Abstract: Anterior cruciate ligament reconstruction (ACLR) remains one of the most commonly performed orthopaedic surgeries in adolescents and young adults. However, selection of the optimal graft for the individual patient remains controversial, considering multiple graft options, subtle technique differences, and wide-ranging bodies of evidence for each graft option in largely adult populations. However, multiple epidemiologic studies clearly demonstrate adolescents as the most greatly affected age-based sub-population, with the highest rates of re-tear and global morbidity, due to psychological and physical effects of long absences from athletic activity. Nevertheless, methodologically rigorous comparative studies specific to the adolescent athlete are largely absent from the literature. The purpose of the current study is to therefore investigate the outcomes of ACLR in adolescents receiving either patellar tendon/bone-tendon-bone (BTB) autograft (ACLR-BTB) or hamstring tendon autograft (ACLR-HS), using retrospective propensity score matching techniques to generate comparable cohorts. Methods: The study was designed as a retrospective chart review, with collection of cross-sectional data from a single pediatric tertiary care center over a thirteen year period (2003-2015). An initial cohort of patients, aged 13-19 years at time of primary ACLR-BTB or primary ACLR-HS by one of 5 surgeons, was identified through a comprehensive electronic medical record database query. Propensity score matching of ACLR-BTB and ACLR-HS subjects through a logistic regression model, with caliper restriction of 0.1 standard deviations, was then applied, based upon specific baseline characteristics that are frequently used by some surgeons to guide graft selection: age, sex, and body mass index (BMI). The resultant cohort of patients obtained a 1:2 (ACLR-BTB: ACLR-HS, 83 patients:186 patients) match. A chart review was performed to identify patient demographics, surgical data, and post-operative outcomes including graft rupture/re-tear and length of clinical follow-up. Patients were additionally contacted to obtain longer term sport participation and re-injury data that may have been investigated or addressed at outside institutions, as well as to obtain functional outcomes using region-specific questionnaires (Pedi-IKDC and HSS-Pedi FABS), which are validated for both this younger population and adult populations. Due to previous literature-based reports on greater anterior knee pain following ACLR-BTB, compared to ACL-HS, scores from the questions specific to knee pain or kneeling pain were extracted from the Pedi-IKDC results and analyzed to assess the potential influence of anterior knee pain on overall scores within this adolescent population. Results: At time of ACLR, the mean age and BMI of the matched ACLR-BTB patients were 17.1 years (sd: +/-1.14 years) and 25.8 (sd: +/-5.04), compared to 16.9 years (sd: +/- 1.38, p: 0.18) and 24.9 (sd: +/- 5.01, p: 0.18) for matched ACLR-HS patients, with similar male preponderance (ACLR-BTB: 77%, ACLR-HS: 72%, p: 0.47) and mean length of follow-up (ACLR-BTB: 42.9 months; ACLR-HS: 43.3 months). While mean Pedi-IKDC scores were slightly higher in the ACLR-BTB group (88.8; sd: +/-10.2, range: 56.5-100) than the ACLR-HS group (85.2; sd: +/- 16.1, range: 23.9-100), this difference was not statistically different (p: 0.50). When scores on questions regarding knee pain and kneeling difficulty were analyzed, no differences were seen between graft cohorts (ACLR-BTB: median knee pain score: 4, ACLR-HS: 4 p: 0.73; ACLR-BTB median kneeling difficulty score: 4, ACLR-HS: 4, p: 0.21). Activity level, based on the HSS-Pedi FABS score, was also similar (ACLR-BTB: 16, range: 3-29 vs. ACLR-HS: 17, range: 0-30; p: 0.96). Rates of ACL graft re-tear were not significantly different between groups, both when calculated based all possible follow-up methods (ACLR-BTB: 11%, ACLR-HS: 11%, p: 0.91), or when those patients responding to long-term follow up questionnaires were isolated (ACLR-BTB: 15%, ACLR-HS: 16%, p: 0.85). Conclusion/Significance: Despite previous studies, including large, multi-country registry-based analyses, demonstrating lower re-tear rates following ACLR-BTB than ACLR-HS, the current study, focused exclusively on adolescent cohorts matched for age, sex, and BMI, showed no difference in graft re-tear rates between the two cohorts at medium-term follow-up. Moreover, activity scores and functional knee outcome scores appear to be equivalent between these younger graft-based populations. In contrast to previous studies associating BTB autograft with greater long term anterior knee pain, adolescents appear to have equal degrees of knee pain or kneeling pain, regardless of graft choice, which may stem from greater healing and biologic remodeling capacity at graft harvest sites than adults or more modern techniques of patellar bone grafting and paratenon closure. Given the consistently high adolescent ACL re-tear rates in this and other studies, continued focus on ACL prevention programs and optimizing the timing and safety of return to play remains critical.

