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Background: Quantitative magnetic resonance imaging (qMRI) methods were developed to establish the integrity of healing anterior cruciate ligaments (ACLs) and grafts. Whether qMRI variables predict risk of reinjury is unknown. Purpose: To determine if qMRI measures at 6 to 9 months after bridge-enhanced ACL restoration (BEAR) can predict the risk of revision surgery within 2 years of the index procedure. Study Design: Cohort study; Level of evidence, 2. Methods: Originally, 124 patients underwent ACL restoration as part of the BEAR I, BEAR II, and BEAR III prospective trials and had consented to undergo an MRI of the surgical knee 6 to 9 months after surgery. Only 1 participant was lost to follow-up, and 4 did not undergo MRI, leaving a total of 119 patients for this study. qMRI techniques were used to determine the mean cross-sectional area; normalized signal intensity; and a qMRI-based predicted failure load, which was calculated using a prespecified equation based on cross-sectional area and normalized signal intensity. Patient-reported outcomes (International Knee Documentation Committee subjective score), clinical measures (hamstring strength, quadriceps strength, and side-to-side knee laxity), and functional outcomes (single-leg hop) were also measured at 6 to 9 months after surgery. Univariate and multivariable analyses were performed to determine the odds ratios (ORs) for revision surgery based on the qMRI and non-imaging variables. Patient age and medial posterior tibial slope values were included as covariates. Results: In total, 119 patients (97%), with a median age of 17.6 years, underwent MRI between 6 and 9 months postoperatively. Sixteen of 119 patients (13%) required revision ACL surgery. In univariate analyses, higher International Knee Documentation Committee subjective score at 6 to 9 months postoperatively (OR = 1.66 per 10-point increase; P = .035) and lower qMRI-based predicted failure load (OR = 0.66 per 100-N increase; P = .014) were associated with increased risk of revision surgery. In the multivariable model, when adjusted for age and posterior tibial slope, the qMRI-based predicted failure load was the only significant predictor of revision surgery (OR = 0.71 per 100 N; P = .044). Conclusion: Quantitative MRI-based predicted failure load of the healing ACL was a significant predictor of the risk of revision within 2 years after BEAR surgery. The current findings highlight the potential utility of early qMRI in the postoperative management of patients undergoing the BEAR procedure.

The purpose of this study was to evaluate the physical and psychological effects of COVID-related elective surgery delays on young sports medicine patients.We conducted a cross-sectional study of patients (10-25 years old) who had elective sports medicine surgery delayed due to the COVID crisis. Electronic surveys were sent to patients and included the 12-item Short Form Health Survey (SF-12), which yields a physical component score (SF12-PCS) and a mental component score (SF12-MCS), the PROMIS Psychological Stress Experience survey (PROMIS-PSE), and self-designed questions about patient concerns regarding the COVID crisis and delayed surgery.Of the 194 eligible patients with delayed elective sports surgeries, 107 patients (55%) elected to participate (mean age 17.6 ± 3.09 years, 30% male). The mean surgical delay was 76 days (CI 57-98). Delayed surgery patients scored significantly lower than population norms on the SF12-PCS (mean 39.3, CI 37.0-41.7;Young sports medicine patients reported significant physical and emotional symptoms associated with COVID-related surgical delays. Patients were most concerned about delays resulting in missed sport seasons. Those who reported greater levels of concern with surgical delays reported more emotional symptoms and higher levels of psychological stress.

The purpose of this study was to review the current literature on perioperative pain management in hip arthroscopy, periacetabular osteotomy and surgical hip dislocation. A systematic review of the literature published from January 2000 to December 2022 was performed. Selection criteria included published randomized controlled trials, prospective reviews and retrospective reviews of all human subjects undergoing hip preservation surgery. Exclusion criteria included case reports, animal studies and studies not reporting perioperative pain control protocols. Thirty-four studies included hip arthroscopy in which peripheral nerve blocks were associated with a significant reduction in pain score (P = 0.037) compared with general anesthesia alone. However, no pain control modality was associated with a significant difference in postanesthesia care unit opioid use (P = 0.127) or length of stay (P = 0.251) compared with general anesthesia alone. Falls were the most common complication reported, accounting for 37% of all complications. Five studies included periacetabular osteotomy and surgical hip dislocation in which peripheral nerve blocks were associated with an 18% reduction in pain on postoperative Day 2, a 48% reduction in cumulative opioid use on postoperative Day 2 and a 40% reduction in hospital stay. Due to the low sample size of the periacetabular osteotomy and surgical hip dislocation studies, we were unable to determine the significant difference between the means. Due to significant between-study heterogeneity, additional studies with congruent outcome measures need to be conducted to determine the efficacy of regional anesthesia in hip arthroscopy, periacetabular osteotomy and surgical hip dislocation.

Heterotopic ossification (HO) is a known complication after hip arthroscopy in adults, positively associated with larger cam resection, male sex, older age, and obesity, and negatively associated with nonsteroidal anti-inflammatory drug (NSAID) use and capsular closure. However, it has not been well-documented in adolescents. The purpose of this study was to determine the incidence and risk factors for the development of HO in adolescent patients undergoing hip arthroscopy.Clinical and operative records from a pediatric institution were queried to identify patients aged 21 years or younger who underwent hip arthroscopy between 2008 and 2018. The 27 cases that developed HO were matched 1:4 on age and sex with 107 controls. The bivariate analysis assessed the relationship between demographic and perioperative factors on the development of HO. Multivariable logistic regression evaluated the association between prophylactic NSAID use (indomethacin 75 mg, 3 wk) and HO, controlling for surgeon and extent of cam resection (change in alpha angle).Twenty-seven of 595 (4.5%) hips that underwent hip arthroscopy developed HO within 2 years of surgery. Prophylactic indomethacin was not significantly associated with developing HO [30% (8/27), P=0.83], after controlling for surgeon and extent of cam resection-nor were age, sex, and body mass index percentile. Of patients who developed HO, a smaller proportion underwent reoperation for HO excision among those who received prophylactic indomethacin than those who did not [13% (1/8) vs. 63% (12/19), P=0.03].The incidence of HO within 2 years of hip arthroscopy in this adolescent population was 4.5%. Although studies in the adult hip arthroscopy population have pointed to a protective role of NSAIDs (eg, indomethacin) in radiographic HO, the effect was less certain in this adolescent sample. Larger studies are important to further evaluate the role of prophylactic NSAIDs and variations in arthroscopic technique in developing HO.Level III-therapeutic, case-control study.

