The Effects of Age and Height on Gait Smoothness in Adolescent Athletes.

(1) Background: Despite evidence of increased rates of sports injury during the years surrounding peak growth in adolescents, little is known regarding the relationship between adolescent growth and gait stability. The aim of this study was to gain a better understanding of how chronological age and height relate to gait stability in both male and female adolescents. (2) Methods: Participants (N = 67; females: n = 34, ages 8.7-15.9 years; males: n = 33, ages 10.0-16.7 years) completed two trials of treadmill walking at varying speeds: the preferred walking speed and 30% above and below. Trials were separated by a bout of fatiguing exercises. HarmonicRatios of the trunk, calculated from acceleration signals taken during walking, were used to quantify gait stability. Data were separated by sex and relationships between height and chronological age, and HarmonicRatios were assessed using multiple linear regression. (3) Results: Females' HarmonicRatios improved with chronological age both before and after fatigue. Males' HarmonicRatios increased with chronological age before fatigue; however, this effect was eliminated post-fatigue. Females' height was negatively associated with HarmonicRatios post-fatigue. Males' height was positively associated with HarmonicRatios pre-fatigue. (4) Conclusions: The study findings suggest sex differences in the effects of fatigue on gait stability during adolescence. In both sexes, HarmonicRatios increased with chronological age. These improvements were eliminated for males and altered for females with fatigue. The results of this study indicate the need for the reevaluation of sports progression based on chronological age in adolescents.

Predicting Success of Deformity Correction With Tension Band Plating in Early-Onset Tibia Vara.

BACKGROUND: Angular deformity correction with tension band plating has not been as successful in early-onset tibia vara (EOTV) as it has been in other conditions. Our hypothesis is that perioperative factors can predict the success of lateral tibial tension band plating (LTTBP) in patients with EOTV. METHODS: A retrospective review was performed at 7 centers evaluating radiographic outcomes of LTTBP in patients with EOTV (onset <7 y of age). Single-event tibial LTTBP outcome was assessed through medial proximal tibial angle (MPTA). The final limb alignment following comprehensive limb growth modulation (CLGM), which could include multiple procedures, was assessed by mechanical axis zone (MAZone), mechanical tibio-femoral angle (mTFA), and mechanical axis deviation (MAD). Preoperative age, weight, deformity severity, medial physeal slope, and Langenskiöld classification +/- modification were investigated as predictors of outcome. Success was defined as the correction or overcorrection to normal age-adjusted alignment. The minimum follow-up was 2 years except when deformity correction, skeletal maturity, or additional surgery occurred. RESULTS: Fifty-two patients with 80 limbs underwent 115 tibial LTTBP procedures at a mean age of 5.3 y, including 78 primary, 21 implant revisions, and 15 reimplantations for recurrence. Tibial LTTBP resulted in a mean change of +8.6 o in MPTA and corrected 53% of tibias. CLGM resulted in MAD correction for 54% of limbs.Univariate analysis showed that success was best predicted by preoperative age, weight, MPTA, and MAD. Multivariate analysis identified that preoperative-MPTA/MAD and preoperative-weight<70 kg were predictive of MPTA and MAD correction, respectively. The probability of success tables are presented for reference. CONCLUSION: Successful correction of MPTA to age-adjusted norms following a single-event LTTBP occurred in 53% of tibias and was best predicted by preoperative-MPTA and preoperative body weight <70 kg. Comprehensive growth modulation corrected limbs in 54%. The probability of correction to age-adjusted MAD is best estimated by preoperative-MAZone 1 or 2 (MAD ≤40 mm). Limbs with preoperative-MAD>80 mm improved, but ultimately all failed to correct completely with CLGM. Osteotomy may need to be considered with these severe deformities. While modified Langenskiöld classification and medial physeal slope have been shown to predict the outcome of osteotomy, they were not predictive for LTTBP. Change in MPTA was common after physeal untethering. LEVEL OF EVIDENCE: Level-III.

Predicting Deformity Correction of Growth Modulation in Late-onset Tibia Vara.

