Genu Valgum in Pediatric Patients Presenting With Patellofemoral Instability.

BACKGROUND: Lower extremity valgus is a commonly described factor associated with patellofemoral instability (PFI) and, if identified before skeletal maturity, can be treated with guided growth. The prevalence of valgus alignment in the pediatric and adolescent PFI population is largely unknown. PURPOSE: The aim of this study was to report the prevalence of valgus alignment in adolescent patients presenting with PFI; with secondary assessment of high-grade valgus (zone II or III), coronal asymmetry, and associations of these findings with body mass index (BMI). STUDY DESIGN: A retrospective cohort study. METHODS: A total of 279 consecutive patients (349 knees) with a diagnosis of PFI presenting to a single orthopedic pediatric sport medicine surgeon were identified. A retrospective chart review was performed to collect demographic and clinical data, chronologic and bone age, sex, BMI, mechanism of injury, and the presence of osteochondral fracture. Full-length standing hip-to-ankle alignment radiographs were graded for knee alignment mechanical zone utilizing standard linear femoral head center to talar center assessment. In addition, mechanical axis deviation, mechanical lateral distal femoral angle and medial proximal tibial angle (MPTA) were also calculated. RESULTS: Mean patient age was 14.0±2.5 years. There were 162 (58.1%) females and mean BMI was 24.3±6.4. Seventy patients (25.1%) had bilateral PFI. Standing alignment radiographs were available for 81.4% of knees (n=284). Valgus alignment was present in 172 knees with PFI (60.6%). High-grade valgus, defined as zone 2 or greater, was present in 66 knees (23.3%). Overall, 48.9% had asymmetry of coronal alignment (n=139). The mean mechanical lateral distal femoral angle was 85.4±2.8 and the mean MPTA was 88.2±2.6. There was a greater MPTA in female patients (88.8±2.4 vs. 87.5±2.7, P <0.001). A higher BMI (24.87±6.95, P =0.03) was associated with valgus alignment. CONCLUSIONS: There is a high (60%) prevalence of lower extremity valgus in adolescent patients presenting with PFI, with nearly 1 in 4 presenting with high-grade valgus. The treatment team should be aware of this association as it may be an important consideration in the pediatric and adolescent PFI populations. LEVEL OF EVIDENCE: Level III.

Changes in Fracture Shortening Occur in the First 2 Weeks Following Completely Displaced Adolescent Clavicle Fractures.

BACKGROUND: Shortening of midshaft clavicle fractures has been described as a critical fracture characteristic to guide treatment. The degree to which shortening may change in the initial weeks following injury has not been well studied. The purpose of this study was to evaluate the change in shortening of adolescent clavicle fractures in the first 2 weeks following injury. METHODS: This was a multicenter study of prospectively collected data, which was acquired as a part of a cohort study of adolescent clavicle fractures. A consecutive series of patients 10 to 18 years of age with completely displaced diaphyseal clavicle fractures with baseline radiographs 0 to 6 days from the date of injury, as well as 7 to 21 days from the date of injury, were included. Measurements of end-to-end (EES) and cortex-to-corresponding-cortex (CCS) shortening were performed. RESULTS: A total of 142 patients were included. Baseline radiographs were obtained at a mean of 1.0 day following injury with mean EES of 22.3 mm, and 69% of patients demonstrating >20 mm of shortening. Follow-up radiographs obtained at a mean of 13.8 days postinjury demonstrated a mean absolute change in EES of 5.4 mm. Forty-one percentage of patients had >5 mm of change in EES. When analyzing changes in shortening relative to the specific threshold of 20 mm, 18 patients (41%) with <20 mm EES increased to ≥20 mm EES, and 19 patients (19%) with ≥20 mm EES decreased to <20 mm EES at 2-week follow-up. CONCLUSIONS: Clinically significant changes in fracture shortening occurred in 41% of adolescents with completely displaced clavicle fractures in the first 2 weeks after injury. In 26% of patients, this resulted in a change from above or below the commonly used shortening threshold of 20 mm, potentially altering the treatment plan by many providers. There is no evidence to suggest that adolescent clavicle fracture shortening affects outcomes, and as such, the authors do not advocate for the use of this parameter to guide treatment. However, among physicians who continue to use this parameter to guide treatment, this study supports that repeat radiographic assessment 2 weeks postinjury may be a better measure of the true shortening of this common adolescent injury. LEVEL OF EVIDENCE: Level IV-case series.

