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Introduction: Avulsion fractures of the ischial tuberosity (AFIT) are uncommon injuries that sometimes require operative fixation with screws, suture anchors, or cortical suspensory buttons. This study reviewed a series of surgically managed AFITs at a single institution and compared outcomes among fixation strategies. We hypothesized there would be no difference in outcomes between fixation types., Methods: We conducted a retrospective review of all patients treated operatively at a single institution from 2010 to 2022 for AFIT identified by CPT code (27215). We collected patient demographics, injury characteristics, Revised Modified Oxford Bone Score, radiographic measures, fracture classification (type 1-lateral vs. type 2-complete), surgical fixation technique, postoperative complications (Modified Clavien-Dindo-Sink [M-CDS] Complication Classification), and time to return to sport (RTS). Descriptive statistics and univariate analyses were performed., Results: Study criteria identified 16 patients with surgically treated AFITs during the study period. Patients were predominantly male (88%) with a mean age of 14.8±0.8 years. Injured patients most commonly participated in soccer (38%), with the most common mechanism of injury being running/sprinting (50%). The avulsed fracture fragments were a mean of 42.6 mm in size, with an average maximal displacement of 21.1 mm and predominantly type 1-lateral (75%). Surgical constructs included: screws (4), suture anchors (5), cortical suspensory buttons (6), and combined (1, screw and suture anchor). Postoperative complications occurred in 8 patients (50%) including 7 type 1 and 1 type 3 M-CDS. No statistically significant difference was found between fixation types among the studied outcome variables; however, re-fracture (1 case [M-CDS type 3]) was only observed with a combined (screw and suture anchor) construct., Conclusions: This retrospective cohort study demonstrated that postoperative complications after ORIF for AFIT were not infrequent but were largely low in severity. Refracture occurred only with a combined screw and suture anchor construct. Consistent return to sport was achieved across all fixation types, with no significant difference in complication rate between constructs, although the available study sample limited robust analysis. This study is also, of note, one of the first to report outcomes from cortical suspensory buttons (CSB)-a relatively novel intervention for AFIT. Findings from this retrospective case series of multiple surgical techniques serve to bolster the limited literature base regarding the operative treatment of AFITs in adolescents., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Patellofemoral osteochondral fractures (OCFs) have the potential to hinder patients' function and quality of life. Several fragment fixation techniques have been described, with both metallic screw and bioabsorbable fixation showing favorable functional outcomes. Despite the promising results associated with both fixation methods, no study has directly compared their functional outcomes., Purpose: To compare the functional and radiographic outcomes between bioabsorbable and metallic screw patellofemoral OCF fixation in an adolescent cohort., Study Design: Cohort study; Level of evidence, 2., Methods: A retrospective review was conducted identifying surgically treated pediatric patients (<18 years of age) with OCFs of the patellofemoral joint. Inclusion criteria were treatment with metallic screw or bioabsorbable fixation (bioabsorbable compression screw, suture bridge, or chondral darts), with preoperative radiographs and operative notes available for review. Patient information, injury characteristics, treatments, and outcomes were collected with a specific focus on return-to-activity time and postoperative complications. Univariate analyses were conducted to compare radiographic and functional outcomes between groups., Results: According to the study criteria, 37 knees in 37 patients (84% male), with a mean age of 14.2 ± 1.8 years, were identified. A total of 24 patients were injured during sports participation, with basketball and football being the most common sports. OCF fixation cohorts consisted of 12 patients treated with metallic screw fixation and 25 with bioabsorbable fixation. No statistically significant differences were appreciated when comparing median time to full activity between the fixation groups ( P = .427). However, time to full activity was unequally distributed, with 66.7% of the metallic screw fixation group returning to activity later than the total cohort's median, compared with 42.9% of the bioabsorbable fixation group ( P = .04). Two-thirds (8/12) of patients treated with metallic screws required return to the operating room for hardware removal compared with no patient treated with bioabsorbable fixation ( P < .001). Two complications occurred with no significant differences appreciated between groups ( P = .202). However, both postoperative complications were recorded in the metallic screw fixation group: 1 patient with osteochondral malunion and another with arthrofibrosis., Conclusion: This study demonstrated that pediatric patellofemoral OCFs had good outcomes with high healing and low complication rates regardless of fixation type. Because of the high rate of secondary hardware removal procedures, metallic screw constructs delayed the return to sports and activity time. Patients treated with bioabsorbable fixation did not require a secondary operation for hardware removal and thus were more likely to recover sooner. Future studies are necessary to assess the potential outcome differences between different types of bioabsorbable fixation methods. Based on these findings, surgeons can consider bioabsorbable fixation as an option for the management of OCF lesions., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: S.B. has received education payments from Arthrex and Gotham Surgical Solutions & Devices. K.M. has received education payments from Liberty Surgical, Paladin Technology Solutions, Arthrex, and Smith & Nephew. B.A.W. has received education payments from Liberty Surgical and Arthrex. T.G. has received education payments from Paladin Technology Solutions and hospitality payments 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., (© The Author(s) 2024.)

Background: Axial extensor mechanism alignment is routinely assessed in patients with patellofemoral instability.Although many of these assessments are described using magnetic resonance imaging, it is plausible that ultrasound (US) imaging could be utilized to provide similar information in a more cost-effective and time-efficient manner., Purpose: To (1) describe and assess the reliability of a novel measure of extensor mechanism alignment of the patellofemoral joint using musculoskeletal US and (2) establish the construct validity of this measure through comparison of patients with and without patellar instability., Study Design: Cohort study (diagnosis); Level of evidence, 3., Methods: Patients with (n = 24; 14.2 ± 3.1 years; 83% female) and without (n = 26; 14.7 ± 2.8 years; 69% female) a clinical history of patellofemoral instability (PFI) participated. Extensor mechanism alignment was assessed bilaterally on US, measuring the distance between the midpoint of the patellar tendon to the lateral trochlear ridge (MPT-LTR). Interrater reliability of the measurements was assessed using the intraclass correlation coefficient (ICC), with a minimum of 1 week between measurements for test-retest reliability. Differences between limbs were assessed using paired-samples t tests, and between-group differences were compared using independent-samples t tests., Results: Patients with PFI demonstrated a significantly smaller MPT-LTR distance than healthy controls on both their involved (8.1 ± 3.6 vs 12.6 ± 2.6 mm) and uninvolved (8.9 ± 3.4 vs 12.9 ± 2.4 mm) limbs ( P  < .001 for both), indicating greater lateralization of the patellar tendon relative to the trochlea. There were no differences found between limbs for either patients with PFI ( P  = .26) or controls ( P  = .46). Interrater reliability was good (ICC = 0.785; 95% confidence interval [CI], 0.579-0.890), and test-retest reliability (n = 8) was excellent (ICC = 0.958; 95% CI, 0.790-0.992)., Conclusion: The US-based MPT-LTR distance demonstrated good-to-excellent reliability. When compared with controls, the MPT-LTR distance was smaller in patients with PFI, indicating greater lateralization of the extensor mechanism., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: B.W. has received education payments from Arthrex and hospitality payments from Smith & Nephew and Stryker. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2024.)

