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Background: Citation analysis reflects the influence a work has on a field of research and can be used to identify "classic" works and their qualities in medical specialties. By analyzing the characteristics of these works, we intended to determine what qualities make for a highly cited work in pediatric orthopaedic sports medicine., Purpose: To identify the top 25 most cited articles in the field of pediatric orthopaedic sports medicine., Study Design: Cross-sectional study., Methods: The Science Citation Index Expanded feature within the Web of Science database was searched using a Boolean string, generating 2008 pediatric orthopaedic sports medicine articles arranged by number of citations. The top 25 most cited articles were reviewed for authors, year of publication, source journal, country of origin, region of origin, diagnosis or condition of focus, and level of evidence (LOE)., Results: Most of the articles were published in the 2000s (range, 1992-2016). The mean number of citations was 166 (range, 119-329), and the mean citation density was 13.25 (range, 4.25-29.57). There were 18 of 25 studies performed in the United States. A plurality of the articles were published in the American Journal of Sports Medicine . The LOE ranged from 2 to 4, with the most common being level 2 (11/25). Anterior cruciate ligament (ACL) injury management (14/25) and epidemiological studies on the incidence of various sports injuries (6/25) were the most represented topics of study. Since the 1990s, the mean citation density for articles related to ACL injuries in young athletes and the epidemiology of sports injuries has been increasing., Conclusion: This evaluation demonstrated that ACL injuries and the epidemiology of sports injuries had the highest citation density of the most influential studies in pediatric orthopaedic sports medicine. We identified attributes such as country of publication, journal of publication, and LOE that make for a highly cited pediatric orthopaedic sports medicine article. Overall, citation density in pediatric sports medicine is increasing. Nonetheless, the most represented LOE in the most cited works is level 2, with no level 1 studies being represented in the top 25. In terms of both topics and LOE, this study allows surgeons to identify deficiencies in the existing literature and meaningfully design future studies to improve on these., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: R.J.M. has received nonconsulting fees from Philips Electronics North America Corporation; hospitality payments from Globus Medical and Medical Device Business Services; and consulting fees from OrthoPediatrics Corp and Philips Electronics North America Corporation. 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., (© The Author(s) 2024.)

Background: Although the risk of concomitant injury with anterior cruciate ligament (ACL) tears as a function of specific sports participation has been studied in adults, the topic has not been examined in pediatric and adolescent patients., Purpose/hypothesis: The purpose of the study was to determine if certain sports were associated with a higher risk of concomitant injuries in the setting of an ACL tear. It was hypothesized that the risk of concomitant injuries with ACL tears will differ by type of sport participation in the pediatric population., Study Design: Cross-sectional study; Level of evidence, 3., Methods: Patients ≤18 years old from 2 tertiary children's hospitals who had undergone primary ACL reconstruction between 2006 and 2018 were included. Sport at the time of injury, demographic factors, and injury pattern (medial meniscal [MM] tears, lateral meniscal [LM] tears, posterior cruciate ligament [PCL] tears, medial collateral ligament [MCL] tears, lateral collateral ligament [LCL] tears, and any concomitant injury) were identified., Results: A total of 855 patients with a mean age of 15.5 ± 1.7 years (range, 7-22 years) met the inclusion criteria. Of the included patients, 353 (41.3%) had an isolated ACL tear. A concomitant MM tear was identified in 27.6% of patients, LM tear in 42.9%, PCL injury in 0.4%, MCL injury in 3.0%, and LCL injury in 0.5%. There was no difference in the likelihood of concomitant MM injuries by sex (29.3% for male patients vs 26% for female patients; P = .31) or by sex within basketball (29.3% for male patients vs 25.6% for female patients; P = .96) or soccer (32.3% vs 26.3%; P = .06). Boys had higher proportions of LM injuries overall (51.7% for male patients vs 34.6% for female patients; P < .001) but not within the basketball subgroup (50.5% vs 40.0%; P = .86) or the soccer subgroup (59.7% vs 40.0%; P = .19). No statistically significant associations were found between patient age and specific ACL concomitant injury patterns. When stratifying by body mass index, it was found overweight and obese individuals constituted a greater proportion of LM (49.6% vs 39.1%; P = .01) but not MM (29.4% vs 25.5%; P = .28) injuries when compared to normal-weight patients. Using basketball as the comparison group, soccer and football injuries were 18% more likely to result in any concomitant injury, including concomitant MM, LM, PCL, MCL, and LCL injuries., Conclusion: In the pediatric population, soccer and football players were more likely to present with a concomitant injury in addition to ACL injury relative to basketball players. This study aids in understanding sport-associated ACL injury patterns and can help physicians with patient counseling and injury prevention., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: P.D.F. has received consulting fees from WishBone Medical and hospitality payments from Medical Device Business Services. A.G. has received education payments from Rock Medical Orthopedics. R.J.M. has received compensation for services other than consulting from Philips Electronics North America Corp. 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., (© The Author(s) 2024.)