Abstract: The purpose of this study is to compare the re-tear rates and medium-term functional outcomes in matched cohorts of adolescent athletes who underwent primary anterior cruciate ligament reconstruction (ACLR) with patellar tendon/bone-tendon-bone autograft (BTB) versus hamstring tendon autograft (HS). Methods: An initial cohort of 731 patients, aged 13-19 years, who underwent ACLR-BTB or ACLR-HS between 2003-2015 at a pediatric tertiary care hospital by one of 5 surgeons, was identified through a comprehensive electronic medical record database query. Propensity score matching was performed through a logistic regression model, based on characteristics frequently used by some surgeons to guide graft selection: age, sex, and body mass index (BMI). The resultant cohort of 269 patients allowed for a 1:2 (BTB: HS, 83:186) match. A chart review was performed to identify patient demographics, surgical data, and post-operative outcomes, including ACL re-tear and length of clinical follow-up. Patients were additionally contacted to obtain longer term sport participation and re-injury data that may have been investigated or addressed at outside institutions, as well as to obtain patient reported outcomes (PRO) using validated knee function and activity questionnaires (Pedi-IKDC and HSS-Pedi FABS). Individual questions from the Pedi-IKDC that related to anterior knee pain or kneeling pain were specifically investigated to assess the potential effect of these factors, commonly cited aspects of donor site morbidity associated with BTB grafts, on overall scores within this adolescent population. Results: No significant differences were seen in demographic and clinical characteristics of the two matched graft-based cohorts (overall mean clinical follow-up: 54 months), as listed in Table 1. In the sub-population providing PROs (52% response rate, mean PRO follow up: 81 months), no significant differences were seen in activity level, median Pedi-IKDC scores, or knee pain. BTB patients demonstrated superior scores regarding ability to kneel than HS patients. Rates of ACL graft re-tear were not significantly different between groups, both when calculated based on all possible follow-up methods (ACLR-BTB: 11%; ACLR-HS: 12%; p: 0.72), or amongst patients responding to long-term follow up. Conclusion: Despite previous studies, including large, multi-country registry-based analyses, demonstrating lower re-tear rates following ACLR-BTB than ACLR-HS, the current study, focused exclusively on adolescent cohorts matched for age, sex, and BMI, showed no difference in graft re-tear rates between the two cohorts at medium-term follow-up. Moreover, activity scores and overall functional knee outcome scores appear to be equivalent between these younger graft-based populations, with no suggestion of increased donor site morbidity with BTB autograft, as it relates to knee pain or kneeling ability. For skeletally mature adolescents, graft choice may not influence outcome following ACL reconstruction. Consistent with previous studies, the current study reveals relatively high ACL re-tear rates in adolescents, the sub-population most affected by this common injury. [Table: see text]

Abstract: Return-to-sport (RTS) following anterior cruciate ligament reconstruction (ACLR) is influenced by multiple physical and psychological variables. Psychological readiness has been associated with improved patient reported outcomes as well as RTS rates in young athletes. The COVID-19 pandemic may have altered the typical recovery process for patients undergoing ACLR. Hypothesis/Purpose: To compare 6-month postoperative levels of psychological readiness to RTS in ACLR patients before and during the pandemic. Methods: Patients were prospectively enrolled 6 months after primary ACLR at a single academic sports medicine practice, from December 2018 until May 2021. Patients were categorized into pre-COVID (enrollment prior to March 13, 2020) and COVID groups (March 13, 2020 - May 26, 2021). Demographic information, outcomes scores including the ACL-Return to Sport after Injury Scale (RSI) and PROMIS Psychological Stress Experiences (PROMIS-PSE), and physician RTS clearance were obtained and compared for both groups. Comparisons were performed utilizing Chi-square, Student’s t-tests and linear regression. A