Which Factors Increase the Risk of Reoperation After Meniscal Surgery in Children?

BACKGROUND: Meniscal injuries in children can pose treatment challenges, as the meniscus must maintain its biomechanical function over a long lifetime while withstanding a high activity level. While the adult literature contains a plethora of studies regarding risk factors for failure of meniscal surgery, such reports are scarcer in children. PURPOSE: To determine the rate at which children undergoing meniscal surgery require subsequent reoperation as well as to define risk factors for reoperation in this population. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: A retrospective institutional database of 907 first-time meniscal surgical procedures performed between 2000 and 2015 was reviewed. All patients were <18 years old. Demographic and intraoperative information was recorded, as were concurrent injuries or operations and subsequent procedures. Univariate analysis consisted of chi-square and independent-samples t tests. Multivariate logistic regression with purposeful selection was then performed to adjust for confounding factors. RESULTS: The mean ± SD patient age was 13.2 ± 2.1 years, and 567 (63%) were male. The mean postoperative follow-up duration was 20.1 ± 10.1 months. Overall, 83 patients (9%) required repeat surgery at a mean of 23.2 months after the index operation. After adjustment for confounders in a multivariate model, meniscal repair resulted in 3.1-times higher odds of reoperation when compared with meniscectomy (95% CI, 1.2-8.3; P = .02), while white-white zone tears had 2.8-times lower odds of reoperation (95% CI, 1.01-7.7; P = .04) versus red-red and red-white zone tears. CONCLUSION: Approximately 9% of children undergoing meniscal surgery will require reoperation at a mean 23.2 months after the index operation. Repair carried approximately 3-times higher odds of reoperation than meniscectomy, while white-white zone tears had nearly 3-times lower odds of requiring repeat surgery when compared with tears in other zones.

Did a Minimum Case Requirement Improve Resident Surgical Volume for Closed Wrist and Forearm Fracture Treatment in Orthopedic Surgery?

OBJECTIVE: The purpose of this study is to determine whether the 2013 implementation of ACGME minimum case requirements was associated with increased documented case volume of closed manipulation of forearm and wrist fractures (CMFWF) for graduating orthopedic surgery residents. DESIGN: We reviewed ACGME case log data for CMFWF among graduating orthopedic surgery residents from 2007 to 2016. Annual national mean, and median number of CMFWF performed by residents in the 10th, 30th, 50th, and 90th case volume percentile were evaluated. Preminimum (2007-2010) data was compared to postminimum (2013-2016) values to assess the impact of ACGME minimum requirements on resident case volume. SETTING: Review of publically available ACMGE Orthopedic Surgery Residency Program case log data. PARTICIPANTS: ACGME case log data for orthopedic surgery residents graduating between 2007 and 2016. RESULTS: National mean number of CMFWF increased significantly pre- to postminimum requirement (30.0 ± 2.84 to 45.0 ± 3.36, p < 0.001). Between 2010 and 2016 there was a 1100%, 300%, 83%, and 9% increase in the median number of CMFWF within the 10th, 30th, 50th, and 90th percentiles, respectively. CONCLUSIONS: ACGME's 2013 case minimum requirement corresponded to an increase in case counts for CMFWF; the greatest increase occurred in residents below the 50th percentile of case volume. Implementation of case minimum requirements may allow for more accurate depiction of resident experience and program strengths with regards to procedural exposure. However, the current case log system measures only case quantity, which may inaccurately depict mastery of given procedures. Future work should focus not only on improving case counts in underperforming residents and training sites, but also on refining metrics that ensure accurate assessment of resident skill for essential orthopedic procedures prior to graduation.

ACL Tears in School-Aged Children and Adolescents Over 20 Years.

