Arthroscopic Bankart Repair for Anterior Glenohumeral Instability in 488 Adolescents Between 2000 and 2020: Risk Factors for Subsequent Recurrent Instability Requiring Revision Stabilization.

BACKGROUND: After arthroscopic Bankart repair (ABR) for anterior glenohumeral instability (GHI), adolescent athletes have higher rates of subsequent recurrent GHI than any other subpopulation. Elucidating which adolescents are at highest risk of postoperative recurrent GHI may optimize surgical decision-making. PURPOSE: To identify prognostic factors associated with subsequent recurrent GHI requiring revision stabilization surgery (RSS) after ABR. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: The study included patients 12 to 21 years old who had undergone ABR for anterior GHI at a pediatric tertiary care hospital by 1 of 5 sports medicine fellowship-trained surgeons between 2000 and 2020. A multivariate Cox proportional hazards model, with percentage of patients with recurrent GHI undergoing subsequent RSS, was used with a time-to-event outcome analysis. The Cox model effects were expressed as the hazard ratio (HR). All tests were 2-sided, with an alpha of .05. RESULTS: Records of 488 adolescent patients with ABR (78% male; mean age, 16.9 ± 1.98 years) were analyzed. Of these, 86 patients (17.6%) underwent subsequent RSS for recurrent GHI, yielding a cumulative risk of 8.8% at 2 years, 16.5% at 5 years, and 20% at 15 years. RSS occurred at a mean of 2.6 ± 2.1 years after ABR. Risk factors for RSS included >1 preoperative dislocation (2 dislocations: HR = 7.4, P = .0003; ≥3 dislocations: HR = 10.9, P < .0001), presence of a Hill-Sachs lesion (small: HR = 2.5, P = .0114; medium-large: HR = 4.2, P = .0004), younger age (1-year decrease: HR = 1.2, P = .0015), and participation in contact sports (HR = 1.8, P = .01). Adolescents with only 1 preoperative dislocation had a cumulative incidence of RSS (3.2%), which was significantly lower than those with 2 (24.2%) or ≥3 preoperative dislocations (33.5%). CONCLUSION: The number of dislocations before index ABR was the strongest risk factor for recurrent GHI requiring RSS in adolescents with anterior GHI, with 2 dislocations conferring >7-fold increased risk compared with a single preoperative dislocation. Other significant risk factors included the presence of a Hill-Sachs lesion, younger age, and participation in contact sports.

Single versus double percutaneous pinning of pediatric distal radius fractures.

The aim of this study was to compare early clinical and radiographic results of single- versus double-pin fixation of unstable pediatric distal radius fractures. A total of 103 consecutive closed distal radius fractures treated with either single or double percutaneous pinning at a tertiary level I pediatric hospital were analyzed. All patients had open physes and had fractures that failed initial closed reduction and casting. Postoperative fracture displacement was assessed by measuring the difference in angulation of the radius in the anteroposterior and lateral views from intraoperative fluoroscopic images to postoperative radiographs taken on the day of pin removal. Complications were identified from the medical record review. In 103 operative distal radius fractures in 101 patients (70 males, 31 females), 52 and 51 distal radius fractures were treated with single and double pinning, respectively. The median [interquartile range (IQR)] age at the time of surgery was 12.1 (9.0-14.0) years, with the single-pinning group being younger by 1.9 years (P < 0.01). Median (IQR) postoperative angulation in the anteroposterior radiograph (coronal plane) was 2° (1-7°) with one pin versus 1° (0-2°) with two pins (P < 0.01). Median (IQR) postoperative angulation in the lateral radiograph (sagittal plane) was 3° (1-10°) with one pin versus 1° (0-2°) with two pins (P < 0.01). There were no significant differences in complications between the single- and double-pinning groups. Double-pin fixation resulted in a statistically significant, but clinically negligible, reduction in postoperative fracture displacement compared with single-pin fixation. Complication rates were similar in both groups. These findings suggest that either single- or double-pinning techniques can be effective, provided appropriate reduction and postoperative immobilization are achieved.

Pediatric and Adolescent Distal Radius Fractures: Current Concepts and Treatment Recommendations.

Distal radius fractures are the most common skeletal injuries requiring intervention in children. These injuries are classified by fracture pattern, location, displacement, and angulation. While each unique fracture pattern warrants slightly modified treatment plans and follow-up, the goals of treatment remain constant. Successful outcomes depend on restoration of motion and function, and attaining acceptable sagittal and coronal alignment is a necessary first step. For displaced fractures, closed reduction is often necessary to restore alignment; well-molded cast application is important to maintain fracture alignment. Fractures with bayonet apposition, if well aligned, may not need formal reduction in some patients. Special attention should be paid to the physis-not only for physeal-involving fractures but also for all distal radius fractures-given that the proximity to the physis and amount of remaining skeletal growth help guide treatment decisions. Casting technique is essential in optimizing the best chance in maintaining fracture reduction. Surgical intervention may be indicated for a subset of fractures when acceptable alignment is not achieved or is lost at subsequent follow-up. Even among experts in the field, there is little consensus as to the optimal treatment of displaced metaphyseal fractures, illustrating the need for prospective, randomized studies to establish best practices.

