A Comparative Analysis of International Knee Documentation Committee Scores for Common Pediatric and Adolescent Knee Injuries.

BACKGROUND: Several different etiologies cause knee pain in the pediatric and adolescent population, including anterior knee/patellofemoral pain, patellar instability, anterior cruciate ligament (ACL) tears, meniscal tears, osteochondritis dissecans (OCD) lesions, and discoid meniscus. The purpose of the current study was to determine the relative morbidity of different causes of knee pain in children and adolescents using the International Knee Documentation Committee (IKDC) score. METHODS: We performed a retrospective review of prospectively collected data of a cohort of pediatric and adolescent patients with knee pain who presented to a single surgeon. Each patient completed an IKDC questionnaire at the time of diagnosis and patients were grouped by diagnosis for analysis. Statistical analysis was performed to compare the IKDC scores of the 7 diagnostic groups, and a P-value <0.05 was considered significant. RESULTS: The IKDC mean score for all 242 patients was 50.3±18.3. The mean IKDC score for patients with isolated meniscal tears was 41.2±16.0, combined ACL and meniscal injuries was 50.2±13.9, and isolated ACL tears was 48.1±14.1. The mean IKDC score for patients with symptomatic discoid meniscus was 46.3±13.2, anterior knee pain/patellofemoral pain was 49.0±17.4, patellar instability was 49.2±22.1, and OCD lesions was 62.2±19.5. CONCLUSIONS: The IKDC scores of most of the diagnostic groups were similar to the overall average score, with the notable exception of patients with OCD lesions exhibiting statistically significant less morbidity reflected by a higher IKDC score. Although symptoms in each individual clinical presentation may vary, knowledge of the relative morbidity of these diagnostic groups is valuable in counseling patients and their families regarding these common pediatric and adolescent sources of knee pain. LEVEL OF EVIDENCE: Level IV.

Treatment of femur fractures in young children: a multicenter comparison of flexible intramedullary nails to spica casting in young children aged 2 to 6 years.

BACKGROUND: Spica casting is the standard of care for femur fractures in children up to 6 years of age. The indications for surgery are controversial. We sought to compare immediate spica casting (Spica) and flexible intramedullary nailing [titanium elastic nailing (TEN)] in a group of children ages 2 to 6 years. We hypothesized that young children can be successfully treated with flexible nails, resulting in faster return to ambulation and an equivalent complication rate when compared with spica casting. METHODS: This was a multicenter retrospective review of 215 patients, 141 treated with immediate spica casting, and 74 treated with elastic nails. Patient demographics, fracture characteristics, mechanism of injury, associated injuries, outcomes, and complications were recorded and compared between the 2 groups. RESULTS: Patients in the elastic nailing group were more likely to be injured as a pedestrian struck by an automobile (Spica 8% vs. TEN 26%, P=0.001), and had increased rates of associated injuries (P<0.001). Time to fracture union was similar between the 2 groups (P=0.652). The TEN group had shorter time to independent ambulation (Spica 51±14 vs. TEN 29±14 d, P<0.001) and return to full activities (Spica 87±19 vs. TEN 74±28 d, P=0.023). CONCLUSIONS: TEN is a reasonable option for treatment of femur fractures in young children when compared with spica casting with shorter time to independent ambulation and full activities. Fractures associated with a high-energy mechanism are especially appropriate for consideration of treatment with TEN. LEVEL OF EVIDENCE: Level III, this was a retrospective comparative study.

Acute compartment syndrome after intramedullary nailing of isolated radius and ulna fractures in children.

BACKGROUND: There exist varying reports in the literature regarding the incidence of compartment syndrome (CS) after intramedullary (IM) fixation of pediatric forearm fractures. A retrospective review of the experience with this treatment modality at our institution was performed to elucidate the rate of postoperative CS and identify risk factors for developing this complication. METHODS: In this retrospective case series, we reviewed the charts of all patients treated operatively for isolated radius and ulnar shaft fractures from 2000 to 2009 at our institution and identified 113 patients who underwent IM fixation of both-bone forearm fractures. There were 74 closed fractures and 39 open fractures including 31 grade I fractures, 7 grade II fractures, and 1 grade IIIA fracture. If the IM nail could not be passed easily across the fracture site, a small open approach was used to aid reduction. RESULTS: CS occurred in 3 of 113 patients (2.7%). CS occurred in 3 of 39 (7.7%) of the open fractures compared with none of 74 closed fractures (P=0.039), including 45 closed fractures that were treated within 24 hours of injury. An open reduction was performed in all of the open fractures and 38 (51.4%) of the closed fractures. Increased operative time was associated with developing CS postoperatively (168 vs. 77 min, P<0.001). CS occurred within the first 24 postoperative hours in all 3 cases. CONCLUSION: CS was an uncommon complication after IM fixation of pediatric diaphyseal forearm fractures in this retrospective case series. Open fractures and longer operative times were associated with developing CS after surgery. None of 45 patients who underwent IM nailing of closed fractures within 24 hours of injury developed CS; however, 51.4% of these patients required a small open approach to aid reduction and nail passage. We believe that utilizing a small open approach for reduction of one or both bones, thereby avoiding the soft-tissue trauma of multiple attempts to reduce the fracture and pass the nail, leads to decreased soft-tissue trauma and a lower rate of CS. We recommend a low threshold for converting to open reduction in cases where closed reduction is difficult.

