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Background: Osteochondritis dissecans (OCD) lesions in the knee are most commonly found in the medial femoral condyle (MFC). However, a paucity of literature has explored the characteristics or morphology of patellar OCD lesions., Purpose/hypothesis: The purpose of this study was to analyze patellar tracking and patellofemoral measurements of pediatric patients with patellar OCD compared with patients with MFC OCD. It was hypothesized that the patients with patellar OCD would demonstrate an increased bony sulcus angle, cartilaginous sulcus angle, and tibial tubercle-trochlear groove (TT-TG) distance compared with patients with MFC OCD., Study Design: Case series; Level of evidence, 3., Methods: Patients aged ≤18 years diagnosed with either a patellar or MFC OCD lesion at a single tertiary care hospital between January 2016 and May 2023 were analyzed. Patients with a history of patellar instability were excluded. The Caton-Deschamps index, cartilaginous bony height, trochlear depth, patellar tilt, lateral patellar displacement, cartilaginous sulcus angle, bony sulcus angle, and TT-TG distance were assessed on magnetic resonance imaging (MRI). Patients were matched 1:2 based on sex and chronological age within 2 years between the patellar and MFC OCD groups., Results: A total of 40 extremities in 34 patients with patellar OCD were matched to 80 extremities in 73 patients with MFC OCD. The mean age at the time of MRI was 14.1 ± 2.3 years, and 23% were female. Compared with patients with MFC OCD, patients with patellar OCD had a significantly greater TT-TG distance (11.55 ± 4.15 vs 13.35 ± 4.07 mm, respectively; P = .03). The cartilaginous sulcus angle (150.63°± 7.20° vs 128.09°± 14.07°, respectively; P < .001) and bony sulcus angle (144.70°± 7.78° vs 137.37°± 9.62°, respectively; P < .001) were higher in the patellar OCD group compared with the MFC OCD group. Of patients with patellar OCD, 40% had a TT-TG distance >15 mm, and of patients with MFC OCD, 20% had a TT-TG distance >15 mm. The patellar OCD group had 3.7 times the risk of having a patellar dislocation compared with the MFC OCD group., Conclusion: An increased TT-TG distance and sulcus angle were associated with patellar OCD in pediatric patients. Patients with abnormal patellofemoral morphology who undergo treatment for a patellar OCD lesion may subsequently develop a patellar dislocation; in this study, patients with patellar OCD without a history of patellar dislocations demonstrated a nearly 4-fold higher dislocation rate compared with an age- and sex-matched group of patients with MFC OCD., 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 BICMD and WishBone Medical; has received royalties from Springer; and holds stock in HS2, HSS ASC Development Network, Osso VR, and Joint Effort Administrative Services Organization. D.W.G. has received royalties and consulting fees from Arthrex and OrthoPediatrics. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Background: Although osteochondritis dissecans (OCD) lesions are well-described in the femoral condyles and have been associated with varus limb alignment, there is limited data on OCD lesions in the trochlea., Purpose: To compare the baseline imaging characteristics in pediatric patients with trochlear OCD with those with medial femoral condyle (MFC) OCD to understand whether measures of coronal plane alignment predispose to OCD development by anatomic location., Study Design: Cross-sectional study; Level of evidence, 3., Methods: This study retrospectively reviewed all pediatric patients (age ≤18 years) diagnosed with isolated trochlear OCD at a tertiary-care medical center from January 2016 to May 2023; all included patients had weight-bearing hip-to-ankle alignment radiographs. Hip-knee-ankle angle (HKA), mechanical lateral distal femoral angle (mLDFA), medial proximal tibial angle (MPTA), mechanical axis deviation (MAD), Caton-Deschamps Index (CDI), patellar tilt, and sulcus angle were measured on initial/preoperative anteroposterior and lateral knee radiographs. Tibial tubercle-trochlear groove (TT-TG) distance and OCD lesion size were measured on initial/preoperative magnetic resonance imaging sequences. Patients were 1 to 2 matched based on age (±2 years) and sex to a cohort with isolated MFC OCD., Results: A total of 18 extremities in 16 patients were included in the trochlear OCD cohort and matched to 36 extremities in the MFC OCD cohort. The mean age at the first clinical visit for all patients was 14.8 ± 1.5 years and did not differ significantly between the two groups ( P = .40). The extremities with trochlear OCD had significantly less varus HKA (1°± 2° vs -1°± 2°; P = .004) and MAD (4 ± 8 vs -3 ± 8 mm; P = .004) compared with the MFC cohort as well as lower mLDFA (86°± 2° vs 88°± 2°; P = .004). There were no differences in MPTA, CDI, patellar tilt, sulcus angle, TT-TG distance, or OCD lesion size between groups., Conclusion: Pediatric patients with trochlear OCD had statistically less varus coronal plane alignment compared with age- and sex-matched patients with MFC OCD, with the latter exhibiting more significant varus based on the HKA and MAD., 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. D.W.G. has received consulting fees from OrthoPediatrics, nonconsulting fees from Arthrex and Synthes, and royalties from Arthrex and OrthoPediatrics Canada. 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.)

