The Pressure Is on: Dorsal Versus Volar Univalves for Long-arm Casts.

BACKGROUND: Fiberglass casts are routinely used to treat fractures of the upper extremity. When posttraumatic edema is anticipated, the cast is often valved to hopefully prevent potential complications, especially compartment syndrome. Due to volar forearm compartments being most involved with upper extremity compartment syndrome, volar skin surface pressures (SSP) are paramount. Despite past literature showing that a univalved cast will retain a 3-point mold better than a bivalved cast, there is a paucity of information analyzing the effects of univalving on the volar SSP. We hypothesized that a volar univalve technique would have a greater decrease in the volar skin surface pressures compared to a dorsal univalve in long-arm casts. METHODS: A 100-mL saline bag attached to an arterial line pressure transducer was placed between a long-arm cast and the skin along the volar forearm of a single adult volunteer. Fourteen casts were applied by a single certified orthopaedic technologist with 30 years of experience and assigned randomly to receive either a volar or dorsal univalve. We calculated the change in volar forearm SSP on each cast in 4 stages: isolated univalve, with a 3-mm cast spacer, with a 6-mm spacer, and with bivalve. Statistical analysis of the data was performed using a Mann-Whitney U test. RESULTS: When comparing volar versus dorsal univalve, volar SSP significantly dropped by a mean of 32.00 versus 20.43 mm Hg ( P value=0.001) in stage I, 45.14 versus 38.00 mm Hg in stage II ( P value=0.026), and 56.53 versus 49 mm Hg in stage III ( P value=0.001). There was no significant difference between the 2 groups after a bivalve was performed at stage IV ( P value=0.318). CONCLUSION: Our findings support that a volar univalve with a 6-mm spacer will provide the greatest reduction of skin surface pressure while theoretically maintaining the cast's structural integrity and biomechanical properties when compared to a bivalved cast. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Operative Treatment of Distal Tibial Fractures in Children Managed With Epiphyseal Screws: A Comparison of Outcomes When Screws Are Retained Versus Removed Following Fracture Union.

BACKGROUND: Fractures of the distal tibial epiphysis in children are often accompanied by articular surface disruption. With increased displacement, internal fixation is frequently performed with an epiphyseal screw to close the fracture gap. Despite limited, high-level clinical evidence to support implant removal, epiphyseal screws are commonly removed after fracture healing due to potentially increased contact forces on the tibiotalar joint. The purpose of this study was to investigate and compare outcomes and complications in children that underwent surgical treatment of distal tibial epiphyseal fractures with placement of an epiphyseal screw(s) and had the implant(s) retained versus removed at a minimum of 2-year postoperative follow-up. METHODS: Children younger than 18 years from two urban tertiary care centers who underwent operative management of distal tibia Salter-Harris III and IV fractures using epiphyseal screws (2013-2020) were divided into two cohorts: retained epiphyseal screws and implant removed. Demographics, intraoperative, postoperative, and radiographic data were collected. Patient-reported outcomes (PROs) using the Foot and Ankle Ability Measure (FAAM) and Single Assessment Numeric Evaluation (SANE) questionnaires were collected at the final follow-up. Statistical analysis, including power analysis, was performed. RESULTS: Fifty-two children were included (30 males, 22 females) with a mean age of 13.3 years at the time of injury (range, 7.7-16.4 years). Thirty-five children retained the implants; seventeen had implants removed. All completed the FAAM questionnaires at a mean follow-up of 4.4 ± 1.9 years, while 29 completed the SANE questionnaire at a mean follow-up of 4.4 ± 1.7 years. No statistically significant difference in patient demographics, surgical variables, or PROs was observed. Six children experienced complications from the initial surgery, including infections and complex regional pain syndrome, with no difference in complication rates between the cohorts ( P =0.08). Furthermore, no complication was observed as a result of implant removal. CONCLUSIONS: Children with retained epiphyseal implants have similar functional outcomes as compared with those who had implants removed after distal tibial epiphyseal fracture fixation and union. LEVEL OF EVIDENCE: Level III-Retrospective comparative study.

Depression Screening in Pediatric Orthopedic Surgery Clinics and Identifying Patients At-Risk.

