Retrospective cohort study. To describe long-term clinical and imaging results focusing on the uninstrumented lumbar spine after posterior spinal fusion for adolescent idiopathic scoliosis. Although previous studies found rates of low back pain after long fusion for adolescent idiopathic scoliosis which are comparable to rates found in the general population, many surgeons believe that the long lever arm associated with the fusion mass will result in increased stress at uninstrumented caudal intervertebral discs and accelerated degenerative changes. This is a retrospective chart and imaging review of adolescent idiopathic scoliosis patients treated with posterior fusion and segmental instrumentation. Patients completed follow-up examination, outcome questionnaires, radiographs, and magnetic resonance (MR) imaging. MR images were scored for evidence of degeneration of lumbar discs below the level of the fusion. Twenty patients participated in the study, providing 90 discs below fusions for evaluation. The average follow-up was 11.8 years. The distal level of fixation was at L1 on average. The major curve averaged 55° ± 11° before surgery and was corrected to 25° ± 10° at follow-up. Follow-up MR imaging demonstrated new disc pathology in 85% of patients enrolled. Only one patient demonstrated significant degenerative disc disease at the junctional level, whereas most pathology was seen at the L5-S1 disc. The average Pfirrmann grade at uninstrumented levels deteriorated from 1.1 before surgery to 1.8 at follow-up. The greatest degree of degeneration was seen at the L5-S1 disc space where average degenerative scores increased from 1.2 before surgery to 2.3 after surgery. Three patients with severe disc disease were taking nonsteroidal anti-inflammatory drugs for pain, but no narcotics. Only mild scoliosis research society (SRS) and Oswestry changes were noted in this severe degeneration group. Despite demonstrating an accelerated rate of L5-S1 disc degeneration, our study group has good functional scores and maintenance of correction over 10 years postfusion. In this long-term MR imaging follow-up study, disc degeneration was found remote to the lowest instrumented vertebra.

Background: There is no standardized complication classification system that has been evaluated for use in pediatric or general orthopaedic surgery. Instead, subjective terms such as major and minor are commonly used. The Clavien-Dindo-Sink complication classification system has demonstrated high interrater and intrarater reliability for hip-preservation surgery and has increasingly been used within other orthopaedic subspecialties. This classification system is based on the magnitude of treatment required and the potential for each complication to result in long-term morbidity. The purpose of the current study was to modify the Clavien-Dindo-Sink system for application to all orthopaedic procedures (including those involving the spine and the upper and lower extremity) and to determine interrater and intrarater reliability of this modified system in pediatric orthopaedic surgery cases. Methods: The Clavien-Dindo-Sink complication classification system was modified for use with general orthopaedic procedures. Forty-five pediatric orthopaedic surgical scenarios were presented to 7 local fellowship-trained pediatric orthopaedic surgeons at 1 center to test internal reliability, and 48 scenarios were then presented to 15 pediatric orthopaedic surgeons across the United States and Canada to test external reliability. Surgeons were trained to use the system and graded the scenarios in a random order on 2 occasions. Fleiss and Cohen kappa (κ) statistics were used to determine interrater and intrarater reliabilities, respectively. Results: The Fleiss κ value for interrater reliability (and standard error) was 0.76 ± 0.01 (p < 0.0001) and 0.74 ± 0.01 (p < 0.0001) for the internal and external groups, respectively. For each grade, interrater reliability was good to excellent for both groups, with an overall range of 0.53 for Grade I to 1 for Grade V. The Cohen κ value for intrarater reliability was excellent for both groups, ranging from 0.83 (95% confidence interval [CI], 0.71 to 0.95) to 0.98 (95% CI, 0.94 to 1.00) for the internal test group and from 0.83 (95% CI, 0.73 to 0.93) to 0.99 (95% CI, 0.97 to 1.00) for the external test group. Conclusions: The modified Clavien-Dindo-Sink classification system has good interrater and excellent intrarater reliability for the evaluation of complications following pediatric orthopaedic upper extremity, lower extremity, and spine surgery. Adoption of this reproducible, reliable system as a standard of reporting complications in pediatric orthopaedic surgery, and other orthopaedic subspecialties, could be a valuable tool for improving surgical practices and patient outcomes.

