Transosseous Repair of Isolated Posterior Medial Meniscal Root Injuries in Children and Adolescents.

The meniscal roots are critically important for maintaining knee stability, functional load distribution, and proper knee kinematics. Although adult meniscal root injuries have been a topic of increasing research, medial meniscus injuries also occur in pediatric and adolescent patients, with up to 2% of meniscal injuries involving root attachments. The purpose of this Technical Note is to demonstrate the transosseous repair of isolated posterior medial meniscal root injuries in children and adolescents, including tear visualization on magnetic resonance imaging and during arthroscopy, operative technique, and postoperative management.

Pelvic Tilt in Adults With Cerebral Palsy and Its Relationship With Prior Hamstrings Lengthening.

BACKGROUND: Current studies assessing the change in pelvic tilt for ambulatory patients with cerebral palsy (CP) after surgical hamstring lengthening (SHL) lack a comparison cohort without prior SHL and are limited to younger patients. This study presents gait data of middle-aged adults with CP, primarily focusing on the pelvis, and compares pelvic tilt, trunk tilt, and knee flexion between those with and without prior SHL. MATERIALS AND METHODS: A consecutive series of 54 adults with CP, a mean age of 36±13 years, and Gross Motor Function Classification System (GMFCS) levels I-III were included. Thirty-two (59%) had SHL performed at a mean age of 8±5 years. Three-dimensional gait analysis data prospectively collected at a mean of 28±14 years postoperatively were retrospectively analyzed. Chi-square tests were used to compare demographic and surgical history data and statistical parameter mapping was used to compare knee flexion during stance and pelvic and trunk tilts during the gait cycle between SHL and SHL-naive groups. RESULTS: Age, GMFCS level, sex, race, topography, and ethnicity were not different between the groups (P=.217-.612). Anterior pelvic tilt throughout gait was significantly greater in the SHL group compared with the SHL-naive group (63%-87%; P=.033). This difference was augmented after accounting for other surgical history and revision SHL (0%-32%, P=.019; and 46%-93%, P=.007). CONCLUSION: Within a cohort of adults with CP, GMFCS levels I-III, and a mean age of 36 years, those with a history of SHL, performed a mean of 28 years prior to 3-dimensional gait analysis, walked with increased anterior pelvic tilt compared with those without a history of SHL. [Orthopedics. 202x;4x(x):xx-xx.].

Sagittal spinopelvic alignment in ambulatory persons with cerebral palsy.

PURPOSE: This study aimed to describe the spinopelvic alignment of a cohort of young ambulatory individuals with cerebral palsy (CP) and compare it to published spinopelvic alignment data for the typically developing adolescents. METHODS: Thirty-seven adolescents (18 females) with CP at GMFCS I-III were included in this retrospective case series. Lumbar lordosis and pelvic incidence were measured, and their mismatch was calculated. A model that calculates predicted lumbar lordosis based on pelvic incidence in normative data was utilized to calculate a predicted lumbar lordosis in this cohort with cerebral palsy. RESULTS: At imaging, ages were mean and standard deviation 13.5 ± 3.0 years. Pelvic incidence was 46.2° ± 12.9°, pelvic tilt was 2.8° ± 9.4°, sacral slope was 43.6° ± 10.8°, and measured lumbar lordosis was 59.4° ± 11.6°. There were no differences in pelvic incidence or lumbar lordosis among the GMFCS levels; however, pelvic incidence was higher in females. Pelvic incidence-lumbar lordosis mismatch greater than 10° was found in 67% of the cohort. Mean predicted lumbar lordosis based on the model was 54.7° ± 8.5°, averaging 8° less than measured lordosis. CONCLUSION: PI-LL mismatch was identified in 67% of this cohort of ambulatory adolescents with CP, in part due to greater lordosis than predicted by a model based on data from adolescents without CP. The implications of this finding, such as the correlation between sagittal spinopelvic alignment and quality of life in this population, should be assessed further in ambulatory patients with cerebral palsy. LEVEL OF EVIDENCE: Level IV-retrospective cohort study and literature comparison.

Does Periacetabular Osteotomy Change Sagittal Spinopelvic Alignment?

