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The purpose of the study was to quantify the frequency, severity, and location of patellofemoral (PF) articular cartilage changes recurrent patellar instability treated surgically in patients with preoperative clinical patellar crepitation.A single-surgeon database was queried for all knees with recurrent patellar instability between 3/2000 and 6/2012 (n=214). Only knees which underwent knee arthroscopy during the surgical treatment were included (n=148). PF articular cartilage condition was assessed arthroscopically.There were 148 knees in 130 patients (mean age, 16 y), which met inclusion criteria. There were 93 females and 37 males. Diagnoses were dislocations [122 (82.4%)] and subluxations (26). Preoperatively 28 knees (18.9%) had PF crepitation. Statistical analysis demonstrated preoperative PF crepitation was correlated with medial patellar facet lesions (P=0.0022) and were 3.6 times more likely to have medial patellar facet lesions. Crepitation was correlated with the higher outerbridge (OB) patellar grades (P0.0001) and larger patellar lesion size (P=0.0021). At arthroscopy 89 knees (60.5%) had patellar articular cartilage damage with a mean OB grade of 1.3 (0 to 4) and mean size of 93.2 mm (0 to 750). The femoral articular cartilage was identified in 29 knees (19.7%) with a mean OB grade of 0.44 (0 to 4).PF articular damage was present in 63% of knees, which were surgically treated for patellar instability. The patella was involved in 61% (mean, 129 mm) and femoral trochlea in 20% (mean 166 mm) of knees. Knee with preoperative PF crepitation (20% of cohort) more commonly had medial patellar facet lesions with higher OB grades, and larger patellar lesion size than knees without preoperative crepitation. Because of the high frequency of patellar (83%) and femoral (36%) articular damage documented at the time of surgical reconstruction, visualization of the PF joint is recommended when knees have preoperative PF crepitation.Level IV.

BACKGROUND Excessive femoral anteversion is a developmental condition that can become symptomatic into adolescence and manifest as anterior knee pain, tripping, and or problems with sports. Femoral derotational osteotomy about an antegrade intramedullary nail (IMN) is an accepted option to treat this condition. This is the first report of the clinical and functional outcomes of treatment of excessive anteversion with femoral derotational osteotomy stabilized with an IMN. METHODS We prospectively enrolled 28 consecutive patients between 2013 and 2014 who underwent derotational osteotomy. Physical examination measures were used to calculate the amount of angular correction with focus on internal and external rotation of the hip, as well as the trochanteric prominence angle test of femoral anteversion. The International Knee Documentation Committee-9, Marx, and Tegner activity scales were 3 patient-reported outcomes recorded. RESULTS After femoral derotation osteotomy over an IMN, femoral anteversion, as measured by the trochanteric prominence angle, improved an average of 29 degrees (P

Spica casting is the standard of care for femur fractures in children up to 6 years of age. The indications for surgery are controversial. We sought to compare immediate spica casting (Spica) and flexible intramedullary nailing [titanium elastic nailing (TEN)] in a group of children ages 2 to 6 years. We hypothesized that young children can be successfully treated with flexible nails, resulting in faster return to ambulation and an equivalent complication rate when compared with spica casting.This was a multicenter retrospective review of 215 patients, 141 treated with immediate spica casting, and 74 treated with elastic nails. Patient demographics, fracture characteristics, mechanism of injury, associated injuries, outcomes, and complications were recorded and compared between the 2 groups.Patients in the elastic nailing group were more likely to be injured as a pedestrian struck by an automobile (Spica 8% vs. TEN 26%, P=0.001), and had increased rates of associated injuries (P0.001). Time to fracture union was similar between the 2 groups (P=0.652). The TEN group had shorter time to independent ambulation (Spica 51±14 vs. TEN 29±14 d, P0.001) and return to full activities (Spica 87±19 vs. TEN 74±28 d, P=0.023).TEN is a reasonable option for treatment of femur fractures in young children when compared with spica casting with shorter time to independent ambulation and full activities. Fractures associated with a high-energy mechanism are especially appropriate for consideration of treatment with TEN.Level III, this was a retrospective comparative study.