BACKGROUND: Up to 25% of youth experience a depressive episode by 18 years of age, leading the US Preventive Services Task Force to recommend depression screening within this population. This study aimed to understand the prevalence of depression identified within pediatric orthopedic clinics compared with primary care clinics after the implementation of a screening program and present data on the prevalence of moderate-severe depression across specific pediatric orthopedic clinics, characterizing and identifying specific populations at higher risk. METHODS: A retrospective review was performed to identify all patients screened using the 2-item and 9-item versions of the Patient Health Questionnaire (PHQ-2/PHQ-9) and the Columbia-Suicide Severity Rating Scale over a 2-year period (October 2018 to January 2021) within pediatric primary care and orthopaedic clinics. Demographic and clinical characteristics were collected. Statistical analysis was performed to compare scores between orthopedic and primary care clinics, as well as between the different pediatric orthopedic subspecialties and included χ 2 test, ANOVA, and logistic regression. RESULTS: There were 32,787 unique adolescent patients screened in primary care clinics, with an additional 14,078 unique adolescent patients screened in orthopaedic clinics, leading to a 30% increase in the overall number of patients receiving depression screening. 5.2% of patients in primary care pediatric clinics screened positive for moderate-severe depression versus 2.0% in pediatric orthopaedic clinics ( P <0.001). 2.7% of primary care patients were at risk of self-harm compared with 0.8% of orthopedic patients ( P <0.001). Within orthopaedic subspecialty clinics, the spine patients were at the highest risk of moderate-severe depression (3.5%), significantly higher than both the sports (1.4%, P =0.006) and patients with acute fracture (1.3%, P <0.001). CONCLUSIONS: This study demonstrates the high incidence of patients screening positive for depression in pediatric and adolescent orthopaedic clinics. By identifying high-risk clinics and patient groups, health care systems can apply a more practical approach and appropriately deploy behavioral health specialists for timely counseling and treatment discussions. LEVEL OF EVIDENCE: Level-III.

Subsequent Forearm Fractures Following Initial Surgical Fixation.

INTRODUCTION: Forearm fractures are a common pediatric injury. Currently, there is no consensus on treatment for fractures that recur following initial surgical fixation. The objective of this study was to investigate the subsequent fracture rate and patterns and describe the treatment of these forearm fractures. METHODS: We retrospectively identified patients who underwent surgical treatment for an initial forearm fracture at our institution between 2011 and 2019. Patients were included if they sustained a diaphyseal or metadiaphyseal forearm fracture that was initially treated surgically with a plate and screw construct (plate) or elastic stable intramedullary nail (ESIN), and if they subsequently sustained another fracture that was treated at our institution. RESULTS: A total of 349 forearm fractures were treated surgically with ESIN or a plate fixation. Of these, 24 sustained another fracture, yielding a subsequent fracture rate of 10.9% for the plate cohort and 5.1% for the ESIN cohort ( P =0.056). The majority of plate refractures (90%) occurred at the proximal or distal plate edge, while 79% of the fractures treated previously with ESINs occurred at the initial fracture site ( P <0.001). Ninety percent of plate refractures required revision surgery, with 50% underwent plate removal and conversion to ESIN, and 40% underwent revision plating. Within the ESIN cohort, 64% were treated nonsurgically, 21% underwent revision ESINs, and 14% underwent revision plating. Tourniquet time for revision surgeries were shorter for the ESIN cohort (46 vs. 92 min; P =0.012). In both cohorts, all revision surgeries had no complications and healed with evidence of radiographic union. However, 9 patients (37.5%) underwent implant removal (3 plates and 6 ESINs) after subsequent fracture healing. CONCLUSIONS: This is the first study to characterize subsequent forearm fractures following both ESIN and plate fixation and to describe and compare treatment options. Consistent with the literature, refractures following surgical fixation of pediatric forearm fractures may occur at a rate ranging from 5% to 11%. ESINs are both less invasive at the time of initial surgery and can often be treated nonoperatively if there is a subsequent fracture, while plate refractures are more likely to be treated with a second surgery and have a longer average surgery time. LEVEL OF EVIDENCE: Level IV-retrospective case series.

Allograft Anterior Cruciate Ligament Reconstruction in Adolescent Patients May Result in Acceptable Graft Failure Rate in Nonpivoting Sports Athletes.

BACKGROUND: Studies have demonstrated that pediatric patients have an increased risk of failure with allograft anterior cruciate ligament reconstruction (ACLR); however, there is no study investigating whether allograft ACLR may be safe in older adolescent patients who are not returning to competitive pivoting sports (ie, low risk). The purpose of this study was to assess outcomes for low-risk older adolescents selected for allograft ACLR. METHODS: We performed a retrospective chart review of patients younger than 18 years who received a bone-patellar-tendon-bone allograft or autograft ACLR by a single orthopaedic surgeon from 2012 to 2020. Patients were offered allograft ACLR if they did not intend to return to pivoting sports for 1 year. The autograft cohort was matched 1:1 based on age, sex, and follow-up. Patients were excluded for skeletal immaturity, multiligamentous injury, prior ipsilateral ACLR, or concomitant realignment procedure. Patients were contacted to obtain patient-reported outcomes at ≥2 years follow-up, including single assessment numerical evaluation, surgery satisfaction, pain scores, Tegner Activity Scale, and the Lysholm Knee Scoring Scale. Parametric and nonparametric tests were used as appropriate. RESULTS: Of the 68 allografts, 40 (59%) met inclusion and 28 (70%) were contacted. Among the 456 autografts, 40 (8.7%) were matched and 26 (65%) were contacted. Two allograft patients (2/40; 5%) failed at a median (interquartile range) follow-up of 36 (12, 60) months. There were 0/40 failures in the autograft cohort and 13/456 (2.9%) among the overall autografts; neither were significantly different from the allograft failure rate (both P > 0.05). Two (5.0%) patients in the autograft cohort required manipulation under anesthesia and arthroscopic lysis of adhesions. There were no significant differences between cohorts for single assessment numerical evaluation, Lysholm, Tegner, pain, and satisfaction scores (all P > 0.05). CONCLUSIONS: Although ACL allograft failure rates remain nearly two times higher than autograft failure rates in older adolescents, our study suggests that careful patient selection can potentially bring this failure rate down to an acceptable level. LEVEL OF EVIDENCE: Level III; retrospective matched cohort study.

