Pre-operative gait kinematics and kinetics do not change following surgery in adolescent patients with femoroacetabular impingement.

BACKGROUND: Femoroacetabular impingement (FAI) is a condition where the femoral head-neck junction collides with the acetabulum. Open or arthroscopic treatment of FAI aims to increase hip motion while reducing impingement during passive or dynamic movements. RESEARCH QUESTION: What are the biomechanical characteristics of the hip and pelvis in adolescents and young adults diagnosed with FAI syndrome 1) pre-operatively compared to controls and 2) pre- to post-operatively? METHODS: 43 patients with FAI and 43 controls were included in the study. All patients with FAI had cam deformities and underwent unilateral hip preservation surgery (either open or arthroscopic). Pre- and post-operative imaging, patient-reported outcomes, and gait analysis were performed. Joint angles and internal joint moments were evaluated with an emphasis on the pelvis and hip. A comparative analysis was conducted to evaluate the gait patterns before and after surgical treatment, as well as to compare pre-operative gait patterns to a control group. RESULTS: 43 patients with FAI (28 female, 16.5 ± 1.5 yrs) and 43 controls (28 female, 16.0 ± 1.5 yrs) were included. Pre-operative patients with FAI had decreased stride length and walking speed compared to controls, with no significant change following surgery. There were no differences in sagittal and coronal plane hip and pelvis kinematics comparing pre- to post-operative and pre-operative to controls. Pre-operatively, differences in internal hip rotation angle (pre: 3.3˚, post: 3.9˚, controls: 7.7˚) and hip extensor moment (pre: 0.121, post: 0.090, controls: 0.334 Nm/kg) were observed compared to controls with no significant changes observed following surgery. SIGNIFICANCE: Compensatory movement strategies in pelvic and hip motion are evident during gait in patients with FAI, particularly in the sagittal and transverse planes. These strategies remained consistent two years post-surgery. While surgery improved radiographic measures and patient-reported outcomes, gait did not elicit biomechanical changes following surgical treatment.

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.

Differences in Short-Term Sport-Specific Functional Recovery After Primary ACL Reconstruction in the Adolescent Athlete.

BACKGROUND: Although anterior cruciate ligament (ACL) injury rates have been studied extensively, it is unclear whether levels of functional and psychological readiness for return-to-sport after primary ACL reconstruction (ACLR) differ based on an athlete's primary sport. HYPOTHESIS: Youth athletes in different primary sports will demonstrate differences in short-term functional recovery, as well as patient-reported psychological and functional recovery after primary ACLR. STUDY DESIGN: Retrospective cohort study of consecutive patients treated for ACL injury in pediatric sports medicine clinics. LEVEL OF EVIDENCE: Level 3. METHODS: Patients included underwent primary ACLR between December 1, 2015 and December 31, 2019 and reported sports participation at the time of injury. Demographic data, sports participation, surgical data, functional testing scores (Y-Balance Test [YBT]), functional and psychological patient-reported outcome measures (PROMs), and timing of return-to-play clearance were reviewed. YBT scores were the primary metric for clearance. Four groups were studied: soccer, football, basketball, and other. RESULTS: A total of 220 male and 223 female athletes were included; 65.28% of soccer players were female and 100% of football players were male (P < 0.01). At initial postoperative YBT testing (6-9 months), soccer players had higher operative (P < 0.01) and nonoperative (P < 0.01) leg composite scores when compared with basketball players. No significant differences were found between sports in functional or psychological PROMs at presurgical baseline or 6 months postoperatively. When compared with football, soccer players completed functional clearance in a shorter time from surgery (P = 0.02). Multivariate analysis showed level of competition as a significant independent variable for clearance in female athletes. CONCLUSION: After primary ACLR, athletes, especially female athletes, demonstrated short-term sport-specific differences in YBT scores. Soccer players attained clearance sooner than football players. Level of competition influenced YBT composite scores in all athletes and time to clearance in female athletes. CLINICAL RELEVANCE: Sport-specific differences in reinjury should be investigated to determine whether changes in return-to-play evaluation should be implemented.

Tibial Spine Fractures in the Child and Adolescent Athlete: A Systematic Review and Meta-analysis.

