Tibial Spine Fractures in the Child and Adolescent Athlete: A Systematic Review and Meta-analysis

BACKGROUND

Tibial spine fractures (TSFs) are uncommon injuries that may result in substantial morbidity in children. A variety of open and arthroscopic techniques are used to treat these fractures, but no single standardized operative method has been identified.

PURPOSE

To systematically review the literature on pediatric TSFs to determine the current treatment approaches, outcomes, and complications.

STUDY DESIGN

Meta-analysis; Level of evidence, 4.

METHODS

A systematic review of the literature was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) guidelines using PubMed, Embase, and Cochrane databases. Studies evaluating treatment and outcomes of patients <18 years old were included. Patient demographic characteristics, fracture characteristics, treatments, and outcomes were abstracted. Descriptive statistics were used to summarize categorical and quantitative variables, and a meta-analytic technique was used to compare observational studies with sufficient data.

RESULTS

A total of 47 studies were included, totaling 1922 TSFs in patients (66.4% male) with a mean age of 12 years (range, 3-18 years). The operative approach was open reduction and internal fixation in 291 cases and arthroscopic reduction and internal fixation in 1236 cases; screw fixation was used in 411 cases and suture fixation, in 586 cases. A total of 13 nonunions were reported, occurring most frequently in Meyers and McKeever type III fractures (n = 6) and in fractures that were treated nonoperatively (n = 10). Arthrofibrosis rates were reported in 33 studies (n = 1700), and arthrofibrosis was present in 190 patients (11.2%). Range of motion loss occurred significantly more frequently in patients with type III and IV fractures (P < .001), and secondary anterior cruciate ligament (ACL) injury occurred most frequently in patients with type I and II fractures (P = .008). No statistically significant differences were found with regard to rates of nonunion, arthrofibrosis, range of motion loss, laxity, or secondary ACL injury between fixation methods (screw vs suture).

CONCLUSION

Despite variation in TSF treatment, good overall outcomes have been reported with low complication rates in both open and arthroscopic treatment and with both screw and suture fixation. Arthrofibrosis remains a concern after surgical treatment for TSF, but no significant difference in incidence was found between the analysis groups. Larger studies are necessary to compare outcomes and form a consensus on how to treat and manage patients with TSFs.

Genu Valgum in Pediatric Patients Presenting With Patellofemoral Instability

BACKGROUND

Lower extremity valgus is a commonly described factor associated with patellofemoral instability (PFI) and, if identified before skeletal maturity, can be treated with guided growth. The prevalence of valgus alignment in the pediatric and adolescent PFI population is largely unknown.

PURPOSE

The aim of this study was to report the prevalence of valgus alignment in adolescent patients presenting with PFI; with secondary assessment of high-grade valgus (zone II or III), coronal asymmetry, and associations of these findings with body mass index (BMI).

STUDY DESIGN

A retrospective cohort study.

METHODS

A total of 279 consecutive patients (349 knees) with a diagnosis of PFI presenting to a single orthopedic pediatric sport medicine surgeon were identified. A retrospective chart review was performed to collect demographic and clinical data, chronologic and bone age, sex, BMI, mechanism of injury, and the presence of osteochondral fracture. Full-length standing hip-to-ankle alignment radiographs were graded for knee alignment mechanical zone utilizing standard linear femoral head center to talar center assessment. In addition, mechanical axis deviation, mechanical lateral distal femoral angle and medial proximal tibial angle (MPTA) were also calculated.

RESULTS

Mean patient age was 14.0±2.5 years. There were 162 (58.1%) females and mean BMI was 24.3±6.4. Seventy patients (25.1%) had bilateral PFI. Standing alignment radiographs were available for 81.4% of knees (n=284). Valgus alignment was present in 172 knees with PFI (60.6%). High-grade valgus, defined as zone 2 or greater, was present in 66 knees (23.3%). Overall, 48.9% had asymmetry of coronal alignment (n=139). The mean mechanical lateral distal femoral angle was 85.4±2.8 and the mean MPTA was 88.2±2.6. There was a greater MPTA in female patients (88.8±2.4 vs. 87.5±2.7, P <0.001). A higher BMI (24.87±6.95, P =0.03) was associated with valgus alignment.

