Evaluation and Management of Glenohumeral Instability in Adolescent Patients: An Expert Consensus Statement.

Background: Management of glenohumeral instability in the adolescent population can be both challenging and controversial. There are no current guidelines for optimal management of glenohumeral instability in this population (unidirectional or multidirectional), and the cutoff ages for transition to adult treatment are not known. Purpose: To develop consensus-based guidelines for the management of glenohumeral instability in adolescents. Study Design: Consensus statement. Methods: A 26-question, multiple-choice survey was developed after 2 rounds of iterations and was submitted to the orthopaedic surgeons of the Pediatric Research in Sports Medicine (PRiSM) Society. The survey comprised 3 sections-demographics, practice setting, and decision-making-and included cutoff ages and management in 5 specific case scenarios. Consensus-based guidelines were generated with 66% response agreement. An indication score was then applied to each response related to more aggressive management to determine if variables related to consensus (or lack thereof) could be identified. Results: A total of 54 responses were returned. Of the respondents, 59% were from academic practice, 84% were pediatric orthopaedic fellowship trained, and 46% performed >25 shoulder instability cases per year. In the setting of first-time anterior shoulder dislocation, nonoperative treatment was preferred for boys aged <14 years and girls aged <13 years. Besides age, proximal humerus physeal status, injury mechanism, sport, and presence of bony injury affected treatment selection. The presence of a Bankart lesion was an indication for stabilization in first-time dislocations for contact athletes with a closing or closed physis, but not in patients with an open physis or noncontact injury mechanisms. For recurrent anterior shoulder dislocation, stabilization was preferred irrespective of physis status. Initial nonoperative treatment was preferred for multidirectional instability. Conclusion: In the setting of first-time anterior shoulder dislocation in patients with open physes, nonoperative treatment was preferred for boys <14 years and girls <13 years. Future multicenter prospective studies focusing on outcomes would help to validate current practice patterns, especially in scenarios for which no consensus was reached.

Treatment of Refractory Osteochondral Lesions of the Talus with a Novel Transmalleolar Drilling Technique: A Case Report.

CASE: A 15-year-old adolescent girl underwent revision surgery for a posteromedial osteochondral lesion of the talus (OLT). To provide anatomic reduction of her lesion, fluoroscopy and ankle arthroscopy facilitated a transmalleolar tunnel for screw fixation. Now, 8 years after surgery, the patient reports high patient satisfaction and pain-free functional use of her ankle. CONCLUSION: A transmalleolar tunnel technique provides an alternative method to treat posteromedial OLT. This minimally invasive procedure allows patients to be spared potential complications from a medial malleolar osteotomy or a posteromedial incision. Most importantly, this case report demonstrates a positive long-term patient outcome.

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.

MRI Features That Contribute to Decision-Making for Treatment of Capitellar OCD Lesions: An Expert Consensus Using the Delphi Method.

Background: Most healthcare providers utilize magnetic resonance imaging (MRI) to assist in diagnosing and treating osteochondritis dissecans (OCD) of the capitellum. However, consensus on imaging features that portend clinically relevant information in the care of these lesions has not been determined. Purpose: To conduct a survey on the MRI features of a capitellar OCD that are salient for clinical decision-making using a classic Delphi protocol. Study Design: A consensus statement. Methods: Invitations to participate were sent to 33 healthcare providers identified as capitellar OCD experts. A classic 3-round survey method was used to gather agreement and consensus on the level of importance for clinical decision-making on 33 MRI features. A concise list of features that guide decision-making on the stability of an OCD lesion and the ability of an OCD lesion to heal with nonoperative care was also identified. Agreement and consensus were determined a priori as ≥66%. Results: Of the 33 identified experts, 20 agreed to participate, and 17 (52%) completed all 3 rounds. Of the 33 MRI features evaluated, 17 reached agreement as important for clinical decision-making by the experts. Consensus was reached for a concise list of MRI features that were significant to decision-making (94%), suggestive of a stable lesion (100%), had the potential to heal with nonoperative treatment (94%), were suggestive of an unstable lesion (100%), and had low potential to heal with nonoperative treatment (88%). Conclusion: This 3-round Delphi process produced consensus on clinically relevant MRI features that contribute to clinical decision-making for capitellar OCD. The results of this study will be used as the basis for an interrater reliability assessment of the identified salient features, creating the foundation for developing a reliable MRI assessment tool rooted in clinical experiences. The development of a standardized assessment of capitellar OCD is intended to improve clinical practice and patient outcomes.

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.

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.

Changes in Fracture Shortening Occur in the First 2 Weeks Following Completely Displaced Adolescent Clavicle Fractures.

