Cases and Current Concepts in Pediatric Sports Medicine

THE MOST MEMORABLE “DIFFICULT CASES” FROM THE FACULTY Arthrofibrosis Following Tibial Spine Fracture Fixation Benton Heyworth, MD1–7 A case was presented of an 11-year-old boy who sustained a completely displaced tibial spine fracture with accompanying lateral meniscus tear (Fig. 1). The mechanism was a twisting injury sustained in a gym class. The patient was treated arthroscopically with screw fixation to address the tibial spine fracture and all-inside repair of the meniscus (Fig. 2). Postoperative treatment included toe-touch weight-bearing for 2 weeks in a brace locked in extension, followed by full weight-bearing in the brace locked in full extension. Motion was progressed from 0 to 30 degrees weeks 0 to 2, 0 to 60 degrees weeks 2 to 4, and 0 to 90 weeks 4 to 6. Therapy was initiated 2 weeks postsurgery.FIGURE 1: Coronal magnetic resonance image delineating lateral meniscus tear.FIGURE 2: Lateral x-ray image noting screw fixation for displaced tibial spine fracture.Three months after surgery, limitation in flexion and extension was reported and the diagnosis of arthrofibrosis was made. Options considered at that time included continuation of physical therapy, dynamic splinting, manipulation under anesthesia, and arthroscopic lysis of adhesions. The decision was made to proceed with arthroscopic lysis of adhesions (Fig. 3) followed by manipulation under anesthesia. At the time of surgery, a stable Lachman with slight asymmetry in comparison with the contralateral side was noted. Manipulation was gentle, as physes remained open. After surgery, motion was noted to be 3 to 130 degrees.FIGURE 3: Arthroscopic image of lysis of adhesions.Meniscus repair in the setting of tibial spine reduction and fixation likely increased the risk of arthrofibrosis. Consideration for earlier motion and earlier progression to weight-bearing was mentioned, as was a high index of suspicion for arthrofibrosis in this scenario. Arthroscopic lysis of adhesions with early gentle manipulation, with respect to open physes, as performed, was appropriate in this setting. The Case for Suture Fixation for Tibial Spine Fractures in Children Michael T. Busch, MD Effectiveness of suture fixation was described, having stood the test of time as a high-quality surgical treatment for tibial spine fractures in pediatric patients. Advantages include the use of readily available instruments and supplies, while remaining consistent for almost all cases, from routine fractures to comminuted and small fragment fractures. In support of the use of sutures, multiple disadvantages of screw fixation were described. Risk of comminution during introduction of the screw may go unnoticed at the time of surgery, making it particularly troublesome. Technical requirements for screw fixation may be greater than that in suture fixation. Introduction of the screw involves a challenging angle because of the patella, making precise placement difficult. This method also runs the risk of scraping the trochlear cartilage with the guide pin, drill bit, or the screw itself. The risk of damage to the physis using screw fixation was emphasized. The recommendation was made when one approaches a tibial spine fracture with screw fixation in mind to be prepared with a backup plan for suture fixation, should comminution be discovered or created. The technique was discussed, passing 2 absorbable sutures through the anterior cruciate ligamen from drill holes in a retrograde manner and tensioning with a knot appropriately at the epiphysis or metaphysis while visualizing the reduction arthroscopically. Postoperative recommendations included cryotherapy and knee immobilizer for 2 to 3 days, followed by immobilization in a full weight-bearing cylinder cast for 3 to 4 weeks. After cast removal, aggressive therapy and emphasis on motion is necessary to avoid stiffness. Osteochondritis Dissecans John D. Polousky, MD A 13-year-old boy with a history of Crohn disease and complaints of left knee pain and swelling was presented. His symptoms had previously been attributed to Crohn arthropathy by his rheumatologist. No trauma was acknowledged, medications included Remicade and Imuran. Examination noted a significant effusion of the knee with full range of motion and a stable ligamentous testing. Imaging was consistent with osteochondritis dissecans of the posterior aspect of the lateral femoral condyle (Figs. 4–6). After failure of nonoperative management, surgical intervention was pursued.FIGURE 4: Coronal magnetic resonance image noting osteochondritis dissecans lesion of the medial femoral condyle.FIGURE 5: Coronal magnetic resonance image noting posterior location of the medial femoral condyle osteochondritis dissecans.FIGURE 6: Coronal computed tomography scan image noting osteochondritis dissecans lesion of the medial femoral condyle.Arthroscopic fixation of the lesion was performed with absorbable pins. Postoperatively, the