Breaking the Rules in Three Dimensions: What to Expect After a Thoracic-only Fusion With Structural Thoracic and Thoracolumbar Curves.

OBJECTIVE: Despite guidelines to fuse both thoracic and thoracolumbar/lumbar (TH/L) curves in patients with structural curves in both regions, a thoracic-only fusion allows preservation of lumbar motion segments. The purpose of this study was to assess the 2-year postoperative three-dimensional (3D) radiographic and clinical outcomes of patients with double or triple major (thoracic curves >TH/L curves) structural curves who underwent a thoracic-only fusion. METHODS: A prospective adolescent idiopathic scoliosis registry was queried for double or triple major curves undergoing thoracic-only posterior fusion and a minimum 2-year follow-up. 3D reconstructions were generated from bi-planar radiographs. Paired sample t tests were used to assess differences in the coronal, sagittal, and axial planes pre and postoperatively, as well as Scoliosis Research Society Questionnaire-22 scores. Pearson correlations were utilized to identify variables related to spontaneous lumbar derotation. RESULTS: Twenty-two patients met the inclusion criteria. Both thoracic [61 ± 10 degrees to 20 ± 9 degrees ( P < 0.001)] and lumbar curves [41 ± 7 degrees to 22±7 degrees ( P < 0.001)] had significant coronal improvement and T5 to T12 kyphosis improved from 7 ± 14 degrees to 23 ± 8 degrees ( P < 0.001). The thoracic apical translation was significantly improved postoperatively (4.7 ± 1.5 to 0.5 ± 1 cm, P < 0.001), but the lumbar apical translation was unchanged (-1.7 ± 0.6 to -1.7±0.8 cm, P = 0.94). Scoliosis Research Society Questionnaire-22 scores significantly improved by 2 years postoperative. CONCLUSIONS: Unlike the 3D correction observed in nonstructural TH/L curves after thoracic-only fusion, patients with double or triple major curves demonstrated only spontaneous coronal correction of the lumbar curve, whereas the sagittal and axial planes were not significantly improved. These radiographic parameters did not negatively affect subjective or clinical outcomes at minimum 2-year follow-up. LEVEL OF EVIDENCE: Level IV-therapeutic.

Postoperative Access and Compliance Following Medial Patellofemoral Ligament Reconstruction in Hispanic Adolescents Mirrors the Non-Hispanic Adolescent Population.

BACKGROUND: Disparity in surgical care of patellar instability patients has not been fully investigated in the adolescent Hispanic population. This demographic has been shown to have differences in their care, including a lower rate of surgical treatment for patellar instability. Socioeconomic factors have been cited as a factor that influences patient outcomes and its relationship with ethnicity in context of patellar instability has not been evaluated. METHODS: Review performed of patients <19 years of age who underwent MPFL reconstruction between September 2008 and December 2015. Demographics, patient median household income data, and clinical variables were collected. Generalized linear mixed model (GLMM) with subject as random effects factor was utilized to evaluate differences between ethnicity groups due to nonindependence of data. It was then expanded to incorporate interactions between ethnicity and income. RESULTS: Ninety-five patellar dislocation events met criteria in 85 adolescents (mean age: 15.5 y). Thirty-four (40%) adolescents identified as Hispanic. In univariate analysis no differences were found between Hispanic and non-Hispanic patients. The multivariate GLMM demonstrated a significant interaction between ethnicity and income. The Hispanic group in the >100% State median income category had the highest rate of postoperative clinic appointments attended (P=0.019). The Hispanic group in the <100% State median income category had the lowest rate of physical therapy appointments attended (P=0.044). No differences were observed for duration of follow-up (P=0.57) or final Kujala score (P=0.75). CONCLUSIONS: Hispanic ethnicity alone is not associated with inferior postoperative management after MPFL reconstruction in adolescents. However, when socioeconomic status is considered, Hispanic patients of lower-income backgrounds are found to have lower compliance with postoperative rehab recommendations. LEVEL OF EVIDENCE: Level III.

What Happens to Youth Baseball Players Diagnosed With Little League Shoulder and Little League Elbow Syndrome?