Nonoperative Versus Operative Treatment of Z-Type Comminuted Clavicle Fractures in Adolescents: A Prospective Substratified Cohort Analysis.

OBJECTIVES: To compare the clinical, radiographic, and patient-reported outcomes of nonoperative and operative treatment of adolescents with comminuted "Z-type" midshaft clavicle fractures. DESIGN: Prospective observational cohort. SETTING: Eight tertiary care pediatric centers. PATIENT SELECTION CRITERIA: Patients aged 10-18 years who were treated either operatively or nonoperatively for a diaphyseal clavicle fracture between 2013 and 2017 were screened/enrolled at the time of injury. The current subcohort analysis was derived from a larger adolescent clavicle study population of 907 patients. OUTCOME MEASUREMENTS AND COMPARISONS: Complications and validated patient-reported outcome measures (PROs):(ASES, QuickDASH, Marx Shoulder Activity Score, EQ-5D, EQ-VAS, and patient satisfaction score) were compared between operative and nonoperative cohorts. RESULTS: Eighty-one patients (69 male [85.2%], 12 female; average age 15 years [11.1-18.7]; 78 with sports participation [96.2%]) were followed through bony healing and return to sports, while 59 patients (73%) completed 2-year follow-up with PROs, 26 of whom were treated nonoperatively and 33 treated operatively. All demographic and fracture characteristics were similar (P > 0.05) between the 2-year follow-up cohorts except for fracture shortening, which was greater in the operative cohort (23 vs. 29 mm, P = 0.01). After controlling for this potential confounder through both regression and propensity matched subgroup analysis, nonoperative versus operative cohorts showed no difference in rates of nonunion (0%), delayed union (0% vs. 2.3%, P = 1.0), symptomatic malunion (2.7% vs. 0%, P = 0.4), refracture (2.7% vs. 2.2%, P = 1.0), unexpected subsequent surgery (5.4% vs. 11.4%, P = 0.45), or clinically significant complications (5.4% vs. 16%, P = 0.17). There were no differences in any PROs between cohorts, both before and after controlling for the difference in fracture shortening (all P-values >0.05). CONCLUSIONS: In this prospective comparison of complications and 2-year PROs in adolescents with comminuted Z-type clavicle fractures, nonoperative and operative treatment yielded similar outcomes. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

5-Year Radiographic and Functional Outcomes of Nonoperative Treatment of Completely Displaced Midshaft Clavicular Fractures in Teenagers.

BACKGROUND: Optimal treatment of completely displaced midshaft clavicular fractures in adolescents remains controversial, with some favoring surgical management and others favoring a nonoperative approach. Few studies have comprehensively assessed longer-term nonoperative outcomes. PURPOSE: To prospectively assess patient-reported outcomes (PROs) and radiographic remodeling ≥5 years after injury in teenagers undergoing nonoperative treatment of completely displaced clavicular fractures. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Adolescent patients previously enrolled in a prospective study from a single institution with nonoperatively treated, completely displaced midshaft clavicular fractures ≥5 years from injury were eligible for the study. Patients were clinically evaluated for scapular dyskinesia and strength deficits. Bilateral clavicular imaging assessed residual shortening, displacement, and angulation. PROs included the American Shoulder and Elbow Surgeons (ASES), the shortened version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH), Marx Shoulder Activity Scale, cosmesis, and return to sports data. RESULTS: A total of 24 patients were available for the follow-up, of whom 17 (71%) consented to additional imaging. The mean cohort age at the time of injury was 14.5 ± 1.1 years, with 88% being male. At a mean follow-up of 6.1 years, all fractures had healed, with no patient requiring secondary interventions. Significant remodeling was observed across all measurements, with improvements of 70% in shortening (22.8 to 6.8 mm; P < .001), 73% in superior displacement (13.4 to 3.6 mm; P < .001), and 83% in angulation (10.4° to 1.8°; P < .001). Thirteen patients (72%) had a >2-cm initial shortening, and all remodeled to <2 cm. PROs were almost universally excellent, with mean ASES, QuickDASH, and Marx activity scores of 99 ± 3, 1 ± 3, and 20 ± 1, respectively, with 79% of patients reporting perfect scores in all 3 domains. Most patients (58%) were completely satisfied with their shoulder appearance, 38% were more satisfied than not, 1 patient (4%) was neither satisfied nor dissatisfied, and no patients were dissatisfied. All patients except 1 who were interested in sports returned to sporting activities. PROs were not associated with bony remodeling (P > .05). CONCLUSION: Teenaged patients with completely displaced clavicular fractures treated nonoperatively can expect excellent radiographic and clinical outcomes 5 years after injury.

