Stable childhood osteochondral lesions of the talus: short-term radiographic outcomes suggest risk for early osteoarthritis.

Recent literature suggests that adults do not necessarily develop osteoarthritis if they have an osteochondral lesion of the talus (OLT). The purpose of this study was to determine if children with OLT are at risk to develop any radiographic evidence of early joint degeneration despite treatment efforts. Fifty-six ankles were identified over 6 years with stable OLT that underwent operative treatment. Preoperatively, each lesion was classified according to Berndt-Hardy for radiographs, Hepple for MRI, and Ferkel and Sgaglione for computed tomography. Radiographs were also evaluated for physeal status, OLT characteristics (location, border, size), and signs of osteoarthritis (Kellgren and Lawrence Scale). Despite incomplete treatment to radiographic resolution, the Kellgren-Lawrence scores still worsened in 23% of the children (pre-op score: mean 0.42 and median 0 versus post-op score: mean 0.69 and median 1). No risk factors (preoperative classification, age, physeal patency) were associated with advancing radiographic evidence of articular degeneration utilizing univariate analysis. However, a classification and regression tree analysis revealed that a patient age of 11.5 years old could be predictive of advancing Kellgren-Lawrence scores with one-third of older children worsening (P = 0.038). Despite active treatment of OLT, the ultimate prognosis is guarded with approximately one out of four children advancing their Kellgren and Lawrence score during treatment. In contrast to the natural history of adult OLT, the short-term advancement of degenerative disease in childhood OLT suggests a potentially different outcome and warrants further investigation into better treatment methods to preserve ankle health in these young patients.

Efficacy of Self-Directed Learning in the Supracondylar Fracture Performance Improvement Module at an Academic Pediatric Orthopedic Institution.

Maintenance of certification (MOC) within a medical society requires continuing medical education that demonstrates life-long learning, cognitive expertise, and practice-based self-assessment. This prospective study sought to evaluate whether a self-directed Practice Improvement Module (PIM) would improve pediatric orthopedic patient outcomes, thus demonstrating evidence of life-long learning (Part II MOC credit) in treating supracondylar humerus fractures. Six surgeons and 113 patients were included. There was no significant difference in actual fracture outcome before or after PIM at any level of surgeon experience regarding radiographic appearance or need for reoperation (p > 0.10). Junior staff demonstrated a statistically significant improvement in the percentage of time that marking the operative site was documented in the chart by the surgeon before (38%) and after (65%) PIM (p = 0.02). The self-directed education portion of the supracondylar fracture PIM led to modest improvement in documentation habits among junior staff, without impact on overall patient outcomes. Therefore, the PIM appears to be less useful in providing evidence for life-long learning as it relates to surgical outcomes (Part II MOC/CME), yet, it may directly benefit practice-based self-assessment (Part IV MOC), and the self-assessment and Personal Improvement Plan may be the most important portion of the PIM to improve outcomes.

Femoral Neck Aspiration Aids in the Diagnosis of Osteomyelitis In Children With Septic Hip.

BACKGROUND: The role of femoral aspiration (FA) in the treatment of septic arthritis of the hip is controversial. The purpose of this study was to determine if FA conducted concomitantly with irrigation and debridement (I&D) of the septic hip aids in microorganism and osteomyelitis identification and alters the treatment plan, or if the risks of the procedure outweigh its potential benefit. We also compare preoperative magnetic resonance imaging (MRI) with FA for diagnosis of osteomyelitis cooccurring with septic arthritis. METHODS: Retrospective review was performed of all patients treated at a single institution between January 2003 and June 2014 for suspected septic hip arthritis. Eighty-three patients were identified with suspected or confirmed septic arthritis and 28 patients (33%) had cooccurring osteomyelitis. Demographic and clinical data were recorded for each patient. The sensitivity and specificity of FA and MRI for diagnosing osteomyelitis were determined. RESULTS: Among the 83 patients with confirmed or suspected septic arthritis, 31 patients (37%) had a FA performed at the time of the hip I&D, resulting in positive cultures in 17 patients. All of these patients had other positive cultures (blood and/or joint fluid) that grew the same organism. 54 patients (65%) had a preoperative MRI. The MRI was falsely negative in 10 patients, 6 of whom had a positive FA resulting in appropriate management of osteomyelitis. Missed or delayed diagnosis of osteomyelitis resulted in significant morbidity in 3 patients (avascular necrosis and femoral neck fracture, extensive lower extremity osteomyelitis, and subtrochanteric fracture with malunion). No complications associated with FA were identified. FA and MRI were found to have sensitivity/specificity for osteomyelitis of 100%/100% and 38%/95%, respectively. CONCLUSIONS: Although FA did not improve microorganism identification, it did aid in the diagnosis of cooccurring osteomyelitis when treating children with septic arthritis, especially in patients with false negative MRI findings for osteomyelitis. We recommend FA at the time of septic hip I&D as its benefits appear to far outweigh its risks. LEVEL OF EVIDENCE: Level III-diagnostic study.

