Introduction: Osteochondral lesions of the femoral head in young patients are a rare but challenging clinical problem. Fresh osteochondral allograft (OCA) transplantation has been proposed as one potential treatment option that may improve function and delay hip arthroplasty. However, there is a paucity of published data. The purpose of this study was to assess allograft survivorship and patient-reported outcomes in patients undergoing OCA transplantation for osteochondral lesions of the femoral head. Methods: Sixteen patients (16 hips) who underwent femoral head OCA transplantation for the treatment of avascular necrosis between 1985 and 2021 were included. Mean age was 21.0±10.1 years (range: 11.6 to 43.5 y) and 56% were male. Mean allograft diameter was 26.9±4.2 mm (range: 20 to 35 mm) and mean thickness was 10.2±3.2 mm (range: 5 to 15 mm). We evaluated the frequency and type of further surgery, Hip Disability and Osteoarthritis Outcome Score (HOOS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), modified Harris Hip Score (mHHS), and UCLA function score. Clinical failure was defined as conversion to total hip arthroplasty. Results: Six of 16 hips (38%) experienced clinical failure (5 total hip arthroplasties and 1 resurfacing arthroplasty), with a mean time to failure of 3.6±2.6 years (range: 1.0 to 8.5 y). Allograft survivorship for patients under age 18 was 85.7% at 3 years and 42.9% at 5 years compared with patients over age 18 years who experienced a survivorship of 66.7% at 3 and 5 years (P=0.911). Of the remaining 10 hips, the mean follow-up duration was 4.1 years (range: 1.9 to 7.4 y). At the latest follow-up, mean HOOS was 74.5±20.2 (range: 48.6 to 100), mean WOMAC was 79.9±18.2 (range: 56.1 to 100), mean mHHS was 74.9±20.9 (range: 41 to 100.1), and mean UCLA score was 7.0±2.7 (range: 4 to 10). Conclusions: Young patients with large chondral lesions of the femoral head may benefit from fresh OCA transplantation, but failure rates remain quite high for this challenging patient population. OCA can be considered as a useful treatment option that preserves function and delays the need for arthroplasty in young individuals with osteochondral lesions of the femoral head.

Background: Transphyseal anterior cruciate ligament (ACL) reconstruction can be a reliable and safe treatment for skeletally immature patients, with low reported rates of major growth disturbances. However, more subtle knee morphologic and radiologic characteristics, such as the α-angle (sagittal orientation of the notch roof) and posterior tibial slope, may theoretically be affected by this surgical technique and potentially represent risk factors for ACL graft tears. The objective of this study was to compare radiologic knee morphology characteristics between the operated knee and the paired contralateral knee in skeletally immature patients following transphyseal ACL reconstruction. Methods: This is a retrospective matched within-subject case-control study on 25 skeletally immature patients with a radiologic follow-up 9 or more months after a transphyseal anatomic ACL reconstruction. The α-angle, medial posterior tibial slope, mechanical hip-knee-ankle angle, and leg length were assessed with a biplane x-ray imaging system (EOS) with the nonoperative limb used as an internal control. Results: The mean chronological age of the cohort was 11.8 years (range: 8.3 to 15.0). The α-angle was a mean of 3.3 degrees (SD=5.1) smaller, or more vertical, on the surgical knee than on the contralateral knee at a median of 2.1 years [interquartile range (IQR)=0.3 to 4.0], with mean α-angles of 36.6 degrees (SD=6.6 degrees) and 39.9 degrees (SD=5.3), respectively (P=0.002). Other radiologic parameters were not significantly different between sides. A post hoc analysis showed a median side-to-side difference in α-angles of −5.0 (IQR: −7.0 to −1.9) in males versus 0.6 (IQR: −4.3 to 3.8) in females (P=0.009). Conclusion: Transphyseal anatomic single-bundle ACL reconstruction in skeletally immature patients is associated with a relative decrease in α-angle, or verticalization of the notch roof, after a median follow-up of 2 years. A greater impact in α-angle was observed in male patients. Level of Evidence: Level III—prognostic case-control study.

Background: Slipped capital femoral epiphysis (SCFE) is a pediatric hip disorder affecting roughly 1 in 10,000 children and adolescents, with delayed diagnosis and treatment leading to poor outcomes. This study compares the association between presenting hip or knee pain symptomatology and its effects on time to diagnosis and treatment of SCFE, mid- to long-term complications, and risk of requiring hip reconstructive surgeries. Methods: A retrospective cohort study was conducted comparing SCFE presentations with chief complaints of either hip or knee pain that led to SCFE surgery. Propensity score matching adjusting for demographic factors, was performed on these cohorts. Survival analysis was implemented on the matched cohorts to compare time to imaging, primary SCFE surgery, complications, and the need for additional interventions. Results: A total of 724 patients undergoing surgery for SCFE were identified, with either an initial presentation of hip or knee pain. After propensity score matching, 145 patients were included in each group. The average age of patients was 11.5 years old. Children in the knee pain cohort experienced a significantly longer delay of ∼92 days in obtaining hip/pelvis imaging [98.51 vs. 6.79 d, hazard ratio (HR) 1.62, 95% CI: 1.22-2.14; P=0.034] and an average delay of ∼82 days in undergoing surgery from presentation [106.38 vs. 24.34 d; HR 2.39, 95% CI: 1.83-3.14; P<0.0001] compared with the hip cohort. Furthermore, knee pain patients had an increased risk of chondrolysis and osteoarthritis [risk ratio (RR) 1.88, 95% CI: 1.10-3.24; P=0.019] and higher need for hip reconstruction (RR 1.68, 95% CI: 1.002-2.83; P=0.045). Conclusion: This study is the first report attributing increased risks of chondrolysis, osteoarthritis, and need for future hip reconstructive surgeries to the delay in diagnosis among SCFE patients presenting with knee pain. Maintaining a high index of suspicion for SCFE among children presenting with knee pain, particularly among overweight adolescents, is crucial. Level of Evidence: Level III—therapeutic studies—investigating the results of treatment.

Background: The Ponseti method is accepted as an effective primary conservative treatment for idiopathic clubfoot (IC) using serial casting, percutaneous Achilles tenotomy, and prolonged bracing. The outcomes of its use in treating rigid clubfoot in arthrogryposis are unclear. This study assesses the outcomes of the Ponseti method in children with IC and arthrogrypotic clubfoot at an average age of 10 years. Methods: Outcomes of the Ponseti method were retrospectively studied in ambulatory children ages 8.0 to 12.9 years in the gait lab between 2004 and 2024. Children were excluded due to the presence of nonidiopathic or nonarthrogryposis-related clubfoot and history of posteromedial release. The Ponseti treatment included serial casting and Achilles tenotomy in infancy, followed by night bracing until age 5 in both cohorts. Clubfoot groups were compared with typically developing children by analyses of foot pressure data, passive range of motion, Gross Motor Function Measure Dimension-D, and Pediatric Outcomes Data Collection Instrument. Surgical history was also recorded. A subsection of these children visited the gait lab at age 4.0 to 6.9 years (2003 to 2021) and data from their visits were abstracted for a longitudinal study. Results: One hundred seventy-seven children were reviewed (48 with clubfoot associated with arthrogryposis, 129 with IC) with an average age of 9.4±0.9 years. Repeat surgical intervention was used in 33% of IC feet and 44% of arthrogrypotic clubfeet. Residual equinovarus and limitations in range of motion were present in both clubfoot groups compared with typically developing feet (P<0.05). The foot deformity and passive range of motion restrictions were more severe in children with arthrogrypotic clubfeet (P<0.05). The arthrogrypotic clubfoot group additionally exhibited limited gross motor and global function (P<0.001). In 5-year to 10-year comparisons, both subgroups showed more limitations in ankle motion but improvements in dynamic equinovarus deformity and function at age 10 years (P<0.05). Conclusions: Despite residual deformity, children with idiopathic clubfoot achieve typical functional outcomes through Ponseti treatment. Children with arthrogrypotic clubfeet exhibit functional limitations, but the Ponseti method is effective in improving foot position while minimizing the need for surgical intervention. Level of Evidence: Level III—therapeutic studies–investigating the results of treatment.

Background: Septic arthritis of the hip is a pediatric orthopaedic emergency. Joint synovial fluid aspiration is a critical step of diagnosis, which may be delayed due to limited personnel or operating room (OR) availability. To expedite diagnosis, orthopaedic residents perform ultrasound-guided bedside arthrocentesis in the emergency department (ED). This study aims to evaluate the impact of this practice on time to diagnosis and definitive treatment of septic arthritis of the hip and minimizing trips to the operating room. Methods: This is a retrospective study of patients presenting to our pediatric orthopaedic tertiary care emergency room requiring a hip aspiration to rule out septic arthritis between 2003 and 2023. We identified all patients who had resulted hip synovial fluid nucleated cell count during the above time period. Chart review was performed to determine how synovial fluid was collected via interventional radiology (IR), in the OR with an orthopaedic surgeon, or via bedside aspiration with the on-call resident. Clinical outcomes were primarily defined as time points in clinical care. Patient demographics, Kocher criteria values, time to aspiration, and final treatment are presented. Kruskal-Wallis and Fisher exact tests were used to compare demographic and clinical differences in RStudio using a two-sided level of significance of 0.05. Results: Hip aspiration was performed in the workup of septic arthritis in 57 patients (median age 5.1 y; 58% female). Aspiration occurred in the ED for 28 patients, interventional radiology (IR) for 11, and in the OR for 18 patients. Bedside aspiration avoided a trip to the OR for 15 patients (54%). Median time to obtaining joint fluid was significantly shorter for patients undergoing bedside or IR-guided aspiration compared with OR aspiration (7.4 vs. 5.3 vs. 15.7 h, respectively; bedside vs. OR P=0.007, IR vs. OR P=0.013). Time from presentation to OR for open surgical debridement, total operative time, and the percentage of patients requiring open surgical debridement did not significantly differ between groups. Discussion: Bedside aspiration decreases the time to diagnosis of septic arthritis and can prevent ~50% of children from going to the OR. This is beneficial for the patient as it may allow for earlier antibiotic administration, provide pain relief, and avoid possible complications of general anesthesia. Level of Evidence: Level III—retrospective chart review.

