Background:Tibial spine fractures (TSFs) are uncommon injuries in pediatric patients, often requiring operative fixation. While complications such as arthrofibrosis and anterior cruciate ligament (ACL) insufficiency have been previously reported, the risk factors associated with unplanned reoperation remain incompletely understood. Purpose:To identify the most common complications leading to reoperation and to evaluate associated risk factors, using a multicenter quality improvement registry. Study Design:Case-control study; Level of evidence, 3. Methods:A multicenter registry of operatively treated pediatric TSFs was retrospectively reviewed from July 2018 to March 2025 across 27 institutions. Grade 3 complications were defined as complications resulting in reoperation, unplanned hospitalization, or interventional radiologic procedures. Complication types, patient and injury characteristics, fixation methods, and intraoperative findings were analyzed. Bivariate and multivariate logistic regression analyses were performed to identify independent risk factors for Clavien-Dindo grade 3 complications. Results:A total of 532 patients were included (mean age, 12.1 years; 73.4% men). Overall, 56 patients (10.5%) underwent reoperation. The most common reasons for reoperation were stiffness (4.9%) and ACL insufficiency (3.6%). Screw fixation of TSFs was associated with a 4.5-fold increased risk of grade 3 complications compared with suture fixation (P = .009). Both suture and anchor fixation (P = .045) and longer operative times (P = .020) were also associated with higher complication rates. Meniscal or intermeniscal ligament entrapment was significantly associated with increased stiffness-related reoperation (P = .045). Patients who underwent delayed ACL reconstruction (ACLR) were older (P = .041) and more likely to have concomitant meniscal tears (P = .011) at the time of their TSF. Conclusion:Stiffness and ACL insufficiency represented the most frequent indications for reoperation after TSF fixation. Screw fixation, meniscal entrapment, and prolonged operative time were significant predictors of reoperation. Older age and concomitant meniscal injuries increased the risk of delayed ACLR.

Background: The incidence of pediatric anterior cruciate ligament reconstructions (ACLR) has drastically increased over the last 20 years. Previous studies have sought to characterize postoperative complications, but few have utilized a prospective, surgeon-reported protocol. This study aimed to utilize a large, multicenter, prospective collection from a quality improvement registry to determine complication incidence ≤8 months after ACLR. Additional aims sought to compare complication rates between the prospective database and a non-prospective database, as well as between early-career (≤5 y) and more experienced surgeons (>5 y). Methods: This study is a review of complication rates after pediatric ACLR submitted to 2 different collection instruments: the Sports Cohort Outcomes Registry (SCORE), a multicenter, prospective quality improvement registry, and the American Board of Orthopaedic Surgeons (ABOS) Part II Oral Exam database. Patients within the SCORE database underwent surgery from 2018 to 2025 and were ≤18 years old at the time of surgery, while ABOS patients underwent surgery from 2000 to 2021 and were ≤19 years old. Frequencies of complications were calculated, and statistical analysis followed using χ 2 and Fisher’s exact tests. Additional comparisons were performed based on surgeon experience. Significance was set at P <0.05. Results: Out of 8516 total cases in the SCORE database, 992 (11.6%) experienced a complication ≤8 months post-operation, and there was no significant difference between SCORE and ABOS incidence of total complications (11.6% vs. 11.1%, P =0.2296) (SCORE % vs. ABOS %, P value). In addition, there were no differences in medical complications (0.8% vs. 0.9%, P =0.2182), surgical complications (10.8% vs. 10.1%, P =0.0777), and infection (1.3% vs. 1.5%, P =0.2023). The most common complication, stiffness, had significant differences in reported rates between SCORE and ABOS (4.8% vs. 3.6%, P =0.0013). Differences were also noted in reoperation (3.7% vs. 1.8%, P <0.0001), wound-healing delay (1.3% vs. 0.5%, P <0.0001), pain (1.2% vs. 0.4%, P <0.0001), nerve palsy (1.0% vs. 0.7%, P =0.0325), readmission (0.6% vs. 1%, P =0.0047), and deep vein thrombosis (0.1% vs. 0.2%, P =0.0119). Further analysis of SCORE surgeons with >5 years of experience versus SCORE surgeons with ≤5 years of experience yielded no differences among any complications. In addition, significant differences were no longer found for only DVT (0% vs. 0.2%, P =0.6247) and nerve palsy (0.3% vs. 0.7%, P =0.3281) when comparing SCORE surgeons with ≤5 years of experience versus ABOS surgeons. Conclusion: This study provides the first comprehensive list of complications after pediatric ACLR with a large, entirely pediatric, and prospective patient cohort. In addition, it provides the first statistical comparison between pediatric ACLR complications as reported by a prospective database versus a non-prospective database and finds that prospective studies may allow for more accurate determination of reoperation rates and surgical-related complication rates, such as pain, stiffness, and wound-healing delay. In addition, this study provides evidence that complication rates after ACLR do not differ between early-career (≤5 y) and more experienced (>5 y) surgeons.

