Publications by authors named "Henry B Ellis"

71 Publications

Orthopaedic Surgery Pediatric Sports Medicine: Characterizing Practice Patterns and Subspecialization.

J Pediatr Orthop 2022 Jul 19. Epub 2022 Jul 19.

Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO.

Background: Pediatric sports medicine is a new and rapidly growing subspecialty within orthopaedic surgery. However, there is very limited literature on the practice of pediatric sports medicine in North America. Therefore, the purpose of this study was to evaluate and describe the current practice patterns of orthopaedic surgeons specializing in pediatric sports medicine.

Methods: An online survey was distributed to orthopaedic surgeons specializing in pediatric sports medicine through the Pediatric Research in Sports Medicine Society. The purpose of the survey was to characterize (1) surgeon demographics, (2) the breakdown of different joint specialization, and (3) the specific procedures for joints that the surgeons specialize in.

Results: Responses from 55 orthopaedic surgeons were collected and analyzed. Most respondents considered pediatric sports medicine as the primary focus of their practice (89.1%, n=49/55). The number of fellowships completed was almost evenly split between either a single fellowship (52.7%, n=29/55) or 2 or more (47.3%, n=26/55). The most common combination of fellowships was pediatric orthopaedics and adult sports medicine (32.7%, n=18/55). Most survey respondents had been in practice for <10 years (69.0%, n=38/55) and were affiliated with an academic center (61.8%, n=34/55). On average, 77.5% of the patients treated were <18 years old. The knee joint was the most specialized joint, with 98.2% (n=54/55) respondents reporting that the knee joint constituted ≥25% of their practice. The knee joint constituted a mean of 52.1% of the respondents' overall practice, followed by the shoulder (15.2%), hip (13.9%), ankle (7.5%), elbow (7.1%), and wrist (4.2%).

Conclusions: Pediatric sports medicine practices are variable and have distinct practice patterns in pediatric, orthopaedic, and adult sports practices. In the current study, most surgeons are less than 10 years into practice, affiliated with academic centers, and have typically completed either 1 or 2 fellowships after residency. Surgeons were most commonly specialized in the knee joint and cared for patients <18 years old.

Level Of Evidence: Level of evidence IV.
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http://dx.doi.org/10.1097/BPO.0000000000002209DOI Listing
July 2022

Quantifying the Relationship Between the Medial Quadriceps Tendon-Femoral Ligament and Patellar Borders: A Pediatric Cadaveric Study.

Am J Sports Med 2022 07 28;50(9):2433-2438. Epub 2022 Jun 28.

Investigation performed at Stanford University School of Medicine, Stanford, California, USA.

Background: The medial patellofemoral complex (MPFC) is a structure composed of the medial quadriceps tendon-femoral ligament (MQTFL) superiorly and the medial patellofemoral ligament (MPFL) inferiorly. The pediatric MPFL anatomy has been well described, but the precise anatomy of the MQTFL has only recently been described and studied in skeletally immature patients.

Purpose: To describe the anatomic relationship between the MQTFL and its insertion on the quadriceps tendon and patella in pediatric specimens.

Study Design: Descriptive laboratory study.

Methods: A total of 22 pediatric cadaveric knee specimens were dissected to analyze attachment of the MQTFL to the quadriceps tendon and patella. Dissection was facilitated using lateral parapatellar arthrotomy followed by eversion of the extensor mechanism to evaluate MQTFL fibers from its undersurface.

Results: The mean specimen age was 7.4 years. Specimens were divided based on age into a younger cohort (1-2 years), middle cohort (4-8 years), and older cohort (9-12 years). The quadriceps tendon attachment (QTA) of the MQTFL proximal to the patella extended a median of 5.0 mm in the younger cohort, 11.4 mm in the middle cohort, and 12.0 mm in the older cohort, with significant differences found between the younger and middle cohorts ( < .047) and the younger and older cohorts ( < .001). The QTA as a percentage of patellar articular height averaged 44.4% across all specimens. The vertical height of the patella measured a median of 14.0 mm, 22.3 mm, and 27.3 mm in the younger, middle, and older cohorts, respectively.

Conclusion: This study expands on the recently described anatomy of the pediatric MPFC to quantify the anatomic relationship between the MQTFL attachment to the quadriceps tendon and patella in a more clinically relevant cohort of donor specimens.

Clinical Relevance: As access to pediatric cadaveric tissue is extremely limited, a better understanding of MPFC and MQTFL anatomy will support surgeons in preoperative planning and intraoperative considerations for their approach to MQTFL and MPFL reconstruction. This may facilitate improved anatomic surgical stabilization of the patellofemoral joint in pediatric patients.
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http://dx.doi.org/10.1177/03635465221103250DOI Listing
July 2022

A Pilot Randomized Controlled Trial of Docosahexaenoic Acid for the Treatment of Sport-Related Concussion in Adolescents.

Clin Pediatr (Phila) 2022 Jun 19:99228221101726. Epub 2022 Jun 19.

Texas Orthopaedic Associates, Dallas, TX, USA.

The objective was to examine the use of docosahexaenoic acid (DHA) for the treatment of sport-related concussion (SRC) in adolescent athletes. We hypothesize that participants who intake 2 g of DHA daily will not experience differences in recovery compared with participants who take a placebo. This double-blind, randomized controlled pilot trial was performed in a tertiary pediatric sports medicine clinic from 2013 to 2017 in adolescents (14-18 years) presenting with diagnosed SRC within 4 days of injury. Forty participants were randomized into DHA or PLACEBO group and were instructed to take 2 capsules twice daily for 12 weeks. Participants in the DHA group were symptom-free earlier than the PLACEBO group (11.0 vs 16.0 days, = .08) and were cleared to begin the Return to Sport progression (14.0 vs 19.5 days, = .12) sooner. The use of 2 g/day of DHA was well-tolerated and did not significantly affect recovery times in adolescent athletes following SRC. ClincalTrials.gov, NCT01903525.
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http://dx.doi.org/10.1177/00099228221101726DOI Listing
June 2022

Epidemiology of Pediatric Gymnastics Injuries Reported in US Emergency Departments: Sex- and Age-Based Injury Patterns.

Orthop J Sports Med 2022 Jun 13;10(6):23259671221102478. Epub 2022 Jun 13.

University of Texas Southwestern Medical Center, Dallas, Texas, USA.

Background: Despite increasing participation rates in youth gymnastics, the majority of epidemiologic literature focuses on older elite athletes or stratifies athletes by level of competition.

Hypothesis: The authors hypothesized that sex- and age-based patterns in youth gymnastics-related injuries exist, which are otherwise overlooked in an unstratified population.

Study Design: Descriptive epidemiology study.

