Nonoperative Versus Operative Treatment of Z-Type Comminuted Clavicle Fractures in Adolescents: A Prospective Substratified Cohort Analysis

OBJECTIVES

To compare the clinical, radiographic, and patient-reported outcomes of nonoperative and operative treatment of adolescents with comminuted "Z-type" midshaft clavicle fractures.

METHODS

DESIGN

Prospective observational cohort.

SETTING

Eight tertiary care pediatric centers.

PATIENT SELECTION CRITERIA

Patients aged 10-18 years who were treated either operatively or nonoperatively for a diaphyseal clavicle fracture between 2013 and 2017 were screened/enrolled at the time of injury. The current subcohort analysis was derived from a larger adolescent clavicle study population of 907 patients.

OUTCOME MEASUREMENTS AND COMPARISONS

Complications and validated patient-reported outcome measures (PROs):(ASES, QuickDASH, Marx Shoulder Activity Score, EQ-5D, EQ-VAS, and patient satisfaction score) were compared between operative and nonoperative cohorts.

RESULTS

Eighty-one patients (69 male [85.2%], 12 female; average age 15 years [11.1-18.7]; 78 with sports participation [96.2%]) were followed through bony healing and return to sports, while 59 patients (73%) completed 2-year follow-up with PROs, 26 of whom were treated nonoperatively and 33 treated operatively. All demographic and fracture characteristics were similar (P > 0.05) between the 2-year follow-up cohorts except for fracture shortening, which was greater in the operative cohort (23 vs. 29 mm, P = 0.01). After controlling for this potential confounder through both regression and propensity matched subgroup analysis, nonoperative versus operative cohorts showed no difference in rates of nonunion (0%), delayed union (0% vs. 2.3%, P = 1.0), symptomatic malunion (2.7% vs. 0%, P = 0.4), refracture (2.7% vs. 2.2%, P = 1.0), unexpected subsequent surgery (5.4% vs. 11.4%, P = 0.45), or clinically significant complications (5.4% vs. 16%, P = 0.17). There were no differences in any PROs between cohorts, both before and after controlling for the difference in fracture shortening (all P-values >0.05).

CONCLUSIONS

In this prospective comparison of complications and 2-year PROs in adolescents with comminuted Z-type clavicle fractures, nonoperative and operative treatment yielded similar outcomes.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Effect of Age and Sex on Anterior Cruciate Ligament Functional Tests Approximately 6 Months After Anterior Cruciate Ligament Reconstruction

Purpose

To examine age- and sex-related differences in postoperative functional outcomes at approximately 6 months after anterior cruciate ligament reconstruction (ACLR).

Methods

In this study, patients who underwent primary ACLR performed a series of return-to-sport functional tests at 5 to 8 months after surgery. Functional tests included strength tests (knee extensors, knee flexors, hip abductors, and hip extensors), a balance test (Y-balance composite score), and hop tests (single, triple, crossover, and 6-m timed hop tests). Limb symmetry was calculated to compare the reconstructed limb with the uninvolved limb. A 2-way multivariate analysis of covariance was used, and effect size was calculated for data analysis.

Results

A total of 176 subjects were included in this study. There were no significant interaction between age and sex on return-to-sport functional tests after ACLR. Also, no main effects of age and sex on return-to-sport functional tests were found in our data.

Conclusions

Age and sex do not significantly affect functional test performance after ACLR 6 months postoperatively.

Level of Evidence

Level III, retrospective review of prospective cohort study.

Changes in Fracture Shortening Occur in the First 2 Weeks Following Completely Displaced Adolescent Clavicle Fractures

BACKGROUND

Shortening of midshaft clavicle fractures has been described as a critical fracture characteristic to guide treatment. The degree to which shortening may change in the initial weeks following injury has not been well studied. The purpose of this study was to evaluate the change in shortening of adolescent clavicle fractures in the first 2 weeks following injury.

METHODS

This was a multicenter study of prospectively collected data, which was acquired as a part of a cohort study of adolescent clavicle fractures. A consecutive series of patients 10 to 18 years of age with completely displaced diaphyseal clavicle fractures with baseline radiographs 0 to 6 days from the date of injury, as well as 7 to 21 days from the date of injury, were included. Measurements of end-to-end (EES) and cortex-to-corresponding-cortex (CCS) shortening were performed.

RESULTS

A total of 142 patients were included. Baseline radiographs were obtained at a mean of 1.0 day following injury with mean EES of 22.3 mm, and 69% of patients demonstrating >20 mm of shortening. Follow-up radiographs obtained at a mean of 13.8 days postinjury demonstrated a mean absolute change in EES of 5.4 mm. Forty-one percentage of patients had >5 mm of change in EES. When analyzing changes in shortening relative to the specific threshold of 20 mm, 18 patients (41%) with <20 mm EES increased to ≥20 mm EES, and 19 patients (19%) with ≥20 mm EES decreased to <20 mm EES at 2-week follow-up.

CONCLUSIONS

Clinically significant changes in fracture shortening occurred in 41% of adolescents with completely displaced clavicle fractures in the first 2 weeks after injury. In 26% of patients, this resulted in a change from above or below the commonly used shortening threshold of 20 mm, potentially altering the treatment plan by many providers. There is no evidence to suggest that adolescent clavicle fracture shortening affects outcomes, and as such, the authors do not advocate for the use of this parameter to guide treatment. However, among physicians who continue to use this parameter to guide treatment, this study supports that repeat radiographic assessment 2 weeks postinjury may be a better measure of the true shortening of this common adolescent injury.

LEVEL OF EVIDENCE

Level IV-case series.

Management and subsequent outcomes of patellar sleeve injuries: A retrospective case series of 90 pediatric and adolescent patients

Purpose

This study aims to report the epidemiology of patellar sleeve injuries, describe diagnostic findings and treatment, and assess functional outcomes following different treatments.