BACKGROUND: The long-term prognosis of baseball and softball players diagnosed with Little League elbow (LLE) and Little League shoulder (LLS) is unknown. Many of these athletes are potentially at risk of developing future shoulder and elbow injuries that may require surgical intervention. This study's purpose is to retrospectively assess 5-year patient-reported outcomes and career progression of a series of youth baseball and softball players diagnosed with LLE and LLS. METHODS: This institutional review board-approved, single-center, retrospective study evaluated 5-year outcomes of a cohort of youth baseball and softball players diagnosed with LLE and LLS between 2013 and 2017. Demographic and clinical data was recorded including age, gender, primary position, and months played per year. A standardized phone survey was obtained approximately 5 years post-treatment to assess upper extremity function, career progression, and pain recurrence. RESULTS: Sixty-one patients (44 LLE, 17 LLS) met the inclusion criteria and participated in a standardized phone survey. The mean age at the time of diagnosis was 13.2 years and all but one of the athletes were male. On average, about 80% (34/44 LLE, 15/17 LLS) played baseball 9 months or more per year. After diagnosis and nonoperative management, more than 80% (37/44 LLE, 14/17 LLS) were able to return to competition, but up to 40% of players changed positions (9/44 LLE, 7/17 LLS). Five years later, less than half (21/44 LLE, 8/17 LLS) were playing baseball actively. The recurrence rate was >20% (9/42 LLE, 6/17 LLS) with a mean time of recurrence of 8.8 months. Patients who experienced symptom recurrence were less likely to play baseball 5 years later and had lower patient-reported outcomes. CONCLUSIONS: A diagnosis of LLE and LLS in early adolescence can be a setback for a young athlete. Fortunately, most athletes will be able to return to competition with ∼50% still competing at 5 years. Very few will progress to future arm surgery, but recurrence rates are relatively high, and these athletes are less likely to participate in their sport 5 years later. LEVEL OF EVIDENCE: Level IV-Retrospective cohort study.

Intermediate Outcomes of Medial Ulnar Collateral Ligament Reconstruction Using Gracilis Allograft in Adolescent Patients.

Background: Autograft palmaris has been the primary choice for the reconstruction of the medial ulnar collateral ligament (UCL) in the elbow. Agenesis of the palmaris tendon is not rare, and outcomes of allograft reconstruction in the breadth of athlete types found in the adolescent population are lacking. Hypothesis: Allograft tendon reconstruction of the medial UCL in the young elbow would have low failure rates and satisfactory outcome scores. Study Design: Case series; Level of evidence, 4. Methods: The records of patients who underwent allograft medial UCL reconstruction (UCLR) by a single surgeon between 2009 and 2019 were reviewed. Patient-reported outcome scores in adolescent patients obtained at a minimum 4-year follow-up (for intermediate assessment) were recorded, with no exclusion according to sex or sport type. Outcomes included the Timmerman-Andrews score, the Single Assessment Numeric Evaluation (SANE), and the Conway-Jobe score. Results: Of 29 patients who underwent allograft UCLR, 10 adolescents (40% women; mean age at surgery, 15.8 years [age range, 15-17 years]) met the inclusion criteria and were included in the study. The mean follow-up was 8 years (range, 4.3-11.9 years). There were 4 overhead athletes (baseball, water polo) and 6 impact sports athletes (motocross, gymnastics, wrestling, and soccer). The mean SANE score was 86.3, and the mean subjective Timmerman-Andrews score was 92.5. The Conway-Jobe score was "excellent" in 7 of 10 participants; nonetheless, 3 elected not to return to sport (2 for reasons unrelated to the elbow). No patients experienced loss of range of motion, contracture, or ulnar nerve neuropathy. There was 1 patient with early failure (10%) who required revision reconstruction . Conclusion: Allograft reconstruction for medial UCL instability in adolescent patients from sport and trauma mechanisms demonstrated excellent patient-reported functional scores in this study. If the patient and surgeon desire to avoid autograft morbidity or agenesis of the palmaris longus, allograft tendon UCLR appears viable for both the throwing and the high-impact adolescent athlete, regardless of sex.

Arthroscopic Shoulder Stabilization in High School Football Players.