BACKGROUND: Growth modulation in late-onset tibia vara (LOTV) has been reported to yield variable results. We hypothesized that parameters of deformity severity, skeletal maturity, and body weight could predict the odds of a successful outcome. METHODS: A retrospective review of tension band growth modulation for LOTV (onset ≥8 y) was performed at 7 centers. Tibial/overall limb deformity and hip/knee physeal maturity were assessed on preoperative anteroposterior standing lower-extremity digital radiographs. Tibial deformity change with first-time lateral tibial tension band plating (first LTTBP) was assessed by medial proximal tibia angle (MPTA). Effects of a growth modulation series (GMS) on overall limb alignment were assessed by mechanical tibiofemoral angle (mTFA) and included changes from implant removal, revision, reimplantation, subsequent growth, and femoral procedures during the study period. The successful outcome was defined as radiographic resolution of varus deformity or valgus overcorrection. Patient demographics, characteristics, maturity, deformity, and implant selections were assessed as outcome predictors using multiple logistic regression. RESULTS: Fifty-four patients (76 limbs) had 84 LTTBP procedures and 29 femoral tension band procedures. For each 1-degree decrease in preoperative MPTA or 1-degree increase in preoperative mTFA the odds of their successful correction decreased by 26% in the first LTTBP and 6% by GMS, respectively, controlling for maturity. The change in odds of success for GMS assessed by mTFA was similar when controlling for weight. Closure of a proximal femoral physis decreased the odds of success for postoperative-MPTA by 91% with first LTTBP and for final-mTFA by 90% with GMS, controlling for preoperative deformity. Preoperative weight ≥100 kg decreased the odds of success for final-mTFA with GMS by 82%, controlling for preoperative mTFA. Age, sex, race/ethnicity, type of implant, and knee center peak value adjusted age (a method for bone age) were not predictive of outcome. CONCLUSIONS: Resolution of varus alignment in LOTV using first LTTBP and GMS, as quantified by MPTA and mTFA, respectively, is negatively impacted by deformity magnitude, hip physeal closure, and/or body weight ≥100 kg. The presented table, utilizing these variables, is helpful in the prediction of the outcome of the first LTTBP and GMS. Even if complete correction is not predicted, growth modulation may still be appropriate to reduce deformity in high-risk patients. LEVEL OF EVIDENCE: Level III.

Femoral Deformity in Tibia Vara and Its Response to Growth Modulation.

BACKGROUND: While tibia vara is a disorder of the proximal tibial physis, femoral deformity frequently contributes to the overall limb malalignment. Our purpose was to determine how femoral varus deformity in tibia vara responds to growth modulation, with/without lateral tension band plating (LTBP) to the femur. METHODS: One-hundred twenty-seven limbs undergoing LTBP for tibia vara were reviewed. All had tibial LTBP and 35 limbs also had femoral LTBP for varus. Radiographs were measured for correction of the mechanical lateral distal femoral angle (mLDFA) and mechanical axis deviation (MAD). Preoperative-femoral varus was defined with an age-adjusted guide: mLDFA >95 degrees for 2 to below 4 years and mLDFA >90 degrees for 4 to 18 years. The 35 limbs having femoral LTBP were compared with 50 limbs with femoral varus and no femoral LTBP. In addition, 42 limbs that did not have preoperative-femoral varus were followed. Patients with early-onset (below 7 y) tibia vara were compared with those with late-onset (≥8 y). Outcome success was based on published age-adjusted mLDFA and MAD norms. RESULTS: Following femoral LTBP, the mean mLDFA decreased from 98.0 to 87.1 degrees. All femurs had some improvement, with 28/35 femurs (80%) achieving complete correction. One limb, with late follow-up, overcorrected, requiring reverse (medial) femoral tension band plating.For the 50 limbs with femoral varus and only tibial LTBP, 16/22 limbs (73%) with early-onset and 11/28 limbs (39%) with late-onset completely corrected their femoral deformities. If the limb had preoperative-femoral varus, femoral LTBP statistically correlated with successful mLDFA correction and improvement of MAD, only in the late-onset group.Forty-two limbs, without preoperative-femoral varus, had no change in their mean mLDFA of 87 degrees. However, 4 femurs (10%) ended with posttreatment varus. CONCLUSIONS: Femoral LTBP is effective in correcting femoral varus deformity in the tibia vara. For femoral varus associated with late-onset tibia vara, femoral LTBP should be considered. Those that had femoral LTBP had statistically more successful femoral and overall limb varus correction. However, in early-onset tibia vara, with associated femoral varus, observation is warranted because 73% of femurs are corrected without femoral intervention. This study was underpowered to show additional improvement with femoral LTBP in the early-onset group. Even limbs with normal femoral alignment, should be observed closely for the development of femoral varus, during tibial LTBP treatment for tibia vara. LEVEL OF EVIDENCE: Level III.