Methods

A medical database was queried from 1990 to 2016 to identify patients ≤18 years presenting to a single pediatric institution with a patellar sleeve injury. Patients with significant comorbidities or previously operatively treated for ipsilateral knee injuries were excluded. Standard demographic data, mechanism of injury, skeletal maturity, injury-related radiographic parameters, along with treatment paradigms, post-treatment clinical and radiographic findings, and patient-reported outcomes were collected.

Results

A total of 90 patients, mean age of 10.7 years (range: 7-17) was included, of which 69 (77%) were male. Seventy-three percent of all injuries occurred while playing sports (particularly football/basketball/soccer), with "direct blow" or "landing" being the most prevalent mechanisms of injury. Twenty-six (29%) underwent operative treatment, with transosseous suture fixation being the most popular surgical technique (73%). Of the 64 (71%) non-operatively treated patients, 18 (39%) were placed in a hinged knee brace locked in extension with the remainder split between casting and standard knee immobilizer. Compared to the non-operative cohort, a higher percentage of the operative group had a pre-treatment extensor lag (p < 0.001) and greater fragment displacement (p < 0.001) with patella alta (p < 0.001) on imaging. There was no difference in outcome scores (Pedi-IKDC/Lysholm) or patella alta on radiographs between groups. Post-treatment surveys indicated no difference in residual pain or ability to return to sport.

Conclusion

This large case series provides valuable epidemiologic, clinical, and radiographic data describing patellar sleeve fractures, along with outcomes following non-operative and operative treatments.

Level of evidence

IV.

5-Year Radiographic and Functional Outcomes of Nonoperative Treatment of Completely Displaced Midshaft Clavicular Fractures in Teenagers

BACKGROUND

Optimal treatment of completely displaced midshaft clavicular fractures in adolescents remains controversial, with some favoring surgical management and others favoring a nonoperative approach. Few studies have comprehensively assessed longer-term nonoperative outcomes.

PURPOSE

To prospectively assess patient-reported outcomes (PROs) and radiographic remodeling ≥5 years after injury in teenagers undergoing nonoperative treatment of completely displaced clavicular fractures.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Adolescent patients previously enrolled in a prospective study from a single institution with nonoperatively treated, completely displaced midshaft clavicular fractures ≥5 years from injury were eligible for the study. Patients were clinically evaluated for scapular dyskinesia and strength deficits. Bilateral clavicular imaging assessed residual shortening, displacement, and angulation. PROs included the American Shoulder and Elbow Surgeons (ASES), the shortened version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH), Marx Shoulder Activity Scale, cosmesis, and return to sports data.

RESULTS

A total of 24 patients were available for the follow-up, of whom 17 (71%) consented to additional imaging. The mean cohort age at the time of injury was 14.5 ± 1.1 years, with 88% being male. At a mean follow-up of 6.1 years, all fractures had healed, with no patient requiring secondary interventions. Significant remodeling was observed across all measurements, with improvements of 70% in shortening (22.8 to 6.8 mm; P < .001), 73% in superior displacement (13.4 to 3.6 mm; P < .001), and 83% in angulation (10.4° to 1.8°; P < .001). Thirteen patients (72%) had a >2-cm initial shortening, and all remodeled to <2 cm. PROs were almost universally excellent, with mean ASES, QuickDASH, and Marx activity scores of 99 ± 3, 1 ± 3, and 20 ± 1, respectively, with 79% of patients reporting perfect scores in all 3 domains. Most patients (58%) were completely satisfied with their shoulder appearance, 38% were more satisfied than not, 1 patient (4%) was neither satisfied nor dissatisfied, and no patients were dissatisfied. All patients except 1 who were interested in sports returned to sporting activities. PROs were not associated with bony remodeling (P > .05).

CONCLUSION

Teenaged patients with completely displaced clavicular fractures treated nonoperatively can expect excellent radiographic and clinical outcomes 5 years after injury.

Prevalence and Predictors of Concomitant Meniscal Surgery During Pediatric and Adolescent ACL Reconstruction: Analysis of 4729 Patients Over 20 Years at a Tertiary-Care Regional Children's Hospital

Background

The rate of concomitant meniscal procedures performed in conjunction with anterior cruciate ligament (ACL) reconstruction is increasing. Few studies have examined these procedures in high-risk pediatric cohorts.

Hypotheses

That (1) the rates of meniscal repair compared with meniscectomy would increase throughout the study period and (2) patient-related factors would be able to predict the type of meniscal operation, which would differ according to age.

Study Design

Cohort study (prevalence); Level of evidence, 2.

Methods

Natural language processing was used to extract clinical variables from notes of patients who underwent ACL reconstruction between 2000 and 2020 at a single institution. Patients were stratified to pediatric (5-13 years) and adolescent (14-19 years) cohorts. Linear regression was used to evaluate changes in the prevalence of concomitant meniscal surgery during the study period. Logistic regression was used to determine predictors of the need for and type of meniscal procedure.

Results

Of 4729 patients (mean age, 16 ± 2 years; 54.7% female) identified, 2458 patients (52%) underwent concomitant meniscal procedures (55% repair rate). The prevalence of lateral meniscal (LM) procedures increased in both pediatric and adolescent cohorts, whereas the prevalence of medial meniscal (MM) repair increased in the adolescent cohort (P = .02). In the adolescent cohort, older age was predictive of concomitant medial meniscectomy (P = .031). In the pediatric cohort, female sex was predictive of concomitant MM surgery and of undergoing lateral meniscectomy versus repair (P≤ .029). Female sex was associated with decreased odds of concomitant LM surgery in both cohorts (P≤ .018). Revision ACLR was predictive of concomitant MM surgery and of meniscectomy (medial and lateral) in the adolescent cohort (P < .001). Higher body mass index was associated with increased odds of undergoing medial meniscectomy versus repair in the pediatric cohort (P = .03).

Conclusion

More than half of the young patients who underwent ACLR had meniscal pathology warranting surgical intervention. The prevalence of MM repair compared with meniscectomy in adolescents increased throughout the study period. Patients who underwent revision ACLR were more likely to undergo concomitant meniscal surgeries, which were more often meniscectomy. Female sex had mixed effects in both the pediatric and adolescent cohorts.