Nonoperative Versus Operative Treatment of Type IIA Supracondylar Humerus Fractures: A Prospective Evaluation of 99 Patients.

BACKGROUND: Although current clinical practice guidelines from the American Academy of Orthopaedic Surgeons suggest that Type II and III supracondylar humerus (SCH) fractures be treated by closed reduction and pin fixation, controversy remains as to whether type IIa fractures with no rotation or angular deformity require surgery. The purpose of our study was to prospectively compare radiographic and functional outcomes of type IIa SCH fractures treated with or without surgery. METHODS: Between 2017 and 2019, 105 patients between 2 and 12 years of age presenting with type IIa SCH fractures and without prior elbow trauma, neuromuscular or metabolic conditions, were prospectively enrolled. Ten orthopaedic surgeons managed the patients with 5 preferring surgical treatment and 5 preferring an initial attempt at nonoperative treatment. Patients in the nonoperative cohort were managed with a long-arm cast and close radiographic follow-up. Patients underwent a standardized protocol, including 3 to 4 weeks of casting, bilateral radiographic follow-up 6 months postinjury, and telephone follow-up at 6, 12, and 24 months. RESULTS: Ninety-nine patients met the inclusion criteria (45 nonoperative and 54 operatives). Of the nonoperative patients, 4 (9%) were converted to surgery up to their first clinical follow-up. No differences were identified between the cohorts with respect to demographic data, but patients undergoing surgery had on average 6 degrees more posterior angulation at the fracture site preoperatively (P<0.05). At the final clinical follow-up (mean=6 mo), the nonoperative group had more radiographic extension (176.9 vs 174.4 degrees, P=0.04) as measured by the hourglass angle, but no other clinical or radiographic differences were appreciated. Complications were similar between the nonoperative and operative groups: refracture (4.4 vs 5.6%), avascular necrosis (2.2 vs 1.9%) and infection (0 vs 1.9%) (P>0.05). Patient-reported outcomes at a mean of 24 months showed no differences between groups. CONCLUSION: Contrary to American Academy of Orthopaedic Surgeons guidelines, about 90% of patients with type IIa supracondylar fractures can be treated nonoperatively and will achieve good radiographic and functional outcomes with mild residual deformity improving over time. Patients treated nonoperatively must be monitored closely to assess for early loss of reduction and the need for surgical intervention.

Age and CRP Associated With Improved Tissue Pathogen Identification in Children With Blood Culture Negative Osteomyelitis: Results From the CORTICES Multicenter Database.

BACKGROUND: Acute hematogenous osteomyelitis (AHO) is a relatively common condition in children, and identifying the offending pathogen with blood or tissue cultures aids in diagnosis and medical management while reducing treatment failure. Recent 2021 AHO clinical practice guidelines from the Pediatric Infectious Disease Society recommend obtaining routine tissue cultures, particularly in cases with negative blood cultures. The purpose of this study was to identify variables associated with positive tissue cultures when blood cultures are negative. METHODS: Children with AHO from 18 pediatric medical centers throughout the United States through the Children's ORthopaedic Trauma and Infection Consortium for Evidence-based Study were evaluated for predictors of positive tissue cultures when blood cultures were negative. Cutoffs of predictors were determined with associated sensitivity and specificity. RESULTS: One thousand three children with AHO were included, and in 688/1003 (68.6%) patients, both blood cultures and tissue cultures were obtained. In patients with negative blood cultures (n=385), tissue was positive in 267/385 (69.4%). In multivariate analysis, age ( P <0.001) and C-reactive protein (CRP) ( P =0.004) were independent predictors. With age >3.1 years and CRP >4.1 mg/dL as factors, the sensitivity of obtaining a positive tissue culture when blood cultures were negative was 87.3% (80.9-92.2%) compared with 7.1% (4.4-10.9%) if neither of these factors was present. There was a lower ratio of methicillin-resistant Staphylococcus aureus in blood culture-negative patients who had a positive tissue culture 48/188 (25.5%), compared with patients who had both positive blood and tissue cultures 108/220 (49.1%). CONCLUSION: AHO patients with CRP ≤ 4.1 mg/dL and age under 3.1 years are unlikely to have clinical value from tissue biopsy that exceeds the morbidity associated with this intervention. In patients with CRP > 4.1 mg/dL and age over 3.1 years, obtaining a tissue specimen may add value; however, it is important to note that effective empiric antibiotic coverage may limit the utility of positive tissue cultures in AHO. LEVEL OF EVIDENCE: Level III-Retrospective comparative study.

