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Background: Osteochondritis dissecans (OCD) of the knee is a focal idiopathic alteration of subchondral bone and/or its precursor with risk for instability and disruption of adjacent cartilage. Treatment options focused on preventing premature osteoarthritis vary depending on multiple patient and lesion characteristics, including lesion mobility. Purpose: To differentiate lesion mobility before arthroscopy using a multivariable model that includes patient demographic characteristics and physical examination findings. Study Design: Cohort study (Diagnosis); Level of evidence, 2. Methods: Demographic, preoperative physical examination, and radiographic data were collected from a multicenter national prospective cohort of patients with OCD of the knee. Inclusion criteria included patients <19 years of age and patients with arthroscopically confirmed mobility status based on the Research on Osteochondritis Dissecans of the Knee arthroscopy classification. Multivariable logistic regression analysis using stepwise model selection was used to determine factors associated with the likelihood of a mobile versus an immobile lesion. A 75% partition of the data was used for model training, and 25% was used as a validation cohort. Quantitative model fit statistics were computed using the holdout data, including sensitivity, specificity, and the area under the receiver operating characteristic curve (AUC), along with the corresponding 95% CI. Results: A total of 407 patients in the prospective cohort met inclusion criteria, and 62% were male. The mean ± SD age was 13.7 ± 2.2 years, height 161.8 ± 5.3 cm, and weight 59.2 ± 42.2 kg. Arthroscopic evaluation yielded 235 immobile and 172 mobile lesions. Multivariable analysis determined that the best model to predict lesion mobility included chronologic age ≥14 years (P <.001), effusion on physical examination (P <.001), and any loss of range of motion on physical examination (P =.07), while controlling for male sex (P =.38) and weight >54.4 kg (P =.12). In the 25% holdout validation sample (n = 102), a sensitivity of 83%, a specificity of 82%, and an AUC of 0.89 (95% CI, 0.82-0.95) were achieved with these predictive factors. Conclusion: Age, effusion, and loss of motion can predict knee OCD lesion mobility at the time of arthroscopy. Education about lesion mobility can help with surgical planning and patient and family counseling. [ABSTRACT FROM AUTHOR]

Background: Discoid lateral meniscus (DLM) is the most common congenital abnormality of the meniscus. Tears are common; treatment is frequently not definitive, often requiring reoperation. Purpose: To report the clinical manifestations, physical characteristics, operative treatments and findings, complications, and reoperations of DLM in pediatric patients from multiple centers across North America. Study Design: Case series; Level of evidence, 4. Methods: Consecutive patients who underwent treatment for symptomatic DLM at 9 institutions between 2000 and 2020 were included. Patient data, presenting symptoms and signs, surgical findings, treatments rendered, and postoperative complications, including reoperation rates, were collected. Means with ranges and counts with proportions are reported for continuous and categorical variables, respectively, and comparisons were made using either the chi-square or Fisher exact test. Results: In total, 784 patients (867 knees) were included with a mean age at diagnosis of 12 years (range, 1-22 years) and a mean follow-up of 22.6 months (range, 0-154 months). Common preoperative symptoms were locking (33%) and snapping (30%). At surgery, tears in the DLM were present in 647 knees (594 patients [76%]); 95 knees (11%) had multiple tears; and in 140 knees, tears extended into >1 zone. Tears, when present, were more common within the posterior horn (41%) or body (34%) than the anterior horn (25%). Peripheral rim instability was reported in 241 knees (28%). Significantly more knees had instability posteriorly (15%; P =.0004) and anteriorly (9%; P =.0013) than along the body (3%). Tear type was most commonly complex (38%) or horizontal (34%). A total of 358 knees in 333 patients with tears (42% of all patients) underwent repair (55% of knees with tears). A total of 175 complications were reported, occurring in 139 knees in 134 patients (17%); 116 of these knees with complications (83%) had a single complication, while 23 (17%) had >1. Of the 784 patients, 105 (13%) underwent reoperation, undergoing 135 additional procedures related to their DLM. Of those, 60 (44%) were repeat arthroscopy and meniscal trim; 40 (30%), arthroscopy and meniscal repair; and 17 (13%), an articular cartilage procedure. Conclusion: Locking and snapping were common presenting symptoms. Over three-quarters of patients had meniscal tears, which were most often complex and located posteriorly. Seventeen percent of patients experienced complications, and a sixth of patients with complications had >1. Reoperation was typically for persistent symptoms or meniscal retear. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: Bone–patellar tendon–bone (BPTB) autograft size may be one modifiable predictor of anterior cruciate ligament (ACL) reconstruction postoperative success, as smaller graft diameter has been associated with higher rates of rupture requiring revision. However, measuring the true intra-articular tendinous graft diameter of the soft tissue portion of a BPTB graft with standard intraoperative methods is difficult while keeping the graft intact. Purpose/Hypothesis: The purpose of the study was to use 3-dimensional magnetic resonance imaging (MRI) measurements to determine the cross-sectional area of the soft tissue, tendinous portion of a standard BPTB autograft with 10-mm diameter bone plugs, and, by calculation, the collagen graft size (ie, graft diameter), as would typically be reported in ACL reconstruction studies that consider soft tissue graft size. It was hypothesized that the calculated collagen graft diameter of 10-mm BPTB autografts would be significantly smaller than 10 mm. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 100 patients (10 girls and 10 boys at each age from 13 to 17 years) who underwent a knee MRI at a single academic orthopaedic center without documented extensor mechanism pathology were identified. The central 10-mm width of the patellar tendon that would be harvested for BPTB autograft was measured. The region of interest area tool was then used to measure the cross-sectional area of a 10-mm BPTB graft with subsequent soft tissue autograft diameter calculation. Results: The mean calculated tendinous graft diameter of a 10 mm–wide BPTB graft was 6.3 ± 0.5 mm and was significantly smaller than a 10-mm reference (P ≤.001). There was no significant association between age and cross-sectional area or graft diameter. Conclusion: Modern 3-dimensional imaging-based measurement techniques demonstrated that the true intra-articular tendinous soft tissue portion of 10-mm BPTB autografts shows substantial variation and is significantly smaller in diameter than the tunnels typically reamed to accommodate the bone plug portions of these grafts. Moreover, as graft size is a predictor of rupture rate, preoperative MRI-based evaluation may be an important tool when considering BPTB autograft for ACL reconstruction. Future comparative clinical research utilizing graft size as a study variable should consider quantifying and utilizing the diameter of the soft tissue component of BPTB autografts. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: A recent study has reported that the radiographic measurement of posterior tibial slope (PTS) is larger in male pediatric patients with tibial spine fractures (TSF) than in controls. However, they found no difference in PTS between female patients and controls. Purpose: (1) To identify whether PTS is larger in female pediatric patients with TSF than in female controls and (2) to validate the relationship between PTS and pediatric TSF in male patients. Study Design: Cross-sectional study; Level of evidence, 3. Methods: After an a priori power analysis, 84 pediatric patients with TSF (50 female patients and 34 male patients) and 84 age- and sex-matched controls were enrolled in this study. Demographic information, including sex, age, and race, was recorded. Skeletal maturity was determined based on the stage of epiphyseal union on knee radiographs. PTS was defined as the angle between a line perpendicular to the longitudinal axis of the tibia and the posterior inclination of the medial tibial plateau on standard knee lateral radiographs. Results: The mean age when the TSF occurred was 11.2 ± 2.7 years for female patients and 12.9 ± 2.5 years for male patients. There was no significant difference in skeletal maturity between female patients and female controls or between male patients and male controls. The mean PTS was not significantly different between female patients (8.8°± 2.8°) and female controls (8.3°± 3.1°) (P =.366) or between male patients (9.0°± 2.8°) and male controls (9.3°± 2.6°) (P =.675). Those with a PTS >1 SD (2.9°) above the mean (8.8°) had no greater odds (1.0 [95% CI, 0.4-2.5]; P ≥.999) of having a TSF than others. Conclusion: PTS was not found to be a risk factor for pediatric TSF in female or male patients in this study. [ABSTRACT FROM AUTHOR]

