Medial Patellofemoral Ligament Reconstruction Improves Patella Alta.

BACKGROUND: Patellofemoral instability (PFI) is a common problem with various anatomic risk factors identified, including patella alta as one of the most powerful predictors. Given that the medial patellofemoral ligament (MPFL) is the primary soft tissue stabilizer of the patella, a common procedure to treat recurrent patellar instability is MPFL reconstruction. The aim of this study is to examine the relationship between MPFL reconstruction and patellar height. We hypothesize that after reconstruction, patellar instability patients would have demonstrable reduction in patella height and patella alta correction. METHODS: Patient records were queried for patients who underwent MPFL reconstruction for recurrent patellar instability. Patient and operative demographics were collected. We measured Insall-Salvati ratio (ISR), Caton Deschamps index (CDI), and Blackburne-Peel ratio (BPR) in all patients at various time points. The height indices were compared across the preoperative, immediately postoperative, and 6-month time points in a pairwise fashion using paired-sample t-tests. Further subgroup analysis of patients (n=27) with elevated preoperative Caton Deschamps Index (defined as >1.3) was completed. RESULTS: The final cohort was 103 patients. There was a significant difference between pre- and postoperative ISR (P<0.001) and at 6-month follow up (P<0.001), between preoperative CDI and the 6-month follow-up (P<0.0010), and between the postoperative and preoperative CDI (P<0.001). There was also a difference between preoperative and postoperative BPR (P<0.001), as well as between the preoperative and 6-month follow-up BPR (P=0.002). Twenty-seven patients had an initial CDI greater than 1.3. Differences were observed between pre- and postoperative mean CDI (P=0.001) and at 6-month follow-up (P=0.006), between both postoperative and 6-month ISR (both P<0.001), and preoperative mean BPR and the postoperative (P=0.004) and 6-month mean BPR (P=0.027). CONCLUSIONS: Patients with pre-existing patella alta and recurrent patella dislocations who undergo isolated MPFL reconstruction have decreased patella alta at their 6-month follow-up as measured by ISR, CDI, and BPR. Patients without patella alta do not demonstrate statistically significant differences after their MPFL reconstruction. LEVEL OF EVIDENCE: III (retrospective comparative study).

Surgically Treated Ischial Tuberosity Avulsion Fractures in Adolescents: Risks and Outcomes of 3 Fixation Constructs.

INTRODUCTION: Avulsion fractures of the ischial tuberosity (AFIT) are uncommon injuries that sometimes require operative fixation with screws, suture anchors, or cortical suspensory buttons. This study reviewed a series of surgically managed AFITs at a single institution and compared outcomes among fixation strategies. We hypothesized there would be no difference in outcomes between fixation types. METHODS: We conducted a retrospective review of all patients treated operatively at a single institution from 2010 to 2022 for AFIT identified by CPT code (27215). We collected patient demographics, injury characteristics, Revised Modified Oxford Bone Score, radiographic measures, fracture classification (type 1-lateral vs. type 2-complete), surgical fixation technique, postoperative complications (Modified Clavien-Dindo-Sink [M-CDS] Complication Classification), and time to return to sport (RTS). Descriptive statistics and univariate analyses were performed. RESULTS: Study criteria identified 16 patients with surgically treated AFITs during the study period. Patients were predominantly male (88%) with a mean age of 14.8±0.8 years. Injured patients most commonly participated in soccer (38%), with the most common mechanism of injury being running/sprinting (50%). The avulsed fracture fragments were a mean of 42.6 mm in size, with an average maximal displacement of 21.1 mm and predominantly type 1-lateral (75%). Surgical constructs included: screws (4), suture anchors (5), cortical suspensory buttons (6), and combined (1, screw and suture anchor). Postoperative complications occurred in 8 patients (50%) including 7 type 1 and 1 type 3 M-CDS. No statistically significant difference was found between fixation types among the studied outcome variables; however, re-fracture (1 case [M-CDS type 3]) was only observed with a combined (screw and suture anchor) construct. CONCLUSIONS: This retrospective cohort study demonstrated that postoperative complications after ORIF for AFIT were not infrequent but were largely low in severity. Refracture occurred only with a combined screw and suture anchor construct. Consistent return to sport was achieved across all fixation types, with no significant difference in complication rate between constructs, although the available study sample limited robust analysis. This study is also, of note, one of the first to report outcomes from cortical suspensory buttons (CSB)-a relatively novel intervention for AFIT. Findings from this retrospective case series of multiple surgical techniques serve to bolster the limited literature base regarding the operative treatment of AFITs in adolescents.

