Background:
Meralgia paresthetica is a painful compressive neuropathy of the lateral femoral cutaneous nerve, with minimal literature existing about the disorder in children. Easily overlooked, a misdiagnosis can lead to unnecessary imaging or surgical intervention. The purpose of this study was to increase provider awareness and compare patient-reported outcomes between surgical and nonsurgical management.
Methods:
We retrospectively reviewed records of pediatric patients treated for meralgia paresthetica by a single provider. Patients were initially treated with physical therapy, anti-inflammatories, and local injection to confirm the diagnosis. Individuals with persistent symptoms were offered surgical decompression. Patient-reported outcomes were assessed using the International Hip Outcome Tool 33 (iHOT-33) survey.
Results:
Twenty-four patients were treated. The mean age was 12.7 years (range: 9 to 17 y). Ninety-two percent were female, 63% had bilateral involvement, and 38% were referred with an alternate diagnosis. The average BMI was 20.96. Local injection provided immediate relief for all patients and lasted an average of 11 days. Seventy-one percent (17/24) had persistent symptoms in follow-up and underwent surgical decompression. All patients improved following initial decompression, but 4/17 (24%) had recurrence of symptoms requiring a second surgery. All recurrences had accessory nerves missed during the first surgery. Seventy-nine percent of patients (19/24) completed the iHOT-33 survey at an average of 33 months after intervention (injection or surgery). The average iHOT-33 score was higher in the operative group but was not statistically significant (7.88 vs. 6.72, P=0.250).
Conclusions:
Meralgia paresthetica can be readily diagnosed using physical examination and confirmed with a local injection, without the need for advanced imaging. In our cohort, it predominantly affected thin, adolescent females. Steroid injection provided definitive treatment for 29% of our patients. Persistent symptoms can be improved with surgical decompression, and we found a high rate of aberrant anatomy and accessory nerves in this population. Outcomes were not significantly different between local injection only and surgical management. More studies are needed to determine the role of ligation versus decompression.
Level of Evidence:
Level IV—case series. 
Objective:
As the incidence of pediatric and adolescent anterior cruciate ligament (ACL) reconstruction rises, knowledge of contributing factors to decision-making regarding graft selection and technique is important. Variations in ACL reconstruction (ACLR) regarding graft choice, tunnel placement, and technique may depend on patient age, sex, and surgeon preference. The purpose of this study was to review technique and graft source of pediatric ACLR based on these factors.
Methods:
A prospective, surgeon-driven, multicenter quality/performance improvement registry was queried to evaluate graft selection and technique in primary ACLR. Data regarding ACLR in those 19 years or younger performed by 23 contributing surgeons was collected. Frequency of graft use and surgical technique were stratified by patient age and sex.
Results:
A total of 3968 ACLRs were included, with an average age of 15.1 years (range: 6 to 19 years), 53.7% males, with a majority using autograft (97.4%). Of ACLR, 82.9% of those under age 11 used iliotibial band (ITB) graft and extra-articular extraphyseal technique. ITB use was similar in females (80.0%) and males (83.5%). For ages 11 to 15, soft tissue quadriceps (STQT, 38.1%), hamstring (HS, 23.5%), and ITB (16.6%) were most frequently used. STQT use was 40.1% in females and 36.2% in males. ITB was used more in males than females (25.6% and 7.4%, respectively). After age 15, STQT (30.9%), bone patellar tendon bone (BTB, 27.8%), and HS (24.8%) were most common. STQT was the dominant graft in females (35.5%) in this group, while BTB (32.3%) was the most frequent in males. When comparing the early (2018 to 2020) to the late (2020 to 2022) portion of collection period, quadriceps tendon autograft use increased from 30.5% to 48.0%.
Conclusions:
Variation exists in graft selection and technique for pediatric and adolescent ACLR. ITB, extra-articular extraphyseal technique, is favored in patients under age 11. Quadriceps autograft use has increased in ACLR in this patient population in recent years.
Level of Evidence:
Level III—retrospective cohort study. 
