I'm going to update multi-center research in the upper extremity and pediatric sports medicine. Here are my disclosures. So clearly multi-center research is key in improving our treatment of pediatric sports medicine patients. We'll review existing collaborations and published and unpublished data from a few different study groups. So multi-center research continues to drive changes in practice in orthopedics and sports medicine. We've seen this from Moon and Mars as leaders in pushing this forward across orthopedics. Prospective multi-center cohort studies are critical and are often the ideal study design for generalizable, powerful tools to answering key clinical questions. So pediatric sports medicine I think is an ideal target for multi-center research. Pediatric and adolescent patients are often bunched in with the adult counterparts in sports medicine but may have different outcomes. The small numbers in this population make it difficult to do single-center studies or require long retrospective studies that often introduce significant confounding. So efforts in the knee have been very fruitful from Rock to Pluto and are probably a little bit ahead of us in the upper extremity. And then special mention of PRISM, Pediatric Research in Sports Medicine, we'll hit on a little bit as well that's clearly driving a lot of this multi-center research. So the shoulder is a big part of a pediatric sports medicine practice. This is a study we published looking at practice patterns in pediatric sports medicine that around 15% of operative volume is shoulder related and it's probably even higher for the non-operative side. So where are we in 2023? We have growing multi-center research in upper extremity pediatric sports. I think the FACTS study, as we kind of prefaced earlier, is an ideal model. Ben Hayworth from Boston who's here, special credit, is really driving this for a number of years. So FACTS is function after adolescent clavicle trauma and surgery and has really driven changes in our clinical treatment of these patients. So we'll spend some time going through FACTS and where it's been. So FACTS has put together a great group of 15 investigators across eight sites with varied approaches to clavicle treatments when this study was implemented, which made it possible to really figure some of these things out. So early FACTS studies went back to the basics, radiologic measurements, even how we measure clavicle shortening has been challenged that many times we're probably overestimating the true amount of shortening if we don't look at a cortex to cortex type measurement. We published the epidemiology of clavicle fractures as sort of the initial step to then looking at the outcome. So two-year outcomes, a key study published last year. So this is sort of the flow of this study. Again, the adolescent clavicle, these are tough patients to follow that took a lot of work to find these. Of the displaced fractures, about 275 are then followed for outcomes. If we look at operative versus non-operative treatment, of course, it's not surprising that there are some differences. We see differences in age, differences in shortening, differences in combination between the two groups, which are important as we go to analysis. When we look at unadjusted outcomes, these groups are very similar from ASES, QuickDash, EQ5D, VAS, all nearly identical, if anything, the non-operative groups doing slightly better. If we dichotomize these looking at maybe suboptimal outcomes, we see the same trends below. No significant differences, no evidence that on average patients are better with surgery. But what about those confounders? So we've looked at this a couple of ways. So if we adjust for age, if we adjust for fracture type and the amount of shortening, we can use statistical tools to look into this and we still see no significant effect of operative treatment. Then we also did a subgroup sort of matched analysis looking at matching on those same parameters and find the same things. No obvious trends towards any differences in these groups. So in conclusion, from this two-year study, we see that at least at two years, we don't see much of a benefit in terms of our patient-reported outcomes. Operative treatment does come with a higher risk of subsequent surgery, typically hardware removal, and this really challenged some of the existing literature out there that non-unions we know are very uncommon in this population, but symptomatic malunions in this cohort prospectively were less than 1%, which is much less than the literature might have suggested. So this begs the question, what drives the excellent outcomes in this subgroup compared to our adult counterparts? Is it fracture settling? Is it fracture remodeling? Is it tolerance of the deformity? So we've looked at this a few different ways. So settling, looking at early changes in alignment from injury to that kind of six-week healed state. On average in kids, this appears to be a favorable phenomenon. So many of them improving significantly. So shortening, angulation, or superior displacement, most of the patients get a little bit better during this first six-week period, and very few actually get worse. If we look at remodeling, we heard a little bit about this earlier from Samuel at five years. This also shows that many of these patients remodel significantly. So this may be playing a role when we look at these patients down the road that many of them remodel. As we saw, the rate's 82% near-complete remodeling at five years, and that data was showed earlier. So one of the best tools from this study is this appendix that's available with the article. A great tool to have in clinic when you're talking to patients and families and making these decisions. So we can really show them a similar patient and how that fracture looked a couple years later. So here's a 13-year-old male, nine months later, significant improvement in that radiograph. So that really hits home for the patients. Almost a 14-year-old male here, seven years later, fairly hard to detect the fracture there. A 16-year-old female, I think it actually is, and then a two-year follow-up. So that's a great tool to help you in clinic, I think, talk patients and make those decisions with now good evidence that we really didn't have a couple years ago. That then begs the question, which we just kind of hit on, is who does need surgery then? Is it older patients, athletes, overhead athletes, Z-type fractures or skin tenting? We've tried to look at some of those groups and facts as well. So this is adolescent athletes with severe fracture patterns greater than 25 millimeters of shortening or significant to a comminution. And we see the same trends. Continuous PROs are similar. And then the states of symptomatic problems down the road are also very similar. So that clearly, we don't see a strong difference there. We also looked at Z-type fractures. This is commonly used as an indication for surgery. And just like the slide before, no evidence for any difference. Those treated nonoperatively just did just as well as those treated operatively. Even skin tenting, sort of tenting or tented skin, sort of skin potentially at risk, even leaving those fractures alone seems to do okay. Only 3% convert from nonoperative to operative treatment. And then eventual outcomes are very similar. So in summary, the vast majority of clavicle fractures in that 10 to 18-year-old age group have excellent outcomes with nonoperative treatment. And now we have great, strong literature to support that discussion with families. Many of the commonly used surgical indications aren't really supported by the literature when we really dive into it. And this really empowers better shared decision-making in this population. So upper extremity research, a couple of other things not as developed as facts, but are out there. Adolescent proximal humerus fractures run by Pouya Hosenzadeh at Wash U, the ROCKIT study by Carl Nissen and Don Bay, and then the PRISM group has a shoulder research interest group as well. So just briefly to hit on those. Proximal humerus fractures are often similarly sports-related. Historically, these have been viewed as very tolerant of deformity. So this was across five institutions looking at displaced proximal humerus fractures. 78 patients enrolled and followed over time. Pretty evenly split between operative and nonoperative treatment. At six weeks, they saw small differences where the operative patients were better with upper extremity function. But as you get to three and six months, all those differences disappeared. So very similar to the clavicle that they seem to do pretty well as well. Even when you look at the most severe fractures, those trends were similar. Elbow OCD is coming our way. Some early research going on there. The ROCKIT group's done this in knees for over a decade. ROCKIT expanded this to the elbow and talus with Carl Nissen and Don Bay. They have one study out looking at the basic reliability of elbow OCD radiology and more to come with over 100 patients enrolled and a growing list of investigators. So that's something we'll definitely see in the coming years. And then finally, PRISM. PRISM is really the brainchild of Hank Chambers who founded this and really pushed it along. It's really meant for research. So these research interest groups or RIGs are putting individuals together to do this research from multiple centers. The shoulder RIG has 15 to 20 members. And I think we'll eventually move towards prospective multicenter studies such as pediatric and adolescent shoulder instability I think will be a great thing that we need to learn more about in the future. So in conclusion, multicenter prospective research is increasing in pediatric sports medicine. These like facts have really changed treatment of countless patients across the United States and abroad. And then future research will really drive our improved evidence in these other conditions as well. Thank you.

multi-center research

pediatric sports medicine

upper extremity injuries

collaborations

FACTS study