Are the Current Little League Pitching Guidelines Adequate? A Single-Season Prospective MRI Study.

BACKGROUND: Little League throwing guidelines have recently been implemented in an attempt to lessen the growing number of elbow injuries occurring in youth baseball players. HYPOTHESIS/PURPOSE: The purpose of this study was to examine pre- and postseason changes seen on magnetic resonance imaging (MRI) in youth baseball players' elbows in an attempt to identify risk factors for pain and MRI abnormalities, with a particular focus on the current Little League guidelines. We hypothesized that MRI abnormalities would be common in pitchers with high pitch counts and poor guideline compliance. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: A prospective study of Little League players aged 10 to 13 years was performed. Players were recruited prior to the start of the season and underwent bilateral elbow MRI as well as a physical examination and completed a questionnaire addressing their playing history and arm pain. At the end of the season, a repeat MRI and physical examination were performed. MRIs were read by blinded radiologists. During the season, player statistics including innings played, pitch counts, and guideline compliance were recorded. Physical examination findings and player statistics were compared between subjects with and without MRI changes utilizing chi-square and analysis of variance techniques. RESULTS: Twenty-six players were enrolled. Despite 100% compliance with pitching guidelines, 12 players (48%) had abnormal MRI findings, and 28% experienced pain during the season. There was a significant difference in distal humeral physeal width measured pre- to postseason (1.54 vs 2.31 mm, P < .001). There was a significant loss of shoulder internal rotation during the season, averaging 11°. While pitch counts, player position, and throwing curveballs/sliders were not significantly associated with changes seen on MRI, year-round play was associated with abnormalities (P < .05). Much lower compliance (<50%) was observed with nonenforced guidelines, including avoidance of single-sport specialization, year-round play, and throwing curveballs/sliders. CONCLUSION: Arm pain and MRI abnormalities of the medial elbow are common in Little League baseball players who comply with the Little League throwing guidelines, especially those playing year-round.

The Pediatric/Adolescent Shoulder Survey (PASS): A Reliable Youth Questionnaire With Discriminant Validity and Responsiveness to Change.

BACKGROUND: Health-related quality of life tools for shoulder pathology in adults have been developed, such as the Disabilities of the Arm, Shoulder, and Hand (DASH) or QuickDASH. However, some content is not applicable to or readily grasped by a younger population. PURPOSE: To evaluate the psychometric properties of a new 13-item pediatric/adolescent shoulder survey (PASS). STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: An initial development cohort of children was given the PASS, QuickDASH, and single assessment numeric evaluation (SANE) in a prospective fashion. Internal reliability and concurrent validity were evaluated. Subsequent to this, the PASS, along with the QuickDASH, was incorporated into routine clinical evaluation of shoulder injuries. The secondary cohort was established via a retrospective review of patients (age <18 years) evaluated in our sports clinics for shoulder complaints. Discriminant validity and floor/ceiling effects were evaluated. A subset of patients with scores available both pre- and within 6 months postoperatively was analyzed to assess responsiveness to treatment. RESULTS: Overall internal reliability of the shoulder survey was good in the development cohort of 127 patients, with Cronbach α = 0.86. Total score averaged 59.7% ± 17.9% in this cohort (range, 18.75%-100%). Significant correlations between all surveys were observed (r = 0.51-0.79, P < .05). A total of 127 surveys were available for the secondary cohort. The QuickDASH demonstrated significant differences between sexes with regard to scores (P < .05). Both tools were able to discriminate between patients with acute injuries and diminished clinical examinations (P < .05). A significant correlation was observed between duration of symptoms and scores on the PASS. The subset of 25 patients with pre- and postoperative data showed significant change in total score and the symptoms/limitations domain of the PASS, with significant correlation with length of time since surgery. CONCLUSION: This 13-question pediatric/adolescent-focused shoulder survey shows excellent psychometric properties, good discriminant ability, and early evidence of responsiveness to change, especially when compared with an adult-formatted questionnaire.

Rate and Risk Factors for Delayed Healing Following Surgical Treatment of Lateral Condyle Humerus Fractures in Children.

