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.

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.

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.

Management of Pediatric and Adolescent Sublime Tubercle Injuries: Isolated and Complex Patterns Demonstrate Distinct Etiologies and Radiographic Outcomes.

BACKGROUND: The aim of this study was to assess the patient demographics, epidemiology, mechanism of injury, and natural history of sublime tubercle avulsion injuries. METHODS: A multicenter retrospective study was performed in which sublime tubercle avulsion injuries were identified by surgeon records and database query of radiology reports. Demographic data and imaging were reviewed for each case, and injuries were classified as type 1 (isolated injuries with a simple bony avulsion or periosteal stripping) or type 2 (complex injuries with an associated elbow fracture or dislocation). Treatment modality and evidence of radiographic healing at a minimum of 3 months were collected. RESULTS: Forty patients (78% male) with a median age of 15 years (range, 8 to 19 years) were identified with sublime tubercle avulsion injuries. Sixty-eight percent of cases (n=27) were determined to be type 1 injuries, and 32% (n=13) were classified as type 2 injuries. The majority of type 1 injuries (59%) occurred via a noncontact mechanism in overhead-throwing athletes, whereas 100% of the type 2 injuries were sustained via a contact mechanism. Type 1 injuries presented in a delayed manner in 19% of cases, whereas no type 2 injuries (0%) were delayed in presentation. Type 1 injuries infrequently underwent surgical intervention (19%), whereas 54% of type 2 injuries required surgery. Of those that did not undergo initial surgical management at a minimum of 3-month radiographic follow-up, 9/11 (82%) of type 1 injuries and 0/4 (0%) of type 2 injuries demonstrated evidence of healing. Only 1 case required reoperation (type 2 injury). CONCLUSIONS: This series of adolescents with sublime tubercle avulsion injuries expands our understanding of the epidemiology of this rare injury, which was previously only described as a noncontact injury in baseball players. Type 1 injuries are more likely to occur via a noncontact mechanism and generally demonstrate radiographic evidence of healing after a period of rigid immobilization. Conversely, type 2 injuries are more likely to undergo initial surgical intervention, and those managed nonoperatively are less likely to achieve radiographic healing. Further studies are needed to elucidate treatment protocols and long-term functional outcomes. LEVEL OF EVIDENCE: Level IV-case series.

AP Radiographic Assessment of the Pediatric Pelvis for Developmental Dysplasia of the Hip.

Mastering the art of roentgenographic analysis of the pediatric AP pelvis is paramount in the evaluation of developmental dysplasia of the hip. Understanding the normal radiographic development and the age-dependent changes in normal values allows assessment for pathologic changes. The goal of improving the analysis of the AP pelvis is to increase early detection of disease, assess progress toward normal values, and precisely follow the effects of treatment to improve clinical outcomes.

Intermediate Outcomes of Shoulder Synovial Chondromatosis in an Adolescent Boy: A Case Report.

CASE: Synovial chondromatosis is a rare condition affecting synovial joints. It occurs uncommonly in the shoulder and is rare in the pediatric population. We present a case of a 13-year-old male patient with shoulder pain who was diagnosed with synovial chondromatosis and a posterior labral tear. He was treated with arthroscopic loose body removal, synovectomy, and posterior labral repair and recovered well from the surgery. Four years after the surgery, he developed pain in the same shoulder, but the cause of the pain was not investigated per the patient's decision. CONCLUSION: Synovial chondromatosis should be considered in pediatric patients presenting with shoulder pain and loss of function with potential for recurrence.

Transarticular Versus Retroarticular Drilling of Stable Osteochondritis Dissecans of the Knee: A Prospective Multicenter Randomized Controlled Trial by the ROCK Group.

