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Background: After arthroscopic Bankart repair (ABR) for anterior glenohumeral instability (GHI), adolescent athletes have higher rates of subsequent recurrent GHI than any other subpopulation. Elucidating which adolescents are at highest risk of postoperative recurrent GHI may optimize surgical decision-making., Purpose: To identify prognostic factors associated with subsequent recurrent GHI requiring revision stabilization surgery (RSS) after ABR., Study Design: Case-control study; Level of evidence, 3., Methods: The study included patients 12 to 21 years old who had undergone ABR for anterior GHI at a pediatric tertiary care hospital by 1 of 5 sports medicine fellowship-trained surgeons between 2000 and 2020. A multivariate Cox proportional hazards model, with percentage of patients with recurrent GHI undergoing subsequent RSS, was used with a time-to-event outcome analysis. The Cox model effects were expressed as the hazard ratio (HR). All tests were 2-sided, with an alpha of .05., Results: Records of 488 adolescent patients with ABR (78% male; mean age, 16.9 ± 1.98 years) were analyzed. Of these, 86 patients (17.6%) underwent subsequent RSS for recurrent GHI, yielding a cumulative risk of 8.8% at 2 years, 16.5% at 5 years, and 20% at 15 years. RSS occurred at a mean of 2.6 ± 2.1 years after ABR. Risk factors for RSS included >1 preoperative dislocation (2 dislocations: HR = 7.4, P = .0003; ≥3 dislocations: HR = 10.9, P < .0001), presence of a Hill-Sachs lesion (small: HR = 2.5, P = .0114; medium-large: HR = 4.2, P = .0004), younger age (1-year decrease: HR = 1.2, P = .0015), and participation in contact sports (HR = 1.8, P = .01). Adolescents with only 1 preoperative dislocation had a cumulative incidence of RSS (3.2%), which was significantly lower than those with 2 (24.2%) or ≥3 preoperative dislocations (33.5%)., Conclusion: The number of dislocations before index ABR was the strongest risk factor for recurrent GHI requiring RSS in adolescents with anterior GHI, with 2 dislocations conferring >7-fold increased risk compared with a single preoperative dislocation. Other significant risk factors included the presence of a Hill-Sachs lesion, younger age, and participation in contact sports., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: B.E.H. has received consulting fees from and owns stock in Imagen Technologies and is an educational consultant for Arthrex and Kairos Surgical. M.S.K. has received royalties from OrthoPediatrics and Ossur and support for education from Kairos Surgical. D.E.K. has received support for education from Kairos Surgical and consulting fees from Miach, Smith + Nephew, and DePuy. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Background: Quantitative magnetic resonance imaging (qMRI) methods were developed to establish the integrity of healing anterior cruciate ligaments (ACLs) and grafts. Whether qMRI variables predict risk of reinjury is unknown., Purpose: To determine if qMRI measures at 6 to 9 months after bridge-enhanced ACL restoration (BEAR) can predict the risk of revision surgery within 2 years of the index procedure., Study Design: Cohort study; Level of evidence, 2., Methods: Originally, 124 patients underwent ACL restoration as part of the BEAR I, BEAR II, and BEAR III prospective trials and had consented to undergo an MRI of the surgical knee 6 to 9 months after surgery. Only 1 participant was lost to follow-up, and 4 did not undergo MRI, leaving a total of 119 patients for this study. qMRI techniques were used to determine the mean cross-sectional area; normalized signal intensity; and a qMRI-based predicted failure load, which was calculated using a prespecified equation based on cross-sectional area and normalized signal intensity. Patient-reported outcomes (International Knee Documentation Committee subjective score), clinical measures (hamstring strength, quadriceps strength, and side-to-side knee laxity), and functional outcomes (single-leg hop) were also measured at 6 to 9 months after surgery. Univariate and multivariable analyses were performed to determine the odds ratios (ORs) for revision surgery based on the qMRI and non-imaging variables. Patient age and medial posterior tibial slope values were included as covariates., Results: In total, 119 patients (97%), with a median age of 17.6 years, underwent MRI between 6 and 9 months postoperatively. Sixteen of 119 patients (13%) required revision ACL surgery. In univariate analyses, higher International Knee Documentation Committee subjective score at 6 to 9 months postoperatively (OR = 1.66 per 10-point increase; P = .035) and lower qMRI-based predicted failure load (OR = 0.66 per 100-N increase; P = .014) were associated with increased risk of revision surgery. In the multivariable model, when adjusted for age and posterior tibial slope, the qMRI-based predicted failure load was the only significant predictor of revision surgery (OR = 0.71 per 100 N; P = .044)., Conclusion: Quantitative MRI-based predicted failure load of the healing ACL was a significant predictor of the risk of revision within 2 years after BEAR surgery. The current findings highlight the potential utility of early qMRI in the postoperative management of patients undergoing the BEAR procedure.

