Adolescent Idiopathic Scoliosis: Increased Body Mass Associated with Decreased Bracing Outcomes.

Bracing reduces the need for surgical intervention in patients with adolescent idiopathic scoliosis (AIS). However, bracing outcomes with variable body mass index (BMI) are understudied. The authors sought to determine the association of BMI with bracing outcomes. The authors performed a retrospective cohort study of 104 patients presenting with AIS. Initial Risser score, hours of bracing per day, BMI percentile, and curve magnitude pre- and postbracing were collected. There was no detectable difference between years of brace wear or primary curve magnitude at time of presentation between both groups. Overall, 29% (25/87) of underweight/normal weight patients and 59% (10/17) of overweight/obese patients had curves ≥ 45 degrees at the end of bracing (p = 0.016). Odds of having a curve ≥ 45 degrees after bracing were 3.5 (95% confidence interval: 1.2 to 10.3, p = 0.021) times higher for overweight/obese patients compared with underweight/normal weight patients. Increased overlying adipose tissue may reduce the corrective forces required to straighten the spine. (Journal of Surgical Orthopaedic Advances 33(1):029-032, 2024).

Compression Screw Fixation for Pediatric Olecranon Fractures.

BACKGROUND: Pediatric olecranon fractures can be treated with several methods of fixation. Though postoperative outcomes of various fixation techniques, including cannulated intramedullary screws, have been described in adults, functional and radiographic outcomes of screw fixation in pediatric patients are unclear. In this study, we assessed clinical, radiographic, functional, and patient-reported outcomes of pediatric olecranon fractures treated with compression screw fixation. METHODS: We retrospectively identified 37 patients aged 16 years or younger with a total of 40 olecranon fractures treated with screw fixation at our level-1 trauma center between April 2005 and April 2022. From medical records, we extracted data on demographic characteristics, time to radiographic union, range of elbow motion at final follow-up, and complications during the follow-up period. Patient-reported outcomes were evaluated using the Quick Disabilities of the Arm, Shoulder, and Hand and Patient-Reported Outcomes Measurement Information System Pediatric Upper Extremity Short Form 8a measures. RESULTS: There were no malunions or nonunions at the final mean follow-up of 140 days (range, 26 to 614 d). Four patients had implant failure (11%), of whom 3 experienced fracture union with no loss of fixation or need for revision surgery. One patient underwent a revision for fracture malreduction. Screw prominence was documented in 1 patient. Instrumentation was removed at our institution for 33 of 40 fractures. Mean time to radiographic union was 53 days (range, 20 to 168 d). Postoperative range of motion at the most recent follow-up visit showed a mean extension deficit of 6 degrees (range, 0-30 degrees) and mean flexion of 134 degrees (range, 60-150 degrees). At the final follow-up, the mean (±SD) Quick Disabilities of the Arm, Shoulder, and Hand score was 4.2±8.0, and the mean Patient-Reported Outcomes Measurement Information System score was 37±1.5, indicating good function and patient satisfaction. CONCLUSIONS: All 37 patients in our series had excellent radiographic, functional, and patient-reported outcomes after screw fixation. We observed no cases of nonunion or malunion, growth disturbance, or refracture. These results suggest that screw fixation is a safe and effective option for pediatric olecranon fractures. LEVEL OF EVIDENCE: Level IV, case series.

The Financial Burden of Nonoperatively Treated Pediatric Distal Radius Fractures: Medical Debt in Privately Versus Publicly Insured Patients.

BACKGROUND: Patients with public health insurance have greater difficulty obtaining orthopaedic care than their privately insured counterparts because of lower reimbursements. However, the relationship between insurance status and financial burden for patients and treating institutions is unknown. We compared patient medical debt and uncompensated hospital costs by insurance type for pediatric patients who received nonoperative treatment for distal radius fractures (DRFs). METHODS: We reviewed medical records of 100 pediatric patients (above 18 y) treated nonoperatively at our US academic hospital for DRFs from 2016 to 2020. Patients were grouped according to insurance type at the time of treatment: preferred-provider organization (PPO), n=30; health maintenance organization (HMO), n=29; Medicaid, n=28; and uninsured, n=13. These groups were matched by number of encounters, total original charge, and total number of charges. The primary outcomes were patient medical debt and uncompensated costs to the hospital, comprising unpaid balance, uncollectible debt, and self-adjustments offered by the hospital. χ2 tests and analysis of variance were used to compare financial outcomes among subgroups (alpha=0.05). RESULTS: Patient medical debt (ie, uncollectible debt) was generated by 20% of PPO, 7.7% of uninsured, and 6.9% of HMO patients (P=0.06). Medicaid patients generated no patient medical debt, whereas PPO patients generated a mean (±SD) of $15±$39 and HMO patients generated $26±$130, which was not significantly different than that of uninsured patients ($25±$89) (P<0.0001). Uncompensated costs were generated by 54% of uninsured, 20% of PPO, 6.9% of HMO, and 0% of Medicaid patients (P<0.0001). Uncompensated costs were the same as uncollectible debt for privately insured and Medicaid patients, whereas uninsured patients generated an additional $550±$600 from self-adjustments (P<0.0001). CONCLUSION: Unlike the Medicaid group, the privately insured and uninsured groups incurred patient medical debt and uncompensated costs after nonoperative DRF treatment. Thus, orthopaedic providers should be cost conscious with privately insured patients, while publicly insured patients may provide more consistent-albeit lower-reimbursement for the hospital. LEVEL OF EVIDENCE: Level III.

