Mininder Singh Kocher

Athletes. Front. Pediatr. 14:1840962. doi: 10.3389/fped.2026.1840962 Error in figure/tableThe figures were in the wrong order in the online version of this paper. The images for figure 5 and 6 have been swapped. Figure 5 has the correct caption and placement in the text, but this image should be switched with the Figure 6 image. Similarly, Figure 6 has the correct caption and placement in the text, but the image should be switched with the figure 5 image. The order has now been corrected. The original version of this article has been updated. Reminder: Figures, tables, and images will be published under a Creative Commons CC-BY license and permission must be obtained for use of copyrighted material from other sources (including re-published/adapted/modified/partial figures and images from the internet). It is the responsibility of the authors to acquire the licenses, to follow any citation instructions requested by third-party rights holders, and cover any supplementary charges..

Anterior cruciate ligament (ACL) injuries in skeletally immature patients are becoming increasingly prevalent. These injuries present a unique set of challenges because of the presence of open physes and the associated risk of inducing a growth disturbance with traditional ACL surgical management. This review highlights the relevant anatomy, biomechanics, epidemiology, and risk factors associated with ACL injuries in the skeletally immature population and outlines a thorough evaluation process to determine the appropriate treatment strategy for each individual patient. Although non-operative management may be appropriate in select patients, operative intervention may be best for complete ACL injuries to prevent the risk of secondary injury to associated intra-articular structures. Both physeal-sparing and physeal-respecting approaches may be considered, and the most appropriate treatment option can be determined through assessment of remaining growth. Surgical management of these injuries with the correct approach can result in low complication rates [including retear rates (6%–11%) and low growth abnormalities (1%–2%)], as well as high rates of return to sport and patient satisfaction.

Background: A reliable measure of bone age is of critical importance when planning anterior cruciate ligament reconstruction (ACLR) in a pediatric population. The Greulich and Pyle (G&P) method is still the most common method for bone age determination; however, it is based on radiographs from healthy Caucasian children of high socioeconomic status (SES) in Cleveland, Ohio, in the 1920s to 1940s and may not reflect the modern diverse United States population. The aim of our study was therefore to assess the degree of agreement between chronological age and bone age measured using G&P and further investigate whether there are any systematic differences across race, ethnicity, or SES. Methods: This was a retrospective subanalysis of PLUTO (Pediatric ACL: Understanding Treatment Options), a prospective multicenter cohort study investigating outcomes in pediatric ACLR. All patients with bone age scores using the G&P method preoperatively were included. Data on race, ethnicity, biological sex, BMI, and SES [using a composite marker known as the area deprivation index (ADI)] were collected. Bland-Altman analysis was used to assess the agreement between chronological-measured and G&P-measured age. Systematic bias was defined as a significant mean difference between chronological-measured and G&P-measured age and was determined using Student t test for the cohort and within strata; and differences across strata were determined using a one-way ANOVA. P -values across strata were adjusted using the method of Benjamini and Hochberg to control the false discovery rate. Results: A total of 472 patients were included in the final analysis. Chronological age at evaluation was lower than the determined bone age for the cohort with a systematic bias of 2.9 months (SD, 12.8) ( P P P =0.008), and 15 years ( P =0.008). Female patients had a 3.9-month greater bias compared with males ( P =0.003). Underweight patients exhibited nearly 15.9 months lower bone age versus chronological age ( P =0.008). No systematic biases were detected across ethnicity ( P =0.21), race (0.13), or ADI index quartiles ( P =0.23). Conclusion: Our study supports the continued use of G&P for bone age assessment across different racial, ethnic, and sociodemographic groups, with no significant differences detected across these strata. The observed ∼2-year limits of agreement between G&P bone age and chronological age reinforce the importance of skeletal age assessment in this cohort, particularly during the peripubertal period where large differences between chronological and skeletal age can exist. Systematic biases were found in certain age strata, between sexes, and in patients with low BMI. Clinicians should be aware of these variations and consider using multiple methods of assessing skeletal maturity when making growth-sensitive clinical decisions. Level of Evidence: Level III—retrospective cohort.

