Iatrogenic Common Peroneal Nerve Injuries From Inside-out Lateral Meniscus Repair: A Report of 2 Cases.

CASES: We report 2 cases of common peroneal nerve (CPN) palsy after inside-out lateral meniscus (LM) repair with very different presentations, occurring despite the standard surgical precautions (open counter incision and proper retraction between the biceps femoris tendon, lateral gastrocnemius, and capsule). On exploration, needle was found to have penetrated the nerve in one case and the nerve sheath in the other case. Patient 1 had near-complete neurological recovery, while patient 2 had partial neurological recovery after suture removal and neurolysis. CONCLUSION: CPN palsy can occur despite following all precautions during LM repair and should be managed as an iatrogenic injury unless proven otherwise.

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.

Anterior Cruciate Ligament Injury in Skeletally Immature Patients.

The incidence of anterior cruciate ligament (ACL) injury continues to increase in the skeletally immature population. These injuries were historically treated with nonsurgical measures in this age group due to concerns for iatrogenic damage to the physis during ACL reconstruction. However, delayed surgery often led to recurrent instability, meniscal tears, and chondral damage. With the development of newer and safer surgical techniques with satisfactory outcomes, ACL reconstruction has become much more common in this age group. The patient's skeletal age is often used to determine remaining growth, which helps to decide the surgical technique chosen. These techniques include physeal sparing, partial transphyseal, and transphyseal surgical options, using soft-tissue autografts. Each technique has been shown to have favorable patient-reported outcomes, but no technique is without the risk of complications. This article will review the management of skeletally immature ACL injuries, including relevant anatomy, risk factors for injury, assessment of skeletal age, and different treatment options and outcomes.

The Number of Patellar Dislocation Events Is Associated With Increased Chondral Damage of the Trochlea.

BACKGROUND: Patellofemoral instability is associated with chondral injuries to the patella, trochlea, and lateral femoral condyle. Although studies have demonstrated an association between patellar dislocations and chondral injuries, the influence of the number of dislocations on chondrosis is not established. PURPOSE: To elucidate the precise association between the number of patellar dislocation events and the severity of chondral injuries in a multicenter cohort study at the time of patellar stabilization procedures. STUDY DESIGN: Cross-sectional study; Level of evidence, 2. METHODS: A prospective multicenter cohort study (JUPITER [Justifying Patellar Instability Treatment by Early Results]) database was queried for cases of primary patellofemoral instability procedures from December 2016 to September 2022. Cartilage lesions were classified using the International Cartilage Repair Society (ICRS) classification system during an arthroscopic or open evaluation (direct visualization), with grades 2 to 4 considered abnormal. The number of dislocations was categorized as 1, 2-5, and >5. Categorical variables were compared with the chi-square test, and binary logistic regression was performed to identify predictors of the presence of chondral lesions. RESULTS: A total of 938 knees (mean age, 16.2 ± 3.8 years; 61.4% female) were included, with 580 (61.8%) demonstrating a chondral injury. The most affected region was the patella (n = 498 [53.1%]), followed by the lateral femoral condyle (n = 117 [12.5%]) and trochlea (n = 109 [11.6%]). There were no differences in the presence (P = .17) or grade (P = .63) of patellar lesions by the number of dislocations. Patients with >5 dislocations more frequently had trochlear chondral lesions (19.8%) compared with those with fewer dislocations (1, 7.6%; 2-5, 11.0%; P < .001). More dislocations were also associated with a higher proportion of ICRS grade 2 to 4 trochlear lesions (>5, 15.3%; 2-5, 10.0%; 1, 6.9%; P = .015). Combined patellar and trochlear lesions were also more common in those with >5 dislocations (P = .001). In multivariable regression, >5 dislocations was the only variable predictive of a trochlear lesion (odds ratio, 3.03 [95% CI, 1.65-5.58]; P < .001). CONCLUSION: This large prospective cohort study demonstrated that recurrent patellar dislocations can lead to more severe chondral damage in specific locations in the knee. More than 5 dislocations was associated with a >3-fold increase in the incidence and severity of trochlear chondral injuries. There were no differences in the presence or grade of patellar lesions by the number of dislocations. These findings should caution surgeons regarding prolonged nonoperative treatment.