BACKGROUND: Osteochondritis dissecans (OCD) of the medial femoral condyle (MFC), a common cause of pediatric chronic knee pain, is often found to be stable at arthroscopy. OBJECTIVE: To investigate the performance of MRI for identifying instability of MFC OCD in children. METHODS: This retrospective study included 59 children (37 boys, 22 girls; mean age, 12.5±2.2 years) with 69 MFC OCD lesions, who underwent knee MRI from January 2016 to October 2023. Two radiologists independently reviewed examinations to determine regional findings (effusion, skeletal maturity, secondary physis visibility, progeny composition), as well as direct (osteochondral defect, intraarticular body, cartilage alteration, bone plate disruption, receded ossification front) and indirect (progeny-parent bone interface, radius of curvature, parent-bone low-signal intensity (SI) marginal rim, perilesional marrow edema) findings of instability; disagreements were resolved through consensus. Two investigators assessed an additional indirect finding, cyst(s), in consensus. Demographic characteristics, and lesion volume were collected. The reference standard for lesion stability was arthroscopy (n=52) or follow-up evaluation (based on symptoms and imaging findings) in patients managed conservatively (n=17). Stable and unstable lesions were compared. RESULTS: Forty-nine lesions were stable, and 20 were unstable. Sensitivity and specificity for instability, among features showing significant associations with instability, were 70.0% and 100.0% for skeletal maturity, 75.0% and 75.5% for osteochondral progeny composition, 100.0% and 85.7% for cartilage alteration, 85.0% and 81.6% for presence of progeny-parent bone interface, 30.0% and 100.0% for extensive interface, 90.0% and 34.7% for cyst(s), 45.0% and 91.8% for altered radius of curvature, 80.0% and 89.8% for parent-bone low-SI rim, and 50.0% and 81.6% for extensive perilesional marrow edema. In multivariable analysis, factors independently associated with instability included larger lesion volume and indirect signs (presence of interface, cyst(s), altered radius of curvature, parent-bone low-SI rim, and extensive perilesional marrow edema). Frequency of instability was 0.0%, 7.4%, 16.7%, 75.0%, 83.3%, and 100.0% for lesions with 0, 1, 2, 3, 4, and 5 indirect signs. CONCLUSION: Lesion instability was associated with an increasing number of indirect MRI signs. CLINICAL IMPACT: Assessment of lesion stability by MRI can help guide decisions between arthroscopy and conservative management for MFC OCD in children.

The purpose of this study was to estimate monthly and annual trends in youth sports-related injury over the years 2016-2020 using the National Electronic Injury Surveillance System (NEISS) database to measure the impact of COVID-19 on overall and sport-specific rates of injury. Children and adolescents (0-19 years) presenting to USA emergency departments with sport participation injury from 2016 to 2020 were identified. Descriptive statistical analyses were performed of injury patterns. An interrupted time series analysis was applied to estimate changes in injury trends during COVID-19. Proportional changes in injury characteristics during this period were examined. An estimated 5 078 490 sports-related injuries were identified with an annual incidence of 1406 injuries per 100 000 population. Seasonal peaks in injuries occurred during September and May. About 58% of injuries were associated with contact sports, such as basketball, football, and soccer, and the most common injuries were sprains and strains. After the pandemic onset, there was a statistically significant 59% decrease in national youth sports-related injuries compared with the average estimates for 2016-2019. While the distribution of injury characteristics did not appear to change, the location of injury appeared to shift away from school toward alternative settings. A significant reduction in youth sports-related injuries was identified in 2020 coinciding with the COVID-19 pandemic, persisting throughout the rest of the year. No changes in the anatomic or demographic distribution of injuries were identified. This study expands our epidemiologic understanding of youth sports-related injury trends and how they changed following the pandemic onset., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: COVID-19 restrictions created a period of disrupted sports participation for youth athletes. The physical conditioning, sports training habits, and patterns of sports activity resumption upon returning to normal sports activity are currently unknown., Purpose/hypothesis: This study aimed to determine the extent to which youth athletes maintained their training levels during the early stages of the COVID-19 pandemic and understand the strategies that enhanced motivation and adherence to a training regimen while in isolation. A secondary aim was to analyze how youth athletes returned to activity and identify injuries associated with prolonged sports interruption., Study Design: Observational / Survey Study., Methods: A survey designed to determine activity changes, type of organized instruction, and athlete preferences for training support were distributed by email using snowball sampling methodology to athletes 14-21 years old who were involved in competitive sports when pandemic restrictions were enacted. As sports activities resumed, a follow-up survey was distributed to the same respondents to identify feelings of preparedness, training habits, and injuries., Results: Of the155 subjects (mean age 16.1 ± 2 years, 64.5% female) that completed the initial survey, 98% reported a stoppage of in-person sports participation and 70% decreased their exercise/training volume, with 41% (n=63) reporting > 50% reduction. Most athletes (86%) received instruction from coaches, with written workouts (70%) being most common; however, most athletes (70%) preferred instructor-led, group training sessions. Of the 43 subjects that completed the follow-up survey (34% response rate), there was an increase in athletic exposures compared to mid-pandemic levels, and 25% reported sustaining a sports-related injury shortly after resuming sports activities., Conclusions: Pandemic-related sports restrictions resulted in a significant reduction in youth athlete training and conditioning. Coaches attempted to maintain training via the use of written workouts; however, athletes preferred instructor-led, group training sessions. There was a rapid resumption of sports activities, which may have contributed to the high rate of injuries in this study., Level of Evidence: 3., Competing Interests: We, the authors, affirm that we have no financial or commercial affiliations related to the performance or outcome of this manuscript.

The purpose of this study was to investigate whether an elbow arthrogram after closed reduction and percutaneous fixation of lateral condyle fractures results in a change in surgical management. This is a retrospective review of lateral condyle fractures managed with closed reduction and percutaneous fixation followed by an elbow arthrogram at our institution between 2008 and 2019. Chart and radiographic review was performed and operative notes were reviewed to determine rates of subsequent intervention after arthrogram. Descriptive statistics were used to summarize the data. This study included 47 patients. The majority of patients were male (34 patients, 72%), and the mean age at time of injury was 5.5 ± 2.6 years. The mean radiographic displacement was 2.6 mm (range 0.8-6.9 mm). All fractures were managed by fellowship-trained pediatric orthopaedic surgeons with an average of 10.5 years of experience (range 0-32 years). Fractures were stabilized with percutaneous pins in 44 patients (94%) and percutaneous screws in three patients (6%). No patients had subsequent changes in management after an elbow arthrogram. There were no complications related to performance of the arthrogram. Closed reduction and percutaneous fixation is often indicated for mildly displaced lateral condyle fractures. Articular reduction after percutaneous fixation is commonly assessed using an elbow arthrogram; however, it did not change surgical management in any case reviewed over the 10-year study period. While there seems to be little risk of performing an arthrogram, the clinical utility should be further evaluated., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: In adults, anterior glenohumeral instability has been associated with a tall and narrow glenoid morphology, assessed using the glenoid index (GI; glenoid height-to-width ratio) on magnetic resonance imaging (MRI). This morphological association has not been assessed in children and adolescents., Purpose/hypothesis: To examine the association of GI and other MRI measurements of interest supported in studies on adults with anterior glenohumeral dislocation in patients aged ≤19 years. We hypothesized that these patients would have a significantly greater GI (relatively taller and narrower glenoid morphology) compared with healthy controls., Study Design: Case-control study; Level of evidence, 3., Methods: An institutional radiology database was queried over a 10-year period to identify patients aged ≤19 years who had been diagnosed with radiographically confirmed anterior shoulder dislocation and who underwent glenohumeral magnetic resonance arthrography as well as those without dislocation with normal shoulder arthrogram studies (controls). Patients with bony Bankart lesions were excluded. The following glenohumeral dimensions were measured on shoulder arthrogram: GI, glenoid version, coracohumeral interval, and rotator interval width/depth. Comparative analysis between the 2 groups was performed using the Student t test for each variable, followed by receiver operating characteristic (ROC) analysis to determine discriminative ability when statistically significant., Results: Overall, 55 participants (33 male and 22 female patients; mean age, 15.4 ± 2.1 years) were enrolled; 22 patients were in included in the dislocator group and 33 patients comprised the control group. The mean GI in the dislocator group was significantly greater than the control group (1.55 ± 0.14 vs. 1.38 ± 0.08; P < .001). ROC analysis revealed adequate discrimination of GI in predicting glenohumeral dislocation (area under the curve = 0.88). A GI ≥1.45 was 83% sensitive and 79% specific for predicting dislocation in the study cohort., Conclusion: Patients with anterior glenohumeral dislocation had increased GI (taller and narrower glenoid morphology) than controls. This useful MRI measurement may help identify patients at risk for primary or recurrent anterior glenohumeral instability events and may therefore help with guiding treatment and prevention., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: P.D.F. has received education payments from Smith & Nephew and hospitality payments from Medical Device Business Services. A.L.N. has received education payments from Smith & Nephew and hospitality payments from Zimmer Biomet. T.J.G. has received education payments from Arthrex and Liberty Surgical. J.T.L. has received education payments from Arthrex and Liberty Surgical and nonconsulting fees 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., (© The Author(s) 2021.)