Background: The purpose of this study was to compare a cohort of pediatric open distal tibia fractures to open tibial shaft fractures regarding demographics and treatment outcomes. Methods: This is a retrospective review of 39 open distal tibia fractures (D group) and 55 open tibia shaft fractures (S group), treated from January 2007 to May 2017 at a single level 1 pediatric trauma center. Mann-Whitney test was used to compare means between groups. Results: There was no statistically significant difference between the 2 groups regarding demographics, injury mechanism, or injury severity scores. While the D group had nearly 4x times the rate of open reduction internal fixation (ORIF) compared with the S group [15% (6/39) vs. 4% (2/54)] and twice the rate of external fixation [15% (6/39) vs. 7% (4/54)], these were not statistically significant (P>0.05). D group had more Gustilo-Anderson type III open fractures compared with S group [46% (18/39) vs. 26% (14/54), P=0.04], longer mean operative times (2.5 vs. 2.1 h, P=0.04), longer hospitalization (8.7 vs. 6.5 d, P=0.01), and longer time to full weight-bearing (11.4 vs. 7.2 wk, P=0.03). Postoperative complications (delayed union, limb length discrepancy, infection) were similar between the 2 groups, although D group had nearly twice the rate of return to the operating room after index surgery [49% (19/39) vs. 26% (14/54), P=0.03]. Although over twice as many fractures in D group required a free flap compared with S group [18% (7/39) vs. 7% (4/54)], this did not reach statistical significance (P>0.05). Two patients in each group eventually underwent amputation; all patients had Gustilo-Anderson IIIB or IIIC fractures. Radiographic angulation at final follow-up was similar between the 2 groups (P>0.05). Conclusions: This study highlights the challenges in treating open distal tibia fractures compared with open tibial shaft fractures. Families should be counselled on a possibly prolonged treatment course, both inpatient and postoperatively, when patients sustain an open distal tibia fracture. Level of Evidence: Level III—retrospective comparative study.

Background: A subset of patients with flexible pediatric pes planovalgus (PPV) will have recalcitrant symptoms and functional impairment despite maximizing nonoperative methods and seeking surgical care. The primary aim of this study was to compare the clinical course and radiographic improvement including final alignment for patients who underwent the minimally invasive corrective subtalar extra-articular screw arthroereisis (SESA) technique compared with the traditional modified Evans reconstruction (MER) technique for flexible PPV correction. Methods: Forty-five feet in 31 PPV patients aged 10 to 19 years treated at a single institution with (1) SESA +/− Vulpius or accessory navicular or tarsal coalition excision (22 feet) or (2) MER +/− Vulpius (23 feet) from 2010 to 2022 were identified. Patients with no weight-bearing postoperative x-rays were excluded. Comprehensive preoperative and postoperative radiographic measurements were obtained from standing radiographs. Radiographic outcomes were evaluated across treatment groups using noninferiority analysis. Comparisons in clinical characteristics were conducted using mixed-effects regression modeling to account for the correlation between bilateral measurements within the same patient. Results: Surgery was performed at an average age of 13.7 years (SD, 1.9); the cohort was 53% male. There were no differences in age, BMI, or laterality between the SESA and MER cohorts. The SESA cohort had a significantly shorter operative time compared with MER (51 vs. 167 min; P<0.001). One patient in the MER cohort required a return to the operating room for hardware removal in the setting of pseudoarthrosis, and another for a buried pin. Time to weightbearing in the SESA cohort was a median 3 weeks earlier than the MER cohort (P=0.004). The SESA procedure was found to be noninferior to MER with respect to postoperative radiographic alignment as well as in the improvement in alignment from preoperative to postoperative measurement (all P<0.05). Conclusions: For painful pediatric pes planovalgus (PPV), subtalar extra-articular screw arthroereisis (SESA) offers a less invasive approach with noninferior outcomes compared with modified Evans reconstruction (MER). Our study found similar radiographic improvements and deformity correction in adolescents treated with SESA versus MER, along with shorter procedures and earlier weightbearing. No major complications were observed. Long-term follow-up and patient-reported outcome studies are needed, especially postscrew removal. Level of Evidence: Therapeutic case-control study, level III.

Background: Stable slipped capital femoral epiphysis (SCFE) is often considered semi-urgent, prompting admission for in situ screw fixation (ISF), which may increase the cost/burden of care. Avascular necrosis (AVN) affects 25% to 50% of patients with unstable SCFE, yet it is uncommon after stable SCFE. Among patients presenting with stable SCFE, little is known about the relationship between diagnosis and surgical timing with regard to slip progression or complications. Methods: This retrospective observational study included all patients younger than 18 years with stable SCFE at initial diagnosis treated with ISF between 2000 and 2020 at 4 centers. Patients with Loder unstable SCFE at the time of initial SCFE diagnosis were excluded. Timing data included time from (1) symptom onset to diagnosis, (2) symptom onset to surgical team evaluation, (3) symptom onset to surgery, (4) diagnosis to surgical team evaluation, (5) surgical team evaluation to surgery, and (6) diagnosis to surgery. Regression analyses explored relationships between timing and slip progression to unstable, subsequent procedures, and complications as graded by the modified Clavien-Dindo-Sink system. Results: A total of 298 patients with 362 stable SCFEs were included. The mean time from symptom onset to diagnosis was 134 days, from diagnosis to surgical team evaluation was 3.2 days, and from surgical team evaluation to surgery was 2.1 days. The mean follow-up was 2.4 years. Eighteen percent of hips were affected by a complication. Two patients initially diagnosed with stable SCFE progressed to unstable SCFE, having experienced falls after diagnosis and before orthopaedic evaluation; one of these went on to develop AVN. Time elapsed between symptom onset, diagnosis, surgical team evaluation, and surgery was not associated with the incidence or severity of complications or subsequent procedure. Conclusions: The urgency of surgical treatment of stable SCFE does not appear to affect mid-term outcomes. If surgical management of stable SCFE is not performed urgently, it is critical to avoid weight bearing and falls to reduce progression to an unstable SCFE. Level of Evidence: Level III, therapeutic.

Background: Arthroscopic knee procedures such as meniscus and ACL repairs are cornerstone interventions in pediatric and sports orthopaedics. While venous thromboembolism (VTE), including pulmonary embolism (PE) and deep vein thrombosis (DVT), is a rare yet devastating complication in major joint surgeries, its association with minimally invasive procedures remains relatively unexplored. Emerging evidence shows rates of VTE in adolescent orthopaedic patients approaching that of adults, highlighting the need to further characterize the unique risk profile of this population. Therefore, this study aims to compare VTE rates, risk factors, and chemoprophylaxis use in adolescents versus adults undergoing arthroscopic knee procedures. Methods: A retrospective cohort study using the TriNetX Research Network identified 301,585 patients who underwent knee arthroscopy from January 2003 to January 2023, including 29,984 adolescents (aged 14 to 17) and 271,601 adults (aged 18 years or older). Propensity score matching based on sex and relevant comorbidities, including diabetes mellitus, tobacco use, oral contraceptive (OCP) use, and obesity yielded balanced cohorts of 29,984 each. Univariate logistic regression analysis was performed for preliminary assessment of the risk factors associated with VTE. P<0.01 was considered significant. Results: Adults had a higher 90-day incidence of DVT (1.3% vs. 0.8%) and PE (0.3% vs. 0.2%) than adolescents. Combined DVT/PE incidence was 1.5% in adults and 0.8% in adolescents (RR: 1.782). Univariate analysis showed OCP use (OR: 3.167), obesity (OR: 3.445), tobacco use (OR: 23.975), and diabetes (OR: 34.064) were significant VTE risk factors in adolescents; sex was not. Adults more frequently received postoperative chemoprophylaxis (24% vs. 20%, P<0.001), with aspirin being the most common agent (23% in adults vs. 19% in adolescents, P<0.001). Conclusion: Adolescents undergoing knee arthroscopy have a lower risk of VTE compared with adults, with an incidence below 1%. Routine VTE prophylaxis may not be necessary for all adolescents but should be considered for those with significant risk factors, including diabetes, tobacco use, and obesity. Further research is warranted to refine prophylaxis guidelines in this population. Level of Evidence: Level III—retrospective cohort study.

Background: Achondroplasia (ACH) is the most common skeletal dysplasia and is characterized by a short-limbed short stature, sagittal spinal malalignment, and genu varum. Vosoritide promotes longitudinal bone growth in children with ACH; however, its effects on various disease-specific complications, other than short stature, are unknown. This study aimed to investigate the therapeutic effects of vosoritide on spinal and lower limb malalignment in children with ACH. Methods: This single-center, open-label, prospective study included patients with ACH aged younger than or equal to 15 years who received vosoritide treatment and had a minimum follow-up period of 1 year. To evaluate alignment after vosoritide treatment, radiologic parameters were measured from sagittal radiographs of the spine and anteroposterior radiographs of the bilateral lower limbs before the administration of vosoritide and 12 months after treatment. Paired t tests were used to compare parameters before and after vosoritide treatment. Results: Seventeen patients (mean age, 7.6±2.7 y) were included. After 1-year treatment of vosoritide, the mean height increased by 5.4±1.3 cm. Changes in spinal alignment after 1 year of vosoritide treatment were 1.5 degrees for cervical lordosis, −1.3 degrees for thoracic kyphosis, −2.8 degrees for thoracolumbar kyphosis, −5.2 degrees for lumbar lordosis (LL), −2.2 degrees for pelvic tilt, −2.6 degrees for pelvic incidence, −0.4 degrees for sacral slope, and 2.6 mm for C7 sagittal vertical axis. Alignment changes in the lower limbs were −3.4 degrees for mechanical axis angle (MAA), 1.7 degrees for mechanical lateral proximal femoral angle (mLPFA), −2.8 degrees for mechanical lateral distal femoral angle (mLDFA), −0.2 degrees for medial proximal tibial angle, and −0.5 degrees for lateral distal tibial angle. The LL, MAA, mLPFA, and mLDFA levels showed statistically significant changes towards the normal range after treatment. Conclusions: One-year treatment of vosoritide decreased the exaggerated LL and improved genu varum deformity in children with ACH. Vosoritide therapy may not only increase longitudinal bone growth but also improve spinal and lower limb malalignment in children with ACH. Level of Evidence: Level II: prospective comparative study.

Background: Pediatric anterior cruciate ligament reconstruction (ACLR) in skeletally immature patients is still controversially debated, with several gaps in its literature. More information is needed about the role of concomitant meniscal injuries in postoperative outcomes and return to pre-injury sports level (RTS). Methods: Fifty skeletally immature patients who underwent ACLR were enrolled prospectively: 21 had meniscal injury additionally, and 29 did not. Patients were assessed with Tegner, Lysholm, Pedi-IKDC, and subjective knee value (SKV) scores presurgery and 6, 12, and 24 months postoperatively. The primary outcome was RTS at 24 months. Secondary outcomes were the 24-month clinical results and the mapping of prognostic factors to RTS in the meniscal injury group. Logistic regression model to estimate OR [95% CI], t test for parametric and Wilcoxon test for nonparametric variables (comparisons of 2 independent groups) were used, as well as t test or Wilcoxon test for paired data, according to the distribution of differences (postoperative-preoperative, paired groups) were used. Results: Out of 50 patients with a mean age of 13.2 years (range 9 to 16), the meniscal injury group had 67% RTS (12/18), and the isolated ACLR group had 75% RTS (18/24) after 24 months, which was not statistically significant, OR=0.67 [0.17 to 2.60], P=0.6. 24-month Lysholm scores were significantly higher in the isolated ACLR group (medians, 95.5 vs. 100.0, P=0.01). There was no significant difference between the groups of Tegner scores, Pedi-IKDC and SKV. No prognostic factors were found for worse RTS after meniscal injury. Conclusions: There is no difference in RTS 24 months after ACLR with or without meniscal injury in the skeletally immature patient. Level of Evidence: Level of evidence I—prospective, comparative cohort study.