Background:
Transphyseal anterior cruciate ligament (ACL) reconstruction can be a reliable and safe treatment for skeletally immature patients, with low reported rates of major growth disturbances. However, more subtle knee morphologic and radiologic characteristics, such as the α-angle (sagittal orientation of the notch roof) and posterior tibial slope, may theoretically be affected by this surgical technique and potentially represent risk factors for ACL graft tears. The objective of this study was to compare radiologic knee morphology characteristics between the operated knee and the paired contralateral knee in skeletally immature patients following transphyseal ACL reconstruction.
Methods:
This is a retrospective matched within-subject case-control study on 25 skeletally immature patients with a radiologic follow-up 9 or more months after a transphyseal anatomic ACL reconstruction. The α-angle, medial posterior tibial slope, mechanical hip-knee-ankle angle, and leg length were assessed with a biplane x-ray imaging system (EOS) with the nonoperative limb used as an internal control.
Results:
The mean chronological age of the cohort was 11.8 years (range: 8.3 to 15.0). The α-angle was a mean of 3.3 degrees (SD=5.1) smaller, or more vertical, on the surgical knee than on the contralateral knee at a median of 2.1 years [interquartile range (IQR)=0.3 to 4.0], with mean α-angles of 36.6 degrees (SD=6.6 degrees) and 39.9 degrees (SD=5.3), respectively (P=0.002). Other radiologic parameters were not significantly different between sides. A post hoc analysis showed a median side-to-side difference in α-angles of −5.0 (IQR: −7.0 to −1.9) in males versus 0.6 (IQR: −4.3 to 3.8) in females (P=0.009).
Conclusion:
Transphyseal anatomic single-bundle ACL reconstruction in skeletally immature patients is associated with a relative decrease in α-angle, or verticalization of the notch roof, after a median follow-up of 2 years. A greater impact in α-angle was observed in male patients.
Level of Evidence:
Level III—prognostic case-control study. 
Background:
Arthroscopic knee procedures such as meniscus and ACL repairs are cornerstone interventions in pediatric and sports orthopaedics. While venous thromboembolism (VTE), including pulmonary embolism (PE) and deep vein thrombosis (DVT), is a rare yet devastating complication in major joint surgeries, its association with minimally invasive procedures remains relatively unexplored. Emerging evidence shows rates of VTE in adolescent orthopaedic patients approaching that of adults, highlighting the need to further characterize the unique risk profile of this population. Therefore, this study aims to compare VTE rates, risk factors, and chemoprophylaxis use in adolescents versus adults undergoing arthroscopic knee procedures.
Methods:
A retrospective cohort study using the TriNetX Research Network identified 301,585 patients who underwent knee arthroscopy from January 2003 to January 2023, including 29,984 adolescents (aged 14 to 17) and 271,601 adults (aged 18 years or older). Propensity score matching based on sex and relevant comorbidities, including diabetes mellitus, tobacco use, oral contraceptive (OCP) use, and obesity yielded balanced cohorts of 29,984 each. Univariate logistic regression analysis was performed for preliminary assessment of the risk factors associated with VTE. P 
Introduction:
Treatment of stable juvenile osteochondritis dissecans (OCD) of the knee in adolescents is controversial. Traditionally, initial management has been nonoperative. However, early subchondral drilling is also a consideration to potentially reduce the recovery time because ∼50% of stable OCD lesions eventually require surgery after a period of failed nonoperative care. This study uses choice-based conjoint (CBC) analysis to explore patient and family preferences regarding initial nonoperative treatment versus early drilling.
Methods:
This study used a CBC survey using Sawtooth Software (Lighthouse Studio version 9.2.0) to collect demographic information and preferences on surgical scenarios. Anonymous participants were recruited through the Prolific crowdsourcing platform. Eligible participants were US residents over 18 years of age with children aged 12 to 17. Data were analyzed using Hierarchical Bayes and logistic regression to determine the importance of each attribute and correlate preferences with demographic variables.
Results:
Of the 474 participants, the highest importance was placed on minimizing treatment failure (46.3%), followed by the likelihood of needing surgery (22.4%), cost (11.8%), time on crutches (10.8%), and return to normal activities (8.7%). Simulation of surgical decision-making showed a strong preference for early surgery (90.8%) over conservative treatment (9.2%). Preferences varied slightly by demographics, with female participants valuing recovery time more and male participants prioritizing cost.
