Association of Spanish as a Primary Language With Retear Rates After Pediatric ACL Reconstruction.

Background: Anterior cruciate ligament (ACL) injuries are one of the most common knee injuries in pediatric patients in the United States. The patient's primary spoken language may affect outcomes after ACL reconstruction (ACLR). Purpose/Hypothesis: The purpose of this study was to identify differences in ACLR outcomes between patients whose primary, preferred spoken language was either English or Spanish. It was hypothesized that there would be a difference in retear rates between patients preferring English versus Spanish. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective cohort study was performed on pediatric and adolescent patients who underwent ACLR at a single institution. Patients were divided into 2 cohorts based on their preferred spoken language: English or Spanish. All patients underwent either hamstring tendon or bone-patellar tendon-bone autograft ACLR performed by the same surgeon with the same postoperative rehabilitation protocols. Linear regression, chi-square tests, and multivariate logistic regression were used to determine if outcomes, graft tear, revision surgery, and contralateral injury differed between groups. Results: A total of 68 patients were identified: 33 patients whose preferred language was English and 35 patients whose preferred language was Spanish. The overall mean age of the patients was 16.4 ± 1.4 years (range, 13.2-20.5 years), and the mean follow-up time was 3.26 ± 1.98 years (range, 0.53-8.13 years). Patients who preferred Spanish were more likely than those who preferred English to experience graft tears requiring revision surgery after ACLR (P = .02; odds ratio [OR] = 5.81; adjusted OR = 1.94), at a tear rate of 14.3%. Conclusion: Patients who preferred to speak Spanish experienced higher graft tear rates when compared with patients who preferred speaking English, even after adjusting for sex, sport played, graft type, type of insurance, and time to surgery.

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.

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.

Hip Pain in Adolescent Patients.

Hip pain is a common complaint in adolescents. There are several causes for hip pain in this population, with dysplasia and impingement being the most common; however, other conditions such as extra-articular impingement, torsional disorders, labral tears, and osteochondral lesions also require consideration. Many of these conditions are related to underlying anatomic abnormalities and increased activity in this age group. An understanding of the common pathologies of the adolescent hip is integral to the evaluation, diagnosis, and treatment of these patients.

Open Fractures in National Football League Athletes: Analyzing Performance and Return to Sport.

INTRODUCTION: Open fractures are potentially devastating injuries for the professional athlete. We sought to compare return to sports (RTS) and performance in National Football League (NFL) athletes sustaining open versus closed fractures. METHODS: NFL athletes with surgically treated open and closed fractures of the forearm, tibial shaft, and ankle from 2009-2018 were identified through publicly available reports and records. Data including demographics, RTS, career duration, and the approximate value performance metric before and after injury were collected. Statistical analyses were performed comparing open to closed injuries. Continuous variables were compared using Mann-Whitney U or two sample t- tests while categorical variables were compared using Fisher's exact test. RESULTS: Ninety-five athletes met inclusion criteria (10 open and 85 closed fractures). Overall, 90% (n = 9) returned to sport after an open injury and 83.5% (n = 71) returned after closed injury with a median time missed of 48.9 (range 35.1 - 117.4) weeks and 43.0 (range 2.4 - 108.0) weeks, respectively. Athletes undergoing forearm surgery were able to return sooner, at around 20.8 weeks, and ankle fractures conferred the lowest return rate at 80% (n = 48). There were no significant differences in career duration and post-injury performance between open or closed fracture cohorts. CONCLUSIONS: Although open fractures are relatively uncommon injuries seen in NFL athletes, our study suggests RTS for these players is high. Athletes undergoing surgical treatment for open fractures had similar RTS rates, performance metrics, and career durations compared to those with comparable closed fractures. This information can provide guidance for providers counseling elite athletes on postoperative expectations.

Return to Play After Thumb Ulnar Collateral Ligament Injuries Managed Surgically in Athletes-A Systematic Review.

