Milbrandt, Todd A.

Background: The Green-Anderson (GA) leg-length data remain the gold standard for the age-based assessment of leg lengths in children despite their methodologic weaknesses. We aimed to summarize current growth trends among a cross-sectional cohort of modern U.S. children using quantile regression methods and to compare the median femoral and tibial lengths of the modern U.S. children with those of the GA cohort. Methods: A retrospective review of scanograms and upright slot-scanning radiographs obtained in otherwise healthy children between 2008 and 2020 was completed. A search of a radiology registry revealed 3,508 unique patients between the ages of 2 and 18 years for whom a standard-of-care scanogram or slot-scanning radiograph had been made. All patients with systemic illness, genetic conditions, or generalized diseases that may affect height were excluded. Measurements from a single leg at a single time point per subject were included, and the latest available time point was used for children who had multiple scanograms made. Quantile regression analysis was used to fit the lengths of the tibia and femur and overall leg length separately for male patients and female patients. Results: Seven hundred patients (328 female and 372 male) met the inclusion criteria. On average, the reported 50th percentile tibial lengths from the GA study at each time point were shorter than the lengths in this study by 2.2 cm (range, 1.4 to 3.3 cm) for boys and 2 cm (range, 1.1 to 3.1 cm) for girls. The reported 50th percentile femoral lengths from the GA study at each time point were shorter than the lengths in this study by 1.8 cm (range, 1.1 to 2.5 cm) for boys and 1.7 cm (range, 0.8 to 2.3 cm) shorter for girls. Conclusions: This study developed new growth charts for femoral and tibial lengths in a modern U.S. population of children. The new femoral and tibial lengths at nearly all time points are 1 to 3 cm longer than traditional GA data. The use of GA data for epiphysiodesis could result in underestimation of expected childhood growth. Level of Evidence: Prognostic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Long-term outcomes of surgical treatment for pediatric developmental dysplasia of the hip (DDH) are not well defined. The purpose of this study was to report long-term radiographic and clinical outcomes, survivorship free of total hip arthroplasty (THA), and predictors of subsequent THA following childhood treatment of DDH. This study was a single-institution retrospective review of hips treated for DDH with closed or open reduction at a minimum 10-year follow-up. 107 patients (119 hips) were included with a mean patient age of 3.3 years at childhood treatment. At mean 30.5 years follow-up, 24 hips had undergone THA (20%). Mean patient age at time of THA was 33.5 years. None of the hips treated with closed reduction alone required THA, whereas 8 hips treated with open reduction (25%) underwent THA. Hips with patient age > 4 years at the time of treatment had lower survivorship at 35 years follow-up (50% vs. 85%; p < 0.001). Additionally, femoral osteotomy (OR 2.0, p < 0.001), and previous treatment elsewhere (27% vs. 16%; p < 0.01) were associated with subsequent THA. Early referral and appropriate intervention may prove important, as age and prior treatment were predictive of subsequent THA.

Adolescent idiopathic scoliosis (AIS) can be treated with bracing or surgery, which may affect patient’s physical activity (PA). However, there are limited objective assessments of PA in patients with AIS. This study aims to compare the outcome of spinal bracing vs. surgery in patients with AIS based on a device that measured daily PA. In total 24 patients with AIS participated, including 12 patients treated with bracing and 12 with spinal surgery. Daily PA was measured throughout 4 consecutive days using four tri-axial accelerometers and patient-reported functional status was reported using the SRS-22 questionnaire. The participants were assessed both before the treatment and after treatment at a 12-month follow-up. Patients with AIS had no significant change in their PA levels at the 12-month follow-up after surgical correction. On the contrary, patients with AIS following a year-long bracing treatment had significantly reduced time spent active (P = 0.04) with an average reduction in walking steps by 2137 steps/day (P = 0.005). There was no significant difference in function, pain, self-image and mental health domains following both treatments, as reported by the SRS-22. There was a significant improvement in satisfaction for both treatment groups (P ≤ 0.02). Significantly reduced PA and increased sedentary time are reported in patients with AIS following bracing treatment. An objective PA assessment is recommended to track the effect of scoliosis treatment on PA. Patients with AIS should be actively encouraged to achieve and maintain their recommended daily PA levels irrespective of the type of treatment. Level of evidence: Level II.