Evaluation of Tibial Slope on Radiographs in Pediatric Patients With Tibial Spine Fractures: An Age- and Sex-Matched Study.

Background: A recent study has reported that the radiographic measurement of posterior tibial slope (PTS) is larger in male pediatric patients with tibial spine fractures (TSF) than in controls. However, they found no difference in PTS between female patients and controls. Purpose: (1) To identify whether PTS is larger in female pediatric patients with TSF than in female controls and (2) to validate the relationship between PTS and pediatric TSF in male patients. Study Design: Cross-sectional study; Level of evidence, 3. Methods: After an a priori power analysis, 84 pediatric patients with TSF (50 female patients and 34 male patients) and 84 age- and sex-matched controls were enrolled in this study. Demographic information, including sex, age, and race, was recorded. Skeletal maturity was determined based on the stage of epiphyseal union on knee radiographs. PTS was defined as the angle between a line perpendicular to the longitudinal axis of the tibia and the posterior inclination of the medial tibial plateau on standard knee lateral radiographs. Results: The mean age when the TSF occurred was 11.2 ± 2.7 years for female patients and 12.9 ± 2.5 years for male patients. There was no significant difference in skeletal maturity between female patients and female controls or between male patients and male controls. The mean PTS was not significantly different between female patients (8.8°± 2.8°) and female controls (8.3°± 3.1°) (P = .366) or between male patients (9.0°± 2.8°) and male controls (9.3°± 2.6°) (P = .675). Those with a PTS >1 SD (2.9°) above the mean (8.8°) had no greater odds (1.0 [95% CI, 0.4-2.5]; P≥ .999) of having a TSF than others. Conclusion: PTS was not found to be a risk factor for pediatric TSF in female or male patients in this study.

Midterm Outcomes of Isolated Medial Patellofemoral Ligament Reconstruction for Patellar Instability in Ehlers-Danlos Syndrome.

Background: Patellar instability is frequently encountered in patients with Ehlers-Danlos syndrome (EDS). The clinical outcomes of isolated medial patellofemoral ligament reconstruction (MPFLR) for patellar instability in patients with EDS are unknown. Purpose: To evaluate midterm clinical outcomes of isolated MPFLR for patellar instability in patients with EDS and factors affecting these outcomes. Study Design: Case series; Level of evidence, 4. Methods: In a retrospective study, 31 patients (n = 47 knees) with EDS and patellar instability who underwent isolated MPFLR for recurrent patellar instability between 2008 and 2017 and had a minimum 2-year follow-up were identified. Preoperative radiographic images were measured for anatomic risk factors. Clinical outcomes-including postoperative complications-were evaluated. Factors associated with MPFLR failure were identified. Postoperative patient-reported outcomes (PROs)-including the pediatric version of the International Knee Documentation Committee, the Kujala score, the Hospital for Special Surgery Pediatric Functional Activity Brief Scale, the Banff Patellofemoral Instability Instrument 2.0, and the Knee injury and Osteoarthritis Outcome Score-were collected, and factors affecting PRO scores were analyzed. Results: The mean age of the cohort was 14.9 ± 2 years. At a mean follow-up of 7.2 years, 18 of 47 (38.3%) knees required reoperations, of which 9 of 47 (19.1%) knees required revision stabilization for recurrent patellar instability. Also, 7 of 31 knees (22.6%) with autografts failed compared with 2 of 16 (12.5%) with allografts (P = .69). For autografts, 6 of 17 (35.3%) failures occurred with gracilis, but 0 of 13 (0%) occurred with semitendinosus (P = .02). Compared with patients without failures, patients with failed primary MPFLR were significantly younger (P = .0005) and were able to touch the palm to the floor with their knees extended (P = .03). For radiographic parameters, the patellar height and tilt were significantly higher in the failure group. The postoperative PROs were suboptimal at a mean follow-up of 5.2 years. All but 1 patient were satisfied with the final outcome. Conclusion: At the midterm follow-up, 38.3% of patients with EDS required further surgery after isolated MPFLR for patellar instability; half of these revisions (19.1%) were to address recurrent instability. Recurrent instability after isolated MPFLR was more likely in younger patients and those who could touch the palm to the floor with their knees extended. Postoperative PROs were inferior; nonetheless, patient satisfaction was high.