BACKGROUND: Lateral condyle humerus fracture nonunion after surgical fixation has been reported to be <1%. The purpose of this study was to evaluate the rate and risk factors for delayed healing of pediatric lateral condyle fractures after surgical fixation. METHODS: Retrospective study of all operatively treated lateral condyle fractures at a single institution from 2006 to 2013 was performed. Radiographic evaluation included: measured fracture displacement at both presentation and after surgical fixation, fracture classification, and multiple parameters of pin configuration. Patients who had delayed healing were defined as those not healed by the eighth week of follow-up and were compared with those fractures that healed in <8 weeks to identify risk factors associated with delayed healing. Purposeful selection was utilized to identify factors for entry into a multivariate binary logistic regression model. RESULTS: A total of 210 children were evaluated. Mean follow-up was 25 weeks (4 wk to 5 y). Distribution of Weiss classification was as follows: type 1, 8 (4%); type 2, 61 (29%); and type 3, 141 (67%). There were 33 (16%) delayed unions and 7 of these (3% of the entire cohort) required further surgery to achieve healing. Weiss classification, intraoperative fluoroscopy time, and intraoperative displacement after fixation met criteria for entry into the regression. While Weiss classification did not remain significant within the model, its removal resulted in a 30% change in the parameter estimate for intraoperative fluoroscopy time. For each second increase in fluoroscopy time, there is a 3% increase in the risk of delayed healing. Patients with >1 mm displacement of the lateral cortex after fixation had an increased risk of delayed healing (OR=4.78, P=0.007). CONCLUSIONS: Delayed union of lateral condyle fractures is a matter of concern, and the rate of secondary surgery to achieve healing appears to be higher than previously reported. Risks for delayed healing include amount of residual displacement after reduction and the difficulty in attaining that reduction, as defined by fluoroscopy time. LEVEL OF EVIDENCE: Level IV-therapeutic study, case series.

Does Allograft Augmentation of Small-Diameter Hamstring Autograft ACL Grafts Reduce the Incidence of Graft Retear?

BACKGROUND: Small-diameter hamstring tendons are frequently encountered during anterior cruciate ligament (ACL) reconstructions in patients with short stature or those who are skeletally immature. The role of augmenting these small-diameter autografts with allograft is unclear. PURPOSE: To assess clinical outcomes and failure rates in adolescent patients with small hamstring tendon autografts (<7 mm) that were either augmented with soft tissue allograft or accepted "as is" and not augmented. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A retrospective chart review of all primary ACL reconstructions performed with hamstring autografts identified 385 patients, of whom 50 (13%) had a quadrupled (semitendinosus-gracilis) graft size less than 7 mm. Patients were grouped based on the surgeon's preference either to augment these grafts with allograft (augmented group; n = 26) or to accept the smaller autograft (nonaugmented group; n = 24). Preoperative demographic, injury, and intraoperative data were documented. All patients were contacted to obtain information about outcome scores, subsequent procedures, and complications. Forty patients (20 in each group) were available for 2-year follow-up. RESULTS: The mean age of the entire cohort was 15.7 years (range, 12-18 years), and 38% were male. No between-group differences were found with respect to any of the preoperative or intraoperative variables except extremity side. The mean graft size for the augmented group was 8.9 mm and for the nonaugmented group was 6.4 mm. At a mean follow-up of 3 years, 6 (30%) of the patients in the augmented group had a graft failure, whereas only 1 (5%) in the nonaugmented group had a failure ( P = .04). Five of the 6 augmented failures occurred within 1 year of surgery, whereas the single failure in the nonaugmented group occurred 2.7years postoperatively. No differences were noted in the reported outcomes between patients in the augmented and nonaugmented groups who did not experience graft failure (Lysholm score, 88 vs 92; Tegner score, 6.4 vs 6.3; single-assessment numeric evaluation score, 86 vs 86; satisfaction, 8.4 vs 8.9, respectively). CONCLUSION: Adolescents undergoing an ACL reconstruction frequently have small hamstring tendon autograft size. The augmentation of these small grafts with allograft does not reduce graft failure rates and may in fact lead to higher retear rates, with earlier graft failure.

Significance of the Lateral Humeral Line for Evaluating Radiocapitellar Alignment in Children.

BACKGROUND: The radiocapitellar line (RCL) was originally described for evaluation of the alignment of the RC joint on lateral images of the elbow. Although, many authors have translated the utilization of RCL into coronal imaging, previous studies have not been performed to confirm validity. The purpose of this paper was to identify an accurate way of evaluating pediatric RC alignment in the coronal plane. METHODS: Thirty-seven anteroposterior (AP) radiographs of 37 children were evaluated to determine the position of the RC joint in the coronal plane. All had acceptable magnetic resonance imaging (MRI) studies available for comparison. The lateral humeral line (LHL), consisting of a line along the lateral edge of the ossified condyle of the distal humerus parallel to the axis of the distal humeral shaft, was studied as it related to the lateral cortex of the radial neck. Three children with a confirmed diagnosis of a Bado III, lateral displaced radius, Monteggia fracture were also evaluated. RESULTS: The LHL passed along the edge of or lateral to the radial neck on all AP radiographs and all MRI studies. The RCL failed to intersect the capitellum on 2 AP radiographs. On MRI, the RCL also passed lateral to the capitellar ossification center in 3 patients. In addition, the RCL was seen passing through the capitellum at a mean of the lateral 30% (range, 0% to 64%) on AP radiographs and 26% (range, 0% to 48%) on MRI. For all 3 children with a Bado III Monteggia fracture, the LHL crossed the radial neck and the RCL did not intersect the capitellum. CONCLUSIONS: The RCL can fail to intersect the capitellar ossification center on AP radiographs and MRI in pediatric elbows without injury. The LHL consistently lies lateral to the radial neck in normal elbows and medial to the lateral aspect of the radial neck on all Bado III fracture-dislocations. It, therefore, can be used as an adjunct in evaluating the RC joint on AP imaging. The RCL most commonly intersects the lateral one third of the ossification center on both plain radiographs and MRIs. LEVEL OF EVIDENCE: Level III-diagnostic.