Background: The anatomy of the trochlea plays a significant role in patellar stability. The developmental anatomy of the trochlea and its relationship to patellar stability remains poorly understood. Purpose: To describe the developmental changes of the osseous and cartilaginous trochlear morphology in skeletally immature specimens. Study Design: Descriptive laboratory study. Methods: A total of 65 skeletally immature cadaveric knees between the ages of 2 months and 11 years were evaluated using computed tomography scans. The measurements in the axial plane of both cartilage and bone include medial, central, and lateral trochlear height; sulcus height; medial and later trochlear facet length; trochlear sulcus angle; patellar sulcus angle; condylar height asymmetry; and trochlear facet asymmetry. Additional measurements included trochlear depth and lateral trochlear inclination angle. In the sagittal plane, measurements included curvilinear trochlear length, direct trochlear length, condylar height, and patellar sulcus angle. Results: Analysis of trochlear morphology using condylar height, condylar height asymmetry, and trochlear depth all increased with increasing age. The osseous and cartilaginous sulcus angles became deeper with age until age 8 and then plateaued. This corresponded with an increase in trochlear depth that also plateaued around age 8. Osseous condylar asymmetry increased with age but flipped from a larger medial condyle to a larger lateral condyle around age 8. The continued growth of the trochlea with age was further demonstrated in all measures in the sagittal view. Conclusion: This cadaveric analysis demonstrated that there is an increase in condylar height as age increased by all measurements analyzed. These changes in condylar height continued to be seen through age 11, suggesting a still-developing trochlea past this age. By age 8, a plateau in sulcus angle, and sulcus depth suggests more proportionate growth after this point. Similar changes in trochlear and patellar shape with age suggests that the 2 structures may affect each other during development. Clinical Relevance: This information can help design, develop, and determine timing of procedures that may alter the anatomy and stabilize the trochlear and patellofemoral joint. [ABSTRACT FROM AUTHOR]

Background: Tibial spine fractures (TSFs) are uncommon injuries that may result in substantial morbidity in children. A variety of open and arthroscopic techniques are used to treat these fractures, but no single standardized operative method has been identified. Purpose: To systematically review the literature on pediatric TSFs to determine the current treatment approaches, outcomes, and complications. Study Design: Meta-analysis; Level of evidence, 4. Methods: A systematic review of the literature was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) guidelines using PubMed, Embase, and Cochrane databases. Studies evaluating treatment and outcomes of patients <18 years old were included. Patient demographic characteristics, fracture characteristics, treatments, and outcomes were abstracted. Descriptive statistics were used to summarize categorical and quantitative variables, and a meta-analytic technique was used to compare observational studies with sufficient data. Results: A total of 47 studies were included, totaling 1922 TSFs in patients (66.4% male) with a mean age of 12 years (range, 3-18 years). The operative approach was open reduction and internal fixation in 291 cases and arthroscopic reduction and internal fixation in 1236 cases; screw fixation was used in 411 cases and suture fixation, in 586 cases. A total of 13 nonunions were reported, occurring most frequently in Meyers and McKeever type III fractures (n = 6) and in fractures that were treated nonoperatively (n = 10). Arthrofibrosis rates were reported in 33 studies (n = 1700), and arthrofibrosis was present in 190 patients (11.2%). Range of motion loss occurred significantly more frequently in patients with type III and IV fractures (P <.001), and secondary anterior cruciate ligament (ACL) injury occurred most frequently in patients with type I and II fractures (P =.008). No statistically significant differences were found with regard to rates of nonunion, arthrofibrosis, range of motion loss, laxity, or secondary ACL injury between fixation methods (screw vs suture). Conclusion: Despite variation in TSF treatment, good overall outcomes have been reported with low complication rates in both open and arthroscopic treatment and with both screw and suture fixation. Arthrofibrosis remains a concern after surgical treatment for TSF, but no significant difference in incidence was found between the analysis groups. Larger studies are necessary to compare outcomes and form a consensus on how to treat and manage patients with TSFs. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: Distalization tibial tubercle osteotomy (TTO) is an effective treatment for improving patellar height in patients with patella alta associated with patellofemoral instability and cartilage lesions. The addition of a patellar tendon tenodesis has been suggested; nonetheless, concerns exist regarding possible increased patellofemoral cartilage stresses. Purpose: To evaluate pre- and postoperative patellar tendon length and alignment parameters on magnetic resonance imaging (MRI), as well as patient-reported outcome measures (PROMs) after distalization TTO without patellar tendon tenodesis. Study Design: Case series; Level of evidence, 4. Methods: Twenty skeletally mature patients who underwent distalization TTO with or without anteromedialization at our institution between December 2014 and August 2021 were included. All patients underwent pre- and postoperative MRIs of the affected knee. The Caton-Deschamps index (CDI), the axial and sagittal tibial tubercle–trochlear groove (TT-TG) distances, the distances from the tibial plateau to the patellar tendon insertion and the tibial tubercle, and the patellar tendon length were assessed. PROMs included the International Knee Documentation Committee Subjective Knee Evaluation Form, the Knee injury and Osteoarthritis Outcome Score–Quality of Life subscale, the Kujala Anterior Knee Pain Scale, and the Veterans RAND 12-Item Health Survey mental and physical component scores. Results: The mean patient age at surgery was 27.4 years (range, 14-42 years). Radiographic parameters demonstrated improved patellar height (CDI decreased from 1.36 to 1.11; P <.001) after distalization TTO. The distance from the tibial plateau to the patellar tendon insertion significantly decreased from 20.1 mm preoperatively to 17.9 mm postoperatively (P <.020), and the patellar tendon length decreased from 53.4 mm preoperatively to 46.0 mm postoperatively (P <.001). The patellar tendon insertion was not distalized after distalization TTO, likely because of scarring of the patellar tendon proximal to the osteotomy site. Patients demonstrated significant pre- to postoperative improvements on all PROMs (P ≤.024 for all). There were 4 (20%) complications—2 cases of arthrofibrosis, 1 postoperative infection, and 1 osteotomy delayed union. Conclusion: Distalization TTO without patellar tendon tenodesis was associated with improved radiographic outcomes and PROMs. It provides an additional tool for surgical management of patellofemoral pathology with associated patella alta. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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 (ß = -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. [ABSTRACT FROM AUTHOR]