How often does the preoperative plan for freehand pedicle screw placement match the actual surgical execution in adolescent idiopathic scoliosis?

PURPOSE: To provide a baseline for comparison with future advancements, this study determined the accuracy of preoperative planning of pedicle screw placement using standard radiographs for posterior fusion (PSF) for adolescent idiopathic scoliosis (AIS). METHODS: Ninety-five patients with AIS planned for PSF were prospectively enrolled. Preoperative planning was based upon standard upright posteroanterior and lateral radiographs. The planned number of screws to be placed at each level was recorded. Intraoperatively, all screws were placed by freehand technique. The number of successfully placed screws and the reasons for abandoning screw placement were documented. RESULTS: There were a total of 1783 pedicle screws planned preoperatively. The average planned implant density was 2.0 implants/vertebra. A total of 1723 (96.6%) of the planned screws were placed successfully. Fourteen (0.8%) screws were abandoned after attempted placement (range 0-2 screws/case). Of 241 screws planned in pedicles noted to be "hypoplastic," 13 resulted in the use of a hook or no instrumentation. The placement was not attempted for 49 (range 0-7/case) planned screws due to intraoperative decision-making and a sense that the curve was flexible enough not to require every screw. Three cases (3.2%) required instrumentation of an additional level. CONCLUSIONS: Standard spine radiographs allow for accurate preoperative planning for freehand pedicle screw placement in AIS. Ninety-seven percent of planned screws were placed successfully. The primary reason for deviation from the preoperative plan was intraoperative surgeon decision-making rather than difficulty with screw placement. This study will serve as a baseline when considering the utilization of navigation in PSF for AIS.

Elastic Intramedullary Nails in the Treatment of Pediatric Length Unstable Femur Fractures.

BACKGROUND: Elastic intramedullary nails (EINs) are the treatment of choice for school-age children (5 to 12) with diaphyseal femur fractures. Previous literature suggests that EINs are an effective treatment for stable fracture patterns, but may be inadequate for unstable fracture patterns. The purpose of this study was to evaluate whether patients with length unstable fractures had a higher complication rate than those with length stable fractures when treated with EINs. METHODS: All patients with diaphyseal femur fractures treated with EINs over a 22-year period at a single institution were reviewed. Patients were excluded if they had a pathologic fracture, neuromuscular disorder, spinal cord injury with subsequent involvement of affected limb, metabolic bone disease, or if they did not have at least 6-month follow-up. RESULTS: A total of 85 patients with 87 diaphyseal femur fractures treated with EINs were included in the study. In all, 57.5% of the fractures were categorized as length stable and 42.5% were length unstable. Fourteen percent of length stable patients had a residual angular deformity compared with 5.4% of the length unstable group (P=0.24). The length unstable group experienced more shortening at the fracture site than the patients in the length stable group (P=0.003), but no patient required further intervention for their shortening. Two patients in the length stable group experienced overgrowth >2 cm and required subsequent surgery. No relationship was observed between fracture pattern and frequency of complications (length stable 8% vs. length unstable 10.8%, P=0.69). Finally, the knee immobilizer group (10.7%) and the long leg cast group (18.2%) had significantly higher complication rates than the single leg spica cast group (0%, P<0.05). CONCLUSIONS: There was no significant difference in complication rate between length stable and unstable fractures treated with EINs. Adjunctive spica casting may be protective against postoperative complications. While fracture shortening was more likely in the length unstable group, it did not result in increased rate of limb length discrepancy at final follow-up. LEVEL OF EVIDENCE: Level IV, Case Series.

Practice Variation in the Surgical Management of Children With Acute Hematogenous Osteomyelitis.

INTRODUCTION: The surgical indications to manage children with acute hematogenous osteomyelitis (AHO) remain poorly defined. The purpose of this study was to identify if practice pattern variation exists in the surgical management of pediatric AHO among tertiary pediatric medical centers across the United States. A secondary purpose was to evaluate variables that may impact the rate of surgical intervention among these institutions. METHODS: Children with AHO were retrospectively analyzed between January 1, 2010, and December 31, 2016, from 18 pediatric medical centers throughout the United States. The rates of surgery were identified. Admission vitals, labs, weight-bearing status, length of stay, and readmission rates were compared between those who did and did not undergo surgery. Multivariate regression and classification and regression tree analyses were performed to identify the variables that were associated with surgical intervention. RESULTS: Of the 1003 children identified with AHO in this retrospective, multicenter database, 619/1003 (62%) were treated surgically. Multivariate analysis revealed institution, inability to ambulate, presence of multifocal infection, elevated admission C-reactive protein, increased admission platelet count, and location of the osteomyelitis were significant predictors of surgery (P<0.01). Patients who underwent surgery were more than twice as likely to have a recurrence or readmission and stayed a median of 2 days longer than those who did not have surgery. In the classification and regression tree analysis, 2 distinct patterns of surgical intervention were identified based on institution, with 12 institutions operating in most cases (72%), regardless of clinical factors. A second cohort of 6 institutions operated less routinely, with 47% receiving surgery overall. At these 6 institutions, patients without multifocal infection only received surgery 26% of the time, which increased to 74% with multifocal infection and admission erythrocyte sedimentation rate >37.5 mm/h. CONCLUSIONS: This study is the first to objectively identify significant differences in the rates of surgical management of pediatric AHO across the United States. Variation in the surgical management of AHO appears to be driven primarily based on institutional practice. Twelve institutions operated on 72% of patients, regardless of the severity of disease, indicating that the institution custom or dogma may drive the surgical indications. Six institutions relied more on clinical judgment with significant variability in rates of surgical intervention (26% vs. 74%), depending on the severity of the disease. Surgical intervention is associated with increased recurrence, readmission, and hospital length of stay. As a result of these findings, it is essential to prospectively study the appropriate surgical indications and measure the outcomes in children with pediatric AHO. 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.