Osseous and Cartilaginous Trochlear Development in the Pediatric Knee: A Cadaveric Computed Tomography Study.

Background: The anatomy of the trochlea plays a significant role in patellar stability. The developmental anatomy of the trochlea and its relationship to patellar stability remains poorly understood. Purpose: To describe the developmental changes of the osseous and cartilaginous trochlear morphology in skeletally immature specimens. Study Design: Descriptive laboratory study. Methods: A total of 65 skeletally immature cadaveric knees between the ages of 2 months and 11 years were evaluated using computed tomography scans. The measurements in the axial plane of both cartilage and bone include medial, central, and lateral trochlear height; sulcus height; medial and later trochlear facet length; trochlear sulcus angle; patellar sulcus angle; condylar height asymmetry; and trochlear facet asymmetry. Additional measurements included trochlear depth and lateral trochlear inclination angle. In the sagittal plane, measurements included curvilinear trochlear length, direct trochlear length, condylar height, and patellar sulcus angle. Results: Analysis of trochlear morphology using condylar height, condylar height asymmetry, and trochlear depth all increased with increasing age. The osseous and cartilaginous sulcus angles became deeper with age until age 8 and then plateaued. This corresponded with an increase in trochlear depth that also plateaued around age 8. Osseous condylar asymmetry increased with age but flipped from a larger medial condyle to a larger lateral condyle around age 8. The continued growth of the trochlea with age was further demonstrated in all measures in the sagittal view. Conclusion: This cadaveric analysis demonstrated that there is an increase in condylar height as age increased by all measurements analyzed. These changes in condylar height continued to be seen through age 11, suggesting a still-developing trochlea past this age. By age 8, a plateau in sulcus angle, and sulcus depth suggests more proportionate growth after this point. Similar changes in trochlear and patellar shape with age suggests that the 2 structures may affect each other during development. Clinical Relevance: This information can help design, develop, and determine timing of procedures that may alter the anatomy and stabilize the trochlear and patellofemoral joint.

MPFL Reconstruction and Implant-Mediated Guided Growth in Skeletally Immature Patients With Patellar Instability and Genu Valgum.

BACKGROUND: There is a higher rate of failure of isolated MPFL reconstruction in skeletally immature patients with patellar instability compared to skeletally mature patients. Genu valgum is a known risk factor for patellar instability. There is potential for concomitant surgical correction of genu valgum to achieve better clinical outcomes and to decrease failure rates of MPFL reconstruction. PURPOSE: To evaluate outcomes of combined medial patellofemoral ligament (MPFL) reconstruction and implant-mediated guided growth (IMGG) in skeletally immature patients with patellar instability and genu valgum. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: In a multicenter study, all skeletally immature patients with recurrent patellar instability and genu valgum who underwent MPFL reconstruction using hamstring graft and IMGG using a transphyseal screw or tension band plate for the distal femur and/or proximal tibia were included. The knee valgus angle and mechanical axis were measured on full-length radiographs and anatomic risk factors were measured on MRI. Patients were followed until correction of their lower limb alignment and implant removal or until skeletal maturity. Clinical outcomes, including complications, were analyzed. RESULTS: A total of 31 patients (37 knees) were included in the study. The mean age and skeletal age of the cohort were 12.4 and 12.9 years, respectively. Simultaneous MPFL reconstruction and IMGG were performed in 26 of 37 knees; 11 underwent staged procedures. Twenty knees had transphyseal screws and 17 knees had tension band plates for IMGG. The knee valgus corrected from a mean of 12.4° to 5.1° in 12.1 months. Implants were removed from 22 of 37 knees once genu valgum was corrected. There was no significant difference (P = .65) in the correction rate between plates (0.7 deg/month) and screws (0.6 deg/month). Ten complications occurred in 4 patients (7 knees) and included 5 patellar redislocations, 2 rebound valgus, 1 varus overcorrection, 1 knee arthrofibrosis, and 1 implant loosening. For children <10 years of age, 3 of 6 (50%) knees had patellar redislocations and 5 of 6 knees had a complication. This was statistically significant (P = .003) compared with patients >10 years of age. Similarly, for patients with bilateral knee involvement, 5 of 12 (42%) knees had patellar redislocations and a total of 8 complications occurred in this subset. This was statistically significant (P < .001) compared with patients with unilateral involvement. CONCLUSION: IMGG with plates or screws in the setting of combined MPFL reconstruction improves genu valgum. Children <10 years of age and those with bilateral instability with genu valgum remain difficult subsets to treat with higher complication rates.

