McIntosh, Amy L.

Background: Femoral nerve block (FNB) has become a popular method of postoperative analgesia for anterior cruciate ligament (ACL) reconstruction in pediatric and adolescent patients. Successful rehabilitation after surgery involves return of quadriceps and hamstring strength. Purpose: To compare knee strength and function 6 months after ACL reconstruction in pediatric and adolescent patients who received FNB versus patients with no nerve block. Study Design: Cohort study; Level of evidence, 3. Methods: Patients 18 years or younger who underwent primary ACL reconstruction between 2000 and 2010 at a single institution were identified. If the patient was skeletally immature, a transphyseal ACL reconstruction was performed. Of these patients, 68% underwent reconstruction with a patellar tendon autograft, and in 32% of patients a hamstring autograft was utilized. There were 124 patients who met the study inclusion criteria, including 62 in the FNB group (31 males, 31 females) and 62 patients in the control group (25 males, 37 females). All study patients participated in a comprehensive rehabilitation program that included isokinetic strength and functional testing at 6 months postoperatively. Results: Univariate analysis showed a significantly higher deficit at 6 months in the FNB group with respect to fast isokinetic extension strength (17.6% vs 11.2%; P = .01) as well as fast (9.9% vs 5.7%; P = .04) and slow (13.0% vs 8.5%; P = .03) isokinetic flexion strength. There was no difference in slow isokinetic extension strength deficit between the 2 groups (FNB, 22.3% vs control, 18.7%; P = .20). With respect to function, there were no differences in deficit for vertical jump (FNB, 9.4% vs control, 11.3%; P = .30), single hop (7.6% vs 7.5%; P = .96), or triple hop (8.0% vs 6.6%; P = .34) between the 2 groups. A significantly higher percentage of patients in the control group met functional and isokinetic criteria for return to sports at 6 months (90.2% vs 67.7%; odds ratio, 4.37; P = .002). Conclusion: Pediatric and adolescent patients treated with FNB for postoperative analgesia after ACL reconstruction had significant isokinetic deficits in knee extension and flexion strength at 6 months when compared with patients who did not receive a nerve block. Patients without a block were 4 times more likely to meet criteria for clearance to return to sports at 6 months.

Objectives: Femoral nerve blockade has become a popular method of postoperative analgesia for anterior cruciate ligament (ACL) reconstruction in pediatric and adolescent patients. Successful rehabilitation after ACL reconstruction involves return of quadriceps and hamstring strength and dynamic knee stability. The objective of this study was to compare strength and function six months after ACL reconstruction in pediatric and adolescent patients who received a femoral nerve block versus a control group of patients with no nerve block. Methods: A search of our institutional database was performed to identify patients 17 years of age or younger who underwent primary ACL reconstruction between 2001 and 2010. Revision ACL surgeries and previous contralateral and ipsilateral knee surgeries were excluded. Based on institutional protocol, the patients participated in a comprehensive rehabilitation program and underwent isokinetic strength testing (slow and fast activation) and functional testing (vertical jump, single hop, triple hop) at six months after ACL reconstruction. Results: There were 127 patients that met the inclusion criteria, including 63 patients in the NB group (32 males, 31 females) and 64 patients in the control group (26 males, 38 females). There were no significant differences between the NB group and the control group with respect to age (15.7 ± 1.4 vs. 15.5 ± 1.4, p = 0.26), sex (p = 0.29), BMI (23.7 ± 3.6 vs. 23.8 ± 3.6, p = 0.91), or type of graft used (67% patellar tendon autograft, 33% hamstring autograft vs. 70% patellar tendon autograft, 30% hamstring autograft, p = 0.85). Univariate analysis showed a significantly higher deficit at six months in the NB group with respect to fast isokinetic extension strength (17.6% vs. 11.3%, p = 0.008), as well as fast (12.8% vs. 8.3%, p = 0.029) and slow (9.9% vs. 5.5%, p = 0.029) isokinetic flexion strength. There was no difference in slow extension isokinetic strength deficit between the two groups (NB 22.1% vs. control 18.9%, p = 0.246).. With respect to function, there were no differences in deficit for vertical jump (NB 9.3% vs. control 11.3%, p = 0.267), single hop (NB 7.5% vs. control 7.6%, p = 0.970), or triple hop (NB 7.9% vs. control 6.5%, p = 0.375) between the two groups. A higher percentage of patients in the control group met criteria for return to sports at six months. (88.9% vs. 68.3%, p = 0.008). Conclusion: Pediatric and adolescent patients treated with a femoral nerve block for postoperative pain control after ACL reconstruction had significant isokinetic deficits in knee extension (quadriceps) and flexion (hamstring) strength at six months when compared to patients who did not receive a nerve block. No differences in the results of functional testing were observed between the two groups. A significantly higher percentage of patients in the group who did not receive a block were cleared to return to sports at six months following ACL reconstruction.

