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To evaluate sex differences in incidence rates (IRs) of anterior cruciate ligament (ACL) injury by sport type (collision, contact, limited contact, and noncontact). A systematic review was performed using the electronic databases PubMed (1969-January 20, 2017) and EBSCOhost (CINAHL, SPORTDiscus; 1969-January 20, 2017) and the search terms AND AND ( OR OR ). Studies were included if they provided the number of ACL injuries and the number of athlete-exposures (AEs) by sex or enough information to allow the number of ACL injuries by sex to be calculated. Studies were excluded if they were analyses of previously reported data or were not written in English. Data on sport classification, number of ACL injuries by sex, person-time in AEs for each sex, year of publication, sport, sport type, and level of play were extracted for analysis. We conducted IR and IR ratio (IRR) meta-analyses, weighted for study size and calculated. Female and male athletes had similar ACL injury IRs for the following sport types: collision (2.10/10 000 versus 1.12/10 000 AEs, IRR = 1.14, = .63), limited contact (0.71/10 000 versus 0.29/10 000 AEs, IRR = 1.21, = .77), and noncontact (0.36/10 000 versus 0.21/10 000 AEs, IRR = 1.49, = .22) sports. For contact sports, female athletes had a greater risk of injury than male athletes did (1.88/10 000 versus 0.87/10 000 AEs, IRR = 3.00, < .001). Gymnastics and obstacle-course races were outliers with respect to IR, so we created a sport category of fixed-object, high-impact rotational landing (HIRL). For this sport type, female athletes had a greater risk of ACL injury than male athletes did (4.80/10 000 versus 1.75/10 000 AEs, IRR = 5.51, < .001), and the overall IRs of ACL injury were greater than all IRs in all other sport categories. Fixed-object HIRL sports had the highest IRs of ACL injury for both sexes. Female athletes were at greater risk of ACL injury than male athletes in contact and fixed-object HIRL sports.

Background: The most published surgical technique for fixating Type 4 (Salter–Harris II) tibial tubercle avulsion fractures is uni-cortical in nature, and stability is suboptimal. This study presents a technique modification that is consistent with AO principles, by which the screws are aimed distally to purchase the posterior cortex of the distal fragment. This technique is defined as a “Distal Cortical Fixation”. This modification has not been studied to date and harbors potential advantages. We aimed to assess the safety and efficacy of surgical fixation techniques for the above-mentioned fractures and to describe the new modification. Methods: A retrospective review was conducted at a level 1 children’s hospital for surgically treated Salter–Harris II tibial tubercle fractures. Inclusion criteria were patients who sustained Salter–Harris II tibial tubercle avulsion fractures and were documented to reach one of two radiographic endpoints: union (regardless of alignment) or non-union that necessitated additional interventions. Medical records and radiographic studies were analyzed for fracture union and alignment. A comparative analysis was conducted to evaluate outcomes based on different fixation techniques that included Distal Cortical Fixation, a Proximal Screw Technique, and a crossed or multiple screws/pins construct. Results: A total of 37 patients were included with a mean age of 14.8 ± 1.2 years, with 34/37 (91.9%) being male. The most common procedure was a 1 to 3 screw fixation with a Distal Cortical Fixation (n = 21 (56.75%)), followed by a Proximal Screw Technique (n = 8, 21.62%), and a crossed or multiple screws/pins construct (n = 8, 21.62%). There was no difference between the groups in medical history and demographic features. The mean follow-up duration was 35.17 ± 36.79 weeks. There were no non-unions, and only a minimal change in the sagittal and coronal alignment (0.4 ± 1.94 (p = 0.872) and 0.53 ± 3.51 (p = 0.296) degrees, respectively) was noted and was not associated with the surgical technique. Conclusions: The surgical treatment of Salter–Harris II tibial tubercle avulsion fractures, including Distal Cortical Fixation, was presented and was found to provide satisfactory union rates on a short term follow up.