Three-dimensional analysis of spinal deformity correction in adolescent idiopathic scoliosis: comparison of two distinct techniques.

PURPOSE: To compare 3D postoperative deformity correction using two distinct commonly utilized techniques for the treatment of adolescent idiopathic scoliosis (AIS). METHODS: AIS patients with major thoracic (Lenke 1-2) curves at two sites who underwent deformity correction via posterior spinal instrumented fusion using one of two distinct techniques were retrospectively reviewed. Patients were matched 1:1 between sites for Lenke type (95% Lenke 1) and follow-up time. The "band site" performed posteromedial translation using thoracic sublaminar bands and 5.5-mm rods. The "screw site" performed spine derotation using differential rod contouring with pedicle screws and 5.5-mm rods. 3D measures of deformity from spinal reconstructions were compared between sites. RESULTS: Preoperatively, the groups had similar thoracic curve magnitudes (band, 55 ± 12° vs. screw, 52 ± 10°; p > 0.05); the "screw site" had less T5-T12 kyphosis (2 ± 14° vs. 7 ± 12°, p = 0.05) and greater thoracic apical rotation (- 19 ± 7° vs. - 14 ± 8°, p = 0.007). Postoperatively, the "screw site" had greater percent correction (61% vs. 76%, p < 0.001) and kyphosis restoration (p = 0.002). The groups achieved a similar amount of apical derotation (p = 0.9). The "band site" used cobalt chromium rods exclusively; the "screw site" used cobalt chromium (3%) and stainless steel (97%; p < 0.001). The "band site" performed significantly longer fusions. CONCLUSIONS: Significant variations were found between two commonly utilized techniques in AIS surgery, including rod material, correction mechanisms, and fusion levels. Significantly, a greater 3D deformity correction of the coronal and sagittal planes was observed at the "screw site" compared to the "band site", but with no difference in axial plane correction.

Does Youth Baseball Result in Morphologic Changes of the Lateral Elbow? A Prospective MRI Study.

BACKGROUND: Stress from overhead throwing results in morphologic changes to the shoulder in youth baseball players. With greater valgus torque stresses, the elbow experiences injuries specifically attributed to throwing. However, no previous work that we know of has assessed throwing-related morphologic changes of the elbow without associated conditions. QUESTIONS/PURPOSES: (1) Do children who play competitive baseball have enlargement or overgrowth of their radial head shape and/or capitellum compared with the nondominant elbow on MRI? (2) Do children who stop playing year-round baseball have less enlargement of the lateral elbow structures than children who maintain a high level of play? METHODS: A prospective study was conducted between 2015 and 2018 on preadolescent boys who underwent voluntary MRI of their bilateral elbows before the start of the spring baseball season. Twenty-six children agreed to participate out of a four-team league that was asked to participate; their first MRI was obtained at a mean (range) age of 12 years (10 to 13). We also obtained their history related to throwing and performed a physical examination. Players had a mean of 5.6 years of playing before their first MRI, and half the children (13 of 26) were year-round baseball players. Sixty-two percent (16 of 26) reported being either or both a pitcher or catcher as their primary position. No child was excluded from participation. Three years later, these boys were asked to return for repeat MRI and physical examinations. Fifty-eight percent (15 of 26) of players were still playing at the 3-year MRI. Continued play or new onset of pain was documented. Radiographic measurements were then compared between dominant and nondominant arms, and the differences of these changes were compared between those who had continued playing during the study period and those who had quit. The measurements were made in all three planes of the radial head and capitellum, both osseous and cartilaginous. Measurement intrarater and interrater reliability were in the good-to-excellent range (intraclass correlation coefficient 0.77 to 0.98). RESULTS: When we compared dominant and nondominant arms, we found there was no dominant arm overgrowth (difference between baseline and 3-year measurements) in any measurement; for example, sagittal capitellum measurements in dominant arms were 2.5 ± 1.1 mm versus non-dominant arms: 2.8 ± 1.1 mm (mean difference -0.23 [95% CI -0.55 to 0.08]; p = 0.13). There was only undergrowth of the cartilaginous axial diameter of the radial head (change in dominant: 2.5 ± 1.3 mm; change in nondominant: 3.2 ± 1.7 mm; mean difference -0.64 mm [95% CI -1.2 to -0.06]; p = 0.03). There was no enlargement of the lateral elbow structures when children who continued to play were compared with children who stopped playing; for example, the difference in the bone-only growth ratio of the sagittal radial head to humerus of those still playing was 0.001 ± 0.03 and it was 0.01 ± 0.03 for those not playing (mean difference -0.01 [95% CI -0.04 to 0.01]; p = 0.29). CONCLUSION: In healthy children who play baseball for multiple years between the ages of 6 to 11 years, continued torque at the elbow from throwing does not result in morphologic changes as it does in the shoulder. Despite evidence that injuries and surgery because of long-term participation in a throwing sport results in a larger radial head and capitellum, our study presents evidence that outside an injured elbow, throwing alone does not appear to change the morphology of the lateral elbow. Therefore, changes to the radial head size could presuppose other elbow pathology and future study could be performed to better evaluate the correlation. LEVEL OF EVIDENCE: Level I, prognostic study.

