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.

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.

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.

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.

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.

The Female Athlete: Key Differences Between Girls and Boys.

Studies have shown female athletes to be subject to different risks than male athletes, even for the same sports and particularly after puberty. The purpose of this article is to identify some of those differences, discuss how treatment for female athletes differs both for healing and prevention, and emphasize key school nurse roles in identifying and responding to female athlete injuries.

Does a Weekly Didactic Conference Improve Resident Performance on the Pediatric Domain of the Orthopaedic In-Training Examination?

BACKGROUND: Performance on the Orthopaedic In-training Examination (OITE) has been correlated with performance on the written portion of the American Board of Orthopaedic Surgery examination. Herein we sought to discover whether adding a regular pediatric didactic lecture improved residents' performance on the OITE's pediatric domain. METHODS: In 2012, a didactic lecture series was started in the University of Pittsburgh Medical Center (UPMC) Hamot Orthopaedic Residency Program (Hamot). This includes all topics in pediatric orthopaedic surgery and has teaching faculty present, and occurs weekly with all residents attending. A neighboring program [UMPC Pittsburgh (Pitt)] shares in these conferences, but only during their pediatric rotation. We sought to determine the effectiveness of the conference by comparing the historic scores from each program on the pediatric domain of the OITE examination to scores after the institution of the conference, and by comparing the 2 programs' scores. RESULTS: Both programs demonstrated improvement in OITE scores. In 2008, the mean examination score was 19.6±4.3 (11.0 to 30.0), and the mean percentile was 57.7±12.6 (32.0 to 88.0); in 2014, the mean examination score was 23.5±4.2 (14.0 to 33.0) and the mean percentile was 67.1±12.1 (40.0 to 94.0). OITE scores and percentiles improved with post graduate year (P<0.0001). Compared with the preconference years, Hamot residents answered 3.99 more questions correctly (P<0.0001) and Pitt residents answered 2.93 more questions correctly (P<0.0001). Before the conference, site was not a predictor of OITE score (P=0.06) or percentile (P=0.08); there was no significant difference found between the mean scores per program. However, in the postconference years, site did predict OITE scores. Controlling for year in training, Hamot residents scored higher on the OITE (2.3 points higher, P=0.003) and had higher percentiles (0.07 higher, P=0.004) than Pitt residents during the postconference years. CONCLUSIONS: This study suggests that adding a didactic pediatric lecture improved residents' scores on the OITE and indirectly suggests that more frequent attendance is associated with better scores. LEVEL OF EVIDENCE: Level III-retrospective case-control study.

Predictors of conversion from conservative to operative treatment of pediatric forearm fractures.

Forearm fractures occur commonly in children; however, there is still uncertainty on what leads to conversion from conservative to operative management. Patients who initially underwent closed reduction and casting for diaphyseal forearm fractures were evaluated for predictors of conversion to operative management. We found that the 20 of 124 (16%) patients in whom there was conversion to operative management were significantly older (11.1 vs. 5.7 nonoperative), had less angulation in the anterior-posterior (or coronal) plane (20.2 vs. 12.8° for the radius, 17.5 vs. 7.8° for the ulna), had a more proximal ulnar fracture location, and had more translated or shortened radius fractures.

Anterior cruciate ligament tears in children and adolescents: a meta-analysis of nonoperative versus operative treatment.

BACKGROUND: Debate regarding the optimal initial treatment for anterior cruciate ligament (ACL) injuries in children and adolescents has not resulted in a clear consensus for initial nonoperative treatment or operative reconstruction. HYPOTHESIS/PURPOSE: The purpose of this meta-analysis was to systematically analyze aggregated data from the literature to determine if a benefit exists for either nonoperative or early operative treatment for ACL injuries in the pediatric patient. The hypothesis was that combined results would favor early operative reconstruction with respect to posttreatment episodes of instability/pathological laxity, symptomatic meniscal tears, clinical outcome scores, and return to activity. STUDY DESIGN: Meta-analysis. METHODS: A literature selection process included the extraction of data on the following clinical variables: symptomatic meniscal tears, return to activities, clinical outcome scores, return to the operating room, and posttreatment instability/pathological laxity. A symptomatic meniscal tear was defined as occurring after the initial presentation, limiting activity, and requiring further treatment. Instability/pathological laxity was defined for the sake of this study as having an episode of giving way, a grade ≥2 Lachman/pivot-shift test result, or a side-to-side difference of >4 mm as measured by the KT-1000 arthrometer. All studies were evaluated using a formal study quality analysis. Meta-analysis was conducted for aggregated data in each category. RESULTS: Six studies (217 patients) comparing operative to nonoperative treatment and 5 studies (353 patients) comparing early to delayed reconstruction were identified. Three studies reported posttreatment instability/pathological laxity; 13.6% of patients after operative treatment experienced instability/pathological laxity compared with 75% of patients after nonoperative treatment (P < .01). Two studies reported symptomatic meniscal tears; patients were over 12 times more likely to have a medial meniscal tear after nonoperative treatment than after operative treatment (35.4% vs 3.9%, respectively; P = .02). A significant difference in scores between groups was noted in 1 of 2 studies reporting International Knee Documentation Committee (IKDC) scores (P = .002) and in 1 of 2 studies reporting Tegner scores (P = .007). Two studies reported return to activity; none of the patients in the nonoperative groups returned to their previous level of play compared with 85.7% of patients in the operative groups (P < .01). Study quality analysis revealed that the majority of the studies were inconsistent in reporting outcomes. CONCLUSION: Meta-analysis revealed multiple trends that favor early surgical stabilization over nonoperative or delayed treatment. Patients after nonoperative and delayed treatment experienced more instability/pathological laxity and inability to return to previous activity levels than did patients treated with early surgical stabilization.