BACKGROUND: Tibial spine fractures (TSFs) are uncommon injuries that may result in substantial morbidity in children. A variety of open and arthroscopic techniques are used to treat these fractures, but no single standardized operative method has been identified. PURPOSE: To systematically review the literature on pediatric TSFs to determine the current treatment approaches, outcomes, and complications. STUDY DESIGN: Meta-analysis; Level of evidence, 4. METHODS: A systematic review of the literature was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) guidelines using PubMed, Embase, and Cochrane databases. Studies evaluating treatment and outcomes of patients <18 years old were included. Patient demographic characteristics, fracture characteristics, treatments, and outcomes were abstracted. Descriptive statistics were used to summarize categorical and quantitative variables, and a meta-analytic technique was used to compare observational studies with sufficient data. RESULTS: A total of 47 studies were included, totaling 1922 TSFs in patients (66.4% male) with a mean age of 12 years (range, 3-18 years). The operative approach was open reduction and internal fixation in 291 cases and arthroscopic reduction and internal fixation in 1236 cases; screw fixation was used in 411 cases and suture fixation, in 586 cases. A total of 13 nonunions were reported, occurring most frequently in Meyers and McKeever type III fractures (n = 6) and in fractures that were treated nonoperatively (n = 10). Arthrofibrosis rates were reported in 33 studies (n = 1700), and arthrofibrosis was present in 190 patients (11.2%). Range of motion loss occurred significantly more frequently in patients with type III and IV fractures (P < .001), and secondary anterior cruciate ligament (ACL) injury occurred most frequently in patients with type I and II fractures (P = .008). No statistically significant differences were found with regard to rates of nonunion, arthrofibrosis, range of motion loss, laxity, or secondary ACL injury between fixation methods (screw vs suture). CONCLUSION: Despite variation in TSF treatment, good overall outcomes have been reported with low complication rates in both open and arthroscopic treatment and with both screw and suture fixation. Arthrofibrosis remains a concern after surgical treatment for TSF, but no significant difference in incidence was found between the analysis groups. Larger studies are necessary to compare outcomes and form a consensus on how to treat and manage patients with TSFs.

Risk Factors for Suboptimal Outcome of FAI Surgery in the Adolescent Patient.

BACKGROUND: Surgical treatment for adolescent patients with femoroacetabular impingement (FAI) is increasing. The purpose of this study was to determine the clinical outcomes of FAI surgery in a multicenter cohort of adolescent patients and to identify predictors of suboptimal outcomes. METHODS: One hundred twenty-six adolescent hips (114 patients < 18 years of age) undergoing surgery for symptomatic FAI were studied from a larger multicenter cohort. The group included 74 (58.7%) female and 52 male hips (41.3%) with a mean age of 16.1 (range 11.3 to 17.8). Clinical outcomes included the modified Harris Hip Score (mHHS), Hip disability and Osteoarthritis Outcome Score (5 domains), and University of California Los Angeles activity score. Failure was defined as revision surgery or clinical failure (inability to reach minimally clinical important differences or patient acceptable symptoms state for the mHHS). Statistical analysis was used to identify factors significantly associated with failure. RESULTS: There was clinically important improvement in all patient-reported outcomes for the overall group, but an 18.3% failure rate. This included a revision rate of 8.7%. Females were significantly more likely than males to be classified as a failure (25.7 vs. 7.7%, P =0.01), in part because of lower preoperative mHHS (59.1 vs. 67.0, P < 0.001). Mild cam deformity (alpha angle <55 degrees) was present in 42.5% of female hips compared with 17.3% male hips. Higher alpha angles were inversely correlated with failure. Alpha angles >63 have a failure rate of 8.3%, between 55 and 63 degrees, 12.0% failure rate, and <55 degrees (mild cam) failure rate of 37.5%. Patients who participated in athletics had a 10.3% failure rate compared with nonathletes at 25.0% ( P =0.03, RR (relative risk) 2.4). CONCLUSIONS: Adolescent patients undergoing surgical treatment for FAI generally demonstrate significant improvement. However, female sex, mild cam deformities, and lack of sports participation are independently associated with higher failure rates. These factors should be considered in surgical decision-making and during patient counseling. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Comparison of Gait and Functional Outcomes Between Open and Arthroscopic Treatment of Adolescent and Young Adult Femoroacetabular Impingement.

