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The purpose of this study was to evaluate the physical and psychological effects of COVID-related elective surgery delays on young sports medicine patients.We conducted a cross-sectional study of patients (10-25 years old) who had elective sports medicine surgery delayed due to the COVID crisis. Electronic surveys were sent to patients and included the 12-item Short Form Health Survey (SF-12), which yields a physical component score (SF12-PCS) and a mental component score (SF12-MCS), the PROMIS Psychological Stress Experience survey (PROMIS-PSE), and self-designed questions about patient concerns regarding the COVID crisis and delayed surgery.Of the 194 eligible patients with delayed elective sports surgeries, 107 patients (55%) elected to participate (mean age 17.6 ± 3.09 years, 30% male). The mean surgical delay was 76 days (CI 57-98). Delayed surgery patients scored significantly lower than population norms on the SF12-PCS (mean 39.3, CI 37.0-41.7;Young sports medicine patients reported significant physical and emotional symptoms associated with COVID-related surgical delays. Patients were most concerned about delays resulting in missed sport seasons. Those who reported greater levels of concern with surgical delays reported more emotional symptoms and higher levels of psychological stress.

Skeletal maturity is a critical consideration for pediatric orthopedic surgeons, general pediatricians, endocrinologists, metabolic bone disease specialists, rheumatologists, and physiatrists in the development and modification of treatment plans for growing children. Arguably the most widely utilized method of determining skeletal age, the Greulich and Pyle method (GPM), unfortunately has many shortcomings. Between the method reflecting limited population metrics and its reliance on a voluminous hard-copy radiographic atlas, the GPM may not lend itself to widespread use or optimized learning in the modern era of orthopedics. In 2013, the Shorthand Bone Age (SBA) method suggested a simpler approach by demonstrating reliability when just a single feature for each skeletal age, depending on patient sex, was sufficient in providing an accurate bone age estimate reflective of the full GPM. In addition to the SBA, an expanding body of research has emerged over the past two decades, attempting to provide the orthopedic community with simpler yet effective tools to determine skeletal age. In this review, we compare and present the spectrum of current concepts encompassing validated bone age determination methods for each of six commonly imaged anatomic locations: hand/wrist, elbow, shoulder/proximal humerus, hip/pelvis, knee, foot/ankle. All methods are presented visually in table format, with detailed graphic design, quantitative approximations to generate relative consistency between systems, and age-based color-coding for ease of memorization and use. All images are derived from patients presenting to the study institution within the past three months, so as to harness modern image quality and populations while also adhering to the principles and age-based features inherent to each system’s different categories. The purpose of this review is multifaceted: to enable better incorporation of skeletal age considerations into daily practice by caregivers in many disciplines; to enhance awareness regarding the full array of tools that may spare young patients additional and unnecessary radiation; and to serve as a springboard for a mobile application to be utilized in any clinical setting by anyone with a mobile device.

Discoid meniscus is the most common congenital variant of the meniscus. Its variability in pathology leads to a spectrum of clinical presentations in patients. Treatment must be tailored to the specific pathology of the discoid meniscus. Imaging studies such as radiographs and magnetic resonance imaging can be useful in confirming the diagnosis, but may be the most accurate in determining specific pathology. Thorough intraoperative evaluation of the discoid is critical to appropriate surgical management. Rim preservation and repair is preferred to prevent degenerative changes in the knee.

The Micheli anterior cruciate ligament (ACL) procedure is a combined intra-articular and extra-articular knee stabilization technique that combines lateral augmentation with ACL reconstruction using the iliotibial band as an autograft for both aspects of the technique. Its primary indication is for ACL reconstruction in skeletally immature patients with more than 2 years of growth remaining. Studies have shown it to be effective at restoring knee biomechanics to have minimal risk of complications, including those associated with growth disturbances and a relatively low ACL graft rupture rate. Additional studies are needed to better understand the potential utilization of this technique and related modifications in the marginally skeletally immature patient, skeletally mature adolescent, adult, and revision ACL reconstruction settings.

Background: The optimal treatment of midshaft clavicle fractures is controversial. Few previous comparative functional outcome studies have investigated these fractures in adolescents, the most commonly affected epidemiologic subpopulation. Purpose/Hypothesis: The purpose was to prospectively compare the outcomes of operative versus nonoperative treatment in adolescents with completely displaced midshaft clavicle fractures. The study hypothesis was that surgery would yield superior outcomes. Study Design: Cohort study; Level of evidence, 2. Methods: Patients aged 10 to 18 years treated for a midshaft clavicle fracture over a 5-year period at 1 of 8 pediatric centers were prospectively screened, with independent treatment decisions determined by individual musculoskeletal professionals. Demographics, radiographic clinical features, complications, and patient-reported outcomes (PROs) were prospectively recorded for 2 years. Regression and matching techniques were utilized to adjust for potential age- and fracture severity–based confounders for creation of comparable subgroups for analysis. Results: Of 416 adolescents with completely displaced midshaft clavicle fractures, 282 (68) provided 2-year PRO data. Operative patients (n = 88; 31%) demonstrated no difference in sex (78% male) or athletic participation but were older (mean age, 15.2 vs 13.5 years; P < .001), had more comminuted fractures (49.4% vs 26.3%; P < .001), and had greater fracture shortening (25.5 vs 20.7 mm; P < .001) than nonoperative patients (n = 194; 69%). There was no difference in mean PRO scores or rates of “suboptimal” scores (based on threshold values established a priori) between the operative and nonoperative treatment groups (American Shoulder and Elbow Surgeons, 96.8 vs 98.4; shortened version of the Disabilities of the Arm, Shoulder and Hand, 3.0 vs 1.6; EuroQol [EQ] visual analog scale, 93.0 vs 93.9; EQ–5 Dimensions index, 0.96 vs 0.98), even after regression and matching techniques adjusted for confounders. Operative patients had more unexpected subsequent surgery (10.4% vs 1.4%; P = .004) and clinically significant complications (20.8% vs 5.2%; P = .001). Overall, nonunion (0.4%), delayed union (1.9%), symptomatic malunion (0.4%), and refracture (2.6%) were exceedingly rare, with no difference between treatment groups. Conclusion: Surgery demonstrated no benefit in patient-reported quality of life, satisfaction, shoulder-specific function, or prevention of complications after completely displaced clavicle shaft fractures in adolescents at 2 years after injury. Registration: NCT04250415 ( ClinicalTrials.gov identifier).

OBJECTIVE The primary objective of this study was to identify differences in the treatment approach for isolated, displaced midshaft clavicle fractures in adolescent patients 15-18 years of age at adult versus pediatric hospitals. The secondary objective of this study was to identify factors associated with the surgical treatment of these fractures in this age group. DESIGN Retrospective cohort study. SETTING Two adult and one pediatric tertiary care referral hospitals. PATIENTS/PARTICIPANTS Adolescent patients 15-18 years of age with isolated, displaced midshaft clavicle fractures treated at 2 adult tertiary care referral hospitals and one pediatric tertiary care referral hospital were identified. A total of 214 patients, 105 from the adult hospitals and 109 from the pediatric hospital, were included. INTERVENTION Nonoperative versus surgical treatment of clavicle fractures. MAIN OUTCOME MEASUREMENT Surgical treatment. RESULTS A multivariable logistic regression analysis showed that superior-inferior fracture displacement [odds ratio (OR) 1.13, 95% confidence interval (CI) 1.06-1.20], dominant upper extremity injury (OR 2.60, 95% CI 1.19-5.67), and treatment at an adult hospital (OR 5.28, 95% CI 2.28-12.2) were independently associated with the surgical treatment of adolescent displaced midshaft clavicle fractures. CONCLUSIONS After controlling for relevant demographic and fracture characteristics, adolescent patients treated at adult hospitals for displaced midshaft clavicle fractures have more than 5 times the odds of surgical treatment than those treated at a pediatric hospital. Significant practice variation across institutions reflects ongoing controversy in surgical indications and underscores the need for high-quality prospective outcome studies. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Purpose Patellofemoral instability is a common cause of knee pain and dysfunction in paediatric and adolescent patients. The purpose of the study was to evaluate the frequency of patellar dislocations seen in emergency departments (EDs) and the rates of surgical procedures for patellar instability at paediatric hospitals in the United States between 2004 and 2014. Methods The Pediatric Health Information System database was queried for all paediatric patients who underwent surgery for patellar instability or were seen in the ED for acute patellar dislocation between 2004 and 2014. This was compared with the annual numbers of overall orthopaedic surgical procedures. Results Between 2004 and 2014, there were 3481 patellar instability procedures and 447 285 overall orthopaedic surgical procedures performed at the included institutions, suggesting a rate of 7.8 per 1000 orthopaedic surgeries. An additional 5244 patellar dislocations treated in EDs were identified. Between 2004 and 2014, the number of patellar instability procedures increased 2.1-fold (95% confidence interval (CI) 1.4 to 3.0), while orthopaedic surgical procedures increased 1.7-fold (95% CI 1.3 to 2.0), suggesting a 1.2-fold relative increase in patellar instability procedures, compared with total paediatric orthopaedic surgeries. Conclusion This study shows a significant rise in the rate of acute patellar instability treatment events in paediatric and adolescent patients across the country. Surgery for patellar instability also increased over the study period, though only slightly more than the rate of all paediatric orthopaedic surgical procedures. This may suggest that increasing youth sports participation may be leading to a spectrum of increasing injuries and associated surgeries in children. Level of Evidence IV

