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.

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.

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.

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.

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.].

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.

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

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

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

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

Relationship Between Age and Pathology With Treatment of Pediatric and Adolescent Discoid Lateral Meniscus: A Report From the SCORE Multicenter Database.

BACKGROUND: Surgical treatment options of discoid lateral meniscus in pediatric patients consist of saucerization with or without meniscal repair, meniscocapular stabilization, and, less often, subtotal meniscectomy. PURPOSE: To describe a large, prospectively collected multicenter cohort of discoid menisci undergoing surgical intervention, and further investigate corresponding treatment of discoid menisci. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A multicenter quality improvement registry (16 institutions, 26 surgeons), Sports Cohort Outcomes Registry, was queried. Patient characteristics, discoid type, presence and type of intrasubstance meniscal tear, peripheral rim instability, repair technique, and partial meniscectomy/debridement beyond saucerization were reviewed. Discoid meniscus characteristics were compared between age groups (<14 and >14 years old), based on receiver operating characteristic curve, and discoid morphology (complete and incomplete). RESULTS: In total, 274 patients were identified (mean age, 12.4 years; range, 3-18 years), of whom 55.6% had complete discoid. Meniscal repairs were performed in 55.1% of patients. Overall, 48.5% of patients had rim instability and 36.8% had >1 location of peripheral rim instability. Of the patients, 21.5% underwent meniscal debridement beyond saucerization, with 8.4% undergoing a subtotal meniscectomy. Patients <14 years of age were more likely to have a complete discoid meniscus (P < .001), peripheral rim instability (P = .005), and longitudinal tears (P = .015) and require a meniscal repair (P < .001). Patients ≥14 years of age were more likely to have a radial/oblique tear (P = .015) and require additional debridement beyond the physiologic rim (P = .003). Overall, 70% of patients <14 years of age were found to have a complete discoid meniscus necessitating saucerization, and >50% in this young age group required peripheral stabilization/repair. CONCLUSION: To preserve physiological "normal" meniscus, a repair may be indicated in >50% of patients <14 years of age but occurred in <50% of those >14 years. Additional resection beyond the physiological rim may be needed in 15% of younger patients and 30% of those aged >14 years.

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

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

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

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

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

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

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

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

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

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

Bony Remodeling of Adolescent Displaced Clavicle Fractures: A FACTS Study.

BACKGROUND: Bony remodeling of displaced clavicle fractures in adolescents remains poorly understood. PURPOSE: To evaluate and quantify clavicle remodeling in a large population of adolescents with completely displaced fractures, which were treated nonoperatively, to better understand the factors that may influence this process. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Patients were identified from the databases of a multicenter study group investigating the functional outcomes of adolescent clavicle fractures. Patients between the ages of 10 and 19 years with completely displaced middiaphyseal clavicle fractures that were treated nonoperatively and who had further radiographic imaging of the affected clavicle at a minimum of 9 months from initial injury were included. Fracture shortening, superior displacement, and angulation were measured on the injury and final follow-up radiographs using previously validated techniques. Furthermore, fracture remodeling was classified as complete/near complete, moderate, or minimal, using an original classification system found to have good to excellent reliability (interobserver reliability = 0.78, intraobserver reliability = 0.90). Classifications were subsequently analyzed quantitatively and qualitatively to determine the factors associated with deformity correction. RESULTS: Ninety-eight patients (mean age, 14.4 ± 2.0 years) were analyzed at a mean radiographic follow-up of 3.4 ± 2.3 years. Fracture shortening, superior displacement, and angulation significantly improved during the follow-up period by 61%, 61%, and 31%, respectively (P < .001). Furthermore, while 41% of the population had initial fracture shortening >20 mm at final follow-up, only 3% of the cohort had residual shortening >20 mm. Fracture remodeling was found to be associated with follow-up time; those with longer follow-up time demonstrated more remodeling (P = .001). Eighty-five percent of patients aged <14 years and 54% of patients aged ≥14 years at time of injury with a minimum follow-up of 4 years underwent complete/near-complete remodeling. CONCLUSION: Significant bony remodeling occurs in adolescent patients with completely displaced clavicle fractures, including older adolescents, and appears to continue over longer time intervals, even beyond the adolescent years. This finding may help explain the low rate of symptomatic malunions in adolescents, even in severely displaced fractures, and particularly when compared with rates reported in adult studies.

Age, Sex, and BMI Differences Related to Repairable Meniscal Tears in Pediatric and Adolescent Patients.