Prevention of Anterior Cruciate Ligament Rupture in Female Athletes: A Systematic Review.

BACKGROUND: A number of reports have been published on the effectiveness and design of intervention programs for the prevention of rupture of the anterior cruciate ligament (ACL) in female athletes. The purpose of this study was to systematically review the literature to determine the effectiveness of neuromuscular training programs in preventing ACL injury in female athletes. METHODS: A systematic review was performed with use of the PubMed, MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases. The search terms included "anterior cruciate ligament" and "ACL" combined with "prevention" and "intervention." The searches included material indexed by September 30, 2013. Data concerning study design, the characteristics of participants, the details of the neuromuscular programs, the types of sports, and number of ACL ruptures were extracted from the studies. Study heterogeneity was assessed with funnel plot and Egger regression methods. Pooled effects were calculated with use of a DerSimonian-Laird random-effects model. The number needed to treat was calculated on the basis of pooled incidence data. RESULTS: The risk of ACL rupture was 1.83 times higher for female athletes who did not participate in neuromuscular ACL-prevention training programs (odds ratio [OR], 1.83; 95% confidence interval [95% CI], 1.08 to 3.10; p = 0.02). In studies that focused exclusively on soccer, the risk of ACL rupture was 2.62 times higher for nonparticipating athletes (OR, 2.62; 95% CI, 1.59 to 4.32; p < 0.01). When the data were analyzed according to the timing of the intervention, no significant effects were found. In studies in which the program took place both preseason and in-season, the risk (odds ratio) of ACL rupture for nonparticipating athletes was 2.34 (95% CI, 0.82 to 6.7; p = 0.11). In studies in which the intervention took place in-season only, the risk (odds ratio) of ACL rupture for nonparticipating athletes was 1.25 (95% CI, 0.23 to 6.75; p = 0.8). The number needed to treat to prevent a single ACL rupture was 128.7 athletes. We found no significant heterogeneity among the included studies. The I value was 35.40% (p = 0.11). No significant publication bias was found in our included studies. CONCLUSIONS: The results of this systematic review and meta-analysis favor a protective effect of neuromuscular training programs on the risk of ACL rupture in female athletes. This protective effect is more pronounced in soccer players. Additional research is needed to design the optimal training program. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions to Authors for a complete description of levels of evidence.

All-epiphyseal anterior cruciate ligament reconstruction using fluoroscopic imaging.

Anterior cruciate ligament injuries in the pediatric population have been increasing in recent years. While reconstruction can often provide the best chance of restoring stability and preventing degenerative joint disease, the skeletally immature patient with open physes can represent a treatment challenge to the orthopaedic surgeon. Here, we present a technique developed by the senior author that uses two-dimensional fluoroscopy, obviating the need for computed tomography imaging. Intraoperative technical details of this procedure are highlighted. This technique allows the orthopaedic surgeon to reconstruct the ligament in a physeal-sparing manner without the need for intraoperative computed tomography scanning, and with less risk of radiation exposure.

Approach to the pediatric supracondylar humeral fracture with neurovascular compromise.

Supracondylar fractures of the humerus are exceedingly common in pediatric patients but may present treatment challenges when complicated by neurovascular compromise. Patients presenting with poor perfusion should be treated with urgent reduction because this is a limb-threatening emergency. If perfusion does not improve, or if a previously perfused extremity loses perfusion after reduction, arterial exploration is warranted. Controversy exists over whether to observe or explore a reduced, perfused, but pulseless extremity with a supracondylar fracture. Minimal management requires that these injuries be carefully monitored for 48 hours for loss of perfusion or the development of compartment syndrome. In general, nerve injuries accompanying supracondylar fractures of the humerus are neurapraxias and may be treated conservatively; however, nerve palsy with accompanying pulselessness warrants immediate exploration. Patients should be treated more urgently if excessive swelling, antecubital ecchymosis, skin puckering, an absent pulse, or fractures in the same limb are present. If a hand is not perfused or compartments are firm, emergent treatment should be considered.

Evidence-based medicine: management of pediatric forearm fractures.

Forearm fractures are common injuries in the pediatric population. Successful treatment of these fractures should result in complication-free functional pronosupination. Traditionally, these have been treated with closed reduction and casting, but the last several decades have seen a dramatic increase in the operative treatment of these fractures. However, little high-level evidence exists to guide management. The data from the limited set of studies available suggest that closed treatment does usually result in satisfactory outcomes, particularly in younger patients; operative fixation is usually successful as well but comes with a significantly increased complication rate. The ideal study to aid in evidence-based decision-making for pediatric forearm fractures would be a randomly controlled trial comparing closed reduction and casting versus intramedullary nailing versus plating; in children ranging from 8 years old to skeletally mature; with closed forearm fractures, complete or greenstick with >20 degrees of angulation; with a minimum of 5 years of follow-up (or to maturity); with the primary outcome defined as final pronation and supination; using an validated functional outcome tool; and precisely defining the complications from each treatment.