Background: Current anterior cruciate ligament reconstruction (ACLR) guidelines utilize single-leg hop tests (SLHTs) to assist in return-to-sport decision making. A limb symmetry index (LSI) of ≥90% is often required; however, after ACLR, most youth athletes cannot achieve this standard. Reporting the performance of age-matched normative controls will allow clinicians to compare post-ACLR performance with noninjured peers, improving the utility of SLHTs. The purpose of this study was to report hop test LSI within healthy youth athletes and determine whether athlete performance surpasses post-ACLR requirements., Hypothesis: The LSI for the majority of healthy youth athletes will be ≥90%., Study Design: Cross-sectional cohort study., Level of Evidence: Level 3., Methods: Each participant performed a single hop (SH), triple hop (TrH), crossover hop (CrH), and timed hop (TiH). A 3-trial mean was utilized to calculate an LSI (nondominant/dominant leg [self-reported kicking leg]) for each hop. The frequency of pass/fail at ≥90% LSI was calculated. Pearson correlation coefficients analyzed the relationship between the different hops, and a 2-way analysis of variance determined the effects of age and sex on LSI., Results: A total of 340 participants (54% male; mean age, 10.9 ± 1.5 years; range, 8-14 years) were included. The mean LSI was >95% for each SLHT (SH, 97.9% [SD, 0.7]; TrH, 96.6% [SD, 0.6]; CrH, 96.8% [SD, 0.8]; TiH, 96.5% [SD, 0.6]). When analyzed as a test battery, only 45% of participants achieved this standard. Significantly weak to moderate correlations existed among hop tests ( P < 0.01; r = 0.342-0.520). Age and sex had no effect on LSI ( P < 0.05)., Conclusion: While the mean LSI in our sample was >95% for each individual hop test, participant performance across all SLHT components varied, such that less than half of healthy athletes could achieve ≥90% LSI across all hops., Clinical Relevance: Current guidelines require ≥90% LSI on SLHTs. The majority of healthy youth athletes could not achieve this standard, which questions the validity of this LSI threshold in youth athletes after ACLR.

Background: Pitching velocity is a critical measure of performance, but it may also play a role in the development of injury. It has been proposed that increased humeral retrotorsion (HRT) may be an advantageous adaptation among throwers, resulting in increased throwing velocity. However, there is limited published data directly investigating this relationship., Purpose / Hypothesis: The purpose of this study was to examine the effects of HRT on pitching velocity in a group of youth baseball players. We hypothesized that there would be a positive association between pitching velocity and increased humeral retrotorsion., Study Design: Cross-sectional cohort study., Methods: Demographic and physical variables that may correlate to pitching velocity (age, height, weight, glenohumeral external rotation (ER) range of motion, dominant arm humeral retrotorsion and shoulder internal rotation (IR) strength) were assessed. Univariate analysis using Pearson correlation coefficients examined the relationship of each variable to pitching velocity. Significant variables were retained and entered into a multivariable regression analysis., Results: All variables significantly correlated with pitching velocity (p<0.05) with the exception of ER (r = -0.169,p = 0.145). Multivariable regression model was significant and accounted for 81.7% of pitching velocity (R 2 = 0.817 F(5,70) = 62.59,p<0.001). Player age (B = 1.7,p < 0.001), height (B = 0.225,p = 0.001) and shoulder IR strength (B = 0.622, p < 0.001) significantly contributed to the model. After accounting for all other variables, HRT had a non-significant (B = 0.005,p = 0.884) and very small contribution to pitching velocity adding only .005mph per degree of HRT., Conclusions: Pitching velocity in youth baseball players is strongly influenced by age, height and IR strength. In opposition to the hypothesis, the degree of humeral retrotorsion did not have a significant effect on pitching velocity., Level of Evidence: Level 3., Competing Interests: Conflict of Interest Statement: We, the authors, affirm that we have no financial or commercial affiliations related to the performance or outcome of this manuscript., (© 2020 by the Sports Physical Therapy Section.)

Background: Greater frequency and intensity level of sports participation may be contributing to an increasing incidence of anterior cruciate ligament (ACL) tears in skeletally immature athletes. Prior studies have assessed the functional outcomes of physeal-respecting ACL reconstruction in this patient population based on adult functional outcomes scoring systems; however, there is only sparse literature evaluating functional outcomes of this specific patient population. This study aimed to retrospectively evaluate a cohort of pediatric patients who had undergone all-epiphyseal ACL reconstruction (AEACLR) with a set of clinically validated, pediatric-specific patient-reported functional outcomes scores (PRFOS). We hypothesized that patients who had rerupture would have significantly lower outcomes scores compared with those who did not rerupture., Methods: This was a retrospective evaluation of AEACLR patients at a single, tertiary care, children's hospital within a period of 2 years and had >6 months of initial clinical postoperative follow-up. Those who consented to participation were provided an online combined survey including questions relating to demographics and rerupture as well as 3 validated pediatric PRFOS. Statistical analysis of the cohort demographics, PRFOS, and subgroup analysis of the rerupture group compared with the ACL intact patients was performed., Results: The mean functional outcome scores at a mean of 48.6 months from surgery demonstrated excellent return to functional activity (Mean International Knee Documentation Committee, 93.8; Pedi-Patient-Reported Outcomes Measurement Information System, 98.8; Pedi- Functional Activity Brief Score, 21.6). There was a 13% rerupture rate and rerupture patients had a significantly decreased Pedi-International Knee Documentation Committee (94.9 intact vs. 86.0 rerupture; P=0.001) and Pedi-Patient-Reported Outcomes Measurement Information System (99.4 intact vs. 95.4 rupture; P=0.001) scores., Conclusions: AEACLR patients have excellent outcomes based on pediatric-specific PRFOS. Rerupture patients demonstrated a decrease in functional outcomes scores compared with intact ACL patients. The results demonstrate the efficacy of AEACLR as measured by pediatric-specific functional outcome scores for the treatment of ACL rupture in skeletally immature athletes., Level of Evidence: Level III-retrospective comparative study.

» Septic arthritis of the knee is the most common type of septic arthritis in children, and it may result in irreversible joint damage. » Staphylococcus aureus is the most common pathogen associated with septic arthritis, but other causative pathogens are possible in children with certain risk factors. » The diagnosis of septic arthritis of the knee is based on history and physical examination, blood tests, and arthrocentesis. » Empiric treatment with anti-staphylococcal penicillin or a first-generation cephalosporin is usually recommended but may be tailored according to local resistance patterns and clinical culture data. » Open or arthroscopic surgical debridement including extensive lavage is effective in eradicating infection, and most patients do not require additional surgical intervention.