Knee Flexion Angle of Fixation During Anterolateral Ligament Reconstruction or Lateral Extra-articular Tenodesis: A Systematic Review and Meta-analysis of Lateral Extra-articular Reinforcement Techniques Performed in Conjunction With ACL Reconstruction

Background

Anterolateral ligament reconstruction (ALLR) or lateral extra-articular tenodesis (LET) is being used more frequently in conjunction with anterior cruciate ligament reconstruction (ACLR). However, the knee flexion angle at which fixation of ALLR or LET is performed during the procedure is quite variable based on existing technique descriptions.

Purpose/Hypothesis

The purpose of this study was to identify whether flexion angle at the time of ALLR/LET fixation affected postoperative outcomes in a clinical population. It was hypothesized that ALLR/LET fixation at low versus high flexion angles would lead to no statistically significant differences in patient-reported outcome measures and graft failure rates.

Study Design

Systematic review; Level of evidence, 4.

Methods

The PubMed, Embase, and Cochrane Library databases were searched according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to identify published clinical studies of ACLR with ALLR/LET in which the knee flexion angle at the time of ALLR/LET was reported. A priori, low flexion was defined as 0° to 30°, and high flexion was defined as 60° to 90°. Studies were excluded if the flexion angle was between 31° and 59° because these angles constituted neither low nor high flexion angles and including them in an analysis of high versus low flexion angle at fixation would have biased the study results toward the null. The overall risk of bias was assessed using the Newcastle-Ottawa Scale. The pooled results of the studies were analyzed using the International Knee Documentation Committee (IKDC), Lysholm, and Tegner scores, along with reported graft failure rates.

Results

A total of 32 clinical studies (5230 patients) met inclusion criteria: 22 studies (1999 patients) in the low-flexion group and 10 studies (3231 patients) in the high-flexion group. The median Newcastle-Ottawa Scale score was 6. Comparisons of patients with a low flexion angle versus a high flexion angle demonstrated no differences in the IKDC (P = .84), Lysholm (P = .67), or Tegner (P = .44) scores or in graft failure (3.4% vs 4.1%, respectively; P = .69).

Conclusion

The results of this review indicated that ACLR performed in conjunction with ALLR/LET provides good to excellent patient-reported outcomes and low graft failure rates when ALLR/LET fixation is performed in either low or high knee flexion.

Association Between Posterior Tibial Slope and ACL Injury in Pediatric Patients: A Systematic Review and Meta-analysis

BACKGROUND

The posterior tibial slope (PTS) has been proposed to be a radiographic risk factor for anterior cruciate ligament (ACL) injury in adults. However, this has not been well established in pediatric patients.

PURPOSE

This systematic review and meta-analysis was performed to investigate any association between PTS and ACL tears in the pediatric population.

STUDY DESIGN

Systematic review and meta-analysis; Level of evidence, 4.

METHODS

A systematic review was performed to identify studies that examined the relationship between PTS, medial tibial slope (MTS), and lateral tibial slope (LTS) and ACL tears in children and adolescents aged ≤18 years. Full-text observational studies comparing PTS, MTS, and/or LTS values between pediatric (≤18 years of age) patients with and without ACL injury were included in this analysis. Review articles and case series were excluded. The authors calculated the mean difference (MD) via a restricted maximum-likelihood estimator for tau square and a Hartung-Knapp adjustment for random-effects model.

RESULTS

A total of 348 articles were identified in the initial database search, yielding 10 for final inclusion and analysis. There was no statistically significant association between PTS (MD, 1.13°; 95% CI, -0.55° to 2.80°; P = .10), MTS (MD, 0.36°; 95% CI, -0.37° to 1.10°; P = .27), or LTS (MD, 1.41°; 95% CI, -0.20° to 3.02°; P = .075) and risk for ACL injury in this population.

CONCLUSION

The current study found that unlike what has been shown in adult populations, increased PTS may not be a significant risk factor for ACL tears in pediatric and adolescent patents. LTS was the only measured parameter that neared statistical significance, perhaps suggesting a potential role for this measurement in determining ACL risk if further research is done in this population.

Prevalence and Predictors of Concomitant Meniscal and Ligamentous Injuries Associated With ACL Surgery: An Analysis of 20 Years of ACL Reconstruction at a Tertiary Care Children's Hospital

BACKGROUND

There is an increasing rate of procedures being performed for concomitant injuries during anterior cruciate ligament (ACL) surgery. Few studies have examined risk factors for these associated injuries in young patients.

HYPOTHESIS

There are patient-related factors predictive of concomitant knee pathology that differ between age-based cohorts.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Natural language processing was used to extract clinical variables from available notes of patients undergoing ACL surgery between 2000 and 2020 at a single institution (5174 ACL surgeries; mean age, 17 ± 4 years; 53.1% female; accuracy, >98%). Patients were stratified to pediatric (5-13 years), adolescent (14-19 years), and young adult (20-35 years) cohorts. Logistic regression was used to determine predictors of concomitant injury to the menisci, medial collateral ligament (MCL), posterolateral corner (PLC), and posterior cruciate ligament (PCL).

RESULTS

Between 2000 and 2020, 54% of pediatric, 71% of adolescent, and 70% of adult patients had ≥1 concomitant soft tissue injury. In children and adolescents, increased age was consistently predictive of sustaining a concomitant injury (P < .02). Female children had increased odds of concomitant medial meniscal injury, while female adults had decreased odds (P≤ .046). Adolescent and adult female patients had decreased odds of concomitant lateral meniscal injury (P≤ .027). Female children had increased odds of injury to the MCL (P = .015), whereas female children and adolescents had decreased odds of PCL injury (P≤ .044). Adolescents undergoing revision ACL surgery had increased odds of meniscal injury (P≤ .001) and decreased odds of concomitant MCL injury (P = .028). Increased body mass index (BMI) was associated with increased odds of concomitant medial meniscal injury in all cohorts (P≤ .041), lateral meniscal injury in adults (P = .045), and PLC injury in children (P = .016). Contact injuries were associated with increased odds of MCL injury in adolescents (P = .017) and PLC injury in adolescents and adults (P < .014).