Objectives: A tibial tubercle-trochlear groove (TT-TG) distance of 20 millimeters (mm) is typically used when determining whether tibial tubercle medialization is performed for the surgical treatment of patellar instability. Without knowledge of how the variability of an individual's TT-TG distance is influenced by through-the-knee femorotibial rotation, the use of a specific TT-TG distance during preoperative planning for patellar instability may lead to incorrect decisions on the use of tibial tubercle medialization. We hypothesized that knee joint internal/external (IE) rotation is related to the TT-TG distance., Methods: Eight independent human cadaveric knee specimens (age: 32 ​± ​6 years; 4 males, 4 females) were utilized. A robotic manipulator (ZX165U, Kawasaki Robotics, Wixom, MI, USA) instrumented with a universal force/moment sensor was used to determine knee joint IE rotation under applied moments of ±5 newton-meters (Nm) at full extension. Two independent reviewers selected the trochlear groove and tibial tuberosity points on computerized tomography (CT) images of each specimen to define TT-TG. To determine the influence of knee joint IE rotation on TT-TG distance, three-dimensional (3D) models generated from CT scans were registered to tibiofemoral kinematics. Linear regression was performed to determine the relationship between knee joint IE rotation and TT-TG distance. The regression coefficient, standard error of measurement (α ​= ​0.05), and coefficient of determination (r 2 ) were reported., Results: At 0° of rotation, the mean TT-TG distance was 14.2 ​± ​5.0 ​mm. Knee joint IE rotation averaged 23.0 ​± ​4.2°. For every degree of knee joint IE rotation, TT-TG distance changed by 0.52 ​mm., Conclusion: TT-TG distance was linearly dependent on knee joint IE rotation, changing by 0.52 ​mm for every degree of knee joint IE rotation. Thus, an offset of IE rotation of 10° would lead to a change in TT-TG distance of 5.2 ​mm, enough to alter the surgical decision-making for/or against tibial tubercle medialization., Level of Evidence: IV: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Daniel W. Green reports a relationship with Arthrex Inc that includes: consulting or advisory. Daniel W. Green: Royalties – Arthrex Inc and Pega Medical., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Patellofemoral instability is associated with chondral injuries to the patella, trochlea, and lateral femoral condyle. Although studies have demonstrated an association between patellar dislocations and chondral injuries, the influence of the number of dislocations on chondrosis is not established., Purpose: To elucidate the precise association between the number of patellar dislocation events and the severity of chondral injuries in a multicenter cohort study at the time of patellar stabilization procedures., Study Design: Cross-sectional study; Level of evidence, 2., Methods: A prospective multicenter cohort study (JUPITER [Justifying Patellar Instability Treatment by Early Results]) database was queried for cases of primary patellofemoral instability procedures from December 2016 to September 2022. Cartilage lesions were classified using the International Cartilage Repair Society (ICRS) classification system during an arthroscopic or open evaluation (direct visualization), with grades 2 to 4 considered abnormal. The number of dislocations was categorized as 1, 2-5, and >5. Categorical variables were compared with the chi-square test, and binary logistic regression was performed to identify predictors of the presence of chondral lesions., Results: A total of 938 knees (mean age, 16.2 ± 3.8 years; 61.4% female) were included, with 580 (61.8%) demonstrating a chondral injury. The most affected region was the patella (n = 498 [53.1%]), followed by the lateral femoral condyle (n = 117 [12.5%]) and trochlea (n = 109 [11.6%]). There were no differences in the presence ( P = .17) or grade ( P = .63) of patellar lesions by the number of dislocations. Patients with >5 dislocations more frequently had trochlear chondral lesions (19.8%) compared with those with fewer dislocations (1, 7.6%; 2-5, 11.0%; P < .001). More dislocations were also associated with a higher proportion of ICRS grade 2 to 4 trochlear lesions (>5, 15.3%; 2-5, 10.0%; 1, 6.9%; P = .015). Combined patellar and trochlear lesions were also more common in those with >5 dislocations ( P = .001). In multivariable regression, >5 dislocations was the only variable predictive of a trochlear lesion (odds ratio, 3.03 [95% CI, 1.65-5.58]; P < .001)., Conclusion: This large prospective cohort study demonstrated that recurrent patellar dislocations can lead to more severe chondral damage in specific locations in the knee. More than 5 dislocations was associated with a >3-fold increase in the incidence and severity of trochlear chondral injuries. There were no differences in the presence or grade of patellar lesions by the number of dislocations. These findings should caution surgeons regarding prolonged nonoperative treatment., 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 consulting fees from Arthrex, intellectual property royalties from Arthrex and Pega Medical, and speaking fees from Synthes. B.E.H. has received support for education from Arthrex, Kairos Surgical, and Pylant Medical, and owns stock options in Imagen Technologies. J.M.B. has received consulting fees from Miach Orthopaedics, compensation for services other than consulting from Smith+Nephew, and support for education from Arthrex and Steelhead Surgical. S.N.P. has received consulting fees from Pfizer, support for education from CDC Medical, and compensation for serving as a faculty member or speaker from Synthes. B.E.S.S. has received consulting fees from Arthrex and research support from ConMed; her spouse has received consulting fees and royalties from 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.

Pediatric patellar instability can impair function and restrict activity participation. If left untreated, it can lead to a degenerative knee. The incidence of patellar dislocations is highest in adolescents between 10 and 17 years of age; more than half of all first-time patellar dislocations occur during sports. This article reviews the evidence of risk factors for traumatic patellar instability, surgical interventions, and return-to-sport (RTS) considerations for pediatric and adolescent athletes. Anatomic risk factors for patellar instability in pediatric and adolescent patients include trochlear dysplasia, elevated tibial tuberosity-trochlear groove (TT-TG) distance, patella alta, genu valgum, femoral anteversion and tibial torsion, and hyperlaxity., Competing Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Daniel W. Green, MD, MS, FAAP, FACS, reports relationships with Arthrex Inc. and Pega Medical. The other authors declare no potential conflicts of interest., (© The Author(s) 2024.)

Background: The rate of anterior cruciate ligament (ACL) rupture in active, skeletally immature patients is increasing. Although hamstring tendon autograft (HTA) was previously deemed the gold standard, recent studies have shown HTA to have a high failure rate in this high-risk population of young competitive athletes, and quadriceps tendon autograft (QTA) has yielded excellent preliminary outcomes in some studies examining this population., Purpose: To evaluate 3-year clinical and patient-reported functional outcomes of primary ACL reconstruction (ACLR) with soft tissue QTA in skeletally immature patients., Study Design: Case series; Level of evidence, 4., Methods: Skeletally immature patients who underwent ACLR with a full-thickness soft tissue QTA were included. Preoperative patient and surgical data were collected. The ACLR technique was selected predicated upon skeletal age and included all-epiphyseal and complete transphyseal techniques. Patients were followed for a minimum of 2 years with successive clinical visits or were contacted via telephone. Patients who did not have minimum 2-year follow-up after 3 contact attempts via telephone were excluded. Information regarding return to sports (RTS) and concomitant or subsequent surgical procedures was collected. Pediatric International Knee Documentation Committee (Pedi-IKDC), Hospital for Special Surgery Functional Activity Brief Scale (HSS Pedi-FABS), and Single Assessment Numeric Evaluation (SANE) scores were collected., Results: Of 85 adolescent patients aged 11.1 to 17.6 years (mean age, 14.1 ± 1.2 years), 2 patients were determined to be lost to follow-up after 3 failed contact attempts. Of the patients included in this study (N = 83), 26 patients (31%) underwent all-epiphyseal and 57 patients (69%) underwent complete transphyseal ACLR. Additionally, 48 patients (58%) underwent concomitant lateral extra-articular tenodesis using the iliotibial band with a modified Lemaire technique. The mean follow-up time was 3.7 ± 1.2 years (range, 2-7 years). Twenty (24%) patients had subsequent surgical procedures, of which 3 (4%) were due to graft failures. At a mean 3-year follow-up, the mean Pedi-IKDC, HSS Pedi-FABS, and SANE scores were 90, 23, and 94 respectively; the RTS rate was 100%; and the rate of RTS at the previous level of performance was 93%., Conclusion: Use of a soft tissue QTA for ALCR in a high-risk skeletally immature population of athletes resulted in excellent postoperative outcomes with low rates of graft failure and high return to sport rates., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: F.A.C. has received royalties from Arthrex, Saunders Mosby Elsevier, and Wolters-Kluwer Health Lippincott Williams and Wilkins; consulting fees from Arthrex; and support for education from Gotham Surgical Solutions & Devices. D.W.G. has received royalties and consulting fees from Arthrex, royalties from Pega Medical, speaking fees from Synthes, and hospitality payments from OrthoPediatrics. 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.

