The Creation and Validation of an Ankle Bone Age Atlas and Data Predicting Remaining Ankle Growth.

BACKGROUND: The purpose of the current study was 2-fold: (1) to create and validate an ankle bone age atlas spanning the pediatric and adolescent years and (2) to utilize this atlas in conjunction with distal tibia/fibular growth data as measured on serial radiographs to develop a predictive growth model for the lower extremity. METHODS: Radiographs were surveyed to identify distinguishable, reproducible, radiographic features. Radiographic features of the tibia, fibula, hindfoot, and midfoot from 270 patients were identified and a "standard" for each age/sex was selected to create an atlas. A separate cohort of 90 ankle radiographs was selected to validate the atlas. A subcohort of 41 patients with left-hand radiographs within 3 months of ankle imaging was used to compare the 2 bone age approaches. Harris growth lines were evaluated in 304 serial images of the distal tibia to determine the remaining growth. RESULTS: The distal tib/fib ossification centers provided the best age assessment for early childhood (male age: 1 to 8 y; female age: 1 to 4 y). The ossification/fusion of the calcaneal apophysis provided the best age assessment in the preadolescent stage (male age: 6 to 14 y; female age: 5 to 12 y). The closure of the distal tib/fib physes best determined skeletal maturity (male age: 14 to 16 y; female age: 12 to 14 y). The ankle atlas had excellent interobserver and intraobserver reliability (intraclass correlation coefficient=0.993, P <0.001 and 0.998, P <0.001), respectively. We found an excellent correlation between the patient's chronologic age and ankle bone age ( r =0.984; P <0.001). Ankle bone age assessment and Greulich and Pyle were correlated ( rs =0.822, P <0.001). We found that males with a bone age of ≥15 years and females with a bone age of ≥13 years had ≤2 mm of residual growth of the distal tibia/fibula physes. CONCLUSIONS: bone age can be determined using ankle films ordered to assess/treat ankle injuries. This tool, along with our growth remaining table, may have important clinical implications when managing patients with ankle trauma with premature physeal closure. LEVEL OF EVIDENCE: IV.

Medial Patellofemoral Ligament Reconstruction for Adolescents With Acute First-Time Patellar Dislocation With an Associated Loose Body.

BACKGROUND: The management of adolescents with acute first-time patellar dislocation with an associated loose body remains a debated topic. The rate of recurrent dislocation in these patients may be up to 61% if the medial patellofemoral ligament (MPFL) is repaired or not addressed surgically. To our knowledge, a prospective evaluation of MPFL reconstruction for adolescents with acute first-time patellar dislocation with an associated chondral or osteochondral loose body has not been previously performed. PURPOSE/HYPOTHESIS: The purpose of this study was to analyze patients with a first-time patellar dislocation who required surgery for a loose body, comparing those who underwent MPFL repair or no treatment with those who underwent MPFL reconstruction during the index procedure. The hypothesis was that performing MPFL reconstruction would reduce the rate of recurrent instability and improve patient-reported outcomes compared with MPFL repair or no treatment. A secondary objective was to report outcomes of those patients who underwent reconstruction versus those who did not. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: This was a prospective analysis of adolescents treated with MPFL reconstruction for acute first-time patellar dislocation with associated loose bodies between 2015 and 2017 at a single pediatric level 1 trauma center with minimum 2-year follow-up. Retrospective analysis was previously performed for a similar cohort of adolescents treated with MPFL repair or no treatment. Patient characteristic data, radiographic measurements, and surgical variables were compared. Primary outcome measures included recurrent subluxation or dislocation and the need for further stabilization procedures. Secondary outcomes included Kujala score, Single Assessment Numeric Evaluation score, patient satisfaction, and ability to return to sport. RESULTS: A total of 76 patients were included, 30 in the MPFL reconstruction cohort and 46 in the MPFL repair or no-treatment cohort. The only difference noted in patient characteristic, radiographic, or surgical variables was a smaller Insall-Salvati ratio in the reconstruction group (1.29 vs 1.42; P = .011). Compared with MPFL repair or no treatment, MPFL reconstruction was associated with less recurrent instability (10.0% vs 58.7%; P < .001), fewer secondary procedures (6.7% vs 47.8%; P < .001), and more frequent return to sports (66.7% vs 39.1%; P = .003). No differences in patient-reported outcomes were noted. CONCLUSION: Performing concomitant MPFL reconstruction in adolescents with first-time patellar dislocation and an intra-articular loose body results in a 5-fold reduction in recurrent instability, reduces the need for subsequent surgery, and improves patients' ability to return to sports compared with repairing or not treating the MPFL.

Risk Factors for Adverse Radiographic Outcomes After Elastic Stable Intramedullary Nailing of Unstable Diaphyseal Tibia Fractures in Children.