Glenoid Pathology, Skeletal Immaturity, and Multiple Preoperative Instability Events Are Risk Factors for Recurrent Anterior Shoulder Instability After Arthroscopic Stabilization in Adolescent Athletes.

PURPOSE: To identify risk factors for recurrent shoulder instability after arthroscopic stabilization in adolescent athletes. METHODS: A retrospective case-control study was undertaken of all patients younger than 18 years undergoing arthroscopic shoulder stabilization for anterior instability between 2009 and 2016. Two patient cohorts were identified: (1) patients with recurrent instability (frank dislocations or subluxations) after arthroscopic stabilization and (2) an age- and sex-matched cohort of patients with no recurrent instability at a minimum of 2 years' follow-up from index surgery. Patient demographic, injury, radiographic, and surgical variables were recorded. Variables with P < .10 on univariate analysis were entered into a binary logistic multivariate regression analysis. RESULTS: We identified 35 patients (20.5%) in whom arthroscopic stabilization failed at a mean of 1.2 ± 1.0 years after their index surgical procedure. A separate age- and sex-matched cohort of 35 patients with no evidence of recurrent instability was identified (mean follow-up, 5.4 ± 2.0 years; minimum follow-up, 2 years). Univariate analysis identified increased glenoid bone loss (P = .039), decreased glenoid retroversion (P = .024), and more than 1 instability event prior to surgery (P = .017) as significant risk factors for recurrent instability. Multivariate regression analysis revealed that glenoid retroversion less than 6°, skeletal immaturity, and more than 1 prior instability event significantly and independently predicted future recurrence. The risk of recurrence after arthroscopic stabilization was increased by 3 times in patients with 2 risk factors and by 4 times in patients with all 3 risk factors. CONCLUSIONS: Anterior glenoid bone loss, glenoid version, skeletal immaturity, and multiple preoperative instability events are risk factors for failed arthroscopic stabilization in adolescent athletes with anterior instability. LEVEL OF EVIDENCE: Level III, case-control study.

Changes in superior displacement, angulation, and shortening in the early phase of healing for completely displaced midshaft clavicle fractures in adolescents: results from a prospective, multicenter study.

BACKGROUND: Progressive displacement of diaphyseal clavicle fractures has been observed in adult patients, at times necessitating a change from nonoperative to operative treatment. Whether this occurs in adolescent patients has not been well investigated. The purpose of this study was to assess the rate and extent of progressive clavicle fracture displacement in adolescent patients following injury and during the early stages of healing. METHODS: This was a multicenter study evaluating prospective data that had previously been collected as part of a larger study evaluating the functional outcomes of adolescent clavicle fractures. A consecutive series of completely displaced diaphyseal clavicle fractures in patients aged 10-18 years treated at 1 of 3 tertiary-care pediatric trauma centers was included; all fractures underwent standardized imaging within 2 weeks of the date of injury and during the course of healing (5-20 weeks after injury). Measurements of clavicle shortening, superior displacement, and angulation were performed using validated techniques. Progressive displacement and/or interval improvement in fracture alignment, as well as the subsequent need for surgical intervention, was noted. Patient demographic and radiographic parameters were assessed as possible risk factors for interval displacement. RESULTS: One hundred patients met the inclusion criteria. Mean end-to-end shortening, cortex-to-cortex shortening, superior displacement, and angulation at the time of injury were 24 mm, 15 mm, 15 mm, and 7°, respectively. At a mean of 10 weeks after injury, the fracture alignment improved across all 4 measurements for the overall cohort, with mean improvements of 3.5 mm in end-to-end shortening, 3.3 mm in cortex-to-cortex shortening, 2.1 mm in superior displacement, and 2° in angulation. By use of a clinical threshold of a change in shortening or displacement of 10 mm or change in angulation of 10°, 26% of fractures improved, 4% worsened, and 70% remain unchanged. Patients with more severe fractures were more likely to have improved alignment than were patients with less displaced fractures (P < .001). No patient underwent surgical intervention for progressive displacement. CONCLUSION: Significant early improvements in fracture alignment were observed in a substantial percentage of adolescent patients with completely displaced clavicle fractures. Among the most severely displaced fractures, shortening improved approximately 6 mm and angulation improved approximately 9°. In 4% of cases, increased displacement was observed, but this tended to be mild, and in no cases did it prompt surgical intervention. This finding indicates that the true final deformity after an adolescent clavicle fracture is commonly less than that present at the time of injury.