Femoral lengthening over a pediatric femoral nail: results and complications.

BACKGROUND: Limb lengthening by callotasis as described by Ilizarov has become the standard method of lower extremity lengthening. Lengthening over an intramedullary nail to allow early removal of the external fixator has also become common in adults but few studies have addressed the efficacy in children. METHODS: A retrospective review of 37 consecutive children who had undergone femoral lengthening with external fixator over an intramedullary nail was performed. Charts were reviewed for demographics, surgical details, and complications. Radiographs were examined to determine magnitude of lengthening and to calculate lengthening index. RESULTS: The average age of the 37 patients was 11.6 years (range, 8.1 to 17.0). The amount of lengthening averaged 7.0 cm (range, 3.0 to 11.4 cm), which represented a mean 20.4% increase in length. The mean time in the fixator was 81 days. The lengthening index was 1.21 days/mm. Thirteen patients developed major complications (37.8%) including 4 limbs that failed to lengthen initially, 3 fractures (1 before fixator removal and 3 after fixator removal), 2 nail failures, 4 deep infections, and 2 joint subluxations requiring operative care. The 3 fractures after fixator removal were treated with exchange nailing as were the 2 intramedullary nail failures. Four patients (10.8%) developed deep infections requiring irrigation, debridement, and IV antibiotics. One patient developed a late hip subluxation, which was treated with a shelf osteotomy but resulted in pain and limitation of motion. One patient developed knee subluxation during lengthening requiring operative intervention. The technique was successful in obtaining a good result with a functional lengthened femur without unresolved problems in 94% of the patients despite a significant rate of major complications, particularly in those with a congenital etiology. Only 2 of the 37 patients ultimately had results that were ultimately compromised by complications. CONCLUSIONS: Femoral lengthening over an intramedullary nail with the aid of an external fixator has shown to be an effective method for correcting limb length discrepancy. The technique has a high complication rate similar to other methods of lengthening. LEVEL OF EVIDENCE: Level IV-Case Series.

Tibia fractures: what should be fixed?

PURPOSE: The purpose of this study is to provide a summary of the absolute and the relative surgical indications for both closed and operative treatment of tibial shaft fractures. METHODS: A literature review of the pertinent literature was undertaken, and a limited number of the most significant papers are cited. Recommendations are provided for fractures that are most likely to need surgical intervention and relative indications for fractures that may benefit from surgical stabilization. RESULTS: Successful closed treatment can be achieved either by casting and conventional 3-point molding or by utilizing the Sarmiento technique of casting. Either technique depends on soft tissues to maintain bony alignment. The reported results are significantly improved after surgical stabilization after open tibial shaft fractures and tibial shaft fractures associated with ipsilateral femoral fractures. Relative indications for surgical stabilization include comminuted fractures, displaced fractures with an intact fibula, and displaced fractures in adolescents. Compartment syndrome remains the most significant early complication encountered when treating tibial shaft fractures in children and adolescents by either closed or surgical methods and should be considered in the face of pain out of proportion to the injury or increasing narcotic requirements. CONCLUSIONS: Tibial fractures are one of the more common injuries treated by orthopedic surgeons. Although most can be treated by closed techniques, certain fractures benefit significantly from surgical stabilization.

Titanium elastic nailing radius and ulna fractures in adolescents.

