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

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

Resident muscle stem cell myogenic characteristics in postnatal muscle growth impairments in children with cerebral palsy.

Children with cerebral palsy (CP), a perinatal brain alteration, have impaired postnatal muscle growth, with some muscles developing contractures. Functionally, children are either able to walk or primarily use wheelchairs. Satellite cells are muscle stem cells (MuSCs) required for postnatal development and source of myonuclei. Only MuSC abundance has been previously reported in contractured muscles, with myogenic characteristics assessed only in vitro. We investigated whether MuSC myogenic, myonuclear, and myofiber characteristics in situ differ between contractured and noncontractured muscles, across functional levels, and compared with typically developing (TD) children with musculoskeletal injury. Open muscle biopsies were obtained from 36 children (30 CP, 6 TD) during surgery; contracture correction for adductors or gastrocnemius, or from vastus lateralis [bony surgery in CP, anterior cruciate ligament (ACL) repair in TD]. Muscle cross sections were immunohistochemically labeled for MuSC abundance, activation, proliferation, nuclei, myofiber borders, type-1 fibers, and collagen content in serial sections. Although MuSC abundance was greater in contractured muscles, primarily in type-1 fibers, their myogenic characteristics (activation, proliferation) were lower compared with noncontractured muscles. Overall, MuSC abundance, activation, and proliferation appear to be associated with collagen content. Myonuclear number was similar between all muscles, but only in contractured muscles were there associations between myonuclear number, MuSC abundance, and fiber cross-sectional area. Puzzlingly, MuSC characteristics were similar between ambulatory and nonambulatory children. Noncontractured muscles in children with CP had a lower MuSC abundance compared with TD-ACL injured children, but similar myogenic characteristics. Contractured muscles may have an intrinsic deficiency in developmental progression for postnatal MuSC pool establishment, needed for lifelong efficient growth and repair.

Are Neighborhood Conditions Associated With Surgical Delays and Meniscus Tears in Children and Adolescents Undergoing ACL Reconstruction?

BACKGROUND: Markers of a patient's social determinants of health, including healthcare insurance and median household income based on ZIP Code, have been associated with the interval between injury and ACL reconstruction (ACLR) as well as the presence of concomitant meniscus tears in children and adolescents. However, the aforementioned surrogate indicators of a patient's social determinants of health may not reflect all socioeconomic and healthcare resources affecting the care of ACL injuries in children and adolescents. The use of multivariate indices such as the Child Opportunity Index (COI) may help to better identify patients at risk for increased risk for delay between ACL injury and surgery, as well as the incidence of meniscus tears at the time of surgery. The COI is a summative measure of 29 indicators that reflect neighborhood opportunities across three domains: education, health and environment, and social and economic factors. COI scores range from 0 to 100 (100 being the highest possible score), as well as five categorical scores (very low, low, moderate, high, and very high) based on quintile rankings. QUESTIONS/PURPOSES: To investigate the relationship between neighborhood conditions and the treatment of ACL injuries in children and adolescents via the COI, we asked: (1) Is a lower COI score associated with a longer delay between ACL injury and surgery? (2) Does a higher proportion of patients with lower COI scores have meniscus tears at the time of ACLR? METHODS: In this retrospective, comparative study, we considered data from 565 patients, 18 years or younger, who underwent primary ACLR at an urban, tertiary children's hospital between 2011 and 2021. Of these patients, 5% (31 of 565) did not have a clearly documented date of injury, 2% (11 of 565) underwent revision reconstructions, and 1% (5 of 565) underwent intentionally delayed or staged procedures. Because we specifically sought to compare patients who had low or very low COI scores (lowest two quintiles) with those who had high or very high scores (highest two quintiles), we excluded 18% (103 of 565) of patients with moderate scores. Ultimately, 73% (415 of 565) of patients with COI scores in either the top or bottom two quintiles were included. Patient addresses at the time of surgery were used to determine the COI score. There were no differences between the groups in terms of gender. However, patients with high or very high COI scores had a lower median (IQR) age (15 years [2.6] versus 17 years [1.8]; p < 0.001) and BMI (23 kg/m 2 [6.1] versus 25 kg/m 2 [8.8]; p < 0.001), were more commonly privately insured (62% [117 of 188] versus 22% [51 of 227]; p < 0.001), and had a higher proportion of patients identifying as White (67% [126 of 188] versus 6.2% [14 of 227]; p < 0.001) compared with patients with low or very low COI scores. Medical records were reviewed for demographic, preoperative, and intraoperative data. Univariate analyses focused on the relationship of the COI and interval between injury and surgery, frequency of concomitant meniscus tears, and frequency of irreparable meniscus tears treated with partial meniscectomy. Multivariable regression analyses were used to determine factors that were independently associated with delayed surgery (longer than 60 and 90 days after injury), presence of concomitant meniscal injuries, and performance of meniscectomy. Multivariable models included insurance and race or ethnicity to determine whether COI was independently associative after accounting for these variables. RESULTS: Patients with a high or very high COI score had surgery earlier than those with a low or very low COI score (median [IQR] 53 days [53] versus 97 days [104]; p < 0.001). After adjusting for insurance and race/ethnicity, we found that patients with a low or very low COI score were more likely than patients with a high or very high COI score to have surgery more than 60 days after injury (OR 2.1 [95% CI 1.1 to 4.0]; p = 0.02) or more than 90 days after injury (OR 1.8 [95% CI 1.1 to 3.4]; p = 0.04). Furthermore, patients with low or very low COI scores were more likely to have concomitant meniscus tears (OR 1.6 [95% CI 1.1 to 2.5]; p = 0.04) compared with patients with high or very high COI scores. After controlling for insurance, race/ethnicity, time to surgery, and other variables, there was no association between COI and meniscectomy (OR 1.6 [95% CI 0.9 to 2.8]; p = 0.12) or presence of a chondral injury (OR 1.7 [95% CI 0.7 to 3.9]; p = 0.20). CONCLUSION: As the COI score is independently associated with a delay between ACL injury and surgery as well as the incidence of meniscus tears at the time of surgery, this score can be useful in identifying patients and communities at risk for disparate care after ACL injury. The COI score or similar metrics can be incorporated into medical records to identify at-risk patients and dedicate appropriate resources for efficient care. Additionally, neighborhoods with a low COI score may benefit from improvements in the availability of additional and/or improved resources. Future studies should focus on the relationship between the COI score and long-term patient-reported functional outcomes after ACL injury, identification of the specific timepoints in care that lead to delayed surgery for those with lower COI scores, and the impact of community-based interventions in improving health equity in children with ACL injury. LEVEL OF EVIDENCE: Level III, therapeutic study.