What's New in the Management of Pediatric Anterior Cruciate Ligament Tears and Tibial Spine Fractures.

As the number of pediatric and adolescent patients participating in sports continues to increase, so too does the incidence of anterior cruciate ligament (ACL) tears in this population. There is increasing research on pediatric and adolescent ACL tears; hundreds of articles on the topic have been published in the past few years alone. It is important to highlight the most pertinent information in the past decade. In discussing pediatric ACL tears, it is also important to review tibial spine fractures. These injuries are rightfully grouped together because tibial spine fractures often occur with a mechanism of injury similar to that of ACL tears, but typically in a younger age group. Because management is different, understanding the similarities and differences between the two pathologies is important. Recent updates on the epidemiology, diagnosis, management, and outcomes of both pediatric ACL tears and tibial spine fractures need to be reviewed.

What's New in Osteochondritis Dissecans of the Knee, Elbow, and Ankle.

Osteochondritis dissecans is a condition of the subchondral bone, with secondary effects on the articular cartilage. It most commonly affects the knee, elbow, and ankle and is typically seen in young, active populations. Many osteochondritis dissecans lesions are asymptomatic, but more advanced lesions can cause pain, swelling, and mechanical symptoms. Multiple treatment options have been proposed, including nonsurgical and surgical approaches. It is important to be aware of the epidemiology, presenting symptoms, and indications for nonsurgical and surgical treatment options for osteochondritis dissecans of the knee, elbow, and ankle.

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

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

Patellar-Trochlear Morphology in Pediatric Patients From 2 to 11 Years of Age: A Descriptive Analysis Based on Computed Tomography Scanning.

BACKGROUND: Despite the critical role the trochlea plays in patellofemoral (PF) pathology, the development of the trochlea is poorly understood. The purpose of this study was 2-fold: (1) Describe quantitative osseous and soft tissue anatomy of the patella and trochlea in skeletally immature cadaveric specimens utilizing known measurements used in PF instability, and (2) evaluate additional measurement techniques in the sagittal plane as they relate to PF morphologic development. METHODS: Thirty-one skeletally immature fresh frozen cadaveric knees between the ages of 2 and 11 years old were evaluated using 0.625 mm computed tomography scans. In the axial plane, measurements included condylar height asymmetry, trochlear facet asymmetry, trochlear depth, osseous sulcus angle, cartilaginous sulcus angle, patella sulcus angle, and tibial tubercle-trochlear groove distance. In the sagittal plane, measurements included previously undescribed measurements of trochlear length and condylar height asymmetry which are based on the anterior femoral cortex. RESULTS: Analysis of trochlear morphology using condylar height asymmetry (both axial and sagittal), trochlear facet asymmetry, and trochlear depth and length demonstrated an increase in the size of the medial and lateral trochlea as age increased. There was more variability in the change of size of the medial trochlea (height, length, and facet length) than the lateral trochlea. The osseous sulcus angle, cartilaginous sulcus angle, and patella sulcus angle decreased (became deeper) with age until after 8 years and then plateaued. CONCLUSIONS: This cadaveric analysis demonstrated that there is an increase in the medial and lateral trochlear height as age increased by all measurements analyzed. The findings also demonstrate that the shape of the patella and trochlea change concurrently, which suggests that there may be interplay between the 2 during development. These new sagittal measurement techniques evaluating the medial, central, and lateral trochlear height and length with respect to age may help guide clinicians when investigating patellar instability in skeletally immature patients. LEVELS OF EVIDENCE: Level IV.

Is Anteromedial Drilling Safe in Transphyseal Anterior Cruciate Ligament Reconstruction in Adolescents with Growth Remaining?