Methods: Publicly available injury data from the National Electronic Injury Surveillance System were collected on pediatric gymnastics injuries presenting to emergency departments in the United States. Participation data from the National Sporting Goods Association were used to calculate national injury incidence rates in 7- to 11-year-olds (childhood) and 12- to 17-year-olds (adolescence) from January 1, 2012, to December 31, 2018. tests were conducted for the comparison of injury rates between girls and boys within each age group and for overall injury rate across age groups.

Results: Girls participated in gymnastics at a frequency 6.5 times that of boys in childhood and 13.5 times that of boys in adolescence. An estimated 72,542 youth gymnastics-related injuries were reported in US emergency departments each year. A large proportion (61.3%) occurred in childhood, with female predominance in both age groups. Overall, there was no difference in weighted annual injury rate (injuries per 100,000 athlete-days per year) by age group (6.9 [childhood] vs 8.8 [adolescence]; = .19) or sex (7.4 [girls] vs 8.1 [boys]; = .65). In adolescence, boys were more likely than girls to experience injury (16.47 vs 8.2; = .003). Wrist and lower arm fractures were more common in childhood than adolescence (1.07 vs 0.43; = .002) and specifically in girls (childhood vs adolescence, 1.06 vs 0.37; = .001). Ankle injuries and concussions were more common in adolescence vs childhood ( = .01 and .0002).

Conclusion: Upper extremity injuries predominated among childhood gymnasts, particularly girls. In adolescence, girls and boys experienced increases in concussions and foot and ankle injuries. Although representing a lower overall number of training gymnasts as compared with girls, adolescent boys experience a higher rate of injuries overall.
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http://dx.doi.org/10.1177/23259671221102478DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9201328PMC
June 2022

Sport Participation and Psychosocial Factors Which Influence Athletic Identity in Youth Athletes With Anterior Cruciate Ligament Injury.

Front Psychol 2022 31;13:906300. Epub 2022 May 31.

Center for Excellence in Sports Medicine, Scottish Rite for Children Orthopedic and Sports Medicine Center, Frisco, TX, United States.

Athletic identity, or the degree with which individuals identify with the athlete role, is an important rehabilitation factor for sports care providers to consider; however, it lacks extensive study in youth. The purpose of this study was to identify demographic, sport participation, and psychosocial measures which correlate with youth athletic identity after anterior cruciate ligament injury. Participants completed standardized sports medicine intake and patient-reported outcome measures, including the Athletic Identity Measurement Scale (AIMS). A total of 226 participants were included, and two groups were created based on high or low total AIMS score. Results indicated that sex ( = ), years active in sport ( = ), activity level ( = ), and ACSI-Coachability ( = ) differed by AIMS score. While youth athletes appear resilient, these results emphasize that they identify strongly with the athlete role and may suffer psychosocial consequences after injury. Future work should evaluate similar factors over course of recovery in a larger, diversified population.
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http://dx.doi.org/10.3389/fpsyg.2022.906300DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9197472PMC
May 2022

Is Nonoperative Treatment Appropriate for All Patients With Type 1 Tibial Spine Fractures? A Multicenter Study of the Tibial Spine Research Interest Group.

Orthop J Sports Med 2022 Jun 3;10(6):23259671221099572. Epub 2022 Jun 3.

Investigation performed at University Hospitals Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA.

Background: Type 1 tibial spine fractures are nondisplaced or ≤2 mm-displaced fractures of the tibial eminence and anterior cruciate ligament (ACL) insertion that are traditionally managed nonoperatively with immobilization.

Hypothesis: Type 1 fractures do not carry a significant risk of associated injuries and therefore do not require advanced imaging or additional interventions aside from immobilization.

Study Design: Case series; Level of evidence, 4.

Methods: We reviewed 52 patients who were classified by their treating institution with type 1 tibial spine fractures. Patients aged ≤18 years with pretreatment plain radiographs and ≤ 1 year of follow-up were included. Pretreatment imaging was reviewed by 4 authors to assess classification agreement among the treating institutions. Patients were categorized into 2 groups to ensure that outcomes represented classic type 1 fracture patterns. Any patient with universal agreement among the 4 authors that the fracture did not appear consistent with a type 1 classification were assigned to the type 1+ (T1+) group; all other patients were assigned to the true type 1 (TT1) group. We evaluated the rates of pretreatment imaging, concomitant injuries, and need for operative interventions as well as treatment outcomes overall and for each group independently.

Results: A total of 48 patients met inclusion criteria; 40 were in the TT1 group, while 8 were in the T1+ group, indicating less than universal agreement in the classification of these fractures. Overall, 12 (25%) underwent surgical treatment, and 12 (25%) had concomitant injuries. Also, 8 patients required additional surgical management including ACL reconstruction (n = 4), lateral meniscal repair (n = 2), lateral meniscectomy (n = 1), freeing an incarcerated medial meniscus (n = 1), and medial meniscectomy (n = 1).

Conclusion: The classification of type 1 fractures can be challenging. Contrary to prior thought, a substantial number of patients with these fractures (>20%) were found to have concomitant injuries. Overall, surgical management was performed in 25% of patients in our cohort.
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http://dx.doi.org/10.1177/23259671221099572DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9168882PMC
June 2022

Treatment Variability and Complications Associated With Pediatric Lateral Ankle Injuries: A POSNA Quality, Safety, and Value Initiative Survey.

Orthop J Sports Med 2022 Jun 1;10(6):23259671221100223. Epub 2022 Jun 1.

Scottish Rite for Children, Dallas, Texas, USA.

Background: Isolated pediatric lateral ankle injuries, including ankle sprain (AS) and nondisplaced Salter-Harris type 1 (SH-1) distal fibular fracture, are common orthopaedic sports-related injuries. Variability in treatment is suspected among pediatric orthopaedic surgeons. Complications from medical treatment or lack thereof have not been reported in this population.

Purpose: The purpose of this study was to investigate treatment variability and associated complications after pediatric AS and SH-1 via a survey of members of the Pediatric Orthopaedic Society of North American (POSNA).

Study Design: Cross-sectional study. Level of evidence, 5.

Methods: A voluntary, anonymous survey was distributed to POSNA membership (approximately 1400 members) via email. Survey questions, specific to both grade 1 or 2 AS and nondisplaced or minimally displaced SH-1 injuries in skeletally immature patients, focused on initial evaluation, immobilization, return to sports, and complications. We analyzed variability both in treatment between AS and SH-1 injury and in respondent characteristics. For statistical analysis, chi-square or Fisher exact test was used for categorical variables, and analysis of variance was used for continuous variables.