BACKGROUND: Shortening of midshaft clavicle fractures has been described as a critical fracture characteristic to guide treatment. The degree to which shortening may change in the initial weeks following injury has not been well studied. The purpose of this study was to evaluate the change in shortening of adolescent clavicle fractures in the first 2 weeks following injury. METHODS: This was a multicenter study of prospectively collected data, which was acquired as a part of a cohort study of adolescent clavicle fractures. A consecutive series of patients 10 to 18 years of age with completely displaced diaphyseal clavicle fractures with baseline radiographs 0 to 6 days from the date of injury, as well as 7 to 21 days from the date of injury, were included. Measurements of end-to-end (EES) and cortex-to-corresponding-cortex (CCS) shortening were performed. RESULTS: A total of 142 patients were included. Baseline radiographs were obtained at a mean of 1.0 day following injury with mean EES of 22.3 mm, and 69% of patients demonstrating > 20 mm of shortening. Follow-up radiographs obtained at a mean of 13.8 days postinjury demonstrated a mean absolute change in EES of 5.4 mm. Forty-one percentage of patients had >5 mm of change in EES. When analyzing changes in shortening relative to the specific threshold of 20 mm, 18 patients (41%) with <20 mm EES increased to ≥20 mm EES, and 19 patients (19%) with ≥20 mm EES decreased to <20 mm EES at 2-week follow-up. CONCLUSIONS: Clinically significant changes in fracture shortening occurred in 41% of adolescents with completely displaced clavicle fractures in the first 2 weeks after injury. In 26% of patients, this resulted in a change from above or below the commonly used shortening threshold of 20 mm, potentially altering the treatment plan by many providers. There is no evidence to suggest that adolescent clavicle fracture shortening affects outcomes, and as such, the authors do not advocate for the use of this parameter to guide treatment. However, among physicians who continue to use this parameter to guide treatment, this study supports that repeat radiographic assessment 2 weeks postinjury may be a better measure of the true shortening of this common adolescent injury. LEVEL OF EVIDENCE: Level IV-case series.

Porcine computational modeling to investigate developmental dysplasia of the hip.

While it is well-established that early detection and initiation of treatment of developmental dysplasia of the hip (DDH) is crucial to successful clinical outcomes, research on the mechanics of the hip joint during healthy and pathological hip development in infants is limited. Quantification of mechanical behavior in both the healthy and dysplastic developing joints may provide insight into the causes of DDH and facilitate innovation in treatment options. In this study, subject-specific three-dimensional finite element models of two pigs were developed: one healthy pig and one pig with induced dysplasia in the right hindlimb. The objectives of this study were: (1) to characterize mechanical behavior in the acetabular articular cartilage during a normal walking cycle by analyzing six metrics: contact pressure, contact area, strain energy density, von Mises stress, principal stress, and principal strain; and (2) to quantify the effect on joint mechanics of three anatomic abnormalities previously identified as related to DDH: variation in acetabular coverage, morphological changes in the femoral head, and changes in the articular cartilage. All metrics, except the contact area, were elevated in the dysplastic joint. Morphological changes in the femoral head were determined to be the most significant factors in elevating contact pressure in the articular cartilage, while the effects of acetabular coverage and changes in the articular cartilage were less significant. The quantification of the pathomechanics of DDH in this study can help identify key mechanical factors that restore normal hip development and can lead to mechanics-driven treatment options.

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.

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.

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.

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.

Comparison of Outcomes in Pediatric and Adolescent Posterior Cruciate Ligament Injuries With and Without Meniscal Tears: Operative Versus Nonoperative Management.

Background: Despite the posterior cruciate ligament (PCL) being an essential stabilizer of the knee, there is a paucity of data regarding injury management in pediatric patients. Purpose/Hypothesis: The purpose of this study was to evaluate differences in outcomes after operative (OP) versus nonoperative (NOP) management of pediatric isolated (single-ligament) PCL tears. It was hypothesized that managing PCL tears operatively would lead to improved functional outcomes compared with NOP management, especially in the setting of an associated meniscal tear. Study Design: Cohort study; Level of evidence, 3. Methods: Pediatric patients with an isolated PCL injury between 2006 and 2020 were identified and grouped according to whether they had a concomitant meniscal tear (PCL+M) or no meniscal tear (PCL-M). These cohorts were further sorted into OP, NOP, and nonoperative converted to operative (NOP2OP) treatment cohorts. Outcome data collected included Lysholm score, current activity level, and whether the patient returned to sports after treatment. Results: A total of 48 patients (49 knees) met study inclusion criteria (31 male, 18 female; mean age at injury, 15.6 years; age range, 8.3-18.9 years). There were 37 knees in the PCL-M cohort (30 NOP, 2 NOP2OP, and 5 OP) and 12 knees in the PCL+M cohort (4 NOP, 4 NOP2OP, and 4 OP). The mean duration of follow-up was 6.2 years (range, 2.4-15.7 years). The mean Lysholm scores were not significantly different between the OP and NOP knees in either the PCL-M cohort (P = .582) or the PCL+M cohort (P = .570); however, the PCL-M cohort overall had significantly higher scores compared with the PCL+M cohort (92.7 ± 13.0 vs 82.8 ± 18.8, respectively; P = .019). Conclusion: The pediatric patients in this series had similar functional outcomes when managed operatively or nonoperatively for their single-ligament PCL tear. When considering concomitant meniscal injury, the results indicated that children with meniscal injury had a worse outcome than those without a meniscal injury. Shared decision-making with patients and their family should take these results into consideration.