Does operative fixation affect outcomes of displaced medial epicondyle fractures?

PURPOSE: Long-term functional results remain equivocal between operative fixation and closed management of displaced humeral medial epicondyle fractures. The purpose of this study was to determine whether a functional difference exists between treatment types. METHODS: One hundred and forty patients with a displaced medial epicondyle fracture between 2007 and 2014 met the inclusion criteria. Of this large cohort, only 12 patients agreed to return to clinic at a mean follow-up of 3 years for prospective evaluation. Data collection included radiographs, physical examination, validated outcome tools, and grip strength testing with a Jamar dynamometer. RESULTS: Both groups were comparable with regard to age, dominant side injured, length of follow-up, preinjury sports involvement, and initial displacement (10 mm operative vs. 9 mm nonoperative); however, half of the surgical group presented with an associated unreduced elbow dislocation versus 0 % in the nonoperative group. Both treatment methods resulted in high patient satisfaction and elbow function scores. There were four osseous nonunions (67 %) and one malunion (17 %) in the nonoperative group versus none in the operative group (p = 0.015). Patients treated nonoperatively had a nonsignificant decrease in grip strength (9 ± 6 lbs) as compared to operative patients (6 ± 5 lbs, medium effect size eta = 0.25, p = 0.25). CONCLUSIONS: In this small cohort, operative management of displaced medial epicondyle fractures resulted in a higher rate of fracture union and return to sports. Other objective and subjective measures were similar between the two treatment groups.

Preseason Assessment of Radiographic Abnormalities in Elbows of Little League Baseball Players.

BACKGROUND: Youth baseball has been associated with elbow pain and elbow abnormalities, leading to the implementation of throwing and pitching guidelines. The purpose of the current study was to examine elbow abnormalities on magnetic resonance imaging (MRI) in asymptomatic Little League baseball players and to correlate these findings with the players' throwing history and physical examinations. METHODS: A prospective study of Little League players who were 10 to 13 years of age was performed. Players were recruited prior to the start of the season and underwent bilateral elbow MRI. All players underwent a physical examination and responded to a questionnaire addressing their playing history and any arm pain. The MRIs were read by 2 radiologists. Responses on the questionnaire and physical examination findings were compared between subjects with and without positive MRI findings utilizing chi-square and analysis of variance techniques. RESULTS: Twenty-six players were enrolled. The majority (77%) were right-handed and 14 (54%) were a pitcher and/or catcher. Nine players (35%) had 12 positive MRI findings: 7 findings of edema or signal change of the medial epicondyle apophysis, 2 findings of fragmentation of the medial epicondyle, and 3 findings of edema or signal change of the sublime tubercle. The prevalence of positive MRI findings and a history of arm pain were not greater in pitchers and catchers compared with other players. Players with a positive MRI finding demonstrated greater reduction in shoulder internal rotation (12°) compared with the nondominant arm (3°) (p = 0.04). The two factors associated with a positive MRI finding were year-round play (47% of year-round players compared with 11% of non-year-round players; p < 0.01) and working with a private coach (71% compared with 21%; p = 0.02). Additionally, a history of pain was associated with year-round play and a private coach (p < 0.05). CONCLUSIONS: MRI abnormalities involving the medial aspect of the elbow are common in year-round Little League baseball players, especially those with internal rotation deficits and private coaches. Although Little League guidelines potentially lessen abnormalities seen in pitchers, further refinement of these guidelines addressing year-round play, pain, and private coaching should be considered. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Incomplete Follow-up After Growth Modulation Surgery: Incidence and Associated Complications.