BACKGROUND: Anterior cruciate ligament (ACL) tears are thought to occur with increasing frequency in young patients. No study has shown increased incidence over time. We hypothesized the incidence of ACL tears in young patients has increased over the past 20 years. METHODS: This descriptive epidemiology study is a retrospective review of insurance billing data of all patients aged 6 to 18 years with Current Procedural Terminology, Fourth Revision codes for ACL tear and reconstruction or International Classification of Diseases, Ninth Revision, Clinical Modification codes from 1994 to 2013. Injuries were normalized to persons per year enrolled in the insurance database based on age and sex. Analysis was performed based on sex and age (6-14, 15-16, and 17-18 years). RESULTS: The rate of ACL tears per 100 000 person-years averaged 121 ± 19 (range 92-151). All trends increased significantly except for the male 6- to 14-year-old and 17- to 18-year-old age groups. Overall there was an annual increase of 2.3%. Females had significantly higher incidence except in the 17- to 18-year-olds. Females peaked at age 16 years and males at age 17 years, with rates of 392 ACL tears and 422 ACL tears per 100 000 person-years, respectively. CONCLUSIONS: The incidence of ACL tears in pediatric patients increased over the last 20 years. Females were at higher risk except in the 17- to 18-year -old group. Peak incidence is noted during high school years. These data help target the most at-risk patients for ACL prevention programs.

T-condylar fractures of the distal humerus in children: does early motion affect final range of motion?

PURPOSE: T-condylar fractures of the distal humerus are infrequent injuries in children. There are little data regarding outcomes in this age group. The adult literature demonstrates a high rate of postinjury stiffness. We describe a large series of T-condylar fractures in children and set out to identify factors that influence the postoperative range of motion (ROM) in children. Our hypothesis was that starting motion early (<3 weeks) would favorably influence the postoperative ROM. METHODS: Patients were identified based on the Current Procedural Terminology (CPT) code for ORIF of supracondylar distal humerus fractures with intracondylar extension (24546). Patient records and radiographs were reviewed to determine the demographics, fracture characteristics, surgical approach and fixation, and postoperative immobilization time. Our outcome measure was ROM in flexion/extension at 3 months, 6 months, 1 year, and final follow-up. Patients were analyzed by Morrey's criteria of -30° extension and 130° flexion to assess for postoperative elbow stiffness. RESULTS: Thirty-eight potential patients from 1992 to 2010 were identified with specific T-condylar patterns. Twelve patients were excluded due to insufficient follow-up or lack of final ROM data. Our cohort included 26 patients (average age 13.4 years). The average postoperative immobilization time was 3.4 weeks (range 0.9-12 weeks). At the final follow-up, patients had -12° average extension and 130° average flexion. Nine patients (35 %) were stiff and 17 patients (65 %) had functional motion postoperatively. At 3 and 6 months, starting motion early yielded better flexion and extension ROM. Late-motion patients obtained similar results at the 1-year follow-up. Open fractures, gender, and age were all not significantly associated with elbow stiffness in our series, given the limited numbers. CONCLUSION: Early ROM was associated with an earlier gain of functional motion without clear adverse consequences. Despite similar findings at the final follow-up, practitioners should consider instituting early ROM protocols to decrease the duration of stiffness and potential disability for the child and the family.

The pediatric knee: current concepts in sports medicine.

As the popularity and intensity of children's athletics have increased, so has the risk for knee injuries. Fractures of the tibial eminence may be treated operatively or nonoperatively depending on fracture classification, but arthrofibrosis is a potentially significant complication. Anterior cruciate ligament rupture presents treatment challenges as regards the optimal timing and method of reconstruction. A number of novel reconstructive techniques have been developed to minimize risks to the physes in this population. Recent studies have focused on the prognosis, surgical indications, and operative techniques for osteochondritis dissecans in children. A number of authors have also sought to better-define the optimal diagnostic testing and management of patellar dislocation. In this review, we provide an update on current concepts for tibial eminence fractures, anterior cruciate ligament injuries, osteochondritis dissecans of the knee, and patellar dislocation in young athletes.

Do oblique views add value in the diagnosis of spondylolysis in adolescents?

