Background: Outcomes following shoulder instability events suggest high rates of recurrence for the pediatric population. Previous studies have not focused on those with open physes at the proximal humerus, and longer-term surgical outcomes have not been evaluated for this population. The purpose of the current study is to evaluate patient-reported outcomes and recurrence rates in skeletally immature children and adolescents undergoing arthroscopic stabilization procedures. Methods: A retrospective review of all skeletally immature patients who underwent arthroscopic shoulder stabilization between 2009 and 2021 from 2 pediatric hospitals was performed. Demographic, injury, imaging, and intraoperative data were recorded. Patient-reported outcomes, including the Pediatric/Adolescent Shoulder Survey (PASS), return to sport, instability recurrence, and need for revision surgery, were documented. Statistical analysis was performed to assess risk factors for recurrence. Results: One hundred one skeletally immature patients met the inclusion criteria. The mean age at the time of surgery was 14.8 ± 1.4 years, and 74% were males. The majority of patients had anterior instability (78%), 17% had posterior instability, and 5% had multidirectional instability. Contact sports were responsible for 47% of injuries. The average number of dislocations before surgery was 2.6 ± 3.4. At a mean follow-up of 5.1 ± 2.9 years, the mean PASS score was 88 ± 14. A total of 35 patients (34.7%) experienced recurrent instability, and 10 patients (10%) had a revision procedure. Patients with recurrent instability were found to be younger, had longer clinical follow-up duration, and had a lower final PASS score. Direction of instability was not associated with recurrence rate. Other factors such as sex, number of dislocations before surgical intervention, and participation in contact sports were not significantly associated with recurrent instability. Conclusions: While the majority of skeletally immature children and adolescents undergoing arthroscopic shoulder stabilization can achieve favorable outcomes, recurrent instability remains a problem, as ∼1 in 3 patients may experience recurrent instability with younger patients being at particular risk. Level of Evidence: Level IV—retrospective case series prognostic study.

Objective: This study aims to comparatively evaluate clinical and radiologic outcomes of lateral humeral condyle fractures (LHCFs) in infants (0 to 12 mo), toddlers (1 to 3 y), preschool childrens (3 to 5 y), and school-age childrens (5 to 12 y) with a secondary objective of assessing the prognostic utility of the Normalized Lateral Elbow Swelling-to-Humerus Diameter (N-LES-H) index, particularly for Jakob Type I fractures. Methods: A total of 133 pediatric patients treated for LHCFs between 2012 and 2023 were retrospectively reviewed. Patients were stratified by age and treatment modality (operative vs. nonoperative). Fractures were classified per the Jakob system. For Jakob Type I injuries, the N-LES-H index was calculated using AP radiographs. Functional outcomes were measured through the Mayo Elbow Performance Score (MEPS) and Flynn criteria. Radiographic outcomes included deformity (varus/valgus), lateral condylar overgrowth, and avascular necrosis (AVN). Statistical analyses included logistic regression and ROC analysis. Results: Among 133 patients (mean follow-up: 6.2 ± 2.5 y), 63 were <36 months (32 conservatively, 31 operatively treated) and 70 were >36 months (34 conservative, 36 operative). An N-LES-H index >1.8 significantly predicted surgical necessity in Jakob Type I fractures (AUC: 0.884, P<0.001). Varus deformity (>5 degrees) and condylar overgrowth were more prevalent in younger surgical patients (P<0.05). MEPS outcomes were excellent in 132 cases. According to Flynn criteria, outcomes were excellent in 114, satisfactory in 16, and poor in 3, with significant group differences (P<0.05). Conclusion: Although complication rates were higher in the <36-month cohort, age-appropriate treatment yielded favorable functional outcomes. Conservative management was effective in selected Type I and II fractures in this group, likely due to greater remodeling potential. The N-LES-H index proved to be a reliable, objective and age-independent tool for treatment stratification in Jakob Type I LHCFs. These findings support the integration of the N-LES-H index into clinical decision-making algorithms and warrant validation through future multicenter prospective studies. Level of Evidence: Level III—Retrospective comparative study.

Background: Lateral extra-articular tenodesis (LET) has gained popularity as a supplementary method for ACL reconstruction (ACL-R) to reduce the risk of graft rupture in adults. However, information on the effectiveness and safety of this procedure in pediatric and adolescent patients remains limited. This study aimed to evaluate the functional outcomes and complications of lateral extra-articular tenodesis associated with ACL-R in adolescents at a minimum follow-up of 2 years. Methods: A consecutive series of patients aged ≤18 years who underwent ACL-R + LET in a 6-year period was retrospectively analyzed. Outcome measures included participants’ return to sports, complications, concomitant or subsequent surgical procedures, and patient-reported outcome measures such as the Single Assessment Numeric Evaluation (SANE), Pediatric International Knee Documentation Committee (Pedi-IKDC), and HSS Functional Activity Brief Scale (HSS Pedi-FABS). Results: Forty-two patients were included in the final analysis. The mean follow-up duration was 41 months, with a mean patient age of 16.1 ± 2 years (range: 13 to 18 y); 81% were male. Thirty-nine patients (93%) participated in organized sports such as soccer, rugby, or volleyball. Autologous hamstring tendon grafts were used in 100% of cases. At a mean follow-up of 41 months (range: 24 to 66 mo), the median SANE, Pedi-IKDC, and HSS-Pedi FABS scores were 89.1, 94.3, and 26.7 points, respectively. A 100% successful return to sport (RTS) was observed at a mean of 10.2 months, with 89.7% of patients returning to their preinjury or a higher level of sport. Three patients (7%) underwent additional ipsilateral knee surgical procedures, comprising 2 meniscal surgeries and one arthroscopic lysis of adhesions. No graft injuries were observed during the study period. Conclusion: The findings of this study suggest that ACL-R associated with LET in high-risk adolescent patients is associated with favorable patient-reported outcomes, a high return to sports, and a low rate of complications, including graft rupture, at an average follow-up of 3.5 years. Study Design: Case series. Level of Evidence: Level IV.

Background: Volcano deformity is an intra-articular deformity discovered after the wide use of the tension band plate (TBP) all over the world. Controversy on whether this is a pervasive effect that applies to all TBP treatments or just a sporadic event is still under debate. In contrast, percutaneous epiphysiodesis using transphyseal screws (PETS) has been under the radar for producing intra-articular influence. This study aimed to evaluate the potential for such central deformity. Methods: Fifty-three patients who received percutaneous epiphysiodesis using transphyseal screws (PETS) from January 2017 to March 2024 to both the distal femur and proximal tibia at our institution were reviewed. Forty-two patients with a minimum 1-year follow-up with a minimum 1-year implant retention period were included in the study. For the quantitative analysis, 2 sets of radiographs were selected. The first set consisted of the immediate postoperative X-rays, while the second set comprised the latest follow-up radiographs meeting the defined inclusion criteria. Radiologic parameters for assessment of central deformity for our study were intercondylar distance, intercondylar notch depth (femur), and intercondylar eminence height (tibia). In addition, preoperative scanogram and final scanogram at the last follow-up were used to assess alignment. Results: The operated limb demonstrated a significant decrease in intercondylar distance between initial and final radiographs (mean change: −1.92±1.46 mm, P<0.001), while the nonoperated limb showed no statistically significant change (P=0.094). Furthermore, notable differences were observed in other parameters of the operated limb. Intercondylar notch depth decreased by −1.47±1.45 mm (P<0.001), and intercondylar eminence height increased by 0.85±0.92 mm (P<0.001). In contrast, measurements on the nonoperated limb remained consistent, mirroring the findings for intercondylar distance. Conclusions: Intra-articular deformity may result from PETS for both the femur and the tibia. The clinical importance of these findings is yet to be determined. Further research is needed to better understand the nature of this change. Level of evidence: Level IV.

Background: Monteggia fractures are a complex elbow injury that can be missed in up to 50% of pediatric elbow injuries during initial radiographic assessment due to their subtlety. The development of more advanced diagnostic tools is crucial to ensure appropriate treatment for patients. This study investigates whether an automated deep learning pipeline can accurately identify these injuries by quantifying radiocapitellar misalignment and detecting associated ulnar fractures. Methods: The automated pipeline utilizes a 2-step, deep learning approach to detect both characteristics of a Monteggia fracture. To identify radial head dislocation, 320 pediatric anteroposterior (AP) and lateral elbow radiographs were used to train a U-Net++ neural network to segment the capitellum and radial neck. Segmentation accuracy was evaluated using the Dice score and intersection over union (IoU). The output segmentations were used to algorithmically construct the radiocapitellar line and measure its displacement from the capitellum. A binary classifier was then trained on 157 paired AP and lateral radiographs to detect the presence of ulnar fractures. Results: The pipeline displayed high accuracy for the segmentation of both the capitellum (Dice: 0.878 ± 0.098; IoU: 0.794 ± 0.130) and radial neck (Dice: 0.912 ± 0.105; IoU: 0.852 ± 0.142). For the detection of radial head displacement, the model achieved a sensitivity of 92.3%, specificity of 96.3%, and accuracy of 95.0% on lateral elbow radiographs, and a sensitivity of 100.0%, specificity of 96.9%, and accuracy of 97.5% on AP radiographs. The ulnar fracture detection model achieved an accuracy of 87.5% and an area under the curve of 0.923. Conclusion: This study introduces an automated pipeline for the detection of Monteggia fractures in pediatric radiographs. By combining segmentation-based measurement of radial head displacement with binary detection of ulnar fractures, the pipeline demonstrates high diagnostic performance. The model’s ability to detect subtle radiographic findings with performance metrics exceeding those of expert interpretation highlights its potential as a clinical decision support tool. Level of Evidence: Level III.