Background: Surgical treatment options of discoid lateral meniscus in pediatric patients consist of saucerization with or without meniscal repair, meniscocapular stabilization, and, less often, subtotal meniscectomy. Purpose: To describe a large, prospectively collected multicenter cohort of discoid menisci undergoing surgical intervention, and further investigate corresponding treatment of discoid menisci. Study Design: Cohort study; Level of evidence, 3. Methods: A multicenter quality improvement registry (16 institutions, 26 surgeons), Sports Cohort Outcomes Registry, was queried. Patient characteristics, discoid type, presence and type of intrasubstance meniscal tear, peripheral rim instability, repair technique, and partial meniscectomy/debridement beyond saucerization were reviewed. Discoid meniscus characteristics were compared between age groups (<14 and >14 years old), based on receiver operating characteristic curve, and discoid morphology (complete and incomplete). Results: In total, 274 patients were identified (mean age, 12.4 years; range, 3-18 years), of whom 55.6% had complete discoid. Meniscal repairs were performed in 55.1% of patients. Overall, 48.5% of patients had rim instability and 36.8% had >1 location of peripheral rim instability. Of the patients, 21.5% underwent meniscal debridement beyond saucerization, with 8.4% undergoing a subtotal meniscectomy. Patients <14 years of age were more likely to have a complete discoid meniscus (P <.001), peripheral rim instability (P =.005), and longitudinal tears (P =.015) and require a meniscal repair (P <.001). Patients ≥14 years of age were more likely to have a radial/oblique tear (P =.015) and require additional debridement beyond the physiologic rim (P =.003). Overall, 70% of patients <14 years of age were found to have a complete discoid meniscus necessitating saucerization, and >50% in this young age group required peripheral stabilization/repair. Conclusion: To preserve physiological "normal" meniscus, a repair may be indicated in >50% of patients <14 years of age but occurred in <50% of those >14 years. Additional resection beyond the physiological rim may be needed in 15% of younger patients and 30% of those aged >14 years. [ABSTRACT FROM AUTHOR]

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

Background: Tibial spine fractures are common in the pediatric population because of the biomechanical properties of children's subchondral epiphyseal bone. Most studies in porcine or adult human bone suggest that suture fixation performs better than screw fixation, but these tissues may be poor surrogates for pediatric bone. No previous study has evaluated fixation methods in human pediatric knees. Purpose: To quantify the biomechanical properties of 2-screw and 2-suture repair of tibial spine fracture in human pediatric knees. Study Design: Controlled laboratory study. Methods: Cadaveric specimens were randomly assigned to either 2-screw or 2-suture fixation. A standardized Meyers-Mckeever type 3 tibial spine fracture was induced. Screw-fixation fractures were reduced with two 4.0-mm cannulated screws and washers. Suture-fixation fractures were reduced by passing 2 No. 2 FiberWire sutures through the fracture fragment and the base of the anterior cruciate ligament. Sutures were secured through bony tunnels over a 1-cm tibial cortical bridge. Each specimen was mounted at 30° of flexion. A cyclic loading protocol was applied to each specimen, followed by a load-to-failure test. Outcome measures were ultimate failure load, stiffness, and fixation elongation. Results: Twelve matched pediatric cadaveric knees were tested. Repair groups had identical mean (8.3 years) and median (8.5 years) ages and an identical number of samples of each laterality. Ultimate failure load did not significantly differ between screw (mean ± SD, 143.52 ± 41.9 7 N) and suture (135.35 ± 47.94 N) fixations (P =.760). Screws demonstrated increased stiffness and decreased elongation, although neither result was statistically significant at the.05 level (21.79 vs 13.83 N/mm and 5.02 vs 8.46 mm; P =.076 and P =.069, respectively). Conclusion: Screw fixation and suture fixation of tibial spine fractures in human pediatric tissue were biomechanically comparable. Clinical Relevance: Suture fixations are not biomechanically superior to screw fixations in pediatric bone. Pediatric bone fails at lower loads, and in different modes, compared with adult cadaveric bone and porcine bone. Further investigation into optimal repair is warranted, including techniques that may reduce suture pullout and "cheese-wiring" through softer pediatric bone. This study provides new biomechanical data regarding the properties of different fixation types in pediatric tibial spine fractures to inform clinical management of these injuries. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