BACKGROUND: Anteroposterior, lateral, and right and left oblique lumbar spine radiographs are often a standard part of the evaluation of children who are clinically suspected of having spondylolysis. Recent concerns regarding radiation exposure and costs have brought the value of oblique radiographs into question. The purpose of the present study was to determine the diagnostic value of oblique views in the diagnosis of spondylolysis. METHODS: Radiographs of fifty adolescents with L5 spondylolysis without spondylolisthesis and fifty controls were retrospectively reviewed. All controls were confirmed not to have spondylolysis on the basis of computed tomographic scanning, magnetic resonance imaging, or bone scanning. Anteroposterior, lateral, and right and left oblique radiographs of the lumbar spine were arranged into two sets of slides: one showing four views (anteroposterior, lateral, right oblique, and left oblique) and one showing two views (anteroposterior and lateral only). The slides were randomly presented to four pediatric spine surgeons for diagnosis, with four-view slides being presented first, followed by two-view slides. The slides for twenty random patients were later reanalyzed in order to calculate of intra-rater agreement. A power analysis demonstrated that this study was adequately powered. Inter-rater and intra-rater agreement were assessed on the basis of the percentage of overall agreement and intraclass correlation coefficients (ICCs). PCXMC software was used to generate effective radiation doses. Study charges were determined from radiology billing data. RESULTS: There was no significant difference in sensitivity and specificity between four-view and two-view radiographs in the diagnosis of spondylolysis. The sensitivity was 0.59 for two-view studies and 0.53 for four-view studies (p = 0.33). The specificity was 0.96 for two-view studies and 0.94 for four-view studies (p = 0.60). Inter-rater agreement, intra-rater agreement, and agreement with gold-standard ICC values were in the moderate range and also demonstrated no significant differences. Percent overall agreement was 78% for four-view studies and 82% for two-view studies. The radiation effective dose was 1.26 mSv for four-view studies and 0.72 mSv for two-view studies (difference, 0.54 mSv). The charge for four-view studies was $145 more than that for two-view studies. CONCLUSIONS: There is no difference in sensitivity and specificity between four-view and two-view studies. Although oblique views have long been considered standard practice by some, our data could not identify a diagnostic benefit that might outweigh the additional cost and radiation exposure.

Imaging modalities for low back pain in children: a review of spondyloysis and undiagnosed mechanical back pain.

PURPOSE: Mechanical low back pain is common in the pediatric population; recent studies have shown that undiagnosed mechanical low back pain (UMLBP) is the most common cause of low back pain presenting in adolescents, accounting for up to 78% of cases. Spondylolysis/spondylolisthesis is the most common cause with diagnosed pathology observed in this age group. The goals of this study are to: determine the natural history of low back pain, evaluate the value of radiographic studies in establishing a diagnosis of spondylolysis, and determine the cost and radiation effective doses (EDs) associated with those studies with the associated risks radiation exposure. METHODS: A retrospective review of patients records aged 10 to 19 years who presented to our institution with mechanical low back of undiagnosed etiology from January 1, 2000 to January 1, 2008 were identified. Patients with previous back surgery, high-energy trauma, congenital syndromes, or medical comorbidities were excluded. UMLBP was defined as back pain with etiology undetected by examination and imaging. We reviewed the following data: age at presentation, sex, the number of follow-up visits, the total length of follow-up, the type of imaging studies performed, and the results from imaging studies. Age-specific radiation EDs were calculated for 10 to 14.9 years, 15 to 18 years, and adults for plain films, fine cut 2-level L-spine computed tomography (CT) scans, and bone scans (BSs). RESULTS: A total of 2846 patients (63% female) with average age of 14.3 years were identified. A total of 2159 (76%) patients had UMLBP, 61% of that had ≤2 follow-up visits. One hundred and ninety-four patients (7.8%) were diagnosed with spondylolysis; 119 (86%) by plain film, 56 (12.5%) by BSs, and 17 (1.5%) by CTs. Most patients (74%) with spondylolysis had a positive plain film study. There was no significant difference between 2-view (anterior-posterior, lateral) and 4-view (anterior-posterior, lateral, right oblique, left oblique) studies in sensitivity (78% vs. 72%, P=0.39). Advanced imaging was pursued in 90/354 (25%) patients with negative plain film studies. The sensitivity of BS for spondylolysis was 84% (73 of 88 BSs were positive). The sensitivity of CT for spondylolysis was 90% (44 of 49 CTs were positive. BSs exposed patients to much more radiation than CTs and plain film studies. CONCLUSIONS: Mechanical low back pain is common in adolescents and in most cases is undiagnosed; most require no imaging and ≤2 office visits. For spondylolysis, 2-view plain films are often diagnostic and oblique views did not add significant value. Advanced imaging increases diagnostic accuracy, but adds to the cost and considerable radiation exposure. Because diagnosis of spondylolysis rarely changes clinical management, physicians should use ionizing radiation studies sparingly in children.

