Lewis J, Christiano A, Erdman MK
… +4 more, Upp L, Hynes K, Wolf J, Strelzow J
J Bone Joint Surg Am
· 2026 Apr · PMID 41961974
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BACKGROUND: Bone density can impact treatment decisions for orthopaedic conditions. While ad-hoc intraoperative surgeon assessment of bone quality is common, the accuracy of such evaluation remains unknown. The primary p...BACKGROUND: Bone density can impact treatment decisions for orthopaedic conditions. While ad-hoc intraoperative surgeon assessment of bone quality is common, the accuracy of such evaluation remains unknown. The primary purpose of this study was to determine whether orthopaedic surgeons' intraoperative assessment of bone quality closely correlated with validated measures. METHODS: In this prospective cross-sectional study, we enrolled adult patients undergoing orthopaedic surgery at a Level-I trauma center. Eligibility required an opportunistic computed tomography (CT) scan of the lumbar spine, glenoid, wrist, pelvis/femur, proximal tibia, or calcaneus. Seven surgeons, blinded to objective measures of bone quality, provided intraoperative bone-quality assessments using a 10-point Likert scale and categorized bone quality as normal, osteopenic, or osteoporotic. Hounsfield units (HUs) were measured on CT using a previously published technique. All images were reviewed by a single orthopaedic surgeon, blinded to intraoperative bone-quality assessments. RESULTS: Of the 229 patients enrolled, 215 had available CT data and were included in the study. The average age of these patients was 44 years (range, 18 to 95 years), with 40.5% being female. Over half of the patients (61%) were Black or African American, while a quarter of the patients (25%) were White. The most common surgical sites included the femur (39 patients, 18.1%), ankle (31, 14.4%), and acetabulum (26, 12.1%). A positive linear relationship between HU and surgeon bone-quality assessments was observed (r = 0.66; p < 0.0001), which was consistent across surgical anatomic sites. Abnormal bone quality was correctly identified by surgeon assessment with 84% sensitivity and 97% specificity. CONCLUSIONS: This study demonstrated that surgeons can reliably detect abnormal bone quality through intraoperative assessment across numerous surgical sites. Intraoperative assessments may provide actionable and reliable feedback regarding bone density without additional cost or radiation in cases when opportunistic scans are not available. This information can inform intraoperative decision-making and presents opportunities for bone-health interventions. LEVEL OF EVIDENCE: Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.
J Bone Joint Surg Am
· 2026 Apr · PMID 41961966
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BACKGROUND: Female surgeons more commonly delay childbearing and experience higher rates of infertility than women in the general population. More women are entering orthopaedic surgery but face unique challenges in fami...BACKGROUND: Female surgeons more commonly delay childbearing and experience higher rates of infertility than women in the general population. More women are entering orthopaedic surgery but face unique challenges in family building. The accessibility of fertility preservation strategies among female orthopaedic surgeons remains underexplored. We aimed to investigate facilitators of and barriers to oocyte cryopreservation, especially during orthopaedic residency. METHODS: A survey regarding family planning and experiences surrounding oocyte cryopreservation was designed and distributed via residency program directors, regional orthopaedic societies, and the Ruth Jackson Orthopaedic Society. Female orthopaedic surgery residents, fellows, and attending physicians were invited to participate. RESULTS: Of 169 participants, 107 (63%) reported intentionally delaying childbearing and 58 (34%) reported delaying or planning to delay for ≥4 years. Although 91 respondents (54%) had considered oocyte cryopreservation, only 36 (21%) had undergone or planned to undergo at least 1 cycle and 55 (33%) ultimately decided not to undergo it. Inflexible scheduling of work, lack of insurance coverage, and restrictive leave policy were the most important barriers to oocyte cryopreservation during residency. Among current residents and fellows, 30 (38%) would not have been comfortable telling program leadership that they were planning to undergo oocyte cryopreservation and 25 (32%) reported that they would not have been provided adequate scheduling flexibility. When given 5 multiple-choice questions about female fertility and the oocyte cryopreservation process, respondents answered a mean of 1.46 questions correctly. CONCLUSIONS: This study revealed a high degree of interest in oocyte cryopreservation among survey respondents but identified persistent barriers of financial burden, inflexible scheduling, institutional stigma, and limited fertility knowledge. Residency programs should prioritize schedule flexibility, proactive leadership support, and privacy-conscious accommodations for fertility-related care as well as structured reproductive health education for trainees. CLINICAL RELEVANCE: Barriers to fertility preservation during orthopaedic training directly affect physician well-being and the ability to recruit and retain women in this specialty, which, in turn, impact patient access to quality care from a diverse physician workforce.