Is Preferred Language Other Than English Associated With Delayed Surgery After ACL Injury in Children and Adolescents?

BACKGROUND: Previous studies have investigated the impact of social determinants of health, such as the type of healthcare insurance and household income, on children and adolescents with ACL tears. However, despite the increasing incidence of ACL injury in young patients and a substantial proportion of families who may prefer languages other than English, the relationship between language and clinical care remains unclear. QUESTIONS/PURPOSES: To investigate the relationship between language and the care of children and adolescents with ACL tears, we asked: (1) Is a preferred language other than English (PLOE) associated with a delay between ACL injury and surgery? (2) Is a PLOE associated with a greater odds of a patient experiencing a meniscal tear and undergoing a meniscectomy than in those who prefer English? METHODS: We treated 591 patients surgically for ACL injuries between 2011 and 2021. Of those, we considered patients aged 18 years or younger who underwent primary ACL reconstruction for this retrospective, comparative study. Five percent (31 of 591) of patients were excluded because the date of injury was not clearly documented, 2% (11 of 591) were revision reconstructions, and 1% (6 of 591) underwent procedures that were intentionally delayed or staged, leaving 92% (543 of 591) for analysis. The mean age was 16 ± 2 years, and 51% (276 of 543) of patients were boys. The family's preferred language was noted, as were demographic data, time between injury and surgery, and intraoperative findings. A language other than English was preferred by 21% (113 of 543) of patients. Of these, 94% (106 of 113) preferred Spanish. In a univariate analysis, we used independent-samples t-tests, Mann-Whitney U-tests, and Fisher exact tests, as appropriate. Purposeful-entry multivariable regression analyses were used to determine whether PLOE was associated with increased time to surgery, concomitant meniscus injury, or performance of meniscectomy while adjusting for confounding variables. Variables were included in multivariable models if they met the threshold for statistical significance in univariate testing (p < 0.05). RESULTS: The median time between injury and ACL reconstruction was shorter in families who preferred English compared with those with a PLOE (69 days [IQR 80] versus 103 days [IQR 107)]; p < 0.001). After controlling for potentially confounding variables like insurance and age, we found that patients whose families had a PLOE had greater odds of undergoing surgery more than 60 days after injury (OR 2.2 [95% CI 1.3 to 3.8]; p = 0.005) and more than 90 days after injury (OR 1.8 [95% CI 1.1 to 2.8]; p = 0.02). After controlling for insurance, age, and other factors, PLOE was not associated with surgical delay beyond 180 days, concomitant meniscal tears, or performance of meniscectomy. CONCLUSION: In this study of children and adolescents undergoing primary ACL reconstruction, patients whose families prefer a language other than English experienced a longer delay between injury and surgery. In areas with a large proportion of families with a PLOE, partnerships with primary care clinicians, emergency departments, schools, athletic teams, and community organizations may improve efficiency in the care of children with ACL injuries. Clinicians proficient in other languages, reliable interpreter services, and translated references and resources may also be impactful. Our results suggest a need for further research on the experiences, needs, and long-term outcomes of these patients, as well as the association of preferred language with results after surgery. LEVEL OF EVIDENCE: Level III, therapeutic study.

A Multicenter Comparison of Open Versus Arthroscopic Fixation for Pediatric Tibial Spine Fractures.