Pediatric anterior cruciate ligament reconstructions (ACLR) have increased dramatically in recent years. However, a comprehensive list of short-term complications related to this procedure has yet to be reported. This study aimed to report complication rates in pediatric ACLR using submissions to the American Board of Orthopaedic Surgery (ABOS) Part II Oral Examination. A secondary goal was to assess the relationship of complications with patient sex, geographic region of surgery, surgical volume, and surgeon fellowship training. A query was submitted to the ABOS Part II Oral Examination Case List Database for all ACLR performed in patients younger than 19 years between 2000 and 2021. Surgeon fellowship training, geographic region of surgery, and patient demographics were included, along with medical, surgical, and anesthetic complications, reoperation, and readmission. Statistic comparisons used chi-square tests for categorical variables with significance set at P < 0.05. Surgical complications were the most common type of complication, present in 10.1% of pediatric ACLR. Stiffness (3.6%) and infection (1.5%) were the most prevalent surgical complications. Females had higher rates of overall complications than males (11.9% vs. 10.4%, P = 0.010). Females also had higher rates of surgical complications (10.7%-9.5%, P = 0.019) -- specifically stiffness (5.0%-2.2%, P < 0.001). However, males had higher rates of infection (1.8% vs. 1.3%, P = 0.047). Geographic analyses showed higher infection rates in Hawaii and Alaska and lower surgical complication rates in the Northwest region. Procedures completed by surgeons with a fellowship training other than Sports Medicine and/or Pediatric Orthopaedics had lower rates of overall complications (8.9%, P < 0.001) and surgical complications (8.3%, P < 0.001). This study establishes that female pediatric and adolescent patients are at an increased risk for complications following ACLR. Arthrofibrosis was more than twice as common in females than in males. Geographic region and fellowship training may be associated with complications in this population. Cross-Sectional Study. (1)Complications following ACL reconstruction may be associated with geographic region and fellowship training.(2)Females present with more short-term complications following ACL reconstruction.(3)There was a higher reported infection rate overall for surgeons in their board collection period than infection rates in the literature, with males having an overall higher infection rate than females.(4)Arthrofibrosis is more than twice as common in females than males following ACL reconstruction. III.

Background: Arthrofibrosis is a somewhat rare complication of anterior cruciate ligament reconstruction (ACLR). Several factors may increase arthrofibrosis likelihood after ACLR, including sex, age, meniscal surgery, graft size, range of motion, and/or graft type. The purpose of this study was to determine arthrofibrosis rates following ACLR using 2 autograft choices: all-soft tissue quadriceps tendon (STQ) and quadriceps tendon with a patellar bone block (QPA). Additionally, we explored which variables were associated with the development of arthrofibrosis over the year following ACLR. Methods: Using a retrospective design, we evaluated outcomes among patients 10-18 years of age who underwent a primary ACLR using a quadriceps tendon autograft. Arthrofibrosis was defined as cases requiring follow-up surgical intervention involving manipulation under anesthesia (MUA) and/or lysis of adhesions (LOA) to restore range of motion. This definition was intended to capture clinically meaningful cases necessitating a second anesthesia exposure, rather than to measure the broad biological incidence of scar tissue formation. Predictor variables examined were sex, insurance type, preoperative range of motion, and graft choice. Results: A total of 352 patients who underwent ACLR were included, including surgeries performed on 366 unique ACLs. Of these, 342 ACLRs used a QPA graft and 24 used an STQ graft. The overall arthrofibrosis rate following ACLR was 3.6% (n = 13). Among these 13 patients, 8 underwent LOA for loss of terminal knee extension (STQ: n = 1, QPA: n = 7), 3 underwent MUA for loss of terminal knee flexion (STQ: n = 0, QPA: n = 3), and 2 required both procedures. The mean time from ACLR to secondary intervention was 8 months for LOA, 2.4 months for MUA, and 9.1 months when both procedures were performed simultaneously. Overall, 5.5% of female patients developed arthrofibrosis compared to 0.7% of male patients (OR = 0.13, 95% CI [0.01, 1.15]). Conclusions and clinical relevance: Our data indicate that 3.6% of patients experienced arthrofibrosis requiring intervention following ACLR. We found no statistically significant clinical predictors of arthrofibrosis following quadriceps autograft ACL reconstruction in the studied dataset. Future work should seek to determine patient-specific arthrofibrosis risk factors. Key Concepts: (1) Arthrofibrosis occurred in 3.6% of patients after anterior cruciate ligament reconstruction using either quadriceps tendon-patellar bone autografts or all-soft tissue quadriceps tendon autografts. (2) Female patients had a higher rate of arthrofibrosis than males, although the difference was not statistically significant. (3) Preoperative range of motion did not predict arthrofibrosis risk. (4) No single factor predicted arthrofibrosis risk, thus risk appears to be multifactorial. Level of Evidence: Level III