Purpose: The purpose of this systematic review was to summarize the available data on how surgical management of injuries to the thumb ulnar collateral ligament (UCL) complex affects athletes and their return-to-play (RTP) and postinjury performance metrics in addition to evaluating rehabilitation guidelines. Methods: A systematic search was performed on PubMed and Embase databases for articles on outcomes of surgical treatment of thumb UCL injuries in athletes. Articles with expert recommendations on postoperative management and RTP guidelines were also included separately. Study characteristics were recorded, including sport, RTP rates, and data on performance. Recommendations were summarized by sport. The Methodological Index for Non-Randomized Studies (MINORS) criteria was used to assess methodological quality. The authors also present their recommended return-to-sport algorithm. Results: Twenty-three articles were included, including 11 with reports on patients and 12 expert opinions on guiding RTP. The mean MINORS score for the applicable studies was 9.4. In the 311 patients included, RTP was 98.1% in aggregate. No performance detriments were noted in athletes after surgery. Thirty-two (10.3%) patients had postoperative complications. The recommendations on timing to RTP vary by sport and author, but all recommended initial thumb protection when returning to sport. Newer techniques, such as suture tape augmentation, suggest the permission for earlier motion. Conclusions: Return-to-play rates after surgical treatment of thumb UCL injuries are high, with reassuring return to preinjury level of play with few complications. Recommendations for surgical technique have trended toward suture anchors and, now, suture tape augmentation with earlier motion protocols, although rehabilitation guidelines vary by sport and author. Current information on thumb UCL surgery in athletes is limited by the low quality of evidence and expert recommendations. Type of study/level of evidence: Prognostic IV.

#OrthoTwitter: Relationship Between Author Twitter Utilization and Academic Impact in Orthopaedic Surgery.

Background #OrthoTwitter has evolved to disseminate findings and engage the public. However, the academic impact of Twitter utilization in orthopaedic surgery is unknown. Questions/purposes The purpose of the study was to evaluate relationships between the author and manuscript Twitter activity and citations. Methods Manuscripts in 17 orthopaedic journals from 2018 were identified. Citations, online mentions, impact factors, and subspecialties were obtained. H-index and Twitter account details for authors were obtained for a subset of manuscripts. Relationships between Twitter activity and citations were evaluated. Results 2,473/4,224 (58.5%) manuscripts were mentioned on Twitter (n=29,958 mentions), with Twitter manuscripts cited more frequently (median 10 vs. 7, p<0.0001). Twitter mentions, impact factors, non-open-access status, and subspecialties were associated with citation counts. Articles mentioned in 10, 100, and 1,000 Tweets were observed to have a 1.1-fold, 1.7-fold, and 245-fold increase in citations. In author-level analyses, 156 (20.0%) first and 216 (27.7%) senior authors had Twitter accounts. Citation count was associated with increasing senior author H-index (ß est=0.13, p<0.05), Twitter mentions (ß est=0.0043, p<0.0001), impact factors (ß est=0.13, p<0.0001), and having a first (ß est=0.20, p<0.05) or senior author (ß est=0.17, p<0.05) on Twitter. Articles published in arthroplasty (ß est=0.49, p<0.05), general interest (ß est=0.55, p<0.01), sports (ß est=0.63, p<0.01), and non-open access journals (ß est=0.41, p<0.001) were cited more. H-index correlated with followers for first (rho=0.31, p<0.0001) and senior authors (rho=0.44, p<0.0001). Conclusion Author Twitter utilization is independently associated with manuscript citations. Authors should be aware of the potential association between social media utilization and traditional academic impact. Understanding the relationship between social media utilization and academic impact is necessary to effectively disseminate research.

Adolescent elbow osteochondral lesions following prior elbow fracture pinning.

Purpose: Pinning of pediatric elbow fractures has been shown to be a safe procedure with a low complication profile. This study identified patients who underwent cartilage surgery for elbow osteochondral lesions or osteochondritis dissecans who had prior ipsilateral elbow pinning. Methods: Records of patients who underwent ipsilateral cartilage surgery for osteochondritis dissecans and prior percutaneous pinning for elbow fractures were identified. Demographics were compiled and the clinical, radiographic, and surgical results were tabulated for patients with at least 1-year of follow-up from initial presentation. Results: In total, 6/52 (11.5%) pediatric patients from 2012 to 2021 who underwent isolated elbow osteochondritis dissecans surgery (mean age at surgery 13.4 ± 1.5 years) had a history of ipsilateral elbow pinning (mean age at surgery 6.9 ± 2.4 years). Of these, five had a history of a supracondylar fracture while one patient sustained a lateral condyle fracture. Overall, three of six patients had mechanical symptoms at presentation and three had abnormal radiographs. All patients underwent pre-operative magnetic resonance imaging and the five patients with an osteochondritis dissecans lesion <1cm2 underwent arthroscopy and microfracture while one with a 4-cm2 lesion underwent open osteochondral allograft transfer. All patients demonstrated improved motion at final follow-up and all patients were able to return to full desired activity following surgery. Conclusion: This study demonstrates that the history of elbow fracture pinning may predispose patients to future elbow chondral injuries in adolescence. Although patients appear to do well following consequent osteochondritis dissecans surgery, patients and parents may be advised of possible association of elbow pinning and elbow osteochondral lesions. Level of Evidence: III, case-control study.

