MRI findings of peroneal tendon tears do not necessarily correlate to clinical findings in paediatric and adolescent patients.

PURPOSE: Pathologic abnormality of the peroneal tendons are thought to be an under-appreciated source of vague ankle and hindfoot pain in paediatric patients, partly because they can be difficult to diagnose and differentiate from lateral ankle ligament injuries. While magnetic resonance imaging (MRI) is the primary imaging modality used to detect peroneal tendon pathology, previous studies in adults have found that positive MRIs demonstrate a positive predictive value (PPV) of associated clinical findings around 48%. There are no similar known published studies in the paediatric population. Our objective was to determine the positive predictive value of peroneal tendon pathology as diagnosed by MRI as related to positive clinical exam findings in the paediatric and adolescent population. METHODS: This IRB approved retrospective study was conducted at a tertiary children's hospital. Inclusion criteria included patients under 18 years from our tertiary care institution with (a) ankle MRI findings indicating pathology of the peroneus brevis/longus tendons confirmed by a board certified paediatric musculoskeletal radiologist and (b) formal review of the clinical examination by a fellowship trained paediatric orthopaedic surgeon. Patients with congenital deformities or previous surgical intervention of the lateral ankle were excluded. RESULTS: Forty-seven patients (with 48 MRIs) met inclusion criteria over a ten year period. The majority of the positive MRI scans (70%) demonstrated a peroneus brevis split tear. Of the patients with positive findings on MRI, 17 patients had an associated positive clinical exam. The positive predictive value of MRI for peroneal tendon tears with positive clinical findings was 35.41% (95% confidence interval = 31.1% to 41.6%). There were 31 patients with MRI positive findings with a negative clinical exam. CONCLUSION: Despite having a negative clinical exam, a high percentage of patients had positive MRI findings suggestive of peroneal tendon pathology which confirms findings of adult populations demonstrating a high rate of incidental finding of peroneal tendon pathology on MRI in paediatric patients.

Skeletal Maturity Is Associated With Increased Meniscal and Chondral Pathology in Patients Under 21 Years of Age Undergoing Primary Anterior Cruciate Ligament Reconstruction Within 6 Months of Injury.

PURPOSE: To compare injury profiles of meniscal and/or chondral injury in skeletally mature (SM) with immature (SI) patients undergoing primary anterior cruciate ligament reconstruction (ACLR). METHODS: Current Procedural Terminology code 29888 was queried from January 2012 to April 2020. Patients younger than 22 years who underwent primary ACLR within 6 months of injury were included. Exclusion criteria included age older than 22 years, treatment after 6 months, revision ACLR, concurrent osteotomy, or multiligamentous injury. All patients required a minimum 1-year follow-up. Demographics and intraoperative pathology were recorded. Data were analyzed for factors affecting intra-articular injury and stratified by sport. RESULTS: Of 927 patients (739 SM, 188 SI), the mean age was 16.63 and 14.00 years for the SM and SI cohorts, respectively (P < .001). There were more SM males (51.4%) compared to SI males (81.9%) (P < .001); however, in univariate analysis, sex did not significantly affect the rates of meniscal (P = .519) or chondral injury (P = .961). In total, 887 meniscal injuries were recorded (344 medial, 543 lateral) in 659 patients. SM sustained greater rates of medial meniscal tear (MMT) (P < .001) and underwent higher rates of partial meniscectomy (P = .022). Male sex conferred meniscal injury (95% confidence interval [CI], 0.43-0.81; P = .001). Body mass index prognosticated medial meniscal (95% CI, 1.01-1.06; P = .002) and medial chondral injuries (95% CI, 1.02-1.09; P < .001). Skeletal maturity was a superior predictor of intra-articular pathology than age for all outcomes: MMT (95% CI, 0.00-0.06; P = .002), lateral meniscal tear (95% CI, 0.00-0.75; P = .034), and chondral injury (95% CI, 0.00-0.49; P = .049). In sport subanalysis, soccer anterior cruciate ligament (ACL) injuries were most common (32.6%). Soccer and basketball athletes were more likely SM (P = .016, P = .003 respectively) with increased medial compartment pathology. Football ACL injuries occurred significantly in SI athletes (P = .001) via contact mechanisms (P = .025). CONCLUSIONS: Skeletal maturity affects the meniscal and chondral injury profile in ACL-injured patients. SM patients have greater risk of sustaining concomitant meniscal injury, while chondral injury profile depends more on the mechanism of injury. Mechanism of injury and skeletal maturity status affect risk of sports-related ACL rupture and ACL-concurrent pathology in young patients. Patient-specific variables influence injury profiles within each sport. Skeletal maturity rather than age predicts concomitant intra-articular injury risk. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Tibial Spine Fractures in the Child and Adolescent Athlete: A Systematic Review and Meta-analysis.

