Background: Management of discoid meniscus in pediatric patients requires understanding of the presentation, associated risks, and appropriate techniques. Surgical treatment consists of saucerization, meniscus repair, meniscocapular stabilization, and, periodically, subtotal meniscectomy. The type of meniscal treatment is commonly determined during arthroscopy. Thus, surgeons, patients, and their parents/guardians must be prepared for a variety of surgical options. Hypothesis/Purpose: To compare intraoperative arthroscopic findings and treatment of discoid meniscus across pediatric age groups in a large multicenter quality improvement registry. Methods: A multi-center quality improvement registry (16 institutions, 26 surgeons) monitoring the safety of discoid meniscus surgery was reviewed. Audit processes using CPT codes were designed to ensure that all consecutive cases from 2018-2020 were prospectively entered on patients <19 years old into a HIPAA-compliant electronic platform. Patients were grouped into five groups based on age at time of surgery (<7, 7-10, 11-13, 14-16, >16). Demographic characteristics, discoid type, presence and type of tear, peripheral rim instability, repair technique, and partial meniscectomy/debridement beyond saucerization were reviewed. Chi-Square or Fisher’s exact tests were used for categorical comparisons and a Kruskal-Wallis test for continuous comparisons. Results: 274 patients were identified (mean age 12.4 years, range 3-18; 47.3% females). Complete discoid meniscus and peripheral rim instability were found to be more prevalent in younger age groups (Table 1). Peripheral rim instability was noted in 55.5% of cases, most commonly in the posterior horn (24.8%). While a focal region of instability was most common, the youngest age group was more likely to have either multifocal instability or no instability. Repair was conducted more commonly in the younger cohorts, with a significant decrease in repair percentage (p=0.008) per age group. All-inside was the most common repair technique in all age groups. Partial meniscectomy/debridement beyond saucerization occurred more frequently in older age groups than younger age groups (p=.0002), including 38.4% of cases in the oldest age group (Table 2). Conclusion: Younger patients experienced a greater incidence of complete discoid menisci and meniscus repair in this age group and was more likely to have more than one area of rim instability. However, when meniscal resection beyond a saucerization was required, this was more likely to occur in older patients. [Table: see text][Table: see text]
Background: Anterior Cruciate Ligament reconstruction (ACLr) is commonly performed in pediatric and adolescent patients. The most common early complication associated with ACLr is stiffness, including motion loss and arthrofibrosis. There is minimal literature regarding risk factors for stiffness following ACLr in this age group. Hypothesis/Purpose: To evaluate the incidence and risk factors associated with stiffness following ACLr using a multi-center quality improvement registry. Methods: A multi-center quality improvement registry (16 institutions, 26 surgeons) monitoring the safety of ACLr was reviewed. Audit processes using CPT codes were designed to insure that all consecutive cases were prospectively entered on patients <19 years old into a HIPAA-compliant electronic platform. Stiffness was defined as motion loss that prompted any deviation from the normal post-operative course (Clavien Dindo grade II or greater), including additional clinical or physical therapy (PT) visits, serial/dynamic splinting, or secondary surgery for stiffness (Clavien Dindo grade III). Each case of stiffness and associated complication form was secondarily reviewed to insure consistency of identification and grading. Demographic and peri-operative data were reviewed. Chi-Square or Fisher’s exact tests were used for categorical comparisons and a Kruskal-Wallis test for continuous comparisons. Results: 2,839 ACLr cases (mean age 15.1, 6-19; female 46.9%) were identified, with stiffness reported in 4.2% of patients (including isolated flexion or extension and combined stiffness) and secondary surgery for stiffness (manipulation under anesthesia and/or lysis of adhesions) performed in 1.1% of patients. Loss of extension occurred in 3.8% of patients (59.3% females), while loss of flexion occurred in 3.1% of patients (49.4% females). Overall stiffness occurred with longer tourniquet times (93.0 min vs. 78.8 min, p<0.001) when used. Anterior displacement of medial or lateral meniscus tear were associated with nearly twice the incidence of extension loss (7.1%) and three times the incidence of surgery for stiffness (3.7%). Conclusion: Post-operative stiffness following ACLr is rare but may be associated with certain demographic and perioperative factors, such as female sex, prolonged tourniquet time, and certain concomitant injuries such as anteriorly displaced meniscus tears. The degree to which altered practices and/or additional monitoring/vigilance in the setting of such factors warrants additional study.
Background: Meniscal tears have been reported at higher rates in the pediatric patient in recent years. Meniscus repair to restore meniscus function may be invaluable to the long-term health of the knee. Hypothesis/Purpose: To describe demographic characteristics, tear types, and surgical techniques for meniscus repair in pediatric patients, including risk factors for early repair failure. Methods: A multi-center quality improvement registry (16 institutions, 26 surgeons) monitoring the safety of meniscus repairs was reviewed. Audit processes using CPT codes were designed to ensure that all consecutive cases were prospectively entered on patients <19 years old into a HIPAA-compliant electronic platform. Each meniscus repair case with a complication form was secondarily reviewed to ensure consistency of identification and grading. Demographics, tear type, repair technique, and implant type, when applicable, were included, and a common cause analysis was performed to evaluate risk factors for early repair failures. Results: 1230 meniscus repair cases (mean age 15.2, 5-19; Female 43.8%) were identified, consisting of 49.0% lateral meniscus repair (LMR), 36.0% medial meniscus repair (MMR), and 15.0% LMR+MMR. The majority (69.7%) were performed in conjunction with either ACL reconstruction (ACLr) or tibial spine repair (TSr). In both LMR and MMR, the most common tear type, technique, and implant were longitudinal/vertical tear (50.3%, 80.0%, respectively), all-inside repair (69.3%, 68.9%, respectively), and Smith & Nephew Fast-Fix 360 (37.8%, 36.8%, respectively). An inside-out repair was performed twice as often in both LMR and MMR when performed in isolation without an ACLr or TSr. For both LMR and MMR, surgeons used an average of 2 sutures/devices (38.0%) with 6.5% involving 10+ sutures/implants. Variation in meniscus repair techniques was seen between tear types, displacement, and location (Tables 1, 2). Radial tears were uncommon in the MM (2.7%), but were commonly treated in the LM (12.32%) using all-inside (42.1%), inside-out (30.2%), and outside-in (19.7%) techniques. Meniscus tears with displacement were seen in 35.2% of MM tears and 25.3% of LM tears, with anterior displacement being the most common direction. For both LMR and MMR, the most common technique for tears with displacement was all-inside (58.4%). There were 15 early (<8 months) repair failures (1.2%), most common type and technique of which were MMR (73.3%) and all-inside (73.3%). Conclusion: The techniques utilized for pediatric meniscus tears depend upon tear type, displacement, and whether performed in conjunction with an ACLr or TSr. MMR performed with all-inside technique may be at risk for early failure. [Table: see text][Table: see text]
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