Background: Peripheral nerve blocks (PNBs) are frequently utilized as a regional anesthetic in pediatric orthopaedic surgery for postoperative pain control and reduced time to discharge; however, short- and long-term complications after these procedures are variably reported. Purpose: To identify the frequency of long-term complications in pediatric patients who received regional anesthesia for a lower extremity orthopaedic procedure. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic literature search was performed using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Data were collected on pediatric patients, which included the following: block type, block location, procedure type, patient age, experimental design, and reported outcomes. Full texts were then thoroughly examined to determine whether the article made specific references to long-term (≥6 weeks) complications in pediatric patients who received PNBs. Results: A total of 158 studies were assessed for eligibility. There were 16 of 158 (10%) studies that met inclusion criteria of having a discussion on follow-up to evaluate for long-term complications (≥6 weeks) from pediatric PNBs. Of these 16 studies, 9 documented long-term complications, while 7 reported no complications. The most common complications were motor deficits, chronic pain, reduced range of motion, and neurological paresthesia. Of the 9 studies reporting long-term complications related to PNBs, 16 of 352 patients across 2 studies (5%) reported chronic pain, 45 of 466 patients across 4 studies (10%) reported strength deficits, 16 of 135 patients across 2 studies (12%) reported reduced range of motion, and 11 of 15,387 patients across 4 studies (0.07%) reported sensory deficits. Conclusion: Persistent complications occurred in pediatric orthopaedic patients undergoing lower extremity procedures with PNBs; however, reports in the current literature were rare.

Background: Pediatric patients are often prescribed physical therapy following an orthopaedic diagnosis or surgical procedure; however, many children experience delays, which can consequently prolong recovery. The purpose of this study was to identify the factors that delay the patient's ability to receive timely care after referral to physical therapy (PT).Methods: Pediatric patients who were ordered physical therapy after orthopaedic treatment were prospectively recruited to participate in this study. Patients were administered a demographic questionnaire upon enrollment. Data collected included initial referral, date of authorization, and date of first PT appointment. A delay was defined as a wait of 2 weeks or more between the referral and first physical therapy appointment.Results: Of 100 orthopaedic patients enrolled, 60% (60/100) had government insurance and 40% (40/100) had private insurance. Significant differences were revealed between insurance type (p=0.005), ethnicity (p=0.005), and site of injury (p=0.02) in time to first appointment. Patients with government insurance were 3.4 times more likely than patients with private insurance to experience a delay to physical therapy (95% CI: 1.5, 8.2). Only 27% (11/40) of patients with private insurance experienced a delay as compared to 57% (34/60) of patients with government insurance. Ten percent (6/60) of the patients with public insurance were never able to see a physical therapist while all privately insured patients were ultimately seen in PT. In multivariable analysis, Hispanic ethnicity and hip conditions were associated with delay in receiving PT.Conclusion: Patients with government insurance were over three times more likely to experience a delay in attending a physical therapy appointment than patients with private insurance, and 10% of patients with public insurance never saw a physical therapist. Insurance type may directly influence access to care or may be associated with demographic and socioeconomic factors decreasing the ability to utilize care.Level of Evidence: IIIKey Concepts•There is a delay in time to PT based on insurance type, ethnicity, and site of injury.•Patients with government insurance were over three times more likely to experience a delay in their initial physical therapy appointment than patients with private insurance.

BACKGROUND:The opioid epidemic in the United States is a public health crisis. Pediatric orthopaedic surgeons must balance adequate pain management with minimizing the risk of opioid misuse or dependence. There is limited data available to guide pain management for anterior cruciate ligament reconstruction (ACLR) in the pediatric population. The purpose of this study was to survey current pain management practices for ACLR among pediatric orthopaedic surgeons.METHODS:A cross-sectional survey study was conducted, in which orthopaedic surgeons were asked about their pain management practices for pediatric ACLR. The voluntary survey was sent to members of the Pediatric Orthopaedic Society of North America. Inclusion criteria required that the surgeon perform anterior cruciate ligament repair or reconstruction on patients under age 18. Responses were anonymous and consisted of surgeon demographics, training, practice, and pain management strategies. Survey data were assessed using descriptive statistics.RESULTS:Of 64 included responses, the average age of the survey respondent was 48.9 years, 84.4% were males, and 31.3% practiced in the southern region of the United States. Preoperative analgesia was utilized by 39.1%, 90.6% utilized perioperative blocks, and 89.1% prescribed opioid medication postoperatively. For scheduled non-narcotic medications postoperatively 82.8% routinely advocated and 93.8% recommended cryotherapy postoperatively.Acetaminophen was the most used preoperative medication (31.3%), the most common perioperative block was an adductor canal block (81.0%), and the most common postoperative analgesic medication was ibuprofen (60.9%). Prior training or experience was more frequently reported than published research as a primary factor influencing pain management protocols.CONCLUSIONS:Substantial variability exists in pain management practices in pediatric ACLR. There is a need for more evidence-based practice guidelines regarding pain management.LEVEL OF EVIDENCE:Level V.