Purpose: Hemi-epiphysiodesis procedures in skeletally immature patients are commonly done to correct genu valgum over time. This study seeks to demonstrate the average rate of deformity correction for genu valgum using hinged tension band plates, while examining different age groups and sex-related differences., Methods: A retrospective chart review of patients who underwent hemi-epiphysiodesis with hinged tension band plates for valgus knee deformity from 2012 to 2022 by one pediatric orthopaedic surgeon was performed. Expected time of growth remaining was calculated as the difference between age of skeletal maturity and bone age at time of surgery. The mechanical lateral distal femoral angle, mechanical medial proximal tibial angle, mechanical femoral tibia angle, screw divergence angle, and hinge angle were measured immediately after implant placement and prior to implant removal., Results: 54 skeletally immature patients were treated for pathologic genu valgum. The mean age at time of surgery was 12.5 ± 1.9 years. The radiographic measurement of the valgus deformity between the beginning and end of treatment showed significant correction ( p  = 0.002). The lower limb axis of the younger cohort corrected significantly faster (7.5 ± 4.6°/year) than the older cohort (5.3 ± 2.8°/year) ( p  = 0.030). The mechanical lateral distal femoral angle correction rate was also significantly different between the two cohorts (7.0 ± 4.7°/year vs. 4.8 ± 2.8°/year, respectively ( p  = 0.002)). The group with greater expected time of growth remaining demonstrated a significantly faster rate of correction than the group with less than 2 years of growth remaining ( p  < 0.001)., Conclusion: This study reaffirms the finding that timing is essential when performing temporary hemi-epiphysiodesis for valgus knee deformity in skeletally immature patients., Competing Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: D.S., D.E.C., P.C., J.H., and E.L. have no conflicts of interest to disclose. D.W.G. is a consultant for Arthrex, Inc. and receives royalties for Arthrex, Inc. and Pega Medical. D.W.G. is a consultant for Arthrex, Inc. and receives royalties for Arthrex, Inc. and Orthopediatrics., (© The Author(s) 2024.)

Purpose: Implant-mediated guided growth (IMGG) is used to address coronal plane deformity in skeletally immature patients. Few studies have reported on IMGG and simultaneous medial patellofemoral ligament (MPFL) reconstruction for paediatric patients with concurrent genu valgum and patellofemoral instability (PFI). This study aimed to report on the outcomes of these simultaneous procedures., Materials and Methods: This was a retrospective review of paediatric patients undergoing simultaneous MPFL reconstruction and IMGG between 2016 and 2023. Mechanical lateral distal femoral angle (mLDFA), hip-knee-ankle angle (HKA) and mechanical axis deviation (MAD) were measured on full-length hip-to-ankle plain radiographs. Measurements were taken preoperatively, prior to implant removal and/or at final follow-up with minimum 1-year clinical follow-up., Results: A total of 25 extremities in 22 patients (10 female) underwent simultaneous IMGG and MPFL reconstruction. The mean age at surgery was 12.6 ± 1.7 years. The mean duration of implant retention was 18.6 ± 11.3 months. Nineteen extremities (76%) underwent implant removal by final follow-up. Preoperative HKA corrected from a mean of 5.8 ± 2.3° to -0.8 ± 4.5° at implant removal or final follow-up (p < 0.001), with mLDFA and MAD similarly improving (both p < 0.001). HKA corrected a mean of 0.7 ± 0.9° per month, while mLDFA and MAD corrected a mean of 0.5 ± 0.6°/month and 2 ± 3 mm/month, respectively. At the time of implant removal or final follow-up, 88% of patients demonstrated alignment within 5° of neutral. Only one extremity experienced subsequent PFI (4%). For 14 patients who underwent implant removal with further imaging at a mean of 7.8 ± 4.9 months, only one patient (7%) had a valgus rebound to an HKA > 5°., Conclusion: Simultaneous MPFL reconstruction and IMGG provided successful correction of lower extremity malalignment with only one recurrence of PFI. This approach is a reliable surgical option for skeletally immature patients with genu valgum and PFI., Level of Evidence: Level 4 case series., (© 2024 European Society of Sports Traumatology, Knee Surgery and Arthroscopy.)