Quadriceps tendon autograft is promising with lower graft rupture rates and better functional Lysholm scores than hamstring tendon autograft in pediatric ACL reconstruction. A systematic review and meta-analysis.

Purpose: Graft rupture is the most prevalent complication following pediatric anterior cruciate ligament reconstruction (ACLR). The hamstring tendon (HT) autograft is frequently employed, while the quadriceps tendon (QT) autograft has garnered increased attention recently. This study aims to perform a systematic review to assess the complication rates and functional outcomes associated with these two widely used autografts in skeletally immature patients - comparing HT versus QT autografts. Research question: Is QT autograft better than HT autograft for ACLR in skeletally immature cohorts? Methodology: Three electronic databases (PubMed/Medline, Scopus, and Ovid) were comprehensively searched to identify pertinent articles reporting the outcomes of HT and QT autografts in pediatric ACLR with a minimum 2-year follow-up. Data on the outcome parameters, such as graft rupture rates, contralateral ACL injury rates, functional outcomes, and growth disturbances rates, were extracted. Meta-analysis was performed using OpenMeta Analyst software. Results: Twelve studies were included for meta-analysis (pooled analysis) with 659 patients (QT: 205; HT: 454). The analysis showed that QT autografts had a significantly lesser graft rupture rate than HT autografts (3.5 % [95 % CI 0.2, 6.8] and 12.4 % [95 % CI 6.1, 18.7] respectively, p < 0.001). The graft rupture rates between QT with bone and without bone block showed no statistically significant difference (4.6 % [95 % CI 0.8, 1.0] and 3.5 % [95 % CI 2.0, 8.9] respectively, p = 0.181). The overall contralateral ACL injury rate was 10.2 %, and the subgroup analysis revealed no statistically significant difference between the QT and HT groups (p = 0.7). Regarding functional outcome scores at the final follow-up, the mean Lysholm score demonstrated a significant increase in the QT group compared to the HT group (p < 0.001). There were no significant differences between the two groups concerning growth disturbances at the final follow-up. Return to sports (RTS) varied between 6 and 13.5 months after surgery. Conclusion: QT autografts demonstrate encouraging outcomes, showcasing lower graft rupture rates, better functional outcomes, and comparable contralateral ACL injury rates and growth disturbances relative to the commonly used HT autograft in skeletally immature patients undergoing ACLR.

Consensus-Based Guidelines for Management of First-Time Patellar Dislocation in Adolescents.

BACKGROUND: The management of first-time patellar dislocation remains variable, with limited evidence to support or compare different operative and nonoperative modalities. The primary aim was to establish consensus-based guidelines for different components of nonoperative treatment following a first-time patellar dislocation. The secondary aim was to develop guidelines related to management after failed nonoperative treatment. The tertiary aim was to establish consensus-based guidelines for the management of first-time patellar dislocation with a concomitant osteochondral fracture. METHODS: A 29-question, multiple-choice, case-based survey was developed by 20 members of the Patellofemoral Research Interest Group of the Pediatric Research in Sports Medicine Society. The survey consisted of questions related to demographic information, management of first-time patellar dislocation without an osteochondral fracture, and management of first-time patellar dislocation with a 2 cm osteochondral fracture. The survey underwent 2 rounds of iterations by Patellofemoral Research Interest Group members and the final survey was administered to Pediatric Research in Sports Medicine members, using REDCap. Consensus-based guidelines were generated when more than 66% of respondents chose the same answer. RESULTS: Seventy-nine of 157 (50%) eligible members responded. Sixty-one were orthopaedic surgeons and 18 were primary sports medicine physicians. Eleven consensus-based guidelines were generated based on survey responses. Those that met the criteria for consensus included initial knee radiographs (99% consensus), nonoperative treatment for first-time patellar dislocation without an osteochondral fracture (99%), physical therapy starting within the first month postinjury (99%), with return to sport after 2 to 4 months (68%) with a brace (75%) and further follow-up as needed (75%). Surgical treatment was recommended if there were patellar subluxation episodes after 6 months of nonoperative treatment (84%). Patellar stabilization should be considered for a first-time dislocation with an osteochondral fracture (81.5%). CONCLUSION: Consensus-based guidelines offer recommendations for the management of first-time patellar dislocation with or without an osteochondral fracture. Several changing trends and areas of disagreement were noted in clinical practice. CLINICAL RELEVANCE: In the absence of high-level evidence, consensus-based guidelines may aid in clinical decision-making when treating patients following a first-time patellar dislocation. These guidelines highlight the evolving trends in clinical practice for the management of first-time patellar dislocation. Areas not reaching consensus serve as topics for future research.

