Patient Characteristics and Postoperative Outcomes of Surgically Treated Inferior Pole Patellar Sleeve Fractures.

BACKGROUND: Despite representing over half of all pediatric patella fractures, inferior pole patellar sleeve fractures (PSFs) are a relatively uncommon pediatric injury. As a result, existing literature on PSFs is limited to case reports and small case series. The purpose of this study was to evaluate the radiographic and clinical characteristics of operatively treated PSFs as well as outcomes following surgical management. METHODS: A retrospective review of all inferior pole PSFs requiring surgery from 2007 to 2023 was performed at a single urban tertiary care children's hospital. Cases were identified using diagnostic and billing codes. Patient demographics, injury characteristics, surgical techniques, and postoperative rehabilitation practices were recorded. Regional skeletal maturity, fracture characteristics, and postreduction patellar height were recorded. Postoperative complications were recorded and categorized using the modified Clavien-Dindo Classification System (CDS). RESULTS: Thirty-eight inferior pole PSFs were identified meeting study criteria. The majority of patients were male (86.8%), and the mean age at injury was 11.0 years (range: 7.2 to 15.0). Mean BMI was 21.1. Radiographically, the majority of patients were Epiphyseal Fusion Stage 0 (nonunion), with a median postreduction Caton-Deschamps index (CDI) of 1.2 (IQR: 1.1 to 1.3). These fractures were predominantly treated with suture-based fixation (84%). Postoperative immobilization varied within the cohort, and the initiation of knee ROM was permitted at a median of 3.5 (IQR: 2.0 to 4.6) weeks. All patients regained full range of motion and straight leg raise without extensor lag, and return-to-sport was achieved by a median of 17.6 weeks (IQR: 12.8 to 30.3). Complications occurred in 10 (26.3%) patients, with 3 (7.9%) requiring a return to the OR (CDS Grade III). CONCLUSIONS: Inferior pole PSFs appear to occur most commonly among prepubertal males of normal BMI and normal patellar height. Despite variable rehabilitation protocols, operative management resulted in restoration of extensor mechanism function. Eight percent of patients experienced complications requiring unplanned surgery. This large series improves our understanding of the epidemiology, injury characteristics, and postoperative outcomes of an operatively treated cohort of a rare injury pattern. LEVEL OF EVIDENCE: Level IV.

Patella and Trochlea Osteochondritis Dissecans: Demographics and Treatment Paradigms.

OBJECTIVE: Previous research on patellar and trochlear groove osteochondritis dissecans (OCD) is limited by small sample sizes. This study aims to describe the presentation of patients with OCD lesions of the patella and trochlea and characterize the outcomes of operative and nonoperative treatments. METHODS: This retrospective cohort study identified all patients from a single institution from 2008 to 2021 with patellar and/or trochlear OCD lesions. Patients were excluded from the study if surgical records were unavailable or if the patient had knee surgery for a different injury at index surgery or in the 12 months postoperative. Minimum follow-up was 12 months. Outcomes included a return to sports (RTS), pain resolution, radiographic healing, and treatment "success" (defined as full RTS, complete pain resolution, and full healing on imaging). RESULTS: A total of 68 patients (75 knees) were included-45 (60%) with patellar OCD and 30 (40%) with trochlear. Of the patients, 69% were males. The median age at knee OCD diagnosis was 14 years. At the final follow-up, 62% of knees (n = 44) recovered sufficiently to allow a full RTS and 54% of knees (n = 39) had full pain resolution. Of the 46 knees with radiographic imaging at least 1 year apart, 63% had full healing of the lesion. There was no significant difference in RTS, pain resolution, radiographic healing, or overall success when comparing treatments. CONCLUSIONS: This study provides valuable epidemiologic demographic and outcome data regarding the scarcely reported patellar and trochlear OCD. While over half of patients fully returned to sports and reported full pain resolution, a large proportion continued to experience symptoms over a year after presentation. Future research should aim to better define the treatment algorithms for these OCD subtypes. LEVEL OF EVIDENCE: Level III.

Why Don't Adolescents Wear Their Brace? A Prospective Study Investigating Psychosocial Characteristics That Predict Scoliosis Brace Wear.