Background: The mechanical environment in the hip in people with residual Legg-Calvé-Perthes disease (LCPD) deformity is still poorly understood. Anterior impingement is thought to contribute to poor long-term outcomes such as early-onset osteoarthritis, but it has not been measured directly using imaging in high flexion. Our objective in this study was to determine the association between radiographic morphologic scores of LCPD deformity and reduced anterior hip clearance. Methods: We measured the anterior clearance (β-angle) of 20 LCPD-affected hips (17 patients) scanned in 4 functional postures using an upright open MRI scanner. Mixed effects models were used to describe the relationship between β, posture, and morphologic measures of deformity (Stulberg classification and Sphericity Deviation Score). Results: Hip β-angle was significantly associated with posture (P<0.001). Aspherical (Stulberg III to V) hips had lower β across all postures compared with spherical (Stulberg I to II) hips (difference in β = −39.1 degrees; 95% CI: −71.9 to −6.2 degrees; P=0.020). An increased SDS was strongly associated with reduced β in neutral hip postures (P=0.002, 0.005, respectively), but not with elevated adduction and internal rotation. Due to morphologic heterogeneity, 6 hips (out of 20 overall) did not fit the overall trend. Conclusions: Our results show an association between more severe radiographic deformity and a greater potential for anterior impingement, a known contributor to cartilage degradation. However, the large proportion of cases where morphologic deformity does not align with functional clearance suggests current radiographic measures of deformity may not be sufficient to predict long-term outcomes in every LCPD patient. Clinical Relevance: (1) Hip joint asphericity in LCPD is associated with less anterior clearance and a greater potential for anterior impingement in high flexion postures. (2) Considering both morphologic and functional parameters may improve our understanding of the causes of pain and early-onset osteoarthritisin LCPD, as opposed to morphology alone.

Background: Early physeal-sparing anterior cruciate ligament reconstruction (ACLR) is considered the optimal treatment method in the skeletally immature population to preserve the integrity of the knee joint while reducing the risk of growth disturbances and angular deformities. Contemporary treatment algorithms recommend the use of all-epiphyseal (AE) or Micheli–Kocher (MK) ACLR techniques in patients with considerable growth remaining. Nevertheless, no research exists comparing the 2 techniques. Therefore, the purpose of this review is to comprehensively compare postoperative outcomes and complication profiles following AE and MK ACLR in skeletally immature patients. Methods: A systematic search of Embase, Medline, and PubMed was conducted from inception to April 30, 2024. All studies reporting outcomes and/or complications following AE or MK ACLR were included. Screening and data abstraction were designed in accordance with PRISMA and R-AMSTAR guidelines. Results: Twenty-nine studies with 1177 patients were included. AE ACLR and MK ACLR yielded similar results for rates of return to preinjury level of activity (91.8% and 93.4%, respectively), negative pivot-shift (93.9% and 95.2%, respectively) and Lachman test grades (93.9% and 90.8%, respectively), IKDC subjective scores (94.0 and 93.6, respectively), ROM flexion (144.1 degrees and 136.3 degrees, respectively) and hyperextension (2.5 degrees and 3.1 degrees, respectively). AE ACLR yielded a greater risk of growth disturbances, angular deformities, and graft failures (1.5%, 1.3%, and 10.6%, respectively) but a lower risk of contralateral ACL tears (4.2%) relative to MK ACLR (0.0%, 0.0%, 6.6%, and 6.6%, respectively). Conclusions: Both AE and MK ACLR yield promising rates of RTS, substantially limit anteroposterior laxity, surpass IKDC thresholds for substantial clinical benefit, and regain fully functional ROM to comparable levels, though they yield marginally different complication profiles. However, the majority of the included studies were moderate-quality or low-quality evidence with high statistical heterogeneity. Therefore, no statistical conclusions regarding the differences in complication profiles can be drawn. Future randomized controlled trials or large prospective cohort studies should compare the efficacy and complication profile of QT autograft AE ACLR relative to MK ACLR.

Background: Tibial tubercle osteotomy (TTO) is a surgical procedure for the management of patellofemoral instability (PFI). Tubercle distalization requires a complete osteotomy detachment and has been shown to have an increased rate of certain complications in predominantly adult cohorts. With this study we identify and compare the complication rate of 2 TTO techniques—anteromedializing alone (AM) and anteromedializing with concomitant distalization (AMD) among young patients. Methods: A retrospective comparative study was conducted from 2010 to 2021 at 2 large tertiary care pediatric hospitals identifying adolescent and young adult patients (<21 years) who presented for surgical treatment of PFI undergoing TTO. Groups were stratified based on the type of TTO: AM and AMD. Demographics and radiographic measures were recorded. Postoperative complications were identified and recorded using the modified Clavien-Dindo-Sink (CDS) classification system. Bivariate testing was conducted to compare variables among treatment groups. Results: Seventy-six knees undergoing tubercle osteotomy (47 AM and 29 AMD) were identified. Treatment cohorts had similar demographics, mean preoperative CDI, Oswestry-Bristol classification, and Dejour classifications. Median follow-up was similar between both the groups in the AM and AMD groups (P=0.5). The overall complication was 22% (n=17/76) whereas in the AM group and AMD group was 19% (n=9/47) and 27% (n=8/29), respectively (P=0.57). The most common complications observed in both groups were infection and arthrofibrosis. No significant differences between AM and AMD groups were noted with respect to the grade of complication and individual complication rates (P >0.05). Conclusion: The rate of overall complications was similar to prior adult studies. In this large adolescent cohort, tubercle distalization compared with anteromedial transfer alone did not demonstrate statistically significant differences. Findings from this study help surgeons understand complication rates and improving counselling among adolescent PFI patients being considering for a distalizing TTO. Study Design: Retrospective comparative study; level of evidence III.

Background: Perthes disease is an uncommon pediatric condition affecting the hip joint, causing varying degrees of femoral head necrosis. The underlying cause of Perthes remains unknown, thus it is crucial to identify risk factors associated with its development to aid in early diagnosis and intervention. This study aimed to analyze risk factors associated with Perthes in a large cohort. Methods: A case-control study was conducted using data from a U.S. national database from 2003 to 2023. Patients diagnosed with Perthes were compared with those without the disease. Variables potentially associated with Perthes were analyzed using multivariable logit models, and adjusted odds ratios (AOR) with 95% CI were calculated. Statistical significance was determined, and a P-value <0.05 was considered significant. Results: The study included 4034 patients with Perthes and 3,483,745 age-matched controls. The mean age of patients with Perthes was 8.38 years, compared with 8.35 years in the control group (P=0.27). Significant risk factors identified included male sex (AOR: 3.14, P<0.001), white race (AOR: 2.16, P<0.001), and obesity (AOR: 2.21, P<0.001). Conversely, Black (AOR: 0.26, P<0.001), Hispanic (AOR: 0.53, P<0.001), and Asian (AOR: 0.55, P<0.001) races were associated with lower odds of developing Perthes. Additional significant risk factors included tobacco exposure (AOR: 1.25, P=0.02), hypertension (AOR: 1.64, P<0.001), and thrombophilia (AOR: 9.17, P<0.001). Conclusions: This study is the largest study on Perthes disease in literature, identifying several independent risk factors, including male sex, white race, obesity, tobacco exposure, hypertension, obesity, and thrombophilia. Among children with Perthes, thrombophilia exhibited the highest adjusted odds ratio, despite its rarity. These findings offer valuable insights for further research aimed at elucidating the underlying etiology of Perthes disease, particularly with regards to the roles of vascular and metabolic pathways. Level of Evidence: Level III—prognostic case-control study.

Background: Physeal-sparing procedures are preferred for treating early-onset slipped capital femoral epiphysis (SCFE), reducing limb-length discrepancy (LLD), and femoroacetabular impingement (FAI). This study aimed to investigate the treatment outcomes after physeal-sparing procedures for early-onset SCFE. Methods: We reviewed medical and radiographic records of SCFE patients from 1992 to 2022. Patients under 11 years old and followed up to skeletal maturity were included. Physeal-sparing procedures using a long screw with a short-threaded tip were performed in patients with mild to moderate slips since 2008. Patients were dichotomized into physeal-sparing and traditional in situ fixation (ISF) groups. Radiographic and clinical outcomes were comparatively analyzed between the groups. Results: Fifteen patients underwent physeal-sparing procedures, whereas 12 patients underwent traditional ISF. There was no further slippage in either group. During follow-up, slip angle was significantly decreased in the physeal-sparing group compared with the traditional ISF group (22.0 vs. 8.8 deg, respectively, P<0.01). LLD of>20 mm did not occur in the physeal-sparing group, but was observed in the traditional ISF group (P<0.01). Femoral neck length (FNL), articulo-trochanteric distance (ATD), α angle, and femoral head-neck offset of the physeal-sparing side were comparable to the unaffected healthy side (P=0.08, P=0.25, P=0.14, P=0.13), but differences were seen in healthy versus traditional ISF sides (P<0.01, P<0.01, P<0.01, and P<0.01, respectively). In addition, consistent growth was observed in the physeal-sparing side, but premature physeal arrest developed in the traditional ISF side. Six physeal-sparing patients required screw change procedures as the proximal femur outgrew the screw. The physeal-sparing group scored higher modified Harris Hip Score points than the traditional ISF group (89.5 vs. 85.3, respectively). Conclusions: Using a long screw with a short-threaded tip can stabilize the proximal femoral physis. It may also allow the continual growth and remodeling of the proximal femur in the treatment of early-onset SCFE. Level of Evidence: Level III.

Background: Displaced tibial tubercle fractures in adolescent patients typically require surgical management. There is limited research on the relationship between fracture type, screw construct, and clinical outcomes. Symptomatic screws and the need for screw removal are suggested to be associated with larger screw size. The purpose of this study is to investigate the impact of screw size and fixation construct on treatment outcomes and the risk of symptomatic hardware. Methods: Tibial tubercle fractures treated at a level I pediatric trauma center from January 2010 to December 2022 were retrospectively reviewed. Three groups were defined based on the largest screw size used for fixation (small: <5.0, medium: 5.0 to 6.0, large: >6.0 mm). Bivariate statistics were used to evaluate associations between screw size, patient demographics, and fracture treatment. The primary outcomes studied were rates of postoperative symptomatic hardware, symptomatic hardware removal, and fracture displacement. Univariate and multivariate logistic regression analyses were used to identify independent predictors of symptomatic hardware and symptomatic hardware removal. Results: One hundred eighty-two knees in 168 patients were included. The mean age was 14.5 years (SD: 1.4 y), 94.5% male. Screw size distribution was small in 26 knees (14.3%), medium in 83 (45.6), and large in 73 (40.1%). Screw size was significantly different among the Ogden types (P<0.001). Forty-one patients (22.5%) had symptomatic hardware, and 31 (17%) underwent removal of hardware at a median of 11 months postoperative. Rates of symptomatic hardware were not statistically different in the screw size groups (P=0.184). Screw size, number, and washer use were not associated with risk of symptomatic hardware or removal in multivariate analysis. Conclusion: Symptomatic hardware following operatively treated tibial tubercle fractures is common, occurring in ∼1 out of 5 patients. Fracture type, screw size and number, and fixation construct were not associated with increased risk of symptomatic hardware. Surgeons should counsel patients on the potential for symptomatic hardware and secondary removal procedures, but this should not limit their choice of fixation construct. Level of Evidence: Level III—retrospective, therapeutic study.