BACKGROUND: When operative treatment is indicated, tibial spine fractures can be successfully managed with open or arthroscopic reduction and internal fixation (ARIF). The purpose of the study is to evaluate short-term treatment outcomes of tibial spine fractures in patients treated with both open and arthroscopic fracture reduction. METHODS: We performed an Institutional Review Board (IRB)-approved retrospective cohort study of pediatric tibial spine fractures presenting between January 1, 2000 and January 31, 2019 at 10 institutions. Patients were categorized into 2 cohorts based on treatment: ARIF and open reduction and internal fixation (ORIF). Short-term surgical outcomes, the incidence of concomitant injuries, and surgeon demographics were compared between groups. RESULTS: There were 477 patients with tibial spine fractures who met inclusion criteria, 420 of whom (88.1%) were treated with ARIF, while 57 (11.9%) were treated with ORIF. Average follow-up was 1.12 years. Patients treated with ARIF were more likely to have an identified concomitant injury (41.4%) compared with those treated with ORIF (24.6%, P=0.021). Most concomitant injuries (74.5%) were treated with intervention. The most common treatment complications included arthrofibrosis (6.9% in ARIF patients, 7.0% in ORIF patients, P=1.00) and subsequent anterior cruciate ligament injury (2.1% in ARIF patients and 3.5% in ORIF, P=0.86). The rate of short-term complications, return to the operating room, and failure to return to full range of motion were similar between treatment groups. Twenty surgeons with sports subspecialty training completed 85.0% of ARIF cases; the remaining 15.0% were performed by 12 surgeons without additional sports training. The majority (56.1%) of ORIF cases were completed by 14 surgeons without sports subspecialty training. CONCLUSION: This study demonstrated no difference in outcomes or nonunion following ARIF or ORIF, with a significantly higher rate of concomitant injuries identified in patients treated with ARIF. The majority of identified concomitant injuries were treated with surgical intervention. Extensive surgical evaluation or pretreatment magnetic resonance imaging should be considered in the workup of tibial spine fractures to increase concomitant injury identification. LEVEL OF EVIDENCE: Level III.

Interobserver and Intraobserver Agreement are Unsatisfactory When Determining Abstract Study Design and Level of Evidence.

BACKGROUND: Understanding differences between types of study design (SD) and level of evidence (LOE) are important when selecting research for presentation or publication and determining its potential clinical impact. The purpose of this study was to evaluate interobserver and intraobserver reliability when assigning LOE and SD as well as quantify the impact of a commonly used reference aid on these assessments. METHODS: Thirty-six accepted abstracts from the Pediatric Orthopaedic Society of North America (POSNA) 2021 annual meeting were selected for this study. Thirteen reviewers from the POSNA Evidence-Based Practice Committee were asked to determine LOE and SD for each abstract, first without any assistance or resources. Four weeks later, abstracts were reviewed again with the guidance of the Journal of Bone and Joint Surgery (JBJS) LOE chart, which is adapted from the Oxford Centre for Evidence-Based Medicine. Interobserver and intraobserver reliability were calculated using Fleiss' kappa statistic (k). χ2 analysis was used to compare the rate of SD-LOE mismatch between the first and second round of reviews. RESULTS: Interobserver reliability for LOE improved slightly from fair (k=0.28) to moderate (k=0.43) with use of the JBJS chart. There was better agreement with increasing LOE, with the most frequent disagreement between levels 3 and 4. Interobserver reliability for SD was fair for both rounds 1 (k=0.29) and 2 (k=0.37). Similar to LOE, there was better agreement with stronger SD. Intraobserver reliability was widely variable for both LOE and SD (k=0.10 to 0.92 for both). When matching a selected SD to its associated LOE, the overall rate of correct concordance was 82% in round 1 and 92% in round 2 (P<0.001). CONCLUSION: Interobserver reliability for LOE and SD was fair to moderate at best, even among experienced reviewers. Use of the JBJS/Oxford chart mildly improved agreement on LOE and resulted in less SD-LOE mismatch, but did not affect agreement on SD. LEVEL OF EVIDENCE: Level II.

Predictors of Arthrofibrosis After Pediatric Anterior Cruciate Ligament Reconstruction: What Is the Impact of Quadriceps Autograft?

BACKGROUND: Recent literature on arthrofibrosis after anterior cruciate ligament reconstruction (ACLR) in children and adolescents is limited, especially with regards to quadriceps tendon (QT) autograft. The purpose of this study was to identify predictors of arthrofibrosis after ACLR, with attention to the impact of graft type. METHODS: Patients that underwent primary ACLR at a tertiary children's hospital were reviewed for this retrospective case-control study. Those with multiligament reconstructions, lateral extra-articular tenodesis procedures, allografts, or a modified MacIntosh reconstruction were excluded. Arthrofibrosis was defined as a deficit of 10 degrees of extension and/or 20 degrees of flexion at 3 months after ACLR. Univariate analysis was followed by purposeful entry logistic regression to adjust for confounding factors. RESULTS: A total of 378 patients (mean age 15.9±1.7 y, 49.7% female) were included in the analysis, of which there were 180 patellar tendon (PT), 103 hamstrings tendon (HT), and 95 QT grafts. The rate of arthrofibrosis was 1.9% for HT, 6.3% for QT, and 10.0% for PT (P=0.04). Females developed arthrofibrosis more frequently than males (10.6% vs. 3.2%, P=0.004). Those that ultimately experienced this complication had lower median flexion at 6 weeks after ACLR (88 vs. 110 degrees, P<0.001). In multivariate analysis, PT graft raised the odds of arthrofibrosis 6.2 times compared to HT [95% confidence interval (CI): 1.4-27.6, P=0.02], but there were no significant differences between QT and other grafts. Females were at 4.2 times higher odds than males (95% CI: 1.6-10.8; P=0.003). Patients that were unable to attain 90 degrees of flexion 6 weeks after ACLR had 14.7 times higher odds of eventually developing arthrofibrosis (95% CI: 5.4-39.8; P<0.001). Finally, those with an extension deficit of ≥5 degrees 6 weeks after ACLR had 4.7 times higher odds of experiencing this complication (95% CI: 1.8-12.2, P=0.001). CONCLUSION: The rate of arthrofibrosis with QT autograft is 6.3% after pediatric ACLR. PT autograft, female sex, and motion deficits at 6 weeks after ACLR were predictive of arthrofibrosis in children and adolescents. LEVEL OF EVIDENCE: Level III-prognostic study.