Background: Treatment options for pediatric and adolescent anterior cruciate ligament (ACL) injuries include early operative, delayed operative, and nonoperative management. Currently, there is a lack of consensus regarding the optimal treatment for these injuries. Purpose/Hypothesis: The purpose was to determine the optimal treatment strategy for ACL injuries in pediatric and adolescent patients. We hypothesized that (1) early ACL reconstruction results in fewer meniscal tears than delayed reconstruction but yields no difference in knee stability and (2) when compared with nonoperative management, any operative management results in fewer meniscal tears and cartilage injuries, greater knee stability, and higher return-to-sport rates. Study Design: Systematic review and meta-analysis; Level of evidence, 4. Methods: A systematic search of databases was performed including PubMed, Embase, and Cochrane Library using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Inclusion criteria were a pediatric and adolescent patient population (≤19 years old at surgery), the reporting of clinical outcomes after treatment of primary ACL injury, and original scientific research article. Exclusion criteria were revision ACL reconstruction, tibial spine avulsion fracture, case report or small case series (Results: A total of 30 studies containing 50 cohorts and representing 1176 patients met our criteria. With respect to nonoperative treatment, knee instability was observed in 20% to 100%, and return to preinjury level of sports ranged from 6% to 50% at final follow-up. Regarding operative treatment, meta-analysis results favored early ACL reconstruction over delayed reconstruction (>12 weeks) for the presence of any meniscal tear (odds ratio, 0.23; P = .006) and irreparable meniscal tear (odds ratio, 0.31; P = .001). Comparison of any side-to-side differences in KT-1000 arthrometer testing did not favor early or delayed ACL reconstruction in either continuous mean differences ( P = .413) or proportion with difference ≥3 mm ( P = .181). Return to preinjury level of competition rates for early and delayed ACL reconstruction ranged from 57% to 100%. Conclusion: Delaying ACL reconstruction in pediatric or adolescent patients for >12 weeks significantly increased the risk of meniscal injuries and irreparable meniscal tears; however, early and delayed operative treatment achieved satisfactory knee stability. Nonoperative management resulted in high rates of residual knee instability, increased risk of meniscal tears, and comparatively low rates of return to sports.

Background: The physeal-sparing iliotibial band (ITB) anterior cruciate ligament (ACL) reconstruction (ACLR) is a well-established technique for treating skeletally immature patients with ACL rupture. However, the long-term implications of the procedure on the intricacies of kinetic and kinematic function of the knee have not been comprehensively investigated. Purpose: To assess the short-, mid-, and long-term effects of ITB ACLR on kinetic and kinematic parameters of knee functions. Study Design: Case series; Level of evidence, 4. Methods: A total of 38 patients who had undergone an ITB ACLR as a skeletally immature child were recruited to participate in a 3-dimensional (3D) motion analysis testing protocol at an institutional injury prevention center between 1 and 20 years after reconstruction. Exclusion criteria were congenital ACL deficiency and any other major knee injury (defined as an injury requiring surgery or rehabilitation >3 months) on either knee. 3D and force plate parameters included in the analysis were knee moment, ground-reaction force, and vertical jump height measured during drop vertical jump and vertical single-limb hop. Paired t tests and equivalency analyses were used to compare the parameters between cases (ITB ACLR limb) and controls (contralateral/nonsurgical limbs). Results: Paired t tests showed no statistically significant differences between limbs, and equivalency analyses confirmed equivalency between limbs for all tested outcome variables. Conclusion: The ITB ACLR appears to restore normal, symmetric, physiologic kinetic and kinematic function in the growing knee by 1 year after reconstruction, with maintenance of normal parameters for up to 20 years.

Background: Chronic exertional compartment syndrome (CECS) is primarily seen in running athletes. Previous outcomes of surgical treatment with fasciotomy have suggested moderate pain relief, but evidence is lacking regarding postoperative return to running. Hypothesis: Running athletes with limiting symptoms of CECS will show high rates of return to running after fasciotomy. Study Design: Case series. Level of Evidence: Level 4. Methods: Running athletes treated with fasciotomy for CECS at a single institution were identified using a surgical database and asked to complete a questionnaire designed to assess postoperative pain, activity level, return to running, running distances, overall satisfaction, and rate of revision fasciotomy. Results: A total of 43 runners met the inclusion criteria, and 32 runners completed outcomes questionnaires at a mean postoperative follow-up of 66 months. In total, 27 of these 32 patients (84%) returned to sport(s) after fasciotomy. However, 9 (28%) of these patients pursued nonrunning sports, 5 (16%) due to recurrent pain with running. Of the 18 patients who returned to running sports (56%), the mean weekly running distance decreased postoperatively. Recurrence of symptoms was reported in 6 patients (19%), 4 of whom had returned to running and 2 of whom had been unable to return to sports. All of these 6 patients elected to undergo revision fasciotomy surgery. Twenty-five (78.1%) patients reported being satisfied with their procedure. In the overall cohort, the mean visual analog scale scores for pain during activities/sports decreased from 7.9 preoperatively to 1.7 postoperatively. Conclusion: Fasciotomy for CECS in runners may provide significant improvement in pain and satisfaction in over three-quarters of patients and return to sports in 84% of patients. However, only 56% returned to competitive running activity, with a subset (19%) developing recurrent symptoms resulting in revision surgery. Clinical Relevance: Fasciotomy has been shown to decrease pain in most patients with CECS. This study provides outcomes in running athletes after fasciotomy for CECS with regard to return to sports, maintenance of sports performance, and rates of revision surgery.

Background: Patellofemoral instability (PFI) occurs most commonly in pediatric and adolescent patients, with evolving indications for surgery and changes in surgical techniques over the past decade. Purpose: To characterize the demographic, clinical, and radiologic characteristics of a large cohort of patients undergoing PFI surgery and investigate longitudinal trends in techniques utilized over a 10-year period at a tertiary-care academic center. Study Design: Case series; Level of evidence, 4. Methods: Electronic medical records of patients younger than 25 years of age who underwent primary surgery for lateral PFI from 2008 to 2017 at a single center by 1 of 5 different sports medicine surgeons were retrospectively reviewed. Demographic, clinical, and radiographic parameters of instability were analyzed. Routine surgical techniques included medial retinacular plication/reefing/repair (MRP), medial patellofemoral ligament reconstruction (MPFLR), tibial tubercle osteotomy (TTO), or a combination thereof, with or without lateral retinacular release (LR) or lateral retinacular lengthening (LRL). Exclusion criteria, selected for potentially altering routine surgical indications or techniques, included fixed/syndromic PFI, a formally diagnosed collagen disorder, cases in which a chondral/osteochondral shear fragment underwent fixation or was >1 cm in diameter, and body mass index >30 kg/m2. Results: Of the 492 study patients (556 knees; 71% female; median age, 15.2 years; 38% open physes), 88% were athletes, with the most common sports participated in being soccer, basketball, dance, football, gymnastics, and baseball/softball. While 91% of the cohort had recurrent dislocations, the 9% with primary dislocations were more likely to have small osteochondral fractures/loose bodies ( P < .001). Female patients were younger ( P = .002), with greater patellar tilt ( P = .005) than male patients. Utilization of MPFLR and TTO increased significantly over the study period, while use of MRP+LR decreased. Conclusion: Most patients younger than 25 years of age who underwent PFI surgery were skeletally immature, female, and athletes and had recurrent dislocations. The

Background: Osteochondritis dissecans (OCD) occurs most commonly in the knees of young individuals. This condition is known to cause pain and discomfort in the knee and can lead to disability and early knee osteoarthritis. The cause is not well understood, and treatment plans are not well delineated. The Research in Osteochondritis Dissecans of the Knee (ROCK) group established a multicenter, prospective cohort to better understand this disease. Purpose: To provide a baseline report of the ROCK multicenter prospective cohort and present a descriptive analysis of baseline data for patient characteristics, lesion characteristics, and clinical findings of the first 1000 cases enrolled into the prospective cohort. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Patients were recruited from centers throughout the United States. Baseline data were obtained for patient characteristics, sports participation, patient-reported measures of functional capabilities and limitations, physical examination, diagnostic imaging results, and initial treatment plan. Descriptive statistics were completed for all outcomes of interest. Results: As of November 2020, a total of 27 orthopaedic surgeons from 17 institutions had enrolled 1004 knees with OCD, representing 903 patients (68.9% males; median age, 13.1 years; range, 6.3-25.4 years), into the prospective cohort. Lesions were located on the medial femoral condyle (66.2%), lateral femoral condyle (18.1%), trochlea (9.5%), patella (6.0%), and tibial plateau (0.2%). Most cases involved multisport athletes (68.1%), with the most common primary sport being basketball for males (27.3% of cases) and soccer for females (27.6% of cases). The median Pediatric International Knee Documentation Committee (Pedi-IKCD) score was 59.9 (IQR, 45.6-73.9), and the median Pediatric Functional Activity Brief Scale (Pedi-FABS) score was 21.0 (IQR, 5.0-28.0). Initial treatments were surgical intervention (55.4%) and activity restriction (44.0%). When surgery was performed, surgeons deemed the lesion to be stable at intraoperative assessment in 48.1% of cases. Conclusion: The multicenter ROCK group has been able to enroll the largest knee OCD cohort to date. This information is being used to further understand the pathology of OCD, including its cause, associated comorbidities, and initial presentation and symptoms. The cohort having been established is now being followed longitudinally to better define and elucidate the best treatment algorithms based on these presenting signs and symptoms.

