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Background: Pediatric athletes commonly sustain inversion-type ankle fractures.1,2 Approximately 1% will form post-traumatic subfibular ossicles (SO), especially after tip avulsion fractures.3,4 Athletes with SOs can have pain and recurrent sprains.5,6,7 Here we show the utility of magnetic resonance imaging (MRI) in clinical decision-making for athletes with ankle symptoms and the presence of a SO. Our hypothesis is that MRI can predict which athletes have a stable SO and will respond to non-operative management, and which athletes have an unstable SO and will need surgery. Methods: We performed an IRB approved retrospective cohort study. Children were eligible from our practices if (1) they had radiographic evidence of a SO, (2) they had symptoms of pain and recurrent sprains, and (3) they had undergone MRI during their clinical evaluation. We identified 19 eligible children (20 ankles;) eight girls and eleven boys, ages 5–19 years. Nine involved the left ankle; 11 the right ankle. Most frequent sport was soccer (12/16) followed by basketball (3/14.) From the radiograph we determined ossicle size and location. MRI images were considered positive if fluid-sensitive sequences showed a high-intensity signal between the SO and the fibular epiphysis. Main outcome was treatment (non-surgical or surgical) relative to the MRI findings. Results: Size shape and location: Size and shape were variable. Width ranged from 2 – 10.4 mm and length from 4 – 13.5 mm. Concerning location all were in the distal 1/3 pf the epiphysis. Six were anterior and 14 were anterior-inferior to the fibular tip. MRI findings: Sixteen of the 20 ankles (80%) had positive MRI findings (figure 1), and 4 had negative findings (figure 2). The ATFL attached directly to the fragment in 11 of the 16 MRI positive ankles. Clinical decision making: All athletes with negative MRI findings responded to non-operatively management. Ten of the 16 ankles with positive MRIs have had surgery. Eight had excision of the ossicle and two had internal fixation based on the size of the ossicle. Surgical findings confirmed attachment of the ATFL to the fragment (figure 3.) Six athletes with positive MRIs continue to be under observation. Conclusions The results support our hypothesis that MRI has predictive value in clinical decision-making for symptomatic athletes with a SO. When fluid-sensitive MRI sequences show high signal intensity between the ossicle and the fibular epiphysis, and when the ATFL attaches to the ossicle, the athlete has a poor prognosis for non-operative management. [Figure: see text][Figure: see text] References: Su AW, Larson AN. Pediatric ankle fractures: Concepts and treatment principles. Foot Ankle Clin. 2015;20(4):705-719. Pommering TL, Kluchurosky L, Hall SL. Ankle and foot injuries in pediatric and adult athletes. Prim Care 2005;32(1):133-161. Han SH, Choi WJ, Kim S, Kim S-J, Lee JW. Ossicles associate with chronic pain around the malleoli of the ankle. 2008;90-B:1049-1054. Gamble JG, Sugi M, Tileston KR, Chan CM, Livingston KS. The natural history of type VII all-epiphyseal fractures of the lateral malleolus. Orthop J Sports Med. 2019; 7(3) (suppl 1) DOI 10.1177/2325967119S00116. Pill SG, Hatch M, Linton JM, Davidson RS. JBJS 2013;95: e115(1-6). Han SH, Choi WJ, Kim S, Kim SJ, Lee JW. Ossicles associated with chronic pain around the malleoli of the ankle. J Bone Joint Surg Br. 2008;90(8):1049-1054. Danielsson LG. Avulsion fracture of the lateral malleolus in children. Injury 12:165-167

Introduction: Children and adolescents are prone to both overuse and acute injuries at the tibial tubercle. The most common overuse injury is Osgood Schlatter Syndrome (OSS,) and the most common acute severe injury is tibial tubercle avulsion fracture (TTF). Here we present evidence for a Type VII, all-epiphyseal, tibial tubercle fracture (VIITF) that is different from OSS and TTF. Methods: This IRB–approved study involved patients that were treated and registered at a tertiary care pediatric hospital from 2014 to 2020. We compared the clinical information, the radiographs, the treatments, and the outcomes of 15 patients with VIITF to 19 patients with OSS and to 14 patients with TTF. Results: All VIITF patients had a sudden onset of pain associated with a specific sports-related injury, and all had lateral radiographs showing a chip-like ossific fragment displaced from the secondary center but with no involvement of the physis. All of the OSS patients had an insidious onset of symptoms with no specific injury, and none had radiographs showing a chip-like fragment. All the TTF patients had a sudden onset of pain after an acute injury. Eleven of the 15 VIITF patients (73%) have formed retro-patellar tendon ossicles, and 7 of those patients (46%) have undergone surgery. All but one of the OSS patients have resolved, and all with non-operative management. All the TTF patients have resolved, and all except those with Ogden type IA fractures, had undergone urgent surgery. Conclusions: We accepted our hypothesis. VIITF is different from OSS and TTF and can be differentiated on the basis of clinical and radiographic data. Clinical Relevance: Most patients with OSS resolve with non-operative management, and TTF patients usually require urgent surgery. Children with VIITF do not need urgent surgery but do need to be followed because some can form painful retro-patellar tendon ossicles, have focal anterior knee pain, and may need surgery to resolve their symptoms. Level of Evidence: Level III: Case Control Study.