Background: Medial epicondyle fractures are a common pediatric and adolescent injury accounting for 11% to 20% of elbow fractures in this population. This purpose of this study was to determine the variability among pediatric orthopaedic surgeons when treating pediatric medial epicondyle fractures., Methods: A discrete choice experiment was conducted to determine which patient and injury attributes influence the management of medial epicondyle fractures by pediatric orthopaedic surgeons. A convenience sample of 13 pediatric orthopaedic surgeons reviewed 60 case vignettes of medial epicondyle fractures that included elbow radiographs and patient/injury characteristics. Displacement was incorporated into the study model as a fixed effect. Surgeons were queried if they would treat the injury with immobilization alone or open reduction and internal fixation (ORIF). Statistical analysis was performed using a mixed effect regression model. In addition, surgeons filled out a demographic questionnaire and a risk assessment to determine if these factors affected clinical decision-making., Results: Elbow dislocation and fracture displacement were the only attributes that significantly influenced surgeons to perform surgery (P<0.05). The presence of an elbow dislocation had the largest impact on surgeons when choosing operative care (β=-0.14; P=0.02). In addition, for every 1 mm increase in displacement, surgeons tended to favor ORIF by a factor of 0.09 (P<0.01). Sex, mechanism of injury, and sport participation did not influence decision-making. In total, 54% of the surgeons demonstrated a preference for ORIF for the included scenarios. On the basis of the personality Likert scale, participants were neither high-risk takers nor extremely risk adverse with an average-risk score of 2.24. Participant demographics did not influence decision-making., Conclusions: There is substantial variation among pediatric orthopaedic surgeons when treating medial epicondyle fractures. The decision to operate is significantly based on the degree of fracture displacement and if there is a concomitant elbow dislocation. There is no standardization regarding how to treat medial epicondyle fractures and better treatment algorithms are needed to provide better patient outcomes., Level of Evidence: Level V.

Background: Distal radius fractures are the most common injury in the pediatric population. The purpose of this study was to determine the variation among pediatric orthopaedic surgeons when diagnosing and treating distal radius fractures., Methods: Nine pediatric orthopaedic surgeons reviewed 100 sets of wrist radiographs and were asked to describe the fracture, prescribe the type of treatment and length of immobilization, and determine the next follow-up visit. κ statistics were performed to assess the agreement with the chance agreement removed., Results: Only fair agreement was present when diagnosing and classifying the distal radius fractures (κ=0.379). There was poor agreement regarding the type of treatment that would be recommended (κ=0.059). There was no agreement regarding the length of immobilization (κ=-0.004).Poor agreement was also present regarding when the first follow-up visit should occur (κ=0.088), whether or not new radiographs should be obtained at the first follow-up visit (κ=0.133), and if radiographs were necessary at the final follow-up visit (κ=0.163). Surgeons had fair agreement regarding stability of the fracture (κ=0.320).A subgroup analysis comparing various traits of the treatment immobilization showed providers only had a slight level of agreement on whether splint or cast immobilization should be used (κ=0.072). There was poor agreement regarding whether long-arm or short-arm immobilization should be prescribed (κ=-0.067).Twenty-three of the 100 radiographs were diagnosed as a torus/buckle fracture by all 9 surgeons. κ analysis performed on all the treatment and management questions showed that each query had poor agreement., Conclusions: The interobserver reliability of diagnosing pediatric distal radius fractures showed only fair agreement. This study demonstrates that there is no standardization regarding how to treat these fractures and the length of immobilization required for proper fracture healing. Better classification systems of distal radius fractures are needed that standardize the treatment of these injuries., Level of Evidence: Level II.

Introduction: This study investigated the association of graft-related surgical factors and patient characteristics with the odds of arthrofibrosis after primary anterior cruciate ligament reconstruction (ACL-R)., Methods: A retrospective case-control study assessed consecutive patients who underwent primary ACL-R in one tertiary pediatric hospital. Each arthrofibrosis case was matched to three controls for sex, calendar year, and age at the time of ACL-R, as well as the primary surgeon. Conditional multivariable logistic regression assessed the independent association of graft diameter, time from injury to ACL-R, concomitant knee pathologies, and body mass index., Results: Twenty arthrofibrosis cases of 1,121 ACL-R patients (incidence 1.8%) were matched to 60 controls resulting in the mean age of 14.5 years. An increase of 1 mm graft diameter was associated with 3.2-times increased odds of arthrofibrosis. Other variables were not independently associated with arthrofibrosis., Conclusion: For young patients, the decision on the graft size must consider the possibility of arthrofibrosis with a larger graft versus reinjury with a smaller graft.

Objective: To present the case of a 15 year-old baseball player with Little League Shoulder (LLS) and describe how developmental changes in the angle of humeral retrotorsion (HRT) may contribute to the underlying pathology of this condition., Design: Case report., Setting: Two years earlier, the patient had participated in a healthy player screening program at which time measurements of height, weight, shoulder motion, and HRT were obtained. These same measures were obtained during the initial evaluation after injury. Between measurements, the patient grew more than 12 cm in height and demonstrated a large shift in proximal humeral torsional alignment with a change of 13° and 19° of HRT in the dominant and non-dominant sides respectively., Participant: 15 year-old male (1.88 m, 79.8 kg), right hand dominant baseball pitcher and 3rd baseman diagnosed with right LLS., Conclusion: The pathoanatomical factors contributing to LLS are not well understood. The degree of HRT is a developmental characteristic that changes over the course of physiological maturation. The large changes in HRT seen in this case, may implicate rapid changes in HRT angle create a window of increased susceptibility to physeal damage, and contribute to the development of LLS., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: Baseball players exhibit a more posteriorly oriented humeral head in their throwing arm. This is termed humeral retrotorsion (HRT) and likely represents a response to the stress of throwing. This adaptation is thought to occur while the athlete is skeletally immature, however currently there is limited research detailing how throwing activity in younger players influences the development of HRT. In addition, it is presently unclear how this changing osseous orientation may influence shoulder motion within young athletes., Purpose: To determine the influence of throwing activity and age on the development of side-to-side asymmetry in HRT and shoulder range of motion (ROM)., Study Design: Cross-sectional study; Level of evidence, 3., Methods: Healthy athletes (age range, 8-14 years) were categorized into 2 groups based upon sports participation; throwers (n = 85) and nonthrowers (n = 68). Bilateral measurements of HRT, shoulder external rotation (ER), internal rotation (IR), and total range of motion (TROM) at 90° were performed using diagnostic ultrasound and a digital inclinometer. Side-to-side asymmetry (dominant minus nondominant side) in HRT and in shoulder ER, IR, and TROM were assessed. Statistical analysis was performed with 2-way analysis of variance and Pearson correlation coefficients., Results: Throwers demonstrated a larger degree of HRT on the dominant side, resulting in greater asymmetry compared with nonthrowers (8.7° vs 4.8°). Throwers demonstrated a gain of ER (5.1°), a loss of IR (6.0°), and no change in TROM when compared with the nondominant shoulder. Pairwise comparisons identified altered HRT and shoulder ROM in all age groups, including the youngest throwers (age range, 8-10.5 years). A positive correlation existed between HRT and ER ROM that was stronger in nonthrowers ( r = 0.63) than in throwers ( r = 0.23), while a negative correlation existed with IR that was stronger in throwers ( r = -0.40) than in nonthrowers ( r = -0.27)., Conclusion: Throwing activity causes adaptive changes in HRT and shoulder ROM in youth baseball players at an early age. Other factors in addition to HRT influence shoulder motion within this population.