patient remained symptomatic, with pain and effusion, and imaging was inconclusive regarding healing. Options presented at that juncture included debridement with marrow stimulation, osteochondral autograft transfer (OATS), and fresh osteochondral allograft. The lesion was debrided and a fresh allograft was transplanted (Fig. 7); 6-month follow-up noted pain-free motion with no effusion. Computed tomography (CT) scan was shown to demonstrate incorporation of the allograft.FIGURE 7: Arthroscopic appearance of the medial femoral condyle osteochondritis dissecans lesion.Snap Judgments LucasMurnaghan, MD Dr Murnaghan presented an overview of etiology hip injuries sustained during sports participation. He emphasized the value of the palpable and auditory “snaps” and “pops” that can be used for diagnostic purposes in more subtle, challenging cases. Internal Hip Snapping A 16-year-old dancer was presented who complained of persistent hip symptoms for 2 years. She reported painful and loud snapping deep in the groin, which was reproduced in the clinic by moving the hip from flexion/abduction/external rotation to extension. The etiology of the snapping was reported as iliopsoas snapping (tendon moving over the iliopectineal eminence of the femoral head). Six months of physical therapy accompanied by non-steroidal, anti-inflammatory drugs and psoas tendon sheath injection were provided. Mention was made of arthroscopic treatment for refractory cases, with release of the iliopsoas at the musculotendinous junction.8 External Hip Snapping A 17-year-old cross-country runner was also presented, with reported complaints of right hip snapping and feeling of “the hip popping in and out of the joint.” Examination noted palpable snapping of the iliotibial band over the greater trochanter. Also known as coxa saltans, this was treated with physical therapy focused on stretching of the iliotibial band and non-steroidal, anti-inflammatory drugs. After 6 months of symptoms refractory to this course, surgical intervention was considered. The patient also had femoroacetabular impingement, which was treated with arthroscopic osteochondroplasty. After this portion of the surgery, peripheral compartment arthroscopy was performed to section the iliotibial band in a cruciform manner using a beaver blade and radiofrequency ablator. Femoroischial Impingement A 15-year-old female, high-level gymnast was presented. Right hip painful and audible clunking was reported. Examination noted impingement in flexion, internal rotation, and adduction. Magnetic resonance imaging (MRI) scan was performed, and edema was noted around the quadratus femoris, with narrowing of the quadratus femoris (7.5 mm) and ischiofemoral (11.4 mm) spaces on the right side, left side quadratus femorus space was 12.9 mm and ischiofemoral space was 19.7 (Torriani et al9 noted that a quadratus femoris space of <8 mm and an ischiofemoral space of <17 mm indicate impingement). Examination under anesthesia under lateral cross-table fluoroscopy provided visualization of the clunking. When the hip was extended and adducted, rotation from neutral to external reproduced the clunk, caused by abutment of the greater trochanter on the ischium. Surgical ischioplasty was performed, and a successful postoperative course was reported.10 Medial Epicondyle Fractures: To Fix Eric W. Edmonds, MD Anatomic review of the humeral medial epicondyle was presented, with emphasis on the anterior and posterior bundles of the medial collateral ligament, pronator teres, flexor digitorum superficialis, flexor carpi radialis, and ulnaris. The displacement of the structures of the elbow is based on forces applied by the vectors of the muscles and this appears to contradict historical literature that uses predominately AP plain film to access and discuss displacement (Fig. 8).FIGURE 8: Radiograph of medial epicondyle fracture after repair with suture anchor.Debate regarding operative versus nonoperative management of fractures of the medial epicondyle was based on acceptable amount of displacement. This is a question that is not well answered in the literature. Inter observer and intraobserver reliability of displacement based on AP radiographs of the elbow is low.11 CT scan has been shown to provide better estimate of displacement of the medial epicondyle, but its functional utility may be difficult to justify.12 Stress under fluoroscopy to determine dynamic motion of the fracture fragment may also play a role in the treatment algorithm. Surgical treatment also raises the question of whether or not the surgeon should expose the nerve during fracture repair. Reduction methods provide a variety of options, including clamp, esmarch, K-wire, and dental pick. Dr Edmonds described his preference for the use of K-wire in extremely young, and 4.0 or 4.5 mm cannulated screws for most, noting the possibility of using suture anchors in comminuted variations (Fig. 9), for medial epicondyle fixation. Caution