BACKGROUND: When stable osteochondritis dissecans (OCD) lesions of the femoral condyle in a skeletally immature patient fail to heal with nonoperative methods, the standard of care treatment is condylar OCD drilling. Two primary OCD drilling techniques have been described, but no prospective studies have compared their relative effectiveness. PURPOSE/HYPOTHESIS: The purpose of this study was to compare the healing and function after transarticular drilling (TAD) with that after retroarticular drilling (RAD). It was hypothesized that there would be no difference in rate or time to healing, rate or time to return to sports, patient-reported outcomes (PROs), or secondary OCD-related surgery. STUDY DESIGN: Randomized controlled clinical trial; Level of evidence, 1. METHODS: Skeletally immature patients with magnetic resonance imaging-confirmed stable OCD lesions of the medial femoral condyle who did not demonstrate substantial healing after a minimum of 3 months of nonoperative treatment were prospectively enrolled by 1 of 17 surgeon-investigators at 1 of 14 centers. Patients were randomized to the TAD or RAD group. Tourniquet time, fluoroscopy time, and complications were compared between the treatment groups. Postoperatively, serial radiographs were obtained every 6 weeks to assess healing, and PROs were obtained at 6 months, 12 months, and 24 months. RESULTS: A total of 91 patients were included, consisting of 51 patients in the TAD and 40 patients in the RAD group, who were similar in age, sex distribution, and 2-year PRO response rate. Tourniquet time and fluoroscopy time were significantly shorter with TAD (mean, 38.1 minutes and 0.85 minutes, respectively) than RAD (mean, 48.2 minutes and 1.34 minutes respectively) (P = .02; P = .004). In the RAD group, chondral injury from K-wire passage into the intra-articular space was reported in 9 of 40 (22%) patients, but no associated postoperative clinical sequelae were identified in these patients. No significant differences between groups were detected in follow-up Pediatric-International Knee Documentation Committee, Lysholm, Marx Activity Scale, or Knee injury and Osteoarthritis Outcome Score Quality of Life scores. Healing parameters were superior at 6 months and 12 months in the TAD group, compared with the RAD group, and secondary OCD surgery occurred in 4% of patients who underwent TAD and 10% of patients who underwent RAD (P = .40). Patients in the TAD group returned to sports earlier than those in the RAD group (P = .049). CONCLUSION: TAD showed shorter operative time and fluoroscopy time and superior healing parameters at 6 and 12 months, but no differences were seen in 24-month healing parameters or PROs at all follow-up time points, when compared with RAD. REGISTRATION: NCT01754298 (ClinicalTrials.gov identifier).

Comparing outcomes in the treatment of pediatric and adolescent intraarticular radial head fractures.

Intraarticular radial head (IARH) fractures are uncommon pediatric injuries with unpredictable yet poor outcomes. The aim of this study was to evaluate clinical outcomes of IARH fractures in pediatric and adolescent patients, by testing our hypothesis that surgically managed fractures would have less risk for an unplanned second surgery and better elbow range of motion at the final follow-up. A retrospective review of 53 IARH fractures was performed. Demographic and clinical data were recorded. Concomitant and associated injuries were documented. Initial management and any attempted reduction in the emergency room were documented. The primary outcome was the need for an unplanned second procedure. Motion at final follow-up, presence of pain and need for physical therapy were reviewed. Radiographs were carefully reviewed and analyzed for physeal status, displacement, angulation and percent of radial head involved. We rejected our hypothesis, however, because it was displaced fractures that tended to require an unplanned change in treatment at a higher rate than nondisplaced fractures, regardless of index management with or without surgery. Fracture displacement on the lateral radiograph was a significant risk factor compared to the anterior-posterior images, and younger patients, particularly those with open physis, were at higher risk of an unplanned second procedure. Moreover, 80% of displaced fractures had asymmetric elbow motion after healing was achieved. It is important to counsel patients and families regarding the potential for suboptimal outcomes and elbow stiffness regardless of treatment choice, in the setting of an initially displaced IARH fracture. Level of evidence: Level III.

Meniscal Ramp Lesions in Adolescent Patients Undergoing Primary Anterior Cruciate Ligament Reconstruction: Significance of Imaging and Arthroscopic Findings.