BACKGROUND: Although bracing for adolescent idiopathic scoliosis can prevent curve progression and reduce the risk for future surgery, children frequently do not wear their braces as prescribed. The purpose of this study is to investigate how a broad array of psychosocial characteristics predict future compliance with scoliosis brace wear. METHODS: This was a single institution, prospective cohort study. All adolescents prescribed a first-time brace for adolescent idiopathic scoliosis were eligible. Patients and their parents completed a separate series of questionnaires that assessed baseline psychosocial characteristics across 6 domains: (1) brace-specific attitudes; (2) body image and self-esteem; (3) school performance and social relationships; (4) psychological health; (5) family functioning; and (6) demographics and scoliosis-specific details (242 total questions across 12 validated questionnaires). Objective brace compliance was collected using temperature-sensitive monitors. Defining compliance as percentage of brace prescription completed, comparative analyses were performed to identify baseline psychosocial characteristics that were associated with future wear. A composite measure (Bracing Fidelity Follow-Up Scale [BFFS]) of the 12 most predictive individual questions across all domains (both parent and adolescent) was constructed to help assess which adolescents were at highest risk of failure to wear their brace. Total BFFS score for each parent-adolescent dyad who completed all the included surveys was then determined by awarding one point for each factor that positively influenced future brace wear (maximum 12 points), and a correlation was calculated between total score and percent adherence to prescribed brace wear. RESULTS: A total of 41 patients were included. On average, patients with high self-esteem, above average peer relationships and poor brace-specific attitudes had lower brace compliance, although patients with increased loneliness and parental religiousness had higher compliance. Body image, socioeconomic status, family dynamics, and school performance had no significant relationship with brace use. Total score on the Bracing Fidelity Follow-Up Scale (BFFS) was significantly associated with improved brace wear (r=0.687, P <0.001). Those with a score of 6 or above (n=15/33 [45%], median compliance 96%) were more reliable users (15/15 with compliance >75%), and those with a score of 5 or less (n=18/33 [55%], median compliance 50%) had less consistent brace wear (9/18 with compliance <50%). CONCLUSION: This prospective study identifies numerous baseline psychosocial factors that are associated with future compliance with scoliosis brace wear. Although in need of further validation before widespread clinical application, the novel BFF scale offers a potential opportunity to partially discriminate between compliant and noncompliant scoliosis brace users such that supportive resources (eg, supportive counseling, peer-support groups, additional provider-based education, etc.) can be targeted to those patients most likely to benefit. LEVEL OF EVIDENCE: II.

Pediatric Femoral Shaft Fractures: A Multicenter Review of the AAOS Clinical Practice Guidelines Before and After 2009.

BACKGROUND: To determine if the AAOS clinical practice guidelines (CPG) for the treatment of pediatric femoral shaft fractures (2009) changed treatment, we analyzed pediatric femoral shaft fractures at 4 high-volume, geographically separated, level-1 pediatric trauma centers over a 10-year period (2004 to 2013). METHODS: Consecutive series of pediatric femoral shaft fractures (ages, birth to 18 y) treated at the 4 centers were reviewed. Treatment methods were analyzed by age and treatment method for each center and in aggregate. RESULTS: Of 2646 fractures, 1476 (55.8%) were treated nonoperatively and 1170 fractures operatively. Of the operative group, flexible intramedullary nails (IMN) were used for 568 patients (21.5%), locked intramedullary nails (LIMNs) for 309 (11.7%), and plating for 188 (7.1%). In total, 105 fractures were treated with external fixation or skeletal traction. Analysis before and after the CPG publication revealed a significant increase in the use of interlocked IMNs in patients younger than 11 years (0.5% before, 3.8% after; P<0.001). Over the same time period there was an increase in surgical management, regardless of technique, for patients younger than 5 years (6.4% before, 8.4% after; P=0.206). There were considerable differences in treatment among centers: 74% of fractures treated with plating were from a single center (center A), which also contributed 68% of patients younger than 5 years treated with plating; center B had the highest rate (41%) of flexible IMN in children younger than 5 years; center C had the highest rate (63%) of LIMN in children younger than 11 years; and center D treated the fewest patients outside the CPG guidelines. CONCLUSIONS: Following publication of the AAOS CPG, there was a significant increase in the use of LIMNs in patients younger than 11 years old and a trend toward surgical treatment in patients younger than 5 years. The considerable variability among centers in treatment methods and adherence to the CPG highlights the need for further outcome studies to better define optimal treatment methods and perhaps update the AAOS CPG guidelines. LEVEL OF EVIDENCE: Level III-therapeutic.