The Majority of Patient-reported Outcome Measures in Pediatric Orthopaedic Research Are Used Without Validation.

BACKGROUND: Given that patient-reported outcome measures (PROMs) are increasingly used to inform clinical decision-making, it is vital that they are validated, reliable, responsive, and appropriate for the population under study. The purpose of this systematic review was to assess the rate of PROM use in the pediatric orthopaedic literature, characterize whether each use was in the PROM-validated demographic, and analyze the association between bibliometric factors and the use of PROMs with incomplete validation. METHODS: The Institute for Scientific Information (ISI) Web of Science database was queried for all clinical pediatric orthopaedic studies from 2014 to 2017. All PROMs were recorded for each study independently by 2 reviewers and cross-referenced with the published orthopaedic literature as of 2017 to determine if the PROM had been validated for the study population. PROMs that had not been validated, had been shown to be invalid, or had conflicting validity studies for use in the population of interest were designated as incompletely validated or used without complete validation. The following covariates were recorded for each study: subspecialty, inclusion of a statistician coauthor, sample size, journal, and the journal impact factor. χ analysis was used to evaluate the association between categorical variables and the use of at least 1 incompletely validated PROM. RESULTS: In total, 1000 articles were screened, yielding 653 studies that met our inclusion criteria. A total of 104/653 (16%) publications-reported PROMs. PROMs were used without complete validation 120/165 (73%) times, and 77/104 (74%) studies used at least 1 PROM without complete validation. The most frequent reasons for incomplete validation were (1) using PROMs that had been validated in adults, but not pediatrics (n=47; 28.5%), and (2) using PROMs that had been designated in the literature as invalid for pediatrics (n=27; 16.4%). The incomplete validation of at least 1 PROM was associated with smaller sample size (P=0.01) and subspecialty (P<0.01). Overall rates of PROM use and the proportion of PROMs used without complete validation were both found to be higher than those previously reported. CONCLUSION: The majority of pediatric orthopaedic studies reporting PROMs used at least 1 PROM without complete validation for their study population. LEVEL OF EVIDENCE: Level IV-systematic review of level I, II, III, and IV studies.

Anterior Cruciate Ligament Tear Following Operative Treatment of Pediatric Tibial Eminence Fractures in a Multicenter Cohort.

BACKGROUND: Postoperative ipsilateral anterior cruciate ligament (ACL) tears after tibial eminence fracture fixation has been previously noted in the literature. This study aims to describe the prevalence of and risk factors for postoperative ACL tears in a cohort of patients operatively treated for tibial eminence fracture. METHODS: A retrospective review of children undergoing treatment of a tibial eminence fracture at 10 tertiary care children's hospitals was performed. The primary outcome of interest was subsequent ACL rupture. Incidence of ACL tear was recorded for the entire cohort. Patients who sustained a postoperative ACL tear were compared with those without ACL tear and analyzed for demographics and risk factors. A subgroup analysis was performed on patients with a minimum of 2-year follow-up data or those who had met the primary outcome (ACL tear) before 2 years. RESULTS: A total of 385 pediatric patients were reviewed. 2.6% of the cohort experienced a subsequent ACL tear. The median follow-up time was 6.5 months (SD=6.4 mo). Subsequent ACL tears occurred at a median of 10.2 months (SD=19.5 mo) postoperatively. There was a statistically significant association with higher grade tibial spine fractures (Myers and McKeever type III and IV) and subsequent ACL tear (P=0.01). Patients with a subsequent ACL tear were older on average (13.5 vs. 12.2 y old), however, this difference was not statistically significant (P=0.08). Subgroup analysis of 46 patients who had a 2-year follow-up or sustained an ACL tear before 2 years showed a 21.7% incidence of a subsequent ACL tear. There was a statistically significant association with higher grade tibial spine fractures (Myers and McKeever type III and IV) and subsequent ACL rupture (P=0.006) in this subgroup. Postoperative ACL tears occurred in patients who were older at the time that they sustained their original tibial eminence fracture (13.4 vs. 11.3 y old, P=0.035). CONCLUSIONS: Ipsilateral ACL tears following operatively treated pediatric tibial eminence fractures in a large multicenter cohort occurred at a rate of 2.6%. However, in those with at least 2 years of follow-up, the incidence was 21.7%. Subsequent ACL tear was more likely in those with completely displaced (type III or IV) tibial eminence fractures and older patients. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

How Do Race and Insurance Status Affect the Care of Pediatric Anterior Cruciate Ligament Injuries?