Race, Gender, and Primary Language Were Not Associated With Changes in Opioid Prescribing in Children: Results From a Single Institution, 2010 to 2020.

BACKGROUND: Patients should be prescribed medication based on their medical condition, without prejudice because of their race, gender, or primary language. However, previous research has shown that men are prescribed more medication than women, patients who are White are prescribed more medications than patients who are non-White, and English-speaking people are prescribed more medications than non-English-speaking patients. However, it is unclear whether these differences also occur in pediatric orthopaedic populations. QUESTIONS/PURPOSES: We asked: (1) Was the amount of opiates prescribed at discharge associated with patient age, gender, race, or primary language? (2) Did the amount of opiates prescribed to patients at discharge change from 2010 to 2020? METHODS: In a single center, between January 2010 and December 2019, we treated 331 patients younger than 18 years surgically for upper and lower long-bone extremity fractures. Patients were considered eligible if they had a nonpathologic fracture. Femur fractures were not included. Based on these criteria, all patients were eligible. The mean age was 12 ± 4 years. The mean weight was 57 ± 33 kg. Among these patients, 76% (253 of 331) were boys and 24% (78 of 331) were girls. From the hospital discharge records, we recorded the amount of opiates prescribed at the time of discharge as measured by morphine milligram equivalents (MMEs). We examined the association of age, gender, race, primary language, weight, and year of treatment using this measurement. We determined a patient's race retrospectively by information given by their parents at time of admission. We did not attempt to contact patients to obtain more nuanced information about their racial background. These data were obtained from the electronic health record. The Wilcoxon rank sum test, t-test, or chi-square test was used to assess associations depending on the distribution of variables, as appropriate. Because opioids as measured in MMEs is zero-inflated, a two-part model analysis was used to adjust for confounding variables. One component of the model was for the probability of having any opiate prescription and another was for the mean number of opioids received. Findings were considered statistically significant if p values were < 0.05. RESULTS: In total, 57% (189 of 331) of children were prescribed opiates at discharge after surgery for long-bone fractures. Opiate MMEs increased with patient age (r = 0.38; p < 0.01). Boys and girls showed no difference in the amounts of pain medication (adjusted odds ratio [OR] 1.38 [95% confidence interval (CI) 0.80 to 2.39]; p = 0.71; adjusted opioid difference: 0.35 MME [95% CI -51.7 to 52.4]; p = 0.99), nor were there differences between patients who were White and those who were non-White (adjusted OR 0.78 [95% CI 0.49 to 1.23]; p = 0.28; adjusted opioid difference: 21.5 MME [95% CI -19.3 to 62.4]; p = 0.30), or between patients for whom English was there primary language and those for whom English was not their primary language (adjusted OR 1.16 [95% CI 0.52 to 2.57]; p = 0.71; adjusted opioid difference: 22.7 MME [95% CI -55.7 to 101.3]; p = 0.57) when adjusted for age and weight. There was no change in opioid prescription amounts from 2010 to 2020 after adjusting for changes in patient age across years (Spearman r = -0.08; p = 0.16). CONCLUSION: Fairness in opioid prescribing based on race, gender, or primary language is possible. Additional research is needed to determine what factors in our institution led to this result. We suggest that prescribers should apply consistent protocols based on factors such as weight or injury type rather than making individual decisions for each patient. This will lead to fairer opioid prescribing to patients from different race and gender groups. LEVEL OF EVIDENCE: Level III, therapeutic study.

Using Motion Analysis in the Evaluation, Treatment & Rehabilitation of Pediatric & Adolescent Knee Injuries: A Review of the Literature.

Three-dimensional motion capture systems may improve evaluation, treatment, and rehabilitation of knee injuries, because quantitative assessment of the knee improves understanding of biomechanical mechanisms. The benefit of using motion analysis in pediatric sports medicine is that it allows closer and more focused evaluation of sports injuries using kinematics, kinetics, and electromyogram with physical and imaging to determine what is happening dynamically during sports. Future research investigating knee injuries should focus on identifying risk factors, assessing the effectiveness of surgical and nonsurgical interventions, and developing return to sport/rehabilitation protocols. The literature is focused on motion capture in adults with knee injuries.

Guided Growth for Varus Deformity Following Early Tibial Osteotomy in Infantile Tibia Vara-A Multi-Center Study.