Background: Patellofemoral instability is common in adolescent patients and is frequently associated with increased tibial tuberosity–trochlear groove (TT-TG) distances. Medial patellofemoral ligament (MPFL) reconstruction is a standard treatment; however, the role of tibial tubercle osteotomy (TTO) remains debated. Methods: A retrospective chart review was performed of patients with TT-TG distances ≥20 mm who underwent MPFL reconstruction between 2012 and 2022, with a minimum 2-year follow-up. Patients were stratified into 2 cohorts: MPFL with TTO and MPFL without TTO. Demographic, radiographic, and operative variables were collected, including TT-TG, Insall-Salvati ratio, trochlear dysplasia index (TDI), and tibial tubercle–posterior cruciate ligament (TT-PCL). Outcomes included complications, recurrent instability, and patient-reported outcomes (PROs): Single Assessment Numeric Evaluation (SANE), Kujala, pain, and satisfaction. Results: Thirty patients (31 knees) were analyzed (15 TTO, 16 non-TTO). The cohort’s mean age was 15.3 years, with a mean follow-up of 5.7±2.8 years (TTO) and 4.8±2.1 years (non-TTO) (P=0.40). The TTO cohort had higher TT-TG distances (22.6±2.3 mm vs. 20.8±0.8 mm; P=0.01), elevated Insall-Salvati ratios (1.7±0.2 vs. 1.5±0.3; P=0.04), and longer tourniquet times (83.4±29.0 vs. 56.9±22.1 min; P=0.01). TDI and TT-PCL were not significantly different. No differences were observed in PROs: SANE (84.3±9.3 vs. 86.8±7.2; P=0.42), Kujala (91.4±8.0 vs. 88.5±10.9; P=0.48), pain (1.2±1.6 vs. 1.6±2.1; P=0.88), or satisfaction (9.1±1.1 vs. 9.4±0.8; P=0.56). Complication rates (P=1.0), recurrent instability (P=0.64), return-to-sport (P=1.00), and revision rates (P=0.39) were similar between groups. Conclusions: The addition of TTO to MPFL reconstruction in adolescents with elevated TT-TG distances did not result in significant differences in complications, PROs, or recurrent instability compared with MPFL alone. TTO may not be required in all cases and should be reserved for select patients based on individual anatomic and clinical factors.

Background: Curve progression to surgical range in patients with adolescent idiopathic scoliosis (AIS) is strongly associated with the initial major curve angle and the degree of skeletal maturity as staged by the modified Proximal Humerus Ossification System (PHOS) and other systems. Our purpose was to (1) develop a prognostic model and risk score to estimate the probability of progression to surgical indications in untreated patients using the PHOS and (2) compare its performance to a model using the Risser stage. Methods: Patients from the BrAIST study and 2 other institutions were followed to either skeletal maturity (Risser 4+), a major curve angle of ≥45°, or spinal fusion. Candidate variables for the predictive models included age, sex, major curve angle, Scoliosis Research Society (SRS) curve classification, status of triradiate cartilage, Risser stage, and PHOS. Model calibration and discrimination were evaluated. A probability threshold was set, creating low- and high-risk groups to aid in clinical decision-making. Results: Overall, 164 patients (77% female) were included. The mean age at presentation was 12.2±1.4 years (range: 10 to 16 years), and the mean maximum major curve angle was 24±9° (range: 10° to 43°). Fifty-six (34%) patients progressed to a surgical range or had a spinal fusion. The PHOS model included the major curve angle and the presence/absence of a thoracic apex. The model demonstrated strong discrimination (c-statistic = 0.89) and calibration (ICI = 0.02), performing similarly to one developed in this sample using the Risser stage. The sensitivity was 0.91, the specificity was 0.71, the PPV was 0.62, and the NPV was 0.94 at the probability cut-point of 0.22. Conclusions: This study derived a prognostic model estimating the baseline risk of progression to surgical indications in AIS patients using the PHOS. Estimates from this model can inform the shared decision-making process and motivate compliant bracing. Further validation in larger independent samples and exploration of the PHOS to predict bracing outcomes should be performed. Diagnostic Study Level II.

Purpose: Different cast configurations are available in the literature for the application of the Ponseti cast. To dispel the ambiguity and generate better evidence, we tested 2 cast configurations (standard vs. reinforced) for their effectiveness in terms of retained ankle dorsiflexion and overall cast integrity. Methods: We randomized the 2 limbs of a child with bilateral idiopathic clubfeet (n=30 children) to receive a weight-matched standard cast (circular rolls only) or a reinforced cast (additional knee and plantar slabs). The post tenotomy cast was chosen as the index cast for the research purpose. Evaluations included clinical ankle dorsiflexion, immediate post tenotomy, and at the time of cast removal. Any cast breakages were also noted. Results: The mean child’s age was 3.5 months. The mean ankle dorsiflexion achieved immediately post tenotomy in either cast configuration was identical (15.5 degrees). At follow-up, 9 children presented with broken casts, 2 bilaterally. Overall, 9 standard (30%) and 2 reinforced (7%) casts were broken. For the broken casts, the ankle dorsiflexion was lost significantly. On intergroup comparisons, the reinforced casted limbs retained the ankle dorsiflexion significantly better (P=0.008) compared with the standard configuration. Conclusions: The reinforced cast configuration retained the ankle dorsiflexion much better than the standard cast. Frequent breakages were also noted with the standard cast.

No abstract available

Introduction Song V lateral humeral condyle fractures represent a displaced and rotated fragment, historically treated with open reduction and percutaneous pinning (ORPP) or screw fixation (ORSF). We aim to describe outcomes of Song V fractures and analyze the effect of fixation and reduction type on outcomes. Methods: This retrospective review assessed data from 6 level 1 trauma centers from 2005 to 2019. Inclusion criteria were children aged 1 to 12 with a Song V fracture. Patient clinic and surgical notes until 1 year after the primary intervention were reviewed. Radiographic healing data were collected. Complication metrics included nonunion, delayed union, elbow stiffness, and superficial or deep infection. Results: A total of 281 Song V lateral humeral condyle fractures were analyzed from the 6 centers. The mean age was 8.8 years, and 65.1% were male. K-wires were used in 223 patients (79%) and screws in 58 patients (21%). In all, 6 patients (2.1%) experienced a superficial infection, and 6 patients (2.1%) experienced a deep infection. Five patients experienced nonunion (1.8%). For patients undergoing an ORSF, 78% were radiographically healed at 3 months compared to 81% of patients undergoing an ORPP. No statistically significant differences between ORSF and ORPP were observed for outcome measures such as nonunion, stiffness, and infection, but notably, all 12 infections occurred in the K-wire group. Open reduction was utilized in 268 (95.4%) patients, compared with closed reduction in 13 (4.6%) patients. No significant relationships were seen between reduction type and complications, although results suggested increased rates of infection and elbow stiffness for those with open reduction. Conclusions: The current study is the largest analysis of Song V fractures. We found nonunion and deep infection to occur in roughly 2% of patients. Outcomes were comparable between ORSF and ORPP, with similar rates of radiographic healing, nonunion, and stiffness, while increased infection rates were seen for ORPP. Our findings also suggest closed reduction may be noninferior to open reduction, although further research with a larger sample size is necessary. Level of Evidence: Level III.

Background: Potential complications after elastically stable intramedullary nailing (ESIN) of pediatric forearm fractures include nonunion and malunion. Malunion, especially affecting the radial bow, has been linked to poor postoperative forearm rotation. Pre-bending of nails has been cited as a key step to achieve optimal construct biomechanics and maintain reduction. We hypothesise that unlike in larger medullary diameter bones such as the femur, pre-bending of nails for the treatment of paediatric forearm fractures has no effect on postoperative outcomes. Methods: Forearm fractures treated with ESIN to both bones in our tertiary paediatric orthopaedic centre were identified. Exclusions were made for Galeazzi, Monteggia, intra-articular, and pathologic fractures. Radiographic data, including time to union and magnitude and location of radial bow, were recorded. Demographics, implant data, complications, and time to return of forearm rotation were collected through retrospective review of clinical notes. Results: One hundred three eligible patients were identified with 33 receiving pre-bent nails and 70 receiving unbent nails. There were no significant differences in age, sex, or proportion of open fractures between cohorts. Mean location of maximal radial bow was 69% in both cohorts (P=0.942) and no significant difference in magnitude of maximal radial bow was observed between the pre-bent and unbent cohorts (4.9% vs. 5.3%, P=0.199). Regarding the pre-bent and unbent cohorts there were no significant differences observed in median time to restoration of normal forearm rotational movement (100 vs. 81 d, P=0.452), time to union (44 vs. 42 d, P=0.527), nail diameter used (2.3 vs. 2.2, P=0.138), or complication rates (12% vs. 14%, P=0.911). Conclusions: Pre-bending of the nails before insertion does not have a significant effect on the time to union, restoration of the radial bow, or forearm rotation. As such, this likely represents an unnecessary step in children for whom narrower canal diameters enable a straight nail to provide sufficient cortical contact, stability, and tension to the interosseous membrane. Level of Evidence: Level IV (case series).