BACKGROUND: Previous reports of transphyseal drilling in anterior cruciate ligament (ACL) reconstruction have demonstrated good clinical outcomes without subjective changes in further skeletal development. The purpose of this study is to evaluate radiographic changes during continued growth following a transphyseal ACL reconstruction using an anteromedial femoral (AM) drilling technique in patients with >18 months of growth remaining. METHODS: A review of consecutive adolescents who underwent a soft tissue transphyseal ACL reconstruction using an AM drilling technique was performed. Inclusion criteria was 18 months of growth remaining based on radiographic bone age and standing radiographs at least one year from the index procedure. Demographic, preoperative, and postoperative data, and follow-up three-foot standing lower extremity radiographs were reviewed. Radiographic data included femoral length, tibial length, total lower extremity length, mechanical axis deviation (MAD), lateral distal femoral angle (LDFA), and medial proximal tibial angle (MPTA). RESULTS: In total 12 adolescent patients with a mean age of 13.4 years (range, 12.3 to 14.4) and bone age of 13.4 years (11.5 to 14) at the time of surgery were included. At an average of 2.27-year follow-up (412 to 1058 d), there was no difference in the total growth of the operative and nonoperative limb (48.5 mm vs. 47 mm; P=0.36). In addition, the average increases in femoral length (23.4 mm) and tibial length (25.8 mm) were not statistically different between the operative and the nonoperative limb (P=0.12; P=0.75). There was no statistical difference in mechanical axis deviation, LDFA, or MPTA between preoperative and postoperative radiographs. Mean differences in operative and nonoperative coronal angular changes were all <1.5 degrees. CONCLUSIONS: With at least 2 years of growth remaining, transphyseal ACL reconstruction with anteromedial drilling did not significantly affect the physis or residual growth compared with the contralateral extremity. Although this technique may create a larger defect in the physis, standing radiographs demonstrate there is no change in limb length or angulation in growing adolescents approximately 2 years after surgery. LEVEL OF EVIDENCE: This is a case series; Level IV evidence.

Adolescent clavicle nonunions: potential risk factors and surgical management.

BACKGROUND: Clavicle nonunions in adolescent patients are exceedingly rare. The purpose of this study was to evaluate a series of clavicle nonunions from a pediatric multicenter study group to assess potential risk factors and treatment outcomes. METHODS: A retrospective review of all clavicle nonunions in patients younger than 19 years was performed at 9 pediatric hospitals between 2006 and 2016. Demographic and surgical data were documented. Radiographs were evaluated for initial fracture classification, displacement, shortening, angulation, and nonunion type. Clinical outcomes were evaluated, including rate of healing, time to union, return to sports, and complications. Risk factors for nonunion were assessed by comparing the study cohort with a separate cohort of age-matched patients with a diaphyseal clavicle fracture. RESULTS: There were 25 nonunions (mean age, 14.5 years; range, 10.0-18.9 years) identified, all of which underwent surgical fixation. Most fractures were completely displaced (68%) initially, but 21% were partially displaced and 11% were nondisplaced. Bone grafting was performed in 24 of 25 cases, typically using the hypertrophic callus. Radiographic healing was achieved in 96% of cases. One patient (4%) required 2 additional procedures to achieve union. The primary risk factor for development of a nonunion was a previous history of an ipsilateral clavicle fracture. CONCLUSIONS: Clavicle nonunions can occur in the adolescent population but are an uncommon clinical entity. The majority occur in male patients with displaced fractures, many of whom have sustained previous fractures of the same clavicle. High rates of union were achieved with plate fixation and the use of bone graft.

Distal Femoral Valgus and Recurrent Traumatic Patellar Instability: Is an Isolated Varus Producing Distal Femoral Osteotomy a Treatment Option?