BACKGROUND: Despite early osteotomy, many patients with infantile tibia vara (ITV) have persistent or recurrent varus deformity and disordered growth at the medial proximal tibial physis. Our hypothesis was that lateral tibial tension band plating (LTTBP) could guide correction. METHODS: A retrospective review at 6 centers of 15 patients (16 extremities) was performed of LTTBP for varus deformity following early osteotomy in ITV, diagnosed≤4years of age. Correction of deformity parameters on digital standing anteroposterior lower extremity radiographs determined outcome. RESULTS: Twenty-two LTTBP procedures were performed at mean age of 7.5 years, including 4 revisions for implant failure and 2 reimplantations for recurrence. Single event LLTBP, improved the medial proximal tibial angle with a mean change of 13.4 degrees (0.39 degrees/month). Eleven limbs had preoperative mechanical lateral distal femoral angle (mLDFA)>90 degrees. While n degree femoral procedures were performed, at study end, 11 femurs had mechanical lateral distal femoral angle≤90°. Pretreatment, 13 extremities had mechanical axis zone (MAZone) III varus (81%) and 3 had MAZone II varus (19%). LTTBP's were able to initially correct 13 limbs to MAZone I or valgus but 4 limbs rebounded to MAZone II varus after implant removal. Final limb alignment, after all surgeries and rebound, included 9 in MAZone I, 5 in MAZone II varus and 2 in MAZone III varus. Average follow-up was 3.0 years at mean 10.7 years of age. Fifteen procedures resulted in improvement in MAZone and 7 had no change. On average, those that improved were younger (7.3 vs. 8.0 y), weighed less (45.5 kg with body mass index 26.5 kg/m 2 vs. 67.8 kg and body mass index 35.7 kg/m 2 ), had lower mechanical axis deviation (37.1 mm vs. 43.9 mm), lower medial physeal slope (61.7 vs. 68.7 degrees) and had a higher percentage of open triradiate phases (87 vs. 57%). CONCLUSIONS: LTTBP for residual varus, after initial osteotomy in ITV, resulted in 81% of limbs initially achieving MAZone I or valgus with implant failure revisions and femoral remodeling. Rebound after implant removal reduced the corrected rate to 56%. Ninety-four percent avoided osteotomy during the study period. LEVEL OF EVIDENCE: IV.

Proximal Femoral Focal Deficiency/Congenital Femoral Deficiency: Evaluation and Management.

Proximal focal femoral deficiency is a congenital transverse deficiency in which the femur is globally smaller with a typical proximal deformity at the hip that may include distal involvement of knees, leg, and feet. Congenital femoral deficiency (CFD) describes a broader spectrum of longitudinal deficiency inclusive of proximal focal femoral deficiency. CFD may also include lateral distal femoral hypoplasia, knee cruciate ligament deficiency, rotational instability, patellar dislocation, fibular hemimelia, ray absence, and contralateral limb involvement. Treatment intends to maximize function by limb equalization and deformity correction ranging from nonsurgical management using prosthetics to amputation and may include lengthening, shortening, and complex limb reconstruction. Management decisions depend on overall severity and the patient and family's preferences and priorities. Owing to its complexity, CFD is best treated by clinicians with considerable deformity treatment experience who can help guide decision making and embark on a treatment course that will maximize the functional outcome.

Guided Growth Procedures: Broken Tension Band Implants in Patients With Blount Disease.

BACKGROUND: Tension band plate and screw implants (TBI) are frequently used for temporary hemiepiphyseodeses to manage angular deformity in growing children. The reported implant breakage rate, when TBI is used for deformities in patients with Blount disease, is much higher than when used in other diagnoses. Our hypothesis is that perioperative factors can identify risks for TBI breakage. METHODS: A retrospective case-control study was performed of 246 TBI procedures in 113 patients with Blount disease at 8 tertiary pediatric orthopaedic centers from 2008 to 2018. Patient demographics, age at diagnosis, weight, body mass index (BMI), radiographic deformity severity measures, location, and types of implants were studied. The outcome of implant breakage was compared with these perioperative factors using univariate logistic regression with Bonferroni correction for multiplicity to significance tests. RESULTS: There were 30 broken implants (12%), failing at mean 1.6 years following implantation. Most failures involved the metaphyseal screws. Increased BMI was associated with increased implant breakage. Increased varus deformity was directly associated with greater implant breakage and may be a more important factor in failure for those below 7 years compared with those 8 years or above at diagnosis. There was a 50% breakage rate for TBI with solid 3.5 mm screws in Blount disease with onset 8 years or above of age. No demographic or implant factors were found to be significant. CONCLUSIONS: Breakage of TBI was associated with increased BMI and varus deformity in patients with Blount disease. Larger studies are required to determine the relative contribution and limits of each parameter. Solid 3.5 mm screws should be used with caution in TBI for late-onset Blount disease. LEVEL OF EVIDENCE: Level III.

