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Purpose: Pathologic abnormality of the peroneal tendons are thought to be an under-appreciated source of vague ankle and hindfoot pain in paediatric patients, partly because they can be difficult to diagnose and differentiate from lateral ankle ligament injuries. While magnetic resonance imaging (MRI) is the primary imaging modality used to detect peroneal tendon pathology, previous studies in adults have found that positive MRIs demonstrate a positive predictive value (PPV) of associated clinical findings around 48%. There are no similar known published studies in the paediatric population. Our objective was to determine the positive predictive value of peroneal tendon pathology as diagnosed by MRI as related to positive clinical exam findings in the paediatric and adolescent population. Methods: This IRB approved retrospective study was conducted at a tertiary children's hospital. Inclusion criteria included patients under 18 years from our tertiary care institution with (a) ankle MRI findings indicating pathology of the peroneus brevis/longus tendons confirmed by a board certified paediatric musculoskeletal radiologist and (b) formal review of the clinical examination by a fellowship trained paediatric orthopaedic surgeon. Patients with congenital deformities or previous surgical intervention of the lateral ankle were excluded. Results: Forty-seven patients (with 48 MRIs) met inclusion criteria over a ten year period. The majority of the positive MRI scans (70%) demonstrated a peroneus brevis split tear. Of the patients with positive findings on MRI, 17 patients had an associated positive clinical exam. The positive predictive value of MRI for peroneal tendon tears with positive clinical findings was 35.41% (95% confidence interval = 31.1% to 41.6%). There were 31 patients with MRI positive findings with a negative clinical exam. Conclusion: Despite having a negative clinical exam, a high percentage of patients had positive MRI findings suggestive of peroneal tendon pathology which confirms findings of adult populations demonstrating a high rate of incidental finding of peroneal tendon pathology on MRI in paediatric patients. [ABSTRACT FROM AUTHOR]

Purpose: To describe the first "arcuate sign" case series in the pediatric population, radiologic features of the associated injuries, management, and how they compare with the adult population.Methods: Retrospective study included patients under 18 years of age with a classic "arcuate sign" on radiographs. Data collected included patient demographics, mechanism of injury, and management. Radiographs and advanced imaging (MRI, CT) were reviewed by two musculoskeletal radiologists in a blinded fashion and findings recorded.Results: Seven patients (4 males, 3 females) with mean age 15 years (range 14-17 years) were included in the study. All 7 injuries were related to sports, 5/7 (71%) being non-contact injuries. Five patients had MRI done-1 LCL injury, MPFL sprain, and MCL sprain were reported; 3 popliteofibular ligament and popliteus sprains were seen; and 3 bone contusions were present on imaging. None of the patients had meniscus or cruciate ligament tears. One patient had an additional fracture of the lateral tibial plateau at the ilio-tibial band attachment and an associated peroneal nerve injury. Five out of seven (71.4%) were treated non-operatively and were able to return back to activity at a mean of 7.2 weeks from injury. Two out of seven (28.6%) needed operative intervention for the fracture but not arthroscopic repair.Conclusion: Pediatric patients with a radiographic arcuate sign tend not to have ACL, PCL, or meniscal injuries, and treatment is predominantly non-operative in contrast to literature reported in adults. [ABSTRACT FROM AUTHOR]