To investigate ultrasound (US) femoroacetabular translation measurements in female athlete patients.A prospective cross-sectional study was conducted in female athlete patients50 years. Demographic data, Beighton score/hypermobility status, and sport participation were collected. Hip dysplasia was determined using radiographic measurements (lateral center edge angle, anterior center edge angle, Tönnis angle); femoral version angles were measured with CT or MR. Femoroacetabular translation US measures included neutral (N), neutral flexed (NF), extension external rotation/apprehension (EER) positions. Maximal difference (delta) between US measures was calculated.206/349 female hips were analyzed (median age 21.2 years [range, 12-49.5]). The primary sport group was performing arts (45%, 92/206). Mean Beighton score was 5.2 (SD, 2.5) with 61% (129/206) of hips exhibiting hypermobility (Beighton score ≥5). For each additional unit of Beighton score, N US measurement increased by 0.7 mm (β = 0.7; 95% confidence interval [CI] = 0.22-1.25; P .001), NF by 1 mm (Beighton score was independently associated with dynamic US measures in female athlete patients who are not hypermobile when controlling for other factors.

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.

Background: Anterior cruciate ligament (ACL) revision surgery is challenging for both patients and surgeons. Understanding the risk factors for failure after bridge-enhanced ACL restoration (BEAR) may help with patient selection for ACL restoration versus ACL reconstruction. Purpose: To identify the preoperative risk factors for ACL revision surgery within the first 2 years after BEAR. Study Design: Case-control study; Level of evidence, 3. Methods: Data from the prospective BEAR I, II, and III trials were used to determine the preoperative risk factors for ACL revision surgery. All patients with a complete ACL tear (aged 13-47 years, depending on the trial), who met all other inclusion/exclusion criteria and underwent a primary BEAR procedure within 30 to 50 days from the injury (dependent on the trial), were included. Demographic data (age, sex, body mass index), baseline patient-reported outcomes (International Knee Documentation Committee [IKDC] subjective score, Marx activity score), preoperative imaging results (ACL stump length, notch size, tibial slope), and intraoperative findings (knee hyperextension, meniscal status) were evaluated to determine their contribution to the risk of ipsilateral ACL revision surgery. Results: A total of 123 patients, with a median age of 17.6 years (interquartile range, 16-23 years), including 67 (54%) female patients, met study criteria. Overall, 18 (15%) patients required ACL revision surgery in the first 2 years after the BEAR procedure. On bivariate analyses, younger age ( P = .011), having a contact injury at the time of the initial tear ( P = .048), and increased medial tibial slope (MTS; P = .029) were associated with a higher risk of ipsilateral revision surgery. Multivariable logistic regression analyses identified 2 independent predictors of revision: patient age and MTS. The odds of ipsilateral revision surgery were decreased by 32% for each 1-year increase in age (odds ratio, 0.684 [95% CI, 0.517-0.905]; P = .008) and increased by 28% for each 1° increase in MTS (odds ratio, 1.280 [95% CI, 1.024-1.601]; P = .030). Sex, baseline IKDC or Marx score, knee hyperextension, and meniscal status were not significant predictors of revision. Conclusion: Younger age and higher MTS were predictors of ipsilateral ACL revision surgery after the BEAR procedure. Younger patients with higher tibial slopes should be aware of the increased risk for revision surgery when deciding to undergo ACL restoration.

Background: There is a known association between ice hockey and cam deformity in growing athletes. Similarly, the association between sport specialization and overuse injury in youth athletes has been well established. Limited research exists examining the relationship between cam deformity and sport specialization. Hypothesis/Purpose: Our hypothesis was that there would be a positive association with cam deformity and sport specialization category. Study Design: Retrospective chart review and cross-sectional questionnaire study. Level of Evidence: Level 4. Methods: Study participants included athletes aged 15 to 25 years with symptomatic femoroacetabular impingement (FAI) and considered ice hockey as their primary sport. All participants had completed Dunn lateral radiographs or hip magnetic resonance imaging as part of their clinical evaluation. All participants completed a survey regarding sport specialization level. Multivariable linear regression analysis controlling for sex was used to analyze the association between degree of sport specialization, age of sport specialization, position played, and level played. Comparisons in radiographic parameters across ice hockey groups were conducted using Student t tests and chi-square tests. Results: Sixty-six ice hockey participants made up the cohort. The majority reported high sport specialization (41/66, 62%). The mean age of sport specialization was 10.7 years (SD 3.5). Participants with moderate specialization had 25 times the odds of a cam deformity (odds ratio [OR] 25.2; 95% CI 1.5-410.7; P = 0.02) and those with high specialization had 9 times the odds of cam deformity (OR 9.3; 95% CI 1.2-74.2; P = 0.04) compared with those with a low degree of specialization, controlling for patient sex. No association was detected between the age of specialization and the likelihood of cam deformity when controlling for patient sex. Conclusion: Level of sport specialization was associated with a cam deformity in this cohort of youth ice hockey athletes. Clinical Relevance: This study suggests that an association exists.

Purpose Patellofemoral instability is a common cause of knee pain and dysfunction in paediatric and adolescent patients. The purpose of the study was to evaluate the frequency of patellar dislocations seen in emergency departments (EDs) and the rates of surgical procedures for patellar instability at paediatric hospitals in the United States between 2004 and 2014. Methods The Pediatric Health Information System database was queried for all paediatric patients who underwent surgery for patellar instability or were seen in the ED for acute patellar dislocation between 2004 and 2014. This was compared with the annual numbers of overall orthopaedic surgical procedures. Results Between 2004 and 2014, there were 3481 patellar instability procedures and 447 285 overall orthopaedic surgical procedures performed at the included institutions, suggesting a rate of 7.8 per 1000 orthopaedic surgeries. An additional 5244 patellar dislocations treated in EDs were identified. Between 2004 and 2014, the number of patellar instability procedures increased 2.1-fold (95% confidence interval (CI) 1.4 to 3.0), while orthopaedic surgical procedures increased 1.7-fold (95% CI 1.3 to 2.0), suggesting a 1.2-fold relative increase in patellar instability procedures, compared with total paediatric orthopaedic surgeries. Conclusion This study shows a significant rise in the rate of acute patellar instability treatment events in paediatric and adolescent patients across the country. Surgery for patellar instability also increased over the study period, though only slightly more than the rate of all paediatric orthopaedic surgical procedures. This may suggest that increasing youth sports participation may be leading to a spectrum of increasing injuries and associated surgeries in children. Level of Evidence IV