Functional Outcomes of Arthroscopic Os Trigonum Excision in Adolescents.

BACKGROUND: Outcomes of symptomatic os trigonum excision have been well described as a successful treatment in adults; however, the literature lacks information on standardized longer term functional outcomes in the pediatric population. This study intends to report functional outcomes of arthroscopic os trigonum excision in adolescents who failed conservative management, with the hypothesis that these younger patients would have similar, successful outcomes of adult patients. METHODS: A retrospective study was performed on adolescents who underwent arthroscopic os trigonum excision at a single institution between 2011 and 2017. Patient demographic, clinical history, radiographic, and operative data were documented. Outcome measures included the Foot and Ankle Ability Measure (FAAM) score comprised of the Activities of Daily Living (ADL) and Sports subscales, Single Assessment Numeric Evaluation (SANE) score, ability to return to the same level of sport, and any additional foot/ankle surgery. RESULTS: Ten patients (12 ankles) met criteria with a mean age at surgery of 15.4 years (range, 12 to 18 y) and a mean follow-up of 6.5 years (range, 2.8 to 9.1 y). Mean FAAM ADL subscale, Sports subscale, and SANE scores were 91.0±15.5, 76.3±29.1, and 88.6±15.1, respectively. A chronic duration of symptoms before surgery was associated with a lower FAAM Sports current level of function score (P=0.032). Four patients (40%) discontinued their sport due to continued ankle issues and reported significantly lower FAAM ADL subscale (P=0.01), Sports subscale (P<0.001), and SANE scores (P=0.002). CONCLUSIONS: Os trigonum syndrome in the adolescent population may not have the same rate of success as that seen in adult athletes over the long-term. However, if proven to be refractory to conservative measures and surgical intervention is indicated, patients and their families should be counseled about the risk for persistent ankle symptoms and the possibility that they may not be able to return to their previous level of sport. LEVEL OF EVIDENCE: Level IV-case series.

Radiographic Coronal Imbalance and Shoulder Asymmetry Continue to Improve Between 2 and 5 Years Following Surgery of Adolescent Idiopathic Scoliosis.

BACKGROUND: Managing patients with coronal imbalance (CI) and shoulder height asymmetry following scoliosis surgery can be challenging. Little is known about the course of findings over time and whether they improve or persist. The aim was to report the rate of suboptimal radiographic CI or shoulder asymmetry (SA) at 5 years in patients who were already reported to have CI or SA 2 years after surgery for adolescent idiopathic scoliosis (AIS). METHODS: An AIS database was reviewed for patients with both 2- and 5-year follow-up after surgery. From this cohort, patients with CI>2 cm or SA>2 cm at their 2-year follow-up were identified and reevaluated, using the same parameters, at 5-year follow-up. RESULTS: Of 916 patients, 157 (17%) patients had CI and 69 (8%) patients had SA at 2-year follow-up. At 5 years this improved to 53 (6%) and 11 patients (1%), respectively. CONCLUSIONS: Having coronal or shoulder imbalance 2 years after surgery for AIS does not guarantee continued imbalance 5 years after surgery. Most patients demonstrate some improvement in these measures of clinical deformity. Anticipating the potential course following a postoperative coronal balance and shoulder height differences can help surgeons manage and counsel their patients appropriately. LEVELS OF EVIDENCE: Level II-therapeutic.

Preoperative SRS pain score is the primary predictor of postoperative pain after surgery for adolescent idiopathic scoliosis: an observational retrospective study of pain outcomes from a registry of 1744 patients with a mean follow-up of 3.4 years.