There is a paucity of data on patient reported outcome measures (PROMs) associated with surgical treatment of osteochondritis dissecans (OCD). As a result, preoperative patient and family counseling regarding expected outcomes is difficult. The purpose of this study was to compare pre-to post-operative changes in PROMs amongst cohorts of patients with OCD that underwent one of three lesion-specific surgical treatments: 1) transarticular drilling for stable lesions, 2) drilling and fixation for unstable lesions 3) grafting for unsalvageable lesions. The electronic medical records of pediatric and adolescent patients with knee OCD, at a single institution between January 2017 and August 2019, were reviewed. Patients were categorized into one of three surgical groups, with initial determination confirmed at the time of surgery during diagnostic knee arthroscopy. Differences between groups were assessed with one-way analysis of variance (ANOVA). Of the 78 patients included in this study, 49 (62.8%) were male with a mean age of 13.5 ± 2.2 years. There was no significant difference between the surgical groups for baseline HSS Pedi-FABS (P = 0.58) or PROMIS Mobility (P = 0.47). There were no significant differences in PROMIS PI scores at baseline (P = 0.32), at latest follow-up (P = 0.72), or in interval change from baseline to follow-up (P = 0.42), between the three surgical groups. Lesion-specific surgical management of OCD led to similar improvements in PROMIS PI at a minimum of one-year follow-up. These results may better allow surgeons to reassure patients and families that outcomes are similar when lesions are treated through a lesion-specific algorithm. Level IV: Retrospective cohort study. • Patients with stable, unstable, and unsalvageable lesions had similar patient reported outcomes prior to surgery. • There were no differences in postoperative patient reported outcomes after lesion-specific surgery.Ongoing multicenter research is underway to follow patients with OCD prospectively in the long-term. • Ongoing multicenter research is underway to follow patients with OCD prospectively in the long-term. [ABSTRACT FROM AUTHOR]

Background: The medial patellofemoral complex (MPFC) is a structure composed of the medial quadriceps tendon–femoral ligament (MQTFL) superiorly and the medial patellofemoral ligament (MPFL) inferiorly. The pediatric MPFL anatomy has been well described, but the precise anatomy of the MQTFL has only recently been described and studied in skeletally immature patients. Purpose: To describe the anatomic relationship between the MQTFL and its insertion on the quadriceps tendon and patella in pediatric specimens. Study Design: Descriptive laboratory study. Methods: A total of 22 pediatric cadaveric knee specimens were dissected to analyze attachment of the MQTFL to the quadriceps tendon and patella. Dissection was facilitated using lateral parapatellar arthrotomy followed by eversion of the extensor mechanism to evaluate MQTFL fibers from its undersurface. Results: The mean specimen age was 7.4 years. Specimens were divided based on age into a younger cohort (1-2 years), middle cohort (4-8 years), and older cohort (9-12 years). The quadriceps tendon attachment (QTA) of the MQTFL proximal to the patella extended a median of 5.0 mm in the younger cohort, 11.4 mm in the middle cohort, and 12.0 mm in the older cohort, with significant differences found between the younger and middle cohorts (P <.047) and the younger and older cohorts (P <.001). The QTA as a percentage of patellar articular height averaged 44.4% across all specimens. The vertical height of the patella measured a median of 14.0 mm, 22.3 mm, and 27.3 mm in the younger, middle, and older cohorts, respectively. Conclusion: This study expands on the recently described anatomy of the pediatric MPFC to quantify the anatomic relationship between the MQTFL attachment to the quadriceps tendon and patella in a more clinically relevant cohort of donor specimens. Clinical Relevance: As access to pediatric cadaveric tissue is extremely limited, a better understanding of MPFC and MQTFL anatomy will support surgeons in preoperative planning and intraoperative considerations for their approach to MQTFL and MPFL reconstruction. This may facilitate improved anatomic surgical stabilization of the patellofemoral joint in pediatric patients. [ABSTRACT FROM AUTHOR]

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

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

Background: Treatment options for pediatric and adolescent anterior cruciate ligament (ACL) injuries include early operative, delayed operative, and nonoperative management. Currently, there is a lack of consensus regarding the optimal treatment for these injuries. Purpose/Hypothesis: The purpose was to determine the optimal treatment strategy for ACL injuries in pediatric and adolescent patients. We hypothesized that (1) early ACL reconstruction results in fewer meniscal tears than delayed reconstruction but yields no difference in knee stability and (2) when compared with nonoperative management, any operative management results in fewer meniscal tears and cartilage injuries, greater knee stability, and higher return-to-sport rates. Study Design: Systematic review and meta-analysis; Level of evidence, 4. Methods: A systematic search of databases was performed including PubMed, Embase, and Cochrane Library using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Inclusion criteria were a pediatric and adolescent patient population (≤19 years old at surgery), the reporting of clinical outcomes after treatment of primary ACL injury, and original scientific research article. Exclusion criteria were revision ACL reconstruction, tibial spine avulsion fracture, case report or small case series (<5 patients), non–English language manuscripts, multiligamentous injuries, and nonclinical studies. Results: A total of 30 studies containing 50 cohorts and representing 1176 patients met our criteria. With respect to nonoperative treatment, knee instability was observed in 20% to 100%, and return to preinjury level of sports ranged from 6% to 50% at final follow-up. Regarding operative treatment, meta-analysis results favored early ACL reconstruction over delayed reconstruction (>12 weeks) for the presence of any meniscal tear (odds ratio, 0.23; P =.006) and irreparable meniscal tear (odds ratio, 0.31; P =.001). Comparison of any side-to-side differences in KT-1000 arthrometer testing did not favor early or delayed ACL reconstruction in either continuous mean differences (P =.413) or proportion with difference ≥3 mm (P =.181). Return to preinjury level of competition rates for early and delayed ACL reconstruction ranged from 57% to 100%. Conclusion: Delaying ACL reconstruction in pediatric or adolescent patients for >12 weeks significantly increased the risk of meniscal injuries and irreparable meniscal tears; however, early and delayed operative treatment achieved satisfactory knee stability. Nonoperative management resulted in high rates of residual knee instability, increased risk of meniscal tears, and comparatively low rates of return to sports. [ABSTRACT FROM AUTHOR]