Background Postoperative ipsilateral anterior cruciate ligament (ACL) tears after tibial eminence fracture fixation has been previously noted in the literature. This study aims to describe the prevalence of and risk factors for postoperative ACL tears in a cohort of patients operatively treated for tibial eminence fracture. Methods A retrospective review of children undergoing treatment of a tibial eminence fracture at 10 tertiary care children's hospitals was performed. The primary outcome of interest was subsequent ACL rupture. Incidence of ACL tear was recorded for the entire cohort. Patients who sustained a postoperative ACL tear were compared with those without ACL tear and analyzed for demographics and risk factors. A subgroup analysis was performed on patients with a minimum of 2-year follow-up data or those who had met the primary outcome (ACL tear) before 2 years. Results A total of 385 pediatric patients were reviewed. 2.6% of the cohort experienced a subsequent ACL tear. The median follow-up time was 6.5 months (SD=6.4 mo). Subsequent ACL tears occurred at a median of 10.2 months (SD=19.5 mo) postoperatively. There was a statistically significant association with higher grade tibial spine fractures (Myers and McKeever type III and IV) and subsequent ACL tear (P=0.01). Patients with a subsequent ACL tear were older on average (13.5 vs. 12.2 y old), however, this difference was not statistically significant (P=0.08). Subgroup analysis of 46 patients who had a 2-year follow-up or sustained an ACL tear before 2 years showed a 21.7% incidence of a subsequent ACL tear. There was a statistically significant association with higher grade tibial spine fractures (Myers and McKeever type III and IV) and subsequent ACL rupture (P=0.006) in this subgroup. Postoperative ACL tears occurred in patients who were older at the time that they sustained their original tibial eminence fracture (13.4 vs. 11.3 y old, P=0.035). Conclusions Ipsilateral ACL tears following operatively treated pediatric tibial eminence fractures in a large multicenter cohort occurred at a rate of 2.6%. However, in those with at least 2 years of follow-up, the incidence was 21.7%. Subsequent ACL tear was more likely in those with completely displaced (type III or IV) tibial eminence fractures and older patients. Level of evidence Level III-retrospective cohort study.

The periacetabular osteotomy (PAO) has traditionally been viewed as a large operation with significant morbidity. However, as the technique has been refined over the years and more studies have shown its efficacy, it has gained more acceptance. Multiple studies have shown a high return-to-sport rate in athletes undergoing a PAO. As the literature has shown a high rate of concomitant intra-articular pathology, a combination of hip arthroscopy and PAO has been increasingly used. We believe the PAO-with a return-to-sport rate comparable to hip arthroscopy alone-will continue to gain acceptance. The PAO is here to stay and should not be feared.

Background: The Micheli technique for anterior cruciate ligament (ACL) reconstruction (ACLR) has proven to be a reliable method with a minimal risk for growth disturbance among skeletally immature patients. Purposes: To evaluate the Micheli technique of iliotibial band (ITB) graft passage for ACLR using cadaveric knee models and to measure the distance between the surgical instrument tip and the neurovascular bundle in the posterior knee joint: specifically, the peroneal nerve, tibial nerve, and popliteal artery. Study Design: Descriptive laboratory study. Methods: Gross dissection was performed on 17 pediatric cadaveric knees (12 male and 5 female) aged between 4 and 12 years. To simulate ITB graft passage, we passed a curved-tip hemostat clamp through the posterior capsule, with the knee flexed from 90° to 100°. Next, clinical photographs were taken, and digital imaging software was used to measure the distance in centimeters from the clamp tip to each respective neurovascular structure. Results: The mean distances from the clamp tip to the tibial nerve, popliteal artery, and peroneal nerve were 0.875 cm (range, 0.468-1.737 cm), 0.968 cm (range, 0.312-1.819 cm), and 1.149 cm (range, 0.202-2.409 cm), respectively. Mean values were further calculated for age groups of ≤8, 9-10, and 11-12 years. The mean distance from the clamp tip to the peroneal nerve was 1.400 cm larger for 11- to 12-year-old specimens than for ≤8-year-old specimens (95% CI, 0.6-2.2 cm; P = .005). Conclusion: The neurovascular structures in the posterior knee were in close proximity to the path of graft passage, with distances Clinical Relevance: As the incidence of ACL tears is continuously increasing within the pediatric population, there are a larger number of ACLR procedures being performed. Although neurovascular injuries during ACLR are rare, this study clarifies the close proximity of neurovascular structures during ITB graft passage using the Micheli technique of ACLR.

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.

Background:Tibial spine fractures (TSFs) are relatively rare pediatric injuries. Postoperative arthrofibrosis remains the most common complication, with few studies having examined factors associated with its development.Purpose:To identify risk factors for arthrofibrosis and required MUA or lysis of adhesions in the largest known cohort of patients with TSFs.Study Design:Case-control study; Level of evidence, 3.Methods:This was a multicenter study of 249 patients ≤18 years old who had a TSF between January 2000 and February 2019. Patients were separated into cohorts based on whether they developed arthrofibrosis, defined as a 10° deficit in extension and/or 25° deficit in flexion at postoperative 3 months or a return to the operating room for manipulation under anesthesia (MUA) and/or lysis of adhesions.Results:A total of 58 (23.3%) patients developed postoperative arthrofibrosis, with 19 (7.6%) requiring a return to the operating room for MUA. Patients with arthrofibrosis were younger (mean ± SD, 11.3 ± 2.7 vs 12.3 ± 2.8 years; P = .029). They were more likely to have a nonsport, trauma-related injury (65.4% vs 32.1%; P < .001) and a concomitant ACL injury (10.3% vs 1.1%; P = .003). Those with arthrofibrosis had longer operative times (135.0 vs 114.8 minutes; P = .006) and were more likely to have been immobilized in a cast postoperatively (30.4% vs 16.6%; P = .043). In multivariate regression, concomitant anterior cruciate ligament (ACL) injury (odds ratio [OR], 20.0; P = .001), traumatic injury (OR, 3.8; P < .001), age Conclusion:Surgeons should be cognizant of arthrofibrosis risk in younger patients with concomitant ACL tears and traumatic injuries not resulting from athletics. Furthermore, postoperative immobilization in a cast should be avoided given the high risk of arthrofibrosis. Concomitant ACL injury is associated with a higher return to the operating room for MUA.

Purpose To compare postoperative pain scores and opioid use between patients undergoing a standard arthroscopic anterior cruciate ligament reconstruction (ACLR) using hamstring autograft with those undergoing a suture repair augmented with an extracellular matrix scaffold (bridge-enhanced ACL repair) performed through an arthrotomy and to determine factors predictive of postoperative opioid use and levels of overprescription. Methods A nonrandomized controlled trial was conducted with 20 patients (10 ACLR, 10 bridge-enhanced ACL repair), aged 18 to 35 years. All surgeries were performed by a single surgeon. A pain medication log was provided to patients on discharge. No regional anesthesia was performed. Pain scores via a visual analog pain scale were recorded at each visit. Correlations between preoperative and intraoperative characteristics and postoperative opioid use were determined. Results The total morphine-equivalent dose ranged from 30 to 309 mg (4-42 pills oxycodone) for the ACLR group and 75 to 254 mg (10-34 pills oxycodone) for the bridge-enhanced ACL repair group. The average opioid use per day was 35.8 mg for the patients undergoing bridge-enhanced ACL repair and 44.2 mg for patients undergoing ACLR (P = .29). Pain scores at time points up to 2 years postoperatively were not significantly different between the 2 groups. Across both groups, the average oversupply of oxycodone was 46 pills per patient, a greater than 70% unused opiate rate. Preoperative body mass index and preoperative Knee Injury and Osteoarthritis Outcome Scores pain score were predictive of greater postoperative opioid use per day, whereas age, concurrent meniscal repair, and operative time were not. Conclusions Total overall opiate intake was not different between the patients undergoing bridge-enhanced ACL repair through an arthrotomy and those undergoing arthroscopic ACLR. Both groups had similar pain scores from 2 weeks to 2 years postoperatively. Greater body mass index and greater preoperative pain (lower Knee Injury and Osteoarthritis Outcome Scores pain score) correlated with greater postoperative opioid use per day. There was an overprescription of opioids across all patients. Level of Evidence Level III, case control study (therapeutic).