BACKGROUND: The incidence of meniscus tears and ACL tears in pediatric patients continues to rise, bringing to question the risk factors associated with these injuries. As meniscus tears are commonly repaired in pediatric populations, the epidemiology of repairable meniscus tears is an important for consideration for surgeons evaluating treatment options. PURPOSE: To describe meniscal tear patterns in pediatric and adolescent patients who underwent meniscal repair across multiple institutions and surgeons, as well as to evaluate the relationship between age, sex, and body mass index (BMI) and their effect on the prevalence, type, and displacement of repaired pediatric meniscal tears. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Data within a prospective multicenter cohort registry for quality improvement, Sport Cohort Outcome Registry (SCORE), were reviewed to describe repaired meniscal tear patterns. All consecutive arthroscopic meniscal repairs from participating surgeons in patients aged <19 years were analyzed. Tear pattern, location, and displacement were evaluated by patient age, sex, and BMI. A subanalysis was also performed to investigate whether meniscal tear patterns differed between those occurring in isolation or those occurring with a concomitant anterior cruciate ligament (ACL) injury. Analysis of variance was used to generate a multivariate analysis of specified variables. Sex, age, and BMI results were compared across the cohort. RESULTS: There were 1185 total meniscal repairs evaluated in as many patients, which included 656 (55.4%) male and 529 (44.6%) female patients. Patients underwent surgery at a mean age of 15.3 years (range, 5-19 years), with a mean BMI of 24.9 (range, 12.3-46.42). Of the 1185 patients, 816 (68.9%) had ACL + meniscal repair and 369 (31.1%) had isolated meniscal repair. The male patients underwent more lateral tear repairs than the female patients (54.3% to 40.9%; P < .001) and had a lower incidence of medial tear repair (32.1% vs 41.4%; P < .001). Patients with repaired lateral tears had a mean age of 15.0 years, compared with a mean age of 15.4 years for patients with repaired medial or bilateral tears (P = .001). Higher BMI was associated with "complex" and "radial" tear repairs of the lateral meniscus (P < .001) but was variable with regard to medial tear repairs. CONCLUSION: In pediatric and adolescent populations, the data suggest that the surgical team treating knees with potential meniscal injury should be prepared to encounter more complex meniscal tears, commonly indicated in those with higher BMI, while higher rates of lateral meniscal tears were seen in male and younger patients. Future studies should analyze correlates for meniscal repair survival and outcomes in this pediatric cohort undergoing knee surgery.

Age-, Sex-, and Graft-Specific Reference Values From 783 Adolescent Patients at 5 to 7 Months After ACL Reconstruction: IKDC, Pedi-IKDC, KOOS, ACL-RSI, Single-Leg Hop, and Thigh Strength.

OBJECTIVE: To describe age-, sex-, and graft source-specific reference values for patient-reported, physical function, and strength outcome measures in adolescents at 5 to 7 months after anterior cruciate ligament reconstruction. DESIGN: Cross-sectional study. METHODS: Data were collected at 3 universities and 2 children's hospitals. The participants completed at least one of the International Knee Documentation Committee (IKDC) Subjective Evaluation Form, Pediatric IKDC (Pedi-IKDC), Knee Injury and Osteoarthritis Outcomes Score (KOOS), and Anterior Cruciate Ligament Return to Sport After Injury (ACL-RSI) Scale. Participants also completed single-leg hop tests and/or isokinetic quadriceps and hamstrings strength assessments (at 60°/s). Reference values were summarized using descriptive statistics and stratified for age, sex, and graft source. RESULTS: Reference values were reported for common patient-reported outcomes and measures of physical function and strength from 783 participants (56% females, age = 16. 4 ± 2.0 years) who were in early adolescence (12-14 years, N = 183, 52% females), middle adolescence (15-17 years, N = 456, 58% females), or late adolescence (18-20 years, N = 144, 55% females). Three hundred seventy-nine participants (48.4%) received a bone-patellar tendon-bone autograft, 292 participants (37.3%) received hamstring tendon autograft, and 112 participants (14.3%) received autograft or allograft from an alternative source. CONCLUSION: Reference values for common patient-reported outcomes and measures of physical function and strength differed depending on a patient's age, sex, and graft source. Using patient-specific reference values, in addition to previously described age-appropriate cutoff values, may help clinicians monitor and progress patients through rehabilitation and return to physical activity after anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther 2023;53(4):1-8. Epub: 23 January 2023. doi:10.2519/jospt.2023.11389.

Differences in athletic identity, sport participation, and psychosocial factors following anterior cruciate ligament rehabilitation in youth athletes.

Introduction: While youth sports benefits the developing athlete, athletes may also be subject to injury and subsequent return-to-sport protocols. The current return-to-sport criteria emphasize physical measures; however, psychological measures may also be valuable to inform providers of an athlete's readiness. One such measure is athletic identity defined as the degree to which an individual identifies with the athlete role. To better understand athletic identity in return-to-sport, this study aimed to identify relationships and trends between the Athletic Identity Measurement Scale (AIMS), demographic variables, sport participation measures, and the Athletic Coping Skills Inventory-28 (ACSI-28) in youth athletes during rehabilitation following anterior cruciate ligament reconstruction (ACLR). Methods: A retrospective review was completed of patients who underwent ACLR at a sports medicine clinic between October 2019 and May 2021. Patients responded to a series of patient reported outcomes (PROs) regarding physical and psychological function at a pre-surgical baseline and after 1 year of rehabilitation. Patients were then divided into groups of high/low AIMS and an increased/decreased AIMS between 1 year and baseline for comparison. Independent samples t-tests and ANOVAs were performed as appropriate with a 95% confidence interval. Results: In the final sample, 87 patients (15.3 ± 1.8 years) were included, with 51.7% being females. Total AIMS scores decreased from 50.3 to 47.5 over rehabilitation (p = 0.019). Furthermore, results indicated that nearly all AIMS scores decreased during rehabilitation, with none showing an increase; however, not all domains were significant. Conversely, all sport participation and coping ability PROs increased over time points except for ACSI-Confidence and Achievement Motivation. Generally, those in the groups with high AIMS and an increase in AIMS also had higher scores in physical function and coping ability PROs, with the groups separated by high/low AIMS exhibiting more frequent statistical significance. Discussion: Given these results, it appears that athletes may lose identification with the athlete role after ACLR and struggle even 1 year for rehabilitation, but those who recover athletic identity the best may also be those able to cope most effectively with the stressors induced by injury.

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

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