BACKGROUND: There are few data on the impact of periacetabular osteotomy (PAO) on sagittal spinopelvic alignment. Prior studies have attempted to delineate the relationship by performing measurements on AP radiographs and using mathematical models to determine changes in postoperative pelvic tilt. This information is clinically significant to a surgeon when evaluating acetabular/pelvic position intraoperatively and understanding spinopelvic alignment changes postoperatively; therefore, radiographic changes from PAO should be described in more detail. QUESTIONS/PURPOSES: In this study, we asked: (1) Does the performance of PAO result in consistent changes in spinopelvic alignment, as measured on EOS radiographs? (2) Does this differ for unilateral versus bilateral PAOs? (3) Does this differ in the setting of a mobile spine versus an immobile spine? (4) Does this differ based on preoperative pelvic tilt? METHODS: Mean preoperative and at least 1-year postoperative (15 ± 8 months from surgery, minimum 11 months, maximum 65 months) EOS hip-to-ankle standing and sitting radiographs for 55 patients in a prospectively collected registry who underwent PAO with a single surgeon from January 1, 2019, to January 11, 2022, were measured for pelvic incidence, pelvic tilt, sacral slope, lumbar lordosis, lateral center-edge angle, L1 pelvic angle, and pubic symphysis to the sacroiliac index. Normality was assessed and paired sample t-tests (normally distributed data) or Wilcoxon signed rank tests (not normally distributed data) were utilized to assess if any measurements changed from preoperative to postoperative. Patients were then divided based on whether they had unilateral or bilateral dysplasia and unilateral or bilateral surgery, and these subgroups were analyzed the same way as the entire cohort. Two more subgroups were then formed based on lumbar mobility, defined as a change in sitting-to-standing lumbar lordosis less or greater than 1 SD from the population mean preoperatively, and the subgroups were analyzed the same way as the entire cohort. Finally, two additional subgroups were formed, preoperative standing pelvic tilt less than 10° and more than 20°, and analyzed the same as the entire cohort. RESULTS: For the entire cohort, the median (IQR) standing lateral-center edge angle increased 17°, from a median of 21° (10°) to a median of 38° (8° [95% confidence interval (CI) 16° to 20°; p < 0.001). The median sitting lateral center-edge angle increased 17°, from a median of 18° (8°) to a median of 35° (8° [95% CI 14° to 19°]; p < 0.001). Standing pelvic incidence increased from 50° ± 11° to 52° ± 12° (mean difference 2° [95% CI 1° to 3°]; p = 0.004), but there were no changes for other measured parameters. There were no changes in any of the spinopelvic parameters for patients with unilateral dysplasia receiving a unilateral PAO, but patients with bilateral dysplasia who underwent bilateral PAOs demonstrated an increase in pelvic incidence from 57° (14°) to 60° (16°) (95% CI 1° to 5°; p = 0.02) and a decrease in pubic symphysis to sacroiliac index from 84 mm (24 mm) to 77 mm (23 mm) (95% CI -7° to -2°; p = 0.007). Patients with mobile lumbar spines preoperatively did not exhibit any changes in sagittal spinopelvic alignment, but patients with immobile lumbar spines preoperatively experienced several changes after surgery. Patients with less than 10° of standing pelvic tilt demonstrated a median (IQR) 2° increase in pelvic incidence from median 43° (9°) to 45° (12° [95% CI 0.3° to 4°]; p = 0.03), but they did not experience any other changes in sagittal spinopelvic alignment parameters postoperatively. Patients with preoperative pelvic tilt more than 20° did not experience any change in sagittal spinopelvic parameters. CONCLUSION: PAO increases pelvic incidence, potentially because of anterior translation of the hip center. There were no changes in other spinopelvic parameters postoperatively except after bilateral PAO. Additionally, patients lacking spine mobility preoperatively, indicated by a minimal change in lumbar lordosis between standing and sitting positions, may experience several changes in spinopelvic alignment, including increased mobility of their spine after PAO. This may be because of decreased compensatory spine splinting after increasing acetabular coverage, but further research including patient-reported outcomes is warranted. LEVEL OF EVIDENCE: Level III, therapeutic study.

Exploring Correlations Between Pain and Deformity in Idiopathic Scoliosis With Validated Self-reported Pain Scores, Radiographic Measurements, and Trunk Surface Topographic Measurements.