BACKGROUND: Meniscal ramp lesions are associated with anterior cruciate ligament (ACL) injuries and may affect knee stability when left untreated. The diagnostic accuracy of magnetic resonance imaging (MRI) to identify this meniscocapsular injury of the posterior horn of the medial meniscus remains poor, and the arthroscopic findings require vigilance. PURPOSE: To determine the concordance of arthroscopic and MRI findings to better identify the presence of a ramp lesion in children and adolescent patients undergoing primary ACL reconstruction. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: Patients aged <19 years who underwent primary ACL reconstruction at a single institution between 2020 and 2021 were included. Two cohorts were developed by the presence of a ramp lesion arthroscopically. Basic patient descriptive data, preoperative imaging (radiologist assessment and independent reviewer assessment), and concomitant arthroscopic findings at the time of ACL reconstruction were recorded. RESULTS: An overall 201 adolescents met criteria with a mean age of 15.7 years (range, 6.9-18.2) at the time of injury. A ramp lesion was identified in 14% of patients (28 children). No differences were detected between cohorts with regard to age, sex, body mass index, weeks from injury to MRI, or weeks from injury to surgery (P > .15). The primary predictor of an intraoperative ramp lesion was the presence of medial femoral condylar striations, with an adjusted odds ratio of 722.2 (95% CI, 59.5-8768.2; P < .001); the presence of a ramp lesion on MRI had an adjusted odds ratio of 11.1 (95% CI, 2.2-54.8; P = .003). Patients with neither a ramp lesion on MRI nor medial femoral condylar striations had a 2% rate (2/131) of ramp lesion; those with either of the significant risk factors had a 24% rate (14/54). All patients with both risk factors (100%; n = 12) had a ramp lesion noted on intraoperative examination. CONCLUSION: The concordance of medial femoral condylar chondromalacia, particularly striations, noted during arthroscopy and posteromedial tibial marrow edema on MRI with or without direct evidence of posterior meniscocapsular pathology should increase suspicion for the presence of a ramp lesion in adolescents undergoing ACL reconstruction.

Intermediate-term Outcomes in Adolescent Recurrent Ankle Instability Managed With a Modified Broström-Gould Procedure Augmented With Distal Fibular Periosteum Incorporation.

BACKGROUND: Once a child has developed chronic ankle instability with recurrent events despite conservative treatment, then ligamentous repair is warranted. We utilize a modification of the modified Broström-Gould technique that further incorporates the distal fibular periosteum into the construct. The purpose of this study was to describe the intermediate-term outcomes of our modified Broström-Gould technique for chronic lateral ankle instability in childhood athletes. METHODS: A retrospective review of children who underwent the surgical technique over a 10-year time period (2010 to 2019) was performed, excluding those with <2 years of follow-up. Demographic, surgical, and clinical data were recorded, as well as outcome scores: (1) the Marx activity scale, (2) University of California, Los Angeles activity score, and (3) foot and ankle outcomes score. Recurrent instability events, repeat surgeries, satisfaction with the surgical experience, and return to sport (if applicable) were also recorded. RESULTS: Forty-six children (43 females) with 1 bilateral ankle met the criteria with a mean age at surgery of 14.8 years, and a mean follow-up duration of 4.9 years. The mean Marx activity score was 9.0±5.1, the mean University of California, Los Angeles score was 8.3±1.8, and the mean total foot and ankle outcomes score was 84.0±15.6. Twenty-six ankles (55.3%) reported having at least 1 recurrent episode of instability and 6 of the ankles (12.8%) underwent revision surgery between 3.5 months and 6.5 years of the index procedure. Thirty-nine (84.8%) patients responded that they would undergo our surgery again. CONCLUSION: A modified Broström-Gould procedure can be performed in children with the incorporation of the adjacent periosteum, but recurrence of instability is distinctly possible with longer follow-up with a risk for revision surgery despite good subjective outcomes. LEVEL OF EVIDENCE: Level IV; retrospective case series.

