5-Year Radiographic and Functional Outcomes of Nonoperative Treatment of Completely Displaced Midshaft Clavicular Fractures in Teenagers.

BACKGROUND: Optimal treatment of completely displaced midshaft clavicular fractures in adolescents remains controversial, with some favoring surgical management and others favoring a nonoperative approach. Few studies have comprehensively assessed longer-term nonoperative outcomes. PURPOSE: To prospectively assess patient-reported outcomes (PROs) and radiographic remodeling ≥5 years after injury in teenagers undergoing nonoperative treatment of completely displaced clavicular fractures. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Adolescent patients previously enrolled in a prospective study from a single institution with nonoperatively treated, completely displaced midshaft clavicular fractures ≥5 years from injury were eligible for the study. Patients were clinically evaluated for scapular dyskinesia and strength deficits. Bilateral clavicular imaging assessed residual shortening, displacement, and angulation. PROs included the American Shoulder and Elbow Surgeons (ASES), the shortened version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH), Marx Shoulder Activity Scale, cosmesis, and return to sports data. RESULTS: A total of 24 patients were available for the follow-up, of whom 17 (71%) consented to additional imaging. The mean cohort age at the time of injury was 14.5 ± 1.1 years, with 88% being male. At a mean follow-up of 6.1 years, all fractures had healed, with no patient requiring secondary interventions. Significant remodeling was observed across all measurements, with improvements of 70% in shortening (22.8 to 6.8 mm; P < .001), 73% in superior displacement (13.4 to 3.6 mm; P < .001), and 83% in angulation (10.4° to 1.8°; P < .001). Thirteen patients (72%) had a >2-cm initial shortening, and all remodeled to <2 cm. PROs were almost universally excellent, with mean ASES, QuickDASH, and Marx activity scores of 99 ± 3, 1 ± 3, and 20 ± 1, respectively, with 79% of patients reporting perfect scores in all 3 domains. Most patients (58%) were completely satisfied with their shoulder appearance, 38% were more satisfied than not, 1 patient (4%) was neither satisfied nor dissatisfied, and no patients were dissatisfied. All patients except 1 who were interested in sports returned to sporting activities. PROs were not associated with bony remodeling (P > .05). CONCLUSION: Teenaged patients with completely displaced clavicular fractures treated nonoperatively can expect excellent radiographic and clinical outcomes 5 years after injury.

Vertical Stenosis as a Morphological Risk Factor for Anterior Cruciate Ligament Ruptures in Children: A Magnetic Resonance Imaging-Based Comparison.

BACKGROUND: There are known anatomic variations that may lead to traumatic disruption of the anterior cruciate ligament (ACL) identified within adult and adolescent patients. PURPOSE/HYPOTHESIS: The purpose of this study was to compare the parameters of pediatric knees diagnosed with and without an ACL injury by magnetic resonance imaging. The hypothesis was that children with ACL abnormalities would demonstrate an equivalent notch width index (NWI), but a larger notch height index (NHI), in comparison with age-matched patients without ACL abnormalities, suggesting an association with congenital morphology. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: A retrospective comparison cohort study of pediatric knees was performed by evaluating those with a confirmed ACL rupture/deficiency and those with a benign diagnosis on magnetic resonance imaging. Overall, 6 osseous and cartilaginous measurements and 3 ratios (2 newly described) were determined. They were then grouped for statistical purposes by age: children aged 5 to 11 years and adolescents aged 12 to 19 years. RESULTS: A total of 119 (49 children) consecutive patients with an ACL injury and 139 (72 children) healthy patients met inclusion criteria. The interaction between ACL status and age was significant for condylar measurements (P≤ .001), tibial spine height (P = .003), vertical space above tibial spine (P≤ .001), and NWI (P≤ .001) by 2-way analysis of variance. Although the NHI (P < 0.001) and tibial spine prominence (P = 0.039) demonstrated stenosis in the adolescent group, they did not have significant interactions with age and ACL status (P > 0.05). Regarding the transcondylar width, only the children's group had a significant difference regarding ACL status (P < .001), and the mean values in the children's group with ACL tears were nearly identical to those in the adolescent group both with and without ACL tears. The children's group with ACL tears also had a significantly larger tibial spine height compared with healthy children (P < .001). CONCLUSION: Children, similar to adolescents, demonstrated the effect of the NWI on the risk of ACL tears, but only the adolescent group demonstrated stenosis with the NHI. The morphology of the knee in a child at risk for ACL rupture was not the same as that of an adolescent when considering all dimensions, but it did seem that it was more adolescent-like than child-like at the time of an ACL rupture, refuting the idea of congenital hypoplasia as a common cause.