BACKGROUND: Tibial spine fractures (TSFs) are uncommon injuries that may result in substantial morbidity in children. A variety of open and arthroscopic techniques are used to treat these fractures, but no single standardized operative method has been identified. PURPOSE: To systematically review the literature on pediatric TSFs to determine the current treatment approaches, outcomes, and complications. STUDY DESIGN: Meta-analysis; Level of evidence, 4. METHODS: A systematic review of the literature was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) guidelines using PubMed, Embase, and Cochrane databases. Studies evaluating treatment and outcomes of patients <18 years old were included. Patient demographic characteristics, fracture characteristics, treatments, and outcomes were abstracted. Descriptive statistics were used to summarize categorical and quantitative variables, and a meta-analytic technique was used to compare observational studies with sufficient data. RESULTS: A total of 47 studies were included, totaling 1922 TSFs in patients (66.4% male) with a mean age of 12 years (range, 3-18 years). The operative approach was open reduction and internal fixation in 291 cases and arthroscopic reduction and internal fixation in 1236 cases; screw fixation was used in 411 cases and suture fixation, in 586 cases. A total of 13 nonunions were reported, occurring most frequently in Meyers and McKeever type III fractures (n = 6) and in fractures that were treated nonoperatively (n = 10). Arthrofibrosis rates were reported in 33 studies (n = 1700), and arthrofibrosis was present in 190 patients (11.2%). Range of motion loss occurred significantly more frequently in patients with type III and IV fractures (P < .001), and secondary anterior cruciate ligament (ACL) injury occurred most frequently in patients with type I and II fractures (P = .008). No statistically significant differences were found with regard to rates of nonunion, arthrofibrosis, range of motion loss, laxity, or secondary ACL injury between fixation methods (screw vs suture). CONCLUSION: Despite variation in TSF treatment, good overall outcomes have been reported with low complication rates in both open and arthroscopic treatment and with both screw and suture fixation. Arthrofibrosis remains a concern after surgical treatment for TSF, but no significant difference in incidence was found between the analysis groups. Larger studies are necessary to compare outcomes and form a consensus on how to treat and manage patients with TSFs.

Anterior Displacement of Tibial Spine Fractures: Does Anatomic Reduction Matter?

Background: Operative treatment of displaced tibial spine fractures consists of fixation and reduction of the fragment in addition to restoring tension of the anterior cruciate ligament. Purpose: To determine whether residual displacement of the anterior portion of a tibial spine fragment affects the range of motion (ROM) or laxity in operatively and nonoperatively treated patients. Study Design: Cohort study; Level of evidence, 3. Methods: Data were gathered from 328 patients younger than 18 years who were treated for tibial spine fractures between 2000 and 2019 at 10 institutions. ROM and anterior lip displacement (ALD) measurements were summarized and compared from pretreatment to final follow-up. ALD measurements were categorized as excellent (0 to <1 mm), good (1 to <3 mm), fair (3 to 5 mm), or poor (>5 mm). Posttreatment residual laxity and arthrofibrosis were assessed. Results: Overall, 88% of patients (290/328) underwent operative treatment. The median follow-up was 8.1 months (range, 3-152 months) for the operative group and 6.7 months (range, 3-72 months) for the nonoperative group. The median ALD measurement of the cohort was 6 mm pretreatment, decreasing to 0 mm after treatment (P < .001). At final follow-up, 62% of all patients (203/328) had excellent ALD measurements, compared with 5% (12/264) before treatment. Subjective laxity was seen in 11% of the nonoperative group (4/37) and 5% of the operative group (15/285; P = .25). Across the cohort, there was no association between final knee ROM and final ALD category. While there were more patients with arthrofibrosis in the operative group (7%) compared with the nonoperative group (3%) (P = .49), this was not different across the ALD displacement categories. Conclusion: Residual ALD was not associated with posttreatment subjective residual laxity, extension loss, or flexion loss. The results suggest that anatomic reduction of a tibial spine fracture may not be mandatory if knee stability and functional ROM are achieved.

Posterior Root Tears of the Lateral Meniscus Only Affect Tibiofemoral Contact Forces when the Meniscofemoral Ligament Is Involved: A Cadaveric Study.

Purpose: The objective of this study was to examine the impact of progressive radial tears in the lateral meniscal root on the lateral compartment contact forces and joint surface area through a range of motion of knee and evaluate the role of the meniscofemoral ligament (MFL) in preventing adverse tibiofemoral joint forces. Methods: Ten fresh frozen cadaveric knees were tested using 6 experimental conditions (0% lateral meniscal posterior root tear, 25% tear, 50% tear, 75% tear, 100% tear, 100% tear and resection of MFL) at five flexion angles (0°, 30°, 45°, 60°, and 90°) under 100-1,000-N axial load. Contact joint pressure and lateral compartment surface area were measured using Tekscan sensors. Statistical analysis, including descriptive, ANOVA, and post hoc Tukey analysis, was performed. Results: Progressive radial tears of the lateral meniscal root were not associated with an increase in tibiofemoral contact pressure or decrease in lateral compartment surface area. Complete lateral root tear and resection of MFL were associated with increased joint contact pressure (P < .001) at knee flexion angles of 30, 45, 60, and 90° and decreased lateral compartment surface (P < .001) at all knee flexion angles area compared to complete lateral meniscectomy alone. Conclusion: Isolated complete tears of lateral meniscus root and progressive radial tears of the lateral meniscus posterior root were not associated with any change to tibiofemoral contact forces. However, additional resection of the MFL increased contact pressure and decreased lateral compartment surface area.

