Background: Graft choice for pediatric anterior cruciate ligament reconstruction (ACLR) is determined by several factors. There is limited information on the use and outcomes of allograft ACLR in pediatric patients. The purpose of this systematic review and meta-analysis was to quantify reported failure rates of allograft versus autograft ACLR in patients ≤19 years of age with ≥2 years of follow-up. We hypothesized that there would be higher rates of failure for allograft compared with autograft ACLR in this population. Methods: PubMed/MEDLINE and Embase databases were systematically searched for literature regarding allograft and autograft ACLR in pediatric/adolescent patients. Articles were included if they described a cohort of patients with average age of ≤19 years, had a minimum of 2 years of follow-up, described graft failure as an outcome, and had a Level of Evidence grade of I to III. Qualitative review and quantitative meta-analysis were performed to compare graft failure rates. A random-effects model was created to compare failure events in patients receiving allograft versus autograft in a pairwise fashion. Data analysis was completed using RevMan 5.3 software (The Cochrane Collaboration). Results: The database search identified 1,604 studies; 203 full-text articles were assessed for eligibility. Fourteen studies met the inclusion criteria for qualitative review; 5 studies were included for quantitative meta-analysis. Bone-patellar tendon-bone (BTB) represented 58.2% (n = 1,012) of the autografts, and hamstring grafts represented 41.8% (n = 727). Hybrid allografts (autograft + supplemental allograft) represented 12.8% (n = 18) of all allograft ACLRs (n = 141). The unweighted, pooled failure rate for each graft type was 8.5% for BTB, 16.6% for hamstring, and 25.5% for allograft. Allografts were significantly more likely than autografts to result in graft failure (odds ratio, 3.87; 95% confidence interval, 2.24 to 6.69). Conclusions: Allograft ACLR in pediatric and adolescent patients should be used judiciously, as existing studies revealed a significantly higher failure rate for allograft compared with autograft ACLR in this patient population. Additional studies are needed to improve the understanding of variables associated with the high ACLR failure rate among pediatric and adolescent patients. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: Meniscus tears in the young patient are becoming more prevalent. Knowledge of presenting characteristics and morphology can affect treatment decisions. The purpose of this study was to review and evaluate all the isolated lateral meniscus pathology that required arthroscopic treatment in a pediatric sports medicine practice and compare presenting characteristics between those with a discoid meniscus and those with normal meniscal morphology. Methods: We performed a retrospective review of all isolated lateral meniscus arthroscopic procedures from 2003 to 2012 in a high-volume pediatric sports practice. Presentation, radiographs, and intraoperative findings were reviewed. The prevalence and clinical findings of a discoid meniscus in this population and among all age groups were compared with those with a meniscus tear occurring in a normal meniscus. Results: Two hundred and sixty-one arthroscopies were performed for symptomatic isolated lateral menisci pathology. Of these, 75% were discoid in nature; the remainder was tears occurring in normal menisci. Ninety-six of 99 patients (97%) with lateral meniscus pathology under the age of 13 had a discoid meniscus and 66% presented with no injury. There was a transition within the population at 14 years of age, with a rise in the incidence of normal meniscal body tears. Even after this transition point, meniscal pathology incidence remained notable; 59% of isolated lateral meniscus pathology in patients between the ages of 14 and 16 years old were a discoid meniscus. Magnetic resonance imaging criteria for discoid meniscus (3 consecutive sagittal cuts or coronal mid-compartment measure) were unreliable after the age of 13 years old. The ratio of complete to incomplete discoids in all age groups was 4 to 3. Conclusions: In conclusion, discoid menisci have a high prevalence in isolated lateral meniscus pathology requiring knee arthroscopy. Clinical presentation, imaging, characteristics, and treatment may be different among different age groups. In the adolescent age group (14 to 16 y old), the presentation of a discoid meniscus may not be different from a meniscus tear with normal morphology. Level of Evidence: Level III—diagnostic.