Aims: Temporary epiphysiodesis with tension band plating is used to manage leg length discrepancy. Temporary epiphysiodesis may offer surgical timing benefits over permanent drill epiphysiodesis, but a potential complication is secondary angular deformity. We aimed to describe angular deformity and associated factors after temporary epiphysiodesis. Materials and Methods: In this retrospective review of patients who underwent temporary epiphysiodesis of the distal femur and/or proximal tibia, mechanical axis deviation (MAD) was measured on preoperative and last follow-up radiographs. Changes in MAD and angular deformity were analyzed using nonparametric statistics. Angular deformity was defined as MAD >10 mm from neutral. Results: In our cohort of 12 patients (age at surgery 11.3 ± 2.0 years; postoperative follow-up 2.0 ± 0.9 years), the mean magnitude of MAD change was 14 ± 10 mm. Of five femoral only procedures, four limbs (80%) had lateral (valgus) direction of MAD change, while one had 1 mm varus change. Of two tibial only procedures, both had lateral direction of MAD change. Of five combined femoral and tibial procedures, one limb (20%) had no MAD change, and four limbs (80%) had medial (varus) MAD change. At the last follow-up, 50% (6/12) of limbs had MAD >10 mm from neutral, which they did not have before surgery. Conclusions: For patients with limb length discrepancy, temporary epiphysiodesis with tension band plating may increase the potential for angular deformity. This finding should be considered when this procedure is planned for patients close to skeletal maturity.

BACKGROUND:Grit is the disposition to strive for long-term goals despite setbacks and challenges. Given the lengthy, arduous process of rehabilitation after anterior cruciate ligament reconstruction (ACLR), an athlete's grit may predict postoperative outcomes across time.PURPOSE/HYPOTHESIS:The primary aim of the study was to evaluate the relationships between baseline (preoperative) grit and postoperative knee outcomes across the year after ACLR among adolescents. We hypothesized that athletes with more grit would achieve better postoperative outcomes over time than less gritty athletes.STUDY DESIGN:Cohort study; Level of evidence, 2.METHODS:All participants completed the Short Grit Scale, the Pediatric International Knee Documentation Committee (Pedi-IKDC) Scale, the Lysholm Knee Scoring Scale, the Patient-Reported Outcomes Measurement Information System (PROMIS) pediatric scale for pain interference and mobility, the Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS), and the Quality of Life in Neurological Disorders (NeuroQoL) Lower Extremity Function Short Form at a preoperative appointment and then again at approximately 3, 6, and 12 months after ACLR. We constructed linear mixed models to assess the relationships between baseline grit, time, age, sex, and postoperative outcome measures (statistical significance of α = .05).RESULTS:We included 137 participants (mean age 15.8 ± 2.74 years, 70% female) from a prospective registry of athletes undergoing ACLR by 1 surgeon at a single institution. There were no statistically significant changes in grit over time or differences in grit between age and sex. Higher baseline grit was significantly associated with greater postoperative HSS Pedi-FABS scores (β = 3.72 ± 1.46; P = .01; 95% CI, 0.85-6.59) and NeuroQoL scores across time (β = 3.37 ± 0.93; P < .001; 95% CI, 1.55-5.20). There were no significant associations between baseline grit and Pedi-IKDC, Lysholm, and PROMIS pain interference or mobility scores.CONCLUSION:Athletes with higher baseline grit reported superior postoperative physical function and activity level over the course of 1 year after ACLR compared with less gritty athletes. Grit may be a useful measure in predicting success in regaining physical function across time after ACLR in adolescent athletes.