BACKGROUND: Up to 75% of patients with idiopathic scoliosis (IS) report back pain, but the exact contributors are unclear. This study seeks to assess how pain correlates with demographics, radiographic and surface topographic (ST) measurements, and patient-reported outcome measures (PROMs) in patients with IS. METHODS: Patient-Reported Outcome Measurement Information System (PROMIS) Pain Interference (PI) and Scoliosis Research Society revised (SRS-22r) pain domain from an IRB approved prospectively collected registry containing patients 11 to 21 years old with IS were correlated (Spearman coefficients) with measurements from whole-body EOS radiography and ST scanning, PROMIS 1.0 PROMs, Trunk Appearance Perception Scale (TAPS), and SRS-22r domains. SRS-22r and PROMIS-PI were also compared between different sex, scoliosis severities, and primary curve locations with Mann-Whitney U or Kruskal-Wallis tests, and if significant differences were found, included with the 5 highest univariate correlated variables into stepwise multivariate linear regression models ( P <0.05 to enter, P >0.1 to remove) predicting SRS-22r pain and PROMIS-PI. RESULTS: One hundred and forty-nine patients (14.5 ± 2.0 y, body mass index 20.6 ± 4.1 kg/m 2 , 96 (64%) female, mean major coronal curve 40 ± 19 deg, range: 10 deg, 83 deg) reported mean PROMIS-PI of 42.2 ± 10.0 and SRS-22r pain of 4.4 ± 0.6. SRS-22r self-image was the most correlated variable with both SRS-22r pain (rho=0.519) and PROMIS-PI (rho=-0.594). Five variables, none of which were ST or radiographic measures, strongly predicted SRS pain domain (R=0.711, R2=0.505, N=138). Two variables (SRS-22r self-image and SRS-22r function) were utilized by a model correlated with PROMIS-PI (R=0.687, R2=0.463, N=124). CONCLUSIONS: SRS-22r function and self-image domains were more strongly correlated with SRS-22r pain and PROMIS-PI than any radiographic or ST measurements. LEVEL OF EVIDENCE: Level II-retrospective study.

Validation of the ACL-RSI Scale in Pediatric and Adolescent Patients.

BACKGROUND: The Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) scale is a 12-item questionnaire assessing psychological readiness to return to sport after anterior cruciate ligament reconstruction. It has been validated for use in adults in multiple languages and in an abbreviated 6-question short form. Additionally, literature has been published using this scale in pediatric and adolescent populations, however it has not yet been validated for use with them. PURPOSE: To validate the ACL-RSI scale for use with pediatric and adolescent patients. STUDY DESIGN: Cohort study (Diagnosis); Level of evidence, 2. METHODS: Scores of 6- and 12-item ACL-RSI scales for patients undergoing return-to-sport readiness testing 6 to 8 months after anterior cruciate ligament reconstruction were analyzed. Convergent validity testing was performed against the International Knee Documentation Committee (IKDC)/Pediatric IKDC score, Single Assessment Numeric Evaluation (SANE) score, and peak torque asymmetry of knee flexion and extension using Spearman correlations. Discriminant validity testing was performed against age (Spearman correlation), body mass index (Spearman correlation), and sex (Mann-Whitney U test). Reliability testing was performed by calculating Cronbach's alpha. Floor and ceiling effects were assessed by calculating the number of minimum and maximum scores in the cohort. RESULTS: A total of 51 patients were included in the final analysis. The mean age at surgery was 15.2 ± 2.2 years, and 51.0% were female. The 6- and 12-item ACL-RSI scales demonstrated a strong significant positive correlation with IKDC/Pediatric IKDC scores (R = 0.723 and 0.717, respectively; P < .001) and moderate significant positive correlation with Single Assessment Numeric Evaluation scores (R = 0.516 and 0.502, respectively; P < .001) Age at surgery, body mass index, and sex were not correlated with either ACL-RSI scale. Cronbach's alpha values of the 12- and 6-item ACL-RSI scales in this population were 0.959 and 0.897, respectively. For both the 12- and the 6-item ACL-RSI scales, no floor or ceiling effects were found as the minimum score (0) was not observed in either version, and the maximum score (100) was only observed twice (3.9%) in both versions. CONCLUSION: The ACL-RSI scale is valid to use with pediatric and adolescent patients. The 6-item scale may be a better choice because it has fewer redundancies and minimizes the risk of questionnaire fatigue.