Background: Lateral extra-articular tenodesis (LET) can reduce the risk of graft failure after anterior cruciate ligament (ACL) reconstruction in adolescents and young adults. It is unclear whether the use of this procedure increases risks of complications such as arthrofibrosis after ACL reconstruction using hamstring autograft in adolescents. Hypothesis: Adolescents treated with ACL reconstruction using hamstring autograft with and without modified Lemaire LET have similar rates of arthrofibrosis after surgery. Study Design: Retrospective cohort study; Level of evidence, 3. Methods: Cases of ACL reconstruction using hamstring autograft performed by the senior author from January 1, 2012, to May 20, 2024, in patients aged 10 to 19 years were retrospectively reviewed. LET was not used before 2022 but was routinely used after 2022 based on accruing evidence supporting it. Baseline patient variables were recorded, as were surgical variables, including meniscal repair or meniscectomy, inclusion of LET, and femoral socket drilling method. Complications requiring return to the operating room (RTOR) were identified. Causes for RTOR were noted, including arthrofibrosis, which was defined as a range of motion deficit ≥5° of extension or ≥15° of flexion requiring lysis of adhesions and manipulation under anesthesia within 1 year of surgery. Results: A total of 569 cases were included. Arthrofibrosis rates were similar for patients who underwent hamstring autograft ACL reconstruction with LET (1.2%; 95% CI, 0.03%-6.4%) versus those without LET (3.7%; 95% CI, 2.2%-5.8%) ( P = .34). Conclusion: The rate of arthrofibrosis requiring surgical intervention after hamstring ACL reconstruction is low (<6.5%). The addition of LET to hamstring ACL reconstruction in adolescent patients did not increase the risk of arthrofibrosis in this study.

Background: The increasing prevalence of marijuana usage has prompted research into the potential medical effects. Yet, there is a paucity of literature surrounding the impact on perioperative outcomes after orthopaedic surgeries among pediatric and adolescent populations. Purpose: To compare perioperative outcomes between pediatric and adolescent patients who underwent anterior cruciate ligament reconstruction (ACLR) and attested to marijuana use compared with those who did not attest to marijuana use, and whether sociodemographic factors were associated with positive self-reported marijuana attestation. Study Design: Cohort study; Level of evidence, 3. Methods: This study evaluated perioperative outcomes in patients aged ≤20 years who underwent primary ACLR between January 2011 and December 2017. Patients were divided based on self-reported positive marijuana attestation on forms collected during the surgical intake process. Propensity score matching (3:1 ratio) was used to select matched controls based on age, sex, surgeon, and graft type. Perioperative outcomes and complications were compared between those who self-reported positive marijuana attestation and those who did not report marijuana use. Results: Of 4358 eligible patients, 42 self-reported positive marijuana use on attestation forms (0.96% [95% CI, 0.70-1.30]), with 126 patients in the matched cohort. The mean follow-up was 25.26 months (SD, 27.17 [range, 1-125 months). Patients who self-reported positive marijuana use (n = 42) experienced significantly higher rates of overnight admission for pain (90% vs 29%; P = .004), greater estimated blood loss (10 vs 3 mL; P < .001), lower maximum heart rate in the postanesthesia care unit (74.3 ± 12.8 vs 80.2 ± 14.8 beats per min; P = .04). Time to return to sports (RTS) was 76 days longer in the self-reported positive marijuana attestation cohort (95% CI, 1.1-1.5; P < .001). Higher odds of positive self-reported marijuana attestation were observed in patients living in lower Child Opportunity Index neighborhoods, those identifying as races other than White, and those of Hispanic ethnicity. Conclusion: Positive self-reported marijuana attestation in pediatric and adolescent patients undergoing ACLR was associated with higher rates of overnight admission for pain and prolonged time to RTS, suggesting potential implications for perioperative management and recovery.

Background: Posterior cruciate ligament (PCL) avulsion fractures pose unique technical challenges for surgical fixation in the pediatric and adolescent population. Both arthroscopic and open management have been pursued; nonetheless, the literature is devoid of comparative studies elucidating factors for technique selection or relative outcomes. Purpose: To compare the demographic characteristics, presenting features, clinical course, return to sports (RTS), patient-reported outcomes (PROs), and complications associated with open and arthroscopic fixation cohorts of pediatric patients who sustained an isolated tibial-sided PCL avulsion fracture. Study Design: Cohort study; Level of evidence, 3. Methods: A medical record review was performed for all patients aged 8 to 19 years who underwent operative fixation of a tibial-sided PCL avulsion fracture between 2003 and 2021 at a single pediatric tertiary referral center. Patients were excluded if they sustained a femoral-sided avulsion fracture, underwent a PCL reconstruction, or presented with multiligamentous knee injury requiring surgical intervention for >1 ligament. All patients were sent 3 PRO instruments validated for children: Pediatric International Knee Documentation Committee, Knee injury and Osteoarthritis Outcome Score-Child, and Hospital for Special Surgery Functional Activity Brief Scale. Results: A total of 20 patients met the inclusion criteria, of whom 10 patients were treated with open fixation and 10 with arthroscopic fixation. Also, 15 (75%) patients (7 open, 8 arthroscopic) returned PROs. No differences were detected in demographic characteristics, RTS, or PROs between cohorts. One patient in the open cohort developed a deep-tissue infection in the popliteal fossa, requiring open irrigation and debridement. One patient in the arthroscopic cohort eventually required PCL reconstruction for fracture nonunion associated with persistent instability. Conclusion: No differences in outcomes were detected in this study between cohorts of pediatric patients undergoing open and arthroscopic fixation of tibial-sided PCL avulsion injuries. Regardless of surgical technique, most patients healed without complications and returned to high activity levels. Given the postoperative complications seen in the arthroscopic cohort, further research is needed to investigate the potential biomechanical superiority of open technique fixation constructs.

