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PURPOSE OF REVIEW: The purpose of this study was to review the clinical and functional outcomes of meniscus repair in children and adolescents. RECENT FINDINGS: The sequel of meniscal tears and the outcome of meniscus repair have been well studied in adults. However, these topics have received less attention in the pediatric population despite the high prevalence and potentially critical effect on long-term knee function in children. SUMMARY: Meniscus repair has a healing rate ranging from 33 to 100% with less than 40% reoperation rate. Several factors have been suggested to play a role in healing, such as concomitant ACL reconstruction and complexity of the tear. There is a lack of standardization among the utilization of functional outcome and activity level questionnaires across studies; however, most report improved function postoperatively. Other important considerations include bucket handle tears, the discoid meniscus, rehabilitation and return to sports, and alternatives after failed meniscus repair. Based on the favorable outcomes reported, meniscus repair should be attempted in most meniscus tears in children.

PURPOSE OF REVIEW: Over the past ten years, there has been a change in the management of adolescent clavicle fractures. Utilizing data from the adult population, clinicians have become more aggressive in terms of surgical fixation. The purpose of this paper is to critically analyze the recent literature in regard to adolescent clavicle fractures, and to determine the role of open reduction and internal fixation. RECENT FINDINGS: Although there have been many case series that demonstrate that open reduction and internal fixation can be done safely and with predictable healing, studies which compare operative versus non-operative intervention suggest there may not be functional outcome differences between the two treatment options. SUMMARY: Further study is necessary to determine the specific indications for fixation of clavicle fractures in the adolescent population. Shared decision-making between patient, family, and clinicians is essential to determine the specific fracture patterns and patients who might benefit from fixation to improve functional outcome.

PURPOSE OF REVIEW: The purpose of this manuscript is to 1 define the features associated with borderline acetabular dysplasia and 2 review current status of diagnostic algorithms and treatment options for borderline dysplasia. RECENT FINDINGS: Acetabular dysplasia is a common cause of hip pain secondary to insufficient coverage of the femoral head by the bony acetabulum. Historical classification of acetabular dysplasia has utilized the lateral center edge angle (LCEA); values above 25° are normal and below 20° are considered pathologic. Borderline dysplasia describes hips with LCEA between 20 and 25(o); treatment of these patients is controversial. SUMMARY: While many studies utilize LCEA in classification of borderline dysplasia, isolated reliance on measurement of lateral femoral head coverage to define severity of undercoverage will continue to mislabel morphology. Thorough assessment of the characteristics of mild acetabular undercoverage is necessary for future studies, which will allow effective comparisons of results between hip arthroscopy and periacetabular osteotomy.

PURPOSE OF REVIEW: Congenital pseudoarthrosis of the tibia and fibula are rare conditions that share common treatment strategies. The purpose of this review is to provide an overview of the recent developments in treatments for both conditions. RECENT FINDINGS: Recent literature has focused on the use of BMP and on gait analysis as a tool for measuring long-term functional outcomes. Recent study has indicated rhBMP-2 may shorten the time to initial healing of pseudoarthroses, but not guarantee bony union. Children with initial fractures before the age of four have been shown to have long-term gait outcomes that may be ultimately comparable to children with prostheses. SUMMARY: Both congenital pseudoarthrosis of the tibia and fibula are challenging conditions to treat, which require comprehensive approaches to account for both the biological and mechanical components of the conditions.

PURPOSE OF REVIEW: Spinal deformity is a common issue in pediatric patients with an underlying neurological diagnosis or syndrome. Management of neuromuscular scoliosis (NMS) is a major part of the orthopedic care of such patients, as the deformity is often progressive, and may affect gait, seating and positioning. In addition, untreated large spinal deformities may be associated with pain and/or cardiopulmonary issues over time. RECENT FINDINGS: Recent changes in medical management of the underlying disease process appears to alter the natural history of certain neuromuscular conditions, and in the case of patients with Duchenne’s muscular dystrophy significantly diminish the incidence of spinal deformity. In the most common diagnosis associated with NMS, cerebral palsy, there is evidence that despite a high complication rate, surgical management of spinal deformity is associated with measurable improvements in validated health-related quality-of-life measures. SUMMARY: Spinal deformity is a common finding in patients with neurological diagnoses. It is important for those involved in the care of these patients to understand the natural history of NMS, as well as the potential risks and benefits to the patient and caregivers, of surgical and non-surgical interventions.