Osteochondritis dissecans (OCD) describes a pathologic condition centered at the osteochondral junction that may result in an unstable subchondral fragment (progeny), disruption of the overlying cartilage, which may separate from the underlying parent bone. It is one of the causes of chronic knee pain in children and young adults. The current literature on OCD lesions focuses primarily on the medial femoral condyle (MFC), but inconsistent use of terminology, particularly in the distinction of OCD lesions between skeletally immature and mature patients has created uncertainty regarding imaging workup, treatment, and long-term prognosis. This article reviews the pathophysiology of MFC OCD lesions, highlighting the role of endochondral ossification at the secondary growth plate of the immature femoral condyles, the rationale behind the imaging work-up, and key imaging findings that can distinguish between stable lesions, unstable lesions, and physiologic variants. This overview also provides a case-based review to introduce imaging correlates with the ROCK (Research in Osteochondritis of the Knee) arthroscopic classification.

Background: Postoperative knee arthrofibrosis after arthroscopic ligament reconstruction is a serious complication. Among adolescents, risk factors for postoperative arthrofibrosis are not well characterized and the effectiveness of early manipulation under anesthesia (MUA) is not well established. Purposes: To identify risk factors for arthrofibrosis after arthroscopic knee ligament reconstruction in adolescent patients and to evaluate the safety and effectiveness of early MUA. Study Design: Case-control study; Level of evidence, 3. Methods: The charts of all adolescent patients (<19 years of age) who underwent early MUA (<3 months) for knee stiffness after anterior cruciate ligament (ACL) or medial patellofemoral ligament (MPFL) reconstructions between 2008 and 2021 were retrospectively reviewed. Patients were matched 2:1 with patients without MUA from the same study period. The primary outcome was the final range of motion (ROM) after MUA. Logistic regression analysis was performed to identify predictors of MUA. Results: A total of 25 patients (10 with ACL reconstruction and 15 with MPFL reconstruction) with a mean age of 14.8 ± 2.6 years were included for analysis. Overall, 44% were skeletally immature. Patients underwent MUA at a mean of 63.3 ± 19.5 days after the index surgery. The mean ROM improved significantly from 96.3°± 20.5° to 135°± 9.7° after MUA after a median follow-up of 8.1 months (interquartile range, 5.4-15.0 months). There were no complications associated with MUA, but 2 patients (8.0%) had MUA treatment failure. There were no differences in body mass index, type and frequency of associated procedures, or patellar height on lateral radiographs between the cohorts. The MUA cohort had statistically significant increased operative time, decreased preoperative motion, decreased ROM at 6 weeks postoperatively, and increased pain at 6 weeks postoperatively when compared with the non-MUA cohort. Regression analysis demonstrated that ROM at 6 weeks (OR: 0.83, 95% CI, 0.69-0.98, p = .034) was significantly associated with the need for MUA. Conclusion: The findings of this study suggest that early (<3 months) MUA is safe and effective in treating knee arthrofibrosis in adolescent patients. MUA is a treatment alternative for patients with restricted ROM at 6 weeks that may help them recover full ROM.

Background: Patellar instability is frequently encountered in patients with Ehlers-Danlos syndrome (EDS). The clinical outcomes of isolated medial patellofemoral ligament reconstruction (MPFLR) for patellar instability in patients with EDS are unknown. Purpose: To evaluate midterm clinical outcomes of isolated MPFLR for patellar instability in patients with EDS and factors affecting these outcomes. Study Design: Case series; Level of evidence, 4. Methods: In a retrospective study, 31 patients (n = 47 knees) with EDS and patellar instability who underwent isolated MPFLR for recurrent patellar instability between 2008 and 2017 and had a minimum 2-year follow-up were identified. Preoperative radiographic images were measured for anatomic risk factors. Clinical outcomes—including postoperative complications—were evaluated. Factors associated with MPFLR failure were identified. Postoperative patient-reported outcomes (PROs)—including the pediatric version of the International Knee Documentation Committee, the Kujala score, the Hospital for Special Surgery Pediatric Functional Activity Brief Scale, the Banff Patellofemoral Instability Instrument 2.0, and the Knee injury and Osteoarthritis Outcome Score—were collected, and factors affecting PRO scores were analyzed. Results: The mean age of the cohort was 14.9 ± 2 years. At a mean follow-up of 7.2 years, 18 of 47 (38.3%) knees required reoperations, of which 9 of 47 (19.1%) knees required revision stabilization for recurrent patellar instability. Also, 7 of 31 knees (22.6%) with autografts failed compared with 2 of 16 (12.5%) with allografts (P = .69). For autografts, 6 of 17 (35.3%) failures occurred with gracilis, but 0 of 13 (0%) occurred with semitendinosus (P = .02). Compared with patients without failures, patients with failed primary MPFLR were significantly younger (P = .0005) and were able to touch the palm to the floor with their knees extended (P = .03). For radiographic parameters, the patellar height and tilt were significantly higher in the failure group. The postoperative PROs were suboptimal at a mean follow-up of 5.2 years. All but 1 patient were satisfied with the final outcome. Conclusion: At the midterm follow-up, 38.3% of patients with EDS required further surgery after isolated MPFLR for patellar instability; half of these revisions (19.1%) were to address recurrent instability. Recurrent instability after isolated MPFLR was more likely in younger patients and those who could touch the palm to the floor with their knees extended. Postoperative PROs were inferior; nonetheless, patient satisfaction was high.