OBJECTIVE: To identify associations between race or insurance status and preoperative, intraoperative, and postoperative findings in a large cohort of pediatric anterior cruciate ligament (ACL) reconstructions. DESIGN: Retrospective cohort study. SETTING: Division of Orthopaedics at an urban tertiary care children's hospital. PATIENTS: 915 pediatric (<21) patients undergoing primary ACL reconstruction between January 2009 and May 2016. INDEPENDENT VARIABLES: Insurance status and race. MAIN OUTCOME MEASURES: Delay to surgery, concurrent meniscal injury, sports clearance, postoperative complications, physical therapy, range of motion, and isokinetic strength reduction. RESULTS: Multivariate analysis revealed a significantly longer delay to surgery for black/Hispanic and publicly insured children compared to their counterparts (P = 0.02 and P = 0.001, respectively). Black/Hispanic patients were more likely to sustain irreparable meniscus tears resulting in meniscectomy than white/Asian patients (odds ratio 2.16, 95% confidence interval, 1.10-2.29, P = 0.01). Black/Hispanic and publicly insured children averaged fewer physical therapy (PT) visits (P < 0.001 for both). Nine months after surgery, black/Hispanic patients had significantly greater strength reduction than white/Asian patients. There were no differences in postoperative complications, including graft rupture, contralateral ACL injury, or new meniscus tear along the lines of race, although privately insured patients were more likely to suffer a graft rupture than publicly insured patients (P = 0.006). CONCLUSIONS: After ACL rupture, black/Hispanic children and publicly insured children experience a greater delay to surgery. Black/Hispanic patients have more irreparable meniscus tears and less PT visits. Black/Hispanic patients have greater residual hamstrings and quadriceps weakness 9 months after surgery.

How Often Are Study Design and Level of Evidence Misreported in the Pediatric Orthopaedic Literature?

BACKGROUND: Observational studies are the most commonly used study designs in the pediatric orthopaedic literature. The differences between observational study designs are important but not widely understood, leading to potential discrepancies between the reported and actual study design. Study design misclassification is associated with a potential for misreporting level of evidence (LOE). The purpose of this study was to determine the degree of study design and LOE misclassification in the pediatric orthopaedic literature. METHODS: The Institute for Scientific Information (ISI) Web of Science was queried to identify all pediatric orthopaedic observational studies published from 2014 to 2017. Reported study design and LOE were recorded for each study. The actual study design and LOE were determined on the basis of established clinical epidemiological criteria by reviewers with advanced epidemiological training. Studies with a discrepancy between reported versus actual study design and LOE were identified. The following covariates were recorded for each study: subspecialty, inclusion of a statistician coauthor, sample size, journal, and journal impact factor. χ test was used to identify factors associated with study design and LOE misreporting. RESULTS: In total, 1000 articles were screened, yielding 647 observational studies. A total of 335 publications (52%) did not clearly report a study design in the abstract or manuscript text. Of those that did, 59/312 (19%) reported the incorrect study design. The largest discrepancy was in the 109 studies that were reported to be case series, among which 30 (27.5%) were actually retrospective cohort studies. In total, 313 publications (48%) did not report a LOE. Of those that did, 95/334 (28%) reported the incorrect LOE. In total, 33 studies (19%) reported a LOE that was higher than the actual LOE and 62 (35%) under-reported the LOE. CONCLUSIONS: The majority of observational pediatric orthopaedic studies did not report a study design or reported the wrong study design. Similarly, the majority of studies did not report or misreported their LOE. Greater epidemiological rigor in evaluating observational studies is required on the part of investigators, reviewers, and editors. LEVEL OF EVIDENCE: Level II.

Which Children Are at Risk for Contralateral Anterior Cruciate Ligament Injury After Ipsilateral Reconstruction?

BACKGROUND: Following anterior cruciate ligament (ACL) reconstruction, children are at significant risk for complications, including contralateral ACL rupture. The purpose of this study is to determine which children are at risk for a contralateral ACL tear after ipsilateral reconstruction. METHODS: After review of medical records, we contacted patients who underwent primary ACL reconstruction between 2009 and 2016. Patients were included in the study if they were able to provide follow-up data either in person or remotely at least 2 years after surgery. Demographic data, sports participation, and intraoperative findings and techniques were recorded. All patients were also asked to confirm returning to sport information and postoperative complications (including contralateral ACL tear). Univariate analysis consisted of χ and independent samples t tests. Purposeful entry logistic regression was then conducted to control for confounding factors. Kaplan-Meier analysis was performed to assess contralateral ACL survival. RESULTS: A total of 498 children with average follow-up of 4.3±2.1 years were included in the analysis. The mean age was 15.0±2.3 years and 262 patients (52.6%) were female. Thirty-five subjects (7.0%) sustained a contralateral ACL tear at a mean of 2.7±1.7 years following index reconstruction. Kaplan-Meier analysis revealed the median contralateral ACL survival time to be 8.9 years [95% confidence interval (CI): 8.3, 9.5 y]. In univariate analysis, 11.5% of female patients had a contralateral rupture compared with 2.1% of male patient (P<0.001). Patients with a contralateral tear had a mean age of 14.4±2.0 years compared with 15.1±2.3 years for those without an ACL injury in the opposite knee (P=0.04). After controlling for numerous factors in a multivariate model, female patients had 3.5 times higher odds of sustaining a contralateral ACL tear than male patients (95% CI: 1.1, 10.6; P=0.03). Each year of decreasing age raised the odds of contralateral injury by a factor of 1.3 (95% CI: 1.1, 1.6; P=0.02). Furthermore, children younger than 15 years had 3.1 times higher odds of contralateral rupture than those aged 15 and older (95% CI: 1.3, 7.2; P=0.01). CONCLUSIONS: After adjusting for confounding factors in a multivariate model, female patients were at increased risk of contralateral ACL tear following ipsilateral reconstruction, as were younger children. Specifically, ACL rupture in the opposite knee was more likely in patients below the age of 15 years. LEVEL OF EVIDENCE: Level III-prognostic study.