Decrease in Residual Neurological Symptoms After Institutional Changes in Peripheral Nerve Block Use for Pediatric Knee Surgery.

BACKGROUND: Peripheral nerve blocks (PNBs) have recently been associated with a higher incidence of complications than previously thought. We compared: (1) incidence of PNB-related residual neurological symptoms and (2) patient selection, operative practices, and anesthesia practices for pediatric knee surgery patients before and after changes in PNB administration at our institution. METHODS: We compared data from pediatric patients who underwent knee surgery with PNBs from 2014 to 2016 (cohort 1; 100 patients) or 2017 to 2019 (cohort 2; 104 patients). Cohort 2 was treated after PNB administration was limited to a dedicated anesthesia block team at our institution. We used t tests and χ2 tests, with an α level of 0.05. RESULTS: The incidence of PNB-related neurological complications was lower in cohort 2 (0.96%;) than cohort 1 (6%) (P=0.045). The 1 complication in cohort 2 was numbness proximal to the knee. Cohort 1 had 5 cases of numbness proximal to the knee and 1 case of neuropathic pain upon palpation of the PNB site. The proportion of female patients was greater in cohort 2 (57%) than cohort 1 (36%) (P=0.01); age and body mass index did not differ between cohorts. In cohort 2, the mean operating time was longer, and tourniquets were used more frequently (both, P<0.01). A greater proportion of PNBs were performed by fellows in cohort 2 (67%) versus cohort 1 (55%) (P=0.01). A smaller proportion of PNBs were performed by residents in cohort 2 (6.9%) versus cohort 1 (16%) (P=0.01). The most common anatomic site for PNBs was the femoral nerve (51%) in cohort 1 and the saphenous nerve (51%) in cohort 2 (P<0.01). CONCLUSIONS: The incidence of PNB-related complications after pediatric knee surgery decreased significantly after institutional changes in the regulation of PNB use. This decrease may be explained by shifts toward more experienced providers administering PNBs and preference for more distal anatomic sites, suggesting ways other institutions may lower their PNB complication rates. LEVEL OF EVIDENCE: Level III-retrospective prognostic study.

The COVID-19 Pandemic: Effects on Pediatric Fracture Patterns in the Emergency Department and Subspecialty Follow-up Care.

PURPOSE: The COVID-19 pandemic affected pediatric fracture injury patterns and volume. There is a paucity of research evaluating this trend throughout the pandemic and also follow-up to orthopaedic subspecialty care after emergency fracture management. METHODS: This retrospective cohort study reviewed patients 2 to 18 years of age presenting for fracture care to an urban pediatric emergency department. We assessed patient demographics, clinical care, and follow-up to surgical subspecialist. Time periods investigated included March 30 to September 4, 2020 (pandemic), March 30 to September 4, 2019, and March 30 to September 4, 2018 (prepandemic). Subanalysis within the pandemic was during the "stay-at-home order" verses the phased re-opening of the state. Descriptive statistical analysis, Pearson's χ 2 or Fisher exact tests, and Mann-Whitney U tests were performed. RESULTS: In this population, fractures overall declined by 40% (n=211) during the pandemic compared with 2019 (n=349) and 28% compared with 2018 (n=292). Lower extremity fractures accounted for a greater percentage of injuries during the pandemic compared with prepandemic. Time to surgical subspecialty follow-up was shortest during the 2020 pandemic peak at 9 days and was significantly longer during phased reopening (phase 1: 18 d, P =0.001; phase 2: 14 d, P =0.005). These patterns were also consistent for days to repeat imaging. CONCLUSIONS: We found differences in fracture prevalence, mechanisms, and follow-up care during the pandemic. Time to subspecialty follow-up care was longer during pandemic phased reopening despite overall fewer fractures. Plans to absorb postponed visits and efficiently engage redeployed staff may be necessary to address difficulties in follow-up orthopaedic management during public health crises. LEVEL OF EVIDENCE: Level II.