Limited evidence for graft selection in pediatric ACL reconstruction: a narrative review.

Anterior cruciate ligament reconstruction is the preferred treatment to anterior cruciate ligament injury. With the increase in anterior cruciate ligament injuries in both adults and skeletally immature patients comes the need for individualized anterior cruciate ligament reconstruction graft selection whether it is the type of graft (auto vs. allograft) or the harvesting site (hamstrings, iliotibial band, quadriceps, patella). Several factors need to be considered preoperatively in order to optimize the patients' recovery and restore anterior cruciate ligament strength and function. These include age and bone maturity, preoperative knee flexor/extensor strength, sport participation, patient's needs and anatomical characteristics. This paper aims at bringing evidence supporting the use of a personalized approach in graft selection for faster and more efficient return to sport and propose a theoretical framework to support the approach.

Comparing Musculoskeletal Injuries across Dance and Gymnastics in Adolescent Females Presenting to Emergency Departments.

(1) Background: Studies have yet to identify if there are any differences in musculoskeletal injury patterns between dance and gymnastics. This study aimed to determine if different injury patterns exist in adolescent females participating in those two popular sports. (2) Methods: A cross-sectional study was conducted using data collected from patients presenting to U.S. emergency departments participating in the publicly available, de-identified U.S. Consumer Product Safety Commission's National Electronic Injury Surveillance System (NEISS) throughout the year 2020. Regression analyses were performed to explore if injury patterns were predictive of gymnastics or dancing participation. (3) Results: 518 adolescent females with dance-related injuries and 597 adolescent females with gymnastics-related injuries in 2020 were examined. Strain/sprains (33.3%) and fractures (37.3%) were the most reported dance- and gymnastics-related diagnoses, respectively. Participants were 74% less likely to have a strain/sprain diagnosis in gymnastics compared to dance (OR = 0.26, 95% CI [0.18, 0.38]) and were 3.84 times more likely to have a fracture diagnosis from gymnastics compared to dance (OR = 3.84, 95% CI [2.67, 5.57]), even after adjusting for body party injured. (4) Conclusions: Dance is associated with more sprains while gymnastics typically resulted in a greater likelihood for fractures.

Foot and ankle somatosensory deficits in children with cerebral palsy: A pilot study.

PURPOSE: To investigate foot and ankle somatosensory function in children with cerebral palsy (CP). METHODS: Ten children with spastic diplegia (age 15 ± 5 y; GMFCS I-III) and 11 typically developing (TD) peers (age 15 ± 10 y) participated in the study. Light touch pressure and two-point discrimination were assessed on the plantar side of the foot by using a monofilament kit and an aesthesiometer, respectively. The duration of vibration sensation at the first metatarsal head and medial malleolus was tested by a 128 Hz tuning fork. Joint position sense and kinesthesia in the ankle joint were also assessed. RESULTS: Children with CP demonstrated significantly higher light touch pressure and two-point discrimination thresholds compared to their TD peers. Individuals with CP perceived the vibration stimulus for a longer period compared to the TD participants. Finally, the CP group demonstrated significant impairments in joint position sense but not in kinesthesia of the ankle joints. CONCLUSIONS: These findings suggest that children with CP have foot and ankle tactile and proprioceptive deficits. Assessment of lower extremity somatosensory function should be included in clinical practice as it can guide clinicians in designing more effective treatment protocols to improve functional performance in CP.

Children with Cerebral Palsy Have Similar Walking and Running Quality Assessed by an Overall Kinematic Index.