Variable Guidelines for Pediatric Medial Patellofemoral Ligament Reconstruction Rehabilitation Exists Across PRiSM Member Organizations.

Medial patellofemoral ligament (MPFL) reconstruction, typically used to restore stability to the patellofemoral joint after dislocation, often requires extensive rehabilitation to address acute impairment related to surgical intervention and also underlying non-anatomical deficits that may have contributed to the index injury. Rehabilitation guidelines, including objective functional performance assessment criteria, are lacking in the literature. We sought to summarize the clinical guidelines for rehabilitation and return to activity assessment after MPFL reconstruction as advocated by the member organizations of the Pediatric Research in Sports Medicine (PRiSM) Patellofemoral Research Interest Group (PF-RIG). We obtained and reviewed MPFL rehabilitation guidelines from 11 member organizations of the PRiSM PF-RIG, extracting information on weight-bearing advancement, bracing, use of supplemental strengthening modalities, and any objective criteria for advancing rehabilitation phases. We found highly variable agreement among guideline parameters at each treatment stage, with time-based criteria most widely used for early progression. Although functional metrics like strength or movement tests were more widely used in later phases of rehabilitation, there was substantial variation in testing mode and level of acceptable performance. Our review found that significant variability exists in current practice among PRiSM and PF-RIG member institutions regarding rehabilitation standards after MPFL reconstruction. Although we found broad consensus that objective strength or performance criteria should be employed to establish a better framework for clinical decision-making, most current guidelines lack standardization and sufficient detail to guide ideal clinical practice.

Management of osteonecrosis of the humeral head in the pediatric population: A systematic review.

Purpose: Humeral head osteonecrosis in the pediatric patients most often occurs in patients with underlying hemoglobinopathies, exposure to chronic corticosteroids, or after trauma. The purpose of this study was to perform a systematic review evaluating the prevalence, clinical characteristics, and management of humeral head osteonecrosis in the pediatric population. Methods: PubMed, Ovid MEDLINE, and Scopus were screened with the terms "osteonecrosis," "avascular necrosis," "pediatric," and "proximal humerus" on January 10, 2024. A total of 218 studies were screened, and 74 studies were evaluated for eligibility. Studies that reported on the prevalence and/or management of pediatric humeral head osteonecrosis were included. The systematic review was conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. Results: Twelve studies met inclusion criteria: four retrospective case series, three prospective case series, one retrospective cohort study, one retrospective case-control study, and three case reports. A majority of the studies (67%) discussed chemotherapy-induced osteonecrosis of the humeral head. A total of 77 patients (106 shoulders) with humeral head osteonecrosis were identified. The overall prevalence of osteonecrosis of the humeral head across eight studies examining at-risk populations (underlying hemoglobinopathies or undergoing chemotherapy) was 2%. Intra-articular steroid injections, physical therapy, and activity modification are effective conservative management strategies. Additionally, core decompression and hemiarthroplasty are surgical treatment options. Conclusions: The prevalence of osteonecrosis of the humeral head is low even among at-risk populations with associated medical conditions. A variety of conservative and surgical treatment options have been described, but no comparative evaluations of these modalities has been conducted. Level of evidence: IV.

What is the Utilization and Impact of Advanced Imaging for Tibial Tubercle Fractures? An Analysis of 598 Patients From the Tibial Tubercle Study (TITUS) Group.