Anterior Cruciate Ligament Tear Following Operative Treatment of Pediatric Tibial Eminence Fractures in a Multicenter Cohort.

BACKGROUND: Postoperative ipsilateral anterior cruciate ligament (ACL) tears after tibial eminence fracture fixation has been previously noted in the literature. This study aims to describe the prevalence of and risk factors for postoperative ACL tears in a cohort of patients operatively treated for tibial eminence fracture. METHODS: A retrospective review of children undergoing treatment of a tibial eminence fracture at 10 tertiary care children's hospitals was performed. The primary outcome of interest was subsequent ACL rupture. Incidence of ACL tear was recorded for the entire cohort. Patients who sustained a postoperative ACL tear were compared with those without ACL tear and analyzed for demographics and risk factors. A subgroup analysis was performed on patients with a minimum of 2-year follow-up data or those who had met the primary outcome (ACL tear) before 2 years. RESULTS: A total of 385 pediatric patients were reviewed. 2.6% of the cohort experienced a subsequent ACL tear. The median follow-up time was 6.5 months (SD=6.4 mo). Subsequent ACL tears occurred at a median of 10.2 months (SD=19.5 mo) postoperatively. There was a statistically significant association with higher grade tibial spine fractures (Myers and McKeever type III and IV) and subsequent ACL tear (P=0.01). Patients with a subsequent ACL tear were older on average (13.5 vs. 12.2 y old), however, this difference was not statistically significant (P=0.08). Subgroup analysis of 46 patients who had a 2-year follow-up or sustained an ACL tear before 2 years showed a 21.7% incidence of a subsequent ACL tear. There was a statistically significant association with higher grade tibial spine fractures (Myers and McKeever type III and IV) and subsequent ACL rupture (P=0.006) in this subgroup. Postoperative ACL tears occurred in patients who were older at the time that they sustained their original tibial eminence fracture (13.4 vs. 11.3 y old, P=0.035). CONCLUSIONS: Ipsilateral ACL tears following operatively treated pediatric tibial eminence fractures in a large multicenter cohort occurred at a rate of 2.6%. However, in those with at least 2 years of follow-up, the incidence was 21.7%. Subsequent ACL tear was more likely in those with completely displaced (type III or IV) tibial eminence fractures and older patients. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

Mid-term Patient-reported Outcomes After Lateral Versus Crossed Pinning of Pediatric Supracondylar Humerus Fractures.

BACKGROUND: Closed reduction and percutaneous pinning in a crossed or lateral configuration is the standard treatment for supracondylar humerus (SCH) fractures. We compared mid-term patient-reported outcomes (PROs), radiographic outcomes, and complication rates between patients treated with crossed versus lateral pinning. METHODS: We reviewed 508 pediatric patients treated surgically for Gartland type-III SCH fractures from 2008 to 2017. We included patients aged 5 to 17 years at the time of telephone interviews, who had available radiographs. We excluded those unable to be reached by telephone; those who declined to be surveyed; and those lost to follow-up. Our sample comprised 142 participants (28%) (mean±SD age at surgery, 5.2±2.0 y), 93 (65%) of whom were treated with lateral pinning and 49 (35%) with crossed pinning. Participants' parents completed the Quick Disabilities of the Arm, Shoulder, and Hand and the Patient-Reported Outcomes Measurement Information System Parent Proxy at a mean 4.4 years (range: 2 to 10 y) postoperatively. Postoperative radiographs were reviewed to assess reduction. Bivariate analysis was performed to determine whether outcomes differed by pinning technique (α=0.05). RESULTS: The proportions of participants achieving complete reduction were not significantly different between pin configuration groups (P=0.71). At follow-up, the 2 groups did not differ significantly in any PRO scores (all, P>0.05). CONCLUSION: We found no differences between crossed and lateral pinning of Gartland type-III SCH fractures in terms of radiographic reduction, PROs, or complication rates at mid-term follow-up. LEVEL OF EVIDENCE: Level III.

The Spatial Order of Physeal Maturation in the Normal Human Knee Using Magnetic Resonance Imaging.

