conducting the first Youth Olympic Games in Singapore for 14–18-year-old athletes. The standing of these youth competitions has increased to the stage at which there may be considerable rewards, individual fame or national prestige associated with winning, not only for the athlete but for the coach and his or her entourage. These competitions also represent important showgrounds for young athletes; in some sports, this is often where talented athletes are identified for a future professional career. Unfortunately, in a number of sports it is suspected that the chronological age of the participating players is higher than the age stated on the official documents used to determine the eligibility of the individual. Players with a greater relative age are more likely to be identified as talented because of the likely physical advantages they have over their ‘younger’ peers.1 International sporting federations have uncovered several cases of document fraud, presumably aimed at allowing over-age athletes to gain a performance advantage by competing in a lower age class. At the other end of the spectrum, there are also documented cases of under-aged athletes competing in events in which there is a lower age limit (eg, the age of 14 years in the Olympic Games); particularly in sports in which late maturers may be at an advantage, such as in gymnastics. It should be noted that the participation of over-age or under-age athletes is not always due to intentional cheating. To verify age, …

Osteochondral lesions in the radiocapitellar joint in the skeletally immature : Radiographic, MRI, and arthroscopic findings in 13 consecutive cases

Radiography, magnetic resonance imaging (MRI), and arthroscopy were performed in 13 consecutive cases of osteochondral lesions of the radiocapitellar joint in 12 patients aged 11-16 years. Nine patients had a high activity level, and two patients had a significant trauma before the onset of symptoms. Symptoms were limited range of motion, pain, and catchings or lockings. Clinical findings were decreased range of motion and lateral elbow tenderness. Radiography revealed loose body, flattening of the humeral capitellum, or subchondral cysts (or a combination of these) in all cases but three. There was a good correlation between MRI and arthroscopic examination. Nine lesions were located in the humeral capitellum, one lesion in the radial head, and in three cases, lesions were found in both sites. Loose-body removal, shaving, or subchondral drilling (or a combination of these) was performed in 11 cases. All surgically treated patients improved in the short run. Awareness of the typical clinical and radiologic picture will allow identification of the cases suitable for arthroscopy and surgical treatment. In these cases, MRI can be omitted.

Internal fixation with biodegradable rods in pediatric fractures: one-year follow-up of fifty patients.

Fifty children with transphyseal or osteochondral fractures were treated with biodegradable osteosynthesis material and followed for at least 1 year. All 50 fractures healed, and there were no major complications; 11 of them were fractures of the radial humeral condyle. In a prospective randomized study, they were compared with metal pin fixation of the same fracture (eight cases). No major differences were noted. After the study was completed, we observed two cases of nonunion of intraarticular fractures of the radial head, probably related to foreign body reaction to the resorbable implant material. Biodegradable osteosynthesis material is advantageous in treatment of childrens fractures because it makes a removal operation unnecessary. It is ideal in cases of osteochondral fractures. Further experience with this material is necessary, however, before it can be safely recommended.

Incidence and trends in femur shaft fractures in Swedish children between 1987 and 2005.

Background The surgical treatment of femur shaft fractures in children is changing, and the time spent in hospital is shorter than before. The purpose of this nationwide epidemiology study is to report incidence of pediatric femur shaft fractures in Sweden during 1987 to 2005 by age, sex, cause of injury, severity of injury, and seasonal variation, and to analyze the change in incidence, treatment modalities, and length of hospital stay over time. Methods Children (N=4984) with a diagnostic code for femur shaft fracture in Sweden 1987 to 2005 were selected from the Swedish National Hospital Discharge Registry. Results The overall annual incidence per 100,000 children was 22.9 in boys and 9.5 in girls. The incidence declined by 42%, on average 3% per year, from 19.4 to 11.8 between 1987 and 2005 (P<0.001). The most common cause of injury in children younger than 4 years of age was fall of <1 m; in children 4 to 12 years of age, sports accidents were the most frequent cause of injury; and in children 13 to 14 years of age, traffic accidents. The month of occurrence for femur shaft fractures had a bimodal seasonal variation with a peak in March and in August. Treatment modalities were changing during the study period from the use of traction to an increased use of external fixation and elastic intramedullary nailing. The length of hospital stay decreased by 81%, from 26 days in 1987 to 5 days in 2005 (P<0.001), but had no correlation to the introduction of new surgical treatment methods. Conclusions The present nationwide study of femur shaft fractures shows a decrease of fracture incidence, a shift in the treatment modalities, and shorter length of hospital stay. Level of Evidence Level III, retrospective comparative study.