Should I Plan to Open? Predicting the Need for Open Reduction in the Treatment of Developmental Dysplasia of the Hip.

BACKGROUND: Closed reduction is generally attempted on children under 18 months of age who present as older infants or who fail nonoperative management for developmental dysplasia of the hip (DDH). However, many of these patients will not achieve concentric reduction by closed means and will ultimately require open reduction (OR). Limited evidence exists to predict which patients can be adequately closed reduced versus those who will need open treatment. METHODS: Prospectively collected data from 4 select centers of an international multicenter study group sharing a common treatment approach were reviewed for all DDH infants under 18 months old that required operative management. Patients were categorized into 2 groups: those whose hips were successfully closed reduced or those who ultimately required OR. Factors were compared between the closed reduction and OR groups for 2 separate cohorts-those presenting early in life with ultrasound (US) data, and those presenting later with radiographic data. RESULTS: A total of 154 patients (166 hips) were included in the analysis. Overall, 87.3% were female. In the early-presenting cohort, purposeful entry multivariate regression revealed that patients with Graf IV hips on US had 3.8 times higher odds of requiring an OR. For the later cohort, hips that were clinically irreducible (ie, negative Ortolani sign) had 3.3 times higher odds of requiring OR. Patients with International Hip Dysplasia Institute (IHDI) grade IV hips had 2.5 times higher odds of needing an OR versus those with grade III hips and 15.4 times higher odds than those with grade II hips. Children with an IHDI grade IV hip and a negative Ortolani sign had 4.4 times higher odds of needing OR. CONCLUSION: Children younger than 18 months with dislocated hips who require OR are more likely to have a high-grade radiographic dislocation (IHDI grade IV), negative preoperative Ortolani sign, and a Graf IV classification on initial US. This information may help surgeons budget the use of operating room time and better counsel parents about intraoperative expectations. LEVEL OF EVIDENCE: Level III-Prognostic.

How Does Obesity Impact Pediatric Anterior Cruciate Ligament Reconstruction?

PURPOSE: To assess the relationship of elevated body mass index (BMI) on postoperative outcomes, including graft rupture, contralateral anterior cruciate ligament (ACL) tear, new meniscus injuries, isokinetic strength testing, and range of motion (ROM) in a large group of pediatric patients. We also sought to calculate the risk of graft rupture in overweight patients with small femoral or tibial tunnels. The secondary objective was to evaluate the association between BMI and concurrent meniscus tears and the need for meniscectomy at the time of primary ACL reconstruction. METHODS: We retrospectively reviewed all pediatric patients undergoing primary ACL reconstruction at our institution. BMI percentile for age was used to categorize children as having normal BMI or being overweight or obese per Centers for Disease Control and Prevention guidelines. Demographic data, intraoperative findings and techniques, postoperative complications (including graft rupture, contralateral ACL tear, and meniscus injuries), ROM, and isokinetic strength testing were recorded. Univariate analysis was followed by stepwise, logistic regression to control for confounders. RESULTS: Of the 1,056 patients included, 535 (50.7%) were male and 521 were (49.3%) female, with a mean age of 15.1 ± 2.4 years. The average BMI was 23.1 ± 4.7. There were 675 (63.9%) children with normal BMI, 228 (21.6%) who were overweight, and 153 (14.5%) who were obese. In multivariate analysis, children with elevated BMI had a higher rate of concurrent meniscus tears compared with those with normal BMI (76.3% vs 70.2%; P = .02) and 1.6 times higher odds of requiring a meniscectomy (95% confidence interval, 1.2-2.2; P < .01). The 723 patients included in the analysis of postoperative complications had a mean follow-up duration of 26.2 ± 3.3 months Postoperatively, BMI did not impact the rate of graft rupture, contralateral ACL injury, or new meniscus tears. There was no increased risk of graft failure in overweight children with smaller graft size (≤8 mm). There was no clinically relevant difference in postoperative ROM or isokinetic strength testing. CONCLUSIONS: After ACL rupture, overweight and obese children sustained more overall meniscus tears and more irreparable meniscus tears than those with normal BMI. Graft size did not impact the risk of early graft failure in overweight patients. With an appropriate rehabilitation protocol, there was no increased risk of graft rupture, contralateral ACL injury, or new meniscus tear in early follow-up. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Is Prophylactic Intervention More Cost-effective Than the Treatment of Pathologic Fractures in Metastatic Bone Disease?