Background: Anterior cruciate ligament (ACL) injury rates are affected by frequency and level of competition, sex, and sport. To date, no study has sought to quantify sport-specific yearly risk for ACL tears in the high school (HS) athlete by sex and sport played., Purpose: To establish evidence-based incidence and yearly risk of ACL tears in HS athletes by sex for sports performed at the varsity level across the majority of US high schools., Study Design: Meta-analysis., Methods: PubMed, EMBASE, and Cochrane Central Register of Controlled Trials were searched to identify all articles reporting ACL tears per athletic exposure in HS athletes. ACL injury incidence rates (IRs) by sex and sport were calculated via meta-analysis. State athletic association guidelines were used to determine the number of exposures per season to calculate yearly risk of ACL tears., Results: The search recovered 3779 unique articles, of which 10 met our inclusion criteria, for a total of 700 ACL injuries in 11,239,029 exposures. The IR was 0.062 injuries per 1000 exposures (95% CI, 0.058-0.067). Although more injuries were recorded in males than females, females had a higher rate of injury per exposure (relative risk, 1.57; 95% CI, 1.35-1.82). Relative risk was highest in basketball (3.80; 95% CI, 2.53-5.85) and soccer (3.67; 95% CI, 2.61-5.27). While boys' football had the highest number of ACL injuries at 273, girls' soccer had the highest IR (0.148; 95% CI, 0.128-0.172). In girls, the highest injury risks per season were observed in soccer (1.11%; 95% CI, 0.96%-1.29%), basketball (0.88%; 95% CI, 0.71%-1.06%), and lacrosse (0.53%; 95% CI, 0.19%-1.15%). In comparison, the highest risks for boys were observed in football (0.80%; 95% CI, 0.71%-0.91%), lacrosse (0.44%; 95% CI, 0.18%-0.90%), and soccer (0.30%; 95% CI, 0.22%-0.41%)., Conclusion: There is an approximately 1.6-fold greater rate of ACL tears per athletic exposure in HS female athletes than males. However, there is significant risk in both sexes, particularly in high-risk sports such as soccer, football, basketball, and lacrosse. Knowledge of sport-specific risk is essential for future injury reduction programs, parent-athlete decision making, and accurate physician counseling., (© 2015 The Author(s).)

Distal humeral epiphyseal separations are rare and treatment strategies are not well defined. The case of a full-term male newborn with a distal humeral epiphyseal separation as the result of a birth trauma was reviewed. A literature review of this topic was undertaken to better understand its occurrence, diagnosis, and treatment options. The patient sustained a distal humeral epiphyseal separation during a vaginal delivery. Deformity and decreased movement in the elbow were observed. Radiographs and subsequent ultrasound were used to make the diagnosis of distal humeral epiphyseal separation. Given the displaced and acute nature of the fracture, a closed reduction and percutaneous pinning was performed. Intraoperatively, this was greatly facilitated by an elbow arthrogram. Immobilization consisted of a posterior plaster splint and swathe. Postoperative follow-up with clinical and radiographic examination showed abundant bony healing and early restoration of function. Ultrasound is useful to confirm the diagnosis of a distal humeral epiphyseal separation for elbow injuries in very young patients. However, once the diagnosis is confirmed, an intraoperative elbow arthrogram helps highlight the fracture fragments and ensures proper reduction and fixation of the fracture. [Orthopedics. 2016; 39(4):e764-e767.]., (Copyright 2016, SLACK Incorporated.)

Background: Most studies examining the safety and efficacy of transphyseal anterior cruciate ligament (ACL) reconstruction for skeletally immature patients utilize transtibial drilling. Independent femoral tunnel drilling may impart a different pattern of distal femoral physeal involvement., Purpose: To radiographically assess differences in distal femoral physeal disruption between transtibial and independent femoral tunnel drilling. We hypothesized that more oblique tunnels associated with independent drilling involve a significantly larger area of physeal disruption compared with vertically oriented tunnels., Study Design: Cross-sectional study; Level of evidence, 3., Methods: We analyzed skeletally immature patients aged between 10 and 15 years who underwent transphyseal ACL reconstruction utilizing an independent femoral tunnel drilling technique between January 1, 2008, and March 31, 2011. These patients were matched with a transtibial technique cohort based on age and sex. Radiographic measurements were recorded from preoperative magnetic resonance imaging and postoperative radiographs., Results: Ten patients in each group were analyzed. There were significant differences between independent drilling and transtibial drilling cohorts in the estimated area of physeal disruption (1.64 vs 0.74 cm(2); P < .001), femoral tunnel angles (32.1° vs 72.8°; P < .001), and medial/lateral location of the femoral tunnel (24.2 vs 36.1 mm from lateral cortex; P = .001), respectively. There was a significant inverse correlation between femoral tunnel angle and estimated area of distal femoral physeal disruption (r = -0.8255, P = .003)., Conclusion: Femoral tunnels created with an independent tunnel drilling technique disrupt a larger area of the distal femoral physis and create more eccentric tunnels compared with a transtibial technique., Clinical Relevance: As most studies noting the safety of transphyseal ACL reconstruction have utilized a central, vertical femoral tunnel, surgeons should be aware that if an independent femoral tunnel technique is utilized during transphyseal ACL reconstruction, more physeal tissue is at risk and tunnels are more eccentrically placed across the physis when drilling at more horizontal angles. Prior studies have shown that greater physeal involvement and eccentric tunnels may increase the risk of growth disturbance.

The medial epicondyle serves as the proximal attachment of the medial ulnar collateral ligament and the origin of the flexor pronator musculature and as such it is responsible for resisting the main static and dynamic restraints to valgus force at the elbow. Fractures through the physis in the developing elbow are common and treatment remains controversial. Biomechanical modeling predicts that anterior should be the direction of greatest displacement. Anatomic considerations predict that anterior displacement should have the greatest effect on elbow stability and range of motion making the ulnar collateral ligament too loose in flexion and too tight in extension and potentially leading to valgus laxity in flexion and a block to full extension. In the elite overhead athlete, where elbow stability is critical both for sports performance and the long-term health of the elbow, assessment of anterior displacement is thus theoretically an important consideration. Standard radiographic views cannot adequately assess anterior displacement. Specialized radiographs and 3-dimensional modalities such as computerized tomography and magnetic resonance imaging can adequately assess anterior displacement and in the overhead athlete can sometimes aid in the decision-making process. Here, we present a review of the current literature and the rationale for a treatment algorithm for medial epicondyle fractures in the skeletally immature overhead athlete.

Background: There is good consensus that anterior cruciate ligament (ACL) grafts should be pretensioned to remove creep prior to implantation, but the literature contains little information on the influence of graft preparation or circumferential compression on graft size. The purpose of this study was to investigate how the size of hamstring allografts changes as they are prepared for ACL reconstruction. We hypothesized that grafts decrease in diameter as they are prepared with both tension and circumferential compression. We also investigated the interrater reliability of graft diameter measurements during each step of graft preparation., Methods: Twenty pairs of fresh-frozen human hamstring tendons obtained from an allograft supplier were prepared in a standardized fashion for ACL reconstruction (suturing followed by longitudinal tensioning followed by circumferential compression followed by relaxation). Four blinded raters measured each graft in a sequential manner after each graft preparation step. Interrater reliability was assessed using the intraclass correlation coefficient ICC(2,1). The mean allograft diameter at each time point was calculated and compared across all time points using repeated-measures analysis of variance (ANOVA)., Results: Subjecting the grafts to both tension and circumferential compression significantly decreased their mean diameter (to 7.38 mm compared with 8.28 mm at baseline; p = 0.044). Interrater reliability revealed almost perfect agreement at each measurement interval, with the ICC ranging from 0.933 to 0.961., Conclusions: The average diameter of hamstring ACL grafts decreases by almost 1 mm after they are subjected to both tension and circumferential compression within a standard cylindrical sizing block., Clinical Relevance: Because ACL bone tunnels are drilled in 0.5-mm increments, preparing soft-tissue grafts with circumferential compression in addition to tension may allow creation of tunnels that are one to two incremental sizes smaller. This could permit less bone removal, which may be particularly applicable for certain reconstruction techniques such as pediatric, double-bundle, or revision ACL reconstruction, in which limited space is available for tunnel drilling., (Copyright © 2016 by The Journal of Bone and Joint Surgery, Incorporated.)