Background:Preclinical studies suggest that for complete midsubstance anterior cruciate ligament (ACL) injuries, a suture repair of the ACL augmented with a protein implant placed in the gap between the torn ends (bridge-enhanced ACL repair [BEAR]) may be a viable alternative to ACL reconstruction (ACLR).Hypothesis:We hypothesized that patients treated with BEAR would have a noninferior patient-reported outcomes (International Knee Documentation Committee [IKDC] Subjective Score; prespecified noninferiority margin, –11.5 points) and instrumented anteroposterior (AP) knee laxity (prespecified noninferiority margin, +2-mm side-to-side difference) and superior muscle strength at 2 years after surgery when compared with patients who underwent ACLR with autograft.Study Design:Randomized controlled trial; Level of evidence, 1.Methods:One hundred patients (median age, 17 years; median preoperative Marx activity score, 16) with complete midsubstance ACL injuries were enrolled and underwent surgery within 45 days of injury. Patients were randomly assigned to receive either BEAR (n = 65) or autograft ACLR (n = 35 [33 with quadrupled semitendinosus-gracilis and 2 with bone–patellar tendon–bone]). Outcomes—including the IKDC Subjective Score, the side-to-side difference in instrumented AP knee laxity, and muscle strength—were assessed at 2 years by an independent examiner blinded to the procedure. Patients were unblinded after their 2-year visit.Results:In total, 96% of the patients returned for 2-year follow-up. Noninferiority criteria were met for both the IKDC Subjective Score (BEAR, 88.9 points; ACLR, 84.8 points; mean difference, 4.1 points [95% CI, –1.5 to 9.7]) and the side-to-side difference in AP knee laxity (BEAR, 1.61 mm; ACLR, 1.77 mm; mean difference, –0.15 mm [95% CI, –1.48 to 1.17]). The BEAR group had a significantly higher mean hamstring muscle strength index than the ACLR group at 2 years (98.2% vs 63.2%; P < .001). In addition, 14% of the BEAR group and 6% of the ACLR group had a reinjury that required a second ipsilateral ACL surgical procedure ( P = .32). Furthermore, the 8 patients who converted from BEAR to ACLR in the study period and returned for the 2-year postoperative visit had similar primary outcomes to patients who had a single ipsilateral ACL procedure.Conclusion:BEAR resulted in noninferior patient-reported outcomes and AP knee laxity and superior hamstring muscle strength when compared with autograft ACLR at 2-year follow-up in a young and active cohort. These promising results suggest that longer-term studies of this technique are justified.Registration:NCT02664545 (ClinicalTrials.gov identifier)

Purpose Our primary research question was to investigate the severity of deformity and articular damage as well as outcomes in patients undergoing hip arthroscopy compared with open surgery for the treatment of symptomatic slipped capital femoral epiphysis (SCFE) deformity. Methods Retrospective review of surgical treatment of symptomatic SCFE deformity with a minimum one-year follow-up. Patients were divided into three groups: the arthroscopic group, surgical hip dislocation(SHD) group and SHD with femoral osteotomy (SHD+ITO) group. Deformity severity was quantified. Hip outcome was assessed by the modified Merle d'Aubigné Postel (MDP) scores. Results There were more severe slips treated by SHD and SHD+ITO. There was more severe deformity in the SHD+ITO group than the arthroscopy group (p < 0.001). There were more full thickness acetabular cartilage defects in the SHD and the SHD+ITO groups (> 40%) compared with the arthroscopy group (11%; p = 0.03). The SHD+ITO and SHD group had lower MDP scores compared with the arthroscopy group both before and after surgery but no difference was detected in the amount of improvement from surgery across groups (p > 0.05). Moderate and severe SCFEs had worse preoperative scores but improvement was not different compared with mild SCFEs (p > 0.05). Conclusion Patients undergoing open treatment had more severe SCFE deformity with more extensive articular damage at reconstructive surgery compared with patients undergoing arthroscopy. All groups with SCFE deformity had improved pain and hip function postoperatively. Level of Evidence III

Type 1 tibial spine fractures are nondisplaced or ≤2 mm-displaced fractures of the tibial eminence and anterior cruciate ligament (ACL) insertion that are traditionally managed nonoperatively with immobilization.Type 1 fractures do not carry a significant risk of associated injuries and therefore do not require advanced imaging or additional interventions aside from immobilization.Case series; Level of evidence, 4.We reviewed 52 patients who were classified by their treating institution with type 1 tibial spine fractures. Patients aged ≤18 years with pretreatment plain radiographs and ≤ 1 year of follow-up were included. Pretreatment imaging was reviewed by 4 authors to assess classification agreement among the treating institutions. Patients were categorized into 2 groups to ensure that outcomes represented classic type 1 fracture patterns. Any patient with universal agreement among the 4 authors that the fracture did not appear consistent with a type 1 classification were assigned to the type 1+ (T1+) group; all other patients were assigned to the true type 1 (TT1) group. We evaluated the rates of pretreatment imaging, concomitant injuries, and need for operative interventions as well as treatment outcomes overall and for each group independently.A total of 48 patients met inclusion criteria; 40 were in the TT1 group, while 8 were in the T1+ group, indicating less than universal agreement in the classification of these fractures. Overall, 12 (25%) underwent surgical treatment, and 12 (25%) had concomitant injuries. Also, 8 patients required additional surgical management including ACL reconstruction (n = 4), lateral meniscal repair (n = 2), lateral meniscectomy (n = 1), freeing an incarcerated medial meniscus (n = 1), and medial meniscectomy (n = 1).The classification of type 1 fractures can be challenging. Contrary to prior thought, a substantial number of patients with these fractures (20%) were found to have concomitant injuries. Overall, surgical management was performed in 25% of patients in our cohort.