BACKGROUND: Genu valgum, a risk factor for recurrent patellofemoral instability, can be addressed with a varus producing distal femoral osteotomy (DFO). The purpose of this study is to report 3-year clinical and radiographic outcomes on a series of skeletally mature adolescents with traumatic patellofemoral instability and genu valgum who underwent a varus producing DFO. METHODS: Consecutive patients (n=11) who underwent an isolated DFO for recurrent traumatic patellar instability over a 4-year study period (2009 to 2012) were reviewed. All patients were below 19 years of age, skeletally mature, had ≥2 patellar dislocations, genu valgum (≥ zone II mechanical axis) and failed nonoperative treatment. Exclusion criteria included less than three-year follow-up, congenital or habitual patellar instability, osteotomy indicated for pathology other than patellar instability, or biplanar osteotomies. Demographic, clinical, and radiographic data were retrospectively analyzed. Recurrence of instability and outcome measures (Kujala and Tegner Activity Scale) were collected at final followed-up prospectively. RESULTS: Ten of 11 patients (average age, 16 y; range, 14 to 18 y; 4 male individuals: 7 female individuals) with an average follow-up of 4.25 years (range, 3.2 to 6.0 y) met inclusion criteria. The average body mass index (BMI) of all patients was 31.3 (range, 19.7 to 46.8) with 91% considered overweight (BMI>25) and 55% obese (BMI>30). The average preoperative lateral distal femoral angle was 75.4 degrees with an average correction of 10.4 degrees (range, 7 to 12 degrees) (P<0.001). Mean patellar height ratios were reduced; with Caton-Deschamps Index significantly reduced to 1.08 (range, 0.86 to 1.30) (P<0.005). The average postoperative Kujala score was 83.6 (range, 49 to 99) with 7 subjects (70%) reporting good to excellent function (Kujala > 80) and 8 (80%) having no further episodes of instability. The mean postoperative Tegner activity score was 5.5 (range, 3 to 7). CONCLUSIONS: A distal femoral varus producing osteotomy may change radiographic parameters associated with patellar instability and improve clinical outcomes by reducing symptomatic patellofemoral instability in this patient population. LEVEL OF EVIDENCE: Level IV.

Segmental metadiaphyseal humeral bone loss in pediatric trauma patients: a case series.

BACKGROUND: The management of posttraumatic bone loss is complicated and often requires complex reconstructive procedures. No options exist that are specific to the treatment of the growing skeleton that has intercalary bone loss. We have observed reconstitution of the humerus in 2 cases that have precluded extensive management. METHODS: Two pediatric patients sustained traumatic injuries to the upper extremities, including humeral bone loss, and are presented after spontaneous reconstitution of the segmental bone loss. RESULTS: With treatment restricted to soft-tissue injury and bone stabilization with external fixation, both patients demonstrated radiographic healing of humeral segmental bone loss. Both patients were thought to have a partially intact periosteal sleeve. They have returned to sporting activities with mild loss of function. CONCLUSIONS: In certain pediatric injuries, spontaneous healing of segmental bone defects can occur. This response may obviate the need for complex, interventional procedures. LEVELS OF EVIDENCE: Level IV-case series.

Physeal Bar Formation After Pediatric Medial Malleolus Fractures.

Pediatric medial malleolus fractures are commonly Salter-Harris (SH) type III or IV fractures of the distal tibia and are associated with a risk of physeal bar formation and subsequent growth disturbance. The purpose of this study was to determine the incidence of physeal bar formation following pediatric medial malleolus fracture and evaluate for patient and fracture characteristics predictive of physeal bar formation. Seventy-eight consecutive pediatric patients during a 6-year period who had either an isolated medial malleolar or a bimalleolar ankle fracture were retrospectively reviewed. Forty-one of 78 patients had greater than 3 months of radiographic follow-up and comprised the study population. Medical records were reviewed for demographic information, mechanism of injury, treatment, and need for further surgery. Radiographs were reviewed to assess for initial fracture displacement, adequacy of fracture reduction, SH type, percentage of the physeal disruption from the fracture, and physeal bar formation. Twenty-two of 41 patients (53.7%) developed a physeal bar. The mean time to diagnosis of physeal bar was 4.9 months (range, 1.6-11.8 months). Twenty-seven percent (6 of 22) of bars were diagnosed at greater than 6 months from injury. Adequacy of reduction was predictive of physeal bar formation, although all patients were reduced to within 2 mm. The mean residual displacement of patients with a bar was 1.2 mm compared with 0.8 mm for those without a bar (P=.03). Because the bar formation rate is greater than 50% on radiographs, routine radiographic assessment of all pediatric medial malleolar fractures should continue for at least 12 months after injury. [Orthopedics. 2024;47(1):e33-e37.].

Trends in Nutrition-Related Risk Factors Identified Post-Operatively in Patients Treated for a Lower-Extremity Injury.