Background: Studies on the effect of low serum 25-hydroxyvitamin D level (25OH vit D) on the fracture risk in pediatric patients have had inconsistent results when comparing patients with fractures to healthy controls and patients with upper to lower extremity fractures. Some studies reported that low 25OH vit D was associated with operative treatment of fractures. We decided to compare 25OH vit D between different fracture sites and between fractures treated operatively and nonoperatively. Our primary null hypothesis was that there would not be any differences in 25OH vit D between different sites of fracture. Secondary null hypothesis was that there would be no difference in 25OH vit D between operative and non-operative treatment subgroups. Methods: After IRB approval, we prospectively enrolled pediatric patients with fractures and ordered the lab test for 25OH vit D between October 2021 and April 2025. Inclusion criteria were ages 3 to 18 and upper or lower extremity fractures; exclusion criteria were pathologic fracture, vertebral or pelvic fracture, or patients with metabolic and neuromuscular disorders. Eligible patients were divided into upper extremity (UE), lower extremity above ankle (LEAA), and ankle/foot (AF) fracture groups. Results: The 25OH vit D in the LEAA group (18.9 ng/mL, n=52) was significantly lower than that in the UE group (25.7 ng/mL, n=64, P<.0001) and that in the AF group (23.7 ng/mL, n=40, P=.0033). Defining vitamin D deficiency as 25OH vit D <20 ng/mL and sufficiency as ≥ 30 ng/mL, the percentage of patients with vitamin D deficiency in LEAA group (58%) was significantly greater than that in the UE (30%) and in the AF (30%) groups. The percentage of patients with 25OH vit D sufficiency in the LEAA group (8%) was significantly less than that in the UE (31%) and in the AF (23%) groups. The overall operative treatment subgroup 25OH vit D (21.4 ng/mL, n=87) was lower than that of the non-operative treatment subgroup (24.7 ng/mL, n=69, P=.02). However, within each group, LEAA, UE, and AF, 25OH vit D in the operative and nonoperative treatment subgroups were not significantly different. Conclusions: In our study, lower extremity above ankle fractures had significantly lower 25OH vit D, higher incidence of vitamin D deficiency, and lower incidence of vitamin D sufficiency compared with upper extremity or ankle/foot fractures. Comparing operative and non-operative treatment subgroups, 25OH vit D was lower in the overall operative treatment subgroup but within each group, UE, LEAA, and AF, no significant differences were found between the subgroups. One possible explanation for the discrepancy was that a greater percentage of upper extremity fractures with the higher 25OH vit D was treated nonoperatively (58% = 37/64) and a greater percentage of LEAA fractures with the lower 25OH vit D was treated operatively (81%=42/52). Further studies to confirm these findings and to study associations of vitamin D levels with sites of fracture and treatment methods are needed. Our finding that vitamin D deficiency is in ≥30% of pediatric patients with upper and lower extremity fractures would support the recommendation made by other authors to test 25OH vit D in all pediatric fracture patients. Level of Evidence: Diagnostic level II—development of diagnostic criteria on basis of consecutive patients

Background: Hip displacement in cerebral palsy (CP) is common, with incidence linked to ambulatory status. In the past, children 6 years of age or younger were treated with adductor releases alone, but a high failure rate was reported. Proximal femoral guided growth (PFGG) has had modest improvements in hip migration (∼10%) for older children (6 y of age or older). The purpose of this study was to evaluate the effects of age and preoperative migration percentage (MP) severity on treatment success for young children (6 y of age or younger) with CP. Methods: Children with CP 6 years of age or younger, all Gross Motor Function Classification System (GMFCS) levels and motor types, undergoing PFGG ±adductor tenotomies, were identified. Children were stratified by age (younger than 4, 4 to 6 y), motor type, and preoperative MP. The primary outcome was the MP. A successful outcome was defined as a ∆MP ≥10% (definitive improvement) or ∆MP <5% (no progression) at final follow-up. Changes in MP and differences in success rates between age groups were determined. Results: Forty-four patients (78 hips) were included; follow-up was 1.9 (range: 0.8 to 4) years (22 [50%] ≥2 years follow-up). Concurrent adductor tenotomies were performed in 33 hips. All GMFCS levels showed improvement (GMFCS I-III: MP 37% to 29%, P=0.007, GMFCS IV to V: MP 43% to 37%, P<0.001). Greater MP improvements were seen for hips with preoperative MP ≥40% and for patients <4 vs 4 to 6 years old [41% to 28% (P<0.001) vs. 37% to 37% (P=0.44), respectively]. Definitive improvement was seen in younger children (younger 4 vs. 4 to 6 y: 62% vs. 13%, respectively; P=0.003), and both age groups had high success with no progression (100% vs. 81%, respectively; P=0.07). Conclusions: PFGG was associated with improved hip migration for patients 4 years of age or younger, with high rates of success (no progression) for both age groups. Greater MP improvement was seen with MP ≥40%, possibly secondary to concomitant femoral neck shortening. Although PFGG offers a promising minimally invasive treatment for younger children with CP, further studies with longer follow-up duration, increased sample size, and comparison to an adductor-only group are necessary to determine its true efficacy. Level of Evidence: Level III.

Background: Numerous brace choices exist for the management of adolescent idiopathic scoliosis (AIS); however, there is sparse literature comparing brace efficacy. Much of current bracing practice likely reflects institutional preferences rather than comparative data. Methods: A review of patients age 10 to 18 with AIS of 20 to 45 degrees who were Risser 0 to 2 at initiation of brace treatment treated at a single center was performed. Patients were included if they had completed brace treatment and had either a minimum of 6 month out of brace follow-up or had undergone surgery. Brace success was defined as curve progression ≤5 degrees without the need for surgery. Patients were treated with a Providence nighttime brace (PNB), Boston TLSO (BB), or Rigo-Cheneau (RC) custom brace. Results: Patients treated with 32 PNB, 30 BB, and 37 RC braces met all inclusion criteria. 88% were female, with an average age at brace initiation of 12.0 years. Sixty-two percent of females were premenarchal at the onset of bracing and 66% were Risser 0. Thoracic, thoracolumbar, and lumbar curves averaged 27±7 degrees, 29±6 degrees, and 26±6 degrees at initiation. Thoracic in-brace curve correction was 46±34% compared with thoracolumbar curves (73±36%). Forty-four patients (44%) progressed >5 degrees and 19 patients (19%) progressed to surgery. Twenty-seven percent of patients treated with a BB progressed to surgery compared with 13% of RC and 13% of PNB patients (P=0.2). Among Risser 0 patients, 55% of BB patients progressed to surgery compared with 11% of RC and 10% of PNB patients (P=0.03). Multivariate regression analysis found that skeletally immature (R0) patients treated with a BB had a 5.6-fold higher risk of surgery than RC or PNB patients (P=0.04) and a 2.8-fold higher risk of curve progression (P=0.09); however, this difference was not seen in Risser 1 or 2 patients. Conclusions: Skeletally immature patients (Risser 0) treated with a BB were nearly 6x more likely to require surgery when compared with those treated with a RC or PNB. Patients who were Risser 1 or 2 were successfully treated in any of the 3 braces. Level of Evidence: Level III—retrospective comparative study.

One of the greatest German Renaissance artists, Albrecht Dürer, noted for his realistic works of art, painted and engraved the Christ child and Eve with characteristic postures of the upper limb resembling the sequel of Erb palsy. However, there is no Biblical evidence to suggest that the Christ child or Eve had paralysis of the upper limb. It appears conjectural as to why Dürer chose to depict the limbs of his subjects in this manner.

Background: Distal radius fractures involving the physis are among the most common upper extremity injuries in children and adolescents. Unlike transitional fractures of the distal tibia, known as Tillaux and triplane fractures, transitional fractures of the distal radius have not been well characterized. This study aims to evaluate Salter-Harris III and IV fractures of the distal radius in the pediatric transitional age population to determine if a characteristic fracture pattern exists analogous to the distal tibia. We hypothesized that pediatric transitional fractures of the distal radius would follow a pattern that would ultimately dictate treatment and predict outcomes. Methods: A retrospective chart review of pediatric patients with transitional fractures of the distal radius at a single institution was performed. Salter-Harris III and IV fractures of the distal radius with CT imaging were included. Two independent reviewers determined the metaphyseal fracture plane and the major intra-articular epiphyseal fracture fragments. Descriptive statistical analysis was performed. Results: Thirty patients who met inclusion criteria made the study cohort. There were 5 Salter-Harris III fractures and 25 Salter-Harris IV fractures. Mean age at the time of injury was 15±1.5 years. The metaphyseal fracture demonstrated a coronal fracture plane in all cases, and 20% had a sagittal plane component. The major epiphyseal fracture fragments were identified as dorsal ulnar corner in 70%, radial column in 43%, volar rim in 30%, and dorsal wall in 17%. Patients were treated with open reduction and internal fixation (N=12, 40%), closed reduction and percutaneous pinning (N=4, 13%), or cast immobilization (N=14, 47%). Most patients (N=24, 80%) did not demonstrate a growth disturbance after treatment. Angular deformity, however, was significantly higher in patients with a primary dorsal ulnar corner epiphyseal fragment (N=4, 19% vs. N=0%, P=0.03). Conclusion: Transitional fractures of the distal radius occurred on average at age 15. The injuries demonstrated a consistent pattern, with a coronal fracture plane in the metaphysis and a dorsal ulnar corner fragment in most epiphyses. The dorsal physis may be the strongest portion of the distal radius at the time of injury, though mechanism of injury may impact patterns as well. Level of Evidence: Level III.

Introduction: Legg-Calvé-Perthes disease (LCPD) often causes residual deformities, typically manifesting as an ellipsoidal femoral head shape. This condition arises from initial bone collapse and necrosis, inhibiting growth at the anterosuperior femoral head and resulting in asymmetric growth. The aim of this study is to assess the effectiveness of selective hemiepiphysiodesis in improving femoral head sphericity in patients with LCPD with previous onset of ovalization. Methods: We compared 71 hips undergoing prophylactic selective hemiepiphysiodesis (surgical group) against 86 hips managed nonsurgically (control group). Radiographic evaluations were performed at 3 time points (3 y after disease onset, 5 y after disease onset, and skeletal maturity) to assess disease progression and intervention effects, measuring the ellipsoidal index (EI), the Reimer migration index (RMI), and the articulotrochanteric distance (ATD), with classifications according to the Herring scale and final sphericity assessments. Results: Both cohorts were initially comparable in terms of age at onset, sex, and degree of deformity, showing similar EI, Herring classifications, and RMI (P>0.05). At T2, significant improvements were observed in the EI, RMI, and ATD in the surgical group compared with the control group. At skeletal maturity, the surgical group demonstrated significantly improved sphericity across all 3 indices (P<0.05), confirming the effectiveness of selective hemiepiphysiodesis in halting and partially reversing the ovalization process. The sphericity deviation score was significantly lower in the operated group (28±12) compared with the control group (43±28), the EI improved to 1.68±0.25 in the operated group from 2.11±0.33 in the controls, and the RMI showed a marked improvement (24.0±8.1) compared with controls (32.4±7.3). Conclusions: Growth modulation by selective hemiepiphysiodesis effectively disrupts the progression of femoral head ovalization and enhances sphericity. This intervention presents a viable option for mitigating the ellipsoidal process in patients with LCPD, suggesting a significant potential to improve long-term outcomes by addressing early signs of deformity. Level of Evidence: Level III—retrospective cohort study.