Background: The effect of concomitant meniscal tears, and their associated treatment, on strength and functional recovery after anterior cruciate ligament reconstruction (ACLR) has not been adequately investigated in young populations. Hypothesis: Concomitant meniscal tears, treated with or without repair, would not adversely affect strength, balance, or functional hop test performance at 6 months postoperatively. Study Design: Cohort study; Level of evidence, 3. Methods: The authors retrospectively analyzed return-to-sports (RTS) assessments prospectively collected 6 months after ACLR with hamstring autograft in 165 patients ≤25 years of age. Descriptive, surgical, and RTS testing data were analyzed, and subgroups were compared using analysis of covariance models designed to assess the effects of sex, meniscal tear, and meniscal repair on RTS performance. Results: Included were 115 female (70%) and 50 male (30%) patients with a mean age of 16.4 years (range, 12.3-25 years). Of these patients, 58% had concomitant meniscal tears (59% lateral, 27% medial, 14% lateral + medial), comprising 53% of the female and 70% of the male patients. The authors treated 61% of the tears with repair, with range of motion (ROM) and weightbearing limitations imposed within the first 6 weeks postoperatively, whereas 39% were treated with partial meniscectomy, rasping, or trephination (no ROM or weightbearing restrictions). The mean deficit in hamstring strength at 6 months postoperatively was significantly greater in the meniscal tear group than in those without a tear (32.3% vs 24.6%; P = .028). The meniscal repair group had greater hamstring strength deficits than the group with meniscectomy, rasping or trephination (34.3% vs 26.2%; P = .023). Performance on dynamic balance and functional hop tests was similar among all meniscus subgroups. There were no sex-based effects on any subgroup comparisons. Conclusion: At 6 months postoperatively, both young male and young female patients who underwent ACLR with hamstring autograft demonstrated significant hamstring strength deficits compared with their nonoperative leg. The presence of a meniscal tear and subsequent repair, or its related rehabilitation restrictions, appears to have adverse effects on the postoperative recovery of hamstring strength.

Objectives: Medial epicondyle apophyseal avulsion fractures sustained during throwing represent an understudied, severe variant of medial epicondyle apophysitis, or ‘Little League elbow’. The current study sought to characterize presenting features, treatment options, and clinical results of a large cohort of pre-adolescent and adolescent patients who presented with these fractures. Methods: Skeletally immature athletes with medial epicondyle apophyseal avulsion fractures sustained during throwing from 2003-2017 at a tertiary-care pediatric referral center were identified. Exclusion criteria were fractures sustained during non-throwing activity or prior elbow fracture. Medical records and radiographic images were reviewed for study variables. Treatment decisions were made independently by fellowship-trained pediatric orthopaedic surgeons or sports medicine physicians on a case-by-case basis. Patients treated with open reduction and internal fixation (ORIF) were compared to those treated non-operatively, and all fracture patients were compared to a larger control group of patients diagnosed with medial epicondyle apophysitis/Little League elbow with no fracture. Results: During the study period, a total of 317 patients were diagnosed with Little League elbow due to medial epicondyle apophyseal overuse injury, 50 of whom (16%) sustained a discreet, radiographically confirmed epicondyle fracture sustained during a single throw. Median age of the fracture cohort at presentation was 13.1 years (range 8 years – 16 years). Forty-nine fracture patients (98%) were male baseball pitchers and one (2%) was a male football quarterback. Fracture patients had significantly higher median BMI (21.3 kg/m2 vs. 19.2kg/m2, p=0.004) than the apophysitis control group, but there was no significant difference in age. Of the 37 patients with documentation regarding pre-injury symptoms, 31 patients (84%) described pre-existing medical elbow pain prior to their acute injury, while 6 (16%) denied pain prior to the inciting throw. Of the 12 patients (24%) with documented shoulder exams at presentation, 5 (42%) demonstrated glenohumeral internal rotation deficit (GIRD). Twenty-three patients (46%) were treated with ORIF (22 single screw fixation; 1 suture anchor fixation), while 27 (54%) were treated non-operatively. Median fracture displacement was significantly greater in operative patients than non-operative patients (5.0mm vs. 3.0mm, p=Conclusions: Medial epicondyle apophyseal avulsion fractures in youth throwers represent a severe variant of Little League elbow, constituting approximately 16% of cases within the condition’s spectrum. These fractures may be effectively treated with either non-operative measures, particularly minimally displaced fractures 40% of operative patients may require implant removal. A large majority of patients reported medial elbow pain prior to fracture, suggesting this severe presentation of Little League elbow may be preventable.

Objectives: The public health opioid abuse epidemic has led to nationwide interest in judicious use and close monitoring of opioid pain medication. Knee arthroscopy(KA) and anterior cruciate ligament reconstruction(ACLR) are common procedures in adolescent patients for which narcotics have been historically utilized for post-operative pain management. The purpose of this study is to investigate pain management strategies following basic KA or ACLR by pediatric sports surgeons who contribute to a multi-center quality improvement initiative(SCORE). Methods: Surgeon participants in SCORE represent fifteen U.S. institutions from primarily academic teaching hospitals who specialize in pediatric sports medicine. Surgeons contribute all ACLR and other KA-related cases. A RedCap survey was distributed to all SCORE surgeon participants in December 2019. A KA (defined as a knee arthroscopy that does not include a ligament reconstruction or a cartilage procedure other than chondroplasty) represented a less invasive procedure, while the ACLR represented a more invasive procedure. Survey results were collected and analyzed for both practice patterns of regional anesthesia utilization and post-operative narcotic prescribing volumes. Results: Twenty-eight SCORE surgeon participants completed the survey, a 100% response rate. A planned prescription of a mean of 16.4 pain pills (range 0-40 pills) were reported for pain management following a KA, only 32.1% of surgeons reported adjunctive regional anesthesia techniques for this procedure in addition to general anesthesia. Following an ACLR, surgeons reported a planned prescription of a mean 23.8 pain pills (range 0-40 pills) and most (92.3%) reported utilization of regional anesthesia for their peri-operative analgesia strategy. Of those using adjunctive regional anesthesia, significant variability was reported: 30.7% reported indwelling catheter placement for peripheral nerve block following ACLR as opposed to a single shot injection method, and several block locations were reported to be utilized of which adductor canal (67.9%) block was the most common (see Figure 1). For both procedure types, variability in multi-modal pain management was noted, with incomplete adoption of the use of additional non-narcotic medication (acetaminophen, 64.2%; and NSAIDS, 75%). Cryotherapy devices were applied/prescribed in 75.0% of knee arthroscopy procedures and 92.8% of ACLR. Conclusions: Despite evidence for effective adjunctive pain management strategies, incomplete adoption of multi-modal techniques and reliance on narcotic medication remains a significant component of pediatric sports surgical practice; with on average > 15 pills prescribed following these procedures. Opportunities for reducing practice variability, adoption of multi-modal analgesia strategies, and decreasing post-operative narcotic use following common adolescent knee procedures exist for this subset of pediatric sports medicine specialists

Research has demonstrated similar efficacy of drill epiphysiodesis and percutaneous epiphysiodesis using transphyseal screws for the management of adolescent leg length discrepancy. A cost analysis was performed to determine which procedure is more cost-effective. Patients seen for epiphysiodesis of the distal femur and/or proximal tibia and fibula between 2004 and 2017 were reviewed. A decision analysis model was used to compare costs. Two hundred thirty-five patients who underwent either drill (155/235, 66%) or screw (80/235, 34%) epiphysiodesis were analyzed with an average age at initial procedure of 13 years (range, 8.4 to 16.7 years). There was no significant difference in average initial procedure cost or total cost of all procedures across treatment groups (n = 184). The cost difference between drill and screw epiphysiodesis is minimal. In order for screw epiphysiodesis to be cost-favored, there would need to be a significant decrease in its cost or complication rate. (Journal of Surgical Orthopaedic Advances 30(3):181-184, 2021).