Medial Discoid Meniscus in Children: A Multicenter Case Series of Clinical Features and Operative Results.

BACKGROUND: The discoid medial meniscus is a rare congenital anomaly of the knee. The literature is limited to small case series. PURPOSE/HYPOTHESIS: Our purpose is to report the clinical manifestations and operative treatments of discoid medial menisci in children from multiple centers in North America. We hypothesized that symptoms and signs, arthroscopic findings, surgical treatments, and outcomes are similar to those for symptomatic discoid lateral menisci. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective review identified patients with a diagnosed discoid medial meniscus confirmed at surgery across 8 children's hospitals between January 2000 and June 2021. The literature on discoid lateral menisci was reviewed and summarized for comparison. RESULTS: A total of 21 patients (9 female, 12 male) with 22 discoid medial menisci were identified. The mean ± SD age at the time of diagnosis was 12.8 ± 3.8 years. The most common symptoms and signs were locking and/or clunking, present in 12 of 22 knees (55%), similar to that reported in patients with discoid lateral menisci. Twelve discoid medial menisci were complete (55%); 8, incomplete (36%); and 2, indeterminate (9%). Tears were present in 13 knees, most commonly horizontal cleavage (54%). Five discoid medial menisci were unstable (23%): 3 for posterior tears and 2 for rim insufficiency. All 22 knees underwent arthroscopic saucerization, and of the 13 torn menisci, 7 (54%) were repaired. The median follow-up was 24 months (range, 2-82 months). Four knees underwent reoperation. All knees that required reoperation had undergone repair for a posteriorly located tear. There was a significant association between operative repair and need for reoperation (P = .0048). High rates of peripheral instability were also noted in case series of patients with discoid lateral menisci. CONCLUSION: Patient presentations and treatments for those with discoid medial menisci were similar to those reported for patients with discoid lateral menisci. Knees with discoid medial menisci also demonstrated instability attributed to peripheral insufficiency and posterior tears. Tears were present in over half of knees with discoid medial menisci, and reoperation was more common in knees that underwent repair of tears than those without repair.

An assessment of the diagnosis, treatment, and outcomes of lower extremity stress fractures in pediatric and adolescent populations.

OBJECTIVES: To present one of the first descriptive case series of pediatric and adolescent lower extremity stress injuries, their management, and outcomes in athletes and non-athletes. METHODS: The IRB-approved retrospective study included patients under 18 years at a tertiary children's hospital who were diagnosed with a lower extremity stress fracture/reaction. Demographic data, mechanism of injury, physical exam, radiographic findings, treatment, & outcomes were collected. Descriptive statistical analysis was conducted. RESULTS: Ninety-seven patients with stress injuries on clinical exams and on radiographs or MRI were included. The average age when diagnosed was 11.7 years (range 1.1-18 years) and the most common injuries were to the tibia (n = 33, 28.4%) and the least common involved were the cuneiforms (n = 4, 3.4%). Patients under the age of 14 were more likely to experience cuboid and calcaneal stress injuries (mean age 5.5 and 8.3 years respectively). Nineteen patients (19.6%) had high-risk stress fractures, with the average age of 14.9 years versus 11.6 for those with low risk (p-value = 0.01) and return to activity time being 15 weeks compared to 10.5 (p-value = 0.027). The most common forms of treatment were controlled ankle motion (CAM), walker boots (58.6%), and physical therapy (PT) (38.1%). The mean Lower Extremity Function Score of the patient population was 73.8, indicating no clinically important difference from full functionality. CONCLUSION: Lower extremity stress injuries in this cohort were most seen in the tibia, although patients younger than 14 had a high number of cuboid and calcaneal stress injuries. Those with high-risk stress fractures were older and took longer to recover from when compared to low-risk injuries. Treatment is commonly conservative, with CAM boots and PT being the most frequently utilized interventions and serving as a successful approach to treatment, with patients returning to activity at an average of 11.4 weeks, which is comparable to similar studies.

Tibial Spine Fractures in Young Athletes.

Tibial spine fractures are a relatively rare injury in the young athlete. Previously thought to be the equivalent of a "pediatric anterior cruciate ligament (ACL) tear," contemporary understanding of these injuries classifies them as distinct from ACL injuries in this patient population. Successful treatment hinges on accurate diagnosis paying special attention to fracture displacement and the presence of concomitant intraarticular injury. Surgery can be performed using open or arthroscopic techniques and a variety of fixation options. The most common complication after surgical treatment is arthrofibrosis and, therefore, stable fixation is necessary to allow for early, unimpeded knee motion postoperatively.

Is Nonoperative Treatment Appropriate for All Patients With Type 1 Tibial Spine Fractures? A Multicenter Study of the Tibial Spine Research Interest Group.