BACKGROUND: Given the rare nature of tibial tubercle fractures, previous studies are mostly limited to small, single-center series. This results in practice variation. Previous research has shown poor surgeon agreement on utilization of advanced imaging, but improved evidence-based indications may help balance clinical utility with resource utilization. The purpose of this study is to quantify diagnostic practices for tibial tubercle fractures in a large, multicenter cohort, with attention to the usage and impact of advanced imaging. METHODS: This is a retrospective series of pediatric tibial tubercle fractures from 7 centers between 2007 and 2022. Exclusion criteria were age above 18 years, missing demographic and pretreatment data, closed proximal tibial physis and tubercle apophysis, or a proximal tibia fracture not involving the tubercle. Demographic and injury data were collected. Fracture classifications were derived from radiographic evaluation. The utilization of advanced imaging was recorded as well as the presence of findings not identified on radiographs. Standard descriptive statistics were reported, and χ2 tests were performed (means reported±SD). RESULTS: A total of 598 patients satisfied the inclusion criteria, of which 88.6% (530/598) were male with a mean age of 13.8±1.9 years. Internal oblique x-rays were obtained in 267 patients (44.6%), computed tomography (CT) in 158 (26.4%), and magnetic resonance imaging (MRI) in 64 (10.7%). There were significant differences in the frequency at which CT (7.2% to 79.4%, P<0.001) and MRI were obtained (1.5% to 54.8%, P<0.001). CT was obtained most frequently for Ogden type IV fractures (50/99, 50.5%), and resulted in novel findings that were not visualized on radiographs in a total of 37/158 patients (23.4%). The most common finding on CT was intra-articular fracture extension (25/37). MRI was obtained most frequently for Ogden type V fractures (13/35, 37.1%), and resulted in novel findings in a total of 31/64 patients (48.4%). The most common finding was patellar tendon injury (11/64), but only 3 of these patients required tendon repair. CONCLUSIONS: Substantial variation exists in the diagnostic evaluation of tibial tubercle fractures. CT was most helpful in clarifying intra-articular involvement, while MRI can identify patellar tendon injury, periosteal sleeve avulsion, or a nondisplaced fracture. This study quantifies variation in diagnostic practices for tibial tubercle fractures, highlighting the need for evidence-based indications for advanced imaging. LEVEL OF EVIDENCE: Level III.

Trampolines Versus Playgrounds - A Comparative Assessment of Pediatric Fractures Sustained From Recreational Play.

INTRODUCTION: Using the Pediatric Health Information System, this study compared the relative severity of fractures sustained from trampolines with those from other playground equipment. METHODS: Pediatric patients were identified in the Pediatric Health Information System with trampoline-related injuries (TRIs) or playground-related injuries (PRIs) diagnosed as fractures. Adjustments were made for hospital, year of injury, sex, age, race, median household income, and rurality through propensity score weighting. Four injury-related outcome measures were examined as a proxy for injury severity. RESULTS: A total of 133,232 patients met inclusion criteria. In unadjusted univariate analyses, TRIs were associated with greater odds of severe fracture and lower odds of receiving surgical treatment (OR = 0.954) compared with PRIs. After adjustment, TRIs sustained in late childhood and adolescence were more likely to receive surgical management (OR = 1.092 and OR = 1.192, respectively) while TRIs sustained in younger children were less likely (OR = 0.607) than PRIs. DISCUSSION: Youths in late childhood and adolescence are at increased odds of undergoing surgical management after trampoline fractures. Beyond underscoring the risks of trampoline play, our results highlight the importance of considering age in recreational injury epidemiology and the public health safety initiatives aimed at specific age groups.

Imaging of the Pediatric Knee.

During normal development, imaging findings in the immature knee joint may mimic pathology or indicate transient sites of weakness, prone to injury. This article reviews the development of the knee joint, age- and maturation-dependent imaging considerations, and various developmental variants that can be encountered, subdivided into those that involve the tibiofemoral and patellofemoral compartments, soft tissues, and osseous components. The tibiofemoral compartment section reviews the focal periphyseal edema zone (FOPE), ossification variants of the femoral condyles, distal femoral metaphyseal cortical irregularity from periosteal traction, and the metaphyseal subperiosteal stripe, which should be distinguished from pathologic mimickers such as endochondral ossification dysfunction, osteochondritis dissecans (OCD), fibroosseous lesion, periosteal and subcortical pathologies. The patellofemoral compartment section includes a review of partite patella, dorsolateral defect, variant trochlear morphology, and maturation-dependent sites of transient weakness that are prone to injury from repetitive overuse (Sinding-Larsen-Johansson syndrome and Osgood-Schlatter disease) and avulsion fractures (patellar sleeve and tibial tubercle avulsions). Finally, soft tissue (discoid lateral meniscus, meniscal flounce, anterior cruciate ligament variants) and osseous components (meniscal ossicle, fabella, and cyamella) are reviewed.