Background: Posterior ankle impingement syndrome (PAIS) results from the pinching of anatomical structures in the posterior part of the ankle.Objective: To identify the possible role of imaging in the delayed diagnosis of PAIS and identify key findings on imaging to suggest PAIS in pediatric and adolescent patients.Materials and Methods: Data were collected prospectively in patients younger than 18 years of age who underwent arthroscopy after being diagnosed with PAIS. Imaging was reviewed retrospectively by two radiologists, compared with findings in literature and an age-matched control group, and correlated with arthroscopic findings. Pre- and postsurgical Visual Analogue Scale (VAS) pain and American Orthopedic Foot Ankle Society (AOFAS) ankle-hindfoot scores were noted.Results: Thirty-eight patients (20 females, 18 males), 51 ankles, with an average age of 12.9 years had an average 18-month delay in diagnosis. Twenty-seven of the 38 (73%) patients had previously seen multiple medical providers and were given multiple misdiagnoses. Radiographs were reported normal in 34/47 (72%) ankles. Thirty patients had magnetic resonance imaging (MRI) and findings included the presence of an os trigonum/Stieda process (94%) with associated osseous edema (69%), flexor hallucis longus (FHL) tenosynovitis (16%), and edema in Kager's fat pad (63%). Although individual findings were noted, the impression in the MRI reports in 16/32 (50%) did not mention PAIS as the likely diagnosis. There was a significant difference in the MRI findings of ankle impingement in the patient population when compared to the control group. Surgery was indicated after conservative treatment failed. All 51 ankles had a PAIS diagnosis confirmed during arthroscopy. At an average follow-up of 10.2 months, there was improvement of VAS pain (7.0 to 1.1) and AOFAS ankle-hindfoot scores (65.1 to 93.5).Conclusion: PAIS as a diagnosis is commonly delayed clinically in young patients with radiologic misinterpretation being a contributing factor. Increased awareness about this condition is needed among radiologists and physicians treating young athletes. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study is to compare the efficacy of percutaneous Achilles tenotomy (AT) to combined open Achilles tenotomy and posterior capsulotomy (PC+AT) in the correction of residual equinus deformity in congenital talipes equinovarus after Ponseti serial casting in both idiopathic and non-idiopathic clubfeet. Methods: The authors retrospectively reviewed 591 patients treated for congenital talipes equinovarus between January 1, 2001 and January 1, 2011. Available medical and operative records were reviewed for basic demographic data as well as ankle dorsiflexion pre-operatively, postoperatively and at latest follow up. Results: A total of 167 children with 260 discrete clubfeet that met our inclusion criteria were identified. Of them, 189/260 clubfeet (72.7 %) were idiopathic and 71/260 clubfeet (27.3 %) were non-idiopathic with a mean total follow up of 4.8 ± 2.4 years (minimum follow-up of two years). At latest follow up, there was no statistically significant difference in the mean ankle dorsiflexion ( p = 0.333) or recurrence rate ( p = 0.545) between PC+AT and AT groups in both idiopathic and non-idiopathic clubfeet. Conclusion: In our series, the addition of posterior capsulotomy to Achilles tenotomy did not improve the mean dorsiflexion at latest follow up or decrease the rate of recurrence of equinus deformity in both idiopathic and non-idiopathic clubfeet. It is therefore advisable that percutaneous Achilles tenotomy alone be used in the correction of equinus deformity in both idiopathic and non-idiopathic congenital talipes equinovarus after successful Ponseti serial casting. [ABSTRACT FROM AUTHOR]

Purpose: The management of proximal femoral deformity in fibrous dysplasia (FD) is a challenge to the orthopaedic surgeon. The purpose of this study was to analyze the various presentations of FD of proximal femur and the results of the various treatment modalities for the same. Methods: This is a retrospective cohort study of 23 patients (24 femora) with FD who underwent surgery for the proximal femur. The study sample included 14 males, nine females. Ten patients had a monostotic disease, eight patients had polyostotic disease, and five patients had McCune-Albright syndrome. Results: Group 1: shepherd crook deformity-included five patients who underwent femoral neck osteotomy. Four patients had intramedullary (IM) nailing with neck cross-pinning and all patients showed union. One patient was stabilized with external fixation, which failed. Group 2: nine patients (ten femora) presented with frank pathological fracture. Nine underwent fixation with IM nailing, one with locking plate and screws. Three patients had to undergo more than one procedure and all fractures showed good union. Group 3: nine patients who presented with bone cyst and pain. All patients underwent biopsy; four of them had curettage with bone graft. Conclusion: Shepherd crook deformity can be treated by a well-planned osteotomy and fixation with intramedullary implants with neck cross-pinning. Frank pathological fractures fixation with an intramedullary nail has excellent results even if not accompanied by resolution of the fibrodysplastic lesion. More than one procedure may be required. External fixation is not an optimal choice for fixation of femoral osteotomies in FD. [ABSTRACT FROM AUTHOR]