Background: Adolescent idiopathic scoliosis (AIS) is the most prevalent pediatric spinal condition. During growth, moderate scoliosis is treated with a brace to minimize the risk of progression to the surgical range. However, a minority of patients meet brace indications, with a greater number presenting late, already appropriate for surgery. This study determines the treatment cost differential between brace candidates and late-presenting patients within a public health care setting. Methods: This is a retrospective review of 373 consecutive AIS patients seen for initial consultation in 2014 and followed for 5 years, with a cost-analysis of the 166 patients that either met brace indications (n=63) or presented late (n=103). Patients meeting the Scoliosis Research Society’s brace indications presented with a coronal curve magnitude between 25 and 40 degrees inclusive and were skeletally immature with a Risser ≤2. Late-presenting patients had coronal curve magnitudes of ≥50 degrees (n=73) or were presented with coronal curve magnitudes of >40 degrees and were skeletally immature with Risser ≤2 (n=30). Total treatment cost was estimated for 3 scenarios: (1) use of predetermined cut points for treatment prescription, (2) real-world approximation reflecting actual, nuanced clinical decision-making, and (3) the ideal situation, such that all late patients were instead seen as brace candidates. Results: Each patient who was prescribed a brace and avoided progression to the surgical range saved $23,000 in treatment costs. Eliminating late presentation of AIS would save at least $2 to $3 million per year at a single institution. Conclusion: Significant cost savings can be found by optimizing the number of patients treated with a brace and minimizing the number of patients that present late as likely surgical candidates. This study provides financial impetus for early AIS detection, decreasing the number of avoidable surgeries. Scoliosis screening recommendations in primary care should be re-examined, alongside the development of educational tools, equipping primary care providers, and youth and their caregivers with appropriate knowledge on how to identify AIS. Level of Evidence: Level III—retrospective comparative study.

Background: Children with cerebral palsy (CP) often undergo hip reconstruction through proximal femoral varus derotation osteotomy (VDRO), with orthopaedic implants used for fixation. Posthealing, hardware may be retained or removed, either reactively due to complications or prophylactically. The controversy surrounding implant removal persists. This study aimed to compare the rate of proximal femoral fractures in children with CP who retained their hardware versus those who had it removed after VDRO. A secondary aim was to identify fracture risk factors after VDRO and report complications related to hardware removal. Methods: This retrospective study included 334 children who met inclusion (VDRO procedure) and exclusion (<2 y postoperative follow-up) criteria; 122 were eligible for the hardware removal group. Patients were followed from the initial VDRO to 2 years, hardware removal, or fracture. After removal, follow-up continued for a minimum of 2 years or until fracture. Frequency distribution summarized categorical variables, while mean and range were used for continuous variables. Median and interquartile range (IQR) was utilized for non-normally distributed data. χ2 testing determined fracture risk factors post-hardware removal, with a significance level set at P-value <0.05. Results: Of 334 patients, 11 (3%) experienced a peri-implant fracture after VDRO; 8 (2%) occurred within 2 years. The median time to fracture was 1.3 years (IQR, 3.2; range, 0.0 to 12.4). In the hardware removal group, 10 (5%) of 212 patients fractured postremoval, all within 2 years. The mean time from removal to fracture was 0.48±0.65 years (range, 0.02 to 1.94). Significant risk factors included prior VDRO revision surgery (P=0.029) and hardware removal within 1 year post-VDRO (P=0.007). Conclusion: No significant difference in fracture rates was found between the 2 groups. However, patients with prior revision surgery or hardware removed within 1 year post-VDRO faced increased fracture risks. This study provides evidence to proceed with caution when removing hardware if a patient has had prior revision surgery and to wait at least 1 year after VDRO to remove proximal femoral implants. Level of Evidence: Level III.

Background: Tibial tubercle fractures (TTF) in adolescents can be treated operatively or nonoperatively depending on fracture configuration and displacement. In the modified Ogden classification, the type IV fracture is extra-articular and exits through the posterior physis or metaphysis. No previous publications have reviewed a series of these injuries and compared clinical and radiographic outcomes of operative and nonoperative treatment. Methods: Patients under the age of 18 with Ogden type IV TTFs treated at a single institution between 2013 and 2023 were evaluated. Mechanism of injury, weight percentile, concern for compartment syndrome, time to full weight bearing, time to return to sport/activity, method of treatment, follow-up time, and complications were collected from the electronic medical record (EMR). Posterior tibial slope angle (PTSA), medial proximal tibial angle (MPTA), and anterior fracture gap were measured from the initial injury, postreduction, and final follow-up radiographs. Results: A total of 36 limbs in 33 patients were followed for an average of 182 days, 18 of which were treated nonoperatively and 18 operatively. The mean pretreatment PTSA was 22.4° in the nonoperative and 25.0° in the operative group (P=0.25). The mean final follow-up PTSA was 15.1° in the nonoperative and 14.3° in the operative group (P=0.54). The mean pretreatment MPTA was 84.7° for both groups (P=0.99). The final follow-up mean MPTA was 84.2° in the nonoperative and 85.5° in the operative group (P=0.08). There were no significant differences noted in time to full weight bearing, return to sport/activity, or total follow-up. There were 7 cases with complications, 4 in the nonoperative and 3 in the operative group. Conclusions: The present study suggests that nonoperative and operative treatment for type IV TTFs are equivalent in terms of radiographic and clinical outcomes. Given that joint incongruity is not an issue in these fractures, closed reduction can be attempted unless contraindicated by impending compartment syndrome. Operative management should be performed for failure of closed reduction. Level of Evidence: Level IV.

Objective: Torsional osteotomies of the femur and tibia may be indicated in select individuals with a combination of increased femoral anteversion and external tibial torsion. This study aims to quantify the presurgery and postsurgery levels of pain, function and mobility, and gait patterns in patients with lower extremity torsional abnormalities (LETAs). Methods: Patients with LETA who underwent torsional osteotomy of the femurs and/or tibias were recruited. Before and 1 year postsurgery, participants had a gait analysis and completed patient-reported outcomes. CT torsional assessment was performed at baseline. Paired t tests and statistical parametric mapping were used to assess presurgery and postsurgery changes. Results: Ten participants (18 ± 2 y) completed the study. Participants had 29 ± 10 degrees of femoral anteversion and 45 ± 11 degrees of external tibial torsion. The hip rotational arc and transmalleolar axis improved towards norms following surgery. The major deviations found in the kinematic were observed in the transverse plane, and they improved towards norms postsurgery. The patient-reported outcomes were below norm presurgery but improved significantly postsurgery. Conclusions: Results from this study suggest that LETA can be diagnosed based on radiologic, gait, and physical abnormalities. Postsurgery results showed that torsional osteotomy alleviated pain, restored physical function, and normalized gait patterns. Level of Evidence: Level IV.

Background: Cast wedging is an established technique used to improve the alignment of pediatric fractures. The purpose of this study was to review the effectiveness of cast wedging to treat malaligned pediatric fractures and report the incidence of complications and failure associated with cast wedging. Methods: A retrospective review of a level one pediatric trauma center was performed. Children aged 3 to 18 who underwent cast wedging following a forearm shaft, distal radius, or tibia shaft fracture (January 2005 to January 2021) were reviewed. A total of 294 patients were identified for analysis. Coronal and sagittal angles were measured throughout the course of fracture management. Improved radiologic correction was defined as at least a 50% correction of malalignment in the plane of maximum deformity. Complications associated with cast wedging were recorded, and wedging failure was defined as patients who underwent a secondary procedure. Multivariable logistic regression analysis was used to identify variables affecting outcomes and odds ratios (ORs) with 95% CIs were estimated for final model effects. Results: Cast wedging generated a median 56% correction in angulation, with 74% of the cohort (217/294) achieving at least 50% correction. Twenty-two patients (7%) failed wedging treatment, with half undergoing a repeat closed reduction (12/22, 55%). Eighteen patients (6%) experienced at least 1 complication. Nine patients (3%) sustained a refracture after wedging an average of 8.9 months from the initial injury. Multivariable analysis identified older patients and those who did not achieve 50% radiologic correction after wedging to have increased odds of repeat surgery (OR=1.17; P=0.04 and OR=11.1; P=0.001, respectively). Conclusions: Cast wedging is a safe and effective method to correct malaligned pediatric fractures with a low incidence of complications and refracture. Cast wedging remains an important skill for orthopaedic surgeons managing pediatric fractures. Level of Evidence: Level IV.

Objective: Slipped capital femoral epiphysis (SCFE) is one of the most common hip disorders in adolescents, often linked to obesity. However, other factors, such as vitamin D deficiency, may also contribute to SCFE development. This study investigates the impact of vitamin D deficiency on SCFE development in a large cohort. Methods: We utilized the TriNetX national database to query pediatric patients with documented calcidiol levels. Patients with a recorded visit below the age of 9 and subsequent documented calcidiol levels were followed until SCFE occurrence or age 18. Patients were categorized into vitamin D adequate (≥ 30 ng/mL) and deficient (< 30 ng/mL) groups. Propensity score matching was performed using a multivariable logistic regression model to adjust for baseline characteristics, including age, sex, race, and body mass index percentile. Significance testing was conducted using the Fisher exact test and χ2 tests to compare SCFE risk between the cohorts, with a significance level set at P <0.05. Results: On preliminary analysis, 98,045 patients met the inclusion criteria. After matching, 34,552 individuals in both vitamin D deficient and adequate groups were included, with an average age of 8.4 years at the time of their first visit and 50% females. SCFE occurred in 136 (0.39%) and 48 (0.14%) patients in the vitamin D deficient and adequate groups, respectively (P < 0.0001). Vitamin D deficiency significantly increased SCFE risk, with a relative risk of 2.8 (95% CI: 2-3.9; P < 0.0001) and a hazard ratio of 1.6 (95% CI: 1.1-2.2; P < 0.0001). Conclusion: This study, one of the largest to date, establishes a significant association between vitamin D deficiency and SCFE development. After controlling for potential confounding variables, including body mass index, individuals with vitamin D deficiency were ∼2.83 times more likely to develop SCFE. The study findings highlight the need for further research to evaluate whether supplementation could mitigate this risk of developing SCFE. Level of Evidence: Level III.