To evaluate the interrater reliability of several common radiologic parameters used for patellofemoral instability and to attempt to improve reliability for measurements demonstrating unacceptable interrater reliability through consensus training.Fifty patients with patellar instability between the ages of 10 and 19 years were selected from a prospectively enrolled cohort. For measurements demonstrating unacceptable interrater reliability (intraclass correlation coefficient [ICC]:0.6), raters discussed consensus methods to improve reliability and re-examined a subset of 20 images from the previous set of images. If reliability was still low after the second round of assessment, the measure was considered unreliable.Of the 50 included subjects, 22 (44%) were male and the mean age at the time of imaging was 14 ± 2 years. With 1 or fewer consensus training sessions, the interrater reliability of the following radiograph indices were found to be reliable: trochlea crossing sign (ICC: 0.625), congruence angle (ICC: 0.768), Caton-Deshamps index (ICC: 0.644), lateral patellofemoral angle (ICC: 0.768), and mechanical axis deviation on hip-to-ankle alignment radiographs (ICC: 0.665-0.777). Reliable magnetic resonance imaging (MRI) indices were trochlear depth (ICC: 0.743), trochlear bump (ICC: 0.861), sulcus angle (ICC: 0.684), patellar tilt (ICC: 0.841), tibial tubercle to trochlear groove distance (ICC: 0.706), effusion (ICC: 0.866), and bone marrow edema (ICC: 0.961).With 1 or fewer consensus training sessions, the interrater reliability of the following patellofemoral indices were found to be reliable for trochlear morphology: trochlea crossing sign and congruence angle on radiograph and trochlear depth, trochlear bump, and sulcus angle on MRI. Reliable patellar position measurements included: Caton-Deshamps index and lateral patellofemoral angle on radiograph and patellar tilt and tibial tubercle to trochlear groove distance on MRI. Additional global measurements (e.g., mechanical axis deviation on standing radiographs) and MRI assessments demonstrated acceptable reliability.II, prospective diagnostic study.

Background: Anterior cruciate ligament (ACL) injuries demand individualized treatments based on an accurate estimation of the child’s skeletal age. Wrist radiographs, which have traditionally been used to determine skeletal age, have a number of limitations, including cost, radiation exposure, and inconvenience. Purpose: To evaluate the reliability and validity of a radiographic staging system using tibial apophyseal landmarks as hypothetical proxies for skeletal age to use in the preoperative management of pediatric ACL tears. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: The study included children younger than 16 years of age who underwent ACL reconstruction between July 2008 and July 2018 and received both skeletal age radiography and knee radiography within 3 months of each other. Skeletal age was calculated from hand and wrist radiographs using the Greulich and Pyle atlas. Tibial apophyseal staging was categorized into 4 stages: cartilaginous stage (stage 1), apophyseal stage (stage 2), epiphyseal stage (stage 3), and bony/fused stage (stage 4). Data were collected by 2 independent assessors. The analysis was repeated 1 month later with the same assessors. We calculated descriptive statistics, measures of agreement, and the correlation between skeletal age and apophyseal stage. Results: The mean chronological age of the 287 patients included in the analysis was 12.9 ± 1.9 years; 164 (57%) of the patients were male. The overall Spearman r between skeletal age and tibial apophyseal staging was 0.69 (0.77 in males; 0.60 in females). The interrater reliability for the tibial apophyseal staging was substantial (Cohen κ = 0.66), and the intrarater reliability was excellent (Cohen κ = 0.82). The interrater reliability for skeletal age was excellent (intraclass correlation coefficient [ICC] = 0.93), as was the intrarater reliability (ICC = 0.97). Conclusion: The observed correlation between skeletal age and tibial apophyseal staging as well as observed intra- and interrater reliabilities demonstrated that tibial apophyseal landmarks on knee radiographs may be used to estimate skeletal age. This study supports the validity of knee radiographs in determining skeletal age and provides early evidence in certain clinical presentations to simplify the diagnostic workup and operative management of pediatric knee injuries, including ACL tears.

Purpose: There has been a recent shift towards operative management of mid-shaft clavicle fractures in adults and adolescents. This has been largely based on studies in the adult population that showed reduced rates of nonunion, symptomatic malunion and better short-term functional outcomes. For injuries with a comminuted “Z-type” fracture pattern, characterized by vertical positioning of a segmental fragment, it is commonly accepted to treat surgically due to concerns about healing and bony prominence. The purpose of this study was to assess the clinical, radiographic, and patient-reported outcome measures (PROs) in adolescents with comminuted Z-type mid-shaft clavicle fractures by comparing an operative and nonoperative cohort. Methods: Patients aged 10 to 18 years treated for a diaphyseal clavicle fracture between August 2013 and February 2016 at one of eight geographically diverse pediatric centers were screened and enrolled at the time of injury. Inclusion criteria were a comminuted Z-type fragment ≥1cm in size, with >35 degrees of angulation relative to the long axis of the clavicle, and >100% fracture displacement at time of presentation. Clinical course, complications, validated PROs, quality of life metrics, and satisfaction scores were analyzed and compared between the operative (Op) and nonoperative (NonOp) cohorts. Results: Eighty-two patients (37 NonOp, 45 Op) were included, 60 (73%) of whom provided 2-year PROs with similar response rates between treatment cohorts. There were no significant differences in demographics or fracture characteristics in the two cohorts other than fracture shortening being greater in the operative cohort (mean 29mm) compared to the nonoperative cohort (mean 23mm, p=0.01). This confounder was controlled for in both regression analysis and propensity score matching. There was no statistically significant difference in the rates of nonunion (none), delayed union (Op 2%, NonOp 0%, p=1.0), symptomatic malunion (Op 0%, NonOp 3%, p=0.4), refracture (Op 4%, NonOp 3%, p=1.0), unexpected surgery (Op 11% vs. NonOp 5%, p=0.45), or clinically significant complications (Op 16%, NonOp 5%, p=0.17) between cohorts. There were no differences in PROs (Table 1), even when controlling for fracture shortening. Conclusions: Z-type mid-shaft clavicle fractures are one of the most severe fracture patterns seen in adolescent shoulders. Yet, in this comparative investigation of 2-year PROs and complications, surgery appears to offer no benefit over nonoperative management. Significance: The comparable natural histories between this study’s operative and nonoperative cohorts are critical for surgeons and their adolescent patients to understand when deciding appropriate management, particularly when reviewing what are often very concerning appearing initial radiographs.

Context: Recent epidemiology studies indicated a steady increase of anterior cruciate ligament (ACL) injury in young athletes. ACL reconstruction (ACLR) is currently a standard of care, but the eff...

The etiology of hip pain in pediatric and adolescent patients can be unclear. Osteoid osteoma (OO) about the hip in children has only been described in case reports or small studies. The present study assessed the clinical presentation and diagnostic course, imaging, and treatment approaches in a large cohort of pediatric cases of OO about the hip.Medical record and imaging results were reviewed for all cases of OO identified within or around the hip joint in patients20 years old between January 1, 2003, and December 31, 2015, at a tertiary-care pediatric center. Demographic, clinical, and radiographic data were analyzed.Fifty children and adolescents (52% female; mean age, 12.4 years; age range, 3 to 19 years) were identified. Night pain (90%) and symptom relief with nonsteroidal anti-inflammatory drugs (NSAIDs) (88%) were common clinical findings. Sclerosis/cortical thickening was visible in 58% of radiographs, although a radiolucent nidus was visible in only 42%. Diagnostic imaging findings included perilesional edema and a radiolucent nidus on 100% of available magnetic resonance imaging (MRI) and computed tomography (CT) scans, respectively. Initial alternative diagnoses were given in 23 cases (46%), the most common of which was femoroacetabular impingement (FAI). Delay in diagnosis of6 months occurred in 43% of patients. Three patients underwent operative procedures for other hip diagnoses, but all had persistent postoperative pain until the OO was treated. Of the 41 patients (82%) who ultimately underwent radiofrequency ablation (RFA), 38 (93%) achieved complete post-RFA symptom resolution.Initial misdiagnosis, the most common of which was FAI, and delayed correct diagnosis are common in pediatric OO about the hip. Presenting complaints were variable and nonspecific MRI findings were frequent. Night pain and relief with NSAIDs were present in the vast majority of cases. CT scans provided definitive diagnosis in all patients who received them. As increasing numbers of young, active patients are being evaluated for various causes of hip pain, such as FAI, OO should not be overlooked in the differential diagnosis.Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The frequency of knee arthroscopy procedures is increasing in pediatric and adolescent patients. In general, complications after these procedures in adolescents are uncommon. The purposes of this study are to report the incidence of venous thromboembolism (VTE) in adolescent patients after knee arthroscopy procedures, as well identify risk factors in this patient population.Medical records were reviewed in all pediatric and adolescent patients (≤19 y) who underwent an arthroscopic knee procedure from 2010 to 2014 and were diagnosed with a symptomatic VTE in the postoperative period. Demographic features were recorded, and included age, sex, body mass index, clinical characteristics (diagnosis, type of surgical intervention, tourniquet time), VTE risk factors [family history of VTE, obesity (body mass index30), oral contraceptive use, and smoking use/exposure] and treatment (anticoagulation type/duration).Out of 2783 patients who underwent knee arthroscopy during the 5-year study period, 7 patients (3 males, 4 females, mean age, 16.9 y, range, 15 to 18) developed a symptomatic postoperative VTE (incidence, 0.25%, 95% confidence interval, 0.11%-0.54%). There were 6 unilateral deep venous thrombosis, and 1 bilateral deep venous thrombosis. Arthroscopic procedures performed in this cohort included anterior cruciate ligament reconstruction (3), isolated lateral release (1), meniscectomy (2), and patellar realignment with arthroscopic lateral release, open tibial tubercle osteotomy, and open proximal medial retinacular reefing (1). VTE was diagnosed an average of 9 days following surgery (range, 3 to 16). All patients were initially treated with low-molecular-weight heparin, and 2 were converted to warfarin. Mean duration of anticoagulation treatment was 64 days (range, 28 to 183). All patients had at least 1 identifiable medical or surgical risk factor, including oral contraceptive use (2), smoking (2), obesity (2), an arthroscopically assisted open procedure (4), or tourniquet time60 minutes (3).VTE after adolescent knee arthroscopy has not been well described. The incidence is ∼0.25%. Previously established risk factors for VTE were present in 100% of the affected population. Low-molecular-weight heparin was used to successfully treat this complication.Level IV.