When operative treatment is indicated, tibial spine fractures can be successfully managed with open or arthroscopic reduction and internal fixation (ARIF). The purpose of the study is to evaluate short-term treatment outcomes of tibial spine fractures in patients treated with both open and arthroscopic fracture reduction.We performed an Institutional Review Board (IRB)-approved retrospective cohort study of pediatric tibial spine fractures presenting between January 1, 2000 and January 31, 2019 at 10 institutions. Patients were categorized into 2 cohorts based on treatment: ARIF and open reduction and internal fixation (ORIF). Short-term surgical outcomes, the incidence of concomitant injuries, and surgeon demographics were compared between groups.There were 477 patients with tibial spine fractures who met inclusion criteria, 420 of whom (88.1%) were treated with ARIF, while 57 (11.9%) were treated with ORIF. Average follow-up was 1.12 years. Patients treated with ARIF were more likely to have an identified concomitant injury (41.4%) compared with those treated with ORIF (24.6%, P=0.021). Most concomitant injuries (74.5%) were treated with intervention. The most common treatment complications included arthrofibrosis (6.9% in ARIF patients, 7.0% in ORIF patients, P=1.00) and subsequent anterior cruciate ligament injury (2.1% in ARIF patients and 3.5% in ORIF, P=0.86). The rate of short-term complications, return to the operating room, and failure to return to full range of motion were similar between treatment groups. Twenty surgeons with sports subspecialty training completed 85.0% of ARIF cases; the remaining 15.0% were performed by 12 surgeons without additional sports training. The majority (56.1%) of ORIF cases were completed by 14 surgeons without sports subspecialty training.This study demonstrated no difference in outcomes or nonunion following ARIF or ORIF, with a significantly higher rate of concomitant injuries identified in patients treated with ARIF. The majority of identified concomitant injuries were treated with surgical intervention. Extensive surgical evaluation or pretreatment magnetic resonance imaging should be considered in the workup of tibial spine fractures to increase concomitant injury identification.Level III.

Purpose: The purpose of this study was to quantify the anxiety experienced by patients undergoing pin removal in clinic following closed reduction and percutaneous pinning for supracondylar humerus fractures. Methods: We prospectively enrolled 53 patients (3–8 years) treated for supracondylar humerus fracture with closed reduction and percutaneous pinning between July 2018 and February 2020. Demographic and injury data were recorded. Heart rate and the Face, Legs, Activity, Cry, and Consolability scale were measured immediately before pin removal and after pin removal, and crossover control values were obtained at the subsequent follow-up clinic visit. Results: All patients experienced anxiety immediately prior to pin removal (95% confidence interval, 94%–100%) with a median Face, Legs, Activity, Cry, and Consolability score of 7 (interquartile range, 6–8). In addition, 98% of subjects experienced an elevated heart rate (95% confidence interval, 88%–100%). Patients experienced a median 73% reduction in Face, Legs, Activity, Cry, and Consolability score and mean 21% reduction in heart rate from prior to pin removal to after pin removal ( p Conclusions: Pediatric patients experience high levels of anxiety when undergoing pin removal following closed reduction and percutaneous pinning for supracondylar humerus fractures. This is an area of clinical practice where intervention may be warranted to decrease patient anxiety. Level of evidence: II

Background: Patellofemoral instability (PFI) occurs most commonly in pediatric and adolescent patients, with evolving indications for surgery and changes in surgical techniques over the past decade. Purpose: To characterize the demographic, clinical, and radiologic characteristics of a large cohort of patients undergoing PFI surgery and investigate longitudinal trends in techniques utilized over a 10-year period at a tertiary-care academic center. Study Design: Case series; Level of evidence, 4. Methods: Electronic medical records of patients younger than 25 years of age who underwent primary surgery for lateral PFI from 2008 to 2017 at a single center by 1 of 5 different sports medicine surgeons were retrospectively reviewed. Demographic, clinical, and radiographic parameters of instability were analyzed. Routine surgical techniques included medial retinacular plication/reefing/repair (MRP), medial patellofemoral ligament reconstruction (MPFLR), tibial tubercle osteotomy (TTO), or a combination thereof, with or without lateral retinacular release (LR) or lateral retinacular lengthening (LRL). Exclusion criteria, selected for potentially altering routine surgical indications or techniques, included fixed/syndromic PFI, a formally diagnosed collagen disorder, cases in which a chondral/osteochondral shear fragment underwent fixation or was >1 cm in diameter, and body mass index >30 kg/m2. Results: Of the 492 study patients (556 knees; 71% female; median age, 15.2 years; 38% open physes), 88% were athletes, with the most common sports participated in being soccer, basketball, dance, football, gymnastics, and baseball/softball. While 91% of the cohort had recurrent dislocations, the 9% with primary dislocations were more likely to have small osteochondral fractures/loose bodies ( P < .001). Female patients were younger ( P = .002), with greater patellar tilt ( P = .005) than male patients. Utilization of MPFLR and TTO increased significantly over the study period, while use of MRP+LR decreased. Conclusion: Most patients younger than 25 years of age who underwent PFI surgery were skeletally immature, female, and athletes and had recurrent dislocations. The

Background: Sports-related cervical spine injuries (CSI) are devastating traumas that can result in permanent disability and death. However, there is a paucity of literature on catastrophic CSI sustained in young athletes who require surgical intervention. The objectives of this study were to review injury characteristics, management, and outcomes in pediatric patients who sustained an operative CSI during youth sports. Methods: This was a retrospective review of patients treated at a Level 1 pediatric trauma center for CSI (2004-2019). Children

Background: Magnetic resonance–based measurements of signal intensity have been used to track healing of surgically treated anterior cruciate ligaments (ACLs). However, it is unknown how the signal intensity values in different regions of the ligament or graft change during healing. Hypotheses: (1) Normalized signal intensity of the healing graft or repaired ACL is heterogeneous; (2) temporal changes in normalized signal intensity values differ among the tibial, middle, and femoral regions; and (3) there are no differences in regional normalized signal intensity values 2 years postoperatively among grafts, repaired ACLs, and contralateral native ACLs. Study Design: Cohort study; Level of evidence, 2. Methods: Magnetic resonance imaging scans were analyzed from patients in a trial comparing ACL reconstruction (n = 35) with bridge-enhanced ACL repair (n = 65). The ACLs were segmented from images acquired at 6, 12, and 24 months postoperatively and were partitioned into 3 sections along the longitudinal axis (femoral, middle, and tibial). Linear mixed modeling was used to compare location-specific differences in normalized ligament signal intensity among time points (6, 12, and 24 months) and groups (ACL reconstruction, repair, and contralateral native ACL). Results: For grafts, the middle region had a higher mean normalized signal intensity when compared with the femoral region at all time points ( P < .01) but compared with the tibial region only at 6 months ( P < .01). For repaired ACLs, the middle region had a higher mean normalized signal intensity versus the femoral region at all time points ( P < .01) but versus the tibial region only at 6 and 12 months ( P < .04). From 6 to 24 months, the grafts showed the greatest reduction in normalized signal intensity in the femoral and middle regions (vs tibial regions; P < .01), while there were no regional differences in repaired ACLs. At 2 years after surgery, repaired ACLs had a lower normalized signal intensity in the tibial region as compared with reconstructed grafts and contralateral native ACLs ( P < .01). Conclusion: The results suggest that graft remodeling is location specific. Repaired ACLs were more homogeneous, with lower or comparable normalized signal intensity values at 2 years as compared with the contralateral native ACL and reconstructed grafts.