Background: Idiopathic genu valgum beyond physiological limits may require treatment, which is based on age, growth remaining, and the magnitude of the deformity. There is no consensus on clinical, or radiologic evaluation, indications, and management of idiopathic genu valgum, which can range from observation to surgical treatment using various modalities. If available, such guidelines will help surgeons offer optimal treatment to their patients. The aim of our study was to establish an expert consensus on the evaluation and treatment of idiopathic genu valgum. Methods: An international panel of 29 pediatric orthopaedic surgeons from 17 countries with clinical and research experience in the management of limb deformity participated in a modified Delphi survey. Surgeons were provided with patient and deformity characteristics and voted on 46 statements on history, clinical examination, radiographic evaluation, and treatment options for idiopathic genu valgum in round 1. Consensus was defined as when statements received ≥70% votes. Statements that were important but received <70% votes were reworded for clarity in round 2 (n=13). Results: Consensus was achieved for 28/46 statements and included obtaining a full-length standing radiograph of the lower extremities and measuring joint orientation angles. Participants did not agree to offer surgical treatment based only on the intermalleolar distance. They recommended surgical treatment if the mechanical axis falls in zone 2 or beyond on the lateral side and using guided growth by tension-band plating when the growth remaining is at least 2 years. The panel agreed on performing common peroneal nerve decompression for specific indications such as acute, opening wedge osteotomy of >20 degrees, but not for gradual correction. Consensus was not reached for indications and methods of bone age assessment, treatment when growth remaining is <1 year, indications for implant removal after guided growth in younger children, and the type of osteotomy for acute deformity correction. Conclusions: We have generated consensus statements to guide the management of idiopathic genu valgum. Statements that lack consensus are areas for future multicenter research. Level of Evidence: Level V.

Background: Anxiety and depression (AD) are prevalent comorbidities in pediatric patients and may influence postoperative outcomes. The impact of AD on postoperative pain medication use and emergency room (ER) visits in children with surgically treated lower extremity fractures has not been well-documented. This study aimed to evaluate the association between AD and outpatient postoperative pain medication requirements as well as ER visits in this population. Methods: A retrospective cohort study was conducted using electronic medical records from 2000 to 2023 in a large national database of health care organizations across the United States. Pediatric patients (age below 18) with surgically treated lower extremity fractures were included. Patients were categorized into 2 groups: those with AD and those without (No-AD). Patients were further dichotomized into 2 groups based on fracture location: femur (femur) versus tibia or ankle (tibia/ankle). Outcomes of interest included the use of intravenous (IV) opiates within 3 days postoperatively, the number of outpatient oral (PO) opiate prescriptions, and the proportion of patients with at least one ER visit within 1 year postsurgery. Hazard ratios (HRs) were calculated using Cox proportional hazard models, adjusting for demographic and clinical characteristics. Results: A total of 25,658 patients with either femur or tibia/ankle fractures were included. After matching, 735 patients were included in the AD femur cohort, and 945 in the AD tibia/ankle cohort. Each cohort was matched 1:1 with their control counterparts. In the femur fracture cohort, 49.80% of AD patients and 46.53% of No-AD patients required IV opiates within the first 3 days after surgery (HR, 1.09; P=0.21). Outpatient PO opiate use was significantly higher in AD patients (55.78% vs. 38.50%, HR, 1.64; P<0.001). In addition, AD patients had a higher proportion of ER visits (20.3% vs. 11.7%, HR, 1.68; P<0.001). In the tibia/ankle fracture cohort, 55.2% of AD patients and 48.3% of No-AD patients required IV opiates within the first 3 days (HR, 1.18; P<0.001). Outpatient PO opiate use was also higher in AD patients (46.35% vs. 32.06%, HR, 1.55; P<0.001). ER visits were more frequent in AD patients (21.26% vs. 9.63%, HR, 2.08; P<0.001). Conclusions: Pediatric patients with AD undergoing surgery for lower extremity fractures have increased postoperative pain medication requirements and higher rates of ER visits compared with those without AD. These findings highlight the need for targeted interventions, such as the use of preoperative counseling or multimodal pain regimens, to manage postoperative pain and reduce ER visits in this vulnerable population. Level of Evidence: Prognostic level III.

Background: The prevalence of labral tears in asymptomatic active adults has been reported, but the prevalence of labral tears and other incidental hip lesions in the asymptomatic active pediatric population remains unclear. The purpose of this study was to determine the prevalence of hip abnormalities detected on 3T MRI in an active pediatric population with no hip symptoms and to compare with hip abnormalities found in children and adolescents who underwent an MRI for a hip-related condition. Methods: After IRB approval, pediatric patients self-reporting as athletes and presenting with isolated, acute-onset knee pain requiring knee MRI were prospectively recruited to undergo 3T MRI of their asymptomatic contralateral hip (ASx). A comparison group of pediatric subjects who underwent an MRI for hip pain was enrolled retrospectively (Sx). All MRI scans were anonymized and randomized. Fifty subjects were enrolled for each cohort. Two fellowship-trained musculoskeletal radiologists independently evaluated MRIs for abnormal hip lesions, including labral tears. Inter-reader reliability was evaluated using Cohen Kappa. χ2 or Fisher exact test was used to compare the prevalence of hip lesions between the 2 cohorts. Results: The average patient age was 14.9 years for both cohorts (range 9 to 18 y) and 48% were male. In the ASx group, incidental labral tears were found in 18%, labral/paralabral cysts 6%, cartilage lesion 0%, subchondral cyst 0%, ligamentum teres tear 0%, femoral fibrocystic change 0%, cam lesion 30%, acetabular bone edema 0%, acetabular rim fracture 0%. The prevalence of labral tears (30%, P-value 0.16) and cam lesion (36%, P-value 0.52) in the Sx group was not significantly different from the ASx cohort. No significant correlation was found between the presence of femoral neck osseous bump and labral tear, labral cyst, or paralabral cyst in either cohort. Conclusions: Labral tears were present on 3T MRIs of active pediatric patients with and without hip pain. Although MRI is essential to confirm the surgeon’s suspicion and to detect unexpected pathology, clinical examination and history are crucial in pinpointing clinically relevant abnormal imaging findings. Level of Evidence: Level III.

Background: Femoral head avascular necrosis (AVN) is a devastating complication that can occur in the setting of trauma to the pediatric hip. Bone scintigraphy (BoS) can be used to evaluate femoral head perfusion, but current evidence in support of its use in the pediatric population is lacking. The purpose of this study was to evaluate the sensitivity and specificity of BoS to diagnose femoral head AVN in children. Methods: We retrospectively reviewed patients who underwent BoS to assess femoral head perfusion following treatment of traumatic femoral neck fracture, hip dislocation, or SCFE at a single pediatric hospital. All patients had a minimum radiographic follow-up of 1 year. Assessment of intraoperative femoral head perfusion was also recorded if performed. Results of BoS and intra-op assessments were compared with RAVN (radiographic findings of AVN) at final follow-up. Results: Forty-eight hips were included, and 75% were male. The mean age at the time of surgery was 12.5±1.6 years. The mean age at BoS was 12.7±1.7 years. The mean follow-up was 23.3±13.1 months. RAVN developed in 15% (7/48) of hips. Nine hips had an abnormal BoS: 7 hips had absent perfusion and 2 hips had diminished perfusion. All 7 hips with absent perfusion on BoS went on to develop RAVN with collapse. Neither hip with diminished perfusion on BoS went on to femoral head collapse. No hip with normal BoS developed radiographic evidence of AVN at the final follow-up. BoS demonstrating absent perfusion had a sensitivity of 100% and a specificity of 95% in predicting RAVN. Evidence of femoral head perfusion at the time of surgery (drilling or IOP) had a sensitivity of 17% and a specificity of 80% in predicting RAVN. Conclusions: BoS demonstrates high sensitivity and specificity for predicting postoperative RAVN. Clinicians should have increased suspicion of impending femoral head collapse if there is absent perfusion on BoS at 6 to 12 weeks post-op, even with evidence of preserved femoral head perfusion at the time of surgery.

Background: Greater understanding of the impact of skeletal maturity on outcomes is needed to guide operative treatment of diaphyseal forearm fractures in children and adolescents. The purpose of this study was to compare the complications and outcomes of pediatric diaphyseal forearm fractures treated with intramedullary nailing (IMN) or open reduction internal fixation (ORIF) and to identify a radiographic marker of skeletal maturity that will aid in selecting between treatment options. Methods: A retrospective review of patients aged 10 to 16 years treated operatively for diaphyseal forearm fractures was performed. Markers of skeletal maturity including the olecranon apophysis score, the presence of the thumb adductor sesamoid, and radial epiphyseal capping. Complications were graded with the modified Clavien-Dindo system. Outcomes were scored based on final postoperative range of motion combined with complication grade. Results: A total of 260 patients were included: 163 treated with IMN, 97 treated with ORIF, mean age 12.7 years, 72% male. Among closed forearm fractures treated with IMN, open reduction was required in 45% (53/118). Patients treated with IMN had a higher complication rate than ORIF (27.0% vs. 9.3%, P<0.05), including when stratified by age. Complication rates were not impacted by greater skeletal maturity as indicated by the presence of thumb sesamoid or radial epiphyseal capping. There was no significant difference in outcomes between the ORIF and IMN groups. More skeletally immature patients, as identified by a lack of either the thumb adductor sesamoid or radial epiphyseal capping, had significantly better outcomes with ORIF than patients with greater maturity. Conclusions: Across all age groups and levels of skeletal maturity, ORIF had a significantly lower rates of complications compared with IMN with equivalent outcomes. More skeletally immature patients had significantly better outcomes with ORIF treatment when compared with older patients. The thumb adductor sesamoid, radial epiphyseal capping, and the olecranon apophysis score did not provide useful information to select between ORIF over IMN in this population. Level of Evidence: Level III—retrospective comparative study.

Background: Congenital talipes equinovarus, or clubfoot, can lead to lifelong functional impairments, including diminished gross motor skills (GMS), if left untreated. The Ponseti method corrects idiopathic clubfoot through casting and bracing. Given the importance of GMS in childhood development, this technique must be optimized to support childhood and long-term health outcomes. This study examined immediate posttreatment GMS in 3-year-old children treated with Ponseti, hypothesizing that they would perform on par with their nonclubfoot peers. Methods: Data from 45 children (33 to 46 mo of age) treated for idiopathic clubfoot were analyzed. The Peabody Developmental Motor Scales, 2nd edition, was used to assess GMS, and logistic regression identified factors influencing Gross Motor Quotient (GMQ) scores. Results: Approximately half (n=22) of the patients exhibited below-average GMS (11th to 25th percentile), with 11 scoring below the 10th percentile. Initial deformity severity, gender, and cast numbers did not impact GMQ. Repeat percutaneous tenotomy was associated with lower GMQs. Brace compliance significantly reduced odds of low GMQs by up to 80%. Age at testing and additional surgery were also linked to below-average and poor GMQs. Conclusions: GMS appeared to be impaired in almost half of the 3-year-old patients treated for idiopathic clubfoot, so our hypothesis was disproven. Repeat percutaneous tenotomy was associated with lower GMS, necessitating future recognition of patients who might be at risk of relapse. Brace noncompliance emerged as a significant risk factor, emphasizing early identification of these patients and education for their parents. This study offers a benchmark for clinicians and parents, but research on long-term outcomes is needed. Level of Evidence: Level II, prospective cohort study.