BACKGROUND: The spatial order of physeal maturation around the distal tibia has been shown to place adolescent patients at risk for certain transitional injuries, such as Tillaux or triplane fractures. Less is known about physeal maturation around the knee. The purpose of this study was to establish the spatial order of physeal maturation in the normal human knee using magnetic resonance imaging (MRI). METHODS: We retrospectively collected all knee MRI scans from patients presenting to our institution from January 2004 to January 2014. Patients who were suspected on the basis of clinical or radiographic findings of having abnormal knee physeal development or injury were excluded. We then applied a previously described MRI staging system of knee physeal maturation to the MRI scans of the remaining patients at 8 defined knee locations. Associations between the stage of maturation and mean chronological age were then evaluated across the 8 knee locations. Interrater and intrarater reliabilities were assessed. RESULTS: A total of 165 knee MRI scans (from 98 boys, 67 girls) met the inclusion criteria. Significant differences were found between each stage of physeal maturation and the mean chronological ages at all 8 knee locations for both boys and girls (each, P<0.001). Interestingly, within each stage of physeal maturation, no significant difference was found in the mean chronological ages at any of the 8 knee locations, suggesting that physeal development occurs uniformly in the normal human knee for both boys and girls. Interrater and intrarater reliability were nearly perfect at all locations. CONCLUSIONS: The spatial order of physeal maturation in the normal human knee was uniform across 8 knee locations for both boys and girls. This uniformity may help to explain why transitional injuries do not follow a recognizable pattern in the knee. Furthermore, the uniformity aids with surgical decision making, because minimal growth modulation or disturbance is likely when early physeal closure is present in a portion of the physis. LEVEL OF EVIDENCE: Level III.

Bent Telescopic Rods in Patients With Osteogenesis Imperfecta.

BACKGROUND: Telescopic rods require alignment of 2 rods to enable lengthening. A telescopic rod converts functionally into a solid rod if either rod bends, preventing proper engagement. Our goal was to characterize implant bending as a mode of failure of telescopic rods used in the treatment of osteogenesis imperfecta in children. METHODS: We conducted a retrospective review of our osteogenesis imperfecta database for patients treated with intramedullary telescopic rods at our institution from 1992 through 2010 and identified 12 patients with bent rods. The 6 boys and 6 girls had an average age at the time of initial surgery of 3.1 years (range, 1.8 to 8.3 y) and a total of 51 telescoping rods. Clinic notes, operative reports, and radiographs were reviewed. The rods were analyzed for amount of lengthening, characteristics of bending, presence of cut out, or disengagement from an anchor point. Bends in the rods were characterized by their location on the implant component. The bent and straight rods were compared. Data were analyzed with the Mann-Whitney test (statistical significance set at P≤0.05). RESULTS: Of the 51 telescoping rods, 17 constructs (33%) bent. The average interval between surgery and rod bending was 4.0 years (range, 0.9 to 8.2 y). Before bending, 11 of 17 telescoping rods had routine follow-up radiographs for review. In 10 of the rods, bending was present when early signs of rod failure were first detected. Rod bending did not seem to be related to rod size. There was no area on the rod itself that seemed more susceptible to bending. CONCLUSIONS: Rod bending can be an early sign of impending rod failure. When rod bending is first noted, it may predispose the rod to other subsequent failures such as loss of proximal and distal fixation and cut out. Rod bending should be viewed as an indicator for closer monitoring of the patient and discussions regarding future need for rod exchange. LEVEL OF EVIDENCE: Level III-retrospective review.

Incidence, risk factors, and consequences of radiographic pin migration after pinning of pediatric supracondylar humeral fractures.

Current literature on pin migration is inconsistent and its significance is not understood. We aimed to investigate the incidence, magnitude, predictors, and consequences of radiographic pin migration after pediatric supracondylar humeral fractures (SCHF). We retrospectively reviewed pediatric patients treated with reduction and pinning of SCHF at our institution. Baseline and clinical data were collected. Pin migration was assessed by measuring the change in distance between pin tip and humeral cortex on sequential radiographs. Factors associated with pin migration and loss of reduction (LOR) were assessed. Six hundred forty-eight patients and 1506 pins were included; 21%, 5%, and 1% of patients had pin migration ≥5 mm, ≥10 mm, and ≥20 mm respectively. Mean migration in symptomatic patients was 20 mm compared to a migration of 5 mm in all patients with non-negligible migration ( P < 0.001). Pin migration > 10 mm was strongly associated with LOR [odds ratio (OR) = 6.91; confidence interval (CI), 2.70-17.68]. Factors associated with increased migration included increased days to pin removal ( ß = 0.022; CI, 0.002-0.043), migration outwards versus inwards ( = 1.02; CI, 0.21-1.80), and BMI > 95th percentile (OR = 1.63; [1.06-2.50]). Factors not associated with migration included cross-pinning, number of pins, and fracture grade. In summary, we identified a 5% incidence of radiographic pin migration ≥ 10 mm and determined the factors associated with it. Pin migration became radiographically significant at >10 mm where it was strongly associated with LOR. Our findings contribute to the understanding of pin migration and suggest that interventions targeting pin migration may decrease the risk of LOR. Level of Evidence: Level III - Retrospective Cohort Study.