Background: Destabilizing shoulder injuries are common in high school American football players; however, the rate of recurrent glenohumeral instability and return to play after arthroscopic labral stabilization surgery remains unknown. Purpose/Hypothesis: The purpose of this study was to determine the rate of recurrent instability on return to competitive high school football after arthroscopic shoulder labral stabilization and capsulorrhaphy procedures. It was hypothesized that the instability rate would be greater in players with more years of eligibility remaining (YER) to play at the high school level. Study Design: Case series; Level of evidence, 4. Methods: Consecutive male high school football players with at least 1 YER who sustained at least 1 anterior traumatic inseason shoulder instability episode and underwent arthroscopic stabilization between 2012 and 2017 were identified. Patients and/or families were contacted by phone to discuss (1) recurrent instability episodes and (2) return to competitive sport and/or recreational athletic activity. Statistical analysis was conducted using chi-square tests to compare recurrent shoulder instability with return to play and YER. Results: A total of 45 football players aged 14 to 17 years were included, with a mean follow-up of 4.1 years. Most patients (60%) chose not to return to competitive football, due mainly to fear of recurrent injury. Overall, the recurrent instability rate was 15.6% (7/45). The instability rate in players who returned to football was 16.7%, with 66.7% requiring revision surgery. The instability rate in patients who did not return to football was 14.8%, with no revision procedures required. In players who returned to football, the instability rate in YER group 4 was significantly higher than that in YER groups 1 to 3 (42% vs 10.5%, respectively, P = .03), with each year of play conferring an additional 10% risk of reinjury. There was a significant difference in the type of recurrent instability in players who returned to any sport versus those who did not (P = .029). Conclusion: High school football players who returned to competitive play after arthroscopic shoulder stabilization surgery experienced a higher rate of recurrent instability that was dependent on their YER. Over half of the players chose not to return to football, with fear of reinjury being the most common reason.

The Buford Complex Redefined: A Pathologic Morphology in Sheep's Clothing.

Background: Considered a normal anatomic variant, the Buford complex has not been studied in children. Hypothesis: A Buford complex is not a normal anatomic variant and would, therefore, be present at a lower rate than that seen in the adult population. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Measurements were recorded from magnetic resonance imaging performed over 13 years in children aged ≤11 years for various pathologies unrelated to glenohumeral instability. Interrater reliability was determined to identify Buford complexes, sublabral foramens and tears, and normal shoulders via 16 preadolescent and adolescent patients with confirmed arthroscopic correlation. The Buford complex and labral foramen rates were then compared with a published rate in adults using a binomial probability test. Results: A total of 122 children (62 girls; mean age, 6.4 years [age range, 2 months-10.9 years]) were evaluated. Interrater reliability was 0.846 (95% CI, 0.56-1) to identify anterosuperior labral variants. The expected sublabral foramen count was 23 children, but only 1 was identified (P < .001). The expected Buford complex count was 8 children, but none could be identified (P < .001). Conclusion: The absence of Buford complexes and the significant reduction in sublabral foramen abundance in younger children suggest that these anatomic variants are more likely to be developmental than congenital. The distinct possibility that these previously considered normal variants are truly pathologic findings cannot be ignored. Evidence of a Buford complex could potentially signify an underlying, long-term shoulder instability issue to the treating provider that warrants further investigation or management.

Intrawound Vancomycin Powder Reduces Delayed Deep Surgical Site Infections Following Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis.

STUDY DESIGN: Retrospective. OBJECTIVE: Evaluate whether the use of vancomycin powder (VP) placed in the surgical site prior to wound closure prevents delayed deep surgical site infections (DDI). SUMMARY OF BACKGROUND DATA: DDI after posterior spinal fusion (PSF) in adolescent idiopathic scoliosis (AIS) patients remains a significant major complication. The use of VP to prevent acute surgical site infection has been reported but the impact on DDI is unknown. METHODS: AIS patients treated over the past 20 years with PSF/instrumentation from a large muti-center registry were reviewed. Patients were divided into two groups: intraoperative vancomycin powder placed in the wound (VP) or no antibiotics placed in the wound (NVP). DDI was defined as an infection that occurred >90 days after surgery and required surgical intervention in the operating room. Patients who developed a DDI had secondary verification of VP use or not. Chi square and Kaplan-Meier (K-M) survivorship analyses were used to compare demographics and incident rate of DDI between groups. RESULTS: 4145 cases met inclusion for this study. A total of 43 DDI cases were identified (1.0%). The incidence of DDI for the VP group was 0.2% (4/2111), and 1.9% (39/2034) in the NVP group (P<0.001). Given the difference in follow-up for the 2 groups a Cumulative Survival and Kaplan-Meier analysis revealed the VP group had significantly better "survival" (no DDI) than the NVP group (P<0.001). CONCLUSION: DDIs are significant, adverse events that can greatly complicate patient recovery after PSF for AIS, including rehospitalization. This study found that patients who received VP intraoperatively were 10 times less likely to develop a DDI than those who did not receive VP. Although other advances/changes in surgical techniques may contribute to the significant decrease in infections found in the more recent VP cohort, VP should be considered as a prophylactic measure.