Background: Avascular necrosis (AVN) remains the most dreaded complication of unstable slipped capital femoral epiphysis (SCFE) treatment. Newer closed reduction techniques (with perfusion monitoring) have emerged as a technically straightforward means to address residual SCFE deformity while still minimizing the risk of osteonecrosis. However, limited data exists regarding the reliability of intraoperative epiphyseal perfusion monitoring to predict the development of AVN. The purpose of this study was to evaluate its reliability. Methods: We retrospectively reviewed all patients with unstable SCFE who underwent closed or open reduction with epiphyseal perfusion monitoring using an intracranial pressure (ICP) probe from 2015 to 2023 at a single institution with a minimum 6-month radiographic follow-up. Demographic, clinical, and radiographic data were recorded, including duration of symptoms, type of reduction, capsulotomy performed, presence of a waveform on ICP monitoring after epiphyseal fixation, and development of AVN on follow-up radiographs. Results: Our cohort included 33 hips (32 patients), of which 60.6% (n=20) were male. The average age was 12.5±1.8 years, with a median follow-up of 15.8 months. Eleven hips were treated with open reduction using the modified Dunn technique (10 hips) or anterior approach (1 hip), and 22 hips were treated with inadvertent (5 hips) or purposeful closed reduction using the Leadbetter technique (17 hips). Overall, 8 of the 33 hips in our series (24.2%) developed AVN, 6 of which (20%) had a pulsatile waveform on intraoperative epiphyseal perfusion monitoring. The overall rate of AVN after closed reductions was 31.8% (7 of 22 hips); the incidence of AVN after closed reduction with a detectable waveform was 30% (6 of 20 hips). There was no significant association between time to surgery (P=0.416) or type of reduction (P=0.218) and the incidence of AVN. Conclusions: In this series, intraoperative epiphyseal perfusion monitoring did not reliably predict the development of osteonecrosis. To our knowledge, this is the first study to report AVN after demonstrable intraoperative epiphyseal perfusion following closed reduction of unstable slips. Level of Evidence: Level IV: case series—therapeutic study.

Background: The management of first-time patellar dislocation remains variable, with limited evidence to support or compare different operative and nonoperative modalities. The primary aim was to establish consensus-based guidelines for different components of nonoperative treatment following a first-time patellar dislocation. The secondary aim was to develop guidelines related to management after failed nonoperative treatment. The tertiary aim was to establish consensus-based guidelines for the management of first-time patellar dislocation with a concomitant osteochondral fracture. Methods: A 29-question, multiple-choice, case-based survey was developed by 20 members of the Patellofemoral Research Interest Group of the Pediatric Research in Sports Medicine Society. The survey consisted of questions related to demographic information, management of first-time patellar dislocation without an osteochondral fracture, and management of first-time patellar dislocation with a 2 cm osteochondral fracture. The survey underwent 2 rounds of iterations by Patellofemoral Research Interest Group members and the final survey was administered to Pediatric Research in Sports Medicine members, using REDCap. Consensus-based guidelines were generated when more than 66% of respondents chose the same answer. Results: Seventy-nine of 157 (50%) eligible members responded. Sixty-one were orthopaedic surgeons and 18 were primary sports medicine physicians. Eleven consensus-based guidelines were generated based on survey responses. Those that met the criteria for consensus included initial knee radiographs (99% consensus), nonoperative treatment for first-time patellar dislocation without an osteochondral fracture (99%), physical therapy starting within the first month postinjury (99%), with return to sport after 2 to 4 months (68%) with a brace (75%) and further follow-up as needed (75%). Surgical treatment was recommended if there were patellar subluxation episodes after 6 months of nonoperative treatment (84%). Patellar stabilization should be considered for a first-time dislocation with an osteochondral fracture (81.5%). Conclusion: Consensus-based guidelines offer recommendations for the management of first-time patellar dislocation with or without an osteochondral fracture. Several changing trends and areas of disagreement were noted in clinical practice. Clinical Relevance: In the absence of high-level evidence, consensus-based guidelines may aid in clinical decision-making when treating patients following a first-time patellar dislocation. These guidelines highlight the evolving trends in clinical practice for the management of first-time patellar dislocation. Areas not reaching consensus serve as topics for future research.

Background: Thoracic anterior vertebral body tethering (TAVBT) is an emerging treatment for adolescent idiopathic scoliosis. Tether breakage is a known complication of TAVBT with incompletely known incidence. We aim to define the incidence of tether breakage in patients with adolescent idiopathic scoliosis who undergo TAVBT. The incidence of tether breakage in TAVBT is hypothesized to be high and increase with time postoperatively. Methods: All patients with right-sided, thoracic curves who underwent TAVBT with at least 2 and up to 3 years of radiographic follow-up were included. Tether breakage between 2 vertebrae was defined a priori as any increase in adjacent screw angle >5 degrees from the minimum over the follow-up period. The presence and timing of tether breakage were noted for each patient. A Kaplan-Meier survival analysis was performed to calculate expected tether breakage up to 36 months. χ2 analysis was performed to examine the relationship between tether breakage and reoperations. Independent t test was used to compare the average final Cobb angle between cohorts. Results: In total, 208 patients from 10 centers were included in our review. Radiographically identified tether breakage occurred in 75 patients (36%). The initial break occurred at or beyond 24 months in 66 patients (88%). Kaplan-Meier survival analysis estimated the cumulative rate of expected tether breakage to be 19% at 24 months, increasing to 50% at 36 months. Twenty-one patients (28%) with a radiographically identified tether breakage went on to require reoperation, with 9 patients (12%) requiring conversion to posterior spinal fusion. Patients with a radiographically identified tether breakage went on to require conversion to posterior spinal fusion more often than those patients without identified tether breakage (12% vs. 2%; P=0.004). The average major coronal curve angle at final follow-up was significantly larger for patients with radiographically identified tether breakage than for those without tether breakage (31 deg±12 deg vs. 26 deg±12 deg; P=0.002). Conclusions: The incidence of tether breakage in TAVBT is high, and it is expected to occur in 50% of patients by 36 months postoperatively. Level of Evidence: Level IV

Introduction: Postoperative opioid prescriptions may confer a risk for subsequent opioid use disorders (OUDs). For many children, postoperative analgesia is often the first opioid exposure. The rates of anterior cruciate ligament (ACL) reconstruction in pediatric populations are rising. Here, we use an administrative claims database to describe opioid prescription patterns after ACL reconstruction and their effect on subsequent risk of OUD. Methods: Using International Classification of Diseases (ICD)-9, ICD-10, and CPT codes, we identified patients, with ages 10 to 18, undergoing primary ACL reconstruction between 2014 and 2016 with minimum 1 year follow-up in the Optum Clinformatics Data Mart, which is a nationally representative administrative claims database. Demographic variables and prescription patterns (in morphine milligram equivalents [MMEs]) were analyzed using univariate tests and multivariable logistic regression to determine any potential association with the appearance of anew an ICD-9 or ICD-10 code for OUD within 1 year of the initial procedure. Results: A total of 4459 cases were included and 29 (0.7%) of these patients were diagnosed with an OUD within 1 year of surgery. Upon univariate analysis, opioid represcriptions within 6 weeks were significantly more common among patients with OUD; 27.6% vs. 9.7% of patients that did not develop a new diagnosis of OUD (P=0.005). Multivariable logistic regression indicated an independent significant relationship between total MMEs initially prescribed and the odds of a subsequent OUD diagnosis: for each additional 100 MMEs prescribed in total, the odds of OUD increased by 13% (P=0.002). Patients with a represcription within 6 weeks of surgery had an average increase in the odds of OUD by 161% (P=0.027). Conclusions: In this cohort of patient ages 10 to 18 undergoing primary isolated ACL reconstruction, we found substantial variability in opiate prescribing patterns and higher initial opioid prescription volume, as well as opioid represcription within 6 weeks were predictive of the subsequent development of OUD. Level of Evidence: Level III.

Introduction: Lateral humeral condyle fractures account for 12% to 20% of all distal humerus fractures in the pediatric population. When surgery is indicated, fixation may be achieved with either Kirschner-wires or screws. The literature comparing the outcomes of these 2 different fixation methods is currently limited. The purpose of this study is to compare both the complication and union rates of these 2 forms of operative treatment in a multicenter cohort of children with lateral humeral condyle fractures. Methods: This retrospective study was performed across 6 different institutions. Data were retrospectively collected preoperatively and 6 weeks, 3, 6, and 12 months postoperatively. Patients were divided into 2 cohorts based on the type of initial treatment: K-wire fixation and screw fixation. Statistical comparisons between these 2 cohorts were performed with an alpha of 0.05. Results: There were 762 patients included in this study, 72.6% (n=553) of which were treated with K-wire fixation. The mean duration of immobilization was 5 weeks in both cohorts, and most patients in this study demonstrated radiographic healing by 11 weeks postoperatively, regardless of treatment method. Similar reoperation rates were seen among those treated with K-wires and screws (5.6% vs. 4.3%, P=0.473). Elbow stiffness requiring further intervention with physical therapy was significantly more common in those treated with K-wires compared with children treated with screws (21.2% vs. 13.9%, P=0.023) as was superficial skin infection (3.8% vs. 0%, P=0.002), but there was no significant difference in nonunion rates between the two groups (2.4% vs. 1.3%, P=1.000). Conclusion: We found similar success rates between K-wire and screw fixation in this patient population. Contrary to previous studies, we did not find evidence that treatment with screw fixation decreases the likelihood of experiencing nonunion. However, given the unique complications associated with K-wire fixation, such as elbow stiffness and superficial skin infection, the treatment with screw fixation remains a reasonable alternative to K-wire fixation in these patients. Level of Evidence: Level III—retrospective comparative study

Background: Prior “best practice guidelines” (BPG) have identified strategies to reduce the risk of acute deep surgical site infection (SSI), but there still exists large variability in practice. Further, there is still no consensus on which patients are “high risk” for SSI and how SSI should be diagnosed or treated in pediatric spine surgery. We sought to develop an updated, consensus-based BPG informed by available literature and expert opinion on defining high-SSI risk in pediatric spine surgery and on prevention, diagnosis, and treatment of SSI in this high-risk population. Materials and Methods: After a systematic review of the literature, an expert panel of 21 pediatric spine surgeons was selected from the Harms Study Group based on extensive experience in the field of pediatric spine surgery. Using the Delphi process and iterative survey rounds, the expert panel was surveyed for current practices, presented with the systematic review, given the opportunity to voice opinions through a live discussion session and asked to vote regarding preferences privately. Two survey rounds were conducted electronically, after which a live conference was held to present and discuss results. A final electronic survey was then conducted for final voting. Agreement ≥70% was considered consensus. Items near consensus were revised if feasible to achieve consensus in subsequent surveys. Results: Consensus was reached for 17 items for defining high-SSI risk, 17 items for preventing, 6 for diagnosing, and 9 for treating SSI in this high-risk population. After final voting, all 21 experts agreed to the publication and implementation of these items in their practice. Conclusions: We present a set of updated consensus-based BPGs for defining high-risk and preventing, diagnosing, and treating SSI in high-risk pediatric spine surgery. We believe that this BPG can limit variability in practice and decrease the incidence of SSI in pediatric spine surgery. Level of Evidence: Not applicable.