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.

Patellar osteochondritis dissecans: maturation-dependent patellofemoral joint characteristics.

BACKGROUND: The likelihood of healing of osteochondritis dissecans decreases with skeletal maturity and there are theories that abnormal biomechanical forces contribute to the development and progression of these lesions. OBJECTIVE: To characterize, according to regional skeletal maturity, the morphology and alignment indices of the patellofemoral joint on MRI in patients with patellar osteochondritis dissecans. MATERIALS AND METHODS: MRI examinations of patients with patellar osteochondritis dissecans obtained between January 2008 and May 2023 were retrospectively reviewed to determine regional skeletal maturity, osteochondritis dissecans lesion size and location, patellar and trochlear morphology (Wiberg/Dejour classifications), and to calculate trochlear sulcus angles, trochlear depth index, lateral trochlear inclination, Insall-Salvati index, Caton-Deschamps index, patellar tendon-lateral trochlear ridge, and tibial tubercle-trochlear groove distances. Values were compared between skeletally immature and mature groups. RESULTS: Sixty-eight children (22 girls, 46 boys, age: 14.0 ± 1.7 years) yielded 74 knees with patellar osteochondritis dissecans lesions, 14 (19%) of which were skeletally mature. The most common anatomic location was over the central patella [median ridge (34/74 - 46%) on the axial images and over the middle third (45/74 - 61%) on the sagittal images]. Overall, mean trochlear sulcus angle (high, 151 ± 11°), trochlear depth index (low, 2.8 ± 1.4 mm), and Insall-Salvati index (borderline, 1.3 ± 0.1) were abnormal for the entire sample. Skeletally mature knees were significantly more likely to have higher (more dysplastic) Dejour types when compared to skeletally immature knees (p < 0.01). Knees in the mature group, compared to immature, had significantly more abnormal mean lateral trochlear inclination (15 ± 8° vs. 19 ± 6°, p = 0.03) and patellar tendon-lateral trochlear ridge distance (5.55 ± 4.31 mm vs. 2.89 ± 4.69 mm, p = 0.04). Half of the knees had ≥ 4 abnormal features that predispose to patellofemoral maltracking; mature knees were significantly (p = 0.02) more likely to have a higher number of abnormal features (> 6 features, 7/14, 50.0%) versus immature knees (0-3 features, 33/60, 55.0%). CONCLUSION: In children with patellar osteochondritis dissecans, abnormal patellofemoral morphology and alignment indices were common in all patients and more severe in mature knees.

Consensus-Based Guidelines for Management of First-Time Patellar Dislocation in Adolescents.