Discussion:
Our findings indicate a significant preference for early surgical intervention driven by concerns over treatment failure and the need for a future surgery with a second recovery period. Despite some demographic differences in attribute importance, no specific patient characteristic significantly influenced the overall treatment preference.
Conclusion:
Early drilling of stable OCD lesions of the knee is favored by most parents of adolescents, primarily to reduce the risk of future surgery/recovery. This preference underscores the importance of personalized treatment discussions and highlights the need for shared decision-making tools that incorporate individual patient values. 
Background:
Supracondylar humeral fractures are common in children, and are typically treated with percutaneous pinning. Cross pinning (CP) and lateral entry pinning (LP) are widely used methods. Although previous studies have focused on outcomes such as Baumann and carrying angles, research on rotational malalignment is limited. Furthermore, there have been few comparative studies on alternative surgical techniques. This study aimed to compare rotational malalignment and clinical outcomes between CP and the lateral para-olecranon pinning (LPOP) technique.
Methods:
This retrospective study initially identified 208 pediatric patients who underwent percutaneous pinning for supracondylar humeral fractures between 2005 and 2023. After applying the inclusion and exclusion criteria, 180 patients were included in the study and divided into 2 cohorts: LPOP (n=146) and CP (n=34). The primary outcome was corrective loss of rotation, measured radiographically at surgery and at 4 weeks postoperatively. Rotational malalignment was assessed using the formula described by Henderson and colleagues. Secondary outcomes included Baumann angle, carrying angle, tilting angle, range of motion, anesthesia, and operation times.
Results:
No significant difference was found in corrective loss of rotation between LPOP and CP (θ=0.079±0.24 for LPOP vs. 0.10±0.20 for CP, P=0.57). Secondary outcomes, including the Baumann angle, carrying angle, tilting angle, and range of motion, were similar in both groups. However, the anesthesia and operation times were significantly shorter in the LPOP cohort (P 
Background:
Supracondylar humerus fractures (SCH) are the most common type of elbow fracture in children, with many cases requiring surgery. Treatment of postoperative pain for SCH has high variability, but can often be treated effectively with minimal or no opioids. Furthermore, there is significant morbidity related to pediatric opioid consumption. The goal of this study was to characterize prescription patterns in the United States following closed reduction and percutaneous pinning (CRPP) of SCH.
Methods:
All patients aged 10 or younger years who underwent CRPP of SCH from January 2010 to December 2021 were identified in the PearlDiver Mariner Claims Database. The primary outcome was postoperative pain medication prescriptions in the 30 days following SCH CRPP. Patient demographics, prescription duration, and morphine milligram equivalents (MME) were analyzed. Multivariable-log-binomial mixed regression models were constructed to assess factors associated with increased opioid prescription.
Results:
In total, 43,611 SCH CRPP cases in patients aged 10 or younger were identified from 2010 to 2021. Throughout the study period, 48.6% of patients (21,191/43,611) received and filled a narcotic pain prescription. The percentage of patients receiving opioid medication decreased from 54.7% in 2010 to 27.4% in 2021. Opioid prescriptions totaled a mean of 6.1±2.1 days of narcotics with a mean of 79.2 MME prescribed per patient. Increased patient age, increased Elixhauser comorbidity index, and Medicaid insurance were all associated with increased opioid prescription (P 
Background:
Tibial tubercle fractures (TTF) commonly occur in an athletic adolescent population and typically require operative reduction and fixation. Surgical techniques and postoperative restrictions are varied, with limited knowledge on factors that may affect outcome. We hypothesize that surgical technique and postoperative rehabilitation protocol can affect risk of postoperative complications following surgical treatment of TTF.
Methods:
Retrospective review was conducted including all consecutive surgically treated TTF at a single level 1 pediatric trauma center between January 2010 and December 2022. Patients were excluded for skeletal dysplasia, “conservative.” Initial postoperative casting was performed in 38% of the conservative group compared with 1.9% in the accelerated group (P symptomatic implant (19.7%). There were 4 cases of fracture displacement and 1 case of implant displacement, all occurring in the conservative group. In multivariate analysis female sex (OR: 4.9), initial postoperative casting (OR: 2.6), and lower BMI percentile (OR: 1.02) were independently associated with higher grade II and III complication rate, while distal repair of the avulsed periosteum was associated with lower rate (OR: 0.26).