Physician extenders and advanced practice providers (APPs) are now common in most adult and pediatric orthopaedic clinics and practices. Their utilization, with physician leadership, can improve patient care, patient satisfaction, and physician satisfaction and work/life balance in addition to having financial benefits. Physician extenders can include scribes, certified athletic trainers, and registered nurses, while APPs include nurse practitioners and physician assistants/associates. Different pediatric orthopaedic practices or divisions within a department might benefit from different physician extenders or APPs based on particular skill sets and licensed abilities. This article will review each of the physician extender and APP health care professionals regarding their training, salaries, background, specific skill sets, and scope of practice. While other physician extenders such as medical assistants, cast technicians, and orthotists/prosthetists have important roles in day-to-day clinical care, they will not be reviewed in this article. In addition, medical trainees, including medical students, residents, fellows, and APP students, have a unique position within some academic clinics but will also not be reviewed in this article. With the many different local, state, and national regulations, a careful understanding of the physician extender and APP roles will help clinicians optimize their ability to improve patient care.

Background: Slip progression after in situ fixation of slipped capital femoral epiphysis (SCFE) has been reported as occurring in up to 20% of patients. We review SCFE treated with in situ single screw fixation performed at 2 hospitals over a 15-year period to determine the factors associated with slip progression. Methods: This case-control study reviews SCFE treated with in situ single cannulated screw fixation with minimum follow up of 1 year and full closure of the affected physis. Slip progression (failure) was defined as worsening of the Southwick slip angle of 10 or more degrees or revision surgery for symptomatic slip progression. Univariate and multivariate analyses were performed comparing success and failure groups for patient characteristics, screw type and position, and radiographic measurements. Results: Ninety three patients with 108 slips met all criteria, with 15 hips (14%) classified as having slip progression (failure). All failures had 3 threads or fewer across the physis. Five hips had 2 threads across the physis, and 4 of the 5 were classified as failures. Lower modified Oxford bone scores were found in the failure group, though the difference was small (0.9, P=0.013). Failure was also associated with partially threaded screws (P=0.001). Failed hips were associated with lower initial Southwick angles (32.8 degrees) than successful hips (40.4 degrees) (P=0.047). In the stepwise model for multivariate regression, 4 factors were identified as significant, with lower initial number of threads (P<0.0001), mild initial Southwick category (P=0.0050), male sex (P=0.0061), and partially threaded screw type (P=0.0116) predicting failure. Conclusion: This study is the largest to date evaluating risk factors for slip progression after SCFE fixation, and the first to consider revision surgery for symptomatic slip progression. For stable SCFE, we demonstrate that 4 threads across the physis with a fully threaded screw of 6.5 mm diameter or greater was sufficient to avoid slip progression. We provide a risk stratification for progression of slip showing that in some cases 3 threads across the physis may be sufficient. Level of Evidence: Level III—case-control study.

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.

Background: While management recommendations for distal radius fractures in both young and skeletally mature patients have been generally well-established, controversy still exists regarding optimal management in adolescent patients approaching skeletal maturity. Thus, the goal of this review is to analyze relevant literature and provide expert recommendations regarding the management of distal radius fractures in this patient population. Methods: A PubMed search was performed to identify literature pertaining to distal radius fractures in adolescent patients, defined as 11 to 14 years in girls and 13 to 15 years in boys. Relevant articles were selected and summarized. Results: Distal radius fractures demonstrate significant potential for remodeling of angular deformity and bayonet apposition, even in patients older than 12 years of age. Rotational forearm range of motion and functional outcomes are acceptable with up to 15 degrees of residual angulation. Closed reduction and percutaneous pinning reduces fracture redisplacement but has a high associated complication rate. There is no literature comparing plate versus pin fixation of distal radius fractures in the pediatric population, but in adults plate fixation is associated with higher cost with no improvement in long-term functional outcomes. Conclusions: Remodeling can still be expected to occur in adolescent patients, and even with residual deformity functional outcomes after distal radius fractures are excellent. Up to 15 degrees of residual angulation can be accepted before considering operative management. Smooth pins should be considered over plates as first-line operative management for unstable fractures that fail nonoperative treatment.

Background: The natural history of traumatic glenohumeral dislocation is well-established in young adults, but it is less clear in pediatric patients. We aimed to determine the rate of recurrent instability and medium-term functional outcome following shoulder dislocation in patients aged 14 years or younger. Methods: All patients aged 14 years or younger who sustained a glenohumeral dislocation from 2008 to 2019 presenting to our regional health-board were identified. Patients who had subluxations associated with generalized laxity were excluded. Data was collected regarding further dislocations, stabilization surgery, sporting activity and patient-reported outcomes using the Western Ontario Shoulder Instability (WOSI) Index and Quick Disabilities of the Arm, Shoulder, and Hand score. Results: Forty-one patients with a radiologically confirmed traumatic glenohumeral dislocation were suitable for study inclusion [mean age at injury 12.3 y (range: 7.2 to 14.0 y), male sex 29 (70.7%), median 7.9 y follow-up]. The incidence rate of pediatric glenohumeral dislocation was 2.5 cases per 100,000 population (aged 0 to 14 y) per year. Recurrent dislocation occurred in 43.9% (n=18/41) at a median time of 14.7 months postinjury (range: 1 to 54 mo). Skeletal maturity was associated with significantly higher proportion of recurrent instability (immature 6/24 vs. mature 12/17, P=0.01). One in 5 patients required surgical intervention for recurrent instability [mean 8 (range: 1 to 14) dislocations before surgery]. Twenty-eight patients had completed outcome questionnaires. The median modified WOSI score was 87.1% [270 (interquartile range: 65 to 795)] and the median Quick Disabilities of the Arm, Shoulder, and Hand score was 3.4 (interquartile range: 0 to 9.7). Recurrent shoulder instability was significantly associated with poorer WOSI score (unstable 71.4% vs. stable 94.3%, 95% confidence interval of the difference 6.2-36.9, P=0.04). Conclusions: Traumatic glenohumeral dislocation in patients aged 14 years or younger occurs rarely but is not a benign event. One in 2 patients experienced recurrent dislocation and 1 in 5 ultimately underwent surgical stabilization. Level of Evidence: Level IV.

Background: Increased enrollment in government-based insurance plans has been reported. With youth sports injuries on the rise, increased ordering of advanced imaging such as magnetic resonance imaging (MRI) has occurred. This study sought to report on the impact of insurance type on access to and results of knee MRI in pediatric sports medicine patients. Methods: A retrospective review of 178 consecutive pediatric sports medicine clinics was completed. Inclusion criteria: patients younger than 18 years, routine knee MRI ordered, sports medicine diagnosis, and insurance. Data included basic demographics, injury date, date and location (urgent care vs. clinic) of the first presentation, details of MRI ordering and approval, date and location of MRI follow-up, MRI results (negative, minor findings, major findings), and eventual treatment required. Results: A total of 168 charts underwent a complete review. The patients’ average age was 14±3 years and 54% (N=90) were female. Ninety-eight had government insurance and 70 had commercial insurance. The time between injury and MRI completion was significantly longer with government insurance (34 vs. 67 d, P<0.01). Government insurance had increased wait time between the first visit and MRI completion (11 vs. 40 d, P<0.001) as well as MRI order and completion (9 vs. 16.5 d, P<0.001). There was no significant difference in positive findings on MRI between insurance groups, including both major and minor findings nor in the proportion receiving eventual operative treatment. Conclusion: Pediatric sports medicine patients with government insurance have delays in obtaining knee MRI, despite there being no difference in the rate of positive findings and subsequent operative treatments. Level of Evidence: Level III—case-control study.

Background: The long-term effects of small limb length discrepancies have been poorly documented in the literature. References to low back pain, hip pathology, knee pathology, and foot problems abound in the popular literature. Health care providers frequently recommend the use of lifts for structural and functional limb length discrepancies, yet the natural history of limb length inequality as well as the effectiveness of treatments that may be recommended are obscure. The purpose of this paper is to document and evaluate the literature associated with small limb length discrepancies. Methods: A search of the English literature was carried out using PubMed to identify papers dealing with the effects of limb length discrepancies. Papers reporting only expert opinion or case reports were excluded. Results: Papers dealing with the natural history of limb length discrepancy as well as studies in which gait analysis was performed in patients with limb length discrepancy were identified. Only 10% of the population has exactly equal lower limb lengths. Approximately 90% of the population has a limb length discrepancy <1.0 cm. Hip and knee pathology is present in an increased number of patients with limb length discrepancies over 5 mm. Hip pathology is more often present in the long leg, knee pathology has been reported in various studies to be more common in either the long or short leg. Low back problems seem to be more common on the short side in patients with limb length discrepancies. A number of different compensatory mechanisms for limb length discrepancy have been identified during gait analysis. Conclusions: There seems to be a consensus that limb length discrepancies >2.0 cm are frequently a problem. There is some evidence that limb length discrepancies as little as 5 mm can lead to long-term pathology.

Introduction: Adolescent idiopathic Scoliosis (AIS) affects 2% to 3% of the population of which only 0.3% to 0.5% of affected patients will have a curvature of >20 degrees, the curve magnitude at which treatment is generally recommended. For AIS the current natural history data is limited and most of the information comes from a small body of literature from the University of Iowa. Methods: The Iowa natural history studies began as retrospective reviews but beginning in 1976, the cohort was followed prospectively. Outcomes assessed in this group of patients included; mortality, pulmonary function, pregnancy-(effect of pregnancy on scoliosis and the effect of scoliosis on pregnancy), radiographic, curve progression, and osteoarthritis. In addition, validated questionnaires were used to evaluate back pain, pulmonary symptoms, general function, depression, and body image. Results: Patients with untreated AIS can function well as adults, become employed, get married, have children, and grow to become active older adults. Unfortunately, untreated scoliosis may lead to increased back pain and pulmonary symptoms for patients with large thoracic curves. Patients with untreated AIS can also develop substantial deformity, and the cosmetic aspect of this condition cannot be disregarded. Conclusions: The summary findings of this unique lifetime natural history of AIS patients provides patients and parents a solid evidence base upon which to make informed decisions.