BACKGROUND: Metastatic bone disease is a substantial burden to patients and the healthcare system as a whole. Metastatic disease can be painful, is associated with decreased survival, and is emotionally traumatic to patients when they discover their disease has progressed. In the United States, more than 250,000 patients have metastatic bone disease, with an estimated annual cost of USD 12 billion. Prior studies suggest that patients who receive prophylactic fixation for impending pathologic fractures, compared with those treated for realized pathologic fractures, have decreased pain levels, faster postoperative rehabilitation, and less in-hospital morbidity. However, to our knowledge, the relative economic utility of these treatment options has not been examined. QUESTIONS/PURPOSES: We asked: (1) Is there a cost difference between a cohort of patients treated surgically for pathologic fractures compared with a cohort of patients treated prophylactically for impending pathologic lesions? (2) Do these cohorts differ in other ways regarding their utilization of healthcare resources? METHODS: We performed a retrospective study of 40 patients treated our institution. Between 2011 and 2014, we treated 46 patients surgically for metastatic lesions of long bones. Of those, 19 (48%) presented with pathologic fractures; the other 21 patients (53%) underwent surgery for impending fractures. Risk of impending fracture was determined by one surgeon based on appearance of the lesion, subjective symptoms of the patient, cortical involvement, and location of the lesion. At 1 year postoperative, four patients in each group had died. Six patients (13%) were treated for metastatic disease but were excluded from the retrospective data because of a change in medical record system and inability to obtain financial records. Variables of interest included total and direct costs per episode of care, days of hospitalization, discharge disposition, 1-year postoperative mortality, and descriptive demographic data. All costs were expressed as a cost ratio between the two cohorts, and total differences between the groups, as required per medical center regulations. All data were collected by one author and the medical center's financial office. RESULTS: Mean total cost was higher in patients with pathologic fractures (cost unit [CU], 642 ± 519) than those treated prophylactically without fractures (CU, 370 ± 171; mean difference, 272; 95% CI, 19-525; p = 0.036). In USD, this translates to a mean of nearly USD 21,000 less for prophylactic surgery. Mean direct cost was 41% higher (nearly USD 12,000) in patients with a pathologic fracture (CU, 382 ± 300 versus 227 ± 93; mean difference, 155; 95% CI, 9-300; p = 0.038). Mean length of stay was longer in patients with pathologic fractures compared with the group treated prophylactically (8 ± 6 versus 4 ± 3 days; mean difference, 4; 95% CI, 1-7; p = 0.01). CONCLUSIONS: These findings show economic and clinical value of prophylactic stabilization of metastatic lesions when performed for patients with painful lesions compromising the structural integrity of long bones. Patients sustaining a pathologic fracture may represent a more severe, sicker demographic than patients treated for impending pathologic lesions. LEVEL OF EVIDENCE: Level IV, economic and decision analysis.

Pediatric monteggia fractures: a multicenter examination of treatment strategy and early clinical and radiographic results.

BACKGROUND: Monteggia fractures remain challenging pediatric injuries because of difficulties in diagnosis, propensity for instability, and complexity of late reconstruction. The objective of this investigation was to assess the efficacy of the following treatment strategy based upon ulnar fracture pattern: closed reduction (CR) for plastic/greenstick fractures, intramedullary (IM) pin fixation for transverse/short oblique fractures, and open reduction and internal fixation for long oblique/comminuted fractures. METHODS: A total of 112 acute Monteggia fracture patients were retrospectively analyzed at two level 1 pediatric trauma centers from 2000 to 2011. Mean age was 6.9±2.9 years (range, 0.6 to 16.7 y); 54% were male. Mean clinical follow-up was 19.8 weeks. Fracture patterns were classified and patients were separated into 3 groups: treatment according to the strategy versus more rigorous versus less rigorous intervention. The Fisher exact test was used to compare the rates of failure between the groups. "Failure" was defined as failure to obtain and maintain an anatomic reduction of the radial head and/or loss of ulnar reduction during follow-up. RESULTS: None of the 57 patients treated according to the strategy experienced failure, nor did any of the 23 patients treated more rigorously. In contrast, 6 of 32 patients (19%) who were treated less rigorously compared with the recommended strategy demonstrated recurrent radiocapitellar instability (n=3), loss of ulnar fracture reduction requiring revision surgery (n=2), or both events together (n=1) (P<0.001). Specifically, all treatment failures occurred in complete fractures treated nonoperatively-there were 6/18 failures (33% failure rate) of complete fractures treated nonoperatively compared with 0/52 failures of complete fractures treated operatively (P<0.001). Other complications were similarly distributed between the treatment groups and consisted of 1 ulnar nonunion, 2 compartment syndromes, and 3 transient nerve palsies/neuropraxias. Comminuted fractures required open reduction of the radiocapitellar joint more than other fracture types (P<0.001). CONCLUSIONS: In this pediatric Monteggia series, recurrent instability only occurred in patients who were not treated according to the ulnar-based strategy. Complete ulnar fracture patterns are at risk of failure without initial operative treatment. LEVEL OF EVIDENCE: Level III, therapeutic.

VEPTR to treat nonsyndromic congenital scoliosis: a multicenter, mid-term follow-up study.