BACKGROUND: Management of femoroacetabular impingement (FAI) through an arthroscopic or surgical hip dislocation (SHD) approach has been shown to have similar clinical success and patient-reported outcomes. However, there are limited data comparing functional outcomes. The purpose of this study was to compare gait and functional outcomes of adolescent/young adult patients with FAI treated by either an arthroscopic or open SHD approach. METHODS: We identified prospectively enrolled adolescent/young adult patients (≤20 years old) who underwent surgical treatment for FAI through an SHD or arthroscopic approach. Participants were evaluated in a movement science lab preoperatively and postoperatively (minimum 8 months postoperatively) with barefoot walking and a 30-second single-limb balance trial on the affected side. Participants also completed the Harris Hip Score at the same timepoints. Differences from preoperative to postoperative were determined using a paired-samples t test for each surgical technique, and differences between the SHD and arthroscopic groups were determined using an independent samples t test (α=0.05). RESULTS: Fifty-five participants (42F, 16.2±1.4 y) were tested and grouped by surgical intervention. The SHD and arthroscopy groups consisted of 28 and 27 participants, respectively, with no significant difference between the SHD and arthroscopic cohorts in age (16.4±1.2 vs. 15.9±1.5 y, respectively, P =0.218) or sex distribution (78.6% vs. 74.1% females, respectively, P =0.75). Each group demonstrated significant postoperative improvement in Harris Hip Score (SHD: 64.8±16.4 to 81.8±17.8; arthroscopy: 57.0±16.7 to 84.7±19.7; preoperatively to postoperatively, respectively, both P <0.001). During gait, increased maximum hip flexion was observed following surgical intervention for the SHD group (32.3±5.7 vs. 36.1±5.2, P =0.003). No other clinically significant changes were detected in the SHD or arthroscopic groups preoperatively to postoperatively in trunk, pelvis, or hip kinematics in the coronal plane. During the balance task, neither cohort demonstrated markers of clinically significant abductor dysfunction. However, post operatively, the arthroscopy group was able to balance longer than the SHD group (18.8±7.8 vs. 14.2±2.7 s, respectively, P =0.008), although no differences were detected in trunk or pelvis position in the coronal plane during balance. CONCLUSIONS: Both open SHD and arthroscopic treatment of FAI resulted in improved clinical outcomes with no clinically significant abductor dysfunction 1 year post operatively. However, further study is needed to determine whether more dynamic tasks can potentially elicit subtle differences between the groups. LEVELS OF EVIDENCE: Level II-prospective study.

Soft Tissue Cam Impingement in Adolescents: MRI Reveals Impingement Lesions Underappreciated on Radiographs.

BACKGROUND: Femoroacetabular impingement (FAI) has been described as repetitive and abnormal contact between a structurally abnormal proximal femur (cam) and/or acetabulum (pincer), occurring during the terminal range of motion of the hip. While cam and pincer lesions have traditionally been defined as osseous abnormalities, there may be a subset of adolescent patients whose impingement is primarily soft tissue (nonosseous). The existence of a nonosseous cam lesion in adolescents with FAI has not been well described. PURPOSE: To identify and characterize a series of adolescent patients with nonosseous (soft cam) FAI identified on magnetic resonance imaging (MRI) and compare these patients' clinical presentation and outcome with those of a cohort with primary osseous cam FAI in the same age group. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A prospective institutional registry of patients with symptomatic FAI was reviewed. Patients were included if they had an MRI scan and a lateral radiograph of the hip (45° Dunn or frog) at a baseline visit. On MRI, the anterolateral femoral head was evaluated using radial, coronal, sagittal, or axial oblique sequences. A soft cam lesion was identified by the presence of soft tissue thickening of ≥2 mm at the anterolateral femoral head-neck junction. An alpha angle was measured on MRI scans and radiographs when a lesion was identified. The cohort with soft cam lesions was reviewed and findings and outcomes were compared with those of a cohort with osseous cam lesions. Continuous variables were first examined for normality, and then nonparametric tests-such as the Kruskal-Wallis test-were considered. The change between pre- and postoperative patient-reported outcomes (PROs) was described by mean and standard deviation and evaluated with an independent-samples t test. RESULTS: A total of 31 (9.3%) of 332 hips (mean age, 16.4 years [range 13.1-19.6 years]; women, 83.9%) were identified with a soft tissue impingment lesion on MRI at the femoral head-neck junction between the 12 and 3 o'clock positions. These lesions demonstrated a thickened perichondral ring (71%), periosteal thickening (26%), or a cartilaginous epiphyseal extension (3%). The mean alpha angle on MRI was greater than on radiographs (63.5°± 7.9° vs 51.3°± 7.9°; P < .0001). A total of 22 patients (71%) with soft impingement underwent hip preservation surgery. When compared with patients in the osseous cohort who also underwent surgical management, both groups showed similar significant improvements from pre- to postoperatively (soft: modified Harris Hip Score [mHHS], 26.9 ± 18.2; Hip disability and Osteoarthritis Outcome Score [HOOS], 31.4 ± 22.9; osseous: mHHS, 22.8 ± 20.8; HOOS, 27.4 ± 20.1; P < .0001), with a mean follow-up of 3.4 years (range, 1-7 years) in the soft cam cohort and 3 years (1-10.1 years) in the osseous cam cohort. CONCLUSION: Clinicians should be aware of nonosseous or soft cam lesions that cause impingement in adolescent patients without an obvious osseous cam on radiographs. MRI is required to detect these soft cam lesions. When nonoperative treatment fails, the PROs in these patients after operative management are comparable with those in patients with osseous cam lesions. Further research is needed to determine whether the soft cam precedes an osseous cam or whether it is a separate entity.