Background: With an annual incidence of 177 per 100,000 patients, supracondylar humerus fractures (SCHF) are the most common elbow fracture in the pediatric population.1,2 Pain control after closed reduction and percutaneous pinning (CRPP) of SCHF may be improved with the use of a local anesthetic. We aimed to assess the effects of local bupivacaine administration on immediate post-operative pain and opioid requirements. Methods: A retrospective chart review was performed for patients undergoing CRPP of SCHF from September 1, 2018 to September 30, 2022 at a single institution. Two groups (local vs. no local) were formed based on intraoperative administration of bupivacaine. Post-anesthesia care unit (PACU) records were reviewed for type and dose of pain medications administered and pain scores. Results: Three hundred thirty-five patients (114 local, 221 no local) were included in review. No differences were noted in demographic or injury characteristics. The local and no-local groups had average PACU pain scores of 2.2±3.2 and 3.3±3.5, respectively. There was no significant difference between groups in percentage of patients who received Tylenol, Motrin, and Toradol. There was a significant difference in the number of patients who received morphine with 42% of patients in the local group requiring morphine compared with 64% of patients in the no-local group. The average weight-based dose of morphine in the local group was 0.002 mg/kg±0.001 and 0.003 mg/kg±0.008 in the no-local group. No differences were noted in postoperative complications or unexpected follow-up. Conclusions: The use of local bupivacaine intraoperatively improved pain control as evidenced by fewer patients requiring morphine and lower pain scores in the local group. Local bupivacaine is a low-cost, low-risk intervention that can be used after CRPP of SCHF that may improve immediate postoperative pain and facilitate quicker transition to oral pain medications with decreased need for IV opioid medications. Level of Evidence: Level IIIB—retrospective comparative study.

Background: In torsional malalignment syndrome (TMS), knee varus is observed when feet are neutral but disappears with external foot rotation. The underlying cause of this phenomenon—whether it results from visual alterations from limb rotation or reflects an additional structural abnormality in the lower extremity—along with the potential for simpler treatment options beyond rotational osteotomy, has not been previously investigated. Methods: Eighteen subjects with TMS and ten control subjects had weight-bearing orthoroentgenograms and non-weight-bearing 3D CT scans of the lower limb. Mechanical lateral distal femoral angle (mLDFA) and medial proximal tibial angle (MPTA) were measured. Changes in the mechanical axis during femoral rotation were analyzed with 2D and 3D CT images processed with Adobe Photoshop and PowerPoint. Morphologies of the distal femur and proximal tibia were evaluated. Six subjects received guided growth with percutaneous epiphysiodesis transphyseal screws (PETS). Results: TMS subjects showed significantly greater mLDFA and knee varus on weight-bearing radiographs, but not on 3D CT, indicating that weight-bearing contributes to the varus appearance. Although external rotation on 3D CT caused medial axis shift and mLDFA reduction in both groups, the degree of change in TMS subjects was similar to controls and insufficient to explain the pronounced varus, implying an additional structural abnormality. While femoral contours appeared normal, TMS subjects exhibited a significantly steeper posterior slope of the medial tibial plateau—averaging 7.0 degrees more than the lateral slope and also significantly steeper than in controls. In patients treated with PETS, the mean mLDFA improved from 90.2 to 88.1 degrees, and all reported cosmetic satisfaction, with no deterioration in LEFS or TLKSS scores. Conclusions: A steeper posterior slope of the medial tibial plateau likely contributes to knee varus in TMS subjects when feet are neutral. Although PETS doesn’t address the underlying rotational deformity, it improved coronal alignment and appearance in selected patients without functional compromise, offering a simple and cosmetically effective treatment alternative. Level of Evidence: Level III—diagnostic studies.

Background: Trauma centers may utilize fracture clinics primarily staffed by advanced practice clinicians (APC) for management of basic fractures that typically require few visits. It is unclear if provider continuity is important in these brief health care encounters. The purpose of this study was to determine the association between continuity of care and patient satisfaction scores in APC-run urgent/fracture clinics. Methods: This was a retrospective IRB-approved study at a pediatric tertiary-care Level-1 trauma hospital. We reviewed prospectively collected Press Ganey data from 2021 to 2023 for acute injury/fracture patients seen in a pediatric orthopaedic fracture clinic, which is APC-staffed and physician-supervised. Demographic and clinical data were collected along with the results of 4 Press Ganey patient satisfaction survey items (recommend provider, teamwork, recommend practice, overall rating). Univariate and multivariable models were conducted to determine independent predictors of patient satisfaction, including the effect of continuity of care. Results: A total of 230 follow-up encounters were reviewed. Median age was 11 years (range, 0 to 17). The majority of patients were male (59%), White (75%), with a very high child opportunity index (72%). Patients who saw the same provider at follow-up had a higher proportion of top-box ratings compared with those who saw a different provider for 3 of 4 outcomes: 88% versus 76% for staff teamwork (P=0.04), 94% versus 78% for recommend practice (P=0.003), and 93% versus 76% for overall rating of care (P=0.003). After adjusting for consistency of care, location, age, sex, child opportunity index, injury region, and geographical distance from clinic, the odds of receiving a top-box rating for recommend practice were 4.7 times higher (P=0.004) and 3.8 times higher for overall rating (P=0.002) for patients with continuity of care-provider. Conclusions: Continuity of APC care-provider has a positive impact on patient satisfaction in a pediatric fracture clinic, as patients who saw the same provider in successive follow-up visits. Demographic, geographic, and clinical factors had comparatively little effect on patient satisfaction. The provider remains a fundamental factor in patient experience. Level of Evidence: Level II.

Background: Increased femoral anteversion is a common problem in children, but the condition usually normalizes spontaneously over time. There is limited knowledge of the long-term consequences of persistently increased anteversion. The purpose of this study was to analyse the long-term functional complaints of untreated adults with idiopathic increased anteversion compared with a control group. Methods: Study participants were recruited from our institutional register of increased femoral anteversion during the period 1975 to 2008. Inclusion criteria were anteversion angle ≥30 degrees and no other disorders affecting the lower limbs. Outcome measures were the HAGOS and KOOS questionnaires, radiographic signs of osteoarthritis, and clinical examination. A control group of 24 healthy individuals was examined with the same methods. Results: Fifty-eight patients (46 females) with a mean age of 46.2 years were included in the AV group. The mean anteversion angle was of 40.2 degrees in the anteversion group and 20.6 degrees in the controls. The mean external foot progression angle was 0.5 degrees in the anteversion group and 4.6 degrees in the controls (P <0.001). The anteversion group scored significantly worse than the control group in 5 out of 6 HAGOS subscales: Pain (P=0.032), Symptoms (P=0.041), Sport/Rec (P=0.001), PA (P=0.036), and QOL (P=0.001). The KOOS subscale Symptoms was the only subscale with a worse score in the AV group (P=0.006). Only 1 patient in the anteversion group had hip osteoarthritis. Conclusions: Untreated adults with idiopathic increased femoral AV at a mean age of 46 years experienced more hip pain and limitations in participation in physical activities and sports compared with healthy individuals, but the limitations were mostly small to moderate and would hardly influence the present strict indications for surgical correction in children. Level of Evidence: Level II—prospective comparative study.

Background: Adolescent idiopathic scoliosis (AIS) is a common pediatric spinal deformity, with disparities in care often linked to socioeconomic status (SES). The Childhood Opportunity Index (COI) and Index of Concentration at the Extremes (ICE) are SES markers that have been used to evaluate health disparities in orthopaedic care. The utility of these SES markers in identifying differences in AIS presentation remains unclear. Methods: Medical records between 2017 and 2020 were reviewed for patients newly diagnosed with AIS from our city-center institution with around 600,000 patient encounters annually from all communities. Patient home addresses were used to assign nationally available COI 2.0 and ICE scores. COI, which ranges from 0.0 to 100.0, was categorized into quintiles: very low (<20.0), low (20.0 to 39.9), moderate (40.0 to 59.9), high (60.0 to 79.9), and very high (>80.0). ICE was divided into ICE White versus Black income (ICEwbinc) and ICE White, Black, and Hispanic income (ICEwnhinc), with scores ranging from −1 to 1. SES markers were evaluated for associations with major curve angle magnitude at presentation and at 1-year follow-up. Results: Of 486 eligible patients, 330 (67.9%) were female. The mean major curve angle at presentation was 26 degrees. Average COI was significantly higher in White patients (73.6) compared with Hispanic patients (30.4; P<0.001). ICEwbinc (0.4 vs. 0.0; P<0.001) and ICEwnhinc (0.33 vs. −0.1; P<0.001) were highest in White patients and lowest in Hispanic patients. Very low COI was associated with the highest average body mass index (23.4) compared with the very high COI group (20.5; P<0.001). SES markers were not associated with major curve angle at presentation and 1-year follow-up. Conclusions: SES markers were not associated with AIS presentation or progression. These findings contribute to the growing literature showing that equitable access to AIS care is increasing across the nation. Future studies should focus on the role of early clinical detection contributing to equal access to AIS care. Level of Evidence: Level III—retrospective comparative study.