BACKGROUND: The management of first-time patellar dislocation remains variable, with limited evidence to support or compare different operative and nonoperative modalities. The primary aim was to establish consensus-based guidelines for different components of nonoperative treatment following a first-time patellar dislocation. The secondary aim was to develop guidelines related to management after failed nonoperative treatment. The tertiary aim was to establish consensus-based guidelines for the management of first-time patellar dislocation with a concomitant osteochondral fracture. METHODS: A 29-question, multiple-choice, case-based survey was developed by 20 members of the Patellofemoral Research Interest Group of the Pediatric Research in Sports Medicine Society. The survey consisted of questions related to demographic information, management of first-time patellar dislocation without an osteochondral fracture, and management of first-time patellar dislocation with a 2 cm osteochondral fracture. The survey underwent 2 rounds of iterations by Patellofemoral Research Interest Group members and the final survey was administered to Pediatric Research in Sports Medicine members, using REDCap. Consensus-based guidelines were generated when more than 66% of respondents chose the same answer. RESULTS: Seventy-nine of 157 (50%) eligible members responded. Sixty-one were orthopaedic surgeons and 18 were primary sports medicine physicians. Eleven consensus-based guidelines were generated based on survey responses. Those that met the criteria for consensus included initial knee radiographs (99% consensus), nonoperative treatment for first-time patellar dislocation without an osteochondral fracture (99%), physical therapy starting within the first month postinjury (99%), with return to sport after 2 to 4 months (68%) with a brace (75%) and further follow-up as needed (75%). Surgical treatment was recommended if there were patellar subluxation episodes after 6 months of nonoperative treatment (84%). Patellar stabilization should be considered for a first-time dislocation with an osteochondral fracture (81.5%). CONCLUSION: Consensus-based guidelines offer recommendations for the management of first-time patellar dislocation with or without an osteochondral fracture. Several changing trends and areas of disagreement were noted in clinical practice. CLINICAL RELEVANCE: In the absence of high-level evidence, consensus-based guidelines may aid in clinical decision-making when treating patients following a first-time patellar dislocation. These guidelines highlight the evolving trends in clinical practice for the management of first-time patellar dislocation. Areas not reaching consensus serve as topics for future research.

Rotator Cuff Injuries in the Pediatric Population: A Retrospective Review of Patient Characteristics and Treatment at a Single Center.

BACKGROUND: As youth participation in contact and overhead sports has increased in recent decades, so has the occurrence of injuries of the shoulder. Rotator cuff injury (RCI) is an infrequent shoulder pathology in pediatric patients and its description in the literature has been scarce. A greater understanding of RCI characteristics and treatment outcomes in children and adolescents would improve our understanding of this pathology and help to better guide clinical decision-making. HYPOTHESIS: To identify pediatric patients with magnetic resonance imaging-confirmed RCI treated at a single center to summarize injury characteristics, treatment, and outcomes. It was hypothesized that injuries would occur predominantly in overhead throwing athletes and would demonstrate good outcomes among both operatively and nonoperatively treated patients. STUDY DESIGN: Cross-sectional study. LEVEL OF EVIDENCE: Level 4. METHODS: A retrospective review of pediatric patients (<18 years old) diagnosed with and treated for an RCI between January 1, 2011 and January 31, 2021. Patient demographics, injury mechanism and type, treatment, and outcomes were collected. Descriptive statistics were performed. Bivariate testing was used to compare operatively and nonoperatively treated cohorts. RESULTS: A total of 52 pediatric patients treated for a rotator cuff avulsion, partial tear, or complete tear were identified. Mean age was 15 years and 67% of patients were male. Injuries were related most commonly to participation in throwing sports. Operative management occurred in 23% of patients, while 77% were managed nonoperatively. Treatment cohorts differed based on tear type, with all complete tears being managed operatively (P < 0.01). Associated shoulder pathology was common, with the most frequent finding being anterior shoulder instability pathology. Return to play was longer for operatively managed patients (7.1 vs 4.5 months; P < 0.01). CONCLUSION: The present study expands the limited data available regarding RCIs in pediatric patients. Most injuries are associated with sports and involve the supraspinatus tendon. RCIs were associated with good outcomes and low rates of reinjury in patients managed both nonoperative and operatively. RCI should be considered in throwing athletes with shoulder pain, even in skeletally immature patients. CLINICAL RELEVANCE: This retrospective study fills the hole in the literature by detailing the patterns associated with RCI characteristics and treatment outcomes. In contrast to studies of adult RCIs, our results suggest that outcomes are good regardless of treatment type.

Disparate Impact: How Does Social Deprivation Affect Patient-reported Outcomes After ACL Reconstruction in Children and Adolescents?