Elective musculoskeletal surgery is associated with postoperative weight changes in pediatric and adolescent patients.

Purpose: Patients of elective orthopedic surgeries often reduce activity levels during postoperative recovery. It is unclear whether these extended periods of modified activities lead to weight changes. The purpose of this study was to evaluate changes in body mass index percentile in pediatric patients over 2.5 years following primary musculoskeletal surgeries. Methods: Institutional records for utilized current procedural terminology codes were used to identify patients aged 21 years or younger who underwent elective surgery at a single pediatric orthopedic institution between October 2016 and December 2018. Non-primary surgeries and patients without preoperative body mass index measurements were excluded. Demographic characteristics, height, weight, and body mass index within 30 months of surgery were collected. Body mass index relative to age was calculated. Analysis of body mass index changes at follow-up intervals of 3-7, 9-18, and 24-30 months after surgery was performed for the overall sample, within surgical categories, and within preoperative weight classifications. Results: A total of 1566 patients (53.1% female, average age 12.4 years) were included. Over one-third of patients were overweight or obese at presentation. The average change in body mass index percentile relative to baseline was increased at all follow-up intervals. Values reached significance at 9-18 months (p = .002) and 24-30 months (p = .001). While underweight and normal-weight patients had increased body mass index at all three timepoints, overweight or obese patients decreased. Conclusions: Patients undergoing elective orthopedic procedures may experience significant changes in body mass index percentile postoperatively. At extremes of weight, patients experience improvement toward the mean, but most patients may undergo body mass index increases beyond what would be expected during normal growth. Level of evidence: Retrospective level III.

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.

Suture-Bridge Fixation of Osteochondral Fractures and Osteochondritis Dissecans in the Knee: Excellent Rates of Early Lesion Stability and Osseous Union.

BACKGROUND: Preservation of articular cartilage in the setting of acute or chronic injury in the adolescent and young adult knee is paramount for long-term joint health. Achieving osseous union, minimizing implant-related injury, and eliminating the need for reoperation for traumatic chondral and osteochondral lesions (OCLs) and osteochondritis dissecans (OCD) remain a challenge for the orthopaedic surgeon. PURPOSE: To evaluate radiographic healing, patient-reported outcomes, and short-term complications after suture-bridge fixation of chondral fragments, osteochondral fractures, and OCD lesions in the knee. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: The study included consecutive patients (38 patients, 40 knees) treated within a single academic sports medicine institution who underwent suture-bridge fixation of an OCL or an OCD lesion of the knee from initiation of the technique in October 2019 through March 2021. The suture-bridge technique entailed bioabsorbable knotless anchors placed on the outside margins of the lesion with multiple strands of hand-tensioned absorbable (No. 0 or No. 1 Vicryl) or nonabsorbable (1.3-mm braided polyester tape) bridging suture. Healing was assessed by radiography and magnetic resonance imaging (MRI), with MRI scans obtained on all OCD lesions and any chondral-only lesions. MRI scans were available for 33 of 40 (82.5%) knees within 1 year of surgery and were evaluated for lesion healing. Complications and rates and timing of return to sport were evaluated. Patient-reported outcomes in the OCD cohort were evaluated with the Knee injury and Osteoarthritis Outcome Score (KOOS) to determine early pain and functional improvement. RESULTS: In total, 33 (82.5%) lesions demonstrated full union, and no lesions failed treatment. MRI assessment of healing (mean, 5.8 months; range, 3-12 months) demonstrated 9 (64.3%) OCD lesions with full union, 5 (35.7%) OCD lesions with stable union, and no OCD lesions with nonunion. Of the OCLs, 17 (89.5%) had full union, 2 (10.5%) had stable union, and none had nonunion. The 7 bony OCLs without an MRI scan demonstrated complete radiographic union. In 30 (75.0%) lesions, patients returned to sports at a mean of 6.5 months (range, 3.8-10.2 months). KOOS Activities of Daily Living, Pain, Quality of Life, and Symptoms scores demonstrated significant improvement from baseline at 6 months and at 1 year. There were 2 (5%) complications, consisting of reoperation for marginal chondroplasty on an otherwise stable lesion, and re-operation for intial un-treated patellar instability, with no reoperations for failure or revision of the suture-bridge construct. CONCLUSION: In this series of OCLs and OCD lesions of the knee, suture-bridge fixation demonstrated excellent rates of MRI and radiographic union and good early outcomes with minimal short-term complications. This technique may be used for lesion salvage as an alternative to metallic and nonmetallic screw/tack constructs in the treatment of these challenging lesions. Longer term follow-up and investigation are warranted.