Context: Several investigations have noted that throwing athletes exhibit a more posteriorly oriented humeral head (humeral retrotorsion) in the dominant arm. This asymmetry is believed to represent an adaptive response to the stress of throwing that occurs during childhood. The significance of this alteration and factors that affect its development are currently not clear., Evidence Acquisition: Basic science, research studies, and review articles were searched through PubMed with search terms including humeral torsion, humeral retrotorsion, and with 1 of the following: pediatric, adult, baseball, pitching, shoulder, and range of motion. The references from each article were reviewed for further inclusion. This review included articles through March 2015., Study Design: Clinical review., Level of Evidence: Level 4., Results: The throwing motion creates stressors that result in bony adaptations that occur while skeletally immature. These osseous changes likely contribute to the observed shift in the arc of rotational range of motion noted in throwing athletes and may play a protective role against injury. However, too much or too little retrotorsion may predispose the shoulder to injury. The degree of "optimal" humeral retrotorsion and factors that influence its development are not fully understood., Conclusion: Evidence supports the assertion that the throwing motion creates stressors that alter bony anatomy while young. It is important to determine what specific factors affect this adaptation and its relationship to injury., (© 2015 The Author(s).)

Objectives: We hypothesized that the method of stress external rotation more accurately reproduces the mechanism of injury, and therefore this diagnostic method more likely detects ankle instability than the fibular stress examination., Design: Prospective cohort comparison study., Setting: Level 1 trauma center., Patients: Twenty-eight consecutive patients with unstable ankle fractures presenting within 7 days from the time of injury. Previous ankle surgical history or age younger than 18 years was excluded., Intervention: Stress external rotation and lateral fibular stress examination was performed intraoperatively., Main Outcome Measure: Radiographic measurement of the tibiofibular clear space, tibiofibular overlap, and medial clear space were recorded., Results: After normalization of the fluoroscopic measurements, there was no difference in detecting changes in tibiofibular clear space or tibiofibular overlap. However, there was a significant difference in detecting medial clear space widening with stress external rotation. Compared with lateral fibular stress, stress external rotation demonstrated a 35% increase (P < 0.05) in medial clear space widening. This difference correlates with the 1-2-mm difference of additional widening with stress external rotation., Conclusions: Untreated instability impacts patient outcomes. The difference in widening with stress external rotation was significantly greater than lateral fibular stress and appreciable on standard fluoroscopic views. Stress external rotation radiographs are a more reliable indicator of mortise instability than traditional lateral fibular stress., Level of Evidence: Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background: In the skeletally immature population, the incidence of anterior cruciate ligament (ACL) injuries and ACL reconstructions appears to be increasing. Differences in surgical techniques, physiology, and emotional maturity may alter the rehabilitation progression and impact the outcomes when compared with adults. Reports of objective strength recovery and performance-based outcome measures after pediatric ACL reconstruction (ACLR) are limited., Study Design: Retrospective case series., Level of Evidence: Level 4., Methods: All patients that underwent all-epiphyseal ACLR from January 2008 to August 2010 were identified. Isokinetic peak quadriceps/hamstring torque values and functional performance measures in unilateral hopping tasks were extracted and compared with the noninjured limb. A limb symmetry index (LSI) of ≥90% was considered satisfactory., Results: Complete data were available for 16 patients (mean age, 12.28 years; range, 8.51-14.88 years). By a mean 7 months (range, 3.02-12.56 years) postoperatively, only 9 of 16 (56%) were able to achieve a satisfactory LSI for quadriceps strength. For hamstring strength, 15 of 16 (94%) were able to achieve satisfactory LSI. By a mean of 12 months (range, 5.39-24.39 months) postoperatively, only 6 of 16 subjects (38%) were able to achieve satisfactory performance on all functional hop tests. At a mean 15.42 months (range, 8.58-24.39 months) postsurgery, only 4 of 16 (25%) subjects were able to achieve an LSI of ≥90% on all testing parameters., Conclusion: For some pediatric patients, significant strength and functional deficits may be present at greater than 1 year after ACLR. This population may require more prolonged rehabilitation programs to allow for adequate recovery of strength and function because of unique characteristics of normal growth and development.

Background: The optimal treatment of medial epicondyle fractures in pediatric athletes remains unclear., Purpose: To evaluate the outcomes of operative and nonoperative management of medial epicondyle fractures in young athletes., Study Design: Case series; Level of evidence, 4., Methods: The records of all children with fractures of the medial epicondyle over a 5-year period, with a minimum 2 years of follow-up at a pediatric tertiary referral center, were reviewed. Patients with intra-articular entrapment of the fracture fragment or ulnar nerve entrapment were excluded. Treatment decisions were made primarily based on injury mechanism and elbow laxity or instability. Patients were contacted and asked to complete a modified Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire., Results: Complete data with 2-year follow-up were available for 20 athletes: 6 treated nonoperatively and 14 treated operatively. At the latest follow-up, both groups achieved excellent DASH scores. Half of each cohort required physical therapy, and 6 of 14 patients who received operative treatment reported numbness. All patients were either very or completely satisfied with their treatment. Fourteen patients were overhead athletes (8 treated operatively, 6 nonoperatively). Excellent DASH scores were achieved in both groups, and all overhead athletes were able to return to their sport at the next appropriate level. Seven patients were baseball pitchers and sustained a fracture while throwing (4 treated operatively, 3 nonoperatively). None felt their performance was limited after treatment, and excellent DASH scores were achieved in both groups., Conclusion: These data demonstrate that nonoperative treatment can be successful in young athletes with low-energy medial epicondyle avulsions, a stable elbow, and minimal fracture displacement. Surgical management can be successful in athletes who sustain more significant trauma, who have elbow laxity or instability, or who have significant fracture fragment displacement after a fracture of the medial epicondyle.

Background: The management of the pediatric patient with an Anterior Cruciate Ligament (ACL) rupture is evolving towards earlier reconstruction. The rehabilitation progression and outcomes for skeletally immature individuals undergoing ACL reconstruction (ACL-R) are not well described in the literature. Differences in surgical procedure, age related physiology, and emotional maturity may have a significant impact on recovery and return to sports. The purpose of this case report is to present the rehabilitation and outcome of a skeletally immature patient that underwent an all-epiphyseal ACL-R, highlight important considerations in the rehabilitation process and present topics for future research., Case Description: Single subject case report of an 8 year-old boy who underwent all epiphyseal ACL-R after complete ACL rupture., Outcomes: The patient was able to achieve at least 90% strength symmetry and pass all necessary functional criteria to return to sports by 9 months post surgery. Two year follow up data indicated that the patient was able to make a full return to previous level of athletic activity, as well as maintain lower extremity strength and power over time., Discussion: Objective outcome measures, rehabilitation protocols and time frame for return to sports for skeletally immature patients following physeal sparing or all epiphyseal ACL-R are not well described in the literature. This case report outlines objective measures of strength and functional recovery in a patient from this unique population. As ACL-R in the skeletally immature patient is studied more, new information on rehabilitation progression and outcomes may alter the rehabilitation program and timeline for return to unrestricted activity., Level of Evidence: 4, Case Report.

