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Objectives: To explore outcomes after tibial rigid intramedullary nailing (RIMN) in skeletally immature patients, with a focus on post-operative complications and iatrogenic changes in tibial slope due to anterior physeal arrest., Methods: Design: Retrospective case series., Setting: A large, tertiary care health system in the rural Mid-Atlantic United States, including two Level 1 trauma centers and one Level 2 trauma center., Patient Selection Criteria: Included were skeletally immature patients within 2 years of skeletal maturity undergoing tibial RIMN for OTA/AO 42 A to C fractures between March 2009 and January 2024 with post-operative follow-up more than 1-year., Outcome Measures and Comparisons: The primary outcome was change in tibial slope after RIMN. Secondary outcomes included post-operative weight-bearing status and complications., Results: Thirty-seven skeletally immature patients were included (mean age 15.2 ± 1.3 years, 76% male). For 22 patients with minimum 6-month post-operative radiographs (mean 18.4 ± 12.7 months), there was no significant change from pre- to post-operative tibial slope (80.0 ± 1.9° vs 80.1 ± 1.6°, p=0.86). Time to achievement of full weightbearing across the series averaged 45.4 ± 35.6 days. Five (14%) of patients necessitated hardware removal, and 89% of patients reported they had returned to "normal" activity at latest follow-up (mean 56.2 ± 42.5 months)., Conclusions: This study demonstrated that RIMN for tibial shaft fractures in skeletally immature pediatric patients within 2 years of maturity was not associated with iatrogenic physeal injury and resultant changes in tibial slope. Additional favorable clinical outcomes, the potential for early weight-bearing, and few associated post-operative complications, indicate that RIMN is a safe option for skeletally immature patients with tibial shaft fractures. Caution should be exercised when extrapolating these results to younger pediatric patients with >2 years of skeletal growth remaining., Level of Evidence: IV., Competing Interests: Potential Conflicts of Interest and Funding Sources: Jessica L. Koshinski BS: None are declared. Joshua T. Bram MD: None are declared. Preston W. Gross BS: None are declared. Sarah H. Hine MD: None are declared. Daniel S. Hayes BS: None are declared. Peter D. Fabricant MD, MPH: BICMD, Inc. (Paid consultant), Clinical Orthopaedics and Related Research (Editorial or governing board), HS2, LLC (Stock or stock Options), HSS ASC Development Network, LLC (Stock or stock options), Joint Effort Administrative Services Organization, LLC (Stock or stock options), Osso VR (Stock or stock options) Mark A. Seeley MD: Consultant for OrthoPediatrics., (Copyright © 2025 Wolters Kluwer Health, Inc. All rights reserved.)

Case: A 10-year-old girl presented after closed reduction of an elbow fracture dislocation. She demonstrated intact vascularity but a dense median nerve palsy. Preoperative magnetic resonance neurography (MRN) precisely mapped the median nerve entrapped within the medial epicondylar fracture. Intraoperatively, the median nerve was freed preceding reduction and fracture fixation. Postoperatively, neurological symptoms completely resolved, and she regained full elbow function., Conclusion: Median nerve injury can present without associated vascular injury. In this case, MRN was helpful in preoperatively illustrating the spatial relationship between the median nerve and the medial epicondyle., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C416)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Bone-patellar tendon-bone (BPTB) autograft size may be one modifiable predictor of anterior cruciate ligament (ACL) reconstruction postoperative success, as smaller graft diameter has been associated with higher rates of rupture requiring revision. However, measuring the true intra-articular tendinous graft diameter of the soft tissue portion of a BPTB graft with standard intraoperative methods is difficult while keeping the graft intact., Purpose/hypothesis: The purpose of the study was to use 3-dimensional magnetic resonance imaging (MRI) measurements to determine the cross-sectional area of the soft tissue, tendinous portion of a standard BPTB autograft with 10-mm diameter bone plugs, and, by calculation, the collagen graft size (ie, graft diameter), as would typically be reported in ACL reconstruction studies that consider soft tissue graft size. It was hypothesized that the calculated collagen graft diameter of 10-mm BPTB autografts would be significantly smaller than 10 mm., Study Design: Cross-sectional study; Level of evidence, 3., Methods: A total of 100 patients (10 girls and 10 boys at each age from 13 to 17 years) who underwent a knee MRI at a single academic orthopaedic center without documented extensor mechanism pathology were identified. The central 10-mm width of the patellar tendon that would be harvested for BPTB autograft was measured. The region of interest area tool was then used to measure the cross-sectional area of a 10-mm BPTB graft with subsequent soft tissue autograft diameter calculation., Results: The mean calculated tendinous graft diameter of a 10 mm-wide BPTB graft was 6.3 ± 0.5 mm and was significantly smaller than a 10-mm reference ( P ≤ .001). There was no significant association between age and cross-sectional area or graft diameter., Conclusion: Modern 3-dimensional imaging-based measurement techniques demonstrated that the true intra-articular tendinous soft tissue