Background: Adolescent dancers may be a high-risk population for patellofemoral instability (PFI), but the condition remains under-investigated, to date, in this sub-group of athletes. Purpose: The purpose of this study was to (1) investigate the descriptive epidemiology of PFI in adolescent dancers, (2) analyze the efficacy of various patellar stabilization procedures within this population, and (3) compare PFI in dancers to a larger control group of matched, non-dancer athletes. Methods: A retrospective review of athletes, ages 10 to 19, who presented to a single tertiary care center with PFI between 2008 and 2017 was performed. Based on each patient’s primary sport, the cohort was divided into a dancer and a non-dancer control group. Demographics, clinical and radiologic features, surgical stabilization technique, and postoperative course and clinical outcomes were collected. Independent categorical groups were tested using chi squared and Fisher exact tests. Results: 258 adolescent athletes were included, 41 of whom were dancers, all females. This group was therefore matched with a control group of similarly aged, all-female athletes with PFI (Table 1). 54 athletes had bilateral PFI, yielding 285 knees for analysis. There was no difference between dancer and non-dancer athletes’ age, BMI, laterality, mechanism of injury, nor number of preoperative instability events. However, dancers had lower Dejour Classifications (p=0.044), smaller patella inclination angles (20.9±8.14 versus 25.0±9.84; p=0.004), and smaller Caton-Deschamps Indices (1.18±0.161 versus 1.25±0.189; p=0.041). Among dancers, there was no association between surgical stabilization technique and rates of recurrent instability (p=0.418) nor re-stabilization procedures (p=1.0) (Table 2). However, dancers who underwent tibial tubercle osteotomy (TTO) had higher rates of subsequent, non-stabilization procedures (66.7%), all for implant removal, compared to those undergoing isolated medial retinacular repairs (MRP) (3.8%) (pConclusions: Female dancers with PFI have similar demographic and clinical features as other female athletes with PFI, but have lower rates or less severe trochlear dysplasia, lateral tilt and patella alta. Therefore, the ligamentous laxity inherent in dancers may be a more powerful risk factor for PFI than other non-modifiable risk factors. Notably, the TTO was a powerful stabilization procedure for this sub-population with low rates of recurrent instability episodes and no revision stabilization procedures performed. Rates of implant removal surgery following TTO may be substantial, though this may be technique or surgeon dependent. Tables/Figures: [Table: see text][Table: see text]

Background: As participation and specialization in youth sports has increased, so too has the incidence of overuse conditions, such as medial epicondyle apophysitis, or Little League Elbow (LLE). Hypothesis/ Purpose: The study purpose was to assess the demographic features, clinical presentation, management, and outcomes of a population of skeletally immature athletes with this increasingly common, but understudied, condition. Methods: A retrospective analysis was performed of patients diagnosed with LLE between 2003 and 2017 at a tertiary-care pediatric hospital. All patients had open apophyses with a clinical history of repetitive overhead athletic activity and radiographic and/or physical exam findings consistent with LLE. Study variables were derived from the electronic medical record. Results: Three hundred seventeen subjects (mean age: 12.8 years, range 8yrs – 16yrs; 310 males, 98%) were identified. The vast majority were baseball players (n=310, 98%), though there were several tennis players (n=4, 1%) and football quarterbacks (n=3, 1%). Two-hundred sixty-eight patients (85%) presented with apophysitis, while 49 (15%) presented with acute avulsion fractures from throwing (with 84% reporting preceding medial elbow pain). The acute fracture patients are the subject of a separate study. In the apophysitis cohort, all of whom presented with medial elbow pain, other presenting findings/symptoms included decreased elbow range of motion (16%) and concomitant ipsilateral shoulder pain (13%). Amongst those with documented shoulder exams, a majority (55%) demonstrated glenohumeral internal rotation deficit (GIRD) with a significantly longer time from diagnosis to resolution of symptoms (p=0.025). All apophysitis patients were treated with rest (complete cessation 75%, relative rest/position change 25%). Mean follow up was 32 months (sd 33 months). Return to sports occurred at a median of 12 weeks from diagnosis (IQR 7wks – 18wks). Recurrence of elbow pain occurred a median of 24 months (IQR 11mo - 43mo) following initial diagnosis in 13% of patients, a sub-cohort with significantly longer duration of symptoms prior to index presentation (p=0.024). One patient also suffered a subsequent medial epicondylar avulsion fracture while throwing in the setting of non-compliance with recommended rest. Conclusion: Little League Elbow is most commonly seen in adolescent and pre-adolescent male pitchers but may rarely be seen in other overhead athletic sub-populations. Careful evaluation of the entire kinetic chain is critical to identify concomitant pathology such as GIRD, which may portend a prolonged recovery. Proper treatment is necessary to minimize recurrence and development of epicondyle avulsion fractures, which represent a potentially preventable, but severe variant of LLE.

Background: The most common presentation of knee osteochondritis dissecans (OCD) is a stable lesion on the lateral aspect of the medial femoral condyle (MFC) in an adolescent or pre-adolescent athlete. Standard of care for conservative treatment, include activity modification and weight bearing protection. Failed conservative management often leads arthroscopy and drilling of the lesion. Two different primary drilling techniques have been utilized, but no prospective studies have compared their relative effectiveness. Hypothesis/Purpose: The study hypothesis was that trans-articular (TAD) and retro-articular drilling (RAD) would demonstrate similar rates of healing, times to return to sports, and patient-reported outcome scores (PROs). Methods: Skeletally immature (n=113) patients presenting with radiograph indicated stable OCD of the MFC who did not demonstrate healing despite a minimum of 3 months of non-operative treatment were prospectively enrolled and randomized to TAD or RAD, for which 17 surgeon-investigators (at 14 centers, representing all major regions in the U.S.). Serial radiographs were obtained every 6 weeks to assess healing, and PROs were obtained at 6 months, 12 months, and 24 months. Twelve patients were due to lesion instability detected at the time of surgery, Results: Ninety-one study subjects were included, consisting of 51 TAD and 40 RAD patients, with the two groups being of similar age (12.6 years vs. 11.9 years), sex distribution (45% vs. 27% female, p=0.081), and 2-year PRO response rate (both 90%). No significant difference between TAD and RAD was detected in follow-up Pedi-IKDC, Lysholm, Marx knee activity score, or KOOS QOL scores (Table 1). Revision/additional OCD surgery occurred in 10% of patients in RAD and 4% in TAD. 71% of TAD patients reached a ‘healed’ status at a mean of 1.15 years, compared with 58% RAD patients at a mean of 1.06 years. Conclusion: While both primary forms of OCD drilling (TAD and RAD) showed consistent post-operative healing, achieving a completely ‘healed’ status was often a more prolonged process, taking approximately 1 year, despite clinical improvement being achieved much sooner. While PROs were similar between drilling techniques, revision surgery rates were more than twice as common with RAD compared with TAD but the overall risk was low and the Absolute Risk was only 6%. [Table: see text]

Acknowledgements: The authors would like to acknowledge Drs. Matthew Milewski, Yi-Meng Yen, and Adam Yanke for their contributions. Background: Surgical decision-making and pre-operative planning for children and adolescents with patellofemoral instability relies heavily on skeletal maturity status. In order to be clinically useful, radiologic assessments of skeletal maturity must demonstrate acceptable interrater reliability and accuracy. Purpose: The purpose of this study was to evaluate the interrater reliability among surgeons of varying experience levels and specialty training backgrounds when evaluating skeletal maturity in the distal femur and proximal tibia of children and adolescents with patellofemoral instability. Study Design: Cross-sectional study Methods: Six fellowship-trained orthopedic surgeons (4 pediatric orthopedic, 2 sports medicine) who perform a high volume of patellofemoral instability surgery examined 20 blinded and randomized knee radiographs and MR images. They assessed these images for clinically relevant growth (open physis) or clinically insignificant growth (closing/closed physis) remaining in the distal femoral and proximal tibial physes. Fleiss’s kappa was calculated for each measurement. After initial ratings, raters discussed consensus methods to improve reliability and assessed the images again in order to determine if training and new criteria improved interrater reliability. Results: Reliability for initial assessments of distal femoral and proximal tibial physeal status was poor (Kappa range: 0.01 – 0.58). After consensus building, all assessments demonstrated almost perfect interrater reliability (Kappa = 0.99 for all measurements). Conclusion: Surgical decision-making and pre-operative planning for children and adolescents with patellofemoral instability relies heavily on radiologic assessment of skeletal maturity. This study found that initial interrater reliability of physeal status and clinical decision making was unacceptably low. However, with the addition of new criteria, a consensus-building process, and training, these variables became highly reliable. Clinical Relevance: Lack of assessment reliability can jeopardize patient care, both when determining surgical indications as well as choosing an appropriate procedure based upon skeletal maturity. Surgeons should focus on using reliable imaging metrics in children and adolescents with patellofemoral instability, and measurements that remain unreliable after consensus building and training should be removed from clinical decision-making algorithms. What is known about the subject: Treatment of patellofemoral instability heavily relies on skeletal maturity status. Physeal assessments of the knee must be reliable and clinically relevant to ensure optimal patient care. What this study adds to existing knowledge: Physeal assessment of the knee without training can be unreliable among fellowship trained orthopedic surgeons. With consensus building and training in the use of the methods described in this manuscript, physeal assessments can demonstrate almost perfect reliability.