BACKGROUND: Research has indicated that lower socioeconomic status is associated with delays in the treatment of anterior cruciate ligament (ACL) injuries; however, there is a paucity of literature evaluating its association with patient-reported outcomes (PROs). Using the Area Deprivation Index (ADI), a validated proxy for socioeconomic status, the study aimed to determine how relative socioeconomic disadvantage is related to PROs after primary ACL reconstruction (ACLR) in pediatric patients. METHODS: This retrospective cohort study included all patients 18 years old or above who underwent primary ACLR at an academic institution between 2018 and 2021. Exclusion criteria included multiligament injury, congenital ACL absence, and absent outcomes data. The minimum follow-up was 6 months. A Patient-reported Outcomes Measurement Information System (PROMIS) 50 Pediatric self-report questionnaire was completed at postoperative visits, and domain scores for pain, physical function/mobility, fatigue, anxiety, depression, and peer relationships were generated. The National ADI percentile was calculated using the patients' addresses. Patients were divided into quartiles (low, moderate, moderate-severe, and severe ADI), and comparative analyses were performed to determine the relationship between ADI and PROMIS. RESULTS: A total of 413 patients were identified, including 49% (n=207), 33% (n=139), 11% (n=48), and 7% (n=30) from the low, moderate, moderate-severe, and severe deprivation areas, respectively. As compared with those in the low-deprivation quartile, patients in the severe deprivation quartile had delayed time to the first clinic visit (11 vs. 16.5 d, P=0.044) and surgery (51 vs. 80 d, P=0.004). There were no differences in the number of additional procedures required at index surgery. All quartiles had progressive improvements in physical function/mobility and pain scores throughout recovery, but at 9 months, there was significantly more pain in the severe deprivation cohort, despite no difference in self-reported physical function and mobility. Those with severe socioeconomic disadvantage had worse psychosocial outcomes, including significantly increased depression, fatigue, and anxiety and decreased peer relationship scores. CONCLUSIONS: Although there were no differences in preoperative PROMIS scores, pediatric patients living in areas with higher levels of socioeconomic deprivation/disadvantage had worse psychosocial PROs after ACLR. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Stationary bike injuries prompting emergency department presentation in pediatric patients: an epidemiological study.

OBJECTIVES: Potential harms of stationary bike injuries in pediatric patients have been highlighted in the literature, but prior work is limited to case series and without population-level analysis. The purpose of this study is to examine the epidemiology of pediatric stationary bike injuries occurring in the US over the last decade using a national database. METHODS: Injuries resulting from stationary bike use in pediatric patients from 2012 to 2021 were identified using coding from the National Electronic Injury Surveillance System (NEISS) database. Patient demographics, injury characteristics, and case narratives were examined. National annual estimates of injury frequency/incidence were calculated using weighting and survey package in R. Univariate analyses were used to compare injuries among groups. RESULTS: We identified 525 stationary bike injuries representing an estimated total of 15,509 injuries in the population. Pediatric patients sustained an average of 1,551 injuries annually, with an estimated yearly increase of 288 injuries (p < 0.01) after 2019. While males sustained more injuries, there were age-dependent differences in frequency of injuries between sexes (p < 0.01). The upper extremity was the most commonly injured body region overall, but children 5 and under sustained more injuries to the head/neck. The most common overall injury type was lacerations, while fractures predominated in the 6 to 11-year-old age group. Fifty-six percent of injuries were sustained not while riding the bike, most notably among children under 12. CONCLUSION: Our findings indicate that the impact of stationary bike injury in the pediatric population is not insignificant, and most injuries are related to improper play rather than traditional exercise use. Gender and age-related patterns differed in regard to the type and mechanism of injury sustained. Children 5 and under sustain a disproportionate amount of injuries to the head, neck, and upper extremity. As stationary bikes grow in popularity, preventative measures should be considered to reduce injuries to young children.

Quantifying the impact of the coronavirus 2019 pandemic on youth sports-related injuries in the USA.