Background: Type 1 tibial spine fractures are nondisplaced or ≤2 mm-displaced fractures of the tibial eminence and anterior cruciate ligament (ACL) insertion that are traditionally managed nonoperatively with immobilization. Hypothesis: Type 1 fractures do not carry a significant risk of associated injuries and therefore do not require advanced imaging or additional interventions aside from immobilization. Study Design: Case series; Level of evidence, 4. Methods: We reviewed 52 patients who were classified by their treating institution with type 1 tibial spine fractures. Patients aged ≤18 years with pretreatment plain radiographs and ≤ 1 year of follow-up were included. Pretreatment imaging was reviewed by 4 authors to assess classification agreement among the treating institutions. Patients were categorized into 2 groups to ensure that outcomes represented classic type 1 fracture patterns. Any patient with universal agreement among the 4 authors that the fracture did not appear consistent with a type 1 classification were assigned to the type 1+ (T1+) group; all other patients were assigned to the true type 1 (TT1) group. We evaluated the rates of pretreatment imaging, concomitant injuries, and need for operative interventions as well as treatment outcomes overall and for each group independently. Results: A total of 48 patients met inclusion criteria; 40 were in the TT1 group, while 8 were in the T1+ group, indicating less than universal agreement in the classification of these fractures. Overall, 12 (25%) underwent surgical treatment, and 12 (25%) had concomitant injuries. Also, 8 patients required additional surgical management including ACL reconstruction (n = 4), lateral meniscal repair (n = 2), lateral meniscectomy (n = 1), freeing an incarcerated medial meniscus (n = 1), and medial meniscectomy (n = 1). Conclusion: The classification of type 1 fractures can be challenging. Contrary to prior thought, a substantial number of patients with these fractures (>20%) were found to have concomitant injuries. Overall, surgical management was performed in 25% of patients in our cohort.

Interobserver and Intraobserver Agreement are Unsatisfactory When Determining Abstract Study Design and Level of Evidence.

BACKGROUND: Understanding differences between types of study design (SD) and level of evidence (LOE) are important when selecting research for presentation or publication and determining its potential clinical impact. The purpose of this study was to evaluate interobserver and intraobserver reliability when assigning LOE and SD as well as quantify the impact of a commonly used reference aid on these assessments. METHODS: Thirty-six accepted abstracts from the Pediatric Orthopaedic Society of North America (POSNA) 2021 annual meeting were selected for this study. Thirteen reviewers from the POSNA Evidence-Based Practice Committee were asked to determine LOE and SD for each abstract, first without any assistance or resources. Four weeks later, abstracts were reviewed again with the guidance of the Journal of Bone and Joint Surgery (JBJS) LOE chart, which is adapted from the Oxford Centre for Evidence-Based Medicine. Interobserver and intraobserver reliability were calculated using Fleiss' kappa statistic (k). χ2 analysis was used to compare the rate of SD-LOE mismatch between the first and second round of reviews. RESULTS: Interobserver reliability for LOE improved slightly from fair (k=0.28) to moderate (k=0.43) with use of the JBJS chart. There was better agreement with increasing LOE, with the most frequent disagreement between levels 3 and 4. Interobserver reliability for SD was fair for both rounds 1 (k=0.29) and 2 (k=0.37). Similar to LOE, there was better agreement with stronger SD. Intraobserver reliability was widely variable for both LOE and SD (k=0.10 to 0.92 for both). When matching a selected SD to its associated LOE, the overall rate of correct concordance was 82% in round 1 and 92% in round 2 (P<0.001). CONCLUSION: Interobserver reliability for LOE and SD was fair to moderate at best, even among experienced reviewers. Use of the JBJS/Oxford chart mildly improved agreement on LOE and resulted in less SD-LOE mismatch, but did not affect agreement on SD. LEVEL OF EVIDENCE: Level II.

All-epiphyseal versus trans-epiphyseal screw fixation for tillaux fractures: Does it matter?

BACKGROUND: Tillaux fractures occur primarily in adolescents due to the pattern of physeal closure and are classified as Salter-Harris type III physeal fractures. Operative management with screw fixation is recommended for more than 2 mm of displacement or more than 1 mm of translation. However, the efficacy and complications of trans-physeal vs all-physeal screw fixation have not been investigated extensively. AIM: To compare the clinical and functional outcomes of trans-physeal (oblique) and all-epiphyseal (parallel) screw fixation in management of Tillaux fractures among pediatric patients. METHODS: This was an ethics board approved retrospective review of pediatric patients who presented to our tertiary children's care facility with Tillaux fractures. We included patients who had surgical fixation of a Tillaux fracture over a 10 year period. Data analysis included demographics, mode of injury, management protocols, and functional outcomes. The patients were divided into group 1 (oblique fixation) and group 2 (parallel fixation). Baseline patient characteristics and functional outcomes were compared between groups. Statistical tests to evaluate differences included Fisher's Exact or Chi-squared and independent samples t or Mann Whitney tests for categorical and continuous variables, respectively. RESULTS: A total of 42 patients (28 females and 14 males) were included. There were no significant differences in body mass index, sex, age, or time to surgery between the groups [IK2]. Sports injuries accounted for 61.9% of the cases, particularly non-contact (57.1%) and skating (28.6%) injuries. Computed Tomography (CT) scan was ordered for 28 patients (66.7%), leading to diagnosis confirmation in 17 patients and change in management plan in 11 patients. [GRC3] Groups 1 and 2 consisted of 17 and 25 patients, respectively. For mid to long-term functional outcomes, there were 14 and 10 patients in groups 1 and 2, respectively. Statistical analysis revealed no significant differences in the functional outcomes, pain scores, or satisfaction between groups. No infections, non-unions, physeal arrest, or post-operative ankle deformities were reported. Two (4.8%) patients had difficulty returning to sports post-surgery due to pain. One was a dancer, and the other patient had pain while running, which led to hardware removal. Both patients had parallel fixation. Hardware removal for groups 1 and 2 were 4 (23.5%) and 5 (20.0%) patients, respectively. The reasons for removal was pain in 2 patients, and parental preference in the remaining. CONCLUSION: This is the largest reported series of pediatric patients with Tillaux fractures comparing functional outcomes of different methods of screw fixation orientation to the physis, which showed no difference regarding functional outcomes.