Objectives: Quadriceps tendon (QT) autograft has emerged as an increasingly popular soft tissue graft alternative to the hamstring tendon (HS) autograph for ACL reconstruction (ACLR). However, utilization of the technique is not yet widespread, particularly in the population of adolescent athletes, for whom safety and effectiveness of the technique remains under-investigated, despite this being the most affected epidemiologic sub-population, with regard to primary ACL injury, post-ACLR re-tear, and overall complications. The study hypothesis was that QT-ACLR would have equivalent or lower rates of perioperative complications and early ACL re-tear than historically reported for HS ACLR. Methods: A retrospective review of all 12-19 year-old athletes who underwent primary QT-ACLR by a single surgeon at a tertiary care pediatric hospital were included, with prospective outreach performed at 1 and 2 years to collect PROs and confirm absence of ACL re-tear or revision surgery. Patients with Results: 90 patients (93 knees, 70% female) were included, with a mean age of 16.0 years (±1.85) and mean follow up of 12.6 months (IQR 9.1-21.4). Concomitant meniscal pathology was detected in more than half of patients, with 30% undergoing meniscal repair and 27% partial meniscectomy. There were 51 complications overall in 36 knees (39%, Table 1). Secondary surgery for a complication was performed in 22 knees (24%), most commonly for a cyclops lesion/arthrofibrosis (15%), but also for revision ACLR (5%) and removal of implants (1%). Of note, 6 additional knees (6%) were diagnosed by MRI for a cyclops lesion/arthrofibrosis, but were successfully treated with non-operative measures, including physical therapy, dynamic splinting, and/or intra-articular cortisone injections. ACL graft tear was more common in the first 25 knees for whom QT-ACLR was performed (16% vs. 1%, p=0.02), indicating that initial re-tear could be a function of the surgical learning curve and technique adjustments. Early graft tear rate of 5% is similar to reported rates in HS autograft in adolescents. Arthrosibrosis/cyclops lesions were more frequently observed than historically reported for other graft types, and were not significantly different based on learning curve (20% vs. 22%, p=1.00). Pedi-IKDC (Table 2) showed significant improvement from baseline to 6-month (pConclusions: Quad tendon ACLR shows a relatively high overall early post-operative complication and subsequent surgery rate in adolescents, most notably cyclops lesions/arthrofibrosis, most cases of which underwent arthroscopic debridement/LOA. This is consistent with previous adult QT-ACLR studies. Graft tear rates at 1-year post-operatively are similar to historically reported re-tear rates of the HS ACLR for adolescents, with a higher re-tear rate in the earlier sub-cohort, which may relate to surgical learning curve. Continued research into minimizing risks and quantifying longer term ACL re-tear risk will be critical for this young, active population, who are increasingly undergoing ACLR with the QT autograft, which remains relatively understudied, particularly in the adolescent sub-population.

Objectives: Operative management of clavicle fractures is increasingly advocated for athletes and young adults. Surgical indications and optimal treatment for comminuted or severely shortened clavicle fractures in adolescent athletes remain unclear. The purpose of this study was to evaluate the outcomes of non-operatively and operatively treated comminuted and/or severely shortened (>25mm) clavicle fractures in older adolescent athletes. Methods: Athletes aged 14 to 18 years with mid-shaft clavicle fractures who had non-operative (NONOP) or operative (OP) treatment at one of eight participating centers between 2013 and 2017 were screened for the presence of comminution and/or fracture shortening >25mm. Demographics, injury mechanism, fracture characteristics and treatment (NONOP vs. OP) were prospectively recorded and patients followed for a minimum of two years. Complications, rates and timing of return to sport (RTS), and patient reported outcomes (PROs: ASES, QuickDASH, MARX shoulder activity, EQ-5D, EQ-VAS, and patient satisfaction) were analyzed. Results: The two groups included 137 patients (70 NONOP, 67 OP), with a similar distribution among various sports—most commonly football—and rates of competitive athletic participation (NONOP: 81%, OP: 85%) (Figure 1). Of the 137 patients, 100 [NONOP n=52, 15.3 years, 44 males (84.6%); OP n= 48, 15.5 years, 40 males (83.3%)] provided PROs at > 2 years. Comminution (C) and shortening (S) were not different between groups [NONOP C=24 (46.2%), S=28mm (24.5, 33.2); OP C=35 (72.9%), S=28mm (25.0, 36.5)], but the OP group demonstrated 3 mm greater vertical displacement [NONOP 13.0 (9.6, 18.0) mm, OP 16.0 (11.8, 21.0) mm; pConclusions: In this prospective multi-center cohort of comminuted and/or severely shortened (>25mm) clavicle fractures in adolescent athletes, there was no difference in complications, RTS, or PROs between non-operatively and operatively treated patients at 2 years. Despite several studies suggesting the contrary in adult populations, comparably excellent outcomes of severe clavicle fractures in adolescent athletes can be achieved with non-operative treatment.

Background: Historically, the most commonly utilized technique to address recurrent patellofemoral instability (PFI) was a combined proximal and distal realignment, specifically the tibial tubercle osteotomy (TTO) with a proximal medial retinacular plication/reefing/tightening/repair (MRP). Rising interest in the medial patellofemoral ligament reconstruction (MPFLR) over the last decade, now frequently performed as a more powerful isolated proximal realignment procedure, has prompted debate over the optimal technique to treat this common condition. Hypothesis/Purpose: The study hypothesis was that no difference would be detected in recurrent PFI rates or revision surgery rates between patients who underwent TTO-MRP vs. MPFLR. Methods: With cohorts derived from a large, single-center PFI database of 523 patients who underwent a variety of stabilization procedures, 114 eligible MPFLR patients were matched to 109 TTO patients based on age, gender, BMI, and TT-TG distance. Propensity score matching was conducted using logistic regression models to produce 1:1 matching, and a caliper of 0.2 standard deviations of the estimated propensity score was used to for the nearest neighbor matching algorithm. Final matching procedure resulted in 84 MPFLR patients and 84 TTO patients. These were compared on demographics and post-operative clinical results. Results: Demographic and radiologic comparisons of the cohorts are shown in Table 1, with the only difference between groups being an expected higher rate of patients with open physes in the MPFLR cohort. Table 2 shows the TTO-MRP group had longer follow up times, but comparable rates of return to sports. The MPFLR group had a higher rate of recurrent instability, but not to a significant degree, and a significantly higher incidence of revision patellar stabilization surgery (pConclusion: The TTO-MRP shows equivalent or superior results to the MPFLR for treatment of PFI. However, implant removal may be common with TTO, though this may be somewhat technique-dependent. In the current landscape of increasing interest and utilization of MPFLR as an all-encompassing PFI surgery, the influence of distal bony realignment to minimize recurrence should not be underappreciated. Tables/Figures: [Table: see text][Table: see text]

Objectives: The most common presentation of knee osteochondritis dissecans (OCD) is a stable lesion on the lateral aspect of the medial femoral condyle (MFC) in an adolescent or pre-adolescent athlete. The standard of care for primary treatment is non-operative, and includes rest/activity modification and often weight bearing protection or bracing. Failed conservative management often leads arthroscopy and drilling of the lesion. Two different primary drilling techniques have been utilized, but no prospective studies have compared their relative effectiveness. The study hypothesis was that retro-articular drilling (RAD), the slightly newer technique, would not be inferior to trans-articular (TAD), with regard to rate of healing, time to return to sports (RTS), and patient-reported outcome scores (PROs). Methods: Skeletally immature (n=113) patients presenting with MRI-confirmed stable OCD of the MFC who did not demonstrate substantial healing after a minimum of 3 months of non-operative treatment were prospectively enrolled by one of seventeen surgeon-investigators (at 14 centers, representing all major geographic regions in the U.S.) and randomized to TAD or RAD. Post-operatively, serial radiographs were obtained every 6 weeks to assess healing, and PROs were obtained at 6 months, 12 months, and 24 months. Twelve patients were closed out at time of surgery due to lesion instability detected during arthroscopy. Power analysis determined that in order to detect a difference in 2-year IKDC score between RA and TA groups with 80% power, sample sizes of 37 subjects per group would be required if the true standard deviation were 15. This analysis was based on conducting an independent samples Student’s t-test with alpha set to 5%. Results: Ninety-one study subjects were included, consisting of 51 TAD and 40 RAD patients, respectively, with the two groups being similar in age (12.6 years vs. 11.9 years), sex distribution (45% vs. 27% female, p=0.081), and 2-year PRO response rate (both 90%). No significant differences between TAD and RAD were detected in follow-up Pedi-IKDC, Lysholm, Marx knee activity score, or KOOS QOL scores (Table 1). Revision/additional OCD surgery occurred in 10% of patients in RAD and 4% in TAD (p=0.40). 73% of TAD patients reached a ‘healed’ status at a mean of 1.15 years, compared with 60% RAD patients at a mean of 1.21 years. Conclusions: While both primary forms of OCD drilling (TAD and RAD) showed consistent post-operative healing, achieving a completely ‘healed’ status was often a more prolonged process, taking approximately 1 year, despite clinical improvement and RTS being achieved much sooner. PROs were similar between drilling techniques. Significantly higher powered studies are needed to better elucidate the greater revision surgery rates in RAD compared with TAD, but overall risk is low and absolute risk only 6%. The current data support either drilling technique, which may be technically simpler, without the need for fluoroscopy, with TAD, and may be more protective of the chondral articular surface with RAD.

