Lateral Patellar Inclination Angle Measured via a Two-Image Technique on Axial Magnetic Resonance Imaging.

Lateral patellar inclination (LPI) measures patellar tilt and is historically described on axial X-ray or a single magnetic resonance image (MRI). Given the variability in patellar height, LPI may be better represented by performing this measurement on two separate axial MRI images. We hypothesized that a two-image LPI measurement would be different from the current single-image LPI and have similar, if not superior reliability. Sixty-five patients treated for patellar instability (PI) between 2014 and 2017 were identified. Single image and two-image LPI were measured on axial MRI images. All measurements were performed by two independent observers. Reliability analysis was based on three observers' measurements of 30 randomly selected patients. Both the one image and two image LPI showed good inter-rater reliability (intraclass correlation coefficient [ICC] = 0.71 and 0.89, respectively), although the two image LPI had less variability. Both single image and two image LPI had near perfect intra-rater reliability (ICC = 0.98 and 0.98, respectively). Average single image LPI (14.6 ± 9.9 degrees) was 6.1 ± 3.4 degrees less than the average two image LPI (19.6 ± 9.4 degrees) (p = 0.037). Referencing a previously described 13.5 degrees maximum threshold, 54% of the patients had excessive patellar tilt based on single image LPI, while 73% had pathologic patellar tilt based on two image LPI. Two image LPI has similar reliability with less inter-rater variability compared with the historical single image LPI measurement. Significantly greater patellar tilt was identified with two image LPI that was found with single image LPI. A larger percentage of patients were classified as having pathologic patellar tilt based on two image LPI than single image LPI. The two image LPI provides more consistent and representative measurements of patellar tilt. Previously described threshold values for patellar tilt should be re-examined using this new measurement technique to appropriately risk stratify patients with PI and patellofemoral pain.

Demographics and Epidemiology of Discoid Menisci of the Knee: Analysis of a Large Regional Insurance Database.

BACKGROUND: A discoid meniscus is a morphological variant of normal knee joint meniscus shape and ultrastructure that can lead to traumatic tearing of this tissue and early joint osteoarthritis. PURPOSE/HYPOTHESIS: The purpose of this study was to determine the prevalence of discoid menisci in a large, ethnically diverse regional cohort and to evaluate possible risk factors. The hypothesis was that there would be no difference in the epidemiological distribution of discoid menisci based on ethnicity or sex. STUDY DESIGN: Descriptive epidemiology study. METHODS: The study population was from a regional, integrated health care system cohort from Kaiser Permanente of Southern California that, as of 2016, included more than 4.5 million patients. Patient demographics included age, sex, and ethnicity within this cohort. Potential risk factors analyzed included age, sex, ethnicity, and body mass index (BMI). Unique characteristics of a discoid meniscus were analyzed, including a symptomatic versus asymptomatic meniscus, location of meniscal tear and type of meniscus, and frequency of meniscal surgical treatment. RESULTS: A total of 223 patients with a confirmed discoid meniscus were identified, yielding an overall prevalence rate of 4.88 per 100,000 patients. Those identifying as Black had the lowest prevalence (2.68/100,000), while Hispanic ethnicity had the highest (6.01/100,000). However, there was no significant difference with regard to ethnicity (P = .283), nor any significant difference between sexes. BMI did not significantly influence the rate of discoid menisci (P = .504). A majority (77.5%) of patients were symptomatic, while 22.5% of patients with discoid menisci were asymptomatic and discovered incidentally. Symptomatic discoid menisci were more likely to be operated on compared with asymptomatic discoid menisci (71% vs 14%, respectively; P = .001; odds ratio, 14.8 [95% CI, 5.8-37.2]). Horizontal and bucket-handle tears were the more common tear types. Of the discoid menisci in this cohort, 55.6% underwent surgery, with 95.2% undergoing reported saucerization. CONCLUSION: In this very diverse population-based cohort of patients, there did not seem to be a significant predilection of discoid menisci with regard to ethnicity. Neither sex nor BMI significantly influenced the rate of discoid menisci. More than three-quarters of those with a diagnosed discoid meniscus were symptomatic. Of the tears that occurred with discoid menisci, horizontal and bucket-handle tears made up the largest proportion.

Correction to: Paediatric proximal ACL tears managed with direct ACL repair is safe, effective and has excellent short-term outcomes.

Authors would like to update the full author names.