Conclusion:
Postoperative casting and repair of the distal periosteal avulsion are modifiable treatment decisions impacting risk of complications following surgical treatment of TTF. Decreasing variability in care, including implementing an accelerated rehabilitation protocol, may improve outcomes.
Level of Evidence:
Level III. 
Background:
Waterproof casting materials have been demonstrated to improve the patient experience through subjective patient satisfaction and discomfort measures. However, the increased cost of raw materials has limited its wide adoption as a standard of care. The purpose of this study was to compare unplanned healthcare utilization and the financial implications of using waterproof versus cotton liners for nonoperative fractures in pediatric patients.
Methods:
A single institution retrospective chart review analyzed 950 pediatric patients with 977 nonoperative upper and lower extremity fractures who received either standard or waterproof cast liners from January 1, 2020, to December 31, 2021. Generalized logistic and linear models were used to determine whether cast liner material was associated with recasting and to what extent this was associated with the total cost of casting materials over the course of fracture care. Incremental Cost Effectiveness Ratio (ICER) was calculated based on casting material costs and the likelihood of unplanned cast changes between groups.
Results:
Of the 977 castings included, 804 (82.3%) had standard casts, and 173 (17.7%) had waterproof casts placed as initial treatment. The proportion of casts requiring recasting was significantly higher in patients with standard casts (43.3%) compared with those with waterproof casts (11.6%) (P 
Introduction:
Breastfeeding is recommended exclusively until at least 6 months of age by the American Academy of Pediatrics. For mothers of children with hip dysplasia (DDH), Pavlik harness treatment may impact breastfeeding. The aim of this study was to assess how Pavlik harness treatment may impact breastfeeding by evaluating patient-reported outcomes (PRO) associated with breastfeeding.
Methods:
This was a prospective cohort study of mothers of patients treated in a Pavlik harness for DDH at 3 months of age. Controls were recruited from patients evaluated for DDH who had normal ultrasounds. Patients with neuromuscular/developmental conditions were excluded. The validated beginning breastfeeding survey-cumulative (BBS-C), breastfeeding self-efficacy scale-short form (BSES-SF), and patient health questionnaire-8 (PHQ8) were administered to mothers at the initial clinic appointment and 2, 4, 6 weeks postbaseline.
Results:
A total of 29 cases and 29 controls were enrolled. There were no ifferences in baseline demographics or socioeconomic/educational status between maternal cohorts. There were similarly no differences in demographics or birth characteristics between children except presenting age was lower in the DDH cohort (30.7±22.1 vs. 58.7±21.4 d, P80% of the time. Mothers of 13% of DDH patients reported that the Pavlik usually/always negatively impacted their breastfeeding ability at 6 weeks. The DDH cohort had lower BBS-C problem scores at 4 (17.6±6.4 vs. 20.8±3.7, P=0.045) and 6 weeks (17.2±6.2 vs. 20.2±3.3, P=0.029). BSES-SF scores were additionally lower among the DDH group at 2 (47.6±11.8 vs. 54.1±10.2, P=0.047) and 4 weeks (48.5±13.0 vs. 55.6±10.3, P=0.040). There were no differences in PHQ-8 scores.
Conclusion:
Pavlik harness treatment for DDH was associated with lower patient-reported breastfeeding efficacy PROs. Pavlik harness treatment did not lead to earlier breastfeeding cessation 6 weeks after harness initiation. Lower breastfeeding efficacy for these mothers may justify early education regarding effective breastfeeding methods in a harness.
Level of Evidence:
Level II—prospective therapeutic cohort study. 
Background:
Surgical treatment of a dislocated hip at walking age includes open reduction (OR) with or without osteotomies of the pelvis and/or femur. Three-dimensional imaging, such as computerized tomography (CT), can be utilized postoperatively to determine femoral head position following cast placement. Alternatively, intraoperative 3D imaging (O-arm) may be used for the same purpose. Disadvantages of CT include limited access to the patient’s airway and high radiation dose. The current study aimed to determine the ability of O-arm imaging to visualize femoral head position following surgical treatment of a dislocated hip, and compare radiation dosage between CT and O-arm.