The purpose of this study was to estimate monthly and annual trends in youth sports-related injury over the years 2016-2020 using the National Electronic Injury Surveillance System (NEISS) database to measure the impact of COVID-19 on overall and sport-specific rates of injury. Children and adolescents (0-19 years) presenting to USA emergency departments with sport participation injury from 2016 to 2020 were identified. Descriptive statistical analyses were performed of injury patterns. An interrupted time series analysis was applied to estimate changes in injury trends during COVID-19. Proportional changes in injury characteristics during this period were examined. An estimated 5 078 490 sports-related injuries were identified with an annual incidence of 1406 injuries per 100 000 population. Seasonal peaks in injuries occurred during September and May. About 58% of injuries were associated with contact sports, such as basketball, football, and soccer, and the most common injuries were sprains and strains. After the pandemic onset, there was a statistically significant 59% decrease in national youth sports-related injuries compared with the average estimates for 2016-2019. While the distribution of injury characteristics did not appear to change, the location of injury appeared to shift away from school toward alternative settings. A significant reduction in youth sports-related injuries was identified in 2020 coinciding with the COVID-19 pandemic, persisting throughout the rest of the year. No changes in the anatomic or demographic distribution of injuries were identified. This study expands our epidemiologic understanding of youth sports-related injury trends and how they changed following the pandemic onset.

Does Skeletal Maturity Predict the Pattern of Tibial Tubercle Avulsion Fracture?

BACKGROUND: Proximal tibial physeal development and closure is thought to relate to tibial tubercle avulsion fracture (TTAF) patterns. Prior work has yet to formally evaluate the relationship between skeletal maturity and fracture pattern.  Using 2 knee radiograph-derived skeletal maturity assessments [growth remaining percentage (GRP) and epiphyseal union stage], we examined their association with TTAF injury patterns using the Ogden and Pandya fracture classifications. We hypothesized that different TTAF injuries would occur during unique periods of skeletal development. METHODS: Pediatric patients sustaining TTAFs treated at a single institution (2008-2022) were identified using diagnostic and procedural coding. Demographics and injury characteristics were collected. Radiographs were reviewed to assign epiphyseal union stage, Ogden and Pandya classifications and for measurements to calculate GRP. Univariate analyses examined the relationship between injury subgroups, patient demographics, and skeletal maturity assessments. RESULTS: Inclusion criteria identified 173 patients with a mean age of 14.76 (SD: 1.78) and 2.95% (SD: 4.46%) of growth remaining. The majority of injuries were classified Ogden III/Pandya C. Most (54.9%) were the result of the axial loading mechanism. Ogden groups showed no significant differences across all patient characteristics studied including age and GRP. With the exception of Pandya A fractures, we did not identify a direct relationship between GRP, age, and Pandya groups. Epiphyseal union stage differed for Pandya A and D groups. CONCLUSIONS: A predictable pattern in TTAF characteristics across skeletal (GRP), epiphyseal union, or chronologic age was not identified in this study. Distal apophyseal avulsions (Ogden I/II and Pandya A/D) occurred across a broad chronologic and skeletal age range. No differences were identified in epiphyseal or posterior extension (Ogden III/IV and Pandya B/C) injuries. Although differences in age and GRP were identified among Pandya As, this is thought to be due to the degree of skeletal immaturity that is a prerequisite for differentiation from Pandya Ds. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

Automated Clustering Technique (ACT) for Early Onset Scoliosis: A preliminary report.

PURPOSE: While the C-EOS system helps organize and classify Early Onset Scoliosis (EOS) pathology, it is not data-driven and does not help achieve consensus for surgical treatment. The current study aims to create an automated method to cluster EOS patients based on pre-operative clinical indices. METHODS: A total of 1114 EOS patients were used for the study, with the following distribution by etiology: congenital (240), idiopathic (217), neuromuscular (417), syndromic (240). Pre-operative clinical indices used for clustering were age, major curve (Cobb) angle, kyphosis, number of levels involved in a major curve (Cobb angle) and kyphosis along with deformity index (defined as the ratio of major Cobb angle and kyphosis). Fuzzy C-means clustering was performed for each etiology individually, with one-way ANOVA performed to assess statistical significance (p < 0.05). RESULTS: The automated clustering method resulted in three clusters per etiology as the optimal number based on the highest average membership values. Statistical analyses showed that the clusters were significantly different for all the clinical indices within and between etiologies. Link to the ACT-EOS web application: https://biomed.drexel.edu/labs/obl/toolkits/act-eos-application . CONCLUSION: An automated method to cluster EOS patients based on pre-operative clinical indices was developed identifying three unique, data-driven subgroups for each C-EOS etiology category. Adoption of such an automated clustering framework can help improve the standardization of clinical decision-making for EOS.