Results: The survey response rate was 16.4% (229/1400). Of the respondents, 27.7% used examination only to distinguish between AS and SH-1, whereas 18.7% performed serial radiography to aid with diagnosis. A controlled ankle motion boot or walking boot was the most common immobilization technique for both AS (46.3%) and SH-1 (55.6%); the second most common technique was bracing in AS (33.5%) and casting in SH-1 (34.7%). Approximately one-third of all respondents recommended either outpatient or home physical therapy for AS, whereas only 11.4% recommended physical therapy for SH-1 ( < .01). Results showed that 81.2% of respondents reported no complications for SH-1 treatment and 87.8% reported no complications for AS treatment. Cast complications were reported by 9.6% for SH-1 and 5.2% for AS. Rare SH-1 complications included distal fibular growth arrest, infection, nonunion, late fracture displacement, and recurrent fracture.

Conclusion: Significant variability was found in primary treatment of pediatric AS and SH-1 injuries. Rare complications from injury, treatment, and neglected treatment after SH-1 and AS were reported.
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http://dx.doi.org/10.1177/23259671221100223DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9163735PMC
June 2022

What Are the Causes and Consequences of Delayed Surgery for Pediatric Tibial Spine Fractures? A Multicenter Study.

Orthop J Sports Med 2022 Mar 7;10(3):23259671221078333. Epub 2022 Mar 7.

All authors are listed in the Authors section at the end of this article.

Background: The uncommon nature of tibial spine fractures (TSFs) may result in delayed diagnosis and treatment. The outcomes of delayed surgery are unknown.

Purpose: To evaluate risk factors for, and outcomes of, delayed surgical treatment of pediatric TSFs.

Study Design: Cohort study; Level of evidence, 3.

Methods: The authors performed a retrospective cohort study of TSFs treated surgically at 10 institutions between 2000 and 2019. Patient characteristics and preoperative data were collected, as were intraoperative information and postoperative complications. Surgery ≥21 days after injury was considered delayed based on visualized trends in the data. Univariate analysis was followed by purposeful entry multivariate regression to adjust for confounders.

Results: A total of 368 patients (mean age, 11.7 ± 2.9 years) were included, 21.2% of whom underwent surgery ≥21 days after injury. Patients who experienced delayed surgery had 3.8 times higher odds of being diagnosed with a TSF at ≥1 weeks after injury (95% CI, 1.1-14.3; = .04), 2.1 times higher odds of having seen multiple clinicians before the treating surgeon (95% CI, 1.1-4.1; = .03), 5.8 times higher odds of having magnetic resonance imaging (MRI) ≥1 weeks after injury (95% CI, 1.6-20.8; < .007), and were 2.2 times more likely to have public insurance (95% CI, 1.3-3.9; = .005). Meniscal injuries were encountered intraoperatively in 42.3% of patients with delayed surgery versus 21.0% of patients treated without delay ( < .001), resulting in 2.8 times higher odds in multivariate analysis (95% CI, 1.6-5.0; < .001). Delayed surgery was also a risk factor for procedure duration >2.5 hours (odds ratio, 3.3; 95% CI, 1.4-7.9; = .006). Patients who experienced delayed surgery and also had an operation >2.5 hours had 3.7 times higher odds of developing arthrofibrosis (95% CI, 1.1-12.5; = .03).

Conclusion: Patients who underwent delayed surgery for TSFs were found to have a higher rate of concomitant meniscal injury, longer procedure duration, and more postoperative arthrofibrosis when the surgery length was >2.5 hours. Those who experienced delays in diagnosis or MRI, saw multiple clinicians, and had public insurance were more likely to have a delay to surgery.
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http://dx.doi.org/10.1177/23259671221078333DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8905066PMC
March 2022

Osteochondral Allograft for Unsalvageable Osteochondritis Dissecans in the Skeletally Immature Knee.

Orthop J Sports Med 2022 Feb 11;10(2):23259671211072515. Epub 2022 Feb 11.

University of Texas Southwestern Medical Center, Dallas, Texas, USA.

Background: While an excellent option for osteochondral defects in the adult knee, fresh osteochondral allograft (FOCA) in the skeletally immature adolescent knee has been infrequently studied.

Purpose: To compare radiographic and patient-reported outcomes (PROs) in skeletally mature and immature adolescents after FOCA in the knee for treatment of unsalvageable osteochondritis dissecans (OCD).

Study Design: Cohort study; Level of evidence, 3.

Methods: Included were 34 patients (37 knees) who underwent size-matched FOCA of the knee for unsalvageable OCD lesions. All patients were aged ≤19 years and had a minimum of 12 months of follow-up. Patient characteristics, lesion characteristics, reoperations, and PROs were evaluated and compared between patients with open physes (skeletally immature; n = 20) and those with closed physes (skeletally mature; n = 17). Graft failure was defined as the need for revision osteochondral grafting. Postoperative radiographs were analyzed at 1 year and the final follow-up for graft incorporation and classified as A (complete), B (≥50% healed), or C (<50% healed).

Results: The mean patient age was 15.4 years (range, 9.6-17.6 years), and the mean follow-up was 2.1 years (range, 1-5.3 years). The mean graft size was 5.0 cm and did not differ significantly between the study groups. Patients with open physes were younger (14.7 vs 16.2 years; = .002) and more commonly male (80% vs 35%; = .008). At the 1-year follow-up, 85% of immature patients and 82% of mature patients had radiographic healing grades of A or B. Patients with open physes were more likely to achieve complete radiographic union at 1 year (65% vs 15%; = .007) and demonstrated better Knee injury and Osteoarthritis Outcome Score (KOOS) Daily Living (96.8 vs 88.5; = .04) and KOOS Quality of Life (87.0 vs 56.8; = .01) at the final follow-up. Complications were no different in either group, and graft failure occurred in only 1 skeletally mature patient with a trochlear lesion.

Conclusion: FOCA treatment for unsalvageable OCD in the young knee may be expected to yield excellent early results. Despite the presence of open physes and immature epiphyseal osteochondral anatomy, equivalent or improved healing and PRO scores compared with those of skeletally mature patients may be expected.
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http://dx.doi.org/10.1177/23259671211072515DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8844736PMC
February 2022

Youth athletes sleep more, practice less, and may lose interest in playing sports due to social distancing mandates.

Prev Med Rep 2022 Apr 2;26:101722. Epub 2022 Feb 2.

Scottish Rite for Children, Center for Excellence in Sports Medicine, 2222 Welborn St, Dallas, TX 75219, USA.

