What follows are highlights from these studies:

Use of Imaging to Identify Alignment Issues in Pre-Pubertal Children After ACL Reconstruction

A new multi-center prospective study from researchers at HSS evaluated two specialized surgical reconstruction techniques commonly used to treat ACL injuries by restoring knee stability while minimizing risks of growth disturbances in children with open growth plates (skeletally immature) and more than two years of growth remaining.

Researchers compared changes in lower extremity alignment among 112 pre-pubescent patients (girls younger than 12 and boys younger than 14) who had either a physeal-sparing combined intra/extra-articular reconstruction with iliotibial band (ITB) autograft (77 patients) or an all-epiphyseal reconstruction (35 patients). All patients had x-rays taken before surgery and again one year after surgery to measure and compare growth changes in both legs.

They found that approximately 25% of children in the study developed subtle postoperative changes such as differences in leg length and angular deformity that could raise their risk of reinjury in the future. However, there were fewer growth disturbances among older patients who had less than two years of growth remaining. 

“It’s important to make people aware that even though these procedures are safe overall and designed to respect the growth plates, there is still a risk of kids experiencing alignment issues afterward,” says Peter D. Fabricant, MD, MPH, pediatric orthopedic surgeon at HSS and senior author of the study.

An ACL injury is a painful tear or sprain of the ligament connecting the femur (thighbone) to the tibia (shinbone). These injuries have become common among physically active children, especially with year-round participation in sports and an increased level of competition.

In adult patients, the standard ACL reconstruction technique involves drilling tunnels in the femur and tibia to secure a new ligament. For children who are still growing, the growth plates—where the bones grow and gain length—are exactly where the surgeon would need to drill those tunnels. That is why alternative surgical techniques have been developed that reconstruct the ACL and minimize damage to the growth plate in young patients.

“If you injure the growth plate in a younger child who has many years to grow, there’s a lot of time during which that growth plate can grow abnormally,” explains Dr. Fabricant. “Prepubertal patients are the most vulnerable population for growth plate injury, so this study focused on that subset of patients to determine the incidence of developing deformity after surgery.”

This is the first multicenter study to rigorously assess leg alignment before and after surgery and compare the surgical leg to the uninjured leg to identify and monitor postoperative growth disturbances. Such changes may not be reliably measured with clinical examination alone.

“This study gives evidence to support the use of imaging to routinely check a patient’s alignment before surgery, check it after surgery, and monitor these kids for growth disturbances so that we can intervene in minimally invasive ways while they are still growing,” explains Dr. Fabricant. “This is important because only checking alignment when there is a concern is very subjective and there may be missed opportunities for early intervention.”

One minimally invasive surgical technique used to correct alignment issues is called implant-mediated guided growth. This involves placing implants around the growth plate that guide it to grow in a way that encourages realignment. The technique avoids the need for a much bigger operation (osteotomy) to realign the bone and a lengthy recovery, as would be the case for an adult.

“You can only do guided growth surgery when the growth plate is still actively growing, which for some of these kids is only a year or two after their surgery,” explains Dr. Fabricant. “If you aren’t routinely imaging to monitor alignment and you don’t realize it in time, then you’re beyond that window of being able to do that minimally invasive surgery.”

Use of Imaging to Identify Alignment Issues in Adolescent Children With Open Growth Plates After ACL Reconstruction

A second study led by researchers at HSS found that 15% to 30% of adolescent patients who had ACL reconstruction with soft-tissue autograft developed changes in leg alignment, but no patients developed growth-related complications requiring intervention.

For adolescent patients who still have open growth plates and less than two years of growth remaining, ACL reconstruction with soft-tissue autograft is often the technique of choice. This procedure involves drilling tunnels in the bone that would be similar to an adult ACL reconstruction, but the surgeon uses a graft and implants that don’t typically affect the growth plate.

“Even though this procedure is largely safe for adolescents, there is still a possibility of alignment changes after surgery,” notes Peter D. Fabricant, MD, MPH, pediatric orthopedic surgeon at HSS and senior author of the study. “This study adds more evidence to support the need to take x-rays before and after surgery and monitor this population until they reach skeletal maturity.”

