{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,1]],"date-time":"2026-10-01T18:59:20Z","timestamp":1790881160389,"version":"4.1.0"},"reference-count":36,"publisher":"Ovid Technologies (Wolters Kluwer Health)","content-domain":{"domain":["lww.com","ovid.com"],"crossmark-restriction":true},"short-container-title":[],"abstract":"\n Background:<\/jats:title>\n Tibial tubercle avulsion fractures occur in pediatric patients during periods of physeal vulnerability and have been associated with exposure to growth hormone therapy (rhGH). Diffusion tensor imaging-magnetic resonance imaging (DTI-MRI) can detect alterations in physeal microarchitecture by characterizing water diffusion along the organized cartilaginous columns of the physis. This study leveraged DTI-MRI to evaluate whether initiation of rhGH therapy is associated with temporally distinct changes in tibial tubercle physeal microstructure, which could potentially predispose children and adolescents to tibial tubercle avulsion fractures.<\/jats:p>\n <\/jats:sec>\n \n Methods:<\/jats:title>\n Patients were recruited as part of a multicenter prospective cohort study. Skeletally immature patients aged \u22656 years scheduled to initiate rhGH therapy underwent DTI-MRI before rhGH administration and 4, 8, and 12 months after therapy initiation. Linear mixed-effects models were used to assess the effect of time on DTI metrics, with Dunnett-adjusted post hoc comparisons. Baseline skeletal age was included as a covariate.<\/jats:p>\n <\/jats:sec>\n \n Results:<\/jats:title>\n \n Fifty-three patients were enrolled; 68% were male, 83% were White, and the mean skeletal age at therapy initiation was 10 \u00b1 3 years. The apparent diffusion coefficient (ADC) in the tibial tubercle increased in 71% of patients after rhGH administration, with the maximum increase at 8 months. In adjusted mixed-effects models, ADC was significantly higher at 8 months compared with baseline (1.61 \u00d7 10\n \u22123<\/jats:sup>\n [95% confidence interval (CI): 1.55 to 1.68 \u00d7 10\n \u22123<\/jats:sup>\n ] versus 1.52 \u00d7 10\n \u22123<\/jats:sup>\n [95% CI: 1.46 to 1.58 \u00d7 10\n \u22123<\/jats:sup>\n ] mm\n 2<\/jats:sup>\n \/sec, p = 0.041). Greater skeletal age was independently associated with lower ADC (\u03b2 = \u22123.17 \u00d7 10\n \u22125<\/jats:sup>\n , p < 0.001), higher fractional anisotropy (\u03b2 = 0.011, p < 0.001), and higher tract volume (\u03b2 = 0.106, p = 0.015).\n <\/jats:p>\n <\/jats:sec>\n \n Conclusions:<\/jats:title>\n DTI-MRI identified temporally distinct microstructural changes at the tibial tubercle following rhGH initiation. The increase in ADC suggests transient physeal expansion and remodeling within at least the first 8 months of treatment, during a time in which ADC would typically be decreasing with normal skeletal maturation. This study therefore provides mechanistic insight into the reported association between rhGH therapy and tibial tubercle avulsion fractures. Adjusting impact sports and activities during this vulnerable time should be strongly considered.<\/jats:p>\n <\/jats:sec>\n \n Level of Evidence:<\/jats:title>\n \n Therapeutic\n Level II<\/jats:underline>\n . See Instructions for Authors for a complete description of levels of evidence.\n <\/jats:p>\n <\/jats:sec>","DOI":"10.2106\/jbjs.26.00599","type":"journal-article","created":{"date-parts":[[2026,10,1]],"date-time":"2026-10-01T18:02:25Z","timestamp":1790877745000},"update-policy":"https:\/\/doi.org\/10.1097\/lww.0000000000001000","source":"Crossref","is-referenced-by-count":0,"title":["Microstructural Vulnerability of the Tibial Tubercle Apophysis During Growth Hormone Therapy"],"prefix":"10.2106","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-8070-685X","authenticated-orcid":false,"given":"Peter D.","family":"Fabricant","sequence":"first","affiliation":[{"name":"Pediatric Orthopedic Surgery Service, Hospital for Special Surgery, New York, NY"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0009-8477-9413","authenticated-orcid":false,"given":"Samuel A.","family":"Beber","sequence":"additional","affiliation":[{"name":"Pediatric Orthopedic Surgery Service, Hospital for Special Surgery, New York, NY"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0911-3031","authenticated-orcid":false,"given":"Camilo","family":"Perdomo-Luna","sequence":"additional","affiliation":[{"name":"Pediatric Orthopedic Surgery Service, Hospital for Special Surgery, New York, NY"},{"name":"Division of Pediatric Radiology, Columbia University, Irvine Medical Center, New York, NY"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0008-1510-4327","authenticated-orcid":false,"given":"Katherine D.","family":"Groff","sequence":"additional","affiliation":[{"name":"Pediatric Orthopedic Surgery Service, Hospital for Special Surgery, New York, NY"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9358-6770","authenticated-orcid":false,"given":"Sarah","family":"Lu","sequence":"additional","affiliation":[{"name":"Pediatric Orthopedic Surgery Service, Hospital for Special Surgery, New York, NY"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8730-5901","authenticated-orcid":false,"given":"Ola","family":"Kvist","sequence":"additional","affiliation":[{"name":"Division of Pediatric Radiology, Columbia University, Irvine Medical Center, New York, NY"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8623-1138","authenticated-orcid":false,"given":"Sogol","family":"Mostoufi-Moab","sequence":"additional","affiliation":[{"name":"Divisions of Endocrinology and Oncology, Children\u2019s Hospital of Philadelphia, Philadelphia, Pennsylvania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7286-6864","authenticated-orcid":false,"given":"Daniel W.","family":"Green","sequence":"additional","affiliation":[{"name":"Pediatric Orthopedic Surgery Service, Hospital for Special Surgery, New York, NY"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9571-9776","authenticated-orcid":false,"given":"Diego","family":"Jaramillo","sequence":"additional","affiliation":[{"name":"Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"276","published-online":{"date-parts":[[2026,10,1]]},"reference":[{"issue":"4","key":"bib1-20261001","doi-asserted-by":"crossref","first-page":"e0186","DOI":"10.2106\/JBJS.RVW.19.00186","article-title":"Epidemiology, Diagnosis, and Management of Tibial Tubercle Avulsion Fractures in Adolescents","volume":"8","author":"Cole","year":"2020","journal-title":"JBJS Rev."},{"issue":"4","key":"bib2-20261001","doi-asserted-by":"crossref","first-page":"251","DOI":"10.5435\/JAAOS-D-15-00328","article-title":"Lower Extremity Avulsion Fractures in the Pediatric and Adolescent Athlete","volume":"25","author":"Schiller","year":"2017","journal-title":"J Am Acad Orthop Surg."},{"issue":"4","key":"bib3-20261001","doi-asserted-by":"crossref","first-page":"246","DOI":"10.1007\/BF00351348","article-title":"Radiology of postnatal skeletal development. 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