No abstract

Background: Identifying risk factors for recurrent patellar dislocation after a primary dislocation may help guide initial treatment. Magnetic resonance imaging (MRI) measurements relating the alignment of the extensor mechanism to trochlear morphology have been shown to distinguish patients with dislocations from controls, but their usefulness in predicting the risk of a second dislocation is not known. Purpose: To identify the association of novel MRI measures of patellar containment with recurrent instability in pediatric patients presenting with a first-time patellar dislocation. Study Design: Cohort study (Prognosis); Level of evidence, 3. Methods: The study was conducted at a tertiary care children’s hospital (2005-2014) on patients (age, 8-19 years) with a first-time patellar dislocation. MRI measurements were made by 2 independent raters. Interobserver reliability was assessed for all measurements via an intraclass correlation coefficient (ICC). Only measurements with an ICC >0.8 were included. Univariable and multivariable logistic regression analyses were used to evaluate variables associated with recurrence. Results: A total of 165 patients with a median age of 14 years and a slight (57.6%) female predominance was identified. The median follow-up length of the whole cohort was 12.2 months (interquartile range, 1.6-37.1 months). Subsequent instability was documented in 98 patients (59.4%). MRI measurements with excellent correlation (ICC > 0.8) were the tibial tubercle to trochlear groove distance (TT-TG), the tangential axial width of the patella, the tangential axial trochlear width, the axial width of the patellar tendon beyond the lateral trochlear ridge (LTR), and the tibial tubercle to LTR distance. In univariate analysis, all mentioned MRI measurements had significant association with recurrent instability. However, after both backward and forward stepwise regression analyses, the tibial tubercle to LTR distance was the only independent predictor of recurrent instability ( P = .003 in both). Patients with a tibial tubercle to LTR distance value greater than –1 mm had a significantly higher rate of recurrent patellar dislocation (72%). Conclusion: Of numerous axial view MRI parameters, only the tibial tubercle to LTR distance demonstrated a statistically significant association with recurrent patellar instability upon multivariable logistic regression analysis during short-term follow-up of a pediatric population presenting with initial lateral patellar dislocation. Interobserver correlation of the tibial tubercle to LTR distance was good (ICC > 0.8) and similar to that of TT-TG.

The use of a washer to supplement screw fixation can prevent fragmentation and penetration during the surgical treatment of pediatric medial epicondyle fractures. However, concerns may arise regarding screw prominence and the need for subsequent implant removal. The purpose of this study is to evaluate the impact of washer utilization on the need for hardware removal and elbow range of motion (ROM). All pediatric medial epicondyle fractures treated with a single screw over a 7-year period were queried for this retrospective case-control study. Hardware removal was performed only if the patient experienced a complication or implant-related symptoms that were refractory to non-operative management. Of the 137 patients included in the study, a washer was utilized in 90 (66%). Thirty-one patients (23%) ultimately underwent hardware removal. There was not an increased need for implant removal in those with a washer (P = 0.11). When analyzing a subgroup of 102 athletes only, there was similarly no difference in the rate of implant removal if a washer was used (P = 0.64). Overall, 107 (78%) patients regained full ROM at a mean of 13.9 ± 9.7 weeks after surgery with no significant difference along the lines of washer use. Use of a washer did not affect the need for subsequent implant removal or elbow ROM after fixation of medial epicondyle fractures, even in athletes. If there is concern for fracture fragmentation or penetration, a washer can be included without concern that future unplanned surgeries may be required.

The rapid rollout of vaccinations in response to the COVID-19 pandemic has led to their widespread distribution and administration throughout the world. The benefit of these vaccinations in preventing the spread of the disease and diminishing symptoms in patients who contract COVID-19 has been fervently studied and reported. While vaccinations remain an effective and generally safe method of limiting disease transmission and virus-related mortality, vaccine administration is not completely without risk. Shoulder injuries related to vaccine administration (SIRVA) have been described with previously available vaccines but have yet to be widely reported in the COVID-19 vaccination population. We present a case report of a young, high-functioning patient who presented with acute subacromial bursitis after COVID-19 vaccine administration due to improper vaccination technique. The patient was treated with arthroscopic shoulder surgery and had near immediate relief of shoulder symptoms.

Background: Accurate and efficient diagnosis, as well as a consistent and effective treatment of acute hematogenous osteomyelitis, are paramount to ensure successful clinical outcomes. Noninvasive measures of isolating the causative pathogen from blood cultures have low sensitivity, with published rates often <50%. The use of interventional radiology (IR)-guided percutaneous biopsy has gained traction as a nonsurgical means of obtaining tissue cultures with a reported increased sensitivity of > 90%. This study aims to determine the utility of IR-guided biopsy in the management of pediatric patients with acute hematogenous pediatric osteomyelitis (OM). Methods: An IRB-approved retrospective review was completed of children younger than 18 years admitted to a single institution for treatment of magnetic resonance imaging or culture/biopsyproven acute hematogenous OM. Patients were excluded for the diagnosis of chronic recurrent multifocal OM, incomplete documentation, treatment initiation at an outside institution, open surgical debridement, and concomitant septic arthritis. Patients who underwent IR-guided biopsy were compared with those treated empirically without biopsy. Results: Fifty patients were included for analysis. Fifteen (30%) had IR-guided biopsies; 35 (70%) were treated empirically. The average age at diagnosis was 11.8 years old (SD: 4.9). Of the 15 patients who underwent IR-guided biopsy, a pathogen was identified in 12 cases (80%); 14 of these patients had concomitant blood cultures with only 1 (7%) positive result (P < 0.01). Of the 11 patients with positive IR-guided biopsy results in the setting of negative blood cultures, 9 (82%) had alterations in their antibiotic regimen as a result of the biopsy. The average time from blood sample collection to definitive antibiotic initiation was nearly double that of time from IRguided biopsy collection to definitive antibiotic initiation (70.8 vs. 36 h; P < 0.01). Conclusion: IR-guided biopsy increased pathogen identification by 47% over blood cultures alone and decreased the time to definitive antibiotics. As such, IR-guided biopsy is an effective and safe diagnostic tool for pathogen identification and appropriate antibiotic selection. Orthopaedic surgeons are encouraged to incorporate IR-guided biopsy early in the treatment pathway for patients with acute OM without an indication for open surgical intervention.