CONCLUSION

These findings support the hypothesis, as there were multiple factors that significantly affected the risk of concomitant injuries that differed between cohorts. Increased age, BMI, and contact injury history were generally associated with increased odds of sustaining a concomitant injury, whereas female sex and revision ACL surgery had mixed effects. Further studies are essential to investigate the sex-based differences in risk for concomitant injuries and to develop tailored treatment plans that minimize the risk of secondary ACL injury.

Does Tibial Tuberosity Osteotomy Improve Outcomes When Combined With Medial Patellofemoral Ligament Reconstruction in the Presence of Increased Tibial Tuberosity-Trochlear Groove Distance? A Systematic Review and Meta-analysis

Background

There has been recent debate regarding the optimal surgical management strategy for recurrent patellofemoral instability in the presence of an increased tibial tuberosity-trochlear groove (TT-TG) distance. In particular, performing a combined tibial tuberosity osteotomy (TTO) and medial patellofemoral ligament reconstruction (MPFLR) for patients with a TT-TG >20 mm has been questioned, with the hypothesis that an isolated MPFLR (iMPFLR) would be just as effective.

Purpose

To pool and compare outcomes after MPFLR+TTO versus iMPFLR in patients with a TT-TG >20 mm.

Study Design

Systematic review; Level of evidence, 4.

Methods

PubMed-MEDLINE, Embase, Web of Science, and Cochrane Central were searched, and a systematic review was performed. Included were studies that reported postoperative redislocation rates and/or functional outcome scores for patients with recurrent patellar instability and a TT-TG >20 mm who underwent either MPFLR+TTO or iMPFLR and had minimum 2-year follow-up data. Methodologic quality was assessed using the modified Coleman Methodology Score (mCMS). A proportional meta-analysis comparing redislocation, subjective instability, and total complication rates was performed, and mean postoperative functional outcome scores were pooled using a random-effects model with a restricted maximum likelihood estimator.

Results

In total, 1548 studies were screened, from which 13 were included for analysis. Of the 386 included patients (406 knees), 276 underwent MPFLR+TTO and 110 underwent iMPFLR. The mean mCMS was 61.3 ± 10.5 (range, 48-77). The pooled postoperative redislocation rate was 1.22% (95% CI, 0.22%-7%), with no significant difference between the study groups (P = .9995). The pooled complication rate was 10.17% (95% CI, 6.2%-16.3%) with no difference between groups (P = .9275), although the MPFLR+TTO group had higher heterogeneity in complication rates (I2 = 79.4%) compared with iMPFLR (I2 = 0%). There was no group difference in the pooled postoperative Lysholm scores (P = .5177), but patients who underwent iMPFLR had significantly higher postoperative Kujala scores compared with those who underwent MPFLR+TTO (P = .0283).

Conclusion

Even in the presence of previously indicative anatomic factors (TT-TG >20 mm), TTO combined with MPFLR does not seem to confer additional benefit compared with iMPFLR. This finding could be advantageous in minimizing the burden of additional surgery with its associated risks. The study findings should, however, be interpreted with caution given the heterogeneity of the studies.

Adolescent and young adult hip and knee strength profiles relate to running gait biomechanics

OBJECTIVES

Compare and assess relationships between strength and running biomechanics among healthy adolescents and young adult males and females.

DESIGN

Retrospective cohort.

SETTING

Clinic.

PARTICIPANTS

802 healthy participants (570 F, 232 M; 16.6 ± 2.3 years).

MAIN OUTCOME MEASURES

Mass-normalized knee flexor and extensor strength, hip adductor and abductor strength, hamstrings-to-quadriceps (H:Q), and abductor-to-adductor (Abd:Add) ratios were obtained using hand-held dynamometry. Mass-normalized peak vertical ground reaction force (vGRF), %stance, cadence, and stride length were obtained using an instrumented treadmill. Multivariate analyses of variance were used to compare strength and biomechanics across ages and sexes. Linear regressions were used to assess the relationships between strength and biomechanics, accounting for speed, age, and sex. Independent t-tests were used to compare strength between strength ratio profiles.

RESULTS

Strength and running biomechanics significantly differed between sexes (p-range: <0.001-0.05) and age groups (p-range: <0.001-0.02). Strength and strength ratios were significantly associated with increased cadence (p-range:0.001-0.04) and stride lengths (p-range:0.004-0.03), and decreased vGRF (p < 0.001). Lower H:Q ratios had significantly lower strength measures (p < 0.001). Higher Abd:Add ratios had significantly increased abductor strength (p < 0.001).

CONCLUSIONS

Strength and running biomechanics differed by sexes and ages. Hip and knee strength and strength ratios were related to select spatiotemporal and kinetic biomechanical features.

Intrarater and Interrater Reliability of Radiographic Characteristics in Skeletally Immature Patients With Anterior Cruciate Ligament Tears: A PLUTO Study Group Reliability Study

BACKGROUND

Radiographic measurements of limb alignment in skeletally immature patients with anterior cruciate ligament (ACL) tears are frequently used for surgical decision-making, preoperative planning, and postoperative monitoring of skeletal growth. However, the interrater and intrarater reliability of these radiographic characteristics in this patient population is not well documented.

HYPOTHESIS

Excellent reliability across 4 raters will be demonstrated for all digital measures of length, coronal plane joint orientation angles, mechanical axis, and tibial slope in skeletally immature patients with ACL tears.

STUDY DESIGN

Cohort study (diagnosis).