Background Shoulder arthroscopy is not common in the pediatric and adolescent population, but the frequency may be on the rise. The purpose of the study was to determine the incidence of acute complications of arthroscopic shoulder surgery in children and adolescents. Methods A retrospective, cross-sectional review was performed identifying patients aged 18 years or less who underwent an arthroscopic shoulder procedure from 1997 to 2009 at Institution 1 and 2007 to 2010 at Institution 2. Exclusion criteria included open procedures and missing records. Demographic and surgical data were collected, including intra-operative and post-operative complications during the first 6 months. The complications were divided into minor (no secondary treatment) and major (secondary treatment rendered). Results Two hundred children, mean age 15.9 years, met criteria and 73 % were boys. All procedures were performed under general anesthesia, but 51 % included inter-scalene regional anesthesia. There were 16 (8.0 %) total complications recorded. Major complications occurred in five (2.5 %) patients, including two tendinitis/bursitis requiring injections, one broken pain pump catheter requiring an accessory incision to retrieve, one pain control readmission, and one laceration of the cephalic vein requiring ligation. Minor complications occurred in 11 (5.5 %) patients, including allergic reactions, transient dysesthesias, headaches, bronchitis, syncope, transient hypotension, and uvula swelling. Conclusion Although we found no seriously deleterious outcomes, it is important to recognize that an additional service was rendered for 2.5 % of children undergoing shoulder arthroscopy. The events that did occur may be preventable and this study should serve as a baseline to improve quality and safety of shoulder arthroscopy in the pediatric population.

Background Aneurysmal bone cysts (ABCs) are a benign aggressive tumor that occurs rarely in the pelvis in the pediatric population. Pelvic ABCs may involve the triradiate cartilage and/or the acetabulum, which increases the technical difficulty of surgical treatment and has potential implications on the growth and development of the hip joint. This study examines the clinical presentation, rate of surgical complications, and recurrence rate, as well as, long-term clinical and functional outcomes of children with pelvic ABCs treated at a single institution by a single treatment modality. Methods Between 1988 and 2008, 142 children with histologically confirmed ABCs were treated at our institution. Seventeen (12 %) tumors were located in the pelvis. A total of 13 pelvic ABCs (5 ilium-periacetabular, 4 pubic, 3 ilium-iliac wing, and 1 ischium) were included in this study. There were eight male and five female patients with a mean age of 12.9 years (range 4.1–17.5 years) at the time of surgery. The Toronto Extremity Salvage Score (TESS), the Musculoskeletal Tumor Society 1993 (MSTS’93) score, and the Short Form Health Survey Sf-36 were obtained at a minimum 5-year follow-up in all patients (mean follow-up 11.5 years, range 5.5–19.8 years). The mean age at follow-up was 24.3 years (range 14.6–32.6 years). Results All patients were treated surgically with intralesional curettage extended with a high-speed burr and bone grafting. Eight patients received adjunctive therapy with phenol. Five patients had preoperative selective arterial embolization. Of the 13 patients, 1 had a local recurrence diagnosed at 6 months after surgery. The only complication in the cohort was a superficial wound infection. At the latest follow-up, all patients were free of disease. The mean TESS score was 95 and the mean MSTS’93 score was 93 %. The mean self-rated general health score, according to the SF-36 was 87 % of total points possible. Conclusions Extended curettage and bone grafting of pelvic ABCs in the pediatric population can yield high clinical and functional scores at an average of 11 years follow-up with a low rate of complications and recurrence. Level of evidence IV, case series.