matched analysis was conducted between groups controlling for age, sex, and graft type. Results: 231 patients were included in the present study (89 males, 142 females; mean age 16.9 years), with 76% (176/231) in the pre-COVID group and 24% (55/231) in the COVID group. There were no significant differences in age and sex between the two population cohorts. There was a significant difference in time from surgery to enrollment in the COVID group compared to the pre-COVID group (7.1 vs 6.2 months, p 〈 0.001). In the matched cohort (n=126, 37/126 COVID group), the COVID group was cleared earlier by their physician to RTS compared to the pre-COVID group (6.9 months vs 8.5 months, p 〈 0.001). While there was no significant difference between groups in 6 month ACL-RSI scores (63.8 pre-COVID vs 66.6 COVID, p=0.48), both groups yielded globally low scores. There were no significant associations between matched groups in PROMIS-PSE (p=0.71), IKDC (p=0.55), Pedi-IKDC (p=0.15), and Pedi-FABS (p=0.77) scores (Table 1). Conclusion: Young athletes demonstrated similar levels of psychological readiness to RTS at 6 months following ACLR prior to and during the COVID-19 pandemic. Patient-reported outcome scores were similar in pre-COVID and COVID ACLR patients, suggesting that the pandemic may not have played a detrimental role in perceptions of recovery. Psychological readiness may not be fully optimized at 6 months post-ACLR and young athletes may benefit from additional time and training for progressive confidence, muscle strength, and performance. [Table: see text]

Abstract: With rising participation in youth sports such as baseball, proximal humeral epiphysiolysis, or Little League shoulder (LLS), is being seen with increasing frequency. However, there remains a paucity of literature regarding the causes, natural history, or treatment outcomes of LLS. Purpose: To analyze the demographic, clinical, and diagnostic features of a population of LLS patients, with an emphasis on identifying underlying risk factors for the development and recurrence of LLS after nonoperative treatment. Study Design: Case series; Level of evidence, 4. Methods: A departmental database at a high-volume regional children’s hospital was queried to identify cases of LLS between 1999 and 2013. Medical records were reviewed to allow for analysis of age, sex, athletic information, physical examination and radiologic findings, treatment details, clinical course, and rates of recurrence. Results: Ninety-five patients (93 males, 2 females; mean age, 13.1 years; range, 8-16 years) were diagnosed with LLS. The number of diagnosed cases increased annually over the study period. All patients had shoulder pain with overhead athletics; secondary symptoms included elbow pain in 13%, shoulder fatigue or weakness in 10%, and mechanical symptoms in 8%. While the majority of patients (97%) were baseball players (86% pitchers, 8% catchers, 7% other positions), a small subset (3%) were tennis players. On physical examination, 30% were reported to have glenohumeral internal rotation deficit (GIRD), defined as a decreased arc of rotational range of motion of the shoulder. Treatment recommendations included rest in 99% of cases, physical therapy in 79% (including 100% of patients with GIRD), and position change upon return to play in 26%. Average time to full resolution of symptoms was 2.6 months, while average time to return to competition was 4.2 months. Recurrent symptoms were reported in 7% of the overall cohort at a mean of 7.6 months after initial diagnosis. The odds of recurrence in the group with diagnosed GIRD (14%) were 3.6 times greater than those without GIRD (5%; 95% CI: 0.7-17.1), but this difference was not statistically significant ( P = .11). Conclusion: Little League shoulder is being diagnosed with increasing frequency. While most common in male baseball pitchers, the condition can occur in females, youth catchers, other baseball positions players, and tennis players. Concomitant elbow pain may be seen in up to 13%. After rest and physical therapy, recurrent symptoms may occur in a small subset of patients (7%), generally 3 to 6 months after return to sports. Almost one-third of LLS patients had GIRD, and this group had approximately three times higher probability of recurrence compared with those without GIRD.