BACKGROUND: Extraperiosteal tension plates have become the predominant method for angular deformity correction in skeletally immature patients, with some surgeons using them in very young children with the intent of removing the implants once the correction is complete. The purpose of this study is to determine the incidence of incomplete follow-up and to assess the outcomes of children who were lost to follow-up with retained implants. METHODS: A quality initiative survey was performed at 2 institutions on children treated with extraperiosteal tension plates around the knee because of sentinel events that occurred at each institution. Compliance with follow-up was noted, and children with open perigenicular physes on latest radiograph with retained implants were identified with attempts to reestablish care. Subsequent review of those children was performed, including clinical results, radiographic results, and the need for second deformity surgery. RESULTS: A total of 200 children treated with tension plates were identified (116 at institution #1, 84 at institution #2). The most common indication for surgery was genu valgum (54%), and the mean age at initial surgery was 11.7 years (range, 3.1 to 16.8 y). A high rate of retained implants with incomplete follow-up was identified at both institutions, where a total of 23 patients (12%) were lost with implants still in place. Only 7 of 23 patients returned for evaluation: 3 reached skeletal maturity with no complications, but 4 overcorrected creating the opposite angular deformity. Two of those children required osteotomies to remedy their overcorrection. Two additional patients were reachable, but failed to return for follow-up and the remaining patients were unreachable. CONCLUSIONS: The incidence of incomplete follow-up was significant at both institutions (12% combined incidence). Of those who were found for follow-up, nearly one third required a surgery beyond simple implant removal. Incomplete follow-up among this cohort was identified as a significant quality of care issue, and an EMR system has been established to actively follow children receiving growth modulation surgery. LEVEL OF EVIDENCE: Level IV.

Diagnostic shortcomings of magnetic resonance arthrography to evaluate partial rotator cuff tears in adolescents.

BACKGROUND: Recent evidence suggests an increase in the incidence of partial articular-sided rotator cuff tears in adolescent athletes, but the accuracy of diagnostic studies has not been previously assessed in this cohort. This study was performed to assess the ability of magnetic resonance imaging with arthrography (MRIa) to diagnose partial rotator cuff (PRC) pathology in the adolescent age group. METHODS: All patients under the age of 19 years who underwent shoulder arthroscopy, between August 2008 and August 2010, were grouped based on the presence of a PRC tear diagnosed by either MRIa or arthroscopy. The control cohort included children without evidence of an intraoperative PRC. Surgical findings were then correlated with the preoperative MRIa findings and the accuracy of MRIa reading. Interclass coefficient was then determined for the MRIa reviewers. RESULTS: Thirty-one of 89 adolescents (mean age, 15.9 y; 36% girls and 64% boys) who underwent arthroscopic shoulder surgery were found to have radiographic or arthroscopic evidence of a PRC injury. There were 17 boys and 14 girls in the PRC group, with a mean age of 15.6 years. The PRC injuries involved either the supraspinatus tendon, infraspinatus tendon, or both. MRIa was 44% sensitive and 87% specific, with a positive predictive value of 64% and a negative predictive value of 74% with arthroscopic findings used as the gold standard. The ICC between reviewers was κ=0.57, with an absolute agreement of 84%. CONCLUSIONS: The overall diagnostic accuracy of the MRIa with regard to adolescent PRC injuries was 72%. MRIa was found to be specific, but not sensitive for the diagnosis of this pathology. The high false-negative rate seen in this adolescent cohort indicates that a PRC injury may be present even with a negative MRIa. Therefore, if clinical suspicion indicates a PRC injury, then the treating physician should consider management for rotator cuff pathology despite negative MRIa findings. LEVEL OF EVIDENCE: Level III--retrospective cohort study.

Results of Displaced Pediatric Tibial Spine Fractures: A Comparison Between Open, Arthroscopic, and Closed Management.

BACKGROUND: Displaced tibial spine fractures are frequently treated with surgical reduction and fixation, but no comparison studies have been performed. This study was undertaken to compare fragment reduction and adverse outcomes between open arthrotomy [open reduction and internal fixation (ORIF)], arthroscopy [arthroscopic-assisted internal fixation (AAIF)], and closed management [closed management and casting (CMC)] of pediatric tibial spine fractures. METHODS: A retrospective review of children treated for displaced tibial spine fractures from 2003 to 2011 was performed after categorizing into the 3 treatment groups. Demographics, mechanism of injury, radiographic measures (plain film and computed tomography), treatment, duration of immobilization and follow-up, final range of motion, and complications were recorded. Families were contacted to obtain long-term Lysholm scores, return to activity, pain, and satisfaction with treatment. RESULTS: Seventy-six children (mean age, 12.4 y) met criteria with 29 ORIF, 28 AAIF, and 19 CMC. Radiographic measurements between x-ray and computed tomography scans found a mean error of 1 mm (SD=1.33 mm; inter-class coefficient = 0.977, P < 0.001). Initial fracture displacement was similar between AAIF and ORIF, 10.3 ± 4.4 mm and 10.8 ± 3.9 mm; but, less in CMC group (5.3 ± 2.6 mm). The mean reduction amount was 8.6 ± 4.7, 9.1 ± 4.0, and 2.3 ± 2.6 mm, respectively. A Bonferroni post hoc analysis revealed a difference between surgical and nonoperative reduction (P < 0.001), but not between AAIF and ORIF (P=0.9). Arthrofibrosis occurred with equal frequency in surgical cohorts (AAIF 12.5%, ORIF 11.1%), compared with none in the CMC group. Yet, the CMC group had a 16.7% risk for reoperation secondary to instability, loose bodies, or impingement. Twenty-four percent of each cohort was available (at mean 6.0 y) for interview with mean (median) Lysholm score: ORIF 97.4 (99), AAIF 95 (100), and CMC 86 (97.5), P = 0.35. CONCLUSIONS: Open or arthroscopic treatment of displaced tibial spine fractures affords a better reduction than closed management, but with higher risk for arthrofibrosis. Closed management may be successful when displacement is < 5 mm, and advanced imaging may not be necessary to delineate the amount of displacement.