Intermediate Outcomes of Shoulder Synovial Chondromatosis in an Adolescent Boy: A Case Report.

CASE: Synovial chondromatosis is a rare condition affecting synovial joints. It occurs uncommonly in the shoulder and is rare in the pediatric population. We present a case of a 13-year-old male patient with shoulder pain who was diagnosed with synovial chondromatosis and a posterior labral tear. He was treated with arthroscopic loose body removal, synovectomy, and posterior labral repair and recovered well from the surgery. Four years after the surgery, he developed pain in the same shoulder, but the cause of the pain was not investigated per the patient's decision. CONCLUSION: Synovial chondromatosis should be considered in pediatric patients presenting with shoulder pain and loss of function with potential for recurrence.

Allograft Anterior Cruciate Ligament Reconstruction in Adolescent Patients May Result in Acceptable Graft Failure Rate in Nonpivoting Sports Athletes.

BACKGROUND: Studies have demonstrated that pediatric patients have an increased risk of failure with allograft anterior cruciate ligament reconstruction (ACLR); however, there is no study investigating whether allograft ACLR may be safe in older adolescent patients who are not returning to competitive pivoting sports (ie, low risk). The purpose of this study was to assess outcomes for low-risk older adolescents selected for allograft ACLR. METHODS: We performed a retrospective chart review of patients younger than 18 years who received a bone-patellar-tendon-bone allograft or autograft ACLR by a single orthopaedic surgeon from 2012 to 2020. Patients were offered allograft ACLR if they did not intend to return to pivoting sports for 1 year. The autograft cohort was matched 1:1 based on age, sex, and follow-up. Patients were excluded for skeletal immaturity, multiligamentous injury, prior ipsilateral ACLR, or concomitant realignment procedure. Patients were contacted to obtain patient-reported outcomes at ≥2 years follow-up, including single assessment numerical evaluation, surgery satisfaction, pain scores, Tegner Activity Scale, and the Lysholm Knee Scoring Scale. Parametric and nonparametric tests were used as appropriate. RESULTS: Of the 68 allografts, 40 (59%) met inclusion and 28 (70%) were contacted. Among the 456 autografts, 40 (8.7%) were matched and 26 (65%) were contacted. Two allograft patients (2/40; 5%) failed at a median (interquartile range) follow-up of 36 (12, 60) months. There were 0/40 failures in the autograft cohort and 13/456 (2.9%) among the overall autografts; neither were significantly different from the allograft failure rate (both P > 0.05). Two (5.0%) patients in the autograft cohort required manipulation under anesthesia and arthroscopic lysis of adhesions. There were no significant differences between cohorts for single assessment numerical evaluation, Lysholm, Tegner, pain, and satisfaction scores (all P > 0.05). CONCLUSIONS: Although ACL allograft failure rates remain nearly two times higher than autograft failure rates in older adolescents, our study suggests that careful patient selection can potentially bring this failure rate down to an acceptable level. LEVEL OF EVIDENCE: Level III; retrospective matched cohort study.

Subsequent Forearm Fractures Following Initial Surgical Fixation.