Background: Anterior cruciate ligament (ACL) revision surgery is challenging for both patients and surgeons. Understanding the risk factors for failure after bridge-enhanced ACL restoration (BEAR) may help with patient selection for ACL restoration versus ACL reconstruction., Purpose: To identify the preoperative risk factors for ACL revision surgery within the first 2 years after BEAR., Study Design: Case-control study; Level of evidence, 3., Methods: Data from the prospective BEAR I, II, and III trials were used to determine the preoperative risk factors for ACL revision surgery. All patients with a complete ACL tear (aged 13-47 years, depending on the trial), who met all other inclusion/exclusion criteria and underwent a primary BEAR procedure within 30 to 50 days from the injury (dependent on the trial), were included. Demographic data (age, sex, body mass index), baseline patient-reported outcomes (International Knee Documentation Committee [IKDC] subjective score, Marx activity score), preoperative imaging results (ACL stump length, notch size, tibial slope), and intraoperative findings (knee hyperextension, meniscal status) were evaluated to determine their contribution to the risk of ipsilateral ACL revision surgery., Results: A total of 123 patients, with a median age of 17.6 years (interquartile range, 16-23 years), including 67 (54%) female patients, met study criteria. Overall, 18 (15%) patients required ACL revision surgery in the first 2 years after the BEAR procedure. On bivariate analyses, younger age ( P = .011), having a contact injury at the time of the initial tear ( P = .048), and increased medial tibial slope (MTS; P = .029) were associated with a higher risk of ipsilateral revision surgery. Multivariable logistic regression analyses identified 2 independent predictors of revision: patient age and MTS. The odds of ipsilateral revision surgery were decreased by 32% for each 1-year increase in age (odds ratio, 0.684 [95% CI, 0.517-0.905]; P = .008) and increased by 28% for each 1° increase in MTS (odds ratio, 1.280 [95% CI, 1.024-1.601]; P = .030). Sex, baseline IKDC or Marx score, knee hyperextension, and meniscal status were not significant predictors of revision., Conclusion: Younger age and higher MTS were predictors of ipsilateral ACL revision surgery after the BEAR procedure. Younger patients with higher tibial slopes should be aware of the increased risk for revision surgery when deciding to undergo ACL restoration.

Background: Magnetic resonance-based measurements of signal intensity have been used to track healing of surgically treated anterior cruciate ligaments (ACLs). However, it is unknown how the signal intensity values in different regions of the ligament or graft change during healing., Hypotheses: (1) Normalized signal intensity of the healing graft or repaired ACL is heterogeneous; (2) temporal changes in normalized signal intensity values differ among the tibial, middle, and femoral regions; and (3) there are no differences in regional normalized signal intensity values 2 years postoperatively among grafts, repaired ACLs, and contralateral native ACLs., Study Design: Cohort study; Level of evidence, 2., Methods: Magnetic resonance imaging scans were analyzed from patients in a trial comparing ACL reconstruction (n = 35) with bridge-enhanced ACL repair (n = 65). The ACLs were segmented from images acquired at 6, 12, and 24 months postoperatively and were partitioned into 3 sections along the longitudinal axis (femoral, middle, and tibial). Linear mixed modeling was used to compare location-specific differences in normalized ligament signal intensity among time points (6, 12, and 24 months) and groups (ACL reconstruction, repair, and contralateral native ACL)., Results: For grafts, the middle region had a higher mean normalized signal intensity when compared with the femoral region at all time points ( P < .01) but compared with the tibial region only at 6 months ( P < .01). For repaired ACLs, the middle region had a higher mean normalized signal intensity versus the femoral region at all time points ( P < .01) but versus the tibial region only at 6 and 12 months ( P < .04). From 6 to 24 months, the grafts showed the greatest reduction in normalized signal intensity in the femoral and middle regions (vs tibial regions; P < .01), while there were no regional differences in repaired ACLs. At 2 years after surgery, repaired ACLs had a lower normalized signal intensity in the tibial region as compared with reconstructed grafts and contralateral native ACLs ( P < .01)., Conclusion: The results suggest that graft remodeling is location specific. Repaired ACLs were more homogeneous, with lower or comparable normalized signal intensity values at 2 years as compared with the contralateral native ACL and reconstructed grafts.