CONCLUSIONS

There is a high (60%) prevalence of lower extremity valgus in adolescent patients presenting with PFI, with nearly 1 in 4 presenting with high-grade valgus. The treatment team should be aware of this association as it may be an important consideration in the pediatric and adolescent PFI populations.

LEVEL OF EVIDENCE

Level III.

Radiographic Changes After Medial Patellofemoral Ligament Reconstruction in Skeletally Immature Patients Compared With an Age- and Sex-Matched Cohort

BACKGROUND

Despite recent evidence that medial patellofemoral ligament reconstruction (MPFLR) in the skeletally immature patient is both safe and effective, there are limited data evaluating postoperative coronal- and sagittal-plane growth and radiographic patellofemoral parameters in this population.

PURPOSE

The primary purpose was to assess radiographic measures of coronal-plane alignment, longitudinal growth, patellar congruence, and trochlear dysplasia after MPFLR in a skeletally immature population. A secondary purpose was to assess this population compared with a matched cohort with a focus on trochlear dysplasia prevalence and the effect of MPFLR on patellar height.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 28 children with a minimum 1-year follow-up who underwent isolated MPFLR were identified. All patients were skeletally immature, defined as fully open physes on both sides of the knee joint, at the time of surgery. The development of a limb length discrepancy or angular growth abnormalities were assessed on standing hip-to-ankle radiographs, patellar tilt and congruence were measured on the Merchant view of the knee, and the grade of trochlear dysplasia and patellar height were assessed on lateral knee radiographs. A sex- and age-matched group of patients who underwent anterior cruciate ligament reconstruction was formed as a control for patellar height and trochlear dysplasia measurements.

RESULTS

The mean patient age was 11.71 ± 2.02 years at the time of surgery with a mean follow-up of 23.54 ± 12.49 months. All but 1 patient in the MPFLR group had preoperative features consistent with trochlear dysplasia. There was no significant difference in limb length or coronal-plane alignment at final follow-up (P = .725 and P > .999, respectively). Both the MPFLR and the anterior cruciate ligament reconstruction groups had a statistically significant decrease in the Caton-Deschamps index between the preoperative and postoperative time points (mean, 0.18 ± 0.20 and 0.11 ± 0.14, respectively; P = .161).

CONCLUSION

MPFLR may be safely performed utilizing an epiphyseal femoral socket in a skeletally immature cohort without affecting normal longitudinal growth or coronal limb alignment. The previously reported effect of MPFLR in reducing patellar height may be related to physiological growth based on similar changes noted in a comparison cohort that did not undergo the procedure.

Impact of Occupation on 12-Month Outcomes After Anterior Cruciate Ligament Reconstruction in Male Patients

Background

The impact of a physically demanding occupation on clinical outcomes after anterior cruciate ligament (ACL) reconstruction (ACLR) is largely unknown.

Purpose/Hypothesis

The purpose of this study was to assess the influence of occupation on 12-month outcomes after ACLR in male patients. It was hypothesized that patients undertaking manual work would not only have better functional outcomes in terms of strength and range of motion but also higher rates of joint effusion and greater anterior knee laxity.

Study Design

Cohort study; Level of evidence, 3.

Methods

From an initial cohort of 1829 patients, we identified 372 eligible patients aged 18 to 30 years who underwent primary ACLR between 2014 and 2017. Based on a preoperative self-assessment, 2 groups were established: patients engaged in heavy manual occupations and those engaged in low-impact occupations. Data were collected from a prospective database including effusion, knee range of motion (using side-to-side difference), anterior knee laxity, limb symmetry index for single hop and triple hop, International Knee Documentation Committee (IKDC) subjective score, and complications up to 12 months. Because of the significantly lower rate of female patients undertaking heavy manual occupations compared to low-impact occupations (12.5% and 40.0%, respectively), data analysis was focused on male patients. Outcome variables were assessed for normality, and statistical comparisons were made between the heavy manual and low-impact groups using either an independent-samples t test or the Mann-Whitney U test.