Age, Sex, and BMI Differences Related to Repairable Meniscal Tears in Pediatric and Adolescent Patients.

BACKGROUND: The incidence of meniscus tears and ACL tears in pediatric patients continues to rise, bringing to question the risk factors associated with these injuries. As meniscus tears are commonly repaired in pediatric populations, the epidemiology of repairable meniscus tears is an important for consideration for surgeons evaluating treatment options. PURPOSE: To describe meniscal tear patterns in pediatric and adolescent patients who underwent meniscal repair across multiple institutions and surgeons, as well as to evaluate the relationship between age, sex, and body mass index (BMI) and their effect on the prevalence, type, and displacement of repaired pediatric meniscal tears. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Data within a prospective multicenter cohort registry for quality improvement, Sport Cohort Outcome Registry (SCORE), were reviewed to describe repaired meniscal tear patterns. All consecutive arthroscopic meniscal repairs from participating surgeons in patients aged <19 years were analyzed. Tear pattern, location, and displacement were evaluated by patient age, sex, and BMI. A subanalysis was also performed to investigate whether meniscal tear patterns differed between those occurring in isolation or those occurring with a concomitant anterior cruciate ligament (ACL) injury. Analysis of variance was used to generate a multivariate analysis of specified variables. Sex, age, and BMI results were compared across the cohort. RESULTS: There were 1185 total meniscal repairs evaluated in as many patients, which included 656 (55.4%) male and 529 (44.6%) female patients. Patients underwent surgery at a mean age of 15.3 years (range, 5-19 years), with a mean BMI of 24.9 (range, 12.3-46.42). Of the 1185 patients, 816 (68.9%) had ACL + meniscal repair and 369 (31.1%) had isolated meniscal repair. The male patients underwent more lateral tear repairs than the female patients (54.3% to 40.9%; P < .001) and had a lower incidence of medial tear repair (32.1% vs 41.4%; P < .001). Patients with repaired lateral tears had a mean age of 15.0 years, compared with a mean age of 15.4 years for patients with repaired medial or bilateral tears (P = .001). Higher BMI was associated with "complex" and "radial" tear repairs of the lateral meniscus (P < .001) but was variable with regard to medial tear repairs. CONCLUSION: In pediatric and adolescent populations, the data suggest that the surgical team treating knees with potential meniscal injury should be prepared to encounter more complex meniscal tears, commonly indicated in those with higher BMI, while higher rates of lateral meniscal tears were seen in male and younger patients. Future studies should analyze correlates for meniscal repair survival and outcomes in this pediatric cohort undergoing knee surgery.

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).

Factors influencing surgical decision-making in pediatric and adolescent scaphoid fractures.

We aimed to assess the risk of conversion to surgical intervention in children initially managed with casting for an isolated scaphoid fracture with a secondary aim of assessing the incidence and management of occult scaphoid fractures without signs of fracture on initial radiographs. A retrospective review was performed. Our primary outcome was conversion to surgery. Subsequent evidence of fracture in those with only initial snuffbox tenderness was recorded for the secondary aim. Three hundred and eighty-four wrists with radiographic evidence of a scaphoid fracture were included. Twenty-one scaphoid fractures failed conservative treatment. Subjects that failed cast treatment were older than those that did not (15.9 years vs. 14.0 years; P < 0.001). Subjects with a delay in treatment of at least 6 weeks from injury were 8× more likely to require surgery than those with prompt treatment ( P < 0.001). Surgical conversion varied based on fracture location: distal pole 0.7%, waist 7.4%, and proximal pole 23.5% of the time ( P < 0.001). A total of 14% of wrists managed in a cast without radiographic evidence of fracture at presentation subsequently demonstrated a fracture on follow-up films. The primary predictor of failed conservative treatment is a delay in presentation. We found that the sequelae of delay in presentation or diagnosis of a scaphoid fracture increased the likelihood of requiring surgery. Therefore, clinical suspicion should dictate early management and these factors should play a role in determining when to initiate casting in the setting of pediatric scaphoid fractures. Level of evidence: III.