Objectives: Medial epicondyle apophyseal avulsion fractures sustained during throwing represent an understudied, severe variant of medial epicondyle apophysitis, or ‘Little League elbow’. The current study sought to characterize presenting features, treatment options, and clinical results of a large cohort of pre-adolescent and adolescent patients who presented with these fractures. Methods: Skeletally immature athletes with medial epicondyle apophyseal avulsion fractures sustained during throwing from 2003-2017 at a tertiary-care pediatric referral center were identified. Exclusion criteria were fractures sustained during non-throwing activity or prior elbow fracture. Medical records and radiographic images were reviewed for study variables. Treatment decisions were made independently by fellowship-trained pediatric orthopaedic surgeons or sports medicine physicians on a case-by-case basis. Patients treated with open reduction and internal fixation (ORIF) were compared to those treated non-operatively, and all fracture patients were compared to a larger control group of patients diagnosed with medial epicondyle apophysitis/Little League elbow with no fracture. Results: During the study period, a total of 317 patients were diagnosed with Little League elbow due to medial epicondyle apophyseal overuse injury, 50 of whom (16%) sustained a discreet, radiographically confirmed epicondyle fracture sustained during a single throw. Median age of the fracture cohort at presentation was 13.1 years (range 8 years – 16 years). Forty-nine fracture patients (98%) were male baseball pitchers and one (2%) was a male football quarterback. Fracture patients had significantly higher median BMI (21.3 kg/m2 vs. 19.2kg/m2, p=0.004) than the apophysitis control group, but there was no significant difference in age. Of the 37 patients with documentation regarding pre-injury symptoms, 31 patients (84%) described pre-existing medical elbow pain prior to their acute injury, while 6 (16%) denied pain prior to the inciting throw. Of the 12 patients (24%) with documented shoulder exams at presentation, 5 (42%) demonstrated glenohumeral internal rotation deficit (GIRD). Twenty-three patients (46%) were treated with ORIF (22 single screw fixation; 1 suture anchor fixation), while 27 (54%) were treated non-operatively. Median fracture displacement was significantly greater in operative patients than non-operative patients (5.0mm vs. 3.0mm, p=Conclusions: Medial epicondyle apophyseal avulsion fractures in youth throwers represent a severe variant of Little League elbow, constituting approximately 16% of cases within the condition’s spectrum. These fractures may be effectively treated with either non-operative measures, particularly minimally displaced fractures 40% of operative patients may require implant removal. A large majority of patients reported medial elbow pain prior to fracture, suggesting this severe presentation of Little League elbow may be preventable.

Background Little data exists on surgical outcomes of sports-related cervical spine injuries (CSI) sustained in children and adolescent athletes. This study reviewed demographics, injury characteristics, management, and operative outcomes of severe CSI encountered in youth sports. Methods Children below 18 years with operative sports-related CSI at a Level 1 pediatric trauma center were reviewed (2004 to 2019). All patients underwent morden cervical spine instrumentation and fusion. Clinical, radiographic, and surgical characteristics were analyzed. Results A total of 3231 patients (mean, 11.3±4.6 y) with neck pain were evaluated for CSI. Sports/recreational activities were the most common etiology in 1358 cases (42.0%). Twenty-nine patients (2.1%) with sports-related CSI (mean age, 14.5 y; range, 6.4 to 17.8 y) required surgical intervention. Twenty-five were males (86%). Operative CSI occurred in football (n=8), wrestling (n=7), gymnastics (n=5), diving (n=4), trampoline (n=2), hockey (n=1), snowboarding (n=1), and biking (n=1). Mechanisms were 27 hyperflexion/axial loading (93%) and 2 hyperextension injuries (7%). Most were cervical fractures (79%) and subaxial injuries (79%). Seven patients (24%) sustained spinal cord injury (SCI) and 3 patients (10%) cord contusion or myelomalacia without neurological deficits. The risk of SCI increased with age (P=0.03). Postoperatively, 2 SCI patients (29%) improved 1 American Spinal Injury Association Impairment Scale Grade and 1 (14%) improved 2 American Spinal Injury Association Impairment Scale Grades. Increased complications developed in SCI than non-SCI cases (mean, 2.0 vs. 0.1 complications; P=0.02). Bony fusion occurred in 26/28 patients (93%) after a median of 7.2 months (interquartile range, 6 to 15 mo). Ten patients (34%) returned to their baseline sport and 9 (31%) to lower-level activities. Conclusions The incidence of sports-related CSI requiring surgery is low with differences in age/sex, sport, and injury patterns. Older males with hyperflexion/axial loading injuries in contact sports were at greatest risk of SCI, complications, and permanent disability. Prevention campaigns, education on proper tackling techniques, and neck strength training are required in sports at high risk of hyperflexion/axial loading injury. Level of evidence Level III-retrospective cohort study.

Background: The cross-sectional area (CSA) of the anterior cruciate ligament (ACL) and reconstructed graft has direct implications on its strength and knee function. Little is known regarding how the CSA changes along the ligament length and how those changes vary between treated and native ligaments over time. Hypothesis: It was hypothesized that (1) the CSA of reconstructed ACLs and restored ACLs via bridge-enhanced ACL restoration (BEAR) is heterogeneous along the length. (2) Differences in CSA between treated and native ACLs decrease over time. (3) CSA of the surgically treated ACLs is correlated significantly with body size (ie, height, weight, body mass index) and knee size (ie, bicondylar and notch width). Study Design: Cohort study; Level of evidence, 2. Methods: Magnetic resonance imaging scans of treated and contralateral knees of 98 patients (n = 33 ACL reconstruction, 65 BEAR) at 6, 12, and 24 months post-operation were used to measure the ligament CSA at 1% increments along the ACL length (tibial insertion, 0%; femoral insertion, 100%). Statistical parametric mapping was used to evaluate the differences in CSA between 6 and 24 months. Correlations between body and knee size and treated ligament CSA along its length were also assessed. Results: Hamstring autografts had larger CSAs than native ACLs at all time points ( P < .001), with region of difference decreasing from proximal 95% of length (6 months) to proximal 77% of length (24 months). Restored ACLs had larger CSAs than native ACLs at 6 and 12 months, with larger than native CSA only along a small midsubstance region at 24 months ( P < .001). Graft CSA was correlated significantly with weight (6 and 12 months), bicondylar width (all time points), and notch width (24 months). Restored ACL CSA was significantly correlated with bicondylar width (6 months) and notch width (6 and 12 months). Conclusion: Surgically treated ACLs remodel continuously within the first 2 years after surgery, leading to ligaments/grafts with heterogeneous CSAs along the length, similar to the native ACL. While reconstructed ACLs remained significantly larger, the restored ACL had a CSA profile comparable with that of the contralateral native ACL. In addition to size and morphology differences, there were fundamental differences in factors contributing to CSA profile between the ACL reconstruction and BEAR procedures. Registration: NCT 02664545 ( ClinicalTrials.gov identifier).