What Are the Causes and Consequences of Delayed Surgery for Pediatric Tibial Spine Fractures? A Multicenter Study.

Background: The uncommon nature of tibial spine fractures (TSFs) may result in delayed diagnosis and treatment. The outcomes of delayed surgery are unknown. Purpose: To evaluate risk factors for, and outcomes of, delayed surgical treatment of pediatric TSFs. Study Design: Cohort study; Level of evidence, 3. Methods: The authors performed a retrospective cohort study of TSFs treated surgically at 10 institutions between 2000 and 2019. Patient characteristics and preoperative data were collected, as were intraoperative information and postoperative complications. Surgery ≥21 days after injury was considered delayed based on visualized trends in the data. Univariate analysis was followed by purposeful entry multivariate regression to adjust for confounders. Results: A total of 368 patients (mean age, 11.7 ± 2.9 years) were included, 21.2% of whom underwent surgery ≥21 days after injury. Patients who experienced delayed surgery had 3.8 times higher odds of being diagnosed with a TSF at ≥1 weeks after injury (95% CI, 1.1-14.3; P = .04), 2.1 times higher odds of having seen multiple clinicians before the treating surgeon (95% CI, 1.1-4.1; P = .03), 5.8 times higher odds of having magnetic resonance imaging (MRI) ≥1 weeks after injury (95% CI, 1.6-20.8; P < .007), and were 2.2 times more likely to have public insurance (95% CI, 1.3-3.9; P = .005). Meniscal injuries were encountered intraoperatively in 42.3% of patients with delayed surgery versus 21.0% of patients treated without delay (P < .001), resulting in 2.8 times higher odds in multivariate analysis (95% CI, 1.6-5.0; P < .001). Delayed surgery was also a risk factor for procedure duration >2.5 hours (odds ratio, 3.3; 95% CI, 1.4-7.9; P = .006). Patients who experienced delayed surgery and also had an operation >2.5 hours had 3.7 times higher odds of developing arthrofibrosis (95% CI, 1.1-12.5; P = .03). Conclusion: Patients who underwent delayed surgery for TSFs were found to have a higher rate of concomitant meniscal injury, longer procedure duration, and more postoperative arthrofibrosis when the surgery length was >2.5 hours. Those who experienced delays in diagnosis or MRI, saw multiple clinicians, and had public insurance were more likely to have a delay to surgery.

Does Insurance Status Affect Treatment of Children With Tibial Spine Fractures?

BACKGROUND: Previous studies have reported disparities in orthopaedic care resulting from demographic factors, including insurance status. However, the effect of insurance on pediatric tibial spine fractures (TSFs), an uncommon but significant injury, is unknown. PURPOSE: To assess the effect of insurance status on the evaluation and treatment of TSFs in children and adolescents. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: We performed a retrospective cohort study of TSFs treated at 10 institutions between 2000 and 2019. Demographic data were collected, as was information regarding pre-, intra-, and postoperative treatment, with attention to delays in management and differences in care. Surgical and nonsurgical fractures were included, but a separate analysis of surgical patients was performed. Univariate analysis was followed by purposeful entry multivariate regression to adjust for confounding factors. RESULTS: Data were collected on 434 patients (mean ± SD age, 11.7 ± 3.0 years) of which 61.1% had private (commercial) insurance. Magnetic resonance imaging (MRI) was obtained at similar rates for children with public and private insurance (41.4% vs 41.9%, respectively; P≥ .999). However, multivariate analysis revealed that those with MRI performed ≥21 days after injury were 5.3 times more likely to have public insurance (95% CI, 1.3-21.7; P = .02). Of the 434 patients included, 365 required surgery. Similar to the overall cohort, those in the surgical subgroup with MRI ≥21 days from injury were 4.8 times more likely to have public insurance (95% CI, 1.2-19.6; P = .03). Children who underwent surgery ≥21 days after injury were 2.5 times more likely to have public insurance (95% CI, 1.1-6.1; P = .04). However, there were no differences in the nature of the surgery or findings at surgery. Those who were publicly insured were 4.1 times more likely to be immobilized in a cast rather than a brace postoperatively (95% CI, 2.3-7.4; P < .001). CONCLUSION: Children with public insurance and a TSF were more likely to experience delays with MRI and surgical treatment than those with private insurance. However, there were no differences in the nature of the surgery or findings at surgery. Additionally, patients with public insurance were more likely to undergo postoperative casting rather than bracing.