Paediatric proximal ACL tears managed with direct ACL repair is safe, effective and has excellent short-term outcomes.

PURPOSE: Anterior cruciate ligament (ACL) surgery in the paediatric population has long been a challenge. Non-operative treatment will result in persistent instability which can lead to chondral and meniscal injuries. The results of primary open ACL repair are poor. Concerns of growth plate disturbance with transphyseal techniques and issues with relatively small-diameter grafts in Tanner 1 and 2 patients, which are inadequate, have contributed to these challenges. With advancing instrumentation, there is renewed interest in ACL repair. The minimally invasive approach of arthroscopic primary ACL repair retains the native ligament. The objective and subjective outcomes at 2 years are presented. METHODS: Paediatric patients, less than 16 years of age, presenting acutely with complete proximal ACL ruptures underwent direct arthroscopic ACL repair, reinforced by a temporary internal brace, which was subsequently removed after 3 months. Patient-reported outcome measures including the Lysholm, Tegner and KOOS scores were collected at 6 months, 1 year and 2 years post-operatively. RESULTS: Twenty patients (age 6-16) completed data at 2 years post-operatively. There were no failures, no complications and no growth disturbance out to 2 years. The 2-year postoperative outcomes; Lysholm 95 (90-100), Tegner 7 (6-10), KOOS-Child 96.5 (88.9-100) demonstrated statistically significant improvements following surgery (p < 0.001). Objective measurements with an accelerometer did not demonstrate any significant side-to-side difference. CONCLUSION: ACL repair for proximal ACL tears in the paediatric population demonstrates the potential for excellent outcomes at short-term follow-up. This presents an attractive alternative to ACL reconstruction when an adequate ACL remnant permits direct repair. Our results demonstrate that paediatric ACL repair is safe and effective.

Prospective Evaluation of a Treatment Protocol Based on Fracture Displacement for Pediatric Lateral Condyle Humerus Fractures: A Preliminary Study.

BACKGROUND: To prospectively evaluate a displacement-based classification system and an outcome-derived algorithm in the treatment of children with lateral condyle fractures. METHODS: All children with a lateral condyle fracture were prospectively enrolled at our institution between 2013 and 2016. Fractures were classified and treated on the basis of the following classification system: type 1: <2 mm; treated with long arm casting, type II: 2 to 4 mm; treated with closed reduction and percutaneous pinning (CRPP), and type III: >4 mm; open reduction and percutaneous pinning (ORPP). Functional outcomes were assessed at 6 to 12 weeks and at 1-year follow-ups using the Pediatric Outcomes Data Collection Instrument (PODCI). RESULTS: A total of 55 patients (mean age, 6 y; range 2 to 12 y) were prospectively enrolled. There were 17 (31%) type I fractures treated with a long arm cast, 8 (15%) type II treated with CRPP, and 30 (54%) type III treated with ORPP. Postoperative complications included delayed union (N=5) and pin site infection (N=3). Delayed unions on the basis of fracture type was type I (1/17, 6%), type II (1/8, 13%), and type III (3/30, 10%) (P=0.85). The rate of delayed unions in type II and III fractures fixed with k-wires was 11% (4/38). Four patients required a second operation with screw fixation. No significant differences were found across PODCI domains at 1-year follow-up when comparing our study population with normative data. CONCLUSIONS: This is the first prospective study of a treatment protocol for pediatric lateral condyle fractures and validates the use of displacement as a guide for best evidence-based treatment. Children with a lateral condyle fracture can achieve excellent functional outcomes in all classification types with comparable complication rates when radiographic fracture displacement is used to guide surgical and clinical decision making. LEVEL OF EVIDENCE: Level II.

Pediatric and Adolescent Forearm Fractures: Current Controversies and Treatment Recommendations.

Pediatric and adolescent forearm fractures continue to present treatment challenges. Despite high-level evidence to the contrary, traditional guidelines for nonsurgical treatment have been challenged in favor of surgical intervention, but it is unclear if this results in improved outcomes. Recent evidence suggests that certain open fractures in children may be successfully treated nonsurgically. Good results have been achieved with closed reduction and appropriate casting and clinical follow-up. Further research investigating functional outcomes into adulthood is needed.

Evidence-based review: management of open pediatric fractures.

Open fractures in the pediatric population are rare. As such, recommendations for care based on high-level studies are scarce. Furthermore, most level I and II recommendations come from studies involving open fractures in adults. Although it is generally accepted that open pediatric fractures have better outcomes than open fractures in adults, the lack of quality studies provide ample opportunities to answer questions regarding care of these injuries. This review explores the available literature and gives corresponding recommendations based on the level of evidence.