Clinical Outcomes of Adolescents With Anterior Shoulder Instability and Glenolabral Articular Disruption Lesions Compared With Isolated Bankart Lesions.

Background: Glenolabral articular disruption (GLAD) lesions may occur in adolescents with anterior shoulder instability, resulting in articular cartilage loss and reduced functional glenoid surface area. Purpose/Hypothesis: To compare failure rates and patient-reported outcomes (PROs) between adolescents with versus without GLAD lesions who were treated for anterior shoulder instability with arthroscopic stabilization. It was hypothesized that the comparison would yield no significant differences. Study Design: Cohort study; Level of evidence, 3. Methods: Patients aged ≤18 years who were treated for anterior shoulder instability with arthroscopic stabilization between 2010 and 2021 were retrospectively identified. Those patients with a GLAD lesion identified at the time of surgery were compared with patients with >2 years of retrospective follow-up who were matched to the no-GLAD cohort according to pathology and management. Demographic and patient characteristics including recurrent instability, complications, and reoperations were recorded. All patients in the GLAD cohort were contacted to obtain PRO data, including the Single Assessment Numeric Evaluation; the shortened version of the Disabilities of the Arm, Shoulder, and Hand questionnaire; and the Pediatric Adolescent Shoulder Survey. Patients were also asked about recurrent instability and additional shoulder problems. Results: Of 35 included patients (mean age, 15.4 ± 1.6 years; 80% male), 15 patients (43%) with GLAD lesions and 26 patients without GLAD lesions were identified. Both cohorts had similar patient characteristics, number of anchors, and anchor constructs; the mean follow-up period was significantly different (GLAD vs no-GLAD, 6.9 ± 3.3 vs 3.4 ± 1.2 years, respectively; P < .001). Seven of 15 GLAD patients (46.7%) underwent loose body removal; 4 of 15 GLAD patients (26.6%) and 9 of 26 no-GLAD patients (34.6%) had recurrent subjective instability (P = .7). No significant group differences were found in PRO scores, reoperation rates (15% no-GLAD vs 20% GLAD), or percentage of patients with recurrent instability between cohorts (P > .05). Conclusion: Adolescent patients with and without GLAD lesions treated arthroscopically for anterior shoulder instability had similar PROs and failure rates at intermediate duration of follow-up. GLAD lesions may be managed in a similar surgical manner as isolated Bankart tears in teenagers, with expectations of similar outcomes.

Assessment of Thresholds for Clinically Relevant Change in the Pediatric/Adolescent Shoulder Survey After Shoulder Instability Surgery: Factors Associated With Meaningful Improvement in Outcomes.

Background: The pediatric/adolescent shoulder survey (PASS) score is a subjective measure of shoulder symptomology in younger patients. Purpose: To establish the minimal clinically important difference (MCID) and minimal detectable change (MDC) for the PASS score in adolescents after surgical treatment for shoulder instability. Study Design: Case series; Level of evidence, 4. Methods: Included were patients aged 12.5 to 23 years who underwent surgical treatment for shoulder instability and who had completed PASS forms preoperatively and at 3 months postoperatively. The MCID was established using an anchor-based approach, with the Single Assessment Numeric Evaluation (SANE) and shortened version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) as anchors. Change in PASS score between anchor groups was determined using receiver operating characteristic curve analysis. MDC with 90% confidence (MDC90) was also calculated. Range of motion and strength data at 3-month follow-up were evaluated to identify the optimal postoperative PASS score. Factors associated with improvement in PASS score beyond the MDC90 and MCID were determined in a subset of patients with ≥6-month follow-up data. Results: A total of 95 patients were included. The mean PASS score improved significantly from preoperatively to postoperatively (57 ± 15 to 75 ± 16; P < .001). The anchor-based MCID ranged from 12.5 to 13.2 points, with an area under the receiver operating characteristic (AUC) curve of 0.87 for the SANE and 0.99 for the QuickDASH. The MDC90 was 16.5 points. The optimal PASS score at 3 months after surgery was ≥85 (AUC, 0.66). Shorter duration of symptoms, lower preoperative forward elevation, and higher preoperative external rotation were associated with improvement in PASS score above the MDC90 and/or MCID for the subset of patients (n = 25) with ≥6-month follow-up data. Increased number of suture anchors, less preoperative external rotation deficit, and number of previous dislocations had a moderate effect on improvement in outcomes. Conclusion: A postoperative increase in PASS score of ≥16.5 points had a 90% chance of being a true-positive change, while a score change of approximately 13 points was likely clinically relevant. The optimal PASS score after surgery was ≥85. Shorter duration of symptoms, preoperative range of motion, number of surgical anchors, and number of previous dislocations were associated with achieving a clinically relevant improvement in PASS score at minimum 6 months postoperatively.