In-person sport participation was suspended across the United States in the spring of 2020 to slow the spread of the novel coronavirus (COVID-19). The purpose of this study was to survey the impact of COVID-19 on young athletes during a period of social and organized sports restrictions. An anonymous cross-sectional survey study was conducted of youth athletes in the midst of social distancing mandates and consisted of six components: demographics, sport participation, changes in sport-related goals/aspirations, sleep habits, and measures of anxiety and depression. 711 individuals who accessed the survey link yielded 575 (81%) participants with responses available for analysis. All respondents (aged 13.0 years) played organized sports, 62% were single-sport athletes, and 74% considered high-level. Participants were training ∼3.3 h less per week, spending more time outside, and 86% of participants continued to train while social distancing. Sleep duration increased (∼1.2 h/night) and sleep quality improved in 29% of young athletes. Additionally, 22% and 28% reported PROMIS® anxiety and depression scores characterized as 'mild', 'moderate', or 'severe'. Older single-sport participants reported higher depression scores, while higher anxiety scores were seen in female participants with fewer years played. 10% of young athletes and 20% of teenagers changed their sports-related goals. Training style modifications, decreased training, and increased sleep quantity and quality were positive effects of COVID-19 restrictions, while athletic aspirational changes were undesirable effects. Single-sport athletes may be at greater risk for psychological symptoms when their routine is altered.
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http://dx.doi.org/10.1016/j.pmedr.2022.101722DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8811421PMC
April 2022

Epidemiology of Pediatric Basketball Injuries Presenting to Emergency Departments: Sex- and Age-Based Patterns.

Orthop J Sports Med 2022 Jan 17;10(1):23259671211066503. Epub 2022 Jan 17.

Scottish Rite for Children, Dallas, Texas, USA.

Background: There is limited epidemiologic data on pediatric basketball injuries and the comparison of these injuries before and after adolescence and between male and female athletes.

Purpose: To assess common sex- and age-based injury patterns in pediatric basketball players.

Study Design: Descriptive epidemiology study.

Methods: Injury data from the National Electronic Injury Surveillance System (NEISS) and participation data from the National Sporting Goods Association were used to complete this study. Data on pediatric basketball injuries between January 2012 and December 2018 in patients aged 7 to 11 years (childhood) and 12 to 17 years (adolescence) were extracted and used to calculate national injury incidence rates with 95% CIs. Sex and age group patterns were examined utilizing Pearson chi-square tests. tests were conducted for the comparison of injury rates between female and male athletes in each age group and overall injury rate across age groups.

Results: An average of 9582 basketball injuries were reported annually in the NEISS, which calculated to an annual national estimate of 294,920 injuries. The most common diagnoses were ankle strain/sprain (17.7%), finger strain/sprain/fracture (12.1%), concussion/head injury (9.4%), knee strain/sprain (4.5%), and facial laceration (3.3%). There was a significant increase in injury prevalence in adolescents (12- to 17-year-old category: 238,678 injuries per year) when compared with childhood (7- to 11-year-old category: 56,242 injuries per year) ( < .0001). Concussions/head injuries occurred at a high rate in childhood, second only to finger strain/sprain/fracture, and at a similar rate in females and males (injuries per 100,000 athlete-days: 4.9 [95% CI, 3.1-6.7] vs. 5.9 [4.3-7.5], respectively; = .41). From childhood to adolescence, injury prevalence increased for all areas and across both sexes, except for female finger strain/sprain/fracture; however, the rate of increase for concussion/head injuries and knee injuries was significantly higher in female compared with male athletes ( < .0001 for both). In adolescents, ankle injuries were the most common injury overall.

Conclusion: Ankle injuries continue to be the most predominant pediatric basketball injury. However, disproportionate rates of both knee and concussion/head injuries in female athletes during adolescent basketball are of concern and have implications for injury prevention.
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http://dx.doi.org/10.1177/23259671211066503DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8777358PMC
January 2022

A Multicenter Comparison of Open Versus Arthroscopic Fixation for Pediatric Tibial Spine Fractures.

J Pediatr Orthop 2022 Apr;42(4):195-200

Case Western Reserve University.

Background: 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.

Methods: 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.

Results: 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.

Conclusion: 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 Of Evidence: Level III.
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http://dx.doi.org/10.1097/BPO.0000000000002049DOI Listing
April 2022

Descriptive Epidemiology From the Research in Osteochondritis Dissecans of the Knee (ROCK) Prospective Cohort.

Am J Sports Med 2022 01 24;50(1):118-127. Epub 2021 Nov 24.

The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.

Background: Osteochondritis dissecans (OCD) occurs most commonly in the knees of young individuals. This condition is known to cause pain and discomfort in the knee and can lead to disability and early knee osteoarthritis. The cause is not well understood, and treatment plans are not well delineated. The Research in Osteochondritis Dissecans of the Knee (ROCK) group established a multicenter, prospective cohort to better understand this disease.

Purpose: To provide a baseline report of the ROCK multicenter prospective cohort and present a descriptive analysis of baseline data for patient characteristics, lesion characteristics, and clinical findings of the first 1000 cases enrolled into the prospective cohort.

Study Design: Cross-sectional study; Level of evidence, 3.

Methods: Patients were recruited from centers throughout the United States. Baseline data were obtained for patient characteristics, sports participation, patient-reported measures of functional capabilities and limitations, physical examination, diagnostic imaging results, and initial treatment plan. Descriptive statistics were completed for all outcomes of interest.

Results: As of November 2020, a total of 27 orthopaedic surgeons from 17 institutions had enrolled 1004 knees with OCD, representing 903 patients (68.9% males; median age, 13.1 years; range, 6.3-25.4 years), into the prospective cohort. Lesions were located on the medial femoral condyle (66.2%), lateral femoral condyle (18.1%), trochlea (9.5%), patella (6.0%), and tibial plateau (0.2%). Most cases involved multisport athletes (68.1%), with the most common primary sport being basketball for males (27.3% of cases) and soccer for females (27.6% of cases). The median Pediatric International Knee Documentation Committee (Pedi-IKCD) score was 59.9 (IQR, 45.6-73.9), and the median Pediatric Functional Activity Brief Scale (Pedi-FABS) score was 21.0 (IQR, 5.0-28.0). Initial treatments were surgical intervention (55.4%) and activity restriction (44.0%). When surgery was performed, surgeons deemed the lesion to be stable at intraoperative assessment in 48.1% of cases.

Conclusion: The multicenter ROCK group has been able to enroll the largest knee OCD cohort to date. This information is being used to further understand the pathology of OCD, including its cause, associated comorbidities, and initial presentation and symptoms. The cohort having been established is now being followed longitudinally to better define and elucidate the best treatment algorithms based on these presenting signs and symptoms.
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http://dx.doi.org/10.1177/03635465211057103DOI Listing
January 2022

Patellar instability: will my patella dislocate again?

Curr Opin Pediatr 2022 02;34(1):76-81

Divison of Pediatric Orthopedic Surgery, Hospital for Special Surgery, New York, New York.

Purpose Of Review: The incidence of patellar instability in pediatric patients ranges is 50-100 in 100,000 patients per year. Risk of recurrent dislocations however has been cited from 8.6% to 88% depending on individual patient factors. This manuscript highlights the demographical, historical, and anatomic factors associated with recurrent patellar instability following a first-time patella dislocation in the pediatric population.