Faster Rate of Correction with Distal Femoral Transphyseal Screws Versus Plates in Hemiepiphysiodesis for Coronal-Plane Knee Deformity: Age- and Sex-Matched Cohorts of Skeletally Immature Patients.

BACKGROUND: Hemiepiphysiodesis (guided-growth) procedures have become the primary method of treatment for coronal-plane knee deformities in skeletally immature patients. Two leading techniques involve the use of a transphyseal screw or a growth modulation plate. However, clinical references for the estimation of correction are lacking, and no consensus has been reached regarding the superiority of one technique over the other. Therefore, the purpose of this study was to compare the rates of correction for distal femoral transphyseal screws and growth modulation plates in age- and sex-matched cohorts with coronal deformities. METHODS: Thirty-one knees were included in each cohort on the basis of propensity scoring by chronological age and sex, and radiographic images were retrospectively reviewed preoperatively and postoperatively. Each case was measured for limb length, mechanical axis deviation (MAD), mechanical lateral distal femoral angle (LDFA), and bone age. RESULTS: Both the MAD and LDFA rate of correction significantly differed between the screw and plate cohorts. The MAD rate of correction was observed to be 0.42 ± 0.37 mm/week (1.69 mm/month) in the plate cohort and 0.66 ± 0.51 mm/week (2.64 mm/month) in the screw cohort. The LDFA rate of correction was observed to be 0.12° ± 0.13°/week (0.50°/month) in the plate cohort and 0.19° ± 0.19°/week (0.77°/month) in the screw cohort. CONCLUSIONS: The current study provides simple clinical references for the rate of correction of MAD and the LDFA for 2 methods of hemiepiphysiodesis. The results suggest that transphyseal screws may correct coronal knee deformities during the initial treatment stage more quickly than growth modulation plates in distal femoral guided growth. LEVEL OF EVIDENCE: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Atypical Shoulder Instability Patterns in Adolescents Following Traumatic Anterior Shoulder Dislocation.

BACKGROUND: Traumatic anterior shoulder instability is common in the adolescent athlete, and when it is untreated, the recurrence rate is high. Atypical lesions-such as anterior glenoid periosteal sleeve, humeral glenohumeral ligament, and insertional tendon avulsions-may occur within this population, and accurate diagnosis and appropriate lesion management are key to treatment success. PURPOSE: To evaluate the age, skeletal immaturity, bone loss, and uncommon soft tissue lesions as correlates of posttraumatic anterior shoulder instability lesion patterns in an adolescent population. STUDY DESIGN: Cross-sectional study, Level of evidence, 3. METHODS: Consecutive patients ≤18 years of age (160 shoulders) treated within a single institution for traumatic anterior shoulder instability between June 2013 and June 2021 were reviewed. Demographics, injury mechanism, radiographic and magnetic resonance imaging of lesions, the presence of any bone loss, operative findings, and physeal status were recorded. An overall 131 shoulders met the inclusion criteria. Instability lesion type was analyzed categorically by age <15 or ≥15 years; individual age was assessed for correlation with any bone loss present. Atypical lesions-anterior labral periosteal sleeve avulsion, humeral avulsion of the glenohumeral ligament, subscapularis avulsion-were assessed for correlations with age, open physeal status, and the presence of any bone loss. RESULTS: An overall 131 shoulders (mean, 15.3 years; range, 10.5-18.3) were identified for this study: 55 in patients <15 years old and 76 in patients ≥15 years old. Bony injuries such as Bankart and Hill-Sachs lesions were more common in the ≥15-year-old group (P = .044 and P = .024, respectively). Bony Bankart injuries were found at a rate of 18.2% in the <15-year-old group, as compared with 34.2% in the ≥15-year-old group (P < .05). Anterior labral periosteal sleeve avulsions were more common in the <15-year-old group (n = 13 [23.6%] vs n = 8 [10.5%]; P < .044), as were all atypical lesions combined (n = 23 [41.8%] vs n = 13 [17.1%]; P < .0018]. CONCLUSION: In this series of anterior shoulder instability in children and adolescents, instability lesions varied significantly by age. Bone loss was associated with older age at presentation, and atypical lesions were more common in patients <15 years of age. Treatment teams should be aware of less common soft tissue injuries in this young age group and ensure careful review of adequate imaging for proper diagnosis and treatment in these younger patients.