Purpose The purposes of this study were to determine the frequency of acute and subacute complications (within 6 months) of arthroscopic knee procedures in patients aged 17 years or younger and to determine associated risk factors. Methods We identified all patients aged 17 years or younger who underwent arthroscopic knee procedures at our institution from 1997 to 2009. Patient demographic and surgical data were collected from the medical and surgical records, with specific focus on intraoperative and postoperative complications. Results During the study period, 1,002 knee arthroscopies were reviewed. The overall complication rate was 14.7%. Major complications occurred in 21 surgeries (2.1%) and included the following: septic arthritis (n = 3, 0.3%), wound complication requiring operative revision (n = 9, 0.9%), arthrofibrosis requiring manipulation (n = 4, 0.4%), other unplanned subsequent surgery (n = 4, 0.4%), and death (n = 1, 0.1%). Surgeries with an anesthesia time of 265 minutes or greater ( P = .026), operative time of 220 minutes or greater ( P = .013), or tourniquet time of 114 minutes or greater ( P < .001) and surgeries with 3 or more Current Procedural Terminology codes ( P = .003) had a statistically significant increase in risk of major complications. The incidence of minor complications was 12.6%, which included persistent effusion/hemarthrosis requiring arthrocentesis (n = 59, 5.9%) and superficial wound infection (n = 18, 1.8%). Conclusions Major complications after knee arthroscopy in children and adolescents are rare, but minor complications are more common. If possible, surgeons should avoid prolonged anesthesia, surgery, and tourniquet times. The pediatric patient's medical and family history should be reviewed to identify important risk factors. Level of Evidence Level IV, therapeutic case series.

Objectives: Arthroscopic knee procedures are commonly performed in pediatric/adolescent patients. Reported complications following these procedures are low, however, no childhood specific data exists. Therefore, the purpose of this study is to determine the acute complications (within 6 months) of arthroscopic knee procedures in patients aged 17 years or less. Methods: This is a retrospective review of patients aged 17 years or less who underwent an arthroscopic knee procedure from 1997 to 2009 at a single institution. Demographic and surgical data was collected, in addition to specific data on intra-operative and post-operative complications. Minor complications included peripheral nerve block failure, regional anesthesia failure requiring conversion to general anesthesia, superficial wound infection/dehiscence, persistent knee effusion requiring aspiration, and sensory nerve dysesthesia. Major complications included death, major medical complication, septic arthritis, wound requiring repeat closure, arthrofibrosis, equipment failure, and revision surgery. Results: 1015 patients (555 males (54.7%), 460 females (45.3%)) with average age 15.3 (range 4-17) years were analyzed. The average operative time was 133.9 minutes (range 14-520). 467 (46%) underwent ACL reconstruction, 465 (45.8%) underwent synovectomy, treatment of an OCD lesion, meniscal treatment, or lateral release, 52 (5%) had a medial patellofemoral ligament reconstruction +/- tibial tubercle transfer, 17 (1.7%) arthroscopic fixation of a tibial eminence fracture, and 14 (1.4%) other ligament reconstruction. There were 147 (14.5%) total complications recorded. Major complications occurred in 21 (1.4%) of patients and minor complications in 126 (12.4%) of patients. Major complications included: intra-articular instrument breakage in 1(0.098%), septic arthritis in 4 patients (0.394%), 9 wounds requiring repeat closure (0.886%), arthrofibrosis in 5 patients (0.492%), unplanned subsequent surgical procedure in 3 patients (0.002%), and death in 1 patient (0.098%). 2 patients were readmitted to the hospital (1 DIC, 1 a-fib and syncope). There were no pulmonary emboli or DVTs, and no vascular injuries. No patients developed CRPS. Minor complications included:5 patients (0.492%) sensory nerve paresthesias, 10 (0.985%) patients with failed regional anesthetic, 16 (1.57%) patients with post-operative pain pump that required early discontinuation, 18(1.77%) patients with superficial wound infection/irritation, 60 (5.91%) patients with persistent effusion/hemarthrosis requiring arthrocentesis, and 17(1.67%) patients had medical problems that required intervention (asthma exacerbation, urinary retention). Conclusion: Major complications following knee arthroscopy in children and adolescents are relatively low 1.4%. Minor complications are more common (12.4%) but did not alter the post-operative course or recovery. DVT, PE, and CRPS did not occur in this patient cohort.