portion of 10-mm BPTB autografts shows substantial variation and is significantly smaller in diameter than the tunnels typically reamed to accommodate the bone plug portions of these grafts. Moreover, as graft size is a predictor of rupture rate, preoperative MRI-based evaluation may be an important tool when considering BPTB autograft for ACL reconstruction. Future comparative clinical research utilizing graft size as a study variable should consider quantifying and utilizing the diameter of the soft tissue component of BPTB autografts., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: D.W.G. has received royalties from Arthrex and OrthoPediatrics Canada ULC; nonconsulting fees from Synthes GmbH and Arthrex; consulting fees from OrthoPediatrics; and education payments from Terumo BCT. B.E.H. has received education payments from Kairos Surgical, Pylant Medical, and Arthrex and nonconsulting fees from Arthrex. P.D.F. has received consulting fees from WishBone Medical. 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. Ethical approval for this study was obtained from the Hospital for Special Surgery (ref No. 2022-1725)., (© The Author(s) 2024.)

Background: Spondylolysis is common in athletes participating in gymnastics, football, dance, and weightlifting. Few studies have reviewed return to sports (RTS) rates in young athletes after surgical intervention for spondylolysis., Purposes: We sought to review the literature on RTS frequencies and timing, as well as postoperative treatment, in children and adolescents who underwent spondylolysis surgery., Methods: This was a systematic review, using the PubMed, Embase, and Cochrane databases, of primary, peer-reviewed studies published from 2014 to 2022 that investigated child and adolescent RTS after spondylolysis surgery. Each author independently reviewed each study's design, number of participants, age range, fixation, postoperative course of treatment, frequency of RTS, and reasons for failure of RTS., Results: The initial search produced 106 articles; 25 were reviewed in full and 9 were included in the final analysis, with a combined total of 177 patients. Sample sizes ranged from 5 to 52 participants. The most common fixations were direct repair (6 studies, n = 120), indirect repair (3 studies, n = 22), and fusion (2 studies, n = 35). Five studies mentioned the use of immediate postoperative immobilization. Physical therapy programs were initiated most often at 6 weeks postoperatively. The RTS rate of the 177 athletes (median age younger than 23 years) was 76% to 100%. The most common reason for failure to RTS was lower back pain., Conclusions: This systematic review suggests that young athletes RTS at a high rate following spondylolysis surgery, but more rigorous study is warranted. The review also found varied preferred fixation methodologies and postoperative treatment regimens across the available studies., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2024.)

Background: Anterior knee pain is a common reason for referral to a pediatric orthopedic surgeon. Although previous studies have found that adults with anatomic risk factors for patellofemoral instability (patella dislocation) are predisposed to anterior knee pain, no studies have elucidated the relationship between anatomic risk factors for patellofemoral instability and anterior knee pain in children. Purpose : We sought to characterize common radiographic findings in adolescent patients with a chief complaint of anterior knee pain and to determine the prevalence of abnormal patellofemoral morphology. Methods : We conducted a retrospective review of patients 13 to 18 years old with anterior knee pain at a single tertiary care metropolitan institution from 2016 to 2021. X-rays and magnetic resonance imaging (MRI) were evaluated in those diagnosed with "chondromalacia patellae," "chondromalacia," "patellofemoral disorders," or "anterior knee pain." Patella alta, tibial tubercle-trochlear groove (TT-TG) distance, tubercle height, Wiberg patella type, patellar tilt, and trochlear dysplasia characterization were recorded. Results : Of the 293 adolescents with anterior knee pain included, 62 had bilateral anterior knee pain. Of the 172 MRIs, 72 (42%) met criteria for patella alta, Caton-Deschamps Index (CDI) >1.3, 35% had a TT-TG distance >15 mm, and 32% had lateral patellar tilt >15°. Magnetic resonance imaging findings included infrapatellar fat pad signal hyperintensity (41%) and patellofemoral dysplasia (23%). Of all 293 adolescents, 74% had images showing abnormal patellofemoral morphology, of which 30% had a history of 1 or more patellar dislocation. Overall, 40% of the adolescents had surgery, most commonly medial patellofemoral ligament (MPFL) reconstruction (18%). Conclusions : In this retrospective review, nearly 3/4 of adolescents with anterior knee pain had images showing abnormal patellofemoral morphology, including patella alta, increased TT-TG distance, trochlear dysplasia, or abnormal lateral patellar tilt; only 18% had MPFL surgery. These findings suggest that primary care providers might consider obtaining X-rays and/or MRIs to evaluate for pathology that warrants orthopedic evaluation., Competing Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: S.M.S., MD, reports relationships with Organogenesis, Moximed, Smith & Nephew, Vericel, American Journal of Sports Medicine, Arthroscopy Association of North America, Engage, Stryker, and JRF Ortho. The other authors declared no potential conflicts of interest., (© The Author(s) 2024.)