Patellofemoral instability (PFI) is an increasingly prevalent issue affecting pediatric and adolescent patients. Anatomic factors, including lateralization of the tibial tubercle and patella alta, can contribute to increased risk of initial and recurrent PFI. In the case of recurrent PFI, chondral injuries of the patellofemoral compartment can occur. These anatomic pathologies can be surgically addressed using tibial tubercle osteotomy (TTO), adjusting the angle and direction of the osteotomy as needed to achieve the desired correction. We discuss the indications and present our technique for performing TTO, including the modifications that can be made to the procedure to address the specific pathoanatomy of the patient.Key Concepts•Lateral patellar instability is a common condition impacting adolescent patients with tibial tubercle lateralization and patella alta being common modifiable risk factors for recurrence.•The tibial tubercle osteotomy is a versatile procedure permitting the treatment of patellofemoral instability and associated cartilage injuries by adjusting the angle of the osteotomy cut and tubercle transfer as needed to address the specific pathology.•Risks of osteotomy are greater than soft tissue reconstruction procedures alone, but many can be mitigated with meticulous osteotomy and soft tissue closure techniques.

Background: The incidence of anterior cruciate ligament (ACL) injuries has steadily increased in young athletes and may have long-term implications for physical function and quality of life. ACL injury prevention programs have been developed and refined over the past several decades and have been shown to reduce the risk of ACL injuries by up to 70%. However, awareness and understanding of these programs among parents of athletes is unknown. This study aims to evaluate knowledge and attitudes toward ACL injury prevention programs for parents of young athletes involved in cutting and pivoting sports at varying levels of competition.Methods: A cross-sectional survey was nationally distributed to a convenience sample of parents of young athletes between the ages of 5 and 18. The survey focused on questions relating to demographic information, history of ACL injury, knowledge of ACL injury prevention programs, and factors influencing program awareness. Descriptive statistics were used to summarize participant characteristics and determine prevalence of program awareness.Results: A total of 244 parents completed the survey with 74% indicating their child's primary sport was soccer. Seventy-seven percent of these athletes began specializing in their primary sport at an average age of 8 years old (SD = 2.72). Only 18% of parents reported knowledge of ACL injury prevention programs and just 6% reported their child has ever participated in one. Of the 29 (12%) athletes who had experienced an ACL injury, only 17% had participated in an ACL injury prevention program. The most commonly reported barrier to ACL injury prevention program participation was the lack of awareness of where to get such training and it not being readily offered to their child. Sixty-eight percent of all parents would have their child participate in an ACL injury prevention program if offered to them.Conclusion: There is a lack of awareness of ACL injury prevention programs among parents of young athletes involved in high injury-risk sports. However, most parents would be interested in their child utilizing an ACL injury prevention program if it were offered.Levels of Evidence: Level IVKey Concepts•Given the young age at which athletes are specializing in their sport and other contributing factors, ACL injury prevention programs are becoming increasingly important.•Parents of youth athletes demonstrate a lack of awareness regarding ACL injury prevention programs.•Barriers to the utilization of ACL injury prevention programs include both a lack of knowledge of their availability and where to access this form of training.•Many parents are interested in having their child participate in an ACL injury prevention program.•Spreading awareness of ACL injury prevention programs will require a multi-faceted approach.

Background: Dynamic limb valgus and stiff landing are two known risk factors for anterior cruciate ligament (ACL) injury. These biomechanical risk factors can be evaluated through motion analysis testing. Hypothesis/Purpose: The purpose of this study was to compare risk scores for dynamic limb valgus and stiff landing between limbs with recent ACL reconstruction and uninjured (contralateral and control) limbs. Methods: Sports motion analysis data were reviewed for 177 pediatric patients after recent primary ACL reconstruction (ACLR) and 63 uninjured control subjects ages 8-17 years. 3D motion analysis data were collected while subjects performed the following sports-related tasks: heel touch from 6” or 9” step (depending if height >155 cm), drop jump from 41 cm height, lateral shuffle, forward-backwards deceleration, single leg hop, and 45° cutting. Each limb was scored for components of dynamic limb valgus (hip stability, pelvis stability, trunk stability) and stiff landing (shock absorption, hip strategy) based on the kinematic and kinetic measures in Table 1. Each scoring category was rated for each applicable task as adequate (2), borderline (1), or inadequate (0) based on values from the literature and laboratory norms. Percentage scores by scoring category were compared among reconstructed, contralateral, and control limbs using chi-square tests and ANOVA. Results: For the overall risk factors, stiff landing was worse in controls compared with both the reconstructed and contralateral limbs of patients (p<0.001), but dynamic limb valgus was worse in the ACLR limbs (p≤0.03) (Figure 1). Shock absorption (p<0.001), hip strategy (p<0.001), and trunk stability (p=0.005) differed significantly between groups. Shock absorption and hip strategy were both worse in the control group compared with the patient reconstructed and contralateral limbs, while trunk stability was best in the control group and worst in the ACLR group. Conclusion: Post-operative ACLR patients demonstrated better biomechanics than controls on both the reconstructed and contralateral limbs in terms of avoiding stiff landing, particularly through better shock absorption. This may reflect training in proper biomechanics during physical therapy and rehabilitation. ACLR limbs were worse than control limbs only in trunk stability, which can be corrected with targeted training and awareness. Motion analysis is useful for identifying risky movement patterns so biomechanics can be corrected prior to return to play. Table 1 Kinematic and kinetic variables used for each scoring category Figure 1. Distribution of scores for stiff landing and dynamic limb valgus for each group