Jiang B, Fan J, Lai Y
… +4 more, Cai Y, Ding Z, Luo Z, Zhou Z
J Bone Joint Surg Am
· 2026 Apr · PMID 41961954
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BACKGROUND: Major anxiety symptoms are commonly observed in patients undergoing total hip arthroplasty (THA); these symptoms exacerbate pain and compromise hip recovery. Olanzapine demonstrates clinically meaningful effi...BACKGROUND: Major anxiety symptoms are commonly observed in patients undergoing total hip arthroplasty (THA); these symptoms exacerbate pain and compromise hip recovery. Olanzapine demonstrates clinically meaningful efficacy in reducing anxiety; thus, we investigated its anxiolytic effect and benefits for enhancing recovery in these high-risk patients. METHODS: We prospectively enrolled 135 patients who were scheduled for primary THA at our institution between April 2024 and March 2025 and who scored at least 40 points on the State-Trait Anxiety Inventory-State (STAI-S) before surgery. Patients randomly received oral olanzapine (2.5 mg), alprazolam (0.4 mg), or a placebo once nightly for 5 days beginning on the day of admission. The 3 groups (45 patients in the olanzapine group, 45 in the alprazolam group, and 44 in the placebo group after 1 patient was lost to follow-up) were compared postoperatively in terms of the STAI-S score, Pittsburgh Sleep Quality Index (PSQI), visual analog scale (VAS) pain score, opioid consumption, and functional recovery of the hip. Adverse events related to drugs and surgery were recorded. RESULTS: Compared with placebo and alprazolam, olanzapine was associated with significantly lower STAI-S scores on postoperative days (PODs) 1 and 3, significantly lower resting VAS pain scores on PODs 1 to 3, and significantly lower incidence of postoperative nausea and vomiting. The olanzapine group and the alprazolam group demonstrated significantly better sleep quality based on the PSQI on POD 3 compared with the placebo group. Moreover, the olanzapine group had lower opioid consumption on PODs 1 to 3 than the placebo group. Patients in the olanzapine group exhibited better Harris hip scores and Hip Disability and Osteoarthritis Outcome Scores. The 3 groups did not significantly differ in terms of adverse events. CONCLUSIONS: Perioperative low-dose olanzapine may be an effective option for reducing anxiety levels, sleep disorders, and postoperative nausea and vomiting, mitigating postoperative pain and enhancing hip recovery among patients with anxiety symptoms undergoing THA. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
Terhune EB, Carstens MF, Fruth KM
… +5 more, Hannon CP, Bedard NA, Perry KI, Berry DJ, Abdel MP
J Bone Joint Surg Am
· 2026 Apr · PMID 41961950
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BACKGROUND: Contemporary rotating-hinge total knee arthroplasties (RH-TKAs) have shown reasonable short-term survivorship in smaller series, but concerns remain regarding risks of aseptic and septic failure. The purpose...BACKGROUND: Contemporary rotating-hinge total knee arthroplasties (RH-TKAs) have shown reasonable short-term survivorship in smaller series, but concerns remain regarding risks of aseptic and septic failure. The purpose of this study was to assess outcomes of contemporary RH-TKAs in one of the largest series to date. METHODS: We retrospectively identified 575 RH-TKAs (60% used for aseptic etiologies and 40% used during reimplantation in 2-stage treatment of periprosthetic joint infection [PJI]) from 2002 to 2021 at a single institution. The mean age was 67 years, 58% were female, and the mean body mass index was 33 kg/m2. Sixty-five percent had Anderson Orthopaedic Research Institute (AORI) type-2B or 3 bone loss. Kaplan-Meier survivorship analyses were performed. The mean follow-up was 6 years (range, 2 to 19 years). RESULTS: Survivorship free from any revision was 76% at 5 years and 64% at 10 years. The most common revision indications