Background: Operative treatment of displaced tibial spine fractures consists of fixation and reduction of the fragment in addition to restoring tension of the anterior cruciate ligament., Purpose: To determine whether residual displacement of the anterior portion of a tibial spine fragment affects the range of motion (ROM) or laxity in operatively and nonoperatively treated patients., Study Design: Cohort study; Level of evidence, 3., Methods: Data were gathered from 328 patients younger than 18 years who were treated for tibial spine fractures between 2000 and 2019 at 10 institutions. ROM and anterior lip displacement (ALD) measurements were summarized and compared from pretreatment to final follow-up. ALD measurements were categorized as excellent (0 to <1 mm), good (1 to <3 mm), fair (3 to 5 mm), or poor (>5 mm). Posttreatment residual laxity and arthrofibrosis were assessed., Results: Overall, 88% of patients (290/328) underwent operative treatment. The median follow-up was 8.1 months (range, 3-152 months) for the operative group and 6.7 months (range, 3-72 months) for the nonoperative group. The median ALD measurement of the cohort was 6 mm pretreatment, decreasing to 0 mm after treatment ( P < .001). At final follow-up, 62% of all patients (203/328) had excellent ALD measurements, compared with 5% (12/264) before treatment. Subjective laxity was seen in 11% of the nonoperative group (4/37) and 5% of the operative group (15/285; P = .25). Across the cohort, there was no association between final knee ROM and final ALD category. While there were more patients with arthrofibrosis in the operative group (7%) compared with the nonoperative group (3%) ( P = .49), this was not different across the ALD displacement categories., Conclusion: Residual ALD was not associated with posttreatment subjective residual laxity, extension loss, or flexion loss. The results suggest that anatomic reduction of a tibial spine fracture may not be mandatory if knee stability and functional ROM are achieved., (© The Author(s) 2023.)