Three-dimensional vertebral shape changes confirm growth modulation after anterior vertebral body tethering for idiopathic scoliosis.

PURPOSE: To evaluate three-dimensional (3D) vertebra and disk shape changes over 2 years following anterior vertebral body tether (AVBT) placement in patients with idiopathic scoliosis (IS). METHODS: Patients with right thoracic IS treated with AVBT were retrospectively evaluated. 3D reconstructions were created from biplanar radiographs. Vertebral body and disk height (anterior, posterior, left and right) and shape (wedging angle) were recorded over the three apical segments in the local vertebral reference planes. Changes in height and wedging were measured through 2 years postoperatively. Change in patient height was correlated with changes in the spine dimensions. RESULTS: Forty-nine patients (Risser 0-3, Sanders 2-4) were included. The mean age was 12.2 ± 1.4 years (range 8-14). The mean coronal curve was 51 ± 10° preoperatively, 31 ± 9° at first postoperative time point and 27 ± 11° at 2-year follow-up (p < 0.001). The mean patient height increased 8 cm by 2 years (p < 0.001). The left side of the spine (vertebra + disc) grew in height by 2.2 mm/level versus 0.7 mm/level on the right side (p < 0.001). This differential growth was composed of 0.5 mm/vertebral level and 1.0 mm/disk level. Evaluation of the change in disk heights showed significantly decreased height anteriorly (- 0.4 mm), posteriorly (- 0.3 mm) and on the right (- 0.5 mm) from FE to 2 years. Coronal wedging reduced 2.3°/level with 1.1°/vertebral level change and 1.2°/disk level. There was no differential growth in the sagittal plane (anterior/posterior height). Patient height change moderately correlated with 3D measures of vertebra + disk shape changes. CONCLUSIONS: Three-dimensional analysis confirms AVBT in skeletally immature patients results in asymmetric growth of the apical spine segments. The left (untethered) side length increased more than 3 × than the right (tethered) side length with differential effects observed within the vertebral bodies and disks, each correlating with overall patient height change.

Vertical Stenosis as a Morphological Risk Factor for Anterior Cruciate Ligament Ruptures in Children: A Magnetic Resonance Imaging-Based Comparison.

BACKGROUND: There are known anatomic variations that may lead to traumatic disruption of the anterior cruciate ligament (ACL) identified within adult and adolescent patients. PURPOSE/HYPOTHESIS: The purpose of this study was to compare the parameters of pediatric knees diagnosed with and without an ACL injury by magnetic resonance imaging. The hypothesis was that children with ACL abnormalities would demonstrate an equivalent notch width index (NWI), but a larger notch height index (NHI), in comparison with age-matched patients without ACL abnormalities, suggesting an association with congenital morphology. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: A retrospective comparison cohort study of pediatric knees was performed by evaluating those with a confirmed ACL rupture/deficiency and those with a benign diagnosis on magnetic resonance imaging. Overall, 6 osseous and cartilaginous measurements and 3 ratios (2 newly described) were determined. They were then grouped for statistical purposes by age: children aged 5 to 11 years and adolescents aged 12 to 19 years. RESULTS: A total of 119 (49 children) consecutive patients with an ACL injury and 139 (72 children) healthy patients met inclusion criteria. The interaction between ACL status and age was significant for condylar measurements (P≤ .001), tibial spine height (P = .003), vertical space above tibial spine (P≤ .001), and NWI (P≤ .001) by 2-way analysis of variance. Although the NHI (P < 0.001) and tibial spine prominence (P = 0.039) demonstrated stenosis in the adolescent group, they did not have significant interactions with age and ACL status (P > 0.05). Regarding the transcondylar width, only the children's group had a significant difference regarding ACL status (P < .001), and the mean values in the children's group with ACL tears were nearly identical to those in the adolescent group both with and without ACL tears. The children's group with ACL tears also had a significantly larger tibial spine height compared with healthy children (P < .001). CONCLUSION: Children, similar to adolescents, demonstrated the effect of the NWI on the risk of ACL tears, but only the adolescent group demonstrated stenosis with the NHI. The morphology of the knee in a child at risk for ACL rupture was not the same as that of an adolescent when considering all dimensions, but it did seem that it was more adolescent-like than child-like at the time of an ACL rupture, refuting the idea of congenital hypoplasia as a common cause.