The Surgical Management of Osteochondritis Dissecans of the Knee in the Skeletally Immature: A Survey of the Pediatric Orthopaedic Society of North America (POSNA) Membership.

BACKGROUND: While the characteristics of osteochondritis dissecans (OCD) of the knee that require surgery to heal have been described, several surgical techniques/procedures exist with no consensus established regarding timing of treatment and specific surgical intervention. In this study, we aim to determine current trends in surgical treatment for OCD lesions in the skeletally immature who have failed 6 months of nonoperative management by surveying a large cohort of orthopaedic surgeons. METHODS: An electronic survey designed using REDCap to capture surgeon treatment preferences for OCD lesions was distributed to members of the Pediatric Orthopaedic Society of North America (POSNA). The survey inquired about treating physicians' training and demographics. It then offered a series of clinical vignettes alongside imaging describing patients with varying degrees of severity of OCD following nonoperative treatment. Surgeons were prompted to select from a variety of multiple-choice-based options for further patient management. Standard descriptive statistics were used to summarize and compare the responses. RESULTS: Of the 129 POSNA members completing the pediatric survey, 97.7% were attending level orthopaedic surgeons, the majority identifying with an academic institution and treating mostly skeletally immature patients. In the skeletally immature population, the majority would treat intact, stable OCD lesions with drilling in a retroarticular or transarticular manner. Preferred treatment for unstable, salvageable lesions was screw fixation using bioabsorble materials or metal with variable pitch with no bone graft. The majority of respondents would treat unstable, unsalvageable OCD lesions with chondroplasty and osteochondral transplant/transfer or microfracture/drilling. CONCLUSIONS: The POSNA membership appears to agree on principle in terms of treatment modalities for various stages of OCD lesions in the skeletally immature, whereas individual techniques of achieving these principles may vary. Members endorse drilling for stable intact lesions; fixation for unstable, salvageable lesions; and "defect fill" for unsalvageable lesions. CLINICAL SIGNIFICANCE: OCD surgical treatment patterns can be used in future studies to determine which techniques are most effective for given indications, with the goal of designing a research-proven optimal treatment regimen for skeletally immature patients.

Candidate Loci are Revealed by an Initial Genome-wide Association Study of Juvenile Osteochondritis Dissecans.

BACKGROUND: Osteochondritis dissecans (OCD) is a condition that oftentimes causes significant knee pain in pediatric patient populations. If left untreated, OCD significantly increases the risk of developing degenerative osteoarthritis along with its associated consequences and costs. Although a genetic component has been suggested to play a role in this disorder, few studies have been carried out in order to determine the underlying genetic etiology of this relatively common complex trait. The goal of our study was to perform an initial genome-wide association study (GWAS) to uncover candidate loci associated with the pathogenesis of OCD. METHODS: Blood samples were acquired from 2 cohorts, aged 0 to 18 years old, consisting of 209 OCD cases and 1855 population-matched controls. Agencourt Genfind DNA isolation technology was used to isolate high-quality DNA from each sample. Genotype data was then generated utilizing the Illumina Infinium BeadChip array to examine single-nucleotide polymorphisms (SNPs). RESULTS: In an initial GWAS analysis of our cohort, where a SNP was excluded if the Hardy-Weinberg Equilibrium test P<0.0001, the minor allele frequency<5%, and the genotyping call rate<90%, we obtained our first results for OCD. Although there was no SNP strictly reaching the threshold for genome-wide significance at this early stage, multiple SNPs (35) at several loci revealed evidence of suggestive association with OCD (P<5.0×10). CONCLUSIONS: The results from our preliminary study are encouraging. Herein we not only discuss the relevance and applicability of GWAS in studying a genetic basis for OCD, but have also identified top signals that may suggest loci involved in coordinated expression as well as a transcription factor involved in development that may be highly relevant to this trait. CLINICAL RELEVANCE: If genetic predispositions for OCD are detected early enough in life, attempts at activity modification, counseling, and orthopaedic monitoring may successfully reduce progression of this condition, which may lead to progressive osteoarthritis in the third to fourth decade in at-risk patients.

Safe transcranial electric stimulation motor evoked potential monitoring during posterior spinal fusion in two patients with cochlear implants.

