Stockton Troyer

The evaluation and treatment of adolescents and young adults with hip pain has seen tremendous growth over the past 20 years. Labral tears are well established as a common cause of hip pain but often occur because of underlying bony abnormalities. Femoroacetabular impingement (FAI) and acetabular dysplasia are now well-established causes of hip osteoarthritis and are increasingly treated in the prearthritic stage in hopes of improving symptoms and prolonging the longevity of the native hip. Beyond FAI and acetabular dysplasia, this patient population can present with a complex and variable group of underlying conditions that need to be taken into account. Expertise in the conservative management of this population, including physical therapy, is valuable to maximize the success. Preoperative, surgical, and postoperative decision-making and care in this population is complex and evolving. A comprehensive, multidisciplinary approach to the care of this patient population has been used for over 20 years by our institution with great success. The purpose of this article is to review the “team-based approach” necessary for successful management of the spectrum of adolescent and young adult hip disorders.

The purpose of the current study was to identify risk factors for deep infection after an open long-bone fracture in pediatric patients. Systematic billing queries were utilized to identify pediatric patients who presented to a level I trauma center from 1998 to 2019 with open long-bone fractures. There were 303 open long-bone fractures, and 24 (7.9%) of these became infected. Fractures of the tibia/fibula (p = 0.022), higher revised Gustilo-Anderson type (p = 0.017), and a longer duration of time between the injury and hospital presentation (p = 0.008) were all associated with the presence of deep infection. Those who went on to have a deep infection also required more operative debridements (p = 0.022) and a total number of operative procedures (p = 0.026). The only factor that remained significant in multivariable regression was the duration between the injury and hospital presentation (OR 1.01 [95%CI 1.003–1.017]; p = 0.009), where the odds of deep infection increased by 1% for every minute of delayed presentation.

Background: The quadriceps tendon (QT) is increasingly considered for primary and revision anterior cruciate ligament reconstruction in skeletally immature patients, as it may be harvested as a purely soft tissue graft with considerable tissue volume. Because of distinct rectus tendon (RT) separation from the QT complex, the potential for RT retraction exists and could lead to QT weakness after QT graft harvest. Purpose: To describe the anatomy of the pediatric QT and clarify decussation of the RT and QT to avoid the risk of delayed RT retraction and QT weakness after QT graft harvest. Study Design: Descriptive epidemiology study. Methods: Nine cadaveric knee specimens (aged 4-11 years) underwent gross dissection. Coronal-plane width and depth of the QT were measured at intervals proximal to the superior pole of the patella at distances of 0.0, 0.5, 1.0, and 1.5 times the length of the patella. The distance was measured from the superior patellar pole to the point of RT separation from the remainder of the deeper/posterior QT. Results: The median patellar length was 28 mm (interquartile range, 26-37 mm). The coronal-plane width of the QT was larger superficially/anteriorly when closest to the patella but wider when measured deeper/posteriorly as the tendon extended proximally. The median distance between the superior pole of the patella and RT separation from the QT was 0.95 times the patellar length. The distance to widening of the deeper/posterior aspect of the QT was 1.14 times the patellar length proximal to the patella. Conclusion: The RT begins a distinct separation from the QT above the superior pole of the patella at a median of 0.95 times the patellar length in skeletally immature specimens. The deeper/posterior aspect of the QT begins to increase in coronal-plane width proximally after a distance of 1.14 times the patellar length above the knee, while the superficial/anterior aspect of the tendon continues to narrow. Awareness of the separation of the RT from the QT, and the coronal-plane width variation aspects of the QT proximally, is important for surgeons utilizing the QT as a graft to avoid inadvertent release of the RT from the rest of the QT complex.