BACKGROUND: Traditionally, adolescent idiopathic scoliosis (AIS) has not been associated with back pain, but the increasing literature has linked varying factors between pain and AIS and suggested that it is likely underreported. PURPOSE: Our objective was to investigate factors associated with post-op pain in AIS. METHODS: A prospectively collected multicenter registry was retrospectively queried. Pediatric patients with AIS having undergone a fusion with at least 2 years of follow-up were divided into two groups: (1) patients with a postoperative SRS pain score ≤ 3 or patients having a reported complication specifically of pain, and (2) patients with no pain. Patients with other complications associated with pain were excluded. RESULTS: Of 1744 patients, 215 (12%) experienced back pain after postoperative recovery. A total of 1529 patients (88%) had no complaints of pain, and 171 patients (10%) had pain as a complication, with 44 (2%) having an SRS pain score ≤ 3. The mean time from date of surgery to the first complaint of back pain was 25.6 ± 21.6 months. In multivariate analysis, curve type (16% of Lenke 1 and 2 curves vs. 10% of Lenke 5 and 6, p = 0.002) and a low preoperative SRS pain score (no pain 4.15 ± 0.67 vs. pain 3.75 ± 0.79, p < 0.001) were significant. When comparing T2-4 as the upper instrumented vertebrae in a subgroup of Lenke 1 and 2 curves, 9% of patients had pain when fused to T2, 13% when fused to T3, and 18% when fused to T4 (p = 0.002). CONCLUSION: 12% of all AIS patients who underwent fusion had back pain after postoperative recovery. The most consistent predictive factor of increased postoperative pain across all curve types was a low preoperative SRS pain score. These slides can be retrieved under Electronic Supplementary Material.

Risk Factors for Adverse Radiographic Outcomes After Elastic Stable Intramedullary Nailing of Unstable Diaphyseal Tibia Fractures in Children.

OBJECTIVES: Elastic stable intramedullary nails (ESIN) are commonly utilized to treat unstable pediatric tibia fractures but have been associated with complications. The purpose of this study was to identify risk factors for adverse radiographic outcomes after ESIN of pediatric tibia fractures. METHODS: A retrospective review of all patients who underwent diaphyseal tibia fracture stabilization with ESIN between 2010 and 2018 at 3 pediatric level 1 trauma centers was performed. Inclusion criteria were open growth plates, no intra-articular or physeal fracture involvement, and radiographic follow-up until union. Patient demographics, injury mechanism, fracture characteristics, and implant fill relative to the medullary canal were recorded. Radiographic outcome measures included achievement of and time to union, residual angular deformity, and additional procedures. RESULTS: One hundred seventy-two patients met inclusion criteria and were followed for a mean of 1.2 years. Nonunions were observed in 3% of the patient cohort. Another 10% required >6 months to heal, but did not require further surgical intervention. Angular deformities were common with 57% having a residual deformity ≥5 degrees and 14% having a residual deformity ≥10 degrees. Of the patients with a residual deformity between 5 and 10 degrees, 3% were symptomatic, where as 26% of the patients with a residual deformity ≥10 degrees were symptomatic. Greater angular deformities were associated with open fractures, compartment syndrome, and longer time to union. Patient age, weight, tibial comminution, and canal fill were not associated with nonunions or malunions. CONCLUSIONS: ESIN of pediatric tibia fractures results in reliable healing for a majority of patients, but poses risks for residual angular deformities and delayed healing. Open fractures and compartment syndrome were associated with adverse radiographic outcomes.

The Curse of the All-Star Team: A Single-Season Prospective Shoulder MRI Study of Little League Baseball Players.

BACKGROUND: Throwing guidelines have been implemented in Little League baseball in an attempt to minimize injuries in young baseball players. We hypothesized that playing pitcher or catcher and increased innings played during the season would result in dominant shoulder magnetic resonance imaging (MRI) abnormalities. METHODS: A prospective evaluation of Little League players aged 10 to 12 years was performed. Players recruited before the start of the season underwent bilateral preseason and dominant shoulder postseason MRI, physical examination, and questionnaires addressing their playing history and arm pain. Innings played, player position, pitch counts, and all-star team selection were recorded. RESULTS: In total, 23 players were enrolled. The majority (19/23, 82.6%) were right-handed and 16 of 23 (69.6%) played at least 10 innings as pitcher or catcher. Sixteen were selected for the all-star team. Fourteen players (60.9%) had positive dominant shoulder MRI findings not present in their nondominant shoulder. Eight players (34.8%) had new or worsening postseason MRI findings. Thirteen players (81.3%) selected to the all-star team had abnormal MRI findings whereas only one (14.3%) player not selected as an all-star had MRI abnormalities (P=0.005). Year-round play (P=0.016), innings pitched (P=0.046), innings catcher (P=0.039), and number of pitches (P=0.033) were associated with any postseason MRI abnormality, but not for new or worsening MRI changes. Single sport athletes and players playing for multiple teams were significantly more likely to have abnormal MRI findings (P=0.043 and 0.040, respectively) when compared with multisport athletes playing on a single team. CONCLUSIONS: MRI abnormalities involving the dominant shoulder are common in Little League baseball players and often develop or worsen during the season. Contrary to our hypothesis, MRI abnormalities were not associated with player position and pitch counts. Instead, they were most closely associated with year round play, single sports participation, and all-star team selection. The increased demands required for all-star selection comes at a price to the young athlete as the majority of players selected for this honor had abnormal MRI findings in their throwing shoulder while few non all-stars demonstrated such pathology. LEVEL OF EVIDENCE: Level II.