Manipulation Under Anesthesia is Safe and Effective for Management of Early Postoperative Knee Arthrofibrosis in Adolescent Patients.

BACKGROUND: Management of postoperative knee arthrofibrosis can be challenging and the preferred time for intervention remains controversial. The purpose of this study is to evaluate the safety and efficacy of early (<3 mo postoperatively) manipulation under anesthesia (MUA) for the treatment of knee arthrofibrosis in adolescent patients. We hypothesized that early MUA could restore normal knee motion with a low complication rate and without the need for more invasive intervention. METHODS: In a retrospective review, 57 patients who underwent MUA for postoperative knee arthrofibrosis were identified. The time between the index surgery and MUA as well as changes in range of motion (ROM) before and after MUA were analyzed. Descriptive statistics with median and interquartile range were used to analyze this non-parametric study cohort. Repeated measures ANOVA was performed to assess improvement in ROM over time. A P value <0.05 denoted statistical significance. RESULTS: The median age of the cohort at time of MUA was 14.5 years [interquartile range (IQR) 12.9 to 17.6)]. 54.4% were male. Median time to MUA was 64 days (IQR 52 to 79) after index surgery. ROM before MUA was 90.0 degrees (IQR 75 to 100), which improved to 130 degrees (120 to 135) after MUA. At final median follow-up of 8.9 months (IQR 5.1 to 16.1), mean ROM was 133 degrees (130 to 140). There were no iatrogenic fractures or physeal separations associated with MUA. 12.3% (n=7/57) failed MUA either due to the need for subsequent repeat MUA (n=2), need for lysis of adhesions (n=3) or need for surgery after MUA (n=2). Those who failed early MUA and required subsequent procedures had ROM >120 degrees at final follow-up. CONCLUSIONS: Postoperative knee arthrofibrosis can be safely and effectively treated with early (<3 mo postoperative) MUA. There were no iatrogenic fractures or physeal separations during MUA. Patients who had recurrence of motion deficits after early MUA and required further intervention, regained satisfactory knee motion at final follow-up. Although further research is warranted to better characterize risk factors for knee arthrofibrosis in adolescent patients, early recognition and MUA is a safe and effective treatment for arthrofibrosis to help patients regain full ROM without invasive intervention. LEVEL OF EVIDENCE: Therapeutic Study - Level IV.

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.

Patients with bilateral patellar instability have multiple and symmetric risk factors in each knee.