Relationship Between Age and Pathology With Treatment of Pediatric and Adolescent Discoid Lateral Meniscus: A Report From the SCORE Multicenter Database.

BACKGROUND: Surgical treatment options of discoid lateral meniscus in pediatric patients consist of saucerization with or without meniscal repair, meniscocapular stabilization, and, less often, subtotal meniscectomy. PURPOSE: To describe a large, prospectively collected multicenter cohort of discoid menisci undergoing surgical intervention, and further investigate corresponding treatment of discoid menisci. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A multicenter quality improvement registry (16 institutions, 26 surgeons), Sports Cohort Outcomes Registry, was queried. Patient characteristics, discoid type, presence and type of intrasubstance meniscal tear, peripheral rim instability, repair technique, and partial meniscectomy/debridement beyond saucerization were reviewed. Discoid meniscus characteristics were compared between age groups (<14 and >14 years old), based on receiver operating characteristic curve, and discoid morphology (complete and incomplete). RESULTS: In total, 274 patients were identified (mean age, 12.4 years; range, 3-18 years), of whom 55.6% had complete discoid. Meniscal repairs were performed in 55.1% of patients. Overall, 48.5% of patients had rim instability and 36.8% had >1 location of peripheral rim instability. Of the patients, 21.5% underwent meniscal debridement beyond saucerization, with 8.4% undergoing a subtotal meniscectomy. Patients <14 years of age were more likely to have a complete discoid meniscus (P < .001), peripheral rim instability (P = .005), and longitudinal tears (P = .015) and require a meniscal repair (P < .001). Patients ≥14 years of age were more likely to have a radial/oblique tear (P = .015) and require additional debridement beyond the physiologic rim (P = .003). Overall, 70% of patients <14 years of age were found to have a complete discoid meniscus necessitating saucerization, and >50% in this young age group required peripheral stabilization/repair. CONCLUSION: To preserve physiological "normal" meniscus, a repair may be indicated in >50% of patients <14 years of age but occurred in <50% of those >14 years. Additional resection beyond the physiological rim may be needed in 15% of younger patients and 30% of those aged >14 years.

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.

Intrarater and Interrater Reliability of Radiographic Characteristics in Skeletally Immature Patients With Anterior Cruciate Ligament Tears: A PLUTO Study Group Reliability Study.

BACKGROUND: Radiographic measurements of limb alignment in skeletally immature patients with anterior cruciate ligament (ACL) tears are frequently used for surgical decision-making, preoperative planning, and postoperative monitoring of skeletal growth. However, the interrater and intrarater reliability of these radiographic characteristics in this patient population is not well documented. HYPOTHESIS: Excellent reliability across 4 raters will be demonstrated for all digital measures of length, coronal plane joint orientation angles, mechanical axis, and tibial slope in skeletally immature patients with ACL tears. STUDY DESIGN: Cohort study (diagnosis). METHODS: Three fellowship-trained orthopaedic surgeons and 1 medical student performed 2 rounds of radiographic measurements on digital imaging (lateral knee radiographs and long-leg radiographs) of skeletally immature patients with ACL tears. Intrarater and interrater reliability for continuous radiographic measurements was assessed with intraclass correlation coefficients (ICCs) across 4 raters with 95% CIs for affected and unaffected side measurements. Interrater reliability analysis used an ICC (2, 4) structure and intrarater reliability analysis used an ICC (2, 1) structure. A weighted kappa coefficient was calculated for ordinal variables along with 95% CIs for both interrater and intrarater reliability. Agreement statistic interpretations are based on scales described by Fleiss, and Cicchetti and Sparrow: <0.40, poor; 0.40 to 0.59, fair; 0.60 to 0.74, good; and >0.74, excellent. RESULTS: Radiographs from a convenience sample of 43 patients were included. Intrarater reliability was excellent for nearly all measurements and raters. Interrater reliability was also excellent for nearly all reads for all measurements. CONCLUSION: Radiographic reliability of long-leg radiographs and lateral knee x-rays in skeletally immature children with ACL tears is excellent across nearly all measures and raters and can be obtained and interpreted as reliable and reproducible means to measure limb length and alignment. LEVEL OF EVIDENCE: Level III.