High Incidence of Intra-articular Injuries With Segond Fractures of the Tibia in the Pediatric and Adolescent Population.

BACKGROUND: Segond fractures (avulsion fractures of the proximal lateral tibia) are highly associated with anterior cruciate ligament (ACL) tears in adult patients. This large case series of pediatric Segond fractures describes the associated intra-articular knee injuries to determine if these fractures have a high incidence of ACL tears or its equivalent injury in young patients. METHODS: Institutional review board approved retrospective study at a tertiary children's hospital of patients under 19 years who were diagnosed with a Segond fracture between 2009 and 2019 was conducted. Demographics, clinical data, imaging features, associated injuries, and treatment information were collected. RESULTS: Fifty-three patients (44 males and 9 females) with median age 15.4 (11.8 to 19) years with Segond fractures of the proximal tibia on radiographic imaging were included. Diagnosis of associated injuries was established based on clinical examination, radiology report, and arthroscopic findings. Median Segond fracture size was 2.0×9.0 mm measured on standard anteroposterior knee radiographs. Magnetic resonance imaging (MRI) was obtained in 49/53 (92.5%) patients. Associated injuries included ACL tears (39 patients, 73.6%), tibial spine fractures (9, 17.0%), and other injuries (5, 9.4%). 37/53 (69.8%) patients had meniscal injury. Three (5.7%) patients sustained multiligament injuries. All associated injuries were confirmed by either MRI/computerized tomography or direct operative examination. Among Segond fractures found with ACL tears, 12 (30.8%) were contact injuries, 30 (76.9%) were sports injuries. In associated tibial spine fractures, 7 (78%) injuries were contact in nature and were sports related. There was a statistically significant difference (P=0.013) in age, patients with tibial spine fractures (median 13.6 y) being younger than those with ACL tears (median 15.4 y). 12/53 (22.6%) had associated articular cartilaginous injuries, 3 of which were treated surgically. Overall, 81.1% of patients were treated operatively for associated intra-articular injuries. CONCLUSIONS: This large case series of Pediatric Segond fractures suggests a high association with intra-articular injuries, specifically, ACL tears and its equivalent injury, that is, tibial spine fractures, the later more common in the younger patient population. An MRI is recommended in patients with a Segond fracture for characterizing the exact intra-articular injury to help plan the appropriate management. LEVEL OF EVIDENCE: Level IV-prognostic.

Causes of delayed diagnosis of posterior ankle impingement in the pediatric and adolescent population.

PURPOSE: The purpose of this study was to identify and characterize various causes of delay in the diagnosis of posterior ankle impingement syndrome (PAIS) in pediatric patients. METHODS: IRB approved prospective study of patients under 18 years who underwent arthroscopic surgery for the diagnosis of posterior ankle impingement after failed conservative treatment at a tertiary children's hospital. Radiographic findings were compared with an age-matched control group. Descriptive and inferential statistics were employed. RESULTS: 47 patients (61 ankles), mean age 13 years, had an average 14 months delay in diagnosis of PAIS from the initial presentation. 33 (70%) patients had seen multiple medical providers and given other diagnoses. 9 (19%) patients participated in ballet or soccer, and 16 (34%) patients had unrelated associated foot and ankle diagnoses. 25 (41%) of 61 ankles did not have pain on forced plantar flexion; all 61(100%) ankles had tenderness to palpation over the posterior ankle joint line. Radiographs were reported to be normal in 37/52 (71%) ankles, while MRI report did not mention the diagnosis in 20/41 (49%) studies. There was a significant difference in the MRI findings in the patient population when compared to the control group. Indication for surgery was failed conservative treatment. All 61 ankles had posterior ankle impingement pathology confirmed visually during arthroscopy. At average 15 months follow-up, there was significant improvement pre- to post-operatively (p<0.001) for both pain VAS (6.9-0.9) and AOFAS ankle-hindfoot scores (65-94). CONCLUSION: Multiple clinical and imaging factors can lead to delayed diagnosis of posterior ankle impingement. An increased awareness about the features of PAIS is needed amongst medical providers involved in treating young patients.

Pediatric and adolescent Lisfranc injuries - Presentation, treatment and outcomes.