Recent Findings: In recent years, various studies have focused on identifying risk factors for recurrent patellar instability following a primary patellar dislocation. A mix of patient factors, including age of first dislocation, patella alta, elevated tibial tubercle to trochlear groove and trochlear dysplasia have all been noted in the literature, which have helped to develop various scoring tools to predict recurrent dislocation following nonoperative treatment.

Summary: Risk of recurrent patellar instability in patients who have previously suffered a patellar dislocation can be due to many factors. These risk factors should be used and applied to a variety of risk scores in order to provide physicians and healthcare providers with a tool to counsel patients and families on their patellar redislocation risk and help guide further management.
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http://dx.doi.org/10.1097/MOP.0000000000001080DOI Listing
February 2022

Does Insurance Status Affect Treatment of Children With Tibial Spine Fractures?

Am J Sports Med 2021 12 15;49(14):3842-3849. Epub 2021 Oct 15.

Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago Illinois, USA.

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; ≥ .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; = .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; = .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; = .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; < .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.
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http://dx.doi.org/10.1177/03635465211046928DOI Listing
December 2021

Comparison of Weightbearing and Nonweightbearing Juvenile Osteochondritis Dissecans Lesions of the Lateral Femoral Condyle.

Orthop J Sports Med 2021 Aug 11;9(8):23259671211026901. Epub 2021 Aug 11.

Department of Sports Medicine, Scottish Rite for Children, Dallas, Texas, USA.

Background: Repetitive microtrauma may contribute to osteochondritis dissecans (OCD) lesions of the femoral condyle. The effect of differential loading between OCD weightbearing (WB) zones has not been studied.

Purpose: To determine whether clinical and radiographic variables differ by WB zone in lateral femoral condyle OCD lesions.

Study Design: Cohort study; Level of evidence, 3.

Methods: We retrospectively reviewed a consecutive series of patients aged <18 years with lateral femoral condyle OCD lesions presenting at a single institution between 2004 and 2018. Patients with OCD lesions outside of the lateral femoral condyle were excluded. Lesions were localized on radiographs using the Cahill and Berg classification, referencing the Blumensaat line and an extension of the posterior femoral cortex. Progeny bone characteristics evaluated at baseline and 24-month follow-up included ossification, distinct borders from parent bone, and displacement. Baseline lesion dimensions were measured on magnetic resonance imaging (MRI) scans. We evaluated posttreatment pain level, return-to-activity rate, and patient-reported outcome measures (PROMs) including the Pediatric International Knee Documentation Committee score, Knee injury and Osteoarthritis Outcome Score, and Pediatric Functional Activity Brief Scale.

Results: A total of 62 lateral femoral condyle OCD lesions (mean follow-up, 24.1 months) presented within the study period: 26 WB lesions and 36 nonweightbearing (NWB) lesions. At presentation, no differences between the lesion types were observed in symptom chronicity or symptomatology. NWB lesions were deeper on MRI scans (sagittal depth, 7.11 vs 5.96 mm; = .046; coronal depth ratio, 0.05 vs 0.01 mm; = .003), were more likely to develop progeny bone (69.4% vs 44%; = .047), and demonstrated higher radiographic healing rates (52.8% vs 24%; = .025) compared with WB lesions. PROMs at follow-up were available for 25 of 62 patients (40.3%), with no statistically significant differences between cohorts at any time. Return to full activity was observed in 72% of WB and 82.1% of NWB lesions ( = .378).

Conclusion: Lateral femoral condyle OCD lesions of the knee in WB and NWB zones presented similarly at initial evaluation; however, NWB lesions demonstrated higher rates of progeny bone formation and radiographic healing at mean 2-year follow-up.
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http://dx.doi.org/10.1177/23259671211026901DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8361527PMC
August 2021

Continued play following adolescent sport-related concussion: Prospective data from the North Texas Concussion Registry (ConTex).

Appl Neuropsychol Child 2021 Aug 15:1-12. Epub 2021 Aug 15.

Department of Sports Medicine, Scottish Rite for Children, Frisco, TX, USA.

Our study aims were to identify the frequency of continued play following sport-related concussion (SRC), defined as continuing athletic activity on the same day following a suspected SRC, characteristics associated with continued play, and whether continued play was associated with worse outcomes. A prospective study of participants ages 13-18 years diagnosed with SRC at a pediatric sports medicine clinic over a 4-year period was conducted. A comparison was performed between athletes who reported continued play following SRC (PLAY) and those who did not (NO PLAY). Of 441 participants, 231 (52.4%) were in the PLAY group. The PLAY group recalled less severe balance problems from the day of injury ( = 0.02), but reported greater symptoms of trouble falling asleep, concentrating, and remembering at their initial clinic visit ( < 0.05). There was no difference in recovery time between groups. Greater symptom severity score at the initial clinic visit and longer time to presentation were associated with prolonged recovery in both groups ( < 0.01). In conclusion, more than half of the athletes in this sample continued to play on the same day following SRC. Our results indicate the need for a heightened focus on education and additional efforts to reduce continued play following SRC in adolescents.
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http://dx.doi.org/10.1080/21622965.2021.1957677DOI Listing
August 2021

Failure Rates of Autograft and Allograft ACL Reconstruction in Patients 19 Years of Age and Younger: A Systematic Review and Meta-Analysis.

JB JS Open Access 2020 Oct-Dec;5(4). Epub 2020 Dec 30.

Texas Scottish Rite Hospital for Children, University of Texas Southwestern, Dallas, Texas.

Background: Graft choice for pediatric anterior cruciate ligament reconstruction (ACLR) is determined by several factors. There is limited information on the use and outcomes of allograft ACLR in pediatric patients. The purpose of this systematic review and meta-analysis was to quantify reported failure rates of allograft versus autograft ACLR in patients ≤19 years of age with ≥2 years of follow-up. We hypothesized that there would be higher rates of failure for allograft compared with autograft ACLR in this population.

Methods: PubMed/MEDLINE and Embase databases were systematically searched for literature regarding allograft and autograft ACLR in pediatric/adolescent patients. Articles were included if they described a cohort of patients with average age of ≤19 years, had a minimum of 2 years of follow-up, described graft failure as an outcome, and had a Level of Evidence grade of I to III. Qualitative review and quantitative meta-analysis were performed to compare graft failure rates. A random-effects model was created to compare failure events in patients receiving allograft versus autograft in a pairwise fashion. Data analysis was completed using RevMan 5.3 software (The Cochrane Collaboration).

Results: The database search identified 1,604 studies; 203 full-text articles were assessed for eligibility. Fourteen studies met the inclusion criteria for qualitative review; 5 studies were included for quantitative meta-analysis. Bone-patellar tendon-bone (BTB) represented 58.2% (n = 1,012) of the autografts, and hamstring grafts represented 41.8% (n = 727). Hybrid allografts (autograft + supplemental allograft) represented 12.8% (n = 18) of all allograft ACLRs (n = 141). The unweighted, pooled failure rate for each graft type was 8.5% for BTB, 16.6% for hamstring, and 25.5% for allograft. Allografts were significantly more likely than autografts to result in graft failure (odds ratio, 3.87; 95% confidence interval, 2.24 to 6.69).