This study investigated trends within a custom Sports Nutrition Assessment for Consultation (SNAC) survey designed to identify nutrition-related risk factors among post-operative lower-extremity youth athletes. Athletes aged 8-18 years who completed the SNAC at a sports medicine institution after lower-extremity surgery were reviewed for associations between SNAC questions and age/sex differences. Of 477 patients (15.0 ± 2.0 years; 47.8% female), 319 (66.9%) answered 'yes' to at least one question and were identified for a consult, though 216 (64.3%) declined. The most frequent questions to prompt a consult were a desire to better understand nutrition for recovery (41.5%) and regularly skipping at least one meal a day (29.8%). Inter-question responses were often significantly related, especially regarding appetite changes, weight changes, and/or meal-skipping. While consult acceptance was not significantly different between sex/age, males were more likely to report a desire to better understand nutrition (p = 0.004) and a weight change (p = 0.019), and females were more likely to report struggling with dizziness/fatigue (p < 0.001). Additionally, older athletes reported an appetite change (p = 0.022), meal-skipping (p = 0.002), a desire to better understand nutrition (p < 0.001), a weight change (p < 0.001), and an effort/recommendation to change their body composition/weight (p = 0.005). These findings demonstrate a link between risky nutrition behaviors and physical detriments.

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.

Avulsion and Soft Tissue Injuries of the Ulnar Collateral Ligament in Children and Adolescents.

BACKGROUND: Although pediatric medial epicondylar fractures and apophysitis are well studied, patterns of subapophyseal avulsion and ligamentous injuries of the medial elbow in this population merit investigation to inform optimal treatment strategies. PURPOSE: To describe the occurrence and demographic correlates of ulnar collateral ligament (UCL) avulsion and soft tissue injuries of the pediatric and adolescent elbow. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: An institutional review board-approved review was conducted to identify consecutive patients with medial elbow injuries treated in a tertiary pediatric sports medicine practice between 2016 and 2021. Radiographs were obtained during injury evaluation, and patients with nondisplaced medial epicondylar apophysitis and complete epicondylar fracture were excluded, resulting in 150 patients with soft tissue injuries occurring distal to the medial epicondyle apophysis (subapophyseal) for study. Radiographs were evaluated for bony avulsion of the UCL from either the medial epicondyle proximally or the ulnar sublime tubercle distally. Injuries without radiographic evidence of bony avulsion, but with clinical examination findings consistent with ligamentous injury, were classified as radiographically negative UCL injuries, and magnetic resonance imaging (MRI) was performed to further evaluate these injuries if moderate to severe medial swelling of the elbow or significant concern for medial structural injury was present on examination. These MRI scans were evaluated to classify the UCL injury and assess for periosteal or cartilaginous avulsions. RESULTS: A total of 150 patients (mean age, 12.5 ± 3.4 years; 70 female), 55% (150/274) of the entire medial elbow injury population, had a subapophyseal injury. Of these patients, 62 had a bony avulsion detected on radiograph, and 88 had a radiographically negative injury. In addition to the 62 radiographic avulsions, the 61 MRI scans obtained on those radiographically negative injuries revealed 33 complete UCL disruptions, resulting in 63.3% (95/150) of patients sustaining a complete ligamentous disruption. With the MRI scans, 37 (61%) cases of cartilaginous or periosteal avulsion of the UCL were diagnosed. Overall, 66% of all 150 subapophyseal injuries had a bony, cartilaginous, or periosteal UCL avulsion. Patients with cartilaginous (mean age, 10.3 years) and bony (mean age, 10.6 years) avulsions were younger than those with central ligament injury (mean age, 14.2 years) or periosteal (mean age, 14.2 years) avulsions (P = .005). There was a significant association between the mechanism of injury and the location of UCL tear identified on MRI scans: traumatic falls were associated with distal tears, and throwing injuries were associated with proximal tears (P < .001). CONCLUSION: UCL central ligament and avulsion lesions may be frequently diagnosed after injury to the pediatric medial elbow, the majority of which are complete injuries, and may require MRI for diagnosis. The mechanism of injury may predict the location of ligamentous injury, and osteocartilaginous avulsions are more likely to present at younger ages than injuries to the soft tissue of the UCL or periosteum. The prevalence of these injuries merits further investigation into best protocols of nonoperative treatment or surgical repair techniques and outcomes.

Knee Flexion Angle of Fixation During Anterolateral Ligament Reconstruction or Lateral Extra-articular Tenodesis: A Systematic Review and Meta-analysis of Lateral Extra-articular Reinforcement Techniques Performed in Conjunction With ACL Reconstruction.