were PJI (54%) and aseptic loosening (20%). RH-TKA used in the primary setting showed better survivorship compared with RH-TKA used during reimplantation after PJI (79% versus 60% at 10 years). Survivorship free from revision for aseptic loosening was 96% at 5 years and 90% at 10 years. Survivorship free from revision for PJI was 84% at 5 years and 81% at 10 years. Survivorship free from revision for PJI was even lower for RH-TKAs used during reimplantation, 74% at 5 years and 73% at 10 years. RH-TKA used during reimplantation in the treatment of PJI was associated with an increased risk of any revision (HR = 2, p < 0.001). Radiographic analysis of 425 knees that were not revised and had radiographs available for review showed that 6% of femoral components and 8% of tibial components had evidence of loosening at the time of final follow-up. The mean Knee Society Score improved from 33 to 69 at 2 years (p < 0.001). CONCLUSIONS: The 10-year survivorship free from aseptic loosening was 90% in this large series of RH-TKAs. This represents one of the best survivorships free from aseptic loosening published to date. Knees with prior PJI had markedly poorer survivorship than knees treated for aseptic etiologies, with double the risk of revision. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Cheng EY, Mirzaei A, Goodman SB
… +4 more, Cui Q, Mont MA, Jones LC,
the ARCO Clinical Practice Guideline workgroup
J Bone Joint Surg Am
· 2026 Jun · PMID 41961916
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BACKGROUND: Nontraumatic osteonecrosis of the femoral head (ONFH) can lead to major disability in patients of all ages. It presents at various levels of severity and can be either symptomatic or asymptomatic. There is a...BACKGROUND: Nontraumatic osteonecrosis of the femoral head (ONFH) can lead to major disability in patients of all ages. It presents at various levels of severity and can be either symptomatic or asymptomatic. There is a vast array of management strategies. Treatment is often subject to physician bias. Clinical practice guidelines that are broad-based, internationally developed, consensus-driven, and strictly evidence-based are needed. The aim of this guideline by the Association Research Circulation Osseous (ARCO) was to develop international evidence-based recommendations to assist physicians and patients in managing ONFH. METHODS: ARCO convened an international, multidisciplinary guideline panel that was balanced to minimize potential bias from conflicts of interest. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was utilized, including GRADE Evidence-to-Decision frameworks. The panel prioritized clinical questions, defined criteria for the systematic review of evidence, evaluated the statistical analysis, and, by consensus, approved recommendation statements, which were then subject to external review by content experts and stakeholders (a health policy-maker and a patient). RESULTS: The panel agreed on 12 recommendations for the diagnosis, evaluation, and management of ONFH. CONCLUSIONS: Key recommendations of these guidelines require accurately staging ONFH and determining when pain may be due to ONFH. They establish principles for optimal decision-making by assessing the quality of evidence backing various treatments and identifying numerous areas for additional investigation. CLINICAL RELEVANCE: This international evidence-based guideline provides standardized recommendations for the diagnosis and management of nontraumatic ONFH. It synthesizes all available evidence using GRADE methodology and offers practical, consensus-supported guidance for accurate staging, imaging selection, treatment decision-making, and the identification of patients who would benefit from joint-preserving interventions. The guideline supports clinicians in reducing practice variation, improving diagnostic accuracy, and optimizing treatment pathways for patients with ONFH.