Background: Compared with male senior authors, female senior authors publish less often in orthopedic journals than expected based on their population proportion. It is unknown whether this trend is also present among orthopedic trainees. Purpose : We sought to determine whether there is a gender discrepancy in the publication volume and authorship status among orthopedic residents. Methods : We conducted a cross-sectional analysis to evaluate the research productivity of male and female orthopedic residents. The top 10 ranked US orthopedic surgery residencies by research output in 2021-2022 were obtained from Doximity. Residents' names were recorded from each institution's residency website. We classified each resident as male or female, searched on PubMed, and recorded the number of publications relevant to orthopedic surgery. Resident contribution to each publication was recorded as either a first/last author or a middle author. To assess contributions by postgraduate year, we compared male and female junior residents (PGY1-3) and senior residents (PGY4-5) using the number of total publications, middle author publications, first/last author publications, and the difference between the number of middle and first/last author publications. Results : Among the 335 male and 117 female residents included, male residents had more total publications than female residents. Among PGY4-5, male residents had more total publications and middle author publications. There was no difference in the number of first/last author publications between male and female PGY4-5 residents. Conclusions : Our cross-sectional analysis found that in the 2021-2022 academic year, male orthopedic surgery residents published more often than female residents, although among PGY4-5 residents, we found no gender differences in number of first/last author publications. The difference in total publications among PGY4-5 residents is likely due to differences in middle author publications. Future research should consider residents' self-identified gender, including non-binary and gender-fluid identity., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2023.)

Background: In-office procedures can be painful and anxiety-provoking for pediatric patients. Minimizing such pain and anxiety in children improves the patient experience and promotes a rewarding and productive patient-caregiver-provider relationship, which may for some young patients be their first memorable encounter with the healthcare system. Although virtual reality (VR) techniques have proven to be helpful in minimizing pain and anxiety during procedures in pediatric intensive care settings, it remains unclear how VR affects objective and subjective measures of pain and anxiety in children undergoing in-office orthopaedic procedures such as cast removal or percutaneous pin removal after fracture healing., Questions/purposes: Is a VR gaming simulation more effective than either of two forms of noninteractive visual distraction (VR goggles or tablet computer displaying a noninteractive video) for reducing (1) objective measures of pain and anxiety and (2) subjective measures of pain and anxiety in children undergoing in-office cast removal or percutaneous pin removal?, Methods: This study was a randomized controlled trial with two parallel, separately analyzed cohorts: children undergoing in-office cast removal or in-office percutaneous pin removal at a single urban tertiary institution. We approached eligible patients who were scheduled to undergo outpatient cast or percutaneous pin removal and who met prespecified inclusion criteria. We enrolled until 105 patients were available for analysis in each of the cast removal and pin removal cohorts. Of note, the study institution was in an urban epicenter of the coronavirus-19 pandemic, and clinical research was paused sporadically, which resulted in a longer-than-expected enrollment period. In the cast removal cohort, all patients were eligible for inclusion and were enrolled and randomized into one of three groups: VR gaming simulation (n = 37), VR goggles with a noninteractive video (n = 36), or a tablet computer with the same noninteractive video (n = 40). Eleven percent (4), 8% (3), and 3% (1) withdrew from each of the three intervention groups, respectively. In the pin removal cohort, all patients were eligible for inclusion and were enrolled and randomized into the same three groups (37, 44, and 41 patients, respectively). In the pin removal group, 14% (5), 18% (8), and 10% (4) withdrew from each of the three intervention groups, respectively. In all, 235 patients were enrolled in the study and 210 patients (mean ± SD age 9 ± 3 years; 48% [100] girls) were included in the final analyses. There were no clinically important differences in age, gender, preprocedure pain, or anxiety among the intervention groups. Primary outcomes included preprocedure-to-maximum heart rate increase (objective measure) and preprocedure and postprocedure pain and anxiety using a VAS (subjective measures). One-way ANOVA and Bonferroni-adjusted pairwise comparisons were used to calculate between-group differences for the primary