Conclusions: Allograft ACLR in pediatric and adolescent patients should be used judiciously, as existing studies revealed a significantly higher failure rate for allograft compared with autograft ACLR in this patient population. Additional studies are needed to improve the understanding of variables associated with the high ACLR failure rate among pediatric and adolescent patients.

Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.2106/JBJS.OA.20.00106DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8312832PMC
December 2020

Coronal and Transverse Malalignment in Pediatric Patellofemoral Instability.

J Clin Med 2021 Jul 8;10(14). Epub 2021 Jul 8.

Scottish Rite for Children, Dallas, TX 75219, USA.

Patellofemoral instability (PFI) encompasses symptomatic patellar instability, patella subluxations, and frank dislocations. Previous studies have estimated the incidence of acute patellar dislocation at 43 per 100,000 children younger than age 16 years. The medial patellofemoral ligament (MPFL) complex is a static soft tissue constraint that stabilizes the patellofemoral joint serving as a checkrein to prevent lateral displacement. The causes of PFI are multifactorial and not attributed solely to anatomic features within the knee joint proper. Specific anatomic features to consider include patella alta, increased tibial tubercle-trochlear groove distance, genu valgum, external tibial torsion, femoral anteversion, and ligamentous laxity. The purpose of this paper is to provide a review of the evaluation of PFI in the pediatric and adolescent patient with a specific focus on the contributions of coronal and transverse plane deformities. Moreover, a framework will be provided for the incorporation of bony procedures to address these issues.
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http://dx.doi.org/10.3390/jcm10143035DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8307206PMC
July 2021

Elbow Overuse Injuries in Pediatric Female Gymnastic Athletes: Comparative Findings and Outcomes in Radial Head Stress Fractures and Capitellar Osteochondritis Dissecans.

J Bone Joint Surg Am 2021 09;103(18):1675-1684

Texas Scottish Rite Hospital for Children, Dallas, Texas.

Background: Radial head stress fractures (RHSFs) and capitellar osteochondritis dissecans (COCD) are rare but may be seen in gymnasts. The purpose of this study was to compare the clinical and radiographic characteristics and the outcomes of RHSF and COCD in pediatric and adolescent gymnastic athletes.

Methods: Classical gymnasts and competitive tumblers ≤18 years of age presenting with RHSF or COCD over a 5-year period were reviewed. Radiographic characteristics, clinical characteristics, and patient-reported outcomes were compared.

Results: Fifty-eight elbows (39 with COCD and 19 with RHSF) were studied; the mean patient age was 11.6 years. Gymnastic athletes with RHSF competed at a higher level; of the athletes who competed at level ≥7, the rate was 95% of elbows in the RHSF group and 67% of elbows in the COCD group. The RHSF group presented more acutely with more valgus stress pain than those with COCD (p < 0.01) and demonstrated increased mean valgus angulation (and standard deviation) of the radial neck-shaft angle (13° ± 3.8° for the RHSF group and 9.3° ± 2.8° for the COCD group; p < 0.01) and decreased mean proximal radial epiphyseal height (3.7 ± 0.6 mm for the RHSF group and 4.2 ± 1.5 mm for the COCD group; p < 0.01). At a minimum of 2 years (range, 2.0 to 6.3 years), the RHSF group reported fewer symptoms; the QuickDASH (abbreviated version of the Disabilities of the Arm, Shoulder and Hand questionnaire) score was 1.75 ± 3.84 points for the RHSF group and 7.45 ± 7.54 points for the COCD group (p < 0.01). Those at a high level (≥7) were more likely to return to gymnastics independent of pathology, with the RHSF group reporting higher final activity levels with the mean Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS) score at 26.0 ± 7.5 points compared with the COCD group at 23.6 ± 5.7 points (p < 0.05). Of the 9 patients with bilateral COCD, only 3 (33%) returned to gymnastics.

Conclusions: RHSF with features similar to the more familiar COCD lesion may present in gymnastic athletes. Those with RHSF may present more acutely with a high competitive level and may have a better prognosis for return to competitive gymnastics than those with COCD.

Level Of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.2106/JBJS.20.01863DOI Listing
September 2021

Changes in superior displacement, angulation, and shortening in the early phase of healing for completely displaced midshaft clavicle fractures in adolescents: results from a prospective, multicenter study.

J Shoulder Elbow Surg 2021 Dec 2;30(12):2729-2737. Epub 2021 Jun 2.

Washington University Orthopedics, St. Louis, MO, USA.

Background: Progressive displacement of diaphyseal clavicle fractures has been observed in adult patients, at times necessitating a change from nonoperative to operative treatment. Whether this occurs in adolescent patients has not been well investigated. The purpose of this study was to assess the rate and extent of progressive clavicle fracture displacement in adolescent patients following injury and during the early stages of healing.

Methods: This was a multicenter study evaluating prospective data that had previously been collected as part of a larger study evaluating the functional outcomes of adolescent clavicle fractures. A consecutive series of completely displaced diaphyseal clavicle fractures in patients aged 10-18 years treated at 1 of 3 tertiary-care pediatric trauma centers was included; all fractures underwent standardized imaging within 2 weeks of the date of injury and during the course of healing (5-20 weeks after injury). Measurements of clavicle shortening, superior displacement, and angulation were performed using validated techniques. Progressive displacement and/or interval improvement in fracture alignment, as well as the subsequent need for surgical intervention, was noted. Patient demographic and radiographic parameters were assessed as possible risk factors for interval displacement.

Results: One hundred patients met the inclusion criteria. Mean end-to-end shortening, cortex-to-cortex shortening, superior displacement, and angulation at the time of injury were 24 mm, 15 mm, 15 mm, and 7°, respectively. At a mean of 10 weeks after injury, the fracture alignment improved across all 4 measurements for the overall cohort, with mean improvements of 3.5 mm in end-to-end shortening, 3.3 mm in cortex-to-cortex shortening, 2.1 mm in superior displacement, and 2° in angulation. By use of a clinical threshold of a change in shortening or displacement of 10 mm or change in angulation of 10°, 26% of fractures improved, 4% worsened, and 70% remain unchanged. Patients with more severe fractures were more likely to have improved alignment than were patients with less displaced fractures (P < .001). No patient underwent surgical intervention for progressive displacement.