Background: Genu valgum is a well-known feature of multiple hereditary exostoses (MHE). Though prior reports have demonstrated successful treatment with hemiepiphysiodesis, details regarding the correction rate and comparison to an idiopathic population are lacking. This study aimed to detail our institution's experience with guided growth of the knee in patients with MHE and compare this to an idiopathic population., Methods: All pediatric patients (age 18 and younger) with MHE who underwent lower extremity hemiepiphysiodesis at a tertiary care medical center between January 2016 and December 2022 were retrospectively reviewed. Preoperative and postoperative mechanical lateral distal femoral angle (mLDFA) and medial proximal tibial angle (MPTA, the primary outcomes) were measured in addition to mechanical axis deviation (MAD) and hip-knee-ankle angle (HKA). Patients were 1:2 matched based on age, sex, and physes instrumented to a cohort with idiopathic genu valgum., Results: A total of 21 extremities in 16 patients with MHE underwent hemiepiphysiodesis of the distal femur, proximal tibia, and/or distal tibia. The mean age at surgery was 11.7±2.2 years. Mean MAD corrected from zone 1.9±0.7 to -0.3±1.5, while mLDFA corrected from 83.4±2.9 to 91.7±5.2 degrees and MPTA corrected from 95.3±3.6 to 90.5±4.0 degrees in distal femurs and proximal tibias undergoing guided growth, respectively. Three extremities (14.3%) experienced overcorrection ≥5 degrees managed with observation. There were no differences in correction rates per month for mLDFA (0.54±0.34 vs. 0.51±0.29 degrees, P =0.738) or MPTA (0.31±0.26 vs. 0.50±0.59 degrees, P =0.453) between MHE and idiopathic groups. For 11 extremities in the MHE group with open physes at hardware removal, they experienced a mean recurrence of HKA of 4.0±3.4 degrees at 19-month follow-up., Conclusion: Hemiepiphysiodesis corrects lower extremity malalignment in patients with MHE at a similar rate compared with an idiopathic coronal plane deformity population. Rebound deformity of 4 degrees at 19 months after hardware removal in patients with remaining open growth plates should make surgeons conscious of the remaining growth potential when planning deformity correction., Level of Evidence: Level III., Competing Interests: D.W.G. has royalties in Arthrex Inc. and Pega Medical. D.W.G. is a consultant for Arthrex Inc. R.F.W. is a consultant for SpineGuard Co. And is on the editorial board for Children’s Orthopaedics and Spinal Deformity. E.R.D. is an Orthopediatrics consultant and an AAOS official spokesperson. The remaining authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: The purpose of this study was to report clinical and surgical outcomes of medial patellofemoral ligament reconstruction (MPFLR) and concomitant quadriceps lengthening to treat fixed and obligatory patellofemoral instability (PFI) in the pediatric population., Methods: Patients with obligatory or fixed PFI who underwent simultaneous MPFLR and quadriceps lengthening from 2008 to 2020 were reviewed. Of the 413 records, 24 fit the inclusion criteria. Demographic information, surgical details, associated diagnoses, and outcome measures were collected for each knee. Complications and additional surgeries were also obtained., Results: The final cohort included 20 patients (10 male, 10 female), with a total of 24 knees. The average age at the time of surgery was 11.9 ​± ​3.1 (5.4-17.3). Seventeen were obligatory dislocators in flexion and 7 were fixed dislocators. Average follow-up was 4.3 ​± ​2.4 (1.3-9.4) years. One patient was lost to follow-up and excluded from the study. The mean outcome measures were as followed; KOOS 82, HSS Pedi-FABS 9, IKDC 76, Kujala 78, BPII 67, and SANE 90. Six patients had subsequent instability episodes. Ten patients had a subsequent surgery., Conclusions: Reports on quadriceps lengthening to treat PFI in the pediatric population are rare. Six (25 ​%) of the 24 knees included had subsequent PFI. Although this is a high rate of recurrent instability, no second surgeries were indicated for infection, extensor mechanism weakness, or contracture. The authors conclude that simultaneous MPFLR and stepwise quadriceps lengthening can be used to effectively manage fixed and obligatory PFI in this difficult patient population., Level of Evidence: IV., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

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: There is a higher rate of failure of isolated MPFL reconstruction in skeletally immature patients with patellar instability compared to skeletally mature patients. Genu valgum is a known risk factor for patellar instability. There is potential for concomitant surgical correction of genu valgum to achieve better clinical outcomes and to decrease failure rates of MPFL reconstruction., Purpose: To evaluate outcomes of combined medial patellofemoral ligament (MPFL) reconstruction and implant-mediated guided growth (IMGG) in skeletally immature patients with patellar instability and genu valgum., Study Design: Case series; Level of evidence, 4., Methods: In a multicenter study, all skeletally immature patients with recurrent patellar instability and genu valgum who underwent MPFL reconstruction using hamstring graft and IMGG using a transphyseal screw or tension band plate for the distal femur and/or proximal tibia were included. The knee valgus angle and mechanical axis were measured on full-length radiographs and anatomic risk factors were measured on MRI. Patients were followed until correction of their lower limb alignment and implant removal or until skeletal maturity. Clinical outcomes, including complications, were analyzed., Results: A total of 31 patients (37 knees) were included in the study. The mean age and skeletal age of the cohort were 12.4 and 12.9 years, respectively. Simultaneous MPFL reconstruction and IMGG were performed in 26 of 37 knees; 11 underwent staged procedures. Twenty knees had transphyseal screws and 17 knees had tension band plates for IMGG. The knee valgus corrected from a mean of 12.4° to 5.1° in 12.1 months. Implants were removed from 22 of 37 knees once genu valgum was corrected. There was no significant difference ( P = .65) in the correction rate between plates (0.7 deg/month) and screws (0.6 deg/month). Ten complications occurred in 4 patients (7 knees) and included 5 patellar redislocations, 2 rebound valgus, 1 varus overcorrection, 1 knee arthrofibrosis, and 1 implant loosening. For children <10 years of age, 3 of 6 (50%) knees had patellar redislocations and 5 of 6 knees had a complication. This was statistically significant ( P = .003) compared with patients >10 years of age. Similarly, for patients with bilateral knee involvement, 5 of 12 (42%) knees had patellar redislocations and a total of 8 complications occurred in this subset. This was statistically significant ( P < .001) compared with patients with unilateral involvement., Conclusion: IMGG with plates or screws in the setting of combined MPFL reconstruction improves genu valgum. Children <10 years of age and those with bilateral instability with genu valgum remain difficult subsets to treat with higher complication rates., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: D.B. has received support for education from Arthrex and Legacy Ortho. D.P. has received support for education from SeaPearl Inc and Liberty Surgical. E.J.W. has received support for education from Legacy Ortho. M.E. has received support for education from MedInc of Texas and Arthrex. N.F. has received support for education from Arthrex and Sequoia Surgical and compensation for services other than consulting from Arthrex. J.A.S. has received support for education from Arthrex and Micromed and compensation for services other than consulting from Arthrex. D.G. has received consulting fees from OrthoPediatrics and Arthrex, royalties from Arthrex, and compensation for serving as a faculty or speaker from Synthes GmbH. S.N.P. has received consulting fees from Pfizer, support for education from CDC Medical, and compensation for serving as a faculty or speaker from Synthes GmbH. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Background: There are various reported complications after primary anterior cruciate ligament reconstruction (ACLR) necessitating additional surgery in skeletally immature patients, regardless of technique and autograft type., Purpose: To analyze the rate and type of complications encountered with soft tissue quadriceps tendon autograft (QTA) for ACLR in patients ≤18 years as well as the overall rate of second surgery, unrelated to the use of the QTA., Study Design: Case series; Level of evidence, 4., Methods: A total of 141 patients ≤18 years who underwent ACLR with a QTA and had minimum 6-month follow-up were included. All patients underwent ACLR by utilizing a full-thickness soft tissue QTA. Complications associated with the QTA harvest site and use of QTA were reported., Results: The mean age of the included cohort (84 men, 57 women) was 14.8 ± 1.6 years. The average follow-up was of 2.0 ± 1.2 years. A total of 30 (21%) patients had a subsequent complication that required surgical intervention; in 11 (8%) patients, the complication was specifically associated with the use of a QTA, whereas in 19 (13%) patients, the complication was related to the ACLR. In addition, 13 (9%) patients underwent a contralateral ACLR procedure. Of the QTA-related complications, 2 patients developed osteochondritis dissecans (OCD)-like lesions in the superior aspect of the patella, 2 patients had injured their quadriceps extensor mechanism and required surgical repair, and 8 patients had a subsequent procedure to remove nonabsorbable sutures used for donor site quadriceps tendon closure. One of the patients who underwent the removal of nonabsorbable sutures also had an arthroscopic debridement of patellar chondral damage., Conclusion: We reported complications encountered with soft tissue QTA for ACLR. The complication rate for QTA harvest was 8%. However, given that the removal of nonabsorbable sutures from the donor site was caused by the surgical technique used, the revised nonsuture-related complication rate for QTA graft harvest was 2%. Although the use of a QTA has recently gained popularity due to its high return-to-sport and low graft-failure rates, surgeons should be aware of the complications associated with using this graft type., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: F.A.C. has received consulting fees from Arthrex; nonconsulting fees from Arthrex; royalties from Arthrex, Elsevier, and Wolters Kluwer Health; and financial or material support from Elsevier and Wolters Kluwer Health. K.M.L. has received education payments from Arthrex, Evolution Surgical, and Smith & Nephew. D.W.G. has received consulting fees from OrthoPediatrics and Arthrex; nonconsulting fees from Arthrex, Synthes, and AO Trauma International; royalties from Arthrex, Current Opinion in Pediatrics, Pega Medical, and Wolters Kluwer Health; and financial or material support from Current Opinion in Pediatrics and Wolters Kluwer Health. 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.)