METHODS

Three fellowship-trained orthopaedic surgeons and 1 medical student performed 2 rounds of radiographic measurements on digital imaging (lateral knee radiographs and long-leg radiographs) of skeletally immature patients with ACL tears. Intrarater and interrater reliability for continuous radiographic measurements was assessed with intraclass correlation coefficients (ICCs) across 4 raters with 95% CIs for affected and unaffected side measurements. Interrater reliability analysis used an ICC (2, 4) structure and intrarater reliability analysis used an ICC (2, 1) structure. A weighted kappa coefficient was calculated for ordinal variables along with 95% CIs for both interrater and intrarater reliability. Agreement statistic interpretations are based on scales described by Fleiss, and Cicchetti and Sparrow: <0.40, poor; 0.40 to 0.59, fair; 0.60 to 0.74, good; and >0.74, excellent.

RESULTS

Radiographs from a convenience sample of 43 patients were included. Intrarater reliability was excellent for nearly all measurements and raters. Interrater reliability was also excellent for nearly all reads for all measurements.

CONCLUSION

Radiographic reliability of long-leg radiographs and lateral knee x-rays in skeletally immature children with ACL tears is excellent across nearly all measures and raters and can be obtained and interpreted as reliable and reproducible means to measure limb length and alignment.

LEVEL OF EVIDENCE

Level III.

MRI Analysis of Knee Bony Morphology Variations in Children and Adolescents With Lateral Discoid Meniscus Compared With Asymptomatic Healthy Controls

BACKGROUND

Lateral discoid meniscus accounts for most meniscal tears in children 10 years of age and younger. The role of bony morphology in discoid meniscus has been previously studied in a limited capacity using radiographs.

PURPOSE

To use magnetic resonance imaging to measure features of the femoral condyles and tibial plateaus in patients with discoid meniscus to assess potential determinants of symptoms and subsequent surgery and to compare with matched controls to investigate age-related changes in bony features.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

After institutional review board approval, detailed morphology of the femoral condyles and tibial plateau was measured in 177 patients (3-18 years of age; 56% female) with confirmed lateral discoid meniscus. Measurements from 269 participants (3-18 years of age; 55% female) with asymptomatic knees were used as controls. Two-way analysis of variance with Holm-Šídák post hoc was used to compare measurements between discoid menisci and matched controls. Independent t tests were used to compare aspects of bony morphology within the discoid meniscus cohort.

RESULTS

Compared with controls, patients with a lateral discoid meniscus had a larger bicondylar width and notch width (7- to 10-year-old and 15- to 18-year-old age groups; P < .05), larger tibial plateau width (11- to 14-year-old and 15- to 18-year-old age groups; P < .001), and smaller lateral (P < .02) and coronal (P < .02) tibial slopes across all age groups. Among patients with a discoid meniscus, larger bicondylar width, larger tibial plateau width, larger notch width, and a flatter lateral femoral condyle were associated with pain (P < .005) and lateral meniscal tears (P < .02). Larger notch width and notch width index were also associated with subsequent surgery (P < .05).

CONCLUSION

There are clinically significant abnormalities in bony morphology in patients with a discoid meniscus, including larger femoral condyles and tibial plateaus and a flatter tibial plateau. Additionally, femoral size, femoral curvature, and tibial plateau size may influence the likelihood of knee pain, meniscal tear, and need for surgery. These findings highlight the importance of bony morphology in discoid meniscus pathophysiology in children and adolescents. Such measurements may also aid radiographic detection of discoid meniscus and guide decisions regarding the timing of potential surgical intervention.

Bilateral osteochondritis dissecans of the knee in pediatric and adolescent patients presenting with unilateral symptoms: An epidemiological and radiographic analysis

Purpose

This study aims to determine the prevalence and characteristics of bilateral osteochondritis dissecans of the knee in patients presenting with unilateral symptoms and compare this cohort to patients with unilateral disease.

Methods

Records of patients ≤18 years old from 2003 to 2016 with a diagnosis of osteochondritis dissecans of the knee and strictly unilateral knee pain were identified. Contralateral (asymptomatic) knee imaging within 1 year of initial presentation was required. Lesion characteristics were evaluated by assessing size, location, and Hefti staging. Both surgical and nonoperative treatments were recorded. Patients with unilateral osteochondritis dissecans were compared to those with bilateral disease.

Results

Eighty patients, 63 males (79%) and 17 females (21%), with an average age of 13.1 years old, were included. Twenty (25%) of the presenting/symptomatic lesions were deemed stable on magnetic resonance imaging. A positive correlation between lesion size and Hefti classification was appreciated. Twelve patients (15%) were found to have bilateral osteochondritis dissecans on contralateral imaging. There was no significant difference in skeletal maturity between patients with bilateral versus unilateral disease. Fifty-two patients (77%) with unilateral disease underwent surgical intervention, while 9 (75%) of those with bilateral disease underwent surgery on either knee. In patients with an asymptomatic contralateral lesion, 67% ultimately underwent surgical intervention on the contralateral knee.

Conclusions

In patients presenting with unilateral osteochondritis dissecans symptoms, there was a 15% prevalence of bilateral disease, with no difference in age, sex, physeal status, or lesion characteristics between patients with unilateral vs bilateral osteochondritis dissecans lesions. Given the prevalence of asymptomatic contralateral lesions and the required intervention, this study supports early bilateral radiologic knee evaluation.

Level of evidence

IV, Retrospective Case series.

Development of Anatomic Risk Factors for ACL Injuries: A Comparison Between ACL-Injured Knees and Matched Controls

BACKGROUND

Several tibiofemoral anatomic features have been repeatedly associated with increased anterior cruciate ligament (ACL) injury risk. Previous studies have highlighted age and sex differences among these anatomic risk factors, but little is known about the normal and pathologic development of these differences during skeletal maturation.