Previous clinical studies have shown that psychological factors have significant effects on an athlete's readiness to return to sport after anterior cruciate ligament (ACL) reconstruction (ACLR).We hypothesized that patients who underwent bridge-enhanced ACL restoration (BEAR) would have higher levels of psychological readiness to return to sport compared with patients who underwent ACLR.Randomized controlled trial; Level of evidence, 1.A total of 100 patients (median age, 17 years; median preoperative Marx activity score, 16) with complete midsubstance ACL injuries were randomized to either the BEAR procedure (n = 65) or autograft ACLR (n = 35 [33 hamstring and 2 bone--patellar tendon-bone]) and underwent surgery within 45 days of injury. Objective, functional, and patient-reported outcomes, including the ACL--Return to Sport after Injury (ACL-RSI) scale, were assessed at 6, 12, and 24 months postoperatively.Patients who underwent the BEAR procedure had significantly higher ACL-RSI scores at 6 months compared with those who underwent ACLR (71.1 vs 58.2;Patients who underwent the BEAR procedure had higher ACL-RSI scores at 6 months postoperatively. Better ACL-RSI scores at 6 months were related most strongly to higher IKDC scores at 6 months and were also associated with lower pain levels, better muscle recovery, and less knee laxity at 6 months.NCT02664545 (ClinicalTrials.gov identifier).

Background: Little is known about sex-based differences in anterior cruciate ligament (ACL) tissue quality in vivo or the association of ACL size (ie, volume) and tissue quality (ie, normalized signal intensity on magnetic resonance imaging [MRI]) with knee anatomy. Hypothesis: We hypothesized that (1) women have smaller ACLs and greater ACL normalized signal intensity compared with men, and (2) ACL size and normalized signal intensity are associated with age, activity levels, body mass index (BMI), bicondylar width, intercondylar notch width, and posterior slope of the lateral tibial plateau. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Knee MRI scans of 108 unique ACL-intact knees (19.7 ± 5.5 years, 62 women) were used to quantify the ACL signal intensity (normalized to cortical bone), ligament volume, mean cross-sectional area, and length. Independent t tests were used to compare the MRI-based ACL parameters between sexes. Univariate and multivariate linear regression analyses were used to investigate the associations between normalized signal intensity and size with age, activity levels, BMI, bicondylar width, notch width, and posterior slope of the lateral tibial plateau. Results: Compared with men, women had significantly smaller mean ACL volume (men vs women: 2028 ± 472 vs 1591 ± 405 mm3), cross-sectional area (49.4 ± 9.6 vs 41.5 ± 8.6 mm2), and length (40.8 ± 2.8 vs 38.1 ± 3.1 mm) ( P < .001 for all), even after adjusting for BMI and bicondylar width. There was no difference in MRI signal intensity between men and women (1.15 ± 0.24 vs 1.12 ± 0.24, respectively; P = .555). BMI, bicondylar width, and intercondylar notch width were independently associated with a larger ACL ( R 2 > 0.16, P < .001). Younger age and steeper lateral tibial slope were independently associated with shorter ACL length ( R 2 > 0.03, P < .04). The combination of BMI and bicondylar width was predictive of ACL volume and mean cross-sectional area ( R 2 < 0.3). The combination of BMI, bicondylar width, and lateral tibial slope was predictive of ACL length ( R 2 = 0.39). Neither quantified patient characteristics nor anatomic variables were associated with signal intensity. Conclusion: Men had larger ACLs compared with women even after adjusting for BMI and knee size (bicondylar width). No sex difference was observed in signal intensity, suggesting no difference in tissue quality. The association of the intercondylar notch width and lateral tibial slope with ACL size suggests that the influence of these anatomic features on ACL injury risk may be partially explained by their effect on ACL size. Registration: NCT02292004 and NCT02664545 ( ClinicalTrials.gov identifier).

Purpose: The uncommon nature of tibial spine fractures may result in delayed presentation, diagnosis, and treatment. Elucidation of the contributing factors to such delays may provide an opportunity to improve patient care. The purpose of this study is to evaluate risk factors for and perioperative consequences of delayed surgical treatment of pediatric tibial spine fractures. Methods: We performed a retrospective cohort study of tibial spine fractures treated surgically at 10 institutions between 2000 and 2019. Demographic and preoperative data were collected as was information regarding intra-operative management and findings. Attention was focused on delays in evaluation and treatment, which were treated as both continuous and categorical variables. Surgery ≥21 days after injury was considered “delayed.” Univariate analysis was followed by purposeful entry multivariate regression to adjust for confounding factors. Results: A total of 368 subjects (mean age 11.7±2.9 years) were included. The median time between injury and surgery was 11 days (interquartile range 13 days). In multivariate analysis, patients that underwent delayed surgery had 2.3 times higher odds of having seen another provider before the treating surgeon (95% CI 1.1-4.8, p=0.02) and 3.8 times higher odds of having undergone magnetic resonance imaging (MRI; 95% CI 2.1-6.9, p

Background: Sports-related cervical spine injuries (CSI) are devastating traumas with the potential for permanent disability. There is a paucity of literature on operative CSI sustained in youth athletes. Hypothesis/Purpose: The aims of this study aims were to review injury characteristics, surgical treatment, and outcomes of severe pediatric CSI encountered in youth sports. Methods: We reviewed children less than 18 years old with operative sports-related CSI at a pediatric Level 1 pediatric trauma center between 2004−2019. All cases underwent modern cervical spine instrumentation and fusion. SCI were stratified according to the American Spinal Injury Association Impairment Scale (ASIA). Clinical, radiographic, and surgical characteristics were compared between groups of patients with and without spinal cord injury (SCI). Results: Three thousand two hundred and thirty-one children (mean, 11.3y±4.6y) were evaluated for CSI at our institution during the 16-year period. The majority of traumas resulted from sports/recreational activities and were seen in 1365 cases (42.3%). Of these, 171/1365 patients (12.5%) were admitted and 29/1365 patients (2.1%) required surgical intervention (mean age, 14.5y±2.88y; range, 6.4y–17.8y). Sports included: eight football (28%), seven wrestling (24%), five gymnastics (17%), four diving (14%), two trampoline (7%), one hockey (3%), one snowboarding (3%), and one biking injury (3%). Mechanisms were 19 hyperflexion (65%), eight axial loading (28%), and two hyperextension injuries (7%). The majority of operative CSI were fractures (79%) and/or subaxial defects (72%). Seven patients (30%) sustained SCI and three patients (10%) spinal cord contusion or myelomalacia without neurologic deficits. The risk of SCI increased with age (15.8y vs. 14.4y; p=0.03) and axial loading mechanism (71% vs. 14%; p=0.003). Postoperatively, two SCI patients (29%) improved 1 ASIA Grade and one (14%) improved 2 ASIA Grades. Increased complications developed in SCI than patients without SCI (mean, 2.0 vs 0.1 complications; p=0.02). Clinical and radiographic fusion occurred in 24/26 patients (92%) with adequate follow-up (median, 32 months). Ten patients returned to their previous activity and nine to sports with a lower level of activity. Conclusion: The overall incidence of sports-related operative CSI is low. Age- and gender discrepancies exist, with male adolescent athletes most commonly requiring surgery. Hyperflexion injuries had a good prognosis; however, older males with axial loading CSI sustained in contact sports were at greatest risk of SCI, complications, and permanent disability. [Figure: see text][Table: see text][Table: see text]