Transcranial electric stimulation (TES) motor evoked potentials (MEPs) have become a regular part of intraoperative neurophysiologic monitoring (IONM) for posterior spinal fusion (PSF) surgery. Almost all of the relative contraindications to TES have come and gone. One exception is in the case of patients with a cochlear implant (CI). Herein we illustrate two cases of pediatric patients with CIs who underwent PSF using TES MEPs as part of IONM. In both instances the patients displayed no untoward effects from TES, and post-operatively both CIs were intact and functioning as they were prior to surgery.

Management and subsequent outcomes of patellar sleeve injuries: A retrospective case series of 90 pediatric and adolescent patients.

Purpose: This study aims to report the epidemiology of patellar sleeve injuries, describe diagnostic findings and treatment, and assess functional outcomes following different treatments. Methods: A medical database was queried from 1990 to 2016 to identify patients ≤18 years presenting to a single pediatric institution with a patellar sleeve injury. Patients with significant comorbidities or previously operatively treated for ipsilateral knee injuries were excluded. Standard demographic data, mechanism of injury, skeletal maturity, injury-related radiographic parameters, along with treatment paradigms, post-treatment clinical and radiographic findings, and patient-reported outcomes were collected. Results: A total of 90 patients, mean age of 10.7 years (range: 7-17) was included, of which 69 (77%) were male. Seventy-three percent of all injuries occurred while playing sports (particularly football/basketball/soccer), with "direct blow" or "landing" being the most prevalent mechanisms of injury. Twenty-six (29%) underwent operative treatment, with transosseous suture fixation being the most popular surgical technique (73%). Of the 64 (71%) non-operatively treated patients, 18 (39%) were placed in a hinged knee brace locked in extension with the remainder split between casting and standard knee immobilizer. Compared to the non-operative cohort, a higher percentage of the operative group had a pre-treatment extensor lag (p < 0.001) and greater fragment displacement (p < 0.001) with patella alta (p < 0.001) on imaging. There was no difference in outcome scores (Pedi-IKDC/Lysholm) or patella alta on radiographs between groups. Post-treatment surveys indicated no difference in residual pain or ability to return to sport. Conclusion: This large case series provides valuable epidemiologic, clinical, and radiographic data describing patellar sleeve fractures, along with outcomes following non-operative and operative treatments. Level of evidence: IV.

Bilateral osteochondritis dissecans of the knee in pediatric and adolescent patients presenting with unilateral symptoms: An epidemiological and radiographic analysis.

Purpose: This study aims to determine the prevalence and characteristics of bilateral osteochondritis dissecans of the knee in patients presenting with unilateral symptoms and compare this cohort to patients with unilateral disease. Methods: Records of patients ≤18 years old from 2003 to 2016 with a diagnosis of osteochondritis dissecans of the knee and strictly unilateral knee pain were identified. Contralateral (asymptomatic) knee imaging within 1 year of initial presentation was required. Lesion characteristics were evaluated by assessing size, location, and Hefti staging. Both surgical and nonoperative treatments were recorded. Patients with unilateral osteochondritis dissecans were compared to those with bilateral disease. Results: Eighty patients, 63 males (79%) and 17 females (21%), with an average age of 13.1 years old, were included. Twenty (25%) of the presenting/symptomatic lesions were deemed stable on magnetic resonance imaging. A positive correlation between lesion size and Hefti classification was appreciated. Twelve patients (15%) were found to have bilateral osteochondritis dissecans on contralateral imaging. There was no significant difference in skeletal maturity between patients with bilateral versus unilateral disease. Fifty-two patients (77%) with unilateral disease underwent surgical intervention, while 9 (75%) of those with bilateral disease underwent surgery on either knee. In patients with an asymptomatic contralateral lesion, 67% ultimately underwent surgical intervention on the contralateral knee. Conclusions: In patients presenting with unilateral osteochondritis dissecans symptoms, there was a 15% prevalence of bilateral disease, with no difference in age, sex, physeal status, or lesion characteristics between patients with unilateral vs bilateral osteochondritis dissecans lesions. Given the prevalence of asymptomatic contralateral lesions and the required intervention, this study supports early bilateral radiologic knee evaluation. Level of evidence: IV, Retrospective Case series.

Trends in Pediatric Anterior Cruciate Ligament Reconstruction: The Effect of COVID-19.