Background Limb lengthening by callotasis as described by Ilizarov has become the standard method of lower extremity lengthening. Lengthening over an intramedullary nail to allow early removal of the external fixator has also become common in adults but few studies have addressed the efficacy in children. Methods A retrospective review of 37 consecutive children who had undergone femoral lengthening with external fixator over an intramedullary nail was performed. Charts were reviewed for demographics, surgical details, and complications. Radiographs were examined to determine magnitude of lengthening and to calculate lengthening index. Results The average age of the 37 patients was 11.6 years (range, 8.1 to 17.0). The amount of lengthening averaged 7.0 cm (range, 3.0 to 11.4 cm), which represented a mean 20.4% increase in length. The mean time in the fixator was 81 days. The lengthening index was 1.21 days/mm. Thirteen patients developed major complications (37.8%) including 4 limbs that failed to lengthen initially, 3 fractures (1 before fixator removal and 3 after fixator removal), 2 nail failures, 4 deep infections, and 2 joint subluxations requiring operative care. The 3 fractures after fixator removal were treated with exchange nailing as were the 2 intramedullary nail failures. Four patients (10.8%) developed deep infections requiring irrigation, debridement, and IV antibiotics. One patient developed a late hip subluxation, which was treated with a shelf osteotomy but resulted in pain and limitation of motion. One patient developed knee subluxation during lengthening requiring operative intervention. The technique was successful in obtaining a good result with a functional lengthened femur without unresolved problems in 94% of the patients despite a significant rate of major complications, particularly in those with a congenital etiology. Only 2 of the 37 patients ultimately had results that were ultimately compromised by complications. Conclusions Femoral lengthening over an intramedullary nail with the aid of an external fixator has shown to be an effective method for correcting limb length discrepancy. The technique has a high complication rate similar to other methods of lengthening. Level of evidence Level IV-Case Series.

BACKGROUND Circumferential casts can contribute to elevated compartment pressures in the setting of acute swelling. We have developed a novel casting method (A-frame cast) that allows cast placement while leaving the antecubital fossa free of casting material. The purpose of this study was to evaluate the safety, efficacy, and complications associated with acute placement of this definitive cast after closed reduction percutaneous pinning (CRPP) of acute supracondylar distal humerus fractures. METHODS A retrospective medical record reviewed 436 patients treated with CRPP of supracondylar fractures by 3 surgeons who routinely used an A-frame cast over a 12-year period. All complications or the need for cast modification were noted. Patients with open reduction, ipsilateral fractures, or patients lost to follow-up were excluded. RESULTS There were 387 patients who met inclusion criteria, including 204 type 2 fractures and 183 type 3 fractures. Forty-three patients had preoperative nerve palsy and 1 had preoperative vascular injury. Of these 387 patients, 369 (95.3%) had an uneventful postoperative course. Nineteen patients (4.9%) required either cast splitting (15) or strict elevation (4) secondary to pain and swelling. Seven of these 19 patients had preoperative nerve palsy and 1 had preoperative vascular injury. The average time from procedure to cast splitting was 17.6 hours. No patients lost their reduction or required a second surgical procedure related to a complication from casting. CONCLUSIONS An "A-frame" cast provides sturdy immobilization without increased risk of compartment syndrome after CRPP of supracondylar fractures in the pediatric population. Consideration should be given to splitting the cast prophylactically in patients with preoperative neurological or vascular deficits. LEVEL OF EVIDENCE IV-Case Series.

BACKGROUND The purpose of this study was to report early outcomes after patellar realignment surgery (PRS) was performed for patellar instability in children and adolescents. METHODS The study cohort consisted of 23 patients (27 knees) who had PRS between March 1, 2000 and July 30, 2004, by a single surgeon, with a minimum 3-year follow-up and validated outcome measures. Preoperative diagnoses were dislocations in 22 knees and subluxations in 5 knees. The mean age was 14 years and 1 month. RESULTS Postoperatively, 2 knees had possible recurrent dislocation/subluxation episodes; neither required surgery. Persistent patellofemoral mechanical symptoms have been reported in 10 knees. At a mean follow-up of 5 years and 1 month, the mean Lysholm score was 69.3 and the mean International Knee Documentation Committee (IKDC) score was 65.6. The mean Tegner activity level was 5.4. Patients reported improvement in knee function and pain in 26 of 28 knees (93%). Significant group differences were identified for age at surgery, preoperative diagnosis, and length of preoperative knee symptoms. The group with scores ≥ 70 were younger (13.1 vs. 14.9 y), were all patellar dislocators (vs. 66% in the < 70 group), and with shorter length of symptoms (13 mo vs. 24 mo). In the ≥ 70 groups the Tegner activity levels were higher at 6.8 versus the < 70 group at 4.3. CONCLUSIONS At a mean of 5 years after PRS, 93% of patients reported persistent improvement in knee function and pain, and recurrent patellar dislocation/subluxation episodes were infrequent (7%). Despite the low rate of postoperative patellar instability the patients' subjective opinion of knee function was less than expected (mean IKDC 65.5). Further investigation is warranted to identify causes for this suboptimal outcome at a mean of 5 years postoperatively. CLINICAL RELEVANCE These data reinforce the recurring theme documented in other areas of orthopaedics of a disconnection between the "surgical" success (93% improved) and patient's subjective outcome (mean IKDC of 65.6). LEVEL OF EVIDENCE Level III.