Ashraf, Ali

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.

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.

Purpose Children with multiple hereditary exostoses (MHE) have numerous osteochondromas, with the most prominent lesions typically over the appendicular skeleton. A recent report noted a high rate of intracanal lesions in this patient population and recommended preventative spinal screening with magnetic resonance imaging (MRI) or computed tomography (CT). We sought to evaluate the prevalence of spinal stenosis from intracanal osteochondromas at our pediatric orthopedic center in order to evaluate if routine screening is warranted. Methods All pediatric patients treated for MHE were retrospectively identified. Records were reviewed to determine demographics, previous orthopedic surgery, and indication and results of axial spine imaging (CT or MRI). Imaging studies were reviewed to evaluate the presence of intracanal and compressive spinal lesions. Results Between 1990 and 2011, axial imaging was performed in nine patients with MHE due to concerns of pain, weakness, and/or dizziness. These patients had moderate disease involvement, with a mean of 4.9 previous orthopedic surgeries to address skeletal osteochondromas. Two patients with MHE had cervical spinal stenosis secondary to intracanal osteochondromas. Both children successfully underwent spinal decompression. Thus, of our MHE population undergoing axial imaging, 22 % were noted to have intracanal lesions. Conclusions Our experience reveals a >20 % rate of compressive intracanal osteochondromas in MHE patients undergoing spinal imaging. These two patients represent 5 % of the MHE patients treated at our center. These lesions may be slow growing, and significant consequences can occur if not identified promptly. Thus, we confer that routine axial screening of the spinal canal may be warranted in these children.