BACKGROUND The prevalence of venous thromboembolism (VTE) may be increasing in children; however, scarce literature exists comparing incidence rates between pediatric orthopaedic patients and other pediatric patients. The purpose of this study was to compare the incidence, anatomic locations, and risk factors of VTEs between orthopaedic and nonorthopaedic pediatric related patients to determine if important differences exist. METHODS Computed tomography and ultrasound data were reviewed for children (below 19 y old) with a diagnosed VTE between January 1, 2009 and December 31, 2016. Demographic and clinical data, including VTE anatomic location and risk factors, were recorded. Two major cohorts were identified: orthopaedic-related (ORTH) and nonorthopaedic-related (NORTH) VTEs. Incidence rates were estimated and risk factors were compared using χ2 testing. RESULTS There were 373 children diagnosed with a VTE (average age 10.3 y) of a total of 810,097 treated as in-patients for an incidence rate of 4.60 per 10,000 cases (95% confidence interval=4.15 to 5.10 per 10,000 cases). The rate of ORTH VTEs (28 of 188,669 orthopaedic patients, 1.48 per 10,000 cases) was significantly lower than that of NORTH VTEs (345 of 621,428 nonorthopaedic patients, 5.55 per 10,000 cases; P

Solitary osteochondromas, or osteocartilaginous exostoses (OCEs), represent the most common benign bone tumor. Despite frequently causing symptoms about the knee in younger populations, there is minimal previous literature investigating surgical treatment.We retrospectively reviewed the records of patients20 years old who had undergone surgical treatment of symptomatic, pathologically confirmed, solitary periarticular knee OCE at a single pediatric center between 2003 and 2016. The clinical course, radiographic and pathological features, and complications were assessed. Prospective outreach was performed to investigate patient-reported functional outcomes.Two hundred and sixty-four patients (58% male, 81% athletes) underwent excision of a solitary OCE about the knee at a mean age (and standard deviation) of 14.3 ± 2.24 years. Fifty-five percent of the procedures were performed by orthopaedic oncologists, 25% were performed by pediatric orthopaedic surgeons, and 20% were performed by pediatric orthopaedic sports medicine surgeons, with no difference in outcomes or complications based on training. Of the 264 lesions, 171 (65%) were pedunculated (versus sessile), 157 (59%) were in the distal part of the femur (versus the proximal part of the tibia or proximal part of the fibula), and 182 (69%) were medial (versus lateral). Postoperatively, 96% of the patients returned to sports at a median of 2.5 months (interquartile range, 1.9 to 4.0 months). Forty-two patients (16%) experienced minor complications not requiring operative intervention. Six patients (2%) experienced major complications (symptoms or disability at6 months or requiring reoperation), which were more common in patients with sessile osteochondromas (p = 0.01), younger age (p = 0.01), and distal femoral lesions as compared with proximal tibial lesions (p = 0.003). Lesion recurrence was identified in 3 patients (1.1%). Overall, the median Pediatric International Knee Documentation Committee (Pedi-IKDC) and mean Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS) scores were 97 (interquartile range, 93 to 99) and 16.7 ± 8.15, respectively, at a median duration of follow-up of 5.8 years.In our large cohort of pediatric patients who underwent excision of solitary knee osteochondromas, most patients were male adolescent athletes. Most commonly, the lesions were pedunculated, were located in the distal part of the femur, and arose from the medial aspect of the knee. Regardless of surgeon training or lesion location, patients demonstrated excellent functional outcomes, with minimal clinically important postoperative complications and recurrences, although patients with sessile lesions and younger age may be at higher risk for complications.Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background:Differences in postoperative recovery after anterior cruciate ligament reconstruction (ACLR) between men and women have been demonstrated in the adult population. Sex-based differences have been incompletely investigated in adolescents, which represent the subpopulation most affected by ACL injury.Purpose/Hypothesis:The purpose of this study was to compare the 6-month postoperative functional recovery after ACLR between adolescent boys and girls. It was hypothesized that significant differences in postoperative strength, dynamic balance, and functional hop test performance would be seen between the sexes.Study Design:Cohort study; Level of evidence, 3.Methods:Included in this study were athletes aged 12 to 19 years with closed or closing growth plates who underwent ACLR with hamstring autograft between May 2014 and May 2018 at a single institution. All athletes had undergone strength and functional testing between 5 and 8 months postoperatively. Exclusion criteria were previous knee surgery (contralateral or ipsilateral knee), concomitant injury/surgery other than meniscal tear/repair, allograft supplementation, and incomplete medical records. The limb symmetry index (LSI) for strength (measured with handheld dynamometer), as well as dynamic Y-balance and functional hop test performance, was compared between groups. To account for differences in physical characteristics between the sexes, 1-way between-group multivariate analysis of covariance was used to analyze the data.Results:Overall, 543 patients (211 boys, 332 girls) were included. There was no significant difference in age, body mass index, incidence of concomitant meniscal pathology, use of regional anesthesia, or time to functional testing between cohorts. Female athletes demonstrated a statistically significantly greater deficit in quadriceps strength LSI compared with male athletes (boys, +3.4%; girls, –2.3%; P = .011). Both male and female athletes demonstrated 33% hamstring strength deficits, with no statistically significant sex-based differences in dynamic balance or functional hop testing.Conclusion:Female athletes demonstrated greater quadriceps strength deficits than male athletes at 6 months after ACLR with hamstring autograft. Severe hamstring strength deficits persisted in both male and female patients at this time point. The correlation of such deficits to risk of ACL retear warrants continued study in the adolescent population and may support a delay in return to sports, which has been suggested in the more recent literature.

Background: Growth disturbance is an uncommon but potentially serious complication after anterior cruciate ligament (ACL) reconstruction in skeletally immature patients. Purpose: To describe how the pediatric ACL literature has assessed preoperative skeletal maturity and the amount of growth remaining and to comprehensively review the incidence, reporting, and monitoring of postoperative growth disturbance. Study Design: Systematic review; Level of evidence, 4. Methods: This review included studies reporting original research of clinical outcomes of skeletally immature patients after ACL reconstruction. Patient characteristics, surgical techniques, preoperative assessments of skeletal maturity or growth remaining, and postoperative assessments of growth disturbances were extracted. Results: A total of 100 studies met inclusion criteria. All studies reported chronological age, and 28 studies (28%) assessed skeletal age. A total of 44 studies (44%) used Tanner staging, and 12 studies (12%) obtained standing hip-to-ankle radiographs preoperatively. In total, 42 patients (2.1%) demonstrated a leg length discrepancy (LLD) >10 mm postoperatively, including 9 patients (0.5%) with LLD >20 mm; furthermore, 11 patients (0.6%) with LLD underwent growth modulation. Shortening was the most common deformity overall, but overgrowth was reported more frequently in patients who had undergone all-epiphyseal techniques. Most LLDs involved the femur (83%). A total of 26 patients (1.3%) demonstrated a postoperative angular deformity ≥5°, and 9 of these patients underwent growth modulation. The most common deformities were femoral valgus (41%), tibial recurvatum (33%), and tibial varus (22%). Although standing hip-to-ankle radiographs were the most common radiographic assessment of growth disturbance, most studies inadequately reported the clinical and radiographic methods of assessment for growth disturbance. Additionally, only 35% of studies explicitly followed patients to skeletal maturity. Conclusion: This systematic review described significant variability in the reporting and monitoring of growth-related complications after ACL reconstruction in skeletally immature patients. The incidence of LLD and angular deformity appeared to be low, but the quality of research was not comprehensive enough for accurate assessment. Registration: CRD42019136059 (PROSPERO)

Background/Purpose: The prevalence of venous thromboembolism (VTE) may be increasing in children; however, scarce literature exists comparing incidence rates between pediatric orthopaedic patients and other pediatric patients. The purpose of this study was to compare the incidence, anatomic locations, and risk factors of VTEs between orthopaedic and non-orthopaedic related pediatric patients. Methods: Computed tomography and ultrasound data were reviewed for children (

Background/Purpose: Medial epicondyle apophyseal avulsion fractures sustained during throwing represent an understudied, severe variant of medial epicondyle apophysitis, or ‘Little League elbow’. The study sought to characterize presenting features, treatment options, and clinical results of a large cohort of these fractures. Methods: Skeletally immature athletes with medial epicondyle apophyseal avulsion fractures sustained during throwing from 2003-2017 at a tertiary-care pediatric referral center were identified. Exclusion criteria were injuries sustained during non-throwing trauma or prior elbow fracture. Medical records and radiographic images were reviewed for study variables. Treatment decisions were made independently …