Background: Anterolateral ligament reconstruction (ALLR) or lateral extra-articular tenodesis (LET) is being used more frequently in conjunction with anterior cruciate ligament reconstruction (ACLR). However, the knee flexion angle at which fixation of ALLR or LET is performed during the procedure is quite variable based on existing technique descriptions. Purpose/Hypothesis: The purpose of this study was to identify whether flexion angle at the time of ALLR/LET fixation affected postoperative outcomes in a clinical population. It was hypothesized that ALLR/LET fixation at low versus high flexion angles would lead to no statistically significant differences in patient-reported outcome measures and graft failure rates. Study Design: Systematic review; Level of evidence, 4. Methods: The PubMed, Embase, and Cochrane Library databases were searched according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to identify published clinical studies of ACLR with ALLR/LET in which the knee flexion angle at the time of ALLR/LET was reported. A priori, low flexion was defined as 0° to 30°, and high flexion was defined as 60° to 90°. Studies were excluded if the flexion angle was between 31° and 59° because these angles constituted neither low nor high flexion angles and including them in an analysis of high versus low flexion angle at fixation would have biased the study results toward the null. The overall risk of bias was assessed using the Newcastle-Ottawa Scale. The pooled results of the studies were analyzed using the International Knee Documentation Committee (IKDC), Lysholm, and Tegner scores, along with reported graft failure rates. Results: A total of 32 clinical studies (5230 patients) met inclusion criteria: 22 studies (1999 patients) in the low-flexion group and 10 studies (3231 patients) in the high-flexion group. The median Newcastle-Ottawa Scale score was 6. Comparisons of patients with a low flexion angle versus a high flexion angle demonstrated no differences in the IKDC (P = .84), Lysholm (P = .67), or Tegner (P = .44) scores or in graft failure (3.4% vs 4.1%, respectively; P = .69). Conclusion: The results of this review indicated that ACLR performed in conjunction with ALLR/LET provides good to excellent patient-reported outcomes and low graft failure rates when ALLR/LET fixation is performed in either low or high knee flexion.

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.

5-Year Radiographic and Functional Outcomes of Nonoperative Treatment of Completely Displaced Midshaft Clavicular Fractures in Teenagers.

BACKGROUND: Optimal treatment of completely displaced midshaft clavicular fractures in adolescents remains controversial, with some favoring surgical management and others favoring a nonoperative approach. Few studies have comprehensively assessed longer-term nonoperative outcomes. PURPOSE: To prospectively assess patient-reported outcomes (PROs) and radiographic remodeling ≥5 years after injury in teenagers undergoing nonoperative treatment of completely displaced clavicular fractures. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Adolescent patients previously enrolled in a prospective study from a single institution with nonoperatively treated, completely displaced midshaft clavicular fractures ≥5 years from injury were eligible for the study. Patients were clinically evaluated for scapular dyskinesia and strength deficits. Bilateral clavicular imaging assessed residual shortening, displacement, and angulation. PROs included the American Shoulder and Elbow Surgeons (ASES), the shortened version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH), Marx Shoulder Activity Scale, cosmesis, and return to sports data. RESULTS: A total of 24 patients were available for the follow-up, of whom 17 (71%) consented to additional imaging. The mean cohort age at the time of injury was 14.5 ± 1.1 years, with 88% being male. At a mean follow-up of 6.1 years, all fractures had healed, with no patient requiring secondary interventions. Significant remodeling was observed across all measurements, with improvements of 70% in shortening (22.8 to 6.8 mm; P < .001), 73% in superior displacement (13.4 to 3.6 mm; P < .001), and 83% in angulation (10.4° to 1.8°; P < .001). Thirteen patients (72%) had a >2-cm initial shortening, and all remodeled to <2 cm. PROs were almost universally excellent, with mean ASES, QuickDASH, and Marx activity scores of 99 ± 3, 1 ± 3, and 20 ± 1, respectively, with 79% of patients reporting perfect scores in all 3 domains. Most patients (58%) were completely satisfied with their shoulder appearance, 38% were more satisfied than not, 1 patient (4%) was neither satisfied nor dissatisfied, and no patients were dissatisfied. All patients except 1 who were interested in sports returned to sporting activities. PROs were not associated with bony remodeling (P > .05). CONCLUSION: Teenaged patients with completely displaced clavicular fractures treated nonoperatively can expect excellent radiographic and clinical outcomes 5 years after injury.