Despite the increasing incidence of sports-related knee injuries in youth athletes, few studies have reported on the diagnosis and treatment of pediatric and adolescent meniscal root injuries. To describe traumatic posterior meniscal root injuries in a pediatric and adolescent population and compare the presentation of meniscal root injuries versus that of nonroot injuries. Cohort study; Level of evidence, 3. A study was conducted of all knee arthroscopies performed on consecutive patients treated in a pediatric sports practice from March 2012 through February 2015. All patients who were younger than 20 years at the time of their injury and who underwent an arthroscopy with meniscal injury were included. Patients with discoid lateral meniscus, atraumatic meniscal cysts, partial-thickness meniscal root injuries (LaPrade type 1), and recurrent root tears were excluded. A comparative analysis of root and nonroot injuries was performed. A total of 314 patients had surgery for meniscal injury (mean patient age, 16.0 years; range, 10.5-19.6 years). Of these patients, 58 (18.5%) posterior meniscal root injuries were identified. The root injuries were more likely to have joint line tenderness on preliminary physical examination compared with nonroot injuries (96.5% vs 58.6%, respectively; P < .001). Root injuries rarely occurred in isolation compared with nonroot meniscal tears (6.9% vs 17.6%; P = .021) and were frequently treated in combination with anterior cruciate ligament (ACL) injuries (86.2%). Lateral root injuries occurred more often in conjunction with ACL injuries compared with medial root injuries (84.8% vs 22.2%; P < .001). On review of preoperative imaging, meniscal extrusion occurred more often in root injuries than in nonroot injuries (32.8% vs 3.5%; P < .0001) and was uncommonly seen in the skeletally immature patient. Extrusion was seen more often in medial than lateral root tears (66.7% vs 21.7%; P = .008). A majority of patients (57/58) underwent transosseous suture repair of the meniscal root. When treating a pediatric or adolescent patient for a traumatic meniscal tear, a surgeon may expect to see a posterior meniscal root injury in as many as 1 in 6 patients. When treated for an ACL, contact, or multiligament injury or meniscal extrusion, a pediatric or adolescent patient may demonstrate a meniscal root avulsion or complex meniscal tear. These data provide practitioners with an improved ability to identify and treat meniscal root injuries that otherwise lead to rapid cartilage degeneration.

Purpose of review: The incidence of patellar instability in pediatric patients ranges is 50–100 in 100,000 patients per year. Risk of recurrent dislocations however has been cited from 8.6% to 88% depending on individual patient factors. This manuscript highlights the demographical, historical, and anatomic factors associated with recurrent patellar instability following a first-time patella dislocation in the pediatric population. Recent findings: In recent years, various studies have focused on identifying risk factors for recurrent patellar instability following a primary patellar dislocation. A mix of patient factors, including age of first dislocation, patella alta, elevated tibial tubercle to trochlear groove and trochlear dysplasia have all been noted in the literature, which have helped to develop various scoring tools to predict recurrent dislocation following nonoperative treatment. Summary: Risk of recurrent patellar instability in patients who have previously suffered a patellar dislocation can be due to many factors. These risk factors should be used and applied to a variety of risk scores in order to provide physicians and healthcare providers with a tool to counsel patients and families on their patellar redislocation risk and help guide further management.

Patellofemoral instability (PFI) encompasses symptomatic patellar instability, patella subluxations, and frank dislocations. Previous studies have estimated the incidence of acute patellar dislocation at 43 per 100,000 children younger than age 16 years. The medial patellofemoral ligament (MPFL) complex is a static soft tissue constraint that stabilizes the patellofemoral joint serving as a checkrein to prevent lateral displacement. The causes of PFI are multifactorial and not attributed solely to anatomic features within the knee joint proper. Specific anatomic features to consider include patella alta, increased tibial tubercle–trochlear groove distance, genu valgum, external tibial torsion, femoral anteversion, and ligamentous laxity. The purpose of this paper is to provide a review of the evaluation of PFI in the pediatric and adolescent patient with a specific focus on the contributions of coronal and transverse plane deformities. Moreover, a framework will be provided for the incorporation of bony procedures to address these issues.

Background: Glenoid bone loss can affect the outcome and treatment for posttraumatic recurrent anterior glenohumeral instability. Clinical presentation in the adolescent age group with shoulder instability and glenoid bone loss is largely unknown. On the basis of this information, we believe there will be a high incidence of glenoid bone loss in adolescent patients with recurrent glenohumeral instability. We hypothesize that high-impact injuries, sports injuries, and reductions requiring sedation will be factors associated with glenoid bone loss. Methods: We performed a retrospective cross-sectional cohort study reviewing consecutive adolescent patients (n=114) with recurrent traumatic glenohumeral instability between 2004 and 2012. Chart analysis included demographic, presenting, and radiographic data. Glenoid bone loss was interpreted from plain radiographs, computed tomography (2D and/or 3D), magnetic resonance imaging, and/or arthroscopy. We compared possible risk factors between subjects with and without glenoid bone defects using the χ² test or 2 sample t tests. Results: Glenoid bone loss was seen in 55 patients (48.2%) with 15 of these patients (27%) having critical bone loss. Forty-five percent of appreciated glenoid bone loss was not visualized on plain radiographs. The average age was 15.1 years (range, 6.5 to 18.1) with male to female ratio 3.7:1. Male sex, older age, and taller stature were all statistically associated with glenoid bone loss (P=0.02, 0.01, and 0.02, respectively). Primary dislocations that occurred during sports were more likely to have glenoid bone loss (55.9% vs. 78.2%, P=0.01). The presence of an apprehension sign on physical examination was positively correlated with bone loss (P=0.008). Conclusions: The presence of glenoid bone loss in primary traumatic glenohumeral instability in the adolescent population is high, however, not as high as previously reported. Factors associated with glenoid bone loss include male sex, older age, taller stature, sports injuries, and the presence of apprehension on physical examination. Level of Evidence: This study establishes patients who may be at high risk for glenoid bone loss based on mechanism of injury and physical examination findings. This prognostic study is a level II retrospective study.