Purpose: There are various anatomic risk factors for patellofemoral instability (PFI) that help guide surgical treatment, including the tibial tubercle to trochlear groove (TT-TG) distance. However, no study has analysed the temporal changes in TT-TG prior to surgical intervention. This study sought to understand the variations in TT-TG over time for pediatric patients suffering from PFI prior to surgical intervention. The authors hypothesised that the TT-TG would substantially change between time points., Methods: Patients undergoing medial patellofemoral ligament (MPFL) reconstruction between 2014 and 2019 by one of two fellowship-trained orthopaedic surgeons were identified. Patients were included if they had two preoperative magnetic resonance imaging (MRI) performed on the same knee within 7.5 months of each other prior to any surgical intervention and had an initial TT-TG greater than 10 mm., Results: After considering 251 patients for inclusion, 21 patients met the final inclusion criteria. The mean age was 14.5 ± 2.5 years and 61.9% were female. TT-TG was initially noted to be 15.1 ± 1.8 mm. At mean time after sequential MRIs of 5.0 ± 1.9 months, TT-TG was noted to be 16.7 ± 3.2 mm. The differences between initial and subsequent TT-TG ranged from a 21.2% decrease to a 61.1% increase, with a mean difference of an 11.3% increase. Comparison between initial and subsequent TT-TG values demonstrated a significant difference (p = 0.017). Change in tibiofemoral rotation ranged from -9.2° to 7.5°. When comparing the change in TT-TG to change in tibiofemoral rotation, a significant correlation was found (p = 0.019)., Conclusion: Despite only a mean time between MRIs of 5 months, variations in TT-TG ranged from a decrease of 21.2% to an increase of 61.1%. The significant relationship between the changes in TT-TG and changes in tibiofemoral rotation between MRIs suggest that TT-TG measurements may vary due to variations in tibiofemoral rotation at the time of individual MRIs., Level of Evidence: Level IV., (© 2024 European Society of Sports Traumatology, Knee Surgery and Arthroscopy.)

Purpose of Review: Pigmented villonodular synovitis (PVNS) is a rare diagnosis in pediatric patients and commonly presents with symptoms of swelling and pain. Early diagnosis is important to prevent secondary degeneration into the subchondral bone. This review will analyze the etiology, clinical signs/symptoms, diagnosis, treatment, and recent literature on PVNS in the pediatric population., Recent Findings: Many theories of PVNS etiology have been described in the literature; however, an inflammatory response has been most widely accepted. PVNS can occur in any joint, but most commonly in the knee. The most common treatment for PVNS is synovectomy, and long-term follow-up is necessary to detect disease persistence or recurrence., Summary: Although uncommon, PVNS does occur in the pediatric population and this diagnosis should be included in the differential of atraumatic joint swelling and pain., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Quadriceps tendon autograft (QTA) has recently gained popularity in the treatment of anterior cruciate ligament (ACL) ruptures in pediatric patients. The addition of lateral extra-articular tenodesis (LET) to an ACL reconstruction (ACLR) has been found to reduce the risk of ACL retear in high-risk patients., Purpose: To (1) compare ACL graft maturity using signal intensity ratios (SIRs) on magnetic resonance imaging (MRI) scans in skeletally immature patients undergoing ACLR with QTA either with or without concomitant LET and (2) evaluate LET safety by calculating the physeal disturbance-related reoperation rate in the ACLR+LET group., Study Design: Cohort study; Level of evidence, 3., Methods: The records of patients aged ≤18 years who underwent ACLR between 2015 and 2021 were reviewed retrospectively. Patients undergoing ACLR with QTA who had open distal femoral and proximal tibial physes on MRI scans and a minimum 2-year follow-up data were included. SIR values were measured on sagittal MRI scans by averaging the signal at 3 regions of interest along the ACL graft and dividing by the signal of the posterior cruciate ligament at its insertion. Statistical analysis was performed to evaluate differences in SIR values at 6 months, 1 year, and 2 years postoperatively in patients who underwent ACLR alone versus ACLR+LET., Results: Overall, 29 patients were included in the study: 16 patients in the ACLR+LET group and 13 patients in the ACLR-only group. There were no significant differences in SIR values between groups at the 6-month or 1-year postoperative timepoints. At 2 years postoperatively, the median SIR of the ACLR+LET group was significantly lower than that of the ACLR-only group on both univariate (1.33 vs 1.86, respectively, P  = .0012) and multivariate regression analyses adjusting for both sex and surgical technique (β = -0.49 [95% CI, -0.91 to -0.05]; P  = .029). There were no cases of reoperation for physeal disturbance in patients who underwent ACLR+LET., Conclusion: The addition of LET to an ACLR with QTA was associated with lower average SIR values and thus improved graft maturity at 2 years postoperatively compared with ACLR alone in skeletally immature patients. The addition of LET to an ACLR was found to be safe in skeletally immature patients., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: F.A.C. has received nonconsulting services from Arthrex, royalties from Arthrex, and consulting fees from Arthrex. D.W.G. has received consulting fees from OrthoPediatrics and Arthrex, royalties from Arthrex and Pega Medical, nonconsulting fees from Arthrex and Synthes. 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.)