Two-Year Functional Outcomes of Operative vs Nonoperative Treatment of Completely Displaced Midshaft Clavicle Fractures in Adolescents: Results From the Prospective Multicenter FACTS Study Group.

BACKGROUND: The optimal treatment of midshaft clavicle fractures is controversial. Few previous comparative functional outcome studies have investigated these fractures in adolescents, the most commonly affected epidemiologic subpopulation. PURPOSE/HYPOTHESIS: The purpose was to prospectively compare the outcomes of operative versus nonoperative treatment in adolescents with completely displaced midshaft clavicle fractures. The study hypothesis was that surgery would yield superior outcomes. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Patients aged 10 to 18 years treated for a midshaft clavicle fracture over a 5-year period at 1 of 8 pediatric centers were prospectively screened, with independent treatment decisions determined by individual musculoskeletal professionals. Demographics, radiographic clinical features, complications, and patient-reported outcomes (PROs) were prospectively recorded for 2 years. Regression and matching techniques were utilized to adjust for potential age- and fracture severity-based confounders for creation of comparable subgroups for analysis. RESULTS: Of 416 adolescents with completely displaced midshaft clavicle fractures, 282 (68) provided 2-year PRO data. Operative patients (n = 88; 31%) demonstrated no difference in sex (78% male) or athletic participation but were older (mean age, 15.2 vs 13.5 years; P < .001), had more comminuted fractures (49.4% vs 26.3%; P < .001), and had greater fracture shortening (25.5 vs 20.7 mm; P < .001) than nonoperative patients (n = 194; 69%). There was no difference in mean PRO scores or rates of "suboptimal" scores (based on threshold values established a priori) between the operative and nonoperative treatment groups (American Shoulder and Elbow Surgeons, 96.8 vs 98.4; shortened version of the Disabilities of the Arm, Shoulder and Hand, 3.0 vs 1.6; EuroQol [EQ] visual analog scale, 93.0 vs 93.9; EQ-5 Dimensions index, 0.96 vs 0.98), even after regression and matching techniques adjusted for confounders. Operative patients had more unexpected subsequent surgery (10.4% vs 1.4%; P = .004) and clinically significant complications (20.8% vs 5.2%; P = .001). Overall, nonunion (0.4%), delayed union (1.9%), symptomatic malunion (0.4%), and refracture (2.6%) were exceedingly rare, with no difference between treatment groups. CONCLUSION: Surgery demonstrated no benefit in patient-reported quality of life, satisfaction, shoulder-specific function, or prevention of complications after completely displaced clavicle shaft fractures in adolescents at 2 years after injury. REGISTRATION: NCT04250415 (ClinicalTrials.gov identifier).

Outcomes of bioabsorbable fixation in the treatment of osteochondral lesions of the knee in adolescent patients.

BACKGROUND: Bioabsorbable fixation in managing osteochondral lesions is increasing in popularity. The purpose was to report on outcomes using bioabsorbable fixation nails for osteochondral lesions of the knee in a pediatric and adolescent population. METHODS: A retrospective review of pediatric patients undergoing surgery with bioabsorbable fixation for knee osteochondral lesions was performed. Demographic, clinical, and surgical data was collected including symptom duration, lesion location, size, use of bone grafting, and number of implants. Return to activities was documented. Patients recommended revision surgery were compared to those who were not. RESULTS: 47 patients with median age 13.9 years and 25.5% female were included with median clinical follow-up of 47.3 weeks. 87.2% of patients were cleared for full activities. Four male patients (8.5%) were recommended revision surgery, of whom three underwent surgery including removal of loose bioabsorbable fixation. Demographic data did not differ between the group with successful versus failed primary surgery (p > 0.05). Symptom duration was more acute (<1 month) in the four recommended revision surgery (75% versus 9.3%, p = 0.008). The group recommended revision also had larger lesion size (median 5.4 cm2 versus 2 cm2, p = 0.04). Distal femoral physeal status, lesion location, necessity for bone grafting, and number of implants did not differ between groups. CONCLUSIONS: Adolescents had a high return to activity following bioabsorbable fixation for knee osteochondral lesions with 87.2% cleared for full return. In the 8.5% of patients who were deemed to have failed primary fixation, symptoms were more likely to be acute in nature with larger lesion sizes.

Younger Patients Are More Likely to Undergo Arthroscopic Meniscal Repair and Revision Meniscal Surgery in a Large Cross-Sectional Cohort.