Changes in height, weight, and body mass index after posterior spinal fusion in juvenile and adolescent idiopathic scoliosis.

Purpose: Posterior spinal fusion for idiopathic scoliosis is known to increase spinal height, but the impacts on weight and resulting body mass index are unknown. This study assesses body mass index, weight, and height percentile changes over time after posterior spinal fusion for idiopathic scoliosis. Methods: Body mass index, weight, and height age- and sex-adjusted percentiles for patients with idiopathic scoliosis undergoing posterior spinal fusion between January 2016 and August 2022 were calculated based on growth charts from the Centers for Disease Control for Disease Control and compared to preoperative values at 2 weeks, 3 months, 6 months, 1 year, and 2 years. The data were analyzed for normality with a Shapiro-Wilk test, and percentiles were compared with the Wilcoxon signed-rank tests. Results: On average, 12.1 ± 2.3 levels were fused in 269 patients 14.4 ± 1.9 years, and percentiles for body mass index, weight, and height preoperatively were 55.5 ± 29.4%, 57.5 ± 28.9%, and 54.6 ± 30.4%, respectively. Body mass index and weight percentiles decreased at 2 weeks (-10.7%, p < 0.001; -4.6%, p < 0.001, respectively) and 3 months (-6.9%, p < 0.001; -3.2%, p < 0.001, respectively) postoperatively. Postoperative weight loss at 2 weeks averaged 2.25 ± 3.09% of body weight (0.98 ± 4.5 kg), normalizing by 3 months. Body mass index percentile normalized at 1 year, but height percentile was increased at 2 weeks (2.42 ± 1.72 cm, p < 0.001) and through 2 years. Conclusion: Despite initial height increase due to deformity correction, acute postoperative weight and body mass index percentile decreases postoperatively normalize by 1-year body mass index percentile. Physicians may benefit from utilizing this information when discussing the postoperative course of posterior spinal fusion with idiopathic scoliosis. Level of evidence: 4, Retrospective Case Series.

The Perils of Sleeper Plates in Multiple Hereditary Exostosis: Tibial Deformity Overcorrection Due to Tether at Empty Metaphyseal Hole.

BACKGROUND: Hemi-epiphysiodesis is the mainstay of treatment for angular deformities at the knee in children with multiple hereditary exostosis (MHE). Upon deformity correction, the metaphyseal screw may be removed from the hemi-epiphysiodesis plate, the sleeper plate technique, with anticipated reimplantation of the metaphyseal screw should the original deformity recur. The aim of the present study is to compare the incidence of complications with the sleeper plate technique with complete plate removal in an MHE cohort. METHODS: Patients under the age of 18 with MHE who underwent hemi-epiphysiodesis of the proximal tibia and/or distal femur between February 1, 2016, and February 6, 2022 with a minimum 2-year follow-up or follow-up to skeletal maturity were identified via ICD-10 codes. Patient charts and radiographic images were reviewed to assess for the bone(s) treated, the use of sleeper plates, and whether any complication occurred, including overcorrection from bony ingrowth at the empty holes or deformity recurrence. RESULTS: In 13 patients, 19 knees underwent hemi-epiphysiodesis at 30 sites; 13 distal femoral and 17 proximal tibial. Of 30 plates, 18 (60%) were removed completely upon deformity correction and 3 (10%) did not require removal due to skeletal maturity. Four of 13 (30.8%) femoral plates and 5 of 17 (29.4%) tibial plates were left as sleeper plates. All 5 tibial sleeper plates developed bony ingrowth into the empty metaphyseal screw hole, which led to unintended progressive deformity overcorrection. In the majority of cases, the deformity was addressed by the removal of the plate and exophytic bone and hemi-epiphysiodesis on the other side of the affected proximal tibia with subsequent resolution of the deformity. CONCLUSIONS: All tibial sleeper plates developed bony ingrowth into the screwless metaphyseal hole. The bony ingrowth functioned as a tether, resulting in progressive deformity overcorrection. Sleeper plates should be avoided at the proximal tibia in patients with MHE, and extreme caution should be exercised when considering this technique at the distal femur or other sites. LEVELS OF EVIDENCE: Level III-retrospective comparative study.