Background/Purpose: The discoid meniscus is a congenital variant that is reported to be present in 3-5% of the United States population. Treatment involves partial meniscectomy and saucerization to obtain a more anatomic-appearing meniscus. The immediate post-operative cross-sectional morphology is often squared due to the inherent thickness of the discoid meniscus at the resection margin. The purpose of this study is to determine if the discoid meniscus can remodel and regain the triangular cross sectional configuration of a normal meniscus after surgical intervention. Methods: A retrospective chart review was performed to identify all patients undergoing partial meniscectomy for symptomatic discoid meniscus within the past 3 years at our institution. Patients were included if they had a subsequent knee magnetic resonance imaging (MRI) study. Each MRI study was evaluated by two orthopaedic surgeons independently. The extent of remodeling was graded on the cross-sectional morphology of the saucerized discoid meniscus on coronal and sagittal T1-weighted images of the corresponding knee mri based on the following scheme: 1) complete for a triangular cross-section, 2) partial for a trapezoidal cross-section , and 3) none for a square cross-section. Descriptive means and statistical analysis for intraclass correlation coefficient (ICC) were performed using Microsoft Excel. Results: A total of 11 patients and 14 knees were included in this study. Average age at time of surgery was 10.85. Average time to the follow-up MRI of the same knee was 540.50 +/- 341.84 days. 2 knees required additional surgical intervention following their index surgery. Complete remodeling was identified in 78.5% (11/14) knees. 1 knee had no remodeling and 2 knees had partial remodeling. Our ICC was 0.87 (95% CI: [0.66,0.96]). Conclusion: Our results indicate that the discoid meniscus has the potential to remodel into a “normal” triangular cross-sectional morphology after partial meniscectomy and saucerization. In our series, 21.4% (3/14) knees did not experience complete remodeling. This may have been due to over resection of the discoid meniscus at the index surgery owing to the extent of an existing tears. The remodeling all occurred within a two-year time frame though the exact time is unknown. This study indicates no additional intervention is required at the central resection margin to thin out the thick edge that often results from the meniscal biter.

Background: Discoid lateral meniscus (DLM) is a congenital anomaly of the knee where the normally “O” shaped lateral meniscus has redundant tissue filling the “O” and covering the lateral tibial plateau. The redundant tissue can cause mechanical symptoms and pain. Treatment of symptomatic DLM is arthroscopic saucerization to reshape the meniscus to a more normal contour. Enough tissue must be removed to eliminate mechanical symptoms but not too much as to create instability. The residual width of the meniscus is crucial at the popliteus hiatus because here the peripheral rim is unattached to the capsule. The literature recommends a residual width of 6-8 mm.1,2 Purpose/Hypothesis: The primary purpose of this research is to determine the width of the meniscus at the popliteal hiatus in normal specimens. Our null hypothesis is that a residual width of 6-8 millimeters will be sufficient for saucerization of DLM. Methods: We made direct measurements of lateral meniscus radial width from the outer rim at the popliteus hiatus to the inner edge (Figure 1) in 19 specimens (ages 2 months to 120 months.) We measured one four-year-old specimen with bilateral complete DLM. We also measured 39 digital images of specimens (ages 1 month to 132 months) using ImageJ. Finally, we made direct measurements of 8 skeletally mature specimens. Results: Figure 2 shows the relationship of meniscus width as a function age. The average width of specimens Conclusions: We rejected our null hypothesis. Direct measurements suggest that a residual width of 6-8mm is insufficient for children 8-years and older. A width of at least a full centimeter more closely approximates our findings, and for adolescents consider a residual rim of 15 mm. For children less than six-years-old a residual width of 6-8mm is sufficient. References: Kocher MS, Logan CA, Kramer DE. Discoid lateral meniscus in children: diagnosis, management, and outcomes. J Am Acad Orthop Surg 2017;25:736-743. Hayashi LK, Yamaga H, Ida K, Miura T. Arthroscopic meniscectomy for discoid lateral meniscus in children. J Bone Joint Surg. 1988;70-A: 1495-1500. [Figure: see text][Figure: see text]