Purpose: Although most patellar dislocations are associated with medial patellofemoral ligament (MPFL) injury, many patients also sustain concomitant patellar osteochondral fractures following a patellar dislocation. Few prior studies have described or evaluated risk factors for patellar osteochondral fractures in pediatric patients. The purpose of the present study was to describe the incidenceand location of patellar osteochondral fractures following acute patellar dislocation in pediatric patients. In addition, we described risk factors for patellar osteochondral fractures in this population. We hypothesized that most fractures would occur at the inferomedial quadrant of the patella following a traumatic injury mechanism., Methods: Following Institutional Review Board approval, the electronic medical record was queried to identify pediatric patients ≤ 18 years old who underwent MPFL reconstruction (MPFLR) or non-operative treatment for patellar instability between July 2016 and February 2020. Osteochondral fractures were defined as full-thickness chondral injuries with attached subchondral bone or purely osseous injuries measuring ≥ 3 mm (mm) in at least two magnetic resonance imaging (MRI) planes. Patients were included in the study if they had complete preoperative x-ray and MRI studies with minimum 6-month follow-up. Patients were excluded if they had incomplete imaging, isolated chondral fractures, or less than 6 months follow-up. Univariate analysis was used to identify patient factors associated with osteochondral fractures. Multivariate regression analysis was used to identify risk factors for osteochondral fractures., Results: Sixty patients (63 knees) were included in the study, 15 (23.8%) of whom had a patellar osteochondral fracture. The majority of osteochondral fractures (87%) involved the inferomedial quadrant of the patella. Univariate analysis showed an association between male sex (p = 0.041), skeletal immaturity (p = 0.028), and decreased patellar tilt (p = 0.021) and patellar osteochondral fractures. Multivariate regression analysis identified male sex as an independent risk factor for osteochondral fractures (relative risk: 4.8, 95% confidence interval [CI]: 1.08-20.9, p = 0.039). No patients had recurrent dislocation at minimum 6-month follow-up. All patients with osteochondral fractures returned to sports at most recent follow up., Conclusion: In this study, 23% of pediatric patients with acute patellar dislocations have a concomitant patellar osteochondral fracture. The majority of patellar osteochondral fractures involve the inferomedial quadrant of the patella. Male sex is an independent risk factor for patellar osteochondral fractures, and skeletal immaturity is associated with patellar osteochondral fractures in this population., Level of Evidence: Level III., (© 2023. European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA).)

Purpose: Understanding how surgical procedures influence anatomic factors associated with patellofemoral instability can help guide surgeons when planning treatments for individual patients. This study sought to understand how patellar tilt is affected in adolescent patients with elevated pre-operative tibial tuberosity to trochlear groove (TT-TG) values undergoing medial patellofemoral ligament reconstruction (MPFLR) with or without an anterior medializing osteotomy (AMZ)., Methods: Utilizing a prospective database of 274 patellofemoral instability patients who underwent MPFLR ± AMZ by one of two orthopedic surgeons at a single institution, those who underwent MPFLR + AMZ were identified. Pre-operative and post-operative magnetic resonance imaging (MRI) were used to measure TT-TG distance, while radiographs were used to measure patellar tilt (tilt). Patients were matched based on age at surgery (within 2 years) and pre-operative TT-TG distance (within 2 mm) to a comparison cohort of patients who underwent isolated MPFLR (iMPFLR) without osseous procedures., Results: A total of 56 patients were analyzed (28 per group). The mean age of the cohort was 15.5 ± 2.0 years and was similar between both groups (15.9 ± 1.9 versus 15.1 ± 2.0 years [n.s]). When comparing the two cohorts, significant pre- to post-operative decreases in patellar tilt for both MPFLR + AMZ (6.6 degrees, p < 0.001) and iMPFLR (3.9 degrees, p = 0.013) were noted. While there were no differences in pre-operative patellar tilt (21.2 ± 3.5 versus 21.1 ± 3.4 [n.s]), post-operatively, MPFLR + AMZ had significantly less patellar tilt than iMPFLR (13.2 ± 5.5 versus 16.5 ± 4.4, p = 0.017)., Conclusions: This study found that patellar tilt significantly improved in participants undergoing either MPFLR + AMZ or iMPFLR. In addition, those undergoing MPFLR + AMZ were found to have significantly lower post-operative tilt than those undergoing iMPFLR. If patellar tilt is found pre-operatively to be significantly elevated and a risk for future dislocations, these findings suggest that surgeons might strongly consider MPFLR with AMZ to further address the increased tilt., Level of Evidence: III., (© 2023. The Author(s) under exclusive licence to European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA).)

Case: This report describes 2 cases of femoral-sided posterior cruciate ligament (PCL) avulsion injuries. A 10-year-old male patient presented with a chronic nonunion of a bony PCL femoral avulsion. In addition, a 4-year-old boy presented with an acute, displaced PCL femoral avulsion off the medial femoral condyle. Both injuries were repaired using arthroscopic techniques., Conclusion: Femoral-sided PCL avulsions are very rare in pediatric patients and have not been reported often. We hope to increase the awareness of PCL femoral avulsion injuries in pediatric patients by describing 2 unique cases., 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/C129)., (Copyright © 2023 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: To the authors' knowledge, no previous study has thoroughly described the anteroposterior dimensions of tibial spine fractures (TSFs) on 3-dimensional imaging. The extension of TSFs into weightbearing regions of the tibial plateau, posterior extension within the epiphysis, and potential association between fracture size and patient age may have implications for treatment strategies and clinical outcomes., Hypothesis: TSF fragments would commonly involve weightbearing regions of the tibial plateau, would be larger in younger patients, and would extend more posteriorly than the anatomic footprint of the tibial spine., Study Design: Case series; Level of evidence, 4., Methods: Consecutive magnetic resonance imaging studies obtained between 2012 and 2020 in patients 5 to 18 years of age at the time of imaging for TSFs were included, measured, and classified via the Green and Tuca grading system. Anteroposterior fracture dimensions were measured and normalized to anteroposterior midepiphyseal length, as was fracture height to epiphyseal height. Extension into the weightbearing surface of the tibial plateau was recorded. Intraclass correlation coefficient and kappa values were calculated. Mean fracture bed size was compared using independent-samples t tests between older and younger patients based on median age and sex., Results: Of 54 TSFs, 1 (2%), 28 (52%), and 25 (46%) were grades 1, 2, and 3, respectively. Fracture beds spanned 45% of the anteroposterior midepiphysis, and 54% of the TSF beds extended to the posterior third of the epiphysis. Younger and female patients, on average, had larger anteroposterior dimensions to TSF beds ( P = .018 and .006, respectively). The medial and lateral weightbearing surfaces of the tibial plateau were affected 57% and 25% of the time, respectively., Conclusion: This study demonstrated that TSF beds were larger in younger patients, extended to the posterior third of the epiphysis in 54% of cases, and should be examined carefully for extension into weightbearing regions of the tibial plateau. In pediatric patients, the TSF often involves more of the tibial plateau than the anatomic footprint of the tibial spine, and clinicians should be aware of the potential for extension posteriorly and into the weightbearing surfaces.