Pediatric meniscus morphology varies with age: a cadaveric study.

PURPOSE: In adolescent patients, meniscal tear injury can occur either in isolation (e.g., discoid lateral meniscus tears) or in association with other traumatic injuries including tibial eminence fracture or ACL tear. Damage to meniscal integrity has been shown to increase contact pressure in articular cartilage, increasing risk of early onset osteoarthritis. In symptomatic patients failing conservative management, surgical intervention via meniscus repair or meniscus transplant is indicated. The purpose of this study was to evaluate the radial dimensions of pediatric menisci throughout development. The hypothesis was that the average radial meniscus dimensions will increase as specimen age increases, and mean medial and lateral region measurements will increase at a linear rate. METHODS: Seventy-eight skeletally immature knee cadaver specimens under age 12 years were included in this study. The meniscal specimens were photographed in the axial view with ruler in the plane of the tibial plateau and analyzed using computer-aided design (CAD) software (Autodesk Fusion 360). Measurements were taken from inner to outer meniscus rims at five 45 degree intervals using the clockface as a reference (12:00, 1:30, 3:00, 4:30, 6:00), and total area of meniscus and tibial plateau was recorded. Generalized linear models were used to evaluate the associations of radial width measurements with age, tibial coverage, and lateral vs. medial meniscus widths. RESULTS: All radial width measurements increased significantly with specimen age (p ≤ 0.002), and all lateral-medial meniscal widths increased (p < 0.001). The anterior zones of the meniscus were found to increase at the slowest rate compared to other regions. Tibial plateau coverage was found to not significantly vary with age. CONCLUSIONS: Meniscus radial width and lateral-medial meniscus width are related to age. The anterior width of the meniscus varied least with age. Improved anatomic understanding may help surgeons more effectively plan for meniscus repair, discoid resection/saucerization/repair, and also support appropriate selection of meniscus allograft for transplantation.

Radiographic Predictors of Reoperation in Adolescents Undergoing Hip Preservation Surgery for Femoroacetabular Impingement.

BACKGROUND: Femoroacetabular impingement (FAI) is a condition caused by repetitive abutment of a morphologically abnormal proximal femur and/or acetabulum that may result in chondral and labral pathology. An understanding of radiographic parameters associated with successful primary surgery has not been well established. PURPOSE: To determine preoperative radiographic parameters that predict reoperation for FAI and correlate radiographic measurements with outcomes in these patients. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: A prospectively collected institutional registry of adolescent patients (age, <19 years) who underwent surgery for FAI (arthroscopic/open) was reviewed. Preoperative standing anteroposterior pelvic radiographs were analyzed for femoroepiphyseal acetabular roof (FEAR) index, as well as lateral center-edge angle (LCEA) and alpha, Tönnis, and Sharp angles. Patient-reported outcomes (PROs) (modified Harris Hip Score, Hip disability and Osteoarthritis Outcome Score) were analyzed preoperatively and at 1- and 2-year followup. Radiographic indication of risk for reoperation was evaluated using receiver operating characteristic (ROC) analysis. Spearman correlation was calculated between radiographic measurements and PROs at 2 years postoperatively. RESULTS: A total of 81 patients (91 hips) underwent primary surgery (57 surgical dislocations vs 34 arthroscopies) for FAI. The mean age at time of primary operation was 16.23 years (range, 10.4-19.6 years) (73.6% female). Eleven hips (12.1%) underwent reoperation at a mean of 20.6 months from primary surgery. The LCEA, FEAR index, Tönnis angle, and Sharp angle before index surgery were significantly different (P < .05) between patients who underwent reoperation and those who did not. ROC analysis indicated that LCEA <22°, FEAR index >-8.7°, Tönnis angle >6.0°, and Sharp angle >44° were predictors for increased risk of reoperation. Using the cutoff values from the ROC analysis in this series, 43% of patients with an LCEA ≤22° had a repeat procedure, while only 8% of those with an LCEA >22° had a repeat procedure. Similar trends were seen with the other aforementioned acetabular radiographic measurements (FEAR index, Tönnis angle, Sharp angle). Patients who did not require a reoperation demonstrated significant improvement in all PRO categories from their preoperative to 2-year postoperative visits (P < .0001). CONCLUSION: In patients undergoing treatment for FAI, a reoperation was associated with radiographic signs of hip dysplasia, indicating that patients with a shallower acetabulum are at risk for a repeat operation.