Rotator cuff injury in the pediatric population: a systematic review of patient characteristics, treatment, and outcomes.

Rotator cuff injuries (RCIs), traditionally thought to be an adult-type pathology, have been reported in the pediatric population, but there remains limited evidence regarding this injury pattern in pediatric patients. The purpose of this study was to systematically review the literature to characterize the epidemiology, injury patterns, treatment modalities, and outcomes for pediatric patients with RCIs. A systematic review was performed in accordance with Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines, reviewing Pubmed, Embase, Cochrane, and CINAHL databases. Studies reporting imaging confirmed RCIs, and treatment outcomes in patients less than 18 years of age were included. Patient demographics, mechanism, injury type, and injury location were recorded. Treatment type and patient outcomes were abstracted when available and summarized with descriptive statistics. Our search identified 28 studies published from 1994 to 2020, which included 215 total tendons injured in 185 patients. Twenty-six studies were classified as level IV evidence, whereas only two were level III. When described, the most injured tendon ( n = 184) was the supraspinatus, whereas the most described injury type ( n = 215) was a partial tear. Surgical intervention was pursued in 75.8% of injuries, with arthroscopy being more common than open repair (79.4% vs. 20.6%). Nonoperative treatment was primarily utilized for partial tears. Among the 24 studies reporting on return to sports, nonoperatively managed patients returned later than those treated operatively (mean: 10.7 vs. 7 months). Only eight studies included patient reported outcome measures (PROMs), and just five had pre- and posttreatment scores. Three complications were noted, all in operative patients. RCIs in pediatric patients have been reported in the literature with increasing frequency over the last decade, but the quality of evidence remains poor with inconsistent injury descriptions and outcome reporting. Excellent results were seen for all injury types and locations with both operative and nonoperative treatments. The literature for pediatric RCIs remains limited in guiding management decisions indicating a need for more high-quality studies to compare outcomes across injury and treatment type. Level of evidence: level III.

Patellar Instability in Young Athletes.

This article summarizes the latest research related to pediatric patellar instability. The epidemiology, patterns of patellar instability, and underlying pathoanatomy are unique in children and adolescents. Information related to the natural history and predictive factors of patellar instability in young patients would allow for better patient counseling and management decisions. The components of nonoperative treatment for first patellar dislocation are outlined. Physeal-respecting surgical techniques, including medial patellofemoral ligament reconstruction in skeletally immature patients, are discussed. The indications and outcomes for quadricepsplasty to address more complex instability patterns are presented. Evaluation and management strategies for specific anatomic risk factors is provided.

Distal Adductor Magnus Avulsion Fracture Treated with Excision After Failure of Nonoperative Management: A Case Report.

CASE: In this case report, we discuss a skeletally immature gymnast who presented with an isolated distal femoral adductor tubercle avulsion fracture that went on to develop a painful nonunion. After the failure of extensive nonoperative intervention, she had resolution of her symptoms with bony excision and soft-tissue repair. CONCLUSION: It is important for clinicians to be aware of this atypical injury pattern and that surgical intervention may be necessary because conservative treatment may not always resolve symptoms.

Radiographic Evaluation of Pediatric Patients with Patellofemoral Instability.

PURPOSE OF REVIEW: The purpose of this review is to highlight the radiographic assessments of utility in the evaluation of a pediatric patient with patellofemoral instability to facilitate a thorough work-up. Understanding of these measures is useful in understanding evolving research in this field, providing accurate patient risk assessment, and appropriately directing surgical decision-making. RECENT FINDINGS: Recent literature has broadened the radiographic characterization of the pediatric patellar instability and its anatomic risk factors. Knee MRI can inform the assessment of skeletal maturity and novel axial alignment measurements may enhance our identification of patients at increased risk of recurrent instability. Additional improvements have been made in the objective measurement and classification of trochlear dysplasia. Knee MRI-based skeletal age assessments may obviate the need for hand bone age assessments in growing children with patellofemoral instability. Novel objective measures exist in the evaluation of pediatric patellar instability both in the assessment of axial alignment and trochlear dysplasia. Future work should focus on how these measures can aid in guiding surgical decision-making.