PURPOSE: To evaluate recent trends in the treatment of meniscal tears with arthroscopic repair and debridement and to assess revision surgery within 2 years using a large cross-sectional database. METHODS: Patients with a diagnosis of meniscal tear from 2010 to 2017 were queried using the Mariner data set from PearlDiver. Patient demographic data were analyzed and tracked via International Classification of Diseases, Tenth Revision codes to investigate subsequent ipsilateral meniscal procedures and conversion to total knee arthroplasty within 2 years after index meniscal surgery. RESULTS: Of the 1,383,161 patients with a diagnosis of meniscal tear, 53.0% underwent surgical treatment. Surgical treatment consisted of meniscal debridement in 96.6% of patients and meniscal repair in 3.4%. The percentage of meniscal repairs increased from 2.7% to 4.4% over the 8-year period evaluated, whereas the percentage of meniscal debridement decreased from 97.3% to 95.6% (P < .0001). Younger patients were more likely to undergo meniscal repair (23% of those aged 10-19 years) than older patients (<1% of those aged ≥60 years). Among the 191,729 patients with International Classification of Diseases, Tenth Revision coding and 2-year follow-up, 10.6% of patients with index meniscal repair required a revision meniscal operation and 1.2% underwent conversion to arthroplasty. Subsequent meniscal procedures within 2 years after index meniscal repair included meniscal debridement in 81.6% of patients and revision repair in 18.4%. Patients who initially underwent meniscal debridement were less likely to undergo revision meniscal surgery (5.1%), but 4.7% required conversion to arthroplasty. Patients aged 10 to 19 years were most likely to undergo revision meniscal procedures after both index meniscal repair (12.8%) and meniscal debridement (8.8%). CONCLUSIONS: The rate of meniscal repair is increasing over time, with patients younger than 30 years most likely to undergo repair for a meniscal tear. Revision surgery for meniscal repair or debridement is more common in adolescents and patients who undergo an index meniscal repair. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Association of Insurance Status With Treatment Delays for Pediatric and Adolescent Patients Undergoing Surgery for Patellar Instability.

Background: Health care disparities have been highlighted in pediatric sports medicine, but the association between insurance status and delayed care for patients undergoing surgery for patellar instability has not been defined. Purpose: To determine whether there is an association between insurance status and delays in care in pediatric and adolescent patients undergoing surgery for patellar instability. Study Design: Cohort study; Level of evidence, 3. Methods: This was a retrospective case series at a safety-net tertiary referral center of pediatric and adolescent patients undergoing surgical treatment for patellar instability. Insurance status was classified as public or private. We calculated the times from injury to clinical evaluation, injury to magnetic resonance imaging (MRI), injury to surgery, clinical evaluation to MRI, and clinical evaluation to surgery. Comparisons were made between insurance groups. Results: Included were 78 patients (38 public, 40 private insurance) who underwent surgery for patellar instability. The public insurance group was older (P = .019), with a lower proportion of White patients (15.8% vs 52.5%; P = .0005), higher proportion with Hispanic ethnicity (55.3% vs 15.0%; P = .0001), and higher proportion of Spanish-speaking patients (21.1% vs 2.5%; P = .007). Publicly insured patients had longer times from initial injury to clinical evaluation (466 vs 77 days; P = .002), MRI (466 vs 82 days; P = .003), and surgery (695 vs 153 days; P = .0003), as well as a longer time from clinical evaluation to surgery (226 vs 73 days; P = .002). Multivariable models confirmed insurance status as an independent predictor in each of the identified delays. Conclusion: Significant delays were seen for pediatric and adolescent patients with patellar instability and public insurance (approximately 6 times longer to clinical evaluation, more than 5.5 times longer to obtain MRI, and 4.5 times longer to surgery) relative to injured patients with private insurance. Even after adjusting for delays to clinical evaluation, publicly insured patients had a delay from clinic to surgery that was triple that of privately insured patients.

Allograft Medial Patellofemoral Ligament Reconstruction in Adolescent Patients Results in a Low Recurrence Rate of Patellar Dislocation or Subluxation at Midterm Follow-Up.