Background: Patellofemoral instability is common in the pediatric and adolescent population, yet prognosis after the first dislocation has been difficult to determine. Purpose: To describe the demographics of pediatric and adolescent patients with a first-time patellofemoral dislocation and to determine predictors of recurrent instability. Study Design: Case-control study; Level of evidence, 3. Methods: A search of the Mayo Medical Index database between 1998 to 2010 was performed, and 2039 patients were identified. Inclusion criteria were (1) age 18 years or younger, (2) no history of patellofemoral subluxation/dislocation of the affected knee, (3) radiographs within 4 weeks of the initial instability episode, and (4) a dislocated patella requiring reduction or convincing history/findings suggestive of acute patellar dislocation (effusion/hemarthrosis, tenderness along medial parapatellar structures, and apprehension with lateral patellar translation). Radiographs were evaluated for trochlear dysplasia (Dejour classification) and patella alta (Caton-Deschamps and Insall-Salvati indices). Skeletal maturity was graded based on the distal femoral and proximal tibial physes (open, closing, or closed). Results: A total of 222 knees (120 male [54.1%] and 102 female [45.9%]) in 210 patients with an average age of 14.9 years (range, 9-18 years), met the inclusion criteria. Twenty-four patients (10.8%) underwent early surgery. All others were initially treated nonoperatively. Of the 198 patients in this group, 76 (38.4%) had recurrent instability, and 39 (51.3%) of these required surgical treatment. Recurrent instability was associated with trochlear dysplasia ( P < .01). Patients with both immature physes and trochlear dysplasia had a recurrence rate of 69% (33/48), with a hazard ratio of 3.3. Age, sex, body mass index, and patella alta were not statistically associated with recurrent instability. Conclusion: Nonoperative treatment for first-time patellofemoral dislocation resulted in a 62% success rate. However, skeletally immature patients with trochlear dysplasia had only a 31% success rate with nonoperative management. Nearly half of patients with recurrent instability required surgical intervention to gain stability.

Objectives To review the need for operative intervention and critical care services for motocross truncal injuries in children. Design cohort Retrospective review of patients identified via the hospital trauma registry. Setting Our Level 1 Pediatric Trauma Center serves five motocross tracks. These patients require frequent medical care for injuries. Participants All patients ≤17 years of age with truncal injuries sustained during motocross activities, between 2000 and 2011, were identified through the trauma registry. Primary and secondary outcome measures Operative intervention, intensive care unit (ICU) admission, length of stay, morbidity and demographics were reviewed. Results Motocross injured 162 children. Thirty (18.5%) were thoracic or abdominal injuries. Operative intervention was required in eight (27%) patients. Mean injury severity score (ISS) was 11.8. ICU admission was required in 50% and average hospital length of stay was 4.1 days. The most common injuries include pulmonary contusion, pneumothorax, spleen and liver lacerations. 13% of subjects suffered truncal injury from motocross on more than one occasion. Conclusions Paediatric motocross-related truncal injuries are significant. Surgical intervention is required in 27% of patients. The lower ISS incurred from motocross combined with high surgical and ICU admission rates suggests focal high-impact injuries to the chest and abdomen. Despite significant injury, 13% of motocross patients suffer recurrent injuries. Parents and children need injury prevention education.

Abstract Osteochondritis dissecans (OCD) of the humeral capitellum most commonly affects young athletes engaged in sports that repetitively stress the elbow. It is characterized by localized injury of subchondral bone of the humeral capitellum. To determine the best treatment option for OCD in young athletes, it is important to differentiate between stable and unstable OCD lesions. Stable lesions can be treated with rest, whereas unstable lesions, as well stable lesions that do not respond to conservative therapy, may require a surgical approach. Magnetic resonance imaging is the diagnostic study of choice to evaluate capitellar OCD lesions and loose bodies and to accurately determine the stability and viability of the OCD fragment. A variety of surgical approaches have been reported, from internal fixation of large fragments to autologous chondrocyte grafts. Arthroscopic surgery is becoming the standard treatment of capitellar OCD. This minimally invasive approach shows good results, a low risk of operative morbidity, and early recuperation postoperatively. The distal ulnar portal we describe here allows for ergonomic exposure to the posterolateral capitellum, providing easier access for drilling, burring, and local debridement of lesions amenable to arthroscopy.