Results

Of 230 male patients, 98 were included in the heavy manual occupation group, and 132 were included in the low-impact occupation group. Patients in the heavy manual occupation group were significantly younger than those in the low-impact occupation group (mean age, 24.1 vs 25.9 years, respectively; P < .005). There was a greater range of active and passive knee flexion in the heavy manual occupation group than in the low-impact occupation group (mean active, 3.38° vs 5.33°, respectively [P = .021]; mean passive, 2.76° vs 5.00°, respectively [P = .005]). There was no difference in effusion, anterior knee laxity, limb symmetry index, IKDC score, return-to-sport rate, or graft rupture rate at 12 months.

Conclusion

At 12 months after primary ACLR, male patients engaged in heavy manual occupations had a greater range of knee flexion, with no difference in the effusion rate or anterior knee laxity, compared with those engaged in low-impact occupations.

Epidemiology and management of maxillofacial fractures in an Australian trauma centre

BACKGROUND AND AIM

Trauma is a leading cause of morbidity and mortality, with a considerable proportion of trauma patients sustaining concomitant maxillofacial (MF) injuries. The purpose of this study was to review and analyse the epidemiology, management and complications of patients with MF fractures managed by the Faciomaxillary Surgery Unit at the Alfred Trauma Hospital in Melbourne. The secondary objective of the study was to determine the risk factors for developing postoperative complications.

METHODS

A retrospective records review was performed for 980 patients who were treated for MF fracture(s) from January 2009 to December 2011. Descriptive statistics were used and independent demographic and injury-related factors assessed for association with outcome using multivariate logistic regression.

RESULTS

A total of 1949 MF fractures from 980 patients were treated over the study period. Males (n = 785, 80.10%) and patients aged 15-24 years (n = 541, 55.20%) were the most frequently affected (mean age (standard deviation, SD) 27.69 (19.22)). The most common aetiology was assault (n = 293, 29.90%). The majority presented with fractures of the orbit (n = 359, 36.33%). In total, 803 fractures from 500 patients were treated operatively. Mandibular fractures were most commonly treated surgically (79.82%). Postoperative complications occurred in 69 of 500 patients treated surgically (13.8%), most commonly due to infected metalware (n = 16, 3.20%). Multiple fractures were associated with a higher probability of requiring surgery (p < 0.001) and developing postoperative complications (p < 0.001) compared to isolated fractures.

CONCLUSION

MF fractures most commonly affected young males, often as a result of an assault. Per bony injury, mandibular fractures had the greatest proportion that was managed operatively. High-energy injuries were associated with an increased risk of sustaining multiple MF fractures and developing postoperative complications.

Thrombolytic therapy for acute myocardial infarction: evaluation of a selective approach to invasive diagnosis and therapy in a community hospital

To investigate the effectiveness of selective catheterization and revascularization after thrombolytic therapy for myocardial infarction, we studied the early and late clinical course of 100 consecutive patients treated with streptokinase and an intensive medical regimen. Catheterization was performed because of recurrent angina or evidence for reperfusion and myocardial salvage. Fifty-six patients were catheterized, and 37 underwent revascularization. Hospital mortality was 8%. Among the 92 hospital survivors, after 1 year follow-up there was no significant difference between the revascularized and nonrevascularized groups in total survival (97% and 100%, respectively) or in infarct-free survival (97% and 95%, respectively). During total follow-up of 34 (+/- 13) months, late clinical events (death, reinfarction, late revascularization, and severe angina) occurred in 16% of 37 revascularized patients and in 27% of 55 patients not revascularized (p = 0.31). Cumulative hospital and late survival for the entire group was 91% at 1 year and 86% at final evaluation. Excellent long-term survival and a low incidence of recurrent infarction may be achieved after thrombolytic therapy, using selective catheterization and revascularization based on widely available clinical estimates of further ischemic risk.

Cerebral CT findings in toxemia of pregnancy

Cerebral CT findings in two patients who had eclampsia are presented. Diffuse cerebral edema and basal ganglia involvement, which were previously undescribed to our knowledge, are exhibited.

Accumulation of MDP in hepatic metastases from mucinous adenocarcinoma of the colon

The case of a 66-year-old man with mucinous adenocarcinoma of the rectum with metastases to the liver is presented. Several mechanisms of accumulation of MDP are identified and correlated with CT scan findings.