PURPOSE: Bilateral involvement is common in patients with patellar instability. The management of bilateral patellar instability is associated with increased complication rate. The higher complication rate in this cohort may be related to the presence of underlying anatomic risk factors. The purpose of the study was to evaluate the presence and side-to-side differences in risk factors between knees in bilateral patellar instability. METHODS: In a retrospective study (2008-2017), demographic information, characteristics of patellar dislocation and anatomic risk factors on MRI (trochlear dysplasia, patellar height, tibial tubercle lateralization, patellar tilt, sulcus angle, bump height) were evaluated in both knees of all patients (n = 32, 15 males and 17 females) with bilateral patellar instability. The risk factors were analyzed based on established cut off values and were compared between gender, laterality and more symptomatic (index) knee. Knee symmetry and absolute differences between risk factors for both knees were analyzed. RESULTS: The mean age of 32 patients was 14.6 ± 2.3 years. Of the 4 major anatomic risk factors, the most common were trochlear dysplasia in 59/64 (92.1%) knees and patella alta in 51/64 (79.7%) knees. Tibial tubercle lateralization was the least common risk factor being present in 8/64 (12.5%) knees. Of 64 knees, 55 (85.9%) had 2 or more risk factors and 30 (46.8%) had 3 or all 4 risk factors present. There were no significant differences in risk factors based on gender, laterality or index knee. There was symmetry between paired knees for 31/32 (96.8%) patients for trochlear depth, 29/32 (90.6%) for patellar tilt, 27/32 (84.3%) for TT-TG distance and 25/32 (78.1%) for patellar height. There were no significant differences in absolute measurements between knees for any of the risk factors. CONCLUSION: Patients with bilateral instability had multiple risk factors, with trochlear dysplasia being the most common and increased TT-TG distance being the least common. Majority of patients had 2 or more risk factors and about half had 3 or 4 risk factors in each knee. There was symmetry between paired knees for each risk factor without any significant differences between the index knee compared to the contralateral knee. LEVEL OF EVIDENCE: Level III.

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.

4-in-1 Quadricepsplasty for Habitual and Fixed Lateral Patellar Dislocation in Children.

BACKGROUND: Habitual and fixed patellar dislocations represent extreme forms of patellar instability and can lead to significant functional loss. The underlying complex pathoanatomy of a laterally positioned and shortened extensor mechanism poses challenges in its management. The purpose of our study was to evaluate the anatomic risk factors and outcomes of a 4-in-1 quadricepsplasty (wide lateral releases, Insall proximal tube realignment, Roux-Goldthwait patellar tendon hemi-transfer, and step-wise quadriceps lengthening) for stabilization of habitual and fixed patellar dislocation. METHODS: In a retrospective study, all patients with habitual and fixed patellar dislocation who underwent 4-in-1 quadricepsplasty and had a minimum 2-year follow-up were identified. Preoperative magnetic resonance imagings were evaluated for the presence of anatomic risk factors. As a prospective part of the study, patient-reported outcomes were collected using validated instruments including Pedi-IKDC, HSS-Pedi FABS activity score, BPII 2.0 score, Kujala score, and KOOS score. RESULTS: Seventeen knees (12 patients) formed the study cohort. Twelve knees had habitual dislocation (9 in extension and 4 in flexion) and 5 had fixed dislocation. Mean age was 9 years. 6/17 (35.3%) knees were associated with syndromes. On magnetic resonance imaging, trochlear dysplasia was the most common anatomic risk factor present in 15/17 (88.2%) knees. 13/17 (76%) knees had presence of 2 or more risk factors. At the mean follow-up of 43.3 months, the mean Pedi-IKDC score was 88.1, the HSS-Pedi FABS activity score was 15.6, the BPII 2.0 score was 78.2, the Kujala score was 90, KOOS score was 93.9, and overall patient satisfaction score was 83.3. For complications, 3/17 knees (17.6%) had recurrent patellar instability, 1 knee had postoperative stiffness that required manipulation under anesthesia and 1 knee had a superficial wound infection. CONCLUSIONS: Most patients with habitual and fixed patellar dislocation present during the first decade of life. There are several underlying anatomic risk factors, the most common being trochlear dysplasia and patellar tilt. The 4-in-1 quadricepsplasty technique provides reliable patellar stabilization, satisfactory clinical results, and acceptable patient-reported outcomes at a minimum 2-year follow-up, with a 17.6% redislocation rate. LEVEL OF EVIDENCE: Level IV.

Common Pediatric Fractures for Community Orthopaedic Specialists: Fix Them or Ship Them?

It is important to focus on common pediatric fractures seen in community emergency rooms, including supracondylar humerus, elbow, forearm, distal radius, and femoral shaft fractures, along with periarticular fractures around the knee and ankle in children. The principles of surgical and nonsurgical management of these fractures are based on the fracture type and age of the patient. The orthopaedic surgeon should be aware of important tips and tricks to help manage these injuries and be familiar with common complications that may occur when these injuries are encountered during trauma call.

