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 (\u3e20%) were found to have concomitant injuries. Overall, surgical management was performed in 25% of patients in our cohort

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 \u3c1 \u3emm), good (1 to \u3c3 \u3emm), fair (3 to 5 mm), or poor (\u3e5 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 ( 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

Subsequent Surgery After Revision Anterior Cruciate Ligament Reconstruction: Rates and Risk Factors From a Multicenter Cohort

BACKGROUND: While revision anterior cruciate ligament reconstruction (ACLR) can be performed to restore knee stability and improve patient activity levels, outcomes after this surgery are reported to be inferior to those after primary ACLR. Further reoperations after revision ACLR can have an even more profound effect on patient satisfaction and outcomes. However, there is a current lack of information regarding the rate and risk factors for subsequent surgery after revision ACLR. PURPOSE: To report the rate of reoperations, procedures performed, and risk factors for a reoperation 2 years after revision ACLR. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: A total of 1205 patients who underwent revision ACLR were enrolled in the Multicenter ACL Revision Study (MARS) between 2006 and 2011, composing the prospective cohort. Two-year questionnaire follow-up was obtained for 989 patients (82%), while telephone follow-up was obtained for 1112 patients (92%). If a patient reported having undergone subsequent surgery, operative reports detailing the subsequent procedure(s) were obtained and categorized. Multivariate regression analysis was performed to determine independent risk factors for a reoperation. RESULTS: Of the 1112 patients included in the analysis, 122 patients (11%) underwent a total of 172 subsequent procedures on the ipsilateral knee at 2-year follow-up. Of the reoperations, 27% were meniscal procedures (69% meniscectomy, 26% repair), 19% were subsequent revision ACLR, 17% were cartilage procedures (61% chondroplasty, 17% microfracture, 13% mosaicplasty), 11% were hardware removal, and 9% were procedures for arthrofibrosis. Multivariate analysis revealed that patients aged <20 years had twice the odds of patients aged 20 to 29 years to undergo a reoperation. The use of an allograft at the time of revision ACLR (odds ratio [OR], 1.79; P = .007) was a significant predictor for reoperations at 2 years, while staged revision (bone grafting of tunnels before revision ACLR) (OR, 1.93; P = .052) did not reach significance. Patients with grade 4 cartilage damage seen during revision ACLR were 78% less likely to undergo subsequent operations within 2 years. Sex, body mass index, smoking history, Marx activity score, technique for femoral tunnel placement, and meniscal tearing or meniscal treatment at the time of revision ACLR showed no significant effect on the reoperation rate. CONCLUSION: There was a significant reoperation rate after revision ACLR at 2 years (11%), with meniscal procedures most commonly involved. Independent risk factors for subsequent surgery on the ipsilateral knee included age <20 years and the use of allograft tissue at the time of revision ACLR

The 5-Strand Hamstring Graft in Anterior Cruciate Ligament Reconstruction

The use of anterior cruciate ligament reconstruction in the pediatric and adolescent population has been increasing in recent years. Autograft hamstring graft is favored in this population, but these patients often have smaller hamstring tendons that yield smaller final graft constructs. These smaller grafts are associated with an increased need for revision surgery. We describe a technique for obtaining a larger-diameter anterior cruciate ligament graft construct from autologous hamstring graft without allograft supplementation

Pediatric Orthopedic Trauma Care During the COVID-19 Pandemic: A Survey of the Pediatric Orthopedic Society of North America