CONTEXT: The number of pediatric anterior cruciate ligament reconstructions (ACLRs) occurring yearly increased almost 6-fold from 2004-2014. We find it interesting that limited recent data exist on rates of ACL injury and reconstruction in children and adolescents, especially in the context of COVID-19. OBJECTIVE: Given the effect of the COVID-19 pandemic on youth sports seasons and the postponement of many elective surgeries, we sought to examine the changes in rates of ACLR during this period. DESIGN: Retrospective cohort study. SETTING: This study used the Pediatric Health Information System (PHIS) database to identify eligible patients at PHIS-participating hospitals nationwide from January 2016-June 2021, with March 1, 2020, considered the start of the COVID-19 pandemic. PATIENTS OR OTHER PARTICIPANTS: Using Current Procedural Terminology codes, patients 18 years old and younger who underwent ACLR surgery were identified. MAIN OUTCOME MEASURE(S): Patient demographics and overall rates of surgery prepandemic and intrapandemic were compared. Data were analyzed using bivariate, mixed-model, and time series analyses. RESULTS: A total of 24 843 ACLRs were identified during this time period. In total, 1853 fewer surgeries than expected were performed after March 2020 given prepandemic trends. Intrapandemic demographics revealed an increase in the proportion of patients who identified as White and with private insurance and a decrease in the proportion who identified as Black and with public insurance. Also, the proportion of ACLRs by region shifted, with more surgeries performed in the Midwest and fewer in the Northeast. In the model adjusted for hospital-level variability, only race and insurance status remained significant. CONCLUSIONS: Based on prepandemic trends, fewer patients than projected underwent ACLR once the pandemic began, likely due to a combination of decreased rates of injury and delayed surgery.

Selecting the Next Class: The "Virtual Orthopaedic Rotation".

INTRODUCTION: When the COVID-19 pandemic forced the cancellation of visiting subinternships, we pivoted to create a virtual orthopaedic rotation (VOR). The purpose of this study was to assess the effect of the VOR on the residency selection process and determine the role of such a rotation in the future. METHODS: A committee was convened to create a VOR to replace visiting orthopaedic rotations for medical students who are interested in pursuing a career in orthopaedic surgery. The VOR was reviewed and sanctioned by our medical school, but no academic credit was granted. We conducted three 3-week VOR sessions. During each session, virtual rotators participated in regularly scheduled educational conferences and attended an invitation-only daily conference in the evenings that was designed for a medical student audience. In addition, students were paired with faculty and resident mentors in a structured mentorship program. Students' orthopaedic knowledge was assessed using prerotation and postrotation tests. RESULTS: From July to September 2020, 61 students from 37 distinct medical schools participated in the VOR. Notable improvements were observed in prerotation and postrotation orthopaedic knowledge test scores. In postrotation surveys, both students and faculty expressed high satisfaction with the curriculum but less certainty about how well they got to know each other. In the subsequent residency application cycle, 27.9% of the students who participated in the VOR were selected to interview, compared with 8.7% of the total application pool. DISCUSSION: The VOR was a valuable substitute for in-person clinical rotations during the COVID-19 pandemic. Although not likely to be a replacement for conventional away rotations, the VOR is a possible adjunct to in-person clinical rotations in the future.

Increased Glenoid Index as a Risk Factor for Pediatric and Adolescent Anterior Glenohumeral Dislocation: An MRI-Based, Case-Control Study.