PURPOSE: To evaluate rates of recurrent instability in adolescent patients with medial patellofemoral ligament (MPFL) reconstruction with allograft and associations of anatomic risk factors with complications. METHODS: A retrospective review identified patients of a single surgeon who underwent MPFL reconstruction with allograft for recurrent patellar instability with minimum 2-year follow-up. Surgical management was recommended after a minimum 6 weeks of nonoperative management and included MPFL reconstruction with gracilis allograft using a double-bundle technique. Preoperative radiographs were evaluated to assess physeal closure, lower-extremity alignment, trochlear morphology, and Insall-Salvati and Caton-Deschamps ratios. Magnetic resonance images were reviewed to evaluate the MPFL, trochlear morphology, and tibial tubercle trochlear groove distance (TT-TG). Descriptive statistics were used to characterize data. The primary outcome was recurrent instability. RESULTS: 20 patients (24 knees; 18 knees in 14 females and 6 knees in 6 males; average age 15.7 years; range 11.5 to 19.6) underwent MPFL reconstruction with allograft (mean ± standard deviation follow-up 5.2 ± 1.7 years; range 2.2 to 8.1). Physes were open in 9 knees. The Insall-Salvati ratio was 1.09 ± 0.16, and the Caton-Deschamps index was 1.17 ± 0.15. Preoperatively, 19 patients were noted to have trochlear dysplasia, and TT-TG was 15.3 ± 3.9 mm. Three of 4 knees (16.7%) with non-hardware-related complications had open physes: 3 (12.5%) had recurrent instability, 2 of which underwent subsequent operation, and 1 sustained a patella fracture after a fall, requiring open reduction and internal fixation. The average Insall-Salvati ratio of these 4 patients was 1.21 ± 0.20, Caton-Deschamps index was 1.18 ± 0.17, and TT-TG was 17.5 ± 3.3 mm, none of which were statistically different from the group without complications. There were no clinically noted growth disturbances postoperatively. CONCLUSIONS: MPFL reconstruction using allograft tissue may be performed safely in the pediatric and adolescent population with good outcomes at midterm follow-up, few complications, and a low rate of recurrent instability. LEVEL OF EVIDENCE: IV, case series.

Pediatric firearm-associated fractures: Analysis of management and outcomes.

BACKGROUND: Firearm-associated injuries (FAIs) are among the leading causes of morbidity and mortality in children living in the United States. Most victims of such injuries survive, but may experience compromised function related to musculoskeletal injuries. Although complex firearm-associated fractures (FAFs) often require specialized orthopaedic, vascular, and plastic surgical intervention, there is minimal research describing their management and outcomes. The purpose of this study is to describe the epidemiology and presentation of pediatric FAFs, as well as evaluate the management and outcomes of these injuries. AIM: To describe the epidemiology and presentation of pediatric FAFs, as well as evaluate the management and outcomes of these injuries. METHODS: A retrospective chart review was performed at a major, pediatric level 1 trauma center. The study included patients aged 18 or younger who presented with FAIs between 2008-2018. Additional data was collected on patients with FAFs including demographic and clinical data such as age, sex, race, payor type, fracture location, injury severity score (ISS), and radiographic and clinical outcomes. The management of FAFs was analyzed as well as need for readmission and reoperation. Descriptive statistics were used to summarize the results and univariate analyses were performed to assess differences between groups. RESULTS: Between 2008 and 2018, there were a total of 61 patients who presented with FAIs. In this cohort, 21 patients (34%) sustained FAFs (25 fractures) with a mean age of 11 (Range: 10 mo to 18 years old) at the time of presentation. Approximately 52% (n = 11) of patients with FAFs were male, 76% (n = 8 and n = 8, respectively) identified as black or other, and 71% (n = 15) had government insurance. FAFs were most commonly noted in the upper extremity (n = 7) and lower extremity (n = 6). In patients with FAFs, the mean ISS at presentation was 11.38 (Range: 2-38), and 24% of patients (n = 5) were classified as having a major trauma. There were no significant differences in age, sex, race, and payor type in FAF patients that presented with and without major trauma (P > 0.05). When comparing FAF and non-FAF patients, there was a statistically significant difference in ISS (11.38 vs 14.45, P = 0.02). In total, 33% (n = 7) of patients with FAFs required orthopaedic surgical management, which was most commonly comprised of debridement (n = 6/7, 86%), and 14% (n = 1/7) of these patients required coordinated care with plastic and/or vascular surgery. There were no significant differences in age and payor type in patients with FAFs treated with and without orthopaedic surgery. Of the patients with FAFs, 52% (n = 11) had a minimum 90-d follow-up, and 48% (n = 10) had a minimum 2-year follow-up. Two patients were readmitted within 90-d, while one patient required a reoperation within 2-years. CONCLUSION: Over 25% of FAIs in pediatric patients result in FAFs. FAFs often present to pediatric trauma centers and the majority of these injuries occur in non-Caucasian males with government insurance. Most FAFs do not need orthopaedic surgical management; 14% of these injuries require subspecialty care by orthopaedic surgery, vascular surgery, or plastic surgery. Patients with FAFs also have lower ISS compared to patients who sustained FAIs without fracture. Thus, these patients should be treated at pediatric trauma centers with specialty care and additional research is needed to focus prevention efforts, understand reasons for poor follow-up, and evaluate outcomes after injury.