Background: Radiographic surveillance of the hip is vital in the diagnosis and treatment of developmental dysplasia of the hip (DDH) in children. The acetabular index (AI) and the acetabular depth ratio (ADR) are radiographic parameters for evaluation of acetabular morphology. Normal reference curves for these parameters that allow for serial evaluation of acetabular development in a manner that is independent of age are necessary and clinically useful. The purpose of this study was (1) to establish normal values of AI and ADR in the normally developing pediatric hip up to age 14, (2) to generate percentile reference curves of both parameters, (3) to determine the extent of correlation between AI and ADR, and (4) to assess intrarater and interrater reliability of AI measurement. Methods: We identified 1734 patients who underwent anterior-posterior pelvic radiography between 2004 and 2014. A total of 1152 patients (age range, 0.15 to 13.97 y; 2304 hips) were identified as radiographically normal in the radiology report, signed by the attending pediatric radiologist on the basis of the absence of structural deformity of the hip and previously established reference values for DDH assessment. A review of the medical records confirmed that patients had no diagnosis of DDH or any other orthopaedic hip pathology. The AI and ADR were measured in all radiographs. Normal values and fully parametric percentile curves were generated from birth to skeletal maturity. Correlation between AI and ADR was assessed using linear regression analysis. Results: Normal AI decreased, and ADR increased, with age. Percentile curves were generated for AI and ADR. Using the provided equations, measured values can be converted to age-appropriate percentile and Z-score. The 2 parameters exhibited strong correlation (Pearson correlation=−0.789, P<0.001). For every unit increase in ADR, AI decreased by 0.94 degrees. Conclusions: We present updated normative values of AI that expand up to age 14, and novel reference values for ADR. The reference curves allow for the easy conversion of measured values to percentile and Z-score. Using the presented method during surveillance of the pathologic hip, change in acetabular development can now be assessed in a manner that is independent of age and the natural development of the acetabulum. Level of Evidence: Level IV—case series.

Background: Fractures in children are an important public health issue and a frequent cause of emergency room visits. The purpose of this descriptive epidemiological study was to identify the most frequent pediatric fractures per 1000 population at risk in the United States using the 2010 National Electronic Injury Surveillance System (NEISS) database and 2010 US Census information. Methods: The NEISS database was queried for all fractures in 2010 in children between the ages of 0 and 19 years. The NEISS national estimates were compared with the 2010 US Census data to extrapolate national occurrence rates. Results: The annual occurrence of fractures increased from ages 0 to 14, peaking in the 10 to 14 age range (15.23 per 1000 children). The annual occurrence rate for the entire pediatric population (0 to 19 y) was 9.47 per 1000 children. Fractures of the lower arm (forearm) were the most common among the entire study population, accounting for 17.8% of all fractures, whereas finger and wrist fractures were the second and third most common, respectively. Finger and hand fractures were most common for age groups 10 to 14 and 15 to 19 years, respectively. The overall risk of a fracture occurring throughout childhood and adolescence was 180 per 1000 children, or just under 1 in every 5 children. Conclusions: Pediatric fractures represent a significant proportion of pediatric emergency department visits in the United States. Children between 10 and 14 years of age have the highest risk of having fractures. Overall, forearm fractures were the most common pediatric fractures. Most pediatric fractures can be treated on outpatient basis, with only 1 of 18 fractures requiring hospitalization or observation. Level of Evidence: Level III–Retrospective comparative study.

Background: Calcaneal apophysitis is a frequent cause of heel pain in children and is known to have a significant negative effect on the quality of life in affected children. The most effective treatment is currently unknown. The purpose of this study is to evaluate 3 frequently used conventional treatment modalities for calcaneal apophysitis. Methods: Three treatment modalities were evaluated and compared in a prospective randomized single-blind setting: a pragmatic wait and see protocol versus a heel raise inlay (ViscoHeel; Bauerfeind) versus an eccentric exercise regime under physiotherapeutic supervision. Treatment duration was 10 weeks. Inclusion criteria: age between 8 and 15 years old, at least 4 weeks of heel pain complaints due to calcaneal apophysitis based, with a minimal Faces Pain Scale-Revised of 3 points. Primary exclusion criteria included other causes of heel pain and previous similar treatment. Primary outcome was Faces Pain Scale-Revised at 3 months. Secondary outcomes included patient satisfaction and Oxford Ankle and Foot Questionnaire (OAFQ). Points of measure were at baseline, 6 weeks, and 3 months. Analysis was performed according to the intention-to-treat principles. Results: A total of 101 subjects were included. Three subjects were lost to follow-up. At 6 weeks, the heel raise subjects were more satisfied compared with both other groups (P<0.01); the heel raise group improved significantly compared with the wait and see group for OAFQ Children (P<0.01); the physical therapy group showed significant improvement compared with the wait and see group for OAFQ Parents (P<0.01). Each treatment modality showed significant improvement of all outcome measures during follow-up (P<0.005). No clinical relevant differences were found between the respective treatment modalities at final follow-up. Conclusions: Treatment with wait and see, a heel raise inlay, or physical therapy each resulted in a clinical relevant and statistical significant reduction of heel pain due to calcaneal apophysitis. No significant difference in heel pain reduction was found between individual treatment regimes. Calcaneal apophysitis is effectively treated by the evaluated regimes. Physicians should deliberate with patients and parents regarding the preferred treatment. Level of Evidence: Level 1—therapeutic randomized controlled trial.

Background: The aim of this study was to assess the patient demographics, epidemiology, mechanism of injury, and natural history of pelvic apophyseal avulsion fractures. Methods: A retrospective records review of imaging and clinical documentation was performed for patients diagnosed with pelvic apophyseal avulsion fractures at our institution from 2007 to 2013. Patient’s Risser score, triradiate status, fracture location, size, and displacement were recorded based on initial injury radiographs. Further clinical and radiographic chart review was utilized to determine mechanism of injury, presence of multiple/bilateral injuries, nonunion, chronic pain, as well as any surgical interventions performed. Results: We identified 225 patients diagnosed with 228 apophyseal avulsion fractures with mean age of 14.4 years. Males represented 76% of the patients. Anterior inferior iliac spine (AIIS) avulsions were the most common, representing 49% of all avulsion fractures, followed by anterior superior iliac spine (30%), ischial tuberosity (11%), and iliac crest (10%). The most common mechanism of injury was sprinting/running (39%) followed by kicking (29%), but the mechanism varied by fracture type with 50% of AIIS avulsions caused by kicking. Multiple pelvic fractures were identified in 6% of patients. Pain >3 months out from initial injury was present in 14% of all patients and AIIS avulsion fractures were 4.47 times more likely to have chronic pain. Five nonunions were identified, 4 of which were ischial tuberosity avulsions. Initial fracture displacement >20 mm increased the risk of nonunion by 26 times. Surgical treatment was indicated in 3% of cases. Conclusions: In this series, nearly all pelvic avulsion fractures (97%) were managed successfully with a conservative approach. Contrary to prior studies, AIIS avulsions represented half of the avulsion fractures. AIIS and ischial tuberosity fractures are at increased risk of developing future pain and nonunions, respectively. Patients and families need to be counseled about this possibility because future intervention may be necessary. Level of Evidence: Level IV—therapeutic.

Background: Much attention has been given to the relationship between various training factors and athletic injuries, but no study has examined the impact of sleep deprivation on injury rates in young athletes. Information about sleep practices was gathered as part of a study designed to correlate various training practices with the risk of injury in adolescent athletes. Methods: Informed consent for participation in an online survey of training practices and a review of injury records was obtained from 160 student athletes at a combined middle/high school (grades 7 to 12) and from their parents. Online surveys were completed by 112 adolescent athletes (70% completion rate), including 54 male and 58 female athletes with a mean age of 15 years (SD=1.5; range, 12 to 18 y). The students’ responses were then correlated with data obtained from a retrospective review of injury records maintained by the school’s athletic department. Results: Multivariate analysis showed that hours of sleep per night and the grade in school were the best independent predictors of injury. Athletes who slept on average <8 hours per night were 1.7 times (95% confidence interval, 1.0-3.0; P=0.04) more likely to have had an injury compared with athletes who slept for ≥8 hours. For each additional grade in school, the athletes were 1.4 times more likely to have had an injury (95% confidence interval, 1.2-1.6; P<0.001). Conclusion: Sleep deprivation and increasing grade in school appear to be associated with injuries in an adolescent athletic population. Encouraging young athletes to get optimal amounts of sleep may help protect them against athletic injuries. Level of Evidence: Level III.

Background: Abnormal range of motion (ROM) is a common sign of pathology in the pediatric hip, yet there are little data in the literature defining what the normal hip ROM is in children. The purpose of this study was to establish normative values for hip ROM in children of varying ages. Methods: We performed an Institutional Review Board approved, prospective study of otherwise healthy patients receiving fracture care at our institution. Inclusion criteria were boys and girls aged 2 to 17, who were being treated for an isolated upper extremity injury and who had no underlying musculoskeletal condition, history of lower extremity injury, or other systemic diagnosis. All patients were evaluated with a standard measurement technique using the same double–long-armed goniometer. Supine abduction, adduction, and hip flexion were measured with care taken to stabilize the pelvis. Internal and external rotation in flexion were assessed with both the hip and knee flexed to 90 degrees. In the prone position, hip extension was recorded as was internal and external rotation in extension. Left and right measurements were averaged to produce a single data point for each index. On the basis of a power analysis (to detect a minimal detectable difference of 6 degrees), 2 separate cohorts of 23 patients were randomly selected for the assessment of intraobserver and interobserver reliability. Results: We measured 504 hips in 252 pediatric patients, including 163 boys and 89 girls. We found a decreasing trend in ROM for almost all indices with advancing age, although this decline was less apparent among girls. Intraobserver reliability demonstrated excellent agreement (intra class correlation coefficient>0.81) for all indices. Interobserver assessments revealed excellent agreement for abduction, external rotation in flexion, internal rotation in extension, and external rotation in extension. Substantial agreement (intra class correlation coefficient, 0.61 to 0.8) was found for adduction, flexion, extension, and internal rotation in flexion. Conclusions: Normative values for hip ROM in children of varying ages have been established with acceptable intraobserver and interobserver reliability. Level of Evidence: Level II (Diagnostic).

Abstract: We devised a new Functional Mobility Scale (FMS) to describe functional mobility in children with cerebral palsy, as an aid to communication between orthopaedic surgeons and health professionals. The unique feature of the FMS is the freedom to score functional mobility over three distinct distances, chosen to represent mobility in the home, at school and in the wider community. We examined the construct, content, and concurrent validity of the FMS in a cohort of 310 children with cerebral palsy by comparing the FMS to existing scales and to instrumented measures of physical function. We demonstrated the scale to be both valid and reliable in a consecutive population sample of 310 children with cerebral palsy seen in our tertiary referral center. The FMS was useful for discriminating between large groups of children with varying levels of disabilities and functional mobility and sensitive to detect change after operative intervention.