BACKGROUND: In adults, anterior glenohumeral instability has been associated with a tall and narrow glenoid morphology, assessed using the glenoid index (GI; glenoid height-to-width ratio) on magnetic resonance imaging (MRI). This morphological association has not been assessed in children and adolescents. PURPOSE/HYPOTHESIS: To examine the association of GI and other MRI measurements of interest supported in studies on adults with anterior glenohumeral dislocation in patients aged ≤19 years. We hypothesized that these patients would have a significantly greater GI (relatively taller and narrower glenoid morphology) compared with healthy controls. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: An institutional radiology database was queried over a 10-year period to identify patients aged ≤19 years who had been diagnosed with radiographically confirmed anterior shoulder dislocation and who underwent glenohumeral magnetic resonance arthrography as well as those without dislocation with normal shoulder arthrogram studies (controls). Patients with bony Bankart lesions were excluded. The following glenohumeral dimensions were measured on shoulder arthrogram: GI, glenoid version, coracohumeral interval, and rotator interval width/depth. Comparative analysis between the 2 groups was performed using the Student t test for each variable, followed by receiver operating characteristic (ROC) analysis to determine discriminative ability when statistically significant. RESULTS: Overall, 55 participants (33 male and 22 female patients; mean age, 15.4 ± 2.1 years) were enrolled; 22 patients were in included in the dislocator group and 33 patients comprised the control group. The mean GI in the dislocator group was significantly greater than the control group (1.55 ± 0.14 vs. 1.38 ± 0.08; P < .001). ROC analysis revealed adequate discrimination of GI in predicting glenohumeral dislocation (area under the curve = 0.88). A GI ≥1.45 was 83% sensitive and 79% specific for predicting dislocation in the study cohort. CONCLUSION: Patients with anterior glenohumeral dislocation had increased GI (taller and narrower glenoid morphology) than controls. This useful MRI measurement may help identify patients at risk for primary or recurrent anterior glenohumeral instability events and may therefore help with guiding treatment and prevention.

Narrow Notch Width is a Risk Factor for Anterior Cruciate Ligament Injury in the Pediatric Population: A Multicenter Study.

PURPOSE: The purposes of this study were to evaluate the notch width index (NWI) as a risk factor for anterior cruciate ligament (ACL) rupture in the pediatric and adolescent patient population via multicenter analysis and to detect any differences in the NWI among cohorts having sustained either a unilateral or bilateral ACL rupture. METHODS: A consecutive series of patients ≤19 years old was enrolled from January 1999 through July 2010 at 2 academic pediatric orthopaedic tertiary-care hospitals. Demographic and anatomic morphology data were collected for 3 cohorts: unilateral ACL ruptures, bilateral ACL ruptures, and a control group. A single blinded reviewer determined notch width measurements via T2 coronal magnetic resonance imaging sequences in a standardized manner, using a previously described technique. RESULTS: Of the 68 patients included for analysis, 22 sustained unilateral ACL rupture, 23 sustained bilateral ruptures, and 23 comprised the control group. There was a statistically significant difference appreciated in direct comparison of the NWI in the bilateral rupture group and the control group, as well as between the unilateral rupture group and the control group. There was no statistically significant difference between the NWI in the unilateral versus the bilateral rupture group. CONCLUSION: Given the known inconsistencies in the existing literature, our findings provide further support of a narrow NWI as a significant contributing factor to both unilateral and bilateral ACL injury risk in the pediatric and adolescent patient population. LEVEL OF EVIDENCE: III, retrospective cohort study.

Sport-Specific Yearly Risk and Incidence of Anterior Cruciate Ligament Tears in High School Athletes: A Systematic Review and Meta-analysis.

BACKGROUND: Anterior cruciate ligament (ACL) injury rates are affected by frequency and level of competition, sex, and sport. To date, no study has sought to quantify sport-specific yearly risk for ACL tears in the high school (HS) athlete by sex and sport played. PURPOSE: To establish evidence-based incidence and yearly risk of ACL tears in HS athletes by sex for sports performed at the varsity level across the majority of US high schools. STUDY DESIGN: Meta-analysis. METHODS: PubMed, EMBASE, and Cochrane Central Register of Controlled Trials were searched to identify all articles reporting ACL tears per athletic exposure in HS athletes. ACL injury incidence rates (IRs) by sex and sport were calculated via meta-analysis. State athletic association guidelines were used to determine the number of exposures per season to calculate yearly risk of ACL tears. RESULTS: The search recovered 3779 unique articles, of which 10 met our inclusion criteria, for a total of 700 ACL injuries in 11,239,029 exposures. The IR was 0.062 injuries per 1000 exposures (95% CI, 0.058-0.067). Although more injuries were recorded in males than females, females had a higher rate of injury per exposure (relative risk, 1.57; 95% CI, 1.35-1.82). Relative risk was highest in basketball (3.80; 95% CI, 2.53-5.85) and soccer (3.67; 95% CI, 2.61-5.27). While boys' football had the highest number of ACL injuries at 273, girls' soccer had the highest IR (0.148; 95% CI, 0.128-0.172). In girls, the highest injury risks per season were observed in soccer (1.11%; 95% CI, 0.96%-1.29%), basketball (0.88%; 95% CI, 0.71%-1.06%), and lacrosse (0.53%; 95% CI, 0.19%-1.15%). In comparison, the highest risks for boys were observed in football (0.80%; 95% CI, 0.71%-0.91%), lacrosse (0.44%; 95% CI, 0.18%-0.90%), and soccer (0.30%; 95% CI, 0.22%-0.41%). CONCLUSION: There is an approximately 1.6-fold greater rate of ACL tears per athletic exposure in HS female athletes than males. However, there is significant risk in both sexes, particularly in high-risk sports such as soccer, football, basketball, and lacrosse. Knowledge of sport-specific risk is essential for future injury reduction programs, parent-athlete decision making, and accurate physician counseling.