Changes in superior displacement, angulation, and shortening in the early phase of healing for completely displaced midshaft clavicle fractures in adolescents: results from a prospective, multicenter study.

BACKGROUND: Progressive displacement of diaphyseal clavicle fractures has been observed in adult patients, at times necessitating a change from nonoperative to operative treatment. Whether this occurs in adolescent patients has not been well investigated. The purpose of this study was to assess the rate and extent of progressive clavicle fracture displacement in adolescent patients following injury and during the early stages of healing. METHODS: This was a multicenter study evaluating prospective data that had previously been collected as part of a larger study evaluating the functional outcomes of adolescent clavicle fractures. A consecutive series of completely displaced diaphyseal clavicle fractures in patients aged 10-18 years treated at 1 of 3 tertiary-care pediatric trauma centers was included; all fractures underwent standardized imaging within 2 weeks of the date of injury and during the course of healing (5-20 weeks after injury). Measurements of clavicle shortening, superior displacement, and angulation were performed using validated techniques. Progressive displacement and/or interval improvement in fracture alignment, as well as the subsequent need for surgical intervention, was noted. Patient demographic and radiographic parameters were assessed as possible risk factors for interval displacement. RESULTS: One hundred patients met the inclusion criteria. Mean end-to-end shortening, cortex-to-cortex shortening, superior displacement, and angulation at the time of injury were 24 mm, 15 mm, 15 mm, and 7°, respectively. At a mean of 10 weeks after injury, the fracture alignment improved across all 4 measurements for the overall cohort, with mean improvements of 3.5 mm in end-to-end shortening, 3.3 mm in cortex-to-cortex shortening, 2.1 mm in superior displacement, and 2° in angulation. By use of a clinical threshold of a change in shortening or displacement of 10 mm or change in angulation of 10°, 26% of fractures improved, 4% worsened, and 70% remain unchanged. Patients with more severe fractures were more likely to have improved alignment than were patients with less displaced fractures (P < .001). No patient underwent surgical intervention for progressive displacement. CONCLUSION: Significant early improvements in fracture alignment were observed in a substantial percentage of adolescent patients with completely displaced clavicle fractures. Among the most severely displaced fractures, shortening improved approximately 6 mm and angulation improved approximately 9°. In 4% of cases, increased displacement was observed, but this tended to be mild, and in no cases did it prompt surgical intervention. This finding indicates that the true final deformity after an adolescent clavicle fracture is commonly less than that present at the time of injury.

Outcomes of Arthroscopic Surgical Treatment of Osteochondral Lesions of the Elbow in Pediatric and Adolescent Athletes.

BACKGROUND: Osteochondral injuries of the elbow are limiting and affect the ability of pediatric and adolescent athletes to participate in sports. PURPOSE: To report short- and midterm outcomes on athletes undergoing microfracture or fragment fixation of osteochondral elbow lesions and evaluate the effects thereof on sporting activity. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: This was a retrospective study analyzing patients who underwent surgical treatment via microfracture or fragment fixation for osteochondral elbow lesions. Patients were treated at a single institution by a single surgeon between 2012 and 2019. Diagnosis was confirmed with magnetic resonance imaging, and patients were indicated for surgery after having persistent symptoms despite trialing rest, immobilization, and/or activity restriction for at least 3 months. Demographic data including sports of choice were collected preoperatively. Imaging and intraoperative findings were documented, and any complications were noted. Range of motion (ROM) was compared pre- to postoperatively. Return-to-sport evaluation included the ability to play the preoperative sport of choice. RESULTS: In total, 23 patients (25 elbows) were included with a mean follow-up of 23.5 months (range, 6-60.3 months) and a mean age of 13.8 years. Of 25 lesions, 20 (80%) were on the athlete's dominant side. There was significant improvement from pre- to postoperative ROM, including extension (mean ± SD, 6.4° ± 5.3° to 0.04° ± 0.2°; P < .00001), flexion (129.2° ± 10.6° to 138.6° ± 4.4°; P = .00013), and arc of ROM (122.6° ± 13.2° to 138.6° ± 4.4°; P < .00001). Mean lesion size was 81.9 ± 59.3 mm2 (range, 15-225 mm2). All elbows demonstrated radiographic healing postoperatively. Mean time to release to sport was 4.48 ± 1.38 months (range, 2.5-8 months). Six (26.1%) patients changed or stopped their preoperative sporting activity, including 2 of 4 gymnasts and 4 of 11 baseball players. CONCLUSION: Arthroscopic technique with lesion debridement and microfracture or fixation appears safe and results in radiographic healing; however, with these techniques, there remains a high rate of inability to return to sport in patients involved in higher-demand upper extremity activity, such as baseball and gymnastics. Further treatment strategies, including cartilage restoration procedures, may be warranted in this population.