The prospective multicenter study included 99 patients (50 boys and 49 girls with a median age of about 14 years) who had less than two years of growth remaining and underwent a primary transphyseal ACL reconstruction with soft-tissue autograft. Researchers used x-ray imaging before surgery and one year after surgery to measure and compare differences in leg alignment.

“We know that leg alignment is a vital factor in predicting injury, reinjury, and surgical failure, so measuring alignment preoperatively is extremely important because you gain the opportunity to address alignment issues at the same time as the ACL surgery with no additional risk,” explains Dr. Fabricant.

For example, if a patient is found to have a borderline alignment issue before surgery, some surgeons may be encouraged to perform an implant-mediated guided growth surgery at the same time as the ACL reconstruction because they know that there is a risk of potentially worsening post-operative alignment if they don’t.

“The logical next step is to strongly consider intervening on alignment problems when necessary in order to prevent reinjury,” says Dr. Fabricant.

The HSS investigators found that the odds of taking human growth hormone therapy were 15 times higher among children who experienced a fracture to the growth plate of the upper shinbone compared with a matched comparison group who experienced midshaft tibia fractures, according to a new study published December 21 in the Journal of Bone and Joint Surgery. 

In children, human growth hormone therapy has been used for decades to treat growth hormone deficiency due to underlying medical conditions such as Turner syndrome, very small weight at birth, Prader-Willi syndrome and chronic renal insufficiency. However, in 2003, its use became more widespread in children, when the U.S. Food and Drug Administration approved it for the treatment of short stature with no known cause, called idiopathic short stature. Since then, an increasing number of children have been taking growth hormone therapy to boost their height.

Fractures to the growth plate at the top end of the shinbone, or tibia, are called proximal tibia physeal avulsion fractures. “We have been seeing more cases of tibia growth plate fractures in our emergency room and outpatient offices,” says senior author Peter D. Fabricant, MD, MPH, a pediatric orthopedic surgeon at HSS. “While kids are still growing, the tibia growth plate is structurally weaker than the patellar tendon. When a child or adolescent lands awkwardly or forcefully contracts their quadriceps muscle, instead of the patellar tendon rupturing, it pulls off a piece of bone from the growth plate because the growth plate is weaker.”

“At HSS, a big part of what our pediatric orthopedic service does is treat children with significant fractures and orthopedic injuries,” says study co-author Daniel W. Green, MD, MS, FAAP, FACS, chief of the Pediatric Orthopedic Service at HSS. “Parents frequently ask our pediatric orthopedic surgeons if human growth hormone caused their children’s fractures. Given the volume of patients we treat, we were able to investigate the relationship between tibia growth plate fractures and growth hormone therapy in pediatric patients.”

The study is the first to formally quantify this concerning relationship. The researchers analyzed hospital records for two groups of pediatric patients treated at HSS between February 2016 and May 2023—66 patients who experienced proximal tibia physeal avulsion fractures and a comparison group of 66 patients who had midshaft tibia fractures, which involve the same bone but not the growth plate area. Patients in both groups were 13 years of age on average, with similar body mass indices. The percentage of males in each group was 82 percent.

The analysis revealed that seven, or 11 percent, of patients with a proximal tibia physeal avulsion fracture reported taking human growth hormone, whereas zero patients in the comparison group were taking growth hormone. Therefore, the odds of taking growth hormone therapy were 15 times higher among patients with proximal tibia physeal avulsion fractures than the comparison group. Most patients, 86 percent, were taking growth hormone for increasing stature.  

“Tibia growth plate fractures are rare but serious injuries. They account for less than 3 percent of pediatric fractures, but more than 40 percent of patients with these fractures require surgical repair,” says Dr. Fabricant. “Moreover, whether a patient requires surgery or not, these fractures require a long recovery period—12 weeks for healing the break and regaining range of motion, plus several more weeks to months to recover strength and endurance before resuming normal activities.”