Improving Lower Extremity Casting Quality by Providing an Experienced Assistant in Pediatric Tibia Fractures Managed by Trainees.

Background: The value of employing an orthopedic technician or advanced practice provider (OT/APP) to assist trainees during on-call hours has not been assessed. As the third most common pediatric long bone fracture, most tibial fractures can be managed with closed reduction and casting. Purpose: We sought to determine whether clinical outcomes could be positively affected for traumatic childhood tibia fractures by using an experienced OT/APP to aid orthopedic surgery residents with closed reduction and casting. Methods: We performed a retrospective chart review of tibial shaft fractures that occurred between 2010 and January 2017. Fractures undergoing manipulation and closed reduction by orthopedic surgery residents (post-graduate year 2 to 4) in the emergency department were included and differentiated into 2 cohorts: (1) residents who performed the procedure alone and (2) residents who were assisted by an OT/APP. Comparisons in cast quality and treatment success were made using univariate statistics followed by a multivariate Classification and Regression Tree (CART) analysis. Results: Of the 73 patients who met our criteria, 38 received treatment by a resident alone and 35 by a resident assisted by an OT/APP. Evidence to support our hypothesis was found with the resident-alone group "over" padding the casts posteriorly. Univariate analysis demonstrated that the rate of subsequent surgical intervention was more than double in the resident-alone group (31% vs 14%), yet OT/APP castings underwent more wedging at follow-up (17% vs 0%). CART analysis revealed initial fracture severity and lack of OT/APP assistance as predictors of surgical intervention with terminal nodes, in increasing order of risk of requiring surgical intervention: lower translation on sagittal and anteroposterior (AP), lower sagittal translation with greater AP translation, greater sagittal translation with OT/APP assistance, and greater sagittal translation without assistance. The initiation of a cast application-training program in 2015 decreased the need for surgical treatment in the resident-only group (pre-program 38.5% vs post-program 17%), although this was not statistically significant. Conclusion: When residents were assisted by OT/APP with initial tibia closed reduction and casting, subsequent loss of reduction was more likely to be managed with cast wedging; when this assistance was not available, there was a higher rate of fractures needing surgical intervention due, in part, to poor casting technique. The reduction in the rate of surgical intervention after an internal training program was implemented suggests that trainees may improve their casting ability without added help of an experienced assistant. Future study should be performed on distal radius fractures to determine if the presented findings are valid across casting types.

A comparison of cone beam computed tomography, standard computed tomography and plain radiographs in the evaluation of medial epicondyle humerus fractures.

The ideal technique to measure medial epicondyle humerus fracture displacement minimizes radiation exposure while maximizing measurement accuracy and reliability. This study compares the radiation exposure and accuracy of displacement measurements of the four-view X-ray examination (XR), computed tomography (CT) and in-clinic cone-beam CT (CBCT). A cadaveric humerus underwent medial epicondyle osteotomy. The fragment was fixed to the humerus at clinically relevant displacements (6 to 18 mm). Dosimeters were placed around the distal humerus and simulating thyroid location. XR, CT and CBCT were performed at each displacement. Four pediatric orthopedists measured the maximum linear displacement on each XR and 3D reconstruction of the CT and CBCT images. Focal (elbow location) and thyroid radiation exposure was compared between modalities. Intra- and interclass correlation coefficients (ICC) for displacement measurements were determined. Mean focal radiation exposures for XR, CT and CBCT were 0.008, 2.061 and 0.478 rad, respectively (P = 0.001). Exposures 10 inches from the elbow for XR, CT and CBCT were 0.001, 0.066 and 0.010 rad, respectively (P = 0.006). At 12 inches, there was no significant difference in exposure between XR and CBCT ( P = 0.114). Intra- and interobserver reliabilities were excellent for all measures, except lateral x-ray. CBCT and CT had significantly less deviation from the actual displacement compared to XR ( P < 0.05). In-office CBCT of the elbow exposes patients to significantly less radiation than conventional CT. All X-ray images (except lateral), CT and CBCT had equal reliability in evaluating medial epicondyle fractures, which contrasts with previous evidence.