Fischer G, Kilian E, Schömig F
… +13 more, Vitale J, Oriordan D, Puhakka J, Reitmeir R, Ropelato M, Haschtmann D, Kleinstück F, Fekete T, Jeszenszky DJ, Porchet F, Vajkoczy P, Galbusera F, Loibl M
J Bone Joint Surg Am
· 2026 Apr · PMID 41921058
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BACKGROUND: Optimal surgical treatment for recurrence of lumbar disc herniation (LDH) remains controversial, with options ranging from repeat microdiscectomy (MD) to instrumented fusion (IF). This study aimed to guide su...BACKGROUND: Optimal surgical treatment for recurrence of lumbar disc herniation (LDH) remains controversial, with options ranging from repeat microdiscectomy (MD) to instrumented fusion (IF). This study aimed to guide surgical decision-making by analyzing reoperation rates, clinical and radiographic risk factors for treatment failure, and functional outcomes following MD versus IF. METHODS: Prospectively collected data from 450 patients in our outcomes database who underwent surgery for recurrent LDH from 2004 through 2023 were retrospectively analyzed. Clinical assessment included predominant symptoms, neurological deficits, and American Society of Anesthesiologists (ASA) grade. Radiographic assessment included disc height, Pfirrmann grade, facet angle, and Modic changes on magnetic resonance imaging, as well as spinopelvic parameters on standing radiographs. Patient-reported outcomes were assessed using the Core Outcome Measures Index (COMI) and achievement of the minimal clinically important change (MCIC) of ≥2.2 points. Propensity-score matching (PSM) was performed to control for confounding factors. Reoperation rates were analyzed with a minimum 5-year follow-up. RESULTS: Of 450 patients with recurrent LDH, 316 (70.2%) underwent MD and 134 (29.8%) underwent IF. In 192 patients after PSM, IF showed nonsignificantly higher MCIC achievement (odds ratio [OR] = 1.20, 95% confidence interval [CI]: 0.66 to 2.17, p = 0.65) and lower COMI scores compared with the MD group (3.34 ± 2.89 versus 4.01 ± 2.95, p = 0.059; derived Oswestry Disability Index [ODI]: 23.8 versus 28.1). IF demonstrated significantly lower reoperation risk compared with MD (15.7% [116/316] versus 36.7% [21/34], p < 0.001). The reoperations following MD were predominantly subsequent IF (73.3%) and repeat MD (23.3%), while the reoperations after IF were predominantly adjacent segment surgery (57.1%) and hardware revision (33.3%). BMI of ≥35 kg/m2 was a significant predictor of reoperation after MD (univariate OR = 3.63, p = 0.039), while disc height of <6 mm (OR = 1.97) and Modic type-1 changes (OR = 1.78) showed trends toward increased reoperation risk (both p < 0.10). CONCLUSIONS: Although both procedures achieved clinical improvement, IF demonstrated superior long-term durability as shown by significantly lower reoperation rates over extended follow-up. Our findings support a risk-stratified surgical selection: IF should be strongly considered in patients with BMI of ≥35 kg/m2 and those with progressive disc degeneration, whereas MD remains appropriate for patients without these risk factors. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Leggieri F, van Laarhoven SN, León Muñoz VJ
… +4 more, Moya-Angeler J, Akkaya M, Civinini R, Innocenti M
J Bone Joint Surg Am
· 2026 May · PMID 41921052
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BACKGROUND: The aim of this systematic review was to evaluate the impact of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) on medical complications, implant failure rates, and health-care-related costs in patients...BACKGROUND: The aim of this systematic review was to evaluate the impact of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) on medical complications, implant failure rates, and health-care-related costs in patients undergoing hip or knee arthroplasty. METHODS: A comprehensive search of electronic databases, including PubMed, Embase, Web of Science, the Cochrane Library, the World Health Organization International Clinical Trials Registry Platform (ICTRP), and the UK Clinical Trials Gateway, was conducted and was limited to studies from database inception to March 31, 2025. Inclusion criteria comprised randomized controlled trials or cohort studies involving adults (≥18 years old) undergoing total joint arthroplasty (TJA) while receiving a GLP-1 RA treatment of any dosage or duration. The risk of bias was assessed using the Cochrane risk-of-bias tool and ROBINS-I (Risk Of Bias In Non-Randomized Studies - of Interventions) assessment. Due to substantial heterogeneity in the study designs, a qualitative synthesis approach was employed. RESULTS: Eight retrospective studies met the inclusion criteria, encompassing 22,611 GLP-1 RA users and 77,810 controls. The mean patient age ranged from 56 to 64 years. Hospital readmission rates showed the most consistently favorable results among GLP-1 RA users, with 3 studies reporting significant reductions of 29% to 47% during the 90-day postoperative period. Five studies demonstrated that GLP-1 RA use was associated with significant reductions, ranging from 30% to 44%, in periprosthetic joint infection (PJI) rates, whereas 3 studies found no significant differences. Hospital resource utilization favored GLP-1 RA therapy, with several studies demonstrating shorter hospital stays and lower 90-day costs. Medical complications yielded variable results: some studies reported increased vascular and pulmonary events among GLP-1 RA users, whereas others observed reduced sepsis and hypoglycemic events in those patients. CONCLUSIONS: GLP-1 RA therapy was associated with reduced hospital readmissions and decreased hospital costs within 90 days postoperatively, although its benefits for PJI prevention showed mixed results, with some studies demonstrating significant reductions in PJI while others showed no difference. No consistent clinical advantages were observed at the 2-year follow-up. LEVEL OF EVIDENCE: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.