Background: While access to pediatric tissue for cartilage conditions is limited, recent research on the use of pediatric cartilage tissue for implantation has shown promising results. These pediatric grafts may include bulk osteochondral allografts, morselized cartilage, or cellular manipulation products. The purpose of this study was to evaluate the parameters of cartilage thickness in different regions of the pediatric knee from a larger pediatric knee specimen research database. Methods: CT Scans of 12 skeletally immature knees ranging from ages 7 to 11 were evaluated. Cartilage thickness measurements were taking in the following regions: 1. Femoral Condyles - Cahill Zones 1, 2, 4, and 5 (Fig. 1) on coronal plane CT images, the region of greatest cartilage thickness on medial and lateral femoral condyles using coronal plane CT images, and Cahill Zones A, B, and C on sagittal plane CT images (Fig. 2). 2. Tibial Plateau – the region of greatest cartilage thickness identified on the medial and lateral sides of the tibial plateau using coronal plane CT images (Fig. 1). 3. Patella – the region of greatest cartilage thickness identified on axial and sagittal CT images (Fig. 3 and 4). Results: The cartilage on the medial femoral condyle had an average thickness of 4.86 mm ± 0.61 mm at its thickest point and the cartilage on lateral femoral condyle had an average thickness of 3.71 mm ± 0.52 mm at its thickest point. The cartilage on the medial tibial plateau had an average thickness of 2.80 mm ± 0.26 mm at its thickest point and the cartilage on the lateral tibial plateau had an average thickness of 3.29 mm ± 0.45 mm at its thickets point. The cartilage on the midpoints of Cahill zones 1, 2, 3, and 4 had an average thickness of 2.93 mm ± 0.62 mm, 3.42 mm ± 0.66 mm, 2.81 mm ± 0.46 mm, and 3.30 mm ± 0.73 mm respectively. The cartilage on the midpoints of Cahill zones A, B, and C had an average thickness of 3.81 mm ± 0.68 mm, 4.40 mm ± 0.49 mm, and 3.82 mm ± 0.68 mm respectively. The cartilage at its thickest point on the patella had an average thickness of 4.53 mm ± 0.38 mm from an axial view and 4.40 mm ± 0.49 mm from a sagittal view (Fig. 5 and 6). Conclusion: Pediatric knees demonstrate relatively thick cartilage regions in multiple zone of the knee, compared with adult specimens. Increasing access to and use of this tissue for cartilage grafts, non-manipulated tissue, and manipulated tissue offer significant opportunity to address cartilage loss. Osteochondral allograft procedures may benefit from access to such tissue, with relatively high volume and thickness of normal articular cartilage. [Figure: see text][Figure: see text][Figure: see text][Figure: see text][Figure: see text][Figure: see text]

Background: Recent research has identified posterior tibial slope as a risk factor for anterior cruciate ligament (ACL) injury, due to increased forces on the ACL with this tibial anatomy. Biomechanical studies suggest that altering a patient’s posterior tibial slope may lower the risk of ACL injury. Due to the presence of an open physis, guided growth may be used to reduce the posterior tibia slope in this high risk skeletally immature population. The primary purpose of this study was to quantify and measure the posterior tibial slope in pediatric knees. Methods: Forty-four pediatric knee CT scans were analyzed using OsiriX, an imaging software. Specimens analyzed were between the ages of 2 and 12 years of age. The proximal tibial slope for each specimen was measured on CT scan sagittal slices at 2 locations: 1) At the medial tibial plateau at the mid region of the medial femoral condyle, as determined on a coronal slice through the femoral condyle; 2) At the lateral tibial plateau at the mid region of the lateral femoral condyle, as determined on the coronal slice through the femoral condyle. The measurement of the posterior tibial slope was determined by placing two lines parallel to the diaphysis of the tibia, one located in the middle of the diaphysis and one located at the most posterior aspect of the diaphysis. The most proximal aspect of both the medial and lateral tibial plateau were then identified and angle measurements were taken in reference to the parallel lines. The angle measurements were plotted graphically by age in order to account for variability in development within age groups. The anterior medial and lateral tibia plateau widths were measured by identifying the mid region of the respective plateaus. From this point, the distance between the top of the tibial plate and the physis was measured. Results: The average posterior tibial slope angle for the medial and lateral tibial plateau were (5.53° ± 4.17°) and (5.95° ± 3.96°) respectively. Independent samples t-test and ANOVA indicate the difference between the posterior tibial slope angle of the medial and lateral tibial plateau were not statistically significant (p < 0.05). When plotted graphically by age, a slight negative trend between age and posterior tibial slope was identified. As age increases, the medial and lateral posterior tibial slope decreases. The mean anterior medial tibial plateau width and lateral tibial plateau width were .99 cm and 1.19 cm respectively. Discussion/Conclusion: ACL primary and secondary injury occur at very high rates in the skeletally immature, especially in females at age 11 and older, and in males at age 13 and older. This data set offers some preliminary values for posterior tibial slope in patients without a history of ACL injury, allowing for comparisons to patients with ACL Injury. Increased tibial slope is a risk factor for ACL injury. In the skeletally immature, one option to alter the tibial slope is the use of guided growth with implants to slow the anterior growth of the proximal tibia, reducing the posterior slope of the tibia, and possibly lower the risk of ACL injury in this high-risk population. [Figure: see text][Figure: see text][Figure: see text][Figure: see text][Figure: see text][Table: see text][Table: see text]