BACKGROUND: Traditional surgical management of multiple congenital vertebral anomalies in young children, including fusion in situ and hemiepiphyseodesis, do not promote spinal growth nor address the associated thoracic insufficiency syndrome. We hypothesize that vertical expandable prosthetic titanium rib (VEPTR) with expansion thoracoplasty may control spinal deformity, allow spinal growth, and address thoracic insufficiency syndrome in children with nonsyndromic complex congenital spinal deformities. METHODS: Eight pediatric spine centers prospectively entered clinical and radiographic data into a database on every congenital spinal deformity treated with VEPTR as part of an Food and Drug Administration study. We retrospectively reviewed these data and excluded patients with spina bifida, Jarcho-Levin, or other syndromes. Data analysis focused on surgical technique and expansion frequency, change in Cobb angle and thoracic heights, and adverse events for a consecutive series of patients with at least 2 years of follow-up. RESULTS: Twenty-four children with an average age at surgery of 3.3 years (range, 1.0 to 12.5 y) were treated with VEPTR insertion and expansion thoracostomy and were followed for an average of 40.7 months (range, 25 to 78 mo). Twenty-three (95.8%) had associated rib fusions. All patients had subsequent expansion surgery; 50% had 5 or more expansions. Twenty patients (83.3%) had an improvement in Cobb angle during treatment with an average improvement of 8.9 degrees. All had an increase in thoracic height, with a mean increase of 3.41 cm. The most common adverse events were device migration in 7 patients and infection or skin problems in 6 patients. CONCLUSIONS: VEPTR insertion with expansion thoracoplasty represents a successful treatment paradigm for nonsyndromic congenital spinal deformities. We report multicenter data with midterm follow-up of children without syndromic diagnoses, in which the vast majority had an improvement in Cobb angle and thoracic height over the treatment period. Challenges include the demands of multiple procedures, skin problems, and device migration. LEVEL OF EVIDENCE: Level IV-prognostic study.

Impact of specialty and level of training on CT measurement of femoral version: an interobserver agreement analysis.

BACKGROUND: To determine the interobserver agreement on femoral version measurements between an orthopedic attending, orthopedic senior and junior residents, and an attending radiologist. MATERIALS AND METHODS: Postoperative computed tomography (CT) scanograms of 267 patients who underwent femoral intramedullary (IM) nailing with corresponding radiology attending reads for femoral version were collected and de-identified. Femoral version measurements performed by a trauma fellowship-trained attending orthopedic surgeon (ORTHO), a senior orthopedic resident (PGY4), a junior orthopedic resident (PGY1), and a musculoskeletal fellowship-trained attending radiologist (RADS) were compared via Pearson's interclass correlation coefficient to assess interobserver level of agreement. RESULTS: Version measurements provided by the two attending physicians exhibited the highest level of agreement (r = 0.661, p < 0.01). The orthopedic attending and the senior resident had the next highest level of agreement (r = 0.543, p < 0.01). The first-year orthopedic resident had the weakest agreement across the board: with the orthopedic attending, the radiology attending, and the senior resident. CONCLUSION: Regardless of specialty, experience and higher levels of training produce stronger agreement when measuring femoral version. Residents in training, especially those who are junior, produce weak agreement when compared to their senior colleagues. LEVEL OF EVIDENCE: Level III, diagnostic study.

Epidemiology of pediatric cartilage restoration procedures in the United States: insurance and geography play a role.

OBJECTIVES: The purpose of this study is to analyze the epidemiology of children and adolescents undergoing osteochondral autograft transplantation (OAT), osteochondral allograft transplantation (OCA), and autologous chondrocyte implantation (ACI) in the United States. METHODS: The Pediatric Health Information System, a national database consisting of 49 children's hospitals, was queried for all patients undergoing OAT, OCA, and ACI between 2012 and 2018. Demographic information was collected for each subject. United States Census guidelines were used to categorize hospitals geographically. Univariate analysis was followed by purposeful entry multivariate regression to adjust for confounding factors. RESULTS: A total of 809 subjects with a mean age of 15.4 ± 2.4 years were included in the analysis. Of these, 48.6% underwent OCA, 41.9% underwent OAT, and 9.5% underwent ACI. After adjusting for confounders in a multivariate model, ACI was 3.6 times more likely to be performed in patients with private insurance than those that were publicly insured (95% CI 1.6-8.0, p = 0.002). Furthermore, a patient in the Northeast was 33.1 times more likely to undergo ACI than in the West (95% CI 4.5-246.1, p = 0.001). OAT was performed most frequently in the West and Midwest (52.4% and 51.8% of the time, respectively; p < 0.001). CONCLUSION: In the United States, there is substantial variation in the procedures performed for cartilage restoration in children and adolescents. Though ACI is the least commonly selected operation overall, it is significantly more likely to be performed on patients with private insurance and those in the Northeast.

On the Rise: The Increasing Frequency of Pediatric Shoulder Stabilization Surgery in Children and Adolescents.

The management of shoulder instability in children and adolescents continues to evolve. The purpose of this study was to evaluate the epidemiology of shoulder stabilization procedures in a large, nationally representative pediatric population. The Pediatric Health Information System (PHIS) database was queried for patients 18 years and younger undergoing surgical shoulder stabilization between 2008 and 2017. Patients undergoing arthroscopic surgery were compared with patients undergoing complex (open or bony augment stabilization) procedures. Annual trends were calculated using linear regression. A total of 3925 procedures were performed, of which 92.9% were arthroscopic Bankart repairs. There was a significant increase in overall pediatric shoulder stabilizations and arthroscopic repairs between 2008 and 2017. Complex procedures were performed most often in the Northeast, but the annual frequency did not increase nationally. [Orthopedics. 2023;46(3):e167-e172.].