Background: Skin tenting is a commonly utilized surgical indication for clavicular fractures. The impact of skin tenting on fracture outcomes has not been investigated in adolescents. The present study compared the clinical and patient-reported outcome measures (PROMs) of nonoperatively and operatively treated adolescent clavicular fractures with skin tenting at presentation. Methods: Patients 10 to 18 years old with completely displaced midshaft clavicular fractures managed at 8 participating institutions from 2013 to 2022 were filtered to identify a cohort with either of 2 categories of skin tenting at initial presentation: (1) “skin tenting” or (2) “skin-at-risk for necrosis” (i.e., tented, white, and hypovascular). Demographics, fracture characteristics, treatment, complications, time to return to sport, and PROMs (i.e., American Shoulder and Elbow Surgeons score; Quick Disabilities of the Arm, Shoulder and Hand; Marx Shoulder Activity score; and European Quality of Life visual analog scale [EQ-VAS]) were analyzed at a minimum of 1-year follow-up. Results: A total of 88 (12%) of 764 prospectively enrolled adolescents with completely displaced midshaft clavicular fractures presented with skin tenting. Patients with skin tenting had older age and greater comminution, shortening, and superior displacement than those without skin tenting. A total of 58 patients with skin tenting (66%) underwent open reduction and internal fixation (ORIF), and 30 (34%) underwent nonoperative treatment, none of whom developed skin-related complications. However, 3 patients in the nonoperative cohort (10%) underwent early conversion to ORIF at a mean of 27 days (range, 6 to 62 days) post-injury. Although the nonoperative cohort was an average of <1 year younger than the ORIF cohort (nonoperative cohort, 14.5 years; ORIF cohort, 15.4 years; p = 0.04), there were no differences in sex (p = 0.23), shortening (p = 0.13), superior displacement (p = 0.14), or comminution (p = 0.32) between groups. PROMs were available for 63% of patients 1 or 2 years post-injury, with no differences in the PROMs European Quality of Life 5 Dimensions 5 Level Version (EQ-5D-5L) and EQ-VAS, complications (p = 0.76), or time to return to sport (p = 0.80) between treatment groups. Conclusions: In this large cohort of prospectively enrolled adolescent patients with clavicular fractures, 12% of patients with completely displaced clavicular fractures presented with skin tenting, approximately one-third of whom were definitively treated nonoperatively, though 10% of the initial nonoperative cohort underwent early conversion to ORIF. Adolescents with skin tenting treated nonoperatively demonstrated no differences in PROMs, complications, or time to return to sport, compared with patients who underwent ORIF. Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Background: A discoid lateral meniscus (DLM) is the most common meniscus variant and is commonly treated with arthroscopic saucerization. There are mixed data regarding long-term results after surgery, especially in terms of radiological parameters. Purpose/Hypothesis: The aim was to evaluate the functional and radiological results of patients who underwent arthroscopic saucerization for a symptomatic DLM. It was hypothesized that successful outcomes can be achieved by avoiding excessive resection while reshaping only to an extent that prevents mechanical symptoms. Study Design: Case series; Level of evidence, 4. Methods: This study retrospectively analyzed pediatric and adult patients who had a symptomatic discoid meniscus between 2000 and 2018, who underwent arthroscopic saucerization with at least 10 mm of peripheral length, and who had at least 5 years of follow-up. Radiological parameters were measured on both preoperative and follow-up radiographs. Patient-reported outcome measure scores were recorded at follow-up. Results: The study included 57 knees of 53 patients (mean age, 27.6 years [range, 6-65 years]). The mean follow-up duration was 12.1 years (range, 5.0-23.1 years). There were 31 knees in the pediatric group and 26 knees in the adult group. No significant difference was found between the groups or between preoperative and follow-up values for the femorotibial angle ( P > .05). When the preoperative and follow-up Kellgren-Lawrence grades were compared, no change was observed in the pediatric group ( P = .125), while grades were shown to progress in the adult group ( P < .001). The mean Lysholm score was 94.61 ± 7.61 and 84.23 ± 14.90 for the pediatric and adult groups, respectively ( P = .001). Overall, 2 patients underwent arthroscopic surgery because of a symptomatic recurrence of symptoms, and 2 patients underwent arthroplasty because of osteoarthritis. The 10-year survival rate was 90.6%. Conclusion: Limited saucerization of a DLM helped to preserve coronal-plane knee joint alignment. Functional and radiological results were superior in the pediatric patients. Even when alignment was more varus in older patients, preoperative and follow-up femorotibial angles were not statistically significant. This outcome may be used to guide treatment in appropriately selected cases.