Background: Musculoskeletal infections (MSKIs), including osteomyelitis and pyogenic arthritis, present significant health risks in pediatric populations. This study evaluates the risks of septic deep vein thrombosis (DVT), intensive care unit (ICU) admission, and mortality in children diagnosed with lower extremity MSKIs, with a focus on methicillin-resistant Staphylococcus aureus (MRSA) infections. Methods: This retrospective cohort study from a multi-institutional database included 38,023 pediatric patients diagnosed with lower extremity MSKIs. Incidence and risk factors for DVT, ICU admission, and mortality were collected. Comparisons were made between age groups and MRSA versus non-MRSA infections. The association between CRP levels and outcomes was also examined. Multivariable logistic regression models were utilized. Results: The mean age of the cohort was 8.49 years. Overall, 1.52% of patients developed septic DVT, 0.49% required ICU admission, and 0.48% died. Patients with MRSA had significantly higher risks of DVT (RR 4.89, P<0.001) and mortality (RR 3.57, P<0.001) compared with those without MRSA. CRP levels were also markedly higher in MRSA patients (P<0.001). When comparing age groups, those <12 years had a higher risk of ICU admission (RR 2.03, P<0.001), whereas the 12 to 18 age group had a higher risk of DVT (RR 0.71, P<0.001). Among patients with DVT, the mortality risk was significantly increased (RR 5.18, P<0.001). MRSA patients with DVT had the highest mortality risk (RR 5.38, P<0.001) and elevated CRP levels (P<0.001). Conclusions: Reporting the largest series of children with lower extremity MSKI, our study found increased risk of DVT, ICU admission, and mortality in pediatric patients with MRSA. MRSA patients with septic DVT had significantly higher level of CRP than those without DVT (100.95 mg/L vs. 61.59 mg/L, P<0.001). MRSA infections with septic DVT had the highest rate of mortality (7.24%). Clinicians should consider proactive screening and aggressive management strategies for septic DVT in the at-risk population, especially in patients with high CRP. Level of Evidence: Prognostic level III.

Introduction: Tibial shaft fractures are common fractures in children. The optimal management should be selected based on the fracture type, the child’s weight, and the presence of open growth plates. When surgical treatment is indicated, elastic-stable intramedullary nailing (ESIN) is considered the generally preferred method in children with open physes. However, in some cases, alternative treatment may be required. Aim: The aim of this study was to compare the outcomes of tibial shaft fractures in children treated with ESIN versus minimally invasive plate osteosynthesis (MIPO). Methods: Fifty-nine children were treated for unstable tibial shaft fractures between 2018 and 2023 (27 with MIPO and 32 with ESIN). Patients’ demographics, fracture type, surgery duration, and complications were recorded based on medical records. Bone healing, tibial axis, and implant position were assessed on follow-up radiographs. Functional outcomes were evaluated using the EFAS Questionnaire at 3.7±1.8 years (range: 1.0 to 6.8) after surgery. Results: Bone union was achieved in all patients. The total complication rate was 7.4% in the MIPO group and 15.6% in the ESIN group (P=0.4365). No reoperations were required in the MIPO group, while 12.5% of patients in the ESIN group required reoperation (P=0.1176). A plaster cast was applied in 46.9% of ESIN patients and in none of the MIPO patients. The surgery duration was significantly longer in the MIPO group (79.0 vs. 41.8 min in the ESIN group; P=0.0001). There was no significant difference in the final tibial axis at the final follow-up (2 ESIN patients underwent reoperation for axis correction). There was no significant difference in EFAS Questionnaire scores: 38.1±2.1 in the MIPO group versus 36.5±3.9 in the ESIN group (P=0.1235). Conclusions: Minimally invasive plate osteosynthesis is a promising alternative to elastic-stable intramedullary nails in the most severe, unstable tibial shaft fractures. Plating provides better stabilization without the need for a plaster cast; however, surgery time is longer. Level of Evidence: Level III.

Introduction: Safe retrograde femoral nail placement across the distal femoral growth plate could broaden fracture and reconstructive management options for skeletally immature patients, especially in resource-poor settings. Previous data suggested up to 7% of the distal femoral physis can be violated using a retrograde implant without subsequent growth arrest or inhibition. When the intramedullary implant is locked in the metaphysis, the bone will grow with the nail passing from the epiphysis to the metaphysis. However, the consequences of this growth across the physis are not well understood. Methods: Retrograde femoral nails measuring 8 mm in diameter with a single metaphyseal interlocking screw were inserted across the distal femoral physis of a single hind limb in ten 3-month-old sheep. Physeal violation from implant placement was calculated based on the ratio of the nail width to the physeal width on anteroposterior and lateral radiographs obtained preoperatively. Four sheep were sacrificed at 5 months, while 6 sheep were sacrificed at 9 months. Both the surgical and contralateral control hind limbs were harvested and femoral lengths measured, followed by histologic analysis at the physis. Results: When compared with the overall area of the distal femoral physis, mean growth plate violation was 5.4% (range, 3.4% to 7.4%). The nail migrated proximally across the physis in all specimens. In the specimens sacrificed at 5 months, the operative limb was a mean of 6.1 mm (range, 3 to 9 mm) shorter when compared with control limbs. In the specimens sacrificed at 9 months, there was a mean of 3.3 mm (range, 2 to 5 mm) of limb shortening. Histologic analysis demonstrated normal-appearing cellular activity at the growth plate adjacent to the path created by the nail in all specimens, with obliquity of the physis and small bony bridging appreciated across the physis in some 5-month specimens but no 9-month specimens. Conclusion: Placement of a retrograde femoral nail with a metaphyseal interlocking screw resulted in a mean violation of 5.4% of the growth plate, with proximal implant migration across the physis in all specimens. Shortening of the operative limb was greater and histologic findings more abnormal in specimens sacrificed at 5 versus 9 months, suggesting resumption of more normal growth plate activity with time. Level of Evidence: Level IV.

Background: Patients with congenital scoliosis may develop a large, unbalancing “compensatory” curve as they grow, which can be severely deforming. It is important to identify characteristics of patients who develop a “dominant” compensatory curve (one that is larger than the congenital curve) to help identify patients who may benefit from prophylactic treatment. Methods: By searching the Pediatric Spine Study Group database, we identified 307 patients 18 years and above with congenital scoliosis who had preoperative radiographs taken during at least 2 years of natural growth (period of no bracing or surgery). Seventeen patients (6%) had a dominant compensatory curve, and 290 had no compensatory curve or one that was smaller than the congenital curve. Of those 290 patients, 100 were randomly selected to serve as a control group, which we refer to as the “nondominant curve group.” We analyzed the type of congenital anomaly and its vertebral level, as well as the major curve angles of the congenital and compensatory curves at initial and latest follow-up. We compared vertebral level and type of anomaly between groups using χ2 tests. Alpha = 0.05. Results: The congenital anomaly was at L4 or more caudal in 18% of patients in the dominant curve group and no patients in the nondominant curve group (P<0.001). Similarly, the congenital anomaly was at T6 or more cranial in 59% of patients in the dominant curve group and 28% of patients in the nondominant curve group (P<0.001). At the latest follow-up, the dominant curve group had a mean (and SD) congenital curve of 55±19 degrees and a compensatory curve of 73±24 degrees. The frequencies of wedge, hemivertebrae, and bar vertebral anomalies did not differ between groups. Conclusions: In pediatric patients with congenital scoliosis, a dominant compensatory curve was associated with vertebral anomaly at L4 or caudal, or T6 or cranial. These findings can help clinicians prioritize prophylactic treatment for patients who may be at high risk for developing a dominant compensatory curve. Level of Evidence: Level III.

Objective: This study aimed to evaluate the current trends and practices in medial patellofemoral ligament reconstruction (MPFL-R) among pediatric and adolescent patients in South America. Methods: A cross-sectional web-based survey consisting of 21 questions, Supplemental Digital Content 1, http://links.lww.com/BPO/A960 was distributed to members affiliated with 4 pediatric orthopaedic societies from Argentina, Brazil, Chile, and Colombia. The survey collected data on demographics, patient selection criteria, surgical preferences, graft choice, fixation methods, and use of adjunctive procedures. Descriptive statistics (mean and SD) were calculated for continuous variables and frequencies. Percentages were calculated to summarize qualitative data. Results: A total of 132 completed surveys were collected, with the following distribution: Argentina (11.4%), Brazil (61.4%), Colombia (10.6%), and Chile (16.7%). Sixty percent of the participants had been in practice for more than 10 years. Most surgeons (84.8%) favored autografts, with semitendinous (54.5%) and quadriceps tendons (41.7%) being the most common choices. Preferences for femoral fixation included suture anchors (41.7%) and interference screws (37.9%), whereas patellar fixation preferences included suture anchors (48.5%), periosteum-based (36.4%), and patellar tunnels, (15.2%). There were diverse practices in distal realignment techniques and variable indications and approaches for derotation osteotomy in patients with femoral anteversion across the surveyed countries. Most surgeons (55.3%) preferred staging-guided growth and MPFL-R for skeletally immature patients with significant genu valgum. A common trend identified was the limited experience with trochleoplasty techniques. Conclusions: This survey revealed substantial variability in MPFL-R practices among pediatric orthopaedic surgeons in South America. These findings underscore the need for standardized guidelines and further research to optimize surgical outcomes in pediatric and adolescent patients. Understanding regional differences can inform future collaborative efforts to develop best practices and improve patient care in this population. Level of Evidence: Level V.