Spectrum of operative childhood intra-articular shoulder pathology.

PURPOSE: With increased sports participation and medical community awareness, there appears to be an increase in pediatric musculoskeletal injuries. Our purpose was to identify the intra-articular injury pattern seen within the pediatric shoulder. METHODS: A retrospective review was performed at two tertiary-care children's hospitals between 2008 and 2011 on all patients who underwent magnetic resonance imaging (MRI) and subsequent shoulder arthroscopy. Exclusion criteria included: girls >14 years old and boys >16 years old. Demographics, MRI and arthroscopic findings were recorded. Labral pathology was grouped: Zone I (Bankart lesions, 3-6 o'clock for right shoulder), Zone II (posterior labral lesions, 6-11 o'clock), Zone III (SLAP lesions, 11-1 o'clock), and Zone IV (anatomic variants, 1-3 o'clock). RESULTS: One hundred and fifteen children met criteria, mean age 14.4 years (range 8-16). There were 24 girls and 91 boys, with 70 right shoulders. Of 108 children, labral pathology involved: 72 Zone I (16 isolated anterior), 56 Zone II (15 isolated posterior), 38 Zone III (four isolated superior), and three had an isolated Buford complex. Seventy had more than one labral zone injured, and 31 (30 %) had more than two zones injured. Non-labral pathology included partial rotator cuff tears and humeral avulsions of the glenohumeral ligament. CONCLUSION: With 94 % of intra-articular pathology being labral tears, the distribution of proportion in children differs from adults; moreover, 23 % involved only the posterior or posterosuperior labrum. Treating surgeons should be prepared to find anterior tears extending beyond the zone of a classic Bankart lesion and an association with C rotator cuff tears.

The use of a portable CT scanner for the intraoperative assessment of talocalcaneal coalition resections.

BACKGROUND: Intraoperative assessment of talocalcaneal (TC) coalition resection can be challenging, with no reliable plain radiographic view available for evaluation. Therefore, in March of 2011, we began using a CereTom portable CT scanner to assess TC coalition resections intraoperatively. This study evaluates the use of intraoperative CT during surgical resection of TC coalitions. METHODS: Patients who received CT scans before and after TC coalition resection, by a single surgeon, were included. Those treated without (control group, n=12 feet) and with (intraoperative CT group, n=14 feet) intraoperative CT scan were retrospectively compared. Two blinded pediatric orthopaedic surgeons assessed the quality of resection using a side-by-side comparison of preoperative and postoperative CT scans. Each resection was rated as "excellent," "fair," or "poor," and medical records were reviewed to evaluate clinical outcome. RESULTS: Substantial agreement was found between blinded reviewers (κ=0.71, 81% absolute agreement). Quality of resection was improved in the intraoperative CT group, with 57% of patients receiving an excellent rating compared with 25% in the control group. Patients in the intraoperative CT group were 4.0 times more likely to have a complete resection as compared with patients in the control group; however, this was not statistically significant (odds ratio, P>0.05; 95% confidence interval, 0.74-21.5). Intraoperative CT altered surgical decision making in 3 feet (21%) in the intraoperative CT group, leading to further resection and a subsequent excellent postoperative rating in 2 of these patients. There was 1 reoperation in the control group for continued pain and residual coalition identified on postoperative CT scan. In the intraoperative CT group there have been no reoperations for recurrent or residual qcoalition. CONCLUSIONS: This study illustrates that intraoperative CT can alter surgical decision making and may improve the ability to obtain a complete resection in TC coalition surgery. In these technically challenging cases, intraoperative scans give immediate imaging feedback to surgeons, allowing intervention if residual resection is identified. If intraoperative CT scan is available, it should be considered for surgical treatment of TC coalition resections. LEVEL OF EVIDENCE: Level III retrospective case-control study.