Purpose: To evaluate whether decreased hamstring autograft size and decreased patient age are predictors of early graft revision., Methods: Of 338 consecutive patients undergoing primary anterior cruciate ligament (ACL) reconstruction with hamstring autograft, 256 (75.7%) were evaluated. Graft size and patient age, gender, and body mass index at the time of ACL reconstruction were recorded, along with whether subsequent ACL revision was performed., Results: The 256 patients comprised 136 male and 120 female patients and ranged in age from 11 to 52 years (mean, 25.0 years). The mean follow-up was 14 months (range, 6 to 47 months). Revision ACL reconstruction was performed in 18 of 256 patients (7.0%) at a mean of 12 months after surgery (range, 3 to 31 months). Revision was performed in 1 of 58 patients (1.7%) with grafts greater than 8 mm in diameter, 9 of 139 patients (6.5%) with 7.5- or 8-mm-diameter grafts, and 8 of 59 patients (13.6%) with grafts 7 mm or less in diameter (P = .027). There was 1 revision performed in the 137 patients aged 20 years or older (0.7%), but 17 revisions were performed in the 119 patients aged under 20 years (14.3%) (P < .0001). Most revisions (16 of 18) were noted to occur in patients aged under 20 years with grafts 8 mm in diameter or less, and the revision rate in this population was 16.4% (16 of 97 patients). Age less than 20 years at reconstruction (odds ratio [OR], 18.97; 95% confidence interval [CI], 2.43 to 147.06; P = .005), decreased graft size (OR, 2.20; 95% CI, 1.00 to 4.85; P = .05), and increased follow-up time (OR, 1.07; 95% CI, 1.02 to 1.12) were associated with increased risk of revision., Conclusions: Decreased hamstring autograft size and decreased patient age are predictors of early graft revision. Use of hamstring autografts 8 mm in diameter or less in patients aged under 20 years is associated with higher revision rates., Level of Evidence: Level III, retrospective comparative study., (Copyright © 2012 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: Despite surgical and mechanical stabilization of an acutely injured joint through ligament reconstruction, meniscus repair, or labral repair, the risk of posttraumatic arthritis remains high. Joint injury triggers three phases of pathogenic events: the early (acute) phase involves joint swelling, hemarthrosis, expression of inflammatory cytokines (especially interleukin-1 [IL-1] and tumor necrosis factor-α [TNF-α]), and biomarkers of cartilage catabolism; an intermediate phase is characterized by reduction of joint inflammation, ongoing joint catabolism, but no evidence yet for typical features of radiographic osteoarthritis (OA); and a late phase characterized by radiographic OA., Hypotheses: We hypothesize that the early phase of acute knee injury represents a window of opportunity for providing biologic treatment to promote healing and to slow or prevent a subsequent cascade of destructive joint processes leading to OA., Proposed Program: We propose a phase II, randomized, placebo-controlled, double-blinded, clinical trial to treat acute knee injuries with intraarticular injection of an IL-1 inhibitor. Patient-centered outcomes will include pain reduction and improvement of knee function. MR imaging and measurement of biochemical markers will be monitored during the subsequent 2 years to determine if the structural response to injury can be reversed., Significance: If this model is validated, modulation of the molecular pathways responsible for articular cartilage breakdown will augment current reconstructive procedures in the treatment of acute joint injuries and prevent the development of injury-related arthritis.

Background: In skeletally immature patients with an anterior cruciate ligament (ACL) tear and significant growth remaining, the risk of inducing a growth disturbance with early reconstruction must be balanced against the risk of further intra-articular damage by delaying treatment until closer to skeletal maturity., Hypothesis: Increased time from injury to ACL reconstruction in children ≤14 years of age will be associated with increased meniscal and chondral injuries at the time of reconstruction., Study Design: Cohort study; Level of evidence, 3., Methods: With institutional review board approval, the records of a consecutive series of patients 14 years of age and younger who underwent ACL reconstruction between 1991 and 2005 were reviewed. Demographic, magnetic resonance imaging (MRI), and intraoperative findings were analyzed. Meniscal and articular cartilage injuries were graded. Logistic regression models using both univariable and multivariable regression procedures were used to identify factors independently associated with intra-articular lesions. Fisher exact test and Kaplan-Meier analysis were used to test for differences in intra-articular injuries by time from injury to surgery., Results: Seventy patients were identified. Twenty-nine patients (41%) underwent reconstruction more than 12 weeks from the time of injury. Logistic regression analysis revealed time to surgical reconstruction (odds ratio, 4.1) and a history of a sense of knee instability (odds ratio, 11.4) to be independently associated with medial meniscal tears. Time to surgical reconstruction was also independently associated with medial and lateral compartment chondral injuries (odds ratios, 5.6 and 11.3, respectively). Testing time as a continuous variable, survivorship analysis also confirmed a significant association of time to reconstruction with medial meniscal injury as well as lateral and patellotrochlear cartilage injuries. When present, a delay in treatment of over 12 weeks (29 patients) was associated with an increase in the severity of medial meniscal tears (P = .011) and higher grade lateral and patellotrochlear chondral injuries (P = .0014 and P = .038, respectively)., Conclusion: Young patients who underwent surgical reconstruction of an acute ACL tear >12 weeks after the injury were noted to have a significant increase in irreparable medial meniscal tears and lateral compartment chondral injuries at the time of reconstruction. When a subjective sense of knee instability was present, this association was even stronger.

Introduction: Management of a first-time anterior shoulder dislocation (FTASD) involves important clinical and policy decisions. Predictive disease modeling can improve the quality of information disseminated in treatment discussions. In this paper, we describe a general-purpose, publicly available model and illustrate its potential as a tool for management of a FTASD., Methods: A Markov decision model of the natural history of a FTASD was constructed. Outcome probabilities and effectiveness were derived from the literature or estimated by expert opinion where necessary. Outcomes were the Western Ontario Shoulder Instability index (WOSI) and the probability of a patient experiencing recurrent instability, undergoing surgical stabilization, and having a stable shoulder at 10 years. The model was both internally and externally validated. Outcomes were examined for specific cases., Results: The model was effectively externally validated against two studies, a Swedish prospective cohort of Hovelius et al and Botonni et al's military cohort. It can produce detailed outcome predictions for individuals; eg, an 18-year-old man has a 77% risk of dislocation in year 1 and a 32% chance of having a stable shoulder in 10 years., Conclusion: Detailed and specific information about prognosis is critical in the management of a FTASD. Disease modeling lends itself well to these needs and allows improved shared decision-making. Our model was externally validated and can predict specific outcomes. As a publically available resource, it will allow physicians to accurately predict the expected outcome of treatment based on covariates, patient demographics, and their own surgical success rates., (Copyright © 2011 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.)