outcomes., Results: There were no intervention-level groupwise differences between VR goggles with an interactive game, VR goggles with a noninteractive video, or the tablet computer with the same video in preprocedure-to-maximum heart rate increase in the cast removal cohort (18 ± 21 bpm versus 14 ± 11 bpm versus 20 ± 16 bpm, respectively; largest mean difference -6 bpm [95% CI -16 to 3]; p = 0.36) or pin removal cohort (27 ± 20 bpm versus 23 ± 12 bpm versus 24 ± 19 bpm, respectively; largest mean difference 4 bpm [95% CI -7 to 14]; p = 0.99). Similarly, there were no intervention-level groupwise differences in preprocedure to postprocedure VAS pain in the cast removal cohort (1 ± 1 versus 1 ± 2 versus 0 ± 2, respectively; largest mean difference 0 points [95% CI 0 to 1]; p = 0.89) or pin removal cohort (0 ± 3 versus 2 ± 3 versus 0 ± 3 points, respectively; largest mean difference 1 point [95% CI 0 to 3]; p = 0.13). Finally, there were no intervention-level groupwise differences between the same intervention groups in preprocedure to postprocedure VAS anxiety in the cast removal cohort (-2 ± 2 versus -1 ± 2 versus -1 ± 2 points, respectively; largest mean difference -1 point [95% CI -2 to 1]; p = 0.63) or pin removal cohort (-3 ± 3 versus -4 ± 4 versus -3 ± 3 points, respectively; largest mean difference -1 point [95% CI -2 to 1]; p = 0.99)., Conclusion: During in-office cast and pin removal in pediatric patients, simple distraction techniques such as tablet video viewing are as effective as higher-fidelity VR headset video and interactive games in minimizing objective measures of procedural pain and subjective measures of pain and anxiety. Because of these findings and because of the associated costs, implementation logistics, and variable tolerance by young patients, widespread use of VR distraction techniques in the pediatric orthopaedic outpatient setting is unnecessary., Level of Evidence: Level I, therapeutic study., (Copyright © 2023 by the Association of Bone and Joint Surgeons.)

The meniscal roots are critically important for maintaining knee stability, functional load distribution, and proper knee kinematics. Although adult meniscal root injuries have been a topic of increasing research, medial meniscus injuries also occur in pediatric and adolescent patients, with up to 2% of meniscal injuries involving root attachments. The purpose of this Technical Note is to demonstrate the transosseous repair of isolated posterior medial meniscal root injuries in children and adolescents, including tear visualization on magnetic resonance imaging and during arthroscopy, operative technique, and postoperative management., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: D.W.G, reports a relationship with Arthrex that includes consulting and roylaties and with Orthopediatrics that includes royalties. P.D.F. reports a relationship with WishBone Medical and with Osso VR that includes: consulting or advisory. All other authors (K.K.N., R.H.J., P.W.G., P.C., D.E.C., A.M.F., H.G.G.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

Background: The Pavlik harness has been used for approximately a century to treat developmental dysplasia of the hip (DDH). Femoral nerve palsy is a documented complication of Pavlik harness use, with an incidence ranging from 2.5% to 11.2%. Rare reports of brachial plexus palsy have also been documented. The primary purpose of the current study was to evaluate the incidence of various nerve palsies in patients undergoing Pavlik harness treatment for DDH. Secondary aims were to identify patient demographic or hip characteristics associated with nerve palsy., Methods: We performed a retrospective review of patients diagnosed with DDH and treated with a Pavlik harness from February 1, 2016, to April 1, 2023, at a single tertiary care orthopaedic hospital. Hip laterality, use of a subsequent rigid abduction orthosis, birth order, breech positioning, weight, and family history were collected. The median (and interquartile range [IQR]) or mean (and standard deviation [SD]) were reported for all continuous variables. Independent 2-sample t tests and Mann-Whitney U tests were conducted to identify associations between the variables collected at the initiation of Pavlik harness treatment and the occurrence of nerve palsy., Results: Three hundred and fifty-one patients (547 hips) were included. Twenty-two cases of femoral nerve palsy (4% of all treated hips), 1 case of inferior gluteal nerve palsy (0.18%), and 2 cases of brachial plexus palsy (0.37%) were diagnosed. Patients with nerve palsy had more severe DDH as measured by the Graf classification (p < 0.001) and more severe DDH as measured on physical examination via the Barlow and Ortolani maneuvers (p = 0.003)., Conclusions: Nerve palsies were associated with more severe DDH at the initiation of Pavlik harness use. Upper and lower-extremity neurological status should be scrutinized at initiation and throughout treatment to assess for nerve palsies. The potential for femoral, gluteal, and brachial plexus palsies should be included in the discussion of risks at the beginning of treatment. Families may be reassured that nerve palsies associated with Pavlik harness can be expected to resolve with a short break from treatment., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: No external funding was received for this work. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/H864)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Published literature describes slipped capital femoral epiphysis as a complication of recombinant human growth hormone (rhGH) therapy that may be related to decreased physeal strength. The purpose of the current investigation was to utilize a case-control study design to determine whether a greater proportion of pediatric patients sustaining physeal avulsion fractures of the proximal tibia were undergoing rhGH therapy at the time of injury compared with a cohort of matched controls., Methods: A case-control design study design was utilized. Patients 4 to 18 years of age with proximal tibial physeal avulsion fractures (cases) or midshaft tibial fractures (controls) at our institution from February 1, 2016, to May 4, 2023, were identified. Cases and controls were matched 1:1 on the basis of age (within 1 year), sex, and body mass index (within 3 kg/m 2 ). A total of 132 patients were included in the analysis (mean age, 13 ± 2 years). rhGH exposure was compared using conditional logistic regression with Firth correction., Results: We found that 11% of the patients with a proximal tibial physeal avulsion fracture were on rhGH therapy at the time of injury compared with 0% of patients with midshaft tibial fractures (odds ratio [OR], 15.0; 95% confidence interval [CI], 1.8 to 1,946.7; p = 0.007). There was no significant difference in the proportion of sports-related injuries between cases (70%) and controls (67%) (OR, 1.15; 95% CI, 0.55 to 2.39; p = 0.85). Among subjects with proximal tibial avulsion fractures, the proportion requiring surgery did not differ significantly between patients receiving and those not receiving rhGH therapy (43% versus 41%, respectively; p = 0.99)., Conclusions: This study demonstrates that the proportion of subjects who sustained proximal tibial physeal avulsion fractures and were receiving recombinant human growth hormone therapy at the time of injury was significantly greater than that of an age, sex, and body mass index-matched control group with midshaft tibial fractures (11% versus 0%, respectively, representing 15-times greater odds of exposure). This quantifies a previously unreported serious orthopaedic complication associated with rhGH therapy., Level of Evidence: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/H819 )., (Copyright © 2023 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: The Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) scale is a 12-item questionnaire assessing psychological readiness to return to sport after anterior cruciate ligament reconstruction. It has been validated for use in adults in multiple languages and in an abbreviated 6-question short form. Additionally, literature has been published using this scale in pediatric and adolescent populations, however it has not yet been validated for use with them., Purpose: To validate the ACL-RSI scale for use with pediatric and adolescent patients., Study Design: Cohort study (Diagnosis); Level of evidence, 2., Methods: Scores of 6- and 12-item ACL-RSI scales for patients undergoing return-to-sport readiness testing 6 to 8 months after anterior cruciate ligament reconstruction were analyzed. Convergent validity testing was performed against the International Knee Documentation Committee (IKDC)/Pediatric IKDC score, Single Assessment Numeric Evaluation (SANE) score, and peak torque asymmetry of knee flexion and extension using Spearman correlations. Discriminant validity testing was performed against age (Spearman correlation), body mass index (Spearman correlation), and sex (Mann-Whitney U test). Reliability testing was performed by calculating Cronbach's alpha. Floor and ceiling effects were assessed by calculating the number of minimum and maximum scores in the cohort., Results: A total of 51 patients were included in the final analysis. The mean age at surgery was 15.2 ± 2.2 years, and 51.0% were female. The 6- and 12-item ACL-RSI scales demonstrated a strong significant positive correlation with IKDC/Pediatric IKDC scores ( R = 0.723 and 0.717, respectively; P < .001) and moderate significant positive correlation with Single Assessment Numeric Evaluation scores ( R = 0.516 and 0.502, respectively; P < .001) Age at surgery, body mass index, and sex were not correlated with either ACL-RSI scale. Cronbach's alpha values of the 12- and 6-item ACL-RSI scales in this population were 0.959 and 0.897, respectively. For both the 12- and the 6-item ACL-RSI scales, no floor or ceiling effects were found as the minimum score (0) was not observed in either version, and the maximum score (100) was only observed twice (3.9%) in both versions., Conclusion: The ACL-RSI scale is valid to use with pediatric and adolescent patients. The 6-item scale may be a better choice because it has fewer redundancies and minimizes the risk of questionnaire fatigue.