PURPOSE

To investigate differences in anatomic risk factors at various stages of skeletal maturation between ACL-injured knees and matched controls.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

After institutional review board approval, magnetic resonance imaging scans from 213 unique ACL-injured knees (age, 7-18 years, 48% female) and 239 unique asymptomatic ACL-intact knees (age, 7-18 years, 50% female) were used to measure femoral notch width, posterior slope of the lateral and medial tibial plateau, medial and lateral tibial spinal height (MTSH, LTSH), medial tibial depth, and posterior lateral meniscus-bone angle. Linear regression was performed to assess change in quantified anatomic indices with age for male and female patients in the ACL-injured cohort. Two-way analysis of variance with Holm-Sidak post hoc testing was performed to compare anatomic indices between ACL-injured knees and ACL-intact controls in each age group.

RESULTS

In the ACL-injured cohort, notch width, notch width index and medial tibial depth increased with age (R2 > 0.1; P < .001) in both sexes. MTSH and LTSH increased with age only in boys (R2≥ 0.09; P≤ .001), whereas meniscus-bone angle decreased with age only in girls (R2 = 0.13; P < .001). There were no other age differences in quantified anatomic indices. Patients with ACL injury consistently had a significantly higher lateral tibial slope (P < .01) and smaller LTSH (P < .001) as compared with ACL-intact controls across all age groups and sexes. When compared with age- and sex-matched ACL-intact controls, ACL-injured knees had a smaller notch width (boys, 7-18 years; girls, 7-14 years; P < .05), larger medial tibial slope (boys and girls, 15-18 years; P < .01), smaller MTSH (boys, 7-14 years; girls, 11-14 years; P < .05), and larger meniscus-bone angle (girls, 7-10 years; P = .050).

CONCLUSION

The consistent morphologic differences throughout skeletal growth and maturation suggest a developmental role in high-risk knee morphology. The observed high-risk knee morphology at an earlier age preliminarily suggests the potential of knee anatomy measurements in identifying those with a predisposition toward ACL injury.

Effect of Age and Sex on Psychological Readiness and Patient-Reported Outcomes 6 Months After Primary ACL Reconstruction

Background

Successful return to sport after anterior cruciate ligament (ACL) reconstruction (ACLR) can be affected by a patient's physical and psychological state throughout the rehabilitation process.

Purpose

To prospectively compare differences in patients at 6 months after primary ACLR with the ACL-Return to Sport after Injury (ACL-RSI), International Knee Documentation Committee (IKDC) or pediatric (Pedi)-IKDC, Hospital for Special Surgery Pediatric Functional Activity Brief Scale (Pedi-FABS), and Patient-Reported Outcomes Measurement Information System-Psychological Stress Experiences (PROMIS-PSE) scores.

Study Design

Prospective cohort study; Level of evidence, 2.

Methods

Patients enrolled were 8 to 35 years old who underwent primary ACLR and had their 6-month follow-up appointments between December 2018 and March 2020. Patients were divided into 3 age groups as follows: (1) preadolescents (10-14 years); (2) adolescents (15-18 years); and (3) adults (>18 years). Outcomes on the ACL-RSI, IKDC/Pedi-IKDC, Pedi-FABS, and PROMIS-PSE were compared according to age group, graft type (hamstring, patellar tendon, quadriceps, or iliotibial band autograft), and sex.

Results

A total of 176 patients (69 male, 107 female), with a mean age of 17.1 ± 3.1 years were included in the study. The mean ACL-RSI scores were significantly different among age groups (preadolescents, 75 ± 18.9; adolescents, 61.5 ± 20.4; and adults, 52.5 ± 19.8 [P < .001]) and graft types (P = .024). The IKDC and PROMIS-PSE scores were also significantly different among age groups (P < .001 and P = .044, respectively) and graft types (P = .034 and P < .001, respectively), with the iliotibial graft and the younger age group performing the best. There was no significant difference in the Pedi-FABS either by age group (P = .127) or graft type (P = .198). Female patients had lower ACL-RSI scores and higher (worse) scores on PROMIS-PSE than their male counterparts (P = .019 and P < .001, respectively), with no sex-based differences on IKDC or Pedi-FABS scores. The ACL-RSI and IKDC were positively correlated (Spearman r = 0.57; P < .001), while the ACL-RSI and PROMIS-PSE were negatively correlated (Pearson r = -0.34; P < .001).

Conclusion

This study suggests that psychological profiles and subjective perceptions of knee function 6 months after ACLR may vary in patients of different ages and between the sexes. Preadolescent patients had better scores on a majority of patient-reported outcomes compared with adolescent and adult patients.

Transarticular Versus Retroarticular Drilling of Stable Osteochondritis Dissecans of the Knee: A Prospective Multicenter Randomized Controlled Trial by the ROCK Group

BACKGROUND

When stable osteochondritis dissecans (OCD) lesions of the femoral condyle in a skeletally immature patient fail to heal with nonoperative methods, the standard of care treatment is condylar OCD drilling. Two primary OCD drilling techniques have been described, but no prospective studies have compared their relative effectiveness.

PURPOSE/HYPOTHESIS

The purpose of this study was to compare the healing and function after transarticular drilling (TAD) with that after retroarticular drilling (RAD). It was hypothesized that there would be no difference in rate or time to healing, rate or time to return to sports, patient-reported outcomes (PROs), or secondary OCD-related surgery.

STUDY DESIGN

Randomized controlled clinical trial; Level of evidence, 1.

METHODS

Skeletally immature patients with magnetic resonance imaging-confirmed stable OCD lesions of the medial femoral condyle who did not demonstrate substantial healing after a minimum of 3 months of nonoperative treatment were prospectively enrolled by 1 of 17 surgeon-investigators at 1 of 14 centers. Patients were randomized to the TAD or RAD group. Tourniquet time, fluoroscopy time, and complications were compared between the treatment groups. Postoperatively, serial radiographs were obtained every 6 weeks to assess healing, and PROs were obtained at 6 months, 12 months, and 24 months.