Background: Some surgeons are now considering fixation of traumatic chondral-only fragments in juvenile knees, but few data remain to guide treatment. Purpose: To determine if surgical fixation of chondral-only fragments in the juvenile knee results in an adequate healing response with successful imaging and clinical outcomes. Study Design: Case series; Level of evidence, 4. Methods: Data were collected on 16 skeletally immature patients treated with fixation of chondral-only fragments with a minimum 1-year follow-up. Patients were selected by the operating surgeons based on the quality and size of the chondral fragment. Demographic data, lesion characteristics, surgical procedure details, complications, and postoperative imaging were assessed. Validated outcome measures were collected pre- and postoperatively and included the following scores: International Knee Documentation Committee (IKDC), Marx Activity Scale, Knee injury and Osteoarthritis Outcome Score (KOOS), Hospital for Special Surgery Pediatric Functional Activity–Brief Scale (HSS Pedi-FABS), Patient-Reported Outcomes Measurement Information System (PROMIS)–Physical Health and PROMIS–Psychological Health, and Tegner. Results: The mean age of our patient cohort was 14.9 years. The mean size of the repaired defects measured 3.2 cm 2 . Injury sites included the patella (n = 1), medial femoral condyle (n = 3), trochlea (n = 4), and lateral femoral condyle (n = 8). Within the mean follow-up time of 42.3 months (range, 15-145), there was 1 clinical failure with loosening of the chondral fragment and the need for reoperation. At a mean follow-up of 3.5 years, the mean (interquartile range) patient-reported outcome scores were as follows: IKDC, 95.2 (94.3-100); Marx Activity Scale, 11.5 (11.5-16); KOOS, 95.81 (93.5-95.81); HSS Pedi-FABS, 16.94 (11.5-26); PROMIS–Physical Health, 93.75% (90%-100%); PROMIS–Psychological Health, 90% (88.75%-100%); and Tegner, 5.69 (4.75-7). All patients who were engaged in sports before injury returned to the same or higher level of competition with the exception of 1 patient. Conclusion: Primary repair of chondral-only injuries with internal fixation can be a successful treatment option in selected patients. Clinical and imaging results at final follow-up suggest that reintegration of the cartilage fragment is achievable and leads to excellent clinical function and a high return-to-sports rate.

Purpose: The purpose of this study is to compare pediatric hip aspiration in the operating room under general anesthesia or via bedside aspiration under moderate sedation and delineate the anesthetic time required. Methods: A database query conducted at two academic institutions identified all patients under the age of 17 who underwent hip aspiration between 2000 and 2017. At one institution, aspiration was performed in the operating room under general anesthesia. Patients were kept anesthetized until cell count was complete. At the second institution, aspiration was performed in the emergency room at bedside under sedation. The medical record was reviewed for demographic data, hip aspiration results, diagnoses, treatment, and anesthesia time. Results: A total of 233 patients (233 hips) with a mean age of 7.2 years were identified. Seventy-five patients underwent aspiration in the operating room, and 158 patients underwent bedside aspiration. Patients with a negative aspiration averaged 87 min under anesthesia when performed in the operating room and 29 min under sedation when performed at bedside. Patients with a negative aspiration performed in the operating room after 5 pm averaged 99 min under anesthesia, and 73 min under anesthesia when performed between 7 am and 5 pm (p < 0.01). Seventy-eight (49%) patients who underwent bedside aspiration did not require operative intervention and therefore avoided general anesthesia. Conclusion: Pediatric hip aspiration performed in the operating room results in prolonged anesthesia times while synovial fluid is transported and processed. Anesthesia times are significantly longer after 5 pm. Bedside aspiration resulted in significantly less anesthesia exposure, with half of patients undergoing bedside aspiration avoiding general anesthesia altogether. Level of evidence: Level III.