Background: Quadriceps tendon (QT) turndowns are an alternative method for medial patellofemoral ligament (MPFL) reconstruction, with several distinct advantages: 1. Avoids the use of patella bone tunnels, which have been associated with patella fracture, 2. Avoids the use of separate incision for hamstring tendon harvest, and 3. Avoids the use of allograft tissue, which adds a significant cost. The disadvantage of the Quad Tendon graft is that the most distal reflection point on the patella may not duplicate the patella origin of the native MPFL. The purpose of this study was to determine whether a QT graft for MPFL reconstruction is anatomically analogous to the native MPFL origin in a skeletally immature population. Methods: Three skeletally immature cadaveric knee specimens (ages 10 and 11, 11) were dissected to reveal the MPFL and QT origins on the patella. The proximal and distal extent of the MPFL was marked on the medial border of the patella. The medial aspect of the quad tendon was reflected as far as possible in both a medial and distal position on the patella, to function as the MPFL graft. The distance was measured between the midpoint of the patellar origin of the MPFL in the coronal plane, and the most distal aspect of the patellar origin of the reflected quad tendon. Results: In the 10, 11, and 11 year-old specimens, the distance between the midpoint of MPFL patellar origin and the QT patellar origin was 3.4 cm, 4.3, and 3.7 mm. In all cases, the QT reflected origin was at least 7 mm anterior to the to native MPFL origin on the medial border of the patella. Conclusion: A disparity exists between the patellar origin of the MPFL and the patellar origin of the quad tendon, with the patellar origin of the MPFL being more medial, more distal, and more posterior than the reflected patellar origin of the QT graft. Surgeons performing MPFL reconstructions may find this anatomically valuable as they attempt to duplicate the normal anatomy of the patella stabilizers during surgical reconstruction. While the QT remains a good graft choice for MPFL reconstruction, attachment of the QT graft at the native origin of the MPFL may better reproduce the anatomy of the MPFL. Figures: [Figure: see text][Figure: see text]

Background: In skeletally immature patients, the MPFL femoral origin as near or below the physis in most age groups. Although MPFL reconstruction procedures that employ patella drill holes facilitate graft tension adjustment, recent research demonstrates significant risk of patella fractures if patella drill holes are utilized. For this reason, the use of patella drill holes may be best avoided, but this technical alteration makes graft tension fixation more challenging during MPFL reconstruction in the skeletally immature. The purpose of this study was to evaluate the feasibility of developing a physeal respecting femoral drill for the MPFL origin with surgical model simulation, which allows for graft tensioning during MPFL reconstruction. Methods: Pediatric cadaveric specimens (n=5) were dissected by a group of fellowship trained pediatric and/or sports orthopaedic surgeons, and these specimens were then subject to CT Scans for the creation of 3D models. Specimens, aged 7, 9, 10, 11 and 11 years, were used to develop surgical simulations. CT Scans were loaded into Osyrix, converted to appropriate file structure, and then 3D models were loaded into Blender (Stichting Blender Foundation, Buikslotermeerplein 161, 1025 ETAmsterdam, the Netherlands). These models were used to evaluate 3D models of the knee, with placement of medial femoral condyle drill holes starting at the MPFL femoral origin, and entering the joint just anterior to the PCL femoral origin. The anatomic goals of the surgical simulation include: 1. Place drill hole at the MPFL origin on the femur. 2 Enter the intercondylar notch region of the femur anterior to the PCL origin allowing for arthroscopic visualization. 3. avoiding the articular cartilage on the medial femoral condyle. 4. Avoid the femoral physis throughout the course of drilling from the femoral MPFL Origin point to the entry location into the intercondylar notch. In the specimens, a full length drill hole was placed with either a 4 or 5 mm drill hole. Results: All specimens were subject to the surgical modeling and simulated drill hole placement. In each case, a drill hole was successfully placed meeting all the goals of the simulation: 1. Starting Point at MPFL, 2. Exit point anterior the PCL origin, 3. Exit point posterior to the articular cartilage, and 4. Avoidance of direct physeal injury. Figures 1 and 2. Conclusion: Setting graft tension during MPFL reconstruction is one of the significant technical challenges during MPFL reconstruction, and appropriate graft position and tension may be the most critical elements of successful MPFL reconstruction. Historically, graft tension has been set on the patella, using drill holes for the MPFL attachment point on the patella, but this technique has been associated with patella fractures. In order to allow for adjustment of graft tension on the femoral side of the MPFL graft during surgical reconstruction, a surgical simulation was developed to confirm the anatomic appropriateness and safety of placement of femoral drill holes which allow for adjustment of graft tension. This surgical simulation model confirms that MPFL femoral origin anatomy can be reproduced with injury to the physis, the PCL, or the articular cartilage of the femoral condyle. This drill hole and graft can be visualized arthroscopically and allow for appropriate graft tensioning during the procedure. [Figure: see text][Figure: see text]