Evaluation of the Optimal Femoral Fixation Site for Medial Patellofemoral Ligament Reconstruction in the Skeletally Immature Patient.

The aim of this study was to assess which femoral fixation site, distal to the physis, most closely emulates the native medial patellofemoral ligament (nMPFL) length relationship in the pediatric knee. Lateral knee radiographs were taken incrementally, from 0° to 120° of flexion. The femoral origin of the nMPFL and 3 other MPFL femoral fixation sites distal to the physis were identified (P1, 1 cm distal to physis along the posterior femoral cortex; P2, 2 cm distal to physis along the posterior femoral cortex; P3, 1 cm distal and 1 cm anterior). Virtual MPFL lengths were measured from all sites. Measurement reliability was assessed using intraclass correlation coefficients. Primary comparison between simulated MPFL length at native and femoral fixation sites was made using a repeated measures analysis of variance at 30° flexion. Bivariate Pearson correlation was used to assess the relationship between fixation sites and nMPFL through the range of motion (alpha=0.05). The intra-class correlation coefficient for intraobserver reliability of MPFL length measurement was excellent. Analysis of variance showed virtual MPFL lengths from proposed femoral fixation sites at 30° were significantly different from nMPFL length (P<.01). The P1 MPFL had the least difference in means compared with nMPFL (-2.6±1.8 mm). Correlational analysis showed that P1 MPFL had the closest relationship with nMPFL compared with other femoral fixation sites (R=0.91, P<.01). The P1 MPFL had the length change most comparable to that of nMPFL (23.9±3.1 mm vs 13.3±2.85 mm) compared with the other simulated MPFLs. Femoral graft fixation site 1 cm distal to the physis in the lateral view along the posterior femoral cortex closely represents the length relationship of the nMPFL. [Orthopedics. 2023;46(2):108-113.].

Patellar Instability in Young Athletes.

This article summarizes the latest research related to pediatric patellar instability. The epidemiology, patterns of patellar instability, and underlying pathoanatomy are unique in children and adolescents. Information related to the natural history and predictive factors of patellar instability in young patients would allow for better patient counseling and management decisions. The components of nonoperative treatment for first patellar dislocation are outlined. Physeal-respecting surgical techniques, including medial patellofemoral ligament reconstruction in skeletally immature patients, are discussed. The indications and outcomes for quadricepsplasty to address more complex instability patterns are presented. Evaluation and management strategies for specific anatomic risk factors is provided.

Comparative Effectiveness of Nonoperative Versus Operative Treatment of Completely Displaced Clavicle Shaft Fractures Among Children.

The goal of this study was to compare outcomes among children treated nonoperatively vs operatively for completely displaced clavicle fractures. This was a retrospective cohort study of nonoperative vs operative treatment of completely displaced clavicle fractures sustained between 2006 and 2015 among pediatric patients. Data were collected on patient demographics, fracture characteristics, time to return to full activities, treatment complications, and patient-reported outcome measures. Fifty-five patients were identified in the nonoperative group, with a mean age of 11.6 years (range, 8-14 years). The operative group contained 55 patients, with a mean age of 14.3 years (range, 9-17 years). All fractures healed, with a mean time to return to full activities of 90.4 days in the nonoperative group and 89.7 days in the operative group (P=.941). Twelve (22%) nonoperative patients sustained a refracture of their clavicle compared with 4 patients in the operative group (P=.031). Fifteen patients (27%) in the operative group required a second surgery for removal of surgical implants. On the shortened form of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) survey, 17 of the 22 nonoperative patients reported a score of zero (indicating no disability) (range, 0-7) vs 22 of 25 in the operative group (range, 0-9) (P=.329). Patients treated nonoperatively had a 22% rate of refracture, whereas patients treated operatively had a 27% rate of undergoing a second surgery for removal of surgical implants. These data can aid in the shared decision-making process with patients and families when deciding on treatment for displaced pediatric clavicle fractures. [Orthopedics. 2022;45(6):373-377.].