Study Design: Prospective cohort., Objective: To determine if distal spinal fusion level is associated with postoperative sport participation after posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS)., Summary of Background Data: The concept of "saving a level" during PSF for AIS refers to minimizing the distal extent of lumbar fusion to theoretically allow for increased postoperative spinal mobility and a more predictable return to athletic activity, as well as minimizing the risk of degenerative disc disease. There are few prospective studies evaluating the correlation between distal fusion level and timing of return to sports., Materials and Methods: Adolescent patients undergoing PSF for AIS between 2009 and 2019 were approached at their presurgical visit to participate in this prospective study. Participants were followed for a minimum of 2 years after surgery. Sports participation (classified by sport type and level of competitiveness) and radiographic data were collected at the initial visit. At each postoperative visit, it was noted whether patients returned to the same sport type and level of competitiveness., Results: After an a priori power calculation was performed, a total of 106 participants were included in the analysis with a mean age of 14 ± 2 years. Distal fusion levels ranged from T11 to L4. There was no significant association between distal fusion level and return to the same level of sports participation ( P = 0.192). Of the participants, 93% returned to sports with no significant differences by distal fusion level ( P = 0.081). Distal fusion level demonstrated no difference in return to preoperative sport ( P = 0.486) or return to the same type of sport ( P = 0.247)., Conclusions: This study found no association between distal fusion level and postoperative sports participation. Even though many patients may elect to change sports, nearly all patients returned to sports, and the majority of patients returned to the same level of sports competition or higher after PSF for AIS., Competing Interests: P.D.F.: Clinical Orthopedics and Related Research: Editorial or governing board, Osso VR: Stock or stock Options, WishBone Orthopedics: Paid consultant. D.W.G.: American Academy of Orthopaedic Surgeons (AAOS): Board or committee member, AO Trauma International: Paid presenter or speaker, Arthrex, Inc: IP royalties; Paid consultant; Paid presenter or speaker, Current Opinion in Pediatrics: Editorial or governing board; Publishing royalties, financial or material support, New York County Medical Society: Board or committee member, New York State Society of Orthopedic Surgeons: Board or committee member, PatelloFemoral Foundation: Board or committee member, Pediatric Orthopedic Society of North America: Board or committee member, Pediatric Research in Sport Medicine: Board or committee member, Pega Medical: IP royalties, Wolters Kluwer Health—Lippincott Williams & Wilkins: Publishing royalties, financial or material support. J.S.B.: OrthoPediatrics: Paid consultant, Wishbone: Paid consultant. R.F.W.: Medtronic: Paid consultant, OrthoPediatrics: IP royalties, Spine Deformity Journal Editorial Board: Editorial or governing board, Springer: Journal of Children’s Orthopedics Editorial Board: Editorial or governing board. The remaining authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: With the rise of social media and other web-based platforms, there has been a shift in how medical research findings are disseminated. Questions/Purposes : We sought to investigate how often orthopedic surgeons use different knowledge-seeking methods and how confident they were in their ability to stay up-to-date. Methods : We distributed a 23-question survey to 120 orthopedic surgeons employed at a single tertiary-care metropolitan orthopedic hospital. The survey collected the surgeons' use of reference managers, RSS feeds, and preferred methods of staying up-to-date. Respondents were asked to report the number of hours they spent staying up-to-date per week and their success with keeping up with orthopedic specialty literature. Results : A total of 85 physicians responded (median age, 52 years); 83% of respondents who spent 3 or more hours a week in keeping up-to-date with the literature said they felt successful in doing so, while 40% of participants who spent less than 1 hour a week said they felt successful. Fifty-five percent of surgeons under the median age used social media, while only 29% of surgeons over the median age used social media. Conclusions : This survey suggests that spending only 1 to 2 hours per week was enough to make the orthopedic surgeons we surveyed feel confident that they were keeping up with the literature in their specialty. These findings also suggest that it may be more important for surgeons to choose a convenient method of literature review that will enable them to maximize time spent reading, rather than attempting to use any one source., Competing Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Peter D. Fabricant, MD, MPH, reports relationships with WishBone, Osso VR, and Pediatric Orthopaedic Society of North America (POSNA). The other authors report no potential conflicts of interest., (© The Author(s) 2022.)