Syndromic Involvement of Patients Presenting With Congenital Upper Limb Anomalies: An Analysis of 4,317 Cases.

PURPOSE: This study investigated the patterns of syndromic involvement for patients with congenital upper limb anomalies (CULAs). We hypothesize that patients with CULAs will present with predictable syndromic patterns. METHODS: This retrospective study queried the multicenter Congenital Upper Limb Differences (CoULD) Registry. Of the 4,317 patients enrolled, 578 (13%) reported one or more syndromes. Syndromes were confirmed to be recognized by the Online Mendelian Inheritance in Man. Demographics were reviewed and compared with the full CoULD registry group. Syndromes reported by five or more patients were examined to determine the type of CULA according to Oberg/Manske/Tonkin classifications. RESULTS: Of the 578 children with one or more reported syndromes, 517 had Online Mendelian Inheritance in Man recognized syndromes (cohort A), In cohort A, 58 syndromes were each represented by a single patient within the registry. Forty-eight syndromes in cohort A were reported by two or more patients, which accounted for 461 of the total patients with reported syndromes. However, VACTERL and Poland syndromes were the most commonly reported syndromes. Patients with CULAs and syndromes frequently exhibited bilateral involvement (61%), compared with the entire CoULD group (47%) and other orthopedic (50%) and medical conditions (61%) compared with the entire CoULD group (24% and 27%, respectively). Additionally, they exhibited a lower frequency of family history of a congenital orthopedic condition (21%) or a family member with the same CULA (9%) compared with the entire CoULD group (26% and 14%, respectively). CONCLUSIONS: Associated syndromes were recorded in 578 patients (13%) in the CoULD registry as follows: 58 syndromes represented by a single patient, 48 by 2 or more patients, and 23 syndromes by 5 or more patients. Rare syndromes that are only represented by a single patient are more likely to be unknown by a pediatric hand surgeon, and consultation with a geneticist is advised. TYPE OF STUDY/LEVEL OF EVIDENCE: Differential Diagnosis/Symptom Prevalence Study IV.

Treatment of Severely Shortened or Comminuted Clavicular Fractures in Older Adolescent Athletes.

BACKGROUND: Recent evidence suggests that for completely displaced midshaft clavicular fractures, surgery offers no clear benefit over nonoperative treatment in a general adolescent population from 10 to 18 years of age. However, the comparative outcomes of comminuted and/or severely shortened clavicular fractures specifically in older adolescent athletes have not been explored in a focused, methodologically rigorous fashion. HYPOTHESIS: The study hypothesis was that outcomes would be superior in older adolescent athletes who underwent operative treatment compared with nonoperative treatment for comminuted and/or severely shortened clavicular fractures. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: A level 2, multicenter, prospective cohort study investigating the outcomes of midshaft fractures in adolescents between 2013 and 2017 was filtered to analyze the subcohorts of athletes 14 to 18 years of age with either fracture comminution or fracture shortening of ≥25 mm or both. Patient characteristics, injury mechanisms, fracture characteristics, and treatments were compared. Complications, rates, timing of return to sports (RTS), and patient-reported outcomes (PROs) were analyzed. RESULTS: The 2 treatment groups, which included 136 older adolescent athletes (69 nonoperative, 67 operative), showed similar distributions of primary sport type, competition level, comminution, shortening, and 2-year PRO response rate (n = 99; 73%). The operative group demonstrated 3 mm-greater mean superior displacement, which was therefore statistically controlled for as a confounder in the comparative PRO analysis. No 2-year differences in nonunion, delayed union, symptomatic malunion, refracture, clinically significant complications, or rates of RTS were detected between treatment groups. The difference in timing of RTS (operative, 10.3 weeks; nonoperative, 13.5 weeks) was statistically significant. After controlling for the minor difference in superior displacement, regression analysis and matched comparison cohorts demonstrated no differences between the nonoperative and operative groups in mean or dichotomized PRO scores. CONCLUSION: In this prospective, multicenter cohort study investigating older adolescent athletes with comminuted and/or severely shortened clavicular fractures, contrary to the study hypothesis, there were no differences in complications, RTS, or PROs between nonoperatively and operatively treated patients at 2 years. Comparably excellent outcomes of severe clavicular fractures in adolescent athletes can be achieved with nonoperative treatment.