Is Delayed Anterior Cruciate Ligament Reconstruction Associated With a Risk of New Meniscal Tears? Reevaluating a Longstanding Paradigm.

Background: Delayed anterior cruciate ligament (ACL) reconstruction has been associated with an increased risk of meniscal tears. However, studies comparing early versus delayed ACL reconstruction have not clearly demonstrated that meniscal tears diagnosed arthroscopically are new injuries as opposed to concomitant injuries sustained during ACL rupture. Purpose: To determine whether and how delay of ACL reconstruction is associated with risk of "new" meniscal tears (defined as those visualized arthroscopically that had not been detected on magnetic resonance imaging [MRI]) in adult and pediatric patients. Study Design: Cohort study; Level of evidence, 3. Methods: We retrospectively identified patients who underwent primary ACL reconstruction between 2013 and 2022 at our institution. To ensure that MRI reflected initial intra-articular pathology, we included only patients who had an MRI scan within 3 weeks after injury (173 pediatric and 369 adult patients). Multivariate Poisson regression was performed to calculate the adjusted relative risk (ARR) of new meniscal tears after delayed (≥8 weeks from injury) operative treatment. Results: The mean (± SD) time from injury to MRI was 1.0 ± 0.8 weeks for pediatric patients and 1.1 ± 0.7 weeks for adults. Less than half of the meniscal tears observed arthroscopically had been absent on initial MRI. New medial meniscal tears occurred in 15% of pediatric patients and 16% of adults. New lateral meniscal tears occurred in 48% of pediatric patients and 34% of adults. Among pediatric patients, delayed ACL reconstruction was associated with higher risk of new medial tears (ARR, 3.9; 95% CI, 1.5-10) but not lateral tears (ARR, 0.8; 95% CI, 0.4-1.5). In contrast, adults had no significant increase in risk of meniscal tears associated with operative delay. Conclusion: Delayed ACL reconstruction may be acceptable in adults, who may be less active and less injury-prone than children and adolescents.

Medial Discoid Meniscus in Children: A Multicenter Case Series of Clinical Features and Operative Results.

BACKGROUND: The discoid medial meniscus is a rare congenital anomaly of the knee. The literature is limited to small case series. PURPOSE/HYPOTHESIS: Our purpose is to report the clinical manifestations and operative treatments of discoid medial menisci in children from multiple centers in North America. We hypothesized that symptoms and signs, arthroscopic findings, surgical treatments, and outcomes are similar to those for symptomatic discoid lateral menisci. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective review identified patients with a diagnosed discoid medial meniscus confirmed at surgery across 8 children's hospitals between January 2000 and June 2021. The literature on discoid lateral menisci was reviewed and summarized for comparison. RESULTS: A total of 21 patients (9 female, 12 male) with 22 discoid medial menisci were identified. The mean ± SD age at the time of diagnosis was 12.8 ± 3.8 years. The most common symptoms and signs were locking and/or clunking, present in 12 of 22 knees (55%), similar to that reported in patients with discoid lateral menisci. Twelve discoid medial menisci were complete (55%); 8, incomplete (36%); and 2, indeterminate (9%). Tears were present in 13 knees, most commonly horizontal cleavage (54%). Five discoid medial menisci were unstable (23%): 3 for posterior tears and 2 for rim insufficiency. All 22 knees underwent arthroscopic saucerization, and of the 13 torn menisci, 7 (54%) were repaired. The median follow-up was 24 months (range, 2-82 months). Four knees underwent reoperation. All knees that required reoperation had undergone repair for a posteriorly located tear. There was a significant association between operative repair and need for reoperation (P = .0048). High rates of peripheral instability were also noted in case series of patients with discoid lateral menisci. CONCLUSION: Patient presentations and treatments for those with discoid medial menisci were similar to those reported for patients with discoid lateral menisci. Knees with discoid medial menisci also demonstrated instability attributed to peripheral insufficiency and posterior tears. Tears were present in over half of knees with discoid medial menisci, and reoperation was more common in knees that underwent repair of tears than those without repair.