BACKGROUND: To compare accuracy, time and radiation exposure of pediatric femoral tunnel placement using computer navigation with a traditional freehand technique. METHODS: A single all-epiphyseal femoral tunnel was placed in the distal femur of 20 Sawbones™ adolescent knee models. Ten tunnels were drilled using standard fluoroscopic guidance (FG). An additional 10 tunnels were drilled using 3D fluoroscopic computer navigation (CN). Both techniques aimed to match an exact point described by the quadrant system of Bernard. Time to perform the procedure was recorded as were number of single shot fluoroscopic images and approximate effective radiation doses. RESULTS: The deviation from ideal femoral tunnel position was on average 6.4 ± 4.2 mm for FG tunnels and 2.7 ± 3.1 mm for CN tunnels (p

Objectives: Discoid lateral meniscus (DLM) is a congenital anomaly of the knee where the normally “O” shaped lateral meniscus has redundant tissue filling the “O” and covering the lateral tibial plateau. The redundant tissue can degenerate and cause mechanical symptoms and pain. Treatment of symptomatic DLM is arthroscopic saucerization to reshape the meniscus to a more normal contour. Enough tissue must be removed to eliminate mechanical symptoms but not too much as to create instability. The residual width of the meniscus is crucial at the popliteus hiatus because here the peripheral rim is unattached to the capsule. The literature recommends a residual width of 6-8 mm. The primary purpose of this research was to determine the width of the meniscus at the popliteal hiatus in normal specimens. Our null hypothesis was that a residual width of 6-8 millimeters will be sufficient for saucerization of DLM. Methods: We made direct measurements of lateral meniscus radial width from the outer rim at the popliteus hiatus to the inner edge (Figure 1) in 19 specimens (ages 2 months to 11 years.) We measured one four-year-old specimen with bilateral complete DLM (Figure 2.) We also measured 39 digital images of specimens (ages 1-month to 12-years) using ImageJ. Finally, we made direct measurements of 8 skeletally mature specimens. Results: Figure 3 shows the relationship of meniscus width as a function age. The average width of specimens Conclusions: We rejected our null hypothesis. Direct measurements suggest that a residual width of 6-8mm is insufficient for children 8-years and older. A width of at least a full centimeter more closely approximates our findings, and for adolescents consider a residual rim of 15 mm. For children less than six-years-old a residual width of 6-8mm is sufficient.

This review will focus on the evaluation and management of patellar instability in the developing patient. A large number of surgical techniques have been described to prevent recurrent patellofemoral instability in the pediatric population, including both proximal and distal realignment procedures. The wide variety of treatment options highlights the lack of agreement as to the best surgical approach. However, when a comprehensive exam and workup are paired with a surgical plan to address each of the identified abnormalities, outcomes are predictably good. Patellar instability is a common knee disorder in the skeletally immature patient that presents a unique set of challenges. Rates of re-dislocation in pediatric and adolescent patients are higher than in their adult counterparts. Careful consideration of the physeal and apophyseal anatomy is essential in these patients. While the majority of primary patellar instability events can be treated conservatively, multiple events often require surgical intervention.

Study Design This study determines the rate of change in the scoliosis surgery plan in cases presented in preoperative indications conference. Objectives To determine the effect of preoperative indications conference on the plan of surgery and to identify characteristics that increased the likelihood of change. Summary of Background Data Preoperative indications conferences are used as a teaching and planning tool. Levels of fusion, construct options, and necessity for osteotomies are often debated in the planning of scoliosis surgery. Methods Scoliosis surgeries were presented at preoperative indications conference with four attending pediatric orthopedic surgeons present. The operative surgeon committed to a surgical plan before conference. A consensus-based plan was made without knowledge of the operative surgeon's preconference plan. Changes of plan were classified as major, minor, or no change. Results Of the 107 surgical plans, 50 were index surgeries, 13 were revisions, and 44 were scheduled growing rod lengthenings. There were two major changes, including a change to a growing construct from planned fusion, and a change in fusion levels in an adolescent idiopathic scoliosis (AIS) patient. There were 13 minor changes, which included changes in fusion levels (1 to 3; mean = 1.23) and the addition of an osteotomy. The rate of change was 28% for index surgeries and 7.69% for revisions. Of the 14 changes in the 50 index surgeries, there were 8 AIS, 3 cerebral palsy, 1 congenital scoliosis, 1 Ehlers-Danlos, and 1 patient with an undetermined neuromuscular condition. There was 1 change in 13 revision surgeries. There were no changes for growing rod lengthenings and no cancellations as a result of indications conference. Conclusions Although revision scoliosis surgery is complex, index AIS/JIS surgery was most subject to the influence of indications conference. This likely reflects controversy around choosing levels of fusion. Level of Evidence IV.