Background: The safest and most effective technique for anterior cruciate ligament (ACL) reconstruction in skeletally immature patients is currently unknown. Purpose: To evaluate the functional and patient-reported outcomes of a specific all-epiphyseal ACL reconstruction technique in which the graft, bone tunnels, and fixation do not cross the knee growth plates. Study Design: Case series; Level of evidence, 4. Methods: Twenty-seven patients (23 boys, 4 girls; mean age, 11 years; range, 8-15 years) underwent an all-epiphyseal ACL reconstruction with a single femoral transverse epiphyseal tunnel and primarily split tibial epiphyseal tunnels. Outcomes were evaluated in terms of the manual Lachman test, range of motion, pain, return to activity, angular or leg-length deformity on imaging, and International Knee Documentation Committee (IKDC) or Pedi-IKDC score an average of 3.8 years postoperatively, with a minimum 2-year follow-up. Results: The mean IKDC score was 94 ± 11. There were no growth arrests, but 3 patients had knee overgrowth, and 2 required a subsequent guided growth procedure. The ACL graft failed in 4 patients (15%), and 2 patients had contralateral ACL tears (7%). There were 5 subsequent ipsilateral meniscal tears, 4 of which were retears of a repaired meniscus. Ipsilateral knee reinjury significantly correlated with the number of associated injuries at the time of index surgery (P = .040) and the number of sports played (P = .029). Conclusion: All-epiphyseal ACL reconstruction resulted in excellent long-term functional outcomes, despite a high rate of complications (48%) and secondary procedures (37%) in this highly active cohort. The incidence of graft failure was similar to other standard ACL reconstruction techniques for patients younger than 20 years.

Objectives: The utility of Examination under anesthesia (EUA) for patellar instability is such that a negative EUA or inability to dislocate patella under anesthesia cannot rule out patellar instability but a positive EUA or ability to dislocate the patella under anesthesia can confirm the diagnosis of patellar instability. Examination under anesthesia (EUA) has been helpful for evaluation of stability of various joints, including elbow, hip, knee and shoulder. However, the utility of EUA as a diagnostic test for patellar instability has not been evaluated. The first purpose of our study was to evaluate the utility of patellar dislocation during EUA as a diagnostic test for assessment of patellar instability. The second purpose of our study was to evaluate demographic and clinical factors associated with the ability to dislocate patella under anesthesia. Methods: A prospective, multicenter cohort study (JUPITER: Justifying Patellar Instability Treatment by Results) database was queried for patients who underwent a surgical intervention for unilateral patellofemoral instability from a period January 2017 through July 2022. All patients had at least one documented patellar dislocation prior to surgery. Demographic and clinical variables were collected including age, sex, BMI, number of dislocations prior to surgery, J-sign and Beighton score. Prior to surgery, all patients underwent EUA in supine position for the involved and the uninvolved knee. During EUA, a submaximal manual force was applied to dislocate the patella laterally with the knee at 0° and 30° flexion. If the patella could be completely dislocated, then the EUA was considered positive. Results were analyzed descriptively, compared between positive and negative EUA cohorts and using multiple logistic regression analysis. Results: 478 patients who underwent unilateral patellar stabilization formed the study cohort. The mean age of the cohort was 15.8 years. 287 were females. 137 patients underwent surgery after the first dislocation, while 340 had surgery for recurrent patellar instability. Mean BMI of the cohort was 24.4. At 0° knee extension, the sensitivity and specificity of EUA as a diagnostic test for patellar instability were 53.4% and 93.3% respectively. The positive and negative predictive values were 90.7% and 61.9% respectively. At 30° knee flexion, the sensitivity and specificity of EUA for diagnosing patellar instability were 37.8% and 96.3%, respectively. The positive and negative predictive values were 92.5% and 55.9% respectively. Compared to negative EUA, the cohort with positive EUA at 0° and 30° was older (p = 0.0312), had more females (p=0.0021), had >5 patellar dislocations (p = 0.0199), had severe J-sign (p = 0.0018) and a higher Beighton score (p = 0.007). There was no difference in BMI between the cohorts. Multiple regression analysis showed that older age and severe J-sign were factors that would increase the odds of positive EUA at 30° knee flexion. There were no factors associated with positive EUA for contralateral knee. Conclusions: About half (53.4%) of all knees with confirmed patellar instability had a dislocatable patella during EUA with knee in extension; this decreased to 37.8% with the knee at 30° flexion. Due to low sensitivity, patellar dislocation during EUA cannot be considered a diagnostic test for patellar instability or a prerequisite for surgical treatment. However, the specificity of 93.3% and 96.3% at 0° and 30°, respectively, suggests that a positive EUA can help to confirm patellar instability.