Background: Type 1 tibial spine fractures are nondisplaced or ≤2 mm-displaced fractures of the tibial eminence and anterior cruciate ligament (ACL) insertion that are traditionally managed nonoperatively with immobilization., Hypothesis: Type 1 fractures do not carry a significant risk of associated injuries and therefore do not require advanced imaging or additional interventions aside from immobilization., Study Design: Case series; Level of evidence, 4., Methods: We reviewed 52 patients who were classified by their treating institution with type 1 tibial spine fractures. Patients aged ≤18 years with pretreatment plain radiographs and ≤ 1 year of follow-up were included. Pretreatment imaging was reviewed by 4 authors to assess classification agreement among the treating institutions. Patients were categorized into 2 groups to ensure that outcomes represented classic type 1 fracture patterns. Any patient with universal agreement among the 4 authors that the fracture did not appear consistent with a type 1 classification were assigned to the type 1+ (T1+) group; all other patients were assigned to the true type 1 (TT1) group. We evaluated the rates of pretreatment imaging, concomitant injuries, and need for operative interventions as well as treatment outcomes overall and for each group independently., Results: A total of 48 patients met inclusion criteria; 40 were in the TT1 group, while 8 were in the T1+ group, indicating less than universal agreement in the classification of these fractures. Overall, 12 (25%) underwent surgical treatment, and 12 (25%) had concomitant injuries. Also, 8 patients required additional surgical management including ACL reconstruction (n = 4), lateral meniscal repair (n = 2), lateral meniscectomy (n = 1), freeing an incarcerated medial meniscus (n = 1), and medial meniscectomy (n = 1)., Conclusion: The classification of type 1 fractures can be challenging. Contrary to prior thought, a substantial number of patients with these fractures (>20%) were found to have concomitant injuries. Overall, surgical management was performed in 25% of patients in our cohort., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: H.B.E. has received education payments from Pylant Medical; speaking fees from Pylant Medical, Smith & Nephew, and Synthes; and hospitality payments from Arthrex. P.D.F. has received hospitality payments from Medical Device Business Services. T.J.G. has received education payments from Arthrex. I.K. has received education payments from Arthrex and Smith & Nephew and hospitality payments from DePuy Synthes. R.J.L. has received education payments from Arthrex and hospitality payments from Vericel. S.M. has received education payments from MedInc of Texas. T.A.M. has received education payments from Arthrex and consulting fees from Medtronic, OrthoPediatrics, and Zimmer Biomet. N.M.P. has received education payments from Liberty Surgical and Medwest and speaking fees from Arthrex. J.R. has received research support from Smith & Nephew and consulting fees from OrthoPediatrics. B.S. has received education payments from MidSouth Orthopedics. Y.-M.Y. has received consulting fees from Smith & Nephew and hospitality payments from Kairos Surgical. G.A.S. has received education payments from Arthrex and speaking fees from SIGN. 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., (© The Author(s) 2022.)

Background: Preoperative diagnosis of concomitant meniscal tears in pediatric and adolescent patients with acute anterior cruciate ligament (ACL) deficiency is challenging., Purpose: To investigate the diagnostic performance of magnetic resonance imaging (MRI) in detecting meniscal injuries for pediatric and adolescent patients with acute ACL tears., Study Design: Cohort study (diagnosis); Level of evidence, 2., Methods: The authors retrospectively identified patients aged ≤18 years who underwent acute ACL reconstruction between 2006 and 2018 at 2 tertiary academic hospitals. The primary outcomes were arthroscopically confirmed medial, lateral, or any (defined as medial and/or lateral) meniscal tears. To control for chronically deficient knees, patients must have received their MRI study within 4 weeks of injury and must have undergone surgery no more than 8 weeks after their MRI study. Preoperative MRI reports were compared with the gold standard of arthroscopically confirmed tears to calculate sensitivity, specificity, positive predictive value, and negative predictive value. In a secondary analysis, patients were stratified by age into 2 groups (≤13 or ≥14 years), body mass index-for-age data from the Centers for Disease Control were used to classify patients as obese or nonobese, and differences between sensitivity and specificity proportions were analyzed using chi-square test for homogeneity., Results: Overall, 406 patients with a mean age of 15.4 years (range, 10-18 years) were identified. The sensitivity, specificity, positive predictive value, and negative predictive value were as follows: for lateral meniscal (LM) tears, 51.0%, 86.5%, 78.3%, and 65.0%; for medial meniscal tears, 83.2%, 80.6%, 62.3%, and 92.5%; and for any meniscal tear, 75.0%, 72.1%, 81.5%, and 63.8%, respectively. In the stratified analysis, MRI was less specific for the following diagnoses: any meniscal tear in patients aged ≤13 years ( P = .048) and LM tears in obese patients ( P = .020)., Conclusion: The diagnostic ability of MRI to predict meniscal injuries present at acute ACL reconstruction was moderate. Performance was poorest at the lateral meniscus, where MRI failed to detect 97 tears that were found arthroscopically. Specificity was significantly lower in younger patients for any meniscal tear and in obese patients for LM tears., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: P.D.F. has received hospitality payments from Medical Device Business Services. A.G. has received education payments from Arthrex. M.S. has received consulting fees and royalties from OrthoPediatrics and hospitality payments from Stryker. R.J.M. has received education payments from Arthrex, consulting fees from Medical Device Business Services and OrthoPediatrics, speaking fees from Philips Electronic North America, and hospitality payments from Globus Medical and Medical Device Business Services. 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., (© The Author(s) 2022.)