“We hope families deciding whether their children should start or continue growth hormone therapy consider our new evidence as they carefully weigh the pros and cons of therapy in consultation with their pediatric endocrinologists,” Dr. Green says. “Further research is required to tease out whether limiting specific high-impact sports will mitigate the risk of tibia growth plate fractures in active children and adolescents.”

The findings address a common but counterproductive trade-off in orthopedic surgery: Health insurers typically stop paying for rehabilitation before patients are fully recovered and able to return to full physical activity. As a result, up to 30 percent of such patients may reinjure their surgically repaired knee or damage the other, healthy knee, leading to significantly increased healthcare costs in the long term.

The researchers say the findings, which are available online as part of the AAOS 2020 Virtual Education Experience, should prompt insurance companies to consider paying for more rehabilitation sessions for patients who have undergone reconstructive procedures such as ACL surgery.

“Historically, ACL reconstruction has been performed and patients have been cleared back to sports using simple time-based criteria, which is a one-size-fits-all solution for a problem that’s not one-size-fits-all,” said Peter D. Fabricant, MD, MPH, pediatric orthopedic surgeon at HSS. “The purpose of this study was to ask, ‘Is an enhanced postoperative rehabilitation approach cost-effective for insurers?’ We found that although it might cost them a little more money up front to pay for additional sessions and testing, they save money in the long run. These savings occur because they pay for fewer repeat surgeries due to re-tearing or tearing the ACL of the other knee. Both of these happen at a higher rate following reconstruction when using simple time-based criteria to release the patient back to sports participation. Also, patients are happier because they don’t reinjure their knees as frequently.”

For the study, Dr. Fabricant and his colleagues used nationally available data about the costs of rehabilitation and ACL surgery to develop a cost-benefit model for enhanced rehab. These comprehensive programs — which include improving biomechanics in the affected knee and retraining the muscles in the area — are thought to reduce the risk of re-tearing and needing a revision procedure by at least 25 percent, and also reduce the risk of tearing the ACL of the opposite knee by 50%.

According to the model, if the additional cost of a typical enhanced rehab program is less than about $2,500, insurers actually save money because that extra cost is offset by the savings associated with reducing subsequent injury of both knees. If the program is more successful — reducing the risk of revision surgery by say, 50% — the break-even point is even greater, the study showed. Additionally, these re-injuries tend to occur early on, so the cost of a second surgery comes quickly.

The specific nature of the particular rehabilitation program is less important than simply having access to the additional sessions. “This study doesn’t say you need to do exactly these exercises and exactly these things to get these better outcomes,” said Joseph T. Molony, Jr., PT, MS, SCS, CSCS, manager of the Young Athlete Program at HSS who helped conduct the research. “It simply says that if you spend more time at the end of rehabilitation working on neuromuscular retraining, return-to-play testing, looking at mechanics and having more follow-up visits with the physician, you’re going to lower the reinjury rate substantially.”

“The beauty of this study is that we’re not recommending a specific program or number of sessions,” Dr. Fabricant added. “Given any program, whether it involves testing, therapy sessions ­— whatever it is — if you stay within a certain range, any program that meets those criteria would be cost-effective.”

Dr. Fabricant said the findings empower physicians, surgeons, patients, and physical therapists with a critical piece of evidence in their efforts to convince insurers to cover more intensive rehabilitation for ACL injured patients. “This arms the provider with some ammunition so that they can show the insurance companies, not only is it medically necessary, it’s also cost saving.”

Harry “Tate” Greditzer, IV, MD, radiologist at HSS and avid surfer himself, launched a study to determine the kinds of orthopedic injuries a recreational surfer might sustain and how often he or she required surgery. “The primary purpose of the study was to characterize MRI patterns of acute surfing-related injury at HSS, an urban musculoskeletal hospital,” Dr. Greditzer said. “Secondarily, the purpose was to report the proportion of those injuries that required orthopedic surgical intervention.”

Dr. Greditzer and colleagues found that shoulder injuries were the most common, followed by knee injuries. In the study, 17% of patients needed surgery for any type of surfing injury. The research was published online in the journal Sports Health on November 5.

