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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 χ 2 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., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

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., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

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., Competing Interests: A.I.C.: paid CME question writer for JBJS, Arthrex payment >$500 in 2015 (Education, Food/Beverage, Lodging), Committee member POSNA, Committee member PRiSM. H.B.E.: Smith-Nephew—consultant/speaking, Anthrex—education support. T.J.G.: Associate Editor for AJSM; Vericel Corporation—Research Support, Arthrex—Research Support, AlloSource—Research Support, Committee Member POSNA, Committee Member PRiSM. Daniel W. Green: Royalties from Arthrex, and Pega Medical. R. Jay Lee: research support from Arthrex, Vericel, Orthopediatrics. Scott McKay: PRISM and POSNA committees. R.J.M.: consultant: Orthopediatrics; Educational Support: Depuy Synthes. Jason Rhodes: President of GCMAS, Consultant for Orthopaediatrics, Research grant from smith nephew for a different study. Gregory A. Schmale: Arthrex Inc.—funds for “education”; SIGN Inc.—conference fees paid for giving a lecture. Y.-M.Y.: Smith-Nephew—consultant, Kairos surgical—hospitality payment, AJSM Editorial Board. The remaining authors declare no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

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., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

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., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

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.

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.

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.

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.

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.

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.

The fundamental principles of fracture care apply to medial epicondyle fractures in that the goals of treatment are to obtain fracture healing and to promote a return of appropriate motion, strength, and stability. Recent studies have revealed limitations of some classically described evaluation methods and have revealed more precise methods of measuring displacement. The authors of this manuscript describe established principles of care and incorporate recent evidence-based articles to help the clinician study the issues relative to the clinical evaluation and the operative and nonoperative treatment of medial epicondyle fractures.

Background: Arthrofibrosis and decreased range of motion (ROM) are well-described sequelae of tibial eminence fractures. We sought to evaluate the effects of timing of ROM rehabilitation and postsurgical immobilization on clinical outcomes in children with fractures of the tibial eminence., Methods: We retrospectively reviewed the records of all children diagnosed with closed tibial eminence fractures between 2000 and 2010. Patients were treated by experienced surgeons with uniform requirements for return to full activity., Results: Fourteen females and 26 males (40 knees) of mean age 12 years (range, 5 to 17 y) started ROM therapy for a mean of 23 days after treatment (range, 4 to 47 d). Seven patients required additional surgeries for arthrofibrosis at a mean of 3 months after initial fracture treatment (range, 1.5 to 5.5 mo). Compared with patients who started ROM rehabilitation within 4 weeks of treatment, those who started later than 4 weeks required more days to return to full activity (215 vs. 103 d; P=0.011) and were 12 times more likely to develop arthrofibrosis (P=0.029). Even when accounting for other factors in multivariate regression, earlier initiation of ROM therapy was associated with earlier return to full activity (P<0.001). Surgical patients who were immobilized postoperatively required more days to return to full activity (217.5 vs. 103 d; P=0.015) and had a higher rate of arthrofibrosis (36% vs. 0%; P=0.043) than those who were not. Age, sex, fracture classification, and operative versus nonoperative treatment did not have a statistically significant effect on our multivariate model., Conclusions: After definitive treatment, early implementation of ROM rehabilitation results in a more rapid return to full activity. ROM therapy within 4 weeks of treatment results in sooner return to full activity and decreases the likelihood of eventual arthrofibrosis. In surgical patients, postoperative immobilization results in a longer delay until return to full activity and a higher rate of arthrofibrosis., Level of Evidence: Therapeutic study, level III.

Background: In previous studies, 5% to 20% of patients with a discoid lateral meniscus eventually require surgery bilaterally for symptomatic discoid menisci. However, there are little published data specifically on children who require treatment for discoid menisci in both knees. The purpose of this study is to identify differences in clinical and arthroscopic findings between children who require bilateral versus unilateral treatment for symptomatic discoid lateral menisci., Methods: We retrospectively reviewed the records of all patients aged 18 years or younger requiring treatment of discoid lateral meniscus between 1998 and 2007. Data were collected on 16 patients (32 knees) with symptomatic bilateral discoid menisci and 60 patients treated unilaterally with an asymptomatic contralateral knee., Results: At initial presentation, children who were treated bilaterally for discoid menisci were younger than those treated unilaterally (10.4 vs. 12.5 y; P=0.021). Patients under 12 years of age were 4.6 times more likely to eventually require surgery on both knees (P=0.015). Watanabe classification was as follows: complete, 65% bilateral versus 30% unilateral; incomplete, 22% bilateral versus 68% unilateral; and Wrisberg, 13% bilateral versus 2% unilateral (P<0.001). The odds of current or future bilateral symptoms requiring treatment were 4.5 times higher in patients with a complete discoid meniscus (P=0.0017) and 8.4 times higher in those with a Wrisberg type (P=0.048). A tear of the lateral meniscus was more likely to be found intraoperatively in unilateral knees than bilateral (90% vs. 72%; P=0.037)., Conclusions: Patient education and long-term follow-up are important for children who present with a discoid meniscus at a young age or with a complete or Wrisberg type, as these patients may be at increased odds of symptomatic discoid meniscus in the contralateral knee, even several years later. Furthermore, evaluation and treatment of discoid lateral meniscus requires vigilance for meniscal tears., Level of Evidence: Prognostic study, level III.