Development of the Knee Injury and Osteoarthritis Outcome Score for Children (KOOS-Child): Comprehensibility and content validity

Background and purpose The Knee Injury and Osteoarthritis Outcome Score (KOOS) is distinguished from other knee-specific measures by the inclusion of separate scales for evaluation of activities of daily living, sports and recreation function, and knee-related quality of life, with presentation of separate subscale scores as a profile. However, its applicability in children has not been established. In this study, we examined how well the KOOS could be understood in a cohort of children with knee injury, with a view to preparing a pediatric version (KOOS-Child). Material and methods A trained researcher conducted cognitive interviews with 34 Swedish children who had symptomatic knee injuries (either primary or repeated). They were 10–16 years of age, and were selected to allow for equal group representation of age and sex. All the interviews were recorded. 4 researchers analyzed the data and modified the original KOOS questionnaire. Results Many children (n =14) had difficulty in tracking items based on the time frame and an equivalent number of children had trouble in understanding several terms. Mapping errors resulted from misinterpretation of items and from design issues related to the item such as double-barreled format. Most children understood how to use the 5-point Likert response scale. Many children found the instructions confusing from both a lexical and a formatting point of view. Overall, most children found that several items were irrelevant. Interpretation The original KOOS is not well understood by children. Modifications related to comprehension, mapping of responses, and jargon in the KOOS were made based on qualitative feedback from the children.

Occult Intra-articular Knee Injuries in Children With Hemarthrosis

Background: Hemarthrosis after acute knee trauma is a sign of a potentially serious knee injury. Few studies have described the epidemiology and detailed injury spectrum of acute knee injuries in a general pediatric population. Purpose: To document the current injury spectrum of acute knee injuries with hemarthrosis in children aged 9 to 14 years and to describe the distribution of sex, age at injury, type of activity, and activity frequency in this population. Study Design: Descriptive epidemiology study. Methods: All patients in the Stockholm County area aged 9 to 14 years who suffered acute knee trauma with hemarthrosis were referred to Astrid Lindgren Children’s Hospital, Karolinska University Hospital, from September 2011 to April 2012. The patients underwent clinical examination, radiography, and magnetic resonance imaging (MRI). The type of activity when injured, regular sports activity/frequency, and patient sex and age were registered. The diagnoses were classified into minor and serious injuries. Results: The study included 117 patients (47 girls and 70 boys; mean age, 13.2 years). Seventy percent had a serious knee injury. Lateral patellar dislocations, anterior cruciate ligament ruptures, and anterior tibial spine fractures were the most common injuries, with an incidence of 0.6, 0.2, and 0.1 per 1000 children, respectively. The sex distribution was equal up to age 13 years; twice as many boys were seen at the age of 14 years. The majority of injuries occurred during sports. Forty-six patients (39%) had radiographs without a bony injury but with a serious injury confirmed on MRI. Conclusion: Seventy percent of the patients aged 9 to 14 years with traumatic knee hemarthrosis had a serious intra-articular injury that needed specific medical attention. Fifty-six percent of these patients had no visible injury on plain radiographs. Physicians who treat this group of patients should consider MRI to establish the diagnosis when there is no or minimal radiographic findings. The most common serious knee injury was a lateral patellar dislocation. This should be taken into consideration to improve prevention strategies and treatment algorithms in pediatric knee injuries.

Arthroscopic Fixation of Anterior Tibial Spine Fractures With Bioabsorbable Nails in Skeletally Immature Patients

Background A number of arthroscopic techniques have been introduced in the treatment of displaced anterior tibial spine fractures. Several of the procedures are technically demanding or include a second removal operation of metallic implants. Purpose The purpose of this study is to describe and evaluate an arthroscopic technique using bioabsorbable nails in displaced anterior tibial spine fractures. Study Design Case series; Level of evidence, 4. Methods Sixteen consecutive patients, aged 7 to 15 years, with anterior tibial spine fractures type II and III according to Meyers and McKeever, were treated with arthroscopic fixation of the fragment using bioabsorbable nails. After 2 to 5 years, 13 of the patients were evaluated with regard to anterior knee laxity, range of motion, hop tests, Lysholm knee scoring scale, and activity level. Postoperative surgical complications were registered in the whole group of patients. Results One of the 13 patients had an increased anterior knee laxity of 3 mm. Extension deficits of 5° were seen in 4 patients and flexion deficits of 5° to 10° in 3 patients. One patient had an outcome of <90% of the uninjured side in the hop tests. Eleven patients were excellent, 1 was good, and 1 was poor according to the Lysholm knee scoring scale. There was no influence on activity level. There were no inflammatory reactions and all fractures healed without complications. In 1 case, the arthroscopy was converted into an open procedure because of technical problems, still using the bioabsorbable nails. Conclusion The outcome is comparable with other procedures. A second operation for removal of metallic implants is avoided.