Background: Previous studies have reported disparities in orthopaedic care resulting from demographic factors, including insurance status. However, the effect of insurance on pediatric tibial spine fractures (TSFs), an uncommon but significant injury, is unknown. Purpose: To assess the effect of insurance status on the evaluation and treatment of TSFs in children and adolescents. Study Design: Cross-sectional study; Level of evidence, 3. Methods: We performed a retrospective cohort study of TSFs treated at 10 institutions between 2000 and 2019. Demographic data were collected, as was information regarding pre-, intra-, and postoperative treatment, with attention to delays in management and differences in care. Surgical and nonsurgical fractures were included, but a separate analysis of surgical patients was performed. Univariate analysis was followed by purposeful entry multivariate regression to adjust for confounding factors. Results: Data were collected on 434 patients (mean ± SD age, 11.7 ± 3.0 years) of which 61.1% had private (commercial) insurance. Magnetic resonance imaging (MRI) was obtained at similar rates for children with public and private insurance (41.4% vs 41.9%, respectively; P ≥.999). However, multivariate analysis revealed that those with MRI performed ≥21 days after injury were 5.3 times more likely to have public insurance (95% CI, 1.3-21.7; P =.02). Of the 434 patients included, 365 required surgery. Similar to the overall cohort, those in the surgical subgroup with MRI ≥21 days from injury were 4.8 times more likely to have public insurance (95% CI, 1.2-19.6; P =.03). Children who underwent surgery ≥21 days after injury were 2.5 times more likely to have public insurance (95% CI, 1.1-6.1; P =.04). However, there were no differences in the nature of the surgery or findings at surgery. Those who were publicly insured were 4.1 times more likely to be immobilized in a cast rather than a brace postoperatively (95% CI, 2.3-7.4; P <.001). Conclusion: Children with public insurance and a TSF were more likely to experience delays with MRI and surgical treatment than those with private insurance. However, there were no differences in the nature of the surgery or findings at surgery. Additionally, patients with public insurance were more likely to undergo postoperative casting rather than bracing. [ABSTRACT FROM AUTHOR]

Background: As regards anterior cruciate ligament (ACL) reconstruction (ACLR), graft diameter has been identified as a major predictor of failure in skeletally mature patients; however, this topic has not been well-studied in the higher risk pediatric population. Hamstring tendon autograft configuration can be adjusted to increase graft diameter, but tendon length must be adequate for ACLR. Historical parameters of expected tendon length have been variable, and no study has quantified pediatric ACL morphology with other osseous parameters. Purpose: To develop magnetic resonance imaging (MRI)--derived predictors of native ACL graft length in pediatric patients so as to enhance preoperative planning for graft preparation in this skeletally immature patient population. Study Design: Cross-sectional study; Level of evidence, 3. Methods: MRI scans of 110 patients were included (64 girls, 46 boys; median age, 10 years; range, 1-13 years). Patients with musculoskeletal diseases or prior knee injuries were excluded. The following measurements were taken on MRI: ACL length; sagittal and coronal ACL inclination; intercondylar notch width and inclination; and femoral condyle depth and width. Associations between these measurements and patient sex and age were investigated. Univariate linear regression and multivariable regression models were created for each radiographic ACL measure to compare R2. Results: Female ACL length was most strongly associated with the depth of the lateral femoral condyle as viewed in the sagittal plane (R2 ¼ 0.65; P < .001). Other statistically significant covariates of interest included distal femoral condylar width, age, and coronal notch width (P < .05). For males, the ACL length was most strongly associated with the distal femoral condyle width as viewed in the coronal plane (R2 ¼ 0.70; P < .001). Other statistically significant covariates of interest for male ACL lengths were lateral femoral condyle depth, age, and coronal notch width (P < .05). Conclusion: In pediatric populations, femoral condylar depth/width and patient age may be valuable in assessing ACL size and determining appropriate graft dimensions and configuration for ACLRs. The use of this information to optimize graft diameter may lower the rates of ACL graft failure in this high-risk group. [ABSTRACT FROM AUTHOR]

Background: Surgical decision making and preoperative planning for children and adolescents with patellofemoral instability rely heavily on a patient's skeletal maturity. To be clinically useful, radiologic assessments of skeletal maturity must demonstrate acceptable interrater reliability and accuracy. Purpose: The purpose of this study was to examine the interrater reliability among surgeons of varying experience levels and specialty training backgrounds when evaluating the skeletal maturity of the distal femur and proximal tibia of children and adolescents with patellofemoral instability. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: Six fellowship-trained orthopaedic surgeons (3 pediatric orthopaedic, 2 sports medicine, and 1 with both) who perform a high volume of patellofemoral instability surgery examined 20 blinded knee radiographs and magnetic resonance images in random order. They assessed these images for clinically relevant growth (open physis) or clinically insignificant growth (closing/ closed physis) remaining in the distal femoral and proximal tibial physes. Fleiss' kappa was calculated for each measurement. After initial ratings, raters discussed consensus methods to improve reliability and assessed the images again to determine if training and new criteria improved interrater reliability. Results: Reliability for initial assessments of distal femoral and proximal tibial physeal patency was poor (kappa range, 0.01-0.58). After consensus building, all assessments demonstrated almost-perfect interrater reliability (kappa, 0.99 for all measurements). Conclusion: Surgical decision making and preoperative planning for children and adolescents with patellofemoral instability rely heavily on radiologic assessment of skeletal maturity. This study found that initial interrater reliability of physeal patency and clinical decision making was unacceptably low. However, with the addition of new criteria, a consensus-building process, and training, these variables became highly reliable. [ABSTRACT FROM AUTHOR]