Background: The uncommon nature of tibial spine fractures (TSFs) may result in delayed diagnosis and treatment. The outcomes of delayed surgery are unknown., Purpose: To evaluate risk factors for, and outcomes of, delayed surgical treatment of pediatric TSFs., Study Design: Cohort study; Level of evidence, 3., Methods: The authors performed a retrospective cohort study of TSFs treated surgically at 10 institutions between 2000 and 2019. Patient characteristics and preoperative data were collected, as were intraoperative information and postoperative complications. Surgery ≥21 days after injury was considered delayed based on visualized trends in the data. Univariate analysis was followed by purposeful entry multivariate regression to adjust for confounders., Results: A total of 368 patients (mean age, 11.7 ± 2.9 years) were included, 21.2% of whom underwent surgery ≥21 days after injury. Patients who experienced delayed surgery had 3.8 times higher odds of being diagnosed with a TSF at ≥1 weeks after injury (95% CI, 1.1-14.3; P = .04), 2.1 times higher odds of having seen multiple clinicians before the treating surgeon (95% CI, 1.1-4.1; P = .03), 5.8 times higher odds of having magnetic resonance imaging (MRI) ≥1 weeks after injury (95% CI, 1.6-20.8; P < .007), and were 2.2 times more likely to have public insurance (95% CI, 1.3-3.9; P = .005). Meniscal injuries were encountered intraoperatively in 42.3% of patients with delayed surgery versus 21.0% of patients treated without delay ( P < .001), resulting in 2.8 times higher odds in multivariate analysis (95% CI, 1.6-5.0; P < .001). Delayed surgery was also a risk factor for procedure duration >2.5 hours (odds ratio, 3.3; 95% CI, 1.4-7.9; P = .006). Patients who experienced delayed surgery and also had an operation >2.5 hours had 3.7 times higher odds of developing arthrofibrosis (95% CI, 1.1-12.5; P = .03)., Conclusion: Patients who underwent delayed surgery for TSFs were found to have a higher rate of concomitant meniscal injury, longer procedure duration, and more postoperative arthrofibrosis when the surgery length was >2.5 hours. Those who experienced delays in diagnosis or MRI, saw multiple clinicians, and had public insurance were more likely to have a delay to surgery., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: R.J.M. has received education payments from Arthrex and DePuy Synthes, consulting fees from OrthoPediatrics and Philips Electronics North America, and hospitality payments from Globus Medical. T.J.G. has received research support from Allosource, Arthrex, and Vericel and education payments from Liberty Surgical. H.B.E. has received education payments from Arthrex, consulting fees from Smith & Nephew, and speaking fees from Synthes. I.K. has received education payments from Arthrex and hospitality payments from DePuy and Smith & Nephew. R.J.L. has received education payments from Arthrex, OrthoPediatrics, and Vericel. S.D.M. has received education payments from Medinc of Texas. T.A.M. has received education payments from Arthrex and consulting fees from Medtronic USA, OrthoPediatrics, and Zimmer Biomet. J.T.R. has received research support from Smith & Nephew and consulting fees from OrthoPediatrics. B.C.S. has received education payments from Midsouth Orthopedics. G.A.S. has received education payments from Arthrex and SIGN. N.M.P. has received education payments from Medwest Associates and Liberty Surgical. 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., (© The Author(s) 2022.)