RESULTS

A total of 91 patients were included, consisting of 51 patients in the TAD and 40 patients in the RAD group, who were similar in age, sex distribution, and 2-year PRO response rate. Tourniquet time and fluoroscopy time were significantly shorter with TAD (mean, 38.1 minutes and 0.85 minutes, respectively) than RAD (mean, 48.2 minutes and 1.34 minutes respectively) (P = .02; P = .004). In the RAD group, chondral injury from K-wire passage into the intra-articular space was reported in 9 of 40 (22%) patients, but no associated postoperative clinical sequelae were identified in these patients. No significant differences between groups were detected in follow-up Pediatric-International Knee Documentation Committee, Lysholm, Marx Activity Scale, or Knee injury and Osteoarthritis Outcome Score Quality of Life scores. Healing parameters were superior at 6 months and 12 months in the TAD group, compared with the RAD group, and secondary OCD surgery occurred in 4% of patients who underwent TAD and 10% of patients who underwent RAD (P = .40). Patients in the TAD group returned to sports earlier than those in the RAD group (P = .049).

CONCLUSION

TAD showed shorter operative time and fluoroscopy time and superior healing parameters at 6 and 12 months, but no differences were seen in 24-month healing parameters or PROs at all follow-up time points, when compared with RAD.

REGISTRATION

NCT01754298 (ClinicalTrials.gov identifier).

Factors Associated With Meniscal and Articular Cartilage Injury in the PLUTO Cohort

BACKGROUND

Anterior cruciate ligament (ACL) injuries in adults are frequently accompanied by meniscal and articular cartilage damage. However, little is known regarding the association, if any, between physical maturity, hypermobility, or bone bruising and these associated injuries in skeletally immature patients with ACL tears.

PURPOSE

To determine if physical maturity, hypermobility, and/or bone bruising is associated with concomitant meniscal and articular cartilage injury in skeletally immature patients with ACL tears.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

At 10 institutions in the United States, consecutive skeletally immature patients with complete ACL tears were enrolled between January 2016 and June 2020. Univariable and multivariable logistic regression analysis was used to assess the effect of variables on the likelihood of articular cartilage and meniscal injury.

RESULTS

A total of 748 patients were analyzed. Of these, 85 patients (11.4%) had articular cartilage injuries. These patients had a higher bone age (13.9 vs 13.1 years; P = .001), a higher Tanner stage (P = .009), and increased height (162.9 vs 159.9 cm; P = .03) and were heavier (57.8 vs 54.0 kg; P = .02). For each additional Tanner stage, the odds of articular cartilage injury increased approximately 1.6 times (P < .001). Of the total patients, 423 (56.6%) had meniscal tears. Those with meniscal tears were older (12.6 vs 12.0 years; P < .001), had a higher bone age (13.5 vs 12.8 years; P < .001), had a higher Tanner stage (P = .002), had increased height (162.2 vs 157.6 cm; P < .001), and were heavier (56.6 vs 51.6 kg; P < .001). For each additional Tanner stage, the odds of a meniscal tear increased approximately 1.3 times (P < .001). No association was detected between hypermobility or bone bruising and the likelihood of articular cartilage or meniscal injury. Multivariable regression revealed that increasing Tanner stage was associated with an increasing risk of articular cartilage injury, while weight was associated with an increasing risk of meniscal injury.

CONCLUSION

Increasing physical maturity is associated with increased risks of concomitant articular cartilage and meniscal injury in skeletally immature patients with ACL tears. Hypermobility and bone bruising are not associated with articular cartilage or meniscal injury, suggesting that physical maturity, rather than ligamentous laxity, is the primary risk factor for associated injuries in skeletally immature patients with an ACL tear.

Bony Remodeling of Adolescent Displaced Clavicle Fractures: A FACTS Study

BACKGROUND

Bony remodeling of displaced clavicle fractures in adolescents remains poorly understood.

PURPOSE

To evaluate and quantify clavicle remodeling in a large population of adolescents with completely displaced fractures, which were treated nonoperatively, to better understand the factors that may influence this process.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Patients were identified from the databases of a multicenter study group investigating the functional outcomes of adolescent clavicle fractures. Patients between the ages of 10 and 19 years with completely displaced middiaphyseal clavicle fractures that were treated nonoperatively and who had further radiographic imaging of the affected clavicle at a minimum of 9 months from initial injury were included. Fracture shortening, superior displacement, and angulation were measured on the injury and final follow-up radiographs using previously validated techniques. Furthermore, fracture remodeling was classified as complete/near complete, moderate, or minimal, using an original classification system found to have good to excellent reliability (interobserver reliability = 0.78, intraobserver reliability = 0.90). Classifications were subsequently analyzed quantitatively and qualitatively to determine the factors associated with deformity correction.

RESULTS

Ninety-eight patients (mean age, 14.4 ± 2.0 years) were analyzed at a mean radiographic follow-up of 3.4 ± 2.3 years. Fracture shortening, superior displacement, and angulation significantly improved during the follow-up period by 61%, 61%, and 31%, respectively (P < .001). Furthermore, while 41% of the population had initial fracture shortening >20 mm at final follow-up, only 3% of the cohort had residual shortening >20 mm. Fracture remodeling was found to be associated with follow-up time; those with longer follow-up time demonstrated more remodeling (P = .001). Eighty-five percent of patients aged <14 years and 54% of patients aged ≥14 years at time of injury with a minimum follow-up of 4 years underwent complete/near-complete remodeling.

CONCLUSION

Significant bony remodeling occurs in adolescent patients with completely displaced clavicle fractures, including older adolescents, and appears to continue over longer time intervals, even beyond the adolescent years. This finding may help explain the low rate of symptomatic malunions in adolescents, even in severely displaced fractures, and particularly when compared with rates reported in adult studies.

Osteochondritis dissecans of the knee: Imaging, instability concept, and criteria

Osteochondritis dissecans of the knee is an idiopathic, focal, subchondral-bone abnormality that can cause instability or detachment of a bone fragment and overlying articular cartilage, with subsequent progression to osteoarthritis. The degree of lesion instability is best assessed by magnetic resonance imaging. Unstable lesions require operative management with fragment fixation. Level of evidence: V.