Osteochondritis dissecans is a term used to describe the separation of an articular cartilage subchondral bone segment from the remaining articular surface. Juvenile osteochondritis dissecans describes an osteochondritis dissecans lesion found in skeletally immature children with a maximum incidence occurring between the ages of 10 and 20. It is found more frequently in children who are active athletically and involved in organized sports and is twice as common in males as in females. Although the etiology of these lesions is unclear, it is believed that repetitive microtrauma may interrupt the already tenuous epiphyseal blood supply in the growing child and contribute to the development of osteochondritis dissecans lesions. Treatment is dependent upon age at presentation, fragment size, fragment location, and fragment stability. Stable lesions in skeletally immature patients are generally amenable to conservative management. Failed conservative management or unstable lesions will more likely require surgical intervention. Lesions in skeletally mature patients have a more unpredictable course and may require surgery. This review article discusses the anatomy, etiology, evaluation, classification, treatment, and expected outcome of osteochondritis dissecans lesions.

Background: Anterior cruciate ligament (ACL) reconstruction in skeletally immature patients can result in growth disturbance due to iatrogenic physeal injury. Multiple physeal-sparing ACL reconstruction techniques have been described; however, few combine the benefits of anatomic reconstruction using sockets without violation of the femoral or tibial physis. Purpose: To utilize physeal-specific magnetic resonance imaging (MRI) to quantify the zone of physeal injury after all-inside ACL reconstruction in skeletally immature athletes. Study Design: Case series; Level of evidence, 4. Methods: Twenty-three skeletally immature patients (mean chronologic age 12.6 years; range, 10-15 years) were prospectively evaluated after all-inside ACL reconstruction. The mean bone age was 13.2 years. There were 8 females and 15 males. Fifteen patients underwent an all-epiphyseal (AE) ACL reconstruction and 8 patients had a partial transphyseal (PTP) ACL reconstruction, which spared the femoral physis but crossed the tibial physis. At 6 and 12 months postoperatively, MRI using 3-dimensional fat-suppressed spoiled gradient recalled echo sequences and full-length standing radiographs were performed to assess graft survival, growth arrest, physeal violation, angular deformity, and leg length discrepancy. Results: The mean follow-up for this cohort was 18.5 months (range, 12-39 months). Minimal tibial physeal violation was seen in 10 of 15 patients in the AE group and, by definition, all patients in the PTP group. The mean area of tibial physeal disturbance (±SD) was 57.8 ± 52.2 mm ² (mean 2.1% of total physeal area) in the AE group compared with 145.1 ± 100.6 mm ² (mean 5.4% of total physeal area) in the PTP group ( P = .003). Minimal compromise of the femoral physis (1.5%) was observed in 1 case in the PTP group and no cases in the AE group. No cases of growth arrest, articular surface violation, or avascular necrosis were noted on MRI. No postoperative angular deformities or significant leg length discrepancies were observed. Conclusion: The study data suggest that all-inside ACL reconstruction is a safe technique for skeletally immature athletes at short-term follow-up. Physeal-specific MRI reveals minimal growth plate compromise that is significantly lower than published thresholds for growth arrest.

Background: Reinjury rates after anterior cruciate ligament reconstruction (ACLR) are highest among young athletes, who consequently suffer from low rates of return to play. Historically, quantitative measures have been used to determine readiness to return to sport; however, they do not assess modifiable risk factors related to the quality of movement. Purpose: To determine the effectiveness of a criteria-based rehabilitation progression and return-to-sport criteria on efficient return to activity and prevention of second injury in young athletes post-ACLR. Study Design: Case series; Level of evidence, 4. Methods: Between December 2010 and 2013, 42 skeletally immature athletes (mean chronologic age, 12 years; range, 10-15 years) who underwent ACLR using ipsilateral hamstring tendon autograft were prospectively evaluated. All athletes progressed through a criteria-based rehabilitation progression; were assessed at specific time frames for strength, biomechanical, and neuromuscular risk factors predictive of injury; and were provided targeted interventions. The final return to sport phase consisted of quantitative testing as well as a quality of movement assessment of several functional movements with progressive difficulty and sports-specific loading. Clearance for unrestricted activity was determined by achieving satisfactory results on both qualitative and quantitative assessments with consideration for the demands of each sport. Results: The mean time for return to unrestricted competitive activity was 12 months. All but 3 (7%) athletes returned to their primary sport. Thirty-five athletes (83%) returned to unrestricted activity. Of the 6 (14%) who sustained a second injury, 3 (50%) were injured in sports they were not cleared for. All ACL reinjuries occurred in a cutting sport. Half of reinjuries occurred within 1 year of surgery, while the remaining occurred between 1 and 2 years. Eighty-three percent of reinjuries involved highly competitive cutting athletes. Conclusion: In our cohort, the combination of qualitative and quantitative data served as a good indicator for reducing risk and determining readiness to return to sport.