Background: There is a high rate of concomitant injuries reported in pediatric patients with tibial spine fractures, ranging from 40% to 68.8%. Many tibial spine fractures are treated without initial magnetic resonance imaging (MRI). Purpose: To understand rates of concomitant injury and if the reported rates of these injuries differed among patients with and without pretreatment MRI. Study Design: Cross-sectional study; level of evidence, 3. Methods: We performed an institutional review board–approved multicenter retrospective cohort study of patients treated for tibial spine fractures between January 1, 2000, and January 31, 2019, at 10 institutions. Patients younger than 25 years of age with tibial spine fractures were included. Data were collected on patient characteristics, injury, orthopaedic history, pretreatment physical examination and imaging, and operative findings. We excluded patients with multiple trauma and individuals with additional lower extremity fractures. Patients were categorized into 2 groups: those with and those without pretreatment MRI. The incidence of reported concomitant injuries was then compared between groups. Results: There were 395 patients with a tibial spine fracture who met inclusion criteria, 139 (35%) of whom were reported to have a clinically significant concomitant injury. Characteristics and fracture patterns were similar between groups. Of patients with pretreatment MRI, 79 of 176 (45%) had an identified concomitant injury, whereas only 60 of 219 patients (27%) without pretreatment MRI had a reported concomitant injury (P <.001). There was a higher rate of lateral meniscal tears (P <.001) in patients with pretreatment MRI than in those without. However, there was a higher rate of soft tissue entrapment at the fracture bed (P =.030) in patients without pretreatment MRI. Overall, 121 patients (87%) with a concomitant injury required at least 1 treatment. Conclusion: Patients with pretreatment MRI had a statistically significantly higher rate of concomitant injury identified. Pretreatment MRI should be considered in the evaluation of tibial spine fractures to improve the identification of concomitant injuries, especially in patients who may otherwise be treated nonoperatively or with closed reduction. Further studies are necessary to refine the indications for MRI in patients with tibial spine fractures, determine the characteristics of patients at highest risk of having a concomitant injury, define the sensitivity and specificity of MRI in tibial spine fractures, and investigate patient outcomes based on pretreatment MRI status. [ABSTRACT FROM AUTHOR]

Background: Pre- and postoperative standing hip-to-ankle radiographs are critical for monitoring potential postoperative growth arrest and resultant deformities after pediatric anterior cruciate ligament (ACL) reconstruction. Purpose: To determine the prevalence of apparent preoperative leg-length discrepancies (LLDs) that resolve at the first postoperative radiographic examination in patients undergoing ACL reconstruction in order to understand what proportion of the noted preoperative deformities may have been inaccurate. Study Design: Case series; Level of evidence, 4. Methods: A retrospective review of prospectively collected preoperative and first postoperative full-length hip-to-ankle radiographs was performed in a cohort of skeletally immature patients who had an acute ACL injury and underwent subsequent surgical reconstruction. Leg length measurements for both the injured and the uninjured legs were obtained for comparison. Results: A total of 112 patients (mean age, 12.7 ± 1.7 years) were included (79 boys and 33 girls). Leg-length measurement interrater reliability among 3 raters for 25 randomly chosen images was nearly perfect (intraclass correlation coefficient, 0.996; 95% CI, 0.994-0.998). At baseline, there was no apparent preoperative LLD (<5 mm) in 48% (n = 54) of participants, while 37% (n = 41) displayed a small apparent LLD (5 to <10 mm), 12% (n = 13) displayed a moderate apparent LLD (10 to <15 mm), and 4% (n = 4) displayed a large apparent LLD (≥15 mm). Of the patients with an apparent preoperative LLD, 66% (n = 38) of them tore their ACL on the leg measuring shorter. At first postoperative radiographs, 48% (n = 28) of patients with an apparent preoperative LLD showed resolution to no LLD: 46% (n = 19) of patients with a small apparent preoperative LLD, 54% (n = 7) of patients with a moderate apparent LLD, and 50% (n = 2) of patients with a large apparent LLD. Conclusion: A high percentage of patients (48%) with apparent preoperative LLDs showed resolution to no LLDs by their first postoperative imaging, indicating that preoperative hip-to-ankle radiographs display some false LLDs in patients with recent ACL tears who are unable to fully extend their injured leg and bear weight. [ABSTRACT FROM AUTHOR]

Background: Imaging characteristics of osteochondritis dissecans (OCD) lesions quantified by magnetic resonance imaging (MRI) are often used to inform treatment and prognosis. However, the interrater reliability of clinician-driven MRI-based assessment of OCD lesions is not well documented. Purpose: To determine the interrater reliability of several historical and novel MRI-derived characteristics of OCD of the knee in children. Study Design: Cohort study (diagnosis); Level of evidence, 3 Methods: A total of 42 OCD lesions were evaluated by 10 fellowship-trained orthopaedic surgeons using 31 different MRI characteristics, characterizing lesion size and location, condylar size, cartilage status, the interface between parent and progeny bone, and features of both the parent and the progeny bone. Interrater reliability was determined via intraclass correlation coefficients (ICCs) with 2-way random modeling, Fleiss kappa, or Krippendorff alpha as appropriate for each variable. Results: Raters were reliable when the lesion was measured in the coronal plane (ICC, 0.77). Almost perfect agreement was achieved for condylar size (ICC, 0.93), substantial agreement for physeal patency (ICC, 0.79), and moderate agreement for joint effusion (ICC, 0.56) and cartilage status (ICC, 0.50). Overall, raters showed significant variability regarding interface characteristics (ICC, 0.25), progeny (ICC range, 0.03 to 0.62), and parent bone measurements and qualities (ICC range, –0.02 to 0.65), with reliability being moderate at best for these measurements. Conclusion: This multicenter study determined the interrater reliability of MRI characteristics of OCD lesions in children. Although several measurements provided acceptable reliability, many MRI features of OCD that inform treatment decisions were unreliable. Further work will be needed to refine the unreliable characteristics and to assess the ability of those reliable characteristics to predict clinical lesion instability and prognosis. [ABSTRACT FROM AUTHOR]