Pediatric anterior cruciate ligament tears and associated lesions: Epidemiology, diagnostic process, and imaging

The incidence of anterior cruciate ligament injuries in skeletally immature patients has increased in recent years. The gold standard treatment of this type of trauma in children is not yet established. Conservative management may underestimate the risk of new meniscal and chondral tears; on the other hand, a more interventional approach may expose the patient to iatrogenic damage to the growth plate. A correct approach to the skeletally immature patient with knee trauma is therefore essential to guide the decision-making process. This review article aims to present an update on the epidemiology and diagnostic process of pediatric patients with anterior cruciate ligament tears and possible associated injuries. Level of Evidence: V.

Physeal-Sparing Anterior Cruciate Ligament Reconstruction with Iliotibial Band Autograft in the Skeletally Immature Knee

Conventional adult anterior cruciate ligament reconstruction techniques are controversial in skeletally immature patients due to the risk of iatrogenic physeal damage and potential growth disturbance. The physeal-sparing, combined intra- and extra-articular anterior cruciate ligament reconstruction using an autogenous iliotibial band was developed to mitigate this risk in prepubescent, skeletally immature patients, with excellent functional outcomes and a low revision rate. This article describes the surgical details of this reproducible reconstruction technique.

Two-Year Functional Outcomes of Operative vs Nonoperative Treatment of Completely Displaced Midshaft Clavicle Fractures in Adolescents: Results From the Prospective Multicenter FACTS Study Group

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).

Knowledge, Attitudes, and Practices in the Orthopaedic Care of Sexual and Gender Minority Youth: A Survey of Two Pediatric Academic Hospitals

BACKGROUND

Lesbian, gay, bisexual, transgender, and queer (LGBTQ) children and adolescents continue to experience unmet healthcare needs, partly because of clinician biases, discrimination, and inadequate education. Although clinician attitudes and knowledge related to sexual and gender minority health have been well studied in other medical specialties, these have been scarcely studied in orthopaedics.

QUESTIONS/PURPOSES

(1) What are pediatric orthopaedic healthcare professionals' attitudes (perceived importance, openness, comfort, and confidence) toward caring for sexual and gender minority youth? (2) What do pediatric orthopaedic healthcare professionals know about caring for this patient population? (3) What factors are associated with clinician attitude and/or knowledge? (4) What existing initiatives to improve orthopaedic care for this population are clinicians aware of at their home institutions?

METHODS

All 123 orthopaedic healthcare professionals at two pediatric academic hospitals in the Midwestern and Northeastern United States were sent a 34-question, internet-based, anonymous survey. The survey queried respondent demographics, attitudes, knowledge, and practice behaviors at their home institutions related to the care of sexual and gender minority youth. Respondent attitudes were queried using the Attitudes Summary Measure, which is a survey instrument that was previously validated to assess clinicians' attitudes regarding sexual and gender minority patients. Items used to assess knowledge and practice behaviors were developed by content experts in LGBTQ health and/or survey design, as well as orthopaedic surgeons to improve face validity and to mitigate push-polling. Attitude and knowledge items used a 5-point Likert scale. Sixty-six percent (81 of 123) of clinicians completed the survey. Of those, 47% (38 of 81) were physicians, 73% (59 of 81) were licensed for fewer than 20 years, 63% (51 of 81) were women, and 53% (43 of 81) described themselves as liberal-leaning. The response proportions were 73% (38 of 52) among eligible physicians specifically and 61% (43 of 71) among other clinicians (nurse practitioners, physician assistants, and registered nurses). To assess potential nonresponse bias, we compared early responders (within 2 weeks) with late responders (after 2 weeks) and found no differences in responder demographics or in questionnaire responses (all p > 0.05). The main outcome measures included responses to the attitude and knowledge questionnaire, as well as the existing practices questionnaire. To answer our research questions regarding clinician attitudes knowledge and awareness of institutional initiatives, we compared participant responses using chi-square tests, the Student t-test, and the McNemar tests, as appropriate. To answer our research question on factors associated with questionnaire responses, we reported data for each question, stratified by hospital, years since licensure, and political leaning. Comparisons were conducted across strata using chi-square tests for Likert response items and ANOVA for continuous response items. All p values less than 0.05 were considered significant.

RESULTS

Of the respondents who reported feeling comfortable treating lesbian, gay, and bisexual (sexual minority) youth, a small proportion reported feeling confident in their knowledge about these patients' health needs (99% [80 of 81] versus 63% [51 of 80], 36% reduction [95% confidence interval 23% to 47%]; p < 0.001). Similarly, of those who reported feeling comfortable treating transgender (gender minority) youth, a smaller proportion reported feeling confident in their knowledge of their health needs (94% [76 of 81] versus 49% [37 of 76], 45% reduction [95% CI 31% to 59%]; p < 0.001). There was substantial interest in receiving more education regarding the health concerns of LGBTQ people (81% [66 of 81]) and being listed as an LGBTQ-friendly clinician (90% [73 of 81]). Factors that were associated with select attitude and knowledge items were duration of licensure and political leaning; gender identity, institutional affiliation, educational degree, or having LGBTQ friends and family were not associated. Many respondents were aware of the use of clinic intake forms and the electronic medical record to collect and provide patient gender identity and sexual orientation data at their practice, as well as signage and symbols (for example, rainbow posters) to cultivate LGBTQ-welcoming clinic spaces.

CONCLUSION

There were varying degrees of confidence and knowledge regarding the health needs of sexual and gender minority youth among pediatric orthopaedic healthcare professionals. There was considerable interest in more focused training and better use of medical technologies to improve care for this population.

CLINICAL RELEVANCE

The study findings support the further investment in clinician training opportunities by healthcare administrators and orthopaedic associations related to the care of sexual and gender minority patients, as well as in the expansion of medical documentation to record and report important patient information such as pronouns and gender identity. Simultaneously, based on these findings, clinicians should engage with the increasing number of educational opportunities, explore their personal biases, and implement changes into their own practices, with the ultimate goal of providing equitable and informed orthopaedic care.