Background: Preclinical studies suggest that for complete midsubstance anterior cruciate ligament (ACL) injuries, a suture repair of the ACL augmented with a protein implant placed in the gap between the torn ends (bridge-enhanced ACL repair [BEAR]) may be a viable alternative to ACL reconstruction (ACLR)., Hypothesis: We hypothesized that patients treated with BEAR would have a noninferior patient-reported outcomes (International Knee Documentation Committee [IKDC] Subjective Score; prespecified noninferiority margin, -11.5 points) and instrumented anteroposterior (AP) knee laxity (prespecified noninferiority margin, +2-mm side-to-side difference) and superior muscle strength at 2 years after surgery when compared with patients who underwent ACLR with autograft., Study Design: Randomized controlled trial; Level of evidence, 1., Methods: One hundred patients (median age, 17 years; median preoperative Marx activity score, 16) with complete midsubstance ACL injuries were enrolled and underwent surgery within 45 days of injury. Patients were randomly assigned to receive either BEAR (n = 65) or autograft ACLR (n = 35 [33 with quadrupled semitendinosus-gracilis and 2 with bone-patellar tendon-bone]). Outcomes-including the IKDC Subjective Score, the side-to-side difference in instrumented AP knee laxity, and muscle strength-were assessed at 2 years by an independent examiner blinded to the procedure. Patients were unblinded after their 2-year visit., Results: In total, 96% of the patients returned for 2-year follow-up. Noninferiority criteria were met for both the IKDC Subjective Score (BEAR, 88.9 points; ACLR, 84.8 points; mean difference, 4.1 points [95% CI, -1.5 to 9.7]) and the side-to-side difference in AP knee laxity (BEAR, 1.61 mm; ACLR, 1.77 mm; mean difference, -0.15 mm [95% CI, -1.48 to 1.17]). The BEAR group had a significantly higher mean hamstring muscle strength index than the ACLR group at 2 years (98.2% vs 63.2%; P < .001). In addition, 14% of the BEAR group and 6% of the ACLR group had a reinjury that required a second ipsilateral ACL surgical procedure ( P = .32). Furthermore, the 8 patients who converted from BEAR to ACLR in the study period and returned for the 2-year postoperative visit had similar primary outcomes to patients who had a single ipsilateral ACL procedure., Conclusion: BEAR resulted in noninferior patient-reported outcomes and AP knee laxity and superior hamstring muscle strength when compared with autograft ACLR at 2-year follow-up in a young and active cohort. These promising results suggest that longer-term studies of this technique are justified., Registration: NCT02664545 (ClinicalTrials.gov identifier).

Purpose: Paediatric radial neck fractures are challenging to treat. Multiple strategies exist for reduction and fixation; there is no clear consensus on the best surgical technique to achieve reduction. The percutaneous leverage technique is a method for reduction of radial neck fractures that has previously been described by Wallace, though there is a lack of published literature on this technique. We present a technical note and a modest case series on our modification to the percutaneous leverage technique accompanied by intramedullary fixation., Methods: We describe a retrospective series of patients who underwent the modified percutaneous leverage technique for paediatric radial neck fracture reduction followed by flexible intramedullary nail fixation at a single Level I trauma centre from 2008 to 2016. This technique involves making a small incision over the dorsal border of the ulna and using a blunt curved surgical forceps to dissect towards the ulnar border of the radius just distal to the radial neck fracture site. The curved forceps is then used to push the radial shaft away from the ulnar shaft which reduces the radial neck fracture. Intramedullary fixation is then utilized to stabilize the reduction. Pre- and postoperative radiographs and clinical data from the medical record were reviewed, and patient, injury and treatment characteristics as well as complication rates are summarized., Results: We successfully treated a series of eight radial neck fractures with the modified percutaneous leverage technique. This technique allows for a small incision and a minimally invasive method for the reduction of paediatric radial neck fractures. This allowed for subsequent intramedullary fixation and early postoperative elbow mobilization. In our series, no patients developed synostoses or sustained peripheral nerve injuries using this technique., Conclusion: The modified percutaneous leverage technique followed by intramedullary fixation is a safe and effective technique for fixation of displaced paediatric radial neck fractures., Level of Evidence: Level IV., (Copyright © 2020, The author(s).)

Context: The rising popularity and intensity of youth sports has increased the incidence of patellar dislocation. These sports-related injuries may be associated with significant morbidity in the pediatric population. Treatment requires understanding and attention to the unique challenges in the skeletally immature patient., Evidence Acquisition: PubMed searches spanning 1970-2013., Study Design: Clinical review., Level of Evidence: Level 5., Results: Although nonoperative approaches are most often suitable for first-time patellar dislocations, surgical treatment is recommended for acute fixation of displaced osteochondral fractures sustained during primary instability and for patellar realignment in the setting of recurrent instability. While a variety of procedures can prevent recurrence, the risk of complications is not minimal., Conclusion: Patellar stabilization and realignment procedures in skeletally immature patients with recurrent patellar dislocation can effectively treat patellar instability without untoward effects on growth if careful surgical planning incorporates protection of growth parameters in the skeletally immature athlete.