Abstract: Small-diameter semitendinosus-gracilis tendon autografts may be encountered intraoperatively during anterior cruciate ligament reconstruction (ACLR); these have been shown to be at increased risk of graft rupture. One option that surgeons have pursued to reduce the theoretical failure rate of these smaller-diameter grafts is augmenting them with allograft material, thereby forming a larger-diameter hybrid autograft-allograft construct. Purpose/Hypothesis: The purpose of this study was to compare outcomes in adolescent athletes of primary ACLR using a hybrid autologous hamstring tendon and soft tissue allograft construct versus ACLR using small-diameter hamstring tendon autograft. The hypothesis was that the hybrid hamstring autograft-allograft construct would provide superior short-term results. Study Design: Cohort study; Level of evidence, 3. Methods: We performed a retrospective analysis of 47 patients aged between 12 and 20 years who underwent hybrid graft ACLR (mean diameter, 9.1 mm) at a single institution. Electronic medical records including clinic notes, radiographic images, operative notes, and pathology reports were reviewed for study analysis. A control group of 64 patients who underwent small-diameter hamstring reconstruction (mean diameter, 7.1 mm) without allograft supplementation was compiled. Corresponding clinical, radiographic, and surgical characteristics were collected for the control group to allow for comparative analysis. Results: Mean follow-up was 2.7 years for the hybrid cohort and 2.3 years for the control group. Despite a significantly larger mean graft diameter in the hybrid group as compared with the control group ( P 〈 .001), no significant difference in retear rate was seen between cohorts (hybrid, 9%; control, 13%; P = .554). Patients with hybrid anterior cruciate ligament constructs also underwent a comparable number of reoperations overall ( P = .838). Functionally, all patients with adequate follow-up returned to sports, with no significant difference in time to return to sports between the groups ( P = .213). Radiographically, hybrid graft constructs did not undergo a significantly larger degree of tunnel lysis ( P = .126). Conclusion: A cohort of adolescents with hybrid anterior cruciate ligament grafts was shown to have retear rates and overall clinical results comparable with those of a control group that received small-diameter hamstring tendon autografts alone.

Abstract: Peroneal tendon subluxation is an uncommon cause of lateral ankle pain and instability but can be disabling for some young patients. Surgical management may be required to restore function for patients who fail nonoperative management. The purpose of this study was to determine the functional outcomes after surgical management of peroneal tendon subluxation in pediatric and adolescent patients. Methods: A retrospective review of patients presenting to our institution over a 10-year period yielded 18 cases of recurrent subluxation refractory to nonoperative management in 14 children or young adults (mean age 15.0 y). All patients failed nonoperative management and were treated operatively with isolated calcaneofibular ligament transfer to construct a new soft tissue restraint for the peroneal tendons. Patients were evaluated clinically and sent validated questionnaires, including the Foot and Ankle Ability Measure (FAAM) and the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale. Results: All 18 ankles of 14 patients had minimum 2-year follow-up. Ten of 18 ankles (55.6%) returned the outcome surveys at an average of 5.7 years after the index procedure (range, 2. 0 to 9.7 y). The average FAAM activities of daily living score was 93.5 (±2.9) and the sports subscale was 77.8 (±6.1). The mean AOFAS subjective scaled score was 84.3 (±4.5). All patients returned to sports and recreational activity. Complications included 1 case of recurrent subluxation (1/18, 5.5%) treated with revision to a Chrisman-Snook procedure and 4 ankles (4/18, 22.2%) with stiffness or arthrofibrosis treated with a secondary procedure of peroneal tendon release or lysis of adhesions. Conclusions: Surgical management with rerouting of the peroneal tendons under the calcaneofibular ligament appears to be safe and effective for young patients with chronic peroneal tendon subluxation. It provides a low rate of recurrent subluxation, excellent stability, and good long-term functional outcomes. However, the potential for postoperative stiffness appears to be a limitation to the procedure and necessitates aggressive physical therapy to maintain ankle motion. Level of Evidence: Level IV— retrospective case series.