Methods:
Thirteen patients (16 hips) with a dislocated hip at walking age who underwent OR with pelvic ± femoral osteotomies at a single institution were retrospectively reviewed. All patients underwent CT or O-arm evaluation following surgery and spica cast application. Total radiation dose per kilogram was compared between the CT (n=8 hips) and O-Arm 14 (n=8 hips) groups. Radiographic parameters and complication rates were analyzed. Image quality was blindly assessed by 3 fellowship-trained pediatric orthopedic surgeons with hip expertise.
Results:
The mean age was 4.68 years (range: 3.1–7.8) in the CT group and 4.31 (range: 1.2–7.5) in the O-Arm group. The average radiation dose from the O-arm was lower than CT (4.51 19 mGy/kg vs. 6.12 mGy/kg, P=0.37). Five hips in the CT cohort were scanned post-extubation. All surgeons agreed that femoral head position was adequately visualized in all images from both groups. No patient in either group required a cast change post-scanning due to a malpositioned femoral head.
Conclusion:
The O-arm is a reasonable alternative to CT following surgical treatment of a dislocated hip. It may decrease radiation dose and provides adequate visual information to determine femoral head position following surgical intervention and casting. Utilization of the O-arm keeps the patient in the operating room during the study, allowing for immediate revision of the cast position or revision reduction if necessary, while maximizing access to the patient’s airway and minimizing risk for adverse anesthetic events.
Level of Evidence:
Level III, retrospective comparative study. 
Background:
Hip arthroscopy is a commonly performed procedure in adolescents with hip pathology. However, there is limited data on venous thromboembolism (VTE) events in this population, resulting in minimal guidance on appropriate VTE prophylaxis, with the bulk of current guidance extrapolated from the adult population. Therefore, this study aims to assess overall rates of VTE in the adolescent population as well as compare these rates to a matched cohort of adult patients undergoing hip arthroscopy.
Methods:
This retrospective cohort study drew data from the TriNetX platform between January 1, 2003 and March 1, 2024. Adolescent patients, ages 13 to 18, were matched to adult patients (19 and older) undergoing hip arthroscopy, accounting for sex, tobacco use, oral contraceptive use, diabetes mellitus, and overweight/obesity. Outcomes of interest were deep vein thrombosis (DVT) or pulmonary embolism (PE) within 90 days after the procedure. Overall rates were calculated and compared between cohorts. Statistical significance was set at P 
Background:
Legg-Calve-Perthes disease (LCPD) outcomes are largely determined by their age and maturity at onset. In LCPD, there is a known association with delayed skeletal maturity of up to 1.9 years in affected children based on maturity assessment with the Greulich and Pyle (GP) maturity atlas. The GP atlas is the standard for assessing bone age but requires obtaining a separate radiograph of the hand. A new methodology for assessing skeletal maturation in comparison to the GP bone age in children with LCPD was sought.
Methods:
A retrospective review of a prospective, multicenter study of patients with LCPD treated from 1984 to 1991 and followed to skeletal maturity was performed. Patients were included if they had LCPD diagnosed on anteroposterior pelvis radiographs that included the contralateral hip who had bone age radiographs obtained at the time of presentation. Patients were excluded if they presented with bilateral LCPD, the contralateral hip was not visualized on their presenting radiographs, they lacked bone age radiographs at the time of presentation, or they presented outside the range for the Optimized Oxford system. A formula using the greater trochanteric height to femoral head diameter ratio and patient sex (GT+ Sex) for predicting GP bone age was developed. The GP and GT+ Sex bone ages were compared with the chronologic age (CA) to determine the mean discrepancy.
Results:
Seventy-one patients were included (mean 9.5 ± 1.2 y at presentation, 42.2% females). Skeletal maturity assessment by the GP bone age method demonstrated a mean discrepancy of 1.4 years younger than CA (95% CI: 1.01-1.76 y). GT+ Sex bone age assessment demonstrated a mean discrepancy of 1.4 years younger than CA (95% CI: 1.03-1.75 y). The GP bone age was a mean of 0.00 years different than the GT+ Sex assessment bone age (95% CI: −0.3 to 0.3 y). The GT+ Sex assessment bone age correlated significantly with GP bone age (R=0.89, P 
Background:
Stable slipped capital femoral epiphysis (SCFE) is often considered semi-urgent, prompting admission for in situ screw fixation (ISF), which may increase the cost/burden of care. Avascular necrosis (AVN) affects 25% to 50% of patients with unstable SCFE, yet it is uncommon after stable SCFE. Among patients presenting with stable SCFE, little is known about the relationship between diagnosis and surgical timing with regard to slip progression or complications.