Background Anatomic studies of the paediatric posterior cruciate ligament (PCL) demonstrate that the tibial attachment spans the epiphysis, physis and metaphysis. To better reproduce the anatomy of the PCL and avoid direct physeal injury, a double-bundle PCL reconstruction technique that includes both an all-epiphysial and an all-metaphyseal tibial tunnel has been proposed. The purpose of this study was to evaluate tibial tunnel placement in a paediatric double-bundle PCL reconstruction technique that avoids direct physeal injury using a 3-D computer model. Methods Ten skeletally immature cadaveric knee specimens (ages 5–11) were used to create 3-D model reconstructions from CT scans. All-metaphyseal and all-epiphysial tibial tunnels were simulated with the goal of maintaining adequate spacing (≥2 mm) between the tibial physis and tunnels to avoid injury. The all-metaphyseal tunnel, simulated at sizes of 5, 6 and 7 mm, entered anteriorly, below the tibial tubercle (apophysis) and exited posteriorly in the metaphyseal PCL footprint, distal to the proximal tibial physis. Four-millimetre all-epiphysial proximal tibial tunnels were simulated to enter the epiphysis anteromedially and exit posteriorly at the central epiphysial region of the PCL footprint, proximal to the physis. The distance was measured from the all-metaphyseal tunnels to the physis posteriorly and from the all-epiphysial tunnels to the physis, both anteriorly and posteriorly. Results In all specimens, the 4 mm all-epiphysial tunnel and the 5, 6 and 7 mm all-metaphyseal tunnels maintained adequate spacing, ≥2 mm from the physis. In the specimens aged 5–7 years, the 5, 6 and 7 mm all-metaphyseal tunnels measured a mean distance of 3.5, 2.8 and 2.5 mm from the physis, respectively. In the specimens aged 8–11 years, the 5, 6 and 7 mm all-metaphyseal tunnels measured a mean distance of 3.4, 2.9 and 2.6 mm from the physis. In the specimens aged 5–7 years, the all-epiphysial tunnel measured a mean of 2.1 mm to the physis anteriorly and a mean of 2.8 mm posteriorly. In the specimens aged 8–11 years, the all-epiphysial tunnel measured a mean of 2.2 mm to the physis anteriorly and 2.4 mm posteriorly. Conclusion These computer-aided 3-D models of paediatric knees illustrate that 5, 6 and 7 mm all-metaphyseal tunnels as well as 4 mm all-epiphysial tunnels can be placed without direct injury to the proximal tibial physis. The margin of error for direct physeal injury is small, especially for the all-epiphysial tunnel. Further, the all-epiphysial tunnel, while reproducing the anatomy of the PCL epiphysial attachment, may also produce a more extreme ‘killer turn’ of the graft. Modifications to the all-epiphysial tunnel may be considered to reduce the impact of the high ‘killer turn’ angle on the tibia. Level of evidence IV.