Background: Osgood-Schlatter disease (OSD) is a traction apophysitis of the tibial tubercle caused by repetitive strain and chronic avulsion from the patellar tendon. No widely accepted anatomic risk factors have been associated with OSD. Purpose: To determine if OSD is associated with increased posterior tibial slope (PTS). Study Design: Cross-sectional study; Level of evidence, 3. Methods: Forty knees with OSD and 32 control knees examined by the senior author between 2008 and 2019 were included. Patients 10 to 15 years of age with a clinical diagnosis of OSD and available lateral radiograph and magnetic resonance imaging (MRI) were eligible. Age- and sex-matched patients with a history of knee pain but no evidence of OSD on clinical examination and without significant pathology on lateral radiograph and MRI were included in the control group. PTS was defined as the angle between a reference line perpendicular to the proximal anatomic axis and a line drawn tangent to the uppermost anterior and posterior edges of the medial tibial plateau. Measurements were carried out in duplicate on true lateral radiographs by 2 blinded investigators. Interrater reliability of PTS measurements was evaluated using intraclass correlation coefficient (ICC). The independent samples t test was used to compare PTS between the OSD and control knees. Results: The mean age was 12.6 ± 1.6 years and 51% (37/72) of the knees were from male youth. There were no differences in age, sex, and laterality of knees between the OSD and control groups. The mean PTS was significantly higher in the OSD group (12.23°± 3.58°) compared with the control group (8.82°± 2.76°; P <.001). The ICC was 0.931 (95% CI, 0.890-0.957), indicating almost perfect interrater reliability. Conclusion: This study identifies an association between OSD and increased PTS. The clinical implications of this finding have not yet been elucidated. It may be speculated that in patients with OSD, stress from the extensor mechanism through the patellar tendon loads the anterior portion of the tibia disproportionately to the posterior segment, thereby resulting in asymmetric growth and an increased PTS. [ABSTRACT FROM AUTHOR]

Background: With sports specialization and level of competition on the rise, anterior cruciate ligament reconstruction (ACLR) in athletes under the age of 20 has increased significantly in recent years. Reports have demonstrated that the revision ACLR rate is higher and return to sport (RTS) rate is lower in this population. Purpose: To evaluate the 2-year clinical outcomes of 3 cohorts of primary ACLR in pediatric and adolescent athletes under the age of 20 based on skeletal age with a focus on RTS and the incidence of second surgery. Study Design: Case series; Level of evidence, 4. Methods: This is a prospective evaluation of 324 athletes younger than 20 years of age who underwent ACLR with minimum 2-year follow-up. The surgical technique was selected predicated on skeletal age, which includes the all-epiphyseal technique with hamstring autograft in the youngest cohort in elementary and middle school (group 1), the partial transphyseal and complete transphyseal with hamstring autograft performed for athletes in the middle cohort (group 2), and bone-tendon-bone autograft in the skeletally mature high school athletes (group 3). Results: The mean chronological age of the entire cohort was 15 years (range, 8-19 years) with 55% males. The 3 cohorts included 49 patients (15%) in group 1 (mean age, 12 years), 66 (20%) in group 2 (mean age, 14.3 years), and 209 (65%) in group 3 (mean age, 16.2 years). Group 2 athletes had a significantly higher revision ACLR rate (20%) compared with group 1 (6%; P = .039) and group 3 (6%; P = .001). Similarly, group 2 athletes had significantly lower RTS rates (85%) compared with group 1 (100%) and group 3 (94%). Conclusion: The rate of revision ACLR was significantly higher and the RTS rates significantly lower in group 2 compared with groups 1 and 3. This age-related risk profile may be used to counsel athletes and parents preoperatively regarding the expectations of surgery with respect to revision ACLR and RTS rates. [ABSTRACT FROM AUTHOR]

Background: Recent data have shown an increase in youth sports participation at younger ages, which may be linked to greater musculoskeletal injury risk. The Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS) is a validated 8-item instrument designed to quantify the activity of children between 10 and 18 years old. Normative data on pediatric and adolescent activity level are unknown. Purpose: To establish normative activity-level data for American youth and to determine if there is a natural decrease in activity level during adolescence. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A cross-sectional investigation was performed among 2002 US children and adolescents equally split by sex and age and representing census-weighted distributions of state of residency, race/ethnicity, and health insurance status. Respondents completed the HSS Pedi-FABS, as well as survey questions on demographics and sports participation. Normative data were reported with descriptive statistics. Linear regression analysis was performed to determine if there was an effect of age on activity level during adolescence. Results: A total of 2002 respondents completed the survey; the mean age of the respondents at the time of survey completion was 14.0 ± 2.6 years. Mean weekly amount of reported physical activity was 9.3 ± 8.4 hours. HSS Pedi-FABS scores were normally distributed with a mean of 15.4 ± 8.5 points (out of 30 possible points). There was a modest but statistically significant decrease in HSS Pedi-FABS activity scores with increasing age (r = −0.175, P < .001), corresponding to a linear decrease in activity scores by 27% on average from age 10 to 18 years. Conclusion: The current study provides baseline normative data for activity level in a census-weighted representative population sample of 2002 American youth through the use of a validated activity score (HSS Pedi-FABS). There was a modest but statistically significant decrease in activity scores with increasing age. These results will aid future research by providing normative, representative population-level activity data and will help to quantify the natural rate of decreased activity during adolescence. [ABSTRACT FROM AUTHOR]

Background: Anterior cruciate ligament (ACL) injuries in skeletally immature athletes are increasing. Purpose: To evaluate the 2-year clinical outcomes of all-inside, all-epiphyseal ACL reconstruction in skeletally immature athletes with 3 to 6 years of remaining growth, with a focus on return to sport and the incidence of second surgery. Study Design: Case series; Level of evidence, 4. Methods: Twenty-three skeletally immature athletes were prospectively evaluated after all-epiphyseal ACL reconstruction utilizing a hamstring autograft. The athletes’ age, sex, sport, mechanism of injury, radiographs, and magnetic resonance imaging (MRI) findings were noted. The evaluation included a physical examination, KT-1000 arthrometer measurements, isokinetic testing, and validated outcome scores. Standing radiographs and spoiled gradient recalled echo MRI scans were obtained at 6, 12, and 24 months postoperatively. A quality of movement assessment and return-to-sport performance analysis were also performed. Results: Of the 23 athletes, 6 were female (mean age, 11.3 years), and 17 were male (mean age, 12.6 years). At a minimum follow-up of 2 years (range, 24-45 months), the mean International Knee Documentation Committee score was 94.6 ± 4.9, the mean Lysholm score was 97.9 ± 4.0, the mean Marx activity rating scale score was 13.4 ± 3.6, and the mean Hospital for Special Surgery Pediatric Functional Activity Brief Scale score was 23.9 ± 7.0. Lachman and pivot-shift test results were negative in all patients. The mean side-to-side difference on the KT-1000 arthrometer was 0.9 ± 0.5 mm and less tight on the operated side. No significant growth disturbances were noted; however, 6 athletes had a leg-length discrepancy of more than 5 mm (range, 6-18 mm). Two patients had overgrowth in the femur of more than 15 mm (16 mm and 18 mm). Two athletes (8.7%) required second surgery. The mean time to return to unrestricted activity was 13.5 months (range, 8-22 months). Conclusion: The all-inside, all-epiphyseal ACL reconstruction technique using a hamstring autograft demonstrates excellent subjective and objective clinical outcomes in skeletally immature athletes without physeal arrest. [ABSTRACT FROM AUTHOR]