Does using the medial or lateral humeral line improve reliability of Baumann angle measurement on plain x-ray? The effect of humeral length visualized on the x-ray.

BACKGROUND: Baumann angle (BA) is a common measure of coronal plane alignment of the distal humerus. We hypothesize that the reliability of measuring BA would be improved by using the medial and lateral cortical margins of the humerus seen on plain x-ray, rather than the estimated central humeral line, which is the "standard" technique. Further, we analyze whether the amount of humerus visible on the film improves the reliability of the method. METHODS: A total of 71 anteroposterior elbow digital radiographs from patients aged 0 to 12 were measured 3 times by 5 qualified observers. Each digital measurement included (1) BA using the estimated central humeral line; (2) BA using the medial humeral line (BA-MHL); and (3) BA using the lateral humeral line (BA-LHL). Inadequate radiographs or those showing any indication of current or previous fracture were excluded. Intraobserver reliability was estimated for each rater using a 1-way analysis of variance model and interobserver reliability of each set of measurements was estimated using a 2-way analysis of variance. RESULTS: The mean and SD for the BA, BA-MHL, and BA-LHL in females were 70.0 (6.73), 68.0 (6.84), and 72.3 (7.93), respectively, and for males 73.0 (5.22), 70.0 (5.56), and 76.0 (6.18), respectively. Intraobserver reliability (intraclass correlation coefficient) for BA, BA-MHL, and BA-LHL averaged 0.85, 0.92, and 0.90, respectively. Average interobserver reliability (intraclass correlation coefficient) for BA, BA-MHL, and BA-LHL were 0.79, 0.71, and 0.76, respectively. Intraobserver and interobserver reliability of BA and BA-LHL were significantly improved when at least 7 cm of humerus was visible on the x-ray, as compared with <7 cm visible. CONCLUSIONS: Intrarater reliability is better for both BA-LHL and BA-MHL than for standard BA (using the estimated central humeral axis). Interrater reliability was best using standard BA. Reliability of all methods is improved when >7 cm of the distal humerus is visible on the radiograph. In addition, at least 7 cm of the distal humerus on anteroposterior radiographs improves reliability of measuring BA. LEVEL OF EVIDENCE: Diagnostic study-Level II.

The lateral capitellohumeral angle in normal children: mean, variation, and reliability in comparison to Baumann's angle.

BACKGROUND: Angular deformity is the most common complication of supracondylar humerus fracture. Baumann's angle (BA) is an established radiographic measure of coronal plane deformity after this injury. Numerous radiographic methods have been used to assess sagittal plane deformity, however, the mean, variability, and reliability of these measures has not been established. The purpose of this study was to determine the mean, SD, and intraobserver/interobserver reliability of the lateral capitellohumeral angle (LCHA) in children without evidence of fracture and compare them with those of BA. METHODS: Seventy-one sets of anteroposterior and lateral elbow radiographs were selected and stratified into 6-year age categories with equal number of males and females in each category. Five physicians performed 3 separate measurements of LCHA and BA on each film set. Statistical calculations were performed to determine mean, SD, measurement reliability, and differences between patients groups. RESULTS: The mean LCHA ±1 SD and BA ± 1 SD measurements were 50.8 ± 6 degrees and 71.5 ± 6.2 degrees, respectively, and did not vary significantly by age, side, or sex (P>0.05). The LCHA showed good intraobserver (correlation coefficient 0.67) and fair interobserver (0.37) reliability, whereas BA showed excellent intraobserver (0.86) and interobserver (0.80) reliability. The expected SD for repeated measurement of a radiograph by a single observer was 2.6 degrees for BA and 5.2 degrees for LCHA. CONCLUSIONS: The LCHA is a simple measurement to perform using digital tools. In normal elbows, the mean angle is 51 ± 6 degrees and does not vary by age, side, or sex. LCHA variability in normal elbow radiographs is similar to BA. Its reliability is inferior to BA, but improves with age. Sagittal angulation abnormality of at least 12 degrees (<39 or >63 degrees) is necessary to be confident that the change is not because of measurement error alone. Further research is needed to better define the relationship of sagittal plane angular deformity to clinical outcome. LEVEL OF EVIDENCE: Diagnostic study with poor reference standard, Level IV.