Abstract: The optimal treatment approach to clavicle fractures in adolescents remains an area of significant controversy. The purpose of this study was to review the demographic characteristics, treatment approaches, and complications in a large series of adolescent clavicle fractures receiving operative and non-operative treatment. Methods: Radiographic and medical record review was conducted for all cases of patients ages 10-18 years-old who presented to a single tertiary care children’s hospital between 2003-2012 with a mid-diaphyseal clavicle fracture. Demographic data, radiographic features, such as fracture pattern, operative details when applicable, and post-treatment clinical course was analyzed, including the reported time to healing and any known complications. Results: Out of 641 cases reviewed (79% male; mean age 14.3 years), 408 (64%) fractures were sustained during sports, most frequently football (25%), hockey (18%), soccer (12%), snowboarding (12%) and skiing (9%). Other common mechanisms of injury were falls sustained outside of athletic activity (19%) and motor vehicle accidents (5%), with similar distribution of mechanism and similar rates of associated injuries seen within the operative (5%) and non-operative (6%) treatment groups. Greater numbers of clavicle fractures were seen annually over the study period. Among the overall cohort, 82% were treated non-operatively, while 18% were treated surgically, with increasing percentage of patients undergoing surgery over the course of the study period. The mean age was higher in the operative group (15.5 years) than the nonoperative group (14.1 years)(p 〈 0.001). Fifty-eight documented complications occurred in 46 patients (7.2%), were significantly more common in the operative (16%) group than the non-operative (5%) group (p 〈 0.001), and were more common in older patients (p=0.007). Only 1 case of nonunion occurred in each treatment group (p=0.56). The rate of symptomatic implants was 13% in the operative group (leading to plate removal in 9% cases), while the rate of symptomatic malunion was 2% in the nonoperative group. Refracture was significantly more common in the nonoperative group (3%) than the operative group (2%) (p=0.03). Refracture in the non-operative group most commonly occurred in the period before complete healing had occurred. Of the 2 cases of refracture in the operative group, 1 case was a peri-implant fracture and 1 case occurred over 1 year following plate removal. No infections were reported in either group. One of the nonoperative symptomatic malunion patients developed thoracic outlet syndrome requiring osteotomy, which led to symptom resolution. One of the operative patients developed contralateral recurrent laryngeal and hypoglossal neuropraxia (Tapia’s syndrome), causing vocal cord paralysis, tongue deviation, and hoarseness, with near complete resolution at the time of most recent follow up, four months post-operatively. Conclusion: Greater numbers of clavicle fractures are being seen in the adolescent population, with over 60% of cases occurring during sports and an increasing trend towards operative treatment in recent years. Nonunion and symptomatic malunion are rare in adolescents. While refracture is more common following nonoperative treatment, overall complication rates appear to be more common following operative management, the most common of which is symptomatic implants.