PURPOSE: Lisfranc fracture dislocations are rare injuries and even more so in the pediatric population. The main purpose of our study is to present a descriptive analysis of Lisfranc injuries in pediatric patients to add to the current sparse literature on this topic. In addition, our secondary outcome was to analyze any differences in patients treated conservatively versus operatively, and those with isolated Lisfranc injuries versus those with associated foot injuries. METHODS: Charts of patients with Lisfranc injury treated at a tertiary pediatric hospital from January 2010 to July 2019 were reviewed to analyze their demographics, injury characteristics, management details and rehabilitation protocol. Functional outcome was assessed using the Visual Analogue Scale of Pain (VAS) and the Oxford Ankle Foot Questionnaire for Children (OxAFQ-C). RESULTS: 30 patients/cases were included with mean age of 13.6 years and mean follow up of 36 weeks. 20% of the cases were missed on initial presentation. 19 cases were managed operatively while 11 were managed conservatively. The average OxAFQ-C and VAS pain scores were 83% and 1.3, respectively at mean follow-up of 36 weeks. The functional outcomes between conservative and operative cases or between those with isolated Lisfranc injuries and those with associated foot injuries were not statistically significant (p > 0.05). CONCLUSION: Lisfranc injury in pediatrics can be easily missed. High index of suspicion, a thorough clinical examination and the use of advanced imaging is warranted. Various modalities like K-wires, screws and suture-buttons can be used for fixation. Early to mid-term functional outcomes are satisfactory provided that adequate reduction is obtained.

Chemoprotection with botulinum toxin following proximal hamstring-Ischial tuberosity avulsion fracture repair: Running title: Chemoprotection for hamstring avulsion fractures.

INTRODUCTION: Surgical treatment for avulsion injuries of the proximal hamstrings has gained increasing popularity over the past decade. Despite good outcomes, early failures have been noted and have been attributed to slipping and falling, postoperative muscle spasm, or early mobilization. In a recent review of hamstring repair rehabilitation protocols, it was shown that there is marked variability in post-operative management. Post-operative bracing with limiting knee extension and hip flexion is the standard of care in most early rehabilitation protocols. Braces with limitation of hip flexion and knee locked in 900 flexion can be awkward, cumbersome and create fall risk.Chemoprotection has more recently been proposed to be an alternative approach to prevent tendon repair failure and controlled mobilization which has been shown to be superior to complete immobilization. We present the first case series of the use of botulinum toxin for chemo-protection of the proximal hamstring ischial avulsion repair, demonstrating its safety and efficacy. METHODS: Retrospective case series at a tertiary children's hospital which included patients <18 years of age who underwent interventional treatment for proximal hamstring avulsion injuries of the ischium utilizing botulinum toxin as a chemoprotective agent. Data collected included demographic data, injury and treatment details, imaging, post-operative rehabilitation and return to activity. Descriptive statistical analysis was conducted. RESULTS: Five male patients with mean age 14 years (12-17) were included in the study. All were sports related non-contact injuries. Radiographs showed displaced avulsion fractures in all 5 patients. All patients had failed conservative management initially; mean time to surgery from initial injury was 34.4 weeks. 4 patients underwent open reduction and internal fixation (ORIF), 1 patient with less displacement had bone marrow aspirate (BMA) injection; all had chemoprotection using botulinum toxin injected in the hamstrings. No patient required hip immobilization or knee immobilization locked to 90°. We elected to use a brace locked at 20° knee flexion in 2/5 patients. All patients underwent supervised physical therapy and achieved symmetric knee range of motion (ROM). Post-operative radiographs confirmed healing of the avulsion fracture in all 5 patients and they all returned to previous level of activity at mean 32 weeks (21-43) from surgery. None of the patients had a hamstring re-injury at mean follow up of 27 months (11-42). CONCLUSION: Our case series is the first in literature that shows the safety and efficacy of chemoprotection with botulinum toxin for the post-operative management of avulsion injuries of proximal hamstrings, by minimizing the need for cumbersome bracing and allowing controlled motion during physical therapy.

Simultaneous bilateral versus unilateral tibial tubercle fractures.

PURPOSE: Tibial tubercle/tuberosity fractures are rare injuries in young patients accounting for less than one percent of physeal fractures. Bilateral simultaneous fractures are even rarer, with only a few case reports in literature. The purpose of our study was to describe the largest case series of bilateral simultaneous tibial tuberosity avulsion fractures and compare it with unilateral fractures. We also wanted to compare our bilateral fractures case series with all the cases reported in the last 65 years. METHODS: IRB approved retrospective study involving patients under age 18 years with tibial tuberosity avulsion fractures. Bilateral simultaneous fractures were compared to a unilateral group including demographic data, mechanism of injury, clinical exam findings, complication rates, and outcomes including return to function. Statistical analysis was performed using Mann-Whitney and Fisher Exact tests to compare the different groups. RESULTS: 138 patients (131 males, 7 females) from a tertiary children's hospital between 2012 and 2019 with tibial tuberosity avulsion fractures were included. 11 bilateral simultaneous fractures (BL Group) were identified and compared to age matched cohort from the 127 unilateral fracture patients (UL group). There was no significant difference found in BMI, height, weight, age, sex, mechanism of injury, return to functional range of motion, and return to sports between the groups. 7/11 (63%) of the patients in the BL group who sustained simultaneous fractures had to be home bound and could not attend school for an average of 8.3 weeks. There was a higher rate of complications in the BL group (63.3%) compared to the UL group (21.1%), which was statistically significant. The most common complications in the bilateral group were hardware removal and wound dehiscence. CONCLUSION: This first case series comparing unilateral versus bilateral simultaneous tibial tuberosity avulsion fractures suggests that the final outcomes of the two groups are similar, however it shows a significantly higher complication rate and hardware removal rate in the BL group. This study is also the first to highlight the significant initial morbidity in the BL fracture group with issues with regards to early mobility and loss of school-days. Keeping in mind the profound initial impact the bilateral injury poses to the patient; surgeons can possibly plan for rigid fixation for early mobilization to better prepare bilateral fracture patients for the early post-operative recovery process.