Objectives: Adolescents with anterior cruciate ligament (ACL) tears can present with concomitant lower extremity coronal plane angular deformity (CPAD) that both predispose to injury as well as may increase the risk of graft rupture following ACL reconstruction (ACLR). The goal of this study was to examine the safety and efficacy of concomitant ACLR with implant-mediated guided growth (IMGG) compared to isolated IMGG procedures in paediatric and adolescent patients., Methods: Operative records of all paediatric and adolescent patients (age ≤ 18 years) that underwent simultaneous ACLR and IMGG by one of two paediatric orthopaedic surgeons between 2015 and 2021 were retrospectively reviewed. A comparison cohort of isolated IMGG patients was identified and matched based on bone age within one year, sex, laterality, and fixation type (i.e. transphyseal screw vs. tension band plate and screw construct). Pre- and post-operative mechanical axis deviation (MAD), angular axis deviation (AAD), lateral distal femoral angle (LDFA), and medial proximal tibial angle (MPTA) were recorded., Results: A total of 9 participants who underwent concomitant ACLR and IMGG (ACLR ​+ ​IMGG) were identified, with 7 of these participants meeting the final inclusion criteria. The participants had a median age of 12.7 (IQR ​= ​12.1 - 14.2) years and median bone age of 13.0 (IQR ​= ​12.0 - 14.0) years. Of the 7 participants that underwent ACLR and IMGG, 3 underwent a modified MacIntosh procedure with ITB autograft, 2 received quadriceps tendon autograft, and 1 underwent hamstring autograft reconstruction. There were no significant differences in the amount of correction obtained between ACLR ​+ ​IMGG and matched IMGG subjects with respect to any measurement variable (MAD difference: p ​= ​0.47, AAD difference: p ​= ​0.58, LDFA difference: p ​= ​0.27, MPTA difference: p ​= ​0.20). There were also no significant differences in alignment variables per unit time between cohorts (MAD/month: p ​= ​0.62, AAD/month ​= ​0.80, LDFA/month ​= ​0.27, MPTA/month ​= ​0.20)., Conclusion: The results of the current study indicate that concomitant ACLR and lower extremity CPAD correction is a safe approach to treat CPAD concomitantly with ACLR in young patients who present with an acute ACL tear. Furthermore, one can expect reliable correction of CPAD after combined ACLR and IMGG, no different than the correction obtained in the setting of IMGG alone., Level of Evidence: III., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: The incidence of anterior cruciate ligament (ACL) reconstruction (ACLR) in children and adolescents has increased significantly, and many such patients are at increased risk for ACL retear. Lateral extra-articular tenodesis (LET) may be performed in conjunction with ACLR to reduce the risk of ACL retear., Purpose: To evaluate the 2-year clinical outcomes of ACLR with soft tissue quadriceps tendon (QUAD) autograft performed with a concomitant LET using a modified Lemaire technique in skeletally immature patients., Study Design: Case series; Level of evidence, 4., Methods: A consecutive series of adolescent patients who underwent QUAD autograft ACLR and LET with a minimum of 2 years of follow-up data were analyzed retrospectively. ACLR techniques, including all-epiphyseal and complete transphyseal, were indicated based on skeletal age. Outcome measures included return to sports, concomitant or subsequent surgical procedures, and multiple patient-reported outcome measures, including Single Assessment Numeric Evaluation (SANE), Pediatric International Knee Documentation Committee (Pedi-IKDC), and Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS) scores., Results: The final cohort included 49 consecutive adolescent patients aged 11 to 16 years (mean, 14.2 ± 1 years) with a minimum follow-up of 2 years. One patient was lost to follow-up. Of the patients included in the study (N = 48; 27 male, 21 female), 98% participated in high-risk competitive sports. Two (4%) patients were undergoing revision ACLR. Thirty-eight (79%) patients underwent complete transphyseal, and 10 (21%) patients underwent all-epiphyseal ACLR. Sixteen (33%) patients had subsequent surgical procedures, including 5 contralateral ACLR, 4 meniscal surgery, 4 QUAD autograft scar revision, 4 irrigation and debridement (2 patients, 2 each), and 3 hardware removal (2 for hemi-epiphysiodesis and 1 tibial socket button removal) procedures. The rate of graft rupture was 0%. At a mean follow-up of 3.4 ± 1.2 years (range, 2-7 range), the mean SANE score was 93, the mean Pedi-IKDC score was 89, and the mean HSS Pedi-FABS score was 23. The return-to-sports rate was 100%., Conclusion: An LET performed concomitantly with an ACLR is safe and should be considered as a concomitant procedure for adolescent patients with nonmodifiable risk factors who are at high risk of retear.