Anterior Displacement of Tibial Spine Fractures: Does Anatomic Reduction Matter?

Background: Operative treatment of displaced tibial spine fractures consists of fixation and reduction of the fragment in addition to restoring tension of the anterior cruciate ligament. Purpose: To determine whether residual displacement of the anterior portion of a tibial spine fragment affects the range of motion (ROM) or laxity in operatively and nonoperatively treated patients. Study Design: Cohort study; Level of evidence, 3. Methods: Data were gathered from 328 patients younger than 18 years who were treated for tibial spine fractures between 2000 and 2019 at 10 institutions. ROM and anterior lip displacement (ALD) measurements were summarized and compared from pretreatment to final follow-up. ALD measurements were categorized as excellent (0 to <1 mm), good (1 to <3 mm), fair (3 to 5 mm), or poor (>5 mm). Posttreatment residual laxity and arthrofibrosis were assessed. Results: Overall, 88% of patients (290/328) underwent operative treatment. The median follow-up was 8.1 months (range, 3-152 months) for the operative group and 6.7 months (range, 3-72 months) for the nonoperative group. The median ALD measurement of the cohort was 6 mm pretreatment, decreasing to 0 mm after treatment (P < .001). At final follow-up, 62% of all patients (203/328) had excellent ALD measurements, compared with 5% (12/264) before treatment. Subjective laxity was seen in 11% of the nonoperative group (4/37) and 5% of the operative group (15/285; P = .25). Across the cohort, there was no association between final knee ROM and final ALD category. While there were more patients with arthrofibrosis in the operative group (7%) compared with the nonoperative group (3%) (P = .49), this was not different across the ALD displacement categories. Conclusion: Residual ALD was not associated with posttreatment subjective residual laxity, extension loss, or flexion loss. The results suggest that anatomic reduction of a tibial spine fracture may not be mandatory if knee stability and functional ROM are achieved.

Racial differences in late-onset Blount disease.

Purpose: Blount disease is most common among obese Black children. The reason for Blount's racial predisposition is unclear. Given that obesity is a risk factor for Blount disease and the known associations between race, obesity, and socioeconomic status in the United States, we hypothesized that socioeconomic status and severity of obesity differ between Black and non-Black children with late-onset Blount disease. We additionally examined differences in treatment types between Black and non-Black children. Methods: One hundred twenty-five patients from two institutions were included. Age at presentation, age of onset, body mass index, race, sex, and treatment type were recorded. These variables were compared between Black and non-Black children. Insurance type and estimated household income were used as markers of socioeconomic status. Results: Of the 125 patients with late-onset Blount disease, body mass index percentiles were higher for Black patients (96th ± 12th percentile) than non-Black patients (89th ± 22nd percentile) (p = 0.04). Black patients also had lower estimated incomes (US$48,000 ± US$23,000 vs US$62,000 ± US$30,000) (p = 0.01) and much higher rates of Medicaid enrollment (69% vs 24%) (p < 0.01) than did non-Black patients. Regarding treatment types, osteotomy was more common among Black patients (60%) than non-Black patients (38%) (p = 0.033). Conclusion: The race-related associations we found between obesity and socioeconomic status suggest that non-genetic factors may contribute to observed racial differences in the prevalence of Blount disease. Level of evidence: level III.

Synovectomy in juvenile idiopathic arthritis: A systematic review and meta-analysis.