Over the last 40 years, anatomic reduction with plate stabilization has become the standard in adult patients with diaphyseal fractures of the radius and ulna. When operative fixation has been indicated in skeletally immature patients with these fractures, a variety of techniques have been reported, with intramedullary fixation becoming increasingly accepted. There is currently significant variability in the treatment of adolescents with forearm fractures. The purpose of this study was to investigate the clinical and radiographic outcomes in the adolescent population after intramedullary fixation of both bone forearm fractures. A retrospective review identified 32 patients 12-18 years of age who had undergone intramedullary fixation of both forearm bones in the past 20 years at our institution. Galeazzi, Monteggia, radial head, and distal metaphyseal fractures were excluded. Radiographic evaluation was performed to determine union and postoperative radial bow. Clinical follow-up was carried out for postoperative complications and range of motion of the wrist, forearm, and elbow. The mean age of the patients was 14.1 years. A total of 19 fractures were closed injuries, nine were grade 1, three were grade 2, and one fracture was a grade 3b. Of the patients, 15.6% had limited postoperative range of motion. All patients in the older age group, 15-18 years of age, had a normal range of motion. A decrease in radial bow was not associated with limitation in motion. There was a 98% union rate, and all unions occurred by 7.5 months. Only three major complications occurred, two refractures and one ulnar hardware migration, and subsequent radius nonunion occurred in the one grade 3b injury. Flexible intramedullary nailing of both bone forearm fractures provides reliable bony union and excellent postoperative clinical results in adolescents. Level of evidence, IV.

The utility of erythrocyte sedimentation rate values and white blood cell counts after spinal deformity surgery in the early (≤3 months) post-operative period.

PURPOSE: The erythrocyte sedimentation rate (ESR) and white blood cell (WBC) count are frequently obtained in the work-up of post-operative fever. However, their diagnostic utility depends upon comparison with normative peri-operative trends which have not yet been described. The purpose of this study is to define a range of erythrocyte sedimentation rates and white blood cell counts following spinal instrumentation and fusion in non-infected patients. METHODS: Seventy-five patients underwent spinal instrumentation and fusion. The erythrocyte sedimentation rate and white blood cell count were recorded pre-operatively, at 3 and 7 days post-operatively, and at 1 and 3 months post-operatively. RESULTS: Both erythrocyte sedimentation rate and white blood cell count trends demonstrated an early peak, followed by a gradual return to normal. Peak erythrocyte sedimentation rates occurred within the first week post-operatively in 98% of patients. Peak white blood cell counts occurred with the first week in 85% of patients. In the absence of infection, the erythrocyte sedimentation rate was abnormally elevated in 78% of patients at 1 month and in 53% of patients at 3 months post-operatively. The white blood cell count was abnormally elevated in only 6% of patients at 1 month post-operatively. Longer surgical time was associated with elevated white cell count at 1 week post-operatively. The fusion of more vertebral levels had a negative relationship with elevated erythrocyte sedimentation rate at 1 week post-operatively. The anterior surgical approach was associated with significantly lower erythrocyte sedimentation rate at 1 month post-operatively and with lower white cell count at 1 week post-operatively. CONCLUSION: In non-infected spinal fusion surgeries, erythrocyte sedimentation rates are in the abnormal range in 78% of patients at 1 month and in 53% of patients at 3 months post-operatively, suggesting that the erythrocyte sedimentation rate is of limited diagnostic value in the early post-operative period.

Immobilization after pinning of supracondylar distal humerus fractures in children: use of the A-frame cast.

BACKGROUND: Circumferential casts can contribute to elevated compartment pressures in the setting of acute swelling. We have developed a novel casting method (A-frame cast) that allows cast placement while leaving the antecubital fossa free of casting material. The purpose of this study was to evaluate the safety, efficacy, and complications associated with acute placement of this definitive cast after closed reduction percutaneous pinning (CRPP) of acute supracondylar distal humerus fractures. METHODS: A retrospective medical record reviewed 436 patients treated with CRPP of supracondylar fractures by 3 surgeons who routinely used an A-frame cast over a 12-year period. All complications or the need for cast modification were noted. Patients with open reduction, ipsilateral fractures, or patients lost to follow-up were excluded. RESULTS: There were 387 patients who met inclusion criteria, including 204 type 2 fractures and 183 type 3 fractures. Forty-three patients had preoperative nerve palsy and 1 had preoperative vascular injury. Of these 387 patients, 369 (95.3%) had an uneventful postoperative course. Nineteen patients (4.9%) required either cast splitting (15) or strict elevation (4) secondary to pain and swelling. Seven of these 19 patients had preoperative nerve palsy and 1 had preoperative vascular injury. The average time from procedure to cast splitting was 17.6 hours. No patients lost their reduction or required a second surgical procedure related to a complication from casting. CONCLUSIONS: An "A-frame" cast provides sturdy immobilization without increased risk of compartment syndrome after CRPP of supracondylar fractures in the pediatric population. Consideration should be given to splitting the cast prophylactically in patients with preoperative neurological or vascular deficits. LEVEL OF EVIDENCE: IV-Case Series.