Background: Increased posterior tibial slope is associated with increased risk of anterior cruciate ligament (ACL) injury in adults. A similar association has not been rigorously examined in children and adolescents. Purpose: To determine whether alterations in posterior tibial slope are associated with ACL tears in pediatric and adolescent patients and to quantify changes in tibial slope by age. Study Design: Case-control study; Level of evidence, 3. Methods: Magnetic resonance imaging (MRI) studies of the knee were reviewed by 3 raters blinded to each other in a 1:1 sample of cases and age-and sex-matched controls. A total of 76 skeletally immature ACL-injured knees were compared with 76 knees without ACL injury; the mean age of the study population was 14.8 ± 1.3 years. The posterior slope of the articular surface of the medial tibial plateau and lateral tibial plateau was measured by use of a method similar to that used in previous studies in adult populations. The current study technique differed in that the slope was measured on the cartilage surface, not the subchondral bone. Comparisons between knees were made with t tests, and Spearman correlation analysis was used to assess changes in tibial slope with advancing age. Results: Increased slope of the lateral tibial plateau (LTS) was significantly increased in ACL-injured patients compared with controls (5.7° ± 2.4° vs 3.4° ± 1.7°; P < .001). There was no statistically significant difference in the slope of the medial tibial plateau (MTS) in the ACL-injured and control knees (5.4° ± 2.2° vs 5.1° ± 2.3°; P = .42). There was no difference in LTS between male and female patients (4.46° vs 4.58°; P = .75). Receiver operating characteristic (ROC) analysis of the LTS revealed that a posterior tibial slope cutoff of >4° resulted in a sensitivity of 76% and a specificity of 75% for predicting ACL tears in this cohort. Spearman correlation analysis revealed that MTS and LTS decreased, or flattened, by 0.31° (P = .028, correlation coefficient r = -0.18) and 0.37° (P = .009, correlation coefficient r = -0.21) per year, respectively, as adolescents age. Conclusion: The LTS was significantly associated with an increased risk of ACL injury in pediatric and adolescent patients. The MTS was not associated with risk of injury. Posterior slope was found to decrease, or flatten, with age. A cutoff of >4° for the posterior slope of the lateral compartment is 76% sensitive and 75% specific for predicting ACL injury in this cohort. The LTS did not influence the incidence of ACL injury differently between sexes. [ABSTRACT FROM AUTHOR]

The article focuses on the use of physeal-specific magnetic resonance imaging (MRI) to investigate physeal injury after all-insid anterior cruciate ligament (ACL) reconstruction. Topics discussed include the benefits associated with the use of radiographic diagnostic tools to check for absence of physeal injury, the results of the test conducted on the effectiveness of MRI in detecting physeal injury and the influence of tunnel drill angle on the volume of physeal injury.

The article presents a study which determined the yearly rate of anterior cruciate ligament (ACL) reconstruction in New York in the past 20 years as of March 2014. It also examines the age distribution for ACL reconstruction, as well as the effects of patient demographic and socioeconomic factors in ACL reconstruction. In the study, data from the Statewide Planning and Research Cooperative System (SPARCS) database were used.

The article presents a study on the development and validation of a concise and comprehensive activity rating scale for athletically active children and adolescents who are 10 to 18 years old. It cites the lack of outcome measures necessary for conducting outcomes research in orthopaedic surgery. The Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS) can be used to evaluate activity level as a prognostic variable for clinical research.

The article discusses a study that focused on adult anterior cruciate ligament (ACL) reconstruction techniques and the ability of the all-epiphyseal (AE) and over-the-top (OT) reconstruction techniques in restoring knee kinematics. The study concluded that while OT and AE provided anterior and rotational stability and decreased posterior joint contact stresses compared with the ACL-deficient knee, they could not restore the contact mechanics and kinematics of the ACL-intact knee.

Purpose: The purpose of this study was to assess athletic activities associated with spondylolysis in children and adolescents in a New York metropolitan tertiary referral center. Methods: We retrospectively evaluated 137 consecutive cases of symptomatic spondylolysis presenting to one of two pediatric orthopedic spine surgeons. Ten patients who did not participate in any organized athletics were excluded, leaving 127 children for analysis. Data regarding spondylolysis and athletic participation were gathered for analysis. Results: One hundred and twenty-seven patients were analyzed (mean age, 13.9 ± 2.2 yr). All patients had initial x-rays, with nearly all obtaining further advanced level imaging to confirm the diagnosis of spondylolysis. Magnetic resonance imaging was obtained in 42.5% of cases, limited computed tomography scan in 29.1% of cases, and single-photon emission computed tomography scan in 23.6% of cases. The most common location of spondylolysis was at the L5 level (74%), of which 43.6% were bilateral. Of the overall cohort, 2.4% had spondylolysis at multiple levels. The most common athletic activities associated with spondylolysis in this cohort were soccer (19.3%), basketball (17.2%), and lacrosse (9.4%). Conclusion: Although previous reports have implicated participation in various sports in the development of symptomatic spondylolysis in children, lacrosse and baseball have rarely been associated with spondylolysis. We found that in the New York metropolitan area, soccer, basketball, lacrosse, baseball, tennis, and football were most commonly associated with spondylolysis. Therefore, we emphasize consideration of spondylolysis in these children if they present with low back pain. These results may be used to counsel parents and young athletes about the possibility of spondylolysis as an etiology of lumbar back pain and in educating coaches, teachers, school nurses, and primary care providers. [ABSTRACT FROM AUTHOR]