Background: The Grit Scale is used to measure grit, defined by Duckworth and colleagues as the disposition to show perseverance and passion for long-term goals. It has been shown that psychological factors like motivation, coachability, and coping with adversity are correlated with faster readiness for return to sport (RTS) in patients undergoing anterior cruciate ligament reconstruction (ACLR). This study investigates the association between pediatric patients' baseline grit scores and; preoperative Patient-reported Outcomes Measurement Information System (PROMIS) Pain scores and the recovery of range of motion (ROM) after ACLR. The investigators hypothesized that higher preoperative grit scores would predict lower preoperative pain scores and earlier return of knee ROM in patients undergoing ACLR., Methods: This is a retrospective cohort study. Pediatric patients who underwent primary ACLR were assigned the pediatric Grit Scale. Patients were subdivided by meniscal procedures due to differences in postoperative protocols. ACLR alone or with meniscectomy (ACLR ± meniscectomy) were grouped together and ACLR with meniscal repair (ACLR + meniscus repair) represented the other cohort. Patients above the 50th grit percentile were considered "high grit". Patients below the 50th percentile were considered "low grit". Baseline PROMIS pain intensity and interference were collected. ROM was compared by grit cohort using the Mann-Whitney U test with a significance threshold of P ≤ 0.05., Results: A total of 58 patients undergoing ACLR were analyzed: 20 ACLR ± meniscectomy and 38 ACLR + meniscus repair. The mean age was 15.0 ± 2.1 years with 41.4% of participants identifying as females. No significant difference was noted between baseline PROMIS pain intensity and interference and grit score ( P = 0.82, P = 0.91, respectively). Three months postoperatively, for those in the ACLR + meniscus repair cohort, low grit ROM was 130 degrees (interquartile range = 10 degrees), whereas high grit ROM was 135 degrees (interquartile range = 8 degrees) ( P = 0.006)., Conclusions: This study found no differences in pain scores at presentation between grit cohorts but found that patients with grit scores below the 50th percentile undergoing ACLR + meniscus repair have 5 degrees less total ROM at 3 months compared with those with high grit scores. Quicker ROM recovery in patients with high grit may be a leading indicator of these patients' likelihood to achieve other postoperative milestones and meet criteria for RTS more quickly; the relationship between grit and readiness for RTS should be further investigated., Level of Evidence: Level IV; retrospective cohort study., Competing Interests: D.W.G.: AAOS: Board or committee member. AO Trauma International: Paid presenter or speaker. Arthrex, Inc: IP royalties; Paid consultant; Paid presenter or speaker. Current Opinion in Pediatrics: Editorial or governing board; Publishing royalties, financial or material support. New York County Medical Society: Board or committee member. New York State Society of Orthopaedic Surgeons: Board or committee member. PatelloFemoral Foundation: Board or committee member. Pediatric Orthopaedic Soceity of North America: Board or committee member. Pediatric Research in Sport Medicine: Board or committee member. Pega Medical: IP royalties. Wolters Kluwer Health—Lippincott Williams and Wilkins: Publishing royalties, financial or material support. P.D.F.: Clinical Orthopaedics and Related Research: Editorial or Governing board. Pediatric Orthopaedic Society of North America: Board or committee member. Osso VR: Stock or stock options. Wish Bone Orthopaedics: Paid consultant. Research in Osteochondritis of the Knee (ROCK): Board or committee member. The remaining authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose of Review: The purpose of this review is to outline the most recent understanding of torticollis in the pediatric population., Recent Findings: It is important to diagnose the underlying condition of torticollis early in childhood, as some conditions that cause torticollis may result in major developmental delays in early motor milestones. Recent studies have highlighted that many of the rarer causes of torticollis are often misdiagnosed as congenital muscular torticollis, suggesting that physicians should pay close attention to the results of clinical and radiographic examinations when patients present with torticollis., Summary: Congenital muscular torticollis is the most common cause of torticollis. Other, less common causes of torticollis include vertebral abnormalities, ocular torticollis, gastrointestinal disorders, soft tissue infections of the neck, posterior fossa tumors, and benign paroxysmal torticollis. Although rare, these differential