Outcomes in Unicameral Bone Cyst Management Utilizing a Decision Tree Algorithm Approach.

OBJECTIVE: To determine if utilization of a decision tree algorithm could improve the healing rate of unicameral bone cysts (UBCs). METHODS: Creation of the decision tree algorithm was based on previous literature and assessment of our clinical practice. Demographic, treatment, and radiographic data were collected retrospectively. Radiographic healing was determined using the Neer classification. Healing rate, as well as clinical/radiographic characteristics, were compared based on adherence to the treatment algorithm. RESULTS: Forty-seven subjects were included. Mean age at initial surgery was 10.0 ± 3.3 years in children following the algorithm and 9.1 ± 3.2 years in those deviating from the algorithm (p = 0.393). Follow-up was found to be similar among those following the algorithm (37.5 ± 15.8 months) and those deviating from the algorithm (45.2 ± 24.6 months), p = 0.38. Children who followed the algorithm healed at a rate of 75%, while children who deviated from the algorithm healed at a rate 67% (p = 0.552). CONCLUSIONS: Although we reject our hypothesis that a decision tree algorithm for the management of UBCs in the pediatric population could improve the healing rate, we believe that we uncovered some utility in applying an algorithm to this pathology. Our algorithm was designed to minimize risk to the child and maximize healing with the least number of surgical events. Treating surgeons should consider this proposed pathway to determine the best treatment and to help families understand that these lesions rarely heal with a single-event surgery.

Descriptive Epidemiology From the Research in Osteochondritis Dissecans of the Knee (ROCK) Prospective Cohort.

BACKGROUND: Osteochondritis dissecans (OCD) occurs most commonly in the knees of young individuals. This condition is known to cause pain and discomfort in the knee and can lead to disability and early knee osteoarthritis. The cause is not well understood, and treatment plans are not well delineated. The Research in Osteochondritis Dissecans of the Knee (ROCK) group established a multicenter, prospective cohort to better understand this disease. PURPOSE: To provide a baseline report of the ROCK multicenter prospective cohort and present a descriptive analysis of baseline data for patient characteristics, lesion characteristics, and clinical findings of the first 1000 cases enrolled into the prospective cohort. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Patients were recruited from centers throughout the United States. Baseline data were obtained for patient characteristics, sports participation, patient-reported measures of functional capabilities and limitations, physical examination, diagnostic imaging results, and initial treatment plan. Descriptive statistics were completed for all outcomes of interest. RESULTS: As of November 2020, a total of 27 orthopaedic surgeons from 17 institutions had enrolled 1004 knees with OCD, representing 903 patients (68.9% males; median age, 13.1 years; range, 6.3-25.4 years), into the prospective cohort. Lesions were located on the medial femoral condyle (66.2%), lateral femoral condyle (18.1%), trochlea (9.5%), patella (6.0%), and tibial plateau (0.2%). Most cases involved multisport athletes (68.1%), with the most common primary sport being basketball for males (27.3% of cases) and soccer for females (27.6% of cases). The median Pediatric International Knee Documentation Committee (Pedi-IKCD) score was 59.9 (IQR, 45.6-73.9), and the median Pediatric Functional Activity Brief Scale (Pedi-FABS) score was 21.0 (IQR, 5.0-28.0). Initial treatments were surgical intervention (55.4%) and activity restriction (44.0%). When surgery was performed, surgeons deemed the lesion to be stable at intraoperative assessment in 48.1% of cases. CONCLUSION: The multicenter ROCK group has been able to enroll the largest knee OCD cohort to date. This information is being used to further understand the pathology of OCD, including its cause, associated comorbidities, and initial presentation and symptoms. The cohort having been established is now being followed longitudinally to better define and elucidate the best treatment algorithms based on these presenting signs and symptoms.