The Significance of Isolated Hip Click as a Sign of DDH: Implications on Referral Guidelines.

BACKGROUND: The clinical significance of an isolated hip click remains unclear. The rates of developmental dysplasia of the hip (DDH) in those referred for hip click vary from 0% to 28%. The purpose of this study was to evaluate the rate of DDH in patients prospectively referred for isolated hip click. METHODS: We prospectively enrolled patients referred to a single pediatric orthopaedic center with concern for DDH secondary to isolated hip click felt by the pediatrician on examination. Patients with known sonographic abnormalities or risk factors for DDH (breech presentation or positive family history) were excluded. Ultrasounds were obtained upon initial presentation and defined as abnormal if alpha angle <60 degrees and/or femoral head coverage (FHC) <50%. Mild dysplasia, analogous to Graf IIa physiological immaturity, was defined as alpha angle 50<α<60 and/or <50% FHC in a patient <3 months age. Severe dysplasia was defined as ≤33% FHC, which has been proposed to be sonographically consistent with a hip dislocation. RESULTS: Two hundred fifty-five children were referred for isolated hip click. One hundred eighty-nine patients (74%) had normal ultrasound whereas 66 patients (26%) had sonographic abnormalities (mean age 6.5±6.2 wk at initial ultrasound). Fifty patients (19.6%) demonstrated physiological immaturity, 3 patients (1.2%) demonstrated moderate sonographic dysplasia, and 13 patients (5.1%) had sonographic findings consistent with severe dysplasia or dislocated hip. Hips with severe dysplasia were younger than the remaining population (2.8±2.4 wk vs. 6.6±6.2 wk, P <0.001) with no difference in sex distribution ( P =0.07) or first-born birth order ( P =0.36). For those with sonographic abnormality, 18 (27%) patients were treated with Pavlik harness, 1 (2%) was treated with abduction orthosis, and the remainder (71%) were observed for resolution of physiological immaturity. CONCLUSIONS: Infants with isolated hip click identified by their pediatrician may have higher rates of dysplasia than previously reported. We recommend screening ultrasound and/or orthopaedic referral for all infants with isolated hip click. LEVEL OF EVIDENCE: Level II-prospective prognostic study.

Radiographic Changes After Medial Patellofemoral Ligament Reconstruction in Skeletally Immature Patients Compared With an Age- and Sex-Matched Cohort.

BACKGROUND: Despite recent evidence that medial patellofemoral ligament reconstruction (MPFLR) in the skeletally immature patient is both safe and effective, there are limited data evaluating postoperative coronal- and sagittal-plane growth and radiographic patellofemoral parameters in this population. PURPOSE: The primary purpose was to assess radiographic measures of coronal-plane alignment, longitudinal growth, patellar congruence, and trochlear dysplasia after MPFLR in a skeletally immature population. A secondary purpose was to assess this population compared with a matched cohort with a focus on trochlear dysplasia prevalence and the effect of MPFLR on patellar height. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A total of 28 children with a minimum 1-year follow-up who underwent isolated MPFLR were identified. All patients were skeletally immature, defined as fully open physes on both sides of the knee joint, at the time of surgery. The development of a limb length discrepancy or angular growth abnormalities were assessed on standing hip-to-ankle radiographs, patellar tilt and congruence were measured on the Merchant view of the knee, and the grade of trochlear dysplasia and patellar height were assessed on lateral knee radiographs. A sex- and age-matched group of patients who underwent anterior cruciate ligament reconstruction was formed as a control for patellar height and trochlear dysplasia measurements. RESULTS: The mean patient age was 11.71 ± 2.02 years at the time of surgery with a mean follow-up of 23.54 ± 12.49 months. All but 1 patient in the MPFLR group had preoperative features consistent with trochlear dysplasia. There was no significant difference in limb length or coronal-plane alignment at final follow-up (P = .725 and P > .999, respectively). Both the MPFLR and the anterior cruciate ligament reconstruction groups had a statistically significant decrease in the Caton-Deschamps index between the preoperative and postoperative time points (mean, 0.18 ± 0.20 and 0.11 ± 0.14, respectively; P = .161). CONCLUSION: MPFLR may be safely performed utilizing an epiphyseal femoral socket in a skeletally immature cohort without affecting normal longitudinal growth or coronal limb alignment. The previously reported effect of MPFLR in reducing patellar height may be related to physiological growth based on similar changes noted in a comparison cohort that did not undergo the procedure.