OBJECTIVES: Elastic stable intramedullary nails (ESIN) are commonly utilized to treat unstable pediatric tibia fractures but have been associated with complications. The purpose of this study was to identify risk factors for adverse radiographic outcomes after ESIN of pediatric tibia fractures. METHODS: A retrospective review of all patients who underwent diaphyseal tibia fracture stabilization with ESIN between 2010 and 2018 at 3 pediatric level 1 trauma centers was performed. Inclusion criteria were open growth plates, no intra-articular or physeal fracture involvement, and radiographic follow-up until union. Patient demographics, injury mechanism, fracture characteristics, and implant fill relative to the medullary canal were recorded. Radiographic outcome measures included achievement of and time to union, residual angular deformity, and additional procedures. RESULTS: One hundred seventy-two patients met inclusion criteria and were followed for a mean of 1.2 years. Nonunions were observed in 3% of the patient cohort. Another 10% required >6 months to heal, but did not require further surgical intervention. Angular deformities were common with 57% having a residual deformity ≥5 degrees and 14% having a residual deformity ≥10 degrees. Of the patients with a residual deformity between 5 and 10 degrees, 3% were symptomatic, where as 26% of the patients with a residual deformity ≥10 degrees were symptomatic. Greater angular deformities were associated with open fractures, compartment syndrome, and longer time to union. Patient age, weight, tibial comminution, and canal fill were not associated with nonunions or malunions. CONCLUSIONS: ESIN of pediatric tibia fractures results in reliable healing for a majority of patients, but poses risks for residual angular deformities and delayed healing. Open fractures and compartment syndrome were associated with adverse radiographic outcomes.

Progressive Elbow Magnetic Resonance Imaging Abnormalities in Little League Baseball Players Are Common: A 3-Year Longitudinal Evaluation.

BACKGROUND: Prior studies have revealed magnetic resonance imaging (MRI) evidence of elbow pathology in single-season evaluation of competitive youth baseball players. The natural history of these findings and risk factors for progression have not been reported. PURPOSE: To characterize the natural history of bilateral elbow MRI findings in a 3-year longitudinal study and to correlate abnormalities with prior MRI findings, throwing history, playing status, and physical examination. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: A prospective study of Little League players aged 12 to 15 years was performed. All players had preseason and postseason bilateral elbow MRI performed 3 years before this study. Players underwent repeat bilateral elbow MRI, physical examination, and detailed assessment of throwing history, playing status, and arm pain. Imaging was read by a blinded musculoskeletal radiologist and compared with prior MR images to assess for progression or resolution of previously identified pathology. RESULTS: All 26 players who participated in the previous single-season study returned for a 3-year assessment. At the completion of the study, 15 players (58%) had dominant arm MRI pathology. Eighty percent (12/15 players) of MRI findings were new or progressive lesions. Players with postseason MRI pathology at the beginning of the study were more likely to have MRI pathology at the 3-year follow-up than players with previously normal postseason MRI (P < .05), although 6 of the 14 players (43%) with previously normal MRI developed new pathology. Year-round play was a significant predictor of tenderness to elbow palpation (P = .027) and positive MRI findings at 3 years (P = .047). At the 3-year follow-up, 7 players (27%) reported having throwing elbow pain and 3 had required casting. Additionally, differences were noted in the dominant arm's internal and external rotation in those that continued to play baseball (P < .05). CONCLUSION: Dominant elbow MRI abnormalities are common in competitive Little League Baseball players. Year-round play imparts significant risk for progression of MRI pathology and physical examination abnormalities.

Recurrence of Patellar Instability in Adolescents Undergoing Surgery for Osteochondral Defects Without Concomitant Ligament Reconstruction.

BACKGROUND: First-time patellar dislocation with an associated chondral or osteochondral loose body is typically treated operatively to address the loose fragment. The incidence of recurrent instability in this patient population if the medial patellofemoral ligament (MPFL) is not reconstructed is unknown. PURPOSE: To determine the recurrent instability rate in patients undergoing surgery for patellar instability with chondral or osteochondral loose bodies, as well as to identify and stratify risk factors for recurrent instability. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: This was a retrospective analysis of adolescent patients treated operatively for acute patellar dislocation with associated chondral or osteochondral loose bodies between 2010 and 2016 at a single pediatric level I trauma center with minimum 2-year follow-up. Potential demographic, injury-related, radiographic, and surgical risk factors were recorded. The primary outcome variable was recurrent subluxation and/or dislocation. Secondary outcome variables included need for additional procedures, Kujala score, Single Assessment Numerical Evaluation (SANE) score, and patient satisfaction. RESULTS: Forty-one patients were included. In total, 61% experienced recurrent instability at a mean follow-up of 4.1 years and 39% required subsequent MPFL reconstruction. Tibial tubercle-trochlear groove (TT-TG) distance greater than 15 mm was a risk factor for recurrent instability ( P = .03). Patients with TT-TG distance greater than 15 mm and greater than 20 mm had recurrent instability rates of 75% and 86%, respectively. MPFL repair did not reduce the rate of recurrent instability ( P = .87). Recurrent instability was associated with significantly worse mean Kujala (93.9 vs 83.0; P = .01), SANE (88.9 vs 73.1; P = .01), and patient satisfaction scores (9.4 vs 7.3; P = .002). CONCLUSION: If the MPFL is not reconstructed during index loose body treatment, children have a 61% recurrent instability rate. Patients with TT-TG distance greater than 15 mm, and particularly greater than 20 mm, are at highest risk for recurrent instability.