Background: In this study, we evaluate the frequency of trainee grants awarded to pediatric orthopaedic topics, their subsequent publication success, and the recipients' career trajectories post-training. Methods: Research grants awarded by SRS (2020-2024), OREF (2012-2022), AONA (2000-2021), OTA (2012-2022), and POSNA (2014-2024) were obtained from their respective organizations. Only projects awarded to trainees (residents/fellows) and specific to pediatric orthopaedic topics were included. Projects were characterized by study type: (1) basic science, (2) biomechanical, (3) clinical, and (4) other. Univariable analysis was performed to determine the impact of the category of grant and grant amount on subsequent publication. Recipients were also evaluated on post-residency career trajectories, including academic position and specialization in pediatrics orthopaedics. Results: A total of 1015 grants were analyzed, with a total of 55 (5%) that were awarded to trainees. Of these grants, 13% were basic science, 20% were biomechanical, 45% were clinical-based, and 22% were other types. At the time of data collection, 58% (n=32) were published. Project type was not associated with publication success. Of the 35 recipients who finished training at the time of analysis, 80% (n=28) of recipients held an academic position and 63% (n=22) had completed a pediatric orthopaedic fellowship. Conclusions: Pediatric-specific trainee grants are associated with high publication rates. The majority of grant recipients pursue pediatric orthopaedic fellowships and continue in academic medicine. Compared with trauma resident research grants, pediatric grants are less available (397 vs. 55); however, recipients of pediatric grants are more likely to publish their grant (58% vs. 38%) and obtain academic positions following training (80% vs. 45%). Level of Evidence: Level III.

Background: Fractures involving the medial humeral epicondyle are common but no consensus on the best treatment approach exists. Casting alone and open reduction with internal fixation (ORIF) both provide reliable healing, although there is limited evidence to support either approach. This study surveyed surgeons treatment preferences for pediatric medial epicondyle fractures (MEF) and willingness to randomize between casting and ORIF. We hypothesized that low consensus exists in the preferred treatment approach (casting vs. ORIF). Methods: An online survey was emailed in 2017 to members of the Pediatric Orthopaedic Society of North America (POSNA). Demographic information regarding orthopaedic surgeon practice experience and setting, in addition to opinions regarding MEF treatment, were collected. Seven patient cases were presented to assess the surgeon’s preferred treatment approach and willingness to randomize treatment. Results: The survey was completed by 322 POSNA members (∼25% of membership). Respondents were well-represented by POSNA with 55.7% <9, 23.8% 10 to 19, and 20.5% ≥20 years in practice. Most respondents were from an academic setting (77.4%), taught residents (83.3%), and treated primarily pediatric patients (91.6%). Years of experience significantly influenced both their treatment preferences and willingness to randomize, while practice setting only influenced the latter. Factors that influenced treatment approach included chronological/skeletal age (64.2%), known elbow dislocation (74.1%), neurovascular status (65.3%), and the amount of fragment displacement (80.4%). Displacement contributed to the treatment decision with 1.1% opting to operate at any displacement, 2.7% at >2 mm, 24.6% at >5 mm, 27.7% at >10 mm, and 43.9% choosing to analyze factors beyond displacement. Immobilization length varied between the treatments with 63.6% recommending immobilization of ≥4 weeks for casting and 81.9% recommending immobilization of ≤2 weeks for ORIF. The greatest consensus (87%) for ORIF was found in a 14-year-old with a fracture fragment displaced >10 mm, with no elbow dislocation and in the nondominant arm, neurovascularly intact. The lowest consensus (50.9% recommending ORIF) was in an 11-year-old with a fracture fragment displaced >10 mm, with no elbow dislocation and in the nondominant arm, neurovascularly intact. For these cases, 48% and 60% of surgeons were willing to randomize treatment, respectively. For the 7 cases overall, a mean of 58% (range: 48% to 63%) of respondents were willing to randomize treatment. Conclusion: A lack of standardization exists for the preferred treatment approach for pediatric MEF. The decision to pursue casting or ORIF appears multifactorial. Roughly half of the respondents would be willing to randomize the treatment of these injuries.

Background/Objectives: Lateral ankle injuries are common in pediatric populations. Avulsion fractures are a distinct injury involving bony disruption and may be underrecognized given their radiographically occult nature in skeletally immature patients. This study aims to compare the frequency, clinical presentation, and patient-reported outcomes (PROs) of lateral ankle avulsion fractures versus non-avulsion injuries in pediatric patients, with a focus on age-related differences. Methods: Prospective cohort observational study conducted at a tertiary pediatric orthopedic/sports medicine practice. Patients aged 5 to 12 with a first lifetime lateral ankle injury within 30 days of the injury were consecutively enrolled, receiving clinical radiographs and research-based lateral ankle ultrasounds. Patients were classified into avulsion and non-avulsion groups based upon ultrasound findings, and additional comparisons were done between younger (age 5 to 10) and older (age 11 to 12) groups. Results: Among 132 patients (mean age 9.95 (95% CI: 9.54-10.36), 56% younger group, 65% female), 44 avulsion fractures (33%) were identified. Avulsion fractures were significantly more common in the younger group (47%) than in the older group (16%) (P<0.001). Swelling and bruising were more frequent in avulsion fractures (P<0.001). Despite differences in injury type, initial presentation PROs did not differ. Conclusions: Avulsion fractures account for one-third of pediatric lateral ankle injuries and are more frequent in younger children than older children, likely due to greater skeletal immaturity. Swelling and bruising may aid in accurate diagnosis. Longitudinal studies are needed to determine if these fractures lead to subfibular ossicles, which are associated with chronic pain and instability. Level of Evidence: Level II.

Introduction: Tibial tubercle fractures’ (TTF) preferred repair technique with headed cannulated screws is associated with reoperation rates of 50% to 60% for removal of hardware (ROH). A newer screw design is headless compression screws (HCS). Aim: This project hypothesized that utilization of lower-profile HCS would reduce rates of pain and reoperation rates for removal of hardware in pediatric TTF, while maintaining comparable fracture healing and functional outcomes. Methods: An institutional review board approved, multicenter, retrospective, case-control study with data collected for all surgeries between 2014 and 2024. A priori power analysis was performed, targeting significant reduction in ROH rates. Results: A total of 283 TTF were identified; 148 met inclusion criteria, with most excluded for alternative fractures, surgical treatment, or insufficient follow-up. 121 were treated with cannulated, headed screws and 27 with HCS. Patients were 93.2% male, most commonly black (55%), average age 14.5 years, weight 85th percentile, height 71st percentile, and body mass index of 79th percentile. Injuries were most often during basketball (47%). All fracture patterns from Ogden 1A to 4B were represented, and the most common pattern was 3A (31%); no patterns were excluded. The typical repair consisted of 2 to 3 screws of 4.5 to 5.5 mm diameter, and 28% with supplemental fixation. The only difference between the headed and HCS groups was washer usage (50% vs. 0%, P<0.001). Given the demographic difference in washer use, subgroup analysis was performed to separate the washer and washer-less headed cannulated screw constructs. There were no differences in postoperative management, including immobilization (71% knee immobilizer), days to motion (29), and days to weight bearing (35). Total follow-up period was similar (266 d). There were no differences in hardware failure. Neither group experienced nonunion. Compared with headed screws with washers, the HCS group had significantly less pain (38% vs. 11%, P=0.005), relatively fewer wound complications and infections (both 2.5% vs. 0%, P=0.12), and significantly lower rates of ROH (40% vs. 7.4%, P<0.001). Conclusion: Compared with the preferred standard TTF fixation of headed cannulated screws, patients who received HCS had equivalent surgical, healing, and management outcomes, with relatively lower rates of wound complications and infections, significantly less pain, and significantly fewer returns to the operating room for ROH. Evidence: Level III—multicenter case-control.

Background: Pediatric coronal plane deformities are commonly managed by guiding growth by placing an extraperiosteal 2-hole plate across the growth plate with 1 epiphyseal and 1 metaphyseal screw. Once the correction is achieved, removing the metaphyseal screw only (sleeper plate) has been described to facilitate easier future corrections if deformity rebounds. A complication commonly described with this approach is tethering, where the patient continues to overcorrect despite the elimination of tension across the physis. This study aims to evaluate the safety and efficacy of sleeper plates and assess the rate of tethering in stainless steel (SS) versus titanium alloy (Ti) plates. Methods: This study retrospectively reviewed patients who underwent guided growth procedures for coronal plane deformities between February 2014 and September 2023. Fifty-two sleeper plates were identified in 34 patients, out of which 30 were SS and 22 were Ti. We examined for rebounding necessitating screw reinsertion and tethering requiring plate removal. This was done by measuring mechanical lateral distal femoral angle (mLDFA), the medial proximal tibial angle (MPTA), and mechanical axis deviation (MAD) during follow-up. Results: The median age at plate insertion was 8.6 (SS) years versus 9.7 (Ti). The median age at screw removal was 10.7 years for the SS group and 10.8 years for the Ti group after deformity correction. There was no statistically significant difference between the 2 groups with respect to age at plate insertion (P-value=0.945) and the age at screw removal (P-value=0.85). Overall, 40% of plates rebounded with 27% in SS and 59% in the Ti group (P-value=0.027), which could be explained by longer follow-up in the Ti group that was statistically different (P-value <0.001). 4/52 plates had tethering, and, of note, all the tethers were seen in the Ti group, with the median duration between screw removal and tethering first noticed being 1.1 years. All 4 patients corrected over time with the removal of the whole plate, none developed a physeal bar, and all went on to achieve normal alignment. The study had over 80% power to detect differences in tethering with a statistically significant P-value of 0.015. Conclusion: Sleeper plate is a viable technique for correcting coronal plane deformity, though tethering leading to overcorrection is a potential complication, especially with Ti implants. Based on our results, we advise avoiding Ti implants for sleeper plates. Level of Evidence: Level III.