Running ability is critical to maintaining activity participation with peers. Children and adolescents with cerebral palsy (CP) are often stated to run better than they walk, but running is not often quantitatively measured. The purpose of this study was to utilize overall gait deviation indices to determine if children with diplegic CP run closer to typically developing children than they walk. This retrospective comparative study utilized 3D running kinematics that were collected after walking data at two clinical motion analysis centers for children with diplegic cerebral palsy. Separate walking and running Gait Deviation Indices (GDI Walk and GDI* Run), overall indices of multiple plane/joint motions, were calculated and scaled for each participant so that a typically developing mean was 100 with standard deviation of 10. An analysis of variance was used to compare the variables Activity (walking vs running) and Center (data collected at two different motion analysis laboratories). Fifty participants were included in the study. The main effect of Activity was not significant, mean GDI Walk = 76.4 while mean GDI* Run = 77.1, p = 0.84. Mean GDI scores for walking and running were equivalent, suggesting children with diplegic cerebral palsy as a group have similar walking and running quality. However, individual differences varied between activities, emphasizing the need for individual assessment considering specific goals related to running.

Stiff Landings, Core Stability, and Dynamic Knee Valgus: A Systematic Review on Documented Anterior Cruciate Ligament Ruptures in Male and Female Athletes.

Anterior cruciate ligament (ACL) injuries are the most common ligament injury of the knee, accounting for between 100,000 and 200,000 injuries among athletes per year. ACL injuries occur via contact and non-contact mechanisms, with the former being more common in males and the later being more common in females. These injuries typically require surgical repair and have relatively high re-rupture rates, resulting in a significant psychological burden for these individuals and long rehabilitation times. Numerous studies have attempted to determine risk factors for ACL rupture, including hormonal, biomechanical, and sport- and gender-specific factors. However, the incidence of ACL injuries continues to rise. Therefore, we performed a systematic review analyzing both ACL injury video analysis studies and studies on athletes who were pre-screened with eventual ACL injury. We investigated biomechanical mechanisms contributing to ACL injury and considered male and female differences. Factors such as hip angle and strength, knee movement, trunk stability, and ankle motion were considered to give a comprehensive, joint by joint analysis of injury risk and possible roles of prevention. Our review demonstrated that poor core stability, landing with heel strike, weak hip abduction strength, and increased knee valgus may contribute to increased ACL injury risk in young athletes.

Increasing hospital admissions for patellar instability: a national database study from 2004 to 2017.

Objectives: Epidemiology of patellar instability is not fully characterized, as some studies have produced conflicting information or been drawn from limited populations. In this study, we used the Pediatric Health Information System (PHIS) database to examine trends in admissions for patellar instability throughout the United States. We hypothesized that there would be an increasing rate of patellar instability admissions in recent years. Secondarily, we examined how demographic factors and insurance status relate to admissions for patellar instability.Methods: This study queried the Pediatric Health Information System (PHIS). Patients with ICD 9 & 10 codes 8363, 8364, 71,785, M221.0, S83.001, S83.002, S83.003, S83.004, S83.005, and S83.006, were abstracted from PHIS. We included all patients admitted with patellofemoral dislocations that were reported in the PHIS database between 1 January 2004 and 30 April 2017. The rate of patellar instability admissions was examined as well as demographic factors and insurance status.Results: An estimated total of 25,413 admissions for patellar instability were identified by the search of the PHIS database; 15,444 (60.8%) were female patients and 9,966 (39.2%) were male. The adjusted number of admissions per reporting hospital significantly increased over the years studied (r = 0.775, p < 0.001), from 14.5 admissions per reporting hospital in 2004 to 86.0 admissions per reporting hospital in 2016. Of all patellar instability admissions, 55.0% were white, 20.4% were black, 1.7% were Asian, and 22.9% were unknown race. A larger number of admissions occurred in patients with insurance status other than Medicaid in every year data were collected.Conclusions: Based on a PHIS database search, pediatric hospital admissions for patellar instability are steadily increasing. The majority of patients admitted for patellar instability are female, white, and have insurance other than Medicaid. Males admitted for patellar instability tended to be older than females admitted for the same.Level of evidence: II.

The Natural History of Pediatric and Adolescent Shoulder Dislocation.

BACKGROUND: Twenty percent of shoulder dislocations occur in people younger than 20 years old. Management of anterior shoulder instability in young patients remains an evolving and controversial topic. Herein we review the natural history of anterior shoulder dislocation in young patients. METHODS: The English-language literature was searched for studies examining the natural history of pediatric and adolescent shoulder dislocation. Recurrent dislocation was the primary outcome of interest in most studies. RESULTS: Most studies found that recurrent instability was likely in young patients. Several systematic reviews reported the recurrence rate for young patients to be >70%. Recurrent instability was likely to cause greater damage to the joint and may result in more extensive and costly surgery. CONCLUSIONS: Most studies agree that recurrent anterior shoulder instability is likely in young patients. Some authors advocate for consideration of early surgery in this high-risk population.