Background: The Micheli technique for anterior cruciate ligament (ACL) reconstruction (ACLR) has proven to be a reliable method with a minimal risk for growth disturbance among skeletally immature patients. Purposes: To evaluate the Micheli technique of iliotibial band (ITB) graft passage for ACLR using cadaveric knee models and to measure the distance between the surgical instrument tip and the neurovascular bundle in the posterior knee joint: specifically, the peroneal nerve, tibial nerve, and popliteal artery. Study Design: Descriptive laboratory study. Methods: Gross dissection was performed on 17 pediatric cadaveric knees (12 male and 5 female) aged between 4 and 12 years. To simulate ITB graft passage, we passed a curved-tip hemostat clamp through the posterior capsule, with the knee flexed from 90° to 100°. Next, clinical photographs were taken, and digital imaging software was used to measure the distance in centimeters from the clamp tip to each respective neurovascular structure. Results: The mean distances from the clamp tip to the tibial nerve, popliteal artery, and peroneal nerve were 0.875 cm (range, 0.468-1.737 cm), 0.968 cm (range, 0.312-1.819 cm), and 1.149 cm (range, 0.202-2.409 cm), respectively. Mean values were further calculated for age groups of ≤8, 9-10, and 11-12 years. The mean distance from the clamp tip to the peroneal nerve was 1.400 cm larger for 11- to 12-year-old specimens than for ≤8-year-old specimens (95% CI, 0.6-2.2 cm; P = .005). Conclusion: The neurovascular structures in the posterior knee were in close proximity to the path of graft passage, with distances <1 cm in many specimens in this study. When passing the graft through the knee for an over-the-top position, surgeons should consider these small distances between the path of graft passage and critical neurovascular structures. Clinical Relevance: As the incidence of ACL tears is continuously increasing within the pediatric population, there are a larger number of ACLR procedures being performed. Although neurovascular injuries during ACLR are rare, this study clarifies the close proximity of neurovascular structures during ITB graft passage using the Micheli technique of ACLR.

Background: Lateral meniscus deficiency in young patients typically results from irreparable lateral meniscus tears, often associated with discoid meniscus. Such cases present a challenging clinical scenario given the known natural history of meniscus deficiency leading to degenerative lateral knee compartment changes. Managing this problem in a skeletally immature patient presents additional clinical and surgical considerations. Indications: Lateral meniscus allograft transplantation (LMAT) is indicated in patients with prior total or subtotal lateral meniscectomy resulting from irreparable lateral meniscus tears, with the goal of providing chondroprotection to the lateral compartment of the knee. Patients are assessed preoperatively for ligamentous stability of the knee, mechanical alignment, and associated chondral injuries to determine whether secondary procedures may be indicated. Technique Description: We present an all-arthroscopic technique for LMAT using small bone plugs in the anterior and posterior meniscus roots secured through 2 separate anatomic root drill tunnels tied over a bone bridge. The meniscus allograft is further secured using an outside-in suture repair technique. Special attention is given to meniscus allograft preparation, anatomic meniscus root identification, and drilling using a minimally disruptive transphyseal technique. Graft passage, suture management, and meniscus fixation and repair are also highlighted. Results: Anticipated outcomes from LMAT in skeletally mature patients are excellent, particularly if preexisting chondral degenerative changes are not present. Prior studies with greater than 7-year follow-up in adolescent patients undergoing meniscus allograft transplantation have shown reoperation rates of less than 6% with no growth disturbances noted, with most patients able to return to their prior level of sport. Computed tomography modeling data using this technique shows a proximal tibial physeal surface area disruption of less than 2.5%; therefore, the risk of growth disturbance is very low. Discussion/Conclusion: The surgical technique demonstrated here offers a safe and effective approach for the management of lateral meniscus deficiency after subtotal lateral meniscectomy for irreparable meniscus tears in skeletally immature patients. The chondroprotective effect of the lateral meniscus can be restored with an anatomically placed lateral meniscus allograft with minimal disruption to the proximal tibial physis.

Pediatric Sports Medicine is a relatively new subspecialty within Pediatric Orthopaedics, with continually evolving surgical techniques. As a result, many of the procedures performed may not have well-established corresponding CPT codes, leading to considerable variability in how different surgeons code for the same procedure. This article presents case scenarios for common shoulder, elbow, and ankle pathologies treated surgically by pediatric orthopaedic surgeons. The intent is to clarify some discrepancies in coding for these procedures and aid the surgeon in proper billing. It is important to note that the following scenarios are hypothetical and therefore ultimate code selection should always reflect the operative report documentation.