Background: Tibial spine fractures (TSFs) are typically treated nonoperatively when nondisplaced and operatively when completely displaced. However, it is unclear whether displaced but hinged (type 2) TSFs should be treated operatively or nonoperatively., Purpose: To compare operative versus nonoperative treatment of type 2 TSFs in terms of overall complication rate, ligamentous laxity, knee range of motion, and rate of subsequent operation., Study Design: Cohort study; Level of evidence, 3., Methods: We reviewed 164 type 2 TSFs in patients aged 6 to 16 years treated between January 1, 2000, and January 31, 2019. Excluded were patients with previous TSFs, anterior cruciate ligament (ACL) injury, femoral or tibial fractures, or grade 2 or 3 injury of the collateral ligaments or posterior cruciate ligament. Patients were placed according to treatment into the operative group (n = 123) or nonoperative group (n = 41). The only patient characteristic that differed between groups was body mass index (22 [nonoperative] vs 20 [operative]; P = .02). Duration of follow-up was longer in the operative versus the nonoperative group (11 vs 6.9 months). At final follow-up, 74% of all patients had recorded laxity examinations., Results: At final follow-up, the nonoperative group had more ACL laxity than did the operative group ( P < .01). Groups did not differ significantly in overall complication rate, reoperation rate, or total range of motion (all, P > .05). The nonoperative group had a higher rate of subsequent new TSFs and ACL injuries requiring surgery (4.9%) when compared with the operative group (0%; P = .01). The operative group had a higher rate of arthrofibrosis (8.9%) than did the nonoperative group (0%; P = .047). Reoperation was most common for hardware removal (14%), lysis of adhesions (6.5%), and manipulation under anesthesia (6.5%)., Conclusion: Although complication rates were similar between nonoperatively and operatively treated type 2 TSFs, patients treated nonoperatively had higher rates of residual laxity and subsequent tibial spine and ACL surgery, whereas patients treated operatively had a higher rate of arthrofibrosis. These findings should be considered when treating patients with type 2 TSF., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: T.J.G. has received research support from AlloSource, Arthrex, and Vericel and education payments from Arthrex and Liberty Surgical. H.B.E. has received education payments from Arthrex and Pylant Medical and consulting and speaking fees from Smith & Nephew. R.J.M. has received education payments from DePuy and consulting fees from OrthoPediatrics. Y.-M.Y. has received consulting fees from Smith & Nephew and hospitality payments from Kairos Surgical. D.W.G. has received royalties from Arthrex and Pega Medical. A.I.C. has received education payments from Arthrex. I.K. has received education payments from Smith & Nephew and Arthrex/MedInc. G.A.S. has received education payments from Arthrex and nonconsulting fees from SIGN Fracture Care. J.T.R. has received research support from Smith & Nephew and consulting fees from OrthoPediatrics. B.C.S. has received education payments from Midsouth Orthopedics. R.J.L. has received research support from Arthrex, OrthoPediatrics, and Vericel and education payments from Supreme Orthopedic Systems. 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., (© The Author(s) 2021.)