Posterior Cruciate Ligament Femoral Avulsion Fractures in Pediatric Patients: A Report of 2 Interesting Surgical Cases.

CASE: This report describes 2 cases of femoral-sided posterior cruciate ligament (PCL) avulsion injuries. A 10-year-old male patient presented with a chronic nonunion of a bony PCL femoral avulsion. In addition, a 4-year-old boy presented with an acute, displaced PCL femoral avulsion off the medial femoral condyle. Both injuries were repaired using arthroscopic techniques. CONCLUSION: Femoral-sided PCL avulsions are very rare in pediatric patients and have not been reported often. We hope to increase the awareness of PCL femoral avulsion injuries in pediatric patients by describing 2 unique cases.

Extension of Tibial Spine Fractures Beyond the Tibial Spine: An MRI Analysis of 54 Patients.

BACKGROUND: To the authors' knowledge, no previous study has thoroughly described the anteroposterior dimensions of tibial spine fractures (TSFs) on 3-dimensional imaging. The extension of TSFs into weightbearing regions of the tibial plateau, posterior extension within the epiphysis, and potential association between fracture size and patient age may have implications for treatment strategies and clinical outcomes. HYPOTHESIS: TSF fragments would commonly involve weightbearing regions of the tibial plateau, would be larger in younger patients, and would extend more posteriorly than the anatomic footprint of the tibial spine. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Consecutive magnetic resonance imaging studies obtained between 2012 and 2020 in patients 5 to 18 years of age at the time of imaging for TSFs were included, measured, and classified via the Green and Tuca grading system. Anteroposterior fracture dimensions were measured and normalized to anteroposterior midepiphyseal length, as was fracture height to epiphyseal height. Extension into the weightbearing surface of the tibial plateau was recorded. Intraclass correlation coefficient and kappa values were calculated. Mean fracture bed size was compared using independent-samples t tests between older and younger patients based on median age and sex. RESULTS: Of 54 TSFs, 1 (2%), 28 (52%), and 25 (46%) were grades 1, 2, and 3, respectively. Fracture beds spanned 45% of the anteroposterior midepiphysis, and 54% of the TSF beds extended to the posterior third of the epiphysis. Younger and female patients, on average, had larger anteroposterior dimensions to TSF beds (P = .018 and .006, respectively). The medial and lateral weightbearing surfaces of the tibial plateau were affected 57% and 25% of the time, respectively. CONCLUSION: This study demonstrated that TSF beds were larger in younger patients, extended to the posterior third of the epiphysis in 54% of cases, and should be examined carefully for extension into weightbearing regions of the tibial plateau. In pediatric patients, the TSF often involves more of the tibial plateau than the anatomic footprint of the tibial spine, and clinicians should be aware of the potential for extension posteriorly and into the weightbearing surfaces.

Advances in robotics and pediatric spine surgery.

PURPOSE OF REVIEW: Robotic-assisted surgical navigation for placement of pedicle screws is one of the most recent technological advancements in spine surgery. Excellent accuracy and reliability results have been documented in the adult population, but adoption of robotic surgical navigation is uncommon in pediatric spinal deformity surgery. Pediatric spinal anatomy and the specific pediatric pathologies present unique challenges to adoption of robotic assisted spinal deformity workflows. The purpose of this article is to review the safety, accuracy and learning curve data for pediatric robotic-assisted surgical navigation as well as to identify "best use" cases and technical tips. RECENT FINDINGS: Robotic navigation has been demonstrated as a safe, accurate and reliable method to place pedicle screws in pediatric patients with a moderate learning curve. There are no prospective studies comparing robotically assisted pedicle screw placement with other techniques for screw placement, however several recent studies in the pediatric literature have demonstrated high accuracy and safety as well as high reliability. In addition to placement of pediatric pedicle screws in the thoracic and lumbar spine, successful and safe placement of screws in the pelvis and sacrum have also been reported with reported advantages over other techniques in the setting of high-grade spondylolisthesis as well as pelvic fixation utilizing S2-alar iliac (S2AI) screws. SUMMARY: Early studies have demonstrated that robotically assisted surgical navigation for pedicle screws and pelvic fixation for S2AI screws is safe, accurate, and reliable in the pediatric population with a moderate learning curve.