MacKechnie MC, Quintero JE, Amadei R
… +12 more, Rio M, Shearer DW, Bidolegui F, Madrigal R, González Torres JC, Segovia J, Salazar Del Villar M, Vega MO, Morshed S, Kohn MA, Miclau T, ACTUAR Study Group
J Bone Joint Surg Am
· 2026 Apr · PMID 41921051
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BACKGROUND: The study compared health-related quality of life and fracture-healing based on the fixation method following isolated open tibial fractures in Latin America. METHODS: A prospective study was conducted across...BACKGROUND: The study compared health-related quality of life and fracture-healing based on the fixation method following isolated open tibial fractures in Latin America. METHODS: A prospective study was conducted across 18 trauma centers in 8 countries. Adult patients with isolated open tibial diaphyseal fractures were included. The primary outcome measures were Physical Component Summary (PCS) and Mental Component Summary (MCS) scores of the 12-Item Short Form Health Survey (SF-12), which was administered at baseline and at follow-up at 6, 12, 26, and 52 weeks. The secondary outcome measure was the modified Radiographic Union Scale for Tibial Fractures (mRUST) score. RESULTS: Of 422 patients, 389 had a baseline evaluation, with 352 (83.4% of the 422) completing at least 1 SF-12 follow-up and 309 (73.2%) completing at least 1 SF-12 follow-up and having radiographic follow-up within 1 year postoperatively. Initial definitive intramedullary nailing and external fixation or casting followed by staged intramedullary nailing were the most common fixation strategies. Both fixation methods were performed with similar frequency for Gustilo-Anderson (GA) Type-I and II injuries. The majority of GA Type-IIIA and IIIB/C fractures were treated with staged fixation. The presence of minimal or superficial contamination did not influence whether fractures were treated with initial intramedullary nailing or staged intramedullary nailing, whereas the presence of deep contamination was associated with staged management. For all GA types combined, initial definitive intramedullary nailing was associated with significantly higher PCS and MCS scores at 1 year than staged fixation. The mRUST scores at 1 year for all GA types combined were higher with initial definitive intramedullary nailing than with staged intramedullary nailing. CONCLUSIONS: Staged treatment remains common in Latin America, even for less severe injuries. Initial intramedullary nailing was associated with improved PCS and MCS scores and significantly higher mRUST scores relative to staged intramedullary nailing. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
Fehring TK, Otero JE, Fehring KA
… +8 more, Curtin BM, Springer BD, Della Valle CJ, Parvizi J, Hietpas K, Ready A, Odum SM, PJI Study Group
J Bone Joint Surg Am
· 2026 Apr · PMID 41921050
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BACKGROUND: A 2-stage approach is most commonly used to treat periprosthetic joint infection (PJI). Some successful studies of the 1-stage approach were underpowered, lacked a 2-stage comparative group, and excluded pati...BACKGROUND: A 2-stage approach is most commonly used to treat periprosthetic joint infection (PJI). Some successful studies of the 1-stage approach were underpowered, lacked a 2-stage comparative group, and excluded patients with draining sinuses, comorbidities, and/or antibiotic-resistant organisms. Given the morbidity and expense associated with 2-stage treatment, we conducted a prospective, multicenter, randomized trial to compare the results of 1- and 2-stage PJI treatment, specifically including patients with draining sinuses, comorbidities, and resistant organisms. METHODS: Patients presenting for surgical treatment of a chronic PJI with a known organism following primary total hip or knee arthroplasty were included (with infection defined by Musculoskeletal Infection Society [MSIS] criteria). Patients with prior revision, culture-negative infection, or fungal infection, or who were immunosuppressed or had soft-tissue involvement precluding wound closure, were excluded. Patients were classified according to the McPherson host staging system. Clinical success was defined as (1) no clinical failure or reinfection with the same or new organism; (2) no reoperation for PJI; and (3) no PJI-related death. A double-instrument setup was used for all patients, as were similar irrigation and antibiotic protocols. A total of 323 patients (166 one-stage; 157 two-stage) were randomized. Groups