diagnoses should be considered during a clinical work-up for a patient who presents with torticollis., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Supracondylar humerus (SCH) fractures are common pediatric injuries, typically requiring closed reduction and percutaneous pinning or open reduction. These injuries are managed frequently by both pediatric-trained (PTOS) and nonpediatric-trained (NTOS) orthopaedic surgeons. However, some literature suggests that complications for pediatric injuries are lower when managed by PTOS. Therefore, this meta-analysis sought to compile existing literature comparing patients treated by PTOS and NTOS to better understand differences in management and clinical outcomes., Methods: Using preferred reporting items for systematic reviews and meta-analyses (PRISMA) methodology, a systematic review was conducted for all articles comparing SCH fractures managed by PTOS and NTOS in 4 online databases (PubMed, Embase, CINAHL, Cochrane). Study quality was assessed through the use of the Newcastle-Ottawa Scale. Meta-analyses were then performed for postoperative outcomes using pooled data from the included studies. Statistics were reported as odds ratios and 95% CI., Results: This search strategy yielded 242 unique titles, of which 12 underwent full-text review and 7 met final inclusion. All studies were retrospective and evaluated patients treated in the United States. There were a total of 692 and 769 patients treated by PTOS and NTOS, respectively. PTOS had shorter operative times [mean difference, 13.6 min (CI, -23.9 to -3.4), P=0.01] and less frequently utilized a medial-entry pin [odds ratios, 0.36 (CI, 0.2 to 0.9), P=0.03]. There were no differences in time to treatment, the necessity of open reduction, postoperative Baumann angle, or complications including surgical site infection or iatrogenic nerve injury., Conclusions: Despite shorter operative times and lower frequency of cross-pinning when treated by PTOS, pediatric SCH fracture outcomes are similar when treated by PTOS and NTOS. These findings demonstrate that these fractures may possibly be treated safely by both PTOS and experienced fellowship-trained academic NTOS who are comfortable managing these injuries in pediatric patients., Level of Evidence: Level III; Meta-analysis., Competing Interests: P.D.F.: Clinical Orthopaedics and Related Research: Editorial or Governing board. Pediatric Orthopaedic Society of North America: Board or committee member. Osso VR: Stock or stock options. WishBone Orthopaedics: Paid consultant. Research in Osteochondritis of the Knee (ROCK): Board or committee member. The remaining authors declare no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

In recent years, the frequency of anterior cruciate ligament (ACL) tears and ACL reconstruction (ACLR) in skeletally immature patients has increased. Because distal femoral and proximal tibial physes account for the majority of lower-extremity growth, surgical technique and graft selection are crucial to minimize iatrogenic physeal injury. Combined extra- and intra-articular, all-epiphyseal, and transphyseal with soft-tissue grafts are the most common ACLR techniques used in children. Combined extra- and intra-articular ACLR typically is offered to prepubescent patients with ≥2 years of growth remaining. This technique uses iliotibial band (ITB) autograft passed over the lateral femoral condyle and fixed to the anterior tibial periosteum. All-epiphyseal ACLR is similarly used in patients with ≥2 years of growth remaining, provided sufficient epiphyseal maturity to accommodate an all-epiphyseal socket because both the femoral and tibial tunnels are contained within the epiphyses. In postpubertal patients with <2 years of growth remaining, transphyseal ACLR using a soft-tissue autograft (typically hamstring or quadriceps tendon) and metaphyseal femoral fixation can be performed. This minimizes risk of physeal injury. In borderline patients with approximately 2 years of growth remaining, an additional option includes partial transphyseal ACLR, which uses a soft-tissue graft and a transphyseal tibial tunnel, but an all-epiphyseal or over-the-top femoral graft trajectory. Recently, transphyseal ITB ACLR and hybrid transphyseal hamstring with combined over-the-top ITB ACLR also have been described. Existing clinical studies focused on pediatric and adolescent ACL reconstructions have reported a wide range of graft rupture rates for these techniques (4.3%-25%), with contralateral ACL injury rates of 2.9% to 15.6%. Ongoing multicenter research is underway to directly compare surgical techniques for this demographic and quantify graft rupture rates and other clinical outcomes., (Copyright © 2022 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)