Pediatric and Adolescent Shoulder Instability: Does Insurance Status Predict Delays in Care, Outcomes, and Complication Rate?

BACKGROUND: Recurrent shoulder instability results from overuse injuries that are often associated with athletic activity. Timely diagnosis and treatment are necessary to prevent further dislocations and secondary joint damage. In pediatric and adolescent patients, insurance status is a potential barrier to accessing timely care that has not yet been explored. PURPOSE: To examine the effect of insurance status on access to clinical consultation, surgical intervention, and surgical outcome of pediatric and adolescent patients with recurrent shoulder instability. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: We conducted a retrospective review of pediatric and adolescent patients who were treated at a single tertiary children's hospital for recurrent shoulder instability between 2011 and 2017. Patients were sorted into private and public insurance cohorts. Dates of injury, consultation, and surgery were recorded. Number of previous dislocations, magnetic resonance imaging (MRI) results, surgical findings, and postoperative complications were also noted. Delays in care were compared between the cohorts. The presence of isolated anterior versus complex labral pathology as well as bony involvement at the time of surgery was recorded. The incidences of labral pathology and secondary bony injury were then compared between the 2 cohorts. Postoperative notes were reviewed to compare rates of repeat dislocation and repeat surgery. RESULTS: A total of 37 patients had public insurance, while 18 patients had private insurance. Privately insured patients were evaluated nearly 5 times faster than were publicly insured patients (P < .001), and they obtained MRI scans over 4 times faster than did publicly insured patients (P < .001). Publicly insured patients were twice as likely to have secondary bony injuries (P = .016). Postoperatively, a significantly greater number (24.3%) of publicly insured patients experienced redislocation versus the complete absence of redislocation in the privately insured patients (P = .022). CONCLUSION: Public insurance status affected access to care and was correlated with the development of secondary bony injury and a higher rate of postoperative dislocations. Clinicians should practice with increased awareness of how public insurance status can significantly affect patient outcomes by delaying access to care-particularly if delays lead to increased patient morbidity and health care costs.

Revision ACL Reconstruction in Adolescent Patients.

BACKGROUND: High failure rates have been documented after anterior cruciate ligament reconstruction (ACLR) in pediatric patients, and revision surgery is indicated due to high activity levels of children and adolescents. PURPOSE: To define trends in revision ACLR in patients who underwent initial ACLR at younger than 18 years. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: An electronic medical record was used to retrospectively identify revision ACLR procedures performed by 2 surgeons between the years 2010 and 2016 in patients younger than 18 years at initial reconstruction. Descriptive information, intraoperative findings, surgical techniques, and rehabilitation data were recorded from initial and revision surgeries. Descriptive statistics were used. RESULTS: A total of 32 patients (17 girls, 15 boys) met the inclusion criteria, with a mean age of 15.8 years at initial reconstruction. For initial reconstructions, 15 patients underwent transphyseal procedures, 3 patients underwent adult-type procedures using an anatomic reconstruction technique that did not take into account the physis, and 2 patients underwent partial intraepiphyseal procedures. Graft types included hamstring autograft (n = 17), allograft (n = 5), hybrid (n = 4), and bone-patellar tendon-bone autograft (BTB; n = 3). Average primary reconstruction graft diameter was 8.0 mm (girls, 7.72 mm; boys, 8.36 mm; P = .045). After initial reconstruction, 10 patients had postoperative protocol noncompliance, and 8 patients reported delayed recovery. Mean time to retear was 565 days (range, 25-1539 days). At revision, BTB autograft was used in 50% (n = 16), followed by hamstring autograph (31.3%; n = 10) and allograft (12.5%; n = 4); mean graft diameter was 9.05 mm. Chondral surgery was more common during revision (25% for revision vs 0% for index; P = .031). There were 4 patients who required staged reconstruction with bone grafting. At mean final follow-up of 29.5 months (SD, 22.2 months), there were 3 graft failures (9.4%) and 5 contralateral ACL ruptures (15.6%). CONCLUSION: Most patients with ACL graft failure were adequately treated with a single revision. Conversion from a soft tissue graft to a BTB autograft was the most common procedure. Infrequently, patients required staged reconstructions. Providers should have a high index of suspicion for associated intra-articular injuries resulting from graft failure in adolescent patients.