was advised in broaching the far lateral cortex of the humerus at this level, given the close proximity of the radial nerve and risk of injury.FIGURE 9: Three-dimensional computed tomography scan image to assess displacement of medial epicondyle.The issue of whether or not to fix these fractures has been previously centered on the ability to achieve fracture union. But, no data exist regarding functional outcomes in the treatment of the humeral medial epicondyle fracture. Patellofemoral Instability: Approach to Patellofemoral Instability in the Child and Adolescent William L. Hennrikus, MD Predisposition to patellofemoral instability is multifactorial and can often be attributed to multiple factors including activity level and patient anatomy. Instability can often lead to patellar dislocation, an injury that effects approximately 43 in 10,000 children13–15 (Figs. 10, 11). The peak incidence of pediatric dislocation tends to be at the age of 15, and the highest risk demographic are females aged 10 to 17 years.13–17 The medial patellofemoral ligament (MPFL) provides 50% of the patella’s biomechanical restraint, making it the most common cause for chronic instability and the target of most treatment options.18,19 With the redislocation rate ranging from 15% to 44%,16,20,21 effective treatment of first-time dislocations is pertinent to minimizing morbidity.FIGURE 10: Clinical picture of patellar dislocation.FIGURE 11: Radiographic view of the patellar dislocation.Patellar instability presents in children with numerous indicators, including increased Q angle, ligamentous laxity, patella alta, trochlear dysplasia, external tibial torsion, genu valgum, and contractures of the iliotibial band, lateral retinaculum, or vastus lateralis muscles.22–28 In addition, instability can manifest itself in an abnormal gait in pelvic thrust and excessive pronation of the foot.27 It is common for patellar dislocations to be accompanied by significant knee effusion, tears to the MPFL femoral insertion, medial patellar bone bruises, and increased MRI signal in the vastus medialis muscle.26 Generally, the most effective diagnostic technique for instability and dislocation is multiview MRI. Generally, for first-time dislocations, surgical intervention is discouraged unless the patient sustained significant damage to the articular cartilage, osteochondral fracture, avulsion of the vastus medialis obliquus, or when the injury was a result of recurrent instability.29–31 Nonoperative treatment is mostly focused on rehabilitation to strengthen the vastus medialis oliquus, gluteal muscles, and core. Activity modification and bracing to pull the patella away from the source of pain can also be used. There are many surgical procedures aimed at addressing patellar dislocation, including proximal realignment, distal realignment, lateral release, MPFL reconstruction, guided growth with tension plates, or a combination of these techniques. Osteotomies are not performed on pediatric patients due to the risk they pose to the growth plates.32 Lateral release is indicated to address abnormal patellar tilt.33 Joo et al34 reported good results after a 4-in-1 procedure which includes lateral release, vastus medialis advancement, transfer of semitendonous tendon to the patella, and grafting half of the patellar tendon to the medial tibial periosteum. Although the most effective surgical technique is debated, most modern procedures are moving away from nonanatomic extensor mechanism realignments to anatomic procedures focused on reconstructing the MPFL.18,19,35–37 Patellofemoral Instability: MPFL Repair Versus Reconstruction Amy L. McIntosh, MD Radiographic evaluation of patients with patellar instability should include anteroposterior, lateral, and merchant views to look for osteochondral fractures and to assess the physis. Indications for MRI scan include uncertainty of injury mechanism, persistent, large effusion, lack of an accurate exam due to pain, swelling, or apprehension, or identification of osteochondral fracture on radiographs. Three studies were cited28,30,38 to highlight the conflicting data that exists regarding the redislocation rates between conservative treatment compared with surgical reattachment/MPFL repair. On the basis of data from the Mayo clinic published by Camp et al39 the success of MPFL reconstruction at preventing recurrent PFI is significantly higher than MPFL repair. Therefore, MPFL repair is discouraged in patients with recurrent instability. The focus of physical examination should include assessment of lateral patellar glide, patellar apprehension, genu valgum, femoral anteversion, external tibial torsion, lateralization of the tibial tubercle, and generalized ligamentous laxity. Radiographic evaluation is used to determine degree of trochlear dysplasia, patella alta, and tibial tubercle to trochlear groove (TT-TG) distance (Fig. 12A). Signs of trochlear dysplasia include a 4-grade classification system by