Background: The COVID-19 pandemic has dramatically altered the practice of pediatric orthopedic trauma surgery in both outpatient and inpatient settings. While significant declines in patient volume have been noted, the impact on surgeon decision-making is unclear. Purpose: We sought to investigate changes in pediatric orthopedic trauma care delivery as a result of COVID-19 and determine their implications for future orthopedic practice. Methods: An electronic survey was distributed to all members (N = 1515) of the Pediatric Orthopedic Society of North America (POSNA) in March to April 2021; only members who provided care for pediatric orthopedic trauma patients were asked to complete it. The survey included questions on hospital trauma call, inpatient care, outpatient clinic practice, and 3 unique fracture case scenarios. Results: A total of 147 pediatric orthopedic surgeons completed the survey, for a 9.7% response rate, with 134 (91%) taking trauma call at a hospital as part of their practice. Respondents reported significant differences across institutions regarding COVID-19 testing, hospital rounding, and employee COVID-19 screening. Changes in outpatient fracture management were observed, including a decreased number of follow-up visits for nondisplaced clavicle fractures, distal radius buckle fractures, and toddler's fractures. Of respondents who changed their fracture follow-up schedules due to COVID-19, over 75% indicated that they would continue these outpatient treatment schedules after the pandemic. Conclusions: This survey found changes in pediatric orthopedic trauma care as a result of the COVID-19 pandemic. The use of telemedicine and abbreviated follow-up practices for common fracture types are likely to persist following the resolution of the COVID-19 pandemic

Pediatric Anterior Cruciate Ligament Femoral Fixation: The Trans-Iliotibial Band Endoscopic Portal for Direct Visualization of Ideal Button Placement

Pediatric and adolescent anterior cruciate ligament reconstruction is a commonly performed procedure that has been increasing in incidence. Multiple techniques for graft fixation have been described. Button-based femoral cortical suspension fixation of the anterior cruciate ligament graft allows for fast, secure fixation with strong load-to-failure biomechanical properties. The biomechanical properties of button-based femoral cortical suspension fixation are especially beneficial with soft-tissue grafts such as hamstring autografts. Confirmation of a successfully flipped button can be achieved with intraoperative fluoroscopy or indirect viewing; however, these techniques do not provide direct visualization of the flipped button. Our trans-iliotibial band endoscopic portal allows the surgeon to safely and directly visualize the flipped button on the lateral femoral cortex and ensure that there is no malpositioning in the form of an incompletely flipped button or from soft-tissue interposition between the button and the lateral femoral cortex. This portal therefore allows for direct visual confirmation that the button is fully flipped and resting flush against the femoral cortex, deep to the iliotibial band and vastus lateralis

Lateral meniscus width at the popliteus recess and the relevance to saucerization of discoid lateral menisci

Background: Discoid lateral meniscus (DLM) is a congenital anomaly of the knee where the normally “O” shaped lateral meniscus has redundant tissue filling the “O” and covering the lateral tibial plateau. The redundant tissue can cause mechanical symptoms and pain. Treatment of symptomatic DLM is arthroscopic saucerization to reshape the meniscus to a more normal contour. Enough tissue must be removed to eliminate mechanical symptoms but not too much as to create instability. The residual width of the meniscus is crucial at the popliteus hiatus because here the peripheral rim is unattached to the capsule. The literature recommends a residual width of 6-8 mm.1,2 Purpose/Hypothesis: The primary purpose of this research is to determine the width of the meniscus at the popliteal hiatus in normal specimens. Our null hypothesis is that a residual width of 6-8 millimeters will be sufficient for saucerization of DLM. Methods: We made direct measurements of lateral meniscus radial width from the outer rim at the popliteus hiatus to the inner edge (Figure 1) in 19 specimens (ages 2 months to 120 months.) We measured one four-year-old specimen with bilateral complete DLM. We also measured 39 digital images of specimens (ages 1 month to 132 months) using ImageJ. Finally, we made direct measurements of 8 skeletally mature specimens. Results: Figure 2 shows the relationship of meniscus width as a function age. The average width of specimens <3-years-old was 5.5mm. The average width of the ten-year-old specimens was 12mm. The average width of the skeletally mature specimens was 16mm. The four-year-old DLM specimen measured 19 mm. Conclusions: We rejected our null hypothesis. Direct measurements suggest that a residual width of 6-8mm is insufficient for children 8-years and older. A width of at least a full centimeter more closely approximates our findings, and for adolescents consider a residual rim of 15 mm. For children less than six-years-old a residual width of 6-8mm is sufficient