Abstract: Context : To treat anterior cruciate ligament (ACL) injury, ACL reconstruction (ACLR) surgery is currently a standard of the care. However, effect of graft type including bone–patellar tendon–bone (BTB), hamstring tendon, or iliotibial band (ITB) on thigh size, knee range of motion (ROM), and muscle strength are understudied. Objective : To compare postoperative thigh circumference, knee ROM, and hip and thigh muscle strength in adolescent males who underwent ACLR, based on the 3 different autograft types: BTB, hamstring (HS), and ITB. Setting : Biomechanical laboratory. Participants : Male ACLR patients who are younger than 22 years of age (total N = 164). Intervention : At 6- to 9-month postoperative visits, thigh circumference, knee ROM, and hip and thigh muscle strength were measured. Main Outcome Measures : Deficits of each variable between the uninvolved and ACLR limb were compared for pediatric and adolescent ACLR males in the BTB, HS, and ITB cohorts. Baseline characteristics, including physical demographics and meniscus tear status, were compared, and differences identified were treated as covariates and incorporated in analysis of covariance. Results : Data were from 164 adolescent male ACLR patients [mean age 15.7 (1.2) years]. There were no statistical differences in thigh circumference, knee ROM, hip abductor, and hip-extensor strength among the 3 autografts. However, patients with BTB demonstrated 12.2% deficits in quadriceps strength compared with 0.5% surplus in HS patients ( P  = .002) and 1.2% deficits in ITB patients ( P  = .03). Patients with HS showed 31.7% deficits in hamstring strength compared with 5.4% deficits in BTB ( P  = .001) and 7.7% deficits in ITB ( P  = .001) groups at 6- to 9-month postoperative visits. Conclusion : Adolescent male ACLR patients with BTB and HS autografts demonstrated significant deficits in quadriceps and hamstring strength, respectively, at 6 to 9 months postoperatively. Minimal lower-extremity strength deficits were demonstrated in pediatric male ACLR patients undergoing ITB harvest.

Abstract: Bucket-handle meniscal tears (BHMTs), which we define as vertical longitudinal tears of the meniscus with displacement of the torn inner fragment toward the intercondylar notch region, are a well-recognized tear pattern. Optimizing the management of BHMTs in younger patients is important, as preserving meniscal tissue may limit future joint degeneration. Purpose/Hypothesis: The purpose of this study was to review the patient demographics, clinical presentation, operative details, outcomes, and risk factors for a reoperation associated with operatively treated BHMTs in a pediatric population. We hypothesized that the repair of BHMTs in adolescents would yield a higher reoperation rate than meniscectomy in our population. Study Design: Case-series; Level of evidence, 4. Methods: A departmental database was queried to identify all patients 19 years or younger who presented with a BHMT and underwent surgery between October 2002 and February 2013. Clinical, radiological, and surgical data were retrospectively collected, and risk factors for a reoperation and persistent pain were assessed in all patients with longer than or equal to 6 months of follow-up. Results: A total of 280 BHMTs were treated arthroscopically by 1 of 8 sports medicine fellowship–trained surgeons. The mean age at surgery was 15.5 ± 2.5 years (range, 2.1-19.2 years), and most patients were male (177/280; 63%). Most injuries occurred during sports (203/248; 82%) and involved the medial meniscus (157/280; 56%). Concurrent anterior cruciate ligament (ACL) surgery was performed in 103 cases (37%). Meniscal repair was performed in 181 cases (65%) and was more common in younger patients ( P = .01) and for the lateral meniscus ( P 〈 .001). Among 185 (66%) cases with longer than or equal to 6 months of adequate follow-up data (which included 126 meniscal repairs [68%]), a meniscus-related reoperation occurred in 45 (24%) cases. A reoperation related to the original BHMT injury or surgery was more common after meniscal repair than after meniscectomy (40/126 [32%] vs 5/59 [8%], respectively) ( P = .001) and less common with concurrent ACL surgery ( P = .07), although this was not statistically significant. Among patients injured during sports and with adequate follow-up, all but 1 patient (176/177; 99%) returned to sports; a slower rate of return was seen in those undergoing meniscal repair ( P = .002) and concurrent ACL surgery ( P 〈 .001). At final follow-up, 170 of 185 patients (92%) were pain free. For the 15 patients with persistent pain at final follow-up, no identifiable risk factors for persistent pain were identified. Conclusion: Most BHMTs in younger patients occurred in males and during sports and affected the medial meniscus. Concurrent ACL surgery was indicated in approximately one-third of cases and was associated with a lower reoperation rate and slower return to sports. Two-thirds of patients underwent meniscal repair, over two-thirds of whom did not require a reoperation during the study period, despite the high activity levels in this age group.