Incidence of anterior cruciate ligament graft tears in high-risk populations: An analysis of professional athlete and pediatric populations.

BACKGROUND: Professional athletes are at increased risk of injury with high activity levels and additional pressure to return to sports quickly after anterior cruciate ligament (ACL) injury. The purpose of this study was to determine ACL graft re-tear rates in National Basketball Association (NBA), Major League Baseball (MLB), and National Hockey League (NHL) athletes using publicly available databases and to compare these to general populations, National Football League (NFL) athletes, and the pediatric population to establish a baseline for those partaking in high-risk sporting activity. METHODS: A comprehensive online search was performed to identify athletes in the NBA, MLB, and NHL who had a reported ACL tear between 2007 and 2017. For each tear, the type of tear (initial or re-tear) and return to play data were documented. Comparisons of re-tear rates from these leagues to prior registry, meta-analyses, and epidemiologic studies were performed using Fisher's exact or Chi-squared tests. RESULTS: The aggregate re-tear rate was 11.9%. ACL re-tear rates by league did not statistically differ. Return to play rate after index surgery was 95.8%, whereas after a revision procedure was 92.3%. There was a statistically significant difference between the studied ACL re-tear rates (NBA, MLB, NHL) and those of national registries (P < 0.01), and no difference when compared with the pediatric population or with the NFL. CONCLUSIONS: Exposure to higher-risk sporting activity, common to pediatric patients and professional athletes, is a likely major influential factor in ACL re-tear.

Descriptive Epidemiology of Adolescent Clavicle Fractures: Results From the FACTS (Function after Adolescent Clavicle Trauma and Surgery) Prospective, Multicenter Cohort Study.

BACKGROUND: The majority of previous investigations on operative fixation of clavicle fractures have been related to the adult population, with occasional assessments of the younger, more commonly affected adolescent population. Despite limited prospective data for adolescents, the incidence of operative fixation of adolescent diaphyseal clavicle fractures has increased. PURPOSE: To detail the demographic features and descriptive epidemiology of a large pooled cohort of adolescent patients with diaphyseal clavicle fractures presenting to pediatric tertiary care centers in the United States through an observational, prospective, multicenter cohort study (Function after Adolescent Clavicle Trauma and Surgery [FACTS]). STUDY DESIGN: Cross-sectional study; Level of evidence, 4. METHODS: Patients aged 10 to 18 years who were treated for a diaphyseal clavicle fracture between August 2013 and February 2016 at 1 of 8 geographically diverse, high-volume, tertiary care pediatric centers were screened. Treatment was rendered by any of the pediatric orthopaedic providers at each of the 8 institutions, which totaled more than 50 different providers. Age, sex, race, ethnicity, fracture laterality, hand dominance, mechanism of injury, injury activity, athletic participation, fracture characteristics, and treatment decisions were prospectively recorded in those who were eligible and consented to enroll. RESULTS: A total of 545 patients were included in the cohort. The mean age of the study population was 14.1 ± 2.1 years, and 79% were male. Fractures occurred on the nondominant side (56%) more frequently than the dominant side (44%). Sport was the predominant activity during which the injury occurred (66%), followed by horseplay (12%) and biking (6%). The primary mechanism of injury was a direct blow/hit to the shoulder (60%). Overall, 54% were completely displaced fractures, defined as fractures with no anatomic cortical contact between fragments. Mean shortening within the completely displaced group was 21.9 mm when measuring the distance between fragment ends (end to end) and 12.4 mm when measuring the distance between the fragment end to the corresponding cortical defect (cortex to corresponding cortex) on the other fragment (ie, true shortening). Comminution was present in 18% of all fractures. While 83% of all clavicle fractures were treated nonoperatively, 32% of completely displaced fractures underwent open reduction and internal fixation. CONCLUSION: Adolescent clavicle fractures occurred more commonly in male patients during sports, secondary to a direct blow to the shoulder, and on the nondominant side. Slightly more than half of these fractures were completely displaced, and approximately one-fifth were comminuted. Within this large cohort, approximately one-third of patients with completely displaced fractures underwent surgery, allowing for future prospective comparative analyses of radiographic, clinical, and functional outcomes.