were similar with respect to demographics and host classification. After excluding patients who died or were lost to follow-up, 258 of the 323 patients had 2-year follow-up (135 one-stage and 123 two-stage). The rate of patient loss to follow-up was similar between the treatment groups. RESULTS: Sixteen patients in the 1-stage group and 9 patients in the 2-stage group died prior to 2-year follow-up. Overall, the 2-year success rate of 1-stage treatment was 97% (131 of 135), while the success of 2-stage treatment was 91% (112 of 123) (p = 0.04). Compared with the 2-stage group, the 1-stage group had 3-times the odds of overall success in a regression analysis (unadjusted odds ratio = 3.22 [95% confidence interval = 1.0 to 10.38]). After adjusting for specific variables (McPherson host grade, resistant organism, and draining sinuses), 1-stage treatment also had 3-times the odds of success. CONCLUSIONS: The results of this prospective randomized trial indicated that 1-stage treatment (97% success) was statistically noninferior to 2-stage treatment (91% success) when treating chronic PJI following primary total hip or knee arthroplasty, provided the protocols described here are explicitly followed. Extrapolation to other patient cohorts and clinical situations should be avoided. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
Bram JT, Beber SA, Lu S
… +4 more, Pascual-Leone N, Groff KD, Green DW, Fabricant PD
J Bone Joint Surg Am
· 2026 Jun · PMID 41921048
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BACKGROUND: Coronal plane angular deformity remains under-investigated in the context of pediatric anterior cruciate ligament (ACL) tears. We hypothesized that baseline coronal alignment in pediatric and adolescent patie...BACKGROUND: Coronal plane angular deformity remains under-investigated in the context of pediatric anterior cruciate ligament (ACL) tears. We hypothesized that baseline coronal alignment in pediatric and adolescent patients with a first-time ACL injury would differ from that in a matched healthy comparison population of patients without knee pathology. METHODS: Patients ≤18 years of age who underwent primary ACL reconstruction and had preoperative lower-extremity hip-to-ankle alignment radiographs (cases) and individuals without lower-extremity conditions that would influence alignment (controls) were matched 1:1 on the basis of age (±1 year) and sex. Coronal plane parameters included the hip-knee-ankle angle (HKA), mechanical axis deviation (MAD), mechanical lateral distal femoral angle (mLDFA), and medial proximal tibial angle (MPTA). Decision stump analyses were used to identify clinically relevant alignment threshold values. RESULTS: A total of 200 patients were included in the analysis (100 per group). The mean age was 12.7 ± 2.1 years in the ACL group (58% White/Caucasian, 50% female) and 13.1 ± 2.4 years in the control group (49% White/Caucasian, 50% female). Compared with controls, patients with an ACL tear demonstrated increased valgus alignment across all 4 parameters: MAD (-4.1 ± 7.8 versus -0.3 ± 7.6 mm; p < 0.001), HKA (-1.4° ± 2.6° versus -0.5° ± 2.3°; p = 0.006), mLDFA (85.3° ± 1.9° versus 86.1° ± 1.7°; p = 0.004), and MPTA (88.0° ± 1.8° versus 87.2° ± 1.9°; p = 0.004). Conditional logistic regression demonstrated increased odds of an ACL tear associated with each 1-unit increase in valgus alignment, as measured by MAD (inverse odds ratio [OR]: 1.06; 95% confidence interval [CI]: 1.02 to 1.10; p = 0.003), HKA (inverse OR: 1.14; 95% CI: 1.02 to 1.27; p = 0.022), mLDFA (inverse OR: 1.27; 95% CI: 1.08 to 1.50; p = 0.005), and MPTA (OR: 1.28; 95% CI: 1.07 to 1.53; p = 0.006). In the decision stump analysis of HKA, a value of -0.5° demonstrated that 60% of participants with ≥0.5° of valgus alignment had an ACL tear compared with 38% of patients with neutral alignment, varus alignment, or <0.5° of valgus alignment. CONCLUSIONS: Pediatric and adolescent patients with an ACL tear demonstrated greater valgus alignment than age- and sex-matched controls, with each 1° increase in HKA valgus alignment increasing the odds of an ACL tear by 14%. Routine preoperative assessment is necessary as coronal plane deformity is modifiable through concomitant implant-mediated guided growth in skeletally immature patients. The inclusion of coronal plane alignment parameters in ACL-related investigations is warranted to elucidate their contribution to injury risk and surgical outcomes. LEVEL OF EVIDENCE: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.