Background: The COVID-19 pandemic has had a significant impact on pediatric sports medicine patients. Many surgeons found themselves simultaneously managing surgical pathology, concerns of exposure, and limited resources. This led to challenging decisions regarding relative patient and case urgency. Purpose: 1. Define through expert opinion the relative urgency of prototypical pediatric arthroscopic surgical cases 2. Define current practices regarding pre-surgical testing and findings relevant to the recent, current, and potentially forthcoming challenges inherent to the COVID-19 pandemic. We further gathered information regarding variability of current practices and access to resources. Methods: A mixed-methods survey was performed of the POSNA membership, specific to surgeons identifying as sub-specialized in pediatric sports medicine. A clinical vignette style survey was developed by the POSNA QSVI: Sports Committee. Cases included patients with a: meniscal tear, a bucket handle meniscus tear, ACL tear, unstable osteochondritis dissecans (OCD) lesion of the knee, locked knee due to a loose body, OCD of the capitellum, recurrent and primary shoulder instability, traumatic patellar instability with a loose osteochondral fragment, and a patient with a symptomatic discoid meniscus. The survey further asked how resource limitations could impact surgical decision-making, and how pre-operative testing might impact surgical timing and decisions. Information regarding personal and institutional experiences and limitations during the first 6 months of the pandemic was also collected. Results: There were 119 survey respondents, of whom 54 met inclusion criteria. Seventy-five percent were primarily based at a university or academic hospital. Almost 56% of respondents had all scheduled cases cancelled for 4-7 weeks, 22% for 8-11 weeks, and 17% were shut down for more than 12 weeks. Forty-two percent followed guidance from an orthopaedic governing body, most commonly national orthopaedic organizations. There was significant variation in pre-operative testing protocols, ranging from screening questions to PCR testing and rapid testing. Triaging factors chosen by respondents for determining relative urgency, in order, were: Diagnosis, severity of symptoms/pathology, duration of symptoms, age, activity level, originally planned surgical date, and patient request. Each clinical vignette elicited variability in responses, but each had clear leaders in opinion regarding relative urgency. Most cases had more than 2/3 of respondents in relative agreement with respect to urgency. Conclusion: This study provides comparative details of the challenges and resource limitations experienced in pediatric sports medicine, and provides much-needed sub-specialty opinions on standards with respect to relative urgency and triaging for related cases. These experiences and opinions may be of benefit when advocating for patient access and care.

BACKGROUND:The proximal femur is a common location for pathologic fractures in children, yet there is little published information regarding this injury. The purpose of this study was to investigate the outcomes of pediatric pathologic proximal femur fractures due to benign bone tumors.METHODS:A retrospective review of patients treated for pathologic proximal femur fractures from 2004 to 2018 was conducted. Inclusion criteria were age below 18 years and pathologic proximal femur fracture secondary to a benign bone tumor. Patients were excluded if they had <1 year of follow-up. Medical charts and serial radiographs were reviewed for fracture classification, underlying pathology, treatment, complications, and time to fracture healing.RESULTS:A total of 14 patients were included. Mean age was 6±3 (3 to 11) years, and mean follow-up was 44±21 (22 to 86) months. Index treatment was spica casting in 9/14 (68%) patients, while 5/14 (32%) were treated with internal fixation. Of the 9 patients initially treated with casting, 22% (2/9) required repeat spica casting at a mean of 0.6 months after index treatment, 67% (6/9) required internal fixation at a mean of 20.3 months after index treatment, and 11% (1/9) did not require revision treatment. Eighty-eight percent (8/9) of patients treated with casting required revision treatment compared with 40% (2/5) of those treated with internal fixation (P=0.05). Nonunion occurred after 1 refracture, malunion with coxa vara occurred in 2 fractures, and the remaining 11/14 (84%) fractures had a union at a mean of 4.9±3.0 months All cases of malunion occurred in patients initially treated nonoperatively. There were 19 distinct complications in 10/14 (71%) patients. The incidence of any revision surgery was 64% (9/14).CONCLUSIONS:In this series, pediatric pathologic proximal femur fractures demonstrated prolonged time to union, high incidence of revision surgery (64%), and substantial complication rate (71%). In children with pathologic proximal femur fractures, treatment with internal fixation is recommended as this series showed a 78% failure rate of initial conservative management.LEVEL OF EVIDENCE:Level IV.