Tibial fractures after tibial tubercle osteotomies for patellar instability: a comparison of three osteotomy configurations.

PURPOSE: Tibial tubercle osteotomies (TTOs) are a seemingly straightforward technique; however problems with bony union, implant failure, wound infections, and fractures have been reported in the literature. METHODS: A database search identified all patients who had a TTO performed for patellofemoral instability between 1 March 2000 and 30 July 2008 by a single surgeon. The TTO technique was modified twice during the study period (December 2003 and June 2007, respectively), thereby creating three similar patient cohorts. RESULTS: TTOs were performed in 101 knees (90 patients), in which 34 knees (29 patients) received the blunt technique (TTO-B), 32 knees (30 patients) the sloped technique (TTO-S), and 35 knees (31 patients) the greenstick technique (TTO-G). Mean age of the patients (75 females, 15 males) was 16.0 years (range 12.2-20.2 years). Overall, six patients had complications, namely, six tibia fractures and no nonunions, for an overall complication rate of 5.9%. In the TTO-B group, four patients had four tibia fractures for an overall bony complication rate of 11.8%. In the TTO-S group, two patients had two delayed unions which developed into tibia fractures for an overall bony complication rate of 6.2%. There were no complications (0%) in the TTO-G group. No correlation was identified between TTO screw size and complications. The caudal aspect of the osteotomy was the location of the tibia fracture in five knees and the caudal screw in 1 knee, at a mean of 11 weeks postoperatively. All fractures were treated only with splint or cast immobilization and protected weight-bearing. CONCLUSION: The overall bony complication rate was 5.9% for the TTOs in this study. Utilizing the TTO-G technique with rigid two-screw, bicortical fixation the complication rate could be lowered to 0%. Avoidance of periosteal stripping, and secondary cortical devascularization at the caudal aspect of the TTO appears to optimize bony consolidation, thereby minimizing fractures. CLINICAL RELEVANCE: Bony complications are an infrequent problem after TTO. Greensticking the distal end of the TTO can minimize postoperative tibia fractures. Running and sports should not be permitted until complete cortical healing is documented on the lateral radiograph.

Outcomes after patellar realignment surgery for recurrent patellar instability dislocations: a minimum 3-year follow-up study of children and adolescents.

BACKGROUND: The purpose of this study was to report early outcomes after patellar realignment surgery (PRS) was performed for patellar instability in children and adolescents. METHODS: The study cohort consisted of 23 patients (27 knees) who had PRS between March 1, 2000 and July 30, 2004, by a single surgeon, with a minimum 3-year follow-up and validated outcome measures. Preoperative diagnoses were dislocations in 22 knees and subluxations in 5 knees. The mean age was 14 years and 1 month. RESULTS: Postoperatively, 2 knees had possible recurrent dislocation/subluxation episodes; neither required surgery. Persistent patellofemoral mechanical symptoms have been reported in 10 knees. At a mean follow-up of 5 years and 1 month, the mean Lysholm score was 69.3 and the mean International Knee Documentation Committee (IKDC) score was 65.6. The mean Tegner activity level was 5.4. Patients reported improvement in knee function and pain in 26 of 28 knees (93%). Significant group differences were identified for age at surgery, preoperative diagnosis, and length of preoperative knee symptoms. The group with scores ≥ 70 were younger (13.1 vs. 14.9 y), were all patellar dislocators (vs. 66% in the < 70 group), and with shorter length of symptoms (13 mo vs. 24 mo). In the ≥ 70 groups the Tegner activity levels were higher at 6.8 versus the < 70 group at 4.3. CONCLUSIONS: At a mean of 5 years after PRS, 93% of patients reported persistent improvement in knee function and pain, and recurrent patellar dislocation/subluxation episodes were infrequent (7%). Despite the low rate of postoperative patellar instability the patients' subjective opinion of knee function was less than expected (mean IKDC 65.5). Further investigation is warranted to identify causes for this suboptimal outcome at a mean of 5 years postoperatively. CLINICAL RELEVANCE: These data reinforce the recurring theme documented in other areas of orthopaedics of a disconnection between the "surgical" success (93% improved) and patient's subjective outcome (mean IKDC of 65.6). LEVEL OF EVIDENCE: Level III.