Background: While operative treatment of displaced pediatric tibial eminence fractures has generally been shown to be safe, post-operative complications including arthrofibrosis, infection, fixation failure, and postoperative ipsilateral ACL injuries remain prevalent. The purpose of this study was to describe the prevalence of and risk factors for post-operative ACL tears in a cohort of patients surgically treated for tibial eminence fracture. Methods: We performed a retrospective review of children undergoing treatment of a tibial eminence fracture at 10 tertiary children’s hospitals.. The primary outcome was subsequent ACL rupture. Patients with 2 year follow up data and those that had met the primary outcome within the 2 year period, were analyzed for demographics, risk factors and survival analyses Results: 385 pediatric patients were reviewed. Overall, 46 patients had either 2 year follow up data or met the primary outcome measure of an ACL tear prior to the 2 year mark. Mean age was 11.2 years old (SD 2.8), and the median follow time was 36.4 months (SD 17.7 months) There was a 21.7% incidence of subsequent ACL tear in the cohort analyzed. Subsequent ACL tears occurred at a median of 10.2 months (SD 19.5 months) postoperatively. There was a statistically significant association with higher Myers & McKeever grade tibial spine fractures (Type III and IV) and subsequent ACL rupture ( p=0.006). Subsequent ACL tears occurred in patients who were older when they had their original tibial eminence fracture, 13.4 years old versus 11.3 years old ( p=0.035). There was no statistically significant relationship between ipsilateral ACL tear and body mass index, operative time, fixation method used, postoperative weight bearing status, type of postoperative immobilization, contact versus non-contact injury mechanism, type of post-operative physical therapy protocol based on chi-squared or t-test ( p>0.05). Conclusion: Subsequent ipsilateral ACL tears following operatively treated pediatric tibial eminence fractures in a large multicenter cohort occurred at a rate of 21.7%. They were associated with completely displaced (Type III or IV) tibial eminence fractures, and older patients. Clinicians should therefore continue to follow patients for at least 2 years after treatment of pediatric tibial eminence fractures in order to track this potential complication. [Table: see text]

Background: Adolescent dancers may be a high-risk population for patellofemoral instability (PFI), but the condition remains under-investigated, to date, in this sub-group of athletes. Purpose: The purpose of this study was to (1) investigate the descriptive epidemiology of PFI in adolescent dancers, (2) analyze the efficacy of various patellar stabilization procedures within this population, and (3) compare PFI in dancers to a larger control group of matched, non-dancer athletes. Methods: A retrospective review of athletes, ages 10 to 19, who presented to a single tertiary care center with PFI between 2008 and 2017 was performed. Based on each patient’s primary sport, the cohort was divided into a dancer and a non-dancer control group. Demographics, clinical and radiologic features, surgical stabilization technique, and postoperative course and clinical outcomes were collected. Independent categorical groups were tested using chi squared and Fisher exact tests. Results: 258 adolescent athletes were included, 41 of whom were dancers, all females. This group was therefore matched with a control group of similarly aged, all-female athletes with PFI (Table 1). 54 athletes had bilateral PFI, yielding 285 knees for analysis. There was no difference between dancer and non-dancer athletes’ age, BMI, laterality, mechanism of injury, nor number of preoperative instability events. However, dancers had lower Dejour Classifications (p=0.044), smaller patella inclination angles (20.9±8.14 versus 25.0±9.84; p=0.004), and smaller Caton-Deschamps Indices (1.18±0.161 versus 1.25±0.189; p=0.041). Among dancers, there was no association between surgical stabilization technique and rates of recurrent instability (p=0.418) nor re-stabilization procedures (p=1.0) (Table 2). However, dancers who underwent tibial tubercle osteotomy (TTO) had higher rates of subsequent, non-stabilization procedures (66.7%), all for implant removal, compared to those undergoing isolated medial retinacular repairs (MRP) (3.8%) (pConclusions: Female dancers with PFI have similar demographic and clinical features as other female athletes with PFI, but have lower rates or less severe trochlear dysplasia, lateral tilt and patella alta. Therefore, the ligamentous laxity inherent in dancers may be a more powerful risk factor for PFI than other non-modifiable risk factors. Notably, the TTO was a powerful stabilization procedure for this sub-population with low rates of recurrent instability episodes and no revision stabilization procedures performed. Rates of implant removal surgery following TTO may be substantial, though this may be technique or surgeon dependent. Tables/Figures: [Table: see text][Table: see text]

Background: Historically, the most commonly utilized technique to address recurrent patellofemoral instability (PFI) was a combined proximal and distal realignment, specifically the tibial tubercle osteotomy (TTO) with a proximal medial retinacular plication/reefing/tightening/repair (MRP). Rising interest in the medial patellofemoral ligament reconstruction (MPFLR) over the last decade, now frequently performed as a more powerful isolated proximal realignment procedure, has prompted debate over the optimal technique to treat this common condition. Hypothesis/Purpose: The study hypothesis was that no difference would be detected in recurrent PFI rates or revision surgery rates between patients who underwent TTO-MRP vs. MPFLR. Methods: With cohorts derived from a large, single-center PFI database of 523 patients who underwent a variety of stabilization procedures, 114 eligible MPFLR patients were matched to 109 TTO patients based on age, gender, BMI, and TT-TG distance. Propensity score matching was conducted using logistic regression models to produce 1:1 matching, and a caliper of 0.2 standard deviations of the estimated propensity score was used to for the nearest neighbor matching algorithm. Final matching procedure resulted in 84 MPFLR patients and 84 TTO patients. These were compared on demographics and post-operative clinical results. Results: Demographic and radiologic comparisons of the cohorts are shown in Table 1, with the only difference between groups being an expected higher rate of patients with open physes in the MPFLR cohort. Table 2 shows the TTO-MRP group had longer follow up times, but comparable rates of return to sports. The MPFLR group had a higher rate of recurrent instability, but not to a significant degree, and a significantly higher incidence of revision patellar stabilization surgery (pConclusion: The TTO-MRP shows equivalent or superior results to the MPFLR for treatment of PFI. However, implant removal may be common with TTO, though this may be somewhat technique-dependent. In the current landscape of increasing interest and utilization of MPFLR as an all-encompassing PFI surgery, the influence of distal bony realignment to minimize recurrence should not be underappreciated. Tables/Figures: [Table: see text][Table: see text]