Background: Magnetic resonance (MR) bone imaging may reduce radiation exposure compared with computed tomography (CT) in staging lumbar spondylolysis. This study aimed to validate the consistency between MR bone imaging and CT. Methods: We retrospectively investigated short tau inversion recovery (STIR), MR bone imaging, and CT scans of patients diagnosed with lumbar spondylolysis who underwent MRI and CT scans within 2 weeks between November 2021 and March 2023. We identified 190 fractures in 968 pars interarticularis of 105 patients. MR bone imaging was based on Siemens 3 Tesla T1-weighted volumetric interpolated breath-hold imaging (T1 VIBE). The CT-based staging and T1 VIBE-based staging were matched [incomplete fracture, complete fracture, gap of ≥2 mm (gap)]. Results: For fracture detection with CT as a reference, the respective sensitivity, specificity, and accuracy were 94%, 99%, and 99% for incomplete fracture, 74%, 100%, and 98% for complete fracture, 81%, 99%, and 99% for gap, and 97%, 100%, and 100% for any fracture. When we assessed 62 pars with complete fracture or a gap, the rates were 91%, 100%, and 99%, respectively. In staging 190 fractures with CT as a reference, the respective sensitivity, specificity, and accuracy were 94%, 91%, and 93% for incomplete fracture, 74%, 96%, and 91% for complete fracture, 81%, 96%, and 95% for gap, and 97%, 100%, and 97% for any fracture. The respective values were 91%, 98%, and 96% for complete fracture combined with gap. Of 153 pedicles with high signal change on STIR, 10 showed no fracture line, 110 showed incomplete fracture lines, 30 showed complete fracture lines, and 3 showed a gap on T1 VIBE, compared with 5, 109, 39, and 0, respectively, on CT. Conclusions: The T1 VIBE sequence is highly accurate, although it has some limitations in fracture detection. T1 VIBE can be used clinically in conjunction with STIR and may replace CT in determining the treatment strategy for lumbar spondylolysis, resulting in reduced medical radiation exposure to pediatric patients. Level of Evidence: Level III diagnostic study.

Background: The primary goal in the management of developmental dysplasia of the hip (DDH) is to obtain and maintain a stable, concentrically reduced hip via closed or open techniques while limiting iatrogenic risk. Recent studies suggest a 7% risk of recurrent instability following open reduction (OR) of idiopathic DDH and even higher rates of recurrent instability and complications with the management of neuromuscular or syndromic DDH. This study describes a novel technique of ligamentum teres reconstruction (LTR) performed during OR of idiopathic and nonidiopathic DDH. Methods: This is a prospective cohort study of 49 consecutive patients (61 hips) who underwent LTR with OR as an index procedure via a single surgeon from 2020 to 2024. The procedure combines an anterior and limited lateral approach with the use of a suture button device passed through a femoral tunnel and flipped along the inner table of the pelvis, inferior and posterior to the triradiate physis. Demographics, radiographic severity, and short-term outcomes were analyzed. Exclusion criteria included surgery performed in a revision setting (4 patients/4 hips), nonstandard implant (2 patients/2 hips), and <1 year follow-up (10 patients/14 hips). Results: A total of 33 patients (41 hips) met inclusion criteria—18 patients (21 hips) with idiopathic DDH and 15 patients (20 hips) with nonidiopathic DDH. Average follow-up was 27.6 months for idiopathic and 21.9 months for nonidiopathic patients. In the idiopathic cohort, all patients exhibited grade III or IV DDH. No loss of reduction or hardware failure occurred, and 5% of patients sustained minor complications. In the nonidiopathic cohort, only one loss of reduction was noted (5%). Discussion: The addition of LTR via a suture button device to OR demonstrates excellent short-term outcomes, including maintenance of reduction and low complication rates. Further studies are warranted to investigate the long-term effect on acetabular remodeling, range of motion, need for postoperative immobilization, and risk of iatrogenic avascular necrosis and future growth disturbance. Level of Evidence: Level III.

Background: Recurrence in clubfoot after the Ponseti technique is a well-recognized phenomenon. The use of the anterior tibial tendon transfer (ATTT), is a well-documented technique for addressing dynamic supination following treatment. Despite its widespread use, there is a lack of comparative studies evaluating different fixation techniques for ATTT. We conducted a multicenter study to assess and compare the outcomes of 3 techniques. Methods: Three centers collaborated in this comparative analysis. Children with dynamic supination after initial Ponseti treatment who underwent ATTT between 2008 and 2023 were included. A pull-through technique with suture over a button (group A) was employed in 52 patients (72 feet), a pull-through technique using an interference screw fixation (group B) was employed in 23 patients (26 feet), and a suture anchor technique (group C) was employed in 55 patients (65 feet). A retrospective review included demographics, surgical procedures, and outcomes. The comparison between the 3 groups was made with ANOVA and Kruskal-Wallis tests. P values of <0.05 were considered statistically significant. Results: A total of 130 children (163 feet), were included. There were no statistically significant differences in age, sex, side, isolated ATTT, and additional surgery between groups. At final follow-up (mean 42.0 mo), 28 patients (38 feet) experienced some form of relapse: group A, 27.8% (20/72 feet); group B, 30.8% (8/26 feet); and group C, 15.4% (10/65), P=0.56. There were 5 postoperative complications directly related to the ATTT, comprising 4 cases in group A (5.6%) and one in group B (1.5%), P=0.165. Of these complications only one case from group A included pull out of the transferred tendon. There were no cases of overcorrection. Conclusions: All 3 fixation techniques effectively secured the tibialis anterior tendon transfer in this pediatric population following recurrent clubfoot. While the suture anchor technique may offer certain advantages, the decision on fixation method should be individualized, taking into account patient anatomy and the surgeon’s experience. Level of Evidence: Level III—retrospective comparative study.

Background: After reduction of developmental hip dislocations, residual dysplasia is common with rates of secondary reconstructive surgery with pelvic osteotomy ranging from 19% to 60%. The determination and timing of when to proceed with surgery is difficult as acetabular remodeling occurs gradually over the first few years after reduction. The purpose of this study was to evaluate how age at secondary reconstructive surgery influences the clinical and radiographic outcomes after pelvic osteotomy for residual dysplasia. Methods: After IRB approval, we retrospectively reviewed all isolated Salter or Pemberton pelvic osteotomies performed for residual dysplasia after an index closed or open reduction at a single institution between 1983 and 2020 with radiographic follow-up through skeletal maturity. Acetabular index (AI) and migration index (MI) were measured on preoperative, immediate postoperative, and 2-year follow-up radiographs. After triradiate cartilage closure, anterior-posterior pelvis radiographs were measured for lateral center-edge angle (LCEA), Tönnis angle, MI, and lateralization ratio (LR). Univariate and multivariate analysis were used to evaluate outcomes based on age at time of surgery. Results: Ninety-two hips from 83 patients were included. 55 Salter (60%) and 37 Pemberton osteotomies (40%) were performed with mean age at surgery of 5.2±1.7 years. 46% (42/92) hips across both treatment groups had residual dysplasia (LCEA<25 deg.) at final follow-up (mean age 15±3.2 y). However, there was no significant difference in acetabular dysplasia at 2 years postop or after triradiate closure between those hips treated before or after 5 years of age (all P>0.05). Multivariate analysis revealed that only the immediate postoperative MI predicted the final follow-up LCEA (P<0.01), although the rate of dysplasia was still 24% in the most covered hips (MI<10%). Conclusions: Even after pelvic osteotomy for residual dysplasia, there are high rates of dysplasia at skeletal maturity. Only the femoral head coverage achieved, not the age at time of surgery, predicted dysplasia at skeletal maturity. These findings suggest that there is no opportunity cost to short-term continued observation while monitoring for acetabular remodeling. Level of Evidence: Level III.

Background: Genu valgum is common in mucopolysaccharidoses (MPS) patients. Improved life expectancy has led to a focus on quality of life, including the management of genu valgum to preserve mobility and reduce pain. This study assesses outcomes of guided growth for coronal plane knee deformities, including correction rates, complications, and rebound deformity. Methods: A retrospective review of patient notes was undertaken. Presugery and postsurgery standardized long leg alignment films radiographs were assessed for mechanical axis deviation (MAD), genu valgum angle, mechanical lateral distal femoral angle (mLFDA) and mechanical medial proximal tibial angle (MPTA). All patients underwent tension band plating. Statistical analysis was undertaken using Prism software (GraphPad Software Inc., San Diego, CA). Results: Since 2010, of 103 patients referred, 69 knees in 35 patients required surgery for genu valgum deformity. Mean radiographic follow-up was 5.5 years (24 to 110 mo). Fifty limbs (82%) corrected to a normal zone 0/1 MAD from a mean preoperative genu valgum of 19.5 degrees (range: 11.1 to 34.1 degrees). Plate removal occurred at a mean of 34 months with a mean 2.1 degrees valgus achieved (P<0.0001). Forty-four of corrected knees exhibited rebound genu valgum of 15.2 degrees (range: 12.1 to 25.4 degrees) at a mean of 17.2 months (range: 6 to 33 mo) following plate removal. In 8 knees, correction was ongoing. Early age at initial surgery was a significant predictor of recurrence (P<0.002). During treatment, 11 knees (18%) failed to correct fully. Type 4 MPS (P<0.016) and a higher preoperative genu valgum (P<0.005) were statistically significant risk factors for failure. There were no infections. In 3 limbs, screw loosening was observed. Conclusions: Our study presents the largest cohort of MPS patients undergoing guided growth for genu valgum with high rates of success and low complications. Surgery should be undertaken before 20 degrees of genu valgum is evident, especially in type 4 MPS. Recurrence is common and surgery may need to be repeated. Overcorrection of the mechanical axis into varus with close follow-up may limit the number of episodes of guided growth. Level of Evidence: Level IV.