Objectives: To properly evaluate and quantify how children and adolescents with patello-femoral instability (PFI) perceive their functional status, pain level and QOL, there is great importance in identifying the optimal PROs for this patient population. A few different PRO scales have been commonly used to evaluate individuals with PFI, each designed for a different purpose. The aim of this study was to evaluate the correlation between commonly used Patient Reported Outcome (PRO) scores in assessing children and adolescents with PFI, and to evaluate their sensitivity to change following treatment. Methods: The JUPITER study prospectively collected database was utilized to collect preoperative and 1-year postoperative PRO scores of individuals younger than 19 years of age, who were diagnosed with and treated surgically for Patellofemoral instability (PFI). Patients with a documented episode of patellar dislocation were enrolled in the study by 27 patellofemoral surgeons across 11 institutions in the US, irrespective of treatment approach. All patients completed a set of 4 PROs at the time of enrollment (baseline) and at one-year follow-up using either a paper-based or internet-based data collection sheet. BPII 2.0, IKDC, Kujala and KOOS were assessed. We analyzed the correlation between the four scores, evaluated the sensitivity to change, compared pre- and post-operative scores, and calculated minimal clinical important difference (MCID), and ceiling and floor effects. Results: A total of 1,065 cases were reviewed, and 263 were included (Table 1). The median age of the cohort was 15 (IQR 13 to 16) years, with 177 (67.3%) females. The median BPII 2.0 score was lower than the other three scores at baseline and at 1 year follow up (P<0.001, Table 2). BPII 2.0 presented the most substantial change at 1 year following surgery, increasing by a median 35.96 (IQR 14.9 to 52.35) points. The correlations between the four tested PRO scales are depicted in table 3. BPII 2.0, showed moderate correlation with the other three scores. Among themselves, Kujala, pediatric-IKDC and KOOS had strong correlations (Spearman correlation coefficient > 0.7, P<0.001, Table 3). In the lower 50th percentile baseline score group the change in all PRO scores following surgery was more substantial than in the higher 50th percentile score group (P<0.001). BPII 2.0 was found to be free of a ceiling effect as only 8 (3%) patients scored the maximal 100 points at 1 year follow up. On the contrary, a total of 121 (46%) and 75 (28.5%) patients scored 100 on the 1 year follow up KOOS and Kujala scales, respectively. On the IKDC scale a borderline total count of 40 (15.2%) patients scored 100 points, but 15 (5.7%) additional patients scored 98.91 on this scale, making a total of 20.9% of the patient population at almost the top percentage of the scale. Conclusions: BPII 2.0 score was found to be the most sensitive to change following surgery, and the only scale that did not have a ceiling effect. The moderate correlation between BPII 2.0 and the other three scales emphasizes the limited interchangeability between the scores, that measure different outcome dimensions.