Dejour: (A) shallow, (B) flat, (C) asymmetric, and (D) cliff. TT-TG measures the distance from deepest point of the trochlea to the middle of the tibial tubercle. Anything >20 mm is considered abnormal (Fig. 12B).FIGURE 12: A and B, Location of medial patellofemoral ligament graft in the skeletally immature patient. The lateral view notes tunnel in midportion of the patella, the anteroposterior view notes the femoral tunnel in the epiphysis (no physeal involvement).The study “Acute patellofemoral dislocation in pediatric and adolescent patients” by Lewallen et al40 examined the relationship of these indications as well as patient demographics to the prevalence of patellar instability. In 222 knees, they found that age, sex, body mass index, and patella alta were not significantly associated with instability. Trochlear dysplasia was found to have the most significant effect on redislocation rate, with increased risk if the physis was open. Discussion of the various surgical techniques that address patellofemoral instability treatment included growth modulation with MPFL fixation, femoral derotation, and MPFL reconstruction. Narrow indications for acute MPFL repair include osteochondral fracture fixation. Skeletal immaturity and trochlear dysplasia mark the 2 most significant factors in redislocation rates and must be considered while assessing treatment options. In addition, it is vital to treat anatomic abnormalities such as genu valgum, femoral anteversion, and lateralized tibial tubercle. During surgical treatment, physeal-sparing techniques are crucial, with suggestion of emoral graft attachment approximately 7 mm distal to the physis. Anatomy and Treatment of Patellar Instability in Adolescents Hank Chambers, MD There are multiple factors that can predispose a patient to patellar instability, including anatomic shape and morphology, ratio of the patella height to tendon length, cartilage thickness, Q angle, and varying patellofemoral contact forces. Clinical instability can have numerous contributing factors such as trochlear dysplasia, excessive femoral anteversion, MPFL insufficiency, excessive tibial external rotation, and weak vastus medialis obliquus. It is important to take all of these risk factors into account when diagnosing and treating patellar instability, particularly in young patients. Accurate diagnosis begins at the history, in which specificity is the key. Vital information can include the location of injury, sports background, duration of activity, timing of symptoms, and past trauma. Upon physical examination, there are several tests that are crucial to assessing instability: tenderness, range of motion of the hip, knee, and ankle, J-sign, patellar tilt, and Q angle sitting and standing. Various imaging techniques can be used such as AP/lateral/merchant radiographs, CT scan, MRI, and bone scan. Previous trends in diagnosing instability centered on trochlear dysplasia, a sign referred to as “fundamental” in episodic patellar dislocation.41 In addition, a focus was placed on patella alta, lateral offset of the tibial tuberosity, and patellar tilt. However, currently, the emerging concept is that of medial retinacular deficiency being a key component to instability.42 When evaluating trochlear dysplasia, there are several indicators that can be seen through radiographic imaging. The crossing sign is a qualitative measure of instability, referring to the line of the trochlear floor crossing the anterior contour of the lateral femoral condyle. According to Dr Chambers’ research this sign was seen in 96% of patients with trochlear dysplasia versus 3% of the control, making it a fundamental diagnostic tool. In addition, the prominence, or “trochlear bump” is a quantitative measure of dysplasia. By measuring the distance between the anterior edge of the lateral condyle and the anterior cortex, Dr Chambers ascertained that 66% of knees with objective patellar instability had a translation of the anterior trochlear floor of ≥3 mm. The larger the trochlear bump is an indicator that more is the significant dysplasia. Patellar height measurements can present significant challenges. Caton et al43 examined the relationship of the patella to the tibial plateau. They described the ratio of the lower edge of the patellar joint surface to the upper edge of the tibial plateau and the length of the patellar articular surface. Dr Chambers further examined this relationship, and found that the control mean was 0.95, whereas the study group had a mean ratio of 1.12. He concluded that an index superior to 1.12 correlates with a “high” patella. Acute dislocation of the patella is often the result of a twisting injury of the Nonoperative treatment can include reduction with or anesthesia, physical therapy, and operative are arthroscopic lateral release, medial retinacular and as well as MPFL In the from the provided into common and more sports in a

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