Anterior Cruciate Ligament Tear Following Operative Treatment of Pediatric Tibial Eminence Fractures in a Multicenter Cohort.

BACKGROUND: Postoperative ipsilateral anterior cruciate ligament (ACL) tears after tibial eminence fracture fixation has been previously noted in the literature. This study aims to describe the prevalence of and risk factors for postoperative ACL tears in a cohort of patients operatively treated for tibial eminence fracture. METHODS: A retrospective review of children undergoing treatment of a tibial eminence fracture at 10 tertiary care children's hospitals was performed. The primary outcome of interest was subsequent ACL rupture. Incidence of ACL tear was recorded for the entire cohort. Patients who sustained a postoperative ACL tear were compared with those without ACL tear and analyzed for demographics and risk factors. A subgroup analysis was performed on patients with a minimum of 2-year follow-up data or those who had met the primary outcome (ACL tear) before 2 years. RESULTS: A total of 385 pediatric patients were reviewed. 2.6% of the cohort experienced a subsequent ACL tear. The median follow-up time was 6.5 months (SD=6.4 mo). Subsequent ACL tears occurred at a median of 10.2 months (SD=19.5 mo) postoperatively. There was a statistically significant association with higher grade tibial spine fractures (Myers and McKeever type III and IV) and subsequent ACL tear (P=0.01). Patients with a subsequent ACL tear were older on average (13.5 vs. 12.2 y old), however, this difference was not statistically significant (P=0.08). Subgroup analysis of 46 patients who had a 2-year follow-up or sustained an ACL tear before 2 years showed a 21.7% incidence of a subsequent ACL tear. There was a statistically significant association with higher grade tibial spine fractures (Myers and McKeever type III and IV) and subsequent ACL rupture (P=0.006) in this subgroup. Postoperative ACL tears occurred in patients who were older at the time that they sustained their original tibial eminence fracture (13.4 vs. 11.3 y old, P=0.035). CONCLUSIONS: Ipsilateral ACL tears following operatively treated pediatric tibial eminence fractures in a large multicenter cohort occurred at a rate of 2.6%. However, in those with at least 2 years of follow-up, the incidence was 21.7%. Subsequent ACL tear was more likely in those with completely displaced (type III or IV) tibial eminence fractures and older patients. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

A Comparison of Nonoperative and Operative Treatment of Type 2 Tibial Spine Fractures.

BACKGROUND: Tibial spine fractures (TSFs) are typically treated nonoperatively when nondisplaced and operatively when completely displaced. However, it is unclear whether displaced but hinged (type 2) TSFs should be treated operatively or nonoperatively. PURPOSE: To compare operative versus nonoperative treatment of type 2 TSFs in terms of overall complication rate, ligamentous laxity, knee range of motion, and rate of subsequent operation. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: We reviewed 164 type 2 TSFs in patients aged 6 to 16 years treated between January 1, 2000, and January 31, 2019. Excluded were patients with previous TSFs, anterior cruciate ligament (ACL) injury, femoral or tibial fractures, or grade 2 or 3 injury of the collateral ligaments or posterior cruciate ligament. Patients were placed according to treatment into the operative group (n = 123) or nonoperative group (n = 41). The only patient characteristic that differed between groups was body mass index (22 [nonoperative] vs 20 [operative]; P = .02). Duration of follow-up was longer in the operative versus the nonoperative group (11 vs 6.9 months). At final follow-up, 74% of all patients had recorded laxity examinations. RESULTS: At final follow-up, the nonoperative group had more ACL laxity than did the operative group (P < .01). Groups did not differ significantly in overall complication rate, reoperation rate, or total range of motion (all, P > .05). The nonoperative group had a higher rate of subsequent new TSFs and ACL injuries requiring surgery (4.9%) when compared with the operative group (0%; P = .01). The operative group had a higher rate of arthrofibrosis (8.9%) than did the nonoperative group (0%; P = .047). Reoperation was most common for hardware removal (14%), lysis of adhesions (6.5%), and manipulation under anesthesia (6.5%). CONCLUSION: Although complication rates were similar between nonoperatively and operatively treated type 2 TSFs, patients treated nonoperatively had higher rates of residual laxity and subsequent tibial spine and ACL surgery, whereas patients treated operatively had a higher rate of arthrofibrosis. These findings should be considered when treating patients with type 2 TSF.