The investigators noted that previous surfing studies from different regions of the world have described the incidence of injuries along with the type, location, and severity, but the results have been highly variable. Most prior studies have also utilized imaging modalities that are readily available in an emergency setting, but did not focus on high resolution soft tissue imaging modalities such as MRI, as in the HSS study.

HSS investigators conducted a retrospective review of medical records to identify patients with surfing-related injuries who came to HSS for treatment between January 1, 2009 and August 1, 2018. The researchers analyzed the data and reported on the body part injured, diagnosis, and surgical versus nonsurgical treatment.

The search yielded 109 patients with surfing-related injuries who had MRIs. A total of 90 patients came to HSS within six months of their injury and were included in the final analysis. The median age was 36, with patients ranging in age from 12 to 66. Three-quarters of the patients were male.

Acute surfing injuries were diagnosed with an MRI in 72% of study patients. The following injuries were reported:

• Shoulder: 46% of surfing injuries
• Knee: 28%
• Foot or ankle: 9%
• Spine: 6%
• Elbow: 6%
• Other (rib fracture; muscle strain or muscle laceration): 5%

“Although prior studies have shown that injuries related to surfing are primarily found in the head or lower extremities, our study found upper extremity injuries to be more common,” said Peter D. Fabricant, MD, MPH, pediatric orthopedic surgeon at HSS and study author. “The majority of upper extremity injuries occurred at the shoulder with anterior shoulder dislocation being the most common diagnosis. Of the presenting knee injuries, a torn medial collateral ligament was the most frequent.”

Only 17% of all the surfing injuries required surgery at HSS. This percentage may overestimate the number of surfing injuries in general that require surgery, the study authors noted. Tertiary care referral centers such as HSS tend to see a greater proportion of serious injuries requiring surgery.

The study authors noted that the overall diagnostic quality provided by MRI helps to elucidate the most serious soft tissue surfing injuries. However, the exclusive use of this imaging modality for diagnosis was a limitation of the study, as it would not account for other musculoskeletal surfing injuries that do not require an MRI.

“When compared to other extreme sports, surfing seems relatively safe,” said Dr. Greditzer. “However, it’s important to keep in mind that our study looked at recreational surfers. We did not include professional surfers, so the patients in our study were not able to generate as much speed, get barreled, or launch into the air like a professional or amateur can, where the potential for injury is much higher.”

Dr. Greditzer, who has been surfing for more than 20 years, commented on injury prevention for beginning surfers. He says being a good swimmer is the most important attribute for anyone thinking of taking up the sport. He also recommends that beginners take a few lessons to learn the basics and use a soft foam surfboard to start.

"Back pain is common in children and adolescents, and the incidence of children who experienced pain in the past year increases linearly with age (about four % for each year of age)," explains Dr. Fabricant to OTW. "While back pain is common in children and adolescents, it very rarely requires invasive treatment such as injections or surgery, as less than 5% (n=23) of the 40.9% who sought treatment needed surgical or procedural intervention."

Read the full article at Ryortho.com.
 

"We see a lot of kids who have pain from overuse injuries or joint pain from playing sports," says Peter D. Fabricant, MD, MPH, pediatric orthopedic surgeon at HSS and study lead. "Of these kids who had back pain, very few actually required any sort of medical intervention. Most didn't need treatment at all."

Dr. Fabricant says that physical therapy may help by stretching and strengthening key muscles.

The researchers also found that back pain was more common among girls than boys (38 percent to 29 percent). 

Read the full article at HealthDay.com.

Additional Coverage:

• WebMD: One-Third of U.S. Kids Have Back Pain, Study Says

According to a study by the University of Michigan, 15 percent of athletes in contact sports have used opioids for pain management.

The segment reported that a number of athletes feel pressure to stay on the field. Once they are injured or feel pain, they self-medicate with opioids to avoid missing a game.

HSS pediatric orthopedic surgeon Peter D. Fabricant, MD, MPH urged parents and coaches to be more involved in properly managing an injured athlete's pain.

Watch the full segment at nbcnewyork.com. This aired during the February 17, 2018 broadcast.