Racial Diversity in Orthopedic Surgery.

Data from the US Census Bureau, the Accreditation Council for Graduate Medical Education, and the American Academy of Orthopaedic Surgeons reveal that orthopedic surgery is the least diverse of any surgical specialty and that diversity within orthopedics is not improving. Considerable data from both medicine and business suggest that improving diversity within the orthopedic surgery specialty would be of significant benefit to the orthopedic surgery profession and to patients. Multiple avenues for increasing diversity exist, including large-scale pipeline programs as well as personal and institutional efforts examining biases and decision-making processes.

Diagnosis and Treatment of Osteoporosis: What Orthopaedic Surgeons Need to Know.

Osteoporosis, often called a silent disease, is a systemic condition of bone as a result of loss of bone mass and deterioration of its microarchitecture. The result is weakened bone, leading to an increased risk of fragility fractures. An estimated 9 million osteoporotic fractures occur every year worldwide. However, the true incidence of osteoporotic fractures is unknown because many are undetected. Astoundingly, this epidemic equates to an osteoporotic fracture every 3 seconds. Orthopaedic surgeons need to not only treat these fractures but also understand the underlying pathogenesis and risk factors to help prevent them. The management of osteoporosis is a critical part of musculoskeletal care. We must be familiar with the tools to assess osteoporosis and the treatments available, including risks and benefits. This review article is intended to deliver a review of the vast literature and provide the orthopaedic surgeon with the essential information necessary to manage the current osteoporosis epidemic.

Age-Appropriate Pediatric Sports Patient-Reported Outcome Measures and Their Psychometric Properties: A Systematic Review.

BACKGROUND: Phenomena including early sport specialization and year-round training and competition have contributed to an increase in pediatric sports injuries. There has been a concomitant increase in clinical studies focusing on physically active children and adolescents. These studies include investigations of patient-reported outcome measures (PROMs). While the use of PROMs in pediatric orthopaedics has been increasing, PROMs are often inappropriately applied to study populations for whom they are not specifically validated. PURPOSE: The purpose of this study was to establish a comprehensive list of pediatric- and adolescent-validated PROMs and catalog their psychometric properties as a resource for clinicians and researchers. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A systematic review of articles in PubMed, Embase, and the Cochrane library was performed to identify articles developing and validating PROMs appropriate for use in pediatric sports medicine research. The inclusion criteria were as follows: age <18 years, the use of surveys and questionnaires, and the presence of sports-related injuries. The psychometric properties of included PROMs were entered into an electronic database. RESULTS: Our search strategy identified 14,708 unique articles, among which 139 studies (0.9%) were included in the final data analysis. Forty-seven distinct PROMs were identified, as well as 160 cross-cultural adaptations. While all identified PROMs were validated in physically active young participants, only 12 (26%) were specifically created initially for active children. Thirty (64%) PROMs were health-related quality-of-life measures; 13 (28%) were psychosocial measures; and 4 (9%) were activity scales. No studies validated PROMs for use with wrist/hand injuries, and only 1 PROM each was valid for hip, back/spinal, and foot/ankle injuries in pediatric sports. CONCLUSION: This systematic review yielded 47 unique PROMs reliable and valid for use in pediatric and adolescent sports medicine. This list will unify clinicians and researchers in using these age-appropriate measures while identifying areas that are still in need of appropriate PROMs for young athletes.

Reactive scoliosis: a challenging phenomenon in adolescent patients with hip arthritis.

Functional limb length discrepancy (LLD) in adolescents can result from soft tissue contracture following long-standing hip disease. We present a case of a 13-year-old girl with difficulty in ambulation due to right hip pain and LLD. Radiographs revealed severe arthritis of right hip with signs of avascular necrosis of the femoral head. The patient had developed reactive scoliosis of lumbar spine along with pelvic obliquity. After failing conservative management, total hip arthroplasty (THA) without attempting to equalize LLD was performed. At 6-month follow-up, patient was pain free with full range of motion and her functional LLD was completely resolved. In such adolescent patients, reactive scoliosis of spine is reversible, and with no evidence of true LLD, THA without correcting LLD should be the right choice.