Conclusion: Significant early improvements in fracture alignment were observed in a substantial percentage of adolescent patients with completely displaced clavicle fractures. Among the most severely displaced fractures, shortening improved approximately 6 mm and angulation improved approximately 9°. In 4% of cases, increased displacement was observed, but this tended to be mild, and in no cases did it prompt surgical intervention. This finding indicates that the true final deformity after an adolescent clavicle fracture is commonly less than that present at the time of injury.
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http://dx.doi.org/10.1016/j.jse.2021.05.006DOI Listing
December 2021

Changes in Pediatric Sports Injury Presentation During the COVID-19 Pandemic: A Multicenter Analysis.

Orthop J Sports Med 2021 Apr 28;9(4):23259671211010826. Epub 2021 Apr 28.

The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.

Background: The current coronavirus 2019 (COVID-19) pandemic has prompted a multitude of public health response measures including social distancing, school cancellations, and cessation of organized sports.

Purpose: To examine the impact of COVID-19 and corresponding public health measures on the characteristics of common pediatric musculoskeletal injuries associated with sports.

Study Design: Cohort study; Level of evidence, 3.

Methods: This was a multicenter retrospective cohort study comparing patients with sports injuries presenting to 3 geographically diverse level I pediatric trauma hospitals and outpatient orthopaedic surgery clinics in the United States during the COVID-19 pandemic and a prepandemic period at the same institutions. Patients were included if they presented for care between February 15 and July 15 in 2020 (pandemic cohort) or between March 15 and April 15 in 2018 and 2019 (prepandemic cohort).

Results: Included were 1455 patients with an average age of 12.1 ± 4.5 years. When comparing patients presenting in 2018 and 2019 with those presenting in 2020, we observed a decrease in mean age during the pandemic (12.6 ± 4.0 vs 11.0 ± 5.2 years; = .048). Additionally, a decrease in the proportion of injuries attributed to sports (48.8% vs 33.3%; < .001) and those occurring at school (11.9% vs 4.0%; = .001) was observed. The proportion of injuries attributable to clavicle fractures increased during the early stages of the pandemic (13.2% vs 34.7%; < .001). There was no statistically significant delay to care in injuries presenting during the pandemic (41.5 ± 141.2 vs 19.23 ± 79.1 days; = .175).

Conclusion: Across 3 tertiary care institutions, patients were seen without significant delay during the pandemic. We observed a significant decline in pediatric musculoskeletal injuries associated with sports during the COVID-19 pandemic. This decrease has been accompanied by a shift in both injury type and mechanism.
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http://dx.doi.org/10.1177/23259671211010826DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8107815PMC
April 2021

Reliability of Radiologic Assessments of Clinically Relevant Growth Remaining in Knee MRI of Children and Adolescents With Patellofemoral Instability: Data From the JUPITER Cohort.

Orthop J Sports Med 2021 Apr 13;9(4):2325967121991110. Epub 2021 Apr 13.

Investigation performed at Hospital for Special Surgery, New York, New York, USA and Cincinnati Children's Hospital, Cincinnati, Ohio, USA.

Background: Surgical decision making and preoperative planning for children and adolescents with patellofemoral instability rely heavily on a patient's skeletal maturity. To be clinically useful, radiologic assessments of skeletal maturity must demonstrate acceptable interrater reliability and accuracy.

Purpose: The purpose of this study was to examine the interrater reliability among surgeons of varying experience levels and specialty training backgrounds when evaluating the skeletal maturity of the distal femur and proximal tibia of children and adolescents with patellofemoral instability.

Study Design: Cohort study (diagnosis); Level of evidence, 3.

Methods: Six fellowship-trained orthopaedic surgeons (3 pediatric orthopaedic, 2 sports medicine, and 1 with both) who perform a high volume of patellofemoral instability surgery examined 20 blinded knee radiographs and magnetic resonance images in random order. They assessed these images for clinically relevant growth (open physis) or clinically insignificant growth (closing/closed physis) remaining in the distal femoral and proximal tibial physes. Fleiss' kappa was calculated for each measurement. After initial ratings, raters discussed consensus methods to improve reliability and assessed the images again to determine if training and new criteria improved interrater reliability.

Results: Reliability for initial assessments of distal femoral and proximal tibial physeal patency was poor (kappa range, 0.01-0.58). After consensus building, all assessments demonstrated almost-perfect interrater reliability (kappa, 0.99 for all measurements).

Conclusion: Surgical decision making and preoperative planning for children and adolescents with patellofemoral instability rely heavily on radiologic assessment of skeletal maturity. This study found that initial interrater reliability of physeal patency and clinical decision making was unacceptably low. However, with the addition of new criteria, a consensus-building process, and training, these variables became highly reliable.
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http://dx.doi.org/10.1177/2325967121991110DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8047867PMC
April 2021

Reliability of the Cutting Alignment Scoring Tool (CAST) to Assess Trunk and Limb Alignment During a 45-Degree Side-Step Cut.

Int J Sports Phys Ther 2021 Apr 1;16(2):312-321. Epub 2021 Apr 1.

The Micheli Center for Sports Injury Prevention; Waseda University.

Background: Three-dimensional (3D) motion analysis is considered the gold standard for evaluating human movement. However, its clinical utility is limited due to cost, operating expertise, and lengthy data processing time. Numerous qualitative scoring systems have been introduced to assess trunk and lower extremity biomechanics during functional tasks. However, the reliability of qualitative scoring systems to evaluate cutting movements is understudied. Purpose/Hypotheses: To assess the inter-rater and intra-rater reliability of the Cutting Alignment Scoring Tool (CAST) among sports medicine providers and to evaluate rater agreement of each component of the CAST. The hypotheses were: 1) there would be good-to-excellent inter-rater and intra-rater reliability among sports medicine providers, 2) there would be good to almost perfect agreement for cut width and trunk lean variables and moderate to good agreement for valgus variables of the CAST.

Study Design: Repeated Measures.

Methods: Ten videos of a 45-degree side-step cut performed by adolescent athletes were independently rated on two occasions by six raters (2 medical doctors, 2 physical therapists, and 2 athletic trainers). The variables assessed include trunk lean to the opposite direction of the cut, increased cut width, knee valgus at initial load acceptance (static), and knee valgus throughout the task (dynamic). Variables were scored as either present, which were given a score of "1", or not present, which were given a score of "0". Video sequence was randomized in each rating session, and a two-week wash out period was given.

Results: The cumulative inter-rater and intra-rater reliabilities were good (ICC: 0.808 and ICC: 0.753). Almost perfect kappa coefficients were recorded for cut width (k=0.949). Moderate kappa coefficients were found for trunk lean (k= 0.632) and fair kappa coefficients were noted for dynamic and static valgus (k=0.462 and k= 0.533 respectively).

Conclusion: These findings suggest that the CAST is a reliable tool to evaluate trunk and LE alignment during a cutting task by sports medicine providers.