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.

An Activity Scale for All Youth Athletes? Clinical Considerations for the HSS Pedi-FABS.

Background: The Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS) has demonstrated normally distributed scores in children aged 10 to 18 years. It has been used to evaluate knee injuries; however, there is limited information regarding its use in evaluating other injury types. Purpose: To (1) assess the validity and utility of HSS Pedi-FABS in youth athletes with injuries to different parts of the body and (2) evaluate the association between the HSS Pedi-FABS and the Patient-Reported Outcomes Measurement Information System (PROMIS) Pediatric Global Health 7 (PGH), as well as PROMIS-Pain Interference (PGH-PI) and PROMIS-Fatigue (PGH-F) components. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: The authors performed a retrospective review of youth athletes aged 10 to 18 years who completed the HSS Pedi-FABS as part of their previsit intake questionnaire between April 2016 and July 2020. HSS Pedi-FABS score distributions were compared and evaluated for ceiling effects in cohorts determined by demographic, injury characteristic, and sports participation variables; a ceiling effect was determined to be present if >15% of respondents received the highest possible score. HSS Pedi-FABS scores were analyzed for a correlation with PGH, PGH-PI, and PGH-F components. Results: Included were 2274 patients (mean age, 14.6 ± 2.1 years; 53.0% female) participating in 21 distinct primary sports for 9.6 ± 7.9 hours per week. The mean HSS Pedi-FABS scores by injury group were as follows: elbow (22.7 ± 6.7), shoulder (21.0 ± 8.7), ankle (20.2 ± 8.8), knee (19.5 ± 9.1), and hip (15.4 ± 10.4) (P < .001). Broad distribution was seen in each cohort, with no floor or ceiling effects. The HSS Pedi-FABS score correlated with patient-reported hours per week (r = 0.33), days per week (r = 0.33), and years of participation (r = 0.21) (P < .001 for all). All 3 PROMIS components correlated with HSS Pedi-FABS: PGH (r = 0.28), PGH-PI (r = -0.11), and PGH-F (r = -0.15) (P < .001). Conclusion: Study findings indicated that the HSS Pedi-FABS is a valid tool for measuring physical activity level in most injured youth athletes, not just those with knee injuries. The correlation of HSS Pedi-FABS with the PGH suggests a positive relationship of childhood physical activity with general health.

ACR Appropriateness Criteria® Osteonecrosis: 2022 Update.

Osteonecrosis is defined as bone death due to inadequate vascular supply. It is sometimes also called "avascular necrosis" and "aseptic necrosis" when involving epiphysis, or "bone infarct" when involving metadiaphysis. Common sites include femoral head, humeral head, tibial metadiaphysis, femoral metadiaphysis, scaphoid, lunate, and talus. Osteonecrosis is thought to be a common condition most commonly affecting adults in third to fifth decades of life. Risk factors for osteonecrosis are numerous and include trauma, corticosteroid therapy, alcohol use, HIV, lymphoma/leukemia, blood dyscrasias, chemotherapy, radiation therapy, Gaucher disease, and Caisson disease. Epiphyseal osteonecrosis can lead to subchondral fracture and secondary osteoarthritis whereas metadiaphyseal cases do not, likely explaining their lack of long-term sequelae. Early diagnosis of osteonecrosis is important: 1) to exclude other causes of patient's pain and 2) to allow for possible early surgical prevention to prevent articular collapse and need for joint replacements. Imaging is also important for preoperative planning. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Tibial Spine Fractures in Young Athletes.

Tibial spine fractures are a relatively rare injury in the young athlete. Previously thought to be the equivalent of a "pediatric anterior cruciate ligament (ACL) tear," contemporary understanding of these injuries classifies them as distinct from ACL injuries in this patient population. Successful treatment hinges on accurate diagnosis paying special attention to fracture displacement and the presence of concomitant intraarticular injury. Surgery can be performed using open or arthroscopic techniques and a variety of fixation options. The most common complication after surgical treatment is arthrofibrosis and, therefore, stable fixation is necessary to allow for early, unimpeded knee motion postoperatively.