Idiopathic clubfoot has a tremendous worldwide prevalence. If left untreated, the deformity has severely disabling effects on mobility and quality of life. Given its prevalence and significance, numerous studies are published on this condition every year. In this article, we attempt to highlight important themes and findings of studies published on idiopathic clubfoot over the past 3 years.

Brachial plexus birth palsy (BPBP) is an upper extremity paralysis that occurs due to traction injury of the brachial plexus during childbirth. Approximately 20 % of children with brachial plexus birth palsy will have residual neurologic deficits. These permanent and significant impacts on upper limb function continue to spur interest in optimizing the management of a problem with a highly variable natural history. BPBP is generally diagnosed on clinical examination and does not typically require cross-sectional imaging. Physical examination is also the best modality to determine candidates for microsurgical reconstruction of the brachial plexus. The key finding on physical examination that determines need for microsurgery is recovery of antigravity elbow flexion by 3-6 months of age. When indicated, both microsurgery and secondary shoulder and elbow procedures are effective and can substantially improve functional outcomes. These procedures include nerve transfers and nerve grafting in infants and secondary procedures in children, such as botulinum toxin injection, shoulder tendon transfers, and humeral derotational osteotomy.

Complications following spine fusion for adolescent idiopathic scoliosis can be characterized as either intra-operative or post-operative. The most serious and feared complication is neurologic injury, both in the intra- and post-operative period. Other intra-operative complications include dural tears and ophthalmologic or peripheral nerve deficits, which may be related to positioning. Among the most common post-operative complications are surgical site infection, venous thromboembolism, gastrointestinal complications, and implant-related complications. Significant blood loss requiring transfusion, traditionally considered a known sequelae of spine fusion, is now being recognized as a “complication” in large national databases. Pediatric spine surgeons who care for patients with AIS must be thoroughly familiar with all potential complications and their management.

Hip dysplasia is a treatable developmental disorder that presents early in life but if neglected can lead to chronic disability due to pain, decreased function, and early osteoarthritis. The main causes of hip dysplasia in the young adult are residual childhood developmental dysplasia of the hip (DDH) and adolescent-onset acetabular dysplasia. These two distinct disease processes affect the growing hip during different times of development but result in a similar deformity and pathomechanism of hip degeneration. Routine screening for DDH and counseling regarding risks for acetabular dysplasia in families with a history of early hip osteoarthritis may allow early identification and intervention in these hips with anatomical risk factors for joint degeneration.

Aneurysmal bone cysts (ABCs) are benign bone lesions arising predominantly in the pediatric population that can cause local pain, swelling, and pathologic fracture. Primary lesions, which constitute roughly two thirds of all ABCs, are thought to be neoplastic in nature, with one third of ABCs arising secondary to other tumors. Diagnosis is made with various imaging modalities, which exhibit characteristic features such as "fluid-fluid levels," although biopsy is critical, as telangiectatic osteosarcoma cannot be excluded based on imaging alone. Currently, the standard of care and most widely employed treatment is intralesional curettage. However, tumor recurrence with curettage alone is common and has driven some to propose a multitude of adjuvants with varying efficacy and risk profiles. Historically, therapies such as en bloc resection or radiation therapy were utilized as an alternative to decrease the recurrence rate, but these therapies imposed high morbidity. As a result, modern techniques now seek to simultaneously reduce morbidity and recurrence, the pursuit of which has produced preliminary study into minimally invasive percutaneous treatments and medical management.

While some fractures may be managed similarly in adults and children, physeal fractures are uniquely limited to the pediatric population and require special consideration. Although physeal fractures about the knee are relatively rare, they are occurring more frequently due to increasing youth participation in sports and high-energy recreational activities. The evaluation and management of distal femoral and proximal tibial physeal fractures are similar to one another, but fractures of the tibial spine and tibial tubercle are approached somewhat differently. A thorough understanding of the pertinent developmental anatomy is critical for correlating the clinical findings with the imaging work-up, and for anticipating the most common and the most serious complications of each fracture. Diagnosis is usually made with appropriate plain radiographs with advanced imaging often used for preoperative planning. In general, fracture pattern and degree of displacement determine the need for surgical intervention and the overall outcome. While a variety of fixation techniques or constructs may be used, because of the importance of restoring physeal and articular anatomy for avoidance of growth disturbance and degenerative joint disease, respectively, achieving anatomic, rigid fixation is of greater importance than with many other fracture locations in the growing skeleton.