Level Of Evidence: Level 2 Diagnosis.
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http://dx.doi.org/10.26603/001c.21419DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8016420PMC
April 2021

Tractionless Hip Arthroscopy for Septic Arthritis in Children.

Arthrosc Tech 2021 Mar 19;10(3):e659-e667. Epub 2021 Feb 19.

Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A.

Surgical management of septic arthritis in young children is traditionally performed with open techniques, although arthroscopic approaches are commonly used in the knee and shoulder. Hip arthroscopy is technically demanding in small children and requires modification from traditional hip arthroscopy. The purpose of this study is to describe a safe technique to perform hip arthroscopy without traction in the pediatric hip and, secondarily, to report short-term results of a case series. Pediatric hip arthroscopy can be safely performed without traction on a radiolucent table and allows joint irrigation and debridement including drain placement through the use of 1 or 2 portals. Hip arthroscopy is a safe, valuable, minimally invasive technique in the treatment of children with septic arthritis of the hip.
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http://dx.doi.org/10.1016/j.eats.2020.10.079DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7953328PMC
March 2021

Anterior Cruciate Ligament Tear Following Operative Treatment of Pediatric Tibial Eminence Fractures in a Multicenter Cohort.

J Pediatr Orthop 2021 May-Jun 01;41(5):284-289

Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI.

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.
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http://dx.doi.org/10.1097/BPO.0000000000001783DOI Listing
June 2021

A Comparison of Nonoperative and Operative Treatment of Type 2 Tibial Spine Fractures.

Orthop J Sports Med 2021 Jan 22;9(1):2325967120975410. Epub 2021 Jan 22.

Investigation performed at The Johns Hopkins University, Baltimore, Maryland, USA.

Background: Tibial spine fractures (TSFs) are typically treated nonoperatively when nondisplaced and operatively when completely displaced. However, it is unclear whether displaced but hinged (type 2) TSFs should be treated operatively or nonoperatively.

Purpose: To compare operative versus nonoperative treatment of type 2 TSFs in terms of overall complication rate, ligamentous laxity, knee range of motion, and rate of subsequent operation.

Study Design: Cohort study; Level of evidence, 3.

Methods: We reviewed 164 type 2 TSFs in patients aged 6 to 16 years treated between January 1, 2000, and January 31, 2019. Excluded were patients with previous TSFs, anterior cruciate ligament (ACL) injury, femoral or tibial fractures, or grade 2 or 3 injury of the collateral ligaments or posterior cruciate ligament. Patients were placed according to treatment into the operative group (n = 123) or nonoperative group (n = 41). The only patient characteristic that differed between groups was body mass index (22 [nonoperative] vs 20 [operative]; = .02). Duration of follow-up was longer in the operative versus the nonoperative group (11 vs 6.9 months). At final follow-up, 74% of all patients had recorded laxity examinations.

Results: At final follow-up, the nonoperative group had more ACL laxity than did the operative group ( < .01). Groups did not differ significantly in overall complication rate, reoperation rate, or total range of motion (all, > .05). The nonoperative group had a higher rate of subsequent new TSFs and ACL injuries requiring surgery (4.9%) when compared with the operative group (0%; = .01). The operative group had a higher rate of arthrofibrosis (8.9%) than did the nonoperative group (0%; = .047). Reoperation was most common for hardware removal (14%), lysis of adhesions (6.5%), and manipulation under anesthesia (6.5%).

Conclusion: Although complication rates were similar between nonoperatively and operatively treated type 2 TSFs, patients treated nonoperatively had higher rates of residual laxity and subsequent tibial spine and ACL surgery, whereas patients treated operatively had a higher rate of arthrofibrosis. These findings should be considered when treating patients with type 2 TSF.
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http://dx.doi.org/10.1177/2325967120975410DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7841676PMC
January 2021

Complications and Controversies in the Management of 5 Common Pediatric Sports Injuries.

JBJS Rev 2020 12;8(12):e20.00013

Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.

Growing participation in sports among children, along with increasingly intense training regimens, has contributed to an increasing rate of sports-related injuries. Despite the similarities to adult sports injuries, pediatric patients have distinctive injury patterns because of the growing physis and therefore necessitate unique treatment algorithms. Caring for these injured children requires in-depth knowledge of not only pediatric injury patterns, but also the scope of age-specific treatments, the associated complications, and the controversies. When treating motivated pediatric athletes, one must be able to strike a delicate balance between patients' eagerness to return to sport and the need to ensure their long-term health and function. Knowledge of controversies and complications will help both patients and physicians make informed decisions about how best to restore pediatric athletes back to health.
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http://dx.doi.org/10.2106/JBJS.RVW.20.00013DOI Listing
December 2020

The Association of α Angle on Disease Severity in Adolescent Femoroacetabular Impingement.

J Pediatr Orthop 2021 Feb;41(2):88-92

University of Texas Southwestern Medical Center.

Background: Femoroacetabular Impingement (FAI) is a common cause of hip pain in adolescent patients. Clinical exam and radiographic markers, such as α angle and lateral center edge angle (LCEA), are commonly used to aid in the diagnosis of this condition. The purpose of this study was to correlate preoperative α angle and LCEA with preoperative symptoms, intraoperative findings, and preoperative and postoperative patient reported outcomes (PROs) in the adolescent patient.

Methods: A retrospective analysis of prospectively collected data was conducted for all patients who underwent operative intervention for FAI at an academic institution over an 11-year period. Preoperative imaging was obtained and measured for LCEA and α angle. PROs (modified Harris Hip Score, Hip Disability and Osteoarthritis Outcome Score, and UCLA score) were collected preoperatively, as well as 1, 2, and 5 years postoperatively. Operative intervention was either open surgical hip dislocation or arthroscopic, and intraoperative disease was graded using the Beck Classification system. Patients with minimum 1-year follow-up were included in statistical analysis.

Results: There were 86 hips (64 female hips) included with an average age of 16.3 years (range, 10.4 to 20.5 y), with an average of 37 months of follow-up. There was no correlation between severity of preoperative symptoms or difference between pre and postoperative PROs for both α angle and LCEA. Overall, significant improvement was noted in modified Harris Hip Score, Hip Disability and Osteoarthritis Outcome Score, and UCLA Score (P<0.001 for each). Independent of preoperative symptoms, increased α angle correlated with more severe intraoperative labral disease (P<0.001), and longer length of labral tear (Corr 0.295, P<0.01). Femoral head and acetabular articular cartilage damage did not correlate with α angle or LCEA, nor did overall severity of disease.

Conclusions: In adolescent patients with FAI, increased α angle was found to significantly correlate with labral pathology, including increased length of tear and severity of disease, irrespective of preoperative symptoms or postoperative patient reported outcomes.

Level Of Evidence: Level III-retrospective.
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http://dx.doi.org/10.1097/BPO.0000000000001703DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7803481PMC
February 2021
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