BACKGROUND: Juvenile idiopathic arthritis (JIA) is an inflammatory arthropathy with onset in children younger than 16 years. Treatment is primarily medical; however, surgical interventions, such as arthroscopic or open synovectomy, can be beneficial. Many studies have investigated synovectomy in JIA, but the results of these studies have not been synthesized to our knowledge. Therefore, we performed a systematic review of the literature reporting synovectomy as a treatment for JIA to provide clinical recommendations regarding its risks and benefits. METHODS: On March 8, 2022, we searched the Cochrane Library, Embase, PubMed, Scopus, and Web of Science for studies evaluating clinical outcomes of open or arthroscopic synovectomy to treat JIA in patients younger than 18 years. We included only studies published in English and excluded studies of synovectomy to treat other arthropathies, septic arthritis, hemophilia, or foreign body arthropathy. The level of evidence for included studies was determined by using the Oxford Centre for Evidence-Based Medicine criteria. We qualitatively analyzed clinical outcomes data, including patient-reported pain relief, rates of symptom recurrence, and postoperative complications. RESULTS: Of 428 articles assessed, 14 were included in our analysis. One was a randomized trial, 1 was a case-control study, and all others were case-series. Studies consistently reported that synovectomy was associated with improved function and decreased pain postoperatively. However, comparisons with modern medical therapy were lacking. Rates of arthritis recurrence varied, with increasing symptom recurrence with longer follow-up and re-synovectomy rates up to 15%. Oligoarticular disease and early disease course were associated with better response to synovectomy, whereas systemic and polyarticular disease were associated with poor response. Stiffness requiring manipulation under anesthesia was the most common complication (4% of all included patients). CONCLUSION: Although synovectomy is associated with positive functional outcomes and pain reduction postoperatively, there was inadequate comparison thus inadequate evidence to recommend it over modern medical therapy. The current literature suggests that synovectomy should be offered only to patients for whom medical management has failed, while noting the risks of decreased range of motion and symptom recurrence over time.

Understanding the Cheerleader as an Orthopaedic Patient: An Evidence-Based Review of the Literature.

Cheerleading is a highly popular youth sport in the United States and has been increasingly recognized in recent years for its athleticism and competitive nature. The sport has changed dramatically since its inception. When the sport of cheerleading was first developed, its primary purpose was to entertain crowds and support other athletes. Today, cheerleaders are competitive athletes themselves. Cheerleaders, most of whom are in the pediatric age group, and their parents commonly approach orthopaedic surgeons and sports medicine physicians with questions regarding the risks associated with participation in the sport. Appropriate clinical guidance is especially important for athletes returning to the sport after an injury. However, unlike other popular sports (eg, football, basketball, and volleyball), the intricacies of cheerleading are not well-known to those outside the sport, including many health care providers. Previous studies have reported on the epidemiological patterns of injuries associated with cheerleading and how such aesthetic sports affect the body, finding that fractures and concussions are prevalent and that catastrophic injuries are more common than in most other sports. Here, we provide an evidence-based discussion of 10 pertinent topics regarding cheerleading and its risks to the musculoskeletal system. The purpose of this review is to provide a comprehensive resource for orthopaedic surgeons and sports medicine physicians who care for these athletes.

Is Nonoperative Treatment Appropriate for All Patients With Type 1 Tibial Spine Fractures? A Multicenter Study of the Tibial Spine Research Interest Group.

Background: Type 1 tibial spine fractures are nondisplaced or ≤2 mm-displaced fractures of the tibial eminence and anterior cruciate ligament (ACL) insertion that are traditionally managed nonoperatively with immobilization. Hypothesis: Type 1 fractures do not carry a significant risk of associated injuries and therefore do not require advanced imaging or additional interventions aside from immobilization. Study Design: Case series; Level of evidence, 4. Methods: We reviewed 52 patients who were classified by their treating institution with type 1 tibial spine fractures. Patients aged ≤18 years with pretreatment plain radiographs and ≤ 1 year of follow-up were included. Pretreatment imaging was reviewed by 4 authors to assess classification agreement among the treating institutions. Patients were categorized into 2 groups to ensure that outcomes represented classic type 1 fracture patterns. Any patient with universal agreement among the 4 authors that the fracture did not appear consistent with a type 1 classification were assigned to the type 1+ (T1+) group; all other patients were assigned to the true type 1 (TT1) group. We evaluated the rates of pretreatment imaging, concomitant injuries, and need for operative interventions as well as treatment outcomes overall and for each group independently. Results: A total of 48 patients met inclusion criteria; 40 were in the TT1 group, while 8 were in the T1+ group, indicating less than universal agreement in the classification of these fractures. Overall, 12 (25%) underwent surgical treatment, and 12 (25%) had concomitant injuries. Also, 8 patients required additional surgical management including ACL reconstruction (n = 4), lateral meniscal repair (n = 2), lateral meniscectomy (n = 1), freeing an incarcerated medial meniscus (n = 1), and medial meniscectomy (n = 1). Conclusion: The classification of type 1 fractures can be challenging. Contrary to prior thought, a substantial number of patients with these fractures (>20%) were found to have concomitant injuries. Overall, surgical management was performed in 25% of patients in our cohort.

Reliability of a New Arthroscopic Discoid Lateral Meniscus Classification System: A Multicenter Video Analysis.