Background: Lower extremity rotational abnormalities can cause difficulty with ambulation, patellofemoral pain and instability, hip and ankle pain, as well as differences in self-image in children and adolescents. Rotational osteotomies of the femur to correct these torsional differences have been shown to improve function, pain, and self-image. There are no studies to date evaluating risk factors for nonunion after femoral rotational osteotomies in children and adolescents. Methods: Patients 10 to 18 years old treated with femoral rotational osteotomy fixed with intramedullary nailing for idiopathic anteversion and retroversion over a 15-year period were included. Charts and radiographs were reviewed for patient characteristics, laterality, concomitant tibia osteotomy, nail material, interlocking screw construct, and radiographic measurements, including osteotomy location and canal fit. Patients with nonunion were compared with those who fully healed. Results: In this study of 203 femoral rotational osteotomies in 118 adolescent patients, the total incidence of nonunion was 10/203 for a rate of 4.9%. Overall complication rate was 6.9%. Univariate analysis of patient factors revealed that patients who were older, had a higher weight, and higher BMI were at higher risk of nonunion. The use of static interlocking screws and a lower canal fit ratio were also associated significantly with nonunion. Multivariate stepwise linear regression found relative canal fit (P = 0.003) and interlock configuration (P = 0.003) to be significant, and causal modeling identified significant factors related to nonunion as older age, static interlock type, and lower canal fit. Conclusions: Nonunion after femoral osteotomy is associated with higher age, weight, and BMI as well as use of static interlocking screws and lower canal fit ratio. Surgeons can use this information to risk stratify and counsel patients undergoing this procedure. Surgical techniques to minimize the chance of nonunion include use of dynamic interlocking screws and maximizing the canal fit ratio. Level of Evidence: Therapeutic level III—case-control 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.

Objective: Steroid-associated osteonecrosis in pediatric patients with inflammatory and oncologic disease is an uncommon yet debilitating condition causing significant functional disability. Pediatric orthopaedic surgeons encounter this population during stages in which surgical intervention may be necessary for joint preservation. Various risk factors for steroid-associated osteonecrosis have been suggested, but a comprehensive systematic review of the literature has not been performed. The purpose of this systematic review is to investigate incidence and risk factors for steroid-associated osteonecrosis in pediatric, adolescent, and young adult patients to help guide clinical decision-making. Methods: We conducted a systematic review of the literature according to the preferred reporting items for systematic reviews and meta-analyses guidelines. MEDLINE, Embase, PubMed databases, and the Cochrane Central Registry of Controlled Trials were used to search for studies assessing risk factors for osteonecrosis in patients 0 to 21 years of age with systemic corticosteroid exposure. Two reviewers independently screened titles, abstracts, and full texts of retrieved studies for inclusion. Quality assessment of retrospective and prospective nonrandomized case-control and cohort studies was completed using the MINORS criteria. Outcomes and variables of interest included reported incidence and demographic, clinical, radiographic, and genetic risk factors for steroid-associated osteonecrosis. Reported statistics were deemed significant if P <0.05. Due to heterogeneous and limited reporting, data were not combined in a meta-analysis. Results: The literature search revealed 895 articles and 37 articles were included. Of the included studies, 47% were retrospective cohort studies, and 39% were prospective cohort studies. There were 3 randomized controlled trials included. of the included studies, 95% were conducted in patients with leukemia and/or lymphoma. The overall prevalence of steroid-associated osteonecrosis ranged from 1% to 39%. Osteonecrosis was diagnosed with a mean or median of 1 to 2 years after the start of steroid therapy, and the most frequently involved joints were knees, followed by hips. Age older than 10 years, female gender, greater body mass index, and white and non-Hispanic race were the most reported risk factors for steroid-associated osteonecrosis. Core decompression was a frequent operative treatment with variable improvement in outcomes. For pediatric leukemia patients, those stratified as High risk and Intermediate risk were at the greatest risk for steroid-associated osteonecrosis. Conclusion: This systematic review summarizes specific risk factors and demographics of steroid-associated osteonecrosis and helps lay the foundation for future studies to delineate the causal role of risk factors and guides clinical decision-making for current and proposed screening techniques. Steroid-associated osteonecrosis is often asymptomatic with clinical symptoms frequently lagging presentation on advanced imaging. The development of standard clinical pathways that incorporate screening for osteonecrosis may become necessary to improve outcomes through early detection and interventions such as core decompression to reduce pain and prevent progression to early osteoarthritis.

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.

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: The incidence of anterior cruciate ligament (ACL) injuries is increasing among the adolescent population with a peak occurring in the high school age range. Purpose: To characterize recent epidemiologic trends of ACL injuries, ACL reconstruction (ACLR), and retear rates in high school adolescents based on age, participating sport, and mechanism of injury. Study Design: Retrospective case series. Methods: A prospectively maintained institutional database was retrospectively reviewed for all patients 18 or younger who underwent primary ACLR between 2015 and 2020. Odds ratios were calculated for baseline patient characteristics and their association with risk of retear. Multivariate regression analysis was also performed to identify the relationship between retear and specific categorical variables. Results: A total of 482 patients were included, with a mean follow-up time of 13.0 ± 11.8 months. Patients were an average age of 16.1 ± 1.3 years old (range: 13 to 18 y). Initial presentation of ACL injuries in high school athletes often occurred at 16 years old regardless of the sport played. Based on age, high school freshmen and seniors are found to have an increased risk of ACL retear. One hundred three patients (21.6%) completed at least 2 or more years of follow-up after ACLR. Of these patients, 38.8% received a bone-tendon-bone (BTB) autograft, 36.9% hamstring autograft, 14.6% quadriceps tendon autograft, and 3.9% received hamstring allograft or other graft (eg, tibialis anterior and BTB allograft), respectively. There were 25 ipsilateral ACL retears that occurred in the patient cohort (5.2%). Thirteen (52%) of retears were females. Football and soccer were the most common sports played by patients with a retear of the ipsilateral knee (31.8% and 27.3%, respectively). Patients who were 13 to 14 or 18 years old (P = 0.009 and 0.035, respectively) or who received a tibialis anterior/BTB allograft (P = 0.002) were found to have increased risk of ACL retear compared with other age groups. When evaluating by sex, female soccer players had a greater risk of retear compared with male soccer players (P = 0.007). When adjusting for multiple variables, (including age, sex, body mass index, primary reconstruction graft choice, sport, and length of follow-up), the odds of ipsilateral retear in patients who received hamstring autograft (P = 0.02), sustained a contralateral ACL tear (P= 0 .04), or a contact injury (P = 0.01) were increased. Conclusion: Initial presentation of ACL injuries in high school athletes often occurs at 16 years old regardless of the sport played. Based on age, high school freshmen and seniors are found to have an increased risk of ACL retear. However, the overall rate of ACL retear in high school athletes of all ages is low. Patients who underwent ACLR with hamstring tendon autograft had a greater risk of retear compared with other graft types. Female soccer players also had a greater risk of ACL retear. High school athletes must take caution when in the early high school years (underclassman) and more senior years (upperclassman), as susceptibility for ACL retears is elevated. Level of Evidence: Level IV.

Background: Progressive hip displacement is one of the most common and debilitating deformities seen in children with cerebral palsy (CP). The aim of this study was to evaluate the results of temporary medial hemiepiphysiodesis of the proximal femur (TMH-PF) using a transphyseal screw to control hip migration during growth in children with CP. Methods: This was a retrospective study of children with CP and hip dysplasia, age 4 to 11 years and GMFCS levels III-V. There were 28 patients with 56 hips that underwent TMH-PF surgery between 2007 and 2010. Clinical and radiologic evaluation was performed preoperatively, at 6, 12, and 60 months following the index surgery. Acetabular index (AI), neck-shaft angle (NSA) and migration percentage (MP) were measured. All complications were recorded. Results: All radiographic measurements were significantly improved at the final follow-up. Positive correlations were found between NSA, MP, and AI. Multiple regression analysis revealed that MP, time from surgery, and age were influenced by the decrease of the NSA. The femoral physis grew off the screw in 9 hips within 36 months. The screw head broke during attempted screw exchange in 1 hip. The remain cases (4 hips) were treated by placing a second screw parallel to the existing one. Finally, progressive subluxation occurred in 3 hips when the physis grew off the screw and were treated by skeletal reconstruction. Conclusions: TMH-PF was effective in controlling progressive subluxation of the hip in the majority of cases, obviating the need for major reconstructive surgery in these children with CP. Level of Evidence: Level IV.

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: 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.

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: 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.

Abstract: Clinical decision-making for the management of foot deformities in children is primarily based upon the analysis of weight-bearing radiographs of the foot and ankle. However, a comprehensive quantitative technique for the analysis of such radiographs has not been described. Ten radiographic measurements were developed and applied to the foot and ankle radiographs of a normal foot and ankle in 60 children (mean age 10 years, range 5-17 years). Intraobserver variability and interobserver variability were determined for 10 cases. Mean values for the 10 measurements were calculated from the entire study group. Intraobserver variability was excellent, with correlation coefficients for the 10 measurements ranging from 0.89 to 0.99. The absolute value of the mean differences in angular measurements ranged from 0.8 to 2.5 degrees. Interobserver variability was also excellent, with correlation coefficients ranging from 0.86 to 0.99. The absolute value of the mean differences in angular measurements ranged from 0.5 to 3.2 degrees. The mean values, standard deviations, and ranges for the 10 radiographic parameters from the 60 normal feet have been determined. Clinically acceptable variability of 10 selected radiographic measurements of the foot and ankle was achieved, and normal values and ranges for these measurements were determined. Quantitative segmental analysis of foot and ankle alignment, using these 10 radiographic measurements, can be used to describe common malalignment patterns, and this may assist in clinical decision-making and assessment of outcome.

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.