Nonoperative Versus Operative Treatment of Z-Type Comminuted Clavicle Fractures in Adolescents: A Prospective Substratified Cohort Analysis.

OBJECTIVES: To compare the clinical, radiographic, and patient-reported outcomes of nonoperative and operative treatment of adolescents with comminuted "Z-type" midshaft clavicle fractures. DESIGN: Prospective observational cohort. SETTING: Eight tertiary care pediatric centers. PATIENT SELECTION CRITERIA: Patients aged 10-18 years who were treated either operatively or nonoperatively for a diaphyseal clavicle fracture between 2013 and 2017 were screened/enrolled at the time of injury. The current subcohort analysis was derived from a larger adolescent clavicle study population of 907 patients. OUTCOME MEASUREMENTS AND COMPARISONS: Complications and validated patient-reported outcome measures (PROs):(ASES, QuickDASH, Marx Shoulder Activity Score, EQ-5D, EQ-VAS, and patient satisfaction score) were compared between operative and nonoperative cohorts. RESULTS: Eighty-one patients (69 male [85.2%], 12 female; average age 15 years [11.1-18.7]; 78 with sports participation [96.2%]) were followed through bony healing and return to sports, while 59 patients (73%) completed 2-year follow-up with PROs, 26 of whom were treated nonoperatively and 33 treated operatively. All demographic and fracture characteristics were similar (P > 0.05) between the 2-year follow-up cohorts except for fracture shortening, which was greater in the operative cohort (23 vs. 29 mm, P = 0.01). After controlling for this potential confounder through both regression and propensity matched subgroup analysis, nonoperative versus operative cohorts showed no difference in rates of nonunion (0%), delayed union (0% vs. 2.3%, P = 1.0), symptomatic malunion (2.7% vs. 0%, P = 0.4), refracture (2.7% vs. 2.2%, P = 1.0), unexpected subsequent surgery (5.4% vs. 11.4%, P = 0.45), or clinically significant complications (5.4% vs. 16%, P = 0.17). There were no differences in any PROs between cohorts, both before and after controlling for the difference in fracture shortening (all P-values >0.05). CONCLUSIONS: In this prospective comparison of complications and 2-year PROs in adolescents with comminuted Z-type clavicle fractures, nonoperative and operative treatment yielded similar outcomes. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Impact of tunnels and tenodesis screws on clavicle fracture: a biomechanical study of varying coracoclavicular ligament reconstruction techniques.

PURPOSE: The purpose of this study was to compare the load to fracture of distal clavicles with no tunnels, one tunnel, or 2 tunnels and to evaluate the effect of inserting tenodesis screws in the tunnels on load to fracture of the distal clavicle. METHODS: Fifty right sawbone clavicles were obtained and divided into 5 groups (n = 10): group 1, normal clavicle; group 2, one tunnel, no tenodesis screw; group 3, 2 tunnels, no tenodesis screws; group 4, one tunnel with tenodesis screw; and group 5, 2 tunnels with 2 tenodesis screws. Tunnels were created using a 5-mm-diameter reamer, and 5.5 × 10 mm polyethyl ethyl ketone tenodesis screws were used. A 4-point bending load was applied to the distal clavicles. Load to failure was noted for each specimen. RESULTS: Load to failure in clavicles without tunnels was significantly higher (1,157.18 ± 147.10 N) than in all other groups (P < .0005). No statistical differences were noted between groups 2, 3, 4, and 5. Load to failure was not statistically different in clavicles with one versus 2 tunnels. In addition, the use of tenodesis screws in the tunnels did not affect the load required to fracture. CONCLUSIONS: The use of tunnels in the clavicle for coracoclavicular (CC) ligament reconstruction significantly reduces the load required to fracture the distal clavicle. The addition of tenodesis screws does not appear to significantly increase the strength of the clavicle in this construct. CLINICAL RELEVANCE: CC ligament reconstruction techniques commonly use tunnels in the distal clavicle, which may render the clavicle more susceptible to fracture. This study helps quantify the effect of these tunnels on the strength of the distal clavicle.

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.