BACKGROUND: The discoid lateral meniscus (DLM) is one of the most common congenital anomalies of the knee. The pathomorphology of DLM varies. Current classification systems are inadequate to describe the spectrum of abnormality. PURPOSE: A study group of pediatric orthopaedic surgeons from 20 academic North American institutions developed and tested the reliability of a new DLM classification system. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: After reviewing existing classifications, we developed a comprehensive DLM classification system. Four DLM features were evaluated: meniscal width, meniscal height, peripheral stability, and meniscal tear. Stepwise arthroscopic examination using anteromedial and anterolateral viewing portals was established for evaluating these features. Three senior authors who were not observers selected 50 of 119 submitted videos with the best clarity and stepwise examination for reading. Five observers performed assessments using the new classification system to assess interobserver reliability, and a second reading was performed by 3 of the 5 observers to assess intraobserver reliability using the Fleiss κ coefficient (fair, 0.21-0.40; moderate, 0.41-0.60; substantial, 0.61-0.80; excellent, 0.81-1.00). RESULTS: Interobserver reliability was substantial for most rating factors: meniscal width, meniscal height, peripheral stability, tear presence, and tear type. Interobserver reliability was moderate for tear location. Intraobserver reliability was substantial for meniscal width and meniscal height and excellent for peripheral stability. Intraobserver agreement was moderate for tear presence, type, and location. CONCLUSION: This new arthroscopic DLM classification system demonstrated moderate to substantial agreement in most diagnostic categories analyzed.

Pediatric ACL Revision Using Salvaged Iliotibial Band Autograft in a Physeal-Sparing Multiligamentous Knee Reconstruction: A Case Report.

CASE: Iliotibial band (ITB) autograft is used for anterior cruciate ligament (ACL) reconstruction in prepubescent patients. No reports have described ITB salvage techniques for failed reconstruction. We describe a 13-year-old boy who sustained a multiligamentous knee injury, experienced a failed primary reconstruction, and required a revision ITB ACL, lateral collateral ligament, and posterior lateral corner reconstruction with reuse of his ITB autograft. At the 2-year follow-up, he returned to playing competitive sports. CONCLUSION: This case shows that salvage of an ITB ACL autograft can be an option in early reconstruction failure.

Progress in Cheerleading Safety: Update on the Epidemiology of Cheerleading Injuries Presenting to US Emergency Departments, 2010-2019.

BACKGROUND: Although the athleticism required of cheerleaders has increased, the risks of cheerleading have been less studied as compared with other sports. PURPOSE: To update our understanding of the epidemiology of cheerleading-related injuries. STUDY DESIGN: Descriptive epidemiology study. METHODS: We analyzed the National Electronic Injury Surveillance System (NEISS) for cheerleading-related injuries presenting to nationally representative emergency departments (EDs) in the United States from January 2010 through December 2019. Extracted data included patient age and sex, injury characteristics (diagnosis, body region injured, time of year, and location where injury occurred), and hospital disposition. Using patient narratives, we recorded the cheerleading skills, settings, and mechanisms that led to injury. NEISS sample weights were used to derive national estimates (NEs) from actual case numbers. RESULTS: From 2010 to 2019, a total of 9868 athletes (NE = 350,000; 95% CI, 250,000-450,000) aged 5-25 years presented to US EDs for cheerleading injuries. The annual number of injuries decreased by 15%, from 982 (NE = 35,000; 95% CI, 27,000-44,000) to 897 (NE = 30,000; 95% CI, 18,000-42,000) (P = .048), corresponding to a 27% decline in the injury rate per 100,000 cheerleaders (P < .01). The annual number of injuries caused by performing stunts decreased by 24%, from 240 (NE = 8700; 95% CI, 6700-11,000) to 216 (NE = 6600; 95% CI, 4000-9200) (P = .01), with a 36% decline in the corresponding injury rate per 100,000 cheerleaders (P < .01). Despite these decreases, annual incidence of concussions/closed head injuries increased by 44%, from 128 (NE = 3800; 95% CI, 2900-4700) to 171 (NE = 5500; 95% CI, 3400-7700) (P = .02), and patients requiring hospital admission increased by 118%, from 18 (NE = 330; 95% CI, 250-410) to 24 (NE = 720; 95% CI, 440-1000) (P < .01). The hospital admission rate increased by 9.0% (P = .02). CONCLUSION: The number of cheerleading-related injuries presenting to US EDs decreased from 2010 to 2019. However, the incidence of concussions/closed head injuries and hospital admissions increased, suggesting that further measures are needed to improve safety for cheerleaders.