Methods:
This retrospective observational study included all patients younger than 18 years with stable SCFE at initial diagnosis treated with ISF between 2000 and 2020 at 4 centers. Patients with Loder unstable SCFE at the time of initial SCFE diagnosis were excluded. Timing data included time from (1) symptom onset to diagnosis, (2) symptom onset to surgical team evaluation, (3) symptom onset to surgery, (4) diagnosis to surgical team evaluation, (5) surgical team evaluation to surgery, and (6) diagnosis to surgery. Regression analyses explored relationships between timing and slip progression to unstable, subsequent procedures, and complications as graded by the modified Clavien-Dindo-Sink system.
Results:
A total of 298 patients with 362 stable SCFEs were included. The mean time from symptom onset to diagnosis was 134 days, from diagnosis to surgical team evaluation was 3.2 days, and from surgical team evaluation to surgery was 2.1 days. The mean follow-up was 2.4 years. Eighteen percent of hips were affected by a complication. Two patients initially diagnosed with stable SCFE progressed to unstable SCFE, having experienced falls after diagnosis and before orthopaedic evaluation; one of these went on to develop AVN. Time elapsed between symptom onset, diagnosis, surgical team evaluation, and surgery was not associated with the incidence or severity of complications or subsequent procedure.
Conclusions:
The urgency of surgical treatment of stable SCFE does not appear to affect mid-term outcomes. If surgical management of stable SCFE is not performed urgently, it is critical to avoid weight bearing and falls to reduce progression to an unstable SCFE.
Level of Evidence:
Level III, therapeutic. 
Background:
Lumbar partial microdiscectomy (LPM) in adolescents is an infrequently performed procedure, reserved for pain and neurological symptoms unresponsive to nonsurgical management. Most studies have focused on the interventional impact on pain outcomes creating a paucity of data on physical function and mental health outcomes. The study hypothesis is LPMs in adolescents will provide improvements in measured PROMIS domains (mental health, physical function, and pain) at 2 years postoperatively.
Methods:
This study is a retrospective analysis of patients under 21 years of age who underwent LPM surgery by 2 surgeons at a tertiary-care pediatric hospital. PROMIS scores [mobility (MOB), pain interference (PI), upper extremity (UE), physical functioning (PF), peer relationships (PR), anxiety, and depression] were obtained preoperatively and 6 weeks, 3 months, 6 months, 1 year, and 2+ years postoperative. The changes in PROMIS scores were then analyzed and compared at each time point using a mixed model analysis.
Results:
Thirty-six patients with a mean age of 16.6 years (range: 13 to 20 y) at surgery were included in the analysis (2015 to 2022). All patients underwent nonsurgical treatments, which varied according to symptom type and severity and included over-the-counter medications, pain management or physiatry consultations, physiotherapy, selective nerve root and epidural injections, and bracing for a minimum of 3 months. Preoperatively, 4 patients had motor weakness, 11 lower extremity numbness, and 35 lower extremity radicular pain. Postoperatively, there were improvements for MOB (P≤0.05) at each time point, with an estimated mean difference of +11.3 at 2 years (P=0.0027). In PI there was a significant decrease (P≤0.0001) immediately after surgery with sustained improvement (−8.6) at 2 years (P=0.0009). For UE and PR, there was a statistically significant improvement from the preoperative baseline scores to the 1-year postoperative visit for UE (+10.6; P=0.008) and PR (+8.0; P=0.01), but no difference at 2 years. PF, anxiety, and depression domains did not demonstrate any statistically significant changes.
Conclusion:
Using the PROMIS instrument, there were significant improvements postoperatively after LPM in adolescents in MOB, PI, UE, and PR up to 1 year postoperatively, and continued improvement in MOB and PI. These data demonstrate LPM can provide sustained improvement in PROMIS domains up to 2 years of follow-up after surgery.
Level of Evidence:
Level III—retrospective, single cohort study. 
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