Background: Distal clavicle fractures account for a significant proportion of clavicle fractures in the pediatric and adolescent age groups, but clinical decision making to date has largely been informed by adult studies. However, surgical treatment in this younger population may have unique technical and clinical considerations, due to distinct fracture patterns, increased healing potential and periosteal thickness. Hypothesis/Purpose: The objective of this study was to characterize distal clavicle fractures in a cohort of pediatric and adolescent athletes who underwent operative treatment at a single, tertiary-care pediatric center, including surgical techniques used and resultant clinical outcomes. Methods: A retrospective review was performed of all operatively-treated clavicle fractures extending to the coracoclavicular ligaments or lateral, between 2005-2020. Patients >19 years-old or those with pathological fractures were excluded. Radiographic characteristics, surgical fixation construct, time to radiographic healing, return to sports, and complications were analyzed. Results: Fifty-two patients were identified, with mean age 13.8 ± 2.2 years. The majority of fractures were classified as Nenopoulus type IIB (transverse, displaced; 42.3%) or type IIIB (oblique, displaced; 26.9%), with type IIA (transverse, minor displacement; 3.8%), IV (comminuted; 11.6%) , and V (AC dislocation; 15.4%) patterns also observed. Primary direction of displacement was posterior in 90% of cases and superior in 10%. Plate fixation was performed in 53.8% of surgeries, with locking plate (26.9%) and hook plate (17.3%) most frequent. Suture-based fixation was performed in 32.7% of cases (Figure 1). Rate of removal of implants was 66% after plate fixation, the majority of which (72.2%) were planned at the time of primary fixation. Patient age was comparable in suture and plate cohorts (12.9 vs. 13.5, p = 0.19). Total complication rate, including unplanned removal of implants, was higher in the plate fixation group (25%) than in the suture-based fixation group (11.2%). Time to radiographic healing was not significantly different between plate and suture-based constructs (2.9 vs. 2.9 months, p = 0.96) though patients with suture-based constructs returned to sport faster (2.5 vs. 3.6 months, p = 0.014). Conclusion: The vast majority of distal clavicle fractures treated operatively in pediatric and adolescent athletes are posteriorly displaced fractures. When chosen in the appropriate patient, suture-only constructs can lead to similar healing and faster return to sports compared to plate-based constructs, with greatly reduced need for removal of hardware. These data provide a foundation for future comparative research further elucidating precise surgical indications and optimal treatment approaches. [Table: see text]

Background: High-grade trochlear dysplasia (HGTD) has previously been identified as a risk factor for failure of surgical management of patellofemoral instability (PFI). However, limited data exists on the influence of the type of surgical procedure performed on postoperative outcomes in these patients. Hypothesis/Purpose: The purpose of this study was to identify the rates of failure of primary PFI surgery in patients with HGTD compared to those without HGTD and to assess the effect of the type of surgery on recurrent instability and return to OR. Methods: A retrospective review was performed on patients aged ≤19 years who underwent primary surgery for PFI at a single tertiary care center between 2008 and 2017. Patients underwent procedures including medial retinacular plication/reefing/advancement (MRP), graft-based medial patellofemoral ligament reconstruction (MPFLR), tibial tubercle osteotomy with or without MRP (TTO), or combined MPFLR + TTO. Exclusion criteria were BMI >30kg/m2, surgery for fixation of chondral fractures >1cm, and diagnosis of a syndromic disorder. Trochlear dysplasia was evaluated based on pre-operative MRI according to the Dejour classification system. Those with Dejour grade B or higher were designated as having HGTD. Comparisons were made between HGTD patients and non-HGTD patients, with logistic regression utilized to determine if surgery type was associated with recurrent PFI and revision PFI surgery. Results: 303 patients (mean age 15.1 years, 71% female) underwent primary surgical stabilization for PFI with median follow up time of 3.0 years. Approximately half (149/303, 49%) of the cohort had HGTD. Demographics were comparable between HGTD and non-HGTD patients (Table 1). HGTD and non-HGTD cohorts showed similar rates of post-operative instability, revision PFI surgery, and non-PFI secondary surgery. HGTD patients (Table 2) who underwent MPFLR had a 63% decrease in the odds of post-operative PFI compared to those who underwent MRP (OR=0.37; p=0.03). HGTD patients who underwent TTO had an 80% decrease in the odds of post-operative PFI compared to patients undergoing MRP (OR=0.20; p=0.002). Conclusion: Adolescents with PFI and HGTD have similar results after surgical stabilization to those patients without HGTD. Within the HGTD cohort, however, the type of surgery performed significantly influenced outcome. Patients with HGTD that underwent MRP had significantly more recurrent PFI and revision PFI surgery than patients that underwent other procedures, suggesting a limited role for this procedure in this sub-population of PFI patients. [Table: see text][Table: see text]

Background: Adolescents often benefit from surgical management of recurrent patellofemoral instability (PFI). However, the precise radiologic risk factors for failure of PFI surgery remains incompletely investigated. Hypothesis/Purpose: The purpose of this study was to determine the rate of failure, defined as recurrence of instability, in a large cohort of adolescent athletes undergoing primary surgery for PFI, and to identify preoperative radiologic risk factors for recurrence. Methods: A retrospective review was performed on patients aged ≤19 years who underwent primary surgery for PFI at a single tertiary care center between 2008 and 2017. Patients underwent procedures including medial retinacular plication/reefing/advancement (MRP), medial patellofemoral ligament reconstruction (MPFLR), tibial tubercle osteotomy with or without MRP (TTO), or combined TTO/MPFLR. Exclusion criteria were BMI >30kg/m2, surgery for fixation of chondral fractures >1cm, and diagnosis of a syndromic disorder. Preoperative magnetic resonance imaging (MRI) studies were reviewed, and radiologic parameters were recorded. Demographic and radiologic variables were compared between patients with and without subsequent PFI. Logistic regression was utilized to determine which imaging variables were associated with post-operative PFI. Results: 303 patients (mean age 15.1 years, 71% female) underwent surgery for PFI with median follow up time of 3.0 years. At final follow-up, 76/303 (25%) of patients experienced post-operative PFI, with 41 of these patients (54%; 14% overall) undergoing revision PFI surgery. Post-operative PFI patients were younger (14.3 vs 15.4 years; pConclusion: In conclusion, 25% of adolescents experienced post-operative PFI after primary patellofemoral stabilization surgery. However, such patients were more likely to be younger—a known risk factor for recurrence—and were more likely to undergo MRP, a procedure now largely replaced by MPFLR. Radiologic risk factors for failure included open physes, flatter trochlea, greater patellar tilt, and greater patella alta. Such data should guide treatment decisions and inform the risk of failure of surgical stabilization procedures in adolescents with PFI. [Table: see text][Table: see text]

Background: Achilles tendon tears are rare in adolescents and young adults, and management of these injuries remains controversial. Hypothesis/Purpose: To describe long-term limitations and physical activity levels following full or partial Achilles tears in adolescents and young adults, and report rates of surgical management, complications, re-tears, and time to return to sports (RTS). Methods: We conducted a descriptive study of young patients (8-22 years old) who were treated for a partial or full Achilles tear at two pediatric hospitals between 2004-2018. Demographic, imaging, and treatment data were retrospectively collected. Patient reported outcomes were obtained including the Achilles Tendon Total Rupture Score (ATRS), Foot and Ankle Outcomes Score (FAOS), Tegner Activity Scale (TAS), and separate questions about reinjury and return to sport. Results: Of the 41 eligible patients with Achilles injuries, 25 (61%; mean age 18.9 years; 40% male) had a minimum one year of follow-up data and were further analyzed. Twenty-three patients (92%) underwent surgical repair. Twenty patients (80%) returned questionnaires at a median 6.3 years (IQR, 3.4 to 9.7 years), while the other 5 patients were followed for a median of 1.8 years (IQR, 1.1 to 2.5 years). Twenty-two (88%) injuries were full tears, 53% (10/19) with reported location occurring mid-tendon. Median ATRS score was 96 (IQR, 82-100) and median TAS score was 6 (4-8). Median FAOS scores were excellent for symptoms (91), pain (100), ADL (100), and sports (98), and were good for QOL (88). The 6-month RTS probability was 47% (95% CI, 19-66%) and at 12 months was 95% (65-99%). The median time to RTS for partial tears was 5.6 months vs. 6.6 months for full tears (p=0.05). One surgical patient (4%) had a retear which required revision repair while 2 others needed additional surgery (1 - arthroscopy for ankle impingement, 1 - surgery for haglund’s deformity). In addition to the 3 surgical patients requiring re-operation, 8 patients experienced other complications (11/25 total complications, 44%), which included minor wound/scar complications (4), scar formation necessitating hydrodissection (1), Achilles tendonitis (2), and persistent pain following conservative treatment leading to surgical repair (1). Females were more likely to experience a complication (9/15, 60%) compared to males (2/10, 20%), but this difference was not statistically significant (p=0.10). Conclusion: Adolescents and young adults surgically treated for an Achilles injury reported satisfactory long-term outcomes.