Background: Type I tibial spine fractures are non-displaced or minimally displaced (≤ 2mm displacement) fractures of the tibial eminence and ACL insertion traditionally managed nonoperatively with immobilization. Hypothesis/Purpose: We hypothesized that type I fractures do not carry significant risk of associated injuries and therefore do not require additional interventions aside from immobilization. Methods: We reviewed 52 patients classified by their treating institution with type I tibial spine fractures presenting between January 1, 2000 and January 31, 2019 at 10 institutions. Patients of age ≤ 18 years with pre-treatment plain radiographs and at least one year of follow-up were included. Data was collected on patient demographics, injury mechanism, treatment details, presence of concomitant injuries, range of motion (ROM) at final follow-up, treatment complications, and any return to the operating room for the injured knee. Pre-treatment imaging was reviewed by four authors to assess agreement of classification among the treating institutions. Patients were subclassified into two groups to ensure outcomes represented classic type I fracture patterns. Any patient with universal agreement among the four authors that the fracture did not appear consistent with a type I classification were assigned to Type 1+ Group (T1+). All other patients were assigned to the True Type I Group (TT1). We evaluated concomitant injury, need for operative intervention, and treatment outcomes overall and for each group independently. Results: 48 patients met inclusion criteria. 40/48 were TT1 fractures, while 8/48 were T1+ fractures, indicating less than universal agreement among sports specialists in classification of these fractures. Among TT1 patients, 7 of 40 (18.4%) underwent surgical treatment, though this represented 35.7% (5/14) of those who had undergone pretreatment advanced imaging. In the T1+ group, 6 of 8 (75%) underwent surgical treatment, 50% of whom (3/6) had pretreatment advanced imaging. Overall, twelve of 48 patients (25%) had concomitant injuries, nine TT1 patients and three T1+ patients (p=0.77), with 7 concomitant injuries requiring additional surgical management. Conclusions: Classification of type I fractures can be challenging. Nonetheless, a substantial percentage of patients with these fractures (>20%) were found to have concomitant injuries by advanced pretreatment imaging, with surgical management indicated in 58.3% of these patients. Contrary to traditional thought, type I tibial spine fractures do carry a risk of associated injuries. Simple cast immobilization may not be the ideal treatment in all cases. Advanced imaging would be beneficial for those whose plan of care may initially be non-operative treatment.

Background: When operative treatment is indicated, tibial spine fractures can be successfully managed with open or arthroscopic reduction and internal fixation. Hypothesis/Purpose: We hypothesized both approaches can lead to satisfactory outcomes for fracture healing, but that open treatment without preoperative advanced imaging can potentially lead to missed concomitant injuries. Methods: We performed an Institutional Review Board (IRB)-approved retrospective cohort study of pediatric tibial spine fractures presenting between January 1, 2000 and January 31, 2019 at 10 institutions. Patients were categorized into two cohorts based on treatment: arthroscopic reduction and internal fixation (ARIF) and open reduction and internal fixation (ORIF). Surgical outcomes, the incidence of concomitant injuries, and surgeon demographics were compared between groups. Results: There were 477 patients with tibial spine fractures who met inclusion criteria, 420 of whom (88.1%) were treated with ARIF, while 57 (11.9%) were treated with ORIF. Patients treated with ARIF were more likely to have an identified concomitant injury (41.4%) compared to those treated with ORIF (24.6%, p=0.021). Patients treated with ARIF were also more likely to have pre-treatment MRI (41.7% vs. 22.8%, p =0.010). Most concomitant injuries (74.5%) required surgical intervention. The most common treatment complications included arthrofibrosis (6.9% in ARIF patients, 7.0% in ORIF patients, p=1.00) and subsequent ACL injury (2.1% in ARIF patients and 3.5% in ORIF, p=0.86). The rate of complications, return to the operating room, and failure to return to full range of motion were similar between groups. Twenty surgeons with sports subspecialty training completed 85.0% of ARIF cases; the remaining 15.0% were performed by 12 surgeons without additional sports training. The majority (56.1%) of ORIF cases were completed by 14 surgeons without sports subspecialty training. Conclusion: This is the largest study comparing ARIF to ORIF in pediatric tibial spine fractures. This study demonstrated no difference in outcomes or nonunion following ARIF or ORIF for pediatric tibial spine fractures. There were significantly higher rates of concomitant injuries in patients treated with ARIF, however, these patients also had a higher rate of pre-treatment MRI. The majority of these concomitant injuries (74.5%) required surgical intervention. Pre-treatment MRI should be considered in the workup of tibial spine fractures to increase identification of concomitant injury. Concomitant injuries may be missed in tibial spine fractures treated with an open approach, especially in cases where preoperative advanced imaging is not obtained. Surgeon preference and training may impact treatment approach and identification and treatment of concomitant injury.