INTRODUCTION: Forearm fractures are a common pediatric injury. Currently, there is no consensus on treatment for fractures that recur following initial surgical fixation. The objective of this study was to investigate the subsequent fracture rate and patterns and describe the treatment of these forearm fractures. METHODS: We retrospectively identified patients who underwent surgical treatment for an initial forearm fracture at our institution between 2011 and 2019. Patients were included if they sustained a diaphyseal or metadiaphyseal forearm fracture that was initially treated surgically with a plate and screw construct (plate) or elastic stable intramedullary nail (ESIN), and if they subsequently sustained another fracture that was treated at our institution. RESULTS: A total of 349 forearm fractures were treated surgically with ESIN or a plate fixation. Of these, 24 sustained another fracture, yielding a subsequent fracture rate of 10.9% for the plate cohort and 5.1% for the ESIN cohort ( P =0.056). The majority of plate refractures (90%) occurred at the proximal or distal plate edge, while 79% of the fractures treated previously with ESINs occurred at the initial fracture site ( P <0.001). Ninety percent of plate refractures required revision surgery, with 50% underwent plate removal and conversion to ESIN, and 40% underwent revision plating. Within the ESIN cohort, 64% were treated nonsurgically, 21% underwent revision ESINs, and 14% underwent revision plating. Tourniquet time for revision surgeries were shorter for the ESIN cohort (46 vs. 92 min; P =0.012). In both cohorts, all revision surgeries had no complications and healed with evidence of radiographic union. However, 9 patients (37.5%) underwent implant removal (3 plates and 6 ESINs) after subsequent fracture healing. CONCLUSIONS: This is the first study to characterize subsequent forearm fractures following both ESIN and plate fixation and to describe and compare treatment options. Consistent with the literature, refractures following surgical fixation of pediatric forearm fractures may occur at a rate ranging from 5% to 11%. ESINs are both less invasive at the time of initial surgery and can often be treated nonoperatively if there is a subsequent fracture, while plate refractures are more likely to be treated with a second surgery and have a longer average surgery time. LEVEL OF EVIDENCE: Level IV-retrospective case series.

Intermediate-term Outcomes in Adolescent Recurrent Ankle Instability Managed With a Modified Broström-Gould Procedure Augmented With Distal Fibular Periosteum Incorporation.

BACKGROUND: Once a child has developed chronic ankle instability with recurrent events despite conservative treatment, then ligamentous repair is warranted. We utilize a modification of the modified Broström-Gould technique that further incorporates the distal fibular periosteum into the construct. The purpose of this study was to describe the intermediate-term outcomes of our modified Broström-Gould technique for chronic lateral ankle instability in childhood athletes. METHODS: A retrospective review of children who underwent the surgical technique over a 10-year time period (2010 to 2019) was performed, excluding those with <2 years of follow-up. Demographic, surgical, and clinical data were recorded, as well as outcome scores: (1) the Marx activity scale, (2) University of California, Los Angeles activity score, and (3) foot and ankle outcomes score. Recurrent instability events, repeat surgeries, satisfaction with the surgical experience, and return to sport (if applicable) were also recorded. RESULTS: Forty-six children (43 females) with 1 bilateral ankle met the criteria with a mean age at surgery of 14.8 years, and a mean follow-up duration of 4.9 years. The mean Marx activity score was 9.0±5.1, the mean University of California, Los Angeles score was 8.3±1.8, and the mean total foot and ankle outcomes score was 84.0±15.6. Twenty-six ankles (55.3%) reported having at least 1 recurrent episode of instability and 6 of the ankles (12.8%) underwent revision surgery between 3.5 months and 6.5 years of the index procedure. Thirty-nine (84.8%) patients responded that they would undergo our surgery again. CONCLUSION: A modified Broström-Gould procedure can be performed in children with the incorporation of the adjacent periosteum, but recurrence of instability is distinctly possible with longer follow-up with a risk for revision surgery despite good subjective outcomes. LEVEL OF EVIDENCE: Level IV; retrospective case series.