Although pediatric knee dislocations are relatively uncommon, the potential for devastating complications exists. Current treatment has largely been guided by the adult literature as well as small pediatric case series. Early recognition and treatment of vascular injuries is of the utmost importance. Neurological injuries can also lead to devastating long-term complications and therefore prompt recognition is crucial. Ligament reconstruction as opposed to ligament repair has been shown to have improved outcomes in the pediatric population. The subsequent rehabilitation of a child after reconstruction for a knee dislocation also provides a unique challenge. Various sequelae have been described to include neurovascular injuries, residual laxity, stiffness as well as those unique to pediatric patients such as growth disturbance.

Background: Effective pain management for anterior cruciate ligament (ACL) reconstruction may improve both patient satisfaction and function. However, there is limited data supporting clear guidelines regarding pain management for ACL reconstruction in the pediatric population. Hypothesis/Purpose: The purpose of this study is to survey current pain management practices for ACL reconstruction among pediatric orthopaedic surgeons. Methods: A cross-sectional survey study was conducted in which orthopaedic surgeons were asked about their pain management practices for pediatric ACL reconstruction. The voluntary survey was sent to members of the Pediatric Orthopaedic Society of North America (POSNA). Inclusion criteria were performs ACL repair or reconstruction on patients under age eighteen and willing to participate in the survey. Responses were anonymous and consisted of demographics, training, current practice, and pain management strategies. Survey data were assessed using descriptive statistics, Pearson’s chi-squared test and Fisher’s exact test for categorical variables, and two-sample t-test for continuous variables. Results: There were 77 responses, of which 64 fit the inclusion criteria. The average age of respondents was 48.9 years, 84.4% were male, and 31.3% practiced in the southern region of the US (Table 1). 39.1% of respondents utilized preemptive analgesia, 90.6% utilized perioperative blocks, 82.8% routinely advocated for scheduled non-narcotic medications post-operatively, and 93.8% recommended cryotherapy post-operatively (Table 2). Respondents that reported not using a peri-operative block and not advocating for scheduled non-narcotic pain management post-operatively were older on average than those that did (57.6 vs. 47.7 years, p=0.04; 56.7 vs. 47.0 years, p<0.01; respectively). Acetaminophen was the most commonly used pre-operative medication (31.3%), the most common perioperative block was an adductor canal block (73.4%), and the most typically prescribed post-operative analgesic medication was ibuprofen (60.9%). Most respondents reported prescribing 10-20 opioid pills (46.9%), 20.3% prescribed >20 opioid pills, and 10.9% did not prescribe opioid pain medication at all. In total, 89.1% of respondents reported prescribing opioid pain medication post-operatively, however, only 59.4% reported counseling patients on appropriate disposal of extra pills. Prior training or experience was more frequently reported than published research as a primary factor influencing pain management protocols. Conclusion: Significant variability exists in pain management practices in pediatric ACL reconstruction. There is a need for more evidence-based practice guidelines regarding pain management. Table 1. Demographics (N=64) Table 2. Pain Management Practices

Background: For patients with significant growth remaining, the Iliotibial Band ACL reconstruction technique has proven to be reliable procedure with minimal risk for growth disturbance. Recent dissection studies confirm the neuro-vascular bundle is within 1 cm of the ACL graft over the top position, confirming the importance of careful graft passage technique to avoid neurovascular injury. Purpose: The purpose of this study was to evaluate the over the top graft passage technique using pediatric 3-D knee models. Instrument placement for graft passage was assessed for its proximity to the posterior aspect of the femur, maintaining a safe distance from the neurovascular bundle. Materials and Methods: 3D knee models (ages 7, 9, 11 years) were printed from high resolution knee CT scans, including a hinge/pivot mechanism to allow for simulation of knee position during flexion and extension. Various curved tip instruments were used to evaluate the path of the graft passage, with several goals: 1. Allow the instrument to create a graft path through the posterior capsule in the most anatomic femoral position. 2. Keep the tip of the instrument close to posterior and lateral cortex of the femur, to avoid neurovascular injury. The instruments varied in design, arc of curvature, overall length, diameters. Results: Clamp passage was performed using a retrograde approach, i.e. through the notch, passing outside the periosteum of the postero-lateral femur (Figure 1). For some clamps, the arc of the curvature allowed for passage of the instrument with minimal risk of neurovascular injury. For some clamp configurations, the clamps deviated significant from the posterior aspect of the femur during graft passage, which may increase the risk of neurovascular bundle injury. In each case, an instrument was identified that met the criteria for safe passage, but different instruments were required based upon the size of the knee joint. Conclusions: The ITB ACL reconstruction is one of the best options for ACL reconstruction in the skeletally immature. The neurovascular structures are very close to the path for over the top graft placement. Due to the wide range of knee dimensions in this group, different clamp designs may be necessary for optimal over the top graft passage. 3D knee models may guide surgeons for procedure technique and optimal instrument selection for safe graft passage.Figure 1.