Risk factors and complications in hip reconstruction for nonambulatory patients with cerebral palsy.

BACKGROUND: Hip dysplasia is prevalent in nonambulatory children with cerebral palsy, and may contribute to a decreased quality of life (Lonstein in J Pediatr Orthop 6:521-526, 1). Reconstructive procedures such as a femoral varus derotation osteotomy with or without a pelvic osteotomy are commonly employed with the goal of achieving and maintaining well reduced hips. PURPOSES: The goals of this study are both to characterize the complications of reconstructive procedures and to identify risk factors that may contribute to these complications. PATIENTS AND METHODS: A retrospective analysis was conducted among 61 nonambulatory children (93 hips) with cerebral palsy who underwent a femoral varus derotation osteotomy, with or without an open reduction and/or pelvic osteotomy, from 1992 through 2008 at our institution. The average patient age was 8.1 years (2.6-14.7) and the mean follow-up time was 5.9 years (2.1-15.9). RESULTS: The cumulative complication rate per patient including failures to cure was 47.6 %. Spica casting was found to be a risk factor for all complications (P = 0.023); whereas patients younger than 6 years old (P = 0.013) and children with a tracheostomy (P = 0.004) were found to be risk factors for resubluxation following surgery. CONCLUSIONS: Although reported complication rates of hip reconstructive procedures performed upon children with cerebral palsy have varied considerably, those with more severe disease have experienced more complications. We report our tertiary referral center's complication rate and our institutional experiences with risk factors for complications and failures to cure. LEVEL OF EVIDENCE: IV, Retrospective case series.

Isolated distal radial metaphyseal fractures with an intact ulna: risk factors for loss of reduction.

PURPOSE: The purpose of this study was to determine the risk factors for loss of reduction in patients with an isolated distal radius fracture and intact ulna. METHODS: Outpatient records and initial, post-reduction, and follow-up radiographs of children with displaced distal radial metaphyseal fractures and intact ulnas that required closed reduction and casting at our institution were reviewed for demographic factors, body mass index (BMI), initial fracture displacement, residual displacement after reduction, and 3-point cast index. Loss of reduction was defined as angulation ≥15° in the coronal plane for all ages and/or angulation ≥20° in the sagittal plane for patients ≥11 years of age and ≥30° for children <11 years of age. Additionally, all patients who were remanipulated and/or pinned were considered to have lost reduction. RESULTS: Thirty-five of the 76 patients in our series met the criteria for loss of reduction (46%). Multivariate logistic regression revealed that initial angulation in the coronal plane and post-reduction translation in the coronal plane were independent predictors for loss of reduction. Patients with >11° of initial angulation in the coronal plane were 6.3 times as likely to lose reduction (confidence interval [CI]: 1.43-28.3, P = 0.015) and those with any amount of residual translation in the coronal plane after closed reduction were 7.8 times as likely to lose reduction (CI: 2.5-24.0, P < 0.001). CONCLUSION: Our study, the largest dedicated series of distal radial metaphyseal fractures with intact ulnas, indicates that loss of reduction is common, and that risk factors include initial angulation in the coronal plane and post-reduction translation in the coronal plane.

A method for growing a biofilm under low shear at the air-liquid interface using the drip flow biofilm reactor.

This protocol describes how to grow a Pseudomonas aeruginosa biofilm under low fluid shear close to the air-liquid interface using the drip flow reactor (DFR). The DFR can model environments such as food-processing conveyor belts, catheters, lungs with cystic fibrosis and the oral cavity. The biofilm is established by operating the reactor in batch mode for 6 h. A mature biofilm forms as the reactor operates for an additional 48 h with a continuous flow of nutrients. During continuous flow, the biofilm experiences a low shear as the media drips onto a surface set at a 10 degrees angle. At the end of 54 h, biofilm accumulation is quantified by removing coupons from the reactor channels, rinsing the coupons to remove planktonic cells, scraping the biofilm from the coupon surface, disaggregating the clumps, then diluting and plating for viable cell enumeration. The entire procedure takes 13 h of active time that is distributed over 5 d.