Rehabilitation Following Anterior Cruciate Ligament Tears in Children: A Systematic Review.

BACKGROUND: Anterior cruciate ligament (ACL) tears are increasingly prevalent in the pediatric population. ACL rehabilitation is an essential component of recovery following injury and reconstruction, yet there are few explicit descriptions of pediatric-specific ACL rehabilitation protocols in the literature, especially in the context of varying treatment interventions. Our aim was to systematically review the literature on rehabilitation following ACL tears in children in order to describe common principles among different treatment options and areas of future research. METHODS: Using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we performed a systematic review of the PubMed, EMBASE, and Cochrane databases (for the past five years) to identify detailed rehabilitation protocols described in the pediatric population following ACL rupture. When available, the following aspects of rehabilitation were extracted: "prehabilitation" (exercises prior to surgery), bracing, weight-bearing status, range of motion, strength, modalities (ice, heat, electrical stimulation, etc.), plyometrics/proprioceptive exercises, return-to-sport criteria, and suggested ACL injury-prevention programs. RESULTS: Two hundred and two unique articles were identified. Twenty-seven articles meeting inclusion criteria with extractible rehabilitation data were included. A table, categorized by differing orthopaedic intervention, was designed to detail the components and duration of the different aspects of rehabilitation. While there are substantial differences across protocols, several trends emerged, particularly regarding weight-bearing, bracing, range of motion, and strength training. Interestingly, we found that many current protocols are based on time frame alone rather than on functional milestones; of the fourteen unique articles that addressed return-to-sport criteria by specific orthopaedic intervention, seven were based on temporal progression whereas seven also involved achievement of physical milestones. In addition, only three of the eight articles that mentioned a future ACL injury-prevention plan described a formal prevention program. CONCLUSION: We systematically identified, and subsequently outlined and compared, the current trends of the various components of pediatric-specific ACL rehabilitation protocols, categorized by orthopaedic intervention. Several protocols are based on time frames rather than milestones achieved, with newer protocols involving milestone-based progression. Newer protocols are also incorporating formal prevention programs. Just as skeletally immature patients require unique methods of operative fixation, so too do they require catered rehabilitation protocols. To effectively prevent re-rupture or contralateral injury, future research should focus on prospectively evaluating each component of the rehabilitation protocols described and return-to-sport criteria for young patients.

The presentation of Legg-Calvé-Perthes disease in females.

PURPOSE: Legg-Calvé-Perthes disease (LCPD) is uncommon in girls. The presentation of LCPD in female patients has been reported as later in onset and associated with certain high-impact activities. Our aim is to characterize the presentation of female LCPD at a large center, with particular attention to the clinical and radiographic features of late-onset disease (>ten years of age). We perceived an increasing burden of late-onset disease with adult-like radiographic features. METHODS: All patients presenting to a single large urban children's hospital from 1990-2014 with a diagnosis of LCPD were reviewed. Demographic, clinical, and radiographic data for all female patients were examined and compared to historical norms. RESULTS: Four-hundred and fifty-one patients presented with LCPD in the study period, of which 82 (18.2 %) were female. The average age at presentation was 6.58 years in girls, which is similar to the classically reported mean age. Fourteen patients participated in high-impact repetitive activities or those with deep flexion and abduction, although few were late presenters. There were four female patients who presented for initial diagnosis >ten years of age. CONCLUSIONS: There was a paucity of late-onset LCPD in girls in the study population, and the females with LCPD had a very similar age and character to their presentation as did males. Although their presentation is infrequent, three of four older females with LCPD were engaged in high-level physical activity, and their disease may be attributed to high-impact, repetitive athletics. LEVEL OF EVIDENCE: Case series, Level IV.