Introduction: Anterior cruciate ligament (ACL) ruptures are common amongst paediatric patients, especially those participating in competitive sports. While magnetic resonance imaging (MRI) is typically used to confirm the diagnosis, certain radiologic findings can be indicative of an ACL tear, including a lateral femoral notch sign (LFNS) > 1.5 mm (mm). No study has focussed on understanding the resolution pattern of the LFNS in paediatric patients following ACL reconstruction (ACLR). The aim of this study is to determine whether the depth of the LFNS regresses following ACLR. The authors hypothesize that following ACLR, the LFNS will resolve., Methods: All patients who were treated for acute ACL rupture by one of two paediatric orthopaedic surgeons between 2015 and 2020 were collected; 321 patients with the age of 5-18 were collected. Patients were excluded if they underwent previous ipsilateral knee surgeries and if they did not have pre-operative knee radiographs; 274 patients met inclusion criteria. LFNS was measured on pre-operative (PreOp) and most recent post-operative (PostOp) radiographs. A comparison cohort of patients with an LFNS <1.5 mm matched by age within 1.5 years, sex, and laterality was also collected. The median difference was calculated by taking the difference between PreOp LFNS and PostOp LFNS of each participant and finding the median of those values., Results: A total of 274 pre-operative radiographs were analysed for an LFNS depth >1.5 mm. Seventeen radiographs met these criteria with a median age of 16.3 years and a median depth of 1.70 mm. Of the 17 radiographs, 8 (47.1%) of participants were skeletally immature. The median LFNS depth at most recent follow-up and median percent decrease were 1.50 mm and 28%, respectively. Only 11.8% of patients demonstrated no change in LFNS depth from PreOp to PostOp imaging. Wilcoxon signed-rank test indicated that the PreOp LFNS was significantly greater than the PostOp LFNS (p < 0.001). Mann-Whitney U tests with cases and the comparison cohort demonstrated no difference in the percent decrease (p = 0.106)., Conclusion: This study sought to understand the resolution of the LFNS depth following initial ACL rupture. At a median of 7.67 months following ACLR, the LFNS depth decreased significantly by 0.60 mm. These findings suggest that following ACL rupture, the paediatric LFNS has the potential to resolve. Future studies should aim to further assess the resolution pattern of the LFNS with advanced imaging, such as MRI., Competing Interests: Declaration of competing of interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Daniel W. Green reports was provided by Hospital for Special Surgery. Daniel W. Green reports a relationship with American Academy of Orthopaedic Surgeons that includes: board membership. Daniel W. Green reports a relationship with AO Trauma Committee Italy that includes: speaking and lecture fees. Daniel W. Green reports a relationship with Arthrex Inc that includes: consulting or advisory and speaking and lecture fees. Daniel W. Green reports a relationship with Current Opinion in Pediatrics that includes: board membership and funding grants. Daniel W. Green reports a relationship with New York County Medical Society that includes: board membership. Daniel W. Green reports a relationship with NYS Society of Orthopaedic Surgeons that includes: board membership. Daniel W. Green reports a relationship with Patellofemoral Foundation that includes: board membership. Daniel W. Green reports a relationship with Pediatric Orthopaedic Society of North America that includes: board membership. Daniel W. Green reports a relationship with Pediatric Research in Sports Medicine that includes: board membership. Daniel W. Green reports a relationship with Wolters Kluwer Health that includes: funding grants. Douglas N. Mintz only reports a relationship with the New York State Radiological Society in which he is a board member. Douglas N. Mintz reports a relationship with Society of Skeletal Radiology that includes: board membership. Frank A. Cordasco reports a relationship with American Shoulder and Elbow Surgeons that includes: board membership. Frank A. Cordasco reports a relationship with Arthrex Inc that includes: consulting or advisory. Frank A. Cordasco reports a relationship with Saunders Mosby-Elsevier that includes: funding grants. Frank A. Cordasco reports a relationship with Wolters Kluwer Health that includes: funding grants. Peter D. Fabricant reports a relationship with Clinical Orthopaedics and Related Research that includes: board membership. Peter D. Fabricant reports a relationship with Osso VR that includes: equity or stocks. Peter D. Fabricant reports a relationship with Pediatric Orthopaedic Society of North America that includes: board membership. Peter D. Fabricant reports a relationship with Research in OsteoChondritis of the Knee (ROCK) that includes: board membership. Peter D. Fabricant reports a relationship with WishBone Orthopedics that includes: consulting or advisory. Daniel W. Green has patent with royalties paid to Arthrex, Inc. Daniel W. Green has patent with royalties paid to Current Opinion in Pediatrics. Daniel W. Green has patent with royalties paid to Pega Medical. Daniel W. Green has patent with royalties paid to Wolters Kluwer Health. Frank A. Cordasco has patent with royalties paid to Arthrex, Inc. Frank A. Cordasco has patent with royalties paid to Saunders/Mosby-Elsevier. Frank A. Cordasco has patent with royalties paid to Wolters Kluwer Health., (Published by Elsevier Inc.)

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.)

All-epiphyseal anterior cruciate ligament reconstruction (AE ACLR) has become an alternative technique for skeletally immature patients with a significant amount of growth remaining. This technique involves graft fixation within the epiphysis without crossing the physis. Either quadriceps tendon or hamstring autograft can be used when performing this procedure. Previous studies have shown that the complication rate is not higher in AE techniques versus previously developed techniques. Additionally, in our hands, the revision rate was found to be significantly lower in an AE ACLR compared with patients who had a transphyseal ACLR., (Published by Elsevier Inc.)

Purpose of Review: Acute ankle sprains frequently occur in active children and adolescents but may be the initial clinical presentation of other less common disorders affecting the lower extremities. There are many conditions that may cause one or multiple episodes of ankle injury that are misdiagnosed as an acute ankle sprain. This manuscript highlights diagnoses that should be considered when evaluating and managing a child or adolescent who presents initially and/or repeatedly with an acute ankle sprain., Recent Findings: In recent years, various studies have continued to note the prevalence of misdiagnosed ankle sprains, especially amongst the paediatric population. If ankle radiographs demonstrate no abnormalities during an initial clinical examination, often the patient is diagnosed with an acute ankle sprain. However, this can be a misdiagnosis, especially when the patient has had recurrent episodes of ankle injury and ancillary studies are not performed., Summary: There are many diagnoses that can go unnoticed in the initial evaluation of a paediatric or adolescent ankle sprain. It is important for physicians to be aware of these other conditions to ensure proper treatment plans. This manuscript will analyse five conditions that may be misdiagnosed as an ankle sprain, including juvenile idiopathic arthritis, osteochondritis dissecans of the talus, hereditary sensory motor neuropathy (Charcot-Marie Tooth disease), tarsal coalition and transitional ankle fractures., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Anterior cruciate ligament (ACL) injuries and surgical intervention in the pediatric population have increased in the recent years. Although surgical techniques have advanced, evidence-based rehabilitation guidelines that consider all aspects of the youth athlete are currently lacking. The purpose of this commentary is to review the current evidence on unique considerations for the pediatric and adolescent population during rehabilitation and return to sport after ACL reconstruction (ACLR), with a focus on children under 18 years of age. This review revealed that returning a youth athlete to sport after ACLR requires knowledge and appreciation of various aspects of the growing athlete different from adults. In addition to postoperative precautions that contribute to a slow rehabilitation process, young athletes need additional time for strength gains. Address risk of reinjury and for contralateral injury by using neuromuscular training and rigorous return-to-sport training programs. Consider return to sport after 9 months because the reinjury rate is high in this population. A combination of time and objective measures, both quantitative and qualitative criteria, and psychological readiness should be used to assess readiness to return to sport and decrease risk of future injury. Healthcare providers should be aware of the psychosocial impact of injury on the youth athletes and refer to sport psychology when necessary., Level of Evidence: Level V.