Background: Functional outcome scores provide valuable data, yet they can be burdensome to patients and require significant resources to administer. The Knee injury and Osteoarthritis Outcome Score (KOOS) is a knee-specific patient-reported outcome measure (PROM) and is validated for anterior cruciate ligament (ACL) reconstruction outcomes. The KOOS requires 42 questions in 5 subscales. We utilized a machine learning (ML) algorithm to determine whether the number of questions and the resultant burden to complete the survey can be lowered in a subset (activities of daily living; ADL) of KOOS, yet still provide identical data., Hypothesis: Fewer questions than the 17 currently provided are actually needed to predict KOOS ADL subscale scores with high accuracy., Study Design: Cohort study (diagnosis); Level of evidence, 2., Methods: Pre- and postoperative patient-reported KOOS ADL scores were obtained from the Surgical Outcome System (SOS) data registry for patients who had ACL reconstruction. Categorical Boosting (CatBoost) ML models were built to analyze each question and its value in predicting the patient's actual functional outcome (ie, KOOS ADL score). A streamlined set of minimal essential questions were then identified., Results: The SOS registry contained 6185 patients who underwent ACL reconstruction. A total of 2525 patients between the age of 16 and 50 years had completed KOOS ADL scores presurgically and 3 months postoperatively. The data set consisted of 51.84% male patients and 48.16% female patients, with a mean age of 29 years. The CatBoost model predicted KOOS ADL scores with high accuracy when only 6 questions were asked ( R 2 = 0.95), similar to when all 17 questions of the subscale were asked ( R 2 = 0.99)., Conclusion: ML algorithms successfully identified the essential questions in the KOOS ADL questionnaire. Only 35% (6/17) of KOOS ADL questions (descending stairs, ascending stairs, standing, walking on flat surface, putting on socks/stockings, and getting on/off toilet) are needed to predict KOOS ADL scores with high accuracy after ACL reconstruction. ML can be utilized successfully to streamline the burden of patient data collection. This, in turn, can potentially lead to improved patient reporting, increased compliance, and increased utilization of PROMs while still providing quality data., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: R.J.M. has received educational support from Arthrex and Depuy, consulting fees from OrthoPediatrics and Philips Healthcare, and hospitality payments from Medical Device Business Services and owns stock/stock options in Right Mechanics. A.G.P. has received educational support from Arthrex/Medinc of Texas and Depuy, grant support from Medtronic, consulting fees from Zimmer Biomet, and hospitality payments from Zimmer Biomet, Stryker, and Smith & Nephew. 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., (© The Author(s) 2020.)

Background: Tibial spine fractures, although relatively rare, account for a substantial proportion of pediatric knee injuries with effusions and can have significant complications. Meyers and McKeever type II fractures are displaced anteriorly with an intact posterior hinge. Whether this subtype of pediatric tibial spine fracture should be treated operatively or nonoperatively remains controversial. Surgical delay is associated with an increased risk of arthrofibrosis; thus, prompt treatment decision making is imperative., Purpose: To assess for variability among pediatric orthopaedic surgeons when treating pediatric type II tibial spine fractures., Study Design: Cross-sectional study., Methods: A discrete choice experiment was conducted to determine the patient and injury attributes that influence the management choice. A convenience sample of 20 pediatric orthopaedic surgeons reviewed 40 case vignettes, including physis-blinded radiographs displaying displaced fractures and a description of the patient's sex, age, mechanism of injury, and predominant sport. Surgeons were asked whether they would treat the fracture operatively or nonoperatively. A mixed-effects model was then used to determine the patient attributes most likely to influence the surgeon's decision, as well as surgeon training background, years in practice, and risk-taking behavior., Results: The majority of respondents selected operative treatment for 85% of the presented cases. The degree of fracture displacement was the only attribute significantly associated with treatment choice ( P < .001). Surgeons were 28% more likely to treat the fracture operatively with each additional millimeter of displacement of fracture fragment. Over 64% of surgeons chose to treat operatively when the fracture fragment was displaced by ≥3.5 mm. Significant variation in surgeon's propensity for operative treatment of this fracture was observed ( P = .01). Surgeon training, years in practice, and risk-taking scores were not associated with the respondent's preference for surgical treatment., Conclusion: There was substantial variation among pediatric orthopaedic surgeons when treating type II tibial spine fractures. The decision to operate was based on the degree of fracture displacement. Identifying current treatment preferences among surgeons given different patient factors can highlight current variation in practice patterns and direct efforts toward promoting the most optimal treatment strategies for controversial type II tibial spine fractures., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: N.N.O. has stock/stock options in Arbutus Medical. J.M.A. has received consulting fees from Axogen, is a paid speaker/presenter for Axogen and Pacira Pharmaceuticals, has received honoraria from NDI Medical, and receives royalties from Springer Publishing. T.J.G. receives research support from Allosource and Vericel and has received educational support from Liberty Surgical and Arthrex. 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.