Background: Interest in vertebral body tethering (VBT) as an alternative to posterior spinal fusion for adolescent idiopathic scoliosis (AIS) continues to grow. The purpose of this study was to prospectively assess intervertebral disk health on magnetic resonance imaging (MRI) at 1 year following VBT in AIS patients. Methods: AIS patients were enrolled in a prospective surgeon-sponsored Food and Drug Administration (FDA) Investigational Device Exemption (IDE) Study and underwent MRI at 1-year following VBT. All spanned disks and the untethered disks immediately adjacent to the upper instrumented vertebra and lowest instrumented vertebra levels were evaluated according to Pfirrmann grading criteria. Associations between patient factors and preoperative and postoperative disk health and patient-reported outcomes were evaluated. Results: Twenty-two patients were enrolled with a postoperative MRI (25 curves, 188 disks), and 7 patients (7 curves) had both preoperative and postoperative MRIs (67 disks). The mean age was 12.7 years. Most were Risser 0 (65%) and either Sanders Skeletal Maturity Score 3 (35%) or 4 (53%). In the 7 patients with preoperative and postoperative MRI, the mean Pfirrmann grade of the disks spanned by the tether was 1.88 preoperatively and 2.31 postoperatively (P=0.0075). No statistically significant differences in preoperative versus postoperative Pfirrmann grade were identified in the disks adjacent to the upper or lower instrumented vertebrae. No association was found between patient-reported outcomes and Pfirrmann grade. Conclusion: At 1 year postoperatively, increased degenerative changes in disks spanned by the tether was identifiable on MRI without evidence of adjacent segment disk disease. These changes were not associated with patient-reported outcomes. Level of Evidence: Level III.

Background: An increased posterior tibial slope (PTS) results in greater force on the anterior cruciate ligament (ACL) and is a risk factor for ACL injuries. Biomechanical studies have suggested that a reduction in the PTS angle may lower the risk of ACL injuries. However, the majority of these investigations have been in the adult population. Purpose: To assess the mean medial and lateral PTS on pediatric cadaveric specimens without known knee injuries. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 39 pediatric knee specimens with computed tomography scans were analyzed. Specimens analyzed were between the ages of 2 and 12 years. The PTS of each specimen was measured on sagittal computed tomography slices at 2 locations for the medial and lateral angles. The measurements were plotted graphically by age to account for the variability in development within age groups. The anterior medial and lateral tibial plateau widths were measured. The distance between the top of the tibial plateau and the physis was measured. The independent-samples t test and analysis of variance were used to analyze the measurements. Results: The mean PTS angle for the medial and lateral tibial plateaus was 5.53° ± 4.17° and 5.95° ± 3.96°, respectively. The difference between the PTS angles of the medial and lateral tibial plateaus was not statistically significant ( P > .05). When plotted graphically by age, no trend between age and PTS was identified. Conclusion: This data set offers values for the PTS in skeletally immature specimens without a history of ACL injury and suggests that age may not be an accurate predictive factor for PTS.

Background: When operative treatment is indicated, tibial spine fractures can be successfully managed with open or arthroscopic reduction and internal fixation (ARIF). The purpose of the study is to evaluate short-term treatment outcomes of tibial spine fractures in patients treated with both open and arthroscopic fracture reduction. Methods: We performed an Institutional Review Board (IRB)-approved retrospective cohort study of pediatric tibial spine fractures presenting between January 1, 2000 and January 31, 2019 at 10 institutions. Patients were categorized into 2 cohorts based on treatment: ARIF and open reduction and internal fixation (ORIF). Short-term surgical outcomes, the incidence of concomitant injuries, and surgeon demographics were compared between groups. Results: There were 477 patients with tibial spine fractures who met inclusion criteria, 420 of whom (88.1%) were treated with ARIF, while 57 (11.9%) were treated with ORIF. Average follow-up was 1.12 years. Patients treated with ARIF were more likely to have an identified concomitant injury (41.4%) compared with those treated with ORIF (24.6%, P=0.021). Most concomitant injuries (74.5%) were treated with intervention. The most common treatment complications included arthrofibrosis (6.9% in ARIF patients, 7.0% in ORIF patients, P=1.00) and subsequent anterior cruciate ligament injury (2.1% in ARIF patients and 3.5% in ORIF, P=0.86). The rate of short-term complications, return to the operating room, and failure to return to full range of motion were similar between treatment groups. Twenty surgeons with sports subspecialty training completed 85.0% of ARIF cases; the remaining 15.0% were performed by 12 surgeons without additional sports training. The majority (56.1%) of ORIF cases were completed by 14 surgeons without sports subspecialty training. Conclusion: This study demonstrated no difference in outcomes or nonunion following ARIF or ORIF, with a significantly higher rate of concomitant injuries identified in patients treated with ARIF. The majority of identified concomitant injuries were treated with surgical intervention. Extensive surgical evaluation or pretreatment magnetic resonance imaging should be considered in the workup of tibial spine fractures to increase concomitant injury identification. Level of Evidence: Level III.