Background: Treating ACL injuries in prepubescent patients requires balancing the risk of chondral and meniscal injuries associated with delaying treatment against the risk of growth disturbance from early surgical reconstruction. Multiple physeal respecting techniques have been described to address this vulnerable population; however, none restore the native ACL attachments while keeping the graft and fixation entirely in the epiphysis., Description of Technique: We describe a technique of all-epiphyseal ACL reconstruction for use in prepubescent skeletally immature patients. Intraoperative CT scanning with three-dimensional (3-D) reconstruction was used to confirm the precise localization of the all-epiphyseal femoral and tibial tunnels. The femoral tunnel is drilled entirely in the epiphysis of the lateral femoral condyle. The tibial tunnel is drilled from inside-out to the level of the tibial physis using a retrograde drill. Fixation of the soft tissue graft is achieved with a retrograde interference screw in the tibia and an interference screw in the femur., Patients and Methods: Case examples are presented for three boys aged 10-12, Tanner Stage 1 development, with a minimum followup of 1 year., Results: All three patients had stable knees based on Lachman and KT-1000 testing and no evidence of growth disturbance. All had full ROM and symmetric strength for knee flexion and extension. All patients returned to their sports activities using a custom ACL brace., Conclusions: Although longer-term followup will be necessary, this technique provides for an anatomic all-epiphyseal-based ACL reconstruction using intraoperative 3-D imaging to minimize the risk of growth disturbance., Level of Evidence: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Background: The successful incorporation of research into the future careers of residents provides tremendous potential for increasing scientific orthopaedic inquiry and improving musculoskeletal care. Therefore, we sought to assess resident opinions regarding plans and incentives for future research and the opinions of academic chairs who must support them., Methods: Residents from sixteen departments were surveyed with a twenty-four-question online survey. Similar surveys were sent to chairs of all residency-sponsoring departments., Results: The response rate was 44% (183) for the residents and 60% (eighty-six) for the chairs. Forty-two percent of the residents felt certain or likely that they would perform research during their careers, and 28% were undecided. Ninety-nine percent thought that orthopaedic surgeons performing research is important to clinical orthopaedics. Ninety-three percent of the residents expressed the need for monetary incentives for research, but only 40% would help to provide it. Chairs similarly noted the importance of research subsidization (92%) and a willingness to support it (70%). Residents indicated that increased funding and protected time would provide the greatest incentives for research during residency; chairs agreed. After training, debt relief and salary support were most important for residents; chairs chose protected time and a chair who is supportive of research as most important. Primary authorship on a prior manuscript and past research experience were found to be associated with greater future research interest in univariate analyses; primary authorship maintained an independent association in multivariate analysis. Younger residents and women were more likely to be unsure of their research interest., Conclusions: Many orthopaedic residents in training have interest in integrating research into their future practice and support the research mission of orthopaedic surgeons. Our results may aid in identifying residents with high research interest (and those unsure) and help to guide the provision of incentives to actuate those interests.

Little is known about outcomes of glenoid labral repair in Major League Baseball (MLB) pitchers. We hypothesized that following repair, pitching performance would not be significantly different from an uninjured cohort. Fifty-one pitchers were identified who pitched in at least one MLB game prior to undergoing isolated glenoid labral repair. For the three years prior to and following surgery, demographic and performance variables were analyzed for an association with labral injury and repair, and compared to a control cohort of MLB pitchers without history of repair. Following surgery, 72.5% of pitchers returned to MLB at a mean of 13.1 months with no significant change in performance. Starting pitchers had a higher risk of labral injury requiring repair (p< or =0.05). Pitchers that returned to play averaged more innings pitched in the seasons prior to surgery and had a higher body mass index than those that did not return to play (p< or =0.05). Approximately 70% of MLB pitchers undergoing labral repair can be expected to return to competition postoperatively with no significant change in performance. Starting pitchers are more likely to undergo repair, but pitchers with greater preoperative innings pitched per season have a greater likelihood of returning to play., (Copyright Georg Thieme Verlag KG Stuttgart . New York.)

Background: Fractures of the humeral medial epicondyle occur frequently in children. The decision to pursue operative or nonoperative treatment often hinges on the amount of perceived fracture displacement. This study was performed to assess both intraobserver and interobserver agreement in the measurements of displacement of these fractures on radiographs by orthopaedic surgeons with various levels of training., Methods: We performed a retrospective review of the radiographs of thirty-eight patients with a fracture of the medial epicondyle of the humerus. Digital anteroposterior, lateral, and oblique radiographs of each involved elbow made at presentation were presented to five separate reviewers with different levels of orthopaedic training, including two junior residents (junior residents 1 and 2), one fellow, one junior attending surgeon, and one senior attending surgeon. Each reviewer recorded the amount of perceived displacement in millimeters. A difference of >2 mm between measurements represented clinical disagreement between reviewers. Intraobserver and interobserver agreement was assessed by calculating both the intraclass correlation coefficient and the percentage of clinical disagreement between ratings., Results: The intraclass correlation coefficients for intraobserver agreement regarding the measurements on the anteroposterior radiographs were 0.24 (95% confidence interval, 0.00 to 0.68) for junior resident 1, 0.82 (95% confidence interval, 0.41 to 0.95) for junior resident 2, 0.83 (95% confidence interval, 0.46 to 0.96) for the senior attending surgeon, 0.92 (95% confidence interval, 0.69 to 0.98) for the junior attending surgeon, and 0.98 (95% confidence interval, 0.92 to 1.00) for the fellow. The combined intraclass correlation coefficient for intraobserver agreement was 0.76. The reviewers as a group disagreed with their own measurements an average of 26% of the time. The intraclass correlation coefficient for interobserver reliability with regard to the measurements on the anteroposterior radiographs for the group was 0.80 (95% confidence interval, 0.64 to 0.89), and the reviewers disagreed with each other an average of 54% of the time. The intraclass correlation coefficient for interobserver agreement was 0.28 (95% confidence interval, 0.03 to 0.76) for the measurements on the lateral radiographs and 0.62 (95% confidence interval, 0.34 to 0.89) for the measurements on the oblique radiographs, with reviewers disagreeing an average of 87% of the time with regard to the measurements on the lateral radiographs and 64% of the time with regard to the measurements on the oblique radiographs., Conclusions: Intraobserver agreement with regard to measurement of displacement of medial epicondyle fractures of the humerus varied among the reviewers but was low overall. Interobserver agreement was best for the measurements on the anteroposterior radiographs, but this was also low overall. These findings cast doubt on whether the amount of perceived displacement should be used as a criterion for choosing operative or nonoperative management of fractures of the humeral medial epicondyle. Agreement may be improved to acceptable levels by adopting a standard set of measurement guidelines, which include use of the anteroposterior radiograph when possible and consistently measuring at the point of maximal displacement.

Study Design: Prognostic Study, Level II (Retrospective review of prospectively collected data)., Objective: To identify an association between preoperative narcotic use and clinical outcome after cervical arthrodesis., Summary of Background Data: Little data exists regarding the influence that chronic preoperative narcotic use has on clinical outcomes after surgery. Cervical arthrodesis is a common procedure that has a predictably high success rate for relief of radicular pain. In addition, the patient population presenting for this procedure has a high propensity for preoperative narcotic use., Methods: Charts and prospectively collected questionnaires concerning the use of pain medication from 91 consecutive patients who underwent cervical arthrodesis for relief of radicular pain by a single surgeon at a single institution were reviewed. Group I consisted of 47 patients who took narcotic pain medication for their radicular pain on a daily basis for greater than 6 months before surgery. Group II consisted of 44 patients who were not on narcotics chronically before surgery. Postoperative narcotic use and patient outcome based on the modified Robinson criteria were assessed. Patients were observed for a minimum of 2 years., Results: Of the group I patients, 16 (34%) continued to require chronic narcotic pain medication up to 2 years after surgery whereas only 3 (7%) of the group II patients required narcotic pain medication past 3 months (P = 0.002). Of the group I patients, 24 (51%) had a good or excellent result after surgery and 15 (32%) had a poor result whereas 38 (86%) of the group II patients had a good or excellent result and no patient had a poor result (P < 0.001)., Conclusion: Chronic narcotic use before cervical arthrodesis was found to be associated with continued narcotic use after surgery and worse functional outcomes following surgery. While further studies will be necessary to ascertain if this relationship is generalizable to other orthopaedic procedures and to analyze for potential confounding variables, surgeons may want to counsel their patients about the potential for inferior clinical outcomes if narcotics are used before surgery.