Spectrum of shoulder injuries in skeletally immature patients.

This article evaluates the spectrum of epidemiology and treatment of children presenting with shoulder pain. These injuries are discussed to further understand the mechanism of injury, the variation of these injuries with age, treatment options, and outcomes and complications that may arise. A retrospective clinical review was performed to compliment the findings of the literature review.

Partial rotator cuff tears in adolescents: factors affecting outcomes.

INTRODUCTION: In the adult population, rotator cuff tears are common and established treatment methods yield satisfactory results. In adolescents, however, these injuries are uncommon and few treatment methods and outcome reports exist. The purpose of this study was to examine a series of adolescent rotator cuff tears, identify associated pathology, and report treatment outcomes. METHODS: A retrospective comparative analysis of adolescent patients treated for rotator cuff tears diagnosed by magnetic resonance imaging (MRI) or arthroscopy between 2008 and 2010 was performed. Patients were divided by treatment rendered: nonoperative or operative. Demographic and diagnostic variables were compared between the 2 groups. After release to full activity, 3 patient outcome measures were obtained: QuickDASH (Disability of the Arm, Shoulder, and Hand), QuickDASH Sports module, and the Single Assessment Numerical Evaluation (SANE). RESULTS: Fifty-three adolescents (38 boys and 15 girls) with a mean age of 15.8 years (8.8 to 18.8 y) met the inclusion criteria. All rotator cuff tears were partial articular-sided tendon avulsions, and surgical treatment (when required) consisted of debridement to stable edges. All patients underwent a trial of at least 6 weeks of physical therapy, with 57% failing to improve and requiring subsequent surgery. In the patients that were treated nonoperatively, 39% were diagnosed with associated pathology based on MRI findings, whereas operative patients exhibited an associated pathology rate of 70%. Patients with MRI-diagnosed associated pathology were 1.8 times more likely (95% confidence interval, 1.02-3.13, P=0.025) to require surgery compared with those without MRI-identified associated pathology. Nineteen patients (13 operative, 6 nonoperative) completed the outcome questionnaires at a mean 16.9 months after treatment. QuickDASH, SANE, and QuickDASH Sports module scores were not statistically different between nonoperative and operative treatment groups (7.5 vs. 8.1, P=0.90; 85.3 vs. 80.6, P=0.47; and 5.2 vs. 19.5, P=0.39, respectively). All outcome measures exhibited significant correlations with one another, with the strongest correlation being a negative association between SANE and Sports module scores (r=-0.76, P=0.001). DISCUSSION: Isolated partial articular-sided tendon avulsion injuries may be successfully treated with physical therapy, with return to sports expected; however, if associated pathology was present then nonoperative treatment was less successful. Improvement in pain and activities of daily living can be achieved with surgery after failed conservative management for rotator cuff injuries; however, the adolescent athlete will often have residual shoulder complaints during sports participation. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

Tibial tubercle fractures: complications, classification, and the need for intra-articular assessment.

BACKGROUND: Adolescent tibial tubercle fractures are uncommon, complex, high-energy injuries. The use of lateral radiographs in isolation to diagnose and treat these injuries is the standard of practice. However, with a single 2-dimensional (2D) view, there may be a risk that the degree of injury can be underestimated. This study was performed to report on the outcomes of tibial tubercle fractures operatively treated, determine the utility of a single lateral x-ray to accurately document injury severity and pattern, delineate the role of advanced imaging and intraoperative arthroscopy/arthrotomy in injury treatment, and propose a new classification system of tibial tubercle fractures that accounts for the complex 3D nature of proximal tibial physeal closure, and recognizes the importance of intra-articular extension, providing guidance for intervention. METHODS: A retrospective review of operatively treated tibial tubercle fractures at our institution from 2003 to 2010 was performed. Child age, weight, mechanism of injury, Ogden classification (x-ray), advanced imaging results [computed tomography (CT)/magnetic resonance imaging (MRI)] including intra-articular fracture patterns, surgical techniques, intraoperative articular findings, and postoperative complications were collected. In addition, we classified all of our patients into a new classification system (type A--tubercle youth, type B--physeal, type C--intra-articular, type D--tubercle teen) based on a combination of plain radiograph (anteroposterior and lateral), advanced imaging (CT/MRI), and intraoperative arthrotomy/arthroscopy findings. RESULTS: We found 41 tibial tubercle fractures in 40 children (all of whom were male) with a mean age of 15.0 ± 1.1 years, and mean weight of 80.3 ± 23.4 kg. Injuries mostly occurred during jumping activities. At initial presentation, compartment syndrome or vascular compromise was seen in nearly 10% of patients, all of whom had type B--physeal injuries under our new classification system. Fifty percent of injuries were underestimated and/or not appreciated by lateral x-ray alone. In patients with intra-articular involvement, consistent 3D fracture patterns were seen on CT including anterior fragments (sagittal plane), lateral fragments (coronal plane), and anterolateral fragments (axial plane). Our new 4 part classification system was able to classify all fractures: type A (2 patients, mean age, 12.7 ± 0.2 y), type B (13 patients, mean age, 14.8 ± 0.7 y), type C (22 patients, mean age, 15.3 ± 1.1 y), and type D (2 patients, mean age, 15.5 ± 0.1 y). All fractures achieved radiographic union with 2 patients (type A--tubercle youth and type B--physeal) requiring additional procedures due to premature physeal closure. CONCLUSIONS: Tibial tubercle fractures represent high-energy injuries with potentially devastating complications such as compartment syndrome and/or vascular compromise. Intra-articular involvement is often missed with the use of plain x-ray and drastically underestimates injury severity. The use of preoperative CT scan or MRI should be utilized as adjunct to plain lateral radiograph. If intra-articular involvement is recognized preoperatively, arthroscopy or open arthrotomy should be utilized at the time of surgery. Our new classification system is rooted in the development of the proximal tibia, accounts for intra-articular involvement, and provides guidance for treatment. LEVEL OF EVIDENCE: Level III--diagnostic study.

Treatment of displaced pediatric supracondylar humerus fracture patterns requiring medial fixation: a reliable and safer cross-pinning technique.

INTRODUCTION: Treatment of displaced Gartland type 3 supracondylar humerus fractures in children may include closed reduction and percutaneous pinning. The pin configuration may be all-lateral entry or cross-pin. Despite the improved stability possible with cross-pinning, there is an inherent iatrogenic risk to the ulnar nerve of about 6%. As medial fixation may be necessary for certain fracture patterns, this study was conducted to evaluate the risk of ulnar neuropathy using a technique here described and developed to minimize injury to this structure. METHODS: A retrospective review was performed on all children treated for a supracondylar humerus fracture at our institution between 2003 and 2010. All the type 3 displaced fractures were placed into 2 groups: lateral-entry pinning and cross-pinning. The 2 groups were then compared for risk of ulnar nerve injury, and a post hoc power analysis was performed. RESULTS: A total of 381 supracondylar humerus fractures met the inclusion criteria. Our cross-pinning technique was used in 187 (49%) of the children with a mean age of 5.8 years (range, 0.92 to 13.92 y). There were 4 ulnar nerve injuries in the entire cohort and 2 sustained as iatrogenic injuries in the cross-pinning group (1.1%). There was no significant difference between our 2 groups in regard to risk of ulnar nerve injury (P=0.24). There is a statistically significant lower risk of ulnar nerve injury in our cross-pinning technique than previously described techniques (P=0.0028), with a post hoc power analysis of 93%. CONCLUSIONS: Despite the inherent risk for iatrogenic nerve injury with cross-pinning completely displaced supracondylar humerus fractures, there is often a need to use this technique to improve fixation and stability of the fracture. Our method of cross-pinning is safe and reproducible for providing fracture stability with a significant decrease in the risk of iatrogenic ulnar nerve injury (1 in 94) when a medial pin is required. LEVEL OF EVIDENCE: Level III-therapeutic studies.

Treatment of talocalcaneal coalitions.

BACKGROUND: The purpose of this study was to review outcomes of patients treated for symptomatic talocalcaneal coalition with resection and interposition of fat graft. METHODS: A retrospective review was performed on all patients who underwent surgical treatment for symptomatic talocalcaneal coalition over a 13-year period. Ninety-three feet were treated with excision and fat graft interposition by 6 surgeons. All patients underwent a chart review. Patient's outcome was assessed at the last follow-up using the American Orthopaedic Foot and Ankle Society Hindfoot scale. Postoperative computed tomography scans were available for 20 feet. RESULTS: Forty-nine feet had follow-up of at least 12 months and had a score obtained through the American Orthopaedic Foot and Ankle Society Hindfoot scale. At an average of 42.6 months of follow-up, the average score obtained was 90/100 (excellent). The postoperative computed tomography scans demonstrated 1 recurrence (3%), which was treated with repeat excision. An additional patient was reoperated for failure to excise the coalition completely. Eleven patients (34%) underwent a subsequent surgery to correct the alignment of the foot. To the best of our knowledge, none of the patients excluded because of short follow-up had repeat surgery or recurrence. CONCLUSIONS: A symptomatic talocalcaneal coalition can be treated with excision and fat graft interposition, and